Skip to main content

Full text of "The Philadelphia medical journal"

See other formats 


RVNDBOl-ND 
AT  THE 


fNIXtRSIT^   OF 

loftavro  PRESS 


r-^ 


THE 


PBILADELPBIA  MEDICAL  JOURNAL 


A  WEEKLY  JOURNAL  OWNED  AND  PUBLISHED  BY  THE  PHILADELPHIA  MEDICAL, 

PUBLISHING  COMPANY,  AND  CONDUCTED  EXCLUSIVELY  IN  THE 

INTERESTS  OF  THE  M  EDICAL    PROFESSION. 


JAMES  HENDRIE  LLOYD,  A.  M.,  M.  D., 
EDITOR  IN  CHIEF. 


JULIUS  L.  SALINGER,  M.  D., 
ASSOCIATE  EDITOR. 


ASSISTANT     EDITORS. 


JOSEPH   SAII.ER.M.   D., 
D.  L.  EDSALL,  M.  D., 
J.   M.   SWAN,   M.   D., 
J.  H.  GIBSON.  M.  D., 
M.  OSTHEIMER,  M.  D., 


F.  J.  KAT.TEYER,  M.  D., 

T.  L.  COLEY,  M.  D.. 

W.  A.  N.  BORLAND,  M.  D.. 

T.  M.  TYSON,  M.  D., 

A.  ROBIN,  M.  D. 


VOLU  ME  VII. 
JANUARY— JUNE  1901. 


-fi      Si      SS 


PHILADELPHIA. 
THE  PHILADELPHIA  MEDICAL  PUBLISHING  COMPANY. 

1901. 


Entered  According  to  Act    of    Congress. 
In  the  year  1901  by 
THE  PHILADELPHIA  MEDICAL  PUBLISHING  COMPANY. 
In  the  Office  of  the  Librarian  of  Congress  at  Washington. 


ALL  RIGHTS   UESERAT3D. 


The  Pliiladel[)liia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


Jamks  Hendrie  Lloyd,  a.m.,  M.D.,  Editor-in-Chief 
JcLius  L.  Salinger,  M.D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteykr.  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  Colky,  M.D. 

J.  M.  Swan.  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  GiBitON,  M.D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  pnblicatioD.    Reprints  (250)  of  Original  Articles  will  be  furnished  gratis  to  Autliors  making 
the  request. 
The  Editorial  and  Business  Otfices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  3IecUcal  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Pages  8  and  36. 


Vol.  VII,  No.  1 


JANUARY  5,  1901 


$3.00  Per  Axnuji 


Salutatory. — With  the  present  number  the  Phila- 
delphia Medical  Journal  appears  under  new  editorial 
management.  The  occasion  is  not  one  that  calls  for 
extended  comment.  It  may  be  proper  to  state,  how- 
ever, that  the  present  editor  is  not  entirely  new  to  the 
task,  as  he  has  been  a  frequent,  almost  constant,  con- 
tributor to  the  editorial  pages  of  the  Jourxai>  from  its 
inception.  In  this  work  he  has  devoted  his  pen  to  the 
more  strictly  scientific  aspects  of  medicine  as  they  have 
been  discussed  here.  The  change  in  editorial  super- 
vision does  not  necessarily  indicate  any  radical  change 
in  the  general  scope,  appearance,  and  scientific  aims  of 
the  Journal.  What  changes,  if  any,  may  occur  will 
be  the  results  of  careful  forethought  and  for  the  best 
interests  of  our  readers.  In  the  future,  as  in  the  past, 
the  object  will  be  to  present  a  high  class  of  original 
papers,  to  reflect  faithfully  the  most  useful  contempo- 
rary literature,  and  to  relate  weekly  the  most  important 
events  in  the  medical  world.  These  editorial  columns 
will  be  kept  exclusively  for  the  discussion  of  subjects 
that  are  purely  professional.  It  is  due  to  the  host  of 
readers,  subscribers,  and  contributors,  who  have  made 
this  Journal  a  success  in  the  past,  that  acknowledg- 
ment should  be  made  here  now  of  their  support,  and 
that  they  should  be  assured  that  no  effort  will  be  spared 
in  the  future  to  make  the  Journal  a  reflex  of  their 
interests  and  their  views,  as  well  as  a  fitting  exponent 
of  one  of  the  most  important  centers  of  medical  learning 
in  America. 

The   Medico-Legal   Relations  of  the   X-ray. — A 

great  danger  attending  the  introduction  of  new  methods 
of  diagnosis  is  that  the  most  recent  procedure  may  be 
endowed  by  its  advocates  with  more  than  its  proper 
share  of  weight  as  evidence.  With  admirable  foresight, 
the  American  Surgical  Association  has  anticipated  this 
contingency  and,  at  the  meeting  held  in  1897,  appointed 
a  committee,  of  which  Dr.  J.  William  White  was  chair- 
man, to  report  upon  the  medico-legal  relations  of  the 
x-rays.  This  committee  made  a  report  at  the  Washington 
meeting  held  in  May,  1900  (^Avierican  Journal  Medical 
Sci'euces,  July,  1900).  The  facts  collected  by  the  committee 
go  to  show  that  there  have  already  been  cases  of  improper 
use  of  the  skiagram  in  court  and  that  there  is  a  real 
danger  for  the  future  from  the  teaching  of  some  mem- 
bers of  the  profession,  who  have  exalted  skiagraphy 
beyond  its  present  merits.     Grave  mistakes  have  been 


made  in  reference  to  the  presence  or  absence  of  frac- 
tures, one  of  the  most  striking  of  which  is  the  failure 
of  a  skiagram  to  show  the  line  of  fracture  after  com- 
plete osteotomy,  only  24  hours  old.  Defective  plates 
may  lead  to  errors  concerning  foreign  bodies ;  in  one 
instance  such  a  defect  was  considered  to  indicate  the 
existence  of  a  renal  calculus.  It  is  thus  shown  that 
the  x-rays  are  not  infallible  and  that  in  addition  to  the 
skiagram  the  surgeon  should  employ  the  methods 
which  experience  has  shown  to  be  trustworthy  in  draw- 
ing his  conclusions  in  a  given  case.  There  seems  to  be 
no  justification  for  the  teaching  that  x-rays  should  be 
employed  as  a  routine  method  of  examination  in  every 
case  for  the  diagnosis  of  fractures.  Indeed,  in  the 
region  of  the  base  of  the  skull,  the  vertebral  column, 
the  pelvis,  and  the  hips,  the  results  are  far  from  satis- 
factory. Again,  it  should  be  remembered  that  a  skia- 
gram alone  is  very  misleading  with  regard  to  the 
existence  of  deformity.  Furthermore,  after  a  recent 
fracture  an  x-ray  examination  will  not  be  sufficient  to 
prognosticate  union  or  nonunion  with  accuracy.  The 
investigations  of  the  committee  seem  to  show  that 
while  x-ray  burns  are,  in  the  majority  of  cases,  easily 
preventable,  their  cause  is  not  definitely  known.  The 
skiagram  has  already  been  admitted  as  evidence  in 
medico-legal  cases  and  its  use  will  undoubtedly  in- 
crease ;  it  is  necessary,  therefore,  that  its  sources  of 
fallacy  should  be  borne  in  mind.  The  surgeon  should 
familiarize  himself  with  the  appearances  of  skiagrams, 
with  their  distortions,  with  the  relative  values  of  their 
shadows  and  outlines  so  that  he  may  judge  of  their 
teachings  and  not  be  dependent  upon  the  interpretations 
of  others.  The  conclusions  of  the  committee  were 
wisely  adopted  unanimously  by  the  members  as  ex- 
pressing the  views  of  the  American  Surgical  Association. 
The  association,  by  this  action,  while  setting  forth  the 
advantages  of  x-ray  examinations,  avoids  the  fallacy  of 
giving  to  skiagrams  more  than  their  proper  relative 
importance. 

Gastrointestinal  Autointoxication.  —  Weintraub 
stated  in  Lubarsch  and  Ostertags  "  Ergebnisse,"  that 
most  cases  reported  as  instances  of  gastrointestinal 
autointoxication  bear  absolutely  no  resemblance  to  such 
a  condition  except  in  the  name  given  them.  There  is 
certainly  much  more  scientific  truth  in  this  brief  re- 
mark than  in  most  of  the  more  elaborate  writings  con- 


The  Philadblphia 
Medical  Journal 


] 


EDITORIAL  COMMENT 


[Jaxcabt  5,  1  ■ 


cerning  the  subject.  The  publication  of  Bouchard's 
book,  followed  by  Altru's  and  other  somewhat  elaborate 
works,  produced  a  swarm  of  smaller  articles  which 
buzzed  about  one's  ears  so  industriously  that  many  a 
poor  doctor  seems  to  have  concluded  that  there  is  justi- 
fication for  considering  every  case  of  obscure  disease 
the  result  of  poisoning  from  the  alimentary  tract.  If 
only  there  is  some  evidence  of  disturbance  of  the 
stomach  or  bowels,  or  if  treatment  which  is  likely  to 
relieve  disease  of  these  organs  produces  improvement 
the  diagnosis  becomes  clear  at  once — and  the  treatment 
should  evidently  be  to  disinfect  the  gastrointestinal 
tract  by  drugs  or  mechanical  means  until  the  source  of 
the  noxious  thing  is  removed.  Such  wild  enthusiasm 
was  born  of  the  very  originators  of  the  discussion.  In 
order  to  prove  the  doctrine  they  taught  they  looked  in 
but  one  direction.  The  reactive  party  has  now  begun 
to  show  its  head.  Gumprecht  has  pointed  out  that 
there  is  little  or  no  real  demonstration  of  the  existence 
of  poisoning  from  the  stomach,  and  authorities  like 
Ewald  and  Robin  have  stated  only  recently  that  there 
has  been  far  too  free  a  use  of  the  term  gastrointestinal 
autointoxication  and  that  even  clinical  evidence  of  its 
occurrence  is  scanty  and  rarely  found,  and  the  profes- 
sion in  general  has  begun  to  pause  and  deliberate  before 
giving  itself  over  to  such  a  diagnosis. 

Nevertheless  there  is  a  conviction  in  most  reasoning 
minds  that  a  not  inconsiderable  number  of  cases  show 
signs  of  self-poisoning,  and  that  in  many  of  these  cases 
the  gastrointestinal  tract  apparently  bears  a  close  rela- 
tionship to  the  production  of  the  symptoms,  though  a 
clear  recognition  of  the  actual  fault  is  difficult  to 
reach. 

The  most  satisfactory  proof  of  the  accuracy  of  a 
thought  that  must  have  been  in  many  minds — that 
these  cases  should  be  considered  to  be  due  to  general 
metabolic  abnormalities  rather  than  to  simple  digestive 
derangements — has  been  provided  lately  by  Strauss 
and  Phillippsohn  (Zdtschrift  fur  klinische  Medicin,  Band 
xl,  Hefte  5  and  6).  After  a  laborious  and  elaborate 
study  they  conclude  that  there  is  in  the  first  place  ex- 
cellent evidence  that  normally  the  products  of  intestinal 
putrefaction,  while  absorbed  in  considerable  amounts, 
appear  in  the  urine  in  only  small  quantities.  They  have 
in  large  part  been,  therefore,  so  altered  by  the  tissues 
that  their  products  which  appear  in  the  urine  are  harm- 
less and  are  no  longer  recognizable  as  the  products  of 
putrefaction.  Further,  while  one  may  in  some  condi- 
tions, often  thought  to  be  intoxications  from  the  gastro- 
intestinal tract,  find  abnormally  large  amounts  of  vola- 
tile fatty  acids,  ethereal  sulphates,  and  other  substances 
produced  by  putrefaction  in  the  alimentary  tract,  there 
is  usually  no  evidence  that  these  substances  are  actu- 
ally produced  or  absorbed  in  excessive  quantities. 
There  are  many  important  details  in  the  article,  but 
the  main  point  is  indicated  by  what  has  been  stated, 
i.  e.,  in  a  large  number,  probably  a  very  large  number. 


of  cases  thought  to  be  gastrointestinal  intoxication, 
we  should  rather  speak  of  a  tissue  vnioxication.  In  other 
words,  the  gastrointestinal  tract  may  be  producing  only 
a  normal  amount  of  toxic  material,  perhaps  less  than 
normal,  or  possibly  a  little  more  than  normal.  The 
tissues  are,  however,  unable  to  cope  with  even  normal 
amounts,  and  intoxication  results. 

The  moral  from  all  this  story  is  that  we  have  been 
too  narrow  in  our  views,  and  that  the  subject  is  far  less 
easy  than  we  have  been  led  to  believe.  Such  patients 
cannot  be  cured  by  mere  colonic  flushings  or  gastric 
lavage :  they  can  be  cured  only  as  can  persons  with 
other  metabolic  abnormalities,  by  painstaking  control 
of  all  the  details  of  their  lives,  not  of  those  alone  which 
relate  solely  to  the  alimentary  tract. 

The  Diagnosis  of  Mitral  Stenosis. — The  condition 
of  mitral  stenosis  has  given  rise  to  a  great  diversity  of 
opinion  among  medical  authors ;  both  as  to  its  diag- 
nostic features  and  its  pathology.  In  consulting  a  large 
number  of  well-known  works  we  have  been  impressed 
with  the  inadequacy  of  many  of  the  descriptions  for 
general  application.  They  have  no  doubt  fitted  certain 
cases,  but  the  various  phases  of  the  condition  demand 
recognition  and  lucid  explanation,  which  is  too  rarely 
attempted.  First,  the  pathology  demands  our  atten- 
tion. We  find  it  stated  unequivocally  by  some  writers 
of  great  clinical  experience  that  the  left  ventricle  is 
always  atrophied  in  mitral  stenosis,  as  we  should  ex- 
pect it  to  be  theoretically.  Others  hold  that  the  left 
ventricle  is  normal  in  this  condition ;  and  that  if 
atrophy  is  found,  it  is  not  dependent  upon  the  mitral 
stenosis.  This  latter  view,  based  as  it  is  upon  the  ex- 
tensive study  of  careful  postmortem  records,  we  believe 
to  be  the  most  acceptable  and  conclusive.  There  is  no 
marked  difference  of  opinion  as  to  the  other  pathological 
processes  found. 

Discussing  the  character  of  the  murmur,  we  find  it 
stated  generally,  that  it  is  presystolic  in  time  with  its 
point  of  greatest  intensity  a  little  above  and  within  the 
apex-beat,  or  at  the  apex-beat  itself;  and  that  it  is  not 
transmitted.  We  have  even  seen  it  stated,  however, 
that  it  may  be  transmitted  towards  the  sternum  ;  again, 
and  unquestionably  this  is  true,  that  it  is  sometimes 
heard  at  the  left  anterior  axillary  line,  sometimes  high 
up  in  the  axilla,  and  has  been  heard  posteriorly  as  far 
as  the  posterior  axillary  line.  Another  writer  points  out 
that  there  are  three  sets  of  cases  to  be  considered  :  one, 
in  which  there  is  a  diastolic  murmur;  another,  in  which 
the  murmur  is  undoubtedly  presystolic ;  and  a  third. 
in  which  no  murmur  whatever  is  audible. 

All  the  authors  consulted  note  the  characteristic 
thrill,  the  fremmement  of  Laennec,  but  we  are  cautioned 
that  the  murmur  may  be  absent  in  one-third  of  the 
cases  and  that  the  thrill  m.ay  be  felt,  at  times,  when 
the  murmur  is  not  appreciable.  Again,  it  has  been 
pointed  out,  and  proven  conclusively,  that  the  presys- 


Janoart  S,  1901] 


EDITORIAL  COMMENT 


CThe  Phii.adei,phta 
Medical  Journal 


tolic  murmur  is  not  absolutely  pathognomonic  of  mitral 
stenosis,  but  is  heard  in  other  vahnilar  defects. 

As  to  the  characteristics  of  the  murmur  there  is  a 
unanimity  of  opinion.  It  is  loud,  prolonged,  and  of  a 
grinding,  churning  character.  For  the  most  part,  just 
prominence  is  laid  upon  the  accentuation  of  the  second 
sound,  both  over  the  pulmonary  area  and  at  the  apex, 
but  many  authors  fail  entirely  to  mention  the  redupli- 
cation of  the  second  sound  which  is  sometimes  present 
— the  bruit  de  rappel,  or  three-toned  rhythm  of  the  heart, 
a  condition  in  which  a  single  systolic  sound  is  followed 
by  a  double  diastolic  sound. 

The  pulse  is  passed  over  in  many  works  with  too 
great  brevity.  By  some  it  is  stated  that  it  may  be 
regular  and  normal  in  frequency  ;  by  others,  that  it  is 
of  normal  rate  and  irregular ;  again,  that  it  is  irregular 
and  frequent.  We  may  attempt  to  rationalize  this  by 
stating  that,  early  in  the  disease,  with  compensation 
established,  there  may  be  no  alteration  in  character  or 
rate.  The  constant  factors  to  be  heeded  are  the  "  small- 
ness,  softness,  and  emptiness  "  of  the  pulse.  Later  in 
the  disease  its  characteristics  are  its  irregularity  and 
frequency. 

It  would  puzzle  a  student  sorely  to  diagnose  correctly 
many  cases  of  mitral  stenosis  from  some  of  the  descrip- 
tions given.  The  cases  are  so  varied  in  character,  and 
so  often  atypical,  that  we  believe  more  stress  should  be 
laid  upon  diagnosis  by  exclusion.  We  should  notice 
especially  the  enlargement  of  the  right  heart,  the  char- 
acter of  the  murmur,  and  thrill,  when  present ;  the 
character  of  the  pulse,  and  the  familiar  picture  of 
easily  disturbed  equilibrium  of  the  circulation.  No 
less  important  is  the  accentuation  of  the  second  pul- 
monic sound  and  frequent  reduplication  of  the  second 
sound. 

In  conclusion,  it  would  seem  that  much  of  the 
diversity  of  opinion  among  medical  writers  upon  the 
cardinal  points  of  diagnosis  and  pathology  is  due  to 
the  fact  that  current  works  have  been  utilized  too 
freely  without  modifying  carefully  the  opinions  ex- 
pressed by  more  extensive  personal  observation,  and  a 
careful  study  of  the  results  of  contemporary  original 
research. 

By  these  methods  alone,  we  believe,  can  a  harmony 
of  diverse  views  and  the  exclusion  of  error  be  brought 
about. 

The  Stethoscope  Up  to  Date. — Since  1819,  when 
Laennec  first  gave  to  the  world  the  stethoscope,  after  he 
had  already  acquired  such  a  degree  of  proficiency  in 
its  use  that  he  was  able  to  define  very  closely  its  ad- 
vantages and  limitations,  physicians  have  been  listen- 
ing to  the  secrets  of  diseased  processes  that  had  hitherto 
been  so  zealously  guarded  by  nature. 

It  is  true  that  there  were  many  men,  such  as  Clarus, 
professor  of  medicine  at  the  University  of  Leipsic,  who 
until  the  year  of  his  resignation  in  1847  fought  against 


the  methods  of  physical  diagnosis,  and  refused  to  in- 
troduce them  into  his  courses ;  but  the  medical  world 
at  large  was  soon  convinced  of  their  extraordinary 
value,  and  accepted  them  with  enthusiasm,  perhaps  a 
little  excessive.  Nevertheless,  it  is  surprising  that  in 
spite  of  the  complexity  of  the  subject,  comparatively 
so  little  has  been  added  to  the  observations  of  Laennec 
and  his  immediate  followers,  particularly  Skoda.  On 
the  other  hand,  the  mechanical  ingenuity  of  physicians 
and  instrument  makers  has  been  exercised  to  the 
utmost  in  the  production  of  various  forms  of  apparatus 
which  are  designed  either  merely  for  the  purpose  of 
sale  to  those  desiring  a  novelty,  or  because  the  makers 
believe  that  they  in  fact  possess  some  points  of  superi- 
ority over  other  instruments  for  similar  purposes, 
and  yet  it  can  be  said  that  the  single  stethoscope,  per- 
haps a  trifle  lighter  and  more  convenient  than  the 
clumsy  wooden  apparatus  employed  at  first,  but  not 
greatly  better  as  a  machine  for  the  conducting  of 
sounds,  still  holds  its  preeminence.  For  40  years  it 
held  undisputed  sway;  then  an  Englishman,  Walter 
Brj'an,  introduced  a  flexible  rubber-tube  between  the 
funnel  and  the  air-piece,  and  from  this  it  was  but  a 
slight  step  to  the  binaural  stethoscope. 

In  the  sixth  edition  of  "Abhandlung  iiber  Perkussion 
und  Auscultation,"  Skoda  records  that  '■  the  best  form 
of  the  stethoscope  and  the  material  of  which  it  is  con- 
structed is  a  subject  of  particular  anxiety  for  those  who 
are  not  yet  accustomed  to  auscultation,"  for  even  in 
that  day  the  number  of  stethoscopes,  microphones, 
stethophones.  etc.,  was  legion,  and  the  poor  student 
seeking  the  best  instrument  was  confused  with  such  a 
mass  of  advice  that  he  was  thoroughly  puzzled ;  and 
yet,  Skoda,  in  this  sentence,  implies,  as  he  el-ewhere 
states  explicit}',  that  it  makes  very  liitle  difference  what 
instrument  is  used,  provided  that  the  ear  at  the  father 
end  is  educated  to  perceive  the  sounds.  To  one  who 
listens  for  the  first  time,  the  whir  of  noises  heard  over 
the  heart,  or  in  the  chest,  sounds  hopelessly  confused. 
It  is  only  by  prolonged  practice  that  the  ability  ia 
gradually  acquired  to  disregard  all  but  certain  partic- 
ular sound-waves,  and  to  analyze  each  in  regard  to  its 
time,  duration,  and  regularity  with  accuracy. 

It  is  a  carious  fact,  that  so  many  men  who  are  fam- 
iliar with  auscultation  insist  that  that  instrument  that 
conveys  the  sounds  most  loudly  to  the  ear  is  therefore 
the  best.  Even  Laennec,  sharp  auscultator  as  he  was, 
was  more  or  less  addicted  to  this  opinion,  and  in  the 
latest  American  book  upon  physical  diagnosis,  that  of 
Cabot  of  Boston,  the  same  mistaken  idea  is  apparently 
held,  for  in  his  enthusiastic  commendation  of  the 
Bowie's  stethoscope,  he  says  that  the  sounds  conducted 
through  any  one  of  the  12  tubes  in  the  multiple  form 
are  "  as  loud  as  those  to  be  heard  with  a  single  instru- 
ment of  the  ordinary  form,  although  far  fainter  than 
those  to  be  heard  with  a  single  Bowie's  stethoscope.'' 
Sahli,  whose  work  Cabot  probably  consulted,  is  much 


The  Philadelphia"] 
Medical  Journal  J 


EDITORIAL  COMMENT 


Jasuakv  S,  isel 


more  correct  upon  this  point ;  it  is  not  the  intensity, 
but  the  diflferentiation  of  the  sounds  that  is  important. 
Any  one  familiar  with  the  use  of  the  microscope  will 
readily  appreciate  the  disadvantage  of  using  a  high  eye- 
piece with  an  inferior  lens ;  the  field  is  blurred, 
although  the  image  is  large.  It  is  the  same  with  the 
stethoscope  that  conveys  the  sounds  loudly  ;  they  are 
blurred  and  indistinct,  and  it  is  often  impossible  to 
dififerentiate  them  satisfactorily.  It  is  for  the  reason  of 
definition  therefore,  that  differences  exist  in  stetho- 
scopes, and  that  the  advice  given  by  some  clinical 
teachers  is  to  our  mind  incorrect.  It  is  not  sufi&cient  to 
become  acquainted  with  one  form  of  stethoscope,  for 
murmurs  may  be  heard  with  one  and  not  with  another, 
as  we  have  often  been  able  to  prove  to  our  own  and 
others'  satisfaction ;  but  each  man  should  be  trained 
carefully  in  the  movements  of  the  single  and  double 
stethoscopes,  and  immediate  auscultation ;  for  it  is  the 
ear  and  not  the  instrument  that  does  the  work. 

Nerve  Regeneration  ;  Neurotropism. — The  regen- 
eration of  nerves  is  an  interesting  biological  phenome- 
non. Physiologists,  pathologists,  neurologists,  and  sur- 
geons have  all  given  attention  to  it,  but  despite  their 
combined  efforts  many  phases  of  the  process  are  still 
obscure.  That  severed  nerves  can  reunite,  with  return 
of  conductivity,  is  a  fact  firmly  established  by  physio- 
logical and  pathological  evidence. 

It  is,  furthermore,  definitely  known  that  such  union 
can  only  be  brought  about  by  the  regeneration  of  nerve 
fibers,  although  a  partial  restoration  of  function  seems 
to  be  possible  before  an  actual  new  production  of  nerve 
fibers  has  taken  place. 

This  is  shown  in  the  occasional  disappearance  of  an 
old  paralysis  within  a  few  hours  after  a  surgical  opera- 
tion in  which  the  cut  ends  of  the  nerve  are  accurately 
brought  into  apposition. 

Regarding  the  histogenesis  of  new  fibers  two  theories 
have  been  advanced,  called  the  theories  of  continuous 
and  of  discontinuous  regeneration  respectively.  Accord- 
ing to  the  first  the  new  fibers  are  formed  by  a  down 
growth  of  the  old  axis  cylinders ;  according  to  the 
latter  the  axis  cylinder  develops  by  a  process  of  differ- 
entiation of  undiflerentiated  fibers  that  grow  from  the 
central  stump. 

No  unequivocal  proof  of  either  theory  has  been  of 
benefit.  Whichever  be  true,  the  fact  remains  that  the 
new  fibers  come  from  the  old  fibers  of  the  proximal 
end. 

The  steps  in  the  new  formation  are  quite  well  known, 
thanks  to  the  labors  of  Ranvier,  Vanlair,  Huber, 
Stroebe,  and  others.  But  there  is  another  point  at  issue, 
namely,  the  nature  of  the  force  or  forces  that  govern  the 
direction  of  growth.  Why  does  the  central  end  seek  to 
connect  with  the  peripheral  ?  Ranvier  and  Vanlair 
were  of  the  opinion  that  the  governing  force  was 
mechanical,  that  the  nerve  grew  toward  the  peripheral 


end  because,  owing  to  the  gap,  it  was  the  path  of  least 
resistance.  Many  facts  favor  this  theorj',  but  others 
are  against  it.  With  the  view  of  determining  the 
significance  of  the  mechanical  factor  and  the  possible 
cooperation  of  others,  Forssman  undertook  a  very  clever 
series  of  experiments,  the  upshot  of  whidi  is  that  the 
'mechanical  factor  is  subordinate,  and  that  there  is  another 
far  more  potent.  For  the  purpose  of  more  readily 
controlling  the  course  of  the  nerve  fibers,  Forssman 
employed  tubes  of  straw  or  collodion.  The  ends  of  the 
cut  nerve  were  either  introduced  into  the  upper  end 
and  lower  parts  of  the  tube  respectively,  or  the  prox- 
imal was  introduced  into  the  upper  part,  while  the 
distal  end  was  carried  along  the  outside  of  the  tube  and 
by  means  of  an  intercalated  segment  doubled  over  the 
top  of  the  tube  so  as  to  lie  parallel  with  the  central 
stump.  By  means  of  fixation  threads  the  cut  ends 
were  retained  in  place.  After  a  period  of  two  months 
the  animals  were  killed,  the  nerves  excised,  fixed  in 
Miiller's  fluid,  cut  into  vertical  serial  sections,  and 
stained  by  the  Weigert-Pal  method. 

It  was  found  that  the  growth  of  new  fibers  occurred 
by  no  means  necessarilj'  in  the  direction  of  least  resist- 
ance. If,  e.  g.,  the  proximal  end  of  the  nerve  was 
placed  in  the  tube  and  the  peripheral  end  carried 
along  the  outside  to  the  top,  a  piece  of  resected  nerve 
affixed  to  it,  and  then  turned  into  the  tube  so  as  to  lie 
alongside  of  the  central  end,  the  new  nerve  fibers  grow- 
ing out  from  the  latter  were  at  first  directed  peripherad 
into  the  tube ;  but  after  proceeding  thus  for  a  short 
distance,  they  doubled  upon  themselves  and  grew 
toward  the  center,  so  as  to  meet  the  distal  end,  or  the 
intercalated  segment  hanging  into  the  tube  from  above. 
If  only  the  upper  end  waa  placed  in  the  tube,  the 
distal  portion  of  the  nerve  being  entirely  removed, 
almost  no  growth  occurred  down  the  tube,  although, 
mechanically,  there  was  no  obstacle.  The  distal  end  of 
the  nerve  in  some  way  exerts  an  attraction  upon  the 
newly-forming  fibers  and  these  respond  by  growing 
toward  it  along  the  shortest  path.  The  fixation  thread 
has  but  little  influence  in  guiding  them.  In  one  exper- 
iment the  tube  of  straw  was  filled  with  brain  substance, 
and  the  proximal  end  of  the  tibial  nerve  carried  down 
along  the  outside  of  the  tube  to  the  lower  end  and  then 
fastened.  The  distal  portion  of  the  tibial  nerve  had 
been  exsected  as  far  as  its  entrance  into  the  calf-muscles. 
On  examination  remarkable  results  were  noted — while 
manj'  new  fibers  had  gathered  on  the  outside  of  the 
tube,  comparatively  few  had  grown  downward,  although 
the  muscle  interstice  of  the  old  nerve  was  open.  On 
the  other  hand,  a  large  bundle  extended  upward  into 
the  tube  as  far  as  its  top.  When  in  control  experi- 
ments the  tube  was  left  empty,  very  few  fibers  grew 
into  it,  and  then  only  for  a  short  distance. 

If  the  mechanical  principle  were  the  guiding  one  it 
would  be  natural  to  expect  a  more  luxuriant  growth 
under  the  latter  than  under  the  former  conditions.    As 


J  IM'AKV  S,  IWil! 


REVIEWS 


r'HF,  Philadelphia 
Medical  Journal 


we  have  seen,  the  contrary  obtained,  and  therefore  evi- 
dently nerve  substance  possesses  some  peculiar  attrac- 
tive force  which  determines  the  direction  of  growth  in 
the  newly-formed  nerve-fibers.  This  force  is  akin  to 
that  known  as  chemotropism  or  chemotaxis,  and  is 
therefore  designated  by  Forssman  as  neurotraplmn.  In 
its  essence  it  is  probably  also  chemical. 

In  a  more  recent  series  of  experiments,  Forssman 
endeavored  to  determine  the  relative  influence  upon 
the  central  end  of  a  nerve  as  compared  with  that  of  its 
own  peripheral  end.  He  divided  the  peroneal  and 
tibial  nerves,  and  reunited  them  in  the  control  animals, 
while  in  others  he  joined  central  tibial  with  peripheral 
peroneal,  and  vice  versa.  No  difference  was  found. 
The  central  end  of  the  tibial  neurotized  the  peripheral 
end  of  the  peroneal  as  nicely  as  it  did  its  own  distal 
stump.  Even  if  a  segment  of  nerve,  as  of  the  peroneal, 
was  interposed  between  the  cut  ends  of  the  tibial,  the 
result  was  the  same.  When  the  interpolated  nerve 
came  from  another  animal  than  a  rabbit,  as  from 
guineapig,  pigeon,  or  frog,  no  downgrowth  of  new 
fibers  occurred.  If  the  ends  were  left  apart,  and 
united  only  by  a  cotton  thread,  the  distal  end  was  freely 
neurotized,  and  if  a  piece  of  rabbit's  sciatic  was  inter- 
polated, the  neurotization  was  abundant.  It  would 
thus  appear  that  the  nerves  of  other  animals  exerted  a 
negative  neurotropism  on  the  nerve-fibers  of  the  rabbit. 
However,  it  is  not  wise  to  generalize  too  broadly  from 
these  few  experiments. 

Forssman  also  tested  the  neurotropic  power  of  spleen 
and  liver,  placing  emulsions  of  these  organs  in  the 
tubes,  as  in  the  experiment  with  brain  substance. 
No  growth  of  fibers  took  place,  showing  that  the  neuro- 
tropic substance  was  absent. 

The  experiments  which  we  have  cited  possess  a  deep 
significance,  apart  from  their  histogenetic  importance. 
They  constitute  another  illustration  of  that  widespread 
force,  at  present  called  chemical,  which  brings  about 
phenomena  that  by  the  old  philosophy  were  considered 
manifestations  of  a  vital  force.  Neurotropism  and 
chemotropism,  to  be  sure,  do  not  solve  the  mystery, 
they  only  remove  one  of  the  many  enshrouding  veils. 
The  new  century  will  tear  off  others,  but  will  bequeath 
the  problem  still  unsolved  to  a  future  age. 


Sewage  is  a  Fertilizer  for  Seaweed. — Dr.  Letts,  the 
professor  of  chemistry  at  the  Belfast  College  (Ireland),  has 
discovered  that  seaweed  is  a  valuable  test  for  ascertaining 
the  presence  of  sewage  in  sea  water.  Investigations  proved 
that  the  successful  growth  of  the  weed  depends  almost  en- 
tirely upon  the  presence  of  sewage  in  the  water.  The 
greater  the  pollution,  the  more  prolific  was  the  growth  of 
the  weed,  while,  on  the  other  hand,  if  no  pollution  of  the 
water  existed,  the  weed  simply  died.  It  should  be  under- 
Btood  that  these  observations  were  made  on  the  seaweed  and 
sewage  near  Dublin  and  Belfast,  In  other  latitudes,  other 
factors  might  prevail. 


Ket»ictt)5. 


Lessons  on  the  Anatomy,  Physiology  and  Hygiene 
of  Infancy  and  Childhood  for  Junior  Students. 

Consisting  of  Extracts  from  Lectures  given  at  the  Rush 
Medical  College.  By  Alfred  C.  Cotton,  A.M.,  M.D. 
Chicago  :  Chicago  Medical  Book  Co.     $1..50. 

This  will  be  an  extremely  useful  book  for  those  who  are 
students  of  medicine,  in  the  catalog  sense.  Practitioners 
have  in  their  larger  books  of  reference  practically  all  that  is 
in  this  condensed  work,  but  perhaps  not  so  conveniently  put 
togther.  The  lack  of  accurate  proof-reading  renders  it  diffi- 
cult at  times  for  the  reader  to  keep  his  mind  on  the  subject- 
matter.  If  the  book  represents  a  required  course  in  pedi- 
atrics for  all  the  students  in  the  Rush  Medical  College,  they 
and  the  College,  as  well  as  the  future  clientage  of  the  embryo 
physicians,  are  to  be  congratulated  on  the  just  importance 
attached  to  tliis  hitherto  neglected  branch  of  medicine. 

The  Microtomist's  Vade-Mecum.  A  Handbook  of 
the  Methods  of  Microscopic  Anatomy.  By  Arthur 
BoLLES  Lee.  Fifth  Edition.  Philadelphia :  P.  Blakis- 
ton's  Son  &  Co.     1900. 

This  book  needs  no  introduction  to  anatomists  and  zoolo- 
gists; and  to  others  unacquainted  with  it,  the  mere  fact  of  a 
fiftli  edition  is  in  itself  a  sufficient  recommendation. 

In  the  preface  to  this  edition  the  reader  is  informed  that 
the  work  has  been  extensively  revised;  many  old  methods 
have  been  rejected  to  make  room  for  many  new  methods ; 
fuller  consideration  has  been  given  to  the  philosophy  of 
cardinal  general  methods ;  the  chapter  on  cytologic  technic 
has  been  in  tlie  main  rewritten.  Of  especial  interest  is  the 
discussion  of  the  principle  of  precipitation  in  the  process  of 
fixation,  based  on  Fischer's  theory  that  "  the  coagulation 
which  constitutes  fixation  is,  in  the  case  of  the  liquid  and 
semi-liquid  constituents  of  tissues,  ahoays  a  phenomenon  of 
prec-ipitation."  Recalling  the  author's  previous  emphatic  sup- 
port of  Flemming's  opinion  on  the  action  of  potassium  bi-, 
chromate  on  kinetic  chromatin,  which  he  said  gave  "  merely 
unnatural  caricatures  of  the  true  structures,"  it  is  interesting 
to  note,  in  the  section  on  cytologic  fixing  agents  (p.  360),  that 
now  he  regards  some  of  the  chromatin  images  given  by  this 
reagent  as  more  lifelike  than  when  produced  by  acids. 

As  always,  the  book  is  a  treasure-house  of  information 
and  suggestion. 

Egbert's  Hygiene  and  Sanitation.  A  Manual  of 
Hygiene  and  Sanitation.  By  Seneca  Egbert,  A.M., 
M.D.,  Professor  of  Hygiene  in  the  Medico-Chirurgical 
College  of  Philadelphia.  New  (2d)  and  revised  edition. 
In  one  handsome  12mo  volume  of  427  pages,  with  77 
engravings.  Philadelphia  and  New  York  :  Lea  Brotliers 
&.Co.     Cloth,  $2.25  net. 

This  manual  is  a  welcome  addition  to  the  limited  number 
of  exact  and  satisfactory  handbooks  on  hygiene.  To  incor- 
porate 14  distinct  subdivisions  of  this  important  subject  in  a 
12mo  volume  of  427  pages,  allotting  sufficient  reading  mat- 
ter, that  each  division  may  be  of  practical  use,  and  to  do  it 
as  well  as  the  author  has  done,  is  most  gratifying.  The  new 
chapter  on  Military  Hygiene  is  a  necessary  and  welcome 
addition.  Could  the  suggestion  contained  therein  have  been 
applied  practically  during  the  past  few  years,  many  of  our 
soldiers'  lives  would  undoubtedly  have  been  spared.  In 
connection  with  this  chapter  we  feel  that  the  author  has  not 
emphasized  sufficiently  the  value  of  fire  as  a  purifying  and 
destructive  agent  for  camp  offal.  Practically  it  has  been 
found  that  even  the  simpler  forms  of  chemical  disinfectants 
are  not  always  obtainable,  and  to  secure  their  proper  use  in 
camp  is  a  seeming  impossibility.  To  disinfect  properly  the 
contents  of  pits  and  sinks  and  then  cart  away,  requires  so 
much  detail  that  it  will  be  impossible  to  have  it  performed 
without  the  most  constant  watchfulness.  The  New  York 
State  militia  liave  in  practical  use  a  privy  on  wheels  in 
which  all  discharges  from  tlie  men  are  consumed  by  fire 
witliout  the  necessity  of  handling,  and  as  it  accompanies  the 
men  even  on  the  march,  the  danger  of  spreading  infection 
beyond  camp  limits  is  reduced  to  a  minimum.    In  Santiago 


The  Philadelphia*! 
Medical  Journal  J 


REVIEWS 


[Jasoaey  5,  1901 


and  elsewhere  cremation  has  superseded  very  largelj^  chem- 
ical disinfection,  and  ia  every  case  where  cremation  is  at  all 
practicable  it  should  be  used  in  preference  to  other  more 
uncertain  and  troublesome  methods.  We  refer  to  the  de- 
struction of  camp  refuse  and  not  to  the  disinfection  of  cloth- 
inj;,  bedding,  etc.  To  the  country  physician  and  to  those 
without  access  to  the  larger  works  this  book  will  be  found 
especially  useful,  and  we  trust  it  may  have  a  sale  commen- 
surate with  its  unquestionable  value.  Every  rural  health 
officir  should  possess  a  copy. 

Textbook  of  Physiologry.  Edited  by  E.  A.  Schafer, 
LL.L'.,  F.R.S.,  Professor  of  Physiology,  University  of 
Edinburgh.  Vol.  II.  New  York :  The  Macmillan  Co. 
19t)0. 

In  a  notice  of  the  first  volume  of  this  noteworthy  textbook 
of  modern  physiology,  published  in  the  Philadelphia  Med- 
ical Jol'kna!.,  Vol.  I,  page  906,  it  was  stated  that  the  scope 
of  the  work  is  different  from  that  of  any  similar  work  in 
English,  comparable  only  to  Hermann's  Handbook — that  is 
to  say  it  is  a  systematic  arrangement  of  the  whole  sphere 
of  physiologic  facts  and  doctrines  presented  in  their  proper 
connection  and  just  proportion  aad  verified  by  that  copious 
citation  of  original  sources  which  is  so  indispensable  to  the 
advanced  student,  teacher,  and  original  investigator. 

The  second  volume,  comprising  some  1300  pages,  has  just 
been  published  and  in  its  general  make-up  maintains  the 
high  standard  set  by  the  first  volume.  The  articles  are 
written  by  physiologists  whose  names  are  a  sufficient  guar- 
antee for  scientific  accuracy,  thoroughness,  and  philosophic 
presentation  It  is  safe  to  say  there  is  hardly  any  phase  of 
modern  physiology  that  does  not  receive  complete  and  elab- 
orate treatment.  Each  article  is  not  only  a  resumiS  of  all 
that  has  hitherto  been  published  in  works  of  similar  charac- 
ter, but  is  a  thorough  presentation  of  the  results  of  investi- 
gations the  world  over  during  the  past  20  years.  Though 
this  textbook  will  appeal  most  strongly  to  professional  phy- 
siologists and  teachers,  yet  the  practical  character  of  the 
articles  and  their  bearing  on  all  problems  of  clinical  medicine 
will  commend  it  to  teachers  and  practitioners  of  clinical 
medicine  as  well.  In  no  other  work  can  there  be  found  such 
a  wealth  of  facts  and  observations  of  a  practical  character. 

In  a  brief  notice  of  a  work  so  extensive  as  this  nothing 
but  an  enumeration  of  the  table  of  contents  is  possible.  The 
papers  have  reference  mainly  to  the  mechanisms  of  the  cir- 
culation, respiration,  tlie  functions  of  the  central  ner\'ous 
system,  the  general  physiology  of  muscle  and  nerves,  the 
special  senses,  etc.    The  table  of  contents  is  as  follow.s  : 

The  Mechanism  of  the  Circulation  of  the  Blood.  166 
pages.    By  Dr.  Leonard  Hill. 

The  Contraction  of  the  Cardiac  Muscle.  60  pages.  By  W. 
H.  Gaskell. 

Animal  Mechanics.    46  pages.    By  I.  B.  Haycraft. 

The  Muscular  and  Nervous  Mechanism  of  the  Respiratory 
Movements.    38  pages.    By  E.  H.  Starling. 

The  Muscular  and  Nervous  Mechanisms  of  the  Digestive 
Tract.     34  pages.  By  E.  H.  Starling. 

The  Muscular  Mechanisms  of  the  Generative  Apparatus. 
6  pages.    By  E.  H.  Starling. 

The  Mechanical,  Normal  and  Electrical  Properties  of 
Striped  Muscle.    97  pages.    By  J.  Burton  Sanderson. 

Nerve.    100  page".     By  Francis  Goteh. 

Physiology  and  Electrical  Organs.  40  pages.  By  Francis 
Gotch. 

The  Nerve  Cell.    23  pages.     By  E.  A.  Schafer. 

The  Sympathetic  and  Other  Related  Systems  of  Nerves. 
80  pages.     By  J.  N.  Langloy. 

The  Cerebral  Cortex.    86  pages.    Bv  E.  A.  Schafer. 

The  Spinal  Cord.     1(X)  pages.     By  C.  S.  Sherrington. 

The  Parts  of  the  Brain  below  the  Cerebral  Cortex.  37 
pages.    By  C.  S.  Sherrington. 

Cutaneous  Sensations.    81  pages.    By  C.  S.  Sherrington. 

The  Muscular  Sense.    25  pages.    Bv  C.  S.  Sherrington. 

Vision.     12.' pages.     By  W.  H.  R.  Rivers. 

The  Ear.  58  pages.  By  John  Gray  McKendrick  and  Al- 
bert A.  Gray. 

Oil  Vocal  Sounds.  30  pages.  By  John  Gray  McKendrick 
and  Albert  A.  Gray. 

The  Sense  of  Taste.    22  pages.    By  I.  B.  Haycraft. 

There  is  in  addition  a  niost  extensive  index  of  subjects, 
covering  75  pages. 


The  Prevention  of  Valvular  Disease  of  the  Heart. 

By  RiCHAED  Caton,  M.D.,  F.R.C.P.     With  6  illustra- 
tions.   London  :  C.  T.  Qay  &  Sons.    1900. 

Dr.  Caton,  from  a  long  experience  in  the  Liverpool  Royal 
Infirmary,  has  formed  very  positive  views  about  the  treat- 
ment and  prevention  of  valvular  deformity  in  rheumatic  en- 
docarditis. His  little  monograph  is  based  upon  a  study  of 
86  cases.  The  author,  like  so  many  other  pnysicians,  has 
been  discouraged  by  the  enfeebling  and  shortening  of  so 
many  valuable  lives  which  occur  fi-om  this  disease,  and  par- 
ticularly so  since  the  crippling  of  the  heart  happens  in  so 
many  cases  early  in  life  and  the  sufferer,  instead  of  keeping 
step  with  his  fellows  is  compelled  to  fall  out  of  the  ranks, 
losing  hope,  and  even  the  power  to  earn  his  daily  bread. 
Dr.  Caton's  book  is  suggestive  not  so  much  for  the  novelty 
of  his  views  (for  there  is  really  little  that  is  original  in  it)  as 
for  the  force  and  insistence  with  which  he  presents  them. 
His  plan  of  treatment  is  by  prolonged  rest,  after  all  the 
symptoms  of  acute  articular  disease  have  disappeared, 
counterirritation  over  the  heart  by  blisters,  and  the  exhibi- 
tion of  the  iodids.  In  the  acute  articular  stage  he,  of  course, 
uses  the  salicylates  freeh'.  He  claims  that  a  beginning  val- 
vulitis, when  recognized"  early,  can  be  arrested  and  cured  by 
this  means,  and  says  that  the  mistake  too  often  made  in 
practice  is  of  regarding  a  slight  endocarditis  as  beyond  ther- 
apeutic help,  and  permitting  the  patient  to  leave  his  bed 
too  soon.  He  enjoins  adsolute  recumbency  for  several 
weeks.  He  is  careful  to  state  that  he  does  not  claim  to  cure 
well  advanced  cases  of  rheumatic  valvulitis.  His  book  is 
devoted  rather  to  prophylaxis  and  the  treatment  of  incipient 
cases,  and  is  an  excellent  and  su^estive  work. 


A  Comparative  Stndy  of  Dig^italis  and  its  Deriv- 
atives.— Arnold  and  H.  C.  Wood,  Jr.  (A  merican  Jounitil  of 
the  Medical  Sciences,  August,  1900),  as  the  result  of  a  series  of 
experiments  draw  the  following  conclusions :  1.  Dlgitalin 
and  digitoxin  each  represent  the  full  circulatory  powers  of 
digitalis.  2.  Digitalis,  digitalin,  and  digitoxin  stimulate  the 
cardioinhibitory  mechanism  both  centrally  and  periph- 
erally. In  larger  doses  they  paralyze  the  intrinsic  cardio- 
inhibitory apparatus.  3.  'They  all  cause  a  rise  of  blood- 
pressure  by  stimulating  the  heart  and  constricting  the 
bloodvessels.  4.  Very  large  doses  paralyze  the  heart-muscle 
of  the  mammal,  the  organ  stopping  in  diastole.  5.  Digitalin 
of  Merck  is  a  stable  compound,  1  gram  of  it  being  equivalent 
to  about  18  drams  tincture  of  digitalis.  6.  Digitoxin  is  not  I 
to  be  recommended  for  human  medication  on  account  of  its 
irritant  action,  which  makes  it  liable  to  upset  the  stomach 
when  given  by  the  mouth  or  to  cause  abscesses  when  given 
hypodermically,  and  on  account  of  its  insolubility,  which 
renders  it  slowly  absorbed  and  irregularly  eliminated,  having  j 
a  marked  tendency  to  cumulative  action. 

Laryngeal  Tuberculosis. — Cohn  (Journal of  the  Amer-\ 

icon  Medical  Associalion,  November,  190<.^)  divides  laryngeal 
tuborculosis,  as  regards  its  therapeutics,  into  three  stages. 
In  the  first  stage,  with  the  exception  of  a  circumscribed  infil- 
tration, or  ulceration,  the  larynx  is  healthy.    In  this  stage, 
the  only  one  in  which  a  permanent  cure  can  be  hoped  for, 
the  treatment  consists  in  curetment  in  case  an  infiltration 
be  present ;  in  cauterizing  with  lactic  acid  in  case  an  nicer 
be  present.    If  the  general  condition,  especially  that  of  the 
luBgs,  be  good  these  procedures  are  imperative  and  should 
be  repeated  at  intervals  of  from  1  to  3  weeks  until  the  dis 
eased  condition  is  completely  removed.    In  the  second  St.*;;! 
the  larynx  presents  extensive  infiltrations  or  ulceration? 
Here  complete  elimination  of  the  morbid  tissue  can  no  lonjre 
be  hoped  for,  but  antiseptic  treatment  comes  to  the  front,  th« 
author  preferring  antiseptic  inhalations  of  carbolic  or  borii 
acid  or  lysol.    If  the  epiglottis  permit  of  an  inspection  of  thi 
interior  of  the  larynx,  the  antiseptic  swab  CAn  be  used  to  .■id 
vantage.    By  these  methods  secondary  infection,  and  t'n 
terrible  dyspnea  and  dysphagia  of  the  last  stage  is  nreventec' 
Finally,  if  the  case  is  first  seen  in  the  last  pitiful  stage,  s' 
that  can  be  done  is  to  treat  it  symptomatically,  to  adminisie 
a  morphin  powder  before  each  meal,  or.  better  still,  to  app'. 
a  10  or  20^  solution  of  cocain  to  the  phsirynx.     In  impend 
ing  suflfocation,  tracheotomy  must  of  course  be  performed. 


Januaev  6,  1901] 


CORRESPONDENCE 


rjiiE  Philadelphia 
L  Medical  Journal 


dorrcsponbcncc. 


PSEUDOMENSTRUATION. 

By  ALFRED  H.  SCOFIELD,  M.D., 

of  Coggan,  Iowa. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

A  CASE  of  pseudomenstruation  has  just  come  to  my  notice. 

On  November  5,  Mrs. was  delivered  of  twins,  male  and 

female.  Labor  was  extremely  easy,  and  the  infants  were 
well  formed  and  strong,  weighing  a  trifle  over  8  pounds  each. 
About  7  days  later  the  mother  informed  me  that  there  was 
present  in  the  female  child  a  vaginal  discharge,  slightly 
bloody,  lasting  but  a  few  hours.  It  had  disappeared  when 
I  saw  the  child,  but  there  is  in  my  mind  no  doubt  as  to  the 
nature  of  the  discharge. 


FOREIGN  BODY  IN  THE  AIR-PASSAGES. 
By  W.  A.  JOLLEY,  M.D., 

of  RawlinB,  Wyoming. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

The  article  on  "  Foreign  Bodies  in  the  Air-passages,"  in 
a  recent  number  of  The  Philadelphia  Medical  Journal, 
recalls  to  mind  a  peculiar  case  whicn  came  to  my  notice. 

A.  L.  M.,  aged  18,  was  chewing  a  stalk  of  timothy  ;  when 
near  the  head  he  inhaled  the  stalk  and  head.  He  fell  over 
and  was  supposed  to  be  dead,  but  revived  in  a  few  minutes. 
He  then  had  a  severe  bronchitis  and  spat  blood.  He  thought 
that  he  had  swallowed  the  head  of  timothy  and  could  not 
account  for  the  lung  trouble  which  was  supposed  to  be  tuber- 
culosis by  several  physicians  who  examined  him.  He  came 
West,  but  did  not  gain  health  until  one  day  after  a  severe 
•pell  of  coughing  he  raised  what  he  thought  was  a  piece  of 
lung,  but  on  examining  it  closely  he  found  the  head  of 
timothy  which  he  had  inhaled  2J  years  previous.  He  began 
to  improve  at  once,  and  now,  18  years  after,  is  a  strong 
healthy  man  with  the  exception  of  a  bronchorrhea. 


PERCENTAGE  OF  FAILURES. 
By  J.  W.  HOLLAND,  M.D., 

of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  :— 

A  PEW  days  ago  I  saw  a  report  of  the  number  of  graduates 
of  Jeflerson  Medical  College  that  failed  in  the  July  examina- 
tion before  the  State  Board.  The  paper  bore  on  it  the  stamp 
of  the  Alumni  Association  of  the  University  of  Pennsylvania 
and  contained  a  very  laudatory  notice  of  the  University, 
making  odious  comparisons  with  other  institutions.  It  stated 
that  there  were  38  graduates  of  Jefferson  and  4  failures 
among  them. 

I  have  obtained  from  Dr.  Hulshizer,  who  is  a  member  of 
the  Medical  Council,  an  official  list  now  in  my  possession  of 
the  average  of  each  candidate  before  the  Medical  Council. 
According  to  that  oflSjial  statement  there  were  35  JefTerson 
men,  graduates  of  the  class  of  1900,  that  applied,  and  three 
of  thera  failed.  The  report  emanating  from  the  University 
Alumni  probably  counted  in  the  same  graduates  from  Jeffer- 
son College  that  have  applied  a  number  of  times,  one  of  whom 


failed  this  year,  as  he  did  last.  I  protested  last  year  againtt  the 
practice  of  publishing  these  repeated  failures  of  one  man  who 
graduated  years  ago  as  if  they  were  failures  of  the  class  of 
this  year,  when  our  standard  has  risen  with  the  standard 
of  the  Medical  Council.  As  I  make  it  out,  we  had  35  appli- 
cations of  class  1900  and  3  failures,  and  the  total  general 
average  of  our  applicants  of  class  1900  wa?  81.94%. 


TUBERCULOSIS  AND  RUSSIAN  JEWS. 
Ry  MAURICE  FISIIBERG,  M.D., 

of  New  York. 

To  the  Editor  of  The  Philadelphia  Medical  Journal: — 

In  a  paper  published  in  your  valuable  Journal  for  De- 
cember 1,  1900,  entitled  "  Where  the  Dinger  Lies  in  Tuber- 
culosis," by  A.  Dutcher,  the  writer  made  a  few  mi^8tatement8 
which  should  not  pass  uncorrected.  At  first  the  author  clas- 
sifies as  follows:  "Our  190  (tuberculosip)  patients  divide 
themselves  naturally  (?)  into  blacks,  whites,  and  Russians." 
Such  a  classification  reminds  me  of  the  explorer  who  de- 
scribed a  foreign  country  as  containing  a  flora,  a  fauna,  and 
elephants.  Then  the  author  proceeds  to  reveal  "  a  most  dis- 
tressing state  of  affairs  among  the  Russians,  who  are  danger- 
ous elements  in  our  midst  as  breeders  and  spreaders  of  this 
disease  "  (tuberculosis). 

The  danger  in  tuberculosis  consequently  lies  in  the  Rus- 
sian elements.  The  author  has  discovered  this  fact  while 
visiting  tuberculous  patients  in  Baltimore,  "giving  them  a 
few  simple  instructions  of  the  nature  of  the  disease,  the 
mode  of  its  contagion,  and  methods  of  its  prevention."  By 
these  means  20  Russians  have  been  visited,  and  the  observa- 
tions among  this  large  number  of  patients  have  convinced 
the  author  that  the  real  danger  for  Baltimore,  and  the  United 
States  for  that  matter,  lies  in  the  Russians. 

Mies  Dutcher  will  surely  be  amazed  to  hear  that  the  Rus- 
sians (Jews)  are  not  only  not  a  dangerous  element  as  breed- 
ers and  spreaders  of  tuberculotis  in  Baltimore,  but  that  the 
fact  is  that  of  all  the  races  and  nationalities  living  in  the 
United  States  the  Russian  Jews  are  the  least  affected  by 
tuberculosis,  or  any  other  fatal  disease  for  that  matter,  except 
diabetes. 

On  consulting  the  Report  on  Vital  Statistics  of  New  York 
and  Brooklyn  of  the  eleventh  cenfus  of  the  United  Siates, 
we  find  that  the  death-rates  from  tuberculosis  in  New  York 
during  a  period  of  six  years,  ending  May  31,  1890,  were  for 
each  100,000  of  population  for  each  of  the  following  nation- 
alities:  Colored,  744.21;  mothers  born  in  Ireland,  645  78 
Bohemia,  49913;  Scotland,  384  12;  Scandinavia,  357.00 
Germany,  328.80;  France,  324.98;  England,  and  Wales 
20514;  Hungary,  155  05 ;   Russia  and  Poland,  93  21. 

On  looking  at  these  statistics,  based  on  a  Rassian  popula- 
tion in  New  Y'ork  in  1890  of  over  80,000,  it  does  not  look  as 
if  the  Russians  were  "dangerous  elements  in  our  midst  as 
breeders  atd  spreaders  of  tuberculosip,"  the  conclusion  to 
which  Miss  Dutcher  arrived  on  visiting  190  consumptives,  20 
of  which  were  Russians. 

One  more  point:  Under  the  name  Russian  I  understand 
that  Miss  Dutcher  means  Russian  Jews.  It  is  a  well  known 
fact  conceded  by  almost  every  authority  on  the  subject  that  the 
proportion  of  Jews  attacked  by  tuberculosis  is  very  small  iu 
comparison  with  other  nationalities.  Dr.  John  S.  B  llings, 
who,  by  virtues  of  his  having  been  an  expert  speiil  agent 
for  the  census  office  of  the  eleventh  census  in  the  Unit'id 


8 


Tlltt   I'HIL.VDBLPHIA 

Mkdicai.  .Toubnal 


] 


CORRESPONDENCE 


fjAHDABT  5,    1901 


States,  has  made  a  special  study  of  vital  statistics  in  the 
United  States,  states  plainly  that  the  "  members  of  the  Jew- 
ish race  possess  a  distinctly  higher  degree  of  immunity 
against  the  bacillus  of  tuberculosis  and  the  micrococcus  of 
pneumonia  as  compared  with  other  races."  (See  Allbutt's 
System  of  Medicine,  Vol.  1,  p.  20.)  And  in  almost  every  text- 
book on  medicine  and  in  every  paper  on  tuberculosis  where 
the  question  of  the  influence  of  race  and  nationality  on  the 
mortality  from  tuberculosis  is  discussed,  it  is  almost  invari- 
ably mentioned  that  the  Jews  are  the  least  affected  by  this 
disease.  A  statement  to  the  contrary,  with  special  emphasis 
that  the  Russian  Jews  are  breeders  and  spreaders  of  tuber- 
culosis, could  only  be  made  by  one  whose  conclusions  are 
drawn  from  a  study  of  the  enormous  number  of  190  cases, 
20  of  which  are  Russian  Jews. 

Miss  Butcher  makes  a  statement  that  house  to-house  visi- 
tation to  teach  tuberculous  patients  to  destroy  the  sputum, 
to  throw  open  the  windows  to  admit  the  sunshine  and  fresh 
air,  is  productive  of  good  results  and  adds  : 

"  I  feel  that  most  of  these  individuals,  unless  they  be  Rue- 
sians,  are  teachable." 

This  again  is  far  from  being  a  fact :  Physicians  who  prac- 
tise among  this  people  will  testify  that  the  poorer  working 
classes  of  the  Russian  Jews  are  as  teachable  as  any  other 
nationality  of  the  same  social  status. 

The  fact  is  that  they  are  not  bad  pupils,  but  that  the  indi- 
viduals who  undertake  to  do  the  teaching  are  not  well  pre- 
pared for  the  task,  because  they  are  not  acquainted  with  the 
habit,  social  conditions,  and  language  of  the  Russian  Jews. 

Any  intelligent  physician  or  trained  nurse  of  Russian 
Jewish  descent  could  do  the  work  easily  and  satisfactorily. 


PAIN  IN  THE  BACK  AND  HEADACHE  AS  SYMP- 
TOMS OF  INTESTINAL  DISEASE. 

By  ALEXANDER  R.  BECKER,  M.D., 
of  Seattle,  WashiDgton. 

To  the  Editar  of  The  Philadelphia  Medical  Journal  : — 

I  HAVE  just  read  your  capital  editorial  on  Pain  in  the  Back 
as  a  Symptom  of  Intestinal  Disease  (November  17lh,  p.  919), 
and  beg  to  offer  a  few  additional  remarks,  based  upon 
my  personal  experiences  and  professional  observations  dur- 
ing the  last  forty  years. 

During  McClellan's  Peninsular  Campaign  of  1862,  great 
numbers  of  our  men  were  prostrated  with  the  enteric  fever, 
then  and  since  calkd  "  Chickahominy  fever,"  and  their  in- 
variable and  bitter  complaint  was  :  "  Oh !  doctor — my  back, 
my  back !  "  We  were  not  strong  on  pathology  in  those  days, 
and  I  do  not  know  that  any  autopsies  were  made  with  a  view 
to  explaining  that  symptom,  but  I  am  perfectly  sure  that  the 
enteritis  extended  to  a  severe  colitis  at  the  time,  and  has  per- 
sisted in  a  chronic — sometimes  only  recurrent — form  in  very 
many  cases,  and  I  am  suffering  from  it  still,  although  only 
one  of  the  original  five  strictures  now  remains,  and  I  have 
had  a  number  of  patients  among  the  veterans  of  that  cam- 
paign who  have  suffered  more  or  less  as  I  have,  and  still 
complaint  is  made  of  the  weary,  wearing  backache,  which 
grows  so  much  more  severe  with  every  exacerbation,  or  even 
with  the  delayed  movement  so  frequent  with  a  sluggish 
peristalsis. 

I  have  also  had  quite  a  number  of  patients  suffering  from 
this  latter  condition — usually,  but  not  always,  middle-aged 
and  stout — who  have   complained   wearily  or  savagely  of 


backache,  and  in  whom  the  location  of  the  delayed  fecal 
matter  could  be  told  by  the  region  of  the  headache,  the  latter 
coming  on  in  the  right  temple  and  side  of  the  head  as  the 
offending  matter  was  slowly  passing  up  the  ascending  colon, 
passing  to  the  forehead,  and  still  more  to  the  back  of  the 
head  and  neck  as  it  traversed  the  transverse  colon,  and  then 
to  the  left  side  of  the  head  as  it  passed  on  downward— to  be 
sometimes  almost  instantly  relieved  on  defecation,  but,  at 
other  times  only  intensified  thereby,  until,  after  an  interval, 
a  small,  dark,  partly  watery  and  putrid  discharge  brought 
peace  and  comfort. 

Backache,  headache,  colds — how  vast  a  proportion  of 
adult  ills  and  pains  are  covered  by  those  terms,  and  yet  how 
little  of  really  scientific  or  painstaking  (no  pun  intended) 
thought  is  given  them  either  by  the  investigator  or  writer,  or 
practitioner,  but  all  three  arise  largely  from  autointoxication 
— appreciating  which,  we  can  already  give  much  reUef,  and 
more  light  will  come. 


A  RARE  ANOMALY :  ATRESIA  ORIS. 

By  CHARLES  D.  LOCKWOOD,  M.D., 
of  Los  Angeles,  C«L 

To  the  Editor  of  The  Philadelphia  Medical  Joitknal  : — 

I  WISH  to  make  a  preliminary  report  of  an  extremely  rare 
anomaly,  which  recently  occurred  in  my  obstetrical  practice  : 

History  of  case :  November  3,  I  was  called  to  see  Mrs.  H. 
at  6  30  A  M.  She  thought  herself  in  labor,  and  said  she  had 
a  free  discharge  of  water  during  the  night  from  the  vagina. 

Menstrual  history  :  Has  had  4  children,  one  bom  pre- 
maturely. Labors  were  normal.  Last  menstrual  period 
began  March  15. 

Examination :  Fundus  uteri  midway  between  umbilicus 
and  ensiform.  Fetus  freely  movable ;  head  not  engaged ; 
active  fetal  movements ;  heart-sounds  and  uterine  bruit 
distinct. 

Per  vaginam  :  Cervix  high  up ;  external  os  patulous,  in- 
ternal 08  closed ;  rectum  full  of  hard  feces.  There  were  no 
periodic  uterine  contractions.  I  concluded  that  the  bag  of 
waters  had  ruptured  prematurely,  but  the  woman  was  not 
in  labor.    This  proved  to  be  the  fact. 

November  12,  S  a  m.:  Called  again  to  see  the  woman.  She 
had  been  in  severe  pain  during  the  night.  Since  3  am.  pains 
had  been  crampnlike  and  abdominal,  accompanied  by  free 
discharge  of  blood  and  water  from  the  vagina.  Abdominal 
palpation  showed  regular  and  painful  uterine  contractions. 
Fetal  heart-tones  distinct,  150  per  minute. 

Vaginal  examination :  Cervix  well  dilated,  fetal  head  at 
vaginal  outlet.  Head  presented,  occiput  anterior,  closely 
enveloped  in  amniotic  sac.  Amnion  stripped  from  fetal 
head  after  delivery,  when  child  immediately  became  in- 
tensely cyanotic.  Unable  to  find  an  explanation  for  the 
cyanosis,  delivery  of  the  body  was  hastened  by  traction. 
After  a  few  heart-beats  child  died  and  cord  was  cut.  It 
proved  to  be  a  monster,  i.  <.,  cyclopia  or  synophthalmia. 

The  only  facial  organ  approximating  perfect  formation  is 
a  single  eye  situated  in  the  median  line  at  about  the  normal 
location  for  the  root  of  the  nose.  The  supraorbital  ridge  and 
upper  lid  are  imperfectly  developed.  The  lower  lid  is  repre- 
sented by  a  fold  of  skin  lined  with  mucous  membrane. 
There  is  a  total  absence  of  the  nose  and  ears.  At  the  lower 
angle  of  the  face  is  a  tag  of  skin  resembling  the  upper  lip, 
but  there  is  complete  atresui  oris. 

The  branchial  arches,  which  go  to  form  the  lower  maxilla 
and  upper  respiratory  organs,  are  represented  by  two  or 
three  pockets  in  the  akin  of  the  neck  to  the  right  of  the 
median  line. 


jANCiBT  5,    1901] 


CORRESPONDENCE 


rrHE   PHrLADELPBIA 
M.BDICAL  JOCRKAIi 


The  child  otherwise  is  well  nouriahed  and  perfectly  devel- 
oped.   Weight,  6  pounds. 

Careful  inquiry  failed  to  elicit  any  important  hereditary 
influences  bearing  upon  the  etiology  of  the  case. 

The  father  is  mentally  weak  as  the  result  of  sunstroke 
sereral  years  ago. 

The  mother  rode  a  bicycle  continuously  the  first  three 
months  of  pregnancy,  and  in  the  early  weeks  of  gestation 
fell  from  her  wheel  with  considerable  violence. 

The  amniotic  sac  formed  a  tight  cap  over  the  fetal  head, 
and  this  may  have  had  some  bearing  upon  the  maldevelop- 
ment  as  claimed  by  Geoffrey  St.  Hilaire,  who  has  made  a 
careful  study  of  fetal  monstrosities. 

The  specimen  is  in  the  museum  of  the  Loe  Angeles  Med- 
ical School.  After  suitable  preparation,  careful  drawings 
will  be  made  and  the  development  of  the  brain  and  respira- 
tory tract  studied  in  sections. 

I  am  unable  to  find  any  similar  case  figured.  Ziegler 
pronounces  the  condition  of  atresia  oris  extremely  rare. 


APPARATUS    FOR    ADMINISTRATION    OF   CHLORO- 
FORM. 

By  WILLIA:^!  B.  HIDDEN.  M.D., 
of  Boston,  Mass. 

To  the  Bailor  of  The  Philadelphia  Medical  Jodsnal  :— 

It  was  certainly  a  commendable  idea  to  devote  an  issue  of 
j'our  always  interesting  Journal  to  anesthesia.  Xo  one  can 
read  that  number  without  concluding  that  the  disadvantages 
attending  present  methods  are  numerous,  and,  however  the 
■  writers  may  be  groping  after  something  better,  none  seem 
satisfied  with  results  obtained.  Anesthesia  has  never  re- 
ceived the  professional  attention  that  it  deserved.  Custom 
has  barred  the  road  to  progress  by  taking  students,  without 
any  previous  thought  or  training,  to  administer  the  anesthetic, 
and  their  success  baa  been  solely  judged  by  the  rapidity 
with  which  they  prepared  the  patient  for  the  operator.  Hence 
the  anesthetizer  and  surgeon  have  bestowed  so  little  thought 
upon  the  subject,  that  the  idea  of  the  expansive  effect  of  the 
patients'  breath  coming  directly  upon  the  anesthetic,  has 
never  entered  their  minds.  Yet  it  is  easily  proved  that  all 
the  discomfort,  suffering  and  deaths  incident  thereto  are 
clearly  traceable,  by  natural  law,  to  this  one  factor. 

It  is  a  provable  fact  that  the  expansive,  evaporative  pres- 
sure of  ether  and  chloroform  at  a  normal  temperature  just 
equals  the  atmospheric  pressure,  and  every  degree  of  heat 
added,  correspondingly  increases  it,  so  that  the  breath  of 
the  patient  produces  an  evaporative  pressure  of  more  than 
two  atmospheres,  and  generates  a  coldness  that  will  encase  a 
glass  container  in  ice  in  five  minutes.  It  is  this  coldness 
taken  into  the  lungs  that  has  caused  pneumonia  to  follow  the 
use  of  ether.  It  is  this  rapid  expansion  from  the  contact  of 
the  breath  that  has  asphyxiated  the  patient,  given  the  anes- 
thetic in  unequal  quantities,  and  but  for  the  frequent  removal 
of  the  cone  to  replenish  the  anesthetic,  would  have  been  very 
often  attended  with  fatal  results.  These  are  facts,  not 
theories. 

It  is  a  self-evident  truth  that  true  inhalation  demands  and 
should  receive  a  normal  amount  of  fresh  air  with  each  in- 
spiration ;  this,  by  the  usual  methods  of  giving  anesthetics, 
is  made  impossible  by  the  laws  of  physics.  As  we  cannot 
change  the  laws  of  Nature,  we  must  change  our  methods  to 
harmonize  with  them.  So  an  instrument,  simple  in  con- 
struction, has  been  devised,  that  automatically  gives  a  nor- 


mal amount  of  fresh  air,  impregnated  with  the  anesthetic  by 
a  revolving  current  over  it,  insuring  an  equal  quantity  of  the 
chloroform  with  each  inspiration,  and  by  the  automatic  ac- 
tion of  valves,  preventing  the  breath  of  the  patient  from 
contact  with  the  anesthetic,  and  making  every  breath  a  fresh 
one,  laden  with  the  vaporized  anesthetic.  Experience  with 
this  instrument  shows  that  what  we  called  the  sedative  effects 
of  chloroform  are  due  to  the  want  of  oxygen  and  not  to  its 
supposed  action  upon  the  heart  or  nerve-centers;  that  the 
difference  between  vinous  intoxication  and  that  of  anesthetics 
given  by  this  method,  is  simply  a  matter  of  degree  and  no 
more  dangerous.  The  person  who  readily  yields  to  vinous 
intoxication,  as  readily  yields  to  anesthetics  and  the  reverse, 
though  rarely  can  individual  susceptibility  be  predetermined, 
nor  can  any  instrument  make  the  time  uniform. 

Assuming  the  correctness  of  the  principle  involved  in  this 
fi-esh-air  method,  which  no  one  has  ever  disputed,  the  next 
important  query  must  be,  what  anesthetic  will  bear  the  nat- 
ural dilution  of  air  and  still  secure  complete  anesthesia  as 
uniformly  and  quickly  as  consistent  with  absolute  safety  ? 

Chloroform  will  do  this,  ether  will  not. 

It  has  been  truly  said  that  statistics  of  the  deaths  from  the 
use  of  chloroform  and  ether  are  not  reliable.  No  better 
illustration  of  the  fact  need  be  given  than  that  the  deaths 
from  pneumonia  following  the  use  of  ether  are  never  credited 
to  ether,  as  they  certainly  should  be  ;  if  they  were  the  writer 
has  good  reason  for  asserting  they  would  exceed  the  deaths 
from  chloroform. 

Nature's  best  gifcs  to  man  have  been  sources  of  danger  until 
he  learned  how  to  use  them  in  accord  with  her  laws,  and  it  is 
only  in  conformity  with  her  as  coworker  that  we  reach  our 
highest  attainments  ;  so  in  the  use  of  chloroform,  experience 
founded  upon  an  utter  disregard  of  the  law  of  expansion  by 
heat,  is  not  a  reliable  or  even  tenable  basis  of  judgment  as  to 
results,  when  Nature  becomes  a  harmonious  coworker  with 
us,  and  its  benign  effects  are  engrafted  upon  natural  sleep. 


Three  Microorganisms  Other  than  Klebs-LSfQer 
which  Produce  Membranous  Ang-ina.  —  B^ssell 
[Bvffah  Medical  Journal,  December,  1900)  says  the  Bureau 
of  Bacteriology  in  the  city  of  Buffalo  has  observed  that 
Streptococcus  pyogenes,  and  the  micrococcus  of  sputum 
septicemia,  which  belong  to  the  bacteria,  and  Oidium  albi- 
cans, which  belongs  to  the  group  of  fungi,  are  each  capa- 
ble of  producing  a  pseudomembranous  inflammation  which 
macroscopically  cannot  be  differentiated  from  that  produced 
by  the  Klebs-Loffier  bacillus.  So  far  as  observed  in  that  city 
the  Oidium  albicans  has  never  caused  a  fatal  angina ;  but  at 
least  one  death  has  been  caused  by  each  of  the  other 
germs  named,  in  both  of  which  cases  the  antitoxin  of  diph- 
theria was  used  without  appreciable  effect.  Several  deaths 
from  the  Streptococcus  pyogenes  have  been  reported  in  New 
York  City,  in  which  nothing  but  a  bacteriologic  examination 
could  distinguish  the  infection  from  a  true  diphtheria.  The 
author  draws  the  following  conclusions :  1.  Streptococcus 
pyogenes  and  the  micrococcus  of  sputum  septicemia  can 
produce  membranous  anginas,  accompanied  by  physical  dis- 
turbances sufficient  to  result  in  death.  2.  Oidium  albicans 
produces  pseudomembranous  exudates  easily  mistaken  for 
the  Klebs-LorHar  inflammation.  3.  The  only  positive  means 
of  determining  a  Klebs-Loffler  infection  is  by  microscopic 
methods.  4.  From  the  sanitary  standpoint,  as  regards 
quarantine,  anginas  due  to  Streptococcus  pyogenes,  micro- 
coccus of  sputum  septicemia  and  Oidium  albicans  require 
iltle  consideration,     [a.b.c] 


10 


The  Philadklpuia"] 
Medical  Jocrnal  J 


AMERICAN  NEWS  AND  NOTES 


[Jakoaet  S,  1901 


2lmerican  Hems  anb  Xloks. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

Dr.  George  Pales  Baker  of  Philadelphia  was  married, 
on  December  31,  to  Miss  Wallier  of  Pittsburg. 

Dr.  A.  W.  Butt,  a  well-known  physician  of  Paoli,  Pa., 

died  on  December  3l8t  after  two  weeks'  illness. 

Lunacy  Laws. — A  conference  of  delegates  representing 
the  different  county  medical  societies  of  New  Jersey  wa« 
recently  held  in  New  Brunswick  for  the  purpose  of  recom- 
mending amendments  to  the  present  lunacy  laws  of  the  State. 

Diphtberia  Epidemic  Feared. — The  School  Board  of 
Berwyn,  Pa.,  has  made  application  to  the  courts  for  a  sani- 
tary inspection,  owing  to  the  recent  deaths  from  diphtheria 
in  that  township.  The  disease  is  said  to  have  made  its 
appearance  at  Ardmore  and  Malvern.  An  epidemic  of 
diphtheria  is  feared  at  Berwyn.  In  the  home  of  William 
Baylis,  Jr.,  every  member  of  the  family,  except  the  father, 
was  taken  ill.  Florence,  aged  7  years,  died.  The  death  of 
another  child  at  Berwyn  caused  President  James  S.  Lock  • 
wood,  of  the  School  Board,  to  call  the  members  together  to 
discuss  enforcement  of  quarantine  regulations.  It  was  de- 
cided to  ask  the  State  Board  of  Health  for  instructions,  and 
the  result  was  the  advice  to  petition  for  a  sanitary  agent. 
The  State  Board  declined  actively  to  interfere  with  the 
authorities  of  the  township. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 

December  29,  1900 : 

Total  mortality 

Inflammation  of  appendix  2,  bladder  1,  brain 

9,  bronchi  8,  kidneys  16.  heart  1,  lungs  56, 

pericardium    1,    peritoneum    5,    pleura   2, 

stomach  and  bowels  13,  spine  1,  veins  1  .  . 
Lungs — hemorrhage  of  2,  tuberculosis  of  65  . 
Heart — disease  ot  43,  fatty  degeneration  of  3, 

neuralgia  of  1 

Debility  1,  marasmus  11,  inanition  15  .... 

Apoplexy  27,  paralysis  U  

Carcinoma  of  breast  2,  bladder  1,  face  1,  liver 

2,  rectum  2,  stomach  4,  uterus  3 

Diphtheria 100 

Convulsions 

Casualties 

Cirrhosis  of  liver 

Croup,  membranous 

Typhoid  fever 

Septicemia 

Old  age  

Suicide — shooting' 

Scarlet  fever 

Cerebrospinal  fever 

Abscess  of  head  1,  psoas  abscess  1,  alcoholism 

3,  asthma  2,  Brighfs  disease  7,  burns  and 
scalds  4,  cyanosis  3,  diabetes  1,  diarrhea  2, 
disease  of  liver  l.dropsy  of  brain  2,  dropsy  of 
heart  2,  dysentery  2,  epilepsy,  2,  erysipelas 
1,  hemorrhage  of  brain  1,  hemorrhage  of 
stomach  1,  gallstones  1,  hernia  1,  homicide 
1,  indigestion  1,  measles  1,  obstruction  of 
bowels  1,  poisoning  by  carbolic  acid  1,  rheu- 
matism 3,  sarcoma  of  lungs  1,  shock — sur- 
gical 1,  softening  of  brain  4.  strangulation 

1,  tumor  of  brain  2,  ulceration  of  stomach 

2,  uremia  14.  knife  1,  influenza  1,  consump- 
tion of  bowels  1 77 

New  Buildings  for  Philadelphia  Hospital. — City 
Councils  have  appropriated  $80  000  for  the  erection  of  new 
buildings  for  tiie  Philadelphia  Hospital,  one  of  which  will  be 
a  children's  hospital,  and  the  plans  for  the  different  struc- 
tures are  now  being  drafted,  so  that  proposals  can  be  adver- 
tised for  and  work  on  the  various  operations  commenced  as 
soon  as  possible.  Very  little  money  has  been  e.xpended  by 
the  city  in  the  way  of  improving  or  adding  to  this  insti- 
tution during  the  past  25  years,  and  the  facilities  for  accom- 
modating the  unfortunate  men,  women,  and  children  in- 
mates have  been  very  meager.  Adults  and  children  have 
been  forced,  owing  to  insufficient  accommodations,  to  occupy 
the  same  wards.  It  is  proposed  to  expend  the  bulk  of  the 
funds  that  have  been  appropriated  in  the  erection  of  a  mod- 


467 
Casks.     Dkaths. 


116 
67 

47 
27 
38 

15 

14 

IS 

12 

4 

7 

9 

1 

17 

1 

1 

I 


88 


em  scientific  hospital  for  the  cure  of  children's  diseases,  thus 
removing  the  little  ones  from  the  evil  communications  they 
are  now  and  have  been  for  some  time  pact  subjected  to. 

NEW  YORK. 

Dr.  Martin  J.  Downey,  of  Buffalo,  has  been  appointed 

assistant  surgeon  of  the  Erie  railway. 

Dr.  Julius  Ullman,  of  Buffalo,  has  been  appointed  local 
correspondent  of  the  Journal  of  the  American  Medical  A$io- 
ciation. 

Smallpox.— Four  new  cases  of  smallpox  were  reported  to 
the  B  lard  of  Health  of  New  York  City,  on  December  31. 
They  are  all  residents  of  Brooklyn. 

Dr.  Chauncey  Pelton  Smith,  of  Buffalo,  was  elected 
vice-president  of  the  Western  New  York  Alumni  Association 
of  the  University  of  Pennsylvania,  during  its  foundation 
meeting,  held  at  Buffalo,  December  17,  1900. 

The  Brooklyn  Society  for  Neurology. — At  the  an- 
nual meeting  of  the  Brooklyn  S  iciety  for  Neurology,  held 
December  27,  1900,  Dr.  W.  H.  Haynes  was  elected  presi- 
dent, and  Dr.  B.  Onif,  secretary,  for  the  ensuing  year. 

Buffalo  General  Hospital.— The  staff,  their  aasist- 
ants,  and  the  clinical  instructors  have  organized  a  clinical 
society  of  the  Buffalo  General  Hospital,  for  the  purpose  of  a 
closer  efprU  de  corps.  Dr.  Irving  M.  Snow  was  elected 
chairman  ;  Dr.  E.  L.  Ruffner,  secretary  pro  tem. 

Study  of  the  Buhonic  Plague.— The  Board  of  Health 
of  the  City  of  New  York  has  decided  to  build  a  laboratory  to 
be  devoted  to  the  study  of  the  bubonic  plague.  The  con- 
tract haa  been  let  for  a  building  to  cost  about  $20,000,  to  be 
located  on  the  grounds  of  the  Willard  Parker  Hoepitil. 

The  German  Hospital  of  Buffalo  (N  Y)  will  be 
opened  to  receive  patients  about  January  10.  It  is  a  three- 
story  building  with  basement,  of  substantial,  fire-proof  con- 
struction, equipped  with  the  most  modem  facilities.  It  wa» 
formally  opened  with  a  bazaar  which  lasted  two  weeks,  with 
great  success. 

New  York  University.— The  death  of  Dr.  Henry  D. 
NoyfB,  professor  of  ophthalmology  in  the  Medical  School  of 
the  New  York  University,  has  left  a  vacancy  which  has  been 
filled  by  tbe  appointment  of  Dr.  John  E.  Weekee,  University 
of  Michigan,  '81.  Dr.  Weekes  has  been  a  lecturer  in  the 
medical  school  for  the  last  two  years,  in  tne  same  depart- 
ment of  which  he  has  been  made  clinical  professor. 

Dr.  R.  V.  K.  Montfort,  for  40  years  superintendent  of 
public  schools  of  Newbur^h,  N.  Y.,  died  on  December  29, 
aged  76  years.  In  September,  1862,  he  entered  the  Federal 
Army  as  assistant-surgeon  in  the  New  York  Volunteer  In- 
fantry and  was  on  every  battlefield  of  the  Army  of  the 
Potomac  from  Chancellorsville  to  the  end  of  the  war.  He 
was  promoted  surgeon  in  March,  1865,  and  was  mustered  out 
in  June  of  that  year. 

A  New  Accident  Hospital  for  Buffalo,  N.  Y.— 

Pians  have  been  filed  and  ground  broken  for  a  four-story 
building  to  be  known  aa  the  Emergency  Hospital.  It  is  to  be 
60  by  142  feet,  of  steel  construction,  and  to  cost  in  the  neigh- 
borhood of  $(50,000.  It  will  contain  a  dispensary,  a  diet 
kitchen,  an  operating  amphitheater,  and  a  roof  to  be  used 
as  a  solanarium.  When  comp'eted  it  will  be  one  of  the 
most  perfectly  equipped  emergency  hospitals  in  this  country. 

A  bitter  controversy  is  waging  between  C-ommissioner 
John  W.  Keller,  of  the  New  York  Board  of  Charities,  and  a 
number  of  physicians  of  that  city.  Mr  Keller  has  accused 
the  physicians  on  the  medical  board  of  improper  administra- 
tion, and  one  of  them  of  taking  big  fees,  and  the  physicians, 
in  turn,  say  that  Mr  Keller  has  managed  affairs  at  Bellevue 
Hospital  on  a  politic-al  basis.  Tne  trouble  for  the  medical 
board  began  when,  in  his  investigation  of  the  charge  that  a 
patient  had  been  murdered  in  the  insane  pavilion,  C-ommi»- 
sioner  Keller  discovered  what  he  thought  to  t>e  a  need  of  re- 
form in  the  general  administration  of  the  hospital.  A  letter 
to  the  medical  board  last  week  was  so  plain  as  to  leave  the 
board  no  alternative  but  a  defense. 


January  5,  I'JOIJ 


AMERICAN  NEWS  AND  NOTES 


CThk  Philadelphia 
Medical  Journal 


11 


The  Case  of  Dr.  Kindred. — Justice  Leventritt,  in  the 
Supreme  Court  of  New  York,  granted  an  order  to  show 
cause,  under  which  Georg;e  C.  Soann,  tlie  lawyer  who  claims 
$25,000  damages  from  Dr.  J.  J.  Kindred  for  alleged  negli- 
gent treatment  in  a  sanitarium,  will  have  to  show  why  the 
order  for  an  inquest  by  aSUeriff's  jury  to  assess  damages 
should  not  be  set  aside.  Dr.  Kindred  alleges  that  he  was 
never  served  with  the  summons  and  complaint,  and  knows 
nothing  about  the  case. 

State  Comiuission  in  Lunacy. — Governor  Roo«evelt 
has  removed  from  office  Dr.  Peter  M.  Wise,  of  New  York, 
president  of  the  S;ate  Commission  in  Lunacy,  after  giving 
him  an  opportunity  to  make  an  explanation  of  certain  state- 
ments made  by  him  to  the  G  )vernor  on  Dacember  10  and 
11,  in  relation  to  the  alleged  sale  through  him  of  stock  in  a 
copper  mining  company  of  New  Mexico,  in  which  Dr.  Wise 
was  pecuniarily  interested,  to  employes  of  State  hospitals  for 
the  insane  under  the  control  of  the  State  C  )mmissioner  in 
Lunacy  ;  and,  secondly,  in  regard  to  his  part  in  the  construc- 
tion of  an  artificial  ice  plant  on  the  grounds  of  the  Long 
Island  State  Hospital  at  Flatbush.  This  explanation  the 
Governor  considers  unsatisfactory.  Dr.  Wise's  term  would 
have  expired  on  December  31.  The  Governor  states  that  he 
will  not  fill  the  vacancy,  leaving  that  duty  to  Mr.  Odell  when 
he  assumes  office  in  January. 

CHICAGO  AND  WESTERN  STATES. 

Professional  Devotion. — Dr.  B.  C.  Brett,  of  Green 
Bay,  Wis.,  who  is  attending  a  case  of  smallpox  in  that  city, 
has  been  shunned  by  his  townsmen  as  though  he  were  plague 
stricken.  Dr.  Brett  has  sacrificed  all  of  his  private  practice 
to  care  for  his  single  patient. 

St.  Lulce's  Hospital  of  St.  Louis  to  be  Rebuilt.— 

The  directors  of  Sd.  Luke's  Hospital  of  S'.  Louis  have  raised 
within  the  past  few  months  more  than  $100,000  by  voluntary 
subscription,  for  the  purpose  of  removing  the  hospital  from 
its  present  location  and  erecting  a  modern  building. 

State  Sanitarium  for  Consumptives. —  The  State 
Board  of  Health  of  Illinois,  in  its  forthcoming  biennial  re- 
port, will  recommend  the  building  of  a  Slate  sanitarium  for 
coneumptives.  It  will  also  join  with  the  Slate  Board  of 
Charities  in  favoring  a  provision  for  the  special  care  of  epi- 
leptics. 

Plague  in  San  Francisco. — Surgeon  Kinyoun  reporta 
totb^  Marine-Hospital  Service  6  more  fatal  cases  of  plague. 
Dr.  Kmyoun  believes  that  the  infected  area  is  increasing  in 
size,  there  being  now  only  three  blocks  in  the  Chinese  quar- 
ter proper,  in  which  there  has  been  no  case  of  plague  since 
March  last. 

Physician  Killed. — Dr.  Hawkins,  formerly  of  Knox, 
Ml).,  18  dead  at  Ralston,  O.  T.,  the  result  of  a  cowboy  of 
Moody's  ranch  knocking  him  down  and  dancing  on  his 
stomach.  The  doctor  was  over  60  years  of  age,  and  recently 
saved  the  life  of  his  assistant,  over  the  settlement  for  which 
services  the  fatal  dispute  arose. 

Smallpox  in  Lumber  Camps. — From  the  lumber 
camps  of  Michigan  come  reports  that  smal'pox  is  epidemic 
there.  S  milar  reports  come  from  Poplar  Bluff,  Mo.,  and  at 
Kansas  City  extraordinary  sessions  of  the  board  of  health 
were  held  to  cope  with  the  disease.  A  number  of  new  cases 
have  developed  at  Schenectady,  N.  Y. 

San  Francisco's  Quarantine  Station. — Vexatious 
and  expensive  detentions  at  the  San  Francisco  quarantine 
station  of  coaling  vessels  from  Nanaimo  will  hereafter  be 
avoided  by  the  action  lately  of  Surgeon- General  Wyman, 
who  has  arranged  for  giving  vessels  a  clean  bill  of  health  at 
the  port  of  sailing.  The  Calif  )rnia  Congressional  delegation 
brought  the  matter  to  the  attention  of  the  Surgeon-General 
with  the  above  result. 

Physicians'  License  Law. — A.  case  to  test  the  Wiscon- 
sin pnvsicians'  license  law  of  1897  has  been  begun  by  Dr.  W. 
M.  Caswell,  of  Hillsboro,  in  that  State,  who  has  obtained  a 
writ  of  mandamus  to  compel  the  State  Bjard  of  medical 


examiners  to  issue  him  a  license  aa  a  doctor.  The  Board,  he 
alleges,  refused  him  a  license  last  August.  Dr.  Caswell 
alleges  that  he  has  practised  medicine  in  Wisconsin  for  12 
years.  The  case  will  be  heard  January  14,  before  Judge 
Siebecker,  at  Madison. 

Diploma  Mill  Exposed.— James  and  Thomas  Arm- 
strong, principal  officers  of  the  Metropolitan  or  Independent 
Medical  CoUeee  of  Chicago,  were  convicted  recently  in  the 
United  States  District  Court  on  three  charges  of  having  used 
the  mails  to  defraud,  in  connection  with  one  of  the  most 
notorious  "diploma  mills"  in  the  country.  The  jury  de- 
cided they  were  guilty  under  a  statute  which  permits  an 
extreme  penalty  of  18  months  in  jail  and  a  fine  of  $1,500 
each.    Sentence  was  deferred. 

Contagious  Disease  Hospital.  —  A  despatch  from 
Lansing,  Mich.,  under  date  of  December  29,  says :  Attor- 
ney-General Oren  has  in  an  opinion  declared  that  townships 
must  erect  contagious  disease  hospitals.  Attorney  Oren  says 
that  it  is  the  intention  of  the  Legislature  that  each  township 
should  establish  its  own  hospital  for  communicable  diseases. 
Secretary  Baker,  of  the  Slate  Board  of  Health,  will  soon 
advise  the  township  offi  lers  of  this  provision  in  the  law, 
and  recommend  its  immediate  enforcement. 

Consumptives'  Home.— The  next  Legislature  in  Iowa 
will  most  probably  be  asked  to  establish  an  institution  in 
that  Slate  for  the  isolation  and  treatment  of  those  afflicted 
with  tuberculosis.  The  Iowa  State  Board  of  Health  has  just 
issued  10,000  circulars  to  be  distributed  all  over  the  State  in 
an  endeavor  to  arouse  public  sentiment  to  the  nece-sity  of 
this  enterprise.  It  is  stated  that  9  persons  die  daily  in  Iowa 
from  consumption.  Dr.  Coniff,  a  member  of  the  S.ate  board, 
says  that  the  board  is  determined  to  educate  the  people  up 
to  the  danger  of  permitting  consumptives  to  scatter  the 
deadly  germ  broadcast. 

Kansas  Enacts  New  Medical  Laws.— The  Kansas 
State  Board  of  Health  has  prepared  a  number  of  bills  for 
introduction  during  the  winter  session  of  the  legislature. 
One  bill  provides  for  the  establishment  of  a  Slate  B  )ard  of 
Medical  Registration  and  Examination,  consisting  of  seven 
members.  Their  duties  will  be  to  issue  certificates  or 
licenses  to  persons  who  desire  to  practise  medicine.  They 
shall  be  required  to  paas  an  examination  touching  upon 
their  qualifications.  The  law,  however,  will  not  apply  to 
persons  who  have  diplomas  from  reputable  medical  colleges 
or  who  have  practised  medicine  in  the  State  for  20  years 
or  more.  To  these,  certificates  will  be  issued  without  ex- 
amination. The  law  does  not  recognize  persons  who  prac- 
tise christian  science,  faith  cures,  spiritualism,  etc.,  but 
licenses  osteopaths  who  have  taken  a  4  years'  course  of  in- 
struction, and  who  do  not  use  drugs  or  perform  operations 
in  their  practice.  Provision  is  made  for  the  law  to  take  effect 
in  Januarv,  1902,  and  any  person  who  has  not  complied 
with  its  provisions  by  that  time  and  attempts  to  practise 
medicine  without  a  license  will  be  liable  to  a  fine  of  from  $50 
to  $200. 

A  Good  Year  in  Drugs. — An  increase  in  the  drug 
business  for  the  year  just  closed  of  10%  was  recorded.  The 
trade  had  its  sensational  features,  and  in  some  respects  was 
materially  different  from  previous  years.  The  war  in  China 
produced  material  advances  in  all  Chinese  drugs,  but  part  of 
(hem  were  lost.  In  quinin  there  was  an  advance  from  32  to 
39  cents,  but  large  importations  of  bark  produced  a  reaction 
to  the  low  point,  and  the  close  was  heavy.  Castor  oil  jumped 
up  12  cents  and  camphor  16  cents.  The  latter  was  due  to  a 
large  consumption  and  a  reduction  in  supplies.  The  increased 
demand  for  bismuth  for  army  use  caused  an  advance  of 
nearly  50  cents.  The  most  sensational  change  was  in  cocain, 
due  to  various  influences.  Eirlyin  the  vear  it  sold  from 
$6.20  down  to  $3  50,  but  advanced  to  $6  75.  The  enlarged 
consumption  of  carbolic  acid  in  the  Afriiian  war  reduced 
European  supplies,  and  prices  advanced  50 fc.  The  year  was 
not  without  material  declines,  among  the  most  noticeable 
being  a  drop  of  50  cents  in  salol.  The  drug  sundries  had  a 
large  sale,  but  they  are  handled  more  extensively  now  by 
dry  goods  houses  and  department  stores  than  by  wholesalers 
of  drugs.    The  aggregate  business  of  the  year  was  $10,00t),000 


12 


The  Philadelphia"! 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[jAjrcABi  5,  1901 


SOUTHERN  STATES. 

Attorney  Apologizes. — A  full  written  retraction,  with 
ample  apologfif  s,  was  made  by  Attorney  A.  J.  Speckert,  who 
recently  filed  a  $45,000  damage  suit  for  Ida  Mellinper  against 
Dr.  William  Cheatham,  a  prominent  specialist  of  Louisville, 
affirming  that  Dr.  Cheatham  had  imposed  upon  the  girl 
while  treating  her  professionally. 

Dr.  Hartigan  Sues  University. — Dr.  Hartigan,  head 
of  the  medical  department  of  the  West  Virginia  University, 
has  entered  at  Morgantown,  West  Virginia,  suit  for  $25,000 
damages  against  President  J.  H.  Raymond,  of  the  university. 
At  the  meeting  of  the  Board  of  Regents  Dr.  Hartigan  was 
deposed  from  his  position  on  the  recommendation  of  Presi- 
dent Raymond. 

Influenza  Epidemic. — An  epidemic  of  la  grippe  has 
possesfcion  of  Fort  Worth,  Texas,  and  the  cases  are  numbered 
by  the  thousands.  The  symptoms  this  year  are  high  fever, 
acute  pain,  particularly  affecting  the  upper  and  back  part  of 
the  head.  The  weather  had  been  exceedingly  mild  and  the 
recoveries,  as  a  rule,  are  rapid.  A  few  cases  of  meningitis 
have  followed  the  attack  of  la  grippe,  one  fatal. 

The  Virginia  State  Veterinary  Association  held 
its  annual  meeting  in  Richmond,  Va.,  December  28.  Dr.  E 
R.  Niles,  of  Blacksburg,  was  elected  president,  Dr.  H.  S. 
Drake,  of  Leesburg,  first  vice-president,  and  Dr.  H.  Bannis- 
ter, of  Roanoke,  secretary  and  treasurer.  While  the  large 
majority  of  the  members  are  of  course  veterinarians,  still 
physicians  are  eligible  to  membership  and  some  do  contrib- 
ute papers  on  subjects  of  common  interest  to  both  profes- 
sions.   The  next  meeting  will  be  held  in  Norfolk,  Va. 

MISCELLANY. 

Obituary.— Db.  George  G.  Tarbell,  of  Boston,  on  De- 
cember 29  — Dk.  Eeastus  E.  Marcy,  at  New  York  City,  on 
December  29. — Dr.  Louis  Schneider,  aged  56,  of  Williams- 
poit,  Pa.,  on  December  29. 

New  X-ray  Apparatus. — Cowe  desciibes  an  apparatus 
by  means  of  which  the  interior  of  the  thorax  can  be  photo- 
graphed during  respiration.  Pictures  are  said  to  have  been 
obtained,  illustrating  the  intrathoracic  contents  at  various 
stages  of  respiration. 

Pneumonia  in  Alaska.— A  Dawson,  Alaska,  dispatch, 
of  December  18,  states  that  there  had  been  5  deaths  in  as 
many  days  from  pneumonia.  The  disease  was  spreading 
rapid)}'.  Typhoid  fever  also  had  been  epidemic,  but  subsided 
when  cold  weather  set  in. 

Unusual  Hyperpyrexia.— Dr.  F.  B.  Jewett,  of  Howard, 
R.  I.,  in  Providence  Mtdical  Journal,  reports  a  case  of  chronic 
mania,  in  which  the  temperature  would  go  below  96°  for 
several  times  a  number  of  days  in  succession,  and  several 
times  reached  94  6°  to  94  8°. 

Resignation  of  Dr.  flIcGee,— The  following  corres- 
pondence relative  to  the  resignation  of  Dr.  Anita  Newcomb 
McGee  is  of  interest : 

To  the  Editor  of  The  Philadklfhia  Medical  Joprsal  — The 
Army  organization  bill  contains  a  section  putting  the  Army  Nurse 
Corps  into  the  regular  military  establishment,  which  section  was 
written  by  me  at  the  request  of  the  Department.  As  it  provides  for 
the  creation  of  the  office  of  superintendent  of  the  Army  Xurse  Corps, 
the  almost  certainty  of  its  passage  has  seemed  to  offer  a  good  oppor- 
tunity for  my  leaving.  Under  present  conditions  there  is  no  such 
position  as  superintendent  of  the  nurse  corps  and  therefore  no 
vacancy  to  fill  until  the  bill  goes  through.  In  order,  however,  to  be 
able  to  leave  without  waiting  for  that,  a  temporary  arrangement  has 
been  made  by  which  one  of  the  chief  nurses  (Mrs.  D.  H.  Kinney)  is 
to  carry  on  the  work,  and  if  she  chooses  to  accept  it  she  will  of  course 
be  offered  the  appointment  of  superintendent. 
Very  sincerely, 

Anita  Newcomb  Mc-Oee. 

COPY. 

Wae  Dkpabt.mkst,  Sdegkon-Qekeral's  Office, 

Washington,  November  20,  1900. 
To  t!u  Surgeon-General  U.  S  Armi/,   Washington,  D.  C. 

SiE : — The  experimental  and  oVganizing  stages  of  the  Army  Nurse 
C!orp3  being  now  passed,  I  have  the  honor  to  tender  my  resignation 
as  in  charge  of  that  body,  and  to  ask  that  ray  work  be  carried  on  by 
another. 


I  abo  tender  my  resignation  as  Acting  Assistant  Surgeon,  V.  S. 
Army. 

I  cannot  take  leave  of  your  office,  with  which  I  have  been  con- 
nected for  over  2i  years,  without  expressing  in  some  small  degree 
my  pleasure  in  having  been  so  closely  associated  with  your  adminis- 
tration, and  having  been  able  to  render  some  little  assistance  in 
your  very  arduous  and  responsible  duties.  I  wish  also  to  thank 
you,  and  through  you  the  officers  and  clerks  in  this  office,  for  many 
courtesies  received,  the  memory  of  which  will  remain  always  with 
me.  Very  respectfully, 

(Signed)  Asita  Newcomb  McGee, 

Acting  Aaistant  Surgeon,  U.  S.  Army, 
In  charge  Army  Xurae  Oorpt. 

COPY. 

War  Depaktment,  Subgeob-Gekekal's  Office, 

Washlsgtok.  November  21,  1900. 
Dr.  Anita  Newcomb  McGee,  Acting  Asti^t<mt  Surgeon.  V.  S.  Army,  in 
charge  Army   Nurte   Corps,  Surgeon-Generaf  s  Office,    Watkington. 
D.  C. 
Madam: — I  have  the  honor  to  acknowledge  the  receipt  of  your 
letter  dated  November  20, 1900,  in  which  you  tender  your  resignation 
as  an  Acting  Assistant  Surgeon,  V.  S.  Army,  in  charge  of  the  Array 
Nurse  Corps. 

In  accepting  your  resignation  I  desire  to  express  to  you  my  high 
appreciation  of  the  valuable  services  you  have  rendered  during  the 
past  2*  years  in  selecting  trained  female  nurses  foi  duty  at  our  field 
and  general  hospitals  wherever  their  assistance  has  t>een  necessary, 
and  in  organizing  the  "Army  Nurse  Corps"  upon  a  satisfactory 
basis.    You  have  shown  excellent  judgment  and  executive  ability, 
and  have  labored  zealously  both  in  the  interests  of  the  nurses  and 
of  the  Government. 
Your  contract  will  be  annulled  December  31,  1900. 
Very  respectfully, 
(Signed)  Geo.  M.  Stebsbebg, 

Surgeon-General,  U.  S.  Army 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague,  have  been  reported  to 
the  Surgeon-General  U.  S.  Marine  Hospital  Service,  during 
the  week  ended  December  28, 19(X) : 


Smallpox— United  Statbs. 


Florida  : 
Kansas  : 
Kentccky  : 
Mabylank: 
Minnesota  : 

N.  Hampshiee  : 
New  Jebsey  : 
New  Yoek  : 
Ohio: 


TllTKKSSEE  : 

Texas: 
Utah  : 

Washisgtok: 
Wisconsin  : 


Aegentina  : 

Bohemia: 

Brazil: 

Egypt: 
England: 
Peanck : 
India: 
Mexico  : 

Ritssia: 

SooTLAirs: 


Bbaeil  : 
Mexico: 


Jacksonville  . 
Wichita  .  .  . 
Lexington  .  . 
Baltimore  .  . 
Minneapolis  . 
Winona  .  .  . 
Manchester 
Jersey  City  .  . 
New  York  .  . 
Ashtabula  .  . 
Cleveland  .  . 
Portsmouth  . 
Memphis  .  . 
Houston  .  .  . 
Sah  Lake  City 
Tacoma  .  .  . 
Milwaukee  .   . 


Dec.  2  .  . 
Dec.  15-22 
Dec.  22  .  . 
Dec.  22  . 
Dec.  15-22 
Dec.  15-22 
Dec.  15-22 
Dec.  16-22 
Dec.  15-22 
Dec.  15-22 
Dec.  15-25 
Dec  22  .  . 
Dec.  22  .  . 
Dec.  15-22 
Dec.  15-22 
Dec.  15  .  . 
Dec.  22  .    . 


Cases. 

1 

10 

1 

1 

12 

120 

14 

7 

21 

IS 

25 

1 

1 


Dkatiu. 


Smallpox — Foseion. 


Buenos  Ayres 
Prague .... 
Pernambuco  . 
Rio  de  Janeiro 
Alexandria .  . 
London    .    .  . 

Paris 

Calcutta  .  .  . 
Mexico  .... 
Proereso  .  .  . 
St.  Petersburg 
Warsaw  .  .  . 
Glasgow  .   .  . 


Sept.  SO  .  .  . 
Nov.  24-Dec  1 
Oct.  1-15  . 
Oct.  1-31  . 
Nov.  27.  . 
Dec.  H?  . 
Dec.  1-8  . 
Nov.  17  .  . 
Dec.  16  .  . 
Dec.  9-15  . 
Nov.  24-Dec.  1 
Nov.  24-Dec.  1 
Dec.  7-14  .    .  . 


Yellow  Fbvkr.. 


Rio  de  Janeiro 
Vera  Crux   .   . 


Oct.  1-31 
Dec.  14  . 


31 
1 
1 


43 


1 
3 

9 

58 


31 


26 

e» 

1 

14 
6 
2 


S6 

1 


India  : 

STE.MTS 


Cholera. 

Bombay  ....  Nov.  13-20 
Calcutta!  ....  Nov.  10-17 
Madras     ....  Nov.  9-16 


Settlements  :  Singapore    .   .   .  Nov.  10-13 


Bbaeil  : 

India  : 
Japan  : 
Madagascar: 


Plaque. 

I'etropolis  .  .  .  Dec.  10  . 
Rio  de  Janeiro  .  Oct.  1-31 
Calcutta   ....   Nov.  17  . 

Osaka Nov.  2-27 

Tamatave    .   .   .  Nov.  11 . 


31 


26 


1 


Jancart  6,  1901J 


FOREIGN  NEWS  AND  NOTES 


tTHE   PlIILADELPHrA 
Medical  Jocrxal 


13 


Changes  in  the  Medical  Corps  of  the  U.  8.  Navy, 

for  the  week  ended  December  29,  1900. 

Ledbettkk,  R.  E.,  assistant  surgeon,  detached  from  the   "  Monon- 

gahela,"  and  ordered  to  the  "  Constellation." 
BuEB,  C.  R.,  assistant  sureeon,  orders  of  December  19  revoked,  and 

to  resume  duties  on  the  "  Monongahela." 
Bradley,  G.  P.,  medical  director,  commissioned  medical  director 

from  May  31,  1900. 
FiTzsiMONs,  p.,  medical  director,  commissioned  medical  director 

from  November  19,  1900. 
Jones,  W.  H.,  medical  inspector,  retired,  died  at  Bethlehem,  Pa., 

December  13,  1900. 
Barber,  G.  H.,  surgeon,  commissioned  surgeon  from  June  7,  1900. 
Rodman,  S.  S.,  assistant  surgeon,  appointed  from  December  14, 1900. 
Bbisteb,  J.  M.,  assistant  surgeon,  appointed  from  December  14, 

19u0. 

Changes  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  December  27,  1900: 

McIntosh,  W.  p.,  surgeon,  to  proceed  to  Columbus,  Ga.,  for  special 

temporary  duty.     December  23. 
Decker,  C.  E.,  assistant  surgeon,  granted  leave  of  absence  for  14 

days  on  account  of  sickness.     December  24. 
Bahrenborg,  L.  p.  H.,  assistant  surgeon,  relieved  from  duty  at  the 

Immigration  Depot,  New  York,  N.  Y.,  and  directed  to  proceed 

to  Manila,  P.  I.,  and  report  to  the  chief  quarantine  officer  for 

duty.     December  27. 
Duffy,  Francis,  acting  assistant  surgeon,  granted  leave  of  absence 

for  6  days  from  December  29.     December  24. 
LiMLEY,  \V.  J.,  acting  assistant  surgeon,  granted  leave  of  absence 

for  30  days.    December  22. 


foreign  Xl^vos  anb  Hotes. 


GREA.T  BRITAIN. 

Dr.  Alexander  Deas  Davidson,  of  Swansea,  a  well- 
known  ophthalmologist,  died  on  December  7. 

New  Departments  in  the  Royal  Hospital,  Bel- 
fast.— The  Board  of  Management  have  just  given  their 
consent  to  a  suggestion  from  the  medical  staflf  to  establish  a 
new  special  department  for  dermatology  (the  work  to  be 
done  by  one  of  the  present  staff),  and  to  appoint  2  anesthet- 
ists, whose  duty  it  will  be  to  administer  ether,  chloroform, 
etc.  It  is  felt  that  the  time  has  come  to  specialize  in  the 
administration  of  anesthetics  and  also  to  teach  students  in 
such  important  medical  duties. 

Death  of  Dr.  James  Michell  Winn.— Dr.  James 
Michell  Winn  died  at  his  residence  in  Hampstead  on  De- 
cember 8,  in  his  92d  year.  He  was,  it  is  stated,  the  oldest 
doctor  of  Glasgow,  and  also  the  fourth  in  the  list  of  the 
Members  of  the  Royal  College  of  Physicians ;  he  was  not 
the  oldest  in  point  of  age,  there  being  a  senior  to  him  by  6 
months  among  the  Fellows  of  the  College.  Dr.  Winn  was 
born  in  the  parish  of  Budock,  in  Cornwall,  on  December  25, 
1808.  When  about  5  years  of  age  he  went  to  reside  with  his 
parents  at  Lisbon,  and  was  a  resident  in  the  Peninsula  when 
the  battle  of  Vittoria  was  fought  in  1813.  He  commenced 
his  medical  studies  at  St.  George's  Hospital  under  Sir  Ben- 
jamin Brodie  and  Dr.  Chambers.  He  heard  Mr.  Abernethy 
deliver  a  lecture  on  one  occasion,  and  was  struck  with  the 
clear  and  practical  style  of  the  lecturer.  On  leaving  St. 
George's  Hospital  he  went  in  1832  to  the  University  of  Glas- 
gow to  study  for  the  M.D.  degree.  At  that  time  the  cholera 
had  made  its  first  appearance  in  England,  and  the  average 
daily  deaths  at  Glasgow  amounted  to  upwards  of  100.  This 
gave  him  a  good  opportunity  of  studying  the  nature  and 
treatment  of  that  complaint  at  the  Cholera  Hospital.  On 
returning  to  England  he  was  appointed  honorary  physician 
to  the  Royal  Cornwall  Infirmary,  a  position  he  retained  for 
14  years.  In  1852  he  settled  in  London,  where  he  made 
psychology  Ms  chief  study,  and  contributed  numerous 
articles  on  that  subject  to  the  journal  of  Psychological  Medicine. 
He  had  written  previous  to  this,  in  1848,  a  treatise  on  "  Gen- 
eral Paralysis  of  the  Insane."  In  a  work  on  the  "  Nature 
and  Treatment  of  Hereditary  Disease,"  published  in  1869, 
he  propounded  a  theory  that  all  hereditary  disease  was  inter- 
changeable— in  other  words,  mutually  convertible.  Dr. 
Winn  was  buried  at  Kensal  Green  on  December  12. 


CONTINENTAL  EUROPE. 

Gold  Medal  for  Dr.  Potain. — Dr.  Potain  will  have 
reached  the  age  limit  prescribed  by  French  law  for  service 
in  the  universities  at  the  end  of  the  year  1900.  His  col- 
leagues have  decided  to  present  him  with  a  gold  medal  on 
the  occasion  of  his  retirement  from  academic  life,  and  a  fund 
is  now  collecting  for  this  purpose. 

New  Russian  Medical  School. — The  first  semester 
of  the  newly  established  medical  school  in  Odessa  opened  on 
September  1,  with  a  lecture  on  physics  by  Professor  Schwe- 
doflF.  Dr.  Podwyssotsky,  professor  of  pathology,  has  been 
appointed  dean,  and  Dr.  Batoujeff,  professor  of  anatomy,  is 
secretary  of  the  new  faculty  of  medicine  of  the  University  of 
Odessa. 

First  Woman  Pharmacist  in  Russia.— M  me.  Les- 
nievsksja,  who  has  received  the  degree  of  Master  of  Poar- 
macy,  has  also  secured  the  necessary  authorizilion  from  the 
government  to  open  a  pharmacy  in  Moscow.  She  is  the 
first  woman  in  Russia  to  be  accorded  this  privilege.  In  con- 
nection with  her  establishment  there  will  be  a  chemical 
laboratory  and  a  school  for  women  pharmacists. 


Compound  Fractures. — Nicholas  Senn  (The  Chicago 
Medical  Rtcorder,  October,  1900)  says  the  adoption  of  the 
classification  "  open  "  and  "  closed  "  fractures,  which  has 
been  proposed  recently,  would  do  away  with  much  of  the 
confusion  which  has  arisen  in  regard  to  simple,  compound, 
and  complicated  fractures.  The  special  immediate  danger 
in  compound  fracture  is  the  exposure  of  the  medullary 
tissue  to  infection.  It  is  particularly  susceptible,  and  anti- 
sepsis even  in  the  most  careful  hands  will  not  always  pre- 
vent osteomyelitis.  He  quotes  statistics  recorded  previous 
to  the  antiseptic  era,  which  show  a  mortality  of  almost  50% 
in  compound  fracture  cases.  This  he  contrasts  with  a  mor- 
tality of  but  little  more  than  5%  under  the  present  antisep- 
tic treatment.  The  auth6r  says  while  the  latter  has  done  so 
much  in  the  way  of  saving  life,  it  has  perhaps  done  more  in 
the  preventing  of  mutilating  operations,  primary  and  second- 
ary amputations,  and  resections,  and  in  shortening  the  heal- 
ing process,  and  in  improving  and  increasing  the  functional 
results.  Under  strict  antiseptic  precautions,  timely  em- 
ployed, the  majority  of  compound  fractures  heal  in  the  same 
manner  aa  simple  fractures,  in  the  same  length  of  time,  and 
with  no  more  suflfering  and  equally  satisfactory  functional 
results.  Formerly  the  surgeons,  who  had  become  painfully 
aware  of  the  great  dangers  arising  from  inflammation, 
aimed  to  prevent  and  combat  it  by  the  employment  of  ener- 
getic antiphlogistics,  application  of  cold,  restricted  diet, 
venesection,  sedatives,  emetics,  and  cathartics ;  the  rnodern 
surgeons  score  such  marvelous  results  by  excluding  or 
rendering  harmless  the  direct  cause  of  infection,  and  by 
husbanding  the  strength  and  recuperative  energies  of  the 
patient.  Subcutaneous  fractures  suppurate  only  in  excep- 
tional cases,  even  in  the  event  that  the  bone  is  extensively 
splintered,  and  the  soft  tissues  are  seriously  injured.  L'ster, 
based  on  Pasteur's  researches,  showed  that  it  was  not  the 
atmospheric  air,  as  was  formerly  believed,  but  the  micro- 
organisms suspended  in  it  that  produced  the  fermentation 
and  putrefactive  processes  in  the  primary  wound  secretions. 
The  modern  treatment  of  a  compound  fracture  enjoins  a 
heavy  responsibility  on  the  attending  surgeon.  Under  ordi- 
nary circumstances,  and  in  recent  cases,  he  is  expected  to 
protect  the  wound  against  infection,  and  the  patient  from 
its  serious,  immediate,  or  late  consequences.  After  eliminat- 
ing the  cases  requiring  primary  amputation,  two  leading  indi- 
cations preeent  themselves  :  (1)  Healing  of  the  wound  ;  (2) 
repair  of  the  fracture.  Upon  the  results  of  the  first  exami- 
nation must  depend  the  propriety  of  a  primary  amputation. 
Heretofore  surgeons  have  placed  too  much  reliance  on  the 
extent  of  comminution  of  the  fractured  bone  in  deciding 
this  important  question  :— Is  amputation  necessar.N  ?  Experi- 
ence has  shown  that  the  condition  of  the  soft  tissues 
is  more  important  in  determining  the  advisability  of  adopt- 
ing a  conservative  plan  of  treatment.  The  condition  of  the 
vessels,  nerves,  muscles,  skin,  and  neighboring  joints  should 
influence  the  surgeon  in  arriving  at  final  conclusions  as  to 
what  course  he  should  pursue. 


14 


The  Philadki.pmia 

MeI'ICAL   JOt'KNA 


i:] 


THE  LATEST  LITERATURE 


[JaBUABT  5.  1901 


Cl^e  latest  literature. 


British  Medical  Journal. 

December  15, 1900.    [No.  2085.] 

1.  PolyorromenitiB,   or  Combined  Serous  Infiammatione. 

Tayloe. 

2.  Prognosis  and  Treatment  in   Pulmonary  Tuberculosis. 

Maguire. 

3.  The  After  History  of  Applicants  Rejected  for  Life  Assur- 

ance.   Macphail. 

4.  A  Case  of  Varicose  Aneurysm  of  the  Aorta  Communi- 

cating with  the  Pulmonary  Artery.    Clarke. 

5.  What  is  a  Disease  ?    Macilwaine. 

6.  Ttie  Relation  Between  Cause  and  Effect    in    Disease. 

White. 

7.  Myokymia,    or  Persistent  Muscular  Quivering.     Wil- 

liamson. 

8.  A  Brief  Account  of  the  Recent  Epidemic  of  Cholera  in 

Kashmir.    Neve. 

9.  Quinin  Hemoglobinuria.    Welsford. 

10   A  Fatal  Case  of  Poisoning  with  Zinc  Sulphate  ;  Necropsy. 
Mackintosh. 

11.  Metabolic  Fever.    Todd-White. 

12.  A  Case  of  Angioma  of  the  Spinal  Cord,  with  Recurrent 

Hemorrhages.    Harman. 

1. — Taylor  reports  the  case  of  a  woman,  aged  39  years, 
who  was  suffering  from  pain  and  swelling  in  the  abdomen. 
The  patient  came  under  his  care  as  a  case  of  ascites,  and  the 
point  to  be  determined  was  the  origin  of  the  peritoneal 
effusion.  The  choice  seemed  to  lie  between  tuberculous 
peritonitis  and  cirrhosis  of  the  liver.  When,  after  a  few 
days,  the  dulness  increased  in  an  upward  direction,  it  became 
highly  probable  that  there  was  a  liquid  effusion  into  the 
pleura  as  well  as  into  the  peritoneum.  This  frequent  associ- 
ation of  the  serous  cavities  in  a  common  lesion  is  a  fact 
which  has  long  attracted  attention  not  only  in  the  case  of 
combined  tuberculous  peritonitis  and  pleurisy,  but  also  in 
the  case  of  some  more  acute  diseases,  such  as  acute  rheuma- 
tism and  pyemia.  Italian  physicians  have  given  the  names 
polyserositis  and  polyorroineuitis  to  this  multiple  in- 
flammation of  the  serous  cavities.  The  author  considers  the 
latter  term  to  be  the  more  desirable.  We  must  guard  our- 
selves, however,  from  regarding  this  combination  of  lesions 
as  a  separate  disease  and  from  thinking  that  we  have  reached 
the  b  ttom  of  a  given  case  when  we  have  given  it  this  im- 
posing name.  It  obviously  only  represents  a  common  group- 
ing of  pathologic  conditions  of  sufficient  frequency  to  require 
attention,  and  sufficiently  constant  in  its  pathologic  or  eti- 
ologic  antecedents  to  make  its  ttudy  fruitful.  Polyorromen- 
itis  may  be  acute,  subacute,  or  chronic,  and  it  may  be  due  to 
the  action  of  the  pneumococcus,  the  streptococcus,  the  staphy- 
lococcus, the  rheumatic  poison,  or  the  tubercle  bacillus.  It 
is  more  frequent  in  males  than  females,  and  the  majority  of 
the  cases  occur  between  the  ages  of  16  and  30  years.  It  is 
usual  for  one  serous  cavity  to  be  invaded  before  the  others. 
In  the  majority  of  cases  the  peritoneum  is  first  attacked  and 
the  inflammation  subsequently  invades  the  other  mem- 
branes. This  invasion  may  occur  according  to  the  following 
3  types :  (1)  The  peritoneum  is  first  attacked,  then  the 
pleuiffi;  (2)  the  pleura  is  first  the  seat  of  disease,  then  the 
peritoneum :  (3)  pericarditis  follows  a  pleurisy.  Some  of 
those  who  have  written  upon  the  subject  believe  that  sub- 
acute and  chronic  polyorromenitis  are  nearly  always  tuber- 
culous. The  prognosis  of  polyorromenitis  in  general  must 
depend  very  much  on  the  cause.  Tne  treatment  of  the  con- 
dition must  be  conducted  on  the  lines  of  the  treatment  of  the 
separate  tuberculous  lesions  concerned.  The  tuberculous 
nature  of  the  lesion  in  the  patient  reported  in  the  paper  was 
demonstrated  by  a  laoarotomy,  from  which,  however,  no 
benefit  was  derived,    [j  M.S.] 

2. — Will  be  treated  editorially. 

3. — From  1885  to  1S05  the  applications  for  insurance  in  a 
large  company  numbered  5,115  and  the  risks  declined  or  post- 
poned were  409,  or  8.11%.  The  causes  that  determined  the 
rejected  applications  are :  Family  history  of  phthisis,  84 : 
rheumatism  in  applicant,  31;  lung  diseases,  57 ,  heart  dis- 
eases, 50;  genitourinary  diseases,  81;  diseases  of  the  nerv- 
ous system,  25 ;  other  causes,  90.    Of  these  409  rejected  cases 


Macphail  has  ascertained  definitely  that  201  are  living  and 
31  are  dead.  Basing  a  calculation  on  the  normal  death-rate 
of  persons  of  suitable  age  we  should  expect  to  have  25  deaths 
out  of  the  235  subjects  ;  while,  as  a  matter  of  fact,  the  deaths 
number  31.  There  is  no  factor  in  life  insurance  of  more  im- 
portance than  a  family  history  marked  by  tuberculosis.  Of 
late  years,  however,  it  has  been  proved  that  a  bad  family  his- 
tory may  be  largely  neutralized  by  a  good  personal  recird, 
the  chief  indication  being  the  weight  of  the  occupant.  Dr. 
E.  J.  Marsh  has  made  this  very  clear  and  is  led  to  the  follow- 
ing striking  conclusions:  1.  That  the  history  of  consumption 
in  any  member  of  the  immediate  family  increases  the  prob- 
ability of  its  appearance  in  an  applicant.  2.  That  consump- 
tion in  a  brother  or  sister  is  at  least  of  equal  importance  as 
when  it  has  occurred  in  a  parent.  3.  That  persons  who  are 
under  the  standard  or  average  of  weight  are  much  more  lia- 
ble to  consumption  than  those  above  this  standard.  That 
the  peculiarity  of  constitution  that  is  indicated  by  the  ina- 
bility to  take  and  assimilate  a  proper  amount  of  nutriment 
indicates  a  susceptibility  to  phthisis,  or  at  least  is  a  reason- 
able suspicion  of  such  predisposition.  4.  That  persons  who 
exhibit  a  robust  or  well-developed  body  have  little  suscepti- 
bility to  consumptioa.  5.  That  the  personal  condition  of 
weight  and  robustness  has  far  more  value  than  the  family 
history  in  diminishing  the  liability  to  consumption.  6.  Tnat 
the  evidence  presented  by  a  well-developed  body  may  out- 
weigh the  suspicion  attached  to  an  unfavorable  family  record. 
7.  That  these  influences  of  family  history  and  personal  weight 
are  of  the  same  grade  for  every  age,  and  their  importance  is 
not  lessened  by  tae  fact  that  the  individual  has  reached  mid- 
dle life.  In  relation  to  abnormalities  of  pulse,  the  important 
thing  for  life  insurance  is  to  establish  that  the  unusual  con- 
dition is  peculiar  to  the  individual,  that  it  has  persisted  for 
many  years,  that  it  is  not  associated  with  any  objective  symp- 
toms or  with  any  impairment  of  health.  Fifty  cases  out  of 
the  409,  or  12%,  were  rejected  for  causes  connected  with  the 
heart,  and  the  author  has  been  able  to  discover  only  5  deaths 
from  heart  disease.  The  matter  of  albuminuria  must  be 
viewed  from  the  standpoint  of  the  medical  examiner  as  well 
as  that  of  the  director.  To  the  director  the  term  albuminous 
urine  is  one  of  sinister  significance.  On  the  other  hand,  in- 
justice is  wrought  to  many  an  individual  from  this  cause  and 
this  is  the  side  that  appeals  to  the  examiner.  It  is  not  a 
question  whether  or  not  a  substance  supposed  to  be  albumin 
is  present ;  it  is  a  question  whether  or  not  the  applicant  is  in 
good  health.  With  all  these  conflicting  elements  the  med- 
ical examiner  must  feel  constrained  to  lay  aside  his  favorable 
opinion  of  an  individual  case  and  classify  it  the  black- list  of 
albuminuria,  no  matter  how  favorably  he  is  convinced  that 
the  after-history  will  be  favorable.  Many  risks  are  refused 
on  account  of  personal  habits,  especially  in  relation  to  the 
taking  of  alcohol.  There  is  a  wide  difference  of  view  by  ex- 
aminers on  this  point  and  that  view  is  affected  by  the  habits 
of  the  examiner  himself.  All  are  pretty  well  agreed,  how- 
ever, that  alcohol  in  reasonable  amounts  and  at  proper  times 
is  not  only  harmless  but  actually  productive  of  good.  Indeed 
the  case  of  a  total  abstainer  should  be  searched  into  sls  dili- 
gently as  the  case  of  the  habitual  drinker,  since  abstinence 
may  be  due  to  a  knowledge  of  hereditary  taint,  to  personal 
intemperance  in  early  life,  or  to  some  physical  condition 
which  does  not  go  with  robust  health  and  long  life.  But 
there  is  a  class  of  risks  which  all  companies  agree  to  consider 
bad.  This  is  the  class  of  liquor  dealers  and  manufacturers 
that  are  brought  into  daily  and  intimate  connection  with 
alcohol.  Many  cases  are  rejected  on  account  of  pregnancy. 
This  is  to  prevent  women  from  insuring  against  that  particu- 
lar contingency,  and  rules  are  made  accordingly.  If  a  woman 
insures  her  life  under  the  usual  conditions  the  company  lays 
no  restrictions  upon  her  childbearing,  but  they  will  not 
accept  her  within  2  years  of  her  marriage  nor  until  she  has 
borne  her  first  child,  or  until  it  is  pretty  clear  that  she  will 
never  have  any.    [j.m.s  ] 

4.— CUrke  reports  a  case  of  varicose  aneurysm  of  the 
aorta  communicating  with  the  pulmonary  art«ry. 
The  openiig  was  about  the  size  of  a  sixpence,  while  the  thin, 
walled  sac  was  only  the  size  of  a  bantam's  e4tg.  The  mur- 
murs observed  during  life  were  low  pitched,  roaring  and 
varying  in  intensity,  as  it  were  a  background  to  a  loui  sys- 
tolic and  diastolic  sound  ;  these  were  loudest  at  the  sternal 
end  of  the  third  intercostal  space ;  no  tracheal  tugging  or 
laryngeal  paralysis  was  observed,     [w  s.N.] 


JaNUABT  6,  1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
L  Medical  Journal 


15 


6.— Macilwaine  defines  disease  as  the  sum  total  of  the 
consequences  resulting  in  a  patient  from  the  interference 
with  his  physiologic  state  by  a  disease  cause.  According  to 
this  definition  diseases  are  divided  according  to  their  etiol- 
ogy into  those  due  to  intrinsic  causes ;  those  due  to 
extrinsic  causes ;  and  those  due  to  causes  of  undetermined 
origin.  1.  Diseases  due  to  intrinsic  causes  may  be  due  (a)  to 
wear  and  tear,  such  as  atheroma  ;  (6)  to  incomplete  develop- 
ment, puch  as  idiocy ;  (c)  to  failure  of  function,  such  as  gout ; 
and  (rf)  to  unphysiologic  stress,  such  as  writers'  cramp.  2. 
Diseases  due  to  extrinsic  causes  may  be  due  (a)  to  parasites, 
such  as  tuberculosis  ;  (6)  to  nonparasitic  matters  introduced 
into  the  economy,  such  as  alcoholism  ;  and  (c)  to  deleterious 
physical  interference,  such  as  wounds.  3.  Diseases  due  to 
undetermined  causes  may  be  due  (a)  to  tissue  overgrowth, 
such  as  carcinoma,  and  (6)  to  toxemias  of  unknown  origin, 
such  as  cirrhosis  of  the  kidney.     fj.MS.] 

6. — White  believes  that  if  a  disease  is  due  to  a  specific 
causal  agent  it  is  not  characterized  by  specific  anatomical 
or  functional  lesions.  If  a  disease  is  characterized  by 
specific  lesions  we  must  not  expect  to  find  a  specific  causal 
agent.  From  this  it  follows  that  from  the  characters,  histo- 
logic or  macroscopic,  of  the  letions  we  cannot  positively 
aflSrm  that  the  disease  is  due  to  a  specific  causal  agent.  The 
only  means  by  which  we  can  affirm  this  is  to  find  and  isolate 
the  causal  agent  itself.  Variations  in  the  characters  of  the 
lesions  in  diseases  due  to  specific  causal  agents  depend  not 
on  the  nature  of  the  agent,  but  on  the  locality  to  which  it  is 
applied  and  on  its  relative  virulence,    [j.m.s.] 

7. — Williamson  reports  the  case  of  a  man,  aged  21  years, 
a  clerk,  who  was  suffering  from  a  peculiar  persistent  quiver- 
ing of  the  muscles  of  the  limbs,  the  trunk  and  the  face. 
During  the  infancy  of  the  patient,  his  left  leg  had  become 
suddenly  paralyzed  and  had  remained  useless.  At  the  age 
of  16  years  the  paralyzed  limb  had  been  seriously  ir.jured 
and  amputation  had  been  necessary.  The  quivering  of  the 
muscles  of  the  right  leg  began  2  years  before  the  author  saw 
the  patient  and  spread  gradually.  The  most  striking  symptom 
was  the  persistent,  rapid  quivering  of  the  muscles  of  the  right 
leg,  the  arm,  the  trunk,  the  face,  and  the  tongue.  Some- 
times one  small  bundle  of  muscle  fibers  contracted  rapidly, 
giving  the  appearance  of  fibrillary  contraction;  sometimes 
several  bundles  of  muscle  fibers  contracted ;  and  at  other 
times  the  whole  muscle  contracted.  The  symptom  was  best 
seen  in  the  leg,  afiecting  the  muscles  of  the  calf  and  the 
thigh.  The  patient  could  perform  all  the  movements  of  the 
arms  and  the  legs  and  there  was  no  localized  wasting  or 
paresis  of  the  muscles.  There  was  no  rigidity  of  the  limbs. 
The  knee  jerk  was  a  little  increased ;  but  there  was  no  ankle 
clonus.    The  condition  was  diagnosed  niyokymia,     [j  m  s.] 

8. — The  mortality  in  the  epidemic  of  cliolera  in 
Kasbmir,  in  1900,  was  about  66%.  Ncvs  believes  that  pro- 
phylactic treatment  with  sulphuric  acid  is  of  value  in  avert- 
ing the  disease.  The  immense  importance  cf  early  treatment 
with  some  preparation  of  opium  cannot,  in  the  author's 
opinion,  be  too  strorgly  insisted  upon  ;  70  fo  of  those  treated 
by  him  in  that  way  recovered,    [j  m  s.] 

9. — Welsford  reports  the  case  of  a  man  who  was  sufiering 
from  a  high  degree  of  malarial  cachexia.  He  had  had  fre- 
quent slight  attacks  of  blackwater  fever  during  the  3  years 
previous  to  the  time  that  he  was  seen  by  the  author.  On 
admission  to  hospital  the  patient  objected  to  taking  quinin, 
alleging  that  a  single  dose  invariably  made  his  urine  black  ; 
but  he  eventually  consented  to  take  2  10  grain  doses,  the 
last  of  which  was  administered  at  2  o'clock  in  the  afternoon. 
At  6  o'clock  the  patient  had  a  chill  and  his  temperature  rose 
to  105°  with  vomiting  and  pain  and  at  7  o'clock  he  passed  10 
ounces  of  black  urine.  During  the  night  he  improved,  the 
next  morning  his  urine  was  clear  although  it  still  contained 
a  little  albumin.  After  the  patient's  temperature  had  re- 
mained normal  for  7  days  he  was  put  to  bed  and  on  the  third 
day  2  10-grain  doses  of  quinin  wore  given  him  with  the  same 
result.  A  more  doubtful  case  of  quinin  liemoglobinuria 
occurred  in  a  man  mho  was  admitted  with  a  somewhat  severe 
attack  of  blackwater  fever  which  was  treated  without  quinin 
with  good  result.  Three  weeks  later  the  patient's  tempera- 
ture rose  to  100°  and  10  grains  of  quinin  were  ordered  3 
times  a  day.  Two  days  later  his  temperature  rose  suddenly 
to  105°  and  his  urine  became  black  and  continued  so  for  2 
days.  Since  in  this  case  the  symptoms  were  well  marked, 
the  attack  may  have  been  a  relapse,    [j.m.s.] 


10. — Mackintosh  reports  the  case  of  a  woman,  aged  53 
years,  who  swallowed  a  large  packet  of  zinc  sulfate.  She 
was  suffering,  when  seen  by  the  author,  from  severe  pain  in 
the  stomach  and  bowels,  pallor,  cold  extremities,  irregular 
pulse,  cold  sweats  and  purging;  but  she  had  vomitfd  only 
about  a  teaepoonful.  The  patient  died  in  collapse  about  20 
hours  after  taking  the  poison.  At  the  necropsy,  the  mu- 
cous membranes  of  the  stomach  and  the  large  intestine  were 
found  to  present  patches  of  intense  inflammation.  The  in- 
flammation in  the  small  intestine  was  intense  and  diffuse. 

[j.M  s  ] 

11. — Todd  While  suggests  the  term  metabolic  fever 

for  a  form  of  febrile  affection  that  is  common  in  children 
during  the  summer  months  and  that  is  generally  called  a 
bilious  attack.  It  is  characterized  by  severe  frontal  head- 
ache, profuse  perspiration,  vomiting,  constipation,  or  diar- 
rhea, loss  of  appetite,  and  a  temperature  of  about  101  or 
102°.  The  author  has  been  able  to  show  that  in  every  case 
that  has  come  under  his  notice  the  patient  has  taken  some 
unusual  exercise  during  the  days  immediately  preceding  the 
attack,    [j  M.S.] 

12. — Harman  describes  a  rather  uncommon  case  where 
the  necropsy  showed  that  the  right  half  of  the  spinal  cord 
near  the  lumbar  enlargement  had  been  destroyed  b\  angio- 
matous growth,  and  death  evidently  was  produced  by 
pressure  from  a  iiemorrhage.  About  2  years  before  the 
patient  died  he  began  to  show  signs  of  progressive  paralysis 
of  the  right  leg,  and  at  times  had  severe  attacks  of  pain, 
while  on  several  occasions  spasms  of  the  muscles  of  the  leg 
and  bark ;  the  one  that  caused  his  death  was  of  longer 
duration,  as  well  as  more  intense,  and  their  cause  was  pre- 
sumed to  be  due  to  recurring  hemorrhages,     [w.s  n.] 


Medical  Record. 

December  29,  1900.      [Vol.  58,  No.  26.] 

1.  Some  Remarks  on  Medicine  in  1800.    George  K.  Welch. 

2.  A  Case  of  Gonorrheal  Endocarditis  with  Congenital  Mal- 

formation of  Mitral  Valves.    G.  W.  McCaskey. 

3.  The  Operative  Treatment  of  Varicose  Veins  of  the  Lower 

Extremities.    W.  C  Borden. 

4.  Two  Unusual  Cases  of  Aphasia,  with  Special  Reference  to 

the  So-called  Naming  Center.    Graeme  M.  Hammond. 

3. — Borden  does  not  believe  in  the  palliative  treatment 
of  varicose  veins  in  the  lovrer  extremity  as  it  only 
too  often  causes  extension  of  the  diseased  condition  until 
some  more  serious  complication  follows.  This  may  be  obvi- 
ated by  early  operation,  when  the  disease  is  localized,  and 
then  at  that  lime  it  can  be  permanently  cured.  He  favors 
most  the  complete  excision  of  the  diseased  vein,  but  when 
for  some  reason  this  is  contraindicated,  he  finds  that  multi- 
ple ligation  or  excision  of  part  of  the  vein  yields  the  best 
results  under  the  circumstances,  and  in  a  few  cases  where  the 
above  operation  cannot  be  performed,  high  ligation  of  the 
saphenous  may  be  tried,  but  it  rarely  proves  as  satisfactory 
as  the  more  radical  operation,     [w  s  n.] 

4. — Hammond  records  a  case  in  which  there  was  an  in- 
jury of  the  cortex  at  the  junction  of  the  middle  and  pos- 
terior thirds  of  the  superior  temporal  gyrus,  and  a  second 
case  in  which  there  was  an  area  of  softening  in  the  middle 
third  of  the  second  temporal  gyrus.  In  both  cases  there  was 
entire  word-deafness,  and  in  the  second  word-blindness.  He 
believes  that  a  lesion  in  any  part  of  the  speech-area  may  so 
disorder  the  mechanism  of  the  associated  speech-centers 
that  any  or  all  forms  of  aphasia  may  result  and  that  there  is 
as  yet  no  real  evidence  that  a  single  naming  center  exists 
and  some  evidence  against  such  a  view,  and  it  is  at  least  not 
very  improbable  that  there  is  no  such  center,    [dl.e.] 


Medical  News. 

December  S9,  1900.     [Vol.  Ixxvii,  No.  26.] 

1.  The  Nitrite  Treatment  in  Syphilis.     William  BRowNiNa. 

2.  The  Failure  of  the  Consensus  Judgment  with  Reference 

to  Tuberculosis.    Charles  Denison. 

3.  The  Value  of  the  Schumburg  Method  of  Purification  of 

Water  for  Military  Purposes.    John  H.  Huddlbsston. 


16 


The  Philadelpbia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Jakcaby  5.  1901 


4.  A  Theory  of  the  Physiology  of  Spinal  Anesthesia.    H.  H. 
Stonee. 

1. — The  author's  reason  for  employing  the  nitrites  in  syphilis 
is  the  widespread  tendency  of  syphilis  to  cause  arterial 
interference.  The  results  of  this  interference  are  a  nar- 
rowing of  the  lumen.  He  employs  the  medicament  as  a 
vasodilator,  thereby  increasing  the  means  of  transporta- 
tion for  the  remedy.  The  author  calls  attention  to  the  title  and 
emphasizes  that  it  is  intentionally  made,  Use  in  syphilis  and 
not /<»•  syphilis.  He  considers  hypodermic  administration 
as  quite  unsuited,  as  it  makes  the  action  of  the  nitrite  more 
temporary.  A  continuous  action  is  necessary.  Oae  or  two 
grains  of  the  sidium  salt  are  usually  sufficient,  at  least  for 
earlier  doses.  All  of  these  agents  are  explosiye  ijf  improperly 
hardled.     [m.ed] 

2. — Denison  opposes  the  consensus  judgment  relative 
to  the  home  management  and  local  hospital  treatment  of 
tuberculosis,  and  for  the  following  reasons :  (1)  There  is  a 
decided  advantage  in  climatic  change  over  the  home  or 
the  local  sanitarium  treatment,  and  (2)  the  germ  theory  of 
tuberculosis  is  not  the  sole  cause  ot  the  disease,  and  so  is 
not  a  sufficient  foundation  for  either  its  educational  or  legis- 
lative control,     [m.k.d.] 

3. — A  number  of  experiments  with  bromin  solution 
as  a  disinfectant  fir  water  were  made  by  the  author.  Cul- 
tures of  typhoid  bacillus  were  obtained  from  3  sources, 
one  from  laboratory,  one  isolated  from  well-water,  and  one 
from  the  feces  of  a  typhoid  patient.  Croton  water  was 
obtained  from  tap  in  laboratory  from  Hudson  river  at 
Albany,  and  from  a  pool  that  had  been  standing  some  weeks. 
It  was  inferred  that  for  ordinary  drinking  water,  the  mini- 
mum amount  of  bromin  solution,  as  proposed  by  Schumburg, 
was  sufficient  to  disinfect  typhoid  and  coli,  while  the  ordi- 
nary air  bacteria  may  be  much  more  resistant.  It  was 
shown  that,  if  sufficient  bromin  be  employed,  it  is  pos- 
sible to  even  make  stagnant  water,  under  experiment, 
drinkable.  Schumburg  has  devised  a  military  pouch  adapted 
for  preparing  a  day's  water-supply  for  a  regiment  of  1200 
men.     [m.r.d] 

4. — Stoner  considers  the  term  "  medullary  narcosis  "  as 
misleading,  as  it  convej's  the  impression  that  the  injection 
is  made  into  the  substance  of  the  cord.  The  cell  bodies  are 
situated  outside  of  the  canal,  therefore  the  poison  does  not 
gain  access  by  direct  infiltration.  The  most  plausible  theory 
is  supposed  to  be  the  one,  that  the  solution,  thrown  into  the 
cavity  occupied  by  the  axones,  is  absorbed  by  the  latter,  and 
transferred  by  way  of  the  vascular  supply  back  to  the  cell. 
The  motor  neurons  escape  the  paralyzing  effect  of  the  solu- 
tion. Stimuli  over  the  sensory  tract  are  prevented  from 
reaching  their  destination  owing  to  paralysis  and  withdrawal 
of  the  arborizing  extremity  of  the  peripheral  sensory  neuron 
from  contact  with  its  associated  one,  but  in  the  case  of  the 
peripheral  motor  neuron  no  such  ending  takes  place.  The 
reflexes  are  inhibited  in  the  anesthetic  area.  A  portion  of 
the  stimulus  may  pass  up  the  ascending  axone  of  the 
sensory  neuron,  and  upon  reaching  the  brain  give  rise  to 
sensation,  the  other  portion  taking  the  reflex  route,  over  the 
descending  branch.  It  is  selfevident  that  the  solution 
paralyzes  the  arborizing  processes  of  the  collateral  of  the 
descending  branch,  as  well  as  that  of  the  ascending  one,  and 
the  solution  is,  therefore,  removed  from  functional  relation 
to  the  peripheral  motor  neuron,     [m.e.d.] 


Boston  Aledical  and  Surgical  Journal. 

December  S7,  1900.     [Vol.  cxliii,  No.  26  ] 

1.  Operative  Treatment  of  Goiter.    J.  CoixxKS  Warekn. 

2.  Statistics  of  Operative  Treatment  of   Thyroid    Tumors. 

Lincoln  Davis. 

3.  Neoplasms  of  the  Thyroid  Gland.    Chas.  G.  Cumston. 

4.  The    Practical    Use  of  Vital    Statistics.    Feederick    L. 

Hoffmann. 

1. — Warren  operates  in  the  young,  where  a  rapidly  grow- 
ing tumor  has  resisted  medical  treatment,  and  whenever 
pressure  symptoms  arise.  A  U-shaped  incision  is  made, 
sternomastoid  muscle  drawn  aside,  and,  if  necessary,  sterno- 
hyoid, sternothyroid,  and  omohyoid  muscles  are  cut.  He 
avoids  injuring  the  capsule  cf  the  tumor  with  knife  on  account 


of  hemorrhage.  The  tissue  at  upper  and  outer  margin  of  lobe 
clamped  and  divided.  Secure  superior  thyroid  artery  if  is 
possible.  Avoid  clamping  recurrent  laryngeal  nerve.  Tumor 
is  now  dissected  away  by  cutting  the  attachments  to  anterior 
wall  of  trachea.  He  leaves  a  piece  of  gland,  the  siis  of  an 
English  walnut,  to  prevent  operative  myxedema.  Silk  ia 
employed  to  tie  vessels.  Morphin  is  administered  before  or 
directly  after  operation  to  prevent  vomiting.  Dreasings 
should  be  loose,  but  still  give  support.  For  this  purpose  a 
horse-collar  dressing  is  used,  augmented  by  an  ordinary  tin 
internal  aneular  splint  to  the  neck  for  fixation.  Tne  author 
mentions  Reinbach's  80  cases  of  resection  by  this  method, 
with  a  mortality  of  3.75%.  Author  has  operated  on  2  ca°e8 
of  exophthalmic  goiter  with  unfavorable  results,     [me  d.] 

2. — Davis  presents  a  resume  of  operations  for  simple  ma- 
lignant and  exophthalmic  goiter.  Statistics  of  complication* 
and  recurrences  are  also  included.    |  m.e.d.] 

3. — Cumston  reports  42  cises  of  various  neoplasms  of  the 
thyroid.  Excepting  the  malignant  cases,  dyspnea  was  the 
principal  subjective  symptom.  Most  frequently  employs  the 
transverse  incision  of  Kccher.  A  case  of  sarcoma  of  the 
thyroid  gland  is  mentioned,  which  after  operation  resulted  in 
general  sarcomatosis.    [m  r.d.] 


Journal  of  the  American  Medical  Association. 

December  S9,  1900.     [Vol.  iixv,  No.  26  ] 

1.  Treatment  of  Irjuries  to  the  Ureters.    Bteon  B.  Davib. 

2.  Epispadic    Eistrophy    of    the    Bladder    Complete.    Ap 

Morgan  Vance. 

3.  Hemorrhagic  Infection  in  an  Infant  Due  to  the  Typhoid 

Bacillus.    George  Bldmmeb. 

4.  Morphological  Variation  in  the  Pathogenic  Bacteria  with 

Two  Pronounced  Examples.    A.  P.  Ohlmacher. 

5.  Local  V»e  of  Guaiacol  in  the  Treatment  of  Frequent, 

Painful  Urination.    Jesse  Hawes. 

1. — See  Philadelphia  Medical  Jocekal,  Vol.  V,  p.  1273. 
3  _  <<  ..  ..  ,.  J274. 

3. — Blummer  reports  a  case  of  hemorrhagic  infection  in 
an  in''ant  due  to  the  typhoid  bacillus.  Most  of  the  bleeding 
was  from  the  vagina  and  could  not  be  controlled  by  treat- 
ment; death  resulted  on  the  ninth  day.  The  presence  of  the 
typhoid  bacillus  was  demonstrated  in  nearly  all  the  organs, 
and  Widal's  test  was  also  positive,     [w.s.n.] 

4.— See  Philadelphia  Medical  Jodenal,  Vol.  V,  p.  1296. 


Journal  of  Nervous  and  Mental  Diseases. 

December,  1900.     [Vol.  xivii,  No.  12.] 

1.  A  Case  of  So-Called  Landry's  Paralysis  with  Autopsy.  Sid- 

ney I.  Schwab. 

2.  An  Atypical  Case  of  Multiple  Sclerosis.     Chaeles  W. 

Bore  and  D.  J.  McCarthy. 

3.  A  Case  of  Milaria  Presenting  the  Symptoms  of  Dissemi- 

nated Sclerosis,  with  Necroosy.    William  G.  Spillse. 

4.  Note  Upon  the  Occurrence  of  Multiple  Neuritis  and  Beri- 

beri in  Alabama.     E  D.  Bondu»ant. 

5.  Section  of  the  Posterior  Spinal  Roots  for  the  Relief  of  Pain 

in  a  Case  of  Neuritis  of  the  Brachial  Piexos.    Morton 
Peisce. 

1. — Schwab  reports  the  following  case :  A  young  married 
woman,  21  years  of  age,  who  had  had  one  stillborn  child, 
and  two  dying  almost  immediately  after  birth,  and  who  for 
some  months  had  been  emaciating,  noticed  first  a  tingling 
and  numbness  in  the  fingers  of  the  left  hand.  A  week  later 
the  same  symptom  was  noticed  in  the  right  hand,  then  there 
was  gradual  weakening  of  the  lower  extremities.  This 
gradually  increased  until  there  was  weakness  of  all  four  ex- 
tremities, and  loss  of  control  over  the  sphincters.  There  was 
no  fever,  no  sensory  disturbances,  no  less  of  appetite.  She 
died  as  the  result  of  severe  dyspnea.  Microscopically,  the 
cord  and  the  peripheral  nerves  were  normal.  There  was 
some  congestion  of  the  organs,  and  apparently  softening 
of  the  heart- muscle.  Microscopically,  tne  only  important 
change  found  was  a  curious  congestion  of  all  the  bloodve 
sels  of  the  cord,  associated  with  old  and  recent  hemorrha 
into  its  substance.    There  was  no  degeneration  in  the 


JASOABY  »,    1901] 


THE  LATEST  LITERATURE 


[ 


Thb  Philadelphia 
Medical  Journal 


17 


terior  or  posterior  roots.  Schwab  believes  that  it  is  possible 
to  explain  this  condition  either  by  ascribing  it  to  mechanical 
congestion,  or  to  some  toxic  process,    [j  s.] 

2. — Burr  and  McCarthy  report  the  following  case  :  The 
patient,  a  man  of  46,  had  commenced  to  have  difficulty  in 
walking  at  the  age  of  39.  This  gradually  increased.  His 
symptoms  had  been  inability  to  walk  without  watching  the 
ground,  exaggerated  kneejerks,  ankle-clonus,  ataxia  and 
paresis  of  the  lower  extremities.  Towards  the  end  of  his 
sickness  there  waa  extreme  spasm  of  the  limbs  without  wast- 
ing or  atrophic  changes,  and  no  involvement  of  the  arms. 
Death  occurred  suddenly,  and  at  the  autopsy  a  condition  of 
multiple  sclerosis  was  found,  involving  large  areas  in  the 
cord,  and  a  considerable  proportion  of  the  cortex  of  the 
brain.  The  case  is  interesting  because  the  typical  symptoms 
of  multiple  sclerosis  were  never  present ;  that  is,  there  was 
no  intention  tremor,  no  nystagmus,  no  scanning  speech,  and 
no  loss  of  power.  The  oldest  area  of  sclerosis  was  limited  to 
the  posterior  columns  in  the  dorsal  region.  Later  the  lateral 
columns  were  also  involved,  and  gave  rise  to  the  symptoms 
of  ataxic  paraplegia,  and  the  subsequent  spastic  symptom 
development  caused  the  diagnosis  of  spastic  paraplegia.  It 
is  possible  that  the  noninvolvement  of  the  optic  thalamus 
explains  the  absence  of  the  characteristic  symptoms.  The 
changes  in  the  cortex  were  exceedingly  widespread,  and 
even  extended  to  a  considerable  distance  into  the  under- 
lying white  matter.  [Although  several  authorities  are  men- 
tioned, references  have  been  omitted,    j  s.] 

3.— -Spiller  gives  a  brief  abstract  of  his  paper  upon  a  case 
presenting  intention  tremor  of  the  left  arm,  ataxia  of  the  left 
leg,  and  transient  hemiparesis,  aifeoting  first  one  and  then  the 
other  side,  vertical  nystagmus,  scanning  speech,  and  ex- 
aggerated tendon  reflexes  on  the  right  side.  There  was  also 
headache,  vertigo,  drowsiness,  and  diplopia.  At  the  autopsy 
the  capillaries  of  the  central  nervous  system  were  found  to 
be  filled  with  malarial  parasites,  and  there  were  numerous 
small,  recent  hemorrhages.     [J  s] 

4.— Bondurant  mentions  several  epidemics  of  multiple 
neuritis  that  have  occurred  in  various  parts  of  the  South. 
He  has  obtained  reports  of  various  cases  of  multiple  neuritis 
from  other  physicians,  and  has  treated  11  himself.  In  all,  5 
had  no  assignable  cause.  Beriberi  is  exceedingly  common 
in  Mobile  among  the  sailors,  paiticularly  those  working  on 
lumber  ships,     [j  S.] 

6.— Prince  gives  an  abstract  of  his  paper,  of  which  the 
following  is  the  title  :  "  Section  of  the  posterior  spinal  roots 
for  the  relief  of  pain  in  a  case  of  neuritis  of  the  brachial 
plexus,  cessation  of  pain  in  the  affected  area  ;  later  develop- 
ment of  Brown-Sequard's  paralysis  as  a  result  of  laminec- 
tomy ;  unusual  distribution  of  root  anesthesia,  later,  partial 
return  of  sensibility."  This  is  a  sufficient  description  of  the 
case,    [j  s] 


Deutsche  medicinische  Wochenschrift. 

November  22,  1900.     [26.  Jahrg.,  No.  47.] 

1.  Enucleation  of  the  Kidney  by  Ligature  of  the  Ureter.    L. 

Landau. 

2.  Induration  of  the  Connective  Tissue  of  the  Myocardium. 

K.  Dehio. 

3.  Second  Report  Concerning  Malaria  and  Mosquitos  on  the 

West  Coast  of  Africa.    H.  Ziemann. 

4.  A  Case  of  Fatal  Parenchymatous  Colon  Hemorrhage.    L. 

HUISMANS 

5.  Traumatic  Coma  Diabeticum.    W.  Spitzek. 

1. — Landau,  while  operating  on  a  case  of  carcinoma  of 
the  uterus  where  it  had  invaded  some  of  the  other  organs  of 
the  pelvis,  found  the  right  ureter  involved.  The  operation 
was  tedious  and  required  over  1  hour ;  a  nephrectomy  in  ad- 
dition would  have  been  fatal,  therefore  he  simply  excised  the 
malignant  portion  and  brought  the  two  ends  of  the  ure- 
ter together;  the  peripheral  portion  could  not  be  seen.  This 
was  done  only  as  a  temporary  procedure  and  he  fully  ex- 
pected to  perform  a  nephrectomy  when  the  patient's  condi- 
tion would  warrant  it,  but  was  surprised  to  have  the  patient 
recover  without  any  complication,  and  show  no  sign  of  hydro- 
nephrosis. Some  time  after  a  cystoscopic  examination  showed 
that  the  right  ureter  was  performing  its  proper  function. 
This  case  goes  to  show  that  the  ureter  is  not  so  troublesome 


in  healing  as  it  is  usually  thought  to  be,  and  that  operators 
must  use  their  own  judgment  in  dealing  with  these  cases. 
Usually  when  the  ureter  is  wounded  some  plastic  operation 
is  performed  ;  if  it  is  cut,  or  a  portion  excised  near  the  blad- 
der, the  end  is  carried  into  it;  and  should  the  ureter  be  too 
short  the  end  is  then  turned  into  the  bowel.  The  disadvan- 
tage of  this  is  that  the  bowel  soon  becomes  very  irritable. 
When  neither  of  these  operations  can  be  performed  the  kid- 
ney must  then  be  removed,     [w.m  n] 

2. — Dehio  some  years  ago  made  a  study  of  the  changes 
in  the  heart  as  a  person  advances  in  years,  and  the 
publication  of  his  opinion  gave  rise  to  contrary  ones.  Since 
then  he  has  studied  microscopically  36  hearts  and  still  sup- 
ports his  former  theories.  He  divides  these  cases  into  2 
groups.  1.  Those  in  which  there  is  an  atheromatous  or 
arteriosclerotic  change.  2.  Those  in  which  the  cardiac 
degeneration  is  due  to  sclerosis  of  the  coronary  arteries 
or  to  impoverished  blood,  from  some  chronic  poisoning  such 
as  lead,  alcohol,  rheumatism,  or  after  fevers.  In  cases  of 
hypertrophy  and  dilation  the  heart  is  enlarged,  and  this  in- 
crease in  size  is  due  to  the  increase  in  interstitial  substance. 
In  contrast  to  this  there  is  a  diffuse  thickening  of  the  heart- 
muscle  due  to  an  increase  in  the  interstitial  substance  ;  this 
he  terms  myofibrosis.  When  the  heart  of  a  young  healthy 
person  ij  examined  microscopically,  the  muscle  will  be  found 
bound  together  by  a  fine  network  of  connective  tissue  which 
is  an  extension  of  the  subpericardial  and  subendocardial 
tissue  as  well  as  the  adventitia.  If  this  is  now  compared 
with  that  of  an  older  person  it  will  be  found  that  this  net- 
work has  grown  thicker,  and  advance  in  years  renders  it  more 
evident,  until  in  old  age  is  is  quite  marked,  particularly  in  a 
cross-section,  where  this  network  can  be  seen  separating  the 
individual  muscle  fibers;  this  is  evident  of  a  hyperplasia. 
Although  the  muscle  fiber  may  have  apparently  the  same 
thickness  as  in  a  young  person,  there  has  been  some  atrophy 
in  it  caused  by  the  surrounding  connective  tissue.  This 
change  he  terms  senile  myofibrosis,  and  is  exactly  like  the 
former  but  not  of  so  high  a  grade.  These  two  forms  of  degen- 
eration may  both  be  observed  in  one  heart,  and  where  it  does 
occur  it  is  hard  to  discriminate  between  them.  Myofibrosis 
is  most  apt  to  develop  in  the  walls  of  the  ventricles  and  in 
hearts  which  are  hypertrophied  and  dilated,  and  to  a  less  ex- 
tent in  dilation.  In  diseases  were  the  stress  falls  on  the 
left  heart  the  left  ventricle  is  the  usual  place  where  this 
degeneration  is  most  marked,  as  in  diseases  of  the  aortic 
valve,  while  in  diseases  where  the  stress  falls  on  the  right 
heart  the  right  ventricle  is  most  affected,  as  in  emphysema. 
In  10  cases  of  valvular  disease  of  the  heart  occurring  in  young 
people  (15  to  30  years)  myofibrosis  waa  in  some  quite  well 
marked,  and  in  all  to  some  extent.  In  a  case  of  aortic  insuf- 
ficiency and  stenosis  of  the  mitral  value,  in  a  man  of  56  years, 
on  the  left  side  it  was  well  developed,  and  to  some  extent  on 
the  right.  Other  cases  mentioned  support  the  same  idea. 
In  3  cases  of  phthisis  and  2  of  emphysema  the  right  heart 
was  more  involved  than  the  left.  Although  this  view  is  not 
supported  by  most  of  the  German  writers  it  is  by  several 
French  authors  under  the  following  groups  :  1.  Sclerose  en 
foyers.  2.  Sclerose  diffuse  rayonnante,  or  perificiculaire. 
[w.m  n] 

3. — Ziemann  describes  the  weather  conditions  in  Kame- 
ruD,  Victoria,  and  Togo.  He  found  that  the  type  of  fever, 
when  not  previously  influenced  by  quinin,  was  usually 
malignant  tertian.  There  were  some  instances  of  what 
were  probably  continued,  irregular,  or  remittent  fever,  and 
he  believes  that  these  forms  of  fever  do  occur  in  the  tropics 
in  spite  of  the  statements  of  Koch.  He  classes  the  tropical 
parasites  and  the  estivoautumnal  together,  because  of  their 
size  and  the  size  of  the  segmentation  forms.  He  believes 
that  the  tropical  parasites,  however,  are  distinctly  different 
from  ordinary  tertian.  He  has  repeatedly  observed  cases  in 
which  the  temperature  scarcely  rose  above  the  normal,  but 
in  which,  nevertheless,  parasites  were  found  going  through 
their  usual  course  of  evolution.  These  weie  anemic  patients 
who  bad  already  had  fever.  In  still  rarer  cases  the  same  was 
observed  with  the  first  attack  of  malaria.  In  negroes  par- 
ticularly the  subjective  symptoms  of  the  fever  were  found 
but  slightly  marked  in  many  instances.  In  many  cases  one 
finds  marked  general  depression,  with  almost  complete  or 
complete  absence  of  fever,  the  symptoms  disippearing  under 
tl  e  use  of  quinin.  The  basophilic  granule",  which  Piehn  de- 
ECribes  as  probably  the  cause  of  relapses,  Z'.emann  considers 


18 


The  Philadelphia 
Medical  Joubsal 


] 


THE  LATEST  LITERATURE 


[Jashabt  5,  1901 


the  results  of  de|;eaeration.  Clinically  he  considers  the 
prognosis  good  if  treatmeat  is  began  early  and  is  energetic. 
Only  2  cases  died.  Oae  of  them  wa^  moribuad  when  first 
seen,  and  the  other  died  with  severe  convulsions,  and  the 
cerebral  capillaries  were  found  filled  witb  parasites.  Hs  did 
not  see  the  quartan  parasite  in  any  of  his  cases,  aad  ordi- 
nary tertian  parasites  were  seen  in  only  one  of  the  cases. 
His  observations  in  this  respect  differed  largely  from  those  of 
Koch.  He  investigated  a  large  series  of  adults  and  children 
among  the  natives  and  found  splenic  tumor  and  pwasites  in 
a  very  large  number  of  these  cases,  23  fc  of  both  adults  and 
children  showing  evidences  of  malarial  infection,  while  of  the 
children  below  5  years,  37%  showed  infection.  As  many  as 
75  fc  of  the  captured  women  of  the  Bulls  showed  infection, 
and  10%  of  the  children.  Splenic  tumor  was  found  in  33% 
of  the  negroes  of  Togo.  He  decides,  therefore  that  the 
adults  in  this  region  did  not  show  complete  immunity,  but 
rather  an  increased  resistance,  and  the  children  certainly 
showed  no  immunity.  He  h?.s  observed  cases  in  which  a 
relative  immunity  seemed  to  be  acquired,  severe  attacks  giv- 
ing place  to  mild  ones.  In  most  of  the  cases  in  negroes, 
spontaneous  cure  took  place.  He  made  7  infection  experi- 
ments on  negroes,  and  found  that  in  5  malaria  was  produced, 
the  incubation  period  being  from  10  to  12  days.  This  is 
another  evidence  that  the  cases  were  not  completely  im- 
mune. An  interesting  observation  was  that  the  negroes 
with  malaria  often  showed  marked  leukocytosis,  the  leuko 
cytes  being  filled  with  pigment.  This  leukocytosis  probably 
had  something  to  do  with  the  spontaneous  cure.  He  found 
no  places  that  could  be  considered  to  be  free  from  malaria. 

[d  L  E.] 

4. — Huismans  reports  a  case  of  parenchymatous 
bleeding  from  the  colon  in  a  boy  12J  years  old  result- 
ing in  death ;  his  family  history  was  negative.  A  year  pre- 
vious he  had  a  similar  attack,  and  from  that  time  to  his 
present  illness  he  enjoyed  good  health.  The  boy  was  care- 
fully examined  and  the  urine  also,  but  without  result;  an 
injection  of  tuberculin  was  likewise  negative.  Coflee-colored 
stools,  with  some  meteorism,  continued  without  yielding. 
Treatment  consisted  in  the  use  of  opium,  belladonna,  bis- 
muth in  large  doses,  ergotin,  injections  of  normal  saltsolu 
tion,  etc.  The  necropsy  yielded  very  little;  all  the  organs 
were  normal  except  the  colon,  which  showed  signs  of  colitis 
and  was  dark  colored ;  ameba  and  anchylostoma  were  not 
found,  and  the  blood  was  also  normal.     [w.M  n] 

6. — After  a  brief  general  review  of  the  question  of  dia- 
betic coma  and  its  causation  Spitzer  dtscribes  a  case  in 
which  there  had  never  been  any  previous  signs  of  acid  intox- 
ication, and  only  a  mild  glycosuria  that  was  readily  kept 
within  limits.  The  patient,  a  professor,  broke  his  clavicle. 
He  was  intensely  excited  by  this,  and  the  same  day  the  gly- 
cosuria increased  largely,  albumin  appeared  in  the  urine, 
and  the  next  day  acetone  and  diacetic  acid  were  present. 
Large  amounts  of  alkalies  were  given  and  there  was  some 
improvement  in  the  condition,  but  6  days  after  the  injury 
there  was  still  some  obscuration  of  the  intellect,  increasing 
restlessness,  and  persistence  of  the  diacetic  acid  reaction  ; 
the  next  day  the  symptoms  increased  rapidly,  and  2  days 
later  the  patient  died  in  deep  coma.  There  was  no  evidence 
of  the  presence  of  oxybutyric  acid  in  the  urine.  The  shock 
of  the  injury  is  believed  to  have  brought  on  the  fatal  acid  in- 
toxication and  coma  by  increasing  the  glycosuria.  Spitzer  is 
of  the  opinion  that  in  both  normal  and  diabetic  persons  the 
products  of  the  breakdown  of  the  carbohydrates  enter  into 
union  with  the  abnormal  acids  produced  from  the  albumins 
and  fats,  and  prevent  abnormal  synthetic  combinations  of  the 
oxybutyric  acid  and  thus  shield  one  from  acid  intoxication. 
The  increase  in  the  glycosuria  was  an  evidence  of  increased 
imperfection  in  the  assimilation  of  the  carbohydrates,  and, 
he  believed,  by  preventing  the  breakdown  of  the  carbohy- 
drates the  shock  thus  led  to  acid  intoxication,     [d.l.e.] 


Neurologischea  Centralblatt. 

November  15,  1900.    [19.  Jahrg.,  No.  2;i] 

1,  The  Significance  of   the   Scapulohumeral  Reflex.    Von 

Bechterew. 

2.  Imperative  Vomiting.    Von  Bechterew. 

S,  The  Subjective  Response  of  the  Colors  of  the  Spectrum. 

H.  SOLOMONSOHN. 


4.  Clinical  and  Experimental  Contributions  to  the  Qiestion 

of  the  Secretion  of  Tears.    G.  Kosteb. 

5.  The  Destruction  of  the  Pyramidal  Tracts  after  Decassa- 

tion.      M.  RoTHMANN. 

6.  The  Neurosis    of  an  Area  of  the  Cervical  and  Brachial 

Plexus  as  a  Result  of  a  Diseased  Tooth.    F.  Hes^e. 

1. — Von  Bfichterew,  in  reply  to  Haenel,  contends  that  the 
scapulohumeral  reflex  is  not  a  manifestation  of  myotactic 
irricabiiluy,  but  is  really  a  periosteal  reflex.  He  admits  that 
its  loss  or  diminution  is  of  no  clinical  significance.  Oq  the 
other  hand,  its  presence  or  exaggeration  is  practically  of  the 
same  value  as  the  presence  or  exaggeration  of  any  of  the 
other  reflexes  in  the  upper  extremity.  Haenel  himself 
admits  that  it  was  present  in  43  4%  of  his  cases.  [It  apptiars 
to  have  escaped  the  acute  observation  of  von  Bechterew 
hitherto,  that  there  are  really  2  types  of  this  reflex  ;  one  in 
which  the  arm  is  abducted,  and  slightly  rotated,  as  a  result 
of  the  contraction  of  the  infraspinatus,  and  another,  in  which 
the  reflex  action  is  much  more  extensive,  and  involves  con- 
tractions of  the  trapezius  and  deltoid,  and  therefore  the 
abduction  of  the  arm.  The  latter  type  apparent'y  occurs 
only  in  cases  in  whijh  the  pyramidal  tracts  are  diseased  on 
the  same  side,  and  we  have  been  able  to  demonstrate  it  in  a 
number  of  cases  of  hemiplegia.  The  first  form  may,  in  con- 
ditions that  give  rise  to  increased  muscular  irritation,  be 
greatly  exaggerated,    [j.s.] 

2. — Von  Bechterew  reports  two  interesting  cases.  The 
first,  a  man  whose  occupation  was  singing  in  concerts.  On 
one  occasion  on  appearing  before  his  audience,  he  had  a 
slight  tickling  in  the  throat,  followed  by  a  feeling  of  nausea. 
On  every  subsequent  occasion,  upon  his  first  entrance  upon 
the  stage,  this  feeling  of  nausea  has  recurred,  and  in  some 
cases  has  been  followed  by  vomiting.  He  afiirmed  that  the 
consumption  of  a  little  cognac  just  before  leaving  the 
wings,  would  at  least  render  the  symptom  milder,  but  it  has 
gradually  required  more  cogna:  in  order  to  overcome  the 
disability.  Tne  second  case,  a  woman  of  28,  BuS'ers  from 
nausea  every  time  she  leaves  her  dwelling  ;  this  is  followed 
bv  palpitation  of  the  heart,  and  fear  lest  she  should  vomit. 
Not  infrequently  the  attack  terminites  with  profuse  per- 
spiration, on  which  occasion  there  is  actual  vomiting.  This 
patient  has  also  found  that  cognac  is  a  valuable  prophy- 
lactic. Examination  of  the  patient  failed  to  reveal  anytbiog 
excepting  an  exaggeration  of  the  tendon  and  cervicil 
reflexes.  There  is  a  distinct  neuropathic  hereditv.  Treat- 
ment directed  to  the  heart  with  bromids  and  caflfein  cured 
the  patient.  This  form  of  imperative  vomiting  is  similar  to 
imperative  blushing,  and  represents  a  mental  condition  that 
is  manifested  by  a  motor  reaction  on  the  part  of  the  smooth 
muscle  fibers  not  under  the  control  of  the  will,     [j  s  ] 

3. — Solomonsohn  divides  the  causes  of  chromatic  vision 
into  extraocular  and  intraocular.  The  former  are  due,  of 
course,  to  local  variations  in  the  atmospheric  refraction. 
The  latter  may  be  physiologic  or  pathologic.  In  either 
case  we  may  have  a  halo  about  the  flame,  composed  of  the 
spectral  colors,  or  a  circle,  separated  from  the  flame  by  a 
black  area.  The  first  form  under  pathologic  conditions 
occurs  as  a  result  of  the  irritation  of  the  eye ;  the  second,  par- 
ticularly in  cases  of  glaucoma.  The  communication  of 
Adamkiewicz  in  a  previous  number  of  the  CenJralbhU,  there- 
fore neither  describes  an  original  observation,  nur  is  the 
explanation  given  by  that  author  of  any  value,     [j  s] 

4. — In  the  course  of  his  studies  of  Bell's  paralysis.  Koster 
has  noted  the  following  changes  in  the  secretion  of  tears. 
Hypersecretion  occurs  only  as  a  manifestation  of  irritation, 
and  never  as  a  paralytic  phenomenon.  It  is  much  rarer 
than  paretic  secretion.  The  method  of  estimation  was  as  fol- 
lows :  A  piece  of  filter-paper  of  definite  size  was  placed  in 
the  conjunctival  sac  of  each  eye,  and  then  the  mucous  mem- 
brane of  both  nostrils  tickled  with  a  camel's-hair  brush.  In 
about  10  minutes  the  secretion  of  tears  ceased  and  the  amount 
secreted  on  either  side  could  then  be  estimated  by  weighing 
the  paper.  The  point  in  the  course  of  the  facial  nerve  at 
which  the  fibers  going  to  the  tear-ducts  leave,  was  then  deter- 
mined by  exclusion,  to  be  in  the  neighborhood  of  the  genic- 
ulate ganglion,  or  above  it.  The  trigeminus  apparently  acts 
only  reflexly,  and  therefore  the  facial  nerve  is  probably  the 
excitomotor  element.  Experiments  on  dogs,  monkeys  and 
cats,  however,  showed  that  in  spite  of  destruction  of  the  facial 
nerve  downwards  to  the  geniculate  ganglion  the  lacrimal  and 


JANDARY  5,    1901] 


THE  LATEST  LITERATURE 


FThe  Philadelphia 
L  Medical  Journal 


19 


superficial  petrosal  nerves  did  not  degenerate,  and  it  there- 
fore is  necessary  to  assume  that  the  sympathetic  fibers  pos- 
sess an  influence  upon  the  tear  secretion,    [j  8.] 

5. — Rithmann  not  satisfied  with  the  Starlinger  operation 
for  the  destruction  of  the  pyramids  in  the  medulla,  has  de- 
vised the  following  operation  for  the  destruction  of  the 
pyramidal  columns  after  decussation.  The  neck  is 
incised  on  the  right  side  of  the  larynx,  the  anterior  obturator 
membrane  exposed  and  incised,  and  the  dura  opened  from 
the  occipital  bone  to  the  edge  of  the  atlas.  The  needle  is 
now  inserted  in  the  middle  line,  and  moved  up  and  down  as 
far  as  the  bone  allows.  The  animals  sustain  the  operation 
well,  and  can  be  kept  alive  for  almost  an  indefinite  period  of 
time.  Hemorrhage  is  exceedingly  rare,  and  even  when  it 
does  occur,  apparently  is  not  fatal.  The  results  show  that 
with  the  exception  of  the  pyramids  and  the  anterior  ground 
bundle  the  columns  of  the  cord  remain  intact,     [j  s] 

6. — Hesse  reports  the  case  of  a  girl  who,  in  1895,  bit  upon 
a  shot,  causing  severe  pain  in  the  tooth.  Subsequently  there 
were  pains  in  the  upper  and  lower  jaws,  that  soon  extended 
to  the  right  shoulder,  breast,  and  arm.  The  duration  of  the 
attacks  varied  from  J  hour  to  4  hours.  The  exciting  causes 
were  emotional  disturbances,  warm  or  cold  fluids  in  the 
mouth,  or  sudden  jarring  of  the  body.  Two  months  after 
the  injury  to  the  tooth,  paralysis  developed  in  the  right 
arm.  The  tooth  was  still  painful,  and  as  a  reference  to  the 
clinical  reports  showed  that  the  pulp  had  been  exposed 
during  filling  6  years  before,  it  was  decided  to  extract  it. 
The  pulp  was  found  gangrenous,  and  there  was  some  perios- 
titis about  the  roots.  For  the  first  3  weeks  the  pain  was  still 
present,  but  much  milder,  and  after  that  it  disappeared  com- 
pletely,   [j.s.] 


Archiv  fiir  klinische  Chirurgie. 

[Bind  61,  Heft  4  ] 

42.  Necrosis  of  the  Pancreas.    A.  Brentano. 

43.  The  Treatment  of  Severe  Cases  of  Sjoiiosis.    A.  Schanz. 

44.  Thrombophlebitis  of  the  Sinus  Durae  Matris  from  a  Rire 

Cause.    H.  Riese. 

45.  The  Form  of  Fractures  Resulting  from  Direct  Force.  Fr 

Rubinstein. 

46.  Inflammatory  Strictures  of  the  Sigmoid    Flexure  and 

Rectum.    J.  Rotter. 

47.  A  Case  of  Polyposis  Rscti  et  Intestini  Craasi.    J.  Rotter. 

48.  The  Diagnosis  and  Treatment  of  Intestinal  Occlusion. 

A.  VON  Beegmann. 

49.  Statistics  and  the  Technic  of  Bittini's  Operation  in  Pros- 

tatic Hypertrophy.    Albert  Feeudenberg. 

50.  The  Grafting  of  Rib  Cartilage  Into  the  L^rynx  in  Order  to 

Heal  Large  Defects,  and  the  Healing  of  Siddle  Nose 
by  Cirtilaginous  Transplantation.    VoN  Mangildt. 

51.  Subcutaneous    Intestinal    Rupture    and    Its    Operative 

Treatment.    Von  Angerer. 

52.  Replacing  of  the  Index  Finger  by  the  Second  Toe.    Feei 

HERR  von  EiSELSBERG. 

58.  AContribution  to  the  S  jrgical  Pathology  of  the  Omentum 
and  Mesentery.    Paul  L.  Friedrich. 

54.  Progress  in  the  Technic  of  Rectal  Operations.    L.  Rehn. 

55.  Intussusception  Ciused  by  a  Congenital  Cyst  of  the  In- 

testinal Wall.    Dr  Speengel. 

56.  The  Small  Intestine  Ujed  to  Cover  in  Congenital  Ejto- 

pion  of  the  Bladder.    Willy  Anschutz. 

42. — The  cause  of  iaflamniation  of  the  pancreas  is 

generally  a  bacterial  infection  of  the  parenchyma  of  this 
gland.  Sj  long  as  the  inflimniation  is  limited  to  the  gland 
itself  the  clinical  symptonn  are  not  characteristic  enough  to 
differentiate  it  from  other  diseases  of  this  part  of  the  human 
body,  such  as  gallstones  or  gastric  ulcer.  Pronounced  symp- 
toms usually  first  appear  when  the  inflammation  has  spread 
to  the  peritoneum  or  to  the  retroperitoneal  tissues  and  even 
then  the  etiology  of  the  case  is  most  uncertain.  Necrosis  of 
the  pancreas  is  most  commonly  caused  bv  hemorrhagic  in- 
farcts developing  as  a  result  of  the  inflammation.  The 
hemorrhages  which  are  found  around  the  gland  are  likewise 
a  secondary  process  and  are  due  to  erosion  of  the  bloodves- 
sels in  the  necrotic  areas,  and  for  this  reason  are  most  apt  to 
undergo  suppuration.  The  symptoms  of  shock  and  collapse 
which  so  frequently  occur  during  the  course  of  acute  pan- 


creatitis are  due  to  infection  of  the  peritoneum  which  most 
commonly  takes  place  through  the  perforation  of  a  suppura- 
tive center  into  the  abdominal  cavity.  Sometimes  necrosis 
of  the  pancreas  will  bring  about  a  septic  pferitonitis  without 
exudate  which  rapidly  proves  fatal  just  as  in  necrosis  of  the 
appendix.  More  frequently  the  infection  of  the  abdominal 
cavity  remains  limited  to  the  burr^a  omentalis  and  the  ab- 
scesses arising  therefrom  do  not  spread  from  the  immediate 
neighborhood,  so  that  a  diagnosis  of  the  same  can  be  made 
and  proper  treatment  instituted.  Tne  symptoms  of  intes- 
tinal obstruction  which  so  frequently  occur  in  acute  pancrea- 
titis are  due  to  efi"u8ions  into  the  sac  of  the  omentum  which 
cause  irritation  of  the  peritoneum.  Operating  in  the  acute 
stages,  that  is,  when  there  are  symptoms  of  an  acute  and  dif- 
fuse peritonitis,  is  to  be  rigorously  avoided.  The  fat  necrosis 
is  a  consequence  and  not  a  cause  of  the  pancreatic  inflam- 
mation and  is  due  to  the  action  of  the  pancreitic  secretion 
and  an  uuknown  accompanying  agent  on  the  fat  cells.  Dia- 
betes appears  when  the  pancreas  in  whole  or  part  has  been 
destroyed  and  when  the  remaining  bits  of  gland  have  been 
rendered  incapable  of  carrying  on  their  normal  functions 
because  of  shrinking,  etc.     [g.b  w.] 

44. — R'ese  reports  2  intere.sting  cases  of  thrombosis  of 
the  venous  sinuses  of  the  dura  mater.  Tne  symp- 
toms of  the  first  case  lead  to  a  diagnosis  of  ihrombosis  of  the 
cavernous  sinus  caused  by  an  orbital  inflimmation  which 
had  developed  from  an  empyema  either  of  the  maxillary 
antrum  or  of  the  frontal  sinus.  The  opening  of  these  two 
cavities,  however,  failed  to  reveal  the  presence  of  pus,  but  a 
large  abscess  was  found  lying  to  the  side  of  the  pharynx. 
The  patient  died  within  an  hour  after  the  operation.  The  post- 
mortem showed  the  presence  of  a  suppurating  thrombus  of 
the  cavernous  and  circular  sinuses,  and  it  seemed  most  orob- 
able  that  the  course  of  infection  had  been  as  follows :  From 
the  original  infection  in  the  periosteum  of  the  alveolus  of 
the  last  molar  tooth,  it  had  spread  to  the  neighboring 
tissues  of  the  pterygoid  fossa,  thence  to  the  pterygoid  plexus 
of  veins  and  from  here  direct  to  the  cavernous  sinus  through 
the  veins  in  the  foramen  ovale  or  through  the  middle 
meningeal  vein.  The  veins  of  the  orbit  contained  only  post- 
mortem thrombi.  Tne  second  case  was  similar  in  that  the 
cause  of  the  thrombus  was  an  alveolar  periostitis,  but  the 
patient  recovered  ia  the  latter,  thanks  to  an  extensive  opera- 
tion by  means  of  which  almost  the  entire  clot  was  removed. 
In  this  case  the  direction  taken  by  the  thrombotic  process 
was  first  to  the  facial  vein  from  some  periosteal  venous 
branch  and  thence  to  the  internal  jugular  along  which  the 
clot  readily  spread  to  the  transverse  sinus,    [g  b  w  ] 

45.— Rubinstein  says  that,  according  to  his  experience, 
when  a  bone  is  broken  as  the  result  of  direct  force,  the 
fracture  is  of  a  triangular  shape,  provided  the  fractured 
bone  is  broad  or  flat  in  form  or  at  least  possesses  one  or 
more  flat  surfaces.  The  force  which  causes  these  fractures 
is  generally  applied  when  the  bone  is  supported  by  some  firm 
surface,  just  as  a  stick  held  by  one  hand  is  readily  broken  off 
by  the  other.     He  reports  6  typiciil  cases,     [g  b  w  ] 

46. — Rotter  renorts  4  cases  of  inflammatory  stricture 
of  the  sigmoid  flexure  and  of  the  rectum.  The 
character  of  the  cases  were  such  as  to  demand  the  formation 
of  an  artificial  anus,  but  in  all  but  one  the  patient  died  soon 
after  the  operation.  In  the  one  successful  case  the  patient 
was  enabled  to  renew  his  work  and  by  means  of  an  enema 
had  a  fecal  movement  through  the  artificial  opening  every 
second  day.  The  cause  of  the  formation  of  cicatricial  stric- 
tures in  the  lower  rectal  segment  is  found  in  the  existence  of 
complete  and  incomplete  rectal  fistula  which  had  often  ex- 
isted for  years.  The  development  of  the  inflimmation  which 
leads  to  the  later  cicatricial  contraction  is  explained  as  fol- 
lows: the  colon,  from  pressure  of  gas  and  feces  becomes 
distended,  and  the  openings  through  which  the  bloodvessels 
gain  access  to  the  mucous  membrane  are  enUrged,  so  that 
the  mucous  membrane  is  by  the  internal  pressure  forced 
through  them  as  multiple  diveriiiulums.  Masses  of  feces 
gaia  access  to  these  diverticulums  and  by  mechanical  pres- 
sure and  obstruction  cause  ulceration  and  perforation  of  the 
wall  of  the  diverticulum,     [g  B.W.] 

48. — Von  Bsrgmann  says  that  the  presence  of  a  loop  of 
intestine  distended  with  gas  can  be  diagnosed  by  simple  in- 
spection and  palpation  only  whea  the  large  intestine  is  in- 
volved and  then  not  always.  Also  the  knowledge  of  the  po- 
sition of  a  distended  loop  is  not  of  much  service  in  locating 


20 


Tke  Philadklphia 
Medical  Jodrxal 


] 


THE  LATEST  LITERATURE 


'Jasdaet  f,  UOi 


the  point  of  obstruction,  as  it  is  very  rare  that  the  strangu- 
lated loop  is  the  only  portion  of  the  gut  distended.  And 
again  the  palpation  of  a  loop  of  the  intestine,  either  dis- 
tended with  gas  or  rendered  firm  by  peristaltic  contraction, 
is  of  little  importance  in  constriction,  if  the  firmness  disap- 
pears under  narcosis.  In  speaking  of  operating  he  says  that 
when  it  is  necessary  to  resect,  the  Murphy  button  possesses 
the  advantages  of  allowing  an  immediote  passage  of  the  in- 
testinal contents  in  the  proper  direction  and  also  prevents 
the  distention  of  the  freshly  united  surfaces  from  the  pres- 
sure of  the  gas.  In  a  few  rare  cases,  however,  an  unusual 
amount  of  necrosis  of  the  intestinal  wall  results  from  the  use 
of  the  button,  causing  a  perforation.  He  reports  126  cases 
of  intestinal  obstruction  from  his  clinic  and  has  ar- 
ranged them  into  groups  and  sub-groups,     [g  b.w.] 

4:9. — Freudenberg  says  that  Bottlni's  operation  for 
enlarged  prostate  is  not  quite  so  dangerous  a.  procedure  as  is 
generally  supposed.  He  has  collected  from  different  sources 
some  683  cases  which  show  a  mortality  of  5J  % .  In  666  cases 
the  results,  as  far  as  the  benefit  of  the  operation  is  con- 
cerned, are  as  follows:  No  benefit  in  6J%,  more  or  less 
benefit  in  88%,  and  of  these  latter  t  were  cured,  so  that  the 
patient  could  urinate  normally,  while  the  other  i  were 
only  slightly  improved.  Freudenberg,  in  operating,  at  first 
incised  the  prostate  with  the  bladder  empty,  but  having  a 
fatal  case  of  peritonitis  develop  from  burning  through  the 
bladder-wall,  he  adopted  the  method  of  having  the  bladder 
filled  with  fluid.  At  present,  however,  he  inflites  the  bladder 
with  air  and  has  obtained  just  as  good  results  with  less  current 
as  when  a  fluid  was  ussd.  Iq  the  after-treatment  he  has 
stopped  using  continued  catheterization,  except  in  cases  of 
hemorrhage,  very  purulent  urine,  and  when  frequent  cathe- 
terization is  necessary  in  cases  because  of  difficulty  or  pain. 
When  the  results  following  the  first  operation  are  not  satis- 
factory the  surgeon  should  not  hesitate  to  repeat  the  cauteri- 
zation at  another  sitting.  The  chief  reason  for  failure  to 
obtain  good  results  is  a  lack  of  thoroughness  in  the  opera- 
tion, especially  in  the  length  of  the  incision.  Tlie  length  of 
the  cut  differs  with  the  case,  but  it  should  not  exceed  4h  to 
5  cm.,  and  generally  from  2J  to  3J  cm.  will  sufiB^e.  To 
measure  the  proper  length  for  the  incision,  after  introduction 
of  the  instrument,  the  beak  is  turned  backwards  and  the 
finger  in  the  rectum  measures  the  distance  from  this  to  pirs 
membranacea,  and  ^  of  this  distance  will  represent  the 
proper  length  for  the  posterior  cut  and  J  for  the  lateral.  He 
describes  a  new  modification  of  the  instrument  in  general 
use  for  which  he  claims  almost  perfection,     [g.b  w  ] 

50.— Mangoldt  reports  an  interesting  case  of  defect  of 
the  larynx,  covered  in  by  transplanting  a  small  piece  of 
costal  cartilage  over  the  opening.  The  patient  had  originally 
suffered  from  the  presence  of  numerous  polyps  in  the  larynx 
and  the  removal  of  these  by  thyrotomy  had  given  rise  to 
marked  stenosis  of  the  larynx  for  the  relief  of  which  4  trache- 
otomies had,  during  the  course  of  time,  been  performed. 
Finally  the  stricture  was  overcome,  but  an  extensive  opening 
remained  in  the  larynx.  This  was  closed  by  turning  a  flap 
of  skin  from  the  side  of  the  neck  over  the  opening  with  the 
epidermis  facing  the  lumen  of  the  larynx.  Tije  raw  surface 
which  was  left  facing  outward  was  covered  by  a  second  flap 
taken  from  the  front  of  the  sternum,  and  which  included  a 
bit  of  cartilage  from  one  of  the  ribs.  The  result  was  very 
satisfactory  and  the  piece  of  cartilage  prevented  the  skin 
from  sinking  inward  during  inspiration.  A  second  case  of 
laryngeal  stenosis  was  treated  on  a  much  similar  plan, 
except  that  the  operation  was  done  in  5  stages  and  a  flap  con- 
sisting of  2  layers  of  skin  with  the  rib  cartilage  between  was 
first  made  before  the  larynx  was  opened.  Tne  larynx  was  split 
and  the  flip  so  arranged  that  the  cartilage  came  between  the 
separated  edges.  The  result  was  also  good.  In  another  case, 
one  of  syphilitic  saddle  nose,  a  bridge  for  the  nose  was  made 
by  slipping  a  piece  of  costal  cartilage  with  its  perichondrium 
attached  under  the  skin  over  the  nose  through  an  incision  at 
the  glabella.  The  cartilage  healed  in  all  right,  and  after  a 
second  and  correcting  operation  the  patient  had  quite  a  pre- 
sentable nose,    [q.b.w.] 

61. — Von  Angerer  says  that  during  the  past  4  years  there 
have  been  9  cases  of  subcutaneous  rupture  of  the  in- 
testine operated  on  and  only  2  cases  recovered.  Rupture 
of  the  intestine  from  contusion  of  the  abdomen  resembles 
quite  closely  perforating  wounds  of  the  abdomen  as  far  as  the 
treatment  is  concerned,  but  differs  radically  in  that  the  latter 


is  comparatively  easy  to  diagnose  while  the  former  is  most 
difficult,  especially  in  the  early  stages  when  operation  will 
still  be  of  benefit  to  the  patient.  Eirly  diagnosis  is  of  course 
most  important  in  order  that  the  abdomen  may  be  opened 
and  the  ruptured  intestine  treated.  After  24  hours  have 
elapsed  there  is  little  hope  to  be  had  from  operating,  and 
the  later  the  operation  is  delayed  the  greater  are  the  chances 
of  the  patient  dying.  As  to  the  symptoms  which  will  enable 
an  early  diagnosis  to  be  made:  First,  the  kind  of  injury  is 
important,  a  localized  force  such  as  imparted  by  a  horse's 
hoof  or  by  a  stick  is  more  liable  to  cause  rupture  than  is  a 
general  contusion.  In  cases  where  the  symptoms  of  shock  do 
not  during  the  course  of  a  few  hours  tend  to  ameliorate  or 
when  they,  instead  of  decreasing,  increase,  something  more 
than  pure  shock  should  be  suspected.  The  pulse  is  always 
an  important  indication,  though  the  increase  in  frequency 
may  not  come  on  until  several  hours  after  the  accident. 
The  cessation  of  abdominal  breathing  is  an  indication  of 
trouble.  Vomiting  coming  on  immediately  after  the  injury 
and  especially  when  it  increases  in  severity  is  an  almost 
positive  sign  of  some  lesion  to  the  intestinal  tract.  Pain  is 
an  important  symptom  when  it  increases  in  severity,  but 
many  cases  of  intestinal  rupture  exist  without  any  pain 
being  complained  of.  Narcotics  should  be  avoided  in  these 
cases  because  they  tend  to  hide  important  symptoms,  espe- 
cially that  of  pain.  Meteorism  and  the  disappearance  of 
normal  liver-dulness  are  not  such  important  symptoms  as 
is  generally  supposed,  because  intestinal  rupture  often  exists 
without  either  of  them  being  present.  A  rigidity  of  the 
abdominal  muscles  is  an  important  sign  of  peritoneal  irrita- 
tion and  consequently  is  indicative  of  intestinal  rupture. 
Paralysis  of  peristalsis  results  from  contusion  of  the  intes- 
tines and  is  manifested  by  the  passage  of  neither  flatus  nor 
feces.  Urination  is  also  somewhat  hindered.  Tae  treatment 
of  subcutaneous  rupture  of  the  iutestine  should  consist  in 
operation  at  the  earliest  possible  moment  even  when  there 
is  no  positive  proof  of  the  lesion,  but  only  a  strong  suspicion 
of  its  presence.  Delay  means  septic  peritonitis.  The 
abdominal  incision  should  be  large  enough  to  allow  of  an 
easy  examination  of  the  whole  of  the  intestine  as  the 
ruptures  are  most  apt  to  be  numerous.  If  there  is  much 
contusion  around  the  tear,  or  several  tears  exist  in  close 
proximity  to  each  other,  resection  will  often  be  the  sim- 
plest way  of  treating  the  gut.  When  peritonitis  already 
exists  the  intestine  should  be  inspected  outside  of  the 
abdominal  cavity  and  the  general  cavity  flashed  with  sterile 
normal  salt-solution,    [g.b.w.] 

62. — Von  E'selsberg  reports  a  case  in  which  he  replaced 
the  index  finger  of  the  right  hand,  which  bad  been  lost 
through  accident,  by  transplanting  the  second  toe  of 
the  right  foot.  The  method  adopted  was  th»t  of  Nicoladom, 
which  is  briefly  as  follows:  A  square-shaped  flap  of  skin  was 
raised  from  the  dorsal  surface  of  the  fool  over  the  region  of 
the  second  tarsophalangeal  joint.  The  dorsal  tendons  were 
then  cut,  the  j  oint  opened,  the  cartilage  removed  from  the 
end  of  the  phalanx  and  the  flexor  tendons  divided.  The 
stump  of  the  first  finger  having  been  prepared  the  hand  was 
approximated  to  the  foot ;  the  palm  of  the  band  to  the 
dorsum  of  the  foot.  The  flexor  tendons  of  the  toe  were 
united  to  the  flexor  tendons  of  the  finger,  the  bone  of  the 
toe  was  fastened  to  the  bone  of  the  finger  by  a  silk  suture 
passed  through  drilled  holes,  the  extensor  tendons  united 
and  the  flap  of  skin  from  the  foot  stitched  to  the  back  of  the 
hand.  The  parts  were  held  in  position  by  a  plaster-of-paris 
dressing  for  12  diys,  at  the  end  of  which  time  the  nourish- 
ing pedicle  on  the  sole  of  the  foot  was  cut  through.  The 
wounds  healed  promptly  both  on  the  foot  and  the  hand.  The 
functional  result,  however,  was  almost  nothing  up  to  the 
present  writing  ;  sensation  was  noticeably  lacking,     [o.b.w.] 

63. — Friedrich  in  a  series  of  experiments  on  rabbits  has 
shown  that  the  removal  of  portions  of  the  omentum  or 
ligation  of  some  of  the  omental  bloodvessels  is  very  apt  to 
be  followed  bv  multiple  anemic  and  hemorrhagic  infarcts  of 
the  liver.  This  often  happens  even  when  very  small  portions 
have  been  ligated  and  when  as  much  as  J  or  }  of  the  whole 
omentum  is  included.  The  infarcts  develop  in  almost  every 
case.  When  the  ligated  area  includes  the  arteria  epiploica, 
in  many  cases,  there  will  also  be  one  or  more  gastric  ulcers 
formed.  Whether  a  true  ulcer  or  only  a  hemorrhagic  infil- 
tration of  the  mucosa  is  present  depends  on  the  length  of 
time  elapsed  after  the  ligation  of  the  omentum.   Tne  position 


JiSOARV  5,   I90I  I 


THE  LATEST  LITERATURE 


CTuE  Philadelphia 
Medical  Jodenal 


21 


of  the  ulcer  corresponds  to  the  distribution  of  the  arteria 
epiploica  inferiorea.     [a  b.w.] 

54.— Rhen  says  that  in  operating  on  the  rectum  even 
in  extensive  resection?,  one  should  avoid  wounding  the  sa- 
crum. It  is  perfectly  practicable  to  remove  carcinoma  of 
the  rectum  even  when  placed  high  up,  through  incisions  in 
the  perineum  or  vagina,  the  operation  being  as  easily  per- 
formed as  by  the  older  method  of  resecting  a  portion  of  the 
sacrum.  The  rectum  should  be  loosened  extrafascially,  i.  e., 
the  rectum  and  its  fascia  should  be  dissected  free  from  the 
surrounding  tissues  together.  A  high  amputation  should 
be  done  in  all  cases,  in  the  epithelioma  of  the  anus,  as  well 
as  in  those  cases  where  the  neoplasm  is  placed  higher  up. 
The  sphincter  muscles  should,  when  possible,  be  retained, 
though  the  mucous  membrane  of  the  anus  may  be  sacrificed. 
When  the  growth  occupies  the  pelvic  colon  the  combined 
abdominoperineal  method  may  be  of  great  service,    [a  b.w.] 

65. — Sprengel  reports  a  case  of  intussusception  caused 
by  a  congenital  cyst  of  the  intestinal  wall,  presenting  symp- 
toms which  lead  to  the  diagnosis  of  tubercular  peritonitis. 
At  the  operation  an  invagination  of  the  small  intestine  into 
the  colon  was  found  and  though  the  disinvagination  was 
easily  accomplished,  10  cm.  of  the  large  and  6  cm.  of  the  small 
intestine  were  resected.  An  end-to-end  anastomosis  was 
done  with  a  Murphy  button  and  the  abdominal  wound 
closed.  The  recovery  was  uneventful.  The  method  which 
yields  the  greatest  hope  for  a  permanent  cure  in  these  cases 
of  intussusception  in  which  the  mesentery  is  very  long  and 
there  exists  a  great  liability  of  a  recurrence,  is  resection. 
Fastening  the  intestine  to  the  posterior  wall  of  the  abdomi- 
nal cavity  does  not  afford  an  equal  amount  of  security.  The 
exciting  cause  of  the  invagination  in  this  case  was  the  pres- 
ence of  a  congenital  cyst  located  in  the  ileocecal  valve. 
The  cyst  was  undoubtedly  derived  from  the  intestinal  tract 
as  shown  by  the  presence  of  mucous  membrane,  elements  of 
lymphatic  tissue,  and  the  presence  in  its  walls  of  muscular 
fibers,  but  whether  it  was  the  result  of  some  change  in  the 
ductus  omphalomesentericus  or  other  embryologic  abnorm- 
ality, it  is  impossible  to  say.     [g.b  w.] 

66. — Anschutz  report  a  case  of  ectopion  of  the  blad- 
der practically  cured  by  covering  in  the  defect  with  an  iso- 
lated portion  of  the  colon.  The  steps  of  the  operation  were 
carried  out  at  different  times,  making  4  operations  to  com- 
plete the  procedure.  At  the  first,  the  abdomen  was  opened 
just  above  the  bladder  and  12  cm.  of  the  large  intestine  in  the 
neighborhood  of  the  cecum  was  isoated  from  the  rest  of  the 
intestinal  tract.  One  end  of  the  isolated  piece  of  gut  was 
closed  and  the  other  fastened  to  abdominal  incision.  At  the 
second,  the  upper  edge  of  the  bladder  was  fastened  to  the 
lower  margin  of  the  isolated  bit  of  intestine.  At  the  third 
a  plistic  operation  was  done  on  the  penis  to  make  a  urethra. 
At  the  fourth  the  intestine  was  brought  down  over  the  blad- 
der and  sutured  there,  and  after  the  skin  had  been  brought 
over  the  whole  field  a  continuous  cavity  was  made  from  the 
meatus  to  the  top  of  the  new  bladder.  After  the  wounds 
were  healed  the  patient  was  in  a  greatly  improved  condition, 
being  able  by  means  of  a  spring  which  mechanically  com- 
pressed his  urethra  to  control  the  flow  of  urine.  No  excori- 
ations or  other  discomforts  developed  and  the  urine,  except  for 
an  excess  of  mucus,  became  normal  in  character.  Anschutz 
says  that  this  operation  should  not  be  undertaken  as  a  radi- 
cal procedure  when  the  ectopion  is  seen  early  in  life ;  it  is 
adapted  rather  to  remedy  a  bad  state  of  affairs  when  adults 
present  themselves  for  relief  from  this  affliction,     [g.b.w.] 


Deutsche  Zeitschrift  filr  Nervenheilkunde. 

[Band  17,  Heft  5  u.  G.] 

21.  Acute  Anemic  Paralysis  with  Remarks  upon  the  Changes 

of  the  Nerves  in  Acute  Anemia.     Lapinsky. 

22.  Changes  in  the  Central  Nervous  System  in  a  Case  of  Fatal 

Hemorrhage  of  the  Bladder.    Ransohoff. 

23.  Investigations  upon  the  Senile  Changes  in  the  Spinal 

Cord.    Sander. 

24.  The  Extent  of  Neurasthenia  among  the  Various  Classes 

of  the  Population.    PETKfeN. 

25.  Clinical  Contribution  to  the  Knowledge  of  the  Diseases 

of  the  Crura  Cerebri.    Haenel. 
86.  Experimental  Investigations  and  Studies  upon  the  Course 
of  the  Pupillary  and  Visual  Fibers  with  Discussion 


upon  the  Physiology  and  Pathology  of  the  Movements 
of  the  Pupil.    Bach. 

27.  The  Symptomatology  of  the  Trophic  Disturbances  in 

Syringomyelia  (Osteomalacia).    Nalbandoff. 

28.  Clinical  Studies  in  Akromegaly.    Bregman. 

29.  Periodic  Oculomotor  Paralysis.    Mobius. 

21.— Lapinsky  believing  that  a  pure  anemia  of  the 
limb  might  give  symptoms  differing  somewhat  from  those 
produced  by  ligation  of  the  limb,  has  performed  a  number 
of  experiments  chiefly  upon  rabbits.  The  technic  consisted 
of  the  occlusion  by  ligature  of  the  main  arteries  of  the  limb. 
The  artery  selected  was  the  left  common  iliac  and  in  addition 
the  small  arteries  of  the  intestinal  wall  were  also  ligated.  In 
one  case  the  collateral  circulation  was  not  established  for  5 
days,  and  in  the  others  it  appeared  in  4  days  or  less.  The 
first  animal  was  killed  and  the  tissues  examined  microscop- 
ically. The  symptoms  were  interesting.  The  limb  became 
suddenly  cold,  paralyzed,  passive  movement  was  unaf- 
fected, there  was  complete  anesthesia  at  the  end  of  the  first 
hour,  loss  of  the  cutaneous  and  tendon  reflexes  and  rapid 
quantitative  diminution  to  electricity  commencing  during 
the  first  hour.  Typical  reactions  of  degeneration  did  not, 
however,  appear  in  the  muscles.  These  changes  appeared 
to  be  due  to  lesions  of  the  nerve,  those  of  the  muscles,  con- 
sisting of  acute  cloudy  swelling,  being  apparently  less  im- 
portant in  the  development  of  the  symptoms  until  compara- 
tively late  in  the  disease.  Microscopically,  changes  were 
observed  in  the  myelin  sheaths  and  the  axis  cylinders  of  the 
nerves,     [j  s.] 

22.— Ransohoff  has  had  the  opportunity  to  study  the 
spinal  cord  and  a  portion  of  the  brain  from  a  woman 
that  died  at  the  age  of  66  from  an  uncontrollable  hemorrhage 
from  the  bladder  due  t.o  a  carcinoma.  He  found  areas  in  the 
spiual  cord  in  which  the  axis  cylinders  were  greatly  swollen 
and  presented  the  appearance  of  the  hydropic  softening  de- 
scribed by  Minnich.  The  neuroglia  in  these  areas  also  showed 
a  moderate  degree  of  proliferation.  Compound  granular 
cells  were  not  present  in  the  tissues.  In  the  brain  there  were 
numerous  minute  hemorrhages  in  the  cortex,  associated  with 
slight  hemorrhagic  inflammation.  The  changes  in  the  spinal 
cord  resembled  very  closely  those  found  in  progressive  per- 
nicious anemia,  and  taken  in  conjunction  with  those  of  the 
brain  indicate  that  the  process  depends  upon  some  primary 
lesion  in  the  bloodvessels,  probably  multiple  thrombosis.  Th« 
changes  in  the  white  matter  of  the  spinal  cord  are  probably 
to  be  explained  in  the  same  manner.  The  only  clinical 
symptom  which  can  be  ascribed  to  these  alterations  was 
probably  the  period  of  stupor  that  existed  for  6  days  before 
death.  It  is  possible,  however,  that  in  more  acute  stages 
these  changes  would  lead  to  psychoses.  There  was  some 
heterotopia  in  the  spinal  cord,  probably  associated  with  a 
chronic  imbecility  with  which  the  patient  was  affected,  [j.s.] 

23.— Sinder  has  examined  the  spinal  cords  of  &5  persons 
all  dying  at  an  advanced  age.  Macroscopically  changes 
were  found  in  the  brain.  In  the  spinal  cord  he  observed  ths 
disposition  to  calcareous  plates  in  the  membranes.  Micro- 
scopically, the  myelin  sheaths  were  somewhat  paler,  and  hera 
and  there  areas  of  degeneration  were  observed,  that,  when 
stained  by  the  neuroglia  method,  were  found  to  be  entirely 
sclerotic.  The  cells  showed  an  excess  of  pigment,  and  wers 
often  deformed.  The  neuroglia  was  proliferated.  The  blood- 
vessels showed  the  ordinary  senile  changes.  There  was  no 
proliferation  of  cells  in  the  tissue,  although  the  process  was 
probably  chronic.  Numerous  areas  of  fresh  degeneration 
may  be  observed,  and  in  these  spider  cells  are  quite  common. 
The  process  resembles  rather  closely  that  found  in  pernicious 
anemia,  and  is  probably  identical  with  the  charges  already 
described  in  paralysis  agitans.  He  divider  his  cases  into  $ 
groups.  First,  a  mild  form  with  slight  diffuse  loss  of  myelin 
sheaths,  with  slight  secondary  proliferation  of  the  neuroglia, 
and  moderate  degeneration  of  cells.  Second,  a  severe  form 
with  diffuse  degeneration  of  the  myelin  sheaths,  the  appear- 
ance of  foci  of  pronounced  sclerosis  and  severe  degeneration 
of  cells.  Third,  a  presenile  form  with  acute  processes  and 
numerous  foci.  These  can  probably  be  best  termed  ths 
arteriosclerotic  degenerations  of  the  spinal  cord,    [j  s  ] 

24.— PetrfeQ  has  observed  285  cases  of  neurasthenia  in 
the  last  5  years  in  a  service  of  2,478  cases ;  that  is  to  say, 
about  11.5%  of  all  patients  presenting  themselves.  Of  these, 
141  cases  were  men  and  144  cases  were  women.    All  claBsea 


22 


Ths  Philadelphia' 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


[JaSCaet  5,  19C1 


of  men  were  about  equally  affected,  but  there  were  less  than 
half  as  many  women  in  either  the  upper  or  middle  class  as  in 
the  lower  class.  It  therefore  appears  that  among  the  labor- 
ers the  disease  is  practically  as  common  among  women  as 
among  men,  and  the  explanation  is  to  be  found  in  the  fact 
that  the  women  of  those  classes  are  compelled  to  work  quite 
as  hard  as  the  men  physically,  and  are  subjected  to  the  same 
or  even  greater  sources  of  mental  strain.  The  causes  of  the 
disease  in  the  lower  class  were  various  and  in  general  were 
the  same  aa  those  that  have  been  generally  accepted  as  etio- 
logic  factors  among  the  upper  classes.  Among  the  more 
important  were  sorrow  at  the  death  of  a  relation  or  for  simi- 
lar personal  reasons ;  anxiety  as  a  result  of  financial  loss  or 
difficulty  in  obtaining  nutrition ;  overexertion,  chiefly  intel- 
lectual in  character ;  and  some  infectious  disease,  chiefly 
influenza,  although  Petrea  doubts  that  this  is  as  serious  as  is 
commonly  believed.  He  believes  that  depressing  psychical 
infJaences  are  the  most  important  features.  Nevertheless, 
as  all  persons  are  exposed  to  these  influences  and  only  a  cer- 
tain proportion  develop  neurasthenia,  he  is  convinced  that 
there  must  be  some  hereditary  predisposition,  and  he  is 
rather  inclined  to  suppose  that  alcoholic  excesses  on  the  part 
of  the  parents  are  of  considerable  weight.  Improved  hygienic 
conditions  probably  have  a  tendency  to  diminish  the  disease. 
It  occurs  very  commonly  among  the  peasants  whose  mode 
of  life  has  not  changed  particularly.  It  is  probable  that  the 
disease  has  always  been  endemic  in  the  rural  districts.  He 
calls  attention  to  2  or  3  minor  points.  The  more  rapid  the 
development  of  the  disease  the  better  the  prognosis.  It  is 
usually  associated  with  some  other  disturbances  in  the  gen- 
eral condition,  particularly  an  unsatisfactory  nutrition.  It  is 
possible  that  occasionally  it  is  the  result  of  arterial  sclerosis; 
at  any  rate  2  cases  are  reported,  both  men  of  59,  who  had 
tjpic  neurasthenic  symptoms  and  moderate  sclerosis  of  the 
arteries.  In  the  second  case  there  was  a  distinct  history  of 
neurasthenia  in  the  father.  In  4  of  16  cases  that  he  carefully 
investigated  for  hyperesthesia  of  the  skin  the  result  was  posi- 
tive, and  the  hyperesthetic  areas  were  found,  once  on  the 
outer  side  in  the  epigastrium  and  3  times  on  the  lefc  side  in 
the  epigastrium,     [j.s  ] 

23. — Haenel  reports  an  interesting  case  characterized  by 
the  gradual  development  of  left-sided  paralyses,  and  pecu- 
liar disturbances  of  sensation  involving  the  wiiole  of  the 
left  side ;  at  the  same  time  there  was  complete  paralysis  of 
the  muscles  supplied  by  the  third  nerve  on  the  right  side, 
and  involvement  of  the  fifth  nerve  in  both  its  motor-sensory 
portions  on  the  left  side,  the  left  facial,  auditory  and  glosso 
pharyngeal  nerves  on  the  same  side;  the  muscles  of  the 
left  side  were  spastic ;  the  gait  was  correspondingly  altered, 
and  there  were  slight  indicatiom  of  ataxia;  there  was  dis- 
turbance of  equilibrium,  and  a  tendency  to  fall  toward  the 
left ;  ataxia  was  not  evident,  although  when  the  patient  was 
recumbent  there  was  complete  anesthesia  in  the  left  hand ; 
there  was  mimic  paralysis  of  the  left  side  of  the  face.  The 
lesion  is  readily  located  in  the  right  crus  ;  the  center  was 
probably  situated  in  the  fillet,  it  then  probably  ex'enrled 
downward,  involving  the  motor  portion  of  the  pyramidal 
tract,  but  evidently  in  the  fiber*  passing  to  the  hypo- 
glossal nucleus  escaped  ;  it  evidently  extended  also  to  the 
nuclei  of  the  occulomotor  nerve.  The  course  of  the  lesion 
was  peculiar :  the  sensory  disturbances  occurred  first,  and 
were  most  persistent,  but  in  the  course  of  time  complete 
recovery  occurred  in  the  motor  symptoms.  It  is  difficult  to 
understand  either  the  nature  of  the  lesion,  or  the  changes 
that  occurred  in  it.  Three  of  the  symptoms  are  of  partic- 
ular interest.  The  disturbance  of  equilibrium  was  evidently 
caused  by  the  lesion  of  fibers  passing  to  the  cerebellum  ; 
the  mimic  paralysis,  by  involvement  of  the  fibers  of  the  thal- 
amus ;  the  anesthesia  of  the  hand  by  an  interruption  of  the 
cerebral  fibers  of  sensibility.  Haenel  suggests  that  this 
type  of  anesthesia  is  due  to  the  greater  vulnerability  of  the 
fibers  contained  in  the  fine  coordinating  movements  of  the 
extremities,   not  to  their  distinct  anatomic  pDsition.     fj  s.] 

26. — Bach  contributes  an  article  of  exceptional  value 
based  partly  upon  some  careful  experimental  and  histologic 
work  of  his  own,  partly  upon  careful  collation  of  the  work  of 
other  experimenters  in  this  field.  He  produced  evisceration 
of  the  eyeball  upon  various  animals,  pigeons,  rabbits,  cats, 
and  monkeys,  and  also  studied  the  brain  of  a  man  who  had 
been  blind  in  one  eye  for  a  number  of  years.  It  is  impos- 
sible to  do  more  than  give  a  brief  summary  of  his  con- 


clusions. In  the  pigeon  there  is  total  decussation  of  the 
fibers  of  the  optic  nerve ;  in  rabbits,  cats,  apes,  and  men, 
about  one-third  of  the  fibers  do  not  decussate  ;  there  is  ap- 
parently no  direct  communication  between  the  optic  fibers 
going  to  the  corpora  quadrigemina  aid  the  occulomotor 
nucleus,  nor  between  the  optic  fibers  and  the  centers  in  the 
cervical  cord  and  medulla  that  govern  the  movements  of  the 
pupil.  Tne  papillary  fibers  that  decussate  in  the  chiasm, 
decussate  agam  further  oack  in  the  brain  ;  this  is  proved  by 
the  himolateral  pupillary  reaction  that  occurs  in  animals 
that  have  total  decussation  of  the  optic  nerves.  The 
descending  pupillary  reflex  tract  from  the  primary  optic 
ganglia  to  the  medulla,  is  probably  a  portion  of  the  fillet; 
the  ascending  tract  to  the  oculomotor  nucleus  is  almost  cer- 
tainly the  posterior  long  tract.  It  is  not  necessary  to  accept 
an  intimate  anatomic  relation  between  the  cells  for  the 
sphincter  muscles  of  the  pupil  in  the  oculomotor  nucleoB, 
and  the  various  centers,     [j.s  ] 

27. — XalbandofiF  reporta  a  case  of  syringomyelia  that 
is  interesting  chiefly  because  there  were  present  curious 
alterations  in  the  bone  that  have  not  hitherto  been  described. 
The  patient,  a  man  of  31,  had  been  normal  until  27  years, 
although  premonitory  symptoms  had  preceded  this  periid. 
The  disease  probably  commenced  in  the  left  shoulder ;  from 
time  to  time  there  was  severe  pain  and  swelling,  and  later  a 
considerable  amount  of  pus  was  evacuated,  but  a  subsequent 
incision  was  painless ;  later,  repeated  incisions  were  neces- 
sary. As  the  result  of  a  slight  wound  to  the  thumb,  the  part 
commenced  to  swell,  an  abscess  formed  around  the  nail, 
which  was  lost;  the  thumb  then  began  to  enlarge  consider- 
ably. The  symptoms  of  syringomyelia  were  characteristic. 
Nalbandoff  discus-ej  particularly,  the  alteration  in  the 
thumb;  although  the  bone  was  uninjured,  it  was  softer,  and 
as  it  failed  to  produce  a  shadow  with  the  Eoatgenray,  there 
was  probably  a  decalcifi  nation.  It  is  impossible  to  find  a 
fatisfactory  explanation  for  this,  but  it  is  not  likely  that  it 
was  the  result  of  the  abscess.    [J  s  ] 


Deut.sche  Zeitsclirift  fiir  Chirurgie. 

July,  1900.     [Bind  56,  Heft  3  u.  4.] 

9.  1.  The  So-called  Arterio-Me?enteric  Occlusion  of  the 
Intestine.  2.  Pnlegmonous  loflimmation  of  the 
Stomach  Following  Gaatroenterostomy.  3.  A  Crural 
Hernia  in  the  Labium  Mij  ti.     Alfred  Stieda. 

10.  Complete  Extirpation  of  the  Tongue  and  the  Fioor  of  the 

Mouth.    Gottlieb  Koltze. 

11.  Henat  )pexy.    Carl  BomcHEK. 

12.  A  Number  of  Cises  of  Meaingeal  Hemorrhage,  and  a 

Few  R'imarks  on  the  Technic  of  Opening  the  Skull  in 
these  Cjises.    Wie.maxs. 
13   The  Surgical  Treatment  of  E  iteroptoeis.     A.  Blecher. 

14.  Congenital   Absence  of  Muscles  of  Neck.    L.   Kredel. 

15.  Anastomosis  B  'tween  the  B'adder  and  Rectum,  by  Means 

of  Resorbable  Buttons.    Tne  Treatment  of  Exstrophy 
of  the  Bladder.    Jac  ib  Frank. 

16.  Abdominal  Sargerv  in  Private  Houses  and  in  the  Practice 

of  the  General  Practitioner.    Mais^hardt  Schmidt. 

17.  The  Treatment  of  Fracture  of  the  Patella  with  Perma- 

nent Extension.    Lichtekaukr 

9.— 1.  S  ieda  reports  an  interesting  ca^e  of  occlu-ion  of 
the  intestine  at  the  duodeno-jejunal  junction.  Tne  moat 
important  points  gathered  from  a  consideration  of  the  case 
were  the  following :  That  chronic  dilation  of  the  stomach 
connected  with  sinking  of  the  small  intestine  into  the  pel- 
vis, probably  c.innot  of  itself  lead  to  occlusion  of  the  intes- 
tine by  twist  in  the  mesentery.  This  condition  is  much  more 
likely  to  be  due  to  acute  atony  of  the  stomach  or  of  the 
duodenum.  As  this  atony  is  really  the  cause  of  the  acute 
obstructive  symptoms,  it  should  be  termed  acute  gastric 
dilation  of  the  stomach.  The  symptoms  are  very  prone  to 
occur  after  operation,  especially  on  the  bile-ducts.  In  every 
case  in  which  severe  and  continued  vomiting  occurs,  the 
surgeon  should  think  of  the  possibihty  of  gastric  complica- 
tions. The  treatment  of  these  cases  should  be  the  institu- 
tion of  a  proper  prophylaxis.  When  other  means  fail,  the 
performance  of  gas'roenter.^st  iniy  should  be  considered. 
2  This  case  of  "phlegmonous  inflammation  of  the 
stomach  occurred  in  a  womin  of  24.    An  operation  was 


JiNOABT  5,    19  tl] 


THE  LATEST  LITERATURE 


tTHK  Philadelphia 
Medical  Journal 


23 


done  for  gastric  disturbance  which  had  lasted  for  2  years  or 
more  and  consisted  of  pain  and  vomiting,  the  vomiting  often 
con9i8ted  of  "  coffee-grounds."  At  the  operation  a  hard 
tumor  was  found  in  the  region  of  the  pylorus,  almost  the 
size  of  an  apple.  Gastroenterostomy  was  performed,  and 
the  abdominal  wound  closed.  Seven  days  after  the  operation 
the  patient  died.  At  the  postmortem  the  suture  line  was 
found  intact,  not  allowing  any  leakage.  Oa  opening  the 
stomach  an  ulcer  was  found  in  the  region  of  the  pylorus, 
which  was  surrounded  by  a  diffuse  swelling  of  the  entire 
thickness  of  the  extract  wall.  An  anatomic  diagnosis  was 
made  of  carcinomatous  ulcer  of  the  pylorus,  with  phleg- 
monous gastritis  and  purulent  peritonitis.  3.  Hernia  in 
this  case  was  first  noticed  15  years  ago.  Less  than  a  year  ago 
the  patient  experienced  severe  pains  in  the  region  of  the 
rupture,  and  on  removal  of  the  trues,  which  for  some  time 
had  not  held  up  the  hernia  as  it  should,  the  tumor  was  seen 
to  be  markedly  enlarged  and  had  spread  into  the  right 
labium  majora.  At  the  operation,  the  hernia  was  found  to 
be  femoral  and  had  pushed  its  way  up  under  Poupari's  liga- 
ment until  it  gained  a  position  in  the  labium  mnjora.  The 
operation  was  completed  afcer  the  method  of  Bassini,  and 
the  patient  made  a  good  recovery,     [g  b.w.] 

lO. — Koltze  reports  a  case  of  complete  extirpation  of 
tbe  tong'ue  and  floor  of  the  mouth.  The  patient  was  a 
maa  of  53.  In  September,  1898,  a  tumor  developed  on  the 
point  of  his  tongue.  Ttiis  was  removed  by  Langenbeck's 
method,  of  sawing  through  the  left  side  of  the  lower  jaw. 
The  growth,  however,  returned  by  June,  1899,  and  had  de- 
veloped to  such  an  extent  that  it  was  considered  uaadvisable 
to  operate.  When  examined  by  Rose,  the  tongue  was  found 
thickened,  the  left  side  more  than  the  right,  it  was  wrinkled 
and  hard,  and  the  swelling  could  be  traced  clear  to  the  base 
of  the  tongue.  The  posterior  portion  of  the  tongue  closely 
approached  the  soft  palate,  and  the  anterior  almo.st  touched 
the  upper  incisor  tooth,  so  that  the  patient  was  forced  to 
keep  his  mouth  open  the  greater  part  of  the  time.  Opera- 
tion was  done  under  chloroform  narcosis.  An  incision  was 
carried  through  the  entire  thickness  of  the  under  lip  down 
to  the  bone ;  another  cut  running  at  a  right  angle  from  the 
first  was  carried  along  the  edge  of  the  lower  jiw  to  the  left 
angle  of  the  mandible.  A  pkin  flap  was  turned  upwards 
from  the  lower  jiw,  carefully  avoiding  the  mucous  mem- 
brane, and  an  exarticulation  of  the  left  side  was  done.  The 
horizjntal  incision  was  then  carried  toward  the  right  angle 
of  the  jiw,  and  the  latter  sawn  through  with  a  chain  saw  just 
below  the  ascending  right  ramus.  The  vessels  were  tied  a? 
soon  as  they  were  cut,  including  both  lingual  arteries  and 
the  left  facial  artery.  Starting  from  the  left  side  of  the 
wound,  the  tongue,  with  its  adj  lining  infiltrated  tissues  were 
cut  away  with  scissors  and  knife,  and  that  portion  of  the 
tongue  and  floor  of  the  mouth  still  ia  connection  with  the 
hyoid  bone  was  removed  with  Chassaignac's  ecraseur,  just 
immediately  in  front  of  the  epiglottis.  The  diseased  tonsils 
were  removed.  The  mucuouB  membrane  of  the  epiglottis 
was  then  stitched  to  the  remains  of  the  mucuous  membrane 
of  the  under  lip,  and  after  removal  of  an  inch  or  more  of 
the  soft  parts  of  the  chin,  the  skin  of  the  two  sides  of  the 
wound  was  sutured  together.  Feeding  of  the  patient  after 
the  operation  was  done  through  a  tube  introduced  by  him- 
self. Iq  9  days  the  external  wound  had  healed,  and  the 
granulated  surface  in  the  mouth  had  become  much  smaller. 
Fifteen  days  after  the  operation  the  patient  left  the  hospital. 
The  patient  could  swallow  belter  than  before  tlie  operation, 
and  speech  was  also  improved,     [o  b  w  ] 

11. — B6:,ticher  has  written  an  elaborate  article  on  hepat- 
opexy,  considering  the  subject  from  a  clinical  standpoint, 
and  he  ends  his  article  with  the  fjllowing  conclusions:  (1) 
In  cases  of  hepatoptosis,  the  only  real  cure  is  to  be  obtained 
by  the  performance  of  hepatopexy ;  (2)  in  hepatic  antever- 
sion,  that  is  partial  hepatoptosis,  hepatopexy  should  be  done 
when  other  treatment  has  failed  to  set  aside  the  severe  symp- 
toms ;  (3)  in  constricted  liver  found  in  persons  who  lace 
tightly,  hepatopexy  should  be  chosen  in  preference  to  resec- 
tion ;  (4)  in  cases  of  uncomplicated  hepatoptosis,  splendid  re- 
sults may  be  obtained  by  the  performance  of  hepatopexy ; 
(5)  when  the  hepatoptosis  is  only  a  part  of  a  general  splanch- 
noptosis, the  simple  hepatopexy  is  not  indicated, — in  this 
coudition  a  general  reconstruction  of  the  abdominal  wall  as 
performed  by  DePage  offers  the  best  hope  of  success ;  (6)  in 
those  cases  in  which  the  hepatoptosis  has  been  caused  by 


disease  of  the  gallbladder  in  which  there  is  a  marked  con- 
striction of  one  or  more  lobes  of  the  liver,  or  in  which 
one  of  the  lobes  is  floating,  or  in  which  chronic  disease 
of  a  greater  part  of  the  liver  is  present,  the  cholecys- 
totomy  will  afford  better  chances  of  success  if  preceded 
by  hepatopexy ;  (7)  in  order  to  cure  or  to  at  least  relieve 
the  symptoms  caused  by  partial  hepatoptosis,  it  is  not 
necessary  that  a  complete  reposition  of  the  movable  portion 
of  the  liver  should  be  made, — immobilization  will  accom- 
plish just  as  much;  (8)  in  order  to  produce  permanent  fixa- 
tion of  a  movable  liver,  the  efiort  should  be  made  rather  to 
produce  adhesions  than  to  fasten  by  sutures,     [g.b  w.] 

13. — In  speaking  of  surgical  treatment  of  enteroptosis 
in  general,  we  must  remember  that  the  movable  viscera,  such 
as  the  intestines  and  stomach,  cannot  be  fixed  firmly  to  a 
stationary  support  in  the  same  way  that  we  would  stitch  a 
kidney  back  into  the  lumbar  fossa.  Therefore,  an  ideal 
gastropexy  for  the  relief  of  gastroptosia  should  consist  in  the 
shortening  of  the  normal  supports,  which,  by  their  lengthen- 
ing, allow  the  viscera  in  question  to  move  and  drop  forward 
into  various  malpositions.  B.er's  method  of  operating  on 
these  cases  is  briefly  as  follows  :  Three  or  4  sutures  are  passed 
just  below  the  liver  through  the  ligamentum  gastrohepaticum 
in  such  a  manner  as  to  produce  folding — therefore,  a  shorten- 
ing of  the  ligament  when  they  are  drawn  upon  and  tied.  The 
shortening  of  this  ligament  brings  the  displaced  stomach 
back  into  its  normal  position.  Toe  first  suture  is  placed  close 
to  the  ligamentum  hepatico  duodenale  and  includes  the 
serous  and  muscular  coats  of  the  pylorus  and  the  capsule  of 
the  liver.  The  remaining  satures  are  inserted  in  a  direction 
towards  the  cardia.  Blecher  reports  4  cases  in  which  this 
operation  was  carried  out  by  Bier,  and  another  case  of 
colonoptosis  in  which  the  mesocolon  was  shortened  in  a  very 
similar  manner.  In  regard  to  indications  for  operating  in 
cases  of  enteroptosis,  Blecher  concludes  that  all  cases  of  float- 
ing or  movable  kidneys,  which  cause  more  or  less  distressing 
or  serious  symptoms,  should  be  operated  upon  and  the  offend- 
ing organ  firmly  fixed  in  its  normal  position.  Enteroptosis 
does  not  demand  operation  in  the  earlier,  or  what  might  be 
termed,  latent  stages.  Operation,  however,  is  indicated  when 
the  ptosis  is  marked  and  the  use  of  various  abdominal  bind- 
ers are  appirently  valueless;  various  internal  medications 
and  dieting  leave  the  condition  unchanged,    [g  b  w.] 

14. — Kredel  reports  an  interesting  case  of  congenital 
absence  of  the  important  muscles  of  the  neck.  The 
patient,  a  girl,  when  last  examined,  was  10  years  of  age. 
She  possessed  a  marked  cleft  palate,  was  of  rather  delicate 
build  and  showed  an  increasing  scoliosis.  Tne  deforrnity 
caused  by  the  absence  of  the  muscles  of  the  ne^k  was  a  high 
position  of  the  shoulders,  an  unusual  curving  of  the  clavicle, 
and  thinness  of  tbe  neck  itself.  There  was  complete  absence 
of  the  sternomastoid  on  both  sides,  though  electrical  stimu- 
lation caused  a  muscle  bundle,  about  2  mm.  thick,  to  stand 
out  on  the  left,  which  perhaps  was  a  rudiment  of  the  left 
sternomastoid  muscle.  Both  trapezium  muscles  were  also 
absent  in  the  back  between  the  shoulders,  as  well  as  in  the 
neck,  and  no  trace  of  the  omohyoid  could  bs  discovered. 
The  anterior  muscles  of  the  neck,  that  is  sternohyoid  and 
sternothyroid,  were  present,  and  indeed  hypertrophied.  Per- 
haps the  most  surprising  part  of  the  whole  case  was  that 
there  was  practically  no  disturbance  of  function,  all  normal 
movements  of  the  head  being  apparently  retained,    [g.b  w.] 

15.— Frank  has  made  a  series  of  expsriments  on  dogs  in 
endeavoring  to  discover  a  method  of  establishing^  an 
opening  between  the  bladder  and  rectum.  T.ie  re- 
sults he  obtained  are  important  cliaioally,  because  of  their 
application  to  cases  of  exstrophy  of  the  bladder.  The  opera- 
tion consisted  in  nuking  an  incision  in  the  lower  part  of  the 
abdomen,  drawing  forward  the  bladder  and  rectum  and  per- 
forming an  anastomosis  by  means  of  a  resorbable  button 
The  button  consisted  of  decalcified  bone.  Ojt  of  15  dogs 
thus  operated  upon,  9  recovered  and  6  died.  He  says  this 
operation  would  be  more  favorable  in  men,  because  of  tl\e 
ability  of  carrying  out  proper  after-care  and  treatment.  The 
advantages  claimed  for  this  operation  are  :  (I)  The  easy  ex- 
ecution and  the  shortness  of  the  time  of  operation ;  (2)  the 
lack  of  danger  of  ureteral  stricture  through  cicatrization 
and  the  absence  of  the  possibility  of  necrosis ;  (3)  the  pro- 
portionately small  danger  of  infection  ;  and  (4)  the  operation 
is  applicable  not  only  in  exstrophy  of  the  bladder,  but  to  other 
pathologic  changes  of  these  organs,    [g  b.w.] 


24 


Thk  Philadelphia 

Medical  Journal 


] 


PRACTICAL  THERAPEUTICS 


[Jahdabt  5,  IMI 


practical  Ct^crapcuttcs. 

Under  the  charge  of 

A.  A.  STEVENS,  A.M.,  M.D. 


For  Perspiration  of  the  Feet. — A  case  of  excessive 
perspiration  of  the  feet,  of  years'  duration,  and  of  such  an 
oflfensive  character  that  the  subject  had  contemplated  sui- 
cide, was  cured  {Gazelle  Med.  de  Picardie)  by  Legoux  in  15 
days.  The  means  employed  were :  The  feet  were  first  bathed 
for  several  days  in  a  weak  infusion  of  walnuHeaves,  and 
then  there  was  applied  twice  a  day  a  mixture  of 

Glycerin  10  grams. 

Perchlorid  of  iron    30  grams. 

Essence  of  bergamot 20  drops. 

Mix  and  apply  as  directed  twice  each  day. 
The  results  are  surprisingly  rapid  and  happy. — Dietetic  and 
Hygienic  Gazelle. 

Hemoptysis  in  Pulmonary  Tuberculosis.— Hecht 

{Therap.  Monalshefle,  October,  1900)  believes  that  quinin  is 
the  most  valuable  drug.  He  is  skeptical  as  to  the  value  of 
ergot,  though  he  often  prescribes  it.  He  has  had  excellent 
results  with  Huchard's  hemostatic  pills,  the  formula  of  which 
is  as  f  jllows  : 

K. — Ergotin ~| 

Qiinin  sulfate ,        ,   „. 

Powdered  digitals |  of  each  30  grams. 

Extract  of  hyoscyamus J 

Divide  inio  20  pills.    Five  to  ten.pills  daily. 

The  Treatment  of  Blepharitis.— Pyle  (International 
Medical  Magazine,  October,  1900)  states  that  in  approaching 
the  treatment  of  blepharitis  especial  attention  should  be 
•directed  to  the  causal  conditions.  Too  great  stress  cannot  be 
laid  on  the  importance  of  careful  refraction  under  cyclo 
plegia  and  the  prescription  of  sphero  cylindric  lenses,  even 
of  low  power,  in  these  cases.  Any  disturbance  of  the  oculo- 
motor apparatus  should  be  remedied.  If,  as  is  the  rule, 
chronic  conjunctivitis  coexists,  a  mild  stimulating  astringent 
incorporated  in  a  boric  acid  coUyrium  should  be  used.  A 
favorite  eye-lotion  with  the  author  is  the  following : 

B.— Boric  acid  40  grains. 

Sodium  chlorid 10  grains. 

Zinc  chlorid    2  grains. 

Distilled  water   4  ounces. 

Stain  with  pyoktanin  and  doubly  filter  after  straining. 

A  few  drops  of  this  solution  are  instilled  in  each  eye  three 
times  a  day.  All  scales  and  crusts  should  be  carefully  re 
moved  morning  and  night.  Absorbent  cotton  moistened 
with  warm  water,  warm  boric  acid  solution,  or  warm  bi- 
chlorid  solution,  1  to  5000,  may  be  used  to  loosen  the  ac- 
cumulated secretions.  Any  underlying  ulcers  should  be 
cleansed,  the  cilia  epilated,  and  the  cavities  painted  with  a 
2%  solution  of  silver  nitrate  or  lightly  touched  with  a  sharp- 
pointed  lunar  caustic  pencil.  Toe  application  of  fatty  sub- 
stances facilitates  removal  of  crusts,  prevents  further  occlu- 
sion of  the  glands,  softens  the  skin,  prevents  excoriation  by 
the  tears,  and  aflfc^rds  a  vehicle  for  local  medication.  The 
author  prefers  as  an  ointment  "  Pagenstecher's  yellow  salve." 

R . — Yellow  mercuric  oxid  (amorphous) 1  grain. 

Vaselin  3  grains. 

Mix  thoroughly  and  put  in  a  collapsible  tube.  Rub  in 
thoroughly  a  piece  the  size  of  match  head,  each  morning 
and  night. 

Scales,  crusts,  dried  secretions,  etc.,  must  be  thoroughly 
removed  before  each  application  of  the  salve. 

llTreatment  of  Aneurysm  of  the  Aorta In  the 

Section  of  Therapeutics  at  the  recent  International  Congress 
of  Medicine,  Golubinin  (British  Medical  Journal,  October  13, 
19),  of  Moscow,  said  he  had  employed  in  8  cases  the  method 
of  treating  aortic  aneurysm?  by  injection  of  gelatinized  serum 
recommended  by  Lincereaux  and  Paulesco.  The  number  of 
injections  varied  according  to  the  case  from  2  to  15.    Of  the 


8  patients  4  died  in  a  short  time  and  the  other  4  were  lost 
sight  of;  in  3  of  the  cases  belonging  to  the  latter  group  the 
injections  produced  no  effect.  In  the  remaining  one  they 
were  followed  by  slight  improvement  in  the  subjective  symp- 
toms without  modification  of  the  objective  signs.  Dr  Golu- 
binin had  come  to  the  conclusion  that  the  method  did  not 
fulfil  the  expectations  that  had  been  founded  on  it.  Dr. 
Huchard  said :  In  the  treatment  of  aortic  aneurysms  it  is  a 
mistake  to  allow  oneself  to  be  hypnotized  by  the  changes  to 
be  brought  about  in  the  contents  of  the  sac,  that  is  to  say,  in 
the  blood,  and  to  take  no  account  of  the  containing  structure. 
The  method  of  gelatinized  injections,  which  is  useful,  al- 
though insufficient,  is  open  to  this  criticism.  To  complete 
its  action,  especially  in  persons  with  large  heart  and  increased 
arterial  tension — they  are  almost  always  at  the  same  time 
subjects  of  Bright's  disease — medicaments  should  be  chosen 
which  diminish  arterial  tension,  such  as  potaasiun  iodid, 
trinitrine,  nitrite  of  amyl,  and  especially  tetranitrate  of  eryth- 
rol,  or  tetranitrol,  which  Dr.  Huchard  has  now  used  for  a  con- 
siderable time  and  which,  as  compared  with  trinitrine,  has 
the  advantage  of  a  more  durable  action.  Moreover,  an 
essential  point  is  to  supervise  to  diet,  not  in  regard  to  quan- 
tity, as  in  Valsalva's  method,  but  in  regard  to  quality.  Meat, 
which  holds  too  large  a  place  in  our  food,  contains  toxins, 
which  have  an  excessively  powerful  vaso-constrictor  action. 
The  best  treatment  of  aortic  aneurysm  ia  still  absolate  milk 
diet  regularly  adhered  to. 

Herpes  Zoster. — Lush  (Post- Graduate)  recommends 
light  touches  with  the  actual  cautery  over  the  angle  of 
the  rib  and  spine  at  the  exit  of  the  nerve,  and  the  following 
application  : 

R. — Ichthyol 2  drams. 

Magnesium  carbonate 2  drams. 

Zinc  oxid  2  drams. 

Water 4  ounces. 

To  be  sopped  on,  after  which  a  binder  is  to  applied  to  pre- 
vent friction.  Cannabis  indica  and  ars3nic  internally  are 
sometimes  useful. 

Iodized  Starch  as  a  Therapeutic  Agent Solomon 

[Merck's  Archives,  December,  1900)  states  that  iodized  starch 
may  be  prepared  as  f  jUows  :  5  parts  of  iodin  are  triturated  in 
a  small  qiiantity  of  water,  and  95  parts  of  starch  slowly  added 
and  carefully  rubbed  until  the  mixture  is  regularly  and  uni- 
formly a  blue  black.  This  is  now  to  be  slowly  dried,  at  a 
temperature  not  higher  than  101°  F  ,  and  carefully  rubbed 
until  a  fine,  blue  powder  results.  Prepared  thus,  we  have 
approximately  a  5%  iodizjd  starch,  which  is  insoluble  in 
water,  has  the  characteristic  iodin  taste — provided  it  be  held 
in  the  mouth  a  few  seconds — and  a  s'ight  iodin  odor.  It 
should  be  kept  in  glass-stoppered  vials.  It  may  be  pre- 
scribed whenever  iodin  is  indicated,  and  when  the  iodids 
would  ordinarily  be  employed,  iodized  starch  may  be  ex- 
hibited ;  its  action  is  prompt,  and,  in  proper  dose,  energetic 
Being  an  important  article  of  food,  starch  makes  an  admi- 
rable diluent  or  menstruum,  differing  from  other  bases,  like 
potassium,  sodium,  strontium,  etc.,  which  are  each,  to  a 
greater  or  less  extent,  foreign  to  human  economy.  As  a 
rule,  from  3  to  10  grains  in  capsule,  pill,  powder,  or  tablet, 
were  necessary  to  procure  a  desired  effect.  Where  large 
doses  of  the  iodids  had  been  attempted,  but  on  accoimt  of  irri- 
tation could  not  be  continued,  comparative  lest*  showed  the 
necessity  for  equally  large  quantities  of  iodized  starch,  as  much 
as  1  to  2  drams,  suspended  in  barley-water,  being  sometimes 
given.  Even  such  heroic  doses  give  rise  to  no  distressing 
local  effects  on  the  stomach  or  bowel  mucosa.  The  advan- 
tages of  iodized  st-irch  may  be  thus  summarixed :  Pnyeio- 
logically  it  is  an  active  preparation  of  iodin,  for  internal  as' well 
as  for  external  use,  free  from  the  irritant  and  caustic  action 
of  most  iodin  prrductB  It  is  not  objectionable  to  any  of  the 
special  senses,  and  its  convenience  for  preparing  and  admin- 
istering in  capsule,  tablet,  etc,  adds  considerably  to  its 
virtues.  It  is  sufficiently  stable  to  be  preserved"  almost 
indefinitely  under  precautions  known  to  the  apothecary. 
There  can  be  no  doubting  the  absorbability  of  the  iodin  in 
iodized  starch,  but  the  iodid  of  potassium  will  be  found  a 
more  active  preparation.  It  is  in  the  cases  in  which  the 
latter  salt  or  other  iodids  CAnnot  be  tolerated  that  iodised 
starch  becomes  a  valuable  addition  to  our  armamentarium. 


Jandaby  5,  1901] 


PRACTICAL  THERAPEUTICS 


[The  PHn.u>ELPHiA 
Medical  JonsNAL 


25 


Thyroid  Extract  In  Insanity. — Easterbrook  (Srotiiah 
Medical  and  Surgical  Journal,  December,  1900)  reports  the 
following  results :  Out  of  130  patients  treated,  12  recovered, 
29  were  improved,  and  89  unimproved.  Twelve  recoveries 
out  of  130  cases  is  just  over  9^.  If,  however,  the  obviously 
incurable  cases  be  eliminated,  namely,  the  30  "  congen- 
ital "  and  "  chronic  "  cases,  there  remain  100  cases  with  12 
recoveries,  or  12^  of  recoveries  for  all  cases  of  insanity 
which  were  not  hopeless,  but  were  found  to  be  intractable  by 
ordinary  methods.  His  experience  indicates  that  the 
thyroid  treatment  of  insanity  is  more  efficacious  in  women 
than  in  men,  and  that  the  best  all-round  results  are  obtained 
in  the  insanities  connected  with  child-bearing.  His  results 
may  thus,  perhaps,  indicate  that  the  thyroid  gland  is  func- 
tionally more  active  in  women  than  in  men.  Anatomists 
and  physiologists  inform  us  that  the  gland  is  somewhat 
larger  in  women  than  in  men,  and  that  it  often  enlarges 
during  menstruation  and  pregnancy.  He  has  come  across 
no  rational  explanation  of  this  physiological  enlargement  of 
the  thyroid  during  menstruation  and  pregnancy,  but  woul^ 
suggest  that  it  is  either  a  provision  of  nature  to  supply  more 
thyroid  secretion  for  the  development  of  the  embryonic 
tissues  in  their  earliest  stages  ;  or  more  probably,  that  it  is 
an  expression  of  an  increased  maternal  metabolism,  affect- 
ing more  particularly  the  uterus  and  also,  in  cases  of  preg- 
nancy, the  mammse.  All  the  recoveries  were  test  cases  in 
the  sense  that  previous  treatment  had  been  well  tried,  but 
had  failed.  Large  doses  of  thyroid  were  used  in  every  case 
of  recovery.  He  has  had  no  case  of  recovery  (except  the 
myxedematous  patient)  with  small  or  moderate  doses.  This 
seems  to  indicate  that  it  is  the  briskness  and  intensity  of  the 
metabolic  reaction  produced  which  is  the  valuable  effect  of 
thyroid  in  large  doses  in  insanity,  and  he  is  inclined  to  think, 
from  the  clinical  type  of  case  which  is  most  commonly  bene- 
fited by  thyroid,  as  well  as  from  the  condition  of  the  urine 
during  thyroidism,  that  the  drug  owes  much  of  its  value  to 
its  power  of  clearing  out  of  the  system  various  transition 
and  probably  toxic  products  of  metabo!iem. 

Operative  Treatment  of  Cirrhosis  of  the  Liver. — 

Friedrich  Friedmana,  in  the  Ce.nlralblalt  fii.r  die  Orenzgebiete 
der  Medizia  und  Chirurgie  of  August  8,  1900  {Medicine,  0-to- 
ber,  1900),  has  a  resume  of  the  recent  literature  of  this  opera- 
tion. Tlie  first  case  in  which  there  was  a  deliberate  attempt 
to  reestablish  the  circulation  in  the  abdomen  in  a  case  of 
contracted  liver  was  made  in  the  Royal  Hospital  of  Newcastle 
by  Drummond  and  Morrison  in  August,  1894.  The  authors 
had  been  led  to  perform  the  operation  from  a  case  which  had 
been  observed  postmortem,  in  which  anastomosis  had  formed 
in  such  a  way  as  to  permit  of  the  circulation  being  carried 
on  without  the  blood  passing  through  the  liver.  The  possi- 
bilities of  such  communication  are  said  to  be  several  — 
namely,  anastomosis  between  the  coronary  veins  and  those 
of  the  lower  portion  of  the  esophagus;  between  the  hemor- 
rhoidal veins  and  the  hypogastric  veins ;  a  communication 
between  the  veins  found  in  the  hepatic  ligament  and  those  of 
Glisson'a  capsule ;  the  veins  of  the  cecum  and  colon  are  said 
to  anastomose  with  the  internal  mammary  vein.  Since  the 
first  operation,  13  have  been  performed.  Of  these,  5  have 
recovered,  2  were  improved,  in  1  there  was  no  change,  and  5 
died.  These  results  point  conclusively  to  the  value  of  the 
operation,  as  these  patients  had  very  little  to  look  forward  to 
without  surgical  intervention.  The  kind  of  cases  in  which 
the  operation  is  indicated  are  those  in  which  there  is  a 
distinct  mechanical  hindrance  in  the  portal  circulation 
with  recurring  ascites.  It  is  in  this  class  of  c*ses  that 
80  little  is  to  be  hoped  for  from  operative  measures,  the 
patients  having  little  to  look  forward  to  except  a  lingering 
illness  and  comparatively  early  death.  The  technic,  as  car- 
ried out  in  most  of  the  cases,  is  comparatively  simple,  con- 
sisting of  a  small  incision  into  the  abdominal  cavity,  through 
which  a  careful  exploration  is  made  of  the  liver,  gallbladder, 
and  the  surrounding  parts.  The  peritoneum  is  curetted  over 
the  anterior  surface  of  the  abdomen,  and  the  great  omentum 
is  attached  by  sutures  to  the  abdominal  wall.  The  peritoneum 
has  its  epithelial  covering  removed  over  the  lateral  and 
anterior  portion  on  the  left  side  of  the  abdomen,  to  which 
the  spleen  is  likewise  attached.  A  glass  drain  is  then  inserted, 
and  all  ascitic  fluid  of  the  abdominal  cavity  is  removed. 
This  drainage  is  continued  until  no  further  fluid  is  formed, 
which  shows  that  the  collateral  circulation  has  been  estab- 


lished. The  success  of  the  operation  is  absolutely  dependent 
upon  a  functional  intact  condition  of  the  liver  cells ;  the 
ascites  being  merely  dependent  upon  mechanical  hindrance 
to  the  onward  flow  of  blood.  Hence,  in  cases  of  cirrhosis  it 
should  be  undertaken  before  the  process  in  the  liver  has  ad- 
vanced so  far  as  to  involve  the  functional  integrity  of  these 
cells. 

Indications  for  Bleeding. — In  the  Congress  of  Medioine, 
1900,  Hayem  (Treatment,  November  1900)  recommended 
this  procedure  under  the  following  conditions  : 

A  therapeutic  measure  is  "  indicated  "  when  it  is  estab- 
lished that  it  brings  about  under  given  circumstances  an  ame- 
lioration more  marked  than  any  other  means  can  procure. 

The  procedure  of  bleeding  cannot  then  be  considered  as 
"  indicated  "  save  in  those  cases  in  which  it  acts  with  an  in- 
contestable superiority  over  all  other  therapeutic  measures. 

Toe  "  antiphlogistic  method "  of  repeated  bleedings 
appears  to  be  definitely  condemned. 

The  opening  of  a  vein  on  one  or  several  occasions,  at  rela- 
tively long  intervals,  deserves  to  be  maintained  as  a  useful 
and  effective  measure. 

Tne  cases  in  which  bleeding  is  indicated  are,  speaking 
generally,  those  in  which  life  is  immediately  endangered, 
either  by  circulatory  arrangement  or  by  toxemia,  in  such 
conditions  as  the  following : 

1.  Acute  edema  of  the  lung,  particularly  in  disease  of  the 
large  vessels  or  of  the  kidneys. 

2.  Certain  cases  of  pneumonia  of  edematous  or  simply 
congestive  type. 

3.  Certain  mechanical  troubles  of  the  circulation,  due  to 
disease  of  the  heart  or  great  vessels,  particularly  in  high  arte- 
rial tendon,  but  also  in  some  cases  of  evident  asystole,  con- 
gestive, and  hemorrhage  in  subjects  of  high  arterial  tension. 

4.  Recent  or  acute  uremia;  puerperal  eclampsia;  intoxi- 
cation of  the  blood  by  certain  gases,  notably  cirbonic  oxid. 

Value  of  Ovarian  Organotherapy.— Krusen  {Inter- 
national Medical  Magazine,  November,  1900)  draws  the  follow- 
ing conclusion  from  31  years'  experience  with  ovarian  extract 
in  selected  cases:  1.  The  employment  of  ovarian  extract  is 
practically  harmless;  no  outward  effects  beyond  slight  nau- 
sea have  been  noted,  even  when  full  doses  have  been  adminis- 
tered. 2.  In  the  treatment  of  amenorrhea  and  dysmenor- 
rhea, no  good  results  were  secured  ;  (although  in  some  cases 
of  the  amenorrhea  of  obesity  remarkable  results  have  been 
attained  by  the  use  of  the  thyroid  extract).  3.  The  best  re- 
sults were  seen  in  the  second  class  of  cases  for  the  relief  of 
symptoms  of  artificial  menopause,  where  in  a  few  instances 
the  congestive  and  nervous  symptoms  were  apparently  ame- 
liorated. 4.  No  appreciable  result  was  noticed  in  the  use  of 
ovarine  in  the  natural  menopause.  5.  No  definite  or  exact 
reliance  can  be  placed  upon  the  drug,  as  it  often  proves  ab- 
solutely valueless  where  most  positively  indicated.  6.  It  is 
extremely  problematic  whether,  in  those  cases  in  which  re- 
lief was  noted,  the  effect  was  not  due  to  mental  suggestion 
rather  than  to  any  direct  physiologic  action  of  the  drug. 
The  neurotic  type  of  individual  demanding  this  treatment 
will  often  be  relieved  by  any  simple  remedy.  7.  In  those 
instances  in  which  effects  were  noted,  increase  in  dosage 
seemed  to  have  little  influence  in  maintaining  the  effect 
or  preventing  the  patient  becoming  accustomed  to  its  use. 
8.  In  conclusion,  the  theory  which  suggests  the  use  of  this 
extract  seems  to  be  at  fault,  and  the  administration  of 
ovarine  or  ovarian  extract  is  based  upon  a  wrong  assump- 
tion as  to  the  function  of  the  ovary.  In  organotherapy,  the 
best  results  have  been  attained  by  the  use  of  thyroid  and 
adrenal  glands,  and  the  ovary  in  function  is  in  no  sense  anal- 
ogous to  these  organs.  Its  principal  function  is  ovulation, 
and  if  any  peculiar  product  is  coincidently  manufactured, 
the  isolation  of  this  product  has  not  yet  been  accomplished. 

Flechsig's  Opium  Treatment  of  Epilepsy.— S^glar 

and  Heitz  {Archives  de  Neurologic,  August,  1900)  report  the 
results  of  Flechsig's  treatment  in  two  series  of  cases  of  epi- 
lepsy. In  the  first  series  of  12  cases,  6  were  able  to  undergo 
the  full  treatment  without  any  serious  toxic  results;  in  3 
of  these  the  treatment  had  no  result,  while  in  the  other  3, 
watched  for  a  year,  the  number  of  convulsive  attacks  was  re- 
duced by  about  one  half.  In  the  second  series  of  10  cases, 
the  administration  of  the  opium  caused  toxic  symptoms  in 
all  cases,  so  that  the  treatment  was  not  continued. 


26 


The  Philadelphia 
Medical  Journal 


] 


A  PHYSICIAN'S  HOLIDAY  AT  KARLSBAD 


[Jakcabt  5, 19M 


(Driginal  ^irttcles. 


A  PHYSICIAN'S  HOLIDAY  AT  KARLSBAD. 
By  JAMES  TYSOX,  M.D., 

of  Philadelphia. 
Professor  of  the  Theory  and  Practice  of  MediciDe  in  the  University  of  Penna. 

To  THE  American  seeking  Karlsbad,  by  far  the  most  con- 
venient route  is  by  steamer  to  Hamburg  and  thence  by  rail 
via_  Berlin  and  Dresden,  arriving  in  18  hours  by  day  or  night 
train.  A  break  in  the  journey  may  be  made  at  either  of  the 
last  named  places.  Northern  Germany  in  somewhat  flat 
and  monotonous,  but  to  one  who  travels  it  for  the  first  time  it 
is  still  sufficiently  novel  to  make  a  day  trip  enjoyable.  Dres- 
den once  passed,  the  scenery  becomes  more  varied  and  attrac- 
tive. First  is  traversed  the  valley  of  the  Elbe,  swiftly  flowing 
between  high  and  sometimes  rugged  hills,  then  the  valley  of 
the  Eger  to  its  junction  with  the  Tepel  on  both  sides  of 
which  Karlsbad  is  built.  Some  minutes  before  arriving  at 
our  destination  its  nearness  is  proclaimed  by  a  fine  view  of 
the  Stephanie  Tower,  erected  on  the  summit  of  one  of  the 
many  adjacent  hills  to  commemorate  a  visit  of  the  Princess 
Stephanie.  Insignificant  as  appears  the  little  river  Tepel, 
to  the  visitor  in  the  season,  on  more  than  one  occasion 
freshets  have  washed  away  its  bridges,  while  the  town  itself 
has  suflFered  destructive  inundations.  So  narrow  is  the 
valley  in  places  that  there  is  room  for  but  a  single  row  of 
houses  and  shops  on  each  side.  Much  of  the  town  is  built 
in  terrace-like  arrangement  on  the  mountain  sides.  It  has 
grown  rapidly  of  late  years  and  accommodates  now  15,000 
permanent  residents  and  50,000  patients  annually,  exclusive  of 
visitors  and  touriets.  Itself  over  1200  feet  above  the  level  of  the 
Adriatic  Sea,  the  town  is  further  surrounded  by  the  Karls- 
bad Hills,  which  rise  from  200  to  800  feet  higher.  As  the 
stream  is  ascended  the  hills  separate  to  form  a  wide,  luxuri- 
ant meadowed  valley.  This  valley  opens  to  the  north,  which 
expla-ins  the  lower  and  changing  temperature  that  char- 
acterizes it  as  contrasted  with  the  adjacent  country,  and 
necessitates  at  all  seasons  a  judicious  selection  of  clothing. 
Toe  hillg  are  also  covered  with  a  dense  growth  of  fir,  pine, 
oak,  and  beech,  which  by  their  various  shades  of  green  add 
a  further  charm  to  the  beautiful  scenery.  The  hills  are 
traversed  by  miles  and  miles  of  paths  of  easy  grade  provided 
and  scrupulously  cared  for  by  the  authorities  for  the  pleasure 
and  benefit  of  the  patients. 

It  is  at  first  a  disappointment  to  the  visitor  to  find  that 
the  springs  are  not  in  the  center  of  beautiful  parks,  as  is  the 
case  at  so  many  of  the  European  spas,  but  are  in  the  heart  of 
the  town.  In  this  respect  it  is  more  like  Aixla-Chapelle. 
The  springs  are,  however,  surrounded  by  imposing  colon- 
nades ar.d  halls  erected  for  the  convenience  of  visitors,  while 
the  missing  park  is  more  than  compensated  for  by  the  walks 
referred  to,  almost  every  one  of  which  leads  to  a  picturesquely 
situated  caf6,  offering  tempting  refreshment  to  the  pedes- 
trian, and  commonly  presenting  an  extended  view  of  the 
surrounding  country. 

The  several  springs  which  constitute  the  Karlsbad  Spa  do 
not  differ  essentially  in  the  composition  of  their  waters,  the 
chief  diflierence  being  in  the  temperature  at  which  they 
emerge  from  the  earth.  Sodium  sulfate,  sodium  carbonate, 
and  sodium  chlorid  are  the  principal  constituents  of  each, 
and  are  found  in  astonishingly  close  proportions  in  the  dif- 
ferent springs,  as  seen  in  the  appended  table: 

Thus  the  springs  are  of  the  alkaline  saline  class,  contain- 
ing also  considerable  carbonic  acid.  The  temperature  of  the 
different  waters  as  they  are  discharged  is  as  follows  : 

Deg.  R.  Deo.  C.  Dko.  F. 

Sprudel 58.0  72.5  162.5 

Franz  Josephs  Quelle 51.0  6^.7  146.7 

Bernhardsbrunn ...  48.5  60.7  141.2 

Felsenq  idle    47  8  59.7  1S9.5 

Neubninn 47.2  59  0  138.2 

Tiicrcsienbrunu 46  2  57  7  135  8 

Schlosshrunn 39.2  490  120.2 

Kaiserbrunn 38.8  48  5  119.3 

Muehlbrunn 384  48.0  118.4 

Russische  Krone, 36  4  455  113.9 

Marktbrunn   32.8  41.0  105.8 


Dkg.  p..  Deg.  C.  Dbg.  F. 

Elisabethquelle  32.5  40.7  ia5.2 

Parkquelle 32.2  40.2  1014 

Kaiser  Karl  Quelle  31.5  39.4  102  9 

Kochberger  Quelle 31.5  39.4  102  9 

Spitalbrunnen 28.2  35.2  953 

It  will  be  seen  that  the  water  from  the  Sprudel  Spring  ia 
the  warmest,  being  162  5°  F.  It  is  also  spoken  of  as  the 
"strongest,"  but  it  is  evident  that  any  increased  activity  can- 
not be  due  to  increased  proportion  of  constituents.  It  ia 
probably  due  to  the  higher  temperature,  which  favors  its 
more  rapid  absorption  and  greater  activity.  It  is  certainly 
the  most  interesting  to  the  ca£ual  visitor.  Often  totilly 
obscured  by  the  steam  which  arises  in  dense  clouds  above 
and  around  it,  it  suggests  a  huge  boiling  caldron.  From  ita 
center  spout  columns  of  hot  water  which  scatter  the  spray  so 
widely  that  the  water  must  be  dipped  up  with  cups  at  the  end 
of  long  poles,  while  the  girls  serving  it  are  protected  with 
waterproof  coats  and  jaunty  rubber  caps. 

All  the  springs  belong  to  the  municipality  of  Karlsbad,  and 
immense  sums  of  money  have  been  spent  from  time  to  time 
in  constructing  handsome  colonnades  and  sumptuous  bath- 
houses about  them.  Of  the  former,  the  finest  is  the  Muhl- 
brunn  Colonnade,  erected  at  a  cost  of  $320,000,  competing  in 
architectural  beauty  with  any  similar  structure  in  the  world. 
The  Sprudel  Pavilion,  built  over  the  Sprudel  and  Hygeia 
Springs,  is  a  large  and  handsome  hall  constructed  of  glass 
and  iron.  In  connection  with  it  are  also  bathhouses.  The 
bathing  establishments  are  the  "  Kurhaus,"  with  mineral 
water- baths,  mud  baths,  douches,  common  water  baths,  and 
carbonated  water  baths;  the  "  Neubad,"  with  Sprudel  water 
baths  and  mud  baths ;  and  latest  of  all,  the  costly  "  Kaiser- 
bad,"  completed  in  1895  at  a  cost  of  nearly  half  a  million  dol- 
lars. It  contains  thermal  and  common  water  baths,  cold 
douche  and  shower  baths,  mud  baths,  electric  baths,  and 
electric-light  baths,  with  a  complete  Zinder's  establishment 
for  Swedish  hygienic  gymnastic  and  massage.  These  fine 
modern  buildings,  some  of  which  contain  also  offices  and 
reading-rooms,  were  constructed  in  rapid  succession  since 
1875  to  meet  the  growing  demand  of  annually  increasing 
visitors,  taking  the  place  of  older  and  more  imperfecf  struc- 
tures. 

Why  patients  go  to  Karlsbad. — It  is  creditable  to  the  physi- 
cians and  others  interested  in  Karlsbad,  that  they  do  not 
claim  that  the  "  Cure,"  as  it  is  called,  is  applicable  to  all  dis- 
eases. On  the  other  hand,  they  publish  a  long  list  of  which 
the  contrary  is  stated.  Thus  it  is  contraindicated  in  infiim- 
matory  and  febrile  affections,  in  bronchitis  and  tuberculosis 
of  the  lungs,  in  secondary  and  tertiary  syphilis,  in  carcinoma 
and  the  various  degenerations,  in  diseases  of  the  heart  and 
bloodvessels,  especially  atheroma  and  aneurysm,  in  preg- 
nancy, in  advanced  Bright's  disease,  in  the  debility  of  old  age, 
or  where  there  is  decided  weakness  from  any  cause ;  nor,  so 
far  as  I  know,  is  any  eflSciency  claimed  for  these  waters  in 
the  treatment  of  diseases  of  the  nervous  system.  Cirrhosis  of 
the  liver  is  also  an  affection  for  which  no  benefit  is  claimed. 

Before  ttiking  up  the  diseases  for  which  the  treatment  is 
beneficial,  let  us  consider  first  the  eflect  of  the  waters,  and  in 
what  the  treatment  consists.  As  to  whether  they  are  palata- 
ble or  not,  is  largely  a  matter  of  individual  taste.  To  me 
both  warm  and  cold  waters  were  agreeable,  and  to  the  ma- 
jority they  are  not  unpleasant.  Yet,  during  my  visit,  I  met 
one  of  my  Philadelphia  medical  friends  who  told  me  that  the 
Sprudel  water  so  nauseated  him  that  he  was  unable  to  take 
it.  This  I  believe  to  be  unusual.  When  drunk  they  come 
first,  of  course,  in  contact  with  the  mucous  membrane  of  the 
stomach  and  bowels,  and  are  said  to  be  soothing  to  these  sur- 
faces, allaying  pain  and  arresting  sparm.  These  efiects  may 
be  produced  by  neutralizing  unnatural  acidity,  I  see  no",  how 
else.  After  absorption,  their  alkaline  constituents  increase 
the  alkalinity  of  the  blood,  promote  its  solvent  power  and  its 
mobility.  Thus  is  counteracted  any  tendency  to  stagnation, 
especially  in  the  portal  circulation.  This  effect  is  further 
favored  by  the  purgation  which  is  induced  in  a  few  days,  if 
not  immediately  after  their  use  is  commenced.  Such  facility 
of  circulation  also  relieves  the  lymphatic  vessels,  and  it  is 
thought  favors  molecular  change  and  the  absorption  of  sub- 
cutaneous fat  and  inflammatory  products.  By  the  purgative 
effect,  too,  the  bowels  are  flushed  and  cleared  of  mucus  and 
accumulated  feces,  while  normal  secretion  is  thus  stimulated. 


Jahuary  5,  I'JOl] 


A  PHYSICIAN'S  HOLIDAY  AT  KARLSBAD 


rTHE  Philadklphia 
NiEDlCAL  JOCRNAL 


27 


The  effect  of  the  waters  is  increased  when  drunk  on  an  empty 
stomach,  when  absorption  is  most  rapid.  The  hotter  waters 
are  taken  when  more  energetic  action  is  desired,  the  cooler 
when  a  less  positive  effect  is  sought.  The  greater  activity  of 
the  hotter  waters  is  ascribed,  as  already  stated,  to  their  more 
rapid  absorption.  The  quantity  advised  varies  from  two  to 
six  cups  a  day — 10  to  30  ounces — and  is  determined  by  the 
physician  who  is  consulted.  So  far  as  I  could  ascertain,  the 
larger  quantities  are  rarely  ordered.  Several  minutes  should 
be  occupied  ia  the  drinking,  and  from  10  to  15  minutes  al- 
lowed ''  between  cups."  The  promenade,  the  music  of  the 
orchestras  which  play  from  6  to  8  at  the  more  popular 
gpriogs — the  Muhltrunn  and  the  Sprudel — the  novel  sur- 
roundings which  include  especially  peculiarities  of  appear- 
ance and  dress  characteristic  of  different  nationalities,  all 
contribute  to  make  the  time  puss  pleasantly  and  rapidly. 

But  the  drinking  of  the  waters  is  by  no  means  all  of  the 
KarUbad  treatment,  and  it  is  conceded  by  the  most  enthusi- 
astic of  its  supporters  that  if  limited  to  this  only,  the  treat- 
ment would  be  far  less  efficient,  as  well  as  less  picturesque 
and  pleasurable.  The  visit  to  the  springs  is  early,  between 
6  and  8.  Perhaps  the  largest  number  is  found  about  7 
o'clock.  After  the  allotted  number  of  glasses  has  been  drunk 
the  patient  proceeds  to  one  of  the  numerous  bakeries  and 
buys  the  bread  for  his  breakfast,  bread  the  most  delicious  to 
be  found.  It  may  be  a  prescribed  quantity  in  the  shape  of 
rolls,  or  crescents,  or  zwieback,  or  tiie  quantity  and  variety 
may  be  limited  oaly  by  the  appetite  and  taste.  Then  he  pro- 
ceeds to  the  meat  shop,  where  he  buys  his  ten  to  twenty 
kreutztri  worth  of  tempting  cold  boiled  ham.  The  pink  and 
white  paper  packages  containing  these  are  carried  to  one  of 
the  numerous  cafes  from  half  a  mile  to  two  miles  distant. 
A  table  is  selected  always  in  the  open  air,  if  weather  and  sea- 
son permit,  whence,  too,  there  is  commonly  a  pretty  outlo  )k 
towards  the  rich  green  meadows  and  hillsides.  By  this  time 
our  patient  is  quite  hungry  and  welcomes  one  of  the  neatly 
dressed  waitresses  who  comes  with  a  cheerful  "  Guten  Mor- 
gen,"  for  his  order  for  eggs  and  coffee.  The  coffee  is  scarcely 
less  excellent  than  the  bread,  and  he  is  soon  busy  in  the 
pleasurable  occupation  of  breakfasting.  So  far  as  my  ob- 
servation went,  this  breakfast  is  not  at  all  limited  as  to  quan- 
tity, and  the  delightful  surrounding  and  abundant  leisure  do  . 
not  dispose  one  to  eat  less  than  he  desire?. 

Breakfast  over,  there  is  more  walking.  It  may  be  for  a 
short  distance  or  for  miles  ou  the  many  pleasant  paths 
already  described,  where  abundant  resting  places  are  pro- 
vided, until  noon  is  near — the  hour  at  which  the  baths  are 
usually  taken,  although  many  are  prescribed  for  early  morn- 
ing hours.  For  it  is  only  on  the  physician's  prescription  as 
to  kind,  duration  and  temperature  that  the  baths  are 
allowed,  unless  the  visitor  happens  to  be  "  selbst  ein  Artzt," 
when  not  only  is  he  permitted  to  select  his  own  baths,  but 
also  becomes  the  guest  of  the  town,  receiving  a  card  which 
admits  him  to  the  baths  free  of  cost,  except,  of  course,  the 
douceur  to  the  attendant.  In  common  with  all  others  who 
remain  more  than  a  week,  he  must  pay  the  music  tax,  which 
is  collected  by  a  polite  official  who  comes  direct  to  his  rooms 
without  ceremony.  The  tax  is  five  florins,  or  $2.00,  for  the 
ordinary  well-to  do  visitor  who  is  termed  a  person  of  the 
"  first  class,"  eight  florins,  $3.20,  for  a  party  of  two  persons, 
with  a  further  reduction  per  capita  for  parties  of  large  num- 
bers. 

The  bath  completed,  dinner  follows  shortly.  For  this 
the  neighborhood  of  one  o'clock  is  advised,  the  late  dinner 
hour  being  discouraged  by  the  physicians.  Tne  dinner  may 
also  be  more  or  less  prescribed  by  the  physician  whom  the 
patient  has  consulted,  but  here  again,  there  is  much  errone 
ous  conception  as  to  what  constitutes  the  Karlsbad  diet, 
doubtless  because  yeara  ago  greater  stringency  was  insisted 
upon  than  at  present.  At  the  present  day  at  least  the  rigid 
dietary  rules  which  if  neglected  are  followed  by  severe 
punishment  are  a  myth.  For  the  patient  under  treatment 
the  food  is  simple  but  sufficient.  It  may  include  soup,  fish 
except  salmon,  beef,  mutton,  poultry,  game  without  rich 
dressings,  green  vegetables,  including  peas,  beans,  spinach, 
cauliflower  and  the  like.  Spices  and  simulating  condiments, 
such  as  pepper  and  mustard,  are  prohibited.  Soup  is  often 
disallowed  because  it  occasions  distention.  Nor  is  wine 
always  prohibited.  In  fact,  it  is  sometimes  ordered  by  the 
physician,  especially  the  light  wines  of  the  country,  which 
are  good  and  inexpensive.    So,  too,  the  delicious  Miinchener 


or  Pilsen  beer  is  sometimes  allowed  and  even  prescribed. 
Oa  the  other  hand,  champagnes  and  heavy  wines  are  rightly 
prohibited.  The  town  water  of  Karlsbad  is  pure  and  whole- 
some, though  it  is  quite  usual  to  drink  some  one  of  the 
"sauerbrunn,"  or  natural  carbonated  waters,  in  which  the 
vicinity  abounds,  especially  the  Gieshubler  and  Biliner  which 
are  also  used  in  admixture  with  wines.  Oa  the  other  hand, 
waters  highly  charged  with  carbonic  acid  such  as  Apollinaris 
are  discouraged  because  they  are  thought  to  distend  the 
stomach  by  liberated  gases.  Dinner  over,  a  short  stroll  fol- 
lowed after  a  brief  rest  by  a  longer  walk  or  a  drive  may  be 
taken.  At  four  o'clock  the  music  again  invites  to  the  gar- 
den's and  caf(5's  air.  Supper,  especially,  should  be  kept 
within  bounds.  Tea,  bread  and  butter,  an  omelet  and  a  lit- 
tle stewed  fruit  constitute  it  for  the  most  part.  In  the  even- 
ing for  those  who  desire  it  is  the  opera  in  one  of  the  most 
attractive  little  opera  houses  on  the  Continent,  and  at  some 
of  the  larger  hotels,  like  Pupp's,  there  is  music,  but  by  10 
o'clock  most  persons  are  in  bed  or  at  home,  so  that  a  mar- 
velous quiet  settles  down  on  the  town.  Indeed  nothing  so 
much  impressed  as  the  absolute  stillness  which  pervaded  the 
town  soon  after  10  o'clock.  Streets  which  during  the  entire 
day,  and  eppecially  in  the  early  morning  and  early  evening, 
are  filled  with  pedestrians  are  deserted  and  "  early  to  bed  " 
is  as  invariable  as  "  early  to  rise  "  for  which  it  is  also  a  prep- 
aration. On  the  whole,  the  life  at  Karlsbad  is  an  ideal  one, 
with  just  sufficient  amusement,  exercise,  and  treatment  to 
occupy  the  time  pleasantly,  so  that  it  is  not  surprising  that 
persons  return  year  after  year  for  the  pleasure  as  well  as  the 
health-giving  advantages  afforded. 

As  to  the  diseases  for  the  treatment  of  which  Karlsbad  is 
famous,  gout  and  its  complications  are  foremost.  The 
rationale  of  the  effect  can  only  be  inferred,  but  it  appears 
reasonable  to  believe  that  the  action  of  the  waters  is  in  the 
first  place,  depurative  and  neutralizing  on  the  materies  morbi, 
be  it  retained  uric  acid  or  something  else — depurative  by 
their  aperient  action,  and  neutralizing  through  the  increased 
alkalinity  of  the  blood  resulting  from  their  absorption.  Sec- 
ond, the  baths  further  increase  elimination,  and  in  conjunc- 
tion with  massage,  tend  to  remove  the  local  swellings  and 
stiffness  of  joints  which  are  responsible  for  so  much  discom- 
fort in  gout.  Third,  the  vigorous  exercise  which  forms 
an  important  part  of  the  treatment  still  further  increases 
elimination  and  contributes  to  the  removal  of  the  conditions 
referred  to.  Fourth,  the  restricted  diet  from  which  proteids 
and  wines  are  excluded  or  reduced  to  a  minimum,  keeps  out 
substances  which  go  to  make  up  the  toxic  product  causing 
the  disease.  It  is  probably  the  combined  action  of  these 
agencies  which  is  responsible  for  the  beneficial  effect  of  the 
Karbsbad  treatment  on  the  symptoms  of  gout.  It  is  siid  in 
some  instances  the  pains  of  gout  are  increased  by  the  first 
effect  of  the  waters  which  dissolve  out  the  uric  acid  from, 
other  situations  and  carry  it  to  other  vulnerable  points, 
whence  it  is  ultimately  washed  out.  It  is  more  than  likely 
that  the  beneficial  effect  of  the  treatment  on  gout  would  be 
prolonged  after  the  patient  returns  to  his  home  if  the  same 
line — hygienic  and  dietetic — were  kept  up.  It  is  not  only 
the  appetite  and  careless  eating  and  drinking  that  are  re- 
sponsible for  the  retrogression,  but  also  the  trouble  and  diffi- 
culty of  carrying  out  at  home  other  parts  of  the  treatment, 
which  cause  it  to  be  gradually  relaxed  and  followed  by  re- 
lapses which  make  recurring  visits  necessary.  To  be  sur- 
rounded by  social  and  business  demands  at  home  is  very 
different  from  being  one  thousand  or  more  miles  away  with 
nothing  to  do  but  to  carry  out  a  treatment  for  which  ex- 
pressly the  journey  is  made. 

All  that  has  been  said  of  gout  is  equally  true  of  the  tend- 
ency to  uric-acid  deposits  and  gravel,  the  solution  of  these 
being  favored  by  the  alkalinity  of  the  blood  and  secretions. 

The  more  usual  forms  of  rheumatism  of  other  than  gouty 
origin,  articular  and  muscular,  are  also  successfully  treated 
at  Karlsbad  by  massage,  exercise,  the  thermal  baths,  and 
especially  the  peat  baths,  which  are  a  unique  experience. 
Unpleasant  as  is  at  first  the  idea  of  submerging  one's  self  in 
a  mass  of  thick  hot  mud,  yet  the  first  unpleasantness  over- 
come, the  experience  becomes  a  pleasant  one.  The  usual 
notion  of  mud  as  something  purely  filthy  is  soon  dispelled, 
while  there  is  a  fragrance  about  the  organic  matter  of  the  peat 
which  is  agreeable.  It  is  brought  from  some  distance  in  the 
vicinity  of  Mirienbad  where  the  Karlsbad  authorities  own  a 
tract  of  peat  land.    The  peat  is  ground  to  a  required  degree 


28 


The  Philadelphia"] 
Medical  Journal  J 


A  PHYSICIAN'S  HOLIDAY  AT  KARLSBAD 


^lASriBT  5,  1901 


of  fineness  and  then  mixed  with  the  hot  Sprudel  water.  The 
bath  is  taken  commonly  at  a  temperature  of  about  28° 
Reaumur,  or  95°  Fahrenheit.  Massage  forms  an  important 
part  of  the  treatment  of  rheumatism. 

While  upon  the  subject  of  baths  I  may  as  well  describe  the 
two  remaining  baths  which  seem  worth  special  allusion. 
They  are  the  electric  water  bath,  the  electric-light  bath  and 
the  carbonic-acid  water  bath.  In  the  electric  water  bath  the 
patient  is  immersed  in  the  ordinary  tub  bath  at  a  tempera- 
ture of  about  95°  F.,  and  becomes  a  part  of  the  electric  cir- 
cuit. With  sufficient  strength  a  tingling  burning  sensation 
over  the  entire  surface  of  the  body  which  with  stronger  cur- 
rents becomes  even  painful.  In  a  short  time  the  skin  be- 
comes decidedly  reddened.  I  do  not  know  that  any  settled 
explanations  of  the  operation  of  the  electric  water  bath  is 
proposed  by  those  who  employ  it  honestly  for  other  than  the 
mental  effect.  As  stated  the  only  evident  efifect  is  on  the 
skin.  It  is  undoubtedly  counterirritating  to  the  skin. 
Through  this  nutrition  may  be  influenced  first  in  the  skin 
itself  and  second  upon  the  muscular  and  nervous  tissues  be- 
low it.  I  think  it  not  unlikely  that  this  form  of  bath  may 
act  as  a  cardiac  stimulus  similar  to  that  of  the  Nauheim 
bath. 

The  electric-light  bath  is  an  interesting  bath.  It  consists  of  a 
cabinet  in  which  the  patient  is  enclosed,  except  his  head. 
Numerous  electric  lights  project  from  the  sides  of  the  cabinet 
towards  its  interior.  The  bath  is  a  sweat  bath  in  which  the 
heat  is  derived  from  the  electric  lights,  and  of  which  the 
chief  feature  is  that  the  sweating  takes  place  at  a  much  lower 
temperature  than  in  a  vapor  or  hot  air-bath.  My  recollec- 
tion is  that  it  is  about  95°  F.  None  of  the  physicians  with 
whom  I  conversed  at  the  Kaiserbad  were  able  to  ofTer  any 
explanations. 

For  the  carbonic- acid  bath,  the  sprudel  spring  water  is 
charged  with  carbonic  acid  under  pressure,  and  the  baths 
seemed  to  me  almost  identical  with  the  baths  at  Nauheim 
which  I  also  visited.  The  little  bubbles  of  carbonic  acid 
collect  in  immense  numbers  on  the  skin  precisely  as  in  the 
Nauheim  baths,  and  as  the  water  is  also  a  strong  salice  solu- 
tion, the  same  effect  of  cardiac  stimulation  may  be  reason- 
ably expected. 

Next  after  gout — if  not  before — come  portal  congestions 
and  gastrointestinal  catarrhs.  They  are  influenced  through 
the  depurative  action  of  the  waters,  the  bathing,  massage, 
exercise,  and  restricted  diet.  Careful  adjustment  of  diet  is 
most  important  in  these  affections  and  the  local  physicians 
look  closely  to  this,  and  with  the  happiest  results. 

Gallstones  and  hepatic  colic  are  among  affections  for  which 
much  is  claimed  by  the  Karlsbad  physicians,  and  apparently 
with  reason.  It  is  held  that  the  expulsion  of  stones  is 
facilitated,  sometimes  painlessly,  but  more  frequently  with 
the  colicky  pain  usually  associated  with  such  expulsion  after 
the  thermal  treatment.  This  seems  to  be  generally  conceded. 
An  incontrovertible  explanation  has  not  been  offered.  The 
most  likely  is  that  the  results  depend  upon  a  flushing  of  the 
gallducts  by  a  thin  bile  and  the  free  purgation  which  drains 
especially  the  duodenal  end  of  the  bowel.  Another  very 
interesting  consequence  of  the  reputation  Karlsbad  possesses 
in  this  respect  is  the  aggregation  of  a  large  number  of  cases 
of  gallstone  impactions,  which  failing  of  relief  by  the  efJect 
of  the  waters  come  to  the  surgeon's  hands.  As  a  conse- 
quence many  cases  are  received  into  the  local  hospital  by 
Dr. ,  local  surgeon,  who  has  had  remarkable  success. 

Diabetes  is  another  one  of  the  ills  for  which  Karlsbad  is 
resorted  to  by  large  numbers.  It  has  seemed  to  me  that  the 
effects  are  among  the  least  satisfactory  of  any  claimed. 
This  conclusion  is  not  based  on  observation  while  at  Karls- 
bad, for  I  was  there  too  short  a  time  to  justify  any  con- 
clusions. But  it  has  happened  to  me  to  send  a  great  many 
diabetics  to  Karlsbad,  and  while  many  have  been  benefited, 
these  have  always  been  the  milder  cases,  while  the  improve- 
ment has  not  seemed  more  permanent  than  which  always 
took  place  when  they  first  came  under  treatment  at  home 
and  abroad,  and  especially  abroad  where  the  cooperation  of 
other  favorable  influences  is  brought  to  bear.  Indeed,  the 
most  claimed  by  Karlsbad  physicians  with  whom  I  have  dis- 
cusBed  the  matter,  seemed  to  be  as  follows:  In  cases  com- 
ing to  Karlsbad  where  the  best  that  could  be  done  at 
home  was  to  reduce  the  percentage  of  sugar  to  a  fraction  of 
Ijt,  the  result  of  treatment  at  the  Spa  is  to  take  the  sugar 
out  altogether.    In  cases  where  the  home  treatment  removed 


a  portion  of  the  sugar,  but  left  a  considerable  percentage,  the 
Karlsbad  treatment  reduced  the  percentage  of  glucose,  but 
could  not  eliminate  it  altogether.  This  increment  of  effect 
may  be  the  direct  effect  of  the  water  drunk,  probably 
through  its  alkalinity.  An  experiment  by  Salkowski,  to 
which  my  attention  was  called  by  Dr.  Edgar  Gaiw,  at  Karls- 
bad, tends  to  confirm  this  probability.  He  noted  first  that 
the  artificial  digestion  of  starch  by  pancreatic  extract  was 
delayed  by  the  addition  of  saccharine,  and  second  that  this 
inhibitory  effect  was  counteracted  by  the  addition  of  sodium 
bicarbonate  and  the  digestion  proceeded.  On  the  other 
hand,  the  dietetic  treatment  is  no  less  rigid  than  at  home, 
commonly  more  so,  and  more  strictly  carried  out,  while  the 
cheerful  surroundings  have  their  due  influence.  There  can 
be  no  doubt,  therefore,  that  to  the  diabetic  who  is  not  too  far 
advanced  in  the  disease,  and  who  can  afford  a  somewhat  ex- 
pensive journey,  a  trip  to  Karlsbad  will  be  of  service  by 
diminishing  or  removing  his  symptoms,  by  invigorating  and 
encouraging  him,  giving  him  a  fresh  start  as  it  were,  whence 
the  outlook  is  promising  and  hopeful. 

Obesity  is  one  of  the  recognized  objects  of  the  treatment. 
Indeed,  I  never  before  saw  so  many  fat  men  and  women  gath- 
ered in  one  place,  though  by  no  means  every  fat  person  who 
goes  to  Karlsbad  goes  there  to  be  treated  for  obesity.  The 
majority  are  altogether  too  deliberate  in  their  actions,  and 
they  eat  too  much.  The  treatment  for  obesity  is  undoubtedly 
effective  in  reducing  fat,  but  here  as  elsewhere  the  effect  is 
only  accomplished  by  hard  work.  The  following  experience 
related  by  the  late  Professor  Horatio  R.  Bigelow  in  his  inter- 
esting paper  on  Karlsbad,  published  13  years  ago,  may  be 
considered  a  sample.  He  says :  "  When  I  came  to  Karlsbad, 
I  weighed  between  186  and  190  pounds  (American).  As  I  am 
only  5  feet  6J  inches  tall,  this  was  too  portly,  even  for  a  Lon- 
don alderman.  Dr.  Giiinberger  advised  the -K'ur.  I  began 
with  2  glasses  (March  16)  of  Marktbrunn  daily,  to  which  was 
added  on  March  20,  1  glass  of  Miihlbrunn.  This  was  never 
increased  during  the  8  weeks  of  my  cure.  The  water  was 
sipped  gradually  ;  then,  after  a  interval  of  15  minutes,  the 
second  glass  was  taken,  and  so  the  third.  After  that  a  walk 
of  from  1  to  2  hours  and  then  breakfast.  A  cup  of  tea  or 
coffee  (with  milk  and  sugar),  2  rusks  and  2  soft-boiled  eggs, 
then  a  climb  of  2  or  3  hours,  and  home  to  dinner — a  piece  of 
rare  meat  and  one  vegetable  with  an  occasional  glass  of  Hun- 
garian wine.  Then  another  long  walk,  followed  by  a  supper  at 
7,  consisting  of  tea  rusks,  and  cold  mea*.  I  took  a  few  warm 
and  vapor  baths,  especially  when  in  Berlin,  where  I  was  called 
upon  business,  being  absent  about  10  days.  While  away  I 
kept  up  my  diet  rules  most  strictly,  but  not  beirg  able  to 
exercise  as  vigorously,  I  indulged  somewhat  in  Turkish  baths. 
Latterly,  I  have  given  up  coffee  and  take  no  milk  in  my  tea. 
At  first  the  waters  caused  a  natural  but  rather  active  move- 
ment from  the  bowels ;  then,  for  2  or  3  weeks  the  dischargee 
were  more  frequent  (twice,  and  sometimes  3  times  per  day), 
and  then  came  an  interval  of  constipation. 

"  I  weigh  now  (May  26)  about  155  pounds  with  winter  flan- 
nels. My  weight,  naked,  at  the  Kur  Haus  bath  rooms  waa, 
on  May  23,  8"  kilograms — 148  American  pounds.  I  exercise 
3  or  4  hours  daily,  and  observe  a  vigorous  self  denial  in  mat- 
ters of  diet.  It  will  be  seen  that  from  March  4  to  March  10  I 
lost  nearly  a  pound  per  diem,  but  during  this  time  I  am  sure 
that  I  walked  between  24  and  25  miles  daily.  At  no  time 
have  I  felt  unpleasantly."  He  says,  moreover,  "the  share 
of  the  waters  in  this  role  must  be  considered  a  small  one." 

Be  this  as  it  may,  I  am  confident  that  the  benefits  of  the 
Karlsbad  treatment  are  very  great  to  fat  persons,  even  if  it 
does  not  reduce  their  fat,  or  reduces  it  moderately,  as  is  more 
often  the  case.  It  is  the  fat  person  whose  circulation  is  slug- 
gish, whose  bile  is  thick,  whose  gallbladder  is  full  of  facet^ 
stones,  with  or  without  biliary  colic  All  of  these  conditions 
are  benefited  by  the  "  cure." 

The  Karlsbad  waters  are  claimed  to  be  efficient  in  certain 
diseases  of  the  skin.  Erj'sipelas  migrans,  sclerosis  of  the  skin, 
urticaria,  pemphigus,  and  eczema  in  their  milder  forms,  and 
furunculosis  are  mentioned.  I  did  not  have  an  opportu- 
nity to  see  any  of  these  affections  under  treatment  while  at 
Karlsbad,  but  I  have  seen  a  most  obstinate  CAse  of  urtic.aria 
which  resisted  all  ether  treatment  at  home,  greatly  relieved 
by  full  doses  of  the  Karlsbad  Sprudel  salt,  dissolved  in  hot 
water.  At  the  end  of  1  week's  treatment  a  life  of  compara- 
tive comfort  was  substituted  for  one  of  misery. 

A  most  important  and  comparatively  recent  application  of 


jASWiKY  !>,  1901] 


PRIMARY  BRANCHIOGENIC  CARCINOMA 


rTHE 

LMki 


Philadelphia 
DicAL  Journal 


29 


the  Karlsbad  mineral  waters  has  yet  to  be  described.  It  is 
that  of  Dr.  J.  Miiller,  an  accomplished  specialist  in  nose,  ear 
and  throat  aSections.  He  avails  himself  of  the  hot  Sprudel 
water  in  spraying  the  nose  and  throat  with  powerful  sprays 
produced  by  the  pressure  of  expanding  compressed  carbonic- 
acid  gas.  By  substituting  carbonic-acid  pressure  for  atmos- 
pheric air  pressure  he  reduces  the  pressure  from  7  atmos- 
pheres to  li  atmospheres.  The  spray  is  allowed  to  pass  for  10 
to  15  minutes  into  each  nostril  and  10  to  15  minutes  into  the 
throat.  In  this  way  a  most  effectual  irrigation  of  these 
parts  is  secured  as  compared  with  which  the  ordinary  nasal 
spray  is  aa  mist  compared  with  rain.  This  treatment  is 
applied  for  nose,  throat  and  laryngeal  affections,  and  I  have 
reasons  to  believe  that  it  is  efficient.  When  in  Vienna, 
where  Dr.  Miiller  practises  in  winter,  he  uses  the  Karlsbad 
Sprudel  salt  dissolved  in  hot  water. 

No  description  of  Karlsbad  and  ita  treatment  at  this  day 
should  omit  an  allusion  to  the  finely  appointed  Zmder 
establishment  for  Swedish  hygienic  gymnastics  and  mas- age 
at  the  new  "  Kaiserbad  "  under  the  direction  of  the  accomp- 
lished Dr.  D.  Tyrnauer.  This  probably  surpasses  all  similiar 
institutions  of  the  kind,  being  the  newest  and  latest.  It  is 
very  interesting  to  watch  the  patients  passing  from  one 
machine  to  another,  and  securing  thus  every  conceivable 
variety  of  gymnastic  exercise,  everything  working  smoothly 
and  spiritedly.  I  will  conclude  this  paper  by  quoting  with- 
out comment  the  purposes  of  the  treatment. 

1.  To  prevent  the  injurious  consequences  of  a  sedentary 
mode  of  living  or  of  onesided  muscular  action. 

2.  Ailments  and  disorders  of  the  organs  of  movement,  as : 
sprains,  stiffness  and  weakness  after  fractures  of  bones  and 
other  injuries,  crookedness  of  the  limbs  and  of  the  vertebral 
column. 

3.  Dilations  of  the  stomach  and  bowels,  chronic  constipa- 
tion, enlargement  of  the  liver,  hemorrhoids,  neuralgia 
(sciatica),  writer's-cramp  and  similar  affections,  chorea,  cases 
of  paralysis  and  weakness  of  various  kinds. 

4.  Obstructions  to  the  circulation  of  the  blood,  diseases  of 
the  heart  and  their  attendant  consequences,  overaction  of 
the  heart,  weakness  of  the  heart,  beginning  fatty  degeneration 
of  the  heait,  changes  in  the  bloodvessels  from  old  age, 
nervous  heart  complaints. 

5.  Diabetes  mellitus,  uric-acid  diathesis,  gout,  adiposity 
and  chronic  metal-poisoning. 

"  In  all  these  cases,  says  the  published  statement,"  a  com- 
bination of  the  Karlsbad  course  of  baths  and  waters  with  the 
mechanical  treatment  will  be  in  the  highest  degree  success- 
ful." 

The  Mott  Suitable  Time  for  Visiting  — Karlsbad  may  be 
visited  at  any  time,  but  what  is  known  as  "  the  season  "  be- 
gins with  the  fifteenth  of  April  and  extends  to  the  first  of 
October.  The  most  popular  months  are  June  and  July,  and 
during  these  two  months  the  wealthiest  and  most  fashionable 
visitors  are  found,  while  the  rates  for  rooms  are  higher.  Au- 
gust is  also  a  popular  month,  but  towards  the  end  of  it  there 
is  quite  a  decided  falling  off  in  the  number  of  patients  and  vis- 
itors. To  a  person  having  full  control  of  his  time,  I  should  say 
complete  your  "  Cure  "  by  the  middle  of  August,  for  although 
there  are  many  lovely  days  after  this  date,  tlie  mornings  and 
evenings  become  cool  and  the  latter  damp,  especially  in  the 
deeper  and  narrower  parts  of  the  valley  where  the  air  can- 
not change  rapidly  and  thoroughly,  and  persons  subject  to 
catarrhal  troubles  are  apt  to  take  cold.  Moreover,  although 
Karlsbad  is  an  exceptionally  salubrious  city,  in  which  no 
epidemic  has  ever  prevailed,  it  is  reasonable  to  suppose  that 
the  coming  and  going  of  50,000  visitors  must  have  an  effect 
towards  the  end  of  the  season  in  contaminating  the  purity 
of  the  air  and  drainage,  while  occasionally  a  case  of  typhoid 
fever  does  crop  out  towards  the  end  of  the  season. 


The  Committee  on  Scientific  Research  of  the 
American  Medical  Association  desires  to  announce 
that  it  has  available  the  sum  of  $500  for  the  assistance  of 
researches  to  be  undertaken  in  the  next  6  months,  and  that 
the  money  will  be  appropriated  if  applications  be  received 
within  the  month  of  January,  1901.  Applicants  should  state 
clearly  the  character  of  the  research  to  be  undertaken,  and 
the  facilities  at  their  command,  addressing  Dr.  H.  C.  Wood, 
chairman,  1925  Chestnut  St ,  Philadelphia,  Pa. 


PRIMARY  BRANCHIOGENIC  CARCINOMA.' 

By  FREDERICK   SHIMANCK,  M.D., 

of  Milwaukee,  Wis. 

The  following  case,  although  rare,  may  prove  inter- 
esting if  not  instructive.  The  very  fact  of  infrequency 
makes  it  incumbent  upon  us  to  consider  it  more  or 
less  in  detail.  It  is  very  discouraging  indeed  to  one 
vcho  possesses  an  investigating  turn  of  mind  to  en- 
counter disease  which  may  be  never  or  rarely  exhaust- 
ively treated  by  medical  authors. 

Before  we  proceed  to  the  description  of  the  case  un- 
der consideration  it  may  be  profitable  to  briefly  set 
forth  the  anatomy  and  embryology  of  the  development 
of  the  neck,  it  is  not  necessary  to  enter  into  a  minute 
exposition  of  this  very  interesting  subject;  I  merely  de- 
sire to  point  out  some  of  the  salient  facts  in  order  to 
bring  out  more  prominently  some  of  the  practical  sides 
of  embryologic  teaching.  The  branchial  arches  and 
clefts  are  the  primordial  structures  of  the  neck  and 
face  ;  they  enter  into  the  construction  of  the  jaw,  hyoid 
bone,  thymus  and  thyroid  glands ;  styloid  process, 
the  stylohyoid  ligaments,  and  assist  in  the  formation 
of  some  of  the  other  soft  tissues  of  the  neck,  etc.  With 
the  completion  of  all  of  those  parts  the  last  vestiges  of 
embryonic  structures  gradually  disappear,  with  the  ex- 
ception of  the  first  one,  from  which  the  external  audi- 
tory canal,  the  cavity  of  the  tympanum,  and  the  eu- 
stachian tubes  are  developed.  From  the  difference  in 
the  rapidity  of  growth  of  some  of  the  arches,  various 
cavities  are  formed  as  follows  :  Sinus  cervicalis,  fundus 
prsecervicalis,  fundus  branchialis,  sinus  pyriformis. 
These  are  lined  with  ectodermal  or  epithelial  elements. 
These  enter  into  the  formation  of  the  thymus  and  thy- 
roid glands,  etc.  Abnormalities  in  the  development 
may  lead  to  fistulas,  dermoids,  cysts,  or  other  tumors, 
malignant  or  benign.  All  of  the  sinuses  and  pouches 
should  become  obliterated  in  the  formation  and  devel- 
opment of  the  hyoid  bone,  the  thymus  and  thyroid 
glands,  etc.  Should  nature  fail  in  her  physiologic 
functions  we  may  find  enclosed  in  the  depths  of  the 
neck  epithelial  elements  which  are  the  prerequisites  in 
the  formation  of  primary  carcinoma.  The  first  and 
second  branchial  arches  and  clefts  by  their  more  rapid 
growth  overlap  the  third  and  fourth,  thus  forming  a 
space  lined  with  epithelial  cells,  called  cervical  sinus  ; 
other  sinuses  are  formed  in  a  similar  manner. 

From  this  short  and  superficial  review  it  may  be  very 
readily  seen  why  epithelial  tissues  are  at  times  found 
in  the  depths  of  the  neck  where  nothing  of  the  sort, 
under  natural  histologic  conditions  should  ever  exist, 
and  the  reason  for  the  development  of  primary  epithe- 
lioma. 

In  making  differential  diagnoses  between  tumors  of 
the  neck  it  is  important  to  remember  that  branchial 
tumors,  springing  as  they  do  from  embrj'onic  remnants 
of  the  branchial  clefts  and  arches,  are  situated  always 
primarily  anterior  to  the  sternomastoid  muscle,  be- 
tween that  muscle  and  the  hyoid  bone.  The  second 
cleft  and  arch,  which  are  nearly  always  concerned  in 
the  development  of  the  neoplasm,  are  situated  between 
that  muscle  and  the  hyoid  bone,  whence  the  tumor 
spreads  posteriorly,  etc.,  until  finally  the  entire  lateral 
aspect  or  the  neck  may  become  involved.  Of  course, 
this  is  not  the  only  point  of  importance,  but,  I  think, 
one  of    greatest  weight.     The  depth  of   the  tumor, 

1  Read  before  the  Wisconsin  State  Medical  S<  ciety,  June  21 ,  1900. 


30 


The  Philadelphia"] 
Medical  Journal  J 


PRIMARY  BRANCHIOGENIC  CARCINOMA 


[Jascaey  5,  1901 


its  firm  adhesion,  more  properly  speaking,  intimate 
amalgamation,  for  it  forms  part  and  parcel  of  the 
bloodvessels  and  nerves  of  the  neck,  are  perhaps  the 
most  important  conditions  from  a  pathologic  stand- 
point. 

The  case  occurred  in  a  male,  aged  49,  a  farmer.  Up 
to  5  years  ago  the  history  showed  perfectly  health;  the 
family  history  was  negative.  Then  a  tumor  developed 
in  the  right  half  of  the  lower  lip,  which  became  indu- 
rated, and  eventually  ulcerated,  destroying  a  consider- 
able part  of  the  lip. 

Diagnosis  of  epithelioma  was  made,  and  excision  of 
the  ulcerated  and  indurated  mass  followed.  The  union 
was  good  and  the  result  all  that  could  be  desired, i.e., 
no  recurrence  in  the  scar  up  to  the  present  time,  or 
nearly  5  years ;  but  1  year  subsequent  to  the  operation 
an  enlarged  gland  of  about  the  size  of  a  hazel  nut  was 
found  situated  over  the  right  submaxillary  gland,  pain- 
less and  movable.  No  other  glands  were  at  that  time, 
or  at  any  other  time,  discovered.  The  physician  who 
had  the  patient  in  charge  considered  it  carcinomatous 
and  removed  it.  No  microscopic  examination,  to  my 
knowledge,  having  been  made,  it  is  impossible  to  state 
what  its  construction  was ;  but,  judging  that  it  was  soli- 
tary, freely  movable,  and  absolutely  painless  after  hav- 
ing attained  the  §ize  of  a  hazel  nut,  it  is  reasonable  to 
conclude  that  it  was  not  malignant.  At  the  beginning 
a  secondary  gland  tumor  is  generally  movable  because 
the  infectious  material  is  still  confined  and  limited  to 
the  glandular  parenchyma,  the  capsule  eventually  be- 
coming involved  and  destroyed,  when  fixation  and  in- 
filtration of  the  surroundings  rapidly  follows. 

In  the  very  beginning,  then,  mobility  of  a  gland 
tumor  is  not  a  feature  to  be  regarded  in  favor  of  be- 
nignity, but  mobility  and  solitariness  of  a  gland  tumor, 
after  having  existed  some  time  and  having  attained 
considerable  size,  is,  in  my  opinion,  evidence  against 
malignancy. 

It  is  fair  to  assume  that  in  regional  infection  involve- 
ment of  several  glands  takes  place  simultaneously  or  in 
rapid  succession,  since  many  lymphatic  vessels  are 
taking  up  microbes  or  cells  from  the  ulcerating  surface, 
it  is  usual,  therefore,  to  find  many,  or  a  whole  chain  of 
lymph  nodes  enlarged.  Carcinoma  being  of  epithelial 
origin  it  never  occurs  primarily  in  the  glands  of  the 
neck. 

The  conclusion  irresistibly  points  to  adenitis,  prob- 
ably of  an  infectious  nature,  from  the  throat  or  mouth. 

In  June,  1S99,  or  about  4  years  after  the  glandular  episode, 
the  patient  presented  himself  for  treatment  of  a  tumor  of 
the  right  side  of  the  neck.  On  examination  it  was  found 
that  a  round,  smooth,  and  an  elastic  tumor  of  about  the  size 
of  an  orange,  apparently  fluctuating,  existed  in  the  right 
upper  triangle  of  the  neck,  situated  between  the  hyoid  bone 
and  mastoid  pro  ess,  beneath  the  sternomastoid  muscle,  of 
about  2  months'  growth.  It  was  insensitive  to  presure,  nor 
was  it  causing  any  great  subjective  phenomena,  excepting 
some  neuralgic  pain,  not,  however,  of  sufficient  moment  to 
disturb  his  rest.  It  appeared  to  be  quite  movable,  but  that 
must  be  nndei  stood  in  a  relative  sense  on  accountiof  a  great 
looseness  and  mobility  of  the  tissues  of  the  neck— any  tumor 
there  .situated  will  be  comparatively  movable  unless  there  is 
great  induration  from  inflammatory  or  malignant  inliltra- 
tion. 

Nothing  else  could  be  discovered.  At  first  thought,  from 
the  history  as  given  by  the  patient,  diagnosis  of  malignant 
tumor  was  made  with,  however,  considerable  reserve,  owing 
to  its  smoothness,  painlessness,  and  lack  of  infiltration. 

An  exploratory  mcision  was  made  over  it  parallel  to  the 
anterior  border  of  the  sternomastoid,  and,  as  this  was  gradu- 
ally deepened,  suddenly  a  gush  of  yellowish  transparent 


fluid  took  place,  followed  by  a  complete  collapse  of  the 
tumor. 

The  interior  of  the  sac  was  lined  with  an  irregular  mem- 
brane; the  prominences  or  prohferations  apparently  con- 
sisted of  granulation  tissue.  The  whole  of  the  interior  was 
thoroughly  curetted,  and  subsequentl}'  painted  with  iodin. 

The  diagnosis  of  carcinoma  remained  undecided,  and 
further  opinion  was  withheld  pending  the  microscopic  ex- 
amination of  the  scrapings  by  Dr.  Evans,  of  Chicago,  who 
pronounced  it  epithelioma. 

After  closure  of  the  opening  rapid  refilling  of  the  cyst 
took  place  as  also  a  considerable  enlargemen',  of  the  entire 
tumor.  One  month  later  a  second  attempt  at  removal  was 
made  at  the  most  urgent  solicitation  of  the  patient,  how- 
ever, against  my  advice  and  convictions.  Tliis  operation 
consisted  in  freely  laving  open  the  field  of  operation  through 
a  large  U-shaped  incision,  which  commenced  anterior  to  the 
sternomastoid  below  the  angle  of  the  jaw,  and  was  con- 
tinued downward  below  the  tumor,  then  backward  across 
the  neck  in  a  curved  direction,  thence  upward  and  termi- 
nating near  the  external  occipital  protuberance. 

This  incision  extended  through  the  tkin,  the  superficial 
fascia,  platj'-ma,  and  the  sternomastoid  muscle.    This  large 
flap  was   raised   from  below  upward,  expf  sing  a  very  large 
area  which  afforded  a  beautiful  view  of  the  entire  interior  . 
surface  of  the  cyst. 

Its  walls  were  composed  of  a  tough  membrane  of  about 
the  thickness  of  a  postal  card,  on  whose  surface  sprouted, 
here  and  there,  granulation  like  masses,  the  surrounding 
tissues,  or  those  tissues  being  in  intimate  relationship  with 
the  neoplasm  appeared  to  the  naked  eye  and  to  the  touch 
normal ;  no  enlarged  glands  were  palpable  either  in  the  im- 
mediate neighborhood  of  the  tumor  or  elsewhere  An 
attempt  was  made  to  dissect  away  the  cyst  wall,  but  it  soon 
became  evident  that  nothing  short  of  a  removal  of  the  en- 
tire side  of  the  neck  would  suffice,  and  so  the  operation  was 
discontinued. 

As  has  appeared  above  from  the  embryologic  considera- 
tions that  those  neoplasms  of  branchial  origin  enter,  so  to 
speak,  into  the  constitution  of  the  normal  histology  of  the 
neck,  the  extent  of  malignant  dissemination  in  carcinoma 
is  beyond  estimation. 

I  do  not  see  the  philosophy  of  those  extensive  and  hazard- 
ous procedures  when  no  hope  can  be  entertained  of  ultimate 
recovery,  or  even  of  the  prolongation  of  life  or  of  allevia- 
tion of  suffering. 

The  growth  of  the  tumor  increased  verj-  markedly  after 
this  attempt,  and  in  about  8  months  from  that  time  the 
patient  succumbed  to  hemorrhage  from  the  tumor.  From 
the  situation  of  the  tumor,  from  its  cystic  character,  with  an 
epitheliomatous  degeneration,  diagnosis  of  branchial  car- 
cinoma had  been  made,  and  probably  of  primary  origin. 

From  the  history  of  this  case  this  would  at  first  sight 
seem  highly  improbable,  but  if  we  take  into  considera- 
tion the  time — 5  years — which  had  elapsed  since  the 
appearance  of  the  lip  epithelioma,  and  secondly,  no 
gland  involvement  following  it  which  could  be  regarded 
with  any  degree  of  certainty,  it  must  be  admitted  that 
the  branchial  carcinoma  simply  developing  later  than 
that  of  the  lip  does  not  prove  its  dependence  upon  the 
latter. 

Tilmans  says  in  speaking  of  the  prognosis  of  car- 
cinoma : 

"  We  make  distinction  based  upon  their  mode  of 
origin,  between  continuous  and  regional  recurrence ;  the 
former  spring  from  portions  of  the  primary  tumor 
which  were  left  behind  at  the  time  of  operation,  while 
the  latter  (regional  appearance)  are  looked  upon  as  in- 
dependent new  tumors  in  the  cicatrix  or  its  vicinity. 
The  second  kind  sometimes  make  their  appearance  only 
after  the  lapse  of  years." 

All  recurrences  which  occur  later  than  2  years  after 
operation  should  be  considered,  according  to  Snow, 
"  new  independent  tumors  resulting  from  new  injurious 
agencies."  In  looking  up  the  literature  one  is  struck 
with   almost  the  entire   absence  of  anything  definite 


JANDARY  5,  I'.IOl] 


PRIMARY  BRANCHIOGENIC  CARCINOMA 


TTHE  PHILADKLI'UIA 

L  Medical  Journal 


31 


upon  the  subject.  Jordan'  of  Heidelberg,  in  Bergman's, 
Bruns',  and  Mikulicz's  Surgery,  which  is  now  being 
published,  contributes  a  very  interesting  and  practical 
article  from  which  I  have  translated  as  follows  : 

Deep  carcinomas  of  the  neck  are  generally  situated  in  the 
upper  triangle,  and  fully  correspond  in  construction  with 
those  of  the  skin.  There  being,  normally,  no  epithelial  tis- 
sue in  the  place  of  their  occurrence,  Volkman,  who  first,  in 
188 J,  described  3  cases,  considering  their  origin  from  epthe- 
lial  remains  of  branchial  clefts,  therefore  named  these  car- 
cinomas branchiogenic  or  branchial. 

As  a  proof  of  the  correctness  of  this  observation  the 
following  two  points  may  be  produced,  first,  the  topog- 
raphy of  the  tumor;  second,  the  fact  that  the  devel- 
opment of  carcinomas  from  the  epithelium  of  the  cysts 
of  branchial  clefts  has  several  times  been  proved. 

As  a  rule,  the  tumor  ia  situated  in  the  upper  triangle 
of  the  neck,  and  occupies  the  place  between  the  hyoid 
bone  and  the  sternomastoid,  whence  the  tumor  develops 
posteriorly  and  lies  beneath  the  deep  fascia  of  the  neck, 
forming  adhesions  with  the  great  vessels,  the  vagus,  and 
sympatheticus.  The  location  of  the  tumor  with  its 
accepted  origin  corresponds  to  the  second  branchial 
cleft,  the  cervical  sinus,  and  the  relation  which  it  bears 
to  the  bloodvessels  is  clearly  demonstrated  by  the  up- 
ward course  along  the  carotids  of  a  branchial  fistula. 

In  isolated  cases  the  tumor  appeared  in  the  middle 
and  lower  part  of  the  anterior  region  of  the  neck,  a 
fact,  considered  from  the  developmental  history,  and 
from  their  relationship  to  bloodvessels,  is  not  clear. 

The  carcinomatous  degeneration  of  the  branchial 
cysts  has  been  observed  in  the  following  cases  : 

Case  1. — Bruns  reports  a  case  of  a  57  year  old  man  who, 
since  6  months,  had  noticed  a  swelling  in  the  upper  neck 
triangle,  which  on  operation  was  found  to  be  a  cyst  with  hard 
proliferating  walls,  situated  between  the  hyoid  bone  and  the 
large  vessels.  Microscopic  examination  showed  a  pavement 
epithelial  carcinoma,  etc. 

Case  2. —Also  observed  and  treated  by  Bruns.  A  cystic 
tumor  of  5  months'  existence  situated  at  the  division  of  the 
carotids,  which  on  puncture  gave  vent  to  a  considerable 
quantity  ef  yellowish-dark  Huid  containing  epithelial  cells. 
Incision  showed  the  internal  surface  of  a  papillary  construc- 
tion; microscopic  examination  showed  pavement  epithelial 
carcinoma  with  proliferation  into  the  external  wall,  com- 
posed of  connective  tissue. 

Case  3. — Bruns- Richard.  A  congenital  branchial  cyst  sud- 
denly suppurated  ;  a  fistula  with  induration  remained  after 
incision  which  after  a  year's  time  enlarged  and  became  hard. 
Microscopically  it  proved  to  be  an  epithelioma. 

Case  4.  -Quarry-Silcock  incised  a  tumor  of  5  months' 
growth  on  the  right  side  of  the  neck  of  a  man  56  years  of 
age,  which  proved  to  be  a  cyst  lined  with  papillary  tissue  : 
microscope  showed  it  to  be  an  epithelioma. 

Case  5.— Observation  by  von  Quarry-Silcock  :  in  the  lower 
third  of  the  sternomastoid  of  a  man  32  years  old  was 
located  a  cyst  whose  inner  layer  presented  carcinomatous 
degeneration. 

Branchiogenic  carcinomas  are  rare ;  beside  the  8  cases 
already  mentioned  are  also  Gussenbauer's  8  cases  ;  von 
Reynault's  1  case;  Mayor's  1  case;  von  Eigenbrodt's  1 
case;  also,  possibly,  2  cases  reported  by  von  Langen- 
beck  who  described  them  during  his  time  as  vessel- 
sheath  tumors;  as,  also,  1  case  published  by  von 
Regnault  (Czerny)  of  pavement  epithelial  carcinoma 
situated  at  the  place  of  division  of  the  carotids. 

In  1898  I  observed  1  case  in  the  left  upper  neck 
triangle  of  an  old  man  which  had  all  of  the  character- 
istics of  a  branchial  carcinoma.  The  extirpation  with 
a  resection  of  the  internal  jugular  and  the  external 
carotid    was    successfully    accomplished.     Microscope 


showed  pavement-epithelial  carcimoma.  The  patient 
succumbed  two  months  after  the  operation  from  recur- 
rence in  the  neck,  also  gangrene  of  the  leg  from  throm- 
bosis necessitated  an  amputation,  the  autopsy  proving 
the  diagnosis  of  a  primary  branchial  carcinoma. 

Symptomatology  :  So  far  all  of  the  cases  observed 
have  occurred  in  males  and  generally  in  those  of  ad- 
vanced years,  between  40  and  65.  The  tumor  was  oftener 
located  in  the  right  side  of  the  neck.  A  swelling  ap- 
pears in  the  typical  location  which,  in  the  beginning, 
without  causing  any  pain,  slowly  enlarges,  but  in  a  very 
few  months  commences  to  grow  much  faster,  producing 
neuralgic  pains,  radiating  particularly  into  the  occipital 
and  ear  regions  and  may  be  so  intense  as  to  rob  the 
patient  of  sleep.  The  patient's  attention  is  often  di- 
rected by  the  pain  to  the  yet  deeply  located  and  slightly 
prominent  tumor. 

After  a  longer  progress  of  the  case  we  may  find  a 
neoplasm  covered  with  normal  skin,  irregular  and  very 
hard,  situated  between  the  sternomastoid,  to  which  it 
is  firmly  adherent,  and  also  fixed  to  the  underlying 
tissues.  On  the  lower  and  upper  poles  may,  at  times, 
be  felt  the  pulsation  of  the  carotids. 

The  regional  glands  are  indurated  and  the  tumor 
gradually  spreads  over  the  entire  half  of  the  neck ;  the 
skin  adheres  to  the  tumor  and  breaks  through  the  sur- 
face, suppurates  and  produces  hemorrhages ;  internally 
it  ruptures  into  the  great  bloodvessels,  particularly  into 
the  internal  jugular,  thus  leading  to  metastasis  into 
internal  organs.  Through  the  latter,  or  as  a  result  of 
local  complications,  exitus  letalis  follows. 

The  course  of  the  disease  is  rapid,  extending  from 
one-half,  or  at  the  farthest,  to  one  and  one-half  years. 
Diagnosis  is  very  difficult  and  can  only  be  positively 
made  from  the  outcome  of  the  case  after  extirpation, 
t.  «.,  a  cure  or  an  autopsy. 

The  probable  clinical  diagnosis  is  founded  upon  the 
discovery  of  a  tumor  in  the  indicated  location,  sub- 
fascially  situated,  whose  construction  closely  resembles 
a  carcinoma,  and  whose  secondary  development  can  be 
excluded.  It  is  to  be  remembered  that  there  are 
hidden  carcinomas,  for  example,  in  the  nose,  larynx, 
esophagus,  etc.,  which  it  may  be  impossible  to  find, 
while  the  secondary  gland  tumor  becomes  prominent. 

The  following  observation,  which  I  had  a  chance  to 
make  in  August,  1898,  in  this  respect,  is  instructive  : 

In  a  man  of  63,  two  hard  tumors  of  about  the  size  of  an 
apple  were  situated  in  the  right  half  of  thf  neck,  the  one  of 
which  lay  in  the  upper  triangle,  and  was  firmly  adherent  to 
the  sternomastoid,  while  the  other  one  appeared  some  time 
after  the  existence  of  the  first  and  occupied  the  supraclavic- 
ular region. 

Because  the  histologic  con.struct'on  coincided  with  car- 
cinoma, and,  after  the  most  painst  king  examination  of  the 
cavity  of  the  mouth,  of  the  larynx,  and  of  the  esophagUB, 
no  primary  carcinoma  could  be  discovered,  I  decided  that 
we  had  a  branchiogenic  'umor  to  deal  with,  with  gland 
metastasis  in  the  lower  triangle  of  the  neck.  The  extirpa- 
tion could  only  be  accomplished  with  the  r^-section  of  tlie 
common,  the  external  and  internal  car  tids,  the  internal 
jugular,  the  vagus,  and  of  the  .sympathetic.  In  the  jugular 
a  tumor  thrombus  was  found.  Death  from  pneumonia  on 
the  fourth  day.  Autopsy  revealed  a  small  carcinoma  in  the 
lower  third  of  the  esophaeus  developed  in  a  ongitudinal 
direction  and  occupying  only  a  small  part  of  the  circumfer- 
ence, not  at  all  producing  a  stenosis  of  t'e  esopha^; us,  and 
only  infiltrating  its  walls  to  a  small  extent.  Above  the 
cardia  a  cherry-stone-sized  carcinomatous  gland  existed. 

The  secondary  gland  carcinomas  may  frequently  be 
distinguished  in  the  beginning  from  branchiogenic  car- 
cinoma by  remaining   painless  longer,  circumscribed, 


32 


The  Philadelphia 
Medical  Joukna 


'.^] 


THE  RESOURCES  OF  MODERN  MINOR  GYNECOLOGY 


[jAirUABY  S,   1901 


and  movable,  while  the  branchial  carcinomas  from  the 
beginning  are  attached  to  the  large  bloodvessels,  to  the 
nerves,  and  to  the  sternomastoid,  and  early  produce 
pain. 

The  histologic  structure  being  the  same  the  origin  can 
be  shown  only  when  gland  tissue  is  found  in  the  car- 
cinoma. In  a  case  of  neck  tumor  larger  than  an  apple 
situated  in  the  typical  location,  which  was  referred  to 
our  clinic  with  the  diagnosis  of  branchial  carcinoma, 
which,  however,  seemed  doubtful  because  an  examina- 
tion of  the  larynx  was  difficult  on  account  of  edema- 
tous swelling,  a  microscopic  examination  of  the  extir- 
pated tumor  showed  pavement  epithelial  carcinoma 
with  typical  lymph  follicles  in  the  stroma.  It  was 
decided  that  we  had  a  metastasis  of  carcinoma  in  the 
glands,  and  later  successful  laryngoscopic  examination 
demonstrated  the  existence  of  carcinoma  of  the 
larynx. 

The  secondary  gland  carcinomas  are  to  be  differenti- 
ated from  the  very  rare  carcinomas  originating  from  sep- 
arated lateral  offshoots  from  the  thyroid  gland  whose 
topography  and  clinical  appearance  may  very  closely 
correspond  with  branchiogenic  carcinomas.  The  differ- 
entiation of  this  form  of  tumors,  of  which  Berger 
described  a  typic  example,  is  only  histologically 
possible.  Of  noncarcinomatous  tumors,  lymph 
sarcomas,  tuberculous  glands,  and  actinomycosis 
may,  under  certain  circumstances,  be  mistaken  for 
branchial  carcinomas.  The  sarcomas  are  generally  of 
a  softer  consistency  ;  tubercular  glands  may  be  very 
hard  in  consequence  of  fibrous  periadenitis,  and,  since 
in  advanced  age  they  often  appear  isolated,  they  might 
awaken  suspicion  of  malignancy  and  exploratory  in- 
cision may  have  to  be  resorted  to.  The  combination 
of  hard  infiltrations  and  softened  places  is  character- 
istic of  actinomycosis.  The  skin  becomes  involved  in 
the  early  stages  of  the  disease.  The  neuralgic  pains  are 
not  so  pronounced  in  the  above-mentioned  diseases  as 
in  carcinoma.  The  prognosis  is  very  grave.  It  appears 
that  extirpation  has  been  followed  by  only  one  cure 
(case  of  Eigenbrodt.) 

From  the  uselessness  of  other  therapeutic  measures 
operative  removal  should  be  attempted  as  early  as  pos- 
sible. The  operation  is  difficult  as  well  in  the  early 
period  of  the  disease  on  account  of  the  intimate  rela- 
tion of  the  tumor  with  the  vessels  and  nerves.  The 
results  of  the  operation  depend  upon  laying  the  field 
widely  open  ;  it  really  means  an  anatomic  preparation, 
and  therefore  the  utilization  of  flaps  or  cross-cuts  of 
Bruns  and  Gussenbauer  recommend  themselves.  The 
first  cut  runs  parallel  with  the  anterior  border  of  the 
sternomastoid ;  the  second  runs  from  the  middle  of  the 
chin  obliquely,  or  in  the  shape  of  a  bow,  to  the  middle 
of  the  sternomastoid,  and  eventually  to  the  acromion 
process  of  the  scapula.  The  sternomastoid  is  divided 
and  the  four  flaps  are  reflected  in  the  various  directions. 
Should  the  muscle  be  involved  it  must  be  removed 
or  resected,  if  free  it  is  tied  with  catgut.  The  inci- 
sion given  by  de  Guervain  is  to  be  recommended.  It 
runs  along  the  anterior  border  of  the  sternomastoid 
down  to  the  sternum,  thence  at  an  acute  angle  outward 
along  the  clavicle  with  severing  of  the  sternomastoid 
about  H  cm.  above  its  insertion,  and  with  the  reflection 
of  the  ])latysma,  because  it  enables  one  immediately  to 
encircle  the  large  bloodvessels  at  the  lower  angle  of  the 
wound  with  silk  loops.  Owing  to  close  adhesions  the 
internal  jugular  must  always  be  resected  and  the  caro- 
tids many  times ;  one  is  at  times  forced  to  remove  the 


vagus  and  sympathetic  nerves,  which  is  not  serious  be- 
cause of  the  change  in  these  structures  due  to  the  long 
compression.  Considering  the  diflBculties  of  the  proce- 
dure and  the  patients'  advanced  age,  the  mortality  of  the 
operation  is  not  great.  Out  of  the  8  operated  upon  by 
Gussenbauer,  only  1  died  post-operation  from  the  effects 
of  the  ligation  of  the  carotid.  The  chances  of  a  lasting 
result  are  bad. 

The  only  one  who  remained  free  from  recurrence  was 
the  patient  of  von  Eigenbrodt,  whom  he  exhibited  at 
the  Twenty-third  Surgical  Congress.  Of  the  cases  of 
Gussenbauer,  2  died  from  5  to  8  weeks  after  discharge, 
from  recurrence ;  about  the  others  no  report  has  been 
made. 

Radical  operations  being  impossible  in  many  cases, 
we  are  then  limited  to  palliation  and  symptomatic  treat- 
ment, curetment,  chlorid  of  zinc,  and  cauterization. 

In  the  Surgical  Review  (Paris),  according  to  the 
Journal  of  the  American  Medical  Association,  is  an  article 
on  "  Branchial  Epithelioma  of  the  Neck,"  by  V.  Veau. 
The  following  is  an  abstract : 

Si.x  personal  abservations,  added  to  the  48  on  rrcord,  show 
that  "malignant  branchioma"  is  not  so  rare  as  generally 
assumed.  The  treatment  should  be  preventive  in  case  of 
branchial  fistulae,  cysts  and  mixed  tumors,  by  removal  bffore 
malignant  transformation.  If  ablation  of  the  branchioma  is 
possible  it  should  be  extensive.  The  veins  will  have  to  be 
ligated,  but  this  is  free  from  danger.  The  arterj-  should  be 
respected,  its  ablation  may  entail  cerebral  accidents,  and 
ligating  it  to  prevent  or  arrest  hemorrhage  caused  the  death 
of  one  of  Veau's  patients.  The  vagus  may  have  to  be  resected ; 
this  is  less  dangerous  than  ligating  the  primary  carotids.  It 
it  best  not  to  attempt  autoplastics.  The  branchioma  may 
develop  from  various  elements  of  the  branchial  arches 
and  may  be  located  in  the  parotid  and  subinaxillHr>'  glands, 
or  in  the  thyroid  gland,  possibly,  also,  in  the  mediastinum, 
but  it  is  most  frequent  and  most  typical  in  the  neck. 


THE  RESOURCES  OF  MODERN  MINOR  GYNECOLOGY.* 

By  AUGUSTIN  H.  GOELET,  M.D.,       ' 
of  New  York. 
Professor  of  Gynecology  ia  the  New  York  School  of  Clinical  Medicine,  etc 

This  paper  has  been  suggested  by  the  growing  tend- 
ency to  lose  sight  of  the  capabilities  of  minor  gyne- 
cology as  shown  by  the  assertion  of  some  men  that 
they  find  little  use  for  it,  but  after  examining  their 
patients,  they  are  sent  to  the  hospital. 

Is  gynecology  becoming  a  surgical  specialty  ?  If  so, 
I  desire  to  enter  an  earnest  protest  There  is  much  we 
can  accomplish  by  minor  gynecology.  There  are  many 
gynecological  disorders  that  are  curable  by  office  treat- 
ment. 

But  the  man  who  limits  his  resources  to  glycerin 
tampons  and  iodin  applications,  is  truly  in  a  sad  plight 
and  there  are  few  cases  that  he  can  cure  without  re*on 
to  surgery.  It  must  be  admitted  that  not  all  gynecolog- 
ical disorders  are  amenable  to  nonsui^ical  treatment, 
and  I  would  not  be  understood  as  being  opposed  to 
surgical  gynecology.  I  am  heartily  in  favor  of  any 
method  of  treatment  that  gives  the  best  results  for 
the  patient.  But  the  growing  indiflerence  to  nonsur- 
gical treatment  or  minor  gynecology  seems  to  me  an 
error.  The  multiplicity  of  our  moderu  gynecologioal 
resources  shows  that  we  are  better  equipped  than  we 
were   15  or  20  years  ago.     Yet  many  of  these  cases 

•  Read  at  the  meeting  of  the  New  York  State  Medical  Association  hdd  in 
Sew  York,  October  15  to  18,  1900. 


JiKCAKV  S,    1901] 


THE  RESOUKCES  OF  MODERN  MINOR  GYNECOLOGY 


["The  Philadelphia 
L  Medical  Jocenal 


33 


were  cured  even  then.  May  we  not,  by  exercising  a 
little  more  patience  and  perserverance,  avoid  much 
needless  surgery?  Is  it  not  our  duty  to  conserve, 
rather  than  to  destroy  ? 

It  has  occurred  to  me  that  it  might  be  profitable  to 
enumerate  some  of  our  modern  gynecologic  resources 
and  consider  what  they  may  aid  us  in  accomplishing. 
Our  resources  may  be  divided  into  diagnostic  and 
therapeutic. 

Diagnostic  Resources. 

Microscope. — Foremost  among  diagnostic  resources  is 
the  microscope.  It  occupies  the  position  of  a  preven- 
tive resource,  since  by  the  early  detection  of  infection 
through  its  aid,  many  of  the  more  serious  gynecolog- 
ical disorders  may  be  averted.  I  believe  1  am  not 
demanding  too  much  when  I  say  no  man  should  prac- 
tise gynecology,  or  even  examine  gynecologic  cases, 
unless  he  possesses  this  means  of  investigating  the 
character  of  vaginal  discharges,  and  the  knowledge  to 
employ  it  intelligently.  This  applies  to  the  general 
practitioner  as  well  as  to  the  specialist.  It  is  unneces- 
sary to  remind  you  that  many  lives  have  been  wrecked 
and  many  lost,  by  neglect  of  proper  investigation  of 
vaginal  discharges,  both  in  women  and  children.  This 
is  a  diagnostic  resource  that  none  of  us  can  afford  to 
neglect,  or  be  without,  and  is  one  very  important 
advantage  we  have  oyer  our  predecessors  of  a  quarter 
of  a  century  ago. 

Uterine  Endoscope. — This  is  comparatively  a  new  diag- 
nostic instrument,  and  the  one  I  show  you,  which 
illuminates  the  field  by  means  of  a  small  electric  light 
carried  down  to  nearly  the  end  of  the  tube,  is  one 
which  I  presented  in  connection  with  my  paper  on  the 
"  Treatment  of  Endometritis  by  Drainage  and  Irriga- 
tion "  last  year  at  the  Columbus  meeting  of  the  Ameri- 
can Medical  Association.  The  advantages  of  this  instru- 
ment as  an  aid  to  diagnosis  in  conditions  involving  the 
interior  of  the  uterus,  cannot  be  appreciated  until  it 
has  been  used.  One  of  its  chief  advantages  is  in  show- 
ing when  curettage  is  necessary  and  when  it  is  not 
necessary,  and  also  showing  when  the  work  has  been 
done  thoroughly. 

Qystoscope. — It  is  not  necessary  to  enter  into  the  de- 
tails of  the  uses  of  this  instrument.  Its  utility  is  now 
very  generally  recognized  and  no  well-equipped 
specialist  in  this  line  is  without  one.  It  is  positively 
indispensable  for  diagnosis  of  diseaseu  involving  the 
interior  of  the  bladder. 

Sleel  Dilators. — After  the  sponge-tent  was  abandoned, 
because  of  its  liability  to  cause  sepsis,  the  steel  dilator 
came  more  generally  into  use,  and  there  are  a  dozen 
or  more  varieties  on  the  market.  The  advantage  of 
this  instrument,  as  a  means  of  diagnosis,  by  affording 
facility  for  exploration  of  the  interior  of  the  uterus,  is 
too  well  recognized  to  require  more  than  passing  men- 
tion. The  usefulness  of  the  two-branch  dilator  is, 
however,  limited,  since  with  it  only  a  comparatively 
small  degree  of  dilation  can  be  accomplished.  When 
the  cervix  is  rigid,  sufficient  dilation  to  permit  the  in- 
troduction of  the  finger  for  exploration  cannot  be 
accomplished  with  this  instrument.  The  four-branch 
dilator  has  been  made  to  extend  the  degree  of  dilation 
of  the  cervix,  and  answers  the  purpose  better  than  any 
of  its  kind  that  I  have  used.  It  is,  however,  a  powerful 
and  dangerous  instrument  in  careless  hands  and  should 
be  used  with  extreme  caution. 

We  have  never  had  anything  that  produced  such 


thorough  and  satisfactory  dilation  of  the  cervix,  as  the 
sponge  or  laminaria-tent,  and  I  am  sure  that  I  am  not 
alone  in  feeling  deep  regret  in  being  obliged  to  abandon 
them.  Very  frequently  cases  are  encountered  in  which 
exploration  of  the  cavity  with  the  finger  is  desirable, 
yet  the  cervix  is  too  rigid  to  be  dilated  safely  with  the 
steel  dilator. 

Recognizing  this,  I  was  induced  to  devise  a  plan  of 
employing  them  in  a  manner  that  would  be  perfectly 
aseptic.  The  outcome  is  this  rubber  tent-cover  that  is 
made  for  me  by  the  Miller  Rubber  Company.  To  fully 
ai)preciate  its  advantage,  we  must  consider  why  a 
sponge  or  laminaria-tent  could  never  effect  aseptic  dila- 
tion of  the  cervix  when  used  bare.  It  is  certainly 
possible  to  render  the  tent  aseptic,  but  its  expansion 
depends  upon  absorption  of  the  secretion  from  the 
surface  with  which  it  is  in  contact.  Hence  the  secretion 
from  the  cervical  glands,  which  so  frequently  harbors 
bacteria,  is  taken  up  by  the  tent  and  conveyed  to  the 
cavity  above,  where  the  bacteria  find  a  fertile  field  for 
development. 

By  using  the  tent-cover,  this  is  avoided,  because  the 
tent  expands  within  it.  A  strip  of  gauze  is  carried  up 
along  the  side  of  the  tent  and  over  the  end,  one  end  of 
the  gauze  being  left  long.  This  is  wet  and  the  cover  is 
slipped  on  over  it  and  it  is  then  introduced  into  the 
cervix.  One  end  of  the  gauze  is  left  hanging  from  the 
mouth  of  the  cover  in  the  vagina.  The  vagina  is  now 
filled  loosely  with  gauze  and  this  is  made  thoroughly 
wet.  The  capillary  action  of  the  gauze  carries  the 
moisture  from  that  in  the  vagina  to  the  tent  and  causes 
it  to  expand  within  the  cover.  Therefore,  even  if  the 
vagina  is  not  sterile,  there  is  no  risk  of  infecting  the 
endometrium  from  that  source. 

^ne.s(/ie.3?'a.— Anesthesia,  whereby  unconsciousness  of 
pain  and  relaxation  may  be  acquired  to  facilitate  ex- 
amination by  palpation  in  doubtful  cases,  where  the 
patient  is  too  sensitive  to  permit  a  satisfactory  examina- 
tion, is  of  inestimable  value,  as  a  means  of  diagnosis. 
This  advantage  is  only  too  self-evident.  Increased 
dexterity  in  bimanual  palpation  acquired  by  practice, 
and  the  positions  of  the  patient  which  have  been  found 
to  facilitate  these  examinations,  make  examination 
under  anesthesia  less  frequently  necessary  than  formerly, 
but  this  can  only  be  attained  by  a  few  who  have  un- 
usual facilities  and  know  how  to  utilize  them  to  the  best 
advantage. 

Greater  familiarity  with  the  pelvic  organs  and  ab- 
normal growths  in  the  pelvis,  afforded  by  abdominal 
section,  is  one  of  the  many  advantages  we,  of  the  pres- 
ent day,  possess,  and  which  was  denied  us  before  these 
operations  became  so  frequent.  The  immense  aid  this 
is  to  one's  diagnostic  ability  cannot  be  appreciated  until 
one  has  had  this  experience. 

Exploratory  Abdominal  &dw7i.— Finally  may  be  men- 
tioned exploratory  abdominal  and  vaginal  section.  This 
is  a  diagnostic  resource  of  great  value,  since  it  is  now  a 
recognized  procedure  in  doubtful  conditions  within  the 
pelvis  or  abdomen,  where  it  has  been  impossible  other- 
wise to  reach  a  conclusion. 

Therapeutic  Resources. 

It  is  a  mistake  to  think  that  our  therapeutic  resources 
are  few.  I  find  them  more  numerous  and  more  eflScient 
than  when  I  began  this  line  of  work  16  years  ago.  I 
regret  that  I  have  only  time  to  give  a  brief  review  of 
those  that  seem  to  me  the  most  important. 

The  Vaginal  Tampon  and  Local  Applications  of  lodin. 


34 


The  Philadelphia"! 
Mkdical  Journal  J 


THE  RESOURCES  OF  MODERN  MINOR  GYNECOLOGY 


(Jasuabt  5,  laoi 


— The  vaginal  tampon  and  local  application  of  iodin 
are  given  first  place,  not  because  they  are  the  most  in- 
valuable or  the  most  indispensable  of  our  therapeutic 
resources,  but  rather  because  they  have  held  first  rank 
to  long.  It  cannot  be  denied  that  they  still  serve  a 
very  useful  purpose  in  the  treatment  of  gynecologic 
disorders,  especially  those  of  a  chronic  inflammatory 
character,  and  I  do  not  wish  it  to  be  inferred  that  I 
discredit  their  usefulness,  but  I  think  too  much  is 
attributed  to  them  and  they  are  often  misapplied. 

The  application  of  iodin  to  the  vaginal  vault  is  cer- 
tainly beneficial  in  certain  chronic  inflammatory  condi- 
tions about  the  uterus  and  bladder.  It  relieves  pain 
and  soreness,  stimulates  absorption  of  inflammatory 
exudates,  and  is  the  most  reliable  local  antiseptic  that 
can  be  employed.  Therefore,  it  is  particularly  useful 
in  counteracting  infection  about  the  cervix  and  even 
within  the  uterus  when  it  is  properly  applied.  It 
should  not  be  applied  to  the  interior  of  the  uterus,  how- 
ever, in  full  strength,  nor  upon  a  cotton-wrapped  appli- 
cator, but  should  be  diluted  with  water  and  applied 
through  a  double  current  irrigator,  when  the  canal  of 
the  cervix  is  suSiciently  patulous  to  permit  free  drain- 
age afterwards. 

Tampons  soaked  with  glycerin  are  useful  for  effect- 
ing depletion  of  the  pelvic  structures,  but  they  cause 
discomfort  and  do  harm  if  not  properly  used  or  if  they 
are  retained  too  long,  by  exerting  pressure  upon  sensi- 
tive structures.  There  are  some  improvements  in  the 
method  of  using  this  agent  that  have  been  suggested  by 
personal  experience.  For  instance,  if  the  glycerin  is 
applied  on  a  strip  of  absorbent  gauze  that  is  distributed 
loosely  and  evenly  against  the  vaginal  vault  around  the 
cervix,  there  is  less  discomfort  than  from  the  applica- 
tion of  tampons  soaked  in  glycerin.  The  patient  should 
be  placed  either  in  the  Sims'  or  knee-chest  postion  for 
its  insertion.  In  some  instances,  when  even  less  pres- 
sure than  this  latter  exerts  can  be  endured,  I  have  em- 
ployed glycerin  by  placing  the  patient  in  the  knee-chest 
position,  inserting  a  perineal  retractor  and  pouring 
about  half  an  ounce  of  glycerin  into  the  vagina  from  a 
small  test-tube.  Then  a  flattened  tampon  of  nonabsor- 
bent  cotton  is  placed  just  within  the  vulvar  orifice  to 
retain  it  in  the  vagina.  The  patient,  when  possible, 
should  retain  the  recumbent  position  for  an  hour  or  two 
afterwards. 

I  have  found  glycerin  and  iodin  combined,  in  the 
proportion  of  1  part  to  32,  more  satisfactory  than 
boroglycerid,  or  icthyol  and  glycerin.  It  is  an  excel- 
lent astringent  and  possesses  all  the  advantages  of  the 
other  two  remedies  mentioned,  with  none  of  their  dis- 
advantages. 

The  dry-wool  tampon  is  a  very  useful  elastic  support 
for  the  uterus,  when  the  pelvic  structures  are  too  sensi- 
tive for  the  unyielding  pressure  of  a  pessary,  and  by 
applying  it  at  first,  the  parts  are  prepared  for  a  more 
permanent  and  reliable  support.  Thus  the  sensitive 
structures  are  gradually  made  accustomed  to  pressure 
and  the  uterus  is  lifted  in  the  pelvis,  thereby  relieving 
the  obstruction  to  the  return  circulation  and  reducing 
the  weight  of  the  organ.  When  used  for  this  purpose, 
the  surface  of  the  vagina  and  tampon  should  be  coated 
with  some  bland,  nonirritating  antiseptic  powder,  to 
keep  the  tampon  from  becoming  foul  and  prevent  irri- 
tation of  the  vaginal  surface. 

These  tampons  are  best  introduced  with  the  patient 
in  the  knee-chest  position,  and  care  must  be  taken  to 
adjust  them  so  they  will  support  the  uterus  in  the  de- 


sired position,  without  exerting  unequal  pressure  at  dif- 
ferent points. 

Pessaries. — The  pessary  is  certainly  a  very  useful  arti- 
ficial support  for  the  uterus,  but  it  should  be  regarded 
only  as  an  auxiliary  to  other  measures  in  effecting  a  cure. 
Unaided,  it  can  accomplish  little.  Unfortunately,  past 
teaching  has  caused  too  much  to  be  expected  of  it.  An 
enumeration  of  its  uses  and  abuses  would  constitute  a 
chapter  in  itself  and  would  take  up  too  much  space 
here. 

Uterine  Irrigation. — I  regard  uterine  irrigation  one  of 
the  most  important  additions  to  our  gynecologic  re- 
sources, because  it  is  the  only  reliable  method  of  cleans- 
ing the  uterine  cavity  and  it  affords  the  most  effective 
method  of  application  to  the  surface  of  the  endome- 
trium. If  it  has  not  already  done  so,  it  should  supersede 
all  other  methods  of  application  to  the  interior  of  the 
uterus.  The  clinical  irrigator  which  I  show  j'ou  makes  it 
possible  to  employ  this  method  without  previous  dilation 
of  the  canal  of  the  cervix  and  without  an  anesthetic. 
Therefore  it  may  be  used  in  office  or  clinical  work, 
without  discomfort  to  the  patient  and  without  risk  if 
asepsis  is  observed.  It  is  small  enough  to  be  intro- 
duced, in  most  cases,  with  ease,  and  when  it  does  not 
pass  the  internal  os  readily,  it  is  converted  temporarily 
into  an  electrode,  by  slipping  a  piece  of  rubber  tubing 
over  it  for  insulation  and  connecting  it  with  the  nega- 
tive pole  of  the  battery  (galvanic).  By  using  10  M.  for 
half  a  minute  or  a  minute,  the  obstruction  is  overcome. 
If  the  current  is  continued  while  the  irrigation  is  going 
on,  thorough  relaxation  of  the  canal  is  produced  for 
subsequent  drainage.  The  outer  tube  of  this  instru- 
ment is  made  long,  that  the  outflow  ma\'  escape  outside 
the  vulvar  orifice.  It  can  be  employed  in  the  dorsal  or 
lateral  position. 

It  would  consume  more  time  than  I  am  allowed  to 
enumerate  the  advantages  of  uterine  irrigation.  They 
should  be  sufficiently  self-evident  to  make  it  unneces- 
sary. 

Electricity. — Despite  the  fact  that  the  purely  surgical 
gynecologists  have  tried  to  kill  it,  that  they  have  re- 
peatedly declared  it  dead,  that  the  enthusiasts  have 
mortally  wounded  it  by  their  exaggerated  claims,  and 
that  it  has  failed  or  done  harm  when  employed  indis- 
criminately and  incompetently,  it  is  still  very  much 
alive  and  is  doing  much  good.  The  gynecolotrist  who 
does  not  employ  electricity,  neglects  one  of  the  most 
valuable  gynecologic  resources.  It  will  not  be  possible 
here  to  give  you  more  than  a  mere  suggestion  of  its 
capabilities  in  gynecologic  disorders. 

Galvanism. — Galvanism,  or  the  direct  current,  will 
relax  the  cervical  canal  and  promote  drainage  of  the 
cavity  above  and  of  the  submucous  glands  of  the  cer- 
vix as  well,  establishing  thereby  a  condition  essential 
for  the  cure  of  endometritis,  which  cannot  otherwise  be 
done  except  by  surgical  intervention.  It  will  dispel 
pelvic  congestion,  relieve  pain  depending  thereon  and 
promote  absorption  of  exudates  and  effusions  more 
satisfactorily  than  any  other  agent,  except  faradization. 
It  will  relieve  the  symptoms  and  reduce  the  size  of  cer- 
tain varieties  of  fibroid  growths  in  the  uterine  wall  and 
when  they  have  not  attained  too  great  a  size,  or  have 
not  acquired  extraneous  nutrition  through  orsanized 
adhesions  with  adjacent  structures,  they  sometimes  dis- 
appear under  its  use. 

Faradization. — In  faradization  we  have  a  most  effec- 
tive remedy  for  the  relief  of  pelvic  pain  and  conges- 
tion ;  for  promoting  rapid  absorption  of  effusions  and 


JaKCARY  5,  1901] 


HOME  MODIFICATION  OF  MILK 


TThe  Philadelphia 
L  Medical  Joirnal 


35 


exudates,  and  for  the  cure  of  both  acute  and  chronic 
inflammatory  conditions  in  and  about  the  uterus.  As 
a  remedy  in  the  above  named  conditions,  it  is  without 
an  equal.  I  cannot  consume  the  time  here  to  explain 
how  it  produces  these  results.  A  correct  appreciation 
of  its  physiologic  action  will  render  such  explanation 
unnecessary. 

Internal  Medication. — The  administration  of  remedies 
that  act  through  the  general  circulation  and  exert  some 
special  action  upon  the  generative  apparatus,  is  very 
generally  understood.  It  is  only  necessary  to  warn 
against  expecting  too  much  of  them  to  the  exclusion 
of  local  measures,  as  the  busy  practitioner  is  inclined 
to  do.  There  are  a  few  internal  remedies  which,  from 
personal  observation,  I  have  found  particularly  valu- 
able as  auxiliaries  that  deserve  special  mention  here. 

A  combination  of  bromid  and  potassium  iodid  (10 
grains  of  the  former  and  5  of  the  latter),  given  in 
water  3  times  a  day,  is  particularly  beneficial  as  a 
sedative  for  painful  conditions  in  the  pelvis  and  for 
promoting  absorption  of  inflammatory  exudates. 

The  ordinary  compound  cathartic  pills,  given  one 
every  second  or  third  night,  is  one  of  the  most  satisfac- 
tory remedies  for  chronic  constipation  so  common  in 
this  class  of  cases.  Unlike  other  cathartics,  the  dose 
does  not  have  to  be  increased,  but  owing  to  their  stimu- 
lating action  on  the  liver,  it  is  kept  active  and  they  can 
soon  be  dispensed  with.  I  have  never  observed  any 
undesirable  action  from  the  calomel  they  contain. 

The  bromid  of  gold  and  arsenic  1  have  found  very 
serviceable  as  a  sedative  to  the  pelvic  circulation  and 
to  the  generative  apparatus  in  general ;  particularly 
when  there  is  ovarian  irritation,  and  in  anemic  condi- 
tions. It  produces  marked  diminution  in  the  menstrual 
flow,  even  where  the  endometrium  is  in  a  condition  to 
demand  curettage.  For  this  reason  it  is  eflfective  in 
menorrhagia  and  metrorrhagia,  but  it  would  not  be 
appropriate  where  menstruation  is  deficient  except 
when  due  to  anemia. 

I  fully  realize  that  I  have  not  done  my  subject  justice 
and  I  have  omitted  much  that  is  important.  My  ex- 
cuse is  the  limited  time  at  my  disposal  here.  But  if 
what  I  have  said  proves  an  incentive  to  renewed  efforts 
in  the  line  of  minor  gynecology,  which  I  feel  has  been 
much  neglected  of  late,  I  shall  be  repaid  for  the  efibrt 
I  have  made  in  this  direction. 


THE  HOME  MODIFICATION   OF  MILK    FOR  INFANT 
FEEDING. 

By  L.  EMMETT  HOLT,  M.D., 

of  New  Y«rk. 

Every  physician  who  engages  in  infant  feeding  must 
know  something  of  milk  modification.  The  milk  lab- 
oratories have  taught  us  the  great  advantage  of  accuracy 
and  definiteness,  and  the  percentage  method  has  been 
of  very  great  assistance  in  the  modification  of  milk  at 
home.  While  it  may  be  said  that  accuracy  carried  to 
small  fractions  of  a  percent  is  not  absolutely  necessary 
for  practical  results,  it  is  a  matter  of  the  greatest  import- 
ance that  the  physician  know  very  approximately  what 
he  is  feeding.  There  is  great  need  of  a  simple  method 
of  calculating  readily  the  proportions  of  fat,  sugar  and 
proteids,  in  formulas  to  be  made  up  at  home.  It  must 
be  easy  also  to  vary  the  proportion  of  these  dift'erent 
ingredients  separately.  A  method  to  be  really  useful 
at   the  bedside  must  be  one  requiring  the   minimum 


amount  of  arithmetical  calculation,  and  so  simple  as  to 
be  grasped  by  the  average  nurse  or  mother  who  is  to 
prepare  the  food.  While  all  of  the  3  or  4  different 
methods  proposed  secure,  I  have  no  doubt,  equal 
accuracy  with  the  one  here  given,  most  physicians  have 
found  them  too  complex  for  use.  It  is  greater  simplicity 
which  is  aimed  at  in  this  paper. 

No  method  of  home  modification  secures  more  than 
approximate  accuracy ;  since  the  exact  composition  of 
the  elements— milk  and  cream — which  are  used,  it  is 
not  ordinarly  possible  to  know.  There  are,  however, 
some  general  facts,  which  may  prove  of  great  a.«sistance 
to  the  physician  in  making  his  calcu'ations.  The  com- 
position of  herd  milk,  or  mixed  milk  of  a  number  of 
cows,  is  practically  constant  except  in  the  proportion  of 
fat,  this  varying  from  3.50%  to  5.50%  ;  in  the  ordinary 
samples  used  4%  perhaps  may  be  taken  as  the  average, 
except  that  from  Jersey  herds.  As  regards  the  pro- 
teids, it  seems  certain  from  recent  analysis,  that  in 
assuming  4%  as  the  average  we  have  made  a  mistake, 
and  that  3.50%  is  much  nearer  the  truth.  Some  of  the 
foreign  authorities  place  it  as  low  as  3.40%,  others  at 
3.60%,  but  very  few  as  high  as  4%.  The  sugar  is  not 
far  from  4.30%  to  4.50%.  We  shall  therefore  assume  in 
our  discussion  the  composition  of  average  herd-milk 
to  be  :  fat  4%,  sugar  4.50%,,  proteids  3.50%. 

It  is  necessary  to  know  also  the  percentages  of  sugar 
and  proteids  which  are  present  in  cream  containing 
different  amounts  of  fat.  The  following  table,  taken 
chiefly  from  the  analyses  made  by  Adriance,  and  con- 
firmed by  other  observations,  may,  I  think,  be  taken  to 
represent  pretty  nearly  the  composition  of  creams  of 
different  density : 

I.  II.  III.  IV.  V. 

Fat 4.  8.  12.  16.  20. 

Sugar 4.50  4.35  4.2D  4  05  3.90 

Proleids  ....                    3.50  8.40  8.30  3.  iO  3.05 

SalU .76  .70                    .65  .60  .65 

In  most  of  the  modifications  of  milk  for  young  in- 
fants it  is  required  that  the  fat  be  considerably  higher 
than  the  proteids.  A  simple  plan  would  seem  to  be 
first  to  raise  the  percentage  of  fat  to  such  a  point,  that, 
when  the  milk  is  diluted  to  reduce  the  proteids  to  the 
required  figure,  the  fat  shall  also  be  reduced  to  the  per- 
centage which  we  wish  to  use.  Really  the  important 
part  of  the  modification  consists  in  finding  the  best  way 
of  introducing  the  extra  fat  desired.  It  may  be  done 
by  the  addition  of  cream,  or  by  using  the  upper  milk 
after  it  has  been  standing  for  a  given  length  of  time. 

If  cow's  milk  from  a  mixed  herd  is  put  into  bottles 
soon  after  it  is  drawn  and  rapidly  cooled,  it  will  be 
found  that  after  4  hours  the  upper  fourth  will  contain 
nearly  all  the  fat  that  wiU  rise  as  cream  ;  and  that  the 
upper  layers  will  have  nearly  the  same  percentage  of 
fat,  whether  the  milk  has  stood  for  4  hours,  for  8  hours, 
or  over  night  (16  hours).  This  has  been  demonstrated  in 
a  series  of  experiments  made  for  me  by  Messrs.  Upton 
and  Jeft'ers  at  the  Walker-Gordon  Farm  at  Plainsboro. 
After  standing  under  the  conditions  mentioned,  fat  tests 
were  made  with  the  Babcock  apparatus  of  the  different 
four-ounce  layers  of  bottled  milk  which  were  carefully 
removed  with  a  siphon,  with  the  following  results  : 

After  4  hours.  After  8  hours.  Over  night. 

Upper  4  ounce.                    20.60->  lat.  21.2S^  lat.  2Z0O^  fat. 

.Second         "                               6.00     "  6.50    '•  6  5I)    " 

Tuird          "                             l.'iO    "  1.40    "  1.00    " 

Kounh         "                               1.20     "  1.00    "  .30    " 

Fifth           "                             I.IO    "  I.OO    "  .05    " 

Each  of  the  above  percentages  represents  the  averages, 
each  test  having  been  repeated  many  times,  110  different 


36 


The  Phuaoei-phia"] 


HOME  MODIFICATION  OF  MILK 


[J4»CABT  5,    .Al 


tests  ha\-ing  in  aU  been  made.  It  will  be  seen  from  this 
that  the  differences  in  the  composition  of  the  separate 
layers  does  not  after  four  hours  change  very  much 
with  the  period  of  standing.  With  this  knowledge  of 
the  amount  of  fat  in  the  different  layers  of  milk,  it  be- 
comes a  comparatively  simple  matter  to  secure  almost 
any  desired  percentage  of  fat  by  simply  varying  the 
number  of  ounces  removed  from  the  upper  part 
of  the  quart.  Thus,  with  the  milk  in  question,  it 
will  be  seen  that  if  all  of  the  first  and  second  four-ounce 
layers,  and  three  ounces  of  the  third,  or  eleven  ounces 
in  aU,  are  taken  we  shaU  have : 

After  4  boon  11  oances  ooDUtniDg  1(K   fat. 
"      8      "       "        •'  "  IO.-H(  " 

"    16      "  10.«  " 

We  may  assume  that  the  upper  third  of  one  quart  of 
milk  will  contain  under  the  conditions  mentioned  about 
10%  fat.  After  similar  calculations  we  shall  find  also 
that : 

RemoTing  16  ounces  or  upper  half  we  secure  spproximfttely  7<  fat. 

11       ' third    "        "  "  lot    '• 

■•  8       ■■       "      ••  fourth  "       "  "  1S<    " 

6       '■       "      "    fifUi     "       •■  '•  16^    " 

The  formula  in  aU  cases,  with  the  milk  in  question, 
runs  slightly  above  the  percentages  given ;  but  as  the 
Walker-Gordon  milk  with  which  the  tests  were  made 
averages  about  4.25%  fat,  it  may  be  assumed  that  the 
figures  given  represent  very  nearly  what  is  obtained 
when  4.00%  milk  is  used,  this  being  what  the  physi- 
cian is  most  likely  to  have  at  hand. 

Instead  of  this  milk,  if  Jersey  milk  (5.25  to  5.50% 
fat)  is  used,  from  2  to  3  ounces  more  of  each  variety 
may  be  removed  from  the  quart.  If  a  poor  quality  of 
milk  (3.00  to  3.50%  fat)  about  2  ounces  less  should'  be 
taken,  to  keep  the  percentages  of  fat  nearly  like  those 
above  given. 

For  all  who  use  milk  fresh  from  the  cow.  the  simplest 
plan  is  therefore  to  place  that  which  is  needed  for  the 
baby  in  a  glass  quart  jar  or  quart  milk-bottle ;  the  jar 
then  should  stand  in  iced  water  for  at  least  4  hours, 
after  which  the  upper  portion  may  be  removed.  The 
same  plan  can  be  followed  and  essentially  the  s;ime 
result  will  be  obtained,  with  bottled  milk  which  has 
stood  for  8  hours,  or  the  usual  bottled  milk  of  cities 
which  is  delivered  on  the  following  morning,  always 
provided  the  bottling  has  been  done  at  the  dairy  before 
the  cream  has  been  allowed  to  rise.  This  upper-milk 
should  be  removed  with  a  siphon,  spoon,  or  cream- 
dipper,  but  should  not  be  poured  off. 

We  have  now  obtained  five  different  grades  of  milk 
having  different  fat  percentages,  in  which  the  fat  is.  re- 
spectively, five.  four,  three  times  and  twice  the  proteids, 
and  in  which  the  two  are  about  equal.  The  composition 
of  these  milks  in  fat,  proteids,  and  sugar  is  as  follows : 


Fat 


to  proteids  5 : 1  —  164  milk  —  fat  16,  sugar  4.05,  proteids  S.'.>(K 
4:1  — I»t    •'     =   "  IS,     ^     4.15,       "       S.2S« 
••    "         "       S:l  =  10^    "     —  "  10,     "     4.30,       "       S.SK 
••     '•  "        2:1=    74     "      =   ••      7,      "      4.40,         "        3.404 

•'    "  •'        8:7=   44    "      =   "     4,      '•     4.60.        "        Z.SS^ 

Instead  of  using  the  upper  layers  of  bottled  milk 
after  standing,  these  formulas  may  be  obtained  by  mix- 
ing milk  and  cream  as  follows : 

The  16;*  milk  is  the  ordioary  graviiy  cream. 
1.    jjjj    <i      ,.  obtained  by  mixing  1  part  milk  with  3  pans  (16-:)  cream. 

••    10*    " 1 1  tmn 

"      74    ' '        "       3  parts "        "      1      "  ••         " 

**      44    "      "  ordinary  plain  milk. 

The  above  calculations  have  been  given  somewhat  in 
detail  to  show  how  from  the  materials  which  are  ordi- 
narilv  within  reach  in  the  home, — milk  fresh  from  the 


cow,  bottled  milk,  or  milk  and  cream, — we  may  easily 
obtain  a  milk  containing  a  definite  percentage  of  fat,  i.  «., 
4,  7,  10,  13,  and  16%,  which  we  wish  to  use  in  our  mod- 
ification. These  milks  have  been  called  by  different 
names,  as  '"  definite  percentage  milk.''  '■  top  milk."  "  su- 
perfatted milk,'"  etc.  I  shall  hereafter  refer  to  them  aa 
primary  formulas  of  the  different  series.  Once  the  pri- 
mary formula  obtained,  the  subsequent  modification 
becomes  a  comparatively  simple  matter. 

ilo3ification  of  the  Fat  and  Proteids. — Given  the  pri- 
mary formula  in  which  the  ratio  between  the  fat  and 
proteids  desired  is  present  we  may.  by  a  process  of  sim- 
ple dilution,  derive  as  many  secondary  formulas  as  we 
wish,  the  ratio  between  the  fat  and  the  proteids  being, 
of  course,  unchanged.  We  may  make  the  constant  dif- 
ference between  the  formulas  as  large  or  as  small  as  we 
desire.  For  convenience  in  calculation  it  is  easy  to 
make  this  constant  difference  i^  of  the  original  formula. 
With  the  different  primary  formulas  the  following  re- 
sults are  obtained :" 

Seriej  A. — Primary  formula — fit  164.  proteids  3.9K. 
A  formula  cootaioiog  ^  milk  (1  oc  in  20  ox.  mixtnrei  has   .104  fat. 
J,     "      (Joi.     ■•     •■  •'         )     ••    1.604    •■ 

.\odone  '  j>,    "     (Sox.    "     "  "        )    "   2.404   -    etc. 

The  constant  difference  here  between  the  different  for- 
mulas is  .80%  fat.  No  separate  calculation  of  the  pro- 
teids is  necessarv.  as  thev  will  remain  in  all  cases  one- 
fifth  the  fat. 

Seria  B. — Primary  formula — fat  1.354.  proteids  ZSfK. 
Formula  eontaining  J,  milk  (1  ox.  in  20  ox.  mixture)  has  tat    .6.^ 
A    "    (»<»•    "    ■•  "      »       '•      1»0»^ 

And  one        "  A    "    (*"*-    "     "  "      )       "      *.00%.  «tt 

The  constant  difference  between  the  different  formulas 
here  will  be  .65%.  In  this  series  the  fat  will  always 
remain  one-fourth  the  proteids. 

Saiei  C— Primary  formula— fat  104.  proteids  3.3^. 
Formula  containing  J,  milk  (1  ox  in  20  ox.  mixture)  baa  (at   .SOt. 
A    ■•     (2o«. 


And  one 


(3  01. 


) 


LM^.etc 


The  constant  difference  between  the  different  formulas 
here  will  be  .50%  fat.  and  the  proteids  will  be  one- third 
the  fat. 

Series  D. — Primary  formula — fat  74.  proteids  1 54. 

Formula  containing  ^  milk  (I  ox.  in  20  ox.  mixtore)  has  fat    .V<. 

A   ■'     (2<»- »       "       ■'<«• 

And  one  "  A    "     (3  ox.     "    *'  "       >        "     1.054,  etc. 

The  constant  difference  between  the  different  formulas 
here  will  be  .35%  fat,  and  the  proteids  will  always  re- 
main one-half  the  fat. 

Soies  £— Primary  formula— bt  4^  proteids  3>Si. 
Formula  containiBg  A  iBilk  (1  oa.  in  20  os.  mixture)  has   .204  fkx. 

A    "     Cm- )    "    •<•»  " 

And  one  "  A     "     l*o«-     "     "  )     "    •«•»    "      '"■ 

The  constant  difference  between  the  different  formnlas 
here  will  be  .20%  fat. 

Modification  of  the  Suc/ar. — The  range  required  in  the 
modification  of  the  mUk  sugar  is  ordinarily  between 
5%  and  7%.  In  estimating  the  quantity  to  be  added 
to  bring  up  the  proportion  to  this  amount,  account 
must  of  course  be  taken  of  the  sugar  already  present 
in  the  milk.  I  have  found  that  except  for  mixtures 
which  have  proteids  above  2%.  i.  ?,.  those  which  are 
more  than  half  milk,  one  ounce  of  sugar  to  20  ounces 
of  the  mixture  will  give  very  nearly  the  percentage 
required,  i.  e..  about  5%  for  the  lower  mixtures  and 
6.5%  or  7%  for  the  higher  ones.  This  embraces  nearly 
all  the  formulas  required  for  the  first  ten  months,  after 
which  the  close  percentages  are  not  so  im{x>rtant 

The  amount  of  the  sugar  in  the  primary  tbrmolas 


lASUAEY  5,    1901] 


HOME  MODIFICATION  OF  MILK 


tTnK  Pjiiladelpiiia 
Medical  Journal 


37 


varies  between  4.05%  and  4.50%.  A  mixture  which 
contains  ./jy  milk  will  have,  before  any  sugar  has  been 
added,  80%  or  90%  sugar.  If  one  ounce  of  sugar  is 
added  to  each  20  ounces  of  the  mixture,  which  alone 
would  make  the  sugar  5%,  it  will  now  be  raised  to 
5.80  %  or  5.90  % ,  according  as  we  use  the  primary  formula 
of  series  A  or  E.  In  practice  this  may  be  considered 
as  a  6%  sugar. 

If  we  take  a  formula  containing  /^  milk,  the  milk 
mixture  will  give  1.85  or  1.95  sugar,  according  to  which 
primary  formula  we  are  using.  The  addition  to  this  of 
on*ounce  of  sugar  to  each  20  ounces  of  the  mixture 
will  raise  the  total  to  6.85  %  or  6.95  % ,  practically  the 
7%  sugar. 

Lower  percentages  of  sugar,  when  desired,  are  readily 
secured  by  making  the  quantity  added  less  than  1  ounce 
to  each  20  ounces  of  food. 

In  measuring  the  milk-sugar  it  is  to  be  remembered 
that  1  ounce  by  volume  is  very  nearly  1  ounce  by 
weight.  If  the  measuring  is  done  with  the  tablespoon, 
one  even  tablespoon  may  be  calculated  as  3  drams,  or 
2i  even  tablespoon fuls  as  1  ounce.  If  cane-sugar  is 
tised,  the  proportions  should  be  about  one-half  that  which 
has  been  mentioned,  i.  e.,  one-half  ounce  to  each  20-ounce 
mixture ;  as  there  are  few  infants  who  will  bear  cane- 
sugar  in  the  proportion  of  5  %  to  7  %  in  their  food. 

Lime  Water. — It  is  generally  agreed  that  5%  lime 
water  has  the  average  alkalinity  which  is  required. 
This  is  easily  secured  by  adding  1  ounce  of  lime  water 
to  each  20-ounce  mixture.  More  than  this  may  be 
used  without  disturbing  the  calculation. 

Diluent. — For  my  own  part  I  prefer  boiled  water  as  a 
diluent  for  the  first  months  of  life.  However,  the 
method  of  modification  is  not  affected  if  anything  else 
is  used.  One  may,  if  he  prefers,  use  one-half  or  one- 
quarter  of  barley  water,  or  the  dilution  may  be  entirely 
with  this.  The  milk  sugar  is,  of  course,  to  be  dissolved 
in  the  diluent  whatever  it  may  be. 

In  all  the  formulas  given  the  amount  of  water  or  of 
the  diluent  is  to  be  added  in  a  sufficient  quantity  to 
make  up  20  ounces,  this  unit  being  the  most  convenient 
one  for  calculation.  The  quantity  of  the  mixture  may 
be  increased  to  25,  30,  35  or  40  ounces  by  simply  using 
of  each  ingredient,  ^  more,  i  more,  f  more,  or  twice 
the  amount. 

The  foregoing  detailed  description  of  the  different 
steps  in  the  process  of  modification  may,  perhaps,  make 
this  method  seem  very  complex.  However,  the  prac- 
ticable application  of  the  results  is  very  simple.  Below 
are  given  the  various  proportions  derived  from  the  dif- 
ferent primary  formulas,  carrying  out  the  principles 
thus  described.  I  have  written  out  those  which  con- 
tain the  fat  from  about  0.5%  to  4.0%  with  the  combi- 
nations in  the  proteids  with  which  they  are  likely  to  be 
used.  Of  course,  the  number  of  these  derived  might 
be  indefinitely  increased. 

Series  A. — Ratio  of  fat  to  proteids  6  : 1. 

Primary  Formula: — 16^  milk  for  cream)  containing  fat^=I6,  sugar  4.05,  prot«ids 
3.20r.  Tliis  being  the  upper  6  oz.  of  1  quart  of  twttled  milk,  as  above  described, 
or  the  ordinary  gravity  cream. 


Derived  Formulas  Giving  Quantities  for  a  20  or.  Mixture. 
Sugar  I  oz. 

'  with  1  oz.  16;imilk-.fat)  .80,  sugar  5.20,  proteids  .16^ 


I.  <  Liiue  water 

I  Water  ci.  s.  20  oz, 

H. 

III. 

IV. 

v. 

If  more  than  the  20  oz, 


loz.    •'      " 
3oz.     "      " 

4  oz.     "      " 

5  oz.     "      " 
mixture  is  needed. 


1.60, 
2.40, 
5.80. 

4.00, 


5.40, 
6  60, 
3.80, 
6.00, 


.48it 
.64< 
.80<. 


amount  as  25,  30,  35,  40  oz.,  etc..  thus  using 
16'^  milk        2  0Z.1  To  make  fMilk  2H  oz. 

Milk  sugar    1  oz,  f_     25 oz.     i  Sugar  l>ioz. 

Lime  water  1  oz,  f      add      "[  Lime  water  I34  oz. 
■Water  q.  3,  20  oz. )  ^  more,  t  Water  q.  s.  25     oz. 


it  is  convenient  to  calculate  the 


To  make  |  Milk  3     oz. 

80  oz.      I  Sugar  l"4oz. 

add      1  Lime  water  1J4  oz. 

\-^  more,   t  Water  q.  s.  30     oz. 


If  the  formulas  intermediate  between  these  are 
needed,  the  increase  in  the  16%  milk  may  be  made  by 
h  ounce  instead  of  1  ounce;  e.g.,  a  formula  between  II 
and  III  may  be  obtained  by  using  2^  ounces,  which  will 
give  fat  2%,  proteids  .40%. 

Series  B. — Ratio  of  fat  to  proteids  4 ;  I. 

Primary  Formula: — l'-^^  milk  =■  fat  13.0;  sugar  4.15;  proteids  8.25^  obtained  (1) 
as  upper  fourth  of  bottled  milk  ;  or  (2)  by  mixing  1  part  milk  (44)  and  3  parts 
cream  (16^). 

Derived  Formulas  Giving  (Quantities  for  SO  oz.  Mixture. 

{Milk  sugar  1  oz.^i 

Lime  water  1  oz.  ywith  1  oz.  13^milk=fat  0.65,  sugar  5.20,  proteids  .l&f^ 
Water,  q.  s.  20  oz.  J 

II.           "  "  "  2oz. '  1.30,  "  5.40,  "  .3Sj( 

III.  "  "  "  3oz,  "      "         "  2  00,  "  5.60,  "  .SOJi 

IV.  "  "  "  4oz.  "      '•         "  2.65,  "  6.85,  "  .65)1 
v.           "  "  •'  5  0Z.  "      "        "  3.30,  "  6.00,  "  .82* 

VI.  '■  "  "     6oz.     '•      "         "    4.00,      •'      6.25,         "       100* 

In  this  series  as  in  the  preceding  one,  formulas  inter- 
mediate between  those  given  can  be  readily  made ;  the 
directions  for  making  mixtures  of  25  ounces,  30  ounces, 
etc.,  are  also  the  same,  viz.,  by  taking  one- fourth  more, 
or  one-half  more  of  each  of  the  ingredients. 

Series  C. — Ratio  of  fat  to  proteids  3  : 1 

Pnmrtry  Jbrmu/a.— 10,0  milk=fatlO!<.  sugar  4.30,  proteids  3.30^  sbtained  (1) 
as  upper  one-third  of  bottled  milk  ;  or  (2)  equal  parts  of  milk  (4r),  and  cream 
(16f.). 

Derived  Formula  Giving  Quantities  for  SO  oz.  Mixture. 

(  Milk  sugar    1  oz. ") 

I.  {  Lime  water  1  oz.  vwith  1  oz.  10;^  milk=fat    .50,  sugar  5  20,  prot«ids  .17^ 

{,  Water  q.  s.  20  oz.  j 

II.           "                   "  "  2oz. 1.00,  "  5.40,  "  .3Si( 

III.  "                   "  "  3oz.  "     "         "  l..i0,  "  5.60,  "  .50f 

IV.  "                   "  "  4oz, 2,00,  "  5.85,  "  .66J( 

v.           "                   "  "  5oz.  "     "         "  2.50,  "  6  05,  "  .83^ 

VI.  "  "  "      6oz.     "     "         "     3,00,     "         6.25,        "         1.00)6 

VII.  "  "  "      7oz.    "     "        "    3.50,     "        6.50,        "        1.17;< 

VIII.  "  "  "      8oz.     "     "         "     4,00,      "        6.70,         ■'         l.S5)« 

Series  D. — Ratio  of  fat  to  proteids  2:1. 

Primary  Form w/a :— 7^  milk=fat  7,00,  sugar  4.40,  pr«teids  3.40^,  obtained  (1)  by 
using  the  upper  one-half  of  bottled  milk,  or  (2)  by  using  3  parts  of  milk  (4^) 
and  one  part  cream  (16^). 

Derived  Formulas  Giving  Quantities  for  30  oz.  Mixture. 


.36,  sugar  6.20,  proteids  .llf 


[Milk  sugar 

loz.' 

I. 

i  Lime  water  1  oz. 

'With  1  oz 

(.Water  q.  s. 

20«z. 

1 

II. 

"    2  oz. 

III. 

"    3oz. 

IV. 

"    4oz. 

V. 

"    6  oz. 

VL 

"    6  oz. 

VII. 

"    7oz. 

VIII. 

"    8  0Z. 

IX. 

"    9oz. 

X. 

"lOoz. 

XI. 

"  11  oz. 

XII. 

"12oz. 

.70, 

'       5.40, 

"        .35* 

1.06, 

"       5.60, 

'•        .62* 

1.40, 

'       5.80, 

"        .70* 

1.75, 

'       600, 

"        .87* 

2.10, 

'       6.20, 

"       1.05* 

2.45, 

•       6.45, 

"       1.22* 

2.S0, 

"       6.70, 

"       1.40* 

3.15, 

'       6,90, 

•■       1.65* 

3.50, 

'       7.10, 

■'       1.7^ 

3.8i, 

'     *7.30, 

"       I.92« 

4.15, 

'     *7.50, 

■■       2.07* 

Series  E. — Ratio  of  fat  to  proteld,  8 : 7. 

Primary  Formula  .—Plain  milk  =  4.00 ;  sugar,  4.50 ;  proteids,  3.50*. 

Derived  Formulas,   Giving  Quantiti^  for  SO  oz.  Mixture. 


II. 

ni. 

IV. 

V. 

VI. 

VII. 

VUI. 


t  Water,  q.s.  20  oz. 


i}- 


("Milk  sugar   loz.' 
I.  ■!  Lime  water  loz.  ^with   2  oz.  4*  milk=fat  0.40,  sugar  5.40,  proteids  0.35* 


4  oz. 

6  oz. 

8oz. 
10  oz. 
12  oz. 
14  oz. 
16  oz. 


0.80,    ' 

•      5.80, 

.70* 

1.2», 

'       620, 

1.06* 

1.60, 

'       6.70, 

1.404 

2.00, 

'       7.10, 

1.75* 

2.40, 

'     *7.60, 

2.10* 

2.80, 

'     *8.I0, 

2.45* 

3.20, 

'     *8.50, 

2,80* 

Formulas  marked  with  the  asterisk  in  the  last  two 
series  are  the  only  ones  in  which  a  special  calculation 
of  the  sugar  needs  to  be  made ;  the  usual  amount  of 
sugar,  1  ounce  to  a  20-ounce  mixture,  gives,  as  is  seen, 
too  high  a  percentage.  It  is  seldom  that  infants  taking 
the  high  percentages  of  fat  and  proteids  of  these 
formulas  require  the  sugar  to  be  even  as  high  as  7  % . 
A  good  working  rule  for  the  average  case  is  to  add  only 
J  ounce  to  each  20  ounces  for  a  formula  containing  i^ 
or  ^  milk ;  and  above  that  not  more  than  i  ounce. 

Application  of  these  Formula,s  in  Infant  Feeding — This 
is  by  no  means  so  simple  as  their  calculation.  I  seldom 
use  series  A  and  B  with  healthy  children  of  average 
digestion.  They  are  inserted  here  because  they  are  oc- 
casionally advantageous ;  but  for  the  vast  majority  of 


38 


The  Philadelphia"! 
Mkdual  Jocknal  J 


COMPOSITE  TERATOMA  OF  THE  OVARY 


[JaSCaey  5.  190) 


healthy  infants  it  is  rarely  necessary  to  have  the  fat 
more  than  three  times  the  proteids. 

For  health  J'  infants,  the  first  15  months  may  be  con- 
sidered as  made  up  of  three  feeding-periods.  For  the 
first  one,  extending  from  birth  to  the  end  of  the  third 
or  fourth  month,  the  best  results  are  obtained  in  my 
experience  when  the  fat  is  three  times  the  proteids,  or 
the  ratio  existing  in  good  breast  milk. 

The  second  })eriod  extends  from  the  end  of  third  or 
fourth  month  to  about  the  end  of  the  tenth  month. 
During  this  time  the  increase  in  the  strength  of  the 
food  should  be  made  chiefly  of  the  proteids.  With  most 
children  the  best  results  are  obtained  in  this  period  when 
the  fat  is  twice  the  proteids. 

The  third  period  extends  from  the  end  of  the  tenth 
month  to  the  beginning  of  the  fifteenth.  During  this 
the  proteids  are  gradually  increased  until  they  are  nearly 
equal  to  the  fat,  or,  in  other  words,  until  the  child  is 
taking  whole  milk. 

For  the  first  period  the  formulas  of  series  C  are  to  be 
advised.  No  other  primary  formula  than  the  10%  milk 
need  be  considered  until  the  infant  is  three  or  four 
months  old.  The  newly-born  child  can  usually  begin 
with  No.  n  of  this  series  — fat  1.00,  sugar  5.40,  proteids 
.33% — but  seldom,  I  think,  with  a  higher  formula. 
The  percentages  are  gradually  raised  as  the  child  be- 
comes accustomed  to  taking  cow's  milk,  until  No.  VI  or 
No  vll,  3.5—6.5 — 1.17,  is  reached.  From  this  point  a 
healthy  infant  would  probably  pass  to  No.  VII  of  the 
series  D,  and  the  proteids  would  be  rather  rapidly  raised 
until  No.  IX  is  reached.  This  with  Nos.  X  and  XI  will 
carry  a  healthy  infant  until  the  end  of  the  tenth  month. 
From  this  time  until  the  child  is  able  to  take  whole 
milk  such  formulas  as  Nos.  VII  and  VIII  of  series  D 
may  be  used. 

The  low  percentages  of  fat  and  ])roteids  given  in  the 
first  three  or  four  formulas  of  the  last  two  series  are 
applicable  for  those  infants  who  in  the  early  months 
have  special  trouble  with  the  fat,  and,  at  a  later  ])eriod, 
for  many  who  suffered  from  fat-indigestion.  For  many 
of  these  abnormal  cases,  the  fat  must  often  be  made,  at 
least  for  the  time  being,  nearly  or  quite  as  low  as  the 
proteids. 

The  formulas  of  Series  A  and  B,  where  the  fats  are 
very  much  higher  than  the  proteids,  are  useful  in  a  few 
infants  during  the  early  months  who  have  special  dif- 
ficulty in  digesting  the  proteids,  but  who  are  able  at 
the  same  time  to  take  without  difficulty  relatively  high 
fat.  Both  these  series  of  formulas  I  find  occasionally  of 
.service  for  short  periods,  but  I  do  not  think  they  are 
80  generally  useful  in  the  early  months  as  the  slightly 
lower  fats  of  series  C. 

Cmichmons. — In  the  foregoing  discussion  we  have 
considered  only  the  modification  of  the  milk  elements. 
All  other  discussion  of  infant-feeding  is  foreign  to  our 
purpose. 

Three  primary  formulas  can  be  made  to  do  duty  for 
the  entire  year  for  the  vast  majority  of  healthy  infants. 

By  the  method  of  calculation  here  given  on  the  basis 
of  ^j  it  seems  to  be  much  easier  to  pass  from  one  for- 
mula to  another  of  the  same  series  than  by  other 
methods.  Since  the  additions  of  sugar  and  lime  water 
are  constant,  it  is  necessary  only  to  calculate  the  per- 
centage milk  is  increased  bj^  an  ounce  in  each  20-ounce 
mixture.  The  diluent  water  is  in  all  cases  added  in 
sufficient  quantity  to  make  the  total. 

Larger  <iuantities  than  '20  ounces  can  easily  be  calcu- 
lated if  our  increase  is  made  by  5 ;  e.  g,  for  25  ounces 


^  more  of  the  milk,  the  sugar  and  the  lime  water;  for 
30  ounces  ^  more,  etc. 

In  securing  the  primary  formula  my  preference  is 
either  for  milk  fresh  from  the  cow.  or  the  bottled  milk, 
rather  than  for  the  mixtures  of  milk  and  cream,  mainly 
for  the  purpose  of  securing  greater  freshness.  Where 
milk  is  obtained  fresh  from  the  cow,  if  it  is  placed  in 
a  bottle  and  rapidly  cooled  in  the  manner  indicated, 
not  only  will  the  cream  rise  quickly  so  that  the  food 
may  be  made  up  when  the  milk  is  only  4  hours  old. 
but  at  the  same  time  this  rapid  cooling  is  of  the  utmost 
advantage  in  checking  the  early  fermentative  changes 
in  milk. 

In  taking  the  milk  from  the  top  of  the  bottle  it  is  to 
be  remembered  that  the  entire  number  of  ounces 
specified  for  the  primary  formula  should  be  taken, 
although  it  may  not  all  be  needed  to  make  up  the  milk 
for  weaker  formulas. 


A  CRITICISM  OF  THE  DIAGNOSIS  'COMPOSITE 
TERATOMA  OF  THE  OVARY"  MADE  IN  THE 
"PATHOLOGICAL  REPORT"  OF  DR.  K  A.  JONES. 

By  S.  W.  B.\UDLER,  M.D., 
of  New  York  City. 

In  the  Philadephia  Medical  Journal  of  December 
22,  Dr.  Edgar  Allen  Jones  reports,  through  the  courtesy 
of  Dr.  W.  E.  B.  Davis,  "  A  Composite  Teratoma  of  the 
Ovarj',"  accompanied  by  a  pathologic  report.  This  so- 
called  "  teratoma "  contains  more  recognizable  bones 
than  any  other  teratoma  whose  description  I  have 
observed.  Besides,  the  cranial  bones  were  recognized 
and  "  parts  of  the  lung,  hver,  the  stomach,  and  about 
60  cm.  of  the  intestine"  were  found.  A  teratoma  is 
simply  a  solid  dermoid  cyst,  and  it  is  a  question  of 
interest  to  correctly  classify  this  tumor.  We  are  told 
that  "  the  tumor  filled  up  the  left  side  of  the  pelvis  and 
was  attached  to  the  uterus  by  a  large  pedicle,"  and  that 
"  the  fetus  has  the  appearance  of  ha\4ng  reached  the 
sixth  or  seventh  month  of  fetal  development.""  We  are 
not  told,  however,  whether  the  tumor  was  firmly  im- 
bedded, whether  adhesions  were  present,  whether  it 
was  intraligamentous,  etc.  As  no  mention  is  made  of 
placenta  macroscopically,  and  no  mention  is  made  of 
the  examination  of  the  entire  specimen  for  such  tissue, 
we  are  left  in  doubt  as  to  this  side  of  the  question- 
Though  called  "  teratoma  "  of  the  ovary,  the  microscop- 
ical examination  makes  no  mention  of  the  presence  of 
ovarian  tissue  in  the  capsule,  but  an  anotomical  diag- 
nosis is  made  of  ''composite  teratoma,  combined  with 
cystic  adenoma  of  the  ovary."  Although  certain  portions 
of  the  tumor  contain  skin,  no  mention  is  made  as  to 
whether  the  skin  covered  the  fetus  or  lined  the  cyst 
cavitj'. 

The  statements,  however,  concerning  the  presence  of 
vertebrae,  of  too  well  developed  scapula  and  other 
skeletal  bones  are  so  positive  that  we  are  sup,.osed  to 
take  their  presence  for  granted.  Going  on  this  suppo- 
sition I  cannot  believe  that  the  case  is  one  of  teratoma. 
With  the  exception  that  no  mention  is  made  of  the 
presence  of  placental  tissue,  I  see  no  reason  why  the 
author  changes  the  opinion  conveyed  in  the  following^ 
statement :  "  The  most  interesting  feature  of  this  case 
is  the  fact  that  the  fetus  was  so  large,  and,  on  casual 
oliservation,  so  well  formed,  that  it  could  easily  l>e  mis- 
taken for  ectopic  gestation  which  had  ruptured  into  the 


January  5,  1901] 


COMPOSITE  TERATOMA  OF  THE  OVARY 


r^HE  Philadelphia 
Medical  Journal 


39 


I 


cavity  of  a  preexisting  ovarian  cystoma.  As  has  been 
stated  above,  the  diagnosis  of  ectopic  pregnancy  had 
been  made  from  the  history  of  the  case."  Referring  to 
the  history  given  by  the  author,  it  is  evident  that  such 
a  diagnosis  was  quite  naturally  made,  and  I  see  no 
reason  in  any  portion  of  the  report  for  changing  this  view. 
Dr.  Jones  mentions  the  various  theories  as  to  the  origin 
of  dermoids  and  teratomata,  and  says  :  "  The  theory  of 
the  development  of  an  ovum  without  impregnation — 
parthenogenesis — has  some  supporters.  Cohnheim's 
theory  of  embryonal  remnants,  capable  of  producing 
different  kinds  of  growths  (dependent  upon  the  type  of 
the  cell),  is  reasonable,  but  it  is  strange  why  so  many  of 
these  growths  occur  in  the  ovary.  The  theory  which 
has  the  greatest  support  by  the  greatest  number  of  ob- 
servers is  that  of  fetal  inclusion,  t.  e.,  the  inclusion 
within  the  body  of  a  developing  fetus,  the  remains  of 
an  imperfectly  developed  twin.  This,  too,  is  subject  to 
the  criticism  applied  to  Cohnheim's  theory,  but  it  seems 
more  plausible  than  any  of  the  others.  Finally,  it 
must  be  admitted  that  the  pathogenesis  of  the  teratomata 
is  very  obscure." 

The  inclusion,  within  the  body  of  a  developing  fetus, 
of  the  remains  of  an  imperfectly  developed  twin,  and 
especially  the  development  of  such  an  inclusion  in  the 
ovary,  is  a  theory  which  is  today  no  longer  earnestly 
considered.  The  prevailing  idea  as  to  the  origin  of  der- 
moids and  teratomata  of  the  ovary  depends  on  the 
statements  of  Wihas  and  Pfannenstiel  that  these  tumors 
contain  products  of  all  three  blastodermic  layers,  if  not 
macroscopically  yet  microscopically.  This  theory  rests 
further  on  the  microscopical  investigations  of  Wilms, 
who  believes  that  he  finds  the  various  structures  in  an 
arrangement  corresponding  to  that  in  the  normal  fetus, 
such  as  scalp,  brain,  central  canal,  respiratory  tract,  etc. 
This  theory  is  further  defended  by  the  descriptions 
given  by  various  authors  of  the  presence  in  dermoid 
(iysts  of  fingers,  mammae,  eyes,  ribs,  pelvic  bones, 
trachea,  intestinal-Uke  structures,  etc. 

The  statement  of  the  possibiUty  of  a  parthenogenetic 
development  of  an  ovum  is  supported  by  Wendeler. 
He  considers  the  further  growth  of  a  nonfecundated 
human  ovum  to  be  possible  on  analogy  with  the  seg- 
mentation observed  in  the  nonfecundated  ova  of  the 
frog,  the  hen,  and  the  rabbit. 

The  following  may  be  said  against  these  statements  : 

1.  No  dermoids  or  teratomata  of  the  ovary  or  liga- 
rnentum-latum  contain  more  than  the  products  of  ecto- 
derm and  mesoderm.     Entodemi  is  never  present. 

2.  The  arrangement  and  order  of  the  above-mentioned 
microscopical  areas  is  only  an  accidental  grouping  and 
has  nothing  to  do  with  the  formation  of  a  fetus,  as  may 
be  seen  from  the  drawing  No.  130  in  Martin's  "Diseases 
of  the  Ovary,"  1899. 

3.  All  the  above-mentioned  organs  and  structures 
have  been  described  because  of  "  a  resemblance." 
Kiister  found  in  a  dermoid  situated  between  the  bladder 
and  the  uterus  a  bone  "  which  without  doubt  may  be 
called  a  rib,"  and  a  flat  bone  "  which  I  cannot  definitely 
classify,  perhaps  a  pelvic  bone."  Baumgarten  mentions 
a  formation  "  which  has  a  slight  resemblance  to  a  fetal 
eye."  Concerning  other  areas  he  says :  "  All  in  all, 
sections  furnished  a  no  slight  resemblance  to  sections 
through  the  embryonal  stomach  and  intestine." 

In  this  manner,  without  any  positive  proof,  the  theory 
of  parthenogenesis  has  been  built  up.  Even  though  we 
were  to  grant  the  occurrence  in  ovarian  dermoids  of 
various_tissues  of  the  head,'and  other_,  portions  of  the 


body,  it  would  still  remain  an  inexplicable  question 
why  these  various  structures  occur  singly,  and  why 
more  complete  arrangements  are  not  present.  Those 
areas  which  resemble  the  stomach  and  intestinal  glands 
are  nothing  but  cystadenomatous  areas,  and  are  in 
harmony  with  the  real  explanation  of  the  origin  of 
dermoid  cysts.  They  are,  like  them,  due  to  the  devel- 
opment of  regressive  structures  or  displaced  cells. 

4.  The  authors  whom  Wendeler  quotes  and  who  have 
observed  the  segmentation  of  nonfecundated  ova  say 
"  that  these  ova  always  go  to  destruction."  Hensen, 
whom  he  quotes,  says  that  this  segmentation  has  noth- 
ing in  common  with  the  division  of  a  fecundated  ovum, 
and  that  a  parthenogenesis  is  not  to  be  thought  of 
Spee  and  Nagel  say  the  same.  The  previously  accepted 
view  of  a  parthenogenetic  segmentation  of  the  hen's 
egg  is  now  proved  to  be  due  to  a  fecundation  by  dying 
spermatozoa.  Barfurth  and  Lau  have  shown  that  the 
parthenogenetic  development  of  the  bird's  egg  is  only  an 
irregular  segmentation.  Sobotta  asks  whether,  after  all 
this,  we  can  really  sensibly  believe  in  such  a  process  in 
the  ova  of  mammals. 

The  most  pecuUar  tissue  found  in  dermoid  cysts  is 
represented  by  teeth,  which  may  be  milk  or  second 
teeth.  Since  I  absolutely  deny  the  origin  of  these 
tumors  through  parthenogenesis  it  is  necessary  to  ex- 
plain the  origin  of  these  tumors.  These  tumors  result 
from  displaced  ectodermal  and  mesodermal  ceUs,  and 
wherever  ectoderm  and  mesoderm  are  present  teeth  can 
be  formed.  They  are  found  in  dermoid  cysts  of  the 
brain,  of  the  eye,  of  the  neck,  of  the  mediastinum,  of 
the  abdomen  (retroperitoneal),  of  the  ovary,  etc.,  and 
have  as  such  no  specific  value.  These  ectoderm  and 
mesoderm  cells  are  displaced  into  the  ovary  by  the 
Wolffian  duct  and  the  Wolffian  body.  It  is  generally 
granted  that  the  Wolffian  duct  originates  near  the  ecto- 
derm, but  Spee  has  shown  that  it  originates  from  the 
ectoderm  and  that  the  Wolffian  body  as  well  as  the 
germinal  epithelium  of  the  ovary  are  of  ectodermal 
origin.  In  this  way  the  ovary,  the  tube  (duct  oi 
Midler)  and  uterus,  /.  e.  the  epithelium  of  the  two  latter, 
are  of  ectodermal  origin,  and  not,  as  is  generally  believed, 
mesodermal.  It  would  indeed  be  strange  if  we  were  to 
continue  in  the  belief  that  mesoderm  is  capable  of  pro- 
ducing epithelium.  The  Wolffian  duct,  and  the  Wolf- 
fian body,  which  takes  an  important  part  in  furnishing 
the  ovary  with  its  stroma,  may  carry  then  into  the 
ovary  ectodermal  and  mesodermal  cells,  for  they  origi- 
nate from  ectodemi  and  lie  in  mesoderm.  The  Wolf- 
fian duct  and  the  Wolffian  body  are  situated  at  the 
hilus  of  the  ovary  as  the  parovarium  and  the  paro- 
ophoron, and  not  infrequently  their  tubules  are  found  to 
penetrate  into  the  structure  of  the  ovary  itself  The 
development  of  these  tulniles  alone  is  the  cause  of  the 
ovarian  cystic  tumors,  especially  the  cystadenomata.  If 
ectodermal  and  mesodermal  cells  are  likewise  displaced, 
we  find  then  a  dermoid  cyst  or  a  teratoma,  very  fre- 
quently combined  with  a  cystadenoma  in  the  same  or 
other  ovary. 

As  regards  the  teeth,  Olshausen  says  :  "  They  have, 
like  the  teeth  of  the  mouth,  a  crown  sloping  toward  the 
median  line  of  the  body,  so  that  from  the  teeth  the  side 
from  which  the  cyst  was  removed  may  be  diagnosed." 
Hollander  called  Olsliausen's  attention  to  this  fact,  and 
every  time  that  the  latter  put  him  to  the  test  Hollander 
diagnosed  correctly  the  side  of  the  cyst.  Twelve  cj'sts 
containing  teeth  were  examined  for  me  and  in  no  case 
were  right  and  Jeft  teeth  found]  in  the  same  cyst.     In 


40 


Thk  Philadelphia* 
Medical  Journal 


] 


SOME  CASES  OF  TETANY  IN  INFANCY 


fjAKDAEY  5,   1901 


all  the  cases  (six)  in  which  the  history  stated  the  side 
from  which  the  cyst  was  removed,  the  statement  of 
Waldberg,  who  examined  the  teeth,  was  found  to  be 
correct.  Since  ectoderm,  cartilage,  and  Ijone  are  present 
in  pratically  every  dermoid  cyst  of  the  ovary,  teeth  are 
easily  formed,  for,  as  Hertwig  says,  "  the  teeth  are  origi- 
nally nothing  but  ossified  papillae  of  the  skin  and 
nuicous  memlirane." 

The  suprarenal  bodies  lie  close  to  the  genital  organs 
in  the  early  embryonal  period,  and  it  is  said  that  the 
sexual  band  of  the  Wolffian  body  is  concerned  in  the 
formation  of  the  suprarenal  body.  When  we  consider 
that  portions  of  the  suprarenal  bodies  may  be  found  in 
the  llgamentum-latum,  it  is  easy  to  grant  that  sells  or 
cell-groups  of  the  ectoderm  and  mesoderm  which  are 
in  the  closest  relation  to  the  Wolffian  duct  and  the  Wolf- 
fian body  may  be  displaced  by  them  into  the  hilus 
ovarii.  For  that  reason,  too,  a  dermoid  cyst  may  be 
found  in  the  ligamentum-latum  without  involvement  of 
the  ovary. 

In  the  dermoid  cysts  of  the  ovary  ectoderm  products 
are  present  as  squamous  epithelium,  sweat  glands,  seba- 
ceous glands,  hair,  glia  tissue,  etc.,  and  as  glandular 
structures  lined  with  squamous  epithelium,  ciliated  epi- 
thelium, or  cylindrical  epithelium.  Mesoderm  products 
are  present  as  cartilage,  or  bone,  or  teeth  (partly  ecto- 
derm), connective  tissue,  muscle  (almost  never  striated 
muscle),  fat  tissue,  etc.  No  organs,  as  such,  are  present, 
and  pancreas,  liver,  and  lung  have  never  been  described, 
though  Wilms  makes  indefinite  statements  concerning 
the  lung. 

The  following  reasons  are  therefore  to  be  raised 
against  the  theory  of  parthenogenesis  :  1.  The  dermoid 
cysts  of  the  ovary  contain  pi'oducts  of  ectoderm  and 
mesoderm  only.  2.  The  development  of  the  various 
structures  without  placenta.  3.  The  continued  growth 
of  such  a  rudiment  with  the  formation  of  l(Mig  hair  and 
second  teeth.  4.  The  frequent  occurrence  of  bilateral 
dermoids.  5.  The  occurrence  of  several  dermoids  in 
one  ovary.  6.  The  occurrence  of  dermoids  in  the  liga- 
mentum-latum without  involvement  of  the  ovary.  7. 
The  decided  growth  of  these  tumors  at  or  after  puberty, 
and  their  occurrence  in  the  newly  born  and  in  children. 
S.  The  occurrence  of  the  same  tumors  in  the  testicle.  9. 
The  presence  of  only  isolated,  so  called  "  organs  and 
bones."  10.  The  structures  are  always  of  one  side.  11. 
The  frequent  combination  of  these  tumors  with  cyst- 
adenomata.  12.  The  so-called  "  parthenogenetic  fetus  " 
does  not  form  a  Uthopedion. 

As  I  have  said  before,  the  case  of  Dr.  Jones  contains 
too  many  well-defined  organs  to  be  considered  a  tera- 
toma, and  I  see  no  reason  why,  if  we  judge  from  the 
report,  the  case  is  to  be  consid(>red  anything  but  an 
ectopic  gestation,  even  though  complicated  by  the  pres- 
ence of  a  cystic  adenoma  of  the  ovary.  The  finding  of 
chorionic  villi  in  the  tumor  would  prove  a  definite  solu- 
tion, though  as  reported  its  classification  seems  clear. 


SOME  CASES  OP  TETANY  IN  INFANCY. 

By  JOHN  LOVETT  MORSE,  .\.M.,  M.D., 

ol  Boston. 

.\s8istanf  Visiting  Physician  at.  ttie  City  Hospital  an«1  at  the  Infants'  Hospital ; 
Instructor  in  Diseases  of  Children,  Harvard  Atedical  School,  Boston. 

In  1898  I  presented  a  paper  to  the  American  Medical 
Association  on  tetany  in  infancy  and  reported  six  cases. 
Certain  conclusions  were  arrived  at  in  this  paper  which 
form  the  basis  of  the  statements  to  follow. 


Tetany,  like  epilepsy,  must  be  regarded  merely  as  a 
nosologic  entity  and  not  as  a  definite  disease.  The  only 
pathognomonic  symptom  of  tetany  is  spontaneous,  in- 
termittent, paroxysmal,  muscular  contracture.  The  term 
"  tetany  "  should  be  applied,  therefore,  only  to  those 
cases  in  which  this  symptom  is  present,  and  no  cases  of 
increased  reflex  excitability  in  which  this  symptom 
does  not  occur  should  be  regarded  as  examples  of  the 
disease.  Laryngospasm,  Trousseau's  symptom,  Erb's 
symptom  and  the  facial  phenomenon  are  not  pathog- 
nomonic of  tetany  and  do  not,  either  singly  or  in  com- 
bination, afford  sufficient  ground  for  the  diagnosis  of 
this  disease,  because  they  are  not  constantly  present  in 
tetany  and  occur  in  many  other  conditions. 

Etiology. — It  is  probable  that  there  is  no  single  patho- 
logic cause  for  tetany,  but  it  may  arise  from  many 
causes.  In  improper  hygienic  surroundings,  in  rickets, 
in  gastrointestinal  diseases,  in  acute  diseases,  and  in 
various  intoxications  are  found  conditions  capable  of 
causing  the  formation  of  various  toxic  substances.  The 
action  of  all  these  poisonous  substances  may  show  itself 
by  a  special  modification,  rather  functional  than  or- 
ganic, of  the  central  or  peripheral  ner\'ous  system.  The 
various  lesions  of  the  nervous  system  which  have  Ijeen 
found  in  tetany  are  not  inconsistent  with  this  concep- 
tion. 

Frequmcy. — Griffith  was  able  to  find  but  77  cases 
reported  in  American  literature  previous  to  1894.  In  a 
careful  review  of  American  medical  literature  from 
January  1,  1894,  to  January  1,  1898,  I  was  able  to  find 
but  13  additional  cases,  to  which  I  added  6  of  my  own. 
In  a  hasty  review  of  American  literature  since  that  time 
I  have  been  able  U^  find  but  few  reported  cases ;  one  by 
Crandall  in  an  infant,  1  by  M'hite  in  a  child  of  3^ 
years,  1  by  Hand  in  a  child  of  3  years,  1  by  Hub- 
bard in  a  child  of  14  months,  and  2  by  mj-self  in  in- 
fants of  7  and  7^  months.  In  1898  the  conclusion  was 
drawn  that  the  disease  was  a  very  unusual  one  in  Bos- 
ton. As  I  have  seen  7  cases  since  that  time  in  addition 
to  those  reported  by  Drs.  White,  Hubbard  and  myself, 
it  would  seem  as  if  that  conclusion  was  unwarranted  or 
that  the  disease  is  becoming  more  common.  It  may  be 
that  it  really  is  becoming  more  common,  but  it  is  also 
possible  that  the  increase  is  only  apparent,  the  condi- 
tion being  looked  for  and  recognized  more  often  than 
formerly. 

The  7  cases  are  reported  somewhat  in  detail,  as  Ihey 
seem  of  interest  not  only  as  examples  of  the  condition, 
but  also  as  throwing  some  light  on  its  etiology. 

Cask  1.— Doininico  G.  was  bom  January  13,  1900.  at  full 
term,  after  a  rapid  labor.  He  was  fed  partly  on  the  breast 
and  partly  on  condensed  milk  and  did  fairly  well  until  the 
15th  of  February,  when  he  began  to  have  3  or  4  green  niove- 
nioiits  daily.  Tliere  was  no  vomiting.  On  the  19th  of  Feb- 
ruary ho  began  to  ory  constantly.  He  was  seen  on  the  20th 
of  February  by  Dr.  J.  N  Coolidge,  and  the  feeding  regulated. 
At  that  time  spasm  of  the  hands  was  not«d.  although  it  had 
not  been  previously  noted  by  the  parent*.  I  saw  him  with 
Dr.  Coolidge  on  February  i!4.  The  digestive  sympt<.ims  were 
almost  relieved. 

Physical  examination  :  He  was  fairly  developed  and  nour- 
ished. His  liands  and  arms  very  often  took  the  position 
characteristic  of  tetany.  There  was  but  little  spasm  associ- 
ated with  it,  however.  Neither  Trousseau's  nor  Chvosteks 
symptoms  were  present.  Kernig's  symptom  Wiis  absent. 
The  refle-xes  were  nornal.  The  physical  examination  was 
otherwise  normal. 

He  was  seen  again  ^larch  1st.  Tlie  digestive  symptoms 
were  then  entirely  gone.  His  general  condition  was  im- 
proved. The  spasmodic  condition  of  the  arms  was  still 
present,  but  disappeared  within  the  next  2  weeks. 


Jasuaet  5,  1901] 


SOME  CASES  OF  TETANY  IN  INFANCY 


r^HE  tttlLADELPBIA 
Medical  Jocknal 


41 


In  this  case  the  cause  was  undoubtedly  located  in  the 
digestive  tract. 

Case  2.  — Harrj'  F.  was  bottle-fed  and  began  to  have 
diarrhea  about  the  middle  of  July,  1899.  In  spite  of  careful 
feeding  he  continued  to  have  a  typical  fermental  diarrhea. 
There  was  no  vomiting  until  October  1,  after  which  he 
vomited  constantlv.  He  was  admitted  to  the  Infants'  Hos- 
pital, October  12,  aged  11  months,  when  I  first  saw  him. 

Physical  examination  :     Small,  emaciated :  skin  dry 
covered  w.th  a  papular  eruption.     Head  flattened  on 
Frontal  eminences  large.    No  teeth.    Marked  rosary, 
craniotabes     Heart,  lungs,  liver,  and  spleen  normal, 
domen  considerablv  enlarged. 

He  was  fed  carefully  and  held  his  weight.  He  did 
vomit.  He  continued  to  have  from  3  to  5  loose,  usually 
yellow,  movements,  containing  no  curds,  and  rarely  mucus, 
but  usually  very  foul.     With  no  apparent  cause,  the  night  of 


and 

top. 

Xo 

Ab- 

not 


Ttiany  in  Infancy. 

October  21  he  began  to  have  spasms,  in  which  the  hands 
and  feet  became  rigid.  They  were  in  the  position  typical  of 
tetany.  Opisthotonos  was  present,  and  he  cried  constantly, 
as  if  in  much  pain.  The  spasms  continued  during  October 
22,  and  the  temperature  rose  to  39°  C.  A  hemorrhagic  erup- 
tion appeared  all  over  the  body  and  extremities.  Trousseau's 
.symptom  was  very  marked,  but  Chvostek's  sj-mptom  was 
absent.  The  spasms  continued  during  the  night,  and  he 
died  at  6  a.m.,  October  22. 

Although  there  were  signs  of  rickets  in  this  case  they 
were  slight  and  evidently  chronic  in  character,  and  could 
not  well  account  for  the  acute  onset  of  the  tetany.  The 
hemorrhages  in  the  skin  showed  that  there  must  have 
been  marked  toxic  absorption.  This  absorption  was 
presumably  from  the  digestive  tract,  as  no  other  organs 
were  involved.  It  seems  reasonable  to  suppose  that  the 
tetany  was  due  to  these  same  toxic  products. 

Case  3. — Ida  P.  was  an  only  child,  and  breast-fed.  She 
began  to  refuse  the  breast  on  April  8,  when  8  months  old, 


and  developed  a  typical  fermental  diarrhea,  with  some 
vomiting.  She  had  several  convulsions  on  the  ninth  aud 
began  to  cry  constantly.  She  was  admitted  to  the  Infants' 
Hospital  April  16th,  the  diarrhea,  vomiting,  and  crying  un- 
checked. 

Physical  examination  :  Large,  fat  baby.  Head  of  nor- 
mal shape.  No  craniotabes.  No  teeth.  A  marked  rosary. 
Heart,  lungs,  liver,  and  spleen  normal.  The  hands  and  feet 
were  held  in  the  typical  position  of  tetany,  with  but  few  in- 
termissions. Trousseau's  symptom  was  veiy  marked.  The 
facial  phenomenon  was  not  present.  Kemig's  symptom  was 
absent. 

She  was  under  observation  for  a  week.  She  took  food 
poorly,  vomited  a  little,  and  had  from  1  to  3  yellow  or  green 
movements  containing  mucus,  but  not  foul,  daily.  The  tem- 
perature ranged  from  normal  to  40°  C.  She  improved  for  3 
days,  when  the  convulsions  recurred  again.  Washings  from 
the  stomach  and  bowels  at  this  time  contained  much  mucus. 
The  convulsions  increased  in  frequency,  and  the  spasm 
rarely  let  up.  She  was  taken  home  against  advice,  and 
nothing  is  known  as  to  the  further  history. 

In  this  case,  also,  the  rickets  evidentl}*  had  no  part, 
the  onset  of  the  tetany  being  simultaneous  with  that  of 
the  diarrhea. 

Case  4.— Christina  E.  was  badly  fed  until  she  was  8  months 
old,  and  had  various  digestive  symptoms.  During  the  next 
3  months  she  wa=<  fed  on  modified  milk  and  improved 
steadily.  On  October  13,  1899,  while  her  digestive  canal 
seemed  in  perfect  condition,  she  began  to  shake  her  head 
constantly.  On  October  16  she  had  2  convulsions,  after 
which  her  cheeks  swelled.  Her  digestion  was  still  normal. 
She  had  another  convulsion  on  October  18,  and  was  first  seen 
by  me  on  October  19. 

Tlie  general  physical  examination  was  entirely  negative. 
There  were  no,  evidences  of  rickets.  The  hands  were  held 
intermittently  in  the  typical  position  of  tetany.  There  was 
no  pedal  spasm.  The  facial  phenomenon  was  absent.  Trous- 
seau's symptom  was  present  but  not  marked.  Both  cheeks 
were  swollen  and  somewhat  thickened.  The  gums  were 
swollen  over  the  lower  lateral  incisor  teeth  which  had  not 
erupted.  She  had  one  convulsion  the  night  of  October  19, 
but  none  after  that.  Stifthess  continued  in  the  hands  until 
October  28.  Trousseau's  symptom  was  first  absent  on  Oc 
tober  30.  During  all  this  time  digestion  was  normal  and 
there  was  no  loss  of  weight.  The  swelling  of  the  gums  was 
the  same  after  the  relief  of  the  tetany  as  in  the  beginning. 

In  this  case  there  was  no  evident  cause  for  the  tetany 
except  dentition.  The  swelling  of  the  face,  however, 
would  seem  to  point  to  some  toxic  absorption  from 
somewhere,  although  its  source  was  not  evident.  It 
may  have  been  in  the  digestive  tract,  although  there 
were  no  symptoms  of  indigestion. 

Case  5.— Jacob  A.  was  always  badly  fed.  He  began  to  cry 
constantly  on  October  20, 1900,  and  his  legs  and  arms  began 
to  swell  at  the  same  time.  There  was  no  vomiting,  and  the 
movements  were  normal.  He  was  seen  October  22,  when 
10  months  old. 

Physical  examination :  Well  developed  and  nourished. 
Head  rather  square  and  flat  on  top.  Fontanel  level.  No 
craniotabes.  Tw'o  teeth.  Heart,lungs,  and  abdomen  normal. 
The  epiphyses  at  the  wrists  were  slightly  enlarged.  There 
was  a  rather  tense  swelling  of  the  feet  and  legs  half  way  to 
the  knee,  and  of  the  hands  and  lower  halves  of  the  fore- 
arms. This  swelling  was  not  hot.  tender  or  red.  It  did  not 
pit  on  pressure.  The  hands  were  held  in  the  typical  position 
of  tetany.  There  was  moderate  pedal  spasm.  He  was  evi- 
dently siitFering  pain.  Trousseau's  symptom  could  not  be 
tested  because  ot  the  spasm.  The  facial  phenomenon  was 
absent.    Babinski's  and  Kemig's  signs  were  also  absent.* 

*  He  was  admitted  to  the  Infants'  Hospital  and  improved  rapidlv,  Trousseau's 
symptom  being  preseot  during  the  remission.**.  The  swelling  ha'l  almost  disap- 
peared on  the  23d.  On  the  24lh  the  temperature  rose  to  40.5'^  C,  which  war 
evidently  due  to  a  slight  inflammation  of  the  middle  ear  which  disappeared 
after  24  hours.  October  27  tlie  temi^erature  suddenly  rose  from  normal  to  44-  C. 
and  the  respiraUon  to  100.  Spasms  of  the  bands  and  feet  recurred  and  were 
followed  by  rigiditv  of  the  whole  body.  He  became  unconscious  and  died  in  3 
tiouis.    Physical  examination  showed'  nothing  abnormal  except  rigidity. 


42 


The  PHILADfiLfttIA'1 

Medical  Journal  J 


SOME  CASES  OP  TETANY  IN  INFANCY 


[JanOabt  i,  V 


i 


Here  also,  the  rickets,  although  moderately  marked, 
probably  did  not  account  for  the  symptoms.  There  was 
nothing  in  the  digestive  tract  which  pointed  towards  the 
absorption  of  toxic  products  from  there.  The  swelling 
of  the  arms  and  legs  was  practically  certain  proof  of 
the  presence  of  toxic  substances  in  the  circulation.  The 
only  source  for  those  products  which  was  evident  was 
the  inflammation  of  the  middle  ear.  It  seems  hardly 
probable,  however,  that  this  was  the  source. 

Case  6. — John  M.  was  fed  with  great  difficulty  for  the  first 
7  months.  After  thi.s  he  did  very  well  until  March  23,  when 
he  was  14  months  old.  He  then  had  influenza,  as  had  the 
rest  of  the  family.  Abdominal  symptoms  were  marked  and 
profuse  diarrhea  developed.  He  did  not  do  well  and  on 
March  30  the  physician  was  discharged  and  he  was  given  ab- 
sent treatment  by  a  clairvoyant.  He  was  fed  on  albumen- 
water  and  beef  juice.  He  did  not  vomit  and  had  a  few  green 
movements  with  mucus  daily.  The  night  of  April  7  he  had 
a  slight  convulsion  and  his  hands  became  rigid,  at  first  inter- 
mittently and  then  continuously.  The  morning  of  April  8 
he  collapsed,  and  the  physician  was  called  agam.  He  was 
seen  that  noon  with  Dr.  W.  G.  Curtis,  of  Wollaston. 

Physical  examination  :  He  was  small  and  emaciated.  The 
fontanel  was  very  large.  He  had  8  teeth.  The  two  lower 
molars  were  bulging  the  gums,  which  were  inflamed.  The 
tongue  was  fairly  clean  but  red.  The  heart  and  lungs  were 
normal.  The  abdomen  was  full  but  not  tense  or  tender. 
There  was  no  enlargement  of  the  liver  or  spleen.  The  hands 
and  arms  were  in  the  typical  position  of  tetany  and  the  feet 
showed  a  tendency  to  spasm.  Cbvostek's  symptom  was 
present.  Trousseau's  symptom  was  not  tested.  Kernig's 
symptom  was  absent.  The  patellar  reflexes  were  not  ob- 
tained.   The  temperature  was  99°  F. 

It  is  possible  that  the  teeth  may  have  had  some  in- 
fluence here  in  increasing  the  nervous  excitability. 
The  digestive  disturbance,  however,  seems  more  im- 
portant. It  is  possible,  too,  that  the  influenza  may  have 
been  the  first  and  perhaps  the  sole  cause. 

Case  7. — Willie  O.'s  history  was  negative  as  to  syphilis.  He 
had  been  fed  on  various  foods  and  never  did  well.  He  vomited 
off  and  on  and  was  always  constipated,  never  having  a  move- 
ment unaided.  He  began  to  have  convulsi(m8  about  the 
middle  of  February,  1900,  the  convulsions  occurring  about 
once  a  fortnight.  They  lasted  from  1  to  10  minutes  and 
were  accompanied  by  frothing  at  the  mouth,  rigidity  of  the 
body  and  working  of  the  hands  and  feet.  He  was  admitted 
to  the  Infants'  Hospital  April  14,  when  7  months  old. 

Physical  examination  ;  Fairly  developed  and  nourished. 
Head  normal.  Fontanel  large  and  bulging.  Marked  snuf- 
fles. No  craniotabes.  Marked  rosary.  Heart,  lungs,  liver 
and  spleen  normal.  Genitals  normal.  No  paralysis  or  spasm 
of  extremities.  Patellar  reflexes  not  obtained.  Kernig's 
symptom  absent.  Facial  phenomenon  absent.  Trousseau's 
symptom  present. 

The  child  remained  under  observation  about  U  weeks. 
During  the  first  3  weeks  there  was  no  improvement.  He 
lost  weight,  vomited  occasionally  and  was  very  constipated, 
the  movements,  however,  being  normal,  although  sometimes 
offensive.  The  temperature  ranged  from  subnormal  to  39°  C. 
A  small  amount  of  adenoids  was  removed  by  Dr.  A.  Coolidge 
with  no  relief  of  the  snuflles.  He  had  no  convulsions.  The 
hands  and  feet  were  in  the  position  of  tetany  the  greater 
part  of  the  time.  Trousseau's  symptom  was  always  present. 
The  facial  phenomena  were  never  obtained.  He  apparently 
suffered  pain  nnich  of  the  time,  which  was  increased  by 
movement  of  the  extremities.  He  whimpered  all  the  time. 
At  times  his  cry  resembled  that  of  laryngismus  stridulus. 
Lumbar  puncture  was  performed  May  5  and  a  clear  fluid, 
sterile  in  smears  and  cultures,  was  obtained. 

There  was  no  eviilence  of  syphilis  except  the  snuffles  and 
the  failure  to  gain.  As  he  had  not  improved  under  other 
methods  of  treatment,  inunctions  of  mercury  were  begun 
as  a  last  resort.  There  was  no  improvement  for  about  two 
weeks.  Improvement  then  began  and  continued  steadily  to 
complete  cure,  not  only  of  the  tetany  but  of  his  whole  gen- 
eral condition.  The  spasms  had  ceased  by  May  16  and 
Trousseau's  symptom  disappeared  soon  after. 


The  signs  of  rickets  were  slight  in  this  case,  and 
probably  unimportant  as  they  still  remained  after  the 
cure  of  the  tetany.  The  digestive  symptoms  may  have 
accounted  for  the  tetany,  but  the  tetany  was  not  relieved 
with  the  relief  of  the  digestive  symptoms.  It  was  re- 
lieved completely,  however,  under  specific  treatment. 
The  syphilis,  therefore,  must  be  considered  as  the  prob- 
able cause  of  the  tetany  in  this  case. 

On  summing  up  these  cases  it  is  evident  that  there 
was  no  common  etiologic  factor.  Digestive  disturbances 
occurred  in  all  but  one.  In  one  case  they  seemed  the 
only  factor.  In  two  others  they  seemed  the  only  im- 
portant factor.  In  two  more  their  influence  could  not 
be  excluded.    In  one  they  were  apparently  unimportant. 

Slight  evidences  of  rickets  were  found  in  three  and 
moderate  signs  of  rickets  in  one.  In  no  case  were  the 
signs  marked.  In  no  case  were  there  craniotabes.  In 
every  case  the  signs  of  rickets  were  accompanied  by 
other  conditions  capable  of  causing  tetany.  The  ab- 
sence of  craniotabes  and  the  sUght  degree  of  the  other 
rachitic  changes  confirm  the  opinion  that  craniotabes 
is  not  a  cause  of  tetany  and  that  rickets  is  not  a  direct 
cause  of  tetany.  Rickets  probably  acts  only  indirectly 
by  weakening  the  resistance  of  the  nervous  sx'stem  or 
may  be  merely  a  result  of  the  same  case  as  the  tetany. 

In  two  cases  the  gums  were  distended  by  teeth.  In 
one  of  these  no  other  cause  of  tetany  was  evident.  The 
gums  were  in  the  same  condition,  however,  after  re- 
covery. In  the  other  case  influenza  and  diarrhea  were 
also  possible  etiologic  factors.  It  does  not  seem  possible, 
therefort!,  that  difficult  dentition  alone  can  cause  tetany. 
It  may  favor  its  development,  however,  by  exaggerating 
the  excitability  of  the  nervous  system. 

Influenza  seemed  the  possible  cause  in  one  case. 
Syphilis  was  apparently  the  cause  in  one  case,  as  re- 
covery did  not  take  place  until  after  the  use  of  specific 
treatment,  the  tetany  not  improN-ing  when  all  the  dtlu-r 
conditions  excei>t  the  syphilis  were  relieved. 

In  every  ctise  but  one,  conditions  were  present  evi- 
dently capable  of  causing  toxic  products.  In  this  case 
also  it  is  impossible  to  exclude  some  such  condition, 
possibly  digestive.  Absorption  of  these  toxic  products 
into  the  circulation,  with  the  resulting  action  on  the 
nervous  system,  seems  to  oft'er  the  most  reasonable 
explanation  as  to  the  cause  of  the  disease.  It  is  evident, 
too,  that  these  toxic  substances  may  be  of  various  sorts 
and  the  results  of  many  varied  conditions.  The  con- 
clusion seems  warranteil,  therefore,  that  tetany  is  due  to 
the  action  of  the  toxic  products  of  manj'  diseased  con- 
ditit)ns  on  the  nervous  system. 

Treatment. — As  tetany  is  abnost  certainly  due  to  the 
action  of  toxic  substances  on  the  nervous  system,  treat- 
ment must  be  directed  to  the  cure  of  the  primary  disease, 
to  the  prevention  of  the  formation  of  toxic  products,  and 
to  their  elimination,  if  already  formed.  Symptomatic 
treatment  to  relie\'e  the  pain  and  discomfort  is  also 
important.  It  is  not  curative,  however,  and  must  never 
be  used  to  the  neglect  of  the  treatment  of  the  caus;\tive 
condition. 

REFERENCES. 

Crandall:  Archirfs  of  Ptdiatrics,  1S9S,  xv,  S5. 
tJriltiih;  American  J'onriiat  of  yfedical  Sciencrs,  1895,  cix,  l.SS. 
Hand  :  Jourtuil  American  Mfifictil  As4ocialion,  1900,  xxxiv,  362. 
Hubbard  :  Boston  Mfdical  and  .'yurffiaU  Joumiil,  1S99,  cxl,  IS<'». 
Morse:    Journal  Ameriran   Medical  Assyciatioii ,  1S9S ;    Boston  Mtdic*i    and 
Saroical  Jourmtl,  1899,  cxli,  447. 

White  :  Boston  Medieal  and  Surgical  Journal,  1899,  cxli,  439. 


Tuberculosis  in  Germany.— Of  the  1,120,000  de.iths 
recorded  in  the  Gerinau  empire  in  1S99, 110,200  were  caused 
by  tuberculosis. 


i 


jANUiBY   5     ISOl] 


OUTBREAKS  OF  DIPHTHERIA 


r^HE  Philadelphia 
Medical  Journal 


43 


THE  RELATION  OF  STATE  AND  LOCAL  BOARDS  OF 
HEALTH  TO  OOTBREAKS  OF  DIPHTHERLA.* 

By  G.  E.  TYLER,  M.D., 

of  Denver,  Col. 

Secretary  of  Colorado  State  Board  of  Health. 

The  presence  of  one  case  of  genuine  diphtheria  in  a 
•community  is  an  occurrence  of  sufficient  importance  to 
demand  the  earnest  attention  of  those  responsible  for 
the  prevention  of  the  unnecessary  spread  of  disease. 
For  a  single  mUd  case  may  mean  many  severe  ones  and 
the  death  of  not  a  few  indi\'iduals.  If  Pasteur's  now 
famous  aphorism,  "  It  is  in  the  power  of  man  to  cause 
all  parasitic  diseases  to  disapjjear  from  the  world,"  be 
true,  there  is  need  of  greater  abilitj-  in  applying  our 
present  knowledge  concerning  this  one.  As  diphtheria 
is  a  disease  for  which  there  exists  a  positive  method  of 
diagnosis  and  a  specific  treatment,  Pasteur's  prophecy 
ought  to  have  a  fair  testing  in  its  management.  It  is 
my  purpose  to  attempt  to  set  forth  the  methods  to  be 
used  by  health  officials  in  their  battle  with  this  disease. 

There  should,  at  all  times  and  in  all  places,  be  offered 
competent  bacteriologic  facilities  free  of  charge  to  every 
citizen.  The  absolute  uncertainty  of  clinical  phenomena 
for  mild  or  atypical  cases  has  been  repeatedly  proved. 
The  throat  may  present  but  the  faintest  hyperemia,  yet 
the  culture  may  be  positive.  In  well-marked  cases  the 
clinical  appearances  are  sufficiently  distinct  to  warrant 
a  positive  diagnosis  without  the  aid  of  a  bacteriologist, 
but  it  cannot  be  too  strongly  emphasized  that  the 
greatest  skill  in  clinical  work  is  not  sufficient  to  detect 
mild  cases  of  genuine  diphtheria.  Because  of  this  fact 
no  obstacle  should  be  placed  in  the  way  of  obtaining  a 
prompt  bacteriologic  diagnosis.  On  the  contrary,  every 
facility  should  be  offered  the  interested  person,  whether 
he  be  a  physician  or  an  anxious  parent.  Culture  out- 
fits in  convenient  form  should  be  placed  at  accessible 
supply  depots,  each  outfit  being  accompanied  by  plain 
printed  instructions  as  to  the  method  of  use.  In  cities 
messengers  should  be  provided  to  collect  the  outfits  as 
soon  as  the  cultures  have  been  taken.  Whenever  re- 
quested, an  officer  of  the  local  board  of  health  should 
be  sent  to  take  the  culture.  In  small  communities  it  is 
quite  out  of  the  question  to  maintain  a  bacteriologic 
laboratory.  It  then  becomes  the  duty  of  the  State  Board 
of  Health  to  supplement  the  work  of  the  local  board  by 
furnishing  the  necessary  faciUties.  To  accomplish  this, 
the  State  Board  of  Health  must  have  a  competent  bac- 
teriologist, not  appointed  for  political  reasons.  It  must 
also  provide  all  incorporated  towns  which  have  no  local 
laboratory  with  culture  outfits,  and  there  must  be 
prompt  communication  between  the  supply  depots  and 
the  laboratory.  The  culture  outfits  should  be  as  com- 
plete as  possible,  in  order  that  the  cost  of  sending  them 
may  be  reduced  to  the  minimum.  The  former  regula- 
tions of  the  Post  Office  Department  required  a  clumsy 
outfit  which  was  poorly  adapted  to  the  work,  and  which 
required  12  cents  postage  every  time  it  was  mailed. 
Through  the  efforts  of  the  Colorado  State  Board  of 
Health,  assisted  by  others  interested,  the  regulations 
were  so  modified  as  to  permit  the  use  of  a  much  smaller 
outfit.  It  was  formerly  the  custom  to  treat  these  speci- 
mens as  fourth-class  mail,  but  the  new  order  directs 
that  they  be  treated  as  letter  mail.  This  may  mean  a 
difference  of  12  hours  in  the  receipt  of  the  specimen. 
Every  State  Board  of  Health  should  be  granted  sufficient 
funds  to  establish  these  supply  depots.    The  State  Board 

•  Raad  before  the  Colorado  Stau  Medical  Society,  June  21, 1900. 


of  Health  of  Colorado  had  such  depots  established  in 
every  county  about  September  1,  1900.  The  service  of 
the  laboratory  is  free  of  charge  to  every  citizen  and 
reports  are  made  as  promptly  as  possible.  In  every 
positive  case  immediate  report  will  be  made  by  tele- 
graph. A  like  prompt  report  will  be  made  in  negative 
cases  when  requested.  In  sending  specimens  the  name 
of  the  patient  should  be  given  as  well  as  that  of  the 
person  sending  the  specimen. 

Physicians  should  take  cultures  in  every  case  which 
looks  at  all  suspicious.  Much  tact  is  required  to  secure 
the  active  participation  of  some  in  this  movement,  but 
the  wise  health  officer  will  so  protect  the  interests  of  the 
profession  that  all,  except  the  few  who  are  by  habit 
opposed  to  everything,  will  see  the  advantage  to  be 
gained  by  frequent  use  of  the  laboratory. 

Free  antitoxin  should  be  provided  for  all  infected  in- 
dividuals who  cannot  afiord  to  buy  it.  The  early  use  of 
antitoxin  is  of  such  extreme  importance  to  the  success- 
ful management  of  diphtheria  that  physicians  should 
be  given  to  understand  that  whenever  they  have  a  case 
which  demands  it,  antitoxin  sufficient  for  the  patient 
can  be  had  for  the  asking.  As  the  State  Board  of  Health 
has  no  funds  for  such  purpose,  local  boards  must  supply 
this. 

Every  case  of  diphtheria  should  be  reported  to  the 
health  authorities  and  a  record  of  it  be  made  by  them. 
Physicians  outside  the  large  cities  of  Colorado  do  not 
seem  to  know  that  the  law  requires  immediate  report  of 
all  cases  of  contagious  disease,  but  they  have  usually 
been  willing  to  make  such  reports  when  informed  of  the 
law.  The  State  Board  of  Health  furnishes  blanks  for 
such  reports  free  of  charge,  and  is  seeking  to  make  com- 
plete and  accurate  record  of  all  cases.  The  record  made 
by  the  health  authorities  should  show  the  exact  location 
of  the  patient,  the  number  and  names  of  the  rest  of  the 
family,  and  all  others  known  to  have  been  exposed. 
The  local  boards  should  make  note  of  the  milk,  water, 
and  ice  supply,  and,  if  there  are  children  in  the  family, 
the  school  and  Sunday-school  should  be  recorded.  The 
officers  of  such  schools  should  have  early  notification 
of  the  existence  of  the  disease,  the  pubhc  librarian 
should  be  notified  in  order  to  see  whether  any  books 
are  in  the  family,  and  care  should  be  exercised  to  pre- 
vent the  spread  to  other  families  by  the  milk-supply. 
For  the  protection  of  the  pubUc,  every  house  in  which 
diphtheria  is  present  should  be  distinctly  placarded. 
Some  have  questioned  the  necessity  of  the  placard,  but 
every  person  visiting  a  house  has  a  right  to  know  before 
he  enters  whether  he  will  encounter  diphtheria  by 
entering.  If  every  infected  house  is  placarded  without 
favor  to  rich  or  poor,  the  community  will  appreciate  the 
value  and  justice  of  the  regulation.  The  regular  notifi- 
cation of  public  school  and  Simday-school  officers  does 
much  to  educate  public  sentiment.  Furthermore,  the 
record  of  such  data  often  enables  the  intelHgent  health 
officer  to  trace  the  different  cases  to  a  common  source. 

The  great  value  of  keeping  record  of  the  milk-supply 
has  been  demonstrated  many  times. 

The  question  of  quarantine  is  important.  Who  shall 
be  quarantined,  and  for  how  long  ?  The  ■  patient  must 
be  quarantined  until  his  throat  is  free  from  bacUli. 
This  seldom  occurs  under  3  weeks,  and  because  people 
grow  restive  under  repeated  positive  reports  it  is  wise  to 
fix  the  minimum  period  of  quarantine  at  3  weeks,  and 
to  take  no  secondary  cultures  during  this  time.  The 
Colorado  State  Board  of  Health  has  adopted  the  follow- 
I  ing  rule: 


44 


The  Philadelphia 
Medical  Journ 


AL  J 


OUTBREAKS  OF  DIPHTHERIA 


[Jascaby  5,  1901 


"  In  all  cases  where  the  bacteriologist  reports  the  diph- 
theria bacilli  present,  the  patient  should  be  absolutely  quar- 
antined. A  second  culture  should  be  taken  21  days  after 
the  first  and  forwarded  for  examination.  Quarantine  must 
be  maintained  until  the  bacteriologist  reports  the  throat  free 
from  diphtheria  bacilli.  No  children  from  the  family  should 
be  allowed  to  attend  school  until  2  weeks  after  the  throat  is 
free  from  diphtheria  bacilli." 

The  breadwinners  need  not  be  kept  from  their  work, 
unless  they  be  school  teachers,  or  others  who  mingle 
much  with  children,  but  they  should  be  cautioned  to 
beUttle  in  the  sick-room,  or  else  to  be  careful  to  change 
their  clothing  and  bathe  with  antiseptics  before  lea\'ing 
the  house.  Before  a  nurse  employed  in  a  diphtheria 
case  goes  to  another  patient  a  culture  from  her  throat 
should  be  examined  and  her  clothing  should  be  disin- 
fec\ed.  In  fatal  cases  of  diphtheria  the  funeral  should 
be  private  and  under  the  supervision  of  a  health 
officer. 

Those  exposed  should  be  given  immunizing  doses  of 
antitoxin,  and  this  should  be  repeated  in  two  weeks  if 
exposure  continues.  With  the  present  state  of  pubhc 
opinion,  it  is  not  wise  for  health  officers  to  insist  upon 
immunization  of  the  exposed,  but  they  should  do  all 
in  their  power  to  encourage  it.  Some  day  the  custom 
of  immunization  after  exposure  to  diphtheria  will  be  as 
common  as  vaccination  after  exposure  to  smallpox. 

The  State  or  local  board  of  health  should  have  circu- 
lars for  public  distribution,  and  one  of  these  should  be 
placed  in  the  hands  of  the  head  of  the  family  where  the 
disease  appears.  The  following  is  from  a  circular  on 
this  subject  issued  by  the  Colorado  State  Board  of 
Health,  it  being  identical  with  one  previously  issued  by 
the  Denver  Bureau  of  Health  : 

"  Diphtheria  is  a  disease  which  manifests  itself  especially 
in  the  throat.  It  is  so  dangerous  and  so  difficult  of  identifi- 
cation, tliat  every  sore  throat  should  be  regarded  as  suspi- 
cious, and  the  person  suflering  from  it  kept  out  of  school 
until  the  throat  has  been  examined  by  a  competent  person 
and  tbe  nature  of  the  sickness  determined.  The  State 
Board  of  Hea  th  determines  absolutely  the  existence  or 
nonexistence  of  diphtheria  by  a  bacteriologic  examination 
of  the  secretion  from  the  throat,  and  this  examination  is 
made  at  the  request  of  any  citizen  without  charge.  Children 
from  houses  in  which  diphtheria  has  occurred  should  not  be 
allowed  to  resume  school  attendance  until  2  weeks  after  a 
bacteriologic  examination  lias  shown  the  throat  of  the  sick 
person  to  be  free  from  diphtheria  germs,  as  certified  by  the 
health  authorities." 

Toys  with  which  the  sick  child  has  played  should  be 
destroyed  or  soaked  in  a  strong  antiseptic.  Books 
should  be  burned  and  all  articles  which  will  stand  it 
should  be  separately  boiled.  The  necessity  for  thorough 
fumigation  is  apparent.  For  disinfection  of  the  room 
the  Colorado  State  Board  of  Health  recommends  five 
pounds  of  sulphur  to  each  1,000  cubic  feet  of  space  with 
exposure  for  twelve  hours  :  or  formaldehyd  sprinkhng, 
using  five  ounces  of  the  40^  solution  for  each  1,000 
cubic  feet  of  space.  The  objection  to  the  former  is  its 
corrosive  action  and  to  the  latter  its  poor  penetration. 

The  constant  use  of  the  bacteriologic  test,  the  prompt 
application  of  the  serum  treatment,  complete  isolation 
of  infected  individuals,  immunization  of  all  exposed, 
and  thorough  disinfection— these  are  the  methods  wliich 
intelligently  applied  will  prove  the  truth  of  Pasteur's 
aphorism. 


Courtenay  C.  Parsons,  M.R.C.S.,  L.B.C.P.,  Civil 
Surgeon  South  African  Field  Force,  died  of  enteric  lever  in 
Harrissmith,  on  December  2. 


Surgery  of  the  Pleura   and    Lung.— H.  Vemeuil 

(Annaks  de  la  Societe  Beige  de  Chirurgie,  1900,  18me  Annee, 
p.  121)  gives  an  interesting  review  of  this  subject.  He  finds 
that  many  afifections  of  the  pleura  and  lung  formerly  con- 
sidered incurable  are  now  greatly  benefited  by  surgical  inter- 
vention. He  mentions  particularly  empyema,  traumatic 
lesions,  tumors  of  the  lung  and  pleura,  and  encysted  collec- 
tions within  the  lung,  particularly  abscess.  The  diagnosis  in 
these  conditions  is  usually  difficult.  Percussion  and  auscul- 
tation, which  are  often  sufficient  for  medical  diagnosis,  are 
too  incomplete  to  locate  accurately  intrapleural  lesions  for 
surgical  intervention.  Exploratory  puncture  often  gives 
valuable  information ;  in  case  fluid  is  found  it  permits  bac- 
teriologic examination  and  makes  diagnosis  possible  in 
many  cases  of  hydatid  cysts,  collection  of  blood,  tuberculosis, 
or  cancerous  pleurisy.  The  character  of  the  expectoration  is 
of  some  importance,  but  in  many  cases  the  expectoration  is 
moderate  in  amount  from  a  very  large  cavity,  while  with  a 
small  cavity  there  is  abundant  expectoration.  In  cases  of 
doubt,  exploratory  operation  is  many  times  justifiable  with 
direct  palpation  of  the  lung  either  through  the  pleura  or 
after  opening  the  pleura.  But  the  information  obtained 
even  by  exploratory  operation  is  sometimes  uncertain.  Ver- 
neuil  considers  the  x-rays  among  the  most  important  and 
precise  means  of  diagnosis  and  he  believes  that  the  import- 
ance of  their  use  is  increasing.  In  many  doubtful  cases 
where  it  is  impossible  to  make  a  diagnosis  by  auscultation 
and  percussion  and  exploratory  puncture  the  x-rays  have 
given  exact  information.  In  case  of  injury  to  lungs  and 
pleura,  hemorrhage  and  the  presence  of  pneumothorax  are 
the  indications  for  operative  intervention,  but  the  determina- 
tion of  the  time  when  that  intervention  is  desirable  is  often 
very  difficult.  Very  often  the  patient  is  in  an  extremely  bad 
condition,  almost  livid,  the  pulse  small,  and  there  are  signs 
of  a  large  eflusion.  It  is  not  uncommon,  however,  to  find 
that  tbe  condition  of  these  patients  is  completely  trans- 
formed 24  hours  later.  The  amount  of  blood  constituting 
the  hemothorax  is  not  decreased,  but  the  pulse  is  better,  the 
general  condition  improved,  the  dyspnea  entirely  disap- 
peared and  a  perfect  recovery  results  without  operative 
treatment.  Operations  undertaken  under  these  conditions 
ofifer  very  few  chances  of  success  when  one  considers  the  in- 
tense traumatic  shock  and  usually  the  imperfect  prepara- 
tions for  intervention.  Operation  is  consiaered  justibable 
only  when  there  is  the  conviction  that  hemorrhage  is  con- 
tinuing either  from  the  thoracic  wall  or  from  the  lung.  In 
such  cases  a  wound  in  the  lung  may  be  sutured  or  an  injured 
intercostal  vessel  may  be  ligated  successfully  very  frequently. 
The  tamponing  of  the  pleural  cavity,  it  is  thought,  should  6e 
abandoned.  Timid  intervention  is  condemned  as  a  result  of 
much  observation.  Once  the  operation  has  been  decided 
upon  it  should  be  extensive.  In  many  cases  of  empyema  it 
is  believed  that  Estlander's  operation  should  be  resorted  to 
earlier  than  is  now  generally  the  case.  If  it  is  found  that 
after  suflJcient  drunage  for  a  reasonable  length  of  time  im- 
provement does  not  result,  costal  resection  should  not  be 
delayed.  In  the  case  of  an  old  empyema  Schede's  or  De- 
lorme's  operations  are  frequentlj*  indicated.  Primary  tumors 
of  the  lung  with  the  exception  of  hydatid  cysts  and  actino- 
mycosis are  extremely  rare.  Primary  cancer  of  the  pleura 
or  lung  is  rarely  recognized  in  an  early  stage  and  later  on  it 
is  inoperable.  Actinomycosis  has  been  successfully  treated 
by  thoracotomy  and  resection  of  the  lung.  Hydatid  cysts 
are  best  treated  by  incision,  disinfecting,  and  packing.  In 
cases  of  abscess  of  the  lung,  bronchiectasis  or  gangrene  of 
the  lung,  drainage  will  be  necessary.  The  simplest  forms  of 
drainage  are  usually  the  best.  Puncture  is  rarely  sufficient 
in  case  of  abscess  of  the  lung.  Some  favor  the  turning  back 
of  an  osteoplastic  flap,  others  costal  resection.  Vemeuil 
considers  the  latter  the  preferable  method  of  operation  in 
most  cases.  In  operating  for  bronchiectasis  the  results  will 
be  more  favorable,  the  nearer  the  condition  approaches  that 
of  pulmonary  abscess.  Some  surgeons  advocate  tbe  main- 
tenance of  a  bronchial  fistula.  Pneumonotomy  in  pulmonary 
gangrene  has  not  given  very  encouraging  results.  If  the 
patient  recovers  from  the  immediate  eflects  of  the  condition 
the  later  results  seem  more  encouraging.  Pneumopexy  is 
advocated  in  CAses  in  which  there  is  not  adherence  of  the 
parietal  pleura  as  a  means  of  avoiding  the  dangers  of  pneu- 
mothorax. Except  in  very  rare  cases,  surgical  intervenuon 
is  not  considered  justifiable,     [m  b.t,] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.  Reprints  (250)  of  Original  Articles  will  be  furnished  gratis  to  Authors  making 
the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelpliia  Oledical  Joamal»  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8, 


Jamks  Hkndrik  Lloyd,  A.M.,  M.D.,  Editor-in-Chief 
Julius  L.  Salinger,  M.D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailkr,  M.D.  F.  J.  Kaltkyer,  M.D. 

D.  L.  Edsall,  M,D.  T.  L.  Colby,  M.D. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  Gibbon,  M.D. 


Vol.  VII,  No.  2 


JANUARY  12,  1901 


$3.00  Per  Annum 


Parasitic  Hemoptysis  in  the  United  States. — The 

Marine-Hospital  Service  calls  the  attention  of  health 
officers  and  physicians  to  the  important  fact  that  the 
United  States  Bureau  of  Animal  Industry  has  found 
more  than  50  cases  of  infection  in  hogs  by  a  lung  fluke 
known  as  Paragonimus  westermanii.  Heretofore,  this 
parasite  has  been  observed  but  rarely  in  America,  al- 
though it  is  quite  common  in  some  parts  of  China  and 
Japan,  and  possibly  in  the  Philippines.  Drs.  Stiles 
and  Hassall  are  about  issuing  a  report  of  their  investi- 
gations, from  advance  proofs  of  which  the  following 
facts  are  gleaned.  This  parasite  was  originally  de- 
scribed by  Kerbert  (1878)  in  the  tiger,  by  Manson  (1880) 
and  Baily  (1880)  in  man,  by  Railliet  (1890)  in  the  dog, 
and  more  recently  by  others  in  the  cat.  A  full  zoo- 
logical description  of  the  paragonimus  is  given  by  the 
authors,  from  which  we  learn  that  it  is  a  fluke  worm,  8 
to  16  mm.  long,  4  to  8  mm.  broad,  and  2  to  5  mm. 
thick.  It  is  found  encysted,  usually  two  individuals  in 
each  cyst,  with  eggs,  and  its  habitat  is  the  lungs  of 
mammals.  It  seems  to  be  identical  as  observed  in  the 
various  mammals — tiger,  dog,  hog,  cat,  and  man — in 
which  it  has  thus  far  been  found.  Its  life  history  is 
still  very  obscure.  According  to  Stiles  and  Hassall  the 
complete  life  cycle  of  the  lung  fluke  has  not  yet  been 
experimentally  demonstrated.  It  seems  clear  that  the 
egg  does  not  develop  until  it  leaves  the  host  in  the 
sputum.  Manson  and  Nakahama  each  succeeded  in 
hatching  the  eggs  in  warm  water,  but  the  natural  en- 
vironment is  yet  unknown.  Beyond  this  miracidium 
stage  nothing  is  positively  known,  hut  the  presence  of 
cilia  indicates  an  aquatic  life,  and  all  analogy  points  to 
the  probability  of  some  intermediary  host.  Certain  of 
the  invertebrates,  such  as  the  mollusks  (snails,  etc.), 
have  been  under  suspicion ;  as  have  also  chickens  and 
their  eggs,  for  chickens  are  well  known  to  eat  human 
sputum.  This  whole  subject  of  the  life  history  of  the 
Paragonimus  westermanii  is  discussed  in  detail  by  the 
authors. 

The  symptoms  of  parasitic  hemoptysis  vary  accord- 
ing to  the  location  of  the  parasite.  The  lung  infection 
is  the  usual  form.  Spitting  of  blood  is  common.  A 
sputum,  very  similar  to  that  of  pneumonia,  and  of  a 
dirtj'  red  or  brown  color,  due  to  the  presence  of  eggs 
of  the  worm,  is  raised  during  the  intervals  between  the 
hemorrhages.  The  only  constant  and  specific  charac- 
teristic is  the  presence  of  the  eggs  in  the  sputum.     As 


many  as  12,000  eggs  may  be  expectorated  daily.  The 
brain  also  may  be  infected.  Epileptiform  attacks,  of  a 
Jacksonian  or  cortical  type,  result.  These  and  other 
brain  symptoms  are  caused  by  the  presence  of  the 
worm  or  its  eggs,  or  from  emboli  in  the  arteries.  The 
liver  and  other  organs  also  may  be  involved. 

Drs.  Stiles  and  Hassall  state  that  two  cases  of  this 
disease  were  recorded  in  the  United  States  in  1894  and 
1895  ;  one  in  a  cat  in  Michigan  and  the  other  in  a  dog 
in  Ohio.  It  was  hoped  that  the  infection  would  not 
spread,  but  this  hope  has  been  disappointed,  for  the 
meat  inspectors  of  the  Bureau  of  Animal  Industry, 
stationed  at  Cincinnati,  have,  on  repeated  occasions, 
discovered  lesions  in  hogs  which  Stiles  and  HassaU 
have  determined  were  due  to  the  presence  of  this  para- 
site. The  worms  collected  from  hogs  in  Cincinnati  are 
identical  with  those  found  by  Manson  in  man.  Dr. 
Stiles  thinks  the  parasite  has  been  introduced  into  this 
country  from  China  or  .Japan,  and  he  fears  that  our 
troops  returning  from  the  East  will  add  to  the  infection 
already  here  by  bringing  sporadic  cases  of  the  disease 
with  them.  Treatment  so  far  is  inefficacious,  although 
patients  may  live  for  many  years. 

Science  Between  the  Acts. — A  report  comes  from 
Paris  that  Dr.  Hanriot,  of  the  Academy  of  Medicine 
and  the  Board  of  Health,  is  creating  a  sensation  among 
theater  goers,  as  well  as  consternation  among  theater 
managers  in  that  city,  by  a  series  of  experiments  under- 
taken to  prove  that  the  air  of  Paris  theaters  is  loaded 
with  microbes.  When  these  experiments  were  begun 
last  winter,  the  preliminary  results  were  so  alarming  that 
the  French  Government  interfered  for  fear  of  their  in- 
jurious effects  upon  the  approaching  exposition  as  well 
as  upon  the  theaters.  So  paternal  is  the  Republic  over 
there  that  it  even  controls  the  ventilation  of  the  thea- 
ters and  the  distribution  of  bacteria.  Now  that  the 
exposition  is  a  thing  of  the  past.  Dr.  Hanriot  is  once 
more  at  work.  His  method  is  rather  sensational,  as 
becomes  the  atmosphere  of  Paris.  He  arrives  in  the 
midst  of  a  performance  and  settles  himself  in  a  box 
with  his  apparatus  and  assistants.  As  the  apparatus 
makes  a  loud  buzzing  noise  he  graciously  sets  it  going 
only  during  the  intervals  between  the  acts.  He  and 
his  assistants  then  talk  in  a  loud  tone  in  order  to  drown 
the  noise  of  the  machine.  The  immediate  effect  on 
the  audience  is  not  described;  but  the  scientific  results, 


46 


The  Philadelphia"] 
Mbdical  Journal  J 


EDITORIAL  COMMENT 


[Jakuakt  12,  19C1 


as  announced  by  Dr.  Hanriot,  are  important.  He  says 
that  the  air  of  some  of  the  Paris  theaters  is  "  little  bet- 
ter than  dusting."  His  recommendations  are  for  better 
ventilation  and  for  the  substitution  of  leather  for  plush 
upholstering.  This  latter  point  seems  to  be  one  of 
great  importance,  for  Hanriot's  observations  go  to  show 
that  those  theaters  which  are  upholstered  in  plush  are 
the  most  infected. 

Cystitis  TjT>hosa. — The  elimination  of  typhoid 
bacilli  through  the  kidneys  has  been  known  for  a  long 
time.  Smith  and  Gwyn  in  this  country  have  made  some 
very  interesting  studies  in  regard  to  the  possibility  of  the 
dissemination  of  the  disease  by  this  method,  although 
the  earlist  statements  on  the  subject  date  from  Konja- 
jeff  and  J.  Neumann,  and  since  their  publication  in  1889 
the  subject  has  excited  considerable  interest  on  the 
part  of  various  investigators,  such  as  Petruschki  and 
Curschmann.  Lately  the  latter  has  again  taken  up  this 
subject,'  and  draws  a  sharp  distinction  between  the 
mere  presence  of  the  typhoid  bacilli  in  the  urine, 
eliminated  by  the  kidneys  without  harm  to  the  indi- 
vidual, and  the  existence  of  a  true  inflammation  of  the 
mucous  membranes  of  the  bladder,  produced  by  the 
action  of  the  microorganisms.  To  the  latter  he  gives 
the  name  "  cystitis  typhosa."  This  condition  is,  com- 
paratively speaking,  rare,  in  view  of  the  fact  that  in 
anywhere  from  6  to  100%  of  aU  cases  of  typhoid 
fever  examined  by  different  investigators,  typhoid 
bacilli  were  present  in  the  urine,  and  as  the  number 
of  cases  hitherto  examined  exceeds  1,000,  and  the 
average  percentage  is  about  30,  the  frequency  with 
which  typhoid  bacilli  are  found  in  the  urine  is  ex- 
traordinarily great.  Curschmann  has  had  an  oppor- 
tunity of  studying  3  cases  in  which  the  ordinary 
symptoms  of  cystitis  were  present ;  that  is  to  say,  large 
quantities  of  pus-cells  were  found  in  the  urine  together 
with  typhoid  bacilli,  whose  nature  was  proved  by  cul- 
tural peculiarities,  and  their  reaction  to  typhoid  blood. 
The  curious  features  about  these  forms  of  cystitis  are 
the  acid  reaction  of  the  urine,  the  absence  of  epithelium 
from  the  kidneys,  or  the  renal  pelvis,  and  the  absence 
of  any  true  signs  of  nephritis,  although  in  the  early 
stages  of  the  disease,  a  transient  albuminuria,  probably 
febrile  in  character,  is  present.  In  the  first  case,  an 
interesting  feature  was  the  presence  of  virulent  bacilli 
in  the  urine  after  the  cystitis  had  completely  healed. 
The  third  case  showed  certain  peculiarities.  The  in- 
flammatorj'  process  lasted  more  than  4  months,  and 
was  finally  cured  by  injections  of  a  solution  of  silver 
nitrate,  followed  by  the  complete  disappearance  of 
the  typhoid  bacilli  or,  rather,  their  replacement  by  the 
colon  bacilli.  Curschmann  calls  attention  to  a  few  of 
the  characteristics  of  this  disease.  It  can  only  develop 
after  an  attack  of  typhoid  fever,  of  course  after  a  bac- 
teriuria  has  occurred.     Why  this  bacteriuria  produces 

i  Munchtntr  med.  Wochenschrift,  October  16,  1909. 


cystitis  in  such  a  small  proportion  of  all  the  cases,  it  is 
difficult  to  say,  for  the  disease  occurs  in  perfectly 
healthy,  vigorous  individuals  as  well  as  in  the  aged. 
The  subjective  symptoms  are  verj'  slight.  The  patients 
complain  of  practically  no  pain,  and  do  not  have 
dysuria,  excepting  in  rare  cases.  There  is  no  febrile 
elevation  of  the  temperature;  the  urine  has  an  acid 
reaction,  is  cloudy  and  contains  the  bacteria  and  pus. 
The  disease  does  not  extend  to  the  ureters,  nor  to  the 
kidneys.  The  course  is  variable ;  usuallj'  briel,  but  it 
may  be  exceedingly  chronic.  The  prognosis  is  favor- 
able in  all  respects,  and  the  treatment  consists  of  the 
administration  of  salol,  lavage  of  the  bladder  with  a 
solution  of  silver  nitrate,  or  the  administration  of  uro- 
tropin.  (Horton  Smith's  method.)  AU  these  measures 
are  also  useful  in  overcoming  the  simple  bacteriuria. 
The  chief  feature  about  this  condition  is  of  course  the 
fact  that  on  account  of  the  absence  of  subjective  symp- 
toms, the  condition  may  be  overlooked,  particularly  as 
it  often  occurs  after  convalescence  is  well  started,  and 
there  is  no  apparent  reason  for  continued  examination 
of  the  urine.  The  possibility  of  the  dissemination  of 
the  disease  by  this  method  has  already  been  insisted 
upon  by  Gwyn  in  these  columns. 

Influenza  and  Hay  Fever. — The  prevailing  epi- 
demic of  mild  influenza  revives,  even  in  midwinter, 
the  perennial  subject  of  hay  fever.  Some  persons 
think  they  have  made  the  discover}'  that  the  two  dis- 
eases are  in  a  sense  antagonistic ;  or,  at  least,  that  the 
victims  of  hay  fever  are  not  so  prone  to  the  grip  as 
are  the  rest  of  the  world.  This  fact,  if  true,  would 
seem  to  indicate  that  hay  fever,  as  well  as  influenza,  is 
a  disease  of  microbic  origin,  and  that  the  infecting 
organism  of  the  one  has  the  power  of  rendering  its 
victim  immune  to  the  action  of  the  other. 

The  theory  that  hay  fever  is  a  neurosis  is  perhaps 
not  well  based  on  the  observation  of  facts,  and  is  likely 
to  succumb  to  the  all-dominant  microbe.  It  would 
perhaps  be  more  reasonable  to  claim,  as  Dr.  A.  0.  J. 
Kelly  has  done  in  the  case  of  arthritis  deformans,  that 
it  is  an  infectious  trophoneurosis.  The  fact  is  well 
established  that  the  disease  is  curiously  under  the  in- 
fluence of  mental  impression,  and  is  sometimes  con- 
trollable by  agencies  that  control  the  pure  neuroses. 
This  has  been  well  demonstrated  in  this  city  in  recent 
years  by  a  man  of  independent  means,  who  was  him- 
self a  victim  of  hay  fever.  After  traveUng  ever)-  year 
to  different  resorts  in  a  vain  search  for  relief,  he  deter^ 
mined  at  last  to  fight  it  out  in  his  city  house,  where  he 
could  at  least  have  the  comforts  of  home.  He  accordingly 
returned  every  August  to  his  city  house  and  locked 
himself  in.  Strange  to  say,  the  customarA-  attack  was 
averted.  This  experiment  has  proved  absolutely  suc- 
cessful now  for  three  years  in  succession.  Such  a  case, 
it  may  be  thought,  only  goes  to  prove  the  truth  of  the 
pollen    theory — a  theory   which   was    so    elaborately 


Jakdaky  12,  1901] 


EDITORIAL  COMMENT 


[The  Philadelphia 
Medical  Jocenal 


47 


worked  out  by  Blackley  in  England  in  1866-78.  And 
yet  pollen  is  probably  not  absent  from  the  air  of  cities. 
If  a  genuine  antagonism  could  be  demonstrated  be- 
tween hay  fever  and  influenza,  it  would  be  interesting 
to  note  what  use  the  bacteriologists  could  make  of  the 
fact  in  the  way  of  establishing  a  prophylaxis. 

A  New  Treatment  for  Tuberculosis.— From  the 

standpoint  of  its  pathology  the  ideal  method   for  the 
cure  of   tuberculosis   would    be  to  render  the  lungs 
aseptic.     Taking  into  consideration  the  nature  of  the 
air-passages  and  their  constant  exposure  to  the  bacteria- 
laden  atmosphere,  this  is  manifestly  impossible,  at  least 
if  attempted  by  the  inhalation  of  vapors  containing 
antiseptic  substances.     Maguue  {British  MedicalJournal, 
December  15,    1900)   proposes   to  employ  the  blood- 
vessels to  render  the  lungs  aseptic.     After  experiment- 
ing with  cyanide  of  mercury,  iodide  of  potassium,  per- 
chloride  of  mercury,  diastase,  and  nuclein,  he  decided 
that  formic  aldehyd  was  the  most  likely  to  prove  of  use 
as  a  germicide  that  could  be  injected  into  the  periph- 
eral veins,  and  that  would  pass  thence   to   the  lung 
through  the  pulmonary  artery,   diluted  only  by  the 
contents  of  the  right  ventricle.     He  found  that  a  solu- 
tion of  one  part  pure  formic  aldehyd  gas  in  2,000  parts  of 
normal  salt-solution  could  be  employed  with  safety  and 
that  he  could  inject  2  cc.  in  the  space  of  5  heart-beats. 
He  calculated  that  by  this  process  in  the  space  of  5 
heart-beats,  the  lung  would   be   washed   out    with  a 
1 :  500,000  solution  of  formic  aldehyd.     Still   further 
attempts  developed  a  manner  of  using  a  more  rapid 
process  of  injection  and  for  a  longer  time,  so  that  he 
now  believes  that  he  can  sluice  the  lungs  during  a  con- 
siderable number  of  heart-beats  with  a  1 :  50,000  solu- 
tion.    For  the  injection  he   employs  a  buret   at  the 
lower  end  of  which  is  a  soft  rubber  tube  bearing  a  hypo- 
dermic needle  of  large  caliber.     A  bulb,  similar  to  the 
one  used  on  the  Pacquelin   cautery,  is  attached   to  the 
upper   end   of  the  buret   by  a   cork.      The   patient's 
arm  is  ligated  as  for  venesection  and   under  aseptic 
precautions,  the  needle  is  plunged  boldly  into  a  vein, 
the  ligature  loosened  and  the  tap  of  the  buret  turned. 
He  adwises  that  not  more  than  50  cc.  of  the  1 : 2,000 
solution  be  injected  daily.     Larger  quantities  which  he 
had  the  hardihood  to  inject  into  his  own  system  caused 
albuminuria,  copious   hematuria,   and  finally    throm- 
bosis of  a  vein  in  the  arm.     As  a  result  of  this  treat- 
ment cough  is  generally  increased  and  the  expectoration 
becomes  more  frothy  and  mucous.     Of  70  patients  who 
have  been  submitted  to  this  method  of  pulmonary  asep- 
sis, nearly  all  showed  some  improvement  and  in  some 
there  has  been  demonstrated  absolute  disappearance  of 
tubercle  bacilli  from  the  sputum.   It  seems  to  us  that  the 
treatment  suggested  is,  to  say  the  least,  heroic.    Making 
due  allowance  for  the  strength  of  the  solution,  the  action 
of  formic  aldehyd  on  the  organs  after  they  have  been 
removed  from  the  body  should  be  borne  in  mind.     It 


would  seem  reasonable  to  fear  that  after  the  continued 
use  of  a  weak  solution  even,  a  cirrhotic  process  might  be 
induced  in  some  of  the  other  viscera,  if  not  in  the 
lungs,  thereby  setting  up  a  second  serious  disease  while 
curing  the  primary  lesion.  It  would  seem  wise,  before 
this  method  is  generally  employed,  to  study  carefully 
the  action  of  such  a  solution  of  formic  alhehyd  on  the 
red  blood-corpuscles  outside  the  body  ;  because  it  does 
not  seem  out  of  the  range  of  possibility  that  long  ex- 
posure to  such  a  solution  might  seriously  harden  the 
stroma  of  the  cells  and  thus  interfere  with  their  oxygen- 
carrying  power. 

The  Plague  in  Manila. — The  state  of  health  in  our 
recently  acquired  Philippine  Islands  is  a  subject  of 
special  interest  now  to  all  American  physicians.  The 
Government  has  new  problems  to  face  both  in  hygiene 
and  in  practice.  It  thus  happens  that  the  recent  report 
of  Surgeon-General  Sternberg  on  the  prevalence  of 
plague  in  Manila  brings  home  to  us  a  topic  of  great 
moment  from  several  standpoints.  We  are  not  only 
interested  in  plague  as  it  has  prevailed  in  Manila,  but 
also  as  it  may  possibly  be  imported  into  the  United 
States  from  that  center  of  infection.  The  pest  made 
its  first  appearance  in  Manila  in  December,  1899,  little 
more  than  one  year  ago.  The  first  cases  were  reported 
as  instances  of  typhoid  fever.  One  death  occurred  in 
December,  11  in  January,  35  in  February,  49  in  March, 
44  in  April,  17  in  May,  and  11  in  June,  while  during 
each  of  these  months  from  40  to  80  Chinese  died  from 
causes  unknown,  they  having  been  without  medical 
attendance.  The  reported  cases  all  told  numbered  225 
of  which  only  58  recovered.  It  thus  appears  that 
there  was  a  well-established  epidemic  of  the  disease  in 
the  city  of  Manila. 

Only  two  white  men  contracted  the  disease  and  only 
one  American  died  of  it — an  employe  of  the  quarter- 
master's department.  The  epidemic  was  confined 
almost  exclusively  to  the  native  and  Chinese  popula- 
tion. It  is  reassuring,  in  this  connection,  to  read  Sur- 
geon G.  L.  Edie's  confidently  expressed  opinion  that 
but  little  difficulty  will  be  experienced  in  controUing 
the  disease  in  any  intelligent  community  with  modern 
sanitary  methods.  This  opinion  is  hardly  sustained  by 
experience  with  plague  in  other  quarters  of  the  globe, 
and  yet  Dr.  Edie,  who  is  the  Health  Officer  in  Manila, 
had  ample  opportunity  to  form  an  opinion  in  this  epi- 
demic. That  he  can  come  to  such  a  conclusion  after 
combating  plague  in  an  Asiatic  community,  is  certainly 
noteworthy.  He  speaks  highly  of  the  intelligent  and 
efficient  help  rendered  by  the  Chinese.  The  prompt 
detection  of  cases  among  these  people  was  largely  due 
to  the  vigilance  of  the  Chinese  Consul  and  the  Chinese 
merchants.  The  latter  furnished  40  inspectors  [from 
their  own  number,  and  contributed  funds  for  ^building 
and  maintaining  a  pesthouse.  The  Filipinos  also 
were  pressed  into  service  as  inspectors  and  did  efficient 


48 


The  Philadelphia"! 
Medical  Jodbsal  J 


EDITORIAL  COMMENT 


.lAyUAET  12,  19«ll 


work.  The  disease  was  combated  in  a  thoroughly 
scientific  way — such  as  usually  characterizes  the 
Government's  medical  work.  But  Dr.  Edie  says  that 
he  and  his  assistants  were  not  favorably  impressed  with 
either  Haflfkine's  prophylactic  or  Yersin's  serum,  but 
he  acknowledges  at  the  same  time  that  a  thorough  test 
had  hardly  been  given  to  either.  He  says  it  is  almost 
impossible  to  use  them  on  the  Chinese  or  natives  with- 
out resorting  to  force. 

The    Essential    Nature    of    "Whooping-cough. — 

The  efforts  to  determine  the  nature  of  whooping-cough, 
and  its  etiology,  began  with  the  first  reported  appear- 
ance of  cases  of  the  malady  early  in  the  sixteenth  cen- 
tury. Its  contagious  character  was  made  manifest  by 
the  great  epidemics  which  spread  over  Europe  during 
the  latter  part  of  this  period.  Many  theories  have  been 
offered  in  explanation  of  the  condition,  and  in  many 
instances  these  have  been  utterly  irreconcilable.  How- 
ever, it  is  interesting  to  take  careful  notice  of  the  evo- 
lution of  medical  opinion.  We  must  not  dismiss  old 
dogmas  with  a  wave  of  the  hand,  but  with  careful  ju- 
dicial mind  must  sift  out  these  theories,  and  glean  what- 
ever of  truth  there  is  in  them.  It  is  well  to  remember 
that  medical  thought  advances  in  cycles,  and  too  often 
we  have  discarded  as  valueless  what  has  subsequently 
been  readopted,  after,  perhaps,  years  of  vain  groping, 
and  found  to  contain  the  essentials  of  truth. 

The  prevailing  humoral  theory  of  the  eighteenth  cen- 
tury sought  to  attribute  spasmodic  seizures  to  digestive 
disturbances,  and  explain  the  symptoms  by  an  irritat- 
ing action  exerted  upon  the  diaphragm  and  the  respira- 
tory organs.  It  was  Linnffius,  the  botanist,  nearly  two 
hundred  years  ago,  who  attributed  the  condition  to  the 
inhalation  of  a  contagium  animatum.  We  find  that  by 
many  the  disease  has  been  regarded  as  a  simple  bron- 
chitis, of  a  form  involving  mainly  the  finer  bronchioles 
and  the  alveoli.  (Broussais  and  Desruelles,  1824.) 
Loschner  (1868)  held  the  same  view,  but  explained  the 
spasms  of  coughing  by  the  reflex  irritation  caused  by 
the  decomposing  secretion.  Beau  advanced  the  theory 
that  a  mechanical  irritation  of  the  larynx  was  sufficient 
to  produce  the  symptoms,  and  held  that  inflammation 
of  the  laryngeal  mucous  membrane  was  the  cause.  In 
1870,  Letzerich  promulgated  the  theory  of  the  inhala- 
tion of  spores,  and  believed  that  upon  their  multipli- 
cation the  seizures  could  be  brought  about.  Canstatt 
and  Lebert  held  that  the  disease  is  of  zymotic  origin, 
affecting  the  general  system,  and  that  the  paroxysms 
only  indicate  the  respiratory  system  was  most  involved. 
This  theory  was  advanced,  on  account  of  the  frequent 
concurrence  of  measles  with  whooping-cough.  Henoch, 
among  others,  gives  force  to  the  theory  that  pertussis  is 
a  neurosis,  affecting  the  respiratory  nerves  and  the  sym- 
pathetic system.  He  reminds  us  of  the  aura  which  is 
present,  in  the  fact  of  the  child's  anticipating  the  at- 
tacks.    He  concedes  the  catarrhal  condition  of  the  mu- 


cous membrane  present,  but  gives  an  important  place ; 
to  the  nervous  element  of  the  disease,  as  indicated  by 
the  spasmodic  violence  of  the  expirations,  by  the  ap-  • 
nea,  and  the  crowing  sound  of  spasmus  glottidis.     He- 
calls  particular  attention  to  the  fact  that  in  manj'  cases  > 
the  vomiting  is  the  major  symptom,  and  the  cough  but 
slight  in  intensity,  and  further  states  that  it  is  an  open 
question  whether  the  reflex  irritability  of  the  medulla 
acting  through  the  vagus  is  to  be  blamed  here.  i 

As  to  the  pathologic  condition,  it  may  be  stated 
that  the  characteristic  lesions  found  in  an  uncompli- 
cated case  of  whooping-cough  are  a  catarrhal  inflam- 
mation of  the  respiratory  mucous  membrane,  which, 
according  to  to  von  Herff  and  Myer-Hiinn,  is  most 
severe  in  the  nose,  larj'nx,  and  trachea,  although  it  may 
extend  into  the  small  tubes.  In  certain  cases,  however, 
Rossbach  has  found  all  the  parts  of  the  trachea  and 
larynx  normal.  Rehn  found  the  anterior  laryngeal 
wall  to  be  the  portion  most  involved,  while  others  held 
the  opinion  that  the  posterior  wall  of  the  antiarytenoid 
region  seems  so  be  the  general  focus.  The  constant 
occurrence  as  laid  down  by  Beau  and  Gendrin  of  catar- 
rhal inflammation  at  the  entrance  of  the  larynx,  has 
been  proven  to  be  too  broad  a  statement.  It  appears 
that  in  most  of  the  cases  the  catarrhal  inflammation  is 
found  in  the  infraglottic  region,  but  so  s-aried  is  the 
description  of  the  localized  point  of  inflammation  that 
it  would  seem  reasonable  to  assume  that  the  site  of  the 
inflammation  is  dependent  upon  the  locus  minorae  re- 
sistantiae  of  the  membrane.  In  the  majority  of  cases  the 
larynx  is  involved,  or  the  bronchial  tubes  at  their 
bifurcation.  It  is  quite  generally  conceded  that  per- 
tussis is  an  infectious  disease,  and  bacteriologists  have 
been  energetic  in  their  efforts  to  isolate  the  specific 
microorganisms.  The  names  of  Deichler  (1886),  Cohn 
and  Newman  (1895),  Kurloff  (1896),  Czaplewski  and 
Hensel,  Ritter  and  Afanasieff  and,  finally,  Koplik  are 
foremost  among  those  who  claim  to  have  isolated  the 
specific  cause.  The  manifold  complications  of  the 
condition  are  perhaps  exceeded  by  no  other  disease. 
Bronchopneumonia,  emphj'sema,  tuberculosis,  and 
measles  are  especially  important.  We  find  the  inflam- 
mation of  the  bronchial  glands  a  very  constant  featarci 
and  many  have  assigned  to  them  etiologic  importance. 
The  most  acceptable  explanation  of  this  condition, 
however,  is  that  it  is  a  sequela  and  due  to  the  accom- 
panying catarrh  of  the  mucous  membranes.  The 
leukocytosis,  which  so  constantly  is  present  in  whoop- 
ing-cough, affects  especially  the  lymphocytes,  but  we 
must  not  forget  that  lymphocytosis  is  common  in  other 
conditions  in  childhood.  It  would  seem  a  reasonable 
explanation,  at  least  in  part,  to  concede  that  the  specific 
organisms  having  gained  entrance,  upon  some  favor- 
able site  elaborate  a  toxin,  and  that  this  toxin,  being  ab- 
sorbed and  accumulating  in  virility,  acts  particularly 
upon  the  superior  laryngeal  and  vagus  nerves.  The  fact 
must  finally  be  borne  in  mind  that  the  postmortem 


January  12,  1901] 


CORRESPONDENCE 


TThe  Philadelphia 
L  Medical  Journal 


49 


lesions  found,  both  of  the  nervous  and  general  system, 
vary  widely,  and  that  we  are  forced  to  regard  them  as 
complications  rather  than  a  part  of  the  specific  pro- 
cess. There  is  unquestionably  an  infectious  agent 
present  with  its  point  of  secretion  in  the  respiratory 
mucous  membrane,  and  that  an  intoxication  is  pro- 
duced, as  the  disease  progresses,  would  seem  borne  out 
by  the  burden  of  proof. 

A  New  Medical  Journal. — We  extend  a  cordial 
welcome  to  the  New  York  State  Journal  of  Medicine,  the 
first  number  of  which  lies  before  us.  The  new  journal 
is  the  official  organ  of  the  New  York  State  Medical 
Association,  and  will  appear  monthly.  Its  initial  num- 
ber is  highly  creditable,  and  its  succeeding  numbers  we 
doubt  not  will  be  still  better.  In  the  announcement, 
its  editor,  Dr.  J.  H.  Burtenshaw,  says  that  the  new 
enterprise  marks  a  distinct  era  in  the  affairs  of  a  State 
medical  organization.  We  must  call  his  attention  in 
this  connection  to  the  fact  that  the  Pennsylvania  State 
Medical  Society  has  long  had  an  official  organ  in  the 
excellent  Pennsylvania  Medical  Journal. 


(£orrespon6cnce. 


THE  COMMON  FLY  AS  A  FACTOR   IN  THE  TRANS- 
MISSION OF  DISEASED  GERMS. 

By  JOSEPH  LEIDY,  M.D., 
of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

It  has  occasioned  no  little  surprise  to  the  writer  that  while 
the  profession  and  laity  have  shown  a  natural  interest  in  the 
relation  which  the  mosquito  (Anopheles  quadrimaculatus) 
bears  to  the  etiology  of  malaria  as  the  host  through  which 
the  germ  finds  its  way  into  man,  so  little  attention  has  been 
given  to  the  relation  which  the  common  fly  holds  as  a  factor 
in  the  transmission  of  disease. 

The  writer  has  taken  the  opportunity  of  examining  the 
contents  of  the  stomach  and  proboscis  of  a  number  of  flies 
caught  at  random  in  the  reception  ward  of  the  Pennsylvania 
Hospital,  and  of  a  number  which  have  been  allowed  to  feed 
upon  the  discharge  from  suppurating  wounds,  surgical  dress- 
ings, fresh  and  dried  blood  preparations,  and  various  kinds 
of  decomposing  vegetable  and  animal  matter. 

The  results  obtained  from  a  series  of  experiments  in  this 
direction  suggest  interesting  problems,  and  firmly  convince 
the  writer  that  the  fly  may  become  an  important  factor  in 
the  transmission  of  diseased  germs. 

This  preliminary  note  is  made  for  the  purpose  of  calling 
your  attention  at  this  time  to  a  pest  which  it  would  not  be 
wise  to  overlook  while  we  are  making  our  attack  upon  the 
anopheles. 

In  the  Proceedings  of  the  Academy  of  Natural .  Sciences, 
Philadelphia,  1871 :  "  Professor  Leidy  remarked  at  this  time 
(during  the  prevalence  of  smallpox)  he  was  reminded  of  an 
opinion  he  had  entertained  that  flies  were  probably  a  means 
of  communicating  contagious  diseases  to  a  greater  degree  than 
was  generally  suspected.  From  what  he  had  observed  in  one  of 
the  large  military  hospitals,  in  which  hospital  gangrene  had 


existed  during  the  late  rebellion,  he  thought  flies  should  be 
carefully  excluded  from  wounds.  Recently  he  had  noticed 
some  flies  greedily  sipping  the  diffluent  matter  of  some 
fungi  of  the  Phallus  impudicxis. 

"  He  caught  several  and  found  that  on  holding  them  by  the 
wings  they  would  exude  two  or  three  drops  of  fluid  from  the 
proboscis,  which  examined  by  the  microscope  were  found  to 
Bwarm  with  the  spores  of  the  fungus.  The  stomach  was 
likewise  filled  with  the  same  liquid,  swarming  with  spores." 


PREVENTION  OF  TUBERCULOSIS. 
■      By  p.  a.  SHEAFF,  M.D  , 

of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

Measures  for  the  prevention  of  tuberculosis  is  a  subject 
that  justly  calls  for  consideration  and  thought,  not  only  on 
the  part  of  the  medical  profession,  but  by  every  one  inter- 
ested in  their  own  or  others'  welfare. 

Not  until  the  public  at  large  becomes  acquainted  with  the 
facts  in  regard  to  the  care  and  necessity  of  properly  dispos- 
ing of  tubercular  sputum,  and  heeding  the  same,  can  efibrts 
in  this  direction  prove  of  much  avail. 

Efforts  instituted  for  the  prevention  of  a  disease  so  widely 
distributed  and  affecting  so  many  persons  should  receive  the 
consideration  of  every  right-minded  individual,  and  with  all 
due  respect  and  reverence  to  religious  teachings  and  cus- 
toms may  I  call  attention  to  the  prevailing  method  in  regard 
to  the  passage  of  the  communion  cup  in  vogue  in  many  of 
our  churches  ? 

True  it  is  that  some  congregations  have  adopted  the  indi- 
vidual-cup method ;  but  are  they  many,  compared  to  those 
who  have  not  ? 

Is  it  man's  moral  and  religious  duty  to  knowingly  place 
himself  in  a  position  where  he  may  be  the  means  of  infect- 
ing others  or  becoming  infected  himself? 

It  is  not  in  condemnation  of  the  performance  of  this  most 
solemn  religious  rite  that  I  speak,  but  in  observance  of  the 
same  in  a  manner  that  would  accord  with  hygienic  teaching. 


Teaching  Anatomy.— Shepherd  (The  Montreal  Medical 
Journal,  November,  1900)  insists  on  the  oft-repeated  statement 
that  the  dissecting-room  is  the  place  for  the  medical  student 
to  learn  anatomy.  The  lecture  is  little  more  than  a  demon- 
stration ;  and  its  retention  is  the  survival  of  a  method  in 
vogue  when  subjects  were  obtained  only  with  difficulty  and 
at  long  intervals.  Morphology,  however  interesting  and  in- 
structive, has  small  place  in  the  crowded  course  in  anatomy. 
Osteology,  the  anatomy  of  the  nervous  system  and  the  viscera, 
are  the  most  important.  During  recent  years  the  anatomy 
of  the  lymphatics  has  increased  in  importance,  and  that  of 
the  bloodvessels  has  decreased,  except  from  a  purely  surgical 
standpoint.  The  author  questions  the  wisdom  of  teaching 
histology  in  a  separate  course  from  anatomy  and  physiology. 
He  says  as  a  teacher  he  is  daily  amazed  at  the  small  amount 
of  anatomy  retained  by  the  average  fourth-year  man,  and 
even  by  those  who  did  well  in  their  second- year  examination. 
Attention  is  called  to  the  fact  that  the  present-day  teacher  of 
anatomy  is  too  much  specialized,  and  that  the  student  should 
be  taught  the  practical  points  and  these  insisted  upon,  f  From 
the  tone  of  the  author's  address  it  is  exceedingly  doubtful 
whether  he  would  favor  placing  the  whole  course  of  anatomy 
in  the  student's  first  year,  as  is  now  being  done  by  a  few 
schools,    a.b.c] 


50 


The  Philadelphia"! 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Jabuaby  12,  1901 


Timmcan  Xlaws  anb  Hotcs. 


PHUiADELPHIA,  PENNSYLVANIA,  ETC. 

Dr.  H.  C.  Catell  Besig-ns.  —  Dr.  Henry  C.  Catell, 
pathologist  to  the  Pennsylvania  Hospital,  has  resigned. 

Dr.  Anselle  Walker,  of  Freehold,  New  Jersey,  died 
January  6,  from  pneumonia.  He  was  one  of  the  founders  of 
the  New  York  Pharmaceutical  Association. 

Antiseptic  Telephoning. — A  Philadelphia  firm  is  put- 
ting upon  the  market  an  antiseptic  mouth  piece  for  tele- 
phones. The  contrivance  has  been  adopted  by  several 
corporations. 

Dr.  John  M.  Brister,  who  left  on  Monday  for  the 
Mare  Island  Navy  Yard,  where  he  was  assigned  as  assistant 
surgeon.  United  States  Navy,  was  given  a  farewell  dinner  on 
Saturday  evening  at  the  home  of  his  brother.  Dr.  F.  Elmer 
Brister. 

Nurses  Graduate  at  Philadelphia  Hospital.— The 

gra,duatiDg  class  for  the  Training  School  of  Nurses  at  the 
Philadelphia  Hospital,  comprising  13  nurses,  received  their 
diplomas.  This  makes  the  sixteenth  anniversary  of  the 
Training  School. 

A  Practitioner  of  High  Standing  Dead.— Dr.  D. 

R.  Bardin  died  of  Bright's  disease,  at  Avondale.  He 
had  been  practising  since  1866.  Dr.  Bardin  was  born  in  Dal- 
ton,  Mass.,  February  10,  1820.  In  1842  he  graduated  from 
the  New  York  University.  He  obtained  his  medical  degree 
in  1856.  The  deceased  will  be  buried  in  Woodland  Ceme- 
tery. 

Death  of  a  Famous  Army  Nurse.- Mrs.  Anna  Mor- 
ris Holstein,  who  had  obtained  considerable  fame  as  an  armv 
nurse,  died  at  her  home  at  Red  Hill,  near  Norristown,  Pa.,  at 
the  age  of  76.  She  was  matron-in-chief  of  a  hospital  in  which 
there  were  3,000  seriously  wounded  after  the  battle  of  Get- 
tysburg. She  waa  instrumental  in  the  purchasing  of  the 
army  headquarters  of  Washington  at  Valley  Forge. 

Physicians  Choose  Officers.— At  the  meeting  of  the 
College  of  Physicians  held  last  evening,  the  following  physi- 
cians were  elected  officers :  W.  W.  Keen  (reelected),  presi- 
dent; H.  C.  Wocd,  vice-president;  William  F.  Norris,  R.  A. 
Cleemann,  Arthur  V.  Meigs,  and  S.  Weir  Mitchell,  censors; 
Thomas  R.  NeilsoQ,  secretary  ;  Richard  H.  Harte,  treasurer  ; 
Frederick  A.  Taggart  and  Elliston  J.  Morris,  councillors. 

Death  of  Dr.  Richard  Linderman. — We  regret  to 
announce  the  death  of  Dr.  Richard  Johnson  Linderman,  in 
this  city,  who  was  not  only  well  known  in  his  profession,  but 
who  represented  Bucks  County  in  the  State  Senate  from  1869 
until  1870.  He  had  been  ill  for  3  years  with  cardiac  disease.  He 
was  president,  until  about  20  years  ago,  of  the  Quaker  Town 
City  Bank,  and  also  connected  with  various  other  public  as 
well  as  medical  associations. 

Cooper  Hospital  Physicians.— At  the  annual  meeting 
of  the  trustees  of  the  Cooper  Hospital  the  following  were 
elected  as  the  visiting  staff  of  physicians  and  surgeons : 
Medical— Drs.  W.  A.  Davis,  E.  L.  P.  Godfrey,  W.  R.  Powell ; 
surgeons— Drs.  Daniel  Strock,  Joseph  Nicholson,  Paul  M. 
Mecray,  and  E.  A.  Y.  Schellinger;  ophthalmologist— Dr.  W. 
R.  Powell ;  gynecologists— Drs.  Dowling  Benjamin  and  J.  S. 
Baer;  laryngologist- Dr.  E.  S.  Ramsdell ;  pathologist — Dr. 
S.  Bray. 

Course  in  Neuropathology.— An  elective  course  in 
neuropathology  has  Deen  opened  in  the  University  of  Penn- 
sylvania by  Dr.  W.  G.  Spiller,  who  has  recently  been 
appointed  demonstrator  of  that  branch.  The  course  is  open 
to  a  limited  number  of  graduates  and  students  and  will 
comprise  the  study  of  pathology  of  the  central  nervous 
system  and  preparation  as  well  as  examination  of  micro- 
scopic preparations.  This  course  is  of  especial  value  to  pros- 
pective neurologists  who  wish  to  combine  with  their  clinical 
knowledge  apart  of  the  pathologic  manifestations  of  nervous 
diseases. 


Berks  County  Medical  Society,  at  its  banquet,  Jan- 
uary 8,  following  the  annual  meeting,  had  as  its  guests  Dr. 
Martin,  professor  of  surgery  at  the  University  of  Pennsylva- 
nia ;  Dr.  Forbes,  professor  of  anatomy  at  Jefferson  Medical 
College,  and  Dr.  John  Shoemaker,  professor  of  therapeutics 
at  the  Medico-Chirurgical  College.  The  Society  elected  Dr. 
S.  S.  Hill  president ;  Dr.  James  W.  Keiser,  recording  secre- 
tary; S.  Banks  Taylor,  corresponding  secretary,  and  Dr.  A. 
8.  Raudenbush,  treasurer. 

The  Medical  Society  of  the  County  of  Erie  held 
its  eightieth  annual  meeting  January  8th,  electing  officers 
and  delegates  to  the  State  Society.  The  following  program 
was  presented :  A  county  health  officer,  by  Dr.  E.  H. 
Baixod,  president ;  A  review  of  legislation  in  refer- 
ence to  tuberculosis,  by  Dr.  J.  H.  Peyoe;  A  brief 
resume  of  the  grosser  animal  nature,  and  its  ap- 
plication in  medicine,  by  Dr.  Geo.  N.  Jack  ;  Gastro- 
intestinal disease  in  children,  by  Dr.  W.  C.  Caixasan. 

Errata. — In  the  Philadelphu^  Medical  Journal  of  Jan- 
uary 5,  page  24,  the  prescription  credited  to  Dr.  Walter  L. 
Pyle,  should  read  :  Yellow  oxide,  1  grain  ;  vaseline,  3  drams, 
instead  of  yellow  oxide,  1  grain  ;  vaseline,  3  grains.  In  the 
Philadelphia  Medical  Jouksal  of  December  29, 1900,  page 
1237,  in  the  article  entitled  "  Rotary  Lateral  Curvature  of 
the  Spine ;  Their  Diagnosis  and  Treatment,"  Dr.  Daniel  W. 
Marston  should  have  been  mentioned  as  the  associate  in 
the  article  of  A.  M.  Phelps,  A.M.,  M.D.,  instead  of  A.  W. 
Marston,  M.D. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 
January  5,  1901 : 

Total  mortality 453 

Cases.     Deaths. 
Inflammation  of  appendix  4,  brain  13,  bronchi 
8,  kidneys  16,  liver  1,  lunes  60.  peritoneam 
4,  pleura  1,  stomach  and  bowels  17,  tonsils  1  125 

Inanition  13,  marasmus  10,  debility  3  .   .  .   .  26 

Tuberculosis  of  lungs 61 

Apoplexy  16,  paralysis  6 22 

Heart — disease  of  31,  fatty  degeneration  of  5, 

neuralgia  of  2 38 

Uremia  15,  diabetes  2,  Bright's  disease  S  .    .    .  25 

Carcinoma  of  breast  3,  face  1,  liver  6,  stomach 
1,  throat  1,  uterus  1,  jaw  1,  tongue  1   ....  15 

Convulsions 8 

Diphtheria 118  20 

Brain — softening  of  2,  congestion  of  1    ....  3 

Typhoid  fever 95  16 

Old  age 14 

Burns  and  scalds 5 

Teething 2 

Dysentery 2 

Suicide 3 

Cirrhosis  of  liver 6 

Alcoholism 4 

Cyanosis 2 

Gangrene  of  foot 2 

Scarlet  fever 92  3 

Liver,  abscess  of 1 

Abscess  of  stomach  1,  asthma  4,  atheroma  1, 
casualties  7.  cerebrospinal  meningitis  1,  con- 
gestion of  lungs  1,  puerperal  convulsions  1. 
croup,  membranous  2,  dropsy  1,  erysipelas 
1,  fistula  1,  hematemesis  1,  hernia  3,  influ- 
enza 7,  jaundice  1,  leukemia  1,  locomotor 
ataxia  1.  intestinal  obstruction  1,  pyemia  1, 
rheumatism  1,  arterial  sclerosis  1,  septice- 
mia 1,  sarcoma  of  liver  1,  sarcoma  of  neck 
1,  suffocation  1,  tumor  of  chest  1,  ulcera- 
tion of  stomach  1 ,  whooping  cough  3,  um- 
biUcal  hemorrhage  1,  dropsy  1 50 

Pediatric  Society. — At  the  meeting  of  January  8,  Dr. 
S.  M.  Hamill  exhibited  an  infant,  6  months  of  age,  which  ie 
suffering  from  severe  anemia  with  leukocytosis.  The  child 
has  been  breast-fed  since  birth.  The  liver  is  slightly  and  the 
spleen  considerably  enlarged.  Emaciation  is  moderate- 
Examinations  of  the  blood  show  about  3,000,000  erythrocytes, 
leukocytes  varying  from  29,000  to  23,0(X),  hemoglobin  4. ft. 
There  is  a  great  increase  in  the  lymphocytes,  nucleated  rede 
are  present,  and  there  is  marked  poikilocytosis.  There  are 
no  symptoms  of  rickets  or  scurvy  and  no  syphilitic  or  tuber- 
culous family  history.  There  being  no  underlying  disease  on 
which  to  base  a  diagnosis  of  secondary  anemia,  the  case  was 

E resented  as  belonging  to  one  of  the  uncl.sssified  varieties 
etwe«n  leukemia  and  pernicious  anemia. 


JiSCiSr  12,  1901J 


AMERICAN  NEWS  AND  NOTES 


[The  Philadelphia 
Medical  Jocbsal 


51 


De8.  J.  A.  Scott  and  H.  M.  Fisher  reported  a  case  of 
leukemia  in  an  infant  17  months  of  age.  Leukocytosis  has 
been  as  high  as  105,000,  and  nucleated  red  cells  and  myelo- 
cytes are  present.  The  spleen  is  hard  and  extends  below 
the  umbilicus.  Large  doses  of  nux  vomica  have  seemed  to 
give  good  reeuls. 

Dr  E  E  GRAH.4.M  exhibited  a  specimen  showing  malfor- 
mation of  the  bowel.  The  anus  was  a  blind  pouch  1 
inch  in  length,  the  lower  end  of  the  large  bowel  being  1  5 
inches  above  this.  An  opening  in  the  bowel  was  made  when 
the  infant  was  4J  days  old,  but  death  followed  in  48  houi?. 

Dr.  E.  J.  Miller  showed  a  case  of  nodding  spasm. 
The  noddmg  has  lately  diminished,  and  nystagmus  is  prt-s- 
ent.  There  are  evidences  of  rickets  in  the  case,  and  Dr. 
Miller  believes  that  disease  to  be  the  cause  in  the  larger 
number  of  cases. 

Dr.  WiLLLiM  Pefpek  showed  specimens  from  a  case  of 
sarcoma  of  the  liver  and  right  suprarenal  capsule. 
The  child  lived  6i  weeks,  the  increase  in  size  of  the  abdomen 
being  very  marked.  The  liver  was  found  to  be  enormously 
enlarged,  weighing  2  pounds  8  ounces.  The  growth  proved 
to  be  a  typical  lymphosarcoma,  the  suprarenal  capsule  being 
much  more  hemorrhagic  than  the  liver.  Dr.  Pepper  finds  5 
other  cases  recorded,  the  time  of  beginning,  the  symptoms, 
appearance,  and  duration  of  life  being  strikingly  alike  in  all 
of  them.  The  cases  differ  from  ordinary  sarcoma  of  the 
suprarenal  capsule,  one  point  being  that  no  pigmentation  of 
the  skin  was  present.  The  case  is  believed  to  have  been  one 
of  congenital  malignant  disease. 

Philadelphia  County  aiedical  Society. — The  subject 
discussed  at  the  meeting  of  January  9  was  typhoid  fever. 
Dr.  a.  O.  J.  Kelly  read  for  Dr.  J  H.  Musser  and  himself 
the  report  of  a  case  of  hemoglobinuria  complicat- 
ing typhoid  fever.  The  patient  was  a  c<3lortd  laborer, 
21  years  old,  who  had  undoubted  typhoid.  During  the  first 
6  days  after  his  admission  to  the  hospital,  hemoglobinuria 
was  present.  This  condition  being  present  on  admission  ex- 
cluded ice  as  a  causative  agent,  and  its  use  did  not  seem  to 
increase  the  hemoglobinuria.  The  blood  showed  only  15^ 
of  hemoglobin  for  some  days.  There  was  no  history  of 
malarial  fever  in  the  case  and  recovery  followed  the  attack. 

Dr.  William  Osler,  of  Johns  Hopkins  University,  who 
was  present  by  invitation,  read  a  paper  upon  Perforation 
and  perforative  peritonitis  in  typhoid  fever.  Dr. 
Oiler  stated  that  physicians  could  not  congratulate  them- 
selves on  lessening  the  incidence  of  typhoid  fever  in  this 
country,  but  that  they  could  on  the  reduction  of  the  mortal- 
ity which  should  not  now  be  above  7.5  Jo  for  hospitals.  This 
reduction  in  mortality  is  due  to  better  nursirg  and  treat- 
ment, there  being  a  special  class  of  formerly  fatal  cases 
which  are  greatly  influenced  by  modern  nonmedicinal  treat- 
ment, namely,  those  sufTering  from  toxemia.  But  of  every 
100  deaths  from  typhoid  fever  only  50  are  due  to  asthenia, 
while  30  are  the  result  of  perforation  and  20  are  caused  by 
other  complications.  There  has  been  no  material  reduction 
in  the  mortality  of  perforative  cases.  Perforation  is  more 
apt  to  follow  ulceration  high  in  the  bowel,  but  this  situation  is 
better  for  the  surgeon.  The  most  difficult  cases  are  those 
where  perforation  is  low  in  the  bowel  and  occurs  early  in  the 
course  of  the  attack.  Two  clinical  features  are  to  be  empha- 
sized, first,  the  uncertainty  and  variability  of  perforation  and, 
second,  the  necesssity  for  a  complete  revision  of  the  methods  of 
recording  cates  by  the  medical  man.  The  points  to  be  consid- 
ered are  the  perforation  itself  and  the  consecutive  peritonitis. 
It  is  important  to  recognize  the  condition  and  operate  within 
12  hours  after  perforation.  Three  cases  were  detailed,  each 
illustrating  a  certain  class.  The  first  class  had  the  following 
symptoms  suggesting  perforation  :  Sudden  onset  of  pain,  per- 
sistence of  pain,  tenderness  on  pressure,  muscular  rigidity, 
increasing  distention  of  the  abdomen,  movable  dulness  in 
the  flanks.  Against  these,  however,  were :  No  fall  in  tem- 
perature, no  increase  in  pulse-rate,  no  leukocytosis,  no  col- 
lapse. Operation  was  performed  9  hours  after  the  symptoms 
began,  and  a  perforation  was  found  and  sutured.  The  pa- 
tient died  in  a  day  or  two  afterward.  The  wound  in  the 
bowel  had  almost  healed.  This  patient  is  believed  to  have 
died  of  typhoid  fever  and  not  of  peritonitis.  The  second 
case  was  one  having  hemorrhages.  Operation  revealed  such 
a  necrosed  condition  of  the  gut  that  sutures  would  not  hold. 
The  patient  died  on  the  table.    In  this  case  the  symptoms 


were  attributed  to  hemorrhage  when  they  should  have 
been  attributed  to  perforation.  A  point  which  should 
have  been  more  noticed  was  that  the  liver-dulness  was 
obliterated,  though  there  was  abdominal  distention  at 
that  time.  This  belonged  to  a  class  of  cases  in  which 
fatality  is  inevitable  no  matter  when  operation  is  done. 
The  third  case  was  a  child  operated  upon  8i  hours  after 
perforation,  an  uneventful  recovery  following.  The  con- 
clusion reached  after  a  study  of  cases  of  which  the  above 
are  types,  is  that  sweating,  hippocratic  facies,  feeble  running 
pulse,  collapse,  etc.,  are  not  symptoms  of  perforation,  but  of 
peritonitis.  What  is  needed  is  a  fuller  knowledge  of  the 
early  symptoms  of  perforation.  Dr.  Osier  does  not  believe 
that  much  is  to  be  hoped  for  as  regards  the  recognition  of 
the  so-called  perforative  stage ;  but  it  is  the  duty  of  the 
physician  to  study  most  carefully  the  earliest  symptoms  in 
perforation.  In  studying  hospital  notes,  it  is  apparent  that 
many  points  which  should  have  been  noted  are  left  out.  It 
is  essential  that  every  serious  case  of  typhoid  fever  should 
be  watched  by  a  careful  physician  who  is  in  constant  touch 
with  a  surgical  colleague,  it  is  better  that  these  patients  be 
visitsd  by  a  skilled  resident- physician  rather  than  by  an 
interne.  To  leave  them  to  the  care  of  attending  phyi-iciana 
is  to  lose  cases.  To  direct  attention  to  certain  ('efinite 
points,  and  aid  in  the  early  recognition  of  perforation.  Dr. 
Osier  gives  the  fillowing  specific  statements  to  hospital 
physicians  :  1.  When  a  patient  has  abdominal  pain,  the 
night-superintendent  or  nurse  is  instructed  to  at  once  no- 
tify the  physician  of  the  onset  of  pain,  hiccough,  vomiting, 
rise  of  pulse,  increase  of  respiration,  collapse,  or  sweating. 
2.  The  character  of  the  pain  {A)  as  to  its  onset — whether 
it  is  an  aggravation  of  previous  pain  or  whether  it  is  sudden. 
Also  whether  it  yields  to  ordinary  treatment  or  recurs  in 
paroxysms.  (B)  As  to  its  locality — whether  diffuse  or  local, 
in  the  iliac  fossa  or  in  the  hypogastric  region,  if  it  radiates 
to  head  of  penis,  etc.  3.  The  state  of  the  abdomen,  (o)  In- 
spection, whether  flat,  Ecaphoid  or  distended.  If  the  latter, 
is  it  uniform  or  in  the  hypogastric  or  other  region  alone, 
note  respiratory  movements ;  (6)  Palpation — note  degree  of 
tenderness,  muscle  rigidity  or  spasm;  (c)  Percussion — note 
the  condition  of  the  flanks  and  extent  of  liver-dulness ;  the 
latter  should  be  marked  out  every  3  hours,  remembering  that 
obliteration  may  occur  in  a  flat  as  well  as  in  a  distended 
abdomen  ;  (rf)  Auscultation— the  amount  of  peristalsis  present 
and  the  ocurrence  of  a  friction  sound;  (e)  Examination  of 
the  rectum  and  stools.  4.  The  general  condition  of  the  pa- 
tient: (a)  Change  in  expression — pallor,  etc.;  (6)  pulse;  (c) 
temperature ;  (d)  respirations ;  («)  sweating — onset,  etc. ;  (/) 
vomiting,  relation  to  onset  of  pain  ;  (^)  hiccough.  5.  Blood 
examination :  leukocytosis,  whether  stationary  or  rising. 
The  leukopenia  of  typhoid  fever  must  be  remembered  in  this 
connection.  These  statements  should  be  of  help  to  hospital 
physicians.  It  is  in  the  hands  of  the  profession  to  reduce  the 
mortality  of  typhoid  fever.  One  important  preliminary  to  this 
result  is  practical,  firsthand  instruction  in  typhoid  fever  to  se- 
nior medical  students.  This  does  not  mean  lectures  or  recita- 
tions but  the  actual  seeing  of  cases  and  watching  their  progress 
throughout^the  attack.  There  are  many  lessons  for  physi- 
cians to  learn,  and  one  of  the  most  important  is  that  it  is 
necessary  to  watch  in  severe  cases  for  symptoms  of  perfora- 
tion and  to  operate  early.  In  this  way  it  is  probably 
possible  to  save  one-half  of  the  cases.  One  class  of  cases  c>f 
perforation  die  whether  operated  upon  or  not,  and  a  second 
class  ia  saved  from  the  peritonitis  but  dies  of  the  fever  itself, 
but  it  has  been  demonstrated  by  the  surgeon  that  a  third 
class  exists  which  can  be  saved  by  operation.  Eleven  cmses 
of  perforation  occurring  in  the  wards  of  the  Johns  Hopkins 
Hospital  have  been  operated  upon  with  5  recoveries.  Ojt 
of  5  additional  cases  brought  in  and  operated  upon  at  once 
there  was  one  recovery.  In  the  discussion  of  the  paper. 
Dr.  Ernest  La  Place  stated  that  there  must  be  a  closer 
association  of  the  physician  and  surgeon.  The  surgeon 
should  from  the  first  have  a  part  in  the  treatment  of 
typhoid  fever  as  he  does  in  appendicitis.  Typhoid  fever 
must  in  the  future  be  more  and  more  a  hospital-treated 
disease,  where  nurses,  physicians,  and  surgeons  can  watck 
the  cases  and  where  operation  for  perforation  can  be  done 
promptly  and  under  proper  conditions.  Dr.  Joseph  Prick 
agreea  that  yotmg  clinicians  should  receive  more  practical 
education  in  typhoid  fever.  Hospital  training  before  a  di- 
ploma was  granted  would  be  an  ideal  solution  of  the  problem. 


52 


The  Philadelphia"! 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Jabcabt  12,  190t 


He  would  not  hesitate  to  open  the  abdomen  and  ligate  the 
bleeding  vessel  in  a  case  of  severe  hemorrhage.  Out  of  22 
operations  for  suspected  perforation  only  2  failed  to  relieve 
that  condition.  Ten  of  these  patients  are  now  well.  The 
surgery  practised  by  many  surgeons  is  too  much,  the  least 
possible  being  the  best.  Resection  of  the  bowel  is  not  recom- 
mended. When  it  will  not  hold  sutures  it  is  better  to  simply 
make  the  toilet  of  the  abdomen  and  place  a  cofferdam  of 
gauze.  In  4  to  6  weeks  afterward  the  resulting  fistula  can 
be  repaired.  In  many  cases  of  contaminated  peritoneum 
and  feeble  pulse  the  patient  leaves  the  table  in  better  condi- 
tion than  before  operation  if  that  procedure  be  confined  to  the 
toilet  and  open  treatment.  Dr.  M.  H.  Fussell  places  the  most 
confidence  in  obliteration  of  the  liver-dulness  as  a  symptom, 
yet  this  occurred  in  1  caae  without  perforation.  In  1  case 
of  perforation  and  death  a  marked  peritoneal  friction-sound 
had  been  present.  De.  W.  L  Rodman  believes  that  recovery 
after  perforation  is  more  common  than  is  generally  thought. 
Late  reports  of  military  surgeons  regarding  conservative 
treatment  of  gunshot  wounds  of  the  abdomen  and  intestines 
should  have  some  bearing  on  the  perforation  of  tjphoid 
fever.  Until  the  medical  man  tells  more  accurately  how  to 
diagnose  perforation  the  surgeon  must  be  rather  pessimistic 
as  regards  operative  results.  In  closing  the  discussion  Dr. 
OsLER  stated  his  belief  that  recoveries  following  perforation 
are  very  rare.  He  does  not  remember  a  case  recovering 
where  the  diagnosis  was  clear  and  peritonitis  was  present.  A 
third  year  student  can  diagnose  peritonitis  36  to  48  hours 
after  perforation,  but  early  diagnosis  is  need«d.  The  clinician 
must  go  over  the  ground  again  and  again  and  must  be  able 
to  advise  operation  before  general  peritonitis  is  present. 
What  if  a  few  mistakes  in  diagnosis  be  made  and  no  perfora- 
tion be  found  ?  Theee  patients  bear  operation  well  and  should 
be  given  the  benefit  of  the  doubt.  The  clinician  and  general 
practitioner  should  be  awake  to  the  possibility  of  saving  30^ 
to  60%  of  the  cases  of  perforation.  The  practitioner  can 
seldom  say  of  any  case  that  it  would  not  have  recovered 
without  his  aid,  but  the  surgeon  in  many  of  these  cases  can 
say  "  I  saved  that  life." 

NEW  YORK. 

The  New  York  State  Medical  Association  has  just 
issued  the  first  publication  of  its  monthly  Journal. 

Dr.  Knapp's  Gift. — Dr.  Herman  Knapp  presented  to 
the  New  York  Ophthalmic  and  Aural  Institute  as  a  gift  the 
buildings  now  occupied  by  that  institution. 

The  State  Board  of  Health  in  its  monthly  bulletin 
discusses  the  outbreaks  of  smallpox  in  17  places  in  New  York 
State,  and  believes  that  a  troup  of  traveling  minstrels  was 
responsible  for  the  ingress  of  the  disease. 

New  Children's  Ward. — A  committee  was  appointed 
by  the  Board  of  Health,  at  its  meeting  on  December  27,  to 
call  on  John  N.  Keller  for  the  purpose  of  requesting  that  a 
new  children's  ward  be  established  on  Randall's  Island. 

Tuberculous  Hospital. — The  Lf  gislature  will  be  asked 
to  appropriate  $100,000  for  the  erection  of  the  first  pavilion 
of  the  Tuberculous  Hospital,  which  is  to  be  located  at 
Raybrook,  about  4  miles  eaet  of  Saranac  Lake. 

Prize. — Dr.  M.  Hartwig,  President  of  the  Bufialo  Academy 
of  Medicine,  has  offered  a  prize  of  $50  00  for  the  best  paper 
contributed  by  any  member  of  the  academy  during  his  term 
of  office.    Papers  must  be  handed  in  by  July  1. 

I>r.  Lucius  J.  W.  Lee  died  at  his  home  in  Brooklyn,  on 
January  0,  of  pneumonia,  aged  65  years.  Dr.  Lee  was  a  great- 
nephew  of  the  late  Dr.  8.  D.  Gross,  of  Jefferson  Medical  Col- 
lege, Philadelphia.  He  was  a  prominent  practitioner  in  New 
York  and  Brooklyn  for  27  years,  having  devoted  the  latter 
part  of  his  years  to  the  study  of  diseases  of  the  stomach. 

The  New  York  City  Board  of  Health.— The  New 

York  City  Board  of  Health  intends  to  establish  regulations 
among  barbers  which  will  require  the  employment  of  clean 
tools  and  a  fresh  towel  for  each  customer  and  the  abolition  of 
sponges  and  powder  puffs.  The  frequent  cases  of  barbers' 
itch  that  have  reaulted,  due  to  the  infection  from  unclean 
barbers'  utensils,  have  made  it  necessary  to  establish  these 
restrictions. 


A  Large  Fire  at  the  Rochester  Orphan  Asylum.— 

Twenty- eight  bodies  lie  at  the  morgue  and  12  others  more 
or  less  seriously  injured  lie  at  the  different  hospitals  in  the 
city  as  a  result  of  the  terrible  holocaust  which  occurred 
January  8  at  the  Rochester  Orphan  Asylum.  Of  the  dead 
26  were  children,  and  2  were  adults.  The  fire  was  doubtless 
caused  by  an  explosion  of  natural  gas  in  the  boiler  room.  It 
spread  so  rapidly  that  many  of  the  109  inmates  were  over- 
come by  the  flames  and  smoke,  almost  without  warning. 

Dr.  G.  T.  Stewart  Appointed  Head  of  Bellevue. — 

The  New  York  Htrald  of  January  8  prints  the  following  : 
Ordered — That  Dr.  George  T.  Stewart  be  and  he  hereby  is 
transferred  from  the  Metropolitan  Hospital  to  Bellevue  Hos- 
pital, with  sole  power  to  superintend  Bellevue,  Fordham, 
Gouverneur,  and  Harlem  hospitals,  and  with  power  to  sus- 
pend any  interne,  nurse,  or  other  employe  of  the  Deoartment 
of  Public  Charities  assigned  to  duty  in  Bellevue,  Fordham, 
Harlem,  or  Gouverneur  hospitals,  whenever  in  his  judgment 
the  interests  of  the  service  shall  demand  such  suspension. 

Transactions  of  the  New  York  Obstetrical  So- 
ciety.— Regular  meeting  held  December  11,  1900,  Dr.  J.  H. 
BoLDT,  president,  in  the  chair.  Dr  E.  P.  Cragik  presented 
specimens  from  two  cases  of  tumor  complicating  the 
puerperium  and  requiring  removal.  Case  1,  an  ovarian 
cyst,  the  pedicle  of  which  became  twisted  during  the  puer- 
perium and  requiring  removal,  occurred  in  a  primipara. 
After  delivery  an  ovarian  cyst  was  found  high  up  on  the 
right  side  of  the  abdomen.  On  the  fourteenth  day  of  the 
puerperium  fever  set  in  and  continued  with  fluctuations  for 
some  time ;  vomiting  set  in  on  the  thirtieth  day.  An  un- 
eventful recovery  followed  the  removal  of  the  cyst  on  the 
right  side,  together  with  the  left  ovary,  which  was  also  the 
seat  of  a  dermoid  cyst. 

Case  2  was  that  of  a  woman  of  44,  delivered  at  full  term 
after  a  prolonged  labor  by  means  of  low  forceps  application. 
The  placenta  had  to  be  extracted  manually.  The  woman, 
who  had  lost  38  ounces  of  blood,  was  in  a  very  poor  condi- 
tion. Before  the  delivery  a  large  hard  tumor  the  size  of  a 
fetal  head  was  found  on  the  right  side  of  the  fundus  of  the 
pregnant  uterus,  and  this  tumor  was  removed  on  the  thirty- 
second  day  of  the  puerperium  by  an  abdominal  hyaterectomy. 
The  uterus  with  the  lumor  weighed  8  pounds  and  2  ounces. 
Discussed  by  A.  Palmer  Dudley. 

Dr  Brettauer  showed  a  specimen  of  ruptured  tubal 
pregnancy  which  had  been  removed  from  a  woman  of  29, 
married  6  years.  The  entire  ovum  was  found  free  in  the 
abdominal  cavity.  The  patient  died  on  the  fourth  day  owing 
to  a  septic  infection  which  emanated  from  necrosis  of  the 
abdominal  fascia.    Discussed  by  Dr.  Brothers. 

Dr.  Edqab  showed  a  metal  pelvis  and  a  metal  fetal 
head  attached,  as  a  contrivance  to  be  used  ia  the  teaching 
of  obstetrics ;  also  several  bottles  and  jars  to  be  carried  in  a 
canvas  case  by  the  obstetrician.  Discussed  by  Dr.  Dicsinsos. 

The  paper  of  the  evening  was  read  by  Dr.  Malcxjlm  Mac- 
Lean  entitled,  A  plea  for  the  recognition  of  some  of 
the  factors  in  the  mechanism  of  labor.  He  believed 
that  in  many  cases  injuries  have  resulted  from  ignorance  of 
the  principles  governing  the  mechanism  of  labor,  in  which 
case  the  patient,  child  and  physician  were  aff"ected.  He 
avoids  too  hasty  interference  when  the  mother's  tissues  are 
unprepared  and  rigid.  The  membranes  should  be  left  intact 
until  the  dilation  is  complete.  When  the  latter  has  occurred 
and  the  membranes  are  stretched  flatly  across  the  mouth  of 
the  uterus  with  every  pain,  instead  of  protruding  to  the  point 
of  rupture,  unnecessary  delay  may  be  avoid^  with  pro- 
priety, by  rupturing  the  sac.  The  importance  of  employing 
the  fetal  envelope  as  a  rubber  glove  in  intrauterine  manipu- 
lation is  emphasized,  for  if  in  this  manner  germs  are  intro- 
duced by  the  operator  they  will  not  reach  the  fetus  but  will 
subsequently  come  away  with  the  membranes.  According  to 
the  writer,  douching  after  labor  is  not  indicated  since  the 
sinuses  are  filled  with  sterile  clots  and  these  should  not  be 
disturbed  in  the  endeavor  to  remove  germs  that  may  not 
exist.  He  advises  chloroform  when  there  is  a  too  violent 
advance  of  the  presenting  parts  through  an  unprep.'jred 
vulva,  but  the  anesthetic  should  only  be  given  to  the  degree 
of  obstetric  anesthesia  excepting  in  delivery  by  means  of  in- 
struments. Discussed  by  Drs  Dickinson.  Edgar,  Simon 
Marx,  and  closed  by  Dr.  MacLean. 


Jancart  12,  1901] 


AMERICAN  NEWS  AND  NOTES 


CThe  Philadelphia 
Medical  Joubnal 


53 


NEW  ENGLAND. 

Mercy  Hospital.— At  the  annual  meeting  of  the  Mercy 
Hospital  Corporation,  of  Springfield,  Mass.,  held  at  the  Hos- 
pital on  January  2,  the  only  change  in  the  stafif  wss  the  elec- 
tion of  Dr.  J.  P.  Black  to  the  stafT  of  assistant  surgeons. 

Thurber  Medical  Association. — At  a  m«eting  of  the 
Thurber  Medical  Association,  of  Milford,  Mass.,  on  January 
3,  Dr.  E.  H.  Trowbridge  of  Worcester,  read  a  paper  on  "  The 
Medicolegal  Aspect  of  Fractures,"  reciting  a  large  number 
of  cases  and  presenting  a  collection  of  skiagraphs. 

CHICAGO  AND  WESTERN  STATES. 

Dr.  W.  W.  Cole,  of  Columbia,  Ohio,  has  been  appointed 
Director  of  Public  Safety  of  that  city. 

New  Hospital. — A  charity  hospital  will  be  built  at 
Eureka  Springs,  at  a  cost  of  $5,000,  by  Mrs.  R.  C.  Kerens, 
of  St.  Louis. 

Resignation  of  Dr.  Regensburger. — Dr.  A.  T.  Re 

gensburger  has  resigned  the  professorship  of  dermatology  of 
the  College  of  Physicians  and  Surgeons  in  San  Francisco. 

Missouri  State  Board  of  Health.— The  following 
were  elected  at  a  meeting  held  at  Jefferson  City,  January  4  : 
Dr.  C.  K.  Elkins,  president ;  Dr.  J.  T.  McClenachan,  vice- 
president;  Dr.  E  C.  Ml  El  wee,  secretary. 

Fire  in  Children's  Free  Hospital. — On  the  evening 
of  January  3  fire  broke  out  in  the  Children's  Free  Hospital 
of  Chicago,  resulting  from  the  ignition  of  a  Christmas  tree. 
Several  nurses,  who,  by  their  coolness,  succeeded  in  removing 
all  from  danger,  were  shghtly  burnt  during  their  eflForts. 

Smallpox  in  Kansas. — The  schools  of  Columbus,  Kan., 
as  well  as  the  District  Courts  have  adjourned  upon  order  of 
the  State  Board  of  Health,  on  account  of  the  gpidemic. 
There  are  200  cases  in  Cherokee  County.  Almost  the  whole 
of  the  southeastern  portion  of  Kansas  is  affected  with  this 
epidemic. 

The  College  of  Physicians  and  Surgeons,  of  Chi- 
cago, has  received  an  endowment  of  125,000  from  the  dean  of 
the  school,  Dr.  W.  E.  Quine,  for  the  purpose  of  the  college 
library,  and  an  endowment  of  $25,000  from  Dr.  D.  K.  A. 
Steele,  to  be  devoted  toward  the  endowment  of  the  pathologic 
laboratory. 

Dr.  William  H.  Sloan  died  on  January  1,  aged  54, 
having  been  an  active  member  in  Moline  for  20  years,  where 
he  stood  at  the  head  of  the  profession.  He  was  a  member  of 
various  medical  at  sociations,  and  also  took  quite  an  interest 
in  educational  matters.  He  was  a  member  of  the  Board  of 
Education  for  12  years. 

Inherited  Tendency  to  Tuberculosis. — The  Indiana 
State  Board  of  Health  in  its  monthly  bulletin  sites  the  follow- 
ing: A  farmer  of  Adams  County  died  January  1,  1900,  of 
pulmonary  tuberculosis  at  the  age  of  80  years.  His  son  died 
of  the  same  disease  on  May  15,  1900,  and  the  daughter  of  the 
latter  died  December  11,  1899,  the  cause  of  death  also  being 
pulmonary  tuberculosis.  It  is  remarked  that  it  is  possible 
that  the  elder  farmer  may  have  infected  the  home  himself. 

SOUTHERN  STATES. 

Dr.  Foster  Resigns. — Dr.  George  W.  Foster  has  re- 
signed his  position  at  the  Elixateth  Hospital  for  the  Insane 
at  Washington  to  accept  an  appointment  as  Superintendent 
for  the  Second  Hospital  for  the  Insane  at  Bangor,  Maine. 

Columbian  University. — There  was  a  meeting  of  the 
hospital  board  on  January  3.  The  following  officers  were 
elected  for  the  ensuing  year  :  Dr.  F.  A.  King,  president ; 
Rev.  Dr.  S.  H.  Greene,  vice-president;  Mr.  S.  W.  Woodward, 
treasurer,  and  Dr.  E.  A.  de  Schweinitz,  secretary. 

Memphis  Medical  Society. — At  the  annual  meeting 
for  the  election  of  officers  held  Friday  evening,  December  28, 
Dr.  Frank  A.  Jones  was  elected  president ;  Dr.  Alfred  Moore, 
vice-president ;  Dr.  J.  L.  Andrews,  secretary  ;  Dr.  Richmond 


McKinney,  reporter.    The  annual  banquet  was  given  at  the 
Nineteenth  Century  Club. 

St.  Louis  Academy  of  Medical  and  Surgical 
Sciences. — At  the  last  meeting  the  following  officers  were 
elected  for  1901:  President,  Dr.  Emory  Lanphear;  senior 
vice-president,  Dr.  Carl  Pesold;  junior  vice-president.  Dr.  H. 
S.  P.  Lare;  secretary.  Dr.  O.  L.  Sugs;ett;  treasurer.  Dr.  G.  M. 
Phillips;  orator.  Dr.  William  Porter,  and  librarian,  Dr.  H. 
G.  Nicks. 

Richmond  Board  of  Health. — Dr.  Greer  Baughman, 
who  for  the  past  2  years  has  been  studying  medicine  in 
Vienna,  has  returned  home.  Recently  he  was  elected 
demonstrator  in  physiology  in  the  Medical  College  of 
Virginia. 

Out  of  24  cases  of  typhoid-fever  reported  for  December  4 
were  fatal ;  there  were  5  cases  of  diphtheria  with  1  death. 

Senses  Hospital. — At  a  meeting  held  on  January  2, 
1901,  the  Board  of  Trustees  of  the  Senses  Hospital  of  New 
Orleans,  approved  the  appointment  of  Dr.  Gordon  King  as 
surgeon  in  charge  of  the  throat,  ear,  and  nose  department. 
An  entertainment  fer  the  benefit  of  the  hospital  to  be  held 
at  the  French  Opera  House  on  January  18  is  under  prepara- 
tion. Dr.  E  Denegre  Martin  was  appointed  consulting  phy- 
sician of  the  hospital. 

A  New  Drug  Concern. — Arrangements  have  just  been 
completed  for  the  establishment  of  a  new  drug  house  in  New 
Orleans.  The  senior  member  of  the  company  is  S.  P.  Nic- 
kels, who  has  been  manager  and  local  representative  of  the 
Parke,  Dxvis  &  Company  for  the  last  5  years.  It  will  be  the 
only  concern  of  its  kind  south  of  Baltimore,  and  will  devote 
its  attention  to  the  output  of  fluid  extracts,  tinctures,  elixirs, 
etc.,  with  a  full  plant  for  testing  the  physiologic  action  of 
various  drugs. 

MISCELLANY. 

The  rumor  of  President  Elliot  being  about  to  resign  has 
been  officially  denied. 

Obituary. — Harvey  H.  Buekam,  aged  61,  at  Foxville, 
Frederick  County,  Md. 

Smallpox  in  Soldiers'  Home  has  broken  out  in  Leaven- 
worth, Kansas,  jeopardizmg  3,000  veterans  located  there. 

The  Rontgen-rays  succeeded  in  locating  a  $5  gold  piece 
which  had  been  swallowed  by  a  boy  of  Wabash,  Ind.,  five 
years  ago. 

State  Examination.— Out  of  the  19  physicians  who 
took  the  recent  Gonrecticut  State  examination,  14  were 
successful. 

A  new  medical  journal  has  been  issued  at  Havana 
known  as  the  Revista  de  la  Associaiion  Medico  Farmaa.  de  la 
Isla  de  Cuba. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague,  have  been  reported  to 
the  Surgeon-General  U.  S.  Marine- Hospital  Service,  during 
the  week  ended  January  4, 1901 : 

Smallpox— United  States. 


Cases. 

Dka 

DisT.  Columbia 

:  Washington  . 

Dec.  15-22    .    . 

1 

Florida: 

Jacksonville   . 

Dec.  15-22    .    . 

1 

Illinois  : 

Cairo 

Dec.  15-22    .    . 

3 

" 

Chicago    .   .  . 

Dec.  22-29   .   . 

2 

Kansas  : 

Wichita   .   .  . 

Dec.  22-29    .    . 

2 

1 

Nkbkaska : 

Decatur    .    .   . 

April  1-Dec.  14 

416 

4 

N.  Hampshire  ; 

Manchester    . 

Dec.  22-29    .    . 

14 

New  York  : 

New  York  .   . 

.   Dec.  22-29    .    . 

11 

2 

Ohio: 

Ashtabula  .   . 

.  Dec.  22-29    .    . 

5 

Cleveland    .    . 

.  Dec.  22-29    .    . 

20 

Rhode  Island: 

Central  Falls  . 

.  Dec.  26  .    .   .    . 

1 

Tennessee  : 

Memphis  .  .    . 

.  Dec.  22-29    .   . 

2 

Nashville.  .    . 

.  Dec.  22-29    .   . 

1 

Te.xas  : 

Galveston    .    . 

.  Dec.  17  ...    . 

6 

Houston  .    .   . 

.  Dec.  22-29    .    . 

'.'5 

1 

Utah: 

Salt  Lake  City 

.   Dec.  22-29    .    . 

52 

W.  Virginia  : 

Wheeling    .    . 

.  Dec.  15-22    .    . 

3 

Wisconsin  : 

Green  Bay  .   . 

.  Dec.  23-30    .   . 

1 

54 


The  Philadelphia"] 

Medical  Journal  J 


FOREIGN  NEWS  AND  NOTES 


[Januaey  12,  19«1 


Smallpox — Fobeion. 

Cases.  Dkaths. 

Argentina  ;          Buenos  Ayres    .  Oct.  1-30  ....  22  14 

AusT  EIA :                Prague Dec.  1-8    ....  26 

Egypt:                  Alexandria.  .   .  Nov.  26-Dec.  10  .  4  4 

England  :             London    ....  Dec.  1-15 ....  2 

Fbance  :                Paris Nov.  24-Dec.  1   .  103  17 

Dec.  1-8    ...    .  152  14 

Gekece  :                Athens Dec.  1-8    ....  1 

India  :                   Bombay  ....  Nov.  21-27   ...  1 

Calcutta   ....  Nov.  17-24   ...  8 

"                        Madras     ....  Nov.  17-23  ...  1 

Italy  :                   Licata   ....      Dec.  8-15  ....  1 

Mexico  :                Vera  Cruz   .   .   .   Dec.  15-22    ...  1 

Russia  :                 Moscow    ....  Nov.  24-Dec.  1.3  1 

Odessa Dec.  1-8    ...    .  23  7 

"                     St.  Petersburg   .  Dec.  1-8    ...   .  5  3 

Warsaw   ....  Dec.  1-8    ...   .  15 

Scotland  :            Glasgow  ....  Dec.  15-21    ...  67  3 

Yellow  Fever.. 

Cuba  :  Havana    ....  Dec.  8-22  ....  6 

Mexico  :  Vera  Cruz    .   .   .  Dec.  15-22   ...  1 

Cholera. 

India  :                    Bombay   ....  Nov.  21-27   ...  2 

Calcutta   ....  Nov.  17-24   ...  35 

Madras Nov.  17-23   ...  1 

Plaque. 

India  :  Bombay   ....  Nov.  21-27   ...  58 

"  Calcutta    ....  Nov.  18-24    ...  4 

Japan  :  Osaka Nov.  30-Dec.  4  .        4 

Madagascar:  Tamatave    .   .   .  Oct.  29-Nov.  18  .        1 

Dr.  Edwardo  Wilde,  the  Argentine  Minister,  one  of  the 
most  distinguished  representatives  from  South  America,  now 
in  Washington,  is  also  a  physician.  He  has  been  chosen  a 
delegate  to  the  Pan- American  Congress  which  will  begin  its 
session  in  Havana,  Cuba,  February  4,  1901.  Dr.  Wilde  in- 
tends to  present  a  new  plan  for  establishing  sanitary  regula- 
tions in  the  ports  of  the  whole  of  America. 

Cbanges  lu  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  January  3, 1901 :, 

PuEViANCK,  George,  surgeon,  relieved  from  duty  at  Baltimore,  Md., 

and  directed  to  proceed  to  Washington,  D.  C,  reporting  at  the 

bureau  for  duty.    December  29. 
Wkrtenbaker,  C.  p.,  passed  assistant  surgeon,  to  proceed  toShreve- 

port.  La  ,  for  special  temporary  duty.    December  28. 
Stimpson,  W.  G.,  passed   assistant  surgeon,  to  proceed   to  Denver, 

Col.,  for  special  temporary  duty.    January  1. 
Bbown,  B.  W.,  passed  assistant  surgeon,  relieved  from  duty  at  Cape 

Charles  Quarantine,  and  directed  to  proceed  to  Baltimore,  Md., 

and  assume  command  of  the  service,  relieving  Surgeon  George 

Purviance.    December  29. 
WiLLE,  C.  W.,  assistant  surgeon,  to  assume  temporary  command  of 

Cape  Charles  Quarantine,  relieving  Passed  Assistant  Surgeon  B. 

W.  Brown.    December  29. 
Amksse,  J.  W.,  assistant  surgeon,  on  being  relieved  by  Assistant 

Surgeon  L.  H.  P.  Baiirenburg,  directed  to  proceed  to  Manila, 

P.  I.,  and  report  to  chief  quarantine  officer  for  duty.  January  2. 
Lloyd,  B.  J.,  assistant  surgeon,  granted  leave  of  absence  for  18  days 

from  December  11.    Januarys. 
Bahbendurg,  L.  p.  H.,  assistant  surgeon,  bureau  order  of  December 

27,  1900,  directing  him  to  proceed  to  Manila,  is  revoked,  and  he 

is  directed  to  proceed  to  Honolulu,  H.  I.,  reporting  to  the  chief 

quarantine  officer  for  duty.    December  31. 
Brkady,  J.  E.,  acting  assistant  surgeon,  granted  leave  of  absence  for 

4  days  from  January  2.     December  28. 
KoLB,  W.  W.,  hospital  steward,  granted  leave  of  absence  for  30  days 

from  January  29.    January  2. 
Olskn,  E.  T.,  hospital  steward,  granted  leave  of  absence  for  5  days. 

January  2. 

casualty. 

Booth,  A.  R.,  acting  assistant  surgeon,  died  at  Shreveport,  La., 
December  27,  1900. 

Changes  iu  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  January  5,  llHll. 

Crandall,  R.  p.,  surgeon,  detached  from  the  U.S.  T.  S.  "Constella- 
tion," upon  reporting  of  relief,  and  ordered  to  recruiting  duty 
at  Milwaukee,  Wis.,  and  then  home  to  wait  orders. 

McClurg,  W.  A.,  surgeon,  detached  from  the  "  Indiana,"  and  or- 
dered to  the  Naval  Training  Station,  Newport,  R.  I. 

Krister, NL,  J.  assistant  surgeon,  ordered  to  the  "Independence," 
Jaiuuiry  13. 


The  unveiling  of  the  busts  of  Graefe  and  Schweiger 
took  place  on  the  16th  of  December,  1900,  in  the  amphithe- 
ater of  the  University  Eye  Clinic. 


foreign  Tl^vos  anb  Hotcs. 


GREAT  BRITAIN. 

Dr.   Arthur  Robinson   has  been  elected  lecturer  on  ] 
anatomy  at  King's  Collf  ge. 

New  Zealand  Medical  Journal. — A  medical  journal 
haa  been  established  at  Wellington,  edited  by  J.  Malcolm 
Mason,  and  issued  by  the  New  Zealand  branch  of  the  British 
Medical  Association. 

CONTINENTAL  EUROPE. 

Professor  Wollenburg  has  succeeded  Professor  Siemer-  ■ 
ling  in  Tubingen. 

Influenza  in  St.  Petersburg. — Influenza  hae  appeared 

in  epidemic  form  in  St.  Petersburg. 

The  Saxon  Ministry. — The  ministry  at  Saxony  now  re- 
quires that  physicians,  hospital  managers,  and  keepers  of 
boarding-houses  report  all  cases  of  tuberculoab. 

At  a  meeting  of  the  Soci^<5  de  Chirurgie  of  Paris,  M. 
Chaput  related  a  case  in  which  a  woman  had  a  tampon  re- 
moved from  the  abdomen  that  had  been  there  for  seven 
years. 

Artificial  Spectrum.— The  Zeiss  optical  works  in  Jena 
are  producing  an  artificial  spectrum,  which  consists  of  four 
colored  glass  prisms.  The  colors  employed  can  be  com- 
bined so  that  almoit  any  desired  shade  can  be  produced. 

The  oldest  qualified  physician  in  the  world  resides  in 
Karlsbad,  who  is  the  son  of  Gallus  Ritter  von  Hochburger, 
M.D.,  royal  councillor  of  the  Austrian  Court.  He  is  97  years 
of  age,  has  been  in  practice  for  71  years,  and  he  is  in  the 
full  possession  of  his  mental  faculties. 

Medical  University  at  Beyruth. — The  final  examina- 
tion by  the  faculty  took  place  a  short  time  ago  in  Turkey. 
Seventeen  students  obtained  their  diplomas.  The  course 
lasts  four  years,  the  annual  tuition  fee  being  160  franca.  The 
diploma  confers  the  authority  to  practise  medicine  both  in 
France  and  Turkey. 

Tea  and  Alcohol  in  Russia. — The  New  York  Sun,  in 
a  recent  issue,  states  that  tea  was  first  imported  into  Russia 
in  1838.  Nearly  one  pound  per  year  is  now  consumed  on  an 
average  by  each  inhabitant.  The  total  consumption  of  tea 
in  Russia  is  106  000,000  pounds,  and  the  total  cost  thereof 
about  $88,000,000.  For  brandy,  beer,  and  wine,  $.550.0iX>,000 
are  expended.  It  seems  that  the  use  of  tea  is  increasing 
rapidly  relative  to  the  alcoholic  beverages.  It  is  worthy  of 
mention  that  this  has  taken  place  since  the  introduction  of 
machine-made  teas  from  Ceylon  and  India. 


Death  from  Embolus,  with  Autopsy.— Robinson 
(The  Medical  Age,  November  25,  1900)  reports  the  case  of  a 
woman  of  46,  upon  whom  he  did  a  vaginal  hysterectomy  for 
hypertrophic  myometritis.  The  ovaries  and  tubes  were 
surrounded  with  adhesions,  which  were  broken  up,  but  these 
organs  were  not  removed.  She  did  well  fori"  days  after  the 
operation,  when  she  complained  of  pain  in  the  right  leg  and 
thigh.  To  test  the  sciatic,  the  author  flexed  the  leg  on  the 
thigh  and  extended  the  leg,  but  no  pain  was  elicited.  In 
about  2  to  4  minutes  thereafter  the  patient  screamed  with 
pain  in  the  chest,  the  pulse  rose  to  140.  the  breathing  to  4? 
and  pallor  supervened.  She  died  in  45  minutes.  At  the 
necropsy  an  embolus  was  found  at  the  bifurcation  of  the 
pulmonary  artery.  The  left  ovarian  vein  was  filled  with  a 
fibrous  coagulum  about  the  thickness  of  a  lead-pencil.  The 
left  kidney  contained  an  elogated  calculus,  which  accounted 
for  pus  in  the  urine.  The  gallbladder  contained  about  150 
hepatic  calculi,  which  had  given  rise  to  no  symptoms.  The 
author  considers  it  remarkable  that  the  left  renal  calculus 
should  cause  pain  in  the  right  leg  and  thigh.  The  pain  suf- 
fered by  the  patient  was  continuous  and  severe.  The  lesson 
to  be  drawn  from  this  is  that  patients  operated  upon  should 
remain  quiet  for  a  sufficient  length  of  time  after  the  opera- 
tion,    [a  b.c  ] 


jAMSAJty    12,    1901] 


THE  LATEST  LITERATURE 


[■ 


The  Philadelphia 
Medical  Journal 


55 


Cf^c  €atc5t  literature. 


British  Medical  Journal. 

December  22, 1900.    [No.  2086.] 

1.  Clinical  Lecture  on  Syphilitic  Diseases  of  the  Tongue. 

Christopher  Heath. 

2.  Abstract  of  a  Clinical  Lecture  on  Eecurrent  Appendicitis. 

F.  A.  SOUTHAM. 

3.  Quantitative  Color  Teste.    Karl  Grossman. 

4.  Remarks  on  Chronic  Enlargement  of  the  Pancreas  in 

Association  with   or  Producing  Attacks,    Simulating 
Biliary  Colic.    Gilbert  Barling. 

5.  A  Case  of  Congenital  Hypertrophy  with  Stenosis  of  the 

Pylorus.    H.  D.  Rolleston  aud  R  Crofton- Atkins. 

6.  Further  Observations  on  Eaidemic  Arsenical  Peripheral 

Neuritis.    E.  Septimus  Reynolds. 

7.  The  Strength   of  the    Hypertrophied    B'adder.    D.  W. 

Samways. 

8.  Intraperitoneal  Rapture  of   the  Bladder.     W.    Percy 

Blumee. 

9.  Notes  on  a  Cise  of  Profuse  Hydroperit  ineum  Complicat- 

ing Uterine  Fibroids.    A.  C.  Botler  Smythe. 

10.  Otomycosis  in  the  Tropics.    H.  Campbell  Highet. 

11.  Some  Points  in  the  Treatment  of  Spinal  Abscess.    A.  H. 

Tubby. 

12.  A  Case  of  Restoration  of  the  Lower  L'p  After  Almost 

Complete  Excision   for  Epithelioma.    Robert  Ken- 
nedy. 

13.  Two  Cases  of  Blindness  Dae  to  Sphenoidal  and  Eth- 

moidal Sinus  Disease.    G.  Victor  ]VIiller. 

14.  Complete  Prolapse  of  the  Rectum  Successfully  Treated 

by  Intraabdominal  Fixation.    Thomas  S.  Kirk. 

1. — Heath  in  a  clinical  lecture  on  syphilitic  diseases 
of  the  tongue  calls  attention  to  the  fact  that  induration  of 
the  sore  in  this  location  may  not  be  present  to  the  degree 
that  it  is  on  the  genital  organs.  S  jres  upon  the  lips  and 
tongue  that  are  accompanied  in  the  young  by  rapid  lym- 
phatic enlargement  under  the  jaw  are  strongly  suggest- 
ive of  chancre.  The  communicability  of  syphilis  by  mu- 
cous membranes  is  not  questioned  today,  and,  therefore,  a 
specific  infection  of  the  tongue  or  of  the  lip  may  innocently 
be  produced,  although  it  is  possible  that  abominable  prac- 
tices are  often  responsible  for  direct  inoculation  into  the 
tongue.  Drinking  utensils  and  pipes  may  also  convey 
the  virus.  He  presented  a  patient  with  a  secondary  erup- 
tion of  syphilis  and  of  mucous  tubercles  similar  to  the 
mucous  plaques  seen  about  the  female  genitals.  As  in  the 
female  genitals,  the  author  considers  that  various  mucous 
surfaces  in  the  mouth  which  frequently  are  brought  into 
apposition  may  mutually  infect  each  other.  Several  illus- 
trations were  presented  showing  syphilitic  ulcerations  of  the 
tongue.  Thickening  of  the  tongue  is  a  frequent  asso- 
ciated factor  and  may  cause  the  patient  considerable  alarm, 
and  for  treatment  of  this  condition  he  pushes  mercury  in  the 
form  of  a  mercurial  mouth-wash  of  perchlorid  of  mercury, 
from  1 :  2000  upward,  to  be  held  in  the  mouth  for  5  minutes 
by  the  watch.  Mercury  at  the  same  time  is  also  given  in- 
ternally, and  most  satisfactorily  by  inunction.  The  sulphur 
baths  at  Aix  la-Chapelle  are  not  responsible  for  a  cure, 
although  very  pleasant,  but  it  is  the  daily  inunction  of 
mercury  by  the  attendants  which  is  fruitful  of  the  beneficial 
results  that  have  been  so  frequently  obtained.  Syphilitic 
affections  of  the  tongue  may  occur,  which  appear  to  border 
between  secondary  and  tertiary  stages ;  these  are  in  the 
nature  of  lacerations  that  are  not  actually  gummatous  in 
character.  In  discussing  tertiary  syphilis  of  the  tongue, 
he  mentions  a  case  where  throughout  the  substance  of  the 
tongue  there  were  disseminated  little  nodules  consisting  of 
syphilitic  deposit  which  did  not  yield  to  antisyphilitic  treat- 
ment, malignancy  being  suspected.  The  whole  tongue  was 
excised,  and  upon  microscopic  examination  a  distinct  epithe- 
liomatous  condition  was  found  in  addition  to  the  gummata. 
The  author  believes  that  any  continued  irritation,  such  as  a 
pipe,  may  give  rise  to  epithelioma.  Leukoplakia  may 
occur  entirely  distinct  from  syphilis,  tobacco  being  usually 
the  cause.  He  believes  that  the  addition  of  tobacco  will  greatly 
aggravate  a  subject  already  affected  by  syphilis.    Hyper- 


trophy of  the  papillae  of  the  tongue  should  not  be  con- 
founded with  syphilitic  warta  that  are  frequently  seen  at  the 
back  of  the  organ,     [m.r.d.] 

2. — Southam  reports  50  ca'^es  operated  upon,  of  which  35 
were  males  and  15  females.  The  duration  of  symptoms 
varied  from  several  months  to  6  years.  Tne  majority  of 
cases  occurred  in  persons  between  20  and  SO  years  of  age. 
In  forty  cases  the  patients  had  had  3  or  more  recurrences. 
Operation  is  advised  when  a  second  attack  has  made  its 
appearance,  notwithstanding  that  local  symptoms  may  not 
be  present  during  the  interval  of  quiescence.  Suppuration 
occurred  in  15  cases  and  was  usually  found  accompanied  by 
a  perforation  of  the  appendix.  Fecal  concretions  were 
found  in  7  cases,  but  only  in  one  instance  was  a  true  foreign 
body  found  in  the  shape  of  a  pin.  Adhesions  were  present 
in  most  of  the  cases,  but  their  presence  or  absence  were  at 
variance  with  a  number  of  attacks  or  their  severity.  In 
nearly  every  case  there  was  thickening  of  the  walls  of  the 
appendix  and  sometimes  entirely  occluding  its  lumen. 
[m  r  d.] 

3.— Grossman  considers  color  testing  by  means  of 
Holmgren's  wools  as  insulficient  in  many  cases,  as  it  is 
only  a  daylight  test  as  used  at  present.  The  variability  of 
the  quality  of  light,  and  the  disadvantage  at  times  owing  to 
dark  days  are  both  considered  by  the  author  to  give  rise  to 
inconvenience.  The  solution  is  found  by  employing  a  set  of 
colors  adapted  for  a  certain  artificial  light.  Central  color 
scotoma  is  a  very  serious  objection,  especially  becaus3  it 
may  be  acquired  or  even  transient,  as  in  tobacco  ambylooia. 
It  sometimes  occurs  that  the  color- blindness  is  overlooked 
by  the  faulty  examination  (Holmgren)  and  only  subsequently 
detected  while  the  individual  is  performing  his  actual  require- 
ments. If  a  color  signal  be  sufficiently  close  to  the  observer 
it  may  be  strong  and  large  enough  to  exceed  the  area 
occupied  by  the  scotoma,  and  therefore  the  test-object  must 
be,  (a)  variable  in  color,  (6)  variable  in  size,  (c)  variable  in 
intensity,     [m.r  d.] 

4 Barling  states  that  the  diseases  of  the  pancreas  are 

not  well  understood  for  two  reasons :  First,  on  account  of  the 
position  of  the  organ,  it  cannot  be  easily  examined,  and, 
second,  at  autopsy  the  organ  is  not  often  examined.  He 
reports  4  cases  in  which  enlargement  of  the  head  of  the  pan- 
creas waa  fiund  when  operating  on  the  gallbladder  or  the 
ducts,  2  of  the  cases  being  errors  in  diagnosis  as  the  symptoms 
were  atttributed  to  gallstones  which  were  not  found  at  the 
time  of  operation.  The  feature  in  these  cases  was  enlarge- 
ment of  the  head  of  the  pancreas,  producing  a  blocking  of 
the  common  bile-duct  and  associated  attacks  of  colic.  It  is 
further  stated  that  on  account  of  the  relation  of  the  head  of 
the  pancreas  to  the  common  bile-duct  and  the  pancreatic 
duct,  obstruction  may  be  produced  from  swelling  of  the 
head  of  the  pancreas  probably  as  result  of  inflammation.  It 
is  also  stated  that  colic  is  rarely  encountered  from  pancreatic 
calculi  owing  to  the  feeble  muscular  power  of  the  duct 
of  Wirsung.  Colic  due  to  a  pancreatic  calculus  is  character- 
ized by  the  position  of  the  pain,  which  is  either  between  the 
xiphoid  cartilage  and  the  umbilicus  or  in  relation  to  the  left 
costal  arch.  It  is  not  unreasonable  to  infer  that  owing  to 
the  anatomic  relation  of  the  pancreatic  duct  and  gland,  that 
infction  is  liable  to  occur  from  invasion  of  the  microorgan- 
isms of  the  intestines  into  the  organ,  causing  an  inflamma- 
tory swelling  of  the  gland,  such  as  often  occurs  in  the 
salivary  glands.  The  common  bile-duct  may  in  this  way  be 
compressed,  giving  rise  to  jaundice,     [f  j  k  ] 

6.— Rolleston  and  Crofton- Atkins  report  a  case  of  con- 
genital hypertrophy  of  the  pylorus  producing  sten- 
osis in  a  full-term  infant,  which  showed  no  external  abnor- 
malities. The  early  symptoms  were  vomiting  and  convulsions 
which  developed  when  the  infant  was  a  fortnight  old.  Diar- 
rhea developed  a  week  afterwards.  Subsequently  the  vom- 
iting increased,  the  vomited  material  being  highly  acid. 
The  child  lost  weight,  and  constipation  became  a  serious 
and  troublesome  symptom.  Death  occurred  when  the  infant 
was  7;weeks  and  5  days  old.  At  the  autopsy,  great  hyper- 
trophy of  the  pylorus  was  found  with  almost  complete  oblit- 
eration of  the  lumen.  The  wall  of  the  pylorus  measured  8 
mm.  The  circular  muscular  coat  measured  4  mm.,  the  lon- 
gitudinal coat  2  mm  ,  and  the  mucous  coats  2  mm.  in  thick- 
ness. Upon  microscopic  examination  it  was  found  that  the 
mucous  membrane  of  the  pylorus  was  healthy,  and  the  cir- 
cular muscular  coat  showed  some  small- celled  infiltration. 


56 


The  Philadelphia"! 
Mkdical  Joornal  J 


THE  LATEST  LITERATURE 


[Jakcabt  12,  1901 


The  mucous  membrane  of  the  ftomach  revealed'  catarrhal 
inflimmation.  The  gastritis  wa«  believed  to  have  been  a  late 
manifestation,  as  blood  was  found  in  the  vomit  5  days  before 
death,    [p.j.k  ] 

6. — Reynolds  states,  in  discussing  the  cause  and  symptoms 
of  epidemic  arsenical  peripheral  neuritis  amongst 
beer-drinkers,  that  he  has  ascertained  the  source  of  the 
ardsnic— -the  arsenic  being  found  in  the  sulfur  compounds 
from  which  sulfuric  acid  is  made.  The  arsenic  has  also  been 
found  in  the  urine  of  patients  after  partaking  of  beer.  In 
acute  cases  diarrhea  occurred,  and  in  the  suckling  infant 
diarrhea  and  vomiting  developed.  The  nails  were  affected 
in  a  few  cases.  A  few  symptoms  are  reported  which  he  has 
not  yet  seen  described.  la  fair  complexioned  individuals 
the  skin  pigmentation  is  absent  or  is  but  slight  and  showing 
itself  as  a  deeper  pigmentation  of  preexisting  freckles.  The 
eruption  is  in  many  cases  at  first  erythematous,  then  becomes 
darker,  later  marked  pigment  ition  develops,  and  finally  this 
is  followed  by  desquamation  that  persists  for  several  weeks. 
BjlUe  are  rare.  Herpes  zjster  occurs  in  a  number  of  the 
cases  and  is  not  very  uncommon.  Oae  case  of  partial  anes- 
thesia of  the  left  fifth  cranial  nerve  was  observed,  and  a  few 
cases  of  neuralgia  of  some  of  the  spinal  nerves  without 
herpes.  Marked  cardiac  asthenia,  shortness  of  breath,  ex- 
haustion upon  slight  exertion,  sometimes  substernal  and 
epigastric  pain  were  noted  and  in  many  cases  bronchitis  and 
dilation  of  the  heart  were  distinctive  features.  Even  hemop- 
tysis was  noted  in  a  few  of  the  cases.  Hoarseness  was  attrib- 
uted to  the  swelling  of  the  vocal  cjrds  and  not  to  paralysis. 
He  reports  having  seen  150  cases  since  November  18,  1900, 
and  since  that  time  4  deaths  which  were  due  respectively  to 
the  following  causes:  Heart  failure  (one  case);  dilation  of 
the  heart  with  edema  and  bronchitis  (one  case) ;  and  gradual 
heart  failure,  exhaustion  and  extensive  paralvsis  (two  cases). 
He  states  that  it  is  impossible  at  present  to  determine  which 
symptoms  should  be  attributed  to  the  arsenic  and  how  many 
to  the  alcohol.  The  differential  diagnosis  between  beriberi 
is  difficult  and  he  believes  that  the  skin  lesions  of  arsenical 
neuritis  are  the  distinguishing  features.  Severe  heart  failure 
and  some  mental  confusion  does  not  develop  to  the  extent 
as  is  so  common  in  alcoholic  paralysis.  As  to  treatment  he 
endorses,  with  a  few  exceptions,  the  plan  as  directed  by  Dr. 
Judson  Bury  in  the  British  Medical  Journal  for  December  8, 
1900  Sodium  salicylate,  antipyrin,  and  potassium  iodid  he 
believes  should  not  be  employed  because  of  their  depressing 
effects.  Rest  in  bed,  small  doses  of  digitalis  and  liquor 
strychniae  in  tonic  doses  are  recommended  in  the  early 
stages.  Bismuth  and  soda  are  used  in  cases  that  present 
symptoms  referable  to  the  stomach,  and  morphin  is  given  in 
small  doses  for  the  relief  of  pain,     [f  j  k  ] 

7.— Samways  believes  that,  as  the  strength  of  the  hyper- 
trophied  bladder  is  considered  to  possess  no  greater  pre- 
ventative power  against  rupture  than  the  bladder  in  a 
normal  condition,  that  there  is,  therefore,  a  greater  risk  for 
rapture  in  a  bladder  that  is  hypertrophied.  It  appears  that 
the  bladder  usually  hypertrophies  in  such  a  way  that  there 
is  no  increass  in  its  resisting  power.  He  compares  the 
mucous  membrane  between  the  fasciculi  to  the  netting  cov- 
ering a  thin  rubbsr  ball  as  seen  in  spray  apparatuses.  As 
such  netting  guards  against  a  too  great  expansion  of  the  ball, 
so  the  fasciculi  act  in  a  similar  m. inner.  Mathematically  the 
strength  of  a  segment  is  increased  inversely  to  the  size  of 
the  sphere  of  which  it  is  a  part.  A  hypertrophied  bladder 
therefore  is  strengthened  throughout  its  whole  wall.  Should 
spontaneous  rupture  occur  it  is  probably  due  to  additional 
pathologic  changes  rather  than  errors  of  disproportion  in 
mechanical  resistance,     [m  k  d.] 

8. — Blumer  reports  a  case  of  intraperitoneal  rupture 
of  the  bladder,  occurring  in  a  laborer  of  35,  in  conse- 
quence of  a  fall.  Tlie  patient  fell  striking  his  abdomen  on 
the  curbstone,  followed  by  inability  to  micturate.  Upon  ex- 
amination there  was  considerable  distention  of  the  abdomen, 
tenderness  on  pressure  and  absolute  dulness  on  percussion 
across  the  whole  of  the  abdomen,  and  extending  a  little 
above  the  umbilicus.  Upon  catheterization,  196  ounces  of 
bloody  urine  were  evacuated.  The  diagnosis  having  been 
established,  laparotomy  was  performed  under  chloroform- 
anesthesia.  A  vertical  tear  at  the  posterior  wall  of  the  blad- 
der, extending  intj  the  peritoneu  u,  was  sutured.  At  the 
end  of  the  tenth  day,  the  whole  length  of  the  wound  bursted 
open  and  a  large  slough  was  taken  out.  Cystitis  now  set  in,  but 


rapidly  healed  under  boracic-acid  irrigations,  and  salol  inter- 
nally. Tne  case  is  unique  on  account  of  the  little  trouble 
caused  by  the  large  amount  of  fluid  in  the  abdomen,  and 
also,  as  the  history  shows,  that  the  patient  walked  over  2 
miles,  4  days  after  the  injury.  The  absence  of  symptoms  of 
peritonitis  is  also  worthy  of  mention,    [m.e  d] 

9. — Butler-Smythe  records  an  interesting  case  of  profuse 
hydroperitoneum  in  a  woman  40  years  of  age,  the  fluid 
resulting  from  the  presence  of  an  immense  fibromyomatoua 
tumor.  He  believes  that  the  hydroperitoneum  resulted  di- 
rectly from  an  injury  to  the  peritoneal  covering  of  the  tumor 
following  an  accident,  the  patient  having  been  knocked  down 
by  a  cart,  thereby  receiving  contusions  of  the  abdomen  and 
lower  extremities.  Aspiration  had  to  be  performed  5  timee 
in  six  weeks,  and  about  20  pints  of  fluid  was  evacuated  at 
each  time.  Upon  removal  of  the  tumor  through  the  usual 
supravaginal  incision,  it  was  found  to  be  a  simple  multi- 
nodular fibromyoma  without  signs  of  malignant  or  other 
degeneracy.  The  peritoneal  lining,  however,  was  thick  and 
injected;  the  tumor  was  not  edematous.  The  symptoms 
disappeared  rapidly  after  the  removal  of  the  growth.  Tnis 
case  is  of  unusual  interest  because  of  the  rarity  of  this  com- 
plication in  patients  otherwise  free  from  thoracic  or  abdomi- 
nal disease,     [w.a  n.d  ] 

10. — The  growth  of  fungus  in  the  external  auditory  mea- 
tus is  apparently  a  rare  disease  in  temperate  climates,  but 
accDrding  to  the  author's  8  years  of  experience  it  is  very 
common  in  the  tropics.  The  symptoms  vary  from  simply  a 
sensation  of  occlusion  of  the  ear  to  a  considerable  amount 
of  watery  discharge.  Tne  disease  is  usually  bilatera'.  The 
physical  signs  in  typical  cases  are,  occlusion  of  meatus  by  a 
soft  wool-like  substance  of  a  pile  lemon  yellow  or  yellowish- 
green  color.  Tnere  may  be  some  desquamation  of  epithelium 
at  the  walls  of  the  canal.  In  chronic  cases,  in  addition  to  soft 
masses  of  recent  fungus  there  may  also  be  inpactions  resem- 
bling sodden  newspaper.  Microscopic  examination  reveal* 
pencillium  glaucum,  aspergillus,  and,  more  commonly,  the 
mucor  mucedo.  Complications  are  diffuse  inflammation  of 
external  auditory  meatus,  acute  serous  and  chronic  catarrh 
of  the  middle  ear,  perforation  of  the  membrana  tympani, 
swelling  and  even  abscess  of  lymphatic  glands  at  angle  of  jaw, 
and  eczema  of  the  meatus  and  pinna.  Diagnosis — settled  by 
microscope.  Prognosis — favorable,  if  treated  by  physician 
hinnelf.  Treatment — remove  as  much  of  fungus  as  possible, 
syringe  with  warm  solution  of  bichlorid  of  mercury  1 :  5000, 
dry,  and  sponge  with  solution  of  bichlorid  of  mercury  and  alco- 
hol 1 :  1000.  Piug  with  sterile  cotton- wool.  After  fungus  ceases 
to  grow,  insufflate  a  powder  of  boric  acid,  2  parte ;  bismuth 
salicylate,  1  part;  oxid  of  zinc,  3  parts  Prophylaxis  consists 
in  preventing  entrance  of  sea  water  to  the  ear.    [.m.r  d.] 

11.— Tubby  empha^iz^s  the  following  points,  in  the  treat- 
ment of  spinal  abscesses :  1.  Do  not  wait  to  open  a 
spinal  abscess  until  the  skin  is  reddened  and  involved.  2. 
S  J  far  as  possible  open  the  abscess  at  certain  "  seats  of  elec- 
tion," the  places  of  evacuation  to  be  decided  by  the  direction 
taken  by  the  abscess  and  by  the  surgeon.  3.  Wherever 
evacuation  is  decided  upon,  let  it  be  done  as  far  as  possible 
away  from  the  groin,  and  in  such  a  position  that  more  than 
one  opening  can  be  made  into  the  abscess  cavity.  4.  Care- 
fully cleanse  the  cavity  and  rub  the  interior  thoroughly  with 
menthol  or  iodoform  solution.  5.  Avoid  drains  of  all  kinds. 
6.  Be  careful  to  carry  out  perfect  aseptic  measures  from  first 
to  last.  When  patients  are  placed  at  rest  with  the  hopes  of 
causing  absorption  of  flaid,  the  abscess  often  makes  its  way 
to  the  surface.  For  irrigation  he  employs  a  modification  of 
Jones'  solution,  viz  :  Menthol  1  grain,  rectilied  spirits  1  ounce, 
parolein  J  pint.  He  sutures  the  wounds,  avoiding  drains,  be- 
cause of  secondary  infection  with  pyogenic  bacteria,  and  be- 
cause a  drainage  tube  frequently  converts  a  healthy  incision 
into  a  tuberculous  sinus,    [m.r  d.] 

12. — For  restoration  of  the  lower  lip  following  excisions 
of  epiiheliomata,  K-'uiiedy  considers  the  flips  taken  from 
the  side  with  bases  below  to  be  the  best.  The  author's 
case  was  a  man  of  78,  who  had  a  warty  and  partially  ulcer- 
ated growth  of  lower  lip  that  had  recurred  after  16  years. 
An  illustration  of  the  patient  is  presented,  showing  the  res- 
toration after  excision  of  entire  lower  lip.  In  forrner  op>era- 
tions  there  was  a  scarcity  of  mucous  membrane  and  difficulty 
in  occluding  the  gaps  which  remained  after  raising  the  flaps 
to  the  level  of  the  lip.  [m.r.d.] 
13.— Miller  reports  2  cases  of  blindness  due  to  spbe- 


/AKBABY    12,    1901] 


THE  LATEST  LITERATURE 


n 


The  Pi!iladklphi\ 
Medical  Journal 


57 


Doidai  and  ethmoidal  sinus  disease.  The  clinical  course 
of  the  author's  first  case  consisted  of  (  zena,  necrosis  of  the 
nasal  septum,  sphenoidal  and  ethmoidal  sinus  disease,  cere 
bral  cumplication  and  death.  The  turbinates  were  consider- 
ably atrophied  and  there  was  considerable  discharge  of  fetid 
pus  from  the  ethmoidal  cells.  Tne  perpendicular  plate  of 
the  ethmoid  was  considerably  aflFected  by  the  necrosis.  After 
unconsciousness  and  convulsions,  the  patient  became  blind 
within  48  hours;  pupils  reacted  slightly  to  light,  of  which, 
however,  there  was  no  perception.  Paleness  of  both  discs  was 
now  observed.  In  the  second  case  repori  ed,  illness  began  with 
a  small  sore  in  the  roof  of  the  mouth,  followed  by 
failing  vision  about  2  months  later,  with  entire  blindness 
within  4  or  5  days.  There  was  a  history  of  a  nasal  dis- 
charge 3  months  before  admission.  In  this  case  there  was 
a  very  large  perforation  of  the  nasal  septum,  and  granula- 
tion tiisue  invaded  the  ethmoidal  region.  The  sphenoidal 
sinus  was  punctured  1  month  after  admission.  Beginning 
atrophy  of  the  optic  nerves  was  then  noticed.  The  nec- 
ropsy showed  that  the  ethmoid  was  soft  and  considerable 
pus  present  in  the  ethmoidal  cells.  Throughout  the  whole 
brain  there  was  a  general  softening,  but  without  fluid  in  the 
ventricles.  The  author  surmises  that  in  these  cases  there 
was  not  a  true  ozena  on  account  of  the  extensive  loss  of  bone 
tissue.  He  believes  that  cases  of  this  nature  should  be  con- 
sidered as  syphilitic  ones,  and  that  surgical  intervention  is 
the  only  means  of  relief  or  cure,     [m.e.d] 

14. — Kirk  reports  an  operation  for  complete  prolapse  of 
the  rectum  by  intraabdominal  fixation,  the  patient  being  a 
male  child  of  1  year  of  age.  He  prefers  this  method  to  the 
operation  commonly  performed  in  these  severe  cases — 
namely  complete  removal  of  the  prolapsed  portion  of  bowel 
— on  account  of  the  success  attending  the  similar  operation 
of  ventral  fixation  of  the  uterus,  and  on  account  of  a  dislike  to 
mutilate  the  lower  part  of  the  rectum  for  fear  of  giving  rise 
to  stricture  or  incontinence.    The  only  objection  to  this  ap- 

Earently  ideal  operation  is  the  risk  of  a  subsequent  ventral 
ernia,  and  this  can  be  minimized  to  a  great  extent  by  split- 
ting the  muscles  and  aponeuroses  as  far  as  possible,  and  not 
cutting  them.  The  child  made  a  rapid  recovery  and  the 
laparotomy  scar  has  remained  quite  firm,     [w.a.n  d.] 


Lancet. 

December  21, 1900.    [No.  4034  ] 

1.  A  Lecture  on  Pulmonary  Tuberculosis  in  Early  Child- 

hood. With  Special  Reference  to  its  Prevention  and 
to  its  Diagnosis  from  Other  Wasting  Disorders.  Ak- 
THDK  Latham. 

2.  On  Some  Disappointments  of  Surgery.    D'Arcy  Powee. 
8.  Observations  on  Com  pressed- Air  Illness.    Fredeeick  R. 

Wainwright. 
4.  Interesting  Surgical  Cases.    E.  Paget  Th0ESTAn. 

1. — Latham  believes  that  one  of  the  most  important  fac- 
tors in  tuberculous  infection  in  childhood  is  a  contaminated 
milk-supply,  the  bacilli  entering  from  the  intestinal  tract. 
This  appears  to  be  first  infected  by  the  fact  that  the  first  signs 
of  tuberculosis  usually  occur  in  the  lymphatic  glands,  and 
infection  usually  takes  place  in  childhood,  during  the  period 
of  milk-feeding,  that  is  to  say,  the  disease  is  quite  common 
from  the  age  of  6  months  to  2  years,  and  then  rapidly  dimin- 
ishes in  frequency.  It  is  interesting  to  note  that  with  the 
improvements  in  the  hygienic  conditions,  particularly  in 
regard  to  the  milk- supply,  that  has  taken  place  in  the  last  20 
years,  there  has  been  a  gradual  diminution  in  the  number  of 
cases  of  tuberculosis  occurring  in  childhood.  Apparently 
during  this  age  the  general  method  of  distribution  through- 
out the  body  is  through  the  lymphatic  system,  and  it  is  not, 
as  commonly  supposed,  in  the  direction  of  the  lymphatic 
stream,  but  against  it.  Not  infrequently  the  infection  occurs 
in  the  tonsils.  Iq  45  tonsils  removed  from  children  varying 
from  3  months  to  13  years,  7  produced  tuberculosis  in  guinea- 
pigs  into  which  they  were  ino3ulated.  Among  the  varieties 
are:  Tuberculosis  of  the  bronchial  glands,  miliary  tubercu- 
losis, and  tuberculous  bronchopneumonia.  The  first  rarely 
causes  symptoms.  There  is  sometimes  harsh  breathing,  with 
prolonged  expiration  ;  dulness  may  be  made  out  in  the  back 
from  the  spines  of  the  second  to  the  fifth  dorsal  vertebra,  and 
occasionally  the  compression  may  be  so  severe  as  to  interfere 


with  entrance  of  air  into  one  of  the  lungs,  or  partial  occlusion 
of  a  vein  may  give  rise  to  a  venous  hum,  or  edema  of  the  face 
or  arms.  Miliary  tuberculosis  is  characterized  by  wasting, 
moderate  temperature,  and  towards  the  end,  hurried  respira- 
tion, cyanosis,  and  rales  in  the  lungs.  Tuberculous  broncho- 
pneumonia gives  rise  to  physical  signs  similar  to  those  of 
simple  bronchopneumonia,  although  the  fever  is  ordinarily 
not  so  high.  It  usually  commences  more  insidiously,  there 
are  periods  of  remission,  and  often  a  crop  of  downy  hair  on 
the  back  of  the  child,  although  the  relation  of  this  in  the  dis- 
ease is  not  understood.  Not  quite  as  frequently  we  have 
pulmonary  tuberculosis  similar  to  the  form  that  occurs  in 
adults.  The  treatment  consists  of  the  avoidance  of  further 
infection,  fresh  air,  sunlight,  abundant  food,  the  avoidance 
of  fatigue,  and  occasionally  small  quantities  of  stimulants. 
Among  the  drugs,  cod  liver  oil  (if  it  is  absorbed),  creasote, 
and  iodid  of  iron  may  be  used,    [j  s.] 

2. — Power  calls  attention  to  various  disappointments 
that  occur  after  the  simplest  operations,  and  after  such  which 
generally  lead  to  a  permanent  cure.  Some  of  the  disappoint- 
ments in  circumcision  are  removal  of  too  much  foreskin 
and  retraction  of  the  glands.  In  the  operation  for  hare- 
lip, disappointments  arise  from  the  formation  of  a  notch  at 
the  lower  portion  of  the  scar  in  the  lip.  The  recurrence 
of  adenoids.  He  mentions  a  case  of  atresia  of  the 
anus  operated  upon,  in  which  it  was  found  that  the  rectum 
opened  into  the  vagina.  The  renal  calculi  imbedded  in 
the  substance  of  the  kidney  are  sometimes  impossible  to 
detect,  and  even  after  exploratory  incision  into  the  kidney, 
disappointments  are  in  store  for  the  operator.  The  fixation 
of  movable  kidneys  may  give  rise  to  disappointments  to 
both  patient  and  surgeon.  Exhaustion  may  be  so  profound 
during  internal  strangulation  of  the  bowel  that  operative 
procedure,  although  well  performed,  may  fail  to  relieve. 
One  should  be  guarded  in  making  promises  when  operating 
upon  the  vermiform  appendix,  as  the  latter  sometimes  can- 
not be  found,  even  after  extensive  dissection  and  careful 
exploration.  3Iental  disturbances  after  surgical  pro- 
cedures give  rise  to  many  surgical  disappointments.  The 
author  mentions  the  various  disasters  following  fractures, 
formation  of  conical  stump  after  amputation,  especially 
in  children.  Some  dislocations  cannot  be  reduced,  and 
others  with  great  difficulty  in  spite  of  the  apparently  easy 
methods  of  reduction  as  described  in  textbooks,    [m  r.d  ] 

3. — Wainwright  in  discussing  the  efTects  of  compressed  air 
upon  the  human  body,  calls  attention  to  a  possible  etiological 
factor  in  the  high  temperature  of  the  compressed  air,  hav- 
ing often  observed  a  rise  of  from  60°  F.  to  115°  F.  during 
locking  in.  During  the  work  on  the  B.iker  Street  &  Waterloo 
R.  R.  excellent  ventilation  was  obtained  by  the  escape  of 
the  compressed  air,  and  by  providing  artificial  ventilation 
when  this  was  impossible.  As  an  additional  prophylactic 
the  men  were  obliged  to  put  on  dry  clothing  after  leaving 
the  tunnel,  were  kept  for  some  time  in  a  well- warmed  room, 
and  given  hot  coffee.  Altogether  47  cases  of  illness  occurred 
in  120  men  from  May  to  October.  The  symptoms  were, 
pains  in  the  ears,  in  the  nasal  sinuses,  and  in  carious  teeth. 
In  rare  cases  there  was  rupture  of  the  tympanum.  Upon 
leaving  the  lock  the  patients  sometimes  suffered  from  pains 
in  the  joints,  most  frequently  the  knee  joint,  and  occasion- 
ally from  pains  in  the  muscles.  This  pain  was  sometimes  so 
severe  that  the  patient  became  pallid,  perspired  freely,  had 
a  hard  rapid  pulse,  and  cried  and  groaned.  It  sometimes 
persisted  for  several  days  or  even  weeks.  It  did  not  always 
appear  immediately  after  leaving  the  tunnel.  Among  the 
cerebral  symptoms  were  headache,  giddiness,  and  flashes  of 
light  before  the  eyes.  In  one  case  typical  paraplegia  oc- 
curred with  involvement  of  the  bladder  and  rectum.  No 
cases  of  sudden  death  occurred.  Among  the  interesting 
cases  he  records  the  following :  The  patient,  a  man  of  50, 
somewhat  stout,  a  half  an  hour  after  leaving  the  tunnel  had 
severe  pain  in  the  front  of  the  chest,  there  was  then  dyspnea, 
a  sense  of  impending  death,  cyanosis,  with  rapid  feeble 
pulse.  Upon  auscultation  there  was  a  harsh  creaking  and 
tearing  sound  heard  throughout  the  whole  respiratory  course 
in  the  front  of  the  chest.  Percussion  was  negative,  and  in  a 
short  time  the  peculiar  sounds  disappeared,  the  man  was  re- 
compressed  to  18  pounds  and  immediately  relieved.  Pres- 
sure was  gradually  decreased,  and  the  patient  left  the  lock 
perfectly  well,  and  had  no  subsequent  symptoms.  The  fac- 
tors concerned  in  producing  these  symptoms  are :  Deficient 


58 


T^E  Phtladelphia"! 
Medicae  Jocenai,  J 


THE  LATEST  LITERATURE 


[Jaxtiabt  12,  IM 


ventilation,  too  rapid  locking  out,  too  long  a  sojourn  in  the 
compressed  air,  and  of  course  the  condition  of  the  patient ; 
age,  alcoholism,  and  obesity  being  serious  predisposing  fac- 
tors. Regarding  the  way  In  which  these  symptoms  are  pro 
duced,  Wainright  states  that  the  exhaustion  theory  does  not 
accord  with  the  observed  facts,  neither  is  there  any  reason 
to  suppose  that  there  is  excessive  congestion  of  the  centra! 
nervous  system.  There  does  seem  to  be  reason  to  believe 
that  the  blood  discharges  the  excess  of  gases  it  contains  upon 
release  of  pressure,  and  that  this  may  produce  the  various 
symptoms.  This  explains  satisfactorily  the  immediate  relief 
of  the  symptoms  if  the  patient  is  replaced  in  the  lock.  In 
one  case  marked  arterial  sclerosis  was  observed  in  a  man 
who  had  worked  for  7  years  at  high  pressures ;  otherwise  no 
possible  remote  efiects  were  observed.  The  treatment  con 
sists  essentially  of  recompression ;  nothing  else  is  really 
required.  In  conclusion  Wainwright  reports  8  additional 
cases,  in  one  of  whom  there  was  apparently  emphysema  of 
the  arm.    [j  8.] 

4. — Thurston  describe?  24  surgical  cases  occurring  in  the 
practice  of  Dr.  E.  J.  A.  Haynes,  and  the  author,  in  Western 
Australia,  each  of  which  present  features  of  special  interest : 

I.  Left  ovarian  cyst  in  a  woman  of  21,  in  whom  the 
peculiarity  was  a  severe  menorrhagia  which  in  its  severity 
rather  indicated  uterine  than  ovarian  affection.  Uninter- 
rupted recovery  after  ovariotomy.  2.  Carcinoma  of  the 
liver  with  no  symptoms  generally  indicative  of  this  affec- 
tion. The  diagnosis  was  made  after  the  exploratory  incision. 
Death  a  few  months  after.  3.  Extrauterine  fetation  ;  lapar- 
otomy; death.  4.  Perinephritic  abscess;  abdominal  section. 
In  this  case,  after  the  abdominal  incision,  a  tense  tumor 
containing  considerable  pus  was  found,  making  it  doubtful 
whether  it  was  a  localized  psoas  abscess  or  a  perinephritic  one. 
As  no  harm  was  done  to  the  spine,  or  any  other  symptoms 
present  indicating  a  psoas  abscess,  it  was  presumed  that  it 
was  a  perinephritic  one.  5.  Left  extrauterine  fetation ; 
laparotomy ;  death.  6.  Left  extrauterine  fetation  ;  ani-lap- 
arotomy;  pelvic  cellulitis:  death.  7.  Tnis  interesting  case 
was  one  of  hydatids  of  the  brain.  Upon  trephining  over 
the  region  of  the  fissure  of  Roland  hydatid  flaid  and  cysts 
were  found.  The  convulsions  and  hemiplegia  which  had  ex- 
isted improved.  Extensive  involvement  of  the  brain  caused 
death  within  three  months  following  the  operation.  An  early 
diagnosis  might  have  led  to  recovery.  8.  This  case  of  double 
pyosalpinx  even  after  abdominal  sections  refused  to  subside 
until  hydrogen  peroxid  and  formalin  were  employed,  when 
rapid  improvement  followed.  A  collection  of  pus  in  Douglas' 
sac  was  subsequently  evacuated  per  vaginam.  9  Medical  treat- 
ment having  failed  to  benefit  a  tuberculoas  kidney,  the 
left  kidney  was  removed.  Abscesses  were  found  in  the  organ 
and  the  peritonitis  which  followed  showed  that  purulent 
infection  of  the  kidney  must  necessarily  be  followed  by 
involvement  of  the  perineum.  10.  In  a  married  woman  a 
tumor  with  fluctuation  was  located,  situated  in  the  right 
epigastrium.  Uninterrupted  recovery  followed  an  abdominal 
section  for  the  growth,  which  proved  to  be  a  hydatid  cyst. 

II.  In  this  case  upon  abdominal  section,  three  aterine 
fibroids  were  found  attached  to  the  fundus,  the  posterior 
portion  of  which  was  adherent.  The  patient,  a  married 
woman,  being  in  very  low  condition  from  previous  hemor- 
rhages, hysterectomy  was  not  performed,  but  the  patient 
made  an  uninterrupted  recovery  after  the  removal  of  both 
ovaries.  12.  Appendicitis  wi'th  suppuration  ;  evacuation 
of  pus  without  appendicectomy  ;  recovery.  13.  A  woman  who 
had  been  treated  for  appendicitis,  upon  abdominal  incision 
waa  found  to  have  a  patent  Meckel's  diverticolum 
adherent  to  two  coils  of  ileum,  from  which  it  was  successfully, 
but  with  considerable  difficulty,  dissected ;  complete  recovery. 
14.  A  married  woman  from  whom  an  ovarian  tumor  had  been 
removed  in  the  usual  method,  was  seized  on  the  third  night 
after  the  operation  with  dyspnea  and  pain  in  the  left  chest. 
Death  resulted  probably  from  putmonar>-  embohsm.  16  A 
married  woman  having  been  arllicted  with  constant  epi- 
leptiform parosjsms,  which  had  failed  to  subside  under 
the  administration  of  a  great  variety  of  drugs,  was  relieved 
by  the  removal  of  both  ovaries,  if.  After  the  removal  of 
both  ovaries  from  a  married  woman  who  was  slowly  bleeding 
to  death  from  an  enormous  uterine  fibroid,  uninterrupted 
recovery  set  in,  with  shrinking  of  the  tumor  to  half  of  its 
formjr  size.  18.  In  this  case  a  woman  who  was  almost 
moribund  from  hemorrhage  due  to  carcinoma  of  the  cervix 


utf  ri  was  still  able  to  get  about  12  months  after  the  removal 
of  the  blood-  sapply,  which  was  accomplished  by  tying 
the  ovarian  arteries  on  both  sides  with  the  round  ligaments, 
as  well  as  the  arteries  of  the  uterus.  20.  A  patient  with  pain 
in  the  abdomen,  vomiting,  and  convulsions,  who  had  a  tumor 
an  inch  above  M  B  imey's  point;  was  found  upon  abdominal 
section  to  have  had  an  internal  strangulation  in  the 
ileocecal  fossa  into  which  a  loop  of  the  ueum  had  passed. 
The  bowel  was  withdrawn  and  uninterrupted  recovery  fol- 
lowed. 24  Recovery  followed  ligature  of  the  vein  and 
artery  for  traumatic  varicose  aneurysm  of  the  thigh. 
[m.b  d] 


New  York  Medical  Journal. 

December  39,  1900.     [\'ol.  Ixxii,  Xo.  26.] 

1.  The  Treatment    of  Tuberculosis    in    Sanatoria.    P.    H. 

Bbyck. 

2.  Hyperidrosis  of  the  Axilla ;  I'e  Treatment  with  the  Ther- 

mocautery.    LOCTS  KOLIPISSKI. 

3.  The  Eustachian  Bougie.    Loeeszo  B  Loceakd. 

4.  The  Ear  as  a  Factor  in  Causing  Systemic  Disturbance. 

James  L.  Minoe. 

5.  Tne  Importance  of    Postoperative   Treatment  after  Re- 

moving Spurs  of  the  Xasal  Septum.   E.  F.  Skydackeb. 

6.  Observations  on  Nitrogenous  Metabolism  in  a  Case  ol 

Nephritis.    Walter  C.  Klctz. 

1. — With  our  present  knowledge  and  the  actual  practic« 
of  the  public  in  the  matter  of  seeking  medical  advice,  not 
more  than  2-3%  of  patients  are  brought  under  treatment 
for  pulmonary  consumption  until  the  disease  is  weU 
advanced.  It  is  quite  clear,  therefore,  that  in  considering 
the  sanatorium  treatment  of  consumption  we  must 
have  2  distinct  objects  in  view  ;  (1)  the  cure  of  the  disease, 
and  (2)  the  prolongation  of  the  lives  of  patients  and  the 
removal  of  infectious  cases  from  surroundings  in  which  they 
are  a  menace  to  the  health  of  others.  Bryce  calls  attention 
to  the  fact  that  if  municipal  sanatoria  are  established, 
provision  must  be  made  for  patients  who  are  in  an 
advanced  stage  of  the  disease  as  well  as  for  thoee  who 
are  in  the  primary  stage.  The  erection  of  cottage  hos- 
pitals, therefore,  is  a  necessity.  In  such  an  institution 
one  of  the  first  rules  that  must  be  insisted  upon,  if  the 
desired  results  are  to  be  accomplished,  is  that  patiente 
shall  not  be  allowed  to  discuss  their  own  or  other  cases  with 
persons  other  than  the  proper  officials.  Srstematic  means 
must  be  taken  to  provide  wholesome  mental  employment  for 
the  patients.  Consequently,  the  patient's  time  should  be 
carefully  divided  and  each  one  should  keep  a  time  card  on 
which  the  daily  routine,  previously  prescribed,  is  kept  recorded 
as  regularly  as  one  should  keep  a  diary.  Actual  treatment 
should  begin  with  the  arrival  of  the  patient,  when  he  should 
be  put  to  bed  and  kept  there  if  the  afternoon  temperature  risee 
to  above  100°.  Durmg  his  stay  in  bed  the  patient  should  be 
wheeled  daily  to  an  open  window  or  protected  balcony.  Symp- 
tomatic treatment  of  the  pyrexia  is.  as  a  rule,  not  neceesary. 
When  the  fever  has  been  reduced  for  several  days,  the  pa- 
tient is  allowed  to  recline  on  an  adjustable  rechning chair  on 
a  protected  balcony.  Tnis  treatment  in  some  sanatoria  ie 
continued  from  9  a  m.  to  9  p  m.,  after  which  the  patient  goes 
to  his  bedroom  where,  even  in  winter,  the  window  is  left 
open  all  night,  a  screen  keeping  off  the  wind.  The  condition 
of  the  patient  must  determine  when  gentle  exercise  may 
with  advantage  be  added  to  the  treatment.  As  an  adjunct  a 
more  or  less  elaborate  sys:em  of  hydrotherapy  may  be 
adopted.  A  generous  and  nutritious  diet  of  well-cooked'  and 
palatable  food  which  is  easily  digested  is  productive  of  the 
bsst  results.  The  utility  of  fats  and  oils  depends  upon  three 
factors:  1.  Tney  serve,  owing  to  their  oily  nature  and  to 
their  being  broken  up  in  the  intestine  into  fatty  acids  and 
glycerin,  as  laxatives  and  lubricants  of  the  intestinal  walls. 

2.  They  are  but  slightly  acted  upon  by  bacteria,  although  in 
the  absence  of  bile  and  pancreatic  juice  they  may  be  decom- 
posed into  fatty  acids  and  be  largely  discharged  unaheorbed. 

3.  When  absorbed  by  the  columnar  epithelium  of  the  villi. 
they  are  carried  directly  to  the  central  lacteals,  and  thence 
directly  to  the  thoracic  duct,  instead  of  going,  as  in  the  case 
of  starches  and  proteids,  into  the  portal  circulation  for 
elaboration  in  the  liver.    Except  in  patients  with  strong  di- 


*   JaSUABt  12,  1901] 


THE  LATEST  LITERATURE 


PThe  Philadelphia 
L  Medical  Jocbnal 


59 


gestione,  alcohol  is  contraindicated  except  as  a  temporary 
stimulant,  owing  to  its  disturbing  effects  upon  the  glycogenic 
function  of  the  liver.  If,  however,  ales  and  porter  are  well 
borne  they  will  prove  of  value  as  productive  of  heat  and 
energy  in  the  reconstruction  of  tissue.  Meat,  milk,  eggs,  and 
similar  articles  of  diet  should  be  used  up  to  the  limit  of  their 
assimilation  by  the  system.  In  patients  who  are  deprived 
for  a  time  of  the  privilige  of  active  exercise  the  value  of 
massage  as  an  aid  to  the  metabolic  changes  taking  place  in 
the  tissues  cannot  be  overestimated.  Reduced  air-pressures 
are  a  direct  means  of  deepening  the  inspirations  and  of  set- 
ting unused  corners  of  the  lung  tissue  to  work  ;  if  scientific- 
ally practised,  this  method  will  probably  develop  a  definite 
therapeutic  value.  The  personal  hygiene  of  the  patients  is 
a  very  important  part  of  the  routine.  In  very  few  instances 
can  patients  return  to  the  sedentary  pursuits  of  city  life. 

[j.M.S.] 

3. — In  the  treatment  of  several  cases  of  hyperidrosis 

of  the  axilla  Kolipinski  has  adopted  the  following  routine: 
The  base  of  the  axilla  is  washed  and  shaved.  Then  the 
thermocautery  is  applied  with  its  flat  side,  from  10  to  20 
times,  to  the  space  from  which  the  sweat  is  seen  to  ooze,  and 
burns  of  the  second  and  third  degree  are  produced.  A  dry 
bismuth  or  zinc  oxid  dressing  is  applied  and  the  patient  may 
resume  his  ordinary  occupation  in  a  few  days.  The  history 
of  a  case  is  given,    [j  si  s.  | 

3.  —  Lockyard  considers  the  use  of  the  eustachian 
bougie  indicated  only  in  two  conditions,  viz.,  tubal  steno- 
sis and  tinnitus.  This  does  not  include  electrical  treat- 
ment with  copper  bougies  or  insulated  cathetens.  After 
discussing  the  anatomic  structures  and  situation  of  the 
eustachian  tube,  and  especially  the  folds  in  the  mucous 
membrane  at  its  lower  portion,  mentions  several  methods  of 
employment.  These  are  the  use  of  graduated  bougries 
and  rubber  capsules  fastened  to  the  catheter  and  infldted 
after  their  introduction.  A  case  is  mentioned  of  a  man,  sged 
46,  who  had  been  subject  to  increasing  deafness  in  the  right 
ear,  combined  with  subjective  noises,  and  in  whom  7  months 
had  passed  without  a  recurrence  under  the  employment  of 
bougies,  after  many  other  methods  had  failed.  The  dangers 
are  acute  otitis  media,  emphysema,  perforations  of  the  mem- 
brana  tympani,  dislocation  of  the  ossicula ;  aggravation  of 
the  existing  symptoms  and  of  the  local  trouble,  faintness,  and 
fainting.  The  results  are  uncertain,  but  when  beneficial  are 
due  either  to  pressure  upon  cicatricial  tissue  or  by  reflex  in- 
fluence upon  the  auditory  center,     [m  r  d.] 

4. — ^The  frequency  of  middle-ear  disease  in  infancy  is 
astonishing.  That  the  ear  can  be  so  frequently  afiected  in 
infancy  without  attracting  attention  to  that  organ  is  easily 
accounted  for  by  the  fact  that  the  patients  are  often  too 
young  to  indicate  what  they  are  suffering  from.  The  gen- 
eral symptoms  may  so  far  outweigh  the  local  ones  that  the 
ear  is  overlooked  in  our  search  for  their  cause.  Then,  too, 
there  may  be  suppurative  inflammation  of  the  middle-ear, 
with  little  or  no  pain,  and  without  physical  signs,  such  as 
redness  and  bulging  of  the  drum  membrane,  which  are  relied 
upon  for  the  diagnosis  of  such  trouble.  This  is  more  apt  to 
occur  in  infancy,  when  the  eustachian  tube  is  short,  thereby 
allowing  pus  to  escape  by  that  channel,  rather  than  to  accu- 
mulate or  escape  through  a  perforation  in  the  membrana 
tympani.  The  frequent  presence  of  adenoid  tissue  or 
masses  near  the  eustachian  orifii'e  in  the  throat  of  infants  is 
another  reason  why  children  so  often  suffer  from  ear  disease. 
The  treatment  of  cases  of  middle-ear  disease  in  the  early 
stages  is  by  dry  heat  and  gentle  douching  of  the  ear  itself 
with  some  hot  antiseptic  solution.  If  the  symptoms  con- 
tinue without  perforation,  a  paracentesis  of  the  drum  should 
be  made.  The  nose  and  the  throat  usually  require  treat 
ment;  sometimes,  indeed,  adenoids  require  to  be  removed 
The  remote  or  systemic  effects  of  disease  of  the  ear 
are  symptoms  of  meningitis,  acute  intestinal  derangement 
with  cerebral  symptoms,  septic  fever,  continued  high  fever 
and  attacks  of  bilious  fever,     [j  m  s  ] 

6. — Snydacker  in  discussing  the  importance  of  postoper- 
ative treatment,  after  removing  spurs  of  the  na^-al  sfpium 
attributes  failure  of  relief  to  the  substitution  of  the  original 
obstruction  by  the  formation  of  cicatricial  tissue  after  the 
operation.  In  cases  where  spurs  have  been  removed  there  is 
sometimes  observed  the  formation  of  a  new  mucous  mem- 
brane which  however  in  functionating  power  is  inferior  to  the 
original  tissue.      Postoperative  granulations    should  be 


cauterized  until  they  cease  to  form.  The  treatment  should 
not  be  discontinued  until  the  wound  is  entirely  covered  by 
mucous  membrane.  The  patient  should  be  impressed  with 
the  necessity  of  postoperative  treatment,  and  the  in- 
fluence it  exerts  upon  the  subsequent  cure  explained  to 
him.     [m.r.d.] 

January  5,  1901.     [Vol.  Ixxiii,  No.  1.] 

1.  Observations  on  Lateral  Curvature  of  the  Spine ;  Patho- 

logical, Clinical,  Mechanical.    A.  M.  Phelps. 

2.  The  Mesial  Relations  of  the  Inflected  Fissure  ;  Observations 

upon  100  Brains.    Edward  A,  Spitzka. 

3.  The  Importance  of  a  Knowledge  of  Ear  Disease  to  the 

General  Practitioner.    William  H.  Thomson. 

4.  Some   Observations    upon   Specialism  in   the   Arts  and 

Sciences  Generally,  and  upon  Specialties  and  Special- 
ists in  the  Science  and  the  Art  of  Medicine  Particularly. 
William  Bodenhamer. 

5.  A  Contribution  to  the  Symptomatic  Treatment  of  Pul- 

monary Tuberculosis.    J.  R.  L.  Daly. 

6.  A  Case  of  Acromioclavicular  Dislocation  and  its  Treat- 

ment.   Bernard  E.  Henrahan. 

7.  Sexual  Intemperance.    Jennie  G.  Drennan. 

1. — Phelps  has  made  a  careful  study  on  the  dissecting 
table  on  a  case  of  lateral  curvature  of  the  spine.  He 
found  that  the  superficial  erector  spinae  muscles  upon  the 
side  of  convexity  were  entirely  destroyed  by  atrophy  and 
fatty  degeneration,  while  those  upon  the  side  of  concavity 
were  not  so  much  afiected.  He  also  found  that  quadratus 
lumborum,  and  the  erector  spinae  of  the  group  of  muscles  of 
the  deeper  layer  were  entirely  disturbed  by  fatty  changes 
and  atrophy  on  the  side  of  convexity,  while  on  the  side  of 
concavity  the  correspondirg  muscles,  although  somewhat 
degenerated,  were  not  so  much  so  as  upon  the  side  of  con- 
vexity. The  fatty  changes  and  atrophy  on  the  convex  side 
were  evidently  due  to  the  pressure  of  the  muscles  by  th& 
bending  of  the  bones  of  the  spinal  column,  putting  the 
groups  of  muscles  on  the  stretch,  whereas  the  degeneration 
and  atrophy  on  the*  concave  side  were  produced  by  con- 
traction of  these  muscles  and  their  tendons.  When  the 
spinal  column  bends,  producing  disturbance  of  bone  and 
intervertebral  cartilage,  and  by  pressure,  the  ribs  are  dis- 
torted and  overlapping,  and  the  muscles  between  the  ribs 
have  been  joined  by  shortening,  atrophy  and  degeneration, 
it  is  claimed  that  a  cure  of  such  a  lateral  curvature  is  im- 
possible. In  order  to  accomplish  a  cure,  not  only  must  the 
resistance  offered  by  a  wedge  shaped  bone  of  the  vertebral 
column  be  overcome,  but  the  distorted  ribs  mutt  be  rotated 
in  order  to  cure  the  curve.  The  most  that  can  be  hoped  for 
at  the  present  time  from  treatment  is  to  prevent  the  in- 
crease of  the  curvature,  to  remove  the  physiologic  curve,  and 
to  give  the  patient  strength.  This  can  be  partially  accom- 
plished under  anesthesia  by  applying  tremendous  force  to 
the  thorax  or  the  spine,  either  by  machinery  or  by  hand, 
the  resisting  muscles  and  fascia  being  divided  by  the  knife. 
The  patients  are  then  enveloped  in  plaster  of  Paris,  put  to 
bed  and  kept  there  2  or  3  weeks,  after  which  the  operation  is 
repented.  Phelps  prefers  an  aluminum  corset  as  a  substitute 
preparation  for  many  of  the  braces  and  corsets  now  worn 
in  the  acute  forms  of  Pott's  disease  and  lateral  curvature, 
[w  a.n.d  ] 

2. — Spiizka  has  examined  100  brains  of  dissecting  muscle 
subjects  for  the  purpose  of  determining  the  mesial  relations 
of  the  inflected  fissure.  The  brains  were  in  formalin  and 
were  in  a  good  state  of  preservation.  It  was  found  that  in  40 
hemicerebrums  of  the  200  examined  the  inflected  fissure  was 
wanting.  Its  absence  was  symmetric  in  6  grades,  or  3  % ,  while 
it  occurred  22  times  on  the  left  and  18  times  on  the  right-side 
half.  All  further  data  were  based  upon  thelGOhemicerebrums 
in  which  the  fissure  was  presented  as  equivalent  to  100  ia 
91  fc .  The  inflectration  was  situated  on  a  plain  caudad  of  an 
unmistakable  cephalic  paracentral  limb,  while  in  the  remain- 
ing 9ff  this  limb  had  become  separated  from  the  main  pari- 
ceutral  stem  by  a  narrow  isthaius  or  slight  vardum.  In  all 
cases,  however,  the  inflected  fissure  indented  and  lay  partly 
within  the  paracentral  gjrus.  In  63%  of  all  cases  there  was 
only  one  su'h  limb  or  ramus,  binding  the  paracentral  gyrus 
cephalad.  This  arrangement  occurred  a  little  oftener  on  the 
left  half  than  upon  the  right.  In  22%  there  was  an  additional 
ramus,  intraparacentral  in  nature,  and  probably  also  in  origin. 


60 


Thk  PotladklphiaT 
MEDirAL  Journal  J 


THE  LATEST  LITEEATURE 


[Jastabt  IJ,  I 


situated  jast  caudad  of  the  inflected  fissure.  In  the  remain- 
ing 6  fc  the  ramifications  and  disturbances  of  fissuration  were 
80  varied  as  not  to  allow  readily  of  any  classification.  In  the 
large  maj  irity  of  the  hemicerebrums  examined  the  inflected 
fissure  ended  upon  a  meson  as  well  as  upon  a  dorsum  in  a 
simple  manner.  At  times  a  bifurcated  appearance  was  pro- 
duced.    [W.A.K  D  ] 

3.— The  author's  illustrations  of  the  importance  of  a 
knowledge  of  ear  disease  to  the  general  practi- 
tioner are  based  upon  an  experience  of  35  years.  He  em- 
phasizes the  importance  of  this  knowledge  by  referring  the 
reader  to  deaf  and  dumb  asylums,  where  the  havoc  wrought 
by  neglected  cases  of  otitis  media  can  be  easily  seen. 
Chronic  ear  disease  may  prove  fatal  without  the  complication 
of  an  intracranial  abscess.  He  calls  attention  to  the  fact  that 
there  are  special  forms  of  bacteria  which  at  times  pervade  in 
an  accumulation  of  pus  in  the  ear,  and  which  break  through 
all  barriers.  Bacteriologic  examinations  therefore  of  ear  dis- 
charges are  absolutely  essential.  Myoclonus  is  an  early 
manifestation  of  an  organized  exudate  situated  within 
the  cranium,  and  he  believes  that  this  symptom  is  often 
erroneously  considered  by  neurologists  to  be  of  spinal  origin. 
Vertigo  is  described  as  consisting  of  four  varieties — gastric 
or  digestive,  cardiovascular,  ocular,  and  aural.  Thomson 
concludes  his  article  with  a  plea  to  medical  institutions  to 
practically  train  their  students  in  otologic  examination  and 
diagnosis,    [m.e.d.] 

6. — Dily  recommends  camphor  2  grains,  heroin  ^^_  grain, 
and  creosote  1  drop,  prescribed  in  pill  form,  as  a  remedy  in 
phthisical  coughs  which  have  proven  intractable,  especially 
the  cough  which  is  hard  with  scant  tenacious  mucus  and 
little  expectoration.  He  reports  7  cases  in  which  the  remedy 
was  used  with  success.  He  remarks  particularly  the  value 
of  the  camphor  in  those  cases  accompanied  by  nervous  de- 
pression. In  the  obstinate  diarrhea  of  phthisis  Daly  has 
found  the  following  combination,  in  tablet  form,  to  be  of 
service  :  Bismuth  subnitrate  15  grains,  guaiacol  carbonate  1 
grain,  heroin  jV  grain.  The  persistent  irritability  of  the 
stomach  has  been  also  greatly  relieved  by  these  tablets. 
[t.l  c] 

6. — In  the  great  majority  of  dislocations  of  the  acro- 
mioclavicular articulation,  the  acromion  process  is 
displaced  downward  and  inward  beneath  the  clavicle,  the 
outer  end  of  the  latter  bone  riding  on  top  of  the  acromion, 
and  the  cases  are  very  rare  where  dislocation  of  the  acro- 
mion takes  place  upward  with  the  clavicular  injury  beneath 
the  process.  This  fact  is  readily  understood  when  the  struc- 
ture of  the  joint  is  borne  in  mind  and  the  character  of  the 
clavicular  injury  received.  The  dislocation  is  of  sufficient 
frequency  to  make  it  one  of  the  surgical  pathological  phe- 
nomena for  which  the  practitioner  must  be  constantly  on 
the  alert.  The  recognition  of  the  luxation  is  not  difficult, 
yet  it  closely  resembles  a  dislocation  of  the  humerus  for- 
ward. The  rotundity  of  the  shoulder  will  be  outside  and  the 
projection  of  the  overriding  clavicle  may  be  mistaken  for 
the  apparent  projection  of  the  acromion  in  the  shoulder- 
j  Dint  dislocation.  When  it  is  remembered  that  the  shoulder- 
joint  is  carried  slightly  forward  and  inward ;  the  hand  of  the 
injured  side  may  easily  be  carried  to  the  shoulder  of  the  side 
when  the  elbow  is  on  the  chest ;  that  by  following  the  lines 
of  the  clavicle  the  normal  rela'ions  of  this  bDdy  with  the 
acromion  are  disturbed,  the  clavicle  being  on  top ;  that 
there  is  no  marked  fossa  upon  the  head  of  the  humerus  and 
that  the  projection  of  the  clavicle  is  fully  within  one  inch 
within  the  line  of  the  humerus.  The  actual  condition  should 
be  easily  recognized.  Henrahan  regards  a  case  of  this  acci- 
dent, and  adopts  the  treatment  of  reduction  and  retention 
of  the  limited  articular  surfaces  in  position  until  union  of 
the  torn  capsular  ligaments  are  established.  The  latter  is 
accomplished  by  placing  a  pad  on  the  axilla,  a  folded  towel 
of  heavy  texture  placed  over  a  broad  area  at  the  side  of  the 
injury,  and  a  strap  2  inches  wide  is  drawn  across  the 
shoulder  and  under  the  elbow,  a  pad  of  absorbent  cotton 
producing  a  great  pressure  on  the  elbow.  The  strap  is  drawn 
as    tightly  over  tne    shoulder    as   the    patient    can    bear. 

[W.A.N.D.] 

%  1. — Drennan  believes  that  sexual  intemperance  is  not 
to  be  considered  as  a  minor  form,  and  that  it  is  generally 
ignored,  in  comparison  to  liquor  and  other  forms  of  in- 
temperance, and  that  the  abu^e  of  the  sexual  act  is  wrongly 
shielded  by  matrimonial  bonds.     [m.r.d  ] 


« 


Inteetjn^ 


8: 


^\ 


Medical  Record. 

January  5, 1901.    [Vol.  59,  No.  l.J 

1.  The  Prevention   and  Belief  of  Postoperative 

Obstruction.    Clement  Cleveland. 

2.  A  Case   of  Estivoautumnal  Fever  with  Unusual 

toms.    George  L.  Peabody. 

3.  Intestinal  Indigestion.     A.  P.  Stonee. 

4.  On  the  Effect  of  Topical  Applications  of  Excessive  StrengUi 

and  Improper  Diet  and  Hygiene  in  Prolonging  ao^ 
Causing  Skin  Diseases  in  Infanta  and  Young  ChUdren. 
S.  Sherwell. 

5.  The  Clinical  Value  of  the  Heart  Reflex.    Albert  Abraio 

6.  A  Case  of  Perforating  Gastric  Ulcer.    A.  B.  Atheetos. 

1. — Clement  Cleveland  discusses  postoperative  int«s> 
tinal  ohstraction  and  the  methods  for  its  relief.  He  refac 
here,  not  to  the  adynamic  type,  due  to  intestinal  paralyu 
from  peritonitis,  nor  to  that  due  to  opium,  but  to  thoee 
forms  of  intestinal  obstruction  which  occur  from  the  handlkig 
of  the  intestines  during  the  operation.  The  peritoneum,  i 
most  sensitive  and  delicate  membrane,  causes  the  excretion 
of  plastic  lymph  upon  irritation,  and  adhesions  are  very  apt 
to  form  as  a  result  of  this.  Speaking  of  the  meswures  for  i\t 
prevention,  he  advocates  placing  patients  in  the  Trendelen- 
burg posture  during  the  operation.  He  advisee  protectinc 
the  intestines  with  the  omentum,  as  far  as  possible,  and 
covering  them  carefully  with  wet  pads  of  gauze  and  forciiig 
the  intestines  into  the  upper  abdominal  cavity.  He  abo 
mentions  favorably  the  present  custom  of  surgeons  in  leavint 
the  cavity  partly  filled  with  decinormal  salt-solution,  whicE 
serves,  by  its  rapid  absorption,  rather  better  than  an  intn- 
venous  infusion  of  the  same  solution.  It  may  also  lessen  the 
amount  of  plastic  lymph  thrown  out,  and  thus  lessen  the 
possibility  of  adhesions.  He  quotes  5  cases  in  which  the  in- 
sufflition  of  oxygen  has  been  used  for  the  relief  of  poetopa- 
ative  obstruction.  Oxygen  is  administered  per  rectum,  and 
great  relief  has  followed  its  use.  The  writer  believes  that  thif 
acts  not  merely  by  the  power  of  straightening  out  the  inte»' 
tines  and  opening  the  lumen,  but  serves  as  a  stimulus  to 
peristalsis.  Four  of  his  cases  were  desperate  ones,  and  tiu 
insufflition  made  the  diflference  between  life  and  death. 
Oxygen  used  by  the  bowel  must  be  absorbed  to  some  degiw 
and  enter  the  general  circulation,  serving  in  this  way  aa  § 
stimulant  and  tonic,  but  Cleveland  has  used  it  solely  for  ilt 
mechanical  effect,    [t.l  c] 

2. — Peabody  describes  tbe  case  of  a  man  of  3i,  who  'hti 
for  11  years  lived  in  New  York  City  and  had  been  nowher« 
else  during  that  time  excepting  in  Pennsylvania.  He  bad 
daily  attacks  of  severe  headache  subsequently  accompanied 
by  severe  abdominal  pain  in  the  neighborhood  of  the  um- 
bilicus radiating  toward  the  left  kidney.  The  pain  wat 
greatly  relieved  by  vomiting ;  the  condition  had  become  sc 
distressing  as  to  lead  to  great  reduction  of  health.  The 
spleen  was  increased  in  size,  was  hard,  was  tender  to  pres 
sure,  but  did  not  move  with  respiration.  Examinadon  oi 
the  blood  showed  malarial  crescents.  The  use  of  quinii) 
brought  about  entire  cure  and  the  spleen  subsequently  be- 
came immovable.  The  abdominal  pain  was  considered  V. 
be  due  to  adhesions  of  the  spleen  to  the  diaphragm.  Trac- 
tion upon  this  when  the  spleen  was  increasing  in  size  uadei 
the  influence  of  malarial  poisoning  was  thought  to  haw 
caused  the  pain,     [d.l.e  ] 

3. — Stoner  gives  a  general  review  of  digestive  proceaBM, 
noting  that  primary  digestion  in  the  stomach  is  incomplete 
that  the  chief  part  of  digestion '  and  particularly  of  ab»on)- 
tion  takes  place  within  the  small  intestine,  and  that  tne 
facility  of  absorption  is  dependent  upon  the  vitality  of  the 
cells  of  the  intestinal  mucosa.  He  notes  the  unfavorable  in- 
fluence of  gastric  hypochlorhydria  upon  intestinal  digestion- 
and  the  similar  influence  of  gluttony.  The  most  prominent 
symptoms  of  intestinal  indigestion  are  distress  and  abnorma. 
fulness  in  the  hypogastric  or  gastric  region  without  definit< 
tenderness.  There  is  a  constant  desire  to  eructat-e,  but  the 
stomach  is  found  to  contain  no  gas.  There  is  flatulence  anc 
usually  constipation,  and  the  urine  may  contain  a  trace  o 
bile  with  excess  of  urates  and  indican.  There  is  oft*n  markec 
depression  of  spirits.  There  is  intolerance  of  starches,  f»t« 
sweets  and  wines.  Treatment  consists  chiefly  in  prohibitioi 
of  the  latter  forms  of  foods.  Lean  meJits  should  be  allowec 
in  moderate  quantities.    Antacids  are  usefiil.     [d  l  k.] 


Janoarv  12,  1901] 


THE  LATEST  LITERATURE 


CThe  Philadelphia 
Medical  Joubnal 


61 


4. — The  remarks  which  Sherwell  makes  are  chiefly  that 
topical  applications  are  usually  used  too  strong  in  the  treat- 
ment of  skin  aflfections  of  children,  and  may  have  very  dam- 
aging results.  Even  vaseline  is  frequently  irritating,  par- 
ticularly in  children.  In  relation  to  food  and  clothing,  he 
considers  that  children  of  various  ages,  particularly  infant?, 
are  frequently  overfed,  and  fed  too  frequently;  they  are  also 
commonly  clothed  too  warmly,  particularly  in  summer,  and 
this  irritates  the  skin.  The  fear  of  washing  eczematous 
areas  is  also  something  which  he  considers  silly.  He  recom- 
mends a  gentle  washing  once  daily  with  water  made  slightly 
alkaline  with  borax  or  soda,  and  bran  bag.  In  older  chil- 
dren it  is  often  necessary  to  stop  the  use  of  tea,  coffee,  and  a 
large  variety  of  indigestible  foods,  and  salines  are  often 
valuable.  The  skin  usually  needs  soothing  treatment,  [d.l.e.] 

6. — The  heart  reflex  is  best  determined  by  the  use  of  the 
fluoroscope.  After  irritating  the  skin  over  the  heart  by 
various  means,  best  by  active  rubbing  with  a  lead  eraser,  the 
size  of  the  heart  shadow  may  seem  to  grow  much  smaller. 
This  may  be  determined  upon  percussion  also.  A  portion  of 
the  decrease  in  size  is  due  to  the  lung  reflex,  which  consists 
in  dilation  of  the  lung,  thus  partially  covering  the  cardiac 
■dulness.  This  latter  factor  soon  disappears  and  then  the 
cardiac  dulness  may  be  found  much  smaller  than  previously, 
and  this  is  due  to  actual  contraction  of  the  heart  itself. 
Abrams  thinks  that  it  is  this  skin-irritation  which  produces 
the  greatest  effect  in  the  Schott  baths,  and  he  has  found  di- 
rect irritation  of  the  skin  over  the  precordia  valuable  in  the 
treatment  of  cardiac  dilation,  and  considers  it  also  a  valuable 
sign  in  the  differentiation  of  dilated  heart  from  pericardial 
«ffusion.     [d  L.E.] 

6. — The  case  reported  occurred  in  a  man  of  62  who  was 
operated  upon  10  hours  after  the  occurrence  of  perforation. 
Aji  opening  the  size  of  a  lead  pencil  was  found  on  the 
anterior  surface  of  the  stomach,  near  the  pylorus.  The  per- 
foration was  closed  by  two  rows  of  Lembert  sutures.  The 
man  did  fairly  well  for  about  3  weeks,  when  he  vomited  some 
dark  liquid  with  blood  in  it.  After  this  his  recovery  was 
continuous.  He  died,  however,  about  a  year  afterwards,  of 
lung  trouble  it  was  said,    [d.l.e  ] 


Medical  News. 

January  5,  1901.    [Vol.  Ixxviii,  No.  1.] 

1.  A  Study  of  81   Cases  Operated  upon  Under  Analgesia 

Obtained    by    Sabarachnoid     Spinal    Cocainization. 

George  Ryerson  Fowler. 
■2.  The  History,  Aim,  and  Purpose  of  the  Medical  Societies 

of  the  State  and  Counties  of  New  York.    Frank  Van 

Fleet. 
S.  Pneumonia :  Its  Etiology  and  Treatment.    D.  L.  Burnett. 

4.  On  the  Prognosis  of  Hysteria:   A    Contribution  to  the 

Question  of  Fatal  Hysteria.    Joseph  Fraenkel. 

1. — Fowler  believes  that  the  delay  in  the  employment  of 
subarachnoid  spinal  cocainization  is  due  to  the  favor- 
able results  that  have  been  given  by  other  anesthetics  when 
properly  administered.  The  author's  experience  of  this 
form  of  anesthetics  comprises  81  cases  which  have  been 
divided  ud  as  follows :  Operations  involving  the  perito- 
neum, 26  ;  operations  in  the  pelvic  region  not  involving 
the  peritoneum,  34 ;  operations  upon  the  lower  extremity, 
not  included  in  the  above  mentioned  caees,  13;  amputation, 

5.  In  the  3  cases  of  inguinal  hernia  there  was  pain  when 
the  areas  supplied  by  branches  of  the  ileoinguinal  and  ileo- 
typogastric  nerves  were  attacked.  In  a  case  of  acute  appen- 
dicitis, handling  of  the  inflamed  appendix  gave  rise  to  such 
pain  that  a  general  anesthetic  had  to  be  administered  in  ad- 
dition to  the  spinal  one.  In  2  cases  of  varicocele,  pain  was 
produced  by  handling  the  cord,  and  general  anesthetics  had 
Also  to  be  administered  in  addition  to  the  spinal  anesthesia  in 
a.  case  of  anterior  colporrhaphy  and  perineorrhaphy.  In  one 
case  the  patient  hearing  the  call  of  a  surgeon  for  the  second 
Tinife,  after  a  previous  absolutely  painless  procedure,  was 
very  sensitive  to  the  slightest  touch  thereafter.  He  believes 
that  the  technic  of  the  lumbar  puncture  is  not  as  simple  as 
might  be  supposed.  In  stout  individuals  the  spinous  pro- 
•cesses  are  difficult  of  palpation,  and  even  in  cases  where 
Tthere  was  not  considerable  fat  a  patient  that  was  very  nervous 
■when  placed  in  a  direct  posture  would  throw  the  muscles 


into  such  rigidity  as  to  render  it  almost  impossible  to  fix 
the  point  of  the  spinal  process.  Unless  the  lumen  of  the 
needle  had  become  occluded  in  its  passage  through  the 
soft  parts,  cerebrospinal  fluid  flows  without  any  difficulty. 
In  some  cases  aspiration  either  with  the  syringe  that  is  being 
employed  or  a  special  suction  will  still  more  facilitate 
the  outflow  of  the  cerebrospinal  fluid.  He  generally  allows 
a  full  minute  for  the  injection,  thus  giving  ample  time  for  the 
solution  to  thoroughly  mix  with  the  cerebrospinal  fluid.  The 
solution  should  be  freshly  prepared  with  a  menstruum  of 
sterilized  water  and  boiled  for  a  full  minute  before  using.  It 
is  believed  that  a  concentrated  solution  of  a  definite  quantity 
will  not  produce  disagreeable  symptoms  any  more  than  the 
same  dose  in  a  diluted  solution  and  that  the  effect  will  last 
longer.  The  result  seems  to  have  been  affected  but  little  as 
far  as  the  position  of  the  patient  was  concerned  during  the 
injection.  Analgesia  is  present  in  the  soles  of  the  feet  from 
1  to  5  minutes,  and  in  from  5  to  15  minutes  extends  to  the 
umbilicus.  In  none  of  the  author's  cases  did  he  fail  to  reach 
the  umbilicus  when  the  solution  proved  at  all  effective ;  in  2 
cases  it  reached  to  the  vertex.  In  none  of  the  cases  did  the 
analgesia  subside  below  the  umbilicus  under  27  minutes. 
The  amount  of  cerebrospinal  fluid  present  in  each  case  has 
probably  direct  bearing  upon  the  extent  of  the  analgesia. 
With  a  reliable  solution  it  is  believed  that  a  failure  to  pro- 
duce analgesia  depends  upon  the  failure  to  introduce  the 
solution  into  the  spinal  cord.  In  the  greater  number  of  cases 
disagreeable  features  were  present,  among  them  being  vertigo, 
nausea,  vomiting,  headache,  chills,  elevation  of  temperature 
and  increased  pulse-rate,  pallor,  cold  sweat,  and  involuntary 
urination  and  defecation.  The  case  of  Tuffier  in  which 
death  occurred  was  found  upon  a  postmortem  examination 
to  have  been  affected  with  cardiac  and  pulmonary 
lesions.  Such  complications,  however,  have  been  disre- 
garded by  the  author  in  experimenting  with  this  anesthetic. 
In  some  cases  there  were  even  heart-murmurs  present,  and 
in  one  case  there  was  gangrene  of  the  lungs.  The  author 
considers  that  insensibility  to  the  surgical  procedure 
is  not  all  that  should  be  required  of  an  ideal  anesthetic,  and 
that  on  the  other  hand  such  features  as  the  knowledge  by 
patient  of  what  is  taking  place  around  him  and  the  percep- 
tion of  the  gravity  of  the  operation  are  to  be  distinctly 
avoided.  A  further  trial  and  conscientious  study  of  a  large 
collection  of  cases  is  still  required  to  ascertain  the  danger 
that  may  accompany  employment  of  this  form  of  anesthesia. 

[m  R.D.] 

2. — Frank  VanFleet  gives  a  historical  resum<5  of  the  medi- 
cal societies  of  the  State  and  County  of  New  York  from  their 
inception  in  1806.  He  also  takes  up  with  considerable  de- 
tail the  rupture  of  the  societies  from  the  American  Medical 
Association  on  account  of  their  unwillingness  to  subscribe  in 
full  to  the  ethics  of  the  American  Medical  Association  with 
a  special  reference  to  consulting  with  those  who  practise  ex- 
clusive dogma,     [t.l.c  ] 

4. — Fraenkel  discusses  the  prognosis  of  hysteria,  and 
reports  4  fatal  cases.  He  divides  hysterical  conditions  in  3 
separate  groups  from  a  clinical  point  of  view,  and  remarks 
that  these  are  not  fixed  by  strict  boundary  lines  and  can 
show  many  interchanges  and  mutual  displacement.  First, 
the  predominantly  mental  forms,  hysterical  psychoses  with 
more  or  less  pronounced  somatic  symptoms.  Second,  pre- 
dominantly cerebrospinal  forms;  symptoms  of  this  group 
are  mainly  composed  of  phenoma  of  irritation,  or  paralysis 
of  motor  or  sensory  nerves.  Third,  predominantly  splanch- 
nic forms,  the  symptoms  of  which  are  mainly  phenomena  of 
irritation  of  the  motor  or  sensory  apparatus  supplied  by  the 
splanchnic  or  sympathetic  nervous  system.  Around  these 
3  groups  is  wound  the  symptom-complex  of  hysterical  seiz- 
ures— grand  ou  petit  mal  hystd.-ique.  He  believes  that  the 
prognosis  in  the  first  2  groups  is  more  favorable  than  the 
third,  in  which  his  4  fatal  cases  were  classed,    [t.l.c  ] 


Boston  Medical  and  Surgical  Journal. 

January  S,  1900.     [Vol.  cxliv,  No.  1.] 

1.  Experiment  and  Experience  with  the  R'fle.    Henry  G, 

Beyer,  U.  S.  N. 

2.  Clinical  Notes  and  Comments :  Degenerative  Disease  of 

the  Spinal  Cord  Associated  with  Anemia.    Robert  T. 
Edes. 


62 


The  Philadelphia! 
Mbdical  Journal  J 


THE  LATEST  LITERATURE 


[Jabcast  12,  1»»} 


The  Differential  Diagnosislof^InteBtinal^ObBtruction. 
BoYLSTON  Adams.        £_  ^     .       Siv 


Z. 


1. — Beyer  reviews  the  experimental  work  of  Kocher  and 
others  in  regard  to  the  effects  produced  by  rifle  bullet?,  and 
then  showp,  by  reviewing  the  experience  of  surgeons  in  the 
Spanish- American  and  Anglo- Botr  wars,  that  the  damage 
done  to  the  human  body  by  ihe  modern  bulkt  confirms  the 
work  of  the  experimenters.  Eecent  experience  show  the 
proportion  of  killed  and  wounded  to  be  about  the  same 
as  in  the  past — one  to  four — but  of  the  wounded  many 
more  now  recover,  due  to  septic  and  antiseptic  treatment. 
Kocher  showed  experimentally,  and  experience  has  con- 
firmed it,  that,  the  "  explosive  "  effect  of  bullets  is  due,  not, 
as  was  formerly  supposed  ;  (1)  "  to  deformed  and  deforming 
bullets;  (2)  to  indirect  or  ricochet  shots  ;  (3)  to  the  rotation 
of  bullets  ;  (4)  the  melting  of  the  lead  of  the  bullet;"  but  that 
this  effect  is  in  proportion  to  the  velocity  of  the  bullet.  The 
bullet  develops  its  greatest  velocity  a  few  feet  from  the  gun, 
after  that  it  gradually  decreases  until  it  reaches  the  ground. 
In  firing  bullets  through  glass  plates  Kocher  found  that  "  a 
10  mm.  lead  bullet  and  a  7.5  mm.  steel  bullet,  moving  alike 
at  a  velocity  of  595  m.,  produce  like  effects. "  In  experi- 
ments en  tin  cans  filled  with  marbles  he  found  that  the  same 
amount  of  explosive  effect  was  produced  by  hard  bullets 
fired  from  smooth-bore  guns  as  by  lead  bullets  from  rifles, 
provided  they  possessed  the  required  velocity.  This  does 
away  with  the  old  idea  that  rotation  or  deformable  bullets 
were  required  to  obtain  lateral  or  explosive  ettects. 
"  Kocher's  explanation  of  the  nature  and  production  of  the 
lateral  or  explosive  effect  is,  that  the  energy  of  the  bullet  is 
transmitted  from  the  parts  struck,  first,  in  the  direction  of 
the  line  of  fire  ;  next,  with  increasing  vek cities,  in  a  funnel- 
shaped  direction  towards  the  exit,  and,  lastly,  with  still 
greater  and  the  greatest  velocities,  in  all  directions."  Experi- 
ments with  cans  filled  with  water  or  tubstance  saturated 
with  it,  went  to  show  that  the  more  liquid  the  contents  of  the 
vessel  the  greater  was  the  lateral  or  explosive  effect,  which 
was  increased  with  increase  e.f  the  velocity,  regardless  of  the 
kind  of  bullet  used.  Experiments  with  the  water  box  showed 
that  leaden  bullets  made  greater  penetration  under  lower 
than  under  higher  velocity.  A  leaden  bullet  creates  its  own 
resistance  in  the  water  —  the  higher  the  velocity  the 
greater  the  resietanse.  From  the  moment  the  resistance 
reaches  a  point  so  as  to  cause  deformity,  explosive 
effect  also  becomes  apparent.  From  that  time  on  the  effect 
is  increaeed  with  the  velocities  used,  and  at  last  it  results  in 
the  bursting  of  the  box  and  in  the  water  spurting  up  to  the 
height  of  10  feet.  He  concludes,  "that  the  destructive 
effects  of  our  modern  high  velocity  bullets  upon  organs  con- 
taining a  large  percentage  amount  of  (luid  are  produced  by 
hydraulic  pressure."  Saltman  and  Kocher  agree  that  the 
enclosing  capsule  is  not  necessary  to  the  explosive  effect 
from  hydraulic  pressure,  but,  that  this  and  the  deformed 
and  deformable  bullets  increase  the  effect,  which  is  most  of 
all  dependent  on  the  velocity  of  the  bullet.  The  loss  of 
velocity  in  penetrating  different  aims  is  dependent  on  the 
hardness  of  the  bullet  and  it-i  e'aliber,  and  the  large  part  of 
the  loss  of  velocity  being  converted  into  lateral  or  explosive 
effect.  The  reduction  of  the  caliber  of  the  bullet  and  the 
hard  metallic  ja(  ket  has  resulted  in  making  small  skin 
wounds  and  lessening  the  hydraulic  effect  in  soft  parts  at 
close  range,  but  the  injury  to  the  bone  remains  much  the 
same  as  from  the  old  bullets.  It  is  not  unusual  to  find  a 
small  wound  of  entrance  and  exit  and  overextensive  damage 
of  soft  bone,  as  of  an  epiphysis,  for  instance.  Many  favor- 
able prognoses  were  made  during  the  late  war  because  of 
the  small  wounds  of  entrance  and  exit,  and  yet  many  of  these 
patients  are  now  invalided  from  service  from  extensive  sub 
cutaneous  injury,  resulting  in  the  deposition  of  large 
amounts  of  callus  or  extensive  adhesions  of  muscles,  etc. 
Sir  William  MacCormac  attributes  the  benign  character  of 
many  of  the  abdominal  wounds  in  South  Africa  to  the  fact 
that  in  most  instances  the  alimentary  canal  was  empty  and, 
therefore,  the  hydraulic  effect  was  at  a  minimum.  Su.i  e  ihe 
"  amount  of  destruction  experienced  by  any  part  of  a  t)one 
depends  principally  upon  the  amount  of  resistance  wliicli  it 
opposes  to  a  bullet,"  Beyer  argues  that  bone  ir juries  from 
bullets  should  be  classified  according  to  Kocher,  as  of  the 
epiphysis,  the  diaphysis,  or  of  the  metaphj  sis,  as  the  resist- 
ance offered  by  these  parts  differs  so  much.    He  objects  to 


the  term  "  expansive  "  and  thinks  "  explosive  "  the  proper 
word  as  describing  the  lateral  effect  of  a  bullet.  "  The  high- 
est velocity  shots  upon  skulls,  filled  with  brain,  show  that 
they  are  attended  by  a  high  degree  of  explosive  or  hydraulic 
action."  Nerves  and  bloodvessels  sometimes  show  remark- 
able escape  from  injury  even  with  the  modem  bullet,  but 
only  when  velocity  is  low.  An  undeformed  modern  bullet 
passing  through  a  lung  even  at  the  highest  velocity  showe 
better  lateral  action,     [j.h.o.] 

3. — Edes  considers  those  spinal  degenerations  not  usually 
recognized  as  belonging  to  the  well-marked  system-diseases 
and  which  are  accompanied  by  states  of  malnutrition  of  the 
blood.  He  cites  4  cases  illustrating  this  class  of  degenerations 
with  the  results  of  one  necropsy.  The  general  symptoms 
presented  by  such  cases  are  those  of  severe  anemia,  weak- 
ness of  motion  and  coordination  (rather  than  espeiial  groups 
of  muscle- paralyses).  At  first  the  deep  reflexes  are  apt  to  be 
exaggerated  ;  later  there  may  be  absolute  paralyses,  extensive 
anesthesia  and  loss  of  deep  reflexes.  The  sensory  symptoms 
include  numbness  of  the  extremities,  inability  to  use  the 
hands  for  fine  work,  and  sense  of  coldness  in  the  lower  ex- 
tremities. The  notes  of  the  partially  incomplete  autopsy 
given  state  that  to  the  naked  eye  the  brain  seemed  normal 
and  was  not  examined  further,  except  the  medulla  in  its 
lower  portion,  and  some  sections  of  the  cord.  The  author 
concludes  that  the  degeneration  in  this  case  would  seem  to 
follow  the  system- fibers,  unlike  the  majority  of  such  cases, 
in  which  there  is  a  tendency  to  the  formation  of  focal  lesions. 
[t.l.c] 

3. — Z.  B.  Adams  discusses  the  general  causes  of  intestinal 
obstruction  and  quotes  a  list  of  56  cases,  which  in  27  was 
diagnosed  incorrectly.  He  presents  certain  important  points 
in  the  difl'-'rentiation  of  ttie  various  conditions.  F  rst,  between 
obstruction  and  dysentery ;  second,  between  chronic 
and  tuberculous  peritonitis,  especially  in  youug  sub- 
jects. He  states  that  ihe  must  important  diff-rential  diagnosis 
lies  between  strangulation  and  impaction,  or  occlusion 
of  the  lumen,  wheitier  trom  within  or  without.  He  abjures 
the  use  of  opium  or  purgatives  before  the  diagnosis  is  made 
and  insists  upon  routine  examination  by  the  rectum  and  the 
persistent  use  of  high  injection  as  valuable  aids  in  making 
the  diagnosis.  He  points  out  that  celiotomy  in  experienced 
hands  is  a  comparative!}'  harmless  operation,  which  has 
undoubtedly  saved  many  lives,    [t.lc] 


Journal  of  the  American  Medical  Association. 

January  5,  1901.     [Vol.  xxxvi.  No.  1] 

1.  Specialties  and  Specialists.    Joskph  Zeisler. 

2  E'iolopy  of  Dysentery.    Simon  Flex.ser. 

3.  Notes  on  Tropical  Dysentery.    John  Herr  Mctsser. 

4.  Case  of  Malignant  Endocarditis  with  Recoveiy.    M.  S. 

Davis,  Jr. 
5   External  Drainage  of  Lung  Cavities.    LeMoyse  Wills. 

6.  Surgical  Ei-rors  in  Skiagraphy.    Carl  Beck. 

7.  Walled  Off.    John  B.  Deaver. 

8   Toe   .\rmy  Suigeon  in  the    Poilippines.    William    J. 

Lester 
9.  A  N  rniil  Aroumeter.    E.  Ambekg. 

10.  Anibl>e)pia  Following  the  Intoxicating  Use  of  Jamaica 

Ginger;    Subsequent   Recovery   of   Vision.     Edward 
Sturin. 

11.  The  Douche  in  the  Treatment  of  Ophthalmia  Neona- 

torum.    E.  E.  HoLT. 

2.— Flexner,  discussing  the  classific^ation  and  etiology  of 
dysentery,  euius  up  our  present  knowledge  by  stating :  (1) 
Tiiat  no  bacterial  species  yet  described  has  the  especial  claim 
of  being  reirarded  as  the  chief  microorganism  concerned 
with  tie  disease;  (2)  it  is  not  likely  that  any  bacterial 
species  normally  present  in  the  intestine  or  environs  of  man, 
except  where  the  disease  is  endemic,  c*n  be  regarded  as  the 
probable  cause  of  epidemic  dysentery;  (S)  the  relations  of 
i-poradic  and  epidemic  dysentery  are  so  remote  that  it  is 
im  pr.  bable  they  are  produced  by  the  same  cnuse  ;  (4)  the 
pathe>genic  scuon  of  the  Ameba  coli  in  cert&in  examples  of 
triipic  and  sporadic  dysentery  has  been  disproved  by  the 
discovery  of  the  ameba  in  the  normal  intestine,  .\meba 
are  commonly  present,  and  are  concerned  with  the  produc- 
tion of  the  lesions  of  subacute  and  chronic  dysentery.  They 


January  12,  1901] 


THE  LATEST  LITERATURE 


PThe  Philadelphia 
L  Medical  Journal 


63 


have  yet  to  be  shown  to  be  equally  connected  with  the 
acute  dysenteries,  even  in  the  tropics.  Shiga  has  made  a 
careful  bacteriologic  study  of  Japanese  dysentery.  From 
his  cases  examined  a  bacillus  was  isolated  which  fulfilled 
the  requirements  of  a  causative  agent  of  this  form  of  dysen- 
tery. Flexner,  during  3  months'  residence  in  Manila,  care- 
fully studied  the  dysentery  of  the  Philippine  Islands.  He 
^  describes  two  main  forms  of  the  disease,  acute  and  chronic. 
Ameba  were  not  found  in  the  stools.  la  chronic,  ulcerative 
forms  they  were  variable  in  number.  Upon  bacteriologic 
■j  examination  Flexner  isolated  two  types  of  organism  found 
/  especially  in  the  acute  cases.  The  first  organism  is  a  bacillus, 
somewhat  of  the  colon-typhoid  type,  with  peculiarities  of 
growth  described.  This  gave  the  agglutination  test  many 
times  with  the  blood  of  persons  suflTering  from  the  disease, 
whether  the  host  or  another  individual.  Type  2.  Present 
in  all  cases.  Its  properties  agree  with  that  of  B.  coli 
communis.  With  this  organism  the  agglutination  test  was 
frequently  positive  with  the  host  and  rarely  with  other  indi- 
viduals. This  organism  was  found  to  be  absent  from 
healthy  dejecta  or  in  the  stools  of  the  natives  suffering  from 
beriberi.  Flexner  concludes  this  bacillus  to  be  identical 
with  that  described  by  Shiga.  The  results  with  the  aggluti- 
nation test  were  positive  in  cases  of  the  acute  disease  in 
which  infection  with  the  bacilli  was  established.  It  was  also 
present  in  a  case  of  Porto  Rican  chronic  dysentery,  but  was 
inconstant  with  blood  from  other  chronic  cases.  With  sev- 
eral cases  of  chronic  amebic  dysentery  under  Osier's  care  the 
test  was  negative.  As  to  treatment,  Flexner  expects  great 
benefit  from  a  species  of  vaccination  and  witnesses  the 
eflfect  of  injecting  the  dead  bacilli  in  cholera.  The  method 
and  details  will  have  to  be  carefully  evolved,     [t.l.c  ] 

3. — Musser  reports  a  fatal  case  of  Porto  Rican  dysentery 
occurring  in  a  soldier  of  32  years.  The  pathologic  findings 
indicated  dysentery,  ulcerative  and  pseudomembranous 
colitis,  possible  infarction  of  the  lung  and  a  universal  anemia. 
A  positive  test  was  obtained  with  cultures  of  the  bacillus  of 
Shiga — a  point  of  value,  since  the  case  might  have  been 
mistaken  merely  for  one  of  aggravated  scurvy,  the  inter- 
currence  of  which  occurred  during  the  period  of  observation. 
The  course  was  afebrile.  There  was  extreme  emaciation, 
strikingly  sallow  skin  and  a  profound  toxic  state  terminating 
in  the  typhoid  condition.  Bacteriologic  examination  revealed 
the  presence  of  an  organism  corresponding  with  the  Bacillus 
dysenteriae  isolated  from  cases  in  Manilla,     [t.l.c] 

4. — N.  S,  Davis,  Jr.,  reports  a  case  diagnosed  as  malignant 
endocarditis.  The  patient  had  for  7  years  following  an  attack 
of  grip  failed  perceptibly  in  health  and  came  to  the  hospital 
suffering  from  headaches  and  gastric  disturban^,e  with  occa- 
sional attacks  of  dyspnea.  Examination  on  admission  was 
negative  save  a  slight  epigastric  tenderness.  Under  treat- 
ment the  gastric  symptoms  subsided.  Then  fever  was  ob- 
served, which  for  a  few  weeks  indicated  a  typhoidal  curve. 
The  spleen  became  moderately  enlarged,  but  plasmodia  were 
not  found,  nor  was  the  Widal  test  positive.  After  the  first 
week  there  was  a.gradual  decline  in  temperature.  At  this 
time  a  marked  weakness  of  the  first  heart-sound  was  observed 
and  a  roughening  of  the  second  aortic  sound.  This  rough- 
ening gradually  developed  into  a  distinct  murmur.  The 
patient  then  suffered  from  two  severe  chills  followed  by  pro- 
fuse sweating  and  a  third  cold  stage  but  no  distinct  chill. 
Up  to  the  time  of  the  first  chill  the  patient  had  been  treated 
by  the  Brand  method.  The  chills  greatly  reduced  the  pa- 
tient's general  condition,  which  appeared  desperate.  Un- 
guenti  Cred^  was  now  employed  and  a  gradual  recovery  fol- 
lowed. The  aortic  murmur  disappeared,  but  the  second 
sound  remained  rough.  The  diagnosis  seems  to  have  been 
made  upon  the  exclusion  of  typhoid,  malaria  and  tubercu- 
losis and  the  septic  character  of  the  temperature  at  the  time 
i  of  the  chill,  as  well  as  the  cardiac  symptoms  with  the  disap- 
pearance of  the  aortic  murmur  with  convalescence.  The 
urine  contained  but  a  trace  of  albumin,  the  leukocytes  were 
normal  and  there  was  no  report  of  a  bacteriologic  examina- 
tion of  the  blood.  The  diazi  reaction  was  positive.  There 
was  no  history  of  septic  emboli ;  an  intercurrent  phlebitis 
recovered  promptly.  An  incomplete  list  of  reported  cases 
of  recovery  from  malignant  endocarditis  is  added,     [t.lc] 

6. — Wills  advocates  external  drainage  of  the  lung-ab- 
scesses as  conservative  surgery  and  reports  two  cases  operated 
upon  for  this  condition.  The  first  case  was  a  man,  45  years 
of  age,  and  muscular.    When  first  seen  he  had  a  cavity  in  the 


left,  lung  extending  from  the  sixth  interspace  to  the  ninth 
rib  and  apparently  from  the  spinal  column  to  the  midaxil- 
lary  line.  The  patient  gave  a  history  of  dyspnea  with 
vomiting  of  from  a  half  to  one  pint  of  pus  every  morning. 
Examination  of  his  sputum  showed  the  presence  of  tubercle 
bacilli;  he  also  had  septic  temperature.  External  drainage  of 
the  lung  advised  but  declined.  Six  months  later  the  patient 
returned  for  treatment ;  condition  much  worse ;  had  lost  a 
great  deal  of  flesh.  He  was  expectorating  large  quantities 
of  pus  continuously.  Examination  of  chest  showed  evidence 
of  inflammation  of  chest  wall  extending  over  the  fifth,  sixth, 
and  seventh  spaces,  from  the  anterior  axillary  line  forward 
to  and  below  the  left  nipple.  This  area  was  red,  painful,  and 
presented  all  the  signs  of  a  suppurating  focus.  The  suppo- 
sition was  that  the  abscess  had  ruptured  into  the  pleural 
cavity,  and  was  approaching  the  surface.  The  patient's  gen- 
eral condition  was  very  bad.  An  inch  and  a  half  of  the 
sixth  rib  was  resected,  pleura  found  thickened,  but  when 
opened  contained  no  fluid;  lung  congested.  Patient's  con- 
dition became  so  precarious  that  operation  was  stopped; 
rubber  drainage  tube  inserted  in  the  pleura;  wound  closed. 
Ether  anesthesia ;  patient  reacted  from  operation  with  some 
difficulty.  Nine  days  after  the  operation  the  patient  was 
suddenly  seized  with  a  fit  ot  coughing,  and  a  sudden  gush  of 
pus  poured  from  the  mouth  and  at  the  same  time  poured 
through  the  drainage-tube  from  the  wound.  Profuse  dis- 
charge from  the  wound  kept  up,  requiring  frequent  dressing. 
Bichlorid  solution  1:4000  was  used  twice  daily  in  irrigating 
the  cavity ;  patient  showing  no  physiological  effect  of  the 
drug  from  its  us3  in  this  way.  The  patient  was  able  to  taste 
the  irrigating  fluids.  The  patient  went  home,  took  care  of 
the  wound  himself,  washing  it  out  with  bichlorid  solution. 
Eighteen  months  after  the  operation  the  patient  was  prac- 
tically well ;  no  cough,  gained  flesh,  was  able  to  do  manual 
labor.  The  second  case  was  a  man,  aged  30,  not  very  robust. 
Examination  showed  a  cavity  which  extended  from  the  end 
of  the  scapula  as  far  down  as  the  last  rib  and  from  2  inches 
of  the  spinal  column  to  the  miSaxillary  line  on  to  the  right 
side.  No  expectoration  of  pus.  Temperature  varied  from 
subnormal  to  105°  F.  Operation  advised.  Ether  was  ad- 
ministered. Two  inches  of  the  eighth  and  ninth  ribs  were 
resected.  The  pleura  found  healthy  and  empty.  .  Patient's 
condition  became  so  bad  that  the  operation  had  to  be 
stopped.  The  wound  was  closed.  Six  days  after  the  opera- 
tion, wound  perfectly  healed,  but  skin  distended.  Fluctua- 
tion was  noticed.  Wound  was  opened,  and  nearly  2  pinta 
of  brownish,  fetid  pus  gushed  forth.  On  digital  exploration, 
the  finger  entered  directly  into  the  lung  cavity.  The  pleura 
was  adherent  to  the  edges  of  the  wound  so  that  its  cavity  was 
not  implicated.  After  this,  temperature  remained  about 
normal.  Patient's  condition  improved.  Within  a  mouth 
following  the  operation,  the  patient  was  coughing  up  pus 
and  tasted  irrigating  fluids.  Patient  has  not  improved  since. 
The  abscess  cavity  is  still  discharging  a  small  quantity  of 
pus.  He  calls  attention  to  the  fact  that  both  the  patients 
took  ether  badly  and  almost  collapsed  on  the  table,  [j.h.q.] 
6.— Beck  caUs  attention  to  the  fact  that  a  Roitgen- 
ray  picture  is  by  no  means  an  ordinary  photograph 
of  an  object,  but  a  silhouette  only,  and  to  interpret  such 
properly,  a  thorough  knowledge  of  anatomical  conditions 
and  relations  must  be  had.  This  is  particularly  true  of  bones ; 
those  of  the  carpus  and  tarsus  being  especially  hard  to 
understand.  He  gives  instances  of  supposed  fracture  about 
the  wrist  and  ankle  where  the  supposed  fracture  was  due  to 
denseness  of  shadow  produced  by  some  of  the  small  bones. 
The  greatest  diagnostic  difficulties  are  offered  by  the  joints. 
The  more  complicated  a  joint  is,  the  greater  the  difficulty  in 
understanding  a  skiagraph  of  its  various  positions  ;  this  is 
especially  true  of  the  elbow  and  hip  joints.  The  older  the 
fracture  is  the  less  conspicuous  the  fracture-line  will  appear, 
being  more  or  less  overshadowed  by  callus.  Hence,  if  a  case 
fails  to  be  skiagraphed  shortly  altsr  the  injury,  no  evidence 
of  the  fracture  may  be  subsequently  obtained.  Callus  form- 
ation on  the  other  hand  may  be  so  abundant  that,  in  spite  of 
the  absence  of  displacement,  the  fullest  evidence  of  fracture 
may  still  be  furnished  months  after.  In  supposed  fractures 
involving  joints,  a  skiagraph  should  also  be  made  of  the 
corresponding  healthy  articulation.  In  studying  skiagraphs 
of  the  bones  and  joints  of  children,  he  urges  the  necessity 
of  the  knowledge  of  the  time  of  their  ossification.  He  also 
urges  making  the  skiagraph  of  more  thxn  one  position  and 


64 


The  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


(Ja»daet  12,  1901 


illustrates  this  necessity  by  recalling  a  case  of  oblique  frac- 
ture of  the  tibia  in  the  middle  third,  a  skiagraph  of  which, 
taken  from  before  backwards  showed  no  evidence  of  fracture, 
but  one  taken  from  side  to  side  showed  the  fracture  very  dis- 
tinctly. Skiagraphs  of  foreign  bodies  vary  in  size  according 
to  the  distance  from  the  tube,  and  in  skiagraphing  oblong 
bodies  great  errors  as  to  their  extent  may  be  committed. 
Mechanical  and  chemical  errors  must  also  be  considered. 

[j.H.G.] 

7. — Deaver  discusses,  under  this  heading,  appendicular 
abscess.  Opening  and  draining  an  appendix  abscess  does 
not  insure  the  patient  immunity  frcm  subsequent  attacks;  in 
fact,  recurrent  attacks  are  more  likely  to  follow  a  partial 
operation  on  account  of  the  retention  of  a  diseased  appendix. 
He  does  not  believe  that  in  the  case  of  the  walled-off  abscess, 
the  appendix  is  "frequently  discharged  as  slough."  Few 
abscesses  are  completely  walled  oflf.  Many  cases  are  lost  by 
postponing  operation  24  hours  ;  but  few,  if  any,  by  too  early 
surgical  interference.  He  says  he  knows  but  two  things  in  a 
case  of  appendicitis :  ttat  the  appendix  is  11  flamed  and 
that  it  should  come  out.  To  foretell  the  extent  of  the  dis- 
ease is  impossible.  He  divides  abscesses  of  the  appendix 
into  5  varieties  :  1.  Postcecal,  or  postcolic,  the  pus  being 
formed  between  the  layers  of  the  meeocolon ;  it  is  walled-off, 
but  not  so  walled-off  as  to  avoid  infection  of  the  peritoneum 
during  its  evacuation.  He  does  not  approve  of  draining 
such  collections  through  the  loin  space.  2.  Where  the  pus 
is  found  directly  beneath  the  parietal  peritoneum,  being 
limited  by  the  cecum,  coils  of  small  intestines,  the  omentum, 
the  appendix,  the  parietal  peritoneum,  and  masses  of  lymph 
binding  these  together.  In  this  form  a  communication  with 
the  pelvis  is  frequent.  3.  The  collection  of  pus  is  confined 
to  the  pelvis  and  shut  i  ff  from  the  general  peritoneal  ca^'ity. 
The  evacuation  of  such  an  abscess  from  the  vagina  or  rectum 
is  heartily  condemned.  4.  This  variety  is  found  located 
near  the  median  line  of  the  abdomen  and  the  inner  side  of 
the  cecum.  The  retaining  wall  being  composed  of  cecum, 
appendix,  small  intestine,  mesentery,  omentum,  and  the  sig- 
moid flexure  of  the  colon.  In  this  variety  of  w^alled-cff 
absceeses  it  is  sometimes  necessary  to  make  a  second  incision 
to  protect  the  peritoneal  cavity.  5.  In  the  last  variety  of 
appendicular  pus,  there  is  do  attempt  on  the  part  of  nature 
to  confine  the  pus.  It  is  the  most  unfortunate  variety,  and 
if  the  patient  is  not  operated  upon  immediately,  the  chances 
of  recovery  are  reduced  to  nil.  He  then  instances  a  case  of 
an  interne  at  the  German  Hospital,  who  was  taken  sick  with 
abdominal  pain  on  September  30  ;  started  to  work  the  next 
day,  but  was  obliged  to  return  to  bed  with  recurrence  of  pain 
at  noon.  At  1  o'clock  he  was  operated  upon,  and  the  ab- 
dominal cavity  was  found  filled  with  serofibrinous  exudate, 
and  the  appendix  distended  wilh  pus.  Recovery  was  unin- 
terrupted. He  gives  the  mortality  of  operations  done  in  the 
presence  of  pus  as  from  10  to  18%,  while  in  the  presuppu- 
rative  stage  the  mortality  is  5%.  '■  There  is  no  choice  as  to 
the  time  of  operation  in  appendicitis."  He  urges  operation 
as  soon  as  diagnosis  is  made.  He  closes  with  the  following 
conclusions :  1.  Pus  is  an  avoidable  complication  in  the 
treatment  of  appendicitis.  2.  The  patient's  welfare  is  best 
preserved  by  avoiding  any  of  the  complications  incident  to 

EU8-formation.  3.  The  walled- off  abscess  is  not  the  blessing  to 
6  sought,  but  rather  an  evil  to  be  avoided  by  prompt  surgi- 
cal interference  as  scon  as  the  symptoms  of  appendicitis 
manifest  themselves.  4.  Operation  on  cases  of  walled-off 
pus  imperils  the  patient's  chances  for  recovery,  on  account 
of  liability  to  infection  of  the  peritoneal  cavity.  6.  Fecal 
fistula,  as  a  result  of  a  walled-off  appendicular  abscess,  is  an 
unavoidable  sequel  to  appendicitis,  and  should  not  be  per- 
mitted to  occur.  The  latter  statement  is  true  of  all  compli- 
cations and  sequels   of  appendicitis  due  to  pus- formation. 

[j.H.B.] 

8. — Lyster  says  that  as  troops  were  sent  out  from  Manila 
post-hoppitals  were  established  at  regular  intt  rvals  along  the 
route.  Base-hospitals  were  conveited  out  of  public  buildings 
in  the  small  towns  which  were  most  accessible  to  Manila. 
At  Manila  there  are  large  general  hospitals,  one  containing 
as  many  as  1,400  patients  at  one  time.  To  this  hospital  are 
sent  patients  from  the  crowded  baf  e-hospitals.  There  are  also 
a  number  of  hospitals  for  the  treatment  of  special  diseases  ; 
for  surgical  cases ;  for  those  convalescing  from  malarial  fever ; 
for  medical  cases  and  all  diseases  of  the  eye  ;  and  for  soldiers 
who  are  to  be  sent  to  America  for  treatment.    Frcm  this 


latter  the  patients  are  transferred  to  the  general  hospital  at 
San  Francisco.  Contagious  dieeases  are  looked  after  by  a 
special  board  of  investigators.  Medicines,  foods  necessary 
for  the  sick,  instruments,  and  even  ice,  are  now  promptly 
supplied  to  sick  soldiers,  and  it  is  hoped  to  equip  each  base- 
hospital  with  an  ice-machine.  There  is  a  school  of  instruc- 
tion for  the  hospital  corps,  men  giving  them  instruction  m 
the  handling  of  injured  and  also  in  the  nursing  of  the  sick. 
Two  hospital  ships  are  under  the  orders  and  immediate  con- 
trol of  the  medical  department,  one  having  a  capacity  of 
260  beds.  Several  small  lightr  draft  vessels  could  be  used  with 
advantage  in  removing  the  sick  from  point*  along  the  more 
shallow  streams.  The  only  railway  in  Manila  is  supplied  with 
two  special  cars,  fitted  out  with  cots.  A  surgeon  accompanies 
each  trip.  A  difficult  problem  in  Manila  is  public  vacci- 
nation. The  American  soldiers  have  been  remarkably 
free  from  smallpox  because  of  the  frequent  vaccination  at 
home  ;  but  with  the  natives  it  is  far  different,  many  showing 
the  signs  of  the  disease.  Prejudice  and  ignorance  here 
interfere  with  vaccination  as  they  do  in  America  and  Eng- 
land. Vaccine  farms  have  been  established  in  Luzon,  the 
lymph  being  procured  from  the  caribou.  In  this  manner 
the  vaccine  can  always  be  had  fresh.  The  medical  depart- 
ment has  done  a  great  deal  to  improve  the  hygieoe  of  the 
cities  and  towns  throughout  the  island.  The  efforts  of  the 
department  have  resulted  in  limiting  the  bubonic  plague  to  a 
marked  degree.  It  has  been  prevalent  in  Manila  for  several 
months,  but  no  cases  have  been  heard  of  outeide  of  the  city 
limits.  The  use  of  the  odorless  excavator  has  been  intro- 
duced into  Manila.  The  inspection  of  the  abattoir,  of  the 
markets  and  the  foods  for  sale  in  them,  are  duties  which 
develop  on  ihe  medical  officers.  The  house  and  person  of 
the  native  Filippino  are  remarkably  clean,  but  he  is'  in- 
different as  to  his  surroundings  and  whence  his  water  supply 
comes.  Typhoid  is  endemic  in  the  islands,  and  garrisons 
have  to  be  most  careful  in  the  selection  of  their  water  supply. 
Leprosy,  probably  introduced  from  China,  has  spread  until 
there  are  in  Xorthern  Luzon  some  12,000  natives  and  Chinese 
afflicted  with  the  disease,  and  so  far  it  has  been  unrestricted. 
A  special  commission  is  searching  for  an  island  on  which  to 
establish  a  leper  colony,    [j.h.g  ] 

O.— Amberg  describes  a  normal  acoumeter.  The  in- 
■trument  consists  of  a  steel  ball  of  given  weight  falling  at  a 
given  distance  on  a  metalic  block.  The  inttrument  is  con- 
sidered to  be  of  value  on  account  of  the  accuracy  that  can 
be  obtained,  independent  of  the  dissimiliarily  in  the  voices 
of  individuals,    [m.r.d.] 

10. — Stieren  reports  a  case  of  amblyopia  following'  the 
intoxicatlDg  use  of  Jaiuaica  ginger,  with  subsequent 
recovery  of  vision.  The  patient  was  a  contractor  who,  when 
first  seen,  was  totally  blind.  After  a  heavy  debauch,  being 
unable  to  obtain  liquor  of  any  kind,  he  consumed  about  12 
ounces  of  Jamaica  ginger.  This  was  followed  by  stupor, 
total  blindness  and  excessive  thirst.  Upon  examination 
there  was  found  extensive  mydriasis,  unaltered  by  light  or 
accommodation.  The  media  were  clear  and  no  change  was 
seen  in  the  disc  beyond  a  slight  haziness  of  the  edge,  due  to 
slight  retinal  edema.  V.  =  perception  of  moving  hand  at  12 
inches.  The  cornea  was  almost  entirely  anesthetic.  The 
vision  improved  progressively  under  hot  footbaths,  com- 
pound   jalap    powder,  and    pilocarpin     hypodermatically. 

[M.R.D.] 

12. — Holt,  in  discussing  the  application  of  the  douche 
iu  the  treatment  of  ophthalmia  neonatorum,  be- 
lieves that  this  mode  of  therapy  fulfils  the  requirements  of 
cleanliness  which  are  so  essential  in  this  disease.  He  de- 
scribes a  critical  case  that  had  been  treated  by  the  usual 
methods,  such  as  ice  compresses,  silver  nitrate,  etc.,  and 
which  recovered  under  systematic  irrigations  by  means  of  the 
douche,  the  solution  employed  being  1  %  of  boric  acid.  The 
same  fortunate  result  has  been  obtained  in  other  cases  of  the 
author  by  means  of  this  method  when  other  well  known 
methods  had  failed.  In  the  first  case  extensive  involvement 
of  the  cornea  was  believed  to  have  been  present.    [m.R-D.] 


American  Gynecological  and  Obstetrical  Journal. 

Xovember,  1900.     [Vol.  xvii,  Xo.  5.] 

1.  The  Relative  Advantage  of  Vaginal  and  Abdominal  Sec- 
tion :  An  Illustrative  Case.    B.  F.  Bakr. 


JijrtlABT  12,  1901] 


THE  LATEST  LITERATURE 


PThE  PHILiDELPHlA 
USDICAL  JOCRSAL 


65 


2.  Further  Contribution  to  the  Study  of  Pelvic  Hematocele 

and  Its  Relation  to  Tubal  Pregnancy.  Geoeoe  Tucker 
Harbison. 

3.  Injuries  to  the  Bladder  and  Ureters  in  Radical  Surgery  of 

Cancer  of  the  Uterus.    J.  Wesley  Bovee. 

4.  Sarcoma  of  the  Ureters  Associated  with  Fibroma  of  the 

Round  Ligament :  Report  of  an  Unique  Case.  John  G. 
Clark. 

5.  A  Fibromatous  Uterus  in  Labor.    Frank  A.  Stahl. 

6.  Report  of  Icteresting  Cases.    Frank  W.  Talley. 

7.  Ophthalmia  Neonatorum  ;  Its  Prophylaxis  and  Treatment. 

John  E.  Weeks. 

8.  A  Further  Contribution  to  the  Study  of  Full-Term  Ectopic 

Gestation.    Edwin  B.  Cragin. 

1. — Baer  reports  a  case  to  illustrate  the  relative  advantages 
of  vaginal  and  abdominal  section.  The  patient,  a  woman 
of  30,  presented  urgent  symptoms  of  pelvic  suppuration  and 
septic  intoxication,  with  a  hard  tumor  in  the  right  iliac 
region.  Her  condition  making  an  abdominal  section  too 
hazardous,  the  pus  was  evacuated  by  vaginal  incision.  This 
relieved  the  acute  symptoms,  the  patient's  condition  im- 
proved, and  19  days  later  an  abdominal  section  was  made 
and  the  tumor  was  with  difficulty  enucleated  from  ita  attach- 
ment to  the  uterus  and  its  many  adhesions  to  intestines,  and 
removed.    Complete  recovery  resulted,     [w  k.] 

2. — Harrison,  in  this  cootribution  to  the  study  of  pelvic 
hematocele,  agrees  with  Fehling  in  his  estimate  that  in  95% 
of  the  cases,  hematocele  is  due  to  a  tubal  pregnancy,  and 
that  incomplete  tubal  abortion  with  a  resulting  hematocele 
constitutes  the  most  frequent  termination  of  such  preg- 
nancy. In  tubal  abortion  that  causes  hematocele,  the  tubal 
tumor  is  first  of  all  hard,  because  coagulated  blood  dissects 
its  way  between  chorion  villi  and  tube.  Hardness,  in  fact, 
is  proof  of  the  death  of  the  fruit.  The  blood-sac  develops 
gradually,  accompanied  by  the  symptoms  of  pain  of  a  more 
or  less  paroxysmal  character,  and  the  discharge  of  blood  per 
vaginam  at  irregular  intervals,  and  of  a  dark  color.  In 
such  cases  the  indications  for  operative  interference  would 
eeem  to  be  clear,  unless  absorption  occurs  rapidly  and  there 
is  no  serious  disturbance  of  the  health.  The  operation  to  be 
preferred  is  laparotomy,  its  advantages  being  that  you  have 
a  more  complete  survey  of  the  field  of  operation,  can  decide 
with  certainty  as  to  what  is  diseased  and  what  not,  and  are 
better  able  to  control  the  hemorrhage.  Moreover,  convales- 
cence is  much  more  rapid,  as  a  rule,  and  pus- formation  and 
the  retention  of  pus  are  not  likely  to  occur  in  laparotomy. 
[w.k] 

3. — Bovine  says  that  although  statistics  are  not  available, 
there  can  be  no  doubt  that  injuries  to  bladder  and 
ureters  are  more  frequent  in  radical  surgery  for 
cancer  of  uterus  than  in  ordinary  hysterectomy,  as  the 
dissection  is  so  much  wider,  embracing,  as  it  does,  removal 
of  tissues  surrounding  the  ureters  and  bladder,  while  in  the 
ordinary  hysterectomy  for  benign  conditions  one  scarcely 
sees  a  ureter.  Also  these  injuries  are  more  frequent  in 
vaginal  than  in  abdominal  hysterectomy.  Prevention  of 
such  injuries  is  of  the  first  importance,  but  Bov^e  considers 
Kelly's  plan  of  placing  sounds  or  catheters  in  the  ureters 
and  leaving  them  there  during  the  operation  as  inadvisable ; 
because  of  the  extra  strain  on  the  strength  of  the  patient 
incident  to  the  necessary  manipulations.  He  prefers  to 
isolate  the  ureter  except  from  the  peritoneum  early  in  the 
operation,  then  it  can  be  brought  into  view  and  its  injury 
avoided.  If  the  ureter  be  occluded  by  a  ligature,  cut  the 
ligature  and  religate  the  other  tissues  if  necessary.  If  it  be 
compressed  by  a  forceps,  resection  may  be  necessary ;  but 
usually  the  reparative  power  of  this  duct  can  be  reHed  upon 
to  overcome  the  condition.  Longitudinal  or  partial  trans- 
verse incisions  should  be  sutured  at  time  of  operation. 
Complete  transverse  section  will  require  anastomosis  with 
itself  if  high  in  the  pelvis  and  with  the  bladder  if  in  its  lowest 
2  inches.  In  bladder-punctures  or  incisions  immediate 
closure  with  permanent  bladder  drainage  for  a  few  days  will 
usually  suffice.  In  late  bladder  sloughs  and  bladder  injuries 
discovered  after  operation,  a  second  operation  is  usually 
needed,  though  frequently  permanent  catheterization  cures. 
[wk] 

4. — Clark  reports  an  unique  case  of  sarcoma  of  the  uterus 
with  fibroma  of  round  ligament  occurring  in  a  woman  aged 
59.    Sarcoma  of  the  uterus  is  very  rare,  only  154  cases  being 


on  record.  The  one  here  reported  was  a  sarcoma  from  its 
incfption  and  was  on  the  uterine  wall.  In  view  of  the  fact 
that  careful  examination  of  the  bloodvessels  showed  no 
traces  of  round  cells  sowing  blood  infection,  the  prognosis  is 
extremely  favorable.  This  case  is  quite  unique  and  a  similar 
one  may  not  occur  in  1,000  cases.  The  2  types  of  tumor  were 
quite  distinct,  and  one  could  make  out  without  the  slightest 
trouble  the  pure- round  cell  sarcoma  and  the  fibroid  tumor. 
[w  K.] 

6.-— Stahl  reports  a  case  of  fibromatous  tumor  in  labor. 
The  tumor  was  a  pedunculated  fibroid  springing  from  the 
cervicocorporeal  junction,  producing  at  one  time  great  pain 
and  serious  reflex  disturbances  from  pressure  against  the 
superior  strait  to  the  right  anteriorly,  and  was  first  seen  in 
the  fourth  month  of  pregnancy.  The  acute  symptoms  were 
reUeved  by  palliative  treatment,  the  pregnancy  continued 
through  the  seventh  month  when  premature  labor  was  in- 
duced by  climbing  high  steps  in  very  warm  weather.  The 
labor  was  normal  and  a  well-developed  7  months'  fettis  was 
spontaneously  delivered,  but  it  succumbed  6  hours  after 
birth.  The  puerperium  was  normal  and  Stahl  is  of  the 
opinion  that  the  patient  can  now  stand  the  operation  of  the 
vaginal  enucleation  far  better  than  at  the  fourth  month. 

[W.K.] 

6. — Talley  reports  2  cases,  one  of  which  was  an  instance 
of  gonorrheal  salpingitis  with  coexisting  pregnancy,  in  which 
the  pathologic  study  showed  advancing  gonorrheal  infection, 
proceeding  from  the  fimbriated  end  of  tne  right  tube  toward 
the  uterine  cornua  ;  in  the  second  case,  an  ovarian  cyst  had 
been  carried  high  in  the  abdomen  by  the  pregnant  uterus, 
forming  an  attachment  to  the  liver,  and  giving  symptoms 
immediately  after  delivery  through  the  shrinkage  of  the 
uterus  and  "tension  on  the  pedicle,     [w  k.] 

7.— According  to  Weeks  the  caute  of  ophthalmia  neona- 
torum is  usually  the  gonococcus  of  Neisser,  and  the  treatment 
should  be :  1.  Mechanical.  The  conjunctival  sac  should  be 
cleansed  frequently,  the  more  so  bee  ause  of  the  absence  of  tears. 
This  should  be  effected  by  the  employment  of  a  nonirritat- 
ing  aseptic  or  mildly  antiseptic  solution.  Many  consider  a. 
3%  solution  of  boric  acid  as  most  desirable  for  this  purpose. 
2.  The  conditions  for  the  development  of  the  inicroorganism 
should  be  made  as  unfavorable  as  possible ;  this  can  best  be 
done  by  reducing  the  temperature  of  the  conjunctiva.  This 
is  comparatively  easy  by  the  application  of  little  cold  pads 
changed  every  1  or  2  minutes,  and  in  the  acute  stage  used 
from  1  to  4  hours,  3  times  daily,  but  discontinued  as  soon  as 
the  swelling  of  the  lids  subsides.  3.  The  destruction  of  the 
microorganism  as  far  as  is  possible  by  the  application  of  a 
germicide  to  the  surface  of  the  conjunctiva.  Weeks  uses  a 
1  fo  solution  of  silver  nitrate,  applying  it  once  a  day  after 
removing  all  secretion  from  the  conjunctiva.  4.  Constitu- 
tional treatment,  which  should  be  directed  to  the  general 
improvement  of  the  child's  condition,    [w  k.] 

8. — Cragin  reports  a  second  case  of  full-term  ectopic 
gestation  in  which  the  child  was  delivered  alive;  and  he 
believes  that  the  viable  ectopic  fetus  is  worth  saving ;  that 
within  certain  limits  attempts  to  save  the  child  do  not  seri- 
ously increase  the  mortality  or  morbidity  of  the  rnother ; 
hence  in  the  treatment  of  full-term  ectopic  gestation  the 
child  should  receive  more  consideration  that  it  at  present 
enjoys,     [w.k.] 


Centralblatt  fiir  Gynakologie. 

November  10,  1900.     [Xo.  45  ] 

1.  Spiritus  Saponis  as  a  Hand  Disinfectant.    An  Answer  to 

"  Correction  "  of  Paul  and  Sarway.    F.  Ahlfeld. 

2.  Vaginal    Infection.    An  Open   Answer  to  Dr.    Kronig's 

"  Remarks."    F.  Ahlfeld. 

3.  An  Early  Indication  of  Ascites.    L.  Landad. 

4.  A  Jointed  Phantom  for  Demonstration  in  Obstetrical  In- 

struction.   LuDWiG  Ksapp. 

1.— In  answer  to  the  conclusion  of  Paul  and  Sarway  that 
hot  water  and  alcohol  would  not  disinfect  the  hands,  Ahlfeld 
replies  that  in  his  experiments  with  spiritus  saponis,  as  advo- 
cated by  them,  the  results  do  not  compare  in  efficiency  with 
those  obtained  by  hot  water,  soap  and  alcohol  (76-96%)  and 
that  alcohol,  although  much  diluted,  is  the  effective  agent 
in  the  disinfection  by  spiritus  saponis.     [w.k.] 


«6 


Tub  Philadblphia 

AlBDICAL  JODBNAL 


] 


THE  LATEST  LITERATURE 


fjAirrAEY  12, 


2. — Ahlfeld  quotes  a  series  of  experiments  to  show  that  of 
38  tests,  in  28  cases  the  hands  were  made  germ-free  by 
means  of  alcohol,  so  that  in  scraping  them  no  germs  could 
be  obtained  which  would  develop  in  culture  media,  and  that 
in  22  of  the  28  cases  the  hands  were  still  sterile  an  hour  after- 
ward. Hence  aa  a  practical  result  of  these  experiments  he 
concludes  that  contrary  to  Krouig's  opinion,  we  can  under- 
take, not  only  a  mere  examination,  but  a  long-continued 
obstetrical  operation  without  fearing  that  the  field  of  opera- 
tion will  in  this  time  be  infected  by  germs  set  fires  from  the 
hands,    [w  k  ] 

3. — In  Landau's  opinion  it  is  very  important  to  recognize 
the  existence  of  ascites  in  its  early  stages,  and  he  shows  how 
to  make  the  diagnosis  before  the  disease  is  far  advanced. 
When  the  measure  of  fluid  in  the  abdomen  is  small,  it  is  im- 
possible to  grasp  around  the  uterus  while  the  patient  is  Ij'ing 
in  the  ordinary  horizantal  position,  since  the  somewhat  drawn 
back  uterus  presents  to  the  fingers  the  feeling  of  lying  on  an 
air  or  water  cushion.  But  if  the  patient  be  placed  with 
flexed  thighs  and  knees,  as  the  pelvis  is  elevated  the  condi- 
tions are  completely  changed,  the  water  recedes  to  the  dia- 
phragm and  the  palpating  fingers  now  touch  each  other 
around  the  uterus.  The  bladder  must  be  carefully  emptied 
before  the  examination.  As  the  diseass  advances  and  the 
amount  of  fluid  increases,  naturally  the  difference  of  palpa- 
tion in  the  two  positions  is  diminished,  but  then  there  are 
other  indications  present.  Bit  the  one  above  described  he 
considers  of  great  importance  fjr  early  diagnosis  of  ascites. 

fWK] 

4. — Knapp  treats  briefly  of  the  advantages  derived  from 
the  use  of  a  jointed  phantom  in  obstetrical  instructions.  Thus 
all  the  various  positions  before  and  during  delivery  may  be 
clearly  demonstrated  to  the  student,     [w.k  ] 

November  17,  1900     [No.  46.] 

1.  A  Very  Rare  Form  of  Perineal  Rupture.    F.  Englem.^nn. 

2.  Vaginal  Obliteration  for  Prolapse.    8.  Stocker. 

3.  A  "Gebiirmantfel."    An  New  Apparatus   for    Increasing 

Abdominal  Pressure  During  the  Period  of  Expulsion. 
Alfred  Jaks 

4.  A  Very  Simple  Leg  Support.    Kalabin. 

1.— Englemann  reports  a  rare  form  of  perineal  rupture 
occurring  in  connection  with  the  spontaneous  delivery  of  a 
large  child.  The  attendant  said  there  must  be  an  inner 
rupture  since  the  child  was  born  with  a  sudden  jerk,  and 
there  was  no  external  injury  present.  Eiamination  showed 
a  perineum  8  cm.  in  breadth,  intact,  except  in  the  frenulum 
there  was  a  small  tear  and  near  the  anus  an  irregular  open- 
ing communicating  with  the  vagina,  a  kind  of  inner  perineal 
laceration.  Knowing  that  a  central  rupture  may  heal  spon- 
taneously, Eoglemann  trusted  that  this  would  also,  his  only 
fear  being  that  the  fistula  might  become  a  passage  for 
lochial  secretions,  but  the  fear  proved  groundless  and  in  14 
days  the  fistula  was  completely  closed,     [w.k.] 

2. — In  1890  two  new  procedures  were  shown  as  remedies 
for  prolapse  in  elderly  women.  O  le  by  Freund  ralieved  the 
prolapse  in  nonmenstruating  women  by  drawing  downward 
the  uterus  and  stitching  it  to  the  vagina,  the  secretions  being 
discharged  through  a  new  opening  in  the  fundus.  In  the 
same  year  Wormser  published  a  procedure  by  P.  Muller  in 
■which  the  prolapse  was  remedied  by  excision  of  the  vagina 
and  the  inclusion  of  the  uterus  and  reported  many  cases 
thus  treated  with  good  results.  Stocker  fearing  that  hydro- 
metra  might  develop  in  the  uterus  thus  devoid  of  any  ex- 
ternal passage,  devised  a  modification  of  the  method,  adapted 
to  elderly  women  who  still  menstruated.  He  reports  the 
case  of  a  patient,  aged  52,  describes  the  operation,  the  first 
step  of  which  was  to  make  a  long  incision  in  the  left  side  of 
the  vaginal  portio.  The  edges  of  this  wound  were  stitched 
with  catgut,  uniting  the  micous  membrane  with  that  of  the 
cervical  canal.  Then  a  strip  of  thevaginil  mucous  mem- 
brane on  the  left  side,  about  5  cm.  bro.ad,  was  allowed  to 
remain ;  all  the  rest  was  removed  and  the  denuded  surfaces 
united  with  sutures,  thus  leaving  a  very  small  passage  for  the 
discharge  of  all  secretions.  This  operation  was  quickly  and 
easily  performed,  and  the  results  very  satisfactory,    [w  k] 

3. --Jaks,  realizing  that  a  proper  position  of  the  woman  in 
labor  is  a  great  advantage  in  securing  tha  necessary  abdom- 
inal pressure  at  the  period  of  expulsion,  has  contrived  an 


apparatus  which  serves  the  purpose  of  securing  the  bob 
position.  In  an  illustrated  article  he  describes  the  appin^i 
tus,  showing  how  by  means  of  some  strong  material  passiag 
under  the  shoulders  and  hips  and  secured  to  the  footboaw' 
of  the  bed  by  2  sets  of  straps,  support  is  given  to  the  ba<^ 
hips  and  shoulders,  the  symphysis  is  brought  nearer  to  the 
chest,  great  contraction  of  the  abdominal  muscles  secured, 
and  the  abdominil  cavity  lessened.  Tue  diagrams  maka 
clear  its  other  advantages  and  the  writer  thinks  it  not  int' 
probable  that  by  the  help  of  this  apparatus  the  forceps  canbt 
dispensed  with  in  many  cases  in  which  they  would  othe|i> 
wise  be  necessary,     [w  k.] 

4. — Kalabin  describes  a  very  simple  leg  support  which  hA 
has  used  for  14  years  and  which  serves  as  an  assistant  ia 
many  operations.  It  is  of  service  especially  in  all  perined 
or  vagical  operations,  making  it  possible  to  do  the  work  willi 
one  less  assistant.  The  apparatus  is  simple  and  inexpei^ 
sive.     [w  K  ] 

November  Si,  1900.    [No.  47.] 


I 


1.  Case  of  Chorioepith^lial  Vaginal  Tumors.    H.  Schmit. 

1. — It  has  been  stated  in  numerous  publications  that  after 
the  conclusion  of  pregnancy,  at  the  point  of  placental  attach- 
ment, there  are  sometimes  primarily  developed  chorioep^  i 
thelioma,  which  are  of  a  very  malignant  nature,  and  quickly  I 
lead  to  metastatic  growths  on  the  vaginal  walls  or  in  ths  I 
lungs.  Pick  and  Sjhmorl  have  added  2  new  ftcts :  FinI)  I 
that  after  molar  pregnancy  through  migration  of  the  vesicular  ' 
fragment?,  a  metastatic  tumor  may  appear  in  the  vagina; 
and  second,  that  in  other  cases  after  pregnancy,  multiple 
tumors  appear  in  lungs,  liver,  and  intestines,  and  cause  death 
without  their  being  any  primary  tumor  of  the  uterus.  Schmit 
gives  a  full  description  of  a  case  of  his  own,  and  reports  2 
others.  1.  The  case  of  Schmorl,  in  which  there  was  a  nor- 
mal delivery  at  the  end  of  pregnancy.  The  uterus  wm 
sound,  but  multiple  chorioepitholioma  in  vagina,  lungs, 
liver,  kidney,  and  intestines  caused  the  patient's  death.  2. 
The  case  of  Schlagenhaufer  was  one  of  incomplete  abortion. 
The  uterus  was  sound,  but  there  was  an  isolated  vaginal 
tumor,  from  which  the  patient  recovered.  3.  S  ihmit's  case 
was  a  molar  pregnancy  with  spontaneous  delivery.  Tae 
uterus  was  sound  and  healthy,  but  there  were  2  vaginal  ma- 
lignant syncytial  tumors,  the  removal  of  which  was  followed 
by  the  patient's  recovery.  In  both  the  last  cases  the  tumor 
limited  ti  the  vagina  could  be  determined  early  and  opera- 
tive help  brought  at  the  right  time  with  resultant  recovery. 
Now  the  question  remains  whether  or  not  in  both  these 
cases  a  migration  of  fragments  into  the  other  organs  had 
taken  place.  The  probability  is  that  it  had  not,  since  the 
inner  organs  remained  healthy,  but  we  must  remember  the 
possibility  that  such  fragments  might  be  carried  through  the 
blood  to  other  organ?  and  then  piss  away  without  doing  any 
inj'iry,  as  S 'hlageihaufer  remarks,  that  not  alone  the  ana- 
tomical, but  also  the  individual  disposition  of  the  organism 
and  its  peculiar  tissue  must  determine  the  existence  or  non- 
existence of  metastasis,     [w  k] 


Archiv  filr  kllDlsche  Chirurgrie. 

(Bind  62,  Heft  1.] 

1.  A  Study  of  Surgery  of  the  Stomach.    Geo.  Kklusq. 

2.  Stricture  of  the  Pylorus  Following  Corrosion.  F.  v.  E[SELB> 

BERG. 

3.  A    Research    Into    the   Suturing  of    Blood vessel> 

Nerves,  and   the  Uses  in  Surgery  of  an  Absor: 
Metal.    EwiK  Payr. 

4.  Displacement  of  Intestinal  Loops  Following  Gastroenter- 

ostomy.   W.  Peteksex. 
5   The  Operative  Treatment  of  Habitual  Dislo^tion  of  the 
Shoulder.    O  Samter. 

6.  Pseudo  Voice  Folloiving  Total  Extirpation  of  the  Larynx. 

George  Gottstkix. 

7.  Acute  lufltmmatory  Atrophy  of  Bone.    P.  SroECK. 

8.  The  Operative  Treatment  of  Cysts  of  the  Pancreas.    R 

B    Hages. 

9.  The  Teohnic  of  Operations  for  Umbilical  and  Ventitl 

Hernias.    F.  B.  Hages. 
10.  The  Pathogenesis  and  Therapy  of   Various  Forms  of 
Gangrene  of  the  Lower  Extremities.    BrxoK. 


January  12,  1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
L  Medical  Journal 


67 


11.  A  Contribution  to  the  Surgery  of  ^the  ISpleen.    F.  B. 

Hagen. 

12.  The  Radical  Operation  of  R3ctal  Carcinoma.    Heinrich 

Wolff. 

1. — Kelling  has  carried  out  an  elaborate  research  on  the 
stomach,  which  is  divided  into  two  parts.  The  first  deals 
with  gastroenterostomy  and  the  second  with  resection  of 
the  stomach  and  gastric  ulcer.  In  his  work  on  gastroenter- 
ostomy, his  research  consisted  in  experimentation  on  some 
80  dogs.  If  was  found  that  the  pressure  of  the  stomach  dur- 
ing digestion  in  a  dog  was  equal  to  a  column  of  water  from 
S  to  10  cm.  high.  During  vomiting  this  was  increased  i, 
sometimes  J.  On  exciting  the  vagus  nerve,  the  pressure 
reached  10  to  18  cm.  The  greatest  danger  for  the  suture  lies 
in  the  possibility  of  introduction  of  solid  bodies.  According 
to  Chlumsky,  the  sutures  in  this  position  may  hold  a  pressure 
from  37  to  68  cm.  Peritonitis  lowers  considerably  the 
strength  of  the  suture.  It  was  found  that  gastroenterostomy 
in  the  fundus  of  the  stomach  allowed  a  more  rapid  empty- 
ing of  the  organ,  and  because  of  the  frequent  presence  of 
large  particles  of  food,  there  existed  a  tendency  to  dilation 
of  the  fistula.  If  there  is  an  angular  fixation  between  the 
pyloric  portion  of  the  stomach  and  the  upper  duodenum, 
the  emptying  of  the  stomach  is  greatly  hindered,  and  in 
■cases  where  this  angular  flsxion  exists,  pyloroplasty  should 
not  be  done.  Gastroenterostomy  performed  .vith  a  button 
possesses  many  advantages  over  that  of  simple  suturing ; 
•chief  among  these  is  the  prevention  of  the  formation  of  a 
ring  of  mucuous  membrane  which  projects  into  the  stomach. 
Murphy's  button  presents  disadvantages  in  that  it  acts  as  a 
large  and  heavy  foreign  body,  and  is  is  therefore  better  to 
use  some  form  of  button  which  can  be  absorbed,     [g  b  w  ] 

2.— Von  Eiselsberg  reports  6  cases  of  stenosis  of  tlie 
pylorns  following  the  corrosive  action  of  some  chemical. 
In  2  cases  hydrochloric  acid  was  the  chemical,  in  1  sulfuric 
acid,  ill  another  nitric  acid,  and  in  2  the  substance  was  un- 
known. The  patients  appeared  in  from  4  to  12  weeks  after 
the  accident.  The  diagnosis  was  in  all  cases  easy,  and  there 
was  always  typical  symptoms  of  stenosis  of  the  pylorus  pres- 
ent. In  5  of  the  cases,  the  pylorus  was  alone  injured,  the 
esophagus  remaining  free.  In  1  case  both  pylorus  and 
esophagus  showed  the  eftects  of  the  corrosion.  For  the  relief 
of  this  condition,  resection  of  the  pylorus  was  done  once, 
gastroenterostomy  4  times,  and  in  1  a  second  laparotomy 
was  necessary.  Oae  case  died  from  suppurative  bronchitis, 
the  rest  were  cured,  3  for  2  years,  and  2  for  a  few  months  at 
least.  The  operation  of  choice  in  case  of  corrosive  stricture 
•of  the  pylorus,  is  gastroenterostomy.  Resection  is  the  simplest 
procedure,  but  in  many  cases  it  is  contraindicated  on  ac- 
count of  the  length  of  the  stricture.  Simple  jpjunostomy  is 
seldom  more  than  a  palliative  operation,     [g.b  w.J 

3. — Payr  afier  a  long  research  on  animals  and  careful 
study  of  clinical  cases,  suggests  the  following  method  of 
uniting  severed  bloodvessels,  which  seems  most  prac- 
tical and  easily  carried  out.  First,  it  is  necessary  to  provide 
for  temporary  closure  of  the  artery  or  vein.  This  is  best 
done  by  means  of  a  small  spring  forceps  the  blades  of  which 
should  be  covered  with  rubber  tubing.  Supposing  the  artery 
to  be  severed  transversely,  if  the  artery  be  of  small  sizs,  3 
fine  silk  sutures  are  passed  through  the  whole  thickness  of 
the  vessel- wall  at  the  distal  end.  A  small  metal  tube,  slightly 
larger  than  the  artery,  is  slipped  over  the  threads  and  over 
the  end  of  the  bloodvessel ;  bj'  means  of  the  thread  the 
artery  is  then  turned  cuff  like  back  over  the  tube,  so  that  the 
intima  faces  outward.  The  tube  possesses  a  groove  so  that 
by  a  circular  ligature  the  bloodvessel  may  be  securely 
fastened  to  it.  The  peripheral  end  is  secured  in  a  like 
manner  by  3  sutures,  and  drawn  over  the  distal  end 
and  fastened  there  by  means  of  a  circular  ligature.  This 
brings  the  intima  of  the  distal  and  of  the  peripheral  ends  of 
the  bloodvessel  into  direct  relation  with  each  other,  so  that 
a  broad  and  firmer  union  may  readily  take  place.  Toe 
metal  tube  should  consist  of  metallic  magnesium.  By  a 
number  of  experiments  it  was  found  that  magnesium  when 
imbedded  in  the  living  tissue,  is  comparatively  quickly  ab- 
sorbed. The  disappearance  of  the  metal  is  due  to  the 
formation  of  a  soluble  magnesium  salt  formed  by  the  oxygen 
and  carbonic  dioxid,  which  are  present  in  the  tissue.  Payr 
also  presents  another  apparatus  for  closure  of  bloodvessel, 
resembling  somewhat  a  Murphy  button,  and  which  has  the 


advantage  of  being  somewhat  more  easily  used  than  the 
above  described  method,  but  it  does  not  give  quite  so  satis- 
factory results.  Also  in  suturing  nerves,  the  use  of  magne- 
sium tube  presents  many  advantages,  because  of  its  being 
absorbed  by  the  tissues.  As  to  the  rapidity  with  which  the 
magnesium  disappears  when  placed  in  living  tissues  it  has  • 
been  found  that  a  piece  of  magnesium  wire,  1  mm.  in  thick- 
ness, would  in  15  days  be  broken  into  a  number  of  pieces, 
and  the  thickness  lessened  J  to  i  of  its  original  diameter, 
fa  B  w.] 

4.  -Petersen  reports  3  interesting  cases  of  malposition 
of  the  intestines  following  gastroenterostomy.  In 
all  the  cases  the  new  position  of  the  intestine  was  the  same 
though  different  in  degree.  The  condition  consisted,  first,  in 
the  twisting  of  the  axis  of  the  displaced  intestinal  loop  to 
about  90° ;  and,  second,  that  the  displaced  gut,  which  con- 
sisted of  the  efferent  limb  of  the  anastomosis,  passed  through 
a  ring  formed  by  the  stomach,  the  afferent  limb  and  the  pos- 
terior abdominal  wall.  Tais  displacement  did  not  lead  to 
direct  strangulation  of  the  intestine,  or  to  a  disappearance  of 
the  intestinal  circulation.  The  important  pathologic  condi- 
tion consisted  in  a  twisting,  bending,  and  bruising  of  the 
mesentery,  which  necessarily  followed  the  gut  through  the 
opening.  In  the  first  place,  the  displacement  was  so  slight 
that  no  positive  clinical  symptoms  were  manifest.  In  cases 
2  and  3,  so  much  intestine  was  drawn  through  the  ring  that 
extensive  thrombosis  of  the  mesenteric  veins  was  caused,  giv- 
ing rise  to  hemorrhagic  infarct,  paralysis,  and  beginning 
necrosis  of  the  intestine.  In  the  second  case,  the  thick  and 
twisted  mesentery  so  pressed  upon  the  duodenum  as  to  ob- 
struct its  lumen,  and  cause  retention  of  the  bile  to  such  an 
extent  that  the  distention  following  caused  the  suture  to  give 
way,  perforation  and  peritonitis  resulting.  Peterson,  after 
looking  through  the  literature  carefully,  ould  fiud  no  case 
exactly  corresponding  to  the  above.  He  believes  that  the 
most  important  element  in  the  production  of  this  displace- 
ment of  the  intestines  is  to  be  found  in  the  technic  of  the 
operation.  This  is  especially  true  when  use  is  made  of  the 
Murphy  button.  When  simple  suture  is  done,  the  iatestme 
is  fastened  to  the  stomach,  one  lying  parallel  to  the  other, 
and  the  early  stitches  prevent  displacement,  but  when  one 
uses  the  Murphy  button,  the  twisting  and  pushing  which 
attends  the  operation  places  the  intestinal  loops  in  such  a 
relation  to  each  other  as  to  predispose  the  condition  above 
cited.  He  further  says  that  sometimes  the  gauz?  tampons 
are  so  placed  as  to  involve  some  intestinal  loop,  so  that  its 
withdrawal  may  bring  the  efferent  loop  through  the  ring 
above  described.  The  lessons  to  be  learned  from  his  study 
are,  first,  that  the  field  of  operation  should  be  sufiiciently 
large  to  enable  the  operator  to  clearly  see  the  position  of  the 
loops  concerned  in  the  anastomosis ;  and,  secondly,  that  all 
openings  caused  by  the  operation  should  be  closed  as  far  as 
possible,    [g.b  w.] 

6.— Simter  describes  the  following  operation  for  the 
treatment  of  habitual  dislocation  of  the  shoulder. 
The  first  step  consisted  in  establishing  a  free  approach  to 
the  j  )int ;  the  usual  oblique  incision  on  the  anterior  surface 
of  the  shoulder,  between  the  pectoralis  major  and  deltoid, 
does  not  suffice  far  this  purpose,  and  should  be  supple- 
mented by  a  transverse  incision  running  from  the  upper 
end  the  first  incision  horizontally  outwards,  and  which  is 
combined  with  loosening  of  the  deltoid  from  the  anterior 
angle  of  the  clavicle.  Second,  the  joint  capsule  should  be 
opened  in  every  case,  as  otherwise  the  opportunity  for  in- 
spection of  the  joint  itself,  and  the  chance  of  the  discovery 
of  foreign  bodies  would  be  lost.  Third,  the  capsule  should 
be  folded  upon  itself,  as  recommended  by  Mikulicz,  and  a 
suture  placed  through  the  lower  edge  of  the  incision  in  the 
capsule  is  carried  through  the  coraco-acromial  hgament 
and  tied  ;  also  the  tendon  of  the  subseapular  muscle  should 
be  fastened  by  a  suture  to  the  capsule.  In  cases  where  the 
bone  is  very  much  changed,  the  shortening  of  the  capsule  is 
often  favorably  combined  with  some  slight  osteoplastic 
operation  on  the  ends  of  the  bone,    [g  b  w.l 

6.— The  case  reported  by  Gottstein  was  remarkable  in  that 
the  patient  after  complete  removal  of  the  larynx  was 
finally  able  to  speak,  apparently  without  the  use  ot  tne 
lungs  and  the  ordinary  sound-producing  organs.  Ihe  man 
was  47  years  of  age  and  had  been  suffering  for  4  years  from 
a  gradually  increasing  hoarseness  until  lately  dyspnea  devel- 
oped.   Pain  had  never  been  present,  even  in  swallowing  or 


68 


The  PaiLiDELPHLA."] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Jasuaet  12,  1901 


coughing.  The  laryngeal  examination  and  endolaryngeal 
removal  of  a  portion  of  the  tumor  for  diagnosis  showed  the 
growth,  which  involved  the  greater  part  of  the  larynx,  to  be 
carcinomatous.  The  operation  was  done  under  chloroform. 
Laryngotomy  was  performed  and  the  growth  was  seen  to  be 
so  extensive  that  total  extirpation  of  the  larynx  only  could  be 
considered.  After  dissecting  the  larynx  free  from  the  sur- 
rounding muscles,  the  trachea  was  cut  through  just  below  the 
first  cartilage,  and  the  larynx  turned  upwards  and  removed 
just  below  the  epiglottis.  The  tracheal  stump  was  stitched 
into  the  lower  part  of  the  wound.  The  mucous  membrane 
of  the  pharynx  was  closed  by  a  layer  of  catgut,  and  the 
muscles  united  over  it  by  another  catgut  suture.  The  greater 
part  of  the  second  wound  was  also  united  by  sutures.    The 

Eatient  stood  the  operation  well  and  was  discharged  from  the 
ospital  with  a  specially  adapted  talking  apparatus.  The 
apparatus  consisted,  first,  in  a  piece  which  fitted  into  the 
tracheal  opening ;  second,  in  a  rubber  tube  stifiened  by  spiral 
wire;  and,  third,  in  a  metal  tube  which  reached  into  the 
mouth  to  the  last  molar  tooth,  and  which  possessed  an  oval 
opening  on  the  side  near  the  internal  end,  through  which  the 
air  coming  from  the  trachea  found  exit  into  the  mouth.  In 
the  rubber  tube  two  small  apparatus  were  placed.  One  was 
a  valve  which  enabled  the  air  during  inspiration  to  enter  di- 
rectly into  the  tube,  without  first  passing  through  the  mouth, 
and  the  second  was  a  vocal  apparatus,  by  which  an  art:  ficial 
Bound  was  produced  from  the  air  passing  through  the  rubber 
tube.  With  this  apparatus  the  patient  could  talk  loud  and 
distinct,  though  in  a  somewhat  monotonous  voice.  As  this 
apparatus  caused  more  or  less  annoyance  to  the  patient,  ad- 
vantage was  taken  of  the  fact  that  the  patient  was  able  to 
produce  certain  sounds  by  the  mouth  alone,  and  after  train- 
ing and  much  exercise  in  vocal  maneuvers,  the  patient 
returned  one  day  to  the  hospital  able  to  speak  in  a  distinct  and 
loud  voice  without  any  sort  of  artificial  apparatus.  After  more 
practice,  the  patient  was  enabled  to  change  the  pitch  of  his 
voice  to  the  extent  of  almost  a  whole  octave.  A  study  into 
the  production  of  this  voice,  showed  that  the  tone  itself  was 
produced  by  the  muscles  of  the  larynx  contracting  in  the 
region  of  the  epiglottis.  The  air,  which  set  in  vibration  the 
tone-producing  folds,  was  obtained  from  a  space  which  had 
formed  just  below  the  epiglottis.  This  wind-chamber  was 
filled  and  emptied  by  the  muscles  of  the  neck.  It  was  also 
found  that  a  second  space  had  developed  below  the  first  air- 
chamber,  and  this  reserve  depot  enabled  the  patient  to  utter 
a  number  of  words  one  after  another  without  drawing  in  new 
air.    [g  B.W.] 

7. — It  is  a  known  fact  that  in  the  region  surrounding 
tuberculous  disease  of  the  bone,  a  marked  atrophy  or  dis- 
appearance of  the  bone  substance  takes  place,  not  only  in 
the  diseased  bone  itself  but  in  the  adjoining  and  otherwise 
healthy  portion.  This  atrophy  is  diagnosed  by  the  use  of 
the  x-rays,  and  Sudeck  reports  a  number  of  cases  of  atrophy 
of  the  bone  following  inflammatory  disease  of  the  surround- 
ing soft  parts.  In  these  cases  the  condition  was  very  acute, 
developing  within  6  or  8  weeks,  but  disappearing  in  time 
under  proper  treatment.  This  condition  is  not  one  of  func- 
tional atrophy  following  a  lack  of  use  of  the  part,  nor  can  it 
be  ascribed  to  atrophic  changes,  as  the  result  of  reflex  irrita- 
tion through  the  spine.  It  is  most  probable  that  an  inflam- 
matory irritation  exists  to  a  much  greater  distance  than  the 
diseased  area  itself,  and  this  irritation  brings  about  certain 
disturbances  in  nutrition  which  lead  to  the  atrophic  changes, 
[o  B.w] 

8. — Hagen  reports  a  most  interesting  case  of  pancreatic 
cyst  occurring  in  a  boy  13  years  of  age.  Before  the  opera- 
tion the  diagnosis  was  poEsible  only  in  so  far  that  an  inflam- 
matory lluid  was  thought  to  be  present  either  in  the 
abdominal  cavity  or  in  one  of  the  abdominal  organs.  Lap- 
arotomy was  performed  and  after  opening  the  abdomen,  a 
cyst  about  the  size  of  a  child's  head  was  found,  posterior  to 
the  stomach,  firmly  surrounded  by  adhesions,  so  that  it  was 
impossible  to  bring  the  cyst  wall  in  contact  with  the  abdomi- 
nal wall,  and  equally  impossible  to  remove  the  cyst  as  a 
whole.  The  only  hope  of  saving  the  child's  life,  however, 
was  in  the  evacuation  of  the  cyst.  Approach  to  the  cyst 
was  finally  gained  by  first  incising  the  anterior  gastric  wall, 
and  then  through  the  cavity  of  the  stomach  the  posterior 
gastric  wall  was  reached  and  the  cyst  opened.  The  contents 
of  the  cyst  were  easily  removed.  A  finger  passed  in  through 
the  openings  found  the  least  external  resistance  on  the  left 


side  of  the  cyst,  and  with  difficulty  the  stomach  was  here 
displaced  a  little  towards  the  right,  so  that  pushing  firmly  on 
the  abdominal  wall  the  cyst  could  be  brought  in  contact 
with  the  parietal  peritoneum.  The  2  wounds  in  the  etomach 
were  sutured,  first  that  on  the  posterior  wall,  and  afterwards 
that  in  the  anterior  wall.  In  order  to  allow  the  abdominal 
wall  to  fall  in  to  a  sufficient  extent  to  come  in  contact  with 
the  cyst,  it  was  found  necessary  to  resect  a  part  of  the  ninth 
and  tenth  rib  cartilages.  The  cyst  was  then  sutured  to  the 
abdominal  wall,  and  opened.  Examination  of  the  cyst 
showed  that  it  was  evidently  the  result  of  a  chrotdc  intersti- 
tial inflammation  of  the  pancreas.  The  patient  stood  the 
operation  well,  and  2  months  afterwards  the  cyst  had  disap- 
peared and  the  pancreatic  fistula  had  closed,  and  the  patient 
had  gained  20  pounds  in  weight,     [g.b.w.] 

9. — Hagen  proposes  the  following  procedure  for  the  closure 
of  ventral  and  umbilical  hernia.  He  based  his  opera- 
tion on  the  idea  of  covering  the  defective  and  thin  cicatrix 
by  muscular  flaps.  After  incision  through  the  abdominal 
wall,  the  peritoneum  and  fascia  are  united  by  sutures.  After 
extensive  lateral  loosening  of  the  skin,  the  external  sheath 
of  the  rectus  is  divided  at  about  the  middle  of  the  belljf  of 
the  muscle  ;  carefully  avoiding  the  nerve- branches,  a  portion 
of  each  muscle  is  loosened  so  that  it  may  be  turned  inwards, 
placing  the  external  portion  of  the  muscle  against  the 
already  sutured  fascias.  These  muscular  flaps  are  sutured  in 
place  and  the  skin  united  over  them.  Hagen  says  that  be 
has  had  great  success  in  the  practice  of  this  operation. 
[g.b.w.] 

10. — After  an  examination  of  15  specimens  of  gangrene  of 
the  lower  leg  obtained  by  amputation,  of  which  5  were  senile 
eangrene,  5  diabetic  gangrene,  and  5  spontaneous  gangrene ; 
Bunge  comee  to  the  following  conclusions :  In  cases  of 
arterial  sclerosis,  a  high  grade  sclerotic  proliferation  of  the 
intima  was  apt  to  be  found,  causing  stenosis  of  the  lumen  of 
one  or  more  of  the  chief  vessels  of  the  extremity.  This  condi- 
tion was  either  diffuse,  or  occurred  as  multiple,  more  rarely 
single,  circumscribed  stenotic  prohferations,  sometimes  caus- 
ing a  complete  obliteration  of  the  lumen  of  the  vessel.  This 
primary  stenosis  threatened  the  life  of  the  extremity,  first  in 
that  the  exit  of  the  branches  from  the  vessel  involved  were 
closed  by  the  process,  thus  preventing  the  establishment  of 
collateral  circulation  and  secondly  in  that  a  secondary  pro- 
gressive thrombosis  was  apt  to  develop  on  the  changed 
arterial  wall.  In  certain  cases,  especially  those  of  senile  or 
diabetic  gangrene,  a  circumscribed  petrifaction  of  the  arteries 
sometimes  forms,  and  which  has  the  same  clinical  import- 
ance for  the  circulation,  as  the  already  stated  conditions.  In 
these  cases  of  gangrene,  the  only  treatment  is  amputation, 
though  often  it  is  not  necessary  to  go  above  the  knee  for 
the  point  of  selection,     [g.b.w.] 

11.— Lately  the  operation  of  splenectomy  has  been 
growing  rapidly  in  favor,  and  as  the  operative  technic  im- 
proves, the  mortality  percent  has  greatly  lessened.  It  has 
been  shown  by  experiments  on  animals  and  by  observations 
on  persons,  that  it  is  entirely  possible  to  remove  the  spleen 
from  an  otherwise  healthy  man,  without  having  any  serious 
symptoms  develop.  Hagen  has  quoted  360  cases  of  extirpa- 
tion of  the  spleen,  138  of  which  were  followed  by  death.  In 
another  series  of  cases  quoted,  97  operations  before  the  year 
1890  showed  a  mortality  of  42.02%,  and  164  between  1S91 
and  1900  showed  a  mortality  of  only  IS. 9%.  Total  extirpa- 
tion of  the  spleen  should  never  be  done  for  leukemic  hyper- 
trophy, as  statistics  show  a  mortality  of  71.4%.  In  cases  of 
traumatic  rupture  of  the  spleen,  extirpation  cflers  the  best 
chance  of  saving  the  patient's  life.  Splenectomy  gives  even 
more  favorable  results  in  cases  of  splenic  abscess.  In  tuber- 
culosis, the  spleen  should  be  removed  when  the  organ  is 
surrounded  by  an  accumulation  of  pus,  and  is  not  fastened 
by  any  particular  adhesions  to  the  surrounding  structures ; 
in  other  words,  when  there  is  no  danger  of  causing  a  general 
infection  of  the  abdominal  cavity.  Echinococ<;u8  cysts  occur- 
ring in  the  spleen  generally  demand  removal  of  the  whole 
organ.  Also  in  cases  of  neoplasm,  complete  splenectomy 
should  be  performed.  In  cases  of  floating  spleen,  splenec- 
tomy should  be  given  the  preference  over  splenopexy.  Of 
late  vear?,  the  operation  in  cases  of  malarial  hypertrophy 
has  shown  a  great  decrease  in  the  mortality,  and  even  affords 
brilliant  results,  not  only  in  relieving  the  patient  of  a  large 
tumor,  but  in  bettering  his  general  condition.  In  primary 
hypertrophy  of  the  spleen,  associated  with  interstitial  hepa- 


jAjriAKT  12,   1901] 


THE  LATEST  LITERATURE 


DThb  Philadelphia 
Medical  Journal 


69 


titis,  the  operation  of  splenectomy  should  be  performed  aa 
eoon  as  possible  before  serious  change  has  been  able  to 
develop  in  the  more  important  organ.  For  similar  reasons, 
a  spleen  which  shows  simple  idiopathic  hypertrophy,  should 
be  removed  in  order  to  protect  the  liver  from  severe  and  in- 
curable disease.  Hagen  reports  a  case  of  primary  hyper- 
plasia of  the  spleen,  associated  with  interstitial  hepatitis, 
occurring  in  a  woman  of  26.  The  case  was  greatly  benefited 
by  the  removal  of  the  spleen,  and  from  month  to  month  she 
continued  to  show  progressive  improvement  in  her  general 
condition.  Furthermore,  Hagen  reports  2  cases  of  metas- 
tatic inflammation  of  the  spleen,  one  following  a  gangrenous 
chancre,  and  the  other  a  epityphlitic  abscess.  In  the  first 
case  there  was  suppuration  and  necrosis  of  almost  the  whole 
of  the  spleen,  and  the  case  recovered  perfectly  after  splenec- 
tomy. In  the  other  case  there  was  multiple  abscess  follow- 
ing the  appendicitis  with  marked  symptoms  of  sepsis. 
Splenectomy  with  partial  extirpation  of  the  spleen,  after 
resection  of  the  ninth  and  tenth  ribs,  was  done,  and  the  case 
recovered,    [g  b.w.] 

12. — Wolff  says,  regarding  the  indications  for  operation  in 
carcinoma  of  the  rectum,  that  much  depends  upon  the 
individual  merit  of  the  surgeon,  and  upon  the  peculiarities 
of  the  case.  Bergmann  operates  in  even  those  cases  in  which 
there  are  numerous  adhesions  to  the  surrounding  structures, 
and  practically  refuses  operation  only  where  old  age  and 
general  condition  forbid  any  surgical  procedure.  Where  the 
tumor  occupies  a  high  pofition,  and  where  there  is  much 
glandular  involvement,  the  operation  required  is  most  ex- 
tensive and  difficult.  The  best  methods  of  operating  in  all 
cases,  except  in  those  where  the  carcinomatous  process  is 
limited  to  the  lower  part  of  the  rectum,  is  through  a  dorsal 
incision.  Just  how  far  the  new  abdominosacral  method,  sug- 
gested by  Konig  and  others,  offers  more  advantages,  still 
remains  to  be  seen.  The  temporary  resection  of  the  sacrum 
and  coccyx,  as  suggested  by  Schlange,  opens  a  wide  path  to 
the  seat  of  the  disease,  but  presents  the  disadvantages  of 
severe  hemorrhages,  and  of  leaving  a  large  wound  to  heal. 
[qb.w.] 


II  Policlinico. 

(Sezione  Pratica.) 

November  17,  1900.     [Anno  vi',  Fasc.  3.J 

1.  On  Exomphalos.    S.  Ferranti. 

2.  Transactions  of  Congresses. 

3.  On  the  Best-known  Colorimetric  Methods  for  the  Quanti- 

tative Determination  of  Nitric  Acid  in  Water.    V. 
Babonk. 

1. — Ferranti  relates  a  case  in  an  infant  in  whom  umbili- 
cal hernia  developed  30  hours  after  birth.  The  tumor 
attained  to  a  large  size,  yet  was  reduced  in  the  course  of  a 
few  days  by  the  simple  application  of  a  bandage.  He  dis- 
cusses the  theories  of  the  production  of  umbilical  hernias 
and  the  distinctions  between  them  and  diverticular  hernias 
and  urinary  omphaloceles.  The  various  methods  of  treat- 
ment he  resolves  into  two,  the  first  consisting  in  the  reduc- 
tion of  the  hernia  and  the  closure  of  the  ring  or  sac  by 
sutures  (annulorrhaphy),  the  other  in  the  removal  of  the 
umbilical  ring  and  suture  of  the  parietes,  as  in  a  laparotomy 
(omphalectomy).  The  indications  for  and  against  surgical 
intervention  are  stated  and  treatment  by  bandaging  recom- 
mended  in  suitable  cases.    A  bibliography  is    appended. 

[O.B.B  ] 

2. — At  the  congress  of  the  Italian  Surgical  Society, 
Fummi  opened  a  discussion  on  medullary  anesthesia 

with  a  report  of  40  cases  operated  upon  in  Montenovesi's 
wards  at  Santo  Spirito.  Encouraged  by  experiments  on  dogs 
he  used  a  solution  of  cocain  in  glycerin  for  ir  jection  and 
obtained  anesthesia  in  the  thorax,  neck,  and  upper  limbs  as 
well  as  in  the  lower  part  of  the  body.  Owing  to  the  high 
specific  gravity  of  the  solution  in  glycerin  it  is  enabled  to 
ascend  through  the  cerebrospinal  fluid  as  high  as  the  cerebral 
ventricles.  Bastianelli  and  Fioretti  related  their  experience 
of  the  method  from  a  total  of  35  and  25  cases  respectively. 
The  former  surgeon  laid  stress  upon  the  need  of  a  full 
muscular  relaxation  as  one  of  the  contraindications  to  its 
employment.    Damascelli  read  a  "  Contribution  to  the  His- 


tology of  some  Tumors  of  the  Jaw,"  tracing  their  origin  to 
the  paradental  epithelial  residence  found  in  the  adult  jaw 
which  are  germs  of  the  embryonal  dental  membrane.  Cat- 
terina  showed  a  periepithelial  angiosarcoma  removed  from 
the  palate,  and  a  carcinoma  of  the  parotid,  the  origin  of  both 
of  which  he  ascribed  to  embryonal  germs.  Maffucci  de- 
scribed the  symptoms  and  postmortem  appearances  in  a  case 
of  primary  malignant  lymphoma  of  the  stomach,  remark- 
ing on  the  rarity  of  such  growths  and  the  fact  that  many  of 
thrtn  are  undoubtedly  of  infective  origin.  Dalla  Vedova 
related  the  results  of  experiments  on  dogs  from  which  he 
concluded  that  by  injury  to  the  extrinsic  sympathetic  inner- 
vations of  the  stomach  (celiac  plexus,  splanchnics)  ulcers 
strictly  analogous  to  those  in  the  human  sulject  might  be 
produced.  At  the  Obstetric  and  Gynecologic  Congress 
Marocco  read  a  paper  on  hytteropexy  without  suture,  and 
Ferrari  and  Caturani  contributions  on  the  surgical  treat- 
ment of  posterior  displacements  of  the  uterus,  for  which  the 
latter  proposed  a  new  operative  procedure  by  vaginal  fixation 
of  the  round  ligaments.  Vicarelli  advocated  the  tamponage 
of  the  uterus  in  cesarean  section  (Sanger's  operation)  as  a 
means  of  preventing  subsequent  hemorrhage  and  infection. 
Truxxi  suggested  some  changes  in  the  technic  of  the  unilat- 
eral operation  for  removal  of  the  uterine  adnexi.  D'Ales 
sandro  described  a  new  instrument  for  the  permanent  and 
bloodless  dilation  of  the  external  or  internal  os  uteri.  Amadei 
and  Ferri  presented  the  statistics  of  placenta  pi  tevia  in  the 
Guardia  Ostetrki,  of  Milan,  from  January  1,  1897,  to  Septem- 
ber 30, 1900.  Oat  of  a  total  of  5,136  cases  there  were  97  of 
placenta  pr.nevia  (1.89%),  central  in  28,  and  marginal  in  69 
cases,  with  a  maternal  mortality  of  5  cases,  and  a  fetal  mor- 
tality of  41  cases  out  of  the  80  cases  in  which  the  fetus  was 
viable.  Turning  was  employed  in  42  cases,  the  forceps  in  7 
(all  marginal),  and  embryotomy  in  3  caaes.    [g  s.b  ] 

3. — While  the  method  of  Schul  ze  and  Thiemann  is  ad- 
mittedly the  most  accurate  for  the  quantitative  deter- 
mination of  nitric  acid  in  water,  its  difficulties  of 
execution  have  led  chemists  to  employ  by  preference  various 
calorimetric  methods  as  being  shorter  and  more  simple.  Of 
these  Barone  prefers  the  reaction  with  diphenylamin  of 
Hoffmann,  which  is  in  general  use  as  a  qualitative  test  for 
nitrates  in  water,  and  he  has  attempted  to  util'ze  it  for  quan- 
titative purposes  by  comparing  the  tint  produced  in  the 
sample  of  water  with  that  formed  by  the  action  of  diphenyl- 
amin and  sulfuric  acid  upon  different  dilutions  of  known 
strength  of  specially  prepared  nitric  acid.  The  sources  of 
error  are,  however,  so  numerous  that  even  then  the  colori- 
metric method  is  not  to  be  recommended  as  an  exact  one. 
[g  8  B.] 


A  Case  of  Atrophic  Cirrhosis  of  the  Liver  with 
Preascitic  Edema. — Morano  {Oazz.  degli  ospedali  e  delle 
cKn.,  1900,  No.  117)  attributes  the  preascitic  edema  in  atrophic 
cirrhosis  of  the  liver  to  circulatory  disturbances  in  the  vascu- 
lar tone  of  the  vena  cava,  resulting  from  the  hepatic  inflam- 
mation. The  vena  cava  can  also  have  its  lumen  decreased 
by  the  sclerosis  in  the  liver  lobules  in  which  the  vessel  is 
imbedded.  The  resulting  edema  varies  in  intensity  according 
to  the  rapidity  with  which  the  collateral  circulation  is  estab- 
lished,   [m.rd.] 

Akromegaly.— Bregman  {Deutsche  Zeitschft. /.  Nervenheil- 
kunde)  reports  a  case  occ  urring  in  a  man  44  years  of  age.  In 
childhood  both  thumbs  were  exceptionally  large  and  thick, 
apparently  a  family  peculiarity.  The  disease  commenced 
about  the  age  of  38,  the  earliest  symptoms  being  weakness, 
especially  on  the  left  side  of  the  body,  and  excessive  thirst ; 
the  svmptoms  were  in  general  quite  (ypic;  the  skin  was 
greatly  thickened  on  the  hands,  and  there  was  considerable 
desquamation,  and  falling  out  of  the  hair  on  the  left  side  of 
the  body;  in  addition  there  was  glycosuria,  ard  extreme 
atrophy  of  the  left  half  of  the  tongue ;  the  whole  left  side 
was  slightly  paretic ;  there  was  no  indication  of  the  presence 
of  a  brain  tumor,  in  particular  no  disturbance  of  the  eye- 
sight, excepting  that  due  to  a  moderate  glycosuric  retinitis. 
The  cause  of  the  condition  is  probably  some  congenital  de- 
fect ; !  it  is  possible  that  the  severe  labor  to  which  he  was 
subjected,  contributed  in  some  way.     [j.s.] 


70 


Tmk  Puiladelpuia"! 

Mkdical  Juuii 


klpuia"! 

L'RN'AL  J 


A  CASE  OF  URETHRORECTAL  FISTULA 


[fAyi'AET  12   t 


Original  Articles. 


A     CASE    OF    URETHRORECTAL    FISTULA    CURED 
AFTER  A  THIRD  OPERATION. 

Bv  ORVILLE   HORWITZ,  B.S.,  M.D.. 

'of  Philadelphia,  Pa.  • 

Clinical    Professor   of    Genitouriaary    Diseases,    Jefferson    Medical    College  ; 

^.Surgeon  lo  the  Jefferson,  Philadelphia,  and  Children's  (Germantown) 
U^'C-  l^^^s*  Hospitals  and  Hayes  Mechanics  Home. 

Urethrorectal  fistulte  are  the  most  infrequent  of 
any  of  the  maladies  connected  with  the  urethra.  All 
authorities  agree  upon  the  extreme  difficulty  of  curing 
this  disorder.  I  am  in  accord  with  Simon  Duplay 
when  he  says  :  "  There  are  some  examples  of  sponta- 
neous recovery  of  urethrorectal  fistula ;  it  must  be 
acknowledged  that  most  frequently  they  last  indefinitely 
and  the  chances  of  cure  by  surgical  interference  are 
extremely  few." 

The  literature  on  the  subject  throws  but  little  light 
on  the  matter  and  leaves  the  student  in  doubt  as  to  the 
best  method  to  be  pursued  in  order  to  obtain  a  cure. 
Surgical  authorities  differ  widely  as  to  the  most  suit- 
able operation  to  be  performed,  each  having  its  advo- 
cates as  well  as  its  detractors,  and  I  have  thought  that 
by  giving  a  brief  account  of  the  difficulties  and  failures 
encountered  whilst  attempting  to  remedy  a  case  of 
urethrorectal  fistula  which  came  under  my  care,  it 
might  not  only  be  of  interest  to  the  profession,  but 
serve  as  a  guide  to  other  operators  in  search  of  the  best 
method  to  be  pursued  when  dealing  with  cases  of  this 
nature. 

Urethrorectal  fistuliu  are,  in  their  origin,  either  trau- 
matic or  pathological.  Fistula'  may  result  from  the 
lodgment  of  foreign  bodies  in  the  rectum  or  urethra  ; 
they  have  occurred  after  perirectal  lithotomy,  and 
from  wounds  and  abscesses  in  the  prostate  gland,  espe- 
cially if  the  latter  condition  be  due  to  tubercle. 
Pressure  from  stone  in  the  prostate  gland  or  the  impac- 
tion of  a  calculus  in  the  posterior  urethra  has  been 
known  to  cause  them.  Cancer  of  the  prostate,  or 
abscess  of  the  rectum,  the  latter  usually  associated  with 
an  hemorrhoidal  condition,  has  given  rise  to  fistula.  In 
two  instances,  whilst  performing  the  oj^eration  of  pros- 
tatectomy by  means  of  a  perineal  incision,  I  have  been 
so  unfortunate  as  to  wound  the  rectum,  resulting  in  a 
urethrorectal  fistula  in  each  case ;  they  both,  however, 
fortunately  healed  spontaneously. 

So  far  as  I  can  discover  the  cause  in  the  case  I  am 
about  to  recount  is  unexampled.  An  attack  of  acute 
posterior  urethritis  gave  rise  to  an  abscess  which  was 
connected  with  the  membranous  urethra,  finally  ruptur- 
ing into  the  rectum,  and  forming  a  fistulous  connection 
between  the  two  canals. 

The  patient  was  brought  to  me  by  Dr.  Henry  Heiler- 
man,  with  the  following  history  :  He  was  22  years  old, 
by  occupation  a  car  conductor;  he  had  contracted  his 
first  attack  of  gonorrhea  during  the  month  of  October, 
1898.  At  first  there  was  [)rofuse  discharge  from  the 
urethra,  with  little  pain ;  the  discharge  then  became 
very  slight,  with  a  frequent  desire  to  micturate,  followed 
by  the  voidance  of  blood  at  the  termination  of  each 
act;  this  condition  was  associated  with  pain  in  the 
perineum  together  with  spasm  at  the  neck  of  the 
bladder,  and  difficulty  of  urination.  The  temperature 
rose  to  103°.  He  complained  of  constant  pain  in 
the  rectum,  with   tenesmus,   and  a  continual    desire 


for  defecation,  which,  being  associated  with  irritabi  » 
and  spasm  at  the  neck  of  the  bladder,  caused  the  ag<  f 
to  be  unendurable. 

A  digital  examination  of  the  rectum  disclosec  t 
fluctuating  swelling  of  considerable  size,  very  ten 
to  the  touch,  presumed  to  be  an  abscess  of  the  proel 
gland ;  24  hours  later  there  was  a  sudden  discharge 
pus  and  blood  from  the  bowel,  followed  by  instant  si 
sidence  of  pain,  together  with  faU  of  temperate 
After  this  the  greater  portion  of  the  urine  was  paa 
per  rectum  instead  of  by  the  urethra. 

When  admitted  to  the  Jefferson  Hospital  the  pati 
was  in  very  poor  physical  condition.     He  was  pj 
anemic,  had  lost  weight,  passed  his  urine  every  h< 
and  suffered  constant  pain  both  in  the  rectum  and 
the   neck  of  the  bladder.      The   two-glass  urine  t 
showed  both  to  be  cloudy,  containing  pus,  epitheUi 
and  a  trace  of  albumin.     The  bladder  could  not  conti  i 
more  than  one  ounce  of  urine  at  any  one  time.     \Vhi 
this  amount  had  accumulated  the  fluid  would  beji 
to  dribble,  and  to  flow  over  the  buttock  and  thig  . 
which   were  in    consequence  continuaUy   moist    a  I 


Fig.  1. — Showing  the  listulous  tract  connecting  the  rectum  and  urelbrm. 


excoriated  ;  in  spite  of  every  effort  to  keep  the  patiej 
clean  a  most  disagreeable  odor  was  constantly  presen 
After  a  rest  in  bed  of  10  days,  with  the  nece--n 
preparatory  treatment,  the  condition  of  the  patient  .i;i 
so  much  improved  that  it  was  considered  safe  to  mal 
a  urethral  and  rectal  examination.  A  24  F.  bougie  w: 
passed  into  the  urethra,  and  the  patient  placed  in  tl 
"  knee-chest "  posture ;  on  inserting  a  bivalve  reots 
speculum  a  fistulous  opening  could  lie  seen  on  the  ro« 
ofthe  rectum, about  li  inches  from  thesphincter  musci 
apparently  at  the  junction  of  the  membrane  and  pro 
tatic  urethra.  A  filiform  bougie  was  readily  inserte 
along  the  fistulous  tract  from  the  rectum  into  th 
urethra.  The  fistula  was  found  to  run  upward  an 
backward  and  enter  the  membranous  portion  of  th 
canal.  An  endoscopic  examination  of  the  ureihr 
showed  that  the  opening  of  the  fistula  into  the  urethr 
was  smaller  than  that  at  the  rectal  orifice.  This,  togethc 
with  the  fact  that  the  course  of  the  fistula  was  upw.^r 
and  backward,  accounted  for  the  flowing  of  the  urin 
so  readily  into  the  rectum,  and  at  the  same  time  rer 
dering  the  passage  of  fecal  matter  from  the  rectum  int 


k 


(AHUABY  12,  1901] 


A  CASE  OF  URETHRORECTAL  FISTULA 


[The  Philadelphia 
SckEDICAL  JOUBXAL 


■1 


he  urethra  or  bladder  impossible.    Occasionally  flatus 
vould  be  passed  by  the  urethra. 
On  consulting  the  various  authorities  in  order  to  de- 
,  ermine   upon   the   most   satisfactory  operation   to  be 
elected  whereby  to  effect  a  cure,  I  found  that  the  many 
irticles  that  have  been  written  on  the  subject  are  in  the 
nain  quite  unsatisfactory. 
Owing  to  the  size  of  the  rectal  orifice  of  the  fistula, 
:  ogether  with  the  position  and  length   of  the  sinus,  I 
lecided   against   the  employment   of  either   chemical 
.;  ;au8tics  or  electro-  or  thermocautery.     Not  only  do  all 
1  .uthors  agree  that  they  more  frequently  fail  than  suc- 
ceed, but  that  this  method  of  treatment  is  only  suitable 
:  0  the  very  narrow  fistula.    The  various  plastic  opera- 
,  ,ions  suggested  by  Sir  Astley,  Cooper,  Desault,  Duplay, 
j! !5rown,  and  others  did  not  appeal  to  me,  and  I  decided 
ijiotry  an  entirely  different  expedient  than  any  hitherto 
iijuggested. 


.  2. — Showiog  filiforoi  inserted  la  the  tistuloua  opening  in  the  rectum  passing 
through  the  urethra  iuto  the  bladder, 

"    The  patient  was  prepared  for  operation  in  the  usual 

'"'[aanner,  etherized,  and  placed  in  the  lithotomy  position 

'  lAth  the   buttocks  well  elevated  above  the  operating 

■"'ible.    A  24  steel  bougie  was  passed  into  the  urethra. 

■  ,|i.  horse-shoe  incision  was  made,  beginning  midway  be- 

'■'"Iffeen  the  tubero.sity  of  the  ischium  and  the  sphincter 

i"*'!!!  at  the  right  side  across  the  middle  of  the  perineum, 

*'lien    downwards  to    a    corresponding    point  on   the 

"iipposite  side  from  which  it  started.     The  rectum   was 

?'!lien  dissected   free  from  the  surrounding  tissue  until 

''he  fistulous  communication  between  the  rectum   and 

'•'l.rethra  had  been  separated.     The  fistulous  opening  in 

'^iie  bowel  was    freshened,  and  after  a  great    deal    of 

'^jirouble  the  opening  was  closed   by  means   of  6   silk 

'^latures.     An  incision  was  then   made  in  the  median 

'^'"'lline  of  the  perineum,  opening  the  membranous  urethra 

'*i8t  as  is  done  when   performing  the  external  perineal 

I  uHfrethrotomy   by  means  of  a  guide.     This  was  done 


with  a  view   to  freshening  the  edges  of  the 
opening   in   the   urethra.      The   bougie    was 


fistulous 
now  re- 
moved and  a  soft  rubber  catheter  inserted  and  allowed 
to  remain  in  situ,  thereby  establishing  continuous  drain- 
age. The  perineal  wound  was  packed  with  iodoform 
gauze  so  as  to  shut  off  all  communication  between  the 
rectum  and  urethra.  An  effort  was  made  to  keep  the 
bowels  confined  for  one  week  after  the  operation  ;  un- 
fortunately on  the  fifth  day  the  desire  for  defecation 
became  imperative.  During  the  bowel  movement  the 
catheter  was  expelled  from  the  urethra.  Unfortunately 
my  trained  clinic  nurse  was  absent  on  his  summer 
vacation  and  the  individual  on  duty  had  had  but  little 
experience  in  urethral  surgery,  and  in  his  efforts  to  in- 
sert the  catheter,  reopened  the  wound  in  the  bowel  so 
as  to  again  establish  the  fistulous  communication.  For 
some  time  after  this  the  patient  suffered  from  a  urethro- 
perino-rectal  fistula,  both  urine  and  feces  discharging 
from  the  perineal  wound  as  well  as  from  the  rectum. 
Gradually  the  wound  in  the  perineum  closed,  leaving 
the  patient  in  the  same  condition  as  before  the  opera- 
tion except  that  the  rectal  orifice  of  the  fistula  was 
much  smaller  and  nearer  to  the  external  sphincter. 
Dr.  Keen,  who  saw  the  case  at  this  time  in  consultation, 
advised  that  the  actual  cautery  be  tried.  Acting  upon 
this  suggestion,  the  patient  was  again  placed  under  the 
influence  of  an  anesthetic,  and  a  preliminary  supra- 
pubic cystotomy  performed  in  order  to  deflect  the  urine 
from  the  urethra  and  thus  give  the  fistulous  tract  a 
better  chance  to  heal.  The  rectum  was  exposed  by 
means  of  a  Sims  speculum ;  the  fistulous  opening 
thoroughly  seared  by  means  of  the  thermocautery. 
The  bladder  was  drained  by  means  of  the  suprapubic 
opening  for  the  space  of  about  3  weeks,  by  which  time 
it  appeared  as  if  the  communication  which  existed 
between  the  urethra  and  rectum  had  become  obliterated. 
The  suprapubic  wound  was  allowed  to  close  and  for 
about  10  days  no  urine  passed  from  the  urethra  into 
the  rectum  and  the  case  was  looked  upon  as  cured. 
Suddenly,  however,  a  small  abscess  appeared  at  the  site 
of  the  old  opening  in  the  rectum,  which,  on  rupturing, 
reestablished  the  old  fistulous  tract.  The  patient  was 
sent  home  for  a  couple  of  months  in  order  to  recuperate 
before  attempting  another  operation  for  his  relief.  On 
his  return  to  the  institution  a  third  operation  was  per- 
formed, which  proved  successful. 

On  examination,  the  general  condition  was* found  to 
be  about  the  same  as  before  the  second  operation  was 
undertaken.  Then  it  was  decided  to  attempt  to  close  the 
fistula  the  third  time  by  employing  a  method  similiar 
to  that  pursued  when  repairing  vesicovaginal  fistula, 
and  known  as  the  "  American  method ;"  that  is,  by 
denuding  the  margin  of  the  opening  and  approximat- 
ing its  edges  by  suture.  In  order  to  place  the  patient 
in  proper  condition  for  the  operation  he  was  kept  in 
bed  for  a  week,  he  was  placed  on  light  diet,  the  bowels 
being  kept  freely  open  by  means  of  laxatives.  Con- 
tinuous drainage  was  instituted  so  that  the  parts  might 
become  accustomed  to  this  condition,  as  it  was  pro- 
posed to  make  use  of  this  method  so  as  to  keep  the 
wound  free  from  the  urinary  discharge  after  the  opera- 
tion. At  the  end  of  10  days  the  patient  was  placed  in 
the  lithotomy  position,  the  sphincter  ani  well  dilated, 
and  the  Sims  speculum  inserted.  The  anterior  wall  of 
the  rectum  was  drawn  down  by  means  of  the  hemosta- 
tic forceps,  the  edges  of  the  fistulous  opening,  as  well  as 
the  mucous  membrane  within  a  quarter  of  an  inch 
surrounding  the  orifice,  were  denued.     This  procedure 


72 


The  PHU.ADELPHL4"! 
-  MSDICAX  JOCBSAL  J 


FALLACIES  CONCERNING  THE  MENOPAUSE 


[  Jasuaxt  H^l 


was  found  difficult  to  accomplish,  as  the  operation  was 
necessarily  frequently  interrupted  in  order  to  control 
hemorrhage  which  obstructed  the  view  of  the  field  of 
operation.  The  denudation  was  finally  completed  and 
the  opening  closed  by  means  of  5  silkworm-gut  sutures, 
starting  on  the  mucous  membrane,  a  little  beyond  the 
denuded  margin  on  one  side,  and  passing  out  at  a  cor- 
responding point  on  the  other.  Inserting  the  sutures 
was  the  most  difficult  part  of  the  operation ;  the  threads 
were  allowed  to  remain  about  4  inches  in  length,  and 
to  protrude  outside  the  sphincter  muscle.  This  waa 
rendered  necessary  that  they  might  be  easily  reached 
when  it  was  desired  to  remove  them.  The  bowel  was 
irrigated  with  a  saline  solution  and  "  Pennington's 
hollow  rectal  tampon  "  inserted.  The  tampon  served 
not  only  to  prevent  spasm  of  the  sphincter  muscle, 
keeping  the  parts  at  rest,  but  served  at  the  same  time 
to  protect  the  wound,  and,  what  was  most  important, 
provided  for  rectal  drainage.  Had  a  movement  of  the 
bowel  become  necessary  it  could  have  taken  place 
without  pain,  and  the  wound  would  have  been  pro- 
tected from  the  danger  of  infection.  By  means  of  the 
deodorized  tincture  of  opium  the  bowels  were  rendered 
quiescent  for  7  days  after  the  operation,  when  they 
were  moved  by  means  of  repeated  doses  of  sulphate  of 
magnesia  and  a  large  enema  of  hot  water.  The  tam- 
pon served  to  drain  a  large  quantity  of  serum,  some 
liquid  feces,  and  to  permit  the  escape  of  flatus  during 


the  time  it  was  in  place.  The  stitches  were  removed 
on  the  eighth  day  after  the  operation,  when  it  was  found 
that  firm  fibrous  union  had  taken  place.  The  urine 
was  disposed  of  by  means  of  continuous  drainage  for 
2  weeks  after  the  sutures  were  removed.  The  patient 
was  discharged  cured,  and  has  remained  in  perfect 
health  ever  since. 

In  studying  the  history  of  this  case  there  are  two 
points  pertaining  to  it  that  attract  attention.  The  first 
is  the  fact  that  as  soon  as  the  gonorrheal  infection 
spread  to  the  urethra  the  temperature  rose  to  103°, 
showing  that  almost  at  the  start  there  must  have  been 
a  periurethral  inflammation  with  a  tendency  to  the 
formation  of  abscess,  as  it  is  well  known  that  in  un- 
complicated cases  of  acute  posterior  urethritis  there 
are  no  constitutional  symptoms.  The  second  is  that 
although  the  patient  had  a  healthy  rectum  and  sphinc- 
ter ani,  yet  as  soon  as  urine  to  the  amount  more  or  less 
of  one  ounce  accumulated  in  the  rectum,  dribbling 
took  place,  keeping  the  parts  constantly  wet.  This 
would  seem  to  indicate  that  in  cases  of  malignant  dis- 
ease, or  of  exstrophy  of  the  bladder,  where  resection 
becomes  necessary,  with  implantation  of  the  ureters 
into  some  portion  of  the  intestinal  canal,  that  it  would 
be  wiser  to  have  recourse  to  the  sigmoid  flexure,  in- 
stead of  to  the  rectum. 

My  experience  gleaned  from  this  case  would  seem  to 
lead  to  the  conclusion  that  when  dealing  with  a  similar 
cond  ition  of  aflfairs,  it  would  be  proper  to  keep  the  patient 
on  a  light  diet  for  at  least  10  days  previous  to  the  opera- 


tion ;  the  bowels  to  be  frequently  freely  moved,  so  tt 
they  may  be  controlled  after  the  surgical  procedm 
at  the  same  time  a.  continuous  drainage  to  beinstitofa 
so  that  the  individual  may  be  accustomed  to  Q 
method  of  drawing  off  the  urine,  and  the  urethra  I 
came  tolerant  of  the  presence  of  the  catheter.  If  f 
rectal  orifice  be  large,  and  situated  some  distance  bo 
the  sphincter  ani,  the  operation  that  was  resorted 
primarily  is  considered  preferable,  and  is  reon 
mended.  It  would  have  doubtless  succeeded  in  ft 
instance  but  for  the  bungling  of  an  incompetent  nun 
If  the  opening  in  the  rectum  be  situated  in  the  vicini 
of  the  sphincter  the  plastic  operation,  which  waa  he 
so  successful,  is  to  be  preferred. 


* 


FALLACIES  CONCERNING  THE  MENOPAUSK 

By  GEO.  ERETY  .SHOEMAKEE,  M.D., 

of  Pbiladelphia. 

Gf  necologist  to  the  PresbfteriaQ  and  Methodist  Hoepit&ls. 

In  the  year  1779 — 121  years  ago — John  Fothem 
M.D.,  F.R.S.,  in  writing  a  paper  for  the  Medical  Sooe 
in  London,  used  these  words  :  "  The  various  and  absB 
opinions  relative  to  the  ceasing  of  the  menstrual  di 
charge,  and  its  consequences,  propagated  through 
cessive  ages,  have  tended  to  embitter  the  hours  of 
a  sensible  woman.  .  .  .  Some  practitioners, 
other  respects  able  and  judicious,  if  they  have  n 
favored  these  erroneous  and  terrif\-ing  notions,  seem  a 
to  have  endeavored  to  correct  them  with  the  diligeoi 
and  humanity  which  an  object  like  this  requires."' 

The  terrifying  opinions  referred  to  by  John  Fothe 
gill  were  such  as  this  :  That  the  normal  menstrual  flo 
was  an  evacuation  of  morbid  material  or  "  humor,"  u 
that  its  failure  to  escape  from  the  body  by  reason  of  ft 
onset  of  the  menopause,  must  be  injurious,  as  noxioi 
material  was  retained.  Again,  it  was  thought  that  ft 
flow  at  this  time  had  a  special  defiling  or  injaiiai 
magical  influence  on  persons  or  objects. 

Such  views  have  long  been  abandoned  by  the  medic 
profession,  though  large  numbers  of  women  still  thh 
that  some  serious  disorder  is  liable  to  set  in  at  thattia 
of  life.  It  would  seem,  in  fact,  that  medical  opink 
has  swung  entirely  too  far  in  the  opposite  direction,! 
that  at  the  present  day,  any  disorder  occurring  nearfl 
menopause,  so  far  from  exciting  the  slightest  apprehfei 
sion  on  the  part  of  physicians  or  patients,  is  apt  to  1 
entirely  neglected,  as  though  it  were  all  in  the  di 
course  of  Nature.  The  consideration  of  fallacies  t 
garding  the  menopause,  prevalent  at  the  present  dt 
must  deal,  therefore,  not  with  the  terrors  of  the  coai 
tion,  but  with  an  almost  fatalistic  neglect  of  real  di 

In  large  numbers  of  instances,  where  women  oveti 
years  of  age  apply  to  the  gynecologist  with  any  soil 
pelvic  disease  accompanied  by  hemorrhage,  they  in 
state  that  they  have  for  a  long  time  attributed  ftH 
symptoms  to  the  change  of  life  and  were  finally  diivi 
to  seek  relief  by  the  increase  of  the  trouble.  Too  atk 
they  state  that  their  physician,  without  making 
investigation,  has  assigned  the  same  origin  to  ft 
symptoms.  Indeed,  for  a  period  of  25  years  iu 
woman's  life,  ;.  e.,  from  35  to  60  years  of  age,  it  won. 
seem  that  "  the  change  of  life '"  is  popularly  supptosed 
cover  ever.-  pelvic  or  abdominal  symptom.  To  fti 
state  of  affairs,  rather  than  to  any  other  one  caoa^ 


Medic*!  ObserratioDS  and  Inquiriaa,  Lcoidan,  1779,  p.  IM. 


I 


Janwary  12,  I'.iOlJ 


FALLACIES  CONCERNING  THE  MENOPAUSE 


rTHE  PmLADELPmA 
Medical  Joobnal 


73 


due  the  prevalent  large  fatality  from  cancer.  Cases  are 
not  investigated  soon  enough  to  allow  of  real  help.  A 
few  months  ago  a  woman  was  sent  for  an  opinion  by 
her  physician.  She  complained  of  constant  severe 
bleeding  and  was  about  45  years  old.  Asked  whether 
she  had  had  the  change  of  life  she  replied  :  "  Oh,  I  am 
going  through  that  now."  She  had  a  large  fungating 
epithelioma  of  the  cervix,  but  absolutely  refused  opera- 
tion. The  first  and  greatest  fallacy  therefore  is,  that 
persistent  and  severe  symptoms  of  any  kind,  aside  from 
obviously  nervous  flashes  of  heat  and  the  like,  attend 
the  normal  menopause.  The  menopause  is  not  a  dis- 
ease, nor  is  it  attended  by  disease.  It  is  simply  a  period 
of  readjustment  extending  over  a  term  of  one,  two,  or 
three  years  usually,  and  accompanied  by  vasomotor 
disturbances  and  a  few  functional  nerve-symptoms. 

The  view  is  most  dangerous  that  uterine  hemorrhage, 
persistent  and  severe,  is  a  symptom  of  the  menopause, 
and  that  it  may  be  neglected  on  the  theory  that  time 
will  cure  it. 

The  total  loss  of  blood  in  a  given  series  of  months  is 
never  excessive  under  normal  conditions.  If  no  flow  is 
seen  for  2,  3,  or  5  months,  and  then  a  single  free  bleed- 
ing occurs,  even  if  the  quantity  is  great  at  this  one 
time,  there  is  nothing  necessarily  abnormal.  By  ques- 
tioning it  will  be  learned  that  the  total  quantity  divided 
by  the  total  number  of  missed  months  would  not  be 
excessive  for  each  month.  There  is,  on  the  contrary,  no 
justification  for  considering  a  flow  physiological,  when 
it  recurs  nearly  every  day,  or  every  week,  or  every  2 
weeks,  for  months,  or  years  ;  nor  when  by  comparing  a 
number  of  months,  say  6,  it  is  found  to  be  steadily 
increasing ;  nor  when  the  total  quantity  amounts  to  4 
or  5  napkins  a  day  for  prolonged  periods,  and  when 
these  periods  occur  too  often  in  the  year.  Yet  this 
error  is  constantly  made. 

Dr.  John  Milton  Dufi"  questioned  482  healthy  women 
over  52  years  of  age  in  regard  to  bleeding  during  the 
menopause,  and  found  that  out  of  this  number  only 
39,  or  8.2%,  had  any  history  of  what  might  be  called 
hemorrhage.^ 

Owing  to  the  prevalent  idea  among  women  that  hem- 
orrhage is  to  be  expected,  they  allow  excessive  flowing 
to  go  on  for  a  very  long  time  without  consulting  a 
physician.  When  they  do  finally  become  alarmed  or 
suspicious,  they  commonly  spend  some  months  in 
overcoming  a  modest  hesitancy  in  speaking  about  it. 
When  at  last  they  do  this,  it  is  apt  to  be  in  a  casual 
way,  and  with  a  ready-made  diagnosis  that  it  is  the 
"  change  of  life  coming  on."  This  they  do  with  the 
hope  that  the  physician  will  agree  with  them,  and  that 
no  examination  need  be  made.  The  physician  may 
avoid  a  blunder  which  will  afterward  cost  him  much 
in  reputation,  and  his  patient  much  in  welfare,  if  he 
will  at  once  proceed  to  find  out  definitely  whether  or 
not  she  is  bleeding  too  much  by  methodical  questions 
along  the  following  lines: 

a.  What  was  the  normal  for  that  patient  in  early 
life — that  is,  how  many  days'  flow  ?  At  what  interval  ? 
Did  she  use  more  or  less  than  3  or  4  napkins  per  day  ? 

b.  Establish  the  approximate  time  when  she  left  her 
normal,  and  the  average  flow  increased.  This  will  often 
lead  back  several  years,  to  a  miscarriage,  or  a  pelvic  in- 
flammatory attack,  and  will  at  once  increase  the  prob- 
ability that  the  excessive  flow  antedated  the  menopause 
and  has  no  relation  to  it. 

c.  Show  that  the  loss  of  blood  is  or  is  not  progres- 

'  A  mer.  Jour.  Oisleirici,  November,  1899. 


sively  increasing,  taking  months  or  years  together.  If 
it  is  steadily  increasing,  the  periods  becoming  longer 
and  nearer  together,  a  local  condition  involving  at  least 
the  endometrium  is  almost  certain,  provided  of  course 
that  the  total  quantities  are  pathological. 

d.  Put  down  in  figures  the  dates  of  all  recent  periods 
for  a  year  or  more  as  far  as  the  patient  can  remember ; 
beginning  thus  :  How  many  times  were  you  ill  last 
month?  How  long  each  time?  How  many  napkins  f 
How  many  times  the  month  before  ?  etc.,  etc.  This  will 
often  bring  out  a  history  of  very  serious  hemorrhage,  into 
the  details  of  which  the  patient  would  not  otherwise 
enter,  but  simply  say  she  "loses  too  much."  It  will 
often  be  found  that  the  patient  has  bled  almost  daily 
for  many  months.  That  she  cannot  measure  the  quanti- 
ties by  napkins,  but  goes  to  bed  and  uses  a  folded 
sheet,  that  she  hurries  to  the  water  closet  and  passes 
large  vaginal  clots  followed  by  a  gush  of  blood,  or,  as 
one  patient  expressively  said  a  few  days  ago,  she 
"  could  use  a  bucket."  It  may  show  that  she  has  not 
actually  missed  any  periods,  or,  worst  prognosis  of  all, 
that  the  cessation  definitely  occurred  and  that  in  a 
year  or  more  flowing  began  again.  Malignant  adenoma 
or  other  form  of  malignant  disease  is  then  almost  in- 
variably present.  Such  a  definite  investigation  patiently 
made  will  usually  indicate  whether  an  examination  is 
called  for.  The  physician  will  remember  that  a  normal 
period  lasts  4  or  5  days.  The  napkins  may  number 
daily  from  2  to  5  moderately  wet.  The  interval  should 
not  be  less  than  3  weeks,  and  that  any  marked  devia- 
tion, to  be  normal  or  physiological  for  that  person,  must 
extend  back  into  the  period  of  young  womanhood. 

If  an  examination  is  indicated  let  it  be  made  at 
once,  and  thoroughly,  as  a  normal  cervix  does  not  ex- 
clude cancer.  Three  times  during  the  past  year  I  have 
operated  by  vaginal  hysterectomy  in  cases  of  well- 
marked  carcinoma  of  the  fundus  uteri  where  the  cervix 
appeared  absolutely  free  from  the  disease,  and  where  a 
superficial  examination  which  depended  only  on  what 
could  be  seen  through  a  speculum  would  have  failed 
to  detect  the  cancer.  Nothing  can  be  more  dangerous 
to  the  patient  than  deferring  examination  until  all  the 
classical  symptoms  of  cancer  are  present,  namely:  odor, 
pain,  flocculent  watery  discharge  in  addition  to  bleed- 
ing. By  the  time  these  have  appeared  operation  is 
often  useless  as  far  as  freedom  from  recurrence  is  con- 
cerned. Examine  all  cases  which  have  unnatural  bleed-  ■ 
ding,  and  do  not  wait. 

Another  fallacy  is  that  with  fibroid  tumors  of  the 
uterus  which  are  growing  or  causing  disturbance,  the 
patient  will  do  well  to  wait  for  the  menopause.  This 
idea  arose  when  the  mortality  after  fibroid  hysterec- 
tomy was  over  50%.  Now,  when  it  is  6%  or  less,  in 
cases  without  heart  and  kidney  lesions  or  pus  tubes, 
and  when  hemorrhage  has  not  brought  the  patient  to 
the  verge  of  the  grave,  the  question  of  operative  treat- 
ment stands  on  a  different  basis.  The  hope  that  the 
menopause  will  cure  the  case  is  in  itself  fallacious. 
These  patients  bleed  till  they  are  55  or  more  years  of 
age,  thus  waiting  20  years  for  the  menopause  if  they 
begin  to  wait  at  35,  as  some  do.  Meanwhile  they  are 
subject  to  peritonitic  attacks,  to  tube  degenerations 
(and  few  fibroids  are  accompanied  by  normal  tubes), 
and  to  pressure  effects  on  iliac  veins,  kidney,  bladder, 
bowel.  Their  heart-muscles  degenerate,  while  anemia 
directly  invalids  them  besides  aggravating  all  intercur- 
rent disease.  Many  die  while  waiting  for  the  meno- 
pause.    Should  some  survive  till  after  a  long  belated 


74 


The  Philadelphia 
Medical  Journal 


] 


WOUND  OF  THE  TRACHEA 


[Jascaet  12,  1901 


change  has  stopped  the  bleeding,  the  tumor  diminishes 
but  little  usually,  while  the  secondary  lesions  remain. 
There  is  no  regaining  of  robust  health.  The  10,  15,  or 
20  years  of  invalidism  while  waiting  do  not  bring  a 
reward  of  returned  youth  and  strength. 

Let  it  be  understood  that  it  is  not  claimed  that  small 
fibroids  require  removal  when  they  neither  grow  nor 
bleed  nor  cause  symptoms.  It  is  claimed  that  when 
these  symptoms  are  present,  waiting  for  the  menopause 
to  cure  them  is  usually  a  losing  game,  because  the 
menopause  is  deferred  and  all  that  makes  life  worth 
living  is  taken  away  by  complications  in  the  meantime. 

The  moral  is  operate  early  by  removal,  for  fibroma 
of  the  uterus  which  is  growing,  which  bleeds  badly,  or 
which  by  complication  threatens  the  health  of  the 
individual. 

It  may  be  partly  a  coincidence,  but  the  writer  fails  at 
this  time  to  recall  a  case  of  uterine  fibroid  which  gave 
trouble  during  menstrual  life  and  which  was  cured  after 
the  menopause ;  where,  in  other  words,  it  paid  to  wait. 
The  cases  not  operated  upon  which  did  well  after  long 
waiting  have  been  small,  uncomplicated  tumors  which 
did  not  grow  or  bleed.  Cases  which  found  themselves 
rapidly  going  down  hill  and  which  dared  wait  no  longer 
even  though  more  than  45  years  of  age,  have  been  nu- 
merous.    These  briefly  illustrate: 

Mrs.  K  ,  aged  52,  widow,  Ilpara.  Menstruation  normal 
till  aged  41 , 9  years  ago.  Gradually  increased  in  quantity  since, 
till  now  almost  constant  bleeding.  Very  severe  hemor.  liage 
at  periods,  putting  her  to  bed  from  weakness  at  that  time. 
Losing  flesh  decidedly.  Unable  to  work  on  account  of  weak- 
ness from  bleeding.  Formerly  a  strong,  industrious  hard- 
working woman.  Right  foot  and  leg  swell  Bleeding  steadily 
worse  in  spite  of  her  physician's  treatment  Operation, 
hysterectomy  for  adherent  fibroma  extending  above 
umbilicus.     Cured. 

Mrs.  T.,  aged  52,  married,  Ilpara.  Menses  scant  till  age  of 
50,  then  severe  bleeding  began.  Now  pale,  cachectic  from 
anemia.  Hemoglobin  39%.  Has  lost  greatly  in  health  and 
weight.  Mucous  .'tools  for  a  year,  alternating  with  constipa- 
tion. Urination  frequent  and  painful  for  a  year.  Both  legs 
and  feet  swollen  badly  for  a  year.  Very  short  of  breath 
on  walliing.  No  heart-murmurs.  Biagnosis:  Multiple  fibro- 
mata of  uterus.  Alter  getting  hemoglobin  up  to  47  fc,  vagi- 
nal hysterectomy  by  niorcellation.  Cured.  Nine  months 
later  shortness  of  breath  had  disappeared  and  nearly  all 
edema  of  feet,  by  improvement  in  blood.  Note  that  this 
patient's  bleeding"  began  after  she  was  50. 

Mrs.  D.,  aged  48,  has  a  tumor  reaching  above  the  umbilicus, 
•  which  has  bled  till  her  strength  is  gone  Her  hemoglobin 
is  45%.  She  comes  for  treatment  during  her  first  attack  of 
peritonitis.  Temperature  102°,  pain,  tympany,  etc.  She 
has  bled  every  day  for  two  months  Her  tumor  is  adherent, 
her  general  appearance  poor.  The  feet  swell  and  there  is 
pressure  pain  in  the  lower  e-xtrendties.  What  but  hysterec- 
tomy offers  her  any  thing?  How  much  more  it  would  have 
oifered  her  before  the  anemia  was  extreme  and  before  this 
attack  of  peritonitis?  She  is  now  in  the  Presbyterian  Hos- 
pital taking  mammary  extract  and  getting  ready  for  opera- 
tion. 

H.,  aged  48.  Widow,  7  children.  Strong  and  vigorous  till 
one  year  ago  when  hemorrhage  from  fibroma  began.  Gradu- 
ally "increased  till  dangerous  Only  a  few  days  between 
periods.  Severe  attack  of  catarrhal  pneumonia  never  fully 
recovered  from  ;  still  coughs.  Steadily  increasing  weakness 
and  hemorrhage.  Hysterectomy ;  catarrhal  pneumonia 
again  set  in.  Death.  Her  trouble  began  at  47,  and  in  one 
year  had  brought  her  into  a  desperate  position. 

S  ,  aged  50.  On-  child,  7  miscarriages.  Fibroma  for  an 
unknown  number  of  years.  Menopause  delayed  until  aged 
54.  One  j  ear  later  hemorrhage  began  again  and  rapidly  be 
came  severe.  Shown  on  operation  to  be  due  to  adenocar- 
cinoma of  fundus,  complicating  the  fibroma. 

The  number  of  cases  like  the  last  which  appear  in  the 
experience  of  most  men  raises  the  question  whether  the 


irritation  produced  by  the  fibroma  is  a  contributing 
cause  of  the  later  development  of  the  cancer. 

It  is  unnecessary  to  multiply  examples  where  the 
most  serious  conditions  have  menaced  the  life  of  the 
patient  who  has  a  fibroma  after  the  time  of  the  expected 
menopause.  Yet  patients,  often  under  advice,  continue 
to  look  in  vain  for  its  help. 


WOUND   OF  THE  TRACHEA,  WITH   SUTURE  AND 
UNION  BY  FIRST  INTENTION. 

By  E.  S.  GOODHUE,  M.D., 
of  Honolulu,  H.  L 

Wounds  of  the  neck  in  which  the  trachea  is  involved 
are  by  no  means  infrequent.  Usually  they  are  self- 
inflicted  by  some  insane  or  frenzied  hand,  unguided  by 
knowledge  or  consideration  of  the  relation  of  the  tissues 
concerned.  Hence,  the  head  is  thrown  back,  bringing 
the  larynx  into  prominence,  and  leaving  the  important 
vessels  of  the  neck  out  of  reach  of  a  carelessly-used 
instrument. 

In  exceptional  cases  the  tissues  of  the  neck  are  com- 
pletely severed — carotids,  trachea,  esophagus,  to  the 
vertebras — but,  as  a  rule,  the  wound  is  superficial, 
owing  to  the  extension  of  the  neck,  cartilaginous  resist- 
ance, collapse  of  the  thorax,  or  want  of  determination 
on  the  part  of  the  would-be  suicide. 

In  the  case  of  a  barber,  aged  57,  that  came  under  my 
notice,  the  wound  was  made  with  a  sharp  razor,  begin- 
ning at  the  right  ear,  and  passing  over  the  suprahyoid 
space  to  the  extreme  left — from  "  ear  to  ear,"'  through 
all  the  tissues  of  the  neck,  including  esophagus,  and 
causing  almost  instant  death.  The  question  arose  as  to 
whether  such  a  thing  could  be  self-inflicted,  but  here 
was  the  case  with  absolute  proof  of  suicide. 

Generally,  danger  from  hemorrhage  is  not  so  great 
when  the  larj'nx  or  trachea  are  much  injured,  as  the 
large  vessels  lie  outside  of  the  path  of  such  a  wound  ; 
but  cases  are  reported  where  the  cut.  beginning  well 
under  the  ear,  passed  directly  over  the  cricothyroid 
space.  However,  wounds  of  the  larynx  may  be  rendered 
serious  by  spasm  and  edema  of  the  glottis,  inflamma- 
tion, or  the  passage  of  food  into  the  trachea. 

Hemorrhage  occurs  freely  when  the  soft  parts  lying 
above  the  hyoid  bone  are  severed.  Often  there  is  pene- 
tration into  the  cavity  of  the  mouth,  allowing  the  tongue 
or  epiglottis,  or  both,  to  fall  over  the  air-pasisage,  thus 
causing  death  ;  or  the  lingual  and  facial  arteries  are  cut, 
flooding  the  trachea.  But  greater  hemorrhage  is  likely 
to  occur  when  the  carotid  or  thyroid  arteries,  the 
anterior,  external  or  internal  jugular  veins,  or  the  thy- 
roid gland,  are  wounded  in  the  lower  part  of  the  neck. 
Here,  some  of  these  vessels  are  generally  involved,  and 
if  the  trachea  is  completely  severed,  there  is  great 
danger  that  the  freely-flowing  blood  will  find  its  way 
into  the  lungs.  This  condition  is  made  more  serious 
by  the  fact  that  the  trachea,  upon  being  cut.  retracts, 
the  ends  remaining  difficult  to  approximate,  while  each 
inspiration  and  expiration  renders  the  operation  stiD 
more  trying.  These  well-known  facts  are  supported  by 
the  following  case : 

At  8  A.M.,  Sunday,  July  25,  I  was  summoned  bv  telephone 
to  Waikapu,  a  small  village  two  miles  Irom  Malulani  Hos- 
pital where  I  was  In  less  than  half  an  hour.  I  reached  the 
spot  with  my  assistant.  Dr.  Wilbur  McConkey,  and  found 
there  Deputy  Sheriff  Scott,  and  a  native  policeman,  waiting 
for  us. 


JAHHARY  12,  1901] 


LEUKEMIA  AND  SPLENIC  PSEUDOLEUKEMIA 


["The  Philadelphia 
L  Medical  Journal 


75 


Lying  on  her  back,  near  the  house,  was  a  Japanese  woman 
with  lier  throat  cut,  and  life  extinct.  Nearby  was  the  body 
of  a  little  girl  of  four  years,  her  head  attached  to  the  trunk 
only  by  a  narrow  strip  of  skin  in  the  back,  while,  between  the 
two,  was  the  murderer,  Sagata,  a  Japanese  laborer,  aged  39, 
with  an  ugly  cut  just  below  the  cricoid  cartilage,  blanched, 
pulseless  at  the  wrist,  but  still  breathing. 

When  the  officers  arrived  on  the  spot  half  an  hour  pre- 
viously, Sagata  lay  on  his  face  in  a  pool  of  blood  with  a 
dagger  in  his  throat.  He  was  then  unconscious,  as  he  was 
when  I  arrived  We  at  once  placed  the  patient  on  his  back, 
while  I  proceeded  to  examine  the  wound,  at  the  same  time 
requesting  my  assistant  to  give  him  a  hypodermic  injection 
of  aqua  ammoniae  fort.  20  minims,  in  little  over  a  dram  of 
water. 

I  found  a  jagged  cut  half  an  inch  wide,  and  about  one  and 
one  half  inches  long,  just  below  the  cricoid  cartilage,  the 
opening  being  stretched  by  the  knife,  upon  which  the  patient 
had  lain. 

The  vessels  were  not  bleeding  much  bj'  this  time,  and  there 
was  no  fresh  hemorrhage  when  I  removed  the  clots  of  blood 
and  probed  the  wound.  The  superficial  tissues  were  all  cut 
through,  and  blood  still  oozed  from  the  thyroid  gland.  The 
treachea,  between  the  second  and  third  cartilages,  was  com- 
pletely severed,  one  inch  or  more  existing  between  the 
retracted  portions. 

I  was  surprised  to  find  very  little  blood  about  the  inner 
edges  of  the  trachea,  but  with  each  expiration,  mucus  from 
the  trachea,  and  blood  from  the  external  parts,  were  blown 
out  with  a  whistling,  puffing  sound.  About  five  minutes 
from  the  time  the  first  injection  of  ammonia  was  given,  the 
dose  was  repeated,  when  the  patient  slowly  opened  his  eyes. 
I  quickly  cleansed  the  wound  with  aseptic  sponges  and 
forceps,  twisted  the  ends  of  the  few  vessels  that  still  bled 
slightly,  then  attempted  to  bring  the  separated  ends  of  the 
trachea  together.  This  was  not  so  easily  done,  although  I 
finally  succeeded  in  making  a  continuous  suture  with 
chromicised  catgut.  I  included  the  inner  and  outer  covering 
of  the  tube,  in  this  continuous  stitch,  then  to  make  provision 
against  the  tendency  to  reaction,  I  tied  the  cartilages  together 
with  three  stitches,  so  that  the  approximated  edges  might 
be  held  as  closely  together  as  posssible.  I  was  much  hindered 
by  the  smallness  of  the  opening  of  the  wound,  which,  how- 
ever, I  enlarged  somewhat,  making  it  nearly  two  inches 
wide. 

Sagata  now  opened  his  eyes,  looked  around  in  a  bewildered 
way,  and  asked  for  a  drink  of  water,  which  we  gave  him 
with  some  brandy. 

I  now  closed  the  external  wound  upon  a  small  drainage 
tube,  making  the  stitches  with  silk,  covered  this  with  asep- 
tic dressings,  absorbent  cotton,  and  bandages,  when  the 
patient  was  taken  to  the  hospital.  Here  he  was  placed  in  a 
ward  prepared  for  him,  and  given  special  day  and  night 
nurses  and  attendants.  After  careful  dressing  of  the  wound 
by  the  nurse,  the  patient  was  placed  in  bed  with  his  shoulders 
raised,  and  his  head  moderately  flexed  by  bandages.  At 
this  time,  3  p.m.,  temperature  was  100°  F.,  pulse  85.  Patient 
was  given  liquid  food  which  he  appeared  to  relish,  and  his 
bowels  were  moved  by  an  enema,  while  he  was  also  given  a 
saline  laxative. 

July  26,  10  a.m.  Patient  slept  well  preceding  night.  Bowels 
moved  at  1  a.m.  Temperature  100°.  Pulse  80  Felt  "  moitai " 
(well).  There  was  considerable  blowing  through  the  tube, 
with  mucus  and  blood,  so  we  removed  the  tube,  inserting 
another  in  its  place.  Patient  improved  daily,  his  tempera- 
ture and  pulse  gradually  decreasing  until  August  1,  when 
both  had  become  normal. 

The  air  came  less  and  less  through  the  wound,  and  the 
external  opening  closed  up  so  quickly  that  I  had  to  irritate 
the  edges  in  order  net  to  have  it  entirely  heal  up. 

In  three  weeks  the  wound  was  healed,  the  patient  eating, 
sleeping  and  carrying  on  other  functions  as  usual. 

I  was  curious  to  see  the  result  of  my  suture,  but  did 
not  consider  that  I  should  be  justified  in  opening  the 
external  wound  to  satisfy  myself,  and  so  had  removed 
the  tube  and  allowed  nature  to  do  its  perfect  work. 

About  midnight,  August  26th,  I  was  called  to  the 
hospital,  where  I  found  that  our  patient  had  in  some 
way  eluded  the  vigilance  (?)  of  his  attendant,  got  hold 


of  a  jack  knife,  and  ripped  open  the  old  external 
wound,  besides  inflicting  several  slight  wounds  on  his 
abdomen.  He  had  evidently  tried  to  do  the  Japanese 
suicide  act.  Then  I  Vas  able  to  look  upon  my  united 
trachea.  It  appeared  to  be  as  good  as  ever,  and  the 
stitches  were  fast  disappearing.  I  at  once  sewed  up  the 
flesh-wound,  and  on  the  morrow  we  sent  our  patient  to 
Honolulu  to  await  his  trial. 

In  the  following  December  he  was  tried,  found  guilty 
of  murder  on  one  charge,  and  sentenced  to  death,  which 
he  met  in  Honolulu,  March  28,  1898.  At  the  trial,  Mr. 
Dole,  the  prosecuting  attorney,  expressed  his  regret 
that  the  attending  surgeon  had  seen  fit  to  put  the 
Hawaiian  government  to  so  much  additional  expense. 


LEUKEMIA  AND  SPLENIC  PSEUDOLEUKEMIA.* 
By  EVERETT  J.  BROWN,  M.D., 

of  Decatur,  111. 

The  object  of  this  paper  is  to  present  two  cases  of 
the  more  common  form  of  leukemia,  known  as  the 
splenomyelogenous  variety  (one  of  which  has  just  come 
to  autopsy),,  and  a  third  case  of  the  much  rarer  and 
very  interesting  form  of  disease  known  as  splenic 
pseudoleukemia  or  splenic  anemia.  It  is  to  the  latter 
case  that  I  wish  to  call  especial  attention,  for  although 
now  regarded  as  a  rare  disease,  yet  I  anticipate  that 
with  the  revival  of  interest  which  has  been  created 
recently  in  its  study  by  the  two  papers  of  Osier,'  and  the 
critical  summary  of  the  literature  by  Sippy,'  and  his 
report  of  a  recent  case,  many  more  cases  will  be  brought 
to  light,  and  its  clinical  recognition  be  made  easier ;  in 
fact,  such  has  already  been  the  efi'ect,  and  in  the  issue 
of  the  Bosto7i  Medical  and  Surgical  Reporter  for  April  26 
there  appeared  three  articles  on  the  subject,  with  the 
report  of  four  additional  cases  of  the  disease. 

The  leukemias  may  be  divided  into  two  great  classes: 
the  true  and  the  false.  Of  the  true  leukemias  there  are 
three  subdivisions— the  lymphatic,  the  splenic,  and  the 
myelogenous  ;  clinically,  however,  we  cannot  make  this 
sharp  division,  for  the  most  commonly  observed  type 
is  a  combination  known  as  the  splenomyelogenous 
variety  ;  of  the  pure  myelogenous  form  there  are  only 
two  cases  on  record,  hence  its  existence  may  be  doubted. 
The  pure  lymphatic  form,  although  comparatively  rare, 
is  quite  often  observed,  while  the  pure  splenic  variety, 
without  lymphatic  or  medullary  involvement,  is  also 
quite  rare.  An  acute  form  of  true  leukemia  is  now 
quite  frequently  seen,  although  its  proper  place  in  the 
study  of  these  blood-conditions  has  been  hardly  yet 
established. 

Of  the  false  leukemias,  Hodgkin  and  Bonfils 
(quoted  by  H.  C.  Wood')  named  two  varieties  :  lym- 
phatic pseudoleukemia,  or  Hodgkin's  disease,  and  the 
lymphosplenic  pseudoleukemia.  Wood  (1871)  recog- 
nized the  third  variety  :  the  splenic  pseudoleukemia. 
The  relationship  existing  between  pseudoleukemia 
and  leukemia  is  still  in  doubt,  and  it  is  possible  that  in 
time  they  will  be  found  to  be  only  phases  of  the  same 
disease  ;  they  have  the  same  clinical  history,  the  same 
lesions  of  solid  organs,  the  same  general  course,  and 
differ  only  in  the  existence  or  absence  of  a  marked 
leukocytosis  with  some  qualitative  diflerences  in  these 
leukocytes ;  this  similarity,  together  with  the  occurrence 
of  leukocytosis  during  the  course  of  a  pseudoleukemia, 

*  Read  before  the  Illinois  State  Medical  Society,  May  18, 1900,  at  Springfield. 
111. 


76 


TlIK  PllILADKLPHIA 

Mkdical  Journal 


] 


LEUKEMIA  AND  SPLENIC  PSEUDOLEUKEMIA 


[Jabuaey  12,  1»01 


make  one  wonder  if  the  diseases  are  not  identical. 
There  is  one  fact,  however,  that  points  very  strongly 
against  this  supposition,  and  th^  is  the  effect  of  the 
operation  for  the  removal  of  the  spleen,  which  in  leuke- 
mia is  almost  universally  fatal,  while  in  splenic  pseudo- 
leukemia quite  a  number  of  successful  results  are 
recorded. 

Leukemia  may  be  defined  as  a  disease  affecting  the 
blood-producing  functions  of  the  body,  characterized  by 
a  marked  quantitative  and  qualitative  change  in  the 
leukocytes,  and  by  peculiar  changes  either  in  the 
spleen,  bone-marrow  or  lymph-glands,  or  in  all  of  these 
structures,  running  occasionally  an  acute,  but  usually 
a  chronic  course,  and  exhibiting  a  progressive  anemia, 
a  marked  tendency  to  hemorrhages  and  a  fatal  termina- 
tion. The  pseudolenkemisLS  answer  in  a  general  way 
to  the  same  definition,  with  this  difference,  that  there 
is  no  marked  leukocytosis  and  no  peculiar  forms  of 
leukocytes.  Splenic  {jseudoleukemia  therefore,  which 
is  especially  interesting  us  today,  on  account  of  this 
revival  in  its  study,  may  be  defined  as  a  primary 
splenic  hypertrophy  with  a  progressive  anemia,  without 
involvement  of  the  lym])h-glands  and  without  marked 
increase  in  the  white  blood-cells.  For  purposes  of  com- 
parison I  will  first  report  the  two  cases  of  true  leuke- 
mia: 

Case  1. — Sphrwmyelogenoua  leuketnia  ;  pregnancy,  with  abor- 
tion at  six  months,  followed  by  double,  phlegmasia  alba  dolens  — 
Mrs.  G.,  aged  31 ;  a  farmer's  wife;  sent  to  me  on  March  14, 
1900,  with  a  diagnosis  of  ovarian  tumor;  family  history  nega- 
tive, no  malarial  history;  has  had  seven  children,  four  living 
and  in  good  health.  Six  months  ago  she  noticed  a  "  lump  " 
in  the  left  .side  just  under  border  of  ribs ;  it  was  distinct  from 
the  abdominal  enlargement  due  to  the  pregnant  uterus.  On 
January  4,  she  miscarried  at  six  months,  and  in  one  week 
developed  fever,  and  a  week  later,  phlegmasia  in  both  legs, 
which  continues  to  the  present  time.  At  the  time  of  mis- 
carriage the  tumor  was  the  size  of  a  teacup,  but  since  then 
it  has  increased  steadily  in  size.  No  enlargement  of  lymph- 
glands.  She  has  had  recurring  epistaxis,  bowel  hemorrhage 
and  metrorrhagia.  Slie  is  somewhat  emaciated,  pale,  with 
well-marked  melanoderma  resembling  Addison's  disease. 
Ti-mp'rature  100.5°  F.,  puls^  100.  Physical  examination 
shows  a  large  tumor  in  left  side  of  abdomen.  The  dulness 
begins  at  the  ninth  ril)  in  the  axillary  line  and  merges  into 
the  tj-mpanitic  sound  at  a  point  half  way  between  the  last  rib 
and  the  crest  of  ilium  ;  the  tumor-mass  extends  to  the  um- 
bilicus and  downward  to  a  point  midway  between  the  um- 
bilicus and  symphysis;  above  the  umbilicus  the  dulness  is 
continuous  with  that  of  the  left  lobe  of  the  liver;  a  distinct 
notch  is  felt  halfway  l)etween  the  ensiform  and  umbilicus. 
Spleen  moves  vertically,  not  diagonally,  with  respiration  ;  it 
is  tender  on  pressure  and  the  heart-sounds  are  transmitted 
through  it ;  no  bruit ;  heart  apex  in  fourth  space  on  nipple 
line  ;  lun-j-liver  border  at  sixth  rib ;  sternum  and  tibiae  ten- 
der on  percussion. 

Blood  examination :  Hemoglobin  75  % ;  red  cells,  3  600,000  ; 
white,  250,000;  differential  count ;  myelocytes,  38.5%  ;  po'y- 
morphonuclears,  53.3%  ;  lymphocytes,?  %  ;  eosinophiles, 
1.2%  ;  numerous  nucleated  reds,  some  with  double  nuclei. 

Eye  examination  made  by  Dr.  S.  E.  McClelland  shows 
normal  vision,  but  a  pale  retina,  with  both  fields  of  vision 
contracted. 

Urinanalysii :  Color,  yellow;  albumin,  sugar,  bile,  indican 
and  diazo  negative;  chlorids  19%;  phosphates  5%;  urea 
2%;  hcdiment;  amorphous  phosphates. 

May  1.  At  present  writing  she  has  entirely  recovered  from 
the  plile.j;masia,  is  up  and  around  and  able  to  work,  is  taking 
arsenic,  and  appeirs  much  less  anemic;  spleen  remains  the 
same  size  giving  her  the  appearan  e  of  a  seven  months' 
pregnancy ;  she  has  oc  nisioual  slight  fever,  good  appetite, 
epistaxis  at  times  and  metrorrhagia  when  on  feet  much.  Her 
weight  is  1.36  pounds;  in  health  i;  was  165  jiounds.  A  recent 
blood-examination  shows:  hemoglobin,  70%;  white  cells, 
128,000;  in  2,000  the  are  12  nucleated  reds,  all  normoblasts. 


Case  2. — Splenomyelogenous  leukemia,  uncontrollable  priapism 
lasting  S6  days ;    nearly  fatal  epistaxis;   death  from  exhaxuH/m;  ^  1 
autopsy — Jno.  C,  aged  40;  farmer;  seen  first  on  September  ( 
2,  1899.    Father  died  of  gastric  cancer ;  one  sister  of  phthisis,  j  | 
Patient  not  well  for  2  y^ars;  noticed  spleen  enlargement  10 
months  ago.      Has  been  in  bed  for  3  weeks  on  account  of 
the  very  painful  priapism,  which  is  not  affected  by  treat- 
ment, but  requires  the  use  of  the  catheter  and  prevents 
sleep;  a  painful  urethritis  has  now  developed.    Spleen  occu- 
pies the  larger  part  of  the  left  half  of  the  abdomen ;   no 
edema  or  ascites;  patient  is  verj'  anemic;  temperature  and 
pulse  normal ;  no  involvement  of  lymph-g'ands ;  no  melan- 
oderma.   Urine  shows  a  specific  gravi  j' of  1.015;  albumin 
and  sugar  negative;  sediment  of  pua-ce'ls  and  bacteria. 

Blood  examination:  Hemoglobin,  75%;  red  corpuscles, 
2,940  000;  leukocyts,  556,000.  Differential  count;  polymor- 
phonuclear neutrophiles,  56%  ;  myelocytes,  41%  ;  lympho- 
cytes, 2%  ;  esinophiles,  1%. 

Eight  months  later  he  died ;  had  been  up  and  around  most 
of  the  time  since  the  attack  of  priapism  which  lasted  26 
days;  he  had  had  several  slight  attacks  of  this  complication 
before,  but  each  time  it  lated  only  6  or  8  hours ;  at  all  times 
there  was  no  sexual  erethism.  Three  days  before  death  he 
became  totally  deaf;  his  vision  had  been  greatly  affected  for 
months.  Duration  of  life  after  discover}'  of  enlarged  spleen, 
1}  years;  total  period  of  ill  health,  2J  years. 

Autopsy:  Eighteen  hours  postmortem;  with  the  assistance 
of  Drs.  W.  T.  Patterson  and  Will,  Chenoweth.  Emaciation 
not  extreme ;  purpuric  spots  on  arms  at  site  of  hypodermic 
needle  punctures ;  abdomen  quite  flat,  in  marked  contrast 
to  the  enlargement  before  death ;  pleurae  and  lungs  nega- 
tive ;  pericardium  contains  2  ounces  of  clear  yellow  fluid ; 
heart  not  enlarged,  filled  with  semifluid  chocolate  red  blood, 
valves  competent  but  showing  on  mitral  and  aortic  leaflets 
patches  of  atheroma.  Upper  third  of  the  greatly  enlarged 
spleen  firmly  adherent  to  the  diaphragm  and  to  left  lobe  of 
liver ;  it  is  smooth  and  uniformly  enlarged  and  its  right  bor- 
der presents  three  distinct  notches;  it  is  15  inches  long,  8 
inches  wide  and  3J  inches  thick ;  longer  circumference  31 
inches ;  shorter,  19  inches ;  weight,  10  pounds. 

Liver :  weight,  7  pounds ;  right  lobe,  8J  by  10  by  SJ  inches ; 
left  lobe,  9  by  3}  by  2  inches.  Left  kidney  floating,  smaller 
than  right.  Stomach,  intestines,  mesenteric  glands  and 
bladder  normal. 

Histology :  Spleen,  increase  of  cellular  elements.  Mal- 
pighian  bodies  indistinct.  Leukocytes  abundant  in  lymph 
spaces  and  free  in  stroma.  Liver  shows  slight  cirrhosis; 
capsule  thickened,  with  small  hemorrhage}  beneath;  lobules 
show  chronic  congestion.  InSltration  of  leukocytes  between 
liver  cells.  Kidney:  Some  increase  of  connective  tissue  and 
atrophj'  of  glomeruli.  Hemorrhage  into  straight  tubules. 
Increase  of  leukocytes  is  seen  in  capillaries  and  between 
the  tubules. 

The  third  report  is  the  case  of  splenic  pseudoleuke- 
mia previously  mentioned. 

Case  3. — Greatly  enlarged spteeti ;  pro/ounianemia;  adrandnff 
to  cachf^xia ;  no  leukocytosis  ,•  great  ascites  and  edema  ;  denth  from 
exhaustion;  au/opsy.—C.  T.,  male,  American,  aged 54;  farmer; 
married.  First  examined  by  me  in  May,  1S98.  His  father 
is  living  at  80  years ;  mother  died  of  heart  disease.  One 
brother  died  at  55  of  some  abdominal  cancer ;  another 
brother  is  livinj,  but  has  Bright's  disease,  and  one  sister  is 
living  at  55,  but  with  anemia  and  some  svjmach-disease. 
He  belongs  to  the  bet'er  cla^^s  of  fafmer-i,  being  well  to  do, 
and  from  a  very  intellectual  family ;  his  habits  have  ^een 
good  ;  n  D  alcohol,  but  an  exi^e-sive  user  of  t  ibacco  ;  fond  of 
condiments  and  a  good  eater;  no  venereal  history.  He  had 
a  very  severe  and  nrolonged  attack  of  malaria  15  years  ago. 

Present  illness :  For3yeirs  he  bas  not  seemed  well;  was 
irritable  and  easily  tired  and  at  times  had  backache  when 
standing  ;  has  been  pale  and  yellow  for  over  a  year :  6  monihs 
ago  he  coughed  or  spit  blood  (6  or  7  large  mouthfuls).  and 
two  or  three  times  later  he  has  done  the  same,  hut  a*  no 
time  was  there  severe  hemorrhage ;  has  dyspnea  on  exer- 
tion, and  s  ime  heart  palpitation.  Edema  of  ankles  appeared 
first  about  4  months  ago,  gradually  extending  up  the  legs 
and  into  the  abdomen:  m  ire  or  less  cough  exists  and  there 
is  constipation.  Examination:  Avery  large  man,  but  hav- 
ing lost  considerable  in  weight ;  the  anemic  appearance  is 


JanuaRV    I'J,   1901] 


LEUKEMIA  AND  SPLENIC  PSEUDOLEUKEMIA 


[The  Puiladbi-puia 
Medical  Jodbkal 


77 


marked.  Is  up  and  around  most  of  the  time  and  oversees 
his  farm  work ;  mind  is  clear  and  active  and  in  spite  of  his 
forced  levity  one  observes  ia  him  an  intense  anxiety  as  to 
liis  disease.  Skin  is  dry  and  rough  and  subcutaneous  tissues 
flabby ;  temperature  normal.  Pulse  70  to  90.  A  tumor  mass 
(not  large)  is  felt  under  the  left  costal  border;  ascites  and 
edema  considerable.  I  made  a  diagnosis  of  cirrhosis  of  the 
liver,  from  the  ascites,  moderately  enlarged  spleen,  vomiting 
of  blood,  etc.  On  July  5  he  was  examined  by  a  Chicago  spe- 
cialist who  concurred"  in  a  tentative  diagnosis  of  cirrhosis, 
but  mentioned  the  possibility  of  malignancy  or  of  pernicious 
anemia;  the  blood  count,  which  was  as  follows,  excluded 
leukemia.  Hemoglobin  (Fleischl)  35%;  red  corpu.scles  1,- 
450,000 ;  white  corpuscles  6,300 ;  no  nucleated  reds.  Micro 
cytes  and  macrocytes  somewhat  abundant. 

October  24,  spleen  is  enlarging  and  is  felt  as  a  large  firm 
mass  with  smooth  surface  protruding  out  from  under  the  left 
costal  arch  and  extending  to  a  point  beyond  the  umbilicus 
and  downward  to  a  point  within  a  hand's  breadth  of  the 
p  ibic  bone;  it  moves  with  respiration  in  a  diagonal  direc- 
tion, its  edge  is  easily  felt  and  the  whole  tumor  can  be  quite 
readily  grasped  with  the  hands  and  moved  in  a  lateral  di- 
rection. Urine  1.020;  no  albumin.  I  lost  sight  of  the  case 
for  6  months  while  I  was  in  Europe,  and  on  my  return  in 
June,  1899,  iiU  his  symptoms  were  increased  :  larger  spleen, 
more  anemia,  more  dropsy.  Four  days  before  his  death  his 
abdomen  was  tapped  and  a  large  quantity  of  slightly  pink 
fluid  removed.  Death  from  exhaustion.  Duration  of  dis- 
ease, two  years  and  five  months 

Autopsy:  Eighteen  hours  postmortem.  The  subject,  a 
very  large  man,  showed  a  high  grade  of  emaciation ;  the 
subcutaneous  fat  was  greatly  reduced,  the  subcutaneous  tis- 
sues were  edematous,  the  feet  and  legs  were  swollen  and  the 
abdomen  greatly  distended  by  the  ascites  and  the  greatly 
enlarged  spleen.  There  was  no  decided  enlargement  of  the 
lymph-glands  eitlier  externally  or  in  the  abdomen.  The 
ascitic  fluid  was  estimated  at  IJ  gallons,  and  when  held  to 
the  light  in  a  test  tube  showed  a  slight  pinkish  tinge.  The 
organs  were  only  examined  in  situ,  and  sections  removed 
from  them  for  microscopic  examination.  The  spleen  was 
greatly  but  uniformly  enlarged,  filling  the  greater  part  of  the 
left  half  of  the  abdominal  cavity ;  the  surface  was  smooth 
and  showed  m  peritoneal  adhesions;  the  small  notch  at 
right  border  was  well  marked ;  the  liver  was  somewhat 
enlarged  and  presented  a  smooth  surface  and  no  visible  signs 
of  cirrhosis;  pancreas,  kidneys,  stomach  and  intestines 
negative.  Histology:  Pancreas,  small  cell  infiltration  and 
postmortem  necrosis.  Liver :  no  cirrhosis,  but  localized  col- 
lections of  lymphoid  cells  in  the  capillaries  and  a  moderate 
atrophy.  Spleen  :  marked  hyperplasia  of  the  finer  stroma, 
with  collections  of  lymphoid  cells  throughout,  similar  to 
those  in  the  liver.  Throughout  the  stroma  there  are  also 
numerous  giant  cells  with  nuclei  arranged  centrally.  The 
above  report  was  kindlj'  made  for  me  by  Dr.  A.  S.  Warthin, 
in  Dr.  Dock's  laboratory  at  Ann  Arbor. 

The  Index  Catalogue  gives  few  references  under  the 
caption  "  Splenic  Anemia,"  hence  the  literature  must 
be  sought  under  several  other  heads,  such  as  splenic 
hypertrophy,  anemia,  Hodgkin's  disease,  etc.,  but  as  far 
as  I  have  been  able  to  find  there  are  recorded,  before 
the  case  which  I  report  today,  only  51  cases  of  this  dis- 
ease. The  number  of  autopsies  is  even  smaller,  being 
only  18  recorded.  Sippy  was  able  to  select  from  the 
literature  7  cases  in  which  the  spleen  had  been  removed 
for  this  disease;  of  these  5  recovered ;  since  then  Osier 
has  reported  1  additional  case  which  terminated  in 
recovery ;  these  excellent  results  lead  one  to  hope  that 
the  operation  may  be  established  as  a  regular  procedure 
in  all  primary  enlargements  of  the  spleen,  the  main 
contraindication  seeming  to  be  only  a  great  leukocytosis 
or  a  far  advanced  cachexia. 

In  looking  up  the  literature  of  this  subject  it  is  sur- 
prising to  see  how  much  the  older  writers  knew  on  the 
subject  and  how  much  has  since  been  forgotten  about 
it ;  for  years  no  textbooks  mentioned  the  subject  and 
several  of  the  recent  ones  have  nothing  upon  it.     This 


may  be  due  to  the  fact  as  Shattuck'  recently  said,  that 
we  are  classifying  away  ahead  of  our  knowledge,  and 
that  our  ignorance  of  the  so-called  splenic  anemia  is  yet 
great,  and  that  it  is  not  even  a  clinical  entity.  Musser* 
in  his  latest  edition  on  Medical  Diagnosis  does  not 
mention  splenic  pseudoleukemia,  but  speaks  of  a  sec- 
ondary or  so-called  splenic  anemia  which  in  no  case 
exists  as  a  primary  anemia,  but  which  is  distinguished 
from  leukocythemia  by  the  lesser  frequency  of  hemor- 
rhage, by  the  absence  of  leukocytosis  and  by  the  special 
characteristics  of  the  leukocytes.  As  regards  hemor- 
rhage, most  other  observers  differ  from  this  opinion  and 
speak  of  the  various  hemorrhages  as  being  a  special 
characteristic  of  splenic  anemia.  Osier  gives  a  short 
article  on  splenic  anemia  in  his  textbook  and  says  it  is 
a  disease  characterized  by  great  enlargement  of  the 
organ,  profound  anemia  without  leukocytosis  and  with- 
out the  coexistence  of  malaria,  rickets,  or  other  states 
in  which  enlargement  of  the  spleen  is  secondary.  Yet 
in  his  above-mentioned  report,  which  appeared  in  Jan- 
uary, 1900,  he  includes  4  cases  of  undoubted  malarial 
history. 

Stengel'  in  his  article  in  the  "  Twentieth  Century- 
Practice"  mentions  splenic  anemia  under  the  list  of 
synonyms  for  Hodgkin's  disease,  he  dismisses  the  sub- 
ject in  a  few  lines  by  saying:  "Splenic  hypertrophy 
may  be  unassociated  with  changes  in  the  lymphatic 
glands  or  other  structures.  Such  cases  constitute  the 
splenic  anemia  of  Griesinger  and  Striimpell,  or  the 
splenomegalia  primitive  of  Debove  and  Bruhl.  More 
commonly  the  splenic  enlargement  is  followed  by  some 
involvement  of  the  lymphatic  glands,  and  the  latter 
may  become  the  more  conspicuous  feature  of  the  dis- 
ease." In  another  place  he  says  that  cases  spoken  of 
as  splenic  anemia  are  widely  different  in  nature,  some 
belonging  to  the  symptomatic  anemias,  others  being 
cases  of  Hodgkin's  disease. 

Sahli,"  in  his  recent  Klinische  Untersuchungs  Methoden, 
recognizes  the  two  pseudoleukemias,  viz.,  pseudoleu- 
kemia lienalis,  and  pseudoleukemia  lymphatica. 

Eichhorst'  mentions  the  three  forms  of  pseudoleuke- 
mia— the  lymphatic,  the  splenic  and  the  myelogenous  ; 
the  first  being  the  more  common,  the  two  latter  quite 
rare.    He  also  refers  to  H.  C.  Wood's  case  in  1871. 

That  some  obscure  relationship  exists  between  leuke- 
mia and  splenic  pseudoleukemia  there  can  hardly  be  a 
doubt,  but  the  fact  that  surgical  intervention  in  the  case 
of  pure  leukemia  is  always  fatal,  while  in  the  false  form 
it  is  often  successful,  makes  one  believe  in  their  distinct 
entity. 

Sippy  gives  Banti  the  credit  for  first  describing  the 
affection  in  such  a  manner  as  to  attract  the  attention  of 
the  medical  profession.  Banti's  paper*  appeared  in 
1882,  and  although  of  great  value,  yet  it  was  antedated 
by  our  own  countryman,  H.  C.  Wood,  who  described  a 
case  in  the  American  Journal  of  Medical  Sciences  in  1871. 
Banti  gave  the  following  definition  of  the  disease : 
"  Anemia  splenica  is  a  disease  characterized  by  a  pro- 
gressive oligemia,  arising  without  appreciable  cause, 
and  giving  rise  to  grave  disturbances  of  all  the  organic 
functions,  causing  edemas,  hemorrhages,  irregular  fever 
and  followed  constantly  by  death,  and  accompanied  by 
a  notable  tumefaction  of  the  spleen  and  the  liver,  which 
tumefaction  is  independent  of  any  preceding  morbid 
condition  and  is  not  associated  with  any  leukemic 
alterations  of  the  blood." 

A  short  history  of  H.  C.  Wood's  case,  being  the  first 
one  described  in  America,  might  be  of  interest. 


78 


The  Philadelphia"! 
Medical  Jodrnal  J 


TREATMENT  OF  WHOOPING-COUGH 


[Jaicabt  12,  1901 


'i 


Case. — M.,  male,  aged  30  years.  Seen  in  August,  1870. 
Had  served  during, the  last  6  months  of  the  war  in  a  malarial 
district  of  Virginia ;  no  distinct  malaria,  but  cough,  diarrhea, 
and  dysentery.  On  returning  home  he  resumed  his  occupa- 
tion of  confectioner ;  did  much  lifting ;  bowe's  loose  now  for 
3  years ;  also  pain  and  dragging  in  left  side ;  for  2  months 
gradual  loss  of  strength  and  flesh.  Is  now  pale  ;  no  fever; 
tongue  clean;  abdomen  enlarged,  but  free  from  fluid. 
Spleen  shows  dulness  vertically  5J  inches,  and  transversely 
6 J  inches  ;  surface  smooth,  hard  ;  edges  rounded,  tender  oil 
pressure.  Liver  enlarged  ;  vertical  dulness  5J  inches  ;  edge 
1  inch  below  ribs;  urine  normal;  slight  edema  of  legs. 
Blood :  no  increase  of  leukocytes.  The  spleen  gradually 
enlarged,  the  leukocj'tes  diminished,  and  he  finally  died  of 
exhaustion.  Postmortem :  Spleen  8  by  5J  by  4  inches ; 
color,  bright  red;  masses  of  yellowish  color  through  spleen; 
lymphatics  enlarged  in  thorax  and  abdomen.  Spleen  pulp 
contained  usual  elements. 

In  making  a  diagnosis  of  true  leukemia  the  blood- 
examination  tells  everything,  while  in  the  pseudoleuke- 
mias it  furnishes  only  negative  evidence,  for  as  yet  we 
have  found  no  distinctive  quantitative  or  qualitative 
change  in  either  the  white  or  red  cells ;  in  leukemia, 
however,  as  is  well  known,  the  leukocyte  count  usually 
passes  the  100,000  mark,  and  lymphocytes  or  myelo- 
cytes are  more  or  less  abundant  according  to  which  form 
of  the  disease  exists.  Osier  has  already  called  attention 
to  the  remarkable  attacks  of  hematemesis  in  cases  of 
enlarged  spleen,  whether  primary  or  secondary  ;  in  his 
15  cases  of  splenic  pseudoleukemia,  8  had  had  hema- 
temesis ;  in  7  of  these  this  was  the  symptom  for  which 
they  sought  relief,  and  in  2  it  was  the  cause  of  death. 
Sippy's  case  had  repeated  epistaxis ;  the  cases  operated 
upon  by  Pean  showed  hemoptysis,  hematemesis,  hema- 
turia, and  bloody  stools  ;  in  fact,  in  reading  the  histories 
ofmost  cases  of  the  leukemiasone  is  .struck  with  the  fre- 
quency with  which  we  find  some  form  of  hemorrhage ; 
my  case  of  splenic  anemia  had  hemorrhage  from  the 
stomach,  and  the  case  of  splenic  leukemia  which  I  have 
reported  above  in  a  woman  gives  a  history  of  epistaxis, 
metrorrhagia,  and  bloody  stools. 

I  am  indebted  to  my  assistant.  Dr.  C.  Martin  Wood, 
for  valuable  aid  in  studying  these  cases  and  in  searching 
the  literature  of  splenic  anemia. 

REFERliNCES. 

■Osier:  Edinburgh  Medical  Journal,   May,   1899;  .4m«/iraii  Journal  Medical 
StfCTK-M,  January,  1900;   Canada  ^fedical  and  Sur<ricalJournal,  Vol.  xl. 
'  Slppy  :  Amercan  Journal  Mrdic  il  Sciences,  Ociohy.  1(199,  and  November,  1899. 
'  H.  C.  Wood  :  American  .Journal  Medical  SciencOi,  1871 

•  Banti:  Dell' Anemia  SplAiiiw,  Floreiu'e,  1SS2. 

'  F  C  Shaltuck  ;  Boslon  Medical  and  .Suriiical  Reporlcr,  April  26,  1900. 

•  Sahli :  Klinische  UnlersmbiniBs  Mcthoden,  1899. 
'  Eicbhorst :  Specielle  Pathologic  und  Therapie.  " 

•  Slenuel:  Twentieth  Centurv  Practice. 

•  Musser  :  Medical  Diagnosis.. 


SUGGESTIONS  ON  THE  TREATMENT  OF  WHOOPING- 
COUGH. 

By  II.  F.  THOMPSON,  M.D., 
of  Buffalo  Center,  la. 

_  WriooprNG-couGH  is  an  acute  infectious  disease,  occur- 
ring chielly  in  children,  characterized  by  paroxysms  of 
cough  in  rapid  series,  threatening  suffocation,  terminat- 
ing by  a  long-drawn  audible  inspiration,  and  accom- 
panied by  more  or  less  nasal,  laryngeal,  and  bronchial 
catarrh.' 

While  the  exact  cause  of  whooping-cough  has  always 
been  a  matter  of  doubt  it  is  now  generally  accepted  "to 
be  of  microbic  origin,  the  only  question  being  the  iden- 
tity of  the  microorganisms.  It  seems  fairlv  certain 
from  numerous  observations,  both  clinical  and  experi- 


mental, that  such  is  the  case,  and  that  the  specific 
microorganism  generates  a  toxin  ha%ing  a  selective 
action  on  the  center  of  the  vagus  and  superior  laryngeal 
nerves. 

It  has  been  proved  experimentally  that  the  superior 
laryngeal  nerve  is  the  nerve  of  cough,  and  any  irrita- 
tion of  the  areas  suppUed  by  this  nerve,  as  the  pyosterior 
laryngeal  wall,  just  below  the  vocal  cord,  and  the  tra- 
chea to  its  bifurcation,  produces  most  intense  cough. 

Von  HerS,'  in  studying  the  disease  as  it  occurred  in 
himself,  observed  a  marked  congestion  of  the  mucous 
membrane  of  the  under  surface  of  the  interarytenoid 
folds,  with  small  deposit?  of  mucus,  especially  on  the 
posterior  laryngeal  walls.  He  thought  that  the  removal 
of  these  deposits  of  mucus  aborted  the  attack.  But 
be  the  etiologic  factor  what  it  may  be,  the  fact  remains 
that  whooping-cough  is  essentially  a  self-limited  dis- 
ease ;  that  the  etiologic  factor  is  self-destroying,  or  that 
it  eventually  succumbs  to  that  well-known  process 
present  in  all  animal  organisms,  leukocvtosis,  phagocy- 
tosis, or  what  not,  remains  to  be  proved.  The  fact  that 
for  generation  after  generation,  children  have  been 
afflicted  with  whooping-cough,  a  large  percentage  of  ■ 
them  having  recovered  eventually  without  medication  | 
of  any  kind  at  any  stage  of  the  disease,  proves  the  self- 
limitation  of  the  affection. 

The  etiology,  pathology,  symptoms,  and  compUca- 
tions  are  of  small  importance  when  compared  with  the 
treatment.  That  the  treatment  of  whooping-cough  has 
resulted  in  many  failures  and  much  disappointment,  is 
proved  by  the  large  number  of  drugs  that  have  been 
tried.  Until  the  etiologic  fiictor  can  be  demonstrated  to 
an  absolute  certainty,  treatment  must  be  empirical.  The 
symptoms  as  they  arise,  and  the  conditions  as  they  pre- 
sent themselves,  must  be  met  and  treated  secundum 
art  em. 

It  has  been  my  good  fortune  to  have  a  iev;  cases  of 
whooping-cough  under  my  care  of  late,  all  of  which  I 
have  treated  with  heroin,  and  it  is  with  a  view  of  calling 
attention  to  this  drug  in  the  treatment  of  this  disease 
that  this  article  is  presented. 

In  heroin  we  have  a  valuable  therapeutic  agent  which 
allays  cough  and  eases  respiration.  It  reduces  the  num- 
ber of  respirations,  Imt  increases  their  force  and  the  vol- 
ume of  inspired  air.  The  current  literature  is  full  of 
praise  of  its  value  in  the  treatment  of  pulmonary  tuber- 
culosis, bronchitis,  asthma,  laryngitis,  and  other  affec- 
tions of  the  air-passages.  Aside  from  its  almost  specific 
effect  in  relieving  cough,  which  has  now  been  fully  es- 
tablished, heroin  also  exerts  a  distinct  influence  in  allay- 
ing dysjmea.  The  first  to  call  attention  to  this  action 
of  the  drug  was  Professor  Leo.'  who  employed  heroin  in 
various  conditions  attended  with  dyspnea,  and  found 
that  it  acted  promptly  and  without  the  least  depressing 
action  upon  the  heart. 

As  to  the  use  of  the  remedy  in  the  treatment  of 
whooping-cough,  I  find  that  Dr.  A.  Holtk;\mp*  reports 
5  cases  in  children  of  2  to  7  years  of  age.  The  drug 
was  given  guardedly  in  doses  of  y^^y  to  y^j  of  a  grain, 
usually  three  times  daily.  Under  its  administration 
the  attacks  were  diminished  both  in  severity  and  fre- 
quency. Floret*  describes  three  cases  of  whooping- 
cough  in  children  respectively  o.  4,  and  S  years 
old.  The  doses  administered  varied  from  ^  to  -s^y 
grain.  It  was  always  well  tolerated,  and  rendereti  the 
attacks  much  more  infrequent  and  less  violent.  There 
was  also  improvement  of  the  general  (x>ndition  of  the 
patients.     In  two  other  cases  referred  to  by  the  author 


jASfiBT   12,  1901] 


EE-EXPANSION  OF  THE  UTERUS  IN  LABOR 


tTHK  Philadelphia 


,  Medical  Jocbnal 


79 


the  remedy  failed  to  act,  which  is  attributed  by  him  to 
the  administration  of  too  small  doses.  Medea*  found 
heroin  less  useful  in  whooping  cough  than  in  other 
aflFections  of  the  respiratory  tract.  On  the  other  hand, 
Manges'  states  tliat  whooping-cough  has  been  very  favor- 
ably influenced  by  heroin.  The  drug  was  very  well  borne, 
and  the  paroxysms  were  shortenetl  in  25  out  of  33 
cases. 

Heroin  has  been  found  to  be  beneficial  to  a  greater 
or  less  extent  in  all  stages  of  pulmonary  affections,  but 
the  best  results  were  obtained  in  the  more  acute  cases,  in 
which  it  promptly  produces  free  expectoration  and  free- 
dom from  cough  and  pain. 

Referring  to  the  statement  made  by  von  Herff'  that 
the  removal  of  the  deposits  of  mucus  on  the  posterior 
laryngeal  wall  aborted  the  attack,  the  action  of  heroin 
renders  this  removal  easier,  by  allaying  spasm  and  caus- 
ing the  mucus  to  be  more  easily  expectorated.  Tims,  in 
a  nutshell,  we  find  explained  the  beneficial  action  of 
heroin  in  whooping-cough.  The  mucus  accumulates  on 
the  posterior  laryngeal  wall  supplied  by  the  superior 
laryngeal  nerve  (the  ner\-e  of  cough),  irritating  this 
nerve  and  producing  most  intense  cough.  If  these 
paroxysms  can  be  aborted  by  the  removal  of  the  mucus 
tirom  this  area,  we  render  the  patient  less  liable  to  fall 
a  victim  to  the  serious  complications  of  the  second  stage, 
and  from  the  antispasmodic  and  expectorant  qualities  of 
heroin  we  get  the  desired  results. 

Case  1. — A.  V.,  aged  20  months,  was  first  seen  April  2, 
1900.  She  had  a  severe  cough,  ending  with  a  characteristic 
"  wboop,"  and  usually  accompanied  with  vomiting.  Tem- 
perature 101°  F.  I  gave  heroin,  j'j  grain,  every  four  hours, 
and  ordered  warm  baths  for  the  temperature  April  3,  the 
patient  coughing  less,  but  quite  drowsy.  The  bowels  not 
having  moved,  hydrarg.  chlor.  mit.,  }  grain,  was  adminis- 
tered every  three  hours  until  1  grain  had  been  given. 
Heroin  was  continued  for  4  days  at  intervals  of  4  to  8  hours, 
with  complete  disappearance  of  the  cough,  and  no  un- 
pleasant complications. 

Case  2. — James  G.,  aged  4  years,  had  been  suffering  with 
pertussis  for  4  weeks  prior  to  coming  under  notice.  I  was 
told  by  his  father  that  he  had  been  very  had.  He  had 
learned  to  assume  a  position  on  his  knees  and  hands  when 
the  paroxysms  came  on.  He  had  several  attacks  each  day, 
and  seemed  to  be  worse  at  night.  Heroin,  ^'j  grain,was  given 
every  four  hours  for  several  days,  with  a  rapid  amelioration 
of  the  symptoms. 

Case  3. — Mrs.  G.,  mother  of  patient  in  Ca«e  2,  said  that  she 
took  several  doses  of  the  heroin  at  irregular  intervals,  and 
was  benefited  very  much  She  had  a  severe  attack  of  per- 
tussis, and,  like  her  son,  suffered  most  at  night.  The  symp- 
toms subsided,  and  she  is  now  entirely  free  from  the  cough. 

Case  4 — Lloyd  C  ,  aged  15  months,  had  been  suffering  with 
spasmodic  cough  for  3  month-,  and  vomited  several  times 
daily.  He  was  given  heroin,  ^V  grain.  Four  doses  stopped 
his  cough  for  several  days.  July  3,  he  had  another  attack 
with  vomiting.  Heroin  ordered  to  be  continued,  ^V  grain, 
three  times  daily,  the  result  being  prompt  disappearance  of 
all  symptoms  of  whoop  ng-cough. 

Case  5  — M.  C,  father  of  patient  in  Case  4,  aged  27,  began 
taking  heroin,  ^  j  grain,  after  having  pertussis  one  week.  He 
had  been  unable  to  sleep  because  of  the  almost  constant 
cough,  accompanied  with  severe  retchitg.  He  was  given 
the  first  dose  at  6  p.m.  ;  took  another  at  10  p.m  ,  and  ex- 
perienced relief  at  once.  In  all  he  took  6  yVgrain  tablets, 
and  is  entirely  free  from  cough  and  sleeps  well. 

REFERENCES. 

•  ODwyer  and  Nonon,  pp.  2I.S,  Vol.  iri,  Twentieth  Century  Practice  of 
Medicine. 

•Twentieth  Century  Practice  of  Medicine. 
'  Mtdical  Rnifrc,  May  13,  1899. 

•  Deutsche  medicinische  Wochenschrifl,  No.  14,  1399. 
'  Therapeutische  Afonafjhfflf,  No.  6,'l399. 

•  Charlotte  Medical  Jourri'al,  January,  1900. 

'  Jfew  York  Medical  Journal,  January  13  and  20, 1900. 


RE-EXPANSION  OF  THE  UTERUS  IN  LABOR. 

Bt  D.  BENJAMIN,  M.D., 
of  Camden,  N.  J. 

Obstetrician  and  Gynecologist  to  the  Cooper  Ho.-ipital ;  Lecturer  on  Obstetrltai 

Nursing  in  the  New  Jersey  Training  Scho<'l  for  Nurses  :  Formerly 

Chief  of  the  Department  of  Diseases  of  Women  and  ciiildren 

in  the  Camden  City  Dispensary  ;  and  First  Assistant  in 

the  Department  of  the  NerTous  System  and  Brain 

in  the  University  Hospital,  Philauelphia, 

etc.;  Member  American  Medical 

Association. 

I  HAVE  come  to  the  conclusion  that  the  parturient 
womb  during  any  stage  of  labor  and  for  a  few  hours  there- 
after can  be  expanded  to  about  the  same  size  as  it  ivas  when 
labor  began.     This  was  demonstrated  as  early  as  1884. 

When  I  had  arrived  at  this  conclusion,  as  a  process 
of  reasoning  and  investigation,  I  had  occasion  to  try  it 
in  practice,  and  I  have  repeatedly  demonstrated  at  the 
bedside  its  practicability,  when  necessery.  An  appre- 
ciation of  the  importance  and  truth  of  the  foregoing 
proposition  enables  us  to  open  a  very  valuable  field  of 
practice  and  introduce  a  number  of  exceedingly  valu- 
able and  important  procedures  or  operations  based  on 


Fig.  1. — Actual  measurements  of  child  delivered. 

it.  These  will  be  referred  to  in  the  treatment  of  the  com- 
plications and  malpositions  in  which  they  are  applica- 
ble. We  have  been  taught  that  the  forces  of  parturi- 
tion when  thoroughly  aroused  and  in  vigorous  normal 
action  can  not  be  stayed  by  the  hand  of  man  to  any 
great  extent ;  that  the  contracting  and  expulsive  efforta 
of  nature  force  the  child  with  progressive  energy  against 
the  superior  strait  or  into  the  pelvis  with  great  power 
and  firmness,  and  that  as  a  rule  with  the  exception  of 
a  brief  period  after  the  escape  of  the  liquor  amnii,  littl* 
can  be  done  in  the  way  of  releasing  and  manipulating 
the  impacted  head.  Nevertheless  from  extensive  ob- 
servation, I  believe  that  the  uterus  can  be  re-expanded, 
and  the  child's  head  returned  above  the  superior  strait, 
and  converted  into  a  favorable  position  from  any 
unfavorable  one,  thus  frequently  avoiding  craniotomy 
or  cesarean  section.  This  becomes  more  important 
wheH  we  consider  that  podalic  version  is  seldom  justi- 
fiable, for  a  head  that  can  not  be  delivered  by  the 
vertex,  when  presenting,  cannot  be  delivered  by  the 
feet. 


80 


The  Philadelphia"! 
Medical  Journal,  J 


RE-EXPANSION  OF  THE  UTERUS  IN  LABOR 


[JiBCABY  i;;.  ■'.01 


Method  of  Reexpansion  and  Returning  the  Child's 
Head. 

We  will  suppose,  for  instance,  an  extreme  case  in 
which  the  head  has  passed  through  the  superior  strait, 
and  has  become  impacted  low  down  in  the  pelvis  in 
such  a  position  that  it  cannot  escape  through  the  inferior 
strait.  Anesthetize  the  patient,  bring  the  hips  close  to 
the  edge  of  the  bed,  elevate  them  well  above  the  level 
of  the  patient's  shoulders  and  put  an  assistant  in 
charge  of  each  leg.     Having  bared  and  sterilized  your 


arm  and  hand,  and  applied  sterilized  cosmolin,  begin 
making  firm  pressure  with  the  palmar  surface  against 
the  presenting  portion  of  the  head  in  the  direction  of  that 
portion  of  the  axis  of  the  pelvis  occupied  by  the  head  ; 
return  it  by  exactly  the  route  and  flexions  that  it 
came,  making  firm,  steady  pressure  between  the  pains 
and  holding  every  fraction  of  an  inch  gained  when  the 
pain  comes  on  until  it  is  over.  It  will  be  found  to 
give  a  little  between  each  of  the  pains.  The  process  is 
often  a  long  and  laborious  one,  and  since  the  hands 
and  arms  are  apt  to  tire  out,  advantage  must  be  taken 
of  each  opportunity  to  rest  them  without  losing  ground, 
such  for  instance  as  propping  the  elbow  against  the 
knee,  and  foot  against  the  wall,  or  in  any  other  manner 
to  take  the  strain  off  the  muscles,  and  by  occasionally 
changing  hands  or  being  relieved  by  an  intelligent  assist- 
ant. The  womb  will  not  only  begin  to  elongate 
upwards,  but  will  seem  to  relax  its  efforts,  so  much  so, 
that  the  nurse  standing  by  will  sometimes  exclaim  "  the 
pains  have  left  her,"  thus,  gradually  the  head  returns 
above  the  superior  strait,  making  room  for  all  purposes. 
You  can  now  pass  your  hand  around  the  child's  head 
in  all  directions,  and  absolutely  confirm  your  diagnosis 
of  the  position,  removing  the  cord  from  its  neck  in  the 
womb,  if  necessary  ;  or  turning  the  body  of  the  child, 
you  can  firmly  grasp  the  head  and  turn  it  in  the  desired 
direction,  assisted  by  the  other  hand  on  the  outside  of 
the  abdomen. 

Treatment  of   Face   Presentation  with   the  Chin 
Posterior. 

This  most  hopeless  and  dreadful  condition  unfortu- 
nately is  of  frequent  occurrence  and  has  heretofore 
baffled  obstetric  science;  Professor  H.  L.  Hodge,  mas- 


terful in  the  piinciples  of  practice,  summed  up  the 
situation  in  thematter  up  to  his  time  (1864)  as  fo)lo;v:< : 
M.  Caseaux,  also,  denies  the  possibility  of  deliveriec, 
under  these  circumstances,  "  at  term,"  and  he  considers 
them  as  constituting  one  of  the  most  serious  diffirul- 
ties  of  the  obstetric  ait.  In  truth,  the  child  and  mother 
would  peri.sh  without  scientific  assistance. 

Should,  however,  the  head  be  comparatively  small, 
and  the  perineum  greatly  relaxed,  spontaneous  delivery, 
with  the  chin  posterior  is  said  to  have  occurred  in  the 
practice  of  Smellie,  DeLamotte,  Guillemot  and  others. 
This  process,  however,  is  greatly  resisted  by  the  pres- 
sure of  the  chin  against  the  posterior  perineum  ;  and  it 
cannot  be  fully  accomplished  without  such  distention 
of  the  perineum  as  to  allow  the  whole  occipito- mental 
diameter,  measuring  5  inches,  to  intervene  between  the 
perineum  and  the  symphysis  pubis. 

It  is  evident,  therefore,  that  no  such  deliverance  can 
be  effected,  unless  the  child's  head  be  unusually  small, 
and  the  soft  parts  relaxed. 

When  the  usual  natural  proportions  exist  of  mother 
and  child  Professor  Hodge  found  it  necessary  to  resort 
to  craniotomy  which  was  at  that  time  preferable  to 
cesarean  section. 

Nor  has  there  been  any  improvement  in  the  treatr 
ment  of  this  presentation  promulgated  bj'  any  of  our 
authorities  up  to  the  present  time:  Lusk  disposes  of  the 
subject  in  1893,  important  as  it  is,  in  these  lines,  viz  :  "  In 
mento-posterior  the  rotation  of  the  chin  to  the  front  by 
repeated  applications  of  the  forceps  is  inadmissible.  In 


Fig.  $. 

practice  such  efforts  do  not  succeed,  while  they  are  cal- 
culated to  inflict  injury  upon  both  mother  and  child. 
Usually,  if  delivery  becomes  necessary  because  of  dan- 
ger to  the  mother,  craniotomy  should  be  resorted  to." 
Grandin  and  Jarman,  whose  excellent  work  has  re- 
cently been  issued,  say  :  "  If  the  chin  is  turned  poste- 
riorly and  the  head  is  wedged  in  the  pelvic  outlet,  there 
is  little  probability  that  a  living  child  can  be  extracted, 
that  it  seems  to  be  part  of  conservative  treatment  to 
turn  the  attention  to  the  welfare  of  the  mother  and  do 


Jaucaey  12,  1901] 


THE  DISINFECTION  OF  INFECTED  TYPHOID  URINES 


Lmk 


E  Philadelphia 

DICAL  JODRXAL 


81 


craniotomy,  or,  in  favorable  cases,  symphysiotomy." 
(Obstetrical  Surgery,  page  87.) 

The  most  recent  writer,  G.  Ernest  Herman,  advises 
to  make  an  attempt  to  twist  the  chin  around  to  the 
front,  as  follows  : 

"Grasp  the  face  with  the  thumb  and  forefingers. 
Turn  it  around  by  the  shortest  route  so  as  to  bring  the 
chin  to  the  front.  At  the  same  time,  with  the  hand  on 
the  abdomen,  press  the  anterior  shoulder  in  the  same 
direction."     Failing  in  this  he  advises  craniotomy. 

In  an  attempt  to  turn  the  chin  around  to  the  front, 
which  should  be  tried,  you  must  remember  what  is 
usually  lost  sight  of  in  this  presentation,  that  the  axis 
of  the  upper  vertebrae  of  the  neck  is  at  a  right  angle  to 
the  axis  of  the  trunk  and  lower  cervical  vertebrae. 

It  seems  to  be  universally  admitted  by  the  profession 
today  that  the  presentation  under  consideration  gener- 
ally means  death  to  the  child  or  cesarean  section  in 
some  of  its  forms  for  the  mother.  It  is,  therefore,  with 
profound  respect  for  other  authorities  and  deference  to 
the  profession  that  I  venture  to  take  a  different  position 
and  offer  a  more  satisfactory  solution  of  the  problem 
not  only  theoretically  but  by  practical  demonstration. 
Applicable  also  tro  similar  presentations,  it  is  simply 
this  :  Push  the  head  up  out  of  the  pelvis  and  convert 
it  into  an  occipitoanterior  presentation  of  the  vertex, 
according  to  the  rules  given  above  under  method  of 
reexpansion  of  the  uterus  and  returning  the  child's 
head.  To  prove  the  possibility  of  doing  this  let  me 
cite  the  following  typical  case : 

Mrs. was  taken  in  labor  on  October  9,  1884,  it  being 

her  seventh  conlinement;  all  the  others  being  normal,  she 
was  attended  by  a  midwife  as  had  been  her  custom.  After 
being  in  labor  3  days  Dr.  G.  W.  Henry  was  sent  for;  after  4 
hours'  work  finding  delivery  impossible  he  sent  for  his  asso- 
ciate, Dr.  Jesse  Wills.  After  4  more  hours  of  fruitless  en- 
deavor in  which  strenuous  efforts  were  made  to  perform 
version  ;  to  rotate  the  chin  forward,  and  also  to  pull  the 
child  through  by  main  strength  and  the  forceps,  under  ether, 
I  was  sent  for.  I  found  the  woman  still  in  vigorous  labor ; 
she  was  medium-sized,  and  of  normal  proportions;  her  gen- 
eral condition  was  good  considering  the  length  of  time  she 
had  been  in  labor.  Locally  the  parts  were  swollen  and  con- 
gested ;  the  membranes  had  been  ruptured  24  hours  and  the 
water  had  escaped.  The  head  of  the  child  had  passed 
through  the  os  and  was  firmly  impacted  in  the  pelvis,  chin 
in  the  hollow  of  the  sacrum.  One  of  the  eyes  was  greatly 
swollen  from  efforts  at  assistance.  The  child  was  alive  and 
above  the  average  in  size. 

I  had  the  patient  placed  under  the  influence  of 
chloroform  and  found  that  I  could  not  rotate  the  head 
to  the  front  nor  deliver  by  the  application  of  the  for- 
ceps and  downward  traction. 

I  then  explained  to  my  colleague  what  I  proposed  to 
do,  and  proceeded  in  detail  as  in  reexpansion  of  the 
uterus.  In  one  hour  I  succeeded  in  raising  the  chin 
out  of  the  pelvis,  flexing  it  to  the  sternum,  and  deliver- 
ing with  great  ease  in  the  0.  A.  position,  vertex 
presentation.  Below  are  given  the  dimensions  of  the 
head.  The  child,  a  fine-looking  boy  weighing  a  little 
over  10  pounds,  is  living  and  well,  and  the  mother  also. 

This  method  has  the  superlative  advantage  of  saving 
the  life  of  the  child  with  less  risk  to  the  mother  than 
any  other  procedure. 


Intestinal  Catarrh  of  Infants.— Cobn  {Annals  de 
Midecine  et  Chirurgie  Infantile,  No.  24),  in  speaking  of  the 
employment  of  silver  nitrate  in  intestinal  catarrh  of  infants, 
prefers  protargol  in  children  that  are  anemic,  more  ad- 
vanced in  age,  and  with  sensitive  stomachs,    [m  r.d  ] 


THE  DISINFECTION  OF  INFECTED  TYPHOID  URINES.- 

By  NORMAN  B.  GWYN,  M.E., 

of  PhiladelpUa. 

In  previous  communications  I  have  spoken  more 
fully  on  the  presence  of  typhoid  bacilli  in  the  urines  of 
typhoid-fever  patients.  Let  me  briefly  review  the 
work  which  seems  to  make  imperative  the  disinfection 
of  all  such  urines,  unless  proved  bacteria-free  by  care- 
ful bacteriologic  examination.  As  early  as  1881,  Bou- 
chard claimed  to  have  isolated  typhoid  bacilli  from  the 
urines  of  50%  of  cases  of  typhoid  fever;  other  writers, 
Hueppe,  Seitz,  Konjajeff,  Karlinski,  Neumann,  Borges, 
de  la  Faille,  gave  less  alarming  but  positive  results. 
Blumer,  Wright,  Besson,  and  Petruschky  confirmed  the 
work  of  the  earlier  workers,  while  T.  R.  Brown,  Hous- 
ton, Horton  Smith,  Richardson  and  myself  have  con- 
tributed to  the  subject  within  the  last  2  years.  In  this 
country,  Richardson's  important  collection  of  25  cases, 
and  my  own  10,  show  how  frequently  typhoid  bacteri- 
uria  may  occur. 

The  general  conclusions  deducible  from  most  recent 
investigations  may  be  thus  tabulated  : 

1.  In  from  20%  to  30%  of  cases  of  typhoid  fever 
typhoid  bacilli  may  be  present  in  the  urine. 

2.  When  present  they  are  usually  in  pure  culture 
and  may  be  so  numerous  that  the  urine  is  turbid  when 
freshly  voided,  one  of  Petruschky's  cases  showing 
170,000,000  bacilli  in  1  ccm.  of  urine;  one  of  our  own 
showing  500,000,000  per  ccm. 

3.  Appearing  generally  in  the  second  and  third  week 
of  illness,  the  organisms  may  persist  for  months  or 
years.  In  Houston's  case  the  bacilli  had  been  for  3 
years  in  the  bladder,  in  one  of  our  own  bacilli  were 
found  in  the  bladder  3  and  5  years  subsequent  to  the 
attack  of  typhoid  fever. 

4.  Though  often  showing  evidence  of  cystitis  and 
marked  renal  involvement,  the  urine  containing  bacilli 
has  usually  only  the  characteristics  of  a  simple  febrile 
urine,  the  presence  of  the  bacilli  has  no  prognostic  im- 
port, and  they  may  persist  for  some  time  without  caus- 
ing local  change,  multipyling  in  the  urine  which 
remains  persistently  acid. 

The  danger  of  infection  from  infected  typhoid  urine 
must  be  clearly  evident  from  these  facts,  if  one  but 
remembers  that  a  few  drops  carelessly  spilt  may  mean, 
and  often  does  mean,  the  distribution  of  millions  of 
typhoid  bacilli.  The  daily  number  voided  in  cases  in 
which  170  or  500,000,000  organisms  are  present  in  a 
cubic  centimeter,  is  beyond  comprehension. 

It  is  more  than  probable  that  urine,  by  reason  of  its 
apparent  harmlessness,  plays  and  has  played  the  most 
important  part  in  the  spread  of  typhoid  fever,  and, 
unless  we  can  prove  that  a  patient's  urine  is  free  from 
infectious  material,  we  commit  a  great  folly  in  letting  it 
be  disposed  of  without  disinfecting  it,  especially  when 
we  systematically  disinfect  the  feces,  in  which  the 
number  of  typhoid  bacilli  is  small  as  compared  to  the 
number  in  the  urine.  When  we  consider  also  that 
many  cases  may  go  on  distributing  the  millions  of 
bacilli  daily  for  months,  and  sometimes,  as  in  the 
above-mentioned  cases,  for  years,  the  seriousness  of  the 
problem  is  apparent. 

Recently  I  have  investigated  the  ordinary  methods 
of  disinfecting  excreta,  endeavoring  to  ascertain  the 
minimum  amount  of  disinfectant  necessary  for  com- 

<  Read  by  iDTiiation,  October  24,  irOO,  berore  IhePbiladelphiaCoiiniy  Meiliial 

Society. 


82 


The  Philadelphia 

Mkdical  Journal 


] 


THE  DISINFECTION  OF  INFECTED  TYPHOID  URINES 


[jAMDAEr  12,    1901 


plete  disinfection  of  the  urine,  and  as  far  as  possible 
the  shortest  time  in  which  this  minimum  amount 
might  be  effective. 

Investigation  of  Disinfectants. 

Urine  collected  sterile,  or  urine  sterilized  by  heat,  in 
measured  quantities  of  10  c.c.  was  employed,  the  pro- 
portionate amount  of  disinfectant  for  living  bacilli 
made  at  various  times  by  plating  out  large  amounts 
of  the  urine  plus  the  disinfectant.  It  will  not  be  out 
of  place  to  mention  that  not  all  urines  form  suitable 
media  for  the  growth  of  the  typhoid  bacillus  ;  in  one 
acid  albuminous  urine  the  organism  grew  extremely 
tardily,  jjresenting  many  diplobacillus-like  or  diplo- 
coccus-like  forms  and  losing  its  motility  temporarily. 
The  growth  of  the  organism  in  urine,  as  in  bouillon, 
is  productive  of  a  well-marked  alkaline  reaction,  after 
the  first  slight  acidification;  the  constant  acidity 
spoken  of  in  typhoid  bacteriurias  is  probably  due  to 
the  continual  removal  of  the  urines  from  the  bladder 
before  an  alkali  is  formed. 

Disinfection  as  used  in  this  note  will  refer  principally 
to  freshly  voided  acid  urines. 

The  principal  disinfectants  at  present  in  use  in 
hospitals  and  practice  are  :  milk  of  lime,  carbolic  acid, 
bichlorid  of  mercury,  formaldehyd,  chlorinated  lime  and 
liquid  chlorids ;   these  will  be  considered  in  this  order. 

Milk  of  lime,  made  by  slaking  or  dissolving  ordinary 
builders'  lime  in  water,  enough  being  used  to  make  a 
heavy  sediment  (which  must  be  shaken  up  and  used 
with  the  solution),  is  the  cheapest  disinfectant ;  it  is, 
however,  neither  rapid  nor  certain,  and  to  obtain  results 
at  all  satisfactory  one  must  use  a  solution  so  concen- 
trated that  on  standing  it  will  precipitate  half  its  actual 
volume  of  lime. 

With  such  a  solution,  10  c.c.  of  infected  urine  were 
disinfected  by  4-5  c.c.  of  milk  of  lime  in  2^  hours.  A 
precipitate  2i-3  c.c.  deep  of  lime  forms  in  such  experi- 
ments. Yet  living  bacilli  could  be  obtained  from  the 
tubes  after  1-2  hours.  Smaller  quantities  of  this  solu- 
tion require  4-6  hours  for  complete  disinfection,  while 
with  the  ordinary  hospital  solution  10  c.c.  of  infected 
urine  were  disinfected  by  10  c.c.  milk  of  lime  in  4  hours. 
One  cannot  well  use  a  greater  amount  of  disinfectant 
than  this,  which  means  that,  according  to  the  strength 
of  the  solution,  000  or  1200  c.c.  of  milk  of  lime  must 
be  taken  to  completely  disinfect  a  daily  amount  of 
urine  of  say  1200  c.c,  and  that  only  after  2-4  hours. 

1200  c.c.  infected  urine  would  require  000-1200  c.c.  of  milk  of  lime  solutions  for 
complete  disinfection  withlu  2  to  4  hours. 

Carbolic  acid  was  found  to  be  of  value  only  in  large 
amount  or  very  strong  solution.  The  1 :  20,  1  :  40,  1  :  100 
solutions  were  used. 

1  CO.  of  1 :  20  earb.  no.  in  10  o  c.  infected  urine  making  a  dilution  of  carbolic  of 

1 ;  20O  had  only  inhibitory  ellVct  on  organism. 

2  c.c.  of  1 :  20  carb.  ac.  in  10  c.c.  infected  urtno  making  a  dilutiou  of  carbolic  of 

1 :  120  is  etfective  in  2  hours. 
t  c.c.  ot  1 :  20  earb.  au.  in  10  c.c.  infected  urine  making  a  dilution  of  carbolic  of 
1 :  8i  is  fll'ective  in  1  hour. 

4  CO.  of  1  :  20  <-arl\  ac.  in  10  c.c.  infected  uriue  making:  a  dilution  of  carbolic  of 

1 :  70  is  etlective  in  5  minutes. 

5  c.c.  of  1 :  2n  curb.  ac.  in  10  c.c.  infected  uriue  making  a  dilution  of  carbolic  of 

1  :  GO  is  etlective  in  %  to  1  minute. 
4  CO.  of  1 : 40  larb.  ac.  in  10  c.c.  iulected  urine  makini;  a  dilutiou  of  carbolic  of 
1 :  140  Is  elltctive  in  1  hour. 

6  ce.  of  1 :  40  earb.  ae.  in  10  c.c.  infected  urine  making  a  dilution  of  carbolic  of 

1  :  120  is  etlective  in  lo  minutes  to  )^  hour. 

The  1  :  40  solutions  apparently  possess  a  greater  and 
more  rapid  disinfectant  action  than  1  :  20  solutions 
(compare  the  final  dilutions  of  No.  2  of  1  :  40  with  No.  2 
of  1  :  20)  ;  the  greater  tiniount  of  substance  added,  and 
perhaps  the  greater  ditfusibility  of  the  solution,  may 
account  for  the  difl'erence. 


Of  1 :  1000  solution,  an  amount  equal  to  that  of  the  infected 
urine  is  required  for  disinfection  in  ^  to  1  hour. 

From  these  experiments  one  sees  that  carbolic  acid 
is  only  effective  in  strong  solution  and  large  amounts. 

A  daily  amount  of  infected  urine  of  1200  c.c.  would 
require 


360-400  c.c.  of  I  :  20  solution  carbolic) 


480  CO.  of  1  :  40 
1200  c.c.  ot  1 :  100 


>for  complete  disinfection  witliin  i  boor. 


Bichlorid  of  Mercury. — In  contrast  to  these  two  sub- 
stances is  the  action  of  bichlorid  of  mercury,  which 
in  the  urine  is  both  a  powerful  and  rapid  disinfecting 
agent. 

The  1 :  1000  solution,  as  being  most  commonly  used, 
was  first  tried. 

1.  2  c.c  of  1 :  1000  HgC),  solution  in  10  cc  infected  urine  making  a  solution  tf  '■ 

HgCI,  of  1 :  51100  is  eSectiTe  in  1  minute.  ] 

2.  1  c.c  of  1 :  1000  HijClj  solution  in  10  c.c.  infected  urine  making  a  solution  of 

HgCI,  of  1 ;  10.000  IS  effective  in  15  minutes. 

3.  %  c.c.  of  1 :  1000  HgCI-  solution  in  10  c.c.  infected  urine  making  a  solution  of 

HgClj  of  1  :  20,000  is  effective  in  }4  hour.  ; 

4.  l^  c.c.  ot  1 :  1000  HtiCt,  solution  in  10  cc  infected  urine  making  a  solution  of  >i 

HgCI,  of  1 :  40,01  0  i.^  effective  in  1  hour.  ^ 

5.  2  cc  of  1 :  2000  HgCI,  solution  in  10  cc.  infected  urine  making  a  solution  of 

UgCK  of  1 :  10,000  IS  effective  in  15  to  30  minutes,  corresponding  pracucallj 
to  No'  2  of  the  1  :  lOOO  series. 

In  further  experiments  with  HgClj  it  was  readily 
proven  that  when  the  strength  of  the  HgCI,,  in  the 
mixture  of  urine  and  solution  was  between  1  :  5000  and 
1 :  40,000,  disinfection  was  complete  within  an  hour 
and  compared  closely  with  the  results  in  the  1  :  lOOO 
series.  When  the  strength  ranged  from  1 :  50,000  to 
1 :  100,000,  Ih  to  3  hours  were  necessary  for  complete 
disinfection. 

10  c.c.  of  1 :  40,000,  or  t :  50,000  HgCI,  in  10  c.c.  infected  urine  making  a  solnlioa 
of  1 :  80,000,  or  1 :  100,000  is  effective  in  2  to  3  hours. 

Beyond  these  amounts  HgCU  would  hardly  be  em- 
ployed. One  can  readily  calculate  the  amount  of  any 
solution  necessary  for  disinfection  by  comparing  with 
above  results.     The  experiments  further  allow    us  to 

infer  as  follows  : 

1  gram  of  HgCI,  in  5000  cc.  of  urine  would  be  imoiedialelv  etTective,  if  it  eouM 

be  imineiliaiely  dissolved. 
1  gram  <d  HgCI,  m  10,000  cc.  of  urine  would  be  eflective  in   15  minutes,  if  it 

could  l>e  immediately  dissolved. 
1  gram  of  HgCI,  in  20,000  c.c  of  urine  would  be  effective  in  \  hour,  il  it  oouM 

be  immeiiiately  dissolved. 
1  gram  of  HgOl,  in  40,000  c.c.  of  urine  would  be  eflective  in  1  hour,  if  it  could  b« 

immediately  dissolved. 

The  power  of  HgCI.,  can  be  judged  from  the  above 
results.  The  expense  is  almost  offset  by  the  small 
amount  of  the  substance  required  ;  in  addition,  it  is  a 
clean,  odorless  and  easily  applied  disinfectant  if  pre- 
pared in  solution. 

Comparing  bichlorid  of  mercury  with  carbolic  acid, 
we  can  estimate  that : 


I  i:0  cc  of  1  : 
!  60  c.c  of  1 
]  30  c.c  of  I 
[  15  c.c  of  1 
1200  cc  of  urine  would  require  60  c.c  1 : 
1200  cc         SO  cc  1 


1200  cc.  of  urine  would 
require 


1000  bichlorid  solution  1   For  complete 

500  "  "I     disinfectiOB 

f     in   15   mia- 

J        Ut»5. 

^^hour. 


500 

250 

125 

1000  for  disinfection  in 

1000  •■  "  "    1 


Formaldehyd  was  found  a  fairly  efficient  disinfecting 
agent ;  its  expense,  however,  precludes  its  use,  except 
in  a  very  dilute  solution.  It  is  usually  procured  Ib 
the  strength  of  40%,  which  is  given  the  value  of  100 
or  full  strength,  and  its  dilutions  are  reckoned  accord- 
ingly- 

One  per  c*nt  formalin  is  really  1 :  250  Instead  of  1 :  100. 
5  cc  01    14  formalin  were  required  to  disinfect  10  cc  urine  in  h  '•>  }  '','^'- 
3  CO.  of    .■)  "  "  "  ,.         —  .. 

Ice.  of  10  "  '•  " 

6cc.  of    1  "  "  " 

4ccof    6  "  "  " 

2  c.c  of  10  "  "  " 


10  cc.     " 

S  to  1      " 

10  c.c     " 

\  hour. 

10  C.C     " 

5  to  10  min 

10  CO.     •" 

5  to  10    •■ 

10  cc.    '■ 

5  minute*. 

JiBBAKT  12,  1901] 


ADMINISTRATIVE  CONTROL  OF  TUBERCULOSIS 


CThe  Philadelphia 
Medical  Journal 


83 


hour. 


fi^tolhoi 
jgtol  ■■ 
IKtol    " 

{5  minutes. 
5        " 
5        " 


As  compared  with  preceding  substances: 

f  600  c.c.  of    1^  formalin  for  disiHfection  in 

800  C.C.  of    6  "                     " 

1120  c.c.  of  10  "                     " 
1300  C.C.  urine  would -j 

r«qaire I  240  c.c.  oi  10^  formalin  for  disinfection  in 

I  720  c.c.  of    1  "                     " 

[480  c.c  of    5  "                       " 

Chlorinated  lime,  applied  by  making  a  saturated  solu- 
tion and  using  the  supernatant  fluid,  is  one  of  the  most 
reUable  disinfecting  agents.  Free  chlorin  is  evolved 
when  mixed  with  urine,  particularly  if  the  urine  is 
acid.  No  distinct  difference  in  the  disinfecting  power 
could,  however,  be  detected  in  neutral  or  slightly  alka- 
line urines,  in  both  of  which  chlorin  was  evolved, 
although  distinctly  less  than  in  the  acid  urines.  The 
reaction  seemed  to  be  instantaneous  in  all  experiments. 


10  c.c.  . 

5  c.c.  . 

3  0.C.  . 

2cc  . 

1  c.c.  . 
J^cc. 
Jicc. 


ChJorinated  lime  solution  in  10  c.c. 
infected  urine  disinfects  in  from 
few  seconds  to  1  minute. 


It  is  hardly  practicable  to  use  smaller  quantities  than 
this ;  in  disinfecting  large  quantities  enough  solution  to 
produce  a  distinct  reaction  should  be  used  ;  the  evolu- 
tion of  chlorin  and  the  bubbling  over  which  ensues 
might  be  inconvenient  where  large  quantities  of  acid 
urine  acid  are  to  be  disinfected. 

1200  c.c.  of  urine  would  require  SO  c.c.  of  chlorinated 
lime  solution  for  complete  and  immediate  disinfection. 

The  liquid  chlorids,  a  mixture  of  chlorids  of  zinc, 
aluminum  and  copper,  are  much  used  and  are  verj- 
efficient.  A  heavy  precipitate  occurs  when  they  are 
added  to  urine,  due  probably  to  the  throwing  down  of 
the  sulfates  ;  it  may  vary  in  diSerent  urines,  and  was 
most  marked  in  those  of  distinct  acid  reaction. 

1  c.c.  liquid  chlorid  in  10  c.c  infected  urine  disinfects  in  1  hour. 

2  c.c      "  "  10  c.c        "  "  "  %    " 

3cc.      "  **  10  cc.       "  "  '■  Itoominutes. 

4  c.c.      "  "  10  c.c.        "  "  "  immediately. 

In  highly  acid  urines  the  time  for  disinfection  was 
fractionally  longer. 

f  480  c.c.  liquid  chlorids  for  immediate  disinfection. 
1200C.C.  urine  I  360  cc.       '  "  "   ^- ■-'-•--=-•--' —  = 


would  require  I  240  c.c. 
L  120  c.c. 


disinfection  in  1  to  5  minutes. 
o  hour, 
i    •• 


It  is  generally  supposed  and  has  been  stated  that  in 
highly  albuminous  urines  some  disinfectants  become 
less  effective,  and  that  in  the  case  of  bichlorid  of 
mercury  the  formation  of  an  albuminate  of  mercury 
destroys  its  disinfecting  power.  Experiments  did  not 
bear  this  out.  In  a  urine  containing  0.3  %  albumin, 
disinfection  with  various  substances  was  just  as  com- 
plete and  rapid  as  in  other  urines. 

^  cc  1 :  1000  HgCI,  in  10  c.c.  acid  albuminoas  infected  urine  disinfects  in  5  to 

10  minutes. 
4  cc  1 :  20  carbolic  in  10  cc.  acid  albuminous  infected  urine  disinfects  in  15 

minutes. 

2  cc.    l(K  formalin  in  10  c.c.  acid  albuminous  infected  urine  disinfects  in  15 

minutes. 
^  c.c.  chlorinate  lime  solution  in  10  cc.  acid  albuminous  infected  urine  disin- 
fects in  1  minute. 

3  cc  liquid  chlorids  in  10  c.c.  acid  albuminous  infected  urine  disinfects  in  5 

minutes. 

This  short  note  may  help  to  show  the  relative  values 
of  the  various  substances  employed. 

Milk  of  lime  hardly  deserves  the  name  of  a  disin- 
fectant. Carbolic  acid  is  of  use  only  in  large  amounts 
and  in  strong  solution  if  a  speedy  result  is  wished. 
Formalin  is  hardly  serviceable  on  account  of  its  cost, 
but  is  nevertheless  an  efficient  disinfectant.  Bichlorid 
of  mercury,  chlorinated  lime  and  liquid  chlorids  are 


of  real  value,  are  rapid  in  their  action  and  are  efficient 
in  comparatively  dilute  solutions. 

To  summarize  briefly  the  results,  one  may  say  that — 
I.  For  disinfection  immediately  and  within  5  min- 
utes, 

f      4  of  its  volume  of  1 :  20  carbolic  acid  solution. 

13 1:40 ' 

J    "  "       ■'    1 :  lOOO  HgCI,  solution. 

^   "  "        "    l<yf,  formalin. 

1  — ^    "  '*       •*    chlorinated  lime  solution, 

l^     I    "  *'       "    liquid  chlorids. 


A  volume  of  infected  urine  ! 
would  require j 


II.  For  disinfection  within  5—15  minutes, 


A  volume  of  urine  would 
require 


f      i  of  its  volume  oil :  20  carbolic  acid  solution. 
1       i l:40        

A  ">  A  •' i's  volume  ol  1 :  1000  HgCl,  solution. 

i  of  its  volume  of    K  formalin. 

I »        " 

i  ••           •'        "  10!* 

-^  "           "        "  chlorinated  lime  solution. 

^  '*           "        "  liquid  chlorids. 


III.  For  disinfection  within  i  to  1  hour, 


A  volume  of  urine  would  _ 
require 


A  to  j^  its  volume  of  1 :  20  carbolic  acid  solntion. 
«  '1:40       •' 


An  equal " 


1 : 100       " 

1 :  1000  HgCl=  " 

1:2000 

I0;(  formalin. 

5*         " 

1*         " 
'    liquid  chlorids. 


A  volume  of  tirine  would 
require 


IV.  For  disinfection  within  1  to  2  hours, 

A  to  ^^  its  volume  of  1 :  20  carbolic  acid  solution, 

jt    to    i     "        "     "     1:40 

morethan"        "      "     1:100      "  "  '* 

A  to   A l:1000HgCl,. 

— j?j,  "        "      "     lOjf  formalin. 

-A         '.'.     '.!   '.;    ?^      !! 
-J  If 

an  equal  voU— i  its  volume  of  milk  of  lime  solution. 

V.  For  disinfection  within  2  to  4  hours, 

C  J  its  volume  of  1 :  20  carbolic  acid  solution. 
A  volume  of  urine  would  J  ts  to  ^  its  volume  of  1 ;  40  carbolic  acid  solution. 

require j  an  equal  volume  of  1 :  40,000  or  50,000  HgOj  solution. 

[     *'  "        =^  its  volume  milk  of  lime  solution. 

The  disinfection  of  the  urine  in  the  bladder  and 
urinary  system  has  been  referred  to  in  previous  articles, 
urotropin  being  the  only  substance  which  can  claim 
any  direct  action  when  administered  by  the  mouth. 
As  an  irrigation,  bichlorid  solutions,  1 :  100,000  to 
50,000  have,  in  my  experience,  been  verj'  successful, 
removing  the  bacilli  with  much  more  certainty  than 
any  other  method. 


ADMINISTRATIVE  CONTROL  OF  TUBERCULOSIS* 

By  COLLIN'S  H.  JOHNSTON,  B.A.,  M.D., 
of  Grand  Rapids,  Mich. 

Member  of  Michigan  State  Board  of  Health ;  Surgeon  to  Butterworth  Hospital; 

District  Surgeon  of  Detroit  and  Milwaukee  Division  of  Grand 

Trunk  Railway,  etc 

Consumption  is  the  most  prevalent  and  the  most 
fatal  disease  known  to  civilization  at  the  present  time. 
In  looking  over  the  carefully  compiled  statistics  of  the 
last  census  for  many  of  our  large  cities,  one  finds  that 
an  alarming  proportion  of  the  deaths  is  due  to  tubercu- 
losis. In  New  York  City  alone  there  were  51%  more 
deaths  from  this  disease  "than  from  scarlet  fever,  diph- 
theria, typhoid  fever  and  all  forms  of  diarrheal  diseases, 
exclusive  of  cholera  infantum.  In  the  State  of  New 
Hampshire,  in  the  10  years  from  1887  to  1896  inclusive, 
there  were  twice  as  many  deaths  from  consumption  as 
from  diphtheria,  croup,  typhoid  fever,  whooping-cough, 
scarlet  fever,  measles,  and  mumps.  For  the  same 
period  in  our  own  State  the  mortaUty  from  consump- 

»  Read  before  the  Michigan  State  Medical  Society,  at  Mackinaw,  July,  1900. 


84 


The  Phii^delphia"! 
Medical  Jocrnal  J 


ADMINISTRATIVE  CONTROL  OF  TUBERCULOSIS 


[JiLirCAST  12,  un 


tion  was  greater  than  that  of  diphtheria,  croup,  typhoid 
fever,  scarlet  fever,  measles  and  smallpox  combined. 
The  fifty-seventh  annual  report  of  the  Registrar-Gen- 
eral of  Great  Britain  shows  that  the  annual  death-rate 
from  tuberculosis  for  the  20  years  preceding  was  some- 
thing over  67,000.  According  to  the  census  report  there 
were  103,188  deaths  from  consumption  in  the  United 
States  in  the  year  1890.  However,  owing  to  the  fact 
that  thousands  of  cases  of  tuberculosis  recover  everj' 
year,  and  that  many  who  have  the  disease  die  from 
other  causes,  and  also  because  many  cases  are  not  diag- 
nosed during  life,  it  is  only  by  postmortem  examina- 
tions that  we  get  anything  like  a  correct  estimate  of  the 
extraordinary  prevalence  of  this  disease  in  the  human 
race.  Such  examinations  show  that  consumption  is 
much  more  common  than  it  is  generally  supposed  to 
be.  In  4,250  successive  autopsies  in  Breslau  in  1893, 
gross  macroscopical  lesions  c  f  tuberculosis  were  found 
in  1,392,  or  about  one-third  of  all  cases  coming  to  the 
postmortem  table  from  all  causes.  Biggs,  of  New  York, 
found  characteristic  lesions  in  the  lungs  alone  of  60% 
of  his  autopsies,  and  Vrouardel  found  microscopic  evi- 
dences of  tuberculosis  in  75%  of  his  cases  at  the  Paris 
morgue.  Since  many  cases  show  lesions  that  can  be 
seen  only  with  the  microscope,  it  is  evident  that  we  can 
scarcely  overestimate  the  frequency  of  the  disease. 
Exceedingly  interesting  statistics  on  this  point  are  con- 
tained in  an  article  by  Otto  Naegeli  in  the  May  number 
of  Vu-ch(nv''s  Archives.  From  the  results  of  500  autop- 
sies made  between  November,  1896,  and  March,  1898, 
in  the  Pathological  Institute  of  Zurich,  he  concludes  as 
follows  : 

1.  Tuberculosis  during  the  first  year  of  life  is  very 
seldom  found. 

2.  From  the  first  to  the  fifth  year  it  is  infrequent, 
but  almost  regularly  fatal. 

3.  From  the  fifteenth  to  the  fourteenth  year  one-third 
of  all  bodies  are  found  to  be  tuberculous. 

4.  From  the  fourteenth  to  the  eighteenth  year  tuber- 
cular lesions,  active  or  latent,  are  found  in  one  half  of 
all  autopsies. 

5.  From  the  eighteenth  to  the  thirtieth  year  97  %  of 
all  sections  show  tubercular  changes. 

6.  After  the  thirtieth  year,  on  careful  search,  indisput- 
able evidence  of  tuberculosis  is  found  in  over  99%  of 
all  autopsies. 

Surely  Osier  is  right  when  he  says  that  epidemics  are 
the  only  great  sanitary  reformers.  Two  thousand  eight 
hundred  and  twenty- six  times  as  many  people  died 
from  tuberculosis  in  the  State  of  Michigan  in  the  year 
1898  as  from  smallpox,  yet  a  single  case  of  the  latter 
disease  will  arouse  a  whole  community,  and  25  mild 
cases  of  smallpox,  with  2  deaths,  such  as  we  had  in 
Grand  Rapids  recently,  will  almost  give  a  city  of  100,- 
000  people  hysteria.  But  no  comment  whatever  is  ex- 
cited by  the  fact  that  117  people  died  from  consump- 
tion in  Grand  Rapids  during  the  past  year,  being  two 
and  a  half  times  the  combined  deaths  from  all  other 
infectious  diseases.  Here,  then,  is  a  disease  which  is 
constantly  with  us,  manifestly  transmissible,  and  which 
attacks  at  one  time  or  another  almost  every  member 
of  the  human  race,  but  concerning  which  the  medical 
profession  shows  a  neglect  of  sanitary  laws  which  is 
almost  criminal. 

A  point  of  interest  in  this  connection,  however,  is 
that  there  seems  to  be  throughout  the  world  a  gradual 
decrease  in  the  death-rate  from  tubercular  diseases,  and 
the  results  of  Naegeli's  autopsies  show  that  a  large  per- 


cent of  cases  recover.    His  conclusions  on  this  point  are 
as  follows  : 

1.  Before  the  eighteenth  year  recovery  from  tuber- 
cular lesions  is  infrequent. 

2.  In  the  third  decade  one-fourth  of  all  cases  show 
tubercular  changes  that  have  completely  healed. 

3.  In  the  fourth  decade  two-fifths  of  all  cases  show 
lesions  in  which  recovery  has  taken  place,  and  from 
then  on  the  number  of  healed  cases  gradually  increases 
until  it  reaches  three-fourths  of  all  cases  at  the  age  of 
70  years. 

In  England,  from  1851  to  1895,  the  mortality  from 
all  forms  of  tubercular  disease  was  reduced  45  % ,  and 
from  the  pulmonary  form  the  disease  in  mortality  was 
still  more  remarkable  for  the  same  period,  being  about 
48%.  In  Scotland,  between  the  5  years  1870-74  and 
the  5  years  1890-94,  the  decline  in  the  death-rate  from 
tuberculosis  amounted  to  41%.  In  Massachusetts  the 
mortality  fell  from  42  per  10,000  inhabitants  in  1S53 
to  21.8  per  10,000  inhabitants  in  1895.  A  somewhat 
similiar  decline  in  the  death-rate  from  consumption 
has  taken  place  in  New  York  City,  i.  e..  from  3.79  %  in 
1886  to  2.58  in  1896.  Coming  to  our  own  State,  we 
find  that  the  number  of  deaths  from  consumption  has 
diminished  from  112.1  per  100,000  inhabitants  for  the 
5  years  1870  to  1874  to  97.3  per  100,000  inhabitants  for 
the  years  1892-96,  this  being  the  last  group  of  5  years 
the  statistics  of  which  are  as  yet  available  for  com- 
parison— a  decline  of  12.2%. 

But  this  remarkable  reduction  in  deaths  is  not 
limited  to  tubercular  diseases,  for  statistics  show  that 
the  mortality  from  all  sorts  of  infectious  diseases  has 
decreased  in  recent  vears  all  over  the  world.  In  Michi- 
gan the  mortality  from  scarlet  fever  for  the  last  20 
years  has  diminished  90%. from  typhoid  43%.  measles 
60%,  smallpox  70%,  and  whooping-cough  44%.  There 
is,  however,  one  striking  exception  to  the  decrease  in 
the  death-rate  from  tubercular  affections,  Le..  tabes 
mesenterica,  a  disease  to  which  infants  are  peculiarly 
susceptible.  Between  the  years  1S51  and  1895  the 
mortality  in  England  from  this  disease  for  people  oj 
all  ages  diminished  almost  one-half,  but  for  the  s;ime 
period  for  infants  under  one  year  of  age  it  increased 
no  less  than  27.7%;  and  while,  as  just  stated,  in  the 
State  of  Michigan  the  mortality  from  consumption  has 
diminished  12.2%  for  people  of  all  ages  during  the 
years  1870-96,  that  from  tabes  mesenterica  increased 
80%  for  infants  under  one  year  of  age.  It  is  quite 
likely  also  that  a  good  many  deaths  from  this  disease 
are  ascribed  to  marasmus,  chronic  gastrointestinal  dis- 
ease, malnutrition,  weakness,  etc.  The  great  prevalence 
among  infants  of  this  disease  is  also  shown  by  the 
frequency  with  which  its  lesions  are  found  in  postmor- 
tem examinations.  In  an  analysis  of  127  fatal  cases 
of  tuberculosis  in  children  by  Ashby  ^t  Wright,  tabes 
mesenterica  was  found  in  79%.  In  Woodhead's  177 
cases  of  fatal  tuberculosis  in  children,  disease  of  the 
mesenteric  glands  was  found  in  100.  In  155  autopsies 
on  tuberculous  children  dying  in  the  Manchester  Chil- 
dren's Hospital  it  was  found  that  the  lungs  were 
affected  in  91%  and  the  mesenteric  glands  in  65%.  A 
careful  examination  was  made  to  determine  as  nearly 
as  possible  by  which  road  the  infection  had  gained 
access  to  the  body,  and  the  conclusion  w;is  reache*.!  that 
in  at  least  50%  of  the  cases  the  lungs  or  bronchial 
glands  were  first  affected,  and  that  in  at  least  12  or  13% 
the  abdominal  organs  were  primarily  affected,  making 
it  probable  that  the  disease  obtained  access  to  the  body 


JANIARY  12,   1901] 


ADMINISTRATIVE  CONTROL  OF  TUBERCULOSIS 


TThb  Philadelphia 
L  Medical  Journal 


85 


through  the  intestinal  canal.  Purban  states  that  in 
165  cases  of  peritoneal  tuberculosis  examined  after 
death,  53%  were  attributed  to  intestinal  infection.  As 
a  considerable  proportion  of  children  suffering  from 
tubercular  peritonitis  or  disease  of  the  mesenteric 
glands  recover,  these  figures  do  not  adequately  repre- 
sent the  proportion  of  children  so  affected. 

This  great  increase  of  tuberculosis  of  the  intestines 
and  adjacent  glands  in  children  at  a  period  of  life  when 
the  powers  of  resistance  of  the  organism  are  at  their 
lowest  is  very  suggestive  of  the  existence  of  an  infec- 
tive agency  in  children  which  is  not  found  in  adults, 
and  as  the  only  vehicle  by  which  primary  tubercular 
infection  can  be  conveyed  to  the  digestive  tract  of  in- 
fants is  found  in  their  food-supply,  we  are  forced  to  the 
conclusion  that  milk,  which  forms  such  an  essential 
part  of  the  food  of  infants,  is  to  them  a  frequent  source 
of  infection.  Moreover,  the  last  few  years  have  demon- 
strated that  tuberculosis  is  common  in  dairy  cows,  and 
more  particularly  in  .Jerseys.  Of  4,093  cattle  in  Massa- 
chusetts tested  for  tuberculosis,  1,081,  or  25%,  reacted 
positively  to  tuberculin.  These  were  killed  and  ana- 
tomical evidences  of  tuberculosis  were  found  in  all  but 
2.  Amongst  dairy  cattle,  at  the  present  time,  it  has 
been  estimated  that  at  least  25%  are  more  or  less  af- 
fected with  tuberculosis.  This  estimate  is  based  upon 
the  results  of  postmortem  examinations  of  herds  of  cat- 
tle which  have  been  slaughtered  under  the  pleuropneu- 
monia regulations  in  England  and  of  observations  made 
in  public  slaughter-houses.  Where  the  tuberculin  test 
is  used  the  percentage  of  animals  affected  is  consider- 
ably higher.  Tubercle-bacilli  are  generally  found  in 
milk  when  tuberculosis  of  the  udder  is  present,  and  such 
milk  is  said  to  possess  a  virulence  which  can  only  be 
termed  as  extraordinary.  The  experiments  of  the  Royal 
Commission  of  1890  in  England  are  exceedingly  inter- 
esting in  this  connection.  When  guineapigs  are  fed  on 
meat  which  was  intentionally  contaminated  with  tuber- 
cle-bacilli, only  a  few  developed  the  disease,  but  when 
they  were  fed  milk  from  tuberculous  udders  all  became 
infected. 

The  milk  of  an  animal  suffering  from  tuberculosis 
may  also  contain  tubercle-bacilli  and  be  capable  of  com- 
municating the  disease  when  no  demonstrable  disease 
of  the  udder  is  present,  and  bacilli  are  no  doubt  present 
in  a  fair  percentage  of  milks  on  the  market.  Obermul- 
ler  found  that  10%  of  guineapigs  inoculated  with  ordi- 
nary market  milk  became  tuberculous,  and  80%  of 
those  inoculated  with  ordinary  market  cream.  In 
many  instances  the  udder  shows  no  perceptible  disease ; 
in  fact,  tubercular  disease  in  such  a  bulky  organ  may 
be  impossible  of  recognition  on  physical  examination, 
and  in  its  early  stages  is  most  difficult  to  diagnose. 
Nor  does  an  examination  of  milk  for  bacilli  present  an 
infallible  solution  of  the  problem,  for  they  may  be  pres- 
ent at  one  time  and  absent  at  another.  Sidney  Martin 
examined  the  milk  of  5  cows  which  turned  out  to  have 
tuberculosis  of  the  udder,  and  could  find  tubercle- 
bacilli  in  but  3.  Fifteen  test  animals  were  fed  with  the 
milk  that  contained  bacilli,  and  tuberculosis  was  pro- 
duced in  each  one ;  the  milk  of  the  2  cows  which  had 
tubercular  udders,  but  in  whose  milk  no  tubercle-bacilli 
could  be  demonstrated,  was  fed  to  12  test  animals,  and 
4  of  them  developed  tuberculosis. 

Tubercular  bacilli  have  also  been  found  in  butter  and 
cheese.  That  gastric  juice  exerts  any  influence  upon 
them  under  natural  conditions  is  extremely  doubtful, 
as  these  organisms  can  resist  it  from  5  to  6  hours  out- 


side the  body.  Under  natural  circumstances  the 
baciUi  would  have  a  still  better  chance  of  escaping  un- 
harmed, the  gastric  juice  being  diluted  and  the  bacilli 
being  often  coated  with  food  and  more  or  less  protected 
in  this  vra.y. 

1  wish  also  to  call  attention  to  the  possibility  of  con- 
tracting other  forms  of  tuberculosis  than  the  intestinal 
from  infected  milk.  Welch  states  that  postmortems 
show  that  40  to  80%  of  all  cases  of  pulmonary  tuber- 
culosis have  also  intestinal  disease.  Nor  is  it  possible 
in  all  cases  to  tell  which  is  the  primary  and  which  is 
the  secondary  lesion.  He  also  says  that  tubercle  bacilli 
may  enter  the  body  without  leaving  behind  any  lesion 
at  the  point  of  entrance.  Hence,  is  it  not  impossible  to 
denv  that  a  much  larger  proportion  of  cases  of  the 
pulmonary  forms  of  the  disease  may  be  due  to  infec- 
tion from  the  gastrointestinal  tract  than  is  commonly 
supposed  ? 

In  view  of  these  facts  does  it  not  seem  that  the  State  ichich 
does  so  much  to  prevent  the  spread  of  other  infectious  and 
comimmicable  diseases  should  do  more  to  limit  the  spread  of 
this  fatal  disease  by  preventing  the  sale  of  milk  from  tuber- 
culous coics  ? 

The  exclusion  from  dairies  of  every  cow  which  has 
demonstrable  disease  of  the  udder  only  would  form 
some  approach  to  security ;  but  as  tubercle  bacilli  have 
so  frequently  been  found  in  the  milk  of  cows  which  are 
free  from  udder  disease,  and  as  such  disease  is  so  diffi- 
cult of  recognition  in  its  incipiency,  I  believe  that  aU 
cows  responding  to  the  tuberculin  test  are  possible 
sources  of  danger,  and  that  the  sale  of  their  milk 
should  be  prohibited.  The  State  should  pass  laws 
compelling  the  systematic  inspection  of  all  dairies  and 
cowsheds  within  its  borders,  and  of  all  animals  whose 
milk  is  placed  on  sale.  Regular  tests  with  tuberculin 
should  be  made,  and  the  sale  of  any  milk  from  a  dairy 
wherein  a  tuberculous  animal  is  found  should  be  pre- 
vented by  a  prohibitive  penalty  until  such  animal  is 
excluded  from  the  herd. 

This  does  not  mean  by  any  means  that  all  such 
animals  should  be  slaughtered,  for  the  method  of  treat- 
ing tuberculous  herds  which  has  been  worked  out  by 
Professor  Bangs,  the  Government  Veterinarian  of  Den- 
mark, and  which  has  been  thoroughly  tried  in  that 
country  as  well  as  in  parts  of  our  own,  shows  that  the 
disease"  can  be  "  weeded  out  "  in  a  practical  manner. 
The  sale  of  reacting  animals  should  be  prohibited, 
except  for  immediate  slaughter,  which  should  be  done 
under  authorized  veterinary  control,  it  often  being  pos- 
sible to  use  the  meat  under  certain  conditions.  Neither 
statistics  nor  experience  would  seem  to  indicate  that 
tuberculosis  is  communicated  to  any  great  extent 
through  the  agency  of  meat,  for  the  greatest  dimin- 
ution in  the  death-rate  from  tubercular  disease  occurs 
at  those  ages  when  meat  is  most  largely  consumed, 
and  we  know  that  tubercular  deposits  are  very  seldom 
found  in  those  portions  of  a  carcass  which  are  sold  for 
food.  It  has  been  found  that  only  rarely  does  the  tuber- 
cle bacillus  lodge  in  the  muscular  substance  of  a 
carcass,  and,  providing  the  organs  containing  the 
tubercular  deposits  are  destroyed,  the  meat  itself  may 
be  sound. 

For  a  long  time  it  was  believed  that  the  only 
effective  way  of  preventing  the  spread  of  tuberculosis 
in  an  infected  herd  was  to  slaughter  all  animals  that 
reacted  to  the  tuberculin  test,  but  it  is  now  known  that 
animals  affected  in  the  earlier  stages,  which  are  kept 
under  favorable  hygienic  conditions,  will  live  frequently 


86 


The  Phlladklphu"] 
Medical  Joobxal  J 


ADMINISTRATIVE  CONTROL  OF  TUBERCULOSIS 


[jAIfTABT  12, 


J 


for  years  without  the  disease  making  any  apparent 
headway,  and  the  progenj^  of  such  animals  is  scarcely 
more  liable  to  tuberculosis  at  birth  than  that  of  non- 
reacting  animals.  Such  calves  have  in  all  cases  at  the 
Wisconsin  Agricultural  Experiment  Station  stood  the 
tuberculin  test  without  reaction,  showing  that  tubercu- 
losis in  cows  is  contracted  after  birth,  rather  than 
inherited  from  diseased  mothers.  If  such  calves  are 
removed  from  the  infected  atmosphere,  placed  under 
good  hygienic  surroundings  and  fed  on  mUk  free  from 
tubercle  bacUli,  they  wiU  not  show  any  taint  of  disease. 
Treated  in  this  manner,  the  labor  of  years  spent  in 
careful  and  selected  breeding  and  the  large  money 
values  involved  are  not  needlessly  destroyed. 

To  one  who  is  at  all  familiar  with  the  ordinary 
countrv  dairy  it  is  evident  that  some  supervision  of  the 
construction  and  management  of  cowsheds  is  a  reform 
which  is  urgently  called  for,  as  experience  shows  that 
the  amount  of  tuberculosis  in  cows  is  very  materially 
diminished  by  sanitary  surroundings,  and  I  am  very 
glad  to  say  that  the  State  Board  of  Health  of  Michigan 
is  required  by  law  to  pass  upon  the  plans  and  specifica- 
tions of  all  buildings  wherein  cows  are  kept  in  connec- 
tion with  all  State  institutions. 

Moreover,  inasmuch  as  tubercular  infection  in  cows 
is  supposed  to  take  place  mainly  through  the  inhalation 
of  dried  sputum,  no  individual  suffering  from  pulmon- 
ary consumption  should  be  employed  in  any  capacity 
in  or  about  bams,  dairies,  or  milk  wagons. 

Tubercle  bacilli  are  very  seldom  inherited.  The 
germ  may  pass  from  a  tuberculous  parent  into  the  body 
of  a  fetus  which  may  then  be  bom  with  a  tubercular 
lesion,  but  this  has  been  seen  so  rarely  that  it  simply 
enables  us  to  affirm  that  the  inheritance  of  the  bacillus 
is  not  impossible.  Osier  says  that  there  are  now  about 
20  cases  of  congenital  tuberculosis  in  man  on  record. 
So  that  for  all  practical  purposes  the  sanitarian  is  bound 
to  consider  that  tuberculosis  is  not  an  hereditary  dis- 
ease, but  that  every  case  arises  under  circumstances 
which  can  in  a  great  majority  of  instances  be  theoretic- 
ally if  not  practically  prevented.  In  this  connection  I 
wish  to  quote  the  conclusions  of  the  recent  congress  of 
experts  at  Berlin. 

1.  Tuberculosis  is  a  communicable  disease,  due  to 
Koch's  tubercle  bacillus  acting  on  an  organism  pre- 
pared to  receive  it  or  unable  to  resist  the  bacilli  when 
present  in  large  numbers. 

2.  Tuberculosis  is  not  to  any  great  extent  hereditary. 

3.  Tuberculosis  may  be  prevented  by  removing  the 
source  of  infection,  by  improving  the  environment,  and 
by  strengthening  the  individual. 

4.  Tuberculosis  in  many  of  its  severe  varieties  can 
be  cured. 

These  propositions  may  now  be  accepted  as  scientific 
truths.  In  certainty  they  may  take  rank  with  the  laws 
of  gravitation. 

Although  tuberculosis  itself  is  seldom  hereditary, 
there  is  a  certain  type  of  structure  which  has  marked 
hereditary  characteristics  on  account  of  which  feeble 
resistance  is  oflfered  to  the  invasion  of  the  tubercle 
bacillus.  The  relative  importance  of  the  soil  as  com- 
pared with  the  seed  has  been  much  discussed.  In  times 
past,  before  Koch's  discovery,  the  tuberculous  or 
strumous  diathesis  derived  from  inheritance  was  con- 
sidered to  play  a  very  important  part  in  predisposing 
to  tuberculosis,  and  we  are  now  also  certain  that  such 
is  the  case.  Experience  teaches  that  vulnerability  or 
predisposition  to  consumption  runs  in  families.      The 


same  is  true  of  measles,  scarlet  fever,  and  other  infec- 
tious diseases.  This  individual  or  family  susceptibility 
may  be  either  inherited  or  acquired,  and  it  is  not  always 
easy  to  distinguish  between  the  influence  exerted  by 
heredity  and  that  exerted  by  bad  food,  exposure  to 
cold,  foul  air,  and  other  conditions  which  lower  vitality 
and  render  the  individual  a  ready  prey  when  infected.  '  I 

There  can  be  no  doubt  that  some  infectious  diseases,  ' ' 
as  measles  and  whooping-cough,  predispose  to  tubercu- 
losis by  rendering  certain  groups  of  lymphatic  glands, 
such  as  the  cervical  and  bronchial,  a  suitable  soil  for 
the  propagation  of  the  specific  bacillus.  Predisposition 
may  pertain  to  the  individual  only  or  to  an  entire  race, 
and  it  is  well  known  that  tuberculosis  at  the  present 
time  is  much  more  prevalent  among  the  colored  people 
of  the  South  than  among  the  whites. 

The  communicability  of  pulmonary  tuberculosis  is 
now  so  thoroughly  established  and  so  generally  recog- 
nized by  the  medical  profession  that  I  will  not  take 
up  your  time  with  any  arguments  upon  this  point 
Statistics  show  that  about  three-fourths  of  all  deaths 
from  tubercular  disease  are  due  to  consumption,  and  it 
is  generally  believed  that  almost  every  case  is  caused 
by  the  inhalation  of  tubercle  baciUi.  the  most  frequent 
source  of  which  is  the  expectoration  of  consumptive 
individuals.  Sir  William  Broadbent  echoes  the  senti- 
ments of  sanitarians  throughout  the  world  when  he 
says  that  the  prevention  of  the  spread  of  consumption 
from  persons  suffering  from  the  disease  resolves  itself 
into  the  destruction  of  the  sputum,  which  we  know 
retains  its  virulence  for  long  periods  of  time.  Outside 
the  body  the  bacilli  are  found  most  frequently  in  the 
dust  of  rooms  which  have  been  frequented  by  tubercular 
patients,  and  it  has  been  repeatedly  shown  that  dust 
collected  from  hospital  wards,  asylums,  prisons,  hotel 
bedrooms,  private  houses,  etc.,  where  consumptives  have 
been,  is  capable  of  producing  the  disease  in  animals. 
Such  dust  may  retain  its  power  for  producing  tuber- 
culosis for  weeks  or  months.  In  ordinary  breathing 
the  expired  air  is  free  from  bacilli ;  when  talking,  how- 
ever, there  is  an  invisible  spray  constantly  emitted  from 
the  mouth  which  has  been  shown  to  contain  tubercle 
bacilli.  This  is  more  apt  to  be  the  case  in  forcible 
talking,  hawking,  spitting,  etc..  and  Flugge  thinks  this 
spray  is  a  greater  source  of  danger  than  the  dried 
sputum.  Experiments  made  by  directing  a  fine  spray 
containing  bacilli  towards  the  nostrils  of  animals  have 
produced  tuberculosis  in  them,  and  some  weight  should 
be  attached  to  this  point  But  tubercular  sputum 
sprayed  into  the  air  in  this  manner  subsides  at  once, 
and  could  only  infect  when  coughed  into  the  face  of 
someone  and  actually  mixed  with  the  inspired  air. 
Otherwise  the  sputum  must  be  dried  and  broken  up 
into  dust  in  order  to  be  inhaled. 

The  most  important  sanitary  problem  of  today  is  that  of 
the  prophylaxis  of  pulmonary  tubeiTidosis,  but  I  do  not 
believe  that  proper  measures  for  the  suppression  of  this 
disease  can  ever  be  enforced  until  the  public  in  general, 
and  especially  that  portion  of  the  people  who  either  has 
the  disease  or  is  intimately  associated  with  those  suflfer- 
ing  from  it.  become  properly  educated  on  the  subject 
And  here  I  wish  to  state  emphatically  that  I  do  not 
mean  alarmed,  but  educated  in  a  rational  way :  and  it  is 
for  the  purpose  of  enabling  this  to  be  done  that  I  believe 
the  State  should  insist  upon  the  compulsory  notifi- 
cation of  every  case  of  tuberculosis  within  its  borders. 
If  good  is  to  be  accomplished,  it  is  not  to  be  by  starting 
a  panic,  but  by  giving  the  people  such  a  knowledge  of 


Jancahy  12,  1901] 


ADMINISTRATIVE  CONTROL  OF  TUBERCULOSIS 


["The  Philadelphia 
L  Medical  Journal 


87 


this  dangerous  disease  that  they  will  know  themselves 
exactly  wherein  the  danger  lies.  It  should  be  impressed 
upon  them  that  this  is  principally  in  one  direction, 
namely,  the  sputum.  It  should  be  constantly  kept  in 
mind  that  it  is  the  sputum,  and  the  sputum  alone,  that 
is  chiefly  concerned  in  the  spread  of  consumption. 

I  think  there  is  too  great  a  tendency  to  the  use  of 
the  word  "  contagious  "  in  this  connection,  as  it  gives 
rise  to  needless  alarm.  The  word  transmissible  or 
communicable  is  much  better  and  is  far  less  disturbing 
to  the  public.  The  minute  you  use  the  word  "  con- 
tagion "  in  connection  with  a  disease,  the  mental  image 
formed  is  always  that  of  acute  contagion  such  as  exists 
in  smallpox,  scarlet  fever,  measles  or  mumps.  But 
consumption  differs  from  these  diseases  in  this  impor- 
tant particular,  that  whereas  in  the  latter  infection  is 
almost  entirely  beyond  the  control  of  the  patient,  in 
pulmonary  tuberculosis  it  is  limited  to  the  sputum,  the 
disposal  of  which  can  very  easily  be  controlled. 

While  consumption  is  always  the  result  of  infection, 
it  is  far  less  readily  communicated  than  the  diseases 
just  mentioned  which  are  transmissible  from  individual 
to  individual  by  immediate  or  direct  contact,  and  for 
which  the  word  contagion  should  be  reserved.  The 
popular  idea  of  a  contagious  disease  is  one  from  which 
there  is  no  sure  escape  except  by  keeping  away  from  it. 
When  you  proclaim  a  disease  to  be  contagious  the 
people  will  pay  no  attention  to  the  conditions  of  safety 
which  you  may  lay  down,  and  social  ostracism  is  sure 
to  follow.  Isolation,  however,  or  any  form  of  personal 
restraint  upon  consumptives  who  will  faithfully  carry 
out  the  few  simple  measures  for  rendering  their  sputum 
innocuous,  is  entirely  unnecessary,  for  with  these  pre- 
cautions there  is  practically  no  danger  from  even  inti- 
mate association  with  such  people. 

The  most  certain  method  of  getting  correct  informa- 
tion as  to  the  etiology,  dissemination,  and  prevention 
of  consumption  into  the  hands  of  the  people  who  most 
need  it,  is  for  each  and  every  case  of  tuberculosis  to  be 
reported  to  those  whose  business  it  is  to  look  after  the 
sanitary  affairs  of  the  State.  As  far  as  immediate  pre- 
vention itself  goes,  the  notification  of  the  pulmonary 
form  of  the  disease  alone  would  suffice.  Several  forms 
of  tuberculosis,  such  as  hydrocephalus  and  meningitis, 
cannot  be  called  infectious  in  any  sense.  Neither  can 
tuberculosis  of  glands,  bones,  and  joints  communicate 
the  disease  until  a  discharge  is  established.  But  in 
order  to  enable  us  more  thoroughly  to  study  its  life- 
history  and  manner  of  dissemination,  all  forms  of 
tuberculosis  should  be  brought  to  the  notice  of  the 
health  authorities. 

The  people  must  be  taught  that  consumption  is  by 
no  means  a  necessarily /ataZ  disease,  but  that  on  the 
other  hand,  the  large  majority  of  cases,  if  taken  in  time, 
can  be  curtd.  It  is  to  the  interest  of  both  the  patient 
and  his  healthy  neighbor  that  the  former  be  informed 
of  these  facts.  Postmortem  examinations  show  that 
from  40  to  80%  of  cases  of  consumption  have  also  in- 
testinal lesions,  and  the  chances  of  recovery  are  by 
them  greatly  reduced.  People  should  be  taught  that 
these  lesions  may  in  great  part  be  prevented  by  the 
immediate  disinfection  of  the  sputum.  Any  consump- 
tive who  is  well  on  the  road  of  recovery  may  diminish 
his  chances  of  regaining  health  by  self-inoculation  if 
he  does  not  exercise  the  greatest  care  in  destroying  his 
sputum.  And  the  fact  that  every  consumptive  may  be 
a  source  of  danger  not  only  to  himself  but  also  to  his 
associates  if  his  sputum  is  not  destroyed,  should  make 


him  doubly  anxious  for  correct  information  on  these 
points.  With  proper  precaution  victims  of  this  disease 
may  pursue  their  usual  avocations  without  endanger- 
ing others  in  the  least,  and  for  long  periods  of  years 
they  are  often  able  to  perform  the  ordinary  duties  of 
life  with  impunity. 

The  experience  of  several  cities,  notably  New  York 
and  Philadelphia,  shows  that  rooms  occupied  by  con- 
sumptives are  veritable  centers  of  infection  for  the 
spread  of  tuberculosis,  and  maps  employed  for  record- 
ing cases  of  consumption  argue  more  forcibly  than  words 
for  its  infectious  and  communicable  character.  One  of 
the  most  prominent  characteristics  of  an  infectious  dis- 
ease is  that  persons  who  come  in  contact  with  affected 
individuals  fall  victims  to  it.  How  closely  consump- 
tion follows  this  law  is  beautifully  demonstrated  by  a 
comparison  of  the  diagrams  of  smallpox,  diphtheria, 
typhoid  fever,  and  scarlet  fever  with  those  of  phthisis 
in  the  city  of  Philadelphia,  for  the  grouping  and  locali- 
zation is  almost  the  same.  Such  being  the  case,  no  ar- 
gument is  necessary  to  show  that  all  premises  vacated 
by  consumptives  by  reason  of  death  or  change  of  resi- 
dence should  be  thoroughly  renovated  or  disinfected 
before  being  again  occupied.  Moreover,  I  believe  that 
in  all  hospitals,  poorhourses,  asylums  and  jails  those 
persons  affected  with  consumption  should  be  separated 
as  much  as  possible  from  the  other  inmates,  as  is  now 
done  in  the  insane  asylums  of  our  own  State,  and  that 
in  all  such  institutions,  as  well  as  in  all  factories,  shops, 
and  other  buildings  where  people  are  accustomed  to 
congregate  in  considerable  numbers,  rules  for  the  proper 
care  of  sputum  should  be  posted  in  prominent  places, 
and  that  such  buildings  should  be  subjected  to  regular 
inspection  by  the  sanitary  authorities  for  the  enforce- 
ment of  such  regulations. 

Another  important  administrative  measure  for  the 
control  of  tuberculosis  is  the  early  diagnosis  of  all  cases, 
and  to  that  end  boards  of  health  in  many  cities 
throughout  the  country  are  now  making  bacteriological 
examinations  of  all  samples  of  sputum  submitted  to 
them. 

And  last  but  not  of  least  importance  as  a  prophy- 
lactic measure  I  would  recommend  the  establishment 
of  special  hospitals  for  the  management  of  indigent 
cases  of  phthisis,  and  these  hospitals  I  think  should  be 
supported  by  the  State.  I  believe  that  the  time  will 
come  when  every  large  community  will  have  in  its 
immediate  vicinity  a  hospital  for  the  care  of  its  con- 
sumptive poor.  I  do  not  now  refer  to  sanatoria  for 
curative  purposes,  but  to  places  of  shelter  for  incura- 
bles, homes  for  advanced  cases,  which  are  often  con- 
fined to  rooms  whose  surroundings  are  hygienically 
bad  and  which  are  daily  becoming  worse  by  reason  of 
the  absence  of  those  special  precautions  which  are  so 
necessary  to  prevent  the  spread  of  infection. 

The  State  of  Michigan  presents  a  very  good  illustra- 
tion of  the  benefits  derived  from  the  intelligent  sani- 
tary supervision  of  communicable  diseases,  and  also  of 
the  influence  of  general  hygienic  measures  upon  the 
death-rate  of  consumption.  There  were  no  registra- 
tions at  all  of  deaths  in  Michigan  before  1867,  and 
practically  the  returns  do  not  begin  to  be  useful  before 
1869  or  1870.  For  the  period  1870-74  the  death-rate 
from  consumption  in  the  State  was  112.1  per  100,000 
inhabitants.  From  that  time  there  has  been  a  pretty 
constant  decline  in  the  death-rate  until  1896  when  it 
reached  90.4  per  100,000,  a  reduction  of  19.3%,  and 
that,  too,  without  that  thorough  special  treatment  as  an 


88 


The  PhiladelphlaT 
Medical  Jocrnal  J 


ADMINISTRATIVE  CONTROL  OF  TUBERCULOSIS 


[jAinrAET  12,  law 


infectious  disease  which  is  herein  indicated.  A  very 
interesting  fact  in  this  connection,  and  one  which 
serves  to  emphasize  the  point  I  am  endeavoring  to 
make,  is  that  more  than  one-third  of  this  diminution 
in  mortality  has  taken  place  since  the  year  1891,  at 
which  time  the  Michigan  State  Board  of  Health  first 
issued  its  leaflet  on  consumption  and  began  its  weU- 
known  "  campaign  of  education  "  against  the  disease. 
But  when  we  turn  to  the  other  infectious  diseases  we 
find  that  the  combined  effect  of  general  hygienic  meas- 
ures plus  special  eflForts  at  restriction,  has  been  to  reduce 
their  fatality  60%  for  the  same  period.  Inasmuch, 
therefore,  as  we  know  that  the  specific  infection  of 
consumption  can  be  more  easily  controlled  than  that 
of  any  other  of  the  principal  infectious  diseases  with 
which  we  have  to  deal,  are  we  not  warranted  in  believ- 
ing that  the  utilizing  of  those  special  sanitary  meas- 
ures for  the  restriction  of  tuberculosis  which  are  well 
known  to  sanitarians  would  produce  a  much  greater 
reduction  in  the  death-rate  from  tubercular  disease  in 
our  State  ?  Many  of  them  have  been  in  force  in  New 
York  City  for  several  years,  and  Dr.  Biggs,  pathologist 
and  director  of  the  bacteriological  laboratories  of  New 
York,  says  that  most  beneficial  effects  have  already 
resulted  from  them.  Not  only  has  there  been  a  very 
material  decline  in  the  number  of  deaths  from  con- 
sumption, but  there  has  also  been  a  most  gratifv'ing 
increase  of  knowledge  as  to  its  nature  among  the  poorest 
class  of  the  population. 

I  wish  to  acknowledge  my  indebtedness  to  the  fol- 
lowing authorities  whom  I  have  consulted  in  the  prep- 
aration of  this  paper  : 

1.  William  H.  Welch,  Baltimore. 

2.  Administrative  Control  of  Taberculosis.  Thome- 
Thorne. 

3.  Alexander  C.  Abbott,  Philadelphia. 

4.  Publication  of  the  New  York.  New  Hampshire, 
and  Michigan  State  Boards  of  Health. 

5.  Diseases  of  Children.     Ashby  >V:  Wright 

6.  Medical  Diagnosis.     Musser. 

7.  Diseases  of  Children.     Keating,  Vol.  V. 

8.  Practice  of  Medicine.     Osier. 

9.  Prevention  of  Tuberculosis.  Jas.  B.  Russell, 
Glasgow. 

10.  Preventive  Medicine  in  the  Citv  of  New  York. 
H.  M.  Biggs. 

11.  Lawrence  F.  Flick,  Philadelphia. 

12.  Virchows  Archives.  Mav,  1900. 


MenlB^eal  Hemorrhage.— Wiemami  (Dtuischt  Zeii- 
schrift  /.  ChirurffU)  reports  6  cases  of  meningeal  hemor- 
rhage, 3  of  which  recovered  and  3  died.  The  cause  of  the 
lesion  of  the  bloodvessels  was  the  result  of  a  severe  injury. 
In  4  of  the  cases  there  was  marked  injury  to  the  scalp.  In 
those  cases  on  which  postmortem  was  obtained,  the  injury  of 
the  bloodvessel  was  found  to  hare  been  caused  by  a  sharp 
edge  of  bone,  produced  by  the  fracture,  cutting  directly  into 
the  vessel.  In  2  cases  the  hematoma  was  found  in  the  fronto- 
temporal  region,  in  2  cases  in  the  temporoparietal  region,  in  1 
case  in  the  parietal,  and  in  the  remaining  case  the  hematoma 
was  diflfuse  in  character.  The  clinical  symptoms  were  very 
variable,  and  in  only  2  cases  was  the  typical  picture  of  menin- 
geal hemorrhage  observed.  The  chief  or  main  indication  of  ex- 
tradural bleeding,  that  ot  an  interval  of  freedom  from  all  symp- 
toms, was  wamting  in  3  cases.  In  a  few  cases  the  characteristic 
changes  in  pulse  and  respiration  were  noticed.  Tne  cha  racter 
of  the  pupil  also  varied  greatly ;  sometimes  they  wese  dilated, 
sometimes  strongly  contracted,  but  generally  reactionless. 
The  convergence  of  the  eye  towards  the  injured  side  was  no- 
ticed only  in  1  case.  In  4  casee  a  disturbance  of  motion  was 
detected  in  those  parts  of  the  body  corresponding  to  the  cen- 


ters pressed  upon  by  the  hematoma.  In  3  of  the  patients  the 
operation  of  opening  the  skuU,  for  the  purpose  of  removing 
the  clotted  blood  and  to  check  the  hemorrhage  was  carried 
out.  Operation  of  opening  the  skull  consisted  in  all  cases  in 
turning  down  an  osteoplastic  flap  with  chisel  and  mallet. 
Wiemann  lays  great  stress  upon  the  advantages  of  such  opera- 
tion over  simple  trephining.  The  clot  was  generally  removed 
with  the  finger  or  sharp  spoon.  The  most  important  reason 
for  removing  the  clot  is  to  get  rid  of  a  soil  on  which  bacteria 
grow  readily,  and  thus  protect  the  patient  against  infection. 
The  most  difficult  part  of  operating  with  chisel  is  probably 
the  forming  of  a  beveled  edge,  which,  when  the  flap  is  re- 
turned to  its  normal  place,  wQl  afford  a  projection,     [g.b.w.] 

Radical  Care  of  iDguinal  Hernia  in  the  Female. 

— Wm.  B.  Coley  {Yale  Medical  Journal.  December,  19iXi,  Vol. 
VII,  p.  204),  is  of  the  opinion  that  the  treatment  of  inguinal 
hernia  in  the  female  has  not  received  the  attention  it  de- 
serves. From  a  careful  study  of  the  literature  of  this  subject 
and  from  personal  experience  he  finds  that  the  number  of 
cases  of  inguinal  hernia  in  the  female  exceeds  the  total  num- 
ber of  femoral  hernia  in  both  sexes  and  forms  60^  of  all 
cases  of  rupture  in  women.  He  reports  the  results  of  opera- 
tion in  134  personal  cases.  With  regard  to  the  technic  of 
operation  Coley  believes  that  the  excision  of  the  sac  is  a 
matter  of  great  importance.  Of  7  cases  in  which  the  sac 
was  not  found,  4  relapsed  within  a  few  months,  and  2  were 
not  traced.  The  opinion  of  Kelly  that  the  removal  of  the 
sac  is  of  little  importance  he  believes  likely  to  do  much  harm. 
Transplantation  of  the  round  ligament,  Coley  beUeves  is 
never  indicated  The  incision  is  made  ^  to  |  of  an  inch 
above  and  parallel  to  Poupart's  ligament.  The  aponeurooB 
of  the  external  oblique  is  sht  up  over  the  internal  ring  and 
dissected  back  to  the  edge  of  the  rectus  on  the  inner  side 
and  sufficiently  to  expose  Poupart's  ligament  on  the  outer 
side.  The  sac  is  sought  high  up  just  below  the  edge  of  the 
internal  oblique  muscle.  It  is  thoroughly  freed  from  the 
round  ligament,  transfixed  and  tied  off  with  catgut.  The 
wound  is  then  closed  in  3  layers,  kangaroo  tendon  being 
used  for  the  buried  sutures,  and  catgut  for  the  skin.  The 
deep  layer  of  sutures,  4  or  5  in  number,  are  introduced  from 
above  downward,  bringing  the  internal  obhque  and  trana- 
versalis  muscle  over  to  Poupart's  ligament.  The  round  liga- 
ment is  allowed  to  drop  back  into  the  lower  angle  of  tiie 
wound ;  the  aponeurosis  is  closed  with  continuous  Kangaroo- 
tendon  sutures.  The  skin  is  closed  without  drainage,  and 
the  wound  dressed  with  10^  iodoform  gauze  and  moist 
bichlorid  gauze  1 :  5000.  Prior  to  December,  1S9S,  when 
Coley  began  to  use  rubber  gloves,  he  had  96^1  of  primary 
wound  healing.  Since  this  date,  in  150  cases  of  hernia  he 
has  had  but  one  suppuration  in  which  it  was  proved  bao- 
teriologically  to  have  been  due  to  imperfect  sterilization  of 
the  skin.  The  question  of  the  merits  of  absorbable  and  non- 
absorbable material  for  hernia  operations  is  discussed  at  some 
length.  At  the  Hospital  for  Ruptured  and  Crippled,  C-oley 
states  that  he  and  Bull  have  been  using  both  catgut  and 
kangaroo  tendon  for  10  years.  Frequent  bacteriologic 
examinations  have  always  shown  that  the  suture  maienal 
is  sterile,  and  experience  has  shown  that  the  sutures  remain 
vmabsorbed  sufficiently  long  to  fulfil  all  the  requirements 
for  this  operation.  Cutting  the  external  obhque  muscle  ia 
considered  not  only  unnecessary,  but  likely  to  weaken  the 
canal,  for  the  nerve-supply  of  the  muscle  fibers  is  divided 
laterally,  depriving  the  mesial  portion  of  its  nerve-supply 
and  when  drawn  down  the  direction  of  the  muecle  fiber  is 
changed  so  that  it  does  not  work  so  advantageously  as  if 
parallelism  with  Poupart's  ligament  had  been  maintained. 
Since  1S92,  Coley  has  operated  upon  134  cases  of  inguinal 
hernia  in  the  female  without  a  death.  The  ages  of  these 
patients  have  ranged  between  40  and  70.  Eighty  patients 
were  under  14  years  of  age.  In  S,  cases  or  5.9  * ,  suppuration 
occurred,  though  in  every  case  it  was  slight  and  limited  to 
stitch-hole  infection,  not  prolonging  the  stiiy  in  the  hospitaL 
The  average  time  which  the  patient  was  kept  in  bed  has 
been  10  days,  and  they  have  been  allowed  to  go  home  at  the 
end  of  2  weeks.  A  spica  bandage  is  kept  on  for  2  weeks 
longer,  at  the  end  of  which  time  support  of  all  kinds  is  dis- 
continued. All  but  13  of  the  cases  have  been  traced,  and 
not  a  single  relapse  has  been  observed,  though  in  16  casee 
only  from  6  months  to  a  year  has  elapsed  atter  the  opera- 
tion,   [m.b.t.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.    Reprints  (250)  of  Original  Articles  will  be  lurnished  gratis  to  Authors  making 
the  request. 
The  Editorial  and  Business  OtHces  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  Ps. 
See  Advertising  Page  8. 


James  Hendrie  Llovd,  A.M.,  M.D.,  Editor-in-Chief 
Julius  L.  Salinger,  M.D.,  Associate  Editor 
Astistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyer,  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  Coley,  M.D. 

J    M.  Swan,  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  Gibbon,  M.D. 


Vol.  VII,  No.  3 


JANUARY  19,  1901 


$3.00  Per  Annum 


Dr.  Gould's  Ketirement. — The  following  resolution 
was  adopted  January  8, 1901,  at  the  Stockholders'  meet- 
ing of  the  Philadelphia  Medical  Publishing  Company  : 

"  With  the  beginning  of  the  fourth  year  of  the  existence 
of  the  Philadelphiv  Medical  JoirENAL,  the  Stockholders  of 
the  Philadelphia  Medical  Publishing  Company  desire  to  place 
on  record  their  sense  of  deep  appreciation  of,  and  to  extend 
their  cordial  thanks  for,  the  energy  and  enterprise  displayed 
by  the  late  editor  of  the  Journal,  Dr.  George  M.  Gould,  and 
the  loyalty  and  fidelity  of  his  collaborators,  to  which  are  due 
largely  the  phenomenal  circulation  and  influence  that  have 
been  attained  in  such  a  comparatively  short  time." 

The  following  resolutions  also  were  passed  a  few 
days  before,  by  the  Board  of  Tiustees,  pertaining  to  the 
same  subject: 

"  Whereas,  The  term  for  which  Dr.  George  M.  Gould  was 
elected  editor  of  the  Philadelphia  Medical  .Journal  ex- 
pires December  31,  1900;  and, 

"  Whereas,  The  plans  of  the  Board  of  Trustees  provide 
for  a  change  in  the  organization  of  the  business  and  edi- 
torial departments  for  1901 ; 

"  Be  it  Resolved,  That  the  secretary  notify  Dr.  Gould  that 
his  services  as  editor  will  not  be  required  after  December  31, 
1900,  and, 

"  Resolved,  That  the  Board  officially  express  to  Dr.  Gould 
its  high  appreciation  of  the  eminent  services  which  he  has 
rendered  the  Company  during  the  three  years  he  has  been 
editor  of  its  Journal  ;  and  its  desire  that  his  earnest  labors 
in  behalf  of  the  medical  profession  may  ever  be  fruitful  in 
good  results." 

The  Influenza. — The  present  epidemic  of  grip  does 
not  tend  to  support  the  opinions  of  those  who  have 
predicted  that  an  immunity  to  this  disease  would 
gradually  be  established,  and  that  influenza  itself  would 
die  a  natural  death  for  want  of  material  upon  which  to 
feed.  On  the  contrary,  the  fact  has  been  notable  from 
the  very  first  appearance,  about  ten  years  ago,  of  this 
prevailing  infection,  that  the  grip  has  had  a  tendency 
to  attack  the  same  victim  repeatedly,  and  that  it  has 
slowly  and  surely  become  an  endemic  disease  amongst 
us.  This  is  certainly  contrary  to  what  we  expect  to 
see  in  an  infectious  disease,  and  to  what  we  actually  do 
see  in  most  of  the  other  so-called  zymotic  diseases. 
And  yet  that  grip  is  an  infectious  disease,  or  the  pro- 
duct of  a  microbe,  there  is  no  reason  to  doubt.  That 
it  is  contagious,  in  the  sense  that  as  in  any  microbian 
disease  the  spores  or  the  bacilli  themselves  can  be 
passed  from  one  person  to  another,  is  not  to  be  doubted  ; 
and  yet  it  is  probably  not  so  highly  contagious  as  some 
observers  contend.  Certainly,  with  our  present  knowl- 
edge, it  is  not  desirable  that  alarming  statements  to 
that  effect  should  issue  from  the  medical  profession. 


Where  all  persons  are  exposed  to  the  same  cause  many 
may  be  affected  without  direct  personal  contagion. 

With  reference  to  the  subject  of  immunity  from  grip, 
we  wish  we  could  chronicle  some  more  encouraging 
facts.  Turney  {Lancet,  Feb.  5,  1898)  made  a  special 
investigation  on  the  subject  of  relapses,  and  found  in 
England  that  quite  10%  of  the  cases  relapse.  How 
many  persons  have  second,  and  even  third  and  fourth 
attacks  in  succeeding  years,  we  do  not  know.  Turney 
thinks  that  if  any  immunity  is  conferred  it  is  unim- 
portant, and  that  a  first  attack  even  seems  to  predis- 
pose to  a  second.  Many  observers  in  America  will 
confirm  this  statement.  Gresswell  claimed  that  healthy 
persons  are  more  liable  to  be  attacked  than  those  who 
have  been  in  bad  health.  With  reference  to  the  com- 
plications and  sequelfe  of  grip,  it  is  well  to  remember 
that  many  of  these  are  probably  due  to  secondary  in- 
fection. Thus  the  pyogenic  microbes  may  cause  a 
purulent  pleurisy,  or  the  pneumococci  may  cause  a 
pneumonia.  For  these  and  other  infections  the  grip 
merely  prepares  the  soil.  The  disturbances  in  the 
nervous  system  are  probably  due  to  toxins,  although 
some  of  them  closely  simulate  organic  lesions.  Thus 
a  paralysis  of  the  sixth  nerve,  occurring  as  an  early 
symptom,  was  observed  in  a  case  in  this  city  last  year. 
In  the  present  epidemic  in  Philadelphia  grave  compli- 
cations of  any  kind  are  not  so  common  as  in  the  earlier 
years. 

With  reference  to  treatment,  there  seems  to  be 
nothing  new,  and  nothing  very  effective.  There  is  no 
specific  for  grip,  and  until  we  have  a  protective  or  a 
curative  serum  there  probably  will  be  none. 

The  Third  Pau-Ameriean  Medical  Congress. — 

The  fact  that  this  approaching  Congress  is  to  assemble 
in  Cuba  gives  it  quite  a  unique  importance.  That 
island,  which  historically  is  one  of  the  oldest  commun- 
ities in  the  new  world,  has  only  just  recently  joined  in 
a  full  sense  the  American  community  of  nations.  What- 
ever may  be  Cuba's  political  position  in  the  future,  her 
geographical  and  commercial  position  will  always 
make  her  an  important  if  not  a  distinguished  factor  in 
the  public  life  of  this  continent.  In  the  medical  and 
hygienic  sense  her  existence  on  our  very  borders  gives 
her  a  first-rate  importance  with  her  many  unsolved 
problems  of  tropical  diseases  and  tropical  civic  life. 
We  in  America  are  deeply  interested  (if  even  in  a  selfish 


90 


Mbdical  Journal  J 


EDITORIAL  COMMENT 


[January  19,  19*1 


way)  in  some  of  these  Cuban  hygienic  problems,  and 
we  are  also  desirous  of  seeing  the  island  brought  into 
closer  relations,  both  commercial  and  professional,  with 
our  own  country.  It  thus  seems  that  the  idea  of  hold- 
ing the  next  Pan-American  Congress  in  Cuba  is  a  happy 
one.  Moreover,  the  occasion  offers  a  splendid  excuse 
for  some  hardworked  American  physicians  to  take  one 
of  the  most  delightful  winter  trips  imaginable.  The 
round  trip,  including  attendance  at  the  Congress,  and 
some  sightseeing,  can  be  taken  in  a  comparatively 
short  time.  Personal  acquaintance  with  Cuba  as  a 
winter  resort  will  not  be  a  bad  thing  for  a  doctor  to 
have  as  part  of  his  education. 

The  program  offers  an  attractive  collection  of  titles. 
The  fact  is  noteworthy  that  most  of  the  authors 
are  from  the  large  cities  of  the  United  States;  in  fact,  to 
read  the  program,  one  would  imagine  that  New  York, 
Philadelphia,  Chicago  and  Cincinnati  constituted  the 
real  "  Pan-America."  When  the  owners  of  the  familiar 
names  printed  on  this  program  come  together  in 
Havana,  they  will  probably  find  it  difficult  to  realize 
that  they  are  on  a  foreign  soil.  We  are  rather  impressed 
with  the  limited  role  of  some  subjects  for  which  Cuba 
stands  in  a  special  way,  such  as  yellow  fever ;  and  we 
trust  that  the  actual  work  of  the  (Congress  will  bring 
out  more  discussion  and  more  light  on  this  subject  than 
the  program  seems  to  promise. 

Surgical  Intervcutiou  in  Perforative  Ca.ses  of 
Typhoid  Fever. — Dr.  Osier's  paper,  which  is  presented 
in  this  number,  brings  up  the  question  of  operative 
procedure  in  perforation  of  the  bowel  in  typhoid  fever. 
It  is  asserted  confidently  that  a  certain  percentage  of 
the  fatal  cases  from  this  complication  can  be  saved  by 
early  operation.  We  are  told  that  such  patients  bear 
the  operation  well,  and  that  in  the  cases  observed  the 
ill-effects  have  been  attributed  to  the  operation  itself. 
Dr.  Osier's  authority  on  such  a  point  is  important  and 
reassuring.  There  are  some  considerations,  however, 
that  are  not  always  taken  into  account.  The  post- 
operative effect  of  the  surgical  intervention  and  espe- 
cially the  effect  of  the  anesthesia  does  not  cease  witli 
the  return  to  full  consciousness  and  the  passing  off  of 
the  well-known  symptoms  of  shock. 

We  have  caused  the  patient  weakened  by  the  battle 
with  the  fever  to  exhaust  still  further  his  waning 
strength.  In  the  truly  terrific  primary  cardiac  stimula- 
tion of  the  anesthetic  can  such  an  event  fail  but  to  be 
followed  by  its  period  of  compensatory  lowered  vital- 
ity? Not  perhaps  showing  itself  by  marked  shock 
but  a  progressive  asthenic  decline.  We  have  merely 
sounded  a  note  of  warning  as  to  the  effect  of  operation 
per  se  in  the  course  of  a  progressive  febrile  affection 
such  as  typhoid. 

We  agree  fully  in  the  opinion  of  the  value  of  oper- 
ation in  perforative  cases,  and  would  urge  with  Dr.  Osier 
the  necessity  of   careful  personal    observation  of  the 


earliest  symptoms  of  the  complication.  That  even  the 
most  expert  clinicians  fail  to  detect  perforation  in  all 
cases  shows  the  great  need  of  further  knowledge  upon 
the  initial  symptoms  of  its  onset.  Let  us  pay  great 
heed  to  every  detail,  nor  think  no  point  of  minutiae 
too  slight  to  be  carefully  taken  into  consideration. 
The  suggestion  that  typhoid  cases  be  examined  care- 
fully upon  the  slightest  occasion,  not  by  an  inexperi- 
enced interne,  but  by  a  trained  clinical  obser\-er, 
should  be  taken  to  heart.  No  less  valuable  is  the  sug- 
gestion, that  students  receive  constant  bedside  instruc- 
tion in  this  disease  and  not  depend  upon  textbook  or 
lecture.  This  is  a  plea  for  progressive  teaching  which 
it  should  be  our  duty,  as  physicians  and  as  humani- 
tarians, to  preach  as  gospel. 

The  Medico-Leg-al  Aspects  of  the  Case  of  Cadet 
Boox. — From  the  purely  medical  standpoint  this  now 
celebrated  case  is  of  interest  from  the  fact  that  it  haa 
raised  the  very  important  question  of  the  causation  of 
tuberculosis  under  extraordinary  circumstances.  There 
seems  to  be  no  doubt  that  Cadet  Booz  died  of  pulmo- 
nary tuberculosis,  two  years  after  leaving  the  Academy. 
This  disease,  according  to  the  allegations  of  his  friends, 
was  induced  by  certain  maltreatment  which  he  received 
in  the  process  of  "  hazing ''  at  West  Point.  The  partic- 
ular offence  complained  of  was  the  administration  of 
Tabasco  sauce — a  very  hot  and  irritating  condiment 
A  logical  statement  of  the  accusation,  therefore,  would 
seem  to  be,  that  the  administration  of  an  irritating  con- 
diment, such  as  is  used  quite  commonly  on  the  dining- 
table,  can  cause  an  injury  to  the  larynx,  and  upon  the 
seat  of  this  injury  tubercular  infection  can  occur  which 
leads  eventually  to  generalized  pulmonary  tuberculosis. 
This,  as  we  have  said,  is  a  medico-legal  point  of  great 
importance,  not  only  as  it  concerns  the  fair  fame  of 
West  Point,  but  as  it  possibly  might  establish  a  prece- 
dent of  importance  in  medico-legal  practice.  The  Mili- 
tary Court  of  Inquiry,  which  has  just  finished  its  work, 
did  not,  it  seems  to  us,  take  a  very  serious  view  of  thit 
medico-legal  point,  or  attempt  to  throw  much  light 
upon  it,  but  has  contented  itself  with  a  mere  statement 
that  Cadet  Booz  did  not  come  to  his  death  as  a  result 
of  hazing.  K 

Primary  tubercular  laryngitis  is,  according  to  all  au-  ■ 
thorities,  an  extremely  rare  disease.  Morell  Mackenzie 
says  that  he  saw  but  three  cases  postmortem  in  which 
the  larynx  alone  was  involved,  i.  c.  in  which  there  were 
no  tubercular  foci  in  the  lungs.  It  is  conceded,  how- 
ever, that  such  isolated  cases  may  occur.  The  vast 
majority  of  cases  of  laryngeal  tuberculosis  are  secondary 
to  a  lung  lesion.  The  possibility  of  a  wound  or  injury 
of  the  larynx  acting  as  an  exciting  or  predisposing  cause 
of  tubercular  infection  cannot  be  pointblauk  denied, 
but  such  a  contingency  is  regarded  as  likewise  highly 
improbable.  Some  cases,  we  believe,  are  recorded,  but 
their  significance  is  at  least  open  to  doubt.     .\s  tuber- 


I 


ll 


JiXUARV    19,  1901] 


EDITORIAL  COMMENT 


Lm 


The  PlIlLAD*  LPHIA 
EDICAL  JOCK>"AL 


91 


culosis  is  an  infectious  disease,  it  cannot  exist,  of  course, 
without  the  action  of  its  particular  bacillus,  but  in  a 
grave  medico-legal  case  the  proof  would  have  to  be 
overwhelming  that  the  injury  had  been  such  as  to  pre- 
dispose to  an  infection  by  the  bacillus,  and  nothing  like 
this  was  attempted  in  the  inquiry  into  the  case  of  Cadet 
Booz.  It  would  likewise  be  necessary  to  prove  that  the 
laryngeal  disease  was  primary,  and  not  secondary  to  a 
lesion  in  the  lungs.  This  case  has  created  a  great  scan- 
dal in  the  public  mind  about  West  Point,  and  it  is  all 
the  more  desirable,  therefore,  that  no  injustice  be  done 
to  either  side  by  an  inadequate  sifting  of  the  medico- 
legal evidence.  Hazing,  at  its  best,  is  foolish  horse-play, 
but  when  it  leads  to  physical  injury  and  disease  it  is 
intolerable,  and  any  accusation  of  the  kind  should  be 
tested  with  all  the  recognized  rules  of  evidence,  as  well 
88  by  the  teachings  of  medical  science. 

Spinal    Cocainizatioii    and    Mental    Shot-k. — The 

latest  pronouncement  on  the  subject  of  spinal  cocain- 
ization  comes  from  Dr.  Maurice  H.  Richardson,  of  Bos-, 
ton  (Boston  Med.  and  Surg.  Jour.,  January  10),  and  is 
inspired  by  a  visit  he  made  last  August  to  Tuffier's 
clinic  in  Paris.  The  value  of  Dr.  Richardson's  judg- 
ment on  surgical  subjects  will  be  disputed  by  none, 
and  his  unusually  good  opportunity  to  witness  this  new 
method  in  a  clinic  where  it  is  used  so  skillfully,  gives 
his  judgment  all  the  more  interest  and  importance. 
Dr.  Richardson,  in  brief,  saw  two  major  abdominal 
operations  performed  on  patients  who  were  lying  with 
almost  imperceptible  pulses,  blanched  faces,  and  per- 
fectly conscious  minds.  One  of  these  operations  was 
for  the  removal  of  two  ovarian  cysts,  and  the  other  for 
a  large  renal  tumor.  The  skill  with  which  the  opera- 
tions were  performed  was  brilliant  and  remarkable,  and 
the  impression  made  upon  the  minds  of  the  group  of 
American  surgeons  present  was  altogether  favorable,  so 
far  as  the  operator  and  his  technic  were  concerned;  but 
the  impression  made  on  Dr.  Richardson's  mind  by  the 
ghastly  and  even  alarming  condition  of  the  patients 
was  distinctly  unfavorable  to  this  method  of  anesthesia. 
The  condition,  as  described,  was  not  unlike  surgical 
shock.  The  pulse  was  almost  imperceptible,  but  not 
greatly  accelerated  ;  the  face  was  blanched,  and  the 
patient,  perfectly  conscious,  said  repeatedly  that  she 
felt  no  pain.  How  much  of  this  condition  was  due  to 
the  cocain;  and  how  much  to  the  overwhelming  mental 
impression,  is  uncertain,  but  we  are  strongly  inclined  to 
believe,  after  reading  Dr.  Richardson's  graphic  descrip- 
tion, that  the  state  of  mental  shock,  caused  by  the 
patient's  full  consciousness  of  the  horror  of  the  whole 
surgical  procedure,  was  the  vitally  important  fact. 
What  permanent,  or  even  lingering  effect,  this  shock 
may  have  upon  a  patient  is,  of  course,  as  yet  a  mere 
speculative  subject,  and  one  which  surgeons,  who 
usually  see  little  of  their  patients  long  after  an  opera- 
tion, may  not  deem  important;  but  we  are  glad  that  a 


surgeon  himself,  like  Dr.  Richardson,  has  recognized 
this  dreadful  mental  state,  and  has  appreciated  it  fully 
and  described  it  accurately.  To  our  mind  it  furnishes 
one  of  the  strongest  arguments  against  spinal  anes- 
thesia, for  we  believe  that  few  patients,  and  especially 
few  women,  are  so  constituted  in  their  nerves  that  they 
can  lie  fully  awake  and  see  their  abdomens  opened  and 
evacuated  of  tumors,  without  receiving  a  mental  shock 
which  may  be  most  disastrous  in  its  far-reaching 
eflfects. 

Infantile  Scurvy  iu  the  Island  of  Cuba.  —  Until 
very  recently  this  disease  had  not  been  recognized  in 
Cuba.  In  fact  the  subject  had  never  been  discussed 
there  until  Dr.  J.  L.  Duenas,  of  Havana,  contributed  his 
most  interesting  article  on  the  subject  in  a  recent  num- 
ber of  the  Archives  of  Pediatrics  (January,  1901).  Dr. 
Duenas  says  that  since  1894,  when  Xorthrup  and  Cran- 
daU  read  their  paper  on  Infantile  Scurvj'  before  the  New 
York  Academy  of  Medicine,  he  had  looked  in  vain  for 
an  instance  of  this  disease  in  his  practice  until  1898, 
when  he  had  the  opportunity  of  seeing  one  case  of  the 
ordinary  type,  which  promptly  recovered  under  the 
usual  treatment.  In  Duenas"  opinion  the  severe  forms 
of  infantile  scurvy  are  comparatively  rare  in  Havana, 
especially  considering  the  present  condition  of  public 
health  in  that  city.  The  point  of  special  interest  which 
he  makes  in  his  paper  is  a  possible  relationship  in  very 
young  children  between  a  severe  type  of  infantile  scurvy 
and  a  form  of  pernicious  anemia.  Such  observations, 
so  far  as  we  know,  have  been  very  rarely  made,  and  as 
Duenas'  paper  is  founded  upon  a  carefully  observed 
case  it  is  worthy  of  special  comment. 

The  patient  was  a  mulatto  child  24  months  old. 
After  being  weaned  at  6  months  the  child  was  kept  on 
a  diet  consisting  largely  of  rice.  This  diet  was  badly 
borne  and  the  patient  suffered  frequently  from  indiges- 
tion, diarrhea,  and  fever.  The  child  did  not  walk  until 
she  was  16  months  old.  When  Duenas  first  saw  the 
patient  there  were  great  pallor  and  emaciation  with  poor 
physical  development.  There  was  no  evidence  of  rick- 
ets nor  of  any  other  disease,  but  the  left  lower  limb 
was  swollen  and  painful.  The  borders  of  the  gums 
were  purplish,  but  neither  spongy  nor  hemorrhagic. 
The  stools  were  abnormal  and  fetid.  Bleeding  was 
very  free  from  a  pinprick  made  for  the  purpose  of  ob- 
taining a  specimen  of  the  blood.  On  a  diet  of  fresh 
cow's  milk  and  the  juice  of  an  orange  every  day  the 
scorbutic  swelling  of  the  leg  rapidly  disappeared  and 
the  child  seemed  to  improve.  But  this  ichprovement 
was  not  lasting.  After  a  few  weeks  the  child  had  be- 
come still  more  anemic  with  an  earthy  hue  and  a 
wrinkled  skin.  Petechia  and  ecchymotic  spots  were 
also  seen  on  the  skin  of  the  trunk.  An  examination  of 
the  blood  afforded  a  series  of  data  of  diagnostic  impor- 
tance. Laveran's  plasmodia  were  not  found,  nor  was 
there  any  agglutination  of  Eberth's  bacillus.     It  is  thus 


92 


The    PHrLADELPHlA*! 

Hedical  Journal  J 


EDITORIAL  COMMENT 


Jaittabt  Vj,  IM 


seen  that  the  diagnosis  of  malaria  or  typhoid  fever  could 
be  laid  aside.  There  was.  however,  an  advanced  poiki- 
locytosis  and  a  large  number  of  macrocytes  and  micro 
cytes,  two  very  prominent  characteristics  of  progressive 
pernicious  anemia.  There  were  found  no  nucleated  red 
cells.    The  child  failed  progressively  and  died. 

In  discussing  the  significance  of  the  case,  Duenas 
calls  attention  to  the  fact  that  the  etiological  factors  of 
scurvy,  such  as  premature  weaning  and  an  excess  of 
farinaceous  diet  (rice)  were  present.  The  clinical 
symptoms  of  scurvy  were  also  well  marked,  and  a 
rapid  disappearance  of  these  symptoms  occurred  under 
antiscorbutic  treatment.  On  the  other  hand  the  diag- 
nosis of  what  might  be  called  a  secondary  pernicious 
anemia  was  plainly  justified  by  the  clinical  symptoms 
aad  the  microscopic  examination  of  the  blood.  The 
unfavorable  progression  of  the  case  after  the  first 
improvement  in  response  to  antiscorbutic  treatment, 
is  also  in  favor  of  the  diagnosis  of  a  grave  degenerative 
affection  of  the  blood.  The  exact  relationship  of  these 
two  conditions  is  of  course  difficult  to  determine  in  an 
isolated  case.  It  is  well  known  that  symptoms  simulat- 
ing pernicious  anemia  sometimes  occur  when  the  system 
has  been  much  depleted.  They  have  been  seen,  for  in- 
stance, in  cases  of  intestinal  parasites.  We  are  not 
familiar,  however,  with  any  instance,  certainly  with 
any  marked  instance,  of  the  disease  occurring  in  early 
childhood  following  upon  an  infantile  scorbutus  which 
had  already  begun  to  mend  under  appropriate  treatment. 

The  Sigruificauce    of  Kiglit-si«led  Pelvic  Pain. — 

Fully  6-5%,  and  probably  more,  of  the  pelvic  pains  of 
womankind  are  experienced  upon  the  left  side.  An 
explanation  of  this  clinical  phenomenon  is  afiForded  by 
an  anatomic  study  of  the  parts.  For  the  same  reason 
that  varicocele  of  the  left  scrotum  is  much  more  fre- 
quently encountered  than  a  similar  condition  on  the 
right  side,  left  ovarian  and  tubal  disease  of  intrinsic 
origin  is  much  more  common  than  a  corresponding  in- 
dammatory  condition  on  the  right  side.  As  is  well 
known,  the  left  ovarian  vein  empties  into  the  left  renal 
vein  at  right  angles  and  without  the  protection  of  a 
valve,  and  this  vessel  in  its  turn  communicates  with 
the  vena  cava;  while  on  the  other  hand  the  right 
ovarian  vein  empties  directly  into  the  ascending  vena 
cava,  and  is  furnished  with  a  valve  at  the  point  of  junc- 
ture which  opens  upwards  into  the  cava,  whereby 
regurgitation  is  prevented.  On  the  left  side,  therefore, 
stasis,  the  inevitable  result  of  feeble  suction  from  a 
comparatively  slowly  moving  blood-current,  aided  by 
the  action  of  gravity  exerted  through  the  more  or  less 
perpendicularly  running  vessel,  is  of  frequent  occur- 
rence, and  there  follow  of  necessity  a  primary  hyper- 
emia and  a  secondary  chronic  or  subacute  inflammation 
of  the  tissues  of  the  corresponding  broad  ligament  with 
prolapsus  or  descensus  ovarii,  and  pain  and  all  the 
other  sequences  of  adnexal  disease. 


There  may.  however,  and  in  a  certain  proportion  of 
the  cases  encountered  in  a  large  private  or  dispensary 
practice  there  will,  be  found  actual  inflammatory 
changes  with  or  without  exudate  in  the  right  broad 
ligament,  while  cirrhosis  of  the  ovaries — the  disease  of 
sterile  women — will  occur  just  as  surely  upon  the  right 
as  upon  the  left  side,  and  dermoid  cysts  and  other 
cystic  formations  show  no  predilection  for  either  sida 

On  the  other  hand,  however,  a  curious  clinical  fact  ia*- 
the  more  frequent  occurrence  of  tubal  pregnancy  on 
the  right  side.  Bland  Sutton  has  recently  announced- 
that  from  his  studies,  both  clinical  and  postmortem,  he^ 
has  come  to  the  conclusion  that  tubal  gestation  ia' 
much  more  prone  to  occur  in  a  healthy  than  in  a  dis- 
eased tube.  Admitting  the  truth  of  this  statement^ 
which  it  must  be  recognized  is  at  direct  variance  with 
the  teachings  of  the  accepted  textbooks  of  the  day,  it- 
is  not  difficult  to  demonstrate  a  relationship  between 
these  two  clinical  facts.  If  left  tubal  and  ovarian  dis- 
ease is  more  common  than  right  disease  of  the  adnexa, 
and  if  extrauterine  pregnancy  is  more  commonly 
encountered  on  the  right  side — granted  that  Bland 
Sutton's  statement  is  true — then  the  frequency  of  right 
tubal  pregnancy  is  directly  dependent  upon  the  greata 
frequency  of  a  healthy  tube  upon  that  than  upon  the 
left  side.  Now.  the  most  striking  clinical  manifestation 
of  tubal  gestation  is  pain,  occurring  in  sharp  paroxysms' 
at  irregular  intervals,  the  pain  being  located  in  the 
right  ovarian  center  a  little  below  McBumeys  point 
With  this  clinical  phenomenon  associated  with  the 
early  symptoms  of  normal  gestation,  a  careful  f)€lvio 
exploration  will  reveal  the  adventitious  and  exceed- 
ingly tender  growth  in  close  proximity  to  the  uterine 
body,  and  the  diagnosis  may  then  be  made  before 
rupture  has  occurred  and  an  abdominal  section  per- 
formed at  once. 

A  pathological  condition  which  not  infrequently 
closely  simulates  the  foregoing  is  appendicitis.  The 
gynecologist,  too  often  improperly  confining  himself  to 
the  pathology  of  the  pelvic  viscera  to  the  total  exclusion 
of  other  aff'ections  of  the  abdomen,  is  very  apt  to  entirely 
overlook  the  occurrence  of  this  disease  in  the  woman, 
and  to  refer  her  symptom  of  pain  to  some  obscure 
pelvic  condition.  The  realm  of  the  gynecologist,  how- 
ever, is  the  abdomen  just  as  truly  as  the  pelvis,  nor 
should  it  be  limited  to  the  abdominal  cavity,  but  should 
extend  to  the  mammary  glands  also.  He  nee. 'attacks  of 
pain  in  the  right  inguinal  region  should  suggest  to  him, 
as  to  any  other  surgeon,  the  possibility  of  the  presence 
of  an  appendicitis,  and  not  infrequently  a  close  inves- 
tigation of  the  appendix  may  elucidate  an  otherwise 
obscure  c;ise,  and  offer  to  the  patient  chances  of 
recovery  that  might  be  forfeited  by  neglect  of  this  im- 
portant procedure. 

Finally,  every  gynecologist  has  noticed  the  occasional 
occurrence  of  a  referred  pain  in  the  right  ovarian  re- 
gion, in  cases  in  which  a  most  careful  pelvic  explora- 


JAKVAKY  19,  1901] 


CORRESPOXDENCE 


PThK   PHILADKLPHLi 

L  Medical  Journal 


93 


tion  reveals  a  normal  condition  of  that  side  of  the  pelvis 
with,  however,  a  considerable  degree  of  morbidity  on 
the  opposite  side.  This  is  a  curious  phenomenon, 
and  is  a  direct  outcome  of  the  intimate  anastomoses 
that  exist  between  the  pelvic  nerve  plexuses,  and  is  a 
congener  of  the  other,  and  probably  better  known,  re- 
ferred gynecologic  pains,  namely,  those  extending 
down  the  inner  surface  of  the  thigh,  radiating  to  the 
small  of  the  back,  transmitted  to  the  mammae,  or  to 
the  shoulder-blade,  and  referred  to  the  top  of  the  head, 
the  so-called  davm  hystericm. 

In  these  cases,  removal  of  the  offending  organ  on  the 
left  side  will  generally,  but  not  positively,  cure  the  reflex 
pain. 

To  resume,  then,  pain  in  the  right  ovarian  region,  or 
its  immediate  vicinity,  may  indicate  one  or  the  other  of 
the  following  conditions:  First,  a  direct  involvement 
of  the  organs — ovary,  tube,  broad  ligament,  or  pam- 
piniform plexus — of  that  side,  as  demonstrated  by 
macroscopic  or  microscopic  lesions ;  secondly,  right  tubal 
or  broad  ligament  pregnancy;  thirdly,  appendicitis ;  and 
fourthly,  simply  a  transference  of  a  symptom  from  a 
diseased  appendage  on  the  opposite  side  without  any 
appreciable  right  sided  disease. 

Erratum. — A  typographical  error  in  the  fifth  line  of 
the  first  column  of  page  49  in  our  last  issue  demands 
correction.  The  line  should  read  :  "  present  with  its 
point  of  selection  the  respiratory,"  etc. 


(Eorrcsponbcncc. 


A  HATPIN  m  THE  MALE  URETHRA. 

By  p.  J.  KRESS,  M.D., 

of  AlIentowD,  P». 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

Under  correspondence  in  your  Journal,  Vol.  VI,  No.  24 
Dr.  Thomas  M.  Paul,  of  Hazleton,  Pa.,  gives  report  of  a  hat 
pin,  six  inches  long,  extracted  from  the  male  urethra,  aUo 
there  beirg  no  record  of  a  similar  case. 

Iq  1895,  during  my  term  of  service  as  assistant  surgeon  at 
the  State  Hospital,  where  the  doctor  is  at  present,  we  had  a 
similar  case. 

A  man,  aged  about  60  years,  used  a  hat-pin  about  five 
inches  in  length,  if  I  remember  correctly,  in  his  urethra  to 
produce  sexual  excitement.  The  head  of  the  pin  slipped 
into  the  bladder  and  drew  the  end  of  shaft  within  the  meatus 
about  one  inch.  In  attempting  to  get  a  hold  of  the  pin  he 
prf  Bsed  the  point  in  the  lower  wall  of  the  penis,  causing 
severe  hemorrhage. 

When  brought  to  the  hospital  it  was  impossible  to  get  the 
pin  through  the  meatus,  and  the  shaft  being  run  into  the 
tissue  obliquely  the  opening  was  enlarged  by  cutting  along 
the  shaft  from  the  external  side,  and  the  pin  then  drawn  out. 
Dressings  were  applied  and  the  wound  healed  nicely. 

This  case  being  much  like  the  doctor's,  and  occurring  in 
the  same  institution,  gives  me  reason  for  reporting  it. 


TUBERCULOSIS  AMONG  RUSSIAN  JEWS. 
By  a.  L.  benedict,  M.D. 

of  Buffalo,  N.  Y. 

To  the  Editor  o/The  Philadelphia  Medical  Journal  :— 

I  have  read  with  interest  Dr.  Maurice  FIshberg's  letter 
criticising  an  article  by  Miss  A.  Dutcher  in  regard  to  the  fre- 
quency of  tuberculosis  among  the  Russian  Jews.  His 
remarks  as  to  ethnologic  classification  are  certainly  correct, 
yet  it  is  sometimes  practically  impossible  to  avoid  classifica- 
tions that  are  ludicrous  if  interpreted  in  the  strict  scientific 
sense.  For  instance,  pregnancy,  which  is  certaiilly  a  physio- 
logic state,  must  often  be  treated  statistically  as  a  disease. 
In  1890-91,  I  made  a  considerable  number  of  life-insurance 
examinations  which  included  the  work  of  one  or  two  agents 
among  "  Russ-Pole-Jews."  Almost  all  of  the  applicants 
were  rejected  as  under  size  and  having  insufficient  chest 
expansion.  A  large  proportion — I  should  say  fully  half — 
also  presented  the  physical  signs  of  incipient  tuberculosis. 
Most  of  the  applicants  were  workers  in  sweat  shops,  and  they 
seemed  surprised  not  to  be  considered  in  good  health.  Since 
then,  I  have  had  some  little  clinical  experience  confirming 
the  idea  that  tuberculosis  is  much  more  frequent  among 
these  Jews  than  among  the  average  of  the  population  and, 
certainly  among  the  Jews  of  other  nationality.  Personally, 
on  account  of  some  study  in  genealogy  and  heredity,  I  am 
inclined  to  think  that  the  importance  of  heredity  in  the 
etiology  of  disease  has  been  much  overrated.  The  fact  that 
the  Russian  Jews  are  prone  to  tuberculosis  has  nothing  to  do 
with  their  being  Jews,  with  their  having  lived  in  Poland, 
with  their  forced  adoption  by  the  Russians.  For  several 
generations,  at  least,  they  have  been  persecuted  to  such  a 
degree  that  they  have  been  compelled  to  live  in  unhygienic 
surroundings  and  to  subsist  on  inadequate  food.  Since  com- 
ing to  America,  those  to  whom  I  refer  and,  presumably, 
those  who  fell  under  Miss  Dutcher's  observation,  have  been 
occupied  mostly  in  sweat  shops  or,  at  any  rate,  have  been 
herded  together  in  too  crowded  living  rooms.  Manifestly, 
the  same  causes  that  tend  to  render  these  persons  tubercular, 
also  make  them  a  source  of  danger  to  the  community  at 
large. 

Dr.  Fishberg's  statistics  seem  to  be  incontrovertible,  ex- 
cept by  the  general  scepticism  which  one  may  feel  regard- 
ing all  statistics  gathered  in  the  ordinary  routine  of  Boards 
of  Health.  But,  it  should  be  noted  that  his  minimum 
death-rate  from  tuberculosis  is  credited  to  "Russia  and 
Poland " — a  very  different  thing  from  the  class  under  dis- 
cussion. We  have  in  Buffalo  a  considerable  number  of 
Poles.  No  recent  statistics  are  at  hand  and  they  breed  so 
rapidly  that  the  1890  statistics  are  of  no  use,  even  if  we  dis- 
regarded immigration,  which  has  also  been  considerable. 
Probably  we  have  not  less  than  30,000,  nearly  S%  of  the 
total  population.  In  contrast  with  the  "Russ-Pole-Jews," 
they  are  mainly  outdoor  laborers,  especially  in  market 
gardens  in  the  suburbs  and,  so  far  as  possible,  each  family 
secures  a  separate  cottage  and  a  little  plot  of  ground. 
Naturally  enough,  they  are  not  prone  to  tuberculosis  and,  if 
we  include  the  scanty  population  of  highly  tubercular  R;iss- 
PoleJews  in  this  great  mass  of  Slavs,  where  they  do  not  be- 
belong  either  ethnically  or  clinically,  we  must  expect  an 
obscuring  of  fact  by  figures. 


Influenza.— It  is  estimated  that  there  are  70,000  Phila- 
delphians  suffering  from  influenza. 


94 


The  Philadelphia 
Medical  Journal 


] 


SPECIAL  ARTICLE 


[.Tajccabt  :9,  tm 


Special  ^Irttcl^. 


AN  ABSTRACT  OF  THE  REPORT  UPON  THE  EPI- 
DEMIC OF  PEST  IN  JAPAN  FROM  NOVEMBER. 
1899,  TO  JANUARY.  1900. 

By  professor  S.  KITA'SATO, 

Director  of  ibe  Imperial  Institute  for  Infectious  Diseases, 
AND 

DRS.  T.  TAKAKI,  K.  .SHIGO,  and  G.  MORIYA. 

Translated,  with  permission  of  the  Minister  of  the  Interior, 

By  MAUEICE  OSTHEIMER,  M.D. 

The  epidemic  of  pest  appeared  in  Japan  early  in  Novem- 
ber, 1899.  A  commission  for  directing  the  prophylactic 
measures  necessary  to  bring  the  epidemic  under  control,  and 
for  scientific  research,  was  sent  to  Kobe  and  Osaka  at  once 
by  the  Japanese  government.  Professor  Kita«ato,  Director 
of  the  Imperial  Institute;  Dr.  Takaki,  Councillor  in  the 
Ministry  of  the  Interior ;  and  Drs.  Shiga  and  Moriya,  In- 
structors in  the  Institute,  were  named  to  form  this  commis- 
sion. They  succeeded  in  extinguiBhing  the  plague  by  the 
middle  of  January,  1900.  The  number  of  patients  in  the  two 
cities  was  64.    They  were  : 

Died.  Recovered.  Total. 

Bubonic  plague 39  4  43 

Pest- pneumonia  13  0  13 

Pest- carbuncle   3  2  5 

Septicemia  3  0  3 

Total   58  6  64 

Of  these,  35  were  treated  in  hospitals,  29  of  whom  died. 
The  other  29  died  at  home. 

In  Kobe,  a  city  of  230,000  inhabitants,  the  pest  arose 
among  laborers  engaged  with  ship's  refuse.  Thus  7  of  the 
25  cases  found  in  Kobe  are  traced  directly  to  a  ship  which 
had  arrived  from  Bombay  and  Hong  Kong  in  October;  3 
others  had  been  buried  with  ship's  refuse  ;  in  6  cases  dead 
rats  containing  pest-bacilli  were  found  in  the  houses  ;  and  in 
3  cases  infection  followed  from  contact  with  pest-patients. 
In  the  remaining  ('>  cases  the  mode  of  infection  is  not  known. 

In  Osaka,  in  size  the  second  city  of  Japan,  with  750,000  in- 
habitants, the  pest  is  supposed  to  have  entered  through  in- 
fected wadding,  though  there  seems  some  cause  for  suspect- 
ing that  the  wadding  had  been  infected  by  ratp.  The  first 
four  cases  bear  direct  relation  to  this  wadding,  in  which  pest- 
bacilli  were  found  by  Dr.  Iwai,  Director  of  the  Osaka  Muni- 
cipal Hospital  for  Infectious  Diseases.  The  early  cases,  like 
those  in  Kobe,  were  bubonic  in  character.  Toward  the 
middle  of  December,  however,  the  epidemic  grew  more 
malignant,  several  cases  of  pest-pneumonia  occurring  by 
direct  infection. 

In  the  western  part  of  Oaaka  lies  a  small  island.  Shik-aii- 
nhima,  on  which  there  is  a  cotton-spinning  factory,  knnekin- 
seishoicu  kaiaha,  where  over  1,600  women  and  hundreds  of 
men  are  employed.  In  one  room  of  this  factory,  in  which 
63  women  and  10  men  worked,  was  a  girl  named  M.  Adachi. 
She  was  taken  sick  December  19,  1899,  with  symptoms  of 
pneumonia,  and  died  the  2l8t.  Both  the  attending  physician 
and  the  medical  inspector  made  the  diagnosis  of  croupous 
pneumonia;  the  corpse  was  therefore  burned.  Two  days 
after  her  death  her  parents  became  ill  with  exactly  the  same 
symptoms.  Careful  examinations  were  made  and  pest- 
bacilli  found  in  the  sputum.  As  it  was  primary  pest-pneu- 
monia, in  which  the  danger  of  infection  is  very  great,  even 
stronger  precautions  were  taken.  The  patients  were  con- 
veyed to  the  Municipal  Hospital  for  Epidemic  Dseases ; 
those  who  had  been  exposed  were  taken  to  the  Municipal 
Isolation  Pavilions :  and  their  homes  were  at  once  disin- 
fected. 

On  December  25.  in  the  room  in  which  M.  Adachi  had 
worked,  a  woman  developed  a  pest-bubo.  A  systematic  dis- 
infection of  the  entire  factory  followed.  The  men  and  women 
were  isolated  and  examined  daily  by  physicians.  Amoi.g 
those  isolated,  four  cases  of  pest  developed,  two  the  next  day, 
•one  3  days  later,  and  one  after  6  days.  These  all  had  bubonic 


peat,  in  spite  of  the  fact  that  the  baciili  originated  in  M. 
Adachi,  who  had  pest-pneumonia.  Though  the  other 
Adachis  were  isolated,  6  deaths  occurred  in  the  family,  the 
only  one  spared  by  the  disease  being  a  four  year-old  child. 

But  the  power  of  the  disease  had  not  yet  reached  its  end. 
The  physician,  K.  Wakabayashi,  and  the  medical  inspector 
S.  Baba,  who  had  examined  and  treated  M.  Adachi,  her 
parents,  and  U.  Adachi,  also  developed  primary  pest-pneu- 
monia December  30.  "The  third  physician,  T.  Yamanaka,  a 
friend  of  Wakabayashi's,  whom  he  had  treated  before  his 
transfer  to  the  hospital,  became  ill  January  4,  1900.  Besides 
these,  Mrs.  Wakabayashi,  and  Mrs.  Baba  were  taken  sick 
January  3  ;  Wakabayashi's  jinrikiaha  man,  .January  .5th  ; 
Mrs.  Yamanaka,  the  10th  ;  and  Yamanaka's  mother  the  11th. 
All  suSered  from  primary  pest-pneumonia;  in  all  the  disease 
was  fatal. 

Looking  back  now,  the  course  of  the  infe<:tion  is  easily 
traced,  beginning  with  the  girl,  M.  Adachi,  whose  dioease, 
diagnosed  croupous  pneumonia,  was  true  pestrpneumonia. 
As  she  was  a  working-girl  and  lived  in  poorer  circumstances, 
she  kept  at  her  work,  though  she  did  not  feel  well.  As  she 
had  pneumonia,  she  coughed  and  probably  also  expectorated. 
In  this  way  the  pest-bacilli  reached  the  floor  of  the  work- 
room. Thus  it  is  clear  how  two  men  and  three  women, 
working  in  the  same  room,  contracted  glandular  pest.  The 
infection  probably  did  not  come  direct  from  the  lungs,  as  M. 
Adachi  worked  facing  the  wall.  Tnat  these  people  run  about 
without  sufficient  foot  covering  helps  to  confirm  this.  That 
direct  infection  can  follow  in  the  family,  from  the  patient's 
coughing,  or  from  attentions  to  the  patient,  is  beyond  doubt 
Among  the  physicians  the  conditions  were  the  same. 

It  is  well  known  that  rats  are  very  susceptible  to  pesl;- 
bacilli,  and  therefore  well  adapted  to  propaeate  the  germs  of 
the  disease.  On  this  account  pains  were  taken  to  extermi- 
nate them  if  possible,  the  municipal  authorities  paying  5 
sen  (2J  centt)  for  every  rat  delivered  to  them  dead  or  alive. 
In  Kobe  the  total  number  of  rats  bought  reached  20  000 ;  in 
Osaka,  15,000.  Even  more  rats  were  caught  which  did  not 
come  to  the  knowledge  of  the  authorities,  having  been  de- 
stroyed by  private  individuals.  About  one  fifth  of  the  dead 
rats  found  in  Kobe  contained  pest-bacilli ;  in  Osaka  only 
one-tenth. 

In  the  main  custom-house  at  Kobe  pest- rats  were  found 
on  November  21,  1899,  and  12  days  afterward,  a  schoolboy 
who  lived  400  or  500  meters  distant  became  ill.  Upon 
searching,  several  pest- rats  were  found  in  the  dwellings  be- 
tween the  custom-house  and  the  patient's  home.  The 
custom-house  lies  close  to  the  sea,  and  his  home  is  further 
inland,  which  confirms  the  supposition  that  the  disease  in 
the  rats  spread  gradually  up  from  the  sea.  Pest- rats  were 
also  found  in  the  eastern  customhouse  and  on  the  third 
landing  stage  in  Kobe,  whence  it  seems  most  probable  that 
the  rats  came  from  ships.  Pest-rats  were  also  found  in  Gifu, 
where  there  were  no  cases  of  pest,  which  adds  evidence  to 
prove  that  the  rats  brought  the  pest-bacilli  into  Japan. 

Whenever  pest-rats  were  found  near  the  house  of  a  pest- 
patient,  the  bacilli  were  most  probably  spread  by  the  rats. 
In  16  cases  pest- rats  were  found  in  or  near  bouses  where  cases 
of  pest  occurred.  That  pes^rat8  were  found  in  dwellings  far 
distant  from  the  pest  neighborhood,  brings  clearly  to  the 
front  how  closely  the  epidemic  in  the  rats  and  in  man  were 
related.  The  district  in  which  pest-rats  were  found  is  much 
larger  than  that  in  which  cases  of  pest  existed,  though  the 
most  pest  rats  were  seen  where  the  epidemic  raged  most 
fiercely.  While  the  relation  of  the  single  cases  to  the  dead 
rats  cannot  be  fully  shown,  we  can  surely  believe  that  the 
rats  first  became  ill,  and  then  the  epidemic  broke  out  among 
men.  That  probably  occurred  because  the  rate  had  more 
opportunity  to  come  in  contact  with  infected  objects  than 
men. 

From  clinical  investigations  these  conclusions  were  drawn  : 
The  number  of  males  affected  was  twice  that  of  the  females : 
people  from  10  to  40  years  of  age  seemed  most  susceptible 
to  the  disease ;  the  majority  of  patients  were  servants, 
laborers,  and  boatmen  :  the  period  of  incubation  lasted  S  to 
4  days,  though  it  reached  7  to  10  days  in  some  cases.  While 
the  onset  is  generally  sudden  with  a  chill,  it  was  in  a  few 
cases  preceded  by  prodromal  symptoms;  in  19  oases,  con- 
stitutional symptoms  occurred  before  the  buboes,  while  in  7 
cases  they  appeared  simultaneously.  Petechial  eruptions 
were  infrequent,  and  true  roseola  was  seen  in  3  cases. 


Jasuary  19,  1901] 


SPECIAL  ARTICLE 


PThk  Philadelphia 
L  Medical  Joobsal 


95 


Carbuncles  occurred  upon  the  trunk  in  5  cases,  not  once 
upon  the  extremities,  as  is  commonly  the  case ;  which  was 
probably  due  to  the  peculiarities  of  Japanese  costume  and 
the  customs  of  Japanese  life.  In  all  cases  the  carbuncles  were 
primary,  and  pest-bacilli  were  found/  They  lasted  on  an 
average  11  days  ;  while  the  other  forms  of  the  disease  rarely 
existed  over  8  days.  Total  extirpation  is  advised  aa  the  only 
treatment.  Femoral  and  inguinal  buboes  occurred  in  75 
of  the  bubonic  cases,  in  all  of  which  were  pest-bacilli.  The 
ma  in  treatment  employed  was  total  extirpation  of  the  buboes. 
Four  out  of  13  cases  thus  treated  recovered,  all  of  which 
were  inguinal  or  femoral.  In  Osaka,  duritg  the  second  half 
of  the  epidemic,  13  fatal  cases  of  pest  pneumonia  occurred, 
conveyed  by  contact  one  to  the  other.  Not  the  slightest 
difference  in  the  clinical  symptoms  in  primary  and  secondary 
pneumonia  was  found  ;  only  in  the  latter  bloody  sputum  is 
rare,  as  the  patient  dies  too  soon.  Treatment  of  pest- 
pneumonia  by  the  "  Yersin  "  serum  proved  of  no  avail.  Six 
cases  of  mixed  infecticn  were  observed.  Beside  the  pest- 
bacilli,  septicemic  bicilli  like  those  cf  chicken-cholera, 
staining  deeply  by  Gram's  method,  staphylococci,  and 
streptococci  were  seen.  A  positive  diagnosis  can  be  made 
by  bacteriologic  examination  only.  On  the  other  hand,  a 
negative  result  from  bacteriologic  examination  is  of  no  cer- 
tain significance,  since  during  the  onset  of  the  disease  the 
few  bacilli  there  may  easily  escape  the  field  of  the  micro- 
scope; in  pest-pneumonia,  especially  at  the  outset,  frequent 
examinations  must  be  made. 

For  prophylaxis  the  "  HafiFkine  "  serum,  the  "  Yersin  " 
serum,  and  a  new  serum  made  by  Dr.  Shiga's  method  were 
trif  d.  The  "  Hafl  kine  "  serum  was  used  many  times  success- 
fully, the  only  case  cf  pest  developing  after  its  «se  being  in 
a  woman  who  was  probably  infected  before  being  injected. 

But  Dr.  K.Shiga  had,  at  the  time  of  the  epidemic  of  dysen- 
tery, tried  protective  inoculation  against  that  disease.  Ac- 
cording to  his  method  the  vaccine  was  made  thus  :  the  dysen- 
tery cultures  were  ground  up  in  an  agate  mortar,  normal  salt- 
solution  added,  and  then  heated  to  60°  C.  for  20  minutes.  As 
the  substance  of  the  dysentery-bacilli  is  absorbed  with  diffi- 
culty and  causes  marked  infiltration  about  the  site  of  injec- 
tion, a  quantity  of  immunizing  serum  was  added,  equal  to 
that  of  the  vaccine  made.  In  this  manner  it  is  absorbed  with 
the  least  possible  reaction,  and  protection  follows  without 
great  disccrafort  to  the  patient.  After  a  few  days  a  stronger 
injection  follows ;  the  vaccine  is  inoculated  without  the  im- 
munizing serum,  as  the  substance  of  the  bacteria  will  now  be 
easily  absorbed. 

This  method  was  tried  with  the  pest.  The  vaccine  was 
made  as  follows :  All  the  colonies  (5  oese  full)  are  scraped 
from  slant  agar  cultures  which  have  been  kept  3  days  at 
30°  C,  ground  up  in  a  mortar,  and  normal  salt-solution 
added,  enough  to  make  1  ccm.  of  vaccine  contain  1  oese  of 
bacilli.  The  mixture  is  then  heated  at  60°  C.  for  30  minutes, 
carbolic  acid  added  up  to  O.ofo,  and  allowed  to  stand  24 
hours.  The  dose  of  the  vaccine  is  the  following,  first 
injection : 

Vaccine... )   of  each— 0.6  to  1.0  ccra. 

Immunizing  serum J 

A  few  days  later,  after  the  reaction  had  disappeared,  the 
second  injection  follows  : 

Vaccine. 0.6  to  1.0  ccm. 

These  inoculations  were  given  to  47  persons,  not  one  of 
whom  caught  the  pest.  The  reaction  to  the  injections  was  very 
slight,  and  very  well  borne.  The  symptoms  of  the  reaction  are: 
(1)  Slight  pain,  or  tension  feeling  over  the  seat  of  the  injec- 
tion ;  (2)  slight  tenderness  and  redness  with  elevation  of 
temperature  (99.5°  F.) ;  or  more  rarely  (3)  slight  swelling  of  the 
seat  of  the  injection,  mild  fever  (100.4°F.),  slight  headache, 
with  chills,  etc.  In  epidemics  of  pest,  larger  doses  of  this 
vaccine,  which  can  now  be  prepared  in  large  quantities  in 
the  Institute  for  Infectious  Diseases,  may  be  given. 

Of  the  case  histories,  the  following  is  the  most  interesting : 
From  November  15  until  December  4,  Ch.  Yase,  a  police 
servant,  21  years  old,  was  on  duty  during  the  quarantine  of 
the  pesthouses.  On  the  6th  he  noticed  in  the  right  hypo- 
chondrium  a  reddish  swelling  which  itched,  about  the  size 
of  a  millet  seed.  His  temperature  was  101.8°  F.  The  next 
daytlie  swelling  in  the  abdomen  increased  rapidly,  becoming 
dark  red  and  very  painful.     As  he  always   feared  pest  infec- 


tion, he  kept  feeling  in  the  groin  for  buboes.  That  day  for 
the  first  time  he  found  a  slightly  sensitive  spot  in  the  middle 
of  the  inguinal  region.  The  day  following,  the  center  of  the 
abdominal  swelling  was  dark  brown,  the  swelling  itself  being 
as  large  as  a  saucer  and  very  painful.  In  the  most  sensitive 
part  of  the  groin  a  small  bubo  was  palpable.  The  swelling 
pointed  the  day  after,  discharging  a  yellow  purulent  fluid. 
Numerous  blisters  appeared  upon  the  swollen,  infiltrated 
tissue  surroundirg,  and  a  deep  redness  spread  to  the  groins, 
so  that  tlie  wliole  condition  looked  almost  like  erysipelas. 
Pest-bacilli  were  found  in  fluid  withdrawn  by  exploratory 
puncture,  and  the  patient  was  brought  to  the  hospital.  On 
admission,  a  carbuncle  was  found  upon  his  abdomen,  on  the 
right  side  below  the  umbilicus,  the  infiltration  reaching  up 
to  the  umbilicus,  down  to  Poupart's  ligament,  and  across  the 
linea  alba.  'The  head  of  the  swelling  was  as  large  as  a  coin, 
depressed,  and  covered  with  a  dirty  brown  crust.  The  right 
inguinal  glands  were  much  swollen.  That  afternoon  cru- 
cial incisions  were  made,  the  infiltrated  part  of  the  car- 
buncle scraped  out  and  the  inguinal  glands  removed.  Two 
days  later,  as  the  tissue  between  the  carbuncle  and  the 
bubo  was  infiltrated  and  very  sensitive,  it  was  removed. 
The  next  day  the  left  inguinal  glands,  which  were  some- 
what swollen  and  painful,  were  also  removed.  The  edges 
of  the  wounds  upon  the  abdomen  were  still  infiltrated,  so 
that  that  tissue  was  cut  out  the  day  following.  Twenty- 
four  hours  later  a  gland  in  his  neck  had  become  enlarged 
and  tender  and  it  was  also  removed.  From  this  time  on 
he  slowly  improved,  and  was  discharged  in  excellent  con- 
dition 6  weeks  later. 

To  combat  the  epidemic,  Japan  first  of  all  ordered  that  the 
law  regulating  the  quarantine  against  ships  from  foreign 
harbors  or  from  Formosa  be  more  strictly  enforced  than  be- 
fore. Next  the  Minister  of  the  Interior  prohibited  the  intro- 
duc  tion  of  rags,  old  wadding,  old  clothes,  old  bits  of  paper, 
old  leather  or  skins,  and  old  feathers  from  all  harbors  of 
India  and  China ;  from  Hong  Kong  and  Formosa  especially. 
Old  carpets  and  old  hemp-sacks  were  soon  added  to  the  list. 
All  such  material  introduced  before  the  issue  of  the  above 
order  was  to  remain  where  it  was.  Refuse  from  ships  which 
came  from  infected  ports  must  be  burned,  or  thrown  into  the 
sea  at  a  distance  from  land  of  no  less  than  12  kilometers. 
The  length  of  observation  for  a  ship  infected  with  pest  was 
increased  from  7  to  10  days,  and  the  isolation  of  those  open 
to  suspected  pest-infection  was  also  increased  to  10  days. 

As  rats  were  considered  pest-bearing  and  pest  spreading 
factors,  the  Government  ordered  them  caught  all  over  Japan. 
All  dead  rats  were  examined bacteriologically,  and  whenever 
pest  bacilli  were  seen,  the  houses  in  which  the  rats  were 
found  were  disinfected.  Comprehensive  cleansing  was  under- 
taken in  all  parts  of  Japan,  and  in  those  cities  in  which  the 
population  is  thickly  crowded  together,  and  trade  very  active, 
(as  Tokio  and  Y'okohama)  medical  inspection  of  laborers' 
quarters  was  established,  in  order  to  discover  eact  case  of 
pest  just  as  soon  as  it  appeared.  When  a  suspicious  case 
came  to  the  knowledge  of  the  authorities,  a  medical  expert 
was  sent  to  confirm  the  diagnosis.  If  the  case  was  one  of 
true  pest,  or  strongly  suspicious  of  pest,  the  patient  was 
taken  to  the  Municipal  Hospital.  In  order  to  discover  con- 
cealed cases  of  pest,  medical  inspection  was  established.  In 
Kobe  229  physicians,  in  Osaka  374  physicians  were  engaged, 
each  physician  being  given  a  policeman.  Both  visited  their 
district  daily,  to  register  names  and  to  examine  cases.^  The 
physicians  were  ordered  to  specify  in  the  death  certificates 
when  the  patient  became  ill,  when  he  was  first  examined, 
and  when  he  died.  In  all  cases  of  death  from  acute  disease, 
an  autopsy  was  held  by  pest  experts. 

The  disinfection  was  left  in  the  hands  of  the  police.  Dirty 
linen,  dothes,  bed-clothing,  etc.,  were  disinfected  by  steam ; 
for  furniture,  floors,  walls,  columns,  ceilings,  and  the  spaces 
between  the  ceilings,  and  the  space  between  the  ceilingi  and 
the  floor,  or  roof  above,  ofo  carbolic  acid  was  used.  For  the 
disinfection  of  cellars,  kitchens,  sinks,  and  water-closet^", 
slaked  lime  or  chlorid  of  lime  was  employed.  Infected 
articles  of  little  value,  such  as  old  clothes,  mattresses,  wooden 
shoes,  etc.,  were  burned. 

Hospital- Ship    Maine    Beaches    England. —The 

American  hospital-ship  Maitu  has  arrived  at  Southampton, 
with  invalids  from  China. 


I 


96 


The  Philadelphia"] 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[JiSCAEr  19,  19M  I 


21merican  Xlcws  anb  Hotcs. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

Dr.  Basbrod  "W.  James  was  elected  president  of  the 
Peonsjlvania  Fish  Protective  Association. 

New  Laboratory. — Plans  are  being  prepared  for  a  new 
medical  laboratory  for  the  University  of  Pennsylvania. 

Dr.  Artbur  Kemington  has  been  elected  to  fill  the 
position  on  the  obstetrical  staff  of  the  Maternity  Hospital, 
rendered  vacant  by  the  resignation  of  Dr.  W.  Constantine 
Gocdell. 

Grip  Epidemic  at  Princeton. — An  epidemic  of  grip 
has  spread  with  alarming  rapidity  through  the  University 
the  past  few  days.  There  are  18  cases  now  in  the  University 
Hospital. 

Huntingdon  County  Medical  Society. — At  the  first 
regular  meeting  held  January  8.  the  following  officers  were 
elected  :  President,  Dr.  Ella  M.  Gerlach  ;  vice-president,  Dr. 
Bruce  P.  Steel ;  secretary,  Dr.  A.  B.  Brumbaugh  ;  treasurer, 
Dr.  G.  G.  Harman. 

Phjsician  Falls  from  Window  Dead. — Dr.  James 
Boyd  McKelvy,  one  of  the  most  prominent  phyticians  and 
residents  of  Bloomsburg,  76  years  of  age,  died  January  14. 
He  was  a  graduate  of  Williams  College  and  University  of 
Pennsylvania  Aledical  School. 

Tbe  Mayor  of  Elizabeth  Dead.— Dr.  William  A. 
M.  Mack  was  found  dead  in  bed  at  his  home  on  January  14. 
Dr.  Mack  was  born  in  Glen  Gardner,  N.  J.,  44  years  ago. 
He  began  the  study  of  medicine  with  Dr.  Thomas  L.  Hough. 
He  was  a  graduate  of  Bellevue  Medical  College,  a  member 
of  the  Union  County  Medical  Society,  and  the  Clinical  So- 
ciety of  the  Elizabeth  General  Hospital. 

Resignation  of  Dr.  J.  W.  Croskey. — At  the  meeting 
of  the  Board  of  Directors  ot  City  Trusts  on  January  10,  the 
resignation  of  Dr.  John  Welsh  Croskey  as  surgeon  to  Wills 
Eye  Hospital  was  accepted,  to  take  effect  January  1  last,  and 
on  the  recommendation  of  the  committee  of  the  hospital. 
Dr.  McCluney  Radcliffe  was  appointed  to  the  vacancy.  Dr. 
Radcliffe  has  been  connected  with  the  hospital  for  the  past 
17  years  as  assistant  to  Dr.  George  C.  Harlan. 

Annual  Meeting  of  Delaware  County  Medical 
Society. — The  annual  meeting  of  the  Delaware  County 
Medical  Society  was  held  in  Chester,  January  10.  The  elec- 
tion of  officers  resulted  as  follows:  President,  Dr.  George  D. 
Cross,  Chester  ;  vice-president,  Dr.  Partridge,  Ridley  Park  ; 
secretary,  Dr.  Linneas  Fussell,  Media ;  treasurer.  Dr.  D.  W. 
Jefferis,  Chester  ;  reporter.  Dr.  M.  A.  Neufeld,  Chester ;  libra- 
rian, Dr.  Trimble,  Lima;  censors,  Drs.  D.  W.  Jefferis,  Frone- 
field  and  Hammond. 

Germantown  Hospital. — At  the  annual  meeting  of 
the  contributors  to  the  Germantown  Dispensary  and  Hos- 
pital, held  at  the  hospital  building  East  Penn  Street,  Tuesday 
afternoon,  the  report  for  1900  wa^  read,  showing  that  1,080 
patients  were  treated  in  the  hospital  proper  during  the  year, 
an  increase  of  107,  whilst  in  the  dif pensary  there  were  treated 
11,967.  The  following  officfrs  were  elected:  President, 
Elliston  P.  Morris ;  secretary,  Thomas  B.  Homer ;  treasurer, 
William  H.  Haines.  Managers,  Elliston  P.  Morris,  William 
H.  Haines,  Frank  J.  Firth,  Francis  Stokes,  Reed  A.  Williams, 
Jr. ;  Alexander  W.  Wister,  Jr. ;  William  H.  Scott,  Thomas  B. 
Homer,  Morton  Downs,  M.D. ;  Thomas  H.  Shoemaker, 
Henry  L.  Davis,  N.  Penrose  Allen,  Edward  H.  Hance,  George 
W.  Woodward,  M.D. ;  James  Mapes  Dodge. 

Pathological  Society. — At  the  meeting  of  January  10 
Dr.  Joseph  McF.\rlakd  exhibited:  (1)  An  epithelioma 
of  the  mouth  and  skin  of  a  white  cattish,  and  (2) 
A  case  of  thrombosis  of  all  four  chambers  of  the 
heart.  The  patient  from  whom  the  latter  specimen  was 
taken  had  not  been  very  ill  and  the  diagnosis  oi  tuberculosis 
had  been  made.  With  the  exception  of  the  thrombi,  a  hem- 
orrhagic infarct  in  one  lun^  was  the  only  lesion  found.  Des. 
Ida  E.  Richardson  (by  invitation)  and  J.  D.  Steele  showed 


an  Hourglass- contraction  of  the  stomach.    The  par 

tient  died  at  the  age  of  38,  having  had  gastric  pain  and  t 
hemorrhages  more  or  less  frequently  since  the  age  of  15. 
The  contraction  was  very  marked,  being  near  the  middle  of 
the  stomach  and  at  a  point  where  strong  adhesions  bound  it 
to  the  pancreas  acd  liver.  Drs.  F.  X.  Deecum  and  \V.  G. 
Spiller  presented  a  paper  on  Nerve  fibers  in  the  pia  of 
the  cord  as  a  sign  of  regeneration  of  the  cord. 
This  rare  condition  of  nerve  fibers  in  the  pia  was  found  in  a 
case  of  adiposis  dolorosa.  The  fibers  were  more  numerous 
over  the  posterior  columns  of  the  cord  and  were  confined  to 
the  lumbar  and  dorsal  regions.  The  knee-jerks  were  not 
abolished  and  there  was  no  degeneration  of  the  posterior 
roots.  Dr.  L.  Napoleon  Boston  read  a  paper  on  Cultiva- 
tion of  the  aspergillas  in  urine,  and  showed  speci- 
mens by  the  chromoecope.  Drs.  M.  P.  Ravekel  and  D.  J. 
McCarthy  presented  a  paper  on  the  Rapid  diagnosis  of 
rabies.  The  claims  of  Babes  and  Van  Gehucnten  were 
reviewed  acd  the  results  of  experiments  at  the  University 
of  Pennsylvania  given.  Drs.  Ravenel  and  McCarthy  have 
studied  28  cases  of  rabies  in  animals.  These  included  11 
dogs,  1  cow,  1  horse,  and  1.5  produced  cases  in  rabbits.  Ooe 
case  in  a  human  being,  a  girl  of  8  years,  was  also  studied. 
In  the  animals  10  positive  results  were  obtained  from  the 
plexifonn  ganglia.  In  19  of  21  cases  the  rabic  tubercles  of 
Babes  were  found  in  the  bulb.  The  claims  of  Van  Gehuch- 
ten  with  regard  to  street  virus  are  confirmed,  the  conclusion 
being  that  the  changes  in  the  bulb  and  ganglia,  together  with 
the  clinical  history,  afford  a  rapid  and  certain  evidence  of 
the  existence  of  rabies.  Dr.  W.  M.  L.  Coplin  read  a  paper 
on  Branchial  cysts.  The  literature  of  the  subject  was 
carefully  reviewed  and  a  case  reported. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 

January  12,  1901 : 

Total  mortality 469 

Casks.     Dkathb. 
Inflammation  of  appendix  2.  bladder  2,  brain 
16,   bronchi  8,   kidneys  21.  lunes  53,  peri- 
toneum 6,  pleura  1,  stomach  and  bowels  14, 

spine  1 124 

Inanition  10.  marasmus  9,  debility  3 22 

Tuberculosis  of  lungs 52 

Apoplexy  10,   paralysis  10 30 

Heart— disease  of  43,  fatty  degeneration  of  1, 

neuralgia  of  1 ...  45 

Uremia  14,  diabetes  3,  Brigbt's  disease  7  .   .   .  34 

Casualties  .    .  12 

Carcinoma  of  breast  3,  stomach  3,  uterus  4, 

face  1.  leg  1,  rectam  1,  throat  2 15 

Convulsions 15 

Diphtheria 109  21 

Brain — softening  of  3,  congestion  of  5  ....  # 

Typhoid  fever Ill  7 

Old  age IB 

Burns  and  scalds 8 

Dysentery 4 

Suicide 1 

Cirrhosis  of  liver 2 

Alcoholism 1 

Cyanosis 2 

Scarlet  fever 71  6 

Hernia 2 

Abscess  of  neck  1,  abortion  I,  aneurysm  of 
the  aorta  1,  asthma  1,  anemia  1,  congestion 
of  the  lungs  7.  puerperal  con\'ulsions  2, 
membranous  croup  4,  diarrhea  2.  disease  of 
the  brain  3.  of  the  liver  3,  spine  2.  drowned 
1,  dropsy  of  the  abdomen  1.  heart  2.  chest 
1.  of  the  brain  1,  erysipelas  1,  goiter  1, 
hemorrhage  of  the  lungs  2.  homicide  2,  in- 
fluenza 5,  intestinal  obstniction  1.  poison- 
ing by  strychnin  I.  sarcoma  1,  septicemia  S, 
smallpox  1.  syphilis  1,  tetanus  1.  ulceration 
of  the  stomach  3.  unknown  coroner  case  1, 
whooping  cough  3,  suffocation  1 62 

New  Lay  Board  of  Trustees  for  Medico-Chlrurgl- 

cal  College. — At  a  meeting  held  by  the  Board  of  Trust-eee 
of  the  Medico- Chirurgical  College  and  Hospital.  January  lay 
a  change  was  made  in  the  management  of  these  institutions. 
The  old  board,  consisting  of  Drs.  John  V.  Shoemaker.  Jamee 
M.  Anders,  Ernest  Laplace,  W.  Easterly  Ashton,  L.  Webster  A 
Fox,  William  E.  Hughes,  William  L." Rodman,  Isaac  Ott,  I 
Henry  Fisher.  W.  F.  Haehnlen,  Gei^ree  M.  Boyd,  W.  C.  Hoi-  ■ 
lopeter,  Samuel  Disston,  Esq.,  and  William  King.  E-q.,  n-  f 
signed  after  electing  a  new  Board  of  Trustees.     Under  the 
management  of  the  Iward  just  resigned  the  Medic<vChirurgi- 
cal  College  and  Hospital  in  the  last  20  years  (the  first  couri» 


ll 


jANUiKV   19,   10011 


AMERICAN  NEWS  AND  NOTES 


LThe  Philadklphia 
Mkdical  Jocrnal 


97 


of  lectures  was  given  in  1881)  has  grown  in  importance 
until  today  it  ranks  as  one  of  the  tliree  great  medical  insti- 
tutions of  this  city.  Six  hundred  students  are  in  attendance 
during  the  present  semester.  There  is  a  department  of 
Medicine,  Dentistry  and  Pharmacy,  well  attended  by  students 
from  all  parts  of  the  United  States  and  colonies.  The  selec- 
tion of  a  lay  board  is  a  forward  step  in  the  still  further 
progress  of  the  college  and  will  relieve,  the  professors  who 
have  hitherto  acted  as  trustees  and  managers  of  the  college 
and  hospital.  The  increased  size  of  the  classes  and  the  broad 
policy  adopted  in  teaching  demanded  all  the  time  of  the 
various  instructors,  so  that  it  was  necessary  to  hand  over 
the  business  administration  to  a  lay  board,  who  will  now  be 
conducted  by  Judge  Paxson  and  the  new  members  just 
elected,  and  the  Medico-Chirurgical  College  and  Hospital  will 
continue  to  progress  in  the  future  as  it  has  in  the  past. 
The  following  gentlemen  comprise  the  newly  elected  board  : 
Hon.  Edward  M.  Paxson,  ex-Chief  Justice,  president;  Hon. 
James  P.  Sterrett,  ex  Chief  Justice ;  Hon.  A.  M.  Beitler, 
Judge  of  Court  of  Common  Pleas  ;  Hon.  J.  A.  Logan,  gen- 
eral solicitor  Pennsylvania  Railroad  Company  ;  Pemberton 
S.  Hutchinson,  Esq.,  president  Philadelphia  Saving  Fund ; 
Joseph  L.  Caven,  Esq.,  president  ileal  Estate  Title  Com- 
pany; Henry  D.  Paxson,  Esq.,  attorney-at-law;  David  Milne, 
Esq.,  manufacturer ;  W.  Howard  Pancoast,  Esq.,  banker ; 
Theodore  L.  Voorhees,  first  vice-president  Philadelphia  and 
Heading  Company ;  George  A.  Huhn,  Esq.,  banker  and 
broker;  John  A.  Grady,  attorneyat  law ;  William  King, 
Esq.,  honorary  trustee ;  D.  T.  Pratt,  Esq.,  honorary  trustee. 

NEW  YORK. 

The  Manhattan  Dermatological  Society,  of  New 

York  City,  has  been  organized  with  the  following  list  of 
officers  :  President,  Dr.  William  S.  Gottheil ;  vice-president, 
Dr.  Ludwig  Weiss ;  secretary,  Dr.  Jacob  Sobel. 

Prospective  Medical  Legislation. — Among  t"he 
numerous  bills  relating  to  medicine  that  have  been  intro- 
duced into  the  State  Legislature,  the  most  important  are  the 
ones  regulating  midwifery,  the  protection  of  the  physicians 
and  surgeons  from  blackmail  and  unjust  malpractice  suits, 
and  the  elegibility  of  physicians  to  hold  the  office  of  the  presi- 
dent of  the  Board  of  Health. 

The    Manhattan    Dermatological    Society. — The 

second  regular  meeting  was  held  at  the  residence  of  Dr.  L. 
Weiss,  No.  77  East  Ninety- first  Street,  with  Dr.  Wm.  S.  Gott- 
heil in  the  chair.  Dr.  E.  L.  Cocks  presented  a  case  of 
Lichen  planus  on  a  syphilitic  base.  Dr.  B..  Abrahams 
showed  two  cases  of  ichthyosis  in  children  of  3  and  5 
years  of  age  respectively.  Dr.  J.  Sobel  presented  a  case 
of  pediculosis  pubis  showing  to  a  marked  degree  the 
maculae,  ceruleae,  or  hemorrhagic  macules  due  to  the  bur- 
rowing of  the  crab  louse.  Dr.  Gottheil  showed  an  ex- 
tensive lupus  enythematosus  of  the  face  and  a 
xanthenia  of  the  scalp.  A  case  of  hereditary  syph- 
ilis with  lesions  of  the  tongue  and  lipa  was  also  demon- 
strated by  Dr.  Gottheil.  Dr.  B.  F.  OcHS  presented  a  severe 
case  of  eczema  rubrum  which  had  resisted  all  methods  of 
treatment.  Dr.  Weiss  presented  a  patient  with  scrofulo- 
derma of  the  cheek,  and  a  case  for  diagnosis.  The 
latter  was  either  a  lymphangioma  tuberosa  multiplex,  or 
multiple  subcutaneous  syphilomata,  or  gummata.  A  path- 
ologic examination  of  one  of  the  excised  nodules  by  Joseph, 
of  Berlin,  showed  nothing  but  granulation  tissue.  Aortic 
syphilitic  treatment  did  not  effect  a  permanent  cure.  Dr. 
R.  Abrahams  showed  a  case  of  tuberculosis  cutis,  and 
Dr.  Sobel  a  perforation  of  the  hard  palate,  due  to  a 
neglected  gumma — an  obturator  afforded  great  relief.  Dr. 
•Gottheil  showed  photographs  of  a  'case  of  chromophy- 
tosis  of  the  face  in  a  colored  boy,  the  patches  simulating 
leucoderma,  and  of  pityriasis  versicolor  of  the  palms. 
The  latter  case,  a  rather  unique  one.  was  reported  last  year. 
Dr.  Sobel  demonstrated  the  mechanism  and  use  of 
Allen's  comedo  extractor.  Dr.  Gottheil  presented  a 
case  of  dermatitis  herpetiformis  in  a  boy  of  12,  which 
had  improved  rapidly  under  the  use  of  Fowler's  solution. 

New  York  Neurological  Society. —  Stated  meeting 

held  January  1, 1901.    Frederick  Peterson,  M.D.,  president. 

Spinal   Accessory   Paralysis.  —  Dr.  Pearce  Bailey 


presented  a  man  who  last  March  had  been  operated 
upon  for  suppurating  glands  of  the  neck.  During  the  opera- 
tion the  spinal  accessory  nerve  had  been  cut.  There  had  been 
immediate  and  complex  paralysis  of  the  sternomastoid  and 
trapezius.  About  6  weeks  later  the  nerve  had  been  sutured, 
with  considerable  improvement  in  the  symptoms.  During 
the  past  summer  a  weakness  had  appeared  in  the  deltoid  and 
in  the  muscles  supplied  by  the  musculo-spiral  nerve.  There 
had  been  considerable  return  of  power.  A  fairly  large  inci- 
sion had  been  made  at  the  operation  in  the  region  of  the 
mastoid.  On  inspection,  the  shoulder  on  the  aflected  side 
was  seen  to  droop  and  the  scapula  hung  away  from  the  spine. 
The  only  anesthesia  observed  had  been  limited  to  the  ear 
and  over  the  right  side  of  the  face — an  area  corresponding 
to  the  supply  of  the  great  auricular  nerv«,  which  had 
undoubtedly  been  cut  at  the  same  time.  There  was  now 
marked  hyperesthesia  over  the  distribution  of  this  nerve. 
When  first  seen  the  position  of  the  head  had  been  slightly 
towards  the  injured  side  and  a  little  downward.  Dr.  E.  D. 
Fisher  suggested  that  there  was  a  psychical  element  in  the 
case.  He  said  that  on  pressing  along  the  muscles  of  the 
arm  slowly  there  was  no  reaction,  but  if  done  suddenly  there 
was  a  spasmodic  contraction  of  the  muscles  of  this  region. 
Dr.  Joseph  Collins  did  hot  think  the  whole  condition  had 
been  explained  by  Dr.  Bailey,  for,  in  his  opinion,  there  were 
symptoms  of  root  involvement  over  a  rather  extended  area. 
He  could  not  understand  how  these  could  be  explained  by 
mere  section  of  the  spinal  accessory  nerve.  The  tic  of  the 
facial  muscles  and  on  either  side  of  the  neck,  and  the  nar- 
rowing of  the  palpebral  fissure  appeared  to  be  associated 
with  fibrillary  twitchings.  This  would  indicate  a  rather 
extensive  involvement  of  the  anterior  roots  in  the  cervical 
region.  He  would  also  like  to  know  about  the  condition  of 
the  pupils.  Dr.  F.  Peterson  said  that  he  had  seen  this  case 
before,  and  had  been  interested  in  the  complications.  He 
had  seen  the  man  before  the  appearance  of  the  twitchings, 
and  on  first  noting  the  latter  he  had  been  inclined  to  assume 
that  it  was  hysterical.  However,  after  having  made  the  elec- 
trical examination  he  had  felt  sure  that  it  was  not  hysterical, 
but  a  pressure  palsy  involving  a  number  of  nerves,  possibly 
as  a  result  of  sleeping  with  the  arm  in  an  upward  position. 
Dr.  Bailey  said  that  the  suppurating  gland  had  been  situ- 
ated deeply  underneath  the  sternomastoid.  When  first  seen 
by  him  last  April  there  had  been  a  typical  picture  of  paralysis 
of  the  sternomastoid  and  trapezius,  but  no  symptoms  reter- 
able  to  the  arm,  no  tics  and  no  functional  disorders.  The 
man  had  been  completely  incapacitated  for  work,  and  this 
probably  explained  his  psychical  condition.  The  irritative 
condition  of  the  face  was  probably  explicable  by  the  forma- 
tion of  new  connective  tissue  in  the  scar.  As  soon  as  his 
attention  had  been  called  to  the  pressure  palsy  he  had  been 
watched  at  night  and  prevented  from  sleeping  on  his  arm, 
and  this  had  resulted  in  immediate  and  decided  improve- 
ment. It  was  probable  that  in  time  the  man  would  get 
fairly  good  use  of  his  arm. 

Facial  Hemiatrophy. — Dr.  Max  Mailhouse  presented 
a  man,  20  years  of  age,  without  neurotic  family  history. 
Twenty-two  months  ago  a  discoloration  had  appeared  on  the 
right  side  of  the  face  below  the  lower  lid.  It  bad  begun  as  a 
pale,  depressed  spot.  When  first  seen  by  the  speaker,  the 
right  side  of  the  face  had  been  much  atrophied,  and  the 
beard  had  been  absent  on  this  side.  The  mouth  had  been 
drawn  to  the  right  and  the  right  half  of  the  tongue  very  much 
atrophied.  The  apparent  prominence  of  the  right  eyeball 
was  due  to  retraction  of  the  lower  lid.  The  hair  of  the  right 
half  of  the  scalp  was  grayer  than  on  the  left,  and  was  falling 
out.  He  had  been  losing  his  teeth  on  the  right  side.  The 
nasal  cartilage  was  wasted,  and  its  tip  was  turned  to  the 
riglit.  The  muscles  of  mastication  were  also  atrophied,  and 
this  was  associated  with  spasmodic  pain.  There  was  a  fibril- 
lary tremor  of  the  large  muscles.  The  affected  muscles 
reacted  feebly  to  faradization,  and  normally  to  galvanism. 
No  scleroderma  was  found.  For  the  past  two  months  there 
had  been  twitcliing  of  the  muscles  on  the  right  angle  of  the 
mouth,  and  at  times  after  laughing,  this  angle  would  remain 
retracted.  At  such  times  there  was  a  very  tender  spot  in 
front  of  the  ear.  A  blow  of  moderate  severity  had  been  re- 
ceived over  the  mouth  10  years  ago.  No  other  etiologic 
element  could  be  elicited,  and  even  this  one  seemed  to  have 
but  little  weight.  The  atrophy  of  the  tongue  seemed  to  be  a 
strong  argument  for  the  theory  that  this  affection  is  a  tropho- 


98 


The  Philadelphia 
Medical  Journal 


] 


AMERICAN  NEWS  AND  NOTES 


[Jaboakt  19,  ISOl 


neurosis.  De.  C.  L.  Dana  said  that  he  had  met  with  several 
such  cases,  and  had  found  them  all  quite  obscure.  At  one 
time  the  view  had  prevailed  that  it  was  a  trophoneurosis 
due  to  some  lesion  of  the  trophic  root — a  condition  very 
difficult  to  understand.  In  one  of  his  cases  there  had  been  a 
typical  diffuse  trigeminal  neuritis  occurring  in  a  woman  of 
about  40  years.  The  attack  had  begun  with  herpes  and 
neuralgia,  and  had  been  followed  by  a  general  neuralgia  in 
the  course  of  the  fifth  nerve.  After  this  there  had  been 
atrophy  and  some  anesthesia,  and  finally  a  peculiar  pitting 
of  the  face,  like  that  from  smallpox.  In  another  case,  the 
trouble  had  begun,  as  it  often  did,  with  pigmented  spots  and 
neuralgia,  and  this  had  been  followed  by  anesthesia  in  spots 
and  a  typical  progressive  anesthesia  involving  all  the  tissues, 
including  the  masseter  muscle  and  the  bone.  In  this  woman 
there  had  been  deafness  and  some  disturbance  of  vision  on 
the  affected  side.  It  was  difficult  to  understand  how  a  trophic 
or  central  lesion  could  cause  all  these  symptoms.  A  herpes 
was  almost  always  a  sign  of  peripheral  trouble.  Another 
case  had  been  in  a  woman,  who  had  married  at  the  age  of 
17.  Her  husband  had  died,  it  was  said,  of  syphilis  a  few 
years  later,  though  the  woman  denied  ever  having  become 
infected.  She  had  a  progressive  iacial  hemiatrophy  for  a 
number  of  years,  and  had  finally  developed  atrophy  on  the 
same  side,  affecting  the  arm  and  the  leg.  In  none  of  his 
cases  had  there  been  anything  indicating  the  true  nature  of 
the  etiology.  Perhaps  the  best  explanation  was  that  of  a 
peripheral  lesion  as  a  starting  point.  He  had  obtained  no 
definite  results  from  treatment,  perhaps  because  he  had  not 
been  able  to  keep  these  cases  under  treatment  for  a  sufficient 
length  of  time.  If  the  trouble  were  peripheral,  Dercum's 
idea  of  resecting  the  trigeminus  seemed  to  be  worthy  of  con- 
sideration. De.  Fkaenkel  asked  if  any  difference  had  been 
observed  in  the  behavior  of  the  sweat  glands  on  both  sides 
of  the  face.  De.  Mailhouse  replied  that  there  had  been  less 
sweating  on  the  affected  side.  Dk.  Joseph  Collins  thought 
the  disease  could  be  explained  just  as  well  by  a  central  as 
by  a  local  lesion.  He  was  inclined  to  think  that  the  patient 
just  presented  had  a  lesion  in  the  pons,  in  the  area  of  central 
representation  of  the  sympathetic  nervous  system  in  the 
pons.  The  lesion  was  probably  a  slowly  progressive  one 
such  as  a  gliomatosis.  There  already  seemed  to  be  involve- 
ment of  the  motor  nuclei  in  the  medulla  oblongata.  The 
enlargement  of  the  pupil  would  be  explained  by  an  irrita- 
tion of  the  sympathetic  which  had  gone  on  to  paralytic 
effects. 

Progressive  Lingual  Hemiatrophy.— De.  C.  L.  Dana 
presented  in  connection  with  the  last  case  a  rather  rare  form 
of  progressive  lingual  hemiatrophy.  It  occurred  in  a  man, 
26  years  of  age,  who  had  had  the  trouble  3  years,  but  had 
been  otherwise  in  perfect  health.  The  half  of  the  tongue 
was  slightly  wasting  away,  and  this  was  associated  with 
fibrillary  twitchings.  The  patient  was  a  healthy  young  medi- 
cal student  without  history  of  syphilitic  infection  or  nervous 
heredity.  It  did  not  seem  to  him  necessary  to  suppose  that 
there  was  a  gliosis,  for  Mendel  had  already  shown  that  there 
is  a  change  in  the  motor  root  of  the  trigeminus.  Of  course, 
these  changes  might  be  secondary  to  degeneration  and  par- 
tial destruction  of  the  nerve.  De.  Peteeson  said  he  was  in- 
clined to  believe  with  Dr.  Collins,  that  some  central  lesion 
would  best  explain  the  condition.  He  had  seen  several 
cases,  but  all  of  them  in  a  much  earlier  stage.  In  none  of 
them  had  the  tongue  or  the  muscles  of  mastication  been  in- 
volved, or  had  they  presented  the  same  pupillary  phenomena. 
De.  Mailhouse  thought  the  dilation  of  the  pupil  might  be 
explained  by  a  similar  process  involving  the  sphincter 
pupillae  and  causing  weakness.  Hoffmann  had  reported 
some  improvement  from  the  use  of  galvanism  for  half  an 
hour  daily. 

NEW  ENGLAND. 

Dr.  Burt  Andrews,  son  of  Judge  A.  G.  Andrews,  of 
the  Augusta  Municipal  Court,  died  January  12,  aged  32  years. 

The  Boston  Society  for  Medical  Improvement 

will  hold  its  first  meeting  in  the  new  Library  Building  on 
Monday,  January  21. 

Boston  Medical  Library. — The  new  library  building 
was  formally  opened  on  the  evening  of  January  12,  by  Dr. 
David  W.  Cheever,  president.  The  library  has  now  over 
32  000  volumes. 


Harvard  Veterinary  Medical  Alumni  Associa- 
tion.— At  the  dinner  at  the  Parker  House,  Boston,  on  Jana- 
uary  8,  the  officers  elected  for  the  ensuing  year  were :  Presi- 
dent, Dr.  L.  Frothingham,  of  Boston  ;  vice  presidents.  Dr. 
L.  L.  Weeks,  of  Falmouth,  Dr.  W.  E.  Peterson,  of  Waltham, 
Dr.  P.  J.  Crown,  of  Boston;  secretary  and  treasurer,  Dr.  EL 
W.  Babson,  of  Gloucester ;  Council,  for  3  years.  Dr.  G.  B.  Foae, 
of  this  city,  and  Dr.  E.  A.  Madden.  S 

CHICAGO  AND  WESTERN  STATES.  " 

Epidemic  of  Typhoid. — Seventy-two  cases  of  typhoid 
fever  are  reported  to  the  Board  of  Health  of  Ashland,  Wis. 

Smallpox  in  Kansas. — Dr.  W.  B.  Swan,  of  the  State 
Board  of  Health,  reports  267  cases  of  smallpox  in  the  State.. 
The  type  of  the  disease  is  more  severe  than   it  was  laafe. 
winter.  '' 

Dr.  John  M.  Gaston,  who  for  more  than  half  a  cen- 
tury stood  high  in  the  medical  profession  of  IndianapoliB, 
Ind.,  died  January  10,  aged  82.  He  was  one  of  the  organizers 
of  the  Marion  County  (Ind.)  Medical  Society. 

Crusade  of  Vaccination. — A  crusade  of  vaccination, 

against  smallpox  was  carried  on  vigorously  at  Kansas  City. 
January  8.  Doctors  invaded  many  large  office  buildings  and 
places  where  people  congregate  in  large  numbers,  and  vacci- 
nated people  by  the  dozen. 

Grip  Epidemic  in  Chicago. — According  to  estimates 
made  by  ptiysicians  on  January  9,  there  are  100,000  cases  of 
grip  in  Chicago  at  present.  The  last  epidemic  of  grip  in  this 
city,  together  with  impure  water  diseases,  increased  the 
death-rate  from  21,869  in  1890,  to  27,751  in  the  epidemic 
year  of  1891 . 

Smallpox  in  Missouri. — At  a  meeting  of  the  Camden 

City  Board  of  Health,  January  6,  Dr.  S.  C.  James,  resident 
member  of  the  State  Board  of  Health,  said  that  there  are 
cases  of  smallpox  in  over  100  towns  of  Missouri,  and  that  the 
most  vigorous  quarantine  measures  have  failed  to  stop  the 
spread  of  the  disease.  New  cases  are  being  daily  discovered, 
but  the  smallpox  existing  in  Kansas  City  is  not  of  a  virulent 
form,  and  few  deaths  are  expected  to  result  from  it. 

Hospital  to  be  Independent. — At  the  seventh  annual 
meeting  of  the  Norwegian  Tabiiha  Hospital  society  reports 
submitted  showed  that  the  hospital  days  for  the  ye^r  were 
12,034,  and  the  total  expenditures  $12,402.69.  A  proposi- 
tion to  put  the  institution  uuder  the  management  of  one  of 
the  Norwegian  church  societies  was  rejected,  and  patients 
will  be  received  and  treated  as  heretofore,  irrespective  of 
creed  or  nationality.  Toe  hospital  officers  are :  Chief  sur- 
geons, Dr.  C.  Fenger  and  Dr.  A.  Hemboe;  president.  Dr.  K. 
Sandberg ;  secretary,  H.  Rommen ;  treasurer,  H.  A.  Haugan. 

Mosquito  Blamed  for  Yellow  Fever.— The  Ameri- 
can Commission  in  Havana,  under  the  superintendence  of 
Dr.  Reed,  which  has  been  making  experiments  at  Qaemados 
as  to  the  propagation  of  the  yellow  fever  germs  by  the  mos- 
quito, has  obtained  extremely  satisfactorj-  results.    Dr.  Reed 
says  the  experiments  showed  beyond  a  doubt  that  there  is 
no  contagion  from  an  infected  person  or  from  infected  cloth- 
ing, but  that  the  mosquitoes  alone  are  responsible  for  the 
spread  of  the  disease.    In  the  course  of  the  commission's 
investigations  six  non-immune  persons  were  infected  direct 
by  the  bite  of  mosquitoes  which  had  previously  bitten  ye 
fever  patients,  and  five  of  these  developed  yellow  fever. 
last  experiment  made  proved  conclusively.  Dr.  Reed  > 
tends,  the  theory  of  propagation  by  raofquitos.     A  sp' 
building  was  constructed  of  disinfected  material,  and  oir 
the  rooms  was  divided  into  two  sections  by  a  wire  mosq  . 
screen.    In  one  section  were  placed  disinfected  bedding  a^d 
clothing,  and  in  the  other  bedding  and  clothing  from  the-' 
yellow  fever  hospital  which  had  not  been  disinfected.    Two  '  1 
non-immunes  occupied  the  two  sections.    In  the  former  were 
put  several  infected  mosquitoe?.    The  patient  remained  in 
this  room  only  long  enougti  to  be  bitten,  and  in  four  dav-  s 
pronounced  case  of  yellow  fever  developed.     The  paiiem  .> 
now  convalescing.    The  other  subject  slept  in  the  infected 
bedding  for  many  nights  ana  has  not  contracted  the  fever. 
Both  patients  have  been  sleeping  for  20  nights  in  garments 


JANDABY  19,  1901] 


AMERICAN  NEWS  AND  NOTES 


["The  Philadelphia 
L  Mkdical  Journal 


99 


worn  by  yellow  fever  victims  and  in  bedding  from  the  yellow 
fever  hospital.  Dr.  Reed  says  they  are  growing  fat,  and  that 
in  no  instance  in  the  course  of  the  commission's  investiga- 
tions has  a  case  of  yellow  fever  developed  from  exposure  to 
infected  bedding  or  clothing. 

SOUTHERN  STATES. 

Smallpox  in  Galveston. — Smallpox  has  broken  out  to 
a  considerable  extent  in  Galveston.  The  authorities  have 
ordered  that  every  person  in  the  city  should  be  vaccinated. 

Dr.  A.  B.  Richardson  has  been  elected  to  fill  the 
vacancy  in  the  chair  of  mental  diseases  of  the  Columbian 
Medical  School  at  Washington,  caused  by  the  resignation  of 
Dr.  Foster. 

Seven  Thousand  Grip  Gases. — Health  authorities 
state  that  there  are  now  7,000  cases  of  grip  in  Fort  Worth, 
Texas.  Smallpox  is  also  prevailing  in  that  city  to  an  alarm- 
ing extent. 

Death  of  Dr.  Harris. — Dr.  Charles  Morris  Bainbridge 
Harris,  son  of  the  late  Dr.  Thomas  Harris,  U.  S.  N.,  died  Jan- 
uary 8,  at  his  residence,  1917  Kalorama  Ave.,  Washington, 
D,  C,  aged  73. 

Savannah  Hospital. — By  the  will  of  Dr.  William  Dun- 
can, of  Savannah,  Ga.,  who  died  recently,  the  Savannah 
Hospital  will  become  a  beneficiary  of  nearly  one-half  of  his 
estate,  which  is  valued  at  about  $80,000. 

Dr.  W.  J.  Humphreys,  assistant  instructor  in  physics 
at  the  University  of  Virginia,  is  to  be  one  of  the  party  of 
scientists  to  be  sent  by  the  Naval  Observatory  to  Sumatra  to 
observe  the  eclipse  of  the  sun  on  May  18. 

Smallpox  at  Fredericksburg^,  Va. —  Suspicion  of 
smallpox  in  the  adjoining  county  of  Louisa  has  led  the 
County  Board  of  Health  to  order  that  the  public  schools  of 
Green  Springs  and  Louisa  Court  House  districts  be  closed. 

Dr.  David  Caldvrell  Ireland,  a  well-known  physician, 
died  suddenly  January  14,  at  his  home  in  Baltimore.  Dr. 
Ireland  was  born  at  Annapolis,  Md.,  57  years  ago.  He  grad- 
uated from  the  University  of  Pennsylvania  in  1867.  He  was 
president  of  the  Pension  Board  No.  1,  and  of  the  Medical 
and  Chirurgical  Faculty  of  Maryland. 

Springy  Grove  Hospital. — The  annual  report  of  the 
Board  of  Managers  of  the  Maryland  Hospital  for  the  Insane 
{Spring  Grove)  shows  that  the  total  number  of  patients  was 
626.  Of  these  18  were  discharged  as  recovered,  15  discharged 
as  improved,  41  discharged  as  unimproved,  and  42  died. 
The  number  remaining  October  31,  1900,  was  510. 

Presbyterian  Hospital's  "Work. — At  the  annual  meet- 
ing of  the  board  of  governors  of  the  Presbyterian  Eye,  Ear, 
and  Throat  Hospital  of  Baltimore,  January  12,  the  following 
officers  were  elected  :  President,  W.  W.  Spence  ;  vice-presi- 
dents, J.  P.  Ammidon,  R.  M.  Wylie,  Dr.  D.  C.  Oilman,  Thos. 
B.  Gresham ;  secretary.  Dr.  F.  M.  Chisolm ;  treasurer,  John 
L.  Reed. 

Maryland  State  Board  of  Health. — The  Board  held 
its  annual  meeting  January  10.  The  following  ofiicers  were 
elected  :  President,  Dr.  W.  H.  Welch  ;  chemist,  Dr.  William 
B.  D.  Penniman  ;  bacteriologist.  Dr.  William  R.  Stokes ;  in- 
spector, Charles  M.  Mitten ;  clerk,  M.  L.  Rullman ;  labora- 
tory assistant,  E.  M.  White;  clerk  of  vital  statistics,  E.  M. 
Rullman.  Dr.  W.  H.  Welch,  Dr.  James  Bosley,  and  Dr.  J.  B. 
Noel  Wyatt  were  appointed  members  of  the  executive  com- 
mittee. 

Central  Texas  Medical  Officers. — The  Texas  Central 
Medical  Association  closed  its  fifteenth  annual  convention 
January  9.  The  following  officers  were  elected  for  the  ensu- 
ing year :  President,  N.  A.  Oliver,  Waco ;  first  vice-presi- 
dent, E.  D.  Capps,  Fort  Worth  ;  second  vice-president,  W.  B. 
Anderson,  Brownwood  ;  secretary- treasurer,  W.  R.  Thomp- 
son, Fort  Worth.  New  members  of  judicial  council :  W.  C. 
Blalock,  Kosse;  and  B.  W.  D.  Hill,  Dawson.  The  next 
meeting  will  be  held  at  Temple. 


Medical  Society  of  City  Hospital  Alumni  of  St. 

Louis. — The  society  met  in  the  rooms  of  the  board  of  edu- 
cation, 9th  and  Locust  streets,  on  Thursday,  January  17,  at 
8  o'clock  P.M.  The  following  papers  were  presented  :  Re- 
port of  a  case  of  articular  rheumatism  with  fatal 
heartcomplicationsinachild,  by  Dr.  Hudson Talbott  ; 
Points  of  interest  gathered  from  some  Eastern 
Hospital,  by  Dr.  F.  G.  Nifong  ;  Report  of  cases  of  in- 
fectious disease  of  kidney  (postponed  from  January  3), 
by  Dr.  H.  W.  Sopbr. 

Richmond  (Va.)  News.  —  Smallpox  is  at  present  epi- 
demic in  many  counties  in  this  State.  As  a  usual  thing,  the 
cases  are  of  a  mild  type  and  the  death-rate  has  been  remark- 
ably low.  There  are  at  present  11  cases  in  the  smallpox 
hospital  of  this  city. 

At  the  first  meeting  of  the  Academy  of  Medicine  and 
Surgery  this  year,  the  following  ofiicers  were  installed : 
Dr.  Stuart  McGuire,  president ;  Drs.  W.  J.  Mercer,  W.  R. 
Robins  and  J.  M.  Winfree,  vice-presidents;  Dr.  M.  W. 
Peyser,  secretary ;  Dr.  W.  J.  Moseley,  treasurer. 

Death  of  Dr.  Abrani  Claude. — Dr.  Abram  Claude 
died  in  Annapolis,  Md.,  on  January  10.  Dr.  Claude  was  born 
in  Annapolis  on  December  4, 1818.  He  was  the  son  of  Dr. 
Dennis  Claude,  at  one  time  surgeon  in  the  United  States 
Army,  and  was  mayor  of  Annapolis  in  1849,  1850,  and  1867. 
During  the  war  Dr.  Claude  was  assistant  surgeon  in  the  United 
States  Army  ;  professor  of  natural  science  in  St.  John's  Col- 
lege from  1871  to  1883.  The  deceased  was  a  graduate  of  St. 
John's  College  and  of  the  University  of  Pennsylvania.  He 
was  a  man  of  much  learning,  great  polish,  refinement,  and 
invincible  courage  of  conviction. 

Laws  Wanted  by  Medical  Men. — At  the  meeting  of 
the  St.  Louis  Medical  Society  last  night  a  resolution  was  in- 
troduced to  appropriate  $250  to  aid  the  committee  on  legisla- 
tion of  the  Missouri  Medical  Society  in  promoting  whatever 
measures  the  committee  decides  to  present  to  the  Legislature 
at  the  present  session.  The  committee  was  appointed  at  the 
last  session  of  the  Missouri  Medical  Society  to  try  to  secure 
certain  legislation  in  favor  of  the  medical  profession.  One 
of  its  measures  is  a  law  requiring  applicants  to  pass  an  ex- 
amination before  being  registered  to  practise  medicine.  The 
society  is  also  urging  measures  calculated  to  eliminate  poli- 
tics from  the  Missouri  Medical  Society.  The  resolution  will 
probably  not  be  acted  upon  until  the  next  meeting,  on 
January  26. 

The  Johns  Hopkins  Hospital  Medical  Society.— 

The  meeting  of  January  7,  1901,  was  called  to  order  by  the 
president.  Dr.  W.  H.  Welch. 
Typhoid  fever  without  intestinal  lesions,  by  Db. 

Opie  and  Mr.  Bassett.  Dr.  Opie  stated  that  there  are  a 
certain  number  of  cases  of  typhoid  fever  reported  in  which 
no  lesions  have  been  found  at  autopsy  in  either  the  large  or 
small  intestine,  and  that  very  recently  a  case  had  come  under 
his  observation  which  belonged  apparently  to  this  group. 
The  patient  was  a  child,  10  years  of  age,  with  a  good  family 
and  personal  history.  'The  illness  began  5  days  before  admis- 
sion to  the  hospital,  the  first  symptoms  being  headache  and 
backache.  There  were  several  movements  of  the  bowels 
accompanied  with  pain  in  the  abdomen,  and  on  the  following 
day  she  felt  feverish.  On  admission  to  the  hospital,  temper- 
ature was  102.4°,  there  were  typical  rose-spots  on  the  abdo- 
men and  the  agglutination  test  was  positive  when  the  blood- 
serum  was  diluted  1 :  5.  The  disease  appeared  to  be  mild  and 
the  temperature  ranged  from  102°  to  104°  during  the  first 
week.  On  the  thirteenth  day  after  admission  nose-bleeding 
first  began  and  purpuric  spots  appeared  on  the  face.  The 
coagulation  time  of  the  blood,  tested  with  Wright's  capillary 
tubes,  was  4J  minutes.  The  bleeding  was  difficult  to  control 
at  times,  and  on  the  night  of  the  seventeeth  day  after  admis- 
sion she  passed  60  cc.  of  bright-red  blood  from  the  rectum. 
A  blood-test  the  next  day  showed  2,256,000  red  corpuscles, 
3,000  white  corpuscles,  and  41 /»  of  hemoglobin.  Two  days 
later  purpuric  spots  appeared  over  the  face,  neck,  front  and 
back  of  the  chest  and  posterior  surfaces  of  the  arms.  On  the 
twenty- first  day  bleeding  began  again  from  the  nose  and  it 
was  found  impossible  to  control  it.  The  red  corpuscles  then 
numbered  1,700,000,  leukocytes  15,000.  hemoglobm  26%,  and 
the  coagulation  time  was  5}  minutes.  She  died  that  day,  which 


100 


The  Philadelphia"! 
Medical  Joobkal  J 


AMERICAN  NEWS  AND  NOTES 


[Jascabt  19,  ISW 


was  the  twenty-sixth  day  of  her  illness.  At  the  autopsy  nu- 
merous minute  ecchymotic  areas  were  found  in  the  heart- 
muscle,  in  the  lungs,  liver,  kidneys,  and  stomach.  The  small 
intestine  contained  a  brownish-red  fluid,  and  Peyer's  patches 
were  evident  in  the  lower  part  of  the  jejunum  and  through- 
out the  ileum.  The  solitary  follicles  of  the  large  intestine 
were  visible  and  marked  by  minute  points  of  pigmentation. 
The  retroperitoneal  glands  and  the  lymph  glands  of  the  mes- 
entery were  enlarged.  Microscopic  examination  of  the  liver 
showed  foci  of  necrosis  similar  to  those  usually  found  in 
typhoid  fever  and  in  these  areas  were  evidences  of  cell-infil- 
tration. Sections  were  made  through  several  Peyer's  patches 
and  while  there  was  no  evident  hyperplasia  some  sections 
did  show  groups  of  large  epithelioid  cells  similar  to  those  so 
constantly  found  in  typhoid  lesions.  Cultures  were  made 
from  the  various  organs  and  the  colon-bacillus  obtained  from 
the  liver  and  kidneys,  and  from  the  liver,  gallbladder  and 
kidneys  a  motile  bacillus  was  obtained  which  agreed  in  all 
respects,  when  tested  experimentally,  with  a  stock  culture  of 
the  typhoid  organism.  Notwithstanding  the  fact  that  the 
lesions  of  the  intestine  were  so  slight  as  to  be  hardly  recog- 
nizable, and  of  such  a  nature  that  they  might  readily  have 
been  overlooked,  Dr.  Opie  thought  there  could  be  no  doubt 
that  this  was  a  case  of  hemorrhagic  typhoid.  The  hemor- 
rhage from  the  intestines  was  apparently  not  due  to  ulcera- 
tion, for  no  microscopic  lesions  in  the  mucosa  were  noted ;  it 
probably  was  the  result  of  oozing  from  the  mucous  membrane 
of  the  stomach  where  there  were  numerous  ecchymoses.  Dr. 
Opie  presented  a  critical  review  of  all  the  reported  cases  of 
supposed  typhoid  without  intestinal  lesions  and  said  that  he 
could  find  no  conclusive  proof  that  the  infection  could  occur 
without  some  slight  lesion  of  the  intestinal  tract. 

Dr.  FrxcHEE,  in  discussion,  said  that  this  was  the  second 
case  of  hemorrhagic  typhoid  which  had  been  seen  at  the 
Hopkins  Hospital  where  over  1,000  cases  of  this  disease  have 
now  been  treated.  The  first  case  recovered,  but  the  second 
illustrated  very  well  the  hopelessness  of  endeavoring  to  coun- 
teract the  tendency  to  bleeding  in  those  cases  where  a  hemor- 
rhagic diathesis  occurs.  All  the  usual  methods  adopted  to 
stop  bleeding  were  tried  on  this  patient,  including  the  use  of 
suprarenal  extract,  but  without  satisfactory  results.  Dr. 
Welch  remarked  that  there  was  no  question  that  cases  of 
typhoid  fever  could  occur  without  ulceration  of  the  intes- 
tines and  referred  to  the  clinical  history  of  some  mild  cases 
which  would  lead  one  to  suspect  an  infiltration  of  Peyer's 
patches  and  the  solitary  follicles  without  actual  ulceration. 
He  also  referred  to  a  group  of  cases  in  which  death  occurs 
late  in  the  disease  and  when  one  might  readily  suppose  that 
the  typhoid  lesions  had  healed.  He  believed  that  a  less 
careful  pathological  study  than  that  made  by  Dr.  Opie  and 
Mr.  Bassett  would  have  led  to  the  report  of  such  a  case  as 
theirs  as  one  entirely  without  intestinal  lesions. 

Report  Upon  Bacillus  Mortiferous.— Dr.  Harris 
related  the  discovery  of  this  new  organism  and  described  its 
peculiarities.  The  clinical  history  of  the  case  fi-om  which 
the  organism  was  isolated  was  practically  that  which  accom- 
panies a  liver  abscess  and  at  the  operation  the  liver  was 
found  to  be  very  much  enlarged  and  to  present  upon  its  sur- 
face numerous  thin- walled  abscesses.  From  the  pus  of  one 
of  these  abscesses  this  new  bacillus  was  obtained.  It  is  very 
minute  and  is  cultivated  with  very  great  difficulty,  growing 
only  on  media  containing  as  a  basis,  blood,  blood-serum  or 
hydrocele  fluid,  and  then  only  anaerobically.  Experimental 
work  on  animals  showed  that  the  organism  was  quite  viru- 
lent, rabbits  usually  succumbing  withm  6  days.  The  lesions 
were  always  emaciation,  loss  of  subcutaneous  fat,  a  tremen- 
dous degree  of  peritonitis  and  multiple  abscesses  of  the  liver. 

CANADA. 

Dr.  Thomas  Brown  Wheeler,  a  prominent  physician 
of  Montreal,  died  suddenly  on  January  11  in  the  Murray  Hill 
Hotel,  New  York  City. 

MISCELLANY. 

Obituary.— Dk.  Francis  G.  Connelly,  aged  SO,  at  Balti- 
more. 

Grip  in  New  York  City.— From  December  to  March, 
1900,  there  were  5,000  deaths  from  grip. 


Reception  to  Explorer.- Dr.  A.  Donaldson  Smith,  the 
Philadelphian  whose  African  explorations  have  gained  him 
renown,  was  the  guest  of  honor  at  a  reception  held  January 
9,  at  the  Academy  of  Natural  Sciences. 

Influenza. — It  is  estimated  that  there  are  probably 
500,000  cases  of  influenza  in  Greater  New  York,  7,000  in  the 
city  of  New  Haven,  with  a  total  of  40,000  in  Connecticut. 
Conservative  estimates  by  the  Buffalo  officials  place  the 
number  of  cases  at  5,000.  St.  Louis  reports  10,000  cases.  It 
is  estimated  that  1,500  employes  of  the  great  steel  company 
at  Homestead,  Pa.,  are  afflicted  with  influenza. 

Medical  Congress  in  Cuba. — Active  preparations  are 
making  for  the  third  Pan-American  Medical  Congress  to  be 
held  in  Havana,  Cuba,  February  4  to  6.  It  is  expected  that 
there  will  be  1,500  delegates  present,  of  whom  500  wQl  be 
Cuban  physicians,  300  or  400  Americans,  300  Mexicans,  and 
others  from  Argentine,  Uruguay,  Brazil,  Venezuela,  Co- 
lombia, Peru,  Chili,  and  other  Central  and  South  American 
countries. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague,  have  been  reported  to 
the  Surgeon-General  U.  S.  Marine- Hospital  Service,  during 
the  week  ended  January  11, 1901 : 

Smallpox— United  States. 

Cases.       Deatbi.. 


i 


Alabama: 

District  of 

Columbia  : 
Flobida  : 

Georgia: 
Ka>sa8  : 
Kestcckt  : 
LonsiAKA : 
Mabtlaitd: 

MiSNESOTA  : 
N'EBRAiKA  : 

N.  Hampshire: 
New  York  : 
N.  Carolina  : 
Ohio: 


Piknbtlyasia  : 

S.  Carolina  : 
Tennessee  : 
Utah  : 
Washington  : 


At:sTRiA : 
British 

Columbia 

England  : 

France  : 
India  : 


Rt^sbia: 

Scotland  : 
Uruguay : 


Columbia: 
Cuba  : 

Mexico: 


Oirard  .    .   . 
Phoenix    .   . 

Washington 
Jacksonville 
West  Tampa 
Colambus    . 
Wichita 
Ijexington   . 
Shreveport . 
Baltimore   . 
Minneapolis 
Omaha  .    .  . 
Manchester 
New  York  . 
Caswell  Co. 
Ashtabula  . 
Cincinnati  . 
Cleveland    . 
Portsmouth 
Allegheny  City 
Pittsburg . 
Greenville 
Memphis  . 
Salt  Lake  City 
Tacoma    .   .  . 


Smallpox— Foreign. 
Prague Dec.  6-15  . 


Dec.  31 

Reported 

Dec.  29-Jan.  5    . 

6 

Dec  29-Jan.  5    . 

1 

Dec.  29-Jan.  5    . 

o 

Dec.  31 

Reported 

Dec.  29-Jan.  5   . 

12 

Dec.  29-Jan.  7    . 

"> 

Jan. 2    

2 

Dec.  9-Jan.  5  .   . 

1 

Dec.  22-29    .    .   . 

3 

Dec.  22-29    .    .    . 

6 

Dec.  29-Jan.  5    . 

18 

Dec.  29-Jan.  5   . 

13 

Dec.  1-31  ...   . 

ti 

Dec.  29-Jan.  5   . 

1 

Jan. 4    

1 

Dec.  29-Jan.  5   . 

39           1 

Jan. 5    

3 

Jan. 7    

1 

Dec.  29-Jan.  5   . 

11 

Dec.  29 

1 

Dec.  29-Jan.  5   . 

2 

Dec.  29-Jan.  5   . 

4 

Dec.  29 

1 

Nanaimo  .... 
Vancouver  .  .  . 
London  .... 
West.Liverpool . 

Paris 

Bombay  .... 
Calcutta  .  .  .  . 
Madras  .  .  .  . 
Moscow    .   .  .   . 

Odessa 

Glasgow  .... 
Montevideo    .   . 


Dec.  15-21  .  . 
Dec.  1-31  .  .  . 
Dec. 15-22  .  . 
Dec.  9-13  .  .  . 
Dec.  15-22 
Nov.  21-Dec.  4 
Nov.  24-Dec.  1 
Nov.  23-30  .  . 
Dec. 29-Jan. 5 
Dec.  S-15  .  .  . 
Dec- 15-22  .  . 
Dec.  1    .   .  .   . 


22 


6 
41 


Yellow  Fever.. 

Cartagena  .  .  .  Dec.  17  .  . 
Cienfuegos  .  .  .  Jan.  S  .  . 
Matanzas  ....  Jan.  3  .  . 
Vera  Cruz    .   .   .  Dec.  22-29 


Cholera. 

India  :  Bombay   ....  Deo.  4    .   . 

■'  Calcutta   ....  Dec.  1    .   . 

Madras Nov.  30  .   . 

Straits 

Settlements  :  Singapore    .   .   .  Nov.  17-24 


Plaque. 
China  :  Hongkong  .   .   .  Nov.  25  . 

India  :  Bombay   ....  Nov.  4  . 

Calcutta    ....  Dec.  1    . 

Japan  :  Osaka Dec.  4-13 

"                         Wakayama  Ken  Dec  4-13 
Yuasa Dec  4-13 


S 
1 

i 

1 

1 

10 

1 


10 

S3 

3 

24 


1 
23 


Reported. 


Jandasv  in,  1901] 


AMERICAN  NEWS  AND  NOTES 


CThk  Philadelphia 
Medical  Journal 


101 


'  Hospital  Ship  for  the  Philippines.— Army  oflScers 
have  been  sent  from  Manila  to  Hong  Kong  to  negotiate  the 
purchase  of  a  suitable  vessel  for  use  among  the  Philippine 
Islands  for  hospital  purposes.  The  hospital  ehip  Relief, 
which  is  being  used  between  some  of  the  ports  of  the  islands, 
is  unable  to  enter  all  of  the  ports,  and  it  is  the  desire  of  the 
Army  authorities  to  secure  a  smaller  vessel  which  can  enter 
the  shallow  harbors. 

Third  Pan-American  Medical  Congress.— The  fol- 
lowing is  a  partial  list  of  titles  of  papers  to  be  presented  at 
the  Third  Pan-American   Medical  Congress,  to  be  held  at 
Havana,  Cuba,  February  4, 1901 : 
SiTtion  on  Medicine.— President,  Dr.  Carlos  Finlay  ;  secretary,  Dr. 
,      Judson  Daland,  317  S.  18th  street,  Philadelphia,   Pa.     Etiology,  by 
'      Dr.  Elmer  Lee,  New  York  ;  Physical  Diagnosis,  by  W.  H.  Vanden- 
'      barg.   New  York;    Remarks  on  Tuberculosis,   by  Dr.  Liston    H. 
Montgomery,  Chicago ;   Tuberculosis  in   Man   and  Beasl,   by  Dr. 
John  A..  Kelley,  Brooklyn. 
Section  on  General  .Surgerv.— President,  Dr.  Tomas  Plascencia ;  sec- 
■      retary.  Dr.  W.  P.  Nicholson,  Atlanta,  Ga.    Operative  Treatment  of 
1      Prostatic  Hypertrophy,  by  Dr.  Ramon  Guiteras,  New  York :  The 
i      Bearing  of  Local  Leukocytosis  in   Surgery,  by  Dr.  E.  T.  Morris, 
!      New  York ;  Gangrenous  Hernia,  by  Dr.  T.  H.  Manley,  New  York  ; 
Treatment  of  Varicose  Ulcers,  by  Dr.  J.   Medina,  New  Y'ork ;  Co- 
cain  Spinal  Anesthesia,  by  Dr.  G.  R.  Fowler,  New  York;  The  Pro- 
<      nated  foot  and  Its  EtTect   upon    the  Knee-joint,  by  Dr.  Michael 
i      Hoi)e,  Atlanta,  Ga.;  Surgical  Intervention  in  Uterine   Fibroids,  by 
I      Dr.  A.  Vander  Veer,  Albany.  N.  Y.;  Remarks  upon  Postoperative 
Psychical  Disturbances,  by  Dr.  G.  Tucker  Harrison,  New  York  ; 
Knee-joint  Tuberculosis  Differentiation  in  the  Young  and  Adult,  by 
Dr  J.  D.  Griffith,  Kansas  City;  Operative  Treatment  of  Inguinal 
Hernia,  by  Dr.   A.   M.  Phelps,  New   York  ;  Some  of  the  General 
Conditions  and  Features  of  Disability  Attributable  to  Personal  Ac- 
cidental   Injury,  as  well  as    Disabihty  Due   to  Disease   following 
Bodily  Injury,  by  Dr.  L.  H.  Montgomery,  Chicago,  111.;  Remarks  on 
;      Inguinal  Hernia,  by  Dr.  Garmo. 

Section  on  Obstetrics.— President,  Dr.  Eusebio  Hernandez;  secre- 
tary. Dr.  Gustav  Zinke,  13  Garfield  Place,  Cincinnati,  Ohio.  The 
Toxicity  of  the  Urine  in  Pregnancy  and  Its  Relation  to  Puerperal 
Convulsions,  by  Dr.  Milton  J.  Duff,  Pittsburg,  Pa.;  Face  Presenta- 
tion, by  Dr.  J.  A.  Lyons,  Chicago,  111.;  The  Management  of  a  Myo- 
matous Pregnant  Uterus,  by  Dr.  W.  W.  Wathen,  Louisville,  Ky.; 
Experimental  Investigations  on  Puerperal  Sepsis,  by  Dr.  F.  Gaert- 
ner,  Saginaw,  Mich.;  The  Simultaneous  Occurrence  of  Extra-  and 
Intrauterine  Pregnancy  and  a  Tabulated  Record  of  62  Cases  Col- 
I  lected  from  1703  to  1901,  by  Dr.  E.  Gustav  Zinke,  Cincinnati,  0.; 
Cholemia  and  Hemorrhage,  by  Dr.  D.  T.  Gilham,  Columbus,  Ohio  ; 
Renal  Insufficiency  in  Relation  to  Women,  by  Dr.  J.  T.  Jelks,  Hot 
Springs  Ark.;  Clinical  Consideration  Relating  to  Cancer  of  the 
Uterus,  by  Dr.  A.  F.  Currier,  New  York ;  The  Medication  and 
Treatment  of  Uterine  Fibroids,  by  Dr.  W.  B.  Chase,  Brooklyn,  N.Y. 
Section  on  Hynecology  and  Abdominal  Surgery.— President,  Dr. 
Gabriel  Casusa;"  secretary,  Dr.  H.  P.  Newman.  103  State  street,  Chi- 
cago 111.  Cancer  of  the  Fundus  Uteri,  by  Dr.  J.  M.  Baldy,  Philadel- 
phia, Pa.;  Treatment  of  Prolapse  of  the  Uterus,  by  Dr.  H.  T.  By- 
ford,  Chicago,  111.  ;  Ureteral  Implantation  into  the  Intestines— a 
New  Method  with  a  Bacteriologic  and  Histopathologic  Study  of  the 
Kidney,  by  Dr.  Jacob  Frank,  Chicago,  111. ;  Intestinal  Sutures,  All 
Knots  Inside,  by  Dr.  F.  G.  Connell,  Chicago,  111.;  The  Complica- 
tions and  Degenerations  of  Fibroid  Tumors  as  Bearing  Upon  the 
Treatment  of  These  Growths,  by  Dr.  Chas.  P.  Noble,  Philadelphia, 
Pa.  ;  Septic  Peritonitis,  by  Dr.  C.  J.  Anderson,  Chicago,  111.;  The 
Angiotribe,  by  Dr.  H.  P.  Newann,  Chicago,  111. ;  Shock  in  Abdomi- 
nal Surgery,  by  Dr.  F.  B.  Turck,  Chicago,  111. ;  Some  Points  in  the 
Technic  of  Hysterectomy,  by  Both  Infra-  and  Suprapubic  Metliods, 
by  Dr.  W.  H.  Wathen,  Louisville,  Ky.;  Cocain  Anesthesia  by  Lum- 
bar Puncture  in  Gynecology,  by  Dr.  J.  Riddle  Goff,  New  York  ; 
Combined  or  Multiple  Surgical  Ooerations  at  one  Seance  in  Female 
Patients,  by  Dr.  R.  S.  Sutten,  Pittsburg,  Pa. ;  When  and  How 
Should  a  Ruptured  Ectopic  Pregnancy  be  Operated  Upon  ?  by  Dr. 
Paul  F.  Munde,  New  Y'ork ;  The  Author's  Flap  Operation  for 
Atresia  of  the  Vagina,  with  Demonstration,  by  Dr.  Geo.  H.  Noble, 
Atlanta,  Ga. ;  Pelvic  Suppuration,  by  Dr.  Joseph  Price,  Philadel- 
phia. Pa. ;  Water,  Its  Uses  Internally  in  Abdominal  Surgery,  by 
Dr.  W.  H.  Humiston,  Cleveland,  0. ;  Heptotomy  for  the  Relief  of 
Some  Conditions  Produced  by  Biliary  Obstruction,  Dr.  W.  E.  B. 
Davis,  Birmingham,  Ala. ;  Gangrenous  Hernia  and  Intestinal 
Jointing,  by  Dr.  Thomas  H.  Manley,  New  York  :  Surgical  Diag- 
nosis of  Abdominal  Tumors,  by  Dr.  W.  H.  Earles,  Milwaukee, 
Wis. ;  The  Technic  of  Appendicectomy  per  se  and  as  modified  by 
Combination  with  Lumbar  Appendicectomy  and  Lumbar  Explora- 
tion of  the  Gallbladder  and  Bile  Ducts,  by  Dr.  George  M.  Edebohls, 
New  Y'ork ;  The  Operative  Treatment  of  Carcinoma  Uteri,  by  Dr. 
E.  E.  Montgomery,  Philadelphia,  Pa. ;  The  Pus  Factor  in  Appendi- 
citis, by  Dr.  Ramon  Guiteras,  New  York  ;  Three  Dangerous  Opera- 
tions—Repair of  Lacerated  Cervix,  Rapid  Dilation  of  Cervix,  and 
Curetment,  by  Dr.  John  B.  Deaver,  Philadelphia,  Pa.  ;  On  the 
Desirability  of  Combined  Operations  in  Pelvic  and  Abdominal 
Surgery,  by  Dr.  W.  P.  Manton,  Detroit,  Mich. 

Sectinn  on  Ophthalnwlog,/.— President,  Dr.  Enrique  Lopez ;  secretary. 
Dr.  John  R.  Weeks,  40Ea»t  57th  street,  New  York.  A  New  Chn- 
ometer  for  Measuring  the  Torsional  Deviations  of  the  Eye  and  esti- 
mating the  Degree  of  Distortion  produced  by  CyHndrical  Glasses, 


by  Dr.  Alex.  A  Duane,  New  York  ;  Carcinoma  of  the  Orbit,  by 
Dr.  Shumway,  Philadelphia,  Pa.;  Report  of  a  Case  of  Removal  of 
the  Superior  Sympathetic  Cervical  Ganglion  for  Non-inflammatory 
Glaucoma,  by  Dr.  Joseph  Mullen,  Houston,  Tex. ;  Case  of  Bhnd- 
ness  from  Sympathetic  Ophthalmitis  Complicated  with  Secondary 
Glaucoma,  Restoration  of  Vision  by  two  Iridectomies.  One  with 
Extraction  of  Lens  and  Irido-Cystectomy,  and  Tynell's  Operation  of 
Drilling,  by  Dr.  Charles  A.  Oliver,  Pliiladelphia,  Pa. 

Section  on  Laryngology  and  Hhinologi/.— President,  Dr.  C.  Desver- 
nine;  secretary.  Dr.  G.  H.  Makuen,  1419  Walnut  street,  Philadel- 
phia, Pa.  How  to  Prevent  Stammering,  by  Dr.  G.  H.  Makuen, 
Philadelphia,  Pa. ;  The  Tonsils  as  Ports  of  Entry  for  Pathogenic 
Organisms,  by  Dr.  Irving  Townsend,  New  York ;  Injurious 
Effects  of  Forced  Breathing  upon  Voice,  Speaking  and  Singuig,  by 
Dr.  Carl  Seller,  Scranton,  Pa. ;  A  Case  of  Sympathetic  Cough 
Cured  by  Removal  of  Spur  from  the  Nasal  Septum,  by  Dr.  E.  F. 
Ingalls,  Chicago.  111. 

Section  on  Otology.— President.  Dr.  Charles  Desvernine ;  secretary. 
Dr.  J.  F.  McKernon.  &^  West  52d  street.  New  York.  Remarks  on 
Sinus  Thrombosis,  by  Dr.  T.  Y.  Sutphen,  Newark,  N.  J.;  Symp- 
tomatology of  Treatment  of  Sinus  Thrombosis,  by  Dr.  J.  I". 
McKernon,  New  York ;  A  Critical  Review  of  the  Literature  of 
Mastoid  Diseases.  Its  Complications,  by  Dr.  S.  Oppenheimer,  New- 
York  ;  A  Brief  Resume  of  Experience  with  Carbolic  Acid  in  the 
Treatment  of  Mastoid  Wounds  and  Chronic  Suppuration  of  Middle 
Ear,  by  Dr.  Wendell  Phillips,  New  York ;  Report  of  Mastoid 
Cases,  'by  Dr.  J.  0.  McRaynolds.  Jr.,  Dallas,  Tex.;  Some  Re- 
marks on  Mastoid  Operations  as  Done  in  England,  France,  Ger- 
many and  America,  by  Dr.  A.  Hobbs,  Atlanta,  Ga. ;  Importance 
of  an  Inqision  in  the  Inferior  Posterior  Portion  of  Canal  in  Acute 
Attical  Diseases,  by  Dr.  J.  G.  Tansley,  New  York  ;  Review  of 
Otological  Literature  for  Two  Years,  by  Dr.  Wilson,  Bridgeport, 
Conn.;  Use  of  Aqueous  Extract  of  Suprarenal  Capsule  in  fcar 
Diseases,  by  Dr.  W.  A.  Bates,  New  Y'ork  ;  Two  Cases  of  Liga- 
ture of  the  Internal  Jugular  Vein  for  Infective  Thrombosis  of  the 
Sigmoid  Sinus,  due  to  Purulent  Otitis  Media,  One  Recovery  and 
one  Death,  by  Dr.  Fred.  L.  Jack.  Boston,  Mass. ;  Artihcial  Aids 
to  Hearing,  by  Dr.  Ed.  E.  Dench,  New  York ;  Acute  Otitis 
Media  and  Acute  Mastoiditis  in  Scarlatina,  Measles  and  Diphtheria, 
a  Clinical  Report  of  5,000  Cases,  by  Dr.  A.  B.  Duel,  New  York.        _ 

Section  on  Marine  Hygiene  and  Qimranline.— President,  Dr.  Louis 
Cowlev;  secretary.  Dr.  "H.  M.  Woodward,  surgeon  M.  H.  S.,  \\ash- 
ingtoh,  D.  C.  Need  of  a  National  Health  Department,  by  Dr.  L. 
H.  Montgomery,  Chicago,  111.;  On  the  Agency  of  Parasitic  \ermin 
and  Other  Insect  Pests  in  the  Spread  of  Disease,  by  Dr.  G.  Homan, 
St.  Louis,  Mo.;  The  Necessity  for  the  Org'anization  of  Bacterio- 
logical Commissions  for  the  Study  and  Investigation  of  Quaran- 
tinable  Diseases  under  the  Formation  and  Control  of  the  Governing 
Authorities  of  ihe  Countries  Interested— An  Absolute  Requirement 
for  the  Scientific  Management  and  Betterment  of  Maritime  Hygiene 
and  Quarantine,  by  Dr.  Henry  B.  Horlbeck,  Charleston. 

Section  on  Mental  and  Nervous  /)Meases.— President,  Dr.  Gustave 
Lopez  ;  secretary,  Dr.  C.  P.  Hughes,  3857  Olive  street,  St.  Louis.  Mo. 
Morphinism  and  Crime,  by  Dr.  T.  D.  Crothers,  Hartford  Conn.; 
Syphilis  and  Insanity,  by  Dr.  H.  Waldo  Coe,  Portland,  Ore.; 
Trauma  as  an  Exciting  Cause  of  Paralysis  Agitans,  by  Dr.  F.  fa. 
Pearce,  Philadelphia,  Pa.;  Cerebral  Neurasthenia,  Observations  on 
Diagnosis  and  Treatment,  by  Dr.  D.  R.  Brewer,  Chicago,  111  :  Pos- 
sible Cause  of  Insanity  among  Americans  in  the  Orient,  by  Dr.  A. 
J.  Ashmead,  New  York  ;  Autopsycohythymia  or  the  Repetition 
Psychoneurosis,  an  Inquiry  into  a  Cxjndition  of  Morbid  Rhythmic 
Cerebral  Automatism  and  Its  Rhythmic  Forms  of  Mental  Aliena- 
tion, by  Dr.  C.  H.  Hughes,  St.  Louis,  Mo.;  Interrelation  of  the 
Nervous  System  and  Female  Genitals  in  the  Neurotic  Diseases  of 
Women — Subject  for  general  Discu.ssion. 

Section  on  Medical  Pedaqogy  —President,  Dr.  Manuel  Delhii ;  sec- 
retary, Dr.  Otis  K.  Newell,  13  Central  Park  West,  New  ^ork.  A 
Plea  for  Modern  Methods  of  Teaching  in  our  Medical  Colleges,  by 
Dr.  J.W.May,  Kansas  City,  Mo.;  Hospital  Service  a  Prerequisite 
for  a  License  to  Practise  Medicine  and  Surgery,  by  Dr.  G.  \\  .  Gal- 
vin,  Boston,  Mass. ;  Some  Observations  Respecting  the  V  alue  ol  the 
Present  Methods  of  Medical  Education,  by  Dr.  A.  P.  Clark,  Cam- 
bridge, Mass. ;  The  Association  of  American  Medical  Colleges— borne 
of  the  Work  it  Has  AccompHshed,  by  Dr.  D.  S.  Reynolds,  IxjuisviUe, 
Ky.-  The  Next  Educational  Revolution— What  Shall  It  be',  by  Dr. 
D.  B.  Cornell,  Saginaw,  Mich. ;  Remarks  on  the  Method  of  Treating 
Mental  Diseases,  by  Dr.  Ira  von  Gieson  ;  Is  the  smaller  Medical  Col- 
lege a  Useful  Factor  in  the  Advancement  of  Modern  Medical  Educa- 
tion by  Dr.  W.  J.  Gillette,  Toledo.  O. ;  Function  of  Chemistry  in  a 
Medical  Education,  by  Dr.  R.  F.  Ruttan,  Montreal,  Canada. 

Section  on  Dental  and  Buccal  .s'urffcn/.- President,  Dr.  Erastus  Wil- 
son -  Secretary,  Dr.  Eugene  Talbot.  Columbian  Memorial  Building, 
Chicago.  Can  Interstitial  Gingivitis  be  Prevented,  and  How  .'by 
Dr.  M.H.  Fletcher,  Cincinnati,  O. :  Tuberculosis  of  the  Alveolar 
Process  and  Surrounding  Tissues  and  a  Few  Methods  of  Differential 
Diagnosis,  by  Dr.  G.  F.  Eames,  Boston,  Mass. ;  The  Gingivae  and 
Pericementum,  by  Dr.  W.  R.  Walker,  Pass  Christiau,  Miss  ;  Irreg- 
ularities of  the  Teeth  and  Their  Treatment,  by  Dr  A  E.Baldwin, 
Chicago,  111. ;  Treatment  of  Interstitial  Gingivitis,  by  Dr.  Eugene  b. 
Talbot,  Chicago,  III.  ,        „      ■-     .   T^     -i-^ 

Section  on  General  Hygiene  and  Dermograplty .-President,  Dr.  \  in- 
cente  de  la  Guardia ;  secretary.  Dr.  Alvah  H.  Doty,  Quarantine 
Station,  Staten  Island,  N.  Y.  Restrictions  on  Enteric  Fever,  by 
Dr.  H.  B.  Baker,  Lansing,  Mich.;  Problem  of  Infected  \\ell  Per- 
sons, by  Dr.  C.  V.  Chapin,  Providence.  R.  1;  Tricophytira  in 
Reference  to  Public  Hygiene,  by  Dr.  A.  Ravogh,  Cincinnati,  Ohio. 
.Section  on  Dermatology  -ind  .^yphilography.—Pres\aent,  Dr.  Henry 


102 


The  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Jasdart  19,  1901 


Eebelin  ;  secretary,  Dr.  A.  Havogli,  5  Garfield  Place,  Cincinnati,  0. 
Myscosis  Fungoides,  by  Dr.  W.  F.  Breakey,  Ann  Arbor,  Mich. : 
The  Relationship  of  Diseases  of  the  Skin  to  Derangements  of  Other 
Organs,  by  Dr.  Louis  F.  Frank,  Milwaukee,  Wis.   ^.,^^  ,  j..  .,. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  January  12,  1901 : 

Reynolds,  Major  Frederick  P.,  surgeon,  is  granted  leave  for  two 
months,  on  surgeon's  certificate,  to  take  effect  upon  arrival  in 
the  United  States. 

Stoby,  George  B.,  acting  assistant  surgeon,  is  granted  leave  for  one 
month,  on  surgeon's  certificate. 

Wbbber,  First-Lieutenant  Henry  A.,  assistantsurgeon,  orders  relat- 
ing to  him  are  so  amended  as  to  direct  him  to  report  in  New 
York  City  not  later  than  January  14  for  transportation  to  the 
Philippine  Islands  on  the  transport  "Wright,"  and  at  Manila 
to  report  to  the  commanding  general,  division  of  the  PhiUp- 
pines,  for  assignment  to  duty. 

Shockley,  First-Lieutenant  Major  A.  W.,  assistant  surgeon,  leave 
granted  December  1  is  extended  15  days. 

McArthur,  Arthur  W.,  acting  assistant  surgeon,  will  proceed 
from  Chillicothe,  Mo.,  to  Fort  Yates,  to  reheve  Acting  Assistant 
Surgeon  Charles  E  Macdonald. 

MacDonald,  Charles  E.,  acting  assistantsurgeon,  directed  to  pro- 
ceed to  San  Francisco,  Cal.,  for  assignment  to  duty  with  troops 
en  route  to  the  Philippine  Islands,  where  he  will  report  to  the 
commanding  general,  division  of  the  Philippines,  for  assign- 
ment to  duty. 

Jacksok,  Tho.mas  W.,  acting  assistant  surgeon,  leave  granted  De- 
cember 31  is  extended  seven  days. 

Belt,  Harry  D.,  acting  assistant  surgeon,  now  In  New  YorkTCity, 
will  report  for  transportation  to  the  Philippine  Islands  on  the 
transport  "  Wright,"  to  sail  about  January  15,  and  at  Manila 
will  report  to  the  commanding  general,  division  of  the  Philip- 
pines, for  assignment  to  duty. 

ScHiMANN,  Orro,  hospital  steward,  now  at  the  office  of  the  attend- 
ing surgeon,  San  Francisco,  Cal.,  having  relinquished  the  unex- 
pired portion  of  his  furlough  granted  him  September  25,  will 
report  to  the  commanding  general,  department  of  California, 
who  will  furnish  him  transportation  to  Manila,  P.  I.,  for  assign- 
ment to  duty. 

Webber,  First- Lieutenant  Henry  A.,  assistantsurgeon,  now  under 
orders  to  proceed  to  the  Philippine  Islands  on  the  transport 
"Wright,"  is  detailed  for  duty  as  acting  assistant  quartermaster 
and  acting  commissary  of  subsistence  on  that  transport. 

Chamberlain,  First-Lieutenant  Weston  P.,  assistant  surgeon,  hav- 
ing reported  his  arrival  at  San  Francisco,  Cal.,  will  proceed  to 
Fort  Adams  for  duty. 

Allen,  Ira  A.,  acting  assistant  surgeon,  now  at  Ban  Francisco,  Cal., 
will  proceed  to  Hot  Springs,  Ark.,  and  report  at  the  Army  and 
Navy  General  Hospital  for  temporary  duty. 

Reynolds,  Major  Frederick  P.,  surgeon,  leave  on  surgeon's  cer- 
tificate granted  November  12,  is  extended  two  months  on  sur- 
geon's certificate. 

Wadhams,  First^Lieutenant  Sanford  H.,  assistant  surgeon,  is 
granted  leave  for  seven  days  on  account  of  sickness,  to  take  eft'ect 
from  the  expiration  of  the  sick  leave  granted  him  October  13. 

Brooks,  William  H.,  acting  assistant  surgeon,  is  granted  leave  for 
one  month  to  take  effect  upon  his  relief  from  duty  at  Fort 
Schuyler. 

The  following-named  acting  assistant  sureeons  will  proceed  from 
the  places  designated  to  San  Francisco,  Cal.,  and  report  to  the 
commanding  general,  department  of  California,  for  assignment 
to  duty  with  troops  en  route  to  the  Philippine  Islands,  where 
they  will  report  to  the  commanding  general,  division  of  the 
Philippines,  for  assignment  to  duty:  Henry  C.  Biebiiowkr, 
from  St.  Edward,  Neb.;  James  E.  Mead,  from  Detroit,  Mich.; 
Frederick  W.  Richardson,  from  St.  Paul,  Minn. 

The  following-named  acting  assistant  surgeons  will  proceed  from 
the  places  designated  to  New  York  City  for  transportation  to 
the  Philippine  Islands  on  the  transport  "Wright,"  to  sail  about 
January  15,  and  at  Manila  will  report  to  the  commanding  gen- 
eral, division  of  the  Philippines,  for  assignment  to  duty : 
Timothy  F.  Goulding,  from  Boston,  Mass.;  Frank  E.  Thomp- 
son, from  Cleveland,  Ohio;  Archibald  M.  Wilkins,  from 
Delta,  Ohio. 

Changes  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  January  10,  1901 : 

Wasdin,  Eri;ENE,  surgeon,  granted  leave  of  absence  for  15  days 

from  January  14,    January  5. 
Wertexbaker,  C.  p.,  passed  assistant  surgeon,  to  proceed  to  Fon- 

tainebleau.  Miss.,  for  special  temporary  duty.    January  5. 
Stimpson,  W.  G.,  passed  assistant  surgeon,  to  proceed  to  Cripple 

Creek,  Col.,  for  special  temporary  duty.    January  4. 
Nydeqger,  J.  A.,  passed  assistant  surgeon,  to  proceed  to  Chicago, 

III.,  and   report  to  medical  officer  in  command  for  duty  and 

assignment  to  quarters.     January  5. 
Decker,  C.  E.,  assistant  surgeon,  granted  7  days'  extension  of  sick 

leave  from  .lanuary  4.    January  7. 
Anderson,  J.  F.,  assistantsurgeon,  having  been  assigned  to  duty  in 

the  Immigration  Service  at  Liverpool,  England,  relieved  from 

duty  in  V.  S.  Consulate  at  that  port.    January  5. 
Walklkv,  W.  S.,  acting  .issistant  surgeon,  granted  leave  of  absence 

for  3  days.    January  8. 


Cbc  latest  iiteraturc. 


British  Medical  Journal. 

December  S9, 1900.    [No.  2087] 

1.  City  Life  in  ISOO.    G  Fielding  Blasfoed. 

2.  Anatomical  Teaching  in  ISOO.    Alexander  Macalistee. 

3.  Physiology  in  1800.    Hexey  Poweb. 

4.  Pathology  in  1800.    D'Aecy  Poweb. 

5.  Medicine  in  1800.    T.  Clifford  Allbutt. 

6.  Lunacy  and  its  Treatment  in  1800.    Charles  Meecier. 

7.  Midwifery  and  Gynecology  in  1800.    G.  E.  Herman. 

8.  Surgery  in  1800.    Stephen  Paget. 

9.  Sinitary  Knowledge  in  1800.    W.  H.  Corfield. 

10.  The  Poor  Law  in  1800.    J.  Milson  Rhodes.  I 

11.  Military  Medicine  in  1800.  • 

The  Jouma/ contains  "  A  Century's  Retrospect  of  Medicine, 
1800-1900." 


Lancet. 

December  29,  1900.     [No.  4035.] 

1.  The  Bradshaw  Lecture,  on  the  Association  of  Inguinal 

Hernia  with  the  Descent  of  the  Testis.   John  Langton. 

2.  The  Causation,  Prevention,  and  Treatment  of  Postpartum 

Hemorrhage.    G.  F.  Blacker. 

3.  Calcium  lodate  as  an  Iodoform  Substitute  and  Gastro- 

intestinal Antiseptic.    William  Mackle. 

4.  Circumcision  as  a  Preventive  of  Syphilis  and  other  Dis- 

orders.   E.  Haedino  Fbeeland. 

5.  On  a  New  Method  in  the  Discission  of  Soft  Cataracts. 

Peecy  Dcsn. 

6.  A  Case  of  Hydatids  Primarily  Affecting  the  Lung.   Jn:,iC8 

Caesae. 

1. — Mr.  Langton  begins  with  a  description  of  the 
descent  of  the  testis  beginning  at  the  seventh  or  eighth 
month  of  intrauterine  life  and  reaching  the  scrotum  about 
birth,  the  left  being  about  3  weeks  ahead  of  the  right.  The 
processus  vaginalis  is  usually  more  or  less  patulous  at  birth 
and  without  any  protrusion  of  the  abdominal  contents. 
This  is  more  often  true  on  the  right  side,  which  acjounts  for 
the  greater  frequency  of  congenital  hernia  on  this  side. 
The  vaginal  process  may  in  rare  instances  descend  into  the 
scrotum  and  be  cut  off  from  the  abdominal  oivity  and  the 
testis  remain  undescended,  and  frequently  the  process  is 
found  far  in  advance  of  the  testicle.  He  prefers  instead  of 
the  words  "  congenital  hernia  "  to  say  "  hernia  into  the 
cavity  of  the  tunica  vaginalis."  The  former  giving  the  idea 
that  the  hernia  has  existed  from  birth,  which  is  erroneous. 
The  point*  or  rings  of  constriction  frequently  found  in  the 
sacs  of  congenital  hernia  he  thinks  more  frequently  due  to 
attempts  at  occlusion  than  to  a  displaced  neck  of  the  sac- 
Inguinal  hernia  occurs  11  times  more  often  in  boys  than  in 
girls.  In  fac',  in  infant  boys  hernia  is  3  times  more  frequent 
m  the  right  than  in  the  left  side,  but  in  infant  girls  it  is  about 
equal  on  the  two  sides.  Toe  greater  frequency  on  the  right 
side  is  due  to  the  later  patuleucy  of  the  tunica  vaginalis  on 
this  side.  Premature  children  are  more  liable  to  hernia  at 
birth  than  those  born  at  term  and  the  hernia  is  more  apt  to 
be  double.  Frequently  testes  are  retained  in  the  inguinal 
canal  with  accompanying  hernia.  Langton  does  not  think 
these  liable  to  became  the  seat  of  malignant  disease  late  in 
years  as  is  often  stated.  He  has  examined  the  records  of 
7,661  cases  of  hernia  in  males  and  found  4,810  on  the  right, 
2,812  on  the  left,  and  539  on  both  sides.  In  174  cases  the 
testes  were  misplaced.  Toe  proportion  of  misplaced  testes 
on  the  right  and  left  sides  was  as  6  to  4  in  favor  of  the  right. 
A  misplaced  testis  is  usually  small,  soft  and  flattened  and 
more  tender  and  sensitive  than  fully  developed  organs. 
Congenital  hernia  is  divided  into  the  following  vari- 
eties :  First,  hernia  into  the  tunica  vaginalis  testis. 
Second,  hernia  into  the  funicjlar  prccess.  which  de- 
scend into  the  enclosed  funiculiir  process  of  the  tunic. 
Third,  herniae  into  a  post  tunica  vaginalis  sac  called  infantile 
herniae,  where  the  protrusion  is  situated  behind  a  dilated 
tunica  vaginalis  which  is  patulous  as  high  as  the  internal 


JiNCAEY    19,    1901] 


THE  LATEST  LITERATURE 


[ 


TllK    PHILADELPUIA 

Medical  Journal 


10$ 


abdominal  ring.  Under  ihis  head,  too,  are  included  the 
encj'Bted  herniae  which  push  before  them  an  invaginated 
membranous  septum  into  an  inclosed  tunica  vaginalis. 
The  first  variety  is  by  far  the  most  common.  Protrusion  in 
children  is  usually  intestine  alone,  the  omentum  not  being 
Bufficiently  developed  to  occupy  the  sac.  He  thinks  that  in 
nearly  all  cases  of  hernia  in  children  under  6  months  of  age, 
the  hernia  is  into  the  cavity  of  the  tunica  vaginalis.  This 
variety  of  congenital  hernia  may  occur  at  any  age,  but 
rapidly  decreases  in  frequency  after  about  the  sixteenth  or 
eighteenth  year.  It  is  diffitult  of  treatment,  narrowing  of 
the  serous  canal  taking  place  with  apparent  cure  from  the 
use  of  the  truss ;  but  total  obliteration  is  not  hopeful  and  this  is 
especially  true  of  an  unclosed  canal  of  Nuck.  Records  show 
conclusively  that  strangulation  of  the  congenital  hernia  is 
much  more  dangerous  than  that  of  the  acquired  variety. 
Ketention  of  the  testes  in  the  inguinal  canal  with  hernia  in 
their  unclosed  sacs  not  infrequently  accompanies  exstrophy 
of  the  bladder.  Out  of  the  6  cases  of  exstrophy  seen  by  Lang- 
ton,  4  had  congenital  hernia.  The  second  variety,  hernia  into 
the  funicular  process,  is  difficult  to  diagnose,  easily  reduced, 
but  hard  to  retain.  Under  the  third  variety,  infantile  hernia, 
Langton  describes  its  various  forms.  Another  variety  of 
congenital  hernia  is  the  so-called  "  interstitial  hernia,"  which 
he  tliinks  should  be  included  in  variety  number  one,  and 
which  is  often  described  as  intermuscular,  intraparietal, 
interparietal,  ascending,  properitoneal,  and  heraia  e^i  sac. 
In  this  variety  the  testes  are  retained  in  the  inguinal  canal 
in  the  majority  of  cases.  Interstitial  hernia  cccurs  once  in 
every  1,1(X)  cases  of  hernia  in  men,  once  in  every  760 
cases  in  women.  In  the  cases  studied,  the  testes  were 
variously  misplaced  and  the  corresponding  side  of  the 
scrotum  not  developed  or  absent  in  nearly  all.  The  various 
locations  of  this  variety  of  hernia  are  then  enumerated.  In 
42  cases  of  interstitial  hernia,  45^  occurred  in  the  first  year. 
The  greater  frequency  of  interstitial  hernia  in  women  is 
probably  due  to  the  distention  of  the  abdominal  muscles 
during  pregnancy,  as  most  of  the  patients  in  the  cases  col- 
lected had  borne  large  families,     f  j  h  a  ] 

3. — Blacker  remarks  that  the  causes  of  postpartum  hem- 
orrhage are  to  be  sought  in  the  conditions  giving  rise  to 
uterine  inertia.  These  may  be  classified  as  follows :  1. 
Feebleness,  exhaustion,  or  malnutrition  of  the  patient,  due  to 
a,  condition  of  chronic  starvation  or  the  result  of  some  dis- 
ease complicating  the  labor,  such  as  grave  heart-disease.  2. 
Overdistention  of  the  uterus  and  undue  stretching  of  the 
uterine  muscles,  such  as  occurs  in  cases  of  hydramnios  or 
multiple  pregnancies.  3.  Exhaustion  of  the  uterine  muscle 
from  frequent  child-bearing.  4.  Pathologic  cocditions  of  the 
uterine  wall,  as  fibroid  tumors,  marked  fatty  degeneration, 
and  atony,  due  to  septic  infection.  5.  Some  mechanical 
hindrance  to  the  contraction  and  retraction  of  the  uterus, 
such  as  the  retention  of  the  placenta  in  utero,  or  the  pres- 
ence of  adhesions  between  the  uterus  and  surrounding 
structures.  6  Too  rapid  emptying  of  the  uterus,  either  by 
the  application  of  forceps  or  after  version.  7.  Extreme 
nervous  depression  and  shock,  such  as  may  follow  the  birth 
of  a  dead  child.  8.  The  administration  of  chloroform.  9. 
Deficient  coagulability  of  the  blood,  such  as  occurs  in  septic 
affections  and  in  hemophilia.  As  a  means  of  prevention  of 
postpaitum  hemorrhage.  Blacker  recommends  small  doses  of 
ergot  and  strychnin  combined  with  iron  or  hydrochloric  acid 
during  the  last  month  of  pregnancy.  As  a  routine  means 
of  treatment  he  considers  plugging  the  uterus  as  greatly  in- 
ferior to  bimanual  compression.  There  are,  however,  two 
classes  of  cases  with  which  the  latter  method  is  especially  indi- 
cated, namely,  where  the  uterus  is  prevented  frjm  contract- 
ing and  retracting  by  the  presence  of  adhesions,  or  by  the 
existence  of  fibroid  tumors  in  its  wall,     [w.a.n  d  ] 

3. — During  the  last  15  months  Mackie  has  been  using 
calcium  iodate  as  au  iodoform  substitute  and  gastro- 
intestinal antiseptic  in  surgical  practice.  He  claims  that  cal- 
cium iodate  acta  as  a  destroyer  of  bacterial  product  and  also 
has  an  inhibitory  action  on  bacterial  growth.  He  recommends 
calcium  iodate  in  all  cases  where  iodoform  is  commonly 
employed.  Its  advantages  are,  absence  of  smell,  prevention 
of  hypergranulations,  checking  of  fetor  and  a  decrease  in 
pus-formation,  and  also  that  it  may  be  used  in  aqueous 
solution  as  a  mouth  wash,  urethral  injection,  washing  out  of 
the  bladder,  the  vagina,  or  uterus.  Internally  he  has  em- 
ployed it  in  checking  fermentative  changes  in  the  stomach 


in  2  grain  doses  repeated  two  or  three  times  during  the  day. 
He  claims  that  aptrt  from  its  antiaeptic  value  it  possesses 
some  tonic  properties.  For  internal  administration  the  drug 
should  be  given  in  solution.     [f.l.k  ] 

4. — Freeland  discusses  the  following  questions  under 
fircumcision :  1.  Is  the  operation  safe?  2  Does  the 
operation  interfere  with  the  physical  well-being  of  the  indi- 
vidual? 3.  Does  the  end  justify  the  means?  The  firft  is 
answered  in  the  positive;  second,  in  the  negative;  the  third, 
in  the  positive.  He  argues  that  circumcision  not  only  will 
prevent  oftentimes  djsuria,  enuresis,  urinary  retention, 
balanitis,  rectal  prolapse,  and  the  aggravation  of  gonorrhea 
and  other  venereal  diseases,  but  that  it  also  greatly  lessens 
the  tendency  to  contract  syphilis  and  the  spread  cf  this  dis- 
ease. He  produces  figures  to  show  how  much  less  frequent 
syphilis  is  in  the  Hebrew  race  than  in  other  races  and 
attributes  the  fact  to  circumcision.  In  performing  the  opera- 
tion he  advises  the  removal  of  the  entire  prepuce  with  the 
frenum.     [j.h  g  ] 

5. — Dunn  believes  that  the  rapid  absorption  of  soft  lens- 
matter  from  the  anterior  chamber  can  only  occur  after  the- 
reduction  of  intraocular  tension  by  the  removal  of  the- 
aqueous.  In  order  to  bring  this  about  and  to  prevent  some 
of  the  disadvantages  caused  by  the  present  methods  of 
discission,  the  author  proceeded  as  follows  under  chloroform 
anesthesia  :  The  pupil  having  been  well  dilated  with  atropin^ 
a  broad  cataract  needle  is  passed  into  the  anterior  chamber 
of  the  lens,  a  vertical  and  horizontal  incision  being  made  in 
the  capsule.  The  lens  matter  having  been  broken  up  and 
the  needle  partially  withdrawn,  the  latter  was  turned  on  its 
own  axis,  thereby  allowing  the  aqueous  to  escape  slowly. 
On  the  fourth  day  but  a  small  quantity  of  lens  matter 
remained  at  the  bottom  of  the  anterior  chamber,  with  but  a 
remaining  trace  on  the  fourteenth  day.  He  believes  that 
iritis  will  not  follow  this  operation  as  a  result  of  mecbanical 
irritation,  but  only  when  antiseptic  procedures  have  been 
improperly  secured,    [m  r.d] 

6, — The  diagnosis  was  established  by  eliminating  the 
following  factors  :  The  liver  was  of  normal  size,  the  costal  and 
pulmonary  pleurae  were  not  fused,  there  was  no  communi- 
cation between  the  abdominal  and  pleural  cavities,  and  the- 
growth  was  found  either  springing  from  or  attached  to  the 
base  of  the  lung.  There  was  considerable  dyspnea,  cough, 
and  expectoration,  followed  by  extreme  prostration  after 
each  attack.  Paracentesis  thoracis  obtained  2J  ounces  of  a 
gelatinous  material,  which,  upon  microscopic  examination, 
revealed  broken-down  hydatid  cysts  without  booklets.  The 
patient  died  5  days  after  admission  to  the  hospital.  Upon 
opening  the  chest  at  the  autopsy  a  pint  and  a  half  of  yellow 
gelatinous  fluid,  containing  cysts,  was  obtained.  The  author 
believes  that  the  symptoms  in  the  case  excluded  empyema 
or  pleurisy  with  eflusion,  and  that  its  monolateral  locatioa 
eliminated  hydrothorax.     [mb.d.] 


New  York  Medical  Journal. 

January  IS,  1901.     [Vol.  Ixxiii,  No.  2.] 

1.  Prevention  and  Management  of  Infection  of  the  Breast 

During  Lactation.    C.  S.  Bacon. 

2.  Question  of  Operation  in  Appendicitis.    Forbes  Hawkes, 

3.  The  General  Principles  of  Infant  Feeding,  with  a  Simple 

Method  of   Home   Modification   of  Cow's   Milk.    L. 
Emmett  Holt. 

4.  Dyspeptic  Asthma.    Frank  H.  Murdoch. 

5.  Some  Remarks    upon    Tuberculosis    of  Bone.    Edmund 

Owen. 
6    A  Case  of  Gangrenous  Inflammation  of  Meckel's  Diver- 
ticulum Simulating  Appendicitis.    C.  R.  Darnall. 

1. — Bacon  calls  attention  to  the  distinction  between  in- 
fection of  the  breast  and  simple  hyperemia  or  con- 
gestion of  the  breast.  The  establishment  of  the  milk  secre- 
tion is  always  attended  with  more  or  less  painful  congestion 
of  the  breast.  Infection  of  the  breast,  on  the  other  hand,  is 
generally  attended  with  fever,  and  while  it  is  often  con- 
founded with  simple  congestion  it  is  entirely  a  distinct  pro- 
cess. It  is  now  well  known  that  the  fever  attendant  upon  the 
early  puerperium  is  due  to  genital  wound-infection.  Hence 
the  term    'milk  fever"  should  be  entirely  abandoned.    If 


104 


The  Philadelphia. 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


[JaBCABT  19.  1901 


there  is  no  infection  there  is  no  fever.  While  the  simple 
congestion  of  the  breast  is  often  attended  with  the  tender- 
ness which  is  characteristic  of  an  infection,  other  symptoms, 
as  chills  and  fever,  are  absent.  As  soon  as  these  symptoms 
develop,  infection  of  the  breast  exists.  All  measures  tending 
to  the  improvement  of  the  general  health  both  before  and 
after  confinement  are  most  important  in  the  prevention  of 
breast  as  well  as  all  other  infections.  The  two  principles  of 
prophylaxis  are  to  avoid  contamination  with  bacteria  and  to 
avoid  or  heal  as  quickly  as  possible  the  nipple- wounds.  For 
prevention  of  wounds  of  the  nipple  as  well  as  for  their  cure 
the  nipple-shield  is  of  very  great  importance.  When  the 
nipple  wounds  become  infected,  but  before  there  are  any 
symptoms  of  general  infection  or  involvement  of  the  deeper 
breast,  the  local  wound  may  be  treated  like  similar  wounds 
in  other  parts  of  the  body.  Chills  and  fever  indicate  the 
deeper  infection  of  the  breast,  which  should  then  be  sup- 
ported and  put  at  rest  by  a  proper  bandage.  Treated  in  this 
way  from  80%  to  90%  of  all  breast-infections  will  terminate 
without  abscess.  A  valuable  adjuvant  for  the  treatment  of 
breast  icfection  is  the  application  of  cold  by  means  of  the  ice- 
bag.  If  in  spite  of  this  treatment  tenderness  continues  and  a 
suspicion  of  fluctuation  exists,  aspiration  with  the  hypoder- 
mic needle  may  be  performed  and  if  necessary  incision  may 
be  made,     [w.a.n  D.J 

2. — Hawkes  believes  that  the  surgeon  should  operate  in 
all  cases  of  acute  appendicitis,  except  in  those  cases  of  a 
mild  type  which  exhibit  no  bad  signs  or  symptoms  when  first 
seen,  and  the  patients  are  evidently  recovering  from  their 
attack,  but  that  we  should  operate  in  these  cases  later,  that 
is,  during  the  interval.  As  to  whether  every  patient  with 
appendicitis  who  has  recovered  from  a  first  attack  should  be 
operated  upon  before  the  possible  second  attack,  or  this 
should  be  postponed  until  this  second  attack  has  occurred, 
Hawkes'  opinion  varies.  He  believes  that  while  a  certain 
number  of  patients,  23%,  never  have  any  trouble  or  any  sec- 
ond attack,  the  majority,  77%,  do  have  recurrences,  any  one 
of  which  may  be  distinctly  dangerous  or  even  fatal.  There- 
fore operations  afford  the  better  chance  of  an  absolute  cure. 

[w  A  N.D.] 

3.— See  Philadelphia  Medical  Jouenal,  January  5,  1001, 
page  35. 
4. — F.  H.  Murdoch  reports  5  cases  of  chronic  dyspeptic 

asthma,  which  form,  he  says,  he  has  not  seen  described. 
The  acuie  type  presents  asthvudic  seizures  after  meals,  char- 
acterized by  dyspnea,  cyanosis,  and  irregularity  of  the  pulse. 
The  oppression  is  relieved  by  belching  and  all  symptoms  dis- 
appear if  vomiting  occurs.  The  chronic  type  is  marked  by 
continuous  shortness  of  breath  (not  paroxysmal)  on  slightest 
exertion.  This  occurs  in  patients  suflering  from  gastro- 
intestinal diseases,  wilhoxU  any  discoverable  abnormalilies  in 
heart,  lungs,  or  kidneys,  and  yields  readily  to  treatment  of  the 
existing  dyspepsia.  Of  Murdoch's  5  cases  none  complained 
of  dyspepsia,  but  all  came  to  seek  relief  from  the  distressing 
shortness  of  breath.  Murdoch  has  found  that  no  one  form  of 
stomach  trouble  is  responsible  for  the  condition.  Three  were 
suffering  from  achylia  gailrien. 

5.— Owen  believes  that  the  astragalus  is  that  bone  of 
the  foot  which  is  most  frequently  primarily  affected  by  tuber- 
culosis. Involvement  of  the  anklej  lint  by  the  tuberculous 
process  is  indicated  by  a  bulging  beneath  the  tendons  in 
front  of  the  ankle,  and  also  between  the  posterior  portion  of 
the  joint  and  the  tendo  Achilles,  together  with  a  fulness 
about  the  malleoli.  The  author's  experience  has  been  that 
Syme's  amputation  has  been  followed  by  good  results  in 
a  large  number  of  cases  of  tuberculosis  in  this  location. 
[m.rd.  I 

6.— The  symptoms  in  the  author's  case  presented  the  in- 
teresting question  as  to  whether  the  diverticulum  became 
primarily  or  secondarily  involved.  The  symptoms  were 
early  and  constant  elevation  of  temperature,  some  tympa- 
nites, partial  intestinal  obstruction,  wiiich,  when  relieved, 
gave  rise  to  improvement  in  the  condition  of  the  patient. 
Death  followed  laparotomy.  The  autopsy  showed  a  collec- 
tion of  seropurulent  fluid  in  the  abdominal  cavity  and  en- 
gorgement of  the  peritoneal  and  mesenteric  vessels.  The 
diverticulum  of  Meckel  was  gangrenous,  perforated  and 
contained  about  an  ounce  of  foul  smelling  fluid.  'The 
author  believes  that  the  temporary  alleviation  of  the  symp- 
toms was  mainly  due  to  the  hypodermoclysis  of  normal 
salt-solution,    [m'.r.d.] 


Medical  Record. 

January  12,  1901.     [Vol.  59,  No.  2.J 

1.  Coffee  as  a  Beverage  and  its  Frequent  D-;eteriou8  Electa 

Upm  the  Nervous  System  :  A^ute  and  Chronic  Coffee 
Poisoning.    William  M.  Leszynsky 

2.  An  Improved  Method  of  Performing  Suprapubic  Cystot- 

omy.   C.  L  Gibson. 

3.  Some  Remarks  on  the  Modern  Surgical  and  Medical  Treat- 

ment of  Epilepsy.    L.  Piebce  Clakk. 

4.  Report  of  a  Caee  of  Primary  Glioma  of  the  Optic  Nerve. 

Redmond  W.  Payne 

5.  The  Choice  of  Suture  for  the  Patella.    Edwin  M.  Cox. 

1. — The  deleterious  eflFects  arising  from  the  habit  of  coffee- 
drinking  are  discussed  by  Leszynsky.  Oaethird  of  the  coffee 
crop  of  the  entire  world  is  rwnsumed  in  the  Uoited  States. 
He  points  out  the  fact  that  children  are  especially  susceptible 
to  the  effects  of  coffee,  tea,  etc  ,  and  believes  that  these  drugs 
are  frequently  the  unsuspected  cause  of  insomnia,  night 
terrors,  and  some  intellectual  precocity.  He  diatia- 
guishes  between  acute  and  chronic  cotfee-poisoning. 
When  taken  in  sufficient  quantity  by  those  unaccustomed 
to  its  use  it  produces  excitability  even  to  the  point  &f 
delirium.  In  the  chronic  form  it  gives  rise  to  a  depres- 
sive form  of  neurasthenia.  It  closely  resembles  chronic 
alcoholism,  for  which  it  is  frequently  mistaken  and  with 
which  it  is  sometimes  associated.  Guelliot  has  studied  care- 
fully this  form.  He  states  that  digestion  is  first  deranged. 
At  times  there  is  epigastric  pain  radiating  to  the  dorsal 
region.  It  was  similar  to  the  other  neuralgic  pains  from 
which  these  patients  suffer.  The  pulse  is  slow,  soft,  and 
compressible.  Tee  tremor  which  is  present,  at  times,  dis- 
appears after  a  dose  of  coffee  just  as  in  chronic  alcoholism. 
Sexual  impotence  in  the  male  and  profuse  lenkorrhea 
in  the  female  are  prominent  symptoms.  It  has  been  ob- 
served that  confirmed  coffee  drinkers  have  a  slow  pulse 
(from  40  to  60).  In  treating  the  condition,  which  is  fre- 
quently not  distgnosed,  the  stimulant  should  not  be  absolutely 
withdrawn,  but  a  morning  cup  of  coffee  allowed.  The  author 
recommends  nerve  sedatives  and  tonics,  and  at  times 
the  rest-cure  is  necessary.  Most  cases  recover  in  from 
three  to  six  months,     [t.l  c] 

2. — G.bson  under  this  head  discusses  the  application  of 
Kader's  operation  of  gastrostomy  to  the  establishment  of 
drainage  of  the  urinary  bladder.  In  this  operation  the  au- 
thor hopes  to  gain:  (1)  Effective  drainage  of  the  bladder 
without  leakage ;  (2)  rapid  closure  of  the  fistula  on  discon- 
tinuance of  the  drainage;  (3)  the  creation  of  a  permanent 
sinus  which  should  allow  of  permanent  but  periodical  cathe- 
terizition  of  the  bladder,  and,  in  the  intervals,  owing  to  its 
valve  action,  prevent  escape  of  urine  and  do  away  with  the 
discomfort  of  wearing  a  tube  or  dressing.  His  experience 
leads  him  to  believe  that  the  first  two  can  be  more  readily 
obtained  by  this  operation  than  by  any  other,  and  but  for 
the  want  of  a  peritoneal  covering  to  the  bladder  he  thinks 
that  the  third  also  could  be  easily  obtained.  He  believea 
that  further  experimentation  will  result  in  the  accomplish- 
ment of  this,     [j  H  G.l 

3. — Clarke  urges  the  study  of  the  pathological  changes  in 
the  brain  of  epileptics.  He  thinks  tbat  medic&l  treatment 
should  invariably  precede  and  follow  operation.  From  the 
operative  cases  be  would  remove  the  idiopathic  epileptics 
in  whom  the  seizures  have  a  definite  form  of  invasion.  The 
brain  in  such  cases  is  epileptogenic,  one  zone  being  only  » 
little  more  excitable  than  another.  la  Jioksonian  epilepsy 
with  well-marked  trauma  and  no  neurotic  family  history 
trephining  may  be  advised  if  the  epilepsy  has  not  existed  for 
more  than  2  years.  He  think*  that  surgeons  report  cures  too 
early  after  operation.  Some  cases  are  ma^e  worse  by  operation. 
Operations  for  the  purpose  of  relieving  intracranial  pressure 
in  epilepsy  is  not  to  be  advised,  the  pressure  being  the  result 
and  not  the  cause  of  the  convulsions.  He  thinks  Kocher'i 
good  results  in  these  cases  has  been  due  largely  to  their  cato- 
ful  selection  and  to  his  postoperative  bromid  treatment 
Many  cases  of  idiopathic  epilepsy  are  due  to  infantile  cere- 
bral palsies.  When  such  a  history  exists,  operations 
should  not  be  done.  The  opening  in  the  skull  in  operations 
for  epilepsy  should  not  he  closed  with  bones  as  a  relief  frv^m 
pressure  is  of  advantage.  MedicAl  treatment,  he  concludes, 
as  follows:     1.  By  a  combination  of  diet,  regular  occupation. 


jA5tJARY    11),    1901] 


THE  LATEST  LITERATURE 


TThe 
Lmki 


Philadelphia 
KDICAL  Journal 


105 


and  personal  hygiene,  the  bromids  give  the  best  results  in 
treating  idiopathic  epilepsy.  2.  The  bromids,  singly  or  com- 
bined, still  remain  our  chief  sedative  for  the  epileptic  state 
— in  the  young  epileptic  to  secure  a  possible  entire  suppres- 
sion of  attacks  and  ultimate  cure  of  the  disease ;  in  the 
adult,  an  amelioration  of  frequent  paroxysms  and  compara- 
tive physical  and  mental  comfort.  3.  The  bromids  to  be 
effective  in  chronic  and  long-standing  cases  must  be  given  in 
large  daily  doses  to  suppress  convulsions,  from  300  to  400  gr. 
if  necessary.  They  should  be  given  gradually  to  find  the 
sedative  level,  at  which  level  it  is  the  physician's  principal 
duty  to  maintain  them  with  physical  and  mental  comfort  to 
bis  patient.  4.  Hot  and  cold  baths,  high  enema?,  alimentary 
antisepsis,  and  massage  are  absolutely  essential  to  successful 
bromid  medication.  5.  Bromin  is  a  worthy  substitute  for 
the  bromids  in  many  cases  in  which  the  latter  are  contrain- 
dicated  or  cannot  be  given  in  high  dosage.  6.  Salt-starvation 
or  semi  salt  starvation  is  a  great  adjuvant  to  the  bromid 
treatment,  and  should  be  thoroughly  tried  in  all  cases  in 
which  bromids  or  bromin  are  apparently  contraindicated 
before  they  are  discarded,     [j.h.g.] 

4. — Payne's  patient  was  a  female  child,  2J  years  of  age, 
with  negative  family  history.  The  personal  history  showed 
that  in  the  right  eye  there  were  signs  of  convergent  strabis- 
mus shortly  after  birth,  with  the  appearance  of  a  gradually 
progressing  exophthalmos  1  year  later.  There  was  almost 
an  entire  limitation  in  the  downward  movement  of  the 
eyeball  but  with  power  of  moving  the  eye  outward  almost  to 
the  median  line.  Palpation  of  the  globe  met  with  resistance 
and  1  week  before  operation  a  small  body  could  be  felt  at 
the  temporal  side.  Pupillary  reaction  was  sluggish  and  in  the 
fundus  some  postpapillitic  changes  were  noticed.  Tne  diag- 
nosis of  a  benign  tumor  pressing  upon  the  optic  nerve  was 
made.  Upon  laying  open  the  external  canthus,  it  was  found 
that  the  nerve  was  evaginated  and  that  its  sheath  enveloped 
the  tumor.  After  exenteration,  microscopic  examination  of 
the  tumor  showed  destruction  of  the  nerve-tissue  which  was 
replaced  by  glia  cells.  In  addition  to  a  resum(5  of  the  litera- 
ture, the  prognosis  and  pathologic  histology  of  ocular  and 
orbital  neoplasms  are  discussed,  together  with  the  relative 
malignancy  of  optic-nerve  growths,     [m.r.d.] 

6. — Cox,  after  calling  attention  to  the  disadvantages  of 
wire  as  a  sutures,  urges  the  use  of  large,  plain  or  chromicized 
-catgut  in  the  fixation  of  fractures  of  the  patella,  and  gives 
the  histories  of  3  cases  showing  excellent  results  from  the  use 
of  this  suture,     [j.h.q.] 

Medical  News. 

January  IS,  1901.      [Vol.  Ixxviii,  No.  2.J 

1.  Splenic    Anemia — Anemia    with     Enlargement    of    the 

Spleen.     Aloysius  0.  J.  Kelly. 

2.  Some  Diagnostic  Details.    Edgar  Darnall. 

3.  On  Gonorrheal  Cystitis  in  the  Female.    F.  Bierhoff. 

1. — A.  O.  J.  Kelly  reports  a  case  of  splenic  anemia  in  a 

girl  of  22  years.  The  girl  while  never  robust  was  fairly  well 
until  May  of  1899.  Towards  the  close  of  that  summer  pain 
began  in  splenic  region  which  she  attributed  to  a  fall  which 
she  had  recently  sustained.  The  splenic  dulness  extended 
from  the  eighth  interspace  to  two  fingers'  breadth  below  the 
free  margin  of  the  ribs,  and  anteriorly  about  the  same  dis- 
tance beyond  the  ribs.  The  organ  was  distinctly  palpable. 
It  was  hard  and  regular  in  outline  and  the  notch  was  plainly 
made  out.  The  region  was  slightly  tender.  On  February  14 
the  blood  examination  showed  50%  of  hemoglobin  and  8,200 
leukocytes.  The  urine  showed  no  sugar  or  albumin.  There 
was  a  basal  systolic  murmur  present,  the  only  cardiac  symp- 
tom. She  had  two  attacks  of  articular  pain  diagnosed  as 
rheumatism — once  in  the  hip,  then  in  the  right  wrist. 
Sweats  were  frequent  during  March  and  April  and  then 
ceased  entirely,  'ihe  patient's  condition  first  improved  under 
nux  vomica  and  Fowler's  solution,  but  the  improvement 
was  only  temporary  and  there  followed  progressive  decline. 
Splenectomy  was  suggested,  but  the  patient  would  not  sub- 
mit to  the  operation.  Fever  was  present  throughout  the  case, 
ranging  on  an  average  between  100°  and  103°.  Bleeding  from 
an  unusual  source,  the  genitals,  also  occurred.  Towards  the 
close  of  the  case  (the  patient  died  June  19,  1900),  the  dysp- 
nea became  extreme.  This  with  the  anemia  and  enlarged, 
tender  spleen  completes  the  clinical  picture.   The  superficial 


lymphatic  vessels  were  not  enlarged.  No  postmortem  was 
obtained,  so  that  the  condition  of  the  deep  lymphatics  was 
not  ascertained.  The  differential  diagnosis  from  ulcerative 
endocarditis  was  not  an  easy  matter  for  some  time  during  the 
course  of  the  case,     [t  l  c  ] 

3. — Bierhoff  believes  that  many  cases  of  chronic  and  acute 
gonorrheal  prostatitis  may  frequently  simulate  acute  or 
subacute  cystitis.  For  this  reason  he  believes  that  without 
cystoscopy  or  opening  of  the  bladder,  no  positive  diagnosis 
can  be  made  in  the  male.  Of  92  cases  examined  by  the 
author,  67  were  catarrhal,  and  25  suppurative.  Among  these 
three  were  only  5  cases  of  gonorrheal  cystitis,  and  those  were 
found  among  the  suppurative  variety.  In  these  cases  the 
diagnosis  of  gonorrheal  cystitis  was  made  from  .an  examina- 
tion of  the  urine  and  cystoscopy.  In  all  of  the  cases  the 
spread  of  the  disease  beyond  the  originally  infected  area  was 
prevented.  In  all  cases  of  acid  cystitis  the  author  recom- 
mends the  microscopic  examination  of  the  urinary  sediment 
which  will  probably  disclose  the  fact  that  there  are  more 
cases  of  true  gonorrheal  cystitis  than  has  been  supposed. 
He  believes  that  if  appropriate  measures  are  employed  be- 
fore and  after  cystoscopy  in  the  female  during  a  gonorrheal 
cystitis  that  the  dangers  of  this  form  of  instrumental 
examination  are  not  so  great,     [m.r.d.] 


Boston  Medical  and  Surgical  Journal. 

January  10,  1901.     [Vol.  cxliv,  No.  2.] 

1.  A  Short  Account  of  the  Recent   International   Medical 

Congress  in  Paris.    Henry  Barton  Jacobs. 

2.  The  Radical  Treatment  of  Lachrymal  Diseases.    Walter 

B  Lancaster. 

3.  An  Operation  for  Citaract.     Edward  L  Parks. 

4.  Remarks  upon  Spinal  Cocainization  Suggested  by  Cases 

seen  at  Tuflier's  Clinic  in  Paris,  August,  1900.  Maurice 
H.  Richardson. 

5.  The  Purulent  Rhinitis  of  Children  as  a  Source  of  Infection 

in  Cervical  Adenitis.    Carolus  M.  Cobb. 

2. — The  great  majority  of  cases  of  epiphora  are  amenable 
to  the  usual  conservative  treatment  which  consists  of  astring- 
ent and  antiseptic  collyria,  syringing  and  probing,  and  occa- 
sional treatment  of  the  nasal  cavities.  In  spite  of  a  judicious 
selection  and  skilful  application  of  these  methods  there 
remain  a  considerable  number  of  cases  which  are  not  relieved. 
These  are  the  cases  for  which  something  more  radical  must 
be  done,  and  any  method  of  treatment  that  promises  a  quick 
and  sure  relief  from  such  a  condition  is  worthy  of  attention. 
Such  a  method,  it  is  claimed,  is  to  be  found  in  extirpation 
of  the  lachrymal  sac  and  gland.  In  the  case  of  a 
woman  with  an  absolutely  impermeable  nasal  duct  and 
a  lachrymal  fao  distended  to  the  size  of  a  small  lemon  by 
the  long  duration  of  the  disease,  the  sac  was  filled  with 
mucopus,  which  was  infected  with  ozena,  and  which  could  be 
expressed  in  large  quantities  into  the  conjunctival  sac  at  any 
time.  The  appearance  and  the  odor  were  disgusting,  and 
the  patient  was  anxious  for  any  operation  to  gain  quick 
relief.  The  lachrymal  sac  was  removed  and  the  disease  was 
cured.  Removal  of  the  sac  takes  away  the  source  of  irritation, 
and  not  only  does  away  with  the  disease  of  the  sac  and  its 
dangers,  but  diminishes  the  flow  of  tears  materially.  The 
removal  of  the  larger  lachrymal  gland  causes  surprisingly 
little  diminution  in  the  apparent  moisture  of  the  conjunc- 
tival sac.  It  is  only  when  the  eye  is  exposed  to  stimulus 
that  the  difference  is  usually  apparent,  and  then  the  diminu- 
tion is  relative.  There  is  never  an  absolute  dryness  by  any 
means.  Taere  are  some  cases  in  which  removal  of  the  gland 
without  the  removal  of  the  sac  seems  to  promise  relief,  and 
if  so,  is  to  be  preferred.  The  dangers  of  this  radical  treat- 
ment of  lachrymal  diseases  are  :  disfigurement,  orbital 
abscess,  ir  jury  to  the  optic  nerve  and  the  cornea  during  the 
operation,  and  ptosis.  The  possibility  of  excessive  dryness  is 
conceivable  perhaps,  but  has  never  occurred  as  far  as  Lan- 
caster is  aware.    The  history  of  5  cases  i»  given,    [j.m.s.] 

3. — Parks  reports  the  case  of  a  woman,  aged  35  years,  who 
was  nearly  blind.  The  right  eye  was  undeveloped  and  there 
was  a  capsulocretaceous  cataract  in  the  left  eye.  A  very 
large  flap  was  made  and  a  large  iridectomy  was  done  as  a 
first  operation.  Thirty- seven  days  after  the  first  operation 
the  cararact,  which  was  found  to  be  more  capsular  than  ere- 


106 


Tick  PHU.ADELPiiii'] 
Medical  Jocbxal  J 


THE  LATEST  LITERATURE 


[Jaxtaet  19,  ise 


taceoug,  waa  removed.  Five  years  after  the  cpsration  the 
patient  reads  the  tewspapers  without  glasses  ;  tne  visions  is 
\,  and  she  wears  a  4  or  5  J  D.  fer  distance,     f  j.m  s  ] 

4. — Treated  editorially. 

6. — Cobb  reports  the  case  of  a  girl,  aged  5  years,  who  was 
suffering  from  enlarged  glai  ds  on  both  sides  of  the  neck,  just 
below  the  angle  cl  the  jaw.  The  history  of  the  case  was  as 
follows  :  A  child  without  history  of  previous  trouble  with  the 
nose  or  throat  had  diphtheria  at  the  age  of  2  years  and  had  a 
purulent  discharge  from  the  nose  following  this  attack;  2 
years  later  enlarged  tonsils  and  adenoids  are  removed,  and  1 
year  after  the  operation  the  patient  still  had  a  purulent  dis- 
charge from  the  nose  and  a  cervical  adenitis  following  an 
acute  corvza.  There  can  be  no  doubt  but  that  every  case  of 
adenitis  in  the  cervical  region  is  as  truly  the  result  of  infec- 
tion as  adenitis  in  any  otter  part  of  the  body.  The  author 
enters  an  earnest  plea  for  the  treatment  of  these  cases  on  the 
same  lines  that  govern  the  treatment  of  adenitis  in  any  other 
part  of  the  body.  There  is  no  evidence  that  any  considerable 
proportion  of  these  cases  of  cervical  adenitis  is  due  to  tuber- 
cular infection,  and  attention  is  called  to  the  purulent  or 
mucopurulent  diseases  of  the  rasal  cavities  as  a  possible 
source  of  infection.  Infection  having  taken  place  and  the 
discharge  once  established,  absorption  will  sooner  or  later 
occur,  and  the  lymphatics  of  the  nose  being  dirfctly  con- 
nected with  those  of  the  neck,  a  cervical  adenitis  may 
result  at  any  time,  and,  unless  the  puralent  rhinitis  is 
cured,  the  cervical  adenitis  will  run  a  protracted  course.  The 
puiuknt  discharge  from  the  nose  may  not  cause  a  cervical 
adenitis  fc  r  some  time,  because  the  retained  secretion  is  very 
largely  contained  in  bony  cavities,  but  it  eventually  denudes 
the  mucous  memb-ane  over  which  it  flows  and  then  some 
condition,  such  as  an  acute  cold,  blocks  the  flow  of  the  dis- 
charge and  absorption  of  the  retained  secretii  n  takes  place. 
So  long  as  the  source  of  infection  remains  unhealed,  it  is 
hardly  reasonable  to  hope  to  cure  the  adenitis,    [j.m  s.] 


Journal  of  the  American  Medical  Association. 

January  12, 1901.    [Vol.  xxxvi,  No.  2.] 

1.  The  Diagnosis  and  Treatment  of  the  Prebacillary  Stage  of 

Pulmonary  Tuberculosis.    J.  M.  Asdhrs. 

2.  The  Relative  Importance  of  Valvular  and  Muscular  Le- 

sions in  Diseases  of  the  Heart.    S.  Sous  Cches 

3.  A  Clinical  Study  of  Myocarditis.    Lcuis  F.  Bishop. 

4.  A  Plea  for  a  More  Eational  Prognosis  in  Cardiac  Aflec- 

tions.    J.  J.  MoREissEY. 

5.  Surgical  Asepsis  cf  the  Vrethra  and  Bladder,  with  Demon- 

stration of  a  Device  for  the  Purpose.    Fekd.  C.  Val- 

ESTIXE. 

6.  Treatment  of  Prostatic  Hypertrophy.    Parker  Syms. 

7.  Treatment  of  Tuberculosis  of  the  Knee-Joint.    Wisseb 

E.  TOWSSESD. 

8.  Tie  Education  of  the  Sense  of  Touch  in  Feeble-Minded 

Children  and  its  Cotnection  with  Manual  and  Indus- 
trial Training.    Fu.tcher  Beach. 

9.  Euthanasia— A  Medico-Legal  Study.    Lccis   J.  Kosex- 

BEKG  and  N.  E.  Akosstam. 
10.  Eemcval  of  a  Piece  of  Steel  from  the  Globe  by  Electrc- 
magret.    Walter  B.  Johnson.    :        ,v    ■ 

1. — Anc^ers  calls  attention  to  that  period  in  pulmonary 
ttiberculosis  which  precedes  the  presence  of  tuber- 
cle- bacilli  in  the  sputum.  Ue  re.'ers  to  the  fact  that  this 
stage  is  not  tynony moua  with  the "'  pretubercular  stage."  The 
stage  before  the  appearance  of  the  bacilli  is  frequently  a  long 
one.  In  support  of  this  he  quotes  AUbult  and  Turban.  In 
referring  to  the  etiology  of  the  aflcction  he  calls  especial 
attention  to  heredity.  Under  physical  examination  he  men- 
tions in  detail  the  vaiious  modes  of  onset,  calling  particular 
attention  to  "  invasive  symptoms  and  conditions  such  as 
pleiuisy,  gastrointestinal  symptoms,  hemoptysis  and  onset 
with  symptoms  of  laryngitis."  He  calls  attention  to  the  im- 
portance of  taking  systematic  thermometric  records  of  the 
entire  day  for  at  least  several  days  in  succession.  He  cites 
the  value  of  the  tulerculin  test  and  quotes  3  cases  showing 
its  value.  He  further  refers  to  the  value  of  the  x-rays  as 
diagnostic  aids  in  incipient  cases.  Under  treatment  he  calls 
especial  attention  to  the  value  of  "equability  of  climate  with 
an  abundance  of  sunshine."    He  further  insists  upon  the 


importance  of  proper  nutrition.  Amon?  medicinal  agents 
he  prefers  creasote,  cod-liver  oil,  and  the  hypophosphitea. 
A  valuable  bibliography  is  attached  at  the  end  of  the  article. 

[J.    .8.] 

2. — Cohen  gives  a  review  of  the  relative  importance 
of  valvular  and  muscular  lesions  of  cardiac  ori^n. 

He  concludes  with  a  summary  that  the  most  important 
point  to  be  tiken  into  consideration  therapeutically  and  as 
to  prognosis  is  not  the  site  and  nature  of  the  valvular  lesion, 
but  the  condition  of  the  heart-mu=cle,  with  the  exception 
of  mitral  stenosis,  in  which  he  lauds  the  use  of  aconite  to 
reduce  excessive  muscular  eflort  when  compensatorj  hyper- 
trophy is  not  suflicient.     [j.ls  ] 

3. — Bishop,  in  discussing  myocarditis,  calls  attention 
to  the  fact  that  it  is  eminently  a  clinical  disease  and  that 
the  postmortem  findings  do  not  always  coincide  with  the  clin- 
ical manifestations.  Many  of  the  changes  in  the  heart-muscle 
are  dependent  upon  pathologic  changes  in  the  arterial 
system.  A  fatal  attack  of  angina  may  be  brought  about 
in  a  damaged  heart  through  temporary  anemia.  He  (sails 
attention  to  the  fact  that  many  acute  cases  of  myocar- 
ditis are  of  syphilitic  origin.  He  divides  myocarditis  into 
two  clinical  classes  —  those  which  are  due  to  infectious 
diseases  and  those  which  are  due  to  diseases  of  the  blood- 
vessel. He  believes  that  in  persons  beyond  middle  life 
who  are  the  subjects  of  severe  a'.taiks  of  pain  referable  to 
the  left  shoulder  and  left  breast  it  is  reasonable  to  suspect 
myocardiac  disease,  and  such  cases  should  be  carefully 
investigated.  Bishop  says  that  it  is  reasonable  to  suppose 
that  the  pain  of  cardiac  disease  is  due  to  the  'act  that  the 
nerves  of  various  viscera  and  the  nerves  of  the  correspond- 
ing portions  of  the  body  are  connected.  Irregularity  of 
the  force  and  rhythm  of  the  heart's  action  he  believes  is 
an  early  symptom.  The  character  of  the  pulse  is  also  of 
important  diagnostic  value.  He  states  that  myocarditis  is 
quite  common  in  colored  people  on  account  of  syphilitic 
infection.  He  gives  the  report  of  several  CAses  of  myocar- 
ditis,   [f.j.k.] 

4. — Morrissey  in  discussing  the  prognosis  in  cardiac  affec- 
tions comes  !o  the  following  CMDnclusions  :  That  the  condition 
of  the  cardiac  walls,  the  condition  of  the  lesion  and  the  time 
it  has  existed  should  all  be  taken  into  account  when  hear- 
ing a  heart  murmur.  The  individual  should  also  be  taken 
into  account,  especially  pertaining  to  his  occupation  and 
temperament.  It  should  be  remembered  that  murmurs  are 
not  always  indicative  of  endocarditis.  In  life  insurance 
work  too  much  importance  should  not  be  placed  upon 
the  presence  of  a  murmur,  if  the  heart  still  maintains  its 
compensatory  power,  particularly  if  the  occupation  of  the 
patient  is  not  laborious  and  he  has  passed  the  age  when  rhea- 
matic  fever  is  liable.  Morrissey  slates  that  aortic  stenosis  is 
a  favorable  lesion  from  a  prognostic  standpoint  as  regards 
duration  of  li'e.  Too  much  importance  cannot  be  laid  upon 
the  fact  that  a  patient  should  not  be  told  that  he  is  suffer- 
ing from  cardiac  disease  if  the  condition  be  trifling,  for 
neurasthenia  is  apt  to  develop.  Repeated  examinaiicna 
should  be  made  by  the  physician  in  cases  of  cardiac  disease. 
[f.j  k  ] 

6. — \  alentine  gives  an  elaborate  description  of  the  method 
of  surgical  asepsis  of  the  urethra  and  bladder,  to- 
gether with  the  demonstration  of  the  autoirrigator,  a  device 
which  he  has  employed  with  a  considerable  degree  of  satis- 
faction. He  claims  that  this  instrument  enables  the  surgeon 
to  perform  urethral  and  intervesical  irrigations  anywhere. 
It  offers  likewise  a  safe  and  convenient  means  of  anterior 
urethral  irrigation  in  gonorrhea,  when  the  patient  cannot 
visit  his  physician  for  tlie  purpose.  Also  it  furnishes  a  con- 
venient addition  to  the  instrument-bag  for  performing  ante- 
operative  and  postoperative  irrigation  of  the  urethra  and 
bladder.  It  is  also  a  most  convenient  apparatus  for  aseptic 
catheterism.    [w  a  x.p  ] 

6.— Syms  urges  upon  the  profession  the  importance  of  the 
early  recognition  of  obstructing  pro>static  hypertrophy.  He 
insists  that  they  should  submit  such  patients  to  a  radical 
operation  before  cystitis,  prolonged  pain,  infection  and 
fatigue  place  them  in  such  a  condition  that  they  are  unfitted 
to  undergo  a  surgical  operation.  Nothing  can  afford  relief 
to  the  patient  except  some  procedure  which  will  remove  the 
obstruction  to  the  outflow  of  the  urine.  There  are  hut  two 
methods  of  treatment  which  deserve  favor  in  the  minds  of 
the  profession,  namely  :  prostatectomy,  and  secondly,  proe- 


jtxuAur  19,  1901] 


THE  LATEST  LITERATURE 


TTh 

Lm 


Tub  Philadelphia 
edical  jocesal 


107 


tatomy  performed  by  means  of  an  electric  cautery  knife,  the 
operation  being  known  as  that  of  Bottini.     [w  a.n  d  ] 

7. — According  to  Townsend,  the  constitutional  treat- 
ment of  tuberculosis  of  the  knee-joint  should  be 
largely  climatic,  together  with  close  attention  to  any  organ  of 
the  body  which  is  not  in  perfect  condition.  Complete  rest  in 
bed  is  preferable  to  the  ambulatory  treatment  if  the  patient's 
joint  is  tender.  Local  treatment  consists  in  proper  protec- 
tion of  the  articulation,  perfect  rest  of  the  joint,  the  preven- 
tion or  carrection  of  deformity,  the  removal  of  the  tubercu- 
lous process,  and  the  treatment  of  any  complications  that 
may  arise.  To  prevent  deformity  of  the  knee,  plaster  of 
Paris,  leather,  silicate  of  sodium  or  other  materials  may  be 
used.  Care  must  be  taken,  however,  to  see  that  they  are 
made  sufBciently  long  in  order  to  accomplish  the  desired 
result.  The  removal  of  local  tuberculosis  includes  the  oper- 
ations of  arthrectomy,  excision,  and  amputation,  according 
to  the  nature  of  the  case.  In  adults  excision  is  indicated  in 
a  large  number  of  cases,  but  only  exceptionally  in  children. 
[wan  d] 

8.— Beach  endorses  the  suggestion  of  Seguin,  that  the 
proper  way  to  educate  feeble-minded  children  is  the  educa- 
tion of  the  senses,  and  the  more  thoroughly  this  education  is 
conducted,  the  better  will  be  the  training  which  can  after- 
wards be  given.  He  especially  refers  in  this  article  to  the 
education  of  the  sense  of  touch,  which,  in  feeble  minded 
children,  is  much  more  dull  than  in  ordinary  children. 
Such  patients  do  not  suffer  pain  to  the  same  extent  as 
healthy  children.  The  training  conaistj  in  efforts  directed 
toward  the  promotion  of  coordinatioa  and  the  cultivation  of 
the  finer  muscular  movements.  Kindergarten  occupation 
may  prove  especially  serviceable  in  these  cases.  Children 
raised  in  the  country  are  especially  suitable  cases  for  cultivat- 
ing successfully  this  deficient  sense,    [w  as  d.] 

9. — Rosenberg  and  Aronstam  believe  that  the  practice  of 
euthana*ia  would,  in  the  long  run,  cause  more  harm  than 
good.  They  are  convinced  that  it  is  far  better  for  the  welfare 
of  humanity  to  let  a  few  suffer  rather  than  run  the  risk  of 
creating  crime  and  criminals,  which  they  believe  would 
result  from  the  too  frequent  production  of  euthanasia.  In 
no  case  and  under  no  circumstances  should  the  physician 
intentionally  or  directly  cause  death,     [w  a  x  d.] 

10.— Johnson  reports  the  removal  of  a  piece  of  steel 
from  the  vitreous  with  an  electric  magnet  devised  by 
him.  A  chip  struck  the  cornea  causing  an  oblique  wound 
extending  from  limbus  to  limbus  at  the  upper  inner  quad- 
rant, thence  through  the  iris,  causing  prolapse  of  the  latter, 
and  through  the  lens  into  the  vitreous.  Tbe  results  indi- 
cated that  the  eye-ball  could  be  preserved  with  a  prob 
able  later  improvement  of  vision  (patient  could  see  shadows 
after  operation)  by  operative  assistance,     [m.e  d  j 


American  Journal  of  the  Medical  Sciences. 

Janitary,  1901 . 

1.  A  Case  of  Multiple  Fibromata  of  the  Nerves,  with  Arthri- 

tis Deformans.    Robert  B.  Preble  and  Lddvig  Hek- 

TOEN. 

2.  e  Relation  of  Cholelithiasis  to  D'.sease  of  the  Pancreas 
and  to  Fat  Necrosis.     Eugene  L.  Opie. 

3.  A  R  'port  of  a  Case  of  Typhoid  Pleurisy.     Herman  Camp 

GoRDiN'iER  and  Augcst  Jerome  Lartigau 
4    A  Study  of  a  Case  of  Gonorrheal  Ulcerative  Endocarditis 

with  Cultivation  of  the  Gonococcus.    August  Jerome 

Lartigau. 
5.  Obstructive  Biliary  Cirrhosis.    William  W.  Ford. 
0   Dorsal  Dislocation    of   the    Trapezoid,    John    Glendon 

Sheldon. 

1. — Preble   and    Hektoen  report  a  case    of    multiple 
fibromata  of  the  nerves  with  arthritis  deformans. 

The  patient,  a  female,  aged  35,  gives  a  family  history  which 
has  no  bearing  upon  her  own  condition.  The  first  tumor 
appeared  upon  the  forehead  when  the  patient  was  very 
young,  and  after  a  short  interval  many  other  tumors  de- 
veloped in  different  parts  of  the  body.  Joint  changes  showed 
themselves  some  years  after  the  format  on  of  the  tumors. 
The  smaller  joints  in  the  hand  were  affected  first.  The 
tumors  were  almost  without  exception  painless,  and  varied 
in  size  from  time  to  time.    The  patient  complained  of  pain 


in  the  abdomen,  legs,  and  feet;  walking  soon  became  impos- 
sible. T.ie  neoplasms  on  the  forehead  were  arranged  in 
string-like  tortuous  masses,  the  largest  one  being  about  the 
size  of  a  small  bean.  The  tumors  of  the  body,  neck,  and 
limb  varied  from  the  siz  3  of  a  pinhead  to  the  size  of  a  nut. 
In  the  deeper  tissues  the  tumors  were  arranged  parallel  to 
the  long  axis  of  the  body.  They  permitted  of  lateral  motion, 
and  were  not  attached  to  the  skin.  The  arthritic  deformity 
involved  the  joints  of  the  hand,  wrist,  knee,  and  hip.  Tae 
movement  of  the  jaw  was  limited,  and  curvature  of  the  spine 
was  present.  The  joints  of  the  knee  and  hip  were  ankylosed. 
The  nervous  system  showed  no  alterations,  and  the  patient 
was  fairly  intelligent.  Gingrene  of  the  toes  developed  10 
days  before  death.  Upon  postmortem  examination  the  im- 
portant pathologic  lesions  were  the  j  oint  changes,  and  the 
fibromata,  which  appeared  to  spring  from  the  nerve  sheaths. 
The  joints  of  the  wrist,  hand,  ankles,  and  feet  were  especially 
involved ;  some  of  the  joints  were  apparently  completely 
disorganized.  The  tumors  were  connected  with  many  of  the 
nerve  trunks.  Tae  anatomic  diagnosis  was  :  '' Multiple  fibro- 
mata of  the  cerebrospinal  and  sympathetic  nerves ;  com- 
pression of  the  spinal  cord ;  polyarthritis  deformans  with 
kyphoscoliosis,  ankylosis,  and  contracture;  moist  gingrene 
of  the  foot ;  decubitus ;  chronic  dermatitis  of  the  left  leg ; 
inflimmation  of  the  frontal  sinus  ;  chronic  nephritis  ;  mar- 
asmus." The  literature  in  regard  to  these  new  growths  was 
then  carefully  reviewed,     [f  j  k  ] 

3. — Opie  in  an  article  on  the  relation  of  cholelithiasis 
to  disease  of  the  pancreas  and  to  fat  necrosis  directs 
particular  attention  to  the  occurrence  of  pancreatic  disease 
as  a  complication  of  gallstone  colic.  He  mentions  two  ways 
in  which  the  pancreas  may  be  involved.  1.  As  infl  immatory 
changes  are  not  infrequently  dependent  upon  passage  of 
gallstone  such  infiimmation  might  involve  the  pancreas  by 
extension.  2.  A  gallstone  lodging  at  the  orifice  of  the 
common  duct  may  occlude  the  main  pancreatic  duct  and 
favor  the  growth  of  microorganisms  in  the  accumulated 
secretion,  and  even  the  secretion  if  retained  in  the  pincreas 
might  produce  pathologic  changes.  Bilser  described  dis- 
seminated fit  necrosis  in  1S32.  This  necrosis  involves  the 
fat  in  the  neighborhood  of  the  pancreas  such  as  the  omentum, 
subperitoneal  fat  and  mesenteric  fat,  less  frequently  the  sub- 
cutaneous and  pericardial  fat.  Opie  refers  to  Langenhans  as 
demonstrating  that  the  necrosis  is  associated  with  the  separa- 
tion of  the  fat  into  fatty  acids  which  are  insoluble  and  there- 
fore remain  in  the  cell,  and  into  glycerin  which  being  soluble 
is  carried  away.  He  also  mentions  the  researches  of  a  number 
of  investigators  who  believe  that  this  necrosis  is  dependent 
upon  the  pancreatic  secretion  finding  its  way  out  of  the 
gland,  and  that  the  fit-splitting  ferment  of  the  pancreatic 
juice  is  directly  responsible  for  this  pathologic  condition. 
In  his  own  experiments  he  has  shown  that  ligation  of  the 
pancreatic  duct  in  the  cat  is  attended  with  extensive  fat 
necrosis.  The  administration  of  pilocarpin  hastens  this 
pathologic  change.  The  occlusion  of  the  main  pancreatic 
duct  does  not  in  every  case  prevent  an  outflow  of  the  secre- 
tion into  the  intestine  on  account  of  the  communication  of 
the  duct  of  Wirsung  in  the  gland  with  the  duct  of  Santorini 
which  opens  into  the  duodenum.  Schirmer's  observation  on 
the  relations  of  the  two  ducts  are  mentioned :  Oat  of  101 
bodies,  65  were  found  which  had  an  accessory  dact  opening 
into  the  duodenum,  and  that  there  was  an  anastomosis  of 
the  main  duct  with  a  smaller  duct  within  the  organ. 
0.ie  body  showed  3  distinct  openings  into  the  duodenum. 
Four  cases  revealed  a  single  pancreatic  duct  opening  just 
above  the  diverticulum  of  Vater.  In  31  casss  the  smaller 
duct  did  not  open  into  the  duodenum  or  anastomose  with 
the  larger  duct.  From  this  variation  in  the  anatomy  of  the 
ducts  it  is  shown  that  slightly  more  than  one-third  of  the  cases 
of  gallstone  obstruction  at  the  mouth  of  the  common  duct 
would  be  associated  with  retained  panjreatic  secretion.  A 
lengthy  report  of  a  case  is  given  :  The  pvtient,  a  male,  aged 
47,  was  admitted  to  the  Johns  Hopkins  Hospit*!  (service  of 
Dr.  Oiler),  gives  a  previous  history  of  jaundice,  abdominal 
pain  and  fever  lasting  for  3  weeks.  These  symptoms  occurred 
6  months  before  the  present  illness.  Eighteen  days  before 
his  admission  he  was  seized  with  vomiting  and  severe  general 
abdominal  pain  which  lasted  for  5  days.  Hi  was  constipated 
and  there  was  abdominal  distention.  His  .temperature  was 
irregular,  varying  from  100°  F.  to  103°  F  ,  with  chills.  Tae 
pulse  varied  from  100  to  120     Abdominal  distention  and 


108 


The  Philadelphia 
Medical  Joubnal 


] 


THE  LATEST  LITERATURE 


[Jaxtabt  19,  1901 


some  abdominal  pain  and  tenderness  persisted.  Upon  exami- 
nation a  resistent  mass  was  detected  which  occupied  the 
right  hypochondriac  region,  the  right  half  of  the  epigastrium, 
and  the  upper  half  of  the  umbilical  region.  The  leukocytes 
numbered  18,300.  The  urine  is  clear,  the  specific  gravity 
1.017;  sugar  is  not  present,  but  there  is  a  trace  of  albumin. 
The  temperature  varied  between  99.2°  F.  and  1018°  F. 
Another  count  of  the  leukocytes  showed  19,500  per  cubic  mm. 
The  diagnosis  of  suppurative  pancreatitis  was  made  and  the 
patient  was  operated  upon  under  cocain  anesthesia.  A  large 
abscess  was  evacuated.  Death  followed  4  hours  after  the 
operation.  The  autopsy  was  performed  3  hours  after  death. 
An  abscess  was  discovered  occupying  the  position  of  the 
lesser  peritoneal  cavity.  Tne  pancreas  was  large  and  firm  and 
of  a  reddish  color.  Fat  necrosis  was  found  in  the  fat  of  the 
abdominal  walls,  omentum,  mesentery,  in  the  fat  anterior  to 
the  bladder,  in  the  peritoneal  and  retroperitoneal  fat.  A  gall- 
stone, measuring  7  mm.  in  diameter,  was  found  near  the 
orifice  of  the  common  duct.  The  bile  ducts  were  dilated, 
but  the  pancreatic  duct  was  not.  The  gallbladder  con- 
tained over  100  stones.  Upon  microscopic  examination 
the  areas  of  fat  necrosis  showed  necrosis  of  the  fat  cells, 
but  the  outlines  of  the  cells  were  still  preserved.  Tne  pan 
creas  shows  marked  chronic  interstitial  changes  and  dila- 
tions of  many  of  the  acini.  Tnere  are  also  some  necrotic 
areas  and  the  evidences  of  former  hemorrhage.  Inocula- 
tion made  from  the  abscess  wall  revealed  cultures  of  the 
Bat  illus  coli  communis,  the  Bacillus  lactis  aerogenes  and 
the  Bacillus  proteus  vulgaris.  From  the  clinical  and  path- 
ologic evidence  presented  it  was  reasonable  to  believe  that 
the  cause  was  primarily  due  to  a  gallstone,  thereby  caus- 
ing obstruction  and  retention  of  pancreatic  secretion.  A 
biief  history  of  7  other  cases  is  also  given  in  which  a 
calculus  was  lodged  in  the  common  duct  near  its  orifice. 
Six  of  these  cases  were  accompanied  by  fat  necrosis  and 
some  were  associated  with  hemorrhage.  Tnirty-two  cases 
of  pancreatic  disease  and  fat  necrosis  in  association  with 
cholelithiasis  are  tabulated  from  literature.  A  case  of 
Phulpin  is  cited  with  the  report  of  the  autopsy  in  which 
the  anatomic  diagnosis  was  interstitial  pancreatitis  and 
peripancreatic  fat  necrosis  followirg  obstruction  of  the 
pancreatic  duct  from  a  gallstone  in  the  mouth  of  the 
common  duct.  The  following  conclusions  are  drawn  if 
the  gallstone  should  lodge  in  the  orifice  of  the  common 
duct  and  cauee  compression  of  the  pancreatic  duct :  1. 
With  biliary  colic  and  sudden  attack  of  epigastric  pain, 
vomiting  and  collapse,  death  may  occur  in  48  hours.  Tne 
pancreas  will  be  found  enlarged,  with  blood  infiltration  into 
the  organ  and  surrounding  tissues  and  perhaps  some  fat 
necrosis.  2.  Death  may  not  follow  in  48  hours,  but  jaun- 
dice develop  and  the  pancreas  may  become  infected  with 
the  formation  of  an  abscess.  Under  such  circumstances 
the  symptoms  of  sepsis  will  arise,  and  death  occurs  after 
the  lapse  of  some  weeks  or  months.  3.  Repeated  or  long- 
continued  obstruction  of  the  pancreatic  duct  by  gallstone 
may  cause  chronic  interstitial  changes  in  the  pancreas. 
[f.j.k.1 

3. — Gordinier  and  Lartigau  report  a  case  of  typhoid 
pleurisy.  The  patient,  a  physician,  aged  57,  seen  by  Gordi- 
nier on  July  14,  1899,  gave  a  previous  personal  history  of  an 
attack  of  inflammatory  rheumatism  at  the  age  of  16,  which 
lasted  for  several  weeks,  at  20  he  had  typhus  fever,  and  at 
43  he  had  typhoid  fever.  This  illness  lasted  for  4  months, 
and  since  the  attack  of  enteric  fever  he  has  enjoyed  com- 
paratively good  health,  except  that  he  has  suffered  at  times 
from  shortness  of  breath  upon  exertion  and  slight  edema  of 
ankles.  The  present  illness  was  marked  by  loss  cf  appetite, 
malaise,  headache,  constipation,  muscular  and  joint  pain, 
and  colicky  pain  in  the  abdomen.  On  July  10,  1899,  he  was 
confined  to  his  bed,  upon  examiration  the  patient  presented 
cyanosis  of  the  lips,  finger-tips,  and  ears,  the  respirations 
were  hurried,  and  the  pulse  was  small,  irregular  and  rapid 
(120),  bis  temperature  103°  F.,  and  the  tongue  was  coated. 
Tympanites,  tenderness  over  the  right  iliac  fossa,  enlarge- 
ment of  the  liver  and  spleen  were  noted,  but  rose  spots  were 
absent.  Physical  examination  revealed  a  double  mitral  lesion 
with  displacement  of  the  apex  to  the  left  and  redupli- 
cation of  the  second  sound.  The  lungs  showed  congestion 
and  some  edema  posteriorly,  the  urine  gave  a  diazo reaction, 
the  Widal  reaction  was  negative,  leukocytosis  was  absent, 
and  the  Plasmodium  malar'ee  was  not  found  in  the  blood. 


A  provisional  diagnosis  of  typhoid  fever  with  failing  heart 
compensation  and  edema  and  congestion  of  the  lungs  wag 
made.  After  some  days  the  patient  improved,  especially 
those  symptoms  relating  to  the  heart  and  the  lungs,  but  fever 
continued  up  to  this  time.  The  treatment  consisted  in  the 
administration  of  digitalis,  strychnin,  and  nitroglycerin. 
Upon  physical  examination  on  July  17  the  sign?  of  a  right- 
sided  pleural  effusion  were  elicited,  and  two  days  later  the 
signs  were  very  marked.  Aspiration  was  performed  and  two 
quarts  of  a  greenish,  opalescent  fluid  were  withdrawn.  The 
operation  was  repeated  on  two  subsequent  occasions.  From 
the  pleural  exudate  the  Bacillus  typhosis  was  isolated  in 
pure  culture,     [f.j  k  ] 

4. — Litisau  reports  a  case  of  gonorrheal  ulcerative 
endocarditis  with  cultivation  of  the  g-onococcus. 
Tae  patieu',  a  male,  colored,  aged  20,  was  admitted  to  the 
RoDEevelt  Hospital,  August  4,  1900.  It  was  ascertained  that 
the  patient  had  urethral  disease  for  8  weeks  previous  to  his 
admission  to  the  hospital,  and  for  6  weeks  before  he  had  two 
or  three  attacks  of  chills  and  fever  per  week.  Oae  day  before 
admission  he  lost  the  power  of  speech.  On  the  day  he 
entered  the  hospital  his  pulse  was  126,  his  respiration  32, 
and  hia  temperature  103°  F.  His  tongue  was  coated  and  his 
lips  swollen.  An  inguinal  gland  on  the  left  side  was  f  jund 
enlarged.  A  loud  systolic  murmur  was  heard  at  the  apex 
and  was  transmitted  to  the  left.  Several  days  later  (August 
6)  he  developed  low  muttering  delirium.  A  circumcision 
was  performed.  The  urethral  discharge  ceased  after  some 
days  of  treatment  with  irrigations  of  potassium  permanga- 
nate. A  blood  examination  on  August  18  showed  a  leuko- 
cytosis of  11,400  with  a  slight  anemia.  Later  he  developed 
a  swelling  of  the  right  elbow  joint  which  only  lasted  a  day,  bat 
tenderness  persisted.  Fever  was  present  during  the  illness 
and  death  occurred  on  September  5  Postmortem  examina- 
tion showed  ulcerative  endocarditis  of  the  mitral  valve  with 
eccentric  hypertrophy  of  the  lefi  heart.  Urethritis,  edema 
and  congestion  of  the  lungs,  splenic  enlargement  with  infarc- 
tion and  cloudy  swelling  of  the  kidneys  and  liver  were  found. 
Upon  microscopic  examination  of  the  urethra  destruction  of 
the  epithelium  was  found,  and  round  cell  and  polymorphonu- 
clear cell  infiltration  of  the  deeper  tissues.  A  diplocooc  us  resem- 
bling the  gonococcus  tinctorially  and  morphologically  was 
present  upon  the  surface  of  the  membrane  and  in  the  tissues 
beneath.  Sections  of  the  inflamed  mitral  valve  segment  showed 
necrotic  areas,  leukocytic  and  round-cell  infiltration.  Tnere 
were  also  biscuit  shaped  micrococci  as  a  ru!e  arranged  in' 
pairs  and  some  were  within  the  leukocytes.  Innoculation 
from  the  valve  lesion  upon  a  blood  serum  tube  gave  a  growth 
of  two  smaller  grey  colonies  at  the  end  of  4S  hours.  Taeee 
colonies  consisted  of  micrococci  which  were  morpholog- 
ically and  tinctorially  identical  with  the  gonoccccu?.  A 
similar  result  was  obtained  from  an  inoculation  from  the 
heart's  blood.  The  Bacillus  coli  communis  was  found  in  the 
liver,  gall,  and  urinary  bladders.  He  reviews  5  other  cases 
in  which  the  gonococcus  was  obtained  in  culture  ;  (1)  Toat 
of  Tnayer  and  Blumer,  who  obtained  gonococci  from  the 
blood  during  life  and  demonstrated  the  microorganism 
micro8Copica!ly  after  death;  (2)  that  of  Dauber  and  Bjrstj 
who  demonstrated  the  gonococcus  in  pure  culture  in  the 
heart's  blood  ;  (3)  that  ot  Tnayer  and  Lazear,  who  obtained 
cultures  of  the  microorganism  3  times  during  life  and 
from  the  lesions  of  the  pericardium  and  heart ;  (4)  that 
of  Rendu  and  Halle,  who  also  obtained  culture  during 
life  from  the  endometrium  and  heart  lesions  after  death; 
finally  (5)  that  of  Lsnhartz,  who  produced  urethritis  accom-  . 
panied  by  a  purulent  discharge  with  the  gonococci  which 
were  obtained  in  pure  culture  from  an  aortic  valve  lesion. 
Lartigau  draws  the  following  conclusion  :  "  1.  Gonococcad 
urethritis  may  be  the  starting  point  of  a  fatal  septicemia 
induced  by  a  pure  infection  with  the  goncc.ccas.  2.  EndLcar- 
ditis  and  arthritis  are  (.  I'casionally  o  implications  of  such  an 
infectious  disease.  3.  Tne  endocardial  process  may  be  in- 
cited by  the  gonococcus  without  the  association  of  other 
organisms."     [f.i.k] 

6. — Ford  reviews  the  liierature  of  cirrhosis  of  the  liver 
with  special  reference  to  the  frequency  of  ohstructive 
biliary  cirrhosis.  He  gives  a  report  of  21  cases  collected 
from  literature,  and  of  3  cjises  hitherto  unpublished  as  cnrcur- 
ring  since  18S2.  He  mentions  the  researches  of  J.  Wickham 
Legg  and  J.  M.  Charcot  as  being  the  first  observers  to  distin- 
guish obstructive  biliary  cirrhosis  as  a  distinct  pathologic 


JAMCARV    19,   1901] 


THE  LATEST  LITERATURE 


tTlIB  Philadklphia 
Medical  Journal 


109 


condition.  He  also  briefly  cites  the  results  of  the  experi- 
ments of  Legg  "  on  the  changes  in  the  liver  which  follow  lig- 
ature of  the  bile  ducts,"  stating  that  out  of  16  cats  in  which 
the  common  bile  ducts  were  ligated,  12  developed  enlarge- 
ment of  the  liver,  increase  in  the  interlobular  connective  tis- 
sues, and  atrophy  of  the  liver- cells.  Results  in  many  respects 
similar  to  those  of  Legg  were  observed  by  Charcot,  by  tying 
the  bile-duct  in  rabbits.  Both  of  these  observers  naturally 
could  not  exclude  the  ill  effects  produced  by  sepsis.  Two 
cases  were  reported  by  Legg,  in  1874,  which  were  hi^i  first  clin- 
ical observation,  and  in  1876  the  same  author  published  a  case 
of  congenital  deficiency  of  the  hepatic  and  cystic  ducts  with 
interlobular  and  intralobular  cirrhosis  of  the  liver.  Refer- 
ence is  also  made  to  the  monograph  of  Charcot  and  G  jmbault 
published  in  1876  in  which  the  following;  classification  is  set 
forth :  Hypertrophic,  or  Hanot's  cirrhosis,  cirrhosis  depend- 
ing upon  biliary  obstruction  (the  two  conditions  being  identi- 
cal from  an  anatomic  standpoint),  and  Laennec's  atrophic 
cirrhosis.  The  report  of  4  cases  of  cirrhosis  following  biliary 
obstruction  also  appears  in  the  monograph.  Tje  cases  col- 
lected by  Manglesdorff,  of  Leipzig,  up  to  1882,  of  cirrhosis 
depending  upon  biliary  obstruction,  numbered  184.  In  an 
analysis  of  the  cases  collected  by  Ford  he  coneludt  s  that  the 
most  common  cause  is  a  congenital  deficiency  of  the  bile- 
ducts.  As  etiologic  factors,  gallstones  are  next  in  order  of 
frequency.  Round,  sharp  edged  stones  are  much  more  liable 
to  cause  inflammatory  changes  of  the  biliary  passages  than 
smooth,  round  stones,  and  therefore  secondary  sclerotic 
changes  with  stenosis  in  the  ducts  follow.  Cancer  of  the  head  of 
the  pancreas  and  enlarged  glands  at  the  hilus  of  the  liver  are 
rare  caueative  factors.  In  the  early  stages  the  livers  in  cases 
of  obstructive  cirrhosis  are  large,  heavy,  very  firm,  the  sur- 
face is  rough,  the  biliary  passages  are  dilated  and  new 
islands  of  connective  tissue  are  visible.  In  the  later  stages 
in  a  large  proportion  of  cases,  from  the  contraction  of  the 
new  fibrous  tissues,  the  organ  becomes  smaller,  portal  ob- 
struction develops  (ascites,  edema  of  the  extremities,  the 
caput  meduEaa)  and  the  conditions  resemble  more  nearly 
the  cirrhosis  of  Laennec.  Histologically  there  is  an  increase 
in  the  amount  of  fibrous  tissues  which  may  be  interlobular, 
intralobular  or  pericellular  and  is  found  around  the  dilated 
bile-ducts  and  the  bloodvessels.  Many  new-formed  bile-ducts 
are  also  present.  This  reduplication  of  the  bile-ducts,  how- 
ever, is  found  in  many  other  pathological  conditions  of  the 
liver.  Fcrd  calls  attention  to  a  wreath-like  distribution  of 
bile-ducts  which  has  not  been  previously  emphasized  except 
in  the  cases  studied  in  Montreal,  and  he  therefore  suggests 
that  this  change  may  be  of  importance  in  determining  his- 
tologically this  form  of  cirrhosis.  From  a  study  of  the 
clinical  symptoms,  the  cases  of  obstructive  cirrhosis  reveal  a 
symptom- complex  and  subsequent  changes  which  are  very 
characteristic.  The  onset  is  sudden,  marked  by  extreme 
jaundice  and  manifestations  of  cholemia,  clay-colored  stools, 
enlargement  of  the  liver,  absence  of  fever  (only  being  pres- 
ent in  those  cases  presenting  intermittent  jaundice),  emacia- 
tion, and  progressive  loss  of  strength.  Hepatic  incom- 
petence and  autointoxication  is  suggested  instead  of  the  term 
cholemia.  Later  in  the  course  of  the  disease,  when  obstruc- 
tion of  the  liver  is  present,  symptoms  of  portal  obstruction 
arise  which  differentiate  this  from  the  ordinary  cirrhosis  of 
the  liver  in  which  jaundice  is  present.  From  an  etiologic 
standpoint  he  concludes  that  experimentally  cirrhosis  of  the 
liver  can  be  produced  by  obstruction  of  the  flow  of  bile. 
In  man,  however,  there  is  always  some  degree  of  inflamma- 
tion of  the  bile-ducts  and  round-cell  infiltration  accompany- 
ing cirrhosis,  so  that  damming  back  of  the  bile  does  not  only 
lead  to  cirrhosis  but  may  also  lead  to  some  degree  of  in- 
flammatory changes  in  the  bile-ducts.  Granting  that  the 
bile  causes  poisonous  action  on  the  liver-  cells  as  to  cause 
cirrhosis,  yet  we  are  still  in  doubt  as  to  the  route  the  bile 
traverses  in  order  to  come  in  contact  with  the  liver-cells. 
Is  it  direct  or  is  the  bile  first  taken  up  by  the  lymphatic  sys- 
tem and  circulation  before  coming  in  contact  with  the  cells? 
Three  varieties  of  biliary  cirrhosis  have  been  described.  1. 
The  biliary  cirrhosis  of  children  in  India,,  which  is  char- 
acterized by  painless  enlargement  of  the  liver  and  enlarge- 
ment of  the  spleen,  great  thirst,  fever,  jaundice,  increased 
appetite  alternating  with  anorexia,  constipation  and  later  as- 
cites. Anatomically  the  liver  is  bile-stained,  typically  cir 
rhotic,  and  microscopically  presents  the  increase  of  the  bile- 
ducts,  degeneration  of  some  of  the  liver  cells  and  an  abund- 


ance of  fibrous  connective  tissue,  which  is  interlobular  and 
intralobular,  often  surrounding  small  groups  of  liver  cells  so 
that  it  is  really  pericellular.  2.  Hanoi's  cirrhosis  is  charac- 
terized by  attacks  of  abdominal  pain,  a  dull  pain  in  the 
region  of  the  liyer,  increasing  jaundice,  without  clay-colored 
stools,  no  ascites  or  enlargement  of  the  abdominal  veins. 
Emaciation  is  slow  and  bodily  strength  and  fair  health  is 
maintained  for  a  long  while.  Enlargement  of  the  liver 
progresses,  and  fever,  which  is  at  first  slight,  may  become 
marked  and  intermittant.  The  course  of  the  disease  is 
usually  chronic,  although  there  are  acute  cases.  Anatomic- 
ally the  liver  presents  symmetric  enlargement,  is  smooth,  does 
not  show  perihepatitis,  is  jaundiced,  and  the  eommon  and 
hepatic  ducts  are  not  dilated  or  obstructed.  Upon  micro- 
scopic examination  the  new  formed  fibrous  tissue  is  both 
intralobular  and  interlobular,  perhaps  more  often  pericellular. 
There  are  inflammatory  changes  in  and  about  the  bile-ducts. 
3.  Cirrhosis  due  to  biliary  obstruction.  He  gives  the  impor- 
tant difference  between  Hanot's  cirrhosis  and  obstructive 
biliary  cirrhosis  in  a  differential  table,     [f  J  k.] 

6.— Sheldon  reports  a  case  of  dorsal  dislocation  of 
tlie  trapezoid,  which  the  author  states  is  the  second  one 
reported  since  G.iy's  case  in  1809  The  patient  delivered  a 
blow  with  his  fiat  in  such  a  manner  that  the  whole  force  of 
the  blow  was  brought  to  bear  on  the  distal  end  of  the  meta- 
carpal bone  of  the  index  finger.  When  the  blow  was  struck 
there  was  slight  flexion  of  the  wrist  and  elbow-joint.  Patient 
suffered  considerable  pain.  Upon  examination  a  swelling  of 
considerable  hardness  was  seen  that  extended  about  a  centi- 
meter beyond  the  dorsal  surfaces  of  the  other  carpal  bones. 
There  was  no  crepitus,  extravasation  of  blood,  widening  of 
the  wrist,  or  shortening  of  the  metacarpal  bones  of  the  index 
finger.  'The  fluoroscope  showed  dorsal  displacement  of  the 
trapezoid.  Experiments  upon  the  cadaver,  with  application 
of  force  similar  to  that  causing  the  injury  in  the  case  re- 
ported, was  tried  by  the  author  on  12  occasions.  In  no  case 
was  it  possible  to  produce  an  uncomplicated  dorsal  disloca- 
tion of  the  trapezoid,  but  the  result  was  either  that  the 
metacarpal  bone  of  the  index  finger  was  fractured  or  the 
ligaments  were  torn,  rendering  the  application  of  the  force 
in  the  desired  direction  futile.  It  was  found  upon  examina- 
tion of  the  anatomy  of  the  parts  that  division  of  the  dorsal 
ligaments  between  the  trapezoid  and  the  metacarpal  bone  of 
the  index  finger  rendered  it  possible  to  experimentally  simu- 
late the  dislocation,     [m.r.d  ] 


Arcliives  of  Pediatrics. 

December,  1900.     [Vol.  xvii.  No.  12.] 

1.  Fetal  and  Infantile  Typhoid.    John  Lovett  Morse. 

2.  Pulmonary  Tuberculosis  in  Infants  and  Children.    Frank 

P.  NORBORY. 

3.  A   Report  of  187  Cases  of  Measles  with   Reference  to 

Koplik's  Spots  and  Their  Value  in  Diagnosis.    John 

J.  Cotter 
4   Poisoning  by  Vapo-Cresolene.    S.  S.  Ad.\ms. 
5.  Fatal  Intestinal  Hemorrhage  Without  Known  Cause  in 

an  Infant  of  Five  Months.    Maurice  Ostheimer. 

l._See  Philadelphia  Medical  Journal,  Vol.  V,  p.  1284. 

3. — Heredity  is  of  etiologic  importance  in  the  study  of 
tuberculosis,  but  it  has  lost  its  prestige  as  compared  to  its 
former  standing.  In  the  light  of  modern  scientific  inquiry 
infection  has  supplanted  direct  heredity  as  the  etiologic  factor 
par  excellence  in  tuberculosis.  It  is  not  disputed  but  that 
direct  heredity  is  responsible  for  a  limited  number  of  cases. 
The  great  maj  irity  of  cases  of  pulmonary  tuberculosis 
in  infants  and  children,  however,  are  due  to  infection. 
This  is  proven  by  the  fact  that  the  disease  does  not  appear 
until  the  child  is  at  least  3  months  old,  and,  according  to  the 
studies  of  Comby,  there  is  a  steady  increase  of  tuberculous 
cases  from  9fo  during  the  first  year  to  38%  during  the  second 
year.  Tuberculosis  evidently  starts  more  frequently  in  the 
thorax  than  elsewhere.  The  infection  is  not  necessarily 
through  the  respiratory  tract,  for  the  infection  may  come 
from  the  intestines  and  find  its  way  through  the  lymphatics 
to  the  lungs.  Milk  is  undoubtedly  a  source  of  infectioii,  and 
while  not  having  as  vulnerable  point  of  vantage  in  the  intes- 
tine of  a  healthy  infant,  yet  let  disease  or  fatigue  lessen  the 


l\Q         Tbk  PhiladblphiaI 
Medical  JooayAL  J 


THE  LATEST  LITERATURE 


[Jaxuaey  J9, 


resistance  of  the  child  and  infection  is  possible.  The  work  of 
Gehrman  and  Evans  demonstrates  conclusively  that  the  milk 
from  cows  showing  the  tuberculin  reaction  should  not  be 
used,  neither  should  butter  made  from  such  milk  be  used. 
In  infants  we  find  comparatively  few  complications ;  but  in 
patients  more  than  2  years  old  complications  commence  to 
appear.  Of  these,  tuberculous  meningitis  is  the  most  con- 
spicuous and  severe,  while  tuberculous  diseases  of  the  j  jints 
and  bones  occupy  a  conspicuous  place  clinically.  The  infant 
of  tuberculous  parentage  should  receive  proper  care  from 
the  date  of  its  birth.  The  nursling  should  at  once  become 
the  subject  for  artificial  feeding;  the  infant  should  not  live  in 
the  room  with  its  mother ;  and  kissing  should  be  prohibited. 
The  babe  should  live  in  the  open  air  as  much  as  possible ; 
should  have  a  large  airy  nursery;  and  should  have  the  sur- 
roundings conducive  to  good  living  thrown  about  it.  Tne 
diet,  we  know,  must  be  supervised;  the  milk  must  be  under 
inspection  and  should  be  sterilized.  Among  medicines, 
creosote  and  creosotal  have  been  used  with  value  to  the 
patient,     [j.ms] 

3. — Cotter's  studies  furnish  data  concerning  Koplik's 
spots  from  the  complete  records  of  187  cases.  In  these  cases 
Koplik's  spots  were  positive  169  times,  negative  8  times  and 
doubtful  10  times  Poorly  nourished  children  of  the  type 
known  as  marasmic,  those  affected  with  rickets,  or  with  the 
taint  of  hereditary  or  acquired  syphilis  seem  not  to  present 
the  spots  at  all,  or  at  least  not  so  clearly  as  their  more  vigor- 
ous companions.  Two  patients,  a  healthy,  nursing  child,  o 
months  old,  and  a  vigorous  boy  of  3  years,  did  not  show  the 
spots.  After  the  discovery  of  these  spots,  any  attempted 
methods  of  restraint  did  not  arrest  the  progress  of  the  dis- 
ease, so  that  we  can  but  believe  that  when  measles  reaches 
the  stage  of  Koplik's  spots  the  exposure  to  other  children 
has  been  great.  Of  the  entire  187  cases,  not  a  single  one 
presented  Koplik's  spots  as  the  only  evidence  of  the  disease 
which  was  to  follow.  The  author  was  unable  to  isolate  a 
single  case  on  the  strength  of  the  spots  alone,  because  the 
two  symptoms,  fever  and  spots,  invariably  traveled  together. 
[j  M  s  ] 

4.— See  Philadelphia  Medical  Journal,  Vol.  V,  p.  1000. 

6. — Oitheimer  reports  the  case  of  a  boy  who  at  his  birth 
■weighed  7i  pounds.  Ha  did  not  thrive  during  the  first  3 
weeks,  his  weight  falling  to  oJ  pounds.  Then  his  tempera- 
ture rose  to  101°  F.,  with  vomiting  and  diarrhea.  His 
mother  meanwhile  died  of  sepsis.  Upou  a  modified  milk 
mixture  the  weight  of  the  patient  reached  9  pounds.  At  4J 
months  his  temperature  suddenly  rose  to  102.°  Suddenly, 
one  morning  there  was  a  hemorrhage  of  8  ounces  of  bright 
blood  from  the  bowels,  followed  by  collapse,  this  was  followed 
by  another  8  ounce  hemorrhage  2  hours  later,  and  8  hours 
after  that,  6  more  ounces  of  blood  were  passed.  The  autopsy 
showed  no  evidence  of  gross  ulceration  from  which  the 
hemorrhages  could  have  taken  place.  There  were  no  signs 
of  syphilis  nor  of  tuberculosis,    [j.m.s.] 


Ediaburg^h  Medical  Jonroal. 

December,  1900.     [N.  S.,  Vol.  viii.  No.  6.] 

1.  Points  of  Practical  Interest  in  Sargical  Gynecologj-.     VI. 

The  Indications  for  the  0,)eratioa8  of  Hysterectomy 
and  Myohysterectomy  in  Myoma.  H.  Macnaughtox 
Jones. 

2.  The  General  Cafe  of  Ih?  Skin.  Considered  from  the  Point 

of  View  of  Prophylaxis.     W.  Allav  Jamieson. 
8.  Dsntal  Cdrles  as  a  Factor  of  Disease.    J.  R.  Leesos. 

4.  Ooservations  Relating  to  the  Symptoms  and  Efects  of 

Oxygen  Inhalation.    G  Leeb  Dc  Toit. 

5.  Notes  on  Surgery  of  the  Joints.    Arthur  Neve. 

1. — Jones  makes  a  distinction  between  the  terms  hys- 
terectomy and  myohysterectomy.  By  the  former  he 
refers  to  the  operation  of  the  complete  removal  of  the 
uterus,  with  or  without  the  adaexa,  whether  by  the  abdomi- 
nal or  vagiaal  route,  or  by  what  is  known  as  the  combined 
method;  by  the  latter  he  means  the  incomplete  removal  of 
the  uterus,  inasmuch  as  more  or  less  of  the  cervix  uteri  is 
left  and  the  operation  is  completed  without  opening  the 
vagina,  and  hence  is  termed  the  supravaginal  method.  The 
changes  that  may  arise  from  the  presence  of  a  myoma  which 
would  indicate  one  or  another  of  these  operations  he  clASsifies 


as  follows :  (a)  Degenerative  changes  in  the  tumor,  which 
may  be  mucoid,  colloid,  calcareous,  sarcomatous,  suppura- 
tive, gangrenous,  necrobiotic,  telangiectatic,  and  adenocar- 
cinomatous.  (6)  Adaexal  complications :  inflimmatory, 
adhesive,  suppurative,  and  cystic  or  solid  tumors,  (c)  B  jwel 
complications :  obstruction  and  adhesions,  omental  or  intes- 
tinal, {d)  Peritoneal  complications :  peritonitis,  pelvic  or 
general  and  acute,  subacute  or  septic,  and  ascites.  («) 
Vesical,  renal  and  ureteral  complications  :  Displacement  of 
the  bladder  and  ureters,  adhesions,  obstruction  of  the  ureter, 
hydroureter,  hydronephrosis,  pyonephrosis,  and  albumin- 
uria. (/)  Circulatory  complications:  Hemorrhage,  anemia 
and  cardiac  complications,  [g)  Those  arising  from  preg- 
nancy :  Abortion,  miscarriage,  ectopic  gestation,  rupture  of 
the  uterus,  malpresentation,  dystocia,  obstructed  labor,  and 
postpartum  hemorrhage,  (h)  Mental  effects :  The  disorder 
of  mentalizitioa  may  vary  in  degree,  from  the  neurasthenic 
or  hysteric  state  to  phases  of  melancholia,  dementia,  or 
mania.  (t)G3neral  consequences:  Under  this  he  includes  such 
consequences  of  pressure  as  difficulty  in  walking ;  infl  imma- 
tory  changes  in  the  tumor  due  to  exposure  or  traumatism ; 
interference  with  health,  consequent  upon  pain,  weight  of  the 
tumor,  constipation,  urinary  disturbance,  and  the  depression 
and  apprehension  caused  by  the  presence  of  the  tumor. 
Such  examples  as  inversion  of  the  uterus  and  actual  rotation 
of  the  tumor  must  not  be  forgotten,  although  they  are  very 
rare,    [w  a.s  d  ] 

2. — Jamieson  discusses  the  best  method  of  caring  for  the 
skin  and  its  appendages  with  especial  view  to  prophylaxis. 
He  advocates  the  frequent  bathing  in  cold  water  and  believee 
in  the  use  of  the  flash-brush  rather  thin  soip,  the  habitual 
use  of  which  he  deplores.  He  does  not  believe  that  warm 
baths  should  be  taken  often.  The  hair  should  be  washed 
frequently  in  cold  water.  He  advocates  the  use  of  almond 
oil,  as  a  lubricant  when  the  scalp  is  dry,  and  advises  its 
modification,  as  may  be  indicated,  with  eucalyptus  or  resor- 
cin.  He  recommends  finally  Hasgler's  method  for  render- 
ing the  hands  surgically  clean,  as  far  as  possible.  Tbe 
surface  fat  should  be  removed  with  a  paste  of  kaolin  smeared 
over  the  hand  for  a  few  minutes ;  or  as  Jamieson  recom- 
mends the  use  of  a  paste  of  emol-keleet  instead  of  kaolin. 
The  hands  are  then  washed  with  infusion  of  bran  and  tincture 
of  green  soap,  and  dried  with  brisk  rubbing  with  a  rough 
towel.  This  treatment  is  radical,  and  after  the  operation 
efforts  should  be  made  to  restore  the  natural  fat  with  infu- 
sion of  bran  and  lanolin  or  some  other  unguent,    [t.l.c] 

3. — Leeson  advises  the  routine  examination  of  the  teeth 
and  hygienic  care  of  them,  drawing  attention  to  cases  in 
which  various  persistent  neuralgias,  etc.,  had  yielded  when 
the  teeth  were  properly  cared  for.  He  sounds  a  note  of 
caution  lest  this  simple  method  of  procedure  be  overlooked 
in  our  rouiine  examinations  as  to  the  etiology  of  vague  con- 
ditions,   [t.l  c  ] 

4. — Da  Toit  gives  his  observations  relating  to  the  symp- 
toms and  effects  of  oxygen  inhalation.  He  mentions  its 
remarkable  hypnotic  influence  in  many  cases  anl  states  that 
it  has  no  apparent  effect  on  the  respiratory  system.  Oa 
digcition  it  has  the  effect  of  drying  the  mucous  membranes. 
This  is  relieved  by  a  draught  of  acidulated  wat«r.  It  in- 
creases the  appetite  and  thus  asdsts  the  patient  gaining 
weight;  he  also  claims  for  the  gas  an  antipyretic  ac  ion.  Ha 
fur  i  'hes  a  resume  of  the  variois  modes  of  applying  thegis 
to  tie  different  parts  of  the  body.  He  is  espeoiiliy  favorably 
impressed  with  the  rouiine  adminiuration  of  oxygsn  in 
pneumonia,  believing  that  the  gas  does  goo  1  by  reduo  ng  the 
high  temperature  and  grea'ly  easing  the  embarrassed  respi- 
rations. In  the  treatment  of  ulcers  and  wounds  he  follow* 
Reid  in  recommending  that  surgical  dressings  be  not  p'aoed 
on  the  wound  but  on  a  light  wire  cage  or  support,  which 
while  permitting  them  to  afford  protection,  prevents  them 
from  acting  as  foreign  bodies.  Tne  application  of  oxygen 
can  thus  be  facilitated  to  such  wounds.  Upon  the  adminis- 
tration of  oxygen,  the  skin  aroand  the  ulcer  or  inj  ired  por- 
tion becomes  very  dry  and  it  is  recommended  that  Ian  )lin 
be  applied  to  prevent  thj  skin  from  cracking.  In  the  treat- 
ment of  ulcers  the  patients  have  the  g-as  appl.ed  for  several 
hours  at  a  time,  day  and  night,  after  having  h  id  a  sterilized 
water  dressing  applied  at  ct.ier  times,  he  reports  in  general 
very  favorable  results  of  oxygen  in  cases  in  which  he  has  used 
it.    [t.l.c] 

5.— In  the  past  10  years  there  have  been  540  joint  opera- 


Jl»«ARY   19,   1901] 


THE  LATEST  LITERATURE 


[The  Philadelphia 
Medical  Jouhsal 


111 


tions  done  at  the  Kashmir  Mission  Hospital.  Of  this 
number  only  28  were  amputations  for  disease  of  large  joints. 
He  refers  to  the  relative  infrequency  of  amputation  since  the 
introduction  of  antisepsis  and  quotes  figures  to  confirm  this. 
Of  the  cases  operated  ou  97  were  arthrotomies,  with  2  deaths  ; 
So  arthrectomies,  with  2  deaths  ;  70  excisions,  with  4  deaths  ; 
843  other  operations  about  joints,  with  no  deaths.  Indica- 
tions for  artbrectomy  and  for  excision  differ  for  different 
joints,  the  elbow,  for  instance,  requiring  excision  for  a  condi- 
tion, albeit  in  the  knee  joint,  would  only  require  artbrectomy. 
In  order  to  preserve  function  it  is  necessary  to  operate  before 
the  tissues  have  been  destroyed  by  disease  and  the  muscles 
atrophied.  Little  time  should  be  lost  in  drainage  and  rest, 
with  general  treatment,  unless  there  ia  a  local  and  constitu- 
tional response.  Mortality  for  the  540  cases  was  1.5%  ;  for 
the  major  cases,  4^.  Of  the  28  cases  of  amputation  for  dis- 
eased joints  2  died,     [j.h  g  ] 


British  Gynecological  Journal. 

November,  1900. 

1.  The    Gynecologic    Treatment    of   the    Insane.      Ernest 

Hall. 

2.  Pregnancy  Complicated  by  a  Fibroid  Tumor.    Geoege  E. 

Keith. 

1. — Hall  gives  a  conoprehensive  summary  of  the  subject 
of  the  gynecologic  treatment  of  the  insane,  and  as  a 

result,  of  his  investigations  he  concludes  as  follows:  1.  The 
prevalence  of  disease  of  the  pelvic  organs,  and  the  absence 
of  any  other  determinable  organic  disease,  in  many  patients 
who  manifest  psychic  abnormality,  coupled  with  the  fact  that 
in  a  by  no  means  small  percentage  of  cases  the  removal  of 
the  pelvic  disease  is  followed  by  a  rapid  return  to  the  normal 
mental  condition,  justly  lead  us  to  the  conclusion  that  be- 
tween pelvic  diseases  and  mental  aberration  there  exists  some 
correlation,  but  as  to  its  exact  definition  we  cannot  yet  speak. 
2.  In  all  caseg  of  mental  abnormality  in  either  sex  which 
develops  from  the  advent  of  puberty  onwards,  the  condition 
of  the  pelvic  organs,  with  their  functions,  should  be  made  a 
matter  of  searching  inquiry.  3.  Whenever  possible  before 
commitment  in  the  hospital  for  the  insane,  the  pelvic  organs 
should  be  examined,  and  if  any  abnormal  condition  be 
found,  such  condition  should  receive  appropriate  treatment. 
4.  That  gynecologic  treatment  should  be  recognized  as  a  most 
important  part  of  asylum  therapeutics. 

2.  — Keith  reports  a  most  interesting  case  of  pregnancy 
complicated  by  a  fibroid  tumor  which  was  followed  by  an 
attack  of  phlegmasia  dolens  and  pleurisy.  The  p^atient  sub- 
sequently made  a  satisfactory  recovery. 


Berliner  klinische  Wochenschrift. 

October  1,  1900.     [37.  Jabrg.,  No.  40.] 

1.  Concerning  Opiates.    0.  Binz. 

2.  Concerning  Neumann's  Modification  of  Fisher's  Phenyl- 

hydrazin  Test  for  the  Demonstration  of  Sugar  in  the 
Urine.    Margulies. 
S.  Two  Assimilation  Tests  Concerning  the  Effect  of  Oil  Cly- 
sters.   E  Koch. 

4.  Tne  Rile  of  the  Fixed  Cells  in  Inflammation.    P.  Badm- 

garten. 

5.  The  Physiology  and  Patholojiy  of  Bile-secretion.    Albu. 

6.  Experimental  Bence  Jones  Albumosuria.    Zuelzer. 

1. — The  causes  of  artificial  sleep  under  the  influence  of 
hypnotics  and  anesthetics  are  not  underdtood.  The 
anemia  theory  has  not  been  proved.  The  latest  hypothesis 
is  the  one  based  upon  the  presumed  movability  of  the  pro- 
cesses of  ganglion  cells  of  the  nervous  system.  Ether,  mor- 
phin,  and  other  substances,  are  supposed  to  arrest  the  proto- 
plasmic movements  and  to  render  the  cells  unamenable  to 
internal  and  external  stimuli,    [d  r.] 

2. — The  author  endorses  Neumann's  method  (Verhand- 
lungen  der  physiol.  Geaellschaft,  1899)  of  performing  the 
phenylhydrazlu  test.  It  consists  in  the  use  of  a  solution 
of  sodium  acetate  in  acetic  acid  of  from  50  to  75%  strength, 
or  in  glacial  acetic  acid.  A  special  test-tube  is  em- 
ployed, the  urine  is  introduced,  and  the  solution  of  sodium 


acetate  in  acetic  acid  and  2  or  3  drops  of  pure  phenylhydra- 
zin  are  added.  The  whole  is  boiled  down  to  a  certain  point 
indicated  by  a  mark  on  the  tubs,  rapidly  cooled  in  running 
water,  boiled  once  more,  and  again  cooled.  If  sugar  is 
present  the  characteristic  phenylglucosazjn  crystals  appear. 

[D.R.] 

3.— Oil  clysters  were  found  by  Koch  to  influence  metab- 
olism favorably,  in  that  they  increased  the  absorption  of 
nitrogen  and  fat,  while  at  the  same  time  the  fat  introduced 
into  the  rsctum  was  in  part  absorbed  and  aided  nutrition. 

[DR] 

4. — Baumgarten  reviews  the  subject  of  the  role  of  the 
fixed  cells  in  intlanimation.  He  believes  that  they 
play  an  important,  if  not  a  cardinal  part,  and  constitute  the 
primary  point  of  attack  of  the  inflammatory  irritant, 
and  that  upon  their  changes  depend  the  various  phenomena 
of  inflimmatioa.  The  inflammatory  irritant  may  act 
directly  upon  the  leukocytes  (ohemotaxis),  but  the  emigra- 
tion of  these  cells  does  not  occur  through  a  normal,  but 
through  an  altered  vessel  wall.  Tne  inflammatory  prolifer- 
ation of  the  fixed  cells  is  to  be  looked  upon  as  a  reaction  of 
the  living  cells  to  the  damaging  influence  of  the  irritant.  No 
satisfactory  theory  of  inflammation,  in  the  present  state 
of  our  knowledge,  can  be  given.  The  teleologic  view  main- 
tained by  Mirchand,  Buchner,  Metschnikoff,  and  others, 
Baumgarten  rejects,  on  the  ground  that  the  efiects  of  inflam- 
mation are  usually  either  directly  or  remotely  harmful  to 
the  system.  He  defines  inflammation  as  a  pathologic 
procefs  of  the  tissues  produced  by  mechanic,  chemic,  thermic, 
and  parasitic  irritants,  and  constituted  by  alterations  of  the 
circulation  and  nutrition  of  the  tissues,  on  the  one  hand, 
and  the  reaction  of  the  surviving  cells  against  the  irritant 
and  its  harmful  effects,  on  the  other,     [d.r  ] 

5. — Albu  has  had  the  unusual  opportunity  of  observing  a 
patient  with  a  biliary  fistula  that  had  lasted  for  9  years; 
it  was  probably  the  result  of  cholelithiasis.  He  was  able  to 
study  the  bile  chemically,  and  also  the  influence  of  chola- 
gQgues  and  of  diet.  It  seemed  that  fats  increased  the 
flow  of  bile.  Regarding  the  so  called  cholagogues,  he 
found  that  none  had  any  value  in  increasing  the  secretion  of 
bile.  Calomel  and  Carlsbad  waters  produce  an  increased 
flow  of  bile  by  causing  intestinal  peristalsis  and  simul- 
taneously a  stronger  contraction  of  the  bile  passages ;  in 
that  way  they  bring  about  an  opening  of  the  sphincter  of  the 
common  duct  and  a  freer  flow  of  bile,  but  they  do  no'  cause 
an  increased  manufacture  of  bile.  [Albu  says  that  the  use 
of  cholagogues  has  no  phyeiologi3  reason  to  justify  it.  It 
seems  to  us  that  remedies  having  the  power  of  increasing 
the  fl  jw  of  bile,  even  though  it  be  bile  already  manufactured, 
are  not  to  be  despised,  and  have  a  distinct  utility.]  The 
share  taken  by  the  bile  in  digestion  was  also  studied,  and 
here,  too,  the  author  comes  to  iconoclastic  conclusions. 
There  was  no  lessening  in  the  splitting  up  of  fats,  and  there 
was  also  an  abundant  fat  absorption.  The  utilization  of  the 
proteids  in  the  intestines  was  also  unimpaired.  The  anti- 
septic action  of  the  bile  is  entirely  denied  by  Albu.  In 
the  fistula  patient  studied,  and  in  another  case  of  complete 
closure  of  the  common  duct  by  a  pancreatic  cancer,  there 
was  no  particularly  offensive  odor  to  the  feces.  Bile  itself  on 
standing,  quickly  becomes  putrid.  If  decomposition  were 
active  in  cases  in  which  the  bile  does  not  enter  the  intestines, 
it  would  manifest  itself  by  an  increase  in  the  ethereal  sul- 
fates in  the  urine.  These  were  carefully  studied,  and  no 
such  increase  was  found.  He  concludes,  therefore,  that  the 
traditional  view  of  the  antiseptic  action  of  bile  in  the  intes- 
tine must  be  abandoned,     [d  r  ] 

6,— In  a  dog  poisoned  witu  pyrodin,  Zielzsr  found 
Bence- Jones'  albumose  ia  the  urine.  The  reactions 
were  with  nitric  acid  a  heavy  precipitate  in  the  cold,  soluble 
by  heat;  the  same  reactions  were  obtained  by  the  use  of 
sulfosalicylic  acid,  picric  acid,  Alm(5a's  reagen',  acetic  acid, 
and  patassium  ferrocyanid.  A  half  saturation  with  sodium 
chlorid  gave  a  dense  turbidity.  O.i  heating  the  urine;  acidu- 
lated with  acetic  acid  to  within  50  or  60°  C.  a  marked^turbidity 
developed,  which  disappeared  on  heating  to  100°  0.  The 
alcoholic  precipitate  from  the  urine  gave  Millon's,  the  biuret, 
and  the  lead  sulfil  reactions,  and  in  solution  the  same 
reactions  as  the  original  urine.  Bence- Jones'  albumos- 
uria has  been  found  especially  in  diseases  of  the  bones, 
particularly  those  characUrized  by  progressive  anemia. 
Such  an  anemia  was  present  in  the  dog.    This  suggeste  an 


112 


The  PhiladslphiaI 
Medical  Jodbnal  J 


THE  LATEST  LITERATURE 


IJAaCAEY   19,   UW 


examination  of  thie  urine  in  grave  anemias  for  Bence- Jones' 
body,     [d  k  ] 

October  8,  1900.    [37.  Jahrg.,  No.  41.] 

1.  Several  Cp!1  Problems  unci  Their  Significance  for  the  Scien- 

tific Establishment  ot  Organotherapy.   D.  Hansemasn. 

2.  The  Treatment  of  Bronchial  Affections  by  the  Recumbent 

Position.    0.  Jacobson. 

3.  Methods-  for  Prestrving  Anatomic  Preparations  True  to 

Nature.    L.  Pick. 

4.  Experiments  witti  Eye  Magnets.    S.  Tdek. 

5.  Anatomy    of  the  Accessory  Cavities  of   the  Nose.     G. 

BRtiHL. 

6.  The  Application  of  the  Milk  Thermophor.    P.  Sommee- 

FELD. 

1. — The  author  states  that  every  organ  is  necessary  for 
the  maintenance  of  health,  and  that,  as  eelf  evident  as  this 
expression  may  seera,  it,  nevertheless,  has  only  been  recog- 
niztd  recenll)',  and  is  even  st'll  doubted  by  some.  In  disciiss- 
ing  the  metabolism  concerned  in  internal  secretion,  attention 
is  called  to  the  fact  that  there  are  many  organs  possessing 
glandular  structure,  but  no  excretory  passage,  as  the  supra- 
renal capsules,  thyroid,  the  hypophysis,  the  glandula  carotica, 
and  the  specialized  glands  of  some  hibernating  vertebrates. 
From  the  relation  that  metabolism  has  to  the  blcod  it  is 
evident  that  when  any  species  of  cell  functionates  abnor- 
mally that  there  must  also  be  some  changes  in  the  blood, 
and  consequently  also  in  the  functional  activity  of  other 
organs,  depending  upon  the  pathologic  changes  that  have 
been  produced.  The  relations  between  the  thyroid  gland, 
suprarenal  capsules,  pancreas,  pituitary  body  and  generative 
organs  and  the  economy  are  discussed,  and  the  various 
results  following  extirpation  of  these  organs  described. 
[m  r  d.] 

2. — The  first  indication  in  the  treatment  of  all  bronchial 
processes  is  the  removal  of  the  pathologic  exudate  elimi- 
nated by  the  bronchi.  He  believes  that  expectorants  are 
followed  by  the  reproduction  of  the  exudate.  Gravity  and 
altered  alveolar  expiratory  pressure  play  a  minor  role.  The 
therapeutic  t  fleet  desired  is  not  only  to  alleviate  the  expec- 
toration but  also  to  regulate  it.  As  soon  as  the  secretion  has 
reached  such  a  level  that  it  encroaches  uptn  the  area  of 
still  sensitive  mucous  membrane,  expectoration  results. 
This  accounts  for  elimination  of  the  exudate  by  expectora- 
tion when  the  patient  arises  in  the  morning,  who,  during 
the  sleep,  had  the  exudate  evenly  distributed  through  the 
dilated  bronchi  with  the  admission  of  air  into  the  peripheral 
portions  of  various  Ironchial  twigs  and  thence  into  the 
alveoli.  The  procedure  mentioned  in  the  title  is  indicated 
in  chronic  bronchial  blennorrhea  in  consequence  of  a 
difluse,  small,  cylindric  bronchiectasis,  and  can  also  be 
fruitful  of  good  results  in  chronic  abscesses  of  the  lungs 
and  sacculated  bronchiectasis.  Contraindications  are  all 
acute  bronchial  afi'ecticnsand  exceptionally  large  abscess 
cavities,     [m  r  r  ] 

4. — Turli  believes  that  there  are  2  methods  for  extracting 
splinters  from  the  eye.  The  methods,  however,  are  not  to 
be  diflerentiated  by  the  size  of  the  magnet  that  is  employed 
(respectively  the  large  magnet  by  Haab  and  the  small  mag- 
net by  Hirschberg)  or  the  relative  number  of  experiments,  but 
by  the  operative  procedure  that  is  employed.  He  be- 
lieves that  the  small  magnet,  which  in  the  majority  of  cases 
must  necessarily  be  introduced  into  the  vitreous  and  cause 
injury  to  various  tissues  of  the  eye,  is  inferior  to  the  large 
magnet  which  even  upon  external  application  generally 
exerts  sufficient  force  to  withdraw  the  splinter  oiat  of  the 
wound  it  originally  produced,  or  to  conduct  it  to  the  anterior 
portion  of  the  eye  so  that  a  simple  corneal  section  will  be 
sufficient  to  re  nder  its  extraction  easy.  Formerly  the  indica- 
tions for  the  employment  of  either  one  of  the  magnets  has 
been  upon  former  clinical  experiments.  The  author,  how- 
ever, has  made  a  series  of  experiments  regardirg  the  attrac- 
tive power  of  the  two  magnets  upon  splinters  of  a  given 
weight  and  at  given  distances.  In  the  cases  of  the  large 
magnets  the  current  employed  was  from  1  to  18  amperes  and 
in  the  small  magnet  from  SJ  to  -JJ  amperes.  The  results  of 
the  author's  experiments  are  as  follows  :  The  small  niag:- 
net  is  preferable  when  it  can  be  approached  within  a 
few  millimeters  ot  the  splinter  without  injury  to  the  vitreous. 
This  includes  those  foreign  bodies  in  the  anterior  chamber, 


posterior  chamber,  iris  or  lens  which  can  easily  be  reached 
by  a  corneal  section.  In  more  deeply  situated  foreign  bodies 
where  the  small  magnet  can  only  avail  after  penetrating  the 
vitreous,  the  application  of  the  large  magnet  is  indicated. 
The  stronger  magnet  when  properly  applied  is  not  only  the 
more  efl"ective  but  also  the  least  dangerous,    [m.r.d  ] 

6. — The  advantage  of  the  milk  thermophor  ifi  to  preserve 
and  prepare  the  milk  for  some  time  at  a  comparatively  high 
temperature,  thus  obviating  the  necessity  of  warming  the 
milk,  and  with  the  advantage  of  always  having  drinkable 
milk  at  hand.  Formerly,  as  established  by  Fiiigge,  milk  that 
had  been  pasteurized  had  to  be  kept  at  a  low  temperature 
until  used.  Experiments  show  that  the  tubercle-bacilli  were 
killed  in  the  milk  that  had  been  left  in  the  thermophor  for 
4  hours,  and  that  many  typhoid-bacilli  were  killed  as  well. 
He  sums  up  the  results  of  his  experiments  a«  follows  :  Milk 
after  being  in  the  thermophor  for  4  hours  contains  but  veiy  j 
few  germs  (sometimes  none  at  all)  ard  typhoid  and  tubercle- 
bacilli  are  certainly  killed  during  that  time  of  sterilizition. 
[mrd.] 

4 

Deutsche  Zeitschrift  fttr  Chirarg-ie. 

Aiigit.it,  1900.     [56.  Bind,  5  and  6  Heft.] 

18.  Traumatic  Purulent  Osteitis  of  the  the  Skull.  H.  Fischer] 

19.  Hernia  of  the  Anterior  Vaginal  Wall.    Edm.  Rose. 

20.  Acute  Postoperative  Dilation  of  the  Stomach,  as  a  Reeolljj 

of    Compression   of  Duodenum    by    the    Meseater" 
Artery.    P.  Miller. 

21.  Cystadenoma  Mammae  and  ite  Relation  to  Circinoma  ( 

the  Breast.    Tietze. 

22.  Multiple  Echinococcus  of  the  Liver.    Kositzbr. 

23.  Retroperitoneal  Lipoma.    G.  Heiseicics. 

21.  Smaller  Communications,    Occlusion    of   the   Inteetine  ( 
during  Pregnancy.    Tenderich. 

18.— In  almost  every  case  of  purulent  osteitis  of  the  i 
skull,  the  dura  was  sooner  or  later  involved.  Toe  char- 
acter of  the  inflammation  of  the  dura  wm  either  one  of  th^ 
following  forms :  1.  Gangrene  of  the  dura  in  <x)nnectio 
with  gangrene  of  the  brain  substance.  2.  Extradura 
abscess  ;  this  form  being  much  more  frequently  found. 
A  diflfase  pachymeningitis.  This  third  form  was  either 
acute  internal  hemorrhagic  pachymeningitis,  or  perhaps 
diffuse  purulent  pachymeningitis.  In  cases  of  gangrene  the  ' 
dura  was  collapsed,  black  brown  in  (»lor,  empty  of  blood, 
and  very  foul  smelling,  and  when  grasped  by  forceps,  small 
leather  like  pieces  were  broken  off  ea,-ily.  In  the  purulent 
pachymeningitis,  the  dura  was  red,  swollen  and  soft,  and 
sometimes  studded  with  small  hemorrhagic  dots ;  micro- 
scopic examination  showed  small  round-cell  infiltrations. 
Clicicallj'  it  was  impossible  to  recognize  when  gangrene  had  ' 
set  in,  and  sometimes  the  extradural  abscess  was  also  moat 
difficult  of  recognition.  Chief  among  the  indications  point- 
ing toward  abscess,  was  the  presence  of  fever  accompanied 
by  gastric  disturbances,  weakness,  diarrhea,  and  enlarge 
ment  of  the  spleen.  These  symptoms  were  generally  accom- 
panied by  the  usual  signs  of  cerebral  pressure.  The  pulse 
was  generally  quickened.  The  diffuse  form  cf  purulent 
pachymeningitis  caused  death  very  quickly.  The  prognoeis 
however,  of  traumatic  purulent  pachymeningitis  is  no:  abso- 
lutely fatal,  providing  proper  operation  be  instituted  early 
enough.  In  osteitic  leptomeningitis,  the  infection  g.^iins 
access  to  the  pia  either  from  the  extension  of  an  extradual 
abscess  inwards  or  directly  from  the  diseased  bone  itreif. 
Generally  the  process  is  one  that  might  be  termed  "  contact 
infection."  The  suppuration  penetrates  the  whole  ihickneaa 
of  the  dura,  and  finds  its  way  into  the  capillary  network  of 
the  arachnoid,  more  rarely  the  suppurative  process  remains 
external  to  the  dura,  and  in  these  cases  leptomeningitia 
rarely  occurs.  Sometimes  inflammation  of  the  sinoa 
develops  before  the  leptomeningitis,  and  then  the  infection 
gains  access  to  the  pia  by  following  along  the  smaller  veins. 
Simple  leptomeningitis  rarely  occurs,  it  usually  being  asso- 
ciated with  some  complication,  such  as  cerebral  abscess  or 
sinus  phlebitis.  Clinically  we  recognize  two  different  forms 
of  inflammation  of  the  pia,  the  circumscribed  purulent  lep- 
tomeningitis or  abscess  of  the  pia,  and  the  diffuse  leptomen- 
ingitis. The  second  form  is  again  divided  into  leptomen- 
ingitis serosa,  purulent  menigitis  of  the  corter,  and  third. 


January  19,  19J1] 


THE  LATEST  LITERATURE 


[ 


The  Philadelphia 
Medical  Journal 


113 


purulent  leptomeningits  of  the  spine.    The  prognosis  of  all 
forms  of  leptomeningitis  is  very  unfavorable,     [g  b  vv.] 

19.— Rose  reports  an  interesting  case  in  which  the  preg- 
nant uterus  was  displaced  forwards  so  as  to  appear  as  a 
hernia  iu  the  anterior  vaginal  wall.  The  patient  was 
a  married  woman,  38  years  of  age.  She  complained  greatly 
of  dysuria  and  constipation.  Examination  showed  a  hard 
tumor  presenting  in  the  anterior  vaginal  wall,  and  which 
apparently  pressed  the  uterus  upwards  and  backwards. 
Further  examination  under  chloroform  was  made,  and  the 
iumor  was  supposed  to  be  a  myoma  in  the  anterior  wall  of 
the  uterus.  Operation  for  its  removal  was  made  through  an 
incision  reaching  from  the  umbilicus  to  the  symphysis. 
Even  after  the  abdomen  had  been  opened  and  the  hand  had 
explored  the  tumor,  the  diagnosis  of  myoma  was  still  ad 
hered  to.  An  incision  in  the  left  tube,  however,  was  followed 
by  a  stream  of  blood,  which  showed  that  the  diagnosis  was 
not  correct.  After  the  tumor  had  been  brought  up  out  of 
the  pelvis,  it  became  much  softer,  and  aspiration  withdrew 
only  clear  serum  ;  and  also  by  ballotment  a  body  was  felt  to 
strike  against  the  palpating  finger.  Toe  diagnosis  of  preg- 
nancy was  then  made  and  the  abdomen  immediately  closed. 
About  two  months  later,  during  an  attack  of  tonsillitis  and 
influeriza,,  the  patient  aborted,  and  a  fetus  about  the  length 
of  a  finger  was  discharged,    [o.b  w  ] 

20. — Miller  has  written  an  elaborate  article  on  post- 
operative dilation  of  the  stomach,  brought  about 
through  compression  of  the  duodenum  by  the  superior  mes- 
enteric artery.  In  conclusion  he  says  that  incarceration  of 
the  duodenum  by  the  superior  mesenteric  artery  after  ab- 
dominal operation  occurs  quite  frequently,  only  it  ia  not 
diagnosed  as  such,  because  in  the  maj  5rity  of  cases  a  cure  is 
brought  about  either  spontaneously  or  through  washing  out 
of  the  stomach.  The  condition  is  generally  supposed  to  be  a 
severe  postoperative  vomiting,  resulting  as  the  eflects  of  the 
narcotic.  He  does  not  mean  to  say,  however,  that  chloro- 
form vomiting  never  occurs,  and  that  every  case  of  post- 
operative vomiting  is  the  result  of  intestinal  incarceration, 
but  one  should  bear  in  mind  when  dealing  with  cases  of 
severe  and  continued  vomiting  after  operation,  the  possibil- 
ity of  the  presence  of  a  duodenum  incarceration,  and  of  a 
consequent  dilation  of  the  stomach.  Also,  at  postmortems, 
in  a  large  number  of  cases,  the  cause  of  death  has  been  put 
down  to  peritonitis,  whereas  in  truth  the  fatal  result  has  been 
due  to  the  above  form  of  intestinal  obstruction. 

21. — Tietze  has  made  quite  an  elaborate  research  in  the 
pathogenesis  of  cystadenoma  mammae.  He  finds 
two  forms  of  cystadenoma  :  1.  the  cystadenoma  of  Sohim- 
melbusch,  characterized  by  an  overdevelopment  of  the 
epithelium  until  the  alveoli  are  completely  filled  by  the  pro 
duction  of  papillary  projections  of  epithelium,  with  or  without 
connective  tissue  and  by  the  formation  of  villi  containing 
glandular  acini.  This  form  readily  develops  into  carcinoma. 
2.  The  cystadenoma  intracanaliculare.  This  form  is  charac- 
terized by  numerous  small  growths  proceeding  from  the  cyst- 
wall  and  consisting  of  a  mass  of  glandular  acini.  The  pedicle 
of  the  growth  may  be  penetrated  by  the  epithelium.  This 
form  may  develop  into  true  adenoma  or  into  adenocarcinoma 
destruens.  The  transition  form  and  the  true  adenoma  may 
be  further  characterized  by  a  peculiar  network  of  villous-like 
pn  jections  covered  by  epithelium.  Tietze  prefers,  however, 
to  call  both  the  first  and  second  forms  under  the  simple  name 
cystoma  mammae,  as  he  believes  they  are  genetically  thesame. 
Cystoma  mammae  is  generally  due  to  a  peculiar  inflamma- 
tory condition  of  the  breast,  leading  to  the  development  of 
multiple  cysts,  which  are  characterized  by  an  excessive 
growth  of  glandular  epithelium  seen  either  in  the  formation 
of  alveoli  and  acini  or  in  the  form  of  multiple  papillary  ex- 
crescences, which  lead  to  the  development  of  conditions  very 
similar  to  that  of  intracanalicular  adenoma.  Through  the 
growth  of  the  cyst,  the  epithelium  lining  the  cyst  wall  may 
become  flattened  out,  or  entirely  lost.  A  participation  of  the 
connective  tissue  in  the  inflammatory  process  is  often 
present,  but  it  is  of  less  importance  than  the  overgrowth  of 
the  epithelium.  The  disease  has  a  tendency  to  become 
malignant,  either  developing  into  ordinary  carcinoma  or  into 
the  adenocystoma  destruens.  The  tendency  of  the  condition 
to  develop  into  either  cancer  or  adenoma  depends  on  how 
far  the  growth  of  the  epithelium  keeps  to  its  normal  pro- 
clivities of  proliferation,  [g.b  w.] 
22.  — Konilzer  reviews  the  literature  on  multiple  echi- 


nococcus  of  the  liver,  but  in  none  of  the  cass  reported 
can  he  find  any  one  case  in  which  there  were  more  than  3  cysts 
present.  He,  however,  reports  one  from  his  own  experience, 
in  which  5  separate  cysts  existed  in  a  woman  21  years  of  age. 
The  cysts  were  arranged  in  2  groups,  separated  from  each  other 
by  intervening  liver  parenchyma.  The  first  group  was  situated 
on  the  left  part  of  the  liver  and  consisted  of  2  cysts.  These  were 
opened  though  a  laparotomy  and  drained.  The  remaining  3 
were  openea  through  the  pleura  and  emptied.  At  the  same 
time  a  subphrenic  abscess  was  opened.  Exudative  pleuritis 
followed  the  incision  into  the  pleura,  necessitating  resection 
a  rib  and  drainage.  The  patient  was  finally  discharged  cured. 
The  first  group  of  cysts  was  easily  approached,  because  one 
of  the  cysts  projected  just  below  the  sternum.  The  second 
group,  however,  occupied  the  upper  right-hand  part  of  the 
liver  and  was  hidden  under  the  ribs.  The  individual  cysts 
of  both  groups  were  connected  with  each  other,  but  no  con- 
nection could  be  found  between  the  2  groups.  The  contents 
of  the  cysts  consisted  of  thin  pus  containing  numerous  daugh- 
ter cysts  and  bits  of  membrane.  For  the  development  of 
these  separate  groups  of  cysts  it  ia  necessary  for  a  double  in- 
fection to  take  place,  as  there  could  not  be  found  the  slightest 
trace  of  any  connection  between  the  2  groups.  As  regards 
the  frequency  of  occurrence  of  multiple  echinococcus,  Konit- 
zer  says  that  the  multiple  fjrm  occurs  in  about  12  and  xVj^ 
of  hepatic  echinococcus  of  the  liver.  The  diagnosis  of  tlie 
condition  is  very  difficult,  even  at  the  time  of  operation. 
[g.b.w] 

23. — Heinriciue  reports  the  only  case  of  retroperi- 
toneal lipoma  which  has  been  put  on  record  in  Finland. 
The  patient  was  a  woman,  39  years  of  age.  The  growth  had 
been  present  not  over  half  a  year,  but  at  examination  the 
circumference  of  the  abdomen  at  the  umbilicus  had  already 
reached  80  cm.  The  condition  was  such  as  led  to  a  diag- 
nosis of  abdominal  tumor,  but  the  nature  of  the  growth  was 
not  determined  until  the  operation.  The  abdomen  was 
opened  in  the  linea  alba,  and  a  tumor  projected  covered  by 
thin  peritoneum,  of  a  yellowish-red  color.  The  peritoneum 
over  the  tumor  was  split  longitudinally,  and  the  lower 
portion  of  the  growth  shelled  out  of  its  position.  The 
growth  was  found  to  consist  of  6  lobes,  each  about  the  size 
of  an  ostrich  egg.  The  uppjr  part  of  the  tumor,  which  was 
about  twice  the  size  of  a  man's  head,  was  also  removed. 
The  removal  of  the  growth  left  a  large  apace  in  the  abdom- 
inal cavity,  surrounded  by  folds  of  peritoneum.  This  peri- 
toneum was  stitched  to  the  abdominal  wound,  and  the  hole 
packed  with  iodoform  and  sterile  gauze.  Two  months  after 
the  operation  there  was  a  small  unimportant  granulating 
surface  present  when  the  patient  left  the  hospital.  Hein- 
ricius  reports  quite  in  detail  all  those  cases  of  retropsritoneal 
lipoma  which  he  can  find  recorded  in  medical  literature. 
[g  B  w  ] 

24, — Tenderich  reports  a  case  of  intestinal  occlusion 
occurring  in  a  woman  in  the  latter  months  of  pregnancy. 
The  symptoms  led  to  a  diagnosis  of  ileus  with  the  seat  of 
constriction  probably  just  to  the  left  and  below  the  unbilicus. 
Operation  was  performed  under  chloroform,  and  on  opening 
the  abdomen,  the  markedly  dilated  loops  of  the  intestine 
forced  themselves  out  of  the  opening  and  were  only  with  dif- 
ficulty pushed  back  into  the  abdominal  cavity  again.  Occlu- 
sion was  found  to  be  due  to  a  strand  of  membrane,  which 
ran  from  the  region  of  Poupart's  ligament  upwards  to  above 
the  navel.  The  part  of  the  intestine  which  was  constricted 
appeared  to  have  lost  its  vitality,  consequently  it  was  brought 
up  to  the  wound  and  left  exposed  there.  The  second  day 
after  the  operation,  the  patient  still  having  fecal  vomiting, 
the  dressing  was  removed  and  the  suspected  portion  of  the 
intestine  was  found  to  be  completely  necrosed.  The  intes- 
tine was  then  sutured  in  place,  and  an  anus  praeternaturalis 
was  made.  The  patient  then  made  a  gradual  recovery, 
though  fecal  fistula  still  existed  even  after  the  patient  had 
returned  to  her  work.  The  opening,  however,  was  rendered 
tight  by  a  Dupuytren'a  apparatus,     [a  b.w  ] 


Kevue  de  M^decine. 

September  10, 1900.    [20me  Ann^a,  No.  9.] 

1.  Hypertrophic  Hepatopancreatic    Scleroais    with   Hyper- 
splenomegaly.    G.  Guir.LAiN. 


114 


The  Philadelphia"] 
Medical  Jodenal  J 


THE  LATEST  LITERATURE 


[Jascaet  I'i,  IWi 


2.  A  Case  of  Compression  of  the  Superior  Vena  Cava  by  an 

Aortic  Aneurysm  of  Syphilitic  Origin.    C.  DoprER. 

3.  Pneumothorax  with  Valve  Mechanism.    Duplant. 

4.  Precocious  Spinal  Syphilis  with  the  Syndrome  of  Brown- 

S^quard.    Brousse  and  Ardin  Delteil. 

1.— Guillain  reports  the  case  of  a  woman,  aged  52  years, 
without  hereditary  antecedents,  who  had  always  been  in 
good  hea'th  except  for  an  attack  of  variola  at  the  age  of  10 
years,  who  complained  of  icterus.  The  jaundice  began  sud 
denly  7  years  before  the  author  saw  her,  and  had  been  pres- 
ent, with  varying  intensity,  ever  since.  During  the  7  years, 
crises  of  splenic  and  hepatic  pain  had  manifested  themselves. 
At  the  time  of  admission  to  hospital  the  patient  had  slight 
hypertrophy  of  the  liver,  an  enormous  spleen,  and  icterus. 
Except  for  some  slight  disturbance  of  the  digestion  the 
patient  was  healthy.  Examination  of  the  urine,  made  at 
various  times  while  the  patient  was  under  observation, 
showed  the  presence  of  biliary  pigments  but  no  biliary  acids  ; 
in  a  further  development  of  the  case  the  normal  biliary  pig- 
ments disappeared  from  the  urine  but  urobilin  and  its  chro- 
mogen  which  had  existed  from  the  beginning  of  the  case 
persisted.  The  patient  died  after  about  8  weeks'  residence  in 
hospital  after  hemorrhage  from  the  nose,  the  stomach,  and 
the  bowels.  At  autopsy  no  ascitic  fluid  was  found  in  the 
peritoneal  cavity.  The  liver  was  seen  with  its  sharp  inferior 
bolder  extending  well  into  the  left  hypochondriac  region. 
The  spleen,  which  was  covered  above  the  liver,  appeared 
voluminons  and  extended  almost  to  the  crest  of  the  ilium. 
Bjth  the  liver  and  spleen  were  covered  with  a  thick,  resist- 
ant, whitish  false  membrane.  Examination  of  the  pancreas 
showed  relative  hypertrophy  of  the  organ,  a  hypertrophy 
that  seemed  to  be  principally  in  the  neighborhood  of  the 
head  of  the  gland.  Micio  scopically,  the  liver  showed  that  it 
was  the  seat  of  a  portobiliary  cirrhosis  and  presented  the 
lesions  cf  grave  icterus.  The  spleen  presented  a  very  dense 
sclerosis  of  its  capsule,  a  sclerosis  that  was  rich  in  fibers,  but 
poor  in  nuclei.  Tne  substance  of  the  organ  was  also  the 
seat  of  a  sclerosis,  but  the  process  was  not  so  dense  as  it  was 
on  the  free  surface.  The  pancreas  was  the  seat  of  an  histo- 
logic sclerosis  that  explained  its  macros3opic  hypertrophy. 
Toe  sclerosis  was  diffuse  and  more  marked  in  the  lobules 
than  in  the  spaces  between  the  lobules,  so  that  islands  of 
glandular  cells  were  surrounded  by  sclerotic  tissue.  The 
kidneys  showed  the  lesions  of  a  terminal  infection.  The 
case,  therefore,  was  one  of  hypertrophy  of  the  pancreas 
with  histologic  sclerosis  accompanying  sclerosis  of 
the  liver  and  hyperspleuoniegaly.    [j  .m.s] 

2.— In  a  man  who  had  always  been  in  good  health,  the 
following  symptoms  developed  gradually  :  The  neck  increased 
in  volume,  the  face  became  congested  and  bloated,  the 
thoracic  wall  became  the  seat  of  a  hard  edema,  varicosities 
appeared  at  the  base  of  the  thora.\  and  extended  thence 
toward  its  upper  portion  and  its  lateral  aspect.  The  upper 
extremities  were  edematous  and  cyanosed.  At  the  same 
tinie  the  patient  began  to  have  retrocostal  and  scapular 
pains,  vertigo,  attacks  of  suflbcation,  dysphagia,  and  dys- 
phonia,  but  no  palpitation  of  the  heart.  The  vesicular 
murmur  was  heard  all  over  the  right  side  of  the  chest ;  a  soft 
blowing  was  heard  both  during  inspiration  and  during 
expiration  in  the  neighborhood  of  the  right  bronchus;  the 
vibrations  were  absent  at  the  apex  on  the  same  side  ;  and  at 
the  right  of  the  first  piece  of  the  sternum,  in  the  neighbor- 
hood of  a  swelling  on  the  chest-wall,  simple  pulsations  could 
be  seen  that  were  expansile  and  isochronous  with  the  pulse. 
There  was  neither  murmur  nor  thrill ;  the  radial  pulses  were 
equal  and  synchronous,  and  there  was  marked  tachycardia. 
Radiographic  examination  confirmed  the  opinion  drawn 
from  the  clinical  facts  that  the  condition  was  one  of  aortic 
aneurysm  that  involved  the  ascending  and  part  of  the 
transverse  portions  of  the  arch.  Tae  development  of  this 
aneurysm  by  compression  of  the  superior  vena  cava, 
the  right  bronchus,  the  right  pueumogastric  nerve,  and  the 
left  recurrent  laryngeal  nerve,  accounted  for  all  the  symp- 
toms. Dcp'er  believes  that  the  aneurysm  was  probably  of 
syphilitic  origin,     [j.m  s  ] 

3.— Duplant  compares  bronchopleural  fistulae  to  the 
valve  in  the  pneumatic  tires  of  bicycles.  Coughing  dilates 
the  fistulous  tract  and  fills  the  pleural  cavity,  just  as  the 
pump  fills  the  bicycle  tire.  He  believes  that  nearly  all  cases 
of  pneumothorax  possess  a  valve  mechanism,  at  least 


at  a  certain  period  of  their  evolution.  He  records  2  cases 
which  show  that  the  pneumothorax  of  tuberculous  patiente 
is  sometimes  partial  at  the  beginning.  The  existence  of 
fibrillary  adhesions  in  the  serous  membrane  can  alone  ex- 
plain the  progressive  extension  of  the  gas  in  the  thoradc 
cavity.  These  adhesions,  therefore,  do  not  constitute  an 
obstacle  to  the  production  of  a  pleural  perforation,  although 
they  limit  temporarily  the  filling  of  the  serous  cavity  with 
air.  Kupture  of  the  serous  membrane  is  never  seen  when 
there  is  a  total  or  partial  symphysis  of  the  layers  of  the 
pleura,  but  old  solid  strings  that  have  in  some  cases  under- 
gone an  advanced  organizition  are  almost  always  found  in 
the  neighborhood  of  the  perforation.  These  bands  immo- 
bilize a  point  of  the  pleura,  while  the  neighboring  region, 
strongly  pulled  upon  by  an  attack  of  coughing,  ruptures, 
particularly  if  it  is  rendered  more  fragile  by  the  presence  of 
a  subpleural  tubercle  or  a  small  cavity.  Usually  then  a 
bronchocavernous  fistula  is  transformed  into  a  broncho- 
pleural fistula.  The  frequency  of  adhesions  in  tuberculous 
subjects  explains  why  the  maj  ority  of  cases  of  pneumothorax 
occurring  in  tuberculous  subjects  are  at  first  partial  or  mul- 
tilocular.  The  lung  then  does  not  retract  completely  from 
the  beginning,  it  is  necessary  that  the  air  shall  rupture  the 
adhesions  in  the  membranes,  as  in  subcutaneous  emphysema 
it  dissects  the  meshes  of  the  loose  connective  tissue.  Tne 
majority  of  cases  of  tuberculous  pneumothorax  in  which 
there  is  a  bronchopleural  fistula  act  as  do  the  cases  of  pneu- 
mothorax with  a  valve.  But  the  mechanism  of  the  obtura- 
tion of  the  fistula  during  normal  respiration  ought  not  to 
functionate  only  after  the  complete  retraction  of  the  lung 
accompanied  by  absolute  immobilization  of  the  thoracic 
wall  and  the  diaphragm  of  the  affected  side.  The  existence 
of  a  membranous  valve  forming  a  clapper  and  closing  the 
pleural  orifice  is  excei>tional.  In  order  to  cure  a  pneumo- 
thorax with  a  valve  it  is  necessary  to  secure  the  cicatrization 
of  the  serous  orifice  of  the  fistula,    [j  m  s] 

4. — In  the  case  of  a  man,  aged  42  years,  who  entered  the 
hospital  complaining  of  paralysis  of  the  left  leg,  Brousse 
and  Ardin-Delteil  obtained  a  history  of  chancre,  which  had 
developed  6  months  previously.  The  paralysis  began  with 
pain  in  the  lumbar  region,  which  became  worse  in  a  few 
hours ;  this  was  followed  by  the  involuntary  passage  of  urine, 
and  2  days  later  the  patient  found  that  his  left  leg  was  para- 
lyzed. In  botn  legs  there  was  a  well-marked  hyperestnesia 
which  extended  out  to  the  abdominal  wall,  nearly  as  far  as 
the  umbilicus.  There  was  a  painful  area  in  the  neighbor- 
hood of  the  spinous  process  of  the  third  lumbar  vertebra. 
There  was  incontinence  of  feces.  Under  treatment  anes- 
thesia developed  in  the  right  leg,  but  the  symptoms  in  gen- 
eral were  ameliorated,  although  they  did  not  completely 
disappear.  After  several  month  j  the  syndrome  of  Brown- 
Sequard  persisted.  Tae  case  is  one  of  early  spinal 
syphilis,     [j  m  s.] 

Oclober  10,  1900.    [20jie  Annde,  No.  10.]  I 

1.  Trophic  Disorders  and  Disorders  of  Sensation  in  Hemi- 

plegics,    P.  Chatis. 

2.  Spasmodic  Paraplegia  and    Sclerosis  in   Placques  ol    a 

Family  Type.    R.  Cestak  and  G.  Guiu-aix. 

3.  Simple  Persistence  of  the  Ductus  Arteriosus.    G.  G^raro. 

1.— The  study  of  physiology  as  well  as  that  of  pathology 
leads  the  observer  to  the  conclusion  that  the  trophic  func- 
tions of  the  nervous  system  are  intimately  associated  with 
the  sensory  functions.  Chatin  has  studied  the  relations  be- 
twetn  these  two  functions  as  seen  in  cases  of  hemiplegia. 
Short  abstracts  of  li»  cases  of  hemiplegia  are  given.  Of  tneM  h 
patients  11  presented  trophic  or  vasomotor  troubles  and  10  f 
of  these  presented  actual  sensory  difficulties,  while  the 
eleventh  patient  did  not  present  actual  objective  sensory 
disorders.  Ou  the  other  band,  the  remainirg  S  patients,  in 
whom  hemiplegia  was  observed  without  trophic  troubles,  did 
not  present  appreciable  interference  with  sensation.  It 
would  seem  as  though  these  manifestations  were  more  than 
coincidences  and  that  it  is  reasonable  to  conclude  that  trophic 
or  vasomotor  troubles  in  hemiplegia  usually  acoomp.-iny 
sensory  disturbances.  The  trophic  troubles  are  princip.iUy 
in  the  nature  of  amyotrophies.  The  muscular  atrophies  pre- 
dominate in  the  upper  extremity,  while  in  the  lower  ex- 
tremity the  atrophy  ia  expressed   by  a  slight  emaciation. 


January  19,  I'JOIJ 


THE  LATEST  LITERATURE 


riHK  I'mi 
L  Medical 


LADKLPHIA 
JOCRSAL 


115 


Again,  it  is  usually  noticed  that  the  upper  extremity  is  the 
one  that  presents  the  most  marked  contracture,  so  that  this 
condition  is  usually  associated  with  amyotrophy  and  with 
sensory  difficulties.  Arthritic  disorders  are  most  frequently 
Eeen  in  the  shoulder.  The  most  common  trophic  disorder  of 
the  skin  and  its  appendages  is  a  peculiar  deformity  of  the 
nails,  which  are  bent  both  in  the  longitudinal  and  the  trans- 
verse diameters,  but  which  are  not  arrested  in  growth.  The 
skin  becomes  particularly  thin  and  glossy.  Of  the  vasomotor 
troubles  coldness  of  the  affected  members  with  redness  or 
violet  color  of  the  tkin  is  most  common  ;  sensations  of 
pricking,  hemisweating,  and  unilateral  edema  have  also  been 
observed.  This  series  of  cases  seems  to  establish  the  fact 
that  slight  sensory  symptoms  may  persist  in  old  hemiplegics. 
The  anesthesia  is  rarely  absolute;  the  hypoesthesia  is  usually 
most  pronounced  in  the  hand  and  diminishes  as  the  exami- 
nation of  the  forearm  and  arm  progresses.  The  mucous 
membranes  are  usually  uninvolved  even  when  there  is 
marked  hypoesthesia  in  the  face.  The  lower  extremity 
always  presents  much  less  marked  disturbance  than  the 
upper  extremity.  Disorders  of  thermic  sensation  present 
the  same  topography,  but  are  often  better  marked  than  the 
disorders  of  the  other  forms  of  sensation.  There  is  some- 
times a  dissociation  between  the  perception  of  heat  and  cold. 
Disorders  of  the  muscular  sense,  of  the  stereognostic  sense, 
and  sensorial  troubles  have  also  been  noted.  Motor  disorders 
alone,  as  they  mature,  are  accompanied  by  dystrophic  phe- 
nomena, but  motor  disorders  to  which  sensory  disturbances 
are  added  have  many  more  chances  of  being  followed  by  atro- 
phies. In  other  words,  double  lesions  of  the  reflex  arc  are  more 
often  accompanied  by  trophic  manifestations  than  are  simple 
lesions.  The  author  quotes  12  cases  taken  from  the  literature 
that  confirm  his  position,  although  there  are  exceptional 
cases  on  record.  It  seems,  however,  that  the  examination  of 
the  cases  of  atrophy  from  central  lesion,  either  organic  or 
hysteric,  published  up  to  the  present  lime  corroborate  the 
observation  of  the  coexistence  of  trophic  and  fensory  phe- 
nomena. Goldscheider,  Marinesco,  and  Monakow  are  all 
of  the  opinion  that  muscular  atrophy  is  the  result  of  simul- 
taneous reduction  of  the  sensory  functions,  on  the  one  hand, 
and  of  the  motor  and  the  vasomotor  functions  on  the  other 
hand,     [j.m.s.] 

3. — Cestan  and  Guillain  report  2  instances  of  nervous 
disease  that  presented  a  family  type.  In  the  first  instance 
a  boy,  aged  15  years,  had  noticed,  since  the  age  of  8  years,  a 
progressive  and  pure  spasmodic  paraplegia  that  consisted  of 
an  exaggeration  of  the  tendon  reflexes  of  the  lower  extremi- 
ties, a  spinal  trepidation,  and  Babineki's  sign.  The  move- 
ments of  the  arms  became  a  little  stiS'as  the  case  progressed. 
There  was  no  trouble  in  the  face,  the  tongue,  or  the  eyes. 
The  patient's  father  and  his  eldest  sister  presented  the  same 
phenomena,  which  developed  in  a  similar  manner.  For  3 
years  the  patients  had  noticed  a  spasm  of  the  right  tterno- 
mastoid  muscle.  This  spasm  was  iiitermittent  and  produced 
several  rotations  of  the  head  with  lateral  inclination  toward 
the  right  per  minute.  This  spasm  was  the  exact  picture  of 
spasmodic  torticollis.  The  authors  consider  the  case  to  be 
one  of  family  spasmodic  paraplegia.  In  a  second  fam- 
ily there  were  10  children,  of  whom  1  died  of  meningitis  in 
infancy,  2  were  epileptic,  and  2  others  presented  a  special 
form  of  nervous  disease.  Of  the  last  2  patients,  1,  a  boy  16 
years  of  age,  never  walked  in  a  normal  manner,  but  his  ac- 
tual disease  did  not  begin  until  he  was  15  years  old.  The  first 
symptom  was  a  disorder  of  speech;  several  months  later  he 
began  to  present  a  further  disorder  of  gait,  which  was  of  the 
cerebellospasmodic  type.  The  patellar  reflexes  were  exag- 
gerated, Babinski'seign  was  present,  and  his  feet  were  of  the 
type  of  Friedreich.  There  was  slight  ataxia  in  the  upper  ex- 
tremities, but  the  reflexes  were  normal.  The  speech  resem- 
bled that  of  sclerosis  in  placques.  Nystagmus  was  present,  the 
optic  discs  were  slightly  discolored,  and  the  visual  acuity  was 
much  diminished  in  the  left  eye.  A  sitter  of  this  patient,  SI 
years  of  age,  dated  her  illness  from  her  twentieth  year,  the 
initial  symptom  of  which  was  a  disorder  of  gait.  At  the 
age  of  22  years  disorder  of  speech  began,  and  Charcot  and 
Debove  at  that  time  made  the  diagnosis  of  sclerosis  in 
placques.  At  the  time  the  patient  came  under  the  care 
of  the  authors  she  presented  a  very  accentuated  spasmodic 
gait  with  an  almost  absolute  impossibility  of  walking.  The 
reflexes  in  the  legs  were  exaggerated,  Babinski'a  sign  was 
present,  and  there  were  typical  Friedreich's  feet.   There  were 


intentional  tremors  in  the  arms.  The  speech  presented  all 
the  characteristics  of  that  of  sclerosis  in  placques.  Nystag- 
mus was  present,  but  there  were  ro  lesions  at  the  fundus  of 
the  eye.  The  diagncsis  in  these  cases  was  considered  to  be 
sclerosis  in  placques  of  a  family  type.  Before  con- 
cluding that  a  given  disease  is  a  family  form  of  sclerosis  in 
placques  or  a  family  type  of  spasmodic  paraplegia  it  is  neces- 
sary to  exclude  hereditary  syphilis,  to  inquire  into  the  char- 
acter of  the  labor  by  which  the  patient  was  born,  and  to  ex- 
clude meningitis  in  infancy.  In  order  that  a  disease  should 
be  classed  as  a  family  disease  it  is  necessary  that  it  should 
attack  without  change  in  form  several  children  in  the  same 
generation,  that  it  should  begin  at  about  the  same  age  in  all 
the  diseased  children  of  that  generation  ;  and  that  it  should 
be  independent,  clinically,  of  all  external  influence,  from  an 
acquired  aflection,  or  from  an  accident  during  intrauterine 
life,     [j  M  s  ] 

3. — Gerard  contributes  an  exhaustive  paper  on  the  sim- 
ple persistence  of  the  ductus  arteriosus,  which  began 
in  the  September  number  and  is  concluded  in  the  current> 
number.  After  examining  a  large  number  of  cases  he  con- 
cludes that  the  anomaly  may  be  accompanied  by  many  dif- 
ferent symptoms.  The  author  had  intended  to  introduce  a 
chapter  on  the  diagnosis  of  the  condition,  but  has  left  it  cut 
because  it  is  almost  impossible  to  trace  out  the  manifesta- 
tions of  an  affection  that  is  so  rare  and  that  presents  such  a 
wide  range  of  characteristics.  The  persistence  of  the  ductus 
arteriosus  should  rot  be  considered  as  a  clinical  entity  that 
should  be  attached  to  the  cardiopathies,  but  as  an  excep- 
tional aflection  of  a  vessel  of  first  importance  that  has  failed 
to  pass  through  its  customary  evolution,    [j  .M.S.] 


Semaine  M^dicale. 

December  5,  1900. 

1.  Treatment  of   Laryngeal    Tuberculosis  by  Intratracheal 

Injection  of  Iodoform  in  Ether.    L.  Vacheb. 

2.  A  Test  by  Methylene- blue  of  Amyloid  Degeneration  of 

the  Kidney.    Achard  and  Loeper. 

1. — For  some  time  L.  Vacher  has  been  using  with  success 
in  the  treatment  of  laryngeal  tuberculosis  an  intra- 
tracheal injection  of  the  following  mixture  :  Ether  containing 
iodoform  to  saturation,  100  gm. ;  guaiacol,  5  gm. ;  eucalyptol, 
2  gm. ;  menthol,  1  gm.  Two  cubic  centimeters  or  less  is  in- 
jected into  the  tracheal  tissue  with  none  of  the  expected 
discomfort.  On  the  contrary,  there  is  simply  a  quick  sensa- 
tion of  heat,  scarcely  painful,  and  no  spasm  following,  which 
disappears  after  a  few  strong  respirations.  The  bre  ath  for 
some  hours  has  perceptibly  the  odor  of  iodoform  and  of 
guaiacol.  With  this  treatment  followed  judiciously  there 
occurs  a  lessening  of  the  laryngeal  distress  and  a  general 
improvement  in  the  patient's  health.  After  each  injection  a 
laryngoscopical  examination  reveals  the  glottis  surrounded 
by  tissue  filled  with  the  solution  of  iodoform,     [t.h.e.] 

2. — Achard  ai:d  Loeper  note  the  value  of  the  continued 
elimination  by  the  kidneys  of  methylene-blue  as  a  test  diag- 
nostic of  amyloid  change  when  not  complicated  by  sclerotic 
degeneration.  In  the  cases  in  question  the  diagnosis  was 
confirmed  by  autopsy.  When  clinically  there  is  persistent 
albuminuria,  unexplained,  and  accompanied  by  various 
symptoms  as  of  previous  tubercular  infection,  or  inconstant 
polyuria  with  an  excess  of  globulin  upon  the  serin,  the  in- 
definiteness  of  the  latter  will  suggest  the  value  of  the  test  by 
methylene-blue.    [t.h.e.  j 


Pneumonia.— Eerthe'm  {Dtvlsche  m(d.  Vodnnschjifl 
October  4,  1900),  describes  a  case  in  a  14  months-old  child 
which  ended  fatally,  and  in  which  he  found  cocci  which  cor- 
responded in  all  their  characteristics  to  the  meningo- 
coccus. He  reviews  the  literature  and  finds  that  menin- 
gococci have  been  previously  found  in  pneumonias,  and 
have  apparently  caused  the  pneumonia.  They  also  are 
more  commonly  associated  with  bronchitis,  and  it  should  be 
remembered  that  while  this  bronchitis  produced  by  the 
meningococcus  is  usually  harmless  to  the  subject  and  does 
not  tend  to  produce  lesions,  it  may,  perhaps,  be  the  source 
of  further  cases  of  meningococcus  infection,  and  may  be  the 
means  of  spreading  epidemics  of  cerebrospinal  meningitis. 
[d  l  e.] 


lie  The  PhiladelphiaI 

Medical  Journal  J 


PERFORATIVE  PERITONITIS  IN  TYPHOID  FEVER 


[Jakdabt  :9,  1901 


©riginal  21rticlc5. 


ON  PERFORATION  AND  PERFORATIVE  PERITONITIS 
IN  TYPHOID  FEVER.* 

By  WILLIAM  OSLEK,  M.D., 

of  BaUimore,  Md. 
Professor  of  Medicine,  Johns  Hopkins  Univerflity. 

Cullen's  remark  that  the  chief  function  of  a  physi- 
cian was  to  obviate  the  tendency  to  death,  sounds  trite 
and  common]>lace  in  dealing  with  a  condition  such  as 
perforation  of  the  bowel  in  typhoid  fever,  which  is  not 
a  tendency  to,  but,  to  all  intents  and  purposes,  death  it- 
self. Until  within  a  comparativelj'  few  years,  in  the  pres- 
ence of  this  disastrous  event,  we  folded  our  hands  and 
murmured  that  all  was  over.  The  astonishing  results 
obtained  in  acute  peritonitis  from  other  causes  made 
thoughtful  men  ask  themselves  whether  something 
could  not  be  done  in  the  perforative  peritonitis  of 
typhoid  fever.  To  two  physicians  we  owe  the  ardent 
advocacy  of  operation — to  Leyden  in  Germany,  and  to 
J;  C.  Wilson  in  this  country.  Many  of  you  who  listen 
to  me  can  recall  the  skepticism  so  freely  expressed,  by 
no  one  more  strongly  than  by  myself,  as  to  the  practi- 
cability of  the  procedure ;  but  the  surgeons,  particularly 
of  this  country,  took  up  the  question  with  zeal  and 
energy,  and  the  collected  stastistics  of  Keen  and  of 
Finney  show  a  most  gratifying  percentage  of  recoveries. 

I  am  sorry  that  we  cannot,  as  a  profession,  congratu- 
late ourselves  upon  a  reduction  in  the  incidence  of 
typhoid  fever  in  this  country.  Its  widespread  prev- 
alence is  Nature's  judgment  upon  the  transgression  of 
the  plain,  everyday  precepts  which  we  have  been 
preaching  in  deaf  ears  for  two  generations.  We  can 
congratulate  ourselves,  however,  upon  a  striking  reduc- 
tion in  the  mortality  from  the  disease,  for  which  better 
nursing  and  better  methods  of  treatment  are  re- 
sponsible. We  save  5,  6,  or  even  7%  more  patients 
than  we  did  20  years  ago.  We  may  take  71%  as  the 
minimum  typhoid  death-rate  for  general  hospitals,  a 
figure  which  should  include  all  cases  admitted  with  the 
diagnosis  of  typhoid  fever,  but  from  which  the  doubt- 
ful cases  of  febricula,  the  estivoautumnal  malaria,  and 
cases  admitted  with  the  late  sequelae  of  the  disease  are 
carefully  excluded.  It  is  interesting  to  note  the  special 
class  of  fatal  cases  which  has  been  influenced  by  the 
modern  nonmedicinal  methods  of  treatment.  It  is  not 
the  complications,  as  hemorrhage,  pneumonia,  perfo- 
ration, etc.,  but  it  is  the  largest  group  in  which  the 
patients  die  of  the  toxemia.  Among  100  fatal  cases,  50 
die  of  the  progressive  asthenia,  30  of  perforation,  and 
20  of  other  complications.  Of  63  deaths  in  the  first  10 
years  of  the  work  at  the  Johns  Hopkins  Hospital, 
nearly  J^  were  due  to  perforation.  There  has  been  no 
material  change  in  the  percentage  of  cases  with  perfo- 
ration, as  given  in  Fitz's  collection  of  statistics.  Among 
the  fatal  cases  the  relative  proportion  due  to  perfora- 
tion has  become  higher,  owing,  as  I  have  said,  to  the 
striking  reduction  in  the  deaths  in  the  toxemic  group. 

It  is  a  wonder  that  perforation  does  not  occur  more 
frequently  when  we  consider  the  extent  and  character 
of  the  necrotic  processes.  As  the  lower  IS  inches  of 
the  ileum  are  chiefly  involved,  the  perforation  is  usually 
within  this  distance  of  the  valve.  The  higher  in  the 
bowel,  the  more  likely  is  the  perforation  to  be  in  a 

•  Read  «i  the  Philadelphia  CouDiy  Medical  Soi-iety,  January  9, 1901. 


small  ulcer  without  much  infiltration  or  necrosis  of  the 
walls.  The  position  of  the  terminal  loops  of  the  ileum 
make  the  first  symptoms  of  perforation  hypogastric, 
and  may  give  to  the  case  a  pelvic  or  an  appendicular 
aspect.  A  majority  of  the  cases  occur  early  in  the  third 
week ;  the  earlier  the  perforation  the  greater  will  be  the 
difficulties  in  dealing  with  the  bowel.  The  earlier  the 
perforation,  and  the  closer  to  the  valve,  so  much  the 
greater  risk  of  a  widespread  necrosis  of  the  mucosa  and 
a  condition  of  the  gut  most  unfavorable  for  any  surgical 
procedure. 

In  studying  the  clinical  features  of  these  cases  one  is 
profoundly  impressed,  first,  with  their  uncertainty  and 
variability,  and.  secondly,  with  the  necessity  (in  view 
of  recent  surgical  events)  of  a  revision  in  our  methods 
of  dealing  with  these  cases  on  the  medical  side.  The 
accident  may  be  divided  into  two  stages :  First,  the  per- 
foration itself;  and,  secondly,  the  consecutive  peri- 
tonitis. The  all-important  question  is  to  recognize  the 
perforation,  and,  if  possible,  to  operate  within  the  first 
12  hours,  before  there  is  widespread  general  peritonitis. 
Let  me  illustrate  the  uncertainty'  by  sketches  of  three 
recent  cases  : 

Case  I  (No  32.411).— Edgar  G.,  aged  24,  admitted  Octol^r 
11,  1900,  having  been  ill  for  more  than  a  month.  He  looked 
ill,  had  onlv  moderate  fever,  but  on  the  second  day  after 
admission  he  began  to  complain  of  abdominal  tain,  and 
there  was  a  little  fulness.  The  leukocytes  were  7,000.  On 
the  15th  the  abdomen  was  again  slightly  distended,  the  res- 
piratory movements  were  well  seen,  there  was  no  pain,  no 
tension.  The  hepatic  flatness  reached  to  the  costal  margin. 
For  the  next  three  days  the  slight  distention  of  the  abdcimen 
persisted.  There  was  no  diarrhea.  At  9  a.m.  on  the  19th 
he  complained  of  abdominal  pain,  which  was  severe  enough 
to  make  him  cry  out  The  abdomen  was  somewhat  dis- 
tended, the  respiratory  movements  were  well  marked,  the 
muscles  were  held  very  tense,  the  liver-dulness  was  obhter- 
ated  in  the  middle  line.  The  leukocytes  at  9.15  were  4.000 
per  com.  He  had  been  taken  out  of  the  bath  a  little  before 
9  o'clock,  and  wiis  still  blue  and  cyanotic.  At  11  a.m.,  when 
seen  by  Dr.  Futcher,  he  felt  more  comfortable.  He  had  had 
one  exacerbation  of  abdominal  pain  since  10  a.m.  The  res- 
piratory movements  were  well  seen,  though  slightly  limited 
below  the  level  of  the  umbilicus.  The  muscles  were  slightly 
rigid,  but  there  was  no  actual  muscle  spasm.  There  were 
tenderness  and  pain  on  pressure  in  the  lower  abdomen,  most 
on  the  right  side.  Pressure  brought  on  sudden  paroxysms 
of  pain.  Rectal  examination  showed  no  bulging  of  peri- 
toneum posterior  to  bladder.  The  leukocytes  were  counted 
every  hour  between  11.15  and  415,  and  they  did  not  rise 
above  5,2tX\  At  2.30  the  alxlomen  was  considerably  dis- 
tended, the  tenderness  in  the  hypogastric  region  was  marked, 
but  he  complained  of  less  pain.  At  2  p.m.  he  had  a  profuse 
perspiration.  The  pulse  was  of  good  volume  and  good  ten- 
sion, 92  to  the  minute.  The  abdominal  muscles  were  a  little 
more  rigid.  At  4.30  the  patient  was  seen  by  Drs  Futoher, 
McCrae  and  ^litchell  in  consultation.  The  pulse  w.is  still  of 
good  volume,  but  had  increased  slightly,  and  he  had  hic- 
coughed once  or  twice.  Tliere  had  been  no  nansea  and  no 
vomiting.  There  was  still  marked  tenderness  in  the  lower 
abdominal  region.  Pressure  caused  the  patient  to  wince. 
The  muscle  rigidity  was  slightly  greater  over  the  right  rec- 
tus. During  the  day  the  point  of  greatest  tenderness  hjid 
varied.  There  was  no  actual  muscle-spasm.  There  was 
slight  shifting  dulness  in  the  flanks.  The  liver  flatness  was 
not  obliterated.  There  was  no  increase  in  respiration,  but  I 
the  respiratory  movements  were  more  limiteii  Ih'Iow  the 
level  of  the  umbilicus.  The  following  svmptoms  suggested 
the  possibility  of  perforation  :  The  sudden  onset  of  pain  at 
9  A.M.,  the  persistence  of  the  pain  through  the  day.  its  asso- 
ciation with  marked  tenderness  on  deep  pressure,  the  mod- 
erate muscle  rigidity,  the  graduallv  increasing  distention 
during  the  day,  the  suggestive  movab'le  dulness  in  the  flanks. 
The  following  important  symptoms  so  often  present  were 
absent :  No  drop  in  temperature,  no  special  increase  in  the 
rapidity  of  the  pulse,  no  symptoms  of  collapse,  no  nausea 


JiHTARY  19,  1901] 


PERFORATIVE  PERITONITIS  IN  TYPHOID  FEVER 


riHK    PHILADKLPHIA 

L  Medical  Journal 


117 


or  vomiting,  no  obliteration  of  the  hepatic  dulness,  absence 
of  muscle-spasm,  absence  of  any  marked  diminution  of  the 
abdominal  respiratory  movements,  absence  of  any  leukocy- 
tosis. It  was  decided  to  give  the  patient  the  benefit  of  the 
doubt. 

I  saw  him  at  5  30  p.m.  His  general  condition  was  excel- 
lent, there  was  moderate  distention  of  the  abdomen,  the 
respiratory  movements  were  present,  but  were  relatively 
much  more  above  the  navel,  the  tension  of  the  abdominal 
walls  was  of  moderate  grade,  both  iliac  fossae  were  soft  and 
elastic,  no  spot  more  painful  than  another ;  slight  general 
tenderness.     Four    finger's   breadth   of   liver-flatness    were 

f>resent  just  outside  the  parasternal  line.  There  was  no  col- 
apse  He  was  being  prepared  for  operation,  and  a  little 
excited,  and  the  pulse  was  112. 

To  speak  frankly,  in  this  case  I  had  much  more  confidence 
in  the  judgment  of  my  two  assistants,  Drs  Futcher  and  Mc- 
Crae,  than  in  the  symptoms  presented  by  the  patient  The 
sudden  onset  of  pain,  the  subsequent  occurrence  of  pain  in 
paroxysms,  the  tenderness,  the  slight  increasing  distention 
of  the  abdomen  were  the  sole  features  which  warranted  an 
exploration. 

Dr.  Mitchell  operated  at  6  p.m.,  exactly  9  hours  after  the 
onset  of  the  pain.  The  general  peritoneum  was  reddened, 
but  there  was  no  lymph,  and  it  was  not  until  the  coils 
towards  the  pelvis  were  lifted  up  that  a  perforation  was  seen, 
through  which  feces  were  oozing.  He  did  very  well  until 
the  evening  of  the  21st,  when  his  temperature  began  to  rise, 
reaching  105°  on  the  22d,  when  he  died,  more  apparently 
from  the  effects  of  the  fever  than  from  the  peritonitis.  The 
abdominal  symptoms  improved  after  the  operation,  and  at 
the  autopsy  the  wound  on  the  bowel  was  healing  per 
primam. 

Case  II  (No.  32,765). — The  patient  had  been  admitted  on 
November  10,  1900,  from  West  Virginia,  about  the  beginning 
of  the  second  week  of  a  very  severe  attack.  On  November 
15,  the  fourteenth  day,  he  had  a  hemorrhage  from  the 
bowels  at  9.30  p.m.  At  10.80  he  complained  of  very  severe 
pain  in  the  abdomen,  with  which  he  groaned  out  loudly. 
At  10.45  the  abdomen  was  flat,  almost  scaphoid,  the  respira- 
tory movements  were  slight,  there  was  no  tenderness,  no 
■  rigidity,  no  muscle  spasm ;  the  leukocytes  were  7,500. 
Throughout  the  16th  his  temperature  rose,  reaching  nearly 
to  106°.  He  had  some  hiccough  through  the  night  and  in 
the  morning;  no  vomiting.  He  was  pale  and  tremulous. 
The  right  half  of  the  umbilical  region  and  the  right  iliac 
fossa  were  slightly  tender  on  deep  pressure,  and  the  muscles 
were  a  little  more  rigid  than  last  night  There  was  no  defi- 
nite muscle-spasm.  A  very  important  point,  on  which  we 
did  not  put  enougli  stress,  was  the  fact  that  the  hepatic  flat- 
ness, which  reached  to  the  costal  margin  at  11  p.m.,  at  11  a.m. 
was  8J  cm.  above  the  costal  margin.  There  was  no  oblitera- 
tion in  the  midaxillary  line.  The  leukocytes  rose  through 
the  day,  and  at  12.15  p.m.  were  17,500.  I  saw  the  patient  at 
6  P.M  ,  and,  considering  that  he  had  had  a  severe  hemorrhage, 
I  thought  his  condition  fairly  good.  The  temperature  was 
a  little  above  104°;  the  pulse  was  of  fair  volume,  about  120; 
the  tongue  was  dry,  the  abdomen  was  not  distended,  the  res- 
piratory movements  were  present,  there  was  slight  tenderness 
on  deep  pressure.  In  the  nipple  line  the  area  of  liver-dul- 
ne.ss  was  obliterated.  Throughout  the  evening  the  patient 
grew  worse,  the  abdomen  became  distended,  respiratory 
movements  were  absent,  the  abdominal  walls  became  rigid, 
and  there  was  general  muscle-spasm,  and  the  patient  com- 

glained  of  a  good  deal  of  abdominal  pain.  He  had  frequent 
iccough,  and  the  pulse  rose  to  140.  At  10  15  P.M.  he  had  a 
profuse  hemor  hage,  and  though  his  condition  was  desperate, 
it  was  decided  to  operate,  which  was  done  by  Dr.  Finney. 
Gas  was  escaping  from  the  peritoneal  cavity,  and  there  was 
a  bloody  exudate  with  fecal  matter  in  the  pelvis.  About 
12  cm.  from  the  cecum  tliere  was  a  large  gangrenous  ulcer, 
which  presented  two  perforations.  In  the  neighborhood  of 
the  perforations  the  walls  of  the  gut  were  so  swollen  and  in- 
filtrated that  a  suture  would  not  hold,  and  before  anything 
could  be  done  the  patient  died  on  the  table. 

In  this  case,  no  doubt  the  perforation  occurred 
on  the  night  of  the  15th,  but  we  attributed  his 
symptoms  to  the  hemorrhage,  which  occurred  at  the 
eame  time.     There  was  an  absence  of  any  definite  ab- 


dominal changes  until  nearly  24  hours  later.  A  third 
point  of  interest,  which  should  have  made  us  suspect 
perforation  earlier,  was  the  fact  that  at  11  a.m.  on  the 
16th,  without  abdominal  distention,  the  liver-dulness 
reached  a  point  8J  cm.  above  the  costal  border. 

Case  III  (No.  32.925)  is  still  more  interesting  from  the 
standpoint  of  the  study  of  the  symptoms  of  onset  of  perfora- 
tion. This  was  a  child,  aged  8  years,  admitted  on  Novem- 
ber 22,  on  the  fifth  day  of  the  disease.  She  hada-evere 
attack,  the  temperature  rising  to  between  104°  and  105°. 
An  interesting  feature  was  that  the  day  after  admission  she 
began  to  complain  of  pain  in  the  right  half  of  the  abdomen, 
and  continued  to  complain  until  the  28th.  The  abdomen 
was  a  little  full.  After  November  30,  the  pain  was  very 
much  diminished.  On  the  morning  of  December  5,  Dr. 
IVIcCrae  made  a  note  that  her  general  condition  was  good, 
the  abdomen  was  somewhat  full,  everywhere  soft,  nowhere 
tender  The  leukocytes  were  5,500.  At  7.15  p.m.  she  cried 
out  with  abdominal  pain  in  the  right  iliac  fossa.  The  pulse 
was  small,  dicrotic,  and  rapid.  The  abdomen  was  a  little 
more  distended.  She  was  given  turpentine  stupes,  and  after 
each  one  she  w  uld  get  quieter  and  fall  asleep.  At  11  p..m. 
there  was  marked  general  rigidity  of  the  abdominal  muscles, 
no  definite  local  tenderness.  The  respiratory  movements 
were  fairly  free,  though  perhaps  a  little  limited  below  the 
navel,  The  liver  flatness  extended  to  a  point  3  cm.  above 
the  costal  margin  in  the  nipple  line.  At  11.40  p.m.  the 
leukocytes,  which  had  been  ll,5ii0  at  7.30,  were  7,500.  At  1 
A.M.  the  abdominal  pain  persisted,  and  at  times  the  patient 
cried  out  with  its  intensity.  The  pulse  was  150 ;  she  had  not 
vomited ;  the  abdominal  distention  had  not  increased.  The 
tenderness  was  marked,  and  the  slightest  pressure  caused 
her  to  cry  out.  The  respiratory  movements  were  less  marked 
than  2  hours  before.  There  was  marked  rigidity,  and  definite 
muscle-spasm.  The  liver-dulness  was  completely  obliterated 
in  the  nipple  line.  There  was  slight  movable  dulness  in  both 
flanks,  but  the  value  of  this  sign  was  diminished  by  the  fact 
that  the  patient  had  diarrhea.  The  leukocytes  at  1  a.m. 
were  7,700  per  ccm. 

Dr.  Futcher  made  a  diagnosis  of  perforation,  and  urged 
operation,  which  was  done  at  2.30  a.m.  Gas  escaped  when 
the  peritoneum  wrs  opened,  with  cloudy,  yellow,  bile-stained 
fluid,  of  which  there  was  a  good  deal  in  the  right  iliac  fossa, 
and  in  the  pelvis.  The  coils  of  the  small  intestine  were  not 
much  distended,  were  pinkish  in  color,  somewhat  injected. 
The  perforation  was  10  cm.  distant  from  the  cecum,  clean, 
punched  out  in  the  middle  of  a  not  very  prominent  ulcer. 
Golden  yellow,  bile-stained  fluid  was  escaping  through  it. 
The  perforation  was  closed  with  a  pursestring  suture,  rein- 
forced with  3  mattress  sutures  of  fine  silk.  The  patient 
stood  the  operation  well,  and  has  made  an  uneventful 
recovery. 

This  patient  had  had  a  good  deal  of  pain  in  the  abdo- 
men almost  from  admission,  so  that  she  had  been  care- 
fully watched,  but  the  character  of  the  pain  which 
came  on  December  5,  was  different.  It  was  more 
severe,  it  had  exacerbations  of  great  severity,  which 
caused  the  patient  to  cry  out  at  intervals.  The  movable 
dulness  in  this  case  was  shown  at  operation  to  be 
undoubtedly  due  to  the  free  fluid  in  the  peritoneal 
cavity.  As  nearly  as  could  be  judged  the  perforation 
took  place  at  6  p.m.,  and  the  operation  was  begun  at 
2.30  A.M. 

You  will  agree  with  me,  I  think,  after  hearing  the 
narration  of  these  3  cases,  that  the  time-honored 
picture  of  perforation,  with  the  Hippocratic  facies,  the 
feeble  running  pulse,  the  profuse  sweat,  the  distended 
motionless  abdomen  must  be  erased,  as  not  a  picture 
of  perforation,  but  of  peritonitis,  or,  better  still,  a  rough 
draft  of  death.  What  we  need  more  than  anything  at 
present  is  a  fuller  knowledge  of  the  symptoms  of  perfo- 
ration, particularly  of  its  onset,  apart  from  those  of  the 
consecutive  peritonitis.  I  do  not  think  we  are  likely 
to  do  much  with  what  Dr.  Gushing  has  called  the  preper- 


118 


The  Philadelphja" 
Medical  Journai, 


]        PERFORATIVE  PERITONITIS  IN  TYPHOID  FEVER 


[jASCAEr  i:<,  li(M 


forative  stage.  I  do  not  think  we  can  hope  frequently 
to  recognize  a  case  so  early,  but  it  should  be  a  special 
duty  of  hospital  physicians  hereafter  to  study  with 
more  than  usual  care  the  earliest  possible  symptoms  in 
perforation  cases.  I  have  been  looking  over  the  records  of 
the  30  cases  of  perforation  in  typhoid  fever  which  have 
occurred  to  January  1,  1901,  in  my  wards  since  the 
opening  of  Johns  Hopkins  Hospital,  and  in  doing  so 
I  was  reminded  of  the  dying  prayer  of  the  celebrated 
Archbishop  Ussher,  that  the  Lord  would  forgive  him  his 
sins  of  commission.  In  the  matter  of  hospital  histories 
and  notes  even  the  best  men  are  apt,  in  the  hurry  and 
press  of  work,  to  leave  unrecorded  many  important 
points  for  which  the  arm-chair  clinician  in  revising 
the  history  seeks  in  vain.  What  is  essential  in  every 
serious  case  is  the  watchful  care  of  a  man  who  will  be 
quick  to  grasp  changes  in  the  patient's  condition,  and 
who  in  such  cases  is  in  hourly  collusion  with  his  sur- 
gical colleague.  In  large  general  hospitals  with  many 
cases  of  typhoid  fever,  suspected  cases  should  be  visited 
at  short  intervals  by  a  skilled  resident  physician,  and 
not  left  to  the  tender  mercies  of  an  inexperienced 
interne.  To  leave  the  diagnosis  of  perforation  to  the 
attending  physician  is,  in  too  many  cases,  to  sacrifice 
the  life  of  the  patient.  In  3  at  least  of  our  successful 
cases  it  was  the  prompt  action  of  Dr.  Futcher  and  Dr. 
McCrae,  and  the  prompt  cooperation  of  the  resident 
surgeon,  that  decided  the  patient's  chances. 

Perforation  occurs  as  a  rule  in  the  more  severe  cases, 
and  during  the  height  of  the  disease.  The  rare  cases 
during  convalescence  need  scarcely  be  considered. 
Cases  with  diarrhea  and  with  tympanites  are  more 
liable  to  this  accident.  Of  our  30  cases  20  had  diarrhea, 
16  at  the  time  of  perforation,  4  had  constipation  at  the 
time,  and  in  10  the  bowels  were  regular.  In  1  it  is 
not  mentioned.  There  is  an  interesting  group  (6  cases) 
of  perforation  with  hemorrhage.  When  we  remember 
that  a  large  proportion  of  all  cases  of  tyjjhoid  fever  if 
left  alone  have  no  abdominal  symptoms — neither  diar- 
rhea, pain  nor  tympanites — it  is  not  diflScult  for  the 
attendant  to  keep  his  mind  constantly  on  the  alert  for 
the  danger  signals. 

I  have  drawn  u])  a  schedule  of  specific  instructions 
to  be  followed  in  cases  of  typhoid  fever  in  which  per- 
foration is  suspected. 

I.  Instructions  should  be  specific  and  definite  to  the 
night  EUjerintendent  and  head-nurses,  to  notify  the 
house-physician  of  any  complaint  of  abdominal  pain 
by  the  patient,  of  hiccough  or  vomiting,  of  a  special 
rise  of  pulse  or  respiration,  of  sweating,  or  of  signs  of 
collapse. 

II.  House-physicians  should  note  the  character  of 
the  pain.  As  to  (a)  Onset,  whether  only  an  aggravation 
of  slight  abdominal  pain,  such  as  is  common,  both  with 
constipation  and  with  diarrhea, or  whether  it  was  a  sud- 
den, intense  pain  which  caused  the  patient  to  call  out, 
and  which,  though  relieved  by  stupes  and  ordinary 
measures,  soon  recurred  in  paroxysms  and  grew  worse. 

(6)  ITie  locality,  whether  difluse  or  localized  in  the 
hypogastric  or  right  iliac  regions  ;  radiation,  as  to  penis. 
It  is  to  be  borne  in  mind  that  abdominal  pain  of  a 
severe  character  may  be  associated  with  an  acute 
pleurisy,  with  distended  bladder,  with  cholecystitis, 
and  with  a  packed  rectum,  or  may  follow  an  enema. 

III.  State  of  the  abdomen. — The  condition  to  be  noted 
in  writing  at  once  as  to  the  following  particulars: 

(a)  Whether  flat,  scaphoid  or  distended.  Whether, 
if  distended,  it  is  uniform  or  chiefly  hypogastric. 


(6)  Respirator}'  movements,  whether  present,  if  uni- 
form and  seen  both  below  and  above  the  navel. 

(c)  Palpation,  as  to  tension  and  pain,  locality  and  ex- 
tent, and  degree  of  pressure  necessary  to  elicit;  muscle 
rigidity  and  spasm,  whether  present  or  not,  and  in 
which  special  locality,  and  noting  particularly  its  ab- 
sence or  presence  in  the  hypogastric  region  and  the 
right  iliac  fossa. 

(d)  Percussion — character  of  note  in  front  of  abdo- 
men and  in  flanks.  Liver-flatness,  extent,  in  middle, 
nipple,  and  in  mid-axillary  lines.  Note  specifically 
every  third  hour.  Remember,  too,  that  obliteration  may 
occur  in  a  flat  as  well  as  in  a  distended  abdomen.  Aus- 
cultatory percussion  may  be  helpful. 

(_e)  Auscultation — obliteration  of  signs  of  peristalsis ; 
presence  of  friction. 

(/)  Examination  of  rectum,  whether  tenderness; 
fulness  between  rectum  and  bladder. 

(jg)  Stools — character,  frequency,  presence  of  blood  or 
sloughs. 

IV.  General  condition  of  patient  : 

(a)  Facies,  whether  change  in  expression ;  risu.-. 
slight  or  marked  ;  pallor  ;  sweating,  etc. 

(b)  Pulse,  change  in  rhythm,  rate  and  force. 

(c)  Temperature,  whether  a  drop  or  not,  whether 
after  a  tub  or  not. 

(d)  Respiration,  sudden  increase,  not  infrequent, 
whether  shallow,  or  sighing. 

(e)  Sweating,  if  subject  to  during  attack;  if  onset 
with  the  pain  ;  whether  local  or  diS'use. 

(/)  Vomiting,   whether  with  onset  of  pain  or  not; 
character  of  vomiting. 
(g)  Hiccough. 

V.  Bloodc-ount. — Leukocytosis,  stationary  or  rising. 
May  be  marked  and  early.  In  a  majority  of  cases  well 
followed  there  is  a  rise.  The  constant  leukopenia  in 
typhoid  fever  has  to  be  taken  into  account.  Also  a 
count  of  the  red  blood-corpuscles  and  hemoglobin,  as  a 
decided  drop  might  suggest  hemorrhage. 

It  is  in  the  hands  of  the  profession  to  reduce  still  fur- 
ther the  mortality  of  typhoid  fever.  The  death-rate  of 
the  disease  under  the  most  disadvantageous  circum- 
stances may  be  gathered  from  the  shocking  esperienc 
in  the  South  African  campaign,  in  which,  to  SeptemberJ 
there  had  been  more  than  25,0C0  cases  of  typhoid  feverJ 
with  more  than  3,C00  deaths,  20%.  In  the  Spanish-; 
American  campaign  there  were  20,738  cases  of  typhoid 
fever,  with  a  mortality  of  only  1,580 — 7.61%.  The  re- 
markable prevalence  of  the  disease  is  illustrated  better, 
perhaps,  by  the  fact  that  ^-6.24%  of  the  total  deaths" 
during  the  war  were  due  to  this  cause. 

Under  the  favorable  circumstances  with  which  wearej 
surrounded  in  this  country',  and  the  ease  with  whichf 
patients  can  be  nursed  and  cared  for,  the  death-rat 
should  reach  the  lowest  possible  point.    For  this  blesse 
consummation  one  most  important  preliminary  is  nece 
sary.     Our  senior  students  should  receive  a  practicaLl 
first-band,  day  by  day  acquaintance  with  typhoid  ft 
Heaven  knows  there  are  cases  enough   and  to  S} 
in  every  city  in  the  Union  to  provide  instruction  of  this 
sort.     But  is   it  given?     I  do  not   mean  lectures  on 
typhoid  fever,  or  recitations  on  typhoid  fever.     I  mean 
seeing  typhoid-fever  patients  day  by  day,  practically 
having  charge  of  them,  and  watching  their  progress  from 
week  to  week.     This  can  be  done,  and  this  should  be 
done  in  the  case  of  an  all-important  disease  of  this  char- 
acter.   The  worst  indictment  ever  brought  against  the 


•JiKOAKY   19,   1901] 


HEMOGLOBINURIA  COMPLICATING  TYPHOID  FEVER 


CThe  Philadelphia 
Medical  Journal 


119 


medical  schools  of  this  country  is  contained  in  the  re- 
cently issued  report  by  Reed,  Vaughan,  and  Shake- 
speare on  the  prevalence  of  typhoid  fever  during  the 
Spanish-American  War.  Shades  of  W.  W.  Gerhard 
and  of  Austin  Flint!  The  young  doctors,  to  whom 
were  entrusted  scores  of  valuable  lives,  had  practi- 
cally not  got  beyond  the  nosology  of  Rush.  Of  the 
total  number  of  20,000  cases  of  typhoid  fever,  only 
about  50%  were  diagnosed  by  the  regimental  or  hos- 
pital surgeons.  Some  of  the  statistics  are  perfectly  ap- 
palling. Thus  in  80  out  of  85  cases  sent  from  the  Fifth 
Maryland  Regiment  to  civil  hospitals  in  Baltimore,  the 
diagnosis  was  changed  from  malaria  to  typhoid  fever. 
Of  98  cases  sent  from  the  Eighth  New  York  Regiment 
to  New  York  Hospitals  all  were  recognized  as  typhoid. 
A  majority  of  them  had  been  entered  under  other  diag- 
noses. The  authors  of  the  report  do  not  improve 
matters  by  the  lame  apology  that  the  army  surgeons 
probably  did  better  than  the  average  physician  of  the 
country  in  his  private  practice. 

There  are  many  lessons  which  we  all  have  to  learn 
about  typhoid  fever,  but  the  one  I  wish  to  enforce  on 
this  occasion  is  the  necessity  of  watching  carefully  in 
the  severe  cases  for  the  very  first  features  of  perforation, 
in  order  that  the  patient  may  be  given  the  benefit  of 
operation  at  the  earliest  possible  moment.  In  general 
hospitals  it  may  be  feasible  in  the  future  to  save  one- 
half,  at  least,  of  the  perforation  cases.  In  the  severer 
cases,  as  in  the  second  one  which  I  have  related,  the 
condition  of  the  bowel  is  hopeless.  In  another  group, 
illustrated  in  the  first  one,  the  patients  recover  from 
the  operation,  but  die  of  the  eflTects  of  the  disease  itself. 
But  one  of  the  most  gratifying  circumstances  connected 
with  the  disease  has  been  the  demonstration  by  the 
surgeons  that  there  is  a  third  group  in  which  complete 
and  perfect  recovery  may  follow.  To  January  1  of  this 
year  11  cases  of  perforation  have  been  operated  upon 
from  my  wards  by  Dr.  Halsted's  associates  and  assist- 
ants, Drs.  Finney,  Cushing  and  Mitchell,  5  of  which 
have  recovered,  a  percentage  of  45.4.  Five  additional 
cases  have  been  operated  upon  by  them  with  1  recov- 
ery, a  total  of  16  with  6  recoveries,  a  percentage  of  37.5. 


HEMOGLOBINURIA  COMPLICATING  TYPHOID  FEVER. 

By  JOHN  H.  MUSSER,  M.D., 

of  Philadelphia, 

ProfeBsor  of  Clinical  Medicine,  University  of  Pennsylvania ;  Physician  to  the 
University  Hospital,  etc.. 


ALOYSIUS  O.  J.  KELLY,  M.D., 

of  Philadelphia, 

Instructor  in  Clinical  Medicine,  University  of  Pennsylvania  ;  Assistant  Physi- 
cian to  the  University  Hospital,  etc. 

(From  the  Department  of  Clinical  Medicine,  Hospital  of  the  University  of 
Pennsylvania.) 

Although  the  symptoms,  complications,  and  sequels 
of  typhoid  fever  have  been  well  described  by  a  large 
number  of  writers,  it  still  seems  permissible  to  add  to 
the  already  voluminous  literature  on  the  subject,  the 
report  of  a  single  observation  of  a  rather  unusual  com- 
plication— hemoglobinuria.  Reference  to  the  literature 
indicates  that  while  the  occurrence  of  this  complication 
is  by  no  means  unknown,  it  is  exceedingly  rare,  and  it 
is  not  commented  upon  by  a  number  of  systematic 
writers  on  the  subject.  Thus  no  mention  of  the  occur- 
rence of  hemoglobinuria  as  a  complication  can  be  found 


in  the  articles  on  typhoid  fever  in  a  number  of  the 
recent  textbooks  on  the  practice  of  medicine,  such,  for 
instance,  as  those  by  Osier,  Tyson,  Anders,  Wood  and 
Fitz,  Lyman,  Whittaker,  Thompson,  Flint,  Striimpell, 
Eichhorst ;  nor  in  the  System  of  Medicine  by  Pepper, 
the  American  Textbook  of  jNIedicine  by  Pepper,  the 
American  Textbook  of  Practical  Medicine  by  Loomis 
and  Thompson ;  nor  in  the  textbooks  on  diagnosis  by 
DaCosta,  Leube,  and  Musser ;  nor  in  the  Medical  Com- 
plications and  Sequels  of  Typhoid  Fever  by  Hare. 
However,  in  discussing  the  etiology  of  hemoglobinuria 
and  noting  that  it  may  be  provoked  by  the  poison  of 
certain  infectious  diseases,  a  number  of  the  above- 
mentioned  writers — Tyson,  DaCosta,  Wood  and  Fitz, 
Ander.s — casually  mention  typhoid  fever  in  the  list  oi 
such  provocative  infectious  diseases. 

On  the  contrary,  specific  mention  of  the  occurrence 
of  hemoglobinuria  as  a  complication  of  typhoid  fever 
is  made  by  Brannan  (Twentieth  Century  Practice,  xvi, 
681),  Curschmann  (Nothnagel's  Specielle  Pathologie  und 
Therapie,  iii,  177,  1898),  and  Dreschfeld  (Allbutt's 
System  of  Medicine,  825, 1896).  The  last-named  author 
states  merely  that  in  some  severe  cases  of  typhoid  fever 
hemoglobinuria  has  been  observed,  whereas  Cursch- 
mann states  that  a  true  hemoglobinuria  accompanied 
with  hemoglobinemia  has  been  observed  by  him  in  2 
cases  of  typhoid  fever.  In  the  one  case,  the  hemoglo- 
binuria occurred  in  the  middle  of  the  second  week,  in 
the  other  at  the  commencement  of  the  third  week  of 
the  disease.  Both  cases  ended  fatally  under  manifes- 
tations of  intense  intoxication.  In  addition  to  the 
foregoing,  there  has  been  found  a  report  of  a  case  by 
Osier  (.Johns  Hopkins  Hospital  Reports,  v,  311,  1895), 
and  the  report  of  another  case  by  Klemperer  (Charite- 
Annalen,  xx,  133,  1895).  The  last-named  writer  be- 
lieved that  the  etiologic  relationship  of  typhoid  fever  to 
hemoglobinuria  had  not  been  pointed  out  prior  to  his 
communication. 

Doubtless,  other  cases  have  been  observed,  and  some 
of  them  may  have  been  reported,  but  the  complication 
seems  sufficiently  unusual  and  interesting  to  merit 
brief  mention  of  the  following  case  : 

Patrick  H.,  aged  21  years,  single,  a  colored  laborer,  and  a 
native  of  Pennsylvania,  was  admitted  to  the  medical 
wards  of  the  hospital  of  the  University  of  Pennsylvania, 
to  the  service  of  Dr.  Musser,  August  30,  1900.  The  fol- 
lowing history  was  elicited  by  Dr.  Evans,  the  resident 
physician  :  The  patient'.s  parents,  seven  sisters  and  three 
brothers  are  living  and  well.  There  is  no  history  of  tuber- 
culosis or  carcinoma  in  the  antecedents.  The  patient  himself 
went  to  school  until  he  was  19  years  of  age,  since  which  time 
he  has  been  working  as  a  laborer  on  the  railroad.  He  uses 
alcohol  and  tobacco  in  mnderation.  While  he  thinks  that  he 
may  have  had  some  of  the  diseases  of  childhood,  he  does 
not  remember  that  he  was  ever  sick.  He  had  specific 
urethritis  one  year  ago.  He  was  well  until  August  27,  on 
which  day  he  experienced  a  feeling  of  languor,  and  com- 
plained of  headache,  loss  of  appetite,  and  slight  diarrhea. 
He  went  to  work,  however,  but  was  obliged  to  discontinue  on 
account  of  the  headache.  During  the  evening  he  felt  very 
liot  and  drank  considerable  water  to  relieve  his  thirst  which 
was  marked.  The  following  day  he  again  atteinpted  to  work 
but  was  again  obHged  to  discontinue  and  to  take  to  hed.  Since 
then  he  has  complained  of  languor,  weakness,  headache, 
slight  diarrhea,  and  fever.     There  has  been  no  nosebleed. 

On  admission  the  patient's  temperature  was  104°  F.,  his 
pulse-rate  96,  his  respiration-rate  28.  The  following  are  the 
notes  of  the  physical  examination  made  by  Dr.  C.  Y.  White  : 
The  patient  is  a  mulatto,  5  feet  9  inches  in  height,  of  good 
bony  development  and  good  musculature.  He  is  very  sopo- 
rose, and  there  is  marked  subsultus  tcndinum.  The  conjun- 
tivae  are  jaundiced.    The  movements  of  the  eye-balls  are 


120 


The  PHfLAOKr.PHiAl 
Medical  .Journal  J 


HEMOGLOBINUPJA  COMPLICATING  TYPHOID  FEVER 


;ja*caev  19,  i9or 


normal;  the  pupils  are  somewhat  dilated  and  react  to  light 
andtoacconniodation.  The  Tips  are  dry,  the  teeth  good.  The 
tongue  is  heavily  coated,  but  its  movements  are  normal. 
The  visible  mucous  membranes  are  pale.  The  ears  are 
normal.  The  neck  is  short  and  thick  and  reveals  slight  pul- 
sations, but  no  enlargement  of  the  lymphatic  glands.  Nor  is 
there  any  enlargement  of  any  of  the  other  superficial  lym- 
phatics The  chest  is  well  formed  and  of  good  anteroposte 
rior  diameter.  Tliere  are  slight  depressions  on  either  side'of 
the  clavicles  at  the  outer  ends.  The  pectoral  muscles  show 
marked  tremors.  The  pulmonary  resonance  extends  on  the 
right  side  anteriorly  to  the  sixth  rib,  posteriorly  to  the  ninth 
spine;  on  the  left  side  anteriorly  to  the  third  rib,  and  pos 
teriorly  to  the  ninth  spine.  The  percussion  note  as  well  as 
vocal  fremitus  are  normal  on  both  sides.  On  auscultation 
the  inspiration  and  expiration  are  harsh  throughout  both 
lungs  The  absolute  cardiac  dulness  extends  upward  to  the 
third  rib  where  it  joins  the  sternum,  to  the  right  as  far  as 
the  left  edge  of  the  sternum,  and  to  the  left  to  the  fifth  in- 
tercostal space  slightly  outside  the  midclavicular  line,  at 
which  point  the  apex  beat  is  visible  and  palpable.  On  aus- 
cultation there  is  splitting  of  the  first  sound  as  well  as 
accentuation  of  the  second  sound ;  all  sounds  are  boom- 
ing and  the  heart's  action  is  rapid.  The  radial  pulse 
is  rapid  and  of  poor  volume.  The  liver-dulness  ex  ends 
in  the  midclavicular  line  from  the  lower  margin  of  the 
sixth  rib  to  one  finger's  breadth  below  the  costal  margin. 
The  splenic  dulness  extends  from  the  eighth  rib  to  the 
margin  of  the  ribs  and  from  the  posterior  to  the  anterior 
axillary  line.  The  organ  is  palpable.  There  is  slight  ab- 
dominal distention  and  gurgling  in  the  right  iliac  fossa. 

The  urine  was  turbid  and  claret-colored  or  smoky;  its 
specific  gravity  was  1.0.35;  it  was  acid  in  reaction  and  de- 
posited a  heavy  sediment;  it  contained  ^  by  bulk  of  albu- 
min by  the  heat  and  acid  test ;  there  was  no  sugar.  Ex- 
amination revealed  the  coloring  matter  to  be  hemoglobin. 
Microscopically  there  were  amorphous  urates,  granular 
casts,  granular  debris,  and  a  few  epithelial  cells;  there  were 
no  erythrocyte?. 

The  patient  was  ordered  milk  and  albumen  water  (the 
1  itter  on  account  of  his  dislike  for  milk),  a  tub-bath  every 

3  hours  if  his  temperature  should  be  102.4°  F.,  or  higher, 
and  a  sponge  bath  should  the  temperature  be  between  100° 
F.  and  102.4°  F. 

On  September  1,  the  patient's  temperature  remained  per- 
sistently between  101°  F.  and  104.8°  F.,  with  the  exception 
of  short  intervals  following  each  bath.  There  were  marked 
muscular  tremors  and  the  peripheral  circulation  was  poor. 
As  he  complained  much  of  the  milk  which  nauseated  him,  he 
wa?  ordered  more  albumen-water.  In  addition  he  was  given 
whisky  with  each  Inith  and  ;V  of  a  grain  of  strychnin  every 

4  hours.  The  urine  still  contained  a  large  amount  of  blood 
pigment.  The  test  for  biliary  coloring  matters  was  negative. 
The  Gruber-Widal  reaction  was  reported  positive.  Exami- 
nation of  the  blood  revealed  the  following :  Hemoglobin,  15% : 
erythrocytes,  1,950,000;  leukocytes,  8,960. 

On  September  2,  the  patient's  condition  was  unchanged 
except  that  his  pulse  was  feeble  and  dicrotic.  The  stools  were 
reddish-brown  and  watery,  but  revealed  no  blood.  His 
temperature  varied  between  103.8°  F.  and  102°  F.  Hemo- 
globinuria per.sisted. 

On  September  3,  hemoglobinuria  was  still  present.  The 
blood  examination  was  as  follows :  Hemoglobin,  15%:  ery- 
throcytes, 1,00(),(XH1;  leukocytes,  8,880. 

On  September  5,  the  temperature  manifested  some  tend- 
ency to  descend,  being  al)Out  103°  F.,  with  falls  approximating 
3°  F.  with  each  bath.  Hemoglobinuria  was  still  present.  The 
stools  were  watery  and  contained  some  blood-coloring  matter. 
Examination  of  the  blood  revealed  the  following :  Hemoglo- 
bin, 15%;  erythrocytes,  2,430,000;  leukocytes,  8,800. 

On  September  G,  the  urine  was  amber-colored,  clear,  acid 
in  reaction,  and  its  specific  gravity  was  1.020;  it  contained  a 
trace  of  albumin,  a  few  granular  casts,  a  few  epithelial  cells, 
but  no  blood  pigment 

On  September  7,  the  blood-count  was  as  follows :  Hemo- 
globin, 18%  ;  erythrocytes,  3,290,0(X);  leukocytes,  11,760. 
Hemoglobinuria  was  absent.  The  highest  temperature  was 
102.6°  F. 

On  September  8,  hemiglobinuria  was  still  absent.  The 
patient  refused  absolutely  to  take  any  more  milk,  To  dis- 
guise its  taste  it  was  ordered  peptonized. 


On  September  12,  examination  of  the  blood  revealed  the- 
following:  Hemoglobin,  15%  ;  erythrocytes,  3. 300,rXX»;  leukf>- 
cytes,  11,840.  HemogloVjinuria  had  disappeared.  The 
patient's  general  condition  had  improved.  The  highest-,' 
temperature  was  102°  F.  He  was  ordered  ammoniated 
citrate  of  iron. 

On  September  19  and  for  some  days  previous'y,  the  patient 
had  been  noted  to  be  somewhat  irrational,  in  that  he  stated  ^ 
tiiat  since  he  had  been  in  the  hospital  he  had  been  married.* 
and  had  bought  a  house.  His  temperature  for  some  days-J 
had  varied  between  99°  F.  and  100°  F. ;  his  pulse,  which  wa«  T 
somewhat  dicrotic,  was  from  78  to  88  per  minute;  and  his-t 
respirations  from  l8  to  22  per  minute.  The  strychnin  waa-I 
increased  from  j^  to  ,'„  of  a  grain  four  times  a  day,  and  he% 
was  given  half  an  ounce  of  whisky  three  times  a  day.  ■ 

On  September    20,   the    patient's    temperature    reached* 
normal  for  the  first  time.     On  September  23,  the  urine  was^ 
amber  colored   clear,  acid  in  reaction,  and  of  1.012  specific-- 
gravity  ;  it  contained  no  albumin  and  no  sugar.    The  micro-  i 
scope  revealed  only  a  few  leukocytes.    His  delusions  per-* 
sisted,  but  on  all  other  matters  he  was  entirely  rational      Oa  \ 
September  25,  examination  of  the  blood  revealed  :  Hemo- 
globin, 55%  ;  erythrocytes,  2,920,000;  leukocytes,  5,229.    On 
September  27,  the  patient  was  somewhat  uncertain  regarding 
the  changes  in  his  domestic  affairs.     His  temperature  had 
been  normal  for  four  days.     The  further  progress  of  the  case 
was  uneventful.    On  October  8,  the  patient  was  permitted  to 
get  out  of  bed  for  the  first  time  and  he  was  given  a  light 
special  diet.    On  October  17,  he  had  gained   considerable, 
flesh  and  t'trength,  and  he  was  permitted  full  house  diet.   His- 
mental  condition  seemed  good.    He  would  only  smile  when  | 
questioned  regarding  his  suppositious  wife  and  house,  and  > 
he  appeared  to  regard  the  entire  matter  as  a  joke.    On  Octo-t  I 
ber  23,  he  was  permitted  to  go  home.    He  was  still  somewhat-^  [ 
below  par,  but  he  was  gaining  rapidly.    It  is  to  be  regretted-^ 
that  another  examination  of  the  blood  was  not  made     In-, 
all  he  had  had  47  tub-baths,  53  sponge-baths,  and  9  ice-pack 

Aside  from  the  rarity  of  the  complication,  the 
presents  several  features  of  interest.  Of  these  might 
be  mentioned  the  absence  of  malaria  as  an  etiologic 
factor,  the  association  of  marked  hemoglobinemia,  the 
persistence  of  the  hemoglobinuria,  for  at  least  7  days 
(August  30  to  September  5,  inclusive),  and  the  ultimate 
recovery  of  the  patient.  In  passing,  it  is  interesting  to- 
observe  that  the  use  of  cold-water  baths  was  attended . 
by  good  results.  This  is  all  the  more  interesting  wheaj 
we  remember  that  cold  is  certainly  the  provoking  agent 
in  the  causation  of  some  cases  of  hemoglobinuria,  more 
particularly  of  the  paroxysmal  variety.  As  the  patient 
presented  hemoglobinuria  when  admitted  to  the  hospi- 
tal, the  condition  cannot  be  attributed  to  the  action  of 
cold  water.  As  regards  the  nature  of  the  complication, 
there  cannot  be  much  doubt  that  it  was  an  unusual 
manifestation  of  the  typhoid  infection.  The  majority 
of  the  previously-reported  cases  have  been  cases  of 
severe  infection,  and  most  of  them  have  terminated 
fatally.  The  infection  in  our  case,  while  severe.  w;is 
not  extremely  so,  unless  the  hemoglobinuria  itself  be 
considered  an  indication  of  severity  of  infection.  It  is 
not  unreasonable  to  assume  that  the  patient  presented 
a  peculiar  blood-idiosyncrasy,  in  consequence  of  which 
his  hemoglobin  and  the  red  blood-corpuscles  were 
especially  susceptible  to  the  deleterious  action  of  the 
typhoid  infection  or  typhoid  toxin. 


Havana  Health  Stitistics. — The  total  number  of 
yellow  fever  cases  in  Hivana  in  19('>0  was  1.244,  and  the 
deaths  310,  an  average  of  24% .  In  189;^  there  were  284  cases 
and  103  deaths.  The  deaths  from  all  causes  6 102,  the 
smallest  number  in  10  years,  the  average  for  thai  period 
being  10  245.  D.jring  the  ye.*r.  24,124  immigrants  landed  in 
Cuba,  against  16,00t>  the  preceding  year.  Id  December,  liVW 
there  were  62  cases  of  yellow  fever  and  20  deaths,  against  70' 
cases  and  22  deaths  in  December  1M19. 


JiSl-ARY   19,   1901] 


USE  OF  THERMOL  IN  TYPHOID  FEVER 


[The 
Mei 


Philadelphia 
dical  jocbkal 


121 


THE  CLINICAL  USE  OF  THERMOL  IN  TYPHOID  FEVER 
AT  THE  ATLANTIC  CITY  HOSPITAL,  ATLANTIC 
CITY,  N.  J. 

By  a.  B.  SHIMER,  M.D., 

of  Atlantic  City,  N.  J. 

During  my  service  at  the  Atlantic  City  Hospital,  I 
had  occasion  to  employ  thermol  in  a  series  of  fever  cases. 
The  result  was  so  satisfactory  that  I  felt  that  my  expe- 
rience should  be  recorded,  being  impressed  with  the 
almost  specific  action  of  thermol  in  this  group  of  cases, 
an  experience  which  I  feel  can  be  repeated  by  anyone. 
The  most  marked  symptom  of  typhoid  fever  is  the  fever, 
and  its  characteristic  influence  is  best  studied  when  ap- 
plying antipyretic  remedies.     As  is  so  well  known,  the 


abled  to  give  it  more  careful  consideration,  and  in 
"  fever  cases  "  especially  our  observations  were  most  ac- 
curate and  systemized. 

Dr.  Sylvester  J.  Goodman,  the  resident  physician, 
gave  especial  attention  in  noting  its  effects  and  record- 
ing the  course  of  each  case.  The  following  5  cases  of 
typhoid  fever,  taken  at  random  from  our  case-book,  in 
which  was  recorded  32  cases  treated  by  thermol  with- 
out a  death,  will  give  a  fair  resume  of  the  number  of 
cases  treated,  the  chart  of  each  being  an  exact  copy  of 
the  original.  All  these  cases  were  certified  to  by  the 
N.  J.  State  Laboratory  at  Princeton,  N.  J. 

Case  1, — A.  S.,  male,  age  35  years,  white,  single.  Occupation 
that  of  a  signalman  on  the  railroad.     Admitted  to  the  hos- 


Ciist-  AV -/ - - 

DIAGNOSIS 
....U^jiJL'r:^s/kj..yi-?AtAoA - 


lUvisc^ 


Nous  of  Cose 
Naml.J\..^. _ H\ 

Nativity...  .LLuife.^.  .-M^'A^k'U. 


Residrucc. 


Occupation /«i<..tt^rvaj>Jw*^4»-Ai.». 

Pftifie„^r  __V 


Date  of  admusiou.-j 


Diet 


fto^riyAf,  JS8S,  by  Jama  C.  WiUoit,  M.D. 


C. 
(-42° 


38" 


1-35° 


pyrexia  of  the  disease  is  of  serious  consequences,  and 
of  itself  often  leads  to  such.  Hence,  in  the  treatment  of 
a  disease,  the  fever  of  which  is  the  most  marked  symp- 
tom, especial  attention  should  be  given  to  the  cause. 
The  removal  of  the  cause  is  not  readily  realized,  and 
therefore  the  selection  of  some  suitable  antipyretic  pre- 
sents itself  In  choosing  such  a  remedy,  we  must  seek 
one  which  may  control  those  conditions  of"  fever  "  by  in- 
hibiting heat-production,  or  by  dissipating  heat,  or  both, 
with  the  least  deleterious  effect  upon  the  system.  As 
such,  I  have  found  thermol  to  embody  these  points 
most  thoroughly.  My  first  use  of  this  drug  was  in  a 
varied  number  of  cases  in  private  work,  and  the  result 
was  so  pleasing,  I  had  no  fear  or  hesitancy  to  employ 
it  elsewhere.     In  the  wards  of  the  hospital  I  was  en- 


Philadetpfi\a,  J.  B.  LippincoU  Companv. 


pital  July  26,  suflering  with  an  intense  headache,  vomitiii" 
chills,  and  a  feeling  of  general  weakness.  He  had  been  ail- 
ing for  10  days  or  more.  Had  nosebleed  on  several  occa- 
sions. His  bowels  were  constipated.  Had  a  temperature  of 
102.6°  F.  on  admission.  Tenderness  of  the  right  iliac  region, 
with  a  somewhat  enlarged  spleen  and  liver,  and  a  few  rose- 
spots  were  noted.  The  headache  was  most  intense,  so  that 
his  whole  complaint  was  directed  to  this  symptom.  Calomel 
in  divided  doses,  with  salol  and  thermol  0.30,  every  3  hours, 
was  the  treatment  begun,  and  as  the  fever  responded  to  this 
treatment,  no  other  remedies  for  the  fever  were  given.  There 
were  no  complications.  The  case  ran  a  typical  course  with 
the  convalescence  somewhat  more  rapid  than  generally 
noted.  The  patient  was  enabled  to  sit  up  on  the  eleventh 
day  of  his  admission,  about  the  twenty-first  to  the  twenty- 
fiftli  day  of  his  illness.  As  (note  the  chart  here  given) 
the  highest  temperature  was  noted  on  the  day  of  his  admis- 
sion, 102,6,  and  on  the  si.xth  day  and  eighth  day,  the  fall  of 


Cf^Sf  iVv          *v       •                                      

M 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M 

e 

M 

E 

M 

E 

M 

E 

M 

£ 

M 

E 

M 

E 

u 

E 

M 

E 

M 

E 

M 

E 

M 

E 

M|E 

MJE 

M£ 

m|e 

1 

1 

1 

u            ,  DIAGNOSIS 

t'rtnc 

!>(My  Ami 

1 

1 

1 

1 

1 

c. 

0'iypH^.4)-vM^  '+O^L/0 

Y. 
107" 

I06° 

s 

;  105  <^ 

J. 04" 
103° 
102° 

ioi° 

lOO" 

98° 

1    08» 

J    97° 

3      . 

■3 

Du'j<tfDig 
Pulse. 
Retp. 
Dutt. 

1 

1 

1 

-42 

1 

: 

i 

D                        ( 

1 

1 

1 

Bniui.-^ 

1 

.         Sous  of  Cose 
A'am,.tMo^\L.Jy.. ''f\ 

1 

1 

I 

1 

1 

, 

■?■ 

1 

1 

1 

1 

, 

1 

t 

1 

Occuptilion...    Jn:oiAiiJ_AiL/xJ   .-,-.. 

1 

j 

1 

1 

_ 

1 

1 

I 

•V 

S^ 

.  .f 

[ 

1 

1 

1 

■■    \ 

1 

1 

Di,t     (j 

r 

-39 

I 

J 

- 

1 

> 

s 

V 

/ 

S, 

- 

1 

N 

1 

< 

> 

[ 

^ 

/ 

1 

i 

■38 

1 

, 

A 

^ 

K 

\ 

i 

M 

I  ■ 

1 

■ 

L 

. 

1 

\ 

1 

L 

V 

i 

, 

f 

1 

1r^ 

N 

, 

1 

1 

1 

] 

^ 

■ 

; 

i 

v^ 

I 

' 

, 

1 

\ 

i 

' 

! 

) 

1 

, 

; 

1 

( 

1 

1 

1 

i 

1 

1 

1 

^^ 

^ 

?? 

2? 

« 

t*t 

.^ 

se 

;?< 

^ 

?* 

^ 

..^i' 

4o 

^ 

de 

^ 

-■■■ 

\ 

.% 

.^■ 

>c^ 

4- 

^ 

^ 

^ 

-^ 

^ 

* 

.^ 

^ 

* 

^ 

4 

,• 

Uito' 

/?«»/r....J^M^rv>?AAib. - 

~ 

«^ 

^ 

.i^ 

'•^ 

^j 

<i<5 

O^ 

^ 

^ 

>^ 

NO 

Coo^rrghl.  1SS5,  by  Jama  C.  WiUon.  M  D. 


t 


PkilatUlpkia,  J.  B  Lippimoatt  Com^aiy. 


Case  No.. 


DIAGNOSIS 


RevisAT. — ■. 

Sous  of  Cose 

A'ffm<i..^i.t?^.._fw,.._ tt\ 

Age. 3_iD__M£Ay7^?»^ vS.\^ 

Oceufiuion CLcX^DC 

Residence....^ 


>tt 


Dau  of  aJmissioii.  .UUjuXliATT.  .^.  .-•  00 


Diet    ^ 


fitsule... 
C»rr :}>>'.  ISSe.  hy  Jamet  a   wLon.  U  D. 


^ 


Py^iadrlplaa,  J  B   L>ffi.etrt  CwM'j 


JANDAKY  19,  1901] 


USE  OF  THERMOL  IN  TYPHOID  FEVER 


[The  Philadelphia 
Medical  Journal 


123 


the  temperature  was  helow  normal.  This  has  been  noted  by 
other  observers  who  had  used  thermol  in  typhoid  or  otlier 
fevers. 

Case  2. — M.  A.  P.,  an  American  by  birth,  age  22  years, 
male,  single,  white,  and  followed  the  occupation  of  a  trav- 
eler. This  patient  also  gave  a  history  of  being  ill  for  two  or 
more  weeks  prior  to  his  admission  to  the  hospital.  Lost  appe- 
tite, severe  headache,  pain  in  the  back  and  abdomen,  occa- 
sional vomiting,  with  constipation  alternating  with  diarrhea, 
more  severe  after  taking  a  laxative.  This  patient  was  very 
sick  on  admission,  and  almost  delirious.  His  temperature 
was  104°  F.  There  were  numerous  specific  spots  seen  all 
over  the  abdomen.  The  spleen  was  enlarged  as  well  as 
tender.  The  liver  was  also  somewhat  enlarged.  The  ab- 
domen was  tympanitic  and  painful  to  pressure,  not  only  in 
the  iliac  region,  but  over  the  lower  bowel.  The  tongue  was 
very  heavily  coated  and  marked  by  the  teeth, whilst  upon  the 


of  typhoid  fever.  The  patient  was  ill  for  quite  a  long  period, 
and  on  attempt  to  exercise,  fell  in  the  streets,  and  was 
brought  to  the  hospital  in  a  collapsed  condition.  The  same 
symptoms  of  general  malaise,  dizziness,  anorexia,  chilly  sen- 
sations followed  by  a  fever,  headache,  insomnia,  and  consti- 
pation. On  examination  on  admission,  rose-spots  were  at 
once  seen,  with  the  enlarged  spleen  and  liver,  marked  iliac 
tenderness,  and  tympanites.  Bowels  obstinately  consti- 
pated. He  had  besides  the  general  symptoms  of  a  typical 
typhoid,  also  a  dry  cough,  beginning  congestion  of  the  lungs. 
His  pulse  was  also  dicrotic  on  admission,  as  seen  by  Chart  3. 
The  temperature  on  admission  was  104°  F.  A  purgative  of 
calomel  was  given  at  once  with  thermol,  0.30  every  2  or  3 
hours  ;  the  hypodermatic  use  of  strychnia  when  needed,  and 
turpentine  in  the  form  of  an  emulsion  were  the  remedies 
used.  As  seen  by  this  chart,  the  temperature  immediately 
fell,  and  so  continued  with  only  one  rise  on  the  fifth  day 


Cast  Xo T\..... -.- 

M    E 

M 

E 

M 

E 

M 

E 

M 

E 

m!e 

M   E 

M 

E 

M 

E 

MjE 

M 

E 

M    E 

M   E 

M 

E 

M 

£ 

M 

E 

M 

E 

M 

E 

m|e 

mIe 

M 

E 

JlOlf  £2.5 

1 

^              jjDIAGNOSlS 

I  rlfir 

1 

1 

I'. 

107' 

aa^  ■ >■ 

-106  = 

1 

1  los" 

1  104° 
103° 
102" 
101° 

ioo° 

99° 
1    98° 

;  97° 

Do!/ofDis 
Pi^he. 
Rcsp. 

Dm,.,, 

— 

L- 

..I 

-I- 

— 

— 

-4~ 

— [— 

-— 

^— 

— — 

— ^ 

L- 

— 

— 

_ 

— 

— 

— 

_ 

— 

h 

— 

_ 

„    ,    /  1) 

E£VtS£.\i ^ 

Notes  of  CfiSl 
A',i/w.v3_^lMO-, .\i'. 

— 

— 

\ 

1 

J 

1 

j 



-t- 







- 

- 

- 



— 

- 

- 

— 

n 

— 

L- 

1 
1 

i 

- 

-t— 

- 

— 

-t- 

1 
\ 

— 

t 

— 

— T^ 

- 

- 

- 

- 

- 

- 

- 

- 

- 



— 1 — 

H — 

— 

' — — ' 

— 

1 

LZ 

— 

L- 

— 

^ 

— 

I— 

1 

I 

1 

1 

[ 





' 1 

1 



1 

, 





._ 

— 

1 

— 

— 

— 

— 

_j_ 

— 

— 

— 

f— 

^- 

-A 

-t- 

— 

— 

— 

1 — 

— 

— 

OcciipiUion- .  ^3vt-tjUULt\-!i^jAJU^. . . . 

— 

— 

1 

1 

— 

_ 

— 

— 

^r- 

— 

— 

— 

- 

— 

— 

— 

— 

_ 

1 — 

„ 

L— 

— 

— 

— 

_|_ 

_ 

— 

— 

_ 

_j-_ 

— 

-H 

_ 

- 

— 

-- 

■— 

— 

— 

— 

— 

— 

— 

- 

— 

— 

— 

Resuifncc 

1 

1 

1 

- 

-H 

_ 

1 

1 

1 

_ 



, 



_ 

1 



, 









Dal,  of  admission. .  (AvtAS^V. .  i5  ?^.  ..<.'..  mo 

- 



— 

1 

1 

— 

' — 

— 

— 

— 

— ' 

— 

— 

— 

— 

— 

' 

1 

1 

„•       ( 

_ 

— f— 

— 

1 — 

' 

j_ 

— 

_ 



._ 

1 

_ 

_l 

, 





Diet    V) 

—^ — 





— 



— 

1 

1 

— ' 



— 

1 

— 

— 

— 

— 

— 1 

— 

— 

■ 

ii 

1 

1 

1 

1 

\ 

1 — 





_ 

_ 

-t'"^ 





1 

, 



1 — 

_ 

— 

_ 

_ 



_ 



, 





— r^ 

— 

— 

' — 

t 

' — 

^ 

— 

— 

— 

— 

— 

^1 

— 

~ 

— 1 

— 

— 

— 

— 



-J 

V^ 





-iA 









_l_ 



1 

__ 















-f- 

^ 

^ 

~ 

~ 

i 

— 

— 

— 

-^ 

H 

Y- 

— 

— 

— 

— 

— 



u_ 

V 

~ 

— 

— 

'- 

^V 

- 

r 

— 

1 — 

-A 

— 

' — 

— 

— 

— 

— 



\ 

^ 

1 

\ 

1 

1 

^ 

\ 

1 

— 

1 

' 

f^ 

\ 

- 

- 

-^ 

- 

_. 

> 

1 

1 

1 





, 

^ 

1 

A.. 

^- 

, 



- 

1 

4 

J 

— 

— 1 

— 

— 

' 

[ 

— 

— 1 

=V 

7^ 

^-*< 

" 

— 

— 

.-^ 

— \ — 
— (-- 

1 

1 

^^^ 

1 

\ 

1 

'~l 

\" 

^ 

^ 

1 

1 

1 

1 

— 

u 

1 

u 

— 

— 

L 

~\ 

— 

— 

! 

1 

— I 

-1 

_ 

— 

t 

-1- 

— — 

J 

— 

— 

— 

— 

— 

— 

- 

— 

— 1 — 

— |— 

— ^— 

— ;— 



— 

— 

— 

— 

"l 

— 

1 

<^ 

3^ 

c 

■sS 

^ 

Ai 

'^V 

-9 

"^ 

C" 

^ 

^ 

/ 

^'*' 

,oV 

\*^ 

v^^ 

»VV 

\«^ 

A^ 

^ 

K" 

^0 

S'^ 

ULCrfoj^adLA,. _. 

.>* 

•V? 

^ 

Vt 

^^ 

^ 

y% 

^V 

V^ 

^X 

■v^ 

•> 

x-^ 

V^ 

,.'' 

,'' 

fifsu/r. 

^0 

^ 

\ 

•V 

-ti 

•iy 

^ 

v» 

Kl 

«^ 

•v 

-i^ 

^ 

<:? 

c. 

-42' 


f.ujir.jA(,  ISaS.  hy  Jamet  C. 


«.  M.tS. 


4^ 


teeth  were  sordes.  The  pulse  was  weak,  compressible,  and 
dicrotic,  necessitating  the  prompt  use  of  strychnia  hypoder- 
mically.  The  treatment  in  this  case  was  thermol  0.30  doses 
every  three  hours  when  the  temperature  was  above  101,  and 
reduced  to  0.18  when  the  temperature  was  below  this  point. 
His  treatment  besides  this  was  symptomatic;  for  the  tym- 
panitic abdomen,  enemata  of  turpentine  were  given,  whilst 
the  turpentine  in  gram  doses  was  administered  in  an  emul- 
sion. This  patient  recovered,  and  with  no  other  symptoms 
but  those  met  with  in  a  rather  severe  type  of  typhoid.  Dur- 
ing the  whole  course  of  the  disease  no  other  remedy  was 
used  but  the  thermol  for  the  fever,  and  as  the  dose  at  stated 
intervals  was  always  suflicient  to  keep  the  fever  in  safe 
grounds,  it  was  continued.  As,  note  the  chart  No.  2,  twice 
during  the  course  of  the  disease,  the  temperature  reached 
normal.  A  very  happy  result  for  any  method  of  reducing 
temperature  in  typhoid. 

Case  3.— J.  A.  B.,  male,  white,  single,  age  36  years,  occupa- 
tion that  of  an  actor.    This  may  be  termed  a  walking  case 


FhUndelp)da,  J,  B   Lrppincott  Crrmpanv. 


after  admission,  when  it  fell  to  normal  and  so  continued. 
It  is  difiicult  in  hospital  cases  to  exactly  date  the  day  of  the 
disease  from  the  chart,  it  would  appear  that  the  patient  was 
in  the  third  week  of  his  illness  when  admitted,  and  that  the 
thermol  acted  in  the  nature  of  a  specific.  The  effects  in 
Case  3  were  truly  remarkable,  and  such  instances  as  these 
were  sufficient  to  prompt  us  to  use  the  remedy  in  many  in- 
stances. 

Case  4. — Mrs.  B.  M.,  age  20,  married,  and  occupation 
housekeeper.  Came  to  the  hospital  with  a  history  of  feel- 
ing sick  for  the  past  5  weeks.  Her  condition  was  rather  un- 
favorable. Temperature  102.4°  F.  Abdomen  much  enlarged, 
tympanitic  with  typical  spots,  spleen  enlarged  and  tender, 
marked  tenderness  in  the  iliac  region.  Headache,  constipa- 
tion, dry  cough,  pupils  dilated,  face  flushed,  urine  scantj'  and 
contained  albumin.  The  same  method  of  treatment  was 
pursued.  At  first,  a  calomel  purge,  and  then  the  exhibition 
of  thermol  in  0  30  (5  grain)  doses  until  the  normal  line  of 
temperature  was   reached,   once   in   3   hours.      After  this 


»l 


124 


Mkdical  Journal  J 


USE  OF  THERMOL  IN  TYPHOID  FEVER 


[Januabt  19,  ISOl 


the  thermol  was  given  in  0.15  (2J  grains)  doses.  The 
other  treatment  was  enemata,  with  the  use  of  strychnia 
when  indicated.  As  seen  by  tlio  chart,  the  temperature  was 
affected  at  once,  and  never  rose  to  the  height  first  noted. 
This  remarkable  eflect  of  thermol  is  noted  in  every  case,  and 
throughout  the  series  of  cases  so  treated  we  never  saw  the 
temperature  ever  go  beyoud  control. 

Case  5. — A.  H.,  age  21  years,  white,  single,  with  no  occu- 
pation. Had  been  ailing  10  days  before  admission  to  the 
hospital.  He  gave  the  same  typical  history  noted  in  cases 
•of  typlioid.  Headache,  general  malaise,  anorexia,  constipa- 
tion alternating  with  diarrhea,  abdominal  tenderness  with 
nausea,  vomited  up  till  a  day  or  so  before  his  admission, 
when  the  symptoms  became  more  marked.  Two  days  pre- 
vious he  had  nose-bleeding  quite  profusely,  with  a  (-hill. 
The  same  occurred  on  the  day  previous  to  and  on  admission. 
On  examination  his  tongue  was  found  very  heavily  coated. 


Caif  No. V 

R/vtsc-\i. .  .  „  ,   .  ^,. 

'Nous  of  Ct^u 

AV7wr.__-V-'5.^_\>rl-4.-  .--  - ,?t\ 

Occupoiion Jfja:v^Jl.J - 

Residence.. . , 


called  to  the  peculiarity  of  the  temperature  record,  the 
dissimilarity  of  each  from  a  typical  typhoid  tempera- 
ture. I  should  add,  that  in  each  instance,  the  diagno- 
sis was  verified  by  bacteriologic  tests.  Widal's  reaction 
was  found  in  each  case,  nor  was  a  case  pronounced 
typhoid  unless  every  physical  sign  was  in  unison,  to 
be  completed  by  a  Widal  test.  The  specific  action  of 
thermol  is  thus  proven  in  case  No.  .5,  where  a  relapse 
was  noted,  or  rather  where  an  elevation  of  the  temper- 
ature far  beyond  the  normal  temperature  of  that  par- 
ticular case  was  caused  by  the  irritation  of  the  food, 
thermol  acted  specifically  in  reducing  the  temperature^ 
To  summarize,  thermol  is  an  antipyretic  of  specific. 
effect.     In  no  case  was  the  heart's  action  at  all  im- 


Dale  o/admuswii  ,%*J^J^.2ti.. 
Diet 


Rfi«k..A!iM^1SC\f:i.iX^jf=^ 

Cnfyr,))Kl,  1SS6.  h)  Jama  C.  TT/fcon,  M.D. 


-4I» 


se- 


as* 


31* 


36» 


U3B» 


^ 


with  clean  edge,  but  dry.  His  pulse  was  very  weak  and 
rapid,  and  dicrotic.  His  abdomen  much  swollen  and 
covered  with  spots.  Tenderness  over  the  iliac.  Tender- 
ness over  the  whole  abdomen,  and  especially  the  lower 
portions.  The  spleen  enlarged  as  well  as  the"  liver.  Per- 
sistent dry  cough  and  delirium.  The  patient  was  placed 
under  the  same  course  of  treatment.  Thermol,  0.30  every 
3  hours,  etc.  This  case  pursued  the  regular  course  as  noted 
by  the  other  cases  until  the  eighth  day  (see  Chart  No.  5), 
when  tlie  temperature  rapidly  rose  to  105.8  P.  Investiga- 
tion led  to  the  discovery  that  some  kind  but  injudicious 
friend  had  given  the  patient  some  fruit,  with  tjie  result 
noted.  Prompt  purgation  with  enemata,  etc.,  removed  this 
complication,  and  the  progress  was  regular  until  perfect  re- 
covery. Even  at  the  time  of  the  relapse  the  same  plan  of 
giving  thermol  was  persisted  in,  and  the  result  showed  the 
wisdom  of  its  course.  As  the  Chart  No.  5  shows,  the  general 
course  of  the  fever  was  typical. 

In  presenting  this  series  of  cases,  attention  is  at  once 


PkilttJelpkia,  J.  B-  LippioeorT  Compamw. 


paired,  but  was  apparently  strengthened.  There  wi 
in  all  cases  no  greatly  decreased  amount  of  urine,  n( 
did  the  skin  become  exceptionally  dry. 

From  my  observations,  noted  here  as  well  as  in  pri- 
vate practice,  I  believe  that  the  earliest  moment  thermol 
is  administered,  in  any  case,  and  especially  typhoid,  the 
prompter  the  rssults,  and  the  more  specific  its  action. 

As  an  antipyretic,  it  is  harmless,  and  can  be  given  at 
any  time  or  in  any  state,  any  harmful  effect  as  collaj^vse 
or  the  like  never  being  noted. 

The  mode  of  administration  is  0.30  at  interv:Us  of  2, 
3  or  4  hours,  and  to  be  given  when  the  fever  begins  to 
rise ;  and  to  be  continued  even  after  the  fever  has  dis- 
appeared, in  smaller  doses  and  at  longer  interv:Us.  No 
fear  of  collapse  need  to  feared.  Hence,  there  is  no 
need  of  any  additional  medicine,  as  whiskv  or  the  like. 


i 


Tascaey  is,  1901] 


TWO  CASES  OF  LOCALIZED  NEURITIS 


PThe  Philadelphia 
L  Medical  Jouesal 


125 


TWO  CASES  OF  LOCALIZED  NEURITIS  OCCURRING  AS 
A  COMPLICATION  OF  TYPHOID  FEVER.* 

By  H.  J.  WHITE,  M.D., 
Resident  Physician,  Samaritan  Hospital,  Troy,  N.  Y. 

Localized  neuritis  is  one  of  the  rarer  of  the  many 
and  widely  distributed  complications  of  typhoid  fever. 
Multiple  neuritis,  on  the  other  hand,  is  much  more 
■common.  The  etiology  of  the  latter  condition  is  now 
fairly  well  established,  the  most  generally  accepted 
theory  being,  that  the  toxins  produced  by  the  typhoid 
bacillus  act  directly  on  the  nerve  fibers,  causing  a  mild 
perineuritis.  But  the  singling  out  of  one  nerve  or  set 
of  nerves  and  the  production  of  a  paralysis  more  or  less 
complete  of  the  muscles  supplied  by  them,  must  be 
•due  to  som^  special  individual  susceptibility  to  the 
effects  of  the  toxin.  The  first  case  herewith  reported 
is  one  of  double  ulnar  neuritis,  which  is  more  marked 
on  the  right  side. 

M.  C,  aged  50,  a  widower,  teamster  by  occupation, 
was  admitted  to  the  Samaritan  Hospital  May  31,  1900,  and 
gave  the  following  history  :  Family  history  :  Father  died  of 
paralysis,  mother  of  cancer.  No  history  of  tuberculosis  in 
family.  Personal  history  ;  He  has  always  been  very  robust 
iintilthe  present  illness  began.  About  February  1,  1900,  be 
suffered  from  headache,  which  was  followed  by  sore  throat 
and  general  malaise.  His  case  eventually  pursued  the  usual 
course  of  a  moderately  severe  attack  of  typhoid  fever.  At 
the  end  of  6  weeks  he  had  several  attacks  of  hemoptysis ; 
also,  at  about  this  time,  he  complained  of  pain  at  the  inner 
side  of  each  elbow,  which  radiated  downward  along  the 
ulnar  side  of  the  forearms,  and  ended  in  the  little  and  ulnxr 
side  of  the  ring  fingers.  He  described  this  pain  as  sharp  and 
shooting  in  character.  Both  legs  were  slightly  swollen,  and 
there  was  muscular  tenderness  of  the  calf-muscles.  At  tlie 
«nd  of  about  2  weeks  the  lower  extremities  had  regained 
their  normal  condition,  but  the  pain  in  the  arms  was  still 
present,  although  of  a   milder  degree,  and  the  hands   re- 


FiG.  1. — Showing  atrophy  of  interossei  muscles. 

mained  stiff  and  useless.  E.xamination  made  May  31, 
ISOO :  Patient  poorly  nourished,  conjunctivae  pale,  tongue 
protrudes  straight,  no  tremor,  and  is  covered  with  a  grayish- 
white,  moist  coathig.  Pupils  dilated,  respond  to  light  and 
accommodation.  Chest  somewhat  pigeon-shaped,  vocal  frem- 

*  Read  beioro  the  Medical  Association  of  Troy  and  vicinity,  Novemiwr  8, 1900. 


itus  increased  on  the  left  side  from  the  sixth  rib  downward. 
Over  the  same  are.a  is  bronchial  breathing  and  lironch- 
ophdnj',  elsewhere  the  lungs  are  normal.  The  superficial 
area  of  cardiac  dulness  is  7.5  by  6f  m.,  apex-beat  in  the  fifth 
space,  in  nipple-line ;  at  the  apex  is  a  soft,  blowing,  systolic 
murmur  wbich  is  not  transmitted.  Liver  and  spleen  nor- 
mal.   Examination  of  abdomen  negative.    Reflexes  normal. 


Fig.  2. — Showing  contractions  and  position  of  hand  in  ulnar  neuritis, 
post-typhoid. 

Urine  clear  amber  color,  normal  odor,  specific  gravity  1 .020, 
acid;  no  albumin  or  sugar;  microscopically  urates.  Blood: 
Red  cells,  3,44(>,000;  wliite  cells,  6,125;  hemoglobin  70%. 
Repeated  examination  of  the  sputum  failed  to  reveal  any 
tubercle-bacilli,  and  the  area  of  consolidation  in  the  left 
chest  is  probably  fibroid  in  type.  On  the  right  hand  the 
fingers  are' all  stiff,  and  complete  extension  is  impossible. 
The  little  finger  is  strongly  flexed ;  the  thumb  is  abducted; 
and  the  last  phalanx  is  in  a  condition  of  slight  flexion. 
There  is  marked  atrophy  of  all  the  interossei  muscles.  The 
skin  over  the  little  and  ulnar  side  of  the  ring  fingers  is 
smooth  and  glossy  ;  there  is  also  an  absence  of  hair,  and  the 
nails  on  theses  fingers  present  deep  furrows.  There  is  anes- 
thesia, analgesia,  and  thermic  anesthesia  along  the  ulnar 
fide  of  hand,  on  both  sides  of  the  little  finger  and  on  the  ulnar 
side  of  the  ring  finger.  Neither  of  the  motor  nerve-points 
give  any  response  to  the  faradic  current.  The  left  hand  pre- 
sents a  condition  similar  to  that  of  the  right,  excepting  that 
it  is  of  a  much  milder  type,  and  the  hand  has  nearly  regained 
its  normal  condition  without  contractions. 

The  patient  remained  in  the  hospital  until  Septem- 
ber 15,  1900.  Electricity  and  counterirritation  were 
tried,  but  the  condition  remained  unchanged. 

The  second  case  is  one  of  a  still  more  uncommon 
condition  called  the  tender  toes  of  typhoid  fever.  This 
condition  was  first  described  by  Handford,  an  English 
physician,  and  later  by  Osier,  who  considers  it  to  he 
a  form  of  mild  neuritis.  He  also  states  that  this 
complication  is  more  common  after  the  cold-bath  treat- 
ment. 

F.  G.,  aged  28,  single,  a  teamster  by  occupation,  was 
admitted  to  the  Samaritan  Hospital  September  20,  1900. 
Family  and  personal  history  is  entirely  negative.  He  had 
been  complaining  of  headache,  diarrhea,  and  general  malaise 
for  a  week  previous  to  admission,  but  had  not  been  confined 
to  his  bed. 

Examination,  September  21,  1900:  Patient  is  well 
nourished,  tongue  protrudes  straight,  no  tremor,  thick, 
dry,   grayish-white  coating.     Pupils  normal.     Examination 


126 


The  Philadelphia 
Medical  Journal 


] 


ATROPIN  POISONING 


[Jascakt  19, 19n 


of  heart  and  lungs  is  negative  Spleen  percussable  and  pal- 
pable. Tenderness  and  gurgling  in  the  right  iliac  fossa. 
Urine  clear  amber  color,  acid,  specific  gravity  1  032 ;  no 
albumin  or  sugar.  Dia/.o  reaction  postive.  Blood:  Red  cells, 
3,440,000;  white  cells,  6,250;  hemoglobin,  80%  ;  Widal  reac- 
tion positive.  This  case  developed  into  a  severe  type  of 
fever,  and  the  patient  had  in  all  15  cold  baths.  His  heart's 
action  became  extremely  weak,  and  on  October  20  he  had 
an  attack  of  syncope,  in  which  there  was  no  pulse,  and  the 
heart-sounds  were  barely  audible.  He  was  deeply  cyanosed, 
rigid,  and  covered  with  a  profuse  perspiration.  By  means 
of  energetic  stimulation  he  rallied  in  about  half  an  hour. 
On  October  22,  being  the  thirty-third  day  of  the  disease,  he 
complained  of  severe  pain  in  the  tips  of  the  toes  of  both 
feet.  On  examination  nothing  abnormal  could  be  seen. 
There  was  neither  redness  nor  swelling,  and  no  increase  of 
surface  temperature.  Motion  did  not  increase  the  pain,  but 
the  slightest  pressure  caused  him  to  cry  out.  It  was  neces- 
sary to  keep  the  weight  of  the  bedclothing  off  the  feet  by 
means  of  a  bedcradle.  There  was  hyperesthesia  and  hyper- 
algesia of  the  tip  and  bottom  of  each  of  the  toes  ;  thermic 
sense  normal ;  plantar  reflexes  absent ;  kneejerks  normal. 
The  pain  and  tenderness  continued  for  ten  days  and  then 
gradually  abated ;  still,  at  the  end  of  two  weeks,  he  could 
scarcely  bear  the  weight  of  the  bedclothes.  Examination  of 
the  blood,  October  28:  Red  cells  2,990,000;  white  cells, 
6,250;  hemoglobin  60%. 

In  this  case,  as  well  as  the  former,  the  question  of  a 
local  inflammatory  condition  might  arise,  but  the 
absence  of  redness,  swelling  and  heat  as  well  aa  the 
absence  of  leukocytosis  would  entirely  exclude  that 
condition. 

I  am  indebted  for  the  privilege  of  using  these  cases 
to  the  attending  physicians  (Drs.  March  and  Gardinier) 
of  the  Samaritan  Hospital,  Troy,  N.  Y. 


THE    PHENOMENA    OP    ATROPIN    POISONING    FOL- 
LOWING THE  CESSATION  OF  THE  RESPIRATORY 

MOVEMENTS. 

By  EDWARD  T.  REICHERT,  M.D., 

of  Philadelphia. 

Professor  of  Fhysiologj  in  the  University  of  PeDnsjlraaia. 

(From  the  Physiological  Laboratory,  University  of  PennsylTania.) 

In  a  somewhat  recent  article  (University  Medical  Mag- 
azine, 1891,  vol.  iii,  p.  207)  on  certain  physiological 
actions  of  atropin,  I  called  attention  to  the  vulnerability 
of  the  respiratory  center  towards  this  poison,  and  it  was 
shown  that  even  when  arterial  pressure  is  reduced  al- 
most to  zero,  owing  to  the  vasomotor  paralysis,  the 
heart's  action  continued  strong,  and  that  large  doses 
could  still  be  injected  directly  into  the  circulation  be- 
fore the  heart  succumbed.  The  sensitiveness  of  the 
respiratory  center,  as  I  have  shown  also  in  the  actions 
of  strychnin  and  brucin,  is  so  great  as  to  render  impos- 
sible a  study  of  the  full  complement  of  its  actions  on 
mammals  unless  artificial  respiration  is  practised. 
When  this  is  done  several  times  the  minimal  lethal  dose 
can  be  injected  intravenouslj',  and  the  animat  kept  alive 
for  hours,  and  ultimately  recover  normal  respiratory 
movements.  During  this  interval  some  very  interesting 
phenomena  are  developed. 

The  intravenous  injection  of  from  0.02  to  0.04  gram 
of  atropin  per  kilo  of  body-weight  is  sufttcient  to  arrest 
the  respiratory  movements  and  thus  cause  death  by 
asphyxia.  If,  however,  upon  the  cessation  of  the  respi- 
ratory movements  artificial  respiration  be  carried  on, 
the  respiratory  center  soon  exhibits  evidences  of  recov- 
ering activity  in  the  form  of  feeble,  infrequent  respi- 
ratory movements,  which  gradually  increase  in  strength 


and  frequency  until  complete  recovery.  When  the 
first  dose  is  soon  followed  by  another,  the  paralysis 
of  the  respiratory  center  continues  for  a  longer  period, 
and  after  repeated  doses  it  may  exist  for  hours  and  yet 
complete  recovery  occur.  The  center  exhibits  extraor- 
dinary recuperative  power  even  after  doses  many  times 
larger  than  is  necessary  to  arrest  its  activity'. 

A  critical  study  of  the  details  of  such  experiments, 
the  records  of  two  of  which  are  here  embodied,  shows 
that  after  the  cessation  of  the  respirator}'  movements 
three  periods  appear,  each  having  marked  character- 
istics. The  first  period  lasts  for  a  variable  time,  depend- 
ing upon  the  dose,  and  is  characterized  by  tremors, 
occasional  rigid  extensions  of  the  body  and  legs,  clonic 
convulsions,  and  choreal  movements :  increa.jed  intes- 
tinal peristalsis ;  primary  increase  and  Secondary  de- 
crease of  the  pulse-rate;  absence  of  the  conjunctival 
reflex ;  and  very  feeble  activity  of  the  respiratory  cen- 
ter, so  weak  as  to  be  insufficient,  when  artificial  respi- 
ration is  stopped,  to  cause  more  than  a  few  very  shallow 
respiratory  movements.  It  is  a  period  of  waning  ao- 
tivit}'  in  general,  especially  of  respiratory,  vasomotor, 
thermogenic,  and  motor  functions,  the  lessening  of 
motor  activity  being  preceded,  however,  by  a  transient 
increase. 

The  secondperiod  is  also  of  variable  duration,  depend- 
ing upon  the  dose  and  other  conditions  attending  the 
experiments.  During  this  period  there  is  absolute  mus- 
cular quiet  of  the  skeletal  muscles;  the  conjunctival, 
patellar  and  other  tendon  and  skin  reflexes  and  reac- 
tions are  abolished  ;  the  pulse-rate  is  low,  and  the  arte- 
rial pressure  at  a  minimum,  both,  however,  showing 
finally  a  decided  tendency  to  recovery  ;  body  tempera- 
ture continues  to  fall ;  and  the  respiratory  center  is 
paralyzed,  exhibiting  absolutely  no  manifestation  of 
activity  even  al'ter  a  permanent  stoppage  of  artificial 
respiration.  This  period  is  one  characterized  especially 
by  the  complete  paralysis  of  the  respiratory  center ;  sup- 
pression of  the  conjunctival,  patellar  and  other  external 
reflexes ;  and  a  state  of  absolute  quietude  of  the  skele- 
tal muscles. 

The  third  period  is  initiated  by  slight  muscular 
twitches,  which  increase  in  vigor  and  frequency  and 
pass  into  jerkings,  which  in  turn  become  stronger, 
and  after  a  time  violent  in  character  and  paroxysmal ; 
walking  movements  and  others  of  a  rhythmic  character 
may  be  observed  ;  the  body  temperature  may  continue 
falling  notwithstanding  the  marked  general  recovery  of 
activity  ;  and  after  a  time  the  respiratory  center  ex- 
hibits signs  of  a  restoration  of  activity  in  feeble 
respiratory  movements  which  steadily  become  stronger. 
During  this  period  there  is  a  general  waxing  of  activities, 
changes  which,  on  the  whole,  are  the  reverse  of  what 
was  observed  during  the  first  period,  and  culminating 
in  the  recovery  of  the  functional  power  of  the  respira- 
tory center,  and  the  consequent  return  of  effective 
respiratory  movements.  _ 

The  whole  train  of  effects  shows  extraordinary  power 
of  recovery  of  the  system  from  the  actions  of  atropin. 
In  one  experiment  here  recorded  1.5  grams  of  atropin, 
or  over  6  times  the  minimal  lethal  dose,  were  adminis- 
tered in  divided  doses,  yet  within  2  hours  at\er  the  first 
injection  feeble  respiratory  movements  occurred — there 
was  a  return  of  reflexes,  the  pulse-rate  w;vs  higher  than 
it  was  immediately  after  the  first  injection  (^with  pulse- 
curves  about  half  i\s  high\  and  arterial  pre.ssure  had 
increased  about  fourfold.  Fifteen  minutes  later  the 
respiratory   movements  were  sufficiently  frequent  and 


January  19, 1901] 


ATROPIX  POISONING 


The  Philadelphia"] 
Medical  Journal  J 


127 


deep  to  dispense  with  artificial  respiration.  In  the 
second  experiment  1.6  grams,  or  over  7  times  the  mini- 
mal fatal  dose,  were  given  in  divided  doses,  and  the 
same  strong,  general  tendencies  towards  recovery  were 
sooner  or  later  manifest. 


Certain  other  actions  are  also  worthy  of  special  note: 
Intestinal    peristalsis  was    for  a  time  markedly  in- 
creased, this  being  in  accord  with  the  work  of  Meuriot. 
Keuchel,  and  Ott,  and  opposed  to  that  of  Bezold  and 
Bloebaum,  and  lends  support  to  the  theory  that  atropin 


Experiment  No.  1.     Doc — Weight,  8,276  Kilos. 


TIHB. 

Hrs.    MlD.    Sec. 

i 
DOSE,               POLSE, 

grams.        per  mln. 

PREfSCRE, 

mm. 

RECTAL 
TEMP. 

REMARKS. 

0         00       00 
43 
1         00 
3        00 
C        00 
6        30 

'■."., 

lOS 

1152 
15fi 
168 

1.'34 

IIG 
14 
20 

39.90° 

Respirations  so  shallow  that  ariificial  respiration  was  begun.    ConjunctiTal  reflex  Tfry  feeble. 

Intestinal  peristalsis  very  strong. 

«        32 
-        20 

7  80 

8  00 
8        30 

18        00 
18        20 
18        40 
30        00 
1           00        00 

1  30        00 

2  00        00 

2          30        00 

i  " 

1       0.5 
1       0.2 

69 
Irregular. 

144 
168 

180 
198 

14 

14 

32 
40 
.W 
56 

39.48° 

38.45° 
S7.1S" 
36.1.2° 
b6.84° 

respiration  resumed. 

Pulse  curves  very  high  ;  conjunctival  reflex  gone;  patellar  reaction  present  ;  absolute  quietude 

of  s-lveletal  muscles;  vasomotor  centers  paralyzed. 
Motor  quiet ;  heart's  action  irregular. 

Absolute  motor  quiet ;  heart's  action  irregular. 

Slight  jerkings  ;  no  slcin  reflexes  or  tendon  reactions. 

Strong  jerking^  ;  feeble  conjunctival  rtflcx. 

Paroxysms  of  walking  movemeats  every  4  to  6  seconds,  each  accompanied  by  a  feeble  respira- 
tory effort. 

Paroxysms  stronger.  Spontaneous  respiratory  movements  very  good  and  fully  effective  to 
ventilate  lungs. 

Immediate  and  complete  arrest  of  forced  movements;  heart's  action  stronger;  arterial  pressure 
lower  ;  spontaneous  respirations  good. 

.\nimal  chloroformed. 

Duration  of  experiment,  2  hours  and  35  minutes.    Average  uiinimal  lethal  dose  for  dog 
weighing  8,276  kilos,  0.246  gram.    Total  dose  in  this  experiment,  1.5  grams. 

2       31      eo 

2          35        00 

0.24 

(quiniD 

Blllf.) 

Experiment  No.  2.     Dog — Weight,  12,924  Kilos. 


1 

00 
00 
30 

}       - 
I       0.1 

102 
174 

174 
44 

39.98° 

1 

,58 

2 

00 

150 

30 

Artificial  respiration  begun. 

3 
3 

00 
40 

1       0.3 

4 
5 

40 

20 

1       0.4 

5 
6 

40 
10 

j.       0.4 

6 

20 

lOS 

24 

6 

53 

18 
00 

7 

Convulsive  movemenlB. 

8 

36 

20 

38.38° 

ConjunctiTal  retlex  gone  ;  patellar  reaction  remains. 

10 

00 

38.:<5° 

An  occasional  spasmodic  jerk  is  noticed  ;  feeble  spontaneous  respiratory  movements  occur  wheo 

artiticial  respiration  is  stopped  ;  choreal  movements  in  groups  of  4  or  6  occur  coincidently  in 

a.l  four  extremities. 

I.S 

00 

80 

.32 

.      • 

Lies  absohitely  quiet :  all  cutaneous  reflexes  and  tendon  reactions  gone. 

20 

OO 

156 

60 

38.89° 

.Slight  muscular  twitches.     Htari's  action  regular. 

30 

OU 
00 

183 
216 

70 
96 

40 

38.88° 

Strong  walking  movements. 

40 

12 

}       0.4 

40 

32 

40 

35 

00 

153 
198 

66 
86 

Slight  twitching 

1           10 

During  the  last  15  minutes  there  occurred  paroxysmal  attacks  of  strong  jerkings,  which  have 

grown  violent ;  between  paroxvsms  there  are  twitches  and  slight  jerks. 

1          12 

00 

1 

1           14 

00 

1           14 

20 

120 

46 

Verv  little  muscular  excitement  :  puise  curves  higher. 

1          20 

00 

78 

52 

Pulsus  alternans. 

1          30 

00 

Motor  and  sensorv  nerves  absolutely  inexcitable  to  a  strong  Faradic  current,  yet  strong  forced 

movements  occur  in  all  four  extremities  coincidently. 

1           40 

00 

162 

86 

1          40 
1           40 

10 
13 

I      0.3 

(quinin 
sulph.) 

I           40 

4.'* 

Forced  movements,  etc.,  completely  arrested. 

Duration  of  experiment,  1  hour  and  40  minutes.    Average  minima)  lethal  dt>se  for  dog  weigh- 

• 

ing  12,924.kilos,  0.387  grams.     Total  dose  iu  this  experiment.  2.S  gmms. 

These  results  in  conjunction  witli  the  facts  set  forth 
in  the  article  referred  to  in  the  beginning  of  this  paper 
sho'w  that  the  respiratory  and  vasomotor  centers  are 
particularly  susceptible  to  atropin,  and  that  both  exhibit 
tovFards  it  great  powers  of  recovery. 


in  small  doses  excites,  and  in  large  doses  depresses,  the 
inhibito-motor  fibers  of  the  splanchnics. 

The  effects  on  the  reflexes  and  tendon  reactions  are 
not  without  interest.  The  conjunctival  retlex  disap- 
pears, but  the  patellar  reaction  may  remain.     When  the 


128  ^^^  Philadelphia"! 

Medical  Journal  J 


A  CASE  OF  CHOLELITHIASIS 


[UscAEr  10, 191 


poison  is  pushed  the  latter  also  is  suppressed.  The 
absence  of  one  and  the  presence  of  the  other  has  Vjeen 
noticed  also  in  nitrous  oxid  poisoning,  and  in  strych- 
nin paralysis.  In  curarized  animals  the  patellar 
reaction  is  lost  before  the  conjunctival  reflex. 

The  effects  of  large  doses  of  atropin  upon  the  motor 
and  sensory  nerves  are  very  jiositive,  both  being  com- 
pletely paralyzed  during  the  sec'ind  period.  A  curious 
fact  shown  by  these  experiments  is  that  while  the 
motor  fibers  are  absolutely  inexcitable  to  Faradic 
stimulus  they  retain  their  conductivity.  This  is  evident 
in  the  absence  of  response  to  strong  stimulus  when 
applied  to  the  sciatic  nerve,  while  at  the  same  time 
rhythmic  movements  of  undoubted  central  origin 
occur  coincidently  in  all  four  extremities.  This  asso- 
ciated loss  of  irritability  to  Faradic  excitation  and 
retention  of  conductivity  has  also  been  observed  in 
dogs  to  which  enormous  doses  of  strychnin  or  brucin 
have  been  administered,  and  in  nerves  poisoned  with 
boracic  acid,  CO,,  and  coniin,  and  in  regenerating 
nerves. 

The  motor  phenomena  exhibit  certain  features  which 
justify  more  than  a  passing  mention,  especially  those 
of  the  third  period.  This  period  is  initiated  by  grad- 
ually developing  motor  excitement.  The  slight  mus- 
cular twitches  increase  in  strength,  and  finally  pass 
into  jerks,  and  these  steadily  become  more  vigorous. 
The  jerks  at  first  lack  rhythm,  but  as  the  efiects  of  the 
poison  progress  they  tend  to  become  paroxysmal  and 
to  pass  into  forced  movements  of  a  choreal,  or  of  a 
more  or  less  definitely  coordinated  character.  These 
forced  movements,  which,  of  course,  are  of  centric 
origin,  can  be  stopped  immediately  by  the  intravenous 
injection  of  sulphate  of  quinin.  In  the  foregoing  two 
experiments,  0.24  gram  and  0.3  gram,  respectively, 
were  sufficient  to  immediately  and  completely  arrest 
the  motor  excitement. 

Finally,  the  results  of  these  experiments  with  enor- 
mous doses  of  atropin  have  a  very  important  bearing 
upon  the  treatment  of  poisoning  in  man.  They  show 
clearly  that  death  is  due  to  a  paralysis  of  the  respira- 
tory center,  that  the  center  has  great  recuperative 
power,  and  that  if  artificial  respiration,  be  properly 
practised  the  respiratory  center  recovers  its  activity, 
which  is  accompanied  by  general  and  marked  improve- 
ment of  other  depressed  states.  In  man,  it  seems  that 
atropin  poisoning  should  be  readily  treated  if  artificial 
respiration  Vie  persistently  and  intelligently  practised, 
as  by  Laborde's  method,  and  accompanied  by  such 
other  treatment  as  indicatious  suggest. 


REPORT  OF  A  CASE  OF  CHOLELITHIASIS  WITH 
FORMATION  AND  RUPTURE  OF  AN  ABSCESS 
OF  THE  ABDOMINAL  WALL. 

By  JOHN  H.  GIBBON,  M.D.. 

of  Philadelphia. 

Assistant  Siirceon  to  the   Jellerson   College    Hospital :   Surgeon   to  the   Out- 

pnttent  Departments  of  the  Pennsylvania  an<i  Children's  Hospitals; 

Surgeon  to  the  Bryu  Mawr  Hospital. 

The  following  case  of  gallstones  is  reported  because 
of  the  interest  it  holds  from  a  diagnostic  and  patho- 
logic point  of  view.  I  first  saw  the  patient  on  Sep- 
tember 26,  1900,  with  Dr.  E.  J.  Stout,  and  she  was 
admitted  on  that  day  to  the  Jefferson  College  Hospital. 
The  history  she  gave  was.  as  follows: 

R  S.,  a  widow,  50  years  of  age  ;  occupation,  housework. 


Family  History  — Mother  and  one  sister  died  of  apoplexy. 
Father  died  suddenly  in  his  eightieth  year.  Six  sii^ters  and 
one  brother  living  and  well.  Xo  history  of  tuberculosis  or 
malignant  disease  obtainable. 

Pernnnal  //i«(on/. —Remembers  no  illness  in  her  youth. 
Menses  always  normal.  Never  had  tj-phoid  fever.  For  the 
past  15  years  has  suffered  from  dyspepsia. 

Present  trouble  began  4  years  ago,  when  patient  had  a  severe 
attack  of  abdominal  pain  situated  in  the  right  side  of  the 
abdomen,  low  down,  radiating  to  the  umbilicus  and  oc<;a- 
sionally  to  the  right  shoulder.  Since  this  attack  patient  has 
had  many  others,  and  has  never  been  entirely  free  from  pain 
in  the  lower  part  of  the  abdomen  on  the  right  side.  The  at- 
tacks lasted  two  or  three  days,  and  none  were  so  severe  as 
the  first;  patient  never  vomited,  and  was  never  jaundiced, 
never  collapsed  from  pain,  and  never,  so  far  as  she  knows, 
passed  any  gallstones. 

On  November  6,  1899,  had  a  severe  attack  of  pain  lasting 
several  days,  accompanied  by  chill  and  fever  on  the  first  day, 
and  throughout  by  headache  and  constipation,  but  no  vom- 
iting and  no  jaundice.  The  point  of  greatest  pain  was  situ- 
ated in  the  right  ihac  fossa,  and  the  disease  was  diagnosed 
appendicitis  by  her  attending  physician,  a  man  of  ability 
and  large  experience.  The  application  of  an  ice-cap  relieved 
her  suffering.  Patient  recovered  from  this  attack,  as  from 
the  others,  but  continued  to  have  a  dull,  aching  pain  in  the 
right  iliac  region. 

Dr.  Stout  first  saw  the  patient  about  the  beginning  of 
the  following  summer,  when  she  consulted  him  for 
advice  regarding  a  mass  which  was  forming  apparently 
in  the  abdominal  wall  over  the  region  of  the  appendix. 
She  did  not  appear  to  be  verj'  ill  and  did  not  see  her 
doctor  with  any  re.sularity.  About  the  la-st  of  August 
the  mass  softened  and  opened,  discharging  a  small 
quantity  of  pus  and  leaving  a  sinus  which  has  remained 
open  ever  since.  It  is  interesting  to  note  that  when  the 
patient  came  to  Dr.  Stout  she  was  wearing  a  truss 
which  had  been  recommended  by  another  physician  for 
the  relief  of  the  mass,  which  was  supposed  to  be  a 
ventral  hernia. 

On  admmson,  temperature,  pulse  and  resperation. 
normal.  Heart  and  lungs,  normal.  Urine,  turbid, 
amber,  acid;  specific  gravity,  1,021;  no  albumin;  no 
sugar  ;  urea,  1.2  ;  no  pus,  blood,  or  tube-casts. 

Examination  of  the  abdomen  showed  a  small  sinus, 
21,  inches  internal  to  the  right  anterior  superior  spine 
of  the  ilium,  and  f  of  an  inch  below  the  level  of  this 
spine.  Around  the  sinus  the  abdominal  wall  was 
indurated,  red  and  tender  for  a  considerable  area,  so 
much  so  as  to  render  palpation  and  percussion  of  the 
right  side  of  the  abdomen  very  painful  and  of  no 
advantage.  From  the  sinus  there  was  discharged  a 
inucopus.  A  bent  probe  passed  into  it  could  be  moved 
about  in  what  seemed  a  small,  irregular  cavity,  but  it 
could  not  be  passed  to  any  depth  in  any  direction. 

That  there  w.as  an  abscess  of  the  abdominal  wall  was 
apparent,  but  its  cause  was  obscure.  The  very  positive 
history  of  attacks  of  ap{>endicitis  and  the  situation  of 
the  sinus  exactly  over  the  normal  position  of  the 
appendix,  of  course,  made  us  think  of  the  possibility  of 
this  organ  being  the  cause  of  the  trouble ;  but  the 
character  of  the  discharge  and  the  extensive  infiltration 
of  the  abdominal  wall  remaining  so  very  long  after  the 
opening  of  the  abscess,  together  with  the  fact  that  when 
rupture  did  take  place  there  was  only  a  small  amount 
of  pus  discharged,  caused  us  to  put  this  idea  aside  and  i 
examine  in  other  directions.  I 

The  possibility  of  having  to  deal  with  a  suppurating 
cyst  suggested  itself,  and  the  question  of  its  being  a 
broken-iiown  gumma  was  also  discussed.  The  gall- 
bladder never  entered  my  mind,  because  of  the  jvuient's 
history  of  never  having  been  jaundiced,  of  always  hav- 


JAKUIRY  19,  1901] 


A  CASE  OF  CHOLELITHIASIS 


TThe  Philadelphia 
L  fr»EDiCAL  Journal 


129 


ing  the  pain  in  the  right  iliac  fossa,  of  passing  no  stones 
after  the  attacks,  together  with  the  diagnosis  of  appendi- 
citis and  the  situation  of  the  sinus.  The  mucous  char- 
acter of  the  discharge  and  other  facts  in  the  history  of 
the  case  which  were  elicited  subsequently,  should  have 
caused  us  to  consider  the  gallbladder.  I  concluded  it 
was  an  abscess  of  the  abdominal  wall  and  did  not  think 
it  had  any  connection  with  an  abdominal  viscus.  Dr. 
Stout  had  already  given  the  patient  iodid  ;  but  we 
decided,  as  she  had  been  very  irregular  in  her  treat- 
ment, and  because  of  suspicious-looking  scars  on  her 
legs,  to  try  increasing  doses  of  the  iodid  and  the  local 
application  of  mercurial  ointment. 

After  about  a  week  it  was  decided  to  thoroughly 
open  and  curette  the  abscess. 

Operation. — On  making  an  incision  I  found  an  ab- 
scess  dissecting  in  several   directions  and  containing 


about  an  ounce  of  pus  mixed  with  a  clear,  thick  fluid. 
The  abscess  walls  were  thick,  tough,  and  smooth.  After 
curetting  thoroughly  every  pocket,  I  found  one  in  the 
bottom  of  the  wound  that  was  small  and  seemed  to 
contain  something  hard  which  I  could  not  move.  With 
a  hemostat  I  dilated  the  pocket  and  then  withdrew, 
much  to  my  surprise,  a  gallstone,  and  following  it 
51  others.  The  stones  were  uniform  in  size,  being  a 
little  larger  than  peas.  When  I  had  dilated  the  open- 
ing sufficiently  to  admit  my  finger,  I  found  that  it 
went,  not  into  a  sinus  leading  into  the  gallbladder,  as 
I  had  expected,  but  at  once  into  the  gallbladder  itself; 
and  I  was  able  to  pass  the  end  of  my  finger  into  a 
dilated  cystic  duct,  from  which  I  removed  several 
stones.  The  peritoneal  cavity  was  not  opened.  A  large 
drainage-tube  was  inserted  and  the  patient  returned  to 
bed.  She  reacted  nicely,  her  temperature  but  once 
going  above  99°,  and  she  went  home  on  the  twenty-fifth 
day  with  the  wound  practically  healed. 

During  the  first  week  there  was  a  considerable  dis 


charge  of  bile,  which  showed  the  cystic  duct  to  be 
clear  of  obstruction ;  and  as  no  jaundice  developed  after 
the  external  fistula  closed,  we  felt  sure  that  the  com- 
mon duct  too  was  free.  The  fistula  closed  completely 
soon  after  the  patient  went  home,  but  opened  again 
within  a  few  weeks  and  discharged  bile  and  mucus 
until  recently,  when  it  closed  again  and  has  remained 
so  ever  since. 

Diagnosis. — The  first  interesting  question  which  this 
case  suggests  is  that  of  diagnosis.  Not  infrequently 
there  is  difficulty  in  making  a  differential  diagnosis 
between  inflammatory  conditions  of  the  gallbladder 
and  the  appendix ;  and  the  fact  that  a  number  of  ex- 
cellent surgeons  have  reported  cases  where  they  oper- 
ated expecting  to  find  one  of  these  conditions  and,  to 
their  surprise,  have  met  with  the  other,  makes  it  a 
matter  of  importance.  The  error  of  diagnosis,  how- 
ever, I  do  not  think  is  often  made  from  a  want  of 
means  or  symptoms  which  would  at  least  suggest  a 
doubt,  but,  rather,  from  a  tendency  to  consider  only 
the  prominent  symptoms  and  to  make  a  hurried  diag- 
nosis. The  fact,  too,  that  both  the  conditions  require 
operation,  makes  us  less  careful,  and  we  rest  with  the 
idea  of  making  the  diagnosis  after  the  abdomen  is 
opened. 

In  the  case  I  report,  however,  I  think,  from  the  pa- 
tient's history,  that  it  would  have  been  difficult  to 
make  a  correct  diagnosis  of  the  attack  which  she  had 
in  November,  1(899,  everything  pointing  towards  the 
appendix  region  and  practically  nothing  suggesting  the 
gallbladder.  It  has  been  shown  that  gallstones  are 
much  more  common  than  is  generally  supposed,  occur- 
ring in  from  5  to  10%  of  autopsies  done  on  Europeans. 
In  a  large  number  of  these  cases  no  symptoms  were 
present  in  life  which  pointed  to  the  condition.  I  sup- 
pose that  no  one  will  doubt,  in  the  light  thrown  on  this 
case  by  the  operation,  that  the  patient  never  had  ap- 
pendicitis, but  that  what  was  supposed  to  be  this  con- 
dition was  a  displaced  and  inflamed  gallbladder,  which 
was  probably  becoming  adherent  to  the  parietal  peri- 
toneum over  the  right  iliac  fossa.  It  is,  of  course,  a 
question  whether  gallstones  were  present  at  this  time 
and  whetherthey  might  not  have  resulted  from  theinflam- 
mation,  which  in  its  turn  was  due  to  the  colon-bacillus, 
it  having  been  proven  beyond  doubt  that  this  bacillus, 
or  nearly  any  bacterium,  may  produce  a  precipitation 
of  the  solids  of  the  bile  and  the  formation  of  gallstones.' 
It  would  seem,  however,  when  the  previous  history  is 
considered,  that  the  gallstones  were  present  at  this  time 
and  were  the  cause  of  the  inflammation  and  suffering. 
I  do  not  think  it  would  have  been  possible  to  make  a 
diagnosis  of  gallstones  when  the  patient  was  admitted 
to  the  hospital  in  September  of  this  year ;  for,  besides 
the  absence  of  symptoms,  the  inflammation  and  indu- 
ration of  the  abdominal  wall  rendered  examination 
very  unsatisfactory.  The  character  of  the  discharge 
should,  however,  have  made  us  suspect  the  real  condi- 
tion. 

Pathology.— The  first  thought  in  regard  to  the  path- 
ology of  this  case  is  the  abnormal  situation  of  the  gall- 
bladder in  the  right  iliac  fossa.  Enormous  distention 
of  the  gallbladder  is  not  infrequent,  cases  having  been 
reported  where  this  condition  was  mistaken  for  ovarian 
cyst.  Robson  speaks  of  a  specimen  in  St.  Bartholo- 
rnew's  Museum,  in  which  a  greatly  distended  gallblad- 
der formed  the  contents  of  a  femoral  hernia.  Carl  Beck 
reported  in  the  Annab  of  Surgery  for  May,  1899,  an  inj- 

1  Mayo  Robaon's  "  Gallbladder  and  Bile  Ducts." 


130 


The  Phtlsdelphia"] 
Medical  Jocesal  J 


MIRROR-WRITING  AND  DIFFUSE  HYPERTROPHY 


IJA>rABT   1°,    IWI 


teresting  case  of  transposition  of  the  viscera,  in  which 
gallstones  developed  and  were  removed  through  an 
incision  made  along  the  outer  border  of  the  left  rectus 
muscle.  In  my  own  case  it  will  have  been  observed 
that  there  was  practically  no  distention  of  the  gallblad- 
der and  no  ptosis  of  the  liver ;  so  its  abnormal  position 
must  be  accounted  for  in  some  other  way,  and  I  think 
the  correct  explanation  is  a  long  peritoneal  attachment 
to  the  liver.  Under  ordinary  circumstances  the  gall- 
bladder is  in  intimate  relation  with  the  under  surface 
of  the  liver,  being  kept  in  this  position  partly  by  the 
peritoneum,  which  passes  from  its  sides  to  the  liver ;  but 
Brewer  (Annaii  of  Surgery,  .June,  1899)  in  examining 
100  bodies,  found  in  -5  that  the  gallbladder  was  com- 
pletely surrounded  by  peritoneum,  which  on  passing  to 
the  liver  formed  a  mesentery  which  permitted  consid- 
erable mobility.  In  three  cases  there  was  an  extension 
forward  of  the  free  border  of  the  lesser  omentum  to  the 
fundus  of  the  gallbladder. 

Robson  reports  a  case  (Case  No.  234,  p.  281)  which 
in  many  respects  resembles  the  one  here  reported : 
•■'  Strong  family  history  of  phthisis ;  in  12  months  sev- 
eral attacks  of  severe  pain  in  the  right  iliac  region,  ac- 
companied by  swelling  in  the  normal  situation  of  the 
cecum,  and  marked  tenderness  between  anterior  supe- 
rior spine  of  the  ilium  and  the  umbilicus  ;  each  attack 
associated  with  fever,  constipation,  vomiting,  and  abdom- 
inal swelling  ;  and  all  signs  of  local  peritonitis  over  in- 
flamed appendix.  Operation ;  incision  over  cecum :  vis- 
cera matted  together  by  old  and  recent  lymph.  After 
separating  adhesions,  gallbladder  was  reached  at  end  of 
projecting  Riedels  lobe ;  mucopus and  several  gallstones 
removed  ;  tumor  of  cystic  duct  felt,  and  as  on  incision  it 
gave  the  appearance"of  growth,  it,  with  the  gallbladder 
and  projecting  lobe  of  liver,  was  removed  by  means  of 
the  elastic  ligature."     The  patient  recovered. 

Although  in  a  few  cases  adhesion,  ulceration  and  per- 
foration into  stomach  or  bowel  have  taken  place,  yet, 
probably,  in  most  instances  the  gallstones  produce'  an 
empyema  which  is  evident  from  local  and  constitutional 
symptoms.  As  the  organ  is  usually  found  in  its  nor- 
mal position,  adhesion  to  the  pylorus"  or  bowel,  or  to  the 
liver,  is  more  frequent  than  to  the  parietal  peritoneum. 
This  being  true,  the  gallstones  are  much  more  apt  to 
find  their  way  into  these  viscera  than  through  the  ab- 
dominal wall.  When  adhesion  to  the  parietal  perito- 
neum once  takes  place,  and  ulceration  and  perforation 
follow,  an  abscess  forms,  and  the  pus  usuallv  works  its 
way  along  in  the  direction  of  the  umbilicus,  "where  it  is 
apt  to  open  externally.  This  may  not  always  be  true, 
however,  for  many  cases  are  repo"rted  in  which  the  fis- 
tula found  its  external  opening  as  low  down  as  the  sym- 
physis pubis.  Adhesion  of  the  ducts,  and  of  the  gall- 
bladder itself,  to  the  pylorus  and  duodenum  is  frequent, 
as  shown  by  operations  and  autopsies,  and  results  often 
in  dilation  of  the  stomach  or  obstruction  of  the  bowel. 
Obstruction  of  the  bowel  has  also  been  caused  by  a 
large  stone  which  has  ulcerated  into  the  bowel.  'Ul- 
ceration and  perforation  into  the  general  peritoneal 
cavity  may  take  place  without  the  formation  of  pro- 
tecting adhesions,  as  is  shown  by  Case  241  of  Robson "s 
series.  Robson  says  that  "  if  t"he  ulceration  advances 
toward  the  adjoining  hollow  viscera,  stomach,  duode- 
num, or  colon,  adhesions,  as  a  rule,  follow,  and  the 
perforation  is  effected  quietly.  In  one  case  of  this 
kind — after  a  history  of  cholelithiasis,  followed  hv  se- 
vere stomach  symptoms — the  gallstones  were  vomited, 
and   complete    recovery    followed.'      Cases  have  also 


been  reported  where  the  gallstones  have  by  ulceration 
made  their  way  into  the  pleural  caWty  and  the  urinary 
tract.  Occasionally  an  adventitious  sac  has  been  found, 
formed  by  adhesions  of  neighboring  parts,  containing 
gallstones,  and  communicating  with  the  gallbladder 
by  a  small  opening.  There  is,  of  course,  the  constant 
danger  of  rupture  of  such  a  sac,  and  the  production  of 
a  fatal  peritonitis.  Again,  the  gallstones  have  ulcerated 
into  the  walls  of  the  ducts,  and  have  remained  until 
removed  by  the  surgeon. 

Death  from  hemorrhage  not  infrequently  follows 
operations  on  the  gallbladder  in  cases  where  there  has 
been  a  long-standing  jaundice,  which  has  produced  an 
aplastic  condition  of  the  blood.  In  these  cases  death 
from  hemorrhage  has  followed  perforation  of  the  gall- 
bladder. About  a  year  ago  I  saw  death  occur  from 
continued  and  persistent  oozing  of  blood  from  an  in- 
cision into  a  gallbladder  which  was  much  inflamed 
and  where  the  patient  had  long  been  jaundiced. 

Flstidae. — The  question  of  fistulae.  internal  or  exter- 
nal, after  ulceration,  and  of  external  fistula  after  cho- 
lecystotomy  is  of  interest.  It  seems,  from  postmortem 
observations,  that  we  must  conclude  that  the  fistulae 
established  between  the  gallbladder  and  the  other 
hollow  viscera  tend  to  become  obliterated  after  a  time, 
and  this  is  apt  to  be  true  too  of  the  external  fistulae  pro- 
duced by  ulceration. 

Fistulae  following  operation  are  not  nearly  so  frequent 
as  they  were  before  Robson  taught  us  how  to  avoid 
them  by  suturing  the  gallbladder  to  the  fascia  instead 
of  to  the  skin,  as  had  formerly  been  the  practice.  He 
reports  189  choleoystotomies  with  14  fistulae  following, 
but  0  of  these  occurred  in  the  first  10  cases,  where  the 
gallbladder  was  sutured  to  the  skin.  Since  modifying 
the  technic  he  has  not  had  a  single  fistula  where  the 
ducts  have  been  cleared  at  the  time  of  the  operation. 
A  mucous  fistula,  of  course,  indicates  an  obstruction  of 
the  cvstic  duct. 


A  CASE  OF  MffiROR-WRITING  AND  OF  DIFFUSE 
HYPERTROPHY  OF  BOTH  BREASTS  IN  AK 
EPILEPTIC  NEGRESS. 

By  A\  .  (.,.  LIST,  M.D., 

of  Ciodimati,  Ohio. 

Recent  .Assistant  Physicimn  *x  the  Ohio  Hospital  for  Epil^Kies,  GalUpoIis,  OUa. 

MiRROR-wRiTixG  is  a  striking  and  uncommon  phe- 
nomena occasionally  observed  among  feeble-minded  or 
left-handed  children.  It  is  specially  apt  to  occur  in  a 
patient  who  has  had  a  right  hemiplegia  in  early  life. 
Mirror-writers  use  the  left  hand,  and  for  them  the 
natural  way  is  to  write  from  the  right  to  the  left  side  of 
the  page  instead  of  from  left  to  the  right.  The  letters 
are  reversed  and  require  the  aid  of  a  mirror  before  they 
can  be  deciphered.  If  a  word  or  sentence  written  by 
a  mirror-writer  is  held  in  front  of  a  looking-glass  the 
characters  can  be  easily  read  in  the  reflected  image. 
Rotch,  in  his  textbook  on  pediatrics,  describes  two 
cases  of  mirror-writing,  both  occurring  in  negro  chil- 
dren of  defective  menuUity  who  were  also  subject  to 
convulsions,  and  he  says  there  is  a  physiologic  tendency 
for  left-handed  children  to  fall  into  the  habit  of  mirror- 
writing.  According  to  Dana  (^Twentieth  Century  Prac- 
tice of  Medicine,  Vol.  X\  mirror-writing  is  seen  in 
hemiplegics.  more  commonly  in  children.  A  right- 
handed  person  who  has  had  a  right  hemiplegia  attempts 
to  write  with  the  left  hand  and  finds  that  he  almost 


.lANOAKY    r.l,    I'.IOl] 


MIRROR-WRITING  AND  DIFFUSE  HYPERTROPHY 


TTlIE    l*Hl 

L  Mkdica 


ILADELPHIA 
L   JOURNAT- 


131 


unconsciously  writes  from  right  to  left  and  reverses  the 
letters.  The  pathology  of  this  condition  is  unknown. 
Diffuse  hypertrophy  of  the  breast  consists  of  a  general 
hyperplasia  of  the  entire  gland.  The  disease  is  rare. 
Billroth,  in  his  Treatise  on  the  Mammary  Glands,  re- 
marks on  the  rarity  of  this  condition,  having  seen  but 


Flii.  1. — llyi)LTtrol)liy  of  Im.i-t-. 

two  cases  in  his  extensive  experience.  Dennis,  System 
of  Surgery,  Vol.  IV,  quotes  Williams,  who  says  that 
while  2,422  cases  of  mammary  neoplasms  came  con- 
secutively under  treatment  at  Middlesex,  University 
College,  Bartholomew's,  and  St.  Thomas'  hospitals 
during  a  period  of  from  16  to  21  years,  only  6  cases  of 
diffuse  hypertrophy  were  seen  in  this  same  period. 
The  cause  of  the  disease  is  unknown,  but  it  seems  to 
be  associated  with  certain  disturbances  of  the  genital 
organs,  especially  the  menstrual  function.  The  growth 
is  usually  very  rapid  for  several  months,  after  which  it 
ceases.  The  breasts  are  likely  to  increase  again  at 
pregnancy.  This  disease  occurs  more  frequently  in  the 
negro  race.  It  is  said  to  occur  at  two  periods  :  first  at 
the  age  of  puberty ;  second,  in  connection  with  preg- 
nancy. The  great  majority  of  cases  develop  at  the 
onset  of  the  menstrual  function. 

The  concurrence  of  the  above-described  anomalies, 
mirror-writing  and  diffuse  hypertrophy  of  the  breasts, 
were  noted  in  a  patient  who  was  admitted  to  the  Ohio 
Hospital  for  Epileptics,  at  Gallipolis,  November  4, 1897. 
The  history  of  the  patient  is  as  follows  : 

Lillie  Herst,  colored,  female,  aged  17  years,  born  in  Oliio. 
She  was  admitted  to  the  hospital  from  "a  county  infirmary. 
Her  surroundings  in  early  life  were  evidently  very  poor.  Slie 
possesses  a  very  limited  education,  the  freciuency  of  her  epi- 
leptic seizures  preventing  regular  attendance  at  the  school 
■conducted  for  patients.  On  account  of  the  patient's  pro- 
nounced ind)e(ile  condition  no  family  or  previous  history 


could  be  obtained  from  her.  She  is  shy  and  retiring,  of  a 
mild  and  tractable  disposition,  with  cleanly  habits.  Her  only 
occupation  is  that  of  making  beds,  which  she  was  taught  to 
do  only  after  a  painstaking  effort  on  the  part  of  the  atttend- 
ant.  The  general  health  of  the  patient  during  her  residence 
at  the  hospital  has  been  good,  excepting  several  periods  of 
physical  depression  due  to  taking  bromides.  Her  epilepsy 
began  at  the  age  of  3  years  and  has  continued  irregularly 
until  the  present  time.  Her  attacks  are  of  an  atypical  grand 
mal  type ;  there  is  no  petit  mal.  A  seizure  commences  with 
an  aura  of  impending  suffocation,  at  which  time  the  patient 
clutches  her  throat  in  a  violent  manner,  requiring  restraint, 
which  is  followed  by  shrill  cries,  which  continue  throughout 
the  convulsive  part  of  the  attack,  and  the  stage  of  stupor 
which  follows  is  of  short  duration.  She  seldom  has  an  attack 
at  night  and  she  never  was  in  status  epilepticus.  Her 
menstrual  function  has  not  established  itself  in  a  normal 
manner.  The  first  menstrual  flow  occurred  3  months  after 
admission  to  the  hospital,  when  the  patient  was  15  years  of 
age.  During  the  course  of  the  year,  1898,  she  only  menstru- 
ated 3  or  4  times  at  irregular  intervals.  During  the  next 
year  she  menstruated  regularly,  the  flow  was  of  normal 
amount,  lasting  8  to  4  days,  with  no  unusual  physical  or 
nervous  depression.  She  has  menstruated  but  once  during 
the  present  year.  The  physical  examination  discloses  the 
following : 

The  patient  is  a  paralytic  of  average  size  for  her  age  and 
race.  The  gait  is  normal;  the  mensuration  of  both  lower 
extremities  shows  them  to  be  of  the  same  dimensions. 
The  right  patellar  reflex  is  slightly  exaggerated,  but  is 
absent  on  the  left  side.  She  is  unable  to  use  the  right 
arm  for  executing  the  finer  movements ;  it  is  slightly  atro- 
phied,' the  corresponding  measurements  being  SJ^  and  8J 
ccm.  for  the  right  and  left  arms  respectively  Consider- 
able ataxia  of  the  right  hand  still  remains.  The  thoracic 
and  abdominal  viscera  are  normal.  When  she  was  admitted 
her  breasts  were  seen  to  be  a  little  more  enlarged  than 
one  would  expect  to  find  in  a  per.son  of  her  age  and 
physique;  after  the  appearance  of  the  first  menstrual  flow, 
the  breasts  rapidly  enlarged,  so  that  within  a  period  of  6 
months  they  attained  their  present  size.  During  this  time 
.she  also  increased  in  weight  30  to  40  pounds.  In  the 
course  of  the  following  year  she  gradually  lost  the  increased 
weight,  but  no  decrease  in  the  size  of  her  breasts  was 
noticed.  During  the  period  of  rapid  growth  they  were 
slightly  painful  to  touch,  their  increased  weight  causing 
her  considerable  discomfort.  She  complained  of  aching 
and  dragging  pains  at  the  insertion  of  the  pedicles  of  each 
breast.     Both  iiiainnmc  arc    pendulous,  and    dilated  veins 


-•?7'-..X. 


^^t^C/    c^^Z£^t^  /%*^,4^ 


1^.' 


'^   1    H   0    2   Uo  ^  {  J  J  A;^ 
aALUpoj  Si    0  H   \  ^ 


Fig.  2. — Mirror-writing. 

are  visible  at  their  periphery.  The  overlying  skin  is  of 
normal  thickness  and  freely  movable.  There  is  no  increase 
of  fat,  and  the  lobes  of  the  gland-substance  can  easily  be 
palpated.  There  has  never  been  any  secretion  from  either 
breast.  The  measurements  of  each  breast  are  as  follows  : 
The  right  breast  is  11  inches  in  length,  in  the  mamillary 
line,  from  the  attachment  of  its  pedicle  to  its  lowermost 
boundary ;  the  left  10  inches.  The  greatest  circumference 
of  the  right  breast  is  11*  inches  ;  left  breast,  lliS  inches. 


132 


The  Philadelphia"! 
Medical  Journal  J 


MIRROR-WRITING  AND  DIFFUSE  HYPERTROPHY 


[1ASVAX.J   12,  I'JW 


The  fact  that  she  was  a  mirror-writer  was  discovered 
accidentally.  While  visiting  the  cottage  wherein  the 
patient  resided  I  noticed  her  in  the  act  of  copying 
printed  words  from  a  book  on  a  slate.  All  the  letters 
were,  however,  seen  to  be  in  a  reversed  position  as  com- 
pared with  the  original  copy.  When  the  slate  was  held 
in  front  of  a  mirror  the  words  could  then  be  ea.sily  read 
in  the  image.  She  was  given  several  copies  to  repro- 
duce, and  specimens  of  her  writing  are  illustrated  in 
Fig.  2.  Nos.  1  and  2  are  copies  she  was  given,  and  Nos. 
3  and  4  are  her  efforts  at  reproduction.  Nos.  5  and  6 
are  reproductions  from  Noa.  3  and  4,  showing  them  as 
they  appear  in  a  mirror.  The  patient  can  copy  printed 
letters  more  easily  than  script  and  can  only  write  a  few 
simple  words  from  dictation.  She  has  been  taught  to 
write  in  the  normal  manner,  but  when  not  on  her  guard 
she  always  begins  on  the  right-hand  side  of  the  page 
and  reverses  her  letters.  The  left  hand  is  used  exclu- 
sively in  writing. 


A  Method  for  Destroying'  Mosquitos.— In  the  Bulle- 
tin de  Phai III.  de  Lyon  is  recomnaencied  a  method  for  the 
destruction  of  naoequitos.  On  accouct  of  the  well-known 
properties  of  these  insects  in  the  conveyance  of  the  malarial 
parasites,  a  solution  of  potassium  permanganate  1  :  1500, 
has  been  found  to  be  quite  feffeciive  and  cheap,     [m.r.d  ] 

Regardiug'  the  Methods  of  E.xperimeutal  In- 
vestigatiou,  iu  Deteriiiiuiug  the  l^lituiiiatiou  of 
Hydrochloric  Acid  in  the  Human  Stomach,  upon 
the  lugestion  of  Various  Nutritive  Sub.stauces. — 

W.  Bjckmann  {Zfilschri/l  Jar  d,dt.  und  phynikal.  Therapie, 
Bd.  iv,  Hefi  5)  believes  that  more  accurate  results  can  be 
obtained  by  employing  the  substances  used  in  test-meals,  not 
by  weight,  but  by  their  caloric  values,     [m  r  d] 

Dermatitis,  Tetauiis,  Desquamation,  and  Edema 
in  a  Case  of  Urave  Uastroiutestiual  Autointoxica- 
tion.— V.-tleiixa  (duzz  dry/i  Ospedali  e  delle  Clin.,  I'Jl'O,  No. 
Ill)  reporls  a  case  of  gasiroiniestin.-il  auioinioxicaiion  in 
a  cuild  causing  Bcarlatuiiform  iiiflammaiion  of  the  skin, 
tetanus,  defquamhtion  and  tdema,  which  the  author  attrib- 
utes to  the  influence  of  tiie  autointoxication  upon  the  nerv- 
ous system.  The  obseivalions  of  Guida  ati'l  Ponticaccia 
(Dispepsia  e  sistema  nervoso)  are  discussed,     [m.r  d] 

Sarcoma  of  the  Testicle. — Kayser  (MiUheilungen  axis 
dm  Hamlinfi/ifuhm  Sldalskrunketwitntallm,  Bd.  11)  lound  a 
history  of  trauma  iu  7  cases  out  of  21.  The  most  predis- 
posing age  was  that  between  30  and  -10  years.  Tue  begin- 
ning of  Uie  tumor  formation  and  its  further  course  were 
almost  always  painless,  and  in  some  cases  a  hardening  of  the 
testicle  had  existed  for  years  before  the  presence  ol  a  neo- 
plasm could  be  demonstrated.  Tue  condition  was  generaih- 
mouolateral  and  associated  with  hydrocele.  The  prognosis 
was  exlremely  unfavorable  ;  pnly  2  of  the  21  casts  nave  re- 
covered and  16  died  from  metastases.  Secondary  invulve- 
ment  occurs  not  only  by  the  bloodstream  but  also  by  the 
lymphalcs  as  was  seen  in  7  cases  wiih  associated  retro- 
peritoneal lymphatic  involvement.  The  author  does  not 
advise  operation  in  the  presence  (  f  secondary  involvement 
for  fear  of  increasing  the  latter,     [m  r  d  ] 

Contribution  to  the  Study  of  the  Gonococcus 
and  Its  Toxin. — Christmas 's  (Aitual  de  t'Institut  J'a.'<teur, 
1900,  No.  5)  experimet.ts  show  tliat  the  gonococcus,  when 
thri\ing  on  a  culture  medium  especi.slly  suited  for  it,  dimi- 
nates  toxic  material^,  which,  when  applied  in  a  weak  dose  to 
the  brain  of  animals,  causes  death  with  characteristic  symp- 
toms of  poison.  The  culture  medium  must  be  selected  wiih 
particular  care,  the  best  being  calves'  bouillon,  chicken 
bnth,  or  rabbit  broth  with  some  gelatin,  to  which  either 
rabbit's  serum  or  ascitic  fluid,  but  no  peptone,  are  added. 
The  gonotoxin  does  not  arise  from  the  toxic  material  of  the 
dead  batteria,  but  is  a  biologic  product  produced  only  under 
certain  cultural  conditions ;  it  can  be  obtained  from  a  pure 
culture  with  a  saturated  solution  of  ammonium  sulfate.   The 


subcutaneous  injection  of  this  toxin  produces  an  antitoxic 
material  in  the  blood  of  the  animals  experimented  upon. 
[mb.d] 

The  Elimination  of  Bacteria  by  the  Kidneys  and 
Liver. — Mluu  {Annal.  d^  I' Iiutilul  Pasteur,  No.  6),  agrees 
with  those  authors  whose  experiments  showed  that  as  long 
as  the  liver  and  kidneys  are  in  a  normal  condition,  bacteria 
will  not  be  eliminated  by  them.  The  author  icjected  intra- 
venously into  rabbits,  bacillus  subtilis,  pyocyaneus,  prodigi- 
0SU9,  typhosus,  anthracis,  and  staphylococcus  aureus,  and 
the  same  organisms  into  the  subcutaneous  tissue  of  guinea- 
pigs.  From  time  to  time  bacteriologic  examinations  of  the 
urine  were  made,  the  urine  having  been  obtained  from  the 
exposed  bladder  by  aspirating  through  a  slough  in  the 
bladder-wall  so  as  not  to  injure  bloodvessels.  Ttie  same  pre- 
caution was  taken  when  aspirating  bile  from  the  gallbladders 
of  animals.  Both  the  urine  and  bile,  when  unmixed  with 
blood,  never  contained  the  injected  bacteria.  M^tin 
believes  that  theee  organs  only  permit  the  entrance  of  micro- 
organisms from  the  blood  into  their  secretions  when  their 
epithelia  are  the  seat  of  pathologic  changes,    [m.e  d.] 

Induced  Labor  in  Eclampsia.  —  Ludwig  Knapp 
{Prager  ineliciniisthe  Woche-iuchTift,  Vol.  25,  No.  51)  callk 
attention  to  the  successful  results  obtained  in  eclampsia  from 
induced  labor.  In  47%  of  the  author's  cases  the  convul- 
sions ceased,  and  in  23*  %  the  violence  of  the  paroxysms 
diminished  so  that,  on  itie  whole,  70J%  cases  of  eclampsia 
were  partly  or  totallv  relieved  by  the  induction  of  labor. 
He  quotes  Ferri,  of  Milan,  who  had  a  mortality  of  but  7  56  in 
S2  cases  of  eclampsia  in  which  labor  was  induced.  The 
author  remarks  that,  "  Bossi's  dilator  is  the  best  instrument 
for  dilating  the  cervical  canal.  He  describes  a  case  of  a 
primipara,  who  presented  the  prodromal  symptoms  of 
eclampsia;  albumin  in  the  urine;  eclamptic  convu'sions; 
L.  O.  A.  dilation  of  the  cervix  ;  rupture  of  the  membranes  ; 
version  and  extraction  of  an  almost  asphyxiated  full-term 
fetus,  which  was  subsequently  rapidly  resuscitated.  The  con- 
vulsions ceased  after  delivery  and  both  mother  and  child 
were  discharged  in  10  days  without  complicatious.    [me  d  ] 

Regarding  the  Healing  of  Injuries  Produced 
upon  the  Crystalline  Lens  of  the  Frog,  Fish,  and 
Birds. — Kua[.p  {ZtiUchri/t  j'iir  Augenhe'Ukunde,  vol.  lii,  !fo. 
3  and  6;  vol.  iv,  No.  1;  abstracted  by  Pfister  in  the  Corrta- 
pondenz-Blatt  filr  Schwtizer  Atrzte)  in  experimenting  upon  the 
frog  obtained  tliP  following  conclusion  :  1.  Even  wounds  ex- 
tending deeply  into  the  lens  are  not  followed  by  traumatic 
cataract  t^ut  heal  with  but  very  little  remaining  opacity.  2. 
The  union  of  the  wound  in  the  capsule  as  well  as  the 
fil.ing-up  of  the  disturbed  portions  of  the  lens  are  accom- 
pl'sbed  by  tl.e  epithelium  derived  from  the  capsule.  3  The 
cleariug-up  of  the  opacity  is  due  to  the  changes  that 
occur  in  the  cells  of  the  capsule,  which  ultimately  fill  up  the 
gap  produced  by  the  wound.  These  changes  are  an  increased 
transparency  of  the  ctlls  as  well  as  alterations  in  their  shape 
and  position.  4.  Every  irjury  to  ihe  lers  gives  rise  to  the 
new  formation  of  lens-fibers  at  the  equator,  and  for  this 
reason  the  tissue  which  tills  up  the  wound  has  a  tendency  to 
penetrate  deeply.  5.  The  scar  in  the  capsule  is  covered  at  its 
internal  surface  by  a  new  normal  ep  tbelium,  form  ng  a 
capsular  cataract  as  in  the  rabbit.  6.  Ljesof  substance  in 
the  equatorial  region  is  replaced  by  new-formed  lens  fibers. 
7.  Wounds  at  the  posterior  surface  of  the  lens  and  cap:ule 
are  closed  by  "tongue-shaped"  cellular  elements  from  the 
f  quator,  which  later  on  become  changed  to  lens  fibers.  S. 
lujuries  situated  at  the  center  of  the  lens  may  clear  up  by 
themselves.  9.  By  removing  the  lens  and  leaving  the  cap- 
sule, a  new  lens  will  be  formed  from  the  latt;  r.  The  result 
of  No.  9  was  obtained  by  injuring  the  lens  with  a  needle  so 
that  the  whole  lens  was  brought  to  lie  in  the  anterior  cham- 
ber. After  an  almost  total  opacity  of  the  lens  it  was  absorbed 
in  2  months,  and  a  newly-  but  not  entirely  regularly-formed 
lens  could  be  demonstrated.  The  same  rejult  was  observed 
in  three  experiment.-d  luxations  of  the  lens.  In  the  fish  (g^Md- 
fish)  it  was  also  shown  that  deep  and  extensive  injuries  of  the 
lens  did  not  cause  a  total  cataract  but  cniy  a  superfi- 
cial and  circum-cnbed  opacity.  In  the  bird,  although  one 
would  t  xpect  a  t  v.al  opacity  of  the  lens  on  account  of  its  soft 
consistency,  such  did  not  take  place  in  spite  of  the  marked 
traumatism,     [m  R  D  ] 


I 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


Jamks  Hendrie  Lloyd,  A.M.,  M.D.,  Eiiitor-in-Chic/ 
Julius  L.  Salinger,  M.D.,  Associute  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyhr,  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  Coley,  M.D. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dokland,  M.D. 

J.  H.  Gibbon,  M.D. 


Scientific  Articles,  Clinical  Memoranda.  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.    Reprints  (250)  of  Original  Articles  will  be  lurnished  gratis  to  Authors  making 
the  request. 
The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8  and  37. 


Vol.  VII,  No.  4 


JANUARY  26,  1901 


^3.00  Per  Annum 


Recent  Studies  in  Hydrophobia. — The  develop- 
ment, segregation,  and  final  grouping  together  of  the 
individual  symptoms  as  a  separate  disease,  and  the 
search  for  a  pathogenic  factor,  a  distinctive  or  specific 
pathology  to  establish  such  a  grouping  of  symptoms  as 
a  distinct  clinical  entity  on  a  scientific  basis,  are  well 
illustrated  by  the  changes  which  our  ideas  in  regard  to 
hydrophobia  are  undergoing  at  the  present  time.  Al- 
though the  clinical  pictures  as  found  in  the  best  books 
of  medicine  seemed  clear  and  well  defined,  there  could 
always  be  found  men  of  ability  who  denied,  in  the  ab- 
sence of  a  distinctive  pathology,  the  existence  of  such 
a  disease.  Thus,  a  skepticism  had  developed  in  the 
medical  profession  in  regard  to  hydrophobia,  and  one 
may  search  in  vain  the  health  reports  of  Philadelphia 
for  a  case  of  hydrophobia.  Such  a  diagnosis  is  not 
recognized,  and  death  from  this  cause  may  be  found 
under  the  head  of  convulsions,  etc.  At  the  last  meet- 
ing of  the  Pathological  Society  of  Philadelphia,  Drs. 
Ravenel  and  McCarthy  (University  Medical  Maga- 
zine, .January,  1901)  read  a  paper  confirming  the  work 
done  in  Europe  during  the  past  year  on  the  path- 
ology, and  the  diagnosis  from  the  pathological  lesions 
of  hydrophobia.  All  the  material  sent  to  the  Univer- 
sity was  made  use  of  in  this  work.  Van  Gehuchten 
and  Nelis  had  described  the  essential  and  distinctive 
lesions  of  rabies  in  the  peripheral,  sensory,  and  sympa- 
thetic ganglia.  The  normal  intervertebral  ganglion,  or 
ganglion  on  the  cerebral  nerves,  is  composed  mainly  of 
large  ganglion  cells;  each  cell  is  surrounded  by  an 
endothelial  capsule  of  one  layer  of  cells.  Between  the 
capsules  there  is  a  stroma  of  connective  tissue,  nerve- 
fibers,  and  bloodvessels.  In  the  ganglion  of  a  rabid  dog 
the  cells  are  degenerated,  shrunken,  and  may  have  dis- 
appeared. In  the  place  of  the  degenerated  and  atro- 
phied cells  are  the  capsules  filled  up  with  masses  of 
small,  irregular,  nucleated  cells.  As  the  ganglion  cell 
degenerates  and  shrinks  the  capsular  cells  proliferate 
and  fill  up  the  capsule,  and,  together  with  a  leukocytic 
infiltration  which  occurs  in  the  stroma,  give  a  distinc- 
tinctive  picture  to  the  section.  Other  changes  are 
found  in  the  spinal  cord  and  medulla,  but  they  are 
not  so  constant  or  characteristic  as  the  ganglion 
changes.  These  changes  are  not  found  as  a  constant 
pathological  factor  in  any  other  disease,  and  only  very 
rarely  as  an  accidental  factor,  the  result  of  some  direct 
or  indirect  irritation.     These  changes  occur  in  practi- 


cally all  cases  of  street  rabies,  and  are  missing  in  very 
few  of  the  cases  where  the  disease  is  conveyed  by 
subdural  injections  into  rabbits. 

The  changes  above  described  occur  very  early  in  the 
disease,  and  have  a  very  practical  value  as  a  means 
of  early  diagnosis.  Much  valuable  time  for  treatment 
has  been  lost  in  the  past  waiting  for  a  positive  diag- 
nosis in  an  animal  suspected  of  rabies,  who  has  bitten 
several  people.  At  least  14,  and  often  20  to  30  days 
was  necessary  before  a  positive  opinion  could  be  ex- 
pressed, and  an  accident  to  the  experimental  animal 
destroyed  all  evidence  for  or  against  the  diagnosis.  It 
is  now  possible  to  give  an  opinion  within  24  hours  of 
the  death  of  the  animal.  Prophylactic  treatment 
(Pasteur)  may  then  be  instituted  immediately  with 
better  prospects  of  success  and  with  lessened  possibility 
of  a  useless  expenditure  of  time  and  money.  Such 
was  often  the  case  when  the  animal  was  destroyed 
without  a  positive  diagnosis  having  been  made.  These 
investigations  will  furnish  food  for  thought  for  those 
who  hold  that  hydrophobia  is  a  disease  of  the  imag- 
ination, a  fatal  fear,  a  deadly  hysteria ;  and  a  feeling 
of  gratification  to  those  who  have  been  struggling  for 
so  long  a  time  to  establish  it  as  a  distinct  clinical 
entity.  It  is  difficult  to  see  how  fear  or  imagination 
could  cause  such  widespread  changes  in  the  central 
nervous  systein. 

The  Absorbable  Suture. — Ever  since  the  introduc- 
tion of  antiseptic  and  aseptic  surgery  one  of  the  regrets 
of  the  surgeon  has  been  that,  although  his  wounds 
heal  primarily,  yet  not  infrequently  an  early  or  late 
accumulation  of  pus  takes  place,  ''  breaks,"  or  is 
opened,  and  a  sinus  established,  which  continues 
until  finally  there  is  discharged  or  removed  from  it 
one  or  more  silk  sutures  or  ligatures.  This  was  a 
very  common  occurrence  a  few  years  ago  and  is  still 
not  infrequently  met  with  where  silk  is  used  to  any  ex- 
tent. The  suture  or  ligature  which  has  always  seemed 
the  ideal  one  to  the  surgeon,  is  one  that  would  serve 
its  purpose  and  then  be  absorbed  and  not  remain  a 
foreign  body  in  the  tissues.  The  dissatisfaction  which 
has  always  accompanied  the  use  of  suture-materials 
which  had  to  be  removed,  or  which  became  encysted, 
and  oftentimes,  even  though  perfectly  sterile  at  the  time 
of  introduction,  produced  irritation,  inflammation  or 
abscess,  with  which  all  surgeons  are  too   familiar,  has 


134 


The  Philadelphia"] 
Medical  Joubnal  J 


EDITORIAL  COMMENT 


[JascaBT  26,  1961 


caused  both  the  clinician  and  the  laboratory  investiga- 
tors to  labor  for  a  suture  that  would  fulfil  all  the  im- 
mediate requirements  and  that  would  not  give  rise  to 
postoperative  infection.  The  animal  sutures,  which 
are  practically  the  only  ones  which  are  absorbed 
with  any  certainty  in  a  reasonable  time,  have  been 
so  difficult  of  sterilization,  and  consequently  so  pro- 
ductive of  immediate  wound-infection,  that  many 
surgeons  have  been  slow  to  accept  them  in  much  of 
their  work  as  a  substitute  for  silk,  the  sterilization  of 
which  is  so  simple.  Repeated  and  laborious  experi- 
mentations have,  however,  been  so  productive  of  good 
results  that  now,  at  the  close  of  the  past  decade,  we  find 
the  operators  in  all  departments  of  surgery  gradually  dis- 
carding the  nonabsorbable  silk  and  silver  wire  for  the 
absorbable  catgut  and  kangaroo  tendon.  The  alcohol- 
bichloride,  the  cumol  and  the  formalin  methods  of  sterili- 
zation of  animal  sutures  have  become  so  perfectly  satis- 
factory, both  from  a  laboratory  and  practical  point  of 
view,  that  when  properly  carried  out  they  may  be  abso- 
lutely relied  upon.  The  substitution  of  catgut,  both  plain 
and  chromicized,  for  silk  and  silver  wire  has  been  most 
marked  in  the  past  few  years,  and  even  in  tissues  where 
silk  was  thought  to  be  the  only  possible  and  safe  liga- 
ture or  suture-material,  we  find  the  surgeon  now  using 
the  absorbable  animal  suture.  Many  abdominal  sur- 
geons now  use  catgut  entirely  as  a  ligature  for  even  the 
large  pedicles  which  must  be  constricted  in  the  pel- 
vis ;  and  in  appendicial  gallbladder  and  intestinal  sur- 
gery it  is  rapidly  finding  its  way.  Probably  the  one 
place  where  silver  wire  seemed  to  hold  absolute  pre- 
eminence was  in  the  suturing  of  bone,  and  yet  in  this 
work  catgut  and  kangaroo  tendon  are  finding  ardent  ad- 
vocates, who  continue  to  report  good  results  from  its  use. 
In  the  ligation  of  small  vessels  silk  may  now  be  said 
to  have  no  place,  and  in  the  closing  of  wounds,  even 
those  of  the  serous  membranes,  it  is  being  less  and  less 
employed.  Though  the  field  for  the  use  of  both  silk 
and  silver  wire  ia  so  rapidly  contracting,  yet  these  ma- 
terials will  always  have  their  place  in  surgery.  It  is 
certainly  true,  however,  that  in  the  satisfactory  sterili- 
zation of  the  animal  suture  the  surgeon  has  realized 
one  of  his  ideals. 

The  British  Congress  on  Tuberculosis. — Probably 
the  most  important  and  widespread  disease  that  afl^icta 
mankind  is  tuberculosis.  We  hear  so  much  nowadays 
of  some  of  the  other  infectious  diseases,  such  as  plague, 
yellow  fever,  and  malaria,  that  we  are  likely  to  over- 
look the  stupendous  mortality  from  consumption  in  its 
various  forms.  More  than  8,000  people  die  annually 
from  this  disease  in  Pennsylvania  alone;  while  in  the 
United  Kingdom  of  Great  Britain  and  Ireland  GO.OOO 
deaths  are  recorded  annually  from  tuberculosis,  and  it 
is  stated  on  good  authoritj'  that  at  least  three  times 
this  number  of  persons  are  constantly  sulfering  from 
one  form  or  other  of  the  disease.     Moreover,  this  ac- 


tivity of  tuberculosis  is  constant ;  year  after  year  it  is 
and  has  been,  and  apparently  will  continue  to  be,  the 
same  devastation  over  the  face  of  the  globe.  Plague 
and  yellow  fever  are  rather  more  dramatic  in  their 
onset  and  progress,  but  tuberculosis,  while  it  may  not 
appeal  so  strongly  to  the  imagination,  has  a  worse  effect 
on  the  death-rate  than  either  of  the  others. 

As  an  offset  to  this  sombre  picture  we  may  record 
the  fact  that  probably  no  disease  is  being  made  the 
object  of  persistent,  intelligent,  and  organized  opposi- 
tion to  such  an  extent  as  tuberculosis  is  at  the  present 
day.  The  opposition  is  even  taking  on  a  missionary 
zeal  and  evangelical  fervor,  for  the  public  is  being  edu- 
cated by  tracts  and  in  some  places  the  pulpit  is  even 
giving  out  a  warning  cry.  Perhaps  these  popular 
methods  are  not  always  the  wisest,  but  they  at  least 
indicate  a  curious  awakening  on  the  subject  of  con- 
sumption. Much  more  effective  will  be  such  an  as- 
semblage as  the  forthcoming  British  Congress  on  Tuber- 
culosis. This  congress  will  meet  in  London  in  July 
next,  and  the  prospects  are  that  it  will  be  a  most  note- 
worthy gathering.  The  preliminary  program,  which 
lies  before  us,  already  maps  out  wide  territories  for 
scientific  work.  This  work  will  include  medical,  clima- 
tological,  pathological,  bacteriological,  and  veterinary 
tuberculosis,  as  well  as  hygiene  and  state  medicine  in 
reference  to  this  disease;  and  will  be  illustrated  by 
means  of  a  large  museum.  It  is  to  be  hoped  that  many 
of  our  American  specialists  will  take  part  in  this  con- 
gress, not  only  for  their  own  sakes,  but  especially  for 
the  advancement  of  this  work,  than  which  no  greater 
now  enlists  the  sympathies  and  activities  of  scientific 
men. 

Scientific  Work  in  Psychiatrj'. — Dr.  Edwajd  N. 
Brush,  physician-in-chief  to  the  Sheppard  Asylum, 
near  Baltimore,  has  discoursed  in  a  very  rational  and  ■ 
luminous  way,  in  his  recent  annual  report,  on  the  vexed  | 
problem  of  how  to  get  more  scientific  work  done  in 
hospitals  for  the  insane.  Dr.  Brush,  who  has  had  a 
large  experience  in  the  asylums,  does  not  seem  to  have 
been  enervated  by  breathing  the  atmosphere  of  these 
much-maligned  institutions.  He  wants  more  scientific 
work  done  in  them,  while  recognizing  that  there  are  prac- 
tical difficulties  in  the  way  of  converting  all  our  well- 
ordered  asylums  into  busy  hives  of  clinical  and  patho- 
logical workers.  This  seems  to  us  to  be  the  first  abso- 
lutely essential  step  in  the  solution  of  this  whole 
question,  i.  e.,  that  the  asylum  men  themselves  come  to 
recognize  the  need  of  more  science.  "  This  progress 
must  begin  from  within.  It  must  be  spontaneous,  not 
forced  from  without.  Whatever  the  difficulties  may  be. 
there  will  be  found  a  way  to  overcome  them  when 
those  who  are  most  nearly  concerned  feel  the  impulse 
to  forge  ahead.  Whatever  the  obstacles,  only  the  men 
on  the  inside  know  them  well  enough  to  really  sur- 
mount  them.     For  these  reasons  we  believe  that  the 


JaNDAET  26,  1901] 


EDITORIAL  COMMENT 


[■ 


The  Philadklphia 
Medical  Journai. 


135 


one  real  hopeful  sign  for  the  scientific  progress  of  the 
asylums  is  in  the  fact  that  men  like  Brush  are  fully 
awake  to  the  necessity  of  bringing  the  science  of 
psychiatry  up  to  the  same  plane  of  activity  and  fruitful- 
ness  that  has  been  attained  by  the  other  medical  sciences. 
Dr.  Brush  thinks  that  the  failure  to  secure  great  re- 
sults comes  from  the  lack  of  correlation  in  the  past 
between  laboratory  work  and  clinical  work.  These 
two  must  be  better  correlated.  In  this  connection 
we  would  remind  him  of  Kraepelin's  recent  recom- 
mendation that  small  psychiatrical  hospitals  be  estab- 
lished in  connection  with  teaching  clinics.  In  this 
country  it  might  be  better  if  more  small  or  medium- 
sized  hospitals  were  established  with  a  view  to  having 
some  relation  with  a  near-by  clinic  and  laboratory,  so 
that  in  effect  each  would  be  part  of  a  great  teaching 
plant.  One  difficulty  in  this  country  is  the  tendency 
to  hypertrophy.  Institutions  must  swell  to  immense 
proportions,  in  order  to  catch  the  public  eye,  if  they 
are  to  fulfil  their  proper  destinies.  This  should  not  be 
so  with  all  our  hospitals.  A  few  well-selected  and  well- 
studied  cases  will  give  infinitely  better  results  to  science 
than  a  thousand  beds  consigned  to  the  oblivion  of 
routine.  There  is  a  stimulation  that  comes  from  a 
teaching  clinic  that  cannot  be  artificially  produced  any- 
where else  in  the  world.  It  is  this  stimulation,  this 
contact  of  young,  eager,  and  inquiring  minds,  that  is 
lacking  in  many  of  our  hospitals  for  the  insane.  Dr. 
Brush  would  tend  to  solve  the  problems  of  psychiatry 
if  he  would  create  a  teaching  clinic  at  Sheppard  Asy- 
lum, or  utilize  its  material  for  such  a  clinic. 

Erroneous  Pharmacy. — In  these  days  when  the 
markets  are  flooded  with  all  sorts  of  well-recommended 
drugs,  it  is  not  enough  that  these  preparations  be  free 
from  the  taint  of  quackery  and  commercialism.  They 
should  all  be  free  from  the  possibility  of  doing  harm, 
such  as  might  arise  from  the  mistaken  judgment  or  lack 
of  experience  of  the  well-meaning  physician  or  jjhar- 
macist  who  recommends  them  to  the  profession.  Dr. 
William  Murrell  has  just  sounded  a  note  of  warning,  for 
instance,  in  reference  to  one  of  the  new  preparations  of 
arsenic,  known  as  the  cacodylate  of  sodium.  We  are 
told  by  its  sponsors,  who  are  mostly  French  physicians, 
that  although  this  drug  contains  a  large  amount  of 
arsenious  acid  (as  high,  even,  as  55%),  it  has  none  of 
the  toxic  action  of  that  salt,  and  that  it  may  be  given 
by  mouth,  and  even  hypodermically,  in  comparatively 
large  doses.  Dr.  Murrell's  experience  did  not  support 
this  claim.  He  administered  one  grain  of  the  drug  in 
pill  form,  and  before  eleven  doses  had  been  taken  he 
observed  such  well-marked  and  even  alarming  symp- 
toms of  arsenicism,  that  he  was  forced  to  discontinue  its 
use.  A  distinct  odor  of  garlic  was  noted  on  the  breath 
on  the  second  day,  and  by  the  fourth  day  the  patient 
had  been  vomiting,  and  her  face  was  pallid,  eyelids 
edematous,  conjunctivae  injected,  and  her  tongue  pre- 


sented the  appearance  of  a  piece  of  raw  beef.  In  addi- 
tion, and  far  worse,  there  was  arsenical  neuritis  in  the 
limbs,  marked  by  loss  of  power,  abolished  knee-jerks, 
and  pain  in  the  nerve-trunks  on  pressure.  Arsenic  is 
too  virulent  a  poison,  and  Dr.  William  Murrell  is  too  good 
an  authority  for  us  to  let  his  important  letter  in  the 
Lancet  (December  29,  1900)  go  unnoticed.  This  drug 
has  recently  been  used  in  one  of  the  hospitals  of  Phil- 
adelphia with  results  which,  we  are  credibly  informed, 
indicate  that  it  is  a  very  potent  toxic  arsenical  prepa- 
ration. 

In  this  connection  we  would  suggest  that  reputable 
pharmacists,  whose  intentions  are  doubtless  of  the  best, 
and  who,  in  fact,  are  often  misled  by  physicians  them- 
selves into  exploiting  some  particular  medicine,  would 
do  well,  before  launching  new  preparations  of  the  more 
poisonous  drugs,  to  have  them  completely  tested  on  the 
lower  animals.  This  might  wound  the  feelings  of  the 
antivivisectionists,  but  it  would  probably  save  human 
suffering  here  and  there. 

Mosquitoes  and  Disease. — The  search  for  the  patho- 
genic mosquito  still  goes  on.  Having  fastened  the 
responsibility  for  malaria  upon  this  insect,  the  scientists 
seem  bent  upon  fixing  the  blame  for  yellow  fever  upon 
it  too.  We  trust  we  shall  hear  something  more  definite 
on  that  point  at  the  coming  Pan-American  congress  in 
Havana.  The  role  of  the  anopheles  in  malaria  seems 
to  be  well  established,  but  we  still  need  more  definite 
information  about  the  completion  of  the  life-cycle  of 
the  malarial  parasite.  Is  the  mosquito  the  intermedi- 
ary host,  or  is  the  essential  link — "  the  means  by  which 
its  existence  is  assured  from  year  to  year  " — the  indi- 
vidual known  in  the  Lancet  as  "  malarial  man  "  ?  During 
the  past  year  a  few  facts  of  importance — confirmatory 
rather  than  truly  originating — have  been  added  to  our 
knowledge  of  the  propagation  of  malaria.  Thus  Man- 
son's  experiment  on  himself  was  confirmatory.  He 
submitted  himself  to  be  bitten  by  some  imported  ano- 
pheles mosquitoes,  and  promptly  developed  an  attack 
of  tertian  fever.  This  was  a  disease  that  he  could  not 
readily  have  picked  up  in  England,  and  the  plain  in- 
ference is  that  the  imported  insects  gave  it  to  him. 
Again  Drs.  Sambon  and  Low,  with  Signer  Terzi,  betook 
themselves  to  the  most  infected  spot  on  the  Roman 
Campagna,  and  by  protecting  themselves  from  the  bites 
of  mosquitoes,  entirely  avoided  the  disease.  Other 
persons  around  them,  who  took  no  precautions,  as 
promptly  took  it.  The  desideratum  now  is  to  find 
something  that  will  kill  the  mosquito,  and  then  having 
found  it,  to  apply  it.  It  seems  to  us  at  present  writing 
to  be  a  bigger  problem  to  exterminate  the  mosquito  than 
it  is  to  control  malaria  with  quinin.  We  can  kill  the 
parasite  in  the  blood  of  man  more  readily  than  in  the 
system  of  the  mosquito — or  even  than  we  can  kill  the 
mosquito  itself.  In  other  words,  from  an  economic 
standpoint  it  may  be  a  question  whether  it  is  not  as 


136 


TuE  Philadelphia 

Mhdical  Journal 


] 


EDITORIAL  COMMENT 


[Jakcabt  26,  uei 


easy  to  take  malaria  and  cure  it  with  quinin,  as  it  is  to 
go  on  a  still  hunt  after  mosquitoes.  This  is  a  question 
in  prophylaxis  that  has  not  much  more  than  got  itself 
stated.     A  solution  of  it  is  not  yet  in  sight. 

Blood  Concentration. — Frequently  the  examina- 
tion of  the  blood  is  one  of  the  links  in  the  chain  of 
clinical  evidence  forged  in  the  establishment  of  a  diag- 
nosis. A  factor  in  blood  examination  which  has  re- 
ceived too  little  attention  is  the  occurrence  of  blood 
inspissation,  and  this  is  worthy  of  more  thoughtful  con- 
sideration. In  many  instances  a  relative  increase  in 
the  number  of  red  corpuscles  leads  to  false  conclusions 
unless  the  important  factor  of  concentration  is  carefully 
weighed,  and  therefore  detracts  from  the  value  of  blood 
examinations  in  diagnosis. 

The  causes  of  blood  inspissation  are  numerous  and 
constantly  operative.  A  relative  increase  in  the  num- 
ber of  colored  corpuscles  occurs  in  such  conditions  as 
profuse  sweating,  diarrhea,  persistent  vomiting;  the 
withdrawal  of  a  large  quantity  of  serous  fluid  from  the 
body  which  is  quickly  replaced ;  by  depriving  the  sys- 
tem of  liquids,  and  by  increased  blood-pressure.  Cabot, 
in  referring  to  this  subject,  says  :  "  In  the  presence,  there- 
fore, of  any  such  reason  for  concentration,  we  should 
always  modify  our  ordinary  methods  of  inference  from 
the  blood-count." 

It  is  a  well-established  fact  that  in  cholera  during 
the  stage  of  collapse  very  high  counts  are  observed, 
sometimes  reaching  seven  millions  per  cubic  millimeter. 
Not  less  striking  an  illustration  is  the  relative  increase 
of  the  erythrocytes  which  occurs  after  a  drenching 
night-sweat  in  phthisis.  A  very  complex  and  difficult 
problem  is  to  determine  anemia  in  such  diseases  where 
excessive  erythrocytolysis  and  concentration  are  both 
making  progress.  Under  such  circumstances  we  must 
reflect  upon  the  physiology  of  blood  regeneration, 
namely  :  That  the  liquid  elements  are  rapidly  restored, 
the  erythrocytes  more  slowly,  and  lastly  the  hemoglobin 
is  gradually  replaced.  Factors  which  demand  careful 
consideration  in  an  acute  infectious  disease  presenting 
profuse  diarrhea  are,  that  excessive  blood  destruction 
and  concentration  are  both  active.  However,  in  such 
instances,  while  we  should  expect  a  relative  increase  in 
the  percentage  of  red  cells,  the  hemoglobin  would  not 
show  the  same  increase  and  the  corpuscular  richness  in 
hemoglobin  or  color  index  would  be  reduced. 

In  conclusion,  therefore,  when  the  condition  of  the 
blood  is  to  have  an  important  bearing  upon  a  diagnosis, 
the  results  of  such  an  examination  should  be  compared 
carefully  with  such  important  clinical  facts  as  the 
amount  of  liquids  ingested  and  the  rapid  loss  of  fluids 
from  the  body. 

The  Improved  Sanitary  Condition  of  Havana. — 

Major  and  Surgeon  W.  C.  Gorgas,  chief  sanitary  oflicer 
for  Havana,  Cuba,  in  his  monthly  report  for  December, 


1900,  calls  the  attention  of  the  Department  Commander 
to  the  very  excellent  showing  made  by  the  vital  statis- 
tics of  the  city  for  the  last  month  of  the  century.  We 
think  some  of  these  figures  are  worth  quoting,  for  they 
reflect  great  credit  upon  the  American  ofiBcials  who  are 
responsible  for  the  sanitary  condition  of  Havana.  The 
population  of  Havana  is  placed  in  round  figures  at 
250,000.  The  number  of  deaths  for  December  was 
485.  The  smallest  number  for  any  December  in  the 
preceding  10  years  was  517,  in  1893.  The  death-rate 
for  1900  was  23.28.  The  next  smallest  for  the  past  10 
years  was  27.10  for  1899.  The  smallest  death-rates  for 
the  past  10  years  have  been  for  these  two  years,  1899- 
1900;  the  years  of  the  American  occupation.  There 
has  been  a  marked  decrease  in  the  number  of  cases  of 
yellow  fever.  In  November  there  had  been  214  cases 
with  54  deaths ;  in  December  62  cases  with  20  deaths. 
Dr.  Gorgas  calls  attention  to  the  fact  that  most  of  the 
yellow-fever  cases  occur  in  the  recently  arrived  Spanish 
immigrants,  more  than  two-thirds  of  the  cases  occur- 
ring in  persons  who  have  been  in  Cuba  for  less  than 
one  year.  It  is  a  noteworthy  fact  that  Spanish  emigra- 
tion to  Cuba  still  continues  large ;  the  number  for  De- 
cember alone  having  been  4,206.  This  prevalence  of 
the  disease  among  these  newcomers,  who,  of  course, 
are  not  yet  immune,  is  a  striking  instance  of  disease- 
propagation,  and  suggests  strongly  that  some  means 
ought  to  be  devised  to  control  it  if  possible.  A  prophy- 
laxis, like  HaSTiine's  for  the  plague,  is  evidently  a 
desideratum.  These  figures  from  Dr.  Gorgas'  report 
show  what  can  be  and  is  being  done  to  clean  Havana 
and  keep  it  clean.  That  city  has  been  a  more  or  less 
constant  menace  to  the  health  of  the  American  people, 
ind  it  is  gratifying  to  know  that  its  temporary  occu- 
pation by  the  United  States  Government  is  proving  | 
beneficial  in  a  sanitary  and  hygienic  sense.  The  lesson  1 
thus  being  taught  ought  not  to  be  permitted  to  be  for- 
gotten or  ignored  in  the  years  to  come. 

"  Wiener  niedicinische  Wochenschrift." — We  ex- 
tend to  this  valuable  contemporary  our  heartiest  con- 
gratulations on  its  fiftieth  anniversary.  We  do  not 
doubt  that  it  will  continue  to  maintain  its  customary 
prestige  in  the  annals  of  medical  journalism. 


\ 


A  Case  of  Rodent  Ulcer  Healed  by  the  X-rays. — 

T.  Stemheck,  of  8tockholm  (MUthfUungtn  nits  den  GremgtbieUn 
der  Medicin  und  Chinirffie,  Bd.  VI,  Heft  3),  reports  the  case  of  a 
rodent  ulcer  of  9  years'  duration,  occurring  on  the  bridge  of 
the  nose  of  a  woman  72  yeiirs  of  age.  The  patient  was  sub- 
jected daily  from  10  to  12  minutes  to  moderately  strong 
x-rays,  the  lamp  being  removed  15  to  20  cm.  Afl*r  4 
seances  there  was  reaction ;  after  S  to  10  applications  pro- 
fuse suppuration,  which,  however,  soon  diminished.  After 
35  sittings,  during  which  the  ulcer  was  always  cleaned,  there 
followed  desquamation  of  the  epiderm.  AJfter  a  new,  thin, 
smooth  epiderm  had  formed,  the  intensity  of  the  illumination 
was  increased  so  that  the  patient  was  treated  daily  for  15 
minutes  with  the  tube  removed  but  10  cm.  from  the  ulcer. 
Sufficient  time  has  not  yet  elapsed  to  say  whether  a  definite 
cure  was  established,     [m.r.d  ] 


JiNUARV   2fi,    1901) 


REVIEWS— CORRESPONDENCE 


rXiiK  Philadelphia  \V7 

\_  Medical  Journal 


HcDtetDs. 


Euteroclysls,  Hypodernioclysis,  and  Infusion.  With 
a  Chapter  on  the  Carbonated  Bath  and  Some  New  Ap- 
plications; Also  Therapeutic  Addenda.  By  Robkrt 
Coleman  Kemp,  M  D.  Introduction  by  Wm.  H.  Thom- 
son, M.D.,  LL.D.  Infusion,  Shock,  and  Anesthesia,  by 
Robert  H.  M.  Dawbarn,  M.D.  Drawings  by  Thos.  Nast, 
Jr.  Photographs  by  Dr.  A.  W.  Gardner.  8vo,  pp.  xiv, 
349.    New  York  :  .Tames  T.  Dougherty,  1900 

It  is  a  mistake  to  believe  tliat  the  physician's  armamenta- 
rium begins  and  ends  with  the  materia  medica.  In  fact,  liis 
most  potent  weapons,  botli  of  offence  and  defence,  are  at 
times  drawn  from  other  sources.  The  great  value  of  water, 
administered  in  various  ways,  as  a  tlierapeutic  agent  has 
long  been  appreciated,  and  the  little  volume  before  us  deals 
with  its  application  through  the  intermediation  of  the 
bowel,  the  lymphatics  and  the  bloodvessels.  The  subject 
has  become  one  of  great  importance  and  a  diffusion  of 
knowledge  bearing  upon  it  must  bear  good  fruit.  Dr.  Kemp 
has  for  a  number  of  years  devoted  himself,  experimentally 
and  clinically,  to  the  study  of  the  matters  in  hand  and  is, 
therefore,  qualified  to  discuss  them  with  mtelligence  and  judg- 
ment. The  book  is  divided  into  five  parts,  one  on  entero- 
clysis,  the  second  on  hypodernioclysis,  the  third  on  infu.sion, 
the  fourth  on  the  carbonic  acid  bath,  and  the  fifth  on  thera- 
peutic addenda.  In  view  of  the  inherent  imp  rtance  of  the 
.subject  and  the  timeliness  of  publication  the  volume  will  no 
doubt  be  cordially  received. 

A  Compend  of   Diseases  of  the  Skin.     By  Jay   F. 

ScHAMBERG,  A.B.,  M.D.  Pnifcssor  of  Diseases  of  the 
Skin,  Philadelphia  Polyclinic  and  College  for  Graduates 
in  Medicine ;  Fellow  of  the  College  of  Physicians  of 
Philadelphia.  Second  edition,  revised  and  enlarged 
With  105  illustrations.  8vo,  pp.  xv,  291.  Philadelphia : 
P.  Blakistou's  Son  &  Co  ,  1900.     Price  80  cents. 

Discriminatingly  used,  this  little  book  is  capable  of  aiding 
the  student  to  a  readier  understanding  of  the  subject  with 
which  it  deals.  It  affords,  so  to  speak,  an  outline,  which 
must  be  filled  in  by  clinical  observation  and  wider  reading. 
Duhring's  classification  is  followed  and  .special  attention  has 
been  given  to  the  differential  diagnosis  and  treatment  of 
the  more  important  affections. 

International  Clinics.  Edited  by  Henky  W.  Cattell, 
A.M.,  M.D.  Vol.  III.  Tenth  series,  1900.  Philadelphia: 
J.  B.  Lippincott  Company,  1900. 

This  volume  contains  a  symposium  of  7  papers  on  genito 
urinary  diseases.  Four  papers  on  therapeutic  subjects,  3  in 
medicine,  3  in  neurology,  5  in  surgery,  4  in  obstetrics  and 
gynecology  and  1  each  on  diseases  of  the  eye,  laboratory 
methods  and  the  scientific  modification  of  milk  ;  illustrated 
by  18  figures  and  27  plates.  The  articles  will  appeal  espe- 
cially to  the  general  practitioner,  and  that  by  Dr.  Westcott 
on  milk-modification  is  particularly  commendable  as  it  is 
an  ell'ort  to  elucidate  and  to  simplify  a  subject  that  has  been 
involved  in  a  good  deal  of  complexity  and  one  that  is  at  the 
sani '  time  of  the  utmost  importance  from  a  practical  point 
of  view. 

A  List  of  Publications  of  Dr.  Irving  C.  Rosse, 

Washington,  D.  C. 

This  pamplet  contains  a  complete  catalogue  of  Dr.  Rosse's 
publications  covering  the  full  period  of  his  professional  life. 
Dr.  Rosse  is  well  known  as  a  contributor  to  medical  litera- 
ture especially  in  the  domain  of  neurology  and  psychiatry, 
and  for  tho.se  who  desire  to  refer  to  his  writings  this  list  will 
be  a  great  convenience. 


(Eorresponbcncc. 


SUPRARENAL  CAPSULE  IN  ORGANIC  HEART  DISEASE. 
By  SAMUEL  FL0P:RSHEIM,  M.D., 

of  New  York  City. 

To  the.  Editor  of  The  Philadelphia  Medical  Journal:— 

I  INTEND  to  publish  a  second  paper  on  the  use  of  the  supra- 
renal capsule  in  organic  heart  disease.  Will  you  kindly  ask 
the  readers  of  your  Journal  to  send  me  the  reports  of  their 
cases  as  follows  : 

1.  The  condition  of  the  heart  and  pulse,  and  also  the 
pulse-rate. 

2.  The  effect  on  the  heart  and  pulse,  and  also  the  pulse- 
rate,  within  10  minutes  after  the  suprarenal  powder,  3 
grains,  is  chewed  and  swallowed  without  water,  by  the  pa- 
tient. 

218  E.  46th  St. 


DR.  JACOBIS  ADDRESS. 
By  HAROLD  N.  MOVER,  M.D., 

of  Chicago,   111. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  :— 

In  the  presidential  address  before  the  Mississippi  Valley 
Medical  Association  I  referred  to  the  address  of  Dr.  Jacobi 
before  the  International  Medical  Congress  as  misrepresent- 
ing the  medical  profession  of  America.  At  the  time  my 
address  was  prepared  I  had  not  seen  the  address  of  Dr. 
Jacobi,  but  my  information  was  derived  from  more  or  less 
fragmentary  reports  that  had  reached  this  country,  and  cer- 
tain editorial  references  to  the  address  describing  it  as 
"  apologetic." 

A  reading  of  the  full  text  leaves  a  very  different  impres- 
sion on  my  mind.  I.istead  of  apologizing  the  essayist  pays 
a  splendid  tribute  to  the  American  medical  profession,  alike 
free  from  overstated  claims,  or  hypocritical  self-depreciation. 

I  certainly  very  much  regret  the  reference  to  Dr.  Jacobi's 
address,  but  feel  that  I  must  in  part  be  exonerated  as  I 
accepted  statements  which  seemed  authoritative. 

The  whole  matter  reveals  a  phase  of  medical  journalism 
that  I  little  suspected. 


"  ANOTHER  FACTOR  IN  THE  TRANSMISSION  OF 
DISEASE  GERMS." 

By  E.  D.  FREAR,  M.D., 
of  Sloau,  la. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  :— 

Dr.  Leidy's  communication  in  your  Journal  of  January 
12,  calls  to  mind  another  "  Factor  in  the  transmission  of  dis- 
eased germs  "  to  which,  so  far  as  I  know,  the  attention  of  the 
medical  profession  has  not  been  called. 

I  refer  to  the  pestifctrous  pack  peddlers.  This  class  of 
mendicants  is  usually  composed  of  an  undesirable  class  of 
aliens  whose  ideas  of  hygiene,  or  even  of  common  cleanli- 
ness, are  very  limited.  Whenever  they  can  gain  admission 
to  a  house,  their  packs,  which  are  generally  made  up  of 
fabrics  which  are  good  conveyors  of  diseased  germs,  are 
opened  and  spread  over  sofas,  beds,  and  other  convenient 
articles,  and  are  promiscously  handled  by  the  members  of 


138 


Thk  Philadklpula 
msdical  jocrhal 


] 


CORRESPONDENCE 


[Jahoast  2«,  1901 


the  household.  The  air  of  the  room  may  be  impregnated 
with  the  desquamations  of  variola  or  scarlatina,  the  exuda- 
tions of  diphtheria,  or  the  expectoration  of  tuberculosis. 
The  goods  are  carefully  repacked  and  carried  to  the  next 
home,  or  several  homes,  where  the  germs  are  distributed. 
Without  going  into  details,  I  have  seen  two  developments  of 
scarlatina  and.  one  of  diphtheria,  in  each  case  a  clear 
history  of  the  contagium  being  carried  in  this  manner.  I 
recognize  the  fact  that  our  cities  and  more  populous  "com- 
munities are  spared  this  nuisance,  but  it  is  in  the  country, 
where  the  population  is  sparsp,  and  where,  in  many  cases 
the  disease  is  in  so  light  a  form  that  a  physician  is  not 
called,  that  this  danger  exists. 


SURGICAL  INTERVENTION  IN  PERFORATION  IN 
TYPHOID  FEVER. 

By  WILLIAM  OSLEK,  M.D., 
of  Baltimore,  Md. 

lo  the  Editor  nj  The  Philadelphia  Medical  Jouenal  :— 

In  your  editorial  note  on  surgical  intervention  in  perfora- 
tion in  typhoid  fever,  you  lay  stress  upon  the  effect  of  the 
anesthetic.  In  a  mnjority  of  our  cases  the  operation  has 
been  performed  under  cocain,  with  which  the  patients  ap- 
parently suffer  very  little  distress.  In  illustration  of  the 
capacity  of  a  patient  to  stand  repeated  surgical  interference, 
I  may  refer  to  a  case  already  reported  by  Dr.  Gushing  in  the 
Johns  Hopkins  Bulletin.  Three  operations  were  performed 
within  two  weeks,  the  first  on  August  13,  under  chloroform 
anesthesia,  when  a  perforation  was  sutured  ;  13  days  later  the 
patient  suddenly  became  worse,  had  vomiting,  was  collapsed, 
restless,  and  the  abdomen  was  distended,  and  he  had  hiccough. 
He  was  thought  to  have  another  preforation,  and  was  operated 
upon  under  chloroform,  but  nothing  was  found  to  account 
for  the  symptoms.  Two  days  later  he  had  much  more  seri- 
ous symptoms,  and  a  third  operation  was  performed,  also 
under  chloroform.  A  perforation  1  cm.  in  diameter  was 
found  and  sutured,  and  the  bowels  were  irrigated  with  salt- 
solution  and  replaced.    He  made  a  satisfactory  recoTery. 


THE  INDIVIDUAL  COMMUNION  CUP. 

By  HOWAKU  S.  ANDEK-S,  M.I)., 

of  Philsdelphia. 

To  the  Editor  of  Thb  Philadelphia  Medical  Journal  : — 

As  one  who  is — as  the  phrase  gies — "  largely  responsible  " 
for  the  agitsition  in  favor  of  the  adoption  of  individual  com- 
munion cups  as  sanitary  and  not  less  sacred  substitutes  for 
the  single  and  several  commonly-used  thalices  and  cups,  I 
may  refer,  with  propriety,  perhaps,  to  Dr.  Sheaff's  letter,  in 
your  last  issue  of  the  Journal,  concerning  this  matter  in 
relation  to  the  prevention  of  tuberculosis.  I  have  written 
and  spoken  so  often  on  this  subject  that  I  hesitate  before 
putting  forth  again,  lest  the  reform  may  be  harmed  more 
than  helped  by  my  apparent  position  as  an  unbalanced  hob- 
byist or  sacrilegious  sanitarian. 

And  yet,  it  seems  that  the  underlying  facta  and  principles 
of  the  individual  cup  idea,  as  applied  to  schools  as  well  as  to 
churches,  are  quite  obvious  to  every  right-tninking  and  pro- 
gressive physician.  So  that,  while  letters  litce  Dr.  Sheaff's 
are  encouraging  and  gratifying  from  the  interest  shown,  after 
all,  what  are  physicians  doing  in  a  personal,  hand-to-hand, 
practical  way  to  further  this  sanitary  reform  in  the  churches  ? 


Tne  Philadelphia  County  Medical  Society  passed  a  resolution, 
after  my  first  paper  on  the  subject,  in  September,  1894,  fivor- 
ing  the  adoption  of  individual  communion  cupe ;  ministerial 
conferences  and  assemblies  have  done  likewise.  Neverth&. 
lefs,  the  passing  of  resolutions  accomplishes  very  little  in  the 
way  of  actually  bringing  things  to  pass,  unless  the  physicians 
themselves  work  quietly,  rationally,  and  with  tact  and  per- 
sistence among  their  patients,  friends,  and  own  church 
fellow-members. 

Surely,  not  rarely  may  the  occasion  be  opportune  for  the 
family  doctor  to  ask,  Does  your  church  use  individual  com- 
munion cups?  and  if  not,  according  to  the  reply,  an  influen- 
tial word  may  be  uttered.  Especially  does  this  bring  fruitage 
among  women,  who  are  often  instrumental  in  inducing  a 
strong  and  successful  sentiment  against  the  single  chalice  or 
cup.  Since  the  clergymen  are  very  few  who  will  head  the 
movement  in  their  own  churches,  for  reasons  of  propriety, 
but  many  who  will  readily  sanction  it,  it  is  evident  that  the 
initiative  in  agitation  and  action  must  come  from  the  people 
and  church  officers ;  and  these  will  not  move  unless  their 
medical  advisers  teach,  awaken,  and  encourage  them  to  do  so. 

"True  it  is,"  writes  D.-.  Sheaff,  "  that  some  congregationa 
have  adopted  the  individual-cup  method;  but  are  they  many, 
compared  to  those  who  have  not?"  No,  indeed,  they  are 
not  many.  My  latest  statistics — approiimat* — show  that 
there  are  not  more  than  about  800  churches  (representing 
about  500,000  communicants)  in  the  United  States  using  it. 
This  is  more  than  twice  as  many  as  in  1893,  but  a  small 
number  compared  to  the  thousands  not  doing  bo.  However, 
the  movement  is  steadily,  though  slowly,  growing  all  the 
time.  Medical  men  only  can  hasten  it,  primarily,  as  hinted 
before. 

It  should  be  urged,  farther,  that  the  method  is  not  only 
satisfactory  in  hygienic  principle,  but  equally  so  in  practice, 
a«  all  churches  using  it  unanimously  testify;  not  only  clean 
and  sanitary,  but  permitting  also  as  much  of  solemnity, 
dignity,  impressiveness,  and  devotional  concentration  as  by 
the  use  of  a  single  cup  or  of  half  a  dczen  cups  by  many 
mouths  of  uncertain  cleanliness  and  health. 

We  should  think  not  only  of  tuberculosis,  but  of  prevalent 
influenza,  and  follicular  tonsillitis — to  mention  no  other 
transmissible  diseases  in  this  connection  ;  they  may  all  "  go 
to  church  "  with  their  hosts,  in  some  communicable  form. 
The  recent  discussion  in  the  London  Lancet  and  some  of  the 
English  church  papers  concerning  the  revival  of  Lntinction 
as  a  mode  of  administering  the  sacrament,  as  well  as  the 
individual  communion  cup,  shows  the  trend  of  feeling  in  the 
direction  of  more  general  ecclesiaeticil  sanitation  than  now 
obtains  in  celebrating  the  memorial  of  the  Lord's  Supper. 


THE  CURE  OF  URETHRORECTAL  FISTULA. 

By  RICHARD  X.  GIBBONS,  M.D. 

To  the  Editor  of  Thk  Philadelphla  Medical  Journal: — 

Dr.  Thomas  Addis  Emmet,  nearly  a  third  of  a  century  ago, 
operated  through  the  rectum  for  the  cure  of  urethrorectal 
fistula.  In  the  third  edition  of  his  mast«rful  work  on  gyne- 
cologj-,  the  following  and  additional  notes  will  be  found 
relative  to  the  case,  and  for  the  benefit  of  yoiu  readers,  in- 
cluding Prof  Horwitz  and  Prof.  Keen,  I  offer  for  publica- 
tion, quoting  from  the  above  as  follows : 

"  Case  108.— On  May  28, 1870, 1  closed  a  rectourethral  fistuk 
in  a  gentleman  from  Kentucky,  at  the  request  of  the  lata 


JAKIIARY  26,    1901] 


CORRESPONDENCE 


["Thb  Piiiladelphia 
L  Medical  Journal 


139 


Dr.  J.  C.  Nott.  The  case  was  reported,'  but  without  giving 
the  operation  in  detail,  and  I  now  give  it  in  full,  as  it  seems 
to  illustrate  well  the  manner  of  closing  from  the  rectum 
similar  openings  in  the  female  organs. 

"On  the  first  of  December,  1868,  a  large  stone  of  irregular 
shape,  weighing  5  ounces,  was  removed  by  the  lateral  opera- 
tion, which  left  a  fistulous  opening  in  the  rectum,  through 
which  the  urine  passed.  A  portion  of  the  urine  continued 
to  discharge  by  the  rectum  up  to  the  time  of  his  arrival  in 
New  York,  and  no  attempt  had  been  made  to  close  the 
opening.  Net  only  did  a  portion  of  the  urine  pass  through 
the  rectum,  but  feral  matter  and  gas  frequently  escaped 
with  the  urine  through  the  urethra.  The  feces  sometimes 
formed  an  annoying  temporary  obstruction  to  the  passage  of 
the  urine  through  the  penis.  The  bladder  was  irritable,  re- 
quiring the  urine  to  be  passed  off  more  frequently  than 
natural.  The  rectum  was  also  irritable,  but  less  so  than  is 
usual  in  urinary  fistula  opening  into  it.  I  had  no  oppor- 
tunity of  examining  the  case  until  I  was  called  upon  to 
operate.  When  the  parts  were  brought  into  view  by  placing 
my  self-retaining  speculum  in  the  rectum,  two  oval  openings 
were  seen  about  an  inch  apart,  one  leading  into  the  bladder 
and  the  other  to  the  urethra. 


"  Fio.  149.— Rectourethral  ti^stula  iu  a  man  (from  the  rectum)." 

"  Between  these  openings  a  narrow  strip  of  urethral  mucous 
membrane  could  be  traced,  which  represented  all  that  re- 
mained of  the  membranous  portion  of  the  urethra.  The  ap- 
pearance was  as  if  a  section  had  been  removed  by  a  sharp 
knife,  so  as  to  leave  a  small,  i  arrow  portion  in  the  center.  The 
facility  with  which  I  succeeded  in  closing  this  opening,  by 
supply irg  the  loss  from  rectal  tissue,  led  me  subsequently  to 
employ  the  same  method  for  closing  certain  cases  of  recto- 
vaginal fistula.  The  rectum  in  this  neighborhood  forms  a 
double  concave  surface,  due  to  its  direction,  its  long  diam- 
eter, and  its  cylindrical  shape. 

"On  a  correct  appreciation  of  this  fact  rested  the  success  of 
this  operation.  I  soon  ascertained,  by  experimenting  with 
the  tenaculum,  that,  if  I  should  denude  a  portion  of  rectal 
surface  of  a  uniform  width,  in  two  parallel  lines,  from  one 
opening  to  the  other,  I  should  not  be  successful  in  forming  a 
urethral  canal.  This,  doubtless,  was  the  mobt  obvious  mode 
of  procedure,  and  yet  it  was  evident  that,  if  these  freshened 
surfaces  were  turned  over  and  brought  in  contact,  there 
would  result  a  narrowing  in  the  center  in  the  shape  of  an 
hour-gla^s  contraction.  In  order,  therefore,  to  reconstruct 
the  membranous  portion  of  the  urethra  in  this  case,  it  was 


'"Case  of  Rectourethral  Fistula,' 
September,  1870. 


by  J.  C.  Nott,  M.D.,  N.  V.  Med.  Jour., 


necessary  to  remove  the  mucous  membrane  from  the  rectal 
surface  in  the  form  of  an  elliptical  space,  as  shown  in  dia- 
gram Fig.  149.  Four  of  the  sutures  are  there  represented 
lo  have  been  introduced,  for  the  purpose  of  showing  that 
when  these  were  tied  the  denuded  spaces  A  B,  Fig.  149, 
would  form  a  canal  of  uniform  width,  and  the  line  of  union 
would  lie  in  the  direction  C  D  in  the  long  axis." 

It  will  be  noted  by  observation  of  the  accompanying 
sketch,  reproduced  for  me  by  my  son.  Dr.  Horace  J.  Gibbons, 
from  the  original  cut  in  Dr.  Emmet's  work,  marked  "  Fig. 
149,"  and  by  studying  the  above  quotation  from  the  same 
work,  that  his  attempt  to  repair  the  loss  due  to  destruction 
was  not  made  through  any  haphazard  method,  but,  like  all 
the  work  of  this  distinguished  surgeon,  it  was  planned  from 
an  anatomical  viewpoint,  every  consideration  being  given  to 
the  physiolf  gical  necessities  dependent  upon  the  patholog- 
ical conditions ;  hence  this  operation  was  not  done  merely 
to  close  the  fistulous  opening,  but  in  addition  thereto  to 
restore  the  membranous  portion  of  the  urethra,  this  being 
done  with  tissues  that  are  ideal  when  histologically  con- 
sidered. 

Emmet  was  the  first  man  in  all  the  world  to  teach  the 
possibilities  of  dire  disaster  being  brought  about  by  granula- 
tion repair,  the  resultant  scar-tissue  often,  by  its  cicatricial 
contraction,  impinging  upon  the  filaments  of  the  sympathetic 
system  of  nerves,  producing  thereby  reflexly  a  most  expres- 
sive word-torment  in  more  or  less  distant  portions  of  the 
nervous  system,  even  to  the  extent  of  upsetting  the  mind. 

Then,  too,  if  this  operation  was  not  properly  planned,  as 
was  done  by  Dr.  Emmet,  the  "  hour  glass  "  contraction  of 
which  he  speaks  would  have  produced  more  or  less  obstruc- 
tion of  the  urethral  canal  stricture.  This  would  have  hap- 
pened in  Dr.  Horwitz's  case  had  the  suggestion,  made  by 
Professor  Keen,  the  use  of  the  thermocautery,  succeeded 
in  healing  the  fistula,  which  would  have  been  by  granulation. 

It  must  be  borne  in  mind,  too,  that  Emmst  uses  almost 
exclusively  the  silver-wire  suture,  which  is  preferable  to  any 
other  in  plastic  surgery,  where  we  are  most  anxious  to  have 
union  primarily,  as  in  the  work  upon  the  genital  and  urinary 
organs. 

Primary  union,  too,  is  more  likely  to  be  attained  where  the 
delicate  tissues  of  fistulae  in  general  are  handled  by  the  ten- 
aculum, as  is  so  deftly  done  by  Dr.  Emmet,  instead  of  ninch- 
ing  them  by  means  of  hemostatic  or  other  forms  of  tissue- 
holding  instruments. 

The  wire  suture  can  be  quickly,  easily,  and  painlessly 
removed,  merely  using  Emmet's  size  of  Sims'  speculum 
through  the  anus,  the  patient  being  in  Sims'  position,  or  in 
the  Emmet- Bosman-Ao  new  Otis  method,  the  knee-chest 
method  of  posture  for  examining  or  otherwise  dealing  with 
the  rectal  pouch. 

If  patients  are  properly  prepared  as  has  long  since  been 
taught  and  practised  by  Dr.  Eaimet,  Rud  if  they  are  kept  on 
the  right  sort  of  food,  there  is  no  necessity  for  giving  opium, 
neither  is  there  any  necessity  for  the  use  of  any  form  of  clap- 
trap contrivances. 


Cutaneous  Affections  Caused  by  the  Oxyuris  Ver- 
micularis. — Barbagallo  (Qazz.  degli  ospedali  e  detle  din.,  1900, 
No.  Ill)  calls  attention  to  a  caseof  inflammation  of  the  skin  of 
the  thigh  and  around  the  anus,  caused  by  the  oxyuris  ver- 
micularis.  The  erosion  of  the  sliin,  caused  by  scratch- 
ing-, offers  a  suitable  soil  for  the  parasites  and  their  ova. 
The  diagnosis  is  established  by  microscopic  examination  and 
the  efficiency  of  anthelminthic  treatment.  According  to  the 
author,  his  case  is  the  fourth  reported,    [m  k.d.J 


^ 


140 


Thk  Philadelphia"] 
Medical  Joobsal  J 


AMERICAN  NEWS  AND  NOTES 


(Jasuaey  26,  l<m 


21mertcan  Hetos  anb  Hotes. 


PHILADELPHIA,  PENNSYLVAJfIA,  ETC. 

Scarlet  fever  is  prevailing  in  New  Jersey,  the  school- 
houses  of  Vmeland,  Cape  May  county  and  Swainton  have 
been  closed  and  the  church  servi.es  suspended. 

Bacteriologist  Appointed.— William  R.  Copeland,  of 
Pittsbur?,  was  appointed  to  succeed  bacteriologist  Toplis,  of 
the  city's  filtration  force,  whose  resignation  is  announced. 

Influenza  in  Allentown . — Several  schools  in  Allentown 
have  been  closed  on  account  of  influenza,  and  the  business 
of  the  city  is  hampered  in  general  on  account  of  the  disease. 

Appointments. — Dr.  Oliver  J  Bennett,  Allegheny,  Penn- 
sylvania, has  been  appointed  physician  to  the  Western  Peni- 
tentiary of  Pennsylvania.  Dr.  Charles  B.  Smith  has  been 
appointed  surgeon  of  the  Lickawanna  railroad  at  Washing- 
ton. 

Deadlock  Ended  at  Norristown. — The  deadlock  of 
the  trustees  of  the  State  Hospital  for  the  Insane  over  the 
election  of  a  resident  physician  for  the  female  department 
was  ended  on  January  18  when  Dr.  Alice  Bennett  withdrew 
her  name  as  a  candidate  and  Dr.  Mary  Moore  Wolfe  wae 
elected. 

The    Practitioners'   Society  of  Orange,  N.   J. — 

At  the  first  annual  meeting  of  this  society,  held  on  January 
5,  officers  were  elected  as  follows :  President,  Dr.  Edgar 
Calvin  Seibert ;  vice-president,  Dr.  J.  Minor  Maghee  ;  secre- 
tary and  treasurer.  Dr.  Stephen  G.  Lee ;  executive  com- 
mittee, Drs.  M.  Herbert  Simmons,  Walter  Dodge,  and  Frank 
B.  Lane.  Dr.  Edward  J.  Ill,  of  Newark,  and  Dr.  Thomas 
W.  Harvey,  of  Orange,  w6re  elected  honorary  members. 

Philadelphia  Medical  Club.— At  the  annual  meeting 
held  January  11,  the  following  officers  were  elected  for  the 
ensuing  year :  President,  Dr.  E.  L.  Duer ;  vice-presidents. 
Dr.  John  B  Deaver,  Dr.  Philip  Marvel,  of  Atlantic  City; 
secretary.  Dr.  Guy  Hinsdale;  treasurer,  Dr.  F.  S.  Pearce; 
member  of  the  board  of  governors.  Dr.  James  M.  Anders; 
executive  committee.  Dr.  T.  C.  Fulton,  Dr.  James  Van  Bus- 
kirk,  Dr.  L.  Webster  Fox,  Dr.  Ernest  Laplace,  and  Dr.  G.  G. 
Davis. 

College  of  Physicians. — The  report  of  the  Library 
Committee  of  the  College  of  Physicians  of  Philadelphia 
shows  that  on  November  1, 1900,  the  library  contained  61,359 
volumes;  and  in  addition  the  following:  Duplicates,  4,140 
volumes  ;  unbound  reports  and  transactions,  6,416 ;  unbound 
pamphlets,  40,114.  During  the  year  4,158  volumes  were 
added  ;  10,442  books  and  journals  were  issued  to  readers  in 
the  library,  and  2,411  books  and  journals  were  issued  to 
Fellows  of  the  College.  There  were  registered  4,581  visitors 
during  the  year. 

Philadelphia  Neurological  Society.  —  The  stated 
meeting  to  be  held  on  January  28,  at  8.15,  in  the  lower  hall  of 
the  College  of  Physicians  will  be  devoted  to  a  Symposium  on 
Brain  Tumor. 

The  following  papers  are  to  be  presented : 

"  Paresis,  with  Symptoms  of  Brain-Tumor,"  by  Dr.  Wharton 
Sinkler. 

"  A  Case  of  Brain-Tumor,  with  Hemiplegia.  Homonymous  Hemi- 
anopsia and  Wernicke's  Symptom.''  by  Dr.  F.  X.  Dercnm. 

"  A  Case  of  Extensive  Endothelioma  of  the  Brain,"  by  Dr.  John 
K.  MitcheU. 

"  A  Case  of  Tumor  on  the  Pons,  Medulla  Oblongata,  and  Upper 
Part  of  the  Cervical  Cord,  "  by  Dr.  W.  G.  Spiller. 

"The  Localization  of  Brain-Tumors,  Especially  with  Reference 
to  the  Parietal  and  Prefrontal  Regions,  Based  on  Five  Cases  in 
which  the  Sites  of  the  Tumors  were  Located  for  the  Purpose  of 
Operation,''  by  Dr.  Charles  K.  Mills. 

A  Case  of   Unilateral  Oculomotor  Palsy  Probably  Due  to  a 
Gumma,"  by  Dr.  D.  Riesman. 

"A  Case  of  Subcortical  Brain-Tumor,"  by  Drs.  Charles  K.  Mills 
and  Howard  D.  Geisler. 

The  disouEsion  will  be  opened  by  Dr.  G.  E.  deSchweinitz 


and  Dr.  William  J.  Taylor.  Members  of  the  medical  profes- 
sion are  cordially  invited  to  attend  the  meeting. 

"Vital  Statistics  of  Philadelphia  for  the  week  ended 
January  19,  1901 : 

Total  mortaUty 477 

Cases.      Deaths.     ■ 

Inflammation  of  appendix  4.  bladder  1,  brain  I 

13,   bronchi  12,  kidneys  22,  lungs   77,  peri-  ^m 

toneum  7.  pleura  2.  stomach  and  bowels  13,  ^H 

spine  2,  of  laryni  2,  of  liver  1,  heart  3  .   .   .  161      ^H 

Inanition  12,  marasmus  8,  debility  10 30      ^H 

Tuberculosis  of  lungs 51      ^H 

Apoplexy  19,  paralysis  5 24      ^| 

Heart — fatly  degeneration  of  4,  dropsy  of  31  .  35 

Uremia  14,  diabetes  3,  Bright's  disease  4  .   .   .  21 

Casualties 11 

Carcinoma  of  breast  1,  stomach  7,  uterus  2, 

jaw  1,  rectum  1,  liver  4 16 

Convulsions 7  m 

Diphtheria 118  17  ■ 

Brain — softening  of  1,  congestion  of  2  ....  3         ■ 

Typhoid  fever 51  12 

Old  age 14 

Burns  and  scalds 1 

Dysentery 1 

Suicide 2 

Cirrhosis  of  liver 4 

Alcoholism 3 

Cyanosis 1 

Scarlet  fever 70  2 

Hernia 1 

Asthma  1,  congestion  of  the  lungs  2,  croup  1, 
membranous  croup  4,  diarrhea  2,  dropsy  of 
the  liver  2,  dropsy  2,  drowned  I,  epilepsy  1, 
erysipelas  3.  gangrene  4,  hemorrhage  from 
kidneys  1,  from  stomach  1,  uterus  1.  in- 
fluenza 8,  consumption  of  bowels  1,  intes- 
tinal obstruction  4,  edema  of  lungs  2.  poi- 
soning 1,  pyemia  1,  rheumatism  2.  sarcoma 

1,  surgical  shock  1,  septicemia  4,  suffocation 

2,  teething  2.  tetanus  1,  ovarian  tumor  1, 
whooping  cough  2 2 

College  of  Physicians  ;  Section  on  Otology. — At 

the  meeting  of  January  16,  Dr.  Gleajox  exhibited  a  case  of 
Unusual  fracture  of  the  nasal  bones.  A  copper 
rivet  was  forced,  by  the  breaking  of  a  belt,  through  both  nasal 
bones  lodging  just  under  the  skin  of  the  opposite  side.  A 
discussion  on  Mastoid  operations  was  opened  by  Dr. 
Stoct  and  participated  in  by  Dbs  Gleasox  and  R-ikdaix. 

Section  on  Gynecology. — At  the  stated  meeting,  held 
January  17,  Dr.  Charles  P.  Noble  reported  a  case  of 
Cancer  of  the  cervix  and  pelvis  foUowiog  supra- 
vaginal hysterectomy.  Dr.  Noble  reported  this  case 
rather  as  a  refutation  of  the  claim  that  cancer  of  the  stump 
is  apt  to  follow  supravaginal  hvsterectcmy  instead  of  a 
proof  of  that  claim.  He  has  performed  that  operation  175 
times  in  cases  of  fibroids  and  a  larger  number  of  times  for 
other  conditions,  this  being  the  only  case  in  which  malignant 
disease  followed.  From  the  after-condition  of  the  case  there 
wae  reason  to  believe  that  unrecognized  cancer  existed  at 
the  time  of  the  hysterectomy.  Dr.  George  Erety  Shoe- 
maker reported  2  cases :  A.  Ovarian  cyst  followed 
by  suppurating  hematocele.  B  Salpingitis  with 
obscure  localizing  symptoms.  In  the  latter  case  the 
pain  was  principally  in  the  gallbladder  and  epigastric  regions. 
At  first  there  was  tenderness  above  Puupart's  ligament  and 
in  the  region  of  the  appendix,  but  later  the  point  of  greatest 
tenderness  varied  from  the  epigastrium  to  McBurney's  point. 
The  diagnosis  of  salpingitis  was  made  by  vaginal  examina- 
tion under  ether.  Operation  showed  the  tip  of  the  appendix 
adherent  to  the  right  ovary,  but  the  appendix  appeared 
normal  and  was  not  removed. 

Dr.  E.  E.  Mostoomeky  read  a  paper  on  The  treatment 
of  prolapsus  uteri.  Kepair  of  the  pelvic  floor  suffices, 
in  some  cases,  with  perhaps  rejection  cf  the  anterior  vaginal 
wall.  Greatt  r  degrees  require  ventral  suspension  in  addition 
with,  perhaps,  snortening  of  the  uterosacral  ligament*. 
When  there  is  a  hernia  in  addition  U>  the  prolapse,  Douglas's 
culdesac  should  be  obliterated  by  uniting  the  peritonetun 
of  either  side.  When  the  degree  of  prolapse  is  too  great  for 
these  expedients  hysterectomy  is  to  be  performed.  The 
uterus  should  be  brought  out  through  the  anterior  vaginal 
fornix,  the  angiotribe  being  applied  to  each  broad  ligament 
and  a  ligature  of  chromicized  CAtgut  placed  in  the  groove 
thus  formed. 


JaNDaby  26,  1901] 


AMERICAN  NEWS  AND  NOTES 


Tm 


HE    PMILADELPUIA 

EDicAL  Journal 


141 


NEW  YORK. 

Mt.  Sinai  Hospital.— Dr.  Hiram  N.  Vineberg  has  been 
appointed  adjunct  attending  gynecologist  to  the  hospital. 

Bellevue  Hospital. — A  pavilion  has  been  opened  at 
Bellevue  Hospital,  New  York  City,  for  the  reception  of  tu- 
berculous patients. 

Dr.  Moore  Reinstated. — The  official  reinstatement  of 
Dr.  J.  W.  Moore,  of  Bellevue  Hospital  took  place  on  January 
)7,  in  the  medical  wards,  by  order  of  the  Commissioner. 

Dr.  Elipbalet  Nott,  a  well-known  physician,  died  at 
his  home  in  Rexford's  Flats,  Saratoga  County,  Jmuary  22, 
aged  67  years.  He  was  a  nephew  of  the  Rev.  Dr.  Nott,  for 
many  years  president  of  Union  College. 

By  tlie  will  of  James  D.  Sarven,  of  Tarrytown,  the  resid- 
uary portion  of  his  estate,  which  amounts  to  $226,563,  is  to 
be  equally  divided  between  St.  Lukt's  and  the  Presbyterian 
Hospitals  and  the  Bible  and  Tract  Societies,  of  New  York 
City,  making  the  share  of  each  $59,140.91. 

The  BulFalo  Academy  of  Medicine— Section  of 
Obstetrics. — The  regular  meeting  of  this  section  was  held 
Tuesday,  January  22,  1901,  at  8.30  p.m.  The  following  papers 
were  presented :  "  Symphysiotomy,"  by  Dr.  P.  W.  Van 
Peyma.  "  The  Kidneys  and  Their  Relation  to  Operations," 
by  Dr.  Stephen  Y.  Howell. 

New  York  Orthopedic  Dispensary  and  Hospital. 

— The  trustees  of  the  New  York  Orthopedic  Dispensary  and 
Hospital  announce  that  the  surgeon-in-chief.  Dr.  Russell  A. 
Hibbs,  will  give  a  course  of  clinical  lectures  on  Orthopedic 
Surgery  at  the  institution,  on  Monday  and  Thursday  after- 
noons, at  5  o'clock,  from  January  28  to  February  28  (both 
inclusive).  The  course  will  be  free  to  the  medical  profession 
and  students. 

Photographs  of  Surgery.— Experiments  lately  made 
by  E.  H.  Fairchild  in  the  operating  rooms  of  the  Albany 
Hospital  have  proved  that  it  is  possible  to  procure  a  series  of 
photographs  of  a  surgical  operation  and  thus  to  provide  lantern 
slides  as  a  basis  for  surgical  instruction.  Operations  by  Drs. 
Albert  Vanderver  and  Willis  G.  MacDonald  have  been  puccess- 
fully  photographed  in  series,  each  stage  in  the  operation 
being  represented  by  a  photograph  taken  inftantaneously, 
and  without  in  any  way  interfering  with  the  operation. 
Students  of  surgery  find  it  difficult  to  secure  satisfactory  in- 
struction, because  during  the  operations  the  surgeons  are 
too  much  absorbed  to  lecture,  and  afterward  the  opportunity 
is  gene.  By  means  of  a  special  camera  a  series  of  photo- 
graphs can  be  taken,  showing  all  that  any  student  can  see,  and 
with  these  as  a  basis,  the  surgeon  can  give  an  illustrated  lec- 
ture describing  the  operation  in  detail. 

New  York  Academy  of  Medicine— Section    on 

Orthopedic    Surgery,   meeting  of   December  21,  1900. 

Keposition  of  the  Congenitally  Dislocated  Hip. — 

Dr.  Ely,  in  a  recent  visit  to  Vienna,  had  spent  some  time  in 
observing  the  practice  of  Lorerz,  who  was  receiving  cases  of 
congenital  dislocation  of  the  hip  from  all  parts  of  Europe. 
The  cutting  of  tendons  and  instrumental  traction  were 
rarely  seen.  When  the  head  of  the  bone  bad  oeen  replaced 
with  suitable  force  and  manipulation,  the  reduction  was 
maintained  by  a  most  elaborately  applied  plaster-of-paria 
spica,  which  did  not  include  the  trunk,  and  extended  only  to 
the  knee.  The  patient  was  then  sent  home  to  stay  several 
months.  The  results  were  good,  and  sometimes  so  brilliant 
as  to  justify  the  enthutiasm  of  the  operator,  who  believed 
that  when  a  knowledge  of  the  operation  was  widely  spread 
reduction  would  be  made  at  such  an  early  age  as  to  almost 
preclude  the  possibility  of  a  failure.  The  remarkable  statis- 
tics of  successes  which  had  been  published  had  their  origin 
partly  in  enthusiasm,  and  partly  in  the  undoubted  excellence 
of  a  method  applied  with  requisite  technic. 

Dr.  H.  L.  Taylor  reported  that  the  experience  of  Calot  in 
his  hospitals  at  Berck,  on  the  channel  coast  of  France,  had 
showed  that  the  bloodless  reduction  of  congenital  disloca- 
tion of  the  hip  was  applicable  in  children  up  to  8  years  of 
age,  or  later  in  exceptional  cases.  Active  treatment  covered 
from  6  to  22  weeks  and  included  2  or  3  weeks'  traction  with 


a  weight  of  from  10  to  20  pounds,  and  at  the  operation  the 
application  of  a  force  of  300  pounds  for  10  minutes  to  bring 
the  head  of  the  bone  down  to  or  below  the  acetabulum.  When 
the  retaining  apparatus  was  removed,  massage  and  training 
in  walking  completed  the  treatment.  Patients  had  recovered 
without  the  trace  of  a  limp.  He  had  practically  given  up 
the  open  method.  The  correct  attitude  obtained  by  cutting 
would  be  at  the  expense  of  limitation  of  motion  or  ankylo- 
sis, which  might  be  properly  sought  by  this  method  in  cer- 
tain cases  in  which  replacement  was  impossible. 

Dr.  R.  H.  Sayre  had  seen  Lorenz  operate  last  year  in  Paris 
at  the  Redard  clinic.  The  patient,  a  child  of  about  8  yeirs 
of  age,  was  moderately  disabled  by  a  single  dislocation  of  the 
hip.  The  thigh  was  made  to  form  an  angle  of  perhaps  20 
degrees  posterior  to  the  plane  of  the  body.  A  great  deal  of 
force  was  employed  for  tbis  and  in  turning  the  limb  in  vari- 
ous directions.  The  head  of  the  femur  could  be  heard  as  it 
popped  around  on  the  ilium  in  what  must  have  been  a  mass 
of  lacerated  tissues.  The  spica,  which  was  nearly  2  inches 
thick  where  the  strain  came,  included  two  loose  strings  for 
subsequent  use  in  scratching  the  skin  and  keeping  it  clean. 
The  head  did  not  assume  a  permanent  residence  in  the  ace- 
tabulum. It  was  said  that  it  would  do  so  after  the  child  bad 
walked  about  for  a  year  or  two  in  the  spica,  a  question  which 
would  have  to  be  answered  in  due  time. 

Dk.  C.  H.  Jaeger  had  recently  spent  6  weeks  at  Vienna  and 
reported  that  the  treatment  of  congenital  dislocation  at  the 
Lorenz  clinic  was  exLlusively  by  the  bloodless  method.  Dou- 
ble cases  were  treated  singly.  The  results  were  very  favor- 
able. The  spica  was  applied  with  great  care.  Only  a  thin 
layer  of  cotton  padding  was  used.  The  plaster  bandage  was 
applied  very  snugly,  the  thigh  only  being  enclosed  and  a 
narrow  strip  going»about  the  pelvis.  This  left  the  knee  and 
ankle  free  and  also  the  whole  spinal  column.  The  limb  be- 
ing thus  fixed  in  extension  and  abduction,  the  patient  soon 
learned  to  walk  without  crutches  and  with  (in  single  cases)  a 
high  sole  on  the  sick  foot.  It  was  most  interesting  to  see  a 
child  with  double  dislocation,  with  both  legs  strongly  ab- 
ducted, spread-eagle  fashion,  walking  beautifully,  hopping 
with  one  leg,  then  the  other,  without  a  stick  or  help  of  any 
kind.  Lorenz  was  accustomed  to  lay  great  weight  on  having 
the  parents  of  the  patients  extend  the  knee  many  times  daily, 
to  prevent  contracture.  In  opposition  to  these  views  Hoffa 
strongly  advocated  the  open  method. 

Db.  R  W.  Town3END  said  that  Hoffa  had  stated  in  very 
positive  terms  that  none  other  than  the  bloody  operation 
could  be  of  any  use.  An  American  authority  also  had  re- 
ported that  in  a  large  number  of  open  operations  only  2  or 
3  had  exposed  an  acetabulum  in  which  it  was  possible  to 
place  the  head.  The  views  and  practice  of  Lorenz,  however, 
were  those  of  one  whose  experience  with  the  open  operation 
had  been  greater  than  that  of  all  other  operators  combined. 
In  one  of  the  dissections  reported  by  Dr.  E.  H.  Bradford  the 
capsule  had  been  found  pushed  in  front  of  the  head  of  the 
bone  in  such  a  manner  that  perfect  reduction  could  not  be 
made.  This  had  led  to  the  suggestion  that  in  some  cases  the 
open  operation  might  be  modified  by  slitting  the  capsule 
instead  of  gouging  or  boring  the  bone  which  might  lead  to 
ankylosis  or  limited  motion. 

Dr.  Jaeger  thought  that  Hoffa  was  dissatisfied  with  the 
bloodless  procedure  partly  because  of  the  position  in  which 
he  fixed  the  limb  after  reduction  of  the  deformity.  He  ap- 
plied the  spica  with  the  limb  in  extension  and  strong  inward 
rotation,  which  could  not  afford  a  very  firm  hold  for  the  fem- 
oral head  in  the  acetabulum.  In  this  position  it  was  prob- 
able that  the  reluxation  would  occur  during  the  ap{)lication 
of  the  bandage  or  on  the  first  attempt  at  walking. 

Dr.  T.  H.  Myers  said  that  those  American  surgeons  who, 
after  trying  both  methods,  favored  the  opening  of  the  jr>int 
in  every  case,  were  at  variance  with  Lorenz.  In  his  own  ex- 
perience, which  had  been  considerable,  he  had  not  yet 
opened  a  joint,  believing  that  the  bloodless  method  should  be 
tried  first.  It  secured  some  perfect  results,  and  in  the  results 
which  were  not  perfect  the  head  was  placed  anterior  to  or 
above. the  acetabulum,  which  was  bet:er  than  to  leave  it  on 
the  dorsum. 

Dr.  G.  R.  Elliott  had  passed  several  weeks  with  Lorenz 
in  1896  and  had  seen  him  operate  many  times  by  the  non- 
cutting  method,  having  already  begun  to  discredit  the  cut- 
ting operation,  which  he  had  done  so  much  to  perfect.  There 
could  be  no  possible  doubt  of  the  good  results  obtained.    He 


142 


Thb  Philadelphia"! 
Medical  Jodr2;al  J 


AMERICAN  NEWS  AND  NOTES 


[Javuabt  16,  ItM 


had  seen  manj'  inftances  and  had  repeated  them  in  his  own 
practice.  Surcess  lay  in  the  thoroughness  of  the  procedure 
and  in  the  perftction  of  the  technic.  1.  The  head  of  the 
bone  should  be  brought  down  to  the  level  of  the  acetabulum. 
2.  It  should  be  lifted  over  the  posterior  edge  of  the  aceta- 
bulum. 3.  Abduction  should  be  extreme,  even  posterior  to 
the  mid  plane  of  the  body.  4.  The  plaster  bandage  should 
be  pressed  posteriorly  against  the  joint  to  keep  the  reduced 
head  from  slipping  backward.  Great  force  was  often  required, 
but  neglect  of  any  point  would  leave  the  head  cf  the  femur 
resting  on  the  posterior  acetabular  edge  to  be  dislocated  as 
soon  as  the  bandage  was  removed.  Lack  cf  success  would 
be  due  to  want  of  technic  leading  to  imperfect  reduction. 
Thorough  padding  was  necessary  beneath  the  bandage. 
Blood  had  appeared  in  the  urine  of  a  patient  operated  on  by 
him  last  week.  The  child  had  been  laid  face  downward  to 
facilitate  fortifying  the  splint  posteriorly,  and  the  soft  plaster 
bandage  had  pressed  against  the  abdomen  and  hardened. 
Cutting  bandage  relieved  pressure,  and  blood  disappeared. 

Sea- Air  for  Tubercular  and  Rickety  Patients. — 
Dr  Tayloe  in  his  review  of  the  treatment  ai  Berck  said  that 
Calot  was  an  enthusiastic  advocate  of  sea-air  for  patients 
affected  with  external  or  peripheral  tubercular  lesions,  those 
of  the  skin,  glands,  bones  and  joints.  He  rejected  phos- 
phorus in  the  treatment  of  rickets,  prescribing  intestinal 
antiseptics  and  a  diet  mainly  of  milk  and  eggs.  Many  of 
his  patients  were  kept  recumbent.  He  affirmed  that  rickety 
deformities  would  disappear  during  a  S(  journ  at  the  seaside. 

De.  Sayke  had  listened  to  Calot  as  he  described  the  ad- 
vantages of  feaside  treatment.  His  interest  in  the  subject 
was  shared  by  others  of  his  countrymen,  whose  native  en- 
thusiasm perhaps  lent  a  too  rose-colored  light  to  their  views. 

Dr.  Tayloe  had  been  impressed  with  the  picturesque 
quality  cf  Calot's  writings.  His  zeal  often  broke  through 
the  conventional  boundaries  of  scientifiL^  composition.  The 
reader  was  entertained  and  delighted,  but  not  necessarily 
convinced. 

Treatment  of  Pott's  Disease.— Dr.  Ely-  said  that 
Lorenz  used  a  corset  composed  of  perforated  strips  of  cellu- 
loid, metal  hand.-*  and  canvas.  It  laced  in  front  and  was 
probably  sufficiently  comfortable,  but  could  not  be  said  to 
"splint  the  spine." 

Dr.  Taylor  said  that  although  Calot  declared  that  neither 
braces,  plaster  jackets,  nor  corsets  could  prevent  or  arrett 
the  deformity,  all  of  his  patients  wore  the  plaster  jacket 
after  subjection  to  manual  pressure  directed  against  the 
kyphos.  In  certain  cases  ablation  of  spinous  processes 
■without  invasion  of  the  tubercular  territory  was  recom- 
mended in  order  to  facilitate  correction  and  avoid  sores  from 
pressure  of  the  jacket.  The  use  of  suspension,  the  amount 
of  manual  pretsure  and  the  degree  of  lordosis  to  be  en- 
forced were  points  to  be  settled  for  each  case.  Severe  pres- 
sure and  all  trauma! isms  were  to  he  carefully  avoided,  in 
marked  contrast  with  the  violent  proceedings  which  called 
attention  to  the  name  of  Calot  in  1896,  when  he  was  claim- 
ing uniformly  brilliant  results  from  the  outlay  of  all  his 
strength  on  the  kyphos  supplemented  with  cuneiform  resec- 
tions in  obstinate  cases. 

Dti.  Sayee  said  that  Calot's  recent  methods  as  he  had 
heard  him  describe  them  v.iried  but  little  from  those  of  Dr. 
L  A.  Soyrewhen  he  introduced  suspension  and  plaster-of- 
paris  jackets.  CUot  had,  however,  secured  a  distinct  ad- 
vantage in  extending  the  jacket  up  to  the  chin  instead  of 
stopping  at  the  top  of  the  sternum,  thus  promoting  lordosis 
even  of  the  lumbar  spine  and  gaining  a  leverage  over  the 
entire  spine,  which  was  impossible  when  the  upper  part  of 
the  vertebral  column  was  free. 

Treatment  of  Joint- Diseases.— Dr.  Ely  said  that  at 
the  Lorenz  clinic  joint  diseases  generally  were  treated  by 
relei'tiou  in  plaster  cf  Paris.  The  spica  for  hip-disease  usu- 
ally had  an  iron  stirrup  running  down  from  the  bottom  to 
take  up  the  weight  of  the  body. 

Dr  Jakger  said  that  Lorenz  taught  that  traction  per  se 
did  no  good  in  hip  disease  except  as  it  caused  fixation  and 
that  fixation  alone  was  necessary,  as  the  inflamed  j  lint  could 
well  bear  the  weight  of  the  body  so  long  as  there  was  no 
rubbins  of  the  joint  surfaces. 

Dr  Taylor  said  that  Calot  very  justly  believed  that  a  stifi 
j-^int  in  a  good  position  was  better  than  a  movable  jiint  in  a 
bud  position.  It  was  his  practice  to  reduce  the  deformity 
by  fo  ce  and  retain  the  improvement  with  a  plaster  spica 


Complete  ankylosis  in  a  bad  position  required  subcutaneooB 
osteotomy  of  the  femoral  neck. 

Treatment  of  Abscesses.— Dr.  Jaegee  had  noticed 
fewer  abscesses  in  patients  affected  with  hip- disease  at 
Vienna  than  in  patients  of  the  same  kind  in  America,  which 
was  not  easy  to  explain  except  by  climatic  diflferences,  as  the 
poor  there  were  poorer,  and  their  nourishment  probably 
worse,  than  in  this  country. 

Db.  Tay'lor  said  that  Calot  forbade  incision,  cnrettiBg  and 
excision  in  Pott's  and  hip-disease  unless  the  joint  or  abscess 
was  infected  or  a  sequestrum  was  found.  He  took  the  ground 
that  patients  affected  with  these  diseases  practically  always 
got  well  under  closed  treatment  and  always  died  under  the 
open  treatment.  Abscesses  were  to  be  treated  by  roborant 
drugs,  a  full  diet,  correct  hygiene  and  rest.  A  cold  abeceae 
might  be  aspirated  through  healthy  tissue  and  medicated  by 
injections.  By  repeated  aspirations  and  the  application  of 
compresses  and  bandages  openings  which  seemed  inevitable 
might  be  averted  and  in  from  4  to  8  weeks  the  abscess  would 
disappear  without  a  scar  and  with  healing  of  the  bone  in 
most  ca«e8.  It  was  interesting  to  note  that  we  had  (1)  in 
Calot  a  surgeon  of  10  years'  active  experience,  formerly  an 
advocate  of  scraping,  incisions  and  excisions,  with  the  repu- 
tation of  having  done  80  excisions  of  the  hip,  who  was  now 
aggressively  opposed  to  the  operative  treatmect  of  diseases 
of  the  joints,  and  (2)  in  Lorenz  a  surgeon  of  great  experience 
in  the  cutting  treatment  of  congenital  dislocation  of  the  hip 
who  had  given  it  up  in  favir  of  a  bloodless  method.  Ttie 
coincidence  and  the  contrast  batween  the  recent  past  and  the 
present  were  quite  impressive. 

Lateral  Curvature  from  Division  of  the  Spinal 
Accessory  Xerve. — Dr.  R  A.  Hibbs  related  a  case  as  fal- 
lows: A  girl  14  years  old  had  had  g'ands  removed  from  the 
left  side  of  the  neck  6  months  before  she  was  first  seen  a  few 
days  ago.  There  was  spinal  curvature  toward  the  right  with 
drooping  of  the  left  shoulder,  paralysis  and  atrophy  of  the 
trapezius  and  marked  disability  of  the  left  arm.  "The  patient 
declined  an  operation  for  uniting  the  ends  of  the  spinal  ac- 
cessory nerve,  which  had  evidently  been  severed  at  the  point 
where  it  pierced  the  sternocleidomastoid  muscle. 

Dr.  My'ees  recalled  the  rase  of  a  similar  patient,  15  years 
of  sge,  whom  he  had  been  observing  for  3  or  4  years.  He 
saw  her  18  months  after  the  paia'ysis,  and  considerable  per- 
manent atrophy  of  the  muscles  of  the  shoulder,  had  set  in. 
There  was  spinal  curvature  toward  the  opposite  side  which 
did  not  go  on  to  be  extreme  and  was  easily  controlled. 

Fracture  of  Cervical  Vertebrae. — Dr  Satee  related 
the  case  of  a  man  who  was  carried  home  unconscious  after  a 
fall  on  the  head  and  neck  about  2  months  ago.  Oa  retain- 
ing consciousness  there  was  paralysis  of  the  extremities, 
bladder  and  rectum,  in  which  there  w.*8  slow  improvement 
after  2  days.  As  every  attempt  to  wa'k  increased  his  symp- 
toms he  was  kept  in  bed  several  weeks.  A  diagnosis  of 
fracture  and  dislocation  of  the  fifth  and  sixth  cervic*!  verte- 
brae was  made  on  his  history,  the  fl -xion  of  the  head,  the 
absence  of  motion  of  the  head  and  neck,  difliculty  in  swal- 
lowing and  the  disability  of  the  left  upper  extremity.  The 
diagnosis  was  confirmed  by  skia?raphs.  of  which  it  had  been 
necessary  to  take  several  from  different  piinta  of  view.  Ojs 
of  the  negatives  was  taken  after  fastening  a  bandage  tightly 
over  one  shoulder  and  under  the  opposite  arm-pit  so  as  to 
make  a  gulch  in  which  one  edge  of  the  plate  had  been  forced 
so  f*r  as  it  would  go.  The  skiagraphs  and  a  brace  were 
exhibited.  The  latter  consisted  of  a  leather  and  steel  collar 
attached  to  posterior  steel  rods  and  a  pelvis  belt.  Toe  head 
and  neck  would  be  thus  fixed  until  consolidation  was  assured, 
the  brace  being  capable  of  easy  modifi.'atioa  from  time  to 
time  as  the  patient  improved.  He  recalled  an  almi^st  exact 
counterpart  in  a  case  which  occurred  several  years  ago  in 
which  the 'application  of  a  jacket  and  jury-mast  had  been 
followed  by  disappearance  of  the  paralvsig. 

Pneumatic  Perineal  Straps. — Dr.  Mykks  exhibited 
rubber  tubes,  10  inches  long  and  1}  inches  in  diameter,  de- 
signed to  take  the  place  of  the  ordinary  perineal  straps. 
Smaller  sizes  were  also  made.  Etch  tube  was  provided  with 
a  removable  cover  of  C.inton  fl  vnnel  and  a  valve  for  itfl  ition 
by  a  bicycle  pump.  The  straps  we-e  not  el.astic.  They  were 
expensive,  but  very  dur.able.  The  pressure  made  by  them 
was  equalized  automatically,  and  that  made  them  e^speciallf 
comfortable  for  older  children  and  adults  whose  weight  made 
perineal  support  difficult. 


JaKUARY  26,  19011 


AMERICAN  NEWS  AND  NOTES 


CTHE  PHILADELPHIi  I43 

Medical  Jocrnal 


NEW  ENGLAJfD. 

Harvard  University. — A  chair  of  hygiene  is  to  be  eetab- 
lished  at  Harvard,  $156,000  having  been  donated  for  this 
purpose. 

Smallpox  in  Manchester. — The  smallpox  situation 
here  is  no  longer  confined  to  one  dibtrict,  but  cases  are  scat- 
tered throughout  the  city.  E'even  cases  were  found  in  the 
Notre  Dime  Orphanage,  where  there  are  300  or  400  children. 

CHICAGO  AND   WESTERN  STATES. 

Attorney-General  Oreu  decided  that  townships  must 
erect  hospitals  for  contagious  diseases. 

Resigned. — Dr.  Louis  Bazet  has  resigned  as  a  member 
of  the  Board  of  Health  of  San  Francisco. 

Pest-House  at  Fargo. — A  pest-house  has  been  built  at 
Fargo  for  the  reception  of  smallpox  cases  occurring  in  that 
city. 

Sanitarium. — The  Governor  of  Illinois,  in  his  messnore, 
recommends  the  enactment  of  a  law  creating  the  establish- 
ment of  a  sanitarium  for  the  treatment  of  tuberculosis. 

Meeting  of  Medical  Society. — The  Witman  County 
Medical  Society,  of  Portland,  Oregon,  held  its  fourth  quarterly 
meeting  in  Portland,  on  January  16.  Papers  were  read  by 
Dr.  W.  W.  Watkins,  of  Moscow,  and  Dr.  R.  C.  Cofiey,  of 
Portland. 

State  Board  of  Pharmacy. — A  meeting  of  the  State 
Board  of  Pharmacy  was  held  in  Jefferson  City,  Missouri,  on 
January  14.  The  Board  is  composed  of  Dr.  A.  Brandenber- 
ger,  Jefferson  City ;  A.  T.  Ficishmann,  Sedalia,  and  W.  B. 
Kerns,  Bunceton. 

Dr.  Benjamin  Brown,  of  Chicago,  Illinois,  died  at  the 
Ebbilt  House  in  Chicago,  on  January  18.  Dr.  Brown  wa3  a 
well-known  physician  of  the  Western  metropolis.  He  had 
been  ill  for  2  years.  A  sudden  heait  attack,  after  a  2  weeks' 
racking  illness,  terminated  his  life.    He  was  66  years  of  age. 

Dr.  John  Kost,  a  physician  of  Adrian,  Michigan,  who 
has  several  times  made  liberal  donations  to  educational  in- 
ftitutions,  has  given  to  the  College  of  Medicine  and  Surgery 
of  Chicago  a  museum  of  zoological  specimens,  valued  at 
$150,000.  The  articles  filled  5  freight  cars  when  prepared  for 
shipment. 

Dr,  R.  Beverly  Cole,  Coroner,  of  San  Francisco,  Califor 
nia,  and  one  of  the  best  known  physicians  on  the  Pacific 
coast,  died  on  January  14,  in  his  seventieth  year.  He  was  a 
native  of  Virginia,  but  received  his  medical  education  in 
Pbiiadelphia.  His  specialty  was  gynecology,  and  for  30  years 
he  was  professor  of  that  subject  i  i  the  S^ate  University. 

Dr.  Charles  Wesley  Purdy  died  at  Chicago  of  a  com- 
plication of  dieeases.  He  was  born  in  Kingston,  Ontario,  in 
1846,  and  was  graduated  from  the  Q  leen's  University  with 
high  honors.  Dr.  Purdy  made  a  life  study  of  diseases  of  Ihe 
kidneys,  and  wrote  several  books  on  the  subject.  He  received 
several  degrees  from  the  Royal  College  of  Physicians  and 
Surgeons  of  Canada. 

Appointments.— Dr.  I.  Wright  Short  has  been  appointed 
surgi  on  of  the  Lake  Shore  and  Michigan  S  luthern  Railroad 
at  Elkhart,  Ind. — Dr.  Fred  W.  Powers,  Reinbeck,  Iowa,  has 
been  appointed  a  membtr  of  the  State  Board  of  Health  to 
succeed  Dr.  Joseph  H.  Scruggs  of  Keokuk. — Dr.  Victor  C. 
Vaughan,  of  Ann  Arbor,  has  been  appointed  a  member  of  the 
S:ate  Board  of  Health  of  Michigan. 

Osteopathists  Not  Physicians. — A  bill  to  legalize  and 
regulate  the  practice  of  osteopathy  in  Wisconsin  was  intro- 
du.'ed  in  the  State  Senate  on  January  17.  The  bill  does  not 
permit  its  exponents  to  pose  as  physicians,  and  it  is  stated 
that  the  bill  will  afford  no  relief  to  persons  charged  with 
practising  medicine  without  a  license.  The  bill  expressly 
aeclarrs  that  osteopathy  cannot  be  construed  to  be  the  prac- 
tice of  medicine  and  surgery  within  the  meaning  of  the 
Statutes  on  that  sui  ject. 


Bev.  Charles  E.  Conard,  M.D.,  died  at  Quincy,  III., 
aged  81.  He  was  born  in  Siberia,  and  educated  for  the 
church  and  medicine  at  Berlin;  went  to  British  India  in 
1848,  and,  as  the  missionary  who  could  heal,  was  sought 
after  by  thousands  of  the  natives.  He  efctablished  asylums 
for  lepers  and  epileptics  at  Lohordagga;  was  in  Calcutta  dur- 
ing the  Sepoy  outbreak,  and  in  1853  came  to  America. 

Dr.  Thomas  B.  W.  Leland,  was  appointed  Coroner  of 
the  city  and  county  of  Stin  Francisco,  to  succeed  the  late  Dr. 
R.  Beverly  Cole.  Dr.  Leland  holds  the  chair  of  assistant  pro- 
fessor of  physiology  in  the  medical  department  of  the  State 
University ;  he  holds  the  professorship  of  internal  medicine 
in  the  post-graduate  medical  department  of  the  State  Uni- 
versity and  is  also  assistant  surgeon  of  the  Slate  Naval 
Reserve. 

Hospital  for  Insane  Report. — The  board  of  trustees 
of  Milwaukee  Hospital  for  Insane  beld  their  annual  meeting 
on  January  14,  and  elected  the  following  officers  for  the  ensu- 
ing year:  President,  B.  B.  Hopkins;  vice-president,  A.  L. 
Cxry ;  secretary,  A.  F.  Wallschlaeger ;  exofficio  treasurer, 
the  county  treasurer,  Sohultz;  ex'^cutive  committee,  G  E. 
Gustav  Kuechle,  David  Vance,  J.  W.  P.  Lombard ;  visiting 
committee,  Christian  Wahl.  John  F.  Burnham,  Miss  Lillian 
Wall,  Mrs.  Anna  L.  Wall,  Dr.  Ernest  Copelf.nd. 

Dr.  William  Hoskins  Mullins,  son  of  the  late  Pro- 
fessor Samuel  G.  Mullins,  of  Kentuvky,  died  atRjseclare,  111., 
on  January  7.  Dr.  Mullins  was  educated  at  Center,  Columbia 
and  Yale  Colleges,  and  was  a  man  of  rare  gifts  and  attain- 
ments. During  the  civil  war  he  was  a  surgeon  in  the  Federal 
army  and  at  different  times  was  on  the  staffs  of  Generals 
Burnside  and  Thomas.  F.ir  10  years  he  was  a  great  sufferer, 
havicg  been  left  a  physical  wreck  from  an  attack  of  yellow 
fever  after  having  fought  three  epidemics  of  the  disease  in  the 
S  outh. 

For  a  Western  Medical  Organization. — A  Pacific 
medical  association  is  about  to  be  organized.  The  plan  is  to 
have  San  Francisco  the  center  of  a  Western  medical  field, 
embracing  Washington,  Oregon,  Idaho,  Montana,  Utah, 
Nevada,  Arizona,  California,  Alaska,  British  Columbia,  the 
Hawaiian  Islands,  the  Philippine  archipelago,  and  other 
i.-lands  of  the  Pacific,  the  western  part  of  Mexico  and  of  the 
Central  American  republics,  and  possibly  the  empire  of 
Japan.  A  preliminary  meeting  of  the  most  prominent 
physicians  interested  in  this  movement  was  held  in  this  city 
on  January  19. 

Chicago  Clinic. — With  the  January  number  the  Chicago 
Clinic  goes  under  the  editorial  management  of  Dr.  Marcus 
P.  Hatfield  and  Dr.  George  Thos.  Palmer,  who  have  pur- 
chased the  property  from  the  Chicago  Clinical  School.  The 
Clinic  was  started  13  years  ago  as  the  Omaha  Clinic,  by  Dr.  J. 
Homer  Coulter.  The  leading  articles  for  January  are :  "  The 
Limitations  of  Clinical  and  Microscopical  Evidence,"  by  Dr. 
W.  K.  Jacques;  "Diet  Kitchens,"  by  Dr.  Rosa  Engelmann, 
and  "  The  Jugulation  of  Lobar  Pneumonia,"  by  Dr.  Louis  A. 
Malone.  As  a  leading  feature  for  the  year  will  be  a  depart- 
ment on  "The  Relation  of  the  Law  to  the  Practitioner  of 
Medicine  and  Surgery,"  conducted  by  Hon.  John  Mayo 
Palmer,  of  the  Chicago  Bar  and  late  counsel  to  the  Corpora- 
tion of  Chicago. 

Dr.  Lewitt  Takes  His  Seat  on  Health  Board.— At 

a  special  meeting  of  the  Board  of  Health  of  San  Francisco, 
Cal.,  on  January  12,  Dr.  William  B  Lewitt,  the  newly  ap- 
pointed member  of  the  body,  took  his  seat  after  presenting 
his  commission.  Dr.  B.^zet  introduced  his  successor,  who 
was  greeted  by  President  Williamson  with  a  few  complimen- 
tary remarks.  Williamson  spoke  of  the  storms  that  had 
gathered  around  the  board  and  admonished  the  new  mem- 
bers to  stand  firm  when  other  storms  should  arise.  Dr. 
Williamson  was  reelected  president  of  the  board  to  serve 
this  year.  Dr.  Lewitt  was  appointed  on  the  committees  on 
publicity,  food  inspection,  and  finance.  Dr.  Buckley  was 
made  chairman  of  the  hospital  committee.  The  board  de- 
cided to  recommend  to  the  Supervisors  an  amendment  to  the 
ordinance  prohibiting  the  throwing  of  garbage  on  vacant  lols 
by  making  it  a  misdemeanor  for  owners  of  the  lots  to  allow 
them  to  be  used  for  such  a  purpose.    Violations  are  punish- 


144  T^^  Philadelphia"! 

^^  Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Jasvabt  as,  UM 


able  by  a  fine  of  $500  and  imprisonment  for  six  monthis. 
The  Supervisors  will  also  be  requested  to  amend  the  ordi- 
nance prohibiting  the  use  of  cellars  and  underground  apart- 
ments for  sleeping  purpose*  by  making  it  more  stringent  in 
its  operations. 

Anti- expectoration  Ordiuauoe. — The  following  ordi- 
nance was  passed  in  the  city  council  of  Chicago,  January  14 
"  Whereas,  spitting  on  sidewalks,  in  public  places  and  in 
public  conveyances  is  detrimental  to  health,  by  reason  of  the 
danger  of  spreading  contagious  disease,  and  is  alto  a  public 
nuisance  which  should  be  abated,  therefore.  Be  it  ordained 
by  the  City  Council  of  the  city  of  Chicago,  that  no  person 
shall  spit  on  any  public  sidewalk  or  on  the  floor  of  any  pub- 
lic conveyance,  or  on  the  floors  of  any  theater,  hall,  assembly 
room  or  public  building  ;  that  any  person  violating  the  pro- 
visions of  this  ordinance  shall  on  conviction  be  fined  in  a 
sum  of  not  less  than  $1  nor  more  than  $5 ;  that  this  ordi- 
nance shall  be  in  effect  from  and  after  its  passage  and 
approval  by  the  mayor." 

Chicago  Pathological  Society,  regular  meeting, 
January  14,  1901,  Dr.  L.  Hekloen,  preoident,  in  the  chair. 

Dr.  E.  R.  Lecouxt  made  a  report  on  the  histologic 
changes  found  in  the  tissues  of  animals  inoculated  with 
diplococcus  scarlatinae  (Class).  The  changes  described  differ 
only  in  degree  from  those  described  by  Pearce  and  others  in 
persons  that  die  from  scarlet  fever,  the  most  notable  differ- 
ence being  the  lack  of  lesions  in  the  kidneys  in  the  animals. 
Hyperplasia  of  lymphoid  tissue,  focal  necrosis  and  plasma 
cells  in  situations  that  betoken  their  presence  in  the  blood 
were  found  in  the  animals  inoculated. 

Dr.  W.  H.  Wilder  read  a  paper  on  tuberculosis  of  the 
iris  and  showed  specimens  from  a  case  observed  by  him. 

Drs.  D.  R.  Browfr  and  H.  Gideon  Wells  reported  a  case 
of  paralysis  of  the  cranial  nerves  of  the  left  side,  from 
the  fifth  to  the  twelfth  inclusive.  This  paralysis  had  come 
on  in  the  course  of  a  few  months  and  then  remained  station- 
ary for  12  years.  At  no  time  were  there  pressure  symptoms. 
On  account  of  the  history,  coupled  with  a  slight  improve- 
ment under  iodids  and  the  occurrence  of  12  miscarriages,  a 
syphilitic  lesion  involving  the  meninges  and  producing  an 
infranuclear  paralysis  was  diagnosed.  Death  resulted  from 
nephritis.  At  autopsy  a  tumor  was  found  in  the  dura, 
exactly  as  located  clinically,  involving  the  left  petrous  bone. 
Microscopically  it  was  found  to  be  an  endothelial  tumor, 
the  periendothelioma  of  Borrmann,  with  some  spiculae  of 
bone  and  many  multi-  and  uninuclear  giant  cells.  Micro- 
scopically it  resembled  somewhat  a  p^ammoma. 

Dr.  P.41TL  F.  MoRF  presented  gross  and  microscopic 
specimens  of  three  periosteal  chondrosarcomas. 
One  of  the  tumors  was  from  a  boy  of  13  and  had  developed 
on  the  tibia  shortly  after  a  contusion  of  that  bone.  Ttie 
other  2  occurred  in  young  adults,  1  in  a  fern  ;  i  :  ;  ■  <  :  i. 
the  last  in  a  male  patient  aged  19  years.  Tnese  two  latter 
tumors  were  found  to  have  grown  from  the  lower  end  of  the 
femur.  Microscopically  the  neoplasms  all  appeared  as  firm, 
hard,  inelastic,  grayish  white  masses.  Scattered  throughout 
their  substance  were  numerous  islets,  which  looked  to  the 
naked  eye  like  hyalin  cartilage.  Disseminated  foci  of  calci- 
fication of  pinhead  size  gave  the  cut  section  a  slightly  rough 
surface.  ^Microscopically,  the  tumors  were  found  to  be  made 
up  mainly  of  round  and  spindle-shaped  sarcoma  cells.  Tue 
islets  which  appeared  cartilaginous  were  made  up  of  larger 
and  smaller  round  encapsulated  cells  lying  in  a  hyalin  and 
in  a  fibrous  intercellular  substance.  In  the  first"  of  the  3 
specimens  the  invasion  of  the  Haversian  canals  of  the  tibia 
by  sarcoma  cells  could  be  distinctly  traced. 

SOUTHERN  STATES. 

At  the  annual  meeting  of  the  St.  Louis  Academy  of 
Science,  Dr.  Enno  Sander  was  elected  treasurer  for  the  for- 
tieth time. 

Smallpox  in  Missouri.— Sm.allpox  is  rapidly  spreading 
throughout  the  whole  section  of  Northern  Missouri  and 
adjacent  territory  of  other  States. 

Appropriation.— The  Senate  of  Alabama  unanimously 

passed  the  bill  which  appropriated  $2o,000  to  the  Alabama- 
Bryce  Insane  Hospital  at  Tuscaloosa  and  for  completing  the 
department  for  negroes  at  Mount  Vernon. 


Howard  Medical  Association. — The  annual  meeting 
of  the  Medical  Association  of  Howard  County  was  held  in 
EUicott  City,  Md.,  January  5.  Dr.  William  R.  Stokes  and 
Dr.  Frank  Martin,  both  of  Baltimore,  read  papers. 

The  death  of  Dr.  E.  P.  Becton,  Superintendent  of 
the  State  Blind  Institute,  occurred  in  Austin,  Texas,  January 
14,  at  the  age  of  67  years.  He  was  born  in  Tennessee,  but 
had  resided  in  Texas  the  greater  part  of  his  life,  and  was  an 
old  Indian  fighter. 

More  Men  Needed  for  Hospital  Corps  in  Norfolk, 

Va. — The  Surgeon-General  of  the  Navy  will  shortly  aik  for 
the  enlistment  of  additional  men  for  the  hospital  corps. 
The  vacancies  now  existing  in  this  corps,  of  which  there  are 
no  inconsiderable  number,  will  be  filled  as  rapidly  as  pos- 
sible by  enlistments  at  this  and  other  naval  stations. 

Richmond  (Va.)  News.— Dr.  Stockworther,  of  Prince 
William  County,  was  dangerously  hurt  recently  in  a  runaway 
accident. 

The  students  of  the  Medical  College  of  Virginia  adopted 
the  custom  of  wearing  caps  and  gowns.  This  is  the  first 
medical  school  in  Vtrgmia  to  adopt  this  cuftom. 

Cambridge  Hospital. — The  directors  of   the    United 

Charities  Hospital  of  Cambridge,  Maryland,  have  elected  the 
following  local  physicians  as  consultants :  Drs.  Thomas  B. 
Steele  and  Thomas  H.  Williams,  of  Cambridge;  Dr.  Berj*- 
min  L.  Smith,  of  Madison,  Dorchester  County ;  Dr.  George 
P.  Jones,  of  Eai?t  New  Market;  Dr.  Edgar  A.  P.  Jonee,  of 
Lakesville;  Dr.  William  T.  Henry,  cf  Hooper's  Island  ;  Dfb. 
Edward  R.  Trippe  and  Charles  B.  Davidson,  of  Easton. 

Ophthalniological  and  Otological  .Section — Rich- 
mond Academy  of  Medicine  and  Surgery. — There 
was  a  meeting  of  eye,  ear  and  throat  specialists  of  Richmond 
on  December  31,  1900,  at  the  oflSces  of  Dr.  Joseph  A.  Whit*, 
which  resulted  in  the  formation  of  the  above-mentioned 
organiziiion.  It  was  decided  to  have  meetings  once  a  month 
except  July,  August  and  September.  Toe  early  part  of  each 
session  is  to  be  devoted  to  business  matters,  reading  and 
discussion  of  papers,  etc. 

Consolidation  of  the  Marion-Sims  College  of 
Medicine  and  the  Beaumont  Hospital  Medical 
College. — The  governing  faculty  will  include  the  foiluwing : 
Y.  H.  Bond,  professor  of  gynecology  and  pelvic  surgery ;  F. 
J.  Lutz  and  J.icob  Geiger,  professors  of  surgery  ;  W.  A 
McCandless,  professor  of  surgery ;  C.  Barck,  professor  of 
ophthalmology  ;  W.  G.  Moore,  professor  of  medicine  ;  J.  B. 
Lemen,  professor  of  chest  diseases;  A.  Alt,  professor  of  oph- 
thalmology ;  H.  Summa,  professor  of  medicine ;  L.  H. 
Laidley,  professor  of  gynecology  and  pelvic  surgery,  and 
clinical  gynecology;  B.  M.  Hypes,  professor  of  obstetrics ;  J. 
Friedman,  professor  of  clinical  medicine  and  chemistry;  H. 
W.  Loeb,  professor  of  nose  and  throat  diseases  :  W.  B.  Cor- 
sett,  professor  of  obstetrics  and  gynecology :  R.  C.  Atkinson, 
professor  of  diseases  of  children :  J.  R.  Dale,  prvifessor  of 
surgery  ;  C.  G.  Chaddock,  professor  of  diseases  of  the  nervous 
system ;  J.  T.  Lirew,  professor  of  surgical  anatomy  and 
clinical  surgery;  T.  C.  Witherspoon,  professor  of  operative 
surgery  on  the  cadaver  and  clinical  surjery ;  M.  A.  Goldstein, 
professor  of  otology  ;  G.  C.  Crandall,  professor  of  medicine; 
C.  M.  Nicholson,  professor  of  anatomy  and  clinical  surgery; 
H.  H.  Born,  professor  of  anatomy  ;  R.  J.  Stoflel,  pnfessor "of 
therapeutics ;  C.  D.  Lukens,  professor  of  dentistry ;  S.  L 
Sshwab,  professor  of  nervous  diseases  ;  B.  Lewis,  professor  of 
genitourinary  diseases.  In  addition,  the  other  instructors  of 
the  two  institutions  will  be  utilized  to  the  fullest  extent. 

MISCELLANY. 

Harvard  University. — The  total  value  of  gifts  made 
to  Harvard  University  during  the  last  vear  is  announced  as 
$531,519. 

Obituary. — Dr.  Hexrv  Foster,  founder  of  the  Clifton 
Springs  Sanitarium.  New  York,  died  suddenly  on  Jiinu&iJ 
14,  aged  SO. — Dr.  Fraxk  Wkrtz,  of  Linj:swamp  Township 
Kutztown,  Pa.,  J.xnuary  21. — Dr.  Hika.m  tHRiSTOPHKK,  igei 
85,  at  St.  Joseph,  Mo. 


JaKCAKY    26,    UIOl] 


AMERICAN  NEWS  AND  NOTES 


rrii 
Lm] 


E  Philadelphia 
Medical  Journal 


145 


A  new  buildiug'  will  soon  be  erected  at  Alker,  Minn.,  to 
replace  the  sanitarium  which  was  destroyed  by  fire  about  6 
weeks  ago. 

U.  S.  Commissioner  of  Immigration'  has  decided 
that  tuberculosis  is  a  disease  which  may  subject  the  patient 
to  quarantine. 

Delaware  Hospital. — Dr.  William  W.  Lesley,  who  died 
in  Philadelphia  recently,  bequeathed  $11,000  to  the  Delaware 
Hospital  in  Wilmington  for  the  support  of  two  free  beds. 

Bequests. — By  the  will  of  the  late  Henry  Villard,  which 
has  just  been  oflfered  for  probate,  $50,000  each  is  left  to  Har- 
vard and  Columbia  universities,  $10,000  each  to  the  German 
Hospital  and  Dispensary  and  the  New  York  Infirmary  for 
Women  and  Children,  and  $5,000  to  the  Dobbs'  Ferry  Hos- 
pital Association. 

Physicians  of  Havana  recently  gave  a  banquet  to  Dr. 
Carlos  Finlay  as  a  token  of  their  congratulations  for  his 
theory  regarding  the  transmissibility  of  yellow  fever  by  the 
mosquito,  which  he  has  upheld  for  some  time,  notwithstand- 
ing the  opposition,  intolerance,  and  ridicule  to  which  he  has 
been  subjected,  until  his  observations  had  received  recogni- 
tion from  the  medical  world. 

Woodbridge  Treatment. — The  Chicago  Medical  He- 
corder,  January,  1901,  quotes  the  following  :  The  Wood- 
bridge  method  in  the  treatment  of  typhoid  has  not  stood  the 
test  of  experience.  The  opportunity  of  testing  his  method, 
accorded  Dr.  Woodbridge  at  the  Fort  Meyer  Hospital,  gave 
a  mortality  of  about  10%  as  contrasted  with  a  mortality  of 
about  7  %  by  usual  methods. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague,  have  been  reported  to 
the  Surgeon-General  U.  S.  Marine-Hospital  Service,  during 
the  week  ended  January  19, 1901 : 


Smaujox— United  States. 


Cases. 


Deaths. 


California  : 

Oakland   .    . 

.  Dec.  29-Jan 

5 

1 

Connecticut: 

Bridgeport  . 

.  Jan. 7    .   .  . 

3 

Illinois  : 

Cairo  .... 

.  Jan. 5    .    .   . 

8 

'• 

Chicago    .    . 

.  Jan.  5-12  .   . 

19 

Kansas  : 

Wichita 

.  Jan.  5-12  .   . 

6 

Mabyland  : 

Baltimore    . 

.  Jan.  5-12  .   . 

1 

M.\ssacuusktts 

Springfield  . 

.  Jan.  5-12  . 

1 

Minnesota  : 

Minneapolis 

.  Dec.  29-Jan. 

5' 

1 

•' 

Winona    .    . 

.  Dec.  29-Jan. 

5 

30 

N.-  Hampshire  : 

Manchester 

.  Jan.  5-12  . 

21 

New  York : 

New  York  . 

.  Jan. 5-12  . 

17 

3 

Ohio: 

Ashtabula   . 

.  Jan. 5-12  . 

4 

•* 

Cleveland 

.  Jan.  5-12  .   . 

51 

Pennsylvania  : 

Philadelphia 

.  Jan. 5-12  . 

1 

Tennessee  : 

Memphis .   . 

.  Jan.  5-12  .   . 

8 

" 

Nashville     . 

.  Jan.  5-12  .   . 

5 

West  Virginia 

:  Wheeling    . 
Smallpo 

.  Jan. 5-12  . 

X— Foreign. 

1 

Austria  : 

Prague  .  .   . 

.  Dec.  22-29    . 

12 

Canada : 

NewBrunswic 
Port  Elgin  a 
Cape  Tarme 

k, 

tid 
n- 

•  ' 

tine    .   .   . 
Leeds    .   .   . 

.  Dec.  28  .   . 

40 

1 

England : 

.  Dec.  29-Jan. 

5'   . 

'* 

London    .   . 

.  Dec.  22-29    . 

1 

India  : 

Bombay   .   . 

.  Dec.  4-18  .  . 

3 

" 

Calcutta   .   . 

.  Dec.  1-15  .   . 

81 

" 

Karachi    .   . 

.  Dec.  2-16  . 

, 

16 

2 

" 

Madras  .  .   . 

.  Dec.  8-14  . 

1 

Mexico  : 

Vera  Cruz  . 

.  Dec.  29-Jan. 

5' 

4 

2 

Russia  : 

St.  I'etersburg 
Yello 

.   Dec.  15-22    . 

w   Fever. 

5 

1 

Cuba  : 

Havana    .   . 

.  Dec.  29-Jan. 

5 

5 

" 

Matanzas .  . 

.   Dec.  29-Jan 

5 

1 

Mexico  : 

Vera  Cruz    . 
Ch 

.  Dec.  29-Jan. 
OLERA. 

5 

1 

India  : 

Bombay   .   .  . 

.  Dec.  4-18  .    . 

6 

" 

Calcutta   .    . 

.  Dec.  1-15  .   . 

56 

Madras  .   .   . 
Pj 

.  Dec.  8-14  .    . 

lague. 

1 

China  : 

Hongkong  .   . 
Bombay   .   .  . 

.  Nov.  24-Dec 

1    . 

2 

India  : 

.  Dec.  4-18  .   . 

178 

*' 

Calcutta   .   .   . 

.  Dec.  1-15  .  . 

39 

Turkey: 

Conatantinopl 

B  .  Jan. 11  .  .   . 

On    steamship 
"  Berrig  " 

from 

Poti. 

Changes  in  Hospital  Corps  Designs.— The  surgeon- 
general  of  the  army  has  had  under  consideration  the  advisa- 
bility of  changing  the  chevrons  and  cap  devices  worn  by 
enlisted  men  of  the  hospital  corps  of  the  army.  The  new 
designs  proposed  were  last  week  submitted  to  Surgeon-Gen- 
eral Sternberg  and  have  been  approved  on  his  recommenda- 
tion by  the  secretary  of  war.  The  general  order  setting  forth 
the  changes  will  be  issued  shortly,  a  draft  of  it  being  now  in 
preparation.  The  contemplated  changes  relate  to  the  chev- 
rons worn  by  privates,  acting  stewards  and  stewards  of  the 
hospital  corps.  The  Geneva  cross,  which  furnished  a  familiar 
insignia,  will  be  abandoned  in  favor  of  a  modified  Maltese 
cross  in  the  chevron.  The  body  of  this  cross  will  be  emerald 
green  with  a  narrow  white  border.  The  cap  device  for  the 
men  of  the  corps  will  be  a  metal  gold  Miltese  cross  of  smaller 
modification,  which  will  replase  the  silver  Genera  cross 
hitherto  worn. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  January  19,  1901 : 

Edger,  First  Lieutenant  Benjamin  J.,  Jr.,  assistant  surgeon,  now 
at  the  second  reserve  hospital,  Manila,  P.  I.,  awaiting  assign- 
ment, will  report  to  the  commanding  general,  department  of 
Luzon,  for  duty. 

The  following  named  medical  officers  and  acting  assistant  surgeons 
are  authorized  to  proceed  to  Manila  and  report  to  the  president  of 
the  Army  medical  board  for  examination  for  appointment  as  assist- 
ant surgeons,  U.  S.  Army  : 

Department  of  Northern  Luzon — Acting  Assistant  Surgeons  J. 
Ralpu  Shook,  Howard  D.  Lewis,  Horatio  P.  Belt,  Arthur  D. 
Prentice,  William  W.  Reno  and  Calvin  D.  Snyder. 

Department  of  Southern  Luzon^Major  Wilfred  Turnbull,  sur- 
geon, U.  S.  Vols.,  and  Acting  Assistant  Surgeons  Porter  V.  Bal- 
Lou,  R.  Boyd  Miller,  William  M.  Robebts,  Charles  St.  John. 
Arthur  Jordan,  William  E.  Vose,  Gustavus  I.  Hogue,  and 
Charles  L.  Baker. 

Department  of  the  Visayas^ Acting  Assistant  Surgeons  Freder- 
ick D.  Branch,  Conn  R.  Ohliger,  Edwin  C.  Shattuck,  and  Gor- 
don B.  Meldrum. 

Department  of  Mindanao  and  Jolo — Acting  Assistant  Surgeons 
Robert  B.  Grubb  and  A.  Bruce  Henderson. 

First  Reserve  Hospital — Acting  Assistant  Surgeons  Charles  W. 
Farr,  and  Charles  J.  Fitzgerald. 

Second  Reserve  Hospital — Acting  Assistant  Surgeons  Freder- 
ick A.  Dale,  Charles  R.  Reynolds,  and  Paul  T.  Dessez. 

Hospital  No.  3 — Acting  Assistant  Surgeons  John  D.  Brooks  and 
Edmund  Barry. 

Santa  Mesa  Hospital — Acting  Assistant  Surgeon  Francis  M.  Mc- 

CULLUM. 

Separate  Brigade,    Provost   Guard — Acting    Assistant   Surgeons 

Paul  C.  Hutton,  and  John  M.  Feeney. 

Rey'nolds,  Major  Frederick  P.,  surgeon,  granted  leave  of  absence 
for  2  months,  on  surgeon's  certificate,  to  take  effect  upon  arrival 
ill  the  United  States,  is  relieved  from  duty  as  chief  surgeon, 
separate  brigade,  provost  guard,  Manila,  P.  I. 

Moseley,  Major  Edward  B..  surgeon,  is  relieved  from  duty  as  chief 
surgeon,  department  of  Southern  Luzon,  and  granted  3  months' 
leave  of  absence,  on  surgeon's  certificate,  to  take  effect  upon  ar- 
rival in  the  United  States. 

CoMEGYS,  .Major  Edward  T.,  surgeon,  is  assigned  to  the  command 
of  the  first  reserve  hospital,  Manila,  P.  I.,  relieWng  Major  V?il- 
liam  R.  Hall,  surgeon. 

Hall,  Major  William  R.,  surgeon,  will  report  to  the  commanding 
general,  department  of  Southern  Luzon,  for  duty  as  chief  sur- 
geon of  that  department. 

Arthur,  Major  William  H.,  surgeon,  will  report  to  the  command- 
ing general,  department  of  Northern  Luzon,  for  assignment  to 
duty. 

Shreiner,  First  Lieutenant  Edward  R.,  assistant  surgeon,  will  re- 
port to  the  commanding  general,  department  of  Northern 
Luzon,  for  assignment  to  duty. 

Meacham,  Major  Franklin  A.,  surgeon,  upon  relief  by  Major  Wil- 
•  liam  H.  Arthur,  surgeon,  will  report  to  the  commanding  gen- 
eral, separate  brigade,  provost  guard,  Manila,  P.  I.,  for  duty  as 
president  of  the  board  of  health,  Manila,  P.  I.,  relieving  Major 
Guy  L.  Edie,  surgeon. 

Edie,  Major  Guy'  L.,  surgeon,  upon  rehef  by  Major  Franklin  A., 
Meacham,  surgeon,  will  report  to  the  commanding  officer  of 
the  first  available  transport  leaving  Manila,  P.  I.,  carrying  sick 
to  the  United  States,  for  duty  thereon  while  en.  route  to  San 
Francisco,  Cal.,  reporting  to  the  commanding  general,  depart- 
ment of  California,  for  instructions  to  return  to  the  division  of 
the  Philippines. 

Banister,  Major  William  B.,  surgeon,  will  report  to  the  command- 
ing general,  separate  brigade,  provost  guard,  Manila,  P.  I.,  for 
duty  as  surgeon  of  the  Twentieth  Infantry. 

Stemen,  William  E.,  acting  assistant  surgeon,  will  proceed  to  his 
home,  Kansas  City,  Kan.,  where  he  will  report  by  letter  to  the 
Surgeon-General  of  the  Army  for  annulment  of  contract. 

Chamberlain,  First  Lieutenant  Weston  P.,  assistant  surgeon,  is 
granted  leave  of  absence  for  1  month. 

Wadhams,  Fii-st  Lieutenant  Sanford  H.,  assistant  surgeon,  on 
account  of  sickness,  is  granted  leave  of  absence  for  7  days,  to 


146 


The  PHILADEIPlIfA 

Medical  Journ 


.".^] 


FOREIGN  NEWS  AND  NOTES 


[Jasuaby  2e,  1901 


take  efifect  from  the  expiration  of  the  leave  of  absence  granted 
him  October  13,  1900. 
ScHrMACHEE,  Frederick,  hospital  steward,  now  at  Fort  Huachuca, 
will  be  sent  to  Manila.  P.  1.,  for  assignment  to  a  station. 
The  following-named   assistant  surgeons  will  proceed  from  the 
places  designated  to  San  Francisco.  Cal.,  for  assignment  to  duty 
with  troops  en  route  to  the  Philippine  Islands,  where  they  will  re- 
port for  assignment  to  duty:  George  J.  Fakking.  from  Sacaton, 
Ariz  ;  Almok  P.  Goff,  from  Caton.  N.  Y.;  Charles  E.  Jackson, 
from  Canal  Fulton.  Ohio  ;  Joseph  W.  Love,  from  Springfield,  Mo.: 
Thom.\s  C.  McSwain.  from  Bingham,  S.  C:  Robert  C.  Rogers,  from 
Bloomington,  Ind.;  James  W.  Smith,  from  Chicago,  111.;  George  B. 
TuTTLE,  from  St.  Louis,  Mo.;  James  Bourke.  from  Chicago,  111. 
Heller,  Joseph  M.,  acting  assistant  surgeon,  is  granted  leave  of 
absence  for  1  month,  to  take  effect  when  a  medical  officer  shall 
have  reported  at  Fort  Columbus  to  take  his  place. 
Xewgaedex,  Captain  George  J.,  assistant  surgeon,  leave  of  absence 
for  1  month,  granted  November  15,  is  extended  1  month  on  sur- 
geon's certificate. 
Htsell,  Major  James  H.,  surgeon,  honorably  discharged  December 

19,  1900. 
Thomasox,  Major  Henry  D.,  surgeon,   honorably  discharged,  De- 
cember 31,  1900. 
F.\untleroy,  Captain  Powell  C,  assistant  surgeon,  U.  S.  Army,  to 

be  surgeon,  with  the  rank  of  Major.  November,  30.  1900. 
M.iTHEWs,  First  Lieutenant  George  W.,  assistant  surgeon,  V.  8. 
Armv,  to  be  surgeon,  with  the  rank  of  Major,  November  30, 
1900." 
Kneedler,  Captain  William  L.,  assistant  surgeon,  U.  S.  Array,  to 

be  surgeon,  with  the  rank  of  Major,  December  1.  1900. 
Wilcox,  Captain  Charles,  assistant  surgeon,  U.  S.  Army,  to  be 

surgeon,  with  the  rank  of  Major,  January  3. 1901. 
Shaw,  Captain  Henry  H.,  assistant  surgeon,  U.  S.  Army,  to  be  sur- 
geon of  volunteers,  with  the  rank  of  Major,  December  19,  1900. 
Bristee,  J.  M.,  assistant  surgeon,  appointed  assistant  surgeon  from 

December  14,  1900. 
Rodman,  S.  S..  assistant  surgeon,  appointed  assistant  surgeon,  from 
December  U.  1900. 

Ctaaages  in  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ending  January  19, 1901 : 

Anderson.  F.,  surgeon,  ordered  home  and  to  wait  orders,  when 

recruiting  duty  is  completed. 
Lowndes,  C.  H.  T.,  surgeon,  detached  from  the  Naval  Academy, 

January  14.  and  ordered  to  the  "  Lancaster."  via  steamer  from 

New  York  City,  of  January  19. 
Diehl,  0.,  surgeon,  detached  from  the  "Lancaster"  and  ordered 

home,  and  to  wait  orders. 
Ward,  B.  R,,  passed  assistant  surgeon,  detached  from  the  Naval 

Hospital,  Mare  Island,   Cal.,  January  17,  and  to  the  Boston 

Y'ard. 
Dennis,  J.  B.,  assistant  surgeon,  ordered  to  the  Naval  Academy, 

January  14. 
Densis.  j.  B.,  assistant  surgeon,  to  delay  reporting  for  duty  at  Naval 

Academy  until  January  2i . 
Pryor,  j.  C,  assistant  surgeon,  ordered  to  duty  at  Naval  Hospital, 

New  York. 
Williams,  R.  B  ,  assistant  surgeon,  detached  from  the  Navy  Yard, 

New  York,  and  to  the  Navy  Yard.  Pensacola. 
Lippirr.  T.  M.,  assistant  surgeon,  detached  from  the  Naval  Hospital, 

Y'okohama,  Japan,  and  to  Naval  Hospital,  Mare  Island,  Cal., 

via  "Solace." 
Weight,  B.  L.,  assistant  surgeon,  detached  from  the  Naval  Hospital, 

Yokohama,  Japan,  and  to  Naval  Hospital,  Mare  Island,  Cal., 

via  "  Solace." 
Blake.  Second  Lieutenant  D.W.,  detached  from  the  Naval  Hospital, 

Yokohama,  Japan,  and  ordered  to  Naval  Hospital,  Mare  Island, 

Cal.,  via  "Solace." 
Tomb,  Naval  Cadet  W.V.,  detached  from  the  Naval  Hospital,  Ca\'ite, 

P.  I.,  and  ordered  to  the  "General  Alva." 
Reaxey,  Chaplain  W.  H.  I.,  detached  from  the  Naval  Hospital, 

Cavite,  P.  I.,  and  ordered  home  via  the  "  Solace." 

Changes  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  January  17,  1901 : 

Sawtelle.  H.  W.,  surgeon,  leave  of  absence  for  30  days  granted  by 

Bureau  letter  of  December  18,  1900,  revoked.    January  15. 
Mead,  F.  W.,  surgeon,  granted  leave  of  absence'  for  60  days  from 

January  21.    January  11. 
Glennan,  a.  H.,  surgeon,  detailed  to  represent  the  service  at  meet- 
ing of  Third  Pan-American  Congress  to  be  held  at  Havana, 

Cuba,  February  4-8.    January  16. 
Pettus,  W.  j.,  surgeon,  granted  leave  of  absence  for  2  montlis  from 

February  5.    January  11. 
Nydeggee,  j.  a.,  passed  assistant  surgeon,  granted  leave  of  absence 

for  30  days.    January  15. 
Thomas.  A.  R.,  passed  assistant  surgeon,   to  proceed  to  Shields, 

England,  for  special  temporary  duty.    January  15.     Relieved 

from  duty  at  Glasgow.  Scotland,  and  assigned  to  duty  in  the  office 

of  the  X^.  S.  Consul-General  at  London,  England.  December  2,s. 
Lavindeb,  C.  H.,  assistant  surgeon,  to  proceed  to  Vineyard  Haven, 

Mass.,  and    assume    temporary  charge  of  the  service  during 

absence  of  Surgeon  F.  W.  Mead.    January  16. 
McMdllen,  John,  assistant  surgeon,  granted  leave  of  absence  for  21 

days  from  January  21.    January  16. 
Craig,  R.  C,  acting  assistant  surgeon,  granted  leave  of  absence  for 

7  days.    January  17. 


foreign  Xlzvos  anb  Hotes. 


GREAT  BRITAIN. 

Dr.  S.   Gemmell  was  elected  professor  of  the  medical 

clinics  of  Glasgow,  succeeding  Dr.  McCall  Anderson. 

3Ir.  Alexander  Peckover,  the  Lord- Lieutenant  of 
Cambridgeshire,  has  made  a  further  donation  of  £1,000  to 
Adden  Brooke's  Hospital. 

Lieutenant-Colonel  J,   Crofts,  M.D.,  I.MS.,   has 

been  appointed  surgeon  to  his  Highness  the  Maharajah  of 
Jodpore,  and  has  proceeded  to  India  to  take  up  his  duties. 

British  Congress  on  Tuberculosis. — As  president,  His 
Eoyal  Highness,  the  Prince  of  Wales,  will  open  in  person  a 
British  Ccngress  on  Tuberculosis  in  the  Queen's  Hall,  London, 
on  Monday,  July  22, 1901 ;  the  Congress  will  be  held  until  July 
26.  The  Congress  will  consist  of  delegates  from  British 
Colonies  and  Dependencies,  while  Europe,  Asia  and  America 
have  been  invited  to  send  representative  men  of  science  to 
be  the  distingiiished  guests  of  the  Congress.  The  object  of 
the  Congress  is  to  exchange  the  information  and  experience 
gained  throughout  the  world  as  to  methods  available  for 
stamping  out  this  disease.  Papers  will  be  read,  and  clinical 
and  pathological  demonstrations  will  be  given  ;  while  the 
museum,  which  is  to  be  a  spfcial  feature  of  the  Congress, 
will  contain  pathological  and  bacteriological  collections, 
charts,  models,  and  other  exhibits.  Authorities  in  this  and 
other  countries  will  be  invited  to  supply  documents  bearing 
upon  the  historical,  geographical,  and  statistical  aspects  of 
the  subject ;  while  as  a  result  of  the  papers  and  discussions, 
practical  resolutions  will  be  formulated  which  will  serve  to 
indicate  the  public  and  private  measures  best  adapted  for 
the  euppression  of  tuberculosis.  The  work  will  be  divided 
into  four  sections,  as  follows ;  (1)  State  and  Municipal ;  (2) 
Medical,  including  Climatology  and  Sanatoria ;  (3)  Patholog- 
ical, including  Bacteriology  ;  (4)  Veterinary  (luberculosij  in 
Animals),  and  the  Exhibitions  of  Specimens. 

EULES   ASD   EEGCLATIOKS. 

The  Congress  shall  consist  of  honorary  membere,  dele- 
gates, and  members. 

1.  Honorary  members  shall  be  persons  nominated  by  any 
foreign  government  or  university,  or  by  the  executive  com- 
mittee, and  shall  not  pay  any  subscription  whatsoever. 
Delegated  and  ordinary  members  shall  be  other  persons, 
British,  Colonial,  or  foreign,  who  may  wish  to  attend,  includ- 
ing representatives  from  governments  or  institutions  within 
the  British  Empire. 

2.  Delegated  and  ordinary  members  will  receive  their 
cards  on  forwarding  the  sum  of  £1  to  the  secretary  general 
of  the  Congress,  20,  Hanover  Square,  W. 

3.  The  holder  of  a  ticket  of  membership  is  entitled  to 
admission  to  all  the  meetings  of  the  Congress,  and  to  receive 
the  "  Transactions  "  and  other  publications.  Tickets  to  social 
gatherings  and  f  xcursions  will  be  allotted  in  order  of  appli- 
cation, or  by  ballot  if  necessary. 

4.  As  the  expenses  of  the  Congress  will  be  very  consider- 
able, donations  to  the  reception  fund  are  earnestly  invited. 
Donations  of  more  than  one  guinea  will  be  considered  as 
including  member's  subscription,  and  will  entitle  the  donor 
to  all  privileges  of  membership.  Donations  from  corporate 
bodies  may  include  the  subscriptions  of  representatives. 

5.  The  official  language  of  the  Congress  shall  be  Eoglish, 
French,  and  German,  and  authors  of  papers  are  requested 
to  supply  beforehand  abstracts  for  translation. 

6.  Eich  sectional  committee  shall  draw  up  its  own  work- 
ing program  sis  to  papers  to  be  read,  discussions  on  the  sub- 
jects proposed,  and  miscellaneous  communications.  The 
various  sections  will  meet  on  Tuesday,  Wednesday,  Thure- 
day,  and  Friday,  from  9.30  to  l.SO. 

7.  The  speeches  delivered  at  the  general  assemblies,  and 
the  papers  read  before  the  sections,  will  be  published  in  the 
record  of  the  proceedings  of  the  Congress ;  but  as  regaids 
miscellaneous  communications  and  discussions  the  discre- 
tion in  respect  of  publication  will  lie  entirely  in  the  hands  of 
the  "  Transactions  "  committee  and  the  presidents  of  sec- 
tions.   Each  speaker  opening  a  discussion  will  be  limited  to 


JiNCABY  26,    19011 


THE  LATEST  LITERATURE 


("Thb  Philadslphia 
L  Medical  Journal 


147 


80  niinuteu'  duration,  and  each  subsequent  speaker  to  10 
minutes. 

8.  An  abstract  of  every  paper  and  communication  must 
be  sent  to  the  secretary- general,  20,  Hanover  Square,  at  the 
latest  on  or  before  June  15,  1901. 

CONTINENTAL  EUROPE. 

Dr.  Theodore  Kirchhoflf  has  been  appointed  professor 
of  psychiatrics  at  Kiel. 

Professor  Popoco  has  been  appointed  physician  in 
ordinary  to  the  Emperor  of  Russia. 

Dr.  Anton  Prosainpter,  who  for  some  time  has  been 
director  of  the  hospital  in  Bozen,  is  dead. 

Professor  G.  Mya,  formerly  professor  of  clinical  path- 
ology at  Florence,  was  elected  ordinary  professor  of  pedi- 
atrics. 

Professors  Ehrlich  and  Weigert,  of  Frankfurt  a.M., 
have  been  elected  corresponding  members  of  the  Biologic 
Society  of  Paris. 

Dr.  A.  Jentzer  was  elected  professor  of  obstetrics  and 
gynecology  at  Geneva,  succeeding  Professor  M.  A.  Vaucher, 
'  who  has  resigned. 

Dr.  Velde,  who  was  the  German  physician  at  Pekin 
during  the  siege,  and  the  French  physician,  Dr.  Matignon, 
have  been  presented  with  the  cross  of  the  French  legion  of 
honor. 

Professor  Max  Verworn  has  been  appointed  ordinary 
professor  of  physiology  and  director  of  the  physiologic 
laboratories  at  the  Univertity  of  Goitingen.  He  succeeds 
Professor  Meissner, 

Fiftieth  Anniversary  of  the  "Wiener  medicinische 
Wochenschrift. — With  the  beginning  of  this  year  the 
Wiener  medicinische  Wochenschrift  completed  the  fiftieth 
year  of  its  existence. 

Dr.  Anton  Baron  von  Eiselsberg,  professor  of  sur- 
gery in  Konigsberg,  has  been  recommended  by  the  Profes- 
soren  Collegium  as  the  successor  of  the  late  Professor  Albert 
in  the  chair  of  surgery  in  the  University  of  Vienna. 

Dermatologic  Laboratory.  —  Oa  January  1,  1901, 
the  Dermatological  Laboratory  connected  with  Professor 
Unna's  clinic  in  Hamburg  became  an  individual  institution, 
having  been  considerably  enlarged  and  improved  in  teaching 
facilities. 

MISCELLANY. 

A  course  on  the  therapeutics  of  organic  diseases  of  the 
stomach  has  been  established  at  the  Hdpitai  de  la  Pitii?,  of 
.Paris,  under  the  charge  of  Dr.  Albert  R  jblin. 

Capt.  A.  F,  Stevens,  I.  M.  S.,  has  been  appointed  to  the 
charge  of  tlie  ward  of  the  General  Hospital,  Calcutta,  which 
has  been  fitted  out  for  the  reception  of  invalids  from  the  China 
force. 

Capt,  E.  R.  Rost,  I.  M.  8.,  civil  surgeon,  Meiktila, 
Burma,  ha^  found  a  microscopic  germ  in  rice  and  jowari 
srain,  and  also  in  the  rice  liquor  which  the  coolies  and  sepoys 
Irink.  The  result  of  his  experiments  is  stated  to  have  been 
that  beriberi  is  caused  by  this  organism,  which  withstands  a 
remarkably  high  temperature,  so  that  it  is  not  even  always 
destroyed  by  boiling. 


Isolated  Ulnar  Paralysis:  A  Contribution  to  the 
Occupation  Diseases.— F.  Menz  (  Wiener  klin.  Rundschau, 
1900,  No.  21)  reports  a  case  of  isolated  ulnar  paralysis  occur- 
ring in  a  female  telephone  operator.  The  patieat,  who  was 
iccustomed  to  rest  her  left  elbow  upon  the  table  while  hold- 
ing the  receiver  to  her  ear,  became  affected  by  a  paralysis  of 
various  branches  of  the  ulnar  nerve  supplying  the  skin  and 
jmuecles.    [m.r.d.] 


Cbc  i^aksi  literature. 


British  Medical  Journal. 

January  5, 1901.     [No.  2088  ] 

1.  A  Clinical  Lecture  on  Leukooythemia.   Robert  Sadndby. 

2.  An  Address  on  Acute   Dilation  of  the    Heart  in  Diph- 

theria, Influenza  and  Rheumatic  Fever.    D.  B  Lees. 

3.  Epidemic  Arsenical  Poisoning  Amongst  Beer  Drinkers. 

Nathan  Raw,  Frank  H.  Barendt,  W.  B.  Warrington. 

4.  Clinical    and  Pathological    Notes  on  a  Case  of  Human 

Actinomycosis,  with  Conclusioni  drawn  from  it  as  to 
the  Nature  of  the  Disease.     H.  E.  Littledale. 

5.  Notes  on  the  Dialysis  of  the  Toxins  Through  Collodion 

Walls.    M.  Armand  Ruffer. 

6.  A  Case  of  Renal  Colic  Attended  liv  the  Passage  of  Casts  of 

the  Ureter.    J.  H.  Henton  White. 

7.  A  Case  in  Which  Movable  Kidney  Produced  the  Usual 

Symptoms  of  Hepatic  Colic  Successfully  Treated  by 
Nephrorrhapy.    Macpherson  Lawrie. 

8.  The  Sex  of  Patients  Suffering  from  Gastric  Ulcer.  R.  deS. 

Stawell. 

1.— Saundby  reports  2  cases  of  leukooythemia,  1  of 
which  was  fatal.  At  the  postmortem  examination  it  was 
found  that  the  spleen  weighed  5  pounds  3  ounces  ;  on  section 
it  contained  a  few  hemorrhages  but  no  infarcts.  The  liver 
weighed  8  pounds  11  ounces  and  contained  neither  hemor- 
rhages nor  infarcts.  The  stomach  was  normal.  The  small 
intestine  showed  diffuse  catarrh  throughout  4  to  5  feet  of  its 
lower  portion  with  patches  of  congestion.  The  salivary 
glands  were  swollen,  but  Peyer's  patches  were  not  affected. 
In  several  places  there  were  what  appeared  to  be  small 
healed  ulcers,  and  immediately  above  the  cecum  there  was 
an  irregular  and  superficial  ulcer.  The  bone  marrow  of  the 
ribs  was  diflluent  and  light  brown  in  color,  tlrat  in  the  tibia 
and  radius  was  lymphoid  and  fairly  firm,  of  a  brownish  color, 
dotted  with  patches  of  yellow.  Under  the  microscope  the 
marrow  was  extremely  cellular,  showing  numerous  myelo- 
cytes, the  majority  of  which  were  finely  granular  oxyphiles, 
although  some  contained  basophilic  granules ;  coarsely 
granular  oxyphiles  were  uncommon.  There  were  many  red 
nucleated  blood-cells  and  some  with  dividing  nuclei.  Notes 
of  4  other  cases  are  given,    [j.m  s  ] 

2,— Sudden  death  following  diphtheria  has  been  thought 
to  be  due  to  neuritis  of  the  pneumogastric  nerve ;  but  Lees 
is  of  the  opinion  that  it  is  more  likely  due  to  degeneration  of 
the  cardiac  muscle.  The  clinical  indications  that  should  be 
sought  for  to  indicate  the  extent  of  this  degeneration  are :  (1) 
Feebleness  of  the  pulse  wave;  (2)  feebleness  and  diffusion  of 
the  cardiac  impulse;  (3)  extension  of  the  cardiac  dulness  to 
the  left ;  (4)  feebleness  of  the  first  sound  at  the  apex  with 
accentuation  of  the  pulmonary  second  sound,  and  (5)  marked 
accentuation  of  the  aortic  second  sound  with  a  compressible 
radial  pulse.  In  making  a  physical  examination  of  the  heart 
in  these  cases  the  exact  limits  of  the  heart  should  be  ascer- 
tained by  percussion,  and  the  examiner  should  not  be  con- 
tented with  the  limits  of  superficial  dulness.  If  in  the  case 
of  a  child  suffering  from  diphtheria,  the  cardiac  dulness  is 
increased  more  than  one  finger's  breadth  to  the  left  of  the 
midclavicular  line  the  case  should  be  very  carefully  watched. 
If  the  dulness  exceeds  two  fingers'  breadths  to  the  left  of  the 
midclavicular  line  the  child  must  not  be  allowed  to  sit  up  in 
bed  for  any  reason.  The  increase  in  dulnejs  is  sometimes 
very  rapid,  and  the  acute  dilation  thus  indicated  is  frequently 
accompanied  by  vomiting.  The  cases  of  cardiac  dilation 
following  diphtherial  infection  are  probably  not  per- 
manent; the  worst  cases,  however,  are  usually  fatal.  In 
influenza  rapid  dilation  of  the  heart  frequently  occurs,  to  a 
greater  or  less  extent,  withia  a  day  or  two  after  the  onset  of 
the  disease,  and  is  sometimes  accompanied  by  fatal  syncope. 
If  the  dulness  extends  two  fingers'  breadth  to  the  left  of  the 
midclavicular  line  there  is  real  danger.  Minor  degrees  of 
cardiac  dilation  after  influenza  may  cause  a  feeling  of  inca- 
pacity for  exertion  and  the  patient  may  be  thought  to  be  a 


148 


The  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[JiSlAEY    V,,  ISOl 


hypochondriac.  In  rheumatic  fever,  even  in  the  most 
subacute  attacks,  acute  dilation  of  the  heart  seems  to  be 
invariably  present.  The  author  has  never  seen  a  first  attack 
of  this  disease  in  a  child  or  in  an  adult,  in  which  dilation  was 
absent.  This  condition  accom{)anying  rheumatism  is  far  less 
dangerous  than  in  influenza  or  in  diphtheria.  The  difference 
must  be  due  to  the  varying  effects  of  the  several  toxins  on 
the  cardiac  muscle.  The  author  makes  a  plea  for  more 
careful  cardiac  examination  by  percussion  and  palpation. 

[j.M.B.] 

3. — Raw  thinks  that  the  epidemic  of  arsenical  neu- 
ritis from  drinking  beer  which  began  in  June,  1900,  is 
subsiding.  The  author  has  seen  70  cases,  among  which  there 
was  but  1  death.  The  poison  was  detected  in  the  urine  of  5 
patients  out  of  33  examinations.  The  arsenic  was  undoubt- 
edly contained  in  the  sulfuric  acid  used  in  making  the  glu- 
cose which  is  used  by  the  brewers.  The  skin  lesions  studied 
by  Barendt  may  be  divided  into  those  resulting  from  a 
sudden  debauch  and  those  due  to  the  daily  and  not  immod- 
erate use  of  the  poisoned  beer.  The  nervous  symptoms  were 
studied  by  Warrington,  who  found  that  the  patients  who 
showed  the  most  marked  symptoms  of  arsenic  poisoning 
presented  the  leaet  evidence  of  well-defined  neuritis.  In  those 
who  were  but  moderate  takers  of  beer  and  stout,  sensory 
disorders  were  most  prominent,  such  as  numbness,  tin- 
gling, pain,  and  erythromelalgia.  No  distinctive  impairment 
of  sensation  could  be  found,  the  knee-jerk  was  usually  pres- 
ent, and  ataxia  was  not  noted,    [j.m  8.] 

4. — Littledale  reports  the  case  of  a  man,  aged  23  years, 
who  presented  a  swelling  of  4  months'  duration,  that  began 
between  the  angle  of  the  jaw  and  the  mastoid  process  of  the 
temporal  bone.  The  swelling  extended  around  the  back  of 
the  neck  to  the  right  side  and  front  of  the  neck  and  thence 
down  to  the  sternum.  A  diagnosis  of  actinomycosis  was 
made,  but  the  typical  ray  fungus  was  not  found  in  the  pus 
nor  in  the  scrapings  from  the  wall  of  the  abscess-cavity  during 
life.  A  second  abscess  developed  in  front  of  the  sternum 
and  a  third  at  the  vertebral  border  of  the  right  scapula. 
Later,  numerous  abscesses  formed  about  the  back  and  neck. 
The  patient  died  after  8  months'  illness  with  advanced  amy- 
loid disease  and  symptoms  of  pulmonary  tuberculosis. 
Actinomyces  were  demonstrated  in  the  tissues  obtained  at 
the  autopsy.  The  aff^ected  lung  showed  double  infection  with 
tuberculosis  and  actinomycosis,    [j.m  s.] 

6. — Ruffer  and  Creudiropoulo  have  found  that  the  various 
toxins  of  the  Bacillus  pyocyaneus  dialyze  through  the 
walls  of  collodion  sacs,  but  not  in  their  entirety.  The 
time  taken  in  the  dialysis  is  comparatively  long,  and  the 
pathogenic  properties  of  the  toxins  vary  according  to  the 
length  of  the  dialysis.  It  is  probable  that  the  immunizing 
substances  are  among  the  first  to  dialyze,  so  that  advantage 
of  this  property  may  be  taken  in  the  manufacture  of  vaccines. 
[j  M  s.] 

6. — White  describes  a  case  giving  typical  attacks  of  renal 
colic  in  which  were  passed  casts  of  the  ureter.  Microscop- 
ically they  were  elongated,  cylindrical  bodies  of  clear  mucus 
held  together  by  a  few  threads  of  fibrin  and  containing  a  few 
small  granules  and  the  remains  of  a  few  epithelial  cells.  The 
casts  were  about  an  inch  long.  The  patient  greatly  improved 
under  potassium  iodid,  but  showed  no  improvement  under 
the  administration  of  the  mineral  acids.  He  thinks  that 
possibly  the  irritation  of  the  ureter  may  be  due  to  an  encysted 
renal  calculus,    [j.h.q.] 

7. — Lawrie  reports  the  case  of  a  woman  who  suflfered  from 
repeated  attacks  of  typical  hepatic  colic  which  were  re- 
lieved absolutely  by  the  fixation  of  a  very  movable  kidney.  Ex- 
cepting the  attacks  of  pain  there  waa  no  evidence  of  the  pas- 
sage of  gallstones,  but  as  the  patient  suffered  from  a  freely 
movable  right  kidney,  it  was  thought  advisable  to  resort  to 
its  fixation,     [j.h.g.] 

8. — Out  of  '7,700  autopsies  Stawell  found  96  records  of  gas- 
tric ulcer,  55  of  which  occurred  in  males  and  41  in  females. 
These  figures  seem  to  indicate  a  preponderance  of  cases  of 
gastric  ulcer  among  males ;  but  of  the  entire  number  of  au- 
topsies recorded  many  more  of  the  subjects  were  males  than 
females.  Comparing  an  equal  number  of  necropsies  on 
each  sex  the  proportion  seems  to  be  5  males  to  6  females. 
During  life  the  cases  diagnosed  gastric  ulcer  in  males  were  to 
those  so  diagnosed  in  females  as  1  to  4.  Perforation  seems 
to  occur  more  frequently  in  males  in  the  proportion  of  7  to  6. 

[j.M.S.] 


Lancet. 

Janvuary  5,  1901.     [No.  4036.] 

1.  An  Adlress  on  Clinical  Varieties  of  Bright's   Disease. 

John  Rose  Beadfoed. 

2.  A  Series  of  Cases  of  Actinomycosis.    Rickman  J.  Godlee. 

3.  The  After-Results  in  40  Consecutive  Cases   of  Vaginal 

Hysterectomy  Performed  for  Cancer  of  the  Uterus. 
Aethde  H.  N.  Lewees. 

4.  A  Case  of  Deformity  of  the  Skull  Simulating  Leontiasia 

Oisea,  Associated  with  a  Condition  of  Syringomyelia; 
no  Pnysical  Signs  of  Syringomyelia  Preeent.  James 
S.  Colliee. 

5.  Filariasis    and  its  Consequences    in    Fiji.    Moegas  I. 

FlNUCANE. 

6  A  Case  of  Mollities  Oasium  with  Spontaneous  Fracture 
Through  the  Great  Trochanter  of  the  Left  Femur.    J. 

HOGGAN  EWAET. 

7.  A  Caae  of  Cobra- poisoning  Treated  with  Calmette's  Anti- 

venine.    W.  Hasna. 

8.  Membranous    Eiophagitis ;    Expulsion    of   a  Complete 

Cast  of  the  Esophagus.    Nathan  Raw. 

9.  "  Clucks  "  and  "  Clicks."    W.  Aixslie  Hollis. 
10.  Reflections  on  Therapeutics.    Haeey  Campbell. 

1. — Bradford,  in  an  address  on  the  clinical  varieties  of 
Bright's  disease,  comes  to  the  following  conclusions: 
That  two  forms  of  acute  Bright's  disease  should  be  recog- 
nized. On  the  one  hand  a  variety  in  which  dropsy  and  well- 
defined  urinary  changes  are  present.  The  urine  in  this  form 
is  scanty,  highly  albuminous,  and  contains  blood  and  ciste. 
In  the  other  form  dropsy  is  absent.  He  lays  particular  stress 
upon  the  fict  that  the  laat  named  condition  is  distinguished 
with  difficulty  from  congestion  of  the  kidney.  He  farmer 
states  that  in  chronic  Bright's  disease  at  least  two  forms 
should  be  recognized.  Oae  in  which  dropsy  becomes  promi- 
nent, the  urine  is  scanty  and  highly  albuminous.  The  course 
of  the  disease  is  chronic  and  often  marked  by  subacute 
attacks  of  uremia.  In  the  second  variety  the  urine  is  in- 
creased in  amount,  contains  considerable  albumin,  and  dropsy 
is  absent.  Wasting  and  loss  of  strength  soon  show  them- 
selves, and  hypertrophy  of  the  heart  and  vascular  changes 
are  present.  Albuminuric  retinitis  is  a  common  comphca- 
tion  and  acute  uremic  attacks  frequently  develop.  He  finally 
adds  that  two  forms  of  chronic  Bright's  disease  probably 
represent  di£ferent  effects  of  the  same  morbid  condition,  and 
that  chronic  Bright's  disease  need  not  be  preceded  by  the 
acute  form,     [f  j  k  ] 

3. — Lowers  records  a  series  of  40  consecutive  cases  of  vagi- 
nal hysterectomy  performed  for  cancer.  Among  these  40 
cases  there  were  14  in  which  the  disease  had  not  recurred  up 
to  the  date  of  the  report.  Twelve  of  these  were  undoubtedly 
true  carcinoma.  The  conclusions  that  appear  to  follow  from 
a  consideration  of  the  facts  in  this  paper  are:  1.  That  in  a 
certain  proportion  of  the  cases  patients  sufi'ering  from  cancer 
of  the  uterus  may  be  relieved  by  operation  for  periods  of  many 
years — in  some  cases  for  so  long  a  time  that  there  seems  some 
probability  that  the  relief  may  be  permanent,  2.  That  the 
proportion  of  cases  in  which  this  result  can  be  expected  most 
remain  very  small,  so  long  as  patients  generally  seek  ad- 
vice only  at  a  late  stage  of  the  disease.  3.  That  consequently 
the  great  desideratum  is  early  diagnosis.  Improvement  in 
this  direction  depends,  to  some  extent,  on  a  better  apprecia- 
tion on  the  part  of  women  themselves  of  the  eArly  symptoaas 
of  the  disease,  and  especially  of  the  significance  of  bleediiig 
after  the  menopause,  or  a  bleeding  occurring  at  an  earlier 
time  of  life,  between  the  menstrual  period.  It  is  equally 
important  to  bear  in  mind  that  patients  suffering  from  can- 
cer of  the  uterus  may,  and  generally  do,  for  a  relatively  long 
period,  look  quite  well.  They  may  be  well  nourished  or  not 
infrequently  even  excessively  fat.    [w.a.n  d.] 

4. — Collier  reports  an  interesting  case  of  syringomyelia 
which  was  not  suspected  during  life  because  of  the  atisenoe 
of  symptoms  of  this  condition.  The  patient,  a  man  36  years 
old,  presented  a  peculiarly  deformed  skull,  flit  on  top  and 
overhanging  at  the  sides  and  behind  ;  this  had  exist*^!  since 
childhood  and  followed  a  fall  which  the  patient  had  at  that 
time.  The  patient,  at  the  age  of  26  years,  began  to  have  epi- 
leptic fits  which  started  always  in  the  right  arm.  At  the  time 
of  admission  this  arm  was  paretic.  Mr.  Horaley  trephined 
the  skull  over  the  arm  center,  finding  the  bone  tliin,  aad 


JiNDAKY  26,    1901] 


THE  LATEST  LITERATURE 


TThE    FUILADELPUIA 

L  Mhdical  Journal 


149 


egg-shell  like  plates  in  the  dura,  which  was  not  opened.  The 
patient  died  suddenly  3  hours  after  the  operation,  and  from 
no  discoverable  cause.  Necropsy  showed  a  marked  con- 
dition of  syringomyelia.  Collier  remarks  the  not  infrequent 
association  of  syringomyelia  with  akromegaly,  but  in  this 
case  he  thinks  the  peculiar  deformity  of  the  skull  was  due  to 
the  injury  received  in  childhood,  since  the  deformity  made 
its  appearance  at  5  years  of  age.  He  does  not  think  the  syringo- 
myelia was  due  to  injury,  as  the  patient  led  an  active  arti- 
san's life  for  15  years,  having  no  signs  of  paraplegia.  Sudden 
death  frequently  follows  anesthetization  and  operation  in 
case  of  syringomyelia,     [j  h.g.] 

6. — Finucane  states  that  the  most  common  result  of  filari- 
aeis  among  the  natives  and  Europeans  in  the  South  Seas  and 
in  Fiji  is  elephantiasis  of  the  scrotum.  He  describes  the 
operation  for  the  relief  of  this  condition  as  it  is  performed  at 
the  Colonial  Hospital  at  Suva,  Fiji.  Chloroform  is  used  aa 
the  anesthetic.  An  Esmarch's  elastic  tc  urniquet  is  tightly 
applied  above  the  base  of  the  pedicle,  the  ends  are  carried 
aiound,  above  the  crest  of  the  pelvis  and  fastened  behind. 
An  incision  is  made  into  the  elephantoid  tissue  so  as  to  free 
the  glans  penis,  a  No.  8  silver  catheter  is  introduced  into  the 
urethra  and  an  assistant  holds  the  penis  well  up  over  the  ab- 
domen. Then  on  each  side  an  incision  is  made  which  is 
carried  downward  from  the  external  abdominal  ring  to  the 
lower  portion  of  the  scrotum.  The  testes  and  the  cord  are 
carefully  dissected  out  and  held  up  over  the  abdominal  wall. 
Two  skewers  are  next  introduced  into  the  lower  portion  of 
the  base  of  the  tumor  for  the  purpose  of  holding  and  pre- 
venting retraction  of  the  tissues  and  to  avoid  slipping  of  the 
tourniquet  after  the  mass  has  been  separated.  After  removal 
of  the  tumor  the  vessels  are  ligated,  the  tourniquet  is  loosened, 
the  tkewers  are  withdrawn  and  the  edges  of  the  wound  are 
brought  together.  As  a  rule  a  good  scrotum  can  always  be 
fashioned.  Hernia  complicating  elephantiasis  of  the  scrotum 
must  always  be  borne  in  mind.  Amongst  Fijian  women 
elephantoid  enlargement  of  the  arm,  the  leg,  and  the  breast 
is  very  common.  Children  frequently  suffer  from  lymphan- 
gitis of  an  extremity.  He  states  that  quinin  is  given  in 
acute  filarial  attacks  with  good  results,     [f.j.k.] 

6.— Ewart  reports  the  case  of  a  woman,  aged  65  years, 
who  14  years  before  began  to  show  evidences  of  softening 
of  the  tibiae.  The  patient  came  recently  under  his  care 
for  the  treatment  of  a  fracture  through  the  great  trochanter 
of  the  femur  which  occurred  when  the  patient  was  walking 
and  without  any  special  muscular  effort.  The  report  of  the 
case  is  illustrated  by  skiagraphs,     [j  h  a  ] 

7. — Hanna  reports  a  case  of  cobra  poisoning'  treated 
with  Calmette's  antivenine.  While  assisting  in  the  ab- 
straction of  poison  from  a  full- sized  cobra,  the  operator  was 
bitten  in  the  thumb.  The  only  local  treatment  employed 
was  sucking  the  wound.  Within  the  course  of  from  20  to 
30  minutes  after  the  bite,  18  ccm.  of  Calmette's  antivenom- 
ous  serum  were  injected.  About  2J  hours  after  the  injection 
symptoms  of  poisoning  showed  themselves  in  slight  stupor, 
nausea,  vomiting,  and  some  paralysis  of  the  legs.  About  3J 
hours  after  the  bite  another  injection  of  10  ccm.  was  in- 
jected, and  after  a  short  while  all  general  symptoms  disap- 
peared. Pain  and  swelling  persisted  in  the  thumb.  A  slough 
formed  at  the  site  of  the  inoculation.  After  6  weeks  the 
wound  had  nearly  healed.  The  chief  lesson  to  be  learned  is 
that  sucking  of  the  wound  is  of  little  value,  and  that  fresh 
antivenomous  serum  should  be  promptly  used,    [f  j  k.] 

8. — A  case  of  membranous  esophagitis  is  reported 
by  Raw.  The  patient,  a  male,  aged  46,  was  admitted  into 
the  Millroad  Infirmary,  Liverpool,  on  April  10,  1900.  He 
complained  of  substernal  pain  and  difficulty  in  swallowing. 
These  symptoms  had  existed  for  six  months.  On  admission 
he  could  only  partake  of  liquids.  He  vomited  a  complete 
cast  of  the  esophagus  on  April  16.  This  cast  was  8i  inches 
long  and  weighed  2}  ounces  ;  it  was  of  a  greenish  gray  color 
and  very  tough.  Microscopical  examination  showed  that  the 
cast  was  composed  of  a  network  of  fibrin  and  epithelial  cells. 
Vomiting  soon  became  a  symptom,  and  later  even  the  swal- 
lowing of  liquids  was  impossible  on  account  of  the  severe 
pain.  The  patient  was  fed  with  nutrient  enemata.  On  May 
12,  a  gastrostomy  was  performed  and  the  patient  was  now 
fed  through  the  artificial  orifice  as  well  as  by  rectum.  Pro- 
gressive weakness  followed  the  operation,  and  death  occurred 
m  six  weeks.  At  the  necropsy  complete  stenosis  of  the 
esophagus  was  found'.    Gastritis  was  not  present.     The  case 


was  of  particular  interest  because  the  condition  is  so  very 
rare,    [f  .t  k  ] 

lO. — Campbell  in  an  article  entitled  reflections  on 
therapeutics  emphasizes  the  importance  of  relying  upon 
the  strength  of  nature  in  the  healing  art,  and  that  nature  is 
the  great  physician.  He  states  that  the  young  physician  full 
of  theory  has  this  to  learn.  As  the  experienced  observer 
grows  older  his  methods  of  treatment  become  more  simple 
and  more  and  more  he  abides  by  the  call  of  nature.  In  sum- 
ming up  the  treatment  of  many  of  the  acute  infectious  dis- 
eases, particularly  croupous  pneumonia  and  enteric  fever,  he 
lays  great  stress  upon  the  fact  that  the  most  enlightened 
measures  of  treatment  must  be  found  in  nature  and  the 
nurse,    [f.j.k  ] 

New  York  Medical  Journal. 

January  19,  1901.     [Vol.  Ixxiii,  No.  3.] 

1.  A  Peculiar  Case  of  Migratory  Foreign  Body,  with  X-Ray 

Illustration.    D.  Braden  Kyle. 

2.  Two  Cases  of  Hemarthrosis  of  the  Knees.    Rdssell  A. 

HlBBS. 

3.  Report  of  Two  Cases  of  Dermoid  Cyst  of  the  Nose.    H. 

S.    BlRKETT. 

4.  The  Method  of  Examination  of  Infanta.    C.  Herman. 

5.  A  Case  of  Paroxysmal  Hemoglobinuria.   William  Judsos 

Lamson. 

6.  General  Anesthesia;  The  Preliminary  and   After  Treat- 

ment, with  Remarks  on  Chloroform  and  Ether.    E. 
Payne  Palmer. 

7.  Gastric  Ulcer ;  Report  of  Two  Cases.    E.  S.  Goodhue, 

1.— Kyle  reports  an  interesting  case  of  migratory  for- 
eign body— a  needle — which  gave  rise  to  a  series  of  severe 
attacks,  characterized  by  excruciating  neuralgic  pain.  The 
site  of  the  pain  varied  at  times,  leading  to  the  suspicion  of 
mastoiditis,  facial  neuralgia,  ethmoiditis,  and  lastly  suppura- 
tion of  the  maxillary  sinus.  Yet.  when  the  respective  at- 
tacks had  subsided,  all  symptoms  disappeared  for  the  time. 
The  patient  suffered  from  periodic  neuralgic  attacks,  from 
January,  1887,  to  August,  1899,  when  the  last  portion  of  the 
offending  needle  was  removed,  part  having  sloughed  in  an 
attack  confined  to  the  frontal  sinus  in  1893.  An  x-ray  print 
cleared  up  the  diagnosis  in  this  case.  But  the  patient  suf- 
fered from  a  severe  x-ray  burn  24  hours  after  the  picture  was 
taken.  An  acute  dermatitis  of  the  right  side  of  the  face  fol- 
lowed, accompanied  by  loss  of  hair  in  handfuls.  No  ill  efiects 
followed,  and  the  hair  grew  on  again,  but  only  to  the  length 
of  3  inches,    [t.l  c] 

2. — Hibbs  describes  2  cases  of  periodical  hemorrhages 
into  the  knee-joints,  the  patients  being  brothers.  Two  other 
hemophilic  brothers  died  in  infancy,     [j  h.o.] 

3.— Birkett  reports  2  cases  of  dermoid  cyst  of  the  nose 
which  he  operated  upon,  and  mentions  a  third  case  under 
his  care.  In  each  case  the  tumor  had  been  observed  at  birth 
and  had  gradually  enlarged,  and  each  occupied  the  median 
line  of  the  nose.  Both  of  the  cases  operated  upon  did  well. 
Birkett  has  only  been  able  to  find  6  cases  reported  in  the 
literature  on  the  subject,    [j  h  g  ] 

4. — Herman  urges  the  systematic  examination  of 
children  under  a  physician's  care — and  the  throats  of 
those  in  whom  infection  may  be  anticipated.  In  this  way 
personal  peculiarities  may  be  detected  and  we  are  fore- 
armed against  regarding  any  peculiarity  present  in  the  child 
as  produced  by  any  subsequent  diseased  condition.  He  be- 
lieves in  making  as  much  of  an  examination  as  possible 
while  the  child  is  sleeping,  after  being  fed,  and  points  out  the 
value  of  thus  securing  normal  pulse  and  respiratory-  rate 
as  well  as  mean  temperature.  The  throat  should  be  ex- 
amined last.  lu  a  chest  examination  Herman  recom- 
mends that  the  child  should  be  held  lightly  in  the  mother's 
arm  with  the  chin  resting  against  the  shoulder.  For  com- 
parison a  change  of  position  to  the  other  arm  is  recom- 
mended. The  author  uses  a  bimanual  stethoscope.  He 
distinguishes  four  varieties  of  cough :  (1)  the  simple 
catarrhal ;  (2)  the  suddenly  interrupted  short  cough,  which 
causes  pain  (pleuropneumonia) ;  (3)  the  croupy ;  and  (4) 
the  spasmodic  paroxysmal  (pertussis).  He  believes  the  char- 
acter of  the  crv  to  be  less  important.  Mention  is  made  that 
almost  all  cardiac  murmurs  heard  are  organic  and  systolic. 
They  are  frequently  transmitted  posteriorly,  both  to  right 


150 


The  Philadelphia 
Medical  Journal 


■] 


THE  LATEST  LITERATURE 


[Jaxdabt  2>;,  im 


and  left,  by  the  relatively  large  liver.  Points  in  the  systematic 
physical  examination  are  detailed  at  length.  The  author 
has  profited  by  his  association  with  Koplik  in  the  Good 
Samaritan  Dispensary,    [t  l.c] 

6. — Lamson  reports  a  case  of  paroxysmal  hemoglo- 
binuria which  first  showed  itself  in  the  patient,  a  clerk  of 
40  years,  in  November,  1892,  after  a  long,  cold  drive.  These 
attacks  recurred  at  intervals  of  a  few  weeks.  He  became 
emaciated,  but  his  heart  and  kidneys  were  pronounced 
sound.  Since  treatment  his  general  condition  improved,  but 
the  attacks  persisted.  Between  attacks  the  patient  feels 
well,  but  looks  anemic.  A  typical  attack  begins  at  10  a.m. 
with  a  chilly  feeling'  often  becoming  a  decided  rigor.  The 
extremities  are  coid,  and  the  fingers,  nose  and  ears  are 
cyanctic.  He  becomes  icteroid,  and  nausea  follows.  He 
then  pastes  urine  of  portwine  color  frequently  and  in  con- 
siderable amount.  The  chill  lasts  from  IJ  to  3  hours  and  is 
succeeded  by  a  feverish  sensation.  At  times  an  urticaria- 
like eruption  appears  in  the  dorsum  of  the  hands  or  on  the 
right  cheek  ;  or  he  may  have  painful  areas  in  bridge  of 
nose,  around  the  right  orbit,  or  in  the  groin.  Normal  urine 
is  passed  again,  sometimes  in  20  minutes,  often  not  for  sev- 
eral hours,  depending  upon  how  quickly  he  becomes  thor- 
oughly warm.  The  blood  and  urine  between  attacks  are 
not  characteristic  of  any  pathological  condition.  During 
attacks  the  urine  averages  from  1.028  to  1.030.  There  is 
heavy  precipitate  of  albumen  and  hyalin  and  coarse,  gran- 
ular casts.  Blood  is  also  present.  The  plasmodiae  are  not 
found.  Favorable  climatic  surroundings  and  cartful  per- 
sonal hygiene  are,  in  the  author's  opinion,  our  best  thera- 
peutic measures,    [t.l  c  ] 

6. — Palmer  thinks  that  anesthetization  should  be  given 
St  more  important  place  in  the  course  of  instruction  in  our 
medical  colleges  and  that  too  much  of  the  work  is  done  by 
untaught  and  inexperienced  men.  He  thinks  the  anesthetist 
should  be  as  much  of  a  specialist  as  a  worker  in  any  other 
particular  department  of  medicine.  He  describes  minutely 
the  preparation  necessary  for  an  anesthetic  and  the  ones 
which  should  govern  us  in  the  choice  of  the  anesthetic. 
Where  there  is  no  choice  between  ether  and  chloroform,  he 
prefers  the  latter,  but  remarks  on  its  dangers  in  the  hands 
of  the  inexperienced.  He  thinks  in  many  cases  where  the 
patient  is  addicted  to  alcohol  or  drugs  that  the  anesthetiza- 
tion should  be  established  with  chloroform  and  kept  up  with 
ether.  This  is  particularly  true  in  those  cases  where  it  is 
difficult  to  accomplish  complete  muscular  relaxation  with 
ether.  Administration  and  alter-treatment  are  carefully  con- 
sidered.    [j.D  G  ] 

7. — Goodhue  reports  two  cases  of  gastric  ulcer.  In  his 
first  case  the  woman  was  placed  at  absolute  rest  and  fed  by 
rectal  alimentation, then  as  her  condition  grew  better  mouth- 
feeding  was  begun.  She  was  pregnant  six  months  at  the 
time  and  in  spite  of  her  alarming  condition,  the  persistent 
vomiting,  etc.,  recovered  and  gave  birth  to  a  healthy  child 
at  term.  His  second  case  was  diagnosed  as  abscess  of  the 
liver  with  localized  peritonitis.  At  autopsy  a  sinuous,  ter- 
raced, round,  pyloric  ulcer  was  found  in  size  abcut  equal  to 
silver  quarter  of  a  dollar.  The  floor  was  formed  by  the  left 
lobe  of  the  liver  where  there  were  partial  adhesions  and 
abundant  pus.  There  was  also  localized  peritonitis.  This 
was  a  case  in  which  timely  operation  might,  in  the  author's 
opinion,  have  saved  the  life  of  the  patient,     [t  l  c  ] 


New  York  Medical  Ileeord. 

January  19, 1901.    [Vol.  59,  No.  3.] 

1.  The  Mosquito  Theory  of  the  Transmission  of   Yellow 

Fever,  with  its  New  Developments.    Chakles  Finlay. 

2.  Notes  on  Ovarian  Grafting.     Robkrt  T.  Morris 

3.  Case  of  Thrombophlebitis  of    the  Left  Sigmoid    Sinus 

Masking  a  Latent  Brain  Abscess  in  the  Lf  fi  Temporo- 
Sphenoidal  Lobe,  both  Arising  from  Chronic  Otitis 
Media.    Carl  Ivoller. 

4.  Subarachnoid  Cocainization  in  Obstetrics  and  Gynecology  ; 

a  Report  of  21  Cases.    N.  J.  Hawley  and  F.'J.  Taussig. 

5.  Important  Points  in  the  Management  and  Treatment  of 

Consumption.    Charles  R.  Upson. 

1. — Treated  editorially. 

3. — Morris  gives  a  report  of  his  experiments  on  ova- 


rian grafting  which  were  begun  in  1895.  His  ca^es  up  to 
the  present  time  number  12.  He  places  the  ovary  that  is  to 
serve  for  a  graft  in  a  basin  of  physiologic  ealine  solution  at  a 
temperature  of  about  100°  F.  immediately  on  its  removal. 
In  his  later  cases  he  has  chosen  the  broad  ligament  ae  a  site 
for  grafting,  and  as  neariy  as  possible  at  the  point  that  the 
ovary  would  normally  occupy.  In  his  experiments  the  best 
result  in  ovarian  grafting  is  the  avoidance  of  the  menopause. 
He  has  had  one  of  pregnancy  follow  which  was  terminated 
by  early  abortion,  but  the  several  succeesful  pregnancies  that 
have  been  obtained  in  rabbits  by  other  experimenters  indi- 
cate that  fruitful  pregnancy  in  women  as  a  result  of  ovarian 
grafting  may  yet  be  hoped  for.     [w.a.s  d.] 

4. — Hawley  and  Taussig  in  discussing  the  suVject  of  sub- 
arachnoid cocainization  in  obstetrics  and  gyne- 
cology remark  that  the  important  points  in  technic  of 
operation  are :  1.  Surgical  cleanliness  in  all  things  and  a 
fresh  aseptic  solution  of  cocain,  full  strength.  2.  The  needle 
need  not  be  longer  than  7  cm.  and  should  be  kept  sharpened. 
3.  A  nurse  should  stand  at  the  patient's  head  when  the 
punctureismade  to  keep  the  back  arched  forward.  4  During 
the  operation  the  patient's  ears  should  be  kept  closed  with 
cotton  and  the  eyes  covered  with  a  towel  or  cloth.  The 
authors  report  21  cases  so  treated,  2  of  which  presented 
symptoms  that  were  serious  but  did  not  endanger  life.  The 
most  constant  toxic  symptom  was  the  vomiting,  which 
appeared  in  TOJt  of  the  cases,  coming  on  within  10  minutee 
of  the  injection.  Headache  followed  in  3  cases.  A  rise  of  tem- 
perature to  101°  F.  to  lOi'  F.  was  observed  in  most  of  the  cases 
12  hours  after  the  injection.  Tne  first  stage  of  labor  was  not 
aflfected  by  the  cocain.  In  70%  of  the  ca^es  the  piins  were 
neither  as  prolonged  nor  as  powerful.  In  5  cases  the  cocaiD 
seemed  to  have  a  toxic  effect  upon  the  child,  asphyxia  being 
noted,     [w  a  x  d.] 

5.— Upson  d:s  usaes  points  in  the  management  of  tuber- 
culosis. He  calls  attention  to  the  method  of  directing  that 
the  patient's  hand  be  placed  on  the  opposite  shoulder  whii'h 
draws  the  scapula  forward,  when  by  placing  the  ear  over  the 
uncovered  portion  of  lung,  we  can,  if  they  be  present,  "  de- 
tect the  prolonged  tubular  breathing  and  fine  rales  on  cough- 
ing ;  early  evidence  of  the  disease."  Upson  has  for  years 
given  the  patients  suffering  from  tuberculosis  a  printed  list  ol 
general  directions  as  to  the  need  of  care  to  prevent  spread 
of  the  infection,  etc.  His  routine  treatment  includes  no 
new  points.  He  says  he  has  used  intrapulmonary  medica 
tion  with  gratifying  results  and  mentions  employment  o> 
euralyptol,  pice  needle  oil,  menthol  and  formic  aldehyd.  Hit 
method,  however,  is  not  given,    [t.l  c] 


Sledical  News. 

January  19,  1901.     [Vol.  lixviii,  No.  3  ] 

1.  Conclusions    Formed    after  6    Years'  Experience    with 

the  Antitoxin  Treatment  of   Diphtheria.    Hejtey  F 

KOESTER. 

2.  Problems  in  the  Etiology,  Diagnosis  and  Treatment  ol 

Tuberculous     Disease    of   tne    Upper    Air  Passages. 
JosATHAS  Wright. 

3.  Notes  on  the  Interesting  Cases  of  a  Month's  Dispensary 

Practice.    William  L.  Stowell. 

1.— Henrv  F.  Koester  gives  results  of  his  conclusions 
formed  after  B  years'  experience  with  the  anti- 
toxin treatment  of  diphtheria.  He  believes  in  early 
injectK  ns  (  f  aniitixin  in  ciues  whicli  are  even  suspicious.  He 
also  believes  in  immuuiziug  those  with  whom  the  pwtieni 
comes  in  contact.  It  is  his  custom  to  give  30i>  to  SlXtunitsic 
tenement  and  tlat-house  di.-lricts  where  children  cannot  be 
closely  watched  and  where  isolation  cannot  be  practised. 
He  has  never  seen  any  complications  or  sequelae  follow  the 
use  of  antitoxin  as  an  immunizing  agent,  except  in  less  thai: 
10%  of  cases  in  which  an  urticaria-like  rash  appears  anc 
this  is  evanescent.  He  believes  antitoxin  is  a  specific  ir 
diphtheria  when  the  case  is  in  the  early  stages,  or  of  a  ver> 
mild  form,  and  in  these  he  has  not  found  it  necessary  t( 
give  more  than  one  injection.  However,  when  the  disease 
has  advanced  and  putrefactive  changes  are  present,  acojm 
panied  by  foul-smelling  discharges,  aiiii^eptic^  form  »t 
important  adjuvant.  He  employs  a  neutral  solution  o 
hydrogen  peroxid  with  double  or  three  times  its  volume  o 
water.    This  solution  should  not  be  sprayed  in  the  thro»t 


JiMOAKV  2«,    1901) 


THE  LATEST  LITERATURE 


[ 


The  Philadelphia 
Medical  Jocbnal 


151 


but  should  be  thrown  in  with  a  long,  nozzled  hard  rubber 
syringe  holding  an  ounce,  after  depressing  the  tongue  with 
some  foice  against  the  pliarj'nx  so  that  the  liquid  washes, 
not  only  the  tonsils,  but  the  pharynx  and  posterior  nares 
as  well.  This  should  be  repeated  every  hour.  In  nasal 
cases  he  irrigates  the  nose  with  a  saturated  solution  of 
boric  acid.  Oa  the  first  day  every  3  or  4  hours,  without 
force ;  but  aftsr  the  second  or  third  day  when  the  membrane 
begins  to  exfoliate,  a  more  forcible  injection  will  often  be  of 
service  in  detaching  membrane  which  has  been  only  partly 
separated.  Care  should  be  taken  that  nothing  is  forced  into 
the  eustachian  tube.  This  is  avoided  by  instructing  the 
patient  to  keep  the  mouth  open.  In  very  young  children  it 
is  necessary  to  accomplish  by  means  of  a  gag.  The  internal 
treatment  is  very  simple.  He  combines  strychnin  with 
essence  of  pepsin,  or  some  other  vehicle.  The  tincture  of 
the  chlorid  of  iron  and  chlorid  of  potash  he  condemns 
strongly,  and  believes  that  alcoholic  stimulants  are  indicated 
in  only  very  severe  cases.  In  convalescents  he  administers 
the  syrup  of  the  iodin  of  iron  preferably.  He  condemns 
calomel  sublimation,  believing  that  it  is  productive  of  sali- 
vation and  it  renders  the  patients  more  liable  to  complica- 
tions. He  does  not  advocate  steam  inhalations  on  account 
of  the  fact  that  to  be  efTective,  the  windows  and  doors  of 
the  rooms  must  be  closed  and  a  free  supply  of  oxygen 
shut  off.  He  explains  the  urticaria-like  rash  on  the  ground 
that  the  blood  already  surchai^ed  with  the  toxins  and  effete 
products  of  the  diseased  condition  has  reached  its  point  of 
saturation  as  far  as  the  eliminative  action  of  the  kidneys 
and  excretory  apparatus  are  concerned.  Upon  adding  to 
the  blood,  already  surcharged  with  these  products,  a  certain 
amount  of  horse  serum  also  containing  hippuric  acid 
and  other  excrementitious  products,  the  urticaria  follows. 
[t.l  c] 

2. — Jonathan  Wright  concurs  in  the  opinion  that  a  sus- 
ceptibility is  always  associated  with  infection  in  tuberculosis. 
The  presence  of  the  organisms  upon  healthy  and  diseased 
mucous  membranes  without  infection  occurring  is  frequent. 
He  denies  that  the  tubercle  bacilli  are  ever  the  cause  of  large 
tonsils  and  adenoids.  From  a  total  sum  of  nearly  1,000 
specimens  of  tonsils  and  adenoids  examined,  the  ratio  of  oji 
has  been  deducted  as  the  proportion  of  latent  tubercu- 
losis in  them.  In  examining  the  air-tract  in  order  to  arrange 
the  anatomical  localities  in  the  order  of  frequency  of  develop- 
ment of  tuberculous  disease,  we  find  it  proceeds  pretty  regu- 
larly from  the  walls  of  the  bronchi,  and  the  air  vesicles  to 
the  nose,  the  larynx  being  perhaps  more  frequently  involved 
than  the  trachea  or  larger  bronchi,  on  account  of  its  greater 
mobility  and  the  complexity  of  its  gross  anatomy.  Discus- 
sing the  diagnosis  he  emphasizes  3  points :  (1)  The  diag- 
nosis of  incipient  laryngeal  tuberculosis  ;  (2)  the  differential 
diagnosis  of  tuberculous  from  syphilitic  laryngitis 
and  these  include  (3)  the  microscopic  examination  of  the 
sputum.  1.  The  patient  may  come  with  much  less  marked 
local  symptoms  than  in  the  secondary  catarrhal  laryngitis, 
and  yet  have  in  his  larynx  the  unmistakable  evidence  of 
tuberculous  disease  in  its  incipiency.  Inspection  reveals  in 
addition  to  the  pale  larynx  and  velum  pajati,  so  suggestive 
of  pulmonary  phthisis,  one  which  is  congested  only  in  spots. 
There  is  a  heaping  up  of  proliferated  epithelium  on  the  pos- 
terior wall — the  pachydermia  laryngi?.  These  appearances, 
however,  are  merely  suggestive,  and  not  confirmatory  of 
tuberculous  laryngitis.  We  must  have,  in  ad('ition,  some 
local  infiltration  or  ulceration  to  render  this  a  probability. 
We  cannot  be  certain  of  the  diagnosis  until  we  have  excluded 
syphilis  and  found  the  tubercle-bacilli.  2.  Syphilis  of  the 
larynx  is  not  a  common  occurrence  in  his  experience. 
Syphilis  of  the  lungs  he  has  even  observed.  A  mistake  in 
the  two  conditions  is  the  more  distressing  from  the  fact  that 
laryngeal  syphilis  is  usually  easily  curable,  but  with  the 
same  treatmeLt  that  is  used  in  laryngeal  tuberculosis  it 
is  almost  as  fatal  as  the  latter.  With  a  history  of  syphilis 
and  scar-tissue  in  the  pharynx,  or  on  the  epiglottis  with  a 
peculiar  sharp-cut  serpiginous  ulceration,  characteristic  of 
syphiUs  of  the  mucous  membrane,  the  diagnosis  is  easily 
made,  but  in  many  cases  the  two  conditions  present  strik- 
ingly similar  appearances.  The  promptness  and  suddenness 
with  which  laryngeal  stenosis  in  syphilis  may  occur  is  a 
differential  diagnostic  point  which  is  frequently  neglected. 
The  author  closes  with  a  commendable  conservative  criticism 
as  to  methods  of  palliation  and  cure,     [t.l.c] 


Boston  Medical  and  Surgical  Journal. 

January  17,  1901.     [Vol.  cxliv.,  No.  3.] 


1.  Address. 

2.  Address. 

3.  Remarks. 

4.  Remarks. 

5.  Remarks. 

6.  Remarks. 

7.  Remarks. 

8.  Letter.    S, 

9.  The  X  ray 


David  W.  Oheever. 
James  R.  Chadwick. 

F.  W.  Draper. 

William  Osler. 

J   S.  Billings. 

H.  C.  Wood. 

Henry  P.  Walcott. 

Weir  Mitchell. 
.    Williams. 


9. — Williams'  experience  at  the  BDston  City  Hospital  in- 
dicates that  we  have,  either  in  the  x-rays  themselves  or 
from  some  other  form  of  radiation  from  an  excited  Crookes' 
tube,  a  valuable  therapeutic  agent  in  epithelioma  and  that 
the  beneficent  action  of  the  x-rays  can  be  brought  about 
without  causing  a  burn.  Without  causing  pain,  the  applica- 
tion of  the  x-rays  is  followed  by  a  cessation  of  foul  and 
nearly  unbearable  odors,  a  lessening  of  the  discharge  and  a 
diminution  of  the  size  of  the  growth.  The  earlier  the  treat- 
ment is  undertaken  the  better.  It  is  not  improbable  that  we 
shall  find  its  curative  action  limited  to  superficial  growths, 
though  as  a  means  of  relieving  the  painful  features  of  the 
disease  in  other  forms,  it  may  be  of  some  use.  iDetails  of  the 
application  are  promised,     [j  m  s.] 


Journal  of  the  American  Medical  Association. 

January  19,  1901.    [Vol.  xxxvi,  Xo.  3.] 

1.  A  Clinical  Study  of  150  Cases  of  Hyperphoria.  Wendell 

Reber. 

2.  Ovular  Complications  of  Injaries  to  the  Head.    John  T. 

Carpenter. 

3.  The  Silver-injection  Treatment  of  Pulmonary  Consump- 

tion.   Thomas  J.  Mays. 

4.  Tuberculosis  of  the  Lunsrs  Treated  by  Cjmpressioa  with 

Nitrogen  after  the  Method  of  Murphy,  with  Further 
Remarks  on  the  Rationale  of  the  Procedure  and  a 
Record  of  Experiments  on  Dogs.    A.  F.  Lemke. 

5.  Angina  Epiglottidea   Anterior.    Report  of  Three  Cases. 

Clement  F.  Theisen. 

6.  Athrepsia  Infantum— Marasmus,  or  Wasting  Disease- 

Atrophy — Malaesimilation  of  Food ;  Its  Cause  and 
Treatment ;  Proper  Infant  Feedins.   Louis  Fischer. 

7.  Light  and  Seating  in  the  School.    C.  Zimmerman. 

8.  Some  Remarks  on  the  Piantar  Rsflex,  with  Special  Refer- 

ence to  the  Babinski  Phenomenon.    J.  T.  Eskridge 

9.  Costa  Rica,  Its  Physicians  and  Medical  Institutions.    N. 

Senn. 

1.— After  a  careful  investigation  of  his  last  700  cases, 
Reber  believes  that  it  is  impossible  to  determine  what  lenses 
are  to  be  prescribed  in  ametropia  unless  a  thorough  knowl- 
edge of  the  performance  of  the  muscular  function  is  ob- 
tained. He  has  found  that  the  addition  of  a  vertical  prism 
to  the  patient's  curvature  correction  has  often  been  fruitful 
of  relief.  The  author  considers  the  Maddox  rod  of  great 
value  in  these  cases.  Hyperphoria  occurs  in  about  one  sixth 
of  the  patients,  but  only  becomes  worthy  of  special  notice  in 
one-fifth  of  the  refraction  cases.  In  33%  of  all  cases  it  be- 
comes more  manifest  after  the  thirtieth  year.  Correction 
with  prisms  is  of  service  in  about  bOfc  of  all  the  cases. 
Exercising  insuflSeient  convergence  and  repressing  an  excess 
of  convergence  often  bring  about  relief  of  the  symp- 
toms which  frequently  are  neuralgia,  photophobia  and 
physical  tiredness  aftercontinuous  near  work,  the  litter  symp- 
tom generally  being  in  disproportion  to  the  amount  of  work 
done.  As  a  last  resort  tenotomy  of  one  of  the  vertical  mus- 
cles will  have  to  be  performed,     [m.r.d  ] 

2.— Carpenter,  in  discussing  the  ocular  complications 
of  injuries  to  the  head,  other  than  those  directly  pro- 
duced upon  the  eyeballs,  reports  a  case  of  optic  atrophy 
occurring  in  a  man  who  was  thrown  to  the  ground  strik- 
ing the  right  side  of  his  head.  Dimness  of  vision  set  in 
10  days  after  the  accident.  The  case  was  diagnosticated 
as  a  descending  neuritis  originating  from  a  localized 
traumatic  meningitis  at  the  base  of  the  brain  and  involving 
the  optic  nerve.    Four  years  after  the  accident  the  vision 


152 


Medical  Journal 


] 


THE  LATEST  LITERATURE 


[JaXUaev  2S,  1901 


•was  ^\%,  gocd  peripheral    visual  field,   and   an   absolute 
central  scotoma,    [m  r  d.] 

_3. — Mays  advocates  the  use  of  silver  nitrate  injec- 
tions in  the  neck  along  the  course  of  the  pneumogastric 
nerves  in  pulmonary  consumption.  He  advocates  the  use  of 
a2J%  solution  in  5  minim  doses,  the  itjections  being  re- 
peated every  7  or  10  days,  and  in  urgent  cases  every  3  or  4 
days.  The  highest  number  of  injections  given  in  a  single 
case  was  21.  In  reviewing  the  results  of  this  treatment  he 
finds  that  50%  of  the  patients  treated  were  practically  well 
at  the  end  of  a  year  and  a  half.  He  concludes  his  article  by 
giving  the  report  of  a  number  of  cases,     [f.j.k.] 

_4. — Lemke  recommends  the  use  of  intrapleural  injec- 
tions of  nitrogen  in  the  treatment  of  tuberculosis  of  the 
lungs,  stating  that  after  compression  of  the  lungs  fibroid 
changes  develop.  This  cicatrization  assists  nature  in  the 
healing  of  the  tubercle.  Cavities,  if  present,  are  compressed 
and  healing  is  favored,  and  by  the  rest  the  organ  receives  by 
this  method  of  treatment  secondary  infection  and  a  lessened 
tendency  to  hemorrhage  is  brought  about.  Pleural  adhe- 
sions are  not  so  extensive  as  might  be  expected,  ard  he 
further  states  that  after  long  compression  the  healthy  por- 
tion of  the  lung  may  again  expand  when  intrapleural  pressure 
is  removed.  The  risk  of  the  operation  is  very  slight.  He 
concludes  by  saying  that  this  treatment  is  curative  in  some 
cases  and  palliative  in  other.a,  prolonging  life  for  some  time. 
This  treatment  is  also  of  value  just  prior  to  surgical  opera- 
tion when  the  pleural  cavity  is  to  be  opened,    [f  j.k.] 

6. — Angina  epiglottidea  anterior  is  discussed  by 
Theisen  with  a  report  of  three  cases.  He  describes  the  con- 
dition as  being  an  inflammatory  process  accompanied  by 
edema  and  confined  to  the  anterior  surface  of  the  epiglottis. 
The  inflammation  may  extend  by  way  of  the  submucous  tis- 
sue of  the  pharyngo-epiglottic  ligament  to  the  aryepiglottic 
folds.  He  prefers  the  name  of  acute  epiglottitis  or  simple 
epiglottitis  to  angina  epiglottidea  anterior.  The  condition 
is  often  primary  in  the  course  of  an  infectious  disease, 
but  may  be  secondary.  In  the  three  cases  he  reported  the 
onset  was  sudden,  with  fever,  and  other  manifestations  of  an 
acute  infection.  The  local  symptoms  were  diflSculty  in 
swallowing,  severe  pain  in  the  throat,  and  upon  examination 
the  anterior  surface  of  the  epiglottis  was  found  red  and  swol- 
len. Inoculations  taken  from  the  serum  of  the  deeper  tissues 
of  the  epiglottis  revealed  cultures  of  the  Staphylococcus  albus 
and  pneumococcus  in  one  case,  and  the  streptococcus  and 
pneumococcus  in  the  other.  In  the  remaining  case  the  bac- 
teriological examination  was  not  made.  As  to  treatment,  he 
recommends  early  scarifications  and  the  use  of  iced  ichthyol 
sprays,    [f  j.k.] 

6. — AVill  be  considered  editorially. 

7.— Zimmermann,  in  discussing  the  relation  of  visual 
acuity  to  the  degree  of  illumination,  calls  attention  to  the 
necessity  of  light  and  seating  in  the  school.  If  there 
is  a  lessening  in  illumination  the  pupil  will  have  to  bring 
the  book  nearer  to  his  eye  so  that  both  visual  angle  and 
retinal  image  become  larger.  The  increased  amount  of 
accommodation  and  convergence  necesfarily  called  into 
play  causes  strain  and  congestion  of  the  eyes.  If  the  head 
is  bent  in  order  to  facilitate  the  continuation  of  the  pupils' 
work,  there  may  follow  a  compression  of  the  vessels  in  the 
neck  and  a  retardation  of  the  venous  blood.  The  photometer 
devised  by  L.  Weber,  of  Breslau,  permits  a  rapid  determina- 
tion of  the  amount  of  the  illumination  present  in  the  school- 
room during  the  day.  The  unit  of  light  intensity  in  this  case  is 
the  meter- candle  which  equals  the  illumination  of  a  sheet 
of  paper  one  meter  distant  from  a  candle  compcscd  of  stearine, 
6  of  such  candles  being  required  to  weigh  1  pound.  The 
light  from  the  sky  reflected  from  the  ceiling  is  considered  to 
be  the  best.  In  the  lower  stories  of  the  schoolroom,  where 
light  cannot  be  obtained  from  above,  it  is  best  to  have  the 
pupils  seated  so  that  the  windows  are  on  their  left,  thereby- 
preventing  the  formation  of  a  shadow  from  the  hand. 
The  tint  of  the  walls  is  to  be  light  gray.  The  author 
discusses  the  various  experiments  that  have  been  made 
regarding  the  formulation  in  mathematical  terms  of  the 
definite  law  that  exists  between  sight  and  light  intensity. 
Next  to  light  the  most  important  uygienic  principle  that 
demands  the  attention  of  school  legislation  is  the  correct 
seating  of  the  pupils.  It  has  been  shown  by  laws  of  phy- 
sics that  the  bcdy  is  only  comfortable  in  a  sitting  posture  when 
the  point  of  gravity  which  lies  in  front  of  the  tenth  chest 


veitebra  forms  a  perpendicular  to  a  line  drawn  through 
the  tuberosities  of  the  ischia,  the  latter  being  the  rotation 
points  of  the  trunk.  The  distance  between  the  desk  and  seat 
must  be  in  such  relation  to  the  pupil  that  when  in  the  erect 
position  the  eyes  remain  40  cm.  from  the  desk.  The  author 
believes  that  although  the  best  constructed  seats  catmot 
always  obviate  faulty  positions  of  the  students,  nevertheless 
the  observation  of  the  hygienic  principles  mentioned  will 
serve  to  prevent  many  ocular  defects,    [m.e.d.] 


Archives  of  Pediatrics. 

Janiuiry,  1901.    [Vol.  xviii,  No.  1.] 

1.  Congenital  Stenosis  (Spasmodic)  of  the  Pylonia ;  Recovery. 

Thomas  S.  Southworth. 
2   Retropharyngeal  Abscess  and  Adenitis.    Ie^tsg  M.  Snow. 

3.  Pyelonephritis  in  Children,  with  report  of  a  Case  in  which 

Nephrectomy    was    Successfully   Performed.      Loms 
Fischer. 

4.  Clinical  Notes  on  Scurvy  in  the  Island  of  Cuba.    J.  L. 

DtJENAS. 

5.  Remarks  on  the  Pathogenesis  and  Prophylaxis  of  Acute 

Rheumatic  Fever  in  Children.    Hesry  Heimah. 

6.  Malarial  Coma  in  a  Boy.    E.  P.  Stose. 

1. — Southworth  reports  the  case  of  a  baby  in  whom  con- 
genital pyloric  stenosis  was  diagnosed  for  the  following 
reasons  :  1.  The  early  occurrence  and  persistence  of  vomiting 
uninfluenced  by  the  usual  meaaures  for  its  relief.  2.  The 
absence  of  any  vestige  of  milk  residue  in  the  stools  until  the 
ninth  day,  while  the  presence  of  green  mucous  etools  ex- 
cluded obstruction  below  the  duodenum.  3.  Perfect  diges- 
tion of  the  milk  residue  when  it  appeared  in  small  quantities 
in  the  stools,  despite  the  continuance  of  the  vomiting,  which 
seemed  to  preclude  the  possibility  that  that  symptom  was 
due  to  indigestion.  4.  The  absence  of  constipation,  tem- 
perature, or  any  other  symptom  on  the  part  of  the  mother 
that  might  cause  her  milk  to  disagree  with  the  baby; 
maternal  anxiety  was  net  awakened  until  long  after  the  in- 
ception of  the  vomiting.  Two  years  before  the  mother  had 
successfully  nursed  her  first  child.  5.  The  abrupt  cessation 
of  the  vomiting,  which  pointed  to  a  sudden  relief  of  the 
exciting  cause.  The  complete  cessation  of  vomiting  and 
subsequent  absence  of  unfavorable  symptoms  are  in  support 
of  the  view  that  the  pyloric  stenosis  was  functional  and  de- 
pendent upon  the  condition  of  the  pyloric  valve,    [j  m.s.] 

2.— Snow  reports  3  cases  of  retropharyngeal  abscess 
and  adenitis.  In  the  first  case,  at  the  age  of  one  month 
the  baby  had  an  acute  feverish  illness  with  profuse  nasal 
secretion  ;  after  a  few  days  the  fever  sudsided  and  the  nasal 
discharge  lessened,  although  much  pus  with  blood  crusts  still 
came  out  of  the  nose.  At  the  age  of  two  months  the  bloody 
purulent  coryza  persisted.  Exammation  at  that  time  showed, 
about  the  level  of  the  epiglottis,  projecting  forward  from  the 
posterior  pharynx,  in  the  median  line,  a  pyramidal  swelling 
whose  apex  encroached  upon  the  entrance  to  the  esophagus. 
The  ma«s  was  hard,  not  movable  or  fluctuating,  and  was  evi- 
dently an  enlarged  retropharyngeal  lymph  node,  a  result  of 
the  intense  rhinitis.  Under  proper  local  treatment  the 
coryza  rapidly  ameliorated  and  in  two  weeks  the  child  was 
well.  At  the  end  of  two  months  exploration  of  the  throat 
showed  that  the  swelling  had  entirely  disappeared.  The 
second  patient  was  a  boy  of  16  months,  who  suffered  from  an 
attack  of  influenza.  His  head  was  held  st:iHy  erect  and  there 
was  diflSculty  in  swallowing  and  obstructed  snoring,  breath- 
ing, especially  at  night.  The  left  tonsil  was  swollen  and  a 
fluctuating  swelling  lay  behind  it.  The  abscess  was  first 
aspirated  and  afterward  incised  and  evacuated.  Tne  child 
continued  feverish  and  languid  and  was  attacked  by  a  severe 
ileocolitis  lasting  12  days.  The  recovery  was  slow  :  the  neck 
muscles  were  rigid ;  pressure  on  the  top  of  the  head  caused 
acute  pain,  giving  rise  to  a  suspicion  of  cervical  caries  ;  the 
throat  was  clear ;  and  there  was  no  tetdemess  or  prominence 
of  the  cervical  vertebrae.  The  retropharyngeal  abscess  and 
the  continued  fever  and  ileocolitis  were  probably  caused  by 
a  streptococcus  infection.  The  pain  and  rigidity  of  the  neck 
muscles  were  attributed  to  a  synovitis  of  the  cervical  verte- 
brae, also  from  a  streptococcus  infection.  In  the  third  case 
the  patient  was  a  boy  of  15  months  who  had  pharyngitis  and 
tonsillitis.    The  cervical  lymph-nodes  became  enlarged  and 


JAK0ARY  26,   1901] 


THE  LATEST  LITERATURE 


CThe  Philadelphia 
Medical  Journal 


153 


one  evening  an  alarming  attack  of  dyspnea  developed  which, 
however,  was  not  attended  by  cyanosis.  There  was  no  inspira- 
tory recession  of  the  chest.  A  large  fluctuating  swelling  was 
found  in  the  posterior  pharynx.  A  mouth  gag  was  introduced 
for  a  thorough  examination  of  the  throat  and  to  aspirate  the 
swelling.  The  baby  suddenly  became  livid,  stopped  breath- 
ing, and  died.  The  swelling  behind  seemed  to  narrow  the 
lumen  of  the  trachea.  An  autopsy  was  refused,  but  by  ex- 
amining the  throat  it  was  shown  that  the  abscess  extended 
deep  into  the  pharynx,  so  that  only  the  upper  portion  could 
be  reached  by  the  finger.  The  introduction  of  the  gag 
Btretched  the  jaws  and  pressed  the  root  of  the  tongue  back 
against  the  pharyngeal  swelling.  It  is  probable  that  death 
was  due  to  disturbance  of  the  vagus,     f  j.m.s] 

3. — Fischer  reports  the  case  of  a  girl  12*  years  old.  When 
4  years  old  the  child  had  measles  and  chicken-pox.  Follow- 
ing this  attack,  the  urine  became  thick  and  cloudy ;  the  child 
had  fever  and  chills,  but  never  vomited.  When  seen  by  the 
author,  the  patient  proved  to  be  a  very  poorly  nourished, 
constipated  child,  with  a  sallow  complexion  and  flabby  mus- 
cles. Anorexia  and  general  apathy  were  present.  She  com- 
plained of  abdominal  pains,  mostly  on  her  right  side  in  the 
hypochondriac  and  iliac  regions,  the  pain  being  constant  and 
increaaed  on  palpation.  On  examination  a  large  tumor  was 
seen  and  easily  felt  on  the  right  side  of  the  abdomen.  The 
urine  contained  large  quantities  of  albumin,  casts,  blood,  and 
leukocytes.  At  no  time  could  pus  be  found  in  the  urine.  The 
temperature  range  from  1C0°  to  103°.  The  patient  was  oper- 
ated upon,  and  the  tumor  was  found  to  be  of  kidney  origin. 
The  peculiar  lobulated  kidney- tumor  was  peeled  from  its 
bed  without  much  difliculty.  The  tissue  was  so  friable  that 
it  was  removed  piecemeal,  and,  in  breaking  into  the  pelvis, 
about  a  teacupful  of  pus  and  sandy  concretions  were  removed. 
The  renal  vessels,  both  artery  and  vein,  were  destroyed,  so 
that  insignificant  bleeding  occurred.  The  following  is  an 
abstract  of  the  pathologic  report :  The  pelvis  was  a  large  pus 
sac  containing  many  small  calcareous  particles.  Stained 
specimens  did  not  show  organisms.  Th  e  kidney  tissue  proper 
was  the  seat  of  numerous  small  abscesses,  and  here  and 
there  remnants  of  the  kidney  tissue  showed  a  chronic  in- 
terstitial nephritis.  The  case  was  one  of  pyelonephritis 
with  chronic  interstitial  nephritis.  The  patient  recovered, 
and  3  months  after  the  operation  the  child  was  found  per- 
fectly well,    [j.m.s] 

4.— See  editorial  columns  Philadelphia  Medical  Jour- 
nal, Vol.  VII,  p.  91. 

6. — In  acute  rlienmatic  fever  in  children  there  is 
less  liability  to  joint  involvement  than  in  adults  and  it  may 
be  altogether  absent.  Sometimes  the  only  evidence  of  a 
joint  implication  is  the  subjective  symptom  of  pain  com- 
plained of  by  the  child,  the  so-called  "growing  pains."  At 
other  times  when  the  joint  is  involved  the  anatomic  changes 
are  not  so  severe  as  in  adults,  there  being  less  exudation  and 
fewer  structural  changes  of  the  joint  and  the  surrounding 
tissues  and,  therefore,  less  pyrexia.  On  the  other  hand, 
strange  to  say,  there  is  in  childhood  a  greater  tendency  to 
metastasis  of  the  microorganism  and  their  toxins  leading  to 
an  involvement  of  other  tissues  and  serous  membranes  and 
even  the  skin.  We,  therefore,  have  as  a  frequent  accom- 
paniment or  a  manifestation  ot  the  diseased  joints,  a  torticol- 
lis, an  erythema  nodosum,  a  purpura  rheumatica,  a  chorea, 
an  endocarditis,  a  pericarditis,  a  myocarditis,  or  a  formation 
of  tendinous  nodules.  Heiman  has  seldom  found  the  pleura 
involved  in  children  under  4  years  of  age.  Endocarditis  is 
the  complication  most  frequently  present  in  childhood. 
Peptonuria  is  a  frequent  condition  found  in  acute  rheu- 
matic fever  in  children.  This  is  probably  caused  by  an  abund- 
ant destruction  of  the  leukocytes  with  an  absorption  of  their 
peptones.  Rheumatic  fever  is  very  rare  in  children  under  3 
years  of  age,  although  there  are  some  authentic  cases  reported . 
It  is  well  to  remember  that  the  majority  of  cases  of  joint 
disease  in  children  under  1  year  of  age  are  really  manifesta- 
tions of  scurvy.  Tlie  indications  for  the  treatment  of  this 
disease  are :  1.  To  combat  the  poison.  2.  To  alleviate  the 
symptoms.  3.  To  prevent  involvement  of  the  heart,  and  to 
prevent  recurrences.  The  best  method  of  counteracting  the 
poison  is  by  the  salicylates.  In  acute  rheumatic  fever,  the 
author  administers  the  salicylates  prophylaclically.  After 
the  acute  local  and  constitutional  symptoms  have  subsided 
and  the  patient  is  to  all  intents  and  purposes  apparently 
cured,  the  administration  of  the  salicylates  is  continued  in  3 


or  5  grain  doses  3  times  daily,  according  to  age,  for  1  week 
of  each  month  for  a  year  or  more,     [j.m.s.] 

6.— Stone  reports  the  case  of  a  boy  aged  3  years  and  8 
months,  in  whom  there  was  no  history  of  previous  malarial 
attacks.  The  child  lived  in  a  malarial  district  and  his  father, 
mother,  and  an  older  brother  had  had  malaria.  In  the 
course  of  his  illness  the  patient  became  comatosed  and  a 
diagnosis  of  malarial  coma  was  made.  The  blood  con- 
tained the  malarial  organisms ;  recovery  was  complete. 
[j.m.s.] 

The  Practitioner. 

January,  1901. 

1.  The  Epidemiology  of  Rheumatic  Fever.     Arthur  News- 

holme. 

2.  The  Pathology  of  Rheumatic  Fever.    F.  J.  Poynton. 

3.  Rbeumatic  Fever  in  Relation  to  the  Tnroat.    St.  Clair 

Thomson. 

4.  The  Effects  of  Rheumatic  Fever  on   the  Heart.    G.  A. 

Gibson. 

5.  Rheumatism  in  Childhood.    George  F.  Still. 

6.  The  Treatment  of  Rheumatic  Fever.     Akthl'r  P.  Luff. 

7.  Medical  Men  of  Letters — Oliver  Wendell  Holmes. 

1, — Newsholme  has  made  a  thorough  study  of  the  statis- 
tics of  rheumatic  fever.  He  concludes  that  these  statis- 
tics show  two  kinds  ol  epidemics,  which  he  designates  as 
explosive  and  protracted.  The  explosive  epidemics 
terminate  in  one,  or  at  the  utmost  three  years.  The  protracted 
epidemics  are  observed  chiefly  in  large  centers  cf  popula- 
tion, or  when  we  are  studying  the  statistics  of  an  entire 
country.  These  may  represent  the  fusion  of  two  or  more 
explosive  epidemics  which  do  not  exactly  coincide  with  each 
other  in  point  of  time.  He  finds  there  are  certain  favorite 
years  for  epidemics.  Thus,  in  England  these  are  1855-6, 
1859,  1864-5, 1868-71, 1874-6, 1884-5,1888,  and  1893.  In  other 
countries  the  same  years  are  frequently  characterized  by 
epidemics,  but  in  some  instances  there  is  an  anticipation  of 
or  lagging  behind  the  favorite  years  for  England.  While 
there  is  no  regular  periodicity  in  the  epidemic  years,  epi- 
demics are  apt  to  recur  at  intervals  of  3,  4,  or  6  years.  There 
is  in  many  instances  a  regular  alternation  between  the  explo- 
sive and  the  protracted  epidemics,  two  of  the  shorter  and 
smaller  epidemics  commonly  occurring  before  the  return  of 
an  epidemic  of  the  protracted  variety.  The  occurrence  of 
definite  epidemics  is  valuable  confirmatory  evidence  that 
rheumatic  fever  partakes  of  an  infectious  character. 
The  infectious  nature  of  the  disease  is  also  confirmed  by  its 
mode  of  onset,  the  frequent  occurrence  of  preliminary  sore 
throat,  and  the  course  of  the  fever.  The  apparent  absence 
of  infection  from  person  to  person  is  explicable  on  the 
ground  that  the  contagium  is  buried  deep  in  the  infected 
joints.  The  specific  action  of  salicin  is  also  comparable  to 
that  of  quinin  in  malaria  and  mercury  in  syphilis.  There 
is  important  evidence  that  the  infection  of  rheumatic  fever 
may  cling  about  certain  houses  in  a  manner  strikingly  like 
that  of  tuberculosis  and  diphtheria.  The  susceptible  popu- 
lation is  not  attacked  at  the  same  time,  which  may  be  ex- 
plained upon  the  ground  of  the  gradual  convection  from 
place  to  place.  The  disease  is  probably  ubiquitous.  Four 
out  of  every  thousand  persons  are  annually  attacked  by 
rheumatic  fever.  It  is  essentially  an  urban  rather  than 
a  rural  disease.  Newsholme  concludes  that  the  disease 
is  essentially  a  soil  disease,  due  to  a  saprophytic  soil 
organism  which  is  drowned  out  in  wet  years,  and  multiplies 
rapidly  in  dry  years.  Possibly  dust  convection  accounts  for 
a  large  percentage  of  the  cases.  The  inoculation  may  be 
brought  about  by  domestic  vermin,  or  the  house  fly  may 
convey  it  to  milk  and  other  foods.  The  important  observa- 
tion that  dry  years  favor  the  causation  of  rheumatic  fever, 
rather  than  wet  years,  seems  borne  out  by  facts,   [t.l.c] 

2.— Rheumatic  fever  being  preeminently  a  disease  of 
childhood  it  becomes  essential  that  the  pathology  of  the 
disease  must  explain  the  manifestations  which  are  met  with 
in  the  young.  The  cardinal  lesions,  such  as  endo-  and  peri- 
carditis and  nodule  formation,  are  strikingly  comparable  to 
each  other.  Each  shows  a  destructive  and  reparative  pro- 
cess, in  none  does  suppuration  occur.  The  changes  are 
suggestive  of  a  specific  cause  and  analogous  to  the  metastasis 
of  pyogenic  infections.  The  lesions  found  are  characterized 
in  the  human  tissues  by  great  local  resistance  and  a  tendency 


154 


The  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[JiSrAEY  28,  ISM 


to  recovery.  Poynton  gives  a  reBumt'  of  the  theories  of  the 
pathology  of  rheumatic  fever.  He  mentions  Cullen's  theory 
that  the  condition  is  a  direct  result  of  cold  upon  the  joints 
— now  untenable — and  J.  K.  Mitchell's  nervous  theory. 
Poynton  believes  that  the  nervous  theory  exaggerates  the 
importance  of  the  influence  of  the  nervous  system  upon 
other  organs  of  the  body  and  there  is  no  proof  that  carditis, 
pleurisy  snd  subcutaneous  nodules  can  result  from  lesions  of 
the  nervous  system.  The  toxemic  theory  implies  that  the 
cause  of  the  disease  is  some  poison  circulating  in  the  blood. 
It  has  led  to  three  distinct  conceptions  :  (1)  the  chemical 
theory;  (2)  the  neurochemical  and  (3)  the  infectious 
theory.  Ttie  chemical  theory  explains  the  causation  of 
the  disease  on  the  ground  that  lactic  acid  is  the  offending 
material ;  other  authorities  claim  that  uric  acid  is  respon- 
sible. To  both  of  these  theories  Poynton  advances  the  objec- 
tion that  the  proof  that  these  acids  are  in  excess  in  the  blood- 
tissues  or  the  sweat-secretion  of  rheumatic  fever  is  insuffi- 
cient, and  we  are  not  certain  that  the  typical  lesions  may  be 
produced  by  either  or  both  of  these  factors.  It  is  true,  be- 
yond question,  however,  that  Richardson,  in  1853,  and  other 
observers  after  him,  obtained  the  clinical  picture  of  rheu- 
matism by  the  injection  of  a  10%  solution  of  lactic  acid. 
The  clinical  picture  of  rheumatism  favors  greatly  the 
infectious  theory.  This  is  well  borne  out  by  the  path- 
ology of  the  disease  and  the  researches  which  tend  to  prove 
its  epidemiology.  While  there  are  certain  features  of  re- 
semblance between  malaria  and  rheumatic  fever,  the 
local  inflammations  of  the  joints  and  viscera  of  rheumatism 
are  unlike  malaria  and  the  blood  examinations  are  totally 
dissimilar.  The  other  important  views  on  the  nature  of  the 
infection  are  respectively  :  (1)  that  there  is  no  specific  micro- 
organism, but  the  disease  is  a  form  of  septicemia  which 
owes  its  origin  to  staphylococcal  or  streptococcal  infection  ; 
(2)  that  the  infection  is  necessarily  symbiotic;  (3)  that  the 
microorganism  is  a  specific  bacillus ;  (4)  that  the  microor- 
ganism is  a  specific  diplococcus.  The  first  two  of  these  views 
have  hosts  of  supporters  and  in  our  present  state  of  bacteri- 
ological knowledge  the  question  remains  an  open  one.  The 
symbiotic  nature  of  the  infection  has  been  advanced  because 
cocci  have  been  so  frequently  found  in  rheumatic  lesions 
which  are  not  specific.  A  specific  anaerobic  bacillus  has 
been  isolated  by  Alchalme  and  others.  A  diplococcus  has 
also  been  isolated  by  several  observers,  including  the  author 
in  association  with  Paine.  They  have  isolated  these  from 
the  blood,  urine  and  tonsils  in  patients  ill  of  rheumatic 
fever  and  in  the  postmortem  lesions  of  the  condition.  By 
a  series  of  carefully  conducted  experiments  they  have  been 
able  to  produce  by  intravenous  inoculation  into  rabbits, 
polyarthritis,  valvulitis,  pericarditis,  chorea  and  nodules. 
They  have  been  found  in  these  lesions  in  rabbits, 
and  in  both  rabbits  and  man  circulate  in  the  blood 
during  an  attack  of  pericirditis.  The  authors  report 
of  the  great  difficulty  of  recognition  of  the  organ- 
isms, apart  from  their  small  size  and  the  question  of 
technic ;  it  is  on  account  of  the  fact  that  the  disease  is  rarely 
fatal  early  and  the  organisms  are  rapidly  destroyed  in  these 
lesions.  Poynton  suggests  a  possible  explanation  of  the 
rheumatic  recurrences  by  the  persistence  of  a  single  coccal 
form  which  survives  after  the  disappearance  of  the  diplo- 
coccus.    [t.lc] 

3, — In  a  considerable  number  of  cases  of  rheumatic 
fever  the  poison  enters  the  system  through  the  tonsils,  the  in- 
flammation of  which  may  be  the  earliest  indication  of  the  sys- 
temic infection.  The  second  is  that  certain  inflammations 
of  the  tonsil  occur  with  greater  frequency  in  patients  with 
an  arthritic  diathesis.  There  are  two  varieties  of  rheumatic 
sore  throat — faucial  erythema  and  tonsillitis  proper.  Faucial 
erythema  is  more  common  in  adults ;  rheumatic  tonsillitis 
in  children,  iu  whom  it  usually  assumes  the  follicular  type. 
Quinsy  being  more  common  in  older  subjects.  Faucial 
erythema  is  an  initial  manifestation  of  acute  rheumatism. 
Tonsillitis  may  be  the  actual  primary  lesion.  We  know  that 
endocarditis  has  followed  a  nonscarlatinal  tonsillitis  unac- 
companied by  joint  pains.  In  other  cases  the  tonsillitis  has 
immediately  preceded  an  attack  of  arthritis  or  of  chorea. 
Tonsillitis  may  also  occur  during  as  well  aa  at  the  beginning 
of  a  prolonged  rheumatic  attack.  We  can  prove  no  caus.i- 
tive  relation  between  peritonsillar  abscess  and  rheumatism. 
It  has  been  stated  that  one-third  of  all  cases  of  pharyngitis 
and  tonsillitis  are  due  to  the  rheumatic  taint,  but  the  author 


thinks  this  percentage  too  high  and  believes  that  many  are 
secondary  to  purulent  affections  of  the  nose,  or  catarrhal 
conditions  of  the  stomach.  The  theory  that  amygdalitis  is 
chiefly  predisposed  to  by  the  rheumatic  diathesis  is  not  with- 
out its  opponents.  Especially  is  it  pointed  out  that  recurring 
angina  is  rare  in  those  or  an  acute  attack  of  rheumatism — 
that  later  in  life  the  tonsils  become  less  and  less  subject  to 
inflammation,  while  the  tendency  to  rheumatic  conditions 
gradually  increases.  The  salicylates  are  not  specific  against 
tonsillitis.  The  author  concludes :  1.  That  .30  to  80%  of  caeee 
of  acute  rheumatism  are  preceded  by  an  angina.  2.  That 
both  conditions  have  many  etiologic  points  in  common — 
season  of  the  year,  cold,  wet,  fatigue,  depression,  vitiated 
air,  etc.  3.  The  connection  of  angrina  and  rheumatisin, 
though  undoubted  in  a  number  of  cases,  is  not  yet  clearly 
established.  4  The  tonsils  may  be  the  points  of  entry  of  the 
rheumatic  virus,  and  this  even  although  the  naked-eye 
appearance  of  the  throat  gives  no  indication  of  its  beLoe 
affected.  5.  The  particular  affection  of  the  throat  whicS 
is  associated  with  rheumatism  is  not  yet  eatablisbed. 
Apparently  it  is  not  peritonsillar  abscess  (quinsy).  6. 
Peritonsillar  inflammation  does  not  appear  to  be  arrested 
by  the  antirheumatic  remedies.  Many  cases  of  parenchy- 
matous and  lacunar  tonsillitis,  on  the  other  hand,  are  con- 
siderably  benefited  by  such  treatment.  7.  The  qaestioa 
requires  further  research  in  two  directions  :  One  in  differen- 
tiating the  various  forms  of  angina  and  determining  the  one 
which  is  associated  with  rheumatism ;  the  other  to  discover 
the  true  nature  of  rheumatism  itself.  Thomson  points  out 
the  frequent  inflammatory  conditions  of  the  naso-  and  oro- 
pharynx in  their  association  with  rheumatism  and  the  condi- 
tion of  g^ranular  pharyngitis  with  arthritism.  Operations 
on  the  nose  have  been  followed  by  angina;  and  this  in  torn 
by  an  attack  of  rheumatism.  In  many  cases,  also,  there  may 
occur  an  acute  inflammation  in  the  cricoarytenoid  joint. 
This  may  be  mistaken  for  paralysis  of  the  recurrent  laryngeal 
nerve,  but  may  be  differentiated  by  the  following  signs  :  (1) 
Dysphagia ;  (2)  painful  cough  ;  (3)  occasional  tumefaction  oyer 
the  arytenoid ;  (4)  sharp  pain  on  pressure  along  the  poeteriw 
border  of  the  thyroid  cartilage  ;  (5)  the  healthy  arytenoid  is 
not  tilted  forward  into  the  affected  one,  and  the  healthy  cord 
does  not  during  adduction  pass  across  the  median  line  toward 
the  other  side.  In  addition,  this  affection  of  the  cricoarytenoid 
joint  is  usually  associated  with  (a)  the  existence  or  preexist- 
ence  of  an  acute  pharyngeal  catarrh :  (b)  laryngeal  hyper- 
emia ;  (c)  a  more  or  less  pronounced  feverish  condition ;  and 
(rf)  extralaryngeal  manifestations  of  arthritis,     [t.l  c  ] 

4. — Gibson  considers  the  method  of  production  and 
the  nature  of  the  cardiac  lesions  of  rheumatism.  Endo- 
carditis of  the  aortic  cusps  must  have  been  due  to  the  poisons 
circulating  in  the  blood  flowing  over  the  surface  of  the  cusps. 
For  while  the  pericardium  is  a  highly  vascular  membrane, 
for  the  myocardium,  which  is  almost  like  a  sponge,  in  the 
endocardium,  however,  the  valves  differ  in  respect  of  theii' 
vascularity.  While  the  great  venous  valves  of  the  heart  are 
freely  supplied  with  bloodvessels,  the  cusps  guarding  the 
arterial  orifices  are  destitute  of  them,  unless  some  previous 
lesion  has  led  to  their  formation.  There  is  no  doubt  that  the 
cells  of  the  serous  membranes  of  the  heart  are  endowed 
with  a  phagocytic  power  and  while  excercising  their  protec- 
tive power  these  endothelial  cells  may  suffer  and  endo-  or 
peri-carditis  be  developed.  The  classic  experiments  of 
wounding  the  valves  with  a  sterilized  instrument  and  no 
endocarditis  resulting,  and  of  introducing  pyogenic  organ- 
isms by  way  of  the  bloodstream,  and  the  consequent  devel- 
opment of  endocarditis  are  mentioned.  Tne  termina- 
tions of  acute  pericarditis  may  be  perfect  resolution,  but 
"milk  spots''  (the  macul;«  tending)  are  frequently  left. 
These  are  due  to  a  thickening  upon  the  epicwdium.  Adhe- 
sions between  the  two  layers  also  occur  frequently.  The 
first  morbid  appearance  in  the  development  ot  acute  endo- 
cardial lesions  is  the  invasion  of  the  endothelial  layers  by 
the  bacteria  (owing  prob.ibly  to  the  phagocytic  activity 
of  the  endothelial  cells).  Retrogressive  changes  in  these 
cells  lead  to  the  deposit,  on  the  affected  surface,  of 
fibrin,  corpuscles,  and  platelets.  In  this  way  the  early 
phases  of  the  vegetations  are  brought  about.  Then  fol- 
lows a  gradual  fibrous  change,  whicu  may  at  length  show 
fatty  or  calcareous  degeneration.  la  acute  myocarditis 
we  have  a  variable  picture,  but.  m  general,  the  tissues  are 
thickened,  softened,  and  deeply  tinted.    Microscopically,  the 


Ja>uakY  26,  1901] 


THE  LATEST  LITERATURE 


CThe  Philadelphia 
Medical  Journal 


155 


fibers  are  swollen,  the  transverse  striation  almost  entirely 
obliterated,  and  the  interstitial  tissue  contains  leukocytes, 
hemocytes,  and  proliferating  cells.  Later,  the  fibers  are 
granular,  and  the  interstitial  substances  show  much  cellu- 
lar invasion,  or,  on  the  other  hand,  reveal  newly-formed 
fibrous  elements.  As  to  treatment  of  rheumatic  fever,  with  a 
view  to  obviate  implication  of  the  heart,  absolute  rest  is  es- 
sential in  the  horizantal  position.  The  diet  must  be  abun- 
dantly fluid,  to  bathe  the  tissues  thoroughly.  Milk  is  the 
best  food,  but,  as  time  goes  on,  soups,  farinaceous  foods,  and 
the  lighter  forms  of  meats  may  be  added  judiciously.  As  to 
drugs,  the  salicyl  compounds  seem  to  lessen  the  likelihood 
of  cardiac  involvement,  but  they  must  be  begun  early,  and 
taken  in  large  doses,  and  for  a  long  period.  When  the  gen- 
eral symptoms  have  entirely  disappeared,  iodid  of  sodium 
is  most  satisfactory.  It  is  to  be  taken  in  Id-  or  15-grain 
doses  3  times  a  day,  and  kept  up  for  several  weeks.  He  ad- 
vises that  digitalis  or  strophanthus  be  administered  during 
the  attack  to  maintain  the  heart's  activity,  and  that  an  oc- 
casional mercurial  purge  is  of  advantage.  It  is  difficult  to 
explain  the  favorable  action  of  counterirritation  in  this 
condition,  hut  it  is  an  excellent  adjuvant  to  the  other  treat- 
ment, notably,  in  cases  of  mitral  rather  than  aortic  valvular 
infection  (due,  probably,  to  the  fact  that  the  aortic  cusps  are 
without  bloodvessels).  The  author  recommends,  with  Caton, 
small  fly-blisters  over  the  precordia  every  night,  or  every 
other  night,     [t.l.c] 

5.— lu  childhood  the  articular  phenomena  of  rheuma- 
tism are  of  secondary  importance.  There  are  cases  in 
which  tlie  child  has  never  had  a  pain  in  his  joints,  and  yet 
may  present  a  severe  type  of  endocarditis,  and  of  which  cases 
the  rheumatic  nature  is  confirmed  by  the  presence  of  nod- 
ules. It  is  well-known  that  joint  symptoms  in  a  child  are  so 
slight  at  times  that  parents  are  apt  to  dismiss  the  complaints 
with  the  comforting  assurance  that  they  are  "  only  grow- 
ing' pains."  It  would  be  fallacious  to  attempt  to  deter- 
mine the  number  of  cases  of  rheumatism  in  childhood 
were  these  estimated  by  the  joint  affeclions  alone.  Heart 
aflfeclions  may  apparently  occur  alone  as  the  earliest 
symptom.  We  must  not  neglect  the  undoubted  relation 
between  chorea  and  rheumatism.  Our  statistics  err  in 
frequentlj'  classing  as  chorea  only  those  cases  in  which 
there  is  an  association  with  rheumatism.  This  author  has 
found  that  55.7 9^  of  cases  which  come  under  treatment  for 
chorea  showed  positive  evidencs  of  rheumatism.  Tnese 
cases,  commonly  regarded  as  chorea  only,  have  probably 
accounted  in  part  for  the  statement  that  rheumatism  is  a 
disease  of  adolescents  and  adults  rather  than  of  children. 
Rheumatism,  from  a  study  of  the  hospital  cases  made  by 
the  author,  is  a  common  disease  in  the  later  period  of  child- 
hood, rare  in  early  childhood,  and  almost  unknown  in  in- 
fancy. The  slight  articular  pain  frequently  complained  of 
by  children  often  will  reveal  a  real  afi'ection  of  the  joint. 
Jt  is  important  to  remember  that  the  hip  joint  is  fre- 
quently afi'ected,  and  in  such  a  monarticular  case  the 
mistaken  diagnosis  of  beginning  tuberculous  disease  might 
well  be  made.  Pain  from  the  hip,  as  is  often  emphasizsd, 
may  be  referred  to  the  knee.  In  childhood,  dilation  as 
well  as  irregularity  and  rapidity  of  the  heart  may  occur 
without  endocardial  symptoms.  Wasting  is  also  common  in 
this  affection  in  childhood.  Nodules  are  much  more  com- 
mon in  rheumatism  in  childhood  than  in  adults.  The  author 
found  them  present  in  27.5%.  There  is  a  close  association 
between  these  nodules  and  endocarditis.  There  is  one 
result  of  rheumatism  in  adults  which  is  almost  unknown  in 
childhood,  and  that  is  the  cerebral  rheumatism  or 
rheumatic  hyperpyrexia.  Pain  in  the  stomach,  pain  in 
the  side,  usually  the  lower  portion  of  one  axilla,  and  head- 
ache are  common  symptoms.  The  nervous  child  is  par 
excellence  the  rheumatic  child.  Such  children  are  apt  to 
be  excessively  emotional,  or,  on  the  other  hand,  very  timid 
and  shy,  even  to  the  point  of  appearing  morbid.  The  author 
suggests  that  red  hair  is  often  assoeiated,  both  in  children 
and  adults,  with  the  rheumatic  tendency.  Somnambulism 
and  talking  in  the  sleep,  and  lAbit  spasms  are  also  evident 
in  rheumatic  children.  The  author  points  out  lastly  the  im- 
portance of  paying  heed  to  the  trivial  symptoms,  recogniz- 
ing, for  instance,  the  serious  nature  of  "  growing  pains."  By 
this  means  alone  will  early  recognition  of  rheumatic  dis- 
ease be  possible  and  many  cardiac  cases  prevented  altogether, 
or  at  least  have  their  dread  course  greatly  modified,    [t.i.  r.] 


6. — Maclagen  introduced  the  salicyl  compounds  in  the 

treatment  of  rheumatism  in  1874,  and  this  was  followed  later 
by  the  employment  in  Germany  of  salicylic  acid.  These 
drugs  rapidly  reUeve  the  pain  and  reduce  the  temperature  if 
administered  in  suflicient  quantity.  With  regard  to  the 
action  of  the  salicylates  it  has  been  urged  that :  (1 )  They  act  as 
antiseptics,  and  destroy  the  specific  organism  ;  (2)  that  they 
exert  an  antitoxic  action,  and  (3)  that  they  act  as  nerve 
sedatives.  It  appears  probable  that  they  must  exert  a  depres- 
sant action  upon  the  heart  before  they  can  be  introduced  in 
sufficient  quantities  to  saturate  the  blood  up  to  the  necessary 
point.  With  regard  to  the  second  view  they  may  destroy  or 
neutralize  the  offending  toxin.  It  is  true  that  they  are 
powerful  hepatic  stimulants,  and  that  they  also  possess  the 
power  of  combining  with  fatty  acids,  the  seat  of  whose 
manufacture  is  to  a  great  extent  in  the  liver.  It  may  be 
that  one  of  the  toxins  of  rheumatic  fever  is  a  fatty  acid  which 
is  seized  upon  and  removed  by  the  salicylate.  A  decided 
advantage  possessed  by  the  salicylates  is  that  they  produce 
sweating.  In  treating  a  case  of  rheumatic  fever,  the  patient 
should  wear  a  woolen  night  gown  and  sleep  between  blankets. 
The  room  should  be  well  ventilated.  Absolute  and  prolonged 
rest  is  essential,  especially  with  the  view  of  preventing  car- 
diac complications.  The  diet  should  be  fluid,  largely  milk, 
and  plenty  of  water  should  be  taken.  As  to  drugs,  20  grains 
of  soda  salicylate  and  80  grains  of  an  alkaline  carbonate 
should  be  given  every  2  hours  unCil  the  pain  is  relieved 
and  the  patient  is  fully  under  the  influence  of  the  drug, 
when  it  should  be  given  every  4  hours  until  the  tempera- 
ature  has  fallen  to  normal.  Afterwards,  15  grains  of  the 
salicylate  and  20  grains  of  the  alkaline  carbonate  are 
given  every  4  hours  until  all  the  joint  symptoms  have  dis- 
appeared ;  then  3  times  a  day  until  a  fortnight  has  elapsed 
from  the  complete  disappearance  of  the  joint  symptoms. 
The  natural  salt  rather  than  the  artificially  prepared  soda 
salicylate  is  recommended.  By  a  free  movement  of  the 
bowels  at  the  outset  by  a  saline  or  mercurial,  the  effects  of 
salicism  are  largely  prevented.  Salicin,  recommended  as 
being  lessof  a  cardiac  depressant,  is  sometimes  useful  instead 
of  the  salicylate.  The  painful  joints  may  be  blistered,  or  be 
wrapped  in  a  salicylate  of  methyl  preparation,  and  the  air 
excluded.  It  is  important  to  keep  up  the  treatment  long 
enough.  Many  so-called  relapses  are  really  recrudescences 
of  a  disease  not  yet  terminated.  For  endo-  and  pericardial 
aflectione,  local  blisters  are  recommended,  and  stimulants 
when  indicated.  Hyperpyrexia  is  best  treated  by  cold  baths. 
The  author  recommends  the  water  should  be  at  65°  F.,  and 
ice  added  as  the  temperature  of  the  water  rises,  when  the 
patient  is  submerged.  Occasional  courses  of  the  salicylates 
are  useful  in  patients  having  slight  recurrences.  A  largely 
vegetarian  diet  is  recommended,  and  careful  personal  and 
generil  hygiene,     [t.l.c  ] 


Miinchener  medicinische  Wochenschrift. 

October  S,  1900.    [47.  Jahrg.,  No.  40.] 

1.  The  Condition  of  the  Stomach  in  Chlorosis.    Orro  Eos- 

TOSKI. 

2.  Purpura  Hemorrhagica.    Nehekorn. 

3.  A  Causeless  (?)  Case  of  Hysteric  Fever.    E.  Wormsee. 

4.  The  Treatment  of  Spina  Bifida.    C.  Hinnemaxs. 

5.  Operative  Treatment  for  Habitual  Shoulder-Joint  Luxa- 

tion.   Joseph  Muller. 

6.  The  Influence  of  Petroleum  upon  the  Bacillus  of  Diph- 

theria.   J.  Papasotibin. 

7.  The  Present  Standpoint  of  the  Therapy  of  Chronic  Sup- 

puration of  the  Middle  Ear,  and  the  Formation  of 
Cholesteatoma.    Ernst  Lectert. 

8.  The  Duration  of  Yeast  Formation  in    Sugar-containing 

Urine.    Theodor  Lohnstels. 

1.— Meinert  and  others  maintain  that  gastroptosis  is 
one  of  the  characteristic  features  of  chlorosis,  but  in  50 
cases  examined  by  Rostoski  gastroptosis  was  present  in  cnly 
26%.  The  influence  of  the  early  use  of  the  corset  was  dis- 
tinctly demonstrable  in  a  large  proportion  of  the  cases 
suffering  from  gastroptosis  ;  indeed,  all  of  them  had  begun 
to  wear  corsets  before  the  fourteenth  or  fifteenth  year.  It  is 
also  pointed  out  that  the  distention  of  the  stomach  with  gas 
is  not  entirely  reliable  as  a  method  of  determining  the  posi- 


156 


Thb  Philadelphia"! 
Medical  Jocknal  J 


THE  LATEST  LITERATURE 


(jAJtDAKT  2«,  ISOl 


tion  and  size  of  that  organ,  as  the  intestinal  coils,  especially 
the  transverse  colon,  may  when  distended  simulate  the 
stomach.  This  is  particularly  the  case  when  the  abdominal 
walls  are  tense ;  in  relaxed  abdominal  walls  the  outline  of 
the  stomach  is  more  or  less  clearly  visible,     [d.e.] 

2. — A  case  of  purpura  hemorrhagica  in  a  min  of  26 
years,  coming  on  without  any  ascertainable  cause.  There 
were  hemorrhages  into  the  skin  and  from  the  mucous  mem- 
branes, and  at  autopsy  extensive  ecchymoses  were  found  in 
the  internal  organs.  In  addition  there  were  endocarditis  of 
the  mitral  and  aortic  valves,  and  an  abnormally  small  aorta. 
Bacteriologic  examination  of  the  blood  during  life  yielded 
Staphylococcus  aureus,    [d.r.] 

4. — Hennemann  reports  a  case  of  cured  spina  bifida. 
The  deformity  was  represented  by  a  tumor,  situated  on  the 
sacrum,  small  at  birth  but  rapidly  increasing  in  size  after- 
wards. The  growth  was  treated  by  injecting  under  absolute 
aseptic  technic  a  small  quantity  of  Lugol's  solution,  after 
the  contents  of  the  sac  had  been  withdrawn  by  aspiration. 
Eight  days  later  the  tumor  had  reappeared  to  such  an  ex- 
tent that  aspiration  withdrew  350  ccm.  of  cerebrospinal 
fluid,  tinged  yellow  by  iodin.  A  second  injection  of  the 
iodin  solution  was  carried  out,  and  the  third  was  also  re- 
quired. Eight  days  after  the  third  injection  the  tumor  was 
about  the  size  of  a  pear,  and  the  child  rapidly  regained  its 
normal  functions.     [g.h.w.] 

6. — Miiiler  reports  a  case  of  habitual  luxation  of  the 
shoulder  joint,  occurring  in  a  patient,  28  years  of  age. 
The  shoulder  was  easily  dislocated  on  the  slightest  provo- 
cation, but  only  with  difficulty  replaced.  The  operation  was 
undertaken  at  the  urgent  request  of  the  patient.  After  the 
joint  had  been  freely  opened  m  front  and  from  the  axilla,  no 
tear  of  the  capsule  could  be  found  or  any  eSusion  into  the 
joint,  and  other  anomalous  conditions  of  the  bony  parts  were 
also  absent.  The  capsule,  however,  was  found  markedly 
dilated,  so  that  the  head  of  the  humerus  was  easily  displaced. 
The  capsule  was  shortened  by  excising  a  portion  some  4  cm. 
long  and  1}  cm.  in  breadth  and  suturing  the  severed  edges 
together.  Five  months  later  the  patient  had  perfect  use  of 
his  arm  and  had  no  return  of  his  former  trouble,     [g  b  w.] 

6. — Coal-oil  has  long  been  a  home  remedy  for  diph- 
theria, and  has  also  been  employed  by  the  profession,  par- 
ticiilarly  in  America.  Papasotirin  has  studied  its  influence 
upon  the  diphtheria  bacillus  in  cultures,  and  finds  that 
it  has  no  inhibitory  action  whatever,     [d.r  ] 

8— Lohnstein  contends  against  Meyer  that  the  fernieuta^ 
tion  test  for  sugar  is  complete  in  from  8  to  12  hours  at 
room  temperature,  Meyer  having  maintained  that  from  24  to 
48  hours  were  necessary,    [d.r.] 

Odoher  9,  1900.     [47.  Jahrg.,  Xo.  41.] 

1.  Idiopathic  Enlargement  of  the  Heart  and  Its  Relation  to 

Military  Service,     v.  Ziemssen. 

2.  Report    of    Xerosis    Bacillus    in    Spreading    Phlegmon, 

Secondary  to  Wound   Infection  and   Otitis  Interna. 
Warnecke. 

3.  Abscess  Following  Pneumonia  with  the  Diploc3CCU8  of 

Pneumonia  in  Pure  Culture.     Roeget. 

4.  A  Case  of  Acute  Formalin-Poisoning.    J.  Kluber. 

5.  A  Causeless  (?)  Case  of  Hysteric  Fever.    E  Wor.mser. 

6.  The  Present  Standpoint  of  the  Therapy  of  Chronic  Sup- 

puration of   the  Middle  Ear  and  the  Formation  of 
Cholesteatoma.    Ernst  Leutert. 

1. — An  interesting  discussion  of  idiopathic  enlarge- 
ment of  the  heart  and  its  relation  to  service  iu  the 

army.  The  causes  usually  assigned  for  acute  cardiac  dila- 
tion are  overexertion  and  the  abuse  of  alcohol.  The  author 
does  not  believe  that  alcohol  plays  the  role  imputed  to  it. 
More  important  than  either  of  the  causes  given  are  disturb- 
ances of  respiration,  which  are  brought  about  by  the  highly 
improper  uniform  worn  by  soldiers  (tight  collars  and  close- 
fitting  coats),  and  the  carrying  of  heavy  accoutrements,  etc. 
To  these  are  added  in  time  of  war  insufficient  food,  psychic 
influences,  and  nervous  shocks.  In  some  soldiers  there  is 
also  congenit.il  weakness  of  the  heart-muscle.  The  most 
frequent  causes  of  cardiac  weakness  in  time  of  peace  are 
acute  infectious  diseases,  particularly  influenza,  and 
articular  rheumatism.  All  the  causes  bringing  about  dila- 
tion have  in  common  one  factor :  they  produce  an  increase 
in  arterial  pressure,    [d.r  ] 


2.— Warnecke  found  the  xerosis  bacillus,  in  a  case  of 
spreading  phlegmon,  a  sequence  of  chronic  otitis  media, 
and  cholesteatoma ;  in  a  case  of  subacute,  middle-ear  disease ; 
and  in  a  cage  of  leptomeningitis,  secondary  to  ear  disease. 
The  bacillus  was  not  found  in  the  meningeal  pus,  but  in  the 
internal  ear  and  in  the  facial  canal.  The  organism  was  not 
pathogenic  for  animals,     f  d  r.] 

3. — A  metapneumonic  abscess  in  the  anterior  ab- 
dominal wall,  due  to  Fraenkel's  diplococcus.    [d  r.] 

4. — The  patient,  a  man  of  47  years,  had  taken  a  large 
quantity  of  apenta,  with  which  formalin  had  in  some  way 
been  mixed.  The  symptoms  consisted  of  coma,  lasting  for 
several  hours  ;  anuria,  persisting  for  19  hours ;  redness  of  the 
conjunctiva  and  pharynx ;  and  the  presence  of  formic  acid 
in  the  urine.  The  test  for  formalin  in  the  urine  consists  in 
the  development  of  a  black  color  when  the  urine  is  heated 
with  ammoniacal  solution  of  silver  nitrate,     [dr.] 

6. — An  instance  of  hysteric  fever,  with  a  review  of  the 
literature  on  the  subject,     [d  e.] 

6. — Leutert,  however,  takes  exception  to  Koerner's  state- 
ment, and  says  that  though  everyone  acknowledges  the 
existence  of  the  two  forms  of  cholesteatoma,  the  true  choles- 
teatoma is  exceedingly  rare,  so  much  so  that  it  is  scarcely  to 
be  taken  into  our  consideration  as  a  factor  of  clinical  im- 
portance. As  regards  the  diagnosis  of  the  presence  of  a 
cholesteatoma,  this  is  not  of  vital  importance,  as  the  treat- 
ment in  cases  where  there  is  suppuration  of  the  middle 
ear  is  the  same  whether  cholesteatoma  is  present  or  not.  It 
is  important,  however,  to  locate  the  seat  of  disease,  and  this 
can  be  done  witb  practical  exactness  by  knowing  the  position 
of  the  perforation  in  the  tympanic  membrane.  As  to  the 
treatment  of  these  cases:  In  some  of  the  middle- ear  sup- 
Durations  little  can  be  done  towards  curing  the  condition, 
just  as  in  cases  of  ozena  of  the  nose.  Other  cases  dependent 
on  the  presence  of  adenoids  in  the  vault  of  the  phamyx  will 
not  give  way  to  treatment  until  the  adenoids  are  removed. 
The  chief  indication  is  to  remove  the  pus  from  the  tympanum 
and  surrounding  cavities.  This  is  done  best  by  wiping  away 
the  discharge  with  a  cotton  applicator,  or,  better  still,  by 
blowing  air  through  the  eustachian  catheter,  or  even  syring- 
ing with  a  normal  salt-solution  through  the  catheter.  Drain- 
age through  the  external  canal  with  strips  of  gauze  has  little 
to  recommend  it.  Also  the  use  of  powder  blown  in  through 
the  canal  is  of  little  avail,  except  where  the  drum  is  almost 
entirely  destroyed.  When  the  perforation  of  the  drum 
membrane  is  found  situated  in  its  upper  part,  indicating 
caries  of  the  incus,  operation,  consisting  of  the  removal  of 
the  two  external  ossicles,  should  be  done.  When  there  is 
indication  of  disease  of  the  attic  and  of  the  ossicles,  the 
removal  of  the  latter  furnishes  the  best  means  of  draining  the 
upper  part  of  the  tympanic  cavity.  Perforation  in  the  pos- 
terior part  of  Shrapnell's  membrane,  running  to  the  bony 
border,  indicates  disease  of  the  antrum,  and  in  these  cases 
operation  is  always  necessary.  Stacke's  operation  generally 
affords  the  best  results,     [g.b.w.] 

October  16,  1900.     [47.  Jahrg.,  Xo.  42.] 

1.  Cystitis  Typhosa.    Curschmanx. 

2.  A  Contribution  to  the  Knowledge  of  Lithopedons.    Kbob- 

MER. 

3.  Disinfection  with  Smouldering  Blocks  of  CarbolformaL 

Dieudosne. 

4.  The  Frequency  and  Significance  of  Crystals  in  the  Feces. 

SCHILLISG. 

5.  The  Care  of  Hematuria,  Due  to  Hemophiha  by  Gelatia. 

Hahx. 

6.  A  Contribution  to  the  Technic  of  Amputation  Through 

the  Leg.    Mensel. 

7.  The  Eirliesl  Stages  of  Idiopathic  Cardiac  Hypertrophy, 

and  the  Significauce  of  Dilation  as  a  Result  of  Weak- 
ness of  the  Cardiac  Muscles,  in  Considering  Availa- 
bility for  Military  Service.    WoLFFHuaKL. 

3. — Dieudonr.e  has  perfosmed  a  series  of  experiments 
with  the  carboformal  smouldering  blocks :  these  are  really 
small  rectangular  blocks  containing  about  50  gm.  of  solid 
parflformaldehyd.  When  lighted,  care  should  be  taken  that 
they  do  not  burn  with  a  flame,  but  simply  glow  slowly,  so 
that  the  formaldehyd  is  liberated  in  the  form  of  gas.  It 
is  exceedingly  important  iu  this  method,  that  all  the  ex- 
posed surfaces  should  be  thoroughly  moistened  with  water. 


January  26,  1901] 


THE  LATEST  LITERATURE 


CThe  Philadklphia 
Medical  Journal 


157 


To  accomplish  this,  his  method  is  to  heat  some  stones  red 
hot,  and  then  pour  boiUns;  water  over  them  ;  when  steam  is 
very  rapidly  produced.  In  the  experiments  the  gas  was  al- 
lowed to  act  for  about  7  hours,  and  it  was  found  that  a  pro- 
portion of  6  blocks  for  each  cubic  meter  of  space  in  the 
room  sufficed  to  kill  all  forms  of  bacteria,  even  the  spores 
of  anthrax.  Smaller  quantities,  however,  were  inadequate. 
The  method  is  particularly  advantageous  in  the  country, 
where  elaborate  apparatus  for  testing  infection  is  not  obtain- 
able,    [j  s] 

4. — Schilling  has  studied  the  crystalline  forms  that  are 
found  in  the  feces.  The  commonest  are  oxalates  and  car- 
bonates of  lime,  and  particularly  the  triple  phosphates.  The 
oxalates  and  the  carbonates  are  found  in  the  edible  fangi. 
The  triple  phosphates  occur  in  especially  large  numbers 
after  indulgence  in  beef,  pork,  or  game.  They  are  present 
in  stools  with  acid,  aa  well  as  in  those  with  alkaline  reac- 
tion. The  author  mentions  a  number  of  other  forms  of  diet 
giving  rise  to  crystals,  and  describes  certain  chemical  reac- 
tions by  which  their  nature  can  be  recognized.  He  admits 
that  they  are  of  little  value  in  diagnosis,     [j  s.] 

6. — Hahn  reports  a  case  of  hematuria  due  to  hemophilia, 
in  which,  after  other  methods  had  failed  to  stop  the  hemor- 
rhage, the  patient  was  given  large  quantities  of  gelatin  with 
his  food.  The  result  was  excellent.  He  recommends  the 
method  on  account  of  its  simplicity  and  effectiveness,    [j  s.] 

7. — Wolffhiigel  concludes  his  paper  upon  the  idiopathic 
forms  of  cardiac  hypertrophy,  and  the  significance  of  the 
forms  of  muscular  weakness  producing  dilation,  in  decid- 
ing the  question  of  military  serviceableness.  He  believes 
that  particularly  among  recruits  there  is  a  tendency  to  en- 
deavor to  perform  their  duties  after  symptoms  of  cardiac 
exhaustion  are  well  pronounced.  In  other  callings  this  is 
less  likely  to  be  the  case,  because  a  feeling  of  shame  in  ad- 
mitting exhaustion  is  not  so  likely  to  be  present.  Moreover, 
the  equipment  of  soldiers  is  so  arranged  that  it  diminishes 
the  vital  capacity  of  the  lungs,  and  contributes  in  this  way 
to  the  development  of  dypsnea.  He  calls  attention  to  the 
distinction  that  should  be  made  between  mitral  insufficiency 
which  has  a  regulatory  function,  and  that  which  is  due  to 
functional  incapacity  of  the  valves.  In  the  latter,  there  is 
always  dilation  of  the  auricle,  whereas  in  the  former  this 
does  not  occur.  The  regulatory  form  may  be  regarded  as  the 
resource  possessed  by  the  heart  for  escaping  the  results  of 
pressure  in  the  aorta,  that  cannot  be  overcome  by  the  mus- 
cles of  the  left  ventricle.  Considerable  valuable  information 
is  obtained  by  examination  of  the  pulsation  of  the  heart 
with  the  fluoroscope.  He  reports  a  very  interesting  case  in 
which  a  man  who  had  formerly  been  a  locksmith,  and  had 
previously  performed  his  military  duties  in  an  acceptable 
manner,  after  running  a  distance  of  about  two  miles 
and  a  half,  suddenly  fell  dead.  At  the  autopsy  the  right  ven- 
tricle was  enormously  dilated,  and  there  was  also  fatty  de- 
generation in  the  heart  wall.  Ttiis  pitient  had  been  in  the 
habit  of  consuming  large  quantities  of  beer,  but  Wolffaiigel 
believes  that  this  was  of  less  importance  than  the  severe 
physical  exertion  to  which  he  had  been  subjected  for  a  long 
time,    [j  s  ] 


Wiener  klinische  W.ochenschrift. 

October  4,  1900.    [13.  Jahrg.,  No.  40.] 

1.  Eulogy  upon  the  late  Professor  Eduard   Albert,  with  a 

Detailed    list    of    all  his    Works    Published.    Adolf 

LORENZ. 

2.  The  Movements  Seen  in  the  Mouth  and  Throat,  in  Aortic 

losuflBciency.    Hermann  Schlesinger. 

3.  The  Treatment  of  Phthisis  with  Intravenous  Injections  of 

Hetol  by  Landerer's  Method.    Anton  Krokiewicz 

2. — A.  pulsation  has  been  noted  in  aortic  insuffici- 
ency upon  the  mucous  membrane  of  the  mouth  and  phar- 
ynx, an  inward  movement,  following  the  beat  of  the  carotid, 
most  marked  in  the  tonsils  and  in  the  walls  of  the  pharynx. 
Or  a  rhythmic  swelling  is  seen  passing  in  a  wave  over  the 
softer  parts,  the  tongue  growing  palpably  thicker  in  systole, 
and  decreasing  during  diastole,  showing  a  difference  of  1  to 
IJ  mm.  When  this  phenomenon  is  well  marked  through- 
out the  buccal  mucous  membrane,  the  cavity  of  the  mouth 
grows  periodically  narrower.  This  pulsation  in  the  tongue 
was  noticed  in  10  out  of  40  cases.    The  tonsils,  the  palatine 


arch,  and  uvula  came  next  in  frequency.  The  uniform 
narrowing  of  mouth  and  pharynx  occurred  4  times  in  40 
cases.  Once  the  right  side  of  the  uvula  showed  the  pulsation, 
while  the  left  side  remained  perfectly  still.  While  not  always 
seen,  it  is  a  sign  of  great  clinical  interest,  and  should 
always  he  sought,    [m  o.] 

3.— Krokiewicz  treated  43  cases  of  phthisis  with  iiyec- 
tion  of  hetol,  increasing  0  0005  g.  at  each  injection, 
repeated  at  intervals  of  2  to  4  days,  up  to  0  005  g.  In  25 
cases  this  was  the  only  treatment,  the  18  others  had  sub- 
cutaneous injections  of  arsenious  acid  also.  Recovery 
resulted  in  1  case,  5  cases  improved  with  the  arsenic  added, 
and  5  without,  in  all,  26  <^(.  improved.  After  a  full  review 
of  the  reports  hitherto  published,  and  a  detailed  list  of  his 
cases,  he  concludes  that  hetol  injections  are  of  use  only  in 
the  very  beginning  of  phthisis ;  that  they  cause  a  general 
leukocytosis,  followed  by  local  reaction  and  a  tendency  to 
heal,  finally,  and  that  they  are  not  a  specific  against  phthisis. 

[M.O.] 

October  11,  1900.     [13.  Jahrg.,  No.  41.] 

1.  A  Study  of  Trachoma.     C.  ZtEM. 

2.  The  Normal  Great-toe  Reflex  in  Children.    Fritz  Passini. 

3.  Formaldehyde  Disinfection.    Basil  Kluczenko. 

1.— Will  be  abstracted  in  the  next  number. 

3.— Passini  confirms  Babinski's  observations  that  exten- 
sion of  the  great  toe  follows  tickling  the  sole  of  the  foot  in  a 
patient  with  an  organic  lesion  of  the  pyramidal  tracts,  while 
flexion  occurs  in  normal  individuals  (Babinski's  reflex) 
This  extension  is  marked  during  the  last  day  of  tubercular 
meningitis,  flexion  generally  occurring  before  that  time. 
Extension  occurs  in  very  young  children  normally:  only 
during  the  last  three  months  of  the  first  year  does  flexion 
appear.  Well- developed  infants  may  show  it  earlier,  while 
backward  children  may  give  extension  even  after  the  first 
year,     [m.o.] 

3. — A  40^  watery  solution  of  formalin  is  the  best  for  dis- 
infection purposes.  This  is  burned  (the  formaldehyde  rising 
with  the  steam)  for  7  hours,  in  a  room,  all  the  openings  into 
which  have  been  well  closed.  The  articles  to  be  disinfected 
therein  should  be  spread  out,  so  that  the  gas  comes  in  contact 
with  them.  Before  opening  the  room,  ammonia  should  be 
introduced  (a  25%  watery  solution  being  heated  outside_  the 
door,  the  gas  entering  through  the  keyhole)  which  unites 
with  the  formaldehyde  gas,  forming  Hexamethylen- 
tetramin.  An  hour  later,  the  windows  should  be  opened 
wide,  and  the  drops  of  steam  which  had  condensed  about  the 
room  carefully  dried.  No  odor  of  the  formaldehyde  remains. 
[m  o.] 

October  18,  1900.     [13.  Jahrg.,  No.  42.] 

1.  The  Cortical  Visual  Centers.    St.  Bernheimer. 

2.  A  Peculiar  Condition  of  Cyst  Formation  in  the  Central 

Nervous  System,  Postmortem.    Fritz  Hartmamn. 

3.  A  Study  of  Trachoma.    C.  Zeem. 

1.— After  a  complete  review  of  the  experiments  done,  and 
the  conclusions  reached  by  other  investigators,  Bernheimer 
describes  his  experiments  upon  the  brains  of  embryos, 
infants,  and  children.  His  results  confirm  von  Monakow's 
hypothesis,  that  there  is  no  macula  lutea  center  either  in 
the  anterior  or  the  posterior  part  of  the  fossa  calcarina. 
After  detailed  discussion  of  the  views  of  the  others,  he  con- 
cludes that  light  impulses  will  reach  the  cortex,  perhaps 
somewhat  weakened,  even  though  the  usual  conducting 
fibers  between  the  corpus  geniculatum  and  the  cortex  are 
wholly  or  partially  destroyed  by  disease,  as  the  neighboring 
visual  fibers,  from  their  close  contact  in  the  internal  capsule, 
can  assume  the  function  of  the  disabled  bundles.  There- 
fore, as  long  as  any  undiseased  visual  fibers  exist,  it  is  as 
hard  to  imagine  the  total  abolition  of  the  macula  func- 
tion as  the  existence  of  a  circumscribed  macula  nucleus  in 
the  cortex,     [m.o.] 

2.— Toe  patient,  a  major,  aged  C8,  had  a  sudden  attack  of 
unconsciousness,  followed  by  aphasia,  ptosis,  right 
facial  paralysis,  and  drowsiness.  Death  occurred  on  the 
eighth  day,  total  paraplegia  having  come  on  gradually.  The 
autopsy  revealed  small  cysts,  containing  gas  in  great  quanti- 
ties, and  very  sclerotic  bloodvessels  throughout  the  entire 
central  nervous  system.    Small    bacilli  were  found  m  the 


158 


The  Philadelphia") 
Medical  Jockxal  J 


THE  LATEST  LITERATURE 


[JaSCaET  25,  1901 


bloodvessels  of  the  brain  and  about  the  cysts.  There  were 
no  signs  of  inflammatory  or  degenerative  changes  about  the 
cysts.  Hartmann  believes  that  the  bacilli  entered  through 
the  circulation  during  life,  but  multiplied  after  death,  and 
that  the  cysts  were  caused  by  the  gas  generated  postmortem 
by  the  bacteria.  The  literature  upon  the  subject  is  reviewed. 
[m.o.1 

3. — Besides  the  theory  of  contagion  from  contact  with 
gonorrheal  patients,  from  towels,  etc.,  generally  accepted  in 
our  crowded  communities  as  the  cause  of  ^trachoma,  Ziem 
gives  the  etiology  of  the  disease  in  countries  where  it  is  epi- 
demic or  endemic  (Hungary,  Egypt,  Syria,  etc.).  He  divides 
the  causes  into  (a)  excessive  heat  and  glare ;  (6)  fine  powder 
and  dust ;  and  (c)  miasmatic  material  from  swamps,  moors, 
etc.,  which  acts  directly  upon  the  conjunctiva  or  upon  the 
mucous  membrane  of  the  nose;  or,  entering  the  alimentary 
tract,  reaches  the  circulation,  and  finally  becomes  localized 
in  the  eye.  In  explanation  of  each,  he  gives  long  and  inter- 
esting detailed,  historical,  and  geographical  facts,  backed 
with  references  and  statistics.  Then  he  suggests  numerous 
sanitary  and  hygienic  measures  tending  to  lessen  the  occur- 
rence of  this  condition,     [m.o.] 

October  25, 1900.     [13.  Jahrg.,  No.  43.] 

1.  The  Study  of  Hereditary  Syphilis  in  the  Second  Genera- 

tion.   Edmond  Fodrniee. 

2.  The  Occurrence  of  Acute  Nephritis  in  Secondary  Syphilis. 

(Nephritis  Syphilitica  Praecox).   Abraham  Stepler. 

3.  Echinococcus  of  the  Kidney.    Ludwiq  Stein. 

1.— Eournier  has  collected  the  histories  of  the  children  born 
of  the  wedding  of  hereditary  syphilitics.  Out  of  45  such 
marriages,  abortion  occurred  43  times  in  145  pregnancies, 
39  infants  were  either  stillborn  or  died  soon  after  birth,  a 
total  of  82  dead  children  (56%).  Only  63  of  these  children 
lived,  and  they  all  showed  some  hereditary  syphilitic  stig- 
mata. In  19  families,  both  grandparents  were  syphilitic, 
and  one  of  the  parents  had  hereditary  syphilis.  The  histories 
of  the  45  families  are  given,    [m.o.] 

2.— Stepler  reports  a  case  of  acute  nephritis  occurring 
in  a  farmer,  20  years  of  age,  6  weeks  after  a  chancre.  In  the 
urine  were  blood  corpuscles,  casts,  and  12%  albumin.  No 
other  cause  for  the  nephritis  could  be  found,  and  mercurial 
inunctions,  with  potassium  iodid  internally,  cured  him  in 
7  weeks,  by  which  time  albumin  and  casts  had  disappeared. 
An  extensive  review  of  the  literature  of  the  subject  follows, 
with  a  description  of  the  cases  of  Dieulafoy  and  Etienne. 
[mo.] 

3,— Stein  reports  a  case  of  echinococcus  cyst  of  the 
right  kidney,  in  which  the  surgeon  removed  the  cyst, 
leaving  drainage  through  the  abdominal  wound.  The 
patient  recovered  in  24  days.  After  discussing  the  advisa- 
bility of  performing  nephrectomy,  in  place  of  removing  the 
tumor  with  subsequent  drainage,  he  concludes  that  the 
decision  must  rest  with  the  surgeon  during  operation,  after 
he  sees  the  exact  condition  present,    [m.o.] 

November  1,  1900.    [13.  Jahrg.,  No.  44.] 

1.  The  Diagnosis  of  Latent  Carcinoma  of  the  Esophagus. 

C.  HODLMOSER. 

2.  A  Case  of  Posthemiplegic  Intention  Tremor.      M.  Infeld. 

3.  The  Treatment  of  Epilepsy  with  Bromipin.      Wilhelm 

LORENZ. 

!•— Hcidlmoser  reports  two  cases  of  cancer  of  the 
esophagus,  in  both  of  which  the  cardinal  symptom,  dys- 
phagia, was  absent.  Unilateral  recurrent  paralysis  was  the 
one  marked  diagnostic  symptom.  The  first  case  died  with 
signs  of  a  malignant  neoplasm,  localized  within  the  gastro- 
intestinal tract  by  epigastric  pain,  vomiting,  and  flatulence. 
There  was  great  pain  over  the  liver,  which  was  hypertrophied 
and  nodular;  besides,  a  diffuse  peritonitis.  Chemical  ex- 
amination showed  the  absence  of  hydrochloric  acid  and  lac- 
tic acid.  The  stomach  was  somewhat  dilated.  There  were 
no  esophageal  symptoms  ;  only  the  recurrent  paralysis  and 
some  enlarged  subclavicular  lymph  glands.  The  second  case, 
a  woman  who  emaciated  rapidly,  complained  of  trouble  in 
moving  her  tongue,  with  some  pain  in  the  neck.  Her  liver 
was  hypertrophied,  and  both  recurrent  and  hypoglossal 
nerves  on  the  right  side  were  paralyzed.  The  tumor  was 
attached  to  a  tubercular  bronchial  gland,    [m.o.] 


2. — Infeld  deecribes  in  full  a  case  of  intention  tremor  in  a 
man  of  40,  alcoholic,  with  a  criminal  history.  When  about  30 
years  old,  signs  of  severe  cranial  disease  appeared,  unilateral 
headache,  starting  at  a  spot  on  the  left  side  of  the  vertex,  where 
he  had  been  stabbed,  and  cerebral  vomiting,  followed  sud- 
denly by  right-sided  hemiplegia,  with  right-sided  disturbances 
of  vision  and  epileptic  attacks  (with  biting  of  the  tongue  and 
involuntary  micturition).  These  symptoms  gradually  grew 
better,  leaving  only  paralysis  of  the  right  side.  Two  years 
later,  the  intention  tremor  appeared,  at  first  in  both 
right  arm  and  leg,  permanent,  however,  only  in  the  hand. 
Right-sided  ataxia  also  existed.  The  cause  naturally  seems 
to  be  some  change  in  the  brain,  due  to  the  injury,  the 
alcohol,  or  both.  The  entire  literature  of  the  subject  ia 
given,  with  the  quotation  of  many  opinions,  making  a  very 
interesting  article,    [m.o.] 

3. — Lorenz  used  bromipin  in  34  epileptic  cases.  In  11 
patients  the  attack  grew  worse;  in  the  rest  they  remained 
about  the  same.  In  13  cases  the  number  of  attacks  were 
less;  in  3,  the  attacks  were  temporarily  less  frequent;  the 
rest  remained  unchanged.  The  majority  of  the  patients 
gained  in  weight,  and  seemed  in  better  general  condition. 
These  results  are  far  superior  to  those  given  by  the  opium- 
bromid  treatment,    [m.o.] 


Berliner  klinische  Wochenschrift. 

October  15,  1900.     [37.  Jahrg.,  No.  42.] 

1.  Hydrophobia  up  to  the  End  of  the  Nineteenth  Century. 

V.  Babes. 

2.  Contributions  Concerning  the  Action  of  Joliimbin.    A. 

LOEWY. 

3.  Downe's  Urine  Segregator.    A.  Feeudekberq. 

4.  Several  Cell   Problems    and  Their    Significance  for  the 

Scientific  Establishment  of  Organotherapy.   D.  Hasse- 

MASN. 

5.  Methods  for  Preserving  Anatomic  Preparations  True  to 

Nature.    L.  Pick. 

1. — Babes  has  concluded  from  a  series  of  experiments  that 
the  changes  in  the  medulla  oblongata  and  spinal  cord 

caused  by  hydrophobia  are  extensively  diffused,  in  contra- 
distinction to  Schaffer,  who  believes  that  the  changes  are 
localized  in  those  areas  of  the  spinal  cord  into  which  those 
nerves  enter  that  come  from  the  wound.  He  states  that  it 
was  not  a  sense  of  scientific  investigation,  but  a  pity  for 
human  suffering,  which  incited  Pasteur's  discovery.  The 
results  obtained  in  combating  hydrophobia  during  the 
nineteenth  century  are  from  a  practical  point  of  view  to  be 
attributed  to  the  preventative  measures  adopted  by  police 
departments  and  the  enforcement  of  laws  on  sanitation. 
[m.r.d] 

4. — The  author  concludes  his  article  by  diBCOSsing  the 
biologic  foundation  upon  which  organotherapy  is  based. 
There  exists,  according  to  the  author's  views,  an  altra- 
istic  relation  between  different  varieties  of  cells  and  a 
mutual  sympathy  between  a  certain  form  of  cell  and  the 
remaining  variety.  Changes  in  one  form  of  cell  are  followed 
by  changes  in  other  varieties  and  in  such  a  manner  that  a 
progressive  metamorphosis  leads  to  an  altruistic  hyper- 
trophy while  a  regressive  change  leads  to  an  altruistic 
atrophy,    [m  e.d.] 

October  S2,  1900.     [37.  Jahrg..  No.  43.] 

1.  From  the  Surgical  Clinic  in  Greifewald :  Trigger- Finger. 

TiLMANS. 

2.  From  the  Second  Obstetric  and  Gynecologic  Clinic  at  Buda- 

pest (Prof.  W.  W.  Tauffer),  Molecular  Concentration 
of  the  Blocd  in  Puerperal  Eclampsia.    A.  S.  Ziu. 

3.  Fracture  of  the  Greater  Tuberosity  of  the  Humerus.    H. 

Wohlgemuth. 

4.  Hemorrhagic  Erosions  of  the  Gastfic  Mucous  Membrane. 

C.  Pakiser. 

5.  Hydronhobia  up  to  the  End  of  the  Nineteenth  Century. 

V.  Babes. 

1.— Tilmann,  after  reviewing  the  literature  on  the  subject, 
reports  5  cases  of  his  own.  A  thickening  of  some  portions 
of  the  flexor  tendons  was  found  bv  iiim  in  each  one  of  the 


JaNUAKT  26,  1901] 


THE  LATEST  LITERATURE 


[The  Phii^adelphia 
Medical  Journal 


159 


cases;  the  thickening  was  always  found  on  those  fingers 
which  were  employed  in  the  performance  of  unusual  manual 
labor,  and  which,  according  to  the  author,  is  the  cause  of  the 
affection.  The  author's  experiments  upon  the  cadaver  have 
ghown  that  the  localized  thickening  is  due  to  the  bruising' 
of  the  tendons  between  the  hard  substance  that  is  han- 
dled and  the  transverse  ridges  on  the  palmar  aspect  of  the 
metacarpal  bones.  The  treatment  consists  of  immobilization 
of  the  finger  by  means  of  a  splint,  applications  of  tincture  of 
iodin,  and,  later  on,  massage.  In  obstinate  cases  surgical 
intervention  is  the  only  means  for  procuring  permanent  re- 
lief. The  author  splits  the  tendon,  removes  the  cicatricial 
nodule;  this  is  generally  followed  by  good  results,     [m.r.d.] 

2. — Zili  states  that  of  the  various  theories  advanced  re- 
garding the  origin  of  eclampsia  in  pregnancy  the  one  of  Bou- 
chard stands  preeminently  in  the  foreground.  This  author's 
explanation  is  that  in  eclampsia  of  the  pregnant  woman 
large  quantities  of  toxic  materials  accumulate  in 
the  organism  and  cause  the  convulsions ;  the  increased 
amount  of  metabolism  caused  by  the  fetus  causes  poisonous 
products  to  be  thrown  into  the  circulation.  The  liver  is 
prevented  from  exerting  antitoxic  influence  and  the  kidney 
18  hindered  in  its  process  of  elimination.  These  two  points 
are  especially  emphasized  by  the  French.  The  author 
obtains  the  degree  of  molecular  concentration  of  the 
blood  in  eclampsia  by  comparing  its  freezing  point  with 
that  of  distilled  water.  He  states  that  if  the  kidney  is  not 
able  to  eliminate  the  albuminous  products  of  metabolism 
held  in  solution  in  the  blood,  the  freezing  point  will  be  liigher. 
The  molecular  concentration  of  normal  blood-serum  is  con- 
stantly varying  between  0.56-0.58°  C.  (Koranyi,  Dreser).  It 
remains  for  the  kidney  by  its  properties  of  elimination  to 
maintain  this  equilibrium.  As  small  molecules  like  salts 
and  the  many  derivatives  of  albumen  metabolism  slightly 
affect  the  freezing  point,  a  special  apparatus  was  em- 
ployed. The  blood  was  obtained  partially  by  cups  and  par- 
tially by  venesection,  immediately  after  the  convulsions.  As 
Kovac  has  shown  that  carbon  dioxid  raises  the  freezing  point, 
the  blood  was  subjected  to  a  stream  of  oxygen.  After  a  series 
of  experiments  the  following  conclusions  were  deduced:  (1) 
The  blood  in  eclampsia  does  not  show  any  appreciable  varia- 
tion in  its  freezing  point  from  that  of  normal  blood ;  (2) 
therefore  in  eclampsia  there  is  no  retention  of  urinary  salts 
or  of  urea;  (3)  the  normal  value  of  the  freezing  point  of  the 
blood  in  eclampsia  shows  that  the  permeability  of  the  kid- 
neys is  not  affected  in  proportion  to  the  most  uremic  pro- 
cesses ;  (4)  we  are  therefore  led  to  the  assumption  that  the 
supposed  toxic  material  responsible  for  eclampsia  is  to  be 
found  in  a  greater  atom-complex  than  in  a  regressive  albumen 
metabolism,  probably  an  intermediate  product  derived  from 
albumen  molecules,    [m.r  d  ] 

3. — Wohlgemuth  states  that  a  fracture  of  the  greater 
tuberosity  of  the  humerus  occurs  extremely  rarely  as 
an  individual  injury  ;  it  does  occur,  however,  as  an  accom- 
panying injury  in  luxation  and  fracture  of  the  neck  of  the 
nnmerus.  The  rarity  of  the  affection  can  be  seen,  when  Gurlt 
could  only  collect  4  capes  from  literature.  The  diagnosis,  al- 
though considerably  assisted  by  the  x-rays,  can,  nevertheless, 
be  made  sometimes  from  the  clinical  symptoms.  These,  how- 
ever, are  only  characteristic  when  confined  to  the  greater  tu- 
berosity. The  symptoms  are  those  which,  in  rare  cases, 
are  due  to  an  extreme  exertion  of  the  supraspinatus,  infra- 
spinatus, and  teres  major  muscles,  like  lifting  with  the  out- 
stretched arm,  throwing  missiles,  and  cracking  a  whip. 
The  arm  is  slack,  can  only  be  raised  with  great  pain,  and 
the  head  of  the  bone  can  be  plainly  felt  in  the  socket. 
But,  at  the  first  glance,  the  appearance  of  the  shoulder  is 
that  of  luxation,  the  deltoid  being  flattened,  the  acromion 
prominent,  and  the  anteroposterior  diameter  of  the 
shoulder  is  increased.  On  the  other  hand,  the  supra-  and 
mfra-spinatus  muscles  are  not  subject  to  tension,  but  are 
flabby,  and  upon  careful  palpation  a  small  tumor  will  be 
felt  next  to  the  head  of  the  bone,  somewhat  up  and  posterior ; 
this  is  the  fractured  tuberosity,  between  which  and  the  bone 
there  extends  a  deep  sulcus,  in  which  is  situated  the  tendon 
of  the  biceps.  If  pressure  is  made  upon  the  tumor  in  the 
direction  of  the  head  of  the  humerus,  and  rotation  at  the  same 
time  performed,  crepitus  will  almost  always  be  felt,  except- 
ing in  those  cases  where  the  tendon  of  the  biceps  has  been 
interposed.  External  rotation  of  the  arm  is  seriously  im- 
peded, because  the  points  of  insertion  of  the  muscles  have 


been  removed.  If  the  fracture  of  the  greater  tuberosity,  as 
is  generally  the  case,  is  complicated  by  a  subcoracoid  or  sub- 
glenoid luxation,  the  diagnosis  is  more  difficult  and  almost 
impossible  from  the  clinical  manifestation,  provided  reduc- 
tion has  not  yet  Deen  accomplished.  There  is  considerable 
doubt  as  to  whether  luxation  and  fracture  of  the  greater  tu- 
berosity occur  simultaneously,  acd,  if  not,  which  one  of  the 
two  afff  ctions  is  the  primary  one.     [m.r.d.] 

4, — Pariser  gives  a  resume  of  the  views  on  this  affection. 
The  symptoms  are  anorexia,  a  burning  pain  in  the  gas- 
tric region,  profound  emaciation,  and  nausea ;  vomiting  is 
rare.  Unlike  a  gastric  ulcer  in  which  the  character  of  the 
pain  is  cramp-like  and  nagging,  in  this  affection  it  is  of  a 
markedly  burning  character.  Examination  of  the  gastric 
contents  by  means  of  the  test- meal  reveals  little  else  in  most 
of  the  cases  than  subacidity.  The  cause  of  the  aSection 
is  a  circulatory  disturbance  in  the  mucous  membrane,  caus- 
ing acute  inflammation  and  spasm  of  the  muscular  fibers. 
Observers  differ  as  to  whether  this  is  a  distinct  aflection  per 
se  or  an  indication  of  chronic  gastritis.  Treatment  consists 
of  gastric  lavage  with  1 :  1000  or  1 :  2000  solution  of  silver 
nitrate  followed  by  neutralization  with  decinormal  salt-solu- 
tion,   [m.k.d.] 

October  S9,  1900.     [37.  Jahrg.,  No.  44.] 

1.  Vesical  Calculi.    C.  Posner. 

2.  The  Clinical  Value  of  A.  Schmidt's  Method  for  Testing 

the  Function  of  the  Intestines.    H.  Philippsohx. 

3.  Rose's  Diabetes  Milk.     Sandmeyer. 

4.  Four  Cases  of  Disturbance  of  Equilibrium.     Rieken. 

5.  Contribution  to  the  Treatment  of  Callous,  Resilient  Stric- 

tures.    H.  LOHNSTEIN. 

1. — Posner  discusses  at  length  the  various  theories  regard- 
ing the  etiology  of  vesical  calculi.  Palpation  is  of  great 
value  in  recognizing  the  affection,  especially  in  children.  The 
addition  of  sounds,  cystascopy,  and  the  x-ray  render  the 
diagnosis  absolute,     [m.r.d.] 

3.— Sandmeyer  states  that  Rose's  diabetes  milk,  is  abso- 
lutely free  from  sugar,  contains  but  little  albumin,  con- 
siderable fat,  and  is  of  a  pleasant  taste.  The  author  has  em- 
ployed it  in  about  50  cases  of  diabetes  mellitus  with  excellent 
results.  Even  in  very  grave  cases,  he  not  only  succeeded  in 
maintaining  the  bodily  weight,  but  often  even  increased  it. 
Elaborate  formulae  are  appended,     [m.r  d.] 

4. — In  discussing  this  condition,  Rieken  believes  it  proba- 
ble that  gastrointestinal  autointoxication  is  frequently 
responsible  for  this  affection.  He  reports  4  cases  which  came 
on  suddenly  during  damp  weather,  at  a  time  when  influenza 
and  rheumatism  were  prevalent.  The  symptoms  simulated 
in  many  respects  Meniere's  symptom-complexes.  The  ab- 
sence of  deafness  places  these  cases  in  sharp  contradistinc- 
tion to  Meniere's  disease,  and  lead  us  to  reflect  whether  there 
is  not  some  unrecognized  portion  of  the  ear  which,  in  its 
relation  to  the  economy,  may  be  the  seat  of  these  disturb- 
ances,   [m  r.d] 

5, — Lohnstein  has  devised  an  instrument  for  the  treat- 
ment of  callous,  resilient  strictures.  After  dilatation  and 
enlargement  of  the  stricture  ad  maximum,  the  instrument, 
whose  principle  is  that  of  a  Bottini  electric  knife,  is  em- 
ployed. The  modification  of  the  instrument  is  such  that  a 
urethrotome  in  a  canula  is  formed.  The  author  reports 
remarkable  success  in  17  cases.  He  considers  the  instru- 
ment as  indicated  in  cases  where  there  are  cicatrices  in  the 
urethra  that  have  run  their  full  course,    [m.r.d.] 

November  5,  1900.     [37.  Jahrg.,  No.  45.] 

1.  The  Mechanism  of  Certain  Cortical  Disturbances  of  Vis- 

ion in  the  Dog.    E.  Hitzig. 

2.  Nephrectomy  for  Pyelonephritis  Calculosa.    L.  Thumin. 

3.  Purpura  Rheumatica  and  Angina.     A.  Bruck. 

4.  Vesical  Calculi.    C.  Posner. 

5.  The  Clinical  Value  of  A.  Schmidt's  Method  for  Testing  the 

Function  of  the  Intestines.    H.  Philippsohs. 

1.— Hilzig  investigated  the  relation  of  the  reflex  closing 
of  the  lids  to  the  visual  disturbances  produced  in  dogs  by 
operating  on  certain  areas  of  the  occipital  lobe.  He  found 
that  the"  disturbance  of  the  optic  reflex  was  entirely  inde- 
pendent from  the  visual  disturbances.  Injuries  to  the  motor 
areas  of  the  cortex  also,  as  a  rule,  disturb  the  motor  func- 


160 


Thb  Philadelphia"] 
Medical  Jocbnal  J 


THE  LATEST  LITERATURE 


[JiSrABT  28,  1 


tions  connected  with  the  act  of  vision,  that  is,  the  optic  lid 
reflex,  while  in  disturbances  of  the  sensory  portion  of  the 
cortex  this  may  not  occur.  According  to  the  author,  the 
disturbance  of  the  optic  reflex  can  only  be  due  to  a  lesion  of 
the  subcortical  center,    [m.r  d.] 

2. — Thumin  reports  a  case  of  repeated  renal  colic,  on  the 
right  side,  in  a  woman  aged  31.  Repeated  examinations  of 
the  ureter  by  means  of  a  catheter  gave  negative  results. 
Later  on,  however,  a  diagnosis  of  purulent  pyelitis  of  the 
right  kidney  was  made.  In  order  to  test  the  functional 
activity  of  the  right  kidney,  the  phloridzin  test  was  em- 
ployed. The  left  kidney  was  found  to  be  secreting  normally 
and  the  right  not,  showing  a  disease  of  the  parenchyma. 
Complete  recovery  after  nephrectomy,  and  confirmation  of 
the  diagnosis  upon  examining  the  pathologic  anatomy  of  the 
diseased  viscus.    [m.r.d.] 

3. — The  author  makes  a  plea  not  to  neglect  the  tonsils  in 
all  cases  and  varieties  of  rheumatism.  He  refers  to  the  ex- 
tensive literature  on  the  subject  concerning  the  relation 
between  tonsilitis  and  rheumatism.  He  quotes  4  cases 
occurring  in  his  own  practice  in  which  tonsilitis  was  followed 
by  a  typical  petechial  rash  resembling  purpura.  It  is  not 
necessary  that  the  throat  symptoms  should  be  of  a  verv 
severe  nature,  but  that  sometimes  they  may  be  very  mili 
and  yet  the  constitutional  symptoms  of  rheumatism  be  quite 
severe,    [m.e.d.] 

Novembrr  IS,  1900.     [37.  Jahrg.,  No.  46-1 

1.  Contribution  to  the  Symptomatology  of  Facial  Paralysis. 

M.  Bernhardt. 

2.  Autopsy  in  a  Case  of  Akromegaly.    E.  Mexdel. 

3.  The  Treatment  of  Catarrhal  Adhesive  Processes  in  the 

Middle  Ear  by  Intratubular  Pilocarpin  Injections.    F. 

FlSCHEinCH. 

4.  The  Clinical  Value  of  A.  Schmidt's  Method  for  Testing  the 

Function  of  the  Intestines.    H.  Philippsohn. 

1.— Earnhardt  has  observed  in  cases  of  congenital  and 
early  acquired  facial  paralysis  that  the  musculature  of  the 
paralyzed  side  contracted  when  the  facial  nerve  of  the  un- 
affected side  was  subjected  to  electric  stimulation,  and 
that  this  even  occurred  when  currents  were  employed  which 
would  not  even  affect  the  healthy  side.  He  believes  this  to 
be  due  to  the  anatomic  relations  that  exist  between  the 
facial  musculature  of  the  right  and  left  sides.  The  fact  that 
in  healthy  individuals  electric  irritation  of  one  side  will  not 
bring  about  contractions  of  the  opposite  one  is  not  con- 
sidered to  be  of  value  in  pathologic  conditions,    [m.e.d.] 

2.— Postmortem  examination  of  a  case  of  akromeg-aly 
occurring  in  a  woman  of  2-5,  that  had  been  under  observation 
for  some  time,  is  reported  by  Mendel.  Upon  opening  the 
cranium  the  external  surface  of  the  dura  was  found  to  be 
markedly  adherent.  The  inner  surface  of  the  dura  was 
smooth,  and  the  sinuses  were  bloodless.  At  the  base  of  the 
brain,  near  the  chiasma,  a  sarcoma  a  little  larger  than  a 
walnut,  and  composed  of  large,  round  cells,  was  found.  The 
pmeal  gland  was  throughout  normal.  The  thyroid  gland 
waa  considerably  enlarged,  and  extended  to  the  lower  border 
of  the  manubrium.  In  the  anterior  mediastinum  there  was 
found  a  vestige  of  the  thymus  gland  about  8  cm.  in  length. 
The  spleen  was  very  soft ;  the  right  ovary  was  the  seat  of  cys- 
tic degeneration ;  the  left  ovary  normal.  The  breasts  were 
markedly  developed.  Heart,  lungs,  liver,  and  kidneys  were 
normal.  The  bones  of  the  skeleton,  excepting  the  symmetri- 
cal increase  in  volume,  were  normal.  There  were" nowhere 
any  osteophytic  deposits,     [m.r  d.] 

3.— Fischenich  recommends  the  employmentofa2%  aque- 
ous solution  of  pilocarpin  muriate  as  an  injection,  for 
catarrhal  adhesive  processes  in  the  middle  ear.  The  dose 
varies  from  6  to  16  drops,  and  is  often  followed  by  dizziness, 
which  only  lasts  for  a  brief  period.  The  acoustic  acuity  may 
even  increase  after  treatment  has  been  stopped.  The  injec- 
tions are  made  with  a  catheter  in  the  usual  manner,  and 
may  have  to  be  repeated  30  to  50  times,     [m.r.d] 


Deutsche  medicinische  Wocheuschrift. 

November  29, 1900.     [26.  Jahrg.,  No.  48] 

1.  The  Treatment  of  Cardiac  Diseases.    H.  Hellexdall. 

2.  The  Value  of  the  Serum  Reaction  for  Early  Diagnosis  of 

Tuberculosis.    S.  Akloing  and  P.  Courmont. 


3.  Second  Report  Concerning  Malaria  and  Mosquitoes  on  the 

West  Coast  of  Africa.    H.  Zlemask. 

4.  The  Technic  of  Rontgen  Examination.    Albees-Schos- 

beeg. 
•5.  The  Skiagram  of  a  Metal  Spoon  in  the  Esophagus  of  an 
Adult  Maniac. 

1. — Heliendall  describes  a  procedure  which  is  not  widely 
different  from  that  of  Abbee  [see  Munch,  rued.  Wochen- 
schrift  abstract]  excepting  that  the  latter  author  put  a  band 
around  the  body  while  he  describes  an  apparatus  which 
consists  of  suspenders  thrown  over  the  shoulder  to  keep  the 
apparatus  in  the  proper  vertical  position,  and  a  band  passing 
around  the  body  holding  a  spring  and  pad,  so  that  the  result 
is  much  like  that  of  a  trass,  the  pressure  being  exerted 
almost  exclusively  on  the  pad  and  there  being  no  compres- 
sion of  the  chest  in  general.  The  pad  is  placed  below  the 
left  breast  so  as  to  give  support  to  the  heart.  He  states  that 
the  results  from  the  use  of  this  apparatus  have  seemed  to 
him  excellent,  and  he  believes  they  cannot  be  explained 
through  suggestion  alone.  He  found  that  the  apparatna 
was  not  usually  of  practical  value  except  in  the  after-treat- 
ment in  organic  cases,  but  it  was  then  worn  with  great  satis- 
faction. In  purely  functional  cases  it  may  be  worn  with 
great  comfort  through  the  course  of  the  treatment.  Unfavor- 
able efiects  were  not  observed,  and  the  patients  all  stated 
that  they  felt  a  general  sense  of  comfort.  The  palpitation 
became  less,  there  was  less  dyspnea,  and  the  patients  were 
all  unwilling  to  stop  the  use  ot  the  apparatus  after  they  had 
once  tried  it.     [b.l.e.] 

2. — The  article  is  a  reply  to  a  recent  article  of  Beck  and 
Rabinowitch,  abstracted  in  this  journal  from  the  same 
source.  As  to  the  criticisms  of  the  German  authors  con- 
cerning the  bacillus  used  by  Arloing  and  Courmont, 
the  latter  authors  state  that  it  comes  from  the  ordinary  ba- 
cillus of  Koch,  and  always  retains  the  fundamental  pecu- 
liarity that  it  produces  tubercles,  but  under  different  cir- 
cumstances from  the  ordinary  bacillus  As  to  the  criticism 
that  no  such  agglutination  and  clarification  of  the  fluid  could 
be  observed  as  in  cholera  and  typhoid,  they  state  that  the 
phenomenon  of  agglutination  is  one  that  is  subject  to  a  cer- 
tain amount  of  variation  with  whatever  variety  of  bacilloa 
it  is  undertaken,  depending  upon  the  energy  of  the  action 
taking  place  between  the  agglutinating  and  agglutinated 
substances.  They  consider  that  more  or  less  variation  in  the 
behavior  in  tuberculosis  as  compared  with  that  in  typhoid 
cannot  stamp  the  test  at  once  as  valueless.  The  most  sting- 
ing part  of  their  communication  is  their  study  of  the  tablet 
presented  by  Beck  and  Rabinowitch,  and  the  substance  of 
the  final  statements  of  Arloing  and  Courmont  is  that  a  care- 
ful observation  of  the  tables  reported  by  the  German  authors 
will  show  that  while  they  state  that  they  compared  in  73 
cases  the  reaction  to  tuberculin  with  the  serum  reaction, 
one  can  readily  see  that  the  tuberculin  reaction  was  either 
carried  out  only  11  times,  or  that  it  was  negative  in  all  but 
10  cases.  Tne  only  conclusion  to  be  reached  is  that  the 
serum-reaction  was  really  not  compared  with  the  tuberculin- 
reaction,  or  that  the  tuberculin-reaction  was  positive  in  only 
10  of  the  tuberculous  subjects.  In  the  latter  case  Arloing 
and  Courmont  state  that  they  are  content  to  rest  upon  the 
testimony  offered  since  it  shows  that  the  serum-reaction  was 
positive  in  a  larger  number  of  cases  than  the  tuberculin 
reaction.  They  also  report  their  results  from  the  serum- 
diagnosis  of  80  calves  and  70  cows,  the  latter  of  which  were 
more  or  less  tuberculous.  Autopsies  were  made  by  public 
inspectors  who  knew  nothing  of  the  result  of  serum-diag- 
nosis. The  calves  were  all  free  from  tuberculosis,  and  none 
of  them  gave  reaction  in  a  dilution  as  high  as  1 : 5.  With 
one  exception  all  the  tuberculous  cattle  gave  a  reaction  in  a 
dilution  greater  than  1:10.  They  state  that  they  do  not 
consider  that  the  serum  reaction  can  be  absolutely  depiended 
upon  in  every  case,  but  it  is  very  easilj-  carried  out  when  the 
proper  cultures  are  obtained  :  it  does  not  in  any  way  inter- 
fere with  the  comfort  of  the  patient,  and  it  could  be  under- 
taken in  every  case  without  objection  from  the  patient. 
[d.l  e.] 

3.  —  Ziemann  continues  his  article  by  consideriui:  the 
treatment.  Qulnin  is  a  sovereign  remedy.  Phenoooll 
and  methylene-blue  he  found  practically  useless.  Qainin 
should  be  given  during  the  intermission,  and  not  during  the 
fever;  30  grains  a  day  is  the  largest  dose  neceaeary.    Ha 


January  26,  1901 1 


THE  LATEST  LITERATURE 


LThe  Philadelphia 
Medical  Journal 


161 


believes  that  quinin  acts  directly  upon  the  protoplasm  and 
the  parasites,  and  only  secondarily  upon  the  chromatin.  If 
patients  are  very  sensitive  to  quinin,  he  considers  euchinin 
very  useful.  He  has  found  quinin  a  very  valuable  prophy- 
lactic ;  the  amount,  then,  given  should  depend  upon  the 
individual  and  upon  the  region  in  which  he  lives.  He 
believes,  however,  that  it  should  be  given  every  4  days,  in 
doses  of  about  7  grains,  on  an  empty  stomach.  This  will  not 
absolutely  secure  one  from  an  attack  of  malaria ;  but  if 
malaria  does  occur,  it  is  milder  and  is  nnich  more  readily 
managed  by  treatment.  The  proper  hygienic  conditions  of 
the  dwellings,  proper  clothing  and  food,  are  extremely  im- 
portant in  prophylaxis.  Soldiers  sent  to  the  tropics  should 
be  at  least  25  years  old,  and  should  be  well-chosen,  thoroughly 
healthy  men.  Ziemann  was  able,  in  Kamerun,  Victoria,  and 
also  in  Togo,  to  find  specimens  of  the  Anopheles  containing 
malarial  parasites.  He  considers  this  testimony  that  the 
mosquito  is  probably  very  active  in  these  regions  in  spread- 
ing the  disease.  The  methods  in  attempting  to  stamp  out 
malaria  which  he  recommends  are :  To  keep  well  covered 
at  night  with  mosquito  nets ;  keep  rooms  well  aired  and 
lighted,  so  that  the  mosquitos  will  not  collect  in  them;  turn 
the  sea-water  into  fresh  ponds  along  the  coast,  where 
possible ;  and  use  petroleum  upon  the  surface  of  stagnant 
water,  when  this  can  be  carried  out.  The  latter  procedure, 
in  Ziemann's  belief,  can  very  inexpensively  and  readily  be 
made  of  a  good  deal  of  value  in  many  regions.  He  insists, 
also,  that  the  blacks,  whose  hygiene  is  never  good,  should 
not  be  allowed  to  collect  in  the  neighborhood  of  whites. 
Quinin  prophylaxis,  as  recommended  by  Koch,  he  is  inclined 
to  think,  is  an  idle  dream,  as  it  can  be  done  only  in  indi- 
viduals, and  in  order  to  be  effectual  it  should  be  carried  out 
in  every  person  in  the  neighborhood  who  had  malaria  or  who 
is  likely  to  have  a  relapse  of  old  malaria.  This  Ziemann 
considers  impossible,  but  he  does  believe  that  quinin  can  be 
made  very  useful  in  prophylaxis  in  a  good  many  individual 
cases,  and  particularly  among  the  whites.  He  is  rather 
inclined  to  believe  that  man  is  the  only  intermediate  host  of 
the  malaria  parasite,     [d.l  e.] 

4. — Schonberg  does  not  believe  it  possible  for  physicians 
in  private  practice  to  become  expert  enough  in  the  use  of  the 
x-rays  to  make  a  careful  diagnosis  on  account  of  the 
technical  knowledge  required.  Improvements  are 
constantly  being  made  in  the  apparatus  and  a  person  not 
familiar  with  the  technic  is  unable  to  decide  the  uaefuluess. 
The  quality  of  the  ray  depends  upon  the  management,  and 
kind  of  apparatus  used,  the  light  should  be  steady  and 
especially  so  for  the  instantaneous  work  and  for  this  a  good 
current  breaker  is  required.  Some  of  the  mechanical  breakers, 
those  with  a  stream  of  mercury,  are  very  good,  and  the  Weh- 
nelt  is  a  good  one  also,  but  it  makes  too  much  noise  and  the 
fumes  of  sulfuric  acid  cause  considerable  inconvenience. 
For  tissue  differentiation  a  lamp  with  a  good  vacuum  regula- 
tor is  needed  and  for  carrying  large  currents  some  cooling 
device  is  necessary,  and  it  is  with  these  tubes  that  pictures  of 
sclerosed  arteries,  thickened  joints,  etc.,  can  be  made  as  well 
as  examinations  of  the  chest  for  pathologic  processes  in  the 
heart  and  lungs,     [w.s.n.] 

6. — Stembo  found  by  means  of  the  x-rays  a  spoon  in 
the  esophagus  in  a  man  suffering  from  melancholia, 
the  bowl  of  the  spoon  was  toward  the  stomach,  the  length 
20i  cm.,  width  4,1  cm.  It  was  removed  by  performing  a 
gastrostomy.    [w.S  n.] 

December  6, 1900.     [26.  Jahrg.,  No.  49.] 

1.  The  Collective  Presentation  of  the  Results  of  the  Malaria 

Expedition.    R.  Koch. 

2.  The  Reparation  of  Lost  Tissue.    E.  Ziegler. 

3.  The  Occurrence  of  Apnea  in  Diphtheritic  Paralysis  ;  Re- 

covery.   W.  Ebstew. 

4.  Athyrosis  in  Infancy.    Quincke. 

5.  The    Multiplicity  of   Antibodies  Occurring    in    Normal 

Serum.    M.  Neisser. 

6.  Automatic  Heat-regulator  for  Baths.    G.  Gottstein. 

7.  Clinical  Experiments  with  Hedonal.    S.  Heichelheim. 

8.  The  Proof   of  Typhus  Bacilli  in  the  Blood  of  Typhus 

Patients.     M.  Aueebach  and  E.  Unger, 

1. — Koch's  article  is  a  general  review  of  the  observations 
made  in  his  foreign  expedition.  In  German  East  Africa  he 
found  beside  the  ordinary  tertian  and  quartan  parasites  only 


one  parasite  which  is  of  ring  form  or  half-moon  shape,  and 
produces  fever  attacks  of  a  distinctly  tertian  type,  the  type 
becoming  irregular  if  quinin  has  been  used.  This  type  of 
fever  he  prefers  to  call  tropical  fever,  and  the  parasite  the 
tropical  parasite.  He  found  that  an  enormous  percentage  of 
the  children  in  various  regions  showed  evidences  of  malaria, 
while  as  age  advanced  the  percentage  of  those  affected  de- 
creased very  decidedly.  He  considers  from  this  that  there  is 
evidence  of  the  existence  of  an  acquired  immunity  in  a  very 
large  percentage  of  the  natives.  He  believes  that  this  im- 
munity is  further  shown  by  the  fact  that  many  of  the  adults, 
if  they  go  from  one  region  to  another  where  malaria  is  rife, 
are  not  attacked  by  the  disease.  He  does  not  think  that  the 
reason  that  so  many  children  are  affected  is  because  they  are 
excessively  susceptible  rather  than  that  adults  are  partially 
immune ;  were  that  the  case  he  thinks  they  would  become 
constantly  more  gravely  ill,  and  finally  would  all  die.  The  sus- 
ceptibility that  exists  in  adults  is  often  sufficient  to  cause 
their  death,  and  if  the  figures  in  children  were  due  merely  to 
a  greater  native  susceptibility  the  mortality  among  them 
would  be  extremely  great.  His  method  of  examining  for 
parasites  is  as  follows  :  After  making  smears,  the  prepara- 
tions are  moved  rapidly  to  and  fro  until  they  are  dry,  often  a 
difficult  thing  to  accomplish,  since  in  the  tropics  the  humid- 
ity is  sometimes  100 fc  ;  they  are  then  placed  in  a  box  sur- 
rounded by  blotting  paper  and  put  in  a  glass  receptacle 
which  is  well  stoppered,  and  which  contains  a  little  calcium 
chlorid.  This  prevents  the  preparations  from  spoiling  as  a 
result  of  the  constant  humidity.  He  fixes  by  holding  the 
preparation  in  the  fingers  over  a  flame  and  warming,  then  put- 
ting them  in  absolute  alcohol.  He  stains  with  borax  methyl- 
ene-blue  obtained  from  the  Hoechster  factory.  Examina- 
tions of  the  spleen  in  children  discovered  this  organ  often 
extremely  large.  This  is  found  only  rarely  in  very  young 
infanta.  It  was  found  once  in  a  child  6  months  old,  and  never 
below  this  age.  It  is  most  common  between  3  and  6  years 
of  age.  Splenic  tumor  and  malaria  vanish  spontaneously 
later  on,  and  in  later  life  there  are  no  evidences  of  malaria 
left,  and  the  children  become  strong  and  healthy  adults.  He 
thinks  that  malarial  cachexia  occurs  only  in  those  who  have 
not  acquired  a  sufficient  degree  of  immunity,    [d.l.e.] 

2. — Ziegler  gives  a  general  review  of  the  quesion.  Scar  tis- 
sue is  usually  fibrous  connective  tissue.  In  the  skeleton  it 
often  changes  into  cartilage,  then  into  bony  tissue,  and  finally 
into  well-formed  bone  containing  marrow.  The  scars  of  the 
skin,  intestine,  genital  organs,  lungs,  spleen,  lymph-glands, 
heart,  bloodvessels,  brain,  and  various  glands,  are  generally 
connective  tissue  scars  which  may  be  covered  by  epithelium. 
In  the  liver  it  is  not  uncommon  to  find  the  production  of 
new  bile  channels,  and  in  the  intestinal  and  uterine  mucous 
membranes  the  scars  are  frequently  covered  by  epithelium, 
and  this  may  grow  into  the  scar  and  assume  the  character 
of  glands.  In  the  kidneys  and  testicles,  while  damaged 
tubules  may  acquire  new  epithelium,  there  is  no  real  pro- 
duction of  new  tubules.  In  the  brain  and  spinal  cord  there 
may  be,  besides  the  connective  tissue  production,  some 
growth  of  glia,  but  this  is  of  relatively  slight  importance. 
The  muscles  may  produce  new  muscle  fibers,  after  a  time 
largely  replacing  the  scars.  This  does  not  occur  to  any  ex- 
tent in  the  unstriped  muscular  tissue.  Peripheral  nerves 
heal  by  the  production  of  new  connective  tissue,  and  there  is 
also  a  considerable  production  of  new  nerves,  so  that  the  scars 
are  traversed  by  numerous  new  nerves.  There  may  be  a  new 
production  of  glandular  cells  in  the  liver,  the  kidneys,  the  mu- 
cous glands,  the  thyroid,  and  in  the  genital  glands.  Those  cells 
which  show  the  most  ready  new  growth  are  the  cells  of  the 
fibrillar  and  areolar  connective  tissue  and  the  endothelium 
of  the  blood  and  lymph  vessels.  Cartilaginous  tissues  show 
new  growth  only  imperfectly.  Nerve-fibers  grow  purely 
through  outgrowths  from  the  axis-cylinder.  In  some  cases 
when  the  tissues  of  the  damaged  area  are  unable  to  cover  m 
the  defect,  transplantation  of  tissue  of  the  same  kind  from 
elsewhere  will  accompUsh  the  desired  result.  All  animal 
organisms  have  the  power  to  replace  in  some  way  tissue  tliat 
has  been  lost ;  a  number  of  instances  are  mentioned,  in- 
cluding protozoa  and  higher  forms  of  life.  When  tissues 
which  are  not  replaceable  by  local  growth  are  lost,  and  thus 
cause  damage  to  the  organism,  there  is  a  compensatory 
growth  of  the  remaining  tissues  and  an  increased  function 
of  these  tissues.  The  cause  of  the  repair  of  the  tissues  after 
injury  lies  in  the  power  of  growth  and  prohferation  that  the 


162 


The  Philadelphia*] 
Mkdical  Journal  J 


THE  LATEST  LITERATURE 


[JiyCAET  26.    19«1 


tissues  show.  The  starting  point  in  tliis  growth  is  in  the  fact 
that  some  of  the  factors  which  hinder  growth  are  done  away 
with  b}^  the  injury.  In  compensatory  hypertrophy  of  the 
tissues  the  cause  of  the  new  growth  is  to  be  found  in  the 
increase  of  function  which  acta  both  as  a  nutritive  and 
formative  irritant,     [d.l.e] 

3. — The  case  reported  was  that  of  a  child  of  10.  There 
was  severe  diphtheria  of  the  throat  and  subsequently  a 
widespread  involvement  of  various  nerves  with  marked 
paralysis  and  ataxia  of  the  lower  extremities.  There  was 
also  some  paralysis  of  the  hypoglottis  and  of  the  left 
side  of  the  soft  palate  and  of  the  left  vocal  cord.  Ocular 
accommodation  was  largely  paralyzed,  and  there  was  much 
decrease  of  sensation  in  the  legs.  These  nervous  changes 
improved  slowly.  While  in  the  hospital  the  child  had 
sudden  and  violent  attacks  of  apnea.  In  the  first  at- 
tack it  looked  as  if  the  upper  respiratory  passages  had 
been  plugged  by  mucus,  and  the  child  seemed  about  to 
die.  Removal  of  the  mucus  from  the  mouth  and  throat  did 
no  good ;  on  the  contrary',  the  apnea  increased  and  per- 
sisted for  4  hours,  and  the  child  was  kept  alive  only  by  arti- 
ficial respiration.  These  attacks  were  repeated  five  times. 
They  varied  in  duration  from  5  to  34  hours.  There  was  after 
the  first  attacks  evidently  some  aspiration  pneumonia,  but 
the  attacks  in  general  were  certainly  not  due  to  any  local 
change  in  the  lungs.  There  was  no  paralysis  of  the  dia- 
phragm. The  only  cause  to  be  thought  of  was  either  a 
lesion  of  the  respiratory  center  or  of  the  nerves  coming 
\  therefrom.  The  most  satisfactory  explanation  is,  in  Ebstein's 
belief,  a  lesion  in  the  respiratory  center  produced  by  a  poison, 
probaby  produced  by  the  diphtheria  directly,     [d  l  e.] 

4.— Quincke  reports  the  case  of  a  child  who  had  the  fol- 
lowing history  :  It  was  born  in  1896  of  tuberculous  parents. 
It  had  had  some  skin  eruption  when  six  weeks  old,  but  no 
other  definite  signs.  When  about  six  months  old  the  child 
was  brought  to  the  clinic  because  it  swallowed  badly.  The 
tongue  was  thick,  the  child  was  lethargic,  did  not  know  the 
mother,  had  a  coarse  voice,  had  a  cretin-like  face,  the  nose 
was  broad,  the  body  was  moderately  nourished.  The  thyroid 
gland  was  found  to  be  a  small  hard  tumor  about  tbe  size  of  a 
pea.  The  child  was  given  iodothyrin  with  some  improve- 
ment. Afterward  thyraden  was  added,  and  the  child  im- 
proved very  greatly.  When  the  thyraden  was  stopped  the 
child  grew  worse  again,  and  when  the  thyraden  was  once 
more  ordered  there  was  again  a  very  marked  improvement. 
The  child  had  distinctly  improved,  when  three  years  after  first 
seen  it  disappeared  from  observation.  Even  at  that  time,  how- 
ever, the  improvement  had  been  only  moderate.  The  child  died 
in  1900  of  an  intestinal  aflfection.  '  The  postmortem  showed 
brownish  stumps  of  teetb,  the  fontanel  was  only  imperfectly 
ossified,  the  thymus  was  found  very  small,  and  the  thvroiil 
gland  was  absent.  The  adrenals  were  not  discoverable. 
Quincke  directs  attention  to  the  fact  that  there  was  evidently 
a  progressive  atrophy  of  the  thyroid  gland  in  this  case,  so 
that  it  was  entirely  gone  when  the  child  died,  in  its  fourth 
year.  In  other  words,  that  the  change  was  a  progressive 
pathological  process  in  the  gland,  and  not  congenital  absence 
of  the  gland.  The  cretin-like  symptoms  appeared  in  the  first 
six  months  of  life.  It  was  notable  that  the  skin  was  not  like 
that  of  myxedema,  but  soft,  though  somewhat  thickened. 
Unusual  symptoms  were  nystagmus,  a  shaking  movement  of 
the  head,  and  it  was  notable  that  the  child's  height  was  not 
below  the  normal.  The  case  is  additional  proof  of  Kocher"s 
view  that  cretinism  is  due  to  a  qualitative  or  quantitative 
change  in  the  thyroid  function.  It  is  possible  that  specii»l 
toxins  are  active  in  the  disease,  and  that  they  damage  both 
the  thyroid  gland  and  other  organs,  so  that  the  picture  of  the 
disease  is  due  not  only  to  damage  of  the  thyroid  gland,  but 
to  the  etTect  upon  other  organs,  "[d.l.e.] 

6.— There  has  been,  in  Xeisser's  belief,  sufficient  testimony 
in  many  ways  to  show  that  there  are  numerous  anti-bodies 
in  normal  serum.  An  example  which  proves  this  is  the  fact, 
which  has  been  demonstrated,  that  horse-serum  will  pro- 
tect rabbit's  blood  corpuscles  against  tetanolysin  or  staphylo- 
lysin,  and  other  hemolysins,  and  that  there  is  apparently  a 
distinctly  qualitative  difl"erence  in  the  action  of  the  horse- 
serum  toward  these  various  hemolysins.  When  anti-hemo- 
lysins  are  used,  it  is  found  that  they  act  only  against  the 
homologous  hemolysins.  Further  demonstration  of  the  mul- 
tiplicity of  the  auti-bodiesis  shown  by  the  work  which  Neis- 
ser  reports  here.    He  took  the  serum"  from  4  normal  horses, 


and  determined  quantitatively  their  anti-acion  upon  tetano- 
lysin and  staphylolysin ;  he  then  determined  the  amount  of 
staphylolysin  and  tetanolysin  which  produced  complete  so- 
lution of  the  corpuscles  in  one  drop  of  rabbit's  blood,  and 
then  determined  the  amount  of  horse-serum  which  sufficed 
to  overcome  completely  the  dissolving  influence  of  these  poi- 
sons. The  result  was  that  the  influence  of  the  four  serums 
upon  the  tetanolysin  and  the  staphylolysin  was  very  differ- 
ent. The  ratio  of  action  upon  the  tetanolysin  and  the  action 
upon  the  staphylolysin  in  the  first  serum  was  1 :  10,  in  the 
second  serum  1 :  0.67,  in  the  third  1 :  over  40,  in  the  fonrth 
1 :  1.  Such  results  can  be  explained  only  by  the  acceptance 
of  two  different  anti-bodies,     [d.l-e] 

6. — A  description  of  a  special  thennoregulator  for  use  in 
cases  in  which  skin  diseases,  severe  burns,  etc.,  require  pro- 
longed and  permanent  baths. 

7. — Meihyltropylcarbinolurethran  has  been  given  in  oblate 
form  and  has  no  unpleasant  taste.  The  dose  used  is  from  7 
grains  to  30  grains.  The  use  to  which  it  was  put  was  to  pro- 
duce sleep  in  simple  insomnia  produced  by  overexcit^ment, 
hysteria,  neurasthenia,  old  age,  etc.  Seventy-two  cases  are  re- 
ported. The  conclusion  reached  was  that  it  can  be  well  given 
in  any  case  in  which  sleeplessness  is  not  produced  by  pain. 
Sleep  is  usually  induced  within  an  hour.  No  unpleasant  col- 
lateral efiiects  of  any  kind  were  observed.  One  advantage 
aver  other  hypnotics  is  that  one  can  increase  to  relatively 
high  doses  if  necessary.    [d.l.k.] 

8. — Auerbach  and  Unger  made  cultures  from  the  blood  of 
10  cases  of  typhoid^ever,  obtaining  the  blood  by  introducing  a 
needle  into  a  vein.  In  7  of  these  cases  bacilli  were  obtained. 
Only  1  of  these  was  a  severe  and  fatal  case.  The  others  were 
mild  or  only  moderately  severe.  The  tests  were  made 
between  the  twelfth  and  forty-second  days.  The  cultures 
were  made  in  about  300  cc.  of  bouillon  in  an  Ehrlenmeyer's 
flask  ;  18  to  24  hours  afterward  hanging  drops  were  prepared, 
and  usually  the  bacilli  were  at  once  visible.  They  were  after- 
wards identified  by  the  usual  means.  The  authors  consider 
that  this  procedure  is  a  very  valuable  diagnostic  measure. 
It  is  but  little  more  difficult  to  carry  out  than  the  Widal 
test,  or  bacteriological  examination  of  the  spots.  In  one 
case  in  which  the  Widal  test  was  negative  the  spots  were 
absent,  but  the  diazo  reaction  was  positive.  Cultures  showed 
the  presence  of  typhoid  bacilli  in  the  blood,    [d.l.e  ] 


Neurolog-isclies  Centralblatt. 

Bfcember  15, 1900.     [19.  Jahrg.,  No.  24.] 

1.  The  Venereal   Paralysis  of   Horses;    a  Contribution  to 

Comparative  Neuropathology.    J.  Marek. 

2.  The  Techuic  of  Nerve-cell  Staining.    M.  Bielschowski 

and  M.  Plies. 

1. — Marek  has  made  some  very  interesting  studies  upon  » 
venereal  disease  that  apparently  occurs  only  in  horses, 
and  is  characterized  by  a  slight  local  catarrh  with  the  forma- 
tion of  small  nodules  and  erosions.  At  rather  variable  intervals 
there  appear  spots  on  the  skin  about  the  size  of  a  thaler,  and 
slightly  elevated.  They  are  not  tender  nor  warm.  These 
disappear  in  the  course  of  from  1  to  S  days,  others  reappear- 
ing in  diflFerent  parts.  The  animals  suffer  from  a  general 
pruritis  and  hyperesthesia  of  the  skin.  The  nerve-trunks 
are  tender,  the  cutaneous  reflexes  are  exaggerated,  the  tendon 
reflexes  are  lost  or  diminished.  The  electric  reactions  of  tbe 
paretic  muscles  are  very  ire-atly  decreased,  or  show  the 
characteristics  of  degeneration.  The  animals  show  varioos 
degrees  of  paralysis,  and  may  die  of  sloughing  sores.  Micro- 
scopically the  brain  and  spinal  cord  are  normal,  the  periph- 
eral nerves  show  the  characteristic  changes  of  neuritis :  there 
is  round-cell  infiltration,  particularly  in  the  neighborhood  of 
the  bloodvessels,  and  degeneration  and  disappearance  of  the 
nerve- fibere.  In  the  muscles  there  is  some  degeneration  of 
the  intramuscular  nerve  fibers,  hut  no  inflammatory  change. 
Marek  regards  the  condition  as  a  type  of  polyneuritis  iafec- 
tiosa  equorum. 

2. — Bielschowski  and  Plien  recommend  very  highlyithe  use 
of  cresylviolet  for  staining:  nerve  tissues.  It  has  a  strong 
affinity  for  the  chromophilic  sulvstatice.  and  appears  to  replace 
thionin,  toluidin-blue  and  methylene-blue,  and  it  gives  a 
metachromic  effect  with  basophilic  gr.-inales  and  amyloid 
substance,     [j.s  ] 


;a>xary  26,  1901] 


EPIPLOPEXY  IN  CIRRHOSIS  OF  THE  LIVER 


PThe  Philadelphia 

L  iiEDICAL  JOITRN'AL 


163 


(Drit>inal  ^Irticlcs. 


TWO  CASES  OF  EPIPLOPEXY  IN  CIRRHOSIS  OF  THE 
LIVER.* 

By  JOHN  B.  ROBERTS,   :\I.D., 
of  Philadelphia. 

The  suggestion  to  suture  the  great  omentum  to  the 
anterior  abdominal  wall  for  the  purpose  of  establishing 
a  collateral  venous  circulation,  in  cases  of  cirrhosis  of 
the  Uver,  appears  to  be  founded  on  good  physiological 
premises.  Two  cases  recently  operated  upon  are,  perhaps, 
worthy  of  record. 

The  pre^•ious  history  of  Case  No.  1  is  as  follows : 

A  man,  aged  49,  of  temperate  habits,  whose  father  it  is 
said  died  of  cirrhosis  of  the  liver,  though  he  also  was  a  tem- 
perate man,  came  under  my  care  for  distention  of  the 
abdomen  in  November,  1900.  He  was  referred  to  me  on 
account  of  the  cause  of  the  abdominal  distention  and  the 
ascites  being  obscure.  The  slight  yellow  tinge  of  his  con- 
junctivae and  the  other  symptoms  led  me  to  believe  that  the 
abdominal  dropsy  was  due  to  cirrhosis  of  the  liver.  One  of 
the  other  physicians  who  saw  him  was  inclined  to  the  diag- 
nosis of  tubercular  peritonitis.  The  distention  of  the 
abdomen  began  about  -3  months  before  I  saw  him.  There 
had  been  some  jaundice  varying  in  degree  for  about  2 
months. 

It  was  determined  to  evacuate  the  fluid  in  the  peritoneal 
cavity,  and  at  the  same  time  explore  the  condition  of  the 
abdominal  organs,  by  an  incision,  which  would  permit  the 
entrance  of  my  finger.  A  3-inch  incision  was  made  in  the 
middle  line  above  the  umbilicus.  This  disclosed  a  hardened 
liver  with  a  roughened  surface,  and  the  diagnosis  of  hepatic 
cirrhosis  was  made.  This  operation  was  done  under  ether 
narcosis,  because  the  patient  complained  so  much  of  the 
manipulations,  after  the  abdominal  incision  had  been  made 
under  local  anesthesia  with  cocain.  The  wound  was  closed 
with  interrupted  sutures. 

The  patient  for  a  number  of  days  suffered  from  partial 
suppression  of  the  urine,  due  evidently  to  the  ether  and  the 
cirrhotic  condition  of  the  kidneys.  An  examination  of  the 
urine  had  shown  albuminuria  and  casts.  Under  the  use  of 
^ilocarpin  his  condition  improved,  and  24  days  after  the 
hrst  operation  omental  fixation  was  performed. 

On  December  4,  1900,  the  patient  was  operated  upon 
under  local  anesthesia  with  cocain.  He  was  given,  about 
half  an  hour  previous  to  operation,  a  hypodermic  injection 
of  a  quarter  of  a  grain  of  morphin  and  a  hundredth  of  a 
grain  of  atropin.  The  tissues  in  the  middle  line  above  the 
umbilicus  were  then  infiltrated  with  Schleich's  solution 
JTo.  2.  The  incision  was  made  in  the  line  of  the  previous 
exploration  wound.  A  2-inch  incision  was  sufficient  to 
admit  the  forefinger  of  the  operator  and  permit  the  neces- 
sary intraabdominal  manipulations.  Inspection  of  the 
omentum  showed  near  its  lower  margin  a  small  white  nodule 
of  hard  consistence.  This  was  about  the  size  of  a  pea ;  and, 
with  a  portion  of  the  omentum,  was  excised  in  order  to 
permit  subsequent  microscopic  examination.  It  was  thought 
possible  that  it  might  be  malignant  in  character,  though  the 
exploration  of  the  surface  of  the  liver  with  the  finger.'made 
at  the  time  of  the  previous  operation,  revealed  no  nodules 
in  the  liver  as  far  as  its  surface  could  be  examined  through 
the  small  wound. 

The  peritoneal  surface  on  each  side  of  the  abdominal 
wound  was  rubbed  with  a  finger,  covered  with  a  layer  of 
gauze,  for  the  purpose  of  irritating  its  serous  surface."  The 
omentum  was  then  spread  out  ancl  stitched  on  each  side  of 
the  wound  by  four  sutures  of  chromicized  catgut.  These 
were  introduced  from  the  cutaneous  surface  through  the 
entire  thickness  of  the  abdominal  wall.  For  this  purpose  a 
large  curved  needle  was  used.  The  chromicized  catgut  em- 
ployed for  suturing  purposes  was  tied  on  the  external  surface 
of  the  belly.  The  amount  of  skin  included  in  each  stitch 
was  about  one  inch.    The  abdominal  wound  was  then  closed 

*  Read  before  the  Philadelphia  County  Medical  Society,  January  23, 1901. 


with  interrupted  catgut-sutures  and  the  whole  surface  cov- 
ered with  gauze  and  collodion.  The  two  outer  fixation- 
sutures  ran  horizontally  across  the  abdomen ;  the  two  near 
the  middle  line  lay  a  little  obliquely  upwards  and  inwards. 
The  two-inch  incision  gave  sufficient  room  for  manipulation 
and  seemed  to  be  more  desirable  than  a  longer  incision, 
which  would  have  been  required,  if  the  sutures  had  been 
introduced  through  the  omentum  and  the  internal  tissues  of 
the  abdominal  wall,  from  within  the  abdominal  ca%-ity.  Tlie 
long  sutures  carried  through  the  skin  would,  it  was  thought,  • 
give  a  broader  surface  of  contact  between  the  omentum  and 
the  peritoneum  than  the  shorter  sutures  usually  used  when 
intraabdominal  suturing  is  employed.  A  month  later  the 
patient  had  less  ascites  and  the  external  veins  of  the  ab- 
domen and  anterior  surface  of  the  chest  seemed  much  more 
distended  than  before.  His  general  condition  was  that  of 
advanced  Hver  and  kidney  disease-  He  was  more  jaundiced 
and  more  drowsv.  He  died  about  6  weeks  after  the  epiplo- 
pexy.  An  examination  by  Dr.  Stahr  showed  the  otaentum 
attached  to  the  belly-wall  for  about  3  incbes.  The  nodule 
taken  from  the  omentum  resembled  a  spindlecell  sarcoma. 
A  full  autopsy  was  not  made. 

The  other  case  operated  upon  on  the  same  day  had  a 
previous  history  as  follows  : 

A  man,  aged  54,  stated  that  he  had  been  a  heavy  drinker 
and  that  for  the  last  8  months  the  abdomen  had  become 
distended.  Since  the  abdominal  swelling  had  first  been 
noticed  by  him,  he  had  been  tapped  eight  times.  It  was  prob- 
able that  the  disease  had  existed  much  longer  than  8 
months.  When  I  first  saw  the  patient  he  was  emaciated,  a 
good  deal  jaundiced  and  very  weak.  His  nervous  condition 
suggested  the  possibility  of  approaching  delirium  tremens. 
The  abdomen  was  greatly  distended  with  fluid  and  the 
superficial  veins  of  "the  abdomen  were  very  prominent. 
There  was  edema  of  both  legs.'  Examination  of  the  urine 
showed  albumin  and  a  few  hyalin  casts  to  be  present. 

The  man's  general  condition  was  so  bad  that  instead  of 
suturing  the  omentum  to  the  abdominal  wall,  as  I  was  in- 
clined to  do,  I  simplv  tapped  him  and  drew  off  6  pints  of 
ascitic  fluid.  This  was  on  November  26,  1900.  Eight  days 
later,  operation  for  evacuation  of  the  fluid  in  the  abdomen 
and  epiplopexy  was  done.  At  that  time  there  was  scanty 
urine,  and  the  man  was  still  in  bad  condition,  though  better 
than  when  I  first  saw  him. 

In  this  instance  a  2  inch  incision  was  made  in  the  mid- 
dle line,  just  below  the  umbilicus,  because  I  thought  that  I 
could  probably  reach  the  lower  portion  of  the  omentum 
better  than  if  the  incision  was  made  above  the  umbilicus.  I 
found,  however,  that  it  was  impossible  to  reach  the  omentum 
with  my  finger,  because  it  had  been  pushed  upwards  by  the 
intestines  floating  upon  the  ascitic  fluid.  Fxen  when  the  fluid, 
which  was  large  in  amount,  was  emptied  from  the  abdomen 
through  the  opening,  the  omentum  could  not  be  felt.  A  sec- 
ond incision  of  about  the  same  length  was  therefore  made 
above  the  umbilicus.  The  omentum  was  then  found  and 
pushed  downward,  so  that  it  could  be  reached  with  the  finger 
introduced  through  the  lower  incision.  It  was  then  very  easy 
to  spread  out  the  omental  tissues ;  and  two  sutures  of  chrr  mi- 
cized  catgut  were  introduced  on  each  side  of  the  upper  incis- 
ion. WTiile  the  sutures  were  introduced,  the  forefinger  of 
the  operator's  right  hand  was  introduced  through  the  lower 
opening  to  hold  the  omentum  in  place  and  protect  the  intes- 
tines from  injury  with  the  needle,  which  was  carried  through 
the  entire  thickness  of  the  belly-wall  with  the  left  hand. 
This  operation,  which  was  done  under  cocain  anesthesia, 
was  made  quite  easy  because  of  the  great  relaxation  of  the 
anterior  belly- wall,  "due  to  the  prolonged  dropsy  of  the  peri- 
toneum. The  assistant  was  able  to  pick  up  the  relaxed  wall 
in  a  vertical  fold  so  that  the  curved  needle  could  be  intro- 
duced without  going  near  the  intestine.  This  was  probably 
an  error  in  technic,  as  it  made  the  sutures  more  liable  to 
tear  through  the  omentum  when  the  abdominal  wall  was 
released  by  the  fingers. 

The  patient  died  in  uremic  coma  the  day  after  the 
operation.  On  opening  the  abdomen  three  of  the 
stitches  were  found  to  have  torn  through  the  omentum. 
At  the  place  of  one  stitch  a  small  portion  of  the  omen- 
tum was  still  held  against  the  abdominal  wall,  and  in 


164 


The  Philadelphia 

Medical  Journal 


] 


THE  SURGERY  OF  THE  STOMACH 


[Jakcabt  2e,  190) 


two  places  an  ecchymosis  was  seen  in  the  tissue  of  the 
omentum  showing  where  the  needle  puncture  had  been 
made  at  the  time  it  was  sutured  to  the  belly-wall.  One 
stitch  was  still  holding.  There  was  no  evidence  of  in- 
flammatory lymph  at  the  point  where  the  stitches 
were  inserted.  This  probably  was  due  to  the  weak 
condition  of  the  patient  at  the  time  of  the  operation. 
^The  liver  was  very  small  and  hard  and  the  surface  nod- 
ular. It  was  in  appearance  a  typical  hobnail  liver. 
The  kidneys  were  small,  with  notched  surface  and  ad- 
herent capsule.  The  cortex  was  diminished  in  amount. 
Microscopic  examination  subsequently  showed  the  cir- 
rhotic nature  of  the  hepatic  condition. 

It  is  much  too  early  to  reach  a  definite  conclusion  as 
to  the  clinical  value  of  epiplopexy  in  cirrhotic  liver ; 
but  the  operation  is  so  comparatively  trivial  and  the 
disease  so  intractable  that  a  comparatively  early  resort 
to  it  seems  justifiable.  Both  of  these  cases  would  have 
been  operated  upon  earlier  by  me,  if  the  general  condi- 
tion had  been  better. 

The  patient  whose  operation  is  reported  first  became 
seriously  ill  from  partial  suppression  of  urine  after  the 
exploratory  operation  done  to  determine  whether  he 
was  suffering  from  tubercular  peritonitis  or  cirrhosis  of 
the  liver.  That  operation  had  been  started  under  anes- 
thesia by  cocain,  but  was  concluded  under  ether  because 
of  the  patient's  assertion  that  he  was  being  hurt.  It 
was  this  serious  condition,  the  result  of  etherization  in 
connection  with  his  bad  kidneys  and  liver,  that  made 
me  a  little  anxious  about  the  operation  for  fixing  the 
omentum. 

The  case  which  is  here  reported  as  No.  2  was  exceed- 
ingly ill  when  first  brought  under  my  observation,  with 
edema  of  the  lungs  and  a  nervousness  which  seemed  to 
indicate  the  probable  occurrence  of  delirium  tremens. 
He  was  in  a  bad  condition  when  operated  upon,  having 
passed  for  a  few  days  previously  a  much  less  amount  of 
urine  daily  than  is  physiological.  I  was  led,  however,  to 
operate  upon  both  cases  because  of  their  apparent  hope- 
lessness under  medicinal  treatment. 

These  cases  have  taught  me  a  few  points  in  regard 
to  the  technic  of  the  operation.  I  believe  the  method 
carried  out  in  them  is,  in  general,  the  best.  By  this  I 
mean  that  the  incision  should  be  made  above  "the  um- 
bilicus under  local  anesthesia,  and  that  the  sutures 
should  be  carried  through  the  external  skin  by  means 
of  a  curved  needle,  while  the  forefinger  of  one  hand 
within  the  abdomen  holds  the  omentum  against  the 
anterior  abdominal  wall.  It  probably  is  unimportant 
whether  or  not  the  parietal  peritoneum  be  previouslv 
scraped  with  a  curet  or  rubbed  with  a  finger  covered 
with  gauze.  It  is,  however,  important  that  the  omen- 
tum be  rolled  up  a  little,  at  the  point  of  each  suture, 
into  a  sort  of  cord,  so  as  to  prevent  the  stitch  tearinsj 
through  the  friable  tissue.  The  stitch  should  include 
quite  a  wide  area  of  omental  structure.  On  this  account 
it  is  undesirable  that  the  anterior  abdominal  be  pinched 
into  a  fold  during  the  insertion  of  a  stitch,  because  when 
the  tissues  are  relaxed  the  catgut-suture  is  liable  to  tear 
through  the  omentum. 

I  had  originally  intended  in  these  cases  to  make  a 
sort  of  rope  of  part  of  the  omentum  and  stitch  this  in 
the  incision  in  the  anterior  wall,  so  that  the  omental 
tissue  would  be  in  contact  with  the  superficial  fascia. 
I  had  thought  of  even  spreading  its  end  out  under  the 
skin.  I  did  not  do  this  because  I  thought  the  contrac- 
tion of  the  scar-tissue  in  the  wound  would  prevent  venous 
circulation  through  the  portion  of  omentum  thus  drawn 


through  of  the  muscular  wall.  The  importance  of  keep- 
ing the  omentum  fixed  against  the  peritoneal  surface  ol 
the  wall  of  the  abdomen  until  adhe.sion  occurs,  makes  it 
desirable  that  it  should  be  thus  caught  in  the  wound. 
Even  if  cicatricial  contraction  prevents  circulation 
through  the  scar,  and  even  if  a  weak  spot  is  made  in  the 
wall,  creating  a  liability  to  hernia.  I  believe  that  such 
fixation  in  the  wound  is  important. 

I  did  not  undertake  to  stitch  the  surface  of 
the  liver  to  the  anterior  wall  of  the  abdomen  in 
either  case.  In  both  instances  the  disease  was  so 
marked  that  it  would  probably  have  been  difi&cult  to 
have  pushed  the  small  liver  forward  against  the  abdom- 
inal wall  and  to  have  held  it  there  by  suturing,  without 
causing  greater  tension  on  the  sutures  than  is  desirable. 
Epiplopexy,  should,  in  my  opinion,  be  done  as  soon 
as  practicable  after  the  diagnosis  of  cirrhosis  of  the  liver 
is  made.  In  late  cases  the  operation  will  probably  not 
be  of  much  therapeutic  service.  It  seems  as  if  there 
were  good  physiological  grounds  for  believing  it  advan- 
tageous in  early  cases.  The  discomfort  liable  to  arise 
from  the  abnormal  adhesions  and  the  remote  possibility 
of  intestinal  obstruction  by  entanglement  of  the  small 
bowel  are  too  unimportant  to  weigh  against  the  possi- 
bility of  dela}'ing  the  onward  march  of  an  almost  hope 
less,  progressive,  hepatic  disease. 


THE  SURGERY  OF  THE  STOMACH.* 

By  albert  I.  BOUFFLEUR,  M.D., 
of  Chicago. 

Before  considering  the  subject  assigned  to  me,  I  de- 
sire to  express  to  the  oflBcers  and  members  of  the  Society 
my  keen  appreciation  of  the  honor  conferred  ujion  me 
in  my  selection  as  one  of  the  speakers  upon  this  mem- 
orable occasion. 

It  was,  however,  with  considerable  diflBdence  that  I 
consented  to  present  such  a  large  and  important  subject 
in  the  limits  of  a  single  paper  before  such  a  critical 
audience;  knowing  as  I  did.  that  it  would  be  impossi- 
ble to  do  the  subject  full  justice  in  so  short  a  time,  and 
that  to  cover  it  at  all  would  mean  the  briefest  mention 
of  several  conditions  and  procedures,  any  of  which 
might  claim  our  attention  for  a  whole  hour,  and  feeling 
as  I  did,  that  there  are  members  of  your  Association 
who  are  able  to  speak  authoritatively  upon  the  matters 
to  be  considered. 

The  phase  of  the  symposium  upon  which  I  have  been 
requested  to  address  you  forms  one  of  the  most  interest- 
ing chapters  in  modern  surgery.  While  gastrotomy 
was  performed  as  earh'  as  1602  by  Mathis  and  .again  in 
1635  by  Schwabe,  the  works  on  surgery  gave  it  but  little 
attention  until  quite  recently  :  and  likewise,  Sedillot 
seems  to  have  performed  gastrostomy  as  early  as  1849, 
but  the  operation  was  practically  unheard  of  until  1SS6 
when  Hacker  again  presented  the  subject- 
Modern  gastric  surgery  can  be  said  to  have  begun 
about  25  years  ago,  when  Billroth  and  his  assistants 
began  to  develop  the  technic  which  has  made  the  sub- 
sequent wonderful  procedures  possible.  The  radical 
measures  seem  to  have  preceded  the  milder  ones  in  the 
surgery  of  this  organ.  Billroth  successfully  performed 
pylorectomy  in  1S91,  while  Heinecke  and  Mikulicz  pre- 
sented pyloroplasty  iu  lSSG-7.     The  great  mortality  of 

*  Address  delivered  before  the  Michigu  Slate  Uedioal  SocSet}-,  Mackinac  U- 
aod,  Mich.,  July,  1900b 


JANDAEY  26,    1901] 


THE  SURGERY  OF  THE  STOMACH 


["The  Philadelphia 
L  Medical  Journal 


165 


the  more  radical  procedures,  even  in  the  hands  of  such 
experts,  made  the  necessity  of  less  heroic  measures 
imperative.  This  is  frequently  the  case  in  surgery ; 
the  ideal  giving  way  to  the  practicable. 

With  the  wonderful  strides  of  abdominal  surgery, 
that  of  the  stomach  kept  pace,  and  within  a  brief 
space  of  10  years  nearly  all  of  our  present  procedures 
were  successfully  performed.  Since  1890  the  progress 
has  been  in  the  direction  of  modifying  and  improving 
the  technic  of  the  established  procedures,  and  in  widen- 
ing the  scope  of  their  application  until,  as  a  fitting  cli- 
max to  the  close  of  the  brilliant  nineteenth  century,  the 
most  formidable  of  all  possible  operations  upon  the 
stomach — its  total  extirpation — was  successfully  per- 
formed. 

The  stomach  forms  such  an  important  part  of  the 
prhnse  viie  that  its  presence  has  until  comparatively  re- 
cently seemed  absolutely  indispensable  to  life.  While 
from  practical  experience  it  has  been  known  for  years 
that  a  patient  could  not  only  be  sustained  but  hyper- 
uourished  per  rectum,  and  while  resections  of  the 
major  portion  of  the  stomach  had  been  successfully  per- 
formed several  times,  it  remained  for  Schlatter,  a  bold 
Swiss  surgeon,  to  positively  demonstrate  that  man  could 
not  only  withstand  the  operation  of  total  gastrectomy, 
but  that  the  functions  of  assimilation  and  general  bodily 
nutrition  could  be  carried  on  quite  satisfactorily  with- 
out any  stomach. 

While  this  fact,  perhaps,  is  of  the  greatest  interest  to 
the  physiologist,  it  serves  its  purpose  for  the  surgeon 
by  demonstrating  conclusively  that  it  is  admissible  for 
us  to  resect  larger  areas  of  the  stomach  and  even  the 
whole  of  that  organ  for  local  disease  and  thereby  to  give 
to  our  patients  greater  chances  of  freedom  from  local 
recurrence. 

The  surgery  of  the  stomach  has  been  made  possible 
by  the  fact  that  rectal  feeding  is  feasible  and  practica- 
ble in  all  cases,  at  least  for  a  few  days.  While  operative 
measures  were  formerly  largely  for  emergency  condi- 
tions, the  absence  of  the  necessity  for  nourishment  by 
mouth,  the  frequency  with  which  early  diagnosis  is 
now  made,  the  greater  simplicity  and  perfection  of 
operative  technic  and  the  increased  dexterity  of  opera- 
tors have  made  it  practicable  to  operate  for  elective  as 
well  as  emergency  conditions. 

The  surgery  of  the  stomach  can  very  properly  be 
divided  into  operations  for  disease  of  the  stomach  itself 
and  for  conditions  incident  to  the  disease  of  other  organs. 

Diseases  or  conditions  of  the  stomach  which  may 
require  operative  treatment  are  congenital  and  acquired 
deformities,  wounds,  stenosis  or  orifices,  dilation,  dis- 
placement, ulcer  and  cancer.  The  presence  of  foreign 
bodies  in  the  stomach  also  call  for  surgical  measures. 
The  two  conditions  of  other  organs  most  likely  to  call 
for  operation  upon  the  stomach  is  stricture — malignant 
or  benign — of  the  esophagus  and  of  the  upper  part  of 
the  intestinal  tract. 

Since  I  have  been  advised  that  the  other  gentlemen 
will  not  consider  the  surgical  diseases  of  the  stomach, 
it  has  seemed  desirable,  in  order  to  make  my  remarks 
more  comprehensive,  to  briefly  mention  the  character- 
istics, clinical  history  and  diagnosis  of  the  conditions 
before  presenting  the  treatment ;  and  to  avoid  useless 
repetition  I  will  leave  the  description  of  the  various 
operative  measures  until  the  last. 

Congenital  Malformations. 
Congenital  malformations  of  the  stomach  have  been 


observed  frequently,  but  the  character  of  the  conditions 
has  been  varied.  Congenital  malposition  may  be 
present  and  is  most  commonly  connected  with  con- 
genital defects  in  the  diaphragm  or  congenital  abdom- 
inal fissure.  A  septum  dividing  the  stomach  into  two 
chambers  more  or  less  completely  has  been  observed, 
and  congenital  or  acquired  constriction  of  the  stomach 
may  give  rise  to  an  "  hour-glass  "  shape.  The  acquired 
constriction  is  the  result  of  cicatrized  ulcers. 

Prolapse  of  the  gastric  mucous  membrane  through 
the  umbilicus  has  been  observed  by  Tillmans.'  The 
same  author  mentions  congenital  atresia  of  the  pylorus 
as  of  very  rare  occurrence.  A  condition  of  marked 
congenital  hypertrophy  of  the  pylorus  has  been  ob- 
served in  several  instances  and  has  been  the  sub- 
ject of  special  investigation  by  several,  including  Dr. 
John  Thomson  of  Edinburgh,  whose  valuable  contribu- 
tion, fortified  as  it  is  by  the  result  of  postmortem  and 
microscopic  examination,  forms  an  invaluable  addition 
to  the  literature  of  gastric  diseases.^ 

The  symptoms  are  those  of  pyloric  stenosis  and 
death  is  from  starvation.  Thus  far  surgical  measures 
have  apparently  not  been  resorted  to,  but  as  a  probable 
diagnosis  can  now  be  made,  there  would  seem  to  be 
no  reason  why  gastroenterostomy  or  pyloroplasty,  or 
perhaps  gastrotomy  with  dilation,  should  not  be  of  ser- 
vice in  this  condition,  not  only  as  a  palliative  but  also 
as  a  curative  measure.  (Kammerer  has  since  collected 
four  successful  cases.") 

Wolfler  was  the  first  to  operate  for  marked  "  hour- 
glass "  contraction.  In  1894  he  made  an  anastomosis 
between  the  two  chambers — gastroanastomosis.'  Up  to 
date  the  operation  has  been  performed  six  times  with 
one  death." 

Wounds. 

Wounds  of  the  stomach  are  justly  classed  with  the 
most  serious  injuries  of  the  body.  MacCormac  gives 
the  mortality-rate  of  wounds  as  99%.'  The  principal 
symptoms  are  shock,  vomiting  of  blood,  and  severe 
epigastric  pain,  to  be  followed  with  fever  and  peritonitis. 
The  more  distended  the  stomach  the  more  unfavorable 
the  prognosis.  That  penetrating  and  perforating 
wounds  are  not  always  fatal  even  without  prompt  sur- 
gical closure  was  demonstrated  by  the  celebrated  case 
of  Alex.  St.  Martin,  treated  by  Dr.  William  Beaumont, 
in  this  city  in  1822,  and  who  subsequently  became  the 
subject  of  the  exhaustive  experiments  and  observations 
which  placed  the  name  of  Beaumont  on  the  list  of  our 
great  physiologists.  Both  ^[acCormac  and  Tillmans 
have  also  reported  cases  of  bullet  wounds,  and  Larrey 
and  Archer  saber  wounds  of  the  stomach,  which  have 
recovered  without  operation.' 

In  those  cases  in  which  death  does  not  rapidly  super- 
vene from  hemorrhage  or  septic  peritonitis,  abscesses 
may  result,  which  may  be  relieved  by  modern  opera- 
tive measures.  There  can  be  no  question  but  that  early 
celiotomy,  with  accurate  suture  of  the  gastric  wound 
and  careful  toilet  of  the  abdominal  cavity,  will  greatly 
reduce  the  mortality  of  wounds  of  the  stomach. 

Stenosis  of  the-  Orifices. 

Stenosis  of  either  the  cardia  or  pylorus  may  result 
from  cicatrization  of  an  ulcer  or  a  wound,  from  hyper- 
trophy of  the  pyloric  musculature,  or  from  the  growth 
of  malignant  or  benign  neoplasms.  Malignant  growths 
demand  resection  for  their  removal  or  the  formation  of 
a  fistula  for  the  relief  of  their  most  distressing  symp- 


166 


The  Philadelphia' 

Medical  Jocbsal 


] 


THE  SURGERY  OF  THE  STOMACH 


[  Jascaet  26,  ISO: 


toms.  Nonmalignant  stricture  of  the  cardia  can  be 
most  readily  reached  through  the  stomach.  Gastrotomy 
with  immediate  dilation,  or  gastrostomy  with  immediate 
or  later  dilation,  is  indicated. 

Nonmalignant  stenosis  of  the  pylorus  can  be  treated 
by  dilation — pylorodiosis,  pyloroplasty  or  gastroenter- 
ostomy. Loreto  has  practised  dilation  after  gastrotomy 
in  cases  of  nonmalignant  stricture  of  the  pylorus  with 
considerable  success  since  1882,*  but  the  statistics  of 
Barton^  show  a  mortality  of  10  in  25  published  cases, 
which  is  greater  than  that  of  pyloroplasty  which  is 
more  likely  to  be  permanent  in  its  effect.  Hahn  dilates 
the  pylorus  without  opening  the  stomach  by  invaginat- 
ing  the  anterior  wall  on  the  dilating  finger.  This  pro- 
cedure, while  comparatively  safe,  can  obviously  be  of 
value  in  only  the  mildest  cases. 

Pyloroplasty  has  a  mortality  of  about  10%,*  and  while 
it  is  usually  effectual,  the  condition  demanding  its  per- 
formance may  return.  When  the  mass  is  very  extensive 
or  thick  or  bound  down  by  many  adhesions,  the  per- 
formance of  gastroenterostomy  is  to  be  preferred.  The 
low  mortality,  the  ease  and  quickness  of  its  performance 
and  the  results  of  gastroenterostomy  make  it  the  opera- 
tion of  election,  and  unless  the  conditions  are  very 
favorable  for  pyloroplasty,  gastroenterostomy  should 
always  be  performed. 

Dilation. 

Dilation  of  the  stomach  is  usually  indicative  of  mus- 
cular atony  and  functional  inefficiency  of  that  organ. 
While  in  the  vast  majority  of  cases  dilation  is  secondary 
to  some  chronic  diseases  of  the  stcftnach  or  to  obstruction 
on  the  pylorus  or  duodenum,  it  does  occasionally  develop 
as  the  result  of  overloading  of  the  stomach,  and  as  a 
result  of  chemical  insufficiency  resulting  in  fermenta- 
tion and  muscular  insufficiency.  It  may  also  be  due 
to  adhesions  to  other  organs  or  to  generally  impaired 
nutrition  as  observed  in  anemia,  tuberculosis,  etc. 

In  addition  to  the  general  symptoms  of  chronic  gas- 
tric and  intestinal  disturbances,  the  symptoms  of  the 
primary  disease  and  the  individual's  personal  history, 
the  vomiting  at  long  intervals  of  a  large  quantity  of  un- 
digested food  is  characteristic.  As  local  measures,  in- 
cluding lavage,  have  proved  ineffectual  in  many  cases, 
they  may  have  been,  as  a  last  resort,  referred  to  the  sur- 
geon, in  the  hope,  no  doubt  in  many  instances,  that 
even  if  the  operation  did  not  benefit,  it  might  interrupt 
the  long  period  of  suffering. 

The  medical  treatment  of  gastric  dilation  should  be 
largely  dietetic  and  antiseptic.  Frequent  feedings  of 
small  quantities  of  concentrated  and  easily  digested 
foods  with  lavage  and  the  use  of  innocuous  antiseptics 
will  frequently  eflect  wonderful  improvement  and  even 
relief  of  the  condition.  To  Kiissmaul  is  due  the  credit 
of  introducing  the  lavage  method  of  treatment  in  1867.' 
It  lessens  the  weight,  removes  the  mucus  and  products 
of  fermentation,  and  affords  a  means  of  cleansing  and 
locally  treating  the  mucous  membrane. 

Gastroplication  or  "  reefing ''  of  the  stomach  wall,  as 
first  practised  by  Bircher-'  in  1891,  has  been  resorted 
to  in  a  number  of  cases  of  simple  dilation  with  encour- 
aging results.  The  mortality  rate  of  the  operation  itself 
has  thus  for  been  nil  as  far  as  I  have  been  able  to  learn. 
If  the  dilation  be  secondary  to  pyloric  obstruction,  that 
obstruction  must  be  overcome  by  divulsion  after  a  gas- 
trotomy or  gastrostomy,  or  circumvented  by  a  gastro- 
enterostomy which  is  by  far  the  most  rational  and  sus- 
cessful  procedure. 


Gastroptosis. 

Gaatroptosis  may  be  present  as  a  single  affection,  bul 
as  a  rule  it  is  attended  by  ptosis  of  other  abdomina! 
organs,  particularly  the  colon  and  the  small  intestines 
Gastroenteroptosis  is  a  peculiar  affection  and  dependent 
largely  upon  4  factors  :  Weakened  attachments,  in- 
creased weight,  pressure,  and  lessened  abdominal  sup 
port.  It  is  frequently  accompanied  by  dilation,  and 
in  many  instances  is  undoubtedly  caused  thereby ;  oi 
both  may  be  due  to  the  same  general  state  of  malnutri- 
tion. It  occurs  in  persons  of  large,  flabby,  relaxed  and 
pendulous  abdominal  walls,  and  in  thin,  pale,  neuras- 
thenic individuals,  particularly  females.  In  thin  per- 
sons only  is  the  condition  productive  of  marked  symp- 
toms. Pain,  indigestion  and  vomiting,  with  chlorosis 
headache,  palpitation,  nervousness,  etc.,  form  the  com- 
mon group  of  symptoms.  Palpation  and  inflation  usu- 
ally demonstrate  not  only  a  downwardly  displaced 
stomach,  but  frequently  a  dilated  viscus  as  well. 

Rest  in  bed,  with  massage  and  proper  diet,  will  reUevf 
many  of  these  patients  of  their  distressing  symptoms 
If  the  dilation  is  great,  lavage  and  even  "  reefing  "  maj 
be  required.  If  the  displacement  is  marked,  gastropexj 
is  indicated,  and  if  accompanied  by  dilation,  bott 
operations  should  be  performed.  Gastropexy  is  of  valm 
in  relieving  the  symptoms  of  a  displaced  stomach,  bni 
to  be  permanently  beneficial,  reduction  and  fixation  o 
any  other  displaced  organs  should  be  performed  and 
attendant  constitutional  and  local  conditions  should  b< 
given  proper  treatment  subsequently. 

Ulcer. 

Both  Ewald  and  \\'elch  have  made  careful  postmor 
tern  investigations  into  the  frequency  of  round  or  pepti( 
ulcer  of  the  stomach,  and  have  estimated  that  it  occun 
in  fully  5  %  of  mankind.' 

The  presence  of  this  ulcer  seems  dependent  upor 
lowered  vitality  of  the  gastric  mucosa,  as  by  disturbanc* 
of  the  circulation,  etc.,  impoverishment  of  the  blood,  at 
in  anemia  and  chlorosis,  and  the  presence  of  an  exces- 
of  hydrochloric  acid  in  the  gastric  juice.  Loweret 
vitality  and  local  resistance  with  increased  digestiv< 
power  of  the  gastric  juice  would  naturally  result  in  i 
digestion  of  the  stomach-wall  with  the  production  of  ar 
ulcer — a  peptic  ulcer. 

It  occurs  in  females  oOfc  more  frequently  than  ir 
males,  and  whUe  75%  of  aU  cases  occur  between  th« 
ages  of  20  and  60,  no  age  is  exempt  The  greatesi 
number  of  cases  are  observed  in  females  between  2( 
and  30,  and  in  males  between  30  and  40,  but  the  tota 
observations  are  nearly  equally  divided  between  the  -. 
decades  mentioned.  It  is  most  common  in  servant- 
girls,  dressmakers,  and  women  affected  with  anemia 
chlorosis  and  menstrual  disorders,  and  in  men  employee 
in  occupations  wherein  the  stomach  is  subjected  to  pres- 
sure, as  first  noted  by  Habershorn '  and  in  alcoholic! 
and  those  afflicted  with  arteriosclerosis.  Rasmussen 
holds  that  any  pressure  of  the  costal  arches  induce 
anemia  and  atrophy  of  the  gastric  mucosa. 

The  ulcer  is  usually  single,  but  may  be  multiple  ant 
is  most  frequently  situated,  according  to  Frazier,'  & 
follows:  52%  on  anterior  wall :  31%  near  lesser  curva 
ture  ;  27%  near  the  cardia  ;  13%  near  the  pylorus :  anc 
S  %  on  the  posterior  wall. 

The  ulcer  varies  from  1  to  10  cm.  in  diameter,  anc 
Peabody '  has  reported  one  10  by  19  cm.  in  size,  I 
may  he  superficial  or  deep  with  a  tendency  to  destroc 


JaNCAKV  26,  1901] 


THE  SURGERY  OF  THE  STOMACH 


TThk  Philadelphia 
L  Medical  Journal 


167 


tion  of  adjacent  tissue.  This  destructive  tendency 
leads  to  erosion  of  the  bloodvessels  with  the  production 
of  hemorrhage  in  fully  50%  of  the  cases,  and  in  over 
6%,  according  to  Welch/  it  results  in  perforation. 

If  the  perforation  is  anteriorly,  general  peritonitis 
usually  follows ;  if  posteriorly  or  at  the  lesser  curva- 
ture, subphrenic  abscess  in  the  cavity  of  the  lesser 
omentum  is  to  be  expected ;  while  if  the  perforation 
is  preceded  by  a  plastic  peritonitis  with  adhesions  the 
establishment  of  a  fistula  into  one  of  the  abdominal 
viscera  or  thoracic  cavities  could  occur. 

From  the  foregoing  data  it  would  appear  that  over 
50%  of  the  cases  of  ulcer  are  attended  by  hemorrhage 
or  perforation  and,  therefore,  the  condition  is  to  be 
regarded  as  a  truly  serious  one. 

The  diagnosis  may  be  easy,  but  it  is  frequently  ex- 
ceedingly difficult,  not  to  say  conjectural.  It  is  based 
upon  the  presence  of  some  of  the  foregoing  predispos- 
ing factors  and  upon  the  existence  of  pain,  hemorrhage 
and  vomiting.  The  pain  is  usually  localized,  varied 
in  character,  and  aggravated  by  taking  food ;  but  it 
may  come  at  irregular  intervals,  and  even  be  relieved 
by  eating  or  pressure. 

The  hemorrhage  which  is  so  common  in  ulcer,  may 
appear  in  small  quantities  or  be  very  profuse.  It  may 
appear  in  the  vomitus  or  in  the  stools.  Sudden  vomit- 
ing of  a  large  amount  of  bright  red  blood  is  quite  char- 
acteristic of  ulcer.  The  vomiting  usually  occurs  after 
meals,  and  afifords  relief  from  pain.  Localized  epigas- 
tric tenderness  is  often  marked,  but  in  other  cases  firm 
pressure  alone  seems  to  relieve  the  suffering.  The 
symptoms  may  subside  and  even  disappear  with  heal- 
ing of  the  ulcer,  but  it  may  recur,  or  the  cicatrix  may 
distort  the  conformity  of  the  stomach,  or  be  painful,  or 
even  be  the  site  of  a  carcinoma. 

In  the  treatment  of  gastric  ulcer,  medical  measures 
like  ice,  astringents,  opium,  etc.,  with  absolute  rest  are 
indicated  for  first  and  second  attacks,  according  to 
Rodman, '  but  after  the  second  attack  and  particularly 
in  all  cases  of  recurrent  hematemesis,  operative  meas- 
ures are  positively  demanded.  Operation  during  acute 
hematemesis,  and  particularly  the  first,  has  been  very 
unsatisfactory.  Robson  "  gives  the  mortality  as  64.2%, 
which  he  contrasts  with  5%  to  10%  mortality  of  acute 
hemorrhage  treated  medically.  The  reflex  effect  of 
hot  water  enemata  at  a  temperature  of  112°  to  120°  F. 
has  been  advanced  and  successfully  employed  by 
Tripier  in  a  number  of  cases.^ 

A  sufficient  number  of  operations  have  now  been 
reported  to  warrant  some  definite  statements  as  to  the 
advisability  and  success  of  operating.  Rodman"  col- 
lected 31  operations  for  recurrent  or  chronic  hemor- 
rhage with  6  deaths,  a  mortality  of  19.3%,  and  he 
quoted  Robson  as  reporting  a  mortality  of  16.4%  in 
all  operations  for  gastric  ulcer  and  of  only  10.5%  in 
chronic  cases.  These  statements  are  certainly  most 
encourging,  and  with  early  diagnosis  and  operation  at 
the  proper  time,  these  figures  should  be  materially 
reduced. 

Of  the  various  methods  which  have  been  employed 
partial  gastrectomy  or  pylorectomy,  depending  upon 
the  location  of  the  ulcer,  and  the  ligation  of  the  mucosa 
en  masse,  have  been  the  procedures  of  direct  attack 
most  successfully  employed.  According  to  Tillmans' 
and  Keen,'"  Czerny  was  the  first  to  successfully  excise 
agastric  ulcer  in  1882,  but  Greig  Smith"  and  Curtis'* 
give  the  credit  to  Rydygier  in  1881,  while  Wier  and 
Foote''  ascribe  it  to  Kriege  in  1892.    Mikulicz  appears  to 


have  been  the  first  to  operate  by  treating  the  ulcer  directly 
in  1887.'    He  combined  cauterization  with  pyloroplasty. 

When  the  nature  of  the  process  is  considered  it  will 
be  appreciated  that  cauterization  or  ligation  of  the 
bleeding  vessel  alone  does  not  meet  aU  the  surgical  in- 
dications presented. 

Gastroenterostomy  is  rapidly  gaining  favor  as  the 
elective  operation  for  ulcer  with  chronic  hematemesis. 
By  placing  the  stomach  at  rest  and  draining  off  the 
over- acid  gastric  juice,  it  provides  the  two  essential 
factors  for  healing  of  the  ulcer.  Robson'^  is  particularly 
favorable  to  the  procedure. 

In  cases  with  profuse  hemorrhage  some  local  meas- 
ures seem  demanded,  and  anyone  of  the  foregoing 
methods,  particularly  when  combined  with  gastroenter- 
ostomy, would  be  indicated. 

In  cases  of  acute  perforation,  immediate  gastror- 
rhaphy  is  unquestionably  demanded.  Lund  has 
shown  that  during  the  past  3  years  operations   within 

12  hours  gave  a  mortality  of  only  14%,  and  within  24 
hours  27%,  which  contrasts  markedly  with  the  earlier 
statistics,  which  showed  a  mortality  of  50  to  90%.' 

The  investigations  of  Greenough  and  Joslyn'*  revealed 
the  fact  that  only  i  of  the  80%  of  ulcer  patients  dis- 
charged from  the  Massachusetts  General  Hospital  as 
relieved,  remained  well  at  the  end  of  5  years,  which 
would  show  that  permanent  relief  failed  in  60%,  and 
that  20%  of  the  total  number  died. 

Cakcinoma. 

Excepting  the  uterus,  primary  carcinoma  occurs  in 
the  stomach  with  greater  frequency  than  elsewhere. 
Welch'^  found  it  present  in  over  21%  of  cases.  It  is 
most  common  in  males,  while  over  75%  of  the  cases 
occur  between  the  ages  of  40  and  70.  It  may  occur  in 
the  young,  Sutton  having  reported  a  case  in  a  girl  only 

13  years  old.'*  Heredity  seems  to  be  a  predisposing 
factor.  Some  have  thought  that  gastritis,  traumatism 
and  peptic  ulcer  were  also  important  factors  in  its 
production. 

The  varieties  occur  in  the  following  order  of  fre- 
quency :  Cylindrical-celled,  encephaloid,  scirrhous  and 
colloid.  Welch  determined  its  location  in  1,300  cases 
as  follows  :  Pyloric  region  791,  lesser  curvature  148, 
cardia  104,  posterior  wall  68,  difluse  61,  greater  curva- 
ture 34,  anterior  wall  30,  fundus  19.  Secondary  cancer 
may  occur  in  the  stomach,  but  Welch'^  was  able  to 
collect  only  37  cases,  17  of  which  were  secondary  to 
carcinoma  of  the  breast.  Metastasis  is  frequent,  par- 
ticularly in  the  lymphatic  glands  and  in  the  liver. 

The  first  symptoms  noted  are  usually  those  of  chronic 
gastritis,  anorexia,  distress,  flatulence,  and  occasionally 
nausea  and  vomiting.  These  are  in  turn  followed  by 
anemia,  loss  of  weight  and  strength,  and  cachexia.  Pain 
may  or  may  not  be  present.  Hemorrhage  is  usually 
slight,  and  the  vomitus  has  a  dark  "  coffee-ground " 
appearance.  The  vomiting  is  most  common  when  the 
tumor  is  at  the  cardia  or  pylorus. 

The  absence  of  free  hydrochloric  acid  is  no  longer 
considered  pathognomonic,  but  rather  only  a  confirma- 
tory evidence  of  cancer.  Boas"  and  others  hold  that 
the  pressure  of  free  lactic  acid  in  the  stomach,  sufficient 
to  give  the  Ufifelmann  reaction,  i.  c,  the  canary-yellow 
tint  to  the  carboferric  chlorid  solution,  is  of  greater 
significance. 

Progressive  anemia  of  the  secondary  pernicious  type 
is  most  commonly  present.     The  blood-count  is  rarely 


168 


The  Philadelphia 
Medical  Journal 


] 


THE  SURGERY  OF  THE  STOMACH 


[Jajtuaet  26,  1901 


below  50%,  but  tbe  hemoglobin  is  low,  and  leukocy- 
tosis is  usually  marked. 

Examination  commonly  reveals  the  presence  of  a 
tumor  in  the  epigastric  region,  and  if  it  is  located  at 
the  pylorus,  dilation  of  the  stomach  also.  According  to 
Senn,'*  carcinoma  of  the  stomach,  with  few  exceptions, 
proves  fatal  within  a  year. 

The  treatment  of  carcinoma  of  the  stomach  is  palli- 
ative and  radical.  To  enable  radical  resection  meas- 
ures to  be  successful  the  diagnosis  must  be  made  early 
and  the  case  subjected  to  operation  before  regional  dis- 
semination of  the  process  has  occurred.  Resection  of 
the  pylorus,  of  the  stomach-wall,  and  of  the  whole 
stomach  have  their  indications  and  scope  of  employ- 
ment, but  statistics  will  demonstrate  the  comparative 
uselessness  of  radical  measures,  except  when  the  dis- 
ease is  early  recognized,  and  when  it  is  localized  and 
in  a  readily  accessible  part  of  the  organ.  The  mortality 
of  pylorectomy  is  given  as  from  20  to  70%,"  and  of 
extensive  or  total  gastrectomy  from  28  to  33%.  The 
fact  that  the  immediate  mortality  of  these  operations  is 
so  great  is  due  largely  to  the  lateness  with  which  these 
patients  are  sent  to  the  surgeon  and  their  terribly  re- 
duced condition.  That  many  of  those  who  survive  the 
operation  finally  succumb  to  the  disease  but  emphasizes 
the  vital  importance  of  early  diagnosis  and  early  radical 
operation. 

It  is  in  this  class  of  cases  that  a  surgeon  can  afford 
to  ocasionally  err  in  diagnosis  and  even  to  perform  a 
needless  operation  rather  than  to  allow  the  golden 
opportunity  for  a  possibly  successful  radical  operation 
for  a  beginning  carcinoma  to  escape.  The  man  who  is 
not  willing  to  assume  the  responsibility  of  a  probable 
diagnosis  under  such  circumstances  is  not  worthy  the 
title  and  honor  of  being  a  surgeon.  Exploratory  lap- 
arotomy for  diagnostic  purposes  is  recognized  as  a  justi- 
fiable procedure  in  pelvic  and  intestinal  surgery,  and 
surely  it  is  equally  justifiable,  and,  in  our  opinion,  im- 
peratively indicated  in  the  obscure  diseases  of  the 
stomach. 

The  radical  operations  of  the  stomach  require  great 
skill  and  dexterity,  and  a  degree  of  familiarity  with 
abdominal  surgery  possessed  by  comparatively  few,  for 
their  proper  and  yet  essential  rapid  performance.  The 
presence  of  local  dissemination,  unless  limited  to  a  few 
very  accessible  glands,  contraindicates  radical  measures. 
In  such  cases  lavage  with  salol  and  bi.smuth  should  be 
employed  to  prevent  fermentation  and  dilation,  and 
their  resulting  malnutrition. 

The  palliative  operative  measures  consist  in  making 
a  gastrostomy  for  disease  of  the  cardia  or  a  gastroenter- 
ostomy when  the  tumor  is  located  in  the  pyloric  region 
or  lesser  curvature.  These  operations  are  in  no  sense 
curative,  but  are  performed  for  the  sole  purpose  of  pro- 
longing the  patient's  life  and  relieving  the  terrible 
suffering  incident  to  a  death  by  starvation. 

The  mortality  of  these  operations  for  cancer  has  been 
reduced  by  modern  methods  from  over  30%  to  10.5%, 
but  even  the  greater  mortality  is  as  nothing  compared 
to  the  comfort  which  is  afforded  those  who  survive. 
When  performed  early  and  under  favorable  circum- 
stances the  mortality  should  be  practically  nil. 

Foreign  Bodies. 

Foreign  bodies  gain  access  to  the  stomach  through 
the  mouth  and  occasionally  accidentally  as  the  result  of 
a  wound  or  the  falling  into  the  stomach  of  some  insoluble 
mechanism    used    for    performing    gastroenterostomy. 


The  list  of  articles  which  have  been  removed  from  the 
stomach  or  intestines  after  passage  through  the  stomach 
is  quite  remarkable.  Pins,  needles,  nails  and  balls  of 
hair  are  comparatively  common,  but  considerable 
pieces  of  wood  and  glass,  sets  of  teeth,  keys,  pocket 
knives,  table  forks  and  knives,  etc.,  have  been  success- 
fully removed  by  gastrotomy  or  enterostomy.  The 
more  irregular  the  shape,  the  more  pointed  the  article, 
or  the  more  pain  and  other  symptoms  produced,  the 
greater  the  demand  for  immediate  operation.  The  use 
of  the  x-ray  is  of  special  value  in  determining  the 
presence,  nature,  location  and  quantity  of  such  articles 
contained  in  the  gastrointestinal  tract. 

Diseases  of  Other  Organs. 

The  utilization  of  the  stomach  as  a  route  for  attack 
upon  disease  of  the  esophagus  particularly  has  been 
most  satisfactory.  By  the  performance  of  gastrotomy, 
disease  of  that  organ  can  be  investigated  often  by  direct 
digital  examination,  and  nonmalignant  strictures  may 
be  detected  and  divulsed  or  divided.  In  malignant 
disease  of  the  esophagus,  and  in  complete  stenosis  of 
that  organ,  gastrostomy  affords  an  avenue  for  the  proper 
nourishment  of  the  individual. 

In  like  manner  gastroenterostomy  establishes  a  chan- 
nel by  which  food  may  pass  directly  into  the  intestines 
below  an  obstruction  in  the  upper  intestinal  tract.  In 
this  manner  the  local  disease  is  isolated  from  the  food 
current,  and  if  it  is  of  a  malignant  character,  the  rest 
lessens  the  rapidity  of  the  growth,  while  if  the  ob- 
struction is  of  a  nonmalignant  character  it  may  effect 
permanent  relief. 

Operations  Upon  the  Stomach. 

As  an  essential  to  successful  operating  upon  the 
stomach  this  organ  must  be  both  empty  and  clean.  Pre- 
liminary lavage  with  warm  water  and  boric  acid  solution 
should  be  emphasized.  It  is  good  practice  to  utilize  rectal 
feeding  before  operation  in  order  to  accustom  the  rectum 
to  its  new  duties  and  to  derive  the  benefit  of  increased 
nourishment.  The  bowels  should  be  thoroughly  emp- 
tied and  the  general  condition  of  the  patient  looked 
after  with  special  care,  as  his  bodilj'  vigor  is  often 
greatly  reduced. 

The  surgical  operations  performed  upon  the  stomach 
consist  of  gastrotomy,  gastrorrhaphy,  pyloroplasty, 
pylorodiosis,  ligation  of  mucosa  en  masse,  gastrostomy, 
gastroenterostomy,  gastroanastomosis,  pylorectomy,  gas- 
trectomy, gastroplication,  gastropexy  and  gastrolysis. 
Of  these  13,  several  have  numerous  modifications, 
while  some  must  be  preceded  by  gastrotomy. 

Gastrotomy. 

The  operation  of  simply  opening  into  the  stomach 
has  been  most  frequently  made  for  the  removal  of 
foreign  bodies,  but  at  the  present  time  it  is  claiming 
more  attention  as  a  preliminary-  operation  to  those 
directed  to  the  diseased  areas  themselves.  In  ulcer 
when  it  is  proposed  to  cauterize  or  ligate  the  area,  and 
also  when  it  is  desired  to  explore  the  stomach,  or  the 
patency  of  its  orifices  or  the  lower  part  of  the  esoph- 
agus, as  well  as  when  the  dilation  of  stricture  of 
either  orifice  is  contemplated,  it  is.  of  course,  necessary 
to  first  perform  celiotomy  and  gastrotomy. 

The  abdominal  incision  should  vary  with  the  location 
of  the  disease  ;  if  at  the  pylorus,  either  median  or  ver- 
tical incision  at  outer  border  of  right  rectus  ;  or  if  in 
other  parts  of  the  stomach,  an  incision  parallel  to  and 


JaNIAEY  2G,  190J] 


THE  SURGERY  OP  THE  STOMACH 


CThe  Philadelphia 
Medical  Journal 


169 


about  one  finger's  breadth  from  the  edge  of  the  left 
cartilages  will  expose  the  whole  viscus  to  good  advan- 
tage. 

The  incision  into  the  stomach  is  usually  made  in  the 
anterior  surface  after  the  peritoneal  cavity  has  been  well 
protected  by  hot  moist  pads,  and  after  controlling  the 
hemorrhage  of  the  stomach-wall  the  remaining  con- 
tents of  the  stomach  are  removed.  After  exploring  the 
stomach,  removing  the  foreign  body  or  treating  the 
pathologic  condition  found,  the  wound  is  closed  by 
gastrorrhaphy.  Gastrotomy  was  first  successfully  per- 
formed in  1602  by  Mathis  and  again  in  1635  by 
Schwabe." 

Gastrorrhaphy. 

Gastrorrhaphy  means  the  suturing  of  the  stomach- 
wall.  Some  writers  use  the  term  to  indicate  suturing 
of  the  stomach  to  the  abdominal  wall — gastropexy. 
Some  prefer  making  a  continuous  suture  of  the  mucous 
membrane  and  other  of  the  muscular  and  serous  coats 
before  applying  the  Lembert  suture.  Still  others  con- 
tent themselves  with  the  application  of  the  simple 
Lembert  suture.  There  would  seem  to  be  no  reason  to 
doubt  but  that  in  an  organ  so  liable  to  straining  of  the 
hne  of  sutures  by  vomiting,  special  precaution  against 
leakage  should  be  taken.  There  is  certainly  good  reason 
for  applying  two  rows  of  sutures  in  all  gastrorrhaphies, 
and  the  use  of  at  least  one  continuous  suture  is  in  our 
opinion  demanded. 

Pyloroplasty. 

This  procedure  consists  in  the  making  of  an  incision 
through  all  the  coats  of  the  pylorus  parallel  to  the  long 
axis  of  the  stomach  and  the  suturing  of  the  same  at 
right  angles  thereto.  The  Lembert  suture  is  employed 
and  may  be  preceded  by  a  suture  of  the  mucosa,  or 
fortified  by  a  second  row  of  sutures.  It  is  known  as 
^  the  Heineke-Mikulicz  operation,  both  having  simul- 
taneously devised  the  same  method  in  1886-7.  The 
mortality  is  given  as  10%,  but  this  seems  altogether 
too  high  with  our  present  technic. 

Pylorodiosis. 

Loreta's  operation  for  dilation  of  stenosis  of  the 
pylorus  is  equally  applicable  and  probably  even  more 
indicated  in  stenosis  of  the  cardia.  It  consists  in  the 
.  performance  of  gastrotomy  and  the  dilation  of  the 
stricture  by  the  insertion  of  one  or  two  fingers  or  the 
use  of  the  uterine  dilator. 

Ligation  of  Mucosa  en  masse. 

In  operating  for  ulcer,  its  location  is  frequently  de- 
termined to  be  in  a  position  not  admitting  of  ready  ex- 
I  cision.  For  this  class  of  cases  and  particularly  when 
the  stomach  is  fixed  by  adhesions,  the  ligation  of  the 
mucosa  en  masse  has  been  successfully  practised  in 
several  instances.  Unless  the  area  is  supported  by  ex- 
ternal Lembert  sutures  perforation  is  liable  to  occur,  as 
demonstrated  by  Andrews  and  Eisendrath.""  If  to  this 
should  be  added  gastroenterostomy  all  surgical  indica- 
tions would  seem  to  be  filled. 

Gastrotomy. 

As  has  been  previously  indicated,  this  is  an  operation 
establishing  a  fistula  to  admit  of  the  repeated  dilation 
of  stenosis  or  to  prevent  starvation.  It  was  first  per- 
formed by  Sedillot  in  1849."'  Many  methods  and  modi- 
fications have  been  proposed  to  prevent  leakage.  Those 


providing  a  valvular  orifice  have  apparently  been  most 
satisfactory.  The  oblique  incision  parallel  to  the  left 
costal  arch  is  usually  employed. 

Wilzel's  method  (1891)  consists  in  passing  a  medium- 
sized,  soft  catheter  through  a  small  opening  into  the 
stomach  and  then  burying  it  in  the  gastric  wall  in  a 
vertical  position  by  sewing  the  peritoneum  over  it  for 
a  distance  of  5  to  6  cm.  (2  to  2^  inches).  The  stomach 
is  then  sutured  into  the  abdominal  wound. 

Prank'' s  method,  variously  called  Albert-Frank- Koch er 
and  Ssabanajew- Frank  method,  consists  in  making  a 
valve  out  of  a  small  cone  of  the  stomach-wall.  The 
oblique  incision  is  made  and  a  cone  of  the  stomach 
pulled  out  and  its  base  sutured  to  the  parietal  peri- 
toneum. A  second  incision  is  made  just  above  the  rib- 
margin,  the  bridge  of  the  skin  elevated  and  the  cone 
pulled  up  beneath  it  and  the  apex  sutured  into  second 
wound.     Tube  is  inserted  and  first  skin-wound  closed. 

MarwedeVs  method  (1896)  resembles  Witzel's  in  all 
respects,  but  he  incises  the  serous  and  muscular  coats 
for  5  cm.  (2  inches),  then  passes  the  tube  through  the 
mucosa  and  buries  it  by  closing  the  incision  in  the 
stomach-wall. 

Kader-'s  method  (1896)  produces  a  funnel  projecting 
into  the  stomach  by  suturing  two  sections  on  either 
side  of  a  tube  placed  vertically  into  the  stomach.  Each 
pair  of  sutures  increases  the  amount  of  peritoneum 
about  the  tube  and  further  depresses  the  point  of  en- 
trance of  the  tube. 

E.J.Senn's  method  (1896)  consists  in  making  an  auto- 
matic valve  out  of  the  stomach-wall  by  constricting  a 
cone  near  its  apex  with  purse-string  suture  and  after 
incising  the  apex  inverting  it  into  the  stomach  and 
securing  it  there  by  Lembert  suture. 

The  methods  of  Kader  and  Marwedel  are  most  popu- 
lar at  the  present  time,  but  the  method  of  Senn  would 
seem  to  be  an  improvement  over  the  Kader  procedure. 

Gastroenterostomy. 

The  establishment  of  a  connection  between  the  stom- 
ach and  intestine  was  first  performed  by  Wolfler  in 
1881,'°  and  is  indicated  in  the  several  conditions  pre- 
viously noted,  but  particularly  in  pyloric  obstruction, 
cancer  and  ulcer. 

While  the  mortality  has  been  about  10%  in  the  non- 
malignant,  and  about  30%  in  the  malignant  conditions, 
there  would  seem  to  be  no  good  reason  why,  with  our 
present  technic,  the  mortality  of  this  operation  when 
early  performed  should  not  be  practically  nil.  There 
is  certainly  nothing  about  the  operation  itself  which 
should,  in  careful  and  dextrous  hands,  cause  any  mor- 
tality. 

The  anastomosis  should  be  made  on  the  posterior 
wall  of  the  stomach  at  its  lowest  point  and  the  union 
eflfected  by  a  Murphy  button  or  suture. 

Masse'  has  demonstrated  that  regurgitation  of  bile  is 
of  no  consequence,  but  to  avoid  the  possibility  of  an- 
noyance Braun  suggests  the  making  of  a  simultaneous 
duodeno-enterostomy. 

The  incision  for  gastroenterostomy  is  made  in  the 
median  line  above  the  umbilicus,  the  stomach  is  located 
and  then  the  upper  part  of  the  jejunum  is  found  and 
either  turned  over  the  transverse  colon  or  a  small  slit  is 
made  in  the  mesocolon  and  the  posterior  wall  of  the 
stomach  seized  and  both  are  brought  into  the  \yound. 
If  the  sutures  alone  are  to  be  employed  a  continuous 
suture  should  be  applied  in  the  most  posterior  part  of 
the  area  of  intestine  and  stomach  to  be  approximated, 


170 


The  Philadelphia"! 
Medical  Journal  J 


THE  SURGERY  OF  THE  STOMACH 


[  (ISCABT  26.  IMI 


before  either  viscus  is  opened.  After  making  the  inci- 
sion in  both  organs  it  is  best  to  make  a  continuous 
suture  approximation  of  the  two  wound  edges  and 
then  to  carry  the  first  suture  completely  around  the 
second  one.     This  is  a  rapid  and  effectual  method. 

If  a  Murphy  button  is  to  be  employed  a  small  in- 
cision is  to  be  made  in  one  viscus,  two  lateral  sutures 
introduced  as  advocated  by  Murray,  half  of  button 
introduced  and  suture  tied.  After  the  same  is  done  on 
the  other  side,  the  button  is  closed.  This  can  be  forti- 
fied by  a  row  of  sutures,  but  if  the  rent  in  the  meso- 
colon is  closed  about  the  point  of  anastomosis  it  affords 
sufficient  additional  protection.  The  fact  that  this 
operation  with  a  Murphy  button  and  a  continuous 
row  of  sutures  can  be  performed  within  10  minutes 
will  commend  its  use  until  some  better  mechanism  is 
devised.  It  would  seem  that  having  the  lower  half  of 
the  button  larger  than  the  upper  half  would  prevent 
its  dropping  into  the  stomach,  and  thus  avoid  an  objec- 
tion which  has  been  advanced  against  its  usage.  If 
time  is  an  object,  the  button  should  be  employed, 
otherwise  the  operator  can  choose  his  method,  as  both 
are  excellent.  Chaput,  McGraw,  Sonnenburg,  and  later 
Kocher  have  devised  methods  for  the  formation  of 
valvular  openings  to  prevent  regurgitation.  In  1898 
Podrez-'  performed  gastroenterostomy  by  inserting  two 
sutures  at  right  angles  and  tying  tightly  to  produce 
pressure  necrosis.  Sokoloff ''  reports  failure  in  2  out  of 
4  cases.  If  it  is  to  be  successful,  elastic  ligatures  should 
be  employed  as  advised  by  McGraw  in  1891." 

Gastroanastomosis. 

Gastroanastomosis  or  gastrogastrostomy  was  first  per- 
formed by  Wolfler  in  1894,  and  independently  by 
Watson  in  1896,'  for  the  relief  of  marked  "  hour-gla«s  " 
contraction  of  the  stomach.  Its  technic  is  identical 
with  gastrectomy  or  gastroenterostomy. 

Pylorectomy. 

This  procedure  was  advised  by  Merrem  in  1810.'* 
Pean  was  the  first  to  perform  it  in  1879— while  Billroth 
performed  the  first  successful  operation  in  1881." 

The  mortality  of  the  operation  has  been  so  great  that 
its  performance  would  seem  to  be  rarely  justifiable,  but 
the  present  results  of  abdominal  and  gastric  surgery 
would  seem  to  warrant  a  more  favorable  immediate 
prognosis  than  was  formerly  given. 

The  oblique  incision  of  Billroth  directly  over  the 
tumor  or  an  incision  along  the  outer  edge  of  right 
rectus  is  made,  pylorus  liberated  and  pulled  well  into 
the  wound.  The  section  should  be  made  from  3  to  5 
cm.  (li  to  2  inches)  beyond  the  tumor.  After  excision 
the  duodenum  can  be  sutured  into  the  gastric  wound 
by  double  row  of  Lembert  sutures,  or  the  latter  can 
be  closed  and  the  anastomosis  of  the  duodenum  into  the 
posterior  wall  efiected,  or  both  wounds  can  be  closed 
and  a  gastroenterostomy  performed. 

Gastrectomy. 

The  technic  of  partial  gastrectomy  is  identical  with 
that  of  pylorectomy.  Robson  collected  14  cases  of 
extensive  resection  with  mortality  28.5%.  In  total 
gastrectomy,  the  section  of  Die  duodenum  is  first  made 
and  then  the  omenta  and  ligaments  divided  between 
clamps.  The  stomach  is  then  cut  ofl'  from  the  esopha- 
gus, leaving  a  little  of  the  stomach-wall  if  possible. 
The  duodenum  is  then  united  to  the  esophagus  by 
suture  or  a  Murphy  button. 


Schlatter  successfully  performed  complete  gastrectomy 
in  September,  1897.  Death  occurred  14  months  later 
from  general  carcinomatosis.  Since  that  time  the  opera- 
tion has  been  successfully  performed  by  Brigham 
(patient  well  2  years  after),  Delatour  (patient  well  17 
months  after),  Richardson  (patient  lived  11  months  and 
died  from  local  recurrence),  MacDonald  (patient  well 
18  months  after),  and  Harvie  (just  reported"').  Death 
on  the  table  or  within  36  hours  occurred  in  the  cases  of 
Chavasse,  Kobb  and  Bemays.  Of  the  6  successful  cases, 
2  have  died  in  14  and  11  months.     Four  are  still  living. 

A  mortality  of  only  33  %  for  the  operation  per  tie  is 
certainly  remarkable,  and  this  fact,  with  the  ultimate 
results  presented,  demonstrates  the  practicability  of 
this  life-prolonging  and  life-saving  measure.  The 
remarks  made  under  the  treatment  of  carcinoma  con- 
cerning the  importance  of  early  diagnosis  and  early 
operation  need  no  better  proof  as  to  their  correctness 
than  the  above  data. 

Gastroplicatiox. 

Gastroplication  or  "  reefing  "  of  the  stomach- wall,  as 
first  practised  by  Bircher  in  1891,"  is  effected  bj'  the  in- 
sertion of  two  or  more  rows  of  sutures  in  such  a  manner 
as  to  approximate  two  broad  areas  of  the  anterior 
surface  of  that  organ.  The  sutures  include  only  the 
serous  and  part  of  the  muscular  coats. 

Gastropexy. 

Gastropexy  consists  in  the  fixation  of  a  displaced 
stomach  in  its  normal  position.  This  is  usually  accom- 
plished by  the  coaptation  and  fixation  of  a  consider- 
able area  of  the  stomach-wall  to  the  anterior  parietes 
by  several  sutures.  In  some  cases  it  may  be  possible 
to  reef  the  lesser  omentum.  It  is  usually  necessary  to 
fix  the  colon  and  other  displaced  organs  at  the  same 
time. 

Gastrolysis. 

The  term  gastrolysis  is  used  to  designate  the  opera- 
tion of  dividing  adhesions  which  may  fix  or  distort  the 
stomach.  If  the  adhesions  are  cord-  or  ribbon-like  its 
performance  is  both  easy  and  safe,  but  if  they  are 
broad  and  extensive  their  removal  may  compromise 
the  gastric  wall  sufficiently  to  necessitate  resection. 

bibliogkaphy. 

1  TillniHn's  Textbook  of  Stirgery.  vol.  3. 

•  Scottish  Mfdical  and  Surgical  Journal,  1897. 

s  Watson.  Boston  Medical  nnd  Surtricnl  Jowmat,  1896. 

^  P.irk,  Surgery  by  American  Authors,  vol.  2. 

-'  Osier,  Practice  of  Medicine. 

"  Seir  York  Medical  Record,  ISM. 

'  Frazier,  American  Journal  Medical  Sciences,  1900. 

*  Kodiuan,  Journal  American  Medical  Associalicn^  1900. 
".Sem.  Mid.,  Paris.  1S9S. 

i"  Keen,  PiiiLADEi.ruiA  Medical  Journal,  1898. 

it  Greig  Smith,  Abdominal  Surgery. 

'=  Medical  Sens,  1896. 

1*  Hunterian  Lecture?. 

i«  American  Journal  Medical  Sciences,  1899. 

15  System  of  Medicine. 

t"*  :>euii,  Pathologv  and  Treatment  of  Tumors. 

>;  Miinch.  med.  Woch.,  189.<. 

18  Elliott,  International  Textbook  of  Surgery,  vol.  2. 

1'  Gros*.  System  of  Sorcery,  vol.  2. 

io  Annais  ofSiirijerv.  18'.>9.  " 

-1  VoD  Ijtogenbeck's  .IrrS  ,  189S,vol.62. 

-  Ontraltdatl  /.   Chirp.  ,1»»9,  vol.  20. 

■'  Journal  American  Medical  Association^  1391. 

"  Annals  of  Suraerv.  1900. 

■^  Medical  Record.  iS94. 

-^'Curtis,  Annals  of  Surerert/,  1900. 


Budapest. — Dr.  Kuesara,  professor  of  surgerj-  at  the 
University  of  Toki'-),  Japan,  is  at  present  visiting  the  Univer- 
sity of  Budapest.  Dr.  Kogandi,  professor  of  anatomy,  Tokio, 
also  spent  several  weeks  inspecting  the  medical  institutions 
of  Budapest. 


jANHARy  -'6,  1901] 


LIGATURE  OF  THE  INNOMINATE  ARTERY 


TThe 
Lmei 


Philadelphia 
Medical  Journal 


171 


A  CASE  OF  LIGATURE  OP  THE  INNOMINATE  ARTERY 
FOR  ANEURYSM.* 

By  S.  P.  DELAUP,  B.Sc,  M.D., 

of  New  OrhaDs. 

Visiting  Surgeon  to  Charity  Hospital. 

Triple  ligature  of  the  innominate  artery  for  high  innomimte 
arid  carotid  aneurysm  and  also  axillo-subclavian 
aneurysm,  folloived  by  a  simultaneous  double  ligature 
of  the  comnwn  carotid  and  vertebral  arteries  at  a  sub- 
sequent operation.  Death  from  exhaustion  on  the  twenty- 
first  day. 

The  case  which  I  submit  for  your  consideration  is  at 
the  same  time  rare  and  important,  and  further  should 
excite  your  special  interest  in  that  the  first  successful 
case  was  performed  in  this  city  in  1864.  It  will,  no 
doubt,  give  rise  to  criticism ;  but  do  we  not  learn  by 
our  failures  as  much  as  by  our  successes,  and  does  not 
the  history  of  medicine,  surgery  especially,  show  that  it 
is  made  up  of  mingled  failures  and  successes  ?  So, 
although  it  is  my  misfortune  to  report  a  failure,  I  trust 
my  experience  will  be  of  some  service  to  those  surgeons 
who  will  be  bold  enough  to  undertake  this  hazardous 
operation. 

On  considering  the  history  of  this  operation,  since  it 
was  first  performed  by  Valentine  Mott,  in  1818,  one  is 
so  forcibly  struck  by  the  almost  unbroken  record  of 
fatal  results  as  to  question  its  advisabilitj''. 

It  must  be  remembered,  however,  that  the  majority 
of  the  recorded  cases  belong  to  the  preaseptic  period, 
and  some  of  the  more  recent  cases  have  succumbed  from 
faulty  asepsis.  Hence,  viewed  from  the  light  of  modern 
surgery,  the  operation  of  ligature  of  the  innominate 
artery  is  not  only  justifiable,  but  feasible,  though  it 
still  remains  one  fraught  with  danger.  I  cannot  help 
believing  that  the  results  obtained  in  the  next  series  of 
cases  will  be  much  more  encouraging. 

History  of  the  Casf. — A  negro,  58  years  of  age,  is  admitted 
in  my  service  at  the  Charity  Hospital,  on  June  2,  1900.  He 
is  a  man  of  good  development,  well  nourished,  and  presents 
a  pulsating  tumor,  the  size  of  a  large  orange,  on  the  right 
side  of  the  chest.  In  his  right  shoulder,  he  complains  of 
constant  pain,  fulness  and  throbbing,  which  have  existed  with 
varying  intensity  f.^~r  several  weeks  before  admission.  He 
states  that  pain  in  his  shoulder  is  the  lirst  symptom  that 
called  his  attention  to  his  present  trouble,  and  that  occurred 
in  January.  Two  montlis  later  he  noticed  a  sense  of  throb 
bing  at  the  upper  part  of  the  right  side  of  the  chest,  and 
very  soon  afterwards  loss  of  power  in  the  right  arm.  A  swel- 
ling below  the  clavicle  slowly  made  is  appearance  and  has 
gradually  grown  to  its  present  size.  The  pain  likewise  kept 
pace  with  the  growth  of  the  tumor,  and  is  now  so  intense  as 
to  cause  him  to  seek  relief 

On  the  forehead,  between  the  superciliary  ridge  and  right 
above  the  nasal  spine,  a  depression  and  scar  are  very  con- 
spicuous. When  a  boy  of  16  years  he  was  struck  with  a 
hatchet  and  thereby  suffered  a  fracture  of  the  frontal  bone. 
This  injury  seems  to  have  caused  no  bad  ( fleet. 

A  somewhat  indefinite  historj'  of  previous  apoplexy  is 
elicited.  The  attack  occurred  eight  months  ago,  he  was 
confined  to  bed  for  about  one  month  and  was  unable  to  use 
his  left  upper  extremity  for  about  the  same  time.  He  soon 
recovered  and  resumed  his  work  as  a  laborer. 

His  family  history  is  easily  told,  inasmuch  as  negro  ho.s- 
pital  patients,  as  a  rule,  are  unable  to  give  any  information 
on  that  point. 

A  physical  examination  shows  the  existence  of  an  aneurys- 
mal tumor  behind  the  right  pectoral  muscles,  filling  the  bot- 
tom of  the  axillary  space  and  extending  to  the  right  clavicle. 
The  cutaneous  veins  over  that  region  are  much  dilated.     A 


*  Read  before  the  Orleans  Parish  Medical  Society,  November  24,  1900 


systolic  bruit  is  distinctly  heard,  and  an  expansive  thrill 
readily  made  out. 

Tlie  heart-area  is  enlarged,  and  the  apex  is  I'ul'y  i  inch  to 
the  outer  side  of  the  mammary  line.  Two  murmurs  are  dis- 
cerned :  one  at  the  apex  with  ne  first  sound,  the  other  at 
the  second  right  interspace  with  the  first  sound.  Xodif- 
ferencc  can  be  detected  between  the  arteries  in  the  wrists, 
either  in  strength,  fulness,  or  rhythm. 

The  radial  and  ulnar  arteries  on  both  sides  are  very  super- 
ficial and  their  atheromatous  condition  can  be  felt.  Toere 
is  no  edema  of  the  right  hand.  Pressure  with  fc  e  thumb  on 
the  subclavian  artery  over  the  first  rib  obliterated  the  radial 
pulse  and  pulsation  in  tlie  tumor. 

As  well  as  can  be  ascertained  the  lungs  are  normal. 
Nothing  abnormal  is  detected  from  an  examination  of  the 
abdominal  organs.  The  urine  contains  a  trace  of  albumin, 
otherwise  there  is  nothing  noteworthy.  The  veins  of  the 
lower  extremities  have  a  tendency  to  varicosity.  Ihe  pupils 
are  regular.  There  is  no  cough,  and  no  laryngeal  irritation. 
Temperature  up  to  1(10°  nearly  every  day. 

Attempts  were  made  to  secure  sphymographic  tracings  of 
the   right   and    left   radial    pulse,  but  no   record   could   be 


Fig.  1.— .\iiiieiir:ince  of  tuiiinr,  eularged  veins,  etc. 

obtained.  The  diagnosis  of  an  idiopathic  axillo-subclavian 
aneurysm  depending  on  a  general  arteriosclerosis  is  made. 

The"  patient  is  placed  in  bed  and  put  on  a  low  diet  com- 
bined with  potassium  iodid  in  large  doses.  An  ice-bag  on  the 
tumor  is  also  used.  At  tlie  end  of  the  first  week  the  tumor 
appears  to  be  larger.  At  the  end  of  the  second  week,  the 
pulse  still  continues  high,  the  tumor  increases  in  size,  while 
the  pain  in  tlie  arm  is  unbearable  ;  the  patient  lies  in  bed 
with  the  arm  outstretched  and  begs  for  relief  The  medical 
treatment  has  thus  far  been  without  any  appreciable  result. 
I  then  had  a  consultation  with  Drs.  Bloom  and  P.-trham.  and 
as  the  result  of  the  consultation  it  was  decided  to  attempt 
operation  upon  the  third  portion  of  the  subclavian,  and  in 
the  event  of  that  proving  diseased  upon  the  first  portion, 
and  as  a  last  resort  upon  the  innominate,  and  also  if  prac- 
ticable to  complete  the  operation  with  a  hgature  of  the 
axillarv  arterv  above  the  subclavian. 

Operation  —On  June  16,  with  the  cooperation  of  Drs.  Bloom, 
Parkhani,  Marion,  Souchon,  and  other  members  of  the  hos- 
pital staft,  the  following  operation  was  carried  out: 

The  patient  havinu:  been  chloroformed  was  placed  in  the 
usual  position  on  his  back,  witli  the  shoulders  elevated  and 


172 


TuE  Philadelphia' 
Medical  Journal 


] 


LIGATURE  OF  THE  INNOMINATE  ARTERY 


f  JiSCAET  25,  1901 


the  head  well  drawn  towards  the  left  side.  Having  drawn 
the  cervical  skin  upwards  I  made  an  incision  3  inches  in 
length,  extending  from  the  outer  border  of  the  trapezium 
to  the  posterior  border  of  the  sternocleidomastoid  muscle. 
The  skin  flap  with  the  superficial  foscia  and  platysma  muscle 
was  drawn  back  and  the  cellular  tissue  was  dissected  away, 
exposing  the  upper  or  supraclavicular  portion  of  the  sac. 
Tlie  fibers  of  the  subclavius  muscle  were  pushed  upwards, 
carrying  with  them  the  dilated  supraclavicular  vein.  On 
furtter  dissection  I  discovered  that  the  aneurysm  not  only 


Flo.  2. — Anterior  view  of  lieart  and  tumor. 

involved  the  entire  third  portion  of  the  subclavian  artery, 
but  extended  to  the  second  portion.  Ligature  at  cither 
portion  wa.<  out  of  the  question.  The  cutaneous  incision 
w'as  then  prolonged  to  the  middle  of  the  manubrium.  The 
sternoraastoid  muscle  wa*  divided  close  to  its  insertion  into 
the  clavicle  and  sternum.  In  the  cellular  tissue  now  exposed 
a  medium-sized  vein  was  severed  between  two  ligatures. 
The  sternohyoid  and  sternothyroid  muscles  were  also 
divided. 

The  artery  exposed  to  view  was  of  very  large  size,  so  much 
so.  indeed,  that  some  of  those  present  tliought  I  had  reached 
the  innominate  artery.  The  vessel  filled  the  field  of  opera- 
tion so  completely  that  an  incision  of  the  clavicle  and 
sternum  was  decided  upon. 

The  inner  third  of  the  clavicle  was  e^irefully  dissected  and 
its  periosteum  peeled  ofl.  With  a  Gigli  saw  section  was 
made  from  below  upwards.  The  sternal  end  was  freed  with 
care  and  the  section  removed  without  injuring  the  delicate 
structures  behind.  A  tlat  retractor  was  slid  underneath  the 
manubrium  to  protect  the  underlying  parts.  Tlie  right 
sternoclavicular  articulation  and  the  right  half  of  the  notch 
of  the  manubrium  were  cut  out  with  the  rongeur  forceps, 
thus  enabling  me  to  place  the  ligature  in  a  far  more  satis- 
factory manner  than  if  the  ligature  was  slid  down,  in  the 
dark,  behind  the  sternum. 

I  now  went  further  down  in  search  of  the  bifurcation,  but 
this  was  an  extremely  tedious  and  anxious  proceeding  owing 


to  the  dilated  and  diseased  condition  of  the  artery.  It  waa 
found  impossible  to  expose  the  first  portion  of  the  subclavian 
arterj-;  it  could  only  be  felt  with  the  finger  deep  in  the 
wound  behind  the  dilated  innominate  artery. 

I  had  here  to  deal  with  a  fusiform  aneurysm  of  the  innomi- 
nate artery  involving  the  bifurcation  and  extending  up  and  on 
the  common  carotid  in  addition  to  the  subclavian  aneurysm. 
The  art«ry  near  its  origin  from  the  arch  was  about  double 
its  normal  size  and  at  its  upper  part  was  fully  H  inches  in 
diameter.  As  far  as  could  be  ascertained  the  innominate 
aneurysm  continued  upwards  as  the  common  carotid,  form- 
ing one  continuous  sac.  The  first  portion  of  the  subclavian 
artery  was  hidden  behind  the  aneurv-smal  tumor,  and  could 
not  be  exposed ;  to  the  finger  it  felt  of  normal  size.  It  waa 
believed  that  enough  of  the  innominate  was  fairlj-  healthy 
to  place  a  ligature  between  the  fusiform  aneurysm  and  the 
aorta.  The  left  innominate  vein  above  and  the  right  pneu- 
mogastric  and  phrenic  nerves  and  internal  jugular  vein,  on 
the  side,  were  plainly  seen  in  the  wound  and  drawn  out  of 
harm's  way.  The  sheath  of  the  innominate  artery  could 
not  be  separated  as  it  was  closely  adherent  throughout  the 
extent  of  the  artery.  The  index  finger  was  passed  down  to 
the  arch  of  the  aorta  below  and  around  the  innominate 
artery,  near  its  origin. 

Three  ligatures,  two  of  kangaroo  tendon  and  one  of  braided 
silk,  were  applied  in  the  following  manner ;  I  placed  the  first 
kangaroo  tendon  a  little  over  an  inch  above  the  aorta, 
and  before  tying  tested  the  effects  of  pressure  upon  the 
artery  between  my  finger  and  the  ligature,  slightly  lifting 
the  artery  from  its  bed,  and  finding  a  diminished  pulsation 
in  the  radial  artery  and  aneurysm  I  secured  the  ligature 
with  3  square  knots,  using  moderate  firmness  only,  with  the 


.itia  lumor. 


idea  of  not  rupturing  the  co.it^:  of  the  vessel.  This  ligature 
was  not  meant  to  arrest  the  circulation  completely,  but  to 
serve  as  a  butfer  and  protection  for  the  second  one.  The 
second  ligature  of  kangaroo  tendon  was  applieil  about  a  half 
inch  below  the  first  and  about  three-fourths  of  an  inch  from 
the  arch  of  the  aorta.  Gradually  it  was  drawn  tighter  until  the 
circulation  was  completely  cut  olV.  A  third  kangaroo  tendon 
ligature  was  tied  in  tlie  same  place  to  reinforce  the  other  two, 
but-it^kroke.  I  then  used  a  braided  silk  ligature  that  com- 
pletely arrested  the  radial  pulse,  and  finally  secured  it.  prob,-*- 


Ja.MARY  26,  1901] 


LIGATURE  OF  THE  INNOMINATE  ARTERY 


riii 
Lmi 


E  Philadelphia 
Medical  Joubnal 


173 


bly  rupturing  the  coats.  The  ligatures  were  all  passed  from 
within  outward  and  were  put  in  position  with  a  large  aneu- 
rysmal needle  It  was  my  purpose,  if  possible,  to  ligate  the 
common  carotid  and  vertebral  arteries,  but  the  patient,  who 
had  taken  the  anesthetic  admirably  well  and  had  been  under 
i  s  influence  for  over  2  hours,  now  gave  evidence  of  shock, 
so  it  was  deemed  advisable  to  close  the  wound  as  rapidly 
as  possible  and  defer  further  operation  to  a  more  propitious 
time.  Ihe  overlying  muscles  were  sutured  with  kangaroo 
tendons  in  approximately  their  original  positions,  and  the 
jdges  of  the  wound  were  brought  together  with  silkworm- 
i;ut  sutures  The  pulsation  was  gone  from  the  subclavian 
aneurysm  and  right  radial  artery.  The  right  upper  ex- 
tremity from  linger  to  shoulder  was  wrapped  in  sheets  of 
wadding  and  bandaged  to  maintain  its  temperature.  Tlie 
patient  was  at  once  put  to  bed,  and  was  in  fairly  good  con- 
dition. The  operation  lasted  over  2  hours ;  it  was  done  with 
deliberation  and  care,  and  was  practically  bloodless.  The 
preliminarj'  operation  for  exposure  of  the  third  portion  of 
the  subclavian  artery,  the  excision  of  the  clavicle  and  ster- 
num, and  the  dissection  of  the  aneurysm  of  the  innominate 
artery,  were  procedures  that  consumed  considerable  time 
and  "account  for  the  tediousness  and  duration  of  the 
operation.  A  slight  pulsation  in  the  right  radial  artery  is 
detected  at  6  p.m.,  about  4  hours  after  the  operation.  The 
patient  is  drowsy  and  does  not  recover  easily  from  the  anes- 
thetic   Has  a  restless  night;  nausea  and  vomiiing. 

June  17. — A.M.,  temperature  100°,  pulse  110,  respiration  30. 
Patient  restless,  mental  condition  dull.  A  small  but  distinct 
radial  pulse  is  felt,  synchronous  with  left  radial.  There  was 
no  pain  and  no  vomiting.     He  complains  of  headache 

June  IS — A.M.,  temperature  99.4",  pulse  104,  respiration 
20.  Mental  condition  somewhat  improved.  Marked  pulsa- 
tion is  felt  over  the  tumor,  p.m.,  temperature  100°,  pulse 
114,  respiration  18. 

June  19. — A.M.,  temperature  99°,  pulse  100,  respiration  16. 
Mental  hebetude  continues.  Tumor  decidedly  denser  and 
smaller.  Bowels  moved.  Dressings  stained  with  serous 
oozing.  Changed  the  dressings.  Urine:  Sfo  moist  albumin, 
casts.  Got  up  from  bed  during  night  to  get  water,  p.m., 
temperature  100°,  pulse  108. 

June  20  (oth  day).— A.M.,  temperature  98§°,  pulse  100; 
r  M.,  temperature  100°,  pulse  106.  Is  comfortable  and  free 
from  pain. 

June  21  (6th  day). — am.,  temperature  99°,  pulse  100: 
P.M.,  temperature  99|°,  pulse  110. 

June  22  (7th  day).— a.m.,  temperature  100^°,  pulse  112  ; 
P.M.,  temperature  991°,  pulse  110.  Mental  condition  un- 
1  changed.  On  changing  dressings  pus  was  detected  at  two 
'      sutures. 

June  23  (8th  day.)— a.m.,  temperature  99^°,  pulse  106  ; 
r.M  ,  temperature  99|°,  pulse  116.  Changed  dressings  A 
little  purulent  matter  escaped  from  the  wound.  Irrigation 
with  formalin  solution  and  hydrogen  dioxid  solution  was 
made. 

June  24  (9th  day) — a.m.,  temperature  100°,  pulse  118; 
p  M  ,  temperature  994°,  pulse  112.  Pulse  in  right  radial  is 
strong  and  bounding.  There  is  a  small  sinus  which  extends 
downward  and  toward  the  sternum,  under  the  skin  and  IJ 
inches  deep. 

June  25  (10th  day). — a.m.,  temperature  100;°,  pulse  108  ; 
P.M.,  temperature  99°,  pulse  114.  Mental  condition  im- 
proved. 

June  26  (11  th  day).— a.m.,  temperature  99 J°,  pulse  104; 
P.m.,  temperature  99|°,  pulse  112.  Restless  at  night  Mental 
state  is  changed  in  that  the  delirium  is  more  active  and 
talkative.  Has  to  be  restrained  and  tied  to  bed.  Daily 
dressings  continued. 

June  28  (13th  day). — a.m.,  temperature  100°,  pulse  110; 
F'.m.,  temperature  99§°,  pulse  96.  Mental  condition  same. 
Very  little  pus,  luit  granulations  are  unhealthy. 

June  30  (15th  day)  — a.m.,  temperature  985°,  pulse  92 ; 
P.M.,  temperature  99 J°,  pulse  104  Slight  edema  of  right 
hand. 

July  1  (16th  day)  — Patient  is  natural  in  appearance  and 
feels  comfortable.  Since  the  operation  his  mind  has  not 
been  perfectly  clear,  at  times  there  is  actual  delirium. 

July  2  (17th  day).— AM,  temperature  98|°,  pulse  112; 
P.M ,  temperature  99|°,  pulse  92.  Delirium  less  active. 
Wound  looks  more  healthy,  sinus  appears  to  be  closing. 
Hardly  any  discharge. 


July  5  (20th  day).— AM,  temperature  102^°,  pulse  120: 
p  M.,  temperature  102°,  pulse  IIG.  Nothing  to  explain  eleva 
tion  of  temperature.  Patient  is  quiet  and  resting  comfort- 
ably. 

July  6  (21st  day). — Mr  Terry,  the  interne  of  the  ward,  was 
called  at  6  o'clock  that  morning  to  sec  the  patient,  who  had 
had  a  slight  hemorrhage  a  few  minutes  before.  Patient 
stated  that  he  felt  weak  and  chilly.  Temperature  100°, 
pulse  120.  One-fourth  of  a  grain  of  morphin  was  given  and 
a  shot-bag  applied  over  the  aneurysm  and  neck.  When  I 
saw  him  that  morning  at  10  o'clock  he  was  very  weak  and 
his  face  was  covered  with  perspiration.  The  hemorrhage 
from  the  wound  had  been  easily  arrested  and  little  blood 
had  been  lost.  At  that  time  his  temperature  and  pulse 
were  100J°  and  140°  respectively.  I  was  only  waiting  for  the 
wound  to  be  completely  healed  before  attempting  the  ligature 
of  the  common  carotid  and  vertebral  arteries. 

In  view  of  the  fact  that  the  .secondary  hemorrhage  in 
these  cases  usually  comes  from  the  distal  end  of  the 
arterj^  and  that  pulsation  in  the  common  carotid  had 
been  felt  three  days  after  the  operation,  I  decided,  not- 
withstanding the  j)aticiit's  unfavorable  condition,  to  re- 
open the  wound  and  expose  that  artery,  feeling  justified 
in  the  belief  that  that  vessel  was  the  source  of  hemor- 
rhage. Remembering  also  Smyth's  brilliant  ligation  of 
the  vertebral  artery,  I  included  it  as  a  possibility  in 
the  operation.  The  patient  was  placed  upon  the  table 
and  chloroformed.  Witli  Dr.  Bloom's  assistance  I  made 
the  usual  incision  along  the  anterior  border  of  the  sterno- 
mastoid  muscle  antl  readily  exposed  the  riglit  common 
carotid  artery.  A  silk  ligature  was  applied  half  an  inch 
below  the  bifurcation.  More  difficulty  was  experienced 
in  exposing  the  vertebral  arteiy,  not  only  on  accomit 
of  its  deep  situation  in  the  neck,  but  owing  to  the  adhe- 
sion which  had  formed  since  the  first  operation.  The 
artery  was  finally  dissected  out  and  a  silk  ligature  placed 
about  a  half  inch  Irom  the  vertebral  foramen.  Just  as 
the  wound  was  being  prepared  for  closure,  the  patient's 
heart  stopped.  During  tire  operation  very  httle  chloro- 
form had  been  used,  as  his  condition  had  been  poor, 
demanding  active  stimulation.  For  half  an  hour  arti- 
ficial respiration  was  tried,  but  in  vain. 

Postmortem  Examination. — An  autopsy  was  held  an  hour 
after  death  by  myself  but  as  the  body  was  claimed  the  ex- 
amination was  limited  to  the  neck  and  thorax  :  that  is,  those 
parts  actually  involved  in  the  disease  and  operation.  The 
original  line  of  incision  was  practically  healed  with  the 
exception  of  a  small  sinus  barely  admitting  the  introduction 
of  a  slender  probe.  The  sinus  extended  toward  the  sternum 
and  contained  at  its  external  end  a  small  elongated  clot; 
presumably  this  was  the  channel  through  which  the  hemor- 
rhage had  taken  place. 

The  clavicular  stump  was  well  covered  with  a  mass  of 
fibrin,  and  the  sternal  cavity  well  filled  with  the  same 
material.  The  left  lung  was  normal  and  free  from  adhe- 
sions. The  right  lung  was  closely  adherent  to  the  second  and 
third  ribs  about  the  mammary  line,  at  a  place  corresponding 
to  the  base  of  the  subclavian  tumor,  otherwise  the  lung  was 
normal.  The  pericardium  was  smooth.  The  heart  was 
greatly  hypertrophied,  the  left  ventricular  wall  being  about 
an  inch  thick,  aU  the  cavities  of  the  heart,  particularly  on 
the  left  .side,  were  dilated.  The  valves  were  thickened  and 
hard.  The  arch  of  the  aorta  was  thickened  and  dilated,  the 
dilation  aflecting  equally  the  circumference  of  the  artery. 
Of  the  large  branches  springing  from  it,  the  left  common 
carotid  and  subclavian  were  normal  in  size  but  thickened. 
The  innominate  artery  was  a  little  over  two  inches  in  length 
and  at  its  upper  part  presented  a  fusiform  dilation  that  was 
continuous  upwards  into  the  common  carotid  for  about  one 
and  a  half  inches.  The  innominate  artery  about  its  middle 
part  was  surrounded  by  a  thick  and  wide  ring  of  lirm  cica- 
tricial tissue.  No  sinus'  wa?  discovered  leading  to  the  lumen 
of  the  arterv.  The  entire  silk  ligature  was  found  lyin^  in 
the  lumen  of  the  artery  ;  the  knot  was  intact  and  the  liga- 
ture was  held  by  a  posterior  segment  of  the  art:ry.    It  had 


174 


THB   PuILAnKLPIIIA"] 

Medical  journal  J 


LIGATURE  OF  THE  INNOMINATE  ARTERY 


[.Iam'aev  2«,  )9W 


gradually  cut  its  way  through  the  artery  and  the  fibrinous 
rint;  about  it  had  beeu  sufficiently  organized  to  prevent 
hemorrhage  from  the  severed  artery.  No  trace  of  the 
kangaroo  tendons  was  found ;  they  had  evidently  been 
completely  absorbed,  the  distal  and  proximal  ends  of  the 
divided  artery  were  pervious,  and  it  is  to  be  supposed  that 
circulation  .through  the  artery  had  been  reestablished  a  few 
days  after  the  operation. 

The  common  caroid  was  found  dilated,  the  lower  third 
forming  a  part  of  the  innominate  aneurysm  and  the  ligature 
was  found  half  an  inch  below  the  bifurcation  of  the  artery. 
The  subclavian  artery  was  found  to  spring  from  the  posterior 
aspect  of  the  innominate  aneurysm,  it  was  normal  in  si/.e 
but  atheromatous.  1  he  branches  of  the  thyroid  axis  were 
all  much  enlarged,  the  vertebral  was  ligated  about  one 
inch  from  its  origin,  the  suprascapular  was  enlarged  to  three 
times  its  usual  size  and  passed  over  the  upper  portion  of  the 
subclavian  aneurysm.  The  second  and  third  portions  of 
the  subclavian  artery  and  the  first  and  second  portions  of 
the  axillary  arter}'  were  involved  in  the  subclavian  aneurysm. 

The  aneurysmal  tumor  was  found  to  spring  from  the  pos- 
terior aspect  of  the  third  portion  of  the  subclavian  artery 
and  the  first  portion  of  the  axillary.  It  was  flattened  below 
where  it  rested  on  the  first,  second  and  third  ribs;  above  it 
was  deeply  grooved  by  the  clavicle.  A  portion  of  the  second 
rib  was  absorbed,  producing  a  pathologic  fracture. 

Portions  of  the  first,  second,  and  third  ribs  were  removed 
with  the  attached  tumor,  together  with  the  heart ;  the  two 
solid  parts,  the  heart  and  tumor,  being  joined  together  by 
the  first  portion  of  the  sul)clavian  artery  as  by  a  hyphen. 
The  whole  part  was  taken  out  en  masse. 

An  incision  was  made  into  the  aneurysm  parallel  to  its 
base.  It  contained  a  mass  of  dark,  thick  clots  occupying 
the  cavity.  The  process  of  cure  was  evidenced  by  fibrinous 
layers  upon  the  walls  and  on  the  inner  sides  of  this  coating 
were  masses  of  coagulum  less  firm  but  evidently  undergoing 
consolidation.  To  summarize  it  may  be  said  that  this  case 
is  one  of  arteriosclerosis  affecting  the  aorta  and  the  large 
arteries  and  even  the  veins,  presenting  a  fusiform  aneurysm 
of  the  innominate  and  common  carotid  arteries,  also  a  sac- 
culated aneurysm  of  the  subclavian  and  axillary  arteries,  in 
which  a  triple  ligature  of  the  innominate  artery  was  ap- 
plied, followed  by  nonocclusion  of  the  artery  by  the  ligatures, 
severance  of  the  artery  by  the  lower  ligature  with  subse- 
([uent  probable  ulceration  and  slight  hemorrhage,  the  liga- 
ture remaining  within  the  artery  and  the  continuity  of  its 
lumen  being  restored,  and  in  which  a  double  ligature  of  the 
right  vertebral  and  common  carotid  arteries  was  placed  at  a 
subsequent  operation,  followed  by  death  from  exhaustion. 

In  dealing  with  this  case  I  was  fully  impressed  with 
its  gravity.  The  various  plans  of  medical  treatment,  as 
well  as  other  operative  measures  l)esi(les  ligatiu'e  of  the 
innominate,  such  as  amputation  at  tlic  shoulder-joint, 
distal  ligature  of  the  subclavian  at  its  third  portion, 
Stewart's  method  of  electrolysis  through  a  wire,  Mac- 
Ewen's  needling,  had  been  considered  and  set  aside  as 
impracticable  or  unsuitable.  It  was  then  with  a  full 
appreciation  that  I  undertook  it,  and,  notwithstanding 
the  fatal  termination  of  my  case,  I  still  believe  that  lig- 
ature of  the  innominate  artery  may  be  safely  done. 

"The  operations  on  the  vessels  behind  the  clavicle 
and  sternoclavicular  joint,"  says  Barwell  (on  Aneurysm, 
p.  55),  "are  among  the  most  arduous  in  surgerj',  re- 
quiring both  steadiness  and  a  certain  courage.  .  .  . 
Given,  however,  that  the  operation  has  been  performed 
in  a  moderately  short  period,  and  has  been  projierly 
selected,  there  is  no  reason  whj^  the  patient  should  not 
get  well,  provided  the  ligature  has  not  divided  any  of 
the  arterial  coats." 

In  1895  was  published  the  monograph  of  Professor 
Edmond  Souchon.  of  our  city,  a  most  masterly  and  ex- 
haustive treatise  which  has  received  uniform  commenda- 
tion. In  it  he  gives  a  full  account  of  all  previous 
operations  and  formulates  definite  rules  of  jn'ocedure. 
So  succinct,   di'liniti'  and    valuablr   are   the   rules   laid 


down  by  him,  that  the  operative  methods  he  advises  are 
generally  followed.  It  should,  however,  be  stated  that 
no  method  advised  by  him  is  original,  everj'  one  having 
been  employed  by  earUer  operators.  But  Dr.  Souchon 'g 
work  has  given  a  remarkable  impetus  to  the  operation 
for  ligature  of  large  vessels.  He  insists  on  two  points 
as  of  paramount  importance  for  success,  namely,  two  or 
more  noncontiguous,  absorbable  ligatures  and  the  non- 
rupture  of  the  coats. 

The  adhesion  of  the  coats  may  V)e  eilected  in  smaller 
vessels  without  difficulty,  says  Thomson  (British  Medi- 
cal Journal,  Vol.  II,  1882),  but  in  such  a  large  vessel  as 
the  innominate  there  must  be  a  certain  amount  of 
crumpling  of  the  vessel  within  the  ligature  loop  when 
that  is  drawn  tight.  Upon  this  circumstance  liarwell 
observes  :  "  It  would  seem  that  the  tube,  puckered  and 
narrowed  to  a  mere  rift  by  the  ligature,  would  afford  an 
excellent  surface  for,  and  would  soon  get  occluded  by, 
blood-clotting." 

The  postmortem  examination  in  Thomson's  case 
showed  this  condition  to  be  actually  present.  Although 
the  ligature  was  drawn  home,  a  chink  still  appeared  to 
have  been  left,  but  that  chink  was  closed  by  a  firmly 
organized  clot, 'which  projected  through  it  towards  the 
carotid  and  subclavian  arteries.  These  vessels  were  in- 
deed closed  by  a  clot  which  was  throughout  continuous 
with  the  large  mass  which  occupied  the  cardiac  portion 
of  the  innominate. 

A  protest  against  the  principle  of  di\nsion  of  the  ves- 
sel's coats,  when  tied  in  its  continuity,  was  made  by 
Charles  Bell  so  late  as  1842,  and  the  opinion  of  modem 
surgeons  has  upheld  him  in  that  opinion.  As  to  the 
necessity  of  the  formation  of  a  clot  for  the  perfect 
closure  of  an  artery,  Spence's  experiments  (Lectures  on 
Surgery)  show  that  the  presence  of  a  coagulum  within 
the  vessel,  filling  up  its  canal  for  some  distance,  and 
ultimately  becoming  adherent  to  and  incorporated  with 
its  parietes,  was  not  essential  to  perfect  obliteration.  His 
experiments  further  showed  that  however  common  the 
presence  of  a  clot,  or  however  valuable  as  an  accessory 
it  might  be  when  present,  it  was  not  essential  in  the 
process. 

Recent  experience  shows  the  importance  of  applying 
two  ligatures  to  the  vessel  to  insure  complete  and  per- 
manent closure  of  its  lumen.  Thej*  should  be  placed 
about  half  an  inch  apart,  if  space  will  allow.  The 
distal  ligature  is  depended  upon  to  permanently  close 
the  vessel,  and  the  proximal  one  protects  the  first  from 
the  powerful  concussion  of  the  arterial  current.  In  the 
present  case,  just  as  in  Burrell's  case,  the  proximal  liga- 
ture cut  its  way  through  the  arterial  coats  and  was 
found  inside  the  vessel,  the  lumen  of  which  had  been 
restored.  The  danger  from  hemorrhage  in  such  cases  is 
averted  bj*  the  formation  of  a  thick,  fibrinous  ring 
around  the  artery  at  the  seat  of  ligature. 

As  to  the  question  of  the  division  of  the  innominate 
artery  between  two  ligatures,  I  am  do  no  better  than 
quote  Gray's  explicit  opinion  :  "  It  does  not  seem  wise," 
says  he,  "  to  divide  the  innominate  artery  between  the 
ligatures  to  relieve  axis  tension,  as  has  been  done  with 
apparently  good  results  in  tying  the  carotid  and  other 
large  vessels.  The  violence  of  the  systolic  impact,  the 
strain  upon  the  proximal  ligature,  and  the  tendency  of 
that  thread  to  cut  through  the  arterial  coats,  the  unre- 
liable character  of  the  proximal  throml>us.  the  lack  of 
the  firm  lateral  support  which  is  jiresent  in  the  neck, 
thigh,  and  other  large  arteries,  the  fact  that  the  innom- 
inate artery  is   surrounded   by  loose,  cellular  tissue. 


JaNI-ARY  26,  1901] 


LIGATURE  OF  THE  INNOMINATE  ARTERY 


CThe  Philadelphia 
Medical  Journal 


175 


suspended,  as  it  were,  in  soft,  nonresistin^  structures, 
would  all  seem  to  militate  against  the  practice  of  sever- 
ing the  artery  for  fear  of  secondary  hemorrhage." 

It  must  not  be  forgotten  that  successful  ligation  of 
tlie  innominate  artery  is  largely  a  matter  of  asepsis,  and 
it  is  here  that  modern  surgery  should  demonstrate  its 
superiority.  The  surgeon,  nowadays,  does  not  wait 
expectantly  for  the  separation  and  withdrawal  of  the 
ligature  about  the  tenth  day  as  formerly,  but  seals  up 
clie  wound  and  trusts  in  his  asepsis  and  technic. 

The  various  materials  which  have  been  used  for  liga- 
tures in  ligation  of  very  large  vessels  are  as  follows  : 
Silk,  hemp,  catgut,  ox  aorta,  kangaroo  tendon,  etc.,  in 
tact  every  variety  of  material  has  been  employed.  "  It 
would  seem,"  saj-s  Harte,  "that  a  ligature  composed  of 
animal  substance  whioh  would  in  time  lend  itself  to 
the  tissues  and  yet  be  sufficiently  strong,  would  be  most 
likely  to  meet  with  success ;  although  there  is  always 
an  element  of  uncertainty  in  the  employment  of  such  a 
ligature  for  fear  that  it  may  become  absorbed  too  soon 
or  its  knot  become  insecure  through  the  softening  pro- 
cess of  heat  and  moisture." 

Burrell  employed  two  flat,  braided  silk  ligatures, 
passing  one  above  the  other  about  a  half  an  inch  apart. 
His  object  was  to  rest  the  artery  by  severing  the  vessel 
between  them,  thus  avoiding  the  tracheal  tug. 

The  ligature  must  be  aseptic,  and  a  silk  ligature  can 
be  rendered  more  thoroughly  aseptic  than  any  other 
without  injuring  its  strength. 

The  collateral  circulation  in  these  cases  is  established 
through  the  left  carotid  and  vertebral  arteries,  the 
circle  of  WilUs,  the  corresponding  arteries  of  the  right 
side,  also  through  the  thyroid  arteries,  the  intercostals, 
especially  the  superior,  the  mammary,  the  profunda 
and  princeps  cervicis,  and  doubtless  through  many 
other  smaller  vessels  of  the  arterial  system. 

It  has  been  suggested  by  some  surgeons,  and  I  think 
it  unquestionably  safer  that  in  such  an  operation  as 
this,  the  common  carotid  and  perhaps  the  vertebral 
ought  to  be  ligatured  at  the  same  time,  with  the 
object  of  cutting  off  the  recurrent  circulation  not  only 
from  contact  with  the  seat  of  ligature  on  the  innom- 
inate and  preventing  the  formation  of  a  clot,  but  from 
supplying  the  distal  tumor.  The  carotid  was  so  treated 
in  Smyth's  case.  Thomson  states  that  as  a  matter  of 
fact  the  carotid  has  been  frequently  found  closed  when 
the  innominate  only  was  tied. 

The  failure  of  other  methods  than  ligation  for  the  treat- 
ment of  aneurysms  of  the  very  large  arteries  has  led  sur- 
geons to  persist  in  the  method  offering  the  best  results. 
After  consideration  of  the  uniform  fatality  of  the  opera- 
tion by  the  proximal  ligature,  it  would  seem  that  Base- 
dow's method  of  tying  the  carotid  and  subclavian  arteries 
would  offer  a  more  promising  method  of  procedure.  In 
the  only  opportunity  I  have  had  of  witnessing  the  appli- 
cation of  this  method  the  result  was  not  encouraging. 
The  case  was  Dr.  Parham's,  wl;o,  two  days  prior  to  my 
first  operation  on  the  present  case,  operated  for  a  large 
aneurysm  of  the  innominate  artery,  and  syphilitic  in 
origin.  A  catgut  ligature  was  placed  on  the  third  por- 
tion of  the  subclavian  artery  and  on  the  right  common 
carotid  near  its  bifurcation.  The  patient  lived  '20  days 
after  the  operation  and  finally  died  of  suffocation  by 
pressure  on  the  trachea— a  result  probably  due  also  to 
too  much  back-pressure  upon  the  heart. 

For  the  treatment  of  aneurysms  various  methods  have 
been  recommended,  several  of  which  have  apparently 
been  followed  by  good  results,  but  the  history  has  sel- 


17g  The  Puiladelphia"! 

Medical  JocRKAL  J 


LIGATURE  OF  THE  INNOMINATE  ARTERY 


;Ja5Uaey  K,  1901 


2J 


^  a>  a 


ec  5  J;,r-- 


2  *  ei-o  s 


2        °.^ 


'^r. 


W2 


t.MK 


■tS'' 

=1^ 


*  fi,    ~'  £ 


;5!> 


>     "     «^2« 


5 


5  5  =  a 
r:  ^  «  -* 


oT      Soo      "g      -3      -= 


0  :c     . 


o6 


3  S       ST^*" 


to  w 

'9'    O 


P2 


=  5^ 


id  tC 


-*5   C  -J" 


-■  .sr: 

_ 

f '^- 

og  o-_- 

s-o^     . 

liSo  oS 

a-^o 

=  -  a  = 

^'-V- 

J'^^'^ 

Sr-      s- 


1^ 


s^s 

t< 

■<  o 

o 

o 

o 

FI 

H 

» 

« 

fc     ^ 


o 

a 


«  ■*--=! 


S 

o 

» 


a 
n 


s 

H 


SB-:.  -      o 


si 
s 


2  =  ,; 


r^  -OS  — 


&"  M         ^         CO 


wtfS 

H  PS  ^ 
•<  O  fc 

O  E  "-■ 


?5     S5 


tl  *  =  - 

c  —  j;  o 

^  O  oo  — 

^  CO  e^ 


ii        -2 


izi    fz; 


I  f 


;^     »     S&     S5 


OS  ee  «  K 

aSg2 


£; 


o^ 

r- 


<^  c>:*5io 


S  52 


s  ss 


1  § 


o 
S 


c     E         rt 
2;    <       « 


■  £    -•  =    i 

*:  .  2    a"  £«!  = 

" ».  =  -      =  J'  £   ;£ 

no       _;    o  &.    o 


X  a 

F 


■.s 


s       K 


.,■    t 


«>:  = 


f2 


_-5 


X  «      fe  3      %>  .  t-  ca         ^  =  "  3  « i;  a.     *=i  =  e      =      -  -      c  ? 

Bo-  £=S-xS         =         «=.u9         = 


5      fij  5*.  ■ 


:-iH 


~-S 


Si 

ri 

X 

£ 

c 

s 


s 


S    8 


JaBTARV  26,  19011 


LIGATURE  OF  THE  INNOMINATE  ARTERY 


("The  Philadelphia 
L  Medical  Jocrsal 


177 


dom  been  followed  up  for  a  time  sufficiently  long  to 
acquaint  us  with  the  ultimate  results  of  the  operation. 

The  much  lauded  gelatin-injection  treatment,  from 
which,  after  the  favorable  French  accounts,  so  much  was 
expected,  has  proved  a  failure  in  other  countries.  The 
latest  device,  however,  which  consists  in  the  wiring  of 
aneurysm  followed  by  the  passage  of  a  mild  electric  cur- 
rent, has  given  excellent  results.  But  a  few  weeks  ago 
we  listened  with  pleasure  and  interest  to  Dr.  Matas' 
elaborate  report  of  a  case  of  abdominal  aneurysm  treated 
by  this  method.  Stewart's  pioneer  achievements  in  this 
method  of  treatment  have  proved  a  source  of  encourage- 
ment to  the  profession  throughout  the  country.  He 
reports  {Brit.  Med.  Journal,  vol.  ii,  1S97)  a  case  of  a  large 
innominate  aneurysm  completely  cured  by  the  employ- 
ment of  electrolysis  through  ten  feet  of  snarled,  coiled, 
fine  gold  wire  introduced  into  the  sac.  The  patient  died 
from  cereljral  thrombosis  three  and  a  half  years  after  the 
operation.  Stewart  says  that  the  result  of  electrolysis 
through  the  introduced  wire  was  very  decided.  Clot- 
formation,  leading  apparently  to  solidification  of  the  sac, 
was  early  manifest.  This  method  is  worthy  of  further 
trial  in  the  treatment  of  large  aneurysms. 

The  operation  proposed  by  Furguson,  amputation  at 
the  shoulder-joint,  with  ligation  of  the  artery  as  close  as 
possible  to  the  sac,  was  performed  five  times  with  two 
recoveries  (Souchon).  It  was  done  on  the  right  side  by 
Rose  with  partial  success.  Rose  also  tied  the  carotid 
and  thus  succeeded  in  saving  the  patient.  Spencer 
(Brit.  Med.  Journal,  1889,  p.  73)  makes  mention  of  two 
cases  of  subclavian  aneurysm  that  were  treated  by  am- 
putation at  the  shoulder  joint.  The  first  case  was  oper- 
ated on  by  Holden,  who  removed  the  upper  extremity 
for  an  aneurysm  of  the  subclavian  artery.  Death  on  the 
thirty-seventh  day  from  pleurisy  and  bronchitis  resulted. 
The  other  case  was  Willett's.  He  tried  to  ligate  the 
third  portion  of  the  subclavian  artery  for  subclaN'ian 
aneurysm  and  had  to  abandon  the  attempt  owing  to  his 
inability  to  reach  the  proximal  side  of  the  aneurysm. 
The  upper  extremity  was  then  amputated  at  the  shoul- 
der.    Death  followed. 

As  the  postmortem  examination  in  my  case  showed, 
no  fi;rther  operation  would  have  been  successful. 

The  cause  of  death  after  operation  is  either  from  sepsis, 
secondary  hemorrhage,  usually  from  the  distal  side  of 
the  ligature,  or  shock. 

I  have  made  a  very  full  search  into  the  literature  of 
the  subject  and  have  succeeded  in  obtaining  verifications 
of  34  cases,  including  my  own  case,  in  which  the  innom- 
inate artery  has  been  tied  for  subclavian  aneurysm. 
Twenty-nine  were  performed  for  aneurysms  of  the  sub- 
clavian artery,  generally  involving  the  function  of  the 
common  carotid  and  innominate  arteries,  and  five  times 
it  was  )>erformed  for  trauma.  Of  these  five,  one  was  for 
hemoi-rhage  from  the  subclavian  (Lewtas),  one  from 
secondary  hemorrhage  following  ligation  of  the  subcla- 
vian (Hutin),  three  for  secondary  hemorrhage  following 
ligation  of  the  common  carotid  (Lynch,  Partridge,  and 
Harte). 

According  to  Spencer  (Brit.  Med.  Journal,  vol.  ii, 
1889)  subclavian  aneurysm  is  about  tlu-ee  and  a  half 
times  more  common  on  the  right  side  than  on  the  left, 
and  on  the  right  side  about  six  times  more  fretjuent  on 
the  third  portion  than  on  he  first.  The  spontaneous 
are  six  times  more  common  than  the  traumatic. 

Of  the  34  cases  just  mentioned  four  are  usually  re- 
ported as  recoveries.  The  first  is  Smyth's,  of  New 
Orleans,  in   18G4.     In  that  instance,  following  the  sug- 


gestion of  Mott,  he  ligated  the  common  carotid  artery 
also.  This  well-known  case  survived  the  operation,  nar- 
rowly escaped  the  usually  fatal  result,  lived  ten  j^ears, 
then  died  from  rujiture  of  the  reformed  aneurysm,  the 
result  of  reverse  collateral  circulation.  The  second  case 
is  Lewtas',  of  India,  in  1889,  rei)orted  cured  at  the  end  of 
48  days.  The  third  is  Coppinger's,  of  Dublin,  in  1893, 
who  reported  a  recovery  at  the  end  of  42  days.  If 
these  last  two  cases  are  accepted  as  recoveries,  a  fourth 
might  with  justice  be  added  to  the  list,  that  of  Bur- 
red, of  Boston,  in  1876.  Burrell  justly  takes  excep- 
tion to  the  too  early  report  of  Lewtas'  and  Coppinger's 
cases  when  viewed  in  the  light  of  his  own  case  that  lived 
104  days  and  died  of  hypertrophy  and  dilation  of  the 
heart  and  general  arterial  sclerosis,  and  also  of  the  case 
of  Graefe,  of  Berlin,  operated  on  in  1822,  which  died  on 
the  sixty-eighth  day. 

But  a  careful  analysis  of  these  four  successful  cases  will 
show  that  not  a  single  one  has  been  a  complete  cure. 
Smyth's  case  came  nearer  being  a  positive  and  com- 
plete cure  than  any  other.  Still,  his  patient  died  of 
hemorrhage  from  the  aneurysm  ten  years  after  the 
operation.  The  second  and  third  cases  had  not  been 
under  observation  sufttciently  long  to  establish  positive 
cure.* 

Whether  we  think  of  the  hopeless  character  of  these 
subclavian  aneurysms  and  their  most  jiainful  course,  we 
are  led  to  believe  that  other  surgeons  will  in  the  future 
devise  some  safer  and  more  successful  method  of  treat- 
ment. In  the  meantime  we  must  depend  on  our  present 
unreliable  methods.  And  still  such  is  my  confidence  in 
the  method  adopted  in  this  case,  that  I  am  bold  enough 
to  assert,  in  conclusion,  that  under  favorable  circum- 
stances the  operation  by  ligature  is  in  certain  conditions 
justifiable  and  advisable,  and  that,  with  the  improve- 
ments in  the  physical  characteristics  of  the  ligatiu-e 
and  in  the  method  of  its  application,  also  the  modem 
aseptic  methods,  it  may  yet  be  followed  by  favorable 
results. 

In  the  accompanying  statistical  table  of  the  29  ligations 
for  subclavian  aneurysms,  which  I  append  to  this  report, 
I  have  carefully  eliminated  those  cases  wherein  secondary 
hemorrhage  led  to  the  ligation  of  the  innominate  and 
the  unfinished  operations.  These  I  present  in  separate 
lists.  In  compiling  these  tables  I  am  indebted  to  the 
statistics  contained  in  the  works  of  Thomson,  Burrell, 
and  Souchon.  In  the  five  years  since  the  publication  of 
Souchon's  monograph,  there  have  been  recorded  five 
operations  for  the  ligature  of  the  innominate  artery, 
with  as  many  deaths. 

LIST  OF  UNFINISHED  OPERATIONS. 

1.  Porter,  W.  H.,  18'il,  Dublin,  for  subclavian  aneurysm  ;  lisjature  of  in- 
nominate, abandoned  on  account  of  dilated  vessel.  {Dublin  Journal,  1832, 
vol.  i.) 

2.  HoSiiiann,  New  York,  1839,  for  subclavian  aneurysm ;  attempt  to  ligate 
abandoned  on  account  of  f-ize  of  the  innominate.  (Burrell,  Boston  Medical  and 
Surgiciil  Journal,  189.5,  vol.137.) 

3.  Kfy,  London,  184),  for  innominate  aneurysm  ;  abandoned  operation  OB 
account  of  size  of  uueurysmal  tumor.  Death  23  days  after  operation.  (Dublin 
Quarlerlr/ .hunial,  l^fi^.  vo).  IZ.) 

4.  Peiscoto,  Rio  .Janeiro,  1851  ;  patient  is  a  man  33  years  of  age,  with  hemor- 
rhagic lumur  of  right  ear.  Ligatureof  common  carotid.  Hemorrhage.  Expect- 
ant ligature  placed  around  inuoniinate  tliree  weeks  after  eaniid  ligation  hut  not 
tied,  and  removed  after  5  days.  (.Mi-moires  de  I'.icadrinie  Imperiale  de  .Vhlecine, 
1S55,  vol.  19.)  ,    .       ... 

5.  F.  W.  Parham,  New  Orleans,  for  cervical  aneurysm,  involving  the  innom- 
inate. Man,  nged  48  years.  The  innominate  was  exposed  by  rcmov.il  of  a 
part  of  the  sternum,  but  not  ligated  because  it  was  found  so  greatly  enlarge<L 
Death  from  shock  17  hours  after  i>peration.  (New  Orleans  Medical  and  Surgteal 
Journal,  1896.) 


•  In  a  personal  letter  of  Dr.  Alfred  Willett  to  Dr.  Coppinger.  dated  July  4  189^ 

-re  than  two  years  after  the  operation,  the  writer  states  that  the  patient  had 

■11  in  St.  H.irtholomew's  Hospital  because  his  nervous  system  seemed  some- 

_.  I 1 J u...  1 ....J...  (v«n  rrntii  aniT  aifin  of  his  old  aneurvsm 


more 
l)ec 


l>ee]l  in  St.  Hartholomew's  Hospital  because  his  nervous  system  seeuieu  ouuit:- 
what  broken  down,  but  he  was  quite  free  from  any  sign  of  his  old  aneurysm 
(Souchon). 


The  Philadelphia' 
ussicai,  joubkal  j 


BRANCHIAL  CYSTS  AND  FISTULAE 


(Jahitabt  26,  im 


BRANCHIAL  CYSTS  AND  FISTULAE.* 
By  \V.  M.  L.  COPLIX,  M.D., 

of  Philadelphia. 
Professor  of  Pathology  in  the  Jeflerson  Medical  College. 

As  a  result  of  the  complex  developmental  pro- 
cesses requisite  to  the  formation  of  the  organs  arising 
in  the  neck  segment  of  the  embryo  a  multitude  of 
malformations  are  rendered  possible.  The  formation  of 
the  branchial  arches  and  associated  clefts  or  more  prop- 
erly furrow.a,  and  the  fact  that,  at  the  bottom  of  the 
furrows,  internally  as  well  as  externally,  the  epithelium 
of  the  entoderm  and  ectoderm  becomes  contiguous,  con- 
sidered with  possible  errors  at  the  anterior  median 
junction  of  the  projected  developing  columns,  such  as 
failure  of  median  coalescence,  render  it  at  once  ap- 
parent that  all  sorts  of  malformations  or  arrests  in  de- 
velopment may  result.  Such  more  or  less  complete 
persistence  into  extrauterine  life  of  conditions  normally 
entirely  fetal  may  be  manifested  by  almost  anv  degree 
of  abnormality  from  fissure  of  the  entire  neck  to  trivial 
fistulae,  or  from  absence  of  more  or  less  of  the  esoph- 
agus, lung,  or  other  structure  normally  derived  from 
the  foregut,  to  the  persistence  of  fistulae  (often  of 
capillary  dimensionf),  blind  sacs  or  cyst  accumulations 
due  to  external  and  internal  closure  of  canals  without 
coalescence  of  intermediate  tracts.  I  shall  not  attempt 
to  go  into  the  developmental  processes  concerned  in 
the  formation  of  the  branchial  clefts,  as  such  informa- 
tion is  attainable  in  any  of  the  current  works  on  em- 
bryology. 

Hunezowski^  (ITS!))  reported  two  cases  of  congenital 
cervical  fistulae;  Dzondi'  (1S29)  called  them  tracheal 
fistulae  and  Aschersou'  demonstrated  their  pharyngeal 
connection.  Heusinger'  reported  '2  cases  and  gave  a 
table  of  cases,  46.  In  his  inaugural  thesis  (Paris,  1877) 
and  later.  Gusset*  gives  with  considerable  detail  the  result 
of  his  studies  on  the  subject.  GuzmanV  thesis  in  ISSfi, 
and  Bland  Sutton's'  work  on  tumors  should  also  be 
consulted.  Senn'  discusses  branchial  cysts  under  tera- 
tomata.  Recently  Frederick  Shimanck'  reported  cases 
of  branchiogenic  carcinoma  and  reviewed  the  literature 
of  malignant  disease,  arising  in  these  abnormal  cavities. 

With  regard  to  the  classification  of  branchial  cysts 
much  diversity  of  opinion  is  found.  Fevrier'"  speaks 
of  median  and  lateral  cysts.  Depending  upon  their 
proximity  to  the  surface  the  cysts  are  spoken  of  as 
superficial  or  deep.  As  it  is  notalways  possible  to  de- 
termine accurately  from  which  cleft  the  cyst  originated 
the  proposition  to  base  the  classification  upon  the  em- 
bryologic  origin  of  the  defect  can  be  scarcely  regarded 
as  satisfactory.  Less  satisfactory  probably 'is  the  at- 
tempt to  subdivide  these  cysts  according  to  the  contents, 
as  the  latter  must  be  materially  influenced  by  the  pres- 
ence of  inflammation,  hemorrhage,  and  infection,  as 
well  as  its  source ;  similarly  situated  and  genetically 
identical  cysts  may  contain  dissimilar  materials. 

Based,  however,  upon  the  hypothesis  that  such  a 
classification  is  justifiable  such  cy.sts  have  been  called 
atheromatous  (branchial  dermoid.^;),  mucous,  serous, 
and  hematocysts.  As  none  of  these  cysts  are  primarily 
blood-cysts  it  is  probable  that  the  last-named  subdivi- 
sion is  hardly  justifiable.  In  Marsh's"  case  the  cyst 
contained  a  gelatinous  material. 

It  has  been  proposed  to  name  these  cysts  according 
to  their  anatomic  position  in  the  adult.     From  this 

*  Read  before  the  Philadelphia  Pathological  Societv,  .Tanuarv  10, 1901 

t  In  one  of  Heusiuger's  cases  a  thick  whisker  could"  be  passed  into  the  ap«ning. 


point  of  view  such  cysts  are  called  auricular  or  audi- 
tory, parotid,  submaxUlary,  sublingual,  pharj-ngeal, 
tracheal,  etc.  If  carried  to  its  legitimate  conclusion 
such  a  classification  would  be  scarcely  consistent,  as  we 
would  have  substernal,  sternocleidomastoid  and  other 
anatomic  subdivisions  that  would  endanger  our  losing 
sight  of  the  embryologic  origin.  Although  possessing 
many  disadvantages  the  classification  based  upon  the 
character  of  the  cyst  wall,  taken  in  connection  with  the 
origin  of  the  process,  possesses  many  advantages.  This 
would  at  once  subdivide  the  entire  group  into  two  sub- 
groups, one  in  which  the  wall  showed  to  a  varving 
degree  the  histologic  characters  of  the  skin  and  which 
would  merit  the  name  branchial  dermoid,  and  the  other 
in  which  the  epithelial  lining  showed  more  or  leas  - 
striking  resemblance  to  the  mucosa  lining  the  mouth,  I 
pharynx,  or  respiratory  tract.  '  Cysts  of  the  latter 
type  would  be  called  mucous  branchial  cysts.  While 
considering  the  subject  of  classification  it  is  well 
to  remember  that  the  branchial  cyst  is  but  one  type  of 
a  malformation  that  ma}-  be  manifested  by  at  least  four 
pathologic  possibilities:  1.  Branchial  fistulae.  canals 
extending  from  the  external  surface  to  one  of  the  muco- 
membranous  tubes  or  cavities,  such  as  the  pharynx, 
larynx,  etc.  2.  Where  the  external  opening  has  been 
closed  a  blind  fistula,  pouch  or  tract  with  its  internal 
opening  retained,  results.  3.  An  external  fistula  in 
which  the  pharyngeal,  laryngeal  or  other  internal  ori- 
fice has  been  closed  while  the  external  opening  per- 
sists. 4.  Cysts  like  that  observed  in  the  case  reported 
in  which  both  internal  and  external  orifices  have  been 
obliterated,  giving  rise  to  a  closed  cavity  the  wall  of 
which  possesses  an  epithelial  covering.  In  the  experi- 
ence of  Trelai'-  fistulous  openings  are  seven  times  as 
common  as  true  cysts. 

As  already  indicated  the  structure  of  the  wall  de- 
pends to  a  certain  extent  upon  the  type  of  tissue  that 
it  imitates.  In  branchial  cysts  of  the  dermoid  type  the 
wall  does  not  differ  from  that  found  in  other  dermoids 
except  from  the  almost  constant  presence  of  lymphoid 
elements  in  the  extradermal  layer.  This  lymphoid 
layer  may  be  scanty,  consisting  of  a  few  aggregations 
of  lymphoid  cells  scattered  here  and  there  or  such  ag- 
minations  of  lymphoid  tissue  as  to  constitute  distinct 
nodes.  While  it  is  true  that  other  dermoids  may  occa- 
sionally possess  more  or  less  lymphoid  tissue  it  is  very 
rare  to  find  such  accumulated  masses  as  are  observed 
in  the  dermoids  of  the  type  at  present  under  considera- 
tion. In  the  branchial  cysts  imitating  the  mucous 
membrane  in  the  character  of  the  cyst  wall  the  condi- 
tion is  practically  always  that  observed  in  the  case  here 
reported.  In  a  small  number  of  cases  the  lining  has 
been  composed  of  cylindrical  epithelium,  rarely  of  the 
tall  variety,  and  only  exceptionally  ciliated.  Where 
the  epithelium  has  been  subjected  to  considerable  in- 
ternal pressure  it  may  be  flattened,  of  a  low  columnar 
(cuboidal)  type,  or  less  frequently  quite  resembling 
squamous  epithelium.  In  only  exceptional  instances 
is  it  simple,  usually  stratified,  the  number  of  layers  not 
uniform  in  diff"erent  areas  of  the  s;\me  cyst  w.all  and 
not  infrequently  showing  marked  morphologic  peculi- 
arities in  diflerent  areas  of  the  same  lining.  When 
stratified  the  genetic  layer  shows  more  or  less  tendency 
toward  a  distinctly  columnar  type.  It  is  not  probable 
that  epithelium  is  ever  absent,  and  the  only  reported 
case  that  I  have  been  able  to  find  in  which  it  was  sought 
and  not  found  is  that  recorded  by  G.  Broesike,"  but  as 
tlie  specimen  was  not  studied  in  the  fresh  condition  the 


Jasvabt  te,  1901) 


BRANCHIAL  CYSTS  AND  FISTULAE 


PThk  Philadelphia 
L  Medical  Journal 


179 


absence  of  demonstrable  epithelium  is  not  surprising. 
The  muscularis  mucosa  may  be  demonstrated  with 
difficulty  or  it  may  be  on  the  other  hand  quite  conspic- 
uous. Sometimes  it  is  composed  of  a  scattered  layer 
of  smooth  muscle  cells,  abundant  at  points,  irregularly 
scant  in  other  areas,  and  rarely  arranged  as  a  continu- 
ous membrane.  Sometimes  this  layer  is  in  immediate 
apposition  with  a  firm  connective  tissue  stratum  com- 
posed of  fully  formed  fibrous  tissue  in  which  may  be 
found  numerous  leukocytes,  usually  of  the  lymphoid 
type.  This  fibrous  tissue  merges  into  the  loose  connec- 
tive tissue  by  which  the  cyst  is  attached  to  neighbor- 
ing structures.  Elastic  fibers  are  present  in  the  case 
reported.  Adjacent  to  the  fibrous  tissue  and,  when  it  is 
absent,  adjacent  to  the  muscularis  mucosa  could  be 
found  a  varying  amount  of  lymphoid  tissue.  Some 
times  this  lymphoid  tissue  is  in  type  and  arrangement 
a  more  or  less  accurate  reproduction  of  the  structure  of 
the  tonsil.  In  other  instances  there  is  a  lawless  aggre- 
gation of  lymphoid  elements  with  a  scant  reticulum 
scattered  along  the  submucosa  at  irregular  intervals 
and  in  various  sized  aggregations. 

A  number  of  observers.  Gusset,^  Roth."  Monad  and 
Dubar,'°  and  Guzman,®  have  called  attention  to  the 
presence  of  glands  in  the  walls  of  branchial  cysts. 
These  glands  may  be  of  the  serous  or  mucous  type  and 
show  such  aggregations  as  are  found  in  the  pharynx 
and  esophagus  of  lower  animals,  and  though  less  abund- 
ant in  man ;  such  glands  may  be  distended  by  secre- 
tion, constituting  true  cysts  in  the  primary  cyst  wall, 
or  possess  patulous  ducts  communicating  with  the 
general  cyst  cavity.  Commonly  the  glands  are  not 
abundant  and  apparently  may  be  absent  or  overlooked. 
The  cyst  wall  may  be  uniform  and  quite  smooth  or  it 
may  be  irregular,  as  in  the  case  reported,  of  varying 
thickness  depending  upon  the  amount  of  lymphoid  and 
fibrous  tissues  rather  than  upon  the  thickness  of  the 
epithelial  layers. 

Sometimes  the  cyst  extends  in  finger-like  projections 
between  the  muscles,  great  vessels,  and  nerves  of  the 
neck,  or  behind  the  hyoid  bone,  or  downward  behind 
the  sternum  or  along  the  course  of  the  auditory  canal, 
rendering  total  ablation  sometimes  quite  difficult,  if  not 
impossible.  Sometimes  the  tumor  projects  into  the 
pharynx  or  esophagus  or  passes  posteriorly  to  that 
structure  or  between  the  esophagus  and  trachea  or 
larynx,  and  while  presenting  superficially  as  a  rather 
simple  and  readily  accessible  mass  it  may  at  operation 
present  unexpected  difficulties. 

The  communication  of  blind  or  open  fistulae  with 
the  air-passages  may  give  rise  to  air-sacs ;  those  sacs 
possessing  internal  openings  into  the  trachea  may  pre- 
sent the  features  of  that  rare  condition  variously  termed 
aerial  goiter,  aerial  bronchocele,  tracheocele  and  hernia 
of  the  trachea.  Stuart  Eldridge'*  reported  one  such 
case  and  collected  the  literature  bearing  upon  the  sub- 
ject. I  gather  from  a  perusal  of  his  paper  that  he 
believed  it  quite  possible  for  the  defect  to  be  latent,  a 
mere  point  of  weakness,  which,  under  unusual  stress, 
became  manifest. 

With  regard  to  the  symptoms  of  this  condition  little 
need  be  said,  as  they  suggest  themselves.  The  external 
opening  of  fistulous  tn\cts  may  be  situated  almost  any- 
where in  the  anterior  portion  of  the  neck,  about  the 
auditory  canals,  in  the  temple,  in  the  neighborhood  of 
the  jaws,  etc.,  but  always  anterior  to  the  sternocleido- 
mastoid muscles.  The  external  opening  is  commonly 
marked  bv  a  discoid  area  of  scar  tissue  or  sometimes  it 


may  be  so  inconspicuous  as  to  escape  superficial  exam- 
ination. Only  rarely  can  the  fistulous  tract  be  followed 
by  a  probe.  Fevrier'"  reports  the  occurrence  of  severe 
reflex  symptoms — pallor,  palpitation  of  the  heart — as  a 
result  of  attempted  exploration  of  a  pharyngeal  fistula. 
The  discharge  is  usually  clear  mucus,  but  may  be  mis- 
taken for  salivary  secretion  from  which  it  is  easily 
diS"erentiated  by  the  usual  chemical  methods. 

Where  the  fistula  is  complete  and  communicates 
with  the  esophagus  or  pharynx  droplets  of  mUk  maj' 
escape  during  deglutition."  The  location  of  the  external 
opening  is  rarely  a  guide  to  the  extent  and  relations  of 
the  fistulous  tract  or  sac.  Stimulation  of  salivary  secre- 
tion by  citric  acid  or  mastication  usually  stimulates  the 
secretion  from  the  sinus  even  when  it  does  not  com- 
municate with  the  alimentary  canal. 


^ 

,-<-" 

;    ~ 

,  y^" 

C  .-^^l^ 

>»*<v- 

-If 

K. 

-■.'^i^i^i^  . 

■  ^': 

|rn^ 

.#' 

fA 

P?- 

»!^^:- 

.    ""'^c.-.. 

■. 

—      •.'  ^ 

■M^-- 

•i.-V.;..*'.^-.-— ^— 

A.  Section  from  thick  portion  of  wall  of  branchial  cyst.    This  section  ii  richest 

iu  lymphoid  ti^ue  and  show-  the  presence  of  the  cyst  d,  containing  granular 
detritus  and  lined  bv  modified  low  columnar  epihelium, 

B.  Section  of  wall  of  hranch  al  cyst  at  point  wh-re  thictcr  [wrtion  is  thinning 

toward  the  ex-rtmely  thin  layer  shown  at  C  S*'ctions  J  and  ^  are  placed 
with  the  inner  asi>ect  ol  the  cyst  wall  direcl<Ld  upwards. 

C.  The  section  is  reversed,  The  iiiner  aspect  being  directed  downward,    a.  a,  a^ 

Epithelial  laver  of  cvst  wall.  b.b.  b.  cooneciive  lissiie  layer,  c.  c.  lymphoid 
elements  in'  cyst  wall.  .VI  d'  these  lymphoid  elements  arc  aggregated  in 
masses  resembiing  the  tonsil  in  stiucture.  e.  Section  of  one  of  the  f -Ids 
ol  served  in  the  cvst  wall.  f.  Irre;:ularly  dilated  gland  ducts.  Tissue  ti.\ed 
in  HL'ideuhain'ssolution,  "infiltrated  with  paraffin,  stained  with  carmalum 
and  picric  acid.    Zeiss  S  mm.  Apoch.  Piojection  eyepiece  So.  2. 

When  opening  internally  without  an  external  open- 
ing the  condition  is  commonly  spoken  of  as  a  pouch 
or  diverticulum  (congenital)  ;  *  when  communicating 
with  the  esophagus  it  may  fill  during  feeding  or  the 
internal  opening  may  be  so  small  as  not  to  admit  food. 
It  may  be  evacuated  by  pressure,  or  the  patient  may 
find  that  by  assuming  a  certain  position  the  food  does 
not  enter  the  diverticulum. 


»  For  description  of  dissection  see  references  Nos.  12, 13,  and  16. 


I  OQ  The  Philadklphia"! 

Medical  Journal  J 


BRANCHIAL  CYSTS  AND  FISTULAE 


[Jabbart  2C,  1901 


Like  the  flstulae  the  cysts  are,  in  the  neck,  located 
anteriorly  to  the  sternocleidomastoid,  in  the  parotid  or 
auricular  region,  in  the  neighborhood  of  the  hyoid  bone, 
or  maxilla,  in  the  interclavicular  notch,  or  less  com- 
monly substernal,  presenting  at  the  last-named  point. 

The  character  of  the  contents  has  already  been  con- 
sidered. The  striking  resemljlance  in  some  cases  to 
pus  or  to  the  caseous  contents  of  tuberculous  lesions 
may  mislead  the  operator ;  as  indicated  in  the  report 
which  follows  it  would  seem  that  the  character  of  the 
cells  found  in  the  fluid  should  at  once  clear  up  the 
diagnosis. 

With  regard  to  the  age  at  which  the  lesions  manifest 
themselves  it  may  be  said  that  the  flstulae  are  usually 
present  at  birth.  They  may  appear  later  as  a  result  of 
opening  of  pouches  or  cysts  or  incomplete  extirpation. 
Like  dermoids  of  other  kinds  the  cyst  may  escape 
detection  until  adult  life  or  later.  In  Cussett's^  cases 
the  patients  were  10,  15,  21,  22,  and  26  years  of  age. 
In  the  case  reported  the  specimen  was  sent  to  the  labor- 
atory by  Professor  W.  W.  Keen,  to  whom  I  am  indebted 
for  the  following  clinical  notes  : 

C.  E.,  age  38,  first  consulted  me  November  6,  1899,  at  the 
instance  of  Dr.  C.  W.  Richardson,  of  Washington,  D.  C. 
His  father  and  mother  are  living,  and  in  gnod  health.  Of 
his  grandparents  he  knows  nothing,  excep'  that  his  paternal 
grandmother  died  of  old  age  at  about  85 ;  he  believes  that 
all  of  his  fam  ly  were  healthy.  One  sister  died  of  dipiitheria. 
Three  \earsago  he  noticed  a  lump  on  the  lower  jaw  on  the 
left  side,  no  pain,  no  inHammatioii,  in  fact  no  symptoms 
whatever.  Its  size  was  that  of  a  peach  stone  until  about  8 
months  ago,  when  it  began  to  grow  (juite  rapidly.  There 
have  been,  however,  no  symptoms  connected  with  it,  except- 
ing a  slight,  dull  pain  about  the  side  of  liis  face,  and  he 
thmks  it  has  affected  his  head,  as  he  has  become  very 
forgetful.  He  has  lost  28  pounds  in  the  last  6  months, 
weighing  at  present  175  pounds,  but  this  may  be  due  to 
other  causes.  On  examination  I  found  a  soft,  ahnost  ihictuat- 
ing  tumor,  10  by  6  cm.,  presenting  the  features  of  a  lipoma. 

Operation,  November  15.  An  inci.sion  was  made  parallel 
with  the  jaw,  and  after  cutting  down  through  the  mi  lohyoid 
the  back  of  the  lumor  was  reached.  This  proved  not  to  be 
a  fatty,  but  a  cystic  tumor  The  fluid  looked  very  much 
like  pus.  My  judgment  was  that  it  was  a  cold  abscess  either 
in  the  connective  ti.ssue  or  in  a  very  much  enlarged  and 
softened  gland.  I  was  able  to  dissect  the  whole  of  it  out, 
exposing  at  the  bottom  of  the  wound  the  great  vessels  of  the 
neck.  I  very  carefully  washed  the  wound  out  with  salt 
solution,  and  then  closed  it  with  drainage  He  made  a  per- 
fectly smooth  recovery,  highest  temperature  being  100°  F. 

_  Pathologic  Report  —Specimen,  cystic  tumor  of  neck.  Spe- 
cimen consists  of  an  almost  empty,  flaccid  sac,  measuring 
7  cm.  in  its  longest  diameter.  It  is  oval  or  slightly  pear- 
shaped.  It  contains  a  pinkish- white  opa(pie  fluid  that 
resembles  pus.  The  external  wall  of  the  cyst  is  covered  by 
an  nborescent  outline  of  bloodvessels.  The  lines  of  dissec- 
tion from  the  adjacent  tissues  are  recognizable.  Bf  reason 
of  perforations  in  its  wall  it  was  impossible  to  refill  the 
cavity  and  determine  its  capacity.  Approximatelv  one-half 
the  cyst  wall  is  thin  (1  to  2  mm".)  perfectlv  transparent,  and 
containing  a  few  bloodvessels.  The  remaindiM-  of  ihe  wall 
is  thicker,  but  quite  irregular  in  thickness.  Its  maxinunn 
thickness  occurs  in  slightly  bossed  elevations  appr.iaehing  1 
cm.  The  average  thickness  of  the  wall  does  not  exceed  "/iS 
cm.  It  is  irregularly  studded  by  greyish  translucent  eleva- 
tions. The  largest  of  these  elevations  are  palpable,  resem- 
bbng  tubercles.  At  one  point  in  the  thiekened  wall  is  a 
yellowish  mass  appareutly  caseous.  This  mass  is  ovoid,  .7 
cm.  by  .5  cm.  in  diameter.  It  is  situated  within  the  thickened 
wall  an<l  covered  by  a  thin  layer  of  tissue.  At  other  points 
the  cyst-wall  is  traversed  l>y  thin  septa,  dividing  it  into 
irregular  depressions.  In  a  general  way  the  color  is  pinkish 
with  areas  of  what  appears  to  lie  hemorrhage,  some  of  which 
are  purpli-h.  At  some  points  the  wall  is  fibrous  and  very 
dense,  in  other  areas  it  is  soft  and  yielding.     Weight  17  gms. 


Fluid  contents  of  the  cyst :  The  quantity  is  insuffi- 
cient to  determine  the  specific  gravity.  The  cells  vary 
in  size  and  contour  in  the  size  of  the  nucleus  and  in  the 
quantity  of  perinuclear  protoplasm.  The  best  picture 
of  these  cells  is  obtained  in  spreads,  dried,  fixed  Vjy  heat, 
and  stained  in  hematoxylin  and  eosin,  toluidin-blue 
and  eosin,  and  Unna's  polychrome  raethylene-blue. 

1.  The  most  abundant  cell  observed  in  such  prepara- 
tions is  of  relatively  large  structure,  varying  in  size 
from  12  or  15  /i  to  35  or  40  p..  In  shape  these  cells  are 
irregularly  oval,  a  few  are  round  or  discoid,  while  by 
far  the  large  part  are  irregularlj'  polyhedral.  The  ma- 
jority of  these  cells  are  mononuclear ;  occasionally,  a 
cell  is  to  be  found  containing  two  nuclei,  and  in  very 
rare  instances  three  distinct  nuclei  can  be  recognizei 
Some  of  the  nuclei,  indeed  one  may  say  the  majority, 
are  in  a  fair  state  of  preservation.  Nuclear  fragmenta- 
tion. Assuring,  vacuolization  and  polychrome  reactions 
are  recognized.  In  some  of  the  cells  a  distinct  nuclear 
structure  is  no  longer  to  be  recognized.  In  others  the 
nuclear  remains  are  but  faintly  tinted,  constituting  ir- 
regular shadows  in  the  cellular  protoplasm,  while  in 
still  others  the  chromatin  is  fragmented  into  irregularly 
outlined  granules  which  stain  unevenly.  In  many  of 
the  cells  the  nuclear  margins  are  indistinct.  The  peri- 
nuclear protoplasm  is,  for  the  most  part,  finely  granu- 
lar, and  takes  the  acid  stain  with  varying  degrees  of 
intensity.  Its  volume  varies  within  wide  limits  :  the 
diff'erentsized  cells  owe  their  differences  in  size  to  va- 
riations in  the  quantity  of  protoplasm  rather  than  to 
any  variation  in  size  of  the  nucleus,  which  is  rather 
uniform.  There  are  apparently  free  nuclei  which  prob-  j 
ably  belong  to  these  cells  as  indicated  by  the  irregular,  I 
ragged  rim  of  protoplasm  which  stains  unevenly  and 
often  but  slightly.  The  protoplasm  is  vacuolated  in 
many  of  the  cells,  the  vacuoles  varying  in  size  from  1 

or  2 ,"  to  7  or  8  /j.  In  some  of  the  cells  of  this  group, 
the  margin  is  fairly  regular  and  clearly  define<L  In 
others,  the  margin  is  ragged  but  sharply  outlined,  while 
in  still  others  the  protoplasm  fades  off',  and  is  gradually 
lost  without  any  sharply  outlined  limit. 

2.  An  occasional  finely  granular  oxyphile  leukocyte 
can  be  recognized,  although  the  number  of  such  cells  is 
remarkably  small. 

3.  Occasionally  one  finds  a  cell  morphologically  and 
tinctorially  like  a  mononuclear  leukocyte.  These  cells, 
however,  are  not  abundant.  There  are  a  few  masses  of 
cells,  in  which  distinct  differentiation  cannot  be  made 
out,  and  within  these  might  be  included  other  cells  than 
those  described.     A  few  erythrocytes  are  present 

A  count  of  a  thousand  cells  in  sprsiids  made  from 
the  fluid  gives  the  following  result  in  percentages  : 

L  The  large  cells  resembling  the  squamous  epithelial 
cells  described  above,  93.7  9<j- 

2.  Finely  granular  oxyphile  leukocytes  (polymorpho- 
nuclear leukocytes),  l.Sfo- 

3.  Erythrocytes,  .5%. 

4.  Uninuclear  leukocytes  and  unidentified  cells,  4%. 
Portions  of  the  cyst  wall  at  various  points  were  fixed 

in  Heidenhain's  solution,  infiltrated  with  paraffin,  sec- 
tioned, and  sections  stained  with  carnialuiu  alone  and 
with  picric  acid,  hematoxylin  alone  and  with  et^in, 
Unna's  acia  orcein.  Unna's  polychrome  methylene-blue, 
toluidin-blue  alone  and  with  eosin,  toluidin  blue  with 
diff'erentiation  in  styron  and  glycerm-ether.  and  by 
Gram's  method,  and  for  tubercle  bacilli  with  carbol- 
fuchsin. 

For  convenience  in  description,  and  for  the  sake  of 


JaHUART  26,   1901] 


BRANCHIAL  CYSTS  AND  FISTULAE 


["TUK  PULLADELPHIA 

L  Medical  Journal 


181 


brevity,  the  sections   from  the  following  areas  will  be 
considered  : 

A.  Sections  from  the  thin  part  of  the  wall.  B.  Sec- 
tions from  the  thicker  areas. 

A.  The  best  sections  from  this  part  of  the  wall  are  in 
the  neighborhood  of  areas  where  the  thin  wall  is  sud- 
denly or  gradually  converted  into  a  thick  wall  by 
changes  which  will  be  mentioned  later. 

The  inner  aspect  of  the  wall  is  lined  by  large  poly- 
gonal cells,  evidently  epithelial.  Toward  the  free  mar- 
gin the  cell  outlines  are  not  distinct,  the  nuclear  stain 
is  not  strong,  and  vacuoles  are  abundant  in  the  peri- 
nuclear protoplasm,  which,  under  a  very  high  power, 
is  slightly  granular;  although  it  is  impossible  to  give 
accurately  the  thickness  of  this  layer  (which  varies)  as 
it  merges  gradually  with  the  cells  below,  it  may  be 
stated  that  it  approximates  two  or  three  of  the  cell- 
layers.  Just  under  this  layer  the  irregular  polygonal 
cells  become  more  sharply  defined  both  in  outline  and 
stain  reaction.  Toward  the  upper  layer  already  de- 
scribed, the  nuclei  are  less  distinct,  becoming  more  and 
more  clearly  defined,  and  stained  with  greater  intensity 
as  we  approach  the  subepithelial  layer.  The  germinal 
or  basement  layer  of  epithelium  is  irregularly  columnar, 
with  deeply  stained  nuclei,  in  some  of  which  changes 
suggestive  of  karyokinesis  are  to  be  recognized.  From 
this  layer  passing  upward  can  be  recognized  the  gradual 
transition  from  the  irregularly  columnar  form  to  the 
more  or  less  flattened,  irregular,  and  poorly  stained 
cells  already  described  as  present  upon  the  free  surface. 

As  indicated  by  the  above  description  the  epithelium 
of  the  wall  cannot  be  divided  into  distinct  layers,  al- 
though there  is  the  suggestion  of  a  stratum  corneum  and 
stratum  Malpighii.  A  distinct  muscularis  cannot  be 
recognized  in  sections  stained  in  the  usual  nuclear  dyes, 
although  here  and  there  a  few  long  spindle-shaped  cells 
with  rodlike  nuclei  are  to  be  recognized.  In  sections 
stained  in  acid  orcein  a  delicate  basement  membrane 
can  be  recognized  at  nearly  all  points ;  this  structure 
sends  trabeculae  downward  in  many  areas,  penetrating 
the  lymphoid  tissue  below.  While  the  stratum  germin- 
ativum  is  slightly  irregular  one  cannot  say  that  there  is 
anything  more  than  a  mere  suggestion  of  papillae. 
Immediately  under  the  epithelial  layer  described  one 
finds  nearly  the  whole  length  of  the  section  a  slightly 
irregular  layer  of  lymphoid  tissue.  The  reticulum 
varies  in  quantity,  being  at  some  points  rather  abun- 
dant and  at  other  areas  scanty.  It  is  not  rich  in  blood- 
vessels, particularly  toward  the  ej^ithelial  surface;  as 
we  approach  the  outer  limits  more  vessels  are  to  be 
recognized.  The  cells  occupying  the  reticular  spaces 
correspond  for  the  most  part  with  the  usual  type  of 
lymphoid  cell,  and  scarcely  merit  further  description. 
.\  few  finely  granular  oxyphile  leukocytes  are  present, 
although  there  is  certainly  no  excess  of  these  elements. 
At  points  the  outer  wall,  or  I  might  better  say  outer 
limit  of  the  wall,  is  formed  by  lymphoid  tissue.  In 
other  areas  it  is  formed  by  masses  of  fibrillated  connec- 
tive tissue  comparatively  rich  in  bloodvessels  and  con- 
taining a  few  unstriped  muscle- fibers.  The  rough- 
ened and  irregular  free  margin  at  this  point  is,  of  course, 
due  to  its  dissection  from  adjacent  tissue.  I  have  not 
been  able  to  demonstrate  the  presence  of  striped  mus- 
cle-fibers in  this  area. 

B.  Sections  from  Thicker  Areas  in  the  Wall. — As  the 
increased  thickness  of  the  wall  in  different  areas  is  due 
to  different  causes  it  would  be  necessary  to  consider 
these  areas  separately. 


1.  Areas  in  which  the  thickening  is  due  to  a  thicker 
wall  of  lymphoid  tissue.  The  epithelial  covering  in 
these  areas  deserves  no  special  description,  as  it  varies 
little  if  at  all  from  the  epithelial  layer  seen  in  the  thin- 
ner wall.  Partly  as  a  result  of  its  increased  thickening 
and  possibly  from  other  causes,  the  cellular  elements 
usually  present  on  the  mucous  surface  can  be  more 
readily  recognized,  although,  as  is  usual  under  such  cir- 
cumstances, difl'erentiation  into  layers  is  not  clear. 
Cross  sections  of  flattened  cells,  such  as  those  already 
described  as  present  in  the  fluid  contents  of  the  cyst, 
with  flattening,  or  slight  elongation  of  their  nuclei,  are 
to  be  recognized.  There  is  the  same  gradual  transition 
from  the  irregularly  columnar  germinal  layer  to  the 
flattened  surface  layer  already  described.  In  some  of 
the  thicker  areas  the  lymphoid  tissue  is  more  abundant 
and  the  reticulum  scanty.  In  other  areas  the  reticulum 
is  more  abundant,  with  a  suggestion  of  proliferative 
change  and  corresponding  reduction  in  the  richness  of 
lymphoid  cells.  Distinct  arrangement  of  cells  such  as 
compose  adenoid  follicles  of  a  lymphatic  gland  can  be 
recognized,  and  occasionallj^  there  is  a  'suggestion  of 
medullary  cords,  although  demonstration  of  these  struc- 
tures is  not  complete.  External  to  the  lymphoid  areas 
just  described  there  is  the  same  area  of  fibrillated  tissue 
containing  a  few  long,  spindle-shaped  cells  with  rodlike 
nuclei.  A  furtherstudy  of  these  lymphoid  masses  reveals 
the  presence  of  necrotic  spots.  Such  points  embrace  only 
a  few  cells.  Just  beneath  the  germinal  layer  in  some 
of  the  sections  there  is  a  lymphoid  infiltration  of  the 
connective  tissue  not  associated,  however,  with  the  pres- 
ence of  finely  granular  oxyphile  leukocytes.  These 
bodies  are  not  abundant  at  any  point  in  the  section. 

2.  Areas  in  which  the  increased  thickening  of  the 
wall  is  due  to  the  presence  of  cysts.  The  epithelial 
covering  in  these  areas  merits  no  further  consideration 
than  that  already  given.  Only  one  of  these  cysts  will 
be  described.  In  designating  this  distinctly  as  an  addi- 
tional cyst,  the  possibility  of  its  communicating  at 
some  points  with  the  larger  cysts  cannot  be  overlooked, 
although  such  communication  cannot  be  demonstrated 
even  in  serial  sections.  The  wall  of  this  cyst  is  formed 
by  an  inner  zone  of  squamous  epithelium  which  has 
been  detached  or  has  disappeared  from  some  areas.  It 
shows  the  same  general  appearance  as  that  already 
given  for  the  epithelial  lining  of  the  larger  cyst.  At 
one  point  the  two  cavities  are  separated  by  a  thin  wall 
less  than  1  mm.  in  thickness  composed  of  two  epithelial 
surfaces  between  which  is  a  small  quantity  of  fibrillated 
tissue  rich  at  points  in  lymphoid  cells. 

Macroscopically  on  section  this  cyst  possesses  a  diam- 
eter of  .3  cm.  and  corresponds  with  what  was  men- 
tioned in  the  gross  description  as  a  distinctly  yellowish 
mass  measuring  .7  by  .5  cm.  The  difference  between 
the  diameter  in  the  gross  specimen  and  the  section  is 
probably  to  be  attributed  to  shrinking  and  the  removal 
of  fluid  from  the  interior  of  the  cyst  or  to  the  section 
not  passing  through  the  greatest  diameter.  The  cyst 
contents  as  examined  in  the  fixed  and  infiltrated  prep- 
aration are  usuallj-^  composed  of  fine,  intensely  acido- 
philic granules  resembling  in  many  respects  the  detritus 
in  caseous  areas.  That  it  is  not  caseous  in  the  true  sense 
is  shown  by  the  fact  that  it  contains  large  squamous 
epithelial  cells  such  as  have  been  identified  in  the 
fluid  from  the  larger  cyst.  Most  of  these  cells  have 
lost  their  characteristic  stain  reaction,  selecting  only  the 
acid  dye  and  therefore  possessing  indistinct,  irregularly 
defined  nuclei  and  cell  outlines. 


182 


The  Philadelphia 
Medical  Journal 


] 


RAPID  ELIMINATION  OF  THE  GONOCOCCUS 


(Jaituabt  26,  1901 


The  contents  as  here  studied  must  be  considered  to 
be  the  product  of  degenerative  changes  in  the  epithe- 
lium which  has  been  cast  off'  into  the  cyst  cavity. 
Three  smaller  cysts  identical  in  all  their  essentials  with 
that  just  described  have  been  found,  and  it  is  reason- 
able to  infer  that  the  many  small  whitish  or  greyish, 
translucent  elevations  mentioned  in  the  gross  descrip- 
tion were  probably,  or  at  least  some  of  them,  cysts 
resembling  the  one  just  described. 

3.  Sections  from  other  areas  in  the  cyst  wall  show 
evidences  of  chronic  inflammation  manifested  by  a 
lymphoid  and  plasma  cell  infiltration  with  the  produc- 
tion of  fibroblasts,  and  in  some  areas  cicatricial  tissue. 
At  a  few  points  the  mucosa  shows  distinct  papillae. 
They  are,  however,  not  abundant.  Occasionally  there 
is  a  distinct  fold  resembling  the  irregularities  or  rugae 
observed  in  mucos;  e  surrounding  cavities  whose  walls 
possess  considerable  distensibility.  Transverse  section 
of  the  overhanging  rugae  gives  the  appearance,  at 
times,  of  i^uperficial  gland-like  projections.  Serial 
sections,  however,  show  clearly  that  these  are  folds.  In 
other  areas  distinct  glands  are  demonstrable  and  it  is 
evident  that  the  cysts  already  described  have  resulted 
from  distention  of  gland  acini,  or  ducts,  or  both. 

Bacta-iology. — Cultures  were  not  obtained  from  the 
cyst  contents.  Spreads  and  sections  show  the  presence 
of  a  few  cocci  in  the  cyst  contents  and  in  the  wall ; 
these  cocci  stain  bj'  Gram's  method,  are  aj)parently 
staphylococci,  few  in  number,  and  the  absence  of  cellular 
infiltration  as  well  as  the  scant  necrosis  would  indicate 
that  the  infection,  if  such  existed  at  the  time  of  extir- 
pation, is  inconsequential. 

Diagnosis  and  Eemarks. — There  can  be  no  doubt  of 
the  branchial  origin  of  this  cyst.  The  character  of  the 
epithelial  covering,  its  arrangement,  the  morphology  of 
its  cells,  the  structure  of  the  submucosa,  the  presence 
of  cysts  in  the  wall,  the  abundant  lymphoid  tissue  and 
the  cyst  contents  all  point  to  the  branchial  origin.  From 
a  jiractical  view  the  character  of  the  cells  found  in  the 
fluid  contained  within  the  cyst  offers  important  diag- 
nostic aid.  The  small  number  of  leukocytes  of  the 
type  usually  found  in  pus  and  the  presence  of  large 
mononuclear  cells  rich  in  perinuclear  protoplasm,  and 
the  absence  of  necrotic  material  should  be  in  the  future 
of  value  in  diagnosis.  In  cysts  of  endothelial  origin, 
similarly  located,  it  is  not  likely  that  exfoliated  cells 
would  ever  present  the  morphologic  and  tinctorial 
characters  recognized  in  the  case  reported.  Endothelial 
cysts  possessing  richly  cellular  lluid  contents  would,  no 
doubt,  owe  their  cellular  elements  to  the  presence  of 
migrated  leukocytes  and  exfoliated  endothelium,  in 
which  case  no  such  a  cell  count  as  that  reported  would 
be  found.  It  would  therefore  appear  to  the  writer  that 
an  examination  of  the  fluid  that  came  from  such  a  cyst, 
taken  in  consideration  with  its  location  and  clinical 
history  should  make  the  diagnosis  less  difficult  than  it 
at  first  appears. 

With  regard  to  the  treatment  little  need  be  said  ; 
total  ablation,  where  possible,  is  the  only  commendable 
plan.  Pockets  that  cannot  be  excised  may  be  cauter- 
ized. Poncet"  used  chlorid  of  zinc  but  does  not  give 
the  strength  of  the  solution  used ;  tincture  of  iodin, 
carbolic  acid  or  the  actual  cautery  may  be  used.  All 
surgeons  are  agreed  that  the  use  of  irritants  and  escha- 
rotics,  either  by  injection  or  application  with  a  swab,  is 
untrustworthy. 

BIBLIOGRAPHY. 

>UeusiDger:  Ank./.  path,  Anat.  it  P>t(/siol.,  etc,  Berlin,  1865,  i  ?.,  ii,  pp. 
858-S80. 


-  Fischer;  D'uischt  ZtiUch./ur  Chir.,  Hi  ii.     (Quoted  by  Suttoo.j 

^  De  fistuiis  trachege  coDgenilis,  Halse,  18'^. 

<  De  fistulis  coli,  1832. 

5  CiiPEet :  Qon,iT^i  Fran^ais  de  Chirurgie,  2d  session,  Paris  1886,  p.  553  (Chron- 
ologic record  of  reported  case«,  1877  to  1886.) 

fi  GtlzojaD  :   Th^st  de  Paris,  1886. 

'Sutton;  Tumors,  Innocent  and  Malignant,  Pfailadelpbla,  1893. 

8  Senn  ;  Pathology  and  Surgical  Treaiment  of  Tumors,  Philadelphia,  1900. 

s  Philadelphia  Medical  Jocrnal.  vol.  7,  So.  1.,  Januarys,  1901. 
1"  Fevrier  ;  Socifle  de  Ctiintrgic,  1892. 
"  BrUish  ihdical  Journal,  lebrujiry  26, 1898. 
'2  Congr^s  Fran^ai.^  de  Chirurgie,  2<1  session,  Paris,  1886. 
^'Arch.f.palh.  Anal.,  etc  ,  Berlin,  1884,  icviii,  p.  !l4S-3S8. 
"ArcK./.palh.  Anal  ,  etc.  Bd.,  Iixii,  p.  444. 
^^  Bull,  de  la  Socielf  dr  Chirutgv;  22  juillet,  1885. 
^^  Amer.  Jour,  of  the  Med.  Sci.,  new  seriefi,  vol.  Ixxviii,  p.  70. 
'^  Jour,  of  .tnal.  and  Physiol.,  Tol.  ix,  p.  134. 


METHOD  FOR  RAPID  ELIMINATION  OF  THE  GONO- 
COCCUS.* 

By  FOLLES  CABOT,  Jb.,  M.D., 
of  New  York. 

In  the  treatment  of  acute  anterior  gonorrhea  we  should 
devote  our  efiforts  to  the  avoidance  of  complications  and 
to  the  rapid  elimination  of  the  gonococcus,  aiming  in 
this  way  to  shorten  the  course  of  the  disease.  Much 
has  been  done  and  written  upon  the  various  methods 
of  treatment  of  acute  anterior  urethritis  with  the  object 
of  shortening  the  course  of  the  disease.  Nearly  all  the 
methods,  however,  which  have  been  employed  have 
either  entirely  overlooked  the  first  condition  I  have 
mentioned — and  directly  or  indirectly  produced  com- 
plications by  a  too  violent  form  of  treatment — or  else 
by  the  use  of  too  weak  solutions  or  a  faulty  technic  have 
failed  to  overcome  the  resistance  of  this  very  obstinate 
microorganism. 

In  this  paper  I  shall  refer  entirely  to  the  treatment 
of  gonorrhea  in  its  incipient  stage ;  that  is  to  say,  within 
24  to  36  hours  from  the  time  any  moisture  has  appeared 
at  the  meatus. 

In  a  series  of  30  cases  in  which  this  treatment  was 
carried  out,  |  of  the  patients  recovered  after  S  to  10 
days  ;  in  the  remaining  |^  no  complications  ensued,  but 
the  treatment  did  not  markedly  shorten  the  course  of 
the  disease.  Before  describing  the  method  which  I  have 
used  successfully  I  will  refer  to  some  of  the  other  meth- 
ods of  treatment  of  acute  anterior  gonorrhea.  By  one 
method,  at  the  earliest  sign  of  discharge  or  local  manifes- 
tation, the  front  urethra  is  washed  out  with  a  10  :  15,000 
volume  peroxid  solution,  and  then,  Viy  the  aid  of  an 
endoscope  or  frame  speculum,  the  anterior  urethra  for 
fully  an  inch  beyond  the  diseased  area  is  wiped  out 
with  a  silver-nitrate  solution — 5  to  10% — applied  on  a 
cotton  swab  ;  this  procedure  to  be  repeated,  if  necessary, 
in  48  hours.  In  some  cases  this  treatment  has  been 
successful,  but  occasionally  the  reaction  following  the 
use  of  strongly  irritating  solutions  and  manipulation  in 
making  the  applications  led  to  complications;  while  in 
others,  the  course  of  the  disease  was  much  ag-gravated 
and  prolonged.  In  other  words,  the  treatment  was 
much  too  violent  for  the  sensitive  mucous  membrane 
of  the  urethra.  This  method  of  treatment  I  believe  has 
been,  at  the  present  time,  largely  discarded. 

The  advocates  of  irrigating  the  front  urethra  in  the 
early  stage  of  gonorrhea  claim  that  much  can  be  accom- 
plished by  large  volumes  of  hot  medicated  solutions. 
One  method  of  using  these  solutions  is  the  so-called 
Janet  method  ;  that  is,  washing  out  the  whole  urethra 
and  bladder  by  overcoming  the  resistance  of  the  shut- 
ofl'  muscle.  This  method  I  believe  to  be  too  energetic 
in  the  acute  stiige,  and  when  the  front  urethra  is  alone  in- 

•  R<-ad  before  the  Harvard  Medical  Society,  November  S4, 1900, 


JaKCABT  26,  19011 


RAPID  ELIMINATION  OF  THE  GONOCOCCUS 


[Thb  Philadeiphia 
L  Medical  Jocrnai. 


183 


volved,  unnecessarily  thorough ;  if  we  had  to  deal  with 
an  urethral  tract  alone  it  might  do,  but  considering 
that  the  genital  organs  are  intimately  connected  with 
the  urethra  this  treatment  is  liable  to  produce  compli- 
cations and  is,  therefore,  in  my  opinion  in  acute  gon- 
orrhea unsatisfactory  and  dangerous. 

Another  method  of  irrigating  the  front  urethra  is  by 
the  double-flow  nozzle  introduced  at  the  meatus  and 
attached  to  a  fountain  syringe.  This  has  been  used  to 
a  considerable  extent,  the  outlet  opening  being  larger 
than  the  inlet  to  avoid  any  overdistention  of  the 
urethra.  It  has  been  demonstrated,  however,  that  the 
urethra,  after  being  filled  with  the  solution  in  this 
manner,  simply  remains  distended,  the  fluid  entering 
from  the  nozzle  immediately  flowing  out  without  produc- 
ing any  general  change  in  the  body  of  the  fluid  within 
the  urethra.  This  method  is  little  better  in  my  opinion 
than  the  time-honored  one  of  filling  the  urethra  with  a 
solution  from  a  hand-syringe,  allowing  it  to  remain  in 
contact  with  the  urethral  membrane  a  few  minutes  and 
then  repeating  the  operation. 

Still  another  method  by  which  irrigation  has  been 
used  is  by  the  aid  of  a  soft  rubber  catheter  passed  a 
few  inches  into  the  urethra  and  the  fluid  from  a  foun- 
tain-syringe allowed  to  flow  back  over  the  canal  from 
the  eye  of  the  catheter.  In  this  way  the  whole  urethra 
is  bathed  by  a  continuous  flow  of  the  solution.  I 
believe  this  to  be  the  best  of  the  three  methods  just 
described  for  washing  out  the  anterior  urethra.  If  not  in- 
troduced too  far  and  carefully  used  it  is  devoid  of  danger. 
I  believe,  however,  that  one  objection  to  these  methods 
is  that  some  of  the  secretion  remains  in  contact  with 
the  urethra,  thus  preventing  the  solution  coming  in 
contact  with  the  underlying  gonococci.  We  must,  of 
course,  reach  these  deep  microorganisms  in  order  to  pre- 
yent  their  growth. 

The  method  I  have  used,  and  shall  now  describe,  is 
a  compromise  between  the  endoscope  and  silver  nitrate 
abortive  treatment  and  plain  irrigation.  During  the 
past  4  years  I  have  used  several  preparations  of  the 
silver  salts  which  I  have  tound  to  be  much  more  satis- 
factory and  less  irritating  than  silver  nitrate ;  in  fact,  I 
believe  some  of  them  to  be  of  much  more  value  than 
other  antiseptics  in  the  treatment  of  the  earliest  stage 
of  gonorrhea.  I  have  used  argonin,  protargol,  and 
largin.  Argonin  has  been  the  one  chiefly  employed 
by  me.  In  order  to  test  the  comparative  antiseptic 
powers  of  argonin  and  protargol  I  tested  these  salts 
with  pure  cultures  of  the  streptococcus  and  Klebs- 
Lofller  bacillus,  the  results  of  which  tests  are  given  in 
the  following  tables : 

STREPTOCOCCUS. 

Argonin  .  .  .    1  ^  solution ;  10  minutes  exposure;  growth  in  2-4  hours. 

"        .  ,  .   5jfc       "  10       "  '*  DO  growth  io  24  hours. 

Protargol  ..14"  10       "  "  growth  in  24  hours. 

'*        .  .  .    5j(       '*  10       "  '*  no  growth  in  24  hours. 

DIPHTHERIA  BACILLUS. 

Argonin  .  .  .    I  )t  solution  ;  10  minutes  exposure ;  no  growth  in  24  hours. 
Protargol   .  .    If       "  10       "  "  no  growth  in  24  hours. 

It  will  be  seen  from  this  table  that  argonin  and  pro- 
targol seem  to  have  about  the  same  antiseptic  eflect.  I 
also  made  some  tests  with  argentamin  and  other  silver 
salts,  but  my  results  are  insuflicient  for  tabulation.  I 
did  not  test  the  eifect  of  argonin  and  protargol  with 
the  gonococcus  in  my  bacteriologic  experiments  be- 
cause I  believe  the  gonococcus,  which  grows  with  diffi- 
culty in  artificial  media,  to  be  much  more  easily 
destroyed  than  when  in  the  human  body.     Such  ex- 


periments have  been  made,  but  I  am  of  the  opinion 
that  {hey  are  not  of  much  value.  None  of  the  animals 
available  for  bacteriologic  work  can  be  infected  with 
the  gonococcus.  This  statement  is  borne  out  by  the 
majority  of  well-known  investigators.  There  have  been 
a  few  isolated  instances  where  a  gonorrheal  infection  of 
animals  has  been  reported,  as  Fingers  case  of  gonor- 
rheal involvement  of  the  knee-joint  of  a  dog,  and  a  few 
cases  of  peritoneal  infection  in  mice.  We  must,  how- 
ever, accept  the  fact  that  animals  are  of  no  practical 
value  in  bacteriologic  experiments  with  the  gonococcus, 
so  that  artificial  media  and  animals  are  of  little  aid  in 
testing  the  effect  of  drugs  on  this  microorganism.  We 
must,  therefore,  draw  our  conclusions  from  the  tests  of 
various  drugs  on  this  microorganism  in  the  human 
being.  I  have  had  much  less  experience  with  protargol, 
which  contains  8.2%  of  silver,  than  with  argonin, 
which  contains  4.2%  ;  silver  nitrate,  containing  6.3-5%, 
occupies  a  middle  position  between  the  two  first-named 
preparations  in  its  proportion  of  the  basic  salt.  Both 
argonin  and  protargol  are  freely  soluble  in  water. 
Argonin  should  be  freshly  prepared  for  each  treatment. 
Protargol  keeps  better  in  solution  than  argonin.  I  have 
found  argonin  to  be  nonirritating. 

I  shall  give  the  results  obtained  by  the  use  of  argonin 
within  12  or  36  hours  after  the  first  signs  of  local  dis- 
turbance, as  shown  by  slight  moisture  at  the  meatus, 
feeling  of  warmth  in  the  end  of  the  penis  and  slight 
burning  on  urination.  Used  later — that  is.  after  the 
gonococci  have  buried  themselves  deeply  in  the  mucous 
membrane  of  the  urethra — the  treatment  I  advise  would 
be  of  little  advantage.  The  case  must  be  one  of  acute 
anterior  urethritis  with  no  old,  deep  trouble.  This 
condition  must  be  determined  by  an  examination  of 
the  urine  and  of  the  rectum  as  well  as  by  careful 
consideration  of  the  past  and  present  history  of  the 
patient. 

I  first  take  a  specimen  of  the  discharge  for  micro- 
scopic examination,  then  the  patient  passes  urine,  after 
which  the  urethra  is  washed  out  with  hot  water ;  I 
then,  twice  a  day,  introduce  a  10%  solution  of  argonin 
freshly  made ;  this  is  introduced  by  a  Ultzman's  deep 
injection  syringe  or,  better  still,  by  a  rubber  bulb 
holding  about  6  drams.  This  bulb  should  have  a 
rubber  tip  about  2  inches  long;  the  bulbs  are  sold 
under  the  name  of  ulcer  syringes.  The  solution  is 
introduced  hot  and  is  kept  in  the  front  urethra  by 
pressing  the  lips  of  the  meatus  together  as  the  point  of 
the  bulb  is  withdrawn.  Then  I  make  an  application 
with  an  applicator  tightly  wrapped  with  absorbent 
cotton,  of  10%  argonin  solution,  introduced  into  the 
urethra  while  the  solution  previously  introduced  is 
allowed  to  gradually  flow  out.  It  is  much  easier  to 
introduce  the  applicator  while  there  is  some  fluid  in 
the  urethra.  The  cotton  swab  should  be  applied  gently 
to  all  parts  of  the  anterior  urethra  for  two  2  or  3  inches 
and  then  withdrawn.  The  solution  remaining  in  the 
urethra  is  then  allowed  to  escape  and  the  operation  is 
repeated,  not  using  the  applicator  if  the  patient  com- 
plains of  much  pain.  In  some  cases  a  gentle  kneading 
of  the  urethra  while  the  solution  is  in  place  is  of 
advantage. 

I  do  not  believe  in  using  cocain,as  a  rule,  to  deaden 
the  pain,  because  it  interferes  with  our  power  of  gaug- 
ing the  patient's  condition  by  his  natural  sensations. 
Everything  must  be  done  very  gently  and  slowly.  The 
solution  must  be  kept  in  5  or  10  minutes.  The  first 
two  or  three  treatments  will  usually  show  what  the 


184 


Thb  Phii^dslpbia"! 
Medical  Jouknai.  J 


A  CAUSE  OF  SHORTENING  AFTER  COXITIS 


(Jasl-abt  2S,  IMl 


case  is  going  to  do ;  if  all  is  going  well,  the  disease 
instead  of  progressing  in  the  usual  manner  remains 
stationary  for  2  or  3  days  and  gradually  subsides. 
This  treatment  should  be  given  by  the  physician 
himself.  Internally,  citrate  of  potash  may  be  given  to 
render  the  urine  bland.  The  patient  is  directed  to 
soak  the  penis  in  hot  water  three  times  daily ;  the 
general  condition  of  his  health,  the  use  of  alcohol,  etc., 
regulated.  The  patient  should  be  kept  as  quiet  as 
possible. 

If  the  progress  is  favorable  the  strength  of  the  solu- 
tion is  gradually  increased  and  may  be  used  as  strong 
as  30%.  In  addition,  at  the  end  of  two  or  three  days, 
if  everything  is  going  favorably,  I  advise  the  patient  to 
use  an  astringent  injection  composed  of  lead  acetate, 
tannic  acid,  zinc  sulfate,  copper  sulfate,  of  each  2  grains, 
in  tablets.  One  of  these  tablets  is  placed  in  4  to  8 
ounces  of  water  and  used  by  the  patient  after  each 
urination.  Of  course  this  is  in  addition  to  the  argonin 
applications. 

The  personal  equation  comes  into  this  treatment  as 
into  many  others ;  on  this  account  dispensary  patients 
have  not  been  as  satisfactory  as  private  cases.  I  ex- 
amine for  the  gonococcus  every  other  day.  I  expect, 
in  satisfactory  cases,  to  see  improvement  in  three  to  four 
days ;  disappearance  of  the  gonococcus  on  the  sixth  to 
seventh  day,  and  disappearance  of  the  discharge  on  the 
eighth  to  tenth  day.  The  treatment  should  be  con- 
tinued for  a  week  after  the  gonococci  and  discharge 
have  disappeared.  Of  course  the  strength  of  the  solu- 
tion and  the  amount  of  treatment  have  to  be  changed 
with  tlie  condition  of  the  patient.  I  will  here  give  the 
result  of  the  treatment  in  a  case  which  is  typical  of 
several  others  in  which  I  used  this  method. 

Case  1.— Referred  to  me  by  the  courtesy  of  Dr.  Duel. 
July  26,  H.  W.  C  ,  aged  32  years,  complains  of  discharge  of 
one  day,  no  other  symptom,s  except  slight  burning  at  the 
meatus.  Had  clap  a  year  ago,  which  recovered  after  2 
weeks.  Examination  shows  reddened  meatus,  first  urine 
cloudy,  second  perfectly  clear,  discharge  mucopurulent  aud 
fairly  abundant.  Deep  parts  by  rectal  examination  normal. 
Specimen  taken  for  examination.  Gonococci  found.  Ar- 
gonin tOff  solution  used  on  the  26th,  at  ni";ht;  27th  twice; 
28  h  twice ;  his  condition  remained  practically  the  same  No 
urgency  or  frequency  of  urination ;  slight  burning  of  the 
urethra  on  urination  ;  slight  pain  over  left  groin  not  increas- 
ing; general  condition  very  satisfactory.  July  28  introduced 
swab  soaked  in  argonin  solution  2  inches.  Some  slight 
erection  in  early  a.ji.  3(lth,  another  specimen  taken  for  ex- 
amination ;  gonococci  fewer ;  urine  shows  less  pus,  few  par- 
ticles from  front  urethra.  July  31st:  30%  solution.  Redden- 
ing and  discharge  much  less ;  burning  subsided ;  few  erec- 
tions now.  August  1st :  Discharge  very  thin,  no  gonococci  in 
specimen,  discharge  only  seen  on  pressure.  Discharge  dis- 
appeared on  the  2d  of  August ;  on  the  Sth  was  still  absent. 
Injection,  of  the  formula  given  above,  has  been  used  in  the 
last  few  days  in  addition  to  the  argonin  treatment.  On 
August  2d,  argonin  injections  reduced  to  one  a  day  which 
was  continued  up  to  the  8th  when  the  patient  was  discharged 
cured  and  ras  remained  well.  In  this  patient  it  will  be  seen 
that  there  was  no  discharge  after  the  seventh  day,  the  gono- 
cocci disappearing  at  theend  of  6  days.  The  patient'coni- 
plained  of  little  discomfort  on  the  application  of  the  swab 
with  argonin. 

In  conclusion  I  will  add — 

1.  That  this  method  of  treating  incipient  clap  I  be- 
lieve is  devoid  of  danger. 

2.  All  the  cases  which  have  been  satisfactory,  as  far 
as  traced,  have  shown  permanent  results,  there  being  no 
return  later  from  deep  lesions  produced  by  the  treat- 
ment, as  is  sometimes  seen  after  the  use  of  irrigation 
which  has  affected  the  genital  organs. 


3.  Solutions  must  be  freshly  prepared  each  time  and 
must  be  used  hot,  temperature  of  110-120°  F.  I 

4.  Unless  the  patient  is  prepared  to  give  himself  up    ■ 
completely  to  the  physician's  directions  in  all   particu- 
lars there  is  no  use  in  attempting  to  make  a  rapid  cure 
of  his  case  by  this  method. 


'I 


RETARDATION  OF  GROWTH  AS  A  CAUSE  OF  SHORT- 
ENING AFTER  COXITIS.* 

Bv  HEXRY  LING  TAYLOR,  M.D.. 
of  New  York. 

The  muscular  wasting,  so  constant  in  the  early  stage 
of  hip  disease,  appears  to  be  hastened  and  increased  by 
immobilization,  compression  and  suspension  of  the 
affected  limb.  After  months  or  years  of  pathological 
or  mechanical  interference  with  function  the  limb  is 
finally  much  shrunken,  not  only  in  its  muscular  ele- 
ments, but  in  all  its  tissues,  including  the  bones,  whose 
growth  has  not  kept  pace  with  that  of  the  well  limb 
either  in  extent  or  structure ;  they  are  finally  smaller, 
shorter,  and  more  brittle. 

While  the  wasted  muscles  always  seem  capable  of 
development  after  the  subsidence  of  inflammation, 
within  the  limits  imposed  byjoint-function,  one  cannot 
fail  to  be  struck  by  the  superficial  resemblance  between 
the  shrunken  appearance  and  bluish,  clammy,  surface 
of  many  of  these  bandaged  and  restricted  limbs,  and 
the  atrophied  limbs  following  infantile  paralysis.  This 
similarity  extends  in  a  remarkable  degree  to  the  retar- 
dation in  growth,  both  longitudinal  and  circumferential, 
of  the  long  bones  of  the  affected  member. 

My  attention  was  somewhat  forcibly  called  to  the 
importance  of  retarded  growth  after  coxitis  by  the  case 
of  a  boy  of  15,  who  returned  in  1891  after  several  years' 
absence ;  during  the  last  two  he  had  not  worn  any  ap- 
paratus and  had  remained  free  from  disease.  He  had 
grown  rapidly  and  was  in  excellent  health,  but  com- 
plained that  his  leg  had  grown  shorter.  On  me^isuring 
the  lower  limbs,  it  was  found  to  my  surprise  and  cha- 
grin that  the  shortening  had  increased  from  a  trifle 
over  1  in.  in  1887  to  4i  in.  four  years  later.  This  led  to 
separate  measurements  of  the  femurs  and  tibias,  which 
disclosed  a  shortening  of  2  in.  in  the  femur  and  of  If 
in.  in  the  tibia  of  the  affected  side.  The  remainder  of 
the  shortening  was  doubtless  due  to  upward  displace- 
ment of  the  femur,  but  here  was  over  2^  in.  loss  of 
growth  in  4  years. 

This  incident  made  a  deep  impression  and  led  to 
comparative  measurements  from  time  to  time  of  the 
long  bones  of  the  limbs  after  coxitis,  and  occasionally 
after  other  affections.  It  soon  became  evident  that  dif- 
ferences of  1  in.  in  the  length  of  the  tibia  and  of  i  in. 
or  more  in  the  foot  in  old  cases  of  coxitis  were  not  at 
all  uncommon.  Within  the  last  few  months  these  meas- 
urements have  been  repeated  in  a  series  of  cases  of  cox- 
itis, and  also  in  otlier  disabling  affections  of  one  limb, 
to  see  if  any  generalization  was  warranted.  Since  the 
principal  object  of  the  investigation  was  to  ascertain  the 
length  of  the  shaft  of  the  long  bones  on  the  two  sides, 
the  femur  was  measured  from  the  tip  of  tlie  trc>chanter 
to  the  knee  in  the  hip  cases,  to  eliminate  erosion,  dis- 
placement and  bending  of  the  neck,  which  do  not  di- 
rectly concern  this  study.     Measurements  of  the  length 

*  Brad  xt  the  meeting  of  the  American  Orthopedic  Awociation.  WaakiDgtea. 
Mar,  1900. 


JaNCABY  26,  1900] 


A  CAUSE  OF  SHORTENING  AFTER  COXITIS 


rTHB  Philadelphia 
Medical  Joukkal 


185 


of  the  tibia,  of  the  length  of  the  foot,  and  of  the  breadth 
of  the  patella  were  also  taken. 

The  results  in  37  cases  of  coxitis  may  be  seen  in  the 
table,  which  is  divided  into  3  sections  according  to  the 
duration  of  the  disease ;  the  approximate  averages  are 
given  for  each  group. 

The  results  may  be  briefly  summarized  as  follows : 
Femur. — In  23  cases  the  shaft  of  the  femur  of  the  af- 
fected side  was  from  J  to  2i  in.  shorter  than  that  of  the 
well  side.     In  9  cases  there  was  no  demonstrable  difl'er- 
ence,  and  in  1  case  the  femur  was  about  \  in.  longer. 


always  smaller  and  narrower ;  in  many  cases  its  bulk 
seemed  to  be  less  than  half  that  of  the  well  side. 
Twenty-six  cases  showed  a  difference  of  from  ^  to  ^  in. 
in  transverse  diameter,  usually  about  \  in.  In  one 
measured  case  only  was  no  diiference  found ;  this 
patient  had  walked  freely  and  had  never  worn  a 
brace. 

Foot. — In  31  cases  the  foot  was  from  ^  to  1  in.  shorter, 
and  often  distinctly  smaller  in  other  dimensions.  In 
5  cases  no  difference  in  length  was  noted. 

If  the  cases  are  divided  into  3  groups  according  to 


Shortening  in  Inches  after  Coxitis. 


Case,  i   Sex. 


4 

s 

6 
7 
8 
9 
10 
11 
12 
13 
14 


Average . 


15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 


Average  . 


ATeisge . 


87 


Age. 


F. 
M. 
M. 
M. 
M. 
F. 
F. 
F. 
M. 
F. 
F. 
M. 
F. 
F. 


3^ 

7 

5 

5 

6K 

9 

4K 

65l 

6 
13 

7 

7 
11 

9 


Disease. 


DDKATIOS — TEABS, 


Lame- 


Treatr 
meDt. 


M. 

M. 

F. 
F. 
F. 
F. 
F. 
F. 
M. 
F. 
H. 


7 
7 

S>^ 

12 
11 
13 
10 
10 
14 
15 
9% 


11J4 


L.  H. 
K.  H. 
L.  H. 
E.  H. 
L.H. 
L.  H. 
L.  H. 
R.H. 
R.H. 
L.  H. 
L.  H. 
K.  H. 
RH. 
L.  H. 


1^ 
2 

P 

3 
3 

S>l 
3H 
i% 
3K 


None. 
3% 


2K 


SHORTKNING. 


Limb. 


No. 
No. 
No. 
No. 
Yes. 
No. 
No. 
No. 
No. 
No. 
No. 
Yes. 
No. 
No. 


I 

k 
*y* 


i9s 
1 


Femur.       Tibia. 


I 


Fo<)t. 


an. 

R.H. 
R.H. 
R.H. 
R.H. 
L.  H. 
L.  H. 
KH. 
L.  H. 
R.H. 
E.H. 


4 

4 
4 
5 

6 

7 
7 
7 
7 


26 

F. 

27 

JL 

28 

M. 

29 

F. 

30 

M. 

31 

M. 

32 

F. 

33 

F. 

34 

F. 

35 

F. 

36 

'■ 

13 

15 

10>i 

18 

12 

18 

15 

15 

15 

16 

21 


R.H. 
RH. 
L.  H. 
R.H. 
L.  H. 
R.H. 
L.  H. 
R.  H. 
R.H. 
UH. 
L.  H. 


9 

9 

9 
10 
11 
11 
11 

115^ 

14 

17 


a 


7 
6 

1 
2 

le 

7 
5 

1    . 

6 


L.H. 


40 


37 


Yes. 
No. 
So. 
Yes. 
Yes. 
No. 
No. 
Yes. 
Yes. 
No. 


Tes. 
Tes. 
No. 
No. 
No. 
Yes. 
Yes. 
Yes. 
Yes. 
No. 
Yes. 


% 


1% 


2K 
4K 

i 

3 

1 
3 

6K 


i 


X 


K 


2 

4 

1 

2^ 


1 
1 

I 


^/s 


% 


m 


a 


i 

i 


% 


% 


% 


K 


FateUa. 


i 


I 


% 


g 


*  Left  femur  longer. 


Left  leg  longer,  coxa  valga? 

Scarlatioal. 

No  treatment,  always  walked  on  leg. 


Forcible  correction. 


Fracture,  forcible  correction. 


Left  off  brace  2%  years  ago  ;  relapse. 


Forcible  correction. 


No  treatment  last  6  years. 


May,  1899,  Gant's.    No  treatment  before. 
Caries  lumbar  spine.    Gant*s,  1S91. 


—  Denotes  that  the  measurements  on  the  two  sides  were  equaL 
Where  there  is  a  blank  in  the  table,  no  measurement  was  recorded. 


The  shaft  of  the  affected  femur  was  often  very  much 
thinner  to  palpation,  and  the  condyle  much  narrower 
and  smaller.     In  4  cases  the  femur  was  not  measured. 

Tibia. — In  35  cases  the  tibia  was  from  ^  to  2i  in. 
shorter  on  the  affected  side ;  in  2  cases  there  was  no 
difference.  In  20  cases  the  shortening  of  the  tibia  ex- 
ceeded that  of  the  femur ;  in  7  cases  the  two  were 
equal,  and  in  6  the  shortening  of  the  femur  was  the 
greater. 

Fibula. — In  a  number  of  cases  in  which  the  fibula 
was  measured,  it  showed  about  the  same  amount  of 
shortening  as  the  tibia. 

PaUUa. — The  patella  of  the  affected  side  was  nearly 


the  length  of  time  which  had  elapsed  from  the  begin- 
ning of  the  disease  to  the  date  of  the  last  measurement 
the  total  shortening,  as  well  as  the  shortening  of  the 
individual  long  bones,  and  of  the  foot,  and  the  narrow- 
ing of  the  patella  is  found  to  increase  progressively  with 
the  duration  of  the  lameness.  In  some  instances  cases 
of  long  standing,  which  have  had  but  little  mechanical 
treatment,  show  less  shortening,  though  there  might  be 
deformity  and  relapse,  than  cases  of  equal  duration 
where  mechanical  treatment  had  been  prolonged.  After 
forcible  correction  of  the  deformity  retardation  of 
growth  was  exaggerated,  though  the  cases  are  too  few 
to  generalize.     In  some  cases  retardation  was   much 


186 


The  Philadelphia"! 
Medical  Jooenal  J 


A  CAUSE  OF  SHORTENING  AFTER  COXITIS 


[jAjrUART  26,   19*1 


above  the  average  and  in  others  much  below,  from  un- 
known causes. 

Infantile  Paralysis. — In  the  third  group  of  hip  cases 
with  an  average  age  of  15  and  an  average  duration  of 
lameness  of  11  years,  the  average  bone  shortening  was 
slightly  under  |-  in.  in  the  femur  and  slightly  under 
1  in.  in  the  tibia,  or  about  IJ  in.  total.  This  group 
may  be  compared  with  a  group  of  10  cases  of  unilateral 
infantile  paralysis  with  an  average  age  of  13,  and  an 
average  duration  of  lameness  of  11  years,  where  the 
average  shortening  was  about  If  in.  and  in  no  case 
over  2i  in. 

While  the  condition  of  the  muscles  in  the  atrophied 
legs  after  poliomyelitis  is  pathologically  different,  the 
fact  that  the  longitudinal  growth  of  bones  seems  to  be 
no  more  retarded  after  paralysis  than  after  coxitis,  and 
that  in  both  the  affected  limb  is  used  very  imperfectly, 
if  at  all,  in  support  and  locomotion,  suggests  that  inter- 
ference with  the  normal  function  of  the  limb  may  be 
an  important  factor  in  the  retardation  of  skeletal 
growth.  This  inference  is  strengthened  by  the  con- 
sideration that  just  as  we  may  produce  a  partial  paresis 
of  the  circulation  by  bandaging  and  suspending  a  limb, 
so  we  may  cause  such  a  condition  to  disappear  in  cer- 
tain paralytic  cases  by  bringing  a  useless  limb  into 
action. 

Infantile  Hemiplegia. — Many  cases  of  infantile  hemi- 
plegia of  long  standing  show  a  certain  retardation  of 
growth  of  the  long  bones  of  the  affected  side,  though 
usually  less  than  in  poliomyelitis.  (It  is  to  be  noted 
that  the  leg  is  used  more  in  walking  than  in  infantile 
paralysis.) 

Congenital  Dislocation  of  the  Hip. — In  10  cases  of  uni- 
lateral congenital  dislocation  of  the  hip  from  4  to  13 
years  of  age  the  total  shortening  varied  from  ^  to  2^  in., 
but  the  femur  was  shorter  (^  in.)  in  only  one  case,  and 
the  tibia  (^  to  i  in.)  in  5.  The  foot  was  ^  to  f  in. 
shorter  in  the  older  cases,  and  the  patella  was  slightly 
narrower  in  6  cases.  Here  also  we  are  to  note  that  loco- 
motion is  constantly  practised. 

Hip  Excision. — One  case  of  excision  of  the  head  of 
the  femur,  at  2  years,  showed  no  difference  in  any  of 
the  bone  lengths  at  5  years,  though  there  was  upward 
displacement  of  1  in.  It  is  my  impression,  however, 
that  the  considerable  shortening  after  hip  excision  in 
children  will  be  found  to  be  partly  due  to  retarded 
growth,  after  as  well  as  before  the  operation.  After 
knee-excision  in  children  this  shortening  has  been 
shown  to  be  a  progressive  and  most  serious  factor, 
owing  as  has  been  supposed  to  interference  with  the 
epiphyses. 

Fracture  of  Neck  of  Femur  and  Coxa  Vara. — No  oppor- 
tunity for  measuring  cases  of  fractured  neck  of  the  femur 
in  children  has  recently  presented  itself  Dr.  Whitman 
reports  increasing  shortening,  which  he  attributes  to 
change  in  the  angle  of  the  neck.  It  is  possible  that 
these  cases  and  those  of  coxa  vara  occurring  in  the 
period  of  rapid  growth  may  show  some  retardation  on 
the  affected  side,  but  since  the  limb  gets  a  fair  amount 
of  use,  the  retardation,  as  in  the  congenital  hip  disloca- 
tions, would  probably  be  small  and  occasional  only. 

Osteitis  of  the  Knee. — Of  9  cases  measured,  aged  from 
3^  to  33,  G  had  a  duration  of  lameness  under  5  years. 
All  these  showed  lengthening  of  the  affected  limb, 
ranging  from  ^  to  ^  in.  The  3  older  cases  showed 
shortening  from  1  to  2^  in.  In  the  first  group  the 
femur  was  longer  in  4  from  ^  to  f  in.  The  tibia  was 
longer  in  2,  equal  in  2,  and  shorter  in  2.    In  the  second 


group  the  tibia  was  from  ^  to  2f  in.  shorter.  In  7 
cases  the  affected  foot  was  shorter  from  ^  to  IJ  in.,  and 
in  all,  the  affected  patella  was  from  ^  to  f  in.  narrower. 

Here  the  proximity  of  the  inflammation  to  the 
principal  epiphysis  for  growth  modifies  the  result. 
There  is  for  a  time  acceleration  of  growth  in  length 
near  the  focus,  but  this  goes  hand  in  hand  with  retarded 
growth  of  the  patella,  and  foot,  and  of  the  leg  bone,  un- 
affected by  the  irritation.  The  primary  acceleration  is 
followed  by  a  later  retardation  from  disuse,  which 
usually  more  than  counterbalances  it. 

Congenital  Defects  of  One  Loicer  Limb. — The  type  of 
congenital  defect  of  a  limb,  characterized  by  imperfectly 
developed  or  absent  long  bones,  especially  of  the  fibula, 
and  certain  bones  of  the  fibular  side  of  the  foot,  shows 
a  progressive  retardation  of  growth.  Here  the  tibia  or 
femur,  or  both,  may  be  the  fraction  of  an  inch  shorter 
in  early  infancy,  but  the  limb  is  little,  if  at  all  service- 
able for  locomotion,  and  falls  behind  its  mate  in  growth 
until  at  14  or  15  years  the  difference  often  amounts  to 
several  inches.  Cases  of  congenital  pes  equino-varus 
will  sometimes  show  considerable  differences  in  the 
length  of  the  limbs,  tibia,  and  foot,  and  breadth  of 
patella,  after  the  lapse  of  some  years. 

In  considering  these  results  it  should  be  remembered 
that  not  only  is  the  affected  limb  underdeveloped  in  all 
the  in.stances  given,  but  that  the  sound  limb  may  be 
overdeveloped,  since  it  does  far  more  than  half,  and 
often  more  than  the  normal  amount  of  work,  as  is 
plainly  evident  from  its  circumferences.  It  is  not  im- 
possible, though  difiBcult  to  prove,  that  not  only  is  the 
affected  limb  shorter  than  normal,  but  the  sound  limb 
may  be  longer  as  well  as  stouter  than  normal. 

If  so,  this  would  exaggerate  the  difference  between 
the  two  sides,  and  tend  to  make  one  overestimate  the 
amount  of  retardation. 

While  there  may  be  a  primary  neural  factor  in  certain 
classes  of  growth  retardation,  and  while  disuse  may 
produce  its  effect  in  part  through  the  nerve  centers,  the 
writer  is  inclined,  from  a  study  of  the  facts  here  pre- 
sented, to  attribute  to  fixation,  compression,  and  sus- 
pension of  the  affected  limb,  and  to  faulty  or  absent 
locomotion,  an  important  role  in  growth  retardation. 

If  this  inference  is  correct,  while  one  should  not  hesi- 
tate to  make  necessary  sacrifices  in  order  to  promote 
the  comfort  of  the  patient,  combat  deformity,  and  to 
eliminate  disease,  it  is  not  a  matter  of  indifference  how 
long  the  use  of  the  limb  is  restricted.  Protected  loco- 
motion, permitting  joint  and  muscle  action,  with  a 
minimum  of  strain  and  pressure,  would  seem  to  be  in- 
dicated in  the  stage  of  convalescence  from  joint  disease. 
That  method  of  "treatment,  operative  or  mechanical, 
should  evidently  be  selected  which  will  give  the  beet 
functional  result  with  the  least  restriction. 

A  rather  hasty  search  has  revealed  but  few  references 
to  this  topic  in  medical  literature.  Hiiter  makes  some 
general  observations  on  retarded  growth  of  a  limb  after 
coxitis  in  his  work  on  Joint  Disease,  published  (second 
edition)  in  1877.  An  excellent  study,  by  Dr.  Russell 
A.  Hibbs,  of  shortening  of  the  tibia  and  femur  in  50 
cases  of  tuberculous  disease  of  the  hip-joint,  published 
in  the  New  York  Medical  Journal,  December  16,  1899. 
shows  results  similar  to  those  here  given. 

Quite  unexpectedly  to  the  writer,  and  to  some  extent 
contrary  to  his  preconceptions,  this  study,  so  far  as  it 
goes,  appears  to  justify  the  following  conclusions : 

1.  Considerable  retardation  of  growth,  both  in  the 
length  and  thickness  of  the  limb  and  its  component 


I 


J.4XUARY26,  1901] 


REPORT  OF  A  CASE  OF  RABIES 


Tm 


HE  Pail^DELPHIA 

EDicAL  Journal 


187 


bones,  is  the  rule  after  coxitis,  and  other  affections  caus- 
ing long  periods  of  lameness  or  disability  in  childhood. 

2.  The  amount  of  retardation  appears  to  bear  a  dis- 
tinct relation  to  the  amount  and  duration  of  the  restraint 
or  disability. 

3.  This  inhibitory  effect  of  restraint  should  be  con- 
sidered in  selecting  treatment  for  disabling  affections  of 
the  lower  limbs.  Other  things  being  equal,  locomotion 
is  desirable,  and  restraint  for  long  periods  harmful, 
though  complete  or  partial  interference  with  function 
must  often  be  enforced  as  the  least  of  evils. 


A  REPORT  OF  A  CASE  OF  RABIES.* 

By  FREDERICK  KRAUSS,  M.D., 

of  Philadelphia. 

Six  weeks  previous  to  the  attack,  Ida  Z ,  aged  8  years, 

fondled  a  sick  dog,  which  her  elder  sister  brought  in  from  the 
street  because  it  seemed  to  be  suffering.  Suddenly,  without 
any  warning,  the  dog  bit  her  in  the  upper  posterior  border 
of  the  helix  of  the  right  ear. 

The  small  wound  bled  rather  freely,  and  was  immediately 
cauterized  by  a  physician  in  a  neighboring  drug  store.  The 
wound  healed  nicely,  and  no  further  attention  was  paid  to 
the  incident.  The  dog  was  thrust  into  the  highway,  and  was 
lost  sight  of  immediately  after  the  child  had  been  bitten. 

Six  weeks  later,  ou  Saturday,  August  11,  1900,  the  child 
complained  of  toothache,  lassitude,  and  was  nervous.  Her 
mother  gave  her  a  dose  of  castor  oil,  which  operated  freely. 
Sue  passed  a  sleepless  night,  but  did  not  complain  until  the 
next  morning  when  her  mother  began  to  wash  her,  when  she 
sprang  back  and  complained  of  pain  in  her  throat.  This 
pain  returned  whenever  she  was  touched  about  her  face  or 
throat  with  the  wet  towel,  or  even  at  the  slight  draught  of 
air  that  was  caused  by  the  movement  of  the  towel.  At  the 
■breakfast  table  she  tried  to  drink  coffee,  but  could  not  on 
account  of  pain  in  her  throat.  As  the  child  seemed  to  be 
well  otherwise,  the  parents  did  not  send  for  me  until  about 
12.30  P.M.,  expecting  the  symptoms  to  pass  away. 

When,  for  the  tirst  time  I  saw  her,  near  that  hour,  the 
child  seemed  very  bright,  but  shy  in  manner.  Her  pupils 
seemed  abnormally  dilated,  the  tongue  thickly  and  evenly 
coated,  the  breath  very  offensive.  The  temperature  was 
100°  F. ;  Dulse,  101.  Her  gait  and  manner  seemed  normal. 
When  asked  to  drink  water  from  a  glass,  she  at  first  refused 
with  an  expression  of  dread,  saying  it  hurt  her  throat  so 
much,  and  made  her  short  of  breath.  Upon  urging  she  took 
the  glass,  and  with  sudden  determination  took  a  mouthful 
of  water.  Immediately  that  the  water  touched  the  pharynx, 
there  was  frightfully  intense  tonic  spasm  of  the  constrictors 
of  the  pharynx  and  other  muscles  of  the  neck,  lasting  from 
10  to  15  seconds,  and  probably  associated  with  a  spasm  of 
the  glottis,  as  it  was  associated  with  dyspnea  and  followed  by 
a  gasping  breath.  Although  some  tonic  spasm  sti  1  re- 
mained, she  succeeded  in  swallowing  the  small  mouthful  of 
water  in  repeated  efforts  after  the  more  intense  fpasm  had 
subsided.  She  suffered  from  extreme  thirst,  but  each  effort 
at  drinking  produced  the  same  frightful  result,  thus  causing 
her  to  suffer  the  punishment  of  Tantalus.  Solids  could  not 
be  swallowed.  A  slight,  artificially  produced  draught  of  air 
caused  a  similar,  though  less  marked  attack. 

During  the  intervals  she  was  apparently  only  suffering 
from  slight  feverishness  The  wound  caused  by  the  dog-bite 
was  healed,  the  scar  being  slightly  reddened.  She  passed  a 
sleepless  night  in  spite  of  large  doses  of  bromide  and  chloral. 
On  the  following  morning,  August  13,  1900,  she  and  her 
parents  were  delighted  becau.se  of  her  ability  to  swallow, 
after  much  effort,  about  one-half  glass  of  milk.  The  child 
thought  she  felt  better  ;  but  her  temperature  had  risen  to 
101.5°,  lier  pulse  being  extremely  rapid— 130  per  minute. 
5he  insisted  th.at  she  was  not  afraid  of  anvthiug,  but  was 
msily  startled.  She  was  led  to  think  that  she  would  get  well, 
iutat  times  .she  was  haunted  by  a  nameless  dread  of  some- 
thing.   She  still  had  the  grett  pain,  dyspnea  and  spasm  in 


•  Bead  at  a  meeting  of  ike  Northern  Medical  Association,  January  It,  1901. 


her  throat  upon  attempting  to  swallow.  She  was  kept  in  bed 
and  was  fairly  quiet  until  4. 15  p.m.,  when  she  suddenly  sprang 
up  and  assumed  a  crouching  position  at  the  edge  of  the  bed, 
with  an  expression  of  intense,  horrible  fear  continuing  upon 
her  face,  staring  at  the  opposite  wall,  giving  vent  to  short, 
unintelligent  cries  also  expressive  of  fear.  This  lasted  for 
one  or  two  minutes,  when  she  would  wake  as  from  a  dream, 
fondle  her  mother,  saying  "she  had  thought  she  was  near  death 
then."  She  again  laid  down  quietly  for  a  few  minutes,  when 
a  similar  attack  occurred.  She  always  clung  to  her  mother's 
waist,  kissing  her  face  repeatedly  after  each  attack,  and  ask- 
ing whether  her  mother  loved  her  still.  I  asked  her  gently 
not  to  kiss  her  mother,  as  I  feared  a  possible  inoculation, 
and  she  immediately  desisted.  After  a  hypodermic  injection 
of  i  gr.  of  morphin  with  y^ j  gr.  of  atropin.  the  attacks  be- 
came less  frequent.  She  was  sent  to  St.  Christopher's  Hos- 
pital, during  an  entire  remission  of  symptoms  from  5.15  p.m. 
to  8  P..M.  During  this  interval  she  was  quiet  and  rational. 
Afterward  she  became  restless;  later  extremely  excited, 
throwing  arms,  legs,  and  even  entire  body  about  violently, 
losing  all  consciousness  of  surroundings,  emitting  short  cries 
as  though  in  fear,  and  trying  to  escape.  These  convulsive 
and  maniacal  attacks  were  relieved  by  inhalations  of  chloro- 
form, but  recurred  after  one-half  hour's  interval  of  stupor. 
During  the  attacks  the  pupils  were  widely  dilated,  the  lips 
withdrawn  from  the  teeth,  and  an  expression  of  wild  fear 
was  upon  the  face.  The  pulse  was  rapid  but  strong.  The 
temperature,  respiration,  and  pulse  were  as  follows  : 

Temperature.  Pulse.  Respiration. 

At    6p.m 103.0°  F.  144                28 

"     9p.m 104.6°  F.  150               26 

"   12P.M 102.8°  F.  160               28 

"     3  A.M 103.4°  F.  150                32 

"     6  A.M 101.8°  F.  170                40 

The  patient  received  alcohol  and  water  sponge-baths 
whenever  temperature  exceeded  103°  F.  The  maniacal  spasm, 
being  most  intense,  was  not  affected  thereby.  Hypodermic 
injections  of  morphin  were  given  to  prolong  the  action  of  the 
inhalations  of  chloroform.  The  attacks  of  maniacal  excite- 
ment continued  uptil  6  a.m.,  when  the  patient  became  quiet 
and  died  at  7  a.m.  of  August  14. 

The  coroner  was  notified  and  a  postmortem  exami- 
nation made  by  Dr.  Wadsworth,  who  found  severe  con- 
gestion of  the  cerebral  and  spinal  meninges,  numerous 
punctate  hemorrhages  in  the  spinal  cord,  and  a  rupture 
of  the  pleura.  A  portion  of  the  spinal  cord  was  sent  to 
Dr.  Mazyck  P.  Ravenel,  of  the  University  of  Pennsyl- 
vania, for  diagnosis.  In  a  private  communication  the 
latter  says  :  "  I  have  passed  it  through  4  generations  of 
rabbits  with  positive  results  always.  The  examination 
of  the  intervertebral  ganglion  after  the  method  of  Van 
Gehuchten  and  Nelis,  and  of  the  bulb  after  Babe's 
method,  confirmed  the  diagnosis  positively." 

In  spite  of  the  evidence  presented,  the  coroner  of 
Philadelphia,  a  layman,  has  entered  the  case  upon  the 
city  health  records  as  a  case  of  convulsions,  deny- 
ing the  existence  of  such  a  disease  as  hydrophobia. 

The  name  hydrophobia  appears  to  be  a  misnomer,  as 
the  patient  was  not  afraid  of  the  water,  but  of  the  painful 
spasm  and  dyspnea  caused  by  the  touch  on  the  throat 
or  upper  part  of  chest  of  any  liquid,  or  solid,  or  air — 
in  other  words,  a  centripetal  impulse  sent  to  the  gan- 
glion centers  in  the  lower  part  of  the  medulla  and  upper 
part  of  spinal  column,  apparently  the  first  portion  of 
the  cerebrospinal  axis  to  become  affected. 

In  the  early  stages,  the  suggestion  to  the  patient  that 
she  shoulcl  drink  milk  or  water  produced  a  slight  spasm, 
in  memory  apparently  of  the  terrible  spasm  caused  by 
attempts  to  drink.  Later  on  the  sight  of  water  was  not 
especially  distasteful,  except  that  it  was  additional  tor- 
ture for  the  thirsty  soul,  who  longed  to  drink  and  even 
asked  frequently  for  a  drink  of  water,  but  always  found 
that  she  could  not  swallow  without  terrific  and  painful 
local  spasm. 


188 


The  Philadelphia"] 
Medical  Journal  J 


REPORT  OF  A  CASE  OF  RABIES 


[Jascabt  26,  ISO; 


The  prominent  symptoms  were  the  temperature, 
rapid  pulse,  deeply-coated  tongue,  oflFensive  breath, 
slightly  reddened  but  healed  wound,  lassitude,  convul- 
sive contraction,  frightful  in  intensity,  of  the  muscles  of 
the  neck  and  larynx  upon  the  slightest  peripheral  irri- 
tation, dilated  pupils,  her  tendency  at  first  to  be  some- 
what irritable,  later  very  tender  and  loving  as  long  as  she 
retained  consciousness.  Later  the  intense  fear  and 
frightful  convulsive  movements  of  the  body  made  in  an 
apparent  effort  to  escape  from  a  most  terrible  vision, 
the  convulsion  being  sufficiently  great,  indeed,  to  rup- 
ture the  pleura,  unconsciousness,  and  an  apparent  total 
absence  of  paralysis  were  the  final  features  of  this  dis- 
ease, so  rare  apparently  in  the  human  species  in  the 
United  States. 


Phloridzin  Diabetes. — Seelig  (DeiUsche  medicintsche 
Wochenachrifl)  enters  into  a  discussion  of  the  exact  role 
played  by  the  kidneys  in  phloridzin  diabetes.  The  most  char- 
acteristic points  of  this  form  of  diabetes  are,  that  a  glyco- 
suria occurs  after  the  injection  of  phloridzin,  but  instead  of 
hyperglykemia,  as  in  true  typical  diabetes,  the  sugar  of  the 
blood  is  not  increased  and  may  even  be  diminished.  The 
two  chief  theories  as  to  the  production  of  this  glycosuria  are, 
that  some  change  occurs  in  the  kidneys  which  allows  of  the 
passage  of  the  sugar ;  and,  on  the  other  hand,  that  the 
phloridzin  is  split  up  by  the  kidneys  into  phloretin  and 
pblorose,  and  the  free  phloretin  keeps  continually  uniting 
with  sugar  and  being  broken  up  again  by  the  kidneys,  the 
sugar  being  excreted  and  most  of  the  phloretin  for  a  consid- 
erable period  going  through  the  same  cycle  until  ultimately 
all  of  it  also  is  excreted.  An  observation  made  by  Seelig  is 
of  interest  in  this  connection.  A  rabbit  which  had  been 
given  one  gram  of  phloridzin  daily  for  four  weeks,  and  had 
continuous  glycosuria,  was  operated  upon  and  one  kidney 
removed  for  microscopic  examination.  The  animal  recov- 
ered, and  secreted  sugar  for  about  3  weeks  without  any  more 
phloridzin  being  used.  The  iron  chlorid  reaction  for  phlorid- 
zin persisted  2  weeks  after  the  sugar  excretion  had  ceased. 
The  glycosuria  might  be  explained  in  this  case  by  two  means, 
it  was  either  the  result  of  the  sudden  extirpation  of  the  kid- 
ney which  had  so  reduced  the  excretory  power  of  the 
remaining  kidney  that  the  phloridzin  was  excreted  only  with 
abnormal  slowness,  or  it  was  produced  by  changes  in  the 
kidney,  due  to  the  phloridzin,  from  which  the  animal  had 
recovered  only  very  slowly  because  of  the  loss  of  the  other 
kidney.  This  result,  however,  was  obtained  but  once  in  a 
series  of  experiments.  The  occurrence  of  acetonuria 
is  of  interest  in  phloridzin  poisoning  and  other  conditions. 
Acetonuria  occurs  readily  in  men  in  inanition,  and  in  vari- 
ous other  conditions.  Dogs  do  not  show  acetonuria  as  a 
result  of  any  change  in  diet,  but  do  readily  show  it  as  a 
result  of  phloridzin  poisoning,  or  removal  of  the  pancreas, 
and  Seelig  finds  that  the  prolonged  use  of  phloridzin  does 
cause  acetonuria  in  dogs  but  does  not  cause  it  in  rabbits ; 
nevertheless  rabbits  showed  distinct  necrosis  in  the  tubules 
of  the  kidneys  and  they  presented  decided  glycosuria.  It 
has  been  claimed  by  some  authors  that  the  changes  in  the 
kidneys  in  phloridzin  poisoning  are  due  to  the  irritation  of 
the  acetone  excreted  by  them.  This  Seelig  claims  is  not  true 
because  of  these  observations  on  rabbits;  there  was  no  ace- 
tonuria, hence  the  necrosis  must  be  attributed  to  the  phlor- 
idzin, and  he  thinks  the  just  conclusion  from  this  is  that  the 
glycosuria  was  the  result  of  these  changes.  One  would  ex- 
pect if  the  epithelium  of  the  canaliculi  of  the  tubules  of 
the  kidneys  were  damaged  by  any  other  poison,  glyco- 
suria would  not  result  from  phloridzin  poisoning.  This 
is  not  the  case.  Various  poisons  have  been  used 
and  followed  by  phloridzin,  with  the  constant  production  of 
phloridzin  glycosuria.  This,  however,  cannot  be  used  as 
testimony  against  the  renal  origin  of  glycosuria,  as  it  is  well 
known  that  very  minute  remnants  of  the  organ  may  be  sutJi- 
cient  to  carry  on  its  function  fairly  satisfactorily.  Richter 
found  that  very  small  doses  of  cautharidin  given  subcutane- 
ously  produced  glycosuria  which  gradually  disappe.<ired  as  an 
increasing  albuminuria  appeared.  Large  doses  did  not  cause 
glycosuria.    Seelig  directs  attention  to  the  fact  that  Richter 


observed  that  the  glycosuria  did  not  occur  when  the  tuboleg 
were  damaged,  but  did  appear  when  the  dose  was  so  small 
that  the  tubules  were  left  uninvolved,  while  the  glomeruleg 
showed  exudation  and  hyperemia.  He  explains  this  by 
stating  that  just  as  in  phloridzin  diabetes  the  glycosuria  ia  a 
function  of  the  renal  epithelium,  so  must  it  be  in  cantharidjn 
glycosuria,  and  if  the  dose  of  cantharidin  has  been  so  large 
as  to  destroy  the  epithelium  the  glycosuria  will  not  appear. 
He  considers  that  cantharidin  in  small  doses  hag  a  severe 
effect  upon  the  g'.omerules,  but  upon  the  tubules  ezerciaee 
only  sufficient  irritation  to  produce  glycosuria.  In  discussing 
the  cases  in  human  beings  which  have  been  reported  ae 
renal  diabetes  he  states  that  not  one  of  these  is  truly  such  a 
case.  That  of  Koliscb  and  Buber  has  been  frequently  con- 
sidered to  be  true  renal  diabetes.  Seelig,  however,  directs 
attention  to  the  fact  that  glycosuria  occurred  only  after  taking 
food ;  it  was  not,  therefore,  a  true  diabetes,  but  merely  a  regu- 
latory glycosuria,  in  other  words  an  instance  of  taehygiy- 
cosuria. 

The  Connection  Between  Disease  of  the  Uterus 
and  Gastric  Aflfection.— C.  Tuezkai  {The  Hungarian  Medi- 
cal Press, 'So.  41.)  Diseases  of  the  uterus  and  stomach  fre- 
quently coexist.  A  diagnosis  of  disease  between  these  two 
organs  is  often  difficult  as  symptoms  may  be  referable  to 
either  viscus.  This  may  be  due,  first,  to  the  nerve  tract, 
whose  center  is  not  in  the  brain  or  the  spinal  cord  but  in  the 
sympathetic  nervous  system.  From  reflex  action  symptoms 
arise  which  relate  to  both  organs.  The  reflex  tracts  being 
anastomosis  spermatica,  anastomosis  pudendohemorrhoid- 
alis,  genitogastrica,  cutaneocavemosa,  and  the  nervi  splanch- 
nici.  Also  the  anastomosis  uterococliaca  and  anastomogie 
uterospinalis.  The  immediate  roads  of  the  reflex  tracts  are 
direct  connections  of  the  vagus  (excluding  the  ganglion 
solar)  with  the  sympathetic  nervous  system.  The  second 
manner  in  which  mistakes  may  occur  are  due  to  dislocation 
of  the  respective  organs.  The  circulation  only  plays  a  minor 
role  in  this  connection. 

The  Pathogenesis  of  Anemic  Conditions  in  Child- 
hood.—L.  Fiirst  (TherapeutUche  ilonaishefte,  1900,  No.  9) 
believes  that  congenital  anemia  not  infrequently  is  due 
to  heredity.  Habitual  anemia  of  the  parents,  cachexia  as 
a  result  of  tuberculosis,  mahgnant  neoplasms,  diseases  during 
pregnancy,  poor  nutrition  and  lack  of  hygiene,  may  all, 
according  to  the  author,  give  rise  to  anemia  in  the  child- 
Tne  anemia  is  transmitted  by  means  of  the  placental  circu- 
lation and  continues  to  develop  in  the  fetus  in  utero.  The 
alimentary  form  when  present  in  the  nonanemic  newborn  it 
due  to  an  exclusive  milk-diet  which  in  itself  is  deficient  in 
iron.  The  anemia  occurring  from  5  to  V2  years  of  age  if 
characterized  by  rapid  growth,  loss  in  bodily  fat,  and  is 
due  to  the  increased  processes  of  oxidation  during  which  the 
formation  of  new  blood- cells  cannot  keep  pace  with  the  in- 
creased tissue  waste.  The  total  amount  of  blood  decreases 
because  there  is  such  a  great  demand  upon  hematogenesis 
to  supply  the  new  bone  and  muscle.  The  author  describee 
a  development-anorexia  which  is  seen  in  both  sexet 
during  their  school  years,  but  which  occurs  eepeciallv 
toward  puberty  in  the  female  between  V2  and  13  year8_  oi 
age  and  is  occasioned  by  an  overexertion  and  overburdening 
of  the  brain,  nervous  excitation,  and  sedentary  batuts. 
[m.rd.] 

Changes  in  the  Spinal  Cord  in  Pernicions  Ane- 
mia.— W.  Goebel  (iliUheilungen  aus  den  HambuTgiich^n  Staati 
krankenMalten,  Bd.  11)  reports  the  postmortem  examination  o 
6  cases  of  pernicious  anemia.  In  a  child  o  years  of  age 
with  the  exception  of  a  slight  extravasation  of  blood  into  th« 
frontal  lobe,  there  was  no  degeneration  of  the  brain  or  spina! 
cord.  In  older  individuals  there  were  some  profuse  degen- 
erative changes  in  the  cells,  areas  of  disseminated  myelitis 
pigmentation  and  degeneration  of  the  ganglion  cells  (aa  s 
consequence  of  the  cachexia)  and  in  two  cases  changes  were 
found  in  the  extramedullary  roots.  The  pia  was  always 
found  in  a  delicate  and  normal  condition  with  no  changes  ir 
the  bloodvessels  to  which  the  etiology  could  be  ascribed 
The  changes  in  the  gray  matter  were  always  less  than  thost 
in  the  white  and  were  absent  entirely  whenever  the  whiu 
matter  seemed  to  be  affect-ed :  the  intensity  of  the  affecUor 
of  the  gr.^y  matter  was  not  in  direct  proportion  to  that  of  th« 
white.    The  commissural  fibers  were  intact.    [MR d.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and  'Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hexdrie  Lloyd,  A.M.,  M.D.,  Edilor-in-Oiief 
Jn-ics  L.  Salinoer,  M.D.,  Associale  Editor 


Astiitant  Editors 
Joseph  Sailer    M.D. 
D.  L.  Edsall,  M.D. 
J.  M.  Swan,  M.D. 

J.  H. 


F.  J.  Kalteyee,  M.D. 
T.  L.  Coley,  M.U. 

W.    A.    N.    DORLASD,   M.D. 

Gibbon,  M.D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.    Reprints  (250)  of  Original  Articles  will  be  lurnished  gratis  to  Authors  making 
the  request. 
The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  aiedical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising:  Page  8  and  32. 


Vol.  VII,  No.  5 


FEBRUARY  2,  1901 


.00  Per  Annum 


Queen  Victoria's  Death. — The  Queen's  death  evi- 
dently illustrated  the  truth  of  the  old  medical  aphorism 
that  a  person's  life  is  just  as  long  as  the  life  of  the  blood- 
vessels. Her  Majesty  apparently  succumbed  to  the 
changes  in  the  cerebral  circulation,  brought  about  by 
arterial  sclerosis.  This  mode  of  death  is  very  com- 
monly seen  in  the  aged,  in  whom,  after  death,  it  is  not 
always  possible  to  find  gross  or  focal  lesions  in  the 
brain.  The  most  conspicuous  pathological  picture,  as 
a  rule,  is  the  thickening  and  brittleness  of  the  vessels 
forming  the  circle  of  Willis  and  its  branches.  The 
roughening  of  the  inner  coats  of  these  vessels  causes 
small  thrombi  to  form  ;  the  lumen  of  the  vessel  is 
narrowed  or  obliterated ;  slowing  or  stasis  of  the  blood- 
current  results  ;  more  or  less  edema  occurs,  and  nutri- 
tion and  function  are  both  seriously  involved.  The 
process  once  started  probably  spreads  from  one  vessel 
to  another.  It  is  not  necessary  in  every  case  that  ex- 
tensive necrosis  or  softening  of  the  brain-substance 
should  result.  The  clinical  picture  thus  presented  is 
that  which  is  popularly  called  apoplectic,  although  it 
does  not  always  come  on  with  abruptness  in  its  entirety. 
In  the  Queen's  case  there  seem  to  have  been  successive 
attacks.  According  to  apparently  authentic  reports, 
there  was  hemiplegia,  or  rather  hemiparesis,  the  latter 
being  the  more  common  in  these  cases. 

With  the  passing  of  Queen  Victoria,  a  great  epoch 
in  English  history  closes,  and  one  which  has  been  con- 
spicuous for  the  advances  made  in  the  medical  sciences. 
Those  advances,  in  their  vast  extent,  cannot  be  chron- 
icled here  and  now,  and  they  are  not  especially  associ- 
ated with  the  personality  of  the  English  Queen,  but 
they  will  long  be  associated  with  the  period  which 
bears  her  name.  Towards  the  profession  itself  she  was 
reputed  to  be  liberal  and  broad-minded,  and  to  some 
members  of  it  she  was  deeply  attached.  It  will  be 
difficult  for  a  long  while  to  realize  that  the  venerable 
sovereign,  who  has  for  so  many  years  been  associated  in 
all  minds  with  the  power  and  prestige  of  the  British 
Empire,  is  no  more. 

Infantile  Scurvy. — Dr.  Griffith's  paper  in  the  pres- 
ent number  of  the  Journal  calls  attention  to  the  fact 
that  infantile  scurvy  is  rather  more  common  than  is 
generally  supposed,  and  that  it  is  capable  of  doing  an 
immense  amount  of  harm  simply  from  the  fact  that  it 
is  so  readily  overlooked.     This    affection    simulates  a 


number  of  diseases  rather  closely  although  superfi- 
cially, but  in  the  light  which  has  been  shed  on  it  in 
recent  years  there  seems  to  be  no  excuse  any  longer  for 
an  error  in  diagnosis.  Scurvy  is  not  rheumatism,  and 
rheumatism  is  not  scurvy,  but  the  painful  affection  of 
the  joints  in  both  diseases  is  apt  to  mislead  a  careless 
or  ignorant  observer.  Scurvy  in  infancy  is  a  disease 
which  is  almost  as  easily  cured  in  most  instances  as  it 
is  easily  diagnosed.  A  simple  exercise  of  common 
sense  in  returning  the  child  to  the  kind  of  diet  that 
nature  originally  intended  for  it,  is  practically  all  that 
is  required  in  most  cases.  In  other  words,  the  correct 
diagnosis  of  the  disease  is  nine  points  of  the  treat- 

j  ment,  for  when  the  disease  has  been  once  recognized 
the  indications  for  treatment  are  plain  and  unmis- 
takable. 

While  this  is  true  Dr.  Griffith  very  properly  calls 
attention  to  the  fact  that  although  the  cause  of  scurvy 
is  clearly  dietetic,  yet  there  is  no  one  dietetic  fault  that 
can  alone  be  held  responsible.  It  does  seem,  however, 
that  a  too  large  or  too  exclusive  use  of  a  farinaceous  diet 
is  often  an  etiological  factor.  Thus,  as  we  called  attention 
in  these  columns  only  recently,  a  rice  diet  has  been 

I  found  to  cause  this  disease  in  Cuba.  In  this  country 
there  is  no  doubt  a  tendency  toward  a  large  use  of  com- 
mercial foods.  It  is  probably  true  that  when  these  foods 
are  properly  mixed  with  other  ingredients,  such  as  milk, 
which  is  essential  to  the  welfare  of  the  child,  they  are 
beneficially  borne,  and  the  risk  is  not  so  much  that  the 
physician  but  rather  that  mothers  and  nurses  fall  into 
the  way  of  giving  these  foods  too  exclusively.  They 
should  be  only  a  supplementary  portion  of  the  diet, 
not  a  mainstay.  The  collective  investigation  of  the 
American  Pediatric  Society,  made  some  years  ago, 
proved  the  truth  of  this  statement  apparently  beyond 
doubt.  As  to  the  sterilization  of  milk,  it  also  is  pos- 
sibly a  contributing  cause,  although  Dr.  Griffith  e\'i- 
dently  does  not  consider  it  an  important  one.  It  is 
well,  however,  for  physicians  to  remember  that  milk 
which  has  passed  through  the  process  of  cooking  is  not 
the  kind  of  milk  which  nature  originally  intended  for  an 
infant.  We  trust  that  the  exposition  of  this  whole 
subject  of  infant  feeding,  which  is  given  in  the  emi- 
nently useful  and  practical  papers  published  in  this 
number  of  the  Journal,  will  be  of  use  to  clarify  this 
whole  subject,  as  concerns  both  diagnosis  and  treat- 
ment, in  the  mind  of  the  general  practitioner. 


190 


TuE  Philadelphia"! 
Medical  Journal  J 


EDITORIAL  COMMENT 


[Febbuaby  2,  1901 


Rheumatic  Fever  in  Children  and  the  Prevention 
of  Cardiac  Complications. — A  strong  argument  in 
favor  of  the  infectious  nature  of  acute  rheumatic  fever 
is  its  behavior  in  children.  As  Heiman  has  pointed 
out  in  a  recent  paper  (Archives  of  Pediatrics,  January, 
1901),  the  liability  to  joint  involvement  in  children  is 
reduced  to  a  minimum,  and,  in  certain  cases,  growing 
pains  may  be  the  only  subjective  symptom  complained 
of.  On  the  other  hand,  in  the  little  folks,  there  is  great 
danger  of  involvement  of  other  tissues,  particularly  of 
the  serous  membranes,  such  as  the  endocardium.  A 
short  time  ago  Barbier  and  Tollemer  reported  to  the 
Soci^t^  de  Pediatric  (Revue  Mensuelle  des  Maladies  de 
VEnfance,  January,  1901)  the  case  of  a  little  girl  aged 
11  years  who  was  sufiFering  from  an  acute  polyarthritis 
of  18  days'  duration.  This  child  was  suddenly  seized 
with  aphasia  and  right-sided  hemiplegia.  After  several 
days  she  died,  and,  at  autopsy,  a  vegetating  endo- 
carditis of  the  mitral  valve  and  multiple  emboli  in  the 
cerebral  artery  were  discovered.  Realizing  the  danger 
of  involvement  of  the  serous  membranes  we  should  first 
place  our  patients  under  the  most  favorable  conditions 
for  the  prevention  of  such  a  complication  and  then 
be  on  the  lookout  constantly  for  the  first  signs 
of  endocardial  mischief,  so  as  to  cure  the  lesion,  if  pos- 
sible, before  it  becomes  chronic.  Caton  ("  The  Preven- 
tion of  Valvular  Diseases  of  the  Heart,"  London,  1900) 
has  worked  on  this  problem  for  19  years  and,  in  his 
book,  gives  the  results  of  his  studies  and  notes  of  86 
cases  in  which  his  method  has  been  attended  with  a 
greater  or  less  degree  of  success.  For  the  prevention 
and  cure  of  endocardial  lesions  this  author  has  adopted 
the  following  method  :  His  patients  are  clad  in  flannel 
night-gowns.  They  are  kept  in  bed  so  as  to  secure 
complete  pysiological  rest  of  mind  and  body,  thereby 
reducing  the  demand  made  upon  the  heart  to  the 
physiological  minimum.  Pain  is  relieved  by  the 
salicylates.  Small  blisters  are  applied  over  the  upper 
portion  of  the  chest.  These  act  in  reality  as  direct 
stimulants  to  the  vasomotor  and  trophic  nerves  of  the 
ailing  part.  He  exhibits  the  iodides  and  mercury  as 
absorbents,  and  these  drugs  together  with  the  salicylates 
are  kept  up  for  3  or  4  weeks,  or  longer,  if  necessary, 
after  the  acute  symptoms  have  subsided.  He  believes 
that  those  drugs  that  act  directly  and  specifically  on 
the  heart,  the  so-called  cardiac  tonics,  including  digi- 
talis and  caflein,  are  distinctly  injurious.  Heiman,  in 
order  to  prevent  the  occurrence  of  endocarditis,  gives 
from  3  to  5  grains  of  salicylate  for  one  week  of  each 
month  for  a  year  or  more  after  the  acute  symptoms 
have  disappeared. 

We  believe  that  the  strontium  salt  is  the  best  form  of 
the  salicylates  because  it  is  the  least  likely  to  disagree 
with  the  stomach. 

Caton  emphasizes  the  fact  that  the  mitral  valve  is 
afifected  much  more  frequently  than  the  aortic — at  least 
ten  times  as  frequently  in  his  experience.    He  explains 


this  by  the  mechanical  principles  involved  at  the  time 
of  closure  of  the  mitral  valve  during  each  systole  of  the 
heart.  At  this  moment  intracardial  pressure  is  im- 
mensely increased,  and  when  the  cusps  come  together 
they  have  to  withstand  this  pressure.  These  cusps  are 
nourished  and  repaired  through  connective-tissue  chan- 
nels, no  bloodvessels  existing  nearer  than  the  attached 
margins  of  the  cusps.  Under  the  strain  and  defective 
nutrition  the  infecting  agent  attacks  the  valves  at  their 
most  vulnerable  points.  Counterirritation,  he  thinks, 
acts  by  influencing  nutrition  through  the  nervous 
system. 

Enterocolitis. — The  diarrheal  diseases  are  exceed- 
ingly difiicult  to  classify,  as  the  severity  of  the  symp- 
toms are  not  necessarily  dependent  upon  the  gravity  of 
the  local  lesions.  Diarrhea  may  be  defined  as  a  condi- 
tion in  which  soft  or  fluid  evacuations  occur  frequently, 
the  stool  being  either  large  or  small.  The  fluid  charac- 
ter of  the  dejecta  is  caused  by  an  increase  of  the  watery 
elements  entering  into  their  formation.  This  is  pri- 
marily caused  by  the  thin  contents  of  the  jejunum  and 
ileum  being  poured  too  rapidly  into  the  large  intestine 
without  being  absorbed  ;  or  a  massive  transudation  may 
occur  from  the  wall  of  the  intestine  either  from  the 
bloodvessels  or  the  lymph-glands.  In  the  former  ca^e 
a  reaction  for  bile  is  frequently  obtained  with  nitrous 
acid,  but  not  invariably.  The  presence  of  bile  pigment 
in  the  stool  shows  absolutely  that  the  diarrhea  i?  de- 
pendent upon  causes  in  the  small  intestine.  Increased 
peristalsis  either  in  the  small  or  large  intestine  is  the 
second  factor  upon  which  the  occurrence  of  diarrhea 
depends.  The  pathological  increase  of  peristalsis  is 
dependent  upon  many  causes.  In  the  majority  of  in- 
stances, however,  it  is  due  to  some  anatomical  morbid 
lesion  of  the  bowel  itself.  This  is,  however,  not  invari- 
ably the  case.  Increased  peristalsis  may  be  due  to  the 
presence  of  irritating  substances  in  the  bowel,  or  in 
case  that  the  contents  of  the  intestines  are  normal,  to 
an  increased  irritability  of  the  nervous  structure  of  the 
bowel  (the  ganglion  or  the  sensory  nerve) ;  or  the  cen- 
tral nervous  system  may  be  at  fault;  or  toxic  sub- 
stances may  be  present  in  the  circulation  which  increase 
peristalsis.  Any  one  of  these  causes  are  suflicient  to 
produce  the  symptom-complex  known  as  diarrhea. 
It  is,  however,  probable  that  several  of  the  causes  act- 
ing together  give  rise  to  the  condition. 

It  is  now  generally  conceded  that  acute  enterocolitis 
is  almost  invariably  the  result  of  microorganisms,  their 
toxins  or  a  combination  of  both.  Hence  the  afl'ection 
should  properly  be  considered  a  toxemia,  and  although 
inflammatory  changes  arise  in  the  bowel  they  are  not 
the  cause  but  the  result  of  the  influence  of  the  bac- 
teria and  the  ptomains.  No  specific  bacterium  has  as 
yet  been  isolated.  The  means  by  which  the  microor- 
ganisms gain  access  to  the  susceptible  gastrointestinal 
tract  is  undoubtedlv  by  wav  of  the  mouth.     The  ho 


Fkbbdabt  2,  1901] 


EDITORIAL  COMMENT 


[ 


The  Philad  lphia 
Medical  Joorkal 


191 


season  has  been  given  as  a  marked  predisposing  cause 
for  this  affection.  This  is  true  in  so  far  only  as  heat 
increases  the  development  and  activity  of  the  organisms 
which  are  productive  of  this  affection.  Almost  every 
practitioner  has  seen  cases  of  severe  enterocolitis  aris- 
ing in  children  in  the  cold  months  of  the  year  in  which 
food  unquestionably  and  not  heat  was  the  etiological 
factor. 

The  treatment  of  the  affection  should  consist  first 
and  foremost  in  ridding  the  individual  of  the  cause  of 
the  affection.  The  physician  who  treats  symptoms  will 
often  disregard  this  in  paying  attention  only  to  the 
prominent  symptom  of  the  affection,  the  diarrhea,  and 
attempt  to  check  this.  The  contents  of  the  intestinal 
tract  should  be  properly  evacuated.  This  may  be  best 
accomplished  by  the  use  of  castor  oil,  calomel  in  broken 
doses,  or  a  saline.  If  these  are  not  retained  and  vom- 
iting be  a  principal  symptom,  as  it  sometimes  is,  enter- 
oclysis  of  water  often  satisfactorily  accomplishes  the 
same  purpose.  If  high  temperature  be  a  marked  symp- 
tom, ice  water  may  be  used  for  this  purpose.  Opium  as 
a  routine  treatment  is  dangerous,  especially  in  children 
under  one  year  of  age.  The  use  of  some  intestinal  anti- 
septic, such  as  salol,  or  the  bismuth  salts  in  large  doses,  is 
considered  good  practice.  A  valuable  adjunct  to  the  treat 
ment,  besides  most  careful  attention  to  the  diet,  consists 
in  a  change  of  climate.  A  high  mountain  climate,  or 
preferably  the  seashore,  will  in  many  instances,  without 
any  further  medical  treatment,  especially  in  the  milder 
cases,  promote  a  rapid  recovery. 

Hysteria  iu  Cliildren. — Oppenheim,  in  his  work  on 
nervous  diseases — recently  translated  into  English  by 
Dr.  Edward  E.  Mayer,  of  Pittsburg — calls  rather  more 
pointed  attention  to  this  subject  than  used  to  be  the 
custom  in  textbooks.  The  old  fallacy  that  hysteria  is 
an  affection  of  the  morbid  womb,  has  been  most  ten- 
acious, and  it  naturally  excluded  children  from  the 
sphere  of  this  disease.  The  recognition  of  hysterical 
phenomena  in  children  has  therefore  been  a  long  time 
coming,  and  even  yet  the  disease  as  it  affects  children  is 
not  accorded  due  notice,  as  a  rule,  outside  of  special 
treatises.  Oppenheim  seems  to  have  had  a  unique 
experience,  for  he  tells  us  that  he  has  repeatedly  ob- 
served hysteria  in  children  of  from  2  to  3  years  of  age. 
He  also  saw  the  disease  successively  in  4  children  of 
an  hysterical  father — a  fact  which  illustrates  the  now 
well-known  heredity  of  hysteria.  Clopatt's  statistics, 
based  upon  272  cases,  include  but  one  authentic  case 
at  the  early  age  of  3  years.  In  fact,  until  7  the 
disease  is  rare.  Oppenheim  even  goes  to  the  extent  of 
attempting  to  establish  an  analogy  between  infantile 
convulsions  of  the  ordinary  tvpe  and  the  hysterical 
crises  of  adults.  Both,  he  thinks,  are  due  to  incom- 
plete development  of  the  inhibitory  centers.  The 
child's  brain,  therefore,  is  analogous  to  that  of  the 
adult  hysteric.     This  is  rather  an  unhappy  attempt  at 


finding  analogies,  and  may  mislead  some  students.  It 
also  shows  that  German  neurologists  have  not  yet 
acquired  the  clear  analytical  view  of  hysteria,  which 
characterizes  the  French  writers,  for  infantile  convul- 
sions are  very  unlike  the  convulsions  of  true  hysteria 
(whether  in  the  child  or  in  the  adult)  and  are  more  to  be 
compared  with  epilepsy.  They  are  probably  of  toxic 
origin,  and  are  naarked  with  a  profound  uncon-cious- 
ness  that  differs  from  that  seen  in  hysteria.  They  are 
common,  too,  as  a  rule,  in  much  younger  children,  and 
they  are  not  associated  with,  or  followed  by,  the  perma- 
nent stigmata  of  hysteria. 

The  chief  importance  of  this  subject  to  the  general 
practitioner  arises  from  the  fact  that  this  psycho- 
neurosis  may  sometimes  complicate  in  a  most  confusing 
way  the  picture  of  organic  disease.  It  is  not  that  hys- 
tiiria  simulates  organic  disease,  but  that  it  complicates 
it;  this  is  the  important  fact.  The  difficult  task  is  to 
differentiate,  to  disentangle  the  organic  from  the  psychic. 
By  failing  to  do  this,  grave  errors  may  arise,  not  only 
in  diagnosis,  but  in  treatment.  It  is  true,  finally,  as 
Oppenheim  has  not  failed  to  recognize,  that  hysteria 
may  complicate  one  of  the  other  neuroses  ;  thus,  in 
young  children,  an  infantile  convulsion,  of  the  ordinarj' 
type,  due  to  toxemia,  may  be  followed  by  the  manifes- 
tations of  hysteria.  In  such  cases  it  is  needful  to  ex- 
ercise unusual  care  and  acumen  in  order  to  make  a 
correct  diagnosis. 

The  Disorders  of  Dentition. — We  shall  confine 
ourselves  to  the  morbid  conditions  associated  with  den- 
tition, rather  than  any  abnormalities  in  the  teeth  them- 
selves or  their  period  of  eruption.  A  wealth  of  clinical 
experience  has  shown  the  frequent  coexistence  of  cer- 
tain diseased  states  and  the  process  of  dentition.  Yet 
our  seer  has  set  us  the  watchword  through  the  centuries 
that  experience  is  often  "  fallacious,"  and  no  doubt  a 
host  of  conditions  have  been  ascribed  improperly  to 
dentition  which  have  had  nothing  whatever  to  do  with 
the  process,  the  fault  being,  not  of  our  experience,  but 
its  interpretation. 

We  are  confronted  by  two  extreme  views  upon  this 
question.  It  was  the  habit  formerly  to  blame  dentition 
for  practically  all  of  the  ailments  from  which  a  teeth- 
ing child  suffered.  This  led  to  numbers  of  cases  of 
neglect  of  timely  treatment,  it  being  believed  gener- 
ally by  the  laity  and  even  the  profession  that  such 
ailments  would  be  quite  relieved  when  the  offending 
tooth  was  cut.  Again,  it  has  been  too  often  declared 
that  a  little  patient  icilh  its  20  milk  teeth,  and  under  the 
age  of  second  dentition,  was  ill  merely  from  teething. 
This  is  an  error  arising  from  the  lack  of  elemental 
knowledge. 

Jules  Comby,  of  Paris,  and  many  others  hold  that 
dentition  being  a  strictly  physiological  process  has  no 
diseases  dependent  upon  it.  We  believe  with  Vogel, 
of  Dorp.it;  E    Henoch,  of  Berlin,  and  others  that  the 


192 


TsE  Philadelphia 
Medical  Joubxal 


] 


EDITORIAL  COMMENT 


[Fkbbc&bt  t,  IMI 


middle  ground  is  the  sound  one.  It  is  diflBcult  to 
believe  that  all  of  the  coexisting  morbid  conditions 
associated  with  dentition  are  accidental.  We  know- 
that  inflammatory  conditions  of  the  buccal  mucous 
membrane  may,  at  times,  be  local,  but  are  often  general 
and  may  give  rise  to  a  stomatitis,  either  of  the  catar- 
rhal or  aphthous  form.  Extension  of  the  inflammatory 
process,  and  the  reflex  irritation  thus  caused,  have  been 
held  accountable  with  some  degree  of  authority'  as  a 
cause  of  acute  anterior  poliomyelitis  and  possibly 
spinal  meningitis.'  The  excessive  dribbling  of  saliva 
often  wets  through  the  child's  garments  and  gives  rise 
to  a  coryza  and  bronchitis,  which  might  also  very 
readily  arise  from  extension  of  the  inflammation  of  the 
mucous  membrane  to  the  upper  and  lower  air-passages. 
Swallowing  quantities  of  saliva  causes  a  form  of  diar- 
rhea prevalent  during  dentition  and  gastric  and  gas- 
trointestinal disorders.  The  mere  presence  of  a  local 
inflammation  is  suflicient  exciting  cause  of  the  frequent 
elevation  of  temperature  observed.  This,  however,  in 
these  cases  is  not  usually  alarming. 

The  occurrence  of  skin  eruptions  associated  with  the 
cutting  of  certain  groups  of  teeth  and  subsiding  when 
the  teeth  have  appeared  is  too  familiar  to  be  gainsaid. 
These  include  urticaria,  occasional  lichen  and  prurigo, 
eczema  and  impetigo.  Xor  must  we  forget  the  crusta 
lactea  of  the  hairy  scalp. 

The  nervous  system  of  an  infant  is  disturbed  easily 
by  reflex  influences,  and  most  important  are  the  con- 
vulsive phenomena  varying  from  slight  twitchings  to 
pronounced  eclampsia.  Henoch  has  observed  a  partial 
contraction  of  the  muscles  of  the  throat  and  neck  dur- 
ing dentition,  due  to  nerve  irritation.  Competent 
authorities  have  called  our  attention  frequently  to  the 
presence  of  an  otitis  media  of  which  dentition  has  been 
the  causal  factor,  and  we  must  not  overlook  the  con- 
junctival blennorrhea  associated  with  the  cutting  of 
the  canine — or  very  properly  named  "  eye  "  teeth.  The 
precise  connection  of  cause  and  efifect  in  these  cases  is 
often  difl&cult  to  trace.  That  a  physiological  process 
should  give  rise  to  such  manifold  complications  raises 
the  spirit  of  doubt  in  many  minds.  But  the  incontro- 
vertible repeated  association  of  certain  conditions  with 
the  process  of  dentition  forces  us  to  ascribe  an  etiolog- 
ical role  to  the  process  itself,  whether  the  cause  be 
exciting  or  predisposing. 

The  question  is  somewhat  vital  at  times,  for  many 
apparently  serious  conditions,  in  which  the  cause  is  un- 
recognized, might  induce  a  method  of  treatment  quite 
inappropriate ;  for  instance,  in  treating  a  conjunctival 
blennorrhea  or  an  otitis  media  radically,  when  the  cause 
is  resident  in  the  cutting  of  a  tooth  in  a  class  of 
cases  in  which  recovery  will  occur  promptly  when  this 
has  been  accomplished.  Again,  it  is  important  to  guard 
against  the  misinterpretation  of  certain  gastric  or  gastro- 


'Erb. 


'Ejb. 


intestinal  disorders  in  which  the  recognition  of  the 
cause  is  far  more  important  than  routine  treatment, 
with  the  cause  constantly  operative.  The  value  of  lanc- 
ing the  gums  as  a  routine  measure  is  quite  generally 
deprecated,  but  in  certain  conditions  the  local  depletion 
and  the  relief  of  tension  thus  brought  about  will  be  of 
the  greatest  service. 

Kubeola  and  Rubella.  — If  one  consults  the  medical 
dictionaries  he  flnds  that  the  word  rubeola  receives  two 
definitions.  The  first  makes  it  a  synonym  for  rubella, 
or  that  which  is  more  commonly  known  in  this  country 
as  German  measles,  and  the  second  gives  the  word  as  a 
synonym  for  measles.  There  is,  therefore,  some  con- 
fusion as  to  the  proper  significance  of  the  terms  rubella 
and  rubeola.  Jiirgensen  (Xothnagel's  Special  Pathology 
and  Therapeutics.  Vol.  V,  Part  II)  shows  that  rubella 
is  a  nosological  entity,  and  that  it  has  nothing  to  do 
with  either  measles  or  scarlet  fever.  Furthermore,  the 
majority  of  recent  writers  describe  the  two  diseases 
separately.  The  following,  as  is  well  known,  are  the 
chief  differences  between  measles  and  rubella: 

In  measles  the  period  of  incubation  is  from  5  to  14 
days,  or  an  average  of  about  12  days,  while  in  rubella, 
or  German  measles,  this  period  is  from  7  to  21  days. 
In  measles  the  onset  is  gradual  with  anorexia,  fever,  and 
marked  catarrhal  symptoms,  while  in  rubella  the  onset 
is  usually  without  symptoms  until  just  before  the  rash 
appears.  Enlargement  of  the  cervical,  axillarj-,  and 
inguinal  glands  is  very  common  in  the  latter.  In 
measles  the  febrile  stage  is  rather  more  pronounced 
than  in  rubella,  and  in  the  former  disease  the  eruption 
does  not  appear  until  the  fourth  day,  whereas  in  rubella 
it  appears  on  the  second  day.  This  eruption  in  measles 
is  coarse,  papular,  dark  red,  and  much  more  pronounced 
than  in  rubella.  Finally,  there  are  many  more  compli- 
cations or  sequelae  ia  measles  than  in  rubella.  Among 
these  complications  are  the  following  :  Purulent  con- 
junctivitis, stomatitis,  bronchitis,  catarrhal  pneumonia, 
otitis  media,  and  intestinal  derangements.  One  way 
out  of  the  difliculty  caused  by  this  unfortunate  misuse 
of  terms  would  be  to  always  use  the  word  rubella  to 
signify  rotheln  or  German  measles,  but  a  still  better 
way  would  be  to  drop  the  term  rubeola  altogether  and 
refer  to  the  two  diseases  as  measles  and  rubella.  We 
doubt,  however,  whether  any  of  these  Latin  terms, 
namely  roseola,  rubella,  and  rubeola,  will  ever  become 
popular  with  the  profession.  Even  now  many  of  the 
best-read  men  will  hesitate  a  moment  if  they  are  asked 
for  a  prompt  definition  of  these  individual  terms.  On 
the  other  hand  the  terms  measles  and  rotheln,  or  Ger- 
man measles,  are  perfectly  well  understood,  and  are  not 
liable  to  be  mistaken. 

The  Etiologry  of  Yello-w  Fever. — Since  the  paper 
on  the  etiology  of  yellow  fever,  by  Reed  and  his  co- 
workers, appeared  in  the  Philadelphia  Medical  Jour 


FlBBUABY  2,   1901] 


EDITORIAL  COMMENT 


CThb  Philadelphia  iqo 

Medical  Jocesal 


NAL  of  October  27,  1900,  these  investigators  have  dili- 
gently pursued  the  study,  and,  in  the  issue  of  this  jour- 
nal of  December  22,  a  telegram  from  Dr.  Reed  to  the 
surgeon-general  of  the  army  stated  that  inoculations 
had  been  successful  in  80%  of  cases.  Carlos  Finlay,  of 
Havana,  is  the  author  of  the  theory  of  the  transmission 
of  yellow  fever  through  the  agency  of  Culex  fasciata. 
As  early  as  1891  this  author  stated,  in  a  paper  which  was 
published  in  part  only,  in  1892,  that  the  first  idea  of  the 
mosquito  as  the  habitual  agent  of  the  disease  arose  from 
the  difficulty  of  accounting  for  the  propagation  of  yellow 
fever  upon  any  supposition  but  that  of  an  infection  pro- 
duced by  a  natural  inoculating  agent  which  should  first 
become  contaminated  from  a  yellow-fever  patient  and 
afterward  communicate  the  disease  by  inoculating  sus- 
ceptible persons  with  the  germs  which  it  had  picked  up 
and  retained.  Berenger-Feraud  attacked  the  theory  on 
the  ground  thiit  an  epidemic  propagated  from  Havana  to 
Saint-Nazaire  through  the  Anne-Marie,  in  1861,  could  not 
possibly  be  thus  accounted  for.  In  the  New  York  Med- 
ical Journal,  January  19,  1901,  Finlay  explains  this 
epidemic  according  to  the  mosquito  theory.  It  seems 
that  the  Anne-Marie  left  Havana  on  June  13,  1861, 
manned  by  the  same  crew  that  had  navigated  her  from 
France  to  Cuba  one  month  before.  At  the  beginning 
of  the  return  voyage  the  vessel  was  becalmed  for  12  days 
in  the  Florida  channel,  with  suffocating  heat,  frequent 
squalls,  and  heavy  rains.  On  the  first  and  second  of 
July,  1  nonfatal  and  2  fatal  cases  of  yellow  fever  devel- 
oped among  the  crew ;  these  3  men  must  have  been 
infected  before  the  ship  left  Havana.  Between  the 
fourth  and  the  eighth  of  July,  6  new  cases  developed, 
of  which  none  was  fatal.  With  the  loading  and  the 
provisioning  of  the  ship  it  is  highly  probable  that  a 
considerable  number  of  mosquito  eggs  and  larvae  were 
introduced  on  board,  and  that  a  whole  brood  of  new 
mosquitoes  was  produced  on  the  vessel  while  she  was 
becalmed  during  the  first  12  days  of  her  voyage,  and  that 
by  stinging  the  first  3  patients  taken  ill,  some  of  them 
infected  the  next  6  men  who  were  prostrated.  At  this 
time  the  calms  had  ceased  and  the  vessed  had  reached 
cooler  latitudes,  which,  together  with  the  attraction  of 
the  sugar,  caused  the  insects  to  take  refuge  in  the  hold. 
No  new  cases  developed  on  the  voyage  to  France ;  but 
when  the  hold  was  opened  at  the  wharf  at  Saint-Nazaire, 
on  July  27,  the  inoculated  mosquitoes  began  to  sting  all 
the  nonimmune  persons  who  came  within  their  reach, 
19  in  all,  and  all  of  these  contracted  the  disease.  Five 
other  persons  appear  to  have  taken  the  infection  on  the 
wharf  or  on  the  decks  of  other  vessels  in  close  proximity 
to  the  infected  ship.  The  infection  of  4  other  persons 
who  were  not  near  the  ship  is  accounted  for.  Owing  to 
climatic  influences  unfavorable  to  the  development  of 
new  broods  of  mosquitoes,  the  brood  hatched  on  the  ship 
early  in  July  would  have  become  extinct  during  the 
second  week  of  August,  and,  in  point  of  fact,  the  epi- 
demic ceased  at  that  time.     The  chain  is  also  traced  to 


the  Arequipa,  a  ship  moored  next  to  the  Anne-Marie 
at  Saint-Nazaire.  The  mosquito  theory  of  the  transmis- 
sion of  the  disease  has  been  attacked  by  Wasdin  (Phil- 
adelphia Medical  Journal,  November  17, 1900),  prin- 
cipally because  Reed  and  his  fellow  laborers  have  failed 
to  isolate  the  Bacillus  icteroides  from  their  patients.  We 
see,  however,  no  reason  why  the  mosquito  theory  of 
transmission  of  the  disease  in  incompatible  with  Sana- 
relli's  theory  of  the  specificity  of  the  microorganism. 
While  the  work  of  Sanarelli  is  most  valuable,  his  organ- 
ism has  not  been  finally  accepted  by  the  profession  as 
the  cause  of  yellow  fever.  Neither  has  the  profession 
accepted  the  new  theory  of  the  transmission  of  the  dis- 
ease. We  should  be  ready  to  be  convinced  by  compe- 
tent observers  both  that  the  Bacillus  icteroides  is  the 
cause  of  yellow  fever  and  that  it  is  carried  from  one 
person  to  another  by  mosquitoes. 

Prager  medicinische  Woehenschrift.  —  It  again 
becomes  our  pleasant  duty  to  congratulate  one  of  our 
contemporaries  across  the  sea.  The  beginning  of  this 
century  marks  the  twenth-fifth  anniversary  of  the 
Prager  medicinische  Woehenschrift.  With  its  present  con- 
tributors and  the  high-grade  character  of  its  articles, 
it  cannot  fail  to  maintain  its  position  in  medical 
journalism. 


Douglas  Abscess  in  Perityphlitis. — Rotter  {Deutsche 
med.  Woehenschrift,  Oct.  4,  1900)  says  that  among  the  ab- 
scesses caused  by  perityphlitis  the  most  frequent  is  (I) 
that  of  the  pelvic  cavity ;  (2)  the  Douglas  abscess ;  (3) 
that  of  the  lumbar  region ;  and  (4),  the  rarest,  the  sub- 
phrenic abscess.  Out  of  132  cases  of  perityphlitis  he  re- 
ports 41  of  abscess  in  the  Douglas  cavity,  or  about  J.  He 
defines  a  Douglas  abscess  as  one  which  has  its  base  in 
the  peritoneal  folds  of  the  Douglas  sac,  and,  increasing, 
reaches  the  intestinal  loops  above,  which,  when  adherent, 
form  a  covering  for  the  pus  cavity,  separating  it  from  the 
abdominal  cavity.  The  Douglas  abscess  is  formed  when 
the  perforation  of  the  appendix  permits  the  infecting  mate- 
rial to  scatter  through  the  abdomen  and  sink  to  the  lowest 
point,  the  base  of  the  Douglas  fold.  It  occurs  in  case  of  a 
fresh,  circumscribed  perityphlitic  suppuration  in  which  there 
is  a  serous  outflow  into  the  peritoneal  cavity  accompanying  a 
general  peritoneal  inflammation,  and  this  fluid  collecting  in 
the  Douglas  pouch  becomes  infected.  A  frequent  symptom 
accompanying  a  Douglas  abscess  is  a  distended  abdomen 
with  severe  suffering  of  the  patient,  simulating  the  symp- 
toms of  a  diffuse  peritonitis  ;  but  these  symptoms  are  the  re- 
sult of  the  pressure  of  the  abscess  upon  the  rectum  and  other 
organs,  causing  constipation,  etc.,  and  they  diminish  as  soon 
as  the  abscess  is  emptied.  In  women  it  is  often  diffi-ult  to 
determine  whether  the  Douglas  abscess  is  caused  by  disease 
of  the  appendix  or  of  the  generative  organs,  but  Rotter  be- 
lieves that  when  the  contents  contain  colon  bacilli  it  is  of  peri- 
typhlitic origin.  The  diagnosis  of  the  Douglas  abscess  is 
comparatively  easy  and  certain  by  means  of  rectal  examina- 
tion, and  this  is  the  best  method  by  which  to  ascertain  the 
proper  operative  treatment;  for  when  the  presence  of  an  ab- 
scess is  no  longer  in  doubt,  there  can  be  no  other  treatment 
than  operative.  In  women  the  incision  can  usually  be  made 
through  the  posterior  vaginal  wall,  though  in  young  girls 
Rotter  prefers  to  reach  the  Douglas  abscess  through  the  rec- 
tum. If  other  abscesses  are  found  to  exist  which  cannot  be 
emptied  through  the  Douglas  sac  an  abdominal  incision  be- 
comes necessary;  but  this  iuvolves  the  danger  of  spreading 
the  infection  and  causing  peritonitis,  only  to  be  avoided  by 
the  greatest  care  and  surgical  cleanliness,    [w.k.] 


Medical  Jol'Kna 


NAL  J 


CORRESPONDENCE— AMERICAN  NEWS  AND  NOTES 


[FeBBUABT  i,  IMi 


dorrcsponbcncc. 


PARTIAL'TRAUMATIC  PARALYSIS  OF  THE  TRIFACIAL 
NERVE. 

Bt  henry  M.  FISHEn,  M.D., 
of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Joitenal: — 

Michael  S.,  while  working  in  a  stable  one  month  ago,  was 
struck  by  a  companion  with  a  pitchfork.  One  of  the  prongs 
of  the  fork  caused  a  pretty  severe  lacerated  wound  of  the 
mucous  membrane  of  the  right  cheek  and  the  other  made  a 
penetrating  wound  of  the  left  lower  eyelid  about  one-third  of 
an  inch  to  the  left  of  the  middle  of  the  eyeball.  He  was 
taken  to  the  Pennsylvania  Hospital  where  the  wound  of  hie 
right  cheek,  which  was  bleeding  profusely,  was  sutured. 

For  two  or  three  days  there  was  complete  anesthesia  of  the 
left  side  of  his  face  and  he  experienced  difficulty  in  speaking 
and  in  swallowing.  Anesthefia  is  no  longer  absolute  on  the 
affected  side,  but  even  now,  if  he  does  not  pay  strict  atten- 
tion, part  of  his  food  regurgitates  through  his  left  nostril. 

No  hemianesthesia  of  the  tongue.  For  a  few  days  hearing 
was  slightly  impaired  in  the  left  ear  and  even  now  he  experi- 
ences occasional  deafness  on  that  side. 


ABOUT  THE  RED  BLOOD-CELL. 
By   M.  GIRSDAX.'JKY,  M.D., 

of  New  York. 

To  the  Edilorlof  Tas  Philadelphia'Mkdical  Journal  : — 

The  human  red  blood  cell  is  ordinarily  described  as  "a 
circular,  biconcave  disc,  with  rounded  edges,  composed  of  a 
colorless,  structureless,  and  transparent  filmy  framework  or 
stroma.    (Kirke's  Physiology.) 

When,  however,  the  red  blood-cell  is  destroyed,  as,  e.  g.,  in 
"  laky  blood,"  it  appears  under  a  high  power  "  as  an  obscurely 
spongy  reticulated  disc,"  which  may  be  stained  by  various 
reagents  (Foster). 

This  is  all  more  or  less  ancient  history,  and,  of  course,  very 
well  known  to  all  of  us. 

Under  the  following  procedure  the  red  blood-cell  will 
appear  as  a  beautiful  fenestrated  reticulum,  somewhat  re- 
sembling the  foliated  tracery  of  Gothic  architecture  : 

With  the  ordinary  precautions  of  cleanliness,  make  a  thin 
spread  of  newly-shed  blood  in  the  usual  manner.  Fix  the 
film  either  by  leaving  the  slide  for  2  hours  in  a  mixture  of 
equal  parts  of  absolute  alcohol  and  ether,  or  by  gently  heat- 
ing the  slide  over  the  flame  of  an  alcohol-lamp  for  a  few 
minutes.    Flood  the  slide  with  the  following  solution : 

Saturated  alcohol-solution  of  methylene-blue,  3  parts. 

Water 3  parts. 

Absolute  alcohol 3  parts. 

Carbolic  acid,  C.P 1  part. 

Mix ;  wash  it  in  a  gentle  stream  of  water  and  restain  with 

Eosin — sat.  alcohol-sol 1  part. 

Water 10  parts. 

Mix ;  wash  it  in  a  similar  manner  and  restain  with 
Loeffler'ts  solution : 

Concentratedlalcohol-solution  of  methylene- 
blue 30  parts. 

1 :  10,000  watery  solution  of  caustic  potash. .100  parts. 

Mix  ;  wash  in  water,  dry  and  examine  without  cover-glass 
in  cell  or  oil  with  a  -^^  oil-immersion  lens. 


21m?rican  HctDs  ant  Hotcs. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

Dr.  Edward  Stieren  of  Pittsburg,  Pennsylvania,  has 
been  appointed  ophthalmic  surgeon  to  the  McKees  Socks 
General  Hospital. 

Dr.  Charles  A.  Oliver  has  recently  received  the  honor- 
ary degree  of  A.M.  from  Lafayette  College  and  has  been 
made  one  of  the  honorary  vice-presidents  in  the  sfctionof 
ophthalmology  a*,  the  Third  Pan-American  Medical  Congreas. 

State  Board  Examination. — Eighty-seven  applicants 
for  medical  diplomas  took  the  examination  before  the  board 
of  medical  examiners  of  the  State  Medical  Society  ct  Penn- 
sylvania at  Philadelphia  last  December,  and  48  passed,  85 
failed,  2  withdrew  and  2  were  disqualified. 

German  Hospital  Election. — The  annual  meeting  of 
the  trustees  of  the  German  Hospital  was  held  January  29, 
and  the  following  officers  elected  for  the  ensuing  year  :  Presi- 
dent, JohnD  Lankenau ;  vice-president,  M  Richards  M'lckld; 
secretary,  Rev.  F.  Wischan  ;  treasurer,  Charles  Woerwag; 
solicitor,  Joseph  A.  Rosengarttn.  The  entire  medical  stafl 
was  reelected. 

Results  from  Antitoxin. — A  report  prepared  by  the 
Lancaster  Bnard  of  Health,  relative  to  the  use  of  antitoxin 
in  treating  diphtheria,  shows  the  following  results  :  Last  year 
262  cases  of  diphtheria  were  reported  to  the  board  of  health, 
of  which  number  28  resulted  fatally.  In  1892.  when  anti- 
tixin  was  unknown,  260  cases  were  reported,  ard  there 
were  63  deaths.  In  1895  there  were  229  cases  and  68  deaths, 
and  in  1897,  197  cases  and  38  deaths. 

Philadelphia  Polyclinic. — At  the  annual  meeting  of 
the  corporators  of  the  Pniladelphia  Polyclinic,  the  following 
trustees  were  elected  :  William  K.  Donovan,  Judge  Ashman, 
Franklin  B  Kirkbride,  J  E.  Sterrett,  Hon.  Henry  K.  Boyer, 
Georgp  T  L'ppincott,  Nsthaniel  B  Crenshaw,  William  F. 
Read,  C  8.  W.  Packard,  Henry  B.  French,  Nelson  Z.  Grave*, 
John  Scott,  Jr.,  and  James  Crfisby  Brown.  Miss  Marie 
Blanchard  ani  Mrs.  Thomas  S.  Kirkbrice,  Jr  ,  were  eUcted 
members  of  the  corporation.  Dr.  Howard  F.  Hansell,  Presi- 
dent of  the  Faculty,  presented  a  report  covering  the  medical 
work  of  the  institution  during  the  past  year,  and  Miss  Ban- 
field,  Superintendent  cf  the  Hospital,  presented  a  report  of 
the  hospital  and  training  schools. 

Additions  to  Hospital  Staff. — At  the  meeting  of  the 
Department  of  Charities  and  Ccrrection,  J.uiuary  24.  there 
were  13  additional  members  appointed  to  the  medical  board 
of  the  Philadelphia  Hospi'al.  Tne  board  is  constituted  as 
follows : 

Surgeons. — Drs.  W.  Joseph  Heam,  L.  W.  St«inbach,  Orrille  Hor- 
witz,  Krnest  La  Place.  Edvraid  Martin,  J.  C.  DaCosta,  Alfred  C. 
Wood.  Charles  H.  Frazer. 

r/ipsiciaris  —Drs.  R.  G.  Curtin,  J.  H.  Musser.  F.  P.  Henry,  W.  E 
Hughes,  S.  Solis  Cohen,  J.  L.  Salinger,  James  Tyson.  Thomas  G. 
Ashton,  A.  A.  Eshner.  Alfred  Stengel,  H.  B.  Allyn.  David  Kiesman. 

Ohrtetricians  — Drs.  Barton  C  Hirst.  JMward  P.  Davis.  George  Y. 
McKelway.  J.  M.  Fisher,  R.  C.  Norris,  W.  Frank  Haehnlen,  El«»- 
hetli  I,.  Peck,  John  B.  8tiober. 

.Vriiro/offiX..  — Drs.  C.  K.  Mills,  F.  X.  Dercam,  Charles  W.  Btur, 
F.  Savary  Pearce.  William  G.  Spiller,  Charles  S.  Potts. 

Opfirhalmi'l',gixt.'>—l>Ts  G  E.  deSchweinitz,  Charles  A.  Oliver. 
Howard  F.  Hansell,  John  W.  Croskev. 

D.Tmntnlogisls.—Drf.  W.  H.  Stelwagbn,  H.  B.  Hartiell,  E.  S.  Gans. 

I'lithtilogists. — Drs.  W.  M.  L.  Coplin,  Joseph  McFarland,  8imoo 
Fleiner. 

Kartrrwlogist  — Dr.  L.  X.  Boston. 

Lnryngnlogi/ts — Drs.  George  Morley  Marshall.  E.  B  Gleason. 
Charles  P.  Grayson. 

Anefthetizer — Dr.  Charlfs  Leonard. 

Drntiil  Surgnnis  — Drs.  R.  H.  Xones,  M.  H.  Cryer.  L  Xorman 
Broomall,  C.  Stelwagen.  Jr. 

P.-iiMtriftf  —Drs.  William  C.  Hollopeter,  E.  E.  Graham,  J.  P. 
Crozer  Griffith.  J.  Madison  Taylor. 

Orthopedic  Surgeons. — Drs.  H.  Augustus  Wilson,  J.  P.  Mann,  G.G. 
Davis. 

Eegi.'>lrnrs. — Drs.  Joseph  Sailor,  William  C.  Pickett.  Robley  D. 
Newton,  B.  Franklin  Stahl,  W.  A.  X.  DorLind,  J.  H.  McKee. 

The  present  corps  of  50  outdoor  physicians,  consisting  of 
1  regular  and  1  homeopaihist  to  each  of  the  2>  districts  into 
which  the  city  is  divided  for  this  purpose  was  reappointed. 


FKBBCiBT  2,  1901J 


AMERICAN  NEWS  AND  NOTES 


["The  Philadelphia 
L  Medical  Journal 


195 


Vital  Statistics  of  Philadelphia  for  the  week  ended 

January  26,  1901 : 

Total  mortality 536 

CilSES.      Dbaths. 
Inflammation  of  appendix  3,  bladder  1,  brain 
14,   bronchi  12,  kidneys  2-1,   lungs  6»,  peri- 
toneum 7,  stomach  and  bowels  15,  spine  2, 
of  larynx  1,  of  liver  4,  pleura  1,  nerves  1  .  153 

Inanition  13,  marasmus  9,  debility  4 26 

Tuberculosis  of  lungs 53 

Apoplexy  25,   paralysis  16 24 

Heart — fatty  degeneration  of  3,  neuralgia  2, 

other  diseases  of  34  39 

Uremia  11,  diabetes  4,  Bright's  disease  13  .   .   .  28 

Casualties 11 

Carcinoma  of  breast  2.  stomach  5,  uterus  3, 
face  1,  bladder  1,  neck  1,  back  1,  bowels  1, 

rectum  1,  liver  1 17 

Convnlsions 20 

Diphtheria 101  15 

Brain — softening  of  1,  congestion  of  1  ...   .  2 

Typhoid  fever 16 

Old  age 16 

Burns  and  scalds 2 

Dysentery 1 

Suicide 5 

Cirrhosis  of  liver 5 

Alcoholism 1 

Cyanosis 3 

Scarlet  fever 75  4 

Influenza 20 

Abscess — of  brain  I ,  of  head  2,  psoas  1  .   .   .  4 

Asthma  3,  anemia  3,  congestion  of  the  lungs 
2,  carbuncle  2,  cellulitis  of  neck  1,  croup  1, 
membranous  croup  5,  diarrhea  1,  drowned 
1,  epilepsy  2.  erysipelas  1,  senile  gangrene  1, 
of  the  foot  1,  hemorrhage  from  lungs  1, 
homicide  1.  jaundice  1.  leukemia  1,  obstruc- 
tion of  the  bowels  3,  edema  of  lungs  2,  pur- 
pura hemorrhagica  1,  retention  of  urine  1, 
arteiial  sclerosis  2,  surgical  shock  4,  septi- 
cemia 1,  sarcoma  1,  of  the  chest  1,  stricture 
of  esopliagus  1,  tumor  of  abdomen  2,  of 
brain  1,  ovarian  1,  ulceration  of  the  stom- 
ach 3,  whooping  cough  1,  gastric  fever  1  .   .  32 

Philadelphia   County    Medical    Society. — At    the 

stated  meeting,  held  January  23,  Dr  Albert  E.  Roissel  re- 
ported 3  cases  of  nialig-nant  endocarditis.  In  Case  1 
the  ditease  followed  measles.  In  Case  2  the  patient  was  but 
9  years  of  age  and  was  convalescing  from  a  typical  attack  of 
typhoid  fever.  During  the  attack  of  endocarditis  the  tem- 
perature was  mostly  subnormal,  rarely  rising  above  101°. 
There  was  enlargement  of  the  axillary  and  cervical  glands,  a 
leukocytosis  (.f  over  50,000  with  the  presence  of  poikilocytes 
and  niacrocyles,  and  the  spleen  extended  below  the  umbili- 
cus. Autopsy  showed  valve  lesions  and  infarcts  in  the  spleen 
and  livfr.  The  case  was  reported  as  one  simulating  leuke- 
mia. Case  3  terminated  in  recovery.  This  naturally  threw 
some  doubt  on  the  diagnosis,  but  this  was  believed  to  be  cor- 
rect because  (a)  the  patient  had  shortly  before  passed  an  ex- 
amination for  life  insurance;  (6)  during  the  attack  multiple 
abccesses  were  opened  in  various  parts  of  the  body  and  these 
contained  streptococci ;  the  blood  also  contained  streptococci ; 
(c)  the  heart  lesion  has  persisted  since  the  a  ttck,  as  shown 
by  muimurs.  In  ditcutsing  the  paper  Dr.  James  Tysos  said 
he  had  seen  no  recoveries  and  had  come  to  think  the  recov- 
ery of  a  case  meant  error  in  diagnosis.  As  to  the  terminol- 
ogy, he  would  class  cases  as  simple  infective  and  malignant 
infective.  Dr.  J.  M.  Anders  said'  the  chief  interest  lay  in 
the  diagnosis.  Sometimes  a  reasonably  certain  disgnosis  can 
be  bast-d  on  a  septic  temperature,  murmur?,  and  embolic 
symptoms  even  though  there  be  no  primary  disease  to  suggest 
endocarditis.  Visceral  and  cutaneous  embolism  are  the  most 
important  diagnostic  points.  In  obscure  cases  a  diagnosis 
by  exclusion  from  typhoid  fever,  cerebrospinal  fever,  and 
malaria,  can  now  be  made  by  methods  not  formerly  in  vogue, 
as  bloi'd  examinations,  lumbar  puncture,  etc. 

Db  Ji  hn  B  Roberts  read  a  report  of  two  cases  of  epi- 
plopexy  iu  cirrhosis  of  the  liver  and  described  the  tech- 
nic  ot  tue  operation  which  he  uses.  Botu  cases  died,  one  in  6 
months,  the  other  the  day  following  the  operation.  Dr.  Roberts 
stated  that  it  was  yet  tco  early  to  know  the  real  value  of 
operation  in  these  cases,  but  as  the  operation  itself  is  a 
trivial  one  and  the  disease  is  so  intractable  early  operation 
seems  advisable.  The  operation  is  done  under  local  anes- 
thesia, an  incision  beine  made  above  the  umbilicus  and  a 
finger  introduced  to  hold  the  omentum  against  the  abdomi- 
nal wall.    Sutures  of  chromicized  catgut  are  then  passed  by 


a  long  curved  needle  which  penetrates  the  skin,  abdominal 
wall,  and  omentum,  coming  out  through  the  skin  about  an 
inch  from  the  point  of  insertion.  The  abdominal  wall  or 
omentum  should  not  be  rolled  up  as  this  makes  the  stitches 
liable  to  tear  out.  The  omentum  should  also  be  anchored 
in  the  wound  when  the  abdominal  incision  is  closed.  This 
operation  should  be  done  as  soon  as  practicable  after  the 
diagnosis  is  made.  Dk.  Tyson  stated  that  he  had  had  one 
obstinate  case  operated  upon,  the  patient  leaving  in  2  or  3 
months  apparently  cured.  The  impression  made  by  this 
case  was  a  favorable  one  and  he  is  inclinpd  to  encourage  the 
procedure  in  selected  cases.  Dr.  W.  il.  L.  Coplin  considers 
it  a  question  as  to  whether  anything  is  gained  by  shortr cir- 
cuiting the  portal  circulation.  At  autopsy,  in  cases  of  cirrho- 
sis, a  subcapsular  vein  is  often  seen  through  which  a  probe 
can  be  parsed  from  the  portal  to  the  hepatic  vein.  One  case 
was  cited  in  which  ascites  ceased  after  the  patient  had  been 
tapped  at  various  times  during  several  years.  Autopsy 
showed  a  tortuous  vein  on  the  under  surface  of  the  liver  con- 
necting the  portal  and  hepatic  veins,  yet  the  patient  died. 
If  operation  is  to  relieve  ascites  it  is  effective.  If  it  is  to 
overcome  the  condition  causing  ascites  it  does  not  promise 
80  much.  Dr.  Ernest  LaPlace  said  that  in  these  cases  the 
liver  was  already  incapacitated  for  doing  work  and  so  differed 
from  experimental  cases  where  the  liver  function  was  sud- 
denly stopped.  He  believes  the  operation  is  a  rational  one. 
It  does  not  cure  the  patient  but  prolongs  life. 

Dr.  Albert  Bernheim  read  a  paper  on  Albuminous 
nutrition  and  nutritious  albuniin-tropou.  Several 
cases  illustrating  the  value  of  tropon  were  cited. 

A  paper  by  Dr.  L  F.  Flick.  The  summer  cold  ;  swim- 
mings-pools as  an  etiologic  factor,  was  read  by  title. 

Pathological  Society. — The  meeting  of  January  24  was 
devoted  to  *  Symposium  on  diabetes.  Dr.  D.  L.  Edsall 
spoke  on  The  metabolism  of  diabetes.  The  speaker 
stated  that  the  disease  was  a  partial  starvation  affecting  the 
carbohydrates  of  the  food.  The  sum  total  of  metab  ilism  in 
a  case  of  diabetes  is  normal.  The  excessive  output  of  niiro- 
gen  has  been  explained  in  3  ways:  (1)  It  is  the  result  of 
taking  in  large  quantities  of  nitrogenous  food  ;  (2)  it  is  the 
result  of  some  toxic  or  nervous  excitant ;  (3)  not  enough  food 
is  taken  in  and  the  tissues  are  breaking  down.  The  last  may 
be  proved  conect  by  putting  the  patient  on  a  nitrogen 
balance.  As  a  rule,  there  is  no  disturbance  of  digestion. 
Alimentary  glycosuria  is  the  condition  most  closely  resem- 
bling diabetes,  but  differs  from  .t  in  the  following  particulars  : 
(1)  A.imentary  glycosuria  is  purely  dependent  on  the  taking 
of  sugar  in  over  amounts  ;  (-)  it  does  not  tend  to  increase  ; 
(3)  the  sugar  excreted  is  the  same  kind  that  is  taken ;  (4) 
only  carbohydrates  will  cause  it. 

Dr.  Edsall  snoke  for  Dr  Simon  Flexser  (who  cou'd  not 
be  presen)  on  The  relation  of  the  kidney,  liver,  and 
pancreas  to  diabetes.  Concerning  the  kidney  it  was 
stated  that  there  is  no  satisfactory  evidence  of  glycosuria 
without  hyperglycemia.  Pathologically,  there  is  no  evidence 
that  the  kidney  is  related  to  diabetes  in  a  causal  way.  The 
so- called  hvalin  degeneration  of  the  kidney  is  a  deposit  of 
glycogen.  As  to  the  liver  there  are  pathological  alterations 
in  a  large  number  of  cases  of  diabetes,  but  they  are  of  much 
greater  frequency  when  diabetes  is  not  present.  Dr.  Flexner 
has  stated  that  he  can  tell  a  diabetic  liver  by  lookirg  at  it 
owing  to  a  peculiar  appearance  of  the  organ.  There  is  no 
conclusive  clinical  evidence  that  the  liver  is  a  cause  of  dia- 
betes and  experimental  results  are  against  it.  It  is,  there- 
fore, probable  that  it  is  not  a  primary  cause  but  is  accessory 
and  intentifies  the  condition  if  there  is  liver  disea^e  in  con- 
nection with  diabetes.  As  to  the  pancreas,  the  results  of 
experimental  work  with  animals  show  that  diabetes  is  inev- 
itable if  the  pancreas  is  removed.  Tnis  result  is  avoided  if 
only  a  small  part  of  the  organ  be  left.  Some  obsei  vers  sUte 
that  in  diabetes  there  is  a  sclerosis  surrounding  the  islands 
of  Langerhans  in  the  pancreas.     This  has  not  been  proven. 

The  pfper  of  Dr.  John  Marshall  on  The  chemistry  of 
the  urine  in  diabetes  was  read  by  Dr.  A  C.Abbott. 
The  various  tests  for  sugar  were  reviewed  and  their  err  jrs 
pointed  out  Espet  ial  attention  was  called  to  the  fact  that 
formaldeh\d,  chloral  hydrate,  and  chloroform  will  reduce 
cupric  to  'cuprous  oxid.  The  various  phases  of  the  subject 
of  the  evening  were  discussed  bv  Drs.  Wadsworth,  Ries- 
MAS,  CoPLiN,  Daland,  Wilsox,  McFarland  and  Shumway'. 


196 


The  Philadklphia"] 
Medical  Joubnal  J 


AMERICAN  NEWS  AND  NOTES 


(Febecabi  2,  ] 


Neurological    Society. — The  meeting  of  January  28 
was  devoted  to  a  syniposium  on  brain  tumors.     Dr. 

Whaeton  Sinkler  reported  two  cases  of  paresis  with 
symptoms  of  brain  tumor.  Attention  was  called  to  the 
fact  that  in  some  cases  of  paresis  almost  typical  Jacksonian 
convulsions  occur.  Later  on  in  the  disease  hemiplegia,  and 
at  times  aphasia,  occur.  In  these  cases  when  mental  symp- 
toms are  not  prominent  it  is  difficult  to  believe  that  brain 
tumor  is  not  present.  Two  cases  illustrating  this  point  were 
detailfd.  Dr.  F.  X.  Deeccm  gave  the  history  of  a  colored 
boy,  12  years  of  age,  who  had  hemiplegia,  homonymous 
hemianopsia,  and  Wernicke's  symptom.  Autopsy 
revealed  a  large  irregular  mass  in  the  left  occipital  region, 
subcortical,  which  cut  off  the  fibers  of  Gratiolet  and  inter- 
fered with  the  optic  thalamus.  Wernicke's  symptom  was 
probably  due  to  pressure.  Dr  John  K.  Mitchell  reported 
a  case  of  extensive  endothelioma  of  the  brain.  Points 
of  interest  in  the  case  were  :  1.  The  long  period  of  growth, 
symptoms  being  prominent  for  about  9  years.  2.  The  inter- 
mittent character  of  the  symptoms.  There  were  intervals  of 
days  and  even  weeks  when  absolutely  no  symptoms  were 
present.  3.  A  period  of  temporary  improvement  followed 
the  use  of  iodide.  4.  The  large  size  of  the  tumor,  which 
measured  7  by  8  cm.  Dr  Charles  K.  Mills  spoke  of  the 
localization  of  brain  tumors  with  special  reference  to 
the  parietal  and  prefrontal  regions,  5  cases  being  cited.  The 
importance  of  sensory  disturbances  before  motor  phenomena 
appear  was  strongly  emphasized,  as  it  is  largely  by  these, 
with  visual  changes,  that  the  diagnosis  is  made.  Another 
point  to  be  remembered  is  that  every  tumor  of  considerable 
size  invades  some  locality  other  than  that  in  which  it  origi- 
nates. The  reflexes  show  this  well.  Take  the  Babinski 
reflex  when  the  tumor  is  in  the  parietal  region.  If  there  is 
not  much  pressure  this  reflex  will  not  be  present.  As  the 
tumor  grows  toward  the  motor  region  the  plantar  reflex 
changes.  The  same  is  true  of  ankle  clonus  which  comes  on 
as  the  tumor  invades  brain  tissue.  There  is  a  difference  in 
the  sets  of  phenomena  depending  on  which  cerebral  hemi- 
sphere is  involved,  there  being  a  more  distinct  disordering 
of  the  mu'ole  sense  when  the  lesion  is  in  the  left  hemisphere. 
Dr.  a.  a.  Eshner  exhibited  for  Dr.  David  Riepman  a  case 
showing  unilateral  oculomotor  palsy  probably  due 
to  a  gumma.  Dr.  W.  W.  Keen,  in  opening  the  discussion, 
spoke  ot  the  advantage  of  the  large  osteoplastic  flip.  In  one 
case  he  turned  down  a  rather  triangular-shaped  flip,  the 
apex  of  the  triangle  being  below  and  very  small.  A  sign 
elicited  in  one  case  was  a  cracked-pot  sound,  which  could  be 
elicited  from  the  frontal  region  to  the  binauricular  line.  This 
was  due  to  the  bones  forming  the  coronal  suture  being 
slightly  separated  by  the  pressure  of  the  tumor.  The  amount 
of  injury  that  can  be  inflicted  upon  the  brain  without  ill 
results  is  very  great.  In  a  recent  case  the  lateral  ventricle 
was  opened,  this  being  recognized  by  the  change  in  color  of 
the  blood  due  to  admixture  with  the  fluid  of  the  ventricle. 
No  untoward  symptom  followed.  The  early  recovery  of 
motor-function  after  an  operation  is  noticeable,  one"  boy 
moving  his  previously  paralyzed  arm  and  leg  within  48 
hours  after  the  operation.  One  surgical  problem  is  difficult  to 
solve — the  avoidance  of  both  hemorrhage  and  fungus  cerebri. 
Two  of  the  five  cases  reported  by  Dr.  Mills  (all  of  whom 
were  operated  upon  by  Dr.  Keen)  died,  one  from  shock 
and  the  other  from  hemorrhage.  This  hemorrhage 
was  oozing  which  followed  the  operation.  Drainage 
would  perhaps  have  saved  that  patient,  but  one  is 
tempted  to  close  the  wound  without  drainage  in  these 
cases  in  order  to  prevent  fungus  cerebri.  Warned  by 
the  case  lost,  however,  {drainage  of  gauze  was  ustd  for  24 
hours  in  a  case  operated  upon  a  few  weeks  since.  Despite 
the  early  removal  of  the  gauze,  fungus  cerebri  is  now  threat- 
ening This,  however,  is  more  readily  dealt  with  than  is 
hemorrhage.  Nothing  will  be  done  with  the  condition 
should  it  develop  except  a  daily  dressing  and  cutting  it  off 
even  with  the  scalp.  One  case  healed  perfectly  by  thus 
treating  it  conservatively.  In  very  large  tumors  it  is  desir- 
able that  the  operation  be  done  in  two  stages.  The  import- 
ance of  early  operation  was  strongly  urged.  The  family 
physician  or  neurologist  is  the  first  to  see  these  cases.  If 
treatment  for  6  weeks — almost  always  by  the  iodids — causes 
no  improvement  operation  should  be  done  at  once.  Dr. 
W.  J.  Taylor  said  that  there  was  always  more  danger  from 
venous  than  from  arterial  bleeding.    A  point  in  the  operation 


is  the  determination  of  the  thickness  of  the  ekull.  Dr. 
Keen  now  usually  makes  a  preliminary  opening  with  a 
small  trephine  for  this  purpose.  The  flap  is  then  made  with 
chisels.  Dr.  G.  E.  DeSchwetsitz  spoke  on  changes  in  the 
eye  caused  by  brain  tumors.  From  statistics  published  it  i» 
safe  to  say  that  optic  neuritis  occurs  at  some  period  during 
the  course  of  at  least  78^  of  brain  tumors.  Personally,  Db. 
DeSchweinitz  believes  that  the  percfntage  is  larger  than 
this.  Tables  giving  the  relative  frequency  of  location  were 
read.  It  has  been  said  that  two  regions  are  never  affected — 
the  hypophysis  and  medulla.  The  former  is  incorrect. 
Death  from  tumors  of  the  medulla  comes  too  soon  to  allow 
of  optic  neuritis.  This  condition  may  be  unilateral.  When 
so  it  is  4  times  as  frequent  on  the  affected  side.  Choked  disc 
is  not  always  present,  the  inflammation  taking  the  form  of 
a  papillo  retinitis.  The  star-shaped  figure  seen  in  the  mactila 
is  of  importance  in  that  it  also  occurs  in  Bright's  disease  and 
in  syphilitic  retinitis,  hence  it  is  not  pathognomonic  of  brain 
tumor.  Optic  neuritis  is  of  no  value  as  a  localizing  symptom. 
The  size  of  the  tumor  has  no  influence  on  the  degree  of  neu- 
ritis. The  tffect  of  operation  on  choked  disc  is  to  produce 
a  lessening  soon  after  and  there  is  also  an  improvement  in 
vision  in  the  majority  of  cases.  The  appearance  of  total 
blindness  is  of  some  localizing  value.  At  times  there  is  a 
degeneration  of  ganglion  cells  in  the  retina  causing  altera- 
tions in  the  visual  field  which  must  not  be  mistaken  as  a 
sign  of  brain  tumor.  This  is  a  point  which  has  not  received 
the  attention  that  it  deserves.  As  to  the  varieties  of  choked 
disc  there  are  three  :  an  elevation  due  to  edema  of  the  disc; 
elevation  due  to  inflammation,  and  elevation  the  result  of  a 
blending  of  these  two.  Wernicke's  symptom  is  of  import- 
ance, but  is  the  most  difficult  to  elicit  of  any  test  used  in 
connection  with  the  eye.  The  best  way  to  examine  for  this 
is  to  have  the  patient  behind  a  lamp  with  a  rather  weak 
mirror  throwing  a  light  in  his  face.  A  strong  or  short  focus 
mirror  is  then  used  to  throw  a  beam  of  light  in  the  eye. 
Dr.  Dercum  Slid  that  for  astereognosis  to  have  a  localizine 
value  in  cerebral  tumors  sensation  must  be  preserved.  U 
cortical  it  must  be  accompanied  with  motor  or  sensory  phe- 
nomena, especially  motor.  He  has  seen  Wernicke's  symptom 
in  one  case  when  the  patient  was  simply  in  a  dark  room  and 
a  candle  was  used. 

NEW  YORK. 

Numerous  persons  were  vaccinated  in  Oswego,  N.  Y., 
as  a  preventive  of  smallpox.  The  schools  have  been  closed 
for  this  purpose. 

Tuberculosis  Bill. — The  bill  provides  that  the  Commis- 
sioner of  Agriculture  instead  of  the  State  Bjard  of  Health 
shall  have  jurisdiction  over  domestic  animals  affected  with 
tuberculosis,  and  further  provides  for  the  appointment  of  a 
State  Appraiser  of  condemned  cattle.  The  bill  carries  with 
it  an  appropriation  of  $10,000.  The  committee  decided  to 
report  the  bill  favorably. 

State  Medical  Society — The  following  resolution  was 
adopted  by  the  Medical  Society  of  the  State  of  New  York : 
Resolved,  That  the  Medical  Society  of  the  State  of  New  York 
heartily  endorses  the  report  of  the  Tenement  house  Ccmmit- 
tee  appointed  by  Governor  Roosevelt,  and  urgently  request, 
the  legislature  to  adopt  ite  recommendations  regarding  the 
improved  housing  of  the  poor,  and  the  further  control  of  the 
spread  of  infectious  diseases. 

Woman's  Medical  Association  of  New  York  City. 

— The  Alumni  .\^sociation  cf  the  Woman's  Medical  College 
of  the  New  Y'ork  Infirmary  for  Women  and  Children,  has 
undergone  certain  changes.  It  was  deemed  advisable  to 
make  the  society  a  living  force  by  adopting  its  present  more 
comprehensive  name,  and  making  women  physicians,  grad- 
uates of  regular  schools  at  horeie  and  abroad,  eligible  toai^tive 
membership.  The  president  of  the  Association  is  Dr  Eliu- 
beth  M.  Cushier,  and  the  secretary  Dr.  Evelyn  G-irrigues. 

New  Bill    Defining  Practice  of  Medicine.— The 

following  bill  is  under  consideration  in  New  York  Slate: 
"Any  person  shall  be  regarded  as  prattisirg  medicine  within 
the  meaning  of  this  act  who  shall  prescribe,  direct,  recom- 
mend, or  advise,  for  the  use  of  any  other  person,  any 
remedy    or  agent    whataocTer,    whether  with    or    without 


Fbbbdaet  2,  1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia 
L  Medical  Journal 


197 


the  use  of  any  medicine,  drug,  instrument,  or  other  appli- 
ance, for  the  treatment,  relief,  or  cure  of  any  wound,  frac- 
ture, or  bodily  injury,  infirmity,  physical  or  mental,  or  other 
defect  or  disease.  This  article  shall  not  be  construed  as  pro- 
hibiting the  service  of  any  person  in  an  emergency,  or  the 
domestic  administration  of  family  remedies." 

NEW  ENGLAND, 

Dr.  Charles  W.  Stevens  died  suddenly,  January  24, 
1901,  at  his  home,  in  Cbarlestown,  aged  64.  Dr.  Stevens  was 
bom  in  Marlow,  N.H.,  his  father  having  been  a  distinguished 
surgeon,  prepared  for  college  at  Wilbraham  Academy,  and 
was  graduated  at  Harvard  in  the  class  of  1860.  He  went 
abroad  in  1861  and  began  the  study  of  medicine  in  London, 
at  the  same  time  teaching  school.  He  came  home  before 
completing  his  studies  and  took  his  M  D.  from  Harvard  in 
1870.  He  at  once  located  in  Cbarlestown  and  remained  there 
until  his  death.  He  served  as  city  physician  in  1872,  and 
was  at  one  time  surgeon  to  the  Wilson  &  Furness  line  of 
steamers.  Dr.  Stevens  compiled  the  tirst  book  of  college 
songs  ever  published  in  this  country  and  was  the  author  of 
many  works. 

CHICAGO  AND  WESTERN   STATES. 

For  a  State  Hospital. — A  bill  has  been  introduced  into 
the  Senate  of  Missouri  for  the  erection  of  a  State  hospital  to 
cost  $1,000,000. 

Smallpox  in  Iowa. — Forty  cases  of  smallpox  have  been 
reported  in  various  parts  of  the  State  notwithstanding  every 
possible  precaution. 

Smallpox  in  Chicago. — A  requisition  has  been  made 
by  the  Health  Department  for  8  more  men,  on  account  of  the 
prevalence  of  smallpox. 

Dr.  S,  J.  Quint,  formerly  resident  physician  of  the 
California  Hospital,  has  been  appointed  instructor  of  materia 
medica  in  the  medical  department  U.  S.  C. 

Appointment. — Dr.  J.  H.  Davisson,  Dr.  Charles  F.  Tag- 
gart.  Dr.  J.  W.  Trueworthy,  and  Dr.  C.  W.  Bryson  have  been 
appointed  members  of  the  Los  Angeles  Board  of  Health. 

Hospital  for  Tuberculosis,— Treasurer  Edward  G' 
Uhlein  of  the  citizens'  committee  for  the  erection  of  a  hos- 
pital for  the  treatment  of  consumptives,  has  issued  a  report 
for  January,  showing  that  $454  has  been  donated  during  the 
month.  The  amount  now  on  hand  for  the  undertaking  is 
$20,067. 

Oflicers  Chosen. — At  the  annual  meeting  of  the  Medi- 
cal Society  of  City  Hospital  Alumni,  St.  Louis,  the  follow- 
ing officers  were  elected  for  the  ensuing  year :  President, 
Dr.  Norvelle  Wallace  Sharpe ;  vice-president,  Dr.  Francis  L. 
Reder ;  secretary,  Dr.  John  Green,  Jr. ;  treasurer.  Dr.  Horace 
W.  Soper. 

Dr.  Henry  J.  Herrick,  a  widely  known  physician  and 
Burgeon,  died  at  Cleveland,  Ohio.  He  was  for  many  years 
professor  of  the  medical  department  of  the  Western  Reserve 
University.  He  was  a  member  of  the  Loyal  Legion,  and 
served  as  a  surgeon-general  of  the  Ohio  national  guard  dur- 
ing Governor  Foraker's  administration. 

Fox  River  Valley  Medical  Society. — The  annual 
meeting  of  the  Fox  River  Valley  Medical  Society,  of  Green 
Bay,  Wis.,  was  held  January  22,  about  50  members  being 
present.  President  L  O.  Oviatt,  of  Oshkosh,  presided,  and 
Dr.  J.  S.  Reeve,  of  Appleton,  acted  as  secretary.  Dr.  W.  A. 
Slaughter,  ff  Green  Bay,  was  elected  president  of  the  society  ; 
Dr.  A.  M.  Kiersten,  of  Depere,  first  vice-president;  Dr.  C.  E. 
Boyd,  of  Kaukauna,  second  vice-president ;  Dr.  S.  J.  Reeve,  of 
Appleton,  secretary  and  treasurer;  Dr.  H.  B.  Tanner,  of 
Kaukauna,  censor.  It  wae  voted  to  hold  the  next  annual 
meeting  in  Green  Bay.  The  quarterly  meetings  were  decided 
upon  as  follows  r  Waupaca  in  July,  Neenah  in  April,  acd 
Oihkosh  in  October. 

SOUTHERN  STATES. 

Smallpox  in  the    University    of  Virginia. — It    is 

stated  that  there  are  4  cases  of  varioloid  and  2  cases  of 
smallpox  in  the  infirmary. 


Smallpox  in  Virginia. — Smallpox  has  developed  near 
Ewing,  Va.  Nine  cases  have  developed  in  one  family,  and 
the  community  has  been  placed  in  quarantine. 

The  College  of  Physicians  and  Surgeons  of  Balti- 
more has  estabhshed  a  Pasteur  Department  for  the  pre- 
ventive treatment  of  hydrophobia,  at  the  Baltimore  City 
Hospital. 

Pension  Board. — The  following  physicians  have  been 
appointed  on  the  new  Pension  Board  for  Biltimore  City : 
Drs.  A.  Trego  Shertzer,  fleet  surgeon  United  States  Naval 
Veterans,  president ;  Henry  S.  Jarrett,  of  Towson,  secretary ; 
and  Chauncey  T.  Scudder,  treasurer. 

Children's  Hospital  Board.— At  the  annual  meeting 
of  the  incorporators  of  the  Children's  Hospital  at  Washing- 
ton, January  21,  the  following  were  elected  members  of  the 
board  of  directors  :  Landon  W.  Barchell,  Clement  W.  How- 
ard, S.  W.  Woodward,  H.  L.  Biscoe,  Gustav  Lansburgh,  T.  N. 
McAboy,  J.  William  Henry  and  Joseph  E.  Willard.  The 
board  of  directors  elected  officers  as  follows  :  F.  L.  Moore, 
president;  S.  H.  Kauffmann,  vice  president ;  Dr.  W.  P. 
Young,  secretary. 

Richmond  (Va.)  News.— On  the  first  of  the  month  there 
was  held  a  meeting  for  organization  of  the  Ophthalmologic 
and  Otologic  Section  as  a  branch  of  the  Richmond  Academy 
of  Medicine  and  Surgery.  It  is  composed  of  the  members  of 
the  profession  practising  only  on  the  eye,  ear,  and  throat. 
■The  meetings  will  be  held  once  a  month  at  the  different 
members'  houses,  the  chairman  of  the  meeting  to  be  the 
entertainer  of  the  evening.  Dr.  W.  J.  Mercer  waa  elected 
permanent  secretary. 

MISCELLANY. 

Hospital  for  Army  Nurses.— A  bill  has  been  intro- 
duced some  time  ago  and  is  again  being  revised  regarding 
the  erection  of  a  hospital  for  army  nurses. 

Smallpox  Epidemic— It  is  stated  that  Dr.  John  B. 
Fulton,  secretary  of  the  Maryland  State  Board  of  Health, 
regards  smallpox  as  epidemic  in  the  whole  United  States. 

To  Establish  Leper  Colony.— Major  Maus  of  the 
Surgeons'  Department;  Captain  Ahern,  chief  of  the  Forestry 
Bureau,  and  Captain  Horton,  assistant  Chief  Quartermaster, 
sailed,  on  January  26,  on  board  the  Alava,  from  Manila,  to 
complete  the  inspection  of  certain  of  the  southern  islands 
and  recommend  sites  for  leper  and  penal  colonies. 

Obituary.— Dr.  H.  L.  Stickel,  of  York  County,  Pa.,  at 
Harrisburg,  January  24,  aged  4S  years  and  7  months.— Db.  J. 
Stuart  Leech,  of  Downingtown,  Pa.,  January  23  — Dr.  R.  E. 
Beach,  of  Vandalia,  III,  on  January  23.— Dr.  Robert  Graham 
atPittersburg.Pa.,  January  19,  aged  79.— Dr  Grafton  M.  Bos- 
ley,  of  Lutherville,  Md.,  at  Baltimore,  Md.,  January  25, 1901, 
aged  76  years.— Dr.  Erskine  E  Hamilton,  at  Springfield, 
Mass.,  January  22,  1901,  aged  35  years.— Dr.  A..  G.  Priest,  at 
Sbelbyville.  Mo.,  January  24,  1901,  aged  72  years.- Dr.  T.  S. 
Davis,  at  Wesson,  hx.,  January  23, 1901,  aged  45  years.— Dr. 
W.  L.  Simpson,  at  New  York,  January  26.  1901,  aged  38 
years.— Dr  H.  D.  Reardon,  at  Elmira,  N.  Y.,  January  27, 
1901.— Dr.  Frederick  S.  Neilson,  aged  37.  at  New  Market, 
N.  J  ,  January  27,  1901.— Dr.  Edward  J.  Marshall,  aged  60 
years,  at  West  Chester,  Pa.,  January  28,  1901  —Dr.  W.  J. 
Harris,  aged  60  years,  at  Beatrice,  Neb.,  January  26,  1901. 

Hospital  Corps  Exercises  at  Manila.— A  correspond- 
ent at  Manila  under  date  of  December  7  describes  the  ex- 
ercises attending  the  graduation  of  the  second  class  of  the 
hospital  corps  company  of  instruction.  The  event  took 
place  in  Manila  on  December  4  in  Hospital  No.  2,  of  which 
M-^jor  John  S.  Kulp,  surgeon,  is  in  charge.  That  officer  in 
his  address  said : 

"On  behalf  of  the  officers  of  Hospital  3  I  am  glad  to  welcome 
you  this  morning,  and  to  extend  a  cordial  invitation  to  all  to  visit 
our  companv  of  instruction,  hospital  and  camp.  W  itliout  ventur- 
ing to  occupy  the  time  of  those  who  are  so  much  better  cjualitieil  to 
speak.  I  beg  the  privilege  of  a  word  in  answer  to  a  question  asked  a 
few  minutes  ago.  What  is  the  hospital  corps.'  Wherever  our  tlag 
lioats  over  a  garrison,  from  Fort  St.  Micliaels  to  our  own  Bangao,  we 
find   men   of   the   hospital   corps,  wliicli  numbers  about  550  non 


198 


Thb  Philadelphia" 
Medical  Journal  _ 


AMERICAN  NEWS  AND  NOTES 


[Febbcaby  2,  1901 


commissioned  officers,  and  over  3,500  men.  The  reason  that  one 
does  not  hear  about  them  is  because  they  are  usually  at  work,  and 
their  work  is  very  multifarious.  First  of  all  the  private  must  be 
a  good  nurse,  and  we  have  yet  to  hear,  so  far  as  the  hospital 
corps  is  concerned,  of  a  patient  pinning  a  note  to  his  bed  with  the 
legend  '  too  sick  to  be  nursed  today.'  In  addition  this  man  must  be 
a  soldier,  for  his  work  often  takes  him  under  the  fire  of  the  enemy, 
and  a  Mauser  bullet  is  no  respecter  of  persons.  Then  he  must  have 
a  knowledge  of  pharmacy,  must  be  something  of  a  clerk  in  order 
to  make  out  reports,  must  be  a  fairly  good  cook  or  he  will  find  him- 
self unpopular  with  his  comrades  and  in  short  must  be  able  to  fill 
any  place  in  hospital  or  camp.  In  most  military  hospitals,  as  in 
this  institution,  every  position  is  filled  by  men  of  the  hospital 
corps.  But,  I  am  asked,  what  is  the  need  of  military  discipline? 
When  in  a  crowded  ward  a  case  of  cholera  or  plague  develops,  it  Ls 
upon  the  strict  obedience  and  attention  to  duty  of  the  men  of  the 
hospital  corps  that  the  salvation  of  the  surrounding  city  depends. 
When  in  the  operating  room  a  sudden  emergency  arises,  it  is  upon 
their  instant  and  unquestioning  obedience  that  the  life  of  the  pa- 
tient depends.  And  it  is  the  soldier  of  the  hospital  corps  who, 
through  the  long  hours  of  the  night,  watches  by  the  bedside  under 
orders,  for  the  symptom  that  he  knows  is  but  the  surface  play  of 
the  danger  beneath.  And  so  we  think  that  the  highest  form  of  dis- 
cipline is  none  too  strict  for  those  who  at  at  any  time  may  be  called 
upon  to  stand  sentinel  over  the  lives  of  our  friends." 

He  was  followed  by  Lieutenant  William  J.  Lyster,  assist- 
ant surgeon,  commanding  company  instruction,  and  by 
Colonel  Charles  R.  Greenleaf,  chief  surgeon  of  the  division 
of  the  Philippines.  The  audience  then  joined  in  singirg 
"The  Battle  Hymn  of  the  Republic,"  the  music  of  which 
was  composed  by  a  brother  of  Colonel  Greenleaf,  who  also 
wrote  the  original  words  of  "  John  Brown's  Body."  Other 
demonstrations  f)llowed  by  the  class,  showing  the  means 
used  for  the  resuscitation  of  apparently  drowned  persons; 
the  various  manners  of  carrying  injured  men  by  single 
bearers  and  the  final  feat,  which  showed  that  a  corps  man, 
in  addition  to  his  multifarious  duties,  is  required  to  be  an 
athlete  of  no  mean  order.  Six  men,  including  the  four  litter 
bearers,  took  a  litter  with  a  patient  on  it  over  an  obstacle 
more  than  eight  feet  above  the  floor,  and  that  without  dis- 
turbing the  patient  in  any  way.  General  MacArthur  then 
presented  the  certificates  to  the  class.  The  general  had  pre- 
pared to  make  an  address  to  the  men,  but  owing  to  a  mis- 
understanding, it  was  cut  out. 

Toe  graduates  with  their  general  averages,  are  as  follows  : 
Robert  S  Ferguson,  91  5  ;  Samuel  B.  Price,  89  7 ;  William 

C.  Hill,  87.2;  Frank  J.  Foy,  87;  Girdon  F.  Lyon,  85.3; 
Claude  B.-ret-ford,  84  8;  Arthur  F.  Wolf,  82.5;  Edgar  R. 
Hurst,  80  3;  Michael  J.  Dorgan,  77.2;  Ira  L.  Mather,  74.8; 
William  Van  R  Jenner,  73  3 ;  Mayhew  Elliot.  72  5 :  William 

D.  McCarv,  715;  Herman  A.  P  zvbulbki,  708;  David  M. 
Long,  70  2;  Rurfolf  V.  Steiner,  67.8 ;  Charles  A.  Batchelder, 
67.6;  Raleigh  Stbree,  67.4.  Prizes  and  honors  were  as  fol- 
lows: For  the  best  general  average,  Robert  S.  Ferguson, 
honorable  mention,  Samuel  B  Price;  best  drilled  man, 
Henry  C.  Leatherman,  honorable  mention,  Claude  Beres 
ford  ;  best  examination  in  elementary  anatomy  and  physiol- 
ogy, Samuel  B.  Price,  honorable  mention,  William  Van  R. 
Jenner. 

Cbauges  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  January  26,  1901  : 

MuLLiN=,  Tho.m.\s  K.,  acting  assistant  surgeon,  is  granted  leave  of 
absence  for  1  month. 

The  following-named  acting  assistant  surgeons  will  stand  relieved 
from  temporary  duty  at  their  present  stations  on  the  day  of  the 
sailing  of  the  "Grant,"  and  will  report  on  that  transport  for 
temporary  duly  during  the  voyage:  Abraham  D.  Williams, 
Camp  of  Casuals,  Presidio,  Walter  B  Chidesteb,  and  Cab- 
roll  D.  Buck,  Army  General  Hospital,  Presidio. 

Bailey,  Guy  C,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  ]  mixith. 

The  following  named  acting  assistant  surgeons  will  stand  relieved 
from  duty  at  their  present  stations  on  the  day  of  sailing  for  the 
Philippine  Islands  of  the  .\rmy  transport  "Grant,"  and  as- 
signed to  temporary  duty  with  troops  on  that  transport :  upon 
arrival  at  Manila  they  will  report  to  the  commandinsr  general, 
division  of  the  Philippines,  for  assignment  to  duty:  Henry  D. 
Brow.n,  Joskth  W.  IlEnnv,  Joseph  Petty.iohn,  Theodore  H. 
Weisenburu  and  John  H.  Allen  :  .Iohn  S.  Hill;  Compton 
Wilson,  Presidio:  Lawrence  McEvoy,  Alfred  T.  Short, 
Fredkrick  W.  Richardson,  Robert  S.  Spillman,  Army  Gen- 
eral Hospital,  Presidio. 

Williams,  Ali.ik  W.,  acting  assistant  smgeon,  will  upon  expira- 
tion of  prrscnt  leave  proceed  to  Governor's  Island  for  assign- 
ment to  duty  at  Fort  iMilunibus. 

Disney,  Frank  A.  K.,  acting  assistant  surgeon,  now  in  Washing- 
ton, I).  C,  will  proceed  to  San  Franciscn.  Cal,  and  report  for 
temporary  duly  at  the  (ieneral  Hospital,  Presidio.. 


Williams,  Allie  W.,  acting  assistant  surgeon,  is  granted  leave  of 
absence  for  I  month. 

Reed,  Major  Walter,  surgeon,  will,  upon  the  adjournment  of  the 
Pan-American  Medical  Congress  at  Havana,  Cuba,  proceed  to 
Washington,  D.  C,  and  report  to  the  Surgeon -General  of  the 
Army  for  the  purpose  of  continuing  his  investigations  at  the 
Army  Medical  Museum  with  reference  to  the  cause  and  preven- 
tion of  yellow  fever. 

Richards,  First  Lieutenant  William  E.,  resignation  of,  is  accepted 
to  take  effect  February  3. 

Belt,  Harry  D.,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  2  months,  without  pay. 

Tbuax,  Jesse  P.,  acting  assistant  surgeon,  now  en  route  to  Fort 
Casey,  is  relieved  from  the  further  operation  of  the  order  which 
directs  him  to  proceed  to  Fort  Casey,  and  he  will  report  at 
Fort  Flagler  for  duty,  relieving  Acting  Assistant  Surgeon  Wil- 
liam M.  Hendrickson. 

HENDRrcKSON.  WiLLiAM  M.,  acting  assistant  surgeon,  will  proceed 
to  Fort  Casey  for  duty. 

Harris,  Herbert  I.,  acting  assistant  surgeon,  is  detailed  as  a  mem- 
ber of  the  board  of  officers  appointed  January  15  to  meet  at  8t. 
Paul.  Minn.,  for  the  examination  of  officers  for  promotion,  vice 
Lieutenant  Colonel  Cai\-in  DeWitt,  deputy  surgeon-general,  re- 
lieved. 

BispuAM,  First  Lieutenant  William  X.,  assistant  surgeon,  is  re- 
lieved from  duty  at  Columbia  Barracks,  Cuba,  and  will  proceed 
to  Xo.  21  Fifth  street.  Vedado.,  Havana,  Cuba,  reporting  (o  the 
commanding  officer.  Second  Artillery,  for  duty  at  batteries  Xoe. 
3  and  4,  and  the  regimental  hospital,  Vedado,  relieving  Acting 
Assistant  Surgeon  P.  C.  Field. 

Field,  P.  C,  acting  assistant  surgeon,  will  proceed  to  ColnmbiA 
Barracks.  Cuba,  for  duty. 

Cabr.  Major  Lawrence  C,  surgeon,  will  upon  the  expiration  of  the 
leave  granted  him  December  17.  proceed  to  Havana,  Cuba,  and 
report  to  the  commanding  general,  department  of  Cuba,  for  as- 
signment to  duty. 

Morse,  Arthur  W.,  acting  assistant  surgeon,  now  at  Odell,  UL, 
will  proceed  to  San  Francisco,  Cal.,  and  report  to  thecommand- 
ing  general,  department  of  California,  for  assignment  to  duty. 

Conn,  Fbkdeeu  k  A.  W..  acting  assistant  surgeon,  is  relieved  from 
duty  in  the  department  of  Cuba,  and  will  proceed  to  San  Fran- 
cisco, Cal.,  and  report  to  the  commanding  general,  department 
of  California,  for  assignment  to  duty  with  troops  en  route  to 
the  Phihppine  Islands,  where  he  will  report  to  the  command- 
ing general,  division  of  the  Philippines,  for  assienment  to  duty. 

Xeale,  John  S..  hospital  steward,  nmv  at  Columbia  Barracks, 
Cuba,  will  be  relieved  from  further  duty  at  that  post.  February 
10,  and  sent  to  Washington,  D.C.,  reporting  to  Major  John  Van 
Horn,  surgeon,  medical  supply  officer,  for  duty  in  the  patholo- 
gical laboratory  .it  the  Army  Medical  Museum. 

The  following-nameti  olBcers  will  report  to  Colonel  Alfred  A.  Wood- 
hull,  assistant  surgeon -general,  president  of  the  examining 
board  at  the  Army  Medical  Museum  building,  Washington.  D. 
C,  for  examination  for  promotion;  Captains  Ch»elE8  M. 
Gandv,  Jefferson  K  Kean.  Henry  L.  Raymond.  Edward  R. 
Morris.  Leonard  Wood.  Jefferson  E.  Poindexteb,  Cbabub 
E.  Woodruff,  assistant  surgeons. 

Changes  iu  the  Medical  Corps  of  the  U.  S.  Kavy, 

for  the  week  ended  January  26,  1901 : 

FisKE,  G.  y.,  assistant  surgeon,  detached  from  the  "Wheeling" 

and  ordered  to  the  "  Mohican  "  when  the  former  is  put  out  of 

commission. 
Shiffert,  H.  C.  assistant  surgeon,  appointed  assistant  sorgeoB 

from  December  26,  1900. 
Bertolette.  D.  N'.,  me<iical  inspector,  detached  from  the  Medical 

Examining  Boani,  Washington,  and  ordered  home,  January  31. 
Russell,  A.  C.  H.,  surseon.  ordered  to  Washington,  for  duty  as  • 

member  of  the  Medical  Examining  Board,  January  31. 
Rush,  W.  H..  surgeon,  ordered  to  the  Pensacola  Xaval  Station  for 

recruiting  and  other  duty. 
Smith.  R.  K..  passed  assistant  surgeon,  detached  from  the  "Pens*- 

cola.  ■  February  2. 
Stone,  M.  V.,  assistant  surgeon,  detached  from  the  "Solace"  and 

ordered  to  the  "  Isla  de  Luzon." 
Hass,  H.  H.,  assistant  surgeon,  detached  from  the  "  Isla  de  Lazon  " 

and  ordered  to  the  "  Solace." 

Changes  in  the  U.  S.  Marine- Hospital  SerTic«t 

for  the  week  ended  January  24,  1901 : 

PuRViANCK,  Geor^-.k.  surgeon,  granted  leave  of  absence  for  2  days. 

January  IS,  1901. 
William,    I-.   I...  surgeon,  granted  leave  of  absence  for  3  days. 

January  21.  1901. 
Bean,  L.  C,  acting  assistant  sui^eon,  grantevi  leave  of  absence  for  i 

days  from  January  IS.    January  17.  1901. 
Ckah;,  R.  C.  acting  assistant  surgeon,  granted  7  days'  extension  of 

leave  of  absence.    January  22,  1901. 

Health  Keports. — The  following  ca<iee  of  smallpox, 
yellow  fever,  cholera,  and  pli^rue,  have  been  reported  to 
the  Surgeon-General  U.  S.  Marine- Hospital  Service,  during 
the  week  ended  January  26,  1901 : 


FBBKrAKv  2,  laoi] 


FOREIGN  NEWS  AND  NOTES 


CThk  Philadelphia 
Medical  Journal 


199 


Smallpox — United  States. 


District  of 

Columbia  ; 
Florida  : 
Illinois  : 

Kansas  : 
Ke.ntlcky: 

Louisiana  : 

Massachusetts  : 
Minnesota  : 

Nebraska  : 
N.  Hampshire  : 
Xew  Mexico  : 
New  York : 

Ohio  : 

Oklahoma  : 
Pennsylvania : 

Tennessee  : 
Texas ; 
Uta  h  : 
Wisconsin  : 


Belgium  : 
Brazil  : 
Egypt  : 
England: 

France  : 
India  : 
Mexico  : 
Scotland  : 


Straits 

Settlements  ; 


I  Washington 
Jacksonville 
Cairo  .... 
Cliirago  .  . 
Wichita 
Le.xineton  . 
Louisville  . 
New  Orleans 
Shreveport . 
Lawrence  . 
Minneapolis 
St.  Paul  .  . 
Omaha  .  .  . 
Mancliester 
Fort  Stanton 
New  York  . 
Utica.  .  .  . 
Cincinnati  . 
Cleveland 
Sixteen  Counties 
Erie  .  .  . 
Pittsburg 
Memphis . 
Houston  . 
Salt.  Lake  City  . 
Green  Bay  .   .   . 

Smallpox- 

Liege .... 
Pernambuco 
Alexandria 
Leeds     .    . 
London     . 
Paris  ... 
Bombay   . 
Vera  Cruz 
Edinburgh 
Glasgow   . 
Leith  ... 


Jan.  12-19 
Jan.  12-19 
Jan.  5-19  . 
Jan.  1-2-19 
Jan.  12-19 
Jan. 12-19 
Jan.  4-1 S  . 
Jan.  li-19 
Jan.  12-19 
.Tan.  12-19 
Jan.  12-19 
Jan.  5-12  . 
Jan.  8-15  . 
Jan.  12-19 
Jan.  14  .  . 
Jan.  12-19 
Jan.  12-19 
Jan.  12-19 
Jan. 12-19 
Jan.  11  .  . 
Jan.  12-19 
Jan.  12-19 
Jan.  12-19 
Jan.  12-19 
Jan.  12-19 
Jan.  12-29 

-FOBEIQN. 
Dec.  15-22  .  . 
Dec.  S-15  . 
Dec.  17-24  .  . 
Dec.  5-12  .  .  . 
Dec.  29-Jan.  5 
Dec.  29-Jan.  5 
Dec.  18-25  .  . 
Dec.  28-Jan.  5 
Dec.  29-Jan.  5 
Jan.  4-11  .  .  . 
Dec.  29-Jan.  5 


Cases. 


5 

12 
6 
2 
1 
7 
5 
1 

11 
8 
7 

39 
1 
9 
1 
3 

57 

289 

1 

3 


Deaths. 


Colombia  . 
Cuba  : 

Mexico  : 


India  : 

Straits 

Settlements 


India: 
England : 

RussLi: 


Singapore    .    . 

Yellow 

Cartagena  .  . 

Cienfuegos  .  . 

Matanzas  .  .  . 

Vera  Cruz  .  . 


Dec.  1-15  .  .   . 
Fever. 

Jan.  1-7    ..  . 

Jan.  14  ...    . 

Jan.  5-12  .    .   . 

.   .   .  Dec.  29-Jan.  5 

Cholera. 

.   .    .  Dec.  18-25    .    . 


44 

32 

1 


1 

66 

1 


34 

2 


58 


Bombay 

Singapore    .   .   .  Dec.  1-18  . 
Plague. 

Bombay   ....  Dec.  18-25    ...  118 

Hull Jan.  19 5deathsonS.S. 

"  Friary." 
Tsarevak  district  Jan.  5 19         15 


Jorctgn  Hetps  anb  Hotcs. 


GREAT  BRITAIN. 

Indian  Medical  Association. — The  twenty-second 
meeting  of  the  council  of  the  Indian  Medical  Asaociation 
was  held  December  15,  at  Calcutta. 

Smallpox  in  Glasgow. — An  epidemic  of  smallpox  is 
raging  iu  Glasgow.  Twenty-nine  cases  were  reported  on 
January  26,  and  100  cases  in  the  hospitals. 

Dr.  John  White  Aldred,  of  Altrincham,  is  reported 
to  have  died  of  typhoid  fever  at  Kroonstadt,  South  Africa. 
Dr.  Aldred  was  a  distinguished  student  at  Owens  College. 

Plague  among  Troops.— According  to  the  Petit  BUu, 
bubonic  plague  is  raging  among  the  British  troops  in  Cape 
Colony,  and  many  deaths  that  are  attributed  to  enteric  fever 
and  dysentery  are  due  to  plague. 

Enteric  Fever  in  Ceylon.— On  account  of  the  increase 
of  enteric  fever  in  the  Boer  camp  in  Ceylon,  the  govern- 
ment of  India  has  ordered  one  medical  officer  of  the  rank 
of  captain  to  proceed  there ;  another  one  will  shortly  follow 
him. 


Prize  for  X-ray  Tube. — The  Council  of  the  Rontgen 
Society  at  London  announces  that  the  president  has  placed 
ai  its  disposal  a  gold  medal,  to  be  awarded  to  the  maker  of 
the  best  practical  x-ray  tube  for  both  photographic  and 
screen  work. 

Sheffield  Bacteriological  Laboratory. — At  a  recent 
meeting  of  the  Sheffield  Medico  Chirurgical  Society,  Dr. 
Robertson  read  a  paper  on  the  work  done  at  the  bacterio- 
logical laboratory  in  connection  with  University  College  since 
its  establishment.  Courses  of  instruction  for  medical  students 
and  postgraduate  courses,  have  been  held.  During  the  past 
18  months  1,605  swabs  have  been  examined  from  patients 
suspected  to  be  sufiering  from  diphtheria,  nearly  500  speci- 
mens of  blood  have  been  examined  for  serum  reaction,  and 
663  specimens  of  sputum  have  been  examined  for  tubercles. 

SirW.  H.  Farrington,  Bart.,  M.D.— Sir  William 
Hicks  Farrington,  Bart.,  M.D.,  who  died  suddenly  on  Janu- 
ary 5,  at  Penshurst-Kent,  was  the  eldest  surviving  son  of  Sir 
Anthony  Farringtcn,  Bart.,  of  Ottery  St.  Mary.  He  began 
his  medical  education  at  St.  Bartholomew's  Hospital  in  1856, 
became  a  member  of  the  Royal  College  of  Surgeons,  and 
Licentiate  of  the  Society  of  Apothecaries  in  1859-60,  and 
graduated  at  St.  Andrew's  in  1862.  He  held  the  appoint- 
ment of  resident  accoucheur  at  St.  Bartholomew's  under  Dr. 
West,  and  subsequently  he  became  resident  medical  officer 
at  the  London  Fever  Hospital.  On  resigning  this  post  he 
was  appointed  medical  officer  to  Her  Majesty's  convict 
<  Btablishmentat  Gibraltir.  Returning  to  England  in  1866  he 
settled  at  Penshurst  in  Kent,  taking  the  practice  of  Dr.  J.  H. 
Bailer,  who  was  retiring  from  active  life.  In  1870  he  married 
the  youngest  daughter  of  the  late  Mr.  Alexander  Glendin- 
ning,  of  Redleaf,  Kent,  who  survives  him. 


CONTINENTAL  EUROPE. 

A  clinical  service  devoted  to  tropical  diseases  has  been 
instituted  at  the  Medical  College  of  Algiers.  Prof.  M.  Brault 
has  been  appointed  to  take  charge  of  the  service. 

Medical  Club  of  Paris.— The  following  officere  were 
elected  for  1901 :  President,  M.  Peyrot;  vice-presidents,  M.M. 
Cheavallereau  and  M.  Hallopeau;  secretaries,  M  M.  Dol^ria 
and  Lefepre;  treasurer,  M.  Deanos ;  librarian,  M.  Chasse- 
vant. 

Appointments. —  Brussels:  Dr.  Bayet  was  appointed 
professor  of  the  dermatological  clinic,  and  Dr.  Chevel  pro- 
fessor of  the  laryngological  clinic. — Wurzburg  :  Dr.  Friedrich 
Schenck  has  succeeded  Professor  Kossel  as  ordinary  professor 
of  physiology  at  the  University  of  Marburg. — Heidelberg  : 
Professor  Albrecht  Kossel  was  appointed  ordinary  professor 
of  physiology  as  well  as  director  of  the  physiological  labora- 
tory at  the  University  of  Heidelberg. 


A  Case  of  Calcareous  Infiltration  of  the  Liver.— E. 

Mihel  (Srpsi  arhiv za  celokupno  lekarstvo  1900,  No.  lO(Serbisch) 
in  performing  an  autopsy  upon  a  boy  aged  17  years,  who  had 
suffered  from  chronic  pulmonary  tuberculosis  with  cavities 
and  an  old  parenchymatous  nephritis  with  acute  hemor- 
rhagic exacerbation,  noticed  that  the  liver  grated  under  the 
knife.  The  organ  was  of  a  normal  shape,  somewhat  dimin- 
ished in  size,  the  tissue  showing  considerable  vascularization 
and  markings  resembling  a  nutmeg-liver.  Upon  closer  obser- 
vation minute  grayish  yellow  ramifications  were  noticed 
which  felt  rough  to  the  palpating  finger.  Microscopical  exami- 
nation showed  that  these  arborescent  structures  represented 
an  extensive  impregnation  of  the  liver-parenchyma  with 
lime  salts.  The  application  of  a  5^  solution  of  hydrochloric 
acid  caused  the  calcifications  to  become  invisible  under  the 
microscope,  and  as  they  were  seen  to  disappear  without  the 
formation  of  gas  bubbles,  it  was  deduced  that  the  salts  con- 
sisted of  phosphate  of  calcium.  The  calcareous  impregnation 
of  the  liver- cells  was  most  marked  around  the  central  veins. 
At  those  areas  where  the  salts  had  been  removed  by  the 
acid  it  was  plainly  seen  that  the  parenchyma  had  been 
replaced  by  fatty  degeneration.  The  author  could  find  no 
similiar  case  in  literature  where  a  nutmeg  liver  followed 
chronic  pulmonary  tuberculosis,    [m.r  d.] 


200 


The  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Febbdabt  2,  1901 


Cbc  latest  literature. 


British  Medical  Journal. 

January  IS,  1901.     [No.  2089  ] 

1.  Observationa  on  Wind  Exposure  and  Phthisis.    William 

Gordon. 

2.  Jaundice  in  Typhoid  Fever.    George  Ogilvie. 

3.  Influenza  and  the  Nervous  System.    James  Carslaw. 

4.  The  Detection  of  Arsenic  in  Beer  and  Brewing  Material. 

Sheridan  Delepine. 

5.  Note  on  the  Value  of  Inoculation  Against  Enteric  Fever. 

Henry  Cayley. 

1. — After  a  study  of  the  statistics  and  the  death-rate, 
Gordon  concludes  that  the  distribution  of  the  phthisis  death- 
rate  in  the  rural  sanitary  districts  of  Devon  is  due  to  some 
other  cause  than  general  sanitation.  On  the  other  hand,  a 
comparison  of  a  diagram  of  the  deaths  from  tuberculosis  of 
the  lungs  and  a  diagram  indicating  rain  and  all  suggests  a 
kind  of  rough  correspondence.  The  town  with  the  highest 
death-rate  has  the  greatest  rainfall  and  that  with  the  lowest 
death-rate  has  the  lowest  rainfall.  The  correspondence  is 
by  no  means  complete,  however,  and  the  author  concludes 
that  probably,  for  Devonshire  generally,  the  paramount 
influence  that  determines  a  higher  or  a  lower  rate  of  mor- 
tality from  tuberculosis  of  the  lungs  is  the  degree  of 
exposure  to  or  shelter  from  the  west  and  the  southwest 
winds.    [J.M  s.] 

2. — Ogilvie  reports  4  caaes  in  which  jaundice  complicated 
typhoid  fever.  In  the  first,  the  patient  was  a  young  woman, 
aged  22  years.  The  jaundice  was  preeent  from  the  beginning 
of  the  diseaae  and  began  to  disappear  when  the  tempera- 
ture began  to  fall.  It  had  not  quite  cleared  up  8  weeks  after 
the  onset  when  the  patient  was  sent  to  a  convalescent  home. 
The  second  patient  was  a  man,  aged  SOyears.  The  jaundice 
appeared  on  the  fourth  day  after  admission  to  the  hospital, 
or  was  about  the  end  of  the  first  week  of  the  disease.  It 
gradually  disappeared  as  the  temperature  fell,  and  lasted 
nearly  throughout  the  whole  of  the  disease,  about  6  weeks. 
The  third  patient  was  a  man,  30  years  old.  In  this  patient 
the  jaundice  preceded  the  advent  of  the  attack  of  typhoid 
fever  by  about  4  weeks  and  lasted  for  about  3  weeks  of  the 
course  of  the  disease.  The  case  is  one  of  typhoid  fever  in  a 
jaundiced  patient  and  the  jaundice  cannot  be  thought  to  be 
a  symptom  of  the  typhoid.  The  attack  was  prolaably  of 
catarrhal  origin,  although  it  might  have  been  due  to  some 
toxic  process  dependent  on  dysentery.  The  fourth  patient 
was  a  girl,  aged  16  years,  who  parsed  a  lubricoid  worm  dur- 
ing the  attack  of  typhoid.  The  worm  had  evidently  ob- 
structed the  common  bile  duct  and  had  caused  the  jaundice. 
After  a  study  of  the  reported  cases  in  the  literature,  the 
author  concludes  that  the  frequence  of  jaundice  in  typhoid 
fever  is  between  1  %  and  1 J  fo .  This  would  indicate  that  jaun- 
dice is  not  so  rare  and  so  fatal  a  complication  of  typhoid 
fever  as  has  been  frequently  presumed.  It  is  a  most  unusual 
occurrence  for  jaundice  to  appear  at  the  onset  of  the  disease, 
to  last  through  its  whole  course,  and  to  disappear  with  the  fall- 
ing of  the  temperature,  and  yet  to  lead  to  no  serious  results. 
In  fact,  similar  occurrences  are  so  rare  that  they  may  lead  to 
doubts  as  to  the  correctness  of  the  diagnosis  of  typhoid 
fever.  The  cases  reported  by  the  author,  however,  seem  to 
be  true  typhoid  fever  as  indicated  by  the  presence  of  the 
agglutinating  reaction  of  the  blood-serum  in  addition  to  the 
classical  symptoms  of  the  disease.  Clinical  and  pathologic 
evidence  seem  to  prove  that  catarrhal  jaundice  in  typhoid 
fever,  so  far  from  being  the  rule,  is  an  exceedingly  rare  occur- 
rence. While  in  the  first  2  cases  reported  in  the  paper 
catarrhal  jaundice  can  be  excluded,  it  is  more  difficult  to 
come  to  a  conclusion  as  to  the  causation  of  the  symptom. 
It  is  possible  that  there  is  some  direct  action  of  the  specific 
microorganism  of  typhoid  fever  on  the  liver  or  the  bile  chan- 
nels, as  suggested  by  DaCosta,  that  accounts  for  the  occur- 
rence of  the  jaundice  in  these  cases,     [j.m  s  ] 

3. — Cirslaw  reports  4  cases  that  illustrate  the  influence  of 
inilueuza  upon  the  nervous  system.  The  4  patients 
sutTered  from  acute  meningitis.  This  meningitis  may  have 
been  the  principal  incident  of  the  attack  of  influenza,  or,  on 
the  other  hand,  the  infection  may  have  been  a  mixed  one, 


and  the  attack  of  influeBza  may  have  simply  paved  the  way 
for  the  entrance  of  other  toxic  agents  as  well  as  for  the  bacil- 
lus of  Pfeifier.  Although  3  of  the  cases  were  fatal,  a  post- 
mortem examination  was  permitted  on  only  1,  and  in  that 
case  the  examination  was  limited  by  the  friends  to  the  con- 
tents of  the  skull.  In  this  case  the  meningitis  was  found  to 
have  been  of  a  very  acute  type.  Its  bacteriology,  however, 
was  not  very  satisfactorily  made  out.  Diplococci  of  compa- 
ratively large  size  were  found  in  the  films  prepared  at  the 
postmortem,  but  the  attempt  to  make  cultures  from  the  pu- 
rulent effusion  failed.  It  is  possible  that  the  iafluenza  bacillus 
was  present  in  addition  to  the  diplococcus,  both  being  diffi- 
cult to  cultivate  except  in  specially  prepared  media.  Of 
course,  the  infection  may  have  been  a  pure  diplococcic  inva- 
sion from  the  respiratory  tract,  the  catarrhal  involvement  of 
which  would  have  favored  such  an  extension  whether  the 
primary  disease  was  influenza  or  not.  There  waa  in  this 
case  an  alveolar  sarcoma  of  the  round-celled  type  involving 
the  pituitary  body.  The  patient  had  always  been  considered 
a  healthy,  strong,  and  well-developed  young  man,  and  bad 
presented  none  of  the  symptoms  of  akromegaly.  The  only 
symptom  that  could  be  considered  to  bear  any  relation  to 
this  tumor  was  occasional  attacks  of  pain  in  the  head,  of 
short  duration,  which  the  patient  had  experienced  for  about  6 
moiiths  before  his  illness.  The  other  fatal  cases  resembled 
each  other  very  closely.  In  each  the  illness  lasted  about  a 
week  and  occurred  in  strong  and  healthy  young  men,  not  the 
subjects  of  tubercul  )U8  d  sease.  The  first  symptoms  in  each 
case  were  those  of  influenza,  and  the  patients  paesed  some- 
what suddenly  into  a  state  of  unconsciousness  from  which  they 
never  rallied.  The  patient  who  recovered  was  a  boy,  aged  9 
years,  who  was  probably  sufi'eriQg  from  acute  inflammation  of 
the  Ofre'iral  meninges  and  p'  ssibly,  also,  of  the  spinal  men- 
inges. The  onset  of  the  illness  was  sudden  and  the  meningeal 
symptoms  were  early  and  severe,  and,  in  addition  to  other 
characteristic  symptoms,  the  patient  had  a  very  typical 
herpes  labialis.  In  all  these  cases  the  illness  occurred  in 
healthy  subjects  and  at  a  time  when  influenza  was  present  in 
the  neighborhood.  Some  of  the  patients  had  early  catarrhal 
symptoms  that  were  considered  by  their  medical  advisers 
to  be  of  an  influenzal  nature.  In  all  severe  headache  was 
prominent,  and  grave  cerebral  symptoms  developed  with 
alarming  rapidity  and  with  no  apparent  cause  in  the  ears  or 
elsewhere.  They  were  all  characterized  by  very  restless 
delirium  and,  in  general,  little  or  no  paresis  of  limb  or  ocular 
muscle  to  indicate  any  important  localization.  Probably 
the  meningitis  was  more  vertical  than  basal,  although,  in  the 
case  that  came  to  the  autopsy  table,  the  exudation  was  very 
well  marked  both  at  the  base  and  on  the  covexity.  In  that 
case,  however,  there  had  been  localizing  symptoms.  The 
author  adds  a  summary  of  a  very  marked  case  of  postinfluen- 
zal multiple  neuritis.  The  patient's  illness  corresponded 
with  the  usual  features  of  alcoholic  peripheral  neuritis  and 
at  first  there  was  a  suspicion  that  the  disease  might  be  of 
that  nature.  This  etiologic  factor  was  excluded,  however, 
and,  although  the  patient  had  had  a  distinct  attack  of  influ- 
enza, she  persevered  in  her  work  so  that  there  was  more 
likelihood  of  a  complication,  such  as  neuritis,  developing. 

[j  M.S.] 

4. — It  is  a  fact  of  common  knowledge  among  chemists 
and  biologists  that  arsenic  is  one  of  the  most  widely- 
distributed  substances.  It  is  frequently  associated  with  other 
metals  and  sulphur  in  various  mineral  products.  Many  soils 
contain  arsenic ;  vegetables  growing  in  such  soils  may  con- 
tain traces  of  that  body,  which  is  more  abundant  in  their 
seeds.  The  soil  may  also  be  rendered  arsenic^il  artificially,  as 
when  various  chemical  products  are  thrown  upon  the  ground. 
Contamination  of  water  may  occur  under  those  circum- 
stances. Some  valuable  mineral  waters,  more  especially  the 
ferruginous  waters,  contain  minute  quantities  of  the  poison, 
owing  to  their  passage  through  arseniferous  strata.  It  has 
also  been  found  in  sea-water.  It  has  even  been  lately 
asserted  that  arsenic  is  a  normal  constituent  of  the  human 
body.  Taking  these  things  into  consideration,  Deli?pine 
thought  that  the  mere  detection  of  traces  of  arsenic 
would  not  be  suflicient  to  prove  that  any  sample  of  beer  was 
actually  dangerous  to  health.  No  authoritative  stitement 
could  be  found  showing  that  pure  beer  should  be  absolutely 
free  from  arsenic ;  on  the  other  hand,  it  was  quite  conceiv- 
able, on  the  ground  of  general  knowledge,  that  minute  traces 
of  arsenic  might  occur  in  beer  even  prep-ired  from  the  best 


Kbbbdary  2,  1901] 


THE  LATEST  LITERATURE 


[The  Philadelphia 
MEDICAL  Journal 


201 


material,  and  that  this  must  have,  in  fact,  occurred  at  all 
times  since  beer  began  to  be  brewed  from  malt  and  hops. 
After  preliminary  study,  the  author  felt  justified  in  consider- 
ing that  any  beer  containing  about  0.8  grain  of  arsenious 
acid  per  gallon — that  is,  1  part  of  Ae.,0,  per  875,000  parts  of 
beer — should  be  condemned.  By  conducting  Reinsch's  test 
with  care,  he  found  that  it  was  easy  to  detect  the  presence  of 
arsenic  in  100  cc,  and  even  in  as  little  as  20  cc,  of  some  of 
the  suspected  beers.  On  the  other  hand,  no  distinct  trace 
of  arsenic  could  be  found  in  as  much  as  200  cc.  of  beer 
brewed  in  Bavaria,  where  the  use  of  malt  substitutes  is  pro- 
hibited by  law.  After  further  careful  study,  it  was  found  that 
a  sublimate  composed  of  small  but  clear  crystals  of  arsenious 
acid  could  be  obtained  from  the  solution  containing  1  part 
per  million  without  any  previous  concentration  of  the  beer. 
This  amount  of  arsenic  is  higher  than  that  which  we  have  so 
far  found  in  beers  brewed  from  ordinary  malt  and  hops.  On 
the  other  hand,  this  quantity  is  considerably  below  that 
found  in  beers  brewed  from  arsenical  glucose.  It  will  be 
understood  that  the  standard  adopted  for  the  present  is 
purely  artificial,  and  that  bj'  Reinsch's  method  it  would  be 
possible  to  fix  a  much  more  stringent  standard  if  necessary, 
for  there  would  be  no  ditficulty  in  discovering  by  this  test  1 
part  in  5,000,000,  in  10,000,000,  or  even  less,  by  increasing  the 
quantity  of,  or  concentrating  the  fluid  under  examination. 
Supposing  that  an  arsenical  beer  was  entirely  brewed  from 
malt,  the  malt  should  contain  at  least  4  times  more  arsenic 
than  the  beer  prepared  with  it,  since  the  proportion  of  malt 
used  may  be  said  roughly  to  be  }  cf  the  total  amount  of 
beer  produced  from  it.  We  have  not,  however,  found  yet 
any  sample  of  malt  containing  more  than  a  small  fraction  of 
the  arsenic  present  in  arsenical  beer  to  which  cases  of  poison- 
ing had  been  traced.  With  regard  to  the  glucose  and  invert 
sugar,  the  amount  of  arsenic  found  in  some  samples  was 
more  than  sufficient  to  account  for  the  dangerous  contami- 
nation of  the  beer.  The  sulfuric  acid  used  in  the  factory 
from  which  all  the  arsenical  glucose  examined  came  con- 
tained so  much  arsenic  that  it  was  actually  saturated.  A 
deposit  of  arsenious  acid,  or  some  arsenical  compound 
formed  in  the  presence  of  sulfuric  acid,  was  actually  found 
at  the  bottom  of  the  bottle  containing  the  acid  Bent  for  ex- 
amination. By  a  modification  of  Reinsch's  method  described 
in  the  paper,  the  author  found  that  the  amount  of  arsenious 
acid  in  one  sample  of  H,SO,  was  about  2%.     [j  m  s] 

6. — Cayley  gives  the  results  of  the  iuoculation  of  the 
members  of  the  stafi  and  establishment  of  the  Scottish 
National  Red  Cross  Hospital  serving  in  South  Africa 
against  typhoid  fever.  The  first  section  of  the  hospital, 
consisting  of  61  persons,  left  Southampton  on  April  21,  1900. 
During  the  voyage  out  all  except  4  of  the  personelle  were 
inoculated  twice  at  an  interval  of  about  10  days.  The  injec- 
tions were  all  made  in  the  flank  and  were  followed  in  from 
2  to  10  hours  by  marked  symptoms,  both  local  and  constitu- 
tional, that  lasted  for  from  2  to  5  days.  In  many  cases  the 
symptoms  were  as  severe  after  the  second  as  after  the  first 
inoculation.  This  would  seem  to  show  that  it  takes  more 
than  10  days  before  any  immunity  is  established.  Two  of 
the  7  nurses  were  not  inoculated,  because  they  had  already 
had  attacks  of  typhoid  fever,  and  2  of  the  orderlies  were 
only  inoculated  once.  Out  of  about  300  troops  on  board, 
chiefly  volunteers  and  militia,  nearly  100  were  inoculated. 
As  soon  as  the  hospital  reached  the  Cape  it  was  sent  to 
Kroonstadt,  in  the  Orange  River  Colony,  and  remained  there 
as  a  stationary  hospital  until  the  middle  of  October.  Daring 
this  period  there  w^ere  always  many  cases  of  typhoid  fever 
under  treatment  in  the  hospital.  Furthermore,  some  of  the 
medical  officers  and  student  orderlies  had  charge  of  the 
Kroonstadt  Hotel  temporary  hospital,  which  was  crowded 
with  enteric  cases,  and  the  nursing  sisters  did  dutv  for  3 
weeks  in  the  military  hospitals  at  Bloemfontein  in  May  and 
June  when  typhoid  was  at  its  worst.  There  was  not  a  single 
case  of  typhoid  fever  among  the  personelle  of  this  first  sec- 
tion of  the  hospital.  The  second  section  of  the  hospital,  82 
in  all,  left  Soutbampton  in  Maj',  1900.  Nearly  all  were  inoc- 
ulattd  on  board  ship,  but  many  were  inoculated  but  once.  The 
material  for  the  inoculation  had  been  on  board  for  some  time 
and  was  not  so  fresh  as  in  the  first  instance.  Of  this  second  sec- 
tion, one  nurse  had  typhoid  at  Kroonstadt.  She  was  the  only 
one  out  of  36  nurses  who  had  typhoid  and  she  was  also  the  only 
one  wbo  had  not  been  inoculated ;  5  orderlies  of  the  second 
section  had  typhoid,  of  whom  2  died.    Of  these  5,  2  had  been 


inoculated  once  and  3  had  not  been  inoculated.  Of  the  2 
that  died  1  had  been  inoculated  once  and  1  had  not  been 
inoculated.  A  third  section  of  the  hospital  consisting  of  20 
people  went  out  in  July  ;  they  were  all  inoculated  and  none 
of  them  had  typhoid  fever.  At  the  end  of  August,  the  blood 
of  a  number  of  the  staflf  and  establishment  was  examined  for 
the  serum  reaction.  The  blood  of  23  of  the  members  of  the 
first  section,  who  had  been  inoculated  4  months  before,  was 
examined  and  of  these  21  gave  a  good  reaction  and  2  gave  a 
slight  reaction,  the  orderlies  who  had  been  inoculated  but 
once.  The  blood  from  the  22  members  of  the  second  section 
was  tested,  these  had  been  inoculated  for  3  months.  Of 
these,  11  gave  no  reaction,  9  gave  a  very  slight  reaction,  and 
only  2  gave  a  good  reaction.  It  would  appear  from  the 
above  that  the  members  of  the  first  section  were  much  more 
fully  protected  against  typhoid  than  the  members  of  the 
second  section.  It  is  not  quite  clear  why  the  inoculations  of 
the  first  section  were  so  much  more  effective  than  those  of 
the  second  section.  Probably  the  fftshness  of  the  material 
had  an  influence ;  and  the  author  thinks  that  the  dose  for 
each  individual  was  more  carefully  measured  for  the  first 
than  for  the  second  section.  So  far  as  could  be  learned, 
the  members  of  the  first  section  suttered  more  severely 
at  the  time  from  both  local  and  constitutional  disturb- 
ances. The  results  above  given  seem  to  be  very  strong 
evidence  in  favor  of  the  protective  power  of  anti- 
typhoid inoculations,  when  they  are  very  carefully  per- 
formed, and  they  point  to  the  necessity  for  2  inoculations 
at  suitable  intervals.  During  the  period  of  5  months  that 
the  hospital  was  stationed  at  Kroonstadt,  there  were  92 
admissions  for  enteric  fever  with  11  deaths.  Of  the  92  cases, 
15  said  that  they  had  been  inoculated.  Of  the  11  fatal  cases,  1 
occurred  in  a  patient  who  had  been  inoculated  once.  The 
author  fears  that  any  statistics  bearing  on  the  question  of  the 
efficacy  of  the  inoculations  derived  from  the  hospitals  in 
South  Africa,  will  not  be  of  great  value.  At  the  same  time 
he  feels  convinced  that  the  attacks  of  typhoid  fever  were,  as 
a  rule,  much  milder  in  the  inoculated  than  in  the  noninocu- 
lated,  and  that  the  duration  of  the  disease  in  the  inoculated 
was  shorter.     [j.m.s.J 

Lancet. 

January  IS,  1901.    [No.  4037.] 

1.  Two  Clinical  Lectures  on  the  Enlargement  of  the  Pros- 

tate.   P.  Y.  Freyer. 

2.  Pneumococcic  Arthritis.    Edward  J.  Cave. 

3.  A  Case  of  Siriasis.    A.  E.  Griffin. 

4.  Dorsal   Dislocation   of   the   First  Phalanx  of  the   Little 

Finger ;  Reduction  by  Faraboeuf  's  Dorsal  Incision. 
Harold  L.  Barnard. 

5.  The  Treatment  of   Dupuytren's  Contraction  and    other 

Points  in  the  Surgery  of  the  Hand.    A.  H.  Tubby. 

6.  Loss  of  the  Left  Forearm  by  Amputation ;  Death  49  Years 

after ;  Necropsy ;  Localized  Area  of  Atrophy  at  the 
Base  of  the  Right  Second  Frontal  Gyrus.  Peers 
Macldlich. 

7.  A  Case  of  Chronic  Inversion  of  the  Uterus  of  7  Months' 

Duration  Successfully  Treated  by  Aveling's  Repositor. 
Thomas  Oliver. 

8.  The  Relation  of  the  Bowel  Lesion  of  Typhoid  Fever  to  the 

General  Symptoms  of  the  Disease.    T.  J.  JL^claoan. 

9.  P.eflections  on  Therapeutics.    Harry  Campbell. 

I,— Freyer  thinks  that  the  term  "senile"  should  not  be 
applied  to  enlargement  of  the  prostate  gland,  as  it  is  not 
dependent  upon  senility.  About  83%  of  men  past  55  years 
have  enlarged  prostates,  but  only  about  5%  ever  suflfer  from 
symptoms.  W^hen  the  hypertrophy  involves  the  whole  gland 
and  the  enlargement  is  uniform,  symptoms  are  not  usually 
present.  Enlargement  of  the  middle  lobe  gives  rise  to  raost 
trouble.  Sometimes  the  overgrowth,  when  examined  histo- 
logically, resembles  a  fibromyoma,  but  more  often  the  hyper- 
trophy involves  the  glandular  tissue  largely,  and  the  growth 
would  seem  to  be  adenomatous,  and  this  is  always  true  in 
the  beginning.  The  so-called  "  prostatic  tumors,"  localized 
hypertrophies,  may  occur  anywnere  in  the  gland,  and  as 
they  grow,  project  into  the  bladder,  and  have  only  attach- 
ment by  small  pedicles.  The  length  and  course  of  the 
urethra  may  be  greatly  altered,  according  to  the  position  of 


202 


The  Phtladelphia"! 
Medical  Jodrsal  J 


THE  LATEST  LITERATURE 


[Febbcaet  2,  IM! 


the  hypertrophy.  The  changes  in  the  bladder-wall  are 
described  with  the  formation  of  a  postproetatic  poach,  and 
the  extension  of  infection  from  foul  urine  up  the  ureter  to 
the  kidneys.  Constant  straining  at  micturition  may  produce 
prolapse  of  the  rectum  or  hemorrhoids.  Freyer  inclines  to 
the  view  that  the  hypertrophy  is  analogous  to  fibroid  disease 
of  the  uterus,  rather  than  that  it  is  due  to  a  general  arterial 
sclerotifl.  He  describes  the  symptoms  produced  by  enlarge- 
ment of  the  diflferent  lobes  of  the  prostate.  He  advises  that 
when  the  amount  of  residual  urine  is  large,  as  cm  be  deter- 
mined by  palpation  and  rectal  examination,  that  the  whole 
amount  should  not  be  drawn  at  the  first  examination.  He 
urges  a  thorough  examination  of  the  prostate  by  the  finger 
in  the  rectum,  first  in  the  recumbent  position  and  then  in 
the  knee- chest  position,  determining  its  shape,  consistence, 
degree  of  tenderness,  etc.  Examination  with  the  sound  and 
cjstoscope  wiJl  decide  the  degree  of  hypertrophy  of  the 
middle  lobe.  Patient  should  remain  in  bed  for  a  day.  [j.h.g  J 
2. — Cave,  in  an  article  on  pneumococcic  artliritls 
states  that  while  the  condition  is  a  very  uncommon  one,  many 
cases  escape  detection  on  account  of  the  lack  of  bacterio- 
logical examination.  He  gives  a  report  of  a  case  of  his  own 
and  30  collected  from  literature.  The  history  of  his  case  is 
as  follows :  The  patient,  a  man  aged  51  years,  follows  the  oc- 
cupation of  farming.  When  he  was  first  seen  by  Dr.  Cave 
the  signs  of  a  pneumonia  involving  the  right  base  were 
elicited.  His  illness  had  existed  for  11  days.  On  the  sixth 
day  of  the  disease  his  temperature  fell  by  crises,  but  only  to 
rise  again  accompanied  by  signs  of  consolidation  of  the  left 
base.  When  seen  by  Dr.  Cave  the  patient  was  in  a  moribund 
state  and  therefore  too  ill  to  be  carefully  examined.  At  this 
time  it  was  found  that  his  left  shoulder  was  swollen,  red,  and 
edematous.  It  was  ascertained  that  this  shoulder  had  been  in- 
jured 5  days  before  in  struggling  during  his  delirium.  Death 
occurred  an  hour  after  Dr.  Cave's  visit.  From  the  shoulder- 
joint  thick,  greenish,  creamy  pus  was  obtained  by  aspiration. 
The  pus  contained  pneumococci.  Inoculations  were  made 
on  agar  and  blood  serum  and  cultures  of  the  pneumococcus 
developed.  In  an  analysis  of  the  31  cases,  23  terminated 
fatally  and  28  were  immediately  associated  with  pneumonia. 
In  only  2  cases  did  the  arthritis  precede  the  pneumonia. 
Three  cases  occurred  without  pneumonia.  Pneumococcic 
arthritis  is  much  more  common  in  males  than  in  females, 
and  occurs  especially  in  adult  and  in  advanced  life.  The 
upper  extremity  is  involved  more  frequently  than  the  lower. 
In  27  of  the  cases  suppuration  developed,  in  3  there  was  no  pus 
formation,  and  1  case  was  doubtful.  The  pneumococcus  was 
demonstrated  in  30  of  the  cases.  Manifestations  of  wide- 
spread infection  were  observed  in  a  number  of  cases  ;  6 
were  complicated  with  malignant  endocarditis,  5  with 
pleurisy  and  empyema,  2  with  pericarditis,  3  with  nephritis, 
6  withmenirgitis,  and  1  with  peritonitis.  In  some  of  the 
cases  more  than  one  serous  membrane  was  involved  at  the 
same  time.  The  specific  microorganism  is  found  in  the  fluid 
of  the  exudate  embedded  in  some  of  the  cells  and  upon  the 
free  surface  of  the  exudate,  but  not  in  the  deeper  tissues  of 
the  joints.  Permanent  injury  to  the  joint  often  follows  this 
form  of  arthritis,  but  in  some  of  the  milder  cases  complete 
function  is  restored.  Injury  or  previous  disease  of  a  joint 
predisposes  to  pneumococcic  infection.  He  further  states 
that  experimental  evidence  gives  abundant  proof  that  the 
injection  of  the  pneumococci  into  a  joint  in  susceptible  ani 
mals  is  almost  always  followed  by  suppurative  arthritis. 
Subcutaneous  injection  is  often  followed  by  inflammation  of 
a  joint  which  has  been  previously  irritated.  If  the  injection 
be  intravenous,  arthritis  is  more  apt  to  follow.  If  a  rabbit  be 
partially  immunized  to  the  pneumococcus  and  then  a  viru- 
lent culture  injected,  septicemia  is  not  so  liable  to  follow,  but 
rather  local  involvement,  especially  arthritis.  The  clinical 
manifestations  of  pneumococcic  arthritis  vary.  The  local 
symptoms  may  be  slight  or  intense  ;  fever  is  as  a  rule  high, 
and  the  diagnosis  depends  upon  the  finding  of  the  specific 
microorganism  in  the  aflected  joint,  or  upon  the  association 
with  pneumonia  or  other  pneumococcic  forms  of  infection. 
The  prognosis  is  always  grave.  As  to  the  treatment,  in  the 
suppurative  varietj'  of  arthritis,  early  incision,  free  drainage 
and  rest  of  the  part  is  recommended.  When  the  efi"usion  is 
serous  or  serofibrinous  (as  determined  by  aspiration)  rest 
and  compression  are  the  important  measures.  The  after- 
treatment  consists  in  the  use  of  hot-air  baths,  hydrothera- 
peutic  measures,  and  massage,     [f.j.k.] 


3. — Griffin  reports  a  case  of  siriasls.    The  patient,  aged 
25,  an  Englishman,  and  assistant  ecgineer  by  occupatiaa,4 
hsd  been  in  good  health  up  to  the  time  of  the  present  illneas.  ■ 
After  working  for  some  time  in  the  boiler-room  of  the  shipj 
in  which  the  temperature  was  114°  F.,  he  developed  siriaaa.! 
His  pulse  was  as  high  as  169  per  minut«,  his  respiration  601 
per  minute,  and  his  temperature  108.6°  F.     After  a  rather! 
prolonged  illness,  he  finally  recovered.    The  early  treatment  ' 
consisted  of  ice-packs,  cold  sponging,  and  the  administration 
of  digitalis.    Later,  the  treatment  consisted  principally  of 
sponging,  and  the  administration  of  quinin,  calomel,  ammo- 
nium bromid,  and  diaphoretics,     [f.j  k.] 

4. — Barnard  describes  a  case  of  dorsal  laxation  of 
first  phalanx  of  little  finger,  due  to  a  blow  on  the  back 
of  the  hand,  which  it  was  impossible  to  reduce  by  any  form  * 
of  manipulation,  but  which  was  readily  replaced  alter  I 
division  of  the  splenoid  ligament  through  a  small  dorsal  inci- 1 
eion,  after  the  manner  described  by  Farabceaf  for  the  redoo-  f 
tion  of  the  same  dislocation  of  the  thumb.  He  does  not  ' 
think  that  the  slipping  of  the  head  of  the  metacarpal  bone  be- 
tween the  tendons  offers  the  obstruction  to  reduction  that 
was  at  one  time  supposed.  He  has  produced  and  studied  a 
number  of  artificial  dislocations  and  concludes  the  subject 
thus  :  1.  That  dislocation  backwards  of  the  first  phalanx  of 
the  little  finger  is  rarer  than  that  of  the  index  finger  and 
much  rarer  than  that  of  the  thumb.  2.  That,  unlike  the 
similar  dislocation  in  the  thumb,  it  is  probably  produced 
in  most  cases  by  violence  appUed  to  the  dorsal  surface  of 
the  head  of  the  metacarpal  bone.  3.  That  the  3  varieties — 
(a)  incomplete  dislocation  ;  (5)  the  complete  simple  disloca- 
tion ;  and  (c)  the  complete  complex  dislocation — so  admirably 
described  by  Faratceaf  in  the  case  of  the  thumb — apply 
equally  to  the  little  finger.  4.  That  the  incomplete  disloca- 
tion is  easily  reduced  by  pushing  the  phalanx  forward  ;  the 
complete  simple  form  by  the  method  of  maaipulation  sug- 
gested by  Farahcenf ;  whilst  the  complete  complex  disloca- 
tion, the  result  of  Hi-directed  manipulation,  requires  the 
simple  operation  suggested  by  Desault.  Farabceif  and  Hulke. 

6.— Tubby  notes  thatDapuytren's  contraction  of  the 
palmar  fascia  is  more  common  in  men  than  in  women,  that 
it  usually  comes  on  after  40  years  of  age,  and  that  the 
patients  often  give  a  gouty  history.  Cause  is  unknown.  He 
recommends  the  open  method  where  the  fascia  is  dissected 
outwardly,  as  preferable  to  the  older  method  of  subcutane- 
ous division  of  the  fascia.  The  prognosis  in  cases  of 
tendon  division  in  the  hand.  Tubby  says,  is  dependent 
on  3  factors:  first,  the  power  of  retraction;  second,  the 
amount  of  fixation  of  the  tendon  in  its  sheath,  and.  tbird, 
the  character  of  the  structures  at  the  spot  where  division 
occurs,  particularly  as  regards  the  circulation  in  these  parts. 

[j  H.G  ] 

6.— Maclulich  and  Goodall  report  the  case  of  a  man  who 
had  lost  his  left  forearm  from  traumatism  when  a  boy,  and 
who,  at  the  age  of  63  years,  developed  melancholia  and 
died  suddenly  of  angina  pectoris.  Examination  of  the 
brain  showed  but  one  lesion,  a  softening  occupying  the 
gray  matter  of  the  base  of  the  right  second  frontal  convolu- 
tion where  it  joins  the  ascending  frontaL  Toe  area  pre- 
sented signs  of  having  wasted.  It  looked  old,  but  there  was 
no  sclerosis.  The  subjacent  white  matter  showed  no  change 
to  the  naked  eye.  Tbe  point  of  interest  in  the  case  is  the 
possible  relationship  between  the  loss  of  the  arm  and  this 
wasted  area  which  was  anterior  to  the  portion  of  the  brain 
supposed  to  control  the  forearm  and  hand     [i.H  g.] 

8.  —  The  relation  of  the  bowel-lesions  of  typhoid 
fever  to  the  general  symptoms  of  the  disease  is  di»- 
cussed  by  Maclagan.  He  notes  that  fever  is  the  mcst  promi- 
nent syniptom.  He  believes  that  the  fever  and  other  general 
manifestations  in  the  course  of  this  disease  are  not  due  to  the 
local  lesions,  but  to  the  great  number  of  virulent  bacilli  which 
have  found  their  way  into  the  circulation.  The  chief  action 
upon  the  tissues  produced  by  the  bacilli  is  the  consumption 
of  nitrogen  and  water.  He  further  believes  that  the  eesential 
phenomena  of  the  disease,  such  as  increased  elimination  of 
urea,  thirst,  loss  of  appetite,  wasting,  etc.,  are  dependent  upon 
these  two  conditions,  namely,  the  consumption  of  nitrogen 
and  water  by  the  coniagium.  The  sodi  salts  are  eliminated 
in  diminished  quantity  or  they  are  retained,  while  the  potash 
salts  are  more  freely  elimioat'ed.  The  reason  for  this  is  that 
the  soda  salts  are  taken  up  by  the  bacilli,  and  the  potash 
salts,  which  exist  in  the  tissues,  for  reason  of  increased  di»- 


Fkbbcart  2,  1901] 


THE  LATEST  LITERATURE 


[■ 


The  Philadelphia 
Medical  Journal 


203 


integration,  are  eliminated.  When  the  glandular  tissue, 
which  forms  the  focus  for  the  morbid  process,  is  destroyed, 
the  general  manifestations  of  the  disease  come  to  an  end. 
Recrudescence  of  the  fever  is  explained  aa  follows  :  Some  of 
the  intestinal  lesions  are  involved  late  in  the  course  of  the 
disease,  while  others  are  undergoing  healing.  Relapses  are 
explained  in  a  similar  way,  namely,  that  the  pathological 
progress  in  some  lesions  is  greatly  retarded.  He  states  that 
the  uneven  distribution  of  the  microorganisms  in  the  blood 
may  cause  some  of  the  lymphoid  structures  to  escape  infec- 
tion. This  may  occur  even  after  one  or  two  relapses.  The 
local  disturbances  are  due  to  the  multiplication  of  the  bacilli 
in  the  lymphoid  tissues  of  the  intestine.  The  late  symptoms 
in  a  severe  case  may  be  in  part  ascribed  to  a  septic  poisoning 
during  the  stage  of  sloughing  and  ulceration.  At  this  time 
various  forms  of  cocci  are  associated  with  the  primary  infec- 
tion. This  is  especially  likely  to  occur  when  gangrenous 
ulceration  develops,    [f.j.k.] 


New  York  Medical  Journal. 

January  £6,  1901.     [Vol.  Ixxiii,  No.  4.] 

1.  Gastroenterostomy    by  the  Elastic    Ligature.    Theo.   D. 

McGraw. 

2.  Cereals,  Emulsions  and  Proteida  in  Infant  Feeding.    T. 

M.  ROTCH. 

3.  L  Septicemia,  Acute  Bacteriemia;  and  Pyemia,  Chronic 

Bacteriemia.  II.  The  Indications  for  Hysterectomy 
and  the  Indications  for  Abdominal  Section  and  Drain- 
age in  Puerperal  Infection.    H.  J.  Boldt. 

4.  Observations  on  the  Toxic   Effects  of   Some    Common 

Drugs.    Philip  F.  Hakvey. 

5.  The  Treatment  of  Influenza.    W.  H.  Thomson. 

1. — McGraw  has  performed  the  operation  of  gastro- 
enterostouiy  by  the  elastic  ligature  in  5  cases.  Two 
of  these  patients  died  in  collapse  a  tew  hours  after  the  opera- 
tion, 2  of  the  3  others  lived,  one  15  days  and  the  other  14 
days  after  the  operation,  the  one  dying  from  starvation  due 
to  the  anastomosis  having  been  located  too  near  the  ileocecal 
valve,  and  the  other  from  the  formation  of  the  "  vicious 
circle."  The  third  feels  in  perfect  health,  unconscious  of  the 
disease  which  must  sooner  or  later  end  his  life.  The  term 
"  vicious  circle  "  is  applied  by  German  surgeons  to  a  condi- 
tion sometimes  occurring  after  gastroenterostomy,  in  which 
the  food  passes  from  the  stomach  into  the  afferent  instead  of 
the  eflferent  limb  of  the  intestine.  It  then  fills  the  duodenum, 
soon  to  regurgitate  and  pass  again  into  the  stomach.  The 
causes  of  this  condition  are  not  well  understood.  If  not  re- 
lieved it  results  in  the  death  of  the  patient.  McGraw 
emphasizes  the  necessity  of  a  proper  technic  as  regards  :  1. 
The  ligature.  This  should  be  a  hard,  round,  smooth  and 
strong  rubber  cord,  at  least  2  millimeters  in  diameter.  2.  It 
must  include  in  one  loop  all  of  the  tissue  which  it  is  desirable 
■  to  sever.  3.  The  cord  must  be  drawn  as  firmly  and  tightly 
together  as  possible  and  fastened  by  a  silk  thread  which  is 
tied  around  them.  4.  Before  inserting  the  rubber  ligature 
the  viscera  should  be  joined  together  by  a  row  of  Lembert 
sutures  for  a  distance  of  6  or  7  centimeters,  and  when  the 
ligature  has  been  tied  a  similar  row  in  the  front  should  com- 
plete the  function,    [w  a.n.d.] 

2.— Rotrh  discusses  the  sunject  of  cereals,  emulsions, 
and  proteids  in  infant  feeding.  He  states  that  the 
«ddition  of  cereals  to  the  milk  is  chiefly  for  one  of  two 
reasons:  1.  That  the  resulting  food  should  have  a  greater 
nutritive  value  from  the  administration  of  starch  in  addition 
to  the  chief  elements  constituting  human  milk,  namely, 
fats,  milk-sugar  and  proteids.  2.  To  aid  in  the  digestion  of 
proteids  by  acting  in  some  mechanical  way  on  the  coagulum 
of  the  caseinogen,  so  as  to  render  it  finer  and  more  closely 
to  approximate  the  coagulum  of  human  milk.  In  his  ex- 
perience with  milk  carefully  modified  in  the  Uboratories  he 
has  many  times  met  with  a  disturbance  of  the  emulsion, 
but  has  not  been  able  to  see  that  it  did  any  special  harm,  as 
only  part  of  the  emulsion,  and  a  small  part,  is  disturbed. 
The  management  of  the  proteids  in  an  infant's  food  is 
important.  The  results  of  the  experiments  as  to  the  coagu- 
lability of  whey-mixtures  are  still  subjudice,  but  so  far  as  they 


go  they  bear  out  the  theoretic  assumption  that  the  coagula 
are  very  distinctly  finer  than  in  aa  ordinary  midifisd  milk 
of  the  same  total  proteids.  The  management  of  the  coagu- 
lum depends  on  the  mani^ement  of  the  caseinogea,  and  the 
coagulum  will  ba  small  and  fine  if  the  caseinogen  is  kept 
down  to  its  proper  relative  proportion  to  the  whey  proteids. 
[w.a.n.d] 

3._Boldt  discusses  the  indications  for  hysterectomy 
and  the  indications  for  abdominal  section  and 
drainage  in  i>uerperal  infection,  waether  due  to  septi- 
cemia— acute  bacteriemia,  or  pyemia — chronic  bacteriemia. 
He  believes  that  it  is  impossible,  with  our  present  knowledge, 
to  lay  down  absolute  rules  for  the  performance  or  omission 
of  these  operations.  He  suggests  the  following  indications 
for  hysterectomy,  if  it  is  evident  that  less  heroic  treatment  is 
useless :  1.  If,  after  a  full-term  delivery  or  an  abortion,  there 
are  no  conception-products  in  the  uterus,  and  the  pitient 
has  fever  with  exacerbations,  chills,  and  a  small  and  frequent 
pulse  (120  to  140  or  more),  if  careful  observation  should  show 
that  the  infection  comes  from  the  uterus  alone,  that  organ 
being  enlarged,  and  relaxed  in  its  consistency,  if  there  is  no 
evidence  of  peritonitis,  the  parametria  being  free  if  strepto- 
cocci are  found  in  the  uterus,  and  especially  if  the  blood 
shows  the  presence  of  pathogenic  germs.  2.  If  there  are  de- 
composition-products in  the  uterus  which  cannot  be  removed 
satisfactorily  per  vaginam,  if,  on  doing  a  cesarean  section,  the 
uterus  is  found  septic,  then  an  abdominal  hysterectomy  is 
indicated.  Abdominal  section  with  drainage  is  indicated  in 
diffuse  septic  peritonitis  when  there  is  no  evidence  of  an 
exudate  in  the  pelvis.  The  adnexa  are  to  be  left  undisturbed, 
unless  there  is  some  positive  indication  to  do  otherwise. 
[w.A.N.D  ] 

4.— Philip  P.  Harvey  points  to  the  growing  tendency 
towards  greater  conservatism  in  the  treatment  of 
chronic  ailments  by  the  use  of  drugs,  and  there  is 
less  disposition  to  push  certain  medicinal  substances  beyond 
the  point  of  tolerance.  He  details  a  case  in  which  a  patient 
suffering  from  a  pustular  acne  declared  that  she  was  unable 
to  take  arsenic  or  mercury  in  any  form.  He  gave  her  very 
minute  doses  of  bichlorid  of  mercury  and  chlorid  of 
arsenic.  (He  does  not,  however,  state  the  doses.)  The  pa- 
tient tolerated  the  treatment  extremely  well,  and  in  3  months 
was  completely  cured.  He  deplores  the  use  of  mercurials 
in  the  treatment  of  syphilitic  infants,  it  being  estab- 
lished by  observation  that  injurious  effects  may  result,  and 
it  is  extremely  doubtful  that  mercury  has  any  therapeutic 
value  in  syphilitic  conditions  in  infancy.  In  general, 
Harvey  believes  that  we  should  be  cautious  in  administering 
drugs  in  heroic  doses,  and  that  the  study  of  their  action  is 
necessary  before  we  can  say  that  the  drug  is  not  doing  more 
harm  than  good,     [t  L  c  ]  „  .    „ 

5.— W.  H.  Thomson  considers  the  treatment  ot  influ- 
enza. He  believes  that  aconite  is  one  of  the  best  reme- 
dies for  the  general  achings  which  characteriza  the  onset 
of  so  many  febrile  affections.  He  has  often  aborted  an 
acute  tonsillitis  by  giving  early  a  dose  of  the  tincture  of 
aconite  sufficient  to  cause  this  drug's  specific  sense  of  con- 
striction of  the  throat.  He  believes  its  action  is  further  pro- 
moted by  the  addition  of  a  small  dose  of  Dover's  powder. 
He  combines  phenacetin  with  quinin,  and  believes  that 
these  two  drugs  may  possibly  act  as  antitoxins  to  the  influ- 
enza poison.  He  recommends  a  prescription  containing  in 
each  dose,  i  grain  of  solid  extract  of  aconite,  1  grain  of 
Dover's  powder,  4  grains  of  phenacetin,  and  3  grains  of 
quinin,  made  into  2  pills.  Six  pills  are  to  be  taken  on  the 
first  day  of  the  attack,  and  c  n'inued  as  long  as  the  fever 
lasts.  When  coryza  and  nasal  catarrh  are  leading 
symptoms  he  advises  a  pill  of  i  grain  of  belladonna,  with  a 
grain  or  two  of  camphor.  To  this  may  bs  added,  flushing 
of  the  throat  with  a  fountain  syringe,  with  a  solution 
containing  a  quart  of  hot  water,  to  which  2  teaspoonfuls  of 
potassium  chlorate  and  5  drops  of  oil  of  peppermint  are 
added.  In  those  cases  in  which  the  supraorbital  sinuses  be- 
come involved  with  generally  periodic  attacks  of  pain,  and 
often  photophobia,  he  has  found  an  extract  of  ergot  in 
dram  doses,  repeated  every  3  hours,  if  necessary,  to  be  a  spe- 
cific. In  the  dry  cough  which  so  frequently  follows  influ- 
enza, he  has  long  recommended  an  emulsion  of  linseed  oil. 
Adjuvants  to  this  general  treatment  are  advised  when  indi- 
cated, and  especial  importance  laid  upon  complete  rest  in 
bed.     [t.l.c] 


904  ^"^  PhiladelphiaI 

~  Medical  Jocesal  J 


THE  LATEST  LITERATURE 


[Febecakt  2,  J 


Medical  Record, 

January  S6,  1901.     \\6\.  59,  No.  4.] 


Geobge    F. 


1.  Early    Diagnosis    of    Mammary    Tumors. 

Shrady. 

2.  Some    Further  Work  on  the  Moequito- Malaria  Theory, 

with  Special  Reference  to  the  Conditions  Around  New 
York.    Wm.  X.  Berilelet. 

3.  The  Causation,  Prevention,  and  Cure  of  Gout.    ALEXA^- 

DEE  Haig.  !         "    ' 

4.  The  Nonmvxomatous  Character  of  Xasal  Polypi.    Joka- 

THAS  Weight. 

1. — Shrady,  in  making  a  plea  for  early  diagnosis  in  all 
gro'wths  of  the  mammary  gland  diecuEses  in  detail  the 
differential  diagnosis  between  carcinoma  and  the  other  tu- 
mors of  the  breast.  Among  the  early  symptoms  of  cancer  is 
the  "dimpling"  of  the  skin  over  the  growth,  and  this  the 
author  thinks  of  the  greatest  significance,  coming  on  before 
retraction  of  the  nipple  oftentimes.  This  sign  is  seen  in  even 
deep-seated  cancers.  The  "tumor  test"  of  stroking  the 
breast  with  the  flat  of  the  hand  while  the  patient  is  recum- 
bent, will  always  reveal  the  presence  of  the  growth.  These 
two  signs,  with  darting  pains,  are,  in  Shrady's  experience,  the 
earliest  signs  of  cancer.  With  such  symptoms  the  patient 
should  see  a  surgeon  at  once.  He  emphasizes  the  fact  that 
no  mammary  tumor  can  be  trusted  and  that  the  chances  of 
malignancy  are  very  great.  To  make  a  diagnosis  of  a  "  sim- 
ple tumor  "  one  must  be  very  sure  of  his  ground.  The  diag- 
nosis has  a  most  important  practical  bearing  on  ultimate 
results.  Probably  90%  of  breast-tumors  in  older  women  are 
malignant.  Even  adenomata  are  best  removed,  as  malignant 
changes  in  them  are  not  an  impossibility,     [j  h  g.] 

2. — William  H.  Berkeley  presents  some  further  work  on 
the  mosqaito- malaria  theory,  with  special  reference  to 
conditions  around  New  York.  He  touches  upon :  1.  The 
local  species  of  Anopheles  and  their  natural  history.  2.  In- 
oculation experiment*.  3.  The  incubation  period  of  malaria. 
4.  Prophylaxis  and  eradication  of  the  malaria  endemic  in 
our  own  locality.  Of  the  three  species  of  Anopheles,  native  of 
North  America,  he  has  found  two  around  New  York :  A. 
quadrimaculatus  Wiedemann  and  A.  punctipennis  Say. 
He  describes  structural  differences  between  Culei  and  Ano- 
pheles. Anopheles  was  never  found  without  Culex.  Oflenest 
C.  pungens.  Anopheles  was  found  always  in  buildings,  oft- 
enest  on  walls  and  ceilings  of  recently  used  bed-rooms,  and 
was  far  more  abundant  in  the  dwellings  of  the  poor.  The 
adults  were  not  found  out  of  doors.  Berkeley  has  placed  early 
March  as  the  period  in  the  spring  when  the  female  begins  to 
bite.  He  found  Anopheles  as  lat«  in  the  fall  as  November  6. 
He  determined  experimentally  that  the  time  from  egg  to  adult 
does  not  occupy  more  than  19  days,  and  believes  that  care  of 
the  larvae  would  have  further  shortened  the  period.  He  per- 
formed a  series  of  inoculation  experiments  and  succeeded 
after  repeated  trials  in  inoculating  A.  quadrimaculatus  with 
tertian  parasite.  He  was  unable  to  bring  about  infection  in 
man  from  the  bite  of  a  single  infected  mosquito.  As  to  the 
period  of  incubation  between  the  bite  and  chill,  he  reports 
one  case  with  a  clear  history  in  which  it  was  exactly  14  days. 
As  to  the  prophylaxis  he  believes  the  Health  Department 
should  require  malarial  cases  to  be  reported,  and  that  every 
house  should  be  thoroughly  inspected  and  the  inmates  in- 
structed to  kill  all  the  Anopheles  in  the  house ;  to  provide 
the  windows  and  doors  with  screens ;  to  use  every  precaution 
to  isolate  the  patient  from  mosquitoes,  and  to  cause  all  the 
standing  water  in  the  vicinity  to  be  drained,  or  heavily 
petrolized.  Rigid  treatment  with  quinin  should  be  insisted 
upon,     [t.l.c  ] 

3. — Haig  gives  a  general  review  of  his  now  well  known 
theory  concerning  the  etiology  of  gout  and  rheuma- 
tism. He  does  not  accept  the  bacterial  origin  of  rheumatic 
fever,  and  believes  in  the  identity  of  gout  and  rheumatism. 
His  theory  makes  uric  acid  in  soluticn  responsible  for  the 
attacks  in  both  diseases.  He  does  not  believe  that  the  salicy- 
lates are  at  all  times  a  useful  remedy  in  rheumatic  condition, 
but  that  frequently  they  may  do  harm  rather  than  good. 
His  chief  points  in  treatment  are,  that  uric  acid  being  a 
poison  should  be  introduced  into  the  body  in  as  small 
quantities  as  possible,  and  to  this  end  dietetic  measures  are 
important.  Again  it  is  urgent  to  provide  for  the  elimination 
of  poison  already  in  the  body.    It  is  especially  important  to 


see  that  a  proper  quantity  of  albumin  is  taken  in  proportion  i| 
to  the  body-weight.    In  seme  acute  and  chronic  conditions 
we  should  aim  to  diminish  the  alkalinity  of  the  blood  which 
ifl    high,    for  the   purpose  of   favoring  the    best  action  of 
tDe    salicylates.    The  same  principle  holds  for  the  acute  J 
arlhritis  of  gout.    Give  the  salicylates  alone  and  plenty  of  I 
them,  and  on  no  account  with  alkali  or  colchicum,  as  these 
Increase  the  alkalinity  of  the  blood.    Daring  this  treatment 
he  does  not  cut  off  wine  or  cut  down  meat,  for  both  tend  to 
keep  up  the  acidity  of  the  urine  and  diminish  the  a.kalinity 
of  the  blood.    He  believes  that  the  high  blood-pressure  of 
chronic  gout  is  due  to  large  excess  of  uric  acid  in  the  blood 
and  recommends  the  iodid  of  sodium  more  or  less  aided  by 
the  chlorid  and  bromid  of  ammonium  and  chlorid  of  sodium. 
[t.l.c] 

4. — Jonathan  Wright  calls  attention  to  the  histolc^gic 
error  of  classing  nasal  polypi  as  myxomata.  As  the 
result  of  a  careful  study  of  polypi,  he  has  found  some  mucin 
and  occasional  embryonal  new  connective-tissue  cells.  There 
is  little  or  no  new  formation  of  tissue,  but,  on  the  contrary,  a 
separation  of  the  fibers  of  the  preexisting  subepithelial  strom* 
serves  efiusion.     [t.lc.] 


Medical  News. 

January  S6,  1901.     [Vol.  lixviii.  No.  4] 

1.  Lakewood  as  a  Winter  Resort.    Wit.  Gray  Schactflek, 

2.  The  Climatic  Treatment    of  Chronic    Bright's    Diseaae. 

James  Tyson. 

3.  Treatment  of  Syphilis  at  Hot  Springs,  Ark.    Jaiceb  T. 

Jelks. 

4.  Some  Topographical  and  Climatic  Features  of  the  Florida 

Peninsula  ;  with  Special  Reference  to  its  Adaptiveneas 
as  a  Winter  Health  Resort.    James  K.  Crook. 

5.  The  Climatology  of  Neurasthenia.    F.  Savaby  Pearce. 

6.  The  Tonsils  as  Portals  of  Infection.    Jcurs  Ullmas. 

1.— W.  G.  SchaufHer  believes  that  Lakewood,  N.  J., 

possesses  valuable  physical  characteristics  as  a  winter  resort 
and  lays  stress  upon  ita  accessibility  and  its  economic  fea- 
tures. The  greatest  factor  in  its  favor  is  its  comparative 
warmth  and  low  humidity.  A  point  observed  haa  been 
that  in  the  cold  weather  when  the  thermometer  fell  below 
the  freezing  point  the  day  was  invariably  bright  and  sunshiny. 
Damp  days  are  the  exception.  He  recommends  the  place 
for  convalescents  and  neurasthenics  as  well  as  those  suffering 
from  asthma  and  bronchial  affections.     [t.i_c.] 

2.— James  Tyson  and  F.  M.  Tyson,  discuss  the  general 
principles  of  the  climatic  treatment  of  chronic  Bright's  dis- 
etise.  They  conclude  that  there  should  be  as  little  cold, 
moisture'  and  variation  as  possible  and  that  hot  dry 
climates  should  be  more  beneficial  than  a  cold,  dry  cli- 
mate ;  either  is  better  than  a  temperate  climate,  such  as  that 
found  in  the  United  States,  with  ground  saturated  with  moia 
ture  and  consequent  dampness,  with  sudden  changes  of 
temperature,  and  marked  differences  between  night  and  day 
temperatures.  The  effect  of  high  winds  is  highly  detrimen- 
tal. The  mortality  from  renal  disease  is  highest  in  the 
Middle  Atlantic  Coast  region,  next  in  the  North  Atlantic 
and  least  in  the  Southern  Central  region.  In  consider- 
ing these  figures  we  must  not  fail  to  take  into  account  the 
greater  centers  of  population  with  their  accompanying  dis- 
eases, as  syphilis,  scarlet  fever  and  pneumonia,  which  pre- 
dispose to  Bright's  disease.  Also  the  habits  and  surrounding 
conditions  of  those  of  the  great  cities.  In  deciding  upon  a 
fit  climate  to  send  our  cases  to,  we  must  beware  of  high 
altitudes  if  the  patienta  sufler  from  a  failing  he^rt.  or  one  that 
has  already  lost  compensation,     [t.i.c] 

3. — Jelks  considers  the  very  favorable  results  of  the  treat- 
ment of  syphilis  at  Hot  Springs,  Arkansas,  and  believea 
this  to  be  due  to  the  favorable  hygienic  surroundings,  and 
complete  absence  of  business  cares  and  worries  on  the  part 
of  the  patients.  The  eliminating  organs  are  stimulated  bj 
bathing  and  drinking  of  the  hot  water.  It  is  found 
that  large  doses  of  the  acute  syphilitic  remedies  are  well 
born.  As  high  as  50  to  100  grains  of  the  iodide  salts  may  be 
safely  given  at  .-i  dose  three  times  a  day.  The  author  prefer* 
mercurial  ointment  to  any  other  form  of  the  lirug.  I' 
is  found  that  this  too  is  well  borne  in  large  doses,    [ix  c  ] 

4. — Crook  discusses  the  climate  of  Florida  and  its  adap- 


Fkbrtart 


THE  LATEST  LITERATURE 


TThk  Philad   I.PHIA 
L  Medical  Jocrnal 


205 


tiveness  as  a  winter  resort.  He  l)Riieve8  that  the  climate 
benefits  (1)  those  patients  who  sutler  from  recurrent  bron- 
chitis; (2)  those  with  predisposition  to  tuberculosis  but  who 
present  no  recognizable  lesions  of  the  disease  ;  (3)  those  cases 
of  beginning  phthisis  without  cavity  formation ;  (4)  cases  of 
fibroid  phthisis ;  (5)  The  large  valetudinarian  class,  composed 
of  old  rheumatics,  victims  of  subacute  or  chronic  gout,  asth- 
matics, and  intractable  cases  of  chronic  rhinitis,  pharyn- 
gitis, laryngitis,  lumbago,  neurasthenia,  and  general  debility. 
[t.l.c] 

5. — F.  Savary  Pearce  considers  the  climatology  of 
neurasthenia.  He  points  out  that  an  altitude  of  over 
2,000  Jeet  is  unsuitable  as  well  as  districts  menaced  by  high 
winds,  and  frequent  fogs,  cloudy,  saturated  atmospheres  with 
but  slight  movements  of  air-currents,  low  country  (sea-level), 
with  continuous,  non-varying,  although  moderate  heat  as 
Bermuda  and  Florida.  The  ideal  climatic  conditions  for  the 
neurasthenic  include  sea-air  in  a  well- wooded  country,  far 
enough  from  the  coast  to  avoid  fogs.  A  sea-voyage,  provided 
it  be  not  stormy,  will  also  prove  beneficial,    [t  l  c] 

6. — Julius  Ullman  studies  the  tonsils  as  portals  of  in- 
fection. In  his  article,  to  which  is  added  a  copious  biog- 
raphy, he  concludes  :  (1)  That  the  normal  tonsil  has  a  physi- 
ological function,  probably  protective  to  the  organism;  (2) 
however,  this  function  is  frequently  impaired  and  the  tonsil 
becomes  the  nidus  for  the  growth  and  distribution  of  patho- 
genic organisms  in  the  system  ;  (3  and  4)  that  in  many  grave 
processes  as  scarlatina,  the  tonsil  is  the  point  of  infection ; 
(5)  the  relation  between  endocarditis,  chorea,  rheumatism 
and  the  diseased  tonsils  found  in  cases  of  these  conditions  ; 
,  (6)  in  rare  cases  of  typhoid  fever  in  which  no  intestinal 
ulceration  can  be  demonstrated,  the  similarity  of  the  tonsil- 
lar tissue  to  Fever's  patches  suggests  the  possibility  of  bac- 
terial infection  "through  the  tonsil;  (7)  that  scrofulosis  is 
often  associated  with  diseased  tonsillar  tissue,  and  this  is 
often  the  point  of  selection  of  the  tubercle  bacillus;  (8)  he 
concludes  that  much  could  be  accomplished  by  careful  post- 
mortem studies  of  the  tonsils,  which  are  too  seldom  exam- 
ined,   [t.l.c] 


Boston  Medical  and  Surgical  Journal. 

Jamcary  24,  1901.    [Vol.  cxliv.  No.  4] 

1.  A  Short  Abstract  of  the  Early  History  of  Medicine  in  Mas- 

sachusetts to  the  Year  1800.    Elbridge  G.  Cutler. 

2.  The  Great  Toe  (Babinski'l  Phenomenon  :  A  Contribution 

to  the  Study  of  the  Normal  Plantar  Reflex  Bised  on 
the  Observation  of  156  Healthy  Individuals.  Morton 
Prince. 

3.  A  Case  of  Obliteration  of  the  Right  Ureter  by  a  Calcified 

Fibroid  ;  Removal  of  Fibroid  and  Implantation  of  the 
Ureter  into  the  Bladder;  Recovery.  Maurice  H. 
Richardson. 

4.  A  Ca«e  of  Vesical  Implantation  of  the  Ureter  by  Dudley's 

Forceps  Method  after  the  Failure  of  Several  Plastics. 
Edward  Reynolds. 

5.  Pregnancy  Following  Removal  of  Both  Ovaries  and  Tubes. 

M.  A.  Morris. 

2. — In  order  to  acquaint  himself  with  the  exact  character 
of  the  normal  plantar  reflex,  Prince  has  lately  examined 
the  reflex  in  156  presumably  healthy  men  between  the  ages 
of  22  and  33  years,  all  candidates  for  civil  service  examina- 
tion. As  a  result  of  these  observations  the  author  has  been 
able  to  satisfy  himself  that  one  cause  of  the  discrepancies  in 
the  reported  observations  of  different  authors  is  that  there 
may  be  2  distinct  plantar  reflexes,  one  of  which  is  probably 
cerebral  and  one  spinal.  Both  may  be  absent.  The  normal 
spinal  reflex  movement  of  the  toes  in  the  adult  is  always,  as 
shown  by  Babinski,  flexion ;  the  normal  cerebral  reflex  is 
generally  extension  of  the  toes  and  of  the  foot.  If  precau- 
tions are  not  taken  the  cerebral  reflex  may  mask  the  spinal 
reflex  and  give  erroneous  results,  that  is,  override  the  spinal 
flexion  and  produce  an  extension.  The  cerebral  reflex  can 
generally  be  inhibited  by  an  act  of  will  and  thus  leave  the 
spinal  reflex  free.  With  proper  precautions  taken  to  inhibit 
the  cerebral  reflex,  extension  of  the  great  toe  was  not  observed 
once  in  92  individuals.  In  64  individuals  it  was  only  ob- 
served once ;  but  in  this  case  the  extension  of  the  great  toe 
was  slight  and  was  in  all  probability  a  cerebral  reflex,  tince 


insufiicient  precautions  were  taken.  The  significance,  then, 
of  the  Babinski  phenomenon  consists  in  the  extension  of  the 
great  toe.  To  emphasize  this  the  best  term  would  be  the 
great  toe  phenomenon.  The  author  believes  thai  the 
frequency  of  the  spinal  plantar  reflex,  so  far  as  it  concerns 
the  toes,  has  been  exaggerated  owing  to  several  sources  of 
fallacy  having  been  overlooked,  such  as  (1)  mistaking  the 
cerebral  for  the  spinal  reflex ;  (2)  in  stroking  the  sole  it  is 
not  difficult,  by  moderate  pressure  over  the  first  phalanges, 
to  cause  a  purely  mechanical  flexion  of  the  toes ;  (3)  if  the 
stroke  is  made  from  the  toe  toward  the  heel,  pulling  on  an 
elastic  skin  will  do  the  same,     [j  M.S.] 

3. — Richardson  reports  a  case  that  illustrates  the  danger 
of  neglecting  an  old  fibroid.  The  patient  was  a 
woman,  aged  58  years,  who  had  always  been  well  until  10 
years  before  the  author  saw  her.  At  that  time  the  patient 
noticed  a  tumor  in  the  lower  portion  of  the  right  side  of  the 
abdomen  that  gradually  increased  in  size.  The  tumor  was 
painful  and  was  accompanied  by  frequent  aud  painful  mic- 
turition and  sometimes  by  incontinence.  On  examination, 
the  tumor  was  found  to  be  fluctuating  and  it  was  thought  to 
be  an  ovarian  cyst.  On  exposure,  the  growth  proved  to  be  a 
fibroma  of  the  uterus  on  the  right  side  of  which  there 
was  a  large  cyst  and  there  were  several  calcified  areas 
near  the  cyst.  As  the  operation  progressed  the  cyst  was  torn 
and  was  found  to  be  a  dilated  ureter.  The  divided  ureter 
was  sutured  into  the  bladder.  On  removing  the  left  half  of 
the  tumor  the  sigmoid  flexure  was  torn  and  the  opening  was 
closed  by  silk  sutures.  The  patient  made  a  complete  and 
uneventful  recovery,     [j  m.s  ] 

4. — Reynolds  reports  the  case  of  a  woman,  aged  45  years, 
who,  following  a  complete  vaginal  hysterectomy,  8ufi"ered 
from  an  ureterovaginal  fistula.  After  several  plastic 
operations  the  author  implanted  the  ureter  into  the 
bladder  by  Dudley's  forceps  method.  The  operation 
was  followed  by  complete  relief,     f j.m  s.J 

5. — Morris  reports  the  case  of  a  woman  who  was  subjected 
to  double  oophorectomy.  Soon  after  the  operation, 
which  was  successful,  the  patient  began  to  menstrua  e,  which 
function  continued  regularly  and  painlessly  for  4  months. 
Fourteen  months  after  the  operation  the  patient  was  deliv- 
ered, after  a  normal  labor,  of  a  healthy  girl  baby.  The 
child  died  when  it  was  about  3  weeks  old,  and  soon  after  that 
the  patient  again  began  to  menstruate  and  has  continued  to 
do  80  regularly  and  normally  since,    [j.m  s  ] 


Journal  of  the  American  Medical  Association. 

January  S6, 1901.    [Vol.  xxxvi,  No.  4.] 

1.  The  Diagnosis  of  Diabetes  Mellitus.    James  B.  Herrick. 

2.  Diabetes  Mellitus.    The  Mortality  therefrom  in  the  City 

of  New  York  during  the  Period  from  1889  to  1899, 
from  the  Official  Records.  Comments.  Heinrich 
Stein. 

3.  Cutaneous    Diseases    Accompanying    Diabetes.      M.  B. 

Hartzell. 

4.  Post  anesthetic  Paralyses.    C.  C.  Hersman. 

5.  Treatment  of  Neurasthenia.    Daniel  R.  Brower. 

6.  Intubation  in  Private  Practice  and  its  Perfection.    J. 

Trumpp. 

7.  Traumatism  During  Intubation.      Its  Prevention    and 

Treatment.    Johann  von  Bokay. 
S   Fracture  of  the  Pateli.    James  M.  Barton. 
9.  Growths  in  the  Frontal  Sitiu^  ;  Two  Cases;  Operation  ; 

Recovery.    W.  D.  Hamilton. 

10.  Treatment  of  the  Gastrointestinal  Symptoms  in  Typhoid 

Fever.    J.  H.  Anders. 

11.  The  Unbroken  Skin  as  an  Absorbing  Medium.    Thomas 

F.  Reiliy. 

12.  Idiosyncrasy  as  to  Mercury.    A  Case  of  Erythema  Mer- 

cu'riale.  "Albert  Bernheim. 

13.  A  New  Objective  Test   for  Mastoiditis,  with  Report  of 

Case.    Albert  H.  Andrews. 

14.  Ocular  Manifestations  of  Diabetes  Mellitus.    L.  A.  W. 

Alleman.  .  ,  t,   r 

15.  Some  Remarks  on  the  Plantar  Reflex,  with  Snecial  Refer- 

ence to  the  Babinski  Phenomenon.    J.  T.  Eskridge. 
1.— In  an  article  on  diabetes  mellitus,  Herrick  calls  atten- 
tion to  the  many  symptoms  or  complications  accompanymg 


206 


The  Philadelphia" 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


[Frbbcasy  2,  1901 


this  condition  which  are  lightly  passed  over  by  the  physician, 
the  observations  of  which  would  lead  to  an  early  diagnosis. 
Among  the  derangements  of  the  nervous  system  he  calls 
attention  to  the  neuritic  pains  in  the  legs,  with  loss  of  the 
patellar  reflex.  The  trophic  changes  are  falling  out  of  the 
nails,  bullae,  herpes  zoster,  perforating  ulcer,  etc.  Occasion- 
ally there  are  peripheral  paralyses,  cerebral  palsies,  mono- 
plegia, and  even  hemiplegia,  without  anatomical  lesions 
which  can  be  demonstrated  after  death.  Headaches  and 
dizziness  often  lead  the  patient  to  consult  a  physician.  The 
eye  may  give  indication  of  diabetes  by  paresis  of  the  external 
rectus  muscles.  Retinitis  and  atrophy  of  the  optic  nerve,  the 
development  of  bilateral  cataract  in  early  life  should  lead 
one  to  suspect  diabetes.  Furuncles  of  the  external  ear  and 
suppuration  of  the  middle  ear  with  early  involvement  of  the 
mastoid  may  occur.  The  conditions  which  deserve  especial 
attention  are  sexual  impotence  and  psychic  disturbances, 
irritability  of  temper,  suicidal  tendency,  etc.  Of  the  alimen- 
tary tract  he  lays  stress  upon  dilation  of  the  stomach  without 
alteration  of  its  functions.  Vomiting  and  diarrhea,  if  persis- 
tent, may  be  forerunners  of  coma.  Cirrhotic  liver  is  often 
present  with  bronzing  of  the  ekin.  The  examination  of  the 
blood  is  of  little  value,  though  the  color  reaction  of  Bremer 
and  Williamson  might  enable  one  to  recognize  diabetes  with- 
out glycosuria.  The  presence  of  acetone,  Beta  oxybutyric 
acid,  and  the  amount  of  ammonium  excreted  are  of  value 
from  the  standpoint  of  diagnosis  and  prognosis.  The  urine 
in  diabetes  has  a  tendency  to  undergo  rapid  fermentation, 
which  may  occur  in  the  bladder  and  produce  cystitis.  After 
the  attention  has  been  called  to  the  urine,  the  diagnosis  is 
usually  readily  made,  but  owing  to  certain  errors  may  be 
soinetimes  overlooked.  The  sources  of  error  may  be 
(1)  in  the  technic  of  the  examination  for  sugar ;  (2)  the  urine 
may  not  be  examined  by  the  physician;  (3)  that  there  is  no 
sugar  present  at  time  of  examination.  Emphasis  is  laid  on 
the  fact  that  casts  are  found  in  the  urine  during  diabetic 
coma  and  that  their  presence  may  give  warning  of  the  ap- 
proach of  coma.  The  specific  gravity  of  the  urine  may  be 
low  after  the  ingestion  of  large  quantities  of  fluids,  although 
the  amount  of  sugar  present  is  large.  Should  chronic  inter- 
stitial nephritis  supervene  the  amount  of  sugar  may  decrease 
or  entirely  disappear.  In  conclusion  he  calls  attention  to 
the  importance  of  recognizing  the  variety  of  the  disease, 
noting  particularly  the  age,  tendency  to  obesity,  heredity  and 
any  organic  disease  as  etiological  factors.  The  severity  of 
the  disease  depends  not  always  upon  the  amount  of  sugar 
present,  but  rather  upon  the  amount  in  comparison  to  the 
carbohydrates  in  the  diet. 

2.— Stein  discusses  the  mortality  of  diabetes  mellitus  in 
the  city  of  New  York  during  the  period  from  1889  to  1899, 
inclusive.  In  this  article  he  gives  elaborate  statistics,  the 
total  number  of  deaths  in  this  period  was  1,867.  He  also 
gives  s^  number  of  tables  as  to  death-rate  per  thousand  pop- 
ulation, the  mortality  during  the  months  of  the  year,  the 
number  of  deaths  occurring  in  males  and  females  and  their 
age.     [f.t.k.] 

3. — The  cutaneous  lesions  which  accompany  diabetes 
are  disi  uesed  by  Hartzell.  He  states  that  the  first  noticeable 
symptoms  may  be  due  to  inflammatory  disease  of  the  skin. 
In  the  late  stages  of  the  disease  dryness  and  scaling  of  the 
skin  accompanied  by  general  pruritus,  falling  out  of  the 
nails  and  thinning  of  the  hair  occur.  He  states  that  the 
pruritus  is  often  confined  to  certain  regions  of  the  body  and 
that  eczema  is  not  at  all  uncommon.  Erythema  and  urti- 
caria, especially  of  the  chronic  type,  are  also  encountered. 
Acne,  painful  furuncles  and  carbuncles  are  especially  likely 
to  occur  in  elderly  subjects,  and  that  both  dry  and  moist 
gangrene  are  serious  complications  in  the  course  of  diabetes. 
Xanthoma  diabeticorum  is  a  very  common  form  of  erup- 
tion, and  bronzing  of  the  skin  also  takes  place  in  this  disease. 
In  the  early  stages  purpura  may  be  a  complication.  In  the 
management  of  these  skin  affections  attention  must  be 
directed  to  the  underlying  cause  and  the  skin  lesions  treated 
as  those  occurring  in  cases  that  are  not  of  diabetic  origin. 

[F.J.K.] 

4.— In  an  article  on  postanesthetic  paralyses,  Hers- 
man  lays  particular  stress  upon  that  form  of  paralysis  due 
to  pressure  upon  nerve-trunks.  The  most  common  paralysis 
is  that  due  to  pressure  upon  the  brachial  plexus.  During 
anesthesia  faulty  positions  of  the  patient  should  be  guarded 
against  as  much  as  possible  by  the  surgeon,  in  order  to  I 


obviate  medicolegal  complications.  As  a  rule,  recovery 
rapidly  follows  these  forms  of  pressure-paralyses  unless 
there  be  previous  degeneration  or  atrophy  of  the  nerves. 
As  to  treatment  he  recommends  the  use  of  strychnia  and 
massage,  and  electricity  for  those  cases  which  do  not  show 
nerve  atrophy,    [fjk] 

5. — Brower  in  discussing  the  treatment  of  neurasthenia 
states  that  a  very  important  indication  in  the  treatment  is  _ 
mental  and  physical  rest.  The  great  majority  of  cases  I 
simply  require  partial  rest,  absolute  rest  being  iDJuriooa  B 
to  some  of  the  cases.  The  second  indication  is  the  diet- 
etic management.  The  food  should  be  of  a  nitrogenous 
character  and  as  free  as  possible  from  sugar  and  sugar- 
producing  articles.  In  some  instances  predigested  foods 
are  very  valuable  articles  of  diet.  The  third  indication  is 
the  use  of  electricity,  faradism  being  employed  in  the 
absolute-rest  cases,  while  he  recommends  static  elec- 
tricity in  the  partial-rest  cases.  He  states  that  hydro- 
therapy is  the  fourth  indication  and  recommends  a  daily 
wet  pack  in  those  cases  which  are  being  treated  by  absolute 
rest.  In  the  partial- rest  cases  the  shower  bath,  using  either 
warm  or  cold  water,  the  hot-air  bath  and  the  wet  pack  are 
recommended.  Massage  should  be  employed  for  the  abeo- 
lute-rest  cases,  while  the  partial-rest  cases  may  or  may  not 
need  this  measure  of  treatment.  He  does  not  favor  long 
voyages  for  patients  suffering  from  neurasthenia,  but  if  a 
change  of  climate  is  necessary  moderate  mountain  elevation 
should  be  selected.  He  likewise  does  not  find  it  desirable 
for  the  patients  to  make  a  long  stay  at  a  sanitarium.  As 
to  the  medicinal  treatment,  laxatives  should  be  frequently 
used.  Diuretics  are  sometimes  of  service,  and  for  the  nerv- 
ousness he  believes  the  bromids  are  invaluable.  For  the 
anemia  Blaud's  pills  are  of  use.  An  alterative  is  sometimes 
indicated.  The  one  which  he  prefers  is  chlorid  of  gold  and 
sodium.  In  the  dyspeptic  cases,  the  mineral  acids  are  often 
of  use  and  in  the  cases  which  show  a  malarial  element 
quinin  is  recommended.  He  concludes  by  saying  that  the 
patient  should  be  kppt  busy  by  following  a  regular  thera- 
peutic schedule.     [f.j.k.] 

6. — Trumpp  refers  to  the  former  disinclination  of  Euro- 
pean surgeons  to  practice  intubation,  excepting  in  the 
hospital,  where  constant  watch  could  be  kept  over  the  patient. 
In  making  recent  inquiry  of  American  and  European  sur- 
geons he  finds  few  who  do  not  think  the  operation  as  useful 
in  private  as  in  hospital  practice.  The  percent  of  recov- 
eries due  to  the  use  of  serumtherapy  has  been  more  than 
doubled.  He  thinks  the  paients  should  be  left  to  decide  be- 
tween intubation  and  tracheotomy,  both  methods  being  ex- 
plained to  them,  and  that  no  inexperienced  physician  should 
attempt  the  operation.  The  patient  should  always  be  under 
the  surveillance  of  a  reliable  person.  He  strongly  urges  the 
use  of  the  O'Dwyer  hard-rubber  tubes  in  preference  to  those 
of  silver.  They  are  much  lighter,  and  therefore  lees  liable  to 
produce  ulceration  ;  they  adhere  more  readily  to  the  mucous 
membrane,  and  hence  are  not  so  easily  expelled  during  fits  of 
coughing.  His  experience  g:oes  to  prove  the  poin's.  He 
proposes  some  slight  change  in  the  tube  and  obturator  which 
will  render  introduction  easier,  and  a  slight  curve  backward 
in  the  tube  to  prevent  pressure.     \3.h  g.) 

7. — Von  Bokay,  under  traumatism  during  intabs- 
tion,  first  discusses  the  injury  to  the  mucous  membrane 
and  the  formation  of  a  false  passage,  in  introducing  the  tube. 
In  1,200  caees  seen  by  him,  a  false  passage  was  made  in  4 
cases,  which  he  reports  in  detail.  The  diagnosis  of  the  con- 
dition is  made  by  the  fact  that  respiration  is  not  impaired 
by  the  presence  of  the  tube,  but  becoming  obstructed 
entirely  in  a  short  time  ;  the  tube  may  be  felt  to  occupy  an 
oblique  position ;  the  tube  may  be  felt  under  the  skin  in 
front  or  at  the  sides  of  the  larvnx  ;  on  its  withdrawal  there 
may  be  a  flow  of  blood.  Emphysema  may  also  occur. 
Later,  inflammation  develops  around  the  larynx  and  an  ab- 
scess may  form.  Xo  cure  can  take  place  after  the  formation 
of  a  false  passage,  except  a  tracheotomy  is  done.  The  injury 
is  usually  done  by  careless  handling  of  the  instrument,  but 
may  be  due  to  a  faulty  tube.  He  thinks  the  sitting  position 
thebest  in  which  to  introduce  the  tube.  Introduction  should 
be  accomplished  by  keeping  the  instrument  in  the  median 
line,  or  injury  to  the  mucous  membrane  is  likely  to  occur. 
After  the  formation  of  a  false  p.<issage  the  tube  should  im- 
mediately be  withdrawn  and  tracheotomy  performed,  [j.h  q  ] 

8. — Barton  speaks  first  of  the  very  unsatisfactory  results 


FSBRDARY  2,   1901] 


THE  LATEST  LITERATURE 


[ 


The  Philadblphla. 
MsDicAL  Journal 


207 


obtained  in  the  nonoperative  treatment  of  fracture  of 
the  patella,  mentioning  the  long  confinement  to  bed,  the 
prolonged  fixation  of  the  joint  and  the  so  frequent  anky- 
losis. The  mortality  of  the  operative  methods  is  very 
small.  Powers  reports  711  cases  with  but  3  deaths,  due 
to  sepsis,  and  Phelps  reports  420  operations  by  New  York 
surgeons  with  no  deaths  from  sepsis,  1  from  delirium 
tremens,  and  1  from  carbolic-acid  poisoning.  Barton 
thinks  that  no  caae  should  be  denied  operation  because 
facilities  are  not  at  hand  within  a  day  or  two  of  the  acci- 
dent, for  a  little  delay  is  not  injurious  but  of  advantage 
and  the  patient  can  always  travel  without  great  discomfort. 
He  thinks  that  in  all  cases  of  fracture  from  muscular  con- 
traction there  will  be  found  tissue  between  the  fragments 
which  will  make  bony  union  an  impossibility.  The  suture 
should  pass  through  the  fragments  and  not  about  them,  or 
in  the  tissues  covering  them.  Tne  suture  is  brought  out 
on  the  fractured  surface  and  does  not  pass  all  the  way 
through  the  bone  because  this  irritation  of  synovial  mem- 
brane renders  manipulation  difficult.  He  uses  a  suture 
of  heavy  silver  wire.  The  best  time  to  operate  is  about  10 
days  after  the  accident  unless  the  fracture  is  compound, 
when  it  should  be  done  at  once.  Drainage  is  not  usually  re- 
quired. A  rigid  asepsis  is  insisted  upon.  In  closing  the 
wound  he  does  not  carry  the  superficial  sutures  through  the 
entire  thickness  of  the  flap  leet  they  be  the  means  of  infect- 
ing the  joint  from  contact  with  the  skin  staphylococcus. 
[jhg] 

9.— Hamilton  urges  the  high  mortality  of  growths  of  the 
frontal  sinus  as  a  reason  for  early  diagnosis  and  early 
operation.  He  reports  two  cases.  1.  A  man,  aged  36.  Growth 
followed  an  injury  received  at  age  of  14  years.  At  operation 
the  frontal  bone  waa  found  thinned  and  the  meninges  were 
exposed.  An  osteoma,  very  dense,  was  removed  in  frag- 
ments, which  weighed  4}  ounces.  The  patient  recovered  and 
is  attending  to  his  work.  2.  A  man,  aged  27  years.  Growth 
first  noticed  3  years  before.  Besides  a  prominence  over  the 
root  of  the  nose,  he  had  double  exophthalmos,  interference 
with  vision,  and  double  optic  neuritis.  The  growth  in  this 
case  was  much  softer  than  in  the  first,  and  a  number  of 
polypi  were  also  found  in  the  sinuses,  with  an  accumulation 
of  mucus  and  pus.  Destruction  of  the  orbital  roofs  and 
exposure  of  the  dura  were  present.  The  patient  recovered 
with  a  sinus,  but  all  trouble  with  the  vision  disappeared. 
This  growth  also  proved  to  be  an  osteoma,     [j.h.g.] 

10. — The  treatment  of  ^gastrointestinal  symptoms  in 
typhoid  fever  is  discussed  by  Anders.  He  states  that  the 
medicinal  treatment  in  this  condition  is  subsidiary  in  import- 
ance to  such  measures  as  bathing,  feeding,  nursing,  and  the 
proper  use  of  stimulants.  In  typhoid  patients,  nourishment 
should  only  be  taken  in  a  liquid  form.  Milk,  if  well  borne, 
should  be  the  chief  article  of  diet.  He  believes  that  by  regu- 
lating the  amount  and  character  of  the  nourishment  many 
symptoms  relative  to  the  gastrointestinal  tract  may  be  en- 
tirely prevented  or  diminished,  thereby  rendering  medicinal 
agents  unnecessary.  He  states  that  the  treatment  as  recom- 
mended by  Brand  has  a  favorable  influence  upon  the  gastro- 
intestinal tract.  He  advocates  the  administration  of  hydro- 
chloric acid  after  each  ingestion  of  food  for  deficient  gastric 
secretion,  and  adds  that  intestinal  antiseptics  are  valueless 
in  checking  the  growth  of  the  Bacillus  typhosus.  In  the  early 
stages  of  the  disease  he  employs  calomel,  and  if  constipation 
exists  during  the  entire  course,  this  should  be  treated  by 
enemata  of  soapsuds.  During  convalescence,  diarrhea  is  often 
checked  by  a  mild  laxative.  He  protests  against  any  specific 
treatment.  Anders  uses  salol,  which  he  believes  has  an 
inhibitory  action  upon  fermentative  changes.  He  recom- 
mends turpentine  far  distention  of  the  bowel,  and  enemata 
of  oil  of  turpentine  with  asafetida  when  the  stomach  be- 
coines  intolerant.  He  advocates  the  use  of  intestinal  irri- 
gation, if  judiciously  employed,  in  properly  selected  cases. 
Injection  of  cold  water  into  the  rectum  may  be  of  service  in 
some  cases,    [f.j.k.] 

II'— Rsilly  in  an  article  entitled  The  unbroken  skin 
as  an  absorbing  medium,  states  that  the  dose  of  a  drug 
when  applied  to  tne  skin  may  be  quadrupled  in  most  cases, 
and  that  the  essential  features  in  absorption  are  that  the 
drug  should  be  volatile  during  its  application,  or  that  the 
medicinal  agent  should  be  combined  with  a  fatty  base.  In 
the  latter  instance  friction  should  be  employed  when  it  is 
applied.    He  states  that  the  crypts  of  the  sebaceous  glands 


are  the  structures  through  which  absorption  occurs.  Finally, 
he  adds  that  the  unpleasant  effects  of  some  drugs  are  some- 
times prevented  when  the  administration  is  through  the 
skin,     [f  J  K.] 

12. — Bernheim  discusses  idiosyncrasy  as  to  mercury 
and  reports  a  case  of  erythema  mercuriale  in  a  woman 
50  years  of  age.  The  eruption  resembled  that  of  scarlet 
fever  and  was  followed  by  f  urunculosis.  She  had  a  number  of 
attacks  of  this  eruption  during  her  life  which  always  followed 
the  administration  of  mercury,     [f.j  k  ] 

13. — Andrews  offers  a  new  method  of  diagnosing  mastoid 
disease.  A  small  stethoscope  is  placed  over  the  tips  of  the 
mastoid,  and  the  handle  of  a  vibrating  tuning  fork  over  the 
antrum.  If  the  cells  are  obliterated  or  filled  with  pus  or 
granulations  the  sounds  are  much  more  perceptible  than  on 
the  opposite  or  healthy  side,    [j.h  g.] 

14. — The  author  calls  attention  to  the  fact  that  ocular 
manifestations  occur  with  sufficient  frequency  in  sys- 
temic affections  to  be  of  great  value  in  diagnosis.  While  the 
conditions  of  the  eye  ground  in  the  advanced  stages  of  gen- 
eral diseases  have  received  careful  attention  and  study,  the 
earlier  conditions  on  the  other  hand  also  require  careful 
scrutiny  and  investigation.  Ocular  complications,  while  they 
may  exist  in  all  forms  of  diabetes,  are  generally  found  in 
chronic  cases.  The  patients  generally  present  themselves 
for  supposed  errors  of  refraction.  The  author  quotes  a  few 
cases  on  record  in  which  hypermetropia  was  caused  by  diar 
betes  and  which  fluctuated  in  amount  with  variations  of  the 
quantities  of  sugar  in  the  urine.  According  to  Landolt,  this 
is  due  to  a  change  in  the  index  of  refraction  of  the  vitreous. 
Paralyses  of  the  external  ocular  muscles  are  supposed  to  be 
due  to  a  peripheral  neuritis  or  to  even  nuclear  or  peripheral 
hemorrhages.  Paralysis  or  paresis  of  accommodation  is  a 
frequent  early  symptom.  The  author  believes  that  cataract 
occurring  in  diabetes  passed  middle  life  is  due  to  a  general 
disturbance  of  nutrition  and  arterial  degeneration ;  in  the 
young  on  the  other  hand,  there  is  some  direct  relation  be- 
tween the  eye  and  the  general  disturbance.  He  coincides 
with  Hirschberg,  that  there  is  a  distinct  diabetic  retinitis,  char- 
acterized either  by  a  degenerative  or  hemorrhagic  type. 
Retinal  hemorrhages  with  or  without  other  changes  in  the 
retina,  accompanied  or  unaccompanied  with  conjunctival 
hemorrhages  are  always  suggestive  of  diabetes.  Symptoms 
of  toxic  amblyopia  frequently  occur  in  diabetics,  without  a 
history  of  excessive  indulgence  in  either  tobasco  or  alcohol. 
Plastic  iritis  is  encountered  in  diabetes.  Keratitis,  which  is 
notably  an  exponent  of  nutritive  disturbances  occurs  in  this 
disease.  Atrophy  of  the  optic  nerve  and  amblyopia  without 
any  assignable  cause  are  occasionally  met  with  in  diabetes. 
[m.rd.] 

15. — Eskridge  in  an  article  entitled  Some  remarks  on 
the  plantar  reflex  with  especial  reference  to  the 
Babiuski  phenomenon  comes  to  the  following  conclu- 
sions :  That  from .  the  standpoint  of  diagnosis  and  probably 
in  prognosis  the  Bibinski  phenomenon  is  valuable,  but  that 
in  regard  to  organic  disease  of  the  lateral  tract  it  cannot  be 
considered  a  pathognomonic  sign.  Further  he  adds  that  a 
pseudo-Babinski  phenomenon  may  be  due  to  several  poisons, 
and  finally  he  makes  a  plea  for  more  extensive  and  careful 
investigations,     [f.j  k.] 

Miinchener  medicinische  Wochenschrift. 

October  23,  1900.     [47.  Jahrg.,  No.  43.] 

1.  The  Treatment  of  Constipation.    Rocs. 

2.  The  Sargical  Treatment  of  Gangrene  of  the  Mouth.    Von 

Ranke. 

3.  Brief  Communications  on  the  Therapeutics  of  Skin  Dis- 

eases.   Seibert. 

4.  The  Treatment  of  Biliary  Calculi  with  Olive.  Oil.    Vfm- 

HAUER. 

5.  The  Treatment  of  Intestinal  Obstruction  with  Atropin. 

Marcinowski. 

6.  A  Case  of  Thoracopagus.    Toff. 

7.  Bertillon's  Method  for  the  Measurement  of  the  Body,  Pre- 

sented in  a  Practical  Form  for  Physicians.    Wkkgler. 

8.  Contribution  to  the  Knowledge  of  Lithopedons.  Kroemer. 

1. — Roos  hag  performed  some  interesting  experiments  in 
reference  to  a  novel  idea  in  regard  to  constipation.  In  the 
first  place  it  occurred  to  him  that  perhaps  the  colon  bacilli 


208 


The   PHrLADKLPHIAl 

Mkdical  Jocesal  J 


THE  LATEST  LITERATURE 


[Febecast  I.  1 


of  a  conetipated  person  are  more  or  less  responsible  for  the 
condition,  and  therefore  he  fed  these  people  with  cultures  of 
this  microorganism  obtained  from  the  intestines  of  persons 
with  normal  bowel  movements.  Seven  persons  submitted 
themselves  to  this  experiment,  5  of  them  suSering  from 
chronic  conetipation.  Three  of  these  experienced  a  mod- 
erate laxative  effect  lasting  for  about  14  days.  Xo  particular 
effects  were  observed  in  the  others.  In  2  persons  sufferiog 
from  chronic  constipation,  the  same  treatment  waa  employed, 
and  1  of  these  was  greatly  relieved.  Dead  colon  bacilli, 
killed  by  fractional  sterilization,  were  also  employed,  but  the 
results  were  very  slight.  The  Bacillus  aerogenous  lactis  was 
also  tested,  but  it  was  inac.ive,  and  lactic  acid  likewise  proved 
useless,  lioos  then,  after  a  careful  ccnsideration  of  the  liter- 
ature of  the  subject,  discusses  his  results  of  the  administra- 
tion of  the  ordinary  brewer's  yeast.  This  was  employed  in 
20  cases  ;  in  4  without  result.  In  2  cases  it  produced  liquid 
stools,  and  in  the  remaining  merely  a  slight  laxative  effect. 
Sometimes,  however,  it  waa  necessary  to  repeat  the  treat- 
ment for  several  days  before  any  result  was  obtained.  In 
several  cases  the  results  were  brilliant.  One  in  particular,  a 
girl  of  24  years,  waa  relieved  for  the  entire  period  of  subse- 
quent obeervation,  even  after  the  treatment  has  been  discon- 
tinued. Further  experiments  upon  18  persons  with  yeast 
that  had  been  destroyed  by  exposure  to  100°  for  10  hours, 
showed  that  it  was  quite  as  effective  ss  the  living  prepara- 
tion, positive  effect  occurring  in  14  of  the  caaes,  and  Roos 
believes  that  the  plant  probably  contains  a  substance  that 
exercises  a  moderate  irritation  upon  the  intestinal  canal. 

[J.8.] 

3.— Seibert  haa  employed  epikarin  in  tabes  with  very  ex- 
cellent results.  The  drug  resembles  napthol,  and  is  produced 
by  the  introduction  into  the  napthol  molecule  of  a  cjarboxyl 
group,  by  the  means  of  a  creosotic  acid.  A  10%  salve  is 
rubbed  all  over  the  bcdy,  but  particularly  in  the  parta  chiefly 
involved,  for  3  successive  days.  On  the  fourth  day  the 
patient  is  bathed,  and  any  lesions  still  remaining  treated  by 
the  ordinary  method.  There  waa  only  one  failure  in  all  the 
cases  treated.  The  remedy  does  not  relieve  the  itching  and 
does  net  improve  the  eczema  that  is  often  also  present.  It 
is,  however,  very  convenient  and  not  in  the  least  injurious. 
In  the  vulvovaginitis  of  small  children  he  haa  employed 
protargol  in  0.5%  to  1%  solutions.  This  is  used  aa  an  irjec- 
tion  3  times  a  day  until  the  symptoms  of  inflammation  have 
been  relieved.  In  nearly  all  the  cases,  gonococci  were 
present.  He  has  also  employed  ichthalbin  in  cases  of  furun- 
culosis,  in  which  it  apparently  is  of  no  particular  benefit,  and 
in  urticaria,  in  which  there  certainly  seems  to  be  some  favor- 
able ii  fluence.  The  remedy  was  given  In  doses  of  5  gr. 
3  times  a  day  to  children. 

4. — Witthauer  has  employed  olive  oil  in  cases  of  biliary 
colic  with  brilliant  success.  He  gives  it  first  by  the  mouth 
in  1-ounce  doses,  to  which  a  few  drops  of  oil  of  peppermint 
have  been  added.  When  in  the  course  of  time  the  pitients 
find  themselves  unable  to  continue,  he  employs  it  in  the 
form  of  an  enema,  about  400  to  500  cc.  being  injected  at  first 
every  day,  and  later  at  longer  intervals.  He  reports  3  cjases 
in  which  large  numbers  of  stones  were  successfully  and  per- 
manently removed  by  this  method,  without  resort  to  opera- 
tion.    [.TS] 

5. — Marcinowski  reports  2  caaes  of  intestinal  obstruc- 
tion. The  first,  a  woman  of  32,  after  lifting  a  heavy  weight, 
wa9  attacked  by  severe  pain  in  the  abdomen  and  went  into 
CMjllapse  and  vomiting.  Opium  failed  to  relieve  the  symp- 
toms, and  ^'j  of  a  grain  of  atropin  ( 005)  was  injected  hypo- 
dermically.  The  patient  improved  very  rapidly,  an  exudate 
that  had  formed,  disappeared,  the  bowel-movementa  became 
normal  and  ultimately  the  patient  recovered.  In  the  second 
case,  a  man  with  double  hernia  suffered  from  incarceration 
aa  a  result  of  a  fall.  There  was  severe  pain,  active  peristaltic 
movements,  and  bowel  constriction.  An  injection  of  a  simi- 
lar dose  of  atropin  relieved  the  symptoms,     [j  s.] 

7. — Wengler  gives  a  brief  but  sympathetic  description  of 
Bertillon's  method  for  the  identification  of  criminals,  and 
calls  attention  to  its  great  value  to  science  on  account  of  its 
extraordinary  accuracy,     [j  s  ] 

October  SO,  1900.    [47.  Jahrg.,  No.  44.] 

1.  Albumen  and  ita  Artificial  Oxidation.    F.  X.  Shultz. 

2.  Estimation  of  the  Freezing  Point  of  Blood  and  of  Urine  in 


Determining  the  Functicmal   Ability  of  the  Kidneys 
before  Operation.    Heemass  KCmmkll. 

3.  The  Process  of  C!ompensation.    Adolph  Bickel. 

4.  ilixed  Infection  with  the  Influenza  Bacillus  and  the  Bac- 

terium Proteus.    Hass  Doebisg. 

5.  The  Substitution  of  Eucain  B  for  Cocain  in  Cocalnization 

of  the  Spinal  Cord.    Fbitz  Ekgelmasx. 

6.  Some  Little- Known  Pupil-reactions  and  their  Therapeutic 

Significance.    Hass  Kieschskr. 

1. — After  a  review  of  the  chemiats'  investigations  which 
ended  with  the  crystallization  of  albumen,  Schultz  expl&ine 
the  composition  of  the  albumen  molecule  and  ita  reactions. 
He  ends  his  very  technical  article  without  solving  the  old 
problem,  why  albumen  outside  the  body  so  energeticaJly 
reaiata  oxidation,  while  the  albumen  of  the  human  organian 
is  so  easily  oxidized  during  life.     [^  o  ] 

2. — To  find  the  functional  ability  of  the  kidneys  befcre 
operating,  Kiimmell — besides  advising  routine  urine  analysis, 
and  its  examination  after  subcutaneous  injections  of  differ- 
ent substances  (methylene-hlue,  or  phloridzin)  with  catheter- 
ization of  the  ureters  ;  when  normal,  the  urine  from  both 
kidneys  would  be  ahke ;  when  one  is  affected,  the  uriDe 
secreted  by  the  diseased  kidney  would  contain  less  of  the  for- 
eign substance  than  the  other — recommends  strongly  the  de- 
termination of  the  freezing  point  of  the  blood,  which  he 
gives  as  56°  C.  below  that  of  distilled  water,  normally  ;  if  below 
58°  C,  there  is  renal  insuffi  :iency,  and  the  determination  ot 
the  freezing  point  of  the  urine  from  each  kidney,  col- 
lected by  cattierizing  the  ureters,  which,  in  normal  cases,  it 
almost  equal,  but  shows  a  great  dispariiy  when  on»  kidney 
is  affected  ;  the  urine  from  the  diseased  kidney  freezing  at « 
much  lower  temperature  than  that  taken  from  its  fellow.  He 
uses  Beckmann's  method  of  freezing.  Three  cases  are  given, 
in  which  his  diagnosis  thus  established  waa  confirmed  by 
operation,    [mo.] 

3.  — Ewald  has  divided  the  process  of  compensatioD 
in  anatomic  defects  of  the  nervous  system  into  (temporary; 
reparatory  phenomena,  and  (permanent)  degenerative  phe- 
nomena. Bickel  gives  a  series  of  experiments  performed 
upon  lower  animals  from  frogs  up  to  dogs ;  from  which  h€ 
concludes  that  the  more  highly  developed  the  nervous  sys- 
tem, the  easier  and  the  more  widespread  become  thee* 
reparatory  processes.  He  mentions  the  clinical  usefiilneH 
of  these  experiments  in  many  diseases  of  the  nervous  sys- 
tem, especially  in  tabes  dorsalis.     [m  c] 

4. — During  the  last  year  Doenng  saw  152  patients  wilt 
influenza,  41  of  whom  had  complications.  Pneumonia  wat 
the  most  frequent  complication.  True  mixed  infection  vti 
seen  in  13  caaes:  in  S  with  staphylococci,  and  in  5  witl 
streptococci.  In  two  cases  the  bacteriam  proteas  wa* 
found  besides  the  influenza  bacillus.  Tne  great  de 
struction  found  throughout  the  bodv.  and  the  bacteriologit 
investigations  are  fully  described,     [m.o.] 

5. — Eogelmann  tested  Eucain  B,  which  is  said  to  be 
leas  poisonous  and  yet  as  effective  aa  cocain  in  producing 
general  anesthesia,  when  injected  into  the  spinal  canal 
With  one  injection  of  0  01  ccm.  of  Eucain  B,  the  only  effec 
waa  a  slight  paresthesia,  no  anesthesia  at  all.  His  sensatiooi 
are  concisely  described,     [m.c] 


Deutsche  niedicinische  Wochenschrift. 

December  IS,  1900.     [26.  Jahrg.,  Xo.  50.] 


1.  A  (xllective  Statement  of  the  Results  of  the    Malarii 

Expedition.    R.  Koch. 

2.  Concerning  Athyreosis  in  Childhood.    QriscKK. 

3.  A   Preliminary   Communication  Concerning  the  Injurief 

in  the  Heidelberg  Railroad  Catistrophe  of  Octooer  7 

1900.      F.  VOLCKKR. 

4.  On  the  Technic  of  the  EliciUtion  of  the  Patellar  Reflex 

WALBACif. 

IJ— Koch  continues  his  article.    He  thinks  that  the  fre 
quently  observed  decrease  in  the  intensity  of  the  attacks  anc 
the  appearance  of  irregular  fever  are  further  proof  of  Um  . 
occurrence  of  acquired  immunity.    He  believeie.  howcTtr  ■ 
when  splenic  enlargement,   anemia,  and  other  such  syn^)-  * 
toms  exist,  the  patient  should  be  considered   still  a  subject 
of  malaria  and  should  be  so  treated.    In  such  cases  pan 


Febkdary  2,  1901] 


THE  LATEST  LITERATURE 


[THK  PHILA.DELPHIA 
UEDICAX  JO0BNAI, 


209. 


sites  cin  frequently  be  still  discovered.  In  the  manage- 
ment of  malaria  he  again  lays  strong  emphasis  upon 
his  recommendation  of  the  use  of  quinin  for  prophy- 
lactic purposes.  He  thinks  that  all  those  who  are  strongly 
suspected  of  malaria  or  who  are  proved  to  have  it  should  be 
given  quinin  in  order  to  prevent  the  development  of  the 
parasites.  He  insists  upon  the  diflferenee  between  this 
recommendation  and  the  mere  taking  of  quinin  to  ward  off 
malaria.  In  the  latter  caae  one  merely  prevents  infection  ; 
in  the  first  case  one  is  fighting  the  paraaites  which  are  already 
lodged  in  the  patient.  So  far  as  has  been  discovered  man 
and  mosquito  are  the  only  hosts  of  the  parasite.  Koch  gives 
a  series  of  tables  to  show  the  decrease  in  malaria  in  certain 
regions  in  Germany  since  quinin  has  been  freely  used.  Gen- 
eral hygienic  measures  can  produce  some  good  results,  but 
they  cannot  prevent  the  disease.  In  carrying  out  the  quinin 
prophylaxis  it  is  very  important  to  have  a  considerable  body 
of  skilled  assistants  searching  for  parasites.  If  this  cannot 
be  done  regular  records  of  the  temperature  should  be  kept. 
Methylene-blue,  he  finds,  next  to  quinin,  to  be  the  most  valu- 
able drug,  but  it  works  much  more  slowly  than  quinin.  It  is 
useful  when  there  is  a  tendency  to  blackwater  fever.  He 
advises  the  use  of  only  good  preparations  of  quinin, 
preferring  the  hydrochlorate,  strongly  opposing  the  use 
of  pills ;  oblates  he  considers  the  best  method  of  administer- 
ing quinin  in  children  and  often  under  other  circumstances 
a  solution  is  best.  It  is  usualljr  best  taken  in  the  morning 
on  an  empty  stomach,  when  it  is  quickly  and  rapidly  ab- 
sorbed. It  is  often  well  to  give  hydrochloric  acid  with  it,  or 
if  the  stomach  is  not  in  good  condition  to  give  it  hypoder- 
mically.  It  should  not  be  given  in  doses  of  less  than  one 
gram  for  adults.  It  should  be  administered  from  4  to  6  hours 
before  the  attack ;  it  is  repeated  the  next  morning,  and  if  the 
attack  has  not  been  prevented  the  dose  is  increased.  On  the 
following  morning  another  dose  is  given.  Using  these  meas- 
ures over  500  severe  cases  have  been  treated  and  none  lost. 
To  prevent  return  of  the  malaria  attacks  Koch  used  various 
methods  of  administering  quinin.  He  finally  decided  to 
give  quinin  on  two  consecutive  days,  repeating  this  at  an 
interval  of  10  or  11  days.  If  the  cases  are  particularly  per- 
sistent the  time  between  the  doses  is  reduced  to  7  or  8 
days,  or  the  dose  is  increased,  the  latter  perhaps  being  the 
better  procedure.  This  treatment  should  be  carried  out  for 
at  least  2  months,  even  though  the  patient  lives  in  a  malarial 
region.  It  is  important  to  look  out  for  the  possibility  of  black- 
water  fever  in  persons  who  have  had  malaria  before.  One 
should  begin  with  only  a  grain  and  a  half  or  two  grains  of 
quinin,  increasing  it  very  gradually  and  watching  the  urine. 
If  a  rise  of  temperature  occurs  after  taking  quinin,  if  the  urine 
appears  darker,  or  if  there  is  a  tinge  of  icterus,  the  quinin 
dose  should  not  be  increased  or  should  be  decreased  at  once, 
as  these  signs  are  the  early  indications  of  blackwater  fever. 
As  to  other  diseases  he  saw  but  3  cases  of  typhoid,  which 
were  all  imported ;  tuberculosis  was  uncommon ;  beriberi 
was  quite  frequently  seen,  but  was  always  imported,  and 
evidences  of  its  infectious  character  were  readily  seen.  This 
disease  quickly  gave  way  to  treatment  by  rest  and  careful 
nursing  without  medication.  Syphilis  occurred,  but  was 
not  common.  Skin  affections  were  extremely  common. 
[d  l.e  ] 

2.— Quincke  reports  another  case  of  athyreosis  which 
occurred  in  a  child.  It  had  been  a  healthy  infant  and  had 
begun  to  speak.  When  15  months  old  the  features  seemed 
to  change,  the  psychic  growth  stopped,  and  from  the  nine- 
teenth month  on  there  was  loss  of  intelligence  and  of  the 
power  of  speech,  the  child  did  not  walk,  and  there  were 
nutritive  disturbances,  particularly  of  the  teeth.  lodothyiin 
was  used.  There  was  improvement  after  a  week,  the  child 
seemed  normal  after  7  weeks,  and  remained  so  after  4  years. 
The  thyroid  gland  could  not  be  felt  in  this  case.  These 
cases  are  not  instances  of  ordinary  cretinism,  though  they 
may  have  points  of  resemblance  in  their  clinical  appearance 
and  in  their  response  to  thyroid  medication.  They  are  also 
not  ordinary  myxedema,  the  onset  is  too  acute  for  "the  latter 
disease,  while  it  is  not  congenital  cretinism  because  the  on- 
set and  symptoms  occurred  some  time  after  birth,  were  pro- 
gressive, and  in  one  case  at  any  rate  was  accompanied  by 
progressive  decrease  in  the  size  of  the  thyroid  gland.  The 
skin  too,  while  it  showed  changes,  was  soft  and  moist,  with 
no  definite  changes  in  its  volume  and  consistency,  and 
there  were  no  changes  in   the  sweat  secretions  or  growth 


of  hair.  Quincke  prefers  to  call  the  condition  subacute 
athyreosis.  In  the  second  case  the  remarkable  and  per- 
manent improvement  of  the  child  was  very  striking. 
This  might  be  explained  by  the  possibility  of  the  pres- 
ence of  an  accessory  thyroid  which  had  assumed  vicari- 
ous and  increased  function,  or  by  vicarious  functionation 
of  the  thymus.  A  striking  fact  in  both  cases  was  the  de- 
struction of  the  teeth.  The  fact  that  it  was  so  marked  was 
probably  due  to  the  early  age  of  the  patients  and  the  acuity 
of  the  processes.  Quincke  thinks  that  these  cases  are  ex- 
plained only  by  the  acceptance  of  some  relation  to  the 
thyroid  gland  and  the  presence  of  an  autointoxication.  It  is 
probable,  he  thinks,  that  other  organs  than  the  thyroid  are 
involved  in  some  way.  This  would  explain  the  very  varied 
reaction  to  thyroid  preparations  and  the  variation  in  the 
different  symptoms.  He  thinks  also  that  the  thyroid  gland 
probably  produces  other  important  substances  beside  iodo- 
thyrin.  He  considers  it  extremely  important  that  one  should 
look  much  more  frequently  for  thyroid  changes  in  children, 
in  order  to  explain  obscure  conditions,  particularly  mental 
changes,  when  distinctive  cretinoid  symptoms  are  not 
present,    [d.l.e.] 

4. — Walbaum  recommends  the  following  procedure.  The 
half-closed  hand  is  placed  with  moderate  pressure  upon  the 
knee  to  be  examined,  the  finger  tips  resting  over  the  inferior 
patellar  ligament,  while  the  thenar  and  hypothenar  emi- 
nences lie  above  and  to  the  sides  of  the  patella,  and  the  pa- 
tella is  thereby  grasped  between  the  finger  tips  and  the  hol- 
low of  the  hand.  One  then  strikes  this  hand  a  light  blow  with 
the  closed  fist  of  the  other  hand.  If  there  is  even  a  very 
slight  patellar  reflex  one  can  readily  recognize  it  with  the 
finger  tips  over  the  ligament,  even  when  it  is  not  visible. 
[d.l.e.] 

December  SO,  1900.     [26.  Jahrg.,  No.  51.1 

1.  Concerning  the  Importance  of  Pure  Vegetable  Albumin 

as  Nourishment.    A.  Lowey  and  M.  Pickaedt. 

2.  Concerning  the  Bacteria  in  Typhoid   Fever  and  Their 

Practical  Importance.    F.  Neufeld. 

3.  Experimental    Contributions  to    the    Question    of   Iron 

Therapy.    F.  Muller. 

1. — The  paper  is  chiefly  a  study  of  the  albumin  prepara- 
tion called  roborat.  It  was  found  to  be  well  absorbed,  and 
the  assimilation  was  fairly  satisfactory.  It  was  used  on  50 
patients  with  satisfactory  results,    [d.l.e.] 

2. — Neufeld's  paper  is  largely  a  review  of  the  literature  of 
the  question  of  typhoid  bacilluria,  containing  nothing 
especially  new  excepting  the  report  of  4  cases.  He  found  uro- 
tropin  valuable  in  the  treatment  of  the  condition,  but 
insists  that  this  drug  should  be  used  for  a  number  of  weeks, 
since  if  this  is  stopped  there  m*y  be  renewed  infection.  He 
directs  especial  attention  to  the  importance  of  a  typhoid 
bacilluria  in  relation  to  public  health,  the  urine  being  even 
more  important  than  the  feces  because  of  the  prolonged 
time  throughout  which  it  may  show  infection.  Toe  urine  of 
a  typhoid  case  should  be  examined  by  the  naked  eye  at  least 
once  daily,  and  if  it  is  cloudy  urotropin  should  be  given  and 
continued  for  several  weeks.  Other  forms  of  bacilluria  may 
occur  in  typhoid  fever.  An  instance  of  the  excretion  of 
large  numbers  of  active  colon  bacilli  through  the  urine  is 
mentioned.  He  believes  that  if  urotropin  does  not  over- 
come the  bacilluria  it  may  be  considered  to  be  not  a  typhoid 
bacilluria.  He  believes  that  the  use  of  urotropin  in  typhoid 
fever  in  the  army  would  be  of  the  greatest  importance. 
[dle.] 

3. — Mii'ler  took  newborn  pups,  giving  them  only  the 
the  mother's  milk  and  iron-free  food  for  a  long  time  after- 
ward, and  in  order  to  increase  the  anemia  frequently 
abstracted  blood.  When  the  amount  of  hemoglobin  had 
become  very  low  and  constant  he  gave  inorganic  prepara- 
tions of  iron,  and  saw  a  marked  increase  in  the  hemoglobin 
and  red  blood-cells,  while  the  same  increase  did  not  occur  in 
the  other  animals  that  were  not  given  inorganic  iron.  He 
estimated  the  total  amount  of  hemoglobin  by  drawing  all  the 
blood  possible  and  washing  the  animal's  circulation  with 
physiological  salt  solution  until  the  fluid  came  out  com- 
pletely colorless.  He  notes  that  an  average  of  about 
10^  of  the  total  hemoglobin  was  retained  in  the  bone 
marrow.  As  to  the  methods  of  action  of  inorganic  iron  he 
refers  to  the  view  that  it  is  due  to  excitation  of  the  blood- 


210 


TSK  PhujldklphiaI 
Mkdicai,  Jo0»sal  J 


THE  LATEST  LITERATURE 


[Febbuabt  2,  UOl 


producing  organs  to  more  active  function.  He  thinks  that  this 
IB  the  true  explanation,  and  as  testimony  for  this  notes  that 
he  found  a  marked  increase  of  the  nucleated  red  blood-cor- 
puscles of  the  mauTow,  and  there  was  a  marked  increase  in 
the  mitoses  in  the  marrow.  He  directs  attention  to  the  fact 
that  many  preparations  of  iron  have  a  caustic  eflFect  upon 
the  gastric  mucous  membrane,  and  in  direct  proportion  to 
this  effect  are  they  badly  absorbed.  The  oiytartrate  of  iron 
does  not  have  this  infiuence,  nor  do  Blaud's  pills.  They 
should,  therefore,  be  preferred  to  caustic  preparations,  such 
as  the  tincture  of  the  chlorid.  There  is  no  necssity  for  using 
complicated  organic  preparations.  Absorption,  he  states, 
takes  place  through  the  bloodvessels  and  not  through  the 
lymphatics,     [d.l.e.] 

"Wiener  klinische  Woclienschrift. 
November  8, 1900.    [13.  Jahrg.,  No.  45.] 

1.  A  Keflex-T witching  of  the  Abdominal  Muscle,  Observed 

in  Pleurisy  and  Fibrinous  Perihepatitis  ('Respiratory 
Reflex  of  the  Abdominal  Wall  ").    Rudolf  Schmidt. 

2.  The    Technic    of    Enterorrhaphy.     Hebmann    Hd-teb- 

STOISSER. 

3.  The  Subcutaneous  Rupture  of  Tendons.    L.  Ktbchsuye. 

1. — Schmidt  details  a  case  in  which  a  peculiar  reflex- 
twitcliing  existed  in  the  upper  portion  of  the  right  ab- 
dominal rectus,  without  any  relation  to  respiration.  This 
"lightning-like"  contraction,  reaching  up  to  the  fifth  right 
intercostal  space,  occurs  upon  deep  breathing,  toward  the 
end  of  respiration.  It  could  also  be  caused  by  pressure  upon 
the  painful  intercostal  spaces.  When  the  epigastrium  is 
drawn  in,  in  forced  thoracic  breathing,  the  reflex  is  increased. 
It  occurs  in  persons  whose  reflexes  are  excited  easily  and 
whose  muscles  are  well  developed,    [si.o.] 

2. — Hinterstoisser  reports  4  cases  in  which  he  performed 
enterorrhaphy,  ligating  oflF  the  longer  end  of  the  resected 
bowel,  and  attaching  it  to  the  abdominal  wall,  suturing  the 
shorter  end  into  it,  above  the  point  of  ligation.  He  also 
gives  the  literature  on  the  subject,    [m  o.] 

3. — Kirchmayr  reports  2  cases  in  which  the  terminal  pha- 
lanx of  the  index  finger  was  forcibly  flexed,  with  rapture  of 
the  extensor  tendon.  He  gives  a  similar  case  occurring 
in  the  great  toe,  followed  by  operation,  the  torn  tendons 
being  sutured  together,  good  functional  recovery  following. 
He  reviews  the  meager  literature  upon  the  subject,  and  con- 
cludes that  force  applied  suddenly  or  gradually  will  rupture 
healthy  tendons,  while  degenerated  tendons  are  ruptured 
even  more  easily,    [m.o.] 

November  15,  1900.     [13.  Jahrg.,  No.  46.] 

1.  The  Pathology  and  Etiology  of  Fulminating  Gangrene. 

Fkitz  HrrscHMASN  and  Ono  T.  Lin'dksthal. 

2.  The  Closure  of  Defects  of  the  Skull  by  Bjne  Implanta- 

tion.     KOSRAD  BUDISGER. 

3.  Illustrative  Cases  of  Intestinal  Lipoma.    Ferd.  Gross. 

1. — A  man,  in  good  general  health,  came  to  the  hospital 
for  the  relief  of  ankylosis  at  the  elbow  joint,  between  the 
ulna  and  radius.  Resection  cf  the  radius  was  performed, 
and  to  prevent  bony  union,  a  celluloid  plate  was  introduced 
between  the  resected  end  and  the  ulna.  This  plate  had 
been  sterilized  by  boiling  for  10  minutes  before  its  insertion. 
A  few  hours  after  the  operation,  the  patient  began  to  feel 
severe  pain  in  the  arm.  His  fingers  became  almost  blood- 
less and  cold.  On  removal  of  the  bandage  the  circulation 
improved  slightly  and  also  the  sensibility.  The  condition 
became  worse,  however,  on  the  next  day,  and  entire  hand 
was  anesthetic,  cold,  and  pale.  The  forearm  had  a  bluish 
discoloration,  and  on  opening  the  wound,  a  foamy  serous 
fluid  escaped.  Anesthesia  continued,  and  on  the  next  day 
the  process  of  spreading  gangrene  was  well  advanced. 
Amputation  was  refused,  and  with  the  hope  of  relieving  the 
condition  to  some  degree,  extensive  incisions  were  made. 
This  prevented  a  further  spread  of  the  condition,  and  event 
ually  the  line  of  demarcation  formed,  and  amputation  of  the 
forearm  at  its  lower  third  was  undertaken,  8  days  after  the 
first  operation.  The  patient  made  a  good  recovery  from 
this  operation.  A  very  careful  bacteriologic  and  histologic 
study  was  made  in  this  case.     In  the   histologic  study  no 


inflammatotr  change  could  be  found,  and  Hitschmann  and 
Lindenthal  believe  that  from  this  study  it  may  be  assumed 
that  in  this  form  of  gangrene  we  are  not  dealing  with  an  in- 
flammatory process,  but  with  a  primary  necrosis  from  gas 
formation  and  pressure.  This  smgle  observation  they  be- 
lieve is  sufficient  to  show  that  the  commonly  accepted  ideas 
as  to  the  pathology  of  this  condition  are  incorrect,    [m  b.t.] 

2. — Biidlnger  reports  a  case  of  a  boy  5  years  old  who  was 
sufiering  from  tuberculosis  of  the  left  parietal  bone.  The 
diseased  area  was  thoroughly  removed  with  a  curet  and 
rongeur  forceps,  leaving  two  large  defects.  Ten  days  after 
this  operation  small  plates  of  bone  were  inserted  in  the  de- 
fects in  the  skull,  these  plates  having  been  taken  from  the  ob 
calcis  of  a  freshly-amputated  leg.  The  implanted  bony 
plates  healed  in  their  position  firmly,  and  a  year  after  their 
implantation  no  trace  of  a  bony  defect  could  be  felt.  After 
4  years  the  child  died  of  general  tuberculosis.  On  examina- 
tion of  the  bone  which  had  been  inserted  very  little  change 
in  the  region  could  be  found.  Biidinger  recommends  the 
insertion  of  such  plates  of  bone  to  supply  defects  made  in 
operations  upon  the  skull.  He  considers  the  os  calcia 
particularly  well  suited  for  such  implantation  and  emphasizes 
the  necessity  for  the  strictest  antiseptic  precautions,    [m  b  t.] 

3.— Gross  states  that  during  the  last  40  years,  22  cafes  of 
lipoma  of  the  intestine  have  been  reported.  These  tu- 
mors are  of  several  forms.  They  may  occupy  the  lumen  of 
the  intestine  or  its  outer  wall  and  they  may  be  sessile  or 
polypoid,  single  or  multiple.  He  reports  the  case  of  a  man 
47  years  old  who  had  cramplike  pains  in  the  lower  portion 
of  the  abdomen  coming  on  periodically  and  lasting  but  a  few 
moments.  A  tumor  was  made  out,  about  3  cm.  in  breadth 
and  from  10  to  12  cm.  in  length,  which  disappeared  on  firm 
pressure  with  relief  of  the  pain.  The  abdomen  was  not  dis- 
tended, it  was  everywhere  soft,  not  tender  on  pressure,  nor 
was  there  any  muscle-spasm.  On  account  of  the  severity  of 
the  symptoms,  however,  an  operation  was  undertaken,  and 
on  opening  the  abdomen  a  tumor  was  found  within  the  lu- 
men of  the  left  part  of  the  transverse  colon.  Toe  intestine 
was  opened  by  a  longitudinal  Incision  and  a  mass  was  foimd 
the  size  of  a  hen's  egg  covered  with  normal  mucous  mem- 
brane. It  was  attached  by  a  pedicle  near  the  mesentery. 
This  pedicle  was  divided,  bleeding  points  were  ligated,  the 
mucous  membrane  was  sutured,  and  the  Intestine  closed. 
A  good  recovery  followed.  It  is  believed  that  the  coUcky 
attacks  were  produced  by  partial  invagination  of  the  intes- 
tine from  the  dragging  of  the  tumor,     [m.b  T  ] 


Berliner  klinische  Wochenschrift. 

November  19.  1900.    [37.  Jahrg.  Xo.  47.] 

1.  The    Medicolegal    Treatment    of    Border-line    Diseases, 

Together  With  Some  Remarks  on  Diminished   Re- 
sponsibiUty.    A.  Cramer. 

2.  The  Effect  of  Bloodletting  on  Xitrogen  Metabolism.    G. 

AscoLi  and  A.  Draghi. 

3.  The  Morphology  of  Staphylococcus  Albas.    R  Sacx. 

4.  Mothers'  Milk.     M.  CoHS. 

5.  Symptomatology  of  Facial  Paralysis.    M.  Beexbakdt. 

2. — The  article  deals  with  the  relation  of  normal  nitro- 
gen metabolism  to  the  blood.  Jurgensen  states  that 
bloodletting  increases  the  decomposition  of  albumin  just  as 
febrile  processes  do.  Therefore  venesection  in  fevers  is  an 
additional  causative  factor  for  albuminuria.  This  should 
always  be  considered  when  venesection  is  contemplated  in 
fevers  where  there  is  already  an  albuminuria.  The  author 
appends  5  tables  showing  the  effect  of  blocdletting  on  nitro- 
gen metabolism.  On  the  days  when  venesection  was  per- 
formed a  decrease  in  the  nitrogen  metabolism  was  observed 
which,  according  to  the  author,  is  probably  due  to  a  befin- 
ning  regenerating  functional  activity  of  the  organism.  [m.r.d  ] 

3. — Saul,  in  experimenting  with  the  Staphylococcus  albus, 
comes  to  the  following  conclusions  :  The  morphology  of  the 
colonies  depends  upon  the  principle  of  dichotom}',  not  in 
the  botanical,  but  in  the  anatomical  sense  of  the  term.  In 
determining  this  it  is  the  number  of  the  centers  from  which 
the  dichotomous  divisions  originate  that  must  be  considered. 
The  colony  is  not  an  unsystematic  aggregation  of  cells,  but 
represents"  the  entity  of  the  highett  regularity  of  which  the 
organism  is  capable,     [m.k.d.] 


Febbuary  2,  1901] 


THE  LATEST  LITERATURE 


TThk  Philadslpbia 
L  Medical  Joubnal 


211 


6. — The  author  concludes  his  article  by  presenting  a  num- 
ber of  cases  which  showed  that  there  are  cases  of  peripheral 
lesions  in  which  there  is  no  reaction  of  degeneration. 
He  states  that  there  are  cases  where  contractions  are  pro- 
duced on  the  aflected  side,  in  the  muscles  near  the  median 
line  of  the  chin  and  lower  lip,  due  to  the  transmigration  of 
fibers  from  the  unaffected  side ;  these  are  probably  con- 
genital,   [m.b.d.] 

November  26, 1900.    [37.  Jahrg.,  No.  48]. 

1.  Flechsig's  Opium-Bromide  Cure  (Ziehen's  Modification). 

E.  Mayer. 

2.  Treatment  of  Nervous  Diseases  in  the  Family.  R.  Gnauk. 
8.  Treatment  of  Septic  Infection  Emanating  from  the  Uterus. 

Abel. 

4.  The  Sensitiveness  of  Simplified  Modifications  of  the 
Phenylhydrazin  Test  for  Identification  of  Sugar  in 
the  Urine.    A.  Kowaeski. 

6.  The  Medicolegal  Treatment  of  Borderline  Diseases 
Together  with  Same  Remarks  on  Diminished  Respon- 
sibilities.   A.  Cramer. 

1, — The  treatment  consists  of  routine  administration  of 
opium  and  the  bromides,  a  very  careful  diet  and  cold  water 
treatment.  Ziehen  emphasizes  that  the  bromides  should  be 
given  in  large  doses  for  about  one  year.  The  author  believes 
that  the  paroxysms  are  diminished  in  number  and  that  both 
bodily  and  psychic  conditions  are  improved  under  this  treat- 
ment,   [m.r.d.] 

2.— Gnauk  discusses  the  distinctions  that  are  to  be  drawn 
in  the  treatment  of  nervous  diseases  in  the  family  and  out- 
side of  the  same.  The  author  believes  that  in  cases  in  which 
there  are  no  demonstrable  causes,  the  term  "  functional " 
should  be  avoided.  Function  is  affected  in  all  nervous  dis- 
orders, and  therefore  the  term  functional  is  not  a  proper  one 
for  purposes  of  differentiation.  There  exists  between  health 
and  nervous  diseases  the  somewhat  indefinite  conception  of 
nervousness.  Individuals  are  frequently  seen  who  show 
objective  signs  of  nervous  disorders  like  the  so-called  hysterical 
stigmata,  but  who  feel  healthy  and  are  not  incapacitated. 
The  treatment  of  nervousness  is  doubtlessly  no  less  import- 
ant than  the  treatment  of  the  diseases  which  may  result  in 
consequence  of  neglecting  this  condition.  The  author  be- 
lieves that  there  are  cases  which  are  especially  adapted  for 
home  treatment,  among  these  being  patients  who  have 
remained  too  long  in  an  institution  and  have  accustomed 
themselves  to  this  form  of  existence.  In  these  cases,  while 
the  disease  may  have  been  somewhat  checked,  the  improve- 
ment nevertheless  did  not  continue  above  a  certain  level, 
since  the  pathological  condition,  as  it  were,  accommodated 
itself  to  the  conditions  and  environments  of  the  institution. 
Furthermore,  there  are  individuals  who  possess  an  uncon- 
querable antipathy  towards  institutions.  To  this  category 
also  belong  cases  of  nostalgia.  In  no  form  of  disease  is 
uninterrupted  contact  with  the  physician  of  such  importance 
as  in  nervous  disorders.  The  attention  that  the  physician 
pays  to  the  treatment  of  symptoms  is  often  fruitful  of 
astonishing  results.  This  is  particularly  the  case  in  treating 
individual  organs  like  the  stomach,  pelvic  organs  as  well  as 
intemasal  conditions.  Remedies  will  frequently  have  to  be 
employed  which  in  other  individuals  with  the  same  symp- 
toms would  not  be  necessary,  [m  b  d.] 
_  4. — The  author  claims  that  his  method  is  of  value  in  rou- 
tine practice.  It  consists  of  the  following :  Five  drops  of 
pure  phenylhydrazin  and  10  drops  of  strong  acetic  acid  are 
agitated  in  a  test-tube.  To  this  is  added  about  1  ccm.  of  a 
saturated  solution  of  sodium  chlorid,  which  causes  the  mix- 
ture to  assume  a  thick  consistency.  Two  to  3  ccm.  of  urine 
are  then  added  and  the  whole  mixture  heated  for  no  less  than 
2  minutes ;  by  allowing  it  to  cool  slowly  a  yellow  precipitate 
consisting  of  the  typical  phenylglycosazon  crystals  will  result. 
The  rapidity  of  precipitation  depends  upon  the  amount  of 
sugar  contained  in  the  urine.  When  the  sugar  present  ex- 
ceeds 0.2%  the  precipitate  farms  in  a  few  minutes ;  when  less 
sugar  than  this  is  present  5  minutes  to  half  an  hour  will  elapse 
before  the  reaction  is  complete.  This  is  a  very  sensitive  test 
and  permits  of  the  detection  of  even  less  than  0.1  %  of  sugar, 
according  to  numerous  experiments  made  by  the  author. 

[M.ED.]:< 


Revue  de  M^decine. 

December  10,  1900.     [20me  Ann^e,  No.  12.] 

1.  Etiology  of  Viteligo.    E.  Gaucher. 

2.  Reeducation  of  the  Movements  of  the  Heart  by  Methodic 

Exercises.    F.  Lagrange. 

3.  Variations  in  the  Quantity  of  Oxyhemoglobin  in  the  Blood 

of   Nurslings  Treated  by  the  Injection  of   Artificial 
Serum.    M.  Labb6 

4.  Morphin  Replaced  by  Heroin.     No  Euphoria.    No  Toxi- 

comania.   Treatment  of  Morphinomania  by  Heroin. 

A.  MOEEL-LAVALli;E. 

5.  Contribution  to  the  Study  of  Pleurotyphus  and  of  Pleu- 

risies Dae  to  the  Bacillus  of  Eberth.    P.  Remlinger. 

6.  Notes  on  Chinese  Medicine.    Opotherapy  in  China  and 

Indo-China.    J.  Regnault. 

7.  Gastric  Crises  and  Syringomyelia.  R.  Pauly  and  R.  Pouly. 

8.  The  Origin  of  the  Leukocytes  in  the  Marrow  of  Bone  in 

the  Normal  S:ate  and  in  the  Infectious.    O.  Jostnfe, 

1. — Gaucher  has  classified  the  pigmentary  dystro- 
phies of  the  skin,  according  to  their  etiology,  as  follows: 
(1)  Viteligo  with  nervous  etiology  and  nervous  pathogenesis, 
symptomatic  or  trophic  viteligo,  such  as  the  pigmentary 
cutaneous  changes  of  diseases  or  lesions  of  the  nervons  sys- 
tem ;  (2)  pigmentary  dystrophies  with  toxic  etiology  and 
nervous  pathogenesis.  This  class  includes  (a)  the  hyperchro- 
mias of  toxic  origin,  of  which  arsenical  melanoderma  is  the 
type  ;  (6)  the  cutaneous  achromias  and  dyschromias  of  toxi- 
microbic  origin,  such  as  the  leukomelanoderma  of  syphilis 
and  the  white  patches  of  leprosy ;  and  (c)  true  viteligo,  of 
autotoxic  origin,  in  relation  with  a  previous  disorder  of  nutri- 
tion.    [j.M.S.J 

2. — The  article  will  be  abstracted  when  finished. 

3. — Subcutaneous  injections  of  artificial  serum 
have  a  considerable  action  on  the  condition  of  the  blood  and 
their  repetition  produces  a  marked  anemia.  Labb6,  from  a 
study  of  24  cases,  concludes  that  the  blood  of  the  newborn 
contains  a  higher  percentage  of  oxyhemoglobin  than  the 
blood  of  the  adult.  In  healthy  infants  the  blood  contains 
from  15^  to  16%  of  oxyhemoglobin.  This  proportion 
diminishes  during  the  first  10  days  of  extrauterine  life  to 
14%.  The  blood  always  contains  a  high  percentage  of  re- 
duced hemoglobin.  The  various  pathologic  conditions  in 
the  nursling  have  a  less  marked  influence  on  the  quantity  of 
oxyhemoglobin  than  upon  the  weight  and  the  temperature  ; 
for  example,  in  enteritis  the  loss  of  liquids  by  diarrhea  and 
vomiting  is  very  considerable  and  thus  produces  a  relative 
concentration  of  the  blood  and  the  oxyhemoglobin  is  re- 
duced in  small  proportion  or  not  at  all.  In  children  who 
have  been  submitted  to  treatment  by  the  subcutaneous  in- 
jection of  artificial  serum,  particularly  when  these  injections 
are  prolonged  beyond  20  days,  there  is,  in  spite  of  a  marked 
improvement  of  the  general  condition  and  a  rapid  increasA 
of  weight,  a  progressive  diminution  of  the  quantity  of  oxy- 
hemoglobin. This  constituent  of  the  blood  may  suffer  a 
reduction  of  as  much  as  half  its  normal  amount,  so  that  it 
is  present  in  about  %  8  or  9%.  On  this  account  the  child  pre- 
sents a  pallor  of  the  skin  which  appears  at  first  sight  to  be 
pathologic.  This  diminution  of  oxyhemoglobin  is  not  due 
to  the  reduction  of  the  red  blood- corpuscles,  because  these 
elements  are  not  altered  by  a  0.7%  solution  of  sodium 
chlorid  when  the  proportion  mixed  with  the  blojd  does  not 
exceed  one-fifth.  The  cause  of  the  change  should  he  sought, 
then,  either  in  the  dilution  of  the  blood,  which  is  incom- 
pletely compensated  for  by  the  osmotic  phenomena  between 
the  blood  and  the  lymph ;  or  in  the  exhaustion  of  the 
hematopoietic  organs  which  have  been  overworked  by  the 
task  that  the  artificial  serum  imposes  upon  them.  TQe  ap- 
pearance of  this  progressive  anemia  indicates  that  it  is  best 
not  to  prolong  the  injections  too  far  in  children,    [j  M.S.] 

4, — From  his  studies  of   heroin,   Morel-Lavall^e  con- 
cludes that  that  drug  may  be  used  in  all  cases  in  which 
morphin  is  indicated,  because  the  former  has  an  antialgic 
power  almost  equal  to,  and  a  hyperogenic  power  superior  to 
that  of  the  latter  drug.    Heroin  lacks  the  greatest  inconven- 
ience of  morphin,  namely,  that  of  producing  the  agreeable 
sensations  that  follow  the  injection  almost  immediately,  and     ; 
which  incite  the  patient  to  use  the  drug  for  the  pleasure  of     j 
the  thing,  even  after  his  pain  is  cured.     Heroin  controla     ;, 
pain  well,  but  without  that  wonderful  quickness  that  is  char-     ] 


212 


The  Panj^DKLPHLil 
3£eiiical  Jocesal  J 


THE  LATEST  LITERATURE 


[Febscakt  2,  urn 


acteristic  of  morphin ;  the  disappearance  of  suflFering  is  pro- 
greBsive,  relatively  slow,  and  is  often  accomplished  without 
the  patient  being  conscious  of  the  fact ;  then  no  euphoria 
replaces  the  pain  after  the  injection.  There  is  nothing,  in 
fact,  holding  out  an  inducement  to  the  patient  to  repeat  the 
dose  of  the  drug,  and  no  one  will  ever  become  a  heroino- 
maniac.  Heroin,  in  small  doses,  and  kept  up  just  below  the 
somniferous  doee,  produces  without  euphoria  or  any  tempta- 
tion to  replace  one  form  of  intoxication  by  another,  a  sensa- 
tion of  warmth  that  pervades  the  entire  being  and,  in  the 
morphinomaniac  who  feels  the  need  for  the  drug,  stops  the 
enervation  and  the  gnawing  of  the  cold  depression ;  whilst  the 
supporting  ration  of  morphin  permits  of  this  result  only  by 
increasing  the  amount,  heroin  produces  the  result,  at  least 
for  the  small  morphinomaniacs,  without  giving  rise  to  a 
necessity  for  increasing  the  dose.  The  therapeutic  dose  re- 
mains in  all  cases  below  the  narcotic  dose  which,  on  account 
of  the  profound  sleep  that  the  new  alkaloid  determines,  is  a 
guarantee  against  the  danger  of  poisoning.  In  the  serious 
question  of  the  treatment  of  niorpbinoiuaiiia,  it  is  a 
true  progress  to  have  found  the  means  of  doing  away  with 
the  slow  method  of  suppression  by  doing  away  at  once  with 
morphin  without  the  knowledge  of  the  patient  and  continu- 
ing the  supporting  rations  of  hypodermics  with  identical 
effect,  except  that  the  euphoria  does  not  accompany  the  in- 
jection.    [j.M.S,] 

6.— Remlingtr  has  studied  the  pleurisies  that  compli- 
cate typhoid  fever.  He  reports  S  cases.  These  attacks 
of  pleuritis  are  almost  always  caused  by  the  bacillus  of 
Eberth,  and  the  pleurisies  due  to  the  microorganisms  of 
secondary  infection  are  the  exception.  The  effusion  may  be 
serous,  hemorrhagic,  or  purulent.  A  serous  pleurisy  pre- 
ceding the  appearance  of  mild  typhoid  fever,  or  even  of  an 
attenuated  typhoid  fever  only  manifested  by  an  embarrass- 
ment of  the  gastric  functions,  is  a  distinct  morbid  entity. 
The  author  calls  this  pleuro- typhus.  The  prognosis  of  the 
pleurisies  that  appear  in  the  course  of  typhoid  fever  depends 
upon  the  character  of  the  effusion ;  if  the  effusion  is  puru- 
lent, the  prognosis  is  grave.  The  purulent  infection  of  the 
effusion  depends  upon  the  period  of  the  appearauce  of  the 
fluid :  a  pleurisy  appearing  late  is  apt  to  be  purulent. 
WTiether  the  effusion  is  serous  or  purulent,  it  offers  consider- 
able resistance  to  absorption.  In  one  case  the  effusion  per- 
sisted for  75  days.  The  most  interesting  peculiarities  of  these 
pleurisies  are  their  usual  involvement  of  the  left  side,  their 
subacute  evolution,  and  their  tendency  to  become  sterile  by 
progressive  attenuation  of  the  virulence  and  then  by  the 
complete  disappearance  of  the  bacilli  of  Eberth.  A  very 
interesting  class  of  pleuiiiies  due  to  the  typhoid  bacillus  is 
that  in  which  the  pleural  lesion  results  as  a  secondary  infec- 
tion in  the  course  of  some  other  disease.  In  2  published  cases 
a  pleural  effusion  containing  the  Bacillus  typhosus  developed 
in  the  course  of  tuberculosis.  This  particular  point  in  the 
history  of  pleurisies  due  to  the  bacillus  of  Eberth  merits 
special  study.  A  tabulation  of  23  published  cases,  in  addition 
to  those  reported  in  the  body  of  the  paper,  is  given,    [j.m  s.] 

7. — R.  Pauly  and  R.  Pouly  (Pauly)  publish  the  history  of 
a  case  that  shows  the  possibility  of  the  occurrence  of  gastric 
crises  in  the  beginning  or  in  the  course  of  syringo- 
myelia. This  is  a  new  point  in  the  relation  between 
syringomyelia  and  tabes.  The  patient  was  a  man,  40  years 
old,  who  presented  lightning  pains,  gastric  crises,  and  an 
osteoarthritis  of  the  right  foot.  The  diagnosis  of  syringo 
myelia  was  made  from  the  absence  of  the  sign  of  Romberg, 
the  Argyll-Robertson  pupil,  the  exaggeration  of  the  knee- 
jerk  on  one  side  and  its  normal  character  on  the  opposite 
side,  preservation  of  sensibility  to  contact,  disorders  of  the 
sensation  of  pain,  and  thermo  anesthetic  troubles  in  the 
lower  extremities.  If  these  latter  symptoms  had  been  re- 
versed the  diagnosis  would  have  been  more  difficult,    [j  m.s  ] 

8. — Josu^  has  found  that  in  the  infections  the  bone- 
marrow  plays  an  extremely  important  role  in  the  prcduc- 
duction  of  white  blood- corpuscles.  The  normoblasts 
are  not  concerned  in  the  formation  of  leukocytes,  being  only 
interested  in  the  production  of  red  cells.  By  histologic 
methods  the  author  has  demonstrated  all  varieties  of  leuko- 
cytes, except  the  lymphocytes  in  the  marrow,  in  uninter- 
rupted series  from  myelocytes  through  the  stage  of  large 
mononuclear  leukocytes  to  the  polymorphonuclear  forms. 
It  should  be  remembered  that  the  polymorphonuclear  forms 


are  augmented  in  the  majority  of  the  infections.  The  experi- 
ments also  show  that  the  products  of  the  growth  of  the 
staphylococcus  have  the  power  of  starting  the  leukccytopoi- 
etic  activity  of  the  bone-marrow,  thus  explaining  the  cunons 
reaction  that  even  a  circumscribed  suppuration  produces  in 
the  bone  marrow.  It  seems  not  to  be  the  nervous  sysiem 
that  determines  the  reaction,  but  rather  that  the  products  of 
microorganismal  growth  act  directly  on  the  bone-marrow 
after  reaching  it  through  the  blood-paths,    [j.m  s.] 


La  Semaine  Medicale. 

January  S,  1901. 

1.  On  the  Medical  Treatment  of  Hepatic  Colic  with  a  View 

of  Preventing  Recurrence.    M.  A.  Chacffabd. 

2.  Evolution  of  Medical  Docirines  of  the  Nineteenth  Century. 

Leok  Cheesisse. 

3.  The  Occlusion  of  the  Superior  Mesenteric  Artery  at  the 

Junction  of  the  Duodenum  and  Jejunum. 

1. — Chauffard  mentions  the  relative  frequency  of  chole- 
lithiasis In  private  practice  among  the  better  classes  and  its 
comparative  rarity  among  the  hospital  cases.  He  criticises 
the  fact  that  most  physicians  rest  content  when  they  have 
allayed  the  acute  suffering  of  the  hepatic  colic  without 
proceeding  systematically  to  treat  the  case  medically  with  a 
view  to  its  complete  cure.  He  deplores  surgical  interven- 
tion, remarking  that  while  the  cure  may  be  attained  tempo- 
rarily, the  same  conditions  exist  for  the  formation  of  addi- 
tional calculi.  He  thinks  the  chief  factors  which  should  be 
considered  in  any  proposed  treatment  must  include  efiorts  to 
check  the  reflex  excitability  of  the  gallbladder,  to  prevent  the 
formation  or  increase  of  gallstones,  to  increase  the  biliary 
circulation  by  rendering  the  bile  more  fluid  and  more  abun- 
dant, to  maintain  the  bile  in  an  aseptic  condition.  He  be- 
lieves these  conditions  may  be  met  medically,  but  that  pro- 
longed treatment  must  be  instituted  to  insure  success.  The 
treatment  should  be  interspersed  with  frequent  periods  of 
cessation  of  medication.  He  places  salicylate  of  soda  in 
the  first  rank  as  meeting  the  indications  outlined.  The  drug 
should  be  administered  carefully,  in  doses  of  from  1  to  2 
grams  per  day.  The  condition  of  the  kidneys  must  be 
watchea  and  the  cumulative  eSect  of  the  drug  borne  in  mind. 
Frequently  Chauffard  adds  a  gram  or  two  of  Carlsbad  salt 
to  the  treatment.  This  treatment  should  be  rigorouslv  fol- 
lowed for  9  or  10  days  consecutively  of  each  month  and  con- 
tinued for  many  months.  He  believes  it  will  only  be  by  long- 
continued  use  that  the  permanent  cessation  of  the  attacks 
may  be  brouebt  about.  He  has  also  found  Harlem  oil  of 
great  value  as  an  adjuvant  to  this  treatment.  He  advises  the 
alternation  of  the  benzoat«  with  the  salicylate  of  soda. 
Alkaline  baths,  exercise,  massage,  and  careful  attention  to 
personal  hygiene  are  very  important.  He  appends  the  his- 
tory of  2  cases  illustrating  the  gratifying  results  of  this  treat- 
ment,    [t  l.c  ] 

3. — In  the  superior  portion  of  its  insertion  to  the  vertebral 
column  the  mesentery  crosses  the  third  portion  of  the  duc>- 
denum,  with  the  result  that  in  this  last  portion  a  loop  is 
formed  and  the  tension  is  increased  by  the  presence,  at  this 
level,  of  the  superior  mesenteric  "artery.  Occlusion  of 
this  artery  is  not  a  common  condition.  Tne  author  has  col- 
lected 24  reported  cases.  It  is  probablv  dependent  upon 
some  anomalous  condition,  and  the  tendency  to  occlusion 
seems  to  be  increased  by  a  weakened  physical  state.  It  has 
occurred  during  the  simple  administration  of  chloroform, 
when  no  operation  has  been  undergone.  Ptosis  of  the  intes- 
tine increasing  the  mesenteric  tension,  and  acute  dilation  of 
the  stomach,  as  well  as  vague  nervous  derangements,  have 
been  said  to  produce  the  condition.  The  general  symptoms 
would  be  those  of  high  obstruction  generally.  The  f)er8istent 
vomiting  would  remain  bilious  in  character  and  not  become 
fecal.  Constipation,  as  a  rule,  is  absolute,  following,  perhaps, 
one  passage  of  feces  which  was  present  in  the  lower  bowel. 
There  is  considerable  hypogastric  tympany ;  no  fever :  a 
pulse  ranging  as  high  as  120.  The  measures  for  relief  are  at 
first  simple.  The  patient  is  placed  either  in  the  knee-chest 
position  or  lying  flat  on  the  abdomen.  Absolute  diet  is 
insisted  upon.  Rectal  nutrient  enemeta  may  be  employed 
and  gastric  lavage  practised.  These  measures  failing,  gastro- 
enterostomy is  our  last  resource,     [t.uc] 


Fkbkcabv  2,  1901] 


SCURVY,  NOT  RHEUMATISM 


rXHE  Philadelphia 
L  Medical  Journal 


213 


©riginal  Articles. 


SCURVY,  NOT  RHEUMATISM, 
With  a  Report  of  16  Cases  of  Infantile  Scurvy* 

By  J.  r.  CROZER  GRIFFITH,  M.D., 

of  Philadelphia. 

Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Pennsylvania. 

Of  all  the  diseases  of  infancy,  that  denominated  '•  in- 
fantile scurvy  "  is,  in  most  instances,  one  of  the  easiest 
to  recognize  as  it  is  to  treat.  In  a  few,  however,  it  oiiei's 
considerable  difficulties,  and  in  some  it  seems  to  be  one 
of  the  stumbling-blocks  of  physicians  who  have  seen 
either  Httle  or  nothing  of  the  affection.  This  is  gener- 
ally because  the  symptoms  simulate  at  first  other  affec- 
tions, particularly  rheumatism.  On  this  account  it  may 
be  of  value  to  detail  the  following  16  cases,  all  of  them 
seen  within  little  more  than  18  months,  and  9  within  6 
months  before  the  date  of  writing  this  report.  Most  of 
them  illustrate  the  likeness  to  which  the  title  of  the 
paper  refers  and  the  mistakes  which  have  arisen.  In  a 
few  the  diagnosis  offered  no  difficulties. 

Case  1.— A  lady  from  Wilmington  was  one  day  telling  me 
of  the  serious  attack  of  rheumatism  her  little  grandchild 
was  experiencing  under  the  care  of  homeopathic  physician 
of  that  city.  The  little  girl  had  for  weeks  been  suffering 
severe  pains,  especially  in  her  legs,  and  had  not  improved  in 
spite  of  treatment.  I  felt  free  to  say  in  response  to  her  anx- 
ious questions,  "  Mrs. ,  I  cannot  tell  you  positively  what 

your  grandchild  has,  but   I   feel   practically  sure   it  is  not 
rheumatism." 

On  June  1,  1899,  the  child  was  brought  to  me,  and  the  fol- 
lowing history  given  : 

Marion  B.,  18  months  old.  Though  delicate  originally, 
she  had  been  in  good  health  for  months.  The  feeding  had 
been  varied  :  Malted  milk  for  the  first  few  weeks  of  life,  then 
Reed  &  Carnrick's  food,  next  Robinson's  barley,  and  finally 
Imperial  Granum.  The  latter  had  been  commenced  in  Sep- 
tember, 1898,  and  continued  for  the  9  months  preceding  the 
time  of  examination.  It  was  boiled  in  water  and  then  mixed 
with  milk,whichhad  been  scalded  only,  no  prolonged  heating 
being  used.  In  the  last  part  of  March,  1899,  the  child,  then 
16  months  old,  developed  pain  in  lifting  the  right  arm.  This 
soon  disappeared,  but  returned.  Next  her  legs  grew  painful 
Early  in  May  the  gums  of  the  incisor  teeth,  especially  of  the 
lower  jaw,  became  swollen  and  red  and  bled  easily.  A 
change  in  diet  at  last  was  ordered  by  the  physician,  who  now 
probably  suspected  that  his  earlier  diagnosis  of  rheumatism 
had  been  incorrect.  She  was  already  somewhat  better  when 
I  saw  her. 

A  necessarily  hasty  examination  showed  the  child  very 
pale,  and  with  the  gums  slightly  affected.  The  treatment 
ordered  consisted  of  orange  juice,  raw  milk,  beef  juice,  the 
withdrawal  of  Imperial  Granum,  and,  later  on,  the  giving  of 
eggs,  oatmeal,  and  a  more  extended  diet.  Improvement  was 
very  rapid. 

One  must  remain  in  doubt  here  regarding  the  cause 
of  the  disease.  It  is  possible  that  the  too  early  and  free 
use  of  cereal  food  may  have  had  some  influence,  though 
I  am  by  no  means  sure  of  it.  Perhaps  the  child  had 
required  a  more  varied  diet. 

Case  2. —Mr.  C,  of  one  of  the  neighboring  towns  of  New- 
Jersey,  asked  me  to  visit  his  child,  which  I  had  treated  about 
6  months  before.  He  stated  that  the  baby  cried  nearly  all 
the  time,  night  and  day,  and  that  it  appeared  to  have  rheu- 
matism in  its  legs.  The  physician  in  attendance  had  been 
unable  to  reach  a  positive  diagnosis,  but  inclined  to  rheu- 
matism, and  had  treated  for  this. 

*  Read  at  the  meeting  of  the  Philadelpbia'County  Mcdica'  Society,  Decem- 
ber 26,  IWJO 


The  child  was  seen  on  April  10,  1899.  Its  history  and 
appearance  were  as  follows: 

James  C,  14  months  old.  He  had  beeu  plump  and  hearty, 
and  never  ill,  except  for  a  curious  convulsive  condition  when 
about  7  months  old.  He  had  been  fed  on  Malted  Milk,  ex- 
cept for  a  very  brief  interval,  until  November,  1895,  when 
Just's  food  with  sterilized  milk  was  substituted.  About 
February  1,  the  gums  became  sore,  and  about  3  weeks  later 
both  knees  became  swollen.  The  child  lost  strength  and 
weight,  and  often  cried  as  though  in  pain.  Finally,  he  cried 
most  of  the  time,  and  grew  unable  to  straighten  his  legs- 
There  had  been  some  bleeding  of  the  gums. 

Examination  showed  a  pale  but  well-nourished  baby. 
While  sitting  he  kept  the  legs  flexed  and  banging  down- 
wards as  though  paralyzed,  giving  much  the  appearance  of 
the  paralysis  of  a  poliomyelitis.  There  was  some  tenderness 
of  the  knees  and  a  distinct  enlargement  of  the  right  tibia. 
The  gums  of  the  incisor  teeth  were  red  and  swollen.  The 
head  was  slightly  rachitic  and  a  rickety  rosary  was  present. 
The  diagnosis  of  scurvy  was  clear. 

I  ordered  the  administration  of  orange  juice  and  beef 
juice,  the  withdrawal  of  Just's  food,  and  the  use  of  raw 
milk.  Improvement  was  immediate.  The  constant  crying 
stopped  almost  at  once,  and  in  a  very  few  days  all  pain, 
pseudoparalysis  and  redness  of  the  gums  had  vanished. 

Here,  again,  it  appears  that  a  dietetic  error  was  cer- 
tainly the  cause  of  the  disease,  but  the  exact  nature  of 
this  is  uncertain.  The  simulation  of  rheumatism  on  the 
one  hand  and  of  paralysis  on  the  other,  was  very  striking. 

Cases.— "Doctor,"  said  Dr. ,  as  I  met  him  at  a  suburban 

railroad  station,  "  I  have  a  puzzling  case  I  want  you  to  see. 
The  child  appears  to  have  rheumatism,  but  I  wanted  to  ask 
vou  whether  this  is  not  a  very  uncommon  disease  in  in- 
fancy." 

I  replied  that  it  certainly  was  so  in  my  experience.  Mak- 
ing a  mental ''  snap  diagnosis  "  I  presently  asked  :  "  How  are 
the  child's  gums?"  Hearing  that  they  had  been  very  much 
inflamed,  the  diagnosis  of  scurvy  now  became  very  probable. 

At  the  house  the  following  clinical  history  and  results  of 
examination  were  obtained : 

Rosemary  MacN  ,  1  year  old,  seen  May  6,  1899.  She  had 
suftered  from  malnutrition  in  the  early  months  of  life,  but 
later  became  plump  and  hearty.  She  had  been  fed  on  Mel- 
lin's  food  and  sterilized  milk  About  6  weeks  previously 
the  left  knee  became  painful,  and  then  the  right.  Very  soon 
the  middle  of  the  right  thigh  grew  thicker  and  was  painful 
when  touched.  Only  for  the  last  2  weeks  had  the  gums  been 
swollen  and  purplish.  Quite  recently  there  had  been  some 
pain  in  one  arm.  AntLrheuma"tic  treatment  had  been  given 
without  effect. 

Examination  showed  the  right  thigh  swollen  and  hard. 
There  was  no  involvement  of  the  joints.  The  knees  were 
flexed  most  of  the  time.  The  child  let  its  legs  hang  as 
though  they  were  paralyzed.  The  gums  of  the  upper  in- 
cisors were  swollen  and  deeply  purple-red. 

I  gave  it  as  my  opinion  that  the  baby  had  scurvy,  with 
which  the  attending  physician  entirely  concurred,  saying 
that  he  felt  as  though  "  scales  had  fallen  "  from  his  eyes. 

The  child  was  ordered  raw  milk,  Mellin's  food  was  with- 
drawn, and  orange  juice  prescribed.  Pain  disappeared  and 
health  was  regained  with  very  great  rapidity. 

Dietetic  error  was  clearly  the  cause  in  this  case  also. 
Whether  this  was  due  to  the  use  of  Mellin's  food  or  to 
the  sterilization  of  the  milk  cannot  be  definitely  deter- 
mined. 

The  following  case  of  scurvy,  occurring  in  German- 
town,  is  of  interest  only  from  an  etiologic  point  of  view. 
Dr.  Th.  C.  Potter,  with  whom  I  saw  it,  had  already  made 
the  diagnosis. 

Case  4.— Roland  F.,  9  months  old,  seen  February  19,  1900. 
The  child  had  been  healthy  and  well  nourished.  He  had 
been  fed  on  Mellin's  food,  with  which  was  mixed  milk  and 
water,  which  was  heated  but  not  quite  to  boiling.  About4 
weeks  before  seen  by  me  be  developed  fever  and  great  pain 
when  his  right  leg  w'as  moved.  No  swelling  could  be  found 
at  that  time.     This  condition  continued  about  36  hours,  and 


214 


The  PhiladklphiaI 
Medical  Journal  J 


SCURVY,  NOT  RHEUMATISM 


[Fkbecabt  2,  U« 


afterwards  appeared  intermittently,  lasting  a  couple  of  days 
at  a  time.  Finally  it  developed  more  persistently,  accom- 
panied  also  by  edema,  and  last  by  involvement  of  the  gums. 

Examination  showed  the  right  leg  and  thigh  edematous 
and  somewhat  painful  on  passive  movement.  It  could  not 
be  determined  whether  the  tibia  was  thickened  or  only  the 
soft  tissues  affected.  The  gums  of  the  upper  incisors  were 
quite  swollen  and  purplish. 

The  child  was  put  upon  orange  juice,  Mellin's  food  was 
withdrawn,  and  the  milk  not  heated  above  body  heat.  Re- 
covery was  very  rapid. 

In  this  case  we  can  at  least  exclude  any  deleterious 
action  of  prolonged  high  temperature  upon  the  milk, 
since  this  was  at  no  time  employed. 

The  intermittent  nature  of  the  pain  as  often  seen  in 
this  disease  is  also  well  exemplified. 

Case  5. — The  next  case  is  one  of  peculiar  interest  from 
the  fact  that  it  was  brought  to  the  Surgical  Out-patient  De- 
partment of  the  Children's  Hospital,  on  account  of  pain  in 
one  hip,  which  rendered  the  diagnosis  of  hip-joint  disease 
probable.  Dr.  Jopson  carefully  examined  it  there  for  the  ex- 
istence of  coxalgia,  and  decided  to  apply  an  immobilizing 
dressing  as  a  pro\'isional  measure.  This  was  worn  for  some 
days,  the  child  meanwhile  visiting  the  dispensary  once  or 
twice.  Finallj',  at  its  visit  on  May  19,  1899,  the  other  hip 
was  also  found  to  be  painful.  Dr.  Jopson  then  decided  that 
the  affection  was  scorbutic  and  referred  the  case  to  the 
Medical  Department,  where  the  following  history  and  exami- 
nation were  obtained. 

George  T.,  13  months  old.  He  had  been  fed  on  condensed 
milk  for  the  first  4  months  of  life;  next  on  Mellin's  food 
until  8  months  old :  and  since  then  on  Malted  Milk.  He 
thrived  indifferently  well,  but  for  5  months  sweating  had 
been  proftise.     He  had  been  verj'  fretful  recently. 

Examination  showed  the  child  plump  and  of  good  color, 
with  no  osseous  symptoms  of  rickets,  except  slight  beading 
of  the  ribs.  Movement  at  both  hip-joints  and  both  knees 
was  very  painful  There  was  no  affection  of  the  gums.  A 
slight  petechial  eruption  was  present  over  the  dorsum  of  the 
feet. 

The  diagnosis  of  scurvy  seemed  verj'  certain.  The  baby 
was  ordered  orange  juice,  beef  juice,  and  a  mixture  of  milk 
and  water  which  was  to  be  scalded.  In  a  very  few  days  he 
had  evidently  much  less  pain,  and  could  move  the  legs  more 
freely.  The  eruption  was  disappearing.  In  a  few  days 
more  the  symptoms  of  scurvy  had  entirely  vanished. 

It  is  clear  that  sterilized  milk  was  not  an  etiologic 
factor  in  this  case,  since  no  milk  was  added  to  the 
Horlick's  food.  In  fact,  the  use  of  scalded  milk  was  one 
of  the  therapeutic  means  employed  in  the  treatment  of 
the  disease. 

Case  6. — The  next  case  was  a  child  of  a  physician  and 
had  been  under  my  care.  I  can  offer  no  excuse  for  a  failure 
to  make  the  diagnosis  earlier  than  I  did 

Joseph  C.  A.,  born  March  28,  1898.  He  had  been  a 
healthy,  well-nourished  child,  and  had  been  thriving  for 
months  on  a  sterilized  mixture  of  cream,  milk,  and  water, 
with  dry  malt  extract.  When  7  months  old,  he  was  exposed 
considerably  on  a  river  trip  and,  a  few  days  later,  just  before 
the  end  of  October,  he  became  cross  and  fretful,  and  lost  his 
appetite  to  some  extent.  For  the  last  3  days  he  would  crj- 
out  suddenly  while  in  the  arms,  as  though  afraid  or  in  pain. 
The  pain  seemed  to  be  situated  chiefly  in  the  legs. 

Examination  by  me  on  October  31,  1898,  showed  a  large, 
fat  child,  with  slight  beading  of  the  ribs.  Forcible  extension 
of  the  right  leg  made  the  child  start  and  cry.  No  swelling  or 
redness  could  be  discovered  anywhere.  There  was  no  affec- 
tion of  the  gums.    The  2  lower  incisor  teeth  had  been  cut. 

The  history  of  exposure  made  me  underestimate  the  pos- 
sibility of  scurvy,  and  I  made  a  provisional  diagnosis  of 
rheumatism  of  the  right  knee,  and  asked  the  father  to 
report  in  a  few  days. 

The  report  did  not  reach  me,  however,  until  nearly  a 
month  later  (March  23).  The  child  had  continued  fretful 
and  with  pain  in  the  right  leg.  For  a  few  days  he  had  had 
pain  in  the  other  leg  also,  anil  had  seemed  unwilling  to  move 


either  of  them.  Passive  motion  of  them  often  gave  pain* 
There  was  some  sweating  of  the  head.  About  a  week  ago 
the  upper  gums  in  front  looked  like  a  "  blood  blister'"  bnt 
this  had  improved. 

I  at  once  made  the  diagnosis  of  scurvy,  and  visited  the 
child  the  next  day.  Examination  then  showed  the  gums  of 
the  upper  incisors  swollen  a-^d  a  little  red  ;  no  discoverable 
swelling  of  the  tibiae,  some  beading  of  the  ribs. 

I  ordered  orange  juice,  the  withdrawal  of  malt  extract,  and 
the  stopping  of  all  cooking.  In  2  days  the  pain  was  nearly 
and  in  5  days  more,  entirely  gone. 

It  is  impossible  to  be  sure  in  this  case  whether  the 
scur^'y  was  due  to  the  addition  of  malt  extract  or  to 
the  sterilizing  of  the  mUk,  or  to  some  other  cause.  I 
was  unwilling  to  make  a  therapeutic  test  to  determine 
this. 

Case  7. — ^The  following  case  was  interesting  on  account  of 
the  long  continuance  of  the  attack,  about  6  months  in  all, 
and  of  the  difficulty  in  diagnosis  which  it  presented.  The 
■  attributing  of  pain  to  a  trauma  is  worthy  of  note. 

The  case  occurred  in  the  family  of  a  prominent  resident 
of  Easton.  The  father  called  upon  me  on  June  14, 1899,  to 
talk  over  the  condition  of  his  child,  the  nature  of  whose  ail- 
ment had  not,  he  said,  seemed  clear  to  several  physicians 
who  had  been  in  attendance  at  different  times.  One  had 
insisted  that  the  child  must  have  had  a  fall,  while  others 
suggested  the  possibility  of  rheumatism.  From  the  father's 
description  of  the  symptoms,  I  felt  it  extremely  likely  that 
the  case  was  one  of  scurvy.  Two  days  later  I  saw  the  child 
and  obtained  the  following  histor>-  and  examination  : 

E.  D.  W.  ;  16  months  old.  His  nutrition  had  at  first  been 
very  poor,  and  he  weighed  but  9  pounds  at  4  months  of  age. 
At  that  time  he  was  taking  Eskay's  food  and  sterilized  milk. 
Later  different  foods  were  tried,  such  as  Horlick's,  Mellin's, 
and  egg  albumen.  Finally  a  return  to  Eskay's  food  was 
made  and  this  diet  was  continued.  About  February  1,  or 
late  in  January-,  the  child,  being  then  about  one  year  old, 
suffered  from  swelling  and  tenderness  first  of  one  knee,  and 
then  of  both.  He  could  not  use  the  legs  at  all.  Next  one 
arm  became  painftil.  The  pain  in  the  arm  was  intermittent, 
and  to  some  extent  that  in  the  legs  also.  Beef  juice  was 
commenced  in  February  and  continued  until  warm  weather 
began.  During  February  and  March  he  lay  on  his  back  with 
his  feet  drawn  up  and  making  very  little  movement  of  his 
legs.  In  April  and  May  he  was  better  and  had  very  little 
trouble  except  for  a  short  relapse  in  April.  About  the  end 
of  May  be  grew  much  worse.  For  about  two  weeks  before 
he  was  seen  the  gums  had  been  "  congested."  On  May  31  he 
had  nosebleed  and  developed  an  eechymosis  about  both  eves, 
giving  the  appearance  of  a  large  bruise.  The  gums  bled  on 
June  8.  Since  then  they  had  been  purple.  Severe  nose- 
bleed occurred  on  June  7,  and  from  this  time  the  child  had 
been  pale,  languid,  and  weak,  unable  to  sit  up.  and  had 
edema,  rapid  respiration,  loss  of  appetite,  a  poor  digestion, 
and  rather  frequent  vomiting. 

Examination  showed  a  child  fairly  well  nourished  but 
looking  very  ill,  quite  anemic,  and  with  the  legs  and  feet 
very  edematous.  Every  touch  of  them  ehcited  cries  of  pain. 
Movement  of  the  arms  was  painful.  The  eechymosis  of  the 
eyes  had  disappeared,  no  subperiosteal  swellings  were  discov- 
erable in  the  arms  and  legs  and  no  petechiae  found.  The 
gumsof  the  upper  incisors  exhibited  a  slight  purplish  tint. 
The  fontanels  were  opened,  the  ribs  beaded,  the  epiphyses 
of  the  wrists  enlarged. 

In  the  way  of  treatment,  there  was  ordered  the  juice  of 
one  orange  daily,  one  ounce  of  beef  juice  3  times  a  day.  the 
withdrawal  of  Eskay's  food,  the  giving  of  equal  parts  of 
milk  and  water  which  should  be  pasteurized  at  lirst  but  raw 
after  a  few  days,  the  administration  of  iron,  and  the  removal 
to  the  seashore.  This  treatment  was  commenced  at  once, 
the  child  being  taken  to  Atlantic  City  on  June  19.  On  June 
21  he  was  able  to  sit  up  and  by  June  22  all  evidences  of  pain 
had  disappeared.  Ten  days  later  all  edema  had  vanished, 
the  color  w:is  returning  and  the  child  was  plaj-ing.  The 
after-history  is  uneventful.  The  symptoms  of  scurvy  re- 
mained absent  and  the  rickets  slowly  disappeared  under 
treatment  and  in  6  months  was  nearly  gone. 

The  diagnosis  in  this  case  was  clear.     The  prognosis 


Fkbruaky 


SCURVY,  NOT  RHEUMATISM 


PThe  Philadelphia 
L  Medical  Journal 


215 


was  somewhat  uncertain  at  first  owing  to  the  very  greatly 
impaired  strength  of  the  digestion,  the  marked  anemia 
and  the  edema.  The  result,  however,  was  brilliant,  as 
it  usually  is  in  this  disease. 

Cases  8  and  9.— In  March,  1900,  I  received  a  letter  from  a 
physician  asking  me  to  see  with  him  a  case  of  rheumatism 
in  "a  baby  living  in  Germantown.  Before  we  reached  the 
house,  he  tokl  me  that  he  had  used  antirheumatic  treatment 
in  vain,  and  that  he  was  beginning  to  suspect  the  existence 
of  scurvy.  In  fact,  he  had  recently  ordered  fruit-juice  and 
vegetable  soups,  which,  however,  we  found  that  the  mother 
had  not  given,  as  the  diet  seemed  to  her  unreasonable. 

In  the  diagnosis  of  scurvy  I  entirely  concurred  after 
seeing  the  child — or  rather  the  children,  for  the  inter- 
esting feature  is  that  we  had  here  scurv}^  occurring  in 
twills.  One  of  these  cases  was,  without  exception,  the 
worst  I  have  ever  seen.     The  history  is  as  follows : 

Case  8.— Wallace  McC,  aged  13  months,  visited  March  25, 
1900.  The  child  had  been  fed  on  Mellin's  food  with  steril- 
ized milk  from  the  age  of  5  months.  About  11  weeks  before 
seen  by  me  the  gums  had  become  purple.  About  3  weeks 
later  pain  and  edema  developed  in  one  leg  below  the  knee 
and  then  extended  to  all  the  extremities.  The  child  had 
become  unable  to  move  its  legs  in  the  slightest  degree.  There 
had  been  profuse  sweating.  The  condition  of  the  arms  had 
later  improved  considerably. 

Exammation  showed  an  anemic  and  evidently  ill  and  suf- 
fering child.  He  lay  helpless  on  his  back  with  his  legs 
extended  and  swathed  with  cotton  and  wrappings.  He  was 
bathed  in  perspiration  and  wet  with  urine,  for  pain  on  motion 
was  so  great  that  moving,  dressing,  or  changing  of  the 
child  seemed  almost  impossible.  He  was  indeed  a  pitiable 
object  Both  legs  and  both  thighs  were  greatly  swollen 
throughout.  Subperiosteal  thickening  of  the  tibiae  was 
easily  discoverable  and  there  was  distinct  thickening  and 
tenderness  of  the  right  clavicle.  Slight  beading  of  the  ribs 
was  present.  The  fontanel  was  nearly  closed.  The  gums 
of  the  incisor  teeth  were  somewhat  swollen  and  red. 

He  was  ordered  orange  juice,  beef  juice,  and  coddiver  oil 
with  iron,  and  the  use  of  raw  milk  without  Mellin's  food. 
Improvement  was  rapid,  and  in  about  a  week  pain  had  prac- 
tically disappeared. 

Case  9. — The  twin  brother,  Lansing  McC,  had  been  fed  in 
a  similar  manner  and  developed  the  disease  at  the  same 
time,  11  weeks  before  I  saw  him.  The  first  symptoms  were 
redness  of  the  gums  as  in  the  other  case.  After  3  weeks — 
as  in  the  first  case — pain  developed  in  the  legs  and  arms. 
This  had,  however,  been  much  less  severe  than  in  the  brother 
and  had  later  disappeared.  He  had  never  been  iucapacitated 
by  it. 

Examination  showed  a  well-nourished  child  with  a  pasty, 
anemic  appearance.  The  gums  were  swollen  and  very  red. 
There  was  no  discoverable  pain  or  edema  anywhere. 

The  treatment  ordered  was  the  same  as  in  the  last  case 
and  the  improvement  was  as  rapid,  although  not,  of  course, 
as  striking,  since  the  condition  was  so  mucli  less  grave. 

These  2  cases  are  extremely  suggestive.  It  is  a 
curious  fact  that  the  disease  developed  at  the  same  time 
in  both  children  upon  food  which  was  not  different 
from  that  useil  for  months,  and  which  had  apparently 
agreed  perfectly.  The  reason  for  this  we  can  hardly 
understand,  unless  we  assume  the  existence  of  an  infec- 
tion, and  for  this  we  have  hardly  sufficient  ground. 
Again,  it  is  interesting  to  note  that  whereas  the  symp- 
toms in  one  brother  ran  to  edema  and  subperiostial 
involvement,  in  the  other  the  chief  characteristics  were 
the  marked  anemia  and  the  affected  gums. 

Case  10. — The  following  case  is  to  me  extremely  interest- 
ing from  the  point  of  view  of  the  causative  influence  of 
food. 

Lawrence  MacE.,  8  months  old  when  seen  first  on  January 
27,  1900.  The  child  was  a  wretched,  marantic  specimen, 
always  suffering  from  indigestion  and  diarrhea.  He  had 
been  fed  for  the  first  2  months  on  the  breast  and  bottle,  then 


solely  on  Malted  Milk,  and  then  on  condensed  milk.  When 
5  months  old  he  was  placed  upon  barley  water  and  white  of 
egg  for  2  months  and,  finally,  for  the  last  month  upon 
Mellin's  food.  \Vhen  first  seen  he  exhibited  some  edema  of 
the  feet  and  of  the  cheeks.  Involvement  of  the  limbs  and  of 
the  gums  was  looked  for,  but  not  found.  I  started  the  child 
upon  raw,  laboratory  percentage  milk,  which  contained 
barley  water  and  a  very  low  proportion  of  proteids  and  of  fat. 
On  February  19,  1900,  before  circumstances  had  permitted 
more  than  a  very  slight  increase  of  the  percentages,  the  gums 
of  the  upper  incisor  teeth  were  found  to  be  swollen  and  very 
purplish.  Orange  juice  was  at  once  ordered  and  continued, 
and  the  symptoms  of  scurvy  rapidly  disappeared.  No  im- 
mediate change  was  made  in  the  food,  although  later,  and 
as  soon  as  the  digestive  power  improved,  the  percentages 
were  raised. 

It  is  impossible  in  this  case  to  determine  whether  the 
disease  began  to  develop  when  the  child  was  upon 
Mellin's  food,  as  indicated  by  the  edema,  or  whether  the 
involvement  of  the  gums  marked  the  onset  of  the  dis- 
ease, which  was  then  to  be  attributed  to  the  verj'  low 
percentages  of  the  milk  mixture.  It  is  to  be  noted  that 
a  certain  small  amount  of  starch  in  the  form  of  barley 
water  was  present  in  the  food  ordered,  but  that  there 
was  no  cooking  of  the  food  whatsoever.  I  am  inclined 
to  view  the  edema  as  the  earliest  symptom. 

Case  11. — The  next  case  illustrates,  as  many  of  the  others 
have  done,  the  simulation  of  rheumatism  by  scurvy.  It  also 
illustrates  the  development  of  scurvy  independently  of  any 
heating  of  the  food,  and  upon  nourishment  which  seemed 
perfectly  suited  in  every  way. 

Emily  J.,  first  seen  when  4  months  old.  She  had  been  a 
fairly  healthy  child,  and  was  well-nourished,  although  not 
gaining  much  weight.  None  of  the  various  methods  of 
feeding  previously  tried  had  agreed  well.  I  placed  her  on  a 
raw  low-percentage  mixture  of  laboratory  modified  milk 
with  Ijarley  water.  This  agreed  nicely,  and  the  weight 
steadily  increased.  By  the  middle  of  March,  1900,  when  6 
months  old,  she  was  the  picture  of  perfect  health,  jolly,  rosy, 
plump.  She  was  now  taking  a  mixture  of  fat,  3.75%  ;  sugar, 
7%  ;  proteid,  1.50%. 

Ih  April  the  child  lost  appetite,  was  fretful,  and  ceased  to  eat 
much  or  to  gain  in  weight.  The  fat  percentage  was  tentatively 
reduc'd  to  3.50%,  and  finally  to  3%,  owing  to  continued  in- 
digestion. About  the  first  of  May  she  commenced  to  have 
pain  in  the  legs,  only  discovered  when  they  were  handled  in 
a  certain  way,  and  apparently  situated  somewhere  about  the 
ankles.  There  was  still  no  gain  in  weight,  owing  apparently 
to  the  occurrence  of  a  sharp  bronchitis  with  fever.  She 
grew  pale  and  had  continued  signs  of  indigestion. 

Examination  on  May  18,  at  the  age  of  8  months,  dis- 
covered pain  on  passive  movements  of  the  legs  and  indis 
position  to  active  movements  of  them.  There  were  no 
swellings,  edema,  or  affection  of  the  gums.  The  child  had 
cut  no  teeth. 

The  diagnosis  of  incipient  scurvy  was  made  and  the  child 
given  orange  juice,  beef  juice,  salt  baths,  oil  massage,  and, 
later,  codliver  oil  internally.  The  1.50%  of  proteid  was  in- 
creased to  1.75.  The  mixture  was  pasteurized  and  barley 
water  was  stopped. 

In  a  week  the  pain  had  practically  gone,  and  the  child  had 
begun  to  increase  in  weight.  By  the  end  of  May  she  was 
doing  well,  and  the  percentages  in  the  food  were  now  in- 
creased to  fat  3,  sugar  7,  proteid  2.25. 

What  is  most  interesting  aljout  this  case,  apart  from 
the  simulation  of  rheumatic  pain,  is  the  fact  that  the 
scurvy  developed  on  a  mixture  in  which  no  heat  was 
employed  and  in  which  the  percentages  seemed  to  have 
suited  admirabl}'.  I  am  inclined  to  think,  however, 
that  possibly  a  still  greater  increase  of  proteid  was 
needed  ;  yet  it  is  to  be  noted  that  recovery  liegan  after  a 
very  inconsiderable  increase,  .25%,  of  the  proteids  was 
made,  which  seems  to  show  that  the  orange  juice  was 
the  curative  agent.  It  is  conceivable  that  the  barley 
water  mav  have  lieen  an  etiologic  factor.    Pasteurization 


216 


The  Philadelphia 
Medical  Journal 


] 


SCURVY,  NOT  RHEUMATISM 


[Febbdaky  2,  1901 


was  commenced  after  scurvy  had  appeared  and  was  con- 
tinued on  account  of  the  weather  being  quite  warm,  and 
for  fear  that  changes  might  be  taking  place  in  the  food. 

Case  12. — The  following  case  is  like  the  last  in  that  the 
cause  of  the  attack  probably  consisted  in  a  deficiency  in  the 
amount  of  proteids.     Yet  this  is  not  certain. 

Mary  C,  3  months  old  when  first  seen,  December  29,  1899. 
The  child,  always  bottled-fed,  had  never  thriven  in  spite  of 
various  changes  in  her  diet,  and  was  a  feeble,  emaciated 
specimen  with  extremely  weak  digestion.  I  gave  her  a 
pasteurized  low-percentage  laboratory  milk  with  barley- 
water,  and  gradually  increased  this  in  strength.  The  child 
meanwhile  did  remarkably  well,  and  by  the  end  of  June, 
1900,  being  then  10  months  ©Id,  had  gained  7  pounds  in  5 
months.  By  this  time  the  percentage  strength  equalled,  fat, 
3;  sugar,  7;  proteids,  1.25.  For  2  weeks  the  child  seemed  to 
have  pain  when  the  chest  was  grapsed  or  the  legs  moved. 
Orange  juice  was  given  for  3  days,  and  the  jDain  diminished, 
but  as  this  seemed  to  produce  diarrhea  it  was  stopped. 
A  little  later  the  proteid  percentage  was  raised  to  1  50,  and 
then  to  1.75.  As  this  caused  diarrhea  it  was  again  reduced 
to  1.25.  About  the  end  of  July  pain  returned  in  force.  The 
child  was  so  tender  all  over  that  it  would  move  no  more 
than  its  head,  and  its  cries,  when  touched,  were  pitiable. 
There  was  never  any  discoverable  swelling  of  the  limbs  or 
affection  of  the  gums.  Orange  juice  was  again  given,  and  in 
less  than  a  week  all  pain  had  gone  completely. 

The  laboratory  milk  mixture  in  this  case  had  been 
pasteurized  from  the  beginning,  and  was  still  so  during 
and  after  the  attack  of  scurvy.  The  heating  of  the 
food  may  therefore  probably  be  dismissed  as  an  etio- 
logic  factor.  As  stated,  it  seems  most  likely  that  the 
cause  was  a  low  proteid  proportion. 

Case  13. — This  next  case  is  very  like  some  of  the  preced- 
ing in  its  .simulation  of  rheumatism,  and  like  2  others  in  that 
the  possibility  of  the  influence  of  trauma  had  been  enter- 
tained. 

Towards  the  end  of  June,  1900,  a  medical  friend  asked 
me  about  his  baby  of  nearly  a  year  who,  he  thought, 
was  suffering  with  rheumatism.  Yet,  he  said,  he  was  not 
sure,  as  he  bad  always  understood  that  rheumatism  was  un- 
usual in  infants.  He  had  thought,  too,  of  neuritis,  but  had 
excluded  this.  I  suggested  that  the  affection  was  probably 
scurvy,  and  urged  that  he  give  orange  juice  and  change  the 
diet.  On  June  27,  the  father  sent  me  a  full  account  of  the 
case,  which  I  abridge  : 

The  child  was  11  months  old.  He  had  been  fed  since  the  sec- 
ond or  third  month  on  a  scalded  mixture  of  cream,  milk, 
and  water,  with  Eskay's  food  added.  He  had  always  been 
healthy  and  fat,  but  had  no  teeth.  The  first  svmptoms  of 
scurvy  were  manifested  early  in  June.  The  child  (jid  not  move 
its  legs  nearly  as  freely  as  formerly,  seemed  to  have  pain  some- 
where, and  would  no  longer  make  an  effort  to  stand  when 
held  upon  his  feet.  There  was  no  swelling  of  the  legs.  The 
nursemaid  was  very  careless,  and  it  was  fearetl  that  at  some 
time  the  baby  had  had  a  fall.  It  wa.s  also  thought  that  the 
baby  might  have  taken  cold  from  a  careless  use  of  damp 
diapers.  Careful  examination  showed  the  right  ankle  tender 
when  the  foot  was  move  passively,  and,  after  a  few  days,  the 
left  limb  also,  at  some  of  the  joints.  The  child  did  not 
move  its  limbs  willingly.  The  upper  extremities  were  never 
affected.  Salicylate  of  cinchdnidin  was  commenced  in 
small  doses,  and  Eskay's  food  discontinued.  Improvement 
within  a  day  or  two  was  very  great.  The  salicylate  was . 
given  only  for  1  or  2  days,  and  then  replaced  by  orange  juice. 
\Vithiu  2  or  3  days  after  orange  juice  bad  been  started  all 
pain  disappeared,  and  the  child  moved  its  limbs  as  freely  as 
it  had  ever  done. 

The  salicylate  may  have  had  an  analgesic  action, 
although  certainly  not  a  curative  one;  but  it  is  very 
possible  that  the  stopping  of  the  Eskay's  food  was  the 
chief  therapeutic  factor.  The  milk  mixture  had  been 
scalded  previously,  and  this  was  not  stopped  later. 

Case  14. — This  case  is  still  another  instance  of  the  mistak- 
ing of  scurvy  for  rheumatism. 


I  was  asked  by  Dr.  F.  B.  Gummey,  of  Gennantown,  to  see 
with  him  a  little  patient  of  his,  who  was  being  treated  un- 
successfully for  rheumatism  in  one  of  the  New  Jersey  sea- 
side resorts.  He  believed  the  disease  to  be  scurvy,  and  had 
advised  antiscorbutic  treatment,  but  the  local  physician  still 
could  not  abandon  his  earlier  diagnosis  of  rheumatism.  On 
July  13  I  saw  the  case  with  both  physicians,  and  concurred 
in  the  diagnosis  of  scurvy.  The  history  and  result  of  the 
examination  were  as  follows  : 

William  F.,  aged  9  months,  had  never  been  ill  pre- 
viously. He  had  always  been  fed  on  a  sterilized  milk- 
and-water  mixture.  About  2  weeks  before  seen  he  devel- 
oped a  widespread  eczematous  eruption,  fever,  pain  on 
movement,  and  shght  redness  of  the  gums.  This  condition 
continued,  with  some  irregularity  of  the  bowels  and  evidence 
of  impaired  digestion.  Except  that  grasping  the  child's 
chest  seemed  sometimes  to  give  pain,  the  suffiering  soon 
centered  itself  in  the  legs,  and  was  intermittent.  Swelling 
of  the  lower  extremities  soon  developed.  There  had  been 
considerable  sweating. 

Examination  showed  an  exceptionally  hearty  and  well- 
developed  child.  The  lower  extremities  were  "edematous, 
especially  the  legs  and  feet.  No  subperiosteal  thickening 
could  be  discovered,  nor  any  distinct  involvement  of  the 
joints.  The  child  was  unwilling  to  move  its  legs,  and  passive 
movement  gave  pain.  The  gums  were  red,  but  not  swollen 
or  actually  purple.  There  were  7  teeth,  the  fontanel  was 
of  normal  size,  and  there  had  been  but  slight  beading  of  the 
ribs.  Orange  juice  and  beef  juice  were  ordered,  and  sterili- 
zation was  stopped.     Recovery  was  prompt. 

In  this  case  it  appears  very  probable  that  the  sterili- 
zation of  the  food  may  have  been  the  cause  of  the  dis- 
ease, yet  this  is  not  certain. 

The  last  2  cases  show  the  existence  of  hematuria  as  a 
prominent  symptom  of  scun-y. 

Case  15. — As  in  Case  6, 1  admit  that  I  failed  to  make  an 
early  diagnosis ;  in  fact,  was  misled  entirely  as  to  the  real 
nature  of  the  malady,  and  even  later  could  not  for  some 
time  make  myself  believe  that  it  was  really  scorbutic.  The 
case  was  a  most  perplexing  one  and  the  possibility  of  scuri-y 
being  present  was  by  no  means  forgotten.  The  history  is  as 
follows : 

Richard  P.,  born  July  22,  1899.  The  child  was  fairly  well 
nourished,  though  decidedly  below  weight  and  having  a 
tendency  to  sour  vomiting.  He  had  been  fed  constantly  on 
Mcllin's  food  and  a  very  fat  milk.  On  November  15,  1899, 
at  the  age  of  4  months,  tie  was  first  put  upon  raw,  laboratory 
percentage  milk,  to  each  bottle  of  which  the  mother  added 
a  teaspoonful  of  Mellin's  food.  The  child  did  well  and  gained 
weight,  the  proportions  of  fat,  sugar,  and  proteid  being  in 
creased  from  time  to  time  as  indicated,  the  fat,  however,  being 
somewhat  low  on  account  of  the  vomiting.  Possibly  due  to 
this  fact,  some  symptoms  of  rickets  developed.  The  symp- 
toms of  rickets  soon  began  to  improve  decidedly  unSer  a 
stronger  diet,  and  early  in  February  the  child  looked  and 
seemed  remarkably  well.  He  was  now  digesting  a  milk 
mixture  of  the  strength  of  fat  3.2.5,  sugar  6,  proteid  1.25. 

On  February  17,  the  baby  being  then  6  months  old  and  in 
excellent  hea'th,  I  was  sent  for  hurriedly  on  accoimt  of  what 
was  supposed  to  be  an  injury  of  the  leit  arm.  The  mother 
strongly  suspected  that  the  nurse  had  hurt  ihe  child  in  some 
way.  The  arm  had  suddenly  bee  me  painful  and  the  child 
would  not  move  it  Examination  showed  no  discoverabli 
cause  for  this.  The  gums  were  examined  and  found  normal. 
By  the  next  day  the  arm  was  entirely  well  and  the  condition 
was  attributed  to  a  slight  wrench  or  similar  cause. 

On  February  27,  10  days  later,  the  baby  became  fretful 
and  seemed  to  be  in  pain,  .although  he  constantly  moved 
his  hands  to  his  ears  and  pressure  about  them  was  painful, 
yet  it  was  observed  that  passive  movements  of  the  legs  also 
gave  pain.  The  guns  appeared  normal.  By  March's,  ear- 
ache had  disappeared  ana  'be  legs  were  clearly  free  from 
pain.  The  child  now  appeared  to  have  pain  in  the  abdomen. 
The  left  knee  and  ankle  had  become  decidedly  edematous 
but  were  not  painful  on  passi>  e  movement.  The  gums  were 
somewhat  swollen  but  not  red.  The  urine  contained  a  small 
amount  of  albumin. 

Again  suspecting  that  I  might  possibly  be  dealing  with 
scurvy,  I  ordered  the  Mellin's  food  to  be  omitted  from  the 


rKEBCABY   2,   1901] 


SCURVY,  NOT  RHEUMATISM 


tTHE  Philadelphia  217 

Medical  JouBSAL  ' 


mixture.  On  the  next  day  a  sharp  bronchitis  with  fever  de- 
veloped. Movements  of  the  legs  caused  no  pain,  and  the 
swelling  of  the  left  leg  was  somewhat  less  The  urine  was 
smoky  in  appearance  and  contained  abundant  albumin  and 
numerous  red  blood-corpuscles,  but  no  easts.  On  the  day 
following,  March  5,  a  minute  patch  of  purplish  discolora- 
tion was  visible  on  the  gums  of  the  lower  central  incisors, 
the  only  teeth.  Some  pain  on  moving  the  legs  had  reap- 
peared." The  diagnosis  of  scurvy  was  now  very  probable,  yet 
it  seemed  possible  that  with  the  severe  bronchitis  there  was 
some  nephritis,  which  accounted  for  the  symptoms.  The 
child  was  given  the  benefit  of  the  doubt,  however,  and  orange 
juice  was  prescribed. 

Up  to  March  8  the  bronchitis  had  continued  severe, 
with  fever  and  rapid  respiration.  The  urine  was  much 
redder  than  a  nephritis  ordinarily  exhibits,  and  there  had 
been  no  casts  found.  Owing  to  indigestion,  orange  juice  was 
stopped  on  this  date,  although  the  diagnosis  of  scurvy 
seemed  now  beyond  question.  By  March  10,  the  urine 
showed  very  little  blood.  Recovery  from  this  time  on  was 
rapid  and  uneventful. 

The  history  of  this  case  and  the  diagnosis  are  of  con- 
siderable interest.  The  first  very  temporary  pain  in  the 
ami  did  not  give  sufficient  ground  for  a  diagnosis  of 
scurvy.  Later,  the  whole  course  of  the  scurvy  was 
marked  by  the  existence  of  the  symptoms  of  earache, 
severe  bronchitis,  and  indigestion,  which  rendered  the 
discovery  of  the  degree  of  pain  in  the  legs  extremely 
difficult.  The  small  purplish  spot  on  the  gums  was 
trivial  and  of  later  development.  In  reality  it  was  the 
hematuria  which  decided  the  diagnosis  in  my  mind, 
and  to  the  examination  of  the  urine  I  was  led  espe- 
cially by  the  presence  of  the  slight  edema. 

Hematuria  is  a  not  infrequent  symptom  of  scurvj', 
and  sometimes,  according  to  Barlow,  the  only  one.  In 
this  case  it  was  the  most  persistent  as  far  as  could  be 
discovered.  The  case  illustrates  very  well  the  intermit- 
tent character  of  the  pain  in  the  legs,  as  it  so  often 
occurs  in  this  disease. 

The  orange  juice  was  given  for  a  very  short  time 
— only  3  days — and  then  withdrawn,  before  the 
symptoms  of  scurvj-  had  disappeared.  I  hesitate  to 
regard  it  as  having  had  any  material  influence  in  the 
cure  of  the  disease.  It  would  appear  more  likely  that 
in  this  case  the  withdrawal  of  the  commercial  food  was 
the  sole  factor  in  the  cure.  It  is  interesting  to  note  that 
the  milk  was  not  cooked  in  any  way  at  any  time. 

Case  16. — This  last  case  was  even  more  puzzling  than  the 
preceding  one.  The  diagnosis  was  based  entirely  on  the 
occurrence  of  a  hematuria  which  resisted  other  treatment, 
but  promptly  and  permanently  ceased  after  the  administra- 
tion of  orange  juice  was  commenced. 

Francis  V.  W.,  aged  5  months  when  first  seen  by  me  in 
November,  1899.  The  child  had  been  fed  in  various 
ways,  including  laboratory  modified  milk,  but  had  not 
thrived,  and  was  a  thin  specimen  of  about  9  pounds  only, 
always  the  subject  of  severe  indigestion.  Careful  modifica- 
tion of  his  milk  with  the  addition  of  barley-water,  still  done 
at  the  laboratory,  changed  this  condition,  and  he  began  and 
continued  a  steady  gain.  Finally  he  reached,  at  about  the 
age  of  9  months,  a  percentage  mixture  of  fat  4,  sugar  7, 
proteid  1  .50 ;  as  large  a  proteid  percentage  as  it  had  been 
possible  to  use  safely,  and  seemingly  sufiicient  for  his  needs. 
Tlie  food  was  always  uncooked. 

At  this  time,  about  March,  1900, 1  found  that  he  was  pass- 
ing ur  ne  of  a  smoky  tint,  which  stained  the  diaper,  and 
which  contained  numerous  blood-cells ;  and  on  inquiry  I 
learned  that  a  number  of  weeks  before  he  had  had  similar 
urine  for  about  a  week,  and  again,  10  days  ago,  for  a  few 
days.     The  baby  seemed  perfectly  well  in  every  way. 

From  now  on  the  blood  in  the  urine  was  constantly  pres- 
ent, and  generally  to  such  an  extent  that  the  color  w"as  dis- 
tinctly red.  The  general  health  began  to  sufler  somewhat, 
the  child  losing  weight,  being  fretful,  and  at  times  seeming 
to  have  pain  on  urination.    This  last,  however,  was  uncer- 


tain. Poultices  were  used  over  the  bladder  with  the  idea 
that  there  might  be  a  cystitis  present.  Then  hydrastis,  and 
later  ergot  were  tried.  Sometimes  opium  was  used,  as  the 
child  was  verj'  restless  at  night  and  seemed  to  be  suffering. 
Later,  the  evidences  of  pain  disappeared,  but  no  treatment 
had  the  slightest  influence  on  the  hematuria,  which  con- 
tinued unabated.  There  was  never  any  aflection  of  the  gums 
(there  were  no  teeth),  nor  any  swelling  or  discoverable  pain 
in  the  limbs. 

The  hematuria  continued  for  somewhat  over  a  month, 
when  I  concluded  that  it  was  probably  scorbutic  in  origin. 
Orange  juice  was  started  with  astonishing  results.  In  a  few 
days  the  hematuria  stopped  completely  and  permanently, 
the  treatment  with  orange  juice  being  meanwhile  persisted 
in.  The  return  to  good  general  health  was  rapid,  and  in- 
crease in  weight  recommenced. 

I  have  already  called  attention  to  the  fact  stated  by 
Barlow,  that  hematuria  is  sometimes  the  sole  symptom 
of  scurvy.  This  justified  the  diagnosis  of  scurvy  in  the 
case  just  reported.  It  is  of  course  possible  that  the 
bleeding  may  have  been  due  to  a  calculus  or  other 
cause ;  but  the  prompt  cessation  of  the  hematuria  and 
all  other  sj'mptoms  with  the  beginning  of  orange-juice 
treatment  was  almost  too  startling  to  be  a  mere  coinci- 
dence. 

For  the  development  of  the  disease  in  this  case,  I  see 
absolutely  no  cause  unless  it  be  the  use  of  a  too  low 
percentage  of  proteid  in  the  mixture, — a  thing  which 
could  not  be  avoided,  and  which  was  not  changed  at  all 
until  after  the  scorbutic  symptoms  had  disappeared. 

It  is  not  my  purpose  to  enter  into  a  detailed  descrip- 
tion of  the  features  of  scur\\v  or  even  to  analyze  the  cases 
I  have  recorded.  The  striking  characteristics  of  each 
have  already  been  emphasized.  There  are  only  two  or 
three  points  to  which  I  would  like  to  draw  special  at- 
tention. 

It  is  evident  that  although  the  cause  of  scurvy  seems 
clearly  to  be  dietetic,  yet  there  is  no  one  dietetic  fault 
which  can  be  held  responsible.  This  is  the  common  ex- 
perience with  the  disease,  and  the  cases  here  detailed  are 
but  additional  proof  of  it.  Oftenest  we  find  that  scor- 
butic children  have  been  fed  upon  commercial  foods, 
and  there  seems  every  reason  to  believe  that  these  con- 
stitute a  powerful  etiologic  factor.  The  collective  studies 
of  the  American  Pediatric  Society,  in  which,  as  one  of 
the  committee,  I  was  greatly  interested  a  few  years  ago, 
put  this  statement  beyond  question.  In  at  least  one  of 
the  cases  reported  here  the  simple  omission  of  a  pat- 
ented food  from  the  dietary  was  followed  by  disappear- 
ance of  scurvy. 

There  are  cases  on  record  in  which  the  sterilization  of 
milk  has  seemed  to  produce  the  disease.  In  my  own 
experience  this  is  not  a  prominent  factor,  and  I  am 
convinced  that  its  power  is  overrated.  I  would  caU 
attention  to  the  number  of  cases  in  my  Hst  in  which  no 
heating  at  all  was  employed.  In  none  of  the  16  is 
there  any  absolute  proof  of  the  harmful  action  of  heat. 
Yet  it  is  to  be  suspected  in  some  of  them ;  and  that 
cooking  of  the  food  is  capable  of  producing  scurvj' 
seems  to  be  beyond  question  in  some  reported  cases. 

In  some  of  my  cases  it  is  probable  that  the  fault  lay 
in  the  lack  of  a  proper  proportion  in  the  different  ele- 
ments of  the  mixture ;  oftenest  a  too  low  percentage  of 
proteid  ;  but  in  many  cases  of  scurvy  we  are  entire!}' 
unable  to  discover  just  what  the  factor  is.  It  may  read- 
ily be— in  fact  it  must  be — that  it  varies  with  different 
children. 

With  regard  to  symptoms,  it  is  most  important  to 
remember  that  the  affection  of  the  gums  is  generally 
not  the  earUest  symptom  and  that  the  disease  may  exist 


218 


Thk  Philadelphia"] 
Mbdical  Journal  J 


WHEY-CREAM  MODIFICATIONS  IN  INFANT  FEEDING 


[FeBRBABV  Z,    1801 


without  it.  Indeed,  it  is  usually  absent  if  no  teeth  have 
appeared.  Pain  somewhere,  generally  in  the  legs,  is 
oftenest  first  seen,  and  it  is  due  to  this  fact  that  so  many 
mistakes  in  diagnosis  are  made.  So  many  of  my  cases 
bear  out  the  common  experience  that  rheumatism,  more 
than  any  other  disease,  is  erroneously  diagnosticated 
when  scurvy  is  really  the  condition.  Yet  we  may  occa- 
sionally have  scurvy  without  pain  being  a  prominent 
feature'.  Indeed,  although  the  diagnosis  is  easy  in  typi- 
cal and  well-developed  cases,  and  when  one  has  the  pos- 
sibility of  the  presence  of  the  disease  in  mind,  it  is  by 
no  means  so  easy  in  incipient  or  atypical  cases.  One 
should  be  far  from  regarding  the  failure  to  make  a  diag- 
nosis as  a  reproach  to  any  physician. 

Treatment  of  the  disease  is  most  simple,  as  my  case 
histories  and  the  general  experience  with  the  disease 
show.  A  proper  alteration  of  the  diet  and,  even  with- 
out this,  the  administration  of  fresh  fruit  juice,  is  suffi- 
cient to  work  a  cure  which  seems  almost  miraculous. 
Only  in  cases  where  debility  has  grown  extreme,  or 
where  intercurrent  maladies  exist  which  possibly  inter- 
fere with  treatment,  need  we  fear  a  fatal  result.  I  have 
had  one  fatal  case,  not  included  in  this  list  of  histories, 
in  which  the  inanition  from  persistent  chronic  entero- 
colitis was  so  great  that  the  child  died  ; — not,  however, 
of  scurvy. 

That  several  of  the  cases  of  my  list  recovered 
promptly  on  the  use  of  fruit  juices  without  any  change 
of  diet  is  a  noteworthy  fact,  since  in  the  great  majority 
of  reported  cases,  at  least  in  this  country,  some  altera- 
tion of  the  usual  diet  has  also  been  made.  This  is  a 
warning  against  too  quickly  altering  the  food  which  for 
certain  reasons  we  have  deemed  Ijest,  simply  on  the 
ground  that  scurvy  has  developed.  A  curable  scurvy  is 
much  to  be  preferred  to  a  possibly  fatal  diarrhea  or  gas- 
tritis, the  result  of  a  diet  which  may  precipitate  these. 
So,  too,  with  regard  to  the  heating  of  milk.  Even  if  we 
suspect  that  such  heating  is  the  cause  of  scurvy  in  a 
certain  case,  we  should  not  hastily  abandon  it  if  we  see 
any  good  reason  for  continuing  it.  Where  raw  milk  can 
be  used  safely  it  is  to  be  preferred. 


WHEY-CREAM  MODIFICATIONS  IN  INFANT  FEEDING. 
3y  franklin  W.  white,   M.D., 

of  Boston,  Mass., 

Assistant  in  the  Theory  and  Practice  of  Physic,  Harvard  Medical  School ;  Assist- 
ant Visiting  Physician  to  Long  island  Hospital  ;  Assistant  Physician  ^ 
to  Infanta'  Hospital, 

AND 

MAYNARD  LADD,  M.D., 

Assistant   in  Physiological   Chemistry  and  in  Diseases  of  Children,  Harvard 
Medical  School. 

The  scientific  modification  of  milk  in  the  substitute 
feeding  of  infants,  like  most  advances  in  medicine,  has 
been  in  the  nature  of  an  evolution.  The  simple  dilu- 
tion of  milk  with  plain  water,  lime  water,  cereal  waters, 
or  whey,  without  reference  to  the  resulting  percentages 
of  fat,  sugar,  and  proteids,  has  been  generally  acknowl- 
edged to  fall  far  short  of  supplying  a  proper  food  for  in- 
fants of  different  ages  and  development,  and  men 
everywhere  have  tried  to  improve  upon  the  older 
methods.  Frankland,  as  far  back  as  1854,  and  later 
Monti,  Biedert,  Jacobi,  and  others  have  all  contributed 
to  the  study  of  the  subject,  and  to  them  we  owe  the  in- 
spiration of  many  of  our  ideas. 

The  first  step  of  importance  in  the  advancement  of 


infant  feeding  in  this  country  was  the  work  of  Dr.  J.  F. 
Meigs  and  his  son,  Dr.  A.  V.  Meigs,  of  Philadelphia, 
many  years  ago.  The  elder  Meigs  had  observed  in 
a  large  clinical  experience  that  certain  combinations  of 
milk,  cream,  lime-water,  milk-sugar,  and  water,  seemed 
to  agree  with  the  average  infant.  The  younger  Meigs 
undertook  to  estabhsh  a  scientific  explanation  for  the 
successful  results  of  his  father's  empirical  formula.  As 
a  result  of  his  investigations  he  found  that  the  Meigs 
mixture  corresponded  closely  to  his  analysis  of  human 
milk,  esi^ecially  in  regard  to  the  percentage  of  proteids. 
He  then  improved  the  original  formula  in  certain  details 
so  that  the  mixtures  calculated  from  it  were  estimated 
to  yield  a  milk  containing  3.50  %  of  fat,  8.66  %  of  sugar. 
1.21%  of  proteids,  0.25%  of  ash,  and  88.25%  of  water. 
This  was  a  distinct  advance  over  the  old  methods  of 
simple  dilution  of  milk,  as  it  brought  to  the  attention 
of  the  medical  profession  three  verj'  important  points  in 
connection  with  the  subject  of  infant  feeding :  First, 
that  simple  dilutions  of  milk  were  irrational  in  that  all 
the  ingredients  were  reduced  alike ;  second,  that  a  milk 
should  be  modified  to  resemble  human  milk ;  and  third, 
that  the  Meigs  formula  expressed  for  the  first  time, 
though  in  a  Umited  way,  the  idea  of  a  percentage  basis 
in  the  modification  of  milk. 

The  development  of  Meigs'  principle  of  feeding  was 
worked  out  by  Dr.  T.  M.  Rotch,  of  Boston,  who,  in  1890, 
made  the  pertinent  suggestion  that  all  modifications  of 
milk  should  be  expressed  in  percentages  of  fat.  sugar, 
and  proteids,  and  that  prescriptions  for  the  same  should 
be  written  calhng  for  precise  proportions  of  the  various 
ingredients ;  in  other  words,  he  propounded  the  principle 
of  thinking  and  writing  in  percentages.  This  idea  led 
to  the  establishment,  in  1892,  of  the  Walker-Gordon 
milk  laboratories,  under  the  scientific  direction  of  Dr. 
Rotch,  where,  in  accordance  with  his  ideas,  milk  could 
be  obtained  in  a  pure  condition,  and  of  staple  composi- 
tion, and  where  it  could  be  accurately  modified  and 
dispensed.  This  system  of  percentage  modification  was 
developed  and  perfected  by  Mr.  George  E.  Gordon  and 
Mr.  J.  H.  Waterhouse,  under  the  direction  of  Dr.  Rotch, 
until  the  modification  of  the  various  ingredients  of  milk 
has  been  elaborated  to  a  degree  not  conceived  of  in  the 
beginning,  so  that  at  present  almost  any  combination  of 
fat,  sugar,  and  proteids  can  be  obtained. 

The  work  up  to  this  point  has  been  satisfactory  so  &t 
as  the  modification  of  the  percentages  of  fat,  sugar  and 
total  proteids  are  concerned, but  cows  milk  differs  from 
human  milk  in  the  proportions  of  the  two  kinds  of 
proteids,  and  a  modification  that  simply  reduces  the  total 
proteids  as  a  whole  without  reference  to  their  relative 
proportions  has  not  gone  as  far  as  our  knowledge  of  the 
chemistry  of  milk  allows. 

Koenig's  analysis  of  the  proteids  of  cows  milk  and 
human  milk  is  as  follows.  No  attempt  is  made  to  dis- 
tinguish between  lactalbumin,  lactoglobulin  and  other 
proteids  possibly  present  in  whey,  and  we  in  our  paper 
shall  include  them  all  under  the  term  "  whey-proteids." 

Cow's  Milk.  Bunum  Milk. 

Percent.  Percent. 

Cnscinogen 2.88  0.59 

Whey  proteids 0.53  1.25 

Total 8.41  1  S2 

According  to  these  figures  cow's  milk  contains  twice 
as  much  total  proteids  ;\s  does  human  milk,  and  we 
also  see  that,  of  the  total  proteids  in  cow's  milk,  ajiprox- 
imately  ^   is  caseinogen   and  J^   is  whey-proteid.     In 


Februakt  2,  1901] 


WHEY-CREAM  MODIFICATIONS  IN  INFANT  FEEDING 


rxH 
Lm 


The  Philadelphia 
edical  joubnal 


219 


human  milk,  on  the  other  hand,  we  see  that  approxi- 
mately f  is  whey-proteid  and  ^  is  caseinogen. 

If,  then,  we  prescribe  an  ordinary  modified  milk  with 
a  total  proteid  of  1.50%  (the  percentage  of  average 
human  milk),  we  give  0.25%  of  whey-proteid  and  too 
much  caseinogen,  namely,  1.25%.  If  we  attempt  to 
reduce  the  caseinogen  to  0.50%,  the  amount  present  in 
human  milk,  we  get  too  low  a  total  proteid.  It  seems 
reasonable  to  suppose  that  the  disturbance  in  digestion 
in  infants  who  are  being  fed  on  modified  milk  is  due 
not  so  much  to  the  chemical  differences  of  the  proteids 
in  cow's  milk  and  human  milk,  as  to  the  excessive  pro- 
portion of  caseinogen  to  whey-proteids.  Whether  this 
be  true  or  not,  it  is  a  generally  accepted  principle  that 
in  substitute-feeding  we  should  imitate  the  composition 
of  human  milk  as  closely  as  possible. 

Backhaus'  has  attempted  to  modify  the  proportion  of 
caseinogen  and  whey-proteids  in  cow's  milk  so  as  to 
make  it  resemble  that  which  occurs  in  human  milk. 
His  method,  however,  involves  the  partial  predigestion 
of  a  certain  amount  of  caseinogen  by  trypsin  in  order 
to  raise  the  percentage  of  soluble  proteids  in  the  whey. 
This  whey  contains  in  addition  to  ordinary  whey-pro- 
teids 0.5%  of  peptones.  He  gives  the  prescriptions  for 
three  mixtures,  in  only  one  of  which  is  there  any  at- 
tempt to  make  the  proportion  of  caseinogen  and  whey 
proteid  resemble  that  of  human  milk. 

The  credit  of  calling  the  attention  of  the  medical  pro- 
fession in  this  country  to  the  insuflficient  method  of  deal- 
ing with  the  proteids  in  milk  modification  belongs  to  Dr. 
Thompson  S.  Westcott,  of  Philadelphia,  who,  in  a  mono- 
graph on  "  The  Scientific  Modification  of  Milk,"  pubhshed 
in  the  International  Clinics,  Vol.  Ill,  Tenth  Series,  drew 
attention  to  the  differences  in  the  relative  proportions  of 
caseinogen  and  lactalbumin  in  human  milk  and  in  cow's 
milk.  Dr.  Westcott  gives  in  his  paper  certain  general 
formulae  for  the  calculation  of  whey  and  cream  mix- 
tures by  which  the  total  proteids  may  be  raised  without 
increasing  the  percentages  of  caseinogen,  by  the  addi- 
tion of  whey,  in  place  of  water,  to  creams  of  varying 
strength. 

Koenig's  analysis  of  whey  is.  as  follows  : 

Per  cent.  Per  cent. 

Proteids 0.86  Salts 0.65 

Fat 0.32  Water 93.38 

Sugar 0  49 

It  is  obvious  that  it  will  be  impossible  to  raise  the 
percentage  of  whey-proteids  in  a  mixture  of  cream  and 
whey  above  the  percentage  in  the  whey  itself,  and  if  this 
analysis  applies  to  all  specimens  of  whey  the  percentage 
in  the  whey-cream  mixture  will  be  lower  than  0.86%, 
probably  not  exceeding  0.75%.  If  caseinogen  be  now 
added  by  means  of  cream  and  fat-free  milk  in  such  a 
way  as  to  contribute  an  additional  0.50%  of  proteids, 
we  shall  have  a  mixture  with  a  total  proteid  of  1.25%, 
consisting  approximately  of  f  whey-proteids  and  ^ 
caseinogen,  the  proportion  which  occurs  in  human  milk. 
Higher  total  proteids  can  be  obtained  by  increasing  the 
percentage  of  caseinogen  by  the  addition  of  fat-free 
milk,  but  each  increase  necessarily  alters  the  relation  of 
the  two  proteids,  so  that  it  approaches  that  which  occurs 
in  cow's  milk. 

A  mixture' containing  0.75%  of  whey-proteids  and 
0.50%  of  caseinogen  is  eminently  suited  for  an  infant 
in  the  first  two  or  three  months  of  life  and  for  an  older 
infant  with   disturbed   digestion   requiring   weak  and 

'  Allgemeine  med.  Cenl.  Zeitiing,  1896,  vol.  65,  pp.  861-873. 


easily  assimilable  proteids.  It  is,  however,  too  low  a 
percentage  of  total  proteids  to  carry  an  infant  through- 
out the  nursing  period,  and  as  the  child  grows  older  the 
caseinogen  can  be  increased  until  the  total  proteids  are 
the  same  in  proportion  as  in  cow's  milk.  In  the  latter 
months  of  the  nursing  period  the  management  of  the 
proteids  is  less  troublesome  and  the  ordinary  modifica- 
tions, when  intelligently  used,  rarely  fail  to  give  satis- 
factory results. 

Westcott's  formulas  and  calculations  are  based  on  the 
above  analysis  of  Koenig.  On  referring  to  Bulletin  28, 
of  the  United  States  Department  of  Agriculture,  we  find 
that  the  average  of  a  large  number  of  specimens  of  whey 
as  purchased  yielded  a  whey-proteid  of  one  percent, 
(1.00%).  It  is  evident  therefore  that  there  is  some 
variation  in  the  whey-proteids  in  milk  from  different 
sources.  It  was  important  to  know  whether  the  per- 
centage of  whey-proteids  in  the  whey  obtained  by  us 
from  milk  was  not  higher  in  percent  than  that  given  by 
Koenig  and  on  which  Westcott  bases  his  formulas  and 
tables.  It  also  was  important  to  perfect  this  method 
so  that  physicians  might  send  to  the  laboratory  pre- 
scriptions for  definite  percentages  of  whey-proteids, 
caseinogen,  fat  and  sugar.  Finally  it  did  not  seem  suf- 
ficient to  accept  the  method  on  mere  theoretical  con- 
siderations, and  we  therefore  undertook,  at  the  sugges- 
tion of  Dr.  Rotch,  to  compare  the  coagulabihty,  digesti- 
bility and  emulsion  of  whey-cream  modifications  with 
other  forms  of  modified  milk.  In  carrying  out  these  ex- 
periments we  have  utilized  the  conveniences  of  the  milk 
laboratory  where  the  whey  and  various  modifications 
have  been  prepared  under  our  direction,  and  we  wish  to 
acknowledge  our  indebtedness  to  Mr.  George  H.  Walker 
and  Mr.  J.  H.  Waterhouse  for  the  many  courtesies  and 
aids  accorded  us. 

A  preliminary  report  of  the  following  experiments 
was  included  in  a  paper  on  "  Emulsions,  Cereals  and 
Proteids,"  which  was  read  by  Dr.  Rotch  before  the  New 
York  Academy  of  Medicine  in  the  Section  on  Pediatrics 
on  October  18,  1900. 

Method  of  Making  Whey. — The  whey  is  made  by  coagulat- 
ing fat-free  milk  with  liquid  rennet;  about  1  dram  of  rennet 
being  added  to  10  quarts  of  milk.  The  fat -free  milk  was 
made  by  separating  the  fat  of  whole  milk  by  the  centrifugal 
separator.  It  is  more  convenient  and  economical  to  make 
the  whey  in  this  manner  than  from  whole  milk.  The  milk 
was  kept  at  a  temperature  of  30°  C,  till  the  curd  formed 
and  the  whey  was  then  strained  oS  through  muslin  and  ab- 
sorbent cotton.  In  further  preparing  the  whey  for  use  in 
milk  mixtures,  it  was  necessary  to  heat  it  to  a  temperature 
which  would  destroy  the  rennet  which  had  been  added,  with- 
out precipitating  the  whey-proteids.  The  rennet  enzyme, 
according  to  Hammarsten,^  is  destroyed  by  a  temperature  of 
60  to  70°  C,  more  or  less  quickly  according  to  the  duration 
of  heating  and  tlie  concentration  of  the  solution.  Lactal- 
bumin, according  to  Hanimarbten,  is  precipitated  by  a  tem- 
perature of  72°  to  84°  C,  so  it  seemed  possible  to  destroy  the 
rennet  by  heat  without  coagulating  the  whey-proteids. 

After  experimenting  with  different  degrees  and  duration  of 
heat  we  found  that  the  most  convenient  method  of  destroy- 
ing the  rennet  in  whey  was  by  heating  it  rapidly  to  65°  C. 
We  also  found  that  when  clear  fresh  whey  was  gradually 
heated,  the  first  slight  milkiness  in  the  fluid  indicating  a 
precipitation  of  whey-proteids  did  not  occur,  until  a  tem- 
perature of  70°  C.  was  reached,  and  that  no  considerable 
coagulation  took  place  till  the  fluid  was  heated  to  over  80° 
C.  The  temperature  recommended  by  Westcott,  76.5°  C  ,  is 
too  high.  The  rennet  is  destroyed  at  a  temperature  of  5°  C. 
lower,  so  that  the  higher  temperature  is  unnecessary  and 
has  the  objection  of  coagulating  some  of  the  whey-proteids. 
This  coagulation  temperature  was  not  affected  by  changing 


'  Textbook  of  Physiological  Chemistry,  1900,  p.  Tn. 


220 


THB  PHTLADKUBIi"! 
MSDICAI.  JOOKSAL  J 


WHEY-CREAM  MODIFICATIONS  IN  INFANT  FEEDING 


[Febsca^bt  2    1W.I 


the  reaction  of  the  whey  from  slightly  acid  to  slightly  alka- 
line by  the  addition  of  lime-water. 

It  is  therefore  evident  that  by  heating  the  whey  to 
65°  C.  before  mixing  it  with  the  cream  for  infant  feed- 
ing, we  accompHsh  the  desired  object  of  destroying  the 
rennet,  and  preventing  the  coagulation  of  the  cream, 
without  precipitating  the  whey-proteids. 

Analysis  of  Whey. — Various  analyses  were  made  by  Kjel- 
dahl's  method  to  determine  the  amount  of  soluble  proteid 
in  the  original  whey.  Specimens  of  whev  were  also  heated 
to  different  temperatures,  65°,  68°,  75°  and"  SO'  C,  filtered,  and 
then  analyzed  to  find  out  how  much  proteid  had  been  coag- 
ulated at  these  temperatures. 

It  was  also  noted  that  in  unheated  whey  which  stood  for 
24  hours  there  usually  appeared  a  ven,'  slight  flocculent  pre- 
cipitate, but  it  was  shown  by  analysis  "that  this  precipitation 
did  not  affect  the  amount  of  proteid  in  the  whey  apprecia- 
bly. Analysis  of  six  specimens  of  whey  give  the  following 
percent  of  proteid;  0.99, 1.08,  1.03,  1.01, 100,  1.01,  the  aver- 
age being  1  02  % . 

The  following  figures  show  the  amount  of  proteid  left  in  a 
specimen  of  whey  after  heating  it  to  the  given  temperatures 
and  filtering : 

Unheated  whey 1.08% 

Heated  to  65°  C.  and  filtered 1.04 

"  68°  C.    "         "      0.98 

"  75°C.    "         "      0.97 

"  80°  C.    "         "      0.95 

We  see  that  heating  the  whey  within  the  Umits  given, 
produced  only  a  ver}'  slight  and  gradual  coagulation  of 
the  proteid.  The  analyses  of  our  specimens  of  unheated 
whey  agree  with  those  given  by  the  United  States  De- 
partment of  Agriculture  in  the  amount  of  proteid  pres- 
ent, practically  1  % ,  this  being  somewhat  higher  than 
the  amount  found  by  Koenig,  which  is  0.86  fc  ■ 

Westcott  has  based  his  formula  for  cream  and  whey 
mixtures  on  Koenig's  analysis  of  0.865^  proteid  in 
whey  ;  this  is  probably  too  low  an  estimate  for  American 
milk,  as  show  by  the  analysis  of  the  United  States  De- 
partment of  Agriculture  and  by  our  own,  and  therefore 
the  amount  of  total  proteid  obtained  by  mixing  cream 
and  whey,  according  to  Westcott's  formula,  is  probably 
actually  higher  than  given  in  his  tables. 

Analysis  of  Whole  Milk. — Several  analyses  by  Kjeldahl's 
method  were  made  to  estimate  the  relative  proportion  of 
caseinogen  and  whey  proteid  in  whole  milk,  in  order  to  de- 
termine this  relative  proportion  in  the  cream  used  in  the 
whey-cream  mixtures.  The  average  amount  of  total  proteid 
in  whole  milk  was  3.84%  :  the  average  amount  of  whey-pro- 
teids was  0  90%,  or  approximately  i  of  the  total  proteids : 
the  average  amount  of  caseinogen  was  2,94%,  or  approxi- 
mately J  of  the  total  proteids, 

C0MBIX.A.T10XS  Possible  ix  Whey-Cre.a.m  Modificatioxs. 

By  the  use  of  32%  cream,  fat- free  milk,  and  a  very 
concentrated  solution  of  milk-sugar  it  was  found  pos- 
sible on  the  basis  of  our  analysis  of  whole  milk  and 
whey  to  obtain  whey-cream  mixtures  with  a  maximum 
of  0,90%  of  whey-proteids  in  combination  with  per- 
centages of  caseinogen  varjnng  from  0.25%  to  1.00%, 
giving  total  proteids  of  troni  1.15%  to  1.90%.  A  32% 
cream  must  be  used  in  order  to  obtain  the  highest  per- 
centages of  fat  with  the  lowest  percentages  of  caseinogen. 
A  Umited  number  of  combinations  can  be  obtained  with 
creams  containing  less  fat,  as  shown  by  Westcott. 

The  precise  prescriptions  of  fat,  whey-proteids,  casein- 
ogen and  sugar  which  are  now  possible  are  given  in  the 
following  table,  the  entire  credit  of  which  belongs  to  Mr, 
J,  H.  Waterhouse,  who  made  the  mathematical  calcula- 
tions for  us  and   has  introduced  the  process  into   the 


Boston  milk-laboratory.  The  extension  of  the  S3rBtein 
to  the  other  laboratories  of  the  Walker-Gordon  com- 
pany throughout  the  country  will  shortly  be  accom- 
plished. 


Fat, 

Whey-proteid. 

Casein-         < 
ogen. 

Fat 

Whey-protdd. 

ogoi. 

1. 

.50 

.25 

2.50 

.90 

.60 

1. 

.7i 

.25 

2.50 

.75 

.75 

1. 

.90 

.25 

2.50 

.90 

.75 

1. 

.50 

.50 

2.50 

.90 

l.M 

1. 

.75 

.50 

2.50 

.30 

.25 

1. 

.90 

.50 

2.50 

.75 

.25 

I. 

.50 

.60 

3. 

.90 

.IS 

I. 

.75 

.60 

3. 

,■50 

.30 

1. 

.90 

.60 

3. 

.73 

.50 

1. 

.To 

.15 

3. 

.90 

.30 

1. 

.90 

.75 

3. 

.50 

.60 

1. 

.90 

1.00 

3. 

.75 

JB» 

1.50 

..w 

.23 

3. 

.90 

M 

1.50 

.7.5 

.25 

3. 

.75 

.76 

1.50 

.9') 

.25 

3. 

.90 

.76 

1.50 

.50 

.50 

3. 

.90 

1,00 

1.50 

.75 

,50 

3. 

.50 

.25 

1.50 

.90 

.50 

3. 

.75 

.25 

1.50 

..10 

.60 

3.30 

.90 

.25 

1.50 

.75 

.M 

350 

.50 

.» 

1.50 

.90 

.60 

3.50 

.75 

.30 

1.50 

.75 

.75 

3.50 

.90 

.56 

1.50 

90 

.75 

3.30 

.30 

.60 

1.50 

.90 

100 

3.50 

.75 

.SO 

2. 

.50 

.25 

3.30 

.90 

M 

2. 

.75 

.25 

3.50 

.73 

.75 

2. 

.90 

.25 

350 

.90 

.75 

2. 

.50 

.50 

3.50 

.90 

LOO 

2 

.75 

.50 

350 

.51 

.69 

2. 

.90 

.50 

3.30 

.73 

.60 

2. 

.50 

.60 

4. 

.<K) 

.60 

2. 

.75 

.60 

4. 

.75 

.75 

2. 

.90 

.60 

4. 

.90 

.75 

o_ 

.75 

.75 

4. 

.93 

1.00 

2. 

.90 

.75 

4. 

.50 

.S3 

2. 

.90 

1.00 

4. 

.75 

.25 

2.50 

.5") 

.25 

4. 

.90 

.K 

2  5-1 

.75 

.25 

4. 

.50 

JO 

2.50 

90 

.25 

4 

.75 

.30 

2.50 

.50 

.50 

4. 

.90 

.SO 

250 

.75 

.50 

4. 

.30 

.60 

2.50 

.90 

.50 

4. 

.75 

.60 

Aaj  per  cent,  of  sugar  from  4  to  7  mav  be  obtained  with  anr  of  the  above 
combinations. 

EmL'LSIOXS. 

Our  experimental  studies  were  first  directed  to  a  de- 
termination of  the  emulsion  of  whey-cream  mixtures  in 
comparison  with  other  modifications  of  mUk,  in  test- 
tubes  and  in  a  dog  with  an  artificial  gastric  fistula. 

We  compared  the  emulsion  of  whey-cream  mixtures 
with  that  of  plain  cow's  milk,  and  with  ordinary  modified 
milk  made  in  one  case  from  16%  gravity  cream,  in  an- 
other from  16%  centrifugal  cream.  Each  mixture  con- 
tained 3.50  %o  of  fat,  e.OOVf  of  sugar,  and  1.00%  of  total 
proteids ;  the  latter  in  the  whey  mixture  consisted  of 
0.25  %  of  caseinogen  and  0.75  %  of  whey  proteids.  In 
one  series.  5  %  of  lime-water  was  added  to  each  mixture 
and  one  portion  heated  to  75°  C.  and  another  portion 
was  not  heated.  In  a  second  series  the  mixtures  were 
put  up  without  lime-water,  and  one  portion  was  heated 
to  75°  C.  and  another  was  not  heated. 

The  tubes  prepared  in  this  manner  were  delivered  to 
us  at  once,  and  after  being  warmed  and  gently  naixed, 
were  examined  with  a  magnificjition  of  625  diameters. 
The  emulsions  in  all  the  specimens  were  uniform  and 
practically  could  not  be  distinguished  one  from  another. 
A  repetition  of  the  experiment  confirmed  our  obser- 
vations. We  therefore  concluded  that  whey  mixtures, 
plain  milk,  gravity  cream  mixtures,  and  centrifugal 
cream  mixtures  were  essentially  the  same  in  their  emul- 
sion, and  that  neither  the  presence  nor  absence  of  lime- 
water,  the  application  or  non  application  of  heat  for  pas- 
teurization, had  any  influence  upon  the  emulsion. 

We  repeated  the  experiments,  using  the  same  mixtures, 
but  subjecting  them  to  the  influence  of  transportation. 
The  milk  was  carted  about  the  city  for  eight  hours  .and 
then  examined.     No  disturbance  in  the  emulsion  was 


Fkbrcabt  2,  1901] 


WHEY-CREAM  MODIFICATIONS  IN  INFANT  FEEDINCi 


["Thk  Philadelphia 
L  Mkdical  Journal 


221 


noticed  either  in  the  gross  appearance  or  microscopically. 
The  unopened  bottles  after  standing  36  hours  in  the  room- 
temperature  were  perfectly  sweet. 

We  had,  however,  noticed,  as  many  others  have  done, 
that  under  certain  conditions  large,  highly-refracting 
globules  in  the  form  of  a  scum  were  sometimes  seen 
floating  upon  the  surface  of  the  milk  put  up  at  the  labor- 
atory. These  we  analyzed  and  found  to  consist  princi- 
pally of  fat,  indicating  that  the  emulsion  had  l)een  dis- 
turbed. Townsend*  and  others  have  maintained  that 
the  use  of  centrifugal  cream  combined  with  transporta- 
tion was  the  cause  of  this  disturbance.  It  is  clear  from 
the  above  experiment  that  this  explanation  cannot  be 
accepted. 

The  experiment  was  again  repeated  and  the  milk  ex- 
amined with  the  same  result.  The  bottles  were  then 
allowed  to  stand  in  a  comparatively  warm  place  in  a 
kitchen.  Twenty-four  houre  later  only  the  unheated 
bottles  had  soured,  the  remainder  were  sweet  and  none 
of  them  showed  the  scum  of  the  separated  fat-globules. 
We  concluded  from  these  facts  that  transportation  alone 
was  not  sufficient  to  disturb  the  emulsion. 

Finally  we  tried  the  influence  of  heat  and  transporta- 
tion combined.  The  same  series  of  milk  was  used  again. 
The  tubes  were  placed  in  a  box.  the  central  compart- 
ment of  which  was  kept  filled  with  hot  water,  and  were 
carted  about  the  city  for  eight  hours.  At  the  end  of 
that  time  each  specimen  showed  the  scum  of  fat -globules. 
A  second  attempt  failed  to  produce  this  disturbance,  but 
on  investigation  we  found  that  the  hot-water  tank  had 
been  filled  but  once  and  that  owing  to  the  cold  weather 
which  prevailed  the  temperature  within  the  box  had  not 
been  maintained.  A  third  attempt  confirmed  our  first 
results,  and  we  therefore  concluded  that  it  is  the  combi- 
nation of  heat  and  transportation  which  produces  the 
change  in  the  emulsion  irrespective  of  the  character  of  the 
modified  milk.  It  is  also  e\adent  from  our  failure  in  the 
second  attempt  that  considerable  and  prolonged  heat  is 
necessary,  a  condition  which  prevails  only  in  the  hot 
days  of  summer.  It  is  in  such  weather,  moreover,  that 
we  have  most  frequently  observed  the  presence  of  the 
fat  on  the  surface  of  the  milk.  This  disturbance  of  the 
emulsion  can  easih'  be  avoided  by  keeping  the  milk  cool 
during  transportation  in  hot  weather. 

To  determine  whether  any  difference  could  be  found 
in  the  emulsion  of  graNntj'  cream  mixtures  and  centri- 
fugal cream  mixtures  during  actual  gastric  digestion 
we  used  two  mixtures  of  3.50%  fat,  6.00%  sugar  and 
1.00%  proteids;  one  of  these  was  made  from  gra\'ity 
cream  and  one  from  centrifugal  cream.  Each  con- 
tained 5%  of  lime-water  and  was  heated  to  69°C.  The 
milks  were  fed  to  the  dog  at  different  tunes  and  with- 
drawn by  means  of  the  fistula  at  the  end  of  10  minutes. 
The  gastric  contents  were  examined  and  no  essential 
difference  in  emulsion  was  found. 

Coagulability. 

1.  Expenments  in  Test-Tubes. — The  character  of  the 
coagulum  yielded  by  whey-mixtures  in  comparison 
with  various  cream-mixtures,  and  barley-water  mixtures, 
was  determined  in  test-tubes,  and  the  results  controlled 
by  animal  experiments. 

The  mixtures  contained  for  the  m.ost  part,  3.50%  of 
fat,  6.00%  of  milk  sugar,  1.00%  of  proteid. 

In  order  to  determine  whether  the  character  of  the 
coagulum  was  influenced  by  the  kind  of  cream  used  in 

*  Boston  Med,  and  Surg,  Journal,  1900,  Tol.  cxliii,  p.  363. 


making  the  mixture,  or  by  the  degree  of  alkalinity,  or 
by  the  heat  used  in  pasteurizing,  some  of  the  mixtures 
were  made  up  with  centrifugal  cream,  and  others  with 
gravity  cream,  some  with  5%  of  lime-water,  others  with 
no  lime-water,  some  specimens  were  pasteurized  at  T5°C. 
while  others  remained  unheated. 

The  ordinary  3.50 — 6.00 — 1.00  mixtures  were  made 
up  in  the  following  proportions,  for  20  ounces : 

16%  gravity  or  centrifugal  cream  4J  ounces. 

Skimmed  milk 1  ounce. 

Water 14*  ounces. 

Milk  sugar 1  ounce. 

The  3.50—6.00—1.00  whey-mixtures  in  which  0.75% 
of  the  proteid  was  whey  proteid,  and  0.25  %  was  case- 
inogen  were  made  in  the  following  proportions  for  20 
ounces : 

32%  cream 2J  ounces. 

Lime-water  1  ounce. 

Whev 16i  ounces. 

Milk" sugar  (dry)    1  ounce. 

The  barley-water  mixtures  were  made  by  replacing 
10  ounces  of  the  water  in  20  ounces  of  ordinary  3.50 — 
6.00 — 1.00  mixtures  with  barley  water,  making  the 
amount  of  starch  in  the  milk-mixture  about  0.7  % .  The 
experiments  of  White*  have  shown  that  this  is  the  best 
amount  of  starch  to  use,  when  action  upon  the  casein 
coagulum  is  desired. 

Whole  milk  was  occasionally  used  for  comparison 
with  the  milk  mixtures,  but  the  essential  point  was  the 
comparison  of  plain,  centrifugal  and  gravity  cream 
mixtures,  with  whey  mixtures  and  barley-water  mixtures, 
with  respect  to  the  casein  coagulum. 

In  the  experiments  in  test-tubes  the  conditions  present 
in  the  normal  stomach  were  simulated  as  far  as  possible. 
The  milk  was  kept  at  body  temperature  and  was  gently 
agitated  during  coagulation  by  slowly  inverting  the 
tubes  several  times.  As  the  precipitation  of  casein  by 
dilute  acids  is  a  difl'erent  process  from  its  coagulation 
by  rennet,  we  tried  the  action  of  (a)  HCl  alone,  (6) 
rennet  alone,  (c)  HCl  and  rennet  combined.  The  HCl 
and  rennet  combined  gave  rather  uncertain  results,  and 
it  was  thought  best  to  judge  of  this  action  by  animal 
experiments.  Twentv-five  ccm.  of  milk  were  precipitated 
by  the  addition  of  0.5  ccm.  of  5%  HCl,  giving  0.1%  free 
HCl  in  the  mixture,  which  is  the  normal  amount  in  the 
healthy  adult  stomach;  in  the  second  case  25  ccm.  of 
milk  was  coagulated  by  the  addition  of  2  ccm.  of  a 
liquid  rennet  preparation.  The  coagulation  was  usually 
prompt  and  complete  within  a  minute.  The  size  and 
consistency  of  the  curds  were  noted  and  later  the  tubes 
were  moderately  shaken  to  see  whether  the  curd  was 
tough  and  tenacious,  or  soft  and  easily  broken  up  into 
small  fragments. 

The  following  series  of  milk  mixtures  were  coagu- 
lated by  rennet"  and  by  HCl  separately  on  6  occasions 
with  constant  results : 


Table. 


Whole  milk, 
no  lime  water .. 
lime  water,  5  fc . 


unheated, 
75°  C. 


3..50— 6.00— 1.00 Centrifugall6%  cream, 

lime  water,  5% "5°  C 


No  lime  water 


unheated. 
75"  C. 
unheated. 


*JmnMl  <if  the  Boston  Society  of  Medical  Scitnces,  1900,  vol.  t,  No.  4. 


222 


The  PHn-ADELPHiA"! 
Mbdical  Journal  J 


WHEY-CREAM  MODIFICATIONS  IN  INFANT  FEEDING 


[FBBIBABT  2,   19W 


3.50—6.00—1.00 Gravity  16%  cream, 

lime  water  5%    75°  C. 

"  unhealed, 

No  lime  water 75°  C. 

"  unheated, 

3.50—6,00—1.00 Whey-mixture      (whey-pro- 

teids  0.75%,  caseinogen 
0.35%). 

Lime  water 75°  C. 

"  unheated. 

3.50-6.00—1.00 50%  barley  water, 

Lime  water 75°  C. 

No  lime  water unheated. 

There  were  certain  differences  in  the  coagulation  of 
the  milk-mixtures  which  seemed  to  us  unimportant  be- 
cause they  were  either  very  sUght  in  degree,  or  depend- 
ent upon  the  artificial  conditions  of  the  test-tube 
experiments,  but  they  may  bo  briefly  mentioned.  The 
curds  produced  by  HCl  alone  were  always  somewhat 
finer  than  those  yielded  by  rennet.  This  observation 
probably  has  no  practical  value,  as  the  coagulation  of 
milk  in  the  stomach  ordinarily  results  from  the  com- 
bined action  of  HCl  and  rennet.  It  was  also  found 
that  when  the  reaction  of  the  milk  was  slightly  alka- 
line, from  the  presence  of  lime-water,  the  coagulation  by 
rennet  was  somewhat  delayed  and  incomplete.  This  is 
due  to  the  fact  that  the  action  of  rennet  is  inhibited  by 
even  a  very  shght  excess  of  alkaU,  and  has  no  practical 
bearing  on  the  coagulation  of  such  a  milk-mixture  in 
the  stomach,  where  the  alkali  would  be  promptlj' 
neutralized. 

With  reference  to  the  effect  of  pasteurizing  the  milk 
at  75°  C,  it  was  found  that  in  about  one-half  the  speci- 
mens there  was  no  difference  in  the  coagulum  in  the 
heated  and  the  unheated  milk ;  in  the  rest  the  differ- 
ence, although  always  in  favor  of  the  heated  milk,  was 
too  slight  to  have  any  importance. 

A  comparison  of  the  milk-mixtures  brought  out  the 
following  important  facts :  The  coagulum  in  whole 
milk  was  coarse  and  tough.  The  coagulum  in  the  ordi- 
nary 3.50 — 6.00 — 1.00  mixtures  was  finer,  softer  and 
more  flocculent  than  in  the  whole  milk,  which  was  to 
be  expected  since  the  proteid  was  reduced  from  3.8%  to 
1  %   by  dilution. 

The  coagulum  was  just  alike  in  the  mixtures  made 
with  gravity  and  with  centrifugal  cream. 

The  coagulum  with  rennet  in  the  barley-water  mix- 
tures was  much  finer  than  in  the  plain  mixtures,  show- 
ing the  effect  of  barley  water  as  a  diluent  in  mechanic- 
ally separating  the  particles  of  coagulum.  The 
coagulation  of  the  barley  water  and  the  whey  mix- 
tures with  HCl  w;is  unsatisfactory,  owing  to  the 
tendency  of  the  fine  curd  partly  to  redissolve  in  a  small 
excess  of  the  acid. 

The  coagulmn  with  rennet  in  the  whey -mixtures  was 
finest  of  all,  being  finer  even  than  that  yielded  by  the 
barley-water  mixtures. 

A  few  specimens  of  whev-mixtures  containing  2%  of 
fat,  5%  of  sugar,  0.75%  of  whey-proteids  and  0^25%  of 
caseinogen  and  others  containing  3.50%  of  fat,  6.00% 
sugar,  0.75%  of  whey-proteids  and  0.50%  of  caseinogen 
were  compared  with  the  whey-mixture  containing  3.50% 
of  fat,  6  00%  of  sugar,  0.75%  of  whey-proteids  and 
0.25  %  caseinogen  and  it  was  found  that  these  variations 
in  the  percent  of  fat,  sugar  and  caseinogen  did  not 
affect  the  fineness  of  the  curd. 

To  determine  whether  the  amount  of  fat  present  had 
an  influence  on  the  tenacity  of  the  casein  coagulum,  the 


following  experiment  was  tried.  Specimens  of  16% 
cream  were  diluted  with  2  parts  of  water,  and  specimens 
of  fat-free  milk,  equally  diluted  were  coagulated  with 
rennet.  We  found  that  this  variation  in  the  amount  of 
fat  was  without  influence,  as  there  was  no  appreciable 
difference  in  the  tenacity  of  the  coagulum. 

We  also  wished  to  determine  whether  whey,  like  bar- 
ley water  used  as  a  diluent  for  casein,  had  the  power  of 
making  the  coagulum  fine  and  soft  by  getting  between 
the  particles  during  coagulation  aud  preventing  their 
uniting  together  into  a  tough  mass. 

The  following  mixtures  were  coagulated  by  rennet 
and  the  character  of  the  coagulum  noted  : 

1.  16%  cream,  1  part;  water  2  parts. 

2.  "  "  whey  2  parts. 

3.  "  "  barley  water  2  parts. 

The  coagulum  was  coarse  in  No.  1 ;  finer  in  No.  2, 
and  much  finer  in  No.  3.  It  is  therefore  e\-ident  that 
whey  has  distinct  value  as  a  diluent  in  making  the 
casein  coagulum  finer,  but  in  this  respect  is  inferior  to 
barley  water. 

2.  Anitnal  Experiments. — We  selected  from  our  ex- 
periments in  test-tubes  those  results  which  seemed  to  us 
to  have  the  most  practical  bearing  on  the  coagulation  and 
digestion  of  milk,  and  endeavored  next  to  verify  them 
by  experiments  in  the  animal  stomach.  We  compared 
the  size  and  digestibility  of  the  casein  coagulum  yielded 
by  the  following  mixtures,  all  of  which  contained  3.50% 
fat,  6.007<;  milk  sugar,  and  1.00%  proteid,  and  which 
were  made  as  follows  : 

1.  Ordinary  modified  milk  made  with  gravity  cream. 

2.  Ordinary  modified  milk  made  with  centrifugal 
cream. 

3.  Modified  milk  made  with  centrifugal  cream,  and 
containing  50%  of  barley  water  of  a  strength  which 
gave  0.7%  of  starch  in  the  mixture. 

4.  Whey-cream  mixture  containing  0.75%  whey- 
proteid  and  0.25%  caseinogen. 

Five  percent  of  lime  water  was  added  to  all  the  mix- 
tures, and  they  were  pasteurized  at  67°  C.  We  also 
repeated  the  experiment  to  determine  the  value  of  whey 
as  a  diluent. 

A  dog  with  a  gastric  fistula  was  chosen  f  >r  this  work. 
We  wish  to  acknowledge  our  great  indebtednes^s  to  Dr. 
M.  Vejux-Tyrode,  of  Boston,  who  performed  a  successful 
operation  for  fistula  uf>on  the  dog  which  we  used.  The 
fistula  did  not  leak,  the  dog  remained  in  healthy  condi- 
tion and  even  gained  in  weight  during  the  course  of  the 
experiments. 

The  dog  was  fed  with  the  milk  mixtures,  anit  after  a 
certain  interval  the  gastric  contents  were  allowed  to  run 
out  by  removing  the  stopper  of  the  fistula  tube  and  the 
stomach  gently  irrigated  with  warm  water.  Tsventy  to 
thirty  minutes  were  allowed  to  elapse  between  consecu- 
tive experiments.  In  each  case,  we  note<l  the  amount 
of  the  stomach-contents,  the  character  and  size  of  the 
coagulum,  the  amount  of  free  HCl  present  and  the  total 
acidity.  The  object  of  the  chemical  examination  was 
to  make  sure  that  tlie  stomach  was  in  the  same  condi- 
tion in  the  various  experiments. 

In  Series  I  the  dog  was  fed  with  200  ccm.  of  ordinary 
modified  milk  made  with  (a)  gravity  cream,  (6)  centri- 
fugal cream,  and  the  gastric  contents  withdrawn  in  ^ 
hour. 

In  Series  II  the  dog  received  150  ccm.  of  {a)  ordinary 
modified  milk,  (fc)  modilied  milk  with  barley  water,  (c) 
whey-cream  mixture.  The  gastric  contents  were  with- 
drawn in  i  hour. 


Febrcart  2,  1901] 


HANDLING  MILK  FOR  INFANT  FEEDING 


TTh 

Lm 


The  Philadelphia 
EDiCAL  Journal 


223 


Series  III  was  a  repetition  of  Series  II,  using  100 
ccm.  of  the  mixtures  and  withdrawing  the  gastric  con- 
tents after  10  minutes. 

In  Series  IV  the  dog  received  100  ccm.  of  a  mixture 
of  1  part  16%  cream  with  2  parts  of  (a)  water,  (6) 
whey,  (c)  barley  water.  The  gastric  contents  were  with- 
drawn in  10  minutes. 

In  each  series  the  amount  of  gastric  contents  was 
practically  constant,  and  the  acidity  varied  less  than 
0.05%;  therefore,  the  diSerences  found  in  the  curds  can- 
not be  explained  by  variations  in  the  condition  of  the 
stomach. 

It  was  found  that  ordinary  modified  milk  made  with 
gravity  cream  and  with  centrifugal  cream  yielded  a 
fiocculent  coagulum  of  the  same  size  and  character. 

Modified  milk  with  barley  water  and  whej'-cream 
mixtures  both  yielded  a  much  finer  and  more  digestible 
coagulum  than  ordinary  modified  milk. 

Modified  milk  with  barley  water  yielded  a  coagulum 
equally  as  fine  as  whey-cream  mixtures.  In  one  ex- 
periment the  coagulum  in  the  whey-cream  mixture, 
though  equally  fine  and  soft,  was  less  in  bulk  than  the 
coagulum  in  the  barley-water  mixture.  This  is  naturally 
explained  by  the  smaller  amount  of  caseinogen  in  the 
former. 

Series  IV  gave  the  same  result  as  the  corresponding 
experiment  in  test-tubes  and  showed  that  whey  has  a 
distinct  value  as  a  diluent  in  making  the  casein  coagu- 
lum finer,  but  is  inferior  in  this  respect  to  barley  water. 

In  short,  the  results  obtained  in  test-tubes  were  con- 
firmed by  the  animal  experiments  with  the  sole  excep- 
tion that  in  the  animal  stomach  the  modified  milk  with 
barley  water  yielded  a  coagulum  just  as  fine  and  digest- 
ible as  the  whey-cream  mixtures. 

Conclusions. 

We  may  briefly  summarize  our  results  as  follows  : 

1.  By  the  use  of  whey  as  a  diluent  of  creams  of 
various  strengths,  we  are  able  to  modify  cow's  milk  so 
that  its  proportions  of  caseinogen  and  whey-proteids 
will  closely  correspond  to  the  proportions  present  in 
human  milk.  We  therefore  render  it  much  more  digest- 
ible and  suitable  for  infant  feeding. 

2.  The  best  temperature  for  destroying  the  rennet 
enzyme  in  whey  is  65.5°  C.  Whey  or  whey-mixtures 
should  not  be  heated  above  69.3°  C.  in  order  to  avoid 
the  coagulation  of  the  whey-proteids.  The  percentage 
of  whey-proteids  in  the  whe}^  obtained  by  us  was  1  % , 
while  in  the  analysis  of  the  whole  milk,  approximately 
f  of  the  total  proteid  was  caseinogen  and  j  was  whey- 
proteids. 

3.  On  the  basis  of  these  analyses  we  were  able  to  ob- 
tain whey  cream-mixtures,  with  a  maximum  of  0.90% 
and  a  minimum  of  0.25%  of  whey-proteids  in  combi- 
nation with  percentages  of  caseinogen  varying  from 
0.25%  to  1.00%  ;  of  fats,  from  1.00%  to  4.00%  ;  of 
milk-sugar,  from  4.00%  to  7.00%. 

4.  The  emulsion  of  fat  in  whey,  barley-water,  gravity 
cream,  and  centrifugal  cream  mixtures,  were  the  same, 
both  in  their  macroscopic  and  microscopic  appearances. 
The  combination  of  heat  and  transportation,  such  as 
sometimes  occurs  in  hot  weather,  partially  destroys  the 
emulsion  in  all  forms  of  modified  milk,  but  this  dis- 
turbance can  be  prevented  by  the  simple  precaution  of 
keeping  the  milk  cool  during  delivery. 

5.  Whey  cream-mixtures  yield  a  much  finer,  less 
bulky,  and  more  digestible  coagulum  than  plain,  modi- 
fied mixture  with  the  same  total  proteids ;  the  coagu- 


lum is  equalled  in  fineness  only  by  that  of  barley-water 
mixtures.  The  coagulum  yielded  by  gravity  cream- 
mixture  and  centrifugal  cream-mixtures  is  the  same  in 
character. 


PROPER  METHODS  OF  HANDLING  MILK  FOR  INFANT 
FEEDING. 

By  GEORGE  THOMAS  PALMER,  M.D., 

of  Chicago,  111. 

Medical  Director  of  Trinity  Diet  Kitchen  for  Infants ;  Instructor  in  Pediatrics 
at  the  Chicago  Clinical  School. 

The  practitioner  who  has  labored  long  in  the  field  of 
infant  feeding  cannot  but  feel  a  great  sense  of  satisfac- 
tion as  he  sees  the  subject  tending  to  logical  simplicity 
both  of  theory  and  practice.  It  is  gratifying  for  him  to 
seethe  unamimity  of  opinion  in  regard  to  cow's  milk  for 
infant  feeding ;  to  realize  that  the  minute  percentages 
in  milk  modification  which  have  been  so  troublesome 
in  the  past,  are  not  absolutely  essential ;  to  see  the  rapid 
growth  of  the  sentiment  against  sterilization  and  pas- 
teurization and  to  be  able  to  feed  with  safety  a  raw  milk 
as  the  result  of  the  inteUigent  study  of  dairymen. 

There  is  hardly  a  practitioner  today  who  will  dispute 
the  preeminent  advantages  of  cow's  milk  over  any  other 
form  of  substitute  feeding  ;  and  the  opinion  has  been 
logically  formulated  that  sterilization,  being  injurious 
to  the  milk,  is  at  best  a  necessary  evil,  and  an  evil 
which  is  not  necessary  if  proper  dairy  methods  are 
carried  out.  As  to  minute  modification,  Jacobi  was 
certainly  practical  and  logical  when  he  called  the  atten- 
tion of  physicians  to  the  marked  variations  in  the  milk 
of  the  healthful  mother,  not  only  from  day  to  day ;  but 
from  morning  to  evening;  and  remarked  that  if  the 
slight  alterations  and  changes  in  the  percentages  of 
modified  milk  were  as  dangerous  as  they  are  made  out  to 
be,  there  would  not  be  one  living  child  in  all  Creation. 
He  and  many  other  writers  have  called  the  attention 
of  pediatricians  to  the  fact  that  clean  milk  is  far  more 
important  than  any  amount  of  modification. 

That  clean  milk  can  be  procured  in  all  the  large 
cities  is  absolutely  certain.  I  do  not  say  that  sterile 
milk  can  be  found,  for  it  is  known  that  the  milk  is  in- 
vaded with  certain  forms  of  bacteria  before  leaving  the 
udder  of  the  healthy  cow ;  but  milk  that  is  free  from 
the  bacterial  life  deleterious  to  the  infant  can  certainly 
be  obtained.  That  such  a  milk  is  better  than  cooked 
milk  is  beyond  question.  It  is  conceded  that  cooking 
makes  the  food  less  easily  digestible  and  decreases  the 
nutritive  -value,  and  it  is  "further  known  that  even  if  we 
sterilize  we  must  have  a  relatively  pure  milk,  for  no 
amount  of  sterilization  can  purify  a  milk  already  foul, 
and  impregnated  with  the  products  of  bacterial  growth. 

When  it  is  known  that  sterilized  milk  is  more  or  less 
injurious ;  when  it  is  known  that  pure  milk  can  be 
secured  by  proper  attention  to  the  dairy,  certainly  the 
basis  of  infant  feeding  is  established.  That  basis  is  raw 
milk. 

It  is  not  my  desire,  however,  to  enter  into  any  dis- 
cussion of  sterilization  or  pasteurization ;  but  merely  to 
speak  briefly  of  the  methods  that  can  be  and  are 
employed  to 'produce  a  milk  fit  for  infant  feeeding  in 
its  raw  state. 

Trinity  Diet  Kitchen   for  Infants,  a  milk  charity  in 

the  poor  district  of  Chicago,  was  opened  with  the  idea 

of  supplving  a    pure,  modified  cow's  milk   to  be  dis- 

I  tributed  "without  anv  attempt  at  sterilization.     During 


224 


The  Philadelphia"! 
Medical  Journal  J 


HANDLING  MILK  FOR  INFANT  FEEDING 


[Febedaet  2,  1901 


the  summer  just  past  we  have  carried  out  this  plan,  and 
although  the  infant  mortality  in  the  city  has  been  very 
high  and  the  weather  intensely  hot  (one  month  of  the 
hottest  weather  ever  recorded  by  the  Weather  Bureau), 
we  have  had  a  mortahty  of  something  less  than  1  % . 
We  have  never  given  out  1  ounce  of  either  sterilized  or 
pasteurized  milk,  and  we  have  been  so  gratified  with 
our  results  that  we  have  had  no  disposition  to  do  so. 
It  may  be  further  stated  that  we  have  had  almost  no  com- 
plaints of  the  milk  souring,  although  our  clientele  has 
been  the  poor  and  their  hygienic  surroundings  exceed- 
ingly bad.  We  have  merely  taken  the  precaution  to  have 
everything  coming  in  contact  with  the  milk  perfectly 
sterile  and  of  packing  each  supply  with  a  liljeral  quan- 
tity of  ice  before  permitting  it  to  go  out.  The  amount 
of  ice  given  for  each  child  has  been  ample  to  keep  the 
food  cold  and  sweet  for  the  greater  part  of  the  day  and 
instructions  are  invariably  given  that  the  ice  be  replen- 
ished when  it  runs  low. 

Our  success  in  feeding  with  raw  milk  in  unsanitary 
surroundings,  I  believe  to  be  due,  first,  to  the  unvarying 
purity  of  the  milk  ;  second,  to  the  care  given  the  milk 
in  our  kitchen.  The  rigid  instructions  given  the  parents 
in  regard  to  handling  the  milk,  regularity  of  feeding, 
and  absolute  cleanliness  has  also  been  a  factor ;  and  this 
instruction  is  the  more  eftective  on  account  of  the 
repeated  calls  made  l)_v  our  superintendent  and  nurses 
to  see  that  our  instructions  are  being  carried  out  to  the 
letter. 

Through  the  courtesy  of  Mr.  H.  B.  Gurler,  of  DeKallj, 
Ilhnois,  I  was  able  to  closel_y  inspect  the  methods  of  his 
farm  from  which  our  milk  is  derived. 

The  cattle  I  found  to  be  good,  healthy  stock,  all 
tubercuUn-tested  by  the  authorities  of  the  State.  They 
were  originally  Holstein,  Jersey,  Durham,  and  Guernsey 
stock ;  but  for  several  years  they  have  been  invariably 
bred  to  Holstein  Ijulls.  so  that  at  present  the  herd  is 
almost  altogether  Holstein.  The  preference  for  Holsteins 
is  accounted  for  l)y  their  ruggedness  and  almost  invari- 
able good  health,  as  well  as  for  the  evenly  balanced  milk 
they  give.  The  tendency  on  the  part  of  dairymen, 
however,  to  force  the  Holsteins  to  the  very  largest 
amount  of  milk  they  could  give,  has  caused  a  deteriora- 
tion in  the  richness  of  the  milk,  and  this  Mr.  Gurler 
has  overcome  by  breeding  with  a  view  to  increasing  the 
butter  fats.  The  cows  now  on  the  farm  do  not  gi\e  the 
quantity  of  milk  they  formerly  did ;  but  the  butter  fats 
have  increased  so  markedly  that  the  milk  is  almost  a 
rival  of  the  Jersey. 

The  tuberculin  test  proved  only  3  %  of  this  herd  to 
be  tuberculous,  while  the  average  percentage  in  the  herds 
of  this  part  of  the  country  is  from  12  to  14%.  No  full 
grown  cow  actually  born  and  raised  on  this  farm  h:is 
responded  to  the  tuberculin  test,  on  account  of  the  ideal 
hygienic  conditions.  A  sick  cow  afflicted  with  any 
malady  whatever  is  at  once  isolated  and  not  permitted 
to  come  in  any  way  in  contact  with  the  herd.  The 
barns  used  by  these  sick  cattle  are  never  occupied  bv 
the  healthy  stock.  The  herd  is  never  permitted  to  drink 
Ixom  ponds  or  streams,  and  the  only  water  the}-  get  is 
pumped  into  perfectly  clean  troughs  fi-om  an  artesian 
well.  The  food  is  perfectly  clean  and  the  cattle  are  cur- 
ried and  groomed  regularly.  The  udders  are  kept  in 
good  condition  by  washing,  which  occurs  twice  daily, 
and  there  is  a  comparative  freedom  from  infective  pro- 
cesses of  the  udder  on  account  of  the  fact  that  the  cattle 
are  not  overfed  or  forced  to  give  their  greatest  possible 
quantity  of  milk.     Stockmen  have  found  that  overfeed- 


ing is  a  common  source  of  disturbances  in  the  udder. 
Any  cow  with  infected  udder  is  at  once  isolated. 

Another  reason  for  the  comparative  freedom  from 
tuberculosis  is  that  the  calves  are  fed  only  ujxjn  the 
milk  of  perfectly  healthy  tubercuUn-tested  cows  and  not 
upon  the  skimmed  milk  of  unknown  herds,  secured 
fi-om  creameries,  as  is  generally  done  in  this  region. 

The  food  most  depended  upon  is  chopped  cornstalks 
gathered  when  the  com  is  fully  developed  and  when  the 
kernels  have  dented,  but  cut  and  stored  in  silos  before 
it  has  been  permitted  to  dry.  That  this  is  a  satisfactory 
food  is  indicated  from  the  fact  that  when  other  foods 
are  used  in  its  place  the  milk  decreases  in  both  quantity 
and  quaUty.  In  addition  to  this,  silage,  bran,  shorts,  and 
gluten  meal  are  given,  and  during  summer  there  is  most 
excellent  pasturage.  In  turning  the  cows  into  pasture, 
however,  the  greatest  care  is  exercised,  for  the  new  grass 
almost  invariably  causes  diarrhea  in  the  cow.  Even  if 
green-grass  feeding  is  not  permitted  to  this  extent,  Mr. 
Gurler  has  raised  the  question  as  to  whether  the  green 
feeding  could  not  cause  diarrhea  in  the  child  xising  the 
milk,  even  though  the  cow  were  not  affected.  He  tells, 
in  support  of  his  theory,  that  when  laxative  foods  are 
given  to  a  sow  with  a  fi-esh  Utter,  the  sucking  pigs  are 
often  badly  "  scalded  "  when  no  tendency  to  diarrhea  is 
noticed  in  the  dam. 

The  milking  is  done  at  three  in  the  morning  and  three 
in  the  afternoon,  in  stables  with  cement  floors  so  slanted 
as  to  permit  thorough  scrubbing,  which  is  done  daily. 
The  milkers  are  clothed  in  white,  clean  suits,  and  use 
buckets  which  are  covered  with  a  cap  holding  in  place 
two  thicknesses  of  sterilized  gauze  between  which  is 
placed  a  thick  layer  of  absorbent  cotton.  The  milk 
passes  through  this  gauze  and  cotton  before  reaching 
the  pail. 

The  udder  washers  precede  the  milkers  and  throughly 
cleanse  the  udders.  The  milker  then  draws  a  consider- 
able amount  of  milk  from  each  quarter  and  puts  it  in  a 
pail  for  disposal.  He  then  milks  through  the  strainer 
and  when  his  bucket  is  full,  empties  the  milk  into  a  ster- 
ile can,  in  which  process  it  is  again  strained.  These  cans 
are  taken  up  and  reach  the  dairy  within  5  minutes  after 
milking.  The  milk  is  poured  at  once  into  the  receiver 
of  the  separator  and  in  about  10  seconds  passes  through 
and  is  run  into  buckets.  The  milk  and  cream  are  mixed 
again  at  once,  except  that  excess  of  cream  or  milk  which 
must  be  taken  out  to  maintain  the  standard  of  4  %  guar- 
anteed. From  the  separator  the  milk  is  poured  at  once 
into  the  receiver  of  the  cooler,  from  which  it  trickles 
down  over  coils  of  pipe  filled  with  ice  water  and  at  the 
bottom  falls  into  other  pails,  having  in  the  process  at- 
tained a  temperature  of  about  45°  F.  This  temperature 
is  reached  in  about  10  or  12  minutes  after  milking. 
^^'ithin  20  minutes  the  bottles  are  filled  and  sealed,  ready 
for  shipping.  Thej-  are  sent  into  the  city  in  sealed  cases 
packed  in  shaved  ice. 

The  precautions  in  regard  to  cleanliness  of  this  insti- 
tution would  do  credit  to  a  hospital.  Every  article 
used  in  the  place  stands  for  hours  in  a  large  steam 
steriHzing  room  before  use. 

The  process  of  separation  as  here  carried  on,  not  only 
permits  a  uniform  quaUty  of  milk,  but  removes  fi-om 
the  milk  the  mucus  and  slime  and  occasional  blood- 
clots  found  in  all  milk.  It  is  stated  also  that  the  num- 
hev  of  bacteria  is  considembly  decreasetl. 

It  is  this  care  and  attention  to  the  dairy  which  places 
infant-feeding  upon  a  natural  and  sound  basis,  and  this 
is  the  care  which  makes  preservatives  and  sterilization 


FraBOABT  2, 1901]  MODIFICATION  OF  MILK  FOR  PRESCRIPTION  FEEDING        [ 


The  Philadelphia 

Medical  Journal 


225 


equally  unnecessary.  On  the  day  on  which  I  visited 
the  farm,  several  cases  of  this  milk  were  shipped  to 
Paris,  with  every  confidence  that  it  would  reach  the 
European  city  in  perfect  condition.  Certain  it  is  that 
this  milk  has  been  kept  on  ice  in  Trinity  Diet  Kitchen 
for  Infants  for  almost  two  weeks  with  no  sign  of  sour- 
ing or  decomposition. 

I  am  aware  that  able  men  advocate  sterilization,  espe- 
cially when  feeding  under  circumstances  where  the  en- 
^•ironment  is  not  satisfactory ;  but  I  am  firmly  convinced 
that  he  who  teaches  sterilization  teaches  a  bridging  over 
of  faults  which  should  not  have  been  committed ;  ad- 
vocates an  injurious  food  for  an  infant  when  a  little 
care  and  brain  would  have  made  it  unnecessary.  To 
teach  sterilization  is  like  teaching  the  medical  student 
the  use  of  antidotes  for  overdose  of  drugs  without 
teaching  him  anything  of  proper  dosage  or  how  the 
overdose  may  be  avoided. 

After  trying  a  raw  milk  with  the  infants  of  the  poor 
during  a  terribly  hot  season,  and  having  seen  what  can 
be  done  toward  the  preparation  of  a  clean,  pure  milk,  I 
am  ready  to  banish  forever  sterilization  or  pasteuriza- 
tion on  the  same  ground  that  I  would  banish  formal- 
dehyd  or  any  milk  preservative — on  the  ground  that 
they  are  both  injurious  and  unnecessary. 


THE  IMPORTANCE  OF  INSTRUCTION  IN  MEDICAL 
SCHOOLS  ON  THE  MODIFICATION  OF  MILK  FOR 
PRESCRIPTION  FEEDING. 

By  ANDREW  H.  WHITRIDGE,  M.D., 
of  Baltimore,  Md. 

During  the  course  of  instruction,  in  any  modern 
medical  school,  students  have  opportunity  to  study 
more  or  less  practically  the  relation  of  bacteriology  to 
pathology.  Students,  in  the  second  and  third  years  of 
the  course,  gain  enough  laboratory  experience  of  the 
more  important  species  of  bacteria  to  enable  them  to 
make  a  diagnosis  of  infected  tissue  given  for  examina- 
tion. As  students  approach  matriculation  a  very  dis- 
tinct and  imperative  impression  has  been  created  of  the 
role  played  by  bacteria,  both  in  health  and  disease,  and 
of  the  methods  employed  to  deal  with  those  that  are 
regarded  as  pathogenic  in  their  action.  Asepsis  and 
antisepsis  are  familiar  both  in  theory  and  in  practice, 
not  only  in  relation  to  surgery,  but  also  in  the  proper 
estimation  of  the  etiology  and  treatment  of  disease, 
whether  regarded  as  strictly  communicable  or  not. 

The  progress  of  bacteriology  has  been  very  rapid, 
starting  indeed  in  the  realm  of  surgery,  where  it  has 
seized  the  operative  field  as  its  own  ;  yet  scarcely  less 
dominant  in  the  domain  of  medicine,  and  perhaps 
most  authoritative  in  the  comparatively  unobtrusive 
region  of  preventive  medicine.  All  this  rapid  accumu- 
lation of  ascertained  facts,  and  the  brilliant  application 
of  them  to  practice,  deeply  impress  the  mind  of  the 
graduating  student,  and  equip  him  with  a  zeal  accord- 
ing to  knowledge,  unknown  to  his  professional  brethren 
of  an  olden  time.  The  young  practitioner  feels  that  he 
starts  out  with  a  large  measure  of  wisdom,  which  is 
knowledge  put  to  use ;  especially  when  he  is  called 
upon  to  combat  those  diseases  in  which  his  academic 
study  of  bacteriology  and  his  practical  work  in  the 
laboratory  of  the  medical  school  afford  him  both  a  cor- 
rect diagnosis  and  an  adequate  treatment.  He  feels 
somewhat  at  home,  even  in  the  company  of  older  men, 


when  he  has  to  deal  with  the  problems  to  which  bac- 
teriology holds  the  key. 

But  it  is  far  otherwise  when  he  is  called  upon  to  de- 
cide many  of  the  common  questions  and  to  dictate  daily 
procedures  of  general  practice.  The  art  of  preventive 
medicine,  as  applied  to  the  life  of  the  family,  is  often 
a  puzzling  and  unsatisfactory  practice.  Yet  it  ought  to 
be  one  of  the  chief  sources  of  satisfaction  in  medical 
practice.  The  intelligent  laity  is  calling  for  the  advice 
and  cooperation  of  the  profession  in  thousands  of  ways 
outside  of  treatment  for  actual  sickness  or  injury.  The 
care  of  the  body  in  health  is  as  paramount  a  consider- 
ation with  intelligent  patients  as  is  its  cure  in  time  of 
sickness. 

Questions  of  sanitation,  the  practical  hygiene  of  the 
kitchen,  bed-  and  bath-rooms,  and  especially  of  the 
nursery,  dietaries  for  the  man  of  active  business,  or  of 
sedentary  habits,  for  the  school  children,  for  the  aged, 
and  especially  for  the  mother  and  her  baby,  are  now 
questions  for  solution  by  the  family  physician,  and  may 
soon  be  problems  for  specialists  in  this  department. 
These  great  matters  should  form  an  important  part  of 
the  curriculum  of  the  modern  medical  school,  yet  they 
do  not.  Those  physicians  who  are  now  eminent  for 
their  work  in  preventive  medicine  and  hygiene  are  those 
who  have  studied  these  subjects  since  graduation,  and, 
with  some  exceptions,  for  whom  their  medical  school 
education  did  very  little  to  equip  them  to  follow  a  nat- 
ural bent  in  these  directions.  Let  this  question  be  illus- 
trated by  one  example  taken  from  the  many  that  might 
be  cited,  viz  ,  the  most  important  and  pressing  question 
of  infant  feeding. 

During  the  past  15  years  we  have  witnessed  a  great 
change  pass  over  this  question,  both  in  the  minds  of 
the  laity  and  in  those  of  the  members  of  our  profession. 
We  have  seen  a  few  aspects  of  this  question  change  from 
hazy  uncertainty  into  a  phase  of  enlightenment.  This 
change  has  always  been  as  remarkable  as  it  is  encourag- 
ing to  the  profession.  For  example,  it  is  conceded  that 
the  feeding  of  infants  should  be  wholly  under  the  con- 
trol of  the  physician.  Just  as  the  midwife  has  been 
superseded  by  the  obstetrician,  the  ignorant  nurse  or 
untrained  mother  must  be  superseded  by  the  trained 
and  qualified  physician.  This  position  is  held  by  the 
intelligent  laymaia  quite  as  firmly  as  it  ought  to  be  held 
by  the  educated  physician.  That  it  is  very  frequently 
more  firmly  maintained  by  the  patient  than  by  the 
physician  is  largely  due  to  those  medical  schools  which 
have  neglected  to  prepare  the  physician  for  this  impor- 
tant and  remunerative  work.  A  large  part  of  the  mor- 
tality of  infancy  is  traceable  to  the  lack  of  importance 
given  to  the  subject  of  scientific  feeding  in  the  schools. 

It  is  also  conceded  that  in  the  absence  of  the  proper 
breast  milk  some  modification  of  animal  milk  should 
be  employed  as  a  substitute,  and  that  cow's  milk  should 
form  the  basis  of  all  scientific  infant  feeding.  From 
this  position  there  is  now  no  deviation.  Specialists 
differ  as  to  the  forms  of  modification,  as  to  percentages 
and  proportions,  as  to  diluents,  and  other  matters  of 
detail.  But  none  difi"er  from  the  general  proposition 
stated  above.  But  scientific  substitute  feeding  requires 
an  intimate  knowledge  of  milk  ;  of  breast  milk  as  the 
primary  example,  and  of  modified  cow's  milk  as  the 
practical  copy.  It  is  not  the  fault  of  the  average  phy- 
sician that  this  subject  is  to  him  very  often  a  terra  in- 
cognita. It  is  mostly  the  failure  of  the  medical  school 
to  lay  the  suitable  foundation  for  the  experimental 
knowledge. 


226 


The  Philadelphia"! 
Medical  Journal  J 


INTRACRANIAL  HEMORRHAGE  IN  THE  NEWBORN 


[Febbuaxt  2,  1901 


It  is  conceded  that  the  modification  of  milk  for  in- 
fant feeding  is  a  very  simple  thing  of  itself.  Yet  it  is 
often  regarded  as"  a  mystery  and  a  scare,  in  medical 
practice.  The  schools  might  make  its  complete  study 
one  of  the  simplest  as  well  as  one  of  the  surest  means 
of  practical  education. 

In  our  medical  schools  of  the  South  there  are  no 
means  by  which  the  student  or  the  postgraduate  physi- 
cian can  obtain  the  training  necessary  to  enable  him  to 
conduct  thoroughly  scientific  infant  or  invalid  feeding. 
Students  in  some  of  our  Northern  schools  of  medicine 
have  opportunities  to  become  more  or  less  familiar  with 
this  branch  of  medicine,  but  in  the  South  they  have  no 
such  opportunities.  These  should  be  supplied ;  and  I 
here  make  an  earnest  appeal  that  medical  schools  in 
the  South  obtain  qualified  men,  even  if  they  be  not  all 
doctors,  who  will  devote  their  time  and  energy  to  the 
teaching  of  this  great  subject. 

Since  summer  diarrhea  is  such  a  factor  in  our  mor- 
tality, I  suggest  that,  at  least  during  the  summer 
months,  such  of  our  schools  as  maintain  a  high  stand- 
ard of  education  should  appoint  qualified  men  who 
shall  instruct,  by  regular  weekly  lectures,  students  and 
postgraduate  physicians  in  the  practical  knowledge 
needed  to  understand  this  branch  of  our  work.  It 
would  be  an  inestimable  gain  to  earnest  men  to  have 
such  knowledge  of  the  cow,  her  milk,  its  care,  and  the 
bacteriological  relation  of  such  matters  to  the  employ- 
ment of  milk  for  infant  feeding,  imparted  by  a  compe- 
tent instructor.  If  such  a  chair  were  founded,  in  our 
school,  for  example,  and  a  proper  man  found  to  fill  it, 
we  should  realize  that  advance  had  been  made  in  pedi- 
atrics. 

The  milk  laboratories  that  have  been  established  in 
many  cities  of  the  United  States  have  done  much  to 
further  the  scientific  feeding  of  infants.  Those  physi- 
cians who  employ  these  laboratories  most  largely  speak 
most  strongly  of  the  results  obtained.  My  own  experi- 
ence in  the  use  of  milk,  modified  according  to  my  pre- 
scriptions, at  the  laboratories,  has  been  so  satisfactory 
that  I  cannot  praise  this  method  too  highly,  and  I  should 
like  to  see  a  milk  laboratory  within  the  reach  of  all 
physicians  who  have  infants  to  feed  artificially.  This, 
however,  is  impossible,  and  at  best  only  a  percentage  of 
physicians  can  reach  the  laboratories  with  their  pre- 
scriptions. But  all  physicians  intending  to  devote 
themselves  either  to  general  medicine  or  to  the  special 
work  of  pediatrics  should  be  permitted  and  encouraged 
to  lay  a  solid  foundation  for  this  work  while  they  are 
in  the  medical  school.  Therefore,  I  hope  ray  appeal 
for  special  instruction  in  feeding  will  not  be  "made  in 
vain. 


INTRACRANIAL  HEMORRHAGE    IN  THE  NEWBORN. 

By  W.  REYNOLDS  WILSON,  M.D., 

of  Philadelphia. 

Intracranial  hemorrhage  in  the  newborn  is  usuillv 
the  result  of  rhexis  affecting  the  vessels  of  the  menin- 
ges. It  is  a  natural  consequence  of  the  traumatism  of 
birth.  Meningeal  apoplexy,  according  to  Cruveilhier, 
may  be  considered  as  the  cause  of  death  in  one-third 
of  the  infants  who  succumb  sub-partu  or  shortly  after 
birth.  In  the  experience  of  the  writer  15  instances  of 
intracranial  hemorrhage  were  noted  in  20  autopsies 
performed  upon  the  bodies  of  infants  dead  within  3 
weeks  of  birth.     Cerebral  congestion  without  meningeal 


hemorrhage  is  rarely  noted  portmortem  on  account, 
first,  of  the  frequency  of  traumatic  influence  in  deter- 
mining hemorrhage,  and  second,  on  account  of  the 
frailness  of  the  vessel  walls  subjected  to  the  pressure 
of  augmented  vascular  tension. 

The  character  of  the  labor  as  well  as  the  presentation 
and  position  of  the  child  are  to  be  considered  in  their 
bearing  upon  the  etiology  of  meningeal  hemorrhage. 
Traumatic  deliveries,  considered  in  the  sense  of  oper- 
ative deliveries  (instrumental  or  otherwise),  however, 
are  not  solely  responsible  for  intracranial  hemor- 
rhage. Natural  or  spontaneous  deliveries,  where  the 
fetus  is  subjected  to  long- continued  pressure,  con- 
tribute a  quota  of  the  deaths  due  to  this  lesion  in 
the  newborn. 

The  classification  of  these  hemorrhages  may  be : 
(1)  Anatomical,  that  is,  as  to  the  location  of  the 
effusion  occupying  the  meningeal  spaces  ;  (2 1  etiolog- 
ical, as  to  the  occurrence  of  the  hemorrhage  primarily 
from  traumatism,  or  secondarily  from  mechanical 
causes,  such  as  pressure  acting  either  upon  the  vessels 
within  the  cranium  or  interfering  with  the  intra- 
cranial circulation  from  without.  Cachectic  conditions 
dependent  upon  vicious  development  or  nutritional 
defects  are  to  be  included  as  causes. 

The  anatomical  classification  of  intracranial  hemor- 
rhage serves,  perhaps,  the  better  purpose  of  description. 
It  may  be  arranged  as  follows : 

(1)  Extrameningeal ;  (2)  arachnoid,  or  subdural ; 
(3)  subarachnoid  ;  (4)  ventricular  ;  (5)  mixed. 

Cerebral  apoplexy  proper  is  of  rare  occurrence  in 
the  newborn. 

Extrameningeal. 

The  dura  mater  is  closely  applied  by  its  outer  or 
periosteal  lamina  to  the  interior  of  the  skull.  This 
adherence  is  especially  intimate  in  the  newborn. 
Extrameningeal  hemorrhage  (cephalhematoma  interna) 
is  therefore  rare.  Traumata  sufficient  to  cause  lacera- 
tion of  the  middle  meningeal  artery  or  its  branches  are 
usually  the  cause  of  efifusion  in  this  region.  Fracture 
of  the  flat  bones  during  birth  generally  involves 
extensive  laceration  of  the  extradural  vessels.  The 
longitudinal  sinus  is  rarely  the  source  of  bleeding. 
Extrameningeal  hemorrhage  is  usually  accompanied 
by  invasion  of  the  arachnoid  cavity.  This  form  of 
hemorrhage,  if  extensive,  reveals  itself  directly  by 
marked  symptoms.  The  immediate  results  maj-  give 
rise  to  grave  symptoms  of  impaired  motility  and  sensi- 
bility. 

It  is  not  impossible  for  absorption  to  take  place. 
The  fluid  portion  of  the  blood  may  first  be  absorbed, 
the  remainder  of  the  effusion  existing  as  a  blood  cyst 

Arachnoid  or  Subdural. 

Arachnoid  hemorrhage  is  the  result  of  effusion  into 
the  cavity  limited  by  the  arachnoid  membrane  beneath 
and  the  inner  or  supporting  lamina  of  the  dura. 

The  origin  of  this  form  of  hemorrhage  is  usually 
traumatic.  The  liabilit}-  to  rupture  of  the  arteries  and 
veins  traversing  the  surface  of  the  convolutions  is  easily 
comprehended  when  the  character  of  the  membranes 
supporting  these  vessels  is  considered.  The  pia.  for 
instance,  is  nothing  more  than  a  network  of  delicate 
vessels  which  are  held  together  by  the  suppwrling 
areolar  tissue.  The  subarachnoid  tissue  also,  which 
bridges  over  the  space  between  the  pia  and  the  dural 
surface  of  the  arachnoid,  consists  of  fine  trabeculae  in 


Febrcart  2,  1901] 


INTRACRANIAL  HEMORRHAGE  IN  THE  NEWBORN 


CThe  Philadelphia 
Medical  Jocenal 


227 


no  way  constituted  to  withstand  the  shock  of  trauma- 
tism. In  addition  to  this  the  cortical  veins  have 
extremely  thin  walls.  They  are  without  muscular  coat 
and  are  unfurnished  with  valves  (Morris,  Text-Book 
of  Anatomy).  The  traumatic  conditions,  therefore, 
existing  during  birth  are  favorable  to  rupture  of  these 
cortical  vessels  irrespective  of  traumatism.  Pressure 
due  to  obstruction  of  mechanical  origin  during  birth  or 
to  pathological  conditions  in  extrauterine  life  may  so 
increase  venous  pressure  as  to  cause  rupture  with 
extravasation. 

The  causes,  therefore,  of  subdural  hemorrhage,  ac- 
cording to  Barthez  and  Sann6,  may  be  summarized  as 
follows  : 

1.  Direct  injury  to  the  vessels  from  compression  of 
the  head  during  its  expulsion. 

2.  Unusual  molding  of  the  head. 

3.  Torsion  of  the  cervical  vertebrae  during  forcible 
extraction  of  the  head. 

4.  Constriction  and  winding  of  the  cord. 

5.  Compression  of  the  thorax  incidental  to  protracted 
labor. 

Among  the  causes  operative  alike  sub  partu  and  after 
birth  it  is  necessary  to  consider  also  arrest  in  the  en- 
cephalic circulation  from  intra  or  extracranial  pressure. 
Obstruction  of  such  character  may  be  due  to  : 

1.  Neoplastic  growths  within  the  cranium. 

2.  Compression  of  the  superior  vena  cava  by  bronchial 
nodes. 

2.  Compression  of  the  abdominal  vessels  by  tumors 
of  the  liver,  spleen  and  mesenteric  glands. 

The  cachexiae  of  the  newborn — syphilis,  tuberculosis, 
purpuric  conditions,  and  malnutrition,  especially  in 
premature  infants — may  predispose  to  intracranial 
hemorrhage. 

The  compression  hemorrhages  are  likely  to  be  of 
gradual  occurrence  and  are  sometimes  unaccompanied 
by  important  symptoms.  They  may,  therefore,  be  over- 
looked as  a  cause  of  death  in  the  newborn.  Serous 
infiltration  of  the  subarchnoid  space  together  with 
hydrops  ventriculorum  is  apt  to  occur  coincidentally 
with  hemorrhage.  On  the  other  hand,  in  athrepsia  the 
cerebrospinal  fluid  is  lessened.  In  this  way  the  natural 
protection  to  the  encephalic  vessels  is  lessened  (Parrot). 
As  to  the  pathological  evidences,  the  subdural  space 
may  be  occupied  by  an  eifusion  representing  a  more  or 
less  extensive  hemorrhage.  The  extravasation  may 
extend  over  both  hemispheres,  but  it  rarely  involves  the 
anterior  lobes.  The  blood  is  not  apt  to  become  com- 
pletely clotted,  although  small  shred-like  clots  are  some- 
times found  adherent  to  the  arachnoid  and  dural  sur- 
faces. The  effused  blood  may  separate  into  two  layers, 
one  consisting  of  an  imperfectly-formed  coagulum 
bearing  the  imprint  of  the  convolutions  which  are 
sometimes  swollen  and  flattened,  the  other  composed 
of  a  granular  deposit  adherent  to  the  dura.  In  other 
instances  the  solid  portion  of  the  blood  becomes 
absorbed  while  the  liquid  remains,  giving  rise  to 
external  hydrocephalus.  According  to  Parrot  it  is  even 
possible  for  the  effused  blood  to  become  completely 
absorbed. 

The  extravasation  may  vary  in  extent  from  a  few 
grams  to  100  grams  or  more. 

The  points  of  rhexis  are  rarely  to  be  found.  The 
ventricles  are  usually  not  invaded  in  meningeal  hemor- 
rhage, although  the  choroid  plexuses  partake  of  the 
engorgement,  which  is  evidenced  by  the  general  hyper- 
emia of  the  meninges.     Externally  the  periosteum  also 


may  be  the  seat  of  extensive  hyperemia  even  in  cases 
where  there  is  no  evidence  of  external  traumatism. 
The  sinuses  of  the  dura  and  the  plexus  of  veins  held 
within  the  substance  of  the  dura  mater,  and  constitut- 
ing the  basilar  sinus  are  usually  found  distended  with 
blackish  partially-formed  clots.  The  fibrinous  envelope 
which  surrounds  physiological  coagula  is  rarely  found 
in  instances  of  subdural  effusion.  The  membranous 
pellicle  consequent  to  secondary  inflammation  follow- 
ing hemorrhage  is  also  absent. 

Subarachnoid. 

The  locus  of  the  effusion  in  subarachnoid  hemor- 
rhage is  the  subarachnoid  space  proper,  that  is,  be- 
tween the  arachnoid  and  the  pia,  or  between  the  pia 
and  the  brain. 

The  causes  of  subarachnoid  hemorrhage  are  the 
same  as  those  responsible  for  subdural  extravasation  ; 
namely,  rupture  due  to  traumata  or  embarrassment  of 
the  encephalic  circulation.  The  dyscrasia  of  purpura 
and  the  conditions  present  in  athrepsia  may  culminate 
in  subarachnoid  effusion.  Thrombosis  of  the  sinuses 
of  the  dura  mater  and  pressure  from  intracranial 
aneurysms  may  be  noted  as  causes  of  hemorrhage  in 
this  locality. 

The  effusions  may  be  of  varying  extent  and  volume, 
appearing  either  as  disseminated  points  of  extravasa- 
tion on  the  surface  of  the  pia  or  as  a  thick  layer  cover- 
ing the  surface  of  the  brain.  In  extensive  extravasation 
with  edema  the  convolutions  may  be  flattened  as  the 
result  of  pressure.  The  blood,  when  freshly  effused,  is 
liquid,  syrupy  and  brown  in  color.  It  may  form  solid 
blackish  coagula  that  recall  the  fleshy  clots  of  the 
heart  cavities.  The  clot  is  usually  firmly  applied  to 
the  convolutions  and  forced  into  the  intervening 
depressions.  It  is  usually  detachable,  but  in  some 
instances  may  be  so  adherent  as  to  drag  away  portions 
of  the  brain  in  its  removal.  The  localized  effusion  never 
ultimately  becomes  encysted.     (Barthez   and  Sanne.) 

The  effusion  commonly  occupies  the  convexities  of 
the  cerebral  hemispheres  and  the  surface  of  the  cere- 
bellum. It  may  involve  the  base  of  the  brain,  pene- 
trating to  the  spinal  canal  and  to  the  ventricles  by 
means  of  the  foramen  of  Majendie.  The  effusion  may 
be  limited  to  one  side  of  the  brain-surface.  The  veins 
of  the  pia,  on  account  of  their  voluminousness,  usually 
exhibit  extensive  engorgement,  being  distended  with 
blackish  coagula.  The  sinuses  of  the  dura  are  also 
distended  with  clots.  When  the  blood  is  abundant 
and  the  effusion  of  long  standing  the  convolutions  of 
the  brain  may  be  flattened  and  pressed  out  of  shape. 
The  brain  may  be  the  seat  of  local  atrophy  (poren- 
cephalus). 

Ventricular. 

Ventricular  hemorrhage  may  occur  by  the  extension 
of  the  effusion  in  the  subarachnoid  space.  Primary 
hemorrhage  is  rare,  except  from  rupture  of  the  choroid 
plexus. 

Mixed. 

Mixed  hemorrhage  is  characterized  by  the  presence 
of  blood  in  the  subdural  and  subarachnoid  spaces  as 
well  as  in  the  ventricles.  Such  hemorrhage  is  com- 
monly due  to  severe  trauma. 

Symptoms  of  Intracranial  Hemorrhage. 
Should  the  infant  surs-ive  the  shock  of  deliver>'  and  the 


228 


The  Philadelphia 
Medical  Journal 


]        INTRACRANIAL  HEMORRHAGE  IN  THE  NEWBORN 


[Febeuaey  2,  1901 


asphyxia  which  is  apt  to  accompany  hemorrhage — the 
results  of  difficult  labor — the  primary  symptoms  may 
be  masked.  At  first  nothing  abnormal  may  be  noticed 
about  the  child.  This  is  especially  the  case  if  the  lesion 
be  of  intrauterine  origin.  If  the  hemorrhage  occur  in 
extrauterine  life,  the  evidences  are  more  or  less  acute 
in  character. 

The  symptom-complex  is  usually  as  follows  :  somno- 
lence, anorexia,  digestive  disturbances  with  vomiting 
(the  vomited  material  sometimes  consisting  of  bloody 
mucus),  piercing,  hoarse  and  fretful  cry,  contraction  or 
dilation  of  the  pupils,  convulsions.  The  outcome  of 
the  case  is  usually  fatal,  death  being  preceded  by  a 
condition  of  coma.  The  temperature  is  variable  and 
irregular.  A  continued  rise  in  temperature  is  not  com- 
monly observed.  Ordinarily  a  moderate  rise  with 
irregular  depressions  and  exacerbations  continues  until 
a  few  hours  previous  to  death,  when  a  sudden  ante- 
mortem  rise  takes  place.  Exceptionally  a  depression 
in  temperature  occurs  coincidentally  with  the  exhaus- 
tion preceding  death. 

The  following  description  of  meningeal  hemorrhage 
is  typical  of  the  course  of  such  cases :  The  infant  of 
Mrs.  K.  was  extracted  by  forceps,  after  a  delay  of  3i 
hours  with  the  head  fixed  in  the  pelvic  cavity.  The 
evidences  of  intrauterine  asphyxia  were  present  in  the 
irregularity  of  the  fetal  heart-sounds  and  the  presence 
of  meconium  in  the  amniotic  fluid.  The  child  nursed 
and  seemed  well  unto  4  days  after  birth,  when  nystag- 
mus of  both  eyes  was  noticed.  The  temperature  on 
morning  of  the  fourth  day  was  101.|°.  On  the  follow- 
ing day  marked  opisthotonos  was  observad.  The  infant's 
cry  was  shrill  and  incessant. 

On  the  sixth  day  internal  deviation  of  both  eyes  was 
present.  The  infant  was  cyanosed  and  exhibited  ven- 
ous congestion  of  the  surface  in  the  region  of  the  head 
and  thorax.  The  tongue  and  lips  were  red  and  glazed. 
The  right  corner  of  the  mouth  was  drawn  downward 
and  the  under  lip  depressed.  The  emaciation  was  very 
marked,  the  child  having  lost  If  pounds  since  birth. 
The  arms  were  extended  and  rigid,  the  fingers  being 
flexed,  and  the  thumbs  inverted.  The  evening  tem- 
perature was  i'S"  P.  The  respirations  were  labored,  72 
to  the  minute.  General  spasmodic  movements  were 
present. 

On  the  seventh  day  the  child  was  unable  to  swallow. 
At  that  time  It  had  not  been  known  to  urinate  for  2 
days.  General  convulsions  occurred,  followed  by  coma 
and  death. 

Secondary  to  the  shock,  the  result  of  the  lesion,  the 
effects  of  cerebral  compression  are  shown  in  paralysis 
with  spasm  of  all  the  extremities  (diplegia).  Hemi- 
plegia or  paraplegia  may  occur  as  a  possible  conse- 
quence of  hemorrhage  (Rotch).  Hyperesthesia  is  a 
marked  symptom.  In  certain  instances  the  course  of 
the  case  may  be  marked  by  a  condition  of  total  relaxa- 
tion. In  other  cases  the  phenomena  of  compression 
and  the  consequent  paralyses  may  appear  insiduously 
and  therefore  escape  detection. 

Diagnosis  of  Intracranial  Hemorrhage. 

The  evidences  of  a  central  paralysis  are  usually  in- 
dicative of  hemorrhage.  The  condition  of  the  anterior 
fontanel  should  be  noted  ;  in  hemorrhage  the  intra- 
cranial pressure  is  greatly  increased,  causing  a  bulging 
of  the  fontanel,  whereas  in  athrepsia  or  acute  condi- 
tions accompanied  by  defective  nutrition  there  is  a 
depression. 


Conditions  of  cerebral  congestion  may  occur  second- 
ary to  other  acute  lesions  in  the  newborn,  such  as 
asphyxia,  lobular  pneumonia,  disturbances  in  the  gas- 
troenteric tract,  septicemia,  and  tuberculosis.  In  cases 
where  the  hemorrhage  occurs  as  a  manifestation  of  cer- 
tain cachexia,  the  association  of  icterus  and  the  trans- 
lucent edema  of  the  extremities  is  to  be  observed. 
Ecchymoses  in  the  pleura,  the  pericardium,  the  mucosa 
of  the  upper  intestinal  tract,  and  hemorrhagic  infarcts 
of  the  lung  are  commonly  met  with  postmortem  as 
having  been  associated  with  the  principal  hemorrhagic 
lesion. 

Prognosis  of  Intracranial  Hemorrhage. 

Extensive  meningeal  hemorrhage  is  not  likely  to  be 
absorbed.  Hemorrhagic  conditions  occurring  sub  partu 
when  associated  with  the  milder  degree  of  asphyxia 
may  permit  of  recovery.  Where  recovery  occurs  in 
such  cases  the  diagnosis  is  open  to  doubt,  as  cerebral 
congestion  may  be  accountable  for  the  supposed  evi- 
dences of  compression.  The  latter  effects  of  hemor- 
rhage, resulting  in  secondary  pachymeningitis,  may  be 
observed.  Permanent  contractures,  idiocy  and  senso- 
rial disturbances  may  be  the  final  outcome.  Enceph- 
alitis and  leptomeningitis  are  rarely  observed  as  conse- 
quences of  hemorrhage.  Hemorrhagic  foci  compatible 
with  life  may  exist  and  in  some  instances  may  be  ac- 
countable for  the  origin  of  external  hydrocephalus. 

Treatment  of  Intracranial  Hemorrhage. 

According  to  Jewett,  the  primary  object  in  treat- 
ment in  hemorrhagic  lesions  occurring  during  birth 
and  associated  with  asphyxia,  is  to  overcome  the  atelec- 
tasis by  forced  respiration.  Schultz's  method  for  the  in- 
duction of  artificial  respiration,  warm  whisky  baths,  and 
inflation  of  the  lungs  by  forced  inspiration,  should  be 
resorted  to.  The  infant  should  be  regularly  immersed 
in  a  warm  bath  (temperature  105°)  at  intervals  of  an 
hour.  While  in  the  bath  the  surface  should  be  gently 
rubbed.  In  the  intervals  between  bathing  the  infant 
should  be  enveloped  in  a  light  blanket,  and  the  per- 
ipheral circulation  stimulated  by  heaters  applied  to  the 
lower  extremities.  An  ice-cap  should  be  constantly  ap- 
plied to  the  head.  Small  doses  of  sodium  bromid  Qt  gr.) 
combined  with  tincture  of  digitalis  (J-  gt.)  may  be  given 
at  two-hour  intervals.  Inhalations  of  oxygen  may  be  used 
to  counteract  the  results  of  inactivity  of  the  respiratory 
center.  In  case  the  infant  is  unable  to  suckle,  human 
milk  may  be  administered  after  being  pumped  from 
the  breast.  If  breast  milk  is  not  obtainable,  peptonized 
milk,  one  to  seven,  or  a  mixture  containing  two  ounces 
of  milk,  two  of  cream,  fifteen  of  sterilized  water,  one 
of  lime  water,  milk  sugar  31  drams  (F.  1,  S.  5,  P. 
0.75)  may  be  given  by  means  of  a  medicine  dropper. 
In  the  writers  experience  the  administration  of  whisky 
is  without  benefit. 


The  Demonstration  of  Bile  Pigment  in  the  Urine 
in  Cardiac  AtCectious.—F.  On  (Miinchewr  med.  ^yocfuti• 
schrift,  1900,  No.  27).  In  ord(r  to  determine  the  question 
whether  the  yellowish  diecoloiation  of  the  skin  in  grave 
cardiac  affections  is  due  to  a  true  bilirubiu-ict«rus  or  to 
other  pigment*,  the  urine  of  a  series  of  cases  was  examined, 
both  by  Gmelin's  and  the  itnproved  Salkowski  tests.  Po-i- 
tive  results  were  obtained  in  12  case*.  Bv  Salkowski"* 
method  b:le-pigment  is  not  detected  in  the  mine  when  the 
latter  contains  much  albumin  or  even  hemoglobin ;  neither 
when  medicaments  like  ealol  have  been  taken.    [M.R.D.] 


Febrdaby  2,  1901] 


URGENT  AND  SERIOUS  CONDITIONS  IN  THE  NEWBORN 


CThe  Pbiladelphia 
Medical  Joubhal 


229 


THE  CAUSES   AND  TREATMENT   OF    URGENT   AND 
SERIOUS  CONDITIONS  IN  THE  NEWBORN.* 

By  SAMUEL  WOLFE,  A.M.,  M.D., 

of  Philadelphia. 

Physician  to  the  Samaritan  Hospital,  Philadelphia. 

If  we  leave  out  of  consideration  malformations  and 
monstrosities,  the  causes  for  such  conditions  may  he 
divided  into :  (1)  Premature  birth ;  (2)  plural  births ; 
(3)  pressure  on  the  umbilical  cord ;  (4)  pressure  on  the 
head  ;  (5)  pressure  on  the  thorax  ;  (6)  toxic  conditions 
of  the  fetal  blood  incident  to  emotional  and  somatic 
states  incited  in  the  mother  during  parturition ;  (7)  es- 
sential conditions  of  the  fetus. 

Premature  Birth. — Very  few  children  sur\'ive  when 
born  prior  to  the  beginning  of  the  seventh  month  of 
gestation.  The  number  is,  however,  materially  increased 
by  modern  incubator  methods  of  treatment.  It  is  not 
an  easy  matter  to  fix  on  any  organ  or  function  the  dif- 
ficulty or  inability  of  the  infant  to  sustain  extrauterine 
life  from  the  time  it  is  considered  \Tiable  to  the  time 
when  in  due  course  of  development  it  is  intended  for 
this  phase  of  its  existence.  The  immature  condition  of 
the  bulbar  centers,  which  preside  over  the  more  dis- 
tinctly vital  functions,  as  well  as  the  unripe  state  of  the 
organs  directly  concerned  in  circulation,  respiration  and 
nutrition  are  all  concerned.  The  work  which  that  large 
and  important  organ,  the  placenta,  would  in  a  normal 
relation  have  continued  to  perform  for  a  period  of  some 
weeks,  must  now  be  done  by  structures  that  lack  the 
morphologic  and  histologic  perfection,  fully  adapted  to 
it.  Most  practically,  if  not  most  scientifically,  we  may 
speak  of  feeble  vitality,  general  immaturity,  and  inade- 
quate adaptation.  Life  for  the  time  being,  is  patholo- 
gic, rather  than  physiologic.  Nature's  plans  have  been 
disturbed,  powerful  influences  are  prematurely  demand- 
ing acceptance  or  resistance. 

Plural  Births. — Twin  pregnancies  present,  even  at  full 
term,  quite  often  somewhat  immature  products.  Vital- 
ity in  one  or  both  is  apt  to  be  low,  and  death  of  one  or 
both  is  more  common  than  under  the  same  circum- 
stances where  the  birth  is  single.  The  same  remarks 
apply  with  progressively  greater  force  to  plural  births 
where  the  number  exceeds  two.  If  to  the  element  of 
plurality  that  of  premature  nativity  is  added,  the 
chances  for  survival  are  still  further  lessened. 

Pressure  on  the  Umbilical  Cord.— Any  degree  of  pres- 
sure that  interferes  with  the  circulation  through  the 
cord  must  be  injurious  as  affecting  not  only  the  respira- 
tory function  of  the  child,  but  as  interfering  with  the 
whole  train  of  metabolic  functions  which  are  sen-ed  by 
it.  It  is  probable  that  incomplete  obliteration  of  the 
circulation,  while  transmitting  enough  oxygen  to  sustain 
life,  if  long  continued,  results  in  some  of  those  condi- 
tions which  we  will  consider  in  subsequent  sections,  and 
which  are  more  difficult  to  deal  with  than  the  asphyxia 
that  results  from  a  comparatively  short,  complete  com- 
pression. It  is  well  to  remember  that  there  passes 
through  the  cord  to  the  placenta  not  only  COj.  but  all 
waste  products  of  metabolism,  which  in  extrauterine 
life  go  to  such  emunctories  as  the  kidneys  and  skin, 
while  from  the  placenta  the  blood  carries  not  only  oxy- 
gen but  nutritive  proteids.  Bearing  all  this  in  mind 
we  may  see  that  in  partial  interference  with  the  pla- 
cental circulation  degrees  of  inanition  and  of  toxemia 

*  Read  before  the  meeting  of  the  Montgomery  County  Medical  Society,  at 
Norristown,  Pa.,  October  10,  19M. 


comparable  to  uremia  may  be  established.  While  we 
may  admit  that  asphyxia  is  the  chief  result  from  com- 
pression of  the  cord,  we  need  not  and  should  not  ignore 
the  associated  effects.  Indeed  we  are  forced  to  the  con- 
clusion that  in  some  cases  (the  ones,  too,  most  serious  to 
deal  with),  these  usually  secondary  considerations  be- 
come primary  in  importance. 

A  mechanical  effect  of  pressure  on  the  cord  is  the 
clamoring  back  of  the  blood  on  to  the  central  organs 
of  circulation,  with  consequent  distention  and  final 
stoppage. 

Pressure  on  the  Head. — Pressure  on  the  head  must  be 
quite  prolonged  and  very  severe  to  do  serious  injury  in 
the  more  ordinary  presentations  and  positions.  When 
exerted  in  certain  directions,  it  may  result  in  apoplexy 
and  paralysis,  or  in  such  injuries  as  lead  to  the  cerebral 
birth  palsies,  which  develop  beyond  the  period  of  infan- 
tile fife  which  we  are  now  considering,  and  wiU  there- 
fore in  the  present  paper  be  left  out. 

I  can,  however,  see  no  good  reason  for  doubting  that 
head-pressure  is  occasionally  concerned  in  the  produc- 
tion of  those  apparently  lifeless  infants,  by  serious 
interference  with  the  functions  of  the  important  centers 
in  the  medulla  oblongata,  which  prevent  the  normal 
establishment  of  the  respiration,  circulation  and  diges- 
tion. An  atelectatic  lung,  a  feebly  innervated  heart,  or 
a  failure  of  the  infant  to  suckle  or  digest,  one  or  all, 
may  be  the  expression  of  such  a  condition  of  the 
nervous  centers. 

Pressure  on  the  Thorax.  —  Whether  pressure  on  the 
thorax  can  of  itself  beget  any  very  serious  danger  to  the 
life  of  the  infant,  I  admit  is  rather  questionable.  In 
certain  positions,  and  especially  in  breech  presentations 
when  prolonged,  I  am  inchned  to  believe  that  it  can 
seriously  interfere  with  the  action  of  the  heart,  and  thus 
be  an  element  of  danger,  both  before  delivery  and  by  a 
continuation  of  the  effect  after  birth. 

Toxic  States  of  the  Fetal  Blood  Incident  to  Parturition. — 
The  effect  of  depressing  emotions  on  the  mother's  milk, 
as  well  as  the  reactions  of  psychical  states  on  somatic 
functions  generally,  are  sufficiently  well  recognized  to 
warrant  the  behef  that  the  mother's  feelings  can  have 
an  effect  on  the  vitality  of  her  unborn  child.  Close 
observation  on  the  part  of  the  accoucheur  wiU,  I  think, 
tend  to  confirm  this  view.  Prolonged  suffering,  great 
nervousness  and  excitement,  anxiety  and  fear  relating  to 
herself  and  child,  especially  when  coupled  with  the 
exhaustion  due  to  the  physical  strain  of  labor,  and 
which  they  materially  increase,  bode  no  good  for  the 
vitality  of  the  child.  When  joined  to  more  directly 
acting  causes,  with  which  they  are  often  associated,  the 
gravity  of  the  situation  is  increased.  As  to  its  path- 
ology while  obscurity  may  be  still  sufficient  to  allow 
the  skeptic  to  smile  at  its  mention,  there  is  a  fairly 
rational  explanation  in  a  hypothetical  toxin.  This, 
transferred  through  the  placental  circulation  and  acting 
on  nervous  and  muscular  structure  especially,  may  be 
assumed  to  work  very  decided  mischief.  Especially 
impressionable  to  such  a  cause  we  might  suppose  the 
medullar^'  centers,  whose  normal  condition  is  so  impor- 
tant. 

Essential  Conditions  of  the  Fetus. — Under  this  head, 
without  limiting  myself  too  severely  to  scientific  accu- 
racy, I  have  thought  it  practical  to  classify  such  condi- 
tions of  the  child  as  are  inherent  in  the  germ,  whether 
derived  from  the  ovule  or  the  spermatazoa  or  both. 
Also  such  as  affect  the  development  of  its  constitutional 
characteristics,  due  to  influences  acting  on  it  throughout 


230 


The   Philadelphia"! 

SAL  J 


Medical  Jocrsa 


URGENT  AND  SERIOUS  CONDITIONS  IN  THE  NEWBORN 


[Fkbbcaby  2,  1901 


gestation.  Improper  hygiene  and  sanitation,  acute  or 
chronic  diseases,  mental  suffering  or  physical  abuse  act- 
ing on  the  mother  during  any  period  of  her  pregnancy 
are  all  more  or  less  influential  in  determining  the  health, 
development,  and  A-itaUty  of  the  child.  The  discussion 
of  the  transmission  of  syphilis,  tuberculosis,  neurosis, 
and  other  diatheses,  would  lead  into  heredity  in  all  direc- 
tions, and  must  be  here  avoided,  but  its  mention  under 
this  heading  is  fully  relevant. 

The  indications  for  treatment  are  of  course  best  evolved 
out  of  the  most  complete  knowledge  and  recognition  of 
the  numerous  acting  causes,  together  with  the  patholog- 
ical conditions  they  produce,  and  the  means  which  sci- 
entific medicine  has  revealed  that  can  be  applied  in 
remo\'ing  or  overcoming  them.  StiU,  too  refined  a  scien- 
tific method,  here  as  elsewhere,  may  rather  conduce  to 
hesitation  and  irresolution  than  to  that  prompt  and  bold 
action  which  is  best  suited  to  successful  procedure  and 
results.  A  cool  head,  quick  decision,  good  sense,  and 
prompt  action  are  all  necessary. 

In  formulating  indications  and  suggesting  methods  I 
shall  not  be  exactly  guided  by  the  text  of  the  etiology 
or  the  pathology.  As  a  matter  of  fact,  at  the  moment 
of  birth  the  accoucheur  may  find  thrust  on  his  immedi- 
ate care  a  fully  developed,  lusty  infant,  which  even  be- 
fore the  whole  body  is  extruded,  cries  heartily  and 
exhibits  every  sign  of  strong  \-itality  and  good  health. 
He  has  but  Uttle  to  do,  except  to  congratulate  and  com- 
pliment the  mother,  to  wait  a  short  time  before  tying 
anil  severing  the  cord,  and  then  to  pass  the  embryo  man 
or  woman,  who  is  expected  to  mould  the  destinies  of  na- 
tions, to  a  smiling  and  bustling  nurse.  Or  he  may  have 
one  of  two  other  things  —  a  blue,  bloated,  breathless 
baby,  or  a  pale,  withered,  relaxed,  nerveless,  pitiable, 
and  apparently  lifeless  creature. 

In  the  first  instance,  a  slap  on  the  buttocks,  a  sweep 
of  the  finger  over  the  fauces,  or  a  touch  to  the  glottis, 
will  often  be  rewarded  by  a  good  loud  cry,  and  soon  the 
normal  color  is  appearing,  and  in  a  short  time  aU  is  well. 
Occasionally  one  may  be  obhged  to  give  the  youngster 
a  good  dash  of  cold  water  on  the  face,  chest,  or  back,  and 
to  roU  it  for  a  moment  or  two  on  the  bed  before  one  gets 
so  satisfactory  a  result.  But  generally,  when  once  there 
has  been  a  good  cry,  unless  the  child  is  otherwise  feeble 
and  immature,  anxiety  is  over,  and,  to  tell  the  truth, 
with  the  experienced  doctor  has  hardly  at  any  time  been 
present. 

In  the  second  instance,  however,  fixjm  the  first  the 
practitioner  may  have  grave  doubts  of  the  outcome. 
With  the  cord  uncut,  he  proceeds  first,  as  in  the  former 
instances,  attempting  to  start  respiration  by  reflex  ex- 
citement. Failing  in  this  as  he  often  will,  he  begins  the 
Sylvester  method,  changing  by  and  by  to  the  Marshall 
HaU  method  of  artificial  respiration.  Or  he  may  make 
traction  intermittently  on  the  tongue,  or  he  may  thrust 
his  finger  through  the  anus  to  dilate  rapidly  the  sphinc- 
ter, or  resort  to  mouth-to-mouth  inflation.  Failing  still, 
he  calls  for  two  vessels,  one  with  cold  and  the  other  with 
hot  water.  Dips  the  child  for  a  considerable  period  into 
the  hot  bath,  and  then  for  a  moment  into  the  cold,  re- 
peating again  and  again.  He  has  retrained  from  cutting 
the  cord,  but  now  determines  on  this  and  allows  a  small 
quantity,  a  few  teaspoonfuls  of  blood  to  flow  from  it. 
He  then  may  again  resort  to  one  or  another  of  the 
methods  already  enumerated,  or  possibly  adopt  the 
method  of  Byrd  or  of  Schultze.  Somewhere  along  the 
line  he  may  have  seen  a  quick  spasmodic  gasp,  or  have 
heard  a  feeble  moan,  and  he  is  encouraged  to  work  on. 


now  and  then  after  many  minutes,  or  even  an  hour  or 
more  of  strenuous  work,  to  succeed  feirly  in  establish- 
ing a  rather  feeble  respiration.  But  he  is  not  yet  done 
with  his  charge,  as  we  shall  presently  see.  We  have 
been  traveling  fast  in  the  last  few  minutes,  and  lest  you 
may  charge  me  with  haphazard,  reckless  and  excited 
procedure,  I  must  make  myself  a  Uttle  more  clear.  I 
by  no  means  desire  to  create  the  impression  that  we 
should  jump  indiscriminately  and  too  rapidly  from  one 
method  to  another.  While  a  long  siege  may  bring  a 
number  of  them  into  proper  requisition,  any  one  delib- 
erately chosen,  should  be  patiently  and  faUy  practised 
for  some  time.  The  advantages  of  the  Marshall  Hall 
and  the  Sylvester  method  are  that  they  can  be  thor- 
oughly carried  out  without  cutting  the  cord.  Even 
Byrd's  system  can  be  adopted  with  the  cord  attached. 
That  of  Schultze,  however,  requires  separation. 

Respiration  and  circulation  now  being  established,  to 
as  fuU  degree  as  the  more  active  immediate  efforts  can 
accomplish,  we  have  probably  the  task  of  dealing  with 
a  verj-  weak,  premature,  and  immature,  or  otherwise 
diseased  creature.  In  such  cases  especially  no  bathing 
or  washing  of  the  baby  should  be  done  at  once. 
Through  my  whole  practice  I  have  adopted  with  nearly 
all  infants  the  following  method :  Immediately  after 
birth,  before  ligating  the  cord,  the  body  is  laid  on  a 
clean  napkin  sufficiently  removed  from  the  mother's 
discharges  of  blood  to  prevent  them  from  soiling  it,  but 
without  causing  tension  on  the  cord.  Clean  lard  is 
rapidly  rubbed  over  its  whole  body  in  plentiful  quan- 
tity, especial  attention  being  given  to  the  armpits,  groins, 
scalp,  and  back,  where  the  smegma  is  thickest.  A  soft 
clean  cloth  is  used  to  rub  off  the  sm^ma  and  lard  to- 
gether, and  in  five  to  ten  minutes,  the  cord  having  been 
ligated  and  cut,  a  perfectly  clean  child  is  ready  to  hand 
to  the  nurse.     No  unguent  is  as  good  as  lard. 

Cleansing  in  this  way  having  been  accomplished 
while  jealous  care  has  been  meanwhile  observed,  not  to 
allow  it  to  become  chilled,  the  question  arises  whether 
to  wrap  the  immature  child  in  cotton  or  to  place  it  in 
an  incubator.  The  incubator  being  seldom  at  hand  the 
former  must  generally  be  resorted  to  as  a  temporarj- 
expedient,  and  where  the  infant  is  near  fuU  term,  or  is 
not  too  feeble,  it  may  be  a  sufficient  resource  through- 
out. 

The  accoucheur  should  always  have  in  his  obstetric 
bag  enough  absorbent  cotton  for  this  purpose.  The  best 
way  to  apply  it  is  to  lay  down  a  good  thick  layer,  long 
enough  to  reach  from  the  arm-pits  to  the  buttocks,  and 
wide  enough  to  envelop  the  body  of  the  child.  On  this 
at  right  angles  should  be  laid  four  narrower  layers,  twi 
above  and  two  below.  When  the  baby  is  put  on  this 
bed,  the  two  narrow  layers  are  first  brought  forward 
over  the  scapular  regions,  so  that  their  front  ends  rest 
on  the  chest,  when  the  large  layer  is  brought  round  the 
body  and  lightly  run  over  with  a  narrow  bandage,  or 
fastened  by  tapes,  care  being  exercised  that  there  is  no 
tight  binding.  The  legs  and  feet  are  then  separately 
wrapped  in  the  lower  projectmg  layers,  which  are  se- 
cured by  a  bandage.  Lastly  the  sirms  are  separately 
enveloped.  By  pulling  away  soiled  tufts  of  cotton,  and 
replacing  by  others  the  toilet  of  the  infant  can  be  easily 
and  expeditiously  made.  Artificial  heat  must  be  fur- 
nished by  hot  bottles  or  hot  water-bags. 

If  an  incubator  is  determined  on  no  expensive  ap- 
paratus is  essential.  A  little  mechanical  ingenuity,  with 
the  instructions  of  most  textbooks  on  the  subject,  will 
help  one  out. 


FUBBCABY  2,    1901] 


OTITIS  MEDIA  IN  CHILDREN  AND  ITS  TREATMENT 


PThb  Philadelphia 
L  Medical  Jocrsal 


231 


The  feeding  must  be  verj'  carefully  managed.  The 
child  may  be  too  feeble  to  nurse  from  the  breast,  even 
though  such  food  were  available.  Drawing  the  milk 
with  a  breast  pump  and  feeding  with  a  dropper  or 
spoon,  in  about  half-ounce  quantities  can  then  be  re- 
sorted to,  or  a  mixture  of  whey  and  milk  may  be  used 
in  about  the  same  quantity,  to  begin  with.  Much  pa- 
tience and  skill  are  often  required  before  the  proper 
article  for  an  artificial  food  is  finally  found,  and  before 
the  hmits  of  the  chDd's  digestion  are  fully  learned. 
This  subject  is  too  extensive  to  elaborate  within  the 
limits  of  this  paper,  and  my  hearers  are  referred  to  the 
textbooks  for  its  study. 

There  remains  but  one  other  phase  of  the  treatment 
in  such  cases  that  I  wish  to  discuss.  With  all  due  care 
as  to  warmth  and  feeding,  and  other  points  in  hygienic 
regulation,  the  use  of  drugs  may  also  be  required.  In 
spite  of  all  the  faithfulness  he  may  have  exercised  in 
bringing  about  resuscitation,  on  his  first  visit  to  his 
lying-in  patient,  the  doctor  occasionally  finds  instead  of 
normal  quiet  deep  breathing,  that  every  breath  of  the 
child  is  accompanied  by  a  feeble  moan,  or  a  slight  sigh. 
The  pulse  is  almost  imperceptible,  and  the  skin  and  lips 
are  ashen-gray  or  slightly  dusky.  When  the  child  is 
handled,  it  either  does  not  cry  at  all,  or  there  is  only  a 
plaintive  and  pitiable  sound.  He  determines  on  some 
stimulation.  Under  such  circumstances  I  have  found  the 
most  gratifying  results  from  the  administration  of 
atropia  or  nitroglycerin.  The  ordinary  hypodermic  tab- 
lets, which  every  one  carries  in  his  cases  can  be  used  for 
preparing  the  medicine,  in  such  a  way  that  each  tea- 
spoonful  of  the  atropia  solution  contains  from  xoVir  ^ 
y^Vj  of  a  grain,  while  the  trinitrin  solution  should  con- 
tain a  similar  fraction  of  a  drop  of  the  10%  solution. 
A  dose  of  each  or  of  one  or  the  other  may  be  given, 
and  its  effects  watched.  Ordinarily,  it  is  repeated  from 
two  to  six  times  in  the  24  hours.  Improvement  in  the 
complexion,  the  pulse,  and  the  respiration  can  often  be 
noted  within  an  hour  of  the  first  dose,  and  can  be  main- 
tained by  judicious  repetition  till  the  powers  of  nature 
rally.  It  is  especially  this  point  that  I  wish  to  em- 
phasize, as  I  am  not  aware  that  this  medication  has 
been  anywhere  advocated.  I  am  fully  satisfied  that  it 
has  materially  assisted  me  in  a  number  of  instances  of 
this  kind  in  tiding  over  verj'  critical  hours  and  days. 
The  recognized  physiologic  action  of  both  these  pow- 
erful drugs  may  be  invoked,  to  explain  their  usefulness 
in  enabhng  a  weak  heart  to  gain  power,  and  lessening 
the  resistance  in  a  collapsed  lung,  and  incompletely  ex- 
panded systemic  capillaries.  But  theory  aside,  let  me 
ask  at  your  hands  a  careful  trial  with  the  hope  that  you 
may  find  good  results. 


OTITIS  MEDIA  IN  CHILDREN  AND  ITS  TREATMENT.* 

By  H.  V.  WtJRDEMAXN,  M.D., 
of  Milwaukee,  Wis. 

Opbthalmic  and  Aural   Surgeon  to  the    Trinity  Hospital,  to  the  Milwaukee 

Children's  Hospital,  to  the  Milwaukee  County  Hospital  for  Chronic  Insane  : 

Professor  of  Ophthalmology  and  Otology  .Milwaukee  Medical  College  ; 

Ophthalmic  and   .\ural  Surgeon  to  the  Dispensary ;   Managing 

Editor  of  the  Annals  of  Ophthalmology  ;  .-Associate  Editor  to 

t  the  Ophthalmic  Record  ;  First  Vice-'President  Wisconsin 

State  Medical  Society  ;  etc. 

At  the  risk  of  being  deemed  dogmatic,  I  shall  en- 
deavor to  be  as  forcible  as  may  be  consistent  with  the 
deUberations  of  this  association.     Perhaps  I  may  lay 

•  Read  before  the  Wisconsin  State  Medical  Society,  June  21,  1900. 


myself  open  to  criticism  for  my  positive  language,  but 
this  paper  is  a  protest  against  unnecessary  and  some- 
times culpable  ignorance,  and  it  is  not  the  vaporing  of 
one  narrow  mind,  but  the  outcome  of  well-substantiated 
facts.  "  How  long,  Lord,  how  long,"  we  that  know,  may 
well  exclaim,  "  How  long  will  it  be  before  the  average 
intelligent  citizen  will  recognize  the  seriousness  and  im- 
portance to  Hfe  of  inflammation  within  the  ear?  " 

I  have  been  told  time  and  time  again  by  otherwise 
well-informed  people  that  they  "  thought  nothing  of  a 
discharging  ear ; "  and  by  physicians  of  the  first  class 
that  they  "  could  not  get  people  to  pay  any  attention  to 
discharging  ears,  especially  in  the  case  of  children ;  " 
"paid  no  attention  to  the  ear;"  "let  the 'ear-drum 
break  of  itself;  "  "  never  made  a  practice  of  looking  at 
children's  ears  when  sick  with  fever,  unless  their  atten- 
tion was  especially  directed  to  it,"  etc.  This  is  certainly 
a  strange  state  of  affairs,  for  surely  pediatrics  is  a  spe- 
cialty of  the  general  practitioner,  and  a  very  large  pro- 
portion of  children  have  otitis  media.  Indeed,  otitis  is 
mainly  a  disease  of  early  life,  as  is  evidenced  by  the 
average  age  of  patients  with  this  affection  in  aural  prac- 
tice. Perhaps  this  may  be  explained,  as  does  MacEwan,' 
by  the  reason  that  aside  ft'om  a  certain  proportion  of 
cases  that  heal  spontaneously  or  by  treatment,  the  obscure 
and  ofttimes  unrecognized  complications  of  the  disease 
kill  the  patient  before  maturity.  In  regard  to  the 
danger  to  life  from  suppurative  otitis  media  I  voice  the 
opinion  of  all  otologists  and  surgeons  when  I  repeat 
the  remark  of  MacEwan,  who  says  :  "  I  would  sooner 
have  a  charge  of  dynamite  in  my  ear  than  a  drop  of 
pus."  It  is  our  duty  as  members  of  a  benevolent  fra- 
ternity, tired  of  it  though  we  may  be,  to  educate  the 
public  as  well  as  ourselves  in  this  as  in  other  matters  of 
health. 

Most  of  the  diseases  of  infancy  are  certainly  due  to 
definite  bacterial  infection  arising  from  the  pharjmgeal 
postnasal  chamber,  distributing  the  infection  to  the 
middle-ear,  the  brain,  the  lungs,  the  stomach,  and  the 
intestines.  It  is,  therefore,  beyond  question  that  the 
practitioner  of  medicine  should  be  fully  qualified  to 
treat  all  ordinary  diseases  of  the  upper  air-passages,  and 
to  take  charge  of  that  very  common  affection  of  children 
— acute  otitis  media — without  the  necessity  of  referring 
to  an  otologist.  If  properly  treated,  and  seen  early 
enough,  acute  inflammation  of  the  middle  ear  seldom  or 
never  results  in  chronic  suppuration,  and  I  state  with,  all 
the  emphasis  in  my  power  that  chronic  suppuration  of 
the  middle  ear  is  positively  the  result  of  either  neglect, 
improper  or  insufficient  treatment.  (The  exceptions  to 
this  rule  are  so  rare  that  I  can  be  dogmatic  on  this 
point.)  In  a  very  large  proportion  of  cases  the  fault 
lies  with  the  patients  or  the  parents,  and  it  is  only  fair 
here  to  state  that  I  have  many  times  had  the  oppor- 
tunity to  observe  in  consultation  the  most  approved 
scientific  style  of  treatment  by  the  hands  of  the  family 
physician. 

Even  to  one  whose  daily  work  is  among  aural  patients, 
recent  statistics  are  astonishing:  Barth,-  of  Leipzig, 
found  that  out  of  600  infants  ill  with  various  affections, 
80%  were  found  to  have  a  lesion  of  the  middle-ear. 

Von  Troltsch'  found  in  examining  47  petrous  bones 
taken  from  unselected  children,  that  the  middle  ear  was 
normal  in  only  18 ;  29  ears  showing  varying  degrees  of 
purulent  or  mucous  catiirrh.  Schwartze  found  the 
t.ympanum  filled  with  pus  in  2  out  of  every  5  examina- 
tions. Wreden  found  a  normal  middle  ear  in  only  14 
out  of  80  cases  in  children.    Perhaps  the  subject  is  most 


232 


Thk  Philadelphia"! 
Medical  Jopbnal  J 


OTITIS  MEDIA  IN  CHILDREN  AND  ITS  TREATMENT 


[FEEErABT  2,   IWI 


prominently  brought  before  you  by  quoting  the  table  of 
Ponfiek,*  who  made  100  consecutive  autopsies  of  infants, 
finding  the  ears  normal  in  only  9  cases,  there  being 
tmilateral  otitis  media  in  13,  and  bilateral  in  78.  This 
table  and  the  importance  of  the  subject  was  most  forcibly 
called  to  my  attention  by  an  able  article  by  E.  H. 
Pomeroy,'  of  Calumet,  Mich. 

Poxfick's  Table. 


■ 

^ 

c 

•3 

o 

s 

-3 

s 

s 

1 

.2 

s 

g 

« 

2 

c 

2: 

» 

ca 

^ 

U 

X 

NOSDTPECriOOS  PB0CES8ES. 

1.  Congenital  heart-disease 

1 

.  ■ 

1 

•  • 

2.  Extensive  burns 

1 

3.  Noninfectious  dermatitis 

1 

2 

1 

4 

IspEcriot^  Peocesses. 

X.— Acute. 

1.  lolectious  dermatitis 

1 

3 

3 

3 

'  1 

2 

3    Scarlatina                                 .... 

1 
10 

3 

1 

5.  Meningitis  (with  or  without  pneu- 

1 
1 

"^ 

s 

18 

6.  Gastroenteritis,  acute 

7.  Gastroenteritis,    chronic    ( with    or 

without  pneumonia) 

1 

9 

21 

26 

8.  Otitis  media  only 

2 

6 

9.  Otitis  media  with  acute  bronchitis  . 

2 

,  , 

2 

8 

B.— Cftronic. 

10.  Chronic  lubeiculosis  only 

.   . 

1 

3 

Chronic  tuberculosis  with  acute  gen- 

eralization (acute  miliars  tut)er- 

culosis) 

1 

1 

10 

2 

13 

11.  Congenital  syphiUs 

3 

3 

10 

IS 

78 

13 

78 

Ponfick's  attention  to  the  subject  was  drawn  by  ob- 
serv-ation  of  his  own  children  who  liad  been  dangerously 
ill  with  gastroenteritis  :  the  symptoms  became  alarming 
in  spite  of  the  most  careful  attention  of  himself  and 
coUeagiies  and  increasingly  so  until  the  sudden  ameli- 
oration which  was  simultaneous  with  the  discharge  from 
the  ear.  The  improvement  in  the  gastroenteric  condi- 
tion continued  until  there  was  a  cessation  of  the  dis- 
charge from  the  ear.  then  came  a  relapse  of  the  gastro- 
enteric symptoms  very  gradually  and  apparently  in 
connection  with  some  changes  or  faulty  preparation  of 
the  food.  The  change  for  the  worse  was  so  gradual  and 
so  naturally  ascribed  to  the  faulty  food  that  the  dis- 
charge from  the  ear  was  well-nigh  forgotten,  until  it 
recurred  and  with  it  again  a  jironounced  ameUoration 
of  the  gastroenteric  symptoms.  This  happenetl  not 
only  with  one  child,  but  with  two  or  three  in  the  same 
family.  It  impressed  Pontick  so  much  that  he.  with  his 
associates,  obsen-ed  carefully  the  condition  in  the  first 
subsequent  100  autopsies  of  children  under  three  years 
of  age.  The  results  of  these  necropsies  are  embodied  in 
what  will  be  now  designated  Ponfick's  table,  which  con- 
tains some  most  astonishing  presentations  of  facts 
concerning  not  only  gastroenteritis   but  many    other 


conditions  in  infantile  mortality.     This  taVjle  and  paper 
are  thoroughly  discussed  in  Pomeroy's  article. 

At  our  meeting  in  1897  I  went  over  some  of  the  same 
ground  in  a  paper  upon  the  '■  Indications  for  Paracente- 
sis of  the  Membrana  TjTupani  in  Otitis  Media  Acuta," 
which  seemed  to  excite  some  interest  and  discussion 
and  its  publication  was  noticed  elsewhere  in  a  number 
of  medical  journals.  I  then  said  that  from  the  point 
of  view  of  a  modem  otologist  a  discussion  of  the  reasons 
for  early  opening  of  the  drumhead  in  otitis  media 
almost  seemed  superfluous  reiteration.  Since  that  time, 
however,  I  have  had  several  hundred  cases  of  otitis 
media,  both  acute  and  chronic,  in  a  veiy  large  prop)or- 
tion  of  which  more  or  less  pre\nous  treatment  had  been 
done  by  other  physicians,  and  in  not  one  of  which  had 
there  been  a  paracentesis  made  at  the  proper  time.  Most 
of  these  have  come  after  spontaneous  perforation  had 
taken  place.  Those,  however,  who  were  so  fortunate  as 
to  have  applied  for  treatment  early  in  the  course  of  the 
disease  before  infection  of  the  deeper  structures  had 
taken  place  and  before  the  drumhead  had  burst,  recov- 
ered in  a  very  short  time,  the  duration  of  the  average 
case  being  less  than  a  week.  At  that  time  I  gave  the 
following  indications : 

1.  Earache  is  but  a  warning  of  perhaps  dangerous 
disease,  the  pain  of  which  may  be  masked  by  opiates 
to  the  ultimate  risk  of  the  patient's  Ufe. 

2.  If  the  drumhead  is  much  reddened  or  bulging,  or 
if  fluid  is  detected,  it  is  advisable  to  incise  the  mem- 
brane at  once  before  it  bursts,  as  the  character,  location, 
and  extent  of  the  tissue-destruction  is  thereby  limited. 

3.  Pain  is  reUeved  at  once  by  the  paracentesis :  the 
course  of  the  disease  is  shortened,  the  symptoms  miti- 
gated, and  sequelae  prevented  by  this  and  appropriate 
after-treatment. 

4.  If  the  case  is  seen  after  sfKmtaneous  perforation, 
the  hole  in  the  drumhead  will  often  be  found  to  be  too 
small  or  poorly  adapted  for  proper  drainage,  and  it  may 
be  advisable  to  enlarge  it  by  paracentesis. 

5.  The  little  operation  gives  but  temporary  p»ain,  and 
if  the  physician  does  not  make  too  much  of  a  show, 
will  be  tolerated  by  any  patient,  who  will  be  thankful 
for  the  relief  afforded  his  symptoms. 

6.  Meddlesome  after-treatment  should  he  discouraged, 
as  when  the  diseased  part  is  protected  from  further  in- 
fection, and  the  discharge  not  too  frequently  removed, 
the  case  will  usually  run  a  mild  course. 

The  canal  should  be  wipetl  dry  and  rendered  aseptic 
by  sublimate  or  boric  w;\sh.  the  ptiracentesis  done  under 
sufficient  illumination  by  the  head-mirror  and  specu- 
lum, which  should  he  in  the  hands  of  ever>-  pnicti- 
tioner,  who  should  not  hesitate  to  perform  the  operation 
in  any  case  where  an  otologist  is  not  available.  A  wick 
of  iodoform  gauze  should  be  placed  in  the  canal,  to  be 
removed  not  oftener  than  twice  a  day  for  gentle  removal 
of  the  discharge  by  gentle  syringing  with  warm  boric- 
acid  solution,  after  which  the  canal  is  wiped  dry.  .an- 
other wick  of  iodoform  g-auze  inserted,  and  absorbent 
cotton  placed  in  the  canal  to  exclude  the  outer  atmos- 
phere. Attention  to  the  immediate  causes  of  the  mid- 
dle-ear affection  should  be  given,  general  symptoms  met 
by  phenacetin,  atropin  and  quinin,  the  bowels  moved  by 
calomel  and  salines,  and  the  nose  and  throat  sprayed  by 
warm  alkaline  solutions  for  cleansing  purposes  and  the 
nasal  irritation  and  intmnescence  reUeved  by  camphor- 
menthol  or  other  appropriate  spray. 

In  order  to  place  before  you  the  advantages  of  early 
paracentesis  and  the  above  described  tre:itment.  in  my 


FSBBDABY  2,    1901] 


OTITIS  MEDIA  IN  CHILDREN  AND  ITS  TREATMENT 


CThE    PUILAOKLPHIA 
Medical  Journal 


233 


experience,  I  cite  brief  case  histories  of  cases  that  have 
been  under  my  care  (in  private  practice)  from  January 
1,  1900,  to  May  1,  1900.  You  will  note  that  the  cases 
of  acute  otitis  media  which  were  seen  at  an  early  stage 
and  paracentesis  done  are  very  much  alike  in  that  im- 
mediate relief  of  the  pain  and  other  symptoms  was 
obtained  ;  the  duration  was  verj-  brief  and  in  all  cases 
the  drumhead  healed  with  complete  restoration  of  hear- 
ing. A  second  group  of  cases  is  made  of  those  in  which 
spontaneous  perforation  of  the  drumhead  had  occurred 
before  applying  for  treatment.  These  have  likewise  done 
well ;  in  a  number  the  perforation  was  insufficient  to  I 
allow  of  ready  exit  of  .the  discharge  from  the  middle 
ear  and  the  perforation  was  enlarged  with  much  benefit, 
and  in  most  cases  a  speedy  recovery  followed  under 
treatment  by  gauze  drainage. 

A  third  group  of  cases  is  made  of  those  in  which 
chronic  suppuration  of  the  drumhead  attended  by 
necrosis  of  the  walls  of  the  tympanum  and  ossicles, 
polypoid  and  granulation  formation  had  taken  place. 
In  a  number  of  these,  by  minor  operative  procedures 
and  antiseptic  means,  healing  was  obtained  ;  others  are 
yet  under  treatment.  These  and  those  which  I  place 
under  group  4  are  a  decided  contrast  to  those  in  the 
first  and  second  group.  I  hold  them  up  to  you  as 
"  horrible  examples."  All  are  certainly  the  result  of 
neglect,  of  improper  or  of  insufficient  treatment  and 
have  only  come  to  the  hands  of  the  otologist  when 
warned  by  painful  or  severe  sj'mptoms  that  their  life 
was  in  danger.  By  going  back  in  my  case  books  for 
ten  years,  I  could  multiply  such  examples  by  the 
hundred  and  furnish  you  with  many  more,  such  in 
which  the  patients  were  not  so  fortunate,  for  death  en- 
sued before  proper  treatment  could  be  applied.  I  quote 
you  but  one  example  of  the  latter,  which  I  class  under 
group  5,  as  but  one  such  case  has  been  under  my 
observation  during  the  last  4  months. 

Group  I. — Cases  of  Otitis  Media  Acuta,  applying  for  treatment 
bf/ore  spontaneous  perforation  of  drumhead  occurred. 
(7  cases.) 

Case  1. — I.  L.,  age  23,  Wauwatosa ;  referred  by  Dr.  Cutler  ; 
acute  otitis  media  L.:  paracentesis,  gauze  drainage ;  dura- 
tion f  f  discharge  after  beginning  treatment,  5  days. 

Case  2. —  L.  M.,  age  14,  Milwaukee  ;  seen  in  consultation  with 
Dr.  Reinbard ;  suppurative  otitis  media  R  and  L.,  following 
grip ;  treated  by  paracentesis,  and  subsequent  dressings  by 
Dr.  Reinhard  ;  healing  of  both  Mt.  in  2  weeks. 

Case  3.— D.T.,  age  5,  Milwaukee  ;  acute  sup  urative  otitis 
media  L.;  paracentesis,  gauze  dressing ;  duration  3  weeks. 

Case  4. — C.  L.,  age  50.  Milwaukee  ;  referred  by  Dr.  H.  M. 
Brown ;  otitis  media  acuta ;  hemorrhage  R ;  paracentesis, 
gauze  drainage;  duration,  1  week. 

Case  5. — Mrs.  W.  D.,  age  30,  Milwaukee :  referred  by  Dr. 
Berger ;  otitis  media  acuta  L  ;  was  suffering  great  pain  and 
had  taken  considerable  morphin  during  last  3  days ;  para- 
centesis was  done  with  immediate  relief,  gauze  drainage ; 
discha'ge  ceased  in  2  weeks. 

Case  6  — Sr.  A  ,  age  43,  MUwaukee  ;  acute  otitis  media  R.; 
paracentesis  and  antiseptic  dressing ;  duration  of  discharge 
4  weeks. 

Case  7. — Miss  T.  G  ,  age  25,  Milwaukee;  referred  by  Dr. 
Batchelor ;  acute  otitis  media  L.,  several  days ;  no  discharge ; 
mastoid  tender  ;  temperature  100.5°  ;  paracentesis,  free  dis- 
charge, iodoform  gauze  drainage ;  extent  of  treatment,  1 
week. 

Geoup  XL— Cases  of  Otitis  Mfdia  Acuta,  applying  for  treatment 
after  spontaneous  perforation  of  drumhead  occurred. 
(8  cases). 

Case  8. — M.  W.,  age  8  months,  Milwaukee  ;  otitis  media  2 
weeks  following  scarlet  fever ;  large  perforation  in  R.,  small 


in  L.;  paracentesis,  gauze  drainage  both  ears;  duration  about 
6  weeks. 

Case  9. — Miss  E.  H  ,  age  25,  Green  Bay ;  referred  by  Dr. 
Brett;  acute  suppurative  otitis  media  for  2  weeks  R  ,  with 
f^icial  paralysis  of  10  days'  duration  following  grip ;  retention 
symptoms ;  small  perforation  and  bulging  membrana  flac- 
c  da ;  paracentesis  released  considerable  scrum ;  gauze 
drainage  ;  membrane  healed ;  no  discharge  ;  in  3  weeks 
all  symptoms  relieved,  except  the  Bell's  palsy,  which  was 
nearly  well  2  weeks  later. 

Case  10. — W.  \V.,  age  10,  Milwaukee ;  subacute  otitis 
media ;  perforation  L.  Mt.;  this  is  a  recurring  case  ;  patient 
has  been  under  treatment,  more  or  less,  for  the  last  5  .\ears, 
having  had  a  number  of  attacks  of  otitis  media,  each  of 
which  has  been  relieved  within  a  few  days  by  paracentesis 
and  gauze  drainage ;  adenoid  and  other  operations  have 
been  done  with  benefit. 

Case  11. — M.  B.,  age  3,  Milwaukee;  referred  by  Dr. 
Mueller;  otitis  media  acuta  R.  and  L.  1  week:  ruptured 
drumhead  one  side  ;  double  paracentesis  R.  and  L.,  gauze 
dressing ;  healing  in  3  days. 

Case  12. — B.  B.,  age  1,  Milwaukee;  referred  by  Dr. 
Mueller;  otitis  media  acuta  R.  and  L.;  small  perforations 
both  sides  ;  double  paracentesis  R.  and  L  ,  gauze  dressing; 
healing  in  1  week.  &£3i 

Case  13.— Mrs.  A.  H.,  age  25,  Crystal  Falls,  Mich.;  refened 
by  Dr.  Darling ;  acute  suppurative  otitis  media  2  weeks 
before  :  slight  discharge  from  middle  ear,  which  ceased  after 
paracentesis  and  1  dressing. 

Case  14.  Mrs.  C.  M.  P.,  Mt.  Clarp,  N.  J.,  referred  by  Dr. 
Bradlield  of  La  Crosse  for  simple  dressing  for  an  acute  otitis 
media  ;  referred  to  Dr.  Allport,  of  Chicago,  and  Dr.  Knapp, 
of  Isew  York,  as  she  was  on  her  way  home. 

Case  15.— Mrs.  T.  P.,  age  45,  Milwaukee;  acute  suppura- 
tive otitis  media  R.;  discharge  for  4  days  ;  retention  synip- 
toms ;  hyperexia ;  had  been  under  treatment  by  a  high 
potency  homeopathist ;  great  pain  for  5  days ;  paracentesis 
and  gauze  dressing  relieved  symptoms  at  once ;  although 
patient  got  immediate  relief,  she  returned  but  once ;  sub- 
sequent course  unknown. 

Group  III. — Cases    of    Otitis  Media   Suppurativa     Chronica. 
(12  cases.) 

Case  16.— W.  (i.,  age  4,  Milwaukee;  referred  by  Dr.  Jer- 
main  ;  chronic  suppurative  otitis  media ;  perforation  both 
membrana  vibrans  R.  6  months ;  L.  1  month  ;  daily  anti- 
septic dressing  ;  R.  healed  in  1  dressing;  L  within  3  weeks. 

Case17.  — H.O.  R  ,  age  35,  Milwaukee  :  chronic  suppurative 
otitis  media  R.  and  L.  for  7  years;  large  perforations  boh 
membrana  vibrans  and  in  both  membrana  fiaccida  :  very 
foul  discharge ;  treated  antiseptically  3  months  ;  nasal  treat- 
ment, tonsilotomy  ;  at  end  of  2  months  removed  remains  of 
drumhead  and  ossicle  ;  by  antiseptic  treatment  for  2  weeks 
discharge  ceased  ;  since  that  time  patient  has  returned  for  a 
couple  of  visits  with  i-light  catarrhal  otitis  media ;  no  odor 
hears  better  than  before  operation  ;  extent  of  treatment,  4 
months. 

Cask  18.-  S.  H.,  agd  8,  Albion,  Wis. ;  referred  by  Dr.  Lord; 
suppurative  otitis  media  L.  6  months ;  small  perforation 
membrana  vibrans  ;  paracentesis,  iodoform  gauze  dressing  ■ 
suppuration  ceased  in  4  days. 

Case  19.— J  P.,  age  40,  "Milwaukee;  chronic  suppurative 
otitis  media  R.  and  L. ;  large  perforations,  osseous  necrosis; 
referred  to  me  by  Dr.  Miles  Clark  for  opinion  upon  life  in- 
surance, this  was  refused  him  on  account  of  the  unhealthy 
condition  of  his  ears  ;  no  treatment. 

Case  20.— F.  F.,  age  IS,  Milwaukee  ;  referred  by  Dr,  Wm. 
Meyer;  chronic  otitis  media  with  large  perforations  in  the 
right  ear  since  scarlet  fever  10  years  before  ;  treatment  anti- 
septic dressing ;  cured  in  1  week ;  patient  was  later  sub- 
jected to  considerable  operative  treatment,  straightening  of 
nasal  septum  and  hypertrophic  rhinitis ;  duration  of  dis- 
charge 1  week. 

Case  21.— 0.  H.,  age  S.Milwaukee;  deaf-mute  from  sup- 
purative otitis  media  following  scarlatina  at  1  year  of  age 
R.  and  L. ;  jaws  locked  ;  sent  to  Children's  Hospital  for  anti- 
septic treatment,  but  was  there  only  1  day  when  she  was 
removed  bv  her  parent*. 

Case  22.— 0.  H  ,  age  10,  Crvstal  Falls,  Mich.;  referred  by 
Dr.  Darling;  chronic  suppurative  otitis  media  since mfancy, 


234 


The  Philadelphia 
Medical  Journal 


J        OTITIS  MEDIA  IN  CHILDREN  AND  ITS  TREATMENT 


[Febbcart  2,  1901 


with  perforation  both  ears ;  discharge  ceased  in  2  dressings ; 
this  case  had  considerable  adenoids  which  were  removed  by 
operation  ;  duration  of  treatment  4  days. 

Case  23.— S.  B.,  age  5,  Milwaukee;  chronic  otitis  media ; 
perforated  Mt  both  sides.  This  child  had  large  amount  of 
adenoids  ;  operation  was  advised,  but  patient  did  not  return 
after  first  examination. 

Case  24. — J.  H.,  age  35,  Kaukauna ;  referred  by  Dr.  Boyd  ; 
suppurative  otitis  media  L.  for  number  of  years;  large  per- 
foration; this  ear  had  been  "scraped  out"  by  a  quack; 
slight  discharge  which  was  relieved  by  2  dressings ;  duration 
3  days. 

Case  25. — H.  B,  age  8,  Milwaukee;  referred  by  Dr.  Lev- 
ings ;  chronic  suppurative  otitis  media  R.  and  L. ;  large  per- 
forations; this  condition  was  due  to  inflammation  following 
operation  for  cleft  palate  6  years  before  ;  duration  3  weeks. 

Case  26.— O.  E.  P.,  age  32,  Winneconne;  had  at  one  time 
chronic  suppurative  otitis  media  with  very  large  perforation 
membrana  vibrans  ;  no  discharge  for  1  year ;  no  treatment. 

Case  27.— L.  P.,  age  10,  Milwaukee  ;  referred  by  Dr.  O'Mal- 
ley ;  suppurative  otitis  media  R.  and  L  ;  small  perforations 
both  membrana  vibrans  following  scarlet  fever  8  weeks  ago, 
then  when  mastoid  was  swollen  and  an  incision  had  been 
made,  but  no  paracentesis  had  been  done,  she  was  referred 
to  me  by  the  attending  physician,  but  was  not  brought  by 
her  parents  until  4  weeks  later;  when  she  came  to  me  there 
was  hyperexia ;  both  mastoids  tender  and  swollen  ;  foul  pus 
in  both  canals,  but  poor  drainage  ;  child  had  considerable 
adenoids ;  both  mother  and  child  were  exceedingly  nervous 
and  refused  to  have  the  paracentesis  done  in  office,  which 
was  advised,  and  wanted  to  go  to  the  hospital,  but  did  not 
report  there  at  appointed  time.  This  case  had  severe  reten- 
tion symptoms,  and  should  have  had  paracentesis  done  at 
once.     I  do  not  know  what  became  of  her. 

Group   IV.— Gases  of   Anite  and  Chrojiic]  Otitis  Media,  with 
Ivvolvement  of  Mastoid,  necessitating  radical   operation. 

HOT  (5  cases.);  ,^ 

Case  28. — H.  S.,  age  48,  Milwaukee;  acute  suppurative 
otitis  media  R.  5  weeks ;  disi  harge  suddenly  stopped,  due  to 
swelling  shut  of  the  external  canal ;  at  exarnination  had 
hyperexia;  great  vertigo  due  to  severe  mastoiditis;  side  of 
the  head  and  neck  being  badly  swollen  ;  Stacke-Schwartz 
operation  at  hospial ;  found  erosion  of  bone  over  mastoid  as 
well  as  much  pus  which  was  passing  down  the  tissue  of 
neck  ;  subsequent  drainage ;  cure  of  case  in  4  weeks 

Case  29.— J.  W  ,  age  54,  Dubuque,  la.;  suppurative  otitis 
media  L.  for  many  years  I  went  to  Dubuque  in  consulta- 
tion with  Dr.  Gratiot,  of  that  city,  finding  patient  with  great 
vertigo,  pain  inside  of  head,  hyperexia,  and  having  sudden 
cessation  of  discharge  from  ear;  performed  Stacke-Schwartz 
operation  on  mastoid  finding  sclerosed  temporal  bone  ;  cere- 
bral symptoms  relieved  by  operation ;  wound  behind  ear 
closed  by  first  intention ;  duration  of  after-treatment  1 
month ;  no  discharge  from  middle  ear  when  I  saw  him  2 
months  later. 

Case  30.— Sr.  I ,  age  40,  Milwaukee ;  earache  1  month  fol- 
lowed by  discharge  which  suddenly  stopped  1  week  ago ; 
great  pain  ;  much  edematous  swelling  of  mastoid,  extending 
into  neck  ;  hyperexia ;  Stacke-Schwartz  operation  ;  mastoid 
as  well  as  antrum  found  full  of  pus  and  granulations;  dura- 
tion 1  month. 

Case  31  —A.  W.,  age  12,  Kingston,  referred  by  Dr.  Both- 
well  ;  grip  4  weeks  ago,  followed  by  deafness  and  pain  in 
ear;  no  discharge  from  ear  from  that  time  to  tliis  date; 
slight  swelling  and  redness  of  mastoid;  great  pain  on  pres- 
sure and  hyperexia ;  child  had  been  steadily  running  down  ; 
Stacke-Schwartz  operation  showed  the  mastoid  portion  of 
temporal  bone  to  be  a  mass  of  granulation  tissue,  which  was 
readily  removed  with  spoon  ;  rapid  amelioration  and  restor- 
ation to  health  and  healing  of  wound  ;  duration  4  weeks. 

Case  32.— J.  L..  age  16,  Eau  Claire  ;  referred  by  Dr  Lyman  ; 
chronic  suppurative  otitis  media  sinistra  since"  scarlatina  in 
infancy ;  large  perforation  in  membrana  tlaccida,  small  in 
membrana  vibrans  Despite  much  treatment  by  specialists 
a  malodorous  discharge  persisted,  which  contained  much 
exfoliated  epithelium  Diagnosis  of  tympanic  necrosis  was 
proven  by  the  results  of  a  Stacke  operation,  which  secured 
drainage,  improved  hearing,  and  entirely  removed  odor  from 


the  secretiou,  which  occurs  at  times  in  small  quantity  and  is 
readily  controlled. 

Group  V. —  OtUis  Media  Suppurative;  Mastoiditis;  Abscess  of 
Cerebrum  ;  Meningitis  ;  Death.     (1  case.) 

Case  33  — Miss  C.  L.,  age  21,  Wauwatosa  ;  referred  by  Dr. 
Cutler ;  has  been  a  patient  of  mine  for  10  years,  coming  for 
recurring  attacks  of  suppurative  otitis  media ;  patient  has 
been  extremely  neglectful,  never  submitting  to  thorough 
treating,  ceasing  her  visits  and  presumably  each  time  on 
account  of  my  advice  that  she  should  submit  to  the  small 
operation  of  removal  of  the  necrosed  ossicles  and  caries  of 
the  middle  ear  through  the  canal ;  this  was  never  followed ; 
at  all  times  there  was  small  perforation  of  both  tympanic 
memt)ranes.  On  May  4, 1900,  she  was  brought  to  me  by  her 
mother,  having  had  suppurative  otitis  media  for  2  weeks ; 
both  the  family  physician  and  another  aurist  having  been  in 
attendance,  they  having  called  for  me,  but  for  some  reason 
not  having  obtained  me  at  the  time,  no  paracentesis  had 
been  done  and  treatment  had  been  simple  boric  acid  wash. 
When  I  saw  her  there  was  hyperexia,  bulging  of  the  tym- 
panic membrane,  small  amount  of  puss  exuded  through 
small  perforation  on  the  left  side ;  immediate  paracentesis 
with  gauze  dressing  apparently  relieved  the  retention  symp- 
toms, but  one  week  later  typical  sj'mptoms  of  cerebral  ab- 
scess were  evident,  drowsiness,  frontal  headache,  apyrexia, 
dyslexia,  sensorj'  and  motor  aphasia,  etc. ;  trephining  over 
the  temporal  lobe,  together  with  radical  mastoid  operation, 
was  made ;  large  amount  of  pus  evacuated  ;  patient  lived 
for  1  month  after  operation,  death  being  due  to  extension  of 
the  necrotic  process  within  the  cerebrum  ;  this  case  might 
well  have  been  saved  by  the  very  simple  surgical  procedure 
which  had  been  again  and  again  advised  during  the  previoua 
10  years.    Death  15  years  after  original  otitis  media. 

The  technic  of  the  treatment  of  suppurative  otitis 
media  is  so  extremely  simple  and  the  diagnosis  is  gen- 
erall}"  so  easy  that  but  Utile  experience  renders  any 
practitioner  as  skilful  as  the  specialist.  Everj'  physician 
should  possess  and  be  sufficiently  familiar  with  the 
reflecting  mirror  and  aural  speculum  that  he  can  use  it 
for  diagnosis  at  least  in  his  own  practice ;  he  should 
have  a  paracentesis  knife  in  his  pocket-case  and  use  it 
as  freely  as  he  does  the  hypodermic  needle.  In  a  pro- 
fessional experience  of  nearly  20,000  patients,  I  have 
never  seen  from  my  own  hands  or  from  those  of  others, 
any  damage  done  by  paracentesis  of  the  drumhead  for 
acute  otitis  media ;  whereas  its  indications  are  daily  met 
with  in  the  practice  of  the  otologist  and  in  that  of  the 
general  practitioner  so  often  that  he  ought  to  be  familiar 
with  this  branch  of  pediatrics  and  surgery-. 

The  necessity  for  examination  of  the  ear  and  care  of 
aural  inflammation  in  all  cases  of  grave  disease  in  chil- 
dren is  certainly  demonstrated.  But  my  personal  expe- 
rience with  other  physicians,  both  as  a  general  prac- 
titioner and  as  an  otologist,  shows  that  it  is  done  too 
seldom,  A  considerable  portion  of  cases  that  eventually 
come  to  the  aurist  could  have  been  saved  the  additional 
annoyance,  detention  from  business  and  expense  neces- 
sitated by  the  complications  following  the  original 
earache  if  they  had  been  originally  under  scientific 
treatment  by  the  family  physician. 

bibliography. 

>  Dis.  of  Brain  and  Spiaal  Cord.  1$9S. 
-  Archiv.  cf  OloloQV,  Tol.  iXTiii,  Nos.  5  and  6,  1900. 
'  Rotch  :  Pediatrics,  1890. 

«  Berliner  klin.  Wocliauchr.,  September  to  October,  1897. 

'  "  Otitis  Media  in  AU  Grave  Diseases  of  Infancy,"  Botton  Hfedital  Jottnfl, 
JanuarT  18, 1900. 


Ag-aiDst  Tuberculosis. — The  German  Department  of 
the  Interior  has  issued  instructions  conveying  compulsory 
precautions  to  be  taken  against  the  spread  of  tuberculosis  in 
the  Empire,  a  copy  of  which  has  been  sent  to  the  DepirUneat 
of  State  by  I'nited  States  Consul  Monaghan  at  Chemniti. 


Fbbruaby  2,  1901] 


MASTOID  DISEASE  AND  ITS  COMPLICATIONS 


[ 


The  Philadklphia 
mskical  joubnal 


235 


A   CRITICAL     REVIEW    OF    THE    LITERATURE    OF 
MASTOID  DISEASE  AND  ITS  COMPLICATIONS. 

By  SEYMOUR  OPPENIIEIMER,  M.D., 

of  New  York. 

Laryngologist  to  Bellevue  Hospital  Dispensary  ;    Laryngologist  to  University 
Medical  College  Dispensary  ;  Instructor  in  Laryngology, 
University  Medical  College. 

While  the  year  1899  was  not  productive  of  any  radi- 
cal discoveries  relating  to  the  better  appreciation  of 
mastoid  disease,  nor  were  any  new  operative  measures 
devised  for  its  relief,  yet  great  progress  was  made  in 
otology  and  the  diagnosis  and  operative  technic  were 
placed  upon  a  firmer  foundation  by  minute  and  detailed 
studies.  The  function  of  the  specialist,  his  ability  to 
appreciate  the  slightest  details  presented  by  the  anat- 
omy and  the  pathology  of  the  mastoid  and  its  relation 
to  the  surrounding  structures,  the  cerebral  cavity,  the 
sinuses  and  larger  veins,  the  temporal  bone  as  a  whole 
and  lastly  to  the  individual,  is  becoming  better  appre- 
ciated and  as  a  result  the  operative  procedures  upon 
this  region  and  its  contiguous  structures  are  being  per- 
formed more  by  the  otologist  and  less  by  the  general 
surgeon.  During  the  year  many  valuable  papers  have 
been  published  bearing  upon  this  subject  and  it  is  my 
desire  to  direct  your  attention  to  the  salient  features 
that  seem  of  import  in  elucidating  some  of  the  obscure 
points  attached  to  the  diseases  of  this  region. 

While  the  diagnosis  of  acute  mastoiditis  rarely  pre- 
sents any  great  difficulties,  and  in  chronic  cases  consec- 
utive to  suppurative  processes  of  the  tympanum  the 
well  known  signs  of  mastoid  involvement  are  suffi- 
ciently evident  to  indicate  operative  procedures,  yet 
there  are  certain  cases  in  which  additional  aid  is  often 
of  extreme  value.  This  is  shown  in  a  communication 
by  Cozzolino  and  Barrogo-Ciarella,'  who  call  attention 
to  a  new  and  pathognomonic  symptom  of  chronic  mas- 
toid empyema;  the  rapid  reappearance  of  pus  after 
cleansing  of  the  tympanum  and  also  by  its  always  flow- 
ing in  a  single  line  over  the  inner  wall  of  the  cavity 
from  the  posterosuperior  to  the  posteroinferior  seg- 
ment. As  no  further  reports  have  as  yet  appeared  con- 
cerning the  practical  value  of  this  sign,  considerable 
hesitancy  must  be  expressed  before  accepting  such  an 
equivocal  symptom,  as  it  is  hardly  possible  even  for 
the  expert  to  watch  the  downward  flow  of  pus  as  indi- 
cated by  the  authors,  and  further,  although  we  fully 
appreciate  the  fact  that  pus  may  exist  in  the  antrum 
for  long  periods  of  time  without  producing  general  or 
local  symptoms,  other  than  those  of  a  quiescent  chronic 
otitis  suppurativa,  yet  it  seems  hardly  credible  that  this 
should  be  the  only  sign  present  to  the  exclusion  of 
others  of  better  reputation.  One  would  hardly  care  to 
open  the  mastoid  upon  the  evidence  of  this  single 
symptom. 

Bearing  on  the  differential  diagnosis  of  mastoid  dis- 
ease is  the  valuable  paper  of  Bar^  on  the  similarity  of 
anterior  mastoid  abscess  and  furunculosis  of  the  meatus. 
Although  this  question  of  diagnosis  is  not  nearly  as 
frequent  as  the  mere  determination  of  the  presence  or 
absence  of  mastoid  empyema,  yet  I  have  seen  several 
cases  in  which  the  differentiation  was  most  difficult. 
Where  necrosis  is  confined  in  greater  or  less  part  to  the 
anterior  portion  of  the  pneumatic  spaces,  a  fistula  some- 
times forms  and  opens  into  the  external  canal  on  the 
posterior  or  inferior  wall,  and  but  a  few  millimeters 
from  the  meatus.  Around  the  sinus  so  produced  the 
dermal  lining  and  periosteum  become  inflamed,  and  an 


elevation  is  produced  resembling,  to  a  most  striking 
extent,  a  furuncle.  The  similarity  is  decidedly  more 
marked  when  the  opening  of  the  sinus  becomes  ob- 
structed and  the  local  infection  is  most  accurately 
simulated.  The  diagnostic  features,  as  given  by  the 
author,  are  of  sufficient  importance  to  be  quoted 
in  extenso  : 

1.  Early  lymphangitis  and  periauricular  adenitis  are 
the  rule  in  furuncular  affections  of  the  meatus,  and  are 
late  and  exceptional  in  purulent  inflammation  of  the 
limiting  cells.  This  is  consequent  on  the  difference 
between  the  lymphatic  systems  of  the  external  and 
middle  ear. 

2.  Perimastoid  edema  effaces  the  retroauricular  de- 
pression in  furunculosis;  whereas,  in  mastoiditis,  the 
depression  persists  and  remains  circumscribed. 

3.  The  pharyngeal  plexus  may  become  visible  through 
venous  stasis,  induced  by  mastoiditis. 

4.  Spontaneous  pains  and  sensitiveness  are  more  acute 
in  furunculosis ;  they  are  less  marked  in  anterior  abscess 
of  the  mastoid. 

5.  In  inflammation  of  the  anterior  cells,  facial  paresis 
is  sometimes  observed,  as  is  also  an  exaggeration  of  the 
sense  of  taste  and  a  peculiar  sensitiveness  of  the  pharynx 
and  the  end  of  the  tongue. 

6.  The  bacterial  nature  of  the  pus  is  different  in  the 
two  diseases. 

7.  In  the  absence  of  any  febrile  condition,  a  con- 
tinuous disproportion  between  the  pulse  and  the  tem- 
perature is  in  favor  of  mastoiditis. 

In  addition  to  these  points  I  would  add  that  the  pain 
is  a  constant  feature  of  furunculosis,  except  in  a  small 
proportion  of  diabetic  cases  in  which  the  tissue  breaks 
down  with  little  or  no  disturbance  of  sensation,  while 
in  quite  a  large  proportion  of  purulent  affections  of  the 
anterior  cells  there  is  little  pain,  and  frequently  none 
at  all.  While  in  this  form  of  mastoid  abscess,  a  sinus 
usually  exists  by  the  time  the  patient  is  first  seen  and 
can  be  readily  probed,  in  my  experience  this  being  of 
the  greatest  value  in  the  differentiation  of  the  two 
affections. 

The  use  of  percussion  in  the  diagnosis  of  acute  mas- 
toid disease  has  received  considerable  attention  on  the 
continent,  and  Eulenstein,'  considering  this  method  of 
some  value,  has  suggested  the  following  conclusions 
from  a  study  of  10  cases: 

1.  By  means  of  percussion  (compared  with  that 
of  the  other  side)  a  positive  diagnosis  of  a  diseased 
condition  of  the  mastoid  can  be  made,  provided  dul- 
ness  is  elicited. 

2.  Dulness  on  percussion  indicates  the  presence  of  a 
diseased  area  near  the  surface  of  the  bone,  the  degree 
of  dulness  depending  upon  the  extent  of  the  area  in- 
volved. 

3.  The  absence  of  dulness  is  no  proof  that  the  bone 
is  not  diseased. 

4.  Where  other  symptoms  of  mastoid  disease  are 
present  and  there  is  no  dulness  on  percussion,  it  indi- 
cates that  the  diseased  area  is  either  very  small  or  deep- 
seated. 

5.  By  percussion  we  are  enabled  to  recognize  mas- 
toid disease  earlier,  and  it  is  a  valuable  adjunct  to  the 
indications  for  opening  the  mastoid. 

From  a  study  of  6  cases  of  acute  mastoiditis  in  which 
percussion  was  used  as  an  aid  to  diagnosis  in  my  hands, 
it  signally  was  of  no  service,  because  light  percussion 
will  not  elicit  any  sounds  that  can  be  compared  with 
the  normal  side,  and  where  deep  percussion  is  tried  the 


236 


Ths  Philasblphia"! 

Medical  Journal  J 


MASTOID  DISEASE  AND  ITS  COMPLICATIONS 


(Fkbruarv  2, 1901 


pain  is  too  great,  so  that  in  the  majority  of  cases  the 
method  is  impracticable.  Further,  dulness  does  not 
necessarily  indicate  the  presence  of  pus,  as  it  may  be 
demonstrated  in  superficial  edema  of  this  region  with- 
out bone  involvement.  It  may  also  be  exaggerated 
where  the  bone  is  sclerosed,  or  in  those  cases  where  the 
pneumatic  cells  are  few  in  number  or  absent  near  the 
surface.  This  was  demonstrated  in  a  case  recently  ob- 
served, in  which  the  patient  complained  of  intolerable 
pain  over  the  mastoid  area,  swelling  of  the  tip  and  im- 
pairment of  general  health,  with  an  irregular  tempera- 
ture. Dulness  over  the  entire  region  in  comparison 
with  the  normal  mastoid  was  marked,  but  on  opening 
the  process  it  was  found  to  be  normal ;  the  pain  being 
neuralgic  in  character  as  proved  by  its  subsequent  dis- 
appearance, while  the  swelling  resulted  from  glandular 
enlargement. 

The  broadening  of  the  surgical  field  of  the  aurist  has 
been  but  the  inevitable  outcome  of  better  diagnostic 
methods,  and  it  can  safely  be  said  that  many  obscure 
head-lesions  are  being  better  appreciated,  and  their  inti- 
mate etiological  relationship  to  aural  suppuration  affords 
an  inviting  field  for  surgical  measures  presaging  relief 
in  a  greater  proportion  of  cases  than  has  heretofore  been 
possible.  This  has  been  greatly  aided  by  the  detailed 
study  of  individual  cases  of  mastoid  disease  and  its 
complications,  such  an  instance  being  reported  by  Ler- 
moyez  *  of  mastoiditis  with  perforation  of  the  medial 
plate  and  consecutive  abscess  in  the  neck  beneath  the 
insertion  of  the  sternomastoid  muscle.  This  case  oc- 
curred in  an  infant  following  acute  otitis  media,  and 
while  not  unique  at  all,  yet  the  report  is  valuable  as 
teaching  two  important  lessons,  the  first  being  that  the 
serious  symptoms  of  an  uncomplicated  otitis  were  the 
result  of  excessive  treatment,  and,  secondly,  that  the 
presence  of  a  cervical  abscess  should  always  suggest  a 
focus  of  suppuration  in  some  portion  of  the  aural  region. 

Mastoiditis  with  perforation  of  the  medial  plate,  as 
pointed  out  a  number  of  years  ago  by  Bezold,  is  more 
frequent  than  generally  supposed,  and  with  the  deep 
burrowing  of  pus,  the  tissues  of  the  neck  become  in- 
fected, and  extensive  operative  measures  are  required. 
Burnett,'  in  reporting  an  interesting  case  of  acute  mas- 
toiditis with  perforation  of  the  medial  plate  and  con- 
secutive abscess  of  the  neck,  takes  occasion  to  call  atten- 
tion to  the  routes  by  which  mastoid  and  tympanic 
suppuration  are  propagated  to  adjoining  regions.  Three 
ways  are  currently  accepted  ;  by  the  veins,  by  the 
lymphatics,  and  by  the  direct  escape  of  the  pus 
through  a  spontaneous  opening  in  the  medial  plate,  this 
latter  being  socalled  Bezold's  mastoiditis.  Lewis''  and 
Dunn'  report  similar  cases,  showing  clearly  the  possi- 
bilities for  harm  resulting  from  delayed  treatment  of 
simple  mastoid  inflammation.  The  former's  case  was 
one  in  which  the  process  was  filled  with  a  cholestea- 
toma, with  an  eroded  area  in  the  floor  of  the  middle 
cerebral  fossa,  and  another  in  the  wall  of  the  sigmoid 
fossa.  There  was  an  opening  along  the  diagastric 
groove,  through  which  the  mastoid  was  in  direct  com- 
munication with  an  abscess  of  the  neck.  As  the  patient 
was  24  years  old,  and  had  had  a  suppurative  otitis 
media  from  infancy,  it  clearly  becomes  evident  that  the 
double  danger  to  which  she  was  subjected,  both  from  a 
suppurative  process  and  a  mechanical  obstruction  to 
free  drainage  by  the  cholesteatoma,  should  have  been 
removed  several  years  before  she  was  seen  by  the 
author.  Dunn's  case  is  instructive  as  showing  the 
extent    to   which   the  pus   may   burrow   and   extend 


in  several  directions  from  the  mastoid  focus.  There 
were  pain  and  swelling  over  the  left  ear  and  a  partial 
facial  paralysis,  but  no  middle  ear  discharge  at  any 
time.  The  mastoid  was  found  infiltrated  with  pus  and 
granulations,  and  the  patient  did  well  for  10  days, 
when  stiffness  of  the  left  side  of  the  neck  developed 
with  a  swelling  over  the  upper  end  of  the  sternomas- 
toid muscle.  An  abscess  was  then  found  lying  between 
the  sinus  and  the  inner  table  of  the  skull,  and  following 
the  lateral  sinus  along  its  course  for  about  i  inch  and  the 
sigmoid  sinus  for  about  the  same  distance.  Follow- 
ing these  symptoms,  pain  on  swallowing  developed, 
and  finally  an  abscess  in  the  neck  burst  into  the  esoph- 
agus. It  will  be  seen,  therefore,  that  following  the 
original  perforation  of  the  mastoid,  the  pus  had  formed 
an  epidural  and  subpetrous  abscess,  and  had  then  bur- 
rowed deeply  in  the  lateral  cervical  tissues,  ultimately 
producing  a  postesophageal  abscess,  with  the  ultimate 
death  of  the  patient. 

Fougeray*  calls  attention  to  the  frequent  occurrence 
of  the  spontaneous  external  discharge  of  mastoid  em- 
pyemas, and  thinks  that  such  cures  by  external  evacu- 
ation of  the  pus  without  operative  procedure  have  not 
been  sufiiciently  reported  in  the  literature.  He  claims 
that  the  most  frequent  spontaneous  openings  occur  over 
the  antrum,  while  in  other  cases  the  opening  is  de- 
veloped lower  down  in  the  mastoid  surface,  and  some- 
times it  occurs  in  the  digastric  fossa.  A  fourth  form 
occurs  very  rarely,  however,  and  consists  of  an  opening 
upon  the  occipital  surface,  the  purulent  material  travel- 
ing by  way  of  the  pneumatic  cells  sometimes  found  in 
the  occipital  bone.  He  also  adds  to  these  varieties  a 
fifth,  based  upon  a  case  under  his  care,  in  which  the 
pus  discharged  itself  forwards  into  the  auditory  canal 
by  destroying  the  wall  of  the  attic  and  the  posterosu- 
perior  wall  of  the  osseous  auditory  canal.  While  these 
varieties  of  spontaneous  evacuation  of  mastoid  empy- 
ema may  be  frequent  in  the  clinics  of  the  continent, 
they  are  certainly  not  seen  in  this  country,  with  the 
exception  of  that  perforating  the  medial  plate,  except 
when  due  to  some  localized  expression  of  a  consti- 
tutional dyscrasia,  as  syphilis,  tuberculosis  and  dia- 
betes, and  even  then  one  is  hardly  warranted  in  claim- 
ing it  to  be  the  result  of  mastoid  disease,  as  while  this 
process  may  be  implicated,  yet  the  temporal  bone  to  a 
greater  or  less  extent  is  involved  in  the  destructive 
process. 

Of  operative  procedures  upon  the  mastoid,  that  of 
Kuster'  has  been  the  only  new  one  of  importance, 
although  many  modifications  of  older  methods  have 
been  published.  Kuster  calls  his  method  an  osteo- 
plastic opening  of  the  mastoid,  the  method  of  procedure 
being  as  follows  :  The  auricle  is  drawn  forward  and  an 
incision  made  along  its  posterior  border  beginning  a 
short  distance  above  the  level  of  the  auditory  meatus. 
It  then  passes  around  the  tip  of  the  mastoid  and  is 
carried  upwards  along  the  posterior  border  to  the  same 
level  where  it  commenced.  The  incision  is  made  down 
to  the  periosteum  and  is  [/-shaped,  with  the  attached 
portion  of  the  flap  above  and  the  periosteum  then 
pushed  aside,  and  following  the  outline  of  the  flap, 
a  shallow  groove  is  cut  in  the  bone  with  a  chisel.  With 
a  broader  chisel  a  thin  plate  of  bone  is  split  off  from 
below  upwards,  this  segment  remaining  adherent  to 
the  soft  tissues  and  the  entire  flap  is  turned  upwards, 
leaving  the  operative  field  free,  the  surgeon  then  pro- 
ceeding according  to  the  indications  present.  After  all 
diseased  tissue  has  been  removed  the  flap  is  replaced, 


FKBEnARY  2,    1901] 


MASTOID  DISEASE  AND  ITS  COMPLICATIONS 


L  Medical  Journal 


237 


a  small  notch  being  made  in  its  lower  part  for  drainage 
and  the  case  is  dressed  in  the  usual  manner.  The 
author  reports  9  cases  in  which  he  used  this  method, 
and  he  claims  it  is  superior  to  other  methods  because 
there  are  little  resultant  deformity,  rapid  healing  and  a 
good  opportunity  for  the  tampon  in  case  the  sinus  or 
dura  are  injured  during  the  operation.  This  last 
advantage  is  so  trivial  as  to  require  no  comment,  while 
in  other  respects  the  operation  is  based  on  lines  radi- 
cally wrong,  as  it  allows  of  the  external  closure  of  the 
wound  with  retention  of  purulent  material  and  there  is 
no  opportunity  for  the  parts  to  heal  from  within  out- 
wards by  granulation  tissue. 

Suggestive  of  operative  procedures  upon  the  mas- 
toid are  the  following  conclusions  formulated  by  Ran- 
dall'°  upon  the  study  of  100  cases: 

1.  Wilde's  incision  is  not  good  surgery. 

2.  Conservatism  and  expectancy  are  in  order  as  long 
as  there  is  no  pus  demonstrable  outside  of  the  middle 
chamber. 

3.  When  rational  signs  of  pus  are  recognized,  all 
temporizing  must  cease  and  sound  surgical  principles 
must  be  followed. 

4.  A  clean  sweep  of  all  diseased  tissue  must  be  made 
and  sinuses  must  be  explored. 

5.  Have  a  clean  field  before  you  in  operating. 

6.  Good  drainage  must  be  established. 

7.  In  chronic  cases,  it  is  rarely  sufficient  to  clean  out 
the  mastoid  alone. 

One  can  hardly  add  anything  to  these  able  conclu- 
sions except  it  be  in  the  choice  of  instruments  and  then 
merely  to  say  that  the  chisel  and  spoon  should  always 
be  used  in  preference  to  any  method  depending  upon 
the  trephine,  burr  and  dental  engine  which  have  been 
employed  to  some  extent. 

One  of  the  most  important  questions  engaging  the 
otologist  today  is  the  determination  in  advance  of  any 
operative  procedure  of  the  danger  points  on  the  tem- 
poral bone,  the  relation  of  the  sinus  to  the  surface  and 
the  nearness  of  the  cerebral  fossa  to  the  proposed  opera- 
tive field.  While  much  labor  has  been  spent  in  seeking 
external  evidences  of  these  points,  success  has  un- 
fortunately not  been  attained,  although  general  indica- 
tions such  as  those  mentioned  by  Okade"  are  of  value. 
He  concludes  from  the  study  of  111  skulls  that  the 
anthropological  form  offers  no  trustworthy  evidence  of 
the  presence  or  absence  of  the  so  called  dangerous  tem- 
poral bone.  The  relation  of  the  transverse  sinus  to  the 
field  of  operation  should  be  looked  for,  and  unusual 
care  taken  when  operating  on  the  right  side  ;  if  the  mas- 
toid process  is  unusually  small ;  if  the  patient  has  not 
reached  the  age  of  puberty  ;  and  more  care  must  be 
exercised  in  the  case  of  women  than  in  men.  While 
these  indications  are  but  general,  yet  they  present  fea- 
tures of  value  and  are  necessary  in  forming  part  of  the 
foundation  for  future  work  in  this  field. 

As  the  vast  majority  of  cases  of  mastoiditis  are  the 
ultimate  result  of  middle-ear  suppuration  and  the  ma- 
jority of  the  latter  proceed  from  the  infectious  diseases 
of  childhood,  the  paper  of  Dench,'^  dealing  with  the 
mastoid  complications  of  the  e.xanthemata  of  children, 
is  timely  and  contains  much  of  value.  He  considers 
the  treatment  under  prophylaxis  and  after  the  involve- 
ment of  the  mastoid  has  taken  place.  Under  the  former 
heading  the  statement  is  made  that  in  any  eruptive 
fever  in  which  a  sudden  rise  of  temperature  takes  place, 
which  is  not  explainable  by  the  general  condition 
of  the  patient,  we  should  examine  the  ears  for  evidence 


of  inflammation.  One  is  inclined  to  go  even  further 
than  this  and  consider  that  an  examination  of  the 
membrana  tympani  should  be  made  in  every  instance 
of  an  exanthematous  affection,  as  by  adhering  to  this 
rule,  many  cases  of  what  would  undoubtedly  result  in 
mastoiditis  would  be  prevented.  Should  the  tympanum 
be  inflamed  a  free  incision  should  be  made  from  a  point 
just  below  the  tip  of  the  handle  of  the  malleus,  up- 
ward to  the  tympanic  ring ;  and  if  the  temperature 
should  be  very  high,  the  incision  should  be  extended 
outward  a  considerable  distance  along  the  roof  of  the 
auditory  canal,  dividing  the  soft  parts  to  the  bone. 
This  will  permit  the  escape  of  any  secretions  should 
they  be  present  and  will  al,-o  relieve  the  tension  which 
is  a  prominent  factor  in  the  production  of  pain. 

Should  the  mastoid  become  sensitive  to  pressure,  the 
icebag  or  cold  Leiter's  coil  may  be  applied,  but  if  not 
effectual  in  48  hours,  it  should  be  discontinued.  Should 
there  be  a  discharge  from  the  tympanum,  frequent  irri- 
gation of  the  canal  with  a  lukewarm  bichlorid  solution 
may  be  productive  of  much  benefit.  Should  the  case 
not  be  seen  until  a  fluctuating  tumor  has  developed 
behind  the  auricle,  we  should  immediately  operate  and 
even  in  very  young  children  the  mastoid  antrum  should 
be  opened  in  every  instance.  Irrespective  of  the  absence 
of  a  sinus  leading  from  the  interior  of  the  bone,  or  of 
an  apparently  normal  cortex,  the  bony  structures 
should  be  entered  as  we  always  find  in  these  cases 
some  diseased  bone,  either  in  the  mastoid  antrum  or 
in  the  aditus.  In  young  children  the  cranial  bones  are 
thin  and  the  infection  of  the  intracranial  structures 
may  readily  occur  through  the  external  surface  of  these 
bones,  as  well  as  through  the  tympanic  roof,  or  through 
the  posterior  wall  of  the  mastoid  antrum ;  but  if  the 
middle  ear  is  thoroughly  drained  by  a  posterior  open- 
ing into  the  mastoid  antrum,  subsequent  infection  of 
the  intracranial  structures  is  impossible.  In  regard  to 
the  radical  measures  advocated  by  the  author  of  open- 
ing the  membrana  tympani  when  inflammation  super- 
venes, it  certainly  appears  that  this  is  too  severe,  when 
we  have  the  opportunity  to  use  less  radical  measures 
as  hot  irrigation  ;  and  if  this  and  similar  means  fail  after 
24  hours,  then  the  delay  will  in  no  way  compromise 
the  case  and  if  necessary  the  incision  in  the  membrane 
can  be  made.  While  apparently  good  results  are  fre- 
quently seen  from  the  simple  incision  of  the  soft  tissues 
in  mastoiditis,  yet  these  are  the  cases  that  return  later 
for  a  radical  operation,  when  if  the  primary  operation 
had  been  thorough,  the  case  would  have  had  no  further 
difficulty.  It  cannot  be  too  strongly  impressed  upon 
every  practitioner,  that,  as  Dench  well  says,  even  if  the 
mastoid  cortex  be  apparently  normal,  we  must  open  it 
and  establish  free  communication  with  the  middle  ear. 

If  one  were  required  to  point  out  any  subject  in 
otology  in  which  the  greatest  progress  has  been  made 
during  the  year,  he  would  not  hesitate  in  indicating 
that  of  the  sinus  and  brain  complications  of  mas- 
toiditis. While  this  subject  has  been  receiving  more 
and  more  attention  during  the  past  few  years,  the  study 
of  sinus  thrombosis  received  an  added  impetus  from 
the  classic  paper  of  Whiting."  He  divided  sinus 
thrombosis  into  three  stages;  the  first  being  character- 
ized by  a  parietal  or  complete  thrombus,  not  disin- 
tegrated and  accompanied  by  moderate  pyrexia  and 
usually  the  absence  of  rigors.  In  the  second  stage, 
there  is  disintegration  of  the  clot,  with  resultant  sys- 
tematic absorption;  frequent  rigors  and  pronounced 
fluctuations  of  temperature.     During  the  third  stage 


238 


The  Phii>ai>ku>hia.~| 


DISEASES  OF  THE  EAR 


[Fkbbuabt  2,  UOl 


disintegration  has  progressed,  with  systemic  absorp- 
tion, accompanied  by  rigors,  rapid  and  great  fluctua- 
tions of  temperature  and  central  or  peripheral  embolic 
metastasis,  terminating  usually  in  septic  pneumonia, 
enteritis  or  meningitis.  The  author  further  remarks 
that  the  diagnosis  in  the  first  stage  is  seldom  made  pre- 
liminary to  the  operation  for  mastoiditis,  and  the  only 
safeguard  against  the  second  stage  is  to  operate  im- 
mediately upon  the  recognition  of  the  first.  The 
transitional  period  between  the  two  stages  is  usually 
brief  and  its  completion  is  commonly  announced  by  a 
sharp  rigor. 

As  described  by  Whiting  in  performing  the  opera- 
tion for  sinus  thrombosis,  the  usual  mastoid  incision  is 
made  extending  from  1  inch  below  the  tip  of  the  process, 
to  a  point  ^  inch  above  the  temporal  ridge.  A  second  in- 
cision is  than  made  beginning  at  the  center  of  the  first 
and  extending  backwards  2  inches  or  more  towards  the 
occipital  protuberance.  The  pneumatic  cells  and  an- 
trum are  opened,  the  sigmoid  groove  is  quickly  entered 
with  a  curet  or  rongeur  and  the  thrombus  is  eviscer- 
ated, bleeding  being  controlled  by  gauze-packing.  At 
the  moment  the  sinus  wall  is  opened,  the  foot  of  the 
operating  table  should  be  elevated,  to  reduce  the  chance 
of  admitting  air  to  the  sinus  and  to  maintain  the 
equilibrium  of  the  general  intracranial  fluids,  which 
might  be  seriously  disturbed  by  suddenly  inducing 
anemia  of  the  brain,  from  the  profuse  bleeding  from 
the  sinus. 

When  symptoms  of  septicemia  develop  during  an 
attack  of  mastoiditis,  the  indications  of  sinus  involve- 
ment are,  as  already  mentioned,  fairly  well  established  ; 
at  all  events,  however,  it  should  be  the  invariable  rule  to 
operate  immediately.  An  exception  to  this  is  found  in 
the  report  of  2  cases  by  Stanculeaunu  and  Baup,"  but 
this,  of  course,  does  not  in  any  way  invalidate  operative 
procedures.  Both  these  cases  terminated  fatally  and  the 
necropsy  showed  no  lesion  of  the  sinus  nor  of  any  other 
portion  of  the  venous  system,  but  there  were  fatty 
changes  in  some  of  the  viscera  and  an  extremely  viru- 
lent streptococcus  was  found  in  the  blood.  While  the 
bacteriology  of  mastoiditis  and  its  complications  has 
received  some  attention,  yet  much  remains  to  be  done, 
it  now  becoming  better  known  that  the  pneumococcus 
presents  an  almost  insuperable  barrier  to  medicinal 
treatment  of  middle-ear  suppurations  in  which  this 
organism  is  intimately  concerned,  and  the  tendency  to 
mastoid  complications  are  greater  in  such  instances  than 
is  seen  with  almost  all  the  other  organisms. 

When  a  thrombus  has  once  formed  in  the  sinus  and 
becomes  infected,  pyemic  symptoms  are  inevitable ; 
that  pyemia  the  result  of  mastoid  abscess  may  occur 
without  sinus  infection  I  believe  to  be  possible,  although 
this  is  combated  by  Meier,"  who  opposes  the  view  that 
there  are  several  varieties  of  otitic  pyemia,  such  as  that 
with  thrombus  of  the  lateral  sinus ;  pyemia  without 
thrombosis  of  the  sinus,  where  presumably  a  thrombus 
of  the  small  veins  of  the  petrous  portion  exists,  and 
finally  where  the  infection  is  carried  through  the  lym- 
phatics. In  his  experience  he  found  on  careful  exam- 
ination a  thrombus  in  ever}-  instance  and  believes  that 
it  is  frequently  overlooked  and  is  often  situated  low 
down,  even  in  the  bulbar  portion  of  the  jugular  vein, 
the  sinus  proper  being  open  above.  An  exploratorj* 
puncture  is  of  no  value,  for  free  blood  may  be  obtained 
even  when  a  thrombus  is  present. 

As  shown  by  Knapp,"  the  prognosis  of  sinus  throm- 
bosis with  articular  metastasis  is  better  than  when  the 


emboU  lodge  in  the  pulmonary  area.  An  interesting 
case  illustrative  of  the  latter  is  reported  by  Greene" 
in  which  the  symptoms  simulated  typhoid-pneumonia. 
There  were  pain  in  the  left  ear,  face  and  side  of  head 
and  great  swelling  of  the  neck  and  throat.  Chills,  fever, 
emaciation,  insomnia  and  constipation  were  prom- 
inent while  the  mastoid  was  edematous  and  contained 
a  small  amount  of  pus.  In  addition  there  existed  ab- 
scesses of  the  chest,  pharynx  and  neck,  and  a  brain 
abscess  was  also  evacuated,  the  patient  dying  in  a  few 
weeks  from  ^«rebritis.  A  similar  case,  but  presenting 
the  agreeable  contrast  of  recovery,  was  reported  by 
Payne.''  in  which  for  acute  endomastoiditis  a  Schwartze 
operation  was  performed,  but  the  temperature  continued 
high,  cough  and  rigors  developed  and  suppuration  be- 
came so  abundant  that  an  extensive  Stacke  operation 
was  done.  The  temperature  varied  from  96  to  106°  for 
nearly  two  weeks,  when  a  large  slough,  consisting  of 
a  portion  of  the  dura  mater,  presented  at  the  wound. 
The  exact  site  of  the  lung  abscess  was  not  determined, 
but  its  existence  was  shown  by  the  patient  coughing  up 
a  large  amount  of  foul  pus.  After  this  the  case  pro- 
gressed to  complete  recovery.  It  was  well  demonstrated 
by  this  case  that  although  the  prognosis  may  be  prac- 
tically hopeless,  yet  prompt  surgical  intervention  will 
in  many  instances  save  the  life  of  the  patient. 

REFERENCES. 

1  CozzoUdo  and  Barrago-CUrella ;  Journal  of  Laryngology,  JanamiT,  1899. 
'  LoaiB  Bar  :  Journal  of  Laryngology.  Rhinology  and  Otology,  Noranber,  1899. 
'  Euleusiein  :  Archivu  of  Ototogv,  vol.  28,  No.  2, 1899. 

•  Lermoyez :  Ann.  da  MaL  <U  fOreUle,  May,  1899. 

•  Bumell :   Vnirersily  Medical  yfa(jazinf,  Februarr.  1899. 

•  Rotiert  Lewis :  Trans.  American  Larrngological'.Rhinological  and  Ocologicftl 
Societv,  Tol.  8.  Xo.  1,  1S99. 

'  Diinn  :  .lrc*ir«  of  Otology,  toL  27,  Xo.  6.  1899. 

fi  Haiuon  dii  Fouiie'raT  :  Ann.  da  Mai.  de  1  Ortxlle,  ApriJ,  1899. 

«  Kuster :  OmIralblatI  f.  Chirurgvt,  October  28, 1399. 
">  B.  A.  Kandall :  I'mnsutrania  Medical  Journal,  August,  1S99. 
"  W.  Okade  :  Archie  f.  ilin.  Oiiruro.,  Berlin,  ToL  5S,  Xo.  4,  1899. 
^  Dench  :  Pediatrics,  June  15. 1899. 
"  Whiting:  ArchitYj  of  Otology,  toL  27,  Xo.  6, 18  9. 
»  Stanculeaunu  and  Baop ;  Progru  Mf^icale,  Paris,  .\ngusc  19, 1899. 
15  Edgar  Meier :  MUnchencr  medicirtischt  WochentcJtrifl,  Oclobtrr  24, 1899. 
■•  Knapp  :  Archirei  of  Otology,  vol.  28,  Xo.  2,  1899. 

1'  D.  Milton  Greene :  Journal  American  Modical  Attociation.  NATembor  11, 1899. 
"  R.  M.  Payne :  AnnaU  oj  Otology  and  Rhinology,  August,  18^. 


DISEASES  OF  THE  EAR  IN  RELATION  TO  GENERAL 
MEDICINE.' 

BYXATH.4X  G.  WARD,  M.D., 

of  PhUadelphla. 

Otologist  and  Larjngologist  to  St.  Agnes'  Hospital ;  Asistant  in  Idrrngology 
Jetferson  Medial  College  Hospital. 

Diseases  of  the  Ear  i.\  Relation  to  Gexeral  Medicint:. 

Affections  of  the  ear  are  still  looked  upon  by  the 
laity  and  by  many  otherwise  very  able  physicians  as 
being  of  but  little  consequence.  The  general  opinion 
prevails  that  the  child  who  frequently  suffers  with  ear- 
ache will  outgrow  it ;  that  purulent  discharge  from  the 
ear  is  a  slight  ailment,  not  to  be  interfered  with  for  fear 
that  if  checked  it  will  affect  the  general  health,  and 
that  beginning  deafness  in  the  adult  is  beyond  the 
reach  of  therapeutic  agents. 

The  anatomical  structure  of  the  ear,  its  proximity  to, 
and  communication  with,  other  most  important  struc- 
tures plainly  indicate  the  serious  consequences  that 
may  follow  inflammation  of  that  organ. 

The  mucous  membrane  lining  the  tympanum  is  in- 

>  Read  at  a  meeting  of  the  Associated  Physicians  and  Sorgeoas  ol  the  ChiritT' 
Hospital,  Philadelphia,  February  S,  190a 


Fbbkuary  2,  1001] 


DISEASES  OF  THE  EAR 


rrH 
Lm 


Thk  Philadblphia 
KDicAL  Journal 


239 


separable  from  the  periosteum  and  serves  its  function 
in  supplying  nutrition  to  the  bone  beneath,  hence  any 
severe  or  continued  disturbance  in  the  nutrition  of  the 
soft  parts  must  necessarily  lead  to  loss  of  nutrition  and 
caries  of  the  adjacent  bone.  Necrosis  of  bone  in  any 
part  of  the  body  is  to  be  much  feared.  The  disease- 
process  is  not  simply  local,  but  often  causes  grave  sys- 
temic complications,  as  thrombosis,  embolism  (both  of 
which  may  be  infective),  metastatic  abscess,  general 
cachexia,  and  pyemia.  Still  more  momentous  is  nec- 
rosis in  the  tympanic  cavity  on  account  of  its  prox- 
imity to  the  internal  carotid  artery,  internal  jugular 
vein,  lateral  and  superior  petrosal  sinuses,  the  brain, 
and  its  meninges,  from  all  of  which  it  is  separated  by 
a  thin  delicate  and  sometimes  even  deficient  layer  of 
bone. 

Inflammation  of  the  ear  more  frequently  complicates 
those  diseases  that  are  associated  with  catarrhal  affec- 
tions of  the  upper  respiratory  passages,  but  is  by  no 
means  limited  to  such. 

The  importance  of  recognizing  the  disease  in  its  early 
stage  is  emphasized  by  reference  to  some  of  the  mis- 
taken diagnoses  as  given  by  Frothingham.' 


Disease  Present. 

Acute  otitis  media  followed 
by  meningitis 

Acute  mastoid  disease. 

Furuncle  of  auditory  canal. 

Acute  otitis  media. 

Otalgia  dentalis. 

Acute  otitis  media,  both  ears. 

Polypus  from  Shrapnell's 
membrane  the  unrecog- 
nized cause  of  head  symp- 
toms. 

Polypus  in  ear. 

Acute  otitis  media  with  bulla 
of  drum. 

Dried  desquamated  epithe- 
lium in  the  external  canal. 


Diagnosis. 

Unrecognized. 

Cellulitis. 
Mastoid  disease. 
Neuralgia. 

Gathering  in  the  ear. 
Overlooked  in  the  left. 
Head  trouble  due  to  change 
of  life. 


Chronic  catarrhal  disease. 
Malignant  growth. 

Ossicles  coming  out. 


Mumps. 

The  complications  or  sequelae  of  mumps  is  by  metas- 
tasis— usually  orchitis.  A  similar  condition  has  been 
reported  in  the  ear.  In  this,  however,  there  are  no 
acute  inflammatory  symptoms.  There  are  sudden  deaf- 
ness, unilateral  and  usually  permanent ;  giddiness  and 
disturbance  of  equilibrium.  Sometimes  there  is  a  loss 
of  consciousness.  The  condition  is  not  fatal,  therefore 
the  pathological  alterations  are  not  known.  It  is  prob- 
able, however,  that  there  is  a  sudden  extravasation  of 
serum  into  the  labyrinthic  structures.  There  is  no  rela- 
tion between  the  severity  of  the  attack  of  mumps  and 
the  ear  manifestations.  Some  of  the  cases  reported 
were  very  mild  in  character. 

In  measles  the  ears  are  affected,  not  always  producing 
suppuration,  but  causing  hyperemia  and  congestion  of 
the  tympanum.  The  eustachian  tube,  however,  is  still 
more  frequently  involved  and  in  many  cases  is  affected 
before  the  eruption  appears  on  the  skin.  Blebs  have 
formed  beneath  the  outer  layer  of  the  tympanic  mem- 
brane. 

Diphtheria  and  scarlet  fever  more  frequently  produce 
suppuration  of  the  middle  ear  than  other  diseases. 
Sudden  deafness  may_be  caused  by  congestion  and  ex- 
udation in  the  mucous  membrane  and  collection  of 
fluid  in  the  tympanic  cavity,  preventing  the  trans- 
mission of  sound-waves.  Ulceration  and  necrosis  of 
bone  frequently  follow  even  to  the  extent  of  entire 


destruction  of  the  eustachian  canal,  both  cartilaginous 
and  bony,  the  ossicles  and  cochlea.  When  the  process 
is  less  severe  the  tympanic  membrane  usually  ruptures 
and  the  acute  condition  passes  into  that  of  a  chronic 
suppuration  with  continuous  or  intermittent  discharge. 

In  those  cases  in  which  the  diphtheric  fjrocess  in- 
volves the  hose  and  nasopharynx  it  is  most  likely  to 
extend  into  the  middle  ear. 

Burnett'^  reports  such  a  case.  Lommel"  states  that 
"  disease  of  the  organ  of  hearing  and  particularly  of  the 
middle  ear,  occurs  with  uncommon  frequency  in  true 
diphtheria.  We  may  therefore  almost  establish  the 
rule  that  otitis  media  forms  a  part  of  the  clinical  pic- 
ture of  diphtheritic  inflammation  of  the  respiratory 
tract."  In  25  successive  autopsies  of  individuals  who 
had  died  from  diphtheria  24  showed  involvement  of 
the  middle  ear  (9G%).  In  many  the  eustachian  tube 
showed  no  pathologic  changes,  and  in  others  the  tube 
was  but  little  changed.  The  bacillus  of  diphtheria  has 
been  found  in  the  aural  discharge  after  clinical  symp- 
toms had  disappeared.  Sudden  deafness  has  been 
reported  during  convalescence,  at  the  time  of  other 
palsies  and  albuminuria.  The  lesions  involve  the 
auditory  nerve  or  center  and  is  of  the  same  nature  as 
that  which  gives  rise  to  the  more  frequent  diphtheric 
paralysis.  In  a  case  reported  by  J.  C.  Wilson''  the 
deafness  continued  in  spite  of  all  treatment,  while  in 
other  cases  rapid  recovery  was  reported. 

Influenza. 

The  otalgia  of  influenza,  during  the  acute  manifesta- 
tions of  the  disease,  may  be  due  to  inflammation  and 
swelling  of  the  tissue  and  glands  of  the  faucial  region, 
the  pain  being  referred  to  the  ear,  or  there  may  be 
serious  involvement  of  the  tympanum,  varying  from 
simple  occlusion  of  the  eustachian  tube  to  a  suppura- 
tive otitis  media  with  mastoid  involvement.  Often  the 
perforation  in  the  membrana  tympani  is  very  small 
and  needs  to  be  enlarged  by  incision  to  afford  free 
drainage. 

Dench"  reports  cases  of  influenza  with  involvement 
of  the  labyrinth  or  auditory  nerve-trunk.  He  thinks 
the  disturbance  is  angioneurotic  in  character. 

A  serious  involvement,  and  one  usually  not  recog- 
nized during  its  early  progress  on  account  of  the  absence 
of  symptoms  referable  to  the  ear,  is  that  of  a  slow,  pro- 
gressive inflammatory  process  with  organization  of 
fibrous  tissue  in  the  middle  ear  causing  adhesions  of 
the  ossicles  and  thickening  of  the  Mt.,  producing 
chronic  progressive  deafness.  Symptoms  of  this  process 
are  not  manifest  for  from  six  months  to  a  year  after  the 
attack  of  grip. 

Respiratory  Tract. 

Nose.— On  account  of  the  intimate  anastomosis  be- 
tween the  bloodvessels  and  lymphatics  of  the  nose, 
nasopharynx,  and  ear,  any  condition  that  obstructs 
nasal  breathing,  as  constant  hyperemia  or  congestion  of 
the  mucous  membrane,  polyps,  hyperplasia  of  the 
turbinals,  and  foreign  bodies,  will  cause  congestion  of 
the  eustachian  tube  and  middle  ear  by  interfering  with 
the  return  blood. 

Lederman''  records  a  case  of  a  girl,  3  years  old,  who 
had  a  running  ear  for  2  months,  which  appeared  one 
month  after  a  purulent  nasal  discharge.  A  coffee  bean 
was  found  in  the  nostril.  After  its  removal  all  the 
symptoms  disappeared,  and  in  4  days  there  was  no 


240 


The  Philadelphia ~| 
Medical  Journal  J 


DISEASES  OP  THE  EAR 


[Feebi-aey  2,  1901 


trace  of  pus  in  the  ear,  and  in  a  week  the  nasal  secre- 
tions were  almost  normal. 

Nasopharynx. — Ear  involvement  is  aided  in  all  dis- 
eases in  which  the  patient  lies  in  bed,  especially  on  the 
back.  This  position  favors  retention  of  secretion  in 
the  nasopharynx  and  impedes  drainage  from  the  ear 
through  the  eustachian  tubes. 

AUport"'  reported  a  case  of  acute  myringitis  follow- 
ing nasopharyngitis.  Three  large  buila3  formed  be- 
neath the  epiderm  of  the  Mt.  They  did  not  com- 
municate with  each  other,  nor  penetrate  to  the  internal 
surface.  Myles"  has  seen  cases  in  which  adhesions  be- 
tween the  orifices  of  the  eustachian  tube  and  the 
pharyngeal  wall  converted  the  fossa  of  Rosenmuller 
into  small  pockets.  The  adhesions  and  thickening 
caused  partial  closure  of  the  orifices  and  produced 
stuffiness  and  fulness  in  the  ears,  slight  buzzing,  and  a 
deep,  dull  pain  over  the  ear  with  lessened  acuity  of 
hearing,  all  of  which  were  relieved  by  breaking  up  the 
adhesions  and  removing  small  masses  of  lymphoid 
tissue.  Myles  thinks  the  bands  were  the  remains  of 
old  adenoid  tissue. 

Lungs. 

Croupous  and  catarrhal  pneumonia  and  catarrhal 
bronchitis,  especially  when  the  apex  of  the  lung  is  in- 
volved, makes  chronic  otitis  media  worse,  and  often 
causes  a  recurrence  in  those  who  have  had  it  before. 

Meltzer^  has  seen  several  cases  of  lobar  pneumonia 
in  children  in  which  the  earliest  symptoms  were  ear- 
ache and  high  fever.  The  earache  ceased  gradually 
after  the  full  development  of  pneumonia. 

Straight"*  reported  cases  of  chronic  otitis  made  worse 
by  catarrh  of  the  lung  apices.  The  ear-symptoms  im- 
proved or  entirely  disappeared  from  the  internal  ad- 
ministration of  creosote,  and  without  any  local  treat- 
ment. 

Alimentary  Tract. 

The  pain  produced  by  inflammation  in  the  region  of 
the  tonsils  and  of  the  lymphatic  glands  behind  the 
posterior  pillars  of  the  palate  is  often  referred  to  the 
ear,  the  patient  not  complaining  of  any  throat  symp- 
toms. 

Diseases  of  the  alveolar  process  or  teeth  produce 
various  ear  manifestations,  viz.,  "  an  aching  fulness 
which  seems  something  like  a  gathering,  a  heaviness  or 
sense  of  weight,  severe  earache,  and  lessened  acuity  of 
hearing."  (Flagg.)  The  conditions  producing  these 
symptoms  are:  Eruption  of  teeth — especially  when 
impacted, — dental  caries,  pulpitis,  pericementitis,  and 
excementosis  (or,  as  it  was  formerly  termed,  dental  exos- 
tosis), and  alveolar  abscess.  The  ear  may  be  actively 
inflamed  from  these  causes.  Flagg'"  reports  a  case  of  a 
lady  who  had  been  completely  deaf  in  the  left  ear  from 
excementosis.  After  extraction,  improvement  began  in 
2  weeks,  and  in  10  weeks  she  could  hear  ordinary  con- 
versation distinctly.  Similar  troubles  have  been  caused 
by  filling  root  canals  in  which  the  substance  used  is 
forced  out  of  the  apex  at  the  alveolar  process,  or  where 
a  metallic  filling  beneatli  the  edge  of  the  gum  is  left 
rough  with  sharp  angles  to  cause  continual  irritation  of 
the  gum. 

Gastrointestinal  disturbances,  especially  in  children, 
may  be  associated  with  pain  and  congestion  of  the 
tympanum. 

E.  H.  Pomeroy,"  reports  5  cases  in  which  there 
were  no  ear  manifestations,  all  symptoms  gave  evidence 


of  severe  gastrointestinal  disturbances.  In  the  first 
the  ear  involvement  was  unsuspected  during  life  and 
was  only  revealed  at  the  autopsy.  Acting  upon  the 
knowledge  gained  by  this  case,  in  the  succeeding  4 
cases  he  punctured  the  Mt.  A  few  drops  o*  fluid 
escaped  in  each  instance,  followed  by  immediate  ame- 
lioration of  the  intestinal  symptoms  and  a  speedy 
recovery. 

Toynbe  cites  cases  of  total  d^-afness  from  the  exhaus- 
tion caused  by  attacks  of  diarrhea,  cholera,  or  the 
administration  of  violent  purgatives. 

Typhoid  fever  may  give  rise  to  temporary  deafness  due 
to  congestion  and  lowered  nervous  tone,  during  the 
high  temperature  period,  which  usually  passes  away 
during  convalescence.  In  many  cases  severe  otitis 
develops,  ending  in  suppuration,  perforation  of  the  Mt 
and  necrosis  of  the  bony  structures. 

In  tuberculosis  the  ear  is  probably  more  often  pri- 
marily affected  than  is  usually  supposed.  It  is  fre- 
quently involved  during  the  latter  stages  of  pulmonary 
tuberculosis.  In  scrofula  the  enlarged  glands  interfere 
with  the  venous  and  lymphatic  circulation  and  cause  a 
lowered  resistance  in  the  mucous  membrane  and  thus 
favor  throat  and  ear  affections. 

Syphilis. — Syphilitic  manifestations  in  the  ear,  as  in 
other  parts  of  the  body,  may  be  deceptive,  varying  from 
otalgia,  due  to  ulcerations  in  the  nasopharynx,  to  con- 
gestion and  inflammatory  exudation  in  the  Mt.  and 
about  the  head  of  the  malleus  even  to  necrosis  involv- 
ing the  whole  of  the  petrous  portion  of  the  temporal 
bone.  Sudden  deafness  may  occur  during  the  second- 
ary stages  and  is  probably  caused  by  exudation  in  the 
labyrinth. 

In  hereditary  syphilis  the  symptoms  appear  near 
puberty,  both  ears  are  usually  affected. 

Rheumatism. — Acute  otitis  media  has  preceded  attacks 
of  acute  articular  rheumatism.  Chronic  progressive 
changes  leading  to  deafness  may  take  place,  advancing 
so  insidiously  as  to  escape  notice  until  permanent 
damage  has  been  done.  This  is  as  often  found  in 
those  who  suffer  from  uric-acid  diathesis  as  in  tlie 
chronic  rheumatic. 

The  Nervous  System. 

Inflammation  of  the  tympanum  may  be  caused  by 
extension  from  the  cranial  cavity  as  in  meningitis.  In 
locomotor  ataxia  the  fifth  and  eighth  nerves  are  often 
affected.  Collet^  gives  the  pathological  changes  pres- 
ent as  atrophy  of  the  nucleus  in  the  floor  of  the  fourth 
ventricle,  and  of  the  nerve-trunk  producing  nerve-deaf- 
ness and  sclerosis  of  the  inner  wall  of  the  tympanum 
and  of  the  Mt.  Asher^^  reported  a  case  of  serous  exu- 
dative inflammation  of  the  middle  ear  following  intra- 
cranial resection  of  the  second  and  third  branches  of 
the  fifth  nerve,  from  the  foramen  ovale  and  rotundum  up 
to  the  gasserian  ganglion  which  was  not  exposed.  The 
ear  symptoms  appeared  in  3  weeks  after  the  operation 
and  in  the  ear  corresponding  to  the  side  operated  upon. 

In  those  whose  acuity  of  hearing  is  impaired,  mental 
excitement  and  worry  increase  their  disability  and 
may  cause  temporary  or  permanent  deafness. 

CiRCOLATORY   SySTEM    AND    BlOOD. 

Congestion  of  the  ear  in  cardiac  insufficiency  occurs 
as  in  other  parts  of  the  body.  Anemia  and  congestion 
produce  tinnitus.  Hemorrhage  in  the  middle  ear  and 
even  in  the  labyrinth  producing  infarction  are  some- 
times present  in  leukemia.     Atheroma  of  the  blood- 


Febrdart  2,  19M] 


DISEASES  OF  THE  EAR 


TThe  Philadelphia  241 

L  Medical  Journal  ^^a 


vessels  may  take  place  in  common  with  other  general 
senile  changes. 

Kidney. 

In  all  kidney  diseases  in  which  there  is  deficient 
elimination  the  ear  may  become  affected.  In  paren- 
chymatous and  interstitial  nephritis  there  may  be  aural 
hemorrhage,  but  more  frequently  tinnitus  and  deafness. 

MorP  reviews  the  subject  very  extensively  and  con- 
cludes there  are:  "  Irritation  of  the  acoustic  nerve  fila- 
ments from  retained  substances  in  the  blood  due  to 
nonelimination  by  the  kidneys  ;  increased  arterial  ten- 
sion, and  serous  exudation  in  the  labyrinth,  correspond- 
ing to  the  dropsy  in  other  parts  of  the  body."  Morf 
cites  a  case  reported  by  Rosenstein  in  whom  the  hear- 
ing and  other  ear  symptoms  varied  with  the  general 
dropsy — better  as  the  general  dropsy  disappeared,  and 
vice  versa.  Morf  reports  a  case  in  which  the  loss  of 
hearing  and  visual  disturbances  were  the  only  symp- 
toms that  led  to  his  examining  the  urine  and  the  dis- 
covery of  the  kidney  disease.  If  it  be  proven  that 
inflammation  of  the  kidney  produces  such  marked 
efl"ect  upon  the  ear  it  may  partly  explain  the  frequency 
of  otitis  as  a  sequel  to  scarlet  fever.  Voss'^^  says:  "  The 
connection  indeed  is  so  intimate  that  the  progress  of  the 
nephritis  may  be  followed  by  the  course  of  the  otitis. 
Deafness  and  pain  in  one  or  both  ears  may  follow,  or 
even  precede,  a  diminution  of  urine.  The  discharge 
varies  directly  with  the  intensity  of  the  albuminuria." 

Genital  Organs. 

Redness  of  the  membrana  tympani  occurs  in  some 
cases  during  the  menses.  P.  Bourlon"' collected  23  cases 
of  menstruation  through  the  ear.  The  hearing  was  never 
affected  by  the  hemorrhage.  In  some  cases  it  was 
bilateral.  It  does  not  recur  with  any  regularity  and  is 
usually  preceded  by  heaviness,  pain  in  the  head,  ver- 
tigo and  tinnitus.  In  most  cases  the  hemorrhage  from 
the  ear  ceased  as  menstruation  was  reestablished. 

Pritchard"  reported  a  case  of  a  woman  four  months 
pregnant,  who  complained  of  giddiness,  vomiting  and 
vertigo.  The  attacks  were  followed  by  transient  deaf- 
ness. The  same  condition  was  present  during  a  previous 
pregnancy,  ceasing  after  delivery. 

Toynbe"*  reported  a  case,  aged  40,  of  nervous  tem- 
perament and  rather  anemic,  who  consulted  him  in 
1850,  on  account  of  complete  deafness.  She  had  mar- 
ried 10  years  previously  in  India  and  had  always  heard 
well  until  her  first  confinement.  She  suffered  a  great 
deal  from  exhaustion ;  this  was  followed  by  a  great  de- 
gree of  deafness,  so  that  she  could  scarcely  hear 
even  when  the  voice  was  much  raised.  As  she  recov- 
ered and  regained  her  strength  the  deafness  was  much 
relieved,  though  her  former  acuity  of  hearing  was  not 
fully  regained.  During  each  successive  confinement 
in  India,  amounting  in  all  to  four,  the  deafness  greatly 
increased,  and  after  each  recovery  became  more  per- 
manent until  on  the  last  occasion  she  remained  totally 
deaf  and  was  obliged  to  have  recourse  to  signs.  In- 
deed, she  had  never  heard  the  voices  of  her  younger 
children. 

Eye. 

Eye-manifestations  are  not  present  as  long  as  the  ear 
disease  is  limited  to  the  middle  ear  and  mastoid  cells, 
but  there  are  eye-symptoms  in  about  50%  of  the  ear 
cases  complicated  by  intracranial  invasion  of  the  in- 
flammatory process.  When  present  it  is  not  pathog- 
nomonic of  such  a  complication,  but  only  confirmatory. 


The  affections  of  the  eye  reported  as  a  result  of  ear 
disease  are  :  Swelling  and  puffiness  of  the  eyelids,  con- 
junctivitis, keratitis,  retinitis,  neuroretinitis,  papillitis, 
choked  disc,  and,  in  rare  instances,  paralysis  of  some  of 
the  external  muscles.  Inflammation  of  the  lids,  con- 
junctiva and  cornea  may  be  caused  by  infection  con- 
veyed by  the  hand  or  handkerchief  from  the  ear  to  the 
eye. 

As  to  the  frequency  of  papillitis  or  retinitis,  Milli- 
gan^  quotes  Gradenigo  as  follows  : 

Extradural    abscess,  uncomplicated 41    fo 

Septic  thrombosis  of  sinus,  simple  or  com- 
plicated with  extradural  abscess 59.6^ 

Cerebral  abscess,  simple   or  complicated 

with  sinus  thrombosis 57.9^ 

Cerebellar  abscess,  simple  or  complicated 

with   sinus    thrombosis 60    fc 

Leptomeningitis,   simple  or   complicated 

with  sinus  thrombosis 48.9% 

Deugs. 

Overdoses  of  quinin  and  the  salicylates  produce 
marked  tinnitus  by  causing  congestion  within  the  ear. 
Ramsay'^  reported  a  case  of  syphilis  in  whom  the  left 
ear  previously  healthy  became  filled  with  a  serous  fluid 
during  acute  iodism  caused  by  the  administration  of 
KI.  As  soon  as  the  iodid  was  withdrawn  the  deafness 
and  fluid  disappeared  with  the  other  symptoms  of 
iodism. 

Shastid"  reported  a  case  of  chronic  catarrhal  deaf- 
ness in  whom  each  dose  of  belladonna  caused  dryness- 
of  the  throat  and  nose  with  increased  deafness. 

In  a  case  of  my  own,  horaatropin  hydrobromate  was 
ordered  as  a  mydriatic  for  refraction.  During  its  action 
the  deafness  was  much  more  marked  and  after  ita 
efiects  had  passed  off  the  hearing  acuity  returned  to  its 
former  condition. 

Systemic  Results  from  Diseases  of  the  Ear. 

The  more  frequent  are  those  from  extension  by  con- 
tiguity of  tissue,  e.  gr.,  meningitis,  thrombosis  in  the 
venous  channels,  abscess  beneath  the  dura,  in  the 
cerebrum,  or  cerebellum  ;  pyemia,  facial  paralysis  and 
involvement  of  the  mastoid  cells.  As  a  matter  of  fact 
the  latter  is  the  most  frequent,  and  it  is  from  this  source 
especially  the  other  complications  arise.  The  mastoid 
cells  open  into  the  tympanum  posteriorly  and  are 
easily  involved  by  extension.  This  often  results  from 
no  treatment  at  all  or  is  hastened  by  improper  treat- 
ment, as  by  forcible  and  frequent  syringing  of  the  ear 
in  chronic  discharge.  In  children  the  mastoid  cells  lie 
more  nearly  horizontal  than  in  the  adult,  hence  drain- 
age is  less  perfect.  This  accounts  in  part  for  the  more 
frequent  involvement  of  the  mastoid  in  children.  In 
all  severe  cases  that  do  not  readily  yield  to  treatment 
it  may  be  safely  said  there  is  necrosis  of  bone.  The 
symptoms  of  mastoid  involvement  are  :  Intense  pain 
in  the  side  of  the  head,  swelling  or  edema  over  the 
mastoid,  discoloration,  tenderness,  or  acute  pain  on  pres- 
sure behind  the  external  auditory  meatus  just  behind 
the  auricle,  bulging  of  the  tympanic  membrane  or  de- 
pression of  superior  or  posterior  wall  of  the  external 
canal  just  in  front  of  the  tympanic  membrane. 

In  the  child  these  symptoms  may  be  less  manifest 
on  account  of  his  inability  to  make  known  the  nature 
and  seat  of  pain.  When  closely  observed  the  child 
will  be  seen  to  roll  the  head  from  side  to  side,  to  put 
the  hand  to  the  side  of  the  head  ag"ected  and  to  scream 


242 


Thk  Philadklphia"! 
Medical  Journal  J 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


[FEBKUiET  2,   19«1 


when  attempting  to  nurse  on  account  of  the  pain  caused 
by  swallowing.  In  any  case,  with  the  history  of  long- 
continued  discharge  from  the  ear  which  has  ceased 
suddenly,  accompanied  by  rigors  and  subnormal  tem- 
perature, brain  abscess  is  almost  surely  present. 

In  many  cases  the  severity  of  the  cerebral  symptoms 
are  out  of  all  proportion  to  the  pathological  changes 
in  the  meninges  and  brain  as  revealed  at  the  autopsy. 

Epilepsy  has  occurred  from  ear  disease  and  was  re- 
lieved by  projjer  treatment  to  the  ear. 

In  many  of  the  diseases  enumerated  the  ear  trouble 
is  not  due  directly  to  the  systemic  maladj',  but  the 
latter  weakens  the  resistance  of  the  organisms  and  the 
patient  takes  cold,  which  the  more  easily  extends  to  the 
ear  and  produces  much  greater  damage  than  is  general 
in  ordinary  colds.  In  not  a  few  of  these  cases  the 
ear  manifestations  are  a  recurrence  of  a  former  malady, 
which  may  have  been  years  ago  and  at  first  forgotten 
until  closely  questioned,  instead  of  a  primary  disease 
of  this  organ. 

In  records  of  autopsies  revealing  these  ear  involve- 
ments there  are  no  histories  depicting  the  condition 
of  the  ear  as  revealed  by  careful  examination  before 
death.  This,  of  course,  is  due  to  the  want  of  symptoms 
pointing  to  tliat  organ,  but  it  at  the  same  time  suggests 
possible  manifestations  that  are  interpreted  as  pointing 
to  other  organs  that  would  indicate  ear  involvement  if 
rightly  understood. 

The  line  of  progress  for  the  future  is  plain.  Let  the 
general  practitioner  and  the  specialist  work  together, 
observing  in  detail  all  manifestations  of  ear  involve- 
ment and  search  diligently  for  them  even  when  not  so 
plainly  marked.  In  autopsies,  dissections  of  the  tem- 
poral bone  should  be  more  frequently  made  and  the 
findings  compared  with  symptoms  before  death.  By 
eo  doing  great  advances  will  be  made,  and  diseases  of 
the  ear  that  are  now  not  recognissed  will  be  readily  diag- 
nosed and  successfully  treated. 

ISIBLIOGKAPHY. 

General. 
'  Dench  :  Pediiilrli:.'!,  June  16,  1899. 
2  Frolhinghara  :  iVci/.  Jircoid,  August  8,  1896. 
3Halsle(i:  Me(I..Veu's.  March  17,  1900. 
<  Phillips:  Trans.  Soc.  Slati'  N.  Y.,  1K93. 
'Sheppard  :  Trans.  Amer.  Otol.  Soc,  1896. 
■"Siniili,  ,S.  MacCuen  :  N.  Y.  Mei1.  Jmir.,  vol.  60,  1394. 
■  Toyiibe  :  Diseases  of  the  Ear,  1S60. 

Mumps. 

*  Foster :  Med.  Record,  vol.  41,  October,  1S98. 
»  Jollyc  :  Arch,  of  OluL,  ISHS. 
■•°  Minor ;  A'.  }'.  .W,'i/.  Jour.,  March  27,  1897. 

Mkasi.es. 

»  Pfingst  :  Pedtntrici,  Fcbrnarv  1,  1S9S. 

«>  Rudolph  and  Bezold  :  E\Mract  in  .lie*,  of  Old.,  October,  1897, 

"Tobeitz:  Extract  in  Amer.  Year  Book  oi  Med.  and  Surg.,  1S97. 

DiPHTHEKIA   AND  SCARLET   FeVER. 

"  Bezold  ;  .itch,  of  Olol. ,  1.S98. 

"  Burnett :  PAi'/n.  Polr/clinic,  Mav  21,  189S. 

•"Guranowski:  Extract  in  Arcli.  'of  Olol.,  1897. 

"  Loiuniel :  Arch,  of  Olol.,  1897. 

»»  I'ooth  :  Brll.  Med.  Jour.,  1S9S. 

'•  Wilson  :  Boston  Med.  and  Surg.  Jour.,  May  20,  1897. 

Influenza. 
;^Charlier:  Arclt.  of  Pediatrics,  1894,  p.  62. 
-1  Bench  :  Amer.  Medico-Surgical  BtUUHn,  April  15, 1893. 

Respiratory  Tract. 

^  Lederuian  :  Med.  Record,  vol.  45,  p.  461. 

■53  Allnort :  Jour.  Amer.  Med.  Asso.,  January  18,  1896. 

s*  Mylcs ;  Trans  Amer.  Otol.  Soc,  1897. 

"Ball:  Med.  News,  September  21,  1895. 

■"Moltzer:  Philaoki.phia  Medical  Journal,  August  5,  <899. 

>'  Rosh  :  Extract  in  Theran.  Gnz.,  May  l.i,  1894. 

•'Straight :  Med.  Record,  September  22,  1S94  ;  .\ugusl  8,  1896. 

Aluientauy  Tract. 

»  Burchard :  Dental  Path,  and  Therap.,  1898. 
^Denial  Cosmos,  1878,  p.  131. 


^  Jankins :  Extract  in  Annalx  of  Olol.,  Rhinol.  and  Laryngol.,  February,  1889. 

3!  Turnbull :  Med.  and  Surg.  Jour.,  March  31,  1894. 

M  Hartniann:  ArcU.  of  Olol.,  1898. 

^  Minor;  ,V.  )'.  Med.  .lour.,  vol.  60,  1891. 

'■^  Pomeroy  :  Boslon  .Med.  and  Surg.  Jour.,  January  18,  1900. 

TypBoiD  Fevee. 

»  Hcngst:  N.  Y.  Med.  Jour.,  June  6,  1896. 

3^  Keen:  Surgical  Complications  and  Sequels  of  Typhoid  Fever. 

Tuberculosis. 

^  Haenel:  Med.  Cliron.,  January,  1896. 

"  Milligan  :  Hrit.  .Med.  Jour.,  November  16,  1895. 

">  Toynbe :  Diseases  of  the  Ear,  1860. 

Syphilis. 

"Crockett:  Boslon  Med.  and  Surg.  Jour.,  February  11, 1897. 

'-  Uownie,  Arch,  of  Olol.,  1896. 

"  Dunn  :    Va.  Med.  Monthly,  August  7,  I8?6, 

**(iih8ou  :  Aus.'raluiian  3fed.  Gaz.,  February  20,  1899. 

*^  liabermanu  :  Ext.  in  Arch,  of  Olol  ,  18:6. 

<"Heunebert:  Ext.  io  Jour.  Laryngol ,  Khinol.  and  Olol.,  1897. 

*'  Hutchiiisou  :  .4rcA.  of  Surg.,  July,  1897. 

*'  Murcbison  :  Arch,  of  Surg.,  1894. 

Rheuuatisu. 

<»  Buck  :  Med.  Record,  May  22, 1897. 

""Gelle:  Jour.  LarvngoL.RhinoL  and  Olol.,  1897. 

"  Wolf:  Arch,  of  Olol.,  1897. 

Neevocs  System. 

»=AIderton:  Annal.  of  Oph.  and  Olol.,  Ocloljer,  1894. 

""A.-iher:  Ext.  in  .-tmer.  Medico-Surg.  Bulletin,  June  1,  1895. 

«  Barr:  British  Medical  Journal,  M"ay  1,  1897. 

"  Blake  :  Boston  Med.  and  Surg.  Jour.,  August  19,  18»7. 

■'■"Collet:  Kxtnict  in  Practitioner,  May,  189.5. 

'■'  .'^heppard  :  .V.  1'.  Med.  .lour..  May  9,  1896. 

•^  Vou  Slein  :  Extract  in  Arch,  of  Olol.,  1896. 

Circulatory  System  and  Blood. 

"■''^  Findlayson  :  Brit.  Med.  Jour.,  Decemljer  31,  1898. 
•»  Extract  in  Progressive  M'-.d.,  June,  1900. 

Kidney. 

"'Dowling:  ./our.  Amer.  Med.  Asso.,  March  26,  1898. 
<=  Morf :  JriA.  c/  OtoL,  1898. 

Genital  Organs. 

"  Bourbon  :  F.xtract  in  Jour.  .4mer.  Med.  .isso.,  Februarv  24,  1900. 
»'  Prilchard:  King's  College  Hospital  lieports,  1896. 
**  Toynbe:  Diseases  of  the  Ear. 

Eye. 
»■  Habermann  :  Arch,  of  Olol,  1898. 
«"  Lunn  :  Lancet,  1899,  vol.  I. 
«•  .Milligan  :  Practiliontr,  1889,  p.  610. 
"»l-ooley:  .IreA   of  Otol.,  May,  1896. 
'•Rayneranil  Batten:  Lincrt,  1899,  vol.  1. 
"  Stirling  :  Canada  Med.  Record,  Novemlier,  1896. 
'2  Urbantschitsch  :  .4niia'.t  of  Oph.  and  Otol.,  1896. 
'3  Veasey  :  Ophthalmic  Record,  June,  1899. 
'<  Whiting  :  ^rcA.  of  Otol.,  1898. 

Drugs. 

"^  Ramsey  :  Brit.  Med.  Jour.,  December  17, 1898. 

'•  Shastid  :  Jour.  .4inrr.  Med.  Asso.,  September  19, 1896. 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS.* 

By  H.  ILLOWAY,  M.D., 

of  New  Y'ork. 

Formerly  Professor   of  Diseases  of  Children,  Cincinnati  College  of  Medicine 

and  Surgery  ;   Formerly  Visiling  Physician  Jewish 

Uospital,  (Cincinnati ;  etc 

For  the  whole  period  of  his  existence  upon  this 
mundane  sphere,  the  human  being  is  liable  to  colic. 
It  may  lay  hold  of  him  at  any  time,  in  youth,  in  man- 
hood, in  hoary  old  age,  bend  him  double,  twist  him 
into  knots  as  if  he  were  a  practising  contortionist.  It 
is,  however,  at  the  earliest  period  of  his  life — almost 
with  his  entrance  upon  this  nether  globe — that  it  seizes 
upon  him  with  greatest  violence,  holds  him  tenaciously 
in  its  grasp  and  seems  to  vent,  as  it  were,  all  its  malice 
upon  him.  It  is  the  youngest  infant.s  that  are  most 
subject  to  this  ailment ;  it  disturbs  their  rest,  breaks 
in  upon  their  angelic  slumbers,  and  causes  them  to 
make  the  welkin  ring  with  their  outcriejs.  Truly  they 
sutler,  and  those  about  them  are  made  to  feel  the  weiiiht 


*  Read   before  the    Pediatric  Section  of  the  Aoidemf   of  Medicine  at  the 
Meeting,  Thursday,  January  10. 


FBBRUiRY  2,   1901] 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


PThe  Phiuldelpbia 
L  Medical  Joiesal 


243 


of  their  woe.  The  good  mother,  the  kindly  nurse,  are 
driven  to  distraction  in  their  efforts  to  alleviate  baby's 
sufferings  and  frequently,  for  long  periods,  know  no 
rest. 

The  seizures  may  be  sporadic,  that  is  occurring  at 
long  and  various  intervals  and  always  the  result  of 
some  well-defined  sin  of  omission  or  commission  in  the 
care  or  the  feeding  of  the  infant. 

Or  they  may  manifest  themselves  from  the  second  or 
third  day  after  birth,  usually  the  latter,  and  continue 
throughout  a  longer  or  shorter  period  of  time,  recurring 
with  varying  frequency  throughout  the  days  and  nights 
of  that  time.  It  is  this  latter  form  which  has  been 
designated  by  the  older  writers  as  "  infantile  colic,"  and 
to  it  only  this  distinctive  designation  truly  applies. 
Such  infants,  in  the  language  of  the  laity,  are  "  colicky." 

The  duration  of  this  colicky  period  varies,  depending 
in  a  considerable  measure  upon  the  factors  giving  rise 
thereto.  It  ranges  from  4  weeks  to  3  months.  The 
attacks  are  most  frequent  in  the  earlier  period  and  abate 
gradually,  the  paroxysms  becoming  less  frequent  in  the 
24  hours,  and  of  briefer  duration,  and  finally  ceasing 
altogether  by  the  end  of  the  fourth  or  sixth  week,  or 
before  the  end  of  the  third  month.  Exceptionally,  they 
may  continue  with  unabated  severity  for  full  3  months 
to  disappear  very  quickly  or  to  abate  but  gradually  after 
that  time. 

The  attacks  come  on  at  various  intervals  throughout 
the  day  until  a  certain  hour  of  the  evening,  when  the 
infant  will  fall  asleep  and  remain  tranquil  for  five  to 
six  hours.  Later  on  he  will  be  comparativly  free  all 
day  until  6  or  7  o'clock  in  the  evening,  when  he  will 
begin  with  his  cries  and  know  no  rest  except  at  inter- 
vals of  a  few  brief  moments  until  10  or  11  o'clock  or 
even  midnight. 

In  the  very  severest  cases  the  attacks  may  come  on 
with  unwonted  frequency  throughout  the  days  and 
nights  of  this  colicky  period,  and  many  poor  mothers 
will  spend  their  nights  or  the  greater  parts  thereof  in 
measuring  the  length  of  the  apartment,  walking  to  and 
fro  with  baby  in  arm,  in  their  endeavors  to  quiet  it. 

It  is  a  common  saying  among  wise  old  ladies  that 
boys  are  more  subject  to  colic  than  girls.  There  are 
no  statistics  upon  the  subject,  but  my  personal  observa- 
tion is  fuUy  in  accord  with  this.  Moreover,  it  has  even 
seemed  to  me  that  when  girls  were  colicky  the  parox- 
ysms were  much  less  frequent,  less  severe,  and  of  briefer 
duration  than  in  male  infants  thus  affected. 

What  is  colic  ?  Colic  is  an  irregular  peristalsis  mainly 
of  the  small  intestines,  a  contraction  of  the  various  mus- 
cular coats  of  the  intestinal  tract,  accomplished  with 
such  violence  that  the  nerve  filaments  distributed  be- 
tween them  are  unduly  compressed  and  the  sensation  of 
pain  aroused. 

This  peristalsis  is  not  necessarily  attended  by  fecal 
discharge. 

It  is  said  by  some  writers,  and  with  special  reference 
to  "  infantile  colic,"  that  distention  of  the  intestines  by 
gases  may  cause  the  pain.  It  is  true  that  an  extraordi- 
nary distention  of  the  bowel  may  give  rise  to  pain,  but 
it  is  not  the  pain  of  colic.  Flatulence  can  excite  colic 
only  when  there  is  no  extraordinary  distention  of  the 
intestinal  tract  and  the  gases  shift  about  from  one  loop  to 
another,  from  one  section  to  another,  from  one  side  of  the 
transverse  colon  to  another,  from  left  to  right  or  right 
to  left,  exciting  here  and  there  this  irregular  peristalsis. 

Colicky  pains  are  part  of  the  natural  history  of  many 
very  grave  diseases  of  the  intestinal  tract,  of  inflam- 


matory and  ulcerative  processes  therein,  of  various  con- 
genital malformations  thereof,  and  of  various  affections 
of  the  peritoneum,  but  colic  considered  as  an  entity 
is  merely  a  functional  disturbance  with  no  underlying 
pathological  substratum,  and  when  the  paroxysm  is 
over,  the  normal  equilibrium  is  quickly  restored. 

This  is,  no  doubt,  the  explanation  for  the  fact  which 
otherwise  would  be  inexplicable,  that  despite  the  great 
and  frequently  rather  long- continued  suffering  of  the 
infants  afHicted  with  "  infantile  colic,"  they  thrive 
nevertheless,  gain  in  flesh  and  strength  and  progress  as 
well  as  other  children  more  favored  in  this  regard. 

The  causes  of  infantile  colic  and  colic  in  infants  are  : 

1.  Flatulence. 

2.  Sundry  influences  acting  through  the  mother. 

3.  Indigestion. 

4.  Refrigeration. 

I. — Flatulence. 

Of  all  the  etiological  factors,  this  is  the  most  im- 
portant, giving  rise  to  the  most  cases  and  to  the  most 
protracted  ones.  In  fact,  it  is  the  etiological  factor  of 
"infantile  colic." 

As  is  well  known,  in  the  course  of  the  digestive  act, 
various  gases  are  developed  in  the  stomach  and  bowels 
in  the  process  of  the  splitting  up  of  the  food  and  its 
transformation  into  assimilable  material.  Under  ordi- 
nary physiological  conditions  the  gases  are  but  small 
in  quantity,  move  slowly  along  downward  with  the 
chymus,  and  are  finally  discharged  either  alone  or  with 
the  feces,  without  having  caused  the  least  disturbance. 

In  these  colicky  infants,  however,  the  gases  are  either 
developed  in  undue  quantity  or  are  retained  unduly 
long,  and  thus  allowed  to  accumulate  and  then  excite 
this  exaggerated  peristalsis  as  an  effort  of  nature  to 
dislodge  them. 

The  reasons  for  this  flatulent  condition  of  the  infant 
may  lie  in  the  infant  or  they  may  lie  in  the  mother. 

A.  They  may  lie  in  the  infant. 

Up  to  the  time  of  its  birth,  the  infant  was  nourished 
through  the  blood  of  the  mother  and  its  digestive 
organs  lay  dormant.  Now,  suddenly  and  without  any 
especial  preparation,  they  are  called  upon  to  act  their 
part  in  a  very  complex  chemical  operation.  It  is  not 
far  fetched  to  assume — we  not  infrequently  see  it  in 
other  organs — that  the  intestinal  tract  here  has  not 
reached  the  degree  of  normal  efficiency.  Though  the 
colostrum  of  the  first  two  or  three  days  might  be  looked 
upon  in  the  light  of  such  preparation,  it  has  evidently 
not  been  sufiicient  in  the  cases  under  consideration. 
The  digestive  act  is  not  accomplished  with  the  speed 
and  perfection  of  a  later  period,  and  as  a  consequence, 
an  undue  volume  of  gas  is  developed. 

Again,  it  is  a  well-known  fact  that  the  pancreas  is  a 
most  important  factor  in  the  proper  preparation  of  the 
chymus,  as  it  comes  from  the  stomach,  into  assimilable 
material.  This  organ,  however,  does  not  attain  its 
full  power  till  a  much  later  period,  in  part  not  until 
nearly  the  end  of  the  first  year.  It  is  true  that  Zweifel 
found  that  an  extract  of  the  pancreas  of  the  first  month 
from  strong  children  was  capable  of  digesting  albumen, 
and  the  inference  would  be  perfectly  proper  that  the 
secretion  of  the  organ,  as  poured  out  into  the  duodenum, 
should  possess  similar  power.  Still,  even  admitting 
this,  it  is  at  a  much  later  period  than  the  setting  in  of 
the  colic,  the  second  or  third  day. 

This  alone,  in  fact,  would  tend  to  prove  the  correct- 
ness of  the  position  here  taken. 


■944  ^'^^  Philadelphia"! 

Medical  Jodknal  J 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


[Fbbscaby  2,  1901 


Or  it  may  be  that  for  some  reason  the  organ  does 
not  furnish  sufficient  secretion  or  a  secretion  sufficiently 
rich  in  albumen-splitting  and  oil-emulsifying  ferments 
to  complete  the  digestive  process  with  the  rapidity  of  a 
later  period,  and  hence  an  abundance  of  flatus  as  a 
result  of  slower  chemical  operation. 

It  must  be  admitted  that  all  this  is  hypothetical,  as 
we  very  frequently  find  nothing  in  the  stools,  having 
reference  now  to  the  case  of  infantile  colic  more  par- 
ticularly, to  indicate  an  imperfect  digestion,  and  even 
when  such  indications  are  found  they  can,  in  the 
majority  of  instances,  be  readily  accounted  for  by 
extraneous  incidents. 

It  is,  nevertheless,  well  to  bear  this  explanation  in 
mind,  as  it  is  based  on  physiological  data  and  the  clin- 
ical fact  that  slowness  of  digestion  tends  to  the  devel- 
opment of  much  flatus,  and  accounts  for  the  cases,  not 
so  very  many  in  number,  it  is  true,  where  no  extraneous 
factors  or  supposed  factors  can  be  discovered,  and  which 
would  otherwise,  therefore,  be  inexplicable. 

It  is  of  some  moment  in  the  consideration  of  certain 
cases  of  hand-fed  infants  as  will  be  recalled  further  on. 

B.  They  may  lie  in  the  mother. 

1.  The  Mother  is  Constipated. — If  the  mother  be  con- 
stipated, the  infant  also  is  usually  constipated  or  at 
least  costive.     This  allows  of  the  accumulation  of  flatus. 

Again,  all  constipated  persons  are  more  or  less  flatu- 
lent, and  the  milk  of  a  constipated  mother  is  also  of  a 
more  or  less  flatulent  character  and  the  flatulence  will 
develop  in  the  infant. 

2.  The  Diet  of  the  Mother-  may  be  at  Fault. — The  con- 
sumption by  her  of  such  articles  of  food  as  are  known 
to  be  of  flatulent  character,  as  cabbage,  cauliflower, 
peas,  beans,  etc.,  will  make  the  milk  flatulent,  and  the 
infant  nursed  therewith  will  become  flatulent  in  turn. 

II. — Sundry  Influences  Acting  Through  the  Mother. 

1.  Purgatives. — Cathartic  remedies  taken  by  the  nursing 
mother  aff'ect  the  infant  in  a  greater  or  lesser  measure. 
This  is  well  established.  I  have  myself  noted  several 
instances  where  a  dose  of  salts  taken  by  the  mother 
produced  watery  evacuations  in  the  infant,  even  when 
the  mother  was  not  at  all  moved  thereby.  As  is  the 
nature  of  cathartics,  they  may  excite  colic.  I  have 
seen  a  number  of  cases  where  the  administration  of 
some  form  of  senna,  in  decoction  (as  in  Infus.  laxativ. 
Vienens)  or  in  extract  (in  pill  with  other  ingredients) 
was  followed  by  a  very  colicky  state  of  the  infant, 
though  the  mother  was  not  in  the  least  inconvenienced 
thereby.  I  have  seen  the  same  thing  follow  upon  aloes 
and  aloin. 

The  habit  of  taking  purgatives  at  regular  periods  by 
constipated  mothers,  is  frequently  attended  with  much 
suffering  for  the  infant — colics. 

2.  The  eating  of  sour  pickles  or  other  articles  pre- 
pared freely  with  vinegar,  of  raw  fruit,  the  drinking 
freely  of  lemonade  by  the  nursing  mother,  is  usually 
attended  with  colics  in  the  infant. 

3.  Much  Worry,  a7id  Anxious  State  of  Mind  on  the  Part  of 
the  Mother. — There  is  no  question  now  as  to  the  influence 
of  the  mind  upon  the  body,  its  functions  and  secretions  ; 
and  the  lacteal  secretion  is  no  exception  thereto.  This  has 
been  well  recognized,  and  much  stress  is  laid  upon  this 
point,  the  mental  temperament,  in  the  matter  of  the 
selection  of  a  wet  nurse  when  the  necessity  therefor 
arises.  Sir  Astley  Cooper,  in  his  work  on  the  Breast, 
says,  and  the  statement  is  repeated  by  Carpenter  in  his 
Physiology,  that  anxiety  of  mind  of  the  mother  may  be 


the  cause  of  griping  or  tormina  in  the  infant.  I  have 
had  occasion  to  make  the  same  oVjservation.  In  one 
particularly  striking  case,  no  other  possible  cause  for 
the  severe  colic  of  the  infant  could  be  discovered  than 
this  great  mental  worry  of  the  mother,  and  with  its  dis- 
appearance, which  occurred  a  short  time  later,  the 
troubles  of  the  infant  at  once  ceased. 

Fretfulnesfi  on  the  part  of  the  nursing  mother  may  be 
the  cause  of  a  colicky  state  of  the  infant. 

Mts  of  Anger,  Sudden  Fear. — The  milk  nursed  soon 
after  such  will  most  usually  excite  an  attack  of  colic  in 
the  infant.  Even  more  untoward  and  graver  accidents 
have  been  known  to  follow  the  first  of  these  two. 

4.  Paroxysms  of  Pain  Afflicting  the  Mother. — Dewees, 
one  of  the  great  physicians  of  this  country,  and  a  most 
careful  observer,  relates  a  case  of  colic  of  5  months' 
duration,  due  to  such  a  cause.  The  infant  was  a  stout 
child  and  in  good  condition  for  the  first  two  weeks  ;  then 
colics  set  in  and  occasional  vomiting.  He  attended  the 
child,  and  despite  all  he  did  or  could  do,  it  remained 
colicky ;  and  not  alone  that,  but  it  wasted  away.  It 
was  about  the  end  of  the  fifth  month  when  he  noticed 
accidentally  one  day  at  one  of  his  visits,  that  the 
mother  put  her  hand  to  her  cheek  and  pressed  it 
forcibly.  On  inquiry  as  to  the  meaning  of  the  motion, 
he  learned  "  that  she  was  very  much  tormented,  both 
by  day  and  night,  with  the  toothache,  and  had  been  so 
for  some  time  before  the  child  was  born,  and  ever  since.'" 
He  declared  this  to  be  the  cause  of  the  child's  suffer- 
ings, and  directed  that  a  dentist  be  sent  for  at  once. 
This  was  done  and  the  tooth  extracted,  whereupon  the 
infant  was  quickly  relieved  of  its  colic  and  began  at 
once  to  thrive  again. 

This  is  certainly  well  worth  remembering,  as  very 
many  women  suffer  with  their  teeth  during  pregnancy 
and  continue  to  suffer  after  delivery  for  3  or  4  weeks  or 
even  longer,  until  they  are  able  to  go  out  and  consult  a 
dentist.  I  have  myself  known  in  my  clientele  quite  a 
number  of  ladies  who  dated  the  decay  of  their  teeth 
from  their  first  pregnancy. 

As  to  the  mode  of  action  of  these  various  factors 
relating  to  the  mother  and  here  mentioned,  it  suffices 
to  say  here,  as  has  already  been  indicated  above,  that 
they  act  through  the  milk,  and  thus  affect  the  infant. 
As  to  the  details,  these  can  be  found  in  the  various 
works  relating  to  the  nursing  or  feeding  of  the  infant. 

III. — Indigestion. 

Indigestion  may  be  the  result  of  overfeeding  or  of 
the  administration  of  improper  food. 

1.  Overfeediny.  The  infant  is  nursed  too  frequently. — 
This  is  one  of  the  most  grievous  sins  of  commission 
on  the  part  of  the  mother  against  the  well-being  of 
the  child.  Many,  very  many,  mothers  believe  that 
every  time  the  infant  utters  a  cry,  it  is  hungry  and 
must  be  fed,  without  any  regard  to  the  time  that  may 
have  elapsed  since  the  previous  nursing  or  feeding.  I 
have,  in  my  long  experience,  found  that  the  greater 
number  of  children  were  nursed  or  given  the  bottle  as 
often  as  every  hour,  or  even  at  shorter  intervals,  and  at 
periods  when  they  were  fretful  were  put  to  the  breast 
as  often  as  every  half  hour. 

There  is  no  question  in  my  mind,  and  I  have  called 
attention  to  it  elsewhere,'  that  nine-tenths  of  the  troubles 
of  the  digestive  tract  of  infants,  are  due  to  overfeeding. 

1  In  various  articles,  but  more  particularly  in  mr  book,  ** C^nstipatiOD  in 
Adult-s  and  Children,  with  Kspecial  Keference  'to  Habitual  Conslipati  -n  aod  It» 
Most  Succe^ful  Treatment  by  the  Mechanical  Measures,"  Xew  York,  IS?'. 


Fkkruaey  2,  1001] 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


CThe  Philadelphia 
Medical  Journal 


245 


and  though  it  is  true  that  but  very  little  is  said  about 
this  by  writers,  not  at  all  conamensurate  with  its  im- 
portance, it  is  because  mothers,  and  particularly  nurses, 
are  given  to  deception  on  this  point ;  and  unless  you 
cross-examine  very  closely  and  sharply,  you  will  not, 
in  most  cases,  learn  the  truth.  The  mother,  and  most 
certainly  the  nurse,  will  not  usually  admit  that  the 
infant  is  ill  through  her  fault. 

In  consequence  of  this  overfeeding,  an  undue  amount 
of  food  is  introduced  into  the  economy,  much  more 
than  can  be  assimilated.  It  is  a  wise  provision  of 
nature  that  the  great  majority  of  infants  regurgitate 
and  spit  out  the  excess  of  food  that  may  have  been 
taken  during  nursing,  and  therein  the  old  saw  is  right 
that  a  spitting  child  always  thrives.^  In  overfeeding, 
however,  spitting  out  alone  cannot  accomplish  much, 
and  nature  in  its  endeavors  to  guard  the  precious 
homunculus  from  harm,  seeks  to  get  rid  of  the  super- 
fluous aliment  in  a  more  effective  way,  through  the 
bowels.  As  a  result  of  this  effort,  we  have  exaggerated 
peristalsis, — colic. 

There  is  also,  as  would  be  readily  supposed,  much 
flatulence  present  in  these  cases. 

When  continued  for  any  length  of  time  a  dyspepsia 
is  developed,  especially  in  bottle-fed  children,  and  this 
will  tend  to  aggravate  the  paroxysms  of  colic,  make 
them  more  severe  and  more  protracted. 

The  infant  is  overfed  in  quantity,  that  is,  too  large  an 
amount  in  proportion  to  the  age,  is  given  at  one  time, 
though  the  proper  length  of  interval  between  feedings 
is  observed. 

This  applies  only  to  hand-fed  children. 

One  of  the  severest  and  most  intractable  cases  of 
colic  observed  by  me  was  in  an  infant  who  received  a 
properly  prepared  milk  from  an  establishment  making 
a  specialty  of  furnishing  milk  for  infants,  but  to  whom 
at  the  direction  of  a  medical  attendant,  the  inordinate 
•quantity  of  three  times  the  amount  proper  to  its  age 
was  admistered  at  every  feeding,  though  the  intervals 
between  these  were  perfectly  correct. 

It  is  supposed  by  many  physicians  that  overfeeding 
always  leads  to  diarrhea.  This  is  not  the  case.  As  I 
have  pointed  out  elsewhere,'  it  is  most  frequently  pro- 
ductive of  constipation,  especially  in  more  vigorous 
children  and  in  the  cooler  months. 

2.  The  Food  May  Not  Be  of  the  Proper  Character. — Oc- 
casionally the  milk  of  the  mother's  breasts  may  be  of 
an  abnormal  character ;  it  is  too  acid ;  it  is  too  salty, 
etc.  It  naturally  disagrees  with  the  child  and  causes  it 
colic,  diarrhea,  etc. 

Mainly,  however,  this  applies  to  artificial  feeding. 
The  milk  (and  milk  is  really  the  best  food  for  the  very 
young  infants)  may  not  be  of  a  healthy  character.  It 
may  be  acid  ;  it  may  be  sour ;  it  may  contain  unhealthy 
and  irritating  elements.  Again,  though  the  milk  itself 
be  perfectly  normal,  it  may  not  be  properly  prepared, 
not  in  accord  with  the  digestive  capacity  of  the  infant. 

In  isolated  instances,  milk,  no  matter  whence  derived 
or  how  carefully  prepared,  may  not  be  tolerated.  Trous- 
seau* records  a  very  striking  instance  of  this.  The 
children  of  a  shipbuilder  of  Havre  could  not  tolerate 
milk  of  any  kind  for  the  first  seven  years  of  their  life. 
No  matter  whether  it  came  from  the  human  breast 
(mother,  wet-nurses)  or  was  taken  from  diS'erent  ani- 
mals, cows,  goat  and  even  the  ass,  the  same  effect  was 

-  Speikioder— Gedeihkinder. 

8  Se«  my  book  "  Constipation  in  Adults,  Ciiildreu,  etc." 

"*  Trousseau  Clinical  Lectures,  Philadelphia  Edition,  vol.  2, 


always  produced  :  diarrhea  and  vomiting.  They  were 
fed  upon  decoctions  of  grits  and  pearl-barley  and 
thrived. 

Much  the  same  applies  to  other  infant  foods  made 
from  grain.  For  one  reason  or  the  other,  they  may  dis- 
agree with  the  infant,  and  thus  give  rise  to  attacks  of 
colics. 

In  older  infants — infants  who  already  eat — improper 
articles  of  food  are  a  most  frequent  cause  of  colic.  This 
is  particularly  so  among  the  middle  and  poorer  classes, 
where  the  infant  of  10  months  and  over  is  set  to  the 
table  at  mealtime  with  the  adults  and  usually  given  a 
bit  of  something  to  keep  it  quiet.  I  have  not  infre- 
quently seen,  among  the  more  ignorant,  a  father,  a 
mother,  take  the  greatest  delight  in  seeing  their  infant 
suck  a  piece  of  sausage,  a  bit  of  fried  steak,  and  if  the 
infant  was  old  enough  to  bite  off  little  bits  and  munch 
them,  so  much  the  better.  To  them  it  was  a  most 
wonderful  performance. 

It  is  well  to  bear  this  in  mind,  as  when  trouble  follows 
and  inquiry  is  made  by  the  physician  all  such  indis- 
cretion on  the  part  of  the  mother  is  denied  in  toto. 

Sometimes,  though  not  very  frequently,  it  may  happen 
that  the  colicky  state  is  due  to  underfeeding.  As  can  be 
readily  understood,  this  applies  only  to  nurslings.  For 
one  reason  or  another,  usually  from  dire  poverty,  very 
rarely  on  account  of  defective  conformation,  the  breast 
does  not  supply  the  infant  with  sufficient  nourishment. 
The  child  is  always  hungry,  crying,  and  making  suck- 
ling motions.  Reflexly  the  empty  suckling  at  the 
breast,  and  away  from  it,  will  excite  a  gastrointestinal 
peristalsis,  and  as  there  is  nothing  or  very  little  to 
contract  upon,  it  soon  becomes  irregular,  and  griping 
results. 

IV. — Refeigeeation. 

This  may  result  in  various  ways.  The  infant  is 
allowed  to  lay  too  long  in  the  wetted  diaper.  Its  abdo- 
men is  exposed  to  the  cold  air.  Its  food,  if  it  be  hand- 
fed,  is  given  too  cold. 

In  older  infants,  sitting  on  a  wet  floor,  walking  bare- 
foot over  a  wet  or  cold  floor,  or  drinking  water  that  is 
too  cold,  may  excite  an  attack  of  colic. 

We  find  the  same  factors  producing  the  same  effects 
in  adults.  I  have  known  of  instances  in  adults  where 
a  sudden  exposure  of  the  abdomen  to  the  cold  air,  as 
when  the  covers  were  accidentally  thrown  ofl"  during 
the  night,  was  at  once  followed  by  an  attack  of  colic. 
Walking  barefoot  across  a  cold  floor  is  not  an  infrequent 
cause  of  colic  in  persons  not  accustomed  thereto. 

No  further  proof  for  this  etiological  factor  is  neces- 
sary. Indeed,  upon  this  stimulant  action  of  cold  upon 
the  intestines  are  based  the  various  hydrotherapeutic 
procedures  employed  in  the  treatment  of  constipation.' 

Other  Factors. — 1.  Another  factor  assigned  prominence 
by  some  authors  in  the  etiology  of  colic  is  the  swallow- 
ing of  air.  It  is  supposed  to  be  of  great  influence  in  the 
production  of  flatulence.  I  myself  lay  no  stress  npon  it. 
I  do  not  believe  that  any  infant  sucks  in  enough  atmos- 
pheric air  to  cause  colic.  I  have  seen,  time  and  again, 
infants  lie  for  hours  with  the  short  rubber  nipple  in  the 
mouth,  sucking  away,  at  longer  or  shorter  intervals,  with 
great  vigor,  and  this  as  a  steady  practice,  and  I  cannot 
recall  an  instance  where  colic  or  a  colicky  condition 
resulted  in  consequence  thereof. 

2.  Dewees  thought  that  in  a  few  of  his  cases  of  in- 
fantile colic,  a  malarial  influence  was  the  exciting  cause. 

5  See  my  book,  "  Canstipation  in  Adults  and  Children,"  etc. 


246 


The  Philadelphia 
Medical  Journal 


] 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


[FuBEfAET  2,   IMl 


There  was  a  distinct  periodicity  about  the  attacks,  and 
bark  effected  a  cure. 

It  is  worthy  of  note  for  those  practising  in  malarial 
regions. 

Symptoms. — 1.  The  infant  sleeping  quietly  in  its  little 
bed  becomes  restless  all  at  once.  It  twists  and  moves 
about,  now  the  arms,  now  the  legs  being  in  motion. 
The  little  forehead  wrinkles,  the  angles  of  the  mouth 
are  drawn  down,  and  a  few  short  cries  are  emitted. 
These  become  longer,  louder  and  more  forcible,  until  at 
the  height  of  the  paroxysm  the  baby  veritably  screams 
and  continues  to  do  so  until  a  relaxation  sets  in,  which 
is  very  frequently,  in  infantile  colic  always,  coincident 
with  a  more  or  less  large  discharge  of  flatus  through 
the  anus.  It  then  becomes  quiet  again,  the  face  resumes 
its  former  serenity,  and  baby  is  very  soon  asleep  again. 

Or  it  may  happen  in  this  wise  :  The  infant  has  nursed 
and  lies  quietly  and  contentedly  in  the  mother's  or 
nurse's  arms  with  eyes  wide  open  or  in  a  gentle  slum- 
ber. Suddenly,  after  a  more  or  less  brief  period  after 
the  feeding,  the  little  one  becomes  restless.  It  twists 
and  moves,  now  the  arms,  now  the  legs  being  in  motion. 
The  little  forehead  wrinkles,  the  angles  of  the  mouth 
are  drawn  down  and  a  grunt  or  two  or  a  few  short  cries 
are  emitted.  These  become  longer,  louder  and  more 
forcible  as  the  pain  increases,  until  at  the  height  of  the 
paroxysm  the  baby  veritably  screams  and  continues  to 
do  so  until  a  relaxation  sets  in,  which  is  coincident  with 
several  eructations  of  gas,  which  may  or  may  not  be 
followed  by  a  free  discharge  of  flatus.  It  then  becomes 
quiet  again  ;  the  face  resumes  its  former  placidity  ;  even 
a  smile,  if  the  infant  be  old  enough,  may  play  upon  its 
features  and  in  a  very  little  while  it  is  soundly  asleep. 

When  the  attack  is  but  slight,  merely  a  twinge,  only 
the  first  half  of  the  phenomena  will  be  observed — the 
restlessness,  the  movements  of  the  extremities,  the 
wrinkling  of  the  forehead,  the  drawing  down  of  the 
angles  of  the  mouth — or  even  still  more,  the  grunt  or 
short  cry.  Then  just  as  suddenly  a  relaxation  sets  in, 
a  discharge  of  flatus,  an  eructation  of  gas  has  occurred, 
and  the  calm  at  once  returns.  The  features  again  be- 
come placid,  even  smiling. 

In  older  infants,  the  onset  may  be  thus  :  The  baby, 
soundly  asleep,  suddenly  utters  a  loud  and  piercing 
scream  and  awakes.  Or  it  may  be  sitting  in  its  crib  or 
on  the  floor,  playing  and  cooing,  and  suddenly  it 
screams  out. 

If  it  be  but  a  passing  twinge,  the  cry  is  rather  short 
and  not  so  loud,  and  all  is  past  in  a  moment ;  the  child 
is  again  sound  asleep,  having  been  hardly  awakened, 
or  it  is  again  playing  and  cooing  and  smiling  as  before. 

The  face  of  the  infant  is  congested  during  the  crying 
spell ;  occasionally,  and  more  particularly  in  older 
infants  and  children,  the  pain  may  be  so  severe  that 
they  cannot  cry  out  and  then  the  face  is  pale  and  the 
lips  are  blue. 

This  particular  play  of  features,  now  quiet  and 
serene,  placid  and  smiling,  in  the  next  moment  wrinkled, 
drawn  and  expressive  of  suffering,  crying,  and  in  a  very 
short  time  again  serene,  again  smiling,  has  been  likened 
not  inaptly,  by  a — to  me — now  unknown  but  evidently 
rather  poetically  inclined  practitioner,  to  the  phenom- 
ena observed  in  nature  in  the  sweet  spring  days ;  the 
brightly  shining  sun,  all  nature  smiling  ;  then  suddenly 
a  gathering  of  the  clouds,  a  darkening  of  the  horizon, 
a  brief  rain  and  again  the  sun  shining  brightly,  and  all 
nature  again  smiling. 

2.  The  hands  and  feet  become  cold  with  the  onset  of 


the  seizure,  and  continue  so  the  whole  duration  of  the 
paroxysm,  but  quickly  resume  their  normal  warmth 
when  the  attack  has  passed. 

3.  Another  and  very  distinctive  feature  of  simple 
colic  is  the  movement  of  the  legs ;  it  is  not,  as  usually 
described,  a  mere  kicking,  but  the  leg  is  flexed  upon 
the  thigh  and  the  thigh  upon  the  abdomen — all  this 
with  a  rapid,  upward  motion,  and  then  the  whole  limb 
is  let  go  again  and  extended  with  an  equally  rapid 
movement,  and  then  the  procedure  repeated  de  novo. 
This  movement,  made  instinctively,  is  therefore  not  the 
mere  kicking  of  a  petulant  child,  but  a  movement 
wherewith  to  obtain  relief,  to  make  pressure  upon  the 
abdomen — ^^just  what  we  see  done  in  the  adult  when 
similarly  afflicted.  Thus  the  adult,  when  seized  with 
colic,  will  bend  double,  if  he  be  standing  up,  or  sitting  • 
but  if  he  be  lying  down,  he  will  draw  up  his  legs,  flex 
them  upon  the  thighs  and  these  upon  the  abdomen, 
and  thus  make  pressure  upon  his  bowels  and  obtain 
easement.  That  this  view  is  correct  is  demonstrated  by 
this,  that  if  the  infant  can  make  pressure  upon  its  abdo- 
men otherwise,  it  will  not  kick  its  legs.  Thus,  if  at  the 
onset  of  a  seizure,  or  during  a  mild  seizure,  or  while  it 
is  having  colicky  twinges,  as  shortly  after  feeding,  the 
infant  be  held  up  in  arms  with  its  head  upon  the 
shoulders  of  mother  or  nurse,  it  will  press  its  little  belly 
firmly  against  the  mother's  or  nurse's  chest,  as  these 
will  tell  you,  and  thus  ease  itself;  for  it  will  be  quiet 
and  apparently  comfortable,  and  as  long  as  it  is  thus 
held,  there  will  be  no  kicking. 

4.  The  belly  is  usually  hard  during  the  paroxysm — 
a  condition  due  to  the  contraction  of  the  abdominal 
muscles.  As  soon  as  the  attack  is  over,  the  belly  is 
again  soft,  normal  to  the  touch.  There  may  be  some 
fulness  about  it,  particularly  if  there  be  much  flatus 
present,  or  if  the  infant  be  constipated. 

5.  Constipation  or  costiveness  may  or  may  not  be 
present.  I  have  seen  cases  of  infantile  colic  in  infants, 
who  had  regular  and  normal  movements. 

There  is  usually  no  fever,  especially  so  in  infantile 
colic.  In  the  cases  due  to  overfeeding,  more  particu- 
larly in  hand-fed  infants,  or  to  improper  food,  there  may 
be  occasionally  some  elevation  of  temperature,  but  it  is 
generally  only  trivial. 

In  very  severe  cases  the  fontanels  may  be  depressed. 

Diagnosis. — The  symptoms  above  related  are  so  char- 
acteristic and  stand  forth  so  prominently,  that  the  diag- 
nosis of  an  attack  of  colic  is  readily  and  unerringly 
made. 

That  it  is  a  simple  colic  wUl  also  be  recognized  by 
the  very  presence  of  these  phenomena.  In  the  attacks 
of  colic  supervening  in  the  course  of  diseases  of  the 
intestines  or  the  peritoneum,  there  is  no  such  play  of 
the  features  as  described  above.  In  these  ailments, 
more  or  less  grave,  and  always  painful,  the  countenance 
of  the  infant  bears  continuously  an  expression  of  suf- 
fering that  does  not  leave  it  until  convalescence  is  fuUy 
established.  During  the  colicky  seizures,  this  is  intensi- 
fied, and  when  it  is  over,  the  face  is  only  as  before  ex- 
pressive of  suffering,  not  the  again  c^ilm  and  serene 
countenance  of  the  otherwise  healthy  child. 

I  attach  great  importance  to  this  plaj-  of  the  features, 
so  much  so  that  almost  upon  this  alone  I  made  the 
diagnosis  of  simple  colic  in  a  case  to  which  I  was 
called  in  consultation  with  an  excellent  colleague,  who 
was  inclined  to  regard  it  as  one  of  intussusception. 

The  infant,  about  17  months  old  and  well  nourished, 
had  been  taken  out  by  its  mother  one  afternoon  on  a 


Fkheuary  2,  19H] 


INFANTILE  COLIC  A^D  COLIC  IN  INFANTS 


CThb  Philadelphia 
Medical  Jouhnal 


247 


visit  with  her  to  some  relatives,  and  these  in  their  mis- 
taken kindness  had  stuffed  it  with  cake,  milk,  etc. 
When  it  again  reached  home  at  a  late  hour  that  even- 
ing, it  was  restless,  and  at  intervals  would  cry  out 
loudly  as  if  in  pain.  Early  the  next  morning  a  physi- 
cian was  called  who,  having  learned  that  contrary  to 
its  usual  habit  the  child  had  had  no  movement  since 
the  previous  morning,  prescribed  an  enema  and  some 
simple  remedy.  No  movement  resulted.  After  a  while 
a  little  colored  fluid  passed  from  the  bowels,  and  there 
were  some  drops  of  blood  on  the  diaper.  It  continued 
to  cry  out  at  intervals,  as  before. 

I  saw  the  child  about  1  p.m.  It  was  in  its  mother's  arms, 
and  was  then  sleeping  quietly  with  unruffled  counte- 
nance. I  examined  the  abdomen  and  found  it  full,  but 
fairly  soft.  I  could  detect  nothing  abnormal  about  it 
on  deep  palpation.  There  was  some  slight  elevation  of 
temperature,  but  it  was  trivial.  As  I  watched  the  in- 
fant as  it  thus  lay  with  eyes  closed,  evidently  sleeping, 
I  noticed  that  all  at  once  its  face  would  become  drawn, 
it  would  twist  about  somewhat,  make  some  slight  move- 
ment with  its  legs  and  then  in  another  moment  it  was  all 
p'ast,  and  the  face  was  again  as  placid  as  before.  Occa- 
sionally, when  the  twinge  was  over,  a  smile  would 
illumine  its  countenance.  Upon  this  special  feature  I 
made  the  diagnosis  of  simple  colic,  advised  the  appro- 
priate treatment,  and  in  a  short  time,  as  I  was  subse- 
quently informed,  the  infant  was  permanently  relieved. 
Again,  in  the  colics  coming  on  in  the  course  of  the 
grave  pathological  conditions  referred  to,  there  is  no 
kicking  of  the  legs.  Such  forcible  movements  would 
only  aggravate  the  suffering  already  endured,  and  in- 
stinctively, therefore,  the  infant  holds  its  lower  extrem- 
ities motionless,  either  fully  extended  or  but  slightly 
bent  at  the  knee. 

Lastly,  there  is  here  always  an  elevation  of  tempera- 
ture of  a  more  or  less  marked  degree. 

The  contrast  between  these  two  forms  of  colic  is  thus 
very  marked. 

In  the  youngest  infant,  2  to  4  days  old,  the  question 
must  arise  as  to  any  congenital  malformation  of  the 
intestinal  tract,  as  absence  of  anus,  of  anus  and  rectum, 
etc.,  etc.*  This  we  can  readily  decide  by  the  inquiry: 
Has  the  infant  had  the  usual  fecal  movements  ?  If  it 
has  had  the  usual  passages  then  any  such  etiology  is  of 
course  at  once  excluded  ;  if  it  has  not  had  any  move- 
ment, or  if  it  has  had  but  one  movement,  then  we  must 
examine  and  discover  for  ourselves  the  reason  for  their 
absence. 

As  to  the  recognition  of  the  individual  etiological 
factors  of  simple  colic  above  recited,  that  is  here,  as  in 
other  maladies,  a  matter  of  careful  inquiry  and  exam- 
ination. 

This  much  only  need  be  said  in  addition.  The  pres- 
ence of  an  undue  volume  of  flatus  can  be  determined 
by  the  rumbling  and  rolling  heard  in  the  infant's 
bowels  as  we  stand  by  its  crib  or  as  we  hold  it  up  in 
our  arms  against  us ;  or  we  may  detect  its  movements 
in  the  intestines  with  the  hand  laid  lightly  upon  the 
little  abdomen. 

Overfeeding,  or  indigestion,  may  be  indicated  to  us  by 
the  stool.  When  these  are  the  causes  of  the  trouble, 
the  stool  will  contain  an  unusually  large  amount  of 
cheesy  matter  readily  distinguished,  sometimes  so  much 
that  the  stool  may  be  almost  nothing  else  but  curds  and 
perfectly  white  in  color. 

•  See  BodeDhammer.  *'  The  Congenital  Malformations  of  the  Rectum  and 
Anus."     Illowaf ,  ■'  Conatipation  in  Aduits  and  Children,"  etc. 


When  foods  of  the  cereal  group  are  used  they  may 
be  found  in  the  stool  in  readily  recognizable  form. 

If  we  suspect  that  improper  food  has  been  given  the 
infant,  a  macroscopic  or  microscopic  examination  of 
the  feces  may  give  us  certainty. 

Underfeed mr/. — An  almost  constant  crying,  the  cry 
rising  at  times  to  a  scream,  with  which,  at  periods,  no 
kicking  of  the  legs  is  observed,  a  rather  hungry  appear- 
ance of  the  face,  and  a  very  insufficient  gain  in  weight 
or  even  absolute  loss  therein,  should  at  once  direct  our 
attention  to  this  etiologic  factor.  An  examination  of 
the  breast  and  an  inquiry  as  to  its  secreting  capacity, 
will  soon  disclose  to  us  the  true  state  of  affairs. 

In  obstinate  constipation  we  may  find  the  stool  in  the 
form  of  hard,  dry  scybala,  and  not  infrequently  these 
are  party  colored. 

If  the  infant  is  costive  we  will  learn  on  inquiry  that 
it  does  not  have  a  sufficient  number  of  movements,  or 
even  when  it  does  have  these,  that  it  squeezes  until  its 
little  face  is  almost  livid,  and  this  even  when  the  dejec- 
tions are  fairly  soft. 

That  it  is  colic  and  not  hunger  that  makes  the  infant 
cry,  we  will  know  by  the  fact  that  in  hunger  there  is  no 
kicking  of  the  legs,  no  screaming ;  moreover,  the  hungry 
infant  can  be  pacified  for  a  moment,  by  a  change  of 
position,  by  taking  it  up ;  the  infant  suffering  from  an 
attack  of  colic  cannot  and  will  not  be  pacified  until  the 
spasm  is  over. 

Treatment. — The  treatment  of  infantile  colic  and  of 
colic  in  infants  divides  itself  naturally,  as  shown  by  the 
exposition  made  here,  into  two  parts: 

(n)  The  immediate  relief  of  the  infant. 

(b)  The  removal  of  the  exciting  cause. 

I. — The  Immediate  Relief  of  the  Infant. 

From  time  immemorial,  the  aromatics  or  carmina- 
tives have  been  employed  in  the  treatment  of  this 
affection,  and  whilst  at  the  present  day  they  still  suf- 
fice for  many,  others  have  recourse  to  more  potent 
drugs,  the  antispasmodics,  and  others  again  to  still 
more  powerful  agents  as  the  opiates,  chloral,  hydro- 
cyanic acid,  etc.,  giving  them  either  alone  or  in  com- 
bination with  some  aromatic  or  antispasmodic.  Even 
laxatives  in  very  minute  doses  have  found  favor  with 
some.  The  alkalies  are  sometimes  prescribed  with  the 
view,  it  is  said,  of  neutralizing  a  supposed  unnatural 
acidity  of  the  stools,  but  a  scanning  of  the  various 
formula  will  suffice  to  show  that  the  small  doses  ordered 
cannot  accomplish  much,  if  anything,  in  that  direction. 
I  believe  it  to  be  more  a  traditional  practice,  which  it 
is  sought  to  place  upon  a  rational  basis. 

The  alcoholic  stimulants,  which  in  the  very  small 
doses  are  really  aromatics,  have  long  been,  and  still  are, 
the  remedy  of  the  housewives  and  of  the  grandmothers. 

The  favorite  prescription  of  one  of  the  more  ancient 
coryphees  of  medicine  of  this  country,  Dewees,  was  the 
following  : 

li  .—Magnesia  alba,  usta 1  scruple. 

Tiuot.  f.etid.* 60  drops. 

Tinct.  thebaict 20  drops. 

Aq.  font •  1  ounce. 

Of  this  20  drops  are  given,  and  if  the  infant  is  not 
relieved  in  half  an  hour,  then  10  more  are  administered. 
"  This  dose  is  calculated  for  a  child  from  2  weeks  to  a 
month  old.     If  it  be  older,  a  few  more  drops  must  be 

♦Tinct.  AsafcEtid. 
tTlncl.  Opin. 


248 


Ths  Philadelphia 
Medical  Journal 


] 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


[Febbuaby  2,  1901 


given ;  and  as  the  child  advances  in  age  or  becomes 
accustomed  to  its  use,  the  proportions  of  the  ingredients 
must  be  a  little  increased.'" 

Starr,  the  eminent  pediatrist  of  the  City  of  Brotherly 
Love,  makes  a  prescription  as  follows : 

B. — Sod.  bicarbonat 16  grains. 

Syrup i  fluidounce. 

Ag.  menth.  pip-,  enough  to  make 2  fluidounces. 

M.     Sig.— One  teaspoonful  p.r.n.  for  a  child  of  one  month. 

This  prescription,  he  says,  can  be  made  more  effi- 
cient by  the  addition  of  2  drops  of  aromatic  spirits  of 
ammonia  to  each  dose,  or  in  severe  cases,  1  drop  of 
spirit  of  chloroform. 

He  has  found  good  results  follow  the  administration 
of  10  drops  of  gin  in  a  teaspoonful  of  sweetened  warm 
water. 

Bromid  of  potassium  and  chloral  he  thinks  most 
useful  for  the  severe  cases.  This  formula  is  the  follow- 
ing : 

.    B. —  Potass,  bromid 16  grains. 

Chloral  hydrat 8  grains. 

Syrup ; J  fluidounce. 

Ag.  menth.  pip.,  enough  to  make 2  ounces. 

M.  Sig.  — One  teaspoonful  for  a  dose.  Can  be  repeated  if 
necessary  2  to  3  times  at  intervals  of  half  an  hour. 

John  Thompson,  of  Edinburgh,  believes  that  the  best 
immediate  treatment  of  an  attack  of  colic  consists  of 
irrigating  the  lower  bowel  with  a  large  quantity  of 
warm  water  or  administering  a  copious  warm  enema. 
The  application  of  hot  fomentations  to  the  abdomen 
and  of  warmth  to  the  feet  are  also  serviceable,  and  20 
drops  of  whisky  or  a  dose  of  carminative  may  help 
to  relieve  the  child.  An  aperient  is  usually  indicated 
to  clear  away  irritating  matter,  and  if  the  bowels  are 
habitually  constipated,  this  should  be  attended  to. 
When  there  is  obstinate  recurring  colic,  small  doses  of 
codein  (^'j  toj'^  of  a  grain)  are  occasionally  useful  as  a 
temporary  palliative  while  the  diet  is  being  gradually 
regulated.' 

Vogel  teaches  that  the  treatment  of  an  attack  of  colic 
consists  in  the  cautious  employment  of  narcotics,  par- 
ticularly the  preparations  of  opium,  of  hydrocyanic  acid 
and  nux  vomica,  or  in  ethereal,  aromatic  remedies, 
chamomile,  peppermint  or  melissa  teas  applied  per  os 
or  per  anum.' 

As  already  said,  the  home  treatment  of  the  mothers 
and  grandames  consists  in  the  administration  of  some 
alcoholic  liquor,  as  whisky  or  brandy  or  gin,  or  of  a 
decoction  of  some  aromatic  herb,  as  peppermint,  cham- 
omile or  catnip,  or  of  seeds  as  fennel— the  tea  from  the 
latter  being  particularly  favored  by  German  mothers. 

In  the  earlier  days  of  my  practice,  when  crying  in- 
fants were  a  sore  trial,  I  also  prescribed  the  opiates, 
making  use  of  the  variou.s  preparations,  now  of  the 
camphorated  tincture,  paregoric,  then  of  a  certain  sup- 
posedly denarcotized  preparation  of  opium'"  and  again 
of  the  simple  tincture,  usually  ordering  them  in  com- 
bination with  aromatic  syrups  of  rhubarb  or  syrup  of 
ginger  and  some  aromatic  water. 

Infants  become  readily  accustomed  to  opium  and 
soon  require  larger  and  larger  doses  of  it,  and  there- 
fore, in  protracted  cases,  I  preferred  to  avail  myself  of 
other  medicaments.     I  now  remember  very  well" a  most 

'  Dewees  ;  he.  cit.  at  end  of  Article. 

'Clinical  Tioatment  of  Children,  Piuladelpiiia  Medical  Journal,  October 
28,  1899. 

"Melissa  calamintha  smells  like  wild  mint.  It  is  used  popularly  as  a  tea  in 
dysppp.sifl,  In  flatulent  colic. 

'0  VVhich  is  said  to  be  only  about  one-third  the  strength  of  the  simple  tincture 
and  from  which  the  convulsivant  elements,  it  is  claimed,  have  been  removed. 


intractable  case  of  infantile  colic,  in  which  all  home 
remedies  had  been  tried  without  benefit,  for  which  I 
prescribed  ?>  drops  of  laudanum  with  5  drops  of  whisky, 
to  be  given  in  two  doses.  At  first,  the  one  dose  suf- 
ficed, then  after  a  few  days  it  required  both  doses  to 
quiet  the  infant,  and  still  a  few  days  later  even  the  two 
did  not  suffice  and  my  juvenile  friend  kept  up  his 
shrieks  as  before.  He  would  not  be  laid  down  on  his 
bed  at  all,  and  the  only  way  a  moment's  peace  was 
gained  was  by  holding  him  in  arms  and  walking  the 
floor  with  him. 

Being  afraid  to  increase  the  dose  of  opium  beyond 
what  had  been  already  reached,  I  resorted  to  chloral 
hydrate  and  gave  a  prescription  which  I  continued  to 
use  subsequently,  and  which  I  have  always  found  ef- 
fective where  a  soothing  or  hypnotic  effect  was  desired. 
It  reads  thus : 

B.— Chloral  hydrate 6  to  10  grains. 

Mucil.  G.   acac 1  dram. 

Lac   asafetid 2  drams. 

Essent.   anisi  i  dram. 

Aq.  fenicul. 3  drams. 

Sirup  rhei.  aromat IV  dram. 

M.  ft.  mixture.  Sig.  —  One  teaspoonful  for  a  dose  To  be  re- 
peated in  30  minutes,  if  necessary.  For  an  infant  from  2  to 
6  weeks  old.  For  older  infants,  the  dose  of  chloral  can  be 
increased  (to  about  IJ  grains). 

With  larger  experience  I  found  that  a  more  sys- 
tematic treatment  was  required  for  a  condition  pro- 
duced by  dissimilar  causes,  than  the  mere  routine  pre- 
scribing the  same  formula  in  every  case. 

I  also  found  that  certain  simple  remedies  acted  as 
efficiently  and  as  quickly,  yes — even  more  so  than  the 
more  powerful  narcotics  and  hypnotics,  and  that,  there- 
fore, these  could  be  dispensed  with  in  most  instances, 
a  matter  of  certainly  much  moment  to  the  infant,  and 
of  great  advantage  to  it,  as  I  consider. 

In  infantile  colic,  I  have  found  nothing  superior  to 
the  milk  of  asafetida.  Made  from  the  fresh  gum,  as 
directed  in  my  book  on  Constipation,  it  brings  relief 
in  a  very  brief  period  after  its  administration.  It  is 
given,  and  in  a  few  minutes  thereafter,  there  begins  a 
cannonading  on  the  part  of  the  infant,  a  discharge  of 
flatus,  that  would  do  credit  to  a  diet  of  beans ;  or  eruc- 
tations ensue.  The  cries  cease,  the  frowns  pass,  and 
the  child  is  again  quiet,  serene,  smiles. 

I  direct  that  J  to  i  teaspoonful  be  given,  followed,  if 
necessary  (but  this  very  rarely  happens),  in  15  to  20 
minutes  by  a  second  dose,  to  the  youngest  infant.  A  little 
fine  sugar  is  placed  upon  the  tip  of  the  spoon  (if  pre- 
ferred a  drop  or  two  of  the  syr.  rhei.  aromat.  can  be 
put  there)  and  the  spoou  then  placed  to  the  infant's 
lips  and  the  medicine  allowed  to  flow  in. 

Infants,  95  out  of  every  100,  take  it  readily,  even 
like  it,  and  there  is,  therefore,  no  struggling. 

Occasionally,  I  make  use  of  the  following  formula  : 

B. — Lac.  asafetid Jounce. 

Sirup  manna .2i  drams. 

Essent.  anisi J  dram 

Sirup  rhei.  aromat 1  dram. 

M.  Sig— One  teaspoonful  for  a  dose. 

The  remedy  is  innocuous,  and  can,  therefore,  be 
placed  with  perfect  safety  in  the  hands  of  the  mother 
or  nurse,  and  its  administration  fully  intrusted  to  them 
— a  matter  certainly  of  much  moment  for  its  future 
welfare,  to  the  infant  thus  afflicted,  often  requiring, 
especially  at  the  out.set,  2  or  3  more  doses  per  day. 
and  that  for  a  long  period  perhaps,  of  a  medicine  that 
shall  be  eff"ective. 


Fbbruart  2,  1901] 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


HThb  Phii.aj>blphu 

L  MiDICAX.  JOCKNiO. 


249 


To  show  more  clearly  that  I  have  not  exaggerated  as 
to  the  potent  influence  of  asafetida  on  flatulent  and 
spasmodic  states  of  the  intestine,  the  following  case  of 
an  adult,  in  whom  its  use  was  attended  with  brilliant 
results,  is  here  appended  : 

K.  F.,  living  in  a  large  Western  city,  clerk,  aged  22.  An 
inveterate  cigaret  smoker,  a  great  drinker  of  coffee  and 
most  liberal  consumer  of  whisky.  Since  a  number  of  years 
he  had  sulfered  from  frequently  recurring,  violent  attacks 
of  pain  in  his  bowels,  which  in  the  last  year  and  a  half  have 
become  so  severe  that  hypodermic  injections  of  morphia 
were  often  necessary  to  allay  them.  He  was  treated  for 
dyspepsia,  for  liver  trouble,  and  finally  a  condition  of  chronic 
inflammation  of  the  intestine  or  a  chronic  appendicitis  were 
suspected  He  was  badly  run  down,  very  much  emaciated, 
and  not  able  to  do  much.  As  he  was  in  such  bad  shape  and 
nothing  seemed  to  benefit  him  at  home,  he  was  sent  here  to 
me.  I  examined  him  carefully,  and  found  absolutely  no 
pathological  lesion  of  the  intestinal  tract.  The  other  organs 
also  appeared  normal.  I  concluded  that  his  pains  were  due 
to  attacks  of  colic.  I  stopped  his  cigarets,  his  coffee,  his 
alcoholic  drinks,  and  put  iiim  on  a  diet.  The  fourth  day 
after  h'n  arrival  here,  and  whilst  in  my  office,  he  had  a 
most  frightful  seizure.  He  became  pallid,  hands  and  face 
cold,  features  pinched,  pulse  small ;  he  couldn't  speak  ;  it 
looked  like  approaching  dissolution.  I  laid  him  on  the  sofa 
and  then  sought  for  some  remedies.  I  happened  to  have  a 
few  ounces  of  milk  of  asafetida  in  the  office,  and  this 
being  first  at  hand,  I  poured  out  a  ful  ounce,  added  20 
drops  of  Hoffmann's  anodyne  and  made  him  drink  it  In 
5  minutes  thereafter  he  was  up  and  declared  he  was  feeling 
all  riglit  again ;  and  in  a  further  5  minutes  he  left.  He  had 
no  further  attacks  during  the  whole  period  of  his  stay  here, 
and  grew  fat  and  stout.  Returned  home  and  again  among 
his  o  d  companions  he  resumed  his  old  liabits,  and  after  a 
time  the  seizures  again  appeared,  but  never  as  violently  as 
before,  since  he  always  cut  them  short  and  quickly  relieved 
himself  with  a  liberal  dose  of  the  asafetida,  which  he  has 
put  up  for  himself  by  the  quart,  and  which  he  is  never 
without. 

There  can  be  no  possible  objection  to  the  remedy, 
except,  perhaps,  its  odor ;  but  I  have  never  yet  had  a 
sensible  mother  object  to  its  use  on  that  account,  when 
its  more  than  overbalancing  advantages  were  fully  set 
before  her. 

When  the  infant  is  inclined  to  spit  much  after  its 
administration,  indicating  evidently  that  it  does  not 
relish  the  taste,  a  few  teaspoonfuls  of  sweetened  warm 
fennel  tea  will  at  once  wash  away  all  the  residue  that 
may  have  remained  in  the  mouth,  both  of  medicine 
and  odor. 

I  was  informed  by  some  very  observant  mothers, 
that  a  few  teaspoonfuls  of  warm  fennel  tea  increased 
the  rapidity  of  action  of  the  asafetida,  and  that  with 
both  the  infant  was  relieved  in  a  marvelously  brief 
period. 

When  the  attack  comes  on  shortly  after  nursing  (and 
this  may  occur  even  though  we  can  detect  nothing 
abnormal  in  the  milk)  we  can  frequently  prevent  it  by 
giving  the  infant  shortly  before  or  very  soon  after 
nursing,  a  dose  of  the  medicine.  In  older  infants,  4  or 
5  weeks,  we  can  sometimes  obtain  the  same  result  by 
preceding  the  nursing  15  or  20  minutes  with  an  ounce 
of  warm,  sweetened  fennel  tea,  administered  by  means 
of  the  nursing  bottle. 

In  very  mild  seizures,  twinges  only  as  it  were,  sweet- 
ened warm  fennel  tea,  a  few  teaspoonfuls  for  the  very 
young  infants,  an  ounce  or  two,  according  to  age,  for  the 
older  ones,  may  quickly  arrest  the  griping  and  thus 
give  relief. 

If  the  infant  he  inclined  to  be  costive,  an  enema  of 
warm  water  with  a  little  sweet  oil  added  thereto,  or  a 
soap  suppository,  may  be  directed  as  occasion  may  re- 


quire, in  addition  to   the  medicine  to  be  given  inter- 
nally. 

In  the  colic  due  to  overfeeding,  to  indigestion,  to 
constipation,  to  improper  food,  I  have  found  that  the 
suffering  was  quickly  relieved  by  a  mixture  made  as 
follows  : 

R.— Mixt.  rhei.  et  sod *  ounce. 

Hoffmann's  anodyne  40  drops. 

Syr  rhei.  aromat.  enough  to  make  1  ounce. 

M.  Sig  — Dose,  J  teaspoonful  repeated  in  J  to  J  of  an  hour 
for  an  infant  3  to  4  weeks  ukl.  For  younger  infants  the 
dose  is  15  to  20  drops  ;  for  older  ones  from  J  to  1  teaspoonful, 
according  to  age. 

Usuallv  2,  at  most  3,  doses  are  all  that  are  required. 

If  there  be  much  overloading  of  the  bowels,  an  enema,, 
as  described,  or  a  soap  suppository,  in  addition  to  the 
above,  will  be  of  much  benefit. 

If  the  colic  be  due  to  refrigeration,  we  will  direct  the 
application  to  the  abdomen  of  dry  heat,  as  a  couple  of 
layers  of  flannel,  well  warmed,  or  a  tin  plate  heated 
and  sufficiently  covered  with  cloths,  so  as  not  to  burn; 
we  will  have  the  feet  wrapped  in  a  warm  cloth  and  we 
will  order  that  the  child  be  given  a  warm  sweetened 
decoction  of  peppermint  or  fennel  seed  (infants  gener- 
ally seem  to  prefer  the  latter).  By  these  measures  we 
will  quickly  chase  the  furrows  from  the  brow  of  our  little 
patient  and  bring  back  his  cherubim  smile.  He  will 
once  more  be  comfortable. 

Sometimes  the  administration  of  a  little  good  whisky, 
brandy,  or  gin— 10,  lo,  20  drops  (according  to  age)  in 
a  little  sweetened  warm  water — will  accomplish  the 
same  purpose  and  will  bring  quick  relief. 

Or  the  milk  of  asafetida  with  some  aromatic,  as  in 
the  formula  above  given,  may  be  directed,  and  it  will 
be  found  of  great  benefit.  It  is  always  to  be  preferred 
to  the  alcoholic  stimulants  with  infants  inclined  to  be 
nervous,  or  having  a  tendency  to  convulsive  movements. 
Occasionally,  in  infants  with  a  peculiarly  sensitive  in- 
testinal tract,  an  opiate  may  be  required,  and  here  the 
camphorated  tincture  of  opium,  the  paragoric  of  the 
Pharmacopeia  answers  best,  I  believe. 

B.— Tinct  opii.  camphorat 1  fluidounce. 

Aq.  menth.  pip    5  to  5J  fluidounces. 

Syr.  rhei.  aromat 1  to  IJ  fluidounces. 

M.  Sig.— Dose,  i  teaspoonful  repeated  in  i  hour  if  neces- 
sary.    A  further  dose  can  be  given  in  2  hours. 

It  is  only  when  this  condition  unquestionably  exists 
that  the  administration  of  a  preparation  of  opium  in  a 
case  of  simple  colic  (in  an  infant)  is  at  all  necessary  or 
justified. 

II.— The  Removal  of  the  Cause,  i.e.,  the   Prophy- 
lactic Treatment. 

1.  Where  the  cause  lies  in  the  infant,  as  has  been  al- 
ready set  forth  under  heading  I,  A,  there  is  really  noth- 
ing more  to  be  done  than  has  already  been  there  said, 
and  to  bide  the  time.  Starr  believes  that  the  routine  ad- 
ministration through  the  whole  colicky  period  of  a  little 
wine  of  pepsin  (15  drops  three  times  a  day)  is  benefi- 
cial, and  I  have  occasionally  prescribed  the  elixir  of 
lactopeptin,  to  be  taken  3  times  daily  between  meals,  as 
an  agreeable  aromatic  preparation,  very  readily  taken 
by  infants  and  children,  and  I  believe  I  have  derived 
benefit  therefrom.  . 

Thompson  advises  Papain.     He  makes  a  prescription 

thus : 


250  ^"^  Philadelphia"] 

Medical  Journal  J 


INFANTILE  COLIC  AND  COLIC  IN  INFANTS 


[Febecaet  J,  1901 


B.— Sod.  bicarbonat Sgr-ins. 

Papain  (Flakier)    1  grain. 

M.  (t.  pulv.  I.    Sig. — One  after  each  meal. 

Sometimes  he  directs  the  following  mixture  : 

R. — Sod.  bicarbon 3  grains. 

Spirits  amnion,  arouiat 1  minim. 

Spirits  chloroform 1  minim. 

Syrup 10  minims. 

Liill.  water  sufficient  to  make 1  dram. 

M.     After  each  meal. 

I  do  not  favor  the  administration  of  an  alkali,  that  is 
as  routine  treatment,  and  certainly  not  at  all  immedi- 
ately or  shortly  after  meals ;  it  cannot  but  help  to 
impair  a  digestion  already  innately  weak,  perhaps  even 
■cause  an  acidity,  and  thus  still  further  aggravate  the 
evil. 

2.  When  the  infant  is  costive  or  constipated,  we  will 
have  to  regulate  its  bowels  to  the  normal  standard. 
Some  indications,  therefore,  have  been  already  given 
here,  but  the  fuller  details  as  to  the  rules  and  methods 
to  be  employed  for  this  purpose  can  be  found  in  my 
work,  '•  Constipation  in  Adults  and  Children,"  etc. 

3.  If  the  mother  be  constipated,  we  will  seek  to  effect 
a  regular  and  normal  evacuation.  During  the  puer- 
perium  we  will  keep  the  bowels  soluble  by  means  of 
laxatives,  enemas,  glycerin  suppositories,  or  glycerin 
injections,  and  by  the  aid  of  such  articles  of  diet  as  are 
not  contraindicated  by  the  special  period  or  bv  the  con- 
dition of  the  infant  (syrups,  oatmeal,  cracked  wheat,  etc.) 
All  cathartics,  especially  those  that  gripe,  must  be 
avoided,  as  they  may  act  too  energetically  U{)on  the 
infant.  Later  on,  if  a  normal  soluble  condition  of  the 
bowels  has  not  been  attained  by  the  meiisures  already 
named,  we  will  resort  to  the  mechanical  methods,  the 
details  of  which  can  be  found  in  my  work  just  men- 
tioned above. 

4.  If  the  troubles  of  the  infant  be  due  to  a  faulty  diet 
of  the  mother,  we  must  correct  this.  \Ve  will  strike  otf 
from  her  dietary  all  such  foods  as  are  said  to  be  flatu- 
lent and  which  have  been  already  named  above,  and  all 
such  food  preparations  as  are  in" themselves  conducive 
to  colic,  as  has  already  been  set  forth.  Where  the  intes- 
tinal tract  of  the  infant  seems  peculiarly  sensitive,  she 
may  have  to  abstain  from  acid,  raw  fruits,  such  as 
apples,  oranges,  and  sometimes  even  from  some  stewed 
fruits,  as  stewed  apples.  Where,  however,  this  is  not 
the  case,  these  fruits  in  small  quantity  may  be  allowed 
and  will  be  of  great  service." 

The  various  other  indications  in  matters  that  refer  to 
the  mother,  these  may  be  readily  inferred  from  what 
has  been  said  in  the  section  on  etiology  and  need  no 
repetition  here. 

5.  If  the  infant  be  overfed,  either  that  it  be  nursed  or 
fed  too  frequently,  or  that  too  much  be  given  it  at  one 
time,  we  will  insist  on  the  observance  of  proper  periods 
for  nursing  or  feeding,  or  on  the  proper  amount  to  be 
given  at  one  time,  and  fully  impress  upon  the  mother 
the  necessity  of  a  strict  observance  of  these  rules,  both 
for  the  future  welfare  of  the  infant  and  for  her  own 
comfort.  The  details  can  be  found  in  the  various 
treatises  on  diseases  of  children,  and  in  my  work 
already  here  named. 

6.  If  the  infant  be  underfed,  vve  will  have  to  do  one  of 
two  things— either  endeavor  to  secure,  if  possible,  a 
more  abundant  supply  from  the  breast,  or  make  good 
the  deficit  by  properly  regulated  hand-feeding  in 
addition.  ° 

"  See  "  Coosiipation  in  AdulU  and  Ctaildren,"  etc.,  by  the  author. 


As  to  the  proper  character  of  the  food,  a  most  im- 
portant matter  as  regards  the  welfare  of  the  infant 
\Vhilst  many  children  thrive  readily  on  the  various 
artificial  foods  that  may  be  given  them,  others  again — 
the  few,  it  is  true — will  not  do  well  upon  the  most  care- 
ful and  scientific  preparations.  Here,  all  violation  of 
the  well-established  rules  of  artificial  feeding  being 
excluded  (and  this  is  of  the  first  importance,  for,  as  said 
elsewhere,  in  the  great  majority  of  instances,  where  the 
artificial  food  disagrees  with  the  infant,  causes  colic,  etc., 
it  is  not  really  the  food  that  is  to  blame,  but  the  over- 
feeding), the  question  arises  :  Is  it  the  food  that  is  at 
fault,  or  is  the  digestive  capacity  of  the  infant  in- 
sufficient, and  would  it  have  the  same  troubles  even  if 
it  were  nursed  from  the  breast  ?  The  further  details  do 
not  pertain  here :  they  can  be  found  in  the  various 
treatises  on  Diseases  of  Children,  and  in  that  very 
excellent  book,  "  Rojth  on  Infant  Feeding."  I  would 
only  add  this,  that  when  this  question  of  a  proper  food 
presents  itself,  it  is  weU  to  bear  in  mind  the  following 
points  : 

a.  If  the  milk  mixtures  disagree  with  the  infant, 
cause  colic,  etc.,  we  may  improve  them  and  perhaps 
remove  altogether  the  tendency  to  gripe  by  using  as  the 
diluent,  an  aromatic  water,  fennel  or  caraway  water,  as 
has  been  suggested  by  Starr. 

b.  If  we  find  that  milk  disagrees  absolutely,  we  may 
follow  the  lead  of  Trousseau,  as  indicated  in  the  cases 
above  related. 

c.  Or.  where  the  various  foods  seem  to  disagree,  we 
may  adopt  the  advice  of  S'ogel  and  accustom  the  in- 
fants as  quickly  as  possible  to  meat  broths,  which  with 
slight  cereal  additions  make  a  very  excellent  and 
palatable  food. 

In  all  cases  where,  for  one  reason  or  another,  the 
mothers  had  to  give  up  nursing  their  infants  at  a  later 
period,  say  after  7  months,  I  had  recourse  to  feeding 
with  meat  broths  with  the  juice  of  some  cereal,  as  bar- 
ley, rice  or  oatmeal,  added  thereto,  eschewing  milk 
altogether,  especially  if  it  were  near  the  summer 
months,  and  always  found  that  the  children  did  well 
and  thrived  thereon. 

As  to  other  prophylactic  measures  they  are  pointed 
out  by  the  etiological  factors  themselves. 

Complicatioiu  and  Sequela. — It  is  stated  by  some 
writers  that  convulsions  may  supervene  upon  attack  of 
colic. 

That  convulsions  are  sometimes  caused  by  irritant 
substances  in  the  intestinal  canal  I  have  not  infre- 
quently observed.  It  is  possible,  indeed  it  is  more  than 
likely,  that  these  latter  provoke  such  severely  painful 
griping,  as  to  throw  the  infant  into  a  spasm,  but  a  con- 
vulsion following  upon  a  well-marked  attack  of  colic  I 
have  never  witnessed. 

Hiccough  is  a  most  frequent  sequel  of  the  seizure  in 
infantile  colic,  especially  after  seizures  coming  shortly 
after  meals. 

It  can  be  quickly  stopped  by  a  few  grains  of  fine 
sugar  put  into  the  infant's  mouth  by  the  mother's  or 
nurse's  fingers.  A  little  water  will  sometimes  answer 
the  purpose. 

REFEREXCiS. 

rari>enter :  Human  Physiology. 

Dewc«s  ;  .\  Treatise  on  the  Phvsical  and  Medical  Treatment  of  ChUdren. 
Ix>i.d'<D,  1826. 

Starr  ;  The    'isea^t^  of  the  Higeslive  Organs  in  Children. 

Vogel ;  Pisevist's  of  rhihlren,  I'ranslate^l  t'y  R^iphaeL 

Jacobi :  Intestinal  Di>ea<.es  of  Infancy  and  Childho«><I. 

Thompson:  Cliuical  Examination  and  Tieatment  of  Children.  EdiDbai:gfa, 
ISSS 

Illoway  :  Constipation  In  Adults  and  Childrea.  The  Maonillan  CompanT, 
Xew  York. 


February  2,  19M) 


SOME  FUNCTIONAL  FORMS  OF  DEFECTIVE  SPEECH 


TThb  Philadelphia 
L  Medical  Joubnal 


251 


THE  DIAGNOSIS  AND  TREATMENT   OF  SOME  FUNC- 
TIONAL FORMS  OF  DEFECTIVE  SPEECH.' 

By  Ct.  HUDSON  MAKUEN,  M.D., 
of  Philadelphia. 

To  THOSE  not  having  given  especial  attention  to  the 
science  of  speech,  the  subject  is  involved  in  more  or  less 
mystery,  and  this  is  doubtless  due  to  the  fact  that  the 
early  development  of  speech  is  instinctive,  automatic, 
and  imitative,  rather  than  analytic.  It  is  safe  to  say 
that  all  speech  is  defective  when  measured  by  strictly 
accurate  and  scientific  laws ;  and  it  is  only  when  some 
marked  abnormality  arises  that  our  attention  is  called 
to  it.  We  are  satisfied  generally  with  any  form  that 
may  serve  to  express  our  thoughts,  and  have  very  little 
regard  for  its  aesthetic  character.  We  even  grow  accus- 
tomed to  our  faults  of  speech  and  learn  to  accept  them 
in  preference  to  the  correct  forms.  Thus  the  ear  is  not 
always  a  safe  guide  in  these  matters  and  it  becomes 
necessary  to  train  the  sense  of  hearing  as  well  as  the 
faculty  of  speech. 

Schools  have  been  established  for  the  improvement  of 
speech  and  much  good  has  been  accomplished  in  this 
direction  ;  but  the  progress  of  the  work  has  been  greatly 
impeded  by  a  lack  of  uniform  and  scientific  standards. 
These  schools  have  met  the  requirements  of  those 
having  fairly  good  speech,  but  owing  to  their  lack  of  a 
scientific  basis,  they  have  not  reached  that  large  class  of 
unfortunates  whose  speech  is  partially  or  wholly  unin- 
telligible. It  is  to  supplement,  therefore,  the  work  of 
the  schools  that  I  make  a  plea  for  the  careful  study  of 
the  physiology  and  pathology  (if  I  may  use  that  expres- 
sion) of  speech  b}-  physicians;  and  by  no  class  of 
physicians  can  this  work  be  so  successfully  accomplished 
as  by  the  specialist  in  diseases  of  the  throat  and  related 
organs.  Defects  of  speech  belong  naturally  to  our  spe- 
cialty, and  their  careful  study  with  a  view  to  classifica- 
tion, diagnosis  and  treatment,  should  lie  encouraged  in 
every  possible  way.  I  may  add  without  fear  of  being 
misunderstood,  that  not  all  men  engaged  in  throat  work 
can  be  equally  successful  in  meeting  the  difficulties  that 
arise  in  this  particular  line  of  investigation.  Just  as  the 
pathologist  requires  years  of  careful  preparation  for  his 
work,  so  must  the  one  engaged  in  the  studj-  of  speech 
have  acquired  not  only  a  thorough  theoretical  knowl- 
edge of  the  physiology  of  speech  and  voice,  but  also 
that  practical  knowledge  of  the  use  of  the  organs  em- 
ployed in  speaking  which  comes  ft-om  special  training 
in  vocalization  and  articulation.  This  practical  knowl- 
edge is  useful  not  only  in  making  the  diagnosis,  but 
also  in  giving  the  prognosis  and  directing  the  treatment, 
just  as  in  the  treatment  of  any  disease  one  must  know 
what  the  trouble  is,  what  the  cause  is,  and  to  what  ex- 
tent the  cause  may  be  removed  and  the  trouble  cor- 
rected. He  must  learn  to  compare  the  defective  speech 
with  the  normal  speech,  not  in  a  general,  but  in  a  par- 
ticular way.  Each  element  of  the  defective  must  be 
compared  separately  with  the  corresponding  element  of 
the  normal  speech  and  a  complete  record  kept  of  the 
comparison. 

In  following  this  plan  a  serious  difficulty  always 
arises  from  the  fact  that  our  English  alphabet,  in  many 
instances,  gives  filenames  rather  than  the  sounds  of  the 
letters  used  in  the  language.  For  instance,  the  letter 
b  is  composed  of  two  elementary  sounds, — b  and  e ;  g 
is  composed  of  three  elementary  sounds, — d,  zh,  and  e ; 

1  Read  bt-for**  tht*  Lnryug^tlogicai  Section  of  the  New  York  Acadetuj  of  Med- 
icine, October  24, 1900. 


and  the  letter  w  is  composed  of  six  elementary 
sounds, — d,  fl,  b,  1,  y  and  66.  Hence  it  is  clear  that  we 
cannot  compare  the  defective  sounds  in  speech  with 
the  standard  alphabet  of  the  language,  and  we  must 
therefore,  construct  an  alphabet  of  sovmds.  This  was 
done  as  early  as  1827  by  the  British  physicist.  Dr.  Neil 
Arnott;  and  his  alphabet  was  modified  during  the  last 
decade  b}-  Dr.  John  Wyllie,  of  Edinburgh,  who  very 
properly  gives  it  the  name  of  "The  Ph3'siological 
Alphabet."  I  have  reproduced  it  here  with  some 
slight  additions  and  refinements,  and  I  shall  endeavor 
to  show  its  application  in  the  treatment  of  the  various 
forms  of  defects  of  speech.  My  revised  physiological 
alphabet  contains  44  sounds,  which  may  be  designated 
as  follows : 

The  Physiological  Alphabet. 


COKSONANTS. 


VOICELESS 
ORAL 

VOICED 
ORAL 

vmcEi) 

NASAL 

P 

B 

M 

Wh       1       W 

Labio-dentals 

.  .   . 

F                      V 

Full  voici>. 

LiDgTio-dental 

3     .     . 

Th'       1      Th" 

Thick  thou. 

Anterior        .... 
Lingiio-palatals  .  . 

S 

Sh 

T 

Z 
Zh 

R 

N 

Some  zealous  sheep 

leisurely  took  down 

nine  large  rails. 

Posterior    .   . 
Linguu-palata 

S    .     . 

K         1       G 
H                Y 

Ng 

Can  girls  bring  home  yeast? 

VOWELS 

- 

COALESCEKTS. 

a       S\e 

6 

old 

ar       f  ar  e 

or       f  or  e 

S       4  t 

o 

o  n 

ar       f  ar 

or        f  or      (aw> 

a        a  lius 

6b 

6o  ze 

er       h  er  e 

oof        p  oor 

a        a  11 

OO 

1  OO  k 

er       h  er 

ur       p  ur  r 

k        &  sk 

I 

I  t 

e       C?  ve 

tl 

0  p 

«       ?  Ik 

It  is  quite  probable  that  not  one  person  in  a  thousand 
gives  these  sounds  as  here  represented,  and  hence  it  is 
that  nearly  all  speech  is  defective.  There  is  no  perfec- 
tion in  speech,  and  the  best  of  us  only  approximate  the 
correct  forms.  \\'ith  this  alphabet,  however,  as  a  stan- 
dard of  perfection,  we  compare  the  speech  of  each  indi- 
vidual patient  and  we  make  a  record  in  which  appears 
an  exact  account  of  every  deviation  from  the  normal. 
To  those  who  have  learned  to  read  we  give  sentences 
containing  all  the  elements  in  the  alphabet,  and  every 
departure  from  the  correct  sounds  of  these  elements  we 
carefully  note  and  record  for  future  reference. 

Having  thus  determined  in  what  respects  the  speech 
of  the  patient  differs  from  the  normal,  and  having  re- 
corded it  in  the  case  book,  we  proceed  to  investigate  the 
causes  of  the  defect.  These  causes  are  as  numerous  as 
are  the  defects  themselves,  and  they  are  not  always  easily 
discoverable.  A  word  with  reference  to  the  general  de- 
velopment of  speech  may  throw  some  light  upon  the 
subject. 

The  three  mcchani.sms  employed  in  the  early  devel- 
opment of  speech  are  the  auditory,  the  vocal,  and  the 
oral  mechanisms,  and  each  one  of  these  may  be  again 
divided  into  central  and  peripheral  mechanisms.     In 


252 


The  Philadelphia' 
Medical  Journal 


] 


SOME  FUNCTIONAL  FORMS  OF  DEFECTIVE  SPEECH 


[Febbcast  2,  19tl 


the  later  development  of  volitional  speech,  the  higher 
psychic  centers  are  also  employed.  The  child  first  uses 
the  organs  of  speech  in  crying,  and  this  generally  begins, 
in  the  normal  child,  immediately  upon  his  advent.  This 
is  not  an  expression  of  pain,  but  it  is  the  result  of  a  reflex 
action  of  the  musculature  of  the  peripheral  respiratory 
and  vocal  mechanisms.  It  is  entirely  subcortical  and  it  is 
the  result  of  various  external  stimuli  attendant  upon  the 
child's  new  environment.  (That  it  is  independent  of  the 
higher  central  mechanisms  of  speech  is  shown  by  the 
fact  that  a  similar  action  takes  place  in  both  the  deaf 
child  and  the  idiot,  and  to  such  an  extent  is  this  true 
that  it  is  impossible  to  diagnosticate  deafness  in  a  very 
young  child,  and  it  is  very  often  difficult  in  the  first  year 
or  two  to  distinguish  between  the  child  of  normal  and 
the  child  of  abnormal  brain.)  It  is  quite  possible,  how- 
ever, that  the  child  soon  begins  to  experience  a  pleasur- 
able sensation  in  the  use  of  these  organs,  which  acts  as 
a  stimulus  to  the  development  of  their  volitional  exer- 
cise ;  and,  as  I  have  shown  elsewhere,  the  mere  physical 
use  of  the  organs  of  voice,  independently  of  any  intel- 
lectuality, continues  to  give  pleasure  throughout  the  life 
of  the  individual ;  and  this  explains  physiologically  the 
great  delight  that  people  often  take  in  talking,  as  well 
as  the  origin  of  the  development  of  speech. 

After  a  longer  or  shorter  period  of  crying,  the  child 
begins  to  utter  other  apparently  meaningless  sounds,  and 
to  echo  short  words  or  syllables  which  have  been  used 
in  his  presence.  Then  he  gradually  begins  to  associate 
certain  sounds  with  persons  and  things.  All  this  takes 
place  before  the  child  does  much  thinking  on  his  own 
account.  The  pleasure  that  he  derives  from  this  cry- 
ing, babbling,  prattling,  and  almost  unconscious  mim- 
icry of  sounds  now  becomes  a  strong  incentive  to  voli- 
tional effort, — and  it  is  here  that  the  trouble  begins. 
When  the  budding  intellect  begins  to  assume  control  of 
the  hitherto  automatic  speech  processes,  unless  the  en- 
tire machinery  of  speech  is  in  perfect  condition,  there 
will  be  more  or  less  friction  which  may  result  in  either 
defective  articulation  or  stammering,  or,  as  is  often  the 
case,  in  both  of  these  conditions. 

All  speech  is  acquired  by  imitation ;  and  could  nor- 
mal children  have  perfect  examples,  the  result  would  be 
the  development  of  accurate  speech  ;  but  all  children 
are  not  normal  and  they  have  no  perfect  example  or 
model — hence  the  development  of  all  kinds  of  speech, 
from  the  wholly  unintelligible  to  the  proximately  cor- 
rect. The  auditory  center  is  closely  related  to  the 
speech  center,  and  their  development  is  simultaneous. 
The  great  importance  of  the  ear  in  the  development  of 
speech  is  well  illustrated  by  the  fact  that  deaf  children 
do  not  acquire  speech  at  all,  except  a.s  the  result  of  spe- 
cial training.  In  the  young  child  the  auditory  center 
first  receives  the  impressions  of  sound,  and  the  speech 
center  responds  almost  immediately  by  trying  to  repro- 
duce these  sounds.  If,  owing  to  a  taulty  condition  or 
action  of  either  the  central  or  perijtheral  organs  of 
speech  or  hearing,  the  reproduction  happens  to  be  inac- 
curate, the  auditory  center  seems  not  to  be  able  always 
to  detect  this  inaccuracy,  and  it  registers  it  as  being  accu- 
rate. The  trouble  may  arise  originally  from  some  tem- 
porary derangement  of  the  nervous  organization  or  from 
some  abnormal  anatomic  structure  or  pathologic  condi- 
tion of  the  perii)heral  organs  of  speech  and  hearing.  As 
examples  of  abnormal  structures,  I  would  refer  to  hare- 
lip, cleft  palate,  and  other  forms  of  arrested  develop- 
ment ;  and  as  examples  of  pathologic  conditions,  to  the 
various  catarrhal  processes  of  the  throat  and  middle 
ear. 


Defects  of  speech  may  arise,  therefore,  from  either 
subjective  or  objective  causes.  In  the  former  class  woald 
be  included  all  those  that  exist  within  the  child's  own 
organism  ;  such  as  first,  a  defective  hearing  apparatus ; 
second,  a  defective  speech  apparatus  ;  and  third,  a  defec- 
tive psychic  apparatus,  especially  those  centers  presiding 
over  the  intellect  and  will.  In  the  latter  class  would  be 
included  all  those  causes  which  may  arise  from  the 
child's  en\-ironment ;  such  as  first,  bad  hygiene,  affect- 
ing the  general  health ;  second,  the  atmosphere  of  ex- 
citement in  which  so  many  children  Uve  and  by  which 
their  nervous  organizations  become  impaired ;  and  third, 
faulty  examples  of  speech  given  children  by  those  in 
attendance  upon  them,  and  the  encouragement  of  the 
continuation  of  baby  talk  for  the  amusement  of  others. 

No  discussion  of  the  treatment  of  defects  of  speech  is 
satisfactory  which  does  not  deal  with  the  question  of 
prophylaxis.  What  measures  may  we  adopt  in  the 
training  of  children  to  prevent  the  development  of  de- 
fective speech  ?  This  is  an  important  question  because 
of  its  great  practical  value.  To  direct  the  formation  of 
good  speech  habits  is  often  a  simple  procedure,  but 
when  habits  of  faulty  speech  are  once  formed,  we  have 
a  more  difficult  task  to  perform.  That  this  task,  how- 
ever, is  not  altogether  hopeless  has  been  shown  by  the 
results  already  obtained  in  this  work.  The  proper  early 
training  of  young  children  would  undoubtedly  prevent 
the  development  of  defective  speech  in  a  Lirge  percent- 
age of  cases.  The  physical  condition  of  the  child  has 
much  to  do  with  the  development  of  all  his  faculties, 
and  there  is  no  faculty  which  reflects  this  condition  so 
accurately  as  does  the  faculty  of  speech.  Poor  health, 
either  inherited  or  acquired,  is  a  common  cause  of 
defective  speech ;  and  if  it  exists  during  the  first 
few  years  of  the  child's  life,  its  effects  are  specially  pro- 
nounced. Some  of  the  most  serious  cases  I  have  ever 
seen  were  the  result  solely  of  a  marked  asthenic  condi- 
tion due  to  anemia  during  the  early  formative  speech- 
period.  The  general  health,  therefore,  should  be  kept  in 
the  best  ])0ssible  condition. 

In  addition  to  this,  in  many  children  the  demonstra- 
tive disposition,  as  evinced  in  the  babbling  and  prattling 
of  which  I  have  spoken,  should  be  encouraged,  not  in 
an  excitable,  but  in  a  calm  manner.  These  demonstra- 
tive tendencies  in  some  healthy  children  may  occasion- 
ally retiuire  mild  repression,  lest  an  overexuberance  of 
spirits  result  in  an  incoordinate  nerve  and  muscle  action 
which  manifests  itself  in  stammering.  It  is  quite  pos- 
sible that  the  majority  of  cases  of  this  latter  defect 
might  never  have  stammered  if  their  early  training 
had  been  of  the  right  sort.  Baby  talk,  amusing  and 
cute  as  it  may  be,  should  be  encouraged  only  up  to  a 
certain  point,  and  not  beyond  the  period  of  babyhood. 
Examples  of  good  speech  should  be  given  children,  and 
the  imitative  faculty  should  be  encouraged.  It  is  in- 
teresting to  note  what  interest  young  children  often  take 
in  mimicry ;  and  this  tendency,  ol\en  manifested  early 
in  life,  should  be  tiiken  advantiige  of  in  the  develop- 
ment of  speech. 

An  early  examination  of  the  organs  of  speech  should 
be  made  in  all  cases  in  which  the  beginning  of  an  ar- 
rested development  is  suspected.  Hypertrophied  tonsils, 
pharyngeal,  faucial,  and  lingual,  should  receive  early 
attention  and  all  structural  irregularities  should  be  cor- 
rected, keeping  in  mind  the  fact  that  speech  is  greatly 
influeneetl  by  these  conditions  during  the  first  few  years 
of  childhood. 

The  above  prophylactic  measures   are  useful  in  all 


February  2,  1901] 


SOME  FUNCTIONAL  FORMS  OF  DEFECTIVE  SPEECH 


[Thk  Philadelphia 
Medical  Journal 


253 


forms  of  defective  speech,  but  they  are  especially  appli- 
cable in  that  form  known  as  stammering.  Other  forms 
of  defective  speech  are  due  to  arrested  development,  but 
stammering  is  an  acquired  defect.  It  is  not  congenital, 
nor  is  it  inherited,  although  we  have  ample  proofs  of 
the  fact  that  the  nervous  conditions  predisposing  chil- 
dren to  this  affliction  are  often  transmitted  through 
several  generations.  Those  who  acquire  the  habit  of 
stammering  as  a  result  of  these  inherited  tendencies  are 
probably  the  most  difficult  to  cure,  for  it  is  necessary, 
by  systematic  and  persistent  training,  not  onl}'  to  break 
up  the  habit,  but  to  actually  work  some  indescribable 
changes  in  the  anatomy  and  physiology  of  the  nervous 
organization.  The  patient  has  inherited  a  nervous  sys- 
tem that  is  at  least  functionally  defective,  and  that  is 
probably  not  altogether  free  from  organic  defects.  The 
child,  therefore,  whose  ancestors  have  stammered,  and 
he  who  shows  the  slightest  predisposition  to  this  form 
of  defective  speech  should  be  very  carefully  managed 
in  order  that  the  habit  may  not  be  established.  He 
should  be  led  unconsciously  to  think  slowly  and  to  speak 
slowly ;  he  should  be  shielded  from  all  excitement,  and 
never  permitted  to  try  to  descrilie  exciting  events. 
Great  tact  must  be  used  in  diverting  his  attention  from 
the  exciting  subject  to  something  of  less  interest,  with- 
out acquainting  him  with  the  reason  for  it.  This  rea- 
son, however,  he  should  never  know  because  it  would 
arouse  the  fear  of  stammering  and  a  mental  expectancy 
which  militates  very  materially  against  future  freedom 
of  speech.  The  attention  of  the  child  should  never  be 
called  to  the  defect,  and  the  word  stammering  should 
never  be  used  in  his  presence.  This  is  a  most  import- 
ant injunction;  many  children  have  been  made  con- 
firmed stammerers  by  having  had  their  attention  called 
to  the  enormity  of  the  offense,  and  by  having  thus  ac- 
quired a  nervous  dread  of  the  alHiction. 

I  shall  now  endeavor  to  describe  to  you  the  plan  of 
treatment  that  we  have  found  to  be  most  effective,  tak- 
ing up  first,  those  cases  in  which  defective  articulation, 
due  to  arrested  development,  is  most  pronounced  ;  and, 
second,  that  form  of  defective  speech  known  as  stam- 
mering which,  as  I  have  said,  is  an  acquired  form  and 
which,  I  may  add,  generally  manifests  itself  in  a  faulty 
coordination  of  the  vocal  with  the  oral  mechanism.  In 
the  articulatory  form  of  defects  of  speech,  we  first  get 
an  accurate  record  of  the  actual  defects  as  they  exist  by 
comparing  the  faulty  sounds  given  with  the  correct 
sounds  as  indicated  in  the  ph)-siologic  alphabet ;  and 
each  element  of  speech  that  is  found  to  l)e  defective  is 
taken  up  separately  and  the  patient  is  taught  the  phy- 
siology of  that  element.  He  is  shown  to  what  degree 
the  mouth  should  be  open,  and  what  position  the  lips, 
tongue,  and  palate  should  take  for  its  correct  enuncia- 
tion ;  a  hand  mirror  being  used  to  aid  him  in  acquiring 
the  correct  positions.  At  the  same  time  attention  is 
given  to  correct  breathing  and  vocalization.  It  is  ex- 
plained how  the  articulatory  organs  may  be  regarded  as 
moulds  into  which  voice  is  poured ;  and  how  much  for 
each  sound,  a  separate  and  distinct  mould  is  recpiired  ; 
and  the  size  and  shape  of  this  mould,  and  the  manner 
in  which  it  is  made  are  fully  described  and  illustrated. 
The  patient  is  instructed,  while  endeavoring  to  get  these 
positions,  to  give  the  closest  attention  to  the  resultant 
sound,  in  order  that  he  may  as  speedily  as  possible 
hear  the  correct  and  distinguish  it  from  the  faulty  sound. 
This  training  of  the  auditory  center  of  the  brain  is  of 
the  utmost  importance.  Just  as  a  defective  ear  is  an 
insuperable  barrier  to  the  acquirement  of  a  practical 


musical  education,  so  is  an  ear  that  fails  to  distinguish 
between  the  faulty  and  correct  sounds  of  speech  a  great 
hindrance  to  the  development  of  good  speech. 

Not  until  the  patient  begins  to  distinguish  between 
the  faulty  and  correct  sounds  does  he  fully  appreciate 
the  importance  of  attempting  to  improve  upon  his  own 
articulation.  Hitherto  his  speech  has  seemed  to  him  to 
be  the  same  as  that  of  other  people,  and  he  has  won- 
dered, perhaps,  why  he  hius  not  been  understood. 
When  his  ear  detects  the  difference,  his  whole  attitude 
changes  and  he  begins  to  manifest  great  interest  in  his 
condition,  and  to  apply  himself  energetically  to  the  task 
of  improvement;  and  the  rapidity  of  his  progress  is 
often  surprising.  Frequent  repetitions,  however,  of  the 
correct  sounds  are  necessary  to  fully  establish  them  in 
the  cerebral  centers  of  speech  and  to  bring  the  periph- 
eral mechanism  of  speech  under  the  complete  control 
of  these  centers 

All  that  I  have  said  with  reference  to  the  treatment  of 
the  articulatory  forms  of  defective  speech  is  applicable 
also  to  the  treatment  of  stammering.  Stammerers  may 
or  may  not  have  marked  articulatory  defects,  but  like  all 
other  people  having  had  no  special  speech  training,  they 
have  no  voluntary  control  of  the  peripheral  mechanisms 
employed  in  speech.  These  mechanisms  and  the 
muscles  that  control  them  are  automatic  in  their  action. 
If  I  were  to  ask  you  to  describe  the  physiology  of  any 
one  of  the  elementary  sounds  of  the  alphabet  as  given 
above,  you  would  have  difficulty  in  doing  it  because 
you  do  not  know  the  action  of  the  numerous  muscles 
that  control  these  mechanisms.  The  fact  is  that  only  a 
few  of  these  muscles  are  under  the  domain  of  the  will, 
and  in  the  majority  of  stammerers,  they  are  all  in- 
voluntary. 

Now,  why  does  the  stammerer  stammer,  and  what 
actually  takes  place  in  these  peripheral  mechanisms  of 
speech  during  the  stammering  ?  The  patient  himself 
cannot  answer  these  questions.  He  does  not  know  why 
he  stammers,  nor  does  he  know  how  to  avoid  it.  He 
only  knows  that  he  is  never  sure  of  perfect  freedom  in 
speech.  I  can  think  of  no  other  condition  quite  anal- 
ogous to  that  of  the  stammerer;  he  knows  what  he 
wishes  to  do,  but  he  cannot  do  it.  In  the  functional 
articulatory  form  of  defective  speech,  such  as  I  have 
described,  there  is  merely  an  arrested  or  delayed  develop- 
ment of  the  speech  faculty.  This  faulty  development 
would  never  be  recognized  by  the  patient  if  his  attention 
was  not  especially  called  to  it  by  the  fact  of  his  not 
being  understood.  The  stammerer,  on  the  other  hand, 
is  fully  conscious  of  his  defect,  but  he  has  no  power  to 
remedy  it.  His  difficulty  is  not  with  thought,  but  with 
the  expression  of  thought.  He  thinks  in  words,  but  he 
cannot  speak  in  words.  It  is  almost  generally  conceded 
that  the  primary  revival  of  word  memories  takes  place 
in  the  auditory  centers  of  the  brain  and,  simultaneously, 
but  to  a  lesser  degree,  in  the  visual  centers ;  and  the 
molecular  activity  thus  aroused  is  transmitted  with 
greater  or  less  intensity  to  other  portions  of  the  cerebral 
cortex.  When  words  are  to  be  written,  the  impulse  is 
directed  chiefly  toward  the  chirokinesthetic  center; 
and  when  spoken,  towards  the  glossokinesthetic  or 
Broca's  center  ;  when  neither  written  nor  spoken,  this 
impulse  may  be  directed  toward  the  purely  intellectual 
centers  where  the  words  are  selected  and  arranged  for 
purposes  of  silent  thinking. 

It  is  true  that  some  patients  stammer  in  this  process 
of  thinking,  even  when  no  attempt  is  made  at  thought 
expression.     In  these  cases  there  is  a  confusion  of  ideas 


254 


The  Philadelphia 
Medical  Journal 


] 


SOME  FUNCTIONAL  FORMS  OF  DEFECTIVE  SPEECH 


[F»BRIABY  2,   1901 


such  as  we  all  have  experienced  to  a  greater  or  less  de- 
gree, and  it  is  probably  reasonable  to  suppose  that  this 
confusion  of  ideas,  if  sufficiently  marked  and  of  repeated 
recurrence,  would  lead  to  a  hesitation  in  speech  ;  and  in 
nervous,  impressionable  children,  to  more  or  less  severe 
forms  of  stammering.  All  stammerers  experience  a 
greater  or  less  confusion  of  ideas  whenever  they  attempt 
to  express  their  thoughts  in  words,  and  this  confusion 
generally  increases  as  the  necessity  for  the  expression  of 
thought  increases.  There  are  few  stammerers — for 
instance,  who  cannot  at  all  times  swear ;  and  I  do  not 
recall  one  of  the  hundreds  whom  I  have  examined  that 
has  not  been  able  to  talk  or  read  freely  when  alone  or  in 
the  presence  of  dumb  animals.  In  the  ma-iority  of  cases, 
the  greater  the  desire  for  speech  the  greater  the  difficulty. 
This  is  not  always  true.  Occasionally  we  find  one  who 
requires  only  the  stimulus  that  comes  from  an  important 
occasion  to  overcome  the  barriers  of  speech.  The  con- 
fusion of  ideas  of  which  I  have  spoken  is  not  always 
the  cause  of  stammering,  but  in  some  cases  it  is  the 
effect,  and  the  cause  must  be  looked  for  in  the  peripheral 
or  conducting  mechanisms  of  speech.  When  the  glosso- 
kinesthetic  center  receives  the  command  transmitted 
from  the  other  speech  centers,  it  should  immediately 
and  automatically  execute  it.  This  it  oftentimes  fails 
to  do,  and  this  failure  naturally  results  in  a  confusion  in 
the  molecular  activity  of  the  cortical  centers.  This 
automatic  and  almost  instinctive  power  existing  in  the 
conducting  apparatus  is  undoubtedly  inherited  in 
greater  or  less  perfection.  The  ready  acquirement  of 
the  faculty  of  speech  in  children  in  the  second  year 
would  never  be  possible  were  it  not  for  the  operation  of 
this  law  of  inheritance.  There  are  well-authenticated 
records  of  development  of  speech  having  been  delayed 
for  several  years  in  children,  and  then  of  whole  sentences 
having  been  uttered  spontaneously  and  at  once,  without 
any  previous  effort  at  speech.  This  would  seem  to 
prove  that  the  law  of  inheritance  i.s  especially  operative 
in  the  transmission  of  the  faculty  of  sj)eech.  Moreover, 
the  clinical  records  of  all  these  functional  disorders  of 
speech  furnish  additional  and  stronger  proofs  of  the 
operation  of  this  law.  In  almost  all  cases  of  defective 
articulation,  and  in  a  large  percentage  of  cases  of  stam- 
mering, the  defect  may  be  traced  directly  to  some  ances- 
tral origin. 

From  what  I  have  said  we  must  not  conclude  that 
stammering  is  always  of  central  origin.  The  cerel^ral 
conditions  described  above  are  often  induced  by  a 
derangement  in  the  conducting  nervous  ajiparatus  of 
speech.  The  motor  processes  of  speech  are  carried  on 
mainly  in  the  bulb  and  spinal  cord,  and  anything  that 
interferes  with  these  processes  will  naturally  result  in 
disordered  speech.  This  is  probably  the  physiologic 
explanation  of  the  fact  tliat  stammering  is  often  brought 
on  suddenly  by  a  severe  shock  to  the  nervous  system. 
To  the  child  who  has  inherited  a  predisposition  to 
stammer,  a  frigid  or  a  fall  may  precipitate  the  condi- 
tion ;  and  in  like  manner  the  acute  diseases  of  child- 
hood, especially  the  febrile  diseases  which  affect  the 
nervous  system,  are  fruitful  causes  of  this  affliction. 
These  motor  processes  of  speech  may  also  be  deranged 
by  obstructions  to  the  normal  action  of  the  ]ieriphcral 
mechanisms.  Glandular  enlargements  in  the  ]iliarynx 
and  all  the  various  conditions  occludiim;  the  nasal  pas- 
sages, render  the  use  of  these  mechanisms  more  diffi- 
cult, and  interfere  with  their  natural  automatic  action. 
\\'hen  this  takes  place,  it  reacts  upon  the  conducting 
motor  centers,  and  this  in  turn  reacts  upon  the  cortical 


centers  of  speecj,!,  the  whole  resulting  in  a  lack  of  har- 
mony in  the  action  of  all  the  centers  (cortical  and  sab- 
cortical)  employed  in  the  production  of  language  and 
its  expression  by  articulate  speech.  Stammering,  there- 
fore, is  a  complex  phenomenon.  It  appears  in  various 
forms  ;  no  two  cases  are  exactly  alike,  either  in  their 
etiology  or  external  manifestations.  This  being  so,  the 
treatment,  like  the  treatment  of  any  disease,  must  be 
adapted  to  the  individual. 

in  all  cases  the  nose  and  throat  should  be  carefully 
examined  and  all  irregularities,  either  of  a  structural  or 
a  pathologic  character,  should  be  corrected.  A  free  ac- 
tion of  the  tongue  should  also  be  made  possible  by  the 
snipping  of  a  short  frenum,  and,  if  necessary,  by  a  di- 
vision of  the  anterior  fibers  of  the  geniohyoglossus  mus- 
cle. Of  course,  the  many  empiric  operations  performed 
upon  the  tongue  for  the  relief  of  stammering  half  a  cen- 
tury ago  have  long  since  been  discarded  and  no  one 
thinks  of  employing  surgery  now  except  to  correct  actual 
deformities  of  the  organs  or  to  remove  pathologic  ob- 
structions. 

Aside  from  these  simple  surgical  measures  which  are 
rather  more  preventive  than  curative,  and  aside  from 
general  tonic  remedies  to  support  the  nervous  system, 
the  treatment  of  stammering  mu.=t  be  educational.  In 
the  vast  majority  of  cases  there  is  no  appreciable  organic 
lesion,  and  the  trouble,  at  least  so  far  as  we  can  now  de- 
termine, is  purely  functional.  That  there  is  an  inherited 
organic  nervous  structure  predisposing  children  to  this 
affliction  I  am  convinced,  but  it  is  of  so  slight  a  charac- 
ter that  we  have  as  yet  no  means  of  differentiating  it. 
I  repeat  that  the  treatment  must  be  adapted  to  the  indi 
vidual.  We  must  study  carefully  his  physical  condi- 
tion ;  and  I  use  the  term  physical  in  the  broader  sense, 
including  the  whole  being.  A  study  of  the  mental  atti- 
tudes of  the  stammerer  throws  much  light  upon  his  con- 
dition. Physical  education  is  the  treatment,  and  phys 
ical  education  in  its  broadest  and  most  comprehensive 
form.  Mental  attitudes  and  nervous  tendencies  gen- 
erally may  be  entirely  changed  by  suitable  physical 
exercise ;  and  it  is  a  well-recognized  fact  that  the  devel- 
opment of  muscles  is  valuable  only  in  so  far  as  it  devel- 
ops nerve-power.  We  must  reach  the  nervous  mechan- 
isms of  speech  through  the  training  of  the  muscles 
supplied  by  these  nerves  and  employed  in  the  processes 
of  speech.  The  value  of  this  muscle  training  is  not 
limited  to  the  motor  centers  of  speech  in  the  bulb  and 
spinal  cord,  but  it  extends  to  the  cortical  centers  of  the 
brain. 

As  I  have  said,  the  motor  mechanisms  of  speech  are 
largely  automatic  in  their  action  :  and  when  they  fail 
to  work  automaticalh-,  as  they  do  in  the  case  of  the 
stammerer,  an  effort  is  made  to  force  them  into  action. 
This  proves  to  be  an  impossibility  and  results  in  the 
various  grimaces  and  other  contortions  so  characteristic 
of  the  stammerer. 

The  proximate  cause  of  stammering,  therefore,  exists 
in  a  fimctional  derangement  of  the  nervous  mechanisms 
of  speech,  and  this  condition  results  in  an  inharmonious 
and  incoordinate  action  of  the  hitherto  automatic  per- 
ipheral mechanisms.  The  t;\sk  before  us  is  manifestly 
to  restore  the  nervous  mechanisms  of  speech  to  their 
normal  condition  ;  and  at  the  same  time  to  reestablish 
a  normal  automatic  action  in  the  periphenvl  mechan- 
isms. There  is  but  one  rational  and  scientific  methixl 
by  which  this  may  be  accomplishe<l.  The  normal 
functional  activity  of  the  cortical  centers  can  only  be 
restored  by  phj'siologic  exercise,  anil  this  exercise  can 


1901] 


THE  SUMMER  COLD 


CThk  Philadelphia 
Medical  Journal 


255- 


only  come  as  the  result  of  a  conscious  effort  on  the  part 
of  the  patient  to  gain  voluntary  control  over  the  entire 
muscular  system, — giving  especial  attention  to  those^ 
mechanisms  immediately  concerned  in  the  processes  of 
speech.  The  aim,  then,  in  all  cases  should  be  toward 
the  volitional  control  of  muscles,  keeping  in  mind  that 
the  chief  object  to  be  accomplished  is  the  restoration  of 
normal  functional  activity  in  the  nervous  system.  Some 
little  ingenuity  is  necessary  to  determine  just  what  par- 
ticular exercises  msiy  best  suit  individual  cases  ;  and 
great  patience  and  perseverance  are  needed  in  their 
application.  Of  course,  the  busy  doctor  cannot  do  it, 
and  the  average  teacher  will  not  do  it  successfully 
because  he  fails  to  appreciate  the  application  of  the 
exercises  to  the  case  under  consideration ;  and  he  lacks, 
therefore,  the  incentive  to  persistent  and  hopeful  effort. 
Specially  trained  assistants  (not  necessarily  elocutionists) 
are  required,  and  they  must  work  in  entire  harmony 
with  the  physician.  There  must  be  no  differences  of 
opinion  with  reference  even  to  the  details  of  the  work, 
for  this  has  a  bad  effect  upon  the  patient.  Those  having 
defective  speech,  and  particularly  those  who  stammer, 
need  encouragement  and  moral  support ;  and  attention 
to  little  things  is  of  the  greatest  importance  in  their 
treatment. 


THE  SUMMER  COLD  :  SWIMMING  POOLS  AS  AN  ETIO- 
LOGICAL FACTOR. 

By  LAWRENCE  F.  FLICK,  I\r.D., 

of  Philadelphia. 

There  is  a  popular  saying  that  a  summer  cold  does 
not  get  well  until  cold  weather  sets  in.  I  had  always 
looked  upon  this  kind  of  a  cold  as  a  myth  until  the 
past  summer,  when  a  singular  experience  strengthened 
a  conclusion  which  has  long  been  crystallizing  in  my 
mind  that  a  popular  verdict  is  always  based  upon 
truth. 

In  the  early  part  of  July  I  took  my  family  to  the 
country,  but  was  driven  home  within  a  week  by  a 
whooping-cough  scare.  We  remained  home  for  the 
length  of  time  of  the  incubation  period  of  whooping- 
cough,  and  then  decided  to  remain  home  for  the  entire 
summer.  We  were  informed  afterwards  that  the  case 
at  which  we  took  fright  was  not  one  of  whooping 
cough.  As  part  compensation  for  our  summer  trip 
away,  I  took  out  5  season  tickets  in  a  swimming  school, 
on  August  2.  Four  children  and  myself  used  these 
tickets.  The  ages  of  the  children  were  approximately 
7,  10,  12,  and  14  years.  The  two  older  children  could 
swim  a  little,  the  two  younger  and  myself  practically 
could  not  swim  any.  The  swimming  school  to  which 
we  went  is  one  of  the  best  in  Philadelphia,  and  is 
attended  by  the  better  class  of  people.  The  water  in 
the  pool  is  filtered  and  there  is  a  running  stream  in 
and  out  of  the  pool  during  swimming  hours.  I  am 
inclined  to  think  that  the  inflow  and  outflow  of  water 
is  stopped  during  hours  when  the  pool  is  not  used,  as 
I  have,  on  a  number  of  occasions,  gone  to  the  pool  in 
the  morning  before  the  inflow  had  been  started.  I 
have  been  told  that  the  pool  is  thoroughly  cleansed 
once  a  week.  I  have  also  been  told  that  it  takes 
about  24  hours  to  completely  change  the  water  in  the 
pool.  For  the  correctness  of  these  statements  I  can 
not  vouch.  The  rules  of  the  swimming  school  forbid 
spitting  into  the  water  and  also  using  the  water  for 
cleansing  purposes. 


After  we  had  been  going  to  the  school  about  on& 
week  a  report  was  brought  home  by  the  children 
that  some  of  the  young  swimmers  had  a  croupy 
cough.  This  rather  prepared  my  mind  for  an  attack 
of  follicular  tonsillitis  or  possibly  a  cold  in  some  or 
in  all  of  US;  I  did  not  anticipate  anything  more 
serious,  however.  Some  time  near  the  end  of  our 
second  week  of  lessons,  the  youngest  child,  a  boy, 
was  taken  with  what  appeared  to  be  follicular  tonsil- 
litis. He  had  high  fever  lor  48  hours,  almost  constant 
vomiting,  obstinate  constipation,  and  severe  abdom- 
inal pains.  His  tonsils  were  swollen  and  the  follicles 
were  filled  with  a  whitLsh  substance.  After  the  fever 
had  subsided  and  the  gastric  abdominal  symptoms 
had  disappeared  he  was  left  with  a  croupy  cough 
and  a  rather  intense  inflammation  of  the  nasal  mucous 
membrane.  Gradually  this  condition  gave  way  to  a 
chronic  nasal  inflammation  with  free  discharge  of  pur- 
ulent matter  and  a  gradually  increasing  cough  and 
expectoration. 

I  myself  nursed  the  little  fellow,  and  on  the  second 
day  of  his  illness  I  noticed  a  sore  feeling  in  one 
nostril  far  back.  The  nasal  passage  on  the  side 
aS"ected  was  completely  occluded.  The  sore  feeling 
gradually  extended  over  a  larger  surface,  and  together 
with  the  obstruction  gave  me  much  discomfort,  but 
apparently  set  up  no  other  symptoms  of  disease.  I 
concluded  that  I  had  contracted  a  mild  attack  of  the 
disease  which  was  afflicting  my  boy.  Aside  from  the 
pain  and  discomfort  I  suffered  no  inconvenience.  In 
fact  I  felt  myself  to  be  in  unusual  good  health. 
Annoyed  by  the  nasal  obstruction  I  made  persistent 
effort  to  open  up  the  closed  passage  by  douches  of 
antiseptic  solution.  I  used  Seiler's  antiseptic  pastiles 
for  this  purpose.  I  succeeded  in  clearing  the  passage, 
and  immediately  thereupon  I  began  to  notice  the  sore- 
ness rapidly  extending  into  the  pharynx,  into  the 
trachea,  and  into  the  other  nostril.  Within  24  hours 
the  entire  upper  respiratory  tract  was  inflamed.  Now 
for  the  first  time  constitutional  symptoms  began  to 
show  themselves.  These  consisted  of  a  slight  chilli- 
ness and  a  feeling  of  lassitude.  My  appetite  continued 
good.  For  a  week  I  continued  going  to  the  swimming 
pool  irregularly,  and  I  seemed  to  get  some  benefit  from 
the  water.  Gradually,  however,  the  inflammation  ex- 
tended down  further  in  the  bronchial  tubes,  into  the 
antrums  of  Highmore,  into  the  eustachian  tubes,  and 
to  some  entent  into  the  frontal  sinuses.  A  good  deal 
of  frontal  neuralgia  developed.  There  were  few  consti- 
tutional symptoms,  however.  I  became  rather  sensi- 
tive to  cold,  perspired  freely  upon  the  slightest  exertion 
and  felt  an  incapacity  for  occupation  of  any  kind.  I 
now  discontinued  my  visits  to  the  pool.  At  the  end  of 
two  weeks  my  ailment  had  assumed  a  chronic  form, 
which  changed  into  a  subacute  one  when  I  exerted 
myself  much  and  returned  to  a  chronic  one  when  I 
rested.  Medication  seemed  to  have  practically  _  no 
effect.  I  used  many  drugs  internally  and  locally  with- 
out apparently  changing  the  character  or  course  of  the 
disease.  As  soon  as  I  noticed  that  exertion  aggravated 
the  condition  I  remained  as  quiet  as  possible  without 
lying  up.  The  discharge  from  the  antrums  and  frontal 
sinuses  became  very  profuse,  necessitating  the  use  of 
from  15  to  20  handkerchiefs  a  day.  It  was  purulent  in 
character.  The  only  remedy  which  appeared  to  have 
any  effect  upon  it  was  a  douche  of  a  solution  of  tannic 
acid  and  chlorate  of  potash  in  glycerin  and  rose-water, 
which  I  began  to  use  about  the  "end  of  the  third  week. 


256 


The  Philadelphia 
Mbdical  Jouenal 


] 


THE  SUMMER  COLD 


fpEEECAET  2,    1901 


This  materially  lessened  the  amount  of  the  discharge. 
The   disease,  however,  continued  until  late  in  the  fall. 

About  the  time  that  the  disease  began  with  me  it 
also  started  in  the  other  three  children,  there  however 
being  a  few  days  interval  between  the  attacks  of  each, 
beginning  with  the  youngest.  The  youngest,  being  the 
second  youngest  of  the  four  children,  had  quite  a  severe 
attack,  having  to  go  to  bed  with  fever  for  nearly  a 
week.  The  next  older  had  to  go  to  bed  for  a  few  days 
and  had  some  fever.  The  oldest  had  a  slight  fever  for 
a  day,  but  did  not  have  to  go  to  bed.  In  all  of  the 
children  the  symptoms  were  practically  the  same  after 
the  first  few  days,  namely,  frontal  neuralgia,  earache, 
slight  deafness,  obstruction  of  the  nasal  passages,  slight 
croupy  cough,  reddening  of  the  eyelids  with  slight  suf- 
fusion of  the  conjunctiva,  purulent  discharge  from  the 
nose,  and  a  feeling  of  lassitude.  There  was  practically 
no  cough  at  night,  but  always  severe  cough  upon  aris- 
ing in  the  morning  and  some  cough  during  the  day. 
Some  of  the  children  lost  their  appetites  for  a  few  days, 
but  as  a  rule  the  appetite  remained  good.  As  with 
myself  so  with  the  children,  remedies,  with  the  pos- 
sible exception  of  the  tannic-acid  mixture  mentioned, 
were  of  no  avail.  The  most  striking  effect  of  the  dis- 
ease upon  the  appearance  of  the  children  was  the  pro- 
duction of  pallor.  Towards  the  end  of  the  attack  the 
appetite  became  capricious,  but  all  continued  to  eat 
and  none  lost  weight 

At  the  end  of  from  6  to  8  weeks  we  all  began  to 
show  great  nervousness.  I  myself  looked  well  at  this 
time  and  had  gained  in  weight,  but  was  on  the  point 
of  nervous  prostration.  I  was  almost  totally  incapaci- 
tated for  work.     All  energy  seemed  to  have  left  me. 

As  the  cold  weather  came  on  we  all  rapidly  im- 
proved, but  whether  this  was  due  to  the  weather  or  be- 
cause the  disease  had  run  its  course,  I  am  not  prepared 
to  say.  There  remained  with  some  of  the  children 
and  myself  a  tendency  to  congestion  of  the  mucous 
membrane  of  the  nose  which  continues  with  us  to  this 
day.  One  of  the  children,  who  was  then  10  years  old, 
moreover  completely  broke  down  after  going  to  school 
a  month  or  six  weeks  without  any  apparent  cause.  She 
became  exceedingly  nervous,  developed  complete  ano- 
rexia, and  emaciated  rapidly.  From  this  condition  she 
is  now  slowly  recovering.  It  is  but  proper  to  say,  how- 
ever, in  this  connection  that  she  has  been  getting  a 
number  of  second  teeth. 

An  interesting  point  in  the  etiology  of  this  disease, 
which  may  in  part  be  deciphered  from  this  unique  ex- 
perience, is  infection.  The  disease  is  evidently  infec- 
tious rather  than  contagious,  although  it  may  be  both.  I 
am  convinced  that  we  all  contracted  the  disease  directly 
from  the  water.  My  reasons  for  arriving  at  this  con- 
clusion are  as  follows  :  1.  The  severity  of  our  attacks 
was  in  proportion  to  our  inability  to  swim  and  conse- 
quently to  the  extent  to  which  we  sucked  water  into 
the  upper  air-passages  in  trying  to  breathe  under 
water.  I  remember  distinctly  having  had  an  unusually 
unpleasant  experience  of  this  kind  a  day  or  two  before 
my  attack  began.  The  youngest  child,  a  courageous 
little  fellow,  inhaled  water  quite  frequently,  and  he  was 
the  first  to  develop  the  disease.  The  oldest  boy,  who  coilld 
swim  some  and  who  knew  something  about  breathing 
while  swimming,  had  the  mildest  attack.  He  did  not 
develop  his  attack  until  about  the  time  when  he  began 
to  learn  to  dive.  2.  There  were  five  members  of  our 
household,  namely,  my  wife,  two  younger  children, 
and  two  maids,  who  did  not  take  swimming  lessons. 


My  wife  and  the  two  children  were  in  intimate  contact 
with  the  rest  of  us  and  the  two  children  on  several  oc- 
casions were  at  the  swimming  school  as  spectators. 
The  maids  were  in  contact  with  us  likewise,  although 
of  a  less  intimate  character,  and  one  of  them  was  re- 
peatedly at  the  school  as  a  spectator.  The  incubation 
period  of  the  disease,  if  our  experience  may  be  used 
to  determine  it,  coulii  not  well  be  over  two  weeks.  At 
the  end  of  four  weeks  of  intimate  association  the  two 
children  who  had  not  taken  swimming  lessons,  devel- 
oped a  mild  attack,  and  at  the  end  of  five  weeks  my 
wife  developed  a  mild  attack.  The  two  maids  did  not 
contract  the  disease.  There  was  ample  opportunity  for 
infection  of  my  wife  and  the  two  children  through  kiss- 
ing, use  of  towels,  and  use  of  eating  and  drinking 
utensils,  so  that  it  is  quite  possible  that  they  contracted 
the  disease  by  infection.  Contagion  cannot  be  ex- 
cluded, however.  The  fact  that  the  maids  did  not  con- 
tract the  disease  would  seem  to  indicate  that  if  it  is 
contagious  it  is  very  mildly  so. 

It  would  be  interesting  to  know  how  many  of  the 
patrons  of  the  swimming  school  got  the  disease.  One 
of  the  attendants  told  me  that  a  great  many  people  who 
came  there  had  the  same  ailment  which  I  had.  A 
friend,  who  was  going  to  the  school  with  his  two  daugh- 
ters at  the  same  time  we  were,  has  informed  me  since 
that  he  and  his  daughters  contracted  a  cold  there  which 
lasted  them  all  summer.  Two  gentlemen,  one  a  phy- 
sician and  the  other  a  clergyman,  have  since  informed 
me  that  when  they  took  swimming  lessons  at  this  school 
during  another  season  they  contracted  colds  which  lasted 
all  summer.  A  physician  has  told  me  since  that  he  has 
frequently  treated  colds  which  had  been  contracted  at 
the  school,  but  that  he  had  looked  upon  them  as  the 
result  of  exposure  in  wet  clothing. 

I  regret  that  I  am  unable  to  accompany  these  clinical 
observations  with  a  bacteriological  study.  Unfortu- 
nately I  was  unsuccessful  in  my  efiforts  to  find  a  com- 
petent bacteriologist  in  the  city  at  the  time.  Cultures 
from  the  nasal  discharges  of  myself  and  children,  to- 
gether with  a  bacteriological  study  of  the  water  in  the 
pool,  would  no  doubt  have  revealed  the  microorganism 
which  produced  the  disease.  An  opportunity  for  such 
a  study  will  undoubtedly  present  itself  during  another 
season,  when  perhaps  some  of  our  bacteriologists  will 
be  on  the  lookout  for  this  undiscovered  microbe. 


Relation  between  the  Oecnrrence  of  Appendi- 
citis and  the  Presence  of  a  Neurasthenic  Tendency. 

— Sihaumann  {Deutsche  medicinische  Wochenschri/l)  refers  to 
this.  He  has  frequently  observed  appendicitis  in  general 
members  of  neurotic  families,  and  in  a  number  of  instances 
has  seen  appendicitis  appear  without  any  very  apparent  rea- 
son after  severe  neurasthenia  had  existed  for  some  time. 
The  fact  that  appendicitis  is  not  infrequently  combined  with 
mucomembranous  enterocolitis  in  his  belief  shows  also  some 
relation  between  appendicitis  and  neuroeis;  likewise  neuras- 
thenia is  frequently  combined  with  ptosis  of  one  or  more  of 
the  abdominal  organs,  and  it  may  readily  be  believed  that 
alteration  in  the  position  of  the  abdominal  organs  may  lead 
to  appendicitis  and  that  the  appendix  itself  may  be  out  of 
position  and  thus  be  more  subject  to  inflammation  :  it  is  well 
known  that  in  appendicitis  the  appendix  is  not  infrequently 
found  in  peculiar  positions.  Also,  certain  authors  have  ex- 
pressed their  belief  that  chronic  appendicitis  is  a  very  fre- 
quent result  of  movable  right  kidney.  S.-haumann  does  not 
insist  that  he  has  proved  a  direct  relationship  between  neu- 
rosis and  appendicitis,  but  he  does  believe  that  appendicitis 
may  in  some  instances  be  the  result  of  general  neurosis, 
usually  indirectly,    [d.l  e.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned   and   Published   by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hbndrib  Lloyd,  A.M.,  M.D.,  Editor-in-Chief 
JULIDS  L.  Salinqkk,  M.D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailkb,  M.D.  F.  J.  Kaltkyer,  M.D. 

-    "    -  T.  L.  Colby.  M.D. 

M.D. 


D.  L.  Edsall,  M.D. 
J.  M.  Swan,  M.D. 


T.  L.  Colby,  M.D. 

W.    A.    N.    DOKLAND, 


J.  H.  Gibbon,  M.D. 


.Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.    Reprints  (250)  of  Original  Articles  will  be  furnished  gratis  to  Authors  making 
the  request. 
The  Editorial  and  Business  Olfices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Fliiladelphia  Medical  Jonmal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  AdTertising  Page  8. 


Vol.  VII,  No.  6 


FEBRUARY  9,  1901 


$3.00  Per  Annum 


Experimental  Pancreatitis. — It  is  no  discredit  to 
the  fair  reputation  of  our  predecessors  in  medicine  that 
the  knowledge  they  possessed  of  the  pancreas  and  its 
morbid  conditions  should  have  been  vague  and  inaccu- 
rate. Before  1642,  at  which  date  Wirsung  discovered 
the  pancreatic  duct,  thus  proving  the  glandular  nature 
of  the  organ,  it  had  been  the  habit  to  attribute  to  dis- 
eases of  the  pancreas  such  conditions  as  melancholia, 
ague,  and  hypochondriasis  (Fernelius).  And  indeed, 
notwithstanding  Wirsung's  discovery,  it  has  not  been 
until  recent  years  that  anything  like  a  proper  knowl- 
edge of  the  physiology  and  pathology  of  the  pancreas 
has  been  acquired. 

There  is  no  organ  of  the  body  that  is  so  uncom- 
monly the  seat  of  idiopathic  disease,  and  it  is  certain 
that  no  other  pathological  process  presents  a  greater 
variety  of  inconstant  and  contradictory  symptoms. 
Within  the  past  few  years,  however,  experimental 
work,  on  the  one  hand,  and  careful  pathological  study 
on  the  other,  have  evolved  some  order  out  of  the 
chaos,  and  a  vast  deal  is  now  established  with  much 
left  unsolved. 

We  have  to  recall  only  the  situation  of  the  pancreas, 
its  intimate  relations  with  surrounding  structures,  and 
the  great  rarity  of  uncomplicated  pancreatic  disease,  to 
understand  the  nature  of  the  difficulties  which  beset  a 
student  in  both  the  subjective  and  objective  signs  of 
morbid  action. 

Dr.  Simon  Flexner  has  lately  conducted  a  series  of 
experiments  upon  the  pancreas,  the  report  of  which  will 
be  found  in  the  University  Medical  Magazine,  for  Janu- 
ary, 1901.  They  amplify  this  investigator's  previous 
work  in  the  same  field  (1897),  and  form  a  valuable  con- 
tribution to  our  knowledge  of  the  subject.  With  a  view 
of  studying  the  efi'ects  of  injury,  and  of  chemical  sub- 
stances, as  well  as  of  the  various  bacteria,  upon  animals, 
inoculations  were  made  into  the  duct  as  well  as  the 
gland  substance  proper.  Flexner  gives  us  a  resume  of 
his  former  work,  and  the  results  of  other  experiments 
than  his  own.  While  a  great  deal  of  light  has  not  been 
thrown  upon  the  causes  of  pancreatitis,  the  nature 
and  causes  of  fat-necrosis  have  been  established  defi- 
nitely. Flexner's  conclusions  from  his  earlier  paper 
bear  repetition.  He  states  that  the  pancreatic  secretion 
may  enter  the  peritoneal  cavity  without  setting  up  dif- 
fuse inflammation,  but  in  a  certain  number  of  in- 
stances sterile   pancreas  or   its  secretion  causes  local 


fat-necrosis.  The  element  of  infection  plays  a  very- 
insignificant  part.  In  peritoneal  fat-necrosis  the  fat- 
splitting  ferment  is  demonstrable  in  certain  stages  of 
the  pathological  process,  being  present  in  greatest 
amount  early,  and  it  may  disappear  as  healing  advances. 
Flexner  believes  that  it  is  highly  probable,  but  not 
proved  conclusively,  that  steapsin  is  the  direct  cause  of 
necrosis.  Finally,  the  escape  of  the  pancreatic  secre- 
tion into  the  peri-  and  para-pancreatic  tissues  is  the 
origin  of  the  necrosis,  and  this  escape  is  facilitated,  not 
only  by  lesions  of  the  pancreas,  but  by  disturbances  of 
its  circulation,  which  include  the  efi'ects  of  injuries  in- 
flicted upon  the  gland  as  well  as  the  results  of  passive 
congestion.  The  valuable  work  of  Oser  upon  this  sub- 
ject is  referred  to  by  Flexner,  and  Oser's  classification 
of  diseases  of  the  pancreas  is  adopted.  He  enumer- 
ates :  (1)  Acute  hemorrhagic  pancreatitis,  (2)  suppura- 
tive pancreatitis,  (3)  necrotizing  pancreatitis,  and  (4) 
chronic  indurative  pancreatitis.  Experimental  work  has 
thrown  much  light  upon  the  suppurative  and  necrotizing 
varieties,  and  in  those  cases  in  which  the  pancreatitis 
does  not  produce  the  death  of  the  animal,  the  chronic 
indurative  form  is  seen  to  follow.  As  a  result  of  Flex- 
ner's experiments,  he  concludes  that  hemorrhage  per  se 
is  a  common  condition  of  all  forms  of  pancreatitis, 
and  that  when  it  is  excessive  it  dominates  the  pro- 
cess. It  is  more  pronounced  usually  in  inflammatory 
lesions,  and  the  two  conditions  may  be  separate  and 
distinct  in  the  same  organ,  or  parts  of  the  organ.  Fat- 
necrosis  is  due  to  the  perversion  of  the  pancreatic  se- 
cretion and  is  the  direct  result  of  the  action  of  the 
fat-splitting  ferment.  He  calls  attention  to  the  fact  that 
owing  to  the  severity  of  the  means  employed  to  pro- 
voke pancreatitis  in  experimental  cases,  it  is  not  found 
that  hemorrhage  occurs  commonly  independently  of  the 
inflammation.  The  part  which  infection  plays  is  prob- 
ably secondary  to  the  action  of  the  pancreatic  secre- 
tion upon  the  injured  foci. 

There  are  many  phases  of  this  subject  which  we  can- 
not touch  upon  within  the  scope  of  these  remarks.  It 
is,  however,  suggestive  to  enumerate  some  open  ques- 
tions, such  as  the  relation  between  diabetes  and  diseases 
of  the  pancreas,  the  nature  of  the  leukemia  present  in 
animals  experimented  upon ;  the  relations  between  the 
spleen  and  the  pancreas  and  their  functions ;  and, 
finally,  the  relations  between  the  liver  and  the  pan- 
creas.    We  would  call  attention  in  this  connection  to  a 


258 


The  Philadelphia' 
Medical  Journal 


] 


EDITORIAL  COMMENT 


[FEBRaiBT   9,  1941 


paper  by  Opie  which  appeared  in  the  American  Journal 
of  the  Medical  Sciences,  for  January,  1901. 

Contempt  of  Court  versus  Contempt  of  Human 
Life. — Judge  Wiltbank,  of  the  Criminal  Court,  in  this 
city,  pronounced  an  opinion  last  week  which  is  likely 
to  have  an  educational  effect  on  the  public  at  large  and 
on  phj'sicians  in  particular.  In  imposing  a  fine  on  a 
tardy  doctor,  who  had  been  detained  at  the  bedside  of 
a  patient  critically  ill,  the  learned  judge  is  reported 
to  have  said  that  it  were  better  that  the  patient  had 
died  than  that  the  Commonwealth  should  be  treated 
with  contempt.  He  afterwards  graciously  remitted  the 
fine,  but  did  not  reverse  his  own  opinion ;  and  so  the 
record  shows  that  a  Philadelphia  judge,  if  correctly 
reported,  values  the  dignity  of  his  court  above  a  human 
life.  That  every  doctor  will  dissent  from  this  pre- 
posterous opinion  is  happily  certain,  for  the  physician, 
we  believe,  does  not  practise  in  this  city  to-day  who 
would  not  rather  pay  this  fine  many  times  over  than 
desert  a  patient  in  extremis.  The  incident  throws  a 
curious  light  on  the  exaggerated  importance  which 
some  of  the  courts  attach  to  their  own  prerogatives.  The 
truth  is  that  the  courts,  more  than  all  our  other  institu- 
tions, inherit  the  traditions  of  the  dim  past.  They  claim 
a  great  antiquity,  which  lies  in  remote  English  his- 
tory, when  the  judge  upon  his  bench  was  little  less 
sacred  than  the  king  upon  his  throne.  Thus  Black- 
stone  in  his  Commentaries  (Book  III,  Chapter  3)  tells 
us  that  the  judge  represents  the  sovereignty  of  the  king, 
and  that  in  the  contemplation  of  the  law  the  king  is 
supposed  to  be  always  present  in  court.  From  this  fic- 
tion arises  the  great  atrocity  of  contempt,  for  to  be  in 
contempt  of  court  was  really  to  be  guilty  of  a  form  of 
lese  majeste.  In  modern  times,  and  in  a  democratic 
community,  such  a  prerogative  is  not  accorded  to  the 
courts,  especially  here  in  America  ;  and  when  the  value 
of  a  human  life  is  set  opposite  to  the  interests  of  an 
assault  and  battery  case,  we  doubt  not  that  the  sym- 
pathy of  the  public,  as  well  as  its  common  sense,  will 
side  with  the  doctor.  Still,  we  suppose  Judge  Wiltbank 
is  entitled  to  such  vindication  as  he  can  obtain  from 
the  traditions  of  the  bench. 

A  Reminiscence  of  the  Queen. — In  its  memoir  of 
Queen  Victoria,  the  British  Medical  Journal  recalls  an 
incident  in  her  life  that  is  full  of  interest  for  medical 
readers.  In  1853,  at  the  birth  of  her  son,  the  late 
Duke  of  Albany,  she  submitted  to  be  placed  under  the 
influence  of  chloroform.  This  anesthetic  was  adminis- 
tered by  Dr.  John  Snow,  and  was  given  in  doses  of  15 
minims,  the  Queen  being  kept  under  its  influence  dur- 
ing her  accouchement  for  nearly  an  hour.  This  was  at 
a  time  when  chloroform,  especially  in  obstetrical  prac- 
tice, was  still  regarded  with  the  greatest  suspicion,  and 
even  abhorrence.  Eminent  members  of  the  profession 
denounced  its  use  as  not  only  dangerous,  but  unjusti- 


fiable, and  some  of  them  even  went  to  the  fanatical 
extreme  of  proclaiming  that  the  use  of  an  anesthetic  in 
labor  was  a  defiance  of  the  Almighty,  who  had  pro- 
nounced upon  all  women  the  primal  curse  that  they 
should  bring  forth  their  children  in  sorrow  and  pain. 
This  battle  raged  here  in  Philadelphia  as  fiercely  as  in 
England,  and  reputations  were,  for  the  time  being, 
nearly  marred  by  it.  Sir  James  Y.  Simpson,  who 
championed  the  advent  of  chloroform,  used  and  advo- 
cated it  especially  in  obstetrics,  but  it  was  made  to 
sufier  opprobrium  for  nearly  all  the  accidents,  from 
whatever  cause,  that  can  happen  in  childbed.  It  was 
accused,  for  instance,  of  causing  puerperal  insanity,  and 
several  papers  or  references  on  the  subject  were  con- 
tributed to  medical  literature.  In  a  case  happening 
near  Philadelphia,  in  or  about  1853.  legal  complications 
were  barely  averted,  the  doctor  in  the  case  having  ad- 
ministered the  new  anesthetic,  and  the  patient  a  few 
weeks  later  having  gone  insane  and  been  taken  to 
Kirkbride's.  It  is  difficult  for  us  to  realize  in  the  pres- 
ent day  the  unreason  and  prejudice  displayed  against 
this  beneficent  practice,  and  to  fuUy  appreciate  the 
courage  of  Queen  Victoria  and  her  confidence  in  her 
physicians,  as  well  as  the  confidence  of  her  physicians 
in  themselves,  in  thus  resorting  to  the  use  of  an  almost 
unknown  and  apparently  deadly  vapor.  It  is  needless 
to  say  that  the  example  of  the  Queen  was  of  the 
greatest  influence  in  England,  and  presumably  in  the 
world  at  large.  Chloroform  had  undoubtedly  begun  to 
be  used  before  this  date,  but  its  use  under  such  august 
and  auspicious  circumstances  was  the  one  thing  needful 
to  bring  it  into  vogue. 

Huxley  and  Leidy. — These  two  eminent  scientists, 
who  are  of  special  interest  to  our  readers  because  they 
were  both  members  of  the  medical  profession,  are 
brought  prominently  into  notice,  the  former  by  the 
biography  and  memoirs  of  him  that  are  appearing, 
and  the  latter  by  the  presentation  of  his  portrait  to  the 
College  of  Physicians  here  in  his  native  city.  It  is 
much  to  be  regretted  that  the  tribute  of  a  well-written 
life,  such  as  has  just  appeared  of  Huxley,  has  not  yet 
been  paid  to  the  memory  of  Leidy.  Surely  there  was 
enough  in  that  fruitful  and  profound  life — even  though 
it  were  a  comparatively  uneventful  one — to  make  a 
deeply  interesting  book.  Leidy,  unlike  Huxley,  re- 
mained identified  with  the  medical  profession  all  his 
life,  and  spent  his  invaluable  days  in  the  routine  work 
of  teaching  practical  anatomy  to  medical  students.  In 
the  light  of  what  we  know  of  him,  and  of  what  he  did, 
this  life-work,  though  a  sufficiently  noble  one,  must 
be  looked  upon  as  something  of  a  sacrifice.  He  had  the 
genius  of  a  great  morphologist  and  paleontologist,  and 
his  contributions  to  these  sciences  are  sufficient  evi- 
dences of  the  vast  work  he  might  have  accomplished  if 
he,  like  Huxley,  had  devoted  more  of  his  life  to  purely 
scientific  work  instead  of  to  the  work  of  medical  edu- 


Febrdaky  9,  1901] 


EDITORIAL  COMMENT 


CThe  Philadelphia 
Medical  Johenal 


259 


■cation.  However,  the  long  line  of  students  who  for  forty 
years  sat  at  his  feet,  were  the  gainers,  not  only  in  prac- 
tical knowledge,  but  in  the  benefit  derived  from  the  ex- 
ample and  personality  of  a  great  scientist. 

Lord  Avebury  (better  known  as  Sir  John  Lubbock) 
in  his  recent  memorial  lecture  on  Huxley,  delivered  be- 
fore the  Anthropological  Institute  {Popular  Science 
Monthly,  February,  1901),  has  depicted  the  best  and 
most  lovable  traits  of  the  great  "  agnostic."  Huxley  in- 
vented this  term  to  describe  himself,  but  it  represented 
his  logic  rather  than  his  sympathies.  These  latter  never 
hesitated  to  go  forth  even  where  his  reason  could  not 
always  follow.  He  was  many-sided,  and  his  versatility, 
as  Lord  Avebury  shows,  expended  itself  in  three  main 
•channels — science,  education,  and  metaphysics.  In  all 
these  spheres  he  was,  when  need  be,  a  controversialist 
of  the  highest  and  best  type.  That  these  two  great  men, 
Huxley  and  Leidy,  knew  and  thoroughly  appreciated 
•each  other,  is  shown  by  not  a  few  interesting  records 
and  relics.  Huxley,  speaking  of  himself,  says  that  when 
he  was  a  medical  student  he  resolved  "  to  make  the  best 
■of  the  stuff"  that  was  in  him.  He  succeeded  so  well  that 
from  the  beginnings  as  a  medical  student  he  ended 
by  becoming  one  of  the  foremost  thinkers,  investigators, 
and  expounders  of  his  day. 

Neuroses  of  the  Stomach. — For  many  years  it  was 
•customary  to  write  at  length  of  purely  nervous  gastric 
affections.  Recently  there  has  been  a  strong  tendency 
in  the  opposite  direction,  and  some  authors  even  deny 
the  existence  of  purely  nervous  chronic  gastric  dis- 
turbances, insisting  that  these  always  have  an  anatomi- 
cal basis.  The  view  at  present  adopted,  however,  by 
the  most  clearheaded  of  those  interested  in  gastric  dis- 
eases, is  that  if  a  purely  nervous  chronic  disturbance 
of  the  stomach  occurs  it  is  extremely  rare,  but  that  on 
the  other  hand  gastric  disturbances  not  infrequently 
have  primarily  a  purely  nervous  origin,  and,  secondarily, 
through  the  effects  of  the  functional  nervous  condition, 
anatomical  changes  in  the  stomach  occur.  The  essential 
point  insisted  upon  is  that  it  is  almost  always  erroneous  to 
consider  a  protracted  gastric  disturbance  purely  nervous, 
since  anatomical  changes  almost  inevitably  occur  in  the 
stomach  as  the  result  of  prolonged  functional  disturb- 
ance. There  seems  indeed  to  be  but  one  satisfactory 
case  on  record  in  which  marked  disturbance  of  gastric 
function  occurred  throughout  many  years  without  pro- 
ducing distinct  anatomical  changes  in  the  gastric  mucous 
membrane.  The  most  common  results  are  probably  well 
exemplified  in  a  recent  interesting  report  by  Ferrannini 
{Centralblatt  f.  innere  Med.,  January  5,  1901),  who  de- 
scribes a  case  in  which  there  has  been  for  11  years  fre- 
quent attacks  of  what  at  first  was  evidently,  from  the 
symptoms,  an  intermittent  gastrosuccorrhea,  and  which, 
during  the  latter  course  of  the  disease,  had  become  a  con- 
tinuous gastrosuccorrhea.  The  case  ended  with  a  severe 
attack  of  tetany  which  soon  proved  fatal.     The  micro- 


scopic examination  of  the  stomach  demonstrated  the  ap- 
parent course  of  events.  The  changes  in  the  stomach 
were  widespread,  but  distinct  stages  in  these  changes 
could  be  followed  clearly.  The  earliest  alteration  was  in 
the  parietal  cells ;  these  had  increased  in  number,  they 
were  enlarged  and  swollen,  and  there  was  some  dilatation 
of  the  glandular  cavities  and  outlets.  In  later  stages 
the  increase  in  the  number  of  the  parietal  cells  and  in 
their  size  became  much  more  marked,  and  most  of  the 
cells  contained  two  nuclei ;  the  principal  cells  had  be- 
come shrunken  and  decreased  in  number,  and  their 
protoplasm  was  of  a  homogeneous  appearance.  In  more 
advanced' stages  the  changes  in  the  purely  glandular 
tissue  were  even  more  marked,  and  there  was  also  some 
increase  in  the  connective  tissue,  with  moderate  round- 
cell  infiltration.  The  most  important  part  of  the  obser- 
vation was  in  the  fact  that  the  changes  in  the  glandular 
cells  were  so  very  widespread  and  so  far  advanced, 
while  inflammatory  changes  had  appeared  late.  That 
such  changes  should  have  been  so  marked  and  pro- 
tracted as  the  result  of  actual  gastritis,  while  the  con- 
nective-tissue remained  uninvolved,  seemed  highly 
improbable,  and  the  only  proper  conclusion  seemed  to 
be  that  the  condition  was  at  first  purely  irritative  and 
consisted  of  swelling  and  hyperplasia  of  the  HCl 
secreting  cells,  and  that  secondarily  to  this  the  inter- 
stitial tissue  showed  changes.  That  the  inflam- 
matory changes  were  secondary  seemed  evident  from 
the  fact  that  they  began  about  the  free  surface  of  the 
gastric  mucous  membrane  and  not  about  the  glands. 
They  were  therefore  evidently  the  results  of  the  irrita- 
tion of  the  stomach  from  its  own  excessive  secretion, 
and  from  the  stagnation  of  stomach-contents  following 
the  pyloric  spasm  which  this  secretion  produced.  It 
seemed  clear,  then,  that  the  disturbance  in  this  case 
had  been  at  first  purely  functional  and  not  inflam- 
matory, but  that  ultimately  the  prolonged  irritation 
had  in  an  indirect  manner  produced  an  actual  gas- 
tritis. The  case  is  reported  chiefly  in  its  relation  to 
the  interesting  question  whether  a  gastrosuccorrhea 
ever  occurs  without  a  gastritis  or  a  pyloric  stenosis. 
Most  writers  consider  now  that  there  is  always  one  of 
these  anatomical  changes  present.  This  report  seems 
to  show  that  this  is  not  necessary,  for,  as  stated,  the 
gastritis  seemed  to  have  been  a  late  occurrence  in  the 
case,  and  there  was  even  at  the  time  of  death  no  sten- 
osis of  the  pylorus,  so  that  a  Reichmann's  disease  of 
purely  nervous  origin  seems  to  be  wholly  possible  and 
even  probable.  Another  fact  of  great  interest  in  the 
case  is  that  severe  lesions  were  found  in  the  nerve  cells 
of  the  medulla  and  cervical  cord,  the  lesions  having 
the  characteristics  of  those  found  in  severe  toxic  condi- 
tions. These  changes  Ferrannini  considers  to  be  im- 
portant testimony  in  favor  of  the  view  that  tetany  is  a 
toxic  condition  and  not  that  the  symptoms  are  purely 
reflex.  This  view  has  already  received  the  sanction 
of  the  majority  of  those  interested  in  the  question. 


260 


ToK  Philadelphia"! 
Medical  Journal  j 


EDITORIAL  COMMENT 


[Febbdast  9,  isn 


A  Crusade  Against  Illegal  Practitioners. — It  is 

the  purpose  of  the  Medical  Society  of  the  County  of 
New  York  to  begin  an  active  crusade  against  the  un- 
licensed and  therefore  illegal  and  unscrupulous  practi- 
tioners of  that  city,  and  the  society  asks  the  cooperation 
of  the  profession  and  the  public  generally.  From  a 
circular  issued  by  the  committee,  of  which  Dr.  Frank 
VanFleet  is  chairman,  and  Dr.  John  VanDoran  Young 
is  secretary,  we  learn  that  the  medical  laws  of  New 
York  provide  that  before  one  can  practise  medicine  in 
that  State  a  certificate  of  proficiency  shall  be  obtained 
fi-om  the  regents  of  the  university  of  the  State,  which 
is  given  only  after  a  satisfactory  examination.  The 
purpose  of  this  movement  is  to  protect  the  people  from 
incompetent  practitioners  of  medicine.  There  are  many 
irregular  practitioners  in  New  York  City  who  practise 
in  open  defiance  of  law  apparently  without  molestation. 
It  is  needless  to  say  that  we  are  in  complete  sym- 
pathy with  the  object  of  the  society  in  this  matter. 
Philadelphia  has  her  own  troubles  of  a  like  nature  to 
contend  with,  and  we  trust  that  the  action  of  the  Medi- 
cal Society  of  the  County  of  New  York  will  not  only 
be  successful  but  will  be  an  example  for  the  medical 
authorities  of  all  our  large  cities  to  imitate.  Practi- 
tioners of  medicine  are  properly  protected  by  the  law, 
not  however  for  their  exclusive  benefit,  but  first  and 
above  all  for  the  benefit  of  the  public.  The  public 
itself  will  not,  or  does  not,  always  recognize  this  fact, 
and  it  can  only  be  properly  kept  advised  of  it  by  the 
action  of  physicians  themselves  who  must  of  necessity 
constitute  themselves  guardians  of  the  law.  We  shall 
look  with  interest  for  the  results  of  this  crusade. 

Racial  Predisposition  to  Pulmonary  Tubercu- 
losis.— In  illustration  of  the  racial  susceptibility  to 
pulmonary  tuberculosis,  it  may  be  pointed  out  that  from 
1884  to  1890  it  is  estimated  that  among  every  100,000 
of  the  population  there  occurred  annually  in  New 
York  238.48  deaths  from  pulmonary  tuberculosis  in 
white  natives,  483.83  in  white  foreigners,  and  774.21  in 
colored  persons.  Jews,  on  the  contrary,  appear  remark- 
ably exempt  from  the  disease,  36.57  deaths  being  due 
to  pulmonary  tuberculosis  in  every  thousand  deaths 
among  them  in  the  United  States  in  1880,  as  compared 
with  108.79  for  the  general  population. 

According  to  a  communication  in  a  recent  number  of 
the  Reme  (fHygiene  et  de  Police  Sanilaire,  by  Tostivint 
and  Remlinger,  only  34  of  the  entire  number  of  "2,744 
deaths  among  the  Jews  of  Tunis  in  the  five  years  from 
1895  to  1899  were  due  to  tuberculosis — 1.24  per  cent. 
It  is  further  estimated  that  the  average  annual  mortal- 
ity from  tuberculosis  among  the  Mussulman  Arabs 
between  the  years  1894  and  1900  was  11.30  per  1000, 
among  Europeans  5.13  per  1000,  and  among  Jews  0.75 
per  1000.  The  lower  mortality  from  tuberculosis 
among  the  Jews  is  not  attributed  to  ethnic  diS"erences, 
nor  to  peculiarities  in  food,  dress,  and  the  like,  but 


rather  to  their  abhorrence  of  the  dusting  brush,  damp 
cloths  being  preferred  for  wiping  soiled  surfaces,  and  to 
their  frugality  in  the  use  of  furniture. 

Why  there  is  No  Malaria  in  Buffalo. — The  city  of 
Buffalo  is  apparently  to  be  congratulated  on  its  free- 
dom from  malaria,  and  this  freedom,  as  would  natur- 
ally be  supposed,  is  entirely  due  to  the  fact  that  there 
are  few  anopheles  mosquitoes  in  that  city  or  its  environs. 
Dr.  Irving  P.  Lyon,  assisted  by  Mr.  Albert  B.  Wright, 
has  been  making  a  systematic  study  of  the  subject, 
and  has  just  published  a  preliminary  statement  in  the 
Report  of  the  Laboratory  of  Pathology  of  the  University 
of  Bufi'alo.  The  mosquitoes  gathered  for  this  study 
were  found  in  and  around  the  city,  and  the  fact  that 
only  374  of  these  insects  were  caught  in  six  months  is 
in  itself  an  evidence  of  the  salubriousness  of  Buffalo  as 
a  place  of  residence.  Of  this  number  aU  were  of  the 
genus  culex;  in  other  words,  not  one  of  the  pathogenic 
or  malaria-bearing  anopheles  was  found.  Moreover,  all 
but  17  of  the  specimens  were  females ;  and  as  the  fe- 
males are  reputed  to  be  the  real  blood-suckers,  the 
observations  were  not  lacking  in  appropriate  material. 
The  city  of  Buffalo,  it  is  pointed  out,  is  situated  on  the 
shore  of  Lake  Erie,  573  feet  above  the  sea  level,  in  a 
country  that  is  sparseW  wooded  and  the  seat  of  few 
swamps,  marshes,  and  low-lying  places.  Hence,  tins 
region  is  not  what  would  generally  be  called  a  malari- 
ous country.  And,  in  fact,  according  to  the  observa- 
tions of  Dr.  Lyon  and  Mr.  Wright,  the  city  is  re- 
markably exempt  from  malaria.  Offers  were  made  to 
examine  without  expense  the  blood  of  all  persons  in 
public  or  private  practice  who  were  suspected  of  hav- 
ing malaria,  and  in  not  one  instance  was  the  Plasmo- 
dium found.  The  authors,  therefore,  conclude  quite 
legitimately  that  autochthonous  malaria  does  not  exist 
in  and  around  Buffalo.  What  cases  have  been  ob- 
served there  in  the  past  have  apparently  been  im- 
ported from  other  places.  This  comfortable  assurance, 
however,  is  somewhat  rudeh'  shaken  by  a  postscript  in 
which  Dr.  Lyon  and  Mr.  Wright  acknowledge  that  since 
their  own  search,  Mr.  Adams,  a  local  entomologist,  had 
discovered  a  few  anopheles  in  Buffalo. 

This  investigation  by  Lj-on  and  Wright  is  interesting 
not  only  in  itself,  but  also  as  an  evidence  of  the  wide- 
spread concern  now  being  felt  for  the  whereabouts  of 
the  anopheles  mosquitoes  and  of  the  thoroughly  scien- 
tific way  in  which  the  problems  of  malaria  are  being 
worked  out. 

The  Venereal  Diseases  of  the  Lower  Animals. — 

The  advance  of  science  has  gradually  shorn  man  of  his 
preeminence  to  the  other  animals.  Waldeyer  has  shown 
that  his  spinal  cord  is  not  so  greatly  different  from  that 
of  the  gorilla ;  Romaner,  that  his  mental  processes  repre- 
sent merely  a  higher  development  of  qualities  that  exist 
among  the   vertebrates.     \\'hether  the  higher  insects 


Fkbruaey  9,  1901] 


REVIEWS 


PThe  Philadelphia 
L  Medical  Journal 


261 


possess  a  ditferent  psychology  we  do  not  as  yet  know. 
But  for  one  thing  man  has  always  been  supposed  to  be 
distinct.  No  lower  animal  has  ever  been  inoculated  suc- 
cessfully with  syphilis,  and,  in  the  venereal  diseases  at 
least,  we  supposed  that  we  stood  alone.  It  is  true  that 
many  experimental  physiologists  have  observed,  not 
infrequently,  a  drop  of  pus  exuding  from  the  urethra  of 
the  common  cur  that  was  the  victim  of  their  experi- 
ment, and  we  know  that  the  toxin  of  the  gonococcus 
will  kill  mice,  if  bouillon  cultures  are  injected  into  the 
peritoneal  cavity  of  the  animals,  but  the  one  is  not  cer- 
tainly known  to  be  a  contagious  malady,  and  the  other 
is  merely  a  manifestation  of  the  toxic  property  common 
to  many  bacteria. 

It  was  not  so  long  ago,  however,  that  in  an  excellent 
study,  published  in  the  Journal  of  Pathology,  Smith  and 
Washburn  nescribed  a  form  of  infectious  granuloma 
that  ocmrr-d  among  dogs,  attacked  the  sexual  organs 
as  a  ruii-,  was  contagious  by  inoculation,  and  usually 
transmitted  from  one  individual  to  another  during 
coitus ;  and  they  further  expressed  the  opinion  that 
similar  diseases  had  already  been  observed  and  de- 
scribed, although  incorrectly  interpreted,  by  Duplay 
and  Cazin,  Wehr  and  Geissler,  and,  we  might  add,  by 
Moreau  and  Human,  although  the  careful  histological 
studies  made  in  these  instances  point  strongly  to 
tumor  formation. 

More  recently,  Marek  (Neurologisches  Centralblatt,  De- 
cember 15,  1900)  has  described  a  disease  of  horses, 
which,  unless  he  was  so  prejudiced  as  to  be  incapable 
of  accurate  observation,  bears  so  many  ear-marks  of 
syphilis,  that  it  must  belong  to  the  same  category  of 
ailments.  The  first  manifestations  are  upon  the  exter- 
nal genitalia,  and  consist  of  small  nodules  or  erosions 
upon  the  mucous  membrane,  appearing  from  a  few 
days  to  several  weeks  after  sexual  intercourse,  Next 
there  is  a  papular  eruption  upon  the  skin,  and,  finally, 
a  peripheral  degenerative  neuritis,  which  ultimately 
causes  the  animal's  death.  The  most  important  feature 
of  the  whole  matter,  and  one  that  Marek  appears  to 
have  overlooked,  is  the  possibility  of  making  more 
thorough  studies  of  this  condition,  with  a  view  to  the 
discovery  of  the  cause,  than  can  be  undertaken  with 
reference  to  syphilis  in  human  beings,  and  it  is 
scarcely  necessary  to  point  out  that  such  a  discovery 
might — we  had  almost  said  would — be  of  incalculable 
benefit  to  simple  humanity  or  its  inheritors. 


Intussasception  Caused  by  a  Melanotic  Sarcoma 
of  the  Small  Intestine. — Saiole  {Zeitschri/t  filr  Ueilkunde, 
Bd.  xxi,  Heft  9)  reports  a  case  of  a  woman  in  whom  a 
melanotic  sarcoma  of  the  small  intestine  almost  occluded 
the  whole  lumen  of  the  afiFected  portioa  of  the  gut.  There 
was  a  history  that  a  melanotic  sarcoma,  the  size  of  a  fetal 
head,  had  been  removed  from  the  arm  a  short  time  previous. 
No  intestinal  symptoms  have  appeared,  one  year  after  the 
operation,     [m.r.d.] 


^cr>icu?5. 


Physical  Diagnosis  in  Obstetrics.  A  Guide  in  Ante- 
partum, Partum,  and  Postpartum  Examina- 
tions. By  Edward  A.  Ayers,  M.D.,  Professor  of 
Obstetrics  in  the  New  York  Polyclinic;  Attending 
Physician  to  the  Mothers'  and  Babies'  Hospital.  Pp. 
283.    New  York  :  E.  B.  Treat  <fe  Co.,  1901. 

The  foundation  or  underlying  motive  of  this  book  is  the 
brief  systematic  discussion  of  every  point  of  physical  diag- 
nosis bearing  upon  the  parturient  condition.  It  has  devel- 
oped from  the  writi  r's  teaching  e.xperience.  He  argues 
that  the  self-training  of  the  physician  demands  the  same 
explicit  and  systematic  method  as  the  teaching  of  the 
student.  An  elaborate  examination  or  history  chart  is  pre- 
sented which  carries  out  this  idea  by  suggesting  in  print  the 
minute  details  of  possible  co;  ditinns,  thus:  Edema  in  right, 
left,  foreleg,  thign,  vulva.  Fetal  heart  heard,  right,  left, 
above,  below,  umbilicus.  In  using  the  chart  all  items  not 
observed  are  to  be  crossed  out.  I  his  makes  each  examina- 
tion a  factor  in  observation- training,  tliough  the  resulting 
page  is  not  neat  and  the  facts  are  not  easy  to  group. 

With  this  chart  for  a  skeleton  analysis  the  book  is  con- 
structed by  briefly'  discussing  each  minute  point  in  tum^ 
Extended  by  adding  the  child's  history  and  the  maternal 
postpartum  history,  the  result  is  a  succinct  discussion  of 
physical  diagnosis  in  the  entire  obstetrical  field,  viewed 
from  a  simple  practical  standpoint,  which  avoids  as  far 
as  possible  disputed  ground.  An  indis^:  ensable  index  is 
supplied.  [w.A.N.D.] 

Modern  Medicine.  By  Julius  L.  Salinger,  M.D.,  and 
Frederick:  J.  Kalteyer,  M.D.  Philadelphia  and  Lon- 
don :  W.  B.  Saunders  &  Co.    Price  in  cloth,  $4.00,  net. 

The  task  confronting  the  authors  of  this  book  was  an 
heroic  one — that  of  furnishing  within  the  compass  of  some 
800  pages  a  comprehensive  treatise  upon  modern  medicine. 
That  their  efforts  have  resulted  in  producing  a  work  within 
these  limits  which  takes  its  place  with  the  greater  textbooks 
and  not  with  compends  or  manuals  is  a  sufficient  guarantee 
of  the  mastery  of  facts  and  the  industry  of  the  authors.  The 
material  has  been  drawn  from  all  available  sources,  especially 
from  authoritative  woks  in  French,  German,  and  English. 
The  consulting  of  this  broad  bibliography  has  resulted  in  a 
very  acceptable  presentation  of  facts,  without  the  teaching 
of  any  particular  clinician  having  been  followed  ^lavishly. 

There  is  a  great  deal  to  commend  in  the  work  and  but 
little  which  arouses  a  spirit  of  criticism.  We  might  have 
wished  to  find  "  typhoid  intoxication  "  mentioned  and  some 
of  the  facts  of  etiology  marshalled  less  baldly — a  fault  unsur- 
mountable  when  space  is  at  a  premium.  The  first  172  pages 
have  been  devoted  to  a  concise  comprehensive  treatise  upon 
symptomatology,  semiology,  physical  diagnosis,  clinical  bac- 
teriology, and  laboratory  method^.  The  idea  of  grouping 
together  these  divisions  seems  to  us  a  good  one.  Much 
subsequent  repetition  is  avoided  in  discussing  the  separate 
diseases. 

In  the  article  upm  appendicitis  the  writers  have  coined 
the  term  "  evolutionary  tendency "  in  contradistinction  to 
"  hereditary  tendency,"  the  latter  showing  itself  from  gener- 
ation to  generation,  the  "  evolutionary  tendency  "  only  upon 
change  of  environment.  The  use  of  opium  in  the  treatment 
of  peritonitis  has  been  expressed  clearly  and  briefly  :  "  Opium 
given  in  liberal  amounts  is  of  great  value  in  the  treatment  of 
peritonitis.  Early  in  the  disease,  when  the  diagnosis  is  still 
in  doubt,  as  peritonitis  is  often  due  tn  causes  which  necessi- 
tate surgical  intervention,  it  is  sometimes  advisable  to  with- 
hold the  opium  for  a  short  time,  as  it  will  mask  the  symp- 
toms; but  if  the  diagnosis  has  been  made,  or  if  the  diagnosis 
seems  impossible,  it  is  necessary  to  administer  opium  freely." 

Treatment  throughout  hius  been  outlined  admirably.  There 
is  a  commendable  conservatism  and  an  avoidance  of  per- 
nicious polypharmacy.  The  chapters  upon  malaria  and  the 
blood  are  in  every  way  satisfactury,  and  the  accompanying 
plates  are  unusually  accurate. 

The  idea  of  drawing  the  blood-corpuscles  to  a  scale  and 


262 


The   PHILADELPHIi") 

Medical  Jocksai.  J 


REVIEWS 


[FCBBClBY  9,  1901 


showing  them  stained  by  two  methods  should  prove  of  value 
to  the  student  In  the  effect  at  conciseness  no  cases  have 
been  introduced  or  controversial  points  considered.  The 
tables  of  differential  diagnosis  are  well  arranged.  Last,  ►  ut 
not  least,  the  clinical  medicine  of  the  book  is  extremelj-  well 
presented  The  approved  methods  and  the  minutiae  will 
surely  make  the  work  appeal  to  the  student,  who  here  finds 
■within  the  Compaq  of  the  single  volume  a  work  upon  the 
practice  of  medicine  and  clinical  medicine  as  well,    [t  l  c  ] 

The  Use  of  the  Rontgen-ray  by  the  Medical  De- 
partmeut  of  the  Uuited  States  Army  io  the 
War  with  Spaiu,  1898.  Prepared  under  the  direc- 
tion of  Surgeon-General  G.  M.  Stersbebg  by  W.  C. 
BoRDES,  Captain  and  Assistant^Surgeon,  U.  S.  Army. 
Washington  ;    Government  Printing  Office,  1900. 

This  work,  the  most  thorough  and  comprehensive  that  has 
yet  appeared  on  the  application  of  the  Rontgen-ray  appa- 
ratus to  the  diagnosis  and  treatment  of  gunshot  injuries,  is 
based  upon  Borden's  personal  experience  with  the  wounded 
American  soldiers  of  the  Spanish-  American  War. 

He  believes  that  the  place  for  the  Rontgen  ray  apparatus 
is  at  general  hospitals,  permanent  hospitals  on  the  line  of 
communication,  and  on  hospital  ships;  that  for  equipping 
base,  and  general  hospitals  for  war  service,  coil  apparatus 
connected  to  primary  batteries  should  be  supplied ;  that  in 
permanently  established  hospitals  where  there  is  no  dynamo 
current  available,  the  static  machine  will  probably  give  best 
satisfaction  ;  while,  in  permanent-base  hospitals  or  in  hos- 
pital shipi  supplied  by  direct  currents  of  110-120  volts,  the 
break-wheel  apparatus  will  give  the  highest  efficiency. 

Attention  is  called  to  the  fact  in  the  American  Civil  War, 
where  a  much  larger  caliber  rifle  was  used,  and  asepsis  and 
antisepsis  were  unknown,  the  mortality  was  nearly  double 
that  of  the  Spanish-American  War.  Indeed,  it  is  noteworthy 
that  there  is  a  smaller  mortality  as  compared  with  the  num- 
ber of  the  wounded  in  our  lat«  war  than  is  t-o  be  found  in 
the  records  of  any  war  since  the  middle  of  the  last  century. 
The  nearest  approach  to  the  admirable  showing  made  by 
our  military  surgeons  is  afforded  by  a  study  of  the  Japanese 
records  of  the  China-Japan  War. 

In  considering  the  regional  distribution  and  mortality  of 
gunshot  wounds  in  cases  which  came  under  treatment  in  the 
American  Civil  War  and  the  Spanish-American  War,  it  is  to 
be  noted  that  the  mort<ility  percentage  of  head-wounds,  face- 
-wounds,  and  abdominal  wounds  is  about  the  same.  Wounds 
of  the  neck  and  spine  were  attended  by  a  greater  mortality 
in  our  recent  war  than  is  shown  by  the  records  of  the  Civil 
War.  Chest  wounds  show  for  the  Spanish-.-imerican  War 
less  than  half  the  mortality  of  the  Civil  War.  Wounds  of 
the  extremities  show  less  than  one- fourteenth  of  the  mortality 
recorded  in  the  Civil  War.  The  number  of  deaths  in  the 
Spanish  War  from  wounds  of  the  extremities  is  surprisingly 
small,  being  but  10  in  901 ;  of  these  10  cases,  3  died  very 
shortly  after  receiving  their  injuries,  probably  from  hemor- 
rhage. In  the  Civil  War  about  7  %  of  those  wounded  in  the 
«xtremities  were  subject  to  amputation  or  excision,  with  an 
operative  mortality  of  21.6%.  In  the  Spanish-American 
War,  but  3.2%  of"  those  wounded  were  subject  to  major 
operation,  and  IS  7  %  of  these  cases  perished.  Under  con- 
servative treatment  the  mortality  was  9.1*  in  the  Cinl 
War;  in  the  Spanish- American  \Var,  4%.  The  high  mor- 
tality of  the  operative  cases  in  the  Spanish- American  War 
is  to  be  attributed  to  the  fact  that  only  extremely  serious 
<Mises  were  operated  on. 

In  the  chapter  on  lodged  missiles,  Borden  points  out  that 
the  jacketed  ballet  when  undeformed  almost  invariably 
travels  in  a  right  line  after  entering  the  body.  The  large 
number  of  lodged  missiles  seen  in  the  Santiago  campaign 
was  particularly  commented  upon  by  the  surgeons.  In  198 
Mauser  bullet-wounds  seen  by  Borden,  there  were  21  lodged 
bullets.  It  was  quite  possible  that  in  some  cases  the  velocity 
of  the  bullets  had  been  reduced  by  passage  through  the 
branches  of  trees  or  by  glancing.  The  fact  that  the  Rontgen- 
ray  apparatus  often  showed  the  bullet  to  be  deformed  is  con- 
sidered as  fairly  conclusive  of  the  fact  that  the  bullet  had 
previously  struck  some  solid  substance  and  had  glanced 
therefrom.    A  number  of  instructive  and  interesting  cases 


are  reported  in  detail  with  very  admirable  reproductions  of 
the  original  x-ray  pictures.  One  particularly  etriking  plate  is 
that  of  a  private,  still  living,  showing  a  Mauser  bullet  lodg«i 
in  the  brain.  Practical  experience  has  shown  that  ricochet, 
passage  through  bodies  or  low  red  velocity,  does  not  mark- 
edly increase  the  proneness  of  the  jacketed  missile  to  pro- 
duce infection,  and  hence  the  lodgment  of  a  bullet  does  not 
necessitate  the  treatment  that  would  be  given  an  infected 
wound.  They  are  best  treated  by  occlusive  dressings  and 
noninterference  unless  manifestly  infected  or  unless  some 
special  condition  calls  for  operation.  It  also  appears  that 
large  lead  bullets  of  low  velocity  are  not  as  apt  to  make  in- 
fected wounds  as  was  supposed. 

The  third  f  hapter  of  this  book  is  devoted  to  the  localiza- 
tion of  loaded  missiles.  The  method  of  localizing  by  direct 
observation,  by  multiple  observation,  and  by  photographic 
apparatus,  are  taken  up  in  detail. 

The  fourth  chapter  is  devoted  to  gunshot  wounds  of  the 
diaphyses  of  long  bones  Some  striking  instances  are  given 
of  the  explosive  effect  of  the  modern  bullet  at  short  range. 
These  are  fully  illustrated  by  the  plates.  The  treatment  of 
these  wounds  should  be  influenced  by  the  presence  or  ab- 
sence of  infection  rather  than  by  the  extent  of  bone  com- 
minution. Extensive  bone  comminution  is  not  as  a  rule  an 
indication  for  operative  interference  of  any  kind.  Occlusive 
dressings  and  immobilization  give  ass  irance  of  the  best  pos- 
sible results.  Even  though  shortening  of  the  limb  should 
occur,  an  excellent  usefiilness  may  be  expected.  Where 
infection  necessitates  this,  the  wound  must  be  thoroughly 
cleansed  and  all  loose  bone  fragments  must  be  removed ; 
this  treatment  should  be  followed  by  antiseptic  dressings  and 
irrigation.  It  is  noteworthy  that  the  amount  of  bone  com- 
minution is  much  less  and  the  size  of  the  fragments  much 
smaller  in  gunshot  fracture*  of  the  extremities  of  1  mg  bones 
than  in  gunshot  fractures  of  the  shaft  The  involvement  of 
the  joints  does  not  necessitate  a  divergence  from  the  rule  of 
expectant  treatment. 

The  final  chapter  of  this  book  is  devoted  to  radiographic 
technic.  There  is  an  interesting  contribution  in  this  relation 
up  m  the  subject  of  RSntgen-ra.-  burns.  The  factors  which 
influence  the  production  of  these  bums  are  the  length  of 
exposure,  the  nearness  of  the  tub'e  to  the  surface  of  the  body, 
the  physical  condition  of  the  patient,  and  individual  idio- 
syncrasy The  exposure  should  not  exceed  30  minutes  and 
10  inches  should  be  taken  as  the  minimum  distance  of  the 
tube  from  the  body.  Exposures  frequently  repeated  with 
but  sm.'tll  intervals  between  them  will  act  in  the  same  way 
as  a  single  long  exposure. 

This  work  is  a  valuable  addition  to  radiographic  bibliog- 
raphy, and  well  worth  a  place  among  the  public  ition*  of  the 
medical  department  of  the  United  States  Army.  The  last 
statement  is  giving  it  high  praise.  It  is  also  of  distinct  value 
to  the  hospital  surgeon.  The  conclusions  of  Borden,  which 
appear  to  be  based  on  careful,  conscientious,  and  dispassion 
ate  study,  are  likely  to  be  accepted  without  dispute,    [e.m.] 


Perforatioo  of  the  Intestine  in  Typhoid  Fever: 
Its  Surgical  Treatment,  —  X.  Manger  (Thlie  de  Paris, 
G.  Steinheil,  1900,  12S  S.)  emphaaizes  the  following  points  of 
surgical  interest :  Perforation  of  a  typhoid  ulcer  may  lake 
place  in  every  stage  of  the  disease,  also  during  relapses,  but 
generally  occurs  from  the  second  to  the  fourth  week.  It 
occurs  in  ambulatory  cases  as  well  as  in  grave  ones,  and  in 
children  as  well  as  adults.  Almost  always  there  is  one  per- 
foration, rarely  two  are  present.  The  perforation  is  situated 
in  most  cases  within  the  last  60  cm.  of  tlie  small  intestine,  in 
exceptional  cases,  also  in  the  other  portions  of  the  gut  from 
duodenum  to  the  rectum,  and,  not  so  very  rarely,  alio  in  the 
appendix ;  it  has  been  observed  in  Meckel's  diverticulum. 
The  diagnosis  is  not  always  easy,  because  in  grave  cases  the 
symptoms  of  typhoid  fever  may  mask  the  perforation.  The 
most  important  symptoms  are  sudden  pain,  acceleration  of 
the  pulse,  collapse,  and  later  on  manifestations  of  peritonitis ; 
the  temperature  generally  falls,  although  it  may  rise  or 
remain  stationary.  When  symptoms  of  intestinal  pjrforation 
suddenly  arise  in  an  apparently  healthy  individual,  latent 
typhoid  is  always  to  be  suspected.  Tne  author  believes  th&t 
the  treatment  should  only  be  a  surgi.'al  one.  0;  107  cases 
operated  upon,  he  reports  25  recoveries.    [m.r.d  ] 


FXBBCABT  9,   1901] 


CORRESPONDENCE 


CThe  Philadklphia 
Medical  Jodenal 


263 


(lorrcsponbcncc. 


THE  PERCENTAGE  OF  SILVER  IN  SILVER  NITRATE. 
By  WILLIAM  J.  ROBIXSON,  Ph.G.,  M.D., 

of  New  York. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

In  the  paper  entitled,  "  Method  for  Rapid  Elimination  of 
the  Gonococcus,"  by  Dr.  Pollen  Cabot,  Jr.,  there  appears  an 
erroneous  statement  which  should  not,  it  seems  to  me,  go 
uncorrected.  The  author  states  that  silver  nitrate  contains 
•6.35^  of  silver.  The  actual  percentage  is  63.5%.  We  could 
excuse  the  author  on  the  score  of  a  typographical  error,  but 
the  context  of  the  sentence  does  not  permit  us  to  do  so. 
The  author  states  distinctly  that  protargol  contains  8  2%  of 
silver,  argonin  4.2%,  and  silver  nitrate,  containing  6.35%, 
occupies  a  middle  position  between  the  two  first  named 
preparations  in  its  proportion  of  the  basic  salt."  As  a 
matter  of  fact  it  contains  about  8  times  as  much  silver  as 
protargol  and  about  15  times  as  much  as  argonin. 


THE  PERCENTAGE  OF  SILVER  IN  SILVER  NITRATE. 

By  FOLLEX  CABOT,  Jr.,  M.D., 
of  New  York. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

In  answer  to  Dr.  Robinson's  criticism  of  a  statement  in  the 
article  by  me  entitled,  "  Method  for  the  Rapid  Elimination  of 
the  Gonococcus,"  I  will  say  that  the  doctor  is  right  in  his 
correction. 

It  was  a  careless  error  on  my  part.  In  looking  over  some 
literature  on  the  subject,  I  read  a  paper  by  Dr.  Edward  S. 
Peck,  of  New  York,  entitled,  "  Protargol  and  Argonin  in  the 
Treatment  of  Purulent  Ophthalmia  of  Infants,"  published 
in  the  Medical  News,  January  21,  1899.  In  discussing  the 
subject  and  giving  the  amount  of  silver  in  argonin  as  4.2% 
and  protargol  8.3%,  Dr.  Peck  continued  as  follows  :  "  In  this 
connection  it  should  be  noted  that  silver  nitrate  contains 
6.36%  of  silver,  occupying  between  protargol  and  argonin  a 
middle  position  as  to  the  basic  salt." 

I  am  surprised  that  the  error  was  not  noticed  when  I  read 
the  paper. 


INTRACRANIAL  HEMORRHAGE  IN  THE   NEWBORN. 

Bv  W.  W.  KEEN,  M.D., 
of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Journal: — 

I  WAS  very  much  interested  in  reading  the  paper  by  Dr. 
W.  Reynolds  Wilson,  on  "  Intracranial  Hemorrhage  in  the 
Newborn,"  in  your  issue  of  February  2.  I  wish  to  call 
attention  especially  to  the  paragraph  on  treatment,  for  the 
reason  that  Dr.  Wilson  has  omitted,  what  seems  to  me  to  be 
the  most  important  treatment  of  all,  namely,  the  surgical. 
In  the  preceding  paragraph  on  the  "  prognosis,"  Dr.  Wilson 
has  very  properly  called  attention  to  the  widespread  and 
varied  ill  results  that  may  follow  snch  intracranial  hemor- 
rhage, and  has  properly  indicated  the  fact  that  "  extensive 
meningeal  hemorrhage  is  not  likely  to  be  absorbed."  In 
view,  therefore,  of  the  dangers  that  he  points  out,  and  the 
improbability  of  absorption,  it  seems  to  me  clear  that  at  the 
very  earliest  moment  that  it  is  safe  to  do  so,  such  a  patient 
should  be  trephined  and  the  clot  removed. 


I  cannot  but  think  that  obstetricians  have  overlooked  the 
good  that  may  result  from  such  surgical  interference. 

At  my  clinic  at  the  Orthopedic  Hospital,  I  saw  not  uncom- 
monly the  sad  ravages  caused  by  such  an  intracranial  clot, 
and  in  the  other  surgical  clinics,  and  especially  the  neuro- 
logical clinics  of  the  same  hospital,  they  were,  I  believe 
much  more  frequent.  I  do  not  recall  any  case  which  has 
been  operated  on. 

A  considerable  time  ago  Dr.  Weir  Mitchell  called  my 
attention  to  this  condition,  and  we  decided  that  in  any  suit- 
able case,  especially  if  we  could  get  hold  of  it  at  an  early 
date,  such  an  operation  was  not  onlyjjustifiable,  but 
demanded. 

I  have  no  doubt  that  it  is  omitted  from  Dr.  Wilson's 
treatment  for  the  reason  that  up  to  this  time,  I  believe,  it 
has  not  been  done.  That  it  ought  to  be  done,  personally,  I 
have  not  the  slightest  doubt. 


A  CASE  OF  AORTIC  ANEURYSM. 

By  F.  W.  LAKRABEE,  M.D., 

of  Searsport,  He. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

X,  sea  captain,  age  38;  family  history,  good;  previous 
history,  malaria  12  years  ago;  gastric  and  intestinal  dis- 
turbances for  2  years.  One  year  ago  on  return  trip  from 
Hongkong  patient  had  an  internal  abscess  of  some  sort  with 
spontaneous  rupture  into  the  bowel.  Recovery  good ;  had 
since  been  treated  for  rheumatism  and  atrophic  liver. 

First  seen  November  27,  1900.  Symptoms :  Pain  in  the 
left  hypochondriac  region ;  also  in  the  back  to  left  of  the 
spinal  column  from  the  angle  of  the  eighth  rib  to  the  sacrum ; 
a  swelling  over  the  angle  of  the  tenth  rib  on  left  side,  about 
2  inches  in  diameter;  soft,  pulsating,  and  expansile;  pain 
on  pressure  along  tenth  rib ;  liver  displaced  downward  and 
to  right;  the  stomach,  downward  and  to  left;  spleen,  down- 
ward ;  dulness  over  lower  lobe  of  left  lung  posteriorly ;  slight 
bruit  over  the  swelling ;  pulsation  synchronous  with  heart- 
beat; expansion  with  each  pulsation;  pulse,  80;  fair  volume 
aid  quality;  temperature,  normal ;  loss  of  weight,  moderate. 
Aseptic  aspiration  of  a  little  fluid  from  the  tumor  showed 
thick  dark  blood,  which  under  microscope  showed  blood- 
cells  and  fibrin. 

Patient  advised  to  go  to  Massachusetts  General  Hospital, 
which  he  did.  Diagnosis  of  aortic  aneurysm  confirmed  and 
rest  treatment  advised. 

Patient  returned  home  December  12.  Tumor  found  en- 
larged to  4  inches  in  diameter  and  more  conical  in  shape; 
pulsation  more  marked;  bruit  less  distinct;  bowels,  consti- 
pated. Patient  suflered  great  pain  at  times  in  left  hypo- 
chondriac region  and  lefc  iliac,  partially  relieved  by  passage 
of  flatus  on  giving  an  enema.  Pain  seldom  felt  in  tumor. 
Patient  put  to  bed,  bowels  regulated  and  rest  secured  as 
much  as  possible  but  seldom  perfectly ;  relief  from  pain  only 
temporary. 

The  tumor  remained  about  the  same  until  January  2.  At 
that  time  patient  began  to  suS'er  pain  in  the  tumor  and  two 
days  later  the  tumor  was  found  enlarged  upward  and  down- 
waid  so  that  long  diameter  was  about  6  inches  and  short 
diameter  4  inches;  tumor  more  prominent.  Three  days 
later  tumor  was  found  nearly  round  and  about  6  inches  in 
diameter.  Intense  pain  in  left  hypochondriac  and  left  iliac 
regions.  Tumor  swelled  so  that  the  skin  was  very  tense  and 
glossy  and  edematous  in  places;  blebs  appeared  over  most 
prominent  part.  Symptoms  of  cardiac  dilation  supervened 
and  patient  died  from  exhaustion  January  19. 

Postmortem  examination  showed  large  aneurysm  of  ab- 
dominal aorta  arising  just  below  the  diaphragm.  Liver 
atrophic  and  displaced  downward  and  to  the  right;  stomach 
displaced  downward  and  to  the  left;  spleen  downward; 
diaphragm  and  left  lung  crowded  upward;  necrosis  of  parts 
of  ninth  and  tenth  ribs;  aneurysmal  sac  5  inches  in  di- 
ameter which  had  not  ruptured  before  death. 


264 


The  PhiladblphiaI 

Medical  Journal  J 


CORRESPONDENCE 


[FZBECABT  9,  1901 


A  CASE  OF  ANGINA  LUDOVICI. 

By  arch  D.  JONES,  M.D., 

of  Wichita,  Kas. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  :— 

Hating  read  the  report  of  Dr.  G.  G.  Eoss  on  Cases  of  An- 
gina Ludovici,  it  occurs  that  a  report  of  a  case  in  my  prac- 
tice may  be  of  interest.  Although  I  had  never  before  seen 
a  case,  nor  have  I  seen  one  since,  I  did  not  know  that  it  is 
such  a  rare  occurrence : 

Mrs.  W.,  aged  47,  had  been  having  an  ulcerated  lower  mo- 
lar treated.  The  first  disturbance  she  noticed  additional  to 
her  tooth  was  a  swelling  and  burning  sensation  under  her 
tongue  on  the  same  side  as  the  ulcerated  tooth.  She  rinsed 
her  mouth  with  a  preparation  given  her  by  her  dentist,  think- 
ing it  might  be  irritated  by  the  discharge  from  her  tooth ; 
but  that  did  not  suffice.  In  a  few  hours  the  inflammation 
had  spread  to  the  tissues  under  the  other  side  of  the  tongue. 
She  came  then  immediately  to  her  dentist,  who  sent  her  to 
me.  By  that  time,  on  opening  her  mouth  it  gave  the  appear- 
ance of  having  two  tongues,  the  sublingual  tissues  pushing 
out  and  up,  almost  protruding  between  the  teeth.  Her 
tongue  was  so  much  crowded  that  she  could  speak  with  dif- 
ficulty. She  complained  of  a  burning,  throbbing  sensation 
in  the  tissues  under  the  tongue.  I  found  her  temperature 
101.3°,  pulse  102.  I  sent  her  home  and  to  bed,  ordering  the 
ice-bag  applied,  and  the  painting  of  the  inflamed  parts  every 
hour  with  4%  cocain  solution.  I  went  promptly  to  confer 
with  her  dentist,  advising  immediate  removal  of  the  tooth 
and  thorough  irrigation  and  drainage  of  the  cavity.  The 
above  was  done,  but  still  the  inflammation  continued  to  ad- 
vance, the  pharyngeal  tissues  being  considerable  involved  by 
evening,  14  hours  after  the  first  indications  of  the  inflamma- 
tion. With  morning  the  dyspnea  was  considerable,  but  not 
alarming.  The  submaxillary  and  cervical  tissues  were  swol- 
len and  painful.  The  abscess  cavity  was  again  thoroughly 
cleansed,  although  there  was  very  little  accumulation. 

At  6  P.M.  the  condition  seemed  about  the  same.  The  in- 
flammation had  not  advanced,  the  dyspnea  was  about  the 
same.  On  the  morning  of  the  third  day  the  swelling  was 
markedly  diminished.  The  cavity  was  again  irrigated,  no 
discharge  being  noticeable.  The  improvement  from  this  on 
was  steady  and  rapid.  There  was  suppuration  in  the  in- 
flamed tissues.  She  called  at  my  office  on  the  sixteenth 
day  after  the  beginning  of  the  trouble  saying  she  was  per- 
fectly well. 

Whether  the  infection  was  due  to  the  abscess  cavity 
or  to  the  use  of  contaminated  instruments  in  treating 
the  diseased  tooth  I  cannot  say,  but  rather  incline  to  the 
theory  that  it  was  originated  by  the  abscess.  I  believe  by 
the  prompt  removal  of  the  tooth,  thorough  evacuation  of 
the  pus  and  irrigation  of  the  cavity  that  a  fatal  issue  was 
avoided. 

In  the  further  treatment  of  the  case  the  cocain  applications 
were  abandoned  after  6  or  8  hours,  but  the  ice-bag  was  con- 
tinued throughout  the  attack.  The  bowels  were  opened  by 
the  free  use  of  salines.  A  liquid  diet  was  necessarily  used 
and  alcoholic  stimulants  were  freely  administered. 


THERMOL  IN  THE  TREATMENT  OF  ENTERIC  FEVER. 

By  R.  D.  RUDOLF,  M.D., 

of  Toronto,  Canada. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  :— 
In  an  article  in  your  last  issue  Dr.   A.  B.  Shimer,    of 

Atlantic  City,  vaunts  the  value  of  the  synthetic  preparation 

called  thermol  in  the  treatment  of  typhoid  fever. 

I  have  never  used  the  drug,  and  for  aught  I  know  it  may 

be  as  good  or  even  a  better  remedy  in  this  disease  than  Dr. 

Shimer  would  have  us  believe.   But  where  I  would  take  issue 


with  him  is  in  the  fact  that  his  evidence  does  not  prove  hia 
case. 

In  the  first  place,  the  charts  which  he  pubUshed  to  show 
the  effect  of  the  drug  on  the  temperature  are  misleading  in 
that  the  temperature  is  only  recorded  once  in  each  day  and 
no  note  of  the  hour  is  made. 

A  chart  made  from  single  daily  records  of  the  temperature 
will  look  quite  different  from  one  in  which  the  morning  and 
evening  temperatures  are  taken.  The  latter  one  only  will 
show  the  "  typical  typhoid  temperature  "  which  Dr.  Shimer 
notes  is  absent  in  the  charts  given.  In  these  charts  the  trac- 
ing is  said  in  each  case  to  begin  in  the  first  day  of  the  dis- 
ease, but  evidently  this  is  not  the  case,  as  Dr.  Shimer  himself 
states  in  the  text  that  some  of  the  cases  had  been  ill  for 
ten  days  before  admission ;  in  Case  4  the  disease  had 
already  lasted  for  five  weeks.  The  fever  had  therefore  been 
running  in  every  case  given  for  many  days,  and  I  think  that 
any  hospital  could  produce  charts  of  cases  not  treated  by 
thermol  in  which  the  same  gradual  decline  of  fever  occurred. 
The  sudden  rise  occurring  on  the  9th  (really  the  19th)  day  of 
the  disease  in  Case  5  and  following  a  definite  error  in  diet  is 
in  my  experience  not  unusual,  and  the  "  prompt  purgation 
with  enemata  removed  this  complication  "  in  the  words  of 
Dr.  Shimer.  Hence  is  it  not  unfair  for  him  to  state  later  on 
that  "  the  specific  action  of  thermol  is  thus  proven  in  Cise  5, 
where  a  relapse  was  noted  or,  rather  where  an  elevation  of 
the  temperature  far  beyond  the  normal  temperature  of  that 
particular  case  was  caused  by  the  irritation  of  the  food,  ther- 
mol acted  specifically  in  reducing  the  temperature  "  ? 

Dr.  Shimer  sets  out  by  assuming  that  as  "  the  most  marked 
feature  of  typhoid  fever  is  the  fever  .  .  .  hence,  in  the 
treatment  of  a  disease,  the  fever  of  which  is  the  most  marked 
symptom,  especial  attention  should  be  given  to  the  cause. 
The  removal  of  the  cause  is  not  readily  realized, -and  there- 
fore the  selection  of  some  suitable  antipyretic  presents 
itself."  I  think  that  nowadays  few  physicians  will  agree 
with  him  that,  with  hydropathy  available,  typhoid  fever 
should  be  systematically  treated  by  any  antipyretic,  but 
even  fewer  will  follow  him  when  he  recommends  that  "  the 
mode  of  administration  should  be  .30  grams  at  intervals  of 
2,  3,  or  even  4  hours,  and  to  be  given  when  the  fever  begins 
to  rise,  and  to  be  continued  even  after  the  fever  hag  disap- 
peared in  smaller  doses  and  at  longer  intervals."  (The 
italics  are  mine.) 

So  far.  Dr.  Shimer  has  noted  no  depressing  efi"ect8  from 
thermol,  but  if  the  drug  is  entirely  free  from  such  it  must 
difler  from  every  antipyretic  which  has  so  far  been  introduced. 

It  is  with  a  sincere  appreciation  of  the  value  of  Dr. 
Shimer's  work,  and  only  in  order  that  we  may  not  be  unduly 
biassed  by  any  insufficiently  supported  conclusions  that  I 
thus  venture  to  take  up  the  pen  of  criticism. 


Ovarian  Carcinoma  in  an  Eleven- year- old  Girl. 

— K.  Waller  (Hygiea,  OcU)ber,  190ci)  rep  ris  a  case  of  CJirci- 
noma  of  the  ovary  occurring  in  a  girl  11  years  of  age.  The 
patient  had  had  a  brownish  discbarge  from  the  genitalia  for 
7  months.  For  2  months  there  had  been  a  progressive  en- 
larg'^^mfnt  of  the  abdomen  whose  circumference  at  the  time 
of  examination  was  78  cm.  at  the  umbilicus.  Su^picion  of 
pregnancy  seemed  justifiable,  as  by  vaginal  examination 
(two  fingers  could  be  easily  introduced  into  the  vagit  a)  * 
growth  was  felt  which  gave  the  sien  of  ballottemeDt,  and  in 
addition  the  breasts  contained  milk.  C'Oitus  w*e  admitted. 
But  as  the  uterus  was  of  normal  siz-  and  fitunted  posteriorly, 
the  diagnosis  of  carcinoma  of  the  ovary  was  made  ^  The 
existence  of  the  tumor  was  confirmed  by  operation.  Snbee- 
quent  condition  of  the  patient  was  good.    [m.b.d] 


Febbuary  9,  1901J 


AMERICAN  NEWS  AND  NOTES 


CThe  Phii.ai>ei,phu. 
Medical  Jodksai. 


265 


2lmcrican  Xlcws  anb  Holes. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

Dr.  Melville  D.  Hayes,  of  Philadelphia,  has  been 
appointed  assistant  surgeon  in  the  army,  and  has  left  for  the 
Philippines  to  take  up  his  duties. 

The  Samuel  D.  Gross  Prize  of  $1,000  will  be  awarded 
on  October  1, 1901,  no  essay  that  was  deemed  worthy  of  the 
prize  having  been  received  on  January  1,  1900. 

College  of  Physicians. — Abstract  of  the  monthly  re- 
port of  the  Honorary  Librarian,  Library  of  the  College  of 
Physicians  of  Philadelphia,  January,  1901.  Books,  pam- 
phlets, and  journals  received  :  General  Library,  464  volumes, 
1,871  pamphlets,  6,040  journals;  Lewis  Library,  29  volumes  ; 
S.  D.  Gross  Library,  5  volumes.  Accessions,  290  volumes. 
Duplicates,  208  volumes.  Donors,  General  Library,  63.  Tne 
library  received  by  the  will  of  the  late  Dr.  Alfred  Stills,  207 
volumes  of  medical  works  and  a  copy  of  Sir  Joshua  Rey- 
nolds' portrait  of  John  Hunter  by  Leslie. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 
February  2,  1901 : 

Totalmortality 552 

Cases.     Deaths. 

Inflammation  of  appendix  4,  brain  11,  bronchi 

13,  kidneys  28,  liver  2,  lungs  96,  peritoneum 

5,  pleura  3,  stomach  and  bowels  24,  bladder 

2,  heart  1,  larynx  1,  pericardium  1,  veins  1, 

spine  1 193 

Inanition  10,  marasmus  7,  debility  7 24 

Tuberculosis  of  lungs 64 

Apoplexy  16,  paralysis  7    .  23 

Heart —  diseases  of  36,  fatty  degeneration  of  4, 

neuralgia  4    ,    .       44 

Uremia  6,  diabetes  5,  Bright's  disease  11    .   .   .  22 

Carcinoma  of  breast  4,  face  1,  stomach  2, 
uterus  5,  jaw  1,  colon  1,  bladder  1,  lungs  1  .  16 

Convulsions ...  10 

Diphtheria 79  10 

Brain — softening  of  4,  congestion  of  1,  abscess 

of  1,  disease  of  1 7 

Typhoid  fever 47  9 

Old  age 19 

Burns  and  scalds 2 

Suicide 2 

Alcoholism 1 

Cyanosis 1 

Scarlet  fever 66  6 

Abscess  of  liver 1 

Influenza  19,  abscess  of  pelvis  1,  aneurysm  aor- 
ta 1,  asthma  4,  anemia  3,  abortion  1,  casu- 
alties 11,  congestion  of  the  lungs  3,  cirrhosis 
of  the  Uver  4,  cellulitis  1,  tuberculosis  of  the 
bowels  1,  membranous  croup  4,  diarrhea 
2,  disease  of  the  spine  1,  dropsy  of  the 
heart  1,  epilepsy  1,  erysipelas  2,  catarrhal 
fever  1,  malarial  fever  1,  puerperal  fever  1, 
hemorrhage  from  lungs  1,  hemorrhage  from 
uterus  1,  hernia  1,  jaundice  1,  locomotor 
ataxia  1,  lymphadenoma  1,  measles  1,  ob- 
struction of  the  bowels  3,  edema  of  lungs  2, 
poisoning,  carbolic  acid  1,  pyemia  1,  rheu- 
matism 1,  sclerosis,  arterial  3,  shock,  sur- 
gical 1,  septicemia  7,  sarcoma,  liver  1,  sar- 
coma, thigh  1,  suffocation  1,  tetanus  1,  tu- 
mor, abdominal  1,  ulceration  of  the  bowels 
1,  unknown  coroner  case  1,  whooping- 
cough  2 98 

Academy  of  Surgery, — At  the  stated  meeting  of  Feb- 
ruary 4,  Dr.  W.  L.  Rodman  read  a  paper  on  The  best  in- 
cision for  the  removal  of  carcinoma  of  the  breast. 

The  anatomy  of  the  lymphatics  of  the  breast  was  reviewed, 
this  showing  why  cancer  of  the  sternal  quadrants  is  more 
fatal.  The  location  of  the  growth  and  the  age  of  the  patient 
are  the  two  most  important  prognostic  elements.  The 
younger  the  patient  the  less  favorable  is  the  prognosis.  Of 
3  cases  under  30  years  of  age,  2  died  in  a  short  time  of  recur- 
rence and  the  other  bids  fair  to  do  the  same.  Dr.  Rodman 
has  a  pathologist  examine  doubtful  tumors  by  frozen  section, 
as  he  does  not  remove  the  whole  breast  if  the  tumor  be  benign. 
In  operating,  the  breast  is  detached  from  the  sternum  first, 
and  then  worked  toward  the  axilla.  The  area  of  skin  removed 
is  large,  as  it  is  believed  that  more  recurrences  are  due  to  the 
leaving  behind  of  infected  skin  than  to  any  other  one  cause. 


Both  pectoral  muscles  are  removed  only  in  tumors  of  the 
third  degree — those  which  are  adherent  and  immobile — but 
he  is  inclining  more  and  more  toward  their  removal  in  all 
cases,  aa  the  axillary  glands  can  be  reached  more  readily. 
The  best  incisions  used  for  the  operation  are  to  a  greater  or 
less  extent  imitations  of  Halsted's.  The  essential  features  of 
a  good  incision  are  :  1.  It  is  large  enough  to  include  all 
infected  skin.  2.  It  exposes  the  pectoral  muscles  from 
origin  to  insertion.  3.  It  uncovers  the  axillary  vessels  and 
nerves.  4.  It  does  not  interfere  with  the  future  use  of  the  arm. 
5.  No  skin  grafting  is  necessary.  6.  The  operation  can  be 
done  in  a  reasonable  length  of  time.  The  incision  used  by 
Warren  is  a  valuable  step  in  advance.  By  its  use  primary  union 
can  be  secured  after  the  removal  of  large  tumors  without  skin 
grafting.  Dr.  Rodman  has  used  it  in  3  cases  with  good 
results.  In  one  instance  he  modified  it  by  making  an  addi- 
tional curved  incision  above  and  toward  the  opposite  breast, 
the  case  being  one  of  recurrent  growth  and  a  large  amount 
of  tissue  necessarily  removed.  The  operation  takes  less  time 
than  by  the  Halsted  method,  an  important  point  especially 
in  elderly  people.  Patients  are  discharged  in  10  to  12  days 
after  the  operation.  In  discussing  the  paper  De.  W.  J. 
Hearn  stated  that  in  these  cases  he  made  a  very  long  ellip- 
tical mcision  which  extends  from  the  insertion  of  the  pec- 
toral muscle  to  the  costal  margin.  The  boundaries  are 
dissected  well  back  for  flaps.  The  fat  beneath  the  pectoral 
muscles  is  then  removed,  which  exposes  the  small  tributary 
bloodvessels  which  pass  downward.  These  vessels  are  ligated 
before  they  are  cut.  The  pectoralis  major  is  always  removed, 
the  minor  not  in  all  cases.  The  edges  of  the  wound  can 
nearly  always  be  brought  together,  one  straight  line  of 
sutures  being  formed.  Dr.  John  B.  Roberts  always  begins 
above  the  clavicle,  the  flap  being  turned  toward  the  mid 
line  in  order  to  avoid  sloughing  of  the  point  of  the  flap, 
which  is  apt  to  occur  in  the  Halsted  method.  The  infra- 
clavicular glands  are  then  removed.  Both  muscles  should 
be  removed  in  every  case.  Dr.  Rodman  stated  that  the  be- 
lief that  cancer  was  rare  in  the  colored  race  was  passing 
away.  He  finds  the  disease  fully  as  often  in  colored  people 
as  in  whites. 

Dr.  W.  J.  Hearn  exhibited  a  case  of  pneumotomy  for 
gangrene  of  the  lung.  Several  operations  had  been  done 
and  the  wound  drained  for  2  years.  At  the  last  operation 
the  walls  of  the  abscess  cavity  were  stitched  to  the  skin. 
A  plastic  operation  later  on  will  close  the  large  external 
opening  which  now  exists. 

Dr.  Deforest  Willard  reported  a  case  of  traumatic 
aneurysm  of  the  thoracic  aorta  which  has  been  treated 
by  the  insertion  of  wire.  Twenty  feet  of  silver  wire  was  in- 
troduced and  an  80  milliampere  galvanic  current  passed  for 
60  minutes.  The  patient  is  now  doing  well  and  the  pulsation 
has  decreased  at  least  25  fe.  Dr  D.  D.  Stewart  spoke  of  the 
technic  of  the  operation.  He  first  introduces  a  canulated 
needle  to  find  the  thinnest  place  in  the  wall.  In  some  in- 
stances 4  punctures  have  thus  been  made,  this  being  done 
several  days  before  the  wire  is  introduced.  Gold  wire  is  used, 
as  it  can  be  more  finely  drawn,  28  to  30  gauge  being  em- 
ployed. Not  more  than  15  feet  is  introduced  and  this  is 
better  done  through  several  needles,  thus  reaching  all  parts 
of  the  sac.  The  positive  pole  is  applied  to  the  wire 
and  a  current  of  80  to  100  milliamperes  passed  for  30  min- 
utes. One-fourth  grain  of  morphia  is  given  before  the  oper- 
ation and  if  the  heart's  action  is  high  aconite  is  given  for  a 
few  days  before.  Morphia  is  also  given  during  the  operation 
if  the  patient  be  apprehensive  and  excited. 

NEW  YORK. 

Dr.  F.  W.  Barrow,  professor  of  histology  and  biology 
at  BuS"a,lo  University  Medical  College,  was  elected  president 
of  the  New  York  State  Association  of  Science  Teachers. 

Dr.  Seymour  Oppenheimer  has  been  appointed  con- 
sulting otologist  and  laryngologist  to  the  Hebrew  Sheltering 
Guardian  Society  of  New  York. 

University  of  Buffalo.— The  Medical  Department  of 
the  University  of  Bufi'alo  is  in  receipt  of  a  gift  of  $50,000  for 
the  purpose  of  erecting  a  laboratory  to  be  devoted  entirely  to 
research  work.  It  will  be  known  as  the  Gratwick  Research 
Laboratory. 


266 


Thk  Phti.adelphia"| 
Medical  Jocrnal  J 


AMERICAN  NEWS  AND  NOTES 


[F«»BCA«y  9,  1901 


Marine  Hospital. — A  recommendation  has  been  sent  to 
Congress  by  Secretary  Gage  that  $100,000  be  immediately 
made  available  for  the  purpose  of  reclaiming  certain  plots  of 
land  in  Xew  York  harbor  as  a  site  for  a  Marine  Hospital. 

Hospital  for  Dobbs  Ferry,— The  Dobbs  Ferry  Hos- 
pital Association  is  to  erect  a  hospital  on  Ashford  Avenue. 
The  plans  are  to  be  ready  March  1,  and  the  building  begun 
by  May  1.  The  building  will  be  large  enough  to  contain  3 
private  rooms  and  2  wards  containing  6  beds  each. 

New  York  Academy  of  Medicine.— The  report  of 
the  Library  Committee  of  the  New  York  Academy  of  Medi- 
cine shows  that  they  had,  November  30,  89,000  volumes,  in- 
cluding 36,105  duplicates.  The  library  is  growing  at  the  rate 
of  more  than  3,500  volumes  a  year.  The  number  of  journals 
on  file  is  941. 

Manhattan  Dermatologrical  Society.  —  A  regular 
meeting  was  held  at  the  residence  of  Dr.  E.  L.  Cocks,  No. 
156  W.  119  Street,  on  Friday  evening,  February  1,  with  Dr. 
Wm.  S.  Gottheil  as  presiding  officer. 

Dr.  B.  F.  OcHS  presented  3  cases  of  scabies  in  a  father 
and  2  sons.  One  boy  showed  a  severe  impetigo  contagiosa, 
the  other  a  beginning  furunculosis  and  the  father  an  incipi- 
ent beginning  of  the  disease.  Drs.  Oberndoefer  and  Got 
THEIL  took  exception  to  the  use  of  the  term  impetigo  contagi- 
osa except  as  a  distinct  disease.  Drs  Cocks  and  Sobel  spoke 
very  highly  of  Sherwell's powdered  sulphur  treatment.  Dr. 
Weiss  said  that  the  first  case  resembled  Norwegian  scabies 
orsabiesgigantica.  Dr.  Gottheil  presented  for  opinions  aa 
to  treatment,  extensive  keloidal  hypertrophic  growths 
of  the  face  and  elbow,  following  a  severe  burn.  Dk.  Geyser 
recommended  covering  the  false  keloids  with  cloths  moist- 
ened in  a  saturated  solution  of  magnesium  sulfate  and  then 
passing  the  negative  galvanic  electrode  through  this,  for  from 
10  to  20  minutes,  3  times  weekly.  Dr.  Sobel  has  had  very 
fair  results  from  the  passage  of  the  negative  galvanic  needle 
through  the  outlying  dilated  capillaries.  Dr.  Ochs  hae  used 
oleate  of  mercury  with  no  result.  Dr  Abrahams  said  that 
injections  of  95%  alcohol  had  lately  been  recommended. 
The  general  opinion  was  that  thiosinamine  was  useless.  Dr. 
Gottheil  advocated  linear  scarification  and  cross-hatching 
followed  by  mercurial  plaster. 

Dr.  Gottheil  presented  a  relapsing  vesicular  and  erythe- 
matous eruption  of  the  leg,  which  he  first  treated  aa  an 
eczema,  but  which  he  now  considers  dermatitis  herpeti- 
formis. Dr.  Kinch  excluded  eczema  on  account  of  the 
sharp  border  and  marked  pigmentation.  Dr.  Weiss  con- 
sidered it  eczema  vegetans.  Dr.  Cocks  vesicular  eczema,  Dr. 
Abrahams  pemphigus  vulgaris.  Dr.  Ochs  dermatitis  herpeti- 
formis, and  Dr.  Oberndorfer  an  eczema  modified  by  a 
"run  down  "  condition. 

Dr.  L.  G.  Cocks  presented  a  case  of  acne  varioliformis 
cured  by  curettage  and  white  precipitate  omtment— a  promi- 
nent dermatologist  had  diagnosed  syphilis  from  the  appear- 
ance of  the  scars.  Dr.  Oberndoefer  remarked  that  the  scars 
of  acne  varioliformis  were  minute  and  that  white  precipitate 
efi^ected  a  cure  in  both  this  condition  and  syphilis.  Dr.  Sobel 
agreed  that  the  scars  of  acne  varioloformis  were  as  a  rule 
very  small,  but  would  hesitate  to  diagnose  a  condition  from 
the  scars  alone.  Unguentum  hydrargyri  ammoniat.  was  the 
remedy  par  excellence  and  must  be  used  even  after  apparent 
cure.  Dr.  Ochs  thought  that  the  scars  might  have  been  en- 
larged by  the  curet.  Dr.  Weiss  had  seen  large  scars  from 
acne  varioloformis  and  thinks  it  risky  to  make  a  diagnosis 
from  the  scars.    Dr.  Gottheil  considers  it  a  syphilide. 

Dr.  E  L.  Cocks  presented  a  case  of  lupus  vulgraris  of 
the  forehead  and  nose,  and  a  case  which  presented  features 
of  both  a  psoriasis  and  seborrheal  ezema. 

Dr.  Gottheil  presented  a  patient  with  a  fine  desijuam- 
ation  of  the  face  following  a  scarlatiniform  erupiion  of 
three  weeks  ago.  The  fame  patient  showed  a  marked  kera- 
tosis palmaris  et  plantaris  of  one  week's  duration.  Drs. 
Weiss  and  Oberndorfer  considered  the  face  eruption  as  due 
to  a  coal-tar  product.  Dr.  Sobel  said  that  the  patient  ad- 
mitted having  used  quinin  and  he  would  look  upon  this  as 
a  scarlatiniform  erythema  due  to  this  drug.  Dr.  Franklik 
remarked  that  the  hands  were  suggestive  of  acid  burns.  Dr. 
Gottheil  in  closing  said  that  the  keratosis  was  surprisingly 
acute. 


NEW  ENGLAND. 

Appointments. — Drs.  A.  G.  Nadler,  J.  J.  Cohane,  F.  A. 
Kirby,  P.  D.  Littlejohn,  and  E.  P.  Pitman  have  accepted  ap- 
pointments as  school  inspectors  of  New  Haven. — The  Na- 
tional Society  for  the  Study  of  Epilepsy  has  appointed  Drs. 
Max  Mailhouse,  of  New  Hiven ;  F.  K.  Hallock,  of  Cromwell, 
and  E.  A.  Down,  of  Hartford,  a  committee  to  collect  data, 
regarding  the  malady  and  to  instigate  a  movement  in  this 
State  for  establishing  an  asylum  for  such  cases. 

CHICAGO  AND  WESTERN   STATES. 

Acute  contagious  conjunctivitis  is  reported  to  be 
epidemic  in  Chicago. 

Ohio  State  Medical  Society.— The  Ohio  State  Medical 
Society  will  meet  in  Cincinnati  May  8,  9,  and  10. 

Dr.  Charles  Osborne,  Coronor  of  Clinton  County, 
Iowa,  and  a  most  promising  young  physician,  died,  February 
3,  at  St.  Joseph  Hospital,  Dubuque. 

Dr.  Charles  D.  Aaron,  of  Detroit,  Mich.,  has  beea 
elected  clinical  professor  of  diseases  of  the  stomach  and  in- 
testines in  the  Detroit  College  of  Medicine. 

American   Medico-Psychological    Association. — 

The  next  annual  meeting  of  the  American  Medico- Psycho- 
logical Association  will  be  held  in  Milwaukee,  Wis.,  June  11, 
12,  13,  and  14,  1901. 

Smallpox.— Out  of  114  counties  in  the  State  of  Missouri, 
9G  report  smallpox. — During  the  year  1900  there  occurred 
in  the  State  of  Ohio  2,696  cases  of  smallpox.  The  disease 
appeared  in  172  communities  in  62  counties. 

Marriage  Laws. — A  bill  ha«  been  introduced  in  the- 
Minnesota  Legislature  by  Dr.  E.  V.  Chilton,  of  Howard  Lake, 
which  provides  that  a  marriage  shall  not  be  allowed  between 
two  persons  where  either  one  is  or  has  been  subject  to  fits  of 
any  kind,  inssmity,  or  any  loathsome  disease.  The  bill 
further  provides  that  a  certificate  of  a  physician,  showing 
that  the  applicants  are  fit  to  enter  the  married  state,  shall 
accompany  all  applications  for  a  marriage  license.  This  Act 
places  the  age  limit  for  women  at  45  years,  but  no  provision 
is  made  for  men  as  regards  age.  The  penalty  for  a  violation 
of  the  law  is  a  fine  of  $1000  or  5  years  in  the  penitentiary, 
or  both,  and  applies  to  the  persons  who  marry  as  well  as  the 
clergyman  or  justice  performing  the  ceremony. 

A  Medical  Protective  Association.- There  has  been 
organized  at  Fort  Wayne,  Ind  ,  an  association  known  as  the 
"  Physicians'  Guarantee  Company."  The  object  of  this  asso- 
ciation is  to  defend  any  physician  or  surgeon  sued  for  mal- 
practice. It  is  organized  with  a  capital  of  $100,000,  and  has  & 
reserve  fund  of  $.50  000,  and  its  officers  are  men  well  and 
favorably  known  for  many  years — men  like  Drs.  A.  P.  Buch- 
nian  and  Miles  F.  Porter,  for  a  long  time  teachers  in  the 
Fort  Wayne  College  of  Medicine.  It  was  incorporated 
under  a  peculiar  statute  of  Indiana,  which  provides  for  asso- 
ciations ■'  for  the  purpose  of  aiding,  indemnifying,  and  pro- 
tecting the  medical  profession  in  scientific  researches,  and 
in  the  practice  of  medicine  and  surgery'' — a  statute  totally 
different  from  that  found  in  any  other  State,  and  amply  cov- 
ering all  requirements  of  the  company  to  operate  in  every 
State. 

SOUTHERN  STATES. 

Dr.  Fairfax  Schley,  of  Frederick,  has  been  elected 
president  of  the  visitors'  board  of  the  Maryland  School  for 
the  Deaf,  located  in  that  city. 

Successful  Cesarean  Section. — Dr.  George  B.  Johns- 
ton, of  Richmond.  Va.,  reports  a  sucresa'ul  case  of  cesarean 
section.    Patient  had  a  contracted  pelvis. 

Society  for  the  Study  of  Tuberculosis.— A  society 
for  the  study  of  tuberculosis,  which  takes  its  name  from 
Laennec,  the  discoverer  of  auscultation  as  a  means  of  phj»- 
ical  diagnosis,  has  been  organized  in  connection  with  Johns 
Hopkins  Hospital,  Baltimore. 


Fbbrdary  0,  1901] 


AMERICAN  NEWS  AND  NOTES 


[The  PHILADEtPHIA 
Medical  Journal 


267 


Appointed  by  Commissioners. — Dr.  Herbert  N.  Man- 
nicg  has  been  appointed  by  tlie  District  Commisgioners  resi- 
dent interne  at  the  Washington  Asylum  Hospital,  vice  Dr. 
Melville  A.  Hayc,  resigned. 

Dr.  Wm.  D.  Haggard,  Jr.,  of  Nashville,  has  been 
elected  to  fill  the  chair  of  gynecology  and  diseases  of  chil- 
dren in  the  medical  department  of  the  University  of  Tennes- 
see, formerly  occupied  by  his  father. 

Medical  Staff  for  the  Home  for  Friendless 
Women. — The  following  medical  staff  was  elected  in  Janu- 
ary by  the  managers  of  the  Home  for  Friendless  Women,  at 
Loui-ville,  Ky. :  Dr.  Ewing  Marshall,  chairman  ;  Dr.  Henry 
E.  Tuley,  secretary  ;  Dr.  W.  F.  Bnggess,  Dr.  P.  F.  Barbour ; 
Dr.  Lindsey  Ireland,  vice  Dr.  F.  (J.  Simpson  resigned;  Dr. 
Hugh  N.  Leavell,  vice  Dr.  Louis  Frank  resigned. 

Dr.  Paul  Jencke,  a  prominent  physician  of  Linn,  Mo., 
died  January  30,  1901.  He  was  born  in  Dresden,  and  was  a 
graduate  of  the  University  of  Leipz'g.  He  canie  to  the 
United  States  about  1876,  and  attended  the  Missouri  Medical 
(-ollfge  in  St.  Louis,  where  he  graduated  two  years  later. 
The  doctor  came  from  a  prominent  family  in  Germany.  His 
father,  who  died  some  two  years  since,  was  Court  Councillor. 

New  Orleans  Parish  Medical  Society. — The  follow- 
ing (.ffiners  were  elected:  Dr.  E.  Martin,  president;  Dr.  H. 
B.  Gessner,  first  vice  prsident ;  Dr.  L.  G.  LeBeuf,  second  vice- 
president;  Dr.  Geo.  Stumpf,  third  vice-president;  Dr.  W.  M. 
Perkins,  recording  secretary  ;  Dr.  M.  H.  McGuire,  treasurer  ; 
Dr.  S.  P.  Delaup,  librarian  and  corresponding  secretary  ; 
additional  members  to  complete  board  of  directors :  Drs. 
John  Callan,  H.  D.  Bruns  and  T.  S.  Dabney. 

MISCELLANY. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague,  have  been  reported  to 
the  Surgeon-General  U.  S.  Marine-Hospital  Service,  during 
the  week  ended  February  2, 1901 : 


Smallpox— United  States. 


Cases.       Deaths. 


District  of 

Columbia 

:  Washington 

.  Jan. 19-26    .    . 

2 

Florida  : 

Jacksonville 

.  Jan.  12-26    .    . 

10 

Illinois  : 

Chicago 

.  Jan.  19-26    .    . 

25 

Indiana  : 

Michigan  City 

.   Jan.  20-27    .    . 

1 

Kansas  : 

Wichita 

.  Jan.  19-26    .    . 

9 

Kentucky  : 

Lexington   . 

.  Jan. 19-26    .    . 

2 

Louisiana  : 

Shreveport  . 

.  Jan. 19-26    .    . 

5 

New  Orleans 

.  Jan.  19-26    .    . 

11 

3 

Maryland  : 

Baltimore    . 

.  Jan.  19-26    .    . 

1 

Pennsylvania  : 

Erie    .... 

.  Jan.  19-26    .    . 

1 

'* 

Pittsburg  .    . 

.  Jan. 19-;fi    .    . 

2 

Tennessee  : 

Memphis .   . 

.  Jan.  19-26    .    . 

8 

" 

Nashville     . 

.  Jan.  19-26    .    . 

4 

Te.xas  ; 

Houston  .    . 

.  Jan.  19-26    .   . 

44 

1 

Utah: 

Sak  Lake  City 

.   Jan.  19-26    .    . 

31 

Wisconsin  : 

Milwaukee  . 
Smallpo 

.  Jan.  19-26    .    . 
X— FOBEIGN. 

1 

Belgium  : 

Antwerp  .  . 

.  Dec.  29-Jan.  5    . 

1 

Brazil: 

Pernambuco 

.   Nov.  15-30   .    . 

30 

China  : 

Hongkong  . 

.   Dec.  8-15  .       . 

1 

Egypt; 

Alexandria 

.   Dec.  24-31    .    . 

2 

1 

England: 

London     .    . 
New-Castle  -  o 

.  Jan.  5-12  .   .    . 

n- 

1 

Tyne .  .   . 

.  Jan.  5-12  .    .   . 

2 

France : 

Paris .... 

.  Jan. 5-12  .    .   . 

11 

India  : 

Bombay   .    . 

.   Dec.  21-Jan.  1 

4 

Mexico: 

Mexico  .  .    . 

.  Jan.  13-20   .    . 

1 

Tuxpan    .    . 

.  Jan.  14-21    .    . 

1 

" 

Vera  Cruz  . 

.  Jan.  6-13  .    .   . 

3 

Russia  : 

Moscow    .   . 

.  Dec.  22-Jan.  5 

9 

4 

" 

Odessa  .    .  . 

.   Dec.  22-Jan.  12 

137 

24 

" 

St,  Petersburg 

.   Dec.  22-Jan.  5 

6 

2 

II 

Warsaw   .    . 

.   Dec.  22-Jan.  5 

23 

Scotland : 

Glasgow   .   .   . 
Yello 

.   Jan.  11-18   .    . 
w    Fever. 

121 

2 

Cuba  : 

Havana    .    . 

.   .Ian.  12-19    .    . 

2 

Mexico  : 

Vera  Cruz    . 
Oh 

.  Jan. 6-iO .    .   . 

olera. 

5 

India: 

Bombay   .   . 

.  Dec.  21-Jan.  1 

2 

Straits 

Settlements 

:  Singapore    . 

.  Nov.  16-27  .    . 

36 

36 

India  : 

Turkey  ; 


Plaque. 

Bombay  ....  Dec.  24-Jan.  1 
Constantinople.  Jan.  7    .... 


Deaths. 
154 
1 


Quarantining-  Tuberculosis. — Tuberculosis  haa  been 
placed  among  the  diseaees  which  are  sul^ject  to  quaran- 
tine. The  commissioner  of  immigration  has  so  decided  in 
the  case  of  a  Japanese  who  arrived  in  San  Francisco  from 
Japan,  ill  with  lung  trouble.  It  was  decided  that  the  patient 
could  not  land,  but  must  return  to  the  port  from  which  he 
tailed. 

The  Omega  Upsilon  Phi  Fraternity  (medical)  has 
just  organized  two  new  chapters,  one  at  the  University  of 
Co'orado,  composed  of  15  students  and  several  members 
of  the  faculty ;  the  other,  a  graduate  chapter  in  New  York 
City,  to  be  known  as  the  "  Henry  C.  Coe  Chapter,"  in  honor 
of  Professor  Coe  of  the  University  and  Btllevue  Hospital 
Medical  College. 

Obituary. — Dk.  Homer  Octavius  Jetvett,  at  Cortland 
County,  N.  Y..  on  January  30,  1901,  aged  82  years.— Dr. 
Theodore  DeOlermont  Miller,  at  New  York,  on  January 
28,  1901,  aged  59  years.— Dr  Joseph  Ernales  Muse  Cham- 
berlaine,  of  Easton,  Pa.,  on  January  30,  1891,  aged  75  years. 
— Dr  a.  J.  Norris,  of  Macon,  Mo.,  on  January  28,  1901, 
aged  56  years. — Dr.  Michael  Royston  Pigott,  at  Annapolis, 
Md.,  on  January  31,  1901,  aged  35  years  —Dr.  Wesley  W. 
Barkwell,  at  Tucson  Ari ,  on  January  28, 1901. — Dr.  Henry 
W.  Taylor,  at  Sullivan,  Ind.,  on  January  30,  1901,  aged  59 
years. — Dr.  Joseph  Semsch,  at  La  Crcs-^e,  Wis.,  on  January 
30  1901,  aged  87  years.- Dr.  Henry  F.  Baxter,  at  Phila- 
delphia, Pa.,  on  February  1,  1901,  aged  5S  years. — Db. 
Rosier  Middleton.  at  Washington,  D.  C ,  on  January  31, 
1901 — Dr  L.  H.  Jones,  of  Yazoo  City,  Miss.,  at  Jackson,. 
Miss.,  on  January  29,  1901. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  February  2,  1901 : 

Newlove,  George,  acting  assistant  surgeon,  is  assigned  to  duty  at 
Fort  Sill  until  further  orders. 

Barney,  Charles  Norton,  acting  assistant  surgeon,  is  granted 
leave  of  absence  for  1  month. 

Hess,  First  Lieutenant  Louis  T.,  assistant  surgeon,  now  on  duty  at 
the  Army  General  Hospital,  Presidio,  is  relieved  from  further 
duty  in  the  division  of  the  Philippines. 

Stockard,  James  K.,  acting  assistant  surgeon,  now  in  San  Francisco, 
Cal.,  will  report  to  the  commanding  general,  department  of  Cal- 
ifornia, for  assignment  to  temporary  duty  in  that  department. 

LeCompte,  William  C,  acting  assistant  surgeon,  having  reported 
to  the  Surgeon  General  of  the  Army,  will  proceed  to  Fort  Du 
Pont. 

Williams,  Adrian  D.,  acting  assistant  surgeon,  will  proceed  from 
Brooklyn,  N.  Y.,  to  Fort  Adams  for  temporary  duty. 

Bell,  Joseph  L.,  acting  assistant  surgeon,  will  proceed  from  Rich- 
mond, Ind.,  to  (jmaha.  Neb.,  and  report  to  the  commanding 
general,  department  of  the  Missouri,  for  assignment  to  duty  at 
Fort  Crook. 

HicKSON,  Joseph  H.,  hospital  steward  (appointed  January  25). 
now  at  the  Army  General  Hospital,  Presidio,  will  report  to  the 
commanding  general,  department  of  California,  San  Francisco, 
Cal.,  for  assignment  to  duty. 

MuLLiNS,  Thomas  K.,  acting  assistant  surgeon,  is  granted  leave  of 
absence  for  1  month,  without  pay.  to  take  effect  upon  the  ex- 
piration of  the  leave  granted  him  January  8. 

BiSPHAM,  First  Lieutenant  William  N.,  assistant  surgeon,  is  re- 
lieved from  duty  at  Columbia  Barracks,  Cuba,  and  will  report 
at  Cabana  Barracks,  Cuba,  for  duty  as  surgeon,  relieving  Acting: 
Assistant  Surgeon  H.  M.  James. 

Mazzuri,  Paul,  acting  assistant  surgeon,  is  relieved  from  duty  at 
Cabana  Barracks,  Cuba,  and  will  report  at  Columbia  Barracks. 
Cuba,  for  duty. 

Warren,  Stanley  S.,  acting  assistant  surgeon,  now  on  duty  at  Fort 
Clark,  will  proceed  to  Fort  Sam  Houston,  and  upon  arrival  re- 
port to  the  commanding  oflicer  for  duty  during  the  absence  of 
Acting  Assistant  Surgeon  James  S.  Kennedy. 

Kennedy,  James  S.,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  20  days,  to  take  effect  January  21. 

PoLHEMUs,  Captain  Adrian  S.,  assistant  surgeon,  now  on  duty  at 
Fort  Leavenworth,  will  proceed  to  Fort  Riley  for  temporary- 
duty  at  that  post  during  the  absence  of  Captain  Charles  E. 
WoodrufT,  assistant  surgeon. 

De  Witt,  Lieutenant-Colonel  Calvin,  deputy  surgeon-general,  is 
granted  leave  of  absence,  on  surgeon's  certiticate,  for  3  months 
from  about  February  10. 

McCallum,  F.  M.,  acting  assistant  surgeon,  will  proceed  from  Jef- 
ferson Barracks  to  Fort  Reno  for  temporary  duty. 


268 


The  Philadrlphia"! 


FOREIGN  NEWS  AND  NOTES 


[Pbbbcut  9,  isn 


Changes  in  the  Medical  Corps  of  the  tJ.  S.  Navy, 

for  the  week  ended  February  2,  1901 : 

McClubo,  W.  a.,  medical  inspector,  commissioned  medical  Inspec- 
tor, November  19,  1900. 

Shiffkst,  H.  0.,  assistant  surgeon,  ordered  to  the  "  Franklin." 

Grow,  E.  J.,  assistant  surgeon,  detached  from  the  "Culgoa"  and 
ordered  to  the  "  Glacier,"  and  also  to  duty  at  Olongapo,  P.  I. 

CowEN,  J.,  pharmacist,  detached  from  the  "Culgoa"  and  ordered 
to  the  "  Glacier,"  and  also  to  duty  at  the  Naval  Hospital, 
Cavite,  P.  I. 

PiGOTT,  M.  R.,  passed  assistant  surgeon,  died  at  Annapolis,  Md., 
January  31,  1901. 

Changes  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  January  31, 1901 : 

McIntosh,  W.  p.,  surgeon,  to  proceed  to  Jeffersonville,  Ga.,  for 
special  temporary  duty.    January  30. 

Peeet,  T.  B.,  surgeon,  granted  leave  of  absence  for  30  days  from 
February  U.    January  30. 

McMuLLEN,  John,  assistant  surgeon,  upon  expiration  of  leave  of 
absence,  to  proceed  to  Wilmington.  N.  C,  and  assume  temporary 
command  of  the  service  during  the  absence  of  Surgeon  T.  B. 
Perry.    January  30. 

CoRP0T,  G.  M.,  assistant  surgeon,  to  proceed  to  Cleveland.  Ohio, 
and  assume  temporary  command  of  the  service  during  the  ab- 
sence of  Surgeon  W.  J.  Pettus.    January  26. 

B0.4RD  CONVENED. 

Board  convened  to  meet  at  Washington,  D.  C,  on  Tuesday,  Feb- 
ruary 5,  1901;  for  the  physical  examination  of  Second  Assistant 
Engineer  R.  F.  H.\lpin,  R.  C.  S.  Detail  for  the  board— Sur- 
geon Pbeston  H.  Bailhache,  chairman ;  Surgeon  G.  T. 
Vaughan,  and  Assistant  Surgeon  B.  S.  Wabeen,  recorder. 


foreign  Hetps  anb  Hotcs. 


GREAT  BRITAIN. 

Dr.  T.  C.  Vachell  has  withdrawn  his  resignation  as 
physician  to  the  Cardiff  Infirmary. 

Miss  M.  M.  T.  Christie,  M.D.  Lend.,  has  been  ap- 
pointed to  the  permanent  charge  of  the  Victoria  Dufferin 
Hospital  in  Calcutta. 

Smallpox  at  Glasgow.— Smallpox  is  reported  to  be 
increasing  at  Glasgow  to  an  alarming  extent.  Twenty-nine 
new  cases  are  reported  and  hundreds  of  cases  are  being 
treated  in  the  hospitals. 

Elections.  —  Mr.  W.  H.  Willcoi,  M.B.,  B.  Sc.  Lond., 
D.P.H.,  A.T.C.,  hag  been  elfcted  to  the  post  of  lecturer  on 
chemistry  and  physics  at  St.  Mary's  HospiUl  Medical  School, 
London.  Sir  James  Sawyer,  M.D.,  has  been  elected  a  Fellow 
of  the  Society  of  Antiquaries. 

Investigating  Beer-poisoniug — The  ian<^  says:  A 
Eoyal  Commission  has  been  appointed  to  make  investiga 
tions  respecting  the  beer  poisoning  epidemic.  The  Commis- 
sioners are  Lord  Kelvin,  Sir  W.  Hart  Dyke,  Sir  W.  S.  Church 
(President  of  the  Royal  College  of  Physicians  of  London), 
Professor  T.  E.  Thorpe  (Government  Analyst),  Mr.  H.  Cosmo 
Bonsor,  and  Dr.  B.  A.  Whitelegge  (H.  M.  Chief  Inspector  of 
Factories).  Dr.  G.  S.  Buchanan,  one  of  the  medical  inspec- 
tors of  the  Local  Government  Board,  is  the  secretary  of  the 
commission.  Tne  instructions  to  the  commissioners  are  to 
ascertain  with  regard  to  England  and  Wales:  1.  The  amount 
of  recent  exceptional  sickness  and  death  attributable  to 
poisoning  by  arsenic.  2.  Whether  such  exceptional  sickness 
and  death  have  been  due  to  arsenic  in  beer  or  in  other 
articles  of  food  or  drink,  and,  if  so,  (<i)  to  what  extent;  (6) 
by  what  ingredients  or  in  what  manner  the  arsenic  was  con- 
veyed ;  and  (e)  in  what  way  any  such  ingredients  became 
arsenicated.  3.  If  it  is  found  that  exceptional  sickness  and 
death  have  been  due  to  arsenic  in  beer  or  in  other  articles 
of  food  or  drink,  by  what  safeguards  the  introduction  of 
arsenic  therein  cau  be  prevented. 

CONTINENTAL  EUROPE. 

The  Medical  Profession  of  Germany  has  sanctioned 
the  imperial  bill  lengthening  msdical  study  to  at  least  five 
years. 


Kleines  Journal  f.  Hygiene.— A  special  supplement 
to  the  German  magazine,  the  Kleines  Journal,  is  to  be  pub- 
lished by  a  medical  editor,  with  the  title  of  the  Kleines  Jcnir- 
nalf.  Hygiene. 

School  for  Tropical  Diseases. — It  has  been  decided 
by  the  Faculte  de  M^decine  of  Paris  to  establish  a  school  for 
the  study  of  tropical  diseases,  with  special  chairs  of  bacteri- 
ology and  parasitology. 

Royal  Personages   Contract  Measles.— The  Duke 

Regent  of  Mecklenburg- Schwerin  and  the  Dachese,  who  i«  a 
daughter  of  the  late  Grand  Duke,  are  down  with  the  meafilee, 
as  is  also  the  young  Grand  Doke  of  Saxe- Weimar. 

Appointments.— DoEPAT,  Russia:  Dr.  Yewetsky,  pro- 
fessor of  the  medical  faculty  of  Moscow,  has  been  appointed 
professor  of  onhthalmoloey  at  Dorpat,  succeeding  Professor 
Rablmann. — FBEiBCTta  :  Dr.  Adolf  S^hii'e  has  been  appointed 
professor  of  internal  medicine. 

MISCELIi.ANT. 

Obituary.— Dr.  Dcbrceil,  former  professor  of  the  sur- 
gical clinic  at  Montpellier,  France. — Dr.  DccLcs,  former  pro- 
fefsor  of  the  Medical  Clinic  at  Tours. — Peofessob  Fodrezb, 
of  Charkow,  an  eminent  Russian  surgeon. 

The  St.  John's  Ambulance  Association  attended 
1,305  persons  injured  during  the  funeral  crushes  in  London. 
The  association  has  701  doctors  and  nurses  busy  at  26  sta- 
tions. Prior  to  the  arrival  of  the  funeral  train.  Major 
Edward  Bassindale,  a  veteran  oflScer,  fell  dead  in  the  crowd, 
as  the  result  of  excitement.  There  was  a  crush  in  the  crowd 
at  the  Marble  Arch,  when  the  gates  were  unexpectedly  closed 
after  the  procession  had  passed. 

A  Modification  in  Ophthalmic  Test- Types.— The 

Lancft  slates  that  Dr.  E.  Praun,  ol  Darmstadt,  has  proposed 
an  ingenious  substitute  for  the  types  generally  in  use  for  the 
purpose  of  testing  the  sight.  He  observed  that  some  school 
children  and  also  a  railway  engine-driver  whom  he  had 
occasion  to  examine  succeeded  in  learning  the  ordinary  test- 
types  by  heart,  so  that  they  could  name  the  letters  without 
being  able  to  see  them  distinctly,  and  thereby  made  their 
vision  appear  to  be  better  than  it  really  was.  In  order  to 
counteract  this  artifice  Dr.  Praun  suggests  that  the  use  of 
letters  of  the  alphabet  as  test  types  should  be  discontinued 
and  substitutes  for  them  two  thick  parallel  black  lines  of 
unequal  length  j  lined  together  by  their  ends,  some  of  them 
at  an  angle  of  45°  and  others  at  a  right  angle  forming  L. 
These  radiating  pairs  of  lines  he  regards  as  the  hands  of  a 
clock,  and  his  sheet  of  test-types  consists  of  47  such  pairs  of 
lines  of  different  sizes  placed  within  circles,  arranged  in  two 
squares  of  9  and  36  figures  respectively  and  2  separate  fig- 
ures. Each  of  these  squares  is  mounted  on  cardboard  and 
rotated  into  different  positions,  so  that  the  most  retentive 
memory  would  be  unable  to  remember  all  the  possible  com- 
binations and  the  reality  of  the  test  would  be  assured. 


The  Teaching  of  Colonial  Medicine. — Dr.  Boinet, 
Professor  of  Tropical  Diseases  (Gazette  MedioaU  de  Paris, 
J.inuary  5,  1901),  explains  in  his  opening  lecture  the  purpose 
of  the  School  of  Tropical  Medicine  recently  established  in 
Marseilles.  He  expects  to  be  able  to  study  ecientificAlly  nu- 
merous tropical  diseases  which  are  as  yet  obscure ;  he 
hopes  that  men  who  have  returned  from  the  Colonies,  poor 
and  ill,  undermined  by  fever  or  dysentery,  will  receive  aid 
here ;  he  believes  that  students  who  expect  to  practise  in 
tropicAl  countries  will  learn  to  diagnosticate  and  treat  the 
affections  most  commonly  found  there.  This  refers  espe- 
cially to  those  intending  to  enter  the  Army,  the  Marine,  or 
Colonial  Service.  He  thinks  that  all  who  are  destined  to  fill 
civil  posts  in  the  tropics, — government  officials,  mission- 
aries, etc.,  will  here  be  given  the  chance  to  learn  what  to  do, 
should  no  physician  be  within  call.  He  relates  his  own 
experience  in  Tonkin,  in  1SS7,  when  he  had  31  grains  of 
quinin  hypodermically,  and  62  grains  by  the  mouth,  believ- 
ing that  these  large  doses,  given  him  by  his  colleagues,  alone 
saved  his  life.  Besides,  the  cases  which  he  expects  will  be 
sent  to  Marseilles,  such  as  dysentery,  abscess  of  the  liver, 
malaria,  and  leprosy,  are,  or  were,  endemic  in  the  south  of 
France.  While  England  already  hsis  three  Schools  of  Tropi- 
cal Medicine,  this  is  the  first  one  opened  in  France,  [m.o.] 


rBBKUAEY  9,    1901] 


THE  LATEST  LITERATURE 


CThk  Philadelphia 
Medicax  Journal 


269 


Cl^e  latest  literature. 


British  Medical  Journal. 

January  19,  1901.     [Xo.  2090.] 

1.  A  Clinical  Lecture  on  Malignant  Diseases  of  the  Female 

Genitalia.    Thomas  Oliver. 

2.  A  Clinical  Lecture  on  Diagnosis  in  Cancer  of  the  Body  of 

the  Womb.    W.  Hasdfield  Jones. 

3.  Spoon-shaped  Indentations  in  the  Skulls  of  the  Newborn. 

J.  M.  MrNRO  Kerr. 

4.  Impacted  and  Displaced  Gravid  Uterus  with  Fibroid.  Neil 

MACLEOD. 

5.  A  Second   Successful   Case  of  Cesarean    Hysterectomy. 

CoLis  Campbell. 

6.  A  Note  on  the  Treatment  of  Puerperal  Eclampsia.    R. 

P.  Raskes  Lyle. 

7.  A  Note  on  the  Occurrence  of  Abortion.    J.  B.  Hellier. 

1.— Oliver  includes  under  the  term  malignant  diseases 
of  the  female  genitalia  such  affections  as  cancer,  sar- 
coma, malignant  adenoma,  and  deciduoma  malignum.  It  is 
characteristic  of  them  all  that  they  tend  to  pass  beyond  the 
organ  in  which  they  originate  and  to  invade  ctlier  organs  or 
tissues.  He  especially  dwells  upon  malignant  diseases  of  the 
womb.  Carcinomata  originate  under  the  flattened  epithe- 
lium which  lines  the  vaginal  face  of  the  cervix  or  in  the  col- 
umnar epithelial  cells  of  the  tubular  glands  of  the  cervical 
canal.  When  the  disease  is  present  in  the  exposed  part  of 
the  cervix  it  has  usually  originated  beneath  the  flattened 
epithelium  and  tends  to  burrow.  When  the  disease  origi- 
nates in  the  cells  of  the  cervical  mucous  membrane,  or  in 
those  of  the  tubular  glands  of  the  cervix,  the  ciliated  epithe- 
lium loses  ita  cilia,  and  there  follows  marked  proliferation  of 
the  cells,  whereby  the  structure  comes  to  resemble  exuberant 
gland-tissue.  In  cancer  of  the  body  of  the  uterus  the  disease 
arises  either  in  the  ordinary  epithelial  cells  that  line  the 
endometrium,  or  in  those  of  the  tubular  glands.  It  is  when 
the  disease  originates  in  the  glandular  structures  that  it  gives 
rise  to  what  is  known  as  adenoma  malignum.  The  cause  of 
cancer  is  still  unknown.  It  is  certainly  a  local  disease  at  first, 
as  is  shown  by  the  success  which  follows  early  extirpation. 
The  treatment  of  malignant  disease  of  the  uterus  varies  ac- 
cording as  to  whether  the  cases  are  inoperable  or  those  that 
are  suitable  for  operation.  Oliver  has  not  seen  any  benefit 
follow  from  the  internal  administration  and  local  application 
of  arsenic,  nor  has  thyroid  extract  done  any  good.  The  cases 
suitable  for  operation  are  those  in  which  the  disease  is  lim- 
ited to  a  very  email  part  of  the  cervix,  or,  when  located  in 
the  uterus  itself;  the  womb  while  involved  is  freely  movable, 
[w  AS  d] 

2.— Handfield-Jones  from  his  study  of  cancer  of  the 
body  of  the  womb  believes  that  the  following  conclusions 
probably  represent  the  sum  of  our  knowledge  at  the  present 
time  :  (1)  Tnat  in  cases  of  corporeal  cancer  there  is  a  stage 
of  benign  adenoma;  (2)  Uterine  scrapings  are  not  perfec'ly 
reliable,  owing  to  the  tissue  being  only  superficial,  and  the 
deep  part  of  the  gland  not  being  obtained.  Later  scrapings, 
when  the  disease  is  more  advanced,  are  more  reliable ;  (3) 
clinical  signs  are  more  reliable  than  microscopic  evidence ; 
(4)  The  degree  of  malignancy  varies  much,  and  the  disease 
may  run  a  very  slow  c  mrse  ;  (5)  rapid  increase  in  the  size  of 
the  body  of  the  womb  is  the  most  valuable  sign  in  determin- 
ing need  for  extirpation  of  the  whole  organ,    [w.a  n.d  ] 

3- — Kerr  remarks  that  indentations  of  the  fetal  skull 
maybe  either  spoon  or  furrow  shaped.  The  2  varieties 
occur  with  abxit  equal  frequency.  They  have  not,  however, 
the  same  significance,  for  although  the  conditions  producing 
them  are  in  the  main  the  same,  the  furrow-shaped  variety  is 
much  the  less  serious  and  seldom  gives  rise  to  much  immedi- 
ate trouble.  The  spoon-shaped  injury,  which  is  situated 
usually  on  one  or  other  parietal  or  frontal  bones  in  the 
neighborhood  of  the  anterior  fontanel,  is  by  no  means 
uncommon.  With  few  exceptions  the  accident  occurs  when 
there  is  a  deformity  of  the  maternal  pelvis,  and  as  rickets  is 
the  most  common  cause  for  such  deformity  the  irjuryis  gen- 
erally met  with  in  the  ofl^pring  of  women  with  flat,  rachitic 
pelves.  Generally  speaking  the  prognosis  is  not  unfavorable. 
If  the  children  are  born  alive  the  indentation,  in  the  majority 


of  cases,  disappears  in  a  week  or  two,  having  given  rise  to 
no  trouble  at  the  time,  and  producing  no  ill  effects  later.  In 
a  certain  number  of  cises,  however,  the  depressions  are 
deeper  and  produce  a  permanent  deformity.  Ahlfeld  men- 
tions 10  cases  with  2  deaths.  Kerr  has  seen  4  cases  with  2 
deaths.  As  regards  treatment,  Kerr  remarks  that  a  very 
little  fjrce  applied  to  the  depression  from  the  inside  is  all 
that  is  necessary  to  relieve  the  indentation.  The  force  must 
be  applied  early,  otherwise  there  may  occasionally  be  a  little 
difficulty  in  raising  the  bones.  This  force  may  be  secured 
by  making  firm  compression  of  the  head  anteroposteriorly, 
thereby  causing  the  depressed  bone  to  spring  out.  While 
successful  in  a  few  cases  this  method  is  not  always  applicable. 

[w  A  S.D.] 

4.— Macleod  reporls  an  interesting  Cise  of  impacted 
and  displaced  gravid  uterus  at  term  comphcated  by 
fibroid  tumor,  in  which  cesarean  section  was  performed 
together  with  excision  of  the  fibroid  tumor  and  of  the  entire 
anterior  uterine  wall.  The  patient  made  an  uninterrupted 
recovery,     [w.a.s.d.] 

5.— Campbell  recalls  a  succassful  case  of  cesarean  hys- 
terectomy in  a  dwarf  four  feet  in  height.  Tne  operation 
was  performed  under  the  most  unfavorable  c  _)ndition8,  but 
the  patient  made  a  complete  recovery,     [w.a  s.d.] 

6.  —Lyle  remarks  that  there  are  three  great  principles  in  the 
treatment  of  puerperal  eclampsia,  namely,  purifica- 
tion of  the  blood,  the  control  of  convulsions,  and  the  emptying 
of  the  uterus.  Dietetic  infusion  is  a  valuable  addition  to  the 
usual  treatment  adopted  for  purifying  the  blood,  but  it  has  no 
immediate  effect  in  controlling  the  convulsions,  nor  has  it 
any  effect  on  the  action  of  the  uterine  muscles.  He  prefers 
morphin,  judiciously  given,  to  ccntrol  the  eclamptic  seizures. 

[W  AN.D.] 

Lancet. 

January  19, 1901.     [No.  4038  ] 

1.  Tivo  Clinical  Lectures  on  Enlargement  of  the  Prostate. 

P.  J.  Freyer. 

2.  A  Clinical  Lecture  on  Some  Cases  of  Head  Ir jury.  In- 

cluding one  of  which  there  was  L?3ion  of  the  Occipital 
Lobe.    Herbert  W.  Page. 

3.  A  Series  of  Ten  Successful  Cases  of  Cesarean  Section. 

W.  J.  Sinclair.  ' 

4.  An  Account   of   the  Epidemic  Oatbreak  of  Arsenical 

Poisoning  Occurring  in  Beer-Drinkers  in  the  Nirth  of 
England  and  the  Midland  Counties  in  1900.  Ernest 
Septimus  Reynolds. 

5.  Cases  of  Arsenical  Peripheral  Neuritis.    Robert  J.  M. 

BUCHASAX. 

6.  The  Roatgen-Riys  and  the  Diagnosis  of  Urinary  CJculi. 

C.  Massell  TiioULLIN. 

7.  Urotropine  as  a  Urinary  Antiseptic.    P.  J.  Cammidge. 

8.  Infective  Parotitis  after  Abdominal  Section.  Wm  Elder. 

9.  A  Case  of  Gangrene  of  the  Penis.  George  A  Clarksos. 
10.  Reflections  on  Therapeutics.    Harry  Cajmpbell. 

1.— Freyer  thinks  that  in  certain  selected  cases  some  form 
of  operative  treatment  may  be  recommended;  in  a  fe^v cases 
it  is  imperative,  but  that  in  the  large  majority  of  cases  clean 
catheterization  and  a  hygienic  life  is  the  best  treatment. 
When  no  symptoms  are  present  no  treatment  is  required. 
If  symptoms  of  obstraction  are  present  and  the  amount  of 
residual  urine  small,  he  uses  ergot  and  the  weekly  introduc- 
tion of  a  bougie  as  far  as  the  bladder.  When  the  residual 
urine  reaches  4  ounces  the  catheter  should  be  used  once  a 
day ;  6  ounces,  twice  a  day ;  S  to  10  ounces,  three  or  four 
times  a  day.  When  all  voluntary  power  is  lost  the  catheter 
should  be  used  as  of.en  as  the  desire  is  markedly  felt.  Pa- 
tient should  not  be  limited  to  a  certain  hour,  but,  on  the  con- 
trary, should  use  the  catheter  before  pain  and  marked  dis- 
comfort are  felt.  The  choice  of  catheter  will  depend  on  the 
form  of  obstruction — patient  should  never  be  without  one. 
Usually  a  soft  Condea,  No.  7  or  9,  is  most  useful.  Patient 
should  not  be  allowed  to  use  a  metal  catheter.  The  aseptic 
precautions  necessary  in  the  use  of  the  catheter  are  gone 
into  carefully.  The  hygiene  of  the  patient  should  be  care- 
fully looked  after;  the  diet,  the  clothing,  the  bowels,  etc. 
Horseback  and  bicycle  riding  are  to  be  avoided,  as  is  also 
sexual  excitement.    Under  proper  care  many  patlen  s  are 


270 


Thr  Philadelphia 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


[Fbebcabt  'i,  IMn 


able  to  lead  "  useful  and  enj  :)yable  lives  for  15  or  20  yeirs," 
— "  after  entering  on  the  habitual  use  of  the  catheter."  In 
far  advanced  cases  when  urine  is  turbid  or  fetid  the  patient 
should  be  examined  in  his  own  bed  and  only  a  por- 
tion of  the  residual  urine  withdrawn  at  the  first  examina- 
tion. It  is  not  right  to  examine  such  a  case  and  allow  him 
to  go  out-of  doors  immediately  afterward;  he  should  remain 
in  bed.  Urethral  fever  from  catheterizUion  is  apt  to  follow 
in  these  cases.  Cystitis  is  a  common  complication.  In  the 
beginning  boric  acid  should  be  employed,  and  Freyer  has 
found  that  several  large  doses  (25  grains)  are  better  than 
small  doses  frequently  repeated.  When  pus  is  present  irri- 
gation daily  with  some  warm  and  mild  antiseptic  is  em- 
ployed. Silver  nitrite  begun  in  solution  of  1:4000  and 
gradually  increased  to  1 :  750  is  highly  recommended.  For 
the  great  pain  and  scalding  at  the  neck  of  the  bladder  a 
dram  of  a  1%  to  "ifc  solution  of  silver  nitrate  thrown  into 
the  membranous  urethra  is  of  great  advantage.  Com- 
plete retention  of  urine  should  be  relieved  by  catheter, 
aspiration,  or  drainage  as  soon  as  possible  lest  an  atony  of 
the  bladder  result.  The  preprostatic  pouch  is  frequently 
overlooked  and  mistaken  for  the  bladder  cavity  itself.  It  is 
the  dilated  prostatic  urethra  and  bladder  in  front  of  the  en- 
larged middle  lobe.  Freyer  has  frequently  seen  the  pouch 
emptied  by  the  catheter  and  the  attendant  think  he  had 
emptied  the  bladder.  He  has  several  times  removed  stones 
from  this  position.  Hemorrhage  is  liable  to  take  place  in 
the  advanced  cases,  but  is  not  apt  to  be  serious  unless  due  to 
a  ruptured  varicosed  vessel  in  the  gland.  Rest  in  bed  is  the 
most  important  part  of  the  treatment.  Frequent  hemor- 
rhage after  exercise  should  suggest  stone.  Orchitis,  ure- 
thritis, and  balanitis  not  infrequently  occur  a«  complications, 
the  latter  two  particularly  in  patients  suffering  from  diabetes. 
Operative  treatment:  Freyer  describes  the  various  oper- 
ations for  the  removal  of  the  enlarged  portions  of  the  pros- 
tate and  recommends  for  enlargement  of  the  middle  lobe 
the  suprapubic  operation  of  McGill ;  for  enlargement  of  the 
lateral  lobes  an  operation  of  his  own  consisting  of  a  pre- 
liminary incision  through  the  urethra  and  then  Dittel's 
incision  through  the  perineum.  The  wound  in  the  urethra 
allows  the  introduction  of  the  finger  into  the  bladder,  a 
thorough  examination  of  the  gland  and  its  easy  protrusion 
by  the  finger  into  the  perineal  incision,  and  a  means  of 
thorough  drainage  afterwards.  It  also  serves  the  important 
purpose  of  protecting  the  bladder  from  injury,  as  the  finger 
can  appreciate  the  approach  of  the  cutting  instrument. 
Castration  with  its  very  satisfactory  results  in  some  cases 
and  its  ohjectionable  features  to  the  patient  is  carefully  dis- 
cussed. The  mortality  in  the  far  advanced  cases,  the  only 
ones  where  the  operation  is  acceptable,  is  the  greatest  objec- 
tion to  the  operation.  Both  of  these  objections  are  overcome 
in  the  operation  of  vasectomy,  but  the  results  are  hardly 
as  satisfactory.  This  operation  successfully  prevents  the  dis 
tressing  complications  of  orchitis  and  epididymitis  which  so 
frequently  occur  in  prostatic  patients.  In  the  hard  fibroid 
form  of  enlargement  the  operation  was  little  or  no  good. 
Although  preventing  the  expulsion  of  semen  vasectomy  does 
not  interfere  with  the  sexual  power.  Drainage,  as  a  pal- 
liative measure,  should  be  obtained  through  the  perineum 
when  it  ia  required  temporarily  and  when  the  patient  is 
much  enfeebled.  For  permanent  drainage  the  suprapubic 
route  is  the  best,    [j.h.g  ] 

2. — Page  in  a  clinical  lecture  on  head  injuries  urges  the 
close  observation  of  all  symptoms  in  such  cases.  He  first 
speaks  of  a  case  sent  to  the  hospital  as  concussion  and  as 
needing  operation,  in  which  it  was  subsequently  found  that 
the  patient  was  suS'ering  from  embolism.  The  case  first 
shown  is  that  of  a  boy  admitted  to  the  hospital  suffering 
from  an  extensive  fracture  of  the  upper  occipital  region. 
He  exhibits  perimeter  charts  showing  complete  and  absolute 
homonymous  hemianopsia  soon  after  the  injury,  and  later 
charts  showing  nearly  complete  restoration  of  vision.  The 
second  case  shown  was  that  of  a  boy  14  years  of  age  admitted 
in  a  dazed  condition  with  a  large  hematoma  over  the  right 
frontotemporal  region.  The  eyelids  were  swollen  and  com- 
pletely closed.  There  were  no  unilateral  phenomena.  When 
examined  the  next  day  there  seemed  to  be  a  depression  of 
the  bone  beneath  the  hematoma  and  an  exploratory  incision 
was  made,  which  showed  that  the  sense  of  depression  was 
due  to  a  well  marked  temporal  ridge,  and  that  no  fracture  of 
the  skull  was  present.      The  next  case  is  that  of  a  man,  29 


years  of  age,  admitted  in  profound  unconsciousness  with 
relaxation  of  sphincters  and  slight  bleeding  from  the  right 
ear,  which  soon  ceased  and  was  not  succeeded  by  the  escape 
of  carobrospinal  fluid.  There  was  considerable  bruising  on 
the  side  of  the  head,  but  no  unilateral  symptoms.  The 
patient  recovered  slowly  but  complained  of  great  pain  in  his 
head.  The  presence  of  slight  facial  palsy  seemed  to  confirm 
the  impression  that  there  had  been  a  fracture  of  the  base, 
but  this  was  subsequently  explained  by  the  patient  who  said 
it  was  of  long  duration.  Page  thinks  in  the  majority  of 
cases  of  severe  concussion  that  there  has  been  more  or  lesa 
laceration  of  brain  tissue  and  very  commonly  an  extrava- 
sation of  blood  into  the  arachnoid  cavity.  He  urges  that  in 
all  injuries  to  the  head  adequate  rest  must  be  given  to  the 
brain  and  the  patient  not  discharged  from  the  hospital  too 
early,    [j.h  g  ] 

3. — Smclair  reports  10  cases  of  successful  cesarean  section 
performed  during  the  past  10  years.  In  3  of  the  cases  the 
uterus  was  removed.  In  these  cases  no  sugar  was  subse- 
quently found  in  the  urine,  and  the  milk  did  not  appear  in 
tne  breists.  In  2  of  the  cases  previous  craniotomy  had  been 
performed.  In  discussing  these  cases  Sinclair  says  that 
previous  to  and  during  the  operation  the  fewer  manipula- 
tions of  the  uterus,  especially  per  vaginam,  the  better,  and 
that  he  sees  no  advantage  in  the  previous  dilation  of  the 
cervix.  In  all  of  his  operations  the  uterus  was  brought 
through  the  abdominal  incision  before  it  was  opened  and  an 
elastic  tube  was  placed  about  the  cervix  for  the  control  of 
hemorrhage.  Rupture  of  the  membranes  reduces  the  size 
of  the  uterus  and  renders  the  operation  easier.  He  does  not 
think  that  the  elastic  ligature  produces  atony  of  the  uterus. 
He  thinks  that  an  incision  4i  to  5  inches  long  in  the  uterus  is 
necessary  for  safe  delivery.  The  transverse  incision  acroes 
the  fundus  of  the  uterus  is  condemned  because  of  the  likeli- 
hood of  subsequent  adhesion  of  the  bowel  or  the  abdominal 
wall,  which  seriously  complicates  future  pregnancies.  He 
always  makes  the  median  incision  in  the  middle  third  of  the 
uterus.    In  his  recent  cases  drainage  has  been  abandoned. 

[J.H.G.] 

4. — Reynolds  gives  an  account  of  the  epidemic  out- 
break of  arsenical  poisoning'  occurring  in  beer-drinkers 
in  the  north  of  Eagland  and  the  Midland  counties  in  1900. 
Daring  the  year  a  number  of  patients  presented  themselves 
showing  various  skin  eruptions,  such  as  erythema,  keratosis, 
pigmentation  and  herpes  zoster.  These  skin  lesions  occur- 
red in  association  with  alcoholic  paralyses.  For  some  time 
Reynolds  was  at  a  loss  to  explain  why  neuritis  occurred  only 
in  beer-drinkers  and  not  in  spirit-drinkers.  In  many  of  the 
cases  the  skin  lesions  associated  were  herpes.  He  concluded 
therefore,  that  a9  arsenic  was  the  only  known  drug  to  pro- 
duce herpes,  this  was  the  cause  of  the  epidemic.  Oa  Xovem- 
bea  18,  1900,  some  of  the  beer  commonly  partaken  of  by  one 
of  the  sufferers  was  examined  for  arsenii  with  a  positive 
result.  The  arsenic  in  the  beer  was  traied  to  a  number  of 
sources,  the  most  important  origin  was  in  certain  sugars  used 
in  brewing.  A  single  firm  supplied  200  breweries  with  sugar 
which  contained  arsenic.  The  poison  gained  entrane* 
through  the  sulphuric  acid  used  in  converting  starch  into 
sugar.  The  original  source  of  the  arsenic  was  found  in  the 
Spanish  pyrites  used  in  the  manufacture  of  sulphuric  acid.  A 
quantitative  estimation  showed  that  there  was  from  .14  of  a 
grain  to  .3  of  a  grain  of  arsenic  in  a  gallon  of  beer.  Another 
way  by  which  arsenic  may  gain  entrance  is  through  sulphur- 
eted  hops.  He  reports  a  case  of  poisoning  due  to  the  chew- 
ing of  hops.  In  the  cleansing  of  the  barrels  and  the  "  fining  " 
of  the  beer  calcium  bisulfate  and  sulphuric  ajid  were  usod. 
He  cites  still  another  way  in  which  arsenic  may  g&in 
entrance,  namelj',  through  certain  microorganisms  which 
have  the  power  of  taking  up  substances  and  liberating 
poisonous  arsenical  compounds.  The  epidemic  principally 
involved  those  districts  which  were  supplied  with  contami- 
nated sugar.  The  number  of  individuals  poisoned  and  the 
number  of  deaths  could  not  be  accurately  ascertained.  In 
Manchester  alone  2.000  cases  were  reported.  In  discussing 
the  symptoms  he  lays  stress  up3n  the  fact  that  the  diag- 
nosis is  very  easy  in  typical  cases.  The  patient  com- 
plains of  pain  in  the  extremities,  often  shooting  in  char- 
acter, headache,  lachrymation,  cough,  shortness  of  breath, 
and  diarrhea.  In  many  instances  the  patient  has  a  charac- 
teristic  "double-rap"  gait,  the  heel  first  touching  and  then 
the  anterior  portion  of  the  foot.    Rvshee,  edema  of  the  face 


Fbbrdary  9,  1901] 


THE  LATEST  LITERATURE 


[Thk  Philadelphia 
Mbdical  Jouenal 


271 


and  extremities,  pallor  and  some  cyanosis  may  be  striking 
«ign8.  The  skin  lesions  are  numerous  and  present  in  almost 
«very  case.  They  were:  Erythromelalgia,  keratosis,  ery- 
thema, often  accompanied  by  great  itching ;  pigmentation, 
Bimulating  that  of  Addison's  disease,  and  herpes  zoster.  Loss 
of  hair  occurred  in  some  cases.  The  nails  were  thin  and 
brittle,  and  it  appeared  that  some  time  after  the  patient  dis- 
continued taking  the  beer  the  new-formed  portion  of  the  nail 
could  be  distinguished  from  the  diseased  part  by  a  distinct 
ridge.  In  a  few  cases  successive  weekly  drinking  bouts 
seemed  to  produce  a  series  of  ridges  across  the  nails.  Symp- 
toms referable  to  the  nervous  system  were  numerous.  Sen- 
sory affections  were  present  in  every  case,  varying  from  slight 
paresthesia  to  total  loss  of  sensation,  neuralgias  and  tender- 
ness over  the  muscles.  In  one  case  the  sensory  portion  of 
the  left  fifth  cranial  nerve  was  partially  paralyzed  while  the 
motor  portion  was  not  involved.  Motor  symptoms  were 
present  in  about  70%  of  the  cases.  Loss  of  power  was  espe- 
cially prominent  in  the  lower  extremities,  showing  itself 
in  the  gait  and  in  some  instances  there  was  complete  loss  of 
power.  The  hands  and  forearms  were  also  involved  in  many 
■cases.  Early  in  the  course  of  the  disease  the  knee-jerks  were 
often  exaggerated.  Late  in  the  course  of  the  disease,  when 
paralysis  and  atrophy  became  prominent,  the  knee-jerks 
were  absent.  In  a  few  cases  confusional  insanity  developed. 
Signs  of  cardiac  dilation  were  present  in  a  majority  of  the 
cases.  Heart  failure  was  the  chief  cause  of  death  in  the 
greater  number  of  fatal  cases.  Edema  was  often  present. 
The  chief  symptoms  referable  to  the  respiratory  tract  were 
bronchitis,  hemoptysis  and  congestion  of  the  fauces,  and 
of  the  vocal  cords.  In  a  few  instances  of  latent  phthisis, 
rapid  breaking  down  of  the  lung  tissue  occurred  with 
the  arsenical  poisoning.  In  the  early  stages  of  the  poi- 
soning the  appetite  was  increased,  while  in  the  later 
stages  it  became  impaired.  Some  patients  complained  of 
■vomiting  and  of  diarrhea,  with  the  passage  of  blood  in  the 
stools.  Reynolds  states  that  he  believes  that  arsenic  may  set 
up  chronic  interstitial  hepatitis.  He  found  arsenic  in  the 
urine  of  patients  who  had  recently  partaken  of  arsenicated 
beer.  In  some  of  the  cases  moderate  fever  was  present  during 
the  early  course,  which,  as  a  rule,  soon  disappeared.  The 
duration  of  the  disease  lasts  many  months.  In  the  cases 
terminating  fatally,  death  is  as  a  rule  due  to  the  cardiac  failure. 
In  some  instances  it  is  due  to  paralysis  of  the  diaphragm  and 
bronchopneumonia,  and  in  one  case  the  cause  was  phthisis. 
The  cases  may  be  classified  into  four  groups :  (1)  Those  in 
which  all  the  symptoms  are  marked  ;  (2)  those  presenting  skin 
lesions ;  (3)  those  showing  prominence  of  the  cardiac  and 
hepatic  symptoms  ;  and  (4)  those  presenting  paralytic  symp- 
toms. If  a  careful  history  and  examination  be  made,  the 
■diagnosis  is  easy.  From  the  standpoint  of  treatment  he 
sounds  a  note  of  warning  as  to  the  us  3  of  such  depressing 
drugs  as  potassium  iodid,  sodium  salicylate,  antipyrin,  ex- 
algin,  phenacetin,  etc.  After  the  poison  has  been  stopped 
the  treatment  is  symptomatic.  Reynolds  concludes  the 
article  with  a  review  of  previous  epidemics  and  an  analysis 
of  his  personal  statistics,     [f.j.k] 

5. — Buchanan  in  an  article  on  arsenical  peripheral 
neuritis  gives  the  history  of  a  number  of  cases  presenting 
themselves  at  the  Stanley  Hospital,  Liverpool.  In  nearly  all 
of  the  cases  a  history  of  beer-drinking  was  obtained.  Associ- 
ated with  the  neuritis  in  many  of  the  patients  there  were 
other  symptoms  common  to  arsenical  poisoning.  Buchanan 
concludes  the  article  by  saying  that  he  felt  it  his  duty  to 
notify  the  Health  Officer  of  the  city,  giving  the  names  of  the 
establishments  from  which  the  beer  was  purchased. and  the 
names  of  the  patients,     [f.j  k.] 

6. — Moullin  expresses  great  confidence  in  the  Riintgen- 
rays  as  a  diagnostic  measure  in  cises  of  urinarj'  calculus. 
If  two  careful  examinations  be  made  and  no  calculus  found 
it  may  be  taken  as  certain  that  none  is  present.  In  cases  of 
fixed  calculus  he  thinks  this  method  the  only  one  by  which 
the  presence  of  a  calculus  can  be  ascertained.  In  cases  of 
ureteral  calculus  the  rays  are  of  the  utmost  importance. 
Before  the  picture  is  made  the  bowels  should  be  thoroughly 
cleaned  out,  all  clothing  removed  and  the  patient  assume  a 
recumbent  position  when  the  rays  are  applied.  In  renal 
calculi  the  movability  of  the  kidney  from  respiration  often 
renders  the  taking  of  a  skiagraph  difficult.  In  these  cases  a 
firm  binder  should  be  placed  about  the  abdomen  and  the 
patient  be  asked  to  make  shallow  respiration,     [j.h.g.] 


7. — Cammidge  has  made  very  careful  experiments  with 
urotropin  as  a  urinary  antiseptic.  He  finds  that  the  drug 
possesses  no  diuretic  quality  nor  does  it  make  any  appre- 
ciable change  in  the  excretion  of  a  chemical  constituent  of 
the  urine.  The  drug  was  found  in  the  urine  10  minutes 
after  a  10  grain  dose  was  taken,  and  a  small  quantity  was 
found  26  hours  after  the  administration  of  the  drug  was  dis- 
continued. After  4  days  of  administration  the  pxtient  com- 
plained a  great  deal  of  a  sensation  of  formication.  In 
experimenting  with  the  germicidal  qualities  of  urotropin 
he  found  that  the  strong  solutions  kill  microorganisms,  but 
the  weaker  solutions  only  inhibit  their  growth.  The  typhoid 
bacillus  is  very  quickly  destroyed  by  the  drug,  but  the 
bacillus  coli  communis  and  the  staphylococcus  pyogenes 
aureus  show  considerable  resistance.  As  formaldehyde  in 
weak  solutions  kills  B.  coli  communis  it  is  not  thought  that  the 
good  eflfects  produced  clinically  in  cystitis  by  the  adminis- 
tration of  urotropin  are  due  to  the  production  of  free 
formaldehyde,  but  rather  to  urotropin  itself.  From  his  exper- 
iments Cammidge  concludes  that  urotropin  alone  may  by 
prolonged  heating  be  made  to  yield  formaldehyde,  but  that 
this  decomposition  does  not  take  place  at  the  body  tempera- 
ature ;  that  an  alkaline  solution  of  urotropin  may  be  simi- 
larly decomposed,  but  the  body  temperature  is  not  sufficient 
to  cause  the  change  ;  dilute  acids  quickly  decompose  urotro- 
pin on  boiling  with  the  evolution  of  free  formaldehyde  and 
that  this  change  occurs  to  a  less  degree  at  37°  C;  acid  salts — 
e.  g.  of  the  urine — liberate  formaldehyde  from  urotropin  on 
boiling,  but  not  at  37°  C;  that  the  acid  urine  of  a  person 
taking  30  grains  of  urotropin  a  day  does  not  contain  free 
formaldehyde.  If  the  foregoing  be  correct  an  important 
point  in  securing  the  full  eflfect  of  the  drug  would  be  that 
the  urine  should  be  acid  when  it  leaves  the  kidney.  This 
fact  is  borne  out  clinically  in  cases  of  typhoid  cystitis  where 
the  drug  is  of  particular  use,  since  here  the  urine  is  usually 
acid.  Cammidge  urges  that  since  the  typhoid  bacillus  is 
demonstrable  in  the  urine  long  after  the  disease  has  passed, 
that  the  administration  of  this  drug  would  be  of  advantage 
both  to  the  patient  and  the  community  at  large,    [j.h.g  ] 

8. — Elder  reports  a  case  of  infective  parotitis  follow- 
ing abdominal  section  for  appendicitis  in  a  man,  20  years  of 
age.  The  right  parotid  gland  was  involved  3  days  after  the 
operation.  Thirtysix  hours  later  the  left  gland  was  involved, 
during  which  time  the  swelling  of  the  right  had  subsided. 
Intense  pain  and  fever  accompanied  the  swelling.  Elder 
states  that  49  days  before  the  onset  of  the  symptoms  of  par- 
otitis, he  treated  the  patient's  brother  for  mumps.  The 
brothers  did  not  live  in  the  same  room  until  9  days  before 
the  infection  occurred.  He  concludes  by  saying  that  it  is 
impossible  to  say  whether  the  case  was  one  of  true  mumps 
or  parotitis  following  abdominal  section,     [p  j  k.] 

9. — Clarkson  reports  a  ease  of  gangrene  of  the  penis 
occurring  in  a  man,  aged  51  years,  dying  from  arterial 
sclerosis.  The  gangrene  was  complete,  was  moist,  and  no 
local  cause  in  the  condition  could  be  demonstrated.  The 
patient's  general  condition  was  extremely  bad,  and  he  died 
without  anything  radical  being  done  for  his  local  condition. 
Clarkson  refers  to  a  case  of  dry  gangrene  which  occurred  at 
King's  College  Hospital  in  the  service  of  Mr.  Partridge. 
[j.h.g.] 


New  York  Medical  Journal. 

February  2, 1901.     [Vol.  Ixxiii,  No.  5.] 

1.  A  Preliminary  Communication  with  Projection-Drawings, 

Illustrating  the  Topography  of  the  Paracoeles  (Lateral 
Ventricles)  in  Their  Relation  to  the  Surface  of  the 
Cerebrum  and  the  Cranium.    Edward  A.  Spitzka. 

2.  A  Case  of  Arsenical  Dermatitis.    A.  A.  Ohmann  Dumesnil. 

3.  On  the  Sterilization  of  Milk ;  Its  Advantages  and  Limita- 

tions.   A.  D.  Blackader. 

4.  Gallstones  and  Empyematous  Gallbladders.    Edwin  Rick- 

ETTS. 

5.  Appendicitis  in  the  Female.    Floyd  Wilcox  McRae. 

6.  Pharyngeal  Adenoids ;  Their  Frequency  and  Sequelae. 

Philip  D.  Kerrison. 

2.  — Ohmann-Dumesnil  reports  a  case  of  arsenical 
poisoning  in  a  young  woman  of  26  years,  who  took  a  tea- 
spoonful  ot  "  rough  ou  rats  "  with  suicidal  intent.    The  case 


27: 


The  Philadelphia"] 
>Ikdical  Jocrnal  J 


THE  LATEST  LITERATURE 


[Febboast  9,  an 


is  reported  especially  on  account  of  the  arsenical  derma- 
litis  which  developed.  The  lips  and  nose  were  swollen  and 
the  eruption  vesicular,  while  some  pustules  appeared  on  the 
face  and  buttocks.  The  vermilion  of  the  lips  presented 
no  lesions,  but  were  hot  and  dry.  The  localization  of  the 
eruption  is  of  interest,  together  with  the  fact  that  the  derma- 
titis followed  a  single  large  dose  of  the  drug,  while  it  usually 
appears  in  cases  where  small  repeated  doses  of  the  drug  are 
taken.    The  case  terminated  in  recovery,     [t.l  c] 

3. — A.  D.  Blackader  discusses  the  now  much  mooted  ques- 
tion of  the  advantages  and  disadvantages  of  sterilization 
of  milk.  He  concludes  that  by  sterilization  the  proteids 
are  probably  modified  and  rendered  less  digestive.  There  is 
also  a  probable  combination  of  the  saline  ingredients  with 
the  proteids,  and  the  salts  assume  a  condition  in  which  they 
are  less  readily  absorbed.  Natural  ferments  which  assist  in 
the  gastric  digestion  are  possibly  destroyed.  Again  an  alter- 
ation takes  place  in  the  emulsion,  normal  to  milk,  which 
may  also  have  a  distinct  eff  ict  of  lessening  the  digestibility 
of  cow's  milk  by  the  infant.  It  is  important  to  keep  steril- 
ized milk  at  a  continuous  low  temperature  and  to  use  milk 
soon  after  sterilization.  Blackader  recommends  using  fresh 
milk  carefully  drawn  and  in  which  lactic-acid-producing  bac- 
teria in  such  small  numbers  as  to  induce  no  important  alter- 
ations. This  milk  should  not  be  sterilized,  but  when  we  are 
not  sure  of  our  supply  it  is  advisable  to  sterilize  at  the  lowest 
temperature,  namely  60°  C.  maintained  for  15  minutes. 
[t  l.c  ] 

6. — McRae  first  discusses  the  comparative  frequency 
of  appendicitis  in  men  and  women,  and  thinks  that 
the  disease  is  much  more  common  in  the  latter  sex  than  is 
generally  supposed,  because  of  the  frequency  with  which 
this  disease  is  mistaken  for  inflammation  of  the  tube  and 
ovary  of  the  right  side.  Several  of  his  patients  had  had 
treatment  directed  to  the  pelvic  organs  for  a  more  or  less 
prolonged  period.  In  making  a  diagnosis  between  inflam- 
mation of  the  tube  and  ovary  and  of  the  appendix,  it  will  be 
found  that  the  pain  of  appendicitis  is  more  sudden  in  its 
onset,  and  very  much  more  acute  than  that  of  pelvic  die- 
ease  ;  it  is  frequently  accompanied  with  nausea,  and  muscu- 
lar spasm  is  usually  marked ;  the  general  disturbance  is 
greater,  and  the  progress  of  the  disease  is  more  rapid.  An 
intact  hymen  argues  very  strongly  for  appendicitis.  When 
there  is  doubt,  and  the  symptoms  are  aggressive,  it  is  much 
safer  to  operate  than  to  delay.  In  2  of  his  cases,  MacRae 
performed  appendectomy  and  nephrorrhaphy  through  the 
same  incision.  He  then  reports  in  detail  8  operations  done 
in  the  interval  between  attacks,  and  7  operations  done  dur- 
ing acute  attacks.    All  of  these  cases  were  successful,  [j  h.g  ] 

6.  —  Kerrison  discusses  the  frequency,  symptoms,  and 
diagnosis  of  pharyngeal  adenoids  in  detail,  and  con- 
cludes his  article  as  follows  :  1.  That  pharyngeal  adenoids  in 
children  are  very  much  more  common  than  they  are  gener- 
ally supposed  to  be.  2.  That  cases  of  moderate  development 
are  often  not  recognized.  3  That  adenoid  growihs  of  moder- 
ate size,  though  not  necessarily  accompanied  by  marked 
symptoms  at  the  time  of  their  development,  are  often 
responsible  for  grave  conditions  felt  during  adolescence  and 
adult  life.  4  That  unless  removed,  pharyngeal  adenoids  are 
in  nearly  all  cases  accompanied  by  more  or  less  impairment 
of  hearing.  5.  That  the  presence  of  adenoids  adds  greatly  to 
the  gravity  of  intercurrent  diseases  and  increases  the  patient's 
susceptibility  to  the  germs  of  tuberculosis  and  diphtheria.  6 
That  the  periodical  examination  of  children  for  the  presence 
of  adenoids  should  therefore  become  a  routine  measure 
of  prophylaxis.  7.  That  cases  of  moderate  development,  no 
le58  than  those  in  which  the  growths  are  of  large  size,  demand 
prompt  surgical  treatment.  8  That  the  treatment  should 
aim  at  complete  ablation  or  removal  of  the  growth,  which  in 
most  cases  is  best  accomplished  with  the  patient  under  the 
influence  of  a  general  anesthetic,    [j  h.g.] 


Medical  Record. 

February  2,  1901.    [Vol.  59,  No.  5.] 

1.  Radical  Cure  of  Inguinal  Hernia.    A.  M.  Phelps. 

2.  The  Treatment  of  Puerperal  Fever.    H.  J.  Boldt. 

S.  An  Operation  for  the  Relief  of  Stoppage  of    the  Tear 
Passage,  Abscess  of  the  Sac,  etc.    Erasmus  A.  Pond. 


1. — Phelps  gives  a  brief  history  of  the  operations  for  hernia 
and  then  thoroughly  discusses  the  modern  methods  of 
treatment  of  inguinal  hernia,  giving  especial  atten- 
tion to  the  operations  of  Bassini  and  Halsted.  He  claims 
that  many  relapses  follow  these  operations  because  so  much 
destruction  of  the  normal  muscular  tissue  has  taken  place 
from  the  long  continuance  of  the  condition  that  it  is 
impossible,  by  these  methods,  to  sustain  the  pressure  from 
within.  An  additional  reason  why  relapse  takes  place  after 
these  operations  is  that  there  is  no  eff'ort  made  on  the  part  of 
the  surgeon  to  reproduce  the  tissue  which  has  been  destroyed 
by  pressure,  and  to  prevent  the  stretching  of  the  connective 
tissue  which  always  results  from  wound-healing.  McBurney's 
operation  has  also  been  followed  by  the  most  lamentable 
relapses.  Phelpi  proposes  a  new  operation  for  which  he 
claims  the  following  points  of  originality:  1.  The  reproduc- 
tion of  large  masses  of  inflammatory  material  to  restore  the 
abdominal  parietes,  and  the  introdu-ition  of  a  fine  silver 
wire  filigree  throughout  the  entire  inguinal  canal,  over  the 
^transversalis  fascia,  which  adds  to  the  streqgth  of  the  weak- 
ened abdominal  parietes  and  prevents  the  new  material 
from  stretching.  2.  Cutting  ofi"  the  hernial  sac,  and  retreat- 
ing from  the  operation  exactly  as  from  any  abdominal 
operation,  stitching  up  the  peritoneum  and  traasversalis 
fascia  with  a  continued  suture  of  fine  silver  wire.  3.  The 
use  of  fine  silver  wire  with  a  continued  suture.  To  stBrilize 
the  wire,  after  it  has  been  thoroughly  boiled  or  steamed,  he 
throws  it  into  pure  carbolic  acid  a  few  minutes  before  the 
operation,  afr.er  which  he  dips  it  into  alcohol,  holds  it  over 
an  alcohol  lamp,  and  burns  the  alcohol  upon  the  wire. 
Drainage  should  be  avoided  if  possible  ;  but  if  necessary  in 
thick,  abdominal  walls  with  much  fat,  a  glass  drain  is  the 
best,    [w  A  s  D.] 

2. — B  )ldt,  in  speaking  of  the  treatment  of  puerperal 
fever,  classes  under  this  term  only  those  fevers  which  are 
caused  by  the  entrance  into  the  system  of  the  puerperal 
woman  of  pathogenic  microorganisms,  or  toxins,  from  some 
part  of  the  genital  tract.  In  the  treatment  prophylaxis  is 
the  most  important.  It  is,  therefore,  imperative  to  observe 
the  rules  of  antisepsis  in  obstetrics.  I",  is  essential  that  the 
patients  be  kept  at  perfect  rest,  and  attention  must  be  di- 
rected to  the  sea*  of  primary  entrance  of  the  fever-producing 
agents.  When  the  seat  of  the  infection  is  in  the  uterus,  this 
organ  is  found  enlarged  and  relaxed  and  the  cervical  canal 
generally  admits  of  the  introduction  of  the  index  finger. 
All  retained  products  of  conception  must  be  removed  under 
antiseptic  precaution  and  an  intrauterine  douche  is  always 
advisable  before  and  after  manipulations  within  the  uterus. 
Continuation  of  fever  and  purulent  secretions  from  the 
uterus  indicate  repetition  of  the  intrauterine  irrigation. 
Vaporization  is  more  effective  on  infection-elements  in  the 
deeper  structures  of  the  uterus.  The  antiseptic  and  hemo- 
static properties  of  steam  are  well  known,  but  its  dangers 
must  not  be  lost  sight  of.  When  applied  to  tie  interior  of 
the  uterus  it  causes  deep  destruction  of  the  uterine  tissue 
when  used  sufficiently  long  to  render  pathogenic  germs 
situated  in  the  muscular  structure  of  the  organ  inert. 
B  >ldt  believes  that  acute  bacteremia  is  always  fatal. 
Chronic  bacteremia  must  be  treated  according  to  the  indica- 
tions in  the  individual  patient.     |  w  a  s.d  ] 

3. — Pond  describes  an  operation  for  tde  relief  of  lach- 
rymal obstruction  and  suppurative  conditions  of 
the  lachrymonasal  pissagee.  He  believes  that  it  is  superior  to 
probing.  A  long  silver  probe  with  an  eyelet  is  threaded  with 
coarse  siik  and  is  passed  into  tl^e  canal  until  it  emerges  from 
the  nose,  whereupon  the  two  ends  of  the  thread  are  tied.  He 
leaves  the  slitting  of  the  canaliculus  to  the  judgment  of  the 
operator.  It  is  preferable  to  tie  a  larje  knot  so  that  by  pull- 
ing the  string  through  the  canal,  which  is  done  two  or  tnree 
times  a  day,  a  larger  opening  is  produced.  The  string  is 
removed  in  one  week.  The  operation  can  generally  be  per- 
formed under  cocain  anesthesia,  although  ether  may  have  to 
be  employed.  Three  cases  showing  good  results  are 
appended,    [m.rd] 


Medical  Xews. 

Fehrvary  S,  1901.    [Vol.  Ixiviii,  No.  5.] 

1.  An  Historical  Sketch  of  the  Jefferson  Medical  Collie  of 
Philadelphia. 


Febecarv  9,  1901] 


THE  LATEST  LITERATURE 


TTh 

Lm 


The  Philadelphia 
edical  jocenal 


273 


2.  Fatty  Degeneration  of  the  Heart.    Thomas  E.  Sattebth- 

WAITE. 

3.  A  Case  of  Puerperal  Sepsis  from  Retained  Lochia  (Lochio- 

metra),  with  Remark?.    George  P.  Shears. 

4.  Medical  and  Sociological  Aspects  of  the  G.tlve8ton  Storm. 

H.  A.  West. 

3. — Thomas  E.  Satterthwaite  takes  up  the  subject  of  fatty 
degeneratiou  of  the  heart  and  illustrates  his  division  of 
the  condition  into  three  arb.trary  stages  by  a  number  of 
cases.  The  first  stage  is  that  one  in  which  the  prognosis  is 
most  favorable ;  that  is,  if  the  patient  does  not  yield  to  the 
primary  disease  he  will  probably  recover  with  a  sound  heart 
if  properly  treated.  In  the  second  stage  prognosis  is  not 
good  for  total  arrest  of  the  fatty  process,  but  much  improve- 
ment may  be  brought  about.  The  third  stage  is  marked  by 
profound  implication  of  the  internal  viscera,  the  prognosis  is 
unfavorable  and  the  end  may  be  expected  within  a  few 
months.  Fatty  degeneration  of  the  heart  is  a  common 
affection,  but  it  is  not  to  be  classed  as  a  disease  fcui  generis 
but  as  a  process  attending  nonvalvular  as  well  as  valvular 
affections.  It  is  caused  by  fevers,  toxemias,  dyscrasias,  dis- 
orders of  nutrition  and  mechanical  injuries,  hut  it  may  be  a 
physiologic  process,  as  in  senility  or  after  parturition,    [t  l  c  ] 

3. — Shears  reports  a  case  of  puerperal  sepsis  or 
true  lochionietra,  not  so  mucti  because  of  its  rarity 
but  because,  he  ckims,  that  the  Eaglish  and  American 
textbooks  ignore  the  subject  altogether.  He  states  that 
the  sensation  communicated  to  the  palpating  finger  in  these 
cases  is  a  peculiar  one.  The  uterus  has  a  b<  ggy,  eemi- 
elastic  feel,  which  has  been  compared  to  that  of  the  preg- 
nant uterus.  He  confirms  the  statement  of  Oalshausen 
and  Veit  that  without  bacteriological  examination  there  is 
no  positive  di.*gnostic  sign  of  this  condition  except  in 
those  cases  in  which  a.  history  of  retained  placenta  estab- 
lishes the  diagnocis  of  pu  rid  (sapremic)  endometritis.  In 
most  cases  the  diagnosis  can  be  made  with  a  reasonable  de- 
gree of  safety  by  a  process  of  exclusion.  In  sepsis  from  re- 
tained lochia,  the  enlargement  of  the  uterus  disappears  with 
the  removal  of  the  cause.  Tne  possible,  though  rare,  occur- 
rence of  this  form  of  sepsis  from  retrodexion  of  the  puerperal 
uterus  should  not  be  forgotten.  A  bacteriologic  examination 
should  be  restricted  to  those  cases  in  which  it  is  necessary, 
for  purposes  of  treatment,  that  the  diagnosis  be  made  with 
absolute  certainty.  The  streptococcus  is  present  not  only  in 
severe  cases  but  in  all  grades  of  mild  cases,  and  to  wait  until 
the  bacteria  are  found  in  the  blood  current,  as  has  actually 
been  suggested,  is  to  wait  too  long,     [w.a.n.d  ] 

4. — West  discusses  the  Galvestou  storm  from  its  med- 
ical and  sociological  aspects.  After  the  hurricane  and 
due  to  the  overcrowding  and  high  temperature,  as  well  as 
the  lack  of  sanitary  measures,  insects,  especially  flies,  became 
a  petit.  It  was  observed  that  despite  the  fact  that  mosquitoes 
had  always  been  a  pest  in  Galveston,  malaria  was  very  un- 
common. After  the  storm,  however,  the  disease  became 
very  prevalent.  Most  of  the  cases  were  of  the  tertian  form. 
A  small  proportion  wtre  estivoautumnal  and  pernicious. 
Gastrointestinal  catarrh  and  dysentery  became  epidemic. 
Typhoid  fever  was  also  very  prevalent.  Scarlet  fever,  diphthe- 
ria, influenza,  and  dengue  appeared,  but  not  in  epidemic  form. 
Many  cases  of  mixed  infections,  as  of  malaria  and  dysentery 
coexisting  in  the  same  patient,  are  reported.  West  points 
out  the  need  of  proper  sanitary  measures,  especially  the 
disposal  of  the  city  sewage,    [t.l.c] 


Boston  Medical  and  Surgic^vl  Journal. 

January  SI,  1901.      [Vol.  cxliv,  No.  5.] 

1.  The  Treatment  of  the  Liter  Phases  of  Heart  Diseases. 

John  L.  Heffron. 

2.  Peritonsillar  Abscess.    F.  C.  Cobb. 

3.  Retropharyngeal  Abscess  in  the  Adult.    J.  L.  Goodalb. 

1. — Heffron  contributes  a  paper  on  the  treatment  of 
the  later  phases  of  heart  diseases.  When  compensa- 
tion has  failed,  the  first  indication  is  to  relieve  the  heart  of 
all  extra  work,  which  is  best  accomplished  by  rest  in  bed. 
In  the  second  place,  the  volume  of  blood  to  be  propelled  by 
the  heart  should  be  diminished  as  much  as  possible.  For 
this  purpose  the  hydragogue  cathartics  are  the  best,  and  of 


these  the  most  preferable  is  elaterium,  followed  in  order  of 
preference  by  calomel  and  the  saiines.  In  the  third  place, 
the  distressing  nervousness  of  the  patient,  which  increases 
the  irritability  of  an  already  overburdened  heart,  must  be 
controlled.  For  this  puroose  ice-bags  locally,  codein  and 
morphin  may  be  used.  Tne  author  believes  that  heroin  is  a 
modern  fraud.  In  cases  in  which  the  nervousness  is  not  ex- 
treme he  has  had  gratifying  results  from  the  use  of  the 
extract  of  cannabis  indica.  The  diet  must,  of  course,  be 
controlled.  When  failure  of  compensation  has  resulted  in 
dropsy,  it  is  sometimes  necessary  to  withdraw  the  fluid  by 
mechanical  means  before  drugs  will  exert  their  physiologic 
action.  The  author  believes  in  the  use  of  the  hot-air  cabi- 
net in  order  to  promote  the  excretion  of  sweat,  and  in  digi- 
talis, squill  or  potassium  acetate  to  stimulate  the  secretion  of 
urine.  In  order  to  aid  in  the  complete  retrograde  meta- 
morphosis of  waste  matter,  the  author  has  found  the 
svstematic  administration  of  oxygen  to  be  of  very  great  value. 
While  spartein,  cactus,  convallaria,  strophanthus,  and  adonis 
vernalis  are  useful,  digitalis  is  the  drug  that  can  be  the 
most  often  depended  upon.  In  cases  of  sudden  failure  of 
cardiac  power,  drugs  that  act  quicker  than  digitalis,  such  aa 
nitroglycerin,  alcohol,  ammonia,  and  strvchnin  are  used. 
Oertel's  method  of  hill-climbing,  and  the  Schott  method  of 
treatment  by  carbonated  oaths  are  extolled,     [j.m.s  ] 

2. — Cobb  believes  that  peritonsillar  abscess  is  the 
result  of  infection  by  the  microorganisms  of  acute  tonsillitis. 
The  suppuration  may  occur  in  the  tissue  around  the  tonsil 
or  in  a  space  described  by  Chari  as  the  pharyngomaxillary 
fossa.  This  space  is  bounded  by  the  tonsil,  the  internal 
pterygoid  muscle  and  the  palatine  arches.  It  contains  the 
great  vessels  and  is  divided  into  an  anterior  and  a  posterior 
portion  by  the  stylopharyngeus  muscle  and  its  fascia.  The 
conditions  that  may  be  confused  with  peritonsillar  abscess 
are  sarcoma  and  syphilis.  Cases  that  are  untreated  usually 
rupture  spontaneously  between  the  pillars  of  the  fauces. 
Cases  are  on  record  in  which  the  pus  has  made  its  way  into 
the  posterior  portion  of  the  pharyngomaxillary  fossa,  and 
thence  into  the  mediastinum,  with  fatal  results.  Thrombosis 
of  the  large  veins  and  pyemia  have  also  resulted.  The 
author  believes  that  the  knife  only  can  give  relief  and  that 
drugs,  such  as  the  salicylates  and  aconite,  on  account  of  their 
depressing  influence,  contribute  to  the  exhaustion  that 
follows  the  disease.  In  order  to  hasten  the  formation  of  pua 
he  employs  hot-water  gargles,     [j  M  s.] 

3.— Goodale  reports  the  case  of  a  man,  aged  18  years,  who 
presented  a  swelling  in  the  back  of  his  throat  which  had 
gradually  increased  in  size  for  4  weeks.  The  growth  was  not 
accompanied  by  fever  nor  by  other  disturbance  than  dys- 
phagia. Examination  of  the  throat  showed  a  fluctuating 
swelling  on  the  posterior  wall  of  the  pharynx  which  extended 
from  the  level  of  the  short  nalate  beyond  the  range  of  vision. 
Tnis  retropharyngeal  abscess  was  incised  and  some  of 
the  pus  inoculated  inti  a  guineapig.  Seven  weeks  after  the 
inoculation  the  animal  was  killed  and  the  characteristic 
lesions  of  tuberculosis  were  found.  The  patient  experienced 
immediate  relief  after  the  evacuation  of  the  abscess  and  5 
months  after  the  operation  his  throat  was  in  good  condition 
and  his  general  health  was  excellent.  This  seems  to  be  a 
case  of  tuberculous  retropharyngeal  lymphadenitis  ending  in 
suppuration.  Xo  point  of  entrance  for  the  infection  was 
found,     [j  MS  ] 


Journal  of  the  American  Medical  Association. 

February  S,  1901.    [Vol.  xxxvi,  No.  5.] 

1.  Mental  Symptoms  of  Cerebral  Syphilis.    James  H.  Mo- 

Bride.  , 

2.  A  Report  of  Seven  Operations  for  Brain  Tumors  and 

Cyst«.    Herm.  H.  Hcppe. 

3.  The  Skull  and  Its  Contents.     W.  H.  Eables. 

4.  Treatment  of  Tvphoid  Fever.    With  Bactericidal  in  Con- 

nection with  Other  Agents,  and    Some   Consequent 
Deductions.    J.  M.  Peck. 

5.  Influenza  Accompanied  with  Four  Distinct  Pneumonic 

Attacks.    Otitis  Media  Puruleuta  and  Cerebral   Hy- 
peremia, Colitis,  Inanition;   Recovery.    Juuus  VUr- 

MAN.  „    „ 

6.  Aural  Manifestations  of  Syphilis.    Francis  R.  Packard. 


274 


The  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[FEBSU.1BY  9,   UM 


7.  Prevention  of  Intracranial  and  Intravenous  Complications 

in  Suppurative  Diseases  of  the  Ear.    J.  H.   Wood- 
ward. 

8.  The  Cerebral  Neurons  in  Kelation  to  Memory  and  Elec- 

tricity.   Ja.mes  Grant. 

9.  Report  of  Two  Cases  of  Afebrile  Typhoid.    Charles  J. 

Whalen. 

1. — McBride,  in  discussing  the  icental  symptoms  of 
cerebral  syphilis,  states  that  the  mental  derangement  due 
to  either  remote  or  immediate  syphilis  may  simulate  every 
known  form  of  mental  disorder.  In  the  majority  of  cases 
there  is  mental  apathy  and  depression,  a  loss  of  self  control 
and  general  lowering  of  the  mental  procese.  He  gives  the 
history  of  a  case  exhibiting  obscure  early  symptoms.  He  also 
reports  another  case  illustrating  mental  weakness,  incongru- 
ous delusions  and  loss  of  memory.  He  states  that  a  common 
form  of  syphilitic  insanity  is  characterized  by  long  periods 
of  confusion  and  dulness  of  memory,  with  sudden  return  of 
apparent  sanity.  He  emphasizes  the  fact  that  insanity  may 
occur  soon  after  secondary  syphilitic  manifestations,  and  he 
cites  a  case  in  which  it  developed  6  months  after  infection. 
Recovery  from  syphilitic  insanity  hardly  ever  takes  place 
for  the  reason  that  the  repairing  power  of  the  brain  is  de- 
ficient. McBride  holds  the  view  that  syphilitic  disease  cor- 
responds to  the  following  law :  That  the  pathological  changes 
are  as  a  rule  variable,  irregular  and  diffuse.  He  further 
says  that  this  law  holds  good  in  regard  to  the  symptoms 
of  syphilitic  brain  disease.  Another  variety  of  syphilitic 
insanity  is  characterized  by  delusions  of  personal  icjury, 
or  persecution.  Many  icdividuals  suffer  from  nervous 
syphilis  and  inebriety,  so  that  it  becomes  difficult  to  give 
each  its  proper  etiological  significance.  Another  form  of 
insanity  is  characterized  by  systematized  delusions  which 
continue  for  years,  but  later  the  disease  shows  confusion  and 
gross  brain- failure.  He  states  that  some  cases  of  syphilitic 
insanity  and  paretic  dementia  are  strikingly  alike.  Recovery 
from  the  former  occasionally  occurs  while  never  from  paresis. 
Cure  (or  recovery  as  implied  in  many  other  diseases)  prob- 
ably does  not  follow  syphilis.  The  resisting  powers  of  the 
individual  are  undermined.  Brain  disease  is  likely  to  de- 
velop in  those  who  show  bad  hereditary  tendencies.  He 
believes  that  the  intelligent  and  well  educated  are  not  so  lia- 
ble to  insanity  as  the  ignorant  class.  This,  however,  does 
not  apply  to  syphilis,  for  both  classes  are  attacked  by  the  same 
poison,  and  as  the  resisting  powers  of  the  man  of  lower  type 
are  greater  the  poison  therefore  takes  a  weaker  grasp  upon 
his  constitution.  A  definite  diagnosis  between  syphilis  o( 
the  membranes,  of  the  ctrebral  arteries,  and  of  the  brain,  is 
regarded  by  McBride  as  very  difficult  and  often  impossible. 
He  lays  great  stress  upon  the  fact  that  the  entire  natural 
history  of  insanity  should  be  carefully  investigated  so  that  the 
whole  course  of  the  disease  may  be  studied  from  the  begin- 
ning, for  the  finding  of  the  origin  may  aid  in  prevention.  In 
conclusion  he  says  that  syphilitic  insanity  closely  resembles 
the  mental  changes  that  occur  in  the  senile,    [f.j.k.] 

3.— Hoppe  says  that  the  ill  favor  into  which  operations 
for  brain  tumor  have  fallen  is  due  to  the  fact  that  so  many 
operations  have  been  performed  for  suspected  brain  tumor 
where  sufficient  means  have  not  been  taken  for  the  purpose 
of  definitely  localizing  the  growth.  He  urges  that  operation 
for  brain  tumors  and  cysts  should  if  possible  be  performed 
early.  The  fact  that  operations  for  such  conditions  have  a 
high  mortality  should  not  deter  us  from  advising  operation 
when  we  consider  that  all  cases  of  brain  tumor  are  sure  to  be 
fatal.  This  is  true  even  of  the  most  benign  growths,  for  they 
continue  to  grow  and  ultimately  destroy  the  mental  as  well 
as  the  physical  life  of  the  patient.  Improved  results  must 
conae  from  the  neurologists,  not  the  surgeon,  for  early  diag- 
nosis and  localization  are  points  most  to  be  improved. 
There  is  a  great  difference  in  the  mortality  rate  of  the  cases 
operated  upon  where  the  tumor  was  definitely  located  and 
those  in  which  its  situation  was  uncertain.  Hoppe  quotes 
figures  to  prove  this  assertion.  He  reports  seven  cases  of 
brain  tumor  coming  under  his  care  and  operated  upon  by 
several  different  surgeons.  He  concludes  with  the  following  : 
(1)  Tumors  of  the  cortex  or  subcortical  region  which  may 
be  reached  through  the  calvariuni  are  operable ;  (.)  if  pos- 
sible the  operation  should  be  performed  early  when  the 
tumor  is  small ;  (3)  brain  surgery  is  limited  to  the  psycho- 
motor areas ;  (4)  complete  recovery  seldom  follows  operation 


for  tumor.  The  focal  symptoms  and  pain  are  relieved,  but 
epilepsy  and  paralysis  are  seldom  more  than  slightly  dimin- 
ished. It  must  be  remembered,  however,  that  the  life  of  the 
patient  has  been  saved ;  (5)  because  of  the  difficulty  of 
localization  and  the  small  field  for  operation  cerebellar 
tumors  are  inoperable  ;  (6)  the  cumulative  experience  of  all 
writers  is  against  the  exploratory  operation ;  (7)  the  profes- 
sion is  divided  as  to  the  advisability  of  palliative  operations; 
(8)  he  thinks  that  gummata  when  accurately  located  and 
diagnosticated  can  be  operated  upon  with  success.  Metastatic 
carcinomata  are  inoperable,     [j  H.G.] 

3. — Earles  discusses  the  anatomical  relations  between 
the  scalp,  skull  and  brain,  and  urges  a  careful  consid- 
eration and  treatment  of  all  injuries  of  the  scalp  and  skull 
because  of  the  damage  which  may  have  been  done  the 
brain,  or  which  may  result  from  infection  of  the  wound. 
He  then  describes  the  technic  to  be  followed  in  the  care  of 
such  wounds,    [j  h  g  ] 

4. — Peck,  in  discussing  the  treatment  of  typhoid 
fever,  advocates  the  use  of  small  doses  of  acetanilid  in  con- 
j unction  with  the  sponge  bath,  or  in  some  cases  with  the 
cold  plunge.  He  also  advises  the  use  of  chlorin  as  an  Intes- 
tinal antiseptic,  purging  with  calomel  and  thorough  washing- 
of  the  lower  bowel  with  sterilized  water.  Of  77  cases  of 
typhoid  fever  treated  upon  this  general  plan,  all  of  them 
recovered,     [f.j.k.] 

5. — Ullman  reports  a  case  of  influenza  accompanied 
by  4  pneumonic  attacks  with  recovery.  The  patient's 
age  was  23  months.  Tne  first  attack  was  one  of  broncho- 
pneumonia. On  the  eleventh  day  of  the  disease  the  temper- 
ature fell  by  crisis,  only  to  rise  again  in  2  days  with  the 
physical  signs  of  a  consolidated  left  upper  lobe.  On  the 
seventeenth  day  of  the  disease  the  temperature  again  fell  by 
crisis.  About  10  days  later  the  right  lower  lobe  revealed 
crepitant  rales  and  signs  of  consolidation.  This  attack 
lasted  until  the  thirty  fifth  day  following  the  initial  attack.  For 
7  days  after  this  attack  the  temperature  remained  normal. 
On  the  forty-second  day,  counting  from  the  initial  attack, 
the  temperature  rose,  the  pulse  and  respiration  were  fre- 
quent, and  upon  physical  examination,  hronchovesicular 
breathing  and  s ubcrepitant  rales  were  heard  in  the  left  inter- 
scapular and  mammary  regions.  He  concludes  the  article 
by  saying  that  the  patient  made  a  good  recovery,  and  that 
one  year  has  elapsed  since  the  dale  of  the  illness,    [f.j.k. J 

6. — Packard  found  among  2,500  consecutive  cases  treated 
in  the  ear  department  of  the  Pennsylvania  Hospital  7  in 
which  tne  trouble  was  distinctly  of  syphilitic  origin.  He 
then  gives  a  brief  account  of  each  cise.  He  does  not  think 
that  syphilis  is  a  very  frequent  source  of  ear  disease,  and 
yet  it  is  a  complication,  in  a  large  number  of  dispensary 
patients,  requiring  treatment.  Primary  syphilis  of  the  ex- 
ternal ear  is  extremely  rare.  Bulkley,  in  an  analysis  of  9,05$ 
extragenital  chancres  found  27  cases  in  which  the  sore  was 
located  on  the  external  ear.  Secondary  and  tertiary  mani- 
festations are  met  with  much  more  frequently.  Hereditary 
syphilis  of  the  ear  manifests  itself  most  frequently  in  the 
middle  and  inner  ear.  Syphilitic  disease  of  the  middle  ear 
originates  usually  from  infection  through  the  eustachian 
tube.  Lesions  of  the  internal  ear  occur  very  late  in  the 
course  of  syphilis.  The  symptoms  of  this  condition  are  tin- 
nitus and  deafness  coming  on  suddenly  in  either  one  or  both 
ears,  and  not  infrequently  accompanied  by  unilateral  facial 
palsy.  Packard  quotes  very  extensively  from  the  literature 
on  tills  subject,    [j.h.q.] 

7.— Woodward  thinks  that  the  mastoid  cells  are  more 
involved  in  inflammatory  conditions  of  the  middle  ear  than 
is  generally  supposed ;  and  because  of  the  great  danger  of 
extension  to  the  brain  and  its  membranes,  or  to  venous 
sinuses,  he  urges  early  operation  in  all  cases  when  the 
antrum  is  involved  in  the  inflammatory  process.  He  dis- 
cusses at  length  the  following  seven  indications  for  the  mas- 
toid operation  and  illustrates  his  remarks  with  the  report  of 
a  number  of  cases  :  1.  "  Bulging  of  Shrapnel's  membranes, 
with  swelling  at  the  inner  extremity  of  the  auditory  canal." 
The  usual  treatment  of  incision  of  the  drum  is  often  not 
sufficient,  and  unless  it  gives  efficient  drain^e  the  mastoid 
antrum  should  be  opened  at  once.  2.  "  Persistent  tenderness 
over  the  mastoid  process."  This  is  considered  as  indicative  of 
the  mastoid  operation  in  both  acute  and  chronic  cases  of 
otitis  media.  He  thinks  it  a  mistake  to  wait  until  suppura- 
tion   is    assured  ;     he    thinks    the    operation    should    be 


Fkbrdaey  9,  1901] 


THE  LATEST  LITERATURE 


FThe  Philadelphia 

L  ilKDICAL  JOCRNAL 


275 


done  to  prevent  its  formation.  3.  "  Swelling  of  the  soft 
parts  over  the  mastoid  process."  In  suppurative  otitis 
media,  when  this  symptom  presents  itself,  the  radical 
should  be  done.  The  simple  incision  may  cure  a  few 
ca«e8,  but  is  not  enough.  4.  "  Granulations  and  fistulae  in 
the  external  auditory  canal."  These  are  indicative  of  caries 
of  the  walls  of  the  middle  ear,  and  no  treatment  short  of 
the  mastoid  operation  will  result  ;n  a  cure  of  the  condition. 
5.  "  Persistent  and  relapsing  fistulae  behind  the  auricle." 
These  conditions  mean  operation  of  a  radical  kind.  The  cases 
with  relapsing  fistulae  are  more  apt  to  have  brain  complica- 
tions than  are  those  with  persistent  fistulae.  6.  "  Persistent 
and  especially  oflFentive  otorrhea."  These  cases  can  only  be 
cured  by  cleaning  out  thoroughly  all  the  infective  material. 
7.  "Sudden  marked  diminution,  or  absolute  cessation  is  a 
symptom  of  great  significance."  It  means  the  extension  of 
the  process.  Operation  should  be  done  at  once  and  the  sig- 
moid sinus  also  explored.  The  operation  as  described  by 
Macewen  is  recommended.  The  operation  is  done  not  for 
drainage  but  for  the  removal  of  diseased  tissue.  The  dangers 
mentioned  in  connection  with  this  operation  the  author 
thinks  are  greatly  overestimated.  He  closes  with  a  reference 
to  diseases  of  the  ncse  and  throat  as  predisposing  causes  of 
suppurative  diseases  of  the  car.     [j.h.g.] 

9. — Two  cases  of  afebrile  typhoid  are  reported  by 
Whaleu.  He  states  that  Liebermeister  has  called  attention 
to  afebrile  typhoid.  Whalen  believes  that  enteric  fever 
occurs  in  many  different  forms,  and  he  wishes  to  call  atten- 
tion to  2  cases  of  afebrile  typhoid,  which  he  has  observed. 
The  first  case  he  reports  occurred  in  a  male,  aged  23,  and 
the  second  case  in  a  lad,  aged  17.    [f.j.k  ] 


University  3Ietlical  Magazine. 

Janiuiry,  1901. 

1.  Sketch  of  Dr.  Alfred  Stil!tl    Charles  W.  Burr. 

2.  The  Rapid  Diagnosis  of  Rabies.    Mazych  P.  Eavenel  and 

D.  J.  McCarthy. 

3.  Remarks  on  the  Importance  of   the  So-called  Specific 

Lesions  of  Rabies.    William  G.  Spiller. 

4.  Experimental  Pancreatitis.    Sisiox  Flexner. 

5.  Investigation  on  the  Influence  ofKalagua  in  Experimental 

Tuberculosis.    D.  H.  Bergey'. 

6.  Diagnosis  of  Leukemia  from  the  Standpoint  of  the  Blood- 

Changes.    C.  Y.  White. 

1. — Charles  W.  Burr  has  given  us  a  dignified  and  just 
tribute  of  the  late  Alfred  StiUtS,  whose  long  life  of  S6  years, 
80  full  of  professional  activity  and  attainment,  terminated 
on  September  c  f  last  year.  Stillij  was  one  of  those  young 
Americans  who  returned  from  his  European  studies  under 
Louis,  and  others,  whose  zealous  work  did  much  to  place 
modern  medicine  upon  a  basis  of  fact  rather  than  theory. 
He  was  one  of  those  who  recognized  the  distinction  be- 
tween typhus  and  typhoid  fever.  The  other  American  whose 
name  is  associated  with  Still  O's  in  this  connection  is  that  of 
George  C.  Shattuck,  of  Boston.  Dr.  Stille  was  one  of  the 
founders  of  the  American  Medical  Association,  and  its  presi- 
dent in  1871.  He  was  also  an  original  member,  and  for  three 
years,  president  of  the  Philadelphia  Pathological  Society. 
For  many  years  he  filled  the  chair  of  Practice  of  Medicine  in 
the  University  of  Pennsylvania,     [t  l  c] 

2. — Ravenel  and  McCarthy  have  made  a  series  of  studies 
for  the  purpose  of  determining  the  rapid  diagnosis  of 
rabies.  Up  to  the  present  time  the  only  sure  means  of 
diagnosis  in  a  vast  majority  of  the  cases  has  been  the  inocu- 
lation of  rabbits  from  a  portion  of  the  nervous  system  of  the 
animal  inflicting  the  bite.  The  difficulties  of  this  method  are 
apparent,  and  the  most  important  is  the  fact  that  from  2  to  6 
weeks  must  elapse  before  the  diagnosis  can  be  made.  Investi- 
gators have  long  endeavored  to  discover  a  shorter  method  for 
practical  use,  but  it  was  Babes,  in  1886,  who  first  determined 
that  the  essential  lesion  of  rabies  consisted  in  an 
accumulation  of  embryonic  cells  in  the  neighborhood  of  the 
central  canal,  and  especially  about  the  large  modified  cells  of 
the  motor  centers  of  the  bulb  and  cord.  Babes,  in  1892,  re- 
aflirmed  these  observations  and  held  that  it  was  possible  to 
make  a  rapid  diagnosis  of  the  disease  by  microscopic  exami- 
nation of  the  bulb  and  cord.  He  proposes  the  name  "rabic 
tubercle "  for  the  pericellular  accumulations  of  embryon'c 


cells  described  by  Kolesnikoff".  Recently  Nelis  and  Van 
Gehuchten  discovered  in  the  spinal  ganglion  of  two  men  who 
had  died  of  rabies  and  in  a  number  of  animals  peculiar 
changes  which  they  considered  to  be  the  diagnostic  lesions  of 
the  disease.  They  hold  that  Babes  has  attached  an  undue 
importance  to  his  rabic  tubercle,  and  they  believe  that  the 
earliest  lesions  are  found  in  the  peripheral  cerebral  and 
sympathetic  ganglia,  and  the  changes  are  especially 
marked  in  the  intervertebral  ganglion  and  in  the 
plexiforni  ganglion  of  the  pneuniogastric  nerve. 
The  work  of  Ravenel  and  McCarthy  leads  mem  to  adopt  the 
views  of  Van  Gehuchten  and  Nelis.  They  describe  minutely 
the  method  employed  in  the  28  cases  of  rabies  which  they 
have  examined.  They  report  a  case  under  the  care  of 
Dr.  Krauss,  in  which  a  diagnosis  of  rabies  was  made  and 
death  resulted.  Microscopic  examination  of  the  bulb  and 
plexiform  ganglia  of  rabbits  inoculated  from  this  patient 
showed  the  characteristic  lesion.  They  lay  stress  upon  the 
point  that  in  dogs  the  changes  in  the  cerebral,  spinal  and 
sympathetic  ganglion  are  only  specific  of  the  natural  or  street 
rabies.  Their  conclusions  a:  e  as  follows  :  (1)  When  capsular 
and  cellular  changes  in  the  intervertebral  ganglia  with  accom- 
panying clinical  manifestattons  are  present,  they  afford  a 
rapid  and  trustworthy  means  of  diagnosis  of  rabbits.  (2)  When 
these  changes  are  not  present,  however,  we  are  not  to  con- 
clude that  rabies  is  not  present.  These  lesions  afford  valu- 
able contributory  evidence.  (3)  In  certain  cases,  when  the 
capsular  changes  are  slight,  the  changes  are  more  marked  in 
the  distal-peripheral  end  of  the  ganglia.  (4)  That  the  rabic 
tubercle  of  Babes  is  present  sufficiently  often  to  prove  of 
great  value  in  those  cases  where  only  the  central  nervoua 
system  is  obtainable  without  any  of  the  ganglia,  but  in  cases 
where  these  can  be  obtained  they  offer  a  simpler  and  easier 
method  of  diagnosis  than  do  the  brain  and  cord  themselves. 
[t.l.c] 

3. — William  G.  Spiller  advances  the  opinion  from  a  con- 
siderable number  of  careful  observations  that  lesions  similar 
to,  and  possibly  identical  with,  those  cf  rabies  may  occur  in 
other  conditions.  For  instance,  in  the  examination  of  the 
Gasserian  ganglion  in  a  case  of  endothelioma  of  this 
ganglion  he  found  areas  in  which  a  proliferation  of  the 
endothelial  cells  of  the  capsule  in  the  Gasserian  ganglion 
with  complete  destruction  of  the  nerve-cell  body.  While  the 
diagnosis  of  rabies  could  not  have  been  made  in  this  case, 
Spiller  became  convinced  that  irritation  or  intoxication, 
or  some  other  cause,  such  as  a  tumor,  could  produce  a 
proliferation  cf  the  cells  of  the  capsule  about  the  nerve-cell 
body.  In  another  case,  one  of  Landry's  paralysis,  he  found 
changes  strikingly  like  those  described  as  typical  of  rabies. 
He,  therefore,  concludes  that  no  lesions  are  specific  t3  rabies 
but  under  certain  conditions,  the  findings  may  be  of  con- 
siderable importance  in  the  diagnosis  of  rabies,    [t.lc] 

5. — Bergey  has  conducted  a  series  of  experiments  with 
kalagua,  a  plant  which  was  placed  upon  the  market  in 
1898  as  a  specific  remedy  in  the  treatment  of  tubercu- 
losis. A  number  of  physicians  have  reported  wonderful 
results  from  its  use.  He  conducted  five  sets  of  experiments, 
three  with  guineapigs  and  two  with  rabbits.  These  animals 
having  been  inoculated  with  tuberculosis,  were  subsequently 
treated  with  kalagua.  The  most  careful  observation  of  the 
animals  under  treatment  failed  to  reveal  the  slightest 
curative  eflPect  of  the  drug.  On  the  contrary,  the  tuber- 
culous animals  which  were  untreated  were  the  more  thrifty. 
Accompanying  the  article  are  a  series  of  tables  showing  the 
results  of  these  experiments,    [t.l.c] 

6.— C.  Y.  White  discusses  the  blood  picture  in  leukemia; 
the  distinct  types  of  this  disease,  the  difficulties  of_  diagnosis 
that  may  arise  from  certain  known  causes,  and  finally  the 
value  of  the  laboratory  method  in  making  the  clinical  diag- 
nosis. Leukemia,  from  the  microscopic  standpoint,  is 
divided  into  splenomyelogenous leukemia,  lymphatic 
leukemia  or  lymphemia.  The  blood  pictures  in  these  2 
forms  of  disease  are  usually  sharply  defined,  but  in  some 
cases  one  borders  upon  the  other.  Splenomyelogenous 
leukemia  is  characterized  by  the  presence  in  the  circula- 
ting blood  of  a  progressive,  pernicicuj  atemia  of  secondary 
origin.  The  anemia  being  accompanied  by  all  forms  of 
red-cell  degeneration,  and  by  a  leukocytosis,  polymorphous 
in  type  and  associated  with  the  presence  of  foreign  cells  and 
leukocytic  degenerations.  On  the  other  hand,  lymphatic 
leukemia  is  associated  with  a  less  marked  anemia  and  less 


276 


The  Philadelphia 

MkDICAL  JOfRN'AL 


] 


THE  LATEST  LITERATURE 


[F.2BBCABT  9,  ISM 


evidence  of  red- cell  degeneration,  by  a  less  pronounced  leuko- 
cytosis which  is  formed  chiefly  by  an  increase  of  lympho- 
cytes and  the  less  frequent  presence  of  foreign  cells.  The 
difficulty  of  diagnosis  of  leukemia  is  greatly  heightened 
when  it  is  accompanied  by  an  intercurrent  disease.  Two 
cases  are  cited  from  the  literature  showing  the  eflFects  of 
intercurrent  disease  on  leukemic  subjects.  In  one  there 
was  a  septic  condition  engrafted  upon  a  leukemia  of  3 
years' standing ;  in  the  other  a  malignant  tumor  developed 
in  the  course  of  the  case.  Prom  a  clinical  standpoint  alone, 
cases  of  leukemia  are  often  indistinguishable  from  pseudo- 
leukemia, splenic  anemia,  chronic  splenic  tumors, 
enlarged  glands  and  tumors  of  the  left  hypochon- 
driac region.  It  is  the  blood-changes  which  are  usually 
characteristic,  bat  not  so  in  all  cases;  for  treatment  or  the  oc- 
currence of  intercurrent  aflfections  have  frequently  altered  the 
blood  picture.  The  necessity  of  carefully  weighing  all  clin- 
ical data  is  important,     [t.l.c] 


Edinhurgh  Medical  Journal. 

January,  1901.    [N.  S.,  Vol.  ix,  No.  1.] 

1.  The  Borderland.    G.  W.  Balfour. 

2.  Experiences  with  the  Medical  Department  of  the  Army 

in  the  South  African  War.    John  Chiese. 

3.  Address  Delivered  to  the  Edinburgh  Obstetrical  Society, 

at  the  Opening  of  its  Sixty-second  Session.    Milne  R. 
Murray. 

4.  Operative  Procedures  for  Simple  Fractures  which  have 

been  Unscientifically  Treated.    Abbuthnot  W.  Lane. 

2. — Chiene  gives  a  resumi?  of  his  experiences  in  the 
South  African  war.  Many  of  his  points  are  important 
and  of  practical  interest.  Every  one  must  clearly  differen- 
tiate between  ho-pital  trains  and  ordinary  trains  carrying 
invalids.  In  the  former  the  soldiers  were  most  comfortable; 
in  the  latter  it  was  very  often  the  reverse.  The  author  is 
fully  satisfied  that  in  the  future  some  form  of  portable  cook- 
ing stove  must  be  carried  in  these  ordinary  trainf ,  by  means 
of  which  simple  food  may  be  cooked  for  the  soldiers.  On  a 
smooth  road  an  ambulance  cart  is  very  comfortable;  but,  in 
the  author's  opinion,  the  M'Cormack- Brook  ambulance  lit- 
ters are  certainly  more  comfortable  than  ambulance  carts, 
and  he  thinks  it  will  be  a  questior»  for  future  decision 
whether  these  litters  shall  not  take  the  place  of  carts  in  the 
conveyance  of  patients  from  train  to  hospital.  These  litters 
are  of  greatest  service  for  the  removal  of  the  wounded  from 
the  battlefield  to  the  nearest  hospital.  Soldiers  say  they 
would  rather  travel  in  an  ox  wagon  than  in  an  ambulance 
cart.  For  anesthesia  chloroform  was  the  favorite  drug. 
Ether  and  A.  C.  E  were  in  occasional  use.  Cbeine  never 
saw  any  trouble  with  any  form  of  anesthetic.  A  little  strug- 
gling, but  no  sickness  at  the  time,  and  very  little  afterwards. 
Can  the  sickness  in  civil  life  be  a  nervous  condition  which 
does  not  hold  good  amongst  soldiers  in  time  of  war?  He  is 
fully  satisfied  that  the  soldier  accepts  without  demur  any 
decision  that  is  made  in  regard  to  his  treatment.  He  is  con- 
tended and  asks  no  questions.  "  All  right,  I  am  ready,"  is 
his  answer.  The  author  is  satisfied  that  the  eflicient  use  of 
the  x-ray  apparatus  depends  very  much  on  the  experience 
of  the  man  who  uses  it.  Another  thing  which  was  very  evi- 
dent in  South  Africa  was  the  distinct  division  of  patients 
into  two  great  classes ;  those  who  were  anxious  to  go  home, 
and  those  who  wished  to  go  back  and  fight.  The  first  were 
all  septic  cases,  the  second  aseptic  ones.  Dysentery  is  the 
disease  that  most  takes  the  heart  out  of  a  man.  He  was 
very  anxious  that  his  hearers  should  full}-  understand  the 
great  value  of  hospital  trains  and  hospital  ships.  The 
wounds  made  by  lifle  balls  at  a  range  of  between  200  and 
400  yards  were  more  ragged  than  those  produced  at  a  range 
of  1,000  to  1,500.  The  cases  of  head  wounds  must  be  di- 
vided into  two  groups:  (1)  Those  in  which  the  bone  and 
brain  are  severely  injured  and  torn ;  (2)  those  in  which,  with 
a  comparatively  small  bone-wound,  the  brain  is  much  torn. 
In  the  first  the  irjury  is  probably,  if  no  shrapnel  is  being 
fired,  due  to  expanding  or  explosive  bullets.  In  the  second  the 
Mauser  bullet  may  be  the  cause  when  fired  at  a  short  range. 
The  green- coated  bullets  were  examined  chemically  by  Mar- 
Bhall.  Probably  the  cartridges  were  simply  coated  "with  suet 
or  tallow  for  the  purpDse  of  lubricating  the  rifle  barrel.    In 


course  of  time,  the  fatty  acids  originally  present,  and  which 
would  increase  in  quantity  on  keeping,  have  attacked  the 
underlying  metal,  forming  green-colored  copper  salts,  which 
have  gradually  spread  through  towards  the  outer  surface  of 
the  fatty  material.  From  the  point  of  view  of  those  against 
whom  the  ammunition  is  employed,  there  can  be  little 
difference  between  such  coated  cartridges  and  those  which 
have  not  been  so  treated ;  from  one  cause  or  another,  the 
coating  is  fairly  certain  to  be  completely  removed  before  the 
bullet  reaches  its  billet.  In  Africa  the  maj  Diity  of  the  cases 
of  cerebral  hernia  that  the  author  saw  were  on  a  fair  way  to 
recovery,  and  in  some  the  recovery  was  complete.  The 
antiseptic  treatment  can  not  fully  account  for  it.  Possibly 
it  was  the  larger  opening  in  the  bone.  Irvine,  a  civil  surgeop, 
used  solutions  of  formalin  varying  in  strength  from  5  to  25%. 
These  solutions  acted  by  drying  up  the  mass  and  were,  at 
the  same  time,  antiseptic.  Several  cases  of  severe  brain 
irjury  were  followed  by  recovery.  In  several  cases  of 
arteriovenous  aneurysm  much  improvement  resulted  from 
proximal  ligature  of  the  main  artery,  when  the  communi- 
cation was  between  the  carotid  artery  and  the  internal 
jugular  vein.  In  the  thigh,  ligature  of  the  femoral  artery 
did  good.  In  the  leg,  the  aneurysm,  as  a  rule,  was  laid 
open,  and  the  artery  and  vein  ligatured  above  and  below  the 
opening.  The  caies  were  more  allied  to  aneurysmal  varix 
than  to  varicose  aneurysm,  but  there  was  not  the  great  dila- 
tion of  the  vein  that  is  commonly  described  in  such  cases. 
The  absence  of  any  venous  dilation  gave  rise  to  the  query 
as  to  whether  the  condition  could  be  due  to  bruising  of  the 
artery  and  the  vein,  and  subsequent  matting  with  constric- 
tion. The  number  of  cases  of  painful  neuritis  from  bruising 
of  nerves,  the  cases  of  neuritis  due  to  adhesion  of  the  nerves 
to  bone  after  fracture,  and  the  cases  of  neuritis  due  to 
splinters  of  bullets  lodged  in  the  nerve  would  lead  one  to 
suppose  that  possibly  the  same  thing  might  have  occurred 
to  arteries  and  veins  lying  side  by  side,  and  by  matting  and 
constriction,  produce  symptoms  similar  to  those  met  with 
when  there  is  a  communication  between  an  artery  and  a 
vein.  In  lung  injuries  it  was  rare  that  the  patient  said  that 
he  spat  blood  at  the  time  of  the  accident.  Oa  the  other 
hand,  it  must  be  noted  that  in  many  cases  there  was  hemo- 
thorax, probably  from  the  intercostals,  and  most  of  the 
surgeons  were  agreed  that  if  the  blood  was  slowly  absorbed, 
tapping  assisted  absorption,  and  there  was  sJso  general 
agreement  that  a  rise  in  temperature  was  the  first  indication 
that  absorption  had  commenced.  Empyema  as  a  result  of 
lung  injuries  rarely  occurred.  In  all  the  cavities  wounds 
which,  from  former  experience,  would  have  certainly  proved 
fatal,  were  followed  by  recovery.  The  author  saw  several 
cases  of  penetrating  wounds  of  the  abdomen  in  which  com- 
plete recovery  had  taken  plac«  without  operation.  There 
should  be  no  delay  in  sending  out  the  best  incinerators,  and 
compelling  the  authorities  to  burn  the  dejecta.  The  civil 
surgeons  have  been  of  much  service  in  Africa,    [j.m.s] 

4.— Line,  in  discussing  the  operative  procedures  for 
simple  fractures  that  have  been  unscientifically  treated, 
calls  attention  to  2  classes  of  cases.  In  cases  of  the  first  class 
the  prominent  feature  is  the  condition  of  mechanical  disa- 
bility which  so  often  results  from  imperfect  restoration  of 
the  broken  bone  to  its  normal  form.  The  patient  mav  re- 
quire to  be  treated  either  for  a  more  or  less  complete  inability 
to  perform  his  functions  normally,  or  for  pain,  or  for  both 
conditions.  The  degree  in  which  the  above  are  present 
varies  considerably  with  the  displacement  of  the  fragments 
and  with  the  age  and  habits  of  the  patients.  They  are  gener- 
ally very  marked  when  they  oblige  the  sufferer  to  submit  to 
a  serious  operation  which  is  surrounded  with  many  risks 
and  ditficulties.  The  next  class  is  th.it  of  nonunion  between 
the  displaced  fragments,  a  so-called  false-joint  being  devel- 
oped at  the  seat  of  fracture.  A  very  large  number  of  these 
c&ses  have  come  under  the  author's  care,  and  have  derived 
a  varj-ing  amount  of  benefit  from  operative  procedures, 
undertaken  with  the  object  of  restoring  the  deformed  bones 
as  completely  as  possible  to  their  original  form.  In  the 
cases  of  the  upper  extremity  the  patient  usually  suffered 
from  such  a  limitation  of  the  movements  of  the  bones  on 
one  another  that  he  was  altogether  incapacitated  from  fol- 
lowing his  employment.  Occasionally  the  radius  and  the 
ulna  had  united  to  one  another.  Sometimes  also,  in  the 
case  of  a  female  patient,  the  very  obvious  deformity  of  the 
part,  rather  than  the  disability,  induces  her  to  undergo  an 


Fkbedary  9,  1901] 


THE  LATEST  LITERATURE 


TTh 

Lm 


The  PaiiADELPHLi 
EDiCAL  Journal 


277 


operation.  In  the  lower  extremity,  pain,  associated  with  a 
corresponding  amount  of  mechanical  disability,  forces  the 
sufferer  to  submit  to  an  operation,  however  serious.  The 
operative  measures  necessary  to  dissociate  fragments  that 
have  become  firmly  ankylosed  tog'=^ther,  and  perhaps  to 
adJAcent  bones  as  well,  and  to  saw  off  sufficient  bone  from 
each  fragment  in  such  planes  as  will  restore  the  outline  of 
the  necessarily  shortened  bone,  is  often  very  difficult,  and 
may  be  fraught  with  damage  to  important  adjacent  vessels 
and  nerves.  It  seems  little  short  of  ridiculous  to  read  the 
statements  of  surgeons  that  such.  me3hanical  disability  is  a 
rare  sequence  of  fracture,  and  that  it  can  usually  be  obviated 
by  the  use  of  massage  and  passive  movements  at  an  early 
date.  That  massage  and  passive  movements  serve  to 
diminish  the  disability  and  pain  that  wi.uld  otherwise  ensue 
if  these  fractures  are  left  for  an  indefinite  period  in  rigid 
casing,  is  quite  familiar,  but  such  measures  alone  do  not. 
constitute  sufficient  treatment,  and  are  merely  adjuvant. 
The  second  group  of  cases,  namely,  those  of  ununited  or 
imperfect'y  united  fractures,  are  due  also  to  the  same 
unscientifi?  treatment  of  fractures.  Lane  has  never  come 
acrofs  one  instance  in  which  union  would  not  have  resulted 
if  effioieiit  operative  measures  had  been  adapted,  and  further 
more,  he  believes  that  ununited  fracture  is  of  comparatively 
common  oci  urrence.  Twenty  case  histories  and  5  skiagraphs 
are  given,    [j.m  s  ] 


Munchener  medicinische  Wochensclirift. 

November  6,  1900.     [47.  Jahrg.,  No.  45.] 

1.  The  Influence  of  Nutritive  Enemeta  upon  the  Gastric 

Se  retion.    Metzger. 

2.  The  Employment  of  Untwisted  Strings  of  Reindeer  Ten- 

don for  Stitches  and  Ligaments.    Schiller. 

3.  Additional  Contributions  to  the  Bacteriology  of  the  Chemi- 

cal Disinfection  of  the  Hands.     Zauf.^.l  and  Schenk. 

4.  The  Occurrence  of  Demodex  Follif  uloruiu  in  the  Eyelid, 

and  its  Relation  to  Diseases  of  the  Lid.    Huxsche. 

5.  The  R<?lations   of  Oliver's  Symptom  to  Aortic  Aneurysm 

and  Intrathoracic  Tumor.    Jesses'. 

6.  A  Little  Known  Pupilary  Reaction  (The  Orbiculary  Re- 

fix  of  the  Pupil)   and  its  Therapeutic  Application. 

KiRCHNEB. 

1.— Metzger  has  studied  the  effect  of  nutritious  enemata 
upon  the  secretions  of  the  stomach,  in  dogs  and  human  be 
WJgs.  He  found  that  by  the  employment  of  alkarnose  he 
obtained  positive  results  in  8  experiments,  with  free  hydro- 
chloric acid  in  the  stomach-contents  of  4.  Simple  enemata 
of  water  did  not  have  this  effect.  He  then  undertook  to 
study  the  effects  of  different  enemata,  and  found  that  a 
mixture  of  bouillon  and  red  wine  was  most  certain  to  pro- 
duce a  secretion  from  the  glands  of  the  stomach.  Having 
satisfied  himself  with  these  results  in  dogs,  he  undertook  a 
series  of  experiments  upon  human  being.  After  ordinary 
enemata  it  was  found  that  there  was  sometimes  a  sl'ght 
secretion  of  mucus  which  failed  to  give  an  acid  reaction,  or 
gave  such  a  slight  acid  reaction  that  it  could  be  disregarded. 
After,  however,  an  injection  of  bouillon  and  red  wine, 
there  was  a  more  abundant  secretion,  and  also  considerable 
free  HCI.  It  seems  to  be  difficult  to  explain  these  results, 
for  there  is  no  reason  to  believe  that  they  indicate  active 
resorption  in  the  intestine  itself.  He  gives  a  record  of  his 
cases,    [j  s  ] 

2.— Scniller,  although  he  believes  that  as  a  result  of  mod- 
ern methods  of  preparation  catgut  can  be  adequately  steril- 
ized, and  can  be  prevented  from  being  absorbed  too  rapidly, 
nevertheless  has  made  some  investigations  in  order  to  deter- 
mine whether  it  could  not  be  replaced  by  fibrils  from  the 
tendons  of  various  animals.  He  found  that  the  ligamentum 
nuchae  of  the  reindeer  can  be  readily  broken  into  fibers 
after  brief  maceration  in  water,  and  that  these  fibers  are  quite 
strong  and  long  enough.  They  vary  considerably  in  diameter, 
however.  They  can  readily  be  rendered  sterile  by  the  ordi- 
nary methods  employed  for  catgut,  are  very  slowly  absorbed, 
disappearing  between  the  fifth  and  seventh  week,  and  appar- 
ently have  very  little  capillary  action,  so  that  they  are  not 
likely  to  conduct  liquids  deeply  into  the  tissues,     [j  s.] 

3. — Schenk  and  Zaufal  performed  a  series  of  experiments 


upon  their  hands  in  order  to  determine  the  effect  of  various 
methods  of  rendering  them  aseptic.  Vigorous  washing 
with  sand-soap  was  practically  useless ;  aft^r  30  minutes- 
hard  rubbing  the  enormous  number  of  122  colonies  per 
square  cm.  could  be  counted,  in  fact  the  prolonged  rub- 
bmg  seemed  to  bring  the  microorganisms  to  the  surface  in 
even  greater  numbers.  Even  less  satisfactory  results  were 
obtained  by  vigorous  rubbing  with  a  sterile  brush  and  sterile 
soap.  A  series  of  experiments  were  also  made  with  the 
mercurial  ethylendiamyn  solution  of  Kroenig.  Tais  con- 
^ist8  of  4  grams  of  ethylendiamyn,  10  grams  of  citrate  of 
mercury,  and  86  grams  of  water.  For  the  hands  the  solution 
can  be  diluted  from  1  to  30  up  to  1  to  200.  Fragments  of 
skin  which  had  been  previously  washed  with  sand  soap  and 
then  treated  with  this  solution,  were  excised  just  before 
operation,  and  these  remained  perfectly  sterile  for  long 
periods.  The  hands  were  almost  invariably  perfectly  steril- 
izi'd.  Other  solutions,  however,  such  as  bichlorid  of  mercury 
1 :  1000,  or  oxicdid  of  mercury,  can  also  be  employed  with 
success.  They  conclude  that  the  most  perfect  method  of 
sterilizing  the  hands  or  skin  is  to  wash  the  ha'ids  for  5 
minutes  with  sand-soap,  then  3  minutes  emersion  in  one  of 
the  above  mentioned  chemical  solutions,  which  should  be  as 
hot  as  can  be  borne.     [J  s  ] 

4. — Hunsche  has  made  a  number  of  investigations  upon 
the  small  ha  d  sacs  of  the  eye  lid  in  order  to  determine  the 
presence  of  the  demodex.  He  found  that,  omitting  young 
children,  in  whom  they  are  uncommon,  they  occur  in  92J% 
of  all  cases.  After  the  age  of  40  they  are  invariably  present. 
They  are  apparently  in  greater  numbers  in  those  cases  which 
suffer  from  severe  cachectic  states.  They  do  not  apparently 
produce  any  disease  at  all,  either  of  inflammatory  or  other 
nature,     [j.s.] 

o. — Jpssen  reports  2  cases  in  which  the  differential  diag- 
nosis heiween  mediastitial  tumor  and  aortic  aneurysm  wag 
exceedingly  diffi'  ult.  The  first  case,  a  woman  of  35,  had  had 
severe  cough,  diffi  'ulty  in  respiration  and  deglutition  for 
about  2  months.  Two  days  before  admission  to  the  hospital 
she  had  become  hoarse.  The  pulse  was  equal  on  both  sides  ; 
there  was  paralysis  of  the  left  recurrent  nerve,  but  entire  ab- 
sence of  tracheal  tugging.  The  diagnosis  of  stenosis  of  the 
trachea  was  made,  probably  aneurysmal  in  nature,  on  account 
of  the  absence  of  signs  of  vascular  disturbances.  At  the 
autopsy  extreme  atheroma  of  the  aorta  was  discovered,  with 
a  sac-like  dilation  pressing  upon  the  larynx.  The  second 
case,  a  woman  of  45,  had  suffered  from  severe  pain,  diffi^iulty 
in  micturition,  and  rapid  loss  of  power  and  weight.  There 
was  also  severe  pain  in  the  rectum.  There  was  slight  fever, 
due  to  a  cystitis,  which  was  readily  cured  by  appr  )priate 
treatment.  Stie  had  a  severe  attack  of  pain  followed  by 
edema  of  the  face,  more  pronounced  on  the  left  than  on  the 
right  side.  Tnis  was  explained  by  thrombosis  of  the  veins. 
There  was  a  broad  shadow  just  above  the  heart  when  the 
patient  was  examined  with  the  fluoroscope,  and  there  was 
distinct  tracheal  tugging  both  up  and  down,  and  to  the  right 
when  the  trachea  was  pulled  t  )ward  the  left.  Farther  thiom- 
bosis  occurred  and  the  patient  died.  A  diagnosis  had  been 
made  of  tumor  in  the  thorax,  producing  pressure  probably 
aneurysmal  in  nature.  At.  the  autopsy,  however,  a  small 
round-cell  sarcoma  was  found  invading  the  right  lung,  press- 
ing the  aorta  snd  forcing  it  firmly  against  the  trachea  and 
esophagus.  JcSf^sen  therefore  thinks  that  neither  Oliver's 
symptom  nor  Cardarelli's  sign  are  pathognomonic  for* 
aneurysm  ;  nor  do  they  necessarily  occur  in  all  cases  of 
aneurysm  of  the  thoracic  aorta.     [J  s  ] 

6. — Kirchner  gives  a  careful  analysis  of  the  pupillary 
phenomena  described  by  G.illassi,  Westphal,  and  especially 
by  Piliz,  and  mentions  a  few  of  the  positive  results  obtained 
from  these  studies.  It,  is  probable  that  f  jcal  lesions  will  be 
definitely  localized  when,  in  the  presence  of  paralysis  of  the 
facial  nerve  or  of  the  muscles  of  the  bulbus,  this  reaction 
fails.  He  believes  that  the  rtflt'x  passes  along  certain  tracta 
in  the  posi;erior  longitudinal  bundle.  It  is  difficult  to  say 
how  frequently  it  occurs,  and  it  is  not  certain  tUat  it  is  ever 
purely  unilateral.  He  advi  e-i  physici-ins  to  carry  out  in- 
vestigations of  reflex  systematically.     [J  s.] 

November  IS,  1900.    [47.  Jahrg.,  No.  46.] 

1.  The  Principles  of  the  Obstetiician  for  the  First  Nourish- 
ment of  the  Child.    H.  Craemek. 


278 


The  Philadelphia"! 
Medical  Jouenal  J 


THE  LATEST  LITERATURE 


[Feeeuaey  9,  1901 


2.  A  Case  of  Tetany.    F.  Dammer. 

3.  A  Case  of  Formalin  Poisoning.    L.  Zorn. 

4.  The  Treatment  of  Scoliosis  by  Plaster  Jacket.  A.  Schanz, 

5.  Intubation  in  Private  Practice.    Mabx. 

6.  A  Typical  Form  of  Neuralgia  of  the  Larynx.  G.  Avellis. 

7.  Some  of  the  Subjective  Symptoms  of  Neurasthenics.    L. 

HOEFLMAYR. 

8.  Surgical  Communications.    G.  Jochner. 

9.  A  Case  of  Fatal  Spontaneous  Omphalorrhagia  in  a  Hemo- 

philic Iafai.t.    J.  Paulsen. 
10.  The  Qjcurrence  of  Rhodan  in  the  Nasal  Secretion.    A. 
Keller. 

1.— Craemer  considers  one  of  the  first  principles  of  the 
obstetrician  is  not  only  to  bring  the  child  living  into  the  world, 
but  also  to  keep  it  alive;  hence  a  study  of  the  develop- 
ment and  nourishment  of  the  newborn  belongs  to  his  spe- 
cialty. Q'letelet,  in  1835,  first  gave  the  normal  curve  of 
■development  in  the  newborn  child.  This  characteristic 
weight  curve  shows  that  in  the  first  3  or  4  days  the  nourish- 
ment taken  does  not  compensate  for  the  loss  by  sensible  and 
insensible  excretion,  and  there  is  a  loss  in  weight  of  220  to 
250  g.  which  is  regained  by  the  tenth  day.  This  loss  of 
■weight  is  not  to  be  considered  as  a  disadvantage  to  be  avoided 
by  abundant  artificial  nourishment,  but  as  normal.  The  child 
really  needs  but  little  nourishment  during  the  first  48  hours, 
and  may  do  without  any  and  suflFer  no  injary.  On  the  other 
hand,  at  this  time  care  is  needed  in  the  proper  nourishment 
of  the  mother,  beginning  with  nutritious,  easily-digested 
fluids.  We  must  rest  in  the  position  that  the  healthy  woman 
•will  furnish  milk  adapted  to  the  infant.  Yet  there  are  nu- 
merous examples  in  which  irregularity  in  rest  or  care  of  the 
child  or  overabundant  feeding  has  produced  bad  results.  If, 
however,  there  is  a  failure  of  natural  nourishment  for  the 
newborn  infant,  Craemer  agrees  with  the  opinion  of  Biedert 
that  it  is  important  in  the  artificial  feeding  of  infants  that  the 
measure  of  nourishment  should  be  the  smallest  possible  ; 
that  this  principle  is  based  upon  abundant  experience.  He 
thinks,  however,  that  experiments  in  this  direction  should  be 
made  in  carefully  conducted  hospitals.     Iw.k] 

2. — Dammer  reports  a  case  of  tetany  in  a  woman,  35 
years  old,  in  whose  stools  segments  of  taenia  metliocanel- 
lata  were  found.  She  was  given  extract  of  felix  mas  and 
calomel,  followed  by  the  expulsion  of  the  worm  entire,  with 
the  head  attached.  She  was  very  weak  afterward,  and  had 
an  attack  which  began  with  a  "  creeping "  in  the  arms  and 
legs,  followed  by  unconsciousness.  On  regaining  conscious- 
ness, both  upper  and  lower  extremities  were  stiff.  She  per- 
spired, had  tinnitus  aurium,  and  visual  disturbances  during 
the  attack.  Her  hands  were  blue  and  cold.  Toe  attack 
lasted  about  5  minutes.  Other  attacks  occurred,  described 
by  her  physician  as  typical  tetany.  Both  Trousseau's  and 
Chvostek's  signs  were  present.  She  recovered  in  three 
weeks.  As  no  other  cause  for  the  attack  could  be  found, 
Dammer  concludes  that  it  was  due  to  the  extract  of  felix 
mas,  the  calomel,  or  both.  The  literature  of  the  subject  is 
given,    [m.o.] 

3. — Z  )rn  reports  a  case  of  a  man  of  44,  who  by  mistake 
had  swallowed  30  ccm.  of  formalin.  He  had  dyspnea, 
vertigo,  nausea,  vomiting,  and  a  feeling  of  burning  in  his 
mouth  and  stomach.  The  odor  of  formalin  was  still  present 
and  his  stomach  was  immediately  washed  out.  There  was 
slight  cyanosis.  Absolute  anuria  persisted  for  24  hours,  the 
Madder  remaining  empty.  The  bowels  were  loose,  with 
much  mucus.  Tne  urine  passed  later  contained  albumin 
and  casts.  His  pulse  was  small  and  rapid.  Examination  of 
the  glass  which  had  contained  the  poison,  revealed  formalde- 
hyde.   He  recovered  in  a  week,    [m.o] 

4. — After  a  full  review  of  the  literature  upon  the 
subject,  Scharz  states  that  a  plaster  jacket  should  only 
be  applied  in  scoliosis  after  attempts  to  improve  the 
existing  condition  have  been  made  by  all  the  other  known 
methods,     [m.o  ] 

5. — Marx  believes  that  intubation  possesses  most  of  the 
advantages  of  tracheotomy  and  is  an  easier  procedure,  need- 
ing no  assistants  is  quickly  done,  and  as  there  is  no  open 
wound  extension,  preparation  is  unnebessary.  Complications 
are  less  likely  to  occur.  After  the  tube  has  been  introduced 
it  requires  careful  attention,  and  must  be  kept  clean.  A  point 
that  has  been  held  against  intubation  is  the  liability  of  the  tube 
to  be  coughed  up,  or  pulled  out  by  the  string  that  is  intended 


to  keep  the  child  from  swallowing  it.  Should  this  accident 
occur  the  tube  can  be  easily  reintrioduced  with  but  very  little 
inconvenience.  Its  use  is  more  general  than  usually  sup- 
posed, and  it  may  be  used  in  any  constriction  of  the  larynx. 
[w.s.N.] 

6. — Avellis  reports  a  condition  common  to  adults  who 
are  otherwise  well,  yet  complain  of  severe  pain  upon  swal- 
lowing or  talking  loudly.  It  occasionally  dsappears  for 
days,  only  to  return  again.  The  pain  was  unilateral,  occa- 
sionally bilateral,  and  never  occurred  in  neurotic  individuals. 
There  were  no  other  symptoms.  Examination  failed  to 
elicit  anything  abnormal,  either  inside  or  outside.  These 
cases  are  more  frequent  in  spring  and  summer,  and  all  treat- 
ment seems  useless.  Avellis  came  to  the  diagnosis  of 
neuralgia  of  the  larynx  by  finding  thit  the  superior 
laryngeal  nerve,  at  its  outlet  in  the  thyrohyoid  membrane, 
was  very  sensitive  to  pressure.  Another  painful  point  was  in 
the  sinus  pyriformis,  where  the  nerve  lies  very  superficially. 
Treatment  with  the  antineuralgics,  phenacetin,  etc.,  aid 
with  warm  applications  cured  the  condition  at  once.  Avellis 
gives  the  diflFerential  diagnosis  between  this  condition  and 
the  ailments  which  might  be  confused  with  it,  rheumatism  of 
the  cervical  muscles,  lateral  bursitis,  and  hysteria.  He  also 
reviews  the  meaner  literature  upoQ  tha  iubject.    [mo  ] 

7. — Hoeflmayr  details  the  various  cardiac  manifesta- 
tions of  neurasthenia.  Tne  main  condition  to  be  re- 
lieved immediately  in  the  pseudocardiac  attacks  is  constipa- 
tion. In  all  cases  the  bowels  must  be  kept  regular.  Another 
common  symptom,  the  pressure  headache,  can  be  best 
treated  by  daily  cold  bathing,  which  causes  the  blood  to 
leave  the  hyperemic  cerebrum  and  to  spread  through  the 
peripheral  vessels.  He  reports  3  cases  in  which  opium, 
with  attention  to  the  bowels,  brought  about  prompt  recovery. 
[m.o.] 

8. — Jochner  in  an  article  on  surgery  tells  of  2  cases, 
the  first  a  cut  in  the  forearm,  completely  dividing  the  exten- 
sor communis  digitorum.  Erysipelas  followed,  and  when 
the  wound  healed  there  was  considerable  separation  of  the 
muscle  tissue.  After  all  inflammation  had  subsided  the 
ends  of  the  muscle  were  brought  together  with  silk  sutures 
and  perfect  union  followed  ;  although  the  arm  was  stiff  for 
some  time,  massage  and  electricity  restored  it  to  its  normal 
condition.  The  second,  a  case  of  obstruction  of  the  bowel 
with  an  operation  for  relief  (artificial  anus),  a  carcinoma 
being  found  to  involve  the  sigmoid  flsxure.  This  was 
followed  by  a  second  operation  in  which  he  removed  the 
carcinoma  and  brought  the  bowel  together  with  a  Murphy 
button  ;  that  night  the  patient  had  a  large  natural  act  on  of 
the  bowel.  Jochner  fully  expected  some  complication  to 
follow,  but  none  arose,  aud  the  button  was  passed  about  4  ' 
weeks  later.  When  the  patient  had  sufficiently  recovered  a 
third  operation  was  performed  to  close  the  artificial  anus. 

[W.SN  ] 

9.— Paulsen  mentions  as  causes  of  umbilical  hemor- 
rhage 3  diflferent  conditions :  Acute  fatty  degeneration  in 
the  newborn,  regarding  which  there  is  complete  darkness; 
congenital  syphilis;  and  general  sepsis.  Finally,  there  are 
rare  cases  of  umbilical  hemorrhage  in  children  affl.cted 
with  hemophilia.  Grandider  estimates  that  out  of  228 
cases  under  his  observation,  14  were  due  to  hemophilia. 
Paulsen  was  called  to  a  9-day-old  child  suffering  from 
umbilical  hemorrhage.  Tamponing  and  compression  by 
bandages  having  failed  to  check  tlie  bleeding,  he  thought 
to  try  suturing ;  but  the  fl  dw  of  blood  from  the  stitch  canal 
which  coagulated  with  difficulty,  convinced  him  that  it  was 
a  case  of  hemophilia  and  he  was  compelled  to  abandon  the 
attempt.  Tne  child  died  soon  after,  the  death  being  appar- 
ently hastened  by  internal  hemorrhage.  A  large  hematoma 
was  visible  under  the  mucous  membrane  of  the  rectum.  The 
hemorrhage  was  undoubtedly  spontaneous,  since  the  child 
was  found  with  the  blood  flowing  while  in  a  restful  sleep. 
From  his  own  experience  and  also  that  of  other  physicians, 
Paulsen  thinks  there  is  nothing  to  hope  for  from  surgical 
treatment  of  such  cases.  He  wished  to  try  gelatin  injection, 
but  the  rapid  approach  of  death  prevented  and  the  experi- 
ment remains  to  be  made  in  the  future,     [w.k.] 

10.— Keller  mentions  the  fact,  discovered  by  him,  that 
rhodan  is  present  in  the  nasal  secretion,  and  not  in 
the  saliva,  of  children  2  and  3  months  old.  He  used  paper 
colored  yellow  by  a  hydrochloric  acid  solution  of  chlorid  of 
iron,  which  was  turned  red  by  the  rhodan.    [m.o.] 


Februaky  9,  1901] 


THE  LATEST  LITERATURE 


TThk  Philadelphia 
L  Medical  Journal 


279 


November  20, 1900.    [47.  Jahrg.,  No.  47.] 

1.  The    Variability    and    Pleomorphism    of    Bicteria.      E. 

SCHWALBE. 

2.  Has  Hyperemia  or  Cocainanemia  of  the  Cocjunctiva  Pal- 

pebralis  an  Influence  on  the  Volume  and  Pulsation 
of  the  Superficial  Temporal  Artery  ?    0.  Rosenbach. 

3.  A  Contribution  to  the  Knowledge  of  the  Typhoid  Psy- 

choses.   Dieters. 

4.  The  Treatment  of  Chronic  Scoliosis.    Port. 

5.  The  Treatment  of  Diarrhea  and  Vomiting  with  Biedert'a 

Cream-mixtures.    F.  Geenscheim. 
€.  The  Treatment  of  Pachyderma  Laryngis  with  Silicylic 

Acid.      W.  LUBLINSKI. 

7.  Ca«e  of  Foreign  Body  in  the  Nose.    H.  Breitdng. 
S.  Antisepsis  and  Asepsis  in  Antiquity.    Maecuse. 

1, — After  commenting  on  the  two  main  theories  in  D,ir- 
■win's  "Origin  of  Species,"  that  of  "descent"  and  that  of 
"  natural  selection,"  Schwalbe  seeks  to  show  evidence  of  both 
in  bacteriology.  He  reviews  the  subject  from  the  beginning, 
explaining  in  detail  the  pleomorphism  of  bacteria,  takine;  the 
tubercle  bacillus  as  an  example.  Tubercle  bacilli  in 
niammals  and  in  birds  are  but  varieties  of  tbe 
same  species.  Finally,  Neumann's  experiments  with 
staphylococci  prove  that  many  varieties  may  exist,  ea3h 
forming  colonies  of  a  different  color.  It  seems  more  than 
probable,  though  by  no  means  proved,  that  the  theory  of 
natural  selection  exists  even  here.  Thus,  according  to 
Schwalbe,  both  of  Darwin's  main  ideas  prevail  amon^ 
liacteria,  just  as  they  do  among  the  other  living  species. 
[mo] 

2.— Rosenbach  calls  attention  to  the  variability  of  the 
caliber  of  the  temporal  artery  in  various  conditions  such  as 
migraine,  muscular  exertion,  neurasthenia,  etc.  He  has  also 
observed  that  after  the  instillation  of  a  1  %  solution  of  cocain 
into  the  eye  the  temporal  artery  on  the  same  side  becomes 
at  first  sligiitly  larger  and  pulsates  more  vigorously,  then 
when  the  anemia  of  the  corjunctiva  is  complete,  it  is  about 
normal  in  size,  and  as  the  subsequent  hyperemia  appears, 
gradually  decreases.  This  decrease  is  quite  persistent,  being 
present  for  at  least  one  hour  after  the  anemia,  when  the  con- 
junctiva was  about  normal  in  appearance.  As  the  vessel 
became  smaller  it  was  observed  that  its  wall  became  slightly 
more  rigid.  In  a  few  cases  the  artery  contracted  before 
anemia  appeared  in  the  conjunctiva.  This  phenomenon, 
however,  was  apparently  observed  only  in  2  of  a  number  of 
caaes,  although  Rosenbach  insists  that  exceptional  instances 
are  of  the  greatest  value  in  the  elucidation  of  obscure  patho- 
logic facts,    [j  s  J 

3.— Dieters  reports  two  caaes  of  typhoid  fever  in  adults, 
in  both  of  which  a  stage  of  initial  delirium  existed  before 
the  fever  appeared.  They  were  sitter  and  brother.  The 
father  was  an  imbecile  ;  the  mother  and  a  brother  had  been 
insane.  The  man,  aged  25,  had  never  shown  much  intellect. 
He  was  maniacal  for  two  days  without  fever,  growing  calmer 
•when  the  fever  appeared.  The  Widal  reaction  was  positive, 
and  he  recovered.  His  sister,  aged  17,  waa  maniacal  for  3 
weeks.  Then  she  developed  fever,  and  albuminuria,  and  be- 
came very  weak.  She  died  suddenly.  Autopsy  showed 
typical  typhoid  lesions  in  the  intestines.  Dieters  calls 
attention  to  the  fact  that,  in  all  such  cases,  typhoid  should 
.be  suspected.  He  does  not  wholly  agree  with  Audemard, 
•who  thinks  that  such  cases  may  exist  without  ever  showing 
«ny  signs  of  typhoid,     [m.o.] 

4. — Port  has  carefully  studied  the  vertebrae  in  chronic 
flcoliosis  and  has  found  that  the  curvature  of  the  vertebral 
column  is  due  in  the  large  majority  of  cases  to  an  abnor- 
mality in  the  growth  of  the  vertebra ,  or  rather  that  on  account 
of  the  unequal  loading  of  the  spine  the  deformity  occurs. 
As  a  result  he  does  not  believe  that  there  is  any  possible  cure 
after  the  epiphyseal  cartilages  have  ceased  growing,  and  that 
hope  for  cure  only  exists  during  early  childhood,  and  that 
the  pre  gnosis  becomes  progressively  worse  with  advancing 
years.  He  therefore  thinks  it  is  desirable  not  to  undertake 
treatment,  because,  if  the  muscles  on  the  concave  side  are 
«tretched  and  weakened  by  apparatus,  and  the  treatment  is 
interrupted  before  their  strength  is  restored  by  gymnaatics 
the  resulting  scoliosis  will  be  worse  than  before,     [m.o.] 

6. — On  account  of  the  absolute  want  of  good  milk,  the 
mortality  from  diarrhea  'with  vomiting,  among  infants 


under  1  year,  in  Worms  is  the  highest  in  all  Germany.  Gern- 
scheim  treated  such  cases  with  gastric  lavage  and  euter- 
oclysis.  After  purging  with  calomel,  he  gave  a  cream  mix- 
ture (1  part  cream  and  20  parts  water)  to  infanta  under  6 
months  old.  To  older  infants  he  gave  a  mixture  of  oat  meal 
gruel  and  milk  (1  parts  gruel  and  1  part  milk).  Of  37  caaes 
only  1  died.  His  youngest  patient  was  12  days  old  and  she 
is  now  quite  well,     [mo] 

6. — Lublinfki  believes  that  there  is  close  connection  be- 
tween i>achydernia  laryngis  and  leukoplakia  oris, 
both  depending  upon  the  abnormal  tendency  on  the  part  of 
the  epithelium  to  undergo  cornification.  He  uses  in  the 
treatment  of  both  a  solution  of  salicylic  acid  in  alcohol,  with 
moderate  success.  Oa  account  of  the  difficulty  of  applica- 
tion and  the  continual  irritation  of  the  vocal  cords,  cure  is 
uncommon,  and  recurrence  almost  the  rule  in  the  larynx, 
[j.s] 

7. — Breitung  reports  the  case  of  a  boy  3  years  of  age,  who 
placed  a  horn  button  in  the  right  nasal  cavity.  This 
was  pushed  further  into  the  noee  by  the  clumsy  efFurts  of  a 
local  physician,  and  finally  was  only  removed  by  the  com- 
bined effects  of  the  forceps  and  the  method  of  Ssibert,  that 
is,  vigorous  reverse  blowing  with  the  Politzer  bellows,     [j  s.] 

8. — Marcuse  mentions  the  various  methods  employed  by 
Moses,  Hippocrates  and  oth°rs  for  the  prevention  of  the 
spread  of  contagious  diseases,  and  mentions  particu- 
larly the  directions  of  Anagnostakis,  who  advises  clean 
dressings  and  water  so  warm  that  it  can  barely  be  borne. 

[JS] 

November  27, 1900.    [47.  Jahrg.,  No.  48  ] 

1.  Progressive    Hereditary  Spinal    Muscular    Atrophy    in 

Cnildren.    J.  Hoffmann. 

2.  The  TQeory  of  Self  infection  in  Obstetrics.    H.  Fehlikq. 

3.  A  Study  of  Suicide  from  300  Autopsies.  Arnold  Heller. 

4.  The  Artificial  Nourishment  of  Infants.    Soxhlet. 

5.  A  Practical  Method  of  Rendering  Cow's  Milk  More  Di- 

gestible.    VON  DUNGERN. 

6.  Personal  Prophylaxis  and  Abortive  Treatment  of  Gonor- 

rhea.   C.  Kopp. 

7.  The  Effect  of  Naphthalan  in  Eczema  of  the  External 

Ear.    H.  Sagebiel. 

8.  Atropin  Treatment  of  Ileus.    Holz. 

9.  Atropin  Treatment  of  Ileus.    Carl  Demme. 

10.  Atropin  Treatment  of  Ileus.    Luttgen. 

11.  Disinfection  with  the  So-called  Carboformal  Hot  Blocks. 

Erne. 

12.  William  Erb.    Nonne. 

1. — Hoffmann  describes  a  third  type  of  hereditary 
muscular  atrophy,  spinal  in  origin,  occurring  in  early 
infancy.  He  di^itinguishes  it  from  the  two  main  classes, 
pseudohypertrophic  muscular  atrophy  (Erb  and  Duchenne), 
and  progressive  neurotic  muscular  atrophy  (Charcot  Marie). 
Ic  begins  between  the  fifth  and  ninth  month,  in  children  of 
healthy  parents,  hitherto  well,  born  without  instruments.  In 
the  weeks  following,  the  child  moves  the  legs  at  the  hip  joint 
gradually  lees  and  less.  Soon,  then,  a  symmetrical  weakness 
is  noted  in  the  muscles  of  the  back  and  abdomen,  so  that 
the  child  can  with  difficulty  sit  up.  As  months  pass,  the 
shoulders  and  neck  also  become  affected,  and  the  legs,  fur- 
ther down,  first  with  weakness,  then  paralysis.  Finally, 
arms  and  hands  are  paralyzed,  and  the  reflexes  disappear. 
The  organs  of  the  special  senses  and  the  cranial  nerves 
(except  the  twelfth)  are  not  affected.  The  paralysis  is 
flaccid,  atrophic,  followed  later  by  kyphoscoliosis,  contract- 
ures, etc.  The  prognosis  is  fatal,  death  occurring  from  1  to 
4  years  after  the  disease  began.  Autopsy  shows  symmetrical 
degeneration  of  the  peripheral  neurons  of  all  the  nerves 
leaving  the  brain  below  the  hypoglossal,  and  widespread 
severe  muscular  atrophy.  The  brain  is  normal ;  there  are 
no  bulbar  symptoms.  The  literature  of  the  subject  follows. 
[M.o] 

3.— From  an  examination  of  300  bodies  brought  m  aa 
suicides.  Heller  collecta  theae  facta:  The  majority  were 
between  20  and  60  yeara  old ;  more  men  than  women ;  the 
majority  hanged  or  drowned  themselves;  comparatively  few 
men  took  poison  (that  most  used  waa  potaasium  cyanid), 
while  a  number  of  women  took  phosphorus.  The  suicides 
occurred  mostly  in  the  spring  months.    Twenty-four  percent 


280 


The  Philaj>klphxa~| 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Febbuabt  9,  un 


had  acute  diseases;  47%  were  alcoholic;  47%  of  the  women 
were  menstruating  or  pregnant ;  in  all,  43%  were  not  account- 
able for  their  actions.  He  ends  with  a  discussion  of  the 
German  laws  upon  suicide,     [m.o.] 

6. — von  Dungern's  method  of  making  cow's  milk  more 
digestible  is  to  heat  the  milk  ta  the  temperature  of  the  body, 
and  to  cause  clot  formation  by  the  addition  of  lab-ferment, 
added,  as  a  rule,  with  the  milk  sugar.  This  is  tnen  shaken 
up,  so  that  only  very  fine,  easily- digestible  clots  remain. 
[mo] 

6. — Kopp  has  found  that  protargol-glycerin  solution,  ap- 
plied early,  will  abort  most  cases  of  gonorrhea,  and  dwells 
upon  personal  hygiene  as  a  prophylactic  measure,   [w.s.n.] 

7.— Sagebiel  has  employed  naphthalan,  a  peculiar  form 
of  raw  naphtha,  in  cases  of  eczema.  Five  patients  sufiFer 
ing  from  chronic  eczema  gave  extellent  results  in  4,  and  dis- 
tinctly bad  results  in  1.  In  35  othf  r  cases  with  acute  eczema 
the  results  were  satisfactory  in  32,  and  unfavorable  in  3. 
This  substance  has  the  consistency  of  a  salve,  and  is  applied 
directly  without  previous  preparation  of  the  surface,  such  as 
the  removal  of  crusts,  etc.  Then  a  bandage  is  applied  and 
changed  once  in  24  hours,  with  renewed  applications  of  the 
drug.  In  all  the  favorable  cases  desquamation  occurred 
quickly,  and  without  reaction,  and  a  complete  cure  was  ob 
tained  in  an  interval  of  from  2  days  to  3  weeks.  In  the  4 
unfavorable  cases  there  was  a  pronounced  inflammatory 
condition  with  redness  and  swelling      [j  s] 

8. — Holz  reports  the  case  of  a  man,  42  years  of  age,  who 
was  suddenly  attacked  with  colic  like  pains  in  the  abd  )men 
followed  by  gradually  increasing  meteorism,  difE  -ulty  in 
breathing,  and  apparently  complete  obstruction  of  the 
bowels.  The  patient  was  treated  with  opium  and  enemata, 
the  latter  sometimes  of  enormous  size,  but  utterly  without 
results.  Finally,  on  the  fourth  day  J-^  grain  of  atropin  was  in- 
jected hypodermatically.  The  following  day  there  was  ex- 
pulsion of  considerable  flatus,  followed  by  a  firm  movement, 
and  the  patient  rapidly  recovered,     [j.s  ] 

9. — Demme  reports  2  cases  of  intestinal  obstruction 
where  he  injected  0  005  gram  (about  yW  gram)  of  atropin 
into  the  abdominal  wall  and  m  a  few  hours  alterwards  the 
bowels  operated  freely,     [w  s.n  ] 

10. — Luttgen  reports  a  case  of  obstruction  of  the 
bowel  occurring  in  an  anemic  woman  05  yeari  of  age,  who 
for  years  had  sufl'ered  from  an  uncontrollable  femoral  hernia. 
Large  doses  of  castor  oil  and  jalap,  etc.,  as  well  as  injec 
tione,  were  given  without  relief.  Il  then  looked  as  if  the 
hernia  was  the  cause  of  the  trouble,  but  operation  proved  the 
bowel  here  to  be  normal.  The  day  afier  operating  a  solution 
containing  0.005  gram  (about  i',  grain)  atropin  sulfate  was 
injected  into  the  abdominal  wall,  this  caused  severe 
symptoms  of  atropin  poisoning  and  also  considerable  reac- 
tion, but  in  about  12  hours  the  bowels  operated  and  the  case 
then  progressed  favorably,     [w  s.n  ] 

11.— Erne  reports  great  success  in  disinfecting  with  the 
carboformal  hot  blocks. 

12.— A  history  of  E.-b's  life  and  works,  in  celebration  of 
his  sixtieth  birthday. 

December  4, 1900.    [47.  Jabrg.,  No.  49] 

1.  A  Method  of  Determining  the  Internal  Friction  Resist- 

ance of  the  Human  Blood.    Hiksoh  and  Beck. 

2.  The  Application  of  the  Diverticulum  Bjugie  in  Tumors 

of  the  Eiophagus.    Sfarck. 

3.  The  Treatment  of  Tuberculosis,  with   Reference  to   the 

Cause.    Klebs. 

4.  The  Importance  of  Alcohol  for  Disinfection  of  the  Hands 

Braatz. 

5.  Observations  upon  the  Effects  of  Treatment  with  Amvlo- 

form    in   Curonic   Suppuration   of   the   Middle    Eir. 
Sagebiel. 

6.  A  Case  of  Pityriasis  Rubra  Pilaris.     HtioEL. 

7.  The  Action  of  Atropin  upon  the  Intesiines.     Ostermaier. 

8.  The  Justiti.'ation  of  the  Djstrine  of  Sdlf  Infection  in  06 

6tetric3.    Fehlino. 

9.  The  Artificial  Nourishment  of  Infants.    Soxhlet. 

1. — It  is  obvious  that  the  resistance  that  is  exerted  to  the 
movement  of  a  fluid  in  a  system  of  tubes  depends  upon  2 
facts  ;  first,  the  cahber  of  the  tubes,  and  second,  the  internal 
friction  of  the  liquid,  or  its  vicosity.    It  is  not  reasonable  to 


suppose,  therefore,  that  all  cases  of  increased  resistance  in 
the  human  blood  are  due  to  arterial  sclerosis,  and  it  seems 
likely  that  possibly  in  nephritis  the  increased  work  of  the 
heart  may  be  due  to  some  alteration  in  the  composition  of 
the  blood.  The  object  of  Hirsch  and  Beck  was  to  discover 
some  method  by  which  the  amount  of  resistance  due  to  the 
condition  of  the  blood  could  be  measured.  They  adopted  in 
general  the  method  of  Hurthle,  and  working  with  human 
blood  found  that  in  the  same  individual  the  variations  in  the 
time  required  for  a  given  qiantity  of  blood  to  pass  through 
the  capillary  apparatus  was  not  more  than  |  of  a  second, 
whereas  between  different  persons  suffering  from  different 
pathological  conditions  the  variation  was  between  26  and  82 
seconds.  The  essential  feature  of  the  apparatus  is  that  the 
blood  is  forced  through  a  capillary  tube  of  known  size,  by 
constant  pressure  ;  tae  period  required  for  the  blood  to  pass 
through  this  tube  indicates  its  vicosity.  The  reckoning  of 
the  vicosity,  however,  is  accomplished  by  means  of  a  com- 
plicated formula  and  is  compared  with  the  vicosity  of  water, 
at  the  same  temperature,  that  is  38°  C.  The  present  com- 
munication is  preliminary,  and  the  authors  merely  stite 
that  in  more  than  100  experiments  upon  unchanged  human 
blood  they  fouad  that  the  results  agreed  with  the  law  of 
Poiseuille,  and  corresponded  closely  with  those  of  Hurthle 
upon  animal  blood,     [j  s.] 

2. — S:arck,  in  ihe  niudy  of  esophag-eal  tumors,  finds 
that  the  diverticulum  sound  meets  the  requirements 
better  than  all  otners.  It  acts  as  a  pathfiader.  in  cases  of 
malignant  tumors  where  the  surface  is  very  uneven,  with 
many  poc?ket8,  the  exact  width  of  the  canal  can  be  deter- 
mined I  the  location  of  the  tumor  can  easily  be  made  out 
and  its  lower  border  reached  ;  and  the  stomach  and  contents 
can  be  s.udied.  Besides  it  is  of  use  therapeutically,  for  by 
passing  it  through  the  c  jnstricted  p  )rtion,  f  >od  can  be  placed 
fn  the  stomajh,  or  the  stenosis  may  be  dilated,  and  if  any 
irregularities  in  the  canal  exist  they  will  also  be  straightened, 
[w  s  N.] 

3. — Klebs  details  a  series  of  experiments  made  upon 
white  rats,  concluding  that  the  ability  to  withstand  tubercle- 
toxin  bears  no  relation  to  the  weight  of  the  individaal,  that 
tubercle-toxin  may  act  cumulatively;  and  that  tubercu- 
locidin  will  raise  the  temperature  that  the  tubercle  toxin  had 
lowered.  Its  action  decreases  in  power  when  given  in  re- 
peated doses.  Tnerefore  all  tubercle-toxin  must  be  well 
removed  before  thinking  of  treatment  with  specific 
extracts  from  cultures  of  tubercle-bacilli.  He  re- 
ports a  cise  to  illustrate  this.  Tneu  follow  cases  which  were 
treated  with  tuber  -ulocidin,  in  all  of  which  the  tuberculosis 
became  latent.  Success  by  this  treatment  can  only  be 
expected  in  those  morbid  processes  which  were  produced 
directly  by  the  tubercle  bacilli.  Tuberculocidin  may  be 
given  by  the  mouth,  by  hypodermic  injections,  and  by 
applications  directly  to  open  wounds.  Klebs  reports  a  sur- 
gical case  in  which  it  was  successfully  used,    (m  o.) 

4. —  Braatz  givs  the  following  reasons  why  alcohol  is 
valuable  for  disinfecting:  the  hands  :  (1)  Alcohol  atworbs 
the  air  ndd  in  the  pores  ot  the  skin;  (2)  before  a  liquid  can 
reach  the  skin  behind  this  air  it  must  be  absort>ed ;  and 
(3)  alcohol  dissolves  about  10  times  mi)re  air  than  water, 
thereby  reaching  the  germs  better  than  any  antiseptic  dis- 
solved in  the  latter,    [w.s  s  ] 

6. — Sigebiel  has  eiup  oyed  amyloform  in  the  treat- 
ment of  purulent  otitis  of  the  middle  ear,  and  concludes 
thai  It  is  of  little  value.  It  is  c  imposed  of  96%  starch  and 
4%  formaldetjyd,  and  the  starch  being  insoluble,  forms  in 
lumps ;  he  therefore  prefers  some  p  )wder  easily  dissolved, 
such  as  boric  acid  or  xerofor  n.     [w  s.s] 

6. — Hii^el  reports  a  case  of  pityriasis  rubra  pilaris  in  a 
laborer,  72  years  old,  who  was  pcrltc.ly  well  up  lo  2  years 
ago.  Tnen  he  had  cancer  of  the  lower  lip,  which  was  extir- 
pated. Just  a  year  ago  he  notic  d  a  slight  itching  in  the 
extremities,  which  gradually  spread  over  the  entire  C)ody. 
His  body  was  covered  with  thick,  shiny,  scaling  papules, 
never  couflaent,  and  the  extremities  showed  wrinkles  and 
firsures.  About  each  hair  follicle  wa't  a  raised  epidermic 
mass,  looking  like  "goose-flesh."  Under  the  scales  the 
epidermis  was  red  and  hyperemic.  Arsenic,  given  subcu- 
taneously,  was  stopped  on  account  of  diarrhea.  Bjtic  oint- 
ment was  used  externally,    [m  o  J 

7. — Oitermaier  reports  a  case  of  biliary  colic  due  to  gall- 
stones, in  which  the  symptom*  were  relieved  by  a  hypoder- 


IFbbkdary  9,  1901] 


THE  LATEST  LITERATURE 


CThb  Philadelphia 
Medical  Jodsnal 


281 


mic  injeclion  of  '  grain  of  atropin ;  and  of  a  man,  80 
years  of  age,  that  had  been  absolutely  constipated  for  10 
■days,  and  was  profoundly  collapsed,  who  was  greatly  im- 
proved by  a  hypodermic  injfcdon  of  ,'5  grain  of  atropin. 
This  wag  repeated,  and  finally,  on  the  tifteenth  day,  there 
was  a  copious  evacuation  of  feces.  The  p  itient  recovered 
completely.  He  believes  that  in  8u<  h  cases  the  eSect  of 
atropin  is  exceedingly  satisfactory,     [j  9.] 

8. — Fi^hling,  who  does  not  accept  Ahlfeld's  theory  of 
self-iufectioD,  thinks  that  the  name  is  often  incorrectly 
applied  to  cases  in  which  the  \nfection  arises  externally.  His 
reasons  are:  (1)  That  absolute  disinfection  of  the  hands  is 
today  impossible;  (2)  that  there  appear  in  the  genital  tract 
of  pregnant  women  saprophytic  microbes  closely  resembling 
and  easily  mistaken  for  pyogenic  bacteria,  yet  not  usually 
the  cause  of  infection ;  (3)  that  it  is  possible,  during  the 
puerperium,  for  bacteria  to  enter  the  vagina  and  even  the 
uterus  from  the  external  genitalia,  following  injuries  to  tlie 
•vulva.  He  then  gives  the  experience  and  statistics  of  many 
obstetricians,  by  whom  his  views  are  confirmed.  He  says 
that  the  great  advance  in  the  prophylaxis  and  treatment  of 
puerperal  fever  is  only  since  Lister.  Bacteriological  exami- 
nations during  the  last  ten  years  have  shown  us  how  complex 
the  condition  is.  Farther  advance  and  additional  light  can 
only  be  gained  when  bacteriologic  and  clinical  examinations 
keep  together  hand-in-hand.  When  positive  knowledge  has 
been  obtained  concerning  the  above-mentioned  premises,  the 
question  of  self  infection   may  be  definitely  decided,     [mo] 

9. — After  rev'ewing  the  experiments  done  to  find  the  cause 
of  scurvy  and  rickets,  Soxhlet  shows  that  cow's  milk, 
though  containing  about  twice  as  much  sodium  chlorid  as 
human  milk,  is  yet  too  poor  in  salt  to  satisfy  the  increased 
demands  made  by  it  upon  the  hydrochloric  acid  production 
of  the  stomach.  Tae  old  practice  of  adding  a  pinch  of  salt 
to  cow's  milk  when  preparing  an  infant's  food,  is  thus  proved 
to  be  reasonable.  Then  he  details  the  experiments  of  Z  weifel, 
which  show  that  sterilized  milk  is  easier  digested  than  un- 
cooked milk.  He  quotes  many  passages,  where  sterilized 
cow's  milk  was  used  to  cure  rachitis  and  scurvy,  and  ends  by 
advising  the  home  modification  and  sterilizUion  of  milk 
mixtures  by  the  mother,    [mo.] 

December  11,  1901.     [47.  Jahrg.,  Xo.  50  ] 

1.  Contributions  to  the  Question  of  the  Traumatic  Motility  of 

the  Kidneys.    Payr. 

2.  The  Action  of  Certain  Poisons  upon  the  Liver  Flukes  (Dis- 

tomum  Hypaticum).    Tappeiner. 

3.  Is  the  Appearance  of  Acute  lodm  Intoxication  After  the 

Use  of  Potassium  lodid  Dependent  upon  the  Rhodan 
Contained  in  the  Saliva  and  the  Secretions  of  the  Nose 
and  Corjunctiva?    Muck. 

4.  The  Relations  of  the  Immovable  Butyric  Acid  Bacilli  to 

Glanders.    Grassberqer. 

5.  The  Epidemic  of  Smallpox  Observed  in  the  Summer  of 

1900.    Kaufmasn. 

6.  Contributions  from  the  Dprmatologic  Clinic  of  Strassburg 

University:  (1)  A  Case  of  Lichen  Obtusus;  (2)  A  Case 
of  Ptyriasis  Rubra  Pilaris.     Huqel. 

7.  Chloral  and  Hemorrhage.    Model. 

8.  Results  of  Vaccination  in  the  Kingdom  of  Bavaria  in  1899. 

Stompf. 

5. — Kaufmann  gives  a  very  interesting  account  of  a  small 
epidemic  of  smallpox  that  occurred  in  Frankfort  among 
some  strikers  and  the  prisoners  in  a  jiil.  The  course  of  the 
infection  after  some  very  painstaking  inquiries,  was  finally 
clearly  made  out,  and  it  was  found  that  every  case  practi- 
cally was  the  result  of  direct  contact,  with  one  exception, 
and  in  this  it  was  necessary  to  assume  that  in  some  cases 
smallpox  runs  its  course  without  the  typical  vesicular  erup 
lion.  The  source  from  which  the  disease  was  imported  into 
the  city  could  not  be  determined.  Altogether  there  were  26 
cases.  Althoug;h  the  two  attending  physicians  were  not  re- 
stricted in  their  actions  in  any  way,  they  did  not  communi- 
cate the  disease  to  any  others.  Both  visited  the  patients  in 
linen  garments,  and  immediately  after  the  visit  bathed  and 
made  a  complete  change  of  clothing.  The  relation  of  the 
severity  of  the  cases  to  vaccination  is  interes-tirig.  In  one 
case  vaccination  had  occurred  within  a  period  of  6  years 
although  it  liad  not  been  successful.    This  case  was  exceed- 


ingly light.  Five  other  patients  had  been  vaccinated  within 
a  period  of  20  years,  and  had  exceedingly  mild  attai^ks ;  13 
patients  had  been  vaccinated  within  a  period  of  20  to  50 
years  before  the  attack ;  5  had  the  disease  in  a  mild  form,  5 
in  a  moderately  severe  form,  and  3  in  a  very  severe  form; 
5  cases  had  not  been  vaccinated  within  a  period  of  50  years ; 
2  had  the  disease  in  a  severe  form,  and  3  not  in  a  very 
severe  form.  It,  therefore,  seems  to  be  proven  by  this  epi- 
demic, as  in  many  others,  that  the  protective  influence  of 
vaccination  very  gradually  decreases.  Seven  of  the  cases 
were  vaccinated  during  the  attack,  2  for  the  first  time,  and 
in  4  the  vaccination  was  successful.  The  preliminary  exan- 
thema was  sometimes  extensive,  sometimes  restricted  to  two 
or  three  small  spots.  When  it  appeared  in  the  mildest  cases, 
the  patients  felt  perfectly  well,  and  one  of  them  refused  to 
believe  that  he  had  smallpox.  In  the  more  severe  cases  there 
was  fever  and  the  characteristic  pains.  The  initial  fever  was 
not  observed.  The  secondary  fever  showed  three  types,  that 
is  to  say,  the  moderate  and  mild  type  remained  afebrile,  or 
there  was  an  irregular  fever  of  mild  degree,  lasting  for  sev- 
eral days.  Two  cases  had  the  typical  hectic  fever.  In  2 
cases  the  exanthema  appeared  whilst  the  initial  fever  was 
still  high.  Two  cases  were  observed  in  which  an  eruption 
occurred  during  the  initial  fever.  In  one  this  was  hemor- 
rhagic in  type,  in  the  other  roseolar.  Sjquelae  were  not 
serious;  4  "cases  suflFered  from  furunculosis  and  4  from 
seborrheic  eczsma.  Four  of  the  cases  died.  One  was 
brought  to  the  hospital  in  a  comatose  condition,  another 
died  during  suppuration,  a  third  at  the  height  of  the  disease, 
and  a  fourth  was  an  old  man  of  77.     [j.s.] 

6,  — Hiigel  reports  a  case  of  lichen  obtusus  occurring  in 
a  woman  of  37,  having  lasted  for  3  years.  Small  papules 
appeared  on  the  backs  of  the  hands  and  feet.  The  patient 
sutfered  from  severe  itching ;  gradually  the  papules  spread 
to  the  legs  and  forearms  Taese  papules  were  discrete,  about 
4  to  6  mm.  in  diameter,  and  2  to  4  mm.  elevated  above  the 
surface  of  the  skin.  There  was  a  slight  depression  in  the 
center  of  each.  The  old  ones  did  not  disappear.  The  cen- 
tral depression  corresponded  to  a  sweat  pore.  Pathologically 
they  consisted  of  enormous  proliferations  of  the  connective 
tissue  of  the  skin,  which  actually  caused  atrophy  of  the 
papillae.  It  produced  no  general  symptoms.  He  also  re- 
ports a  case  of  pityriasis  rubra  pilaris  in  a  laborer  72  years  of 
age.  At  the  age  of  71  he  noticed  some  itching  in  the  limbs 
and  moderate  desquamation.  Gradually  the  movements  of 
the  legs  became  imperfect,  the  skin  became  thicker  and 
shinier,  and  there  was  considerable  desquamation.  Gradu- 
ally the  whole  surface  was  involved.  As  a  result  of  treatment 
by  arsenic  and  baths  he  gradually  improved,  but  finally  died 
as  the  result  of  a  severe  bronchitis.  At  the  autopsy  an  area 
of  softening  was  found  in  the  right  parietal  lobe,  and,  in  the 
skin,  marked  hypertrophy  of  the  epidermis,  with  iuflamma- 
tory  reaction  around  the  papillary  bodies     [j  s  ] 

7. — Model  reports  his  own  case.  As  a  result  of  almost  total 
agrypnia  he  had  recourse  to  chloral,  and  noticed  whilst 
using  this  that  after  severe  exertion  he  had  a  profuse  hemor- 
rhage Irom  the  nose.  Oa  several  subsequent  occasions  this 
same  manifesta'ion  occurred,  and  he  was  finally  compelled 
to  believe  that  the  epistaxis  was  due  exclusively  to  the  use  of 
chloral,  because  it  never  occurred  unless  the  chloral  was 
used,  and  always  occurred  when  it  was.  He  reports  the  case 
for  the  purpose  of  calling  the  attention  of  the  medical  pro- 
fession to  this  danger.     [J.s.] 

8.— Stumpf  gives  some  elaborate  statistics  of  the  results 
of  vaccination  in  the  kingdom  of  Bavaria  during  1899. 
The  total  population  in  1895  was  nearly  6  000,000.  In  1899 
it  was  found  that  about  200,000  required  inoculation. 
Altogether  about  170,000  were  actually  inoculated,  the 
greater  number  with  glycerin  lymph  obtained  from  calves. 
About  128  000  required  reinoculation  and  125,000  were  actu- 
ally inoculated,  nearly  all  with  good  results.  He  calls  atten- 
tion t5  the  enormous  production  of  lymph  that  is  required 
to  inoculata  this  number  of  people.  Nevertheless,  63  calves 
were  suflicient  to  supply  over  400,000  portions  in  the  year 
1899.  This  lymph  was  of  high  degree  of  virulence,  and 
preserved  its  potency  for  a  long  time.  The  lymph  supplied 
by  the  Central  Vaccine  Institute  of  the  kingdoni  of  B.ivana 
Droved  to  be  more  effective  than  that  from  other  sources. 
In  performing  the  inoculation,  sterile  instruments  were 
always  used;  the  best  sterilizing  medium  being,  apparently, 
alcohol.    A  very  excellent  instrument  is  a  lanoet  of  platin- 


282 


Thk  Philadelphia"! 
Medical  Joubnal  J 


THE  LATEST  LITERATURE 


[Febbuaby  9,  1901 


iridium;  that,  of  course,  can  be  sterilized   by  direct   heat. 

[J.S] 

December  18, 1901.    [47.  Jahrg.,  No.  51.] 

1.  Experience  with  Angiotripsy.    Winterkitz. 

2.  Intra- Tendinous  Ganglia.     Morian. 

3.  The  Determination  of  the  Time  of  Certain  Appearances  in 

Corpses.    Wetzel. 

4.  Tropon  and  Plaemon.     MxJller. 

5.  Contributions  to  the  Knowledge  of  the  Traumatic  Mov- 

ability  of  the  Kidneys.    Paye. 

1. — Winternitz,  stimulated  by  the  apparently  good  results 
of  various  operators  with  angiotripsy  has  collected  the 
statistics  from  Doierlein's  clinic  of  the  cases  in  which  this 
method  was  employed.  They  amounted  to  150,  consisting  of 
96  laparotomies,  52  total  extirpations,  1  vaginal  ovariotomy, 
and  1  nephrectomy.  Four  cases  died,  2  from  indifferent 
causes,  and  2  frotn  peritonitis  as  the  result  of  a  secondary 
hemorrhage  after  total  extirpation  for  myoma.  Kone  of  the 
instruments  employed,  that  is,  those  of  Doyen,  Tuffier,  and 
Thumim,  were  eatitfictory  in  all  cases,  ar.d  in  consequence 
of  the  bad  results  in  2  cases,  Winternitz  believes  that  angio- 
tripsy  will  not  replace  ligatures  or  clamps.    [J  s  ] 

2.— Morian  reports  a  case  in  which  swelling  took  place  in 
the  teudons  of  the  band,  accompanied  by  great  pain, 
and  interference  of  the  movements  of  the  fingers.  At  the 
operation  it  was  found  that  both  the  extensor  tendons  of  the 
index  finger  were  swollen  and  contained  small  cysts,  from 
which  a  colloid  substance  was  evacuated,     [j  s] 

3.— Wetzel  calls  attention  to  the  errors  in  the  features 
suggested  by  Casper  for  the  recognition  of  the  period  for 
which  a  body  has  been  kept  after  death,  before  the  exami- 
nation. These  are  briefly,  that  the  body  becomes  cold  in 
from  8  to  12  hours;  postmortem  discoloration  appears  in 
from  3  to  6  hours;  rigor  mortis  in  from  2  to  4  hours.  The 
eyeball  becomes  soft  in  2  or  8  days;  the  muscles  become 
flat ;  the  abdominal  wall  becomes  green,  8nd  the  peculiar, 
characteristic  odor  appears  in  from  2  to  3  weeks.  For  longer 
periods  the  following  characteristics  are  suggested  :  The 
back  becomes  green,  and  froth  appears  in  the  nose  and 
mouth  in  from  3  to  5  days;  the  whole  body  becomes 
greenish-red,  and  intensely  distended,  and  there  is  collapse  of 
the  cornea  in  from  14  to  20  days ;  the  cellular  tissue  becomes 
emphysematous,  the  entire  body  is  swollen  out  of  shape, 
and  the  nails  fall  off  in  from  14  to  20  days.  Putrid  liquefac- 
tion, rupture  of  the  normal  body  cavities,  loss  of  the  eye- 
balls, and  even  exposure  of  the  bones  occurs  in  from  4  to  6 
months.  Tbese  rules  apply  only  to  bodies  that  have  been  left 
in  the  air.  In  the  winter-time  bodies  will  remain  almost 
unchanged  in  water  for  considerable  time.  Weizel,  as  the 
result  of  his  experience  as  Judicial  Medical  Examiner  for  a 
large  district  in  Germany,  believes  that  these  rules  are  by  no 
means  fixed,  and  that  as  a  matter  of  fact  it  is  necessary  to 
individualize  each  case  presented  for  examination,  for,  as  is 
well  known,  temperature  and  other  modifying  conditions 
have  the  greatest  effect  upon  the  state  of  the  body.  He 
mentions  a  case  of  a  man  who  drowned  himself,  whose  face, 
after  3  days  in  the  water,  became  completely  unrecc^gnizable 
on  account  of  swelling  and  discoloration.  In  another  case 
the  color  of  the  tkin  was  black  or  dark  green,  the  hair,  epi- 
dermis, and  the  nails  had  loosened  or  fallen  ofl ;  the  odor 
resembled  that  of  a  pestilence ;  the  liquid  brain  burst  through 
the  skull  upon  an  attempt  to  open  the  cranial  cavity,  and 
yet  the  body,  after  2  days  in  the  air,  had  remained  only 
2  weeks  in  the  water.  Also,  an  autopsy  upon  2  newborn 
children,  in  which  the  one  with  more  advanced  changes 
in  the  lungs  had  been  buried  for  3  weeks,  after  lying 
2  days  on  its  mother's  bed.-  The  other  had  been  killed 
and  thrown  in  the  water,  where  it  had  remained  for 
4  weeks.  He  then  calls  attention  to  certain  important  feat- 
ures that  he  believes  of  as  much  value  as  those  suggested 
by  Casper.  These  are  the  effects  of  various  of  the  "lower 
animals  that  destroy  bodies.  For  instance,  rats  have  been 
known  to  completely  remove  all  the  soft  parts  from  a  child's 
legs  in  4  hours.  Maggots  have  almost  completely  eaten  the 
soft  parts  of  a  body  in  16  days,  and  in  2  days  they  have  left 
nothing  but  the  skeleton  of  a  child.  On  the  other  hand, 
cases  may  be  excellently  pref  erved  for  long  periods,  particu- 
larly if  carefully  buried  in  the  winter-time,  and  Wetzel  has 
performed  a  perfectly  satisfactory  autopsy  4  months  after 


death.  Decomposition  proceeds  with  varying  degrees  of 
rapidity.  In  an  autopsy  upon  a  newborn  child,  although  the 
soft  parts  had  disappeared,  the  bones  at  the  end  of  4  months 
were  still  in  paitj  attached  together,  and  it  was  possible  to 
determine  that  the  age  of  the  child  was  between  32  and  36 
week^.  In  another  case  it  was  impossible  to  determine  the 
time  in  which  the  body  had  been  kept  after  death,  only  a 
few  bones  remaining;  but  this  was  due  to  the  fact  that 
it  had  been  exposed  to  chickens  who  had  probably  eatea 
the  maggctj  from  it,  and  contributed  to  its  disintegration. 
[j.s] 

4. — Miiller  has  performed  a  series  of  experiments  with 
artificial  preparations  of  albumen.  He  has  used  dogs, 
and  carefully  determined  the  nitrogenous  intake  and  loss. 
It  was  found  that  in  a  preliminary  period  in  which  meat  and 
dog  biscuit  were  employed  there  was  a  slight  excess  of  inges- 
tion over  excretion,  but  that  there  was  considerable  variation 
from  day  to  day.  During  the  tropon  period,  which  latted 
38  days,  there  was  a  considerable  increase,  and  the  sime 
was  true  during  the  terminal  period,  although  the  body- 
weight  of  the  dogs  decreased  considerably.  It  appears 
froma  careful  analysis  of  the  results,  that  about  93%  of  the 
nitrogen  in  meat  was  utilized,  and  on'y  83%  of  that  in  the 
tropon.    [j.s  ] 


Berliner  kliniscbe  Wocbenscbrift. 

December  3, 1901.    [37.  Jahi^.,  Xo.  49.] 

1.  Diabetes  Mellitus.    C.  v.  Noorden. 

2.  Diffuse  and  Chroni''  Eiemaof  the  Skin  with  Laryngeal 

Involvement.    W.  Lublisski. 

3.  Results  in  the   Treatment   of  Sporadic  Cretinism  with 

Tnyrejid  Extract.     H.  Xecmas.s. 

4.  Treatment  of  Fractures  of  the  JiW.    Warnekees. 

5.  The  Treatment  of  Nervous  Diseases  in  the  Family.    R. 

Gnauck. 

1. — Tne  author's  contribution  deals  with  the  current  in- 
vestigations of  diabetes  mellitus.  The  extensive  increase 
in  the  number  of  c  ises  of  diabetes  mellitus  raises  the  ques- 
tion as  to  whether  this  is  due  to  improved  methods  of  ex- 
amination, or  to  an  increase  of  the  disease.  Tbe  mcst 
recently  aclvanced  etiological  factors  are  chronic  alcoholism, 
heredity,  and  racial  predisposition.  Toe  author  believes  that 
the  intermarriage  of  the  Hebrew  race  with  ladogermanic 
races  plays  ai  important  pirt  in  the  dissemination  of  dia- 
betes. The  supporters  of  tbe  theory  that  the  formation  of 
sugar  arises  from  fat,  are  increasing.  The  elimination  of 
substances  containing  no  nitrogen,  and  derived  from  the 
fatty  acid  series  (aceton,  B  oxybutyric  acid),  according  to 
the  investigations  of  Niunyn  are  derived  from  the  B-oxy- 
butyric  acid.  The  origin  of  this  acid  is  still  disputed.  The 
most  recent  opinions  point  to  its  derivation  from  the  higher 
fatty  acids.  It  is  still  a  question  as  to  whether  the  produc- 
tion of  this  substance  during  coma  bears  any  causal  relation 
to  the  latter,  or  whether  both  are  dependent  upon  one  and 
the  same  cause,     [m  r  d  ] 

2. — Luhlinski  reports  a  case  of  diflfuse  chronic  edema- 
of  the  skin  involving  tbe  larjnx,  occurring  in  an 
otherwise  healthy  woman  of  52.  The  edema  spread 
over  the  breast,  neck  and  head,  originally  starting  from  the 
face.  There  were  respiratory  dilfi^uliies  and  the  disturb.^nces 
of  phonation  were  due  to  swelling  of  the  epiglottis,  arytenoid 
cartilages  and  of  the  arytenoepiglottic  and  interarytenoid 
folds.  The  author  has  frequently  seen  c^ses  of  nephritis  in 
which  the  edema  manifested  itself  in  the  epiglottis  and 
around  the  larynx  before  edema  of  the  external  portions  of 
the  body  could  be  seen.  But  in  this  case,  with  absence  of 
headache,  polyuria,  cardiac  symptoms  and  intr.-iocular 
changes,  he  believes  himself  justified  in  making  the  d'ag- 
nosis  given  in  the  title  of  his  paper,  at  the  same  time  duly 
considering  the  previous  occurrences  of  similar  affections. 
The  edema  involving  the  mucous  membrane  gradu.iUy  sub- 
sided under  the  administration  of  arsenic  and  thyroid  ex- 
tract,    [m  R.D.] 

3. — Neumann  calls  attention  to  the  increase  in  bodily 
length,  occurring  after  the  dis.ippearauee  of  myxedema.  It 
shows  that  under  thyroid  medicition,  the  bones  th*t  have  pre- 
viously been  impeded  in  their  growth  are  now  stimulated  to 


FKBRnARY  9,    1901] 


THE  LATEST  LITERATURE 


["The  Phii^dblphia 
L  Medical  Journal 


283; 


renewed  vigor.  It  is  always  to  be  assumed  that  the  body 
haj  previously  been  saturated  with  the  unknown  substance 
contained  in  the  thyroid  gland,  but  the  effect  of  this  internal 
secretion  is  not  always  proportionate  to  the  amount  thrown 
into  the  system.  The  psychical  disturbances  in  cachexia 
Btrumipriva  in  the  adult  and  larger  children,  can,  as  is  well 
known,  be  alleviated.  It  is  emphasized  that  treatment  must 
be  instituted  as  eoan  aa  possible  after  the  occurrence  o{  the 
diseai-e,  if  any  beni-ficial  result  is  to  be  expected.  The  drug 
should  be  cautiously  administered  as  the  tolerance  in  chil- 
dren varies,     [m  R  D  ] 

4. — Warnekres  discusses  the  various  bandages  that  have 
been  devised  forthe  fixation  of  fractured  jiws,  with  the  re- 
port of  several  cases  illustrating  some  of  me  author's  modi- 
fications,    [m  r.d] 

6. — The  author  consider  the  continued  administration  of 
bromide  of  potassium  as  not  only  unnecessary,  but  actually 
harmful  in  nervous  diseases  (epilfp<y  excepted).  He  is 
opposed  to  the  administration  of  alcohol  in  these  cases 
and  believes  that  as  a  remedy  it  can  be  entirely  ditpensed 
with.  In  cases  where  a  stomachic  is  indicated,  the  drug 
can  be  replaced.  Under  no  circumstances  does  he  consider 
the  routine  administration  of  alcohol  justifiable  for  the 
purpose  of  combating  fear,  anxiety  and  precordial  pain,  or 
for  the  purpose  of  producing  a  state  of  well  being  in  the 
patient.  Alcohol  should  be  forbidden  from  the  beginning 
of  the  treatment.  Extitement  should  be  avoided,  but  this  is 
sometimes  impossible  when  the  patient  is  allowed  to  remain 
at  home.  Rest  should  be  insisted  upon  and  regularity  of 
habits  enforced.  Hydrotherapy  instituted  at  home  is  of 
the  greatest  value.  Tuere  are  times,  however,  when  it  can 
not  be  employed  as  there  are  patients  with  hypochondriacal 
tendencies  who  complain  bitterly  of  headache  and  itching  of 
the  skin  after  the  btth.  Electricity  is  of  great  value  at 
home.  The  author  piotests  against  allowing  the  patient  to 
app'y  the  electricity  himself.  The  faradic  and  galvanic 
currents  are  sometimes  entrusted  to  the  patient,  who  is  cer- 
tainly unable  to  objectively  determine  their  strengths  or 
indication.  The  most  popular  and  also  the  most  abused 
remedy  employed  at  home  is  massage.  Localized  massage 
over  nerve  exits,  painful  areae,  etc  .siiould  only  be  performed 
by  the  physician.  The  psychical  treatment  of  patients  at 
home  is  difficult  because  they  cannot  be  kept  under  control. 
Hypnotism,  which  has  been  admitted  into  the  therapeutics 
of  nervous  diseases,  is  of  value  provided  it  is  employed  by 
him    who  has  constant  charge  of  the  routine  treatment. 

[m. R.D.J 

December  10,  1900.     [37.  Jahrg.,  No.  50.1 

1.  From  the  University  Ophthalmological  Clinic  at  Breslau  : 

Remarks  on  Scrofulosis  and  Tuberculosis  with  a  Con- 
tribution   to  Tuberculosis    of   the    Corjunctiva.    W. 

UhTHi'FF. 

2.  The  Functional  Capacity  of  the  Fatty  Degenerated  Heart 

Due  to  Aortic  Insufficiency.    A.  Hasenfeld. 

3.  An  Experiment  in  the  Cure  of  Hernia  of  the  Lungs.    O. 

Vhj.pius. 

4.  Dietetic  Treatment  of  Hyperacidity.    E.  v.  Sohlern. 

5.  Diabetes  Mellitus.    C.  v.  Nooeden. 

1.— Uhthoff  believes  it  justifiable  to  still  further  restrict  the 
term  "  scrofulous."  Especially  in  diseases  of  the  eye  the 
so-called  "scrofulous,"  but  not  truly  tuberculous  affections, 
occur  in  tuberculous  suVjects.  Tuberculosis  itself  frequently 
prepares  the  soil  for  the  so-called  scrofulous  diseases.  Al- 
though the  phlyctenule  most  frequently  occurs  in  scrofu- 
lous and  tuberculous  children  it  should  not  be  considered  as 
directly  characteristic  of  scrofula.  The  autlior  has  observed 
in  his  clinic,  in  a  certain  relatively  small  percentage  of  cises, 
that  phlyctenules  occur  without  the  slightest  symptoms  or 
history  of  scrofula,  tuberculosis,  or  previons  disease  of  the 
eyes.  Bacteriological  examination  of  the  phlyctenule  has 
not  yet  demonstrated  the  etiological  factor.  According  to 
the  experiments  upon  animals,  made  by  Valude  and  others, 
the  healthy  conjunctiva  does  not  present  a  portal  for  the 
entrance  of  the  tubercle-bacilli.  The  author  believes  that 
as  a  whole  the  conjunctiva  does  not  easily  absorb  infec- 
tious materials  as  can  be  seen  per  example  in  diphthe- 
ritic coi  junctivitis,  which  frequently  exists  without  any  sys- 
temic   disturbances.      In    certain  experiments    that    have 


been  made  with  the  toxin  of  pest,  inoculation  into  the 
corjunctiva  produced  positive  results  by  reason  of  the  fact 
that  the  poison  was  conveyed  through  the  lachrymonasal 
passages  into  the  nasopharyngeal  space.  The  author 
reports  a  case  of  tuberculosis  of  the  conjunctiva  occurring  in 
a  girl  of  15  years,  whose  brother  had  died  of  tuberculosis. 
There  had  been  a  previous  prelachrymal  abscess  on  the  left 
side  that  had  undergone  spontaneous  suppuration,  and  had 
left  a  fistula  with  impediment  of  breathing  on  the  affected 
side.  The  upper  and  lower  palpebral  conjunctivae  showed  a 
condition  which  could  easily,  and  was  at  first,  diagnosti cited 
as  trachoma.  There  was  swelling  of  the  preauricular  and 
cervical  glands.  Examination  of  the  nose  and  pharynx 
showed  marked  changes  in  the  mucous  membrane  and  the 
formation  of  granulation  tissue.  Microscopical  examination 
of  excised  portions  of  the  conjunctiva  from  the  lower  lid 
established  with  certainty  that  the  procefs  was  of  a  tuber- 
culous nature  ;  but  those  portions  taken  from  the  upper 
lid  showed  no  signs  of  tuberculosis,  but  simply  chronic 
hyperplasia.  Regarding  the  latter  it  is  still  to  be  determined 
whether  this  nonspecific  portion  of  the  process  is  caused  by 
the  tuberculous  area.  Either  it  is  due  to  the  toxic  effect  of 
the  tubercle-bacilli  which  causes  chronic  thickening,  by 
reason  of  a  long  continued  influence,  or  the  continued  irrita- 
tion due  to  the  presence  of  these  toxins  may  give  rise  to 
secondary  changes  in  the  conjunctiva  without  any  specific 
influence  being  exerted  by  the  toxins  themselves  ;  or  finally 
there  may  be  a  mixed  infection  in  sucli  a  long  exposed 
tuberculous  area,  whereby  organisms  other  than  the  tubercle- 
bacilli  may  give  rise  to  the  secondary  involvement.  That 
non- tuberculous  changes  may  occur  in  tissues  surrounding 
tuberculous  areas  is  illustrated  in  other  tuberculous  inflana- 
malions  of  mucous  membranes  such  as  pleurisy,  meningitis 
and  arthritis,     [m  r.d  ] 

2.— Hasenfeld  coincides  with  Romberg  in  believing  that 
sufficient  proof  has  not  yet  been  produced  to  determine  the 
relation  that  exists  between  valvular  lesions  of  the  heart 
and  coexisting  fatty  degeneration  of  the  heart  mus- 
cle. The  author  produced  both  of  these  conditions  experi- 
mentally upon  well-developed  guineapigs  as  follows :  The  caro- 
tid artery  was  exposed,  a  fine  sound  with  a  small  terminal 
bulb  was  then  passed  into  the  artery  until  the  aortic  valves 
were  disturbed  ;  the  artery  was  then  ligated  and  the  wound 
closed  with  collodion.  During  the  whole  procedure  rigid 
asepsis  was  observed.  The  sub lequent  detection  of  the  dias- 
tolic murmur  and  the  chiracterisiic  puL-e  showed  that  the 
artificial  production  of  the  lesion  was  successful.  The  ab- 
sence of  infection  and  fever  in  every  case  showed  that 
neither  the  endocardium  nor  myocardium  were  infected. 
After  the  aortic  inmfficieucy  had  existed  from  two  to 
three  months  (this  time  was  allowed  to  elapse  in  order  to 
facilitate  the  production  of  fatty  degeneration),  the  animals 
were  poisoned  with  phosphorus,  a  time  being  selected  in  each 
instance  at  which  it  could  be  assumed  that  hypertrophy 
had  already  developed  in  proportion  to  the  valvular  defect. 
Increased  functional  activity  was  experimentally  produced 
by  ligating  the  thoracic  aorta.  After  an  exhaustive  descrip- 
tion of  the  experiments  which  embrace  detailed  observations 
the  author  comes  to  the  following  conclusion  :  (1)  Animals 
with  aortic  insufficiency  bear  phosphorus  poisoning  much 
poorer  than  normal  animals ;  (2)  a  heart  that  is  hyper- 
trophied  by  reason  of  aortic  insufficiency  has  a  particular 
disposition  to  undergo  fatly  degeneration  ;  (3)  a  moderate 
amount  of  acute  fatty  degeneration  has  no  influence  upon 
the  power  and  functional  capacity  of  the  hypertrophied 
heart-muscle,  neither  under  ordinary  nor  increased  fuuctional 
activity ;  (4)  a  marked  amount  of  acute  fatly  degeneration 
gives  rise  to  a  decrease  in  strength  in  the  heart  with  aortic 
insufficiency,    and    even     fatal    circulatory     dist  jrbances, 

[.M.R  D  ] 

4.— Practical  experience  has  shown  the  author  that  the 
carbohydrates,  as  a  rule,  net  only  agree  well  in  patients 
with  hyperacidity,  but  also  hasten  recovery.  The  influence 
of  various  foods  upon  gastric  secretion  is  extensively  dis- 
cussed, as  well  as  the  value  of  various  continental  mineral 
waters,     [m.r.d.] 

6.— In  concluding  his  retrospect  of  diabetes  mellitus  v. 
Noordea  states  that  decreased  absorption  of  fats  and 
nitrogenous  materials  indicates  a  disturbance  of  pancreatic 
secretion.  Pancreatic  diabetes  is  still  hypothetical.  But  little 
progress  has  been  made  in   the  treatment  of  the  disease^ 


284 


The  Philadklphia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


LFebbcabt  9,  1901 


The  influence  of  opium,  antipyrin,  etc.,  is  not  constant  but 
transitory.  While  considerable  has  been  attained  by  dietetic 
treatment,  and  although  we  are  today  better  than  ever  in  the 
position  to  influence  metabolism  in  diabetes,  we  are  still  far 
from  being  masters  of  the  situation,    [m.r.d  ] 

December  17, 1900.    [37.  Jahrg.,  No.  51.] 

1.  Amyloid  Degeneration,  with  Special  Regard  to  the  Kid- 
ney.     M.  LiTTEN. 

■2.  A  Few  Remarks  Concerning  the  Fermentation  and  Diges- 
tion Tests  of  Feces  and  the  Value  of  the  Test  Diet  in 
the  Examination  of  Intestinal  Diseases.    A.  Schmidt. 

3.  The  Relations  Observed  in  the  Oxidation  of  Urinary  Con- 

stituents.    A.  JOLLES. 

4.  Pressure  Irrigations  in  the  Treatment  of  Acute  and  Chronic 

Gonorrhea.    R.  Kutner. 

1. — Litten  believes  that  tuberculosis  is  the  cause  of  .50% 
of  cases  of  amyloid  degeneration.  O^Qer  conditions  givmg 
rise  to  amyloid  degeneration  are  scrofulosis,  suppuration  of 
the  skin,  bones  and  mucous  membranes,  syphilis,  ulceration 
of  the  intestines,  malaria,  pyelitis,  carcinoma,  long-continued 
leg  ulcers,  chronic  bronchitis,  gout,  empyema,  spondylitis 
and  abscess  c  f  the  lung.  He  believes  that  carciuoma  is 
not  as  frequently  the  cause  as  is  supposed,  for  there  is  only 
amyloid  degeneration  with  accompanying  suppuration.  But 
when  this  occurs  it  generally  runs  a  rapid  course,  there  being 
hardly  sufllicient  time  for  the  establishment  of  an  amyloid 
degeneration.  Ti^e  author  believes  that  amyloid  degenera- 
-tion  may  also  arise  without  any  assignable  ciuse,  in  support 
of  which  he  quotes  E.  Wagner  who  had  observed  7  such 
cases.  Among  a  hundred  cases  of  amyloid  degeneration 
observed  by  the  author,  there  was  amyloid  degeneration  of 
the  spleen  in  98%  of  the  cases,  of  tlie  kidneys  in  97%  of 
the  cases,  of  the  liver  in  63%,  and  of  the  intestinal  mucous 
membrane  in  65%  of  the  hundred  cases.  The  author  de 
8cribe8  3formsof  amyloid  degeneration  of  the  kidney  :  1.  Pure 
amyloid  degeneration  of  the  vessels  with  and  without  fatty 
degeneration  of  the  cortical  epithelium.  2  Amyloid  degen- 
eration with  chronic  parenchymatous  nephritis  (large  white 
Amyloid  kidney).  3.  Amyloid  contracted  kidney.  In  the 
first  form  the  parenchyma  of  the  kidney  may  be  entirely 
intact,  without  any  sign  of  fatty  degeneration  of  the 
epithelium,  while  the  vessels  on  the  other  hand  may  be  the 
seat  of  amyloid  deposit  from  the  merest  trace  to  an  amyloid 
degeneration  involving  all  the  glomeruli  as  well  as  other 
capillary  areas.  It  occurs,  however,  that  certain  capillary 
areas  are  exclusively  aSected  by  the  amyloid  change,  such 
as  the  glomeruli,  interstitial  capillaries  of  the  cortex  and  the 
vasa  recta  of  the  medullary  portion  ;  more  frequently,  how- 
ever, the  disease  is  more  difl^use,  embracing  several  capillary 
areas  including  the  vasa  afferentia  and  arteries  up  to  the 
larger  branches.  The  general  symptoms  of  amyloid  degen 
eration  of  the  kidney  are  then  discussed  together  with  the 
various  tests  for  the  detection  of  the  amyloid  material. 
,£m.r.d  ] 

3. —  fhe  article  deals  with  a  number  of  elaborate  experi- 
ments to  determine  the  composition  of  precipitates  formed 
by  the  addition  of  barium  chlorid  to  urine.  The  composi- 
tion of  these  precipitates  as  is  well  known  difl^ers  in  neutral 
and  acid  solutions.  The  author  arrives  at  the  following  con- 
clusions :  In  each  liter  of  urine  the  substances  precipitated 
by  barium  chlorid  require  in  a  healthy  individual  from  19S 
to  243  mgr.  of  oxygen  for  their  oxidation.  The  author  shows 
various  methods  by  which  these  tests  can  be  controlled. 
£m  r  d] 

*•— Kutner  recommends  a  method  for  pressure  Irriga- 
tion in  the  treatment  of  acute  and  chronic  gonorrhea.  A 
N6!aton  catheter  is  introduced  into  the  urethra  for  a  distance 
of  4  cm  ,  and  a  small  quantity  of  irrigation  fluid  introduced 
with  energetic  pressure  from  a  syrinije  coniaining  from  3  to 
4  ounces.  The  organ  is  then  compressed,  permitting  the 
escape  of  the  fluid  from  the  urethra.  This  is  repeated  until 
the  contents  of  the  syringe  has  been  exhausted.  A  model  of 
the  syringe  accompanies  the  article.  The  author  believes 
that  this  is  an  excellent  method  for  disten  ling  the  canal  and 
permitting  thorough  access  of  the  irrigation  fluid.  He  be- 
lieves that  the  procedure  is  so  uncomplicated  that  it  can  be 
•employed  with  advantage  as  a  matter  of  routine  practice. 
£m.r.d.] 


Wiener  Iclinische  Wochenschrift. 

November  22, 1900.     [13.  Jahrg.,  No.  47.J 

1.  The  Question  of  the  Identity  of  Pemphigus  Neonatorum 

and  Impetigo  Contagiosa.    Rudolf  Matzesaueb. 

2.  A  Case  of  Gonorrheal  Endocarditis.    Lddwig  Stein. 

3.  The  Action  of  Iodoform  and  a  Substitute  for  It.    Albxan- 

I     DER  Fraenkel. 

1, — Matzenauer  remarks  that  clinically  the  predominant 
symptom  of  impetigo  contagiosa  is  the  formation  of  a 
crust  or  scab  which  is  usually  wanting  in  pempliigas  ;  and 
Fox  considers  this  characteristic  a  basis  of  diagnosis.  Other 
authors,  however,  think  that  the  scab-formation  depends 
much  upon  the  age  and  condition  of  the  patient.  Impetigo 
contagiosa  belongs  essentially  to  very  young  children  and 
the  coii  fluent  pustules  often  assume  the  circular  form.  While 
pempbigus  sometimes  occurs  in  the  newborn,  yet  it  is  not 
rare  in  itifints  from  2  to  4  years  of  age,  and  also  occurs  in 
older  children,  and  even  adults.  Hiitologically  the  two  are 
so  similar  that  a  description  of  one  will  serve  for  the  other 
also.    [w.K  ] 

2, — Stein  reports  a  severe  case  of  gonorrbea  in  a  man, 
22  years  old,  wiio  was  treated  with  copaiba  during  the  first  2 
weeks.  An  eruption  appeared,  resulting  in  his  entering  a 
hospital  where  he  was  treated  as  a  case  of  typhoid  fever, 
without  any  local  treatment  to  the  gonorrhea  for  2  weeks 
more.  Then  he  was  admitted  to  the  surgical  ward  of  the 
Vienna  General  Hospital,  w.ta  a  large  periurethral  abscess, 
upon  which  Professor  Gassenbauer  operated.  His  heart  at 
that  time  was  normal.  Gnococci  were  found  in  the  pus 
from  the  abscess.  Two  days  later  pain  appeared  in  the 
fingers,  but  no  swelling.  Small  hemorrhages  in  the  skin 
followed  during  the  next  few  days,  and  7  days  after  oper- 
ti  )n  he  died.  Tne  autopsy  showed  vegetative  endocar- 
ditis of  tbe  mitral  valves,  with  parenchymatous 
degeneration  of  the  heart,  liver,  and  kidney.  Tnere  were 
a  purulent  bronchitis,  hemorrhage  into  the  pericardium 
and  pleura,  and  a  purulent  prostatitis.  Weichselbaum 
found  streptococci  in  his  case,  and  supposed  that  the  gcn- 
ococcus  simply  made  the  soil  favorable  for  the  action  of  the 
other  ba'"teria.  S:ein  believes,  too,  that  there  is  generally 
mixed  infection  whenendocirditis  follows  gonorrhea.    [.M.O.] 

3. — Fraenkel  divides  his  study  of  the  action  of  iodoform 
upon  wounds  into  histological  researches  and  clinical 
obitrva'.ions.  From  experiments,  he  shows  that  iodoform 
causes  the  formation  of  giant  cells,  often  acting  as  a  foreign 
body,  yet  accompanied  by  more  exudate,  more  signs  of  in- 
flammation, and  more  connective-tissue  production  than 
when  the  other  sterile  po  wders  were  used.  It  is  therefore  often 
harmful  in  abdominal  wounds,  as  it  delays  healing  on 
accoint  of  these  changes.  In  tuberculosis,  on  the  contrary, 
it  is  of  great  benefit  just  because  of  these  actions.  Yet 
Fraenkel  thinks  that  we  should  seek  something  else,  which 
will  favor  the  growth  of  connective  tissue,  without  any  pos- 
sible harmful  or  poisonous  effect.  Taking  the  known  effect 
of  coal  upon  tuberculosis,  as  seen  in  miners,  as  an  example, 
Fraenkel  used  sterilized  animal  charcoal  in  21  cases  of 
local  tuberculosis.  In  no  case  was  that  inflammatory  reac- 
tion, which  is  the  rule  when  iodoform  is  used,  seen.  The 
results  were  excellent,  though  the  scars  frequently  were 
greatly  discolored  by  the  charcoal,     [m.c] 

November  29, 1900.    [13.  Jahrg.,  No.  48.] 

1.  Radical  Operation  in  Cancer  of  the  Uterus.    E.  Wkrt^ 

HEIM. 

2.  The  "Thread  "  Serum  Reaction.    Philip  Eisesbkrq. 

3.  A  Case  of  Tetanus  Cured  by  Tizzoni's  Tetanus  Antitoxin. 

Edmusd  Homa. 

1. — Because  of  the  dissatisfaction  with  the  results  of  vagi- 
nal operation  for  uterine  cancer  and  the  large  percent- 
age of  recurrence  of  the  disease,  Wertheim  determined  in 
ail  such  cases  to  remove,  by  abdominal  section,  the  organ 
itself  and  also  the  parametrium;  and  having  thus  treated 
S3  cases  reports  the  result.  Of  these,  11  were  carcinoma  of 
the  body,  the  others  were  cancer  of  the  cervix  and  portio 
vaginalis,  of  wliich  5  were  far  advanced  and  5  in  the  very 
e*rly  stage  of  the  disease.  The  mortality  was  very  great,  the 
deaths  being  11,  S  of  which,  however,  were  due  to  the  weak- 


Febrdakt  9,  1901] 


THE  LATEST  LITERATURE 


rTHK  Philadelphia 
L  Medical  Journal 


285 


«ned  condition  of  the  patient  and  the  bad  heart-action  in 
consequence  of  the  long  narcosis.  After  this  experience  he 
would  not  again  operate  in  similar  cases.  Only  3  deaths, 
then,  were  the  direct  result  of  the  operation,  2  from  perito- 
nitis and  1  from  invagination  of  the  small  intestines.  Of  the 
other  22  cases,  3  were  only  palliative  operations,  2  died  from 
fiome  other  disease,  and  17  made  a  good  recovery  ;  and  it  is 
noteworthy  that  in  these  ihere  has  as  yet  been  no  recurrence 
of  the  cancer.  When  the  cancerous  tumor  is  large,  extend- 
ing itself  in  all  directions  and  is  immovable,  or  when  there  is 
a  widely  extended  cavity,  it  is  doubtful  whether  operation 
«hould  not  be  refused;  but  when  the  tumor  is  still  sensitive 
and  small  in  size,  the  decision  is  not  difficult  and  there  should 
be  radical  operation.  If  the  parametrium  is  soft  and  elastic 
the  cancer  is  still  localized.  In  11  cases  of  the  series  reported 
microscopic  examination  determined  carcinoma  of  the  uterus, 
in  only  3  of  which  did  the  clinical  examination  lead  to  the 
true  diagnosis.  Taking  all  things  into  consideration,  Wert- 
heim  believes  from  his  experience  that  one  should  not  shrink 
from  further  advances  in  the  beaten  way,  since  it  is  an  at- 
tempt to  bring  recovery  to  women  otherwise  doomed  to  an 
early  death,     [w  K.] 

3. — Eisenberg  reports  a  case  of  colicystopyelitis  in  a 
girl  of  18,  from  whose  urine,  collected  by  cathnterization,  a 
pure  culture  of  Bacterium  coli  was  obtained.  The  patient's 
blood  serum  gave  with  this  culture  an  "  agglutination,"  and 
later  a  typical  "  thread  "  reaction,  even  when  diluted  1  to  600 
Not  one  of  the  many  colon  bacilli  cultures  from  her  stools  ag- 
glutinated, or  gave  the  "thread"  reaction.  This  "thread" 
reaction  was  present  in  cases  of  typhoid  fever  which  gave 
the  Widal  reaction,  not  in  those  which  did  not.  The  serum 
of  immunized  horses  also  gave  the  typical  •'  thread  "  reac- 
tion. It  ha?  also  been  obtained  with  human  or  dog's  _  blood 
from  healthy  individuals,  with  typhoid  or  colon  bacilli.  He 
believes,  with  Kraua,  that  the  reaction  simply  accompanies 
the  "  agglutination,"  and,  contrary  to  Pfaundler's  opinion,  ia 
not  to  be  regarded  as  specific.  He  gives  the  literature  of  the 
subject,     [m.o.] 

3. — Homa  reports  a  case  of  tetanus  in  a  boy  of  9,  whose 
toes  were  frozen.  Trismus  foUowel,  and  gangrene  set  in  in 
both  feet,  for  which  a  Chopart  and  a  Pirogoff  amputation 
followed.  The  first  tetanic  spasm  came  on  6  hours  after 
•operation.  Tetanus  bacilli  were  found  in  the  discharge,  and 
the  Tizzani  antitoxin  given.  As  many  as  47  attacks  occurred 
in  2i  hours,  yet  the  child  recovered  4  months  later,    [mo] 

December  6, 1900.     [13.  Jahrg.,  No.  49.] 

1.  The  Treatment  of  Peptic  Ulcer  of  the  Stomach.   Anton 

Gluzinski. 

2.  Blood  Pressure  and  its  Relation  to  the  Lymph  Circulation. 

Friedrich  Friedmann. 

3.  Phlegmonous    Appendicitis    Resulting    from    Tonsillitis. 

Richard  Kretz. 

1, — After  reviewing  the  literature  of  the  subject,  Gluzinski 
etates  that  about  30%  of  cases  of  ulcer  of  the  stomacli 
recover,  the  greatest  number  dying  of  perforative  peritonitis. 
The  majority  of  the  ulcers  occur  in  men  ;  and  their  most 
frequent  seat  is  about  the  pylorus.  There  is  usually  stenosis 
of  the  pylorus,  such  cases  eventually  coming,  as  a  rule,  to 
operation.  Prophylactic  treatment  should  be  instituted  in 
all  cases  in  which  injurious  substances  are  swallowed,  in  ane- 
mia and  the  infectious  diseases,  and  when  local  congestion 
exists.  This  is  accomplished  by  diet  and  rest  in  bed,  as  Leube 
advises.  Medical  treatment  should  extend  over  a  period  of 
one  to  two  years.  When  there  is  hypersecrption  of  the 
stomach,  peptic  ulcer  may  be  suspected.  When  atony 
exists,  with  stenosis  of  the  pylorus  (probably  but  a  fiinctioral 
spasm  due  to  the  presence  of  an  ulcer  near  by),  Gluzinski 
treats  by  diet  (to  hinder  stagnation  and  fermentation,  and  to 
diminish  the  acidity)  and  lavage  through  a  double  bougie. 
This  he  continues  for  30  to  40  days,  causing  the  cessation  of 
symptoms  if  the  stenosis  be  functional;  but  when  it  is  me- 
chanical he  advises  operation.  All  cases  destined  for  opera- 
tion should  be  got  into  good  condition  before  the  operation. 
If  there  should  be  any  possibility  of  the  ulcer  becoming 
carcinomatous,  operation  should  not  be  postponed.  The 
presence  of  cancer  is  proved  by  the  examination  of  the 
stomach-contents.  After  operation,  lavage  must  frequently 
fee  kept  up  for  some  time.    Should  perforation  occur,  opera- 


tion must  be  immediate.  Perforation  occurs  mostly  through 
the  posterior  wall  of  the  stomach.  Hemorrhage,  while  fre- 
quent, is  hardly  ever  of  itself  fatal.  When  the  hemorrhage 
occurs  too  often,  operation  must  be  performed,     [m  o  ] 

2. — Friedmann  reports  a  case  of  lymphatic  leukemia 
in  which  emphysema  with  chronic  bronchitis  existed,  from 
cardiac  insufficiency.  Digitalis  caused  these  signs  of  cardiac 
insufficiency  to  disappear  in  4  days,  with  a  marked  reduction 
of  the  lymph-glands.  The  swelling  that  remained  was  much 
softer.  The  relation  of  the  erythrocytes  to  the  leukocytes 
was  39: 1.  while  that  of  mononuclear  leukocytes  to  polynu- 
clear  leukocytes  was  93 : 7.  A  week  later  reds  were  to  whites 
as  83  : 1  Digitalis  was  again  given  for  another  week,  when 
reds  were  to  whites  as  61 : 1.  Under  later  trials  of  the  digi- 
talis, the  swellings  decreased  in  siz3  and  consistency,  yet  the 
lymphocytosis  increased.  He  explains  this  action  as  the 
effect  of  the  increased  blood-pressure  from  the  digitalis, 
causing  an  increised  outflosv  of  lymphocytes  from  the 
lymph-glands  into  the  blood,     [m.o.] 

3.  — Kretz  reports  the  autopsies  of  2  patients  in  whom 
phlegmonous  appendicitis  occurred  with  a  diflfiise  pur- 
ulent peritonitis.  Tfiere  was  also  a  purulent  tonsillitis,  which 
had  passed  unnoticed  during  life,  and  in  the  pus  from  both 
places,  streotococci  were  found.  In  the  second  c^se  in- 
fluenza bacilli  were  also  seen.  He  supposes  that  the  appen- 
dicitis was  due  to  the  virulent  bacilli  being  swallowed. 
Kundrat  has  reported  a  case  of  phlegmonous  gastritis  follow- 
ing tonsillitis.  Perhaps  other  obscure  intestinal  affections 
may  have  been  caused  thus,    [m.o  ] 

December  13, 1900.     [13.  Jahrg  ,  No.  50  ] 

1.  The  Action  of  the  RGatgen  Light  upon  the  Skin.    Kien- 

BOCK.  ,  ,    ■    V, 

2.  Some  Experiences  with  Local  Anesthesia  by  Schleichs 

Method.    V.  Friedlandek. 

3.  An    Aseptic    Bougie    for   Inducing    Abortion.      Ludwiq 

Knapp. 

1.— After  describing  a  number  of  researchps  Kienbo^k 
concludes  that  the  skin  exposed  to  the  Rontgen  light 
undergoes  peculiar  changes.  An  acute  or  chronic  der- 
matitis follows,  accompanied  by  a  shedding  of  the  horny 
epithelium,  and  sometimes  of  the  nails  and  hair  a'so.  Alope- 
cia may  result.  Hyperemia  and  inflammatory  swelling  may 
come  on,  or  blisters  with  serous  or  purulent  secretion,  or  the 
skin  may  be  dry  and  burned,  the  bloodvessels  may  be  much 
afi'ected,  and  there  may  be  much  pain.  As  a  rule  this  does 
not  extend  deeply,  the  underlying  muscles  not  being  at  all 
harmed.  These  effects  only  become  apparent  after  an  incu- 
bation, or  latency,  of  2  to  3  weeks.  Only  in  few  ca^es  is  the 
alopeciapermanent,thehair  usually  growing  again.  The  in- 
tensity of  the  skin  affection  depends  upon  the 
length  of  the  exposure  and  the  number  of  exposures 
to  the  ROntgen-rays.  The  smaller  the  amount  of  light,  the 
longer  is  the  latency  before  the  symptoms  appear.  Ttie  dif- 
ferent parts  of  the  body  react  diSerenlly,  and  individunl  idio- 
syncrasy seems  unknown.  The  younger  the  patient,  the 
greater  is  the  reaction,     [m.o.] 

3.— The  late  Professor  Albert,  during  the  past  year,  oper- 
ated upon  30/0  of  his  cases  with  local  anesthesia  by 
Schleich's  method.  In  the  out-patient  department,  all  kinds 
of  operations  were  done  with  it.  Friedlander  considers  the 
technic,  as  described  by  Schleich,  as  important.  He  experi- 
mented to  determine  the  sensitiveness  of  the  different  parts 
of  the  body.  Yet  when  made  edematous  by  the  injections, 
there  is  but  slight  sensitiveness  left.  When  the  tissue  is  in- 
flamed, its  sensitiveness  increases.  Fried  ander  advises  the 
use  of  Sohleich's  method  in  all  skin  operations;  in  opera- 
tions upon  the  extremities;  in  operations  m  the  abdomen; 
and  in  all  operations  where  ether  or  chloroform  are  contra- 
indicated,      [m.o.]  ...  -1       ^^Aa 

3.— Knapp  describes  a  uterine  bougie,  easily  made 
aseptic,  which  he  uses  to  produce  abortiou.  It  is  simiUar  to 
an  ordinary  male  catheter,    [m.o.] 

December  SO,  1900.     [13.  Jahrg.,   No.  51.] 
1    The  Difference  between  Natural  and  Artificial  Nourish- 
ment of  Infants.    Theodore  Escherich. 

2.  Observations  upon  Workers  with  E  ectricity.    ^^  J^llinek. 

3.  Hyperchlorhydriain  Infants.  Wilhelm  KNOEPFELMACHKli. 


286 


The  Philadelphia 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


[Febbcaby  9,  19M 


1. — After  comparing  the  results  obtained  by  artificial  feed- 
ing with  breast  fed  babies,  Ewherich  says  that  rachitis 
occurs  uo  ofteiier  ia  the  one  than  in  the  other, 

though  the  more  severe  cases  are  seen  among  the  botile-fed. 
He  has  not  seen  a  case  of  infantile  scurvy  among  thousands 
of  infants  ft d  artificially  or  upon  sterilizfd  milk.  He  then 
discusses  the  assimilation  of  the  food  taken  by  an  infant, 
laying  stress  upon  the  relative  absence  of  the  diastatic 
ferment  in  cow's  milk,  and  upon  the  failure  of  the  normal 
changes  in  digestion  and  absorption  of  cow's  milk,  as  com- 
pared with  mother's  milk.  Yet  some  infants  evidently  thrive 
upon  pure  row's  milk.  He  then  elaborates!  upon  the  hypoth- 
esis that  mother's  milk  contains  •'  some  stimulating 
and  tonic  niatorial."     [m  o.] 

2. — Jellinek  studied  the  blood-pressure  in  80  men,  from 
20  to  30  vears  of  age,  at  work  with  electricity.  He  used 
Gartner's  tonometer.  The  mean  blood-pressure  varied 
from  100  to  V20  mm.  of  mercury.  He  details  a  number  of 
experiments  undertaken,  which  may  lead  to  later  develop- 
mpnts.     [m-O.] 

3.  —  Knoepfelmacher  reports  the  case  of  an  infant  of 
10  months,  born  at  8}  months,  and  breast  fed  to  7  months. 
Then,  as  symptoms  of  motor  insufficiency  of  the  stomach 
had  appeared,  she  was  slowly  changed  to  cow's  milk.  Exami- 
nation of  the  stnmarh-contents  fhowed  marked  hyper- 
chlorhydria  (0  95%).  The  history,  as  reported,  suggests 
cong-euital  stenosis  of  the  pylorus,  from  the  vomiting, 
constipation,  loss  of  weight,  and  dilation  of  the  stomach. 
This  confirms  the  theory  of  Thomson  and  Pfaundler,  that 
the  spasm  of  the  pylorus  follows  hyperchlorhydria.  The  child 
thrived  on  pure  cow's  milk,    [m.o.] 

December  S7, 1900.    [13.  Jahrg.,  No.  52.] 

1.  Thomsen's  Disease.    Mahler  and  Beck. 

2.  Splenectomy  for  a  Movable  Hypertrophied  Spleen.   Karl 

?CHWAEZ. 

3.  A    Modification    of    the    Breisky   Speculum.       Ludwiq 

Knapp. 

1. — The  patient,  aged  2-1,  was  the  son  of  wedded  first 
coufins,  in  whose  family  no  nervous  diseases  had  ever  ex- 
isted. As  an  infint  he  had  rachitis,  and  later  measles  and 
pleurisy.  He  did  not  walk  until  4  years  old,  and  then  had 
trouble  in  moving  his  legs.  When  at  school,  he  first  observed 
that  his  movements,  especially  during  exercises,  were  always 
somewhat  behind  those  of  the  others.  Tnis  improved,  then 
grew  worse  at  puberty,  then  better  again.  He  passed  the 
physical  examination  for  the  army  at  20,  but  was  found  un- 
fit for  service  on  being  reexamined.  Since  then,  he  has 
grown  worse.  Rising  from  bed  and  raising  his  glass  to 
drink,  in  the  morning,  are  both  verv  hard.  If  he  hurries,  or 
is  bumped,  his  muscles  become  stiff  and  he  falls.  He  feeh  a 
tickling  on  his  face  and  neck,  which  often  causes  twitching. 
His  reflexes  are  normal,  except  the  plantar  reflex,  which  is 
absent,  as  is  ankle  clonus.  Voluntary  movements,  in  the 
extremities  especially,  show  high-grade  mueole-weakness. 
Continued  slow  eflTort  was  needed  to  move  at  firt-t,  but  if 
repeated,  he  succeded  in  going  quicker.  If  he  made  an  ener- 
getic or  sudden  movement,  tonic  contraction  of  the  muscles 
followed.  Though  the  muscles  all  looked  well  developed, 
the  muscle  power  was  very  low.  The  movements  of  chewing 
were  very  difficult.  In  fact,  the  patient  presented  tne  typical 
picture  of  myotonia  coug'enita.  The  condition  in  the 
extremities,  almost  one  of  paralysis,  Mahler  and  Beck  call 
paramyotonia,  after  reviewing  the  literature  of  the  subject. 
They  consider  Thomsen's  disease  purely  a  spinal  affection. 
In  their  case  there  were  no  disturbances  in  assimilation. 
[m.o.] 

2. — Sohwarz  reports  a  case  of  movahle  spleen  which 
was  first  noted  12  years  before,  in  a  woman  now  aged  36. 
This  movable  tumor  grew  in  size  and  caused  so  much  pain 
that  the  patient  remained  in  bed,  ofT  and  on,  for  weeks.  She 
never  had  malaria;  nor  were  there  any  signs  of  syphilis. 
Laparotomy  was  performed  and  a  spleen  which  weighed  1200 
grains  removed.  It  was  then  discovered  that  she  was  5 
months  pregnant.  Recovery  followed.  Schwarz  concludes 
that  splenectomy  is  always  preferable  to  splenopexy,  except 
when  strorg  adhesions  exist.  E-ipecially  when  the  spleen  is 
hypertrophied  should  splenectomy  be  done,     [m  o.] 

3.— Knapp  describes  a  simple  contrivance  by  means  of 


which  the  Breisky  speculum  will  support  itself,  when  intro- 
duced into  the  vagina,    [m  c] 


Centralblatt  filr  innere  Medicin. 

January  5,  1901.     [25.  Jahrg.,  No.  1  ] 

1.  Histological  Changes  in  the  Central  Nervous  System  and 

Stomach  in  a  Case  of  Gastric  Tetany.    Feerannisi. 

2.  On  the  Auscultation  of  the  Normal  and  Pathologic  Muscle 

Sjunds  and  the  Characteristics  of  the  Same  in  Thom- 
seri'd  Disease.    M.  Heez. 

1. — Treated  editorially. 

2.— Herz  draws  attention  to  the  fact  that  there  has  never 
been  sufficient  study  of  the  sound  given  by  a  muscle  during 
its  contraction.  He  divides  this  sound  into  two  portions : 
one  a  musical  part,  which  he  calls  the  muscle-tone,  and  the 
other  a  mere  noise.  It  has  been  shown  t'oat  in  tetanic  con- 
traction of  muscles  produced  by  electricity  the  pitch  of  the 
tone  is  dependent  upon  the  rapidity  of  tue  interruption  of 
the  current.  The  tone  can  be  produced  by  chemical  irri- 
tants, and  by  strychnia  poisoning.  One  can  readily  hear  the 
muscle-sound  when  the  muscle  is  in  tonic  contraction.  If 
the  patient  stands  upon  the  tips  of  his  toes,  leaning  with  his 
hands  en  a  piece  of  furniture  or  against  the  wall,  the  sound 
can  readily  be  auscultated  in  the  calf-muscles:  or  by  pulling 
upon  something  with  the  hands  it  can  be  auscultated  over 
the  biceps;  by  raising  the  arm  the  deltoid  will  give  a  scuad  ;. 
and  80  by  various  other  methods  other  muscles  may  be  aus- 
cultated. It  is  not  necessary  tD  expose  the  skin.  Pathologic 
changes  are  readily  recognized.  The  intensity  of  the  sound, 
its  character  and  pitch  are  variable,  and  variations  may 
be  readily  determined.  If  the  sound  is  loud  the  tone  be- 
comes deeper  and  the  sound  is  sonorous.  Curiously  this 
character  of  the  sound  is  found  most  frequently  in 
cases  of  disturbed  innervation.  Strong  muscles  give  a 
sound  which  he  characterizes  as  soft,  high  pitched,  and 
hollow.  He  believes  that  important  conclusions  may  be 
reached  by  farther  study  of  the  muscle  sound.  One  of 
the  most  important  things  to  be  studied  ia  the  course  of  ac- 
cidental murmurs  over  the  heart.  It  is  impottant,  he  be- 
lieves, to  investigate  the  relation  between  the  changes  in  the 
heart  tone  and  coincident  changes  in  the  muscle  sounds 
elsewhere.  It  is  also  important  to  make  special  studies  of 
the  sound  in  anemic  conditions,  particularly  in  chlorosis,  in 
cachexia,  in  fevers,  in  the  gouty  diathesis,  in  diabetes,  etc., 
and  of  course  in  various  nervous  affections,  particularly  in 
neurasthenia  and  neuroses.  He  has  found  a  marked  differ- 
ence in  the  sounds  on  the  affected  and  unaffected  sides  in 
cases  of  hemiplegia.  It  may  also  prove  important  to  study 
the  sound  before  and  a^ter  various  therapeutic  procedures. 
In  a  case  of  Thomsen's  diseate  he  made  a  careful  study  of 
the  muscle  sound,  and  found  that  in  the  beginning  of  the 
peculiar  contractions  he  heard  no  sound,  and  his  observa- 
tion was  confirmed  by  Lampa.  Liter  on,  by  continued  aus- 
cultation, the  muscle  sound  gradually  appeared  and  became 
of  normal  strength,  and  at  this  time  the  muscular  spasm  bad 
disappeared.  If  the  disease  were  due  to  a  central  origin  and 
the  spasm  were  similar  to  that  of  tetanus  the  muscle  sound 
should  be  loud ;  if  the  change,  however,  were  in  the  muscle 
fibrils,  and  consisted  of  a  sharp  contractiin  of  the  fibers 
with  a  fixation  of  the  fibers  in  this  position,  and  no  further 
vibrations,  the  muscle  sound  would  be  absent.  The  latter 
was  the  case,    [d.l.e  ] 


Zeitschrift  filr  Heilkande. 

[Volume  xxi  (New  Series,  Volume  1).] 
[Jahrg.  1900,  No.  xi.] 

1.  The  Treatment  of  Tuberculosis  with  Intravenous  Injec- 

tions of  Cinnamic  Acid.    (Conclusiott).    Karl  HoDL- 

MOSER. 

2.  Casuistical  Communicitions.    Mader. 

3.  The  Diagnosis  of  Retroperitoneal  Hernia,  with  Report  of 

a  Case.     Wilhei.m  Scholz. 

4.  The  Bremer  and  Williamson  B'.ood  Reactions  ia  Diabetee 

Mellitus.    E.MIL  Adler. 


Febbuabt  9,  1901] 


THE  LATEST  LITERATURE 


[ 


Thk  Philadklphia 
Medical  Journal 


287 


1. — These  injections  were  given  18  patients,  daily,  from  1 
to  0  months.  Sixteen  of  them  had  phthisic,  1  had  tubercular 
peritonitis,  and  1,  tuberculos-is  of  the  lungs  and  joints.  Eleven 
were  Feen  in  the  Vienna  General  Hospital,  while  7  canae  to 
the  ("ispensary.  After  an  extensive  review  of  the  statistics 
already  published,  Hoilmoser  gives  his  reeultf,  which,  in 
marked  contralto  those  collected  by  F,ankel,90%  improved, 
and  those  reported  by  von  Weismayr,  T\fo  improved,  give 
only  23%  improved.  Whether  such  results  are  really 
due  tj  the  cinnamic  acid,  further  investigations  alone  can 
show.  With  Ewald,  Ho ilmoser  pleads  that  further  experi- 
ments be  undertaken.  The  case- histories  follow  in  detail. 
[m.o] 

2. — These  consist  of  19  case  histories  from  the  Rudolph- 
Spital  in  Vienna.  Among  the  more  interesting  cases  are  the 
following  :  (rt)  a  coachman,  33  years  old,  entangled  in  a  broken 
wire  which  crossed  a  trolley-wire,  was  thrown  to  the  ground, 
badly  shocked.  The  quadriceps  mu,scle  of  both  thighs 
was  thrown  into  tetanic  spasm,  which  lasted  24  hours. 
The  htiffness  in  both  legs  remained  2  weeks.  Had  he  not 
worn  nonconducting  leather  trousers,  he  would  most  prob- 
ably have  been  paralyzed.  (6)  A  case  of  acute  angio- 
neurotic edema  in  a  man  of  28  years,  occurring  several 
times  during  6  month=,  indifferent  parts  of  V\i  body,  for 
which  no  cause  could  he  found,  (c)  A  woman  of  40,  on 
whose  upper  lip  a  carbuncle  suddenly  formed.  Phlebitis 
followed  in  the  facial  vein,  followed  hy  thrombophle- 
bitis of  the  cavernous  sinus.  Metastatic  abscesses 
occurred  in  both  lungs  with  bilateral  fibrinopuruleut 
pleurisy.  Death  followed  5  days  after  the  carbuncle 
appeared,  (rf)  A  woman  of  54,  swallowed  a  spoonful  of 
ammonia,  7  hours  later  she  reached  the  hospital,  and  was 
given  diluted  vinegar  in  large  quantities.  She  vomited  a 
brown  alkaline  fluid.  While  hoarse,  she  complained  only 
of  slight  epigastric  pain.  Her  mouth  was  sore,  yet  she  drank 
milk  and  soup  easily.  She  d  ed  suddenly,  24  hours  after 
taking  the  poison.  The  autopsy  showed  intense  corro- 
sion of  the  mouth,  trachea,  esophagus,  and  stomach, 
in  spite  of  the  very  few  subjective  symptoms.  Striking,  too, 
was  the  lack  of  dyspnea  and  cough.  Mader  supposes  that 
the  ammonia  affected  the  deep  nerve  roots,  causing  anes- 
thesia and  analgesia  (e)  A  woman  of  41,  with  chronic 
phthisis  and  pyothorax,  had  suffered  for  over  4  years 
with  increasing  nervous  symptoms,  weakness,  spasticity  of 
the  extremities,  paresthesia,  twitching?,  and  finally  paralysis 
and  wasting.  From  the  many  small  swellings  aloui;  the 
peripheral  nerves,  the  diagnosis  of  polyneuroma  was  made. 
Death  followed  from  phthisis.  The  autopsy  showed  various 
sized  tumors  upon  almost  all  the  nerves  of  the 
body.  Two  plates  show  these  well.  Their  immenss  num- 
ber 18  btriking.  (/)  A  locksmith,  aged  29,  who  for  2  years 
previous  had  had  chills  and  fever  when  exposed  to  cold 
weather,  was  admitted  after  such  an  attack,  with  hemo- 
globinuria. His  liver  was  swollen  and  painful.  He  had 
suffered  from  malaria  during  childhood.  Cold  applied 
locally  had  no  effect.  Hemoglobin  was  75%,  erythrocytes 
4,400,000,  leukocytes  2,000.  With  iron,  arsenic,  and  good 
food,  he  quickly  recovered.  A  number  of  cases  of  hysteria, 
some  cases  (jf  brain  tumor,  and  of  chronic  lead  poisoning 
are  also  described  in  full,    [m.o  ] 

3. — The  patient,  a  22  yeir-old  girl,  weak  and  poorly  devel 
oped,  had  always  had  a  distended  abdomen,  with  occa- 
sional disturbance  of  digestion.  The  abdominal  distention 
increased  during  the  last  two  years,  with  several  attacks  of 
pain,  followed  by  the  passage  of  fla,tu3  and  sudden  improve- 
ment. She  kept  at  work  until  3  weeks  before  her  death. 
After  a  week  of  constipation,  with  great  pain  and  distention, 
she  entered  the  hospital.  She  was  pale  and  thin.  Her  heart 
was  pushed  upward  and  to  the  right.  There  was  very  little 
expansion  on  the  leftside  of  the  thorax.  Oa  the  right  side, 
tympany  began  at  the  sixth  rib  ;  on  the  left,  at  the  third  rib. 
The  abdomen  was  enormously  distended,  showing 
dilated  veins.  No  tumor  was  at  any  time  palpable.  The 
ascending  and  descending  colon  could  be  made  out, 
widely  dilated.  There  were  no  ascites,  no  vomiting,  and 
no  hiccough.  She  had  diarrhea  generally.  Symptoms  of 
peritonitis  only  appeared  during  the  last  12  hours.  As  the 
case  was  not  diagnosed  during  life,  operation  was  not  con- 
sidered. The  autopsy  revealed  a  retroperitoneal  her- 
nia. The  greater  part  of  the  jejunum,  having  passed  through 
and  stretched  the  opening  in  the  peritoneum  for  the  colica 


sinistra  artery,  was  found  behind  the  descending  colon,  ex- 
tending up  to  the  pancreas,  and  down  to  the  sigmoid  fiexure. 
The  diaphragm  reached  up  to  the  third  rib;  the  heart  lay 
almost  perpendicular  under  the  right  edge  of  thesternum. 
Tne  sigmoid  flexure  was  normal.  The  rest  of  the  colon  was 
dilated,  with  greatly  thickened  walls.  In  the  descending: 
colon  were  a  number  of  oval  perforations.  The  pres- 
sure of  the  filled  jejunum  was  the  evident  cause  of  the  sten- 
osis and  subsequent  perforation.  Though  over  70  such  casts 
have  been  reported,  the  majority  were  not  diagnosed  until 
the  autopsy  revealed  a  retroperitoneal  hernia.  Jonnesco  has 
divided  them  into  4  groups:  (o)  Tne  mpjirity,  found  post- 
mortem, having  caused  no  symptoms;  (6)  those  having 
caused  but  slight  digestive  disturbance;  (c)  some  few,  in 
which  progressive  stenosis  of  the  intestine  fallowed ;  and  (rf) 
those  with  sudden  strangulation  and  death.  Of  group  c,  only 
3  other  cases  have  bee  i  reported  up  to  this  time.  Sjholz 
quotes  them  in  detail.  He  then  calls  attention  to  the  very 
large  abdomen  and  very  small  thorax,  and  to  the 
great  distention  of  the  large  intestine,  both  points  in 
the  diagnosis  of  retroperitoneal  hernia.  Digestive  disturb- 
ance from  early  childhood,  and  a  tumor,  when  present,  also 
aid  in  forming  the  diagnosis,     [mo.] 

4. — ."Vdler  tested  the  reactions  wtiich,  it  was  claimed  by 
Bremer  and  Williamson,  occur  in  staining  diabetic  blood. 
Bremer  claims  that,  with  a  methylene-green  eosin  mixture, 
diabetic  blood  is  stained  green,  while  other  blood  stains  red, 
Williamson  claims  that  diabetic  blood  takes  a  warm  alka- 
line methylene- blue  stain  more  deeply  than  other 
blood.  Oat  of  25  c-ises  tested  for  the  B.emer  reaction,  Ad- 
ler  found  it  in  the  blood  of  5  severe  cases  of  diabetes  mellitus, 
in  2  cases  of  leukemia,  and  in  1  perfectly  well  man.  Other 
investigators  have  published  like  results,  showing  the  Bre- 
mer reaction  to  be  of  no  diagnostic  value.  Toe  VVil- 
liamson  reaction  was  tested  in  180  cases.  It  was  positive 
in  all  cases  of  diabetes  mellitus  tested  (9),  and  in  no- 
other  disease,  no  matter  how  great  the  glycosuria. 
Tae  cause  of  this  reaction  Adler  believes  to  be  a  diminution, 
ia  the  alkalinity  of  the  blood.  He  concludes  that  the  Wil- 
liamson reaction  is  peculiar  to  diabetic  blood,  and 
of  value  in  diagnosis.  The  details  of  his  method  of 
staining  are  given,    [m.o  ] 


Zeitschrift  fUr  klinische  Medicin, 

1900.     [Bind  41,  Heft  1  u.  2.] 

1.  Oa  the  Diagnosis  of  Aneurysm  of  the  Acrta  and  of  the 

Innominate,  and  on  the  Treatmsnt  of  the  Same  with- 
Subcutaneous  Injections  of  Gjlatin.    J.  Sorgo. 

2.  The  Cause  of  Illness  in  Rirefied  Air.     E.  Aron. 

3.  A  Contribution  to  the  Study  of  the  Lite  Form  of  Cyan- 

osis of  Peripheral  Origin.    Tho.mas. 

4.  Oa  the  Methods  of  Determining  the  Fat  in  the  Blood. 

M.  BONNIGER. 

5.  Oa  luterference  of  Sensations.    Adamkiewicz. 

6.  Oa  Percussory  Transsonance.    J.  W.  Euneberg. 

7.  On  Uailateral  Atrophy  of  the  Lung,  and  on  Congenital 

Bronchiectasis.    E.  Neisser. 

8.  Oa  the  loflaenoe  of  Artificial  Sweating  Upon  the  Secre- 

tion of  G-istric  Juice.    P.  Edel. 

9.  Some  Observations  Concerning  Lymphatic  Leukemia, 

M.  ROSENFELD. 

10.  Amatus  Lusitanus  and  His  Period.  A  Cantribution  to 
the  History  of  Medicine  in  the  Sixteenth  Century.  M^ 
Salomon. 

1. — To  be  treated  editorially. 

2.— Aron  describes  at  length  an  apparatus  which  he  has- 
used  for  the  study  of  the  question  at  issue.  His  tables  show- 
that  there  was  a  distinct  reduction  of  the  amount  of  oxygen 
used  in  rarefied  atmosphere  and  also  a  marked  reduction  of 
the  amplitude  of  respiration.  If  oxygen  were  given  the  am- 
plitude of  respiration  approached  close  to  that  observed  be- 
fore the  air  was  rarefied,  but  this  could  not  be  fully  attained. 
He  therefore  decides  that  the  cause  of  the  alteration  m 
breathing  in  rarefied  atmosphere  is  both  a  chemical  and  a. 
physical  one.  He  believes  that  he  is  justified  from  his  results- 
in  recommending  that  trains  passing  over  high  altitudes, 
such  as  the  proposed  Jungfrau  road,  should  have  oxygen  cyl- 


288  Thb  Phiiadelphia"! 

msdical  jocbnal  j 


THE  LATEST  LITERATURE 


fFKBECAST  9,   1901 


inders  in  the  carriages  and  at  the  stations,  as  he  believes  that 
in  this  way  it  would  be  possible  to  avoid  serious  attacks  of 
mountain  sickness,  and  in  some  caaes  probably  to  avoid 
death,    [d  l.e.] 

3. — The  teaching  which  Thomas  follows  is  that  first  pro- 
mulgated by  Bard,  that  the  occurrence  of  cyanosis  depends 
upon  an  increase  in  the  pressure  of  the  left  auricle  as  com- 
pared with  the  pressure  of  the  right.  Bard  previously  taught 
that  this  was  usually  due  to  some  persistence  of  the  foramen 
ovale,  the  opening  being  closed  by  a  membranous  valve 
and  the  valve  driven  open  if  the  pressure  in  the  left  auricle 
becaine  very  high.  Bard  afterward  reported  cases  himself 
in  which  cyanosis  of  a  severe  grade  (blue  sicknesp)  was  seen 
without  any  persistence  of  the  foramen  ovale,  but  in  which 
a  considerable  portion  of  the  lung  parenchyma  was  de- 
stroyed by  tubercular  infiltration  or  other  causes.  If  the 
bloodvessels  are  not  destroyed  with  the  parenchyma  of  the 
luDg,  the  result  will  be  that  a  very  considerable  proportion 
of  the  venous  blood  will  pass  through  areas  in  which  it  is 
impossible  that  the  blood  should  be  aerated.  In  such  cases 
cyanosis  will  result.  If  the  bloodvessels  were  destroyed  or 
obliterated  with  the  lung  parenchyma  the  blood  would  then 
pass  through  the  remaining  more  healthy  parts  of  the  lung 
and  cyanosis  would  probably  be  slight  or  absent;  hence  the 
preservation  of  the  bloodvessels  in  areas  where  the  lung  is 
destroyed  tends  to  cause  cyanosis.  Thomas  reports  a  case 
of  this  kird,  and  re'ers  to  others,     [d  l  e  ] 

4.— Bonninger  has  investigated  a  number  of  methods  for 
the  determination  of  the  fat  in  the  blood,  and  finally  se- 
lected that  recommended  by  Hoppe  Seyler  as  the  most  satis- 
factory. The  methcd  of  cairying  this  out  is  to  take  from  .5 
to  30  grams  of  blood,  receiving  it  in  20  times  its  volume  of 
96^  alcohol,  mix  thoroughly,  allow  it  to  stand  for  from  one 
to  two  days,  and  filter.  The  deposit  collected  upon  the  filter 
is  to  be  treated  again  in  the  same  manner ;  the  part  then 
remaining  is  treated  with  ether,  and  the  remaining  por- 
tion digested  and  then  thoroughly  shaken  with  ether.  The 
various  alcoholic  and  ethereal  extracts  are  collected,  evapo- 
rated slowly  to  ("ryness,  extracted  with  absclute  ether,  thor- 
oughly dried  and  weighed.  A  considerable  portion  of  the 
fat  is  likely  to  be  held  back  in  the  filter  paper,  hence  the 
filter  papers  are  extracted  with  ether  in  the  Soxhiet  appara- 
tus. This  method  gave  extremely  satisfactory  results.  The 
amount  found  in  normal  blood  was  fail ly  constant  and  be- 
tween 0.75  and  0.85%.  The  highest  amount  of  fat  was  found 
in  a  case  of  carcinoma  of  the  esophagus,  where  it  reached 
1.4%.  This  is  probably  a  further  proof  of  a  statement  that 
has  b?en  previously  made  that  the  fat  of  the  blood  increases 
in  hunger;  this  patient  had  bfea  able  to  take  practically  no 
food  for  some  time.  A  similar  cause  may  have  been  active 
in  a  case  of  preumonia  in  which  the  fat  reached  nearly  1  '7. 
It  was  also  found  high  in  diabetes,  in  a  case  of  nephritis,  and 
in  a  case  of  hysteria.  The  serum  was  found  to  contain 
neutral  fat,  lecithin  and  cholesterin.  The  cholesterin  in  hu- 
man serum  is  united  with  fatty  acids,  particularly  oleic  acid. 
The  blood-corpuscles  contain  probably  only  cholesterin  and 
lecithin,  and  no  neutral  fat.     [d.l.k.] 

6. — Adamkiewicz  divides  tabes  dorsalls  into  two  forms — 
one,  a  primary  disease  of  the  nervous  elements,  he  calls  nerve- 
tabes  ;  the  other,  in  which  the  bloodvessels  are  first  aflected, 
he  calls  vessel-tabes.  The  latter  is  the  insterstitial  form,  and 
involves  the  neuroglia.  Syphilis  he  considers  practically  al- 
ways the  cause  of  the  interstitial  form,  while  he  does  not 
think  it  is  nearly  so  active  in  producing  the  other  form;  and 
perhaps  never  produces  it.  The  main  clinical  differences  in 
the  two  are,  that  in  the  parenchymatous  form,  ataxia  occurs, 
with  persistence  of  the  muscular  power;  while  in  the  inter- 
stitial form  there  is  lees  marked  ataxia,  but  more  marked 
muscular  weakness.  In  the  parenchymatous  form  the  skin- 
sensation  is  reduced,  while  in  the  interstitial  form  this  is  not 
the  case;  the  interstitial  cases,  as  a  rule,  sliow  no  constant 
reduction  of  sensation,  but  do  show  various  p.*re8the3ias. 
Paresthesias  are  much  less  prominent  in  the  so-called  nerve- 
tabes.  Adamkiewifz  goes  into  an  elaborate  explanation 
of  the  reasons  of  this  difference  in  sensation.  He  thinks 
the  chief  cause  of  the  variations  in  the  paresthesias  is 
variation  in  the  space  occupied  by  the  neuroglia  tissue,  and 
this  is  produced  largely  by  meteorologic  conditions.  He  calls 
the  disturbances  (f  sensation  produced  by  irritation  of  the 
ganglia  of  ihe  posterior  roots  "  subjective,"  and  denominates 
as  objective  disturbances  those  produced  by  variations  in  the 


acuity  of  perception  of  sensations  caused  by  peripheral  irri- 
tation. These  two  forms  he  considers  act  antagonistically; 
he  describes  them  as  producing  waves  of  sensation,  and 
when  one  wave  is  high  the  other  is  low.  He  believes  that  if, 
at  a  certain  time,  the  wave  of  the  subjective  sensation  be 
high  any  normal  irritation  of  the  periphery  which  would 
ordinarily  produce  an  objective  sensation  will  have  no  result 
unless  it  is  sufliciently  strong  to  overcome  the  subjective 
wave.  This  is  what  he  terms  the  interference  of  two  sensa- 
tions. In  this  way  he  explains  the  tendency  that  patients 
with  disturbance  of  their  eu^jective  sensation  have  of  in- 
stinctively grasping  objects  very  tightly.  The  result  of  this 
is  that  their  objective  sensation  is  made  so  much  stronger 
than  usual  that  the  patients  are  able  to  appreciate  the  oVjec- 
tive  sensation,  when  if  the  object  were  grasped  lightly  the 
sensation  from  the  object  would  be  less  than  the  subjective 
sensation,  and  only  an  ill-formed  objective  sensation  would 
result,    [d  L.E.] 

6.— Runeberg  directs  attention  to  a  method  of  examina- 
tion which  is  practically  nothing  more  nor  less  than  aas- 
cultatory  percasslon.  His  chief  point  is  that  one  should 
place  the  stethoscope  over  the  organ  to  be  examined  and 
then  percuss  gently,  or  stroke  the  finger  tip  gently  toward 
the  periphery  of  the  organ.  So  long  as  one  remains  over 
the  organ  auscultated,  the  sound,  which  he  calls  the  trane- 
sonance-sound,  will  be  clear,  but  it  vanishes  or  changes  its 
character  immediately  upon  passing  the  limits  of  the  organ. 
[d.le.] 

7. — Xeiseer  describes  the  case  of  a  man  who  had  had  a 
cough  as  long  as  he  could  remember,  but  had  no  definite 
history  relating  to  his  condition.  The  chief  points  in  the 
investigation  of  the  man  were  that  he  had  signs  of  marked 
enlargement  of  the  right  lung  with  atrophy  of  the  left  lung 
but  without  anj'  deformity  ef  the  left  chest.  Neisser  thinks 
that  when  deformity  of  the  chest  is  absent  and  yet  there  are 
signs  of  atrophy  of  the  lung,  the  condition  is  probably  one 
that  arose  either  extremely  early  in  life  or  was  congenital. 
He  considers  that  it  is  only  in  very  early  life  when  the  lungs 
are  capable  of  very  considerable  growth,  that  one  lung  could 
so  greatly  hypertrophy  as  to  fill  the  space  left  vacant  by  the 
other,  without  causmg  chest  deformity.  The  most  common 
and  important  cause  of  deformity  of  the  chest  is  pleural 
adhesion,  but  the  chest  may  become  deformed  without 
adhesion,  as  evidenced  by  several  cases  collected  from  litera- 
ture in  which  d<  formity  of  the  chest  occurred  and  subse- 
quently disappeared.  He  thinks  that  if  pleural  adhesions 
had  caused  the  deformity,  the  latter  would  scarcely  have 
disappeared.  The  conditions  which  he  considers  necessary 
in  order  that  atrophy  of  the  lung  shall  produce  no  deformity 
of  the  chest  are,  that  it  should  occur  in  early  life,  when  the 
remaining  lung  is  capable  of  rapid  growth,  and  that  it  should 
be  of  slow  progress,  so  that  time  is  given  for  hypertrophy  of 
the  other  lung.  In  such  cases  the  thorax  also  really  changes 
to  a  certain  extent,  as  compared  with  the  normal,  so  that 
while  there  may  be  no  deformity  of  the  two  sides,  as  com- 
pared with  each  other,  there  will  be  some  deformity  as  com- 
pared with  the  normal  chest,  A  further  evidence  that  in  the 
case  tirst  reported  the  condition  was  congenital  is,  he  believes, 
shown  by  the  fact  that  a  son  of  the  man  afterward  came 
under  observation  and  showed  the  same  condition.  He 
believes  that  the  most  satisfactory  explanation  of  the  occur- 
rence of  this  condition  is  congenital  bronchiectasis,    [duk.] 

8. — Edel  first  refers  to  the  work  of  Simon,  which  seems  to 
show  tliat  sweat-baths  reduce  the  secretion  of  gastric  juice, 
particularly  the  HCl.  These  results  are  contrary  to  those  of 
several  authi^rs,  particularly  Reigel's  results  with  the  use  of 
pilocarpin.  Some  authors  have,  however,  to  a  certain  extent 
confirmed  Simon's  results.  Edel  has  further  investigated  the 
question,  giving  warm  baths  and  then  covering  the  patients 
with  thick  woolen  blankets,  and  giving  them  sul^equent 
test  meals.  The  results  of  his  investigation  suited  brietiy  are, 
that  the  baths  had  little  effect  upon  the  secretion  of  gastric 
juice;  the  secretion  usually  remained  normal  but  sometimes 
increased.  Subsequently  the  acidity  was  most  frequently 
found  elevated.  Edel  believes  that  his  results  are  more  trust- 
worthy than  Simon's,  because  he  used  norm-il  persons.  As 
to  Simon's  belief  that  the  baths  cause  a  persistent  decre.<ise 
in  the  chlorides  of  the  body  fluids,  he  considers  this  mere 
supposition  and  very  improbable,  because  Simon  in  no  way 
controlled  the  intake  of  chlorides ;  if  there  is  a  loss  of 
chlorides  through  baths,  or  by  any  other  means,  it  is  cua- 


FllBBDiBY  9,  1901] 


THE  L.\TEST  LITERATURE 


PThe  Philadelphia 
L  Medical  Journal 


289 


tomary  for  subjects  to  make  this  up  by  subsequently  taking 
in  larger  amounts  of  chlorides,     [d.l  e  ] 

9. — One  recent  view  concerning  chronic  lymphatic  leu- 
kemia is  that  it  is  a  disease  primarily  of  the  lymph  gland?, 
which  has  a  characteristic  blood  picture ;  the  affection  of 
the  liver,  spleen,  and  bone  marrow  is  secondary,  and  pro- 
duced by  metistasis.  Another  view  is  that  it  is  a  primary 
disease  of  the  lymph  glands,  but  produces  the  character- 
istic blood  picture  only  when  the  bone  marrow  becomes 
involved  in  the  lymphadenoid  change.  A  third  view  is  that 
it  is  a  primary  disease  of  the  bone  marrow,  which  consists 
of  a  lymphadenoid  degeneration;  it  may  remain  confined 
to  the  bone  marrow,  or  may  secondarily  through  metastases 
involve  the  lymph  glands,  spleen,  etc.  Tne  fourth  view  is 
that  it  is  a  disease  of  the  whole  lymphatic  tissue,  which 
tissue  is  preexistent  in  all  organs.  R  isenfeld  reports  3  cases, 
and  discusses  them  in  connection  with  the  theories  of  the 
disease.  Tlie  3  cases  showed  distinct  differences  in  the  clin- 
ical course,  in  the  condition  of  the  blood,  and  in  their  post- 
mortem findings.  In  the  first  case  there  was  from  the 
beginning  of  ■^  observation  a  very  marked  reduction  of  the 
red  cells,  while  this  was  but  slight  in  the  second  case.  The 
number  of  lymphocytes  varied  in  the  3  cases.  Toe  number 
of  lymphocytes  in  the  peripheral  circulation  is  not  indica- 
tive of  the  absolute  number  produced,  but  it  was  striking 
that  in  the  3  cases  the  lymphocyte  count  was  4  times 
as  great  as  in  the  second  case,  and  yet  in  the  second 
Cise  the  sole  increase  was  in  the  small  lymphocytes. 
It  is  an  interesting  fact  that  in  this  case  after  treatment  with 
arsenic  and  an  evident  decrease  in  the  size  of  the  lymph 
elands,  there  was  a  marked  increase  in  the  number  of  circu- 
lating lymphocytes.  Probably  the  reduction  of  the  glands 
was  associated  with  a  flooding  of  Che  blood  with  lymphocytes. 
One  remarkable  fact  was  that  in  the  first  case  an  examination 
of  the  blood  while  the  glinds  were  enlarged,  but  before  the 
actual  symptoms  of  leukemia  had  come  on,  showed  no 
marked  blood-changes,  and  the  flooding  of  the  circulation 
with  lymphocytes  apparently  took  place  6  months  after- 
ward. This  was  very  probably  true,  also,  in  the  third  case, 
since  the  lymph  glands  had  become  enlarged  3  or  4  years 
before  the  severe  general  symptoms  appeared.  In  the  second 
case,  in  which  the  increase  in  cells  was,  as  noted,  practically 
entirely  of  the  small  lymphocytes,  the  postmortem  showed 
enormous  involvement  of  the  lymph  glands  with  very 
marked  involvement  of  the  bone-marrow.  The  difficulty  in 
this  case  was  as  to  whether  the  case  was  a  true  lymphatic 
leukemia,  or  lymphemia  with  general  sarcomatosis.  Tne 
diagnosis  of  the  pathologist  was  the  latter  condition'  In  the 
first  case  no  postmortem  was  obtained.  In  the  third 
case  there  was  diS'use  lymphadenoid  degeneration  of  the 
bone-marrow.  The  third  case,  therefore,  stands  be- 
tween those  instances  in  which  there  is  only  involve- 
ment of  the  lymph  glands,  and  other  cases  in  which  there 
is  only  involvement  of  the  bone  marrow.  Rjsenfeld  ac- 
cepts chronic  lymphemia  as  being  one  of  general  lympho- 
sarcomatosis,  and  thinks  that  the  varying  conditions 
found  clinically  are  due  to  the  varied  tissue  involvement  in 
the  sarcomatous  change.  He  notes  the  fact  that  so  far  as 
this  condition  has  been  studied,  when  the  lymph-glands  are 
involved  to  the  almost  complete  exclusion  of  the  bone 
marrow  the  increase  is  chiefly  or  entirely  of  the  small  lympho- 
cytes, while  when  the  bone-marrow  was  chiefly  involved, 
the  large  mononuclear  lymphocytes  were  in  excess.  It  is 
also  notable  that  in  several  cases,  at  any  rate,  when  the  bone- 
marrow  was  uninvolved  there  was  practically  no  change  in 
the  erythrocytes.  His  conclusions  are  that  one  cannot  deny 
the  existence  of  a  primary  disease  of  the  lymph  glands 
which  may  produce  either  an  aleukemic  preliminary  stage, 
or  which  produces  chiefly  an  increase  in  the  small  lympho- 
cytes if  the  disease  has  become  very  widespread.  If  the 
bone  marrow  becomes  involved  sufliciently,  the  blood  picture 
changes,  and  the  large  lymphocytes  become  increased  in 
number,  and  in  such  cases  there  is  likely  to  be  an  onset  of 
severe  clinical  symptoms  and  a  rapidly  progressing  course. 
As  to  Pappenheim's  theory  that  lymphatic  leukemia  is  pri 
marily  myelogenous  in  all  cases,  Rosenfeld's  second  and 
third  cases  speak  strongly  against  this.  Tne  name,  however, 
given  the  condition— lymphatic  leukemia — should  not  indi- 
cate that  the  disease  is  solely  one  of  the  lymph  glands.  It 
should  indicate  rather  that  it  is  a  disease  of  the  lymphatic 
tissue  in  general.    [d.l.e.J 


[Band  41,  Heft  5  u.  6.] 

1.  lodipin    as   an   Indicator   of  the  Mjtor  Power  of  the 

S.omach.     S.  Heichelheim. 

2.  Observations  Concerning  Gycolysis  in  Pithological  Con- 

ditions, Particularly  in  Diabetes  and  Functional  Neu- 
roses.     E.  BlERNACKI. 

3.  A    Contribution     Concerning    Adams-Stokes'    Disease. 

August  Hoff.mann. 

4.  A  Contribution  Concerning  Metabolism  in  Obese  Sub- 

jects.   A.  Jaquet  and  N.  Svenson. 

5.  The  Clinical  and  Bacteriological  Methods  N  )w  in  Use 

in  the  D  agnosis  of  Typho  d  Fever.    E.  Scholz  and 
P.  Kkause. 

6.  The  Production  of  Glycogen  Elsewhere  Than  in  the  Liver 

after  the  Use  of  Levulose.     Hans  Sachs. 

7.  Electrical  Reiction  of  the  Ni^rves   and  Muscles  D  iring 

Curare  Poisoning.     Jui-ius  Donath  and  Hugo  Lukacs. 

8.  Tne  Prognosis  in  Aneurysm  of  the  Aorta.   N.  J.  Kotowt- 

SCHICOFF. 

9.  Amatus  Lusitanus  and  His  Period.    A  Contributioa  to 

History  of  Midicine  in  the  Sixteenth  Century.    M. 
Salomon. 
10.  On  the  Qaestion  of  the  Influence  of  Pilocarpin  upon  the 
Secretion    of  G  istric  Juice.     Anticritical    Remarks. 
Alexander  Simon. 

1. — The  practical  conclusion  which  Heichelheim  reaches 
is  that  in  all  cases  where  it  is  not  possible  to  siphon  the 
stomach  in  order  to  determine  its  motor  power  one  may 
with  advantage  use  iodipin.  The  results  are  not  exact,  but 
they  give  a  general  idea  of  the  motor  power  of  the  stomach, 
and  in  connection  with  other  factors  in  the  case  one  may  by 
this  means  reach  fairly  certain  conclusions.  The  method  is 
very  easily  used.  Tne  one  condition  as  yet  observed  that 
seems  to  interfere  is  icteru-t,  in  which  the  test  seems  to  give 
the  same  result  as  in  weakness  of  the  gastric  motor  power. 
It  was  found  that  in  stenosis  of  the  pylorus  and  gastric 
ecstasy  with  motor  insufficiency  the  reaction  was  practically 
always  delayed  beyond  1  hour,  though  this  was  not  an  abso- 
lutely constant  result.  Tnis  did  not  seem  to  be  the  case  in 
other  gastric  affections.  The  test  consists  of  the  administra- 
tion of  about  a  gram  and  a  half  of  iodipin  in  gelatin  capsules 
and  testing  the  saliva  eyery  quarter  of  an  hour  afterward  for 
the  presence  of  iodin.  The  test  which  Heichelheim  used 
was  to  the  reaction  with  starch  paper  which  had  been  re- 
cently made  and  kept  in  the  dark  after  saturating  it  with 
5%  persulfate  of  ammonia.  The  saliva  should  be  placed 
in  test  tubes  and  a  paper  put  in  the  tube.  It  is  absolutely 
important  to  keep  the  papers  in  the  dark,     [d.l  e  ] 

22. — Bierca  ki  makes  some  very  interesting  observations 
concerning  the  method  of  determining  the  glycolytic  action 
of  the  blood  O.ie  of  the  most  important  points  that  he  dis- 
covered is  that  if  different  quantities  of  the  blood  are  mixed 
with  varying  quantities  of  sugar  the  result  is  by  no  means 
always  proportional  to  the  quantities  used,  and  that  therefore 
in  order  to  compare  observations  one  should  always  use  the 
same  quantity  of  blood  with  the  same  quantity  of  sugar 
solution,  and  the  latter  should  always  be  of  the  same 
strength.  Also,  if  the  quantity  of  sugar  solution  were 
kept  the  same,  increasing  the  amount  of  blood  used, 
it  did  not  seem  to  have  a  proportionate  influence  upon 
the  glycolysis  after  a  certain  optimum  in  the  qmntity 
of  blood  used  was  once  reached.  Oa  the  contrary,  increase 
in  the  amount  of  blood  seemed  to  decrease  the  glycolysis. 
The  use  of  alkaline  solutii  m  caused  much  more  active  gly- 
colysis than  did  physiological  salt- solution.  Blood  which 
had  not  been  defibrinated  was  more  active  than  that  which 
had  been  defibrinated,  and  there  was  a  certain  direct  rela- 
tion between  the  glycolytic  power  of  the  blood  and  the 
amount  of  water  contained  therein.  He  states  that  in  all 
the  cases  of  diabetes  he  observed  distinctly  low  values  for 
glycolysis  when  alkaline  serums  were  used,  but  concentra- 
tion of  the  sugar  solution  abnormally  increased  the  glyco- 
lysis. The  absolute  values  in  diabetes,  then,  were  low,  but 
the  values  obtained  by  increasing  the  percentage  of  sugar 
were  relatively  higher  than  those  obtained  in  health.  He 
does  not  believe,  therefore,  that  his  results  indicate  that 
there  is  any  definite  loss  of  the  glycolytic  power  in  diabetes; 
they  indicate  only  that  there  is  disturbance  of  the  glyco- 
lytic power,  and   it   is  quite  possible    that  these  disturb- 


290 


The  PhiladelphliI 
Medical  Joubkal  J 


THE  LATEST  LITERATURE 


[Febbcaet  9,  IWl 


ances  are  not  due  to  changes  in  the  enzyme  alone,  but 
to  other  factors.  His  observations  concerning  functional 
neuroses  (chiefly  hysteria  and  neurasthenia)  are  interesting. 
The  venous  blood  in  both  diabetes  and  functional  neuroses 
is  pale.  He  also  found  in  a  number  of  cases  very  low  values 
for  glycolysis  in  functional  neuroses,  though  the  values 
varied  greatly ;  a  point  upon  which  he  lays  especial  stress  is 
that  contrary  to  the  normal  conditions  deflbrinated  blood  in 
functional  neuroses  oxidizrs  sugar  more  actively  than  unde- 
fibrinated  blocd.  In  other  words,  the  blood  in  functional 
neuroses  acts  as  a  defibrinated  blood.  He  believes  that  he  is 
justified  in  stating  that  the  most  characteristic  thing  about 
the  blood  in  hysteria  and  neurasthenia  is  that  in  these 
-conditions  is  resembles  defibrinated  blood.  Whether  it  is  a 
cause  or  a  result  of  the  disease  is  questionable.  It  is,  how- 
■€ver,  in  his  belief,  evident  that  there  is  disturbance  of  the 
-chemistry  of  the  blocd  in  neurasthenia  and  hysteria,  and 
that  there  is  some  relation  between  neurasthenia  and  hys- 
teria and  diabetes  as  to  their  blood  conditions,     [d  l.e  ] 

3. — Hoffmann  describes  a  case  in  a  man  of  23  whicj  had 
the  following  clinical  picture.  He  had  always  been  anemic 
and  weakly  and  had  for  a  long  time  had  a  disturbance  of 
the  pulse  rhythm  which  consisted  in  a  pause  after  two  normal 
beats.  Later  the  intermissions  appeared  less  frequently, 
-afterward  attacks  of  loss  of  consciousness  occurred  which 
lasted  for  hours,  and  which  were  accompanied  by  extreme 
infrequency  and  irregularity  of  the  pulse;  strong  cardiac 
<;ontTattioEs  occurred  after  long  partial  pauses,  during 
which  pauses  one  could  hear  weak  heart  tones.  By  increas- 
ing the  general  nutrition  of  the  patient  and  by  administra- 
tion of  oxygen  by  inhalation  the  heart's  action  became  more 
Tegular,  and  the  attacks  of  loss  of  consciousness  disappeared. 
The  chief  characteristics  of  Adams-Stokes'  disease  are  brady- 
cardia, apoplectiform  attacks,  and  disturbance  of  the  breath- 
ing. This  case  seems  to  belong  under  this  head.  Hofimann 
gives  a  brief  review  of  the  cases  of  the  disease  previously 
reported,  and  discusses  the  causation  of  the  peculiar  attacks. 
By  observation  of  the  pulse-curve  and  of  the  heart  with  the 
fluoroscope,  Hoffmann  determined  that  the  intermissions 
observed  were  really  an  evidence  of  weak  interpolated  sys- 
toles, as  is  taught  by  Engelmann,  Wenckebach,  and  others, 
And  he  considers  the  condition  due  to  lack  of  contraction  in 
the  ventricles  while  the  auricles  contract.  The  cause  of  the 
imperfect  or  slowed  action  is  varied.  It  may  be  degenera- 
iion  of  the  heart,  myocarditis,  arteriosclerosis,  or  central 
•nervous  disease,  but  in  the  case  reported  it  seemed  to  be 
merely  imperfect  nutrition  of  the  cardiac  muscle  as  a  result 
of  anemia.  The  factor  which  Hoffmann  thinks  produces  the 
slowing  of  the  heart  is  chiefly  irritation  of  the  vagus  center 
through  anemia  of  this  center,  while  tachycardia  is  due  to 
paresis  of  this  center  which  is  often  produced  through  this 
same  cause.  His  results  from  the  use  of  oxygen  convince 
him  that  this  treatment  may  be  valuable  in  these  cases.  He 
Administered  30  liters  daily,     [d  l.e  ] 

4. — The  conclusions  reached  by  the  authors  are,  that  in 
concert  with  other  observers  they  found  that  the  gaseous  in- 
terchange in  obese  subjects  during  a  period  of  abstinence  was 
normal.  They,  however,  make  the  important  statement  that 
they  found  the  increase  of  gaseous  interchange  after  taking 
xourishment  abnormally  low  in  these  persons,  and  of  only 
<«hoit  duration.  There  has  been  a  good  deal  of  discussion 
^whether  there  is  any  such  thing  as  adiposity  due  to  an  ab- 
xiormal  reduction  of  the  oxidation  of  fats.  If  these  observa- 
•tions  are  correct  they  indicate  that  in  some  persons  there 
.may  be  a  notable  reduction  of  the  fat  consumption,  which, 
•\o  a  considerable  extent  at  least,  explains  the  abnormal  ac- 
<umulation  of  fat.  The  reaction  through  muscular  exercise 
seemed  to  vary  according  to  the  condition  of  the  organs  in 
-general.  In  one  case  the  reaction  was  similar  to  normal.  In 
-other  instances  a  relatively  slight  increase  of  muscular  ac- 
ion  caused  a  very  marked  increase  of  the  oxygen  con- 
jjumption.  They  tested  the  influence  of  the  use  of  thyroid 
aipon  the  fat  accumulation.  In  one  series  of  observations 
they  believed  that  all  the  loss  of  weight  could  be  attributed 
'b  iofs  of  fluids.  In  other  cases,  however,  there  was  certainly 
a  marked  increase  of  tissue  consumption.  This  they  could 
not  observe  in  periods  of  abstinence,  but  it  was  very  apparent 
after  taking  food,  the  normal  increase  in  oxygen  consumption 
being  much  excited  under  the  influence  of  thyroid,    [d  l.e.] 

6. — The  first  question  considered  is  the" value  of  the 
Widal  reaction,  and  the  conclusion  reached  is  that  it  is  of 


little  value  in  establishing  the  diagnosis  early.  They  place  it 
among  typhoid  symptoms  in  general,  any  of  which  may  be 
absent,  and  any  of  which  may  appear  late,  and  they  consider 
that  the  diagnosis  of  typhoid  fever  from  similar  conditions 
must  be  made  through  careful  clinical  observation  and  the 
observation  of  the  course  of  the  disease.  They  report  a 
small  series  of  cases  (55) ;  47  cases  gave  a  positive  result, 
and  8  negative.  Of  the  8  positive  cases  3  gave  a  reaction 
only  after  5  weeks.  One  of  the  negative  cases  died  on 
the  9th  day.  In  3  other  cases  the  last  test  was  made  on 
the  9.h,  18th,  and  25th  days  respectively,  so  that  these  cases 
can  hardly  count  against  the  reaction ;  the  4  others  were 
negative  on  the  621,  73d,  86th,  and  106th  days  of  the  disease. 
As  to  the  clinical  value  of  the  investigation  of  the  spota  for 
typhoid  bacilli,  they  state  that  they  examined  16  cases,  and 
in  14  found  bacilli.  They  insist,  however,  that  the  bacilli 
may  disappear  from  the  spots  after  3  to  5  days,  and  that  the 
examination  must  therefore  be  undertaken  quickly ;  also  it  is 
often  necessary  to  examine  several  spots  before  positive  re- 
sults were  obtained.  Bacilli  were  always  scarce.  In  examin- 
ing the  spots  they  always  made  a  number  of  moderately  deep 
iacisions,  and  then  scratched  the  surface  energetically.  This 
method,  hotvever,  cannot  be  considered  as  anything  more 
than  an  aid  in  diagnosis,  because  spots  are  not  present  in  all 
cases ;  because  they  often  appear  so  late  as  to  be  of  little 
value  in  the  diagnosis ;  because  bacilli  cannot  be  obtained 
from  all  spots  and  the  bacilli  are  likely  to  disappear  early; 
and  because  it  is  very  easy  to  confuse  a  typhoid  eruption 
with  other  eruptions.  PiDrkowski's  method  with  the  Htera<- 
ture  concerning  it  is  then  discussed.  They  tested  the  method 
with  cultures  of  typhoid  bacilli,  and  various  bacilli  belonging 
to  the  colon  group,  with  satisfactory  results,  and  examined 
the  stools  of  19  cases  of  typhoid  fever.  In  all  123  colonies 
from  the  latter  were  examined,  and  in  three-fourths  of  the 
cases  they  obtained  positive  results,  iu  one  fourth  negative. 
But  they  insist  that  while  Piorkowski's  urine  gelatin  medium 
is  a  valuable  addition  to  bacteriological  methods  of  investi- 
gation, a  diagnosis  can  never  be  satisfactorily  made  from  the 
appearance  of  plate-cultures.  The  bacilli  must  show  the 
proper  chemical  and  biological  characteristics  in  order  that 
a  positive  diagnosis  may  be  made.  They  tried  the  influence 
of  adding  urea  and  ammonium  carbonate,  or  mixtures 
of  these,  to  gelatin,  instead  of  using  urine.  The  results 
were  not  satisfactory,  but  they  did  get  satisfactory  results 
from  inoculating  normal  urine  with  the  micrococcus 
urce  instead  of  allowing  it  to  become  alkaliae  sponta- 
neously. They  note  that  it  is  practically  impossible  to  use 
Piorkowski's  method,  in  summer,  however,  as  the  dilute 
gelatin  becomes  fluid  at  a  relatively  low  temperature.  [d.l.e  ] 

6. — Sachs  refers  to  his  previous  work  which  had  appar- 
ently shown  that  in  frogs,  after  extirpation  of  the  hver,  there 
was'  a  marked  reduction  of  the  power  of  using  levulose  in 
the  organism,  while  other  forms  of  sugar  seemed  to  show 
little  change.  He  has  continued  his  work  with  the  idea  of 
determining  whether  levulose  had  any  power  of  increasing 
the  glycogen  production  elsewhere  than  in  the  liver,  extir- 
pating the  liver  and  determining  the  glycogen  in  the  muscles 
with  and  without  the  administration  of  levulose.  He  be- 
lieves that  he  has  shown  that  there  is  no  distinct  increase  of 
the  glycogen  of  the  muscles  after  the  use  of  levulose,  and 
decides  that  the  production  of  glycogen  in  the  liver  is  dif- 
ferent from  the  same  process  in  the  muscles,  since  glucose 
causes  an  increase  in  both  liver  and  muscle  glycogen. 
[d.l  e.] 

7. — The  authors  were  led  to  their  work  chiefly  through 
the  suggestion  that  periodic  paralysis  is  comparable  to  the 
action  of  curare,  and  may  therefore  be  properly  considered 
to  be  the  result  of  some  similar  toxic  ^ent.  In  the  periods 
of  paralysis,  during  the  attacks  there  is  either  complete  or 
almost  complete  loss  of  the  faradic  and  gilvanio  reactions  of 
the  nerves  and  musc'.es.  They  administered  curare  to  a 
series  of  animals,  and  found  that  the  electric  reactions  did 
not  disappear,  both  the  faradic  and  galvanic  currents  show- 
ing an  absence  of  qualitative  or  quantitative  change,  even 
with  complete  paralysis.  Waatever  the  cause  of  periodic 
paralysis  may  be  it  cannot  be  a  substance  which  shows  close 
similarity  to  curare.    [d.l.k  ] 

8. — To  be  treated  editorially. 

10.— Simon  believes  that  his  results  with  pilocarpin  have 
been  confirmed  by  those  of  Tschurilow  and  some  recent 
results  of  Pawlow. '  He  criticises  Riegel's  results  in  that  in 


February  9,  1901] 


THE  LATEST  LITERATURE 


TThk 
Lmei 


Philadelphia 
Medical  Journal 


291 


two  cases  they  showed  a  distinct  decrease  of  the  total  acid- 
ity; and  lie  thinks  that  it  is  quite  possible  in  some  of  the 
cases  that  the  increased  acidity  after  pilooarpin  may  have 
be^n  due  to  increased  secretion  of  stliva  and  the  excitation 
of  gastric  secretion  through  the  swallowed  saliva.  He  makes 
some  other  detailed  criticisms  which  he  believes  support  his 
view  that  sweating  decreases  the  acidity  of  the  stomach- 
contents,    [d.l.e.] 

Archlv  fiir  Verdauuugs-Krankheiten. 

[Band  6,  Heft  4.] 

1.  A  Contribution  to  the  Knowledge  of  the  Protective  In- 

fluence of  the  Intestinal  Tract.  Investigations  Con- 
rernin?  the  Antidotal  Action  of  the  Pancreas.  G.  v. 
Zaremba. 

2.  SurgRry  in  Chronic  Non-Malignant  Gastric  Diseases.    G. 

Kellino. 

3.  A  Peculiar  Gas  Forming  Bicillus  which  was  Isolated  from 

the  Stomach-contents  in  a  Case  Exhibiting  Trouble- 
some Bjrborygmus.    L.  Sansoni  and  L.  Fornaca. 

1,— Ziremba  gives  a  very  interesting  discussion  of  the  lit- 
erature concerning  the  protective  influence  of  the  various 
portions  of  the  gastrointestinal  tract  and  the  glands  connected 
therewith,  but  without  drawing  any  very  decided  conclusions 
AS  to  the  result  of  this  work.  He  first  discusses  the  work  that 
has  been  done  on  the  action  of  the  salivary  glands.  There 
is  some  testimony  that  these  organs  have  a  destructive  influ- 
ence upon  toxins,  but  if  this  exists  its  influence  is  probably 
variable,  and  nothing  very  important  is  known  concerning  it. 
As  to  the  gastric  juice,  it  has  apparently  been  shown  that  not 
only  is  inflammation  to  some  extent  controlled  by  the  gas- 
tric juice,  but  that  toxins  are  destroyed  by  it.  It  is  shown  to 
be  much  more  active  against  certain  toxins,  such  as  the  tetano- 
toxin,  than  against  some  others,  such  as  the  diphtheria  toxin. 
There  is  considerable  probability  that  the  toxins  are  markedly 
altered  in  some  way  in  their  passage  of  the  intestinal  wall ; 
they  thereby  become  less  active.  It  is  also  probable  that 
the  normal  nonpathogenic  intestinal  bacteria  contribute 
largely  to  antidoting  the  toxins  present  in  the  intestinal 
tract  and  controlling  their  production.  As  to  the  liver, 
there  has  been  a  tremendous  amount  of  investigation. 
It  has  been  generally  accepted  by  most  authors  who 
have  not  interested  themselves  especially  in  this  question, 
that  the  liver  is  more  active  perhaps  than  any  other  organ 
in  destroying  poisons  of  bacteria.  It  is  apparently  demon- 
«trated  that  the  liver  does  reduce  the  activity  of  a  certain 
kind  of  poisons,  but  recent  work  has  shown  that  there  is 
apparently  little  difl'erence  in  the  action  of  many  poisons 
when  injected  into  the  portal  vein  or  when  injected  into  the 
general  circulation  ;  it  is  possible  that  the  liver  shows  a  very 
•different  action  upon  diflTerent  poisons,  reducing  or  destroy- 
ing the  activity  of  some,  having  practically  no  influence  upon 
others,  and  even  increasing  the  activity  of  certain  poisons. 
The  general  question  of  the  influence  of  the  liver  is  cer- 
tainly not  settled  at  any  rate.  It  is  fairly  well  demon- 
strated that  the  liver  is  active  in  the  destruction 
of  poisonous  products  of  metabolism,  but  its  exact 
influence  in  connection  with  poisons  absorbed  from 
the  gastrointestinal  tract  is  not  well  known,  and  is  prob- 
ably variable.  The  bile  seems  certainly  to  have  an  anti- 
dotal influence  upon  certain  forms  of  poison,  particularly 
snake  poison  and  tetanotoxin.  It  varies  largely  according 
to  the  percentage  of  bile  present,  the  age  of  the  animal  pro- 
viding the  bile,  and  other  factors.  The  secretion  of  the 
pancreas  has  been  shown  to  have  an  antidotal  influence 
upon  a  number  of  toxins,  but  whether  this  is  an  influence 
that  may  be  exerted  throughout  the  general  circulation,  or 
is  dependent  upon  contact  of  the  pancreatic  juice  with  the 
toxin  is  doubtful ;  the  latter  seems,  from  many  of  the  ex- 

Eeriments,  to  be  more  probable.  Ziremba's  work  has 
een  in  connection  with  the  influence  of  the  pancreas. 
He  made  extracts  of  the  pancreas  and  mixed  these 
extracts  with  diphtheria  toxin,  finding  that  even  in  new- 
born pups  the  pancreas  extract  evidently  had  an  anti- 
dotal influence  upon  the  toxin.  The  same  influence 
was  observed  in  relation  to  the  pancreas  of  young  rabbits, 
guineapigs,  and  calves,  and  there  was  no  very  evident  differ- 
■€nce  between  the  action  of  the  pancreas  of  calves  a  few 
^eeks  old  and  the  pancreas  of  full-grown  cattle.    He  made 


several  investigations  of  the  human  pancreas  from  adult 
subjects.  The  results  were  negative  in  every  instance.  The 
organ  could  not  be  removed  from  the  body  for  a  number  of 
hours  after  death  in  any  of  these  instances,  and  it  is  quite 
possible  that  postmortem  changes  had  destroyed  its  previous 
activity.  It  was  found,  however,  that  the  pancreas  of  a  boy 
4J  years  old  had  a  distinctively  antidotal  influence.  The 
postmortem  in  this  case  was  carried  out  about  two  hours 
after  death,  and  in  several  instances  it  was  found  that  the 
pancreas  of  very  young  children,  upon  whom  postmortems 
were  done  almost  immediately  after  death,  had  a  distinctly 
antidotal  efl"act.  In  two  instances,  however,  absolutely  no 
influence  could  be  observed.  The  conclusion  which  Ziremba 
reaches  is  that  the  pancreas  even  of  extremely  young  chil- 
dren shows  distinctly  antidotal  influences,  but  that  these 
may  be  absent  in  some  condition?,  the  exact  nature  and  in- 
fluence of  which  we  do  not  yet  fully  understand,    [d.l  e.] 

3. — Kelling  gives  a  general  discussion  of  the  surgery  of 
non-malignant  gastric  diseases.  He  ends  by  directing  especial 
attention  to  the  fact  that,  in  cases  of  ulcer,  and  conditions 
following  ulcer,  in  which  proper  treatment  has  been  carried 
out  without  any  satisfactory  results,  it  must  be  considered 
that  there  are  certain  factors  present  which  prevent  the  heal- 
ing of  the  ulcer  or  the  cure  of  its  sequelre.    He  advises  careful 
clinical  observation  and  medical  treatment  of  such  cases,  but 
if  such  practices  are  of  no  avail,  it  is  advisable  to  adopt  sur- 
gical measures,  even  though  it  cannot  be  determined  exactly 
what  the  fault  is.    The  danger  of  hemorrhage,  of  severe  gas- 
tritis, of  perforation,  of  carcinomatous  change,  or  of  a  chronic 
condition  of  ill  health,  is  so  great  that  the  probability  of  being 
able  to  relieve  the  condition  by  surgical  means  mikes  such 
surgical  intervention  advisable.  Thedangers  of  surgery  are  less 
than  the  dangers  of  the  possible  complications  mentioned,  or  of 
protracted  under-nourishment.    Usually  the  best  operation  in 
such  cases  is  gastroenterostomy.  One  of  the  important  con- 
ditions in  which  gastroenterostomy  should  not  be  postponed 
too  long  is  in  case  of  ulcers  in  connection  with  gastroptosis 
and  atony  of  the  stomach.    Internal  treatment  usually  is  not 
very  successful  in  such  cases.    In  some  cases  it  will  be  found 
that  the  ulcer  causes  no  actual  stenosis  at  the  pylorus  itself,  and 
yet  pyloroplasty  causes  marked  improvement.    This  is  prob- 
ably due  to  the  fact  that  there  is  a  great  deal  of  swelling  or 
hemorrhage  about  the  ulcer,  and  that  the  pyloroplasty  in 
increasing  the  circumference  of  the  pylorus  has  decreased 
the  irritation  of  the  ulcer  through  retention  of  the  food  in 
the  pyloric  region.    Kelling  believes  that  the  most  import- 
ant reason  that  ulcers  do  not  heal  readily  in  women,  is  that 
the  menstrual  losses  of  blood  interfere  with  a  proper  nutri- 
tive condition.    Surgery  in  such  cases  is  more  frequently 
demanded  than  in  men.    As  to  adhesions,  he  says  that  if 
these  interfere  with  the  proper  movements  of  the  organ  sur- 
gery should  be  undertaken.    If  they  are  of  acute  inflamma- 
tory nature  they  should  first  be  treated  medically.    Neurosis 
may  be    sometimes    wisely    treated  by    surgery.      In    two 
cases  of  hysterical  vomiting,  and  in  one  case  of  neurasthenic 
periodic  vomiting,  Kelling   has   known  gastroenterostomy 
to   be   entirely  negative    in   its   effects;    but    in    cases    of 
nervous  hypersecretion,  for  instance,  surgery  may  do  a  great 
deal  of  good.    As  to  the  treatment  of  gastroptosis.    He  states 
in  the  first  place  that  the  gastroptosis  itself  is  not  Hkely  to  be 
satisfactorily  and  permanently  influenced  by  any  operation 
directly  on  the  stomach  or  its  supports,  and  unless  there  is 
some  marked  disturbance  of  motility,  or  unless  the  abdomi- 
nal walls  are  extremely  lax,  operation  is  coatraindicated.   Of 
the  dangers  following  operation  upon  the  stomach  he  first 
mentions  pneumonia,  which  is  an  extremely  slight  danger  if 
the  operation  is  properly  carried  out.    Tnere  is  always  some 
danger  of  infection  of  the  peritoneum,  but  this  may  be 
reduced  to  an  extremely  low  percentage.   There  is  also  some 
danger  of  the  occurrence  of  a  so-called  vicious  circle  of  the 
gastric  contents.    Proper  technic  will  usually  prevent  this. 
The  dangers  of  diarrhea  and  intestinal  ulceration  are  depend- 
ent upon  irritation  by  the  extremely  acid  gastric  contents, 
which  are  discharged  directly  into  the  intestine  unneutralized. 
This  may  be  overcome  only  if  one  makes  the  junction  be- 
tween the  stomach  and  the  first  portion  of  the  jfjunum, 
whereby  a  portion  of  the  stomach- contents  flows  back  into 
the  duodenum  ;  in  such  case  a  lateral  gastroenterostomy 
should  be  undertaken,  while  in  cases  where  the  chief  object 
to  be  accomplished  is  complete  emptying  of  the  stomach, 
Roui's  circular  gastroenterostomy  should  be  chosen,  [d.l  e.J 


292 


Thk  Philadelphia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


PFebbcaet  9,  ISO 


3. — The  case  described  is  that  of  a  woman  who  com- 
plained of  loud  borborygmi  with  a  feeling  of  tension  in  the 
gaatric  region,  these  symptoms  coming  on  some  time  after 
each  meal.  There  was  some  mental  depression  and  a  little 
reduction  of  the  general  health,  otherwise  there  were  no  dis- 
tinct changes  in  the  physical  condition.  Examination  of  the 
stomach- contents  showed  the  presence  of  a  peculiar  bacillus 
which  had,  in  brief,  the  following  characteristics  :  It  stained 
by  Gram's;  it  was  facultatively  anaerobic  and  aerobic;  it 
grew  rapidly  in  ordinary  media,  particularly  when  the 
medium  contained  glucose  and  milk  sugar  ;  it  produced 
much  gas,  the  major  portion  of  the  gas  consisting  of  hydro 
gen  and  COj ;  it  produced  acid,  and  grew  well  in  a  medium 
to  which  acid  stomach- contents  had  been  added;  it  was 
pathogenic  when  injected  into  the  peritoneal  cavity,  but  not 
when  introduced  into  the  stomach  ;  it  differed  from  the  Ba- 
cillus lactis  aerogenes,  from  the  Bncilluscoli,  and  from  other 
organisms  which  have  been  described  as  producing  gaseous 
distention  of  the  stomach  and  intestines.  The  symptoms 
complained  of  came  on  about  2  hours  after  eating,  a  time 
when  ordinary  fermentation  could  not  have  occurred ;  there 
was  no  lactic  acid  present,  and  no  other  evidence  of  ordinary 
fermentation  in  the  stomach-contents,  and  the  common  fer- 
mentation bacteria  were  absent ;  therefore,  the  authors  con- 
clude that  the  enormous  gas  production  which  occurred  in 
this  patient  was  due  to  this  microorganism,  particularly 
since  the  gaaes  produced  in  the  stomach  were  found  to  be 
chiefly  hydrogen  and  CO,,     [d  l.e.] 


Deutsches  Archiv  fUr  kliuisctae  Medicin. 

November  1,  1900.    [Vol.  vi.] 

24.  A  Contribution  to  the  Pathology  of  Multiple  Nonsup- 

purating  Myositis.     Struppi.er. 

25.  Formalin  as  a  Preservative  Medium  for  Urinary  Sedi- 

ment and  Diformaldehyde  Urea.    May. 

26.  The  Use  of  Orcein  for  the  Recognition  of  Elastic  Fibers 

in  the  Sputum.    May. 

27.  The  So  called  Early  Fermentation  of  the  Feces,  and  its 

Diagnostic  Significance  for  the  Determination  of  the 
Functional  Capacity  of  the   Intestines.     Keesbergen. 

28.  Clinical   Investigations  upon  the   Circulatory  Organs  in 

the  Early  Stages  of  Syphilis.     Grass.mann. 

29.  Clinical  and  Experimental   Contributions  to   the  Knowl- 

edge of  the  Paralysis  of  the  Facial  Xerves,  with  a 
Cuntribution  to  the  Physiology  of  Taste,  and  the 
Secretion  of  Sweat,  Saliva  and  Tears.     Koster. 

30.  Contributions  to  the  Ca*^uistry  and  Treatment  of  Mykosis 

Fungoides.    Schiffmacher. 

31.  The  Pathology  of  Gastric  Carcinoma.    JCrgensen. 

24. — Struppler,  after  a  brief  discussion  of  the  various 
forms  of  the  disease,  reports  2  cases  of  myositis.  The  first, 
a  man  of  39,  2  days  before  admission  to  the  hospital,  had  a 
sudden  pain  in  the  left  knee,  which  became  severely  swollen. 
Later,  other  large  joints  were  involved,  and  large  reddish  or 
reddish  brown  spots  appeared  on  the  legs.  There  was  diffi- 
culty in  swallowing  and  some  dypsnea.  The  condition  grew 
rapidly  worse,  the  purpuric  eruption  extended  to  other 
areas,  the  respiration  became  more  and  more  affected  as  a 
result  of  edema  of  the  larynx,  and  finally  death  oet  urred  be- 
fore an  operation  could  be  performed.  At  the  autopsy  the 
lungs  contained  pneumonicareas,  and  there  was  hemorrhagic 
myositis  in  the  muscles  of  the  arms  and  legs.  The  patient 
also  had  acute  glossitis.  Microscopically  the  muscles  showed 
acute  parenchymatous  changes.  The  heart mufcle,  however, 
was  not  involved  ;  and  the  spleen  was  only  slightly  enlarged. 
Kevertheless  the  author  believes  that  the  diagnosis  must 
stand  as  given.  It  is  greatly  to  be  regretted  that  no  mention 
is  made  ot  any  bacteriological  studies.  The  second  patient, 
a  man  of  24,  had  severe  attacks  of  acute  articular  rheuma- 
tism and  scrofula.  He  was  suddenly  attacked  with  severe 
pain  in  the  left  half  of  the  head,  which  became  swollen  and 
soft,  there  was  also  swelling  in  some  of  the  larger  joints,  pain 
in  the  muscles  of  the  calves,  but  no  reddening  of  the  skin. 
Subsequently  another  attack  occurred  on  the  left  side  of  the 
head,  and  there  was  some  erythema  of  the  skin  with  purpuric 
eruptions  upon  the  extremities.  The  diagnosis  was  made 
of  polymyositis  acuta  with  erythema  multiforme.     [J  s  ] 

26. — May,  having  had  occasion  to  preserve  urinary  sedi- 


ment, employed  the  method  of  Gumprecht,  that  is  the  addi- 
tion of  a  formalin  solution  to  the  sediment  after  the  super- 
natant fluid  had  been  decanted.  He  found  that  it  was  an. 
excellent  preservative  medium ;  but  that  when  any  con- 
siderable quantity  of  urine  was  allowed  to  remain  with  the 
sediment,  there  was  a  precipitate  of  round  bodies,  slightly 
yellowish,  insoluble  in  almost  everything,  that  occasionally 
had  a  somewhat  concentric  arrangement  with  lines  radiat- 
ing from  the  center.  A  considerable  quantity  of  these  gave 
proportions  of  nitrogen,  hydrogen,  and  oxygen,  correspond- 
ing with  those  of  diformaldehyde  urea.  Further  experi- 
ments showed  that  formalin,  added  to  urine  combined  with 
a  small  proportion  of  the  urea  present,  does  form  this  combi- 
nation. It  is  not  soluble  in  water,  alcohol,  ether,  acetic  acid, 
hydrochloric  acid,  or  ammonia,  but  is  soluble  in  a  2.5%  solu- 
tion of  sulphuric  acid  (25%  )  under  the  influence  of  heat.  It 
is  particularly  important,  because  its  presence  in  the  urinary 
sediment  might  give  rise  to  errors  in  diagnosis,  and  it  is, 
therefore,  important  when  an  attempt  is  made  to  preserve 
the  urine  by  Gumprecht's  method,  to  wash  the  sediment  thor- 
oughly with  water,     [js.] 

26. — May  describes  the  following  method  for  the  demon- 
stration of  elastic  fibers  in  the  sputum :  Equal  portions  of 
sputum  and  10%  of  potassium  hydrate  are  mixed  and  dis- 
solved over  a  water  bath,  then  centrifugated  and  the  super- 
natant fluid  poured  off.  About  2  ccm.  of  Unna's  Tiinzer 
orcein  solution  are  added  to  the  sediment,  and  enough  hy- 
drochloric acid  to  restore  the  cherry-red  color ;  the  tube  i» 
then  plunged  in  boilicg  water,  the  sediment  decolorized 
with  hydroihloric  acid  and  alcohol  and  again  centrifugated. 
Finally  the  sediment  is  examined  under  the  microscope,  and 
the  elastic  fibers  readily  recognized  on  account  of  the 
brownirh-red  violet  color.  0:her  fibrous  elements  are  either 
decolorized,  or  only  faintly  tinged.  The  entire  operation 
requires  about  half  an  hour,     [j  s  ] 

27. — Kerabergen  has  undertaken  a  careful  series  of  ex- 
periments for  the  purpose  of  proving  the  value  of  the  work 
of  Schmidt  and  his  followers.  Specimens  of  the  feces  were 
tested  for  sugar,  starch  and  its  derivatives,  and  for  various 
ferments,  particularly  invertin.  Maltese  was  very  frequently 
present,  even  after  the  specimen  had  remained  six  hours  in 
the  incubator.  It  was  only  persistently  absent  ia  one  case  of 
carcinoma  of  the  rectum.  No  eff  jrt  was  made  to  separate 
the  bacteria  and  the  ferments,  although  this  is  possible  by 
means  of  filtration,  or  even  by  the  addition  of  antiseptics. 
[j.sl 

28. — Grassmann  has  studied  28S  patients  suffering  from 
the  early  stages  of  syphilis  with  reference  to  cardiac  and 
vascular  disturbances.  Of  these  61  were  men,  and  227  were 
women.  The  reason  for  the  excess  of  women  was  that  these 
were  kept  in  a  hospital  under  police  supervision,  whereas 
the  men  came  and  went  as  they  pleased.  Sixty-six  of  these 
patients,  IS  men  and  48  women,  presented  various  circulatory 
anoniiilies  in  the  course  of  treatment.  Among  these  changes- 
were  bradycardia  in  one  woman,  arrhythmia  in  6  cases  with- 
out other  changes,  and  in  3  cases  with  alteration  in  the  heart- 
sounds.  These  symptoms  oc^-urred  both  in  recent  case» 
and  in  those  with  relapses.  In  10  cases  there  was  arrhythmia 
and  increased  frequency  of  the  pulse.  In  a  few  cases  there 
was  simply  increased  frequency  without  other  disturb- 
ance. In  one  of  these  cases  the  increased  frequency  lasted 
for  more  than  10  weeks;  many  of  them,  however  were 
purely  temporary  conditions.  In  many  of  the  cases  there 
was  increase  in  the  force  of  the  second  pulmonic  sound,  but 
in  one  only  of  the  second  aortic  sound.  lu  14  cases  there 
were  distinct  murmurs,  or  impurities  of  the  heart's  sounds; 
in  6  of  these  cases  the  murmurs  disappeared  completely 
with  recovery  from  the  disease.  These  murmurs  were  prob- 
ably chit  fly  functional  because  they  were  heard  either  at  the 
base  of  the  heart,  or  over  the  tricuspid  area,  and  were  sys- 
tolic in  time.  Of  the  subjective  disturbances,  the  most  im- 
portant was  palpitation.  In  discussing  these  ca^es.  Grass- 
mann states  that  he  does  not  believe  that  accentuation  of 
the  second  pulmonic  sound  is  always  associated  with  hyper- 
trophy of  the  right  ventricle.  He  also  discusses  Sp  cases  in 
which  systolic  murmurs  were  heard  at  the  beginning  of 
treatment,  that  were  possibly  the  result  of  nervous  or  mus- 
cular disturbances  of  the  heart  itself.  In  9  of  these  cases  no 
impairment  ensued  in  the  heart  symptoms.  In  17  the  symp- 
toms grew  worse  during  the  employment  of  mercury,  but  in 
the  majority  the  murmurs  were  distinctly  functional  in  type. 


February  9,  1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
L  Medical  Journal 


293 


The  second  pulmonic  tone,  however,  was  often  increased 
without  distinct  enlargement  of  the  right  ventricle.  In  3  of 
the  cases  apparently,  a  mitral  insufficiency  was  in  the  course 
of  development,    [j.s.] 

29. — Ko3ter  in  continuation  of  his  valuable  article  upon 
facial  paralysis,  as  the  result  of  the  study  of  his  cases,  and 
their  comparison  with  others  recorded  in  the  literature, 
reaches  the  following  conclusions  which  we  give  in  full : 
First,  if  the  lesion  is  peripheral,  and  situated  below  the  sty- 
lomastoid foramen,  or  as  far  up  as  the  point  of  branching  of 
the  chorda,  it  can  be  recognized  by  the  fact  that  all  other 
nervous  symptoms  are  absent,  with  the  exception  of  the 
unavoidable  disturbance  of  perspiration  and  the  pure  motor 
paralysis.  Second,  if  the  lesion  is  situated  above  the  branch- 
ing of  the  chorda  there  will  be,  in  addition  to  the  disturbance 
of  motion  and  perspiration,  also  some  disturbance  of  taste, 
and  frequently  alterations  in  the  quantity  of  saliva  secreted. 
Third,  if  the  lesion  is  situated  in  the  geniculate  ganglion, 
there  will  be,  in  addition  to  the  above  symptoms,  disturbance 
of  the  secretion  of  tears,  which  is  permanent,  and  some  dis- 
turbance of  hearing,  indicating  a  simultaneous  lesion  of 
the  acusticus,  which  is  not  always  constant.  Fourth,  if 
the  lesion  is  situated  above  the  geniculate  ganglion,  and 
before  the  entrance  of  the  nerve  into  the  brain,  all  the 
symptoms  above  enumersted  are  present  with  the  exception 
of  loss  of  taste.  Fifth,  if  the  lesion  has  destroyed  the  facial 
nucleus  and  the  immediate  neighboring  tissue  the  same  dis- 
turbances, as  above  described,  will  be  present,  and  the  diag- 
nosis can  only  be  made  nn  account  of  the  presence  of  other 
lesions  indicating  medullary  involvement  (homo-  or  contra- 
lateral paralysis  of  the  extremities,  imperative  laughing  or 
weeping).  Lesions  restricted  to  the  facial  nucleus,  especially 
if  congenital,  produce  only  motor  paralysis  with  a  slight  dis- 
turbance of  the  secretion  of  perspiration.  Koster,  however, 
having  seen  only  2  such  cases,  both  of  which  were  bilateral, 
is  not  quite  positive  regarding  their  localization.  In  a  second 
part  of  the  paper  he  reports  a  number  of  experiments  made 
upon  dogs,  cats,  and  monkeys  which  cannot  be  fully  de- 
scribed here.  A  few  of  the  interesting  results  are,  that  in 
dogs,  cats,  and  monkeys  the  subcutaneous  malar  nerve  has 
no  anatomical  connection  with  the  lachrymal  nerve,  stimula- 
tion of  which  does  not  alter  the  secretion  of  tears.  In  cats  the 
chorda  tympani  contains  sensory  fibers.  The  secretory  fibers 
of  the  submaxillary  and  sublingual  glands  :n  apes  certainly 
pass  downward  and  through  the  facial  nerve",  thus  confirm- 
ing the  supposition  that  the  same  is  true  of  human  beings. 
After  division  of  the  facial  nerve,  degenerated  fibers  are  never 
observed  in  the  lachrymal  nerve,  indicating  that  these  fibers 
do  not  pass  through  the  facial.  As  this  contradicts  the  par- 
tial observations  made  upon  men,  Koater  believes  that  there 
must  be  some  difference  in  the  innervation  of  this  gland, 
[jp.] 

30. — Schiffmacher  reports  the  case  of  a  man  of  42,  who 
for  some  years  had  had  an  itching  eruption  on  the  abdomen. 
This  consisted  of  large  blotches  of  a  bluish  brown-red  color, 
with  elevated  hard,  infiltrated  plaques,  that  almost  had  the 
appearance  of  tumors.  These  were  scattered,  quite  irregu- 
lar, and  upon  their  surface  showed  slight  desquamation. 
There  were  also  a  few  patches  of  eczema  and  erythema. 
The  inguinal  glands  were  swollen,  but  otherwise  the  patient 
was  normal.  Microscopically,  an  excised  portion  of  the 
skin  showed  cellular  infiltration  in  the  papillary  bodies,  con- 
siderable hyperplasia  of  the  rete  Malpighii,  which  sent  pro- 
jections into  the  surrounding  tissues  ;  otherwise,  there  was 
nothing  characteristic.  Although  bacteriological  studies 
were  negative,  Schiffmacher  has  no  doubt  that  this  was  a 
case  of  mykosis  fungoides.  The  patient  was  treated  with 
ascending  doses  of  arsenic,  given  hypodermatically,  which 
in  the  course  of  several  weeks  apparently  produced  almost 
complete  cure,     [j  s  ] 

31.— Jiirgensen  reports  a  case  of  carcinoma  of  the  stomach 
that  had  undergone  degenerative  changes,  and  in  which  free 
hydrochloric  acid  was  present  for  a  long  time.  There  was 
considerable  obstruction  at  the  pylorus  and,  as  a  result,  the 
gradual  inspissation  of  the  tissues,  with  diminution  in  the 
quantity  of  urine.  There  were  also  some  curious  disturbances 
of  the  nerves,  apparently  depending  upon  the  quantity  of 
urine  excreted,  such  as  myosis,  loss  of  reflexes,  and  some 
intellectual  dulness.  Towards  the  end  there  was  moderate 
elevation  of  temperature.  At  the  autopsy  there  was  found 
a  gangrenous  ulcerating  carcinoma  of  the  pyloric  region. 


with  moderate  dilatation  of  the  stomach.  There  was  no 
satisfactory  explanation  of  the  persistence  of  free  hydro- 
chloric acid,    [j  s.] 


Annales  de  J>Iedecine  et  Chirurgie  Infantiles. 

January  1,  1901. 

1.  Alcoholism  in  Childhood.    Dr.  Delobel. 

2.  A  Case  of  Appendicitis  with  Abscess  Formation  and  Rup- 

ture into  the  Bladder ;  Recovery.    Perez  Allak. 

3.  Adenoid  Growths.      A  Statistical    Study    of    the   Cases 

Treated  in  La  Clinique  des  Enfants  Malades,  1899  1900. 
Clinical    and    Therapeutic    Considerations.      Henri 

CUVILLIER. 

4.  Treatment  of  Acute  Mucous  and  Dysenteriform  Colitis  by 

the  Sulfate  of  Soda.    M.  Aviragnet. 

1. — Delobel  contributes  7  cases  to  the  literature  of  alco- 
holism in  infancy  and  childhood.  He  calls  attention 
to  the  fact  that  the  condition  is  much  more  common  than  is 
credited.  In  the  first  period  of  life  the  intoxication  is 
brought  about  through  the  milk  of  the  nurse  or  mother,  who 
are  generally  in  total  ignorance  of  their  deed.  The  child  too, 
is  an  unconscious  agent.  Later,  the  taste  having  been  devel- 
oped, the  child  becomes  eager  to  get  liquor  by  every  possible 
means.  Here  parents  are  frequently  criminally  responsible 
in  letting  the  child  take  sips  of  liquor  "  from  father's  glass  " 
and  telling  their  children  that  it  is  manly  to  drink  and  will 
make  them  big  and  strong.  Alcohol  has  not  been  found 
chemically  in  the  milk  of  intemperate  lactating  women,  but 
the  effects  upon  the  child  prove  the  toxic  property  of  such 
milk.  The  susceptible  child  shows  in  a  brief  space  of  time 
the  profound  systemic  changes  of  chronic  alcoholism 
which  in  the  adult  takes  vastly  longer  to  produce.  A  num- 
ber of  French  authorities  are  quoted  upon  the  effect  of 
alcohol  in  children.  In  general,  it  may  be  said  that  alcohol 
produces  convulsions  in  breast-fed  infants.  This  is  not 
always  the  case.  Sometimes  the  symptoms  developed  are  a 
fretful,  highly  nervous  state,  the  child  constantly  crying  and 
sleeping  but  little.  This  will  in  some  cases  be  followed  by 
digestive  disturbances  and  marked  cachexia.  The  body 
weight  may  be  in  excess  and  the  child  show  signs  of  over- 
nutrition,  but  this  is  generally  followed  by  progressive  debility 
and  wasting.  In  this  type  convulsions  do  not  occur  ;  on  the 
ether  hand  the  child  is  in  a  constant  state  of  agitation,  and 
suffers  from  insomnia.  The  pulse  is  frequent  and  feeble  and 
the  eyes  brilliant,  the  cheek  prominences  are  red,  there  is 
some  pyrexia  and  the  child  has  an  air  of  hebetude  ;  there  is 
excessive  thirst,  while  at  the  breast  he  sucks  vigorously 
and  keeps  up  the  motions  of  suction  in  the  brief  inter- 
vals between  the  constant  crying  for  food.  Death  follows 
unless  the  cause  be  removed.  In  the  first  two  of  Delobel's 
cases,  the  children  had  recurring  convulsions  easily  con- 
trolled by  tepid  baths.  In  each  case  the  wet-nurse  was 
found  to  be  intemperate  and  recovery  followed  her  dis- 
missal. In  the  third  case  there  was  no  convulsions,  but  the 
type  was  one  of  excess  in  body- weight  with  the  accompanying 
symptoms  detailed  above,  and  was  succeeded  by  a  grave 
cachexia  in  which  recovery  seemed  doubtful.  Removal  of 
the  cause — another  intemperate  wet-nurse — marked  the  be- 
ginning of  convalescence.  In  another  case  seen  by  the 
author  the  child  was  in  a  pitiably  nervous  state  due  to  its 
having  been  given  coffee  with  brandy,  because  the  child 
seemed  so  weak  and  sickly.  His  advice  was  not  heeded  and 
the  case  is  not  reported  further.  The  fifth  report  is  that 
of  a  child  of  5  years  who  suffered  from  alcoholic  cir- 
rhosis with  accompanying  ascites  (which  was  several 
times  tapped)  and  in  which  death  resulted.  The  child  had 
been  in  the  habit  of  becoming  frequently  intoxicated  upon  a 
mixture  of  coffee  and  alcohol.  He  presented  all  the  appear- 
ances of  a  confirmed  dipsomaniac.  His  sixth  case  was  one 
of  an  acute  state  of  alcoholic  coma  in  a  child  of  4 
years  who  lived  aboard  a  vessel  with  intemperate  parents. 
The  child  had  secured  and  partly  emptied  a  bottle  of  rum. 
His  last  case  was  one  of  acute  alcoholism  in  a  girl  of  7 
years.  She  was  a  confirmed  inebriate — and  grew  up  to  be  a 
prostitute  who  served  her  term  in  prison.  In  conclusion 
Delobel  urges  that  the  criminal  ignorance  of  such  children  s 
parenU  be  punished  and  that  proper  penal  laws  and  an 
effective  system  of  medical  inspection  be  instituted.  He 
believes  that  education  is  the  surest  method  of  gradually 


294 


The  PhiladelphiaH 

Medical  Jours 


^PHlAl 

knal  J 


THE  LATEST  LITERATURE 


[Febbdasy  9,  190] 


eradicating  the  evil.  The  physician  must  be  on  the  alert  to 
ditcover  possible  alcohohsm  in  the  mother  or  nurse,  and  to 
remember  how  much  secret  and  totally  unsuspected  drink- 
ing is  done,     [t.l  c] 

2. — Perez  Allen  presents  the  report  of  a  case  of  appen- 
dicitis with  rupture  of  abscess  into  the  bladder. 
There  being  no  doubt  as  to  the  diagnosis  of  appendicitis, 
opium  and  bismuth  were  administered  freely.  After  a 
few  days  a  palpable  tumor  was  present  in  the  right  ingui- 
nal region.  Operation  does  not  seem  to  have  been  consid- 
ered. The  abscess  finally  ruptured  into  the  bladder,  and 
symptoms  of  pyuria  appeared.  The  viscus  was  frequently 
flushed.  After  a  few  days  the  urine  became  normal.  One 
of  the  sequelae  of  the  case  was  a  double  orchitis,  from 
which  the  patient  made  prompt  recovery,     [t.l.c] 

3. — Cuvillier  has  reported  that  of  2019  cases  of  adenoid 
growths  treated  in  his  clinic,  La  Clinique  des  Enfants 
Malades,  1214  were  of  the  respiratory  type  ;  75  of  the  auric- 
ular type  and  730  of  mixed  form.  He  details  the  symptoms 
to  which  these  growths  give  lise  by  their  mechanical  obstruc- 
tion, and  as  the  cause  of  bacterial  infection,  etc.  He  points 
out  the  necessity  of  thorough  examination  of  all  cases,  and 
particularly  urges  that  the  condition  be  treated  properly  and 
not  left  to  run  its  course  to  the  child's  detriment.  He  divides 
his  treatment  conveniently  into  prophylactic,  medical  and 
surgical.  Prophylactic  treatment  should  be  instituted  in 
those  cases  which  present  predisposition  to  lymphatic  en- 
largements. It  should  consist  of  general  tonics  and  local 
antisepsis.  He  mentions  among  the  latter  inttillations  of  oil 
and  insuitlations  of  medicated  powders.  He  prefers  men- 
tholated oil  (1 :  50)  on  account  of  its  astringent  and  valuable 
antiseptic  properties.  In  cases  where  this  is  not  well  toler- 
ated, he  recommends  a  combination  of  sterilized  olive  oil 
with  resorcin  (1  part  to  25  of  the  oil).  The  instillation  should 
be  made  two  or  three  times  a  day.  As  another  application, 
borated  vaseline  or  mentholated  vaseline  is  recommended. 
An  excellent  powder  may  be  employed  consisting  of  men- 
thol 10  c.  g.,  boric  acid  and  talcum,  of  each  5  grams.  The  nasal 
irrigation  may  be  prescribed  with  the  above  treatment,  but 
the  author  points  out  very  wisely  the  possibility  of  damage 
by  this  method  and  shows  the  necessity  of  having  the  canal 
freely  open  and  using  but  slight  force  in  the  douching.  Ex- 
plicit directions  are  given  as  to  the  manner  of  using  the 
douche.  The  quantity  should  not  be  more  than  20  ccm. 
the  fluid,  preferably  a  boric  acid  solution.  When  the 
adenoids  are  actually  present,  the  author  directs  that 
medical  treatment  should  consist  of  an  application  of  iodin 
with  glycerin,  1  :  50.  This  will  greatly  reduce  the  size  of  the 
growths  and  act  favorably  upon  the  catarrhal  condition. 
This  treatment  is  merely  palliative  and  surgical  measures  are 
our  only  means  to  effect  a  cure.  The  operation  which  is 
described  must  be  conducted  with  careful  antiseptic  meas- 
ures, both  preparatory  to  and  succeeding  the  operation.  An 
anesthetic — ether  or  bromid  of  ethyl — may  be  employed. 
Adenoids  carefully  removed  do  not  recur  and  radical  opera- 
tion is  insisted  upon,    [t.l  c] 

4. — Acute  colitis  constitutes  a  clinical  type  which  is 
distinct  from  gastroenteritis.  Acute  colitis  may  be  primary 
or  secondary.  In  the  latter  case  it  succeeds  a  gastroenteritis 
or  appears  in  the  course  of  one  of  the  infectious  diseases. 
The  pathology  of  colitis  is  identical  with  that  of  gastroenter- 
itis. Colitis  may  be  divided  into  the  gangrenous  form  with 
glairy  or  mucous  secretions;  and  a  second  variety,  the  dys- 
enteriform.  These  may  appear  as  a  mild  type  with  fever,  or 
a  severe  type  with  the  advent  of  the  algid  state.  The  symp- 
toms of  the  second  variety  are  akin  to  true  dysentery.  The 
pathologic  changes  occurring  in  dysentery,  however,  are 
more  destructive.  Regarding,  as  Aviragnet  does,  that  the 
two  dysenteric  conditions  are  similarly  caused,  he  treats 
them  identically.  His  method  is  to  place  the  patient  at  rest 
in  bed ;  to  relieve  the  abdominal  pain  by  cataplasms  or  hot 
or  cold  applications.  He  disbelieves  in  the  use  of  lavage  of 
the  large  intestine,  arguing  that  distention  of  the  inflamed 
bowel  augments  the  pains,  and  possibly  the  inflammatory 
process.  He  diminishes  tlie  rectal  tenesmus  with  small  in- 
jections of  weak  solutions  of  laudanum,  and  advises  this 
treatment  rather  than  suppositories.  To  combat  the  inflam- 
matory process,  he  discusses  the  use  of  ii  jections  of  ipecac, 
borax,  hyposulfite  of  soda,  and  various  suppositories.  He 
believes  these  means  should  be  rejected  in  the  acute  form  of 
colitis,  because  they  are  insuthcient,  save  in  very  benign 


cases,  and  because  they  add  to  the  irritability  of  the  bowel, 
and  may  increase  the  inflammation  and  pain.  He  discusses 
the  administration  of  calomel  and  ipecac  by  the  mouth  and 
then  takes  up  the  treatment  with  sulfate  of  soda,  from  the 
use  of  which  he  claims  remarkable  curative  results.  He 
prescribes  10  to  15  grams  the  first  day  (administered  in  a 
glass  of  sweetened  water).  This  dose  is  slightly  aperient, 
and  especially  useful  when  stomach  irritability  is  pro- 
nounced. Small  doses  are  given  the  day  following.  For 
example,  to  a  child  of  from  12  to  14  months,  5  grams.  The 
dose  may  be  varied,  and  the  administration  continued  for 
several  days.  The  blood  rapidly  disappears  from  the  stools, 
the  rectal  tenesmus  disappears,  and  diarrhea  soon  ceases. 
The  warm  bath  may  be  used  as  a  valuable  adjuvant  to  this 
treatment.  He  does  not  claim  the  method  of  treatment  a 
new  one,  but  wants  to  emphasize  its  utility,    [t.l.c] 


Annates  de  la  Soci^te  Beige  de  Chirurgie. 

December,  1900.    [8me  Ann^e,  No.  10.] 

1.  Intestinal  Obstruction,  Due  to   Lateral  Pinching  of  the 

Intestine.    Sneyers. 

2.  Invagination  of  the  Small  Intestine  in  the  Rectum,  with 

Strangulation.     Lauwees. 

3.  A  Suppurating  Cyst  of  the  Ovary.    Lebeegdb. 

4.  Luxation  of  the  Sledian  Xerve.    Depage. 

5.  Huge  Double  Inguinal  Hernia.    Deletriz. 

6.  Frontal  Autoplasiy.    Depage. 

7.  Pyemia  of  Olio  Origin.    ViscE. 

8.  Elephantiasis  of  the  Vulva.    Deleteez. 

1. — Sneyers  reports  two  cases  of  lateral  pinching  of 
the  intestine,  both  occurring  in  women,  under  Gimber- 
nai's  ligament.  In  both  cases  the  condition  was  correctly 
diagnosed,  and  both  recovered  after  operation.  The  con- 
striction occurs  generally  at  the  internal  ring,  and  very 
quickly  causes  strangulation.  Pain  and  swelling  at  the  in- 
ternal ring,  with  frequent  stools,  or  flatulence,  should  suggest 
it.  Operation  is  indicated  at  once,  the  bowel  sinking  into 
place ;  or  if  it  is  gangrenous,  resection  will  be  necessary,  as 
in  hernia  operations.  Warm  compresses  applied  to  the 
aflected  bowel  will  soon  show  whether  circulation  has  been 
reestablished  or  not.     [m.o.] 

3. — A  woman  of  T4  years  had  shown  signs  of  internal  stran- 
gulation for  some  days.  For  3  years  she  had  had  prolapse  of 
the  rectum,  which  had  previously  been  easily  reduced.  Four 
days  before  there  was  relapse,  with  great  pain,  the  pain 
persisting  even  after  reduction.  Fecal  vomiting  followed,  and 
rectal  examination  discovered  a  tumor  in  the  rectum. 
Laparotomy  was  performed,  and  00  cm.  of  the  small  intes- 
tine found  invaginated  in  the  rectum,  gangrenous  but  not 
perforated.  The  whole  mass  bulged  into  the  peritoneum, 
which  made  the  sac  for  the  hernia.  The  gangrenous  intes- 
tine was  removed  and  the  ends  sutured.  Drainage  was  left 
in.  Eleven  days  later  two  fecal  fistulae  were  discovered  suid 
sutured,  after  which  the  patient  recovered,  in  spite  of  her 
age.     [m.o.] 

3.— A  woman,  aged  41,  had  had  pain  deep  in  her  pelvis, 
oS  and  on  during  a  pregnancy.  After  her  child  was  horn  a 
tumor  was  discovered  on  the  right  side  of  the  abdomen. 
The  pain  returned  for  a  month  and  then  disappeared.  Five 
months  later,  as  the  mass  was  very  large,  laparotomy  was 
performed  and  a  multilocular  cyst  of  the  right  ovary  found, 
which  when  punctured  emitted  a  thick,  purulent  tiuid,  con- 
taining several  pyogenic  micrococci.  There  were  luany  ad- 
hesions between  the  intestines  and  the  cyst.  The  patient  died 
suddenly  3  days  later.  Lebesgue  thinks  that  the  cyst  became 
purulent,  in  the  absence  of  colon  bacilli,  from  the  influence 
of  the  pregnancy,     [m.o.] 

4. — Depage  presented  a  child  of  14,  who  had  dislocated 
his  right  elbow  3  months  before.  This  was  at  once  reduced, 
and  kept  immobilized  a  week,  after  which  the  arm  was  moved 
under  chloroform,  but  paralysis  of  the  muscles  supphed 
by  the  median  nerve,  and  loss  of  feeling  in  the  forearm  per- 
sisted. Depage  operated  at  the  elbow,  hut  could  not  find  the 
median  nerve.  .\  month  later  he  operated  again  and  found 
the  nerve  behind  the  olecranon.  This  was  then  dissected  out 
and  replaced  on  the  other  side  of  the  process.  Since  then 
movement  of  the  forearm  has  improved  with  electricity,  but 
the  loss  of  sensibility  remains  about  the  same,    [m.o.] 


Fbbruaey  9,  1901] 


THE  LATEST  LITERATURE 


TThk  Puiladklphia 
L  Medical  Jocbnal 


295 


5. — Deletrez  reports  a  case  ot  huge  double  inguinal 

hernia,  which  had  existed  5  years  in  a  man  of  60,  cured  by 
Bassini's  operation.  Photographs  before  and  after  operation 
are  given,     [si.o.] 

6. — Depage  presented  a  patient,  aged  74  years,  who  had 
had  a  rodent  ulcer  upon  the  center  of  his  forehead.  De- 
page  had  made  flaps  from  the  forehead,  cutting  on  either 
side  of  the  central  ulcer,  leaving  them  attached  below. 
These  he  sutured  together  over  the  ulcer,  and  in  the  two 
denuded  spots  above,  on  each  side,  he  planted  skin  by 
Thiersch's  method.  Now  there  are  but  three  scars,  the  tiny 
median  one  where  the  flaps  joined,  and  the  two  outer  ones. 
It  is  needless  to  mention  that  the  patient  was  bald,    [m.o  ] 

7,— A  boy  of  8  years,  with  double  suppurative  otitis, 
complained  of  severe  headache  with  fever  and  delirium. 
Mastoid  operation  was  done,  but  nothing  was  found.  During 
the  next  week  signs  of  peritonitis  developed  and  laparot- 
omy was  performed.  There  were  no  signs  of  peritonitis,  yet 
the  temperature  continued  hectic.  A  few  days  later  tender- 
ness was  noted  in  the  dorsolumbar  spine,  and  the  bowels  and 
bladder  were  emptied  involuntarily.  Then  an  abscess  ap- 
peared over  the  right  external  malleolus,  and  was  opened. 
Next  an  abscess  appeared  about  the  trochanter  of  the  right 
femur,  which  was  also  incised  and  drained.  A  week  later 
another  abscess  appeared  in  the  left  hip,  which  was  at  once 
opened.  During  the  succeeding  month  all  the  abscesses  im- 
proved, and  a  month  later  the  boy  was  well.  Recovery  after 
such  severe  pyemic  infection  seems  remarkable,     [m.o.] 

8. — Deletrez  presented  a  case  of  elephantiasis  of  the 
vulva,  in  a  woman  of  50  years,  who  had  convulsions  as  an 
infant,  epilepsy  later,  was  of  but  slight  intelligence,  had 
strabismus,  and  ankylosis  of  both  hips.  The  growth  began 
12  years  ago.  It  is  now  35  cm.  in  its  anteroposterior  diam- 
eter ;  laterally,  24  cm.  Its  weight  is  5  J  kilograms.  The  surface 
of  the  tumor  is  covered  with  nodes  and  hair.  There  seem 
to  be  no  changes  in  the  skin.  He  expects  to  operate.  Others 
present  disagreed  with  the  diagnosis,  believing  it  to  be  a 
fibrolipoma.    A  photograph  of  the  tumor  is  given,    [m.o.] 


Journal  des  Praticiens. 

January  5, 1901.    [15me  Ann^e,  No.  1.] 

1.  A  Case  of  Mucous  Colitis  with  Hemcrrhaee.  Triboulet. 

2.  The  Preparations  of  Copper  for  Internal  Use.    Lieqeois. 

1. — Triboulet  gives  the  minute  details  of  a  case  of  enteritis, 
at  first  diagnosed  dysentery.  The  acute  attack  over,  but 
little  blood  or  mucus  appeared  in  the  bowel-movements  for 
a  month.  Then  occurred  daily  attacks  of  colic,  followed  by 
mucous  stools,  with  a  great  deal  of  blood,  both  bright  and 
dark-red,  mixed.  During  50  or  60  days,  the  patient,  a  young 
girl  of  20,  lost  40  to  80  grams  of  blood  daily.  Under  high 
injections  of  nitrate  of  silver  the  condition  disappeared. 
[M.o.] 

2. — Li^geois  enumerates  7  preparaiions  of  copper  which 
can  be  given  internally,  giving  their  doses  and  indications, 
and  quoting  authors  who  have  used  them  succestfully. 
[m.o.] 

January  12,  1901.     [15me  Ancee,  No.  2.] 

1.  Ano-rectal   Fistula   as  a  Premonitory  Sign  of  Phthisis. 

Ernest  Barie. 

2.  Abortion   from   a  Medico- Legal   Standpoint.    Professor 

Brouardel. 

3.  The  Heavy  Metals  in  the  Treatment  of  Anemia.  Professor 

Cervello. 

1. — Recent  researches  show  that  about  5%  of  all  phthisical 
patients  have  fistula  in  ano.  Tubercle  bacilli  are  generally 
found  in  the  pus,  alone,  or  with  staphylococci  and  strepto- 
cocci. Though  they  occur,  as  a  rule,  with  or  after  the  pul- 
monary lesion,  they  may  even  precede  the  phthisis,  by 
from  4  to  18  years.  Bari6  reports  5  such  cases,  2  of  which 
had  as  their  exciting  cause  a  traumatism,    [m.o.] 

3. — In  performing  an  autopsy  upon  a  woman  who  is  sup- 
posed to  have  attempted  abortion,  search  must  be  made  for 
the  embryo,  or  pieces  of  it;  or  for  the  placenta;  or  if  the 
uterus  is  empty,  the  thickness  of  its  walls  must  be  measured, 
and  the  insertion  of  the  placenta  sought,  as  this  can  be  recog- 
nized up  to  the  tenth  day  after  the  expulsion  of  the  embryo. 


This  is  possible  even  later,  if  the  uterus  is  kept  in  90^  alcohol. 
The  examination  of  the  ovaries  is  of  only  relative  importance, 
as  no  positive  signs  exist  there.  Stains  of  meconium,  if  found, 
will  prove  the  abortion.  If  an  instrument  has  been  used  to 
cause  abortion,  traces  of  the  damage  done  by  it  will  be  seen. 
This  is  especially  true  when  the  uterus  has  been  perforated. 
Brouardel  advises  his  students,  should  any  one  of  them  be 
called  upon  to  do  an  autopsy  upon  a  suspicious  case,  in 
which  a  physician  is  accused  of  having  performed  abortion, 
to  ask  that  the  accused  physician  be  present  at  the  autopsy 
to  explain  what  he  had  done,  and  why  he  had  done  it ;  and 
then  from  the  result  of  the  autopsy  it  can  soon  be  decided 
whether  the  accused  is  guilty  or  not.     [mo  ] 

3. — Cervello  reviews  the  work  done  on  this  subject  and 
reports  some  experiments  upon  dogs  and  chickens,  in  which 
copper,  zinc,  manganese,  and  mercury  acted  like 
iron  in  cases  of  anemia  and  chlorosis.  He  believes  that 
under  their  use  the  hemoglobin  in  human  blood  will  readily 
increase,    [m.o.] 

January  19,  1901.     [15me  Anr.4e,  No.  3.] 

1.  Alopecia  or  Pseudoalopecia  in  Syphilis.    Alfred  Four- 

NIER. 

2.  The  ES"ect  of  Gout  and  Rheumatism  upon  the  Eye.    A. 

Trousseau. 

3.  Headache  Treated  by  Acetate  of  Ammonium.    Liegeois. 

1.— It  is  not  rare  that  circumscribed  areas  of  absolute 
alopecia  occur  in  the  scalp  or  beard  in  syphilis.  They  are 
small  and, few,  well  circumscribed,  lasting  a  short  time,  but 
recurring  often.  This  appears  later  on  ia  syphilis,  and  is  very 
different  from  that  general  thinning  of  the  hair  seen  early  in 
the  disease,  which  never  returns.  Fournier  concludes  that 
it  may  be  a  manifestation  of  the  syphilis,  or  a  parasyphilitic 
result  of  the  syphilis.    Time  may  prove  which,     [mo.] 

2.— Trousseau  notes  that  symptoms  of  iritis  and  corneal 
sclerosis  may  be  the  first  signs  of  gout  or  rheuma.- 
tism  to  appear  in  the  descendants  of  gouty  or  rheumatic 
families.  He  reports  a  number  of  cases  to  illustrate  this 
occurrence.  He  suggests  treating  these  cases  for  gout  or 
rheumatism  at  once,    [m.o.] 

3.— Headache  after  meals  with  flushes  of  heat,  in  neuras- 
thenics, is  unafTected  by  ammonium  acetate.  Nor  has  it  any 
eflPect  upon  emotional  headache  with  palpitation  of  the 
temporal  arteries.  But  in  the  early  morning  headache  of 
neurasthenia  or  chlorosis,  liquid  acetate  of  ammon- 
ium works  very  well  in  one  dose  of  6  grams.  L  egeois  has 
also  used  this  successfully  in  pseudoangina  pectoris,  in  oph- 
thalmic migraine,  and  in  dysmenorrhea,  in  nervous  subjects. 
[m.0.1 


Relations  Between  Malaria  and  General  Paral- 
ysis.—From  a  study  of  8  cases  Marandon  de  Montyel 
{Revue  de  Medecine,  November  10,  1900)  concludes  that  acute 
malaria  may  produce   progressive  general    paralysis- 

or  general  pseudoparalysis  in  those  who  are  predisposed. 
Chronic  malaria,  also,  may  produce  progressive  general 
paralysis  in  those  who  are  predisposed,  and  probably  may 
induce  it  in  those  who  are  not  predisposed.  Acute  ma- 
laria may  cause  precocious  progressive  general  paralysis 
in  those  who  are  predisposed.  Malarial  manifestations 
supervene,  in  the  course  of  progressive  general  paralysia 
they  are  often  complicated  by  cerebral  congestions  which 
aggravate  the  brain  disease  and  hasten  its  evolution.  The 
progressive  general  paralysis  that  develops  under  the  influ- 
ence of  acute  or  chronic  malaria  nearly  always  has  a  rapid 
evolution.  The  relations  of  the  two  diseases  are  incontesta- 
ble, although  the  one  does  not  often  manifest  itself  as  a 
cause  of  the  other.  The  symptomatology  and  the  pathologic 
anatomy  of  general  paralysis  of  malarial  origin  presents  no 
special  characteristics.  The  histories  of  the  8  cases  are 
given.  Of  the  patients,  in  addition  to  malarial  infection  4 
presented  a  history  of  syphilis  combined  with  family  history 
of  neuroses;  1  gave  a  history  of  cerebral  trauma ;  1  presented 
a  family  history  of  nervous  disease  ;  and  1  had  convulsions 
in  infancy  and  suflered  from  nocturnal  eneuresis  durmg 
childhood.  One  patient  only  gave  a  history  free  froni  hered- 
itary taint  of  nervous  disease,  from  syphilis,  and  from 
trauma,     [.i  m  s.] 


296 


The  Philadelphia"! 
Medical  Journal  J 


PRACTICAL  THERAPEUTICS 


[Febboabt  9,  19«l 


practical  Ct^crapcutics. 


For  Constipation  with  Flatulence. — Illoway  {New 
Orleans  Medical  and  Surgical  Journal)  recommendB  : 

B. — Extract  colooyntb.  co J  grain. 

Terebinth.  Veneta 1  grain. 

Pulv.  aloes,  socot ]J  grain. 

Ext.  nucis  vomic i  grain. 

Ext.  hyoBcyami  (English) 1  grain. 

M.  ft.  mass,  et  ft.  pillul.  No.  1.  Sig.— One  pill  2  or  3 
times  a  day. 

Treatment  of  Freckles.— Jamison  (Brilish  Medical 
Journal]  states :  "  Certain  skins  exhibit  an  exaggerated  sensi- 
tivenefs  to  light,  but  to  only  one  of  the  methods  in  which 
such  react  will  reference  be  made  at  present.  Some  indi- 
viduals, particularly  those  with  reddish  hair,  freckle  readily 
during  the  brighter  part  of  the  year.  This  impressibility 
may  be  congenital,  the  result  of  changes  due  to  age,  or  ac- 
quired as  the  consequence  of  excessive  exposure  to  intense 
radiation.  Theie  can  be  little  doubt  that  these  freckles  are 
an  effort  on  the  part  of  nature  to  protect  areas  which  are 
from  some  cause  more  than  usually  delicate,  to  impart 
rapidly  to  limited  spots  the  same  safeguard  which  the  prog- 
ress of  the  ages  has  given  to  the  darker  races  of  humanity. 
The  researches  of  Bowles  have  proved  that  it  is  the  chemical 
rays  which  are  thus  active,  and  though  their  effects  are  most 
pronounced  on  uncovered  parts,  they  are  not  restricted  to 
thesp.  They  in  this  respect  correspond  to  the  x-rays,  since 
freckles  are  met  with  on  portions  of  the  body  on  which  the 
sunlight  never  impinges  directly  for  any  length  of  time,  if  at 
all.  The  most  remarkable  example  of  this  susceptibility 
occurs  in  xeroderma  pigmentosum.  Not  only  have  we 
intense  freckling,  but  dryness  and  hyperkeratosis,  at  first 
diffuse,  after  a  time  taking  on  a  warty  and  then  a  carcino- 
matous degeneration.  Unna  has  suggested  that  by  due  pro- 
tection from  the  chemical  rays  the  freckling  might  be  modi- 
fied in  this  disease,  the  further  malignant  changes  postponed 
or  arrested,  and  amelioration,  if  not  cure,  obtained.  A  case 
of  this  kind  has  been  under  my  care  for  two  years  and  a  half, 
and  in  it  we  have  been  able  to  check  the  advance  almost  per- 
fectly. An  ointment  staitied  brown  by  the  addition  of  raw 
umber  has  been  pretty  constantly  applied  to  the  face,  a  dark 
brown  veil  worn  whenever  the  child  (now  six)  has  gone  out, 
and  the  warts  on  their  earliest  appearance  treated  with 
salicylic  collodion.  In  this  way  fairly  perfect  rett  has  been 
obtained  for  the  abnormally  tender  skin." 

Prevention  of  Gastric  Fermentation.  —  Ewald 
(New  Orleans  Medical  and  Surgical  Journal)  recommends  : 

R. — Resorcin  resubl 5  0    (75  grains.) 

Bismuth  salicyl.  1 

Pulv.  rad.  rhei.     ^ofeach  100    (ISOgrains.) 

Natr.  sulph.         ] 

Sacchar.  lact 15  0   (250grain8.) 

M.    Sig.— Make  a  powder  ;  J  teaspoonful  twice  daily. 

Contribution  to  the  Study  of  Iodoform  Poison- 
ing.—Anscbiiz  (Beitrage  zur  kliii.  Chir.,  Bd.  xxviii,  H.  1,  p. 
233)  reports  a  case  of  iodoform  poisoning  in  a  man  30  years 
of  age  after  a  third  injection  of  100  ccm.  of  a  10%  iodoform 
glycerin  emulsion  into  a  psoas  abscess.  The  symptoms  in 
this  case  were  as  follows  :  Slight  vomiting  during  the  first  day 
after  the  injection,  a  progressive  somnolence  beginning  on 
the  ninth  day,  a  widely  disseminated  acne  eruption,  desqua- 
mation of  the  buccal  mucous  membrane,  crust  formation  in 
the  nose,  agglutination  of  the  eyelids,  followed  by  increase  in 
the  reflexes  of  the  lower  extremities,  and  stertorous  respira- 
tion. Large  quantities  of  iodoform  were  found  in  the  urine. 
In  spite  of  the  evacuation  of  the  iodoform  emulsion  by  means 
of  saline  irrigation,  death  followed  after  2  days.  The  whole 
clinical  picture  presented  a  grave  case  of  iodoform  intoxica- 
tion which  heretofore  had  only  been  observed  experimentally 
upon  animals.  The  author  considered  the  cause  of  this  rare 
symptom-complex  as  due  to  the  caseation  of  both  suprarenal 
capsules,  which  was  substantiated  postmortem  upon  micro- 


scopic examination.  There  were  no  symptoms  of  Addi- 
son's disease. 

Therapy  of  Fibrinous  Rhinitis.— F.  Peltesohn  {Thera- 
peutische  Monaische/te,  September,  1900)  recommends  a  solu- 
tion of  cyanide  of  mercury  0,  02 :  50,  for  dissolving  the  mem- 
brane. The  solution  is  applied  with  cotton  on  a  probe  and 
applied  alternately  to  each  nostril  for  one  hour  at  a  time. 
He  reports  astonishing  results. 

Amenorrhea. — Bloom  (Gazelle  hebdomadaire  de  Med.  et 
de  Chir.,  April  1,  1900)  recommends  the  following  for  amen- 
orrhea : 

li.— Strychnin,  sulf. 0  002. 

Acid  oxal   0.01. 

KgrnClof-^ O-l- 

Extract  colocynth.  comp  003. 

M.    Sig. — One  powder,  three  times  daily,  after  meals. 

The  Therapy  of  Hemoptysis  in  Tuberculosis. — A. 

Hecht  {Theraptuiische  Monalshefte,  1900,  No.  10)  has  employed 
Huchard's  pills  (ergotin,  quinin  sulphate,  pulv.  fol.  digitalis, 
extr.  hyoscyam.,  of  each  0.1)  in  a  number  of  cases  of  hemop- 
tysis in  tuberculosis.  In  all  cases,  upon  systematic  applic&- 
tion  of  the  remedy  the  hemoptysis  was  checked.  Two  caees 
that  had  withstood  the  customary  remedies  were  checked 
after  employment  of  these  pills.  The  author  believes  that 
the  hemostasis  is  not  to  be  attributed  to  the  ergotin,  but  to 
the  quinin  reinforced  by  the  digitalis. 

For  Bronchial  Asthma^  —  GDldmann  {Wiener  med. 
M'ochenschrift,  1899,  No.  43)  reports  43  favorable  results  with 
Neumeier's  asthma  powder  which  consists  of  strammonium, 
lobelia,  potassium  nitrate,  potassium  iodid  and  sodium 
nitrite.  There  are  no  injurious  manifestations.  A  tea- 
spoonful  of  the  powder  is  placed  in  a  saucer,  ignited,  and 
the  fumes  slowly  inhaled.  The  influence  of  the  remedy  is  a 
local  one,  and  it  has  an  analgesic  effect  upon  the  mucous 
membrane. 

Gargles  in  Acute  Tonsillitis  ;  — 

li. — Tinct.  belladonnae J  dram. 

Glycerin! 2J  drame. 

Decoct.  alth«a.  enough  to  make 6    cunces. 

M.  Sig. — Use  as  a  gargle  two  or  three  times  daily. — Schniizler. 

R. — Tinct.  aconiti S  minims. 

Syrupi  aurantii 3  drams. 

Aquse  destil.  enough  to  make. 2  ounces. 

M.  Sig. — One  teaspoonful  every  two  hours  for  a  child  of  4. 
—J.  A.  M.  A. 

FOE  LOCAL  APPLICATIOS. 

As  a  local  application  the  following  may  be  found  of 
service  in  such  cases  : 

K  . — lodin 3  graina. 

Potassii   iodidi I  dram. 

Glycerini  enough  to  make 1  ounce. 

M.  Sig. — Apply  locally  to  the  tonsils  three  times  a  day  by 
means  of  a  brush  or  cotton  swab. — Medical  Fortnightly. 

AT  COMMEXCE.MEST  OF  ATTACK. 

R.— Tinct.  ferri  perchloridi 1  dram. 

Glycerini 2  ounces. 

M.  Sig. — One  teaspoonful  every  two  hours. 

Iron  given  as  in  the  above  form  without  the  addition  oi 
water  is  by  some  authors  regarded  as  a  specific  in  treatment 
of  tonsiUitis,  believing  that  it  relieves  the  pain,  shortens  the 
duration  and  lessens  the  congestion,  as  it  has  a  local  as  well 
as  a  systemic  eftect. — Medical  Fortnightly. 

Transitory  Glycosuria  in  a  Case  of  Acut«  Mor- 
pbin  Poisoning. — E.  Adler  {Pragrr  med.  i\'i>cAeyiSihrifl, 
1900,  No.  28)  reports  a  CAse  of  transitory  glyc<'>8uria  in  a 
woman,  20  years  of  age,  who  had  taken  about  10  cm.  of  a  5^ 
morphin-solution.  Examination  of  the  urine  showed  on  the 
day  following  the  poisoning  0.7%  of  grape  sugar,  of  which 
hardly  an  appreciable  trace  was  left  on  the  second  day.  The 
patient  rocovered  on  the  third  day.  Pentoses  were  not 
found  in  the  urine. 


February  9,  1901] 


BLINDNESS  FROM  SYMPATHETIC  OPHTHALMITIS 


TThB   fHII^ADBLPHIA 
L  M-EDICAL   JOUKNAL 


297 


0rtc;inal  ^Irticlcs. 


CASE  OF  BLINDNESS  FROM  SYMPATHETIC  OPHTHAL- 
MITIS, COMPLICATED  WITH  SECONDARY  GLAU- 
COMA. RESTORATION  OF  VISION  BY  TWO 
IRIDECTOMIES,  ONE  WITH  EXTRACTION  OF 
LENS,  AN  IRIDOCYSTECTOMY,  AND  TYRRELL'S 
OPERATION  OF  DRILLING.* 

By  CHARLES  A.  OLIVER,  A.M.,  M.D. 

of  Philadelphia,  Pa.,  U.  S.  A. 

Attending  Surgeon  to  Wills'  Eye  Hospital ;  Ophthalmic  Surgeon  to  the  Philadel- 
phia Hospital, 

Sixty  years  ago  Frederick  Tyrrell,  at  that  time  Senior 
Surgeon  to  the  Royal  London  Ophthalmic  Hospital 
and  Surgeon  to  St.  Thomas'  Hospital,  London,  Eng- 
land, wrote  these  words : ' 

"  Of  the  Operation  of  Drilling.  There  arc  many  cases  in 
which  capsular  or  capsule-lenticular  cataract  is  produced 
by  the  extension  of  inflammation  from  the  iris  to  the 
capsule.    .    .    . 

'In  such  cases  the  operation  of  extraction  ought  not  to 
be  attempted ;  because  the  adhesions  between  the  iris  and 
anterior  part  of  the  capsule  of  the  lens,  make  it  e.Ktremely 
difficult  to  get  out  the  lens,  after  the  section  of  the  cornea  is 
made ;  it  cannot  be  accomplished  without  much  violence ; 
and,  when  effected,  is  most  likely  to  excite  deep-seated  in- 
flammation, which  would  be  fatal  to  the  organ  ;  such  has 
been  the  unfortunate  result  of  the  operation  of  extraction 
in  nearly  all  cases  of  this  kind  in  which  I  have  known  it  to 
be  performed. 

"  Some  years  since,  the  practice  at  the  Ophthalmic  Hos- 
pital, in  the  treatment  of  these  cases,  was  to  divide  the  iris 
and  lens  at  the  same  time,  by  Maunoir's  scissors,  so  as  to 
form  an  artificial  pupil,  and  expose  the  lens  to  the  influence 
of  the  aqueous  fluid.  .  .  .  The  result  of  this  practice  was, 
however,  so  very  unsuccessful,  that  I  dreaded  to  undertake 
it;  and,  by  careful  observation,  I  had  good  reason  to  suspect 
that  a  great  deal  of  the  mischief  which  followed  the  opera- 
tion, and  proved  fatal  to  the  eye,  resulted  from  the  pressure 
and  irritation  produced  by  the  divided  portions  of  the  crys- 
talline lens,  which  were  usually  displaced  by  the  operation. 

"  After  much  careful  consideration  of  the  subject.  I  felt 
satisfied  tliat  a  much  better  result  might  be  obtained  by  a 
modification  of  Mr.  Saunders's  operation  for  solution,  by 
which  the  lens  might  be  got  rid  of;  and  that,  subsequently, 
Maunoir's  operation  might  be  performed  with  much  less 
risk. 

"The  plan  I  adoped,  and  have  since  continued,  is  as  fol- 
lows : 

"  The  patient  being  placed  as  if  to  undergo  the  anterior 
operation  for  solution,  I  have  passed  a  very  fine  straight 
needle  through  the  cornea  at  the  outer  part ;  and,  then, 
directing  the  point  to  the  anterior  capsule  of  the  lens  close 
to  the  inner  margin  of  the  pupil  (taking  care  not  to  injure 
the  iris)  and  causing  the  instrument  to  penetrate  the  cap- 
sule, and  enter  the  substance  of  the  lens  to  the  extent  of 
about  one-sixteenth  of  an  inch,  I  have  rotated  the  handle  of 
the  needle  between  the  forefinger  and  thumb,  so  as  to  make 
the  point  act  as  a  drill ;  and  having  secured  an  opening  more 
free  than  could  be  effected  by  a  simple  puncture,  then  I 
have  withdrawn  the  need'e. 

"  By  using  a  very  fine  straight  needle,  of  uniform  thick- 
ness, and  by  introducing  it  a  little  obliquely  through  the 
cornea  I  have  frequently  performed  this  operation,  without 
the  loss  of  a  single  drop  of  aqueous  humor ;  and  I  have  rarely 
found  it  produce  any  inflammation. 

"According  to  the  degree  of  absorption  or  solution,  I  have 
usually  repeated  this  operation,  every  3,  4,  or  5  weeks;  and 
have  been  careful  to  puncture  the  opaque  capsule  in  a  fresh 
l)lace,  at  each  operation ;  and  this  has  generally  enabled  me 
so  far  to  weaken  or  detach  the  portion  of  the  capsule,  occu- 

*  Read  hy  title  before  the  Section  on  Ophthnlmology  of  t!ie  Third  Pan- 
American  Medical  Congress,  held  at  Havana,  Cuba,  in  February,  1901. 

'  A  Practical  Work  on  the  Diseases  of  Uie  Eye,  and  tlicir  Treatment,  Medi- 
cally, Topically,  and  by  Operation.     Vol.  II,  1849,  pp.  464-480. 


pying  the  site  of  the  pupil,  that  it  has  been  easily  displaced 
when  the  lens  has  become  dissolved. 

"  The  extent  of  the  loss  of  lens  may  be  ascertained  by  two 
moans:  first,  the  increase  in  size  in  the  anterior  chamber; 
secondly,  by  the  resistance  offered  to  the  point  of  the 
needle ;  for  as  long  as  much  of  the  lens  remains,  the  opera- 
tor may  feel  resistance  to  the  point  of  the  instrument; 
whereas,  the  capsule  alone  can  hardly  be  felt. 

"  I  think,  upon  the  average,  that  I  have  had  to  repeat  the 
operation  seven  or  eight  times  before  I  have  been  satisfied 
that  the  lens  has  been  removed  ;  consequently  the  cure  has 
been  extremely  tedious ;  but  as  the  plan  incurs  very  little 
risk,  and  does  not  confine  the  patient  for  more  than  two  or 
three  days  after  each  operation,  there  can  be  no  further  ob- 
jection to  it  than  the  slowness  of  its  effects,  which  is  more 
than  counterbalanced  by  the  success  of  the  treatment. 

"  I  have  operated  upon  a  considerable  number  of  these 
cases  by  drilling  ;  and  have  good  reason  to  be  satisfied  with 
the  result  of  the  operation  ;  in  no  instance  has  it  produced 
inflammation  of  importance  ;  and,  out  of  the  few  cases  in 
which  it  has  failed  to  restore  vision,  I  believe  that  the  sensi- 
bility of  the  retina  had  been  previously  and  permanently 
injured  ;  for  I  succeeded  in  getting  rid  of  the  cataract,  and 
in  clearing  the  pupil  to  a  sufficient  extent  to  afford  good 
vision,  provided  that  the  retina  had  retained  sufficient 
power.  It  is  impossible  to  decide  upon  the  condition  of  the 
retina  before  operation  ;  excepting  so  far  as  regards  percep- 
tion of  light,  without  which  the  treatment  should  not  be 
adopted. 

"  The  operation  is  adapted  to  all  cases  of  this  class,  both 
in  young  and  old  persons  ;  for  I  believe  generally  that  the 
lens  is  not  opaque,  but  retains  the  ordinary  consistence ;  and 
even  when  it  is  opaque  in  elderly  persons  in  connection  with 
and  in  consequence  of  the  disease  in  the  capsule,  that  it  has 
not  the  hard  character  of  the  ordinary  cataract. 

"  In  most  of  these  cases  which  I  have  operated  upon  by 
drilling  I  have  been  able  to  effect  all  I  could  desire  by  the 
fine  needle  only ;  but  in  a  few  instances  I  have  been  obliged, 
eventually,  to  make  an  artificial  pupil  by  Maunoir's  plan  of 
operation;  being  unable  to  clear  a  sufficient  space  in  the 
natural  pupil  to  aflbrd  useful  vision  ;  and  these  operations 
for  artificial  pupil  have  been  generally  successful ;  proving 
that  I  had  formed  a  correct  opinion  of  the  principal  cause 
of  failure  in  the  cases  submitted  to  Maunoir's  operation 
whilst  the  lens  remained." 

This  most  graphic  description  is  followed  by  the 
clinical  histories  of  several  cases  occurring  during  the 
years  1836  to  1840.  In  all,  there  were  the  sequelae  of 
gross  inflammation  in  the  anterior  segment  of  one  or 
both  eyes.'  In  each  one  the  procedure  was  tried  with 
successful  results. 

Having  had  a  favorable  individual  experience  with 
the  more  recently  devised  operation  of  Critchett  and 
Story'  for  the  laceration  of  the  lens  capsule  and  the 
evacuation  of  the  lenticular  contents  in  two  cases  of 
sympathetic  ophthalmitis,  which  had  been  considered 
as  irremediably  blind,  and  being  aware  of  Tyrrell's 
much  earlier  plan  of  drilling  in  ca.=es  of  capsular  or 
capsulolenticular  cataract,  induced  me  to  try  the  latter 
oi)eration  upon  a  case  of  blindness  from  a  complicated 
type  of  sympathetic  disease  which  seemed  to  be  pecu- 
liarly appropriate  for  the  procedure. 

As  in  Tyrrell's  method,  and  unlike  the  Critchett- 
Story  plan  in  sympathetic  cases  of  two  needles,  I 
limited  my  instruments  to  but  one,  obtaining  the  cap- 
sular incision  and  producing  the  evacuation  of  the  re- 
maining lenticular  contents  by  means  of  a  fine,  straight 
needle  of  the  pattern  described  by  TyrrelL* 

The  result  of  a  permanent  ^  of  normal  vision  (y'j) 

'  From  the  description,  it  is  probable  that  1  or  2  of  these  cases  were  sympa- 
thelir  in  character. 

'Critchett  :  Royal  Lindon  Ophlhalmic  Hoipital  Reports,  I.  2.  Story;  Trans- 
actions of  the  R-iyal  Academy  of  Medicine,  Ireland,  1S90-189I. 

•  On  Plate  IX,  in  Tyrrell's  work,  the  author  tigurcs  the  .ihapes  and  the  sizes  of 
the  two  forms  of  Saunders's  needle  he  used  ;  the  one  cutting  only  at  the  point, 
and  the  other  cutting  on  each  edge  to  the  shaft.  The  latter  pattern  of  instru- 
ment was  the  one  I  employed. 


298 


THK  PhT  la  DELPHI  A"| 

Medical  Journal  J 


BLINDNESS  FROM  SYMPATHETIC  OPHTHALMITIS 


[FCBEUXRT  9,  1981 


in  quite  a  large  and  well-shaped  field,  in  a  quiet  and 
comfortable  eye,  was  much  more  than  I  dared  to  expect 
in  a  case  of  this  type  of  ocular  disease. 

Briefly,  the  history  of  the  patient  is  as  follows  :  On 
March  16,  1899,  I  received  the  accompanying  note 
from  Dr.  Walter  Lathrop,  superintendent  and  surgeon 
of  the  State  Hospital  for  Injured  Persons  of  the  Middle 
Coal  Field  of  Pennsylvania,  at  Hazleton,  Pa.  "  I  have 
a  young  man  here  who  lost  his  left  eye.  He  had  a 
piece  of  steel  imbedded  in  the  lens ;  I  enucleated  the 
eye,  but  the  right  one  was  already  affected  sympathet- 
ically. It  was  15  weeks  from  the  time  of  injury  till  I 
first  saw  him.  ...  I  feel  as  though  he  would  lose 
the  sight  of  the  right  eye.  He  has  posterior  adhesion 
of  iris  now,  and  some  haziness  of  vision.  .  .  .  Will 
you  take  him  at  Wills'  Eye  Hospital  for  a  few  weeks 
and  do  what  you  can  for  him  ?     .     .     .  " 

One  week  later,  the  patient,  a  27-year  old  laborer, 
reported  to  my  clinical  service  at  the  hospital.  He 
stated  that  his  left  eye  had  been  struck  with  a  piece  of 
steel  some  6  months  previously,  and  that  in  spite  of 
treatment  the  eye  became  blind  in  3  months'  time. 
Dr.  Lathrop,  who  brought  him  to  me,  told  me  that 
when  he  saw  the  patient  for  the  first  time  on  the  28th 
of  January,  1899,  he  had  found  the  injured  eyeball  so 
sore  and  the  fellow-eye  so  irritable  that  he  immediately 
enucleated  the  offending  organ.  Examination  of  the 
removed  eye  by  him  revealed  the  presence  of  a  piece 
of  steel  imbedded  in  the  ciliary  body.  Within  a  week's 
time  after  the  operation,  the  right  eye  became  violently 
inflamed.  Since  then,  in  spite  of  several  exacerba- 
tions, the  gross  signs  of  inflammation  in  the  eye  had 
been  Icept  in  abeyance,  though  unfortunately  with  an 
ever-decreasing  vision.  The  treatment  employed  con- 
sisted in  the  free  use  of  boric-acid  flushing  and  atropin 
instillations  locally,  combined  with  the  internal  admin- 
istration of  quinin. 

When  I  first  saw  him,  there  were  all  the  signs  of  a 
pronounced  sympathetic  iridocyclitis  and  iridocapsuli- 
tis.  Marked  ciliary  injection  existed.  The  iris,  which 
had  been  originally  light  blue  in  color,  had  become 
greenish  and  metallic  in  tint.  Its  tissues  were  thick- 
ened, indrawn,  and  degenerate  in  many  places.  The 
pupil,  which  was  undilated,  was  almost  completely 
surrounded  with  rather  dense  and  firm  posterior  syne- 
chia. Dense  capsular  spots  and  areas  of  newly  formed 
connective  tissue  were  plainly  distinguishable  in  the 
remaining  pupillary  space.  Intraocular  tension  was 
somewhat  diminished,  and  slight  tenderness  in  the 
ciliary  region  could  be  obtained  by  pronounced  palpa- 
tion. Vision  was  lessened  to  -^^  of  normal.  The  fields 
of  vision  for  green,  red,  and  white  were  concentrically 
reduced  to  about  ^  of  their  relative  areas.  No  scoto- 
mata  or  peripheral  indentations  could  be  found. 

I  at  once  admitted  him  into  the  wards  of  the  hospital, 
and,  in  addition  to  his  former  treatment,  ordered  the 
employment  of  hot  stupes  with  tri-weekly  injections  of 
solutions  of  chlorid  of  sodium  deeply  into  the  subcon- 
junctival tissues. 

As  a  result  of  3  weeks'  trial  of  this  treatment,  the 
eye  became  much  more  quiet  Free  communication 
between  the  anterior  and  posterior  chambers  established 
itself  through  the  irregularl}',  though  but  slightly  en- 
larged pupillary  area.  The  iris  became  healthier  in 
tint  and  returned  to  its  proper  plane.  The  ciliary  con- 
gestion lessened,  and  vision  doubled  in  acuity. 

At  10  .\.M.,  on  the  eighteenth  day  after  admission  to 
the  hospital,  the  patient  complained  of  a  severe  attack 


of  pain  in  the  eye.  This,  which  the  resident  surgeon 
of  the  hospital  relieved  by  the  use  of  the  artificial  leech 
to  the  corresponding  temple,  became  so  excruciating, 
that  I  was  sent  for  5  hours  later.  Finding  the  gross 
signs  of  an  acute  attack  of  glaucoma  with  intraocular 
tension  increased  to  plus  3,  I  immediately  made  a 
broad  clean  iridectomy  down  and  in,  in  the  position  at 
which  the  iris  tissue  seemed  to  be  the  best  adapted 
and  most  healthy.  There  was  no  accident,  and  no 
complications  except  the  appearance  of  a  slight  hemor- 
rhage from  the  iris  into  the  anterior  and  posterior 
chambers.  The  tension  of  the  eyeball  at  once  feU  to 
normal.     On  the  following  day  the  wound  healed. 

In  a  week's  time,  the  blood  in  the  chamber  had  dis- 
appeared, the  eye  was  quiet  and  painless ;  and  intra- 
ocular tension  remained  normal ;  but  the  colobomatous 
area  was  much  smaller  and  fast  becoming  annihilated. 
New  connective-tissue  strands  had  appeared,  and  denser 
capsular  thickenings  had  taken  place,  so  reducing  vis- 
ion that  the  patient  was  unable  to  see  more  than  light, 
though  fortunately  in  a  large,  well-formed  and  uninter- 
rupted field. 

Fearing  the  occurrence  of  another  attack  of  secondary 
glaucoma  as  soon  as  the  communication  between  the 
two  chambers  had  closed,  I,  2  days  later,  made  a  broad 
iridectomy  to  the  temporal  side  of  the  previous  one. 
This  done,  I  immediately,  without  the  loss  of  any  vit- 
reous humor,  extracted  nearly  the  entire  lens  in  a  wire 
loop,  removing  all  of  the  visible  portions  of  the  remain- 
ing lenticular  matter  with  repeated  flushings  of  warm 
sterile  solutions  of  boric  acid.  After  cleansing  the  field 
of  operation,  I,  not  fearing  any  glaucomatous  exacerba- 
tion, instilled  several  drops  of  atropin,  and  carefully 
bandaged  the  organ.  Iced  compresses,  directly  applied 
on  the  dressings,  were  at  once  begun,  and  the  patient 
was  kept  in  bed. 

The  immediate  results  were  more  than  I  had  expected. 
Both  central  and  peripheral  vision  remained  as  before. 
The  eye  was  quiet,  intraocular  tension  was  normal,  and 
the  new  pupillary  opening  was  fairly  well  preserved. 

Feeling  sure  that  with  care  no  gross  inflammatory 
reaction  would  arise,  and  that  there  was  but  a  remote 
danger  of  another  glaucomatous  attack,  I  allowed  the 
patient  to  return  to  his  home  for  the  summer  months, 
enjoining  him  to  continue  the  use  of  the  atropin,  not 
to  attempt  to  employ  the  eye,  and  to  return  immediately 
to  the  hospital,  should  anything  untowards  occur. 

In  October,  the  patient,  in  accordance  with  promise, 
returned.  The  pupillary  area  having  been  lost  from  the 
low-grade  irido-capsulitis,  induced  me  first  to  endeavor 
to  make  a  new  one  by  the  performance  of  Knapp's  oper- 
ation for  irido-cystectomy. 

This  I  did  most  successfully,  obtaining  a  new  pupil 
through  both  the  iris  and  the  underlying  false  mem- 
branes and  thickened  capsule.  The  opening,  although 
irregularly  shaped,  was  3  by  4  mm,  in  size  and  was 
centrally  placed. 

The  case  was  dressed  and  cared  for  in  the  same 
manner  as  before. 

As  a  result,  vision  in  a  larger  clear  field  again  arose 
to  what  it  had  after  the  first  iridectomy  (^'-  of  normal). 

Again  the  patient  was  ordered  atropin  and  permitted 
to  return  home. 

On  March  21,  1900,  he  reported  once  more.  At  this 
visit  it  was  noticed  that  although  the  effects  of  the 
iridocystectomy  had  remained  intact,  yet  a  bulging 
capsular  mass,  apparently  containing  some  dense  ma- 
terial,  was   situated  immediately   behind    the   entire 


February  9,  1901] 


UNILATERAL,  PROGRESSIVE,  ASCENDING  PARALYSIS 


[The  Philadelphia 
Medical  Jouknal 


299 


pupillary  area ; — thus  practically  again  reducing  vision 
to  light-perception. 

The  eye  being  unirritated  and  visual  projection  good, 
and  not  wishing  to  disturb  the  good  results  of  the 
iridocystectomy,  I  had  recourse  to  Tyrrell's  method  of 
drilling.  Furnished  with  a  good  needle  similar  to  that 
of  Saunders,  I  followed  the  plan  practised  by  Tyrrell 
with  identical  results  ;  a  few  drops  of  translucent  lens 
matter  escaping  into  the  anterior  chamber  through  the 
broad  opening  made  into  the  anterior  capsule. 

As  an  immediate  result  at  the  time  of  the  operation, 
the  patient  was  able  with  the  aid  of  a  convex  spherical 
lens  of  ten  diopters'  power  to  see  every  motion  given  to 
a  small  lighted  taper  held  some  10  meters'  distance 
away.     This  rough  test  was  most  promising. 

No  reaction  ensuing  in  one  month's  time  and  the 
patient  having  a  corrected  vision  of  one-third  of  normal 
{■j%),  he  was  told  to  continue  the  use  of  the  atropin 
and  was  allowed  to  wear  a  properly-chosen  cataract 
lens. 

At  present  writing,  nearly  one  year  since  the  com- 
pletion of  the  series  of  radical  procedures  instituted 
for  the  restoration  of  the  patient's  vision,  the  condi- 
tions remain  unchanged,  the  eye  is  quiet,  the  sight  is 
still  one  third  of  normal,  and  the  patient  is  daily  em- 
ployed in  making  his  living  as  a  laborer  in  the  coal 
mines. 

Remarks. — For  a  number  of  reasons  the  clinical  his- 
tory of  the  case  is  both  interesting  and  important :  The 
retention  of  the  foreign  body  in  the  injured  eye  for  15 
weeks'  time — with  the  production  of  sympathetic  dis- 
ease before  the  enucleation  of  the  offending  organ;  the 
marked  increase  of  the  gross  symptoms  of  sympathetic 
iridocyclitis  and  iridocapsulitis  one  week  after  the 
removal  of  the  primarily  inflamed  eye  ;  the  abeyance 
of  the  coarse  signs  of  the  inflammation  by  the  em- 
ployment of  appropriate  treatment ;  the  continuance  of 
the  low  grade  inflammatory  changes  in  the  anterior  seg- 
ment of  the  organ ;  the  occurrence  of  the  attack  of 
acute  glaucoma,  with  its  relief  by  a  promptly  per- 
formed uncomplicated  iridectomy ;  the  making  of  the 
second  iridectomy  and  the  successful  removal  of  the 
bulk  of  the  crystalline  lens  by  means  of  a  wire  loop 
without  the  loss  of  any  vitreous  humor  in  order  to  pre- 
vent the  recurrence  of  the  glaucomatic  condition  ;  the 
persistence  of  the  painless  iridocyclitic  and  iridocap.su- 
litic  processes  until,  when  seen  for  the  second  time,  6 
months  later,  the  pupillary  area  was  lost ;  the  restitu- 
tion of  the  pupil  by  the  performance  of  a  Knapp's 
iridocystectomy  ;  the  preservation  of  the  new  pupillary 
area  with  the  appearance  of  the  underlying  capsular 
and  lenticular  mass  extending  over  the  entire  pupil 
space  again  reducing  vision  to  the  perception  of  light ; 
and  at  last,  the  obtainance  of  a  large  permanent  open- 
ing through  the  capsulolenticular  mass  by  the  drilling 
operation  of  Tyrrell  giving  the  patient  an  acuity  of 
vision  of  one  third  of  normal : — all  may  be  mentioned 
as  worthy  of  citation. 


The  use  of  diphtheria  serum  in  Italy,  and  other  coun- 
tries as  well,  is  likely  to  receive  a  severe  check,  says  the 
(London)  Chemist  and  Druggist.  The  Serotherapic  Institute 
of  Milan  made  a  batch  of  serum  on  November  24,  into 
which  the  tetanus  bacillus  was  accidentally  introduced.  The 
result  has  been  that  eight  persons  on  whom  the  serum  was 
used  have  met  with  horrible  deaths  from  tetanus.  The  in- 
stitute was  instantly  closed,  the  serum  was  destroyed,  and  an 
effort  made  to  recall  all  supplies  in  the  hands  of  dealers.  The 
accident  naturally  caused  a  great  scare  in  Italy. 


A  CASE  OF  UNILATERAL,  PROGRESSIVE,  ASCEND- 
ING PARALYSIS.' 

By  WILLIAM  G.  SPILLER,  M.D., 
of  Philadelphia. 

Professor  of  Diseases  of  the  Nervous  System  in  the  Philadelphia  Polyclinic; 

Associate  in  the  Wm.  Pepper  Clinical  Laboratory, 

University  of  Pennsylvania. 

In  the  April  (1900)  number  of  the  Journal  of  Nervous 
and  Mental  Disease,  Dr.  C.  K.  Mills  reported  a  case  of  uni- 
lateral, progressive,  ascending  paralysis,  probably  repre- 
senting a  new  form  of  degenerative  disease.  His  patient 
was  a  man,  52  years  old,  who,  about  2  years  before  com- 
ing under  observation,  had  been  noticed  to  occasionally 
stub  his  right  toes  and  scrape  his  right  heel,  and  to  give 
other  evidences  of  slight  weakness  or  awkwardness  of 
the  right  lower  extremity.  The  man  was  sure  that  the 
weakness  in  the  right  lower  limb  came  on  slowly.  It 
was  not  until  the  implication  of  the  right  lower  limb 
had  been  apparent  18  months  that  he  noticed  any  weak- 
ness of  the  right  upper  limb.  This  weakness  gradually 
became  more  perceptible,  and  a  tendency  to  carry  the 
limb  against  the  body  and  flexed  at  the  elbow  was  pres- 
ent. The  weakness  in  the  upper  limb  was  much  less 
than  that  in  the  lower,  and  some  paresis  of  the  face  was 
detected.  The  right  lower  limb  became  wasted.  A  dis- 
tinct Babinski  reflex  was  not  obtained,  and  no  changes 
in  the  fundus  were  observed.  I  had  an  opportunity  to 
examine  this  very  interesting  case.  As  the  man  was  an 
intelligent  physician  his  statements  were  reliable. 

Unilateral,  progressive,  ascending  paralysis  is  not  a 
common  symptom-complex,  and  yet  a  case  very  similar 
to  the  one  reported  by  Dr.  Mills  has  come  under  my 
care  at  the  Polyclinic  Hospital  during  the  past  year  : 

A  peddler  of  Jewish  parentage,  from  Austria,  41  years  of 
age,  who  denies  all  venereal  disease,  began  4  years  ago  to 
feel  weak  in  the  left  lower  limb  while  walking.  This  weak- 
ness gradually  became  more  intense,  and  in  about  a  year  his 
left  upper  limb  began  to  get  gradually  weak.  He  is  positive 
that  about  a  year  elapsed  after  the  implication  of  the  lower 
limb  before  he  felt  any  weakness  in  the  left  upper  limb.  He 
was  not  unconscious  at  any  time,  and  has  never  had  vertigo, 
headache,  vomiting,  nausea,  or  convulsions.  Diplopia  has 
never  been  observed.  At  the  present  time  the  movements 
of  the  left  lower  limb  are  very  spastic  but  not  in  the  le.ast 
ataxic,  the  toes  of  the  left  foot  are  scraped  along  the  ground 
in  walking  and  the  left  foot  is  turned  inward.  The  move- 
ments of  the  right  lower  limb  are  not  spastic.  The  patient 
states  that  he  is  obliged  to  have  a  new  sole  put  on  the  inner 
side  of  the'  left  shoe  every  4  weeks,  as  he  wears  away  the 
shoe  by  constantly  scraping  it  along  the  ground.  The  right 
kneejerk  is  prompt,  but  the  left  kneejerk  is  much  more 
so.  Ankle-clonus  has  been  obtained  on  the  left  side,  but  not 
on  the  riglit.  Babinski's  reflex  is  very  distinct  on  the  left 
side,  but  is  uncertain  on  the  right  side.  The  resistance  to 
passive  movement  in  the  left  lower  limb  is  below  normal, 
but  the  spasticity  seems  to  be  even  greater  than  the  weak- 
ness. Sensationfor  pain,  touch  and  temperature  is  normal 
everywhere  over  the  body.  The  lower  limbs  are  fairly  w-ell 
developed,  the  left  thigh  in  about  its  central  portion  measures 
in  circumference  39.5  cm.,  the  right  40  cm.  The  reactions  to 
the  galvanic  current  are  normal  when  the  electrode  is 
applied  over  the  left  external  popliteal  nerve  or  the  muscles 
on  the  outer  side  of  the  left  leg  below  the  knee.  Some 
rigidity  on  passive  movement  is  felt  in  the  left  lower  limb. 
Tlie  man  stands  well  alone  on  either  limb. 

The  resistance  to  passive  movement  and  the  grasp  of  the 
hand  are  distinctly  less  in  the  left  upper  limb  ttian  in  the 
right.  The  tendon  reflexes  in  the  left  upper  limb  are  exag- 
gerated. Von  Bechterew's  scapulohumeral  reflex  on  the 
left  side  is  also  exaggerated,  and  at  one  time  a  clonus  of  the 
upper  arm  was  obtained.  The  left  upper  limb  is  held 
slightly  flexed  at  the  elbow  and  against  the  body,  but  no 

1  Read  before  the  Philadelphia  Neurological  Society,  October  22, 1900. 


300 


Medical  JonENAL  J 


UNILATERAL,  PROGRESSIVE,  ASCENDING  PARALYSIS 


[Feeecaey  9,  1901 


contractures  exist  in  any  of  the  muscles  of  the  body.  The 
weakness  of  the  left  upper  limb  is  much  less  than  that  of  the 
left  lower  limb.  No  atrophy  is  found  in  any  of  the  muscles. 
The  man  uses  the  right  hand  almost  alone  in  undressing 
himself 

Speech  is  normal.  The  mouth  cannot  be  drawn  up  as  well 
on  the  left  side  as  on  the  right,  and  slight  flattening  of  the 
left  side  of  the  face  is  noticed.  The  tongue  goes  slightly  to 
the  left  when  protruded. 

The  man  has  never  had  any  rectal  or  vesical  disturbance 
except  that  he  occasionally  finds  some  difiBculty  in  retaining 
the  feces. 

An  examination  of  the  patient's  eyes  was  made  by  Dr.  H. 
F.  Hansen,  May  19,  1900.     His  report  is : 

"  We  find  in  the  right  eye  the  media  clear,  fundus  normal, 
myopia  3  D.  In  the  left  eye  the  media  are  clear,  arteries 
small,  veins  normal,  edges  of  disc  distinct  The  nerve  head 
is  white,  the  atrophy  probably  being  spinal  in  origin,  as  there 
is  no  indication  of  a  previous  neuritis.  Myopia  6  D.  Reac- 
tion of  pupil  is  normal." 

This  case,  therefore,  is  very  similar  to  the  one  re- 
ported by  Dr.  Mills,  but  the  duration  of  the  symptom- 
complex  has  been  longer.  The  optic  atrophy  in  the 
left  eye,  in  association  with  the  left-sided  weakness  and 
spasticity  of  the  limbs,  is  a  singular  observation,  the 
significance  of  which  cannot  be  determined.  A  slowly 
developing  paresis  with  marked  spasticity  of  one  lower 
limb,  extending  after  a  year  to  the  upper  limb  of  the 
same  side,  though  in  less  intensity,  and  implicating 
very  slightly  the  left  side  of  the  face;  associated  with 
exaggeration  of  all  the  tendon  reflexes  on  the  left  side 
of  the  body  and  with  a  very  distinct  Babinski  reflex, 
is  a  most  striking  symptom-complex.  While  the  patient 
at  present  presents  much  the  condition  of  one  with 
ordinary  hemiplegia,  the  history  of  the  affection  dis- 
tinguishes it  fully.  He  has  never  had  anything  resem- 
bling an  apoplectic  stroke.  The  heart  is  normal.  The 
right  side  of  the  body  is  not  implicated,  except  that 
the  kneejerk  on  this  side  is  very  prompt.  The  greater 
implication  of  the  lower  limb  is  not  common  in  hemi- 
plegia resulting  from  a  focal  cerebral  lesion. 

The  case  can  hardly  be  considered  one  of  neuritis. 
The  exaggeration  of  the  reflexes,  the  unilaterality  of 
the  symptoms,  the  absence  of  sensory  disturbances,  etc., 
exclude  neuritis. 

An  atypical  form  of  disseminated  sclerosis  might  be 
thought  of,  but  this  disease  seems  hardly  probable.  The 
usual  symptoms  of  disseminated  sclerosis  are  absent, 
and  it  would  be  an  extraordinary  grouping  of  the 
sclerotic  foci  which  would  leave  the  right  side  of  the 
body  intact  and  cause  a  gradually  ascending  and  spastic 
paresis  of  the  left  side,  very  jjronounced  in  the  lower 
limb,  less  so  in  the  upper,  and  still  less  so  in  the  face. 

Within  a  period  of  4  years  some  more  distinct  symp- 
toms of  disseminating  sclerosis  would  be  expected. 

Hysteria  hardly  seems  probable  on  account  of  the 
absence  of  hysterical  stigmata,  the  presence  of  the 
Babinski  reflex,  the  left  optic  atrophy,  etc. 

The  case  might  be  thought  to  be  one  of  unilateral 
amyotrophic  lateral  sclerosis.  Probst,  in  his  pajier  in 
which  he  has  collected  a  large  number  of  cases  of  this 
disease,  st;ites  that  in  9  amyotrophic  lateral  sclerosis 
began  in  a  hemiplegic  form.  I  have  examined  these 
abstracts  as  given  by  Probst,  and  when  the  cases  seemed 
to  have  any  relation  to  mine  I  have  studied  the  original 
papers.  None  of  these  cases  correspond  with  those  of 
gradually  ascending  unilateral  paralysis  reported  by  Dr. 
Mills  and  myself.  The  one  that  has  the  greatest  re- 
semblance is  reported  by  Vierordt.  A  man,  4S  years 
old,  began  in  August,  1878,  to  have  weakness  of  the 
right  lower  limb,  and  in  the  early  part  of  1879  weakness 


of  the  right  upper  limb ;  then  atrophy  of  the  thenar 
and  interosseous  muscles  of  the  right  hand  developed. 
In  1880  weakness  and  atrophy  were  observed  in  the  left 
upper  and  lower  limbs.  The  disease  therefore  extended 
within  a  few  months  from  the  lower  limb  to  the  upper 
on  the  right  side,  and  within  two  years  the  left  extremi- 
ties were  implicated.  Amyotrophic  lateral  sclerosis, 
even  when  in  rare  cases  it  begins  in  a  hemiplegic  form, 
has  a  much  more  rapid  course  than  the  progressive 
ascending  unilateral  paralysis  as  seen  in  Dr.  Mills'  case 
and  mine,  and  atrophy,  which  was  absent  in  my  case 
after  four  years'  duration  of  the  disease,  begins  early. 
Optic  atroph}',  however,  has  been  observed  in  amyotro- 
phic lateral  sclerosis  (Lannois  and  Lt-pine). 

The  possibility  of  a  cerebral  lesion  implicating  first 
the  center  or  the  nerve  fibers  for  the  lower  limb,  and  later 
those  for  the  upper  limb  and  face  must  be  considered. 
A  hemorrhage  could  hardly  produce  the  symptom-com- 
plex, although  thrombosis  might  We  should  expect 
more  symptoms  after  a  period  of  four  years  if  the  cause 
were  tumor  or  abscess,  and  in  my  case  all  distinct  symp- 
toms of  intracranial  disease  were  absent.  The  man  never 
had  nausea,  vomiting,  headache,  vertigo,  convulsions, 
optic  neuritis,  or  mental  disturbance,  and  optic  atrophy 
which  he  did  have  on  one  side  is  not  necessarily  a  sign 
of  cerebral  disease.  We  cannot,  however,  exclude  the 
possibility  of  some  intracranial  lesion  as  the  cause  of 
the  symptoms. 

Dr.  Mills  believed  that  a  gradual  degeneration  of  one 
pyramidal  tract  would  best  explain  the  symptoms  in 
his  case.  The  sj-mptomcomplex  caused  by  primary 
degeneration  of  the  central  motor  tracts  consists  of 
gradually  developing  paresis  and  rigidity,  especially  in 
the  muscles  of  the  lower  limbs,  spastic  paretic  gait,  ex- 
aggeration of  the  tendon  reflexes,  integrity  of  sensa- 
tion, absence  of  marked  muscular  atrophy,  absence  of 
disturbance  of  rectum  or  bladder,  absence  of  vasomotor 
or  trophic  signs  and  of  mental  symptoms.  The  course 
of  the  disease  is  chronic  and  the  affection  is  often  sta- 
tionary for  years.  Death  is  usually  from  an  intercur- 
rent disease. 

The  cases  of  lateral  sclerosis  with  necropsy  are  ex- 
ceedingly rare.  I  can  refer  to  those  of  Dre.-chfeld. 
Dejerine  and  Sottas.  Friedmann,  Ida  Democh,  and 
Meyer,  and  yet  not  one  of  these  five  cases  was  entirely 
uncomplicated.  In  DreschfeldV  case  some  of  the  cells 
of  the  anterior  horns  were  diseased ;  in  Dejerine  and 
Sottas'  case  the  columns  of  Goll  were  not  perfectly 
intact  in  the  cervical  region :  in  Democh 's  case  symp- 
toms of  neuritis  were  present,  and  in  Friedmann's  case 
and  Meyer's  the  direct  cerebellar  tract  was  not  normal. 
These  cases  seem  to  show,  however,  that  isolated  pri- 
mary degeneration  of  the  pyramidal  tracts  is  possible, 
but  that  a  sharp  distinction  between  such  a  form  of 
degeneration  and  combined  systemic  disease  is  difficult 
or  impossible. 

The  case  reported  by  Dr.  Mills  and  the  one  by  me 
have  the  symptoms  one  should  expect  from  unilateral 
lateral  sclerosis,  but  we  can  hardly  dare  to  hope 
that  the  pathology  of  the  afi"ection  will  speedily  be  de- 
termined, inasmuch  as  it  has  taken  about  '2o  years  to 
establish  the  j^ossibility  of  primary  bilateral  degenera- 
tion of  the  pyramidal  tract  The  symptoms  in  our  case* 
could  best  be  explained  as  the  result  of  unilateral  de- 
generation of  the  pyramidal  tract,  but  we  are  cautious 
in  saying  that  this  is  the  condition  present 


■  Hreschfeld  >t  first  reported  that  the  nerve  «Jl-bodies  of  the  anterior  horns 
w  re  normal,  but  be  is  said  to  hare  modified  this  staieniest  later. 


FUBRUARY  9,    1901] 


CAVITE  FEVER 


[Thb  Pbil^drlphla. 
msdical  jocrsal 


301 


The  recognition  of  a  disease  or  a  symptom-complex  is 
usually  first  made  from  its  clinical  features,  and  the  path- 
ology "of  the  affection  is  determined  later.  The  reports 
of  clinical  cases  of  ascending  progressive  unilateral 
paralysis  are,  therefore,  desirable.  We  have  yet  to  learn 
the  pathology  of  many  well-recognized  diseases.  Ober- 
steiner  said  at  the  recent  Congress  in  Paris  that  when 
he  began  his  medical  studies  few  organic  nervous  dis- 
«ases  were  known.  Little  was  known  of  the  pathology 
of  tabes  or  disseminated  sclerosis,  and  still  less  of 
syringomyelia. 

REFERENCES. 

Probst:  Archivfur Psychiatrie,  vol.  30. 

Vierordt  :  Archiv  fur  Psychiatric,  vol.  14. 

Drt«chfeld  ;  BtUiih  Medical  Journal,  1881,  vol.  1,  p.  154. 

Dej--rine  and  Sottas  :  Arch,  de  Phi/sio  ogie,  1896. 

Frledmann  :  Deutsche  Zeitsch.  JUr  Kei-venhHIkunde,  vol.  16,  Nos.  1  and  2. 

Democh  :  Archiv  /Ur  Psychiatrie,  vol.  33,  No.  1. 

Mever :  Deutsche  Zeitschrijt  fur  Nervenheilkunde,  vol  16,  Nos.  5  and  6. 

Obersteiner  :  Bevue  Neurologitpu ,  No.  18,  Sept.  30,  1900. 


CAVITE  FEVER. 

By  B.  L.  WRIGHT,  M.D., 
Assistant  Surgeon,  U.  S.  Navy. 


Among  the  unclassified  and  unnamed  fevers  which 
were  found  to  exist  in  the  Philippines,  upon  the  Ameri- 
can occupation  of  these  islands,  was  one  with  which 
the  medical  officers  of  the  navy,  attached  to  the  Cavite 
Naval  Station,  came  in  immediate,  constant,  and  close 
relationship. 

The  disease  is  constantly  in  evidence,  usually  in  epi- 
demic form. 

Almost  invariably  every  fresh  arrival  at  the  station 
•contracts  the  disease  within  the  first  2  or  3  weeks  after 
taking  up  quarters  on  the  peninsula. 

At  difi'erent  times  during  the  last  year  and  a  half  4 
battalions  of  marines,  consisting  of  from  300  to  400 
men  and  officers  each,  in  addition  to  numerous  naval 
officers  and  bluejackets,  have  been  quartered  at  the 
naval  station,  or  within  the  limits  of  the  Cavite  peninsula. 

Fully  70%  of  them  have  had  the  disease  one  or 
more  times. 

Those  who  leave  the  station,  and,  after  a  short 
absence  return,  are  just  as  prone  to  become  victims  of 
the  disease  as  are  fresh  arrivals  from  the  United  States 
or  other  parts  of  the  Philippine  group. 

As  far  as  I  have  been  able  to  ascertain  this  fever  is 
endemic,  and  principally  confined  to  the  immediate 
vicinity  of  the  peninsula  of  Cavite ;  a  strip  of  land  not 
more  than  Ah  miles  long  by  li  miles  wide. 

Sporadic  cases  of  the  disease  are  seen  in  other  parts 
of  the  islands,  but  not  often.  Early  in  July,  1900,  the 
U.  S.  S.  Manila,  then  on  her  way  to  Sandakan,  British 
North  Borneo,  had  an  epidemic  of  what  I  believe  to 
have  been  this  disease,  break  out,  which  temporarily 
incapacitated  fully  three-quarters  of  her  crew,  and  all 
but  one  or  two  of  her  officers. 

The  disease  is  unknown  in  Borneo,  and  it  was  evi- 
dently contracted  in  Cavite,  the  Manila  having  left 
the  navy  yard  at  that  place  some  7  or  S  days  prior  to 
the  outbreak. 

Naturally  the  disease  has  been  carefully  studied  by 
those  officers  of  the  medical  corps  of  the  navy  who 
have  been  on  duty  at  the  station,  and  they  have  gradually 
separated  it  from  other  existing  fevers,  and  by  common 
usage  it  has  become  known  as  "  Cavite  fever,"*  under 

*.So  named  by  .Surgeon  George  Pickerell,  U.  S.  Navy,  Surgeon  of  the  Yard  and 
Station.  He  was  oue  of  the  first  to  study  the  disease  and  to  classify  its  sytup- 
toma. 


which  title  I  have  the  honor  of  presenting  it  in  this 
paper. 

Cavite  fever  is  an  acute  infectioua  disease,  character- 
ized by  an  abrupt  onset,  high  temperature,  severe 
muscular  pain,  and  extremely  tender  and  painful  eye- 
balls. The  predisposing  causes  are  high  temperatures, 
low,  damp  localities,  overcrowding,  and  possibly  the 
close  proximity  of  salt  water.  The  exciting  cause  is 
supposed  to  be,  and  undoubtedly  is,  microorganismal, 
although  as  yet  nothing  is  known  of  its  nature.  Of  the 
pathology  we  know  nothing,  as  deaths  from  this  disease 
have  not  been  observed.  The  period  of  incubation  is 
from  2  davs  to  2  weeks.  The  disease  is  of  sudden 
onset,  usually  commencing  with  a  slight  chill ;  in  a 
few  hours  the  temperature  rises  to  a  104°  or  105,°  and 
may  even  reach  107.° 

the  face  is  flushed,  the  eyes  injected,  extremely  pain- 
ful and  tender ;  the  skin  burning  hot ;  the  pulse  full, 
strong  and  rapid ;  the  respiration  accelerated,  and  the 
mind  frequently  delirious ;  the  patient  extremely  pros- 
trated. 

Nausea  and  vomiting  are  usually  present,  the  bowels 
constipated,  and  the  urine  scanty  and  high  colored. 
Headache  and  muscular  pain  are  severe;  the  latter 
usually  located  in  the  muscles  of  the  back  and  legs, 
but  occasionally  in  those  of  the  arms  and  shoulders. 
The  temperature  usually  continues  high,  for  from  3  to 
5  days,  when  it  falls  by 'crisis  ;  the  muscular  pain  may 
or  may  not  cease  with  "the  fall  of  temperature. 

Relapses  are  not  common,  but  second,  third,  and 
even  more  attacks  are  not  unusual. 

This  disease  is  most  apt  to  be  confounded  with 
dengue,  but  the  absence  of  an  afebrile  period,  and  the 
rash,  followed  by  a  second  febrile  attack  of  definite 
duration,  enables  one  to  distinguish  it  from  that  dis- 
ease. The  absence  of  catarrhal  symptoms  separates  it 
from  catarrhus  epidemicus. 

The  treatment  should  be  as  follows  :  Rest  in  bed, 
with  a  liquid  diet.  The  bowels  should  be  freely  opened 
bv  a  brisk  saline  purge,  and  kept  regular  by  small  and 
frequently  repeated  doses  of  calomel.  Such  drugs  as 
antipyrin,  phenacetin,  or  acetanilid,  and  small  doses  of 
quinin  should  be  administered. 

A  good  combination,  which  also  includes  the  proper 
amount  of  calomel,  is  as  follows  : 

E.— Antipvrin 3.8  grams. 

Quinini   sulph 1.2  grams. 

Hvdrarg.   chlor.  mit 0.1  grams. 

M.  ft.  Cap.  Xo  XII.   Sig.— Oue  capsule  every  2  or  3  hours. 

The  high  temperature  should  be  controlled  by  sponge 
baths,  or  bv  "  tubbing,"  and  an  ice-cap  should  be  ap- 
plied to  the  head.  For  a  week  or  10  days  after  recov- 
ery, tonics,  such  as  iron,  quinin  and  strychnia,  should 
be  given. 

I  am  strongly  of  the  belief  that  the  muscular  pain 
is  due  to  a  toxic  peripheral  neuritis. 

Several  cases  of  this  condition,  with  foot-drop  and 
muscular  atrophy,  occurred  on  the  station,  which  at  the 
time  were  ascribed  to  other  causes,  but  which  I  am 
now  inclined  to  believe  were  the  toxic  efiects  of  a 
former  attack  of  Cavite  fever. 

A  case  of  complete  atrophy  of  the  right  supra- 
spinatus,  infraspinatus,  teres  major  and  minor,  and  the 
trapezius,  associated  with  dislocation  of  the  right  scap- 
ula, and  drooping  of  the  shoulder,  occurred  in  the 
case  of  one  of  the  officers  of  the  U.  S.  S.  Manila,  and 
when  seen  last,  just  before  he  left  for  the  United  btates, 
the  left  shoulder  and  arm  were  becoming  afifected. 


302 


Thk  Philadelphia* 

Medical  Journal 


]        EXOPHTHALMIC  GOITER  OF  SYPHILITIC  ORIGIN 


[Febbuasy  9,  1901 


EXOPHTHALMIC  GOITER  OF  SYPHILITIC  ORIGIN. ' 

By  R.  ABRAHAMS,  M.D., 

of  New  York. 

District  Physician  to  the  Mt.  Sinai  Hospital ;  Physician  to  the  Siireical,  Sltin 
and  Venereal  Departments,  Ea=t  Side  Dispensary,  New  York. 

In  presenting  this  communication,  I  am  not  unaware 
of  its  inadequacy.  The  clinical  data  therein  contained 
are  not  sufficient  to  engage  the  attention  of  my  fellow 
practitioners.  But  the  truth  reinains,  now  as  ever,  that 
the  bedside  is  mightier  than  the  laboratory ;  and  that 
one  carefully  observed  dinicnl  fact  is  more  useful  to  the 
patient  and  hia  medical  attendant  than  a  thousand 
slides  and  sections. 

The  three  cases,  to  be  presently  described,  carry  with 
them  a  strong  hint  at  the  etiology  and  treatment  of  a 
very  obscure  and  obstinate  disease.  And  as  he  who 
runs  may  read,  so  he  who  doubts  may  try. 

Case!.— Mrs.  C.  H.,.3.5  years  old,  mother  of  three  children 
Her  family  history  is  gcxnl.  Her  personal  history  was  good 
until  the  .spring  of  1894.  At  that  time  she  contracted  syph- 
ilis from  her  husband.  The  initial  lesion  was  a  large  ulcer 
situated  on  the  right  labium  maju.s.  In  due  time  the  sec- 
ondary symptoms  appeared  in  the  form  of  .small  and  large 
papules.  The  eruption  was  severe  and  universal.  At  this 
stage  she  came  under  treatment.  I  may  add  that  the  mouth, 
tonsils  and  pharynx  contained  many  mucous  patches. 

This  woman  was  put  on  daily  mercurial  inunction.^,  .5 
grams  per  dose.  A  Iter  receiving  ")0  rubbings  of  the  ointment 
all  the  luetic  manifestations  tlisappeared,  and  the  patient, 
though  not  the  doctor,  believed  herself  cured,  perfectly  and 
forever. 

Five  months  later,  the  same  victim  visited  the  office  with 
new  patches  in  her  mouth.  On  this  (occasion  she  also  pre- 
sented an  enlarged  thyroid  gland  and  protruding  eyes.  Her 
story  was  that  '  the  swelling  of  the  neck  and  the  bulging  of 
the  eyes  came  on  simultaneously  two  months  ago."  Coinci- 
deutly  with  this  she  grew  short  of  breath  and  experienced  a 
distressing  palpitation  of  the  heart,  which,  according  to  her 
statement  and  language,  "  made  her  very  n(!rvous." 

Mere  inspection  of  the  patient  was  enough  to  establisli 
the  diagnosis  of  exophthalmic  goiter.  The  three  cardinal 
symptoms  of  the  disease!  were  i)resent  to  an  extent  to  enable 
a  tyro  to  interpret  their  meaning.  The  staring,  bulging 
eyes;  the  enlarged,  soft  atid  pulsating  thyroid,  and  the 
rapid  heart  action  (from  110  to  120  per  niinute)  were  in 
evidence  to  a  convincing  degree.  Anentia  and  tremor  of 
the  hands  were  quite  marked  ;  Grafe'sand  other  minor  signs 
were  absent. 

While  the  mucous  patches  were  treated  locally  with 
silver,  her  other  trouble  was  combated  with  the  regulation 
medicines,  namely:  strophiinthus,  digitalis,  ergotin,  arsenic, 
and  iron,  producing  absolutely  no  ellcct  on  the  morbid  con- 
dition of  Basedow's.  At  the  lapse  of  8  weeks  of  trial  and 
trouble,  the  woman  began  to  complain  of  excruciating  head- 
aches, occurring  especially  in  the  inght.  This  additiotial 
misery  necessitated  the  adnunistration  of  an  iodid.  The 
saturated  solution  of  iodid  of  sodium  was  chosen,  to  be 
taken  in  grailually  increasing  doses.  Beginning  with  15 
drops  the  patient  reached  the  (lose  of  '2  drams'  withiti  12 
days.  Tiie  relief  from  her  headaches  was  established  in 
a  few  days.  Hand  in  hutid  with  this,  signs  of  improvemetit 
in  her  other  morbid  phenomena,  wer(-appreciablv  noticeable. 
The  pulse  flowed  ;  the  goiter  diminished  and  tbij  eves  vi.^iblv 
receded.  The  drug  was  continued,  after  the  henilaches  had 
gone,  with  short  ititermissions.  for  a  period  of  2  months 
when  the  exophthaltnio  goiter  with  its  retinue  of  symptoms 
vanished.  The  womati  had  no  return  of  the  ailnient  ever 
since. 

This  case  made  a  deep  impression  on  me  and  natu- 
rally set  speculation  agog.  Here  is  a  woman  in  whom 
the  syphilitic  process  is  still  smouldering,  as  evidenced 
by  the  appearance  of  patches  in  the  mouth  and  head- 

1  Read  helcire  the  New  York  State  Medical  Association  (New  York  Ck>unt;), 
January  21, 1901.  '" 


aches  in  the  night.  Now  this  woman  develops  a 
typical  form  of  Grave's  disease.  Then,  upon  the  ener- 
getic exhibition  of  one  of  the  old  therapeutic  stand-bys 
of  lues,  the  disease  melts  away  as  if  it  were  a  gumma 
or  a  specific  })eriostitis.  The  conviction  forced  itself 
on  me,  as  it  would,  I  have  no  doubt  on  many  another, 
that  the  exophthalmic  goiter  in  this  patient  was  caused 
by  syphilis  and  cured  by  remedies  antagonistic  to 
syphilis. 

Still,  as  one  swallow  makes  no  summer,  so  one  case 
makes  no  conclusive  evidence.  And  so  the  written 
notes  and  the  mental  comments  lay  smouldering  until 
the  generous  "  law  of  multiplicity  "  threw  another  case 
into  the  crucible  of  experience,  namely  : 

Case  2.— Mrs.  Y.  K.,  36  years  old,  married,  mother  of  5 
healthy  children.  Family  history  good.  Personal  history: 
In  l»-94,  shortly  after  the  birth  of  her  last  child,  she  had  a 
sore  on  her  vulva,  followed  by  enlarged  inguinal  i  lands.  A 
few  weeks  later,  she  says,  "  blotches"  appeared  on  her  body 
and  forehead.  Her  throat  troubled  her  and  the  hair  of  the 
head  was  rapid  y  falling  out.  These  symptoms  and  condi- 
tions shf!  distinct  y  remi^mhered  Instead  of  consulting  a 
physician  she  chose  to  be  treated  by  a  friend,  a  man  who 
served  as  orderly  in  a  '■  European  Hospital."  The  treatment 
apparently  satisfied  the  patient  as  fhe  made  no  effort  to  see 
or  be  treated  by  a  medical  man.  In  189fi,  two  years  after 
her  initial  trouble,  her  historj-  and  status  were  briefly  as  fol- 
lows: Three  unprovoked  abortions,  a  flattened  nose  due  to 
destruction  of  the  septum  and  a  large  perforation  of  the 
hard  palate.  There  was  a  goiter  of  considerable  size ; 
mildly  protruding  eyes,  and  a  heart  action  of  90  to  100  to 
the  minute.  These  latter  slowly  came  on  during  1895.  In 
every  other  respect  the  patient  was  well.  The  woman's 
main  desire  was  to  get  rid  of  the  "swelling  of  the  neck 
which  disfigured  her." 

Treatm'nt.—  T>A\\y  inunctions  for  6  weeks;  result:  com- 
plete disappearance  of  the  exophthalmic  goiter  and  no  re- 
currence of  it  since  then. 

Now,  in  analyzing  this  case,  the  following  facts  and 
conclusions  are  jireeminent :  The  patient's  own  story, 
though  not  couched  in  learned  words,  is  strongly  sugges- 
tive of  an  attack  of  syphilis  of  no  remote  period.  The 
sore  on  the  genitalia ;  the  enlarged  inguinal  glands ;  the 
"  blotches "  which  might  correspond  to  a  roseola  or 
jiajiular  syphilide;  a  sore  throat  which  might  have 
been  mucous  patches ;  and,  lastly,  a  falling  of  the  hair, 
which  needs  no  comment  or  explanation.  This  strong 
suspicion  of  syphilis  becomes  incontrovertible  evidence 
of  it,  when  the  jiatient  appears  for  treatment  2  years 
later — the  three  spontaneous  abortions,  the  deformity 
of  the  nose  and  the  destruction  of  the  hard  palate,  all 
of  which  develojied  since  the  occurrence  of  the  genital 
sore  and  the  cutaneous  "blotches.''  With  this  history 
and  this  anatomical  evidence  before  nie.  there  was  no 
escape  from  the  lurking  suspicion  that  the  patient's 
svphilis  might  be  the  parent  of  her  exophthalmic  goiter. 
The  proof  atlorded  by  the  result  of  the  treatment  sup- 
jilies  overwhelming  evidence  in  favor  of  the  belief  that 
this  case  of  Basedow's  disease  was  unquestionably  of 
syjihilitic  origin. 

In  anticipation  of  a  natural  question  which  may  be 
asked  regarding  the  different  specific  remedies  which 
were  employed  in  the  two  cases,  to  wit.,  iodid  of  sodium 
in  the  first  and  mercury  in  the  second.  The  answer  is 
this  :  The  first  woman  having  been  under  my  care  al- 
most from  the  very  inception  of  her  atliiction  has 
received  a  proper  and  methodical  mercurial  treatment. 
And  when  she  returned  a  few  months  later  complain- 
ing of  syi)hilitic  headaches  the  iodid  was  given,  and  with 
marked  benefit  all  around,  including  the  exophthamic 
goiter.     In  the  second  woman,  however,  the  assumption 


Fbbi  uaby  9,  3901] 


CARBUNCLES  AND  FURUNCLES  OF  THE  UPPER  LIP 


LThk  Philadelphia 
MsDiCAL  Journal 


303 


was  that  her  medical  attendant,  the  orderly,  did  not 
and  could  not  jiut  her  on  mercury,  enough,  at  least,  to 
do  her  good,  and  so  she  was  given  the  benefit  of  inunc- 
tions with  the  stated  satisfactory  result. 

Case  3  —Sadie  K.,  a  woman  27  years  old,  single.  She  does 
not  know  much  about  her  family.  Father  and  mother  died 
from  causes  unknown  to  her.  Her  history  is  as  follows  : 
At  the  age  of  20  slie  adopted  an  immoral  life.  In  a  sliort 
time  gonorrhea  knocked  at  her  door,  and  she  liad  scarcely 
finished  entertaining  this  visitor  when  a  hard  chancre  availed 
itself  of  her  hospitality.  In  1897,  when  slie  considered  her- 
self cured  and  in  good  health,  she  began  to  have  palpitation 
of  the  heart.  This  kept  up  for  about  3  months,  when  the 
thyroid  gland  began  to  enlarge.  Her  eyes  were  always  well 
and  showed  notliing  abnormal  at  this  examination.  For  a 
year  she  was  treated  by  private  and  dispensary  physicians 
with  no  result.  In  1898  she  came  under  my  treatment.  She 
then  presented  a  typical  goiter,  and  a  pulse  ranging  from 
110  to  180,  very  nervous  and  very  despondent.  The  story  of 
her  syphilis  was  so  plain  and  perfect  that  it  could  not  have 
beentold  better  by  an  amateur  specialist.  The  only  physical 
sign  that  could  be  found  to  corroborate  her  history  of  infec- 
tion, however,  was  a  very  slight  leucoderma  on  one  side  of 
her  neck. 

As  this  case  appeared  to  be  in  line  with  the  two 
preceding  ones,  the  patient  was  accordingly  put  on 
iodid  of  sodium,  saturated  solution,  until  she  took 
3  drams  a  day.  The  good  effects  of  the  immense  doses 
of  the  drug  began  to  show  in  less  than  a  month.  The 
heart-action  was  wonderfully  improved  and  the  dimi- 
nution in  the  size  of  the  goiter  was  appreciable  from 
week  to  week.  In  10  weeks,  during  which  time  the 
treatment  was  suspended  for  a  few  days,  the  whole 
pathological  condition  was  obliterated.  Tonics  and 
improved  nourishment  restored  the  woman  to  perfect 
health. 

An  attempt  was  made  to  administer  mercury  by 
injection  and  inunction,  but  the  patient  had  an  un- 
conquerable repugnance  to  mercury  in  any  shape,  form 
or  manner,  even  when  it  was  ordered  as  hydrargirum. 

This  is  the  sum  total  of  my  successful  experience  with 
exophthalmic  goiter.  The  line  of  treatment  in  each 
and  all  of  the  three  cases  proceeded  from  a  clear  and  defi- 
nite conception  of  the  etiological  factor,  which  was  pre- 
sumptively, if  not  positively,  responsible  for  producing 
the  disease. 

In  reviewing  the  clinical  memoranda  which  are  pre- 
sented in  this  paper,  a  few  running  comments  and 
conclusions  are.  perhaps,  justifiable  : 

1.  The  occurrence  of  exophthalmic  goiter  in  three 
undoubted  syphilitics  cannot  be  regarded  as  either  an 
accident  or  coincident. 

2.  The  old  dictum  which  relegates  the  origin  of 
exophthalmic  goiter  to  a  perturbance  or  disturbance  in 
the  cervical  sympathetic  system  should  receive  atten- 
tion only  after  the  existence  of  syphilis,  present  or  past. 
be  absolutely  excluded. 

3.  Those  cases  which  yield  to  mercury  or  iodids 
should  be  favorably  looked  upon  as  being  of  syphilitic 
origin. 

4.  Cases  in  which  all  the  orthodox  remedies  fail 
should  be  put  to  the  test  of  specific  treatment. 

5.  Cases  which  are  characterized  by  gangrene  of  the 
extremities,  various  pigmentation  of  the  skin,  nocturnal 
headaches,  or  other  suspicious  luetic  symptoms,  should 
receive  the  benefit  of  specific  remedies. 

In  conclusion,  I  must  plead  ignorance  of  any  litera- 
ture bearing  on  the  relation  of  Grave's  disease  to  syph- 
ilis. Should  such  exist,  I  shall  then  find  consolation 
in  the  wise  man's  saying  that  "  there  is  nothing  new 


under  the  sun."  On  the  other  hand,  should  I  be  tread- 
ing on  virgin  soil,  I  leave  it  to  you  to  cultivate  it,  so 
that  in  the  near  or  distant  future  a  better  and  larger 
harvest  can  be  gathered  and  reported  by  the  tillers  and 
toilers  of  our  exalted  science. 


THE  SURGICAL  IMPORTANCE  OF  APPARENTLY 
SIMPLE  CARBUNCLES  AND  FURUNCLES  OF  THE. 
UPPER  LIP. 

By  CHARLES  A.  POWERS,  M.D., 

of  Denver,  Col. 

In  1886  or  1887,  a  young  physician,  attached  to  the 
out-patient  department  of  the  Chambers  Street  Hos- 
pital, complained  one  day  of  a  small  boil  on  his  upper- 
lip.  This  was  moderately  tender  and  painful.  He  said 
that  he  felt  generally  indisposed  and  thought  that  he 
would  stop  work  for  a  day  or  two.  Two  days  later  we 
were  greatly  surprised  and  grieved  to  learn  that  he  was 
dead  with  all  of  the  symptoms  of  acute  pyemia  and 
septic  meningitis. 

During  the  winter  of  1890-1,  Dr.  B.  E  Vaughan  brought 
to  me  a  young  gentleman,  a  student  in  the  College  of  Physi- 
cians and  Surgeons,  who  was  suffering  with  a  moderate- 
sized  carbuncle  on  the  left  side  of  the  upper  lip,  just  below 
and  without  the  ala  of  the  nose  The  swelling  was  hard, 
brawny,  indurated,  and  tender,  the  entire  right  side  of  the 
lip  was  considerably  sw^ollen,  the  swelling  extendmg  well  up 
on  the  cheek  alongside  of  the  nose  to  the  margm  of  the 
orbit.  This  cheek  swelling  was  also  brawny  and  indurated.. 
The  young  man  felt  quite'ill ;  his  pulse  was  110.  his  temper- 
ature 102°.  He  had  severe  headache.  He  was  at  once  sent 
to  the  New  York  Cancer  Hospital,  now  known  as  the  Gen- 
eral Memorial  Hospital,  where  I  speedily  operated  under 
ether.  Incision  into  the  carbuncle  revealed  no  free  pus,  but 
the  ordinary  necrotic  area  which  we  see  in  carbuncles,  occur- 
ring, let  us  say.  at  the  back  of  the  neck.  This  necrotic  area 
was  fairly  wide,  extending  over  an  area  f  of  an  inch  in 
diameter"  its  depth  going  to  the  mucous  membrane  of  the 
lip  It  was  found  to  be  continuous  with  another  necrotic 
area  at  the  seat  of  a  brawny  cheek  induration,  and  the  in- 
cision was  carried  outward  iind  upward  into  this  The  entire 
necrotic  area  wa<  thoroughly  excised,  the  incision  extending 
necessarily  well  up  toward  the  margin  of  the  orbit.  The 
wound  wa"s  packed  and  an  ordinary  dressing  applied.  The 
temperature  and  pulse  promptly  fell,  and  in  3  or  4  days  the 
young  man  felt  entirely  well.  The  wound  healed  from  the 
bottom,  leaving  a  rather  ugly  scar.  „  ^  „ 

On  the  morning  of  August  11  of  this  year  D--.  S.  G  Bonney 
kindly  asked  me" to  see  a  young  gentleman  of  17  years  who- 
had  a"  furuncle  of  the  upper  lip  of  about  24  hours'  standing. 
This  furuncle  was  of  moderate  size,  perhaps  half  as  large  as 
half  a  cherrv,  brawny,  indurated,  tender,  and  painful.  The 
entire  lip,  more  espe"cially  its  left  side,  was  greatly  swollen, 
and  this  swelling  extended  to  the  left  cheek.  The  cheek 
was  not  indurated.  The  voung  man  felt  rather  ill ;  his 
temperature  was  101,  his  pulse  about  100°.  The  nature  of 
the  swelling  was  explained  to  his  parents  They  were  told 
of  the  danger  of  .septic  thrombosis  of  the  facial  veins,  this  ex- 
tending to  the  cerebral  sinuses  and  causing  a  rapid  and  fatal 
pyemia.  They  readily  assented  to  operation,  and  2  h  urs- 
biter  the  young  man  was  etherized  at  St.  Joseph's  Hospital, 
and  the  necrotic  area  of  the  furuncle  thoroughly  excised 
through  the  smallest  possible  incision.  The  wound  was 
packed  and  left  to  heal  from  the  bottom.  The  symptoms 
promptly  subsided.  At  the  end  of  24  hpurs  the  young 
gentleman  was  removed  to  his  home,  and  2  days  later  he 
was  out  and  about.  The  resulting  scar  is  small,  and  so 
placed  that  it  will  in  due  time  be  concealed  by  a  moustache. 

Dr.  Bonney,  who  first  saw  this  patient,  said  :  "I 
remember  that  many  vears  ago,  while  a  student  at  the 
Harvard  Medical  School,  I  was  impressed  by  a  state- 
ment made  by  Professor  Cheever  in  his  lectures  on  sur- 


304         "^^  Philadklphia"! 
Hbdicai.  Jocbbal  J 


COCAIN  HABIT  OF  TEN  MONTHS'  DURATION 


[Febbuabt  9,  UOl 


gery.  He  said  :  '  One  of  these  days  it  may  happen  to 
some  of  you  to  see  a  rapidly  forming,  brawny  carbuncle 
of  the  upper  lip.  Remember  that  these  are  fraught 
with  extreme  danger.  The  septic  process  rapidly 
occasions  a  thrombosis  of  the  facial  veins,  this  leading 
"to  a  speedy  pyemia  and  death.'  " 

On  August  80  of  this  year  a  young  man  of  22  entered  my 
office  suffering  with  a  furuncle  of  the  upper  lip,  much  like 
that  just  described,  except  that  the  brawny  area  was  located 
somewhat  near  the  angle  of  the  nose  and  was  beginning  to 
extend  upward  on  the  check.  It  was  of  about  48  hours'  dura- 
tion It  had  been  exceedingly  painful,  the  young  man  felt 
•quite  ill.  His  temperature  was  100°,  bis  pulse  104.  The 
patient  was  at  once  removed  to  St.  Luke's  Hospital,  where 
the  necrotic  area  was  excised  under  ether.  The  main  area 
in  the  lip  proper  was  about  |  of  an  inch  in  diameter,  extend- 
ing well  down  to  the  mucous  membrane.  This  was  continuous 
with  a  necrotic  area  on  the  cheek  just  outside  and  above  the 
ala  nasi,  this  last  area  being  about  half  the  size  of  that  in  the 
lip.  Through  the  smallest  possible  incision  the  entire  mass  of 
necrosed  tissue  was  removed.  Dr.  W  C.  Mitchell,  professor 
■of  bacteriology  in  the  University  of  Denver,  whs  present  and 
took  cultures.  The  growth  showed  a  pure  culture  of  the 
Staphylococcus  pyogenes  aureus.  The  outer  and  upper 
angle  of  the  skin-incision  was  sutured,  the  rest  of  the  wound 
packed  witli  iodoform  gauze  and  the  usual  dressing  put  on. 
Twenty  four  hours  later  the  pulse  and  temperature  were 
normal ;  prompt  recovery  followed. 

The  foregoing  cases  are  typical  of  a  condition  which 
is  fraught  with  great  danger  and  the  importance  of 
■which  is  perhaps  insufficiently  appreciated  by  many 
practitioners  of  medicine.  Unless  these  carbuncles  or 
furuncles  are  promptly  and  thoroughly  excised,  rapid 
thrombosis  of  the  facial  veins,  extending  to  the  cerebral 
sinuses,  is  apt  to  ensue  and  a  speedy  and  fatal  pyemia 
supervenes.  Excision  had  best  be  done  under  general 
anesthesia,  and  the  earlier  it  is  performed  the  smaller 
will  be  the  necessary  incision  with  its  resulting  scar. 
It  is  seen  from  the  foregoing  cases  that  even  a  moderate 
delay  may  necessitate  the  excision  of  a  large  necrotic 
area  from  the  cheek.  In  certain  cases  it  may  be  pos- 
sible to  do  the  operation  through  the  mucous  surface  of 
the  lip.  This  incision  is  especially  useful  in  women. 
The  danger  in  all  these  cases  is  not  from  the  bacterio- 
logical form  of  the  infection  but  from  its  location. 


A  CASE  OF  COCAIN  HABIT  OF  TEN  MONTHS'  DURA- 
TION TREATED  BY  COMPLETE  AND  IMMEDIATE 
WITHDRAWAL  OF  THE  DRUQ. 

By  GEORGE  WILLIAM  NORRIS,  A.B.,  M.D., 
of  Pbiladel]iliia. 

R.  C.  B.,  a  dentist  by  profession,  aged  30,  presented  him- 
self at  the  Pennsylvania  Hospital  as'  a  voluntarv  patient  in 
December  last,  and  came  under  the  care  of  Dr.  A.  V.  Meigs 
"with  the  fol'owiug  history  : 

Ten  months  previous  to  his  admission  he  had  suffered 
severely  from  hemorrhoids,  lor  the  relief  of  which  he  had 
used  cocain  locally  by  rectal  injection.  On  cessation  of  pain 
he  still  continued  to  use  the  drug  in  daily  increasing  doses 
[now  per  hypodermic  injection]  <ni  account  of  it*  stimulating 
and  exhilarating  effect ;  and  when  first  seen  at  the  hospital 
had  been  taking  on  an  average  10  grains  per  diem. 

He  stated  that  until  witliin  a  week  he  had  dailv  attended 
to  his  practice ;  doing,  he  thought,  as  good  work"  as  at  anv 
time,  but  accomplishing  less  in'the  course  of  24  hours,  and 
feeling  a  constant  tendency  to  procrastinate.  Time  to  him 
passed  very  rapidly ;  minutes  seetned  like  seconds,  and  he 
experienced  a  continual,  voracious,  insatiable  appetite. 
When  taking  alcohol,  to  which  he  had  at  one  time  been 
addicted,  be  found  that  it  counteracted  the  effects  of  the 
cocain ;  larger  doses  of  this  drug  being  required  to  produce 


the  usual  effect.  Insomnia  was  constant  unless  he  took 
cocam  ;  upon  the  injection  of  which  in  small  doses  he  slept 
well  for  one  or  two  hours,  when  its  repetition  was  necessi- 
tated. Single  large  doses  kept  him  awake.  For  several 
months  he  had  been  troubled  with  hallucinations  of  hearing, 
and  while  semiconscious  of  his  true  condition,  had  avoided 
street  cars  and  public  gatherings  where  he  imagined  voices 
accused  him  of  being  a  "  cocain  fiend,"  etc.  At  night  he 
would  wander  from  room  to  room  in  his  efforts  to  escape  the 
voices  which  he  heard  talking  about  him,  calling  out,  "  Look, 
he's  going  to  take  another ; "  and  while  reasoning  with  him- 
self on  the  subjective  character  of  his  troubles,  yet  was 
impelled  by  their  vividness  to  flee  from  them  as  from  real 
existences. 

During  the  week  previous  to  his  admission  he  had  had 
syncopal  attacks,  whenever  injections  were  omitted  for  more 
than  two  hours,  and,  as  he  said,  he  had  been  verj-  "  excita- 
ble," having  broken  several  hypodermic  needles  in  his 
muscles.  About  this  time  he  became  alarmed  at  his  symp- 
toms and  sought  aid  at  the  hospital. 

Physical  Examination  — A  prematurely  gray,  lean,  pale 
individual,  with  marked  mydriasis,  a  slight  tremor  of  the 
hands  and  tongue,  restless,  furtive  glances,  excited  speech 
and  indistinct  articulation.  Temperature.  97 ;  respiration, 
20 ;  pulse.  88.  The  skin  of  his  arms  and  legs  shows  innu- 
merable hypodermic  punctures.  The  first  sound  at  the 
ape.x  — sharp,  short  and  high  pitched.  Xo  murmurs.  The 
other  organs,  as  well  as  the  urine,  negative. 

Trfotment. — Complete  withdrawal  of  cocain.  Strychnin 
sulfate,  jV  gr.,  every  fourth  hour.  Sulfonal,  20  gr.,  repeated 
m  two  hours. 

On  the  first  night  the  patient  slept  fairly  well ;  on  the 
second  he  required  no  hypnotic  whatever;  and  except  for  the 
relief  of  an  obstinate  constipation  needed  no  more  active 
medication  than  the  strychnin.  He  volunteered  the  informa- 
tion that  he  felt  like  his  former  self  for  the  first  time  for 
many  months,  and  that  time  once  more  seemed  real  to  him. 
He  complained  of  no  craving  for  the  drug  and  was  allowed 
to  leave  the  hospital  a  week  after  his  admission  [having 
pleaded  financial  obligations]  on  promising  to  place  himself 
under  medical  surveillance. 

The  interesting  features  of  the  case  are :  1.  That  sud- 
den and  entire  withdrawal  of  the  cocain  after  long- 
continued  use  in  large  doses  required  no  more  active 
therapeutic  substitution  without  producing  physical 
effects.  2.  That  the  patient  after  the  first  12  hours 
seemed  to  experience  so  little  craving  for  the  stimulaut 
but  remained  contentedly  in  bed,  reading  the  news- 
papers, and  suffering  none  of  the  agonies  usually  ex- 
perienced on  the  discontinuance  of  a  long-established 
drug  habit. 

On  looking  over  a  considerable  number  of  reported 
cases  of  acute  and  chronic  cocain  intoxication,  the  fol- 
lowing facts  have  been  gleaned  which  it  may  be  of  in- 
terest to  tabulate : 

1.  Cocainism  is  the  most  insidious  of  all  drug  habits. 
The  use  of  the  drug  being  unaccompanied  by  disagree- 
able after-effects — headache,  nausea,  vomiting,  etc., 
which  are  met  with  after  the  ingestion  of  opium  or 
alcohol — the  vice  is  readily  and  rapidly  established. 

2.  Cocainism  is  occasionally  acquired  by  the  local 
use  of  the  drug  in  diseases  of  the  nose  and  throat,  teeth, 
etc.,  but  more  often  as  a  substitute  for  opium  or  alcohoL 

3.  Cocain  is  eventually  tolerated  by  the  system  in 
huge  doses.  (One  case  is  recorded  where  60  grains 
were  daily  consumed.') 

4.  A  relatively  large  number  of  habitues  are  found 
in  the  medical  and  dental  professions.  (It  is  said 
30%.*) 

5.  The  continued  indulgence  in  cocain  invariably, 
and  usually  soon,  leads  to  marasmus,  with  mental, 
moral,  and  nervous  degeneration. 

6.  The  smallest  fatal  dose  on  record  is  J  grain  hypo- 
dermically.' 


Fbbruaby  9,  1901] 


VENTRAL  HERNIA— POSTOPERATIVE  HERNIA 


LThk  Philadelphia 
Mkdicax  Jocrnal 


305 


7.  While  many  cases  of  acute  intoxication  are  being 
continually  reported,  there  are  relatively  few  fatal  cases. 
The  majority  of  such  are  the  result  of  large  doses  in- 
jected into  the  urethra  and  bladder,  e.  g.  : 

5  fluiddrams  of  a  5%  solution  into  urethra.' 

6  fluiddrams  of  a  5^  solution  into  urethra' 

8.  The  amount  of  cocain  sold  yearly  is  rapidly  in- 
creasing, and  its  self-prescribed  use  among  the  laity  and 
lower  classes  becoming  proportionately  more  frequent. 

BIBLIOGRAPHY. 

'  New  York  Medical  Journal,  1894,  p.  611. 
'  Ctnlratblatl fur  Chirurijit,  March  10,  1895. 
'Medical  .Veu-s,  Oclobef  9,  1898. 
«  Australiiin  Medical  Gazelle,  April  20,  1899. 
'  Zeitschrijl/ur  Zahnheitkunde,  1890. 


REPORT  OF  A  CASE  OP  ENORMOUS  VENTRAL  HER- 
NIA: OF  A  CASE  OF  DERMOID  CYST  OF  THE 
OVARY :  AND  OF  A  CASE  OF  PROFOUND  SHOCK 
FOLLOWING  A  CRUSH  OF  THE  ARM.' 

By  FRANCIS  T.  STEWART,  M.D., 

Out-Patient  Surgeon  to  Pennsylvania  Hospital  ;  Associate  in  Surgery,  Phila- 
delphia Polycliaic. 

I  AM  indebted  to  Dr.  Martin  for  the  privilege  of  oper- 
ating upon  and  reporting  the  following  cases: 

Case  1. — A.  C,  aged  40  years,  was  subjected  to  abdominal 
section  four  years  ago  for  pelvic  trouble,  the  nature  of  which 
is  unascertainable.  She  remained  in  the  hospital  one  year 
and  was  kept  supine  several  months.  A  small  hernia  was 
noticed  two  months  after  operation ;  this  rapidly  increased 
in  size  as  she  began  to  walk  about.  The  patient  is  thin  but 
apparently  strong.  The  bowels  are  always  sluggish  and  often 
obstinately  constipated,  but  there  are  no  evidences  of  inter- 
ference with  the  other  abdominal  organs.  The  heart,  lungs, 
and  urine  are  normal.  When  the  patient  is  standing,  a  large, 
soft,  tj'mpanitic  tumor  projects  from  the  abdomen  and  hangs 
down  below  the  pubes.  Wlien  she  is  lying  down,  the  pro- 
tuberance disappears,  and  after  persistent  efforts  at  reduction 
a  mass  the  size  of  two  fists  still  remains.  The  ring  formed 
by  the  separation  of  the  recti  extends  vertically  for  7  inches 
and  laterally  4  inches.  Two  surgeons  had  seen  the  case  and 
refused  to  operate. 

She  entered  the  Pennsylvania  Hospital  December  19, 1899, 
was  put  in  bed  and  given  mild  aperients  for  10  days  without 
any  material  diminution  of  the  hernia.  Under  ether  an 
incision  was  made  from  just  below  the  ensiform  process 
down  nearly  to  the  pubes ;  the  thickened  sac  was  immedi- 
ately encountered  and  opened ;  it  contained  the  lower  half 
of  the  stomach,  all  of  the  transverse  colon,  and  most  of  the 
small  intestines  including  omentum  and  mesentery.  Adhe- 
sions were  numerous  and  dense.  Owing  to  the  diminished 
space  within  the  peritoneal  cavity  almost  all  the  omentum 
was  excised  with  the  sac.  The  intestines,  "  having  sacrificed 
their  right  of  domicile  in  the  abdomen,"  were  most  difficult 
to  replace ;  they  were  attacked,  with  the  patient  in  the 
Trendelenburg  posture,  with  a  great  deal  of  force,  a  large 
amount  of  coaxing,  and  were  finally  induced  to  return  to 
the  abdominal  cavity.  The  peritoneum  was  closed  with  a 
continuous  catgut  suture;  each  rectus  was  loosened  from 
its  sheath,  slid  inwards,  and  united  to  its  fellow  by  heavy 
chromicized  catgut  (I  should  use  silver  wire  in  a  future 
case),  and  the  skin  was  sutured  witli  silkworm-gut.  Broad 
adhesive  strips  were  applied  to  support  and  strengthen  the 
belly  wall.  The  operation  consumed  IJ  hours.  There  were 
considerable  shock  and  nuich  vomiting.  The  respirations 
registered  60  to  the  minute,  remained  rapid  for  one  week, 
and  were  out  of  all  proportion  to  the  pulse-rate  The 
patient  was  kept  in  bed  one  montli.  After  two  months 
there  was  no  recurrence. 

In  most  cases  of  very  large  hernia,  operation  is  said 
to  be  unjustifiable  because  of  the  difficulty  and  often 

1  Read  at  a  meeting  of  the  Philadelphia  County  Medical  Society,  December  26, 
1900. 


impossibility  of  accomplishing  reduction,  on  account 
of  the  increased  danger  to  life,  and  for  the  reason  that 
it  is  usually  fruitless,  the  rupture  reappearing  and 
rapidly  attaining  a  large  size.  We  attempted  operation 
in  the  case  under  consideration  because  of  the  increas- 
ing intestinal  interference  and  unmanageableness  of  the 
tumor,  believing  that  we  at  least  could  make  the  open- 
ing small  enough  to  be  covered  by  a  truss,  and  in  order 
to  gratify  the  patient,  who  appreciated  the  peril  and 
the  uncertainty  of  cure,  but  who  was  willing  to  hazard 
any  procedure  essayed  to  mitigate  her  distressing  con- 
dition. 

Case  2. — A.  B  ,  aged  3^  years,  was  admitted  to  the  Penn- 
sylvania H'  spital  January  29,  1900.  She  had  had  one  child, 
IJ  years  before,  The  menses  had  been  absent  6  weeks,  dur- 
ing which  time  she  complained  of  pelvic  pain  and  leukorrhea. 
Bimanually  an  adherent  mass  could  be  felt  behind  the 
uterus  on  the  right  side.  A  diagnosis  of  ectopic  gestation 
was  made.  At  the  operation  the  mass  proved  to  be  an  in- 
flamed dermoid  cyst  of  the  I'vary,  containing  fatty  detritus, 
cholesterine,  compound  granular  cells,  pus  cells,  and  two 
perfectly  formed  but  atypical  teeth.  The  recover}'  was 
uneventful. 

Formerly  cases  of  this  character  were  regarded  as 
imperfect  ovarian  pregnancies  with  or  without  sexual 
intercourse ;  the  ovary  was  thought  to  be  autogenetic  ; 
and  the  absence  of  menstruation,  which  sometimes  pre- 
cedes the  discovery  of  the  cyst,  lends  credence  to  this 
view,  which  still  has  its  advocates.  The  fact  that  the 
ovary  alone  is  selected  as  the  seat  of  dermoids  in  pre- 
ference to  all  the  other  abdominal  organs,  makes  the 
inclusion  theory  equally  difficult  to  comprehend. 

Cases. —  N.  T.,  male,  aged  23  years,  was  brought  to  the 
Pennsylvania  Hospital  October  14,  1900,  by  the  patrol  wagon. 
He  had  been  found  lying  under  a  freight  train  with  a  badly 
mutilated  left  arm.  He  was  cold,  unconscious,  wet  with 
rain,  and  covered  with  dirt  and  cinders.  The  pulse  could 
scarcely  be  felt,  the  respirations  were  shallow,  the  pupils 
dihited,  and  the  axillary  temperature  approximately  8S°  F. 
The  thermometer  would  not  register,  its  lowest  marking 
being  90°.  With  heat  and  stimulants  the  temperature 
reached  100°  during  the  course  of  10  hours.  The  arm  was 
then  amputated  just  below  the  shoulder  joint  It  was  re- 
marked that  the  axillary  vein  contained  a  thrombus  extend- 
ing far  above  the  point  of  ligation  The  patient  reacted 
from  operation  and  seemed  to  be  doing  very  well,  when  he 
suddenly  and  unexpectedly  expired,  5  hours  after  operation, 
from,  as  we  believe,  a  large  embolus  blocking  the  pulmonary 
artery.    There  was  no  autopsy. 


THE  TREATMENT  OF  POSTOPERATIVE  HERNL4.* 
By  IRVING  S.  HAYNES,  PhB.,  M.D., 

of  New  York. 

Professor  of  Practical  Anatomy,  Cornell  University  Medical  College;  Visiting 

Surgeon  to  the  ilarlem  Hospital;  Member  of 'he  New  Yurk  .Academy 

of  Medicine,  of  the  Society  of  the  Alumni  of  Bellevue 

Hospital,  etc.,  etc. 

The  cure  of  postoperative  hernias  is  only  by  opera- 
tion. These  herniae  are  formed  at  the  site  of  some 
previous  abdominal  operation.  They  are  developed  in 
the  scar  which  gradually  yields  to  the  intra-abdominal 
pressure.  The  sac  is  formed  of  thinned  skin  and  peri- 
toneum united  by  attenuated  scar-tissue.  The  omentum 
is  usually  united  to  the  cicatrix  and  behaves  often  as 
in  a  typical  umbilical  hernia.  The  hernial  ring  is 
formed  by  the  edges  of  the  muscular  and  fafrcial  layers 
of  the  abdominal  wall  welded  into  a  compact  whole  by 

•  Read,  February  7,  1900,  before  the  Society  of  the  Alumni  ot   Belleme 
Hospital. 


306 


The  Philadelphia"! 

Medical  Journal  J 


THE  TREATMENT  OF  POSTOPERATIVE  HERNIA 


[Febbcabt  9,  ian 


-scar-tissue.     Strangulation  does  not  appear  often  and  if 
present  is  usually  caused  by  a  constricting  band. 

These  ruptures  are  usually  easily  and  completely 
Teducible  as  regards  the  intestines,  but,  as  just  stated, 
in  the  majority  of  cases  the  omentum  will  be  found 
■adherent  to  the  bottom  of  the  sac.  The  following  cases 
will  illustrate  the  various  conditions  found  in  this  class 
of  hernia  and  the  steps  of  the  operation  for  their  cure. 

Case  1.— Charles  C,  age  20,  admitted  to  the  Harlem  Hos- 
pital October  16,  1895.  Patient  had  been  operated  upon 
about  one  year  previously  for  an  inguinal  hernia  by  O'Hara's 
method.  A  truss  was  worn  after  the  operation.  Seven 
weeks  previous  to  admission  to  the  hospital  he  left  ofT  the 
truss  and  the  hernia  reappeared  while  lifting.  Examination 
shows  a  left  inguinal  hernia,  reducible,  but  causing  him  great 
pain  and  interfering  with  his  health.  October  £0  a  Bassini 
operation  was  performed,  after  excising  all  the  surrounding 
scar  tissue.  The  internal  inguinal  ring  was  large,  a  large  piece 
of  omentum  lay  in  the  sac  which  reached  to  the  scrotum. 
There  were  many  old  adhesions  present.  The  omentum  and 
sac  were  removed.  Silk  was  used  as  a  ligature  for  the  sac 
and  to  close  up  the  various  muscular  layers.  The  skin  was 
united  with  the  same  material.  The  wound  was  slow  to 
heal  Two  or  three  sutures  had  to  be  removed  to  give  vent 
to  a  bloody  discharge.  It  finally  closed,  with  the  exception 
of  a  small  sinus  that  discharged  a  few  drops  of  pus  daily. 
At  his  own  request  he  was  discharged  December  16,  1895. 
Later  he  entered  the  Post-Graduate  Hospital  in  the  service 
of  my  friend,  Dr.  De  Garmo.  The  doctor  wrote  me  that 
nothing  operative  was  done,  that  after  a  while  two  or  three 
silk  sutures  were  discharged  and  the  sinus  closed  quickly. 
He  was  discharged  with  a  firm  scar  and  no  return  of  the 
hernia. 

Case  2. — Alvin  E.,  age  25,  admitted  to  the  Harlem  Hospital 
January  4,  1896  November  8,  1895,  was  operated  upon  in 
Buffalo  for  septic  peritonitis  due  to  a  perforated  appendix. 
The  wound  was  drained  for  nine  days  and  then  allowed  to  heal 
by  granulation.  Examination  shows  a  scar  5  inches  long, 
parallel  with  and  just  above  Poupart's  ligament;  the  center 
of  tlie  scar  is  over  the  middle  and  outer  thirds  of  the 
ligament.  The  gut  comes  out  through  an  opening  just 
to  the  outside  of  the  normal  internal  inguinal  ring,  and 
runs  down  under  the  skin  along  the  front  of  Poupart's 
ligament  into  the  scrotum,  presenting  many  appearances 
similar  to  an  indirect  inguinal  hernia.  The  hernia  is  easily 
and  completely  reducible.  Operation,  January  7.  Incisions 
were  made  in  normal  tissues  alongside  the  scar,  exposing  in 
turn  all  the  muscular  layers,  a  well  formed  hernial  sac  was 
present  which  was  treated  as  in  an  inguinal  hernia,  being 
dissected  free,  ligated  as  high  up  as  possible,  and  removed. 
The  wound  was  closed  as  in  a  Bassini  operation  for  radical 
cure  of  an  inguinal  hernia.  The  cord  was  placed  in  the 
outer  angle  of  the  incision,  the  transversalis  and  internal 
oblique  muscles  sutured  firmly  behind  it  to  the  inguinal 
ligament  and  the  external  oblique  closed  over  the  cord  down 
to  the  external  ring.  Silk  was  the  suture  material,  applied 
interruptedly  in  the  two  inner  muscles,  and  continuously  in 
the  external  one.  The  skin  was  closed  with  silkworm  gut 
and  the  wound  sealed  with  aristo-collodion.  Result :  pri- 
mary union.  Patient  discharged  January  22,  15  days  after 
operation.  Union  firm.  He  was  seen  February  23,  when  he 
was  at  work  in  a  printing  office  lifting  plates  that  weighed 
60  pounds  each.  During  the  day  he  lifted  and  carried  240  of 
these  plates,  or  14,400  pounds.  May  1,  result  remains  abso- 
lutely perfect. 

Cask  3.— Julia  R.  was  operated  upon  at  the  Harlem 
Hospital  by  tlie  writer  September  21,  1896,  for  a  general 
septic  peritonitis  due  to  a  gangrenous  and  ruptured  appen- 
dix. The  peritoneal  cavity  required  free  drainage.  The 
peritoneum,  muscles,  and  skin  were  sutured  with  silkworm 
gut  in  a  single  layer,  as  haste  was  imperative.  The  child 
recovered  and  was  discharged  in  a  month,  with  a  sinus  pres- 
ent, which  closed  in  December.  The  scar  was  a  weak  one 
and  a  hernia  developed  as  large  as  a  hen's  egg.  The  cover- 
ing of  the  hernia  was  very  thin.  The  margins  of  the  muscles 
could  be  plainly  felt  as  a  thick  ring  about  the  hernia.  She 
was  readmitted  to  the  hospital  and  operated  upon  January 
6,  1897.  Incisions  were  made  on  each  side  of  ihe  scar  and 
•the  cicatrix  removed.    The  cicatrix  included  the  skin  and 


peritoneum.  The  muscular  margins  were  welded  together 
by  the  cicatricial  tissue.  The  cecum  was  adherent  to  the 
peritoneum  along  the  inner  margin  of  the  scar.  The  (  eri- 
toneum  was  dis.--ected  free  about  the  margins  of  the  wound 
and  sutured.  The  adhesions  of  the  cecum  were  not  dis- 
turbed. The  muscles  were  then  separated  and  sutured  sep- 
arately b}-  chromic  gut  applied  continuously.  Silkworm-gut 
was  used  for  the  skin  and  the  wound  sealed  with  collodion. 
Result :  primary  union.  The  child  was  discharged  January 
20,  16  days,  with  a  firm  line  of  union.  Examined  6  months 
later  the  scar  was  solid.  Both  sides  of  the  abdomen  appeared 
ju.st  alike. 

Case  4  — Emma  L  ,  age  28,  admitted  to  the  Harlem  Hos 
pital  January  12,  1897.  Three  months  previous  a  median 
laparotomy  had  been  performed  in  one  of  the  city  hospitals. 
A  hernia  in  the  scar  soon  developed.  Operated  on  January 
18,  1897.  The  ventral  scar,  5  inches  long,  with  the  omentum 
adherent  to  the  peritoneum  was  excised.  The  hernial  sac 
was  composed  of  omentum,  peritoneum,  superficial  fascia 
and  skin  all  blended  by  scar  tissue.  The  peritoneum,  recti 
muscles  and  the  rectal  sheath  were  sutured  separately  with 
silk,  and  the  skin  with  silkworm-gut.  Result :  primary  union. 
Discharged  February  1  with  solid  scar  and  no  hernia. 

Case  5.— Nellie  Mc,  age  28,  admitted  to  Harlem  Hospital 
December  21,  1897.  April  1,  1897,  an  ovariotomy  had  been 
done.  About  the  middle  of  November  she  noticed  a  slight 
bulging  in  the  scar;  this  increased  in  size,  and  on  admission, 
a  rupture  3  inches  in  diameter  was  present.  December  22, 
operation.  The  usual  incisions  were  made  on  either  side  of 
the  scar  in  sound  skin.  These  incisions  exposed  the  margins 
of  the  recti  muscles.  The  peritoneum  was  opened  alongside 
of  the  cicatrix,  which,  with  some  adherent  omentum,  was 
removed.  The  abdomen  was  closed  with  silk  The  peri- 
toneum, the  recti,  the  sheath  of  these  muscles,  and  the 
skin  were  sutured  separately  and  continuously.  Result : 
Primary  union  throughout.  The  patient  was  discharged 
January  11,  1898,  with  a  firm  scar. 

Case  6.— Kate  S.,  age  40,  domestic,  admitted  Januarv  30, 
1898,  to  Harlem  Hospital.  October,  1896,  she  had  been 
admitted  to  a  city  hospital  with  diagnosis  of  rheumatism  of 
the  right  hip.  In  a  week's  time  an  abscess  appeared  and 
ruptured.  An  incision  was  made  for  free  dramage,  and  a 
quantity  of  pus  was  discharged.  The  scar  from  this  incision 
ran  along  the  crest  of  the  ilium  and  down  into  the  thigh 
across  Poupart's  ligament.  September,  1897,  a  hernia  ap- 
peared in  the  scar  and  gradually  increased  in  size,  but  was 
not  painful  until  January,  1898,  then  the  swelling  became 
tender,  red,  and  warm.  On  being  admitted  there  was  found 
a  well-marked  hernia  at  the  site  of  the  former  operation, 
together  with  a  fluctuating  swelling  adjoining  it  on  the  outer 
posterior  side,  evidently  containing  pus.  January  31,  opera- 
tion. An  incision,  parallel  with  the  first  one,  was  made  into 
the  abscess  and  a  large  quantity  of  pus  evacuated.  This 
pus-cavity  was  behind  the  peritoneum,  and  filled  the  iliac 
fossa,  and  extended  upward  into  the  flank.  The  abscess  was 
imdoubtedly  due  to  a  previous  appendicitis.  What  appeared 
to  be  the  stump  of  the  appendix  was  found ;  although  King 
behind,  it  was  not  connected  to  the  cecum,  and  was  so 
much  changed  by  surrounding  granulation  tissue  that  its 
origin  could  only  be  surmised.  "The  abscess  was  thoroughly 
cureted  and  treated  with  H,Oj.  Free  drainage  was  secureii 
by  a  large  tube  passed  through  the  back  ext«mal  to  the 
quadratus  lumborum  and  above  the  iliac  crest.  The  repair 
of  the  hernia  was  now  undertaken.  This  was  particularly 
difficult  because  the  original  incision  had  been  made  so  close 
to  the  iliac  crest  that  the  abdominal  muscles  had  been 
severed  at  their  very  origin,  and  being  carried  down  into  the 
thigh,  Poupart's  ligament  had  been  cut  away  from  the  iliac 
spine.  The  abdominal  muscles  were  freed  near  the  margi- 
nal scar  and  sutured  separately  to  the  crest  of  the  ilium. 
The  transversalis  and  internal  oblique  more  to  the  iliac 
fascia,  the  external  oblique  carried  over  the  outer 
margin  of  the  ilium  and  sutured  firmly  to  the  fascia  latA. 
Poupart's  ligament  was  reformed  by  this  means,  and  by 
suturing  the  three  muscles  firmly  to  the  fascia  latA  internal 
to  the  iliac  spine.  Silk  was  used  for  the  muscles  and  silk- 
worm-gut for  the  skin.  The  wound  healed  nicely.  The 
abscess  cavity  was  drained  from  the  back  until  it  closed. 
Three  months  after  the  operation  the  wound  was  solid,  there 
was  no  sagging  along  Poupart's  ligament,  and  no  indications 
of  a  return  of  the  hernia. 


FEBKnARY  9,   1901] 


THE  TREATMENT  OF  POSTOPERATIVE  HERNIA 


[The  PBaLADELPHlA 
Medical  Journal 


307 


To  make  the  consideration  of  this  subject  complete 
the  conditions  which  predispose  to  the  development  of 
postoperative  hernia  must  be  mentioned,  as  well  as  the 
measures  which  should  be  used  to  minimize  these  fac- 
tors at  the  time  of  the  operation.  The  position  and 
manner  of  the  incision  is  of  some  consequence.  Post- 
operative hernias  are  rare  above  the  level  of  the  umbil- 
icus, and  if  present  usually  do  not  require  operation  ; 
hence,  incisions  above  this  level  will  be  ignored. 

Regarding  the  placement  and  manner  of  making 
incisions  in  the  lower  abdominal  zone  I  will  state  my 
own  preferences.  If  the  condition  is  to  be  reached  by 
traversing  the  muscular  layers  and  an  aseptic  opera- 
tion can  be  probably  jierformed,  the  gridiron  incision 
is  best.  On  the  other  hand,  if  pus  is  probably  present 
a  clean  cut  through  the  muscles  without  separation  of 
their  fibers  is  used.  If  the  trouble  is  more  cen- 
trally located  the  incision  should  be  made  in  the 
median  line.  Division  along  the  semilunar  line  or 
through  the  rectus  muscle  possesses  no  advantage  over 
a  median  incision,  but  many  disadvantages,  as  division 
of  nerves,  vessels,  more  trouble  with  hemorrhage,  diffi- 
culty of  readily  and  quickly  enlarging  the  incisions, 
attending  tearing  and  laceration  of  muscular  tissue, 
and  no  guarantee  that  hernia  will  not  result. 

Make  the  incision  sufficiently  long  to  do  quick  work. 
The  length  of  the  incision  does  not  seem  to  determine 
the  rapidity  of  healing,  nor  does  it  determine  the  ab- 
sence or  presence  of  a  hernia  in  the  future.  The 
chief  factor  in  prevention  depends  upon  the  closure  of 
the  abdominal  wound  by  the  accurate  and  separate 
coaptation  of  the  various  layers,  with  some  slowly  ab- 
sorbable material.  There  are  two  conditions  which 
interfere  with  this  important  procedure.  One  is  the 
necessity  of  maintaining  drainage  through  the  wound  ; 
the  other,  the  state  of  the  patient  demanding  such  haste 
that  the  abdominal  wall  has  to  be  closed  quickly  en 
masse. 

Failure  to  properly  close  the  peritoneum  allows  the 
viscera,  usually  the  omentum  and  intestine,  to  become 
adherent  to  the  wound.  This  arrests  the  free  mobility 
of  the  intestines,  and  later  on  favors  the  development 
of  a  rupture.  Abdominal  drainage  is  less  used  now 
than  formerly,  because  it  has  been  demonstrated  that 
in  many  instances  the  peritoneal  cavity  may  be  thor- 
oughly cleansed  by  hydrogen  peroxid  and  copious 
flushing  with  salt-solution,  and  complete  closure  of  the 
wound  made  possible. 

If  drainage  is  necessary  it  can  often  be  secured 
through  some  place  even  better  than  through  the  ab- 
dominal wound,  as  through  the  vagina  in  pelvic  cases. 
However,  some  cases  must  be  drained  through  the 
wound. 

If  gauze  is  used  it  should  be  wrapped  around  with 
rubber  tissue,  as  suggested  by  Dr.  Morris.  This  pre- 
vents troublesome  adhesions  to  the  muscular  layers  and 
abdominal  viscera.  With  this  drainage,  or  with  tube 
drainage,  the  wound  should  be  closed  by  separate 
sutures  of  the  various  layers  close  to  the  drain,  in  order 
to  obtain  primary  union  throughout  the  greater  part  of 
the  incision. 

A  danger  attending  wound  treatment  in  cases  that 
must  be  drained  is,  that  the  raw  surface  of  the  wound 
may  become  infected,  suppurate,  primary  union  be 
prevented  and  a  long  cicatrix  formed.  Scar  tissue  is 
weak  tissue,  and  if  present  in  any  considerable  amount 
favors  the  development  of  a  hernia.  The  treatment 
>where  hernia  has  resulted  may  be  palliative  or  radical. 


Palliative  treatment  by  belts,  bands,  strapping,  or 
trusses  must  be  used  in  such  individuals  as  will  not 
submit  to  operation,  and  in  those  where  an  operation  is 
contraindicated  on  account  of  the  danger  of  using  an 
anesthetic. 

The  radical  or  operative  treatment  depends  for  its 
success  upon  just  two  factors.  First,  isolation  of  the 
various  layers  forming  the  abdominal  wall ;  and  second, 
the  accurate  and  separate  union  of  the  several  layers 
ior  a  sufficiently  long  time  to  obtain  solid  union. 

Although  the  means  for  cure  can  be  thus  briefly  and 
simply  stated,  like  many  other  conditions,  the  execu- 
tion is  at  times  very  difficult.  A  few  practical  directions 
may  not  come  amiss: 

1.  Make  the  incisions  on  each  side  of  the  old  scar  in 
healthy  skin,  even  though  a  large  segment  must  be 
excised. 

2.  Look  for  and  recognize  the  various  muscular  or 
fascial  planes  at  a  distance  from  their  involvement  in  the 
scar,  then  incise  the  layer  near  the  scar,  but  in  normal 
tissue. 

3.  Divide  the  peritoneum  far  enough  from  the  cica- 
trix so  that  its  normal  features  are  easily  recognized. 

4.  Severe  adhesions  of  the  hernial  sac  to  viscera  or 
omentum,  between  ligatures  when  necessary. 

5.  An  omental  stump  is  to  be  covered  up  by  rolling  it 
into  the  omentum  and  keeping  it  there  by  a  running 
suture  of  free  catgut.  Bare  surfaces  of  intestine  should 
be  covered  by  bringing  the  peritoneal  coats  together. 
Subsequent  adhesions  are  thus  prevented. 

6.  Close  the  wound  with  chromic  catgut. 

It  is  taken  for  granted  that  all  oozing  has  been 
arrested. 

The  peritoneum  is  united  by  a  continuous  strand  of 
No.  0  chromic  gut.  The  muscular  layers  by  No.  1  if 
they  are  thin  and  weak,  or  No.  2  it  thick  and  strong. 
These  sutures  are  interrupted.  They  may  be  the  ordi- 
nary through  and  through,  mattress  or  Lembert,  accord- 
ing to  the  individual  requirements.  The  aim  is  to 
secure  perfect  coaptation  of  the  divided  muscular  fibers. 
When  there  is  tension,  long  relaxation  sutures  must  be 
applied  to  remove  the  strain  from  the  marginal  ones. 

The  fascial  layer  is  closed  by  continuous  or  inter- 
rupted stitches  of  No.  1  chromic,  and  the  skin  by  a 
single  strand  of  No.  0  applied  subcutaneously. 

The  wound  is  protected  by  a  light  dressing  and  sup- 
ported by  rubber  adhesive  bands.  Although  in  most  of 
the  cases  reported  silk  was  the  suture-material,  its  use 
was  necessary  in  the  absence  of  suitable  chromic  gut, 
and  my  preference  is  for  the  latter,  if  perfectly  fresh 
and  sterile.  The  reasons  for  using  a  slowly  absorbable 
material  in  all  hernial  and  abdominal  operations  have 
been  thoroughly  established  and  need  not  be  repeated 
here. 

Rest  in  bed  for  at  least  3  weeks  should  be  observed 
when  possible,  because  the  line  of  union  between  the 
various  layers  cannot  acquire  the  strength  of  the 
united  tissues  themselves  in  less  time. 

Use  no  truss  afterwards.  An  abdominal  belt  with- 
out pads  may  be  worn  for  comfort,  but  is  not  necessary. 


Bristol  Dispensary. — The  annual  report  of  the  Bristo 

Dispeuaary  for  19CK),  which  has  jast  been  issued,  states  that 
10,060  patients  were  treated  during  the  year  and  that  medi- 
cal assistance  was  also  given  in  24  difficult  midwifery  cases. 
The  committee  add  that  the  branch  of  the  dispensary  at 
Bedminster  is  much  appreciated  and  that  the  number  of 
patients  attended  is  larger  than  in  the  preceding  year. 


308 


ThK  PHILiDELPHIA"! 

Medical  Journal  J 


DIETETIC  MANAGEMENT  OF  TYPHOID  FEVER 


[Fkeeuaey  9,  1901 


ON    THE    DIETETIC    MANAGEMENT    OF    TYPHOID 
FEVER* 

By  DAVID  INGLIS,  M.D., 

of  Detroit,  Mich. 

Away  back  in  the  time  when  typhoid  fever  was  first 
differentiated  from  the  other  continued  fevers,  some  one 
originated  the  milk  diet  for  this  disease;  and  the 
medical  profession,  being  subject  to  human  frailties, 
has  gone  on  accepting  the  milk  diet  as  the  proper 
treatment  for  typhoid  fever,  with  a  singular  disregard  of 
the  facts,  which  pass  under  their  observation,  year  after 
year.  Theoretically,  it  would  seem  that  physicians,  in 
active  practice,  would  reason  out  for  themselves  whether 
the  milk  diet  were,  really,  what  it  is  claimed  to  be  or 
not ;  but  it  is  a  remarkable  fact  in  all  human  history 
that  men  have  accepted,  for  generations,  not  what  they 
know  to  be  true,  but  what  they  have  assumed  to  be  true, 
and  so  it  has  been  with  the  medical  profession  and  the 
milk  diet  in  typhoid.  It  has  been  assumed  that  milk 
is  a  liquid  and  that  it  is  readily  assimilated  and  leaves 
little  or  nothing  to  pass  through  the  bowels;  and,  upon 
this  assumption,  it  has  been  further  assumed  that  the 
nutritious  qualities  of  the  milk  have  served  to  keep  up 
the  patient's  strength  to  the  greatest  possible  degree, 
and  that  thus  the  two  main  indications  in  typhoid  fever 
have  been  fulfilled ;  first,  the  avoidance  of  irritation  of 
the  ulcerated  Peyer's  patches,  and  therefore  the  preven- 
tion of  hemorrhage,  and,  second,  the  maintenance  of 
the  general  bodily  nutrition.  These  assumptions  have 
been  quietly  accepted  by  countless  thousands  of  phy- 
sicians, notwithstanding  the  fact  that,  at  the  termina- 
tion of  the  fever,  the  patient  has  been  found  to  be 
emaciated  to  an  extreme  degree,  demonstrating  visibly 
that  the  bodily  nutrition  has  not  been  maintained  to 
any  high  degree,  but  quite  the  contrary. 

Let  us  take  the  first  assumption,  that  milk  is  a  liquid 
which  is  readily  absorbed  and  leaves  little  or  no  detritus 
to  pass  through  the  intestines.  The  fact  is  that  the 
serous  portion  of  the  milk  is  absorbed  through  the  gas- 
tric mucous  membrane,  but  this  constitutes  but  a  small 
part  of  the  bulk  of  the  milk.  The  casein  of  the  milk 
is  rapidly  turned  into  a  solid,  which  is  not  digested  in 
the  stomach  but  is  passed  on  into  the  intestines.  When 
a  patient  has  a  pretty  steady  diarrhea  he  usually  suc- 
ceeds in  passing  out  the  casein  in  small  flocculent 
curds,  and,  as  long  as  he  succeeds  in  doing  ao,  he  remains 
tolerably  safe  from  one  of  the  dangers  of  this  deceptive 
fluid.  If,  however,  he  does  not  have  a  sufliciently 
active  diarrhea  the  casein  is  liable  to  form  masses  of 
scyballae,  not  only  in  the  large  intestine  but  high  up  in 
the  small  intestine.  Wilson,  writing  in  the  Cohtmhus 
Medical  Journal,  says  that,  in  a  number  of  postmortems 
on  typhoid-fever  cases,  he  had  always  found  curds  of 
undigested  milk  in  the  stomach  and  portions  of  these 
curds  in  the  small  bowel,  where  they  were  forming  ideal 
foci  for  fermentation  and  breeding-grounds  for  various 
microbes.  Every  physician  who  has  had  an  extensive 
experience  in  typhoid  fever  is  familiar  with  that  ex- 
ceedingly unpleasant  complication  which  occurs,  by  no 
means  unfrequently,  toward  the  end  of  the  fever,  in 
cases  in  which  the  early  diarrhea  had  stopped,  or  which 
occurs,  even  during  the  progress  of  the  fever,  in  cases 
uncomplicated  by  milk  diarrhea,  the  condition  in 
which  the  rectum  and  colon  become  filled  with  im- 
pacted feces.    The  physician  who  has  once  scooped  out 

*  Bead  before  the  Detroit  Academy  of  Medicine. 


from  the  rectum  the  dense,  hard  masses,  eo  hard,  ^a 
many  instances,  that,  before  attempting  to  break  them 
up  and  remove  them,  it  is  necessary  to  soften  them  by 
injections  of  oil  or  soapsuds,  every  physician  who  has 
had  this  experience  knows  that  this  dense  mass  consists 
of  nothing,  practically,  but  milk.  It  is  an  entire  mis- 
take to  regard  milk  as  a  liquid  in  diet.  It  is  a  liquid 
in  the  tumbler,  but  we  ought  always  to  think  of  it  as 
solid  food.  It  becomes  a  solid  in  the  stomach,  it  enters 
the  small  intestine  a  solid,  and  it  passes  through  a 
solid.  If  the  original  assumption  be  true,  that  it  is 
wise  to  feed  the  patient  so  that  there  shall  be  as  little 
as  possible  of  irritating  detritus  passing  down  over  the 
ulcerated  glands,  then  certainly  milk  does  not  fill  the 
requirements. 

Not  only  is  the  milk  diet,  in  typhoid  fever,  logically 
unsound  because  of  the  large  amount  of  solid  substance 
which  it  sends  down  through  the  small  intestine,  where 
it  is  liable  to  act  as  an  irritant,  but  it  is  a  dangerous  diet 
because  it  forms  an  admirable  culture-medium  for 
various  bacteria.  That  it  is  an  admirable  medium  for 
the  spread  of  the  specific  bacillus  of  typhoid  fever  is 
undoubted.  Whenever  an  epidemic  breaks  out  and  we 
attempt  to  trace  the  source  of  the  intoxication,  we 
search,  first,  for  a  defective  water-supply,  and,  if  we  do 
not  find  the  source  of  contamination  there,  we  immedi- 
ately begin  to  follow  the  routes  of  the  milk  men.  A 
large  number  of  epidemics  have  been  traced,  accurately 
following  a  single  milkman's  route.  If  the  milk  caa 
carry  the  poison  into  the  patient  in  the  first  place,  the 
large  amount  of  undigested  residue  of  solid  milk,  in 
the  small  intestines,  would  seem  to  form  an  admirable 
breeding-place  for  the  further  development  ot  the  speci- 
fic germ  of  typhoid,  but  the  question  is  a  much  wider 
one  than  simply  the  spreading  of  typhoid  bacilli  At 
a  recent  meeting  of  the  Detroit  Academy  of  Medicine 
Dr.  Dock  read  a  paper  on  the  treatment  of  typhoid 
fever.  In  the  discussion  I  brought  up  the  point  just 
alluded  to,  and  Dr.  Dock's  reply  was  to  the  effect  that, 
after  the  first  intoxication,  in  typhoid  fever,  the  bacillus 
of  Eberth  was  found,  not  so  much  in  the  intestinal 
canal  or  on  the  mucous  membrane,  but  in  the  deeper 
structures  of  the  intestinal  wall,  in  the  intestinal  and 
mesenteric  glands,  as  well  as  in  more  distant  glandular 
structures.  It  was  argued  that,  therefore,  the  attempt  to 
produce  intestinal  asepsis  was  useless,  as  the  specific 
bacilli  were  out  of  reach.  Such  an  argument,  while  it 
may  be  technically  correct,  loses  sight  of  a  very  essen- 
tial series  of  facts.  I  suppose  that  no  one  would,  for  a 
moment,  assert  that  all  of  the  bacilli  of  Eberth  left  the 
intestine  and  were  taken  up  in  the  glandular  structures, 
for,  were  this  so,  there  would  not  be  the  slightest  danger 
of  conveying  the  disease  to  others,  by  means  of  the 
dejecta  of  a  typhoid-fever  patient.  Now  the  fact  is 
that,  throughout  the  disease,  the  stools  of  the  patient 
contain  the  specific  germs  in  such  quantities  that  we  all 
thoroughly  understand  that  it  is  from  this  source  — 
practically  from  this  source  only — that  the  disease  is 
propagated  to  others  ;  it  therefore  is  demonstrable  that 
the  specific  bacilli  of  the  disease  remain  in  the  intes- 
tinal canal,  and  there  is  every  reason  to  believe  that 
masses  of  undigested  milk  may  very  easily  form  a 
breeding  ground  for  the  bacilli,  and  so  furnish  a  con- 
stant intoxication  of  the  patient  ;  but,  even  were  there 
no  typhoid  bacilli  left  in  the  intestinal  canal,  there  are 
other  bacilli  which  will  thrive  with  equal  rapidity  ia 
milk,  and  there  is  every  reason  to  believe  that  not  only 
in  typhoid  fever  but  in  many  other  diseases  the  real 


February  9,  1901] 


DIETETIC  MANAGEMENT  OF  TYPHOID  FEVER 


[ThS  PHn.ASBI.PBIA 
Mrdicai.  Jocbhai. 


309 


danger  to  the  patient  proceeds  from  the  secondary  in- 
toxication. Stop,  for  a  moment,  to  consider  the 
phenomena  of  an  ordinary  case  of  consumption.  The 
patient  is  infected  with  the  tubercle  bacillus.  Under 
ordinary  circumstances,  as  long  as  the  infection  is 
purely  tuberculous,  the  patient's  progress,  from  bad  to 
worse,  is  but  slow.  He  has,  indeed,  fever,  cough, 
emaciation,  and  a  small  amount  of  expectoration,  often 
almost  none ;  so  he  may  continue  for  a  considerable 
time,  slowly  getting  worse.  Once  let  some  portion  of 
the  lung-substance  become  necrosed  and  a  secondary 
streptococcus  infection  take  place,  notice  what  a  rapid 
change  occurs.  He  now  develops  hectic  fever,  night- 
sweats,  profuse  expectoration,  diarrhea.  It  might  almost 
be  said  that  the  great  danger  of  the  tuberculous  patient 
was  that  of  a  streptococcus  infection.  It  is  the  second- 
ary infection  that  starts  him  on  the  rapid  downward 
course.  Take,  again,  the  phenomena  of  diphtheria. 
The  primary  infection  is  by  the  LofHer  bacillus.  The 
exudate  in  the  throat  is  the  result  of  the  primary  infec- 
tion. While  it  is  true  that  our  efforts  ought  to  be 
directed  to  overcoming  the  primary  infection  with  all 
possible  speed,  does  any  physician  feel  justified  in 
neglecting  attention  to  the  exudate  ?  Not  at  all.  In- 
deed, he  recognizes  that  the  exudate  forms  a  focus  for 
a  constant  reinfection  of  the  patient.  Not  only  does 
the  exudate  form  a  focus  of  reinfection  by  the  Lofller 
bacillus,  but  by  the  streptococcus  as  well.  And  again 
there  is  reason  to  believe  that  no  small  part  of  the  dan- 
ger of  the  diphtheric  patient  arises  from  the  secondary 
infection.  We  ought  to  keep  precisely  the  same  rea- 
soning in  mind  in  the  management  of  typhoid  fever. 
It  does  not  seem  a  question  of  the  primary  infection  of 
Eberth's  bacillus  alone,  but  anything  which  facilitates  a 
constant  reinfection  by  the  Eberth  bacillus  or  a  second- 
ary infection  by  streptococci  or  the  colon  bacilli,  adds 
enormously  to  the  patient's  dangers. 

On  these  grounds,  then,  it  seems  to  me  that  we  have 
made  a  radical  mistake  in  feeding  milk  to  typhoid-fever 
patients.  Osborne,  in  an  article  in  The  Philadelphia 
Medical  .Journal,  in  December,  1899,  has  this  to  say: 

"In  typhoid  fever,  constipation  keeps  the  partially  di- 
gested milk  or  cither  nutriment  long  in  the  intestines,  the 
mucus  and  ulcerative  sloughs  remain  in  situ,  and  thus 
beautiful  culture  grounds  for  all  sorts  of  bacilli  and  cocci 
are  formed,  while  in  addition,  the  colon  bacillus  adds  its 
toxins  to  the  rest.  Xext,  fermentation  increases  and  gas  is 
formed,  and  tympanites  occurs  with  its  discomfort  and 
dangers  of  perforation  and  of  hemorrhage  from  distention  ; 
meanwhile  the  action  of  the  heart  will  be  impaired  as  a  con- 
sequence of  abdominal  distention.  All  of  this  increases  the 
fever  and  the  cerebral  toxemia.  If  one  has  a  doubt  of  what 
such  bowel  stoppage  causes,  he  has  but  to  recall  instances  in 
which  a  case  of  irregular  chills,  heavily  coated-  tongue,  pro- 
found headache,  high  and  continued  fever,  concentrated 
urine,  constipation,  and  tympanites  has  been  proved,  by 
absence  of  the  malarial  Plasmodium  from  the  blood  and  the 
negative  Widal  serum  reaction,  to  he  neither  malarial  nor 
typhoid,  but  a  pure  case  of  bowel  infection." 

Let  us  return  now  to  the  other  assumption  of  the 
advantages  of  milk  diet,  to  wit :  that  milk  keeps  up  the 
nutrition  of  the  patient  to  the  highest  possible  degree. 
Does  it '?  Let  any  man  who  has  carried  his  typhoid- 
fever  patient  through,  giving  abundance  of  milk,  and 
who  sees  his  patient  reduced  to  a  skeleton,  ask  himself 
the  question,  "  does  it  ?"  The  fact  is  it  does  not.  The 
patient  comes  out  at  the  end  of  the  fever  emaciated 
until  he  could  hardly  become  emaciated  any  further. 
His  pulse  is  weak ;  it  could  not  become  much  weaker 
and  the  patient  live.     It  would  certainly  seem  that  no 


other  food  could  have  brought  the  patient  to  a  condition 
any  worse,  as  far  as  his  nutrition  is  concerned.  I  think 
the  physician,  looking  at  the  emaciated  typhoid  skeleton, 
might  even  ask  himself,  "  How  much  thinner  would  mj' 
patient  have  been  if  he  had  had  no  food  whatever  ?"  It 
would  seem,  therefore,  that  the  primary  assumptions 
so  commonly  accepted  on  close  examination  are  proven 
to  be  wrong  one  and  all.  Now  there  is  another  side. 
Before  the  patient  calls  the  doctor,  in  typhoid  fever,  he 
usually  has  a  period  of  from  a  week  to  ten  days  of 
general  malaise  during  which  he  has  a  moderate  degree 
of  fever,  a  good  deal  of  headache,  and  a  moderate  diar- 
rhea, if  any  ;  he  is  sick,  but  he  is  not  very  sick.  Finally 
the  doctor  is  called.  The  patient  is  put  to  bed  and 
measures  are  taken,  one  way  or  another,  to  moderate  the 
fever.  Theoretically  he  ought  at  once  to  begin  to  be 
somewhat  better,  or,  at  the  very  least,  he  ought  not  to 
grow  rapidly  worse,  for  now,  lying  in  bed,  he  ought  to 
save  his  strength  and  abate  his  fever,  even  if  nothing 
were  done  for  him.  What  happens?  The  officious 
doctor,  eager  to  keep  up  his  patient's  strength,  begins 
to  insist  on  his  taking  considerable  quantities  of  milk. 
The  patient,  led  by  nature's  own  indication,  has  been 
eating  practically  nothing.  Now  the  fever  begins  to 
climb,  step  by  step,  day  by  day,  until  within  three  or  four 
days  it  reaches  its  high  point,  and  now  the  physician 
enters  upon  a  long  fight  in  which  he  endeavors  to  keep 
the  fever  within  moderate  bounds.  It  may  be  that  the 
patient  is  put  into  the  bath  and  the  temperature  is 
forced  down,  only  to  run  rapidly  up  in  the  next  two  or 
three  hours,  when  another  bath  is  given.  So  the  tem- 
perature see-saws,  inevitably  rising  as  soon  as  the  efifect 
of  the  bath  has  passed  off,  and  meantime  the  patient  is 
being  fed  casein,  although  the  doctor  knows  very  well 
that  the  patient's  digestive  powers,  as  far  as  his  stomach 
is  concerned,  have  practically  ceased,  and  the  digestive 
power  of  his  small  intestine  is  even  more  precarious. 
Nevertheless  down  goes  the  casein. 

It  has  been  my  amusement  to  visit  Mt.  Clemens,  the 
"  Mecca  "  of  rheumatic  patients  from  all  parts  of  the 
United  States.  I  have  seen  patients  who  had  scraped 
together,  with  great  difficulty,  enough  money  to  come 
to  Mt.  Clemens,  take  a  bath  every  morning,  be  rubbed, 
scrubbed,  sweated,  in  a  vigorous  attempt  to  eliminate 
the  rheumatic  poison,  and  then,  three  times  a  day,  sit 
down  in  the  dining-room,  study  over  the  bill  of  fare,  in 
which  the  hotel-keeper  had  provided  an  admirable 
menu  consisting  for  the  most  part  of  meat  and  eggs, 
and  then  I  have  seen  the  patient  eat  more  nitrogenous 
food  at  one  meal  than  he  could  wash  out  of  him  by  the 
bath  the  next  morning.  It  seemed  a  most  astonishing 
thing  to  see  a  man,  three  times  a  day,  putting  into  himself 
the  very  substances  out  of  which  is  formed  the  poison 
which  he  is  laboriously  trying  to  get  out  of  himself. 
Precisely  analogous  is  the  process  of  forcing  food  on 
our  typhoid  patients.  The  primary  infection  of  the 
typhoid  bacillus  takes  place  by  way  of  the  sound 
mucous  membrane.  When  the  bacilli  have  begun  to  fill  up 
the  glandular  structures  connected  with  the  intestine, 
the  disease  is  established  and  must  take  its  course,  but 
without  a  fresh  and  continued  infection  it  would  seem 
reasonable  to  believe  that  the  period  of  activity  of  the 
bacilli  would  come  to  an  end  within  a  reasonable  time. 
If  the  intestines  were  emptied,  as  far  as  possible  of  aU 
substances,  which  could  form  a  culture  ground  for 
bacilli  of  any  kind,  the  process  of  reinfection  would, 
thereby,  be  reduced  to  a  minimum.  While  the  primary 
infection  was  pursuing  its  course,  a  certain  waste  of 


310 


The  Philadelphia"] 
Medical  Jocenal  J 


DIETETIC  MANAGEMENT  OF  TYPHOID  FEVER 


[Fbbboabt  9,  1901 


the  tissues  of  the  body  would  undoubtedly  take  place, 
but  the  probability  is,  that  the  febrile  process  would 
very  soon  become  limited,  by  the  absence  of  pabulum. 
In  so  far  as  the  serous  part  of  the  milk  is  absorbed  and, 
in  so  far  as  a  portion  of  the  casein  is  digested  and 
absorbed,  it  is  a  question  deserving  of  careful  investi- 
gation, whether  these  foodstuffs  do  not  simply  serve  to 
feed  the  fever.  That  the  feeding  of  fevers  in  the  so- 
oalled  supporting  treatment,  is  devoid  of  the  striking 
advantages  claimed  for  it,  is  shown  by  the  statistics  of 
the  Massachusetts  General  Hospital.  In  these  the 
mortality  is  shown  to  have  been  practically  the  same 
in  the  days  when  purging,  bleeding,  and  low  diet  were 
■employed,  as  it  is  when  the  feeding  and  supporting 
treatment  are  used.  Now  the  old  treatment  of  low  diet 
included  bleeding  and  purging.  Our  medical  ances- 
tors were  as  dangerous  to  their  patients  as  we  are  to 
ours,  only  in  a  different  way.  If  they  had  been  con- 
tent to  let  their  patients  have  a  low  diet  and  lots  of 
pure  air  and  pure  water  they  would,  I  think  we  will 
all  agree,  have  had  better  results  had  they  omitted  the 
bleeding  and  used  only  so  much  purging  as  would 
keep  the  intestines  fairly  free  from  putrefying  con- 
tents. They  had  a  pretty  good  idea  at  the  bottom  of 
their  purging  process,  but  they  overdid  it.  When  the 
reaction  came  we  went  too  far  the  other  way,  and,  in  a 
■desperate  attempt  to  support  our  patients,  we  also  have 
sinned  by  overdoing. 

A  curious  series  of  experiments  on  animals  has 
been  made,  which  has  shown  that  feeding  does  not  in- 
■crease  the  vital  resistance  in  fevers.  Inoculated  ani- 
mals were  found  to  survive  anj'  given  infection,  with 
little  or  no  food  better  than  those  fed  liberally.  I  know 
that  it  takes  nerve  to  see  a  typhoid  fever  patient  gradu- 
ally wasting  both  strength  and  flesh  as  the  fever  goes 
•on,  and  refrain  from  putting,  what  to  a  well  man  is 
nourishing  food,  into  the  patient.  We  do  not  see  the 
dark  red  stomach,  containing  far  more  mucus  than 
gastric  juice ;  we  cannot  compel  our  imaginations  to 
make  real  to  us  the  swollen,  cyanosed,  almost  or  quite 
necrotic  mucous  membrane  of  the  small  intestine.  If 
we  could  imagine  these  mternal  conditions  so  vividly 
that  it  was  all  as  clear  to  us  as  the  dusky  face,  the 
shrunken  arms  and  legs,  the  hollow  eyes,  it  would  be 
■easier  for  us  to  resist  the  impulse  to  put  a  lot  of  stuff 
■down  out  of  sight  and  hope  for  the  best. 

It  has  been  my  fortune  to  advocate  the  principles  I 
now  contend  for,  in  consultation  at  the  bedside.  The 
■doctor  says :  "  Yes,  doctor,  I  believe  you  are  right  in 
theory ;  I  can  see  that  the  stomach  is  practically  un- 
able to  digest  food,  that  the  intestinal  mucous  mem- 
brane not  only  has  long  since  lost  its  normal  function 
but  is  apt  to  be  damaged  by  irritant  substances  and 
putrefying  ones ;  you  may  be  right  that  the  fire  of  the 
fever  would  be  less  intense  and  would  burn  down  sooner 
if  we  didn't  keep  piling  on  fuel,  but  just  look  at  the  pa- 
tient !  See  how  thin  he  is !  How  weak  his  pulse ! 
Some  time  I'd  like  to  discuss  your  theory  with  you,  but 
I  guess  this  time  I  will  go  on  feeding." 

It  takes  nerve  to  take  an  infant  suffering  from  cholera 
infantum,  take  it  away  from  the  mother's  breast,  cut 
off  cow's  milk,  or  food  of  any  kind,  and  keep  the  baby 
on  sterilized  water  and  Epsom  salts  until  the  nearest 
approach  possible  to  intestinal  asepsis  is  secured,  but, 
fortunately,  the  profession  has  learned  that  degree  of 
•courage. 

I  am  well  aware  of  the  limitations  of  my  own  per- 
sonal experience  in  typhoid  fever,  but  at  least  I  have 


seen  this.  I  have  seen  patients  whose  fever  kept  spring- 
ing up  after  the  bath  like  a  steel  spring,  patients  whose 
brains  were  so  poisoned  that  delirium  was  deepening 
into  coma,  come  out  into  moderate  fever  and  a  clear 
head  within  48  hours  after  the  forced  feeding  was 
stopped  and  a  water  diet  instituted. 

We  are  oppressed  by  this  fear  of  starvation.  Starva- 
tion is  a  slow  process.  Dr.  Tanner  demonstrated  that 
40  days'  starvation  is  endurable  provided  the  patient 
drinks  plenty  of  pure  water. 

The  ideal  diet  for  typhoid  fever  is  pure  water  in 
abundance.  This  will  keep  the  excretions  by  skin, 
lungs,  kidneys,  and  liver  up  to  their  best,  and  our 
typhoid  patients  need  to  keep  all  means  of  elimination 
of  poison  in  fullest  activity,  providing  it  be  not  a  pros- 
trating activity.  The  action  of  kidneys,  liver,  and  skin 
induced  by  superabundant  water  is  never  prostrating. 
This  cannot  be  said  of  action  induced  by  drugs.  It  is 
not  enough  to  give  the  patient  as  much  water  as  he  may 
happen  to  crave,  we  must  use  our  scientific  imagination 
to  picture  the  very  large  quantity  of  water  which  goes 
out  by  the  lungs ;  notice  how  quickly  the  moistened 
tongue  becomes  parched ;  we  must  realize  the  evapora- 
tion from  the  skin  ;  consider  the  diarrhea  and  the  uri- 
nary needs ;  then  put  in  water  enough  to  keep  all  these 
in  full  activity. 

People  have  imbibed  enough  of  current  medical 
opinion  to  make  it  difiicult  to  stop  our  present  danger- 
ous overfeeding.  Even  were  the  attending  physician 
convinced  of  the  safety  of  the  pure  water  diet,  the 
friends  will  insist  that  the  patient's  strength  must  be 
kept  up.  In  such  cases  any  of  the  best  advertised  meat- 
juice  foods  (so-caUed)  can  be  utilized.  They  contain 
little  real  food  value,  and  are,  fortunately,  mostly  ab- 
sorbed in  the  stomach,  and  so  leave  little  or  no  detritus 
to  go  through  the  bowels.  There  comes  a  time  in  the 
course  of  the  fever  whea  the  patient's  appetite  returns. 
This  is  always  a  difficult  period.  Pressure  by  both  the 
patient  and  the  patient "s  friends  is  very  great.  It  is 
hard  to  resist  the  cry  for  all  kinds  of  food  and  lots  of 
it,  yet  there  is  probably  no  man  who  reads  this  who  has 
not  had  the  bitter  experience  of  seeing  his  patient 
quickly  relapse  after  some  newly-tried  indulgence  in 
food.  It  seems  to  me  that  the  best  rule  to  follow  is 
this:  Give  such  foods  as  are  most  completely  digested 
and  absorbed  in  the  stomach  ;  keep  steadily  in  mind 
that  while  the  stomach  maj'  be  acting  but  poorly,  the 
intestinal  condition  is  far  worse.  Still  we  should  send 
down  from  the  stomach  as  little  detritus  as  possible.  A 
tender  lamb  chop  or  a  poached  egg  is  safer  than  a 
tumbler  of  milk ;  safer  now,  safer  all  the  way  through. 

One  thing  I  wish  to  add  in  the  matter  of  stimulation. 
Time  has  been  when  a  convalescing  typhoid  patient 
drank  alcohol  in  great  quantities.    The  practice  seems 
now  largely  gone  by,  and  fortunately  so,  yet  through- 
out these  cases  the  physician  knows  the  need  and  the 
value  of  an  occasional  stimulant.    For  a  long  time  1 
have  used,  instead  of  alcohol,  a  small   drink  of  good 
coffee.      Those  of  us  who  know  how  a  cup  of  coffee  st 
— say  from  two  to  four  in  the  afternoon,  will  keep  .; 
awake  till  two  o'clock  in  the  morning,  know  that  th 
stimulant  effect  of  coffee  is  not  transient  like  that 
alcohol,  but  lasts  hour  after  hour — six.  eight,  ten  hours 
Now,  what  a  typhoid  convalescent  needs  is  not  a  fillip 
which  picks  him  up  and  drops  him  down  again,  he  nee^i- 
a  good,  steady,  lasting  lift,  and  coffee  will  give  it  to  hiiv. 
Don't  have  the  friends  give  him  watery  coffee ;  a  deli- 
cate after-dinner  coffeecup   full   of  good  coffee  with 


Fkbruakt  9,  1901] 


SUDDEN  DEATH  IN  PLEURISY 


rTHE  PHU-ADELPHIA 
Medical  Journal 


311 


cream  and  sugar  will  taste  good  and  do  good,  and  keep 
on  doing  good. 

One  more  practical  point.  I  have  urged  that  such 
foods  as  are  given  should  be  readily  absorbed  by  the 
gastric  mucous  membrane ;  there  is  one  food  of  which 
we  are  apt  to  think  too  little — sugar — we  are  apt  to 
think  of  it  as  simply  a  means  of  sweetening  foods ;  in 
reality  it  is  highly  nutritious — no  other  hydrocarbon  is 
more  promptly  and  easily  absorbed — it  leaves  no  detri- 
tus whatever.  A  man  with  muscles,  tired  from  labor, 
can  recuperate  rapidly  on  sugar.  A  typhoid  patient 
can  take  it  up  rapidly.  I  have  ventured  to  present 
these  thoughts  on  the  dietetic  treatment  of  typhoid 
fever  in  the  hope  that  they  may  stimulate  discussion 
and  induce  men  whose  daily  practice  gives  them  large 
opportunity  to  observe,  to  put  these  ideas  to  a  thorough 
test. 


SUDDEN  DEATH  IN  PLEURISY. 
Witt  Report  of  a  Case. 

By  CHAKLES  LEWIS  ALLEN,  M.D., 
Pathologist  and  Assistant  Physician,  New  Jersey  State  Hospital  at  Trenton. 

Sodden  death  in  pleurisy,  at  any  rate  apart  from 
operative  procedure,  is  certainly  quite  exceptional. 
Trousseau  stated  that  in  a  hospital  and  civU  practice  of 
19  years,  he  saw  only  3  cases.  Few,  if  any  other  ob- 
servers have  encountered  a  greater  number,  hence  it 
seems  proper  to  put  on  record  the  following  case, 
which  presents  some  interesting  and  unusual  features  : 

F.  S.,  44  years  of  age,  a  powerfully  built  and  well-nourished 
man,  insane  for  about  12  years,  and  at  the  time  of  his  last 
illness,  a  terminal  dement,  never  speaking,  so  unable  to  give 
any  account  of  himself,  on  October  1,  1900,  was  noticed  to 
have  lost  his  appetite,  and  appeared  ill.  His  temperature 
was  found  to  be  99°  F.,  his  tongue  slightly  furred,  but  a 
physical  examination  was  negative,  and  no  other  symptoms 
could  be  elicited.  He  was  given  a  calomel  purge.  On 
October  2,  his  condition  appeared  unchanged.  Temperature 
A.M.,  99°,  P.M.,  100°.  On  October  3  he  seemed  better.  Morn- 
ing temperature  98.5° ;  afternoon  temperature,  99°.  Noth- 
ing wrong  was  noticed  during  the  night,  but  on  the  morning 
of  October  4  the  attendant  found  that  he  had  soiled  his  bed, 
something  quite  unusual  for  him,  and  when  he  was  gotten 
up  to  be  cleansed,  he  appeared  quite  weak.  At  about  8  40 
A.M.,  he  was  noticed  to  be  blue  and  collapsed ;  he  vomited, 
his  bowels  moved  involuntarily,  and  he  had  a  convulsion. 
Responding  at  once  to  a  summons,  I  found  him  cyanotic 
and  pulseless,  his  skin  cold  and  covered  with  sweat,  his 
respiration  rapid  and  labored.  A  few  coarse  rales  could  be 
heard  over  the  left  lung,  none  over  the  right.  The  heart- 
sounds  were  inaudible.  Strj'chnin  was  at  once  administered 
hj'podermically,  but  he  was  dead  before  some  hot  bottles 
which  were  being  prepared  could  be  applied. 

An  autopsy,  made  6  hours  after  death,  showed  the  follow- 
ing conditions :  The  brain,  apart  from  some  adhesions  of 
the  dura  along  the  superior  longitudinal  sinus,  and  slight 
milkiness  in  places  of  the  pia  arachnoid,  presented  macro- 
scopically  nothing  abnormal.  The  left  pleural  cavity  con- 
tained about  180  cc.  of  slightly  blood-stained  serum.  The 
left  lung  showed  old  and  very  firm  adhesions  over  its  lower 
portion.  The  left  pulmonary  artery  was  completely  filled  by 
very  firm  dark  clot,  which  extended  into  its  larger  divisions. 
The  right  lung  was  so  firmly  adherent  over  its  whole  area 
that  it  could  not  be  removed  without  tearing  it.  The  greater 
part  of  the  adhesions  were  old,  but  there  was  some  recent 
pleurisy  with  fresh  adhesions  over  its  anterior  surface.  No 
fluid.  Toward  the  lower  portion  of  the  inner  border  of  the 
right  upper  lobe,  there  were  two  hemorrhagic  infarcts,  each 
about  the  size  of  a  pigeon's  egg.  The  lumen  of  the  right  pul- 
monary artery  was  free,  but  its  medium-sized  branches  were 
filled  with  firm,  dark  clots.  Both  lungs  were  deeply  con- 
gested and  somewhat    edematous.    At  both  apices  there 


were  several  areas  of  fibrous  induration  containing  in  their 
centers  a  calcareous  deposit,  apparently  healed  tuberculosis. 
The  bronchial  glands  were  enlarged  and  deeply  pigmented. 
The  pericardium  appeared  healthy.  Its  cavity  contained 
about  30  cc.  of  blood-stained  serum.  The  heart  was  flabby, 
but  its  muscle  appeared  normal.  Each  ventricle  contained 
a  few  soft  clots,  some  dark  and  some  pale.  The  valves  were 
normal.  The  peritoneal  cavity  contained  a  small  amount  of 
clear  serum.  The  liver  was  congested.  The  stomach 
showed  chronic  gastritis.  The  other  organs  were  normal. 
The  microscopical  examination  gave  no  further  information, 
except  to  show  that  the  kidneys  were  not  diseased. 

It  would  seem  as  if  the  pleurisy  should  have  been 
diagnosed  before  death,  but  it  is  to  be  remembered  that 
the  patient  was  demented,  made  no  complaint,  and  it 
was  entirely  impossible  to  get  his  cooperation.  With 
insane  individuals  we  have  often  to  be  content  with  a 
very  imperfect  physical  examination.  Again,  his 
symptoms  pointed  rather  to  a  mild  gastrointestinal 
catarrh,  than  to  any  disease  of  the  lungs,  and  as  he 
seemed  to  be  improving,  his  chest  was  not  examined 
again  after  the  first  day. 

Gee, '  in  speaking  of  sudden  death  in  pleurisy,  gives 
three  causes  for  this  accident :  (1)  Suffocation  from 
rupture  of  an  empyema  into  the  lung ;  (2)  sudden 
development  of  pulmonary  edema ;  (3)  thrombosis  or 
embolism  of  the  pulmonary  artery,  or  thrombosis  of  the 
right  heart,  the  immense  majority  of  all  cases  being  due 
to  this  last  cause.  By  some  authors,  a  kinking  of  the 
aorta  or  vena  cava  through  displacement  of  the  heart 
by  the  effusion,  has  been  held  accountable  for  the 
occurrence  of  thrombosis  or  embolism.  This  view  has 
been  combated  by  Leichtenstern,  ^  who,  from  experi- 
ments upon  the  cadaver,  has  concluded  that  it  is  impos- 
sible for  enough  "  kinking  "  of  the  vessels  to  cause  an 
obstruction  to  be  produced  through  the  tilling  of  the 
pleural  cavity  with  fluid.  It  is,  however,  pointed  out 
by  Rosenbach, '  who  rather  favors  the  vessel-kinking 
theory,  that  it  is  hardly  fair  to  assume  from  experi- 
ments upon  cadavers  that  the  production  of  kinking  is 
impossible  in  the  living  subject,  in  whom  the  condition 
of  the  vessels,  etc.,  is  entirely  different. 

The  occurrence  of  sudden  death  during  or  after 
washing  cut  the  pleural  cavity  was  not  unknown  when 
this  practice  was  commoner  than  it  is  today.  Perhaps 
in  this  case  it  is  to  be  explained  by  the  entrance  into 
the  circulation  of  a  flake  of  fibrin  loosened  by  the 
washing. 

Of  10  cases  of  which  Leichtenstern  ^  gives  a  summary, 
9  were  due  to  thrombosis,  and  1  to  embolism.  As 
favoring  these  conditions,  this  author  gives  the  fol- 
lowing : 

1.  Slowing  of  the  circulation  on  account  of  obstruc- 
tion due  to  compression  of  the  lungs  and  weakening 
of  the  heart  by  the  continued  fever. 

2.  The  pressure  on  the  heart  and  vessels  exceeding 
the  atmospheric  pressure,  the  aspiration  in  diastole  is 
much  diminished. 

3.  The  aspiratory  power  of  the  compressed  lung  is 
diminished  or  lost. 

In  his  experience,  in  the  majority  of  cases  of  sudden 
death,  the  pleurisy  was  right-sided.  In  another  class  of 
cases  death  has  been  due  to  cerebral  embolism.  In 
still  others  to  causes  not  directly  connected  with  the 
pleurisy,  while  there  yet  remain  cases  in  which  the 
autopsy  furnished  no  information  as  to  the  cause  ot 
death.  Weill'  calls  attention  to  the  fact  that  in  some 
cases  death  may  be  due  to  myocardial  disease,  and 
reports  an  instance  of  this  which  he  himself  has  ob- 
served.    In  none  of  the  cases  of  which  I  have  been 


312 


The  Philadelphia"! 
Medical  Jodbnal  J 


SUDDEN  DEATH  IN  PLEURISY 


[Fkbbvaby  9,  1901 


able  to  find  a  report  has  efi'usion  been  absent,  though 
in  some  it  was  of  moderate  extent.  In  the  case  here 
mentioned  the  effusion  was  very  small  indeed,  in  fact, 
it  seems  to  me  probable  that  the  fluid  found  in  the  left 
pleural,  the  pericardial  and  the  peritoneal  cavities  was 
only  exuded  during  the  death  agony.  There  was  no 
evidence  of  recent  pleurisy  on  the  left  side.  The  most 
prominent  condition  was  the  great  extent  and  firmness 
of  the  pleural  adhesions.  That  complete  adherence  of 
one  lung,  however,  need  not  necessarily  cause  much 
embarrassment  of  respiration  or  circulation  is  shown  by 
a  case  reported  by  Warner.*  ;— '_  '^-^.fM-j 

It  seems  to  me  that  in  the  above  case  of  F.  S.  the 
following  sequence  of  events  is  probable.  During  the 
night,  or  early  morning,  a  flake  of  fibrin  was  absorbed 
from  the  area  of  fresh  pleurisy  in  the  right  lung.  This 
being  carried  to  the  pulmonary  vein,  lodged  there,  and 
produced  a  gradual  thrombosis  which  caused  a  fatal 
termination  several  hours  later.  This  case  certainly 
lends  no  support  to  the  theory  of  vascular  kinking, 
since,  though  the  adhesions  were  very  extensive,  there 
was  no  contraction  of  the  chest  and  the  heart  was  not 
displaced. 

REFERENCES. 
I 

iGee:  Article,  Pleurisy  in  "  A  System  of  Medicine,"  edited  by  T.  Clifiord 

Albutt,  vol.  V. 

2  Leichtenstern  :    "Die   plotzlichen  Todeslalle   bei    pleuritiscbem  Exudat," 
Deutsches  Archivf.  klin.  Mcdicin,  1879,  xxv,  S.  5125. 

3  Rosenbach  :    "  Nothnagel's  Specielle  Pathologic   und  Therapie,"  Bd.  xxv, 
I.  Th. 

*  Weill :  "  La  raorte  subite  dans  la  pleur6sie,  Revne  de  Midecine,  1887,  vii,  p.  S3- 
5  Warner :  "  Extensive  pleural  adhesions."    Medical  Record,  1897,  xlv,  p,  205- 


Subphrenic  Abscess. — Krohne  {Deutsche  Med.  M'och.) 
reports  a  case  occurring  in  a  child  7  years  of  age,  which,  on 
account  of  its  difficult  diagnosis  and  etiological  factors,  is 
very  interesting.  About  2  years  previous  to  the  present 
illness  the  child  suffered  from  a  purulent  otitis  of  the  middle 
ear,  this  caused  mastoid  disease,  requiring  operation,  with 
removal  of  some  necrosed  bone ;  after  recovering  from  this 
the  child  enjoyed  fairly  good  health  until  June,  when  it 
developed  a  perityphlitis,  with  some  localized  peritonitis 
which  yielded  easily.  About  the  end  of  July  the  child  de- 
veloped a  hectic  condition  with  concomitant  symptoms  and 
a  tumor  above  the  liver  on  the  right  side ;  a  week  later  a 
purulent  bronchitis  with  the  expectoration  of  a  foul  pus 
developed,  and  it  looked  as  if  collapse  would  soon  follow. 
The  diagnosis  was  then  clear  and  Krohne  decided  to  oper- 
ate. An  incision  6  cm.  long  was  made  on  a  line  with  the 
ribs  about  the  level  of  the  xiphoid,  and  about  a  cup  of  pus 
escaped,  the  adhesions  (between  pleura  and  lung)  gave  way 
and  air  and  pus  entered  the  pleural  cavity.  The 
abscess  was  packed  with  iodoform  gauze  and  washed  with 
i  %  creolin  solution  until  healed.  The  cause  of  this  abscess 
does  not  seem  clear ;  was  the  infection  from  the  ear  or  the 
perityphlitis  ?    [w.s.  n.] 

Ingruinal  Hernia.— In  a  paper  read  by  B.  Merrill  Kick- 
etts,  Ph.B.,  M.D.,  of  Cincinnati,  Ohio,  before  the  Medical 
Society  of  the  State  of  New  York,  Albany,  January  29,  1901, 
Dr.  Ricketts  gives  the  most  complete  and  comprehensive 
description  of  the  anatomy  ot  the  parts  involved  in  inguinal 
hernia  to  be  found  in  any  work.  In  fact,  it  embodies  the 
researches  of  all  the  best  anatomists  and  specialists.  He 
criticises  the  use  of  the  word  canal  in  this  connection. 
He  claims  that,  etymologically  and  anatomically,  the  use  of 
the  word  canal  is  wrong.  Ring  is  the  proper  word.  A  circular 
letter  was  sent  to  over  100  prominent  surgeons.  Many  inter- 
esting facts  can  be  deduced  from  the  replies  received.  Thirty- 
four  surgeons  gave  an  approximate  percentage  of  recurrence 
in  their  practice ;  this  percentage  varies  from  1  to  15^ .  This 
last  percent  agrees  with  the  figures  of  Prof.  Girard,  of  Berne, 
who  claims  that  the  percentage  of  recurrence  in  Europe  will 
amount  to  15^.  The  percentage  will  average  5.6S%,  based 
on  6,027  operations  by  84  surgeons.  From  statements  con- 
tained in  letters  received  in  answer  to  the  circular,  it  is  fair 
to  infer  that  only  one-half  of  the  total  number  of  operations 
were  reported.    This  would  bring  the  percentage  up  to  near 


15%.  These  letters  show  that  infection  is  less  frequent  and 
that  there  is  no  recurrence  when  wire  or  silkworm-gut  ig 
used  in  the  Phelps,  Halsted,  or  Abbe  method  of  operation. 
The  doctor  bears  unequivocal  testimony  to  the  success  of  the 
Phelps  operation ;  he  employs  it  in  his  practice,  and  con- 
eiders  it  to  be  the  ideal  one.  It  is  the  only  one  that  Insures 
a  successful  and  a  permanent  cure.  The  doctor  agrees  with 
Abbe  that  silver  wire  or  silkworm-gut  is  to  be  employed  in 
preference  to  absorbable  sutures.  He  does  not  believe  that 
suppuration  has  anything  to  do  with  causing  recurrence ;  the 
real  cause,  or  rather  causes,  of  relapse  of  recurrence  are 
deficient  origin  (attachment)  of  the  internal  obUque  muscle, 
pressure  of  truss  (where  one  has  been  worn),  length  of  time 
that  hernia  has  existed,  lack  of  nerve  and  blood  supply,  and 
intraabdominal  pressure  rupturing  the  cicatrix ;  the'latter 
factor  can  be  disregarded  if  the  Phelps  method  is  employed, 
because  if  the  wire  mattress  is  once  placed  properly  mere  is 
no  possibility  of  relapse  by  a  rupture  from  the  intraabdominal 
pressure.  The  doctor  doubts  the  doctrine  advanced  by  some 
writers,  that  varicocele  is  a  causative  factor  in  inguinal 
hernia.  He  properly  holds  that  all  herniotomies  should  be 
regarded  as  modified  laparotomies.  The  paper  closes  with 
several  pertinent  questions  :  Is  there  anything  in  the  habits 
engendered  by  our  rapidly- advancing  civilization  that  is  con- 
ducive to  the  production  of  hernia  ?  Is  man  progressing 
toward  perfection  morphologically,  or  degenerating?  The 
doctor  refers  to  an  edict  of  the  Emperor  Constantine,  forbid- 
ding operations  which  involve  the  loss  of  the  cord  and  testi- 
cle, for  fear  that  the  population  of  the  country  would  suffer. 

Abscess  of  the  Liiver  Following'  Typhoid  Fever. 

— Emile  Cassuto  {Gaz.  Heb.  de  Med.  et  de  Chirur  .  January  6, 
1901,  48me  AnnCe,  No.  12).     (Paris  Thesis,  1899-1900,  No. 
626.)    Abscess  of  the  liver  supervenes  very  rarely  in  the 
course  of  typhoid  fever,  particularly  in  Europe,  but  occa- 
sionally in  tropical  or  intertropical  countries.    Caesuto.  who 
has  made  a  very  complete  study  of  these  cases,  shows  that 
hepatic  suppurations  of  typhoid  origin  from  the  anatomo- 
pathologic  point  of  view  present  2  principal  varieties.      The 
first  is  characterized  by  the  small  size  and  the  multiplicity  of 
the  foci,  by  the  multiple  metastatic  foci  secondary  to  suppu- 
ration in  some  other  part  of  the  body,  by  a  diflfuse  form  of 
periangiocholitis  of  typhoid  origin  following  ulceration  of  the 
bile  paths,  by  a  difluse  form  of  peripyelophlebitis  of  typhoid 
origin  consecutive  to  a  juxtaintestinal  suppuration,  or  to  an 
ulcerogangrenous  lesion  of  the  intestine,  particularly  of  the 
appendix.  The  second  form  is  exactly  like  the  circumscribed, 
suppurative  hepatitis  of  dysenteric  origin  and  consists  of 
single  purulent  collections.    In  such   cases  there    are  r." 
ulcerogangrenous  lesions  of  the  intestine,  no  purulent  fc 
near  the  intestines,  and  nothing  in  the  appendix.    The  into- 
tinal  typhoid  ulcerations  are,  in  thesecases,  wellonthe  way  ; 
wards  cicatrization  and  no  gangrenous  process  can  be  demoi: 
strated  in  their  neighborhood.     The  infecting  germs  coming 
from  the  typhoid  ulcers  in  the  intestine  may  reach  the  liver 
in  three  ways:  (1)  By  the  biliary  paths;  (2)  by  the  arteri-:- 
and  (3)  by  the  portal  vein.    In  all  cases  of  multiple  absce- 
due  to  pylephlebitis  or  to  ulcerogangrenous  lesions  of  tiit 
intestines,  the  pus  in  the  liver  presents  the  characters  c: 
fetid  gangrenous  pus.      Also,  in  crises  of  multiple  abscess  o: 
the  liver  of  typhoid  origin  following  a  pylephlebitis,  a  juit,*- 
intestinal  suppuration,  or  an  ulcerogangrenous  lesion  of  the 
intestine,  the  pus  probably  contains  microorganisms  that  are 
strictly  anaerobic  associated  with  the  typhoid  bacillus.    In  2 
cases  of  single  abscess,  bacteriologic  examination,  as  well  as 
direct  microscopic  examination  of  the  pus,  showed  the  pres- 
ence of  a  pure  culture  of  the  bacillus  of  Eberth  in  one  case : 
and  the  bacillus  of  Eberth  associated  with  very  rare  colonies 
of  staphylococci  in  the  other  case.     The  bacillus  of  Eberth 
alone  is  capable  of  producing  pus  in  the  hepatic  tissue.    But 
it  is  to  be  noted  that  this  bacillus  seems  to  lose  much  of  its 
virulence  in  that  organ.     The  symptoms    of   suppurative 
hepatitis  of  typhoid  origin  are  about  the  same  as  those  of 
suppurative  hepatitis  in  general.    The  diagnosis  of  this  com- 
plication of  typhoid  fever  is  often  impossible.    Nevertheless 
if  the  practitioner  remembers  the  possibility  of  itsoccurrenot 
and  makes  daily  examinations  of  the  liver  of  the  patieui 
suflering  from  typhoid  fever,  he  will  probably  be  able  to  diag- 
nose the  condition  occasionally.      The  existence  of  an  em- 
pyema containing  the  bacillus  of  Eberth  oi^ht  to  draw  tb 
attention  to  the  liver  immediately,    [j.m.s.] 


I 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.  Reprints  (250)  of  Original  Articles  will  be  lurnished  gratis  te  Aotliors  making 
the  request.  * 

The  Editorial  and  Business  Offlccs  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Joamal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  AdvertlalDg  Pages  8  and  32. 


Jambs  Hkndrik  Lloyd,  A.M.,  M. D.,  Editor^n-Chief 
JUI.IC8  L.  Salinokr,  M.D.,  AuociaU  Editor 
Asnalant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyer,  M.D. 

D.  I..  Edsall,  M.D.  T.  L.  Coley,  M.D. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dorland,  M.D. 

■    J.  H.  Gibbon,  M.D. 


Vol.  VII,  No.  7 


FEBRUARY  16,  1901 


$3.00  Per  Annum 


Sanitation  and  Progress. — In  his  address  before  the 
Pan-American  Medical  Congress,  just  held  in  Cuba,  Sur- 
geon-General Wyman  gives  expre.ssion  to  some  mature 
thoughts  which  are  evidently  the  results  of  his  wide 
experience.    He  emphasizes  especially  the  need  of  better 
correlation  between  municipal,  national  and    interna- 
tional authorities  in  the  great  undertaking  of  the  elim- 
ination of  contagious  diseases.     He  is  impressed  with 
the  fact  that  we  are  seriously  lacking  in  the  proper 
efforts  to  suppress  many  suppressible  diseases.    Among 
the  diseases  which  he  mentions  as  well  under  control 
are  smallpox  especially,  and  diphtheria,  while  he  thinks 
that  we  are  certainly  on  the  verge  of  the  discovery  of 
specific  remedies  for  both  tuberculosis  and  typhoid  fever- 
Why  then  do  these  and  so  many  diseases  persist  ?      It 
is  that  sanitary  advance  has  not  kept  pace  with  scien- 
tific knowledge.     It  is  also  evident  that  this  scientific 
knowledge  is  not  so  widely  diffused  as  it  should  be, 
even  among  those  in  whom  we  have  a  right  to  expect  it. 
With   regard  to  cities,   a  stronger   public  sentiment 
should  be  created  in   favor  of  municipal  cleanliness, 
which  should  rank  as  one  of  the  foremost  objects  of 
municipal  government.  Dr. Wyman  calls  attention  to  the 
fact,  which  we  sometimes  deplore  as  a  necessity  of  our 
form  of  government,  that  this  field  of  municipal  clean- 
liness is  not  a  field  for  the  national  Government,  but 
distinctly  for  the  States  and  cities,  and  that  the  degree 
of  sanitary  excellence  is  our  cities  is  a  fair  exponent 
of  their  civilization  and  culture.     Our  cities  in  this  re- 
spect are  striking  illustrations  of  the  fact  that  their 
governments  are  the  governments   of  the  people.     It 
is  therefore   necessary  to  cultivate  among  the  people 
a  knowledge   of  sanitary  science  and  a    demand    for 
Buch  knowledge  in  municipal  authorities. 

Dr.  Wyman  sees  no  reason  why  slums  should  be 
allowed  in  any  city.  Too  much  attention  is  paid  to 
public  parks  and  handsome  municipal  buildings, 
whereas  the  most-needed  improvements  are  in  the 
alleys,  around  the  docks,  and  in  the  tenement  districts. 
Another  strong  plea  for  sanitation  lies  in  the  promise 
which  it  would  give  of  getting  rid  of  quarantine.  The 
time  is  at  hand  when  we  must  consider  the  necessity  of 
ridding  ourselves  of  these  restrictions  upon  commerce. 
It  must  be  evident  to  all  intelligent  observers  that 
many  quarantine  methods,  especially  those  still  used 
in  the  more  rural  districts,  are  antiquated,  oppressive, 
and  even  absurd,  and  Dr.  Wyman  does  well  to  call 


attention  to  their  defects.  When  a  large  number  of 
cabin  passenger.-j,  all  of  them  in  good  health,  are  held 
on  board  a  steamer  in  the  upper  cabin  because  of  one 
case  of  infectious  disease  in  the  steerage,  they  may 
reflect  that  their  detention  is  due  primarily  to  the  faulty 
sanitation  of  some  miserable  portion  of  some  foreign 
city,  and  they  may  receive  thereby  a  demonstration  of 
their  personal  interest  in  sanitary  science.  Another 
urgent  need  is  to  decry,  and  punish  if  possible,  muni- 
cipal deception  either  in  the  concealment  of  contagious 
disease  or  by  reports  giving  a  sense  of  false  security  to 
other  communities.  Municipal  morality  in  such  cases 
is  evidently  on  as  low  a  grade  as  municipal  sanitary 
science. 

Finally,  Dr,  Wyman  calls  attention  to  the  urgent 
necessity  of  having  our  legislators  more  thoroughly 
trained  in  the  knowledge  of  sanitary  science.  We  need 
a  class  of  men  who  are  at  one  and  the  same  time  versed 
in  the  law,  who  are  skilled  in  framing  the  laws,  and 
who  are  also  familiar  with  the  requirements  of  sanitary 
science.  It  is  to  be  hoped  that  Dr.  Wyman's  views,  as 
expressed  in  his  address,  will  be  given  wide  publicity. 
They  need  to  be  disseminated  among  people  at  large 
even  more  than  among  the  medical  profession.  Public 
intelligence  alone  can  make  effective  the  methods  of 
true  sanitation.  This  seems  a  hopeless  task  sometimes, 
when  we  consider  the  credulity  of  the  people  with  ref- 
erence to  the  fundamental  questions  of  health  and 
disease,  and  it  is  only  by  the  dissemination  of  such 
knowledge  as  Dr.  Wyman  has  presented  in  his  address 
that  we  can  hope  for  widespread  and  enduring  results. 

Unsolved  Problems  of  Chemistry. — According  to 
Professor  Remsen,  of  Johns  Hopkins  University,  who 
appears  in  a  popular  article  in  one  of  the  magazines,  we 
have  little  positive  knowledge  of  starch,  cellulose,  pro- 
teids,  and  protoplasm,  and  the  outlook  is  not  very  bril- 
liant for  the  improvement  of  this  knowledge  in  the  near 
future.  As  so  much  of  the  hope  of  improvement  in 
practical  medical  science  depends  upon  advances  made 
in  bio-chemistry,  we  greet  this  declaration  of  Professor 
P.emsen  with  considerable  regret.  Of  all  the  substances 
that  go  to  make  up  animal  tissue  the  chemist  is  most 
familiar  with  the  fats.  He  can  take  carbon,  hydrogen, 
and  oxygen  in  the  laboratory  and  can  construct  fats  as 
.  they  occur  in  animals — not  that  the  chemist  often  does 
this  in  fact,  but  that  he  could  do  it  if  he  took  the 


314 


Thk  Philadelphia"! 
Medical  Jofbnal  J 


EDITORIAL  COMMENT 


[Febbcabt  16,  1991 


time  and  trouble.  Sugar  is  not  entirely  an  unsolved 
problem,  especially  since  the  labors  of  Fischer,  of  Ber- 
lin, for  in  its  simpler  form  it,  too,  can  be  made  in  the 
laboratory.  But  with  starch  and  cellulose  the  case  is 
different.  This  latter  substance,  cellulose,  is  the  basis 
of  plants.  It  contains  only  the  three  elements,  carbon, 
hydrogen,  and  oxygen,  and  yet  the  chemist  is  still  igno- 
rant of  how  these  substances  are  combined  to  make  cel- 
lulose. The  proteids  are,  if  anything,  a  still  greater 
mystery.  As  they  are  the  chief  constituents  of  muscle, 
nerve,  and  blood,  it  is  most  essential  that  they  should 
be  understood.  But  Professor  Remsen  seems  to  think 
that  they  will  be  unsolved  problems  for  generations  to 
come. 

Of  all  the  problems  of  synthetic  chemistry  the  most 
important  relates  to  the  construction  of  protoplasm.  This 
is  the  living  tissue.  It  is  derived  from  a  fat,  a  proteid, 
and  a  hydrocarbon,  and  its  exact  construction  (that 
which  renders  it  the  seat  of  life)  is  unknown.  This 
problem  must  be  solved  before  we  can  have  a  real  scien- 
tific knowledge  of  what  constitutes  life.  Professor  Rem- 
sen is  rather  pessimistic,  and  thinks  that  for  a  long  while 
we  shall  have  to  be  content  with  small  returns  from  our 
labors  in  these  fields. 

The  Courage  of  One's  Opiuiou. — One  of  our  daily 
contemporaries  in  this  city  wants  to  have  the  Chris- 
tian Scientists  inoculated  with  the  infectious  diseases. 
This  is  not  for  the  purpose  of  getting  rid  of  the  Chris- 
tian Scientists  (which  would  be  a  consummation  de- 
voutly to  be  wished,  if  some  less  radical  method  were 
employed)  but  merely  for  the  purpose  of  convert- 
ing these  fanatics  and  convincing  them  of  the  reality 
of  disease.  With  a  cynicism  which  we  should  not  like 
to  imitate,  this  worldly-minded  contemporary  suggests 
that  one  Christian  Scientist  take  into  his  system  the 
"  seeds  "  of  tuberculosis ;  another,  the  bacillus  of  Asiatic 
cholera ;  another,  the  microbe  of  tetanus  ;  and  another 
still,  the  parasite  of  malaria.  If  there  is  no  truth  in 
the  discoveries  of  bacteriology  then,  says  our  neighbor, 
every  one  of  these  supreme  tests  would  fail  and  the 
luminous  truths  of  Christian  Science  would  shine  be- 
fore the  world. 

With  these  shocking  suggestions  we  are  not  in  accord, 
and  we  quote  them  with  reprobation,  but  we  cannot 
refrain  from  reminding  our  readers  that  the  scheme  is 
not  altogether  new.  The  late  Professor  Gross  adopted 
the  same  method  of  criticism  on  one  occasion  when  he 
suggested  that  a  proper  test  for  a  non-belief  in  the  ex- 
istence of  hydrophobia  would  be  for  the  doubter  to 
allow  himself  to  be  bitten  by  a  mad  dog.  Such  sug- 
gestions are  never  taken  seriously,  and  it  is  needless  to 
say  that  they  are  never  adopted.  We  should  like  to 
know,  however,  of  what  use  it  would  be  to  convert  a 
Christian  Scientist  by  giving  him  tetanus  or  Asiatic 
cholera?  lie  would  probably  not  live  long  enough  to 
profit  by  his  experience.     But  the  chief  logical  defect 


in  the  plan,  so  far  as  it  relates  to  the  Christian  Scientists, 
is  that  it  ignores  one  of  the  very  elements  of  ignorance, 
superstition  and  delusional  insanity.  These  mental 
states  are  essentially  illogical ;  they  do  not  yield  to  the 
ordinary  processes  of  reasoning,  because  the  faculty  of 
reason  is  undeveloped  or  impotent.  The  more  proof 
there  is  presented,  the  more  obstinacy  there  is  displayed. 
If  it  were  not  for  the  injuries  done  to  innocent  victims, 
it  would  probably  be  just  as  well  to  let  this  cult  go 
unopposed  in  the  belief  that  it  would  some  day  die 
a  natural  death.  But  these  injuries  cry  aloud  for  the 
suppression  of  the  whole  mischievous  sect. 

The  Pneumonias  of  Influenza. — According  to 
Leichtenstern  (Nothnagel's  Special  Pathology  and  Therapy, 
Vol.  IV,  Part  1),  "  Pneumonia  is  the  most  frequent  and 
most  important  complication  of  influenza." 

A  thorough  investigation  of  the  history  of  influenza 
epidemics  proves  that  the  complication,  pneumonia  (in 
some  variety)  has  never  been  absent.  This  was  noted 
as  early  as  1580  by  Bockelius  (quoted  by  Ruhemann) 
and  particularly  emphasized  by  Sydenham  in  1675. 
It  was  for  the  most  part  taken  for  granted  that  broncho- 
pneumonia arose,  as  a  result  of  the  severe  bronchitis 
(the  inflammatory  process  spreading  by  continuity  of 
structure),  or  that  it  was  a  form  of  mixed  or  simul- 
taneous infection  by  the  specific  causes  of  influenza 
and  pneumonia. 

Both  views  are  undoubtedly  correct,  and  were  this 
the  only  variety  of  pneumonia  complicating  influenza, 
the  diagnosis  in  the  majority  of  cases  would  be  an 
exceedingly  simple  one.  There  is,  however,  another 
variety  first  hinted  at  by  Gray  in  1782,  and  particularly 
described  by  Leichtenstern  in  December,  1889,  of  "a 
primary  influenza  pneumonia,"  a  form  of  inflammation 
of  the  lungs  due  to  the  bacillus  of  Pfeiffer  and  its 
toxins,  which  occasionally  even  makes  its  appearance 
simultaneously  with  the  other  phenomena  of  influenza, 
but  more  frequently  arises  at  the  acme  of  the  disease. 
Leichtenstern  calls  this  "  the  pneumonic  form  of  in- 
fluenza." 

The  accuracy  of  this  assertion  was  proven  two  years 
later  by  Pfeiffer  and  others,  who  found  in  the  pneu- 
monic exudates  (in  the  alveolar  lumen  and  alveolar 
septum,  especially  enclosed  in  the  round  cells)  the 
specific  bacilli  of  influenza  in  "extraordinary  amounts." 
Pfeiffer  says:  "  In  smear  cultures  prepared  from  secre- 
tions of  the  trachea  and  larynx  a  mixture  of  various 
microorganisms  was  found,  especially  streptococci  and 
diplococci,  etc.,  but  even  here  the  bacillus  of  influenza 
was  found  to  outnumber  the  other  bacteria.  In  the 
large  bronchi,  all  other  bacteria  (except  the  bacillus  of 
influenza)  gradually  disappear,  and  as  the  finer  bronchi 
are  reached,  especially  when  a  purulent  secretion  is 
present,  and  in  the  pulmonary  tissue,  the  bacillus  of 
influenza  is  alone  found  to  be  present." 

According  to  Pfeiffer,  Beck,  and  Wassermann,  the 


Fkbbdarv  16,  1901] 


EDITORIAL  COMMENT 


CTHE  PHILADELPHIi 
Medical  Joubnal 


315 


anatomical  form  of  this  true  influenza  pneumonia  is  an 
exclusively  catarrhal  one.  It  is  no  doubt  true  that 
the  majority  of  the  pneumonias  are  of  the  broncho- 
pneumonic  form,  nevertheless  there  can  be  no  question 
that  numerous  bronchopneumonias  of  "grippal"  origin 
are  of  a  mixed  form  due  to  the  presence  of  streptococci, 
and  perhaps  diplococci  also,  which  may  even  in  some 
cases  outnumber  the  Pfeiffer  bacillus.  Only  in  this 
manner  can  we  explain  the  numerous  cases  of  pneu- 
monia occurring  in  the  pandemic  of  1889-90,  during 
which  this  condition  was  frequently  observed.  Albu 
even  regards  this  mixed  infection  as  pathognomonic  of 
pneumonia  due  to  influenza  (Deutsche  med.  Wochensch., 
1894,  No.  7).  Besides  this  purely  catarrhal  (broncho- 
pneumonic)  form,  the  croupous  form  is  also  frequently 
observed,  and  a  third  variety  of  mixed  pneumonia, 
that  is,  a  catarrhal- croupous  form,  or,  as  Leichtenstern 
proposes  to  call  it,  a  "  cellular-fibrous  "  variety. 

He  bases  his  opinion  upon  postmortem  findings  in 
which  mixed  and  transitional  forms  are  found,  lobar  and 
lobular  infiltrates,  whose  correct  pathological  classifica- 
tion, whether  catarrhal  or  croupous,  is  both  macro- 
scopically  and  microscopically  exceedingly  difficult. 
In  these  mixed  varieties  (cellular-fibrinous)  catarrhal 
pneumonic  areas  and  fibrinous  areas  are  found  side  by 
side  in  the  same  lung  and  even  in  the  same  lobe  of  the 
lung;  in  some  infiltrated  areas  catarrhal  and  fibrinous 
masses  are  so  intermingled  that  the  composite  picture 
shows  neither  the  one  nor  the  other  form  of  pneumonia. 
Evefl  microscopically  the  differentiation  is  difficult.  In 
the  sections  prepared  according  to  the  method  of 
Weigert,  separate  alveoli  showed  catarrhal  inflammation 
(cellular  exudate  without  or  only  with  slight  amount  of 
fibrin)  while  other  alveoli,  near  or  even  among  these, 
were  found  to  show  the  true  character  of  croupous 
pneumonia.  This  then  establishes  a  so-called  "  lobar- 
lobular  "  form  of  pneumonia,  or,  as  Leichenstern  pro- 
poses to  call  it,  a  "  cellular-fibrinous  pneumonia,"  which 
he  regards  as  characteristic  of  influenza. 

Tetanus  Due  to  Anti-Diphtheritic  Serum. — The 

recent  horrible  deaths  from  tetanus,  occurring  in  several 
persons  who  had  been  inoculated  in  Italy  with  anti- 
diphtheritic  serum,  seem  to  have  been  more  exempt 
from  condemnation  than  many  other  less  important 
mistakes.  Had  only  one  patient  been  infected,  it 
probably  could  have  been  attributed  to  a  subsequent 
secondary  infection,  or  to  an  accidental  occurrence. 
But  it  is  alleged  that  eight  persons  on  whom  the  serum 
was  used,  died  of  tetanus,  and  that  the  serum  was 
directly  traceable  to  the  Serotherapic  Institute  of  Milan. 
There  is  as  little  excuse  for  such  an  outrageous  sacrifice 
of  human  life  as  there  is  for  permitting  a  rabid  dog  to 
run  amuck.  An  institution  that  assumes  the  responsi- 
bility of  manufacturing  a  substance  which  for  curative 
or  prophylactic  purposes  is  to  be  injected  into  a  living 
human  body,  ought  to  be  possessed  of  sufficient  skill 


and  common  sense  to  test  the  serum  before  distribut- 
ing it.  The  consequences  are  not  only  the  shameful 
sacrifice  of  several  human  beings  who  might  have  been 
rescued  from  the  ravages  of  diphtheria,  but  also  the 
loss  of  confidence  in  the  employment  of  serumtherapy. 
It  is  but  a  minor  procedure  to  test  serum  before  it  is 
placed  upon  the  market,  and  this  is  equally,  if  not 
more,  important  than  testing  the  physiological  action 
of  well-known  drugs.  Italy  has  contributed  much  to 
medical  science,  and  it  is  therefore  more  the  pity  that 
she  has  in  this  instance  contributed  such  a  medical 
martyrdom. 

The  Dangers  of  Specialism. — In  certain  obscure 
conditions  it  very  largely  depends  upon  the  point  of 
view  from  which  the  symptoms  are  studied  as  to  what 
the  ultimate  decision  and  diagnosis  will  be.  Thus,  to 
the  surgeon  a  persistent  headache  will  suggest  the  pos- 
sibility of  specific  new  formations  or  growths  of  other 
origin,  to  the  gynecologist  some  pelvic  disturbance,  and 
to  the  ophthalmologist  a  long-continuing  eye-strain. 
Each  is  very  prone  to  be  biased  by  the  line  of  work  in 
which  he  happens  to  be  engaged,  and  to  look  upon  the 
given  case  only  from  the  narrow  beaten  path  of  his 
daily  routine.  Just  here  lies  one  of  the  dangers,  and 
possibly  one  of  the  greatest  of  the  era  of  specialism 
into  which  we  have  been  hurried  by  the  rapid  strides 
that  have  been  made  of  recent  years  in  the  art  of 
Medicine.  The  specialist  must,  to  a  certain  extent,  be- 
come a  narrow  man  in  a  general  sense  in  order  to  become 
at  the  same  time  an  expert  in  a  limited  sense.  Such  is 
the  paradox  that  confronts  the  medical  man  of  the  day. 
The  passing  of  the  general  physician,  as  he  was  known 
a  half  century  ago,  and  as  was  predicted  25  years  ago, 
is  now  realized,  or  nearly  so.  It  is  rare  indeed  to  find 
at  the  present  time  an  all-around  man  with  good 
judicial  powers  in  all  classes  of  cases,  medical  and  sur- 
gical. The  pathologist,  lured  by  the  winning  mysteries 
of  the  autopsy-table,  and  fascinated  by  the  revelations 
of  the  laboratory  and  microscope,  finds  no  time  to 
spend  ia  the  clinic  or  by  the  bedside,  and  neglects 
therapeutics  proportionately  as  he  cultivates  the  post- 
mortem. The  busy  physician,  hastening  from  house 
to  house  and  returning  to  find  his  anteroom  filled 
with  suS'ering  humanity,  is  drawn  irresistibly  into  the 
whirling  vortex  of  symptomatology  to  the  evident  aban- 
donment of  the  pathological  table,  save  as  the  labors 
of  his  equally  busy  colleague  in  that  department  indi- 
cate to  him  a  new  and  better  Ime  of  theraputics.  The 
surgeon  sees  a  surgical  cause  where  the  physician  can 
advance  an  equally  plausible  explanation  on  medical 
grounds,  and  the  physician  too  often  presses  his  po8- 
ology  beyond  the  borderline  of  surgical  intervention. 

Limited  thus  by  his  specialism  and  threatened  at 
times  to  be  carried  beyond  the  line  of  sound  reasoning 
by  his  enthusiasm,  the  practitioner  of  the  twentieth 
century  should  pause  to   consider  the  adage  of  the 


316 


TDK  Philadblphia"] 

MSDtCAL   JOCBSAL  J 


EDITORIAL  CX)MMENT 


[Febeca«t  16,  19n 


lamented  Agnew  :  "  A  good  physician,"  said  he,  "  may 
make  a  good  surp'eon,  but  a  good  surgeon  must  be  a 
good  physician." 

Here  is  the  solution  of  the  whole  question.  Special- 
ism should  be  the  result  of  a  sound  and  natural  growth, 
the  result  of  an  evolution  brought  about  by  a  combina- 
tion of  circumstances  and  natural  inclination.  Begin- 
ning on  the  common  ground  of  general  practice,  the 
young  man  should  then  drift,  or  better  steer,  in  the 
direction  which  he  finds  most  suited  to  his  tastes  and 
opportunities,  thereby  developing  into  a  specialist  with 
a  good  foundation  of  general  medical  knowledge,  able 
to  recognize  causes  foreign  to  his  chosen  territory  and 
thereby  opening  to  his  patient  the  best  prospect  for  early 
and  proper  treatment.  Evil,  indeed,  must  the  conse- 
quences in  most  cases  be  of  a  deliberate  choice  of  a 
specialty  from  the  graduating  day,  with  a  correspond- 
ing neglect  of  everything  else. and  concentration  of  the 
fiaculties  upon  the  chosen  narrow  line  of  work.  Such  a 
course  is  detrimental  to  the  community  at  large  and  to 
the  specialist  himself,  who  thereby  robs  himself  of  ad- 
ditional ability  and  starves  certain  areas  of  brain- cells 
in  order  to  overfeed  others. 

To  a  certain  extent,  it  must  be  admitted,  this  rapid 
growth  of  specialism  has  been  inevitable.  The  marked 
development  of  medicine  and  surgery  along  all  lines, 
has  made  it  impossible  for  the  medical  man  to  take  a 
comprehensive  view  of  every  subject.  It  is  not  the 
specialism  of  necessity,  however,  that  is  objectionable, 
but  that  of  deliberate  choice  without  a  preparatory 
course  of  general  medicine  that  will  afi"ord  a  safe  basis 
upon  which  the  ultimate  specialism  should  be  erected. 

Compulsory  Vaccination  in  the  Public  Schools. — 

As  the  outgrowth  of  a  case  in  whinh  a  child  was 
excluded  from  the  public  schools  of  Philadelphia  on 
account  of  failure  to  present  a  certificate  or  other  evi- 
dence of  successful  vaccination  —  the  position  of  the 
school  authorities  having  been  sustained  by  the  Courts 
—  a  bill  has  been  introduced  into  the  Pennsylvania 
State  Legislature  for  the  repeal  of  the  act  making  such 
evidence  a  prerequisite  of  the  reception  of  school- 
children. We  have  so  often  in  these  columns  dwelt 
upon  the  utility  of  vaccination  in  the  prevention  of 
smallpox,  and  the  fact  is  so  universally  accepted  by 
open  minds,  that  we  wish  to  refer  to  the  circumstance 
only  to  suggest  to  our  readers  to  use  their  influence 
with  their  representatives  in  the  Legislature  to  prevent 
the  possible  repeal.  A  similar  measure  was  defeated 
solely  on  its  merits  a  year  or  two  ago,  and  it  is  the  duty 
of  the  medical  profession  to  see  that  this  new  attack  on 
preventive  medicine  sufi'ers  a  like  fate. 

The  Influence  of  Heredity. — This  influence  has, 
of  course,  always  been  appreciated,  but  probably  never 
to  the  same  degree  or  with  the  same  critical  intelligence 
as  at  present     The  subject  is  of  especial  interest  to  the 


physician  by  reason  of  its  bearings  upon  disease  and 
degeneration.  It  is  true  that  disease  itself  is  not  trans- 
mitted by  heredity,  but  rather  a  peculiar  type  of  tissue, 
which  renders  the  individual  peculiarly  susceptible  to 
the  influence  of  morbific  agents.  Disease  in  the  fetus 
transmitted  from  the  mother  cannot  be  looked  upon  as 
inherited,  but  it  is  acquired  in  much  the  same  way  as 
disease  is  acquired  in  postuterine  existence.  In  illus- 
tration of  the  influence  of  heredity  in  the  development 
of  the  traits  and  qualities  in  the  individual,  Thomas 
Oliver  (Lancet,  November  10,  1900,  p.  133?>)  points  out 
that  the  Derby  has  never  been  won  by  a  horse  that  was 
not  a  thoroughbred,  and  the  same  statement  is  practi- 
cally true  of  the  other  great  English  races,  the  St.  Leger 
and  the  Oaks.  It  appears,  further,  that  the  Derby  has 
never  been  won  by  a  gelding.  Mares,  also,  have  won 
races  far  less  frequently  than  stallions.  With  the  object 
of  maintaining  the  high  standard  of  the  English  race- 
horse, close  breeding  in  and  in  is  practised,  and  as  a 
result  of  this  practice,  it  is  thought  by  many,  the  ani- 
mal is  degenerating.  To  overcome  such  a  result  infu- 
sion of  fresh  blood  becomes  necessary  from  time  to  time. 

Anonymous  Correspondents. — The  man  who  writes 
anonymous  letters  is  usually  a  libeller,  and,  as  a  rule, 
he  is  not  worthy  of  notice.  We  feel  constrained,  how- 
ever, to  announce  that  we  have  received  from  such  a 
correspondent  a  clipping,  which  he  had  cut  from  an- 
other journal,  attributing  to  us  the  publication  of  a 
witless  and  indecent  anecdote.  It  is,  we  trust,  needless 
for  us  to  say  that  this  anecdote  was  never  printed  in 
this  JocRN.iL,  but  as  it  seems  to  be  going  the  rounds 
among  some  of  our  contemporaries  (who  are  entirely 
responsible  for  their  own  taste  in  the  matter),  we  take 
this  occasion  to  say  that  the  anecdote  not  only  never 
appeared  in  this  JorRNAL,  but  that  it  would  have  been 
impossible  for  it  to  appear  under  either  the  former  or 
the  present  editor.  As  our  anonymous  correspondent 
calls  himself  a  "  former  constant  reader  "  he  could  easily 
have  verified  this  fact  for  himself,  and  is  without  excuse 
for  not  having  done  so. 


Plag'ue  in  India. — Tbe  plague  in  India  seems  to  h*re 

attained  unu-iual  severity  except  in  the  central  prorincee. 
It  is  particularly  severe  in  Bengal,  where  a  weekly  mortality 
of  2,500  is  reported.  The  doctors  being  ciiiefly  occupied  in  the 
famine  district,  there  seems  to  be  a  lack  of  an  adequate  medi- 
caI  staff  in  the  plague-iufeeted  portion  of  the  country. 

Appendicular  Form  of  Pneamonia.— La  Srmaine 
Medicate,  February  9,  1901,  saye  that  there  is  a  form  of  croup- 
ous pneumonia  which  in  its  onset  closely  resembles  appen- 
dicitis. Sjme  10  cases  of  this  kind  have  been  reported 
The  early  symptoms  are  ffver,  repeated  chills,  jjain  in 
the  right  iliac  fossa  (over  M  Burney's  point),  someiimes 
bilious  vomiting.  Afer  2  or  3  days  the  pulmonary  symp- 
toms become  manifest  and  then  a  tvpical  case  of  croup- 
ous pneumonia  follows.  Operation  has  been  indicated  in 
some  of  these  CAses  and  a  perfertlv  normal  appendix  found. 
It  is  remarked  that  the  localization  of  the  pain  orer  Mc- 
Barney's  point  is  not  pathognomonic  of  appendicitis  and 
ttiat  in  all  cases  the  lungs  snoald  be  thoroughly  and  re- 
peatedly examined.    [T.L.C.] 


nSRUAET    16,  1901] 


REVIEWS 


FThk  Phiuidelphia 
L  Medical  Journal 


317 


Kcr>icu?5. 


The  American  Year- Book  of  Medicine  and  Sur- 
gery. Under  the  general  editorial  charge  of  George  M. 
Gould,  M  D.  Philadelphia  and  London  :  W.  B.  Saund- 
ers &  Company,  1901.    Price,  $3  75  per  vol ,  net. 

Dr.  Gould's  Year-Book  has  come  to  be  a  familiar  publi- 
cation to  many  busy  doctors,  and  we  doubt  not  that  to  all 
who  take  it  the  work  is  as  useful  as  it  is  familiar.  The  editor 
and  publishers  announce  that  the  issue  for  1890,  in  two 
volumes,  met  with  such  general  favor  from  the  profession 
that  they  have  decided  to  follow  the  same  plan  this  year. 
Therefore,  the  work  ai>pears  in  two  handsome,  large  volumes. 
Several  advantages  are  gained  by  this  plan  of  publication. 
The  volumes  are  more  easily  handled,  and,  what  is  of  the 
first  importance,  they  are  sold  separately,  as  we  understand 
it,  so  that  the  surgeon  or  the  physician,  as  the  case  may  be, 
need  only  buy  the  volume  for  which  he  has  especial  use. 

We  cannot  attempt  here  to  give  a  detailed  review  of  a 
work  which  is  itself  essentially  a  review  of  all  current  medical 
literature.  We  are  familiar,  however,  with  the  past  volumes 
and  have  had  frequent  occasion  to  consult  them,  and  have 
seldom,  if  ever,  been  disappointed  in  finding  in  them  some- 
thing that  we  needed.  The  present  volumes  have  every 
appearance  of  sustaining  the  high  repute  of  their  prede- 
cessors. Such  a  work  in  its  preparation  must  entail  a  vast 
amount  of  labor  upon  the  editor  and  his  collaborators,  and 
they  are  to  be  congratulated  and  thanked  also  for  having 
placed  the  profession  under  obligations  for  such  a  useful 
reference-book. 

We  notice  that  the  volumes  for  this  year  are  quite  pro- 
fusely illustrated,  many  of  the  illustrations  being  full-page 
half-tones.  We  doubt  not  that  the  work  will  continue  to 
merit  its  popularity,    [j.h.i,.] 

A  Textbook  of  Histology,  including  Microscopic 
Technic.  By  A.  A.  Bohm,  M.D  ,and  M.  von  Davidoff, 
M.D.,of  the  Anatomical  Institute  in  Munich.  Edited,  with 
«xtensive  additions  to  both  text  and  illustrations,  by  G. 
Cakl  Huber,  M.D.,  Junior  Professor  of  Anatomy  and 
Director  of  the  Histological  Laboratory,  University  of 
Michigan  Authorized  translation  from  the  second  re- 
vised German  edition,  by  Herbert  H.  Gushing,  M.D, 
Demonstrator  of  Histology  and  Embryology,  Jefferson 
Medical  College,  Philadelphia.  With  351  illustrations- 
Philadelphia  and  London  :  W.  B.  Saunders  &  Co.,  1900. 

The  announcement  of  an  English  version  of  a  German 
work  intuitively  awakens  expectation  of  something  interest- 
ing and  thorough. 

In  his  preface  the  editor  says  that  while  in  the  main  the 
original  text  has  been  retained,  some  changes  in  arrange- 
ment have  been  made  Further,  that  "  additions  to  the 
German  text  have  been  freely  made,"  the  more  important  of 
these  occurring  in  the  chapters  on  Motor  and  Sensory  Nerve- 
endings,  on  Spinal  and  Sympathetic  Ganglia,  on  the  Inner- 
vation of  Glands  and  other  organs,  and  in  the  chapters 
treating  of  organs  with  internal  secretions.  With  this  new- 
text,  that  unquestionably  is  of  great  advantage  to  the  book, 
many  original  and  instructive  illustrations  have  been  incor- 
porated.    The  author's  preface  is  missing. 

A  considerable  portion  of  the  volume  is  devoted  to  micro- 
scopic technic ;  that  of  general  application  being  treated 
in  the  first  50  pages,  that  of  special  application  following 
each  chapter  of  the  general  and  "  special  "  histology —  not  a 
novel  plan  but  an  excellent  one,  in  which  the  authors  follow 
other  German  works  of  this  class  There  is  an  eighteen  page 
index,  but  this  will  not  compensate  the  lack  of  cross-refer- 
ences. How,  for  example,  is  the  practical  person,  whs 
takes  the  w  irk  seriously,  to  find  T.  8")  referred  to  in  the 
technic  number  255,  (page  273),  or  T.  144  in  technic  number 
322,  (page  434)?  The  pages  on  which  T.  85  and  T.  144 
occur  are  not  given ;  a  serious  omission  in  a  book  intended 
for  use  in  the  laboratory  equally  as  in  the  study. 

The  usefulness  to  the  student  of  this  as  of  so  many  text- 


books will  in  some  measure  depend  (on  the  teacher's  selec- 
tive faculty.  It  is  brimful  of  interesting  matter,  descriptive 
and  technical.    [e.l.b.J 

The    American    Illustrated    Medical    Dictionary. 

By  W.  A.  Newman  Dorland,  A.M.,  M.D.  Philadelphia 
&  London :  W.  B.  Saunders  A^lCo.,  1900.  Price,  $5.00. 
Indexed. 

Medical  dictionaries  grow  old  almost  in  the  printer's  hands, 
so  great  is  the  general  advance  along  the  lines  of  scientific 
medicine  and  so  manifold  are  the  terms  employed.  This 
work  of  Dr.  Dorland  is  a  highly  commendable  one,  display- 
ing painstaking  industry  and  wide  reading.  The  definitions 
are  concise,  and,  as  far  as  we  have  been  able  to  determine, 
their  brevity  has  not  markedly  injured  their  accuracy. 
The  work  is  intended  to  stand  between  an  exhaustive  work, 
almost  too  verb  >se  for  every-day  employment  and  the  unsat- 
isfactory pocket  lexicon.  In  no  medical  work  is  typogra  jhy 
so  important  as  in  a  medical  dictionary,  and  the  publishers 
have  every  reason  for  congratulation  in  this  respe  t.  The 
plates  are  accurate  and  beautifully  executed.  In  every  case 
they  enlighten  the  text,  which  is  a  desideratum  not  always 
found. 

In  a  field  so  vast,  it  is  scarcely  comprehensible  that  error 
should  not  have  crept  in,  or  that  certain  definition-i  should 
not  meet  with  criticism  For  instance,  the  ophthalmohigist 
will  take  exception  to  exenteration  and  eviscfralion  being  re- 
garded as  synonyms.  A  nd  the  hematologi.st  will  rise  in  his 
wrath  to  find  under  the  definition  of  a  leukocyte,  "  any  color- 
less, amfehoid  cell-mass,  etc  ,"  whereas,  it  is  known  definitely 
that  all  leukocytes  do  not  show  ameboid  movements 

The  student"  will  be  particularly  interested  in  the  very 
exhaustive  tables  which  are  found.  They  include  new  ana- 
tomical, bacteriological,  and  eponymic  tables  of  diseases, 
operations,  signs  and  symptoms,  stains,  tests,  etc  This 
feature  of  the  work  represents  immense  labor  and  judicious 
tabulation. 

We  cannot  refrain  from  expressing  ourselves  most  favor- 
ably upon  the  decidedly  practical  character  cf  this  work  and 
its  uniform  excellence.    [t.l.c.J 

Flesh  Foods,  with  Methods  for  Their  Chemical, 
Microscopical,  and  Bacteriological  Examina- 
tion. A  Practical  Handbook  for  Medical  Men,  Analysts, 
Inspectors,  and  others.  By  C.  Ainsworth  Mitchell,  B.  A. 
(Oxon.),  F.I.C.,  F.C.S.  Small  8vo.  Pages  xvi,  322,  and 
Index.  London  :  Chas.  GriflBn  &  Co.,  Lim. ;  Philadelphia : 
J.  B.  Lippincott  Co. 

The  author  of  this  work  has  been  for  many  years  an  active 
worker  in  food  analysis.  His  editorial  connection  with  The 
Analyst  has  given  him  a  wide  acquaintance  with  the  current 
literature  in  this  field.  The  work  presents  the  results  of 
these  labors.  The  descriptions  of  analytic  and  bacteriologic 
methods  are  given  in  a  practical  form,  a  knowledge  of  general 
principles  and  technic  in  these  lines  being  assumed. 

The  first  70  pages  are  devoted  to  descriptions  of  the  struc- 
ture and  general  nature  of  flesh,  and  the  essential  differe'nces 
between  the  flesh  of  difl'erent  classes  of  food-animals.  A  sum- 
mary of  the  methods  of  testing  follows,  special  attention 
being  given  to  the  processes  for  examining  animal  fats.  It  is 
interesting  to  note,  in  connection  with  one  of  these  methods, 
that  a  marked  improvement  in  detail,  which  saves  several 
hours'  work  and  which  has  been  adopted  by  many  chemists, 
is  not  noticed  This  improvement  was  devised  in  the  United 
States,  and  the  omission  of  it  by  Mr.  Mitchell  is  merely  one 
of  the  many  instances  of  the  failure  of  English  chemists  to 
appreciate  the  work  done  in  this  country. 

One  chapter  of  25  pages  is  devoted  to  the  examination  of 
sausages,  which  includes  detailed  methods  for  detecting 
horseflesh.  Much  space  is  occupied  with  the  descriptions 
of  the  nature  of  proteids  and  proteid  digestion.  «The  last 
hundred  pages  cover  the  question  of  poisonous  and  infected 
food,  all  the  important  entozoa  being  described  and  figured. 

The  work  is  a  useful  contribution  to  an  important  depart- 
ment of  practical  hygiene  and  interesting  evidence  of  the 
specializing  tendencies  of  modern  times.  It  is  well  written, 
well  I  rinted,  and  well  illustrated,     [h.l.] 


318 


The  Philadelphia"] 
Medical  Journal  J 


CORRESPONDENCE 


[Fbbbuast  16,  un 


(torrcsportbcncc. 


BILATERAL  PAROTITIS  AS  A  COMPLICATION  OF 
PNEUMONIA. 

By  AUGUSTUS  A.  ESHNER,  M.D., 
of  PhiiadelpbU. 

To  the  Editor  of  The  Philadelphia  Medical  Jouknal  : — 

OwisQ  to  the  rarity  of  the  aasociation  I  desire  to  make 
brief  record  of  a  case  of  pneumonia  complicated  by  bi 
lateral  parotitis.  The  patient  was  a  woman,  71  years  old, 
who  was  seized  with  pain  at  the  base  of  the  right  chest,  in 
which  situation  physical  signs  of  pneumonia  developed. 
Breathing  was  not  greatly  embarrassed,  the  temperature 
reached  only  a  moderate  elevation,  and  the  pulse  was  not  un- 
duly accelerated.  A  crisis  failed  to  occur  at  the  expected 
time,  but  the  patient  appeared  to  be  progressing  satisfacto- 
rily. On  or  about  the  eighth  day  both  parotid  glands  were 
markedly  swollen  and  painful,  and  the  temperature,  which 
had  been  declining,  had  now  risen  again.  Some  relief  was 
aflForded  by  the  application  of  ice,  but  the  patient  became 
gradually  weaker  and  death  took  place  4  days  later. 

I  am  without  a  bacteriologic  examination  in  this  case,  and 
cannot,  therefore,  say  whether  the  pneumonia  was  due  to  the 
pneumonia-coccus  or  not,  and  whether  the  parotitis  was  a 
metastatic  complication  or  merely  an  intercurrent  affection. 
Bilateral  parotitis,  as  mumps,  is  observed  apparently  as  an 
independent  affection,  and  parotitis,  commonly  unilateral,  is 
occasionally  observed  as  a  complication  of  typhus  and  typhoid 
fever,  as  well  as  other  infective  processes.  The  question 
thus  naturally  arises  whether  there  is  a  specific  variety  of 
parotitis  (bilateral  mumps)  dependent  upon  an  as  yet  undis- 
covered microorganism,  or  whether  unilateral  or  bilateral 
parotitis  may  be  due  to  any  one  of  a  number  of  microorgan- 
isms— the  typhoid  bacillus,  the  pneumonia  coccus,  etc. 


A  CASE  OF  ILLUMINATING  GAS  POISONING. 

By  Wm.  a.  steel,  M.D., 

of  Philadelphia. 

Besldent  Ptajsiciao,  Hospital  of  the  P.  E.  Church. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

At  the  request  of  my  "Chief,"  Dr.  Henry  M.  Fisher,  I 
report  the  following  case  of  illuminating  gas- poisoning: 

At  11  45  p  M.,  January  13,  Cecelia  B ,  8  years  old,  was 

carried  into  the  Episcopal  Hospital  in  an  asphyxiated  condi- 
tion from  inhalation  of  illuminating  gas.  There  was  a  white 
froth  at  the  mouth,  the  skin  was  clammy  and  livid,  the 
muscles  were  in  general  tonic  spasm,  the  patient  lying  in  a 
position  of  opisthotonos ;  eyes  rolled  up  with  slight  external 
aq  lint,  respirations  jerky  and  intermittent,  radial  pulse,  not 
countable.  Atropin  was  given  hypodermaticallv  and 
oxygen  administered  for  two  hours,  at  the  end  of  which 
time  respirations  were  freer,  the  pulse  could  be  counted  at 
180 ;  hands,  feet  and  face  still  cyanoeed.  Patient  was  then 
put  in  hot  parks,  free  sweating  resulted,  muscular  spaem  re- 
laxed, radial  pulse  fell  to  160,  rectal  temper.'iture  102  3°.  She 
became  quiet  and  seemed  to  fall  into  a  natural  sleep, 
although  consciousness  was  not  regained. 

At  3  00  AM.  the  rectal   temperature  was  106  3°;  at  5.00 
A  M.,  107  2*;  at  7  00  A  m.,  the  mercury  filled  the  entire  ther 
mometer  tube  at  110°.    The  respirations  were  again  jerky, 
radial    pulse    uncountable,    heart-beats   215    per    minute. 
Patient  was  given  a  cold  plunge  and  free  stimulation  hypo- 


dermatically,  followed  by  hypodermoclysis  (1  pint  of  normal 
salt-solution)  in  the  buttocks.  Oxygen  was  administered  for 
one  hour,  and  for  15  minutes  during  each  following  hour, 
temperature  dropped,  after  plunge  to  103.4°.  Free  eneuresi» 
and  sweating  followed  hypodermoclysis  and  bath. 

Patient  became  conscious  6  hours  later,  and  in  fair  physi- 
cal condition,  with  exception  of  tonic  contraction  of  all  the 
muscles  of  the  right  arm.  The  arm  could  be  extended,  giving 
some  pain  to  the  child,  and  at  once  flew  back  to  its  flexed 
condition  when  the  extending  force  was  removed.  There 
was  no  pain  on  pressure  over  the  nerve-trunks.  The  muscles 
gradually  relaxed,  the  arm  assuming  its  natural  condition 
and  function  within  48  hours. 

The  urine  voided  8  to  10  hours  after  the  accident  threw 
down  a  heavy  sediment  of  large  uric  acid  crystals,  otherwise 
it  was  negative. 

Child  was  discharged  well  the  fifth  day  after  the  accident. 


A  CORRECTION. 


By  G.  E.  de  SCHWEINITZ,  M.D., 

of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Jocksal  : — 

ly  the  report  of  the  meeting  of  the  Neurological  Society 
on  January  28,  published  on  page  196  of  the  Philadelphia 
Medical  Jouenal  for  February  2,  1901,  referring  to  the 
ophthalmoscopic  appearances  associated  with  brain  tumor, 
occurs  the  following  sentence  attributed  to  me :  "  The  star- 
shaped  figure  seen  in  the  macula  is  of  importance  in  that  it 
also  occurs  in  Bright's  disease  and  in  syphilitic  retinitia, 
hence  it  is  not  pathognomonic  of  brain  tumor."  This  sentence 
should  read  :  "  The  star-shaped  figure  seen  in  the  macule 
in  albuminuric  retinitis  and  usually  supposed  to  be  pathog- 
nomonic of  Bright's  disease,  especially  of  the  interstitial 
variety,  occurs  also  in  choked  disc,  recurring  hemorrhages 
in  the  retina  and  vitreous  in  young  individuals,  and  some- 
times in  cases  of  syphilitic  neuro-retinitis." 


Essay  on  Thirst :    Its  Causes  and  Sleobanism. — 

Andi^  Mayer  (Gaz.  Heb.  de  Med.  et  de  Chirur.,  December  30, 
1900,  47me  AnntS-,  No.  101;  Paris  Thesis,  1899-1900,  No. 
565)  has  first  studied  the  role  of  water  in  the  organism,  and 
shows  that  although  it  serves  mechanically  for  the  construc- 
tion of  the  cells,  its  principal  role  is  as  a  universal  dissolving 
agent.  He  has  demonstrated,  both  within  and  without  the 
cells,  the  existence  of  solutions  of  organic  matters  and  of 
salts.  These  solutions  ought  to  obey  the  physical  laws  of 
solutions  in  general.  The  author  goes  on  to  show  that 
witnin  the  body  there  are  variations  of  the  osmotic  tension 
of  the  humors,  and  that  the  causes  that  produce  them  ar* 
precisely  those  that  produce  thirst.  In  other  words,  thir«t  is 
due  to  the  increase  of  the  osmotic  tension  of  the  internal 
media.  This  increase  of  tension  brings  a  mechanism  of  vas- 
cular regulation  to  bear  on  all  the  organs  that  have  as  their 
function  the  restoration  of  the  normal  osmotic  tension  when 
that  tension  is  disordered.  This  automatic  mechanism  pro- 
duces as  a  last  manifestation  the  appearance  of  a  physi- 
ologic phenomenon  that  is  the  organic  basis  of  the  sensation 
of  thirst.  The  nervous  c*nt^r  that  controls  this  sensation  is 
situated  in  the  medulla.  \Mietber  or  not  a  cerebral  center 
exists,  the  author  is  nnt  able  at  present  to  locate  it.  Study- 
ing thirst  in  man,  Mayer  divides  the  concomitant  phe- 
nomena into  2  successive  periods  :  The  first,  a  tonic  period, 
during  which  there  is  a  sensory  erethism ;  the  second,  a 
period  of  depression,  corresponding  to  the  period  in  which 
the  osmotic  tension  is  augmented  in  the  entire  circulatory 
system,  and  during  which  there  is  a  sensorial  depression. 
The  author  then  studies  the  psychologic  aspect  of  his  sub- 
ject, and  shows  us  that  in  individuals  attacked  with  morbid 
thirst  there  is  psychologic  trouble  of  conscience,  during 
which  pathologic  impulses  frequently  present  themselves, 
[j  M.s  ] 


Fkbbdabt  16,  1901J 


AMERICAN  NEWS  AND  NOTES 


TThk  Philadelphia 
L  Medical  Joubxtal 


319 


2imerican  Hems  anb  Xloks. 


PHILADELPHIA,  PENNSYLVANIA. 

Milk  Inspection.— W.  J.  Byrnes,  Chief  Milk  Inspector, 
reported  that  during  January  4272  inspections  of  samples  of 
milk  were  made,  and  a  total  of  83,855  quarts  examined.  Of 
this  number  1486  quarts  were  condemned. 

Dr.  Henry  S.  Mellinger,  one  of  the  best  known  physi- 
cians in  Lancaster  County,  died  at  his  home  on  February  7 
at  Creswell,  aged  79  years,  from  apoplexy.  He  graduated 
from  Jefferson  Medical  College,  Philadelphia,  in  1845. 

Physicians  Meet  at  Newtown. — For  the  first  time  in 
50  years,  a  meeting  of  the  Bucks  County  Medical  Society 
was  held  at  Newtown  on  February  7.  The  society  decided 
to  hold  its  winter  meeting  at  this  place  yearly  hereafter. 
Prof  James  Tyson,  of  the  University  of  Pennsylvania,  was 
the  speaker. 

Philadelphia  Neurological  Society. — The  following 
officers  were  elected  for  the  ensuing  year :  President,  Dr. 
James  Tyson;  vice  presidents,  Drs.  C.  S.  Potts  and  F.  X. 
Dercum ;  secretary,  Dr.  A.  A.  Eshner;  treasurer.  Dr.  G. 
Hinsdale ;  councillors,  Drs.  D.  J.  McCarthy,  J.  Sailer,  and 
W.  G.  Spiller. 

Druggist  Censured. — The  coroner's  jury  of  Philadel- 
phia recently  rebuked  a  Philadelphia  druggist  for  selling 
poison  to  a  minor  without  any  prescription  and  recommends 
that  an  act  of  Assembly  be  passed  by  the  Legislature  restrict- 
ing the  sale  of  poisons  and  medicine  containing  poisons. 
Such  legislation  would  undoubtedly  be  of  great  advantage  to 
the  community. 

Dr.  Benjamin  Franklin,  a  native  of  New  York,  died 
February  6,  of  the  grip  at  his  home  in  Newark,  N.  J.,  where 
he  had  practised  medicine  for  25  years.  Dr.  Franklin  was  a 
veteran  of  the  Civil  War,  and  was  a  prisoner  for  7  months  at 
Andersonville.  He  also  served  with  the  Cuban  patriot  army 
in  the  10  years'  war  in  Cuba.  Dr.  Franklin  waa  54  years  of 
age,  and  a  graduate  of  the  University  of  New  York. 

Children's  Hospital. — After  a  lively  meeting  of  the 
Board  of  Managers,  a  new  staff  consisting  of  homeopaths  is 
expected  to  be  in  full  charge  of  the  medical  portion  of  the 
institution.  There  having  been  no  regular  medical  stafi  for 
some  months,  a  number  of  influential  physicians  in  German- 
town  and  other  portions  of  the  city  were  invited  to  act  on 
the  staff.  The  president  decided  with  the  consent  of  a 
majority  of  the  board  to  change  the  institution  from  allopathy 
to  homeopathy,  whereupon  some  of  the  members  of  the 
board  resigned. 

College  of  Physicians. — At  the  stated  meeting  held 
February  6,  Dr.  J.  Chalmers  DaCosta  read  a  memorial  of 
the  late  Sir  James  Paget,  who  was  an  honorary  mem- 
ber of  the  college.  The  address  was  a  fitting  and  eloquent 
tribute  to  the  memory  of  one  who  was  great  not  only  as  a 
surgeon  but  as  an  unassuming  and  conscientious  man. 

Dks.  Jay  Schambeeg  and  J.  Frank  Wallis  exhibited  wax 
models  illustrating  various  cutaneous  diseases  and 
gave  a  detailed  description  of  their  construction. 

Dr.  B.  Alexander  Randall  read  Notes  on  fifty  cases  of 
otitic  extradural  abscess.  The  histories  of  several  cases 
were  detailed.  The  point  emphasized  was  that  in  acute  as 
well  as  chronic  otitis  collections  of  intracranial  pus  may  be 
present  with  but  few  symptoms  referred  to  that  location.  In 
only  one  or  two  instances  has  he  found  involvement  of  the 
eyeground.  In  these  cases  the  antrum  should  be  freely 
opened  to  give  access  to  the  pus  cavity.  As  a  rule  these  ab- 
scesses are  harmless  when  they  are  properly  evacuated. 

Dr.  J.  B.  Roberts  exhibited  a  cast  and  skiagraphs  of  a 
case  of  so-called  Smith's  fracture  of  the  radius 
and  a  skiagraph  of  a  case  of  so-called  Bennett's 
fracture  of  the  metacarpal  bone  of  the  thumb  or 
stave  of  the  thumb.  The  cast  and  skiagraphs  came  from 
Dublin  and  have  been  donated  by  Dr.  Roberts  to  the  Miitter 
Museum. 

Dr.  H.  R.  Wharton  reported  for  Dr.  J.  H.  Mussek  and  him- 


self a  case  of  perforated  gastric  ulcer  ;  operation ;  re- 
covery. The  patient  was  a  man  of  48  who  had  had  gastric 
disturbance  and  pain  for  3  or  4  months  but  had  not  vomited 
blood.  Six  hours  after  the  onset  of  sudden  epigastric  pain 
which  caused  the  man  to  faint  the  abdomen  was  opened.  A 
perforating  ulcer  was  found  on  the  posterior  surface  of  the 
pyloric  end  of  the  stomach  about  one-half  inch  from  the 
duodenum.  The  edges  of  the  opening  were  very  friable,  the 
opening  being  finally  closed  by  infolding  it  by  means  of  six 
silk  sutures  inserted  at  some  distance  from  the  edge.  The 
abdomen  was  flushed  with  6  gallons  of  hot  saline  solution 
and  two  glass  drainage  tubes  inserted.  Recovery  was  un- 
eventful. Dr.  Wharton  believes  thorough  irrigation  is  the 
best  procedure  in  these  cases.  Pelvic  drainage  should  be 
obtained  by  means  of  a  long  drainage  tube  or  by  a  counter- 
opening. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 
February  9,  1901 : 

Total  mortality 549 

Casks.     Deaths. 
Inflammation  of  appendix  1,  bladders,  brain 
11,  bronchi  13,  heart  1,  kidneys  21,  larynx  3, 
lungs   115,   pericardium   2,  peritoneum   10, 

stomach  and  bowels  15,  spine  1 196 

Inanition  12,  marasmus  10,  debility  6 28 

Tuberculosis  of  lungs 77 

Apoplexy  18,  paralysis  5 23 

Heart— diseases  of  24,  fatty  degeneration  of  4, 

neuralgia  3 31 

Uremia  9,  diabetes  4,  Bright's  disease  9  .   .  .   .  22 

Carcinoma  of  breast  3,   stomach  6,  uterus  2, 

tongue  1 12 

Convulsions 15 

Diphtheria 95  15 

Brain — softening  of  1,  disease  of  1 2 

Typhoid  fever 36  7 

Old  age 17 

Burns  and  scalds ■  .  .    .   .  2 

Suicide 2 

Cirrhosis  of  liver 4 

Alcoholism l 

Cyanosis 4  ■ 

Gangrene  of  foot 1 

Scarlet  fever 83  4 

Abscess  of  arm  1,  of  ovaries  1,  abortion  1, 
asthma  1,  aneurysm  of  aorta  1,  casualties  6, 
congestion  of  lungs  10,  childbirth  1,  membra- 
nous croup  2,  epilepsy  1,  erysipelas  3,  gall- 
stones 1,  hemorrhage  from  stomach  2,  from 
uterus  2,  umbilical  hemorrhage  1,  influenza 
28,  intussusception  of  bowels  1,  jaundice  1, 
locomotor  ataxia  1,  necrosis  of  bone  1,  ob- 
struction of  the  bowels  1,  edema  of  glottis  1, 
purpura  hemorrhagica  1,  pyemia  3,  rheu- 
matism 2,  arterial  sclerosis  1,  spine  1,  sur- 
gical shock  1,  sore  mouth  1,  stricture  of 
esophagus  1,  suffocation  2,  tetanus  1,  brain 
tumor  1,  whooping-cough  3 86 

Physicians  Elect  Officers. — The  Atlantic  City  Medi- 
cal Society  held  its  annual  meeting  at  Atlantic  City  February 
6,  and  elected  Dr.  Theodore  Boysen,  of  Egg  Harbor  City, 
president.  The  other  officers  are  residents  of  Atlantic  City, 
and  are  as  follows :  Dr.  W.  K.  Darnall,  vice-president ;  Dr. 
Theodore  Senseman,  secretary  and  treasurer ;  Dr.  A.  B.  Shi- 
mer,  reporter. 

Pediatric  Society.— At  the  meeting  of  February  12,  Dr. 
J.  D.  Target  exhibited  a  case  of  Jacksonian  epilepsy 
in  a  girl  of  7  years.  Convulsive  movements  began  in  the 
left  leg,  which  i»  now  partially  paralyzed,  and  have  now  ex- 
tended to  the  arm.    The  parents  refuse  operation. 

Dr.  J.  P.  Crozer  GRiFFrrH  exhibited:  1.  A  case  of 
splenomegaly,  with  enlarged  liver.  The  child  is  10 
months  of  age,  the  spleen  and  liver  being  greatly  enlarged. 
An  important  point  is  that  there  is  no  decided  evidence  of 
rickets  in  the  case.  Dr.  Griffith  has  seen  several  cases  of  en- 
larged spleen  without  evidence  of  rickets  and  knows  of  no 
reason  why  such  cases  should  not  be  classed  as  splenic  ane- 
mia. 2.  A  case  of  probable  peritonitis  in  a  colored 
girl  of  8  years.  3.  A  case  of  congenital  cyanosis.  The 
infant  becomes  much  more  blue  when  crying.  No  distinct 
heart-murmurs  are  to  be  heard,  but  there  is  accentuation  of 
the  pulmonary  second  sound.  For  these  reasons  there  is  be- 
lieved to  be  an  abnormal  origin  or  a  transposition  of  some 
of  the  bloodvessels. 

Dr.  Jopson  exhibited  a  case  of  nodding  spasm  in 
which  there  is  also  slight  nystagmus  and  some  contraction 


320 


Thb  PhiladelphtaI 
Medical  Jocksal  J 


AMERICAN  NEWS  AND  NOTES 


[FZEKCAET  16,  1901 


of  the  left  stemomastoid  muscle.    There  are  no  well-marked 
Bymptoms  of  rickets. 
De.  D.  L.  Edsall  reported  a  case  of  gamma  of  the  liver 

in  a  child  of  14  years.  The  child  was  deaf  in  both  ears,  had 
ozena,  and  an  old  keratitis,  the  liver  was  enlarged  and  nodu- 
lar and  there  were  effusions  into  the  serous  cavities.  Inunc- 
tions of  mercury  and  the  use  of  the  iodids  soon  caused  an 
improvement  and  finally  a  cure,  so  far  as  can  be  determined, 
the  liver  becoming  normal  in  size  and  the  efiusions  disap- 
pearing. Kidney  involvement,  as  evidenced  by  albuminuria, 
also  cleared  up.  '  The  great  frequency  of  mistakes  in  diag- 
nosis was  noted,  the  condition  very  often  being  diagnosed  as 
malignant,  even  by  prominent  clinicians. 

Dr.  J.  P.  Ceozeb  Griffith  detailed  a  convenient  plan  for 
bedside  case-history  taking'  in  private  practice. 
After  trying  several  plans,  one  which  has  given  satisfaction 
for  nearly  2  years,  is  that  of  a  pocket-case  with  2  large  pockets 
for  cards.  Card  histories  from  the  office  can  thus  be  taken 
to  houses  when  office  patients  are  visited.  Slips  on  which  to 
write  directions  for  diet,  medicine,  etc.,  as  well  as  printed 
slips  giving  directions  for  making  barley  water,  beef-juice,  etc., 
and  preparing  baths,  are  also  carried  in  the  case. 

Dk.  Emeey  Makvel  reported  a  case  of  suppurating 
mastitis  in  the  newborn.  The  infant  was  27  days  old. 
The  abscess,  which  was  incised  and  evacuated,  is  believed  to 
have  been  due  to  irritation  from  within  by  a  hypersecretion 
of  colostrum.  In  such  cases  prophylaxis  may  be  of  use  if 
the  condition  is  recognized  early. 

De.  T.  S.  Westcott  read  A  note  on  the  differential 
modification  of  the  proteids  of  milk.  Formulae  were 
given  based  upon  a  ratio  of  4  to  1  between  caseinogen 
and  whey  proteids.  This  ratio  is  believed  to  be  more  correct 
than  the  former  used — 5  to  1.  The  change  is  based  on  recent 
reports,  especially  that  of  Drs.  White  and  Ladd  In  the  Phila- 
delphia Medical  Jouekal  of  February  2. 

Obstetrical  Society.— At  the  meeting  of  February  7, 
Dr.  Wilmer  Kecsex  read  a  paper  on  Organotherapy  in 
gynecology.  The  literature  of  the  subject  was  carefully 
reviewed,  including  the  use  of  uterine,  mammary,  parotid, 
thyroid,  and  ovarian  extracts.  Of  these  the  thyroid  is  the 
most  efficient  and  has  been  most  thoroughly  tried.  Dr. 
Krusen  has  been  prescribing  ovarian  extract  for  3  years  for  3 
classes  of  cases :  1.  In  amenorrhea  and  dysmenorrhea.  2. 
For  symptoms  following  the  removal  of  the  uterine  append- 
ages. 3.  For  disturbances  due  to  the  natural  menopause. 
Most  cases  are  disappointing,  but  an  occasional  success  in- 
cites to  renewed  use.  The  best  results  are  noticed  in  the 
second  class  of  cases,  the  congestive  and  nervous  symptoms 
being  ameliorated  in  some  in8tanc«8.  Xo  definite  and  exact 
reliance  can  be  placed  on  the  drug.  In  discussing  the  paper, 
De.  Shober  said  that  the  chief  indication  for  the  use  of 
mammary  gland  was  in  uncomplicated  cases  of  bleeding 
fibroids.  It  would  not  cure  the  condition  but  would  control 
the  hemorrhage  and  thus  put  the  patient  in  better  condition 
for  operation.  He  is  also  convinced  that  parotid  extract  will 
control  ovarian  pain  in  patients  who  have  enlarged,  prolapsed, 
and  tender  ovaries  without  adhesions. 

De.  H.  a.  Hare  stated  that  he  would  speak  from  a  theoreti- 
cal rather  than  a  practical  standpoint.  An  important  point 
is  to  know  the  relative  activity  of  the  gland  which  is  being 
prescribed.  A  knowledge  of  the  condition  of  the  animsil 
from  which  the  gland  was  obtained  is  necessary  to  get  defi- 
nite conclusions,  ilany  contradictory  reports  may  have 
thus  arisen.  Again,  the  minute  metabolism  of  each  patient 
is  not  known,  and  thus  the  exact  cause  of  the  condition  may 
be  different  in  diflerent  individuals  and  be  acted  on  diflFer- 
ently  by  the  extract  given.  The  fact  that  some  observers  re- 
port such  gratifying  results  rather  militates  against  the  use  of 
extracts  as  this  is  comparable  to  drugs  which  give  wonderful 
results  in  the  hands  of  some  one  individual  but  which  are  con- 
sidered of  no  value  by  the  profession  at  large.  Because  diflerent 
organs  are  similarly  involved,  as  the  parotid  gland  and  the 
ovary  in  mumps,  does  not  prove  them  to  have  a  physiolog- 
ical connection.  They  may  be  only  baterioloeically  similar. 
The  connection  between  the  ovaries  and  the  mammary 
glands  may  be  only  a  reflex  one.  Physicians  will  not  be 
able  to  employ  organotherapy  in  a  rational  way  until  they 
are  able  to  separate  symptoms  and  locate  more  definitely 
their  cause  in  individual  cases.  Dr.  J.  M.  Baldy  practically 
agreed  with   Dr.  Hare's  conclusions.     The  application  of 


these  remedies  is  very  limited,  although  thyroid  extract  has 
aided  in  controlling  hemorrhage  in  a  few  instances,  in  naUi- 
parous  women  only.  It  has  been  of  use  in  several  cases  of 
irregular  menstruation.  De.  W.  W.  Eubseix,  of  Johns 
Hopkins  Hospital,  stated  that  organotherapy  had  been  prac- 
ticsdly  useless  in  his  experience.  The  use  of  suprarenal 
extract  locally  gave  a  gratifying  result  in  one  case.  The 
patient  hai  been  treated  unsuccessfully  for  9  months  for 
bleeding  from  one  kidney.  Through  a  catheter  J  ounce  of  a 
10^  solution  of  suprarenal  extract  was  introduced.  There 
has  been  no  return  of  the  bleeding  for  3  months.  Dr.  E.  E. 
MosTGOMERY  finds  that  thyroid  extract  may  cause  a  recur- 
rence of  pregnancy  in  obese  women.  He  beUeves  the 
involvement  of  the  parotid  gland  following  operation  to  be 
the  result  of  infection  rather  than  from  a  physiological  con- 
nection. In  the  irregular  bleeding  of  women  who  are  near 
the  climacteric,  thyroid  extract  has  a  certain  use.  It  also 
moderates  the  severe  pain  in  malignant  disease.  Dr.  J.  G. 
CLi  BK  has  been  prescribing  parotid  extract  systematically  for 
3  or  4  months  in  cases  of  dysmenorrhea  with  not  the 
slightest  result.  Dr.  J.  M.  Fisher  stated  that  the  use  of 
thyroid  extract  at  the  JeS'erson  Clinic  reduced  the  weight  of 
patients  and  wag  serviceable  in  some  cases  of  amenorrhea. 
Ovarian  extract  gave  no  results.  In  private  practice  one 
case  had  LmprovM  by  its  use.  Dr.  J.  C.  DaCosta  confines 
the  use  of  thyroid  to  cases  of  fibroid  who  refuse  operation. 
Most  cases  are  reduced  in  size  and  the  hemorrhage  ceases. 
The  decrease  in  size  is  apt  to  be  temporary. 

De.  E.  E.  Montgomery  read  a  paper  on  Operative  treat- 
ment for  cancer  of  the  uterus.  The  condition  of  the 
patient  should  determine  whether  the  vaginal  or  abdominal 
method  should  be  used  in  the  radical  treatment.  The  vaginal 
method  should  be  used  in  cases  where  the  disease  is  confined 
to  the  cervix ;  the  uterus  is  freely  movable,  and  the  vagina  is 
roomy.  The  excision  must  be  made  in  healthy  tissue  and 
reimplantation  prevented  by  a  preUminary  curettement  and 
suturing  of  the  cervix.  In  abdominal  hysterectomy  the 
pelvic  glands  are  not  to  be  removed  as  a  routine  procedure; 
the  glands  are  rarely  involved  in  operable  cases ;  the  prog- 
nosis is  unfavorable  in  patients  under  3.5.  De.  J.  G.  Clark 
makes  the  removal  of  the  glands  dependent  on  the  condition 
of  the  patient.  If,  after  removing  the  broad  ligaments  and 
getting  the  ureters  well  out  of  the  way,  the  patient  is  in  fair 
condition,  he  removes  the  glands.  If  the  patient's  condition 
is  not  good,  the  operation  is  stopped.  The  removal  of  the 
glands  is  of  prognostic  value.  If  they  are  found  by  micro- 
scopic study  to  be  involved,  the  prognosis  is  very  on&vor- 
able.  He  supports  Freund's  views  in  regard  to  the  route 
selected — vaginal,  if  the  condition  is  incurable ;  abdominal,  if 
there  is  hope  of  cure.  Dr.  J.  M.  Baldy  stated  that  cancer  of 
the  fundus  and  of  the  cervix  were  practically  two  diseiaee,  so 
far  as  prognosis  is  concerned.  The  majority  of  the  former 
get  well,  the  latter  all  die.  The  statistics  of  the  German 
writers  are  not  to  be  relied  upon.  The  attempt  to  clear  out 
all  the  glands  will  lose  cases.  Beside  this,  it  is  impossible  for 
any  man  to  dissect  out  all  the  glands  of  the  pelvis.  Patholo- 
gists disagree  regarding  the  condition  present  in  many  of 
these  cases,  hence  the  clinician  must  not  depend  too  much 
upon  their  dictum  and  seek  to  remove  too  muc'n  tissue. 
Owing  to  the  lateness  of  the  hour,  Dr.  Gbo.  Erety  Shokmakkb 
merely  mentioned  several  cases  he  had  to  report. 

XEW  YORK. 

Dr.  John  J.  McGrath  has  been  appointed  attending 

surgeon  to  the  Harlem  Hospital. 

State  Medical  Society. — The  following  officers  were 
elected  January  31,  1901 :  President,  Dr.  Henry  M.  Eisner,  of 
Syracuse  ;  vice-president.  Dr.  Louis  M.  Lanehart,  of  Hemj)- 
stead ;  secretary.  Dr.  F.  C.  Curtis,  of  Albany ;  treasurer.  Dr. 
C.  D.  Ball,  of  Albany. 

Report  of  the  Xew  York  Orthopedic  Dispensary 

and  Hospital.— During  the  year  ending  September  30, 
1900,  164  patients  have  been  admitted  to  the  wards  of  the 
hospital,  110  discharged  improved,  3  unimproved.  S  died  and 
4S  remained  under  treatment  October  1,  1900.  The  number 
of  davs  of  hospital  care  for  free  patients  was  17,902 ;  for  pay 
patients,  2S94  ;  toul,  20,796.  Thirty-six  patienu  were  treated 
by  operative  measures,  and  0/    operations  were  performed. 


FBBBnAKT  16,  1901] 


AMERICAN  NEWS  AND  NOTES 


CThe  Philadelphia 
Meoicaij  Jocbnal 


321 


All  were  successful.  The  out-visiting  nurse  has  made  2265 
visits  to  the  homes  of  patients  discharged  from  the  hospital. 

Neurological    Society    on     Insanity   Law.— At   a 

meeting  of  the  New  York  Neurological  Society,  held  in  the 
Academy  of  Medicine,  resolutions  were  adopted  in  regard  to 
the  qualifications  required  for  the  President  of  the  State 
Commission  on  Lunacy.  Bills  relating  to  this  subject  and 
providing  also  for  a  change  in  the  State  insanity  measures 
are  at  present  before  the  Legislature.  The  resolutions  con- 
demn any  amendment  of  the  State  insanity  provisions  which 
do  away  with  the  clause  providing  that  the  medical  member 
of  the  commission  shall  have  had  five  years'  actual  experi- 
ence in  the  care  and  treatment  of  the  insane. 

Medical  Profession  Honor  Prof.  Francis  J.  Quin- 
tan, M.D.,  Lli.D. — A  large  number  of  physicians  of  New 
York  City  tendered  to  Prof.  Francis  J.  Quinlan  a  compli- 
mentary dinner,  and  a  magnificent  loving  cup  beautifully 
inscribed.  They  gathered  to  give  testimony  of  their  recog- 
nition of  the  esteem  and  appreciation  in  which  they  held 
their  honored  guest  not  only  as  a  physician,  but  as  a  citizen. 
Speeches  were  made  by  Professors  Wyithe,  Townsend,  Rob- 
inson, and  T.  A.  Emmett.  Drs.  Phelps  McGuire  and  Smith 
represented  St.  Vincent's  Hospital ;  Dr.  John  McGarth,  the 
Postgraduate  School ;  Dr.  Joseph  Bissell,  Bellevue  Hospital, 
New  York  City;  Dr.  Aspell,  the  Cornell  Medical  College; 
Drs.  Bodine  and  Doherty,  the  New  York  Polyclinic ;  Dr. 
Thomas  Manley,  the  Harlem  Hospital;  Dr.  Quigley,  the 
Fordham  Hospital;  Dr.  P.  V.  Burnett,  the  Brooklyn  Eye  and 
Ear  Hospital ;  Drs.  Ledermann,  Hepburn,  and  MacDonald, 
the  Manhattan  Eye  and  Ear  Hospital ;  Drs.  Callan  and  Mac- 
Coy,  the  New  York  Eye  and  Ear  Infirmary,  whilst  Dr.  Dal- 
rymple  came  from  New  Rochelle  to  add  to  the  occasion. 
Dr.  Nevin  journeyed  from  Jersey  City,  and  Dr.  Morris  Manges 
ably  represented  Mount  Sinai  Hospital.  Many  other  promi- 
nent doctors  were  seen  at  the  different  tables,  and  the  even- 
ing was  one  long  to  be  remembered  by  all  present. 

New  York  Academy  of  Medicine— Section  on 
Orthopedic  Surgery.- Meeting  of  January  18,  1901.  Dr. 
George  R.  Elliott,  chairman. 

Dr.  Homer  Gibney  presented  a  girl,  aged  17  years,  tall, 
with  a  round  back  or  posterior  curve  of  adolescence,  of 
which  he  exhibited  a  tracing.  He  had  applied  the  plaster 
jacket  she  now  wore,  only  a  few  hours  before,  by  placing  her 
in  the  recumbent  position,  the  body  resting  upon  two  up- 
rights— one  under  the  pelvis,  and  the  other  under  the  point 
of  greatest  prominence  of  the  back.  Her  head  and  shoulders 
were  allowed  to  sag  backwards  and  downwards.  The  position 
maintained,  which  caused  the  patient  some  sufiering,  was  a 
marked  overcorrection.  Another  jacket  would  be  applied 
later.  The  patient  did  not  bear  the  operation  well  on 
account  of  cardiac  complication.  Dr.  Henry  Linq  Taylor 
said  he  had  not  understood  what  diagnosis  had  been  made, 
but  the  girl  seemed  unusually  tall  for  the  age  assigned,  and 
asked  if  the  possibility  of  gigantism  had  been  considered,  as  a 
marked  round  back  was  common  in  such  conditions.  Dr. 
Royal  Whitman  said  he  was  familiar  with  the  history  of  the 
patient.  She  had  some  cardiac  disease,  was  rickety,  over- 
grown, and  badly  nourished.  He  considered  her  condition 
merely  the  round  spine  of  adolescence,  partly  due  to  her 
height  and  heart-weakness,  and  called  attention  to  the 
patient,  showing  lack  of  ordinary  intelligence.  Dr.  George 
R.  Elliott  asked  Dr.  Gibney  how  much  force  in  pounds  he 
had  used  to  correct  the  deformity.  Dr.  Gibney  replied  that 
little  force  beyond  gravity  was  used,  the  sagging  of  the  body 
between  the  supports  appeared  to  give  the  necessary  exten- 
sion. Dr.  W.  R.  Townsend  said  that  he  had  put  up  a  case 
of  spondylose  rhizomelique  last  week  in  a  much  straightened 
position,  followed  by  a  feeling  of  relief  to  the  patient.  Dr. 
Taylor  remarked  that  Kietely  had  described  anterior  crutches 
to  hold  the  shoulders  back,  which  would  seem  to  answer  the 
purpose  of  epaulettes  as  used  in  this  jacket,  without  their 
disadvantages. 

Epicondylar  Fracture  of  the  Elbow. — Dr.  Homer 
Gibney  presented  a  small  boy  who  had  sustained  a  fracture 
of  the  elbow  three  months  previously.  The  fracture  was 
above  the  condyle.  When  the  patient  presented  himself  at 
the  hospital  the  elbow  was  fixed  at  an  angle  of  105°  with 
but  little  movement.  The  joint  was  cut  down  upon  by  Dr. 
V.  P.  Gibney  and  the  detached  fragment  sutured  into  place. 


Dr.  V.  P.  Gibney  said  the  epicondyle  and  nearly  the  entire 
condyle  had  been  displaced,  interfering  with  motion.  He 
had  cut  down  upon  the  joint  and  separated  it  with  an  osteo- 
tome, cleaned  off  the  site  of  the  fragment  and  pushed  it 
down,  suturing  with  kangaroo  tendon;  he  then  put  the  arm 
in  a  straight  position,  left  it  for  four  or  five  weeks  and  then 
allowed  active  motion.  Passive  motion  was  not  employed. 
Dr.  T.  Halsted  Meyers  commented  upon  the  excellent 
result  and  remarked  that  children  were  often  allowed  to  go 
on  with  fracture  at  the  elbow  united  in  poor  position  in  the 
belief  that  they  would  outgrow  the  disability  in  great  degree, 
which  was  true,  but  it  was  better  to  correct  the  deformity 
entirely,  even  resorting  to  open  operation  when  necessary. 
He  called  attention  to  Dr.  Lloyd's  excellent  reports. 

Coxa  Vara. — Dr.  Townsend  presented  a  boy,  aged  14, 
with  the  history  that  three    years  ago,  without  apparent 
cause,  began  to  limp  and  noticed  that  one  leg  was  a  little 
shorter  than  the  other.    The  condition  increased  and  he  has 
had  some  pain.    There  was  one  inch  of  actual  shortening. 
Radiographs  were  shown.      He  diagnosticated  coxa  vara  of 
the  ordinary  type.    He  said  there  were  two  points  to  note  : 
One,    good  flexion  and    extension   with    little    adduction ; 
the  other,  the  smaller  size  of  the  limb.  Dr.  Townsend  showed 
another  skiagraph  of  a  patient  in  which  he  had  made  the 
diagnosis  some  time  ago  of  coxa  vara.    In  this  case,  under 
observation  for  three  years,  there  had  been  a  progressive 
shortening  of  about  4  to  i  inch  each  year,  now  amounting  to 
J  of  an  inch.    Dr.  Whitman  called  attention  to  the  import- 
ance of  the  limitation  of  motion,  that  although  the  patient 
still  retained  10  ^Si  of  abduction,  there  was  an  apparent  short- 
ening of  two  inches.    This  shortening  and  consequent  dis- 
ability was  due  to  the  limitation  of  abduction.    This  deform- 
ity might  be  overcome,  after  preliminary  stretching  of  the 
contracting  muscles,  by  a  cuneiform  osteotomy  at  the  base 
of  the  trochanter  which  would  reestablish  the  angle  of  the 
neck  and  thus  relieve  the  strain  upon  it.      He  advised  this 
operation  in  Dr.  Townsend's  patient,  though  the  best  results 
were    to    be    looked    for    in  younger    patients,  or    at    an 
earlier  stage  of  the  deformity.    Dr.  Elliott  asked  Dr.  Whit- 
man how  large  a  wedge  of  bone  he  would  remove.      Dr. 
Whitman  suggested  cutting  a  paper  model  of  the  bone  as 
shown  in  the  skiagraph,  and  measuring  on  that  the  size  of 
wedge  to  be  cut  out ;  he  thought  one  with  a  base  of  J  of  one 
inch  would  be  sufiicient  in  the  patient  under  discussion.  Dk. 
Elliott  asked  if  the  length  of  the  limb  would  be  much  in- 
creased.     Dr.  Whitman  replied  that  the  actual  increase  in 
length  would  be  slight,  possibly  J  inch  ;  the  important  point 
was  that  there  would  be  no  apparent  shortening  because 
there  would  be  complete  relief  of  the  limitation  of  motion 
which  caused  the  apparent  shortening.    Dr.  Townsend  said, 
he  had  performed  the  operation  referred  to  by  Dr.  Whitman 
in  two  cases  with  good  results  and  saw  no  reason  why  it 
should  not  be  done  in  this  case.    In  one  patient,  however,  a 
little  girl,  aged  7    years,    who    had    slight    coxa    vara,   he 
had  applied    a    traction    splint    and    did    not    see  in  this 
particular  case  why  it  was  not  as  good  as  the  osteotomy 
advised  by  Dr.  Whitman.      He    thought   apparatus    worn 
for  a  few  years  would  give  good  results  in  the  mild  cases. 
Dr.  Meyers  agreed  with  Dr.  Townsend  that  it  would  be 
better  in  the  beginning  of  these  cases  to  use  some  sort  of 
supporting  apparatus  that  would  not  need  bandage  or  plaster, 
thus  avoiding  pressure  atrophy.    He  thought  the  Campbell 
brace  especially  adapted  for  such  cases.     It  removed  part  or 
all  of  the  body  weight  and  was  inconspicuous.    Dr.  V.  P. 
Gibney  asked  just  what  the  Campbell  brace  was.  Dr.  Meyers 
illustrated  it  by  a  drawing  showing  it  extending  to  the  hip. 
Dr.  Gibney  asked  if  the  Campbell  brace  had  always  extended 
to  the  hip  as  drawn  by  Dr.  Meyers.    Dr.  Meyers  said  that  it 
had  for  the  last  18  years.    Dr.  Taylor  said  that  this  brace 
reminded  him  of  the  Dow's  brace  which  was  valuable  when 
it  was  desirable  to  use  a  perineal  crutch  and  allow  motion  at 
the  knee.   He  cited  cases  which  had  done  well  under  the  use  of 
the  hip- splint,  but  could  not  give  final  results  as  the  patients 
had  not  returned  after  treatment  was  discontinued.    He  had 
recently  seen  a  case  of  coxa  vara  in  consultation  when  4  out 
of  6  surgeons  consulted  were  in  favor  of  the  splint  treatment. 
Dr.  Whitman  did  not  favor  the  use  of  apparatus  as  a  routine 
treatment,  believing  that  after  its  discontinuance  the  distor- 
tion was  likely  to  increase.    The  nutrition  of  the  parts  was 
likely  to  be  lessened  rather  than  increased  by  the  use  of 
braces.   He  had  been  disappointed  in  the  final  effect  in  cases 


322 


ThK  FhTT,  a  T>yTfPHT  A  ~] 

Medical  Jocblsax  J 


AMERICAN  NEWS  AND  NOTES 


rFXEECAET   16,  ISO: 


in  which  apparatus  had  been  used.  Finally,  braces  could  j 
not  rectify  the  deformity,  at  best  it  would  but  relieve  the 
symptoms  and  check  progress.  His  operative  results  had 
been  satisfactory.  The  patients  after  operation  did  not  limp. 
Nearly  all  of  his  operative  cases  were  between  the  ages  of  6 
and  10  years.  Dr.  Towssesd  asked  if  the  boy  in  question 
would  walk  perfectly  if  the  adduction  were  overcome.  De. 
WHiTMA2f  said  if  there  was  no  limitation  of  abduction,  the 
boy  would  walk  almost  perfectly;  whatever  limp  persisted 
would  depend  upon  the  actual  shortening.  De.  Elliott  wished 
to  know  what  would  be  the  prognosis  if  the  case  was  left 
untreated.  De.  Whitmak  replied  that  the  patient  would  not 
get  much  worse,  might  get  some  better ;  as  a  rule,  after  the 
more  acute  symptoms  had  subsided  the  patients  adapted 
themselves  to  the  deformity  and  got  along  very  well  with  a 
greater  or  less  degree  of  lunping.  He  stated  that  several  of 
the  German  writers  were  apparently  opposed  to  either 
mechanical  or  operative  treatment.  Dr.  Lons  A.  Weigel, 
of  Eochester,  N.  Y.,  thought  apparatus  might  be  used  to 
advantage  in  the  earlier  stages  of  coxa  vara  for  the  removal 
of  superincumbent  weight  which  is  an  etiologic  factor.  He 
believed  the  diflTerence  in  size  of  the  femora  as  shown  in  the 
radiographs  was  due  to  a  true  atrophy  or  arrest  of  develop- 
ment. If  coxa  vara  is  due  to  defective  nutrition,  develop- 
ment of  the  afifected  side  would  be  retarded. 

Fracture  of  the  Neck  of  the  Femur. — De.  Towssesd 
presented  a  man,  19  years  of  age,  who  in  December,  1899, 
fell  a  distance  of  40  feet,  striking  on  his  hip.  A  diagnosis  of 
contusion  was  made  at  the  hospital  to  which  he  was  taken, 
where  he  remained  in  bed  6  weeks,  at  end  of  which  time  he 
could  not  walk,  except  with  the  aid  of  crutches.  He  came 
to  the  Hospital  of  Ruptured  and  Crippled  in  April,  1900,  and 
a  diagnosis  of  fracture  of  the  neck  of  the  femur  waa  made. 
There  was  one  inch  of  shortening,  inversion  of  foot,  crepita- 
tion at  site  of  fracture  when  movements  were  made.  Extreme 
pain  and  inability  to  bear  weight  on  the  limb  or  lift  it  from 
the  table  when  lying  on  his  back.  A  long,  traction  hip 
brace  and  a  high  shoe  were  applied  and  worn  for  6  months. 
The  man  can  now  walk  with  little  or  no  pain,  and  when 
lying  on  his  back  can  raise  his  leg  nearly  as  well  as  on  the 
sound  side.  There  is  one  inch  of  shorteninp,  no  crepitation 
at  hip,  and  all  motions  are  possible  without  pain.  Dr. 
Townsend  thought  traumatic  cova  vara  could  be  applied  to 
this  case.  Dr.  Melees  thought  the  case  very  encouraging. 
He  had  presented  a  similar  case  some  time  ago,  where  bony 
imion  had  been  secured  after  4  months  of  nonunion.  In  all 
cases  of  fracture  of  the  neck  of  the  femur,  an  earnest  attempt 
to  get  bony  union  should  be  made.  In  recent  cases,  even  in 
old  people,  with  proper  splints  we  would  succeed  many 
times.  In  old  people  where  there  had  been  fracture  without 
real  immobilization  for  many  months,  the  case  waa  not 
hopeless  under  proper  treatment.  Dr.  Weigel  exhibited  a 
radiograph  of  an  unusual  deformity  of  the  tibia  and  fibula, 
following  a  probable  fracture  during  infancy.  The  mother 
had  noticed  a  slight  angle,  middle  §  of  tibia  when  child  was 
3  months  old.  This  had  increased.  The  original  fracture 
may  have  occurred  in  utero.  Dr.  Weigel  also  presented  a 
series  of  radiographs,  showing  congenital  absence  of  bones 
in  members  of  the  same  family.  In  the  5  extremities  shown, 
some  bone  of  the  hand  or  arm  was  absent.  In  one  case 
there  was  a  rudimentary  humerus,  an  imperfect  thumb, 
and  3  fingers.  The  mother  had  no  thumb,  and  gave  a  history 
of  having  born  12  children,  four  of  whom  were  deformed. 
The  mother  attributed  her  own  deficiency  to  maternal  im- 
pression, stating  that  her  mother,  while  pregnant,  was 
shocked  by  seeing  a  man  at  her  house  without  a  thumb.  Dr. 
Weigel  exhibited  another  radiograph  of  a  case  of  extensive 
osteomyelitis  involving  the  whole  of  the  tibia  on  one  side. 
The  patient  had  been  treated  for  articular  rheumatism.  He 
thought  it  possible  in  most  cases  to  make  the  differential 
diagnosis  between  marked  suppuration  and  thickening  or 
eburnation.  When  there  ia  pus  formation,  he  states  that  in 
a  radiograph  it  is  difficult  to  get  a  clear  definition  of  bone 
structure  on  account  of  the  osteoporotic  condition  usually 
present.  Dr.  Weigel  also  exhibited  a  radiograph  of  a  tuber- 
cular focus  in  a  child's  foot,  together  with  another  radio- 
graph taken  2  months  later,  showing  the  reparative  process 
already  well  under  way.  This  patient  waa  treated  oy  fix- 
ation and  rest,  any  radical  surgical  interference  being  contra- 
indicated.  Dr.  Towssexd  asked  for  a  differential  diagnosis 
between  sarcoma  of  bone  and  osteomyelitis.    Dr.  Weigel 


said  that  such  a  differential  x-ray  diagnosis  might  be  difficalt 
to  make  without  an  opportunity  of  comparmg  a  series  oi 
cases.  De.  Elliott  showed  a  skiagraph  of  congenital  dislo- 
cation of  the  hip,  which  was  taken  after  only  1.5  seconds  of  ex- 
posure. The  shortness  of  time  exposure  was  important 
With  restless  children,  long  exposure  waa  often  impossible 
without  an  anesthetic. 

Transactions  of  the  Xew  York  Obstetrical  So- 
ciety.— Stated  meeting,  held  Tuesday,  January  8.  1901. 
President  Dr.  H.  J.  Boldt  in  the  ciiair. 

De.  Jasyeix  presented  a  specimen  of  large  myomatous 
growth  of  the  uterus.  The  history  waa  as  foUows: 
Patient  single,  40  years  of  age,  menstrual  history  regular,  no 
pain  or  bleeding.  One  month  ago  she  had  her  normal 
period,  which  continued  for  several  days,  after  which  she  be- 
gan to  flow  freely.  The  hemorrhage  waa  controlled  some- 
what, but  she  continued  to  flow  for  several  weeks.  Upon 
examination  at  the  end  of  3  weeks,  a  large  abdominal  growth 
was  found  and  the  tumor  removed,  which  is  here  presented. 
Several  cysts  of  the  ovaries  were  removed  at  the  same  time. 
The  case  was  of  interest  because  no  hemorrhage  had  occurred 
until  the  last  month,  although  the  maaa  was  of  large  size. 
The  reason  for  this  liea  in  the  &ct  that  the  tumor  is  probably 
of  the  cystic  variety. 

De.  Boldt  presented  a  speciden  of  tubal  pregnancy, 
in  which  the  fetus  of  2  months  was  found  still  within  the 
tube.  The  great  interest  in  this  case  Mes  in  the  fact  that 
operation  waa  performed  aa  the  process  of  tubal  abortion  waa 
taking  place.  The  abdominal  extremity  of  the  tube  is  dilated 
to  a  diameter  of  1  cm.  The  uterine  end  is  completely  oc- 
cluded. The  tube  is  2i  cm.  in  diameter  at  the  thickest  point. 
The  patient  had  been  bleeding  for  3  months  at  irregular  in- 
tervals, accompanied  by  cramp-Uke  pains.  During  the  week 
before  operation  the  bleeding  waa  very  profuse,  so  that  the 
physician  (who  thought  that  the  patient  had  an  intrauterine 
pregnancy)  said  that  she  would  abort.  Large  clots  were  ex- 
pelled per  vaginam.  The  patient  waa  very  anemic,  and  suf- 
fered great  pain.  In  the  abdomen  there  waa  a  large  quantity 
of  blood  which  had  escaped  at  different  times,  shown  by  the 
varying  degrees  of  consistency  ;  some  clota  were  recent,  bleed- 
ing continuing  from  the  tube,  while  some  were  very  firm  and 
yellowish-red,  the  latter  being  on  the  floor  of  the  pelvis.  The 
bleeding  for  such  length  of  time  without  completion  ef  the 
abortion  is  the  main  interesting  feature. 

De.  VrsEBEEG  said  thatthe  case  waa  of  great  interest,  show- 
ing as  it  did,  that  we  may  get  aa  profuse  a  hemorrhage  from 
the  uterus  in  ectopic  gestation  aa  from  an  intrauterine  abor- 
tion. He  also  emphasized  the  advisability  of  anesthetiz'.ne 
in  cases  of  supposed  abortion  in  order  to  make  a  careful 
diagnosis  of  the  exact  conditions.  Dr.  Beothees  mentioned 
the  fact  that  some  men  thought  it  unnecessay  in  cases  of 
tubal  abortion  to  perform  laparotomy,  or  to  exsect  the  tube. 
But  in  cases  like  this  one  of  Dr.  Boldt's,  where  the  diagnos- 
of  tubal  abortion  is  made  and  where  the  patient  may  lose 
her  life  from  exsanguination,  the  loss  of  blood  occurring 
externally  or  in  the  peritoneum,  one  is  justified  in  doing  an 
abdominal  section  and  removing  the  diseased  tube.  Db. 
Jastbxx  remarked  that  in  many  caaes  upon  which  surgeooa 
are  called  to  operate  there  is  really  a  tubal  abortion  present 
and  no  rupture  of  the  tube  itself.  It  is  rare  for  hemorrhages 
to  continue  from  a  tube  for  2  or  3  weeks  without  abonion 
being  complete.  In  most  cases  tubal  abortion  takes  place 
inside  of  a  week.  In  his  opinion  there  was  no  question  of 
the  necessity  for  operation  in  any  case  where  hemorrhage 
was  going  on.  Dr.  Boldt  in  closing  said  he  believed  that  an 
impregnated  tube  should  be  treated  as  one  of  malignant 
disease  and  operation  waa  therefore  indicated. 

Dr.  H.  J.  Boldt  read  the  paper  of  the  evening.  Tne  sub- 
ject was:  1.  The  Definition  of  septicemia  and 
pyemia ;  2.  The  indication  for  vaginal  hysterec- 
tomy and  for  abdominal  section  and  drainage  in 
puerperal  fever.  The  writer  in  reviewing  the  bacterid' 
ogy  of  the  ailments  under  discussion,  said  that  while  the:- 
were  many  varieties  of  streptococci,  they  could  be  divideu 
into  three  classes  or  varieties,  depending  upon  their  viru- 
lence. In  order  t-o  show  the  various  definitions  for  septi- 
cemia and  pyemia  and  their  mingling  with  the  terms  septic 
infection  and  septic  intoxication, ^hus  creating  confusion,  the 
author  quoted  from  a  number  of  recent  texu>ooks  and  di.- 
tionaries.      So  different     in    meaning    are    these    various- 


I 


Febbcibt  16,  1901] 


AMERICAN  NEWS  AND  NOTES 


rTHE  Phii^dklphia 
L  Medical  Joubnal 


323 


definitions,  that  one  is  necessarily  confused  in  choos- 
ing  the   correct   term  for  a   given  pathological  condition. 

The  best  definition  for  septicemia  is  given  by  Coplin  in  his 
"Manual  of  Pathology,"  third  edition,  published  in  1900. 
This  is  found  on  page  389,  under  the  term  "  Mycoses  of  the 
Blood."  He  states  that  "in  these  the  bacteria  are  present 
and  multiplying  in  the  circulating  blood  in  which  their  pro- 
ducts are  generated.  The  intensity  of  the  septic  phenomena  is 
augmented  by  the  greater  production  of  the  poison,  and  not 
having  even  the  barrier  of  protection  afforded  by  the  neces- 
sity of  osmosis  or  absorption,  they  are  enabled  to  engender 
lesions  not  presumed  to  occur,  at  least  not  to  the  same  extent, 
in  either  sapremia  or  local  infection.  The  embolic  produc- 
tion of  abscess  is  the  essential  element  of  pyemia,  a  disease 
recognized  by  surgeons  as  septicemia,  plus  the  infected 
emboli,  to  which  are  attributed  metastatic  abscesses." 

Delafield  and  Prudden,  in  their  "  Pathological  Anatomy 
and  Histology,"  fifth  edition,  state  that  "  If  from  a  focus  of 
suppurative  inflammation  due  to  microscopic  organisms,  or 
if  from  a  point  of  entrance  of  microscopic  organisms  without 
local  reaction,  the  germs  and  their  product  become  distributed 
through  the  body,  inducing  disease,  the  general  condition  is 
called  septicemia.  If  in  the  invasion  of  the  body  by  the 
microscopic  organisms  and  their  products  new  supplementary 
foci  be  established,  it  is  now  customaxy  to  designate  the  con- 
dition pyemia. 

Dr.  Boldt  in  his  paper  makes  use  of  and  favors  the  terms 
"acute"  and  "chronic"  bacteremia.  He  defines  "acute 
bacteremia  "  as  a  blood  disease  caused  by  microscopic  organ- 
isms invading  the  circulation  from  some  primary  seat  of 
infection.  These  infection-producing  elements  multiplying 
so  rapidly  in  the  blood  that  the  patient  usually  succumbs 
within  5  days  after  the  disease  begins.  Usually  the  para- 
sitic germs  are  streptococci  pyogenes,  but  other  pathological 
germs  may  be  present  also.  Chronic  bacteremia  (or  pye- 
mia) is  likewise  caused  by  the  invasion  of  the  system  by 
microscopic  organisms,  but  they  disseminate  from  an  in- 
fected thrombus.  They  qre  not  diffused  into  the  system  in 
large  quantity,  neither  are  they  possessed  with  the  same 
foudroyant  virulence  from  a  clinical  standpoint.  The  pro- 
duction of  the  abscesses  found  in  the  condition  called 
pyemia,  and  upon  which  the  pathological  difference  between 
the  two  conditions  depend,  is  due  to  the  parasitic  organisms 
finding  a  resting  place  outside  of  the  blood  circulation,  and 
there  giving  rise  to  abscess  formation.  That  there  is  a 
decided  difference  in  the  virulence  of  streptococci  no  one 
will  deny  ;  for  instance,  an  incised  wound  of  the  finger  may 
be  infected  with  pus  containing  streptococci  and  yet  slight 
local  disturbance  result.  On  the  other  hand,  during  an  oper- 
ation on  a  patient  with  puerperal  septic  infection  a  small 
puncture  of  the  epidermis  may  result  in  grave  local  and 
constitutional  symptoms.  When  septicemia  originates 
from  infected  thrombi,  the  infection  elements,  in  the  writer's 
oninion,  are  diffused  to  a  great  extent  through  the  lymph 
channels.    In  acute  bacteremia,  there  is  usually  but  one  chill 

■  or  in  some  instances  there  is  none.  The  infection  is  intense 
and  occurs  suddenly.  There  is  usually  no  repetition  of  the 
chill  because  the  rapidly  multiplying  organisms  are  already 
in  large  quantities  in  the  circulation. 

In  chronic  bacteremia,  on  the  otherlhand,  there  are  repeated 
chills,  due  to  fresh  additions  of  septic  organisms  into  the  sys- 
tem. The  pathological  differences  found  on  autopsy  are  well 
known,  and  harmonize  with  the  manner  in  which  the  patho- 
logical germs  are  introduced  into  the  system.  It  is  impos- 
sible to  distinguish  septicemia  from  pyemia  by  a  bacterio- 

-  logical  examination  of  the  blood  or  tissues.  The  author 
proposes  for  simplicity  to  limit  the  term  "  septic  infection  " 
to  "  local  sepsis,"  reserving  the  term  "  acute  bacteremia  " 
for  what  is    ordinarily  called    septicemia,  and    the    term 

'    "  chronic  bacteremia  "  for  "  pyemia,"  so  called. 

'        Both  acute  and  chronic  bacteremia  are  caused  by  micro- 

■  Bcopic  organisms,  but  one  is  of  short  duration,  the  other  long. 
So  much  then  for  the  definitions  of  the  terms  to  be  used  in 
the  second  part  of  the  paper. 

If  the  definitions  and  the  pathological  changes  of  acute 
bacteremia  are  kept  in  mind,  it  should  be  evident  that  surgi- 
cal intervention,  like  extirpation  of  the  uterus,  whether  per- 
formed by  abdominal  or  vaginal  route  or  an  abdominal  sec- 
tion with  drainage,  must  be  futile.  The  author  believes  that 
it  is  a  common  error  to  report  cases  of  local  sepsis  with  severe 
constitutional  symptoms  as  cases  of  acute  bacteremia,  and  thus 


much  confusion  is  caused.  In  this  way  it  has  been  claimed  that 
hysterectomy  for  acute  bacteremia  has  been  followed  by  re- 
covery. In  the  opinion  of  the  writer  no  such  result  ever  has 
been  or  ever  will  be  achieved  by  the  surgical  intervention 
alluded  to  for  the  cure  of  acute  bacteremia.  If  ever  we  should 
be  fortunate  enough  to  find  a  remedy  for  acute  bacteremia 
it  will  be  found  in  the  realm  of  serumtherapy.  The  writer 
then  said  that  this  decisive  assertion  had  been  verified  by 
clinical  experience  extending  over  the  past  18  years.  During 
this  time  he  had  performed  all  of  the  major  operations  on  a 
large  number  of  patients,  yet  he  had  not  seen  a  single  in- 
stance of  recovery  from  acute  puerperal  bacteremia  (general 
puerperal  sepsis),  even  if  operations  had  been  performed.  In 
his  opinion  the  only  effect  from  the  operations  on  such  pa- 
tients was  to  hasten  death.  Dr.  Boldt  continued  to  perform 
the  various  operations  for  acute  bacteremia,  thinking  that  it 
might  be  possible  to  save  life,  because  others  had  maintained 
that  they  had  been  successful ;  but  it  is  evident  to  him  that 
those  who  made  those  assertions  were  mistaken  in  the  view 
as  to  what  bacteremia  (septicemia)  is.  There  is  no  doubt, 
however,  that  the  operations  alluded  to  in  the  title  of  the 
paper  are  indicated  in  some  patients  ill  with  septic  infection. 

It  is  then  of  the  greatest  importance  to  know  when  to  oper- 
ate, and  for  what  conditions.  It  is  not  easy  to  make  exact  diag- 
nosis, but,  as  a  rule,  we  can  come  to  a  correct  conclusion  after 
observing  the  course  of  symptoms  for  several  days.  Some  pa- 
tients ill  with  sapremia  will  show  such  severe  symptoms  that 
they  simulate  acute  bacteremia,  but  a  short  observatioH  will 
usually  decide  the  question.  Occasionally  patients  who  suffer 
from  toxemia  (sapremia)  may  present  positive  indications 
for  the  removal  of  the  organ  giving  rise  to  the  infection.  To 
illustrate,  B.  S.  Schultze,  in  the  Deutsche  medicinische  Wocken- 
schrifl,  18S6,  No.  44,  mentions  the  following  case :  The  pa- 
tient was  delivered  of  a  dead  child  on  September  7,  the 
placenta  did  not  follow,  and  upon  traction  the  cord  tore  off. 
The  physician  could  not  reach  the  placenta  to  remove  it. 
In  the  hospital  it  was  found  impossible  to  remove  it,  even 
under  full  anesthetics.  She  began  to  show  symptoms  of  in- 
fection two  days  after  delivery,  and  her  condition  became 
much  worse.  She  had  frequent  chills  and  high  temperature, 
so  that  it  was  evident  that  she  would  die  if  the  cause  of  the 
infection  could  not  be  removed,  especially  as  peritoneal  irri- 
tation had  begun.  On  September  13  a  supravaginal  ampu- 
tation was  made.  The  uterine  bicornis  was  gangrenous 
nearly  to  the  peritoneal  cavity.  The  patient  recovered.  An- 
other case  was  reported  by  Sippel  (Centralbl.  f.  Gyndk.,  volj 
18,  p.  667)  in  which  the  placenta  was  removed  by  manual 
extraction,  but  some  placental  fragments  remained  which 
Sippel  could  not  remove,  because  of  the  softened  condition 
of  the  uterus.  The  patient  was  extremely  anemic  from  blood- 
loss  which  was  large.  Septic  endometritis  resulted,  and  IS 
days  subsequent  to  delivery  supravaginal  amputation  was 
performed,  recovery  resulting.  An  infection  by  microscopic 
organisms  had  been  added  to  the  toxic  infection  by  sapro- 
phytes, an  occurrence  not  uncommon  in  sapremia.  In  such 
cases  the  reader  favors  total  extirpation  to  supravaginal  am- 
putation, for  the  reason  that  the  peritoneum  can  be  pro- 
tected from  infection  by  approximate  safeguards. 

In  cases  of  septic  infection  the  author  has  based  his  blood 
investigations  entirely  upon  smear  preparations,  obtained 
from  a  finger,  and  these  were  unsatisfactory.  In  two  in- 
stances when  streptococci  were  finally  found,  previous  exami- 
nation having  proved  negative,  the  patient  succumbed.  In 
3  successful  instances  in  which  indication  for  operation  was 
based  on  clinical  conditions,  the  blood  examinations  were 
negative,  the  second  alone  showing  streptococci.  It  would 
not  in  his  opinion  be  just  to  the  patient  to  wait  always  for 
operation  until  positive  evidence  was  found  in  the  blood. 
The  writer  then  mentioned  a  case  which  had  occurred  in  his 
consultation  practice  in  1893.  He  had  seen  a  patient  3  weeks 
after  delivery  who  had  shown  all  the  symptoms  of  acute 
septicemia.  The  physician  had  not  curetted,  but  relied 
solely  on  vaginal  douches,  stimulants  and  quinin.  When 
seen  by  Dr.  Boldt,  the  patient  was  greatly  emaciated,  tem- 
perature 103,  pulse  124  and  feeble.  There  was  no  exudate 
in  the  pelvis,  but  the  uterus  was  large,  boggy  and  sensitive  to 
touch.  Examination  of  the  interior  of  the  uterus  did  not 
reveal  the  presence  of  placental  tissue.  A  fter  the  examina- 
tion the  patient  had  a  severe  chill,  temperature  rose  to  lOo.S* 
pulse  to  156.  In  view  of  the  gradual  sinking  of  the  patient, 
the  irregular  chills,  fever,  the  size  and  consistency  of  the 


324         The  Philadelphia"] 
Medical  Jodbnal  J 


AMERICAN  NEWS  AND  NOTES 


[Febeuabt  16,  1901 


uterus,  the  condition  was  diagnosed  as  septic  metritis,  and 
hysterectomy  performed  the  following  morning. 

The  diagnosis  proved  correct,  the  tissues  of  the  uterus 
tearing  as  if  decomposed.  The  patient  had  no  more  chills, 
the  highest  temperature  after  the  operation  was  101,  and 
recovery  was  uninterrupted.  Under  similar  conditions  even 
with  a  negative  result  of  blood  examination,  the  writer 
would  adopt  the  same  course  today.  It  is  impossible  with 
ojir  present  knowledge  to  lay  down  absolute  rules  for  the  per- 
formance or  omission  of  the  ojieration  of  hystectomy,  but 
for  general  guidance  I  would  advise  the  following  indications 
for  hysterectomy,  if  it  is  evident  that  less  heroic  treatment  is 
useless : 

I.  If  after  a  full  term  delivery,  or  an  abortion,  there 
are  no  conception  products  in  the  uterus  and  the  patient 
has  fever  with  exacerbations,  chills,  a  small  and  frequent 
pulse  (L20  to  140  or  more),  if  carefal  observation  should 
show  that  the  infection  comes  from  the  uterus  alone, 
that  organ  being  enlarged,  and  relaxed  in  its  consistency, 
if  there  is  no  evidence  of  peritonitis,  the  parametria  free, 
if  streptococci  are  found  in  the  uterus,  and,  especially, 
if  the  blood  shows  the  presence  of  pathogenic  germs. 

II.  If  there  are  decomposition  products  in  the  uterus, 
aa  in  the  instances  reported  by  Schultze,  Prochownik, 
Stahl  and  others,  which  cannot  be  removed  satisfactorily 
per  vaginam ;  if  on  doing  a  cesarean  section  the  uterus 
is  found  septic,  then  an  abdominal  hysterectomy  is  indi- 
cated. Abdominal  section  with  drainage  is  indicated  in 
diffuse  septic  peritonitis,  when  there  is  no  evidence  of 
an  exudate  in  the  pelvis.  The  adnexa  are  to  be  left  un- 
disturbed unless  there  is  a  positive  indication  to  do 
otherwise. 

In  the  discussion  Dr.  Vineberg  said  that  he  agreed  with  Dr. 
Boldt  in  his  indications  for  hysterectomy,  but  that  he  person- 
ally preferred  the  abdominal  route  to  the  vaginal.  He  could 
not  agree  with  the  reader  of  the  paper  with  regard  to  the  defi- 
nitions of  sepsis.  He  thought  there  were  no  grounds  for  the 
introduction  of  the  term  bacteremia.  To  his  mind  there  was 
jjut  one  kind  of  infection.  Many  times,  from  neglect,  putrid 
intoxication  runs  into  acute  septicemia,  and  the  profession 
should  be  taught  that  each  case  of  sapremia  is  one  of  septic 
infection  from  the  onset,  and  that  it  may  pass  into  acute 
septicemia.  Infection  with  other  bacteria,  such  as  the  Bacil- 
lus coli  communis,  the  staphylococci,  and  the  Bacillus  aero- 
genes  capsulatus,  have  also  been  attended  with  fatal  results. 
Dr.  Stone  congratulated  the  reader  of  the  paper,  on  his  suc- 
cessful effort  to  pick  out  and  define  the  different  varieties  of 
puerperal  infection.  To  his  mind  the  profeesion  was  too  apt  to 
think  that  there  was  only  one  form  of  sepsis,  and  that  the  cor 
rect  thing  to  do  ia  each  case  was  to  curet.  This  he  thought 
a  great  mistake,  as  many  cases  get  well  without  curettage. 
Dr.  Abram  Brothers  thought  that  the  question  of  treatment 
depended  upon  the  recognition  of  the  presence  or  absence  of 
local  infection.  This  infection  may  be  due  not  only  to  pla- 
cental debris  after  delivery,  but  to  some  condition  of  local 
infection  occurring  previous  to  delivery.  He  agreed  with 
Dr.  Boldt  that  if  the  diagnosis  of  acute  bacteremia  can  be 
made,  hysterectomy  or  any  other  form  of  local  treatment  is 
contraindicated.  In  his  opinion  the  terms  "  loca'  sepsis," 
" acute  bacteremia,"  and  "chronic  bacteremia"  wrre  well 
chosen.  Dr.  W.  E.  Porter  said  he  believed  that  man  v  cases 
would  not  come  to  hysterectomy  if  persistent  intrauterine 
irrigations  were  properly  carried  out.  In  his  experience  the 
placental  forceps  were  better  than  the  curet  for  the  removal 
of  retained  eecundia.  Dr.  Malcxim  McLean  had  seen  several 
cases  in  which  lactation  had  given  symptoms  severe  enough 
to  make  one  strongly  suspect  septic  infection,  and  he 
advises  the  greatest  caution  in  making  the  diagnosis 
which  would  result  in  the  performance  of  hysterectomy. 
Dr.  G.  L.  Brodhead  referred  to  the  cases  of  hysterectomy  for 
retained  placenta,  which  Dr.  Boldt  had  reported,  and  said  that 
in  his  opinion  if  retained  placenta  could  not  be  reached  by 
the  usual  methods,  it  would  be  better  to  incise  the  cervix  in 
order  to  get  more  space  in  which  to  operate.  Certainly  the 
greater  part  of  retained  placenta  could  be  removed  in  this 
way  and  therefore  hysterectomy  would  never  be  indicated. 
Dr.  Janvrin  said  he  had  never  removed  a  uterus  for  acute 
septicemia,  but  that  he  should  like  to  ask  Dr.  Boldt  to  tell 
how  one  should  know  whether  to  perform  abdominal  or 
■vaginal  hysterectomy.  Dr.  Boldt  in  closing  said  that  he 
would  again  refer  to  the  excellent  definition  given  by  CopMn 


under  the  term  "  mycosis  of  the  blood."  We  must  recognize 
the  fact  that  puerperal  fever  is  always  in  a  degree  a  septic 
infection.  If  fetid  discharges  come  from  the  vagina,  it  does 
not  necessarily  mean  that  the  case  is  a  serious  one.  Patients 
with  acute  bacteremia  may  have  no  fetid  discharge,  and  yet 
there  may  be  an  intense  septic  endometritis.  We  moat 
watch  our  cases  for  a  number  of  days  or  several  weeks,  and 
if  we  find  that  all  treatment  has  failed,  the  patient  is  steadily 
getting  worse,  no  other  cause  for  the  chills,  etc.,  can 
be  found,  where  the  parametria  are  free,  and  there  ie 
no  peritonitis,  where  perhaps  streptococci  are  found  in 
the  uterine  secretions,  then,  under  these  conditions,  we 
are  justified  in  considering  vaginal  hysterectomy.  Abdom- 
inal hysterectomy  should  be  considered  only  in  cases  where 
we  are  called  upon  to  perform  a  cesarean  section  on  a  septic 
uterus,  or  where  there  is  an  intense  septic  intoxication  asso- 
ciated with  a  septic  endometritis,  the  patient's  condition  not 
improving  under  other  treatment.  The  reason  why  the 
placenta  could  not  be  removed  in  the  case  reported  by 
Schultze  was  on  account  of  there  being  a  uterus  bicomia. 
In  the  other  case,  quoted  from  Sippel,  the  general  condition 
of  the  patient  was  such  that  it  was  not  advisable  to  carry  on 
intrauterine  manipulation  further,  so  great  was  the  danger 
of  perforation.  In  conclusion.  Dr.  BMt  said  that  it  re- 
quired great  judgment  to  decide  in  these  cases  what  wa« 
correct  to  do,  but  that  each  must  judge  from  his  own  expe- 
rience with  the  aid  of  all  the  symptoms  present.  We  should 
all  endeavor  to  make  definite  definitions  of  the  diseases  that 
we  are  dealing  with. 

NEW  ENGLAND. 

Diphtheria  at  the  Navy  Yard.— The  receiving  ship 
Wabanh,  the  marine  barracks  and  the  naval  prison  at  the 
Charleston  Navy  Yard  have  been  quarantined  by  order  of 
Admiral  Sampson.  The  quarantine  has  been  established  to 
prevent  the  spread  of  diphtheria. 

WESTERN  STATES. 

Wesley  Hospital. — Dr.  R.  D.  Sheppard,  of  Northwestern 
University,  received  two  donations  to  Wesley  Hospital  on 
February  8,1901,  one  of  $5,000  and  one  of  $1,000. 

College  is  Quarantined. — Ellsworth  College,  of  Iowa 
Falls,  was  placed  in  quarantine  on  account  of  smallpox. 
Over  100  students  and  professors  are  restrained. 

■University  Closed  on  Accoant  of  Scarlet  Fever.— 

The  faculty  of  the  University  of  Wooster,  Mo.,  dismissed  all 
the  students  for  two  weeks  on  account  of  one  young  woman 
who  had  contracted  scarlet  fever. 

New  Hospital. —A  new  hospital,  to  cost  $12-5,000,  and 
which  in  convenience  of  appointments  and  completeness  ie 
expected  to  have  no  superior  in  the  Northwest,  is  about  to 
be  erected  in  Baker  City,  Oregon.  It  will  be  under  the  direc- 
tion of  the  Sisters  of  St.  Francis. 

Prize  Essay  on  the  Dangers  from  Quackery.— 

The  Colorado  State  Medical  Society  offers  a  prize  of  $i5  for 
the  best  essay,  if  deemed  worthy  of  the  prize,  pointing  out 
the  dangers  to  public  health  and  morals,  especially  to  young 
persons,  from  quackery  as  promulgated  by  public  adver- 
tisements. The  competition  is  open  to  all.  Essays  must  be 
type- written  in  the  English  language,  and  submitted  before 
May  15,  1901.  E*ch  essay  must  be  designated  by  a  motto, 
and  accompanied  by  a  sealed  envelope,  bearing  the  same 
motto,  and  enclosing  the  name  and  address  of  the  author. 
The  essay  receiving  the  prize  will  become  the  property  of  the 
Society  tor  publication.  0;her8  will  be  returned  on  appli- 
cation. Essays  should  he  sent  to  the  Literature  Committee. 
Room  315,  McPhee  Building,  Denver,  Colorado. 

SOUTHERN  STATES. 

Dr.  E.  G.  Hill  has  been  elected  secretary  of  the  Man-] 
Chester,  Va.,  Board  of  Health. 
Richmond  (Va.)  News.— Tae   Hunter  McGuire  Me-^ 

niorial  Assocuuion  has  raised  about  $UXX).  When  the 
amount  has  been  somewhat  increased,  it  is  proposed  to  erect 
a  monument  to  this  distinguished  surgeon  in  one  of  the 
public  parks. 


rEBBUABT   16,   1901] 


AMERICAN  NEWS  AND  NOTES 


[The  PHII.ASELPHIA 
Medical  Jooesal 


325 


Appointment. — Dr.  W.  D.  Bacon  has  been  appointed 
resident  physician  of  the  Baltimore  University  Hospital  in 
place  of  Dr.  W.  R.  Stover,  who  recently  resigned.  Dr. 
Edwin  Moriarty  has  been  appointed  assistant  resident  physi- 
cian to  succeed  Dr.  Bacon. 

Vaccination  of  Scbool  Cliildren. — The  Louisiana  State 
Board  of  Health  has  addressed  a  circular  letter  to  all  superin- 
tendents of  parish  public  schools,  all  presidents  of  parish 
boards  of  public  education,  all  principals  of  parish  public 
schools,  presidents  of  State  educational  establishments,  and  to 
the  press  of  the  State,  calling  attention  to  the  following  resolu- 
tion adopted  by  the  board  : 

Be  it  Resolved,  That  copies  of  the  law  be  printed  requiring 
the  vaccination  of  public  school  children,  and  sent  to  each 
superintendent  of  public  schools,  as  well  as  the  presidents  of 
all  educational  institutions  receiving  public  moneys. 

This  circular  is  intended  to  meet  the  danger  resulting 
from  the  prevalence  of  smallpox  in  certain  sections  of  this 
and  adjoining  States. 

In  Memory  of  Dr.  Rohe. — A  memorial  meeting  to 
the  late  Dr.  George  H.  Rohe,  who  died  two  years  ago,  was 
held  February  6  by  the  Medical  Society  of  the  College  of 
Physicians  and  Surgeons  of  Baltimore  in  the  college  amphi- 
theater. The  president,  Mr.  J.  M.  Barry,  of  the  graduating 
class,  presided.  Addresses  concerning  the  life  and  work  of 
Dr.  Robe  were  made  by  Professors  William  Simon,  Aaron 
Friedenwald  and  J.  W.  Chambers.  Short  tributes  were  paid 
to  the  memory  of  Dr.  Rohe  by  Drs.  Henry  M.  Hurd,  Wilmer 
Brinton,  William  R.  Stokes,  Thomas  A.  Ashby,  H.  H.  Biedler, 
and  John  F.  Crouch. 

MISCELLANY. 

Holding  Consumption  in  Check. — Deaths  from  con- 
sumption in  Philadelphia  are  estimated  to  be  one-third  less 
than  they  were  15  years  ago.  The  health  authorities  say  the 
improvement  is  due  to  their  continuous  battle  against  the 
disease. 

Medical  Certificates  for  Immigrants. — The  bill 
amending  the  immigration  laws  so  as  to  exclude  persons 
aflfected  with  insanity,  idiocy,  or  epilepsy  was  favorably  re- 
ported February  5,  from  the  House  committee  on  immigra- 
tion and  naturalization.  The  bill  requires  a  medical  certifi- 
cate from  immigrants  showing  freedom  from  these  ailments 
and  requires  steamship  companies  to  deport  immigrants 
found  to  be  incapacitated  in  this  respect. 

Scarcity  of  Naval  Surgeons. — There  appears  to  be  a 
prevailing  embarassment  in  the  navy  because  of  the  inability 
of  the  medical  corps  to  secure  competent  young  physicians 
as  assistant-surgeons.  The  army  seems  to  be  preferred  on 
account  of  the  higher  rank  which  it  oflFers  and  the  better 
prospects  for  the  future. 

Obituary. — Dr.  J.  C.  Carpenteb,  of  Sherman,  Tex.,  on 
February  3,  1901,  aged  85  years — Dr.  John  Hukdley,  at 
Montague,  Md.,  on  January  SO,  1901,  aged  75  years. — Dr. 
Clayton  A.  Cowgill,  at  Philadelphia,  Pa.,  on  February  5, 
1901,  aged  75  years.  —  Dr.  James  A.  Shuttleworth,  at 
Pleasant  Hill,  Mo.,  on  February  2, 1901,  aged  88  years. — Dr. 
Henry  C.  Hill,  Assistant  Surgeon  of  the  128th  New  York 
Volunteers,  at  Lockport,  on  February  8,  1901,  aged  69  years. 
— Dk.  James  T.  Perkins,  of  Springfield,  Md.,  on  January  30, 
1901,  aged  47  years. — Dr.  S.  H.  Cade,  of  Negreet,  La.,  on 
February  7, 1901. — Dr.  William  P.  Manning,  of  Washington, 
D.  C,  on  February  9,  1901,  aged  56  years.— Dr.  M.  G.  Cun- 
ningham, at  Binghamton,  N.  Y.,  on  February  11,  aged  48 
years. — Dr.  Frank  Bond,  at  Brooklyn,  N.  Y.,  on  February 
10,  aged  74  years. — Dr.  Levi  Royer,  at  New  Windsor,  Md., 
on  February  10,  aged  62  years. — Dr.  Peter  Moir  Barclay,  at 
Newburg,  N.  Y..  on  February  11,  aged  67  years. — Dr.  Samuel 
C.  Busey,  of  Washington,  D.  C.,  on  February  12,  aged  72 
years. — Dr.  Wise,  at  San  Francisco,  Cal.,  on  February  3, 
1901.— Dr.  John  Stuart  Woodside,  at  Chester,  111.,  on  Feb- 
ruary 11, 1901. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague,  have  been  reported  to 
the  Surgeon-General  U.  S.  Marine-Hospital  Service,  during 
the  week  ended  February  9,  1901 : 


Smallpox— United  States. 


Florida  : 
Illinois  : 

Kansas  : 


Kentucky  : 
Louisiana  : 
Massachusetts 
Michigan: 

Montana  : 
Nebraska  : 
N.  Hampshire  : 
New  York : 

North  Dakota 
Ohio  : 


Jacksonville 
Chicago    .   . 
Lawrence    . 
Leavenworth 
Wichita    ,    . 
Lexington  . 
New  Orleans 
Lawrence 
Grand  Rapids 
Manistee . 
Butte    . 
Omaha .   . 
Manchester 
New  York 
Utica     .   . 
Morton  Co. 
Ashtabula 
Cleveland 


Pennsylvania  :    Allegheny  City  .  Jan. 

"  Erie Jan. 

"  Pittsburg  ....  Jan. 

Greenville  .  .  .  Jan. 
Jackson  ....  .Tan. 
Memphis.  .  .  .  Jan. 
Nashville  .  .  .  Jan. 
Galveston    .    .    .  Jan. 

Ogden Jan. 

Salt  Lake  City  .  Jan. 
Eau  Claire  .  .  .  Jan. 
Washington 

Township  Jan. 
Green  Bay  .  .  .  Jan. 
Milwaukee .   .   .  Jan. 


South  Carolina: 
Tennessee  : 


Texas : 

Utah  : 

Wisconsin  : 


Jan. 
Jan. 
Jan. 
Jan. 
Jan. 
Jan. 
Jan. 
Jan. 
.Tan. 
Jan. 
Dec. 
Jan. 
Jan. 
Jan. 
Jan. 
Jan. 
Jan 
Jan 


26-Feb.  2 
26-Feb.  2 
26-Feb.  2 
1-31  .  .  . 
26-Feb.  2 
26-Feb.  2 
26-Feb.  2 
26-Feb. 2 
26-Feb.  2 
26-Feb.  2 
26-Jan.  20 
19-Feb.  2 
26-Feb.  2 
26-Feb.  2 
19-29  .  . 
30  .  .  . 
26-Feb.  2 
26-Feb.  2 
26-Feb.  2 
26-Feb.  2 
26-Feb.  2 
26-Peb.  2 
1-31  .  .  . 
26-Feb.  2 
26-Feb.  2 
12-26  .  . 
1-31  .  . 
26-Feb.  2 
22  . 

22  . 

26-Feb".  2 
26-Feb.  2 


Smallpox — Foreign. 


Austria  : 
Belgium  : 
Brazil  : 
England : 


India: 

Japan  : 

Russia  : 
Scotland : 

Spain : 


Colombia  : 
Cuba: 


Prague  .... 
Antwerp  .  .  . 
Rio  de  Janeiro 
Bradford  .  .  . 
New-Castle  -  on- 

Tyne .... 
Calcutta  .  .  . 
Karachi  .  .  . 
Korea,  Seoul  . 

Moscow  .  .  . 
Glasgow  .  .  . 
Barcelona   .   . 


Jan.  5-12  . 
Jan.  12-19 
Dec.  1-15  . 
Jan.  23.   . 

Jan.  12-19 
Dec.  15-29 
Dec.  16-23 
Dec.  22  .    . 

Jan. 5-12 . 
Jan.  18-25 
Nov.  25-Dec 


Cases. 
1 
4 
2 
4 
22 
2 
9 
2 

1 
4 

39 
6 

32 

50 
1 

10 
2 

49 
5 
2 
8 

20 
18 
4 
37 
32 
29 
12 

20 
1 


21 
3 


Deaths. 


.30 


Yellow   Fever. 


Cartagena 
Cienfuegos 
Havana    . 


Jan. S-13 . 
Feb.  1  .  . 
Jan,  22-29 


India  : 
Straits 

Settlements  :  Singapore 


California  ; 


Cholera. 
Calcutta  ....  Dec.  15-29   . 
.  Dec.  8-15  .   . 

Plaque. — United  States. 
San  Francisco   .  Jan.  12-19   .   . 

Plague. — Foreign. 


India  : 

Japan : 

Turkey : 


Calcutta  .   . 
Osaka   .   .   . 
Wakayama 
Smyrna    .    . 


.  Dec.  15-29  .  . 
.  Dec.  22-Jan.  7 
.  Dec.  22-Jan.  7 
.  -Dec.  30-Jan.  6 


27 


72 
5 

Many  cases 
and  deaths. 
2  1 

324  3 

71 


3 

1 

1 

87 
25 

2  2 


46 


Changes  in  theMedical  Corps  of  the  U.  S.  Ajmy, 

for  the  week  ended  February  9,  1901 : 

MacDonald,  Charles  E.,  acting  assistant  surgeon,  is  assigned  to 
temporary  duty  on  the  transport  "  Oopack  "  during  the  voyage 
to  the  Philippines.  Upon  arrival  at  Manila  he  will  report  to 
the  commanding  general,  division  of  the  PhiUppines,  for  as- 
signment to  duty. 

Bailey,  Gut  G.,  acting  assistant  surgeon,  leave  of  absence  granted 
January  9  is  extended  14  days.  .  u  j  .i 

Belt,  Harey  D.,  acting  assistant  surgeon,  having  relinquished  tbe 
unexpired  portion  of  the  leave  of  absence  granted  him  January 
18,  will  proceed  from  New  York  aty  to  Fort  Trumbull,  and  re- 
port for  temporary  duty.  

The  following-named  acting  assistant  surgeons  will  proceed  irom 
the  places  hereinafter  designated  to  San  Francisco,  tal..  ana  re- 
port to  the  commanding  general,  department  of  (-ahtornia,  tor 
assignment  to  duty  with  troops  en  route  to  the  I  hilippine 
Islands,  where  upon  arrival  they  will  report  to  the  command- 
ing general,  division  of  the  Philippines,  for  assignment  to  duty  : 
Polk  D.  Brown,  Hartsville,  Tenn.:  Henry  M.  Hall,  tedar- 
town,  Ga.;  Melville  A.  Hughes,  Washington,  D.  C;  JiDGAR  vv . 


326 


The  Philadelphia"! 
Medical  Jodbnal  J 


FOREIGN  NEWS  AND  NOTES 


[Fbbbdabt  16,  1901 


Miller,  Chicago,  111. ;  Frank  W.  Pease,  Wahpeton,  N.  D. ; 
Julius  M.  Purnell,  Paris,  Ky. ;  Anton  R.  Schiee,  Oconomo- 
woc.  Wis. 

Deveeeux,  J.  Ryan,  acting  assistant  surgeon,  is  detailed  as  a  mem- 
ber of  the  board  of  officers  at  Washington  Barracks  for  the  ex- 
amination of  officers  for  promotion,  vice  Captain  Edward  L. 
Munson,  assistant  surgeon,  relieved. 

Clossman,  August  Von,  acting  assistant  surgeon,  now  at  St.  Louis, 
Mo.,  will  report  in  that  city  to  Major  Thomas  F.  Davis,  Twelfth 
Infantry,  recruiting  officer,  for  duty  as  examiner  of  recruits. 

Horne,  Willis  S.,  acting  assistant  surgeon,  will  proceed  from  Mar- 
lin,  Tex,,  to  San  Antonio,  Tex.,  and  report  to  the  commanding 
officer,  department  of  Texas,  for  assignment  to  duty. 

Kean,  Jlajor  Jefferson  R.,  surgeon,  will  proceed  to  Washington, 
D.  C,  and  report  on  February  4  to  the  president  of  the  board  of 
officers  convened  in  that  city  for  examination  as  to  his  fitness 
for  promotion. 

A  board  of  medical  officers  to  consist  of  Colonel  Alfred  A.  Wood- 
hull,  assistant  surgeon-general ;  Major  Lonis  A.  Le  Garde, 
surgeon  ;  Captain  William  C.  Borden,  assistant  surgeon  ;  Cap- 
tain Frank  R.  Keefer,  assistant  surgeon,  is  appointed  to  meet 
at  the  Army  Medical  Museum  building,  Washington  D.  C.,  Feb- 
ruary 11,  for  the  examination  of  candidates  for  admission  to  the 
medical  corps  of  the  Army. 

A  board  of  medical  officers,  to  consist  of  Lieutenant-Colonel  Benja- 
min F.  Pope,  deputy  surgeon-general ;  Lieutenant-Colonel  Al- 
fred C.  GiRARD,  deputy  surgeon-general ;  Major  Robert  J. 
Gibson,  surgeon  ;  Captain  William  H.  Wilson,  assistant  sur- 
geon, is  appointed  to  meet  at  the  U.  S.  General  Hospital,  Pre- 
sidio, Monday,  February  11,  for  the  examination  of  candidates 
for  admission  to  the  medical  corps  of  the  Army. 

Girahd,  Major  Joseph  B.,  surgeon,  is  granted  leave  of  absence  for  1 
month,  on  account  of  sickness. 

Hartsuff,  Colonel  Albert,  assistant  surgeon-general,  retirement 
from  active  service,  February  4,  1901,  under  provisions  of  act  of 
Congress,  approved  June  30,  1882,  is  announced. 

Wood,  Major  Marshall  W.,  surgeon,  will  proceed  to  St.  Louis,  Mo., 
and  take  temporary  charge  of  the  medical  supply  depot  at  that 
place  during  the  absence  of  Major  Joseph  B.  Girard,  surgeon, 
and  upon  the  return  of  the  latter  officer  will  rejoin  his  proper 
station. 

Walsh,  Joseph  W.,  acting  assistant  surgeon,  will  proceed,  from 
Brooklyn,  N.  Y.,  to  Washington  Barracks  and  report  at  the  U. 
S.  General  Hospital  at  that  post  for  duty. 

Bahta,  William  ;P.,  'acting  assistant  surgeon,  now  on  temporary 
duty  at  the  U.  S.  General  Hospital,  Presidio,  i?  relieved  from 
further  duty  in  the  division  of  the  Philippines  and  will  report 
to  the  commanding  general,  department  of  California,  for  as- 
signment to  duty  at  that  hospital. 

The  following-named  acting  assistant  surgeons  are  relieved  from 
duty  at  the  U.  8.  General  Hospital,  Presidio,  and  will  report  to 
the  commanding  general,  department  of  California,  for  assign- 
ment to  duty  with  troops  en  route  to  the  Philippine  Islands, 
where  they  will  report  to  the  commanding  general,  division  of 
the  Phihppines,  for  assignment  to  duty  :  William  Alden,  Ed- 
ward A.  SOUTHALL. 

Schumacher,  Frederick,  hospital  steward,  is  assigned  to  tempo- 
rary duty  with  troops  on  the  Army  transport  "  Lawton."  Upon 
arrival  at  Manila  he  will  report  to  the  commanding  general, 
division  of  the  Philippines,  for  assignment  to  duty. 

Pedlar,  A.  J.,  acting  assistant  surgeon,  is  granted  leave  of  absence 
for  1  month. 

Cutter,  J.  B.,  acting  assistant  surgeon,  is  granted  leave  of  absence 
for  1  month. 

Carroll,  James,  acting  assistant  surgeon,  will  proceed  from  Colum- 
bia Barracks,  Cuba,  to  Washington,  U.  C.,  and  report  to  the 
Surgeon-General  of  the  Army  for  duty  in  the  pathological  labo- 
ratory of  the  Army  Medical  Museum  at  the  latter  place. 

DeLaney,  Matthew  A.,  acting  assistant  surgeon,  will  proceed  from 
the  National  Soldiers'  Home,  Va.,  to  Fort  Monroe  for  temporary 
duty. 

Edie,  Guy  L.,  surgeon,  now  in  San  Francisco,  Cal.,  is  relieved  from 
further  duty  in  the  division  of  the  Philippines,  and  will  report 
to  the  commanding  general,  department  of  California,  for  as- 
signment to  temporary  duty  in  that  department. 

ChaDges  in  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  February  9,  1901 : 

Guthrie,    J.    A.,    passed   assistant   surgeon,   detached    from    the 

irankhn,"  and  ordered  to  the  "New  York,"  February  18. 
McCoRMiCK,  A.  M.  D.,  surgeon,  detached  from  the  Naval  Hospital, 

Norfolk,  Va.,  and  ordered  to  the  Naval  Academy. 
Spear,  R.,  passed  assistant  surgeon,  detached  from  the  "Buffalo," 

on  arrival  at  Cavite,  and  ordered  to  the  "  Isla  de  Luzon." 
Grove  W.B.,  assistant  sursjeun,  detached  from  the  "Vermont" 

and  ordered  to  the  Naval  Hospital,  New  York. 
BocHKR   W.  H.,  assistant  surgeon,  detached   from   the  Naval  Hos- 

pital   New  York,  and  ordered  to  Naval  Hospital,  Norfolk,  Va. 
hTONE,  M.  v.,  assistant  surgeon,  detached  from  the  "  Isla  de  Luzon," 

and  ordered  to  the  "  Buffalo." 
Derr,  E.  Z.,  medical  inspector,  ordered  from  the  Naval  Academy, 

February  14. 


DuBosE,  W.  R.,  surgeon,  detached  from  the  Naval  Academy,  Feb- 
ruary 13,  and  ordered  to  the  "  Wisconsin." 

Beetolette,  D.  N.,  medical  inspector,  ordered  to  the  "  New  York," 
February  16. 

Changes  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  February  7,  1901 : 

Bailhache.  Preston  H.,  surgeon,  relieved  from  duty  as  chairman 
of  the  board  for  the  physical  examination  of  Second  Assistant 
Engineer  R.  F.  Halpln.  R.  C.  S.     February  4. 

Vauohan,  G.  T.,  surgeon,  detailed  as  chairman  of  the  board  for  the 
physical  examination  of  Second  Assistant  Engineer  R.  F.  Hal- 
pin,  R.  C.  S.    February  4. 

CoEPUT,  G.  M.,  assistant  surgeon.  Bureau  order  of  January  26, 
directing  Assistant  Surgeon  Corput  to  proceed  to  Cleveland, 
Ohio,  for  temporary  duty,  revoked.    February  2. 

Francis,  Edward,  assistant  surgeon,  to  proceed  to  Cleveland,  Ohio, 
and  assume  temporary  command  of  the  service  during  the 
absence  on  leave  of  Surgeon  Pettus.    February  2. 

Callard,  J.  C.,  acting  assistant  surgeon,  granted  leave  of  absence  for 
5  days  from  February  7.    February  4. 


foreign  Hems  anb  Hotes. 

GREAT  BRITAIN. 

Dr.  W.  H.  Willcox,  has  been  appointed  lecturer  on 
chemistry  and  physics  at  St.  Mary's  Hospital  Medical 
School. 

Dr.  Walter  Myers,  of  the  Liverpool  School  of  Tropical 
^Medicine,  who  has  been  carrying  out  investigations  of  yellow 
fever,  has  fallen  a  victim  to  his  scientific  devotion. 

The  death  of  Mr.  Bowater  John  Vernon,  F.R.C.S.  Eng.,  the 
senior  ophthalmic  surgeon  to  St.  Bartholomew's  Hospital,  is 
announced.  He  was  also  ophthalmic  surgeon  to  the  West 
London  Hospital. 

Royal  College  of  Sargeons. — Tho  following  candi- 
dates passed  the  tinal  examination  for  the  Fellowship  at  the 
last  half-yearly  meeting  of  the  examiners,  and  have  been  ad- 
mitted Fellows  of  the  College  in  the  order  of  their  seniority 
as  members,  viz. :  Messrs.  Frederic  Pinsent  Maynard  (Major 
I.M.S.),  M.B.Durh.,  L.R.C.P.Lond.,  D.P.H.Camb.,  St.  Bar- 
tholomew's Hospital,  member  April  28, 1885;  Edgar  Godfrey 
Carpenter,  L.R.C.P.Lond.,  D.P.H.Camb.,  St.  Bartholomew's 
Hospital,  member  August  1,  1889;  John  Herbert  Parsons, 
M.B.,  B  Sc.Lond.,  L.R.C.P.Lond.,  University  College,  Bristol 
and  London  and  St.  Bartholomew's  Hospital,  member,  No- 
vember 12,  1891 ;  Elmore  Wright  Brewerton,  L.R.C.P.Lond., 
St.  Bartholomew's  Hospital,  member  February  7,  1895; 
Alexander  Gordon  Wilson,  M.B.Lond.,  L.R.C.P.Lond  ,  Lon- 
don Hospital,  member  May  13,  1897 ;  Edward  Septimus 
Earnshaw  Hewer,  L.R.C.P.Lond.,  St.  Bartholomew's  Hospital, 
member  February  10,  1898 ;  Irwin  Walter  WDliam  Hunter, 
M.A.,  B.Sc.Otago,  L.R.C.P.Lond.,  Otago  University,  New 
Zealand,  and  London  Hospital,  member  May  4, 1898  ;  Percy 
William  George  Sargent,  M.A.,  M.B,,  B.C.Camb.,  L.R.C.P. 
Lond.,  Cambridge  University  and  St.  Thomas'  Hospital, 
member  Mav  4,  1898;  Thomas  Alfred  Mayo,  M.B.Camb., 
L.R.C.P.Lond.,  Cambridge  University  and  St.  Bartholomew's 
Hospital,  member  November  10.  1898;  William  Archibald 
Logan,  M.B.,  Ch.B.Dunedin,  L.R.C.P.Lond.,  Dunedin  Uni- 
versity, New  Zealand,  and  King's  College,  London,  member 
July  27,  1899 ;  James  Sherren.  L.R.C.P.Lond.,  London  Hos- 
pital, member  July  27, 1899 ;  Robert  James  Johnston,  B  A., 
MB.,  B.Ch.,  R.U.I.,  Queen's  College,  Belfast,  and  Royal  Uni- 
versity of  Ireland,  not  previously  a  member. 

CONTINENTAL  EUROPE. 

The  Nineteenth  Congress  for  Internal  Medicine 

will  be  held  in  BerUn  April  16-19,  1901. 

Dr.  Karl  Haegler  and  Dr.  Friedrich  Egger  have  been 
appointed  extraordinary  professors  of  medicine  in  the  Uni- 
versity of  Basel. 

Dr.  Martin  Hahn  has  been  commissioned  by  the 
Bavarian  Government  to  proceed  to  Egypt  and  India  for  the 
purpose  of  studying  the  plague. 


Febboaby  16,  1901] 


SOCIETY  REPORT 


TThk  Philadblphia 
L  Medical  Journal 


327 


Society  Keport. 


THIRD  PAN-AMERICAN  MEDICAL  CONGRESS. 
Held  at  Havana,  Cuba,  February  4,  5,  6  and  7. 

[From  our  Special  Correspondent.] 

The  formal  opening  general  session  was  held  at  8.30  o'clock 
this  evening  at  the  "  Gran  Teatro  de  Tacon  "  and  was  presided 
over  by  Military  Governor  General  Leonard  Wood,  who,  in  a 
few  well-chosen  words,  welcomed  the  delegates  to  the  City  of 
Havana  and  to  the  Island  of  Cuba.  The  Tacon  Theater 
bears  the  name  of  a  celebrated  captain-general  of  the 
island.  It  is  on  the  west  side  of  the  Prado  and  fronts  on 
Central  Park.  It  was  built  by  Senor  Francisco  Morti  in  1837 
at  a  cost  of  500,000  centenes  in  gold  coin,  or  about  $2,000,000, 
was  named  after  General  Tacon,  and  is  now  owned  by  an 
American  syndicate.  Its  auditorium  is  in  the  shape  of  a 
horseshoe  and  was  handsomely  decorated.  The  70  boxes  and 
six  balconies  contained  hundreds  of  beautifully  attired  ladies, 
while  the  magnificent  chandelier  dependent  from  the  ceiling 
in  front  of  the  stage  with  ita  1034  gas  jets  brilliantly  illumin- 
ated a  most  imposing  spectacle.  Tne  entire  total  capacity  of 
tne  theater  is  about  4000.  Many  delegates  occupied  seats 
upon  the  platform.  Among  those  from  the  United  States 
were  noticed :  Drs.  A.  M.  Pnelps,  L.  A.  Pilcher,  and  B.  T. 
Whitmore,  of  New  York ;  Liston  H  Montgomery,  Chicago ; 
Joseph  Mullen,  Houston,  Tex.;  J.  W.  HolTiday,  Burlington, 
la;  Roland  G.  Curtin,  Puiladelphia ;  Eaoch  HoUings- 
head,  Pemberton  ;  and  William  J.  Chandler,  South  Orange, 
N.  J.  Beside  these  were  Dr.  John  Guit^ras,  Havana;  Dr. 
John  Si,nto8  Fernandez,  President  of  the  Congress;  Dr. 
Thomas  V.  Coronado,  Secretary-General ;  Dr.  Eusebio  Her- 
nandez, and  probably  fifty  others,  including  the  Mayor,  Hon. 
Alexander  Rodriguez.  Slany  pretty  tropical  plants  sur- 
rounded the  speaker's  platform  and  embellished  the  stage, 
which  presented  a  very  pleising  appearance.  The  entire 
opera  house  was  well  nigh  filled  with  the  elite  of  Havana's 
260,000  inhabitants,  nearly  all  of  whom  were  in  evening  dress. 

The  history  of  the  Congress  was  then  read  by  Dr.  Coro- 
nado. 

He  was  succeeded  by  the  president,  who  dwelt  much  upon 
the  progress  of  medical  science  in  Cuba. 

Great  regret  was  felt  at  the  absence  of  D.-.  C.  A.  L.  Reed, 
secretary  of  the  International  Executive  Committee,  who  was 
announced  on  the  program  for  an  address  of  a  scientific 
nature.    (Subject  not  announced.) 

Dr.  E.  Hernandez,  of  Havana,  then  spoke  extempore  for 
40  minutes.  Among  the  numerous  expressions  he  used  was : 
That  the  general  practising  physician  should  be  held  in  great 
respect  by  the  community  where  he  dwells  for  his  watchful- 
ness in  public  health  matters. 

Everything  was  said  and  done  according  to  the  latest  ap- 
proved Spanish  style.  A  good-8iz3d  orchestra  interspersed 
superb  music. 

Section  on  General  Medicine. 

Dr.  Carlos  A.  Finlay,  Havana,  presiding.  The  import- 
ant paper  in  this  section  today  was  read  by  Major  Walter 
Reed.  For  his  investigations  of  the  relation  of  the  mos- 
quito to  yellow  fever,  see  the  Manual.  Among  other  state- 
ments in  his  paper  was  the  description  of  how  Camp  Lazear 
had  been  established  at  Qaemados,  which  was  strictly  quar- 
arantined  so  that  the  experiments  could  be  carried  out  suc- 
cessfully, Drs.  Reed,  James  Carroll,  and  Agramonte  of  the 
board,  at  first  confined  their  operations  to  themselves,  and 
were  so  enthused  with  the  success  of  their  investigations  that 
they  carried  out  their  work  still  farther  by  obtaining  volun- 
teers to  submit  to  their  experiments  which  showed  that 
the  fever  was  promulgated  by  the  Culex  faeciatus  (genus 
stegomyia)  which  had  been  allowed  to  bite  a  yellow  fever 
patient,  and  subsequently  allowed  to  bite  a  nonimmune 
who  had  been  carefully  quarantined.  Sixty-five  per  cent,  of 
the  experiments  resulted  in  well-defined  cases  of  fever  (bitten 
by  the  female  culex).  To  prove  this  theory,  Dr.  Reed  showed 
that  the  culex  was  to  be  found  in  all  countries  Where  yellow 
fever  existed,  and  that  it  was  never  found  where  yellow 
fever  did  not  exist. 


In  these  cases  the  mosquito  did  not  inoculate  the  non- 
immune until  between  the  twelfth  and  twentieth  day  after  it 
had  bitten  the  patient.  Subcutaneous  and  intravenous  in- 
jections of  blood  taken  from  a  yellow  fever  patient  would 
produce  the  disease  in  a  nonimmune. 

Said  the  speaker,  the  present  quarantine  laws  against 
yellow  fever  were  needless.  We  need  not  scrub  with  bichlorid 
solutions,  nor  disinfect,  fumigate  or  freeze  a  cargo,  merchan- 
dise, trunks,  bedding,  etc.  To  prove  this,  at  Quemados,  non- 
immunes were  dressed  in  clothing  taken  from  yellow  fever 
patients,  and  had  slept  on  bedding  used  by  them,  and  that 
not  one  case  had  developed  from  this  exposure.  The  deten- 
tion system  therefore  was  absurd  and  of  no  avail  whatsoever. 

The  effective  way,  therefore,  to  prevent  carrying  of  the  fever 
was  the  destruction  of  the  mosquitoes  which  might  have 
reached  a  boat.  The  moral  side  of  the  question  of  subject- 
ing human  beings  to  experiments  was  dwelt  upon,  and  in  all 
cases  that  they  had  experimented  upon, — twenty  all  together 
— in  each  instance  the  sutject  had  explained  to  him  the 
danger  of  the  process,  but  in  each  case  the  full  cooperation 
of  the  patient  was  secured.  The  paper  elicited  much  dis- 
cussion. Among  those  parlicipating  were  Drs.  Finlay,  Agra- 
monte, John  Guit^ras,  L.  H.  Montgomery,  of  Chicago,  H.  B. 
Horlbeck  of  Charleston,  S.  C,  and  Ryder,  of  Havana. 

Dr.  Agramonte  followed  by  reading  his  report,  or  rather 
the  combined  report — which  was  the  same  repeated.  Both 
he  and  Dr.  Carroll  deserve  an  equal  amount  of  credit  for 
these  investigations  and  expefriments. 

Intekmediate  Session. 

The  second  intermediate  or  general  session  of  the  Con- 
gress was  held  at  8  30  o'clock  this  evening  at  the  Marti 
Theater,  with  the  president,  Dr.  Fernandez,  in  the  chair. 

This  is  a  handsome  summer  garden  and  theater  in  the 
block  south  of  the  Pasaje  hotel  and  opposite  Parque  de 
Isabel  La  Catolira.  It  is  commodious  and  well  ventilated. 
It  seats  about  1,200  persons. 

The  business  of  this  second  general  session,  while  of  a 
semiformal  nature,  was  transacted  entirely  in  Spanish.  All 
the  speakers  read  from  manuscript.  Many  ladies  occupied 
the  tier  of  boxes  thoughout. 

The  first  address  of  the  evening,  scientific  in  character, 
was  delivered  by  Dr.  Gustavo  Lopez,  vice-president  of  the 
Congress,  and  secretary  of  the  Academy  of  Medical  Sciences. 
He  stood  upon  a  mounted  stand  erected  for  the  purpose 
embellished  with  Cuban  colors.  His  voice  was  faint,  audible 
only  to  those  nearest  to  him.  Nowhere  throughout  the 
theater  was  there  evidence  of  the  Stars  and  Stripes,  and  not 
a  flower  adorned  the  platform. 

During  the  interval  before  the  next  speaker  a  lively  mu- 
sical selection  was  rendered  by  the  orchestra. 

Dr.  Eduardo  Wilde,  minister  plenipotentiary  of  the  Ar- 
gentine Republic  at  Washington  and  City  of  Mexico,  deliv- 
ered the  next  address  from  manuscript.  He  closed  amidst 
plaudits  followed  by  orchestral  music. 

The  last  address  of  the  evening  was  of  a  scientific  charac- 
ter, by  Dr.  Louis  H.  Debayle,  official  delegate  of  the  Re- 
publics of  Nicaragua  and  Honduras,  after  which  the  audience 
adjourned. 

General  Session. 

Dr.  J.  S.  Fernandez  presided.  He  said  Congress  desires 
countries  to  unite  in  stamping  out  yellow  fever. 

As  a  result  of  the  remarks  in  the  address  delivered  on  Tues- 
day evening  at  the  General  (intermediate)  Session  by  Dr. 
Wilde,  the  Argentine  Minister  to  Washington  and  the  rep- 
resentative of  his  government  at  the  Congress,  treating  upon 
maritime  hygiene,  a  general  meeting  was  held  this  forenoon 
of  all  the  Sections  in  the  great  hall  of  the  University  building. 
It  was  a  largely  attended  meeting,  and  it  was  unanimously 
resolved  to  accept  the  motion  proposed  by  Dr.  Wilde  in  his 
address  with  slight  modifications,  as  the  Executive  Commit- 
tee might  consider  advisable,  namely :  To  convene  an  Inter- 
national Health  Congress  which  shall  be  composed  of  dele- 
gates representing  the  various  governments  of  America 
which  may  recognize  the  call.  The  mission  of  the  Congress 
will  be  to  propose  a  plan  for  a  treaty  in  which  ways  and  means 
will  be  advanced  for  the  suppression  of  yellow  fever  at  the 
places  of  its  origin,  and  in  places  where  it  exists. 

Dr.  Porter,  of  Key  West,  Fla.,  without  having  been  ap- 


328 


The  Philadelphia 
Medical  Journal 


] 


SOCIETY  REPORT 


[Febrdabt  16,  ISO! 


prised  of  the  Bcope  of  Dr.  Wilde's  paper,  proposed  a  few 
nours  later  to  Dr.  Fernandez  a  series  of  resolutions  having 
the  same  object  in  view. 

After  considerable  discussion  it  was  decided  to  incorporate 
Dr.  Porter's  resolutions  with  those  of  Minister  Wilde. 

This  step  was  regarded  as  an  important  measure  taken  by 
the  Congress,  and  was  compared  by  many  to  the  well- verified 
experiments  of  Drs.  Reed,  Carroll  and  Agramonte  on  the 
mosquito  aa  a  means  of  propagating/(»&n//a  amarilla. 

If  the  theory  is  correct  that  mosquitoes  are  the  prime  cause 
of  the  disease,  an  international  quarantine  organization  will 
undoubtedly  eradicate  this  frequently  fatal  malady  and  give 
rise  to  a  less  restricted  commerce  and  traffic,  thus  greatly 
facilitating  trade  between  the  United  States  and  infected 
West  Indian,  Central,  and  South  American  ports. 

This  topic  was  discussed  in  detail  by  Secretary  Tamayo, 
Drs.  Horlbeck,  Agramonte,  Fernandez,  Wilde,  Bennett,  Por- 
ter, DeBaile,  Calmek,  and  otherz. 

After  some  remarks  endorsing  Dr.  Horlbeck'3  article,  in 
which  allusion  was  made  to  the  pressing  necessity  for  a  con- 
tinuous effort  in  bacteriological  work  in  respect  to  the  ques- 
tion of  etiology  and  mode  of  transmission  of  yellow  fever, 
Dr.  Joseph  N.  Porter,  State  Health  Officer  of  Florida,  offered 
the  following  resolutions : 

Resolved,  That  this  section  of  Maritime  Hygiene  and 
Quarantine  of  the  Pan-American  Medical  Congress,  now 
being  held  in  the  city  of  Havana,  recommends  that  an  Inter- 
national Commission  of  Bacteriologists  and  quarantine 
officials  of  extended  experience  be  created  to  study  the  eti- 
ology and  manner  of  transmission  of  yellow  fever,  and  that 
the  countries  most  interested  in  this  subject  defray  the  equip- 
ment and  maintenance  of  said  commission. 

Resolved,  Also  that  the  commission  thus  created  shall  re- 
port detailed  results  of  its  labors  and  investigations  to  the 
next  meeting  of  the  Pan- American  Medical  Congress. 

Section  on  General  Medicine. 

Among  the  notable  papers  read  at  this  forenoon's  section 
was  one  by  Dr.  Liston  H.  Montgomery,  of  Chicago,  entitled, 
"  Need  of  a  Department  of  Health  as  a  separate  branch  of 
the  Federal  Government  with  a  physician  at  its  head  as 
secretary,  to  rank  with  parity  and  equal  dignity  as  the  other 
members  of  the  President's  Cabinet." 

GEtfEEAL  OR  InTEEMEDUTE  SESSION. 

This  was  the  closing  general  session  held  at  the  Marti 
Theatre.  Ami  ng  other  business  transacted  was  the  resolution 
sul mitted  by  Drs.  Roland  G.  Curtin  and  G  Hudson  Makuen, 
of  Philadelphia,  upon  the  death  of  Dr.  William  Pepper,  they 
having  been  appointed  by  a  meeting  of  representative  physi- 
cisns  from  the  United  States  at  a  called  meeting  held  on 
Wednesday  morning  at  the  University,  as  their  expression  of 
sorrow.    The  resolution  follows  : 

"  It  is  with  unfeigned  sorrow  that  we  mourn  the  untimely 
death  of  our  honored  president,  Dr.  William  Pepper,  who 
organized  the  Pan-American  Mtdical  Congress,  and  so  ably 
and  successfully  presided  over  the  first  two  meetings.  To  his 
wise  supervision  is  due  much  of  the  success  of  the  Congress 
since  its  inception.  At  this  time  we  especially  feel  the  loss 
of  his  guiding  hand  and  executive  ability  to  help  us  in  achiev- 
ing still  greater  success.  In  our  grief  we  are  not  alone,  for 
many  and  varied  enterprises  are  hampered  by  the  absence 
of  his  painstaking  care.  Among  the  more  prominent  may 
be  mentioned  the  Congress  of  American  Physicians  and 
Surgeons,  the  University  of  Pennsylvania,  the  Commercial 
Museum  (a  great  and  original  conception  of  his  own),  and 
the  Archeoli  >gical  JIuseum  of  Philadelphia.  Let  his  example 
of  untiring  industry  and  the  memory  of  his  useful  life  spur 
us  on  to  cari  y  out  the  important  work  planned  by  our  beloved 
president,  Dr.  William  Pepper.  May  the  crown  of  glorj', 
which  he  richly  deserves,  be  his  is  the  prayer  of  his  associates 
of  the  Pan-American  Medical  Congress." 

Tbe  resolution  was  adopted  by  a  rising  vote. 

Dr.  Walter  C.  Wyman  read  an  elaborate  address  — 
"  Municipal  Sanitation  and  Cleanliness  " — which  dwelt  largely 
upon  infection,  contagious  and  loathsome  diseases,  and  how 
best  to  eliminate  this  class  of  maladies.  He  deprecated  the 
present  method  of  maritime  quarantine  in  the  detention  of 
ships  containing  valuable  cargoes,  etc.  Fresh  air  and  sun- 
shine, good  food  and  cleanliness,  are  among  the  best  remedies 


to  ward  off  infection.  Sanitary  improvements  should  be 
backed  up  by  capital,  the  same  as  public  libraries  and 
charitable  institutions — perhaps  on  the  endowment  plan — or 
capital  thus  employed  should  be  devoted  to  building  better 
homes  for  the  poor.  Philanthropists  should  do  this.  He 
hoped  much  would  be  done  in  this  direction  during  tbe 
twentieth  century. 

Dr.  A.  Vandever,  of  Aloany,  N.  Y.,  responded  Ln  behalf  of 
the  registered  members  of  the  Executive  Committee  of  the 
United  States  in  the  absence  of  Dr.  C.  A.  L.  Reed,  who  waa 
detaint  d  by  serious  illness  in  his  family  from  being  present. 
He  thanked  the  committee  and  profession  of  Havana  for  the 
excellent  airangements.  The  committee  desired  to  express 
its  approbation  to  the  ladies'  committee  for  the  kindly  care 
they  had  manifested  in  looking  after  visiting  ladies. 

It  was  hia  good  fortune  to  attend  the  congress  held  at 
Waahington  and  in  Mexico,  but  for  real  scientifis  work 
neither  of  those  compared  with  this  meeting.  And  during 
this  twentieth  century  a  great  work  will  be  going  on  in  the 
investigation  of  the  etiology  of  yellow  fever  right  here  in 
Havana.  This  congress  was  organized  for  the  specific  pur- 
pose of  studying  contagious  diseases.  None  of  the  Republics 
except  Mexico  had  contributed  anything  towards  studying 
flora,  and  she  had  appropriated  $500  for  this  purpose. 

Again  he  renewed  and  voiced  the  committee's  expression 
for  the  excellent  receptions  and  hospitality  which  had  been 
extended  to  us,  and  for  the  truly  scientific  work  which  had 
been  done  by  the  congress. 

Notes  ox  the  Cokgress. 

About  75  were  present  from  the  United  States  and  about 
325  from  Cuba,  Mexico,  Honduras,  Costa  Rica,  and  other 
Central  and  South  American  countries.  Among  those  pres- 
ent from  the  United  States  were :  G  Hudson  Makuen.  Rol- 
and G  Curtin,  Philadelphia;  A.  M.  Phelps,  Ramon  Guit^raa, 
Reginald  G  Sayre,  F.  C.  Valentine,  Charles  A  )bert8,  Thomas 
B  Ranford,  H.  A.  Komeman,  Charles  E,  Bruce,  B.  T.  Whii- 
more.  New  York  ;  H  L.  E  Johnson,  Walter  Wyman,  Waah- 
ington ;  George  H.  Simmons,  Liston  H  M  n-gomerv,  E. 
Wyllis  Andrews,  Heniy  T.  Byfjrd,  Henry  P.  N-  a  man.  Frank 
C.  Greene,  Chicago;  George  N.  Kreider,  Levi  S.  Pilrher, 
Springfipid,  111.;  Thomas  L  Stedman,J.  L  Medina,  Nev  York; 
Joseph  Y.  Porter,  Key  West,  Fia. ;  E.  Vanhood,  J.  F  Gullet, 
Okala,  Fla. ;  T.  A.  Stoddard,  Puebla,  Col. ;  William  Perrin 
Nicholson,  George  H.  Noble,  Atlanta,  Ga. ;  S.  C.  Curaoa, 
Greensboro,  Ala. ;  William  H.  Earlee,  Louis  F.  Frank,  Mil- 
waukee, Wis. ;  Joseph  Mullen,  Houston,  Tex. ;  J.  Bennett, 
Austin,  Tex.;  J.  T.  B.  Berry,  Brandon,  Miss.;  J.  S.  Foote, 
Omaha,  Neb. ;  W.  Stuart  Games,  Canton,  O. ;  W.  J.  Gillette, 
Toledo.  O. ;  W.  E  B.  Davis,  Brminghsm,  Ala.  ;  Wilbam  M. 
Findley,  Altoona,  Pa. ;  E  Holling*head,  W.  C.  Parry,  Pember- 
ton,  N.  J. ;  Henry  Mitchell,  Newark,  N.  J. ;  A.  Vandeveer, 
Albany,  N.  Y.;  A.  H.  Nichols,  Boston,  Mass.;  J.  D.  Gnffi-.b, 
Kansas  C.ty,  Mo.;  H.  B  Horlbeck,  Charleston,  S  C;  H.  T. 
Young,  J.  W.  Holiday,  Burlington,  la  ;  N  C.  Morse,  Eidor», 
la.;  Wm.  Jepson,  Sioux  Ciiy,  la.;  D.  S.  Fairchild,  Clinton,  la.; 
Thomas  MiDavitt,  St.  Paul,  Minn ;  J.  B  M  Gaugney, 
Winoca,  Minn.;  T.  D.  Crothers,  Henry  Hammond,  Hartford, 
Cinn.  Among  others  more  notable  were  Eduardo  WilJe, 
Washington,  D.  C,  Rep.  Argentine  Republic;  Thomas  N. 
Calnek,  San  Jose,  Costa  Rica  ;  Walter  Reed,  Carlos  A.  Finlay, 
James  Carroll,  Aristides  Agramonte.  John  Gai'^ras,  Alfonso 
Betancourt,  Erastus  Wilson,  R.  0.  Mancour,  Havana. 

It  was  noted  that  no  delegates  were  present  from  Canada, 
Maine,  New  Hampshire,  Vermont,  Washington,  Oregon, 
New  Mexico,  Nevada,  Montana,  North  or  S  'Uth  Dikota, 
Kentucky,  Tennessee,  California,  Kansas,  Utab,  Oklahoma, 
Arizona,  Louisiana,  Indiana,  Arkansas,  Maryland,  Virginia, 
and  West  Virginia. 

Of  course  the  mosquito  theory  absorbed  the  greater 
portion  of  the  discussion.  The  social  functions  were  as  elab- 
orate a?  could  possibly  have  been  anticipated. 

Among  those  speci.*illy  worthy  of  mention  was  the  recep- 
tion by  the  military  governor  (Wood)  of  the  island  at  the 
governmental  palace  on  Monday,  February  4,   fron   1    to 

4  P.M. 

A  visit  to  the  cigar  and  cigarette  factories  of  Henry  Clay 
and  Bock  Co.,  where  700  male  and  500  female  employes  are 
engaged,  was  made  on  Tuesdav,  February  5,  from  12  to  2  p  m. 

A  visit  to  Fort  Cabana  and  Morro  Castle,  opposite  the  city, 
on  Thursday,  the  7th,  at  3  o'clock  p.m. 


Fkbeoart  16,  1901] 


SOCIETY  REPORT 


[Thic  Phii^dklfhia 
msdicai.  joubnu. 


329 


The  grand  ball  at  the  Tacon  Theater  was  given  by  the  cjty 
government  of  Havana  in  honor  of  the  foreign  guests,  mem- 
bers of  the  congress,  on  Friday  evening,  the  8th ;  8,000  people 
were  present  of  the  elite  of  Havana.  Tne  refreshments  served 
on  this  occasion  were  elaborate. 

On  Friday  morning,  the  8th,  about  350  ladies  and  gentle- 
men visited  Rosario,  about  40  miles  from  Havana,  where 
Mr.  Ramon  Pelyo  gave  the  physicians  a  complimentary 
breakfast  at  one  of  the  greatest  sugar  plantations  in  Cuba. 
The  excursion  was  an  exceedingly  enjoyable  one.  His  estate 
is  a  most  magnificent  one,  and  upon  the  arrival  of  the  train 
of  seven  coaches  at  Aguacate  Station  we  were  welcomed  by 
the  school  children,  who,  with  flags  and  banners  flying,  waved 
their  beckoning  huzzas  to  the  excursionists.  Ttie  sight  in 
some  respects  was  pathetic.  These  children  were  of  all 
colors,  ages,  sizes,  etc.,  and  were  all  neatly  attired. 

The  grounds  at  this  estate  abound  in  flowers,  plants,  and 
many  varieties  of  tropical  fruit  trees,  like  a  veritable  garden 
of  Eden.  Royal  palms  soared  high.  The  coflee  bush  was 
covered  with  fragrant,  white  blossoms.  Tne  banana,  orange, 
and  cocoanut  trees  were  all  heavily  loaded  with  fruit.  A 
gigantic  table  in  the  form  of  a  horseshoe  was  prepared, 
covered  with  snowy  linen.  A  feature  of  the  breakfast  was 
the  classical  Spanisn  dish,  rice  and  chicken.  When  the  feast 
was  over,  toasts  and  vote  of  thanks,  eloquent  and  profuse, 
were  offered  by  the  gentlemen  from  various  countries.  Dr. 
Ramon  Guit^ras  responded  in  behalf  of  the  United  States. 

The  authors  of  several  papers,  which  were  announced  to 
be  read  by  physicians  from  the  United  States,  being  absent, 
their  papers  will  in  due  course  appear  in  the  published 
volume  of  proceedings,  which  is  promised  in  about  6  months. 

Db.  R.  O.  Mahcour,  assistant  surgeon  U.  S.  Navy,  official 
delegate  from  the  Navy  Department,  Havana,  secretary  Sec- 
tion on  Marine  Hygiene  and  Quarantine,  read  the  first  paper 
in  this  section  on  Monday,  February  4,  entitled.  Yellow 
fever  and  Sanarelli  Serum  (see  page  87  of  the  Manual). 
His  was  an  exhaustive  and  interesting  report  of  a  grave  case 
of  yellow  fever  which  he  treated  with  Sanarelli  serum.  The 
case  was  a  noteworthy  one  in  so  far  as  it  was  the  first  authen- 
tic case  on  record  of  a  grave  type  of  typhoid  icterus  where  a 
patient  had  black  vomit,  and  recovered  under  this  method 
of  treatment.  The  conclusion  reached  was  that  this  patient 
would  not  have  recovered  had  any  other  method  been  pur- 
sued. Several  physicians  on  duty  in  Havana  at  the  time  saw 
the  case  in  consultation  with  Dr.  Marcour.  The  first 
organ  which  responded  to  the  serum  was  the  kidneys, 
second,  the  nervous  system.  The  irritability  of  the  stomach 
was  quieted  considerably.  Toward  the  beginning  of  convales- 
cence an  erythematous  eruption  appeared  first  at  the  points 
where  the  serum  was  first  injected,  secondly,  where  the 
skin  is  thinnest,  and  later  all  over  the  body.  This  charac- 
teristic eruption  was  also  observed  in  2  other  cases  of 
yellow  fever  treated  with  the  same  serum  by  Dr.  Marcour, 
but  owing  to  the  mild  type  of  bis  other  2  cases  he  did 
not  think  them  of  sufficient  importance  to  the  medical 
profession  to  be  noted  and  report  same  in  detail.  He  re- 
ferred to  them  several  limes  while  reading  his  paper. 
After  the  reading  of  his  paper  the  President  of  the  Section 
translated  it  into  Spanish  to  the  Cuban,  Mexican,  and  South 
American  physicians  present.  The  paper  elicited  much 
discussion  on  the  part  of  the  foreign  members.  Dr.  Marcour 
concluded  by  stating  that  we  need  to  try  the  serum  only 
in  grave  cases,  since  mild  cases  recover  with  simpler 
methods  and  good,  careful  nursing.  The  writer  added  that 
he  is  now  convinced  that  the  Culex  fasciatus  is  the  only 
agent  capable  of  conveying  yellow  fever.  The  paper  con- 
sisted of  38  pages  of  manuscript,  and  it  is  difficult  there- 
fore to  abstract  it  and  do  the  author  justice,  owing  to  the 
large  amount  of  clinical  data  furnished  therein. 

A  papfr  entitled  The  operative  treatment  of  pro- 
lapse and  procidentia  of  the  uterus  was  read  by  De. 
Hekry  T.  Byfokd,  of  Chicago,  1)1.  (See  page  75  of  Manual 
for  abstract )  He  read  his  paper  on  February  4,  before  the 
Section  on  Gynecology  and  Abdominal  Surgery. 

The  Angiotribe. — Dr.  Henry  P.  Newman,  of  Chicago, 
111.,  described  ttie  use  of  his  instrument  on  Thursday  morn- 
ing, February  7.     (See  page  72  of  the  Manual  for  abetiact.) 

A  paper,  New  operation  for  the  radical  cure  of 
hernia,  was  read  by  Dr.  E.  Wyllis  Andrews,  of  Chicago,  III. 
(See  Addenda  of  Manual.)  The  author  read  his  paper  on 
Thursday  forenoon,  February  7,  before  the  Section  of  Gyne- 


cology and  Abdominal  Surgery  as  the  Section  on  General 
Surgery  had  adjourned. 

A  paper— Summary  of  the  progress  made  in  the 
nineteenth  century  in  the  study  of  the  propagation 
of  yellow  fever — was  read  by  Dr.  Charles  A.  Finlay, 
before  the  Section  on  General  Medicine  (president  of  the 
Section),  on  Tuesday  forenoon,  February  5  (see  appendix  of 
the  Manual  for  abstract  of  his  paper). 

On  Wednesday  a.m  ,  February  6,  De.  Ekastus  Wilson, 
Havana,  Cuba,  read  Municipal  hygiene,  or  preventive 
medicine  as  required  by  the  city  of  Havana  (see 
page  134  of  the  Manual  for  abstract),  before  the  Section  on 
General  Hygiene  and  Demography. 

On  Monday  forenoon,  February  4,  a  paper  —  Preva- 
lence of  glanders  in  Havana  among  the  horses  and 
people — was  read  by  Dr.  Honore  E  Laine,  of  Havana, 
Cuba,  president  of  the  Section  on  Veterinary  Surgery.  (See 
latter  portion  of  Manual  for  Abstract ) 

On  Tuesday  forenoon,  February  5,  Dr.  Joseph  Mullen, 
Houston,  Tex.,  read  a  report  of  a  Case  of  removal  of  the 
superior  sympathetic  cervical  ganglion  for  non- 
inflammatory glaucoma  before  the  SeLtii  n  on  Ophthal- 
mology (see  page  106  of  the  Manual  for  mention  of  title). 
This  paper  has  been  promised  to  the  Journal,  hence  will 
appear  in  its  entirety  In  a  subsequent  issue. 

On  Wednesday  forenoon,  February  6,  Dr.  W.  J.  Gillette, 
of  Toledo,  Ohio,  read  a  paper  entitled  Present  methods 
and  tendencies  in  medical  education  in  the  United 
States  in  the  Section  on  Medical  Pedagogy.  (This  paper  is 
promised  the  Journal,  hence  will  be  published  in  a  subse- 
quent issue.) 

On  Wednesday,  a  m.,  February  7,  Dr.  T.  D.  Ceothers, 
Hartford,  Conn.,  read  his  paper  on  Morphinism  and 
crime,  in  the  Section  on  Diseases  of  the  Mind  and  Nervous 
Systedi  (see  page  149  of  Manual  for  announcement  of  title). 

On  Wednesday  a.m.,  February  7,  one  of  the  secretaries  of 
the  Section  on  General  Hygiene  and  Demography  read  a 
paper  written  by  Dr.  Alvah  H.  Doty,  of  New  York. 

AH  the  Sections  met  in  various  halls  of  the  University. 

Dr.  Ferd.  C.  Valentine,  of  New  York,  read  his  paper. 
(See  page  52  of  the  Manual  for  abstract.) 

Dr  James  S.  Foote,  of  Omaha,  Neb.,  read  his  paper.  (See 
page  43  of  the  Manual  for  title.) 

Dr.  J.  D.  Griffith,  of  Kansas  City,  Mo.,  read  his  paper. 
(See  page  47  of  the  Manual  for  title.) 

Dr  W.  E.  B.  Davis,  of  Birmingham,  Ala.,  read  his  paper. 
(See  page  79  of  the  Manual  for  title.) 

The  Badge  — The  badge  worn  by  members  of  the  Congress 
was  of  metal.  The  dimensions  were  between  an  American 
silver  25  cent  piece  and  a  half  dollar,  and  about  as  thick,  was 
silver-plated  and  contained  on  one  side  the  Cuban  coat  of 
arms,  which  consisted  of  the  rising  sun  over  the  sea  between 
two  points  of  land  and  a  key  below  with  the  word  Cuba 
thereon.  The  key^-orCuba  by  geographic  position — is  to  in- 
dicate the  honor,  key  to  the  Gulf  of  Mexico  (or  good  position 
for  naval  and  military  power).  At  the  bottom  of  the  coat  of 
arms  is  a  palm  on  the  right  side,  while  on  the  left  side  our 
flag,  the  Stars  and  Stripes,  is  seen. 

On  the  obverse  side  is  the  inscription,  "Pan-American 
Medical  Congress,  Havana,  1901."  Urn  and  serpent  to  indi- 
cate Science,  and  a  laurel  leaf.  All  of  which  was  suspended 
from  a  yellow  silk  ribbon  bow,  indicative  of  the  medical  (phy- 
sician's ^color  in  Cuba. 


Psychotherapy  of  Pain. — Oppenheim  (Therajne  der 
Qegenwart,  Marcli,  1900)  believes  that  pain  occurring  in  an 
extremity  or  circumscribed  nerve  area  is  often  designated 
as  neuralgia,  while  more  frequently  it  is  of  a  psychogenetic 
orgin,  due  to  neurasthenia,  hjsteria,  or  hypochondriasis.  As 
these  varieties  of  pain  have,  up  to  the  present  time,  defied  va- 
rious therapeutic  measures,  it  is  worthy  of  mention  that  the 
author  claims  to  have  (ured  several  cases  by  psychothera- 
peutic means.  By  systematic  exercises  he  causes  the  patient 
to  neglect  the  pain  emanating  from  the  affected  area,  in  that 
the  patient  concentrates  his  or  her  ei  tire  attention  upon 
some  object  like  the  ticking  of  a  watch.  If  this  fails,  the 
patients  are  taught  to  direct  their  attention  to  two  areas,-— 
one  near  the  seat  of  pain,  the  other  at  some  distance  from  it. 
The  author  claims  by  these  pn  cedures  to  have  established 
insensibility  in  the  former  painful  areas,    [m.e.d.] 


330 


THB  PHn-ADKUHIA"! 
Mkdicai.  JOCXSAl,  J 


THE  LATEST  LITERATURE 


[Fkbbwabt  16,  l»«(j 


tLhi  iakst  ittcrature. 


British  Medical  JoorDal. 

January  26, 1901.     [Xo.  2091] 

1.  A  Summary  of  lUssearches  on  the  Propagation  of  Malaria 

in  British  Centra!  Africa.    C.  W.  Dasiels. 

2.  Notes  on  the  L'fe  History  of  Anopheles  Macalipennis 

(Meigen).    Lons  W.  SiirBW. 

3.  Malaria  and  Mosquitoes  in  Zealand.    A.  Vajt  der  Sheer 

and  J.  Bekde>ts  vas  Beelekom. 

4.  Prelirainary  Note  ou  an  Unclassified  Type  of  West  African 

Fever.    S.  W.  Thompstoke  and  H.  E.  Askett,  and  R. 
A.  Bexxeit. 

5.  Observations  on  15  Cases  of  Hemoglobinuric  Fever  in 

British  Central  Africa.    Hebbeet  Heaesey. 

6.  Note  on  the  Staining  of  Flagella.    J.  BLACKBrEs  Sscith. 

7.  Toe  Prophylactic  and  Curative  Treatment  of   Plague. 

A  LrsTiG  and  G.  GiXEOTn. 

8.  Dysentery  in  South  Africa.    James  Johu  Day. 

9.  Note  on  the  Lesions  Produced  by  Oxyuris  Vermicularia. 

Maec  Aemaxd  Rcitee. 

10.  A   Filaria    Found  in  Sierra  Leone ;    Filaria    Volvulus 

(Lenchart)      W.  T.  Psorr. 

11.  Remarks  on  the  Apparent  Immunity  of  Asiatics  from 

Enteric  Fever.    Feaxcis  W.  Clabk. 

1. — Daniels  believes  that  Anopheles  funestus  (Giles)  is  the 
chief  agent  in  the  distribution  of  malaria  in  East  and 
Central  Africa.  After  feeding  57  specimens  of  anopheles 
on  a  patient  suffering  from  malaria  whose  blood  contained 
crescents,  27,  or  47  5%,  were  foimd  to  be  infected.  These 
57  mosquitoes  had  fed  129  times  on  the  patient  and  out  of 
the  129  feedings,  infection  of  the  mosquitoes  resulted  in  46 
instances,  or  35  5%.  Man  appears  to  be  the  only  interme- 
diate host  of  the  malaria  parasites.  From  June,  1899, 
onwards  the  author  made  observations  on  the  proportion  of 
children  of  different  ages  with  splenic  enlargement,  the 
absence  of  this  condition  in  the  adults  having  been  pre- 
viously noted.  Oat  of  851  children  under  15  years  old  exam- 
ined 216  had  enlarged  spleens.  A  classification  of  these 
observations  into  a  group  under  2  years  of  age,  a  group 
between  2  and  4  years,  and  a  group  from  4  to  15  years,  shows 
an  earlier  Incidence  and  an  earlier  decrease  in  the  proportion 
with  enlarged  spleens  in  the  more  malarious  districts ;  and 
as  chronic  enlargement  of  the  spleen  does  not  always  follow 
even  repeated  neglected  infections,  it  also  indicates  a  very 
high  degree  of  prevalence  of  malaria  in  the  natives  in  early 
life.  Tne  causation  of  enlarged  spleen  as  a  result  of  malaria 
is  not  well  understood,  and  requires  further  investieation. 
This  effect  of  malaria  is  in  part  dependent  on  race.  No  pre- 
ventive method  is  or  can  be  of  general  application  to  the 
exclusion  of  others.  A  combination  of  methods  strictly  in 
accordance  with  local  conditions  promises  the  best  results. 
The  outlook  is  hopeful,  as  a  reduction  in  any  factor  by  any 
one  method  will  mcrease  the  effect  of  any  "other  methods 
adopted.  The  greatest  diflBculty  will  result'  from  the  scepti- 
cism with  which  the  subject  will  be  met  in  the  tropics. 
SaflScient  regard  to  the  species  of  anopheles  has  not  yet 
been  paid  in  describing  their  habits  and  breeding  places. 
The  very  local  distribution  of  some  of  the  species  indicates 
some  important  differences  as  yet  unknown.  It  is  requisite 
for  each  species  of  anopheles  that  direct  proof  should  be 
obtained  whether  the  human  malaria  parasites  develop  in 
them  or  not ;  in  only  a  few  is  the  proof  at  present  conclu- 
sive, and  it  is  being  too  hastily  assumed  that  the  whole 
genus  is  implicated.     fj.M.s.] 

2. — The  paper  is  an  exfKeition  of  the  anatomy  of  the  era, 
larvae,  and  adults  of  Anopheles  maculipennis.    '[j.m.s  ] 

3.— Van  der  Scheer  and  van  Berlekom  refer  to  a  previously 
published  report  of  an  outbreak  of  malaria  in  Middleburg, 
the  principal  town  in  Zealand,  where  for  30 years  this  disease 
had  never  occurred.  There  were  two  marked  peculiarities 
of  this  epidemic  :  (1)  It  consisted  only  of  cases  of  tertian  fever, 
and  (2)  house  epidemics  were  often  observ«l.  The  malaria 
houses  were  reinspected  this  year  with  accuracy,  and  it  turned 
out  that  several  anopheles  were  found.  It  became  evident 
that,  as  in  Italy,  anopheles  prefer  to  live  in  stables  with  rab- 


bita^  horses,  and  other  quadrupeds.  Within  such  stables  as 
were  situated  in  the  neighborhood  of  the  infected  houses  whole 
colonies  of  them  were  found.  The  authors  tried  to  infect  ano- 
pheles by  keeping  them  under  a  mosquito  net,  together  with 
a  person  who  suffered  from  malaria,  and  whose  blood  con- 
tained not  only  the  so-called  febrigenous  parasites  but  also 
gametocytes,  which  are  destined  to  undertake  sexual  func- 
tions in  the  mosquito's  stomach  and  to  form  vermicules. 
Their  experiments  were  immediately  successful,  so  that,  of 
22  mosquitoes  that  had  sucked  blood  containing  gametes,  one 
or  another  stage  of  development  of  the  parasites  was  found 
in  the  bodies  of  18.     [j.m  s  ] 

4. — Thompstone  and  Bennett  describe  a  disease  that  they 
call  hyperpyrexia!  fever  that  is  generally  ushered  in  by 
a  slight  rise  of  temperature,  followed  by  profuse  perspiration 
and  a  fall  in  the  temperature  to  about  '9?*'  F.  After  a  period 
of  apyrexia  of  perhaps  24  hours'  duration,  the  temperature 
begins  again  to  rise,  slowly  at  first,  but  when  105°  is  passed 
with  alarming  rapidity  so  that  107°  may  be  reached  on  the 
second  day.  For  from  14  to  30  days  subsequently  there  is 
absolutely  no  tendency  for  the  temperature  to  fall.  The 
skin  acts  either  very  slightly  or  not  at  all,  and  all  antipyretic 
drugs  fail.  There  is  no  enlargement  of  the  Uver  or  the 
spleen.  The  urine  is  of  normal  character  and  abundant ; 
the  bowels  are  regular  or  inclined  to  looseness.  Tne  mind 
remains  remarkably  clear  in  the  majority  of  cases,  except 
when  the  temperature  is  at  its  highest,  but  constant  symp- 
toms in  the  early  days  are  great  anxiety  and  restlessness.  No 
Plasmodia  or  pigmented  leukocytes  have  ever  been  dis- 
covered, but  in  some  of  the  latter  cases  it  was  noticed  that  the 
blood  tended  to  copulate  the  moment  it  was  exposed  to  the 
air,  so  that  it  was  only  with  great  diflBculty  that  satisfactory 
films  could  be  obtained.  Treatment  of  the  condition  is  by 
baths.  If  the  patient  is  to  recover,  some  change  for  the 
better  is  to  be  looked  for  about  the  end  of  the  third  week. 
Convalescence  is  gradual,  and  it  may  be  6  weeks  after  the 
onset  of  the  fever  before  the  temperature  finally  assumes  its 
normal  course.  On  the  other  hand,  in  50  ^t  of  the  cases  thst 
have  come  under  observation  a  fatal  issue  has  occurred.  At 
the  end  of  the  second  week,  Annett  found  4,384,000  red 
corpuscles,  15,000  white  corpuscles,  and  913%  hemoglobin. 
.4.ttempt8  to  cultivate  microorganisms  from  the  blood  failed. 

[J  MS  ] 

6. — Hearsey  gives  summaries  of  15  cases  of  hemoglo- 
binuric  fever,  which  he  defines  as  an  acute  febrile  disease, 
probably  of  malarial  origin,  and  characterised  by  the  occur- 
rence of  an  extensive  and  rapid  hemolysis,     [j.m.s  ] 

6. — Smith  uses  ths  following  method  for  the  staining  of 
flagella  of  microorganisms.  A  saturated  solution  of  per- 
chlorid  of  mercury,  made  by  boiling,  is  potired,  while  still 
hot,  into  a  bottle  in  which  crystals  of  ammonia  alum  have 
been  placed  in  quantity  more  than  sufiicient  to  saturate  the 
fluid.  The  bottle  is  well  shaken  and  the  solution  is  allowed 
to  cool.  To  10  cc.  of  this  fJuid  10  cc.  of  a  freshly  made  10% 
solution  of  tannic  acid  are  added  and  5  cc  of  carbol  fuchsin. 
Tnese  are  mixed  and  filtered.  The  cover-glasses  are  prepared 
by  washing  them  in  a  stong  solution  of  hydrochloric  acid. 
They  are  taken  from  the  acid,  wiped  with  a  clean  cloth,  and 
thoroughly  heated  over  a  Bunsen  flame.  Oa  a  cover-glass 
which  has  been  sufficiently  heated,  the  film  spreads  with  per- 
fect evenness.  The  traces  of  acid  that  are  left  on  the  glass 
make  it  easier  to  avoid  subsequent  precipitation  of  mordant 
or  stain.  The  bacilli  are  placed  on  the  cover-slip  and  fixed. 
The  mordant  is  then  filtered,  poured  on  the  preparation,  and 
heated  til!  steam  is  given  off.  Boiling  should  be  avoided,  as 
it  leads  to  precipitation.  The  prep»aration  should  be  kept  at 
this  temperature  for  8  minutes.  It  is  then  well  washed  in 
disdlled  water,  and  the  stain  is  added  and  heated  in  the  same 
way  for  S  or  4  minutes.  The  stain  is  made  by  adding  1  cc, 
of  a  saturated  alcoholic  solution  of  gentian  violet  to  10  cc.  of 
a  saturated  solution  of  ammonia  alum.  This  is  filtered  and 
poured  on  the  preparation.  This  method  is  particularly  ap- 
plicable to  bacilli  of  the  typhoid  and  colon  group.  Tne 
flagella  of  the  cholera  bacillus,  the  tetanus  baciUns,  and  the 
vibrio  aquatilis  are  well  stained  by  this  method,     [j.m.5  ] 

7. — Lustig  and  Galeotti  in  their  studies  on  the  treatment 
of  plaffue  determined  to  inoculate,  as  a  preventive  medium, 
the  suDsiance  that  is  alone  able  to  cause  in  the  organism 
treated  an  active  immtmity  produced  by  the  action  of  a 
specific  bactericidal  power.  This  substance  was  obtained  by 
isolating    from   the    microorganisms    the  nacleoprotaid   of 


Fbbroabt  16,  tMl] 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
L  Medical  Journal 


331 


which  they  are  partly  composed,  for  it  is  to  this  that  immu- 
nity is  due,  although  it  can  be  also  produced  by  injecting 
entire  cultures  of  plague  microorganisms.  Through  the  in- 
jection of  this  nucleoproteid,  which  is  an  intracellular  specific 
poison,  the  authors  were  able  to  confer  on  the  serum  of  the 
animals  a  bactericidal  power,  and  very  likely  an  antitoxic  one 
as  well.  The  first  serum  was  obtained  in  the  year  1897  and 
was  tried  in  India  on  6  patients,  5  of  whom  recovered. 
Besides  29  patients  were  treated  with  it  in  the  Poona  Plague 
Hospital,  and  21  of  them  got  well.  The  number  of  patients 
treated  with  this  serum  on  June  10  was  175.  The  results 
were  altogether  very  satisfactory,  but  a  great  difference  in 
the  serums  coming  from  different  horses  was  noted.  The 
mortality  among  the  patients  treated  with  the  serum  may  be 
placed  at  about  53  fo,  while  the  general  mortality  for  plague 
at  the  same  period  was,  according  to  the  official  statistics, 
about  94  ^ .  More  recent  results  of  the  treatment  of  plague 
with  this  serum  have  been  published  in  Dr.  Polverini's  report. 
The  rate  of  recovery  was  39  36  ^ .  At  the  Arthur  Road  Hos- 
pital, 1,190  patients  were  treated  without  serum  during  the 
same  period  with  a  mortality  rate  of  19.57 /o.    [j.m.s.] 

8. — Much  of  the  dysentery  which  the  private  soldier 
in  South  Africa  believes  he  suffers  from  is  not  dysentery. 
It  usually  resolves  itself,  on  questioning  the  patient,  into 
diarrhea,  accompanied  by  griping  pain.  In  the  advance 
through  the  Free  State  one  saw  many  cases  of  acute  diarrhea, 
in  a  large  percentage  of  which  blood  and  mucus  were  passed. 
Very  few  of  these  ended  as  acute  dysentery.  The  few  cases 
of  real  dysentery  occurring  in  Colvile's  Division  improved 
rapidly  under  treatment  with  magnesium  sulphate,  given  in 
hourly  doses  of  1  dram,  and  dieting.  Out  of  some  hundreds 
of  cases  of  acute  diarrhea  and  dysentery  treated.  Day  only 
saw  1  death  occur  actually  in  the  field,  and  that  was  a  case 
of  long  duration.  On  admission,  the  patient  was  immediately 
given  castor-oil,  1  ounce ;  tincture  of  opium,  15  to  25  minims ; 
peppermint- water,  1  ounce;  and  a  diet  of  arrowroot,  milk, 
soda-water,  and  brandy  or  portwine.  As  soon  as  the  bowels 
had  been  thoroughly  cleared,  magnesium  sulphate,  1  dram ; 
dilute  sulphuric  acid,  15  minims ;  and  peppermint-water, 
1  dram,  was  given  every  hour  until  the  stools  became  fecu- 
lent. As  the  tenesmus  was  relieved  and  the  evacuation  of 
blood  and  mucus  ceased,  the  sulfate  of  magnesium  was 
administered  correspondingly  less  frequently,  but  was  always 
continued  for  about  48  hours  after  the  dysenteric  symptoms 
had  ceased.  Several  cases  were  complicated  by  scurvy, 
malaria,  and  synovitis.  There  is  a  great  tendency  to  relapse 
should  the  patient  be  allowed  to  get  about  in  the  sun  too  soon 
during  convalescence.  Cases  of  dysentery  should  be  kept 
separate  from  cases  of  typhoid  fever.  As  much  care  should 
be  taken  to  either  disinfect  or  destroy  the  stools  of  dysentery 
patients  as  of  patients  suffering  from  typhoid,     [j.m.s.] 

9. — At  the  postmortem  examination  of  an  adult  male  who 
had  died  from  chronic  cirrhotic  disease  of  the  liver  and  kid- 
neys Ruifer  noticed  the  oxyuris  vermicularis  in  great 
numbers  in  the  contents  of  the  large  intestine,  more  especially 
in  its  lower  portion.  In  the  rectum,  about  6  inches  from  the 
anus,  3  small  hard  tumors  were  found,  that  lay  within  the  walls 
of  the  intestine,  and  was  of  the  size  of  a  small  nut,  while  here 
and  there  throughout  the  length  of  the  large  intestine  small 
elevations  were  also  noticed.  These  varied  in  size  from  that 
of  a  pin's  head  to  that  of  a  small  pea.  The  mucous  mem- 
brane covering  these  tumors  and  the  elevations  above  no- 
ticed was  quite  intact,  and  there  was  no  sign  of  congestion, 
inflammation,  or  ulceration  around  the  tumors.  Eich  of 
these  tumors  contained  a  calculus  ;  it  shelled  out  quite  easily 
from  the  surrounding  connective  tissue,  which  formed  a 
capsule  around  it.  The  mucous  membrane  and  the  submu- 
cosa  formed  the  anterior  wall  of  the  cyst,  the  posterior  wall 
consisting  of  the  muscular  layer  and  peritoneum,  a  thick 
capsule  of  connective  tissue  surrounding  the  calculi.  These 
calculi  were  rough,  uneven,  but  not  so  hard  that  they  could 
not  be  cut  with  a  strong  scalpel.  They  were  mainly  of  a 
yellowish  black  color,  but  almost  white  in  parts.  The  addi- 
tion of  a  small  drop  of  mineral  acid  to  a  fragment  at  once 
produced  a  strong  evolution  of  gas.  Microscopic  examina- 
tion of  any  one  of  these  calculi  showed  that  they  consisted 
of  an  amorphous  yellowish  brown  substance,  which  con- 
tained numberless  typical  eggs  of  oxyuris  vermicularis.  No 
traces  of  the  worms  themselves  could  be  found  inside  the 
cyst.  The  only  possible  explanation  of  these  facta  is  that  the 
oxyuris  penetrated  through  the  mucous  membrane  into  the 


wall  of  the  intestine,  and  there  laid  its  eggs.  These  acting 
as  an  irritant  produced  a  certain  amount  of  inflammation 
followed  by  calcification.  The  female  either  found  her  way 
back  into  the  intestine,  or  died  and  was  absorbed.  It  is  quite 
possible  that  this  process  takes  place  frequently,    [j  M.S.] 

10. — Prout  examined  a  rounded  tumor,  about  the  size  of 
a  pigeon's  egg,  that  was  removed  from  the  buttock  of  a 
frontier  policeman,  who  complained  of  vague  rheumatic 
pains.  In  appearance  and  consistency  the  tumor  resembled 
a  fatty  tumor,  but,  on  excising  if,  it  was  found  to  be  a  cyst 
containing  what  seemed  to  be  a  mass  of  filariae  bathed  in  a 
semipurulent  fluid.  Later  a  similar  tumor  was  removed 
from  another  frontier  policeman.  On  making  an  incision 
into  this  mass,  a  greenish,  semipurulent  looking  fluid  about 
the  consistency  of  cream  escaped  from  the  cyst.  This,  on 
microscopic  examination,  was  found  to  contain  numerous 
fllarial  embryos.  The  interior  of  the  cyst  was  filled  with  the 
adult  filariae  lying  in  loops  twisted  up  in  the  most  con  using 
fashion,  entering  the  cyst  wall,  running  along  shallow  tun- 
nels, and  reentering  the  cyst.  Owing  to  this  and  the  softness 
and  brittleness  of  the  worm  it  was  a  matter  of  the  greatest 
difficulty  to  dissect  it  out,  and  it  was  found  impossible  to  do 
so  without  breaking  it.  Eventually,  however,  the  author 
succeeded  in  isolating  a  complete  unbroken  adult  male,  and 
the  head,  tail,  and  intermediate  fragments  of  a  female.  These 
two  worms  formed  the  whole  contents  of  the  cyst.  The 
worm  is  considered  to  be  a  specimen  of  filaria  volvulus 
(Lsuckhart).     [j.m.s.] 

11. — During  10  years  only  51  deaths  of  Chinese  from 
typhoid  fever  were  registered  in  Hong  Kong,  as  against  65 
deaths  of  non  Chinese,  although  the  Chinese  form  94%  of 
the  total  population.  Clark  believes,  and  so  stated  in  a 
former  report,  that  the  Chinese  are  so  fully  exposed  to  the 
infection  throughout  the  whole  period  of  their  existence  that 
they  almost  always  contract  the  disease  in  infancy  or  early 
childhood,  when,  if  they  recover,  the  disease  will  have  been 
practically  unnoticed,  while,  if  they  succumb,  the  death  will 
be  attributed  to  diarrhea,  convulsions,  or  some  other  symp- 
tom. Should  they  happen  to  contract  a  second  attack  in 
adult  life,  it  will  be  so  modified  by  the  previous  one  as  to  be 
again  scarcely  recognizable,  or  at  least  to  be  insufficient  to 
drive  the  patient  to  a  hospital  under  European  control. 
During  the  current  year,  while  12  deaths  have  been  registered 
as  due  to  this  disease  among  the  non-Chinese,  22  have  been 
registered  among  the  Chinese,  and  of  these  7  were  in  infants 
under  1  year  of  age,  and  one  a  child  between  the  ages  of  1 
and  5  years.  It  must  be  borne  in  mind  that  these  cases 
have,  moreover,  been  found  amongst  the  few  bodies  of  infants 
that  are  picked  up  in  the  streets  by  the  police,  and  that  no 
postmortem  examination  is  made  of  the  bodies  of  the  1,500 
or  more  infants  that  are  taken  annually  to  the  French  and 
Italian  convents  in  a  moribund  condition,  and  whose  deaths 
are  registered  as  due  either  to  diarrhea,  undefined  fever, 
marasmus,  or  convulsions,  and  that  these  convent  returns 
comprise  about  75%  of  the  total  deaths  in  the  colony  under 
5  years  of  age.  It  would  seem  that  the  immunity  of 
Asiatics  to  typhoid  fever  is  only  an  apparent  one. 
[j.m.s.] 

Lancet. 

January  26,  1901.     [No.  4039.] 

1.  An  Address  on  the  Selective  Influence  of  Poisons  in  Re- 

lation to  Diseases  of  the  Nervous  System.    Fekdkeick 

W.  MOTT. 

2.  A  Lecture  on  Plague.    J.  Mitfoed  Atkinson. 

3.  A  Suggested  Method  of  Preventing  Water-borne  Enteric 

Fever  Amongst  Armies  in  the  Field.   Louis  C.  Paekes. 

4.  Notes  on  Acquired  Syphilis  of  the  Nose  and  Pharynx. 

Chaeles  a.  Paekee. 

5.  Removal  of  a  Foreign  Body  from  the  Bronchus  by  Intra- 

thoracic Tracheotomy.    H.  Milton. 

6.  A  Singular  Case  of  Extensive  Deposit  of  Phosphate  of 

Lime  in  the  Lungs.    Theodoee  Fishee. 

7.  Notes  on  a  Case  of  Poisoning  by  Coal  Tar  Naphtha.    G. 

Herbert  Dodthwaite. 

8.  A  Case  of  Anthrax.    Archibald  Kidd. 

9.  Spleno- Medullary  Leukemia;  Remarkable  Tolerance  of 

Arsenic.     Chjirles  Heaton. 
10.  Results  of  85  Prophylactic  Injections  of  the  Antidiphthe- 
ritic  Serum.    Percy  R.  Blake. 


332 


The  Philadklphia"] 
Mbdical  Jourkal  J 


THE  LATEST  LITERATURE 


[Febecaet  16,  IMl 


1. — Mott  delivered  an  address  before  the  Nottingham 
Society  on  October  10,  1900,  on  "  The  Selective  Influence  of 
Poisons  in  Relation  to  Diseases  of  the  Nervous  System."  He 
points  out  the  important  fact  that  each  nerve-cell,  unit  or 
neuron  possesses  a  biochemical  sensitiveness  or  chemiotaxis, 
which  is  influenced  by  its  lymph-environment.  The  failure 
of  the  neuron  to  carry  out  properly  assimilation  and  dissim- 
ilation owing  to  improper  environment  and  inherent  quali- 
ties is  the  essential  which  governs  functional  diseases  and 
primary  degeneration  of  the  nervous  system.  Secondary 
diseases  of  the  nervous  system  are  due  to  such  causes  as 
hemorrhage,  thrombosis,  embolism,  tumors,  injury  and  dis 
eases  of  the  neuroglia  and  membranes.  In  his  address  he 
refers  only  to  primary  intoxications  and  degenerations. 
While  toxic  substances  circulating  in  the  blood  or  lymph 
come  in  contact  with  all  the  nervous  tissue  equally, 
still  certain  nerve  elements  are  especially  susceptible 
to  some  poisons  and  it  is  through  the  particular  symp- 
toms which  manifest  themselves  that  the  poison  is  often 
recognized.  He  mentions  as  striking  examples,  tetanus  and 
rabies.  Toxic  substances  often  act  as  predisposing  or  exciting 
causes  in  individuals  who  show  an  hereditary  neuropathic  ten- 
dency or  who  are  subject  1 5  excessive  activity  or  stress.  Mott, 
therefore,  points  out  as  cardinal  factors  in  the  causation  in  the 
majority  of  cases,  toxemia,  stress,  and  hereditary  neurosis. 
Largely  through  the  nervous  system  of  the  individual  are 
the  internal  activities  and  the  relation  to  his  surrounding 
environments  maintained.  He  states  that  the  important 
property  of  the  nerve  unit  is  excitability,  and  that  poisons 
may  increase  or  diminish  this  function.  Nature  guards 
against  the  entrance  of  many  poisons  into  the  alimentary 
and  respiratory  tracts  by  the  sense  of  taste  and  smell.  Poi- 
sons in  the  circulation  are  often  neutralized  by  the  secretions 
of  antitoxin.  In  some  instancea  the  nervous  system  shows 
a  gradual  tolerance  to  toxic  environment  (habit  poisoning), 
a  condition  after  once  established  is  often  indispensable  to 
proper  functional  activity,  and  a  rapid  withdrawal  of  such 
toxic  surroundings  would  bring  about  abnormal  activity  of 
the  nervous  system.  He  clearly  states  that  every  nerve  unit 
pofsesses  potential  energy  which  when  called  upon  may  be 
transferred  into  active  energy.  He  further  adds  that  po- 
tential energy  is  maintained  through  the  proper  relation  of 
constructive  and  destructive  metabolism,  and  upon  the  ac 
tivity  of  the  protoplasm.  In  neurasthenia  potential  energy 
is  reduced.  There  is  also  a  relation  existing  between  certain 
nerve  groups.  A  paralysis  of  one  group  may  cause  overac- 
tion  in  another  unopposed  group.  In  this  way  many  symp- 
toins  of  nervous  diseases  are  brought  about.  He  divides  the 
toxic  substances  in  the  blood  or  lymph  which  cause  increase 
or  decrease  excitability  of  the  nerve  elements  into  those  that 
Are  introduced  from  without  (exogenetic)  and  those  that  are 
produced  within  the  body  (autogenetic).  He  calls  particular 
attention  to  such  poisons  as  alcohol,  opium,  hashish, 
morphia,  cocain,  tobacco,  and  absinthe ;  each  causing  speci- 
fic action  on  the  higher  mental  functions,  however,  always 
modified  by  individual  temperament.  He  believes  that  dif- 
ferent toxic  substances  act  upon  certain  projection  fields  or 
identification  centers  of  the  Israin.  He  refers  to  the  effects 
produced  by  haehish,  which  consist  of  remarkable  illusions 
relating  to  the  notion  of  time  and  space.  Also  to  the  efl"ect 
produced  by  morphia,  causing  persistent  and  uncontrollable 
ideation.  He  states  that  alcohol  is  directly  or  indirectly  re- 
sponsible for  20^  of  the  mental  and  nervous  diseases  of  the 
inmates  of  the  London  County  Asylums.  He  refers  to 
chronic  alcoholism  as  causing  dementia.  The  characteristic 
naental  symptoms  of  this  chronic  intoxicatio  ;  are  personal 
illusions,  absence  of  the  knowledge  of  time,  space  and  loss 
of  memory,  especially  for  recent  events.  In  many  of  the 
alcoholic  cases,  peripheral  neuritis  was  associated.  To 
tobacco  is  attributed  a  special  action  upon  the  neurons  if 
central  vision  causing  amblyopia,  and  to  lead  poisoning  i? 
attributed  the  selective  action  upon  the  nerves  which  supply 
the  extensor  muscles  of  the  forearm,  producing  wrist-drop, 
and  also  an  action  on  the  brain  (encephalitic  saturninia). 
The  aflection  known  as  pellegra  is  characterized  by  degen- 
erative changes  in  the  spinal  cord  and  in  the  brain  and  by 
cutaneous  lesions.  The  special  action  upon  the  nervous 
system  produced  by  ergot  poiaonina  is  also  mentioned. 
Under  2  headings  he  then  considers  the  poisons  elaborated 
within  the  body ;  (1)  from  perverted  unctions  of  organs  or 
tissues,  and  (2)  by  microorganisms.     Under  the  first  group  he 


calls  attention  to  the  nervous  derangements  due  to  uremia, 
to  exophthalmic  goiter,  to  toxic  substances  formed  and 
absorbed  during  digestion,  to  cholemia,  to  diabetes  and  to 
pernicious  anemia.  Under  the  second  group  he  mentions 
that  delirium  occurs  in  many  of  the  acute  infectious  diseases, 
and  also  that  the  peculiar  selective  action  of  the  toxin  of 
rabies  and  tetanus  is  striking.  When  tetanus  toxin  is  mixed 
with  an  emulsion  of  nervous  matter  it  loses  its  poisonous 
properties.  He  further  refers  to  the  neurotoxin  of  diph- 
theria and  the  depressive  action  upon  the  nervous  system 
produced  by  influenza.  Finally  he  calls  attention  to  the 
virus  of  syphilis  as  being  responsible  for  many  nervous  dis- 
eases, particularly  locomotor  ataxy  and  general  paralysis  of 
the  insane.  He  cites  the  Argyll- Robertson  pupil  as  being  an 
example  of  the  selective  action  produced  by  the  virus  of 
syphilis.  The  few  manifestations  of  s3rphLlitic  infection  in 
married  women  who  give  birth  to  syphilitic  children,  he 
believes  is  to  be  explained  upon  the  ground  of  spermatic  in- 
fection of  the  ovum  from  the  syphilized  father  and  that  the 
gradual  absorption  of  toxin  from  the  fetus  by  the  mother 
renders  her  immune,    [fjk] 

2. — Atkinson,  in  a  lecture  on  plag^ae,  calls  attention  to 
the  sudden  onset  of  the  disease,  marked  by  chill,  fever,  great 
prostration,  intense  pain  in  the  region  where  the  bubo 
appears,  and  occasionally  delirium.  These  early  symptoms 
are  soon  followed  by  headache,  thirst,  vomiting,  diarrhea, 
and  depression.  The  tongue  is  swollen  and  coat«i,  the  skin 
is  dry,  and  the  conjunctivae  are  injected.  During  the  first 
5  days  the  buboes  appear;  the  temperature  range  is  high 
during  the  first  stage,  which  lasts  from  6  to  10  days.  It  then 
falls  to  normal  and,  with  suppuration,  there  is  a  secondary 
rise.  Carbuncular  afl^ections  and  petechia  are  common. 
Buboes  are  of  large  siz?  in  73%  of  the  cases,  and  small  in  the 
remaining  27  % .  In  90%  suppuration  develops.  The  groin, 
axilla,  neck,  and  the  submaxillary  region  are  the  most 
common  seats  for  the  buboes.  The  most  important 
symptoms  referable  to  the  digestive  tract  are  loss  of  appe- 
tite, vomiting,  and  diarrhea.  The  tongue  is  dry  and 
coated,  there  are  no  important  respiratory  symptoms  in 
the  bubonic  variety.  The  heart  shows  the  signs  of  a 
myocarditis,  and  in  95%  of  the  cases  in  the  epidemic  of 
1896  albumin  was  found  in  the  urine.  Sleepleesnees, 
muscular  twitchings,  deafness  and  delirium  and  coma  are 
common  nervous  symptoms.  He  states  that  amongst  the 
Chinese  the  mortality  is  90%.  The  mortality  of  those 
treated  in  hospitals  varies  from  73%  to  S8%.  In  the  Eiro- 
peana  it  was  between  40%  and  50%.  Early  in  an  epidemic 
the  dsath-rate  is  higher  than  towards  the  close.  The  impor- 
tant pathological  changes  are  swelling  and  suppuration  in 
and  about  many  of  the  superficial  lymphatic  glands,  hemor- 
rhages into  the  skin  and  other  parts  of  the  body,  enlargement 
of  the  spleen  and  inflammatory  changes  in  the  cerebro- spinal 
membranes,  kidneys,  liver  and  heart.  He  mentions  3  vari- 
eties of  the  disease:  (1)  The  bubonic,  which  is  the  most 
common  form  and  comprises  about  70%  of  all  cases.  In 
this  variety  the  infection  is  through  the  skin  ;  (2)  the  pneu- 
monic, a  more  fatal  form  and  occurs  without  external 
buboes.  The  portal  of  infection  being  through  the  respir- 
atory tract;  (3)  the  gastrointestinal  variety  which  is  also 
very  fatal.  He  states  that  the  bacillus  has  been  found 
in  great  numbers  in  the  buboes  and  spleen,  and  also 
in  the  lymphatic  gland,  heart,  lungs,  liver,  kidneys,  walls 
of  the  stomach,  in  the  feces,  vomit,  saliva,  urine  and  in 
the  blood.  The  microorganism  has  ever  been  found  in  the 
blood  corpuscle.  He  gives  the  sizs  of  the  bicillus  as  1  m  in 
length  and  3  ;« in  breadth.  It  decolorizes  by  Gram's  method, 
and  stains  with  the  ordinary  basic  anilin  dye^.  In  the  stained 
preparation  it  shows  the  characteristic  polar  appearance. 
Tne  bacillus  is  motile  and  is  best  cultivated  at  a  temperature 
of  37^  0  ,  but  it  will  grow  at  a  temperature  as  low  as  23°  C. 
The  diplococ^us  of  pneumonia  and  the  streptococcus  wifl  not 
mrive  at  a  low  temperature,  so  that  this  fact  is  of  value  in 
the  isolation  of  the  Bicillus  pestis  from  the  sputum.  The 
microscopical  examination  of  the  blood  in  276  cases  showed 
the  presence  of  the  plague  bacillus  in  221  instances.  If  the 
microorganism  is  not  found  by  microscopical  examination  of 
the  blood,  inoculation  experiments  into  susceptible  animals 
and  upon  artificial  culture  media  should  be  tried.  The  diag- 
nosis of  plague  is  as  a  rule  easy.  It  is  difl"erentiated  from  en- 
teric lever,  particularly  by  a  sudden  onset.  Typhus  fever  runs 
a  shorter  course.  The  disease  is  spread  by  means  of  the  con- 


Fbbbuaey  16,  1901] 


THE  LATEST  LITERATURE 


rCHB  Philadelphia 
MiftDicAL  Journal 


333 


taminated  discharges  from  the  patient  and  is  carried  by  such 
animals  as  mice,  rats  and  pigs.  It  is  not  probable  that  the 
bacillus  is  conveyed  through  the  air,  as  sunlight  in  a  very 
short  while  kills  the  microorganism.  The  germ  may  gain 
entrance  into  the  body  through  the  skin,  the  respiratory 
tract  and  the  gastrointestinal  tract.  In  order  to  prevent  the 
extension  of  the  disease  strict  hygienic  regulations  should  be 
enforced  by  medical  health  officers  and  inspectors  of  the 
local  government  boards.  Any  person  coming  in  contact 
with  a  person  affected  by  this  disease  should  be  placed  in 
quarantine  for  at  least  10  days.  Careful  disinfection  and  the 
burning  of  the  dejecta  should  be  strictly  enforced.  All 
meat  should  be  inspected.  All  rats  should  be  destroyed,  as 
they  seem  to  carry  the  infection.  The  methods  of  personal 
hygiene  should  also  be  rigidly  followed,  especially  the  care  of 
the  skin.  Food  should  be  well  cooked  and  the  water  boiled. 
He  concludes  his  article  by  giving  the  measures  adopted  in 
Hong  Kon?  for  checking  the  disease,     [f.j.k.] 

3.— Parkes  and  Rideal  suggest  a  method  of  preventing 
water-borne  enteric  fever  amongst  armies  in  the  field 
by  means  of  weak  solutions  of  sodium  bisulphate  which  are 
to  be  used  as  drinking  water.  After  a  number  of  experiments 
with  different  substances,  the  authors  conclude  that  sodium 
bisulphate  is  best  suited  for  the  purpose,  and  they  recom- 
mend a  tabloid  of  5  grains  to  be  placed  in  a  cupful  of  water. 
The  solution  should  be  allowed  to  stand  for  15  minutes  before 
drinking.  The  acid  tabloids  render  the  water  more  palatable 
and  aid  in  slaking  thirst.  Three  hundred  and  fifty  tabloids 
weigh  about  a  quarter  of  a  pound,  and  these  are  sufficient  to 
sterilize  over  100  pints  of  water.  These  tabloids  may  also  be 
used  as  thirst  lozenges,     [f  j  k  ] 

4. — Parker  discusses  acquired  syphilis  of  the  nose  and 
pharynx.  He  states  that  primary  syphilis  of  the  nose  is  very 
rare.  The  common  seat  of  the  primary  sore  is  generally  on 
the  ala  or  just  within  the  vestibule.  The  manifestations  of 
secondary  syphilis  of  the  nose  are  coryza,  mucous  patches, 
rhinitis  erythematosa,  and  rhinitis  papulosa  and  superficial 
ulceration.  Tertiary  manifestations  of  the  nose  are  quite 
common.  They  are  gummata,  superficial  ulceration,  deep 
ulceration  and  necrosis,  and  scars  and  deformity.  The  com- 
plications of  tertiary  syphilis  of  the  nose  are  catarrhal  otitis, 
purulent  otitis,  deafness,  pharyngitis,  and  laryngitis  sicca, 
perforation  of  the  hard  palate,  and  cerebral  diseases.  He 
then  mentions  the  diaenosis  of  syphilis  of  the  nose  and  out- 
lines the  treatment.  He  states  that  primary  syphilis  of  the 
pharynx  is  fairly  common  and  the  most  frequent  seat  being 
upon  the  tonsil.  He  mentions  that  Seifert  collected  179  cases 
of  chancre  of  the  pharynx.  He  states  that  the  manifestations 
of  the  secondary  syphilis  of  the  pharynx  are  erythema,  mu- 
cous patches,  and  superficial  ulceration,  and  that  the  tertiary 
lesions  are  gummata,  ulcerations,  scars,  and  deformities.  In 
discussing  the  treatment  of  syphilis  of  the  nose  and  pharynx 
he  states  that  mercury  should  be  given  in  the  primary  and 
secondary  stages  of  the  disease,  and  that  a  combination  of 
iodid  of  potassium  and  mercury  gives  the  best  results  in  the 
tertiary  stage,    [f  j  k  ] 

6, — Milton  reports  a  very  interesting  operation  for  the 
removal  of  a  foreign  body  lodged  in  the  right  bronchus. 
The  patient,  a  man,  40  years  of  age,  had  some  years  pre- 
viously had  a  tracheotomy  done  for  syphilitic  stenosis  of  the 
larynx,  since  when  he  had  always  worn  a  tube.  A  short 
time  before  admission  the  inner  portion  of  the  tube  became 
detached  and  passed  down  the  trachea.  The  tube  could  be 
felt  with  a  probe  through  the  tracheotomy  wound,  but  could 
not  be  seen.  Several  unsuccessful  attempts  were  made  to 
remove  the  tube  with  hooks,  forceps,  coin-catchers,  etc.  It 
was  finally  determined  that  the  only  way  to  remove  the  tube 
was  by  means  of  a  thoracic  section.  Milton  had  on  a  pre- 
vious occasion  removed  a  tubercular  tumor  from  the  anterior 
mediastinum,  and  determined  to  approach  the  bronchus  in 
the  same  manner.  An  incision  was  made  from  the  trache- 
otomy wound  to  the  ensiform  cartilage.  The  sternum  was  di- 
vided with  as  iw,  after  separation  of  the  tissues  beneath  it  with 
the  fiager,  and  the  edges  forcibly  separated  with  strong  re- 
tractors. An  incision  2  cm.  long  was  made  in  the  anterior 
wall  of  the  trachea,  just  above  the  bifurcation.  This  was 
followed  by  a  flow  of  bad-smelling,  frothy  mucus.  The  tube 
had  caused  considerable  ulceration  of  the  bronchus,  but  was 
removed  without  much  difficulty.  There  was  little  hemor- 
rhage and  no  interference  with  circulation  and  respiration. 
The  bronchial  wound  was  closed  with  considerable  difficulty. 


and  a  gauze  drain  allowed  to  pass  from  it  through  the  wound 
in  the  sternum.  Excepting  for  the  point  of  drainage,  the 
external  wound  was  closed  throughout.  The  split  sternum 
was  not  sutured.  The  patient  suffered  no  shock  during  or 
after  the  operation.  For  the  first  24  hours  the  patient  was 
entirely  comfortable,  but  there  was  some  rise  of  temperature. 
The  gauze  drain  was  removed  with  considerable  diffiaulty, 
and  was  followed  by  a  flow  of  fetid  fluid.  Tnere  were  pres- 
ent moist  rales  in  both  lungs,  and  respiration  was  increased 
in  frequency.  The  patient  died  on  the  third  day,  tempera- 
ture 102,  apparently  from  heart-failure.  Postmortem  exami- 
nation showed  anterior  mediastinum  to  be  the  seat  of  an 
acute  septic  condition,  and  both  lungs  showed  a  begin- 
ning pneumonia.  The  pericardium,  pleura,  and  great 
vessels  showed  no  lesion.  There  were  two  pressure-ulcers  of 
the  right  bronchus.  Milton  thinks  that  death  was  due  to 
acute  septicemia.  In  discussing  the  case  he  says  that  he 
thinks  that  the  closure  of  the  bronchial  wound  was  a  mis- 
take, and  that  if  performing  the  operation  again  he  would 
leave  an  opening  through  the  body  of  the  sternum  for  the 
purpose  of  drainage,  and  close  the  slit  in  the  rest  of  the  bone 
with  silver  sutures.  He  remarks  on  the  absence  of  shock  in 
both  of  his  cases.  He  thinks  there  is  little  risk  of  hemor- 
rhage when  an  ordinary  amount  of  care  is  taken.  He  thinks 
the  only  real  danger  in  the  operation  is  sepsis.  Where 
asepsis  can  be  absolutely  assured,  complete  immediate 
closure  of  the  thorax  would  be  indicated.  Drainage  can  be 
accomplished  through  the  sternum,  upwards  through  the 
neck,  or  bick wards  through  the  middle  and  posterior  medi- 
astinum. The  backward  drainage  is  not  as  difficult  as  it 
seems  at  first  sight.  Although  the  method  of  drainage  must 
vary  with  each  case,  Milton  thinks  the  anterior  route  through 
the  sternum  to  be  the  best,     [j.h  g.] 

6.— Fisher  reports  a  case  of  extensive  deposit  of 
phosphate  of  lime  in  the  lungs.  Tne  patient,  32  years 
of  age,  was  admitted  into  the  Bristol  Royal  Infirmary  suffer- 
ing from  pneumonia,  and  died  upon  the  day  of  admission. 
The  autopsy  revealed  complete  consolidation  of  the  right 
lung  and  partial  consolidation  of  the  lower  left  lung.  The 
pneumonia  was  in  the  stage  of  red  hepatization.  Scattered 
throughout  the  right  and  the  left  lung  were  numerous 
granules  about  the  siza  of  grains  of  sand.  These  small  masses 
were  very  dense.  A  chemical  examination  of  these  bodies 
showed  that  they  were  made  up  of  75%  of  phosphate  of  lime. 
Microscopiial  examination  showed  that  they  were  situated  in 
the  walls  of  the  alveoli  and  that  they  were  composed  of  concen- 
tric layers.  The  nodules  were  not  connected  with  any  of  the 
surrounding  bloodvessels.  The  authors  conclude  that  these 
bodies  were  due  to  amyloid  deposits  with  secondiry  infiltra- 
tion of  phaaphate  of  lime,    [f.j.k.] 

7.— D  )uthwaite  reports  a  case  of  poisoning  by  coal-tar 
naphtha  in  a  girl  5  years  of  age.  Between  2  and  3  ouuces 
of  the  liquid  were  taken.  Shortly  after  the  ingestion  of  the 
poison  the  patient  was  in  an  almost  complete  comatose  con- 
dition, the  respirations  were  hurried,  there  was  a  heavy  ben- 
zine-like odor  to  the  breath,  the  face  was  somewhat  livid, 
the  skin  cold  and  clammy,  the  pupils  were  dilated,  and  the 
pulse  was  rapid  and  feeble.  Tne  treatment  consisted  in  the 
use  of  artificial  respiration,  hypodermis  injection  of  brandy 
and  the  administration  ot  common  salt  as  an  emetic.  The 
patient  finally  recovered  from  the  poisoning,  but  succumbed 
to  an  acute  attack  of  bronchitis  some  days  after,     [f  j.k.J 

8.— A  case  of  anthrax  is  reported  by  Kidd  in  a  man  27 
years  of  age.  The  infection  was  probably  conveyed  through 
the  handling  of  hides.  The  lesion  was  situated  on  the  neck 
and  followed  a  crop  of  boils.  The  clinical  manifestitions  of 
anthrax  infection  were  very  well  marked,  although  a  basteri- 
ological  examination  was  not  made.  The  local  treatment 
consisted  in  making  free  incision  into  the  inflammatory  area. 
He  states  that  the  patient  passed  through  a  severe  illness  and 
finally  made  a  good  recovery,    [f  j  k  ] 

9.— Heaton  reports  a  remarkable  tolerance  for 
arsenic  in  a  case  of  splenoraeduUary  leukemia.  Tne  drug 
was  administered  in  the  form  of  arsenious  acid  and  arseniate 
of  soda.  Daring  a  period  of  271  days,  including  intermissions 
of  58  days,  5i  grains  of  arsenious  acid  and  10)  grains  of 
arseniate  of  soda  were  administered  hypodermically.  For 
a  while  the  treatment  had  a  beneficial  effect  upon  the  blood. 
[fjk.]  ....  , 

10.— B'ake  gives  a  report  of  35  prophylactic  injections  of 
antidiphtheritic  serum.      These  prophylactic  measures  were 


334 


The  PHILADKLPHLi"! 

Medicai.  Jodbhal  J 


THE  LATEST  LITERATURE 


[Fkbbcabt  16,  ISO) 


instituted  after  3  cases  of  diphtheria  developed  in  the  Sun- 
trap  Convalescent  Children's  Home,  High  Beach,  Essex,  Eng- 
land. The  cases  of  diphtheria  were  immediately  isolated 
and  the  remaining  35  children  were  treated  with  the  prophy- 
lactic injections.  No  other  cases  of  diphtheria  developed. 
[f.jk.] 

New  York  Medical  Journal. 

February  9,  1901.     [Vol.  Ixiiii,  No.  6  ] 

1.  A  Case  of  Gastrointestinal  Hemorrhage  Caused  by  Fatty 

Degeneration   of  the  Right  Ventricle  of  the  Heart. 
Charles  Phelps. 

2.  A  Clinical  Analysis  of  Digitalis  and  Its  Preparation,  Call- 

ing Special  Attention  to  the  Glucosides  and  More 
Especially  to  Digitoxin.    Leon  L.  Solomon. 

3.  Amebic  Abscesses  of  the  Liver,  with  a  Report  of  Four 

Cases.    C.  R.  Daenall. 

4.  Autointoxication    from    Renal   Insufficiency,  With    and 

Without  Diseased  Kidneys ;  With  Reports  of  Some 
Remarkable  Cases.    James  T.  Jelks. 

5.  Intestinal  Obstruction.    Louis  A.  Hering. 

6.  Some  Remarks  on  Epidural  Hemorrhage,  Without  Frac- 

ture of  the  Skull,  and  Report  of  a  Case.    J.  Shelton 

HOESLEY. 

7.  The  Closure  of  Cutaneous  Wounds  Without  Suture.  How- 

ard LlLLENTHAL. 

8.  Tracheal  Injections  in  the  Treatment  of  Pulmonary  Tuber- 

culosis.   T.  Morris  Murray. 

!■— Charles  Phelps  reports  a  case  of  gastrointestinal 
hemorrhage  caused  by  fatty  degeneration  of  the  right 
ventricle  of  the  heart.  The  patient,  a  man  of  58  years,  tiad 
accumulated  much  abdominal  adipose  tissue  and  had  ac- 
quired a  small  umbilical  hernia.  He  had  suflered  from  no 
other  ailment  than  gout  and  indigestion.  The  operation  upon 
the  hernia  was  simple  and  without  incident  save  that  the 
anesthetics  were  badly  borne.  His  general  cDndition  follow- 
ing the  operation  was  poor,  and  on  the  afternoon  of  the 
fourth  day  he  died,  soon  after  a  large,  gastric  hemorrhage. 
Postmortem :  The  liver  was  found  to  be  slightly  enlarged 
with  considerable  fatty  infiltration.  There  was  a  less  decided 
cortical  atrophy  due  to  chronic  passive  digestion.  Eado- 
arteritis  of  the  small  branches  of  the  hepatic  artery  was 
found.  There  was  also  a  moderate  degree  of  chronic  inter- 
stitial nephritis.  The  lurgs  were  small  and  nearly  bloodless, 
but  otherwise  of  normal  appearance.  The  heart  was  of 
normal  size,  its  right  ventricle  was  covered  with  a  layer  of 
fat,  at  least  J  inch  in  thickness,  and  the  wall  of  this  ventricle 
was  thin  as  paper,  and  almost  pultaceous  in  character.  The 
left  side  of  the  heart  was  less  encumbered  by  fatty  deposits 
and  it  suflered  less  fatty  degeneration  of  its  fiber.  The  cir- 
rhotic disease  of  the  liver  had  not  advanced  sufficiently  to 
account  for  the  fatal  gastrointestinal  hemorrhage,  but  the 
condition  of  the  heart  seemed  to  aflbrd  explanation.  The 
blood  accumulated  in  the  right  side  of  the  heart,  and,  sec 
ondarily,  in  the  inferior  vena  cava  and  portal  system  until 
the  overdistended  gastrointestinal  vessels  finally  gave  way. 
[t.l.c] 

_2. — Leon  L.  Solomon  presents  a  clinical  analj  sis  of 
digitalis  and  its  preparations,  calling  especial  atten- 
tion to  the  glucosides  and  more  especially  to  digitoxin. 
Digitoxin  has  been  especially  recommended  in  chronic 
myocarditis  and  in  cases  of  ruptured  compensation.  He 
recoinmends  a  solution  of  digitoxin  to  which  a  little  chloro- 
form is  added  to  prevent  its  precipitation  and  has  found  the 
following  combination  to  be  of  great  service.  Digitoxin  ji^^ 
grain,  chloroform  1 J  minims,  and  alcohol  (at  90%)  23  minims. 
Water  sufficient  to  make  half  an  ounce,     [t.l  c] 

4.— Jelks  reports  24  cases  of  autointoxication  from 
renal  insufficiency,  with  and  without  diseased  kidnevs. 
The  patients  suflfering  from  renal  insufficiency  die,  usually, 
not  from  the  nephritis  but  from  the  cardiac  complicAtions. 
Hence,  the  main  indications  for  treatment  are  connected  with 
the  heart.  Conditions  of  high  tension  and  overaction  should 
be  met  with  nitroglycerin,  opium,  chloral  hydrate  or  iodide  of 
sodium.  If  dilatation  of  the  heart  is  threatened,  digitaUs  in- 
liision  or  digitalin  should  be  prescribed  with  rest  in  bed.  In 
using  digitalin,  Jelks  prefers  the  German  Merck  digitalin  in 
preference  to  the  American  or  French.    He  administers  this 


remedy  in  doses  from  1*5  of  a  grain  to  i  of  a  grain  3  or  4 
times  a  day.     [t.l.c] 

6.— Hering  first  discusses  the  various  sites  of  intestinal  ob- 
struction and  the  causes  of  this  condition.  In  his  experience 
chronic  constipation  with  fecal  impaction  is  the  most  com- 
mon cause.  The  most  frequent  site  of  the  impaction  '\i  the 
descending  colon.  The  symptoms  of  intestinal  obstruction 
are  next  enumerated  and  discussed.  Prophylaxis  is  best  ao- 
complished  by  preventing  or  overcoming  constipation.  For 
this  purpose  he  not  only  recommends  medicine  and  diet,  but 
particularly  massage  and  exercise.  The  operative  treat- 
ment should  be  instituted  promptly  if  the  use  of  high  ene- 
mata  has  proved  unsuccessful.  The  administration  of  purga- 
tives, particularly  in  cases  of  intussusception,  is  questionable 
treatment.  The  various  methods  of  intestinal  and  anasto- 
mosis are  then  dealt  with.  Aft^r  operation  measures  to 
move  the  bowel  are  not  to  be  instituted  until  the  third  day. 

[j  H.G.] 

6. — Horsley  reports  a  very  typical  case  of  meningeal 
hemorrhage  in  which  operation  gave  immediate  relief  The 
patient  was  a  man  22  years  of  age,  who  was  struck  on  the 
head  with  a  wooden  club.  He  was  unconscious  for  a  shoit 
time  after  the  injury,  but  regained  consciousness  and  felt  per- 
fectly well  until  several  hours  later,  when  he  again  became 
unconscious,  developing  complete  hemiplegia.  Twenty-four 
hours  after  the  injury  Horsley  removed  a  large  epidural  clot 
and  instituted  drainage.  The  next  day  the  patient  was  con- 
scious and  had  an  uninterrupted  convalescence,    [j.h.g  ] 

7. — Lilienthal,  after  discussing  infection  of  wounds  from 
skin  sutures,  recommends  a  method  of  wound  closure  which 
he  has  employed  in  hospital  and  private  practice  with  uni- 
form success  for  3  years.  The  deeper  portions  of  the  wound 
are  closed  with  subcutaneous  sutures  and  the  ekin  is  then 
brought  together  by  means  of  narrow  strips  of  sterilized  zinc- 
rubber  plaster.  This  method  has  resulted  in  aseptic  heahng 
in  all  wounds  and  gives  a  resulting  scar  such  as  follows  the 
use  of  the  subcuticular  suture  without  any  of  the  drawbacks 
of  the  latter,    [j.h.g.] 

8. — Murray  recommends  an  intratracheal  injection 
composed  of  essence  of  thyme,  essence  of  eucalyptus,  es- 
sence of  cinnamon,  of  each  5  grams;  sterilized  olive  oil.  100 
ccm.  This  is  the  solution  recommended  by  Mundell,  of 
Roubaix.  Murray's  results  have  confirmed  Mundell's  to 
some  extent.  He  injects  3  ccm.  3  or  4  times  consecutively. 
The  method  of  administering  intratracheal  irjection  is  sim- 
ple. The  curved  canula  of  the  syringe  is  parsed  between 
the  vocal  cords  and  the  fluid  is  slowly  injected  into  the  tra- 
chea. He  employs  the  Schadel  syringe.  The  usual  effect, 
in  a  majority  of  the  cases,  is  a  slight  explosive  cough.  He 
has  not  observed  a  single  instance  of  glottic  spasm  follow 
even  the  first  injection.  Out  of  13  cases  treated  during  the 
past  7  months,  10  have  been  benefited  decidedly,  the  cough 
and  expectoration  had  been  lessened  and  the  temperature 
lowered.  This  improvement  is  the  more  noteworthy  because 
the  patients  were  very  poor,  not  in  the  hospital,  and  were 
under  the  mojt  unfavorable  surroundings.     [t.l.c  ] 


Medical  Record. 

February  9,  1901.     [Vol.  59,  No.  6.] 

1.  Summary  of  the  Progress  Made  in  the  Nineteenth  Cen- 

tury in  the  Study  of  the  Propagation  of  Yellow  Fever. 
Charles  Finlay. 

2.  Investigations  upon  Corporeal  Specific  Gravity,  and  upon 

the  Value  of  this  Factor  in  Pnysical  Diagnosis.    Hkin- 
EicH  Stern. 

3.  The  Use  of  the  Aqueous  Extract  of  the  Suprarenal  Cap- 

sule as  a  Hemostatic.    W.  H.  Bates. 

4.  The  Clinical  Significance  of  Dulness  in  Appendicitis.    H. 

T.  MtLLER. 

1. — Will  be  treated  editorially. 

2. — Stern  reports  the  result  of  a  series  of  investigations 
on  corporeal  specific  gravity  and  upon  the  value  of 
this  factor  in  physical  diagnosis.  The  determination  of 
the  absolute  weight  of  an  individual  is  an  important  factor 
to  the  physician  and  medical  examiner  in  general.  Fre- 
quently, however,  the  absolute  body  weight  dee?  not  reflect 
tne  real  physical  condition  of  the  organism.  This  is  espe- 
cially important  in  recognition  of  the  fact  that  light  or  heavy 


i 


FSBBUABT    16,    1901] 


THE  LATEST  LITERATURE 


[Thk  Philadelphia 
Medical  Journal 


335 


people  need  not  necessarily  be  afflicted  with  a  wasting  dif« 
ease  or  witli  obesity.  The  specific  weight  of  an  individual 
and  the  density  of  his  structures  have  been  assigned  too 
insignificant  a  role  in  medical  diagnosis  and  therapy.  It  is 
the  density  of  the  organism  and  its  tissues  and  not  its  abso- 
lute weight  which  discloses  with  an  almost  absolute  degree 
of  certainty  its  soundness  as  well  as  a  variety  of  morbid 
conditions.  Stern  describes  his  method  for  the  determina- 
tion of  the  corporeal  specific  gravity  for  which  the  reader 
is  referred  to  his  paper.  The  tabulated  results  of  the  speci- 
fic gravity  of  certain  parts  of  the  body  are  given.  The 
writer  concludes  that  after  the  second  week  of  life,  the 
density  which  is  highest  (1  066)  soon  after  birth  declines  to 
1.048  in  boys  and  1  050  in  girls,  to  remain  at  this  minimum 
until  the  close  of  the  second  year.  Thereafter  a  slow  but 
steady  rise  sets  in,  which  culminates  in  the  male  between  the 
twenty  fifth  and  forty- fifth  year,  and  in  the  female  after  the 
menopause.  In  the  advanced  period  of  life,  the  blood  density 
in  both  sexes  is  raised  once  more,  it  thus  contains  towards 
the  close  of  life  a  similar  degree  of  concentration  as  at  the 
time  of  birth.  The  information  furnished  by  the  body 
density  of  an  individual  will  assist  us  in  determining  certain 
questions.  Among  these  are  :  Body  soundness,  body  immu- 
nity, and  probable  duration  of  life,    [t  l.c] 

3, — W.  H  Bates,  of  New  York,  emphasizes  some  facts  as 
to  the  value  of  suprarenal  substance  as  a  hemostatic. 
He  believes  after  6  years'  experience  in  its  employment  that 
it  is  the  most  powerful  known  astringent  and  hemostatic. 
Satisfactory  results  will  be  obtained  with  a  freshly  prepared 
mixture  of  one  part  of  the  dried  and  powdered  gland,  and  10 
parts  of  water.  For  the  use  in  the  eye  or  ear  the  emulsion 
should  be  filtered.  Sterilization  by  heat  will  not  altsr  its 
efficiency.  The  mixture  when  used  locally  will  always 
control  hemorrhage  from  mucous  membranes.  The  internal 
use  of  the  extract  as  a  hemostatic  is  efficient  in  some  cases. 
Another  important  factor  is  that  suprarenal  extract  when  it 
controls  hemorrhage  locally,  or  after  internal  administration, 
does  so  in  less  than  one  minute,     [t.l.c  J 

4. — H.  T.  Miller  believes  that  sufficient  stress  has  not  been 
placed  upon  the  point  of  dulness  in  appendicitis. 
In  every  instance  in  his  experience  in  which  he  has  relied 
upon  this  symptom  he  has  been  led  to  a  correct  conclusion. 
In  cases  without  any  pronounced  inflammatory  symptoms, 
and  in  which  the  dulness  was  marked,  he  found  the  appendix 
indurated  and  adherent  to  the  adjacent  tissue.  Nineteen 
cases  are  briefly  reported.  In  every  instance  in  which  dul- 
ness was  present,  pus  was  diagnosed,  and  this  was  verified 
either  by  operation,  or  by  autopsy,  with  the  exception  of  2 
cases  of  his  series,    [t.l  c] 


Medical  News. 

February  9, 1901.    [Vol.  Ixxviii,  No.  6.] 

1.  Some  Unusual  Cases  of  Infectious  Diseases — A  Clinical 

Report.    Delancey  Rochester. 

2.  Remarks  upon  the  Constructicn  of  Amputation- stumps, 

with  a  Report  of  Two  Cases  of  Amputation  by  the 
Osteoplastic  Method  of  Bier.  Alexis  V.  Moschcjwitz. 

3.  Parasites  in  the  Blood.    Leon  T.  LeWald. 

4.  General  Remarks  on  the  Combination  of  Ether  (57  parts) 

and  Chloroform  (43  parts),  Known  as  the  M.  S.  Mix- 
ture.   Edward  Adams. 

5.  A  Report  of   some  Cases  of  Abdominal  Surgery,  with 

Remarks  on  the  Diagnosis  of  Carcinoma  of  the  Cecum 
and  the  Surgical  Treatment  of  Carcinoma  of  the  Liver 
and  the  Gallbladder.    Charles  Greene  Cumston. 

1. — DeLancey  Rochester  presents  a  clinical  report  of  six 
unusual  cases.  The  first,  in  which  a  child  had  a  slight  rhinitis 
with  a  pulse  of  80  and  a  temperature  of  100°.  He  was  also 
suffering  from  a  sore  throat  which  had  come  on  about  mid- 
night of  the  day  before.  Rochester  makes  a  practice  of 
taking  cultures  of  sore  throat,  and  did  so  in  this  case  as  a 
routine  matter.  A  report  was  received  that  a  pure  culture 
of  the  Klebs-Loffler  bacillus  was  found.  Antitoxin 
was  at  once  administered,  although  there  was  no  exudate 
visible,  and  the  constitutional  disturbance  was  not  great. 
Twelve  hours  after  the  antitoxin  was  given  he  discharged  two 

Eieces  of  membrane  from  his  nose.    Twenty-four  hours  later 
e  appeared  better,  but  36  hours  afterward  both  tonsils  of  the 


pharynx  were  covered  with  membranous  exudate,  and 

there  was  a  rise  of  temperature  to  101.5°.  His  second  case 
was  somewhat  similar  in  the  throat  symptoms  and  the  bao- 
teriologic  report.  However,  in  this  case  a  croupous  pneu- 
monia developed,  and  pneumococci  were  found  in  the 
sputum  in  pure  culture.  Antitoxin  was  administered  in  this 
case  early  and  in  large  doses.  These  two  cases  are  interests 
ing  as  showing  the  value  of  making  pure  cultures  from  all 
cases  of  sore  throat.  The  second,  particularly,  illustrates 
the  importance  of  using  all  methods  of  diagnosis,  and  the 
possibility  of  synchronous  infection  with  two  virulent 
microorganisms.  Had  it  not  been  for  the  discovery  of 
the  pneumococcusthe  second  case  might  have  been  regarded 
as  a  pneumonia  of  diphtheritic  origin.  His  last  three 
cases  are  those  of  scarlatina  without  eruption.  In 
Case  3  the  child  had  come  home  from  school  sick,  had 
vomited  and  was  complaining  of  headache.  His  temperature 
was  102  6°,  his  pulse  120,  respiration  28.  There  was  a  marked 
bronchitis  and  a  few  patches  of  pneumonic  involve- 
ment at  the  base  of  both  lungs.  Calomel  was  ordered,  the 
chest  was  cupped,  and  hot  foot-baths  given  every  two  hours. 
The  next  morning  the  nurse  called  attention  to  the  fact  that 
during  the  foot-baths  the  child  became  very  red,  but  when 
seen  there  was  no  rash  on  the  body  and  the  tongue  and  throat 
showed  no  evidences  of  scarlet  fever.  In  5  days  the  child 
had  completely  recovered.  In  Cases  4  and  5  the  patients 
were  two  little  brothers  with  very  slight  febrile  symptoms, 
their  throats  were  not  sore,  but  there  was  a  peculiar  mottling 
of  the  skin,  and  they  both  had  vomited.  Eighteen  days  after 
the  first  child  was  taken  sick,  both  he  and  his  brother  ap- 
peared well  and  were  vaccinated.  The  writer  noticed  at  this 
time  that  his  fingers  were  desquamating  a  little,  and  the 
diagnosis  of  scarlet  fever  was  made.  This  doubt  was 
settled  by  an  older  brother  being  taken  ill  in  a  few  days  with 
a  frank  case  of  scarlet  fever.  His  sixth  case  suffered 
from  two  attacks  of  scarlet  fever ;  the  second  occurring 
late  in  the  period  of  desquamation  of  the  first  attack. 
Several  physicians  saw  the  child  during  both  periods  of 
eruption,    [tlc] 

2. — According  to  Moechcowilz  every  amputation- 
stump  should  respond  to  the  following  requirements :  1. 
It  must  be  able  to  support  the  weight  of  the  body.  2  It  must 
be  painless.  3.  It  must  be  no  more  liable  to  local  disease 
than  any  other  portion  of  the  body.  4  It  must  disfigure  its 
owner,  as  is  commensurate  with  the  nature  of  the  ailment. 
He  then  describes  the  technic  of  amputation  of  the  leg  which 
he  uses  as  a  prototype,  all  the  amputations  being  merely 
slight  modifications,  which  can  be  readily  adapted  to  the 
special  limbs  to  be  amputated,    [w.a.n.d.] 

4.— Edward  Adams,  of  New  York,  concludes  that  the 
chief  advantages  of  the  M.  S.  mixture  (the  combination  of 
ether  and  chloroform)  are  the  following:  1.  The  stage  of 
excitement  and  struggling  are  not  marked.  2.  It  requires  a 
short  time  to  get  a  patient  under,— 5  or  10  minutes.  3.  Very 
little  of  the  anesthetic  is  required— on  an  average  about 
40  cc.  are  used  an  hour.  4.  It  is  a  comparatively  safe  anes- 
thetic. 5.  It  is  very  pleasant  to  take.  6.  The  after-effects 
are  not  marked.  7.  Patients  recover  quickly.  8.  It  can  be 
used  in  nearly  every  condition  in  which  either  chloroform  or 
ether  is  employed,     [t.l  c  ] 

6.— Cumston  gives  a  "potpourri"  of  various  surgical 
cases,  illustrating  abdominal  conditions,  especially  those 
connected  with  the  cecum,  liver,  and  gallbladder.  He  gives 
illustrative  cases  in  this  the  first  portion  of  the  paper,  which 
is  to  be  concluded  in  the  subsequent  number  of  the  journal. 
[w.a.n.d.] 


Boston  Medical  and  Surgical  Journal. 

FebriMry  7,  1901.    [Vol.  ciliv,  No.  6.] 

1.  Gonorrheal  Infection.    Benjamin  Tenny. 

2.  A  Bacteriological  Diagnosis  of  the  Gonococcus.    Oscar 

Richardson. 

3.  Treatment  of  Acute  Gonorrhea.    Franklin  G.  Balch. 
4   Gonorrhea  in  Women.    W.  L.  Burraqe. 

5.  Treatment  of  Chronic  Gonorrhea.    Gardner  W.  Allen. 

6.  The  Seminal  Vesicles  in  Gonorrhea.    Chas.  L.  Scoddkb. 

7.  Gonorrheal  Prostatitis.    John  Bapst  Blake. 

8.  Gonorrheal  Conjunctivitis.    Charles  H.  Wiluams. 

9.  When  is  a  Gonorrhea  Cured  ?    Paul  Thorndike. 


336 


Thb  Phii.u>slfhia'I 
Mbdioai,  Joubnai.  J 


THE  LATEST  LITERATURE 


[Febbc/lst  16,  19«1 


1. — Tenney  endorses  Guiard's  conclusion  that  every  case  of 
urethritis  that  lasts  more  than  a  few  days  is,  or  at  least  may 
have  been  at  the  start,  a  true  infection  by  the  gonococ- 
cus.  That  mild  and  transient  inflammations  of  the  urethra 
with  purulent  discharge  do  occur  in  the  course  of  acute 
fevers,  attacks  of  gout  or  articular  rheumatism,  and  are 
acquired  from  instruments  or  from  sexual  contact,  must  be 
admitted.  The  growth  of  the  organism  may  be  divided  into 
3  stages :  1.  Oq  and  in  the  epithelial  cells.  2.  In  the  sub- 
epithelial layer  and  the  leukocytes,  where  they  develop  very 
rapidly.  3,  In  the  epithelial  cells  again,  as  the  growth  of  a 
sort  of  dam  of  new  tissue  beneath  them  furnishes  a  layer 
unfavorable  to  the  development  of  the  gonococci.  The  per- 
sistence of  the  infection  is  a  matter  of  great  importance,  and 
also  a  matter  in  which  the  greatest  care  in  diagnosis  is  neces- 
sary. In  the  declining  stage,  when  pus  cells  must  be  found 
on  the  threads  or  by  sedimentation,  the  greatest  accuracy  in 
staining  by  Gram's  method  is  essential.  While  we  know  that 
this  germ  in  some  individuals  will  reproduce  itself  for  months 
and  even  years  in  some  posket  of  the  urethra,  prostate,  or 
seminal  vesicle,  it  usually  disappears  within  from  3  to  5 
months.  That  sterility  may,  and  often  does,  result  from  a 
gonorrheal  infection,  is  a  simple  and  reasonable  proposition. 
But  sterile  marriages  are  not  necessarily  sterile  because  the 
wife  has  been  infected  by  the  husband.  The  latter  may  have 
become  incapable  of  impregnating  by  the  obliteration  of  his 
seminal  canals,  and  then  have  starved  out  his  gonococci, 
before  marriage.  The  author  does  not  believe  that  in- 
fection of  a  wife  by  a  husband  who  has  had  no  visible 
discharge  for  months  is  at  all  a  common  event.  Neverthe- 
less, it  undoubtedly  has  occurred  in  some  cases,  and  it  is  a 
part  of  the  duty 'of  the  doctor  who  treats  men  with  this  dis- 
ease to  have  a  square  talk  with  every  patient,  and  fully 
explain  why  he  ought  to  make  sure  by  as  competent  exami- 
nation aa  he  can  get  that  he  is  completely  free  of  his  gono- 
cocci before  he  marries,  no  matter  when  that  may  be.  He 
refers  to  the  work  of  Christmas,  who  cultivated  gonococci  and 
thus  produced  a  poison  that  would  kill  a  guineapig  in  from 
5  to  7  hours.  From  this  toxin  an  antitoxin  was  produced. 
As  the  damage  and  discomfort  to  the  ordinary  individual 
appear  to  be  due  more  to  the  marvelous  fertility  of  the  organ- 
ism than  to  its  toxin-producing  power,  one  would  think  the 
usefulness  of  an  antigonotoxin  would  be  limited  to  the  com- 
plications of  gonorrhea  that  are  accompanied  by  constitu- 
tional symptoms.  The  author  is  of  the  opinion  that  about 
20%  of  the  males  and  5%  of  the  females  of  the  community 
may  have  become  infected  at  some  time,  but  certainly  no 
more.  The  common  impression  is  that  no  immunity  follows 
an  attack  of  gonorrhea.  Jadassohn,  however,  introduced 
pus  from  a  fresh  gonorrhea  into  6  urethrae  that  were  in  the 
chronic  stage  of  gonorrhea,  and  of  these  2  only  started  afresh. 
Without  question  gonorrhea  resembles  other  bacterial  dis- 
eases in  the  resistance  oflfered  by  different  individuals  to  its  pro- 
gress and  even  to  its  onset.  In  the  majority  of  cases  the  gono- 
cocci probably  are  confined  to  the  urethral  tissues,  while  in 
others  they  escape  by  the  blood-  or  lymph- channels  to  find 
lodgment  in  some  joint  or  tendon-sheath  or  even  in  the  heart. 
It  seems  a  reasonable  proposition  that  the  same  conditions 
that  favor  the  persistenca  of  the  disease  and  stimulate  the 
pathologic  process  should  also  favor  the  infection.  The  chief 
conditions  that  are  recognized  as  having  this  power  are  the 
use  of  even  moderate  amounts  of  alcohol,  sexual  excitement, 
a  tendency  to  gout  or  rheumatism,  and  tuberculosis.  While 
Tenny  does  not  maintain  that  alcohol  is  the  only  reason  for 
the  usual  human  susceptibility  to  this  organism,  he  does  be- 
lieve that  it  has  an  influence  that  is  too  little  recognized  at 
present     [j  m  s.] 

2. — The  important  diagnostic  point  for  the  gonococcus  is 
its  property  of  decolorizing  by  G.'am's  method.  The  other 
points  of  morphology  and  position  inside  the  leukocytes,  are 
not  necessarily  characteristic.  la  the  bacteriologic  diag- 
nosis of  urethral  inflammation  the  most  important  precau- 
tions are  :  (1)  To  smear  the  pus  on  the  cover-glass  in  a  thin 
film;  and  (2)  to  see  that  the  anilin  oil  gentian- violet  solution 
has  not  decomposed.  In  order  to  avoid  errors  in  this  regard, 
the  solution  should  not  be  more  than  2  weeks  old.  From  the 
so-called  scientific  standpoint  Richardson  does  not  consider 
the  cover-glass  examination  aa  being  conclusive.  The  results 
of  the  cover-glass  examination  must  be  controlled  by  cul- 
tures in  which  the  suspected  coccus  is  isolated  and  its  iden- 
tity proved  by  its  cultural  peculiarities.  From  the  standpoint 


of  the  pathologist,  the  chief  interest  today  attached  to  the 
gonococcus  is  the  role  it  plays  in  inflammatory  processes 
other  than  urethritis.  It  does  not  suffice  to  prove  that  a 
given  case  of  arthritis  is  due  to  infection  with  the  gonococeus 
by  showing  that  cocci  decolorized  by  Gram's  method  are  con- 
tained inside  the  pus-cells  of  the  exudate,  but  in  addition  it 
must  be  shown  that  these  cocci  will  grow  only  on  special 
culture  media  and  it  must  be  rigidly  determined  that  they 
will  not  grow  on  ordinary  culture  media.  Furthermore  it  must 
be  shown  that  these  colonies  on  special  culture  Hiedia  have 
certain  appearances,  and  that  the  micrococci  composing  such 
colonies  are  decolorized  by  Gram's  method  and  have  a  de- 
cided tendency  to  group  in  fours.  The  culture  must  not  be 
more  than  48  hours  old,  because  some  cocci  that  voluntarily 
stain  by  Gram's  method  have  been  observed  to  be  decolorized 
when  the  cultures  are  older.  The  cover- glass  propagation 
of  colonies  should  not  be  made  too  thick,  and  the  judgment 
as  to  whether  the  coccus  decolorizes  or  not  after  treatment 
with  Gram's  method  should  be  made  only  from  portions  of 
the  field  in  which  the  cocci  are  well  separated  from  one 
another.    [j.M.s.l 

3.— Balch  believes  that  it  is  very  doubtful  that  an  injec- 
tion of  any  antiseptic  substance  would  prevent  an  attack 
of  gonorrhea  after  a  suspicious  connection.  Theoretically, 
such  an  injection  should  be  an  extra  safeguard,  because 
the  gonococci  would  not  have  penetrated  the  cells  and  could 
easily  be  reached  by  an  antiseptic.  It  is  best  to  treat  an 
acute  case  of  gonorrhea  twice  a  day  during  the  first  week 
or  10  days  of  its  course  and  after  that  the  patient  should  use 
an  injection  himself  2  or  3  times  a  day  for  2  or  3  weeks 
longer.  As  injections  for  abortive  treatment  Bilch  only 
believes  in  silver  nitrate,  permanganate  of  potassium,  and 
protargol.  He  employs  a  solution  of  1  grain  to  the  ounce  of 
silver  nitrate.  If  there  is  no  evidence  of  very  active  inflim- 
mation  he  uses  2  grains  to  the  ounce.  It  is  unwise  to  use 
stronger  solutions  than  this.  When  permanganate  of  potas- 
sium is  used  from  the  beginning  instead  of  silver  nitrate,  it 
is  best  to  irrigate  with  a  large  amount  of  a  weak  solution, 
such  as  1  to  4,000,  rather  than  with  a  little  of  a  stronger 
one.  Where  it  is  impossible  to  see  a  patient  as  often  as 
these  two  methods  require  protargol  is  a  safe  injection  for 
him  to  use  himself  A.  i%  solution  is  as  strong  as  it  is  beet 
to  begin  with,  and  if  there  is  any  great  amount  of  scalding 
this  should  be  diluted.  With  all  3  of  these  methods  it  is 
often  necessary  to  give  a  mild  astringent  injection  at  the 
end  to  get  rid  of  the  final  gluing  together  of  the  lips  of  the 
meatus  in  the  morning.  If  the  patient  presents  himself 
only  after  the  disease  has  been  fully  developed  for  several 
days,  and  there  is  a  thick,  yellow  discharge  with  scalding, 
piinful  erection,  etc.,  there  is  no  use  in  trying  to  abort  the 
trouble.  If  an  injection  is  used  at  all  it  should  be  very 
mild.  It  is  usually  safest  to  give  no  local  treatment  for  a 
time,  but  to  rely  on  medicine.  The  citrate  and  acetate  of 
potassium  are  useful,  chiefly  because  they  make  a  patient 
thirsty.  The  same  result  can  be  accomplished  by  making 
him  drink  water  as  a  medicine.  It  it  does  not  upset  his 
digestion  at  least  2  quarts  a  day  should  be  druak.  Compound 
salol  capsules  are  good  and  should  be  taken  after  meals  and 
before  going  to  bed.  Urotropin  has  not  done  so  well  as  it 
was  at  first  hoped  it  would.  It  must  always  be  borne  in 
mind  that  while  an  injection  can  cure  a  discharge  it  can  also 
keep  up  one.  In  obstinate  cases  it  is  occasionally  surprising 
to  see  how  quickly  the  discharge  will  cease  when  all  treat- 
ment is  stopped.     [j.MS] 

4. — Clinically  acute  gonorrhea  in  the  female  is 
much  less  frequent  than  in  the  male.  The  disease  is  not,  as 
in  the  male,  always  preceded  by  a  period  of  acute  invasion, 
the  symptoms  of  which  necessarily  attract  the  attention  of 
the  patient  and  the  physician,  and  for  this  reason  gonorrhea 
in  women  is  often  overlookeid.  It  is  sometimes  better  to 
examine  near  the  menstrual  period,  because  at  that  time 
the  congestion  of  the  pelvic  organs  increases  the  discharges, 
and  it  is  probable  that  more  gonococci  are  thrown  off.  Tne 
experiments  of  Wertheim  explain  the  fact  that  a  subject  of 
chronic  gonorrhea  may  infect  his  hitherto  uninfected  wife, 
and  become  again  infected  from  her ;  that  is,  the  gonococcus, 
by  passing  through  the  new  culture  of  the  wife,  again  be- 
comes virulent  for  the  husband.  If  we  are  called  upon  to 
pronounce  when  a  woman  is  entirely  free  from  the  danger 
of  transmitting  gonorrhea,  it  is  at  once  apparent  that  we 
have  to  face  a  more  complicated  problem  than  we  have  in 


FlBRnABT  16,  1901] 


THE  LATEST  LITERATURE 


rXHE  PHmADKLPHIA 

L  Medical  Joubsal 


337 


the  case  of  gonorrhea  in  the  male,  because  of  the  many  pos- 
sible lurking  places  for  the  gonococcus  in  the  sexual  organs 
of  the  female.  As  a  practical  matter  we  may  say  that  a 
woman  is  cured  of  gonorrhea  when  there  are  no  signs  of 
chronic  inflammation  about  the  pelvic  organs,  and  when  two 
or  more  negative  cultures  have  been  taken  from  the  urethra 
and  the  cervical  canal.  As  a  germicide,  protargol,  in  solu- 
tions of  Irom  1%  to  5%  seems  to  be  displacing  silver  nitrate 
as  the  standard  remedy,  and  has  given  better  results  than 
the  many  other  salts  of  silver,     [j  M.S.] 

6, — The  points  at  which  a  subsiding  inflammation  of  the 
urethra  most  commonly  lingers  are  the  penoscrotal  angle 
and  that  portion  of  the  pendulous  urethra  just  anterior  to  it, 
the  bulbomembranous  junction,  the  prostatic  urethra,  and 
the  fossa  navicularis.  In  the  .treatment  of  chronic 
g'onorrhea,  the  objects  to  be  aimed  at  are  the  removal  of 
fibrous  deposits,  the  restoration  of  the  thickened  and  rigid 
mucous  membrane  approximately  to  its  original  soft  and 
elastic  condition,  and  the  cleaning  out  of  diseased  follicles 
and  glands.  The  first  principle  of  this  treatment  is  dilation. 
After  dilation,  the  local  application  of  various  remedies  is 
efiected  by  means  of  injections  or  irrigations,  and  later  the 
urethra  is  inspected  through  the  endoscope  and  local  appli- 
cations made  under  control  of  the  eye  to  such  points  as 
require  them,     [j.m  s.] 

6. — Seminal  vesiculitis  may  be  either  acute  or  chronic. 
Direct  gonorrheal  infection  is  extremely  rare,  but  when  it 
does  occur  it  is  very  acute  and  of  an  extreme  type.  The 
contents  of  the  vesicle  become  purulent,  the  vesicle  wall  and 
the  perivesicular  tissues  are  involved,  and  occasionally  the 
peritoneum,  which  lies  close  to  the  summit  of  the  vesicle,  is 
also  implicated.  There  are  a  few  cases  reported  in  which  a 
general  peritonitis  has  resulted  from  such  peritoneal  involve- 
ment. Aside  from  the  gonococcus,  in  certain  cases  present- 
ing the  signs  of  an  acute  seminal  vesiculitis,  the  only  organism 
found  present  has  been  the  colon  bacillus.  It  is  probable 
that  infection  may  take  place,  therefore,  not  only  by  con- 
tinuity along  the  surface  of  the  urethra  and  through  the 
seminal  duct,  but  also  by  direct  invasion  from  contiguous 
tissues,  such  as  the  rectum.  The  symptoms  of  acute  seminal 
vesiculitis  are  almost  wholly  inflammatory  in  character. 
While  the  acute  inflammatory  process  is  at  its  height  the 
urine  may  be  nearly  clear,  but  it  becomes  purulent  with  the 
decrease  of  the  symptoms  and  the  escape  of  pus  from  the 
vesicular  cavity.  The  involvement  of  the  perivesicular 
tissues  is  determined  by  rectal  palpation  of  the  vesicles.  At 
the  outset  measures  directed  toward  checking  the  inflam- 
matory process  should  be  taken.  If  the  pus  is  present  it 
should  be  evacuated  by  incision  and  drainage  either  through 
the  rectum  or  through  the  perineum.  Chronic  vesiculitis  is 
due  either  to  indirect  gonorrheal  infection  or  to  tuberculous 
infection.  Symptoms  of  chronic  seminal  vesiculitis  of  gonor- 
rheal origin  are  functional  or  neurotic  in  character.  Com- 
plaint is  made  of  perverted  sexual  desire,  irregular  seminal 
emissions,  and  neurotic  sensations.  The  treatment  by  mas- 
sage of  the  vesicles  should  be  instituted  before  resorting  to 
extirpation,  which,  in  turn,  should  be  reserved  for  those 
extreme  cases  that  are  associated  with  serious  or  severe 
subjective  symptoms.  There  are  3  routes  by  which  the 
seminal  vesicle  may  be  reached,  the  inguinal,  the  perineal, 
or  the  sacral.    Details  of  the  different  operations  are  given. 

[j.M.S.] 

7. — The  processes  involving  the  prostate,  that  accompany, 
complicate,  or  are  dependent  upon  a  preexisting  or  coexist- 
ing gonorrheal  urethritis,  may  be  either  acute  or  chronic, 
and  last  from  3  days  to  several  years.  In  extent  these  pro- 
cesses may  be  limited  to  the  prostatic  follicles,  they  may 
involve  the  entire  organ,  or  they  may  penetrate  the  capsule 
and  extend  ta  the  surrounding  tissues.  In  intensity  they 
may  be  of  any  degree  from  a  simple  congestion  with  vague 
symptoms,  to  rigors,  fever,  prostration,  and  death.  Infec- 
tion of  the  prostate  may  come  by  direct  extension  from 
the  urethra,  by  the  blood  or  the  urine,  or  by  continuity  of 
tissue.  In  gonorrhea  the  infection  always  comes  from  the 
urethra  and  from  a  preexisting  posterior  urethritis.  It  is 
evident,  therefore,  that  it  may  be  due  either  to  the  gonococcus 
alone,  or  to  a  mixed  infection.  Clinically,  a  posterior  ure- 
thritis always  precedes  a  prostatitis,  even  though  the  latter  be 
due  to  manipulations  with  unclean  instruments.  Anything 
that  irritates  or  tends  to  increase  the  congestion  accompany- 
ing a  posterior  urethritis  may  act  as  an  exciting  cause  of  a 


prostatitis.  Among  many  agents  may  be  mentioned  alcohol, 
coitus,  prolonged  sexual  excitement,  exposure  to  cold,  forcible 
and  injudicious  injections,  horseback  riding,  bicycling,  and 
such  violent  exercise  as  running  and  jumping.  The  jolting 
coincident  to  a  railroad  journey  may  be  a  determining  factor. 
Prostatitis  usually  appears  at  the  end  of  the  second  or  during 
the  third  week  of  urethritis.  The  acute  cases  may  be  of  the 
type  of  simple  congestion ;  of  inflammation  limited  to  the 
follicles  and  perifollicular  tissues  ;  of  a  process  involving  both 
follicles  and  parenchyma  and  progressing  to  pus  formation 
of  greater  or  less  degree,  and,  finally,  of  a  process  involving 
almost  the  entire  gland  and  extending  to  the  periprostatic 
tissues.  The  chronic  type  is  almost  always  follicular,  although 
it  occasionally  is  characterized  by  one  or  more  small  ab- 
scesses that  develop  without  the  majority  of  the  typical 
symptoms.  The  duration  of  the  acute  congestive  and  follic- 
ular types  is  from  3  days  to  8  weeks ;  of  the  parenchymatous 
and  purulent  types  from  1  to  3  months,  and  of  the  chronic 
type  for  months  or  years.  Ratention  of  urine  is  present  in 
a  large  proportion  of  cases ;  it  may  be  relieved  by  repeated 
catheterization  ;  by  inserting  a  small  catheter  and  leaving  it 
in  place,  or  by  aspirating  over  the  pubes.  Unless  we  desire 
to  utilize  the  catheter  to  facilitate  discharge  of  the  abscess 
through  the  urethra,  aspiration  is  the  method  of  choice.  If 
the  abscess  points  into  the  rectum  the  fluctuating  point  may 
be  incised  with  a  bistoury,     [j.m  s.] 

8.— It  has  been  estimated  that  from  J  to  J  the  existing 
cases  of  blindness  have  been  caused  by  gonorrheal  inflam- 
mations of  the  eyes,  generally  as  a  result  of  infection  of  the 
cornea  and  the  ulceration  and  sloughing  that  often  destroy 
more  or  less  of  that  tissue.    The  disease  generally  occurs  in 
infants,  beginning  from  1  to  5  days  after  birth,  or  in  young 
adults,    and    in    almost   all  cases    is   caused    by    carrying 
to  the  surface  of  the  conjunctiva  some  of  the  diplococci  of 
Neisser.    Other    pyogenic    organisms    may  give  rise  to  a 
purulent  conj  unctivitis  similar  to  the  true  gonorrheal 
form,  so  that  it  is  not  possible  in  any  given  case  to  say  that 
the  trouble  must  be  "due  to  gonorrheal  infection  without 
making  a  bacteriologic  examination.    The  inflammation  of 
the  conjunctiva  will  disappear  in  time  without  any  serious 
results  to  vision,  but  the  principal  attention  must  be  con- 
stantly directed  to  the  condition  of  the  cornea,  to  prevent,  if 
possible,  the  infection  of  its  tissue  with  the  purulent  matter. 
For  this  purpose  the  first  and  most  important  treatment  is 
the  careful  removal  of  the  purulent  discharge.    This  should 
be  done  every  15  minutes  or  J  hour,  if  necessary,  night  and 
day  for  the  few  days  the  disease  is  at  its  height,  and  at  longer 
intervals  as  the  discharge  decreases.    In  the  early  stages  of 
the  disease,  applications  of  cold  may  be  made,  but  should 
not  be  continued  if  corneal  complications  arise.    Williams 
believes  that  silver  nitrate  solutions  should  not  be  used  in 
the  early  stages,  but  in  the  later  stages  of  the  disease,  after 
the  intense  swelling  of  the  eyelids  has  begun  to  subside  and 
the  discharge  is  more  purulent,  a  2%  solution  may  be  applied 
to  the  conjunctival  surface  and  then  neutralizsd  with  salt- 
solution.    Nothing,  however,  should  take  the  place  of  the 
constant  cleansing.    Solutions  of  protargol  appear  to  be  less 
reliable  than  silver  nitrate.    The  edges  of  the  eyelids  and  the 
surrounding  skin  should  be  protected  with  vaseline.    In 
patients  who  are  in  poor  physical  condition,  the  application 
of  heat  will  often  prove  better  than  cold.    If  the  cornea  be- 
comes hazy  and  a  small  ulcer  forms,  continue  the  irrigation, 
use  1  %  atropin  3  times  a  day,  and  hot  applications  rather 
than  cold.    In  some  cases  of  marginal  ulceration  solution  of 
eserin,  i  grain  to  the  ounce,  may  be  used  every  4  hours,  but  it 
must  be  used  with  care.    The  number  of  cases  of  ophthalmia 
neonatorum  have  been  greatly  reduced  by  the  prophylactic 
treatment  of  Cred^.    In  adults,  if  the  disease  has  only  afi'ected 
one  eye,  the  other  eye  should  be  at  once  protected  by  cover- 
ing it  with  a  small  pad  of  absorbent  cotton  and  gauze.    [j.m.s.J 
O.— When  is  gonorrhea  cured  or  ended  ?  We  must 
admit  at  the  beginning  that  the  question  cannot  be  answered. 
The  medical  world  is  united  in  realizing  that  gonorrhea  is 
not  the  simple  disease  it  was  once  considered,  but  is  one  that 
often  spreads  to  places  in  which  its  local  treatment  is  im- 
possible ;  which  very  often  becomes  chronic,  and  sometimes 
defeats  the  efl'orts  of  the  most  expert  for  itj  eradication ; 
which  in  very  many  instances  retains  its  contagious  capa- 
bilities long  after  its  very  existence  is  supposedly  ended. 
Physicians  can  use  every  efl'ort  to  prevent  the  exposure  ot 
innocent  women  to  this  infection,  and  can  teach  the  rest  ol 


338 


Thb  Philadelphia"! 
Mkdicax  Jodenal  J 


THE  LATEST  LITERATURE 


[Fkbsdabt  16,  19M 


the  world,  both  medical  and  nonmedical,  the  necessity  for 
being  similarly  careful.  According  to  Thorndike,  the  methods 
of  examination  at  present  at  our  command  are  fairly  ade- 
quate to  determine  in  any  individual  case  whether  there  are 
still  contagious  possibilities  in  that  case.  The  methods  of 
treatment  at  present  at  our  command  are  fairly  adequate  for 
the  treatment  of  those  cases  in  which  remnants  of  disease 
are  found.  All  such  remnants  of  disease  should  be  treated, 
whether  they  contain  gonococci  or  not.  There  are  a  few 
cases  in  which  the  remnant  of  discharge  persists,  but  in 
which  no  cause  for  its  persistence  can  be  found,  in  spite  of 
many  most  careful  efforts.  Some  of  these  cases  must  prob- 
ably be  allowed  to  marry  with  traces  of  discharge  still  dis- 
coverable; but  none  such  should  marry  until  every  possible 
effort  has  been  made  to  demonstrate  the  noncontagious  char- 
acter of  the  pus  and  until  the  possibility  of  future  trouble  has 
been  explained,    [j.m.s.] 


Journal  of  the  American  Medical  Association. 

February  9, 1901.    [Vol.  xxvi,  No.  6.] 

1.  The  Technic  of  Bloodless  Work.    Robert  H.  M.  Da  wbabn. 

2.  Analgesia  from  Spinal  Subarachnoidean  Cjcainization. 

John  B.  Murphy. 

3.  Rheumatic  Diseases  of  the  Eye.    H.  W.  Woodbuf. 

4.  Ovulation  and   Menstruation  not  Interdependent  Func- 

tions.   C.  C.  Thayer. 

5.  Dysmenorrhea.    George  Tucker  Harbison. 

6.  Treatment  of  Menorrhalgia  of   Pelvic  Origin  by  Elec- 

tricity.   G.  Betton  Massey. 

7.  Movable  Kidney  from   the  Standpoint  of  the  General 

Practitioner.    Alexander  Marcy,  Je. 

8.  Some  Notes  on  the  Climatology  of  Arizona.    William 

DUFFIELD. 

9.  Preventative  Treatment  of  Migraine.     E.  W.  Mitchell. 

10.  Cases  Illustrating  Value  of  Rectal   Injections  of  Salt 

Solution  in  Hemorrhage   and  Threatened  Collapse. 
T.  B.  Gbeenley. 

11.  Physiologic    Resuscitation  in   the    Still-Born.     Daniel 

LiCHTY. 

12.  Clinical  Report.    Cases  of  Ectopic  Pregnancy.    J.  Heney 

Barbat. 

1. — Dawbarn  urges  the  advisability  of  saving  all  blood 
possible  in  every  operation,  and  then  discusses  the  various 
means  of  doing  this.  In  operations  upon  the  extremities 
the  milking  of  the  part  while  it  is  elevated,  and  the  applica- 
tion of  an  Esmarch  tube  is  recommended.  In  operations 
upon  the  leg,  the  middle  of  the  thigh  is  the  best  point  for  the 
application  of  the  constricting  tube,  thus  avoiding  the  exter- 
nal peritoneal  nerve;  in  operations  on  the  forearm,  the  tube 
should  be  applied  in  the  lower  or  upper  third  of  the  arm, 
thus  avoiding  pressure  of  the  musculospiral  nerve.  In  oper- 
ations upon  the  scalp  the  blood  supply  can  be  controlled  by 
the  application  of  a  constricting  elastic  band  around  the 
head.  Bloodless  operations  upon  the  breast  can  be  done  by 
passing  2  long  mattress  needles  underneath  the  gland,  and 
below  them  a  constricting  rubber  band.  In  operations  upon 
the  bladder,  perineum,  and  genitals,  in  both  males  and 
females,  the  Trendelenburg  posture  is  of  great  advantage. 
Dawbarn  then  diecusses  the  cording  of  the  extremities  to 
prevent  bleeding  within  the  abdomen,  thorax,  and  skull.  By 
keeping  the  blood  in  the  extremities,  clotting  in  the  visceral 
cavities  is  hastened.  He  thinks  this  a  good  treatment  in 
cases  of  apoplexy,  particularly  if  instituted  early.  Only  3 
limbs  should  be  corded  at  one  time,  and  the  cordmg  should 
be  carried  out  in  regular  rotation.  The  application  of  the 
Esmarch  bandage  and  tube  over  injuries  about  the  joints 
where  there  is  a  great  deal  of  swelling  for  the  purpose  of 
thoroughly  examining  the  bones,  Dawbarn  haa  olten  found 
useful.  In  performing  the  operation  of  tonsillotomy  the 
author's  method  of  constricting  the  base  of  the  tonsil  with  a 
purse- string  suture  is  recommended.  The  application  of 
first  suprarenal  extract  and  then  cocain  to  the  mucous  mem- 
brane of  the  bladder,  rectum,  and  vagina  is  found  useful  in 
controlling  bleeding  in  operation  on  these  organs,    [j.h.q.] 

3. — Murphy  first  discusses  briefly  the  history  of  spinal 
analgesia  as  first  proposed  by  Corning  and  first  practised  by 
Bier.  Of  631  cases  collected  by  Murphy  of  subarachnoidean 
cocainization  there  was  perfect  analgesia  in  45^,  partial  in 


2.21  % ,  and  in  3.32^  it  was  a  failure.  But  one  death  has  been 
reported  and  that  in  Tuffier's  clinic.  It  is  a  question  whether 
this  death  was  not  due  to  cardiac  lesions,  found  postmortem, 
and  not  to  the  use  of  the  cocain.  Physiological  effect : 
The  effect  is  produced  by  direct  application  of  cocain  to  the 
posterior  roots  and  ganglia  and  not  to  the  cord  itself.  The 
sense  of  contact  is  not  affected,  the  reflexes  are  slightly 
diminished,  some  incoordination  is  usually  present,  intestinal 
peristalsis  and  uterine  contractions  are  usually  stimulated, 
while  the  sphincteric  action  of  the  bladder,  vagina  and 
rectum  are  often  completely  abolished.  Dosage  is  next 
discussed,  and  the  sterihzation  of  the  solution  used.  Murphy 
has  used  with  satisfaction  the  glass  ampullae  containing  the 
solution  which  had  been  prepared  by  certain  well-known 
and  trustworthy  manufacturers.  The  point  of  introduction 
is  a  space  between  the  fourth  and  fifth  lumbar  vertebrae, 
one-half  inch  from  the  median  line,  the  patient  occupying  & 
sitting  position.  In  some  cases  of  spinal  deformity  it  has 
been  impossible  to  insert  the  needle  at  this  point.  Injections 
have  been  made  between  the  sixth  and  seventh  cerebral 
vertebra.  Murphy  thinks  this,  until  further  investigation 
has  been  made,  an  operation  not  free  from  danger.  The  fluid 
should  never  be  injected  except  when  the  cerebrospinal  fluid 
is  flowing  from  the  needle,  and  it  should  always  be  injected 
slowly,  requiring  from  40  to  60  seconds.  Symptoms :  First 
there  is  a  sensation  of  heat  passing  over  the  entke  body, 
then  that  of  thirst,  followed  in  a  few  minutes  by  nausea, 
which  may  last  for  10  minutes.  Preceding  the  vomiting  there 
is  increased  rapidity  of  pulse,  pallor,  and  respiration.  These 
symptoms  last  for  a  few  minutes  usually,  but  are  in  some 
cases  very  marked  and  make  stimulation  necessary. 
Murphy  thinks  that  hyoscin  hydrobromate,  xJti  of  a 
grain,  and  nitroglycerin,  y^j  of  a  grain,  are  ttie  best 
stimulants  under  the  circumstances.  The  analg^e8i& 
usually  appears  in  from  3  to  10  minutes,  though  some- 
times it  may  be  delayed  from  20  to  30.  It  iisualiy  begins 
in  the  feet  and  gradually  ascends,  though  in  rare  instances  it 
may  first  appear  as  a  band  around  the  body  and  then  de- 
scend. And  in  rarer  instances  still  it  has  been  known  to 
ascend  from  the  level  of  the  injection  and  involve  the  upper 
extremities,  the  neck,  and  face.  Amputation  of  the  breast 
has  been  performed  by  this  method.  The  duration  of  the 
analgesia  may  extend  from  12  minutes  to  5  hours.  Muscular 
rigidity  sometimes  interferes  with  abdominal  work.  This 
method  may  be  employed  at  all  ages.  Symptoms :  Head- 
ache, lasting  several  hours  to  several  days,  is  a  usual  post- 
operative symptom.  Prolonged  vomiting  is  unusual.  Vertigo 
and  some  ataxia  in  gait  may  persist  for  some  diys.  The 
temperature  usually  rises  after  the  operation.  Oa  the  day 
after  the  operation  the  patient  is  in  a  much  better  conditioa 
than  when  chloroform  and  ether  have  been  used.  Coma  and 
delirium  both  have  been  observed  in  some  cases.  Mental  ex- 
altation from  cocain  is  frequently  observed.  Failure  to  ob- 
tain analgesia  after  the  employment  of  this  method  Murphy 
thinks  is  due  to  faulty  technic  or  personal  idiosyncrasy. 
[j.H.o  ] 

3. — The  muscular,  fibrous,  and  vascular  portions  of  the 
eyeball  render  it  particularly  susceptible  to  rbeamatic 
affections.  According  to  the  author  some  diseases  of  the 
eye  due  to  chronic  rheumatism  are  iritis,  episcleritis,  scleritis, 
ocular  palsy,  glaucoma,  and  vitreous  opacity.  Toe  author 
reports  a  case  of  iritis,  episcleritis,  and  scleritis,  all  of  unques- 
tionable rheumatic  origin.  He  considers  deep  scleritis  as  the 
most  serious,  but  also  as  a  rare  ocular  disease  due  to  rheuma- 
tism,   [m.b.d.] 

4, — Thayer  gives  a  thorough  review  of  the  literature  of 
the  interesting  subject  of  the  relationship  between  ovu- 
lation and  menstruation.  He  concludes  from  his  in- 
vestigations that  menstruation  is  no  integral  part  of  ovula- 
tion, nor  an  absolute  factor  of  conception,  though  these  two 
conditions  are  usually  concurrent  and  attendant  In  accord 
with  the  general  belief,  he  states  that  there  may  be  ovulation 
without  menstruation,  and  menstruation  without  ovulation, 
and  conception  without  menstruation,    [w.a.s.d  ] 

6. — Harrison,  by  reference  to  the  literature,  presents  an 
interesting  anatomic  description  of  the  source  and  extent  of 
the  distribution  of  the  cerebrospinal  and  sympithetic  nerves 
to  the  pelvic  organ,  and  at  the  same  time  demonstrates  the 
communication  between  them.  He  also  shows  that  in  the 
sympathetic  paths  vasomotor,  secretory,  and  sensory  fibers 
nin,  and  from  this  intimate  relationship  it  ia  easy  to  explain 


Febbdaet  1«,  1901] 


THE  LATEST  LITERATURE 


Medical  Journal 


339 


the  various  morbid  phenomena  of  dysmenorrhea.  With 
reference  to  the  causes  of  dysmenorrhea  it  is  the  common 
practice  to  refer  the  phenomena  to  diseases  of  the  uterus, 
the  tubes,  the  ovariep,  and  the  peritoneal  covering  of  these 
organs,  as  well  as  to  the  pelvic  connective  tissue.  The  etio- 
logic  factors  are  generally  to  be  found  in  inflammatory  pro- 
cesses. He  does  not  believe  that  dysmenorrhea  in  its  full 
type,  if  allowed  to  persist  unchecked,  will  undoubtedly  cause 
oophoritis  and  endometritis,  as  has  been  stated  to  be  the 
case.  He  calls  attention  to  the  fact  that  there  may  be  a 
peculiar  form  of  dysmenorrhea  of  nasal  origin,  the  sensitive 
points  lying  in  the  inferior  turbinate  bones  and  the  tubercu- 
lar  septi,   whiqb   undergo    changes    during   menstruation. 

[w  A.N.D.] 

6. — Massey  urges  the  intelligent  use  of  electricity  in 
the  treatment  of  menorrhalgia  of  pelvic  orgin.    He 

claims  that  expertness  is  readily  gained  by  those  equipped 
with  sufficient  gynecologic  and  electric  trainine,  and  though 
the  actual  work  will  require  some  time  and  trouble,  the 
result,  he  states,  cannot  be  other  than  pleasing  when  it  keeps 
the  patient  at  home,  and  makes  her  a  well  woman,  [w.a.n.d.] 

7. — Marcy  presents  a  study  of  movable  kidney,  as  seen 
by  the  general  practitioner.  He  states  that  the  medical  treat- 
ment of  this  condition  should  jconsiet  in  the  use  of  such 
measures  as  would  improve  the  general  health  of  the  patient, 
together  with  the  accumulation  of  surplus  fat.  The  rest- 
treatment,  with  forced  feeding  and  massage,  is  sometimes 
beneficial.  As  a  tonic  he  prefers  tincture  of  nux  vomica  in 
large  doses,  together  with  cold  douching  of  the  spine  followed 
by  brisk  rubbing.  The  mechanical  treatment  consists  in  the 
use  of  elastic  bandages,  sometimes  fitted  with  a  special  pad, 
called  a  kidney- pad;  this  device  sometimes  relieves  the 
symptom  but  does  not  always  keep  the  kidney  in  its  proper 
place.    The  ideal  treatment  is  surgical,     [w.a.n.d.] 

8. — Duffield,  in  an  article  entitled  "  Some  Notes  on  the 
Climatology  in  Arizona,"  states  that  there  is  a  great  diversity 
of  climates  in  Arizona,  varying  from  subtropical  to  that  of 
the  high  mountain  elevations.  The  advantages  of  the  climate 
are  a  dry  atmosphere,  a  low  percentage  of  humidity  and  a 
high  percentage  of  sunshine.  Arizona  offers  an  elevation  of 
13,000  feet  above  sea  level,  and  the  State  is  well  supplied  with 
mineral  and  thermol  springs,     [f  j  k.] 

9. — Mitchell  in  an  article  gives  the  preventative  treat- 
ment of  migraine.  Meals  should  be  taken  at  regular 
intervals  and  great  care  must  be  exercised  in  not  overfeeding 
the  patient  Especial  precautions  should  be  used  in  exclud- 
ing rich  and  highly  seasoned  food.  The  patient  should  not 
be  allowed  red  meats,  and  stimulants  must  be  excluded. 
Fish,  bacon,  brains,  sweetbreads  and  eggs  may  form  part  of 
the  diet.  Outdoor  exercise  and  frequent  bathing  are  recom- 
mended. The  important  indications  in  medicinal  treatment 
are  to  regulate  the  bowels,  to  keep  the  liver  active,  and  pro- 
mote intestinal  antisepsis.  The  drugs  which  are  indicated 
are  the  various  salicylates,  and  mercurials.  He  gives  a  for- 
mula recommended  by  Dr.  Rachford,  which  is  as  follows : 
sulphate  of  soda  120  grains,  phosphate  of  soda  30  grains, 
salicylate  of  soda  19  grains,  tincture  of  nux  vomica  3  drops, 
distilled  water  to  make  4  ounces.  This  dose  is  to  be  taken 
before  breakfast.  Water  should  be  partaken  of  in  large 
amounts,    [f  j  k.] 

10. — Greenly  recommends  the  injection  of  salt-solu- 
tion into  the  lower  bowel  in  the  treatment  of  threatened 
collapse  from  hemorrhage.  He  uses  an  ordinary 
fountain-syringe  or  a  common  hand-syringe  for  the  purpose 
of  introducing  the  fluid  into  the  rectum.  The  solution  should 
be  heated  to  a  temperature  of  from  110°  F.  to  115°  F. 
A  gallon  of  water  should  contain  1  ounce  of  sodium  chlorid. 
He  believes  that  the  rectal  injections  of  salt-solution  are 
preferable  to  hypodermoclysis  or  intravenous  injection.  He 
has  treated  collapse  following  hemorrhage  with  good  results. 

[PJ.K.] 

11. — In  speaking  of  the  physiologic  resuscitation  of 

the  stillborn  Lichty  remarks,  that  there  is  an  anatomic 
and  physiologic  area  or  center  in  the  medulla  oblongata 
which  is  recognized  as  presiding  over  respiration  is  no  longer 
a  subject  of  doubt  or  discussion.  The  group  of  dynamics 
stored  in  the  centers  coordinating  respiration  is  very  com- 
plex and  of  wide  distribution,  as  evidenced  in  impending 
aephyxis,  dyspnea,  or  aroused  respiration,  when  nearly  all 
the  muscles  of  the  trunk  are  called  into  requisition,  rein- 
forced by  the  rigid  extremities  which  fix  the  trunk  as  auxil- 


iaries. Resuscitation  in  most  cases  of  asphyxia  is  accom- 
plished by  prompt  depression  of  the  upper  zone  of  the  body, 
to  favor  gravitation  of  the  blood,  to  the  dependent  cerebellar 
region  and  medullary  center.  Next  in  importance  to  this 
is  the  supplying  of  artificial  heat  externally;  and  the  sup- 
plementary pressure  of  the  capillaries  by  the  subcutaneous 
subperitoneal,  or  rectal  flushings  with  the  normal  salt- solu- 
tion. This  is  the  method  as  used  in  adults,  and  Lichty  be- 
lieves that  it  would  be  just  aa  efficacious  in  the  case  of  a  new- 
born child.    [w.A  N  D.] 

12.  —  Barbat  records  a  case  of  right- sided  ectopic 
pregnancy.  The  case  is  of  interest  on  account  of  the 
meager  symptoms,  and  the  fact  that  the  ovum,  which  was 
extruded  from  the  left  ovary,  was  fertilized  in  the  left  tube. 

[w  A  N.D.] 


Berliner  klinische  Wochenschrift. 

December  U,  1900.    [87.  Jahrg.,  No.  52.] 

1.  Contributions  to  the  Normal  and  Pathological  Histology 

of  the  Human  Hypophysis  Cerebri.    C.  Benda. 

2.  A  Grave  Spinal  Symptom-complex  Caused  by  a  Serpentine 

Aneurysmal  Change  in  the  Spinal  Bloodvessels.    F. 
Bkasch. 

3.  Extirpation  of  the  Hypophysis  Cerebri.    F.  F.  Friedmann 

and  0.  Maas. 

4.  Amyloid  Degeneration,  with  Special  Regard  to  the  Kid- 

ney.    M.  LiTTEN. 

1. — In  preparing  sections  of  the  human  hypophysis  for 

microscopic  examination,  Benda  has  found  that  the  best 
staining  methods  are  the  blood-staining  methods  of  L. 
Michaelis,  Weigert's  method  for  staining  fibers,  the  author's 
iron-alizarin-toluidin-blue  stain,  and  finally  also  Weigert's  or 
Pal's  methods  for  staining  medullary  sheaths.  In  four  cases 
of  akromegaly  the  author  found  the  hypophysis  enlarged, 
and  in  two  cases  tumors  were  found.  The  author  will  not 
admit  without  qualification  that  enlargement  of  the  gland 
is  responsible  for  the  increase  in  size  of  the  osseous  system. 

[m  R.D.] 

3. — Will  be  abstracted  when  concluded. 

3. — The  authors  have  devised  an  operation  for  extirpa- 
tion of  the  hypophysis,  by  means  of  which  animals  may 
be  kept  alive  for  months  after  the  operation.  They  believe 
that  the  hypophysis  is  not  necessary  for  the  maintenance  of 
life.  In  no  case  have  the  authors  upon  postmortem  exami- 
nation found  any  change  in  an  organ  which  could  have  been 
attributed  to  the  absence  of  the  hypophysis.  The  technic 
of  the  operation  is  described  in  detail,    [m  e.d  ] 

4. — Frequently  a  combination  of  large  white  kidney  and 
amyloid  change  in  its  vessels  is  seen.  Neither  macroscopic 
nor  microscopic  examination  will  reveal  the  condition,  but 
only  the  chemical  test.  This  variety  of  kidney  is  much 
larger  and  heavier  than  normal,  averaging  from  250  to  400 
grains.  The  increase  in  size  affects  equally  all  diameters. 
The  delicate  thinned  capsule  is  easily  stripped  ofT  without 
adhering  to  the  parenchyma.  The  surface  of  this  kidney 
is  strikingly  anemic  with  an  occasional  yellowish  tinge.  The 
consistency  of  the  organ  is  firm.  The  cut  surface  of  the  kid- 
ney has  the  same  waxy  luster  as  the  external  surface.  In 
the  amyloid  contracted  kidney  the  customary  changes  asso- 
ciated with  amyloid  degeneration  are  found.  Thionin  is 
stated  to  be  the  only  stiin  which  colors  amyloid  material  sky 
blue,  while  other  substances  will  be  colored  a  reddish  violet. 
In  the  majority  of  cases  of  amyloid  kidney  the  urine  is  of 
fair  quantity,  pale  yellow,  clear  and  of  a  low  specific  gravity ; 
upon  long  standing  hardly  any  sediment  can  be  seen.  The 
author  believes  that  an  increase  in  the  quantity  of  urine  is 
not  as  frequent  as  has  been  supposed.  Furthermore  there 
is  no  other  renal  affection  in  which  the  urine  varies  so 
markedly.  The  urine  does  not  show  a  systematic  array  of 
conditions,  characteristic  for  amyloid  degeneration  of  the 
kidney.  It  has  been  stated  that  waxy  casts  are  seen ;  but 
there  is  no  reason  why  albumin  casts  may  not  be  the  subject 
of  amyloid  degeneration.  Litten  believes  that  albumin  in 
the  urine  is  absolutely  necessary  for  the  diagnosis  of  amyloid 
degeneration  of  the  kidney.  The  albuminuria  may  be  con- 
stant or  recurrent,    [m.r.d.] 


340 


The  Philadelphia"! 
'J 


Medical  Journal  . 


THE  LATEST  LITERATURE 


[FKBRaABT   16,  1901 


Wiener  klinische  Wochenschrift. 

January  3,  1901.     [14.  Jahrg.,  No.  1.] 

1.  The  Treatment  of  Chronic  and  Infectious  Ulcers  by  Hot 

Air.    Carl  Ullmann. 

2.  The  Ability  of  Bacteria  to  Pass  Through  the  Intestinal 

Wall.    Hugo  Marcus. 
S.  A  Case  of  Pemphigoid  Measles.    J.  Zuhr. 

1.— Ullmann  reviews  the  literature,  telling  how  many 
chemical  substances  have  been  used  aa  counterirritanta  upon 
infected  wounds,  ulcers,  etc.,  to  produce  local  hyperemia. 
Phototherapy,  Rontgen-rays,  etc.,  have  the  same  efiect.  But 
the  simplest  and  oldest  of  all  is  heat.  Hitherto  this  has  been 
applied  as  the  cautery,  as  conducted,  or  as  radiated  heat. 
He  quotes  a  case  of  serpiginous  ulceration  of  the  groin,  in  a 
man  28  years  old,  described  by  Haslund,  treated  by  cautery 
first  without  improvement,  and  then  placed  in  a  permanent 
hot-water  bath  for  19  days.  This  treatment  completely  healed 
the  wound.  He  has  used  hot  air  in  about  150  venereal  and 
nonvenereal  ulcers.  The  apparatus  used  is  then  described. 
It  covers  the  male  genitalia,  wrapped  in  wadding,  after  the 
adjustment  of  which  the  temperature  of  the  enclosed  dry  air 
can  be  raised  to  150°  C,  and  is  kept  there  from  half  to  over 
an  hour.  A  local  hyperemia  results,  with  some  edema,  but 
no  constitutional  symptoms  therefrom.  The  air  must  be  dry, 
so  that  no  burns  occur.  He  reports  a  case  of  venereal  ulcer- 
ation, operated,  and  then  treated  thus,  with  recovery  in 
8  days.  The  details  of  10  more  cases  of  indurated  ulcers 
follow,  all  cured  by  this  treatment,     [m.o.] 

3. — Marcus  replies  to  the  criticisms  made  by  Posner  upon 
the  method  of  performing  his  experiments  to  test  the  ability 
of  bacteria  to  pass  through  the  intestinal  wall.  He  reports 
6  new  experiments  upon  animals  (with  2  control  experi- 
ments), in  all  of  which  infection  of  the  urine  followed,  and 
in  one  instance,  general  infection.  From  these  it  is  striking 
to  note  that  when  the  urine  was  infected  the  blood  was  not. 
The  one  positive  result  of  all  his  experience  is  the  fact  that 
AYith  decided  coprostasis,  the  bacteria  in  the  intes- 
tines never  reach  the  blood,    [m.o.1 

3. — Zuhr  reports  a  case,  a  boy  8  years  old,  who  developed 
typical  confluent  measles  with  huge  blisters  scattered  throagh- 
out  the  eruption.  There  was  albumin  in  the  urine.  Tne 
diazo- reaction  was  negative.  All  the  other  symptoms  of 
measles  were  present.  The  fever  remained  high,  and  death 
occurred  in  10  days.  Zuhr  considers  it  a  rare  case  of  pem- 
phigoid measles,     [m.o.] 


Deutsche  medicinische  Wochenschrift. 

December  27, 1900.    [26.  Jahrg.,  No.  63.] 

1.  Concerning  Experimental  Descending  Tetanus.      L.  Zup- 

NIK. 

2.  The  Reaction  of  the  Prostatic  Secretion  in  Chronic  Pros- 

tatitis and  its  Influence  upon  the  Viability  of  Sperma- 
tozoa.    H.  LOHNSTEIN. 

3.  Sunstroke.    M.  Hkrford. 

4.  Therapy  of  Croupous  Pneumonia.    A.  TAOEgsoN-MoLLER. 

5.  Colpocleisis  with  Artificial  Rectovaginal  Fistula  iu  a  Case 

of  Incurable  Vaginointestinal  Fistula  Due  to  Recur- 
ring Carcinoma.    H.  Saft. 

6.  Concerning  the  Presence    of  Sebaceous  Glands  in  the 

Mucosa  of  the  Cheek.    Lublinski. 

1.— Zupnik  has  been  able  in  a  series  of  animals  of  different 
species  to  produce  a  typical  descendirg  tetanus  which  was 
in  its  symptoms  practically  the  same  as  that  which  occurs 
in  man.  This  was  done  by  inoculating  the  animals  about 
the  feet  or  ankles.  If  the  animals  were  inoculated  about 
the  peritoneum  or  groin,  an  ascending  tetanus  occurred. 
This  seems  to  explain  the  usual  occurrence  of  an  ascending 
tetanus  in  animals — the  character  of  the  disease  depends 
upon  the  point  of  inoculation.  The  minimal  fatal  dose  of 
the  toxin  was  also  variable  according  to  the  point  of  inocu- 
lation. More  toxin  was  required  when  the  animals  were 
injected  about  the  feet,     [d.l  e  ] 

3. — Herford  repcrts  several  interesting  complications  of 
beat  stroke.  Those  chiefly  spoken  of  are :  disturbance  of 
speech,  bleeding  from  the  intestines,  and  acute  icterus.  A 
caae  in  which  there  was  severe  intestinal  hemorrhage  died, 


and  the  postmortem  showed  marked  hyperemia  of  the  gastro- 
intestinal tract  and  other  organs,  and  the  liver  looked  like 
the  liver  of  acute  yellow  atrophy.  There  were  scattered 
small  hemorrhages  in  the  brain.  The  importance  of  this 
find  upon  autopsy  is  indicated  by  the  course  of  2  cases  of 
speech  disturbance.  The  patients  exhibited  marked  ataxia 
after  the  heat  stroke,  with  very  decided  disturbance  of  speech. 
In  one  case  these  symptoms  improved  fairly  rapidly,  and  had 
almost  completely  disappeared  at  the  time  of  the  report. 
The  other  patient  had  shown  comparatively  little  improve- 
ment, and  seemed  unlikely  ever  to  recover  entire  health. 
The  cases  resemble  the  instances  of  acute  ataxia  reported 
by  Leyden,  and  the  combination  of  ataxia  and  tpeech  dis- 
turbance and  other  less  striking  symptoms  remmd  one  of 
multiple  sclerosis.  The  probable  cause  of  these  symptoms 
in  Herford's  belief  was  scattered  small  hemorrhages  in  the 
brain,    [d.l.e.] 

4. — Tne  treatment  of  pneumonia  recommended  is  mani- 
pulation of  the  chest  by  various  forms  of  massage,  frictioa, 
vibratory  exercises,  etc.,  by  means  of  which  it  is  claimed 
pain  can  be  well  controlled,  the  breathing  can  be  improved, 
the  strength  of  the  heart  action  can  be  increased,  and  the 
course  of  the  lung  changes  themselves  can  actually  be 
favorably  influenced,     [d.l  e.] 

6. — Lublineki  describes  at  some  length  one  case,  and  more 
indefinitely  a  series  of  caaes  in  which  he  has  observed  seba- 
ceous glands  in  the  mucous  membrane  of  the  cheeks.  Tne 
one  patient  whose  case  was  described  at  length  was  a  physi- 
cian. The  inner  surfaces  of  the  cheeks  were  covered  with 
numerous  small  yellowish  papules  which  produced  no  sub- 
jective sensations.  There  was  no  history  to  explain  their 
occurrence.  Other  patients  in  which  they  were  observed  had 
usually  a  history  of  excess  in  the  use  of  alcohol  or  tobnceo, 
dyspepsia,  the  use  of  mercury,  or  other  similar  causes.  They 
were  not  infrequently  seen  in  diabetes  and  gout.  They 
usually  appeared  in  the  interdental  spacee,  and  were  com- 
paratively rare  on  the  lips.  They  commonly  caused  no 
symptoms,  and  were  acciaentally  discovered.  Microecopic 
examination,  which  was  undertaken  in  a  number  of  casee, 
showed  that  they  were  undoubtedly  sebaceouB  glands. 
[d.l.e.] 

January  3, 1901.    [27.  Jahrg.,  No.  1.] 

1.  General  Therapy.    L.  BsrEaER. 

2.  The  Reasons  for  Natural  Immunity  Towards  Certain  In- 

fections.   A.  Wassermajtn. 

3.  Concerning  the  Origin  of   Areton    from    Albumen.    F. 

Blumknthal  and  C.  Nkubero. 

4.  The  Protective  Vaccination  of  Hogs  and  Shpep  against 

Foot-andMmth  Disease     Lobffler  and  Uhlbshuth. 

5.  Pathogenesis  of  G  morrheal  E.)ididymiti8.    D.  Baikal 

6.  Etiology  of  Dysentery.    Dkycke. 

2. — Wassermann  reports  in  brief  an  experiment  which 
shows,  in  his  belief,  that  the  natural  resistance  to  disease  is 
due  chiefly  to  the  presence  in  the  orgauirim  of  complements 
(alexines);  that  is,  there  are  present  in  the  normal  blood 
ferment-like  substances  which  have  the  power  to  destroy  bsM>- 
teria,  and  they  are  the  chief  shield  of  the  organism  from  in- 
fection. His  experiment  consisted  in  injecting  norma!  guinea- 
pigs  with  an  agar  culture  of  typhoid  bacilli  mixed  with  normal 
rabbit-serum.  These  animals  lived.  If  instead  of  the  normal 
rabbit  serum  the  serum  was  taken  from  rabbits  which  had 
been  injected  with  normal  guineapig-serum,  the  infected 
guineapigs  died.  The  serum  of  the  latter  series  of  rabbits 
contained  anticomplements  (antialeiines).  In  animals  in- 
fected in  this  way  it  was  observed  that  the  peritoneal  fluid 
about  an  hour  after  infection  showed  large  numbers  of 
motile  typhoid  bacilli,  an  evidence  that  the  organism  in 
these  animals  had  not  controlled  the  infection.  Oa  the  next 
day  the  animal  was  usually  found  deal,     [o  l.k  ] 

3. — Blunienthal  and  Neuberg  briefly  discuss  the  question 
as  to  the  origin  of  acetone,  and  note  that  the  general  ten- 
dency recently  has  been  to  consider  that  acetjue  and  its 
congeners  are  produced  only  by  fats,  and  it  has  recently  even 
been  stated  that  protein  does  not  pr  >duce  acetone  or  its 
congeners.  They  not«  that  some  authors  consider  that  they 
have  produced  acetone  from  casein,  and  ttien  repirt  their 
own  experiments.  It  has  been  showu  by  a  number  of 
authors  that  iron  salts  are  very  important  in  oxidative  pro- 
cesses in  the  body.    They,  therefore,  took  gelatin  solutions. 


Fbbsdart  16,  J901] 


THE  LATEST  LITERATURE 


rrHE  PhILADKLPBU 
UxDtCAL  JOCBHAL 


341 


added  peroxid  of  hydrogen,  and  then  added  a  soluble  iron 
salt  (ferrous  sulfate).  The  vessel  containing  this  mixture 
was  put  in  an  oven  and  frequently  shaken.  After  3  to  5 
days  they  found  that  the  peroxid  of  hydrogen  had  disap- 
peared. They  then  distilled  the  fluid,  and  in  testing  the  dis- 
tillate found  an  aldehyde  present,  and  also,  with  the 
hydroxylamin  test,  found  that  there  was  a  ketone  present. 
They  then  carried  out  the  P-nitrophenylhydrazin  test,  and 
got  a  pronounced  reaction.  They,  therefore,  consider  that 
they  undoubtedly  produced  acetone  and  aldehyde  from 
gelatin  (which  is  a  protein),  and  think  they  thus  demonstrate 
the  possibility  of  its  occurrence  in  this  way  in  the  body. 
They  also  consider  that  one  must  admit  that  the  iron  salts 
may  have  an  important  role  in  oxidative  processes  in  the 
body,     [d.l.e  ] 

4. — The  authors  give  a  general  discussion  of  the  methods 
of  producing  the  serum,  and  its  value  in  treating  animals, 
both  as  a  prophylactic  and  in  the  management  of  the  actual 
disease.  The  serum  is  now  produced  in  a  way  which  allows 
of  an  exact  measurement  of  its  value,  and  is  obtainable  on 
order,    [d.i.  e.] 

6. — Deycke,  in  referring  to  Kruse's  recent  article  in  this 
journal,  states  that  while  working  in  Constantinople  he  found 
that  it  was  possible  in  most  cases  of  dysentery  to  obtain  a 
bacillus  in  much  larger  numbers  than  any  other  organism, 
and  this  bacillus  seemed  to  belong  to  the  colon  group  and 
resembled  the  bacillus  of  typhoid  fever.  It  almost  constantly 
produced  typical  severe  dysentery  in  cats,  and  this  was 
usually  fatal.  The  postmortem  changes  found  were,  losses  of 
mucosa,  petechia,  erosions,  sometimes  ulcerations  and  general 
swelling  of  the  mucous  membrane  of  the  colon.  The  small 
intestine  was  uninvolved.  The  histological  changes  were 
entirely  analogous  to  those  seen  in  man.     [d.l.e.] 

January  10,  1901.    [27.  Jahrg.,  No.  2.] 

1.  Vomiting  from  Chloroform  and  Other  Inhalation  Anes- 

thetics, with   a  Proposition  for  its  Prevention.  '  L. 
Lewin. 

2.  Concerning  the  Chemistry  of  Bacteria.    E.  Bendix. 

3.  Vaginal  and  Abdominal  Section  in  Tuberculous  Perito- 

nitis.   G.  Baumgart. 

4.  The  Determination  of  the  Inferior  Border  of  the  Stomach 

by  Means  of  the  X-rays.    W.  Bechkb. 

5.  Death  from  the  Thymus  Gland.    H.  Kohn. 

6.  The  Quantitative  Estimation  of  Indican  in  the  Urine  and 

its  Clinical  Sigmficance.    Wolowski. 

2. — Bendix  briefly  reports  that  he  has  obtained  a  charac- 
teristic orcin  test  and  a  typical  osazon  of  pentoses  by  proper 
treatment  of  the  bodies  of  typhoid  bacilli,  as  well  as  a  series 
of  otk  er  bacteria.  He  therefore  feels  convinced  that  pentoses 
are  pre^ent  in  these  organisms.  He  has  also  apparently 
shown  that  the  nucleoproteid  of  the  bacteria  contains  the 
pentoses,  and  the  nucleoproteid  is  probably  the  chief  or  sole 
carrier  of  the  pentose  radicle.  It  has  been  shown  that  higher 
organisms  contain  pentoses  chieflj'  in  union  with  nucleopro- 
teids.  This  work  is  therefore  further  testimony  of  the  simi- 
larity of  the  higher  and  lower  organisms,  and  it  is  shown  that 
bacteria  are  able  to  take  comparatively  simple  bodies,  and, 
by  synthesis,  produce  the  characteristic  nucleus  of  compli- 
cated composition  from  them,    [d.l.e  ] 

4. — Becher  recommends  that  the  lower  border  of  the 
stomach  be  determined  by  introducing  a  soft  stomach-tube, 
and  then  pouring  through  this  a  suspension  of  bismuth,  and 
at  once  examining  the  patient  with  the  fluoroscope  and 
marking  the  shadows  seen  with  Levy-Dorn's  special  pencil. 
He  states  ihit  it  is  unnecessary  to  fill  the  tube  after  the  com- 
plicated methods  recommended.  By  the  simple  method  he 
recommends  one  sees  the  tube  readily,  and  the  shadow  can 
eatily  he  seen  where  the  bismuth  suspension  has  reached  the 
lower  border  of  the  ttomach.  He  considers  this  an  exact 
and  rapid  method,     [d.l.e] 

6. — The  case  is  reported  of  a  child  7  months  old  which  was 
brought  into  the  out-patient  clinic  in  moribund  condition, 
and  died  within  two  hours.  The  postmortem  examination 
showed  a  very  large  thymus  gland,  the  weight  being  about  40 
grams  and  the  measurements  8  cm.  by  6  cm.  by  4  cm.  The 
heart  was  hypertrophied  and  dilated,  and  the  aorta  was 
dilated  up  to  the  point  where  the  thymus  gland  compressed  :t 


and  narrowed  its  lumen.  At  this  point  there  had  been  severe 
compression  of  the  aorta  (at  about  the  middle  of  the  arch), 
and  Kohn  considers  that  it  had  undoubtedly  produced  the 
cardiac  dilation  and  hypertrophy,  and  had  caused  death  in 
this  way.  There  has  been  much  discussion  as  to  the  cause  of 
death  in  disease  of  the  thymus  and  it  has  been  denied  that- 
pressure  of  the  thymus  could  have  this  result  alone.  In  this^ 
case  it  seemed  to  be  unquestionable  that  a  fatal  result  had 
ensued  in  this  way.    [d.l.e.] 

6. — Wolowski  describes  at  length  a  method  for  the  quan- 
titative estimation  of  indican,  which  he  states  can  be  carried 
out  within  a  half  hour,  and  which  he  considers  gives  results 
which  are  satisfactory  for  clinical  purposes.  The  details  are 
too  elaborate  to  allow  of  a  complete  description.  It  depends- 
upon  precipitating  out  the  albumins  and  then  the  pigment 
(with  lead),  and  then  adding  to  known  quantities  of  urine 
varying  numbers  of  drops  of  a  solution  of  hypochlorite  of 
calcium  and  some  hydrochloric  acid,  then  adding  chloroform 
and  ultimately  learning  the  amount  of  hypochlorite  that  it 
takes  to  destroy  entirely  the  color  reaction.  He  makes  the 
rather  remarkable  statement  that  in  many  diseases  indicanu- 
ria  is  the  sole  cause  of  the  disease.  Possibly  it  is  meant  that 
it  is  the  index  to  the  severity  of  the  affection  and  to  its  origin. 
He  found  in  many  skin  conditions,  particularly  in  some 
cases  of  asthma,  in  many  cases  of  vertigo,  in  a  case  of  epi- 
lepsy, in  many  gastric  and  intestinal  affections,  and  in 
numerous  nervous  diseases,  particularly  the  neuroses,  that 
the  indican  was  largely  increased,  and  as  the  disease  im- 
proved the  indican  disappeared  more  or  less  completely  from 
the  urine.  The  treatment  which  he  recommends  is  biniodide 
of  mercury  with  intestinal  lavage,     [d.l.e.] 


Journal  des  Praticiens. 

January  26, 1901.    [15me  Ann^e,  No.  4.] 


1.  Disturbance  in  the  Innervation  and  Circulation   of   the 

Heart  in  Infectious  Diseases.    Joseph  Pawinski. 

2.  A  Case  of  Gonorrheal  Myelitis.      M.  Labbe. 

1. — After  a  historical  review  of  the  work  done  by  the  men 
who  discovered  the  relation  of  myocarditis  and  other  changes 
in  the  innervation  and  circulation  of  the  heart  to  the  infecv- 
tious  diseases,  Pawinski  reports  3  cases  in  full.  The  first,  a 
man  of  45,  hereditarily  neuropathic,  had  influenza  pneumo- 
nia after  mental  overwork ;  the  second,  a  man  of  50  years, 
after  a  brother  had  died  of  aneurysm,  had  follicular  tonsillitis ; 
and  the  third,  a  woman  aged  50  years,  who  smoked  cigarets 
continually,  had  influenza  after  having  had  an  operation 
under  chloroform.  Each  attack  was  accompanied  by  severe^ 
nervous  and  cardiac  symptoms.  After  discussing  the  possi- 
bility of  their  being  cases  of  mixed  infection,  Pawinski  in- 
clines toward  believing  that  they  were  not.  He  thinks  thafc 
the  nervous  and  vasomotor  mechanism  of  the  heart  did  not 
functionate  well  in  these  cases  even  before  the  infection  ;  thus, 
after  the  arrival  of  the  influenza  or  pneumonia  bacilli,  severe 
cardiac  attacks  are  at  once  understood.  As  treatment  he  ad- 
vises rest  in  bed,  milk  diet,  and  the  usual  heart  stimulants, 
cafFein,  camphor,  strychnin,  etc.     [m  o.J 

3. — Labhi5  reports  the  case  of  a  man,  aged  35,  who  entered 
the  hospital  with  g^onorrheal  arthritis  existing  for  a 
month  in  both  legs.  He  had  taken  salicylates  without  im- 
provement. Both  knees  were  affected,  both  legs  were  para- 
lyzed, and  he  complained  of  painful  micturition.  These 
symptomsgrew  better  gradually,  yet  the  "  blenorrhagic  foot  of 
Jacquet "  remained  associated  with  a  spasmodic  paraplegia, 
marked  when  he  attempted  to  walk.  The  muscles  of  both 
legs  atrophied,  and  Bibinski's  reflex  was  found.  Syphilis, 
the  infectious  fevers,  and  hysteria  were  all  excluded.  But  for 
17  years  gleet  had  existed  off  and  on,  with  gonorrheal  arth- 
ritis. Labt  e  considers  this  a  case  of  gonorrheal  myelitis, 
with  favorable  progno.ns.  He  advises  sulphur  baths,  massage, 
and  electricity,    [mo.) 


The  Government  of  India  has  sanctioned  the  establigh- 
ment  of  a  ward  in  the  Station  Hospital,  Calcutta,  for  the 
accommodation  of  British  officers  returning  to  India  from. 
China,  and  also  the  enlistment  of  2  nurses  to  attend  them. 


342 


Tub  Philadblphia"! 
Medical  Jodenal  J 


PERFORATING  ULCER  OF  THE  STOMACH 


[Fbbkuast  16,  1901 


©rujinal  Tiviicks. 


PERFORATING   ULCER  OF  THE  STOMACH:  OPERA- 
TION; RECOVERY* 

By  JOHN  II.  MUSSER,  M.D., 

of  Philadelphia, 

Professor  of  Clinical  Medicine,  University  of  Pennsylvania, 


HENRY  R.  WHARTON,  M.D., 

of  Philadelphia, 

Clinical  Professor  of  Surgery,  Woman's  Medical  College;  Surgeon  to  the  Pres- 
byterian and  Children's  Hospitals, 

G.  C,  aged  40,  single,  farmer,  resident  of  Maryland.  He 
used  tobacco  moderately,  but  no  alcohol.  He  was  regular 
in  his  meals,  and  his  dietary  was  not  an  unusual  one.  He 
had  liad  much  care  and  anxiety. 

Had  dyspepsia  for  many  years  previous  to  present  attack, 
chiefly  of  acid  form.  For  3  montlis  prior  to  the  date  of  the 
symptoms  for  which  he  required  operation,  he  suflered  from 
pain  in  the  epigastrium,  and  occasional  attacks  of  vomiting. 
He  never  vomited  blood.  The  pain  was  often  relieved  by 
food,  so  that  it  was  his  custom  to  carry  crackers  and  eat  then 
when  the  gnawing  became  more  pronounced. 

It  may  be  said,  for  many  years  the  patient  has  been  spare 
of  build  and  rather  gaunt,  although  quite  strong.  The  pain 
became  so  severe  and  constant  that  he  decided  to  come  to 
Philadelphia  to  secure  relief.  On  the  morning  of  December 
18,  1900,  he  arose  early,  partook  of  a  light  breakfast,  drove 
to  Annapolis,  a  distance  of  15  miles.  He  arrived  in  Phila- 
delphia at  the  oflice  of  Dr.  D.  Murray  Cheston  about  4.15 
P.M.  On  examination  Dr.  Cheston  found  a  tumor  about  the 
s'ze  of  the  fist  to  the  right  of  the  median  line,  just  below  the 
margin  of  the  riljs.  Further  examination  was  postponed 
until  the  evening,  when  it  was  arranged  the  writer  should 
see  liim  in  consultation. 

At  5  P.M.  the  patient  repaired  to  a  restaurant  to  take  his 
first  food  since  early  morning.  At  this  hour  he  took  a  glass 
of  soda  water.  He  was  at  once  seized  with  violent  pain  in 
tfie  epigastrium  and  fell  on  the  floor  in  a  faint.  He  vomited 
and  symptoms  of  collapse  rapidly  followed.  He  was  removed 
to  Dr.  Cheston's  oflice  where  Dr.  Morris  saw  him  suffering 
from  severe  general  jjaiu  and  collapse.  Dr.  Cheston  saw  him 
at  6.15  P.M. 

The  previously  described  tumor  had  disappeared.  The 
pulse  was  120.  Temperature  97°.  The  abdomen  was  hard. 
The  pain  was  general.  The  writer  saw  him  at  8  p.m.  having 
the  good  fortune  to  have  the  conjoint  advice  of  Drs.  Murray 
and  Radclilfe  Cheston.  The  condition  was  as  indicated 
above.  The  writer  was  impressed  with  the  e.xtreme  board- 
like  rigidity  of  the  flat  abdomen.  It  was  impossible  to 
make  any  impression.  The  epigastrium  was  tympanitic. 
Tlie  pain  was  extreme  and  complained  of  in  many  situa- 
tions. The  patient  complained  of  intense  heartburn  indi- 
cating some  hyperacidity.  There  was  no  vomiting;  some 
retching  occurred,  when  esophageal  and  faucial  burning  was 
extreme. 

The  diagnosis  of  perforation  of  a  gastric  ulcer  was  made 
because  of  first, — the  history  of  the  case;  second,  the  pres- 
ence of  a  painful  and  tender  tumor  which  disappeared 
suddenly;  third,  the  onset  of  acute  pain  and  collapse; 
fourth,  the  hyperacidity  ;  fifth,  the  absence  of  signs  of  affec- 
tion of  the  gallbladder  or  the  appendix,  or  of  pancreatic 
disease.  Pancreatic  hemorrhage  and  acute  pancreatitis 
were  considered  possible,  though  not  probable,  because  of 
the  signs  of  tumor  antecedent  to  the  perforation,  and 
because  of  the  absence  of  the  more  prominent  symptoms  of 
pancreatic  hemorrhage, — tumor  and  tympany. 

It  was  our  belief  that  general  peritonitis  was  advancing 
rapidly,  in  spite  of  the  subnormal  temperature,  because  of 
the  general  pain,  the  increased  pulse-rate  and  the  rigidity  of 
the  muscles. 

It  remains  to  explain  the  presence  and  disappearance  of 
the  tumor.    Without  doubt  perforation  had  occurred  slowly 

Read  at  the  meeting  of  the  College  of  Physicians,  February  fi,  1901. 


and  a  localized  peritonitis  had  set  in.  The  sudden  pain  and 
shock  were  due  to  the  giving  away  of  adhesions  and  ihe  out- 
pouring of  the  stomach-contents  into  the  peritoneal  cavity. 
With  this  accident  the  tumor  disappeared. 

It  was  fortunate  for  the  good  fellow,  no  doubt,  that  he  had 
a  long  fast  preceding  perforation  ;  that  the  opportunity  for 
immediate  operation  could  be  afforded,  and  that  6i  hours 
after  the  perforation,  his  peritoneal  cavity  was  being 
cleansed  with  hot  salt-solution. 

Dr.  H.  R.  Wharton  presented  the  following  notes 
upon  the  case: 

The  previous  history  of  this  case  has  been  given  by  Dr.  .J. 
H.  Musiser.  I  saw  the  patient  on  the  evening  of  December 
18,  19(  0,  f<jur  hours  after  a  sudden  attack  of  pain  in  the  epi- 
gastric region,  which  caused  him  to  faint.  When  I  saw  him 
he  was  suffering  excruciating  pain,  which  he  referred  to  the 
abdomen.  He  was  slightly  nauseated  and  was  making  inef- 
fectual attempts  to  vomit.  The  temperature  was  97°,  the 
pulse  120.  The  atidoraen  was  not  markedly  distended,  but 
the  abdominal  muscles  were  so  rigid  that  it  was  impossible 
to  palpate  any  of  the  abdominal  organs.  He  could  not 
locate  any  especial  point  of  tenderness,  but  complained 
loudly  of  severe  pain  all  over  the  abdomen. 

After  consultation  with  Dr.  M.  Cheston,  Dr.  R.  Cheston, 
and  Dr.  J.  H.  Musser,  we  decided  that  he  was  probably  suf- 
fering from  a  perforated  gastric  ulcer,  and  that  an  operation 
was  advisable. 

He  was  removed  to  the  Presbyterian  Hospital,  and  6} 
hours  after  his  first  attack  of  pain  an  anesthetic  was  admin- 
istered and  it  was  decided  to  open  the  abdomen  in  the  epi- 
gastric region,  as  the  symptoms  pointed  strongly  to  a  per- 
forated gastric  ulcer. 

When  the  patient  was  fully  under  the  influence  of  the 
anesthetic  it  was  noticed  that  the  rigidity  of  the  abdominal 
muscles  was  only  slightly  diminished.  An  incision  3  inches 
in  length  was  made  from  the  tip  of  the  eusiform  cartilage 
towards  the  umbilicus,  and  as  soon  as  the  peritoneal  cavity 
was  opened  it  was  found  that  a  quantity  of  thin  opaque 
purplish  fluid  escaped.  The  incision  was  slightly  enlarged, 
and  the  surface  of  the  stomach  was  exposed  ;  this  organ  was 
grasped  and  partly  removed  from  the  abdomen  and  carefully 
examined  for  the  presence  of  a  perforated  ulcer ;  the  greater 
curvature,  the  lesser  curvature,  and  the  anterior  and  posterior 
surfaces  were  carefully  examined  and  no  ulcer  was  discovered. 
The  stomach  was  replaced  and  the  gallbladder  next  examined, 
thinking  that  this  organ  might  have  been  ruptured,  as  masses 
of  bile-stained  mucus  were  noticed  floating  in  the  abdominal 
effusion.  Tlie  gallbladder  was  found  intact.  The  ascending 
colon  was  next  sought  for  and  drawn  upwards,  and  the 
appendix  inspected  and  found  normal  in  appearance.  The 
abdominal  effusion  was  next  removed  by  sponging,  and  it 
was  then  noticed  that  a  small  amount  of  fluid  still  continued 
to  escape  from  the  region  of  the  pyloric  end  of  the  stomach. 
The  stomach  was  next  examined  by  drawing  it  outward,  so 
that  the  posterior  portion  of  the  pyloric  extremity  was 
exposed  to  view,  and  there  was  disclosed  a  round  opening, 
about  i  inch  in  diameter,  from  which  fluid  could  be  seen  to 
escape.  The  perforation  was  situated  on  the  p  sterior  surface 
of  the  pyloric  end  of  the  stomach,  about  i  inch  from  its  junc- 
tion with  the  duodenum. 

Attempts  were  made  to  invert  the  edges  of  the  opening 
by  introaucing  silk  sutures,  but  as  the  edges  of  the  ulcer 
were  undermined  and  very  friable,  the  sutures  cut  through 
and  without  producing  tlie  desired  result.  Tliere  was  also 
more  or  less  induration  of  the  tissues  surrounding  the  ulcer, 
which  prevented  the  inversion  of  the  edges  of  the  ulcer. 
I  then  decided  to  cover  the  ulcer  by  infolding  the  walls  of 
the  stomach  by  sutures  introduced  some  distance  from  the 
perforation.  This  was  accomplished  by  introducing  six 
sutures  of  silk,  which  effectually  closed  the  opening  ana  pre- 
vented leakage,  and  after  they  were  placed  and  securely  tied, 
a  few  additional  sutures  were  introduced  at  the  ends  of  the 
infolded  tissue.  The  abdominal  cavity  was  next  very  thor- 
oughly flushed  with  hot  saline  solution,  about  3  gallons  being 
employed.  Two  glass  drainage  tubes  were  next  introduced,  a 
long  one  extending  downward  toward  the  pelvis,  and  a  shorter 
one  p.ossed  upward  in  the  region  of  the  pylorus.  The  wound 
was  then  closed  with  silkworm-gut  sutures,  gauze  drains  were 
introduced  to  the  bottom  of  the  drainage  tubes,  and  a  copious 


Febbcaby  16, 19€1] 


ACUTE  LOBAR  PNEUMONIA 


rPHE  PHn^DBLPHIA 
Mbdicax  Journal 


343 


gauze  dressing  was  applied  over  the  wound  and  held  in  place 
by  an  abdominal  bandage. 

The  patient  was  much  shocked  during  the  operation,  but 
reacted  gradually.  The  morning  following  the  operation  he 
was  free  from  pain,  his  temperature  was  normal,  and  pulse 
was  80.  The  patient  was  given  no  nourishment  by  the 
mouth  for  three  days,  liquid  nourishment  and  water  being 
administered  by  the  rectum.  After  this  time  milk  in  small 
quantities  was  given  by  the  mouth.  A  free  discharge  of 
bloody  serum  occurred  from  the  drainage  tubes,  which 
necessitated  frequent  changing  of  the  dressmgs.  The  drain- 
age tubes  were  removed  on  the  fourth  day,  and  small  gauze 
drains  were  substituted  for  a  few  days.  The  patient  suffered 
no  further  inconvenience  and  made  an  uneventful  recovery, 
the  sutures  being  removed  from  the  abdominal  wound  on 
the  thirteenth  day.  Four  weeks  after  the  operation  the 
patient  was  discharged  from  the  hospital  and  returned  to  his 
home. 

Remarks. — Since  Mikulicz,  in  1880,  first  performed  a 
formal  operation  for  the  exposure  and  closure  of  a  per- 
forated gastric  ulcer,  the  procedure  has  been  employed 
in  many  cases  with  most  satisfactory  results.  A  large 
number  of  cases  in  which  operative  treatment  has  been 
employed  have  been  collected  and  analyzed  by  Mikulicz, 
Lindner,  Barker,  Weir,  Lund,  Mitchell,  Tinker  and  Keen, 
and  as  the  result  of  their  studies  much  valuable  informa- 
tion as  to  the  most  frequent  site  of  the  perforation,  the 
prognosis,  diagnosis,  treatment  and  the  details  of  the 
operation,  have  been  added  to  surgical  literature. 

Perforation  is  comparatively  infrequent  in  gastric 
ulcer,  occurring  according  to  various  observers  in  from 
6.5  %  to  18  %  of  all  cases.  In  Tinker's  collection  of  232 
cases,  only  22  cases  of  operation  for  perforation  occurred 
in  the  United  States.  This  accident  is  5  times  more  fre- 
quent in  women  than  in  men.  As  regards  the  results 
of  operations  in  Tinker's  and  Finney's  combined  collec- 
tion of  268  cases,  139  recovered  and  129  died,  giving  a 
mortality  of  48  % .  In  Tinker's  collection  of  cases  oper- 
ated upon  within  12  hours  of  the  perforation,  75% 
recovered,  and  in  a  late  collection  of  cases  83.78%  of 
cases  recovered.  All  observers  agree  that  the  best 
result  is  apt  to  follow  in  cases  in  which  a  short  time 
only  exists  between  the  perforation  and  the  operation. 

The  ulcer  is  more  commonly  situated  upon  the  pos- 
terior wall  of  the  stomach  than  upon  the  anterior  wall, 
in  the  proportion,  according  to  Pariser  and  Lindner,  of 
190  to  10,  and  is  much  more  frequent  near  the  pylorus 
than  at  the  cardiac  end  of  the  stomach.  Mayo  Robinson 
has  observed  that  chronic  ulcers  are  usually  situated 
near  the  pyloric  extremity  of  the  stomach. 

The  possibility  of  more  than  one  perforation  should 
not  be  lost  sight  of,  for  statistics  show  that  in  20  %  of 
the  cases  this  condition  was  present. 

Death  from  perforated  gastric  ulcer  results  from  peri- 
tonitis, caused  by  the  bacteria  which  escape  from  the 
stomach  into  the  peritoneal  cavity  at  the  time  of  perfo- 
ration. Richardson  considers  that  the  size  of  the  per- 
foration, permitting  a  rapid  escape  of  the  stomach-con- 
tents, is  an  important  factor  in  the  development  of  a 
rapid  form  of  peritonitis,  producing,  as  he  describes  it, 
"  a  sudden  overwhelming  of  the  abdominal  cavity  rather 
than  a  spreading  invasion." 

The  ideal  method  of  closing  the  perforation  is  to  ex- 
cise the  edges  of  the  ulcer  and  bring  them  together  by 
sutures.  This,  however,  is  only  possible  in  exceptional 
cases,  and  in  the  great  majority  of  cases  infolding  the 
walls  of  the  stomach  over  the  ulcer  by  sutures  is  the 
procedure  which  can  be  most  rapidly  and  safely  prac- 
tised. Irrigation  of  the  abdominal  cavity  and  careful 
sponging  have  both  been  employed,  but  in  my  opinion 


thorough  irrigation  is  the  safer  procedure;  drainage, 
either  by  glass  tubes  or  gauze,  is  usually  required,  and 
pelvic  drainage  should  be  provided  for,  either  by  long 
tubes  or  by  a  counter-opening  near  the  pelvis. 


RECENT  PROGRESS  IN  THE  TREATMENT  OF  ACUTE 
LOBAR  PNEUMONIA.* 

By  JAMES  K.  CROOK,  M.D., 

of  New  York. 

It  may  be  doubted  whether  in  the  present  state  of 
our  knowledge  any  definite  routine  of  treatment  suit- 
able for  all  cases  of  pneumonia  can  be  safely  laid  down. 
Weighing  carefully  the  bulk  of  recent  testimony,  it 
would  appear  that  many  patients  would  do  fully  as 
well  without  any  drug  treatment  whatever.  According 
to  Eichhorst,^  for  the  past  15  years  cases  of  uncompli- 
cated pneumonia  occurring  in  young  and  strong  sub- 
jects have  received  in  the  clinic  at  Zurich  no  medica- 
tion except  a  weak  solution  of  phosphoric  acid.  Most 
of  these  patients  have  recovered,  yet  phosphoric  acid 
cannot  thereby  be  deemed  a  specific  for  pneumonia.  The 
patients  would  have  got  well  just  the  same  without  medi- 
cine. Even  under  the  most  unfavorable  circumstances, 
as  Osier  points  out,  the  disease  may  terminate  abruptly 
and  naturally  without  the  administration  of  a  dose  of 
medicine.  Young  practitioners  especially  should  bear 
in  mind  the  fact  that  patients  are  more  often  damaged 
than  helped  by  the  promiscuous  drugging  which  is  still 
only  too  prevalent.  All  of  the  late  writers  whose  opin- 
ions are  most  worthy  of  respect  «oncur  in  the  admoni- 
tion to  withhold  drugs  until  the  indications  for  them 
arise.  Concerning  the  most  desirable  methods  of  meet- 
ing the  indications,  however,  there  is  still  more  or  less 
variance.  But  it  will  be  seen  that  there  are  many  ther- 
apeutic procedures  regarding  the  value  of  which  men 
of  judgment  and  experience  are  practically  agreed,  so 
that  the  careful  seeker  after  information  may  easily 
select  a  plan  of  treatment  which,  if  it  will  not  hasten 
the  crisis  or  cut  short  the  disease,  will  at  least  contrib- 
ute to  the  patient's  comfort  and  possibly  tide  him  over 
dangerous  emergencies. 

On  the  Surroundings  of  the  Patient. — There  is  no  difi"er- 
ence  of  opinion  regarding  the  advisability  of  placing 
the  patient  in  a  cheerful,  well-ventilated  apartment  with 
a  temperature  as  nearly  as  possible  between  65°  and 
70°  F.  If  it  is  possible  to  do  this,  nothing  is  gained  by 
covering  the  patient  with  the  customary  "  pneumonia 
jacket"  of  cotton  batting  and  oiled  silk.  A  light  flan- 
nel undervest  with  the  usual  night-shirt  or  gown  is 
much  more  conducive  to  the  patient's  comfort,  and  in- 
terferes less  with  the  physician's  examinations  as  weU 
as  with  the  application  of  local  measures  of  relief  It 
is  also  agreed  that  the  patient's  food  should  be  of  a  fluid 
character,  wholesome  and  easily  digested.  Dr.  Andrew 
H.  Smith '  calls  attention  to  the  fact  that  the  adynamia 
is  due  to  systemic  poisoning  and  not  to  exhaustion, 
and  cautions  against  the  practice  of  overfeeding,  which 
is  liable  to  intensify  the  already  labored  respiration. 

On  the  Use  of  Poultices,  Ice,  etc. — The  time-honored  cus- 
tom of  enveloping  the  affected  side  in  a  big  flaxseed 
poultice  does  not  meet  with  much  encouragement  in 
recent  literature.  Most  writers  ignore  the  subject  alto- 
gether, and  those  who  refer  to  it  do  so  in  terms  by  no 

*  Read  before  the  Medical  Society  of  the  State  of  New  York,  Albany,  Janu- 
ary 29,  1901. 


344 


Thk  Philadelphia"! 
Medical  Jocesal  J 


ACUTE  LOBAR  PNEUMONIA 


^Feeebaey  16,  1901 


means  enthusiastic.  Broadbent'  states  that  poultices 
are  distressing  when  assiduously  applied,  and  thinks 
that  a  3-hour  application  twice  in  24  hours  is  sufficient. 
According  to  H.  F.  Williams  continuous  poulticing  de- 
vitalizes.* Blistering  also  appears  to  be  losing  favor. 
On  the  other  hand,  the  use  of  cold  applications,  includ- 
ing ice-bags,  has  become  a  well-established  therapeutic 
procedure  and  is  endorsed  by  almost  all  recent  writers. 
According  to  Thomas  J.  Mays,'  ice-bags  applied  to  the 
head  and  chest  reUeve  fever,  lessen  the  tendency  to  con- 
vulsions in  children,  allay  the  irritation  of  the  nervous 
system  in  adults,  limit  and  check  the  extension  of  the 
pneumonic  process  by  contracting  the  pulmonar\-  capil- 
laries,      abate  pain  in  the  chest,  support 

the  function  of  the  heart,  and  give  rest  and  comfort  gen- 
erally. This  method  has  the  further  advantage  of  being 
easy  of  application  and  of  not  being  opposed  by  the 
patient's  friends. 

Few  observers  claim  as  much  as  does  Mays  for  the 
ice-bag,  but  almost  without  exception  the  method  is 
cordially  recommended  by  recent  writers.  Sponge- 
baths  also  are  generally  advised.  Hare*^  recommends  that 
after  consolidation  has  taken  place,  hyperpyrexia  be 
treated  by  cold  sponging  with  friction  and  an  ice-bag  to 
the  head  and  heart,  but  no  internal  antipyretics.  It  is 
doubtful  if  anything  we  can  do  for  our  patients  is 
attended  by  less  danger  and  is  followed  by  more  grate- 
ful results  than  are  these  entirely  safe  and  simple  pro- 
cedures. (Vide  articles  by  Raw,'  Walton,*  ^\'illiams,* 
Dreschfeld,"  and  Rees.')  Baruch'"  believes  that  most  of 
the  indications  arising  in  pneumonia  may  be  success- 
fully met  by  properly  applied  hydrotherapeutics.  Ac-  i 
cording  to  Baruch,  thfe  method  of  treatment  fortifies 
the  nervous  system,  stimulates  the  heart,  renders  the 
patient  comfortable  by  reducing  high  temperature  and 
promoting  sleep,  and  makes  for  the  elimination  of 
noxious  products  arising  from  the  presence  of  the 
pneumococcus.  The  only  discordant  note  is  that  of  Sir 
Samuel  Wilks,"  who  maintains  that  cold  as  well  as  hot 
applications  are  harmful.  Cold  applications  are,  of 
course,  not  to  be  used  in  afebrile  cases  occurring  in  old 
and  feeble  persons. 

On  Blood-letting. — Almost  all  recent  writers  deplore 
the  general  abandonment  of  the  old-time  method  of 
blood-letting  in  pneumonia.  There  can  be  no  doubt 
that  our  ideas  regarding  this  procedure  are  undergoing 
a  cautious  revision.  Sir  William  Broadbent  voices  the 
general  sentiment  as  follows:'  "  Venesection  may  be  of 
great  service  when  invasion  of  the  lung  is  so  rapid  that 
the  right  ventricle  cannot  cope  with  the  sudden  resist- 
ance in  the  pulmonary  circulation  and  is  paralyzed  by 
overdistention.  Not  less  than  16  to  20  ounces'  should 
be  removed.  The  same  results  are  not  obtained  later 
when  asthenia  has  become  a  prominent  symptom, 
although  there  is  stiU  a  dilatation  of  the  right  heart." 
Frederico  Rubio"  believes  the  abandonment  of  blood- 
letting to  have  been  a  distinct  loss.  E.  Michel"  highly 
extols  the  value  of  venesection  as  a  standard  method  of 
treatment  in  the  early  stages  of  pneumonia,  with  the 
subcutaneous  introduction  at  the  same  time  of  a 
quantity  of  Hayem's  saline  solution  exactly  equalling 
in  amount  the  blood  withdrawn.  P.  K.  Pel,'^  director 
of  the  Medical  Clinic  at  Amsterdam,  advocates  vene- 
section in  severe  dyspnea  and  cyanosis,  and  believes 
that  it  may  often  save  life.  Sir  Hermann  Weber"  be- 
lieves the  popular  prejudice  against  bleeding  in  modera- 
tion to  be  unfounded.  Professor  Hermann  Eichhorst 
states  that  venesection  is  still  indicated  for  the  pulmon- 


arj'  edema  of  pneumonia,  and  asserts  that  he  has 
saved  many  patients  from  a  sufiFocative  death  by  a 
timely  resort  to  it.  The  change  for  the  better  occurs  so 
suddenly  that  no  one  can  doubt  the  relation  between 
cause  and  effect.  Eichhorst  is  of  the  opinion  as  a  con- 
sultant that  many  physicians  are  altogether  too  timid 
about  resorting  to  the  method.  Even  in  the  case  of 
drunkards  or  old  persons,  it  may  under  certain  cir- 
cumstances be  safely  performed. 

H.  F.  Williams*  recommends  venesection  in  robust 
persons,  10  or  1-5  ounces  of  blood  being  removed  from 
the  general  circulation  to  reUeve  an  overburdened 
heart.  William  Porter^'  goes  so  far  as  to  order  vene- 
section as  soon  as  the  diagnosis  is  well  estaVjlished ; 
that  is,  within  four  days  at  the  farthest  from  the  initial 
chill. 

It  is  the  present  writer's  opinion,  based  on  a  careful 
study  of  the  literature,  as  well  as  from  his  own  experi- 
ence, that  the  special  indications  for  venesection  are  as 
follows : 

Sthenic  type  of  the  disease  in  a  robust,  full-blooded 
person  and  in  an  early  stage. 

The  presence  of  a  forcibly  or  violently  acting  heart 
with  accentuation  of  the  pulmonar}-  second  sound. 

Dyspnea,  with  a  sense  of  suffocation  and  beginning 
cyanosis  of  the  face. 

These  indications  do  not  arise  often,  but  when  they 
do  occur,  the  practitioner  should  be  able  to  meet  them 
by  this  method,  the  swiftest  and  most  surely  effective 
at  the  command  of  medical  science.  The  amount  with- 
drawn is  not  to  be  gauged  by  drams  or  ounces,  but  by 
the  efiect  produced  upon  the  heart's  action  and  the 
respiration  which,  if  favorable,  will  be  practically 
instantaneous.  As  a  rule  it  is  safe  to  abstract  as  much 
as  20  ounces  in  an  average-sized  adult  patient,  although 
in  man}'  cases  half  that  quantity  will  be  sufficient. 

On  Arterial  Sedatives. — A  strong  feeling  has  undoubt- 
edly arisen  in  the  medical  world  against  the  indiscrimi- 
nate use  of  arterial  and  cardiac  sedatives.  Eichhorst' 
strongly  decries  the  use  of  veratrum  viride  and  tartar 
emetic,  which  formerly  possessed  such  an  extensive 
vogue.  The  latter  drug  appears  to  hsve  become  all  but 
obsolete.  So  able  an  observer  as  Hare,'  however,  still 
recommends  the  use  of  veratum  viride  in  sthenic  cases 
in  3  minim  doses  at  15  minute  intervals,  along  with 
sufficient  Dover's  powder  to  lessen  painful  cough  and 
increase  diaphoresis.  Such  treatment  should  be  con- 
tinued only  during  the  first  12  hours. 

Dr.  Melvin,'*  of  Colorado,  states  that  country  doctors 
throughout  the  West  still  adhere  to  veratrum  viride, 
believing  that  it  will  hasten  the  crisis  and  shorten  the 
course  of  the  disease.  Walton'  recommends  2  to  4 
minims  of  tincture  of  veratrum  viride  every  2  hours, 
or  oftener,  watching  the  effect  on  the  pulse  and  gradu- 
ally bringing  it  down  to  70  or  80  per  minute,  ^^'illiams* 
believes  in  the  administration  of  aconite  in  small  doses 
alternately  with  br^-onia  alba  for  sthenic  cases,  while 
Herman  Weber  stiU  maintains  that  small  doses  of  anti- 
mony may  be  beneficial.  C.  Z.  Weber"  also  recom- 
mends antimony,  as  well  as  aconite  and  veratrum 
%-iride,  under  certain  circumstances. 

It  will  thus  be  seen  that  this  plan  of  medication  still 
has  friends.  Most  practitioners,  however,  recognize  the 
danger  of  remedies  which  depress  the  power  of  the 
heart's  action,  and  it  is  not  to  be  doubted  that 
arterial  sedatives  are  used  with  much  less  freedom  than 
formerly.  It  is  the  author's  opinion  that  the  advan- 
tages claimed  for  these  agents  may  be  obtained  with 


Febeuary  16,  1901] 


ACUTE  LOBAR  PNEUMONIA 


rXBB  Philadelphia 
L  Mrdical  Journal 


345 


much  greater  safety  and  with  equal  effectiveness  by  the 
persistent  use  of  cold  sponge-baths  and  ice-bags. 

On  the  Use  of  Calomel  and  other  Purges. — It  was  cus- 
tomary at  one  time  to  begin  the  treatment  of  pneumonia, 
as  a  matter  of  routine,  with  free  purgation,  and  the 
mild  chlorid  of  mercury  was  the  agent  generally 
employed  for  this  purpose.  No  recent  writer,  however, 
seems  to  endorse  this  plan.  Cathartics  are  given  in 
accordance  with  the  requirements  of  the  individual 
case.  As  a  rule,  however,  calomel  is  still  the  purgative 
employed  when  such  treatment  is  required. 

Oft  Antipyretics. — The  use  of  internal  antipyretics  is 
mentioned  by  almost  all  the  writers  of  the  year,  but 
only  to  be  condemned.  Eichhorst '  is  the  only  author 
of  prominence  who  countenances  their  use  in  pneu- 
monia. This  writer,  who  is  opposed  to  the  use  of  cold 
baths,  still  endorses  the  exhibition .  of  phenacetin. 
Quinin  is  no  longer  used  for  its  antipyretic  effect, 
although  several  writers  mention  it  in  general  terms 
as  being  useful.     (  Vide  Raw.') 

On  the  Use  of  Opiates. — Regarding  the  employment 
of  opiates  in  pneumonia,  the  profession  is  still  at  vari- 
ance. Wilks  "  states  that  he  is  satisfied  when  he  sees 
a  patient  taking  a  saline  cathartic,  to  be  followed  by  a 
5  grain  Dover's  powder  every  4  hours.  Dreschfeld  " 
advises  morphia  for  insomnia  until  the  appearance  of 
expectoration,  when  it  may  become  dangerous.  A.  de 
Winter  Baker  ™  is  enthusiastic  for  the  use  of  Dover's 
powders  in  doses  of  5  grains  every  4  hours.  Eichhorst' 
states  that  opiates  should  not  be  given  as  a  rule.  The 
suppression  of  cough  and  secretion  and  the  resulting 
stasis  in  the  bronchi  may  place  the  patient  in  danger 
of  suffocation.  Especially  to  be  avoided  are  hypo- 
dermics of  morphia  for  pleuritic  jjain  which  may  be 
controlled  by  wet  or  dry  cupping  or  local  applications. 

In  the  face  of  the  rather  contradictory  evidence  re- 
garding the  use  of  opiates,  it  would  appear  to  be  a  good 
practice  to  withhold  them  until  positive  indications  in 
the  way  of  loss  of  sleep,  severe  pain,  or  intense  nervous- 
ness, makes  their  exhibition  necessary. 

On  the  Use  of  Alcohol. — The  best  sense  of  the  profes- 
sion at  the  present  day  is  not  in  favor  of  the  routine  use 
of  alcohol  in  pneumonia.  Yet  all  writers  who  mention 
it  admit  its  use  under  proper  conditions.  MicheP* 
believes  it  is  almost  always  indicated  in  alcoholic  sub- 
jects. According  to  Eichhorst,'  it  should  be  exhibited 
only  to  such  patients  as  require  a  promptly  acting 
stimulant  to  the  heart  and  perhaps  to  the  nervous  sys- 
tem. Hence  it  is  indicated,  as  a  rule,  only  in  the 
elderly.  In  youth,  alcohol  should  be  administered  only 
to  drunkards,  for  if  the  stimulant  in  habitual  use  be 
withdrawn,  we  have  to  fear  both  heart  failure  and 
delirium  tremens.  The  antithermic  influence  of  alcohol 
is  not  worth  considering.  Pel"  is  of  the  opinion  that 
in  typical  cases  there  is  almost  always  cardiac  weakness. 
Alcohol  is  then  usually  urgently  indicated,  and  often 
saves  life.  J.  M.  Allen''  gives  no  alcohol,  while  Walton' 
advocates  it  when  the  first  cardiac  sound  becomes  weak. 

Oilman  Thompson,"  in  his  recent  work  on  the  Prac- 
tice of  Medicine,  recommends  the  use  of  alcohol  when 
the  pulse  begins  to  fail  or  increases  in  frequency  to  120 
or  over.  He  advises  10  to  20  ounces  in  24  hours. 
Osier,"  however,  states  that  2  or  3  ounces  of  whisky  in 
the  24  hours  constitute  a  sufficient  dose  in  ordinary 
cases.  Broadbent,'  with  his  usual  felicity  of  expression, 
states  that  stimulants  are  rarely  necessary  but  often 
useful,  and  should  be  reserved  until  their  use  is  indi- 
cated.    It  does  not    appear    that    the    carbonate    of 


ammonia  is  prescribed  as  much  as  formerly.  It  is 
mentioned  in  a  casual  way  by  several  writers,  but  is 
usually  omitted  from  consideration.  It  is  the  writer's 
own  opinion  that  this  preparation  should  not  be  given 
unless  the  expectoration  is  exceedingly  viscid,  tenacious, 
and  difficult  to  raise. 

Digitalis  and  the  Cardiac  Tonics. — There  is  still  much 
<lifierence  of  opinion  relating  to  the  value  of  digitalis 
in  pneumonia,  but  the  weight  of  recent  experience 
offers  but  little -encouragement  to  its  use.  Michel'*  is 
opposed  to  its  employment  in  pneumonia.  He  states 
that  by  its  use  we  but  add  further  poison  to  the  already 
toxemic  circulation.  There  appears  to  be  no  proof  of 
Landouzy's  claim  that  digitalis  is  an  antidote  to  the 
pneumococcus.  Michel'*  prefers  the  use  of  caffein  when 
a  heart  tonic  is  required.  Eichhorst'  also  gives  preference 
to  caffein.  He  has  never  been  able  to  convince  himself 
that  digitalis  exerts  any  influence  whatever  on  the  in- 
flammatory process,  although  it  had  been  regarded  by 
Traube  and  his  followers  as  almost  a  specific. 

Eichhorst'  also  recommends  the  hypodermic  injection 
of  camphorated  oil  hourly  or  half-hourly  in  cases  where 
cardiac  weakness  is  extreme.  Pel"  informs  us  that 
camphor  is  the  most  trustworthy  analeptic  known  to 
medical  science.  In  cases  where  life  is  threatened  from 
failure  of  the  heart,  it  may  administered  in  large 
amount  subcutaneously  with  ether.  He  believes  that 
life  may  often  be  saved  by  this  means. 

Raw'  has  very  little  use  for  digitalis  in  pneumonia. 
In  case  of  rapid  heart  with  a  quick,  soft,  irregular  pulse, 
it  sometimes  does  good  in  large  doses — say  15  or  20 
minims  of  the  tincture  every  two  hours  until  two  drams 
are  taken  ;  or  ,V  or  TiV  of  a  grain  of  digitalis  may  be 
given  hypodermically  to  tide  the  patient  over  a  critical 
period.  Hare"  considers  digitalis  the  best  circulatory 
stimulant,  but  it  often  fails  because  of  high  fever.  If 
the  latter  is  reduced  by  hydrotherapy,  digitalis  is  most 
efficient.  Response  to  the  drug  is  so  slow  that  10  or  12 
minims  may  be  given  hypodermically,  and  so  lasting  that 
12  to  24  hours  may  elapse  before  repetition  is  necessary. 

All  writers  mention  the  use  of  strychnia  in  favorable 
terms.  It  may  probably  be  regarded  as  our  most 
valuable  cardiac  tonic  in  pneumonia.  Perhaps  the 
only  contraindication  to  its  use  is  a  state  of  high 
nervous  tension  with  active  delirium.  Nitroglycerin  is 
recommended  by  several  writers  as  a  cardiac  tonic  in 
pneumonia  in  the  one  condition  of  high  peripheral 
tension.  Its  use  is  not  advised  with  a  great  deal  of 
confidence  by  recent  authors. 

On  Oxygen  Inhalations. — The  use  of  oxygen  inhala- 
tions is  endorsed  by  some  recent  medical  writers,  and 
stated  to  be  useless  by  others.  It  is  admitted  to  be 
safe  by  all.  Salinger"  recommends  its  use  for  15 
minutes  every  2  or  3  hours  when  actual  dyspnea  is 
present.  Broadbent'  states  that  inhalations  of  oxygen 
are  of  direct  benefit  when  the  face  is  livid  and  the  lips 
blue,  and  with  strychnia  and  stimulants,  may  be  instru- 
mental in  saving  life.  Raw'  states  that  his  experience 
with  oxygen  has  been,  on  the  whole,  rather  disappoint- 
ing. No  recent  auther  speaks  very  enthusiastically  of 
the  remedy.  One  gains  the  impression  from  a  perusal 
of  recent  literature,  that  the  chief  advantage  of  oxygen 
inhalations  is  in  impressing  upon  the  patient's  friends 
that  everything  possible  is  being  done  to  effect  relief. 
One  well-known  consultant  states  that  he  generally  de- 
spairs of  the  patient's  life  on  seeing  an  oxygen  cylinder 
by  the  bedside  of  a  pneumonia  patient  to  whom  he  is 
called. 


QAg  The  Philadelphia"! 

Medical  Journal  J 


ACUTE  LOBAR  PNEUMONIA 


[Febsua^t  16,  1901 


On  the  Use  of  Saline  Infusions. — No  striking  contribu- 
tion to  this  subject  is  found  in  recent  literature.  The 
method  is  adverted  to  by  several  writers,  but  they 
offer  no  additions  to  our  knowledge.  William  Ewart 
and  Beaumont  PercivaP*  employed  a  saline  infusion 
with  rather  disappointing  results.  The  cases  reported, 
however,  were  exceptionally  severe  and  the  patients 
were  perhaps  incapable  of  recovery  under  any  method 
of  treatment.  They  regard  the  results  as  warranting  a 
further  trial  of  the  method  in  cases  with  anxious  prog- 
nosis. 

On  Specific  Medication. — In  a  paper'"''  read  before  this 
society  at  its  last  meeting,  the  author  considered  at 
some  length  a  scheme  of  medication  based  upon  the 
discovery  of  the  pathogenic  microorganism  of  pneu- 
monia. This  plan  of  treatment  embraces  two  separate 
and  distinct  methods  of  therapeutic  procedure,  as  fol- 
lows : 

1.  The  administration  by  the  stomach  of  certain 
drugs  tending  to  destroy  the  pneumococcus  by  ren- 
dering the  blood  an  unfit  medium  for  its  culture. 

2.  The  introduction  into  the  patient's  body  of  an 
animal  serum  tending  to  neutralize  the  toxic  influence 
of  the  products  of  bacillary  life.  In  his  former  paper 
the  writer  presented  an  outline  of  what  had  been  ac- 
complished by  this  scheme  of  treatment  up  to  that 
date.  During  the  year  which  has  elapsed  it  would 
appear  that  no  great  progress  has  been  made  in  the 
direction  of  a  specific  drug  treatment  directed  against 
the  pneumococcus.  Several  contributions  appear,  but 
they  do  not  embrace  a  large  number  of  cases  and  their 
results  are  consequently  not  of  special  significance. 
W.  0.  Bridges"  reports  2  cases  of  acute  lobar  pneu- 
monia successfully  treated  with  sodium  salicylate,  15 
grains  every  two  hours,  and  6  successful  cases  treated 
with  guaiacol  carbonate,  in  doses  of  8, 10,  and  12  grains 
every  two  hours. 

J.  M.  Allen"  advocates  the  use  of  sodium  salicylate 
in  15-grain  doses  with  milk  of  magnesia  every  four 
hours.  He  states  that  the  number  of  pneuniococci  in 
the  blood  and  sputum  were  markedly  diminished  dur- 
ing its  exhibition. 

Dr.  Chas.  F.  Stokes™  advocates  the  use  of  creosotal 
in  accordance  with  Dr.  Andrew  H.  Smith's  suggestions. 
He  administers  this  substance  with  apparently  good 
efTect  in  doses  of  12  minims  every  two  hours. 

Caccianiga'°  advises  the  internal  use  of  silver  salts 
in  the  specific  treatment  of  pneumonia,  and  reports 
the  results  in  112  cases  treated  in  this  way.  Two  and 
one-half  to  three  grains  in  pill  form  are  given  in  the 
24  hours,  or  the  drug  may  be  administered  suspended 
in  mucilage.  Under  this  method  the  mortality-rate 
was  17%,  whereas  under  other  forms  of  treatment  a 
death-rate  of  28%  was  observed.  Of  47  sporadic  cases 
only  3  died. 

Comini  also  successfully  treated  5  cases  with  silver 
salts.  A  sixth  case  treated  by  other  methods  died. 
These  reports,  while  somewhat  meager,  are  on  the  whole 
quite  encouraging  and  tend  to  stimulate  further  experi- 
ment in  this  direction. 

On  the  Use  of  Antipneumotoxin. — The  progress  of  se- 
rumtherapy  in  acute  lobar  pneumonia  cannot  be  said 
to  have  been  particularly  brilliant  during  the  year  1900. 
A  singular  dearth  of  activity  is  apparent  in  Prance  and 
Germany,  the  two  countries  to  which  we  naturally  turn 
for  advanced  information  in  this  department.  Anum- 
ber  of  tests  have  been  made  both  with  cultures  prepared 
from  the  blood  of  pneumonia  patients  and  with  animal 


serum,  and  several  clinical  reports  are  found  in  the  lit- 
erature of  the  year,  but  the  net  result  appears  to  leave 
us  about  where  we  were  one  year  ago.  Clinical  expe- 
rience has  been  too  meager  to  allow  of  any  positive  de- 
ductions being  made.  Further  than  this,  no  apparent 
progress  has  been  made  in  standardizing  the  antitoxic 
serum,  and  it  is  impossible  up  to  the  present  time  to 
secure  a  preparation  possessing  any  positive  stability. 

Chas.  B.  Canby '"  publishes  an  account  of  the  use  of 
Pane's  serum  in  .3  cases.  The  results  in  these  cases  ap- 
peared to  demonstrate  a  high  degree  of  value  in  the 
preparation,  each  case  being  followed  by  rapid  recovery. 

J.  C.  Wilson"  considers  in  detail  the  subject  of  serum- 
therapy  in  pneumonia,  and  reports  18  cases  treated  with 
McFarland's  antipneumococcic  serum  in  the  German 
Hospital  of  Philadelphia.  Of  the  18  cases,  4,  or  22%, 
died.  Three  of  the  fatal  cases  were  alcoholic,  while  in 
the  fourth  the  history  in  this  respect  was  unknown. 
The  duration  of  the  attack  in  the  serum  cases  was  5  to 
14  days.  Defervescence  usually  took  place  by  crisis  or 
rapid  lysis.  The  serum  was  administered  in  all  cases 
hypodermically,  the  total  quantity  varying  from  20  cc. 
to  460  cc.  The  immediate  effects  were  more  marked 
and  more  favorable  in  cases  in  which  recently  drawn 
serum  was  used  than  in  those  in  which  it  had  been 
drawn  for  a  longer  period.  They  consisted  in  general  of 
a  lowering  of  the  pulse- rate,  mitigation  of  the  pain,  and  a 
tendency  to  drowsiness.  No  results  could  be  attributed 
to  the  tri-kresol  in  the  serum. 

Dr.  McFarland,  in  his  discussion  of  Wilson's  paper, 
stated  that  the  serum  was  very  difficult  to  cultivate  and 
its  nature  uncertain.  It  might  be  antitoxic  or  anti- 
microbic,  but  was  probably  both.  Alexander  Lambert," 
however,  states  that  the  antipneumotoxic  serum  is  not 
bactericidal  but  bacteriolytic.  He  used  a  horse-serum 
by  subcutaneous  injection  in  12  cases  with  a  result  of 
9  recoveries  and  3  deaths.  It  seemed  to  cause  a  slight 
reduction  of  temperature  and  improvement  in  the 
pulse,  but  did  not  Dring  on  a  crisis  in  any  case.  In  two 
alcoholic  cases  the  serum  had  absolutely  no  effect.  He 
had  not  persisted  in  the  use  of  the  preparation  because 
he  had  been  unable  to  see  that  it  shortened  the  disease 
or  held  in  check  the  pneumonic  process.  Antoaio 
Fanoni"  reports  6  grave  cases  cured  with  antipneumo- 
toxic serum.  In  a  subsequent  communication**  the 
same  writer  states  that  he  has  successfully  treated  9 
additional  cases  by  the  same  means.  Several  other 
writers  report  isolated  cases  treated  with  the  serum,  but 
their  results  add  verv  little  to  our  stock  of  knowledge 
on  the  subject.  The  study  of  antipneumotoxin  is  still 
in  an  elementary  phase  of  development,  and  we  must 
await  further  progress  before  expressing  positive 
opinions  as  to  its  value. 

BIBUOGRAPHY. 

'  Eichhorst :  Thfrapeutische  MonaUchr/ie,  Fehruarr,  1900. 

=  A.  H.  Smith  :  Internal.  Med.  ila.nizine,  October,  1900. 

3  Broadbent:  Practitioner,  Jauuarj,  1900. 

<  H.  F.  Williams:  Broaklijn  Med.  Jour.,  .Vugust,  1900. 

"Thomas  ,1.  Mnvs:  Merck't  .irehiye.r.  May,  1S99. 

"  1[.  A.  Hare  :   fherapeulic  Oazetle,  No.  7,  1899. 

'  Rail :  Medical  Prett  and  Circular,  p.  417,  1900 ;  also,  Liverpool  Ittd.  Ckir., 
No.  .XX,  1000. 

«  Walton  :  nr.;iii.  .Ved.  Semimonlhlv.  No.  3,  1900. 

«  Rees  ;  S/.  Paul  .Medical  .lonrnal,  I9i)0. 

i»  Bariich  :  Boston  Medical  and  Suruical  Journal,  October  18,  1900:   also,  BL  f. 
klin.  Hiidrothrrapie,  Wien,  1900,  X,  225 :  see,  also.  Pick  :  Bl.  (.  tlin.  Hndrotkinipie, 
Wien.  i;'00,  X,  1<4. 
11  Wilts  :  Practitioner.  March,  1900. 
"  Dresohfeld  :  Practitioner,  March,  1900. 

"  Ruliio :  Rerisa  Ihero-.imerican  de  Cienciat  Med.,  December,  1S99. 
"  Michel :  I^  Bulletin  Medicale,  .\pril  U,  ISOO ;  see,  also,  Landouiy  :  Btrrm  i» 
Therap.  Med.-Chir.,  Ixvil,  1900,  p.  *iS. 
"  Pel :  Wiener  Med.  Pressc,  No.  IS,  1S>00, 
i«  Weber,  H. :  PractUioner,  March,  1900. 
"  Porter:  Pi{iL.\uBLriii.\  Mkdioal  Joi;rs.vl,  Decembar  15,1900. 


Fkbkuabt  16,  1901] 


PERIODICAL  INSANITY 


pTHn  Philadklphla 

L  MSDICAX  JOURBAI. 


347 


1^  MilwiD ;  TransactloDS  American   Medical  Aasociation,  1900 ;  also  Medical 
Record,  June  23,  1900. 
le  Weber,  C.  Z.:  Philadelphia  Medical  Jouenal,  September  29, 1900. 
2»  Baker  :  Brit.  Med.  Jour    Jane  16,  1900. 

21  Allen  :  Medical  Record,  June  2:i,  1900 ;  also  Transactions  American  Medical 
Association,  HiOO. 

22  Oilman  Thompson  :  A  Textbook  01  Practical  Medicine,  1900. 
2» Osier  :  The  Theory  and  Practice  of  Medicine,  1898. 

2' Salinger  :  Internal.  Med.  Mag.,  (Ictober,  19U0. 

25  Ewart  and  Perciral ;  Brii.  Med.  Jour.,  September  29,  1900. 

-«Crook  :  Transactions  N.Y.  State  Med.  Soc,  1900  ;  also  Medicine,  p.  277,  1900. 

27  Bridges :  Journ.  Amer.  Med.  Assn.,  xxxt,  p.  74, 1900. 

28  Stokes:  Brooklyn  Medical  Journal,  August,  1900. 

2»  Cacclaniga  :  Gazelle  degli  Ospedale  e  delle  Cliiiicti.,  p.  867,  1900. 

»Canby  :  Maryland  Med.  Jour.,  toI.  xlvil,  p.  113,  1900. 

8'  Wilson  :  Journ.  Amer.  Med.  Assn.,  September  8,  1900. 

»2  Lambert :  Medical  Record,  April  7,  1900. 

^  Fanoni :  Sierolherapia,  Fasc.  7,  1899  ;  also  N.  Y.  Med.  Journ,  Aug.  26,  1899. 

M  Fanoni :  Medical  Record,  p.  169,  1900. 

Other  important  papers  are  as  follows : 

Gallego,  T. :  Algo  del  tratamiento  de  la  pulmonia.  Siglo  Med.,  Madrid,  1900, 
xlvii,  666. 

Graves,  N.  A.:  Prognosis  and  Treatment  of  Acute  Lobar  Pneumonia.  Chicago 
Medical  Times,  1900,  xxxii,  243. 

Barr,  J.:  Zur  Klinik  (^er  Poeumonie.    3fed.  Bl.,  1900,  xxiii,  409-411,  427-428. 

Dominicis^  N.  de.:  Patogenesi  e  trapia  delta  polmonite.    Gazz.  Inlernaz.  di  Med. 


prat.,  Napoli,  1900,  iii,  199-201. 

Miiller,  C:  Zur  Behandliing  der  Luogenentziindung. 
Ztschr.,  Berlin,  1900,  xxix,  353. 


Deutsche  Mil.-Aerzll. 


PERIODICAL  INSANITY  * 

By  a.  R.  DEFENDORF,  M.D., 
Connecticut  Hospital  for  Insane,  Middletown,  Conn. 

Periodicity  in  mental  diseases  has  been  recognized 
from  earliest  times.  The  ancients  supposed  it  to  de- 
pend upon  the  phases  of  the  moon.  Later  it  was  asso- 
ciated with  atmospheric  conditions.  At  the  time  when 
psychiatry  came  to  be  recognized  ae  a  branch  of  medi- 
cal science,  it  was  a  generally  accepted  fact  that  all 
forma  of  insanity  tended  to  recur,  which  belief  is  held 
by  some  alienists  even  to  this  day.  Later  psychiatrists 
began  to  recognize  that  only  certain  cases  of  insanity 
showed  a  recurrence,  each  time  exhibiting  similar 
symptoms.  These  were  divided  into  two  groups,  pe- 
riodical mania  and  periodical  melancholia,  according 
as  they  presented  symptoms  of  excitement  or  depres- 
sion. Falret  and  Baillarger  next  called  attention  to  a 
very  small  number  of  cases,  originating  from  the  same 
groups,  mania  and  melancholia,  which  they  called /o^ic 
circulaire.  It  comprised  cases  in  which  the  periodicity 
was  characterized  by  a  regular  alternation  between  the 
mania  and  the  melancholia,  with  perhaps  a  short  inter- 
val of  lucidity. 

More  recently  many  psychiatrists  have  assigned  the 
name  periodical  insanity  to  a  definite  group,  which 
they  divide  into  periodical  mania,  periodical  melan- 
cholia, and  circular  insanity. 

Spitzka  says  of  this  group  :  "  Periodical  insanity  is 
characterized  by  recurrence  of  mental  disorder  at  more 
or  less  regular  intervals ;  the  attacks  being  separated  by 
periods  during  which  the  patients  present  a  state  of 
apparent  mental  soundness." 

Krafft-Ebing  presents  a  clearer  and  more  definite 
picture  of  this  group  of  psychoses,  which  he  describes 
as  being  characterized  by  anomaUes  of  the  emotions, 
formal  disturbance  of  thought,  accompanied  by  appro- 
priate actions  with  less  pronounced  delusion-formation 
and  infrequent  hallucinations.  He  includes  in  his  pe- 
riodical psychoses,  besides  the  periodical  mania,  period- 
ical melancholia,  and  circular  insanity,  dipsomania, 
abnormal  sexual  impulses,  and  menstrual  insanity. 

Finally  Kraepelin  has  given  the  most  complete  and 
definite  description  of  this  form  under  the  name  of 
manic-depressive  insanity,  assigning  to  it  fundamental 

*  Read  before  the  New  York  Neurological  Society,  October  2, 1900. 


symptoms  which  serve  to  difiFerentiate  the  disease  pic- 
ture at  the  very  onset. 

While  the  tendency  to  recognize  periodical  insanity 
as  a  distinct  disease  has  been  most  marked  among  the 
German  and  French  psychiatrists,  the  English  and 
American  writers  have  paid  little  attention  to  it.  Yet 
most  institutions  in  America  have  for  some  time  pre- 
served a  place  in  the  classification  of  their  cases  for 
those  which  show  a  periodicity.  They  have  been  vari- 
ously called  periodical  mania,  periodical  melancholia, 
recurrent  mania,  recurrent  melancholia,  recurrent  ia- 
sanity,  and  circular  insanity.  Almost  all  of  the  insti- 
tutions have  recognized  periodical  mania;  several 
circular  insanity ;  a  few  periodical  melancholia,  but  only 
a  very  few  have  noticed  that  close  relationship  existing 
between  these  difi'erent  groups,  which  warrants  their 
being  considered  as  one  form  of  mental  disease. 

The  examination  of  the  records  of  the  Connecticut 
Hospital  for  the  Insane  for  the  year  1899  shows  that 
15%  of  the  admissions,  which  numbered  426,  were 
cases  of  periodical  insanity.  Of  these  over  two-thirds 
were  patients  who  had  suSered  from  more  than  one 
attack.  The  records  of  the  Worcester  Insane  Hospital, 
where  the  writer  spent  two  years,  show  that  for  the  year 
1898,  14%  of  .the  admissions,  amounting  here  to  488, 
were  cases  of  periodical  insanity.  Of  these  almost  two- 
thirds  were  suffering  from  the  second  or  later  attacks. 
The  records  for  the  same  hospital  for  the  year  1899  give 
12%  of  the  548  admissions.  The  admissions  at  the 
McLean  Hospital  for  the  year  ending  October,  1899, 
show  over  23%  of  the  cases  to  be  suffering  from  this 
form  of  insanity.  The  records  of  these  institutions 
place  this  disease  in  point  of  numbers  second  only  to 
dementia  praecox. 

Periodical  insanity  may  be  described  as  a  mental 
disorder  which  recurs  at  intervals  throughout  the  life 
of  the  individual.  The  individual  attacks,  which  ap- 
pear in  one  of  three  forms,  the  maniacal,  depressive, 
or  mixed,  are  characterized  by  a  sufficiently  definite 
symptomatology  to  distinguish  them  from  other  forms 
of  mental  disease.  Your  attention  is  called  first  to  the 
symptomatology  of  the  maniacal,  depressive,  and  mixed 
forms,  the  citation  of  cases  illustrating  the  first  two, 
the  etiology,  the  course,  prognosis,  and  difi'erential  diag- 
nosis. 

In  the  maniacal  form  the  most  prominent  symptom 
is  found  in  the  psychomotor  sphere.  There  is  an  in- 
creased facility  in  the  cerebral  centers  for  the  trans- 
lation of  stimuli  into  action,  giving  rise  clinically 
to  what  may  be  called  a  pressure  of  activity.  Every 
impulse  immediately  leads  to  action.  The  patients 
cannot  remain  quiet,  are  constantly  in  motion,  go  from 
one  thing  to  another,  open  and  close  windows,  overturn 
furniture,  dance  about,  laugh  and  sing.  When  the 
condition  is  very  pronounced,  the  impulses  for  action 
crowd  upon  each  other  so  rapidly  that  they  are  unable 
to  accomplish  anything  coherently.  It  is  especially 
noticeable  in  speech.  The  pressure  of  speech  is  so 
strong  that  it  is  impossible  for  them  to  remain  silent. 
The  transfer  of  word  concepts  into  movements  of  speech 
is  greatly  facilitated,  so  much  so  that  the  internal 
associations  of  ideas  give  way  in  the  direction  of  the 
train  of  thought  to  the  purely  external  associations, 
and  we  have  instead  of  coherent  sentences  a  flight  of 
ideas,  and  phrases  abounding  in  sound  associations. 
The  following  is  an  example  :  "  Neatness  of  feet  don't 
win  feet,  but  feet  win  the  neatness  of  men.  Run,  don't 
run  west,  but  west  runs  east.     I  like  west  strawber- 


348 


Thk  Philadelphia"! 
MsDiCAL  Journal  J 


PERIODICAL  INSANITY 


[PXBEDAKT   16,  ISei 


ries  best."  The  same  is  noted  in  attempts  at  writing. 
Single  sentences,  or  phrases,  may  be  well  started,  but 
they  are  soon  resolved  into  a  senseless  enumeration  of 
catch  phrases,  bits  of  slang  and  rhymes.  In  connection 
with  this  intense  psychomotor  restlessness,  it  is  a  striking 
fact  that  there  is  a  great  diminution  of  the  sense  of 
fatigue.  The  patients  exhibit  no  signs  of  fatigue  after 
weeks  or  months  of  incessant  motion.  A  certain  in- 
sensibility to  pain,  heat  and  cold  is  part  of  the  same 
condition. 

In  the  field  of  apprehension  and  comprehension  there 
is  more  or  less  disturbance.  This  is  not  noticeable  in 
the  lightest  forms.  The  greatly  increased  distractibility 
of  attention  is  accountable  in  part  for  this.  Every 
striking  sense  perception  forces  itself  upon  the  patiente 
so  strongly  that  they  respond  immediately.  While 
speaking  of  one  subject,  a  sound  caught  up  from  the 
surroundings  distracts  them  and  leads  into  a  different 
train  of  thought.  In  this  way  they  lose  their  power 
to  choose  and  arrange  correctly  external  impressions. 

It  is  one  of  the  striking  features  that,  associated  with 
great  motor  restlessness  and  incoherence  of  thought, 
the  consciousness  is  mostly  unclouded.  The  patients 
continue  well  oriented  as  to  place,  persons  and  time. 
Their  repHes  may  not  clearly  demonstrate  this,  but  a 
careful  observation  of  the  actions  and  remarks  indicate 
that  they  are  acquainted  with  their  surroundings.  In 
the  extreme  maniacal  condition,  called  delirious  mania, 
the  consciousness  regularly  becomes  clouded,  but  even 
here  one  is  frequently  surprised  by  their  clear  appre- 
hension. 

The  disturbance  in  the  association  of  ideas  is  another 
prominent  symptom.  The  patients  are  quite  unable  to 
follow  out  any  definite  line  of  thought.  They  leap 
suddenly  from  one  thought  to  another.  Their  remarks 
show  a  strong  tendency  to  become  overburdened  with 
details  which  sooner  or  later  will  quite  divert  them 
from  the  original  thought.  The  associations  of  ideas 
which  are  common  to  the  everyday  life  are  the  ones 
which  play  a  prominent  role  in  their  numerous  digres- 
sions and  incoherent  statements.  The  patients  are  rich 
in  words,  not  in  ideas. 

Hallucinations  are  rare.  Likewise  delusion  formation 
plays  an  unimportant  role.  Delusions  when  present  are 
transitory,  unstable,  and  have  little  bearing  upon  the 
actions.  They  are  mostly  expansive,  occasionally  de- 
pressive, and  when  related  are  often  embellished  with 
numerous  fabrications. 

These  patients  very  often  show  some  insight  into 
their  mental  condition.  They  will  say,  "  I  am  crazy,  I 
know  I  am  crazy,"  but  they  rarely  appreciate  the  neces- 
sity for  their  confinement.  In  emotional  attitude  the 
patients  are  happy,  contented,  and  exhibit  a  feeling  of 
well-being.  They  laugh,  sing,  and  joke,  and  are  satis- 
fied with  their  environment.  But  more  characteristic 
are  their  rapid  and  sudden  changes  of  emotional  atti- 
tude ;  in  the  midst  of  joy  and  happiness,  they  tempo- 
rarily may  become  tearful,  complaining  and  abusive. 

In  the  depressive  forms,  the  most  characteristic 
symptom  common  to  all  is  the  psychomotor  retarda- 
tion, which  stands  in  contrast  to  the  psychomotor 
pressure  of  activity  of  the  maniacal  forms.  The  trans- 
lation of  sensory  stimuli  into  motor  impulses  is  very 
slow — is  retarded — and  in  the  most  pronounced  cases 
it  is  entirely  lacking,  giving  rise  to  the  condition  of 
stupor.  In  the  mildest  forms  it  appears  only  as  a  de- 
ficiency in  the  power  to  carry  out  that  which  has  been 
determined  upon.     They  recognize    the    necessity   to 


perform  a  certain  act,  they  determine  to  do  it, 
but  lack  the  power.  Simple  movements,  such  as  walk- 
ing and  talking,  are  performed  verj^  slowly  and  without 
energy.  The  condition  may  become  so  pronounced 
that  there  is  abolition  of  expression,  and  inability  to 
move,  to  leave  their  beds,  and  to  attend  to  the  calls  of 
nature,  or  even  to  utter  a  word,  presenting  the  picture 
of  stupor. 

The  association  of  ideas  undergoes  a  marked  change 
in  that  it  also  shows  retardation.  The  patiente  are 
silent  because  they  have  nothing  to  say.  In  marked 
contrast  to  the  maniacal  states  in  which  there  is  profuse 
production,  here  there  is  an  utter  dearth.  Their 
responses  to  simple  questions  are  uttered  slowly,  in 
low  tones,  and  are  monosyllablic,  indicating  a  lack  of 
reflection  and  a  poverty  of  ideas. 

The  emotional  attitude  is  uniformly  one  of  depres- 
sion, despair,  gloom,  and  anxiety.  The  field  of  apper- 
ception does  not  show  much  disturbance  except  in  the 
more  marked  cases  where  stupor  prevails,  then  there  is 
cloudiness  of  consciousness  with  disorientation,  or  a 
condition  of  dreamy  confusion.  Hallucinations  and 
delusions  are  prominent  features.  The  hallucinations 
are  mostly  of  hearing,  and  of  a  depressive  character. 
The  delusions  are  apt  to  be  uniformly  persistent  and 
stable,  and  are  accompanied  by  a  corresponding  emo- 
tional attitude,  which  is  more  or  less  constant  and  pro- 
nounced. The  delusions  at  first  maj'  be  only  of 
reference,  but  later  they  develop  into  ideas  of  persecu- 
tion and  self-accusations.  Delusions  of  a  somatic 
character  are  also  apt  to  prevail. 

The  mixed  form  comprises  a  mixture  of  these  two. 
Usually  one  type  predominates  over  the  other,  giving 
rise  to  two. forms,  the  maniacal  stupor,  where  the  de- 
pressive symptoms  are  the  most  prominent,  and  the 
stuporous  mania,  where  the  manaical  spmptoms  are  the 
most  marked.  In  the  former  the  patients  remain  the 
greater  part  of  the  time  in  a  stuporous  condition  with 
marked  psychomotor  retardation.  We  have,  interrupt- 
ing the  condition  for  short  periods,  a  typical  maniacal 
state  with  pressure  of  activity,  flight  of  ideas,  and  happy 
exhilarating  attitude.  These  patients  suddenly  jump  up 
from  their  seat  or  bed  and  waltz  about  the  room,  sing- 
ing, perhaps  overturning  some  fellow- patient  in  jest, 
and  after  a  few  minutes,  or  hours,  return  to  their  pre- 
vious stuporous  condition. 

In  the  condition  of  stuporous  mania,  the  typical  ma- 
niacal symptoms  are  interrupted  by  short  periods  of 
depression  with  retardation. 

As  illustrative  of  the  disease,  I  have  selected  two 
cases,  one  of  each  of  the  maniacal  and  the  depressive 
forms. 

Case  I. — J.  H.,  the  patient,  is  a  woman  19  years  of  age. 
Her  mother  is  said  to  be  insane.  She  ha*  a  ^ood  personal 
history.  At  18  years  of  age,  April,  1S99,  foUowmg  an  attack 
of  influenza,  she  became  despondent,  lost  all  activity,  showed 
retardation  in  moTement*  and  speech ;  as  expressed  by 
her  sister,  she  would  remain  seated,  unoccupied,  and  in  one 
place  for  the  entire  day,  and  barely  would  speak  a  word. 
She  expressed  no  delusions  or  hallucinations.  After  3  months 
she  slowly  regained  her  activity,  began  to  sew  and  engage  in 
housework.  She  then  explained  her  condition  by  saying  that 
she  had  felt  all  the  time  as  if  a  heavy  cloud  had"  settled  over 
her,  which  hindered  her  from  thinking,  moving  or  speaking. 
The  consciousness  was  clear.  In  the  fourth  and  tifth  months 
she  would  say  that  the  burden  was  lifting  and  that  she  was 
feeling  like  her  old  self. 

She  was  able  to  return  to  her  shop-work  by  November,  1S99, 
where  she  was  steadily  engaged  until  April  9,  1900.  She 
arose  that  niorning  saying  that  she  had  had  a  dream,  in 


Fbbedaby  16,  1901] 


PERIODICAL  INSANITY 


[Thk  Philadelphia 
Medical  Jocbnal 


349 


which  she  saw  a  man  who  had  laid  commands  upon  her 
and  had  threatened  to  kill  her  unless  she  obeyed.  She  im- 
mediately developed  great  psychomotor  activity,  singing, 
dancing,  talking  incessantly,  and  displaying  many  impulsive 
actions.  She  was  brought  to  the  hospital  on  the  fourth  day, 
at  which  time  she  showed  the  greatest  possible  pressure  of 
activity ;  her  movements  were  incessant,  of  great  variety, 
and  performed  with  much  energy.  She  would  rush  down 
the  corridor,  shouting  at  the  top  of  her  voice,  suddenly  stop- 
ping to  waltz  gracefully  a  few  times,  ending  at  the  door, 
which  she  would  pound  vigorously  as  an  accompaniment  to 
a  Bowery  song,  then  turn  about  and  commence  a  declamation 
abounding  in  sound  associations  and  accompanied  by  the 
wildest  gestures.  Suddenly  she  would  bend  on  her  knees  in 
an  attitude  of  prayer,  singing  softly  a  couple  of  bars,  and 
then  burst  out  in  boisterous  laughter,  making  a  dash  at  the 
clothing  of  the  nurse,  attempting  to  tear  it  from  her.  When 
forcibly  held  in  a  seat,  her  hands,  feet  and  head  were  in  con- 
stant motion,  sometimes  in  rhythm  to  a  song,  at  others  beat- 
ing a  tattoo.  It  is  characteristic  of  these  movements  that 
they  are  purposeless  and  never  show  stereotypy,  are  easy  and 
sometimes  graceful,  but  are  never  constrained,  which  points 
serve  to  differentiate  them  from  those  in  other  forms  of 
psychoses.  The  attention  cannot  be  attracted  except  by  per- 
sistent or  forcible  speech,  sometimes  accompanied  by  a  little 
shaking  of  the  shoulder,  when  she  answers  pertinently  in 
monosyllables,  but  is  sure  to  run  oft'  immediately  into 
irrelevant  remarks,  following  the  line  of  formal  associations. 
Frequently  a  bright  object  held  before  her  leads  quickly  to 
another  train  of  thought,  which  may  be  just  as  abruptly  dis- 
tracted before  half  expressed.  The  content  of  her  thought  is 
rich  in  words,  but  poor  in  ideas.  It  centers  about  her  former 
experiences  with  various  friends,  contains  many  proper 
names,  common  phrases,  slang  and  rhymes.  That  she  is 
keen  of  perception  at  times  is  indicated  by  occasional  re- 
marks which  demonstrate  that  she  knows  something  about 
where  she  is  and  those  associated  with  her.  Her  emotional 
attitude  changes  rapidly  ;  at  one  moment  she  is  laughing 
heartily  over  an  unattractive  picture  in  a  newspaper,  trying 
amiably  to  elicit  the  physician's  pleasure ;  at  the  next  she 
suddenly  assumes  the  attitude  of  defiance,  cursing  him 
roundly,  and  tries  to  relieve  him  of  some  of  his  clothing. 
At  times  she  seems  to  have  hallucinations  of  hearing  and 
appears  to  address  unseen  acquaintances.  Only  occasionally 
does  she  express  depressive  or  expansive  delusions,  which 
are  purely  transitory  and  in  no  way  influence  her  actions. 
The  reflexes  are  exaggerated.  Physically  the  sleep  is  very 
much  disturbed,  the  appetite  is  excellent,  and  she  maintains 
her  normal  weight  in  spite  of  her  greatly  increased  activity. 
This  condition  continued  without  abatement  or  change  for 
four  months,  at  which  time  the  great  activity  began  to  dis- 
appear and  the  train  of  thought  became  more  coherent. 
Since  then  improvement  has  been  gradual.  At  the  present 
time — after  7  months — there  still  remains  volubility,  and 
some  excessive  activity  and  business  about  trifles ;  otherwise 
the  attitude  and  coherence  of  thought  are  quite  normal. 

Case  2. — M.  F.,  a  patient  now  26  years  of  age  with  good 
family  and  personal  history.  At  22  years,  while  out  at 
service,  without  any  apparent  cause,  she  suddenly  became 
despondent,  lost  interest  in  her  work,  took  sparingly  of  her 
food,  became  dull ;  in  movements  gave  evidence  of  retarda- 
tion, was  slow,  sluggish,  spoke  at  first  in  low  tones,  and  in 
reply  to  questions  was  monosyllabic. 

She  did  not  express  delusions  or  give  evidence  of  any 
hallucinations.  The  consciousness  at  first  was  clouded.  In 
the  course  of  five  days  the  retardation  had  so  far  increased 
that  she  remained  in  bed,  paying  no  heed  to  the  calls  of 
nature,  and  becoming  almost  mute.  Once  or  twice  she 
exhibited  impulsive  movements,  when  she  attempted  to 
strangle  herself,  and  threw  her  clothing  out  of  the  window. 

Finally,  after  2  weeks,  she  refused  food  for  1  week.  After 
this  she  continued  profoundly  depressed.  Although  abso- 
lutely silent  she  would  carry  out  the  directions  of  the  nurse, 
showing  the  preservation  of  the  power  of  apperception,  but 
her  movements  were  exceedingly  slow  and  without  energy. 
After  5  months  she  became  a  little  more  active  and  did 
some  mending,  but  she  still  continued  silent.  In  the  follow- 
ing month  she  was  able  to  work  regularly  in  the  dining- 
room,  though  inclined  to  be  reticent  and  diffident.  She 
never  expressed  any  hallucinations  or  delusions.  In  3 
months  more  she  left  the  hospital  completely  recovered. 


with  clear  insight  and  fair  memory  for  events  of  the 
psychosis. 

She  immediately  reentered  service  and  continued  in  that 
employment  until  25  years  of  age,  when  she  again  suddenly 
became  despondent  without  evident  external  cause.  She 
became  listless  in  her  housework,  and  lacked  initiative.  In 
carrying  out  directions  she  required  repeated  prompting. 
Finally,  in  5  days  she  became  so  sluggish  that  she  would 
remain  unmoved  in  one  place  for  hours.  In  the  third  week 
she  expressed  hallucinations  of  hearing,  saying  that  she 
heard  some  one  about  her  repeating  that  she  was  bad,  and 
in  accordance  with  this  idea  she  would  frequently  move  her 
hand  as  if  to  brush  some  one  away.  She  was  able  to  rec- 
ognize her  former  acquaintances,  but  was  unable  to  speak 
to  them.  In  answer  to  questions  she  was  monosyllabic,  or 
would  simply  nod  or  shake  her  head.  Her  answers  were 
much  delayed,  sometimes  requiring  several  seconds  for 
utterance,  and  meanwhile  the  countenance  would  give 
evidence  of  effort.  For  a  few  days  at  a  time  she  would 
exhibit  some  restlessness  when  she  would  walk  slowly  up 
and  down  the  day  room  fidgeting  with  her  hands.  On  a  few 
occasions  she  was  heard  to  mutter  to  herself,  "  Oh,  let  me 
off  the  hall,  the  sinners  are  after  me,  let  me  die!  I  have 
caused  all  sin,  let  me  die,  so  that  I  can  stop  thinking  !  "  but 
most  of  the  time,  for  9  months,  she  sat  quietly  by  herself 
unemployed,  perfectly  mute,  with  dejected  countenance, 
not  even  expressing  delusions  when  questioned.  The  orien- 
tation was  undisturbed,  she  knew  perfectly  the  place,  those 
about  her,  and  the  day  of  the  week  and  month. 

She  then  gradually  became  interested  in  ward  work  and 
would  converse  in  low  tones  to  nurses,  but  not  until  4 
months  later  was  she  able  to  overcome  all  retardation,  to 
speak  out  in  natural  tones,  and  to  work  with  perfect 
freedom. 

During  the  attack  there  was  some  tendency  toward  consti- 
pation and  a  very  moderate  loss  of  weight. 

The  naost  prominent  etiological  factor  in  this  disease 
is  the  defective  heredity,  which  is  found  in  from  70-80% 
of  cases.  Occasionally  the  parents  have  suffered  from 
the  same  form  of  mental  disease.  It  often  happens  that 
the  first  attack  has  an  exciting  cause ;  this  is  especially 
so  in  women  when  it  appears  during  pregnancy  or  the 
puerperium. 

Other  exciting  causes  are  shock,  acute  diseases,  and 
mental  strain.  More  frequently  the  second  and  succeed- 
ing attacks  occur  independently  of  an  external  cause. 
It  occasionally  happens  in  vyomen  that  when  the  first 
attack  appears  during  puerperium  or  pregnancy,  the 
succeeding  attacks  recur  with  each  childbirth,  and 
almost  always  continue  to  recur  after  the  cUmacteric. 
The  first  attack  in  over  one-half  of  the  cases  appears 
before  the  twenty-fifth  year.  Less  than  lOfo  appear 
after  the  fortieth  year.  The  first  attack  is  more  often 
of  the  depressive  form.  Succeeding  attacks  are  likely 
to  be  of  the  same  type  as  the  first,  but  it  very  rarely 
happens  that  all  the  attacks  are  of  the  same  form.  At 
some  time  or  other  during  the  life  of  the  patient  who 
has  been  suffering  from  recurrent  attacks  of  one  form, 
an  attack  of  the  other  form  is  very  apt  to  appear.  The 
interval  between  the  individual  attacks  varies.  In 
4-5%  of  cases  the  attacks  pass  directly  from  one  into 
another,  alternating  between  the  maniacal  and  the  de- 
pressive forms,  presenting  the  picture  of  folie  circulaire 
In  the  other  cases  (95%)  the  invervals  vary  from  a  few 
weeks  to  many  years.  We  have  no  means  of  judging 
whether  the  intervals  are  to  be  short  or  extended.  The 
attacks  are,  however,  more  frequent  between  the  ages  of 
15-25,  and  again  during  the  climacteric. 

It  sometimes  happens  that  only  one  attack  occurs 
during  life,  but  when  there  is  but  one  attack  it 
differs  in  no  essential  particular  from  the  attacks  re- 
curring as  many  as  three  times  annually.  As  the  at- 
tacks are  repeated,  the  lucid  interval  tends  to  shorten, 


350 


The  PmiiiDELPHiA"! 


MEDICAL  EXAMINATION  OF  SCHOOL  CHILDREN        fhbecaey  le,  1901) 


and  the  duration  of  the  attacks  to  lengthen.  The  pa- 
tients do  not  suffer  from  mental  deterioration  except 
when  the  attacks  have  been  long,  frequent  and  severe. 
During  the  lucid  intervals  mental  faculties  are  retained. 
In  the  few  cases  when  the  attacks  have  been  long,  fre- 
quent, and  severe,  there  is  a  very  mild  degree  of  mental 
deterioration,  indicated  by  a  certain  amount  of  con- 
straint, a  lack  of  independence  in  action,  a  tendency  to 
be  morose,  unusual  susceptibility  to  fatigue,  sleepiness, 
and  a  diminished  capacity  for  work,  or,  on  the  other 
hand,  there  may  be  irritability,  self-consciousness,  and 
instability. 

The  prognosis  of  the  psychosis  is  bad,  in  view  of  the 
tendency  to  recurrence,  but  more  favorable  when  one 
considers  the  recovery  from  the  individual  attacks,  and 
the  prospect  for  lucid  intervals  of  varying  length,  during 
which  time  they  are  capable  of  caring  for  families  or 
returning  to  business. 

During  the  height  of  the  disease,  or  in  the  extreme 
maniacal  and  depressive  conditions,  death  may  occur 
from  exhaustion,  or  in  consequence  of  self-inflicted  in- 
juries. 

One  of  the  great  advantages  of  being  able  to  recog- 
nize this  form  of  insanity  at  the  onset  of  the  disease,  is 
the  comparative  certainty  in  forecasting  the  future 
course.  For  instance,  in  the  case  of  the  young  woman 
who  in  April,  1899,  developed  the  depressive  form  of 
periodical  insanity,  lasting  five  months,  then  enjoyed  a 
lucid  interval  of  seven  months,  when  she  suddenly  de- 
veloped an  attack  of  the  maniacal  form,  we  immediately 
offer  a  good  prognosis  for  the  present  attack,  with  a 
reservation  that  5%  of  cases  become  circular.  But  we 
emphasize  the  fact  that  she  probably  will  have  other  at- 
tacks at  varying  intervals,  and  furthermore  that  she  will 
never  suffer  from  great  mental  deterioration.  This  prog- 
nosis, which  we  are  able  to  outline  with  a  great  deal  of 
certainty,  aids  in  the  prevention  of  marriage  and  the  ex- 
cessive engagement  in  business,  both  of  which  patients 
are  very  apt  to  do  in  spite  of  the  moral  restriction 
placed  upon  them  by  the  physician. 

That  periodical  insanity  with  such  a  definite  sympto- 
matology, course  and  outcome,  has  failed  of  recognition, 
except  by  its  periodicity,  is  evidenced  by  the  fact  that 
those  who  describe  it  say  that  it  can  be  recognized  only 
in  this  way. 

Spitzka  says  that  "  the  dcliria  if  present  are  apt  to 
be  of  a  reasoning  character,  while  moral  or  affective 
perversion  and  certain  propensities  and  impulses  not 
ordinarily  found  in  the  simple  insanities,  serve  to  indi- 
cate the  character  of  the  disorder.  Aside  from  these 
signs  it  is  only  the  history'  of  the  case  revealing  the 
periodical  recurrence  of  similar  attacks,  which  serves 
to  justify  a  diagnosis  that  the  disorder  is  probably  a 
periodical  one." 

Chapin  notes*that  the  actions  in  the  recurrent  in- 
sanity are  not  unlike  those  described  as  characterizing 
mania  or  melancholia  in  its  various  manifestations. 

Kirchhoff  says  in  his  description  of  periodical  in- 
sanity, especially  in  reference  to  the  periodical  mania, 
that  diagnostic  doubt  can  only  be  removed  by  the 
repetition  of  the  attacks. 

Berkley  says  "  the  diagnosis  of '  periodical  melancho- 
lia '  can  only  be  made  out  with  certainty  when  a  recur- 
rence has  taken  place."  Of  circular  insanity,  he  says 
that  the  diagnosis  "  can  only  be  made  upon  the  basis  of 
an  indubitable  history  of  the  disease  and  of  the  family 
record,  or  after  observation  for  months  or  years." 

Periodical  insanity  is  distinguished  from  dementia 


praecox  by  its  more  rapid  onset,  absence  of  mental 
deterioration,  and  the  periodicity  of  the  course.  The 
depressive  forms  of  periodical  insanity  are  distinguished 
from  the  conditions  of  depression  encountered  in 
dementia  praecox  by  the  existence  of  retardation,  the 
uniformity  of  the  emotional  attitude,  the  continuous 
presence  of  depressive  delusions.  The  stuporous  state 
in  the  catatonic  form  of  dementia  praecox  is  distin- 
guished by  negativism,  muscular  tension  and  the  tend- 
ency to  constrained  positions.  The  conditions  of  ex- 
citement which  occur  in  dementia  praecox  differ  from 
the  maniacal  forms  of  the  periodical  insanity  by  the 
absence  of  pressure  of  activity  and  flight  of  ideas  with 
formal  associations,  and  by  the  presence  of  delusions 
and  hallucinations.  The  latter  if  present  in  the  mani- 
acal states  are  infrequent,  unstable,  and  have  but  little 
bearing  upon  the  actions. 

In  conclusion  we  may  say  that 

a.  periodical  insanity  is  a  mental  disease  character- 
ized by  a  definite  symptomatology,  course  and  outcome. 

h.  It,  in  point  of  numbers,  is  one  of  the  most  promi- 
nent psychoses. 

«.  The  symptoms  are  sufficiently  characterized  to 
permit  a  diflerentiation  from  other  forms  of  mental 
disease  in  the  first  attack, 

d.  and  allow  the  forecast  of  the  whole  course  of  the 
disease,  i.  e., 

e.  recurrence  of  attacks  throughout  the  life  of  the 
individual,  mostly  of  the  character  of  the  first, 

/.  with  lucid  intervals  of  varying  length  from  weeks 
to  years,  except  in  very  small  percentage  of  cases, 

g.  without  a  tendency  to  mental  deterioration,  except 
in  cases  where  the  attacks  have  been  long,  frequent, 
and  severe,  and  even  then  it  is  of  a  light  grade. 


MEDICAL  EXAMINATION  OF  SCHOOL  CHILDREN.* 

By  EDW.\RD  M.  GREEXE,  M.D., 

Medical  Inspector  of  Schools,  Boston,  Mass. 

The  first  city  in  this  country,  or  abroad,  to  establish 
a  system  of  daily  medical  inspection  in  all  the  public 
schools  was  Boston.  Since  then  similar  methods  of 
inspection  have  been  adopted  in  New  York  City.  Chi- 
cago, and  in  most  of  the  large  cities,  as  well  as  in  many 
of  the  smaller  towns.  Within  a  few  years  we  may  ex- 
pect to  see  some  method  of  medical  inspection  in  gen- 
eral used  throughout  the  country.  The  important 
questions  are  how  comprehensive  and  searching  an 
inspection  is  desirable,  or  practicable,  and  how  to  organ- 
ize and  conduct  the  work  in  the  most  efficient  manner. 

I  can  probably  serve  you  best  by  giving  you  the  de- 
tails of  the  system  in  use  in  Boston,  and  the  results  of 
my  own  observation  and  experience  as  a  Medical  In- 
spector for  the  past  7  years. 

Medical  inspection  of  schools,  both  public  and  paro- 
chial, was  begun  in  Boston  in  the  fall  of  1894  and  was 
secured  only  as  the  result  of  4  years  of  persistent  effort 
on  the  part  of  the  efficient  and  progressive  chairman  of 
the  Boston  Board  of  Health,  Dr.  Samuel  H.  Durgin. 
The  immediate  occasion  which  made  his  appeals  suc- 
cessful was  the  unusual  prevalence  of  diphtheria  in 
Boston  during  the  year  1894. 

The  system  of  inspection  is  under  the  control  of  the 
Board  of  Health.     The  School  Committee  cooperates 


*  Paper  read  at  the  meeting  of  the  PioTidence  Medical  Association  on  Febru- 
ary 4,  1901. 


Fkbbuabt  16,  1901] 


MEDICAL  EXAMINATION  OF  SCHOOL  CHILDREN 


LTuB  Pbiladelpbia 
Mkdical  Journax 


351 


cordially  in  the  work,  by  giving  permission  for  inspec- 
tors to  enter  the  school  buildings  and  examine  pupils, 
and  by  directing  teachers  to  watch  for  cases  of  illness 
and  to  bring  them  to  the  notice  of  the  inspectors. 

The  masters  and  teachers  appreciate  the  fact  that  this 
work  is  beneficial  to  themselves  as  well  as  to  the  pupils, 
and  are  anxious  to  cooperate  in  carrying  it  out.  The 
parents  see,  with  approval,  that  their  children  are  safe- 
guarded from  danger,  and  from  the  general  public  noth- 
ing has  been  heard  but  commendation. 

Inspectors  are  generally  selected  from  the  younger 
men  in  general  practice,  as  they  have  most  time  to  de- 
vote to  the  work.  Many  of  them  have  been  hospital 
internes.  They  must  be  interested  in  the  work,  dis- 
creet, and  tactful,  and  it  is  desirable  that  they  should 
live  in  the  locality  of  the  schools  assigned  to  them. 
There  have  always  been  some  homeopathic  doctors 
among  the  Boston  inspectors.  The  work  has  nothing 
to  do  with  therapeutic  systems,  but  requires  only  the 
ability  to  make  accurate  diagnosis.  In  establishing  a 
work  of  this  kind  it  is  important  to  have  the  support  of 
the  whole  community.  Women  physicians  have  not 
yet  been  appointed  in  Boston,  but  I  am  told  they  have 
been  in  New  York.  If  otherwise  qualified  they  would 
make  good  inspectors,  especially  in  the  higher  schools 
for  girls. 

The  number  of  pupils  in  the  public  schools  of  Boston 
is  about  80,000,  and  there  are  about  13,000  more  in  the 
parochial  schools.  There  are  250  school  buildings,  and 
60  inspectors  of  schools,  each  doctor  thus  having  5 
schools  and  nearly  2,000  children  under  his  care. 

The  pay  of  inspectors  in  Boston  is  only  $200  a  year. 
Though  the  salary  is  small,  the  position  is  an  honor- 
able one,  and  likely  to  increase  a  young  man's  reputa- 
tion though  not  his  practice  directly.  Children  are 
not  allowed  to  go  to  his  house  in  connection  with  school 
work,  and  any  that  he  finds  ill,  are  carefully  directed 
to  call  in  their  own  family  physician,  or,  if  poor, 
directed  to  a  proper  hospital. 

To  maintain  faithful  and  efficient  work  on  the  part 
of  the  inspectors  some  central  supervision  is  necessary. 
A  monthly  report,  filled  out  on  a  printed  form  is  re- 
quired from  each  inspector.  The  report  contains  a  list 
of  the  dififerent  diseases  observed,  and  the  number  of 
cases  of  each  disease  found  in  each  school.  It  also 
records  the  number  of  pupils  sent  home ;  the  number 
of  vaccinations  performed,  the  number  of  consultations 
with  teachers  in  regard  to  such  matters  as  sending 
children  out  of  school  for  contagious  disease  at  home, 
the  determining  when  they  may  return  to  school, 
and  giving  advice  to  the  teacher  on  any  other  sub- 
ject. On  the  back  of  the  blank  forms  there  is 
printed  a  classified  list  of  the  important  or  common 
diseases.  To  secure  uniformity  and  accuracy,  the  in- 
spectors are  requested  to  use  this  approved  nomencla- 
ture in  making  their  reports.  Inspectors  should 
familiarize  themselves,  if  necessary,  with  the  symptoms 
and  appearances  of  all  the  diseases  there  mentioned. 
This  involves,  among  other  things,  a  considerable  knowl- 
edge of  diseases  of  the  skin,  which  is  not  always  pos- 
sessed by  the  general  practitioner. 

These  reports  are  mailed  at  the  end  of  each  month 
to  the  secretary  of  the  Board  of  Health,  who  can  then 
form  some  opinion  of  the  amount  and  quality  of  the 
work  done  by  each  inspector.  At  the  end  of  the  year 
all  the  reports  are  tabulated  and  published  in  the 
annual  report  of  the  Boston  Board  of  Health. 

An  association  of  the  medical  inspectors  has  been 


formed  which  holds  meetings  from  time  to  time,  and  is 
presided  over  by  the  chairman  of  the  Board  of  Health. 
The  objects  of  the  association  are  :  to  make  the  men 
acquainted  with  each  other;  to  establish  an  esprit  de 
corps;  to  secure  uniformity  of  decision  on  questions  of 
school  attendance,  in  order  that  children  of  the  same 
family  in  different  schools  may  be  alike  excluded,  or 
admitted,  after  there  has  been  contagious  disease  at 
home ;  to  discuss  the  methods  by  which  the  contagion 
of  diphtheria,  and  similiar  diseases,  may  be  spread  in 
the  schools,  the  criteria  for  determining  when  the 
danger  of  contagion  is  ended,  etc.  The  association  has 
been  addressed  occasionally  by  specialists  in  diseases 
of  the  eye,  ear,  nose,  and  throat,  etc.,  who  have  dis- 
cussed the  diseases  of  those  organs  which  have  especial 
importance  in  relation  to  our  school  work. 

Let  us  now  follow  the  inspector  as  he  makes  his  daily 
rounds.  He  has  to  deal  with  teachers  as  well  as  pupils. 
The  former  receive  such  instructions  in  regard  to  the 
early  symptoms  of  contagious  diseases  as  helps  them 
to  promptly  detect  suspicious  cases,  and  send  them  to 
the  inspector  for  examination.  They  are  taught  the 
importance  of  having  the  child's  eyes  examined  when 
there  is  a  complaint  of  habitual  headache,  and  the 
necessity  of  examination  for  polypi,  or  enlarged  tonsils, 
in  mouth-breathers,  and  many  other  useful  things. 

The  inspector  sees  only  those  children  to  whom  his 
attention  is  called  by  a  printed  slip  on  which  the 
teacher  has  filled  out  the  date,  name  of  the  child,  the 
number  of  the  school  room,  and  the  complaint  which 
the  child  makes,  or  the  symptoms  which  the  teacher 
has  noticed.  These  slips  are  filled  out  soon  after  the 
opening  of  school,  and  deposited  in  a  convenient  place 
where  the  inspector  finds  them.  On  his  arrival  at 
school,  each  child  is  sent  out  to  him  for  examination. 
On  each  child's  slip  he  records  his  own  diagnosis,  and 
his  advice  in  regard  to  excluding  the  child  from  school 
or  not,  and  any  remarks  he  wishes  to  make  for  the  in- 
formation of  the  teacher.  The  child  hands  the  slip  to 
the  teacher,  and  the  latter  sends  it  to  the  master,  who 
is  obliged  to  keep  these  slips  on  file,  thus  preserving  in 
each  school  a  record  of  all  the  illness  that  occurs  there. 
An  opinion  can  then  be  formed  in  regard  to  the  relative 
sanitary  condition  of  each  building.  Questions  of 
drainage,  plumbing,  heating,  and  ventilation,  are  not 
considered  by  the  medical  inspectors,  but  are  referred 
for  investigation  to  special  experts  of  the  Board  of 
Health. 

The  children  who  come  under  our  inspection  may 
be  divided  into  two  classes:  1.  Those  who  are  the  sub- 
jects of  contagious  disease,  and  who  must  be  excluded 
from  school  tor  the  benefit  of  the  other  children.  2. 
Those  who  are  suffering  from  noncontagious  though 
perhaps  severe  and  disabling  disease,  or  who  are  men- 
tally or  physically  below  the  normal  standard.  Some  of 
this  second  class  may  be  advised  to  stay  out  of  school, 
as  in  cases  of  certain  acute  diseases  of  the  eyes,  or  ears, 
ozena  (if  particularly  off"ensive),  spinal  caries,  epilepsy, 
etc.  A  considerable  number  of  children  of  the  first 
class  are  found, — those  who  are  suffering  with  the 
specific  infectious  diseases,  or  with  contagious  parasitic 
skin  diseases.  Some  are  found  among  the  poorer  chil- 
dren, who  have  returned  to  school  after  some  unreported 
illness,  for  which  they  have  had  no  physician,  and  in 
whose  throats  the  bacilli  of  diphtheria  are  sometimes 
discovered  ;  others  are  found  to  be  still  in  the  desqua- 
mating stage  of  scarlet  fever. 

The  inspector  should  always  have  with  him  one  or 


352 


The  Philadelphia"] 
Medical  Jocrnal  J 


TETANUS  FOLLOWING  CLEAN  OPERATION  WOUNDS 


IFebecast  16,  IStl 


more  of  the  diphtheria  culture  outfits,  which  are  sup- 
plied by  the  Board  of  Health,  and  take  a  culture  from 
every  case  of  acute  pharyngitis,  or  tonsillitis,  which  he 
sees.  Many  cases  of  diphtheria  can  be  discovered  in 
no  other  way.  After  a  culture  has  been  made,  the  child 
is  sent  home  to  remain  until  a  report  has  been  received 
from  the  laboratory  on  the  following  day.  If  a  case  of 
contagious  disease  is  discovered  the  child's  books  are 
wrapped  up  in  a  bundle  and  sent  to  the  Board  of 
Health  for  disinfection  or  destruction,  and  the  desk  and 
seat  are  washed  by  the  janitor  with  a  strong  solution  of 
corrosive  sublimate  or  formaldehyde. 

If  more  than  one  contagious  disease  is  found  in  any 
room  every  child  is  sometimes  examined  by  the  inspec- 
tor. Clinical  thermometers  are  never  used,  on  account 
of  the  difficulty  of  thoroughly  disinfecting  them.  For  a 
tongue  depressor  a  thin,  narrow  piece  of  pine  wood  is 
used  and  burned  after  use,  so  that  nothing  is  carried 
from  one  child's  mouth  to  another's.  This  is  a  very 
important  precaution,  and  has  been  the  means  of  fore- 
stalling criticisms.  The  practice  of  having  a  child  use 
his  own  finger  for  a  tongue  depressor  is  strongly  con- 
demned, in  spite  of  its  convenience,  as  the  soiling  of 
the  fingers  with  the  secretions  of  the  mouth  would 
greatly  increase  the  danger  of  spreading  the  contagion. 

The  question  of  excluding  children  affected  with 
pulmonary  tuberculosis  has  arisen.  For  the  child's 
own  sake,  as  well  as  to  protect  others,  we  advise  the 
exclusion  of  such  children. 

To  protect  the  healthy  from  the  dangers  of  contagion 
is  hardly  more  important  than  to  improve  the  condi- 
tion of  those  who  are  more  or  less  defective  physically. 
Often  they  may  be  advised  of  the  measures  necessary 
to  make  them  healthy  and  vigorous  and  to  greatly  im- 
prove their  capacity  for  pleasant  and  profitable  study. 
It  has  been  a  great  satisfaction  to  me  to  have  detected 
numerous  cases  of  pre\nously  unsuspected  chronic 
hypertrophy  of  the  tonsils,  or  of  adenoid  disease,  and 
to  have  pointed  out  to  these  delicate,  chronically  ailing 
children  the  importance  of  being  carefully  treated  by 
experts  in  diseases  of  the  throat  and  nose.  At  my  sug- 
gestion the  teacher  often  writes  a  note  to  the  parents 
explaining  the  conditions  found,  and  the  importance  of 
treatment  The  improvement  of  mind  and  body  that 
is  later  obser^-ed  in  these  children  is  remarkable.' 

Another  very  important  subject  which  is  brought  to 
our  attention  daily  is  that  of  imperfect  vision,  with  its 
resultant  evils  of  eye-strain,  habitual  headache,  and 
nervous  debility.  Such  cases  are  very  frequent  When 
there  is  no  visible  lesion ;  we  roughly  test  the  child's 
ability  to  read  printed  matter  or  figures  on  the  black- 
board at  normal  distances,  and  if  this  is  not  easily  done, 
or  if  there  is  habitual  headache  without  other  obvious 
cause,  we  have  the  parents  advised  to  take  such  chil- 
dren to  an  oculist  for  expert  examination.  Many  of 
them  go  to  hospital  clinics  where,  I  am  sorry  to  'say, 
they  are  sometimes  turned  over  to  young  and  incoin- 
petent  assistants,  and  return  to  school  wearing  improper 
glasses,  and  without  relief  from  their  unpleasant  symp- 
toms. The  labor  of  examining  so  many  cases  o*"  errors 
of  refraction  proves  tedious  and  uninteresting  to  the 
older  and  abler  occulists  of  the  hospital  staff.  Certainly 
great  good  could  be  accomplished  by  having  a  compe- 
tent oculist  make  a  sy.'temutic  examination  at  the 
school,  once  at  least,  of  all  the  children  in  the  grammar 
flchool  grad&  The  Boston  Board  of  Health  has  not  yet 
been  able  to  see  its  way  to  having  this  service  per- 
formed. 


Much  has  been  done  in  giving  advice  to  individual 
pupils  on  the  subject  of  proper  clothing,  food,  exercise, 
and  cleanliness.  Inspectors  are  sometimes  invit^  to 
address  the  teachers  of  their  schools  on  such  subjects, 
and  sometimes  mothers  of  younger  children  have  been 
present  to  hear  such  addresses. 

A  great  and  salutary  lesson  in  personal  cleanliness, 
and  one  long  remembered,  was  taught  the  children  a 
few  years  ago  when  a  s\'stematic  inspection  was  made 
of  the  heads  of  all  the  school  children  in  Bo-ton.  for 
the  purpose  of  discovering  pediculi  capitis.  One-half 
of  all  the  children  were  found  to  be  infected,  more  or 
less,  with  these  parasites,  in  some  cases  to  a  very  dis- 
graceful extfint.  In  one  of  my  primary  schools,  where 
the  pupils  were  nearly  all  children  of  ignorant  foreign- 
ers recently  arrived  from  the  "  old  country,"  nine  tenths 
of  all  the  children  were  found  to  be  infected.  The 
need  of  proper  treatment  was  so  urgent  that  an  excep- 
tion was  made  in  this  one  instance  to  the  rule  forbid- 
ding the  giving  of  prescriptions,  and  each  infected 
chUd  was  given  printed  directions  to  buy  and  properly 
use  a  good  supply  of  crude  petroleum.  Tnose  who 
were  found  on  subsequent  examination  to  have  neglected 
this  advice  were  promptly  excluded  from  school  until 
they  returned  clean.  Some  heart-burning  was  occa- 
sioned among  the  mothers  and  children  of  the  better 
class  who  were  taken  by  s'arpri^e  at  our  diagnosis,  but 
we  heard  much  more  of  commendation  than  of  criti- 
cism. Some  amusing  incidents  occurred.  One  email 
boy,  ignorant  of  the  object  of  the  examination,  told  his 
mother  on  returning  home  that  the  doctor  had  exam- 
ined his  head,  and  had  told  the  teacher  "  there  was 
nothing  in  it.''  The  fond  mother  at  once  entered  a 
violent  protest  against  having  her  young  hopeful  put 
into  a  class  with  idiots. 

Shower-baths  have  been  put  into  the  basements  of 
some  of  the  recently  constructed  school  buildings,  and 
children  are  now  allowed  and  sometimes  requested  to 
make  a  systematic  use  of  them  during  school-hours. 

Innumerable  other  questions  may  suggest  themselves 
to  you  in  regard  to  this  work,  as  I  have  attempted  to 
present  only  the  most  important  features  of  the  subject 


TETANUS  FOLLOWING  CLEAN  OPERATION  WOUNDS.* 

Br  JOSEPH  B.  BISSELL,  M.D.. 

of  Kew  York. 

Viiltiog  Surgeon  to  Bellerue  uid  St.  Viocenft  Hoapiula. 

The  sudden  advent  of  symptoms  of  tetanus  after  an 
apparently  clean  operation,  where  the  wound  had 
united  by  first  intention,  without  atiy  indication  of 
other  infection,  is  so  rare  that  the  following  2  ca->es  seem 
worthy  of  consideration ;  more  especially  because  in 
both  cases  the  disease  went  on  to  a  fatal  termination. 

The  operations  were  months  apart  Both  took  place 
in  St.  Vincent's  Hospital  in  New  York  City.  One  was 
operated  upon  by  myself,  and  the  other  by  my  colleague. 
Dr.  John  Aspel.  One  occurred  in  one  building  of  the 
hospital,  the  other  in  another  building.  These  build- 
ings are  at  different  ends  of  a  city  block,  only  con- 
nected with  each  other  by  a  long  corridor.  Neither 
operator  was  present  at  the  other's  operation.  There 
was  a  separate  staff  of  assistants,  as  well  as  nurses. 
None  of  the  instruments  were  used  in  both  operations. 

*  Resd  befon  the  New  York  Sute  Medical  Society  u  Aibuij.  Jtaaarj  SI.  IML 


Fkbruaet  16,  1901] 


TETANUS  FOLLOWING  CLEAN  OPERATION  WOUNDS 


FThi  Philadelphia. 
L  Mkdical  Journal 


353 


The  ether  was  given  in  both  cases  by  the  same  physi- 
cian. The  catgut  used  was  prepared  and  treated  in  the 
same  room  and  by  the  same  person,  and  taken  from 
the  same  general  reservoir  in  both  cases  ;  but  the  dress- 
ings as  well  as  the  instruments  had  been  kept  in  different 
operating  rooms.  The  above  two  circumstances  are  all 
that  the  2  cases  have  in  common.  Several  hundred 
other  cases  before  those  operations  and  since  have  had 
the  same  etherizer  and  the  same  catgut,  and  there  have 
been  no  other  cases  of  tetanus.  It  would  seem  fair, 
therefore,  to  throw  out  any  suspicion  of  their  complicity 
in  the  infection.  Both  these  cases  were  women,  and 
both  were  abdominal  operations,  in  a  sense. 

C.iSE  1.— P.  H.,  female,  36  years  old,  German  nativity. 
Family  history  negative.  Her  general  health  had  always 
been  of  the  best  A  few  years  'go  she  had  had  some  trouble 
with  her  teeth,  and  several  had  been  drawn  She  wore  a 
plate  of  false  teeth  when  she  entered  the  hospital.  Had  had 
three  children;  last  child  two  years  ago.  All  of  her  labors 
normal,  and  children  healthy.  About  six  months  ago  her 
present  condition  began.  Her  sym  toms  became  gradually 
worse,  until  up  'n  entering  the  hospital  she  had  a  prociden- 
tia uteri  to  a  degree  that  the  os  protruded  through  the 
vulva.  The  patient  was  a  well-nourished  woman,  all  her 
functions  and  organs  normal,  except  for  constipation.  On 
October  29,  1900,  she  was  prepared  in  the  usual  way  for  oper- 
ation, but  as  there  had  been  a  number  of  cases  in  which  pus 
was  present  in  the  hospital,  special  care  was  taken  in  the 
disinfection  of  the  patient  and  the  antiseptic  precautions 
of  the  surgeons  and  the  dressings.  Under  ether  anesthesia 
the  cervi.x  was  dilated  and  the  uterus  cureted.  As  the  peri- 
neum was  somewhat  rela.xed,  a  moderate  perinorrhaphy  was 
performed.  Next  a  double  Alexander  operation  was  per- 
formed. The  patient  came  out  of  the  anesthesia  in  good 
Condi  ion.  The  operation  was  rather  long,  lasting  about 
two  hours.  The  patient  ran  a  normal  postoperative  course, 
with  the  exception  that  on  the  fifth  day  the  temperature 
was  a  little  over  99°  F.  On  the  fourth  day  following  the  opera- 
tion the  dressings  were  removed  and  the  wounds  in  the  in- 
guinal region  were  found  united  by  first  intention.  The 
etitches  used  were  catgut  in  each  wound,  except  in  the  peri- 
neal wound,  where  one  silkworm  suture  was  put  in.  This 
was  removed,  together  with  the  catgut  stitches,  on  the  sixth 
dav,  when  the  perineal  wound  seemed  to  be  united.  On  the 
fourteenth  day  following  the  operation,  the  patient  com- 
plained of  stiffness  about  her  jaws  and  some  difficulty  in 
opening  her  mouth.  On  the  next  day  the  muscular  rigidity 
about  the  jaws  had  increased,  and  she  exhibited  marked 
signs  of  trismus ;  she  also  had  pain  on  deglutition  as  well  as 
a  feeling  of  constricting  bands  about  her  throat.  Her  tem 
perature  and  pulse  were  normal.  On  November  15th,  the 
day  following,  her  general  condition  was  worss  and  she  had 
an  anxious,  strained  expression  in  her  face  From  time  to 
time  there  was  a  spasmodic  contraction  of  the  facial  mus- 
cles, exhibiting  the  symptoms  of  risus  sardonicus  At  this 
time  began  periodical  contractions  of  the  abdominal  mus- 
cles Two  days  later,  for  the  first  and  only  time,  until  the 
day  before  her  death,  the  temperature  went  to  10<  if.  Her  pulse 
now  became  much  more  rapid  and  she  was  gradually  losing 
strength.  She  continued  to  have  convulsive  movements  of 
different  sets  of  muscles,  principally  in  the  abdominal  region 
and  about  the  face  and  neck ;  her  pulse  at  this  time  running 
from  112  to  120;  her  respiration  being  2-1  to  30.  On  the 
evening  of  November  21st  her  temperature  suddenly  went 
to  102,%,  her  pulse  138,  respiration  101.  When  free  from  her 
convcilsions  she  had  no  pain  and  no  other  symptoms  except 
that  the  jaw  was  very  rigidly  fixed  up  to  4S  hours  before  her 
death.  She  died  on  the  morning  of  November  26,  of  heart 
failure,  her  general  circulatory  condition  having  weakened 
perceptibly  in  the  last  24  hours  The  treatment  consisted  of 
large  doses  of  chloral,  bromide,  and  physostigmine.  Twenty 
grains  of  the  chloral,  15  grains  of  bromide  of  soda,  and  J  of 
a  grain  of  physostigmine  was  given  every  four  hours.  It  was 
possible  by  this  means  to  diminish  the  convulsive  move- 
ments very  markedly,  so  that  there  was  no  great  increase 
of  such  symptoms  from  the  beginnmg  of  her  spasms. 

CiSE  2. — Patient  was  a  fairly  well  nourished   woman,   of 
about  -10  years  of  age,  upon  whom  the  Upavotomy  was  per- 


formed on  September  6,  1900.  The  abdominal  incision  was 
large  and  through  it  a  lOJ-pound  fibroid  was  removed, 
together  with  uterus  and  adnexae  There  was  no  complica- 
tion with  the  removal.  Hemorrhage  was  controlled  and 
prevented  by  the  use  of  the  angiotribe  and  heavy,  silk  liga- 
tures. The  abdominal  wound  was  closed  by  a  single  layer  of 
deep  silkworm-gut  sutures.  A  few  superficial  sutures  of  the 
same  material  were  also  taken.  Ane  thesia  lasted  2  hours, 
and  the  operation  1  hour  and  50  minutes.  At  its  conclusion 
the  patient  was  in  a  very  good  general  condition,  and  ex- 
perienced practically  no  shock.  After  operation  the  patient 
did  well,  and  with  two  exceptions  the  course  was  uneventful — 
the  temperature  was  somewhat  irregular,  and  the  bowels 
somewhat  troublesome.  On  the  morning  following  the 
operation  the  temperature  was  101°,  and  from  this  time  on 
for  8  days  it  did  not  go  below  100°,  but  vibrated  between  this 
and  102°.  This  tempera' ure  was  thought  to  be  due  to  the 
condition  of  the  bowels,  especially  as  there  was  great  diffi- 
culty in  attempting  to  get  intestinal  evacuations.  Eight  and 
onehalf  days  after  the  operation  there  was  first  noticed  a 
slight  trismus  and  a  rigidity  of  the  postcervical  muscles, 
this  condition  grew  so  rapidly  worse  that  inside  of  a  few 
hours  the  jaws  were  firmly  locked,  and  there  was  a  large 
accumulation  of  mucus  in  the  pharynx  with  great  rigidity 
of  the  neck  muscles  In  the  afternoon  of  this  daj*  there 
were  two  sever  spasms  lastiig  about  2  minutes  each  There 
was  rather  profuse  perspi  ation  following  the  injection  of 
antitoxin  which  was  used  at  10  o'clock  in  the  morning  ;  the 
first  symptoms  of  the  tetanus  having  been  noticed  at  9 
o'clock.  Two  more  injections  of  20  cc  each  were  given  dur- 
ing the  afternoon,  i  he  first  injection  contained  40  cc. 
Board  of  Hea  th  antitoxin  was  used.  At  this  time  the  tem- 
perature was  1(13°,  but  soon  fell  to  102°.  remaining  there 
until  the  next  morning.  On  this  day,  the  1.5th,  the  dressings 
were  renoved  and  the  wound  examined.  It  was  of  healthy 
appearance,  and  there  was  no  local  tenderness.  All  sutures 
were  removed.  The  next  day,  September  16,  the  patient 
grew  continually  and  rapidly  worse  The  muscular  rigidity 
was  more  mark-  d.  and  the  clonic  spasms  increased  in 
rapidity  and  duration  until  they  were  coming  on  every  half 
or  even  quarter  of  an  hour.  At  first  only  the  face,  trunk, 
and  upper  extremities  were  rigid ;  later  the  rigidity  was 
general.  In  addition  to  the  antitoxin,  of  which  160  cc.  were 
given,  chloral  and  bromid  and  physostigmine  were  also  used 
as  sedatives.  Chloroform  inhalations  and  morphin  hypo- 
dermatically  were  also  given.  The  temperature  rose  and  the 
pulse  increased  to  105  and  106  respectively,  the  convulsions 
getting  stronger  and  the  patient  getting  weaker,  until  she 
died  of  exhaustion  on  the  afternoon  of  the  16th.  During 
the  last  hour  the  patient  was  semicomatose. 

It  will  be  seen  that  the  course  of  the  tetanus  was 
distinctly  different  in  the  two  cases.  In  Case  No.  1, 
the  disease  began  and  lasted  practically  without  any 
temperature  for  14  days.  It  began  in  this  patient  on  the 
fourteenth  day,  and  death  occurred  at  the  end  of  two 
weeks.  In  Case  2,  it  began  on  the  ninth  day  and  the 
patient  lasted  only  a  little  over  24  hours.  In  the  first 
instance  no  tetanus  antitoxin  was  used,  in  the  second 
case  it  was  used  subcutaneously  in  fairly  large  quanti- 
ties. 

Aside  from  the  sudden  and  startling  appearance  of 
the  tetanus,  going  on  to  death  in  one  case  in  a  little 
more  than  24  hours,  the  most  interesting  feature  for 
discussion  are  the  etiology  and  the  treatment. 

Such  adjectives  as  idiopathic,  rheumatic,  spontaneous, 
and  autoinfectious,  to  describe  the  cause  of  tetanus, 
are  used,  I  believe,  simply  to  cover  up  our  ignorance 
and  are  silly  subterfuges  unworthy  of  scientific  men. 
The  following  facta  about  tetanus  are  proven  and 
undisputed : 

The  disease  is  caused  by  a  germ,  which,  with  its 
toxin  as  well,  has  been  clearly  isolated.  According  to 
Park,  one  of  the  best  known  American  bacteriologists, 
the  tetanus  bacillus  occurs  in  nearly  all  garden  soil, 
superficially  and  to  the  depth  of  several  feet,  especially 


354 


The  PHILiDBLPHIA"! 

Medical  Journal  J 


TETANUS  FOLLOWING  CLEAN  OPERATION  WOUNDS 


[Pbbbdabt  16,  190) 


soil  which  has  been  manured.  It  occurs  in  hay  dust, 
in  the  intestine  of  the  horse  and  the  cow,  and  hence  in 
manure,  in  the  mortar  of  old  masonry,  in  the  dust  from 
rooms,  barracks  and  hospitals,  in  the  air,  and  in  the 
poison  used  on  the  arrows  of  certain  savages  who 
obtain  it  from  crab-holes  in  the  swamps.  The  spores 
of  this  bacillus  are  very  resistant,  they  retain  their 
vitality  for  months  and  years  in  a  desiccated  condition. 
The  bacillus  will  grow  in  the  presence  of  oxygen  or  of 
most  acids.  It  takes  3  hours  soaking  in  a  1  to  1000 
bichlorid  solution  to  destroy  the  spore.  Carbolic  acid 
in  10%  solution  will  kill  it.  An  exposure  of  an  hour 
to  80°  C.  does  not  afifect  it.  A  y\  of  1%  HCl 
solution  will  destroy  it  in  5  minutes.  The  great  viru- 
lence of  this  germ  is  well  known.  It  grows  best  at  37° 
C.  It  does  not  multiply  in  the  human  body,  but 
produces  lesions  through  which  absorption  takes  place 
at  the  point  of  entrance. 

The  toxin  of  tetanus,  according  to  the  best  authori- 
ties, has  a  selective  affinity  for  the  cells  of  nerve-tissue. 
It  acts  directly  on  the  substance  of  the  motor  ganglia 
and  produces  changes  in  them.  In  the  cases  which 
recover  these  changes  either  are  not  produced,  or 
they  cannot  be  very  lasting  ones,  as  but  few  cases  are 
on  record  where,  after  a  cure,  the  results  of  the  mus- 
cular spasms  remain.  Examples  of  the  longevity  of 
the  tetanus  bacillus  are  frequent  and  undisputed.  Her- 
mann Kaposi  reports  a  case  where  the  germ  entered 
the  body  at  the  time  of  an  accident  which  occurred  5| 
years  previous  to  his  operation.  The  operation  devel- 
oped tetanus  and  the  case  terminated  fatally.  Another 
case  was  that  of  an  officer  in  the  German  Army  who 
was  injured  by  a  bullet  passing  through  the  soft  parts 
of  the  pelvis  and  injuring  the  bones.  The  bullet  was 
removed  at  some  distance  from  the  point  of  entrance, 
and  both  entrance-wound  and  wound  of  removal  healed 
kindly.  Two  and  a  half  years  afterwards,  following  a 
hard  day's  exercise  in  stormy  weather,  tetanus  symp- 
toms developed,  and  he  died  on  the  fifth  day.  The 
surgeon  who  reported  this  case  believes  that  this  ex- 
posure to  cold,  with  a  tired-out  body,  had  lowered  the 
resistance  of  the  tissues  so  that  the  tetanus  germ,  which 
had  been  present  and  quiescent  during  these  years, 
was  stimulated  into  activity,  and  the  tetanus  infection 
took  place.  There  was  no  other  exposure  to  a  tetanus 
germ  that  could  be  discovered  after  a  most  careful  in- 
vestigation. 

Cheeseman  reports  a  case  of  tetanus  coming  on  8 
months  after  vaccination.  A  number  of  other  cases  are 
on  record  in  which  the  disease  developed  several  months, 
or  even  years,  after  the  known  exposure  to  the  bacillus. 
Dupuytren  reports  a  case  of  tetanus  following  an  oper- 
ation. At  the  autopsy  it  was  accidentally  discovered 
that  a  tiny  piece  of  a  whip  was  embedded  in  a  scar  on 
the  body.  From  this  foreign  body  tetanus  cultures 
were  produced.  The  patient  had  complained  of  neu- 
ralgic pains  in  the  scar  for  the  past  several  months. 

Morgan  reported  a  case  where  a  splinter,  which  had 
caused  a  neuralgia  lasting  2  months,  was  removed,  and 
rabbits  inoculated  with  it  died  in  a  few  days  of  tetanus. 

In  this  country  and  abroad  numerous  well-authenti- 
cated cases  of  tetanus  are  recorded  following  vaccina- 
tion, erysipelas  injections,  and  other  serum  injections. 
In  many  of  these  the  time  between  the  introduction  of 
the  serum  and  the  development  of  the  tetanus  is  of 
varying  length.  It  is  not  known  how  long  the  tetanus 
bacillus  will  keep  its  vitality  in  living  tissues.  Why 
these  bacteria  should  remain  quiescent  in  the  body  for 


days  or  months,  or  even  years,  and  then  suddenly  be- 
come active  and  produce  their  toxin,  is  hard  to  explairu 
We  can,  however,  surmise  that  the  resistance  of  the 
human  body  to  these  germs,  as  well  as  others,  may 
through  some  injury  to  the  tissues  or  depression  caused 
by  an  operation,  a  severe  cold,  or  other  irritation,  be- 
come weakened  and  thus  give  stimulus  to  the  bacillus 
to  produce  its  toxin,  and  the  disease  occurs. 

As  to  the  point  of  entrance  of  the  poison,  the  bacilli 
themselves  in  all  probability  do  not  enter  very  exten- 
sively, at  any  rate,  the  human  body.  They  make  a 
lesion,  however,  through  which  the  toxin  is  absorbed. 
Thalmann,  in  a  large  number  of  experiments  on  animals, 
proved  that  the  most  favorable  point  for  incubation  of 
the  tetanus  bacillus  and  of  entrance  for  its  poison  was  the 
cavity  left  after  the  extraction  of  a  tooth ;  next  most 
infectious  were  wounds  of  the  nose  and  mouth.  Injec- 
tions of  the  tetanus  bacillus  into  the  stomach,  the  intes- 
tine and  the  urethra  gave  negative  results,  even  when 
the  lining  of  these  organs  had  been  injured  or  was  dis- 
eased. If  the  breathing  apparatus  was  sound  and  un- 
diseased,  no  effect  was  caused  by  the  inhalation  of  the 
germs.  In  one  case  where  catarrhal  inflammation  was 
present  infection  occurred.  Diseased  tonsils  offer  a 
most  acceptable  road  of  entrance  to  the  toxin. 

For  my  own  cases  there  are  only  two  possible  expla- 
nations for  the  origin  of  tetanus — either  want  of  proper 
disinfection  against  this  germ,  or  a  preceding  exposure, 
the  bacillus  remaining  innocuous  until  excited  by  the 
trauma  of  an  operation. 

As  to  the  asepsis  in  my  patients  :  There  had  been 
several  instances  of  slight  infection  in  the  operative 
cases  in  the  hospital,  and  special  pains  were  taken  with 
these  cases  in  order  to  prevent  further  infection.  The 
patient,  the  field  of  operation,  the  hands  of  the  operator 
and  his  assistants,  the  instruments  and  the  dressings 
were  carefully  prepared  and  rendered  as  near  aseptic 
as  practicable  methods  could  devise.  Other  patients 
were  operated  upon  on  that  day,  the  days  preceding 
and  the  following  days  under  as  near  as  possible  the 
same  conditions,  and  no  other  case  of  tetanus  develo{)ed. 

As  regards  a  dormant  bacillus,  the  cases  in  the  liter- 
ature cited  above  would  seem  to  prove  that  such  a 
proposition  is  possible,  and  indeed  much  more  prob- 
able than  that  infection  took  place  at  the  time  of  oper- 
ation. In  the  first  case  reported  by  me — that  of  P. 
H. — the  cavities  left  by  extraction  of  her  teeth  several 
months  before  may  have  been  the  starting  point  of  this 
disease. 

TreaUntnt. — The  modern  treatment  of  tetanus  resolves 
itself  into  two  classes — preventive  treatment  by  means 
of  vaccination,  and  treatment  after  the  disease  is  pres- 
ent. Preventive  treatment  should  be  carried  out  wher- 
ever there  are  cases  of  tetanus  in  the  hospital  or  in  the 
neighborhood  of  an  operation  ;  where  there  is  a  history 
of  exposure,  however  remote,  in  a  given  case  for  opera- 
tion ;  or  in  an  accidental  wound ;  in  those  districts 
where  tetanus  is  common ;  or  in  injuries  where  the 
wound  has  been  contaminated  with  earth  in  any  way. 
The  injection  is  harmless,  if  it  be  a  definite  and  well- 
prepared  antitoxin,  and  the  probability  of  its  success 
is  great.  Tizzoni  reports  two  cases  infected  with  a  very 
virulent  tetanus  culture.  Both  were  students  in  his 
laboratory.  Antitoxin  w;\5i  used  subcutaneously.  One, 
in  which  it  was  used  on  the  third  day  following 
the  infection,  had  very  slight  symptoms  and  re- 
covered. The  other  ca^e  was  injected  within  24  hours; 
at  the  end  of  13  davs  he  had  slight  convulsions  of  the 


FKBKnART    16,  1901] 


ADHESION  OF  THE  SOFT  PALATE 


FThe  Philadelphia 
L  Medical  Jouenal 


355 


muscles  of  the  extremities,  and  recovered  without 
further  symptoms.  Bazy,  in  his  surgical  clinic,  when 
he  thought  there  were  conditions  favorable  to  tetanus, 
immunized  all  his  cases  before  operation  by  injections 
of  the  serum.  In  his  23  cases  none  had  tetanus ;  while, 
under  exactly  similar  conditions  in  the  preceding  year, 
not  having  taken  antitetanic  precautions,  he  had  four 
cases.  In  a  tetanus  epidemic  in  Prague,  at  one  of  the 
obstetric  clinics,  for  nearly  a  year  all  antitoxic  meas- 
ures failed  to  prevent  the  appearance  of  new  cases. 
After  preventive  vaccination  was  used  in  every  woman 
before  confinement,  there  were  no  cases ;  while  in  the 
neighboring  clinics  there  were  numerous  instances. 

When  tetanus  is  present,  it  can  be  treated  in  three 
ways  :  By  medicines,  usually  in  the  form  of  sedatives  ; 
by  injections  of  antitoxin ;  and  by  a  combination  of 
the  two  methods.  A  fourth  way  is  by  the  injection  of 
some  antiseptic  solution,  such  as  bichlorid  of  mercury 
or  carbolic  acid,  or  by  extractives,  such  as  brain  emul- 
sion ;  these  substances,  however,  have  not  proved  satis- 
factory, and  in  several  recorded  cases  this  method  has 
done  positive  harm.  Inasmuch  as  the  antitoxin  affects 
at  once  the  tetanus  poison  in  the  circulation  and  de- 
stroys it  as  rapidly  as  it  arrives,  it  is  unnecessary  to 
reopen  healed  wounds  to  disinfect  or  to  excise  them,  nor 
is  it  necessary  to  amputate  members  of  the  body  ;  tho 
antitoxin  being  able,  as  soon  as  injections  are  begun,  to 
take  care  of  and  neutralize  all  the  toxin  as  fast  as  it  is 
produced. 

The  drug  treatment  consists  almost  entirely  of  seda- 
tives in  large  doses ;  the  heart's  action  being  kept  up 
-at  the  same  time  with  stimulants,  introduced  by  rectum, 
if  necessary,  and  digitalis  and  nitroglycerin  by  hypo- 
dermic medication. 

The  serumtherapy  offers  very  favorable  prospects  for 
the  cure  of  tetanus.  In  experiments  made  upon  ani- 
mals, it  was  found  that  the  injections  of  antitoxin 
•would  either  save  them  from  infection,  or  cause  a  cure 
after  the  outbreak  of  convulsions.  The  serum  must  be 
of  a  high  class  and  of  a  definite  quality.  It  has  no 
specific  poisoning  effect  on  the  organism.  Steuer  proved 
that  a  neutralization  of  the  toxin  by  the  antitoxin  takes 
place  in  a  thoroughly  mechanical  manner ;  this  new 
combination  being  in  itself  harmless.  Antitoxin  affects 
only  the  toxin  in  circulation,  not  that  already  taken  up 
by  the  nerve-cells.  We  cannot  act  by  injections  upon 
the  poison  already  in  combination  with  the  protoplasm. 
The  serum  must  be  absolutely  sterile.  If  possible,  the 
first  injection  must  be  given  inside  of  the  first  24  hours 
after  the  outbreak  of  the  symptoms,  and  must  be 
copious  in  quantity.  It  can  be  given  either  subcutane- 
ously,  intravenous,  subdural,  or  intracerebral.  Sub- 
cutaneous injection  is  used  principally  in  the  preventive 
treatment  and  is  of  little  benefit  after  tetanus  has  ap- 
peared ;  it  must  be  used  in  very  large  doses.  The 
intravenous  is  somewhat  more  favorably  looked  upon, 
but  must  also  be  used  in  large  quantities,  and  is  not  as 
effective  as  the  remaining  two  classes  of  application. 
The  best  injection  of  all  is  the  cerebral  injection,  which 
demands,  however,  a  special  technic  for  the  carrying 
out  of  the  operation,  as  the  antitoxin  serum  must  be 
introduced  into  the  lateral  ventricle  itself.  This  can  be 
best  done  according  to  the  methods  of  Alexander 
Fraenkel  or  Albert  Kocher.  Dr.  Frank  Hartley,  of  New 
York  City,  has  recently  perfected  a  new  method  by 
which  he  is  able  definitely  and  certainly  to  inject  the 
-antitoxin  into  the  lateral  ventricles.  The  subdural,  or 
spinal,  method  is  explained  by  its  name,  the  antitoxin 


being  introduced  beneath  the  dura,  through  a  spinal 
foramen. 

The  quantity  of  antitoxin  injected  by  either  of  these 
methods  depends  somewhat  upon  the  severity  of  the 
symptoms,  bea,ring  in  mind  that  a  proper  serum  is 
harmless  and  too  much  cannot  be  given.  Some  authors 
advise  that  the  intracerebral  injection  should  be  assisted 
by  copious  subcutaneous  and  intravenous,  as  well  as 
subdural  injections. 

Together  with  the  serum  treatment,  chloral  and  the 
bromides  should  always  be  used.  This  combination- 
method  offers  the  best  hope  of  favorable  result. 

Our  antiseptic  measures  against  a  germ  as  tenacious 
of  life  and  as  virulent  as  the  tetanus  spore  is  known  to 
be,  are  not  satisfactory  and  complete.  The  ordinary 
disinfection  of  the  hands  and  the  wound  location  as 
practised  in  the  hospitals  and  in  private  cases  will  not 
destroy  this  bacillus ;  and  until  we  have  some  more 
certain  way  than  that  at  present  in  use,  we  can  never 
be  sure,  in  the  presence  of  this  bacteria  or  its  spore,  of 
preventing  tetanus.  I  present,  therefore,  for  your  con- 
sideration these  few  suggestions  as  to  the  preventive 
and  curative  treatment  in  operative  cases  where  a  pos- 
sible tetanus  germ  is  lurking. 


ADHESION   OF  THE  SOFT  PALATE  TO  THE  POS- 
TERIOR WALL  OF  THE  PHARYNX. 

By  AUGUSTUS  KOENIG,  B.S.,  M.D., 
of  Philadelphia. 

The  influence  of  nasal  obstruction  upon  the  general 
health  and  the  comfort  of  the  individual  is  a  very  pro- 
found one  and  one  whose  dangers  should  not  be  over- 
looked. 

When  nasal  breathing  is  impossible,  it  must  of  neces- 
sity be  supplanted  by  mouth  breathing,  the  evils  of 
which  are  very  obvious.  Firstly  the -air  which  in  our 
cities  and  workshops  is  thoroughly  dust-laden,  is  taken 
directly  into  the  pharynx,  trachea  and  lungs,  instead  of 
being  first  filtered  of  its  foreign  particles  by  the  air- 
passages  of  the  nose.  As  a  result  the  dust  particles  set 
up  an  irritation  of  the  throat  and  lungs.  Within  cer- 
tain limits,  of  course,  the  respiratory  mucous  membrane 
is  able  to  rid  itself  of  and  to  throw  off  there  foreign  sub- 
stances, ciliated  epithedium  lining  the  trachea  being 
especially  constructed  for  this  purpose.  Should  this 
irritation,  however,  be  continued  indefinitely  a  chronic 
catarrhal  inflammation  will  be  the  result,  and  a  con- 
dition will  be  present  closely  allied  to  colaicosis  or 
anthracosis.  Secondly,  the  air  entering  the  pharynx 
directly  is  dry  and  either  hot  or  cold,  depending  upon 
the  temperature  of  the  surrounding  air  and  the  season 
of  the  year.  In  this  case  the  no^e  is  not  capable  of 
carrying  out  its  function  of  equalizing  the  temperature 
of  tiie  inspired  air  and  of  moistening  the  same.  These 
factors  are  all  very  potent  in  producing,  as  a  predis- 
posing cause,  pneumonia,  bronchitis,  laryngitis,  tuber- 
culosis, etc. 

Aside  from  the  possible  production,  secondarily,  of 
these  diseases,  profound  constitutional  symptoms  will 
be  present,  such  as  anemia  and  emaciation,  which 
cause  lassitude,  headache  and  a  general  inability  to  per- 
form both  mental  and  physical  work  properly.  These 
conditions  are  inevitably  the  result  when  the  blood  is 
not  properly  oxygenated  ;  and  proper  oxygenation  can- 
not take  place  in  a  lung  whose  mucous  membrane  is  in 


356  The  Philadklphia"! 

ftkKDICAL  JOUKITAL  J 


TREATMENT  OF  ERYSIPELAS 


[FnKDABT  1«,    ISn 


a  chronic  catarrhal  state,  and  where  a  sclerosis  or  over- 
growth of  connective  tissue  has  taken  place. 

These  facts  will  be  illustrated  by  the  following  case, 
in  which  there  was  practically  a  complete  nasal  obstruc- 
tion, owing  to  an  adhesion  of  the  soft  palate  to  the  pos- 
terior wall  of  the  pharynx.  Operation  in  this  case  was 
followed,  not  only  by  local  improvement,  but  also  by  a 
very  marked  improvement  in  the  general  health. 

Mr.  R.  C,  in  October,  1898,  presented  himself  for  exami- 
n<tion  and  treatment.  His  father  died  at  6J  and  his  mother 
at  40  years  of  age  They  both  died  of  diseases  which  were 
unknown  to  the  patient.  There  was  probably  no  tubercu- 
losis or  cancer  in  the  family  history  The  patient  is  .34  years 
old,  was  bom  in  Glasgow,  Scotland,  and  is  a  maciiinist  by 
trade.  Measles  is  the  only  disease  of  childhood  from  which 
he  suffered.  When  11  years  old  he  caught  cold,  which  re- 
sulted in  an  ulcerated  sore  throat  lasting  8  months  In 
healing,  union  took  place  between  the  soft  palate  and  the 
posterior  wall  of  the  pharynx,  completely  closing  the  poste 
rior  nares,  and  also  attended  b\  total  loss  of  hearing.  There 
is  absolutely  no  history  of  s\  philis  The  patient  went  to  the 
Western  Infirmary  of  Glasgow  for  treatment.  Some  polypi 
were  removed  and  his  throat  op-  rated  upon,  but  apparently 
with  little  success,  as  far  as  the  breathing  wa.s  concer  ed 
The  hearing,  however,  was  greatly  improved  after  the  opera- 
tion. In  October,  1898,  1  found  on  examination  that  the 
anterior  nares  were  fairly  clear.  There  was  an  adhesion  of 
the  palate  to  posterior  wall  of  the  pharynx,  extending  from 
the  right  side  to  within  4  inch  of  left  side.  The  ci>mmunica 
tion  between  the  nose  and  mouth  was  scarcely  enough  to 
admit  a  retractor.  Nasal  breathing  was  almost  completely 
abolished  By  a  great  effort  the  patient  was  able  to  draw  a 
small  amount  of  air  through  the  nose  Owing  to  the  mouth- 
breathing,  the  mucous  membrane  of  the  pharynx  was 
atrophied,  dried,  pan-lied,  and  shining  The  patient  was  very 
thin  and  pale  from  the  an  mia.  He  was  easily  fatigued,  and 
it  was  only  his  strong  will  power  which  enabled  him  to  carry 
on  his  work  successfully. 

No  general  anesthetic  was  given  for  the  operation,  but 
the  parts  were  thoroughly  cocainized  with  a  .5%  solu- 
tion ol  cocain.  The  separation  of  the  soft  palate  from 
the  wall  of  the  pharynx  was  begun  with  a  properly 
curved  pair  of  scissors.  Alter  the  opening  was  consid- 
erably enlarged  the  total  separation  was  accomplished 
by  an  instrument  which  I  had  made,  having  the  general 
curve  of  a  Gott^tein  curet,  but  having  a  double  lateral 
cutting  edge.  The  cocain  had  such  a  contracting  influ- 
ence upon  the  capillaries  that  the  bleeding  was  not  at 
all  excessive. 

Alter  the  operation  the  soft  palate  was  freely  movable 
and  the  jiatient  was  gratiQed  by  being  able  to  draw  his 
first  good  breath.  By  means  of  a  Belloque's  canula  a 
thread  was  passed  through  the  nose  into  the  mouth.  An 
antiseptic  gauze  plug  was  attached  to  this  and  the  na-^o- 
pharynx  well  plugged  to  prevent  hemorrhage.  This 
plug  remained  in  situ  for  48  hours,  when  it  was  removed 
and  the  cavity  well  cleansed  with  Dobell's  solution  and 
covered  with  a  powder  of  aristol  and  tannic  acid. 

The  gauze  plug  was  not  used  after  the  first  4S  hours, 
hut  it  was  replaced  by  a  hollow  silver  plug  which  was 
specially  made  to  fit  the  cavity. 

Through  this  silver  plug  the  patient  was  able  to 
breathe  perfectly,  and  yet  the  freshly  cut  surfaces  were 
held  apart  and  thus  prevented  from  reuniting.  By 
means  of  a  spray  the  patient  was  able  to  keep  the  parts 
clean.     Healing  took  place  in  3  weeks. 

Twenty  months  have  ela[)sed  since  the  operation  and 
there  has  been  no  return  of  the  trouble. 


Formosa.— News  has  bet-n  rei-t-.T  d  at  the  Western  coast 
of  Aaierica  of  afresh  outbreak  of  the  plague,  7  deaths  having 
occurred  in  7  days. 


THE  TREATMENT  OF  ERYSIPELAS. 
By  N.  G.  KEIRLE,  Jr.,  M.D., 

of  Baltimore,  Md. 
PhjhiciaD  in  charge,  Bay  View  Hoepitai. 

During  the  last  fifteen  months  we  have  treated  about 
30  cases  of  erysipelas  by  the  following  method,  and 
with  such  uniform  success  that  we  no  longer  fear  the 
disease.  In  fact,  not  a  single  case  has  failed  to  yield  to 
treatment  in  a  few  days,  usually  three  or  four. 

The  affected  area  is  first  enclosed  in  a  painted  ring  of 
tincture  of  iodin.  The  ring  is  not  to  be  started  at  the 
margin  of  the  reddened  area,  but  from  2  to  3  inche» 
from  it,  and  a  sufficient  number  of  coats  should  be  ap- 
plied to  cause  a  slight  desquamation  of  the  upper  layers 
of  the  skin.  At  the  same  time  the  whole  surface  en- 
closed in  the  ring  is  to  be  covered  with  an  ointment  of 
ichthyol,  about  1  dram  to  1  to  2  ounces  of  vaselin.  This  is 
covered  with  a  piece  of  gauze  and  a  hot  stupe  applied 
and  changed  about  every  4  hours.  At  the  end  of  12  hours 
the  ichthyol  ointment  is  washed  ofi"  and  a  fresh  coat 
applied,  and  if  the  iodin  has  not  had  sufficient  effect, 
one  or  more  new  coats  are  applied.  Internal  treatment 
may  or  may  not  be  instituted,  as  the  result  is  the  same 
in  either  case.  Although  both  iodin  and  ichthyol  are 
used  in  the  treatment  of  erysipelas  we  have  not  heard 
of  any  cases  treated  as  above.  In  our  cases  three  or 
four  days  of  this  treatment  have  not  failed  to  stop  the 
trouble,  the  inflammation  not  crossing  the  painted  line 
of  iodin  except  in  one  case,  in  which  another  ring 
painted  further  out,  and  the  same  treatment  as  at  first, 
effectually  stopped  the  spread  of  the  trouble.  We 
make  no  claim  to  originality,  but  cannot  remember 
having  seen  the  above  used,  and  the  success  is  so  uni- 
form that  we  ofler  it  as  a  suggestion  to  those  who  have 
had  trouble  in  checking  this,  at  times,  troublesome 
disease. 


Wound  of  the  Left  Vertebral  Artery.  —  Bouchaud 
repori«  {Reviw  de  Mfd.,  Nov.  10,  190U)  the  ( ase  of  a  man,  aged 
40,  who,  m  Nov.,  1896,  was  stabbed  during  a  quarrel  in  the 
upper  portion  ol  the  left  side  of  the  neck.  Two  days  after 
I  he  accident  he  bad  partial  loss  of  conscioueness,  which 
lasted  8  da}8.  lathe  hegmning,  all  4  hmbs  were  paral\zed 
as  were  aUo  il  e  muscles  of  the  trunk  and  of  the  neck.  The 
paralysis  was  flucid,  and  was  unaccompanied  by  rigidity  or 
convulsions.  For  15  days  the  patient  had  retention  of  urine 
with  incontineiice,  and  pronounced  respiratory  di£Bculty. 
Sensation  was  almost  completely  abolished,  except  in  the 
face ;  but,  nevertheless,  he  had  for  nearly  4  months  sharp 
lancinating  paits  in  the  shoulder,  back,  and  feet.  There  was 
no  vomiting,  no  difficulty  in  swallowing,  and  there  were  no 
bedsores.  The  symptoms  disappeared  gradually,  and  at  the 
end  of  7  months  the  patient  began  to  walk.  In  April,  1898, 
examination  showed  a  scar  just  behind  the  mastoid  process. 
The  patient  Could  walk,  although  his  legs  were  weak,  hut  the 
patellar  reflexes  were  normal.  The  bands  were  weaker  than 
the  legs,  and  the  dynamometer  showed  greater  weakness  in 
the  left  than  in  the  right  hand.  Sometimes  there  were  in- 
voluntary contractions  of  the  fingers  and  frequent  twi  chings 
in  different  parts  of  the  body.  Speech  was  somewhat  em- 
barrassed. There  was  a  marked  change  in  the  general 
sensation,  eirept  in  the  face,  but  sensations  of  heat  and 
cold  were  readily  perceived,  and  sensation  produced  by  the 
prick  of  a  pin  was  eiaggtrattd.  While  he  could  walk,  the 
patient  could  not  tell  the  character  of  the  material  on  which 
lie  stepped.  The  respiratory,  circulatory,  and  d'eestive 
functions  presented  nothing  abnormal  In  October,  1898,  the 
symptoms  were  less  marked.  The  author  believes  that  the 
vertebral  artery  was  wounded,  and  that  the  blood  was  * ffused 
between  the  di'ira  mater  of  the  cord  and  the  vertebrae ;  the 
rtsultine  compression  of  the  spinal  cord  producing  the  symp- 
toms,    [j  M  s  ] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.    Reprints  (250)  of  Original  Articles  will  be  furnished  gratis  to  Autliors  making 
the  request. 
The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa, 
See  Advertising:  Pages  8  and  34. 


Jaues  Hkndrik  Lloyd,  A.M.,  M. D.,  Eiiitor-in-Chief 
Julius  L.  Salingkr,  M.D.,  Associnte  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyer,  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  Coley,  M.O. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  Gibbon,  M.D. 


Vol.  VII,  No.  8 


FEBRUARY  23,  1901 


$3.00  Per  Annum 


The  3Ietliod  of  Transmission  of  Yellow-fever. — 

In  1881,  Charles  Finlay,  of  Havana,  first  conceived  the 
idea  that  the  yellow  fever  organism  was  conveyed  from 
patients  to  nonimmunes  by  mosquitoes.  He  tells  us  in 
his  address  before  the  Pan-American  Medical  Congress 
at  Havana  that  this  idea  first  occurred  to  him  upon 
studying  a  report  published  by  the  Navy  Department 
in  1880  "  On  the  Yellow  Fever  on  the  United  States 
Steamship  Plymouth."  In  a  footnote  in  this  report  is 
contained  the  following  opinion  of  Dr.  Bemiss:  "The 
poison  of  yellow  fever  is  reproduced  chiefly,  if  not 
wholly,  in  the  body  of  the  patient,  but  undergoes  some 
change  after  it  escapes  from  the  body  which  increases 
its  toxic  quality."  This  statement  gives  no  clue  to  the 
mosquito  theory  of  transmission,  but  it  is  interesting 
in  that  it  suggested  the  line  of  thought  which  led  to 
Finlay 's  theory.  There  had  been  previous  observations 
on  the  increase  in  the  number  of  mosquitoes  during 
yellow  fever  epidemics,  but  to  Finlay  belongs  full  credit 
for  the  development  and  exposition  of  this  view.  For 
many  years  he  was  met  by  strong  opposition,  but  con- 
tinued his  experimental  studies.  In  June,  1900,  the 
Surgeon- General  of  the  United  States  army  appointed 
a  board  for  the  purpose  of  pursuing  scientific  investi- 
gations with  reference  to  the  acute  infectious  diseases 
prevalent  in  the  Island  of  Cuba,  which  was  composed 
of  Dr.  Walter  Reed,  Dr.  James  Carroll,  Dr.  A.  Agra- 
monte  and  Dr.  Jesse  W.  Lazear.  According  to  its  pre- 
liminary report  (Philadelphia  Medical  Journal, 
October  27,  1900)  the  Commission  failed  to  isolate  the 
Bacillus  icleroides  either  from  the  blood  during  life, 
or  from  the  blood  and  organs  of  cadavers.  They 
turned  their  attention  to  Finlay's  theory,  being  im 
pressed  by  the  brilliant  work  of  Ross  and  the  Italian 
observers  in  connection  with  the  mosquito-malaria 
theory.  They  felt  justified  in  concluding  that  Finlay's 
view  was  the  correct  one  and  they  formulated  this 
opinion  by  stating  that  "  the  mosquito  serves  as  the 
intermediate  host  for  the  parasite  of  yellow  fever,  and 
it  is  highly  probable  that  the  disease  is  only  propagated 
through  the  bite  of  this  insect."  Many  yellow  fever 
experts  did  not  believe  that  the  Commission  was  fully 
justified  in  its  conclusions  from  the  facts  at  hand. 
There  was  a  feeling  that  some  other  means  of  infection 
than  the  mosquito  might  have  been  responsible  for 
attacks  observed.  However,  the  Commission  continued 
its  work  with  unremitting  zeal,  and  its  Additional  Note 


upon  "  The  Etiology  of  Yellow  Fever,"  read  before  the 
Pan-American  Medical  Congress  in  Havana  and  pub- 
lished in  the  Journal  of  the  American  Medical  Association 
(February  16,  1901),  confirms  beyond  peradventure 
the  correctness  of  the  original  views.  These  conclu- 
sions are  well  worthy  of  repetition.  It  is  now  deter- 
mined that  the  Culex  fasciatus  serves  as  the  intermediate 
host  for  the  parasite  of  yellow  fever,  and  it  is  also  deter- 
mined that  this  variety  is  identical  with  the  so  called 
Culex  tiniads  as  described  by  Giles.  Theobolt  (according 
to  Howard)  separates  Calex  tiniads  from  the  genus  Culex 
and  places  it  in  a  new  genus,  Stegamina.  It  may  now  be 
accepted  that  malaria  has  a  genus  of  its  own,  Anopheles, 
and  yellow  fever,  the  genus  Stegamina.  Yellow  fever, 
they  have  shown,  is  transmitted  to  the  nonimmune  in- 
dividual by  means  of  the  bite  of  a  mosquito  that  has 
previously  fed  on  the  blood  of  those  sick  with  the  dis- 
ease, and  it  appears  necessary  that  an  interval  of  about 
twelve  days  must  elapse  before  the  mosquito  is  capable 
of  conveying  the  infection.  The  bite  of  a  mosquito  at 
an  earlier  period  after  contamination  does  not  appear  to 
confer  any  immunity  against  a  subsequent  attack.  The 
Commission  have  also  succeeded  in  producing  yellow 
fever  experimentally  b}'  the  subcutaneous  injection  of 
blood  taken  from  the  patient  during  the  first  and  second 
days  of  the  disease,  and  it  has  also  determined  that  an 
attack  of  yellow  fever  produced  by  the  bite  of  the  mos- 
quito confers  immunity  against  the  subsequent  injection 
of  the  blood  of  an  individual  suffering  from  the  non- 
experimental  form  of  this  di-ease.  They  have  further 
proven  that  the  period  of  incubation,  in  13  cases  of  ex- 
perimental yellow  fever,  has  varied  from  4 1  hours  to  5 
days  and  17  hours.  Most  important  is  their  conclusion 
that  yellow  fever  is  not  conveyed  by  fomites  and  that 
it  is  consequently  unnecessary  to  disinfect  articles  of 
clothing,  bedding  or  merchandise  supposedly  contam- 
inated by  contact  with  those  sick  with  the  disease. 
They  obserte  that  a  house  may  be  said  to  be  infected 
with  yellow  fever  only  when  there  are  present  within 
its  walls  mosquitoes  capable  of  conveying  the  parasite 
of  this  disease.  In  consequence  the  spread  of  the 
fever  must  be  controlled  by  measures  directed  to  the 
destruction  of  mosquitoes  and  the  protection  of  the 
patients  against  the  bites  of  these  insects.  The  Com- 
mission seems  to  have  established  definitely  the  mode 
of  propagation  of  yellow  fever,  but  they  have  shown 
that  the  specific  cause  of  the  disease  remains  to  be 


Medical  Journal 


] 


EDITORIAL  COMMENT 


[Febbc^rt  23,  IMl 


discovered,  thus  summarily  disposing  of  Sanarelli's 
claims. 

Dr.  John  Guiteras,  a  well-known  authority  upon 
yellow  fever,  was  one  of  those  who  at  first  opposed  the 
mosquito  theory,  and  especially  the  conclusions  which 
the  Commission  set  forth  in  their  preliminary  report. 
In  a  recent  contribution  to  Revista  de  Medicina  Tropical 
of  Havana,  however,  he  accepts  unreservedly  the  later 
conclusions  of  the  more  elaborate  studies  of  the  Com- 
mission. It  will  be  seen  that  scientific  research  has 
accomplished  more  of  practical  value  from  the  s'tudy 
of  the  theory  of  infection  than  from  the  bacteriological 
causes  of  disease. 

This  subject  opens  a  vast  field  for  preventive  medi- 
cine, and  it  would  seem  reasonable  to  assume  that  en- 
teric fever  may  soon  be  included  in  the  category  of  those 
infections  whose  transmission  is  brought  about,  and  in 
consequence,  the  epidemic  character  maintained  in 
part  by  flies,  gnats  or  other  insects.  It  is  interesting  to 
conjecture  whether  in  the  case  of  enteric  fever  the 
off'ending  insect  will  be  found  to  be  of  one  variety  as  in 
yellow  fever  and  malaria. 

The  Literary  Morals  of  the  Antivivisectionists. — 

Dr.  Keen's  reply  to  the  Antivivisectionists  (published 
in  this  number  of  the  Journal)  is  more  than  a  criti- 
cism ;  it  is  in  itself  a  fine  example  of  human  vivisec- 
tion. It  is  not  quite  so  bad  as  cruelty  to  animals,  be- 
cause animals  at  least  are  always  ingenuous  and  inno- 
cent, whereas  these  particular  antivivisectionists  are,  as 
Dr.  Keen  shows,  just  the  reverse.  The  scarification  ad- 
ministered to  Mr.  James  ^I.  Brown,  is  fortunately  done 
by  a  surgeon  so  eminent  as  Dr.  Keen,  so  that  Mr.  Brown 
will  have  no  occasion  to  complain  in  the  future  that  he 
was  not  scarified  by  skilled  hands.  When  the  Presi- 
dent of  the  American  Humane  Association  again  takes 
up  the  cause  of  suffering  humanity  he  will  have  him- 
self to  attend  to  first,  and  when  he  wishes  to  find  an  ex- 
ample of  a  surgeon  who  can  dissect  a  man  alive,  his 
thoughts  will  doubtless  revert  instinctively  to  Dr.  Keen. 
As  for  the  controversy  itself  (if  that  can  be  called  a 
controversy  which  is  rather  a  case  of  literary  detective 
work)  we  cannot  do  better  than  refer  our  readers  to  the 
letters  themselves.  Dr.  Keen  shows,  with  a  precision 
and  scorn  worthy  of  Junius,  that  the  antivivisectionists 
in  their  pamphlet  had  descended  to  the  methods  of  liter- 
ar}'  dissimulation.  In  a  perverted  cause,  which  they 
proclaim  to  be  one  of  truth  and  humanity;  they  have 
employed  the  weapons  of  misrepresentation  and  falte 
witness.  With  the  merits  of  vivisection,  as  an  abso- 
lutely essential  aid  to  scientific  medicine,  we  are  not  at 
present  concerned — neither  are  we  concerned  with  the 
merits  of  the  antivivisectionists,  for  those  persons  among 
them  who  are  responsible  for  their  pamphlets,  have  ap- 
parently no  very  conspicuous  merits  to  speak  of  We  are 
quite  willing  to  accord  to  public  opinion  and  to  the 
law-making  powers  the  right  to  demand  full  knowledge 


on  this  whole  subject  of  vivisection.  We  can  quite 
readily  concede  that  as  a  method  of  science  it  may  be 
subject  to  occasional  abuse,  and  should  he  properly 
supervised  by  law ;  we  can  even  understand  that  the 
sympathies  of  some  high-minded  persons  are  not  unnat- 
urally stirred  by  the  exaggerated  tales  from  the  labora- 
tories; but,  with  all  this,  we  cannot  suflBciently  con- 
demn the  ignorance,  willfulness  and  perversity  of 
persons  who,  like  Mr.  Brown,  seek  to  cast  opprobrium 
upon  scientific  medicine  for  its  splendid  achievements 
in  modern  bacteriology  and  pathology,  and  who  in  their 
so-called  logical  methods  seek  constantly,  in  the  lan- 
guage of  Socrates,  to  make  the  worse  appear  the  better 
reason. 

A  Doctor  as  Major-General. — Among  the  names 
of  the  16  army  ofiicers,  recently  sent  to  the  Senate  by 
the  President  for  promotion  in  the  U.  S.  regular  army, 
was  that  of  a  doctor  of  medicine.  This  is  noteworthy 
because  the  appointment  is  in  the  line,  and  not  in  the 
medical  staff.  It  is  unprecedented,  so  far  as  we  can 
recall,  either  in  this  country  or  in  any  other ;  in  fact, 
in  any  other  country  than  this  such  a  promotion  would, 
we  suppose,  be  practically  impossible.  The  oflScer  thus 
distinguished  is  Dr.  Leonard  Wood,  the  well-known 
military  Governor  of  Cuba.  Doctor,  or  General,  Wood 
is  a  graduate  in  medicine  of  the  Harvard  Medical 
School.  His  distinguished  career  in  Cuba  is  too  familiar 
to  all  readers  to  need  to  be  recalled  here.  It  is  sufficient 
to  say  that  this  career  has  been  in  both  the  military  and 
civil  service,  and  not  in  a  medical  capacit}'.  We  under- 
stand, however,  that  General  Wood  held  the  regular  army 
rank  of  assistant  surgeon,  and  that  therefore  his  promo- 
tion by  such  a  great  leap  has  called  forth  criticism  in  army 
circles,  in  which  it  is  regarded  as  practically  an  appoint- 
ment from  civil  life  to  high  rank  in  the  regular  army. 
We  are  not  specially  concerned  here  about  these  caste 
distinctions,  and  we  see  no  reason  why  a  medical  man 
should  not  be  thus  advanced  in  a  service  in  which  law- 
yers and  business  mcH  are  sometimes  honored  with  high 
military  rank.  General  Wood  has  earned  his  promo- 
tion as  clearly  as  any  of  the  other  appointees.  It  is  not 
unusual  for  physicians  in  this  country  to  gain  high 
political  positions.  They  have  been  members  of  Con- 
gress and  Governors  of  States,  and  perhaps  it  is  reserved 
yet  for  one  of  them  some  time  to  be  President  It  is 
highly  desirable,  in  fact,  that  the  profession  should  be 
better  represented  in  the  civil  service  of  the  country, 
especially  in  the  law-making  branches. 

The  Medical  £xaniiuatiou  of  School  Children. — In 

his  very  interesting  annual  report  to  the  Board  of  Public 
Education  of  this  city,  the  president.  Samuel  B.  Huey, 
Esq.,  devotes  some  space  to  the  subject  of  the  medical 
inspection  of  school  children.  He  gives  some  figures 
which  make  interesting  reading.  In  the  report  of  the 
visiting  physicians  it  is  shown  that  from  January  1  to 


FSBBDABY  23,    1901] 


EDITORIAL  COMiMENT 


TThe  Pbiladelpbla 
L  Medical  Jocbmax 


359 


October  31,  1900,  there  were  3,446  cases  of  contagious 
diseases  detected  in  the  schools  of  this  city.     Among 
these    diseases    were     diphtheria,     measles,    mumps, 
whooping-cough,    syphilis,  impetigo,    ringworm,    epi- 
demic conjunctivitis,  and  lice.      This  is  a  goodly  show- 
ing, and  would  seem  to  vindicate  the  wisdom  of  those 
who  have  advocated  and  succeeded  at  last  in  establish- 
ing this  system  of  inspection.     212cases  of  lice,  116 
cases  of  impetigo,  and  753  cases  of  ringworm,  turned 
loose  in   our  public  schools,  help   to  make   splendid 
breeding  grounds  out  of  these  nurseries  of  learning  for 
some  rather  unpleasant  affections.    Surely  no  advocacy 
is  needed  after  this  for  a  thorough  system  of  medical 
inspection    and    control.     Of  noncontagious    diseases 
2,430  cases  were  reported — 1000  fewer  than  the  con- 
tagious cases.     This  is  also  significant,  for  it  shows  that 
the  more  serious  affections  are  in  excess  of  the  less 
troublesome  ones.     In  the  Journal  for  last  week  we 
published  an  interesting  paper  on  this  subject  by  Dr. 
Greene,  Inspector  of  Public  Schools  in  Boston,  in  which 
he  describes  in  detail  the  admirable  system  adopted  in 
that  city.     Boston,  we  believe,  was   the  first  city  to 
adopt  a  system  of  inspection  ;  and,  it  is  to  be  noted,  that 
city  is  paying  its  medical  inspectors  for  their  valuable  ser- 
vices while  Philadelphia  is  still  meditating  over  it.    The 
salaries  in  Boston,  to  be  sure,  are  not  high,  but  they  are 
something  to  the  young  men  who  are   devoting  their 
time  and  expert  knowledge  to  the  public  service.     Too 
much  public  medical  work  is  already  done  for  nothing 
by  men  who  can  ill  afford  it,  and  we  do  not  quite  agree 
with  Mr.  Huey  that  the  subject  is  "  a  many-sided  one." 
We  think  it  is  only  a  one-sided  one.     If,  as  Mr.  Huey 
quotes  in  his  report,  the  work  of  the  medical  inspectors 
during  this  last  year  has  averted  epidemics,  this  work 
is  worth  paying  for.     If  it  is  desirable  that  our  public 
schools  should  not  become  hotbeds  for  loathsome  dis- 
eases and  foci  from  which  these  diseases  can  be  spread 
broadcast,  then  it  is  also  desirable  that  the  educated 
physicians  who  give  their  skilled  services  should  be 
paid    for    keeping  the  schools   free   from    contagion. 
The  janitors  are  paid  for  cleaning  out ;  why  are  not  the 
young  doctors  ?     But  Mr.  Huey  promises  that  the  sub- 
ject shall  receive  the  "  thoughtful  consideration  of  the 
Board."     It  is  but  just  to  the  Board  to  say  that  the 
fault  is  not  with  it,  but  with  Councils. 

Asthenic  Bulbar  Palsy.  — This  affection,  which  is  a 
good  example  of  a  bad  disease  with  a  worse  name, 
has  recently  been  interesting  the  neurologists,  and  has 
been  described,  with  reports  of  cases,  by  Dr.  Charles 
W.  Burr  and  Dr.  D.  J.  McCarthy,  in  the  January  num- 
ber of  the  American  Journal  of  the  Medical  Sciences.  We 
are  inclined  to  criticise  the  name — a  name  for  which 
Dr.  Burr  and  Dr.  McCarthy  are  not  responsible — 
because,  first,  most  if  not  all  paralytic  affections  are  in 
their  very  nature  asthenic,  and  therefore  this  term  as 
applied  to  this  disease  is  not  sufficiently  distinctive; 


and,  second,  because  this  particular  disease,  while  often 
presenting  bulbar  symptoms,  is  by  no  means  confined 
to  the  medulla  oblongata,  and  is  sometimes  apparently 
not  even  distinguished  by  marked  bulbar  involvement. 
The  name  myastheyiia  gravis  is  better  in  some  respects 
and  worse  in  others,  for  while  the  disease  is  sufficiently 
grave  it  is  probably  not  located  in  the  muscles. 

Asthenic  bulbar  palsy  was  first  described  by  Wilks 
in  1877,  and  about  60  cases  have  since  been  put  on 
record.  It  is,  in  brief,  a  disease  marked  by  progressive 
weakness,  involving  often  the  extremities,  and  accom- 
panied, as  a  rule,  with  such  bulbar  symptoms  as 
tremor  and  weakness  of  the  lips  and  tongue,  and  im- 
paired deglutition ;  also,  in  some  cases,  with  slight 
involvement  of  the  orbital  muscles.  The  reflexes  may 
be  preserved  or  even  exaggerated.  The  disease  seems 
to  be  confined  largely  to  the  motor  neurons,  but  sensa- 
tion may  in  some  instances  be  somewhat  impaired. 
At  autopsy  but  little  is  discovered  to  account  for  the 
symptoms,  and  in  this  respect  the  disease  has  been 
something  of  a  mystery.  Dr.  Burr  and  Dr.  McCarthy 
in  one  of  their  cases  found  no  gross  lesions,  but  under 
the  microscope  they  observed  chromatolytic  changes, 
with  swelling  and  displacement  of  the  nuclei,  in  the 
nerve  cells  in  the  medulla  oblongata.  In  the  tenth 
nerve  atrophy  of  some  fibers  was  observed,  and  very 
slight  changes  in  the  twelfth.  The  muscular  fibers 
were  normal.  It  is  thus  seen  that  astonishingly  little 
was  observed  to  account  for  a  disease  which  was  evi- 
dently capable  of  making  extensive  ravages  of  a  most 
minute  kind  in  the  nervous  system,  and  yet  of  leaving 
few  traces  of  its  destructive  course.  In  discussing  the 
disease  the  authors  feel  compelled  to  fall  back  upon 
general  physiological  and  pathological  laws,  and  to  draw 
inferences  from  analogous  affections.  They  conclude  that 
the  disease  is  probably  located  in  the  motor  neurons, 
and  that  it  is  due  to  the  activity  of  some  toxin.  It  is 
not  confined  to  the  motor  neurons  arising  in  the  bulb. 
We  think  these  conclusions  are  just,  and  that  asthenic 
bulbar  palsy  may  be  relegated  to  that  class  of  insidious 
disabling  affections  which  are  to  be  regarded  as  in  a 
general  way  due  to  some  intoxicants.  Landry's  paral- 
ysis, while  clinically  different,  is  still  in  this  list,  and 
Bell's  mania,  although  a  psychosis,  is  probably  another 
instance.  It  may  be  recalled  that  some  of  the  most 
violent  poisons,  such  as  those  of  tetanus  and  hydropho- 
bia, as  well  as  such  drugs  as  strychnia  and  morphia, 
can  do  their  deadly  work  and  leave  scarcely  a  trace 
behind.  With  improved  microscopic  technic  we  have 
come  far  enough  to  recognize  some  minute  changes  in 
cytoplasm  which  show  these  results  in  dead,  not  living, 
matter,  but  even  the  most  enthusiastic  among  us  will 
hardly  claim  that  we  can  read  the  secrets  of  many  dis- 
eases in  dead  cytoplasm. 

Anesthesia  from  Subarachnoid  Injection  of  Co- 
eain.— In  1891,  when  (Juincke  first  proposed  lumbar 


360 


The  Philadvlphia"! 
Mkdical  Joce>'al  J 


EDITORIAL  COMMENT 


(FeeecaET  23,  1981 


puncture  of  the  subarachnoid  space,  he  believed  that 
the  proceeding  would  be  useful  from  a  therapeutic 
standpoint.  On  the  contrary,  the  operation  has  de- 
veloped, in  the  hands  of  the  physicians,  into  a  diagnos- 
tic measure  of  great  value.  The  surgeons,  however, 
have  utilized  the  method  for  the  purpose  of  injecting 
cocain  into  the  subarachnoid  space  in  order  to  pro- 
duce anesthesia.  TufiSer  is  one  of  the  foremost  ad- 
vocates of  this  method  of  producing  anesthesia.  His 
first  paper  appeared  in  1899,  and  has  been  followed 
at  various  intervals  by  others  detailing  results  of  his 
work.  Recently  (^Semaine  Medicate,  December  12, 
1900)  he  has  published  the  results  of  252  opera- 
tions which  he  had  performed  under  medullary  an- 
esthesia. These  operations  ranged  in  severity  from 
curettement  of  abscesses  to  gastroenterostomies,  6 ; 
nephrectomies,  2 ;  and  other  intraperitoneal  opera- 
tions, in  all,  142.  Among  the  symptoms  noted  during 
the  period  of  anesthesia  are  a  slight  general  malaise 
and  nausea,  or  vomiting ;  the  latter  symptom  in  20% 
of  the  patients  operated  upon ;  the  pulse  is  accelerated 
and  a  little  soft.  After  the  anesthesia  there  is  a  sensa- 
tion of  thirst  that  lasts  2  or  3  hours,  the  temperature  is 
frequently  elevated,  and  there  is,  in  the  majority  of  the 
patients,  considerable  headache,  the  pathogenesis  of 
which  is  unknown.  Tuffier  considers  this  method  of 
producing  general  anesthesia  to  be  perfectly  safe,  and 
says  that  he  has  never  seen  the  symptoms  assume  such 
an  intensity  that  he  feared  for  the  life  of  his  patient. 
So  far  aa  extraperitoneal  operations  are  concerned,  he 
thinks  that  medullary  anesthesia  will  stand  favorably 
in  comparison  with  general  anesthesia.  He  advises 
only  those  who  are  thoroughly  familiar  with  intraperi- 
toneal surgery  to  employ  the  method  for  abdominal 
operations,  on  account  of  the  anxiety  that  would  be 
caused  by  the  nausea  and  vomiting.  There  has  been 
but  one  death  after  operation  done  under  anesthesia 
thus  produced  ;  the  patient  succumbed  during  a  journey 
undertaken  after  his  convalescence.  At  autopsy,  this 
patient  was  found  to  have  had  serious  cardiac  lesions 
with  congestion  and  edema  of  the  lung. 

Some  surgeons  in  this  country  have  adopted  this 
method  of  producing  anesthesia  when  the  operation 
is  to  be  done  below  the  diaphragm.  In  the  Phila- 
delphia Medical  Joubxal  for  November  3,  1900, 
Fowler  gives  the  results  of  41  successful  applications  of 
the  method  ;  Goldan  reports  18  successful  cases,  and  2 
failures ;  and  Keen  reports  one  case  that  terminated 
fatally  IS  days  after  the  operation,  from  exhaustion  and 
urinary  sepsis.  In  this  case  eucain  was  used  instead  of 
cocain.  Lee  reports  7  cases ;  Rodman  2  ;  LaPlace  2  ; 
and  Marx  reports  42  cases  in  which  the  method  was 
used  for  the  performance  of  obstetrical  operations  or  to 
relieve  the  pain  of  normal  labor.  One  great  objection 
to  the  method  is  the  mental  anguish  that  must  be  pro- 
duced by  the  manipulations  and  the  surroundings  of 
the  operation.     In  order  to  prevent  this  mental  shock. 


some   operators   have    blindfolded    the   patients    and 
stuffed  their  ears  with  cotton-wool. 

It  seems  to  us  that  the  surgeons  are  very  fortunate 
not  to  have  had  a  greater  number  of  unfavorable  results 
following  the  employment  of  this  method.  Of  course, 
a  man  who  undertakes  an  operation  under  this  form  of 
anesthesia  will  be  extraordinarily  careful  at  first,  but 
as  he  becomes  more  used  to  the  method,  may  he  not 
become  less  particular,  and  may  he  not  have  sepsis  as 
a  result  ?  Surely,  the  introduction  of  ^  grain  of  cocain 
into  such  an  extensive  lymphatic  space  aa  the  sub- 
arachnoid space  of  the  cord  must  be  attended  with  some 
risk,  and  what  is  to  prevent  dangerous  cocain  pois- 
oning ?  Indeed  may  not  the  headache,  the  pathogene- 
sis of  which  Tuffier  is  unable  to  account  for,  be  due  to 
the  absorption  of  the  drug?  Still,  the  results  so 
far  reported  seem  to  favor  the  method  in  some 
fields  of  surgery.  In  a  former  comment  in  this 
JocRXAL  we  called  attention  to  possible  psychic  or 
neurotic  manifestations,  as  results  of  mental  shock. 
In  the  present  number  we  publish  an  interesting 
report  of  a  double  amputation  of  the  feet  under  cocain 
anesthesia. 

The  Medical  Aspects  of  the  Siege  of  Peking. — 

In  the  China  Medical  Mi^iionary  Journal  for  -January, 
1901,  there  is  an  interesting  account  by  Dr.  Lillie  K  V. 
Saville  of  hospital  experiences  during  this  celebrated 
siege.  The  number  of  medical  men  and  women  who 
were  present  during  the  siege  was  quite  remark- 
able ;  altogether  there  were  of  all  nationalities  20  men 
and  women  with  medical  and  surgical  degrees.  On 
June  21  the  International  Hospital  was  organized  in 
the  British  Legation.  Mr.  Cordes,  who  was  wounded 
at  the  time  the  German  minister  was  killed,  and  a  Rus- 
sian student  with  a  penetrating  wound  of  the  shoulder 
joint,  were  the  first  patients.  Dr.  Poole  of  the  British, 
and  Dr.  Velde  of  the  German,  Legation  were  on  the 
stafiF,  and  Miss  Lambert  was  the  nurse.  The  women 
doctors  were  asked  to  act  as  nurses,  a  position  which 
was  gladly  accepted  by  them.  The  impromptu  hospi- 
tal was  not  80  badly  off  for  surgical  dressings,  as  Dr. 
Velde  had  a  large  supply  of  the  kind  used  in  the  Ger- 
man army.  He  had  also  a  sterilizer.  Instruments  were 
always  sterilized  before  operations.  To  most  of  the 
medical  attendants  the  experience  with  shot  and  shell 
wounds  was  new,  and  they  had  much  to  learn.  The 
hospital  gradually  grew  until  it  included  an  operating 
room,  five  wards,  and  a  convalescent  ward  for  officers 
and  civUians  ;this  last  in  Lady  Macdonald's  house). 
and  another  for  the  marines  elsewhere.  Three  Ameri- 
can ladies  superintended  the  kitchen,  and  their  work 
was  beyond  all  praise. 

Dr.  Saville  says  that  the  hospital  had  first  claim  to 
the  commissariat  stores,  and  that  nowhere  else  were 
there  such  fragrant  pony  soup  and  such  really  eatable 
mule  stew ;  and  these  delicacies  were  so  appreciated 


FKBBDABT  23,   1901] 


EDITORIAL  COMMENT 


[The  Philadelphia  Qgl 

Medical  Jodenal 


that  she  thought  the  officers  and  men  considered  it 
worth  while  to  be  slightly  wounded  in  order  to  get  a 
few  days  of  such  feeding.  Owing  to  the  difficulties 
caused  by  diverse  languages,  the  patients  were  warded 
according  to  nationality.  Italians  and  French  were  put 
together  with  a  French  Sister  in  charge;  Russians  were 
in  another  room  where  they  were  most  tenderly  cared 
for  by  Madame  de  Giers  herself — the  Russian  Minister's 
wife.  With  the  Russians  were  put  the  Germans,  while 
one  room  was  always  full  of  the  bright  little  Japs. 
English  and  Americans  naturally  went  together.  There 
was  only  one  room,  however,  for  officers  and  civilians, 
and  here  were  nursed  British,  Americans,  Germans, 
French,  Italians,  Austrians,  Dutch,  Australians,  and 
Russians — a  polyglot  assemblage.  It  was  wonderful 
how  the  stores  and  supplies  were  kept  up.  They  repre- 
sented much  self-denial  on  the  part  of  others  and  ex- 
hibited many  expedients.  The  pillows  were  made  from 
the  packing  straw  of  wine  bottles ;  shirts  were  made 
of  the  best  damask  linen  or  of  bright  yellow  cotton. 
There  were  few  bedsteads ;  mattresses  being  placed  on 
the  floor,  but  every  wounded  man  had  a  mattress  with 
sheets  and  pillows. 

Bullets  were  rarely  hunted  for  at  the  first  dressing 
but,  considering  the  circumstances,  a  fairly  good  asepsis 
was  maintained.  Flies  were  the  chief  plague  of  the 
sick.  The  fighting  being  done  mostly  behind  barri- 
cades, the  proportion  of  head  injuries  was  large.  Some 
cases  ot  recovery  are  mentioned  that  are  almost  mar- 
velous in  view  of  the  surroundings  Dr.  Saville  gives 
a  description  of  some  of  these  wounds,  and  says  that 
operations  were  undertaken  for  their  rdlief  not  unsuc- 
cessfully amid  these  distressing  circumstances.  Two 
cases  of  tetanus  occurred.  One  of  these  happened 
to  a  member  of  the  Japanese  Legation,  his  wound 
having  become  contaminated  by  the  flies  which  had 
laid  their  eggs  under  the  dressings.  These  cases  of 
tetanus  were  fatal.  An  exciting  episode  was  caused 
by  a  case  of  strychnin-poisoning.  A  Russian  had 
taken  some  of  the  drug  from  a  bottle  in  mistake  for 
sodium  bicarbonate.  His  life  was  saved,  apparently 
by  chloroform  inhalation  and  induction  of  free  vom- 
iting. 

Toward  the  close  of  the  siege  diarrhea  and  dysentery 
were  prevalent.  There  were  two  deaths  from  the  latter 
disease  among  the  Russians,  who  were  known  to  be 
exceedingly  careless  about  their  drinking  water.  There 
were  also  three  cases  of  typhoid  fever,  one  proving  fatal 
after  the  end  of  the  siege.  During  the  siege  there  was 
no  death  in  the  hospital  of  any  patient  who  survived 
his  injury  24  hours,  excepting  in  the  two  cases  of 
tetanus ;  but  two  patients  died  afterwards.  Dr.  Saville 
says  that  the  harmony  of  action  among  all  persons  who 
attended  upon  the  sick  and  wounded  was  a  striking 
feature  of  the  siege  of  Peking.  Differences  of  creed 
and  nationality  and  of  professional  status  were  laid 
aside,  and  all  worked  together  with   much   happiness 


and  devotion.  The  report  of  this  noble  work  deserves 
to  be  spread  widely  abroad. 

Forest-camps   for   Cases    of    Tuberculosis. — We 

wish  to  endorse  most  heartily  the  proposition  of  State 
Forestry  Commissioner,  Dr.  J.  T.  Rothrock,  to  estab- 
lish camps  on  various  suitably  situated  forest- reserva- 
tions in  Pennsylvania  where  tents  will  be  erected  for  the 
free  use  under  proper  regulations  of  tuberculous  citi- 
zens who  desire  to  avail  themselves  of  the  benefits  of 
open-air  treatment,  but  are  unable  to  secure  other 
change  of  climate.  Pure  air  and  sunshine  constitute  a 
potent  factor  in  the  prophylaxis  and  treatment  of  tuber- 
culosis, and  the  plan  proposed  is  entirely  in  the  line  of 
modern  practice,  from  the  medical  as  well  as  from  the 
philanthropic  point  of  view. 


Acute  Ulceroniembrauous  Asgina  iu   Children 
Due  to  the  Fusiform  Bacillus  and  Spirillum   of 
Vincent. — Aural  Athenasius  {Gaz.  Heb.  de  Med.  el  de  Chirur., 
December  30,  1900;    47me  Ann^e,  No.  104;    Paris   Thesis, 
1899-1900,  No.  550)  has  made  a  complete  study  of  ulcero- 
membranous angina   in  children   and  shows  that  the   fusi- 
form   bacillus    and    the    spirillum    of  Vincent    are    the 
specific  agents  of  the  disease  for  the  following  reasons:  1. 
The  considerable  quantity  in  pure  culture  of  these  microor- 
ganisms in  the  false  membrane  at  the  beginning  of  the  an- 
gina,  even  before  the  appearance  of  ulceration.     2.  The 
almost  inevitable  association  of  the  bacillus  and  the  spirillum 
in  the  false  membrane.    3.  The  absence,  cr  at  most  the  pres- 
ence of  very  few  microorganisms  of  the  mouth.    These  or- 
ganisms have  lost  themselves  in  the  matting  formed  by  the 
interlacing  of  the  spirilli  and  bacilli.     4.  The  diminution  of 
the  number  of  bacilli  and  spirilli  of  which  the  false  mem- 
brane is  composed  as  the  ulceration  proceeds  towards  cicatri- 
zation.   5.  The  concomitant  disappearance  of  all  the  signs 
that  give  this  variety  of  angina  its  special  aspect.    6.  The 
coincident  appearance  in  the  false  membrane  and  in  the 
neighborhood  of  the  tonsils,  of  a  large  number  of  the  normal 
buccal  microorganisms  that  have  been  supplanted  during  the 
disease  by  bacilli  and  spirilli.    7.  The  rapid  repair  cf  the 
lesions  at  the  same  time  that  the  specific  agents  diminish  in 
number.    The  reappearance  of  large  numbers   of  specific 
microorganisms  and  the  extension  of  the  lesions  whenever 
some  unfavorable  feature  interrupts  ihe  regular  progress  of 
the  disease.    In  order  that  these  microorganisms  may  be- 
come virulent  it  is  necessary  that  favoreble  conditions  of  soil 
and  bacterial  association  be  present.    From  the  clinical  point ' 
of  view  the  affection  may  be  divided  into  two  periods  :  First, 
the  period  of  false  membrane  formation ;  and,  second,  the 
period  of  ulceration.    Eich  of  these  stages  of  the  disease  has 
its  special  clinical  manifestations  and  the  second  stage  always 
succeeds  the  first.    The  author  has  never  seen  cure  follow 
the  first  period;  in  all  cases  ulceration  has  followed  the  de- 
velopment of  the  false  membrane.    In  the  stage  of  ulceration 
the  diagnosis  is  only  to  be  made  from  primary  or  tertiary 
syphilitic  lesions  by  bacteriological  examination  of  the  mem- 
brane.  B.actericlogical  examination  will  also  differentiate  the 
disease  from  diphtheria.    The  course  of  the  atfection  is  acute 
and  lasts  about  15  days.     The  result   is  always  favorable, 
and  the  treatment  consists  of  washing  the  nose,  pharynx,  and 
mouth  with  a  weak  solution  of  permanganate  of  potassium. 

[j.M.S.] 


362 


The  Philadelphia"! 
Medical  Journal  J 


REVIEWS 


[Febbdabt  23,  IJOl 


KcpierDS. 


Panama   and    the    Sierras.    A    Doctor's  Wander 

Days.  By  G.  Frank  Lvdston,  M.D.  12mo,  pp.  283. 
Illustrated  from  tlie  Author's  Original  Photographs. 
Chicago  :  The  Riverton  Press,  132  Market  Street.  1900. 
Price,  $1.75.    Prepaid. 

This  interesting  little  book  is  not  too  medical  for  the  laity 
and  not  medical  enough  to  tire  the  physician  who  desires  a 
few  moments  of  recreation.  It  comprises  a  series  of  inter- 
esting anecdotes  and  reminiscences  told  in  a  charming 
manner.  The  illustrations  are  produced  from  original  photo- 
graphs taken  by  the  author  and  are  quite  impressive.  The 
Sierras  and  the  Isthmus  of  Panama  are  so  ably  described 
that  one  can  almost  feel  the  tropical  zephyrs  and  sunshine. 
There  is  an  instinctive  desire  to  finish  the  book  aftt  r  it  has 
been  begun,  and  to  describe  its  contents  would  be  detracting 
from  the  interest  of  those  who  intend  to  read  it.  Concise, 
witty  and  instructive,  "A  Doctor's  Wander  Days"  is  a 
pleasant  divertisement  after  a  doctor's  busy  day.     [m.e.d.] 

Obstetric  and  Gynecologic  Kursing.    By  E.  P.  Davip, 
a.m.,  M.D.     Professor  of  Obstetrics  in  .Jefferson  Medical 
College  and  Philadelphia   Polyclinic.    12mo,  volume  of 
402  pages.      Illustrated.      Philadelphia    and    London : 
W.  B.  Saunders  &  Co.,  1901.     Price,  $1.75  net. 

As  is  stated  in  the  preface,  this  volume  is  designed  to 
furnish  instruction  as  to  the  various  duties  of  the  obstetric 
and  gynecologic  nurse,  and  while  dedicated  to  the  training 
schools  of  the  Jelferson  and  Philadelphia  Hospitals,  it  can 
not  fail  to  be  of  the  utmost  value  to  the  well  trained  nurse 
wherever  she  may  be.  It  is  well-known  that  too  many 
nurses  receive  their  diplomas  with  almost  no  knowledge  of 
obstetric  requirements  and  often  with  absolutely  no  otstetric 
training.  The  theoretical  portion  of  this  defect  can  be 
largely  remedied  by  a  perusal  of  Dr.  Davis's  most  excel- 
lent book,  to  the  preparation  of  which  he  has  brought  the 
experience  of  many  years  of  a  large  and  varied  practice. 
Not  only  are  the  duties  of  a  nurse  in  attendance  upon  a 
woman  in  labor  described,  but  chapters  are  also  given  to 
the  nurse's  duties  in  the  latter  months  of  pregnancy  and 
when  called  upon  to  assist  in  the  various  obstetrical  and 
gynecological  operations.  Numerous  illustrations  still 
further  elucidate  an  instructive  text,  and  a  system  of  black 
captions  renders  reference  easy.  The  book  must  fill  a  long- 
felt  want  to  both  physician  and  nurse,     [w.a.n.d  ] 

Medico- Surgical  Aspects  of  the  Spanish-Aniericau 

War.  By  LlEUTENANT-CoLONEL  NICHOLAS  Senn,  M.D. 
8vo,  pp.  379.     Chicago,  1900. 

In  this  book  are  callected  the  letters  contributed  to  the 
Journal  of  the  American  Medical  Association  by  Dr.  Senn  while 
he  was  a  medical  officer  in  the  service  of  the  United  States. 

Although  a  considerable  part  of  the  book  relates  to 
matters  of  nonprofessional  interest,  many  of  its  pages  deal 
with  subjects  of  the  highest  medical  importance.  Even 
when  the  author  treats  of  subjects  outsitlo  of  the  domain  of 
medicine  he  brings  to  bear  upon  the  discussion  his  well- 
known  professional  acumen.  Medicid  readers  will  therefore 
constantly  find  important  professional  observations  recorded. 
For  example,  Dr.  Senn  speaks  of  the  great  number  of  hernias 
found  in  men  who  had  gone  through  the  campaign.  The 
evidence  seemed  to  fhow  that  this  condition  was  produced, 
not  by  hard  marching  or  violent  exertions,  but  by  "the 
relaxation  of  tissue,  caused  by  disease  and  its  effects,  aided 
undoubtedly  by  the  prevalence  of  intestinal  afiections' which 
must  have  often  resulted  in  increased  abnormal  intraabdom- 
inal tension." 

The  frequency  of  varicocele  in  recruits  was  greater  than 
would  have  been  expected.  Very  few  of  the  cases,  however, 
were  sufliciently  important  to  call  for  active  surgical  treat- 
ment. The  infrequency  of  appendicitis  in  the  niany  thou- 
sand soldiers  directly  or  indirectly  under  the  observation  of 
Dr.  Senn  is  remarkable.     He  says"  that  at  Camp  Wikoff  not 


one  case  came  under  his  observation  which  would  have 
justified  operation. 

A  partial  list  of  the  titles  of  the  letters  will  give  an  idea 
of  the  scope  of  the  volume :  "  Typhoid  Fever  m  the  Porto 
Rican  Campaign,"  "  Recent  Experiences  in  Military  Surgery 
after  the  Battle  of  Santiago,"  "The  Surgerj-  of  Camp 
Wikoff',"  "  Nurses  and  Nursing  in  War,"  "  Physical  Charac- 
teristics of  Ten  Thousand  Men,"  "  A  Compact  Operating- 
Case  for  Military  Service."  These  titles  are  sufficient  evidence 
of  the  value  of  the  book  to  both  military  and  civil  practi- 
tioners of  surgerj'. 

Dr.  Senn's  remarks  on  the  qualifications  and  duties  of  the 
military  surgeon  will  appeal  to  all  practical  men.  He  says 
"The  surgeon  who  understands  the  principles  and  practice 
of  good  cooking  is  of  more  service  to  the  troops  than  the 
one  who  can  repeat,  word  for  word,  the  contents  of  the  most 
exhaustive  treatise  on  materia  medica  and  therapeutics. 
The  medical  officer  with  a  full  knowledge  of  hygiene  and 
sanitation  and  endowed  with  the  faculty  of  making  a  rational, 
practical  use  of  it  is  preferable  to  the  most  expert  clinician." 

[j.H.R.j 

The   History   of    Ancient  Gynecology.      By  W.  J. 

Stewart  McKay,  M.B.,  M.Ch  ,  B.Sc.,  Senior  Surgeon 
to  the  Lewisham  Hospital  for  Women  and  Children, 
Sydney  ;  Late  Surgeon  to  the  Benevolent  Asvlum 
Maternity  Hospital,  Sydney ;  Fellow  of  the  British 
Gynecological  Society,  and  of  the  Obstetrical  Society, 
of  London.  Pp.  302.  New  York  :  William  Wood  <fe 
Co.,  1901. 

The  writer  of  this  w^ork  must  certainly  be  credited  with 
enormous  patience  and  industry,  all  the  more  remarkable 
because  of  the  difficulty  in  obtaining  access  to  the  ancient 
authorities  which  a  residence  in  Australia  must  entail.  In 
writing  the  history  of  ancient  gynecology  as  it  has  never 
been  attempted  before,  he  has  set  down  in  the  form  of 
extracts  or  summary  all  of  importance  that  may  be  found 
relating  to  this  branch  of  medicine  in  the  extant  writings 
of  Egj'ptian,  Hindu,  Greek  or  Roman  authors.  He  has 
utilized  translations  of  Eyptian  and  Arabic  authorities,  but 
has  mostly  consulted  originals.  A  brief  sketch  is  given  of 
the  life  and  works  of  the  more  celebrated  authors,  such  as 
Galen,  Hippocrates  or  Soranus,  after  which  are  collected  all 
the  statements  of  each  concerning  the  diseases  of  women. 
The  writer  is  able  to  say  that  he  believes  he  has  neglected 
no  work  among  ancient  classical  authors  of  any  importance 
which  contains  any  passages  on  gynecologv". 

While  finding  little  in  the  Jewish  Talmud  worth  incorpo- 
rating in  his  book  he  notes  as  a  point  of  interest  gathered  from 
the  commentaries  written  in  the  first  five  centuries  of  our 
era  that  the  Rabbins  made  many  vaginal  examinations. 
They  discovered  that  hysterectomy  was  possible  in  animals 
and  had  undertaken  cesarean  section  on  the  living  woman, 
ttonorrhea  is  also  frequently  mentioned  in  their  writings. 
The  oldest  work  on  medicine  is  a  papyrus,  obtained  in  Egypt 
by  Ebers  in  1872,  dating  from  the  sixteenth  century  before 
the  Christian  era.  Thouga  the  part  of  the  work  specially 
devoted  to  gynecology  hiis  not  been  preserved,  some  facts 
relating  to  the  subject  are  to  be  found  in  the  portions  extant. 
There  are  here  references  to  uterine  prolapse.  1 1  the  use  of 
the  medicated  tampon,  the  suppository,  the  enema,  etc. 
Specialism  in  medicine  is  not  a  modem  development,  for 
Herodotus,  the  Greek  historian,  says  of  the  to  him  ancient 
Egyptians :  "  Some  physicians  are  for  the  eyes,  others  for  the 
head,  others  for  the  teeth,  others  for  parts  about  the  belly, 
and  others  for  internal  disorders." 

How  many  centuries  has  it  taken  before  mankind  learned 
through  aseptic  methods  to  read  literally  these  words  of  an 
old  Greek  physician  :  "  The  napkins  must  be  kept  clean,  be 
of  soft  texture,  as  also  the  linen  used  for  the  eyes,  and  the 
sponges  for  the  wounds  :  for  these  things  are  of  great  im- 
portance for  the  healing." 

Hippocrates  (460  B.  C.)  describes  a  method  of  applying 
the  Trendelenburg  position  for  the  treatment  of  prolapsus 
uteri  which  is  simple  and  eff"ectivc.  Cushions  were  placed 
on  a  ladder,  the  patient  tied  on  by  ankles,  knees  and 
thighs.  One  end  of  the  ladder  was  then  raised  against  the 
gable  end  of  a  house  1 


Fkbruary  23,  1901] 


REVIEWS 


PThb  PhiulDblpbu 
L  Mbdical  Jousnal 


363 


In  the  literature  of  Hindu  medicine,  which  may  antedate 
Christianity  by  a  thousand  j'ears,  are  references  to  the  trocar 
for  tapping  dropsy  and  presumably  ovarian  cysts ;  to  the 
suprapubic  operation  for  stone  in  women  ;  to  the  catheter  ; 
to  nutrient  enemata,  and  numerous  instruments,  including 
the  three-cornered  surgical  needle. 

The  catgut  ligature  for  vessels  and  the  knee  chest  position 
seem  to  have  a  very  ancient  origin.  The  reader  of  this  most 
interesting  book  will  surely  be  inclined  to  agree  with  Solomon 
who  wrote  that  there  was  nothing  new  under  the  sun.  Since 
it  is  also  true,  as  the  same  writer  has  said  that  of  making 
many  books  there  is  no  end,  it  is  helpful  for  the  student 
of  our  art  to  have  access  to  such  a  co  lection  of  data  as 
that  here  under  discussion.  Endless  research  is  thus  avoided. 
Many  subjects  of  interest  are  summarized  in  closing  chapters, 
but  the  absence  of  an  index  greatly  detracts  from  its  con- 
venience for  reference.  Every  practitioner  of  the  gyne- 
cology of  today  may  find  profitable  food  for  thought  in  its 
perusal.    Every  gynecological  writer  should  have  it.    [g.e.s.] 

A  Textbook  on  Practical  Obstetrics.  By  Egbert  H. 
Grandin,  M.D.,  Gynecologist  to  the  Columbus  Hospital; 
Consulting  Gynecologist  to  the  French  Hospital ;  Late 
Consulting  Obstetric  and  Obstetric  Surgeon  of  the  New 
York  Maternity  Hospital ;  Late  Obstetrician  of  the  New 
York  Infant  Asylum;  Fellow  of  the  American  Gyne- 
cological Societ}',  of  the  New  York  Academy  of  Medi 
cine,  of  the  New  York  Obstetrical  Society,  etc.,  etc.,  etc- 
With  the  collaboration  of  Geoege  W.  Jaeman,  M.D., 
Gynecologist  to  the  Cancer  Hospital ;  Instructor  in 
Gynecology  in  the  Medical  Department  of  the  Columbia 
University ;  Late  Obstetric  Surgeon  of  the  New  York 
Maternity  Hospital ;  Fellow  of  the  American  Gyneco- 
logical Society,  of  the  New  York  Academy  of  Medicine- 
of  the  New  York  Obstetrical  Society,  etc  Third  edition' 
revised  and  enlarged.  Illustrated  with  52  full-page  pho- 
tographic plates  and  105  illustrations  in  the  text. 
6Jx9J  inches.  Pages  xiv-511.  Philadelphia:  F.  A. 
Davis  Company,  publishers,  1914-16  Cherry  Street. 
Price,  extra  cloth,  $4.00,  net ;  sheep,  $4.75,  net. 

The  authors  of  this  well  known  and  well  received  book 
have  in  the  present  edition  maintained  the  high  standard  of 
their  previous  work.  A  chapter  dealing  with  the  anatomy 
of  the  female  organs  of  generation  has  been  added,  as  well 
as  a  section  upon  elementary  embryology.  The  illustrations 
are  profuse  and  are  largely  taken  from  photographs  of  the 
living  subjects,  although  there  still  remain  some  of  the 
original  plates  of  manikin-practice.  We  regret  that,  some 
important  subjects  are  disposed  of  in  rather  a  summary 
manner  not  altogether  in  accord  with  the  status  of  a  text- 
book. This  is  eminently  true  of  affections  of  the  fetus  and 
fetal  membranes,  no  mention  whatever  being  made,  for  ex- 
ample, of  malignant  deciduoma,  which  has  of  recent  years 
assumed  an  unusual  importance  in  obstetric  and  gynecologic 
surgery.  The  recent  pathologic  developments  also  in  the 
same  department  do  not  receive  sutficient  attention,  but 
from  a  clinical  and  surgical  standpoint  the  book  is  well  worth 
a  careful  perusal.  The  text  is  clear  and  the  mechanical 
work  excellent,     [w.a.n.d.] 

A  System  of  Practical  Therapeutics.  Edited  by 
HoBART  Emory  Hare,  M.D.  Second  edition,  revised 
and  enlarged.  Vol.  I,  with  illustrations.  Philadelphia  : 
Lea  Brothers  &  Co.    Price,  $5  00. 

This  volume  is  the  first  of  a  practically  new  system  of 
Therapeutics  based  on  Hare's  well-known  system  which  was 
publised  ten  years  ago.  It  is  not  a  mere  reprint,  or  even  a 
second  edition  in  the  ordinary  sense,  but  in  many  respects  is 
a  new  work.  Nearly  one-half  of  the  articles  are  entirely  new 
and  the  rest  of  the  material  has  undergone  a  complete 
revision.  The  scope  of  the  work  has  been  enlarged  so  as  to 
meet  the  wants  of  the  practitioner  in  the  entire  field  of 
medical  and  surgical  therapeutics.  Among  the  subjects 
which  are  presented  in  an  entirely  new  form  are   Diabetes  I 


Mellitus,  Rheumatism,  Spasmodic  Croup,  Scarlet  fever. 
Measles,  Rotheln  and  Varicella,  Typhoid  Fever,  Croupous 
and  Catarrhal  Pneumonia,  Dengue,  Influenza,  Acute  Rheu- 
matism and  Tonsillitis,  Mumps  and  Diseases  of  the  Mouth,. 
Diseases  of  the  Liver  and  Gallbladder,  Tuberculosis,  Rickets, 
Scurvy,  the  Diseases  of  Pregnancy,  Parturition  and  the 
Puerperium,  Fractures  and  Dislocation,  Antisepsis  and 
Asepsis,  Anesthetics,  Minor  Surgery  and  Bandaging,  Disin- 
fection, Mineral  Springs,  Swedish  Movements  and  Massage, 

In  the  wealth  of  material  contained  in  this  first  volume 
we  are  impressed  with  the  value  of  some  chapters  especially, 
and  we  should  like  to  review  them  in  detail  if  it  were  pos- 
sible. Dr.  Edward  Martin,  for  instance,  has  written  on  the 
present  treatment  of  syphilis,  and  has  brought  the  subject 
thoroughly  up  to  date  and  presented  it  in  the  most  practical 
and  interesting  way.  He  believes  that  mercury  should  form 
the  basis  of  treatment  in  all  periods  of  .syphilis,  and  that  this 
drug  is  most  efficacious  when  administered  by  inunction. 
As  to  the  hypodermic  method.  Dr.  Martin  says  that  there 
seems  to  be  no  reason  for  believing  that  it  is  likely  to  be 
adopted  as  regular  treatment  in  preference  to  all  "others. 
The  special  indication  for  this  method  is  found  in  those 
cases  in  which  the  seat  and  rapid  advance  of  the  syphilitic 
lesion  are  such  that  the  patient's  life  is  directly  threatened 
or  he  is  in  danger  of  becoming  seriously  crippled.  This 
method  is,  therefore,  in  our  judgment,  especially  indicated 
in  syphilis  of  the  nerve  centers  and  probably  also  of  the  eye. 
It  is  contraindicated  when  the  kidneys  are  diseased  or  when 
the  patient  is  suffering  from  diabetes  or  marked  visceral 
lesions,  anemia,  or  systemic  dyscrasia. 

Dr.  John  K.  Mitchell  has  written  a  very  full  and  elaborate 
article  on  the  Rest  Cure.  In  this  he  embodies  the  methods 
of  practice  which  have  been  used  especially  at  the  Ortho- 
pedic Hospital  in  this  city  under  the  supervision  of  Dr.  S- 
Weir  Mitchell. 

Dr.  Simon  Baruch  has  written  the  chapter  on  hydros 
therapy.  The  author's  well-known  predilection  for  this 
system  of  treatment  prepares  us  to  expect  the  very  com- 
plete exposition  of  it  which  he  has  given  in  this  chapter. 
He  fails  to  do  justice,  however,  to  the  work  of  Dr.  Jame» 
C.  Wilson,  of  Philadelphia,  and  a  few  others,  in  fam diar- 
izing the  use  of  the  Brand  bath  in  the  treatment  of  enteric 
fever.  The  treatment  of  diabetes  mellitus  is  described  by 
Dr.  James  Tyson,  of  Philadelphia,  in  the  complete  manner 
to  be  expected  of  such  an  authority.  The  article  on  the 
treatment  of  tuberculosis,  by  Dr.  Flick,  is,  in  our  judgment, 
one  of  the  most  valuable  and  complete  in  the  book.  It  is  a. 
review  of  the  subject  which  practically  leaves  nothing  out 
of  count,  and  is  based  on  the  most  recent  and  scientific 
knowledge  of  tuberculosis  as  an  infectious  disease. 

Professor  Remington  has  given  a  most  instructive  paper 
on  prescription  writing  and  the  combining  of  drugs.  Tnis 
ought  to  be  useful  to  every  physician,  if  everj'  physician  will 
take  the  time  to  read  it.  It  is  well  worth  reading,  and  some 
parts  of  it  are  not  a  little  diverting,  especially  the  section 
devoted  to  faults  in  prescription  writing,  with  fac-similar 
illustrations.  The  whole  paper  is  an  admirable  account  of 
what  may  almost  be  called  one  of  the  lost  arts. 

Another  imp  rtant  paper  is  on  disinfection,  by  Dr.  W.  M. 
L.  Coplin.  The  author  starts  with  a  statement  of  the  theory 
of  disinfection,  and  then  describes  all  the  processes  accord- 
ing to  the  most  improved  methods.  It  is  a  paper  of  great 
practical  utility. 

Time  and  space  will  not  permit  us  to  mention  in  detail  all 
the  other  papers  in  this  volume.  Professor  Wood's  intro- 
ductory chapter  on  therapeutic  methods  is  written  with  the 
author's  usual  acumen  and  in  his  well-knoan  style.  Dr. 
James  Stewart  has  contributed  a  very  full  paper  on  rheum- 
atism and  gout.  Among  other  papers  worthy  of  s(  ecial 
note  is  the  one  on  mineral  waters  by  Dr.  James  K  Crook, 
and  the  one  on  diseases  of  the  blood  by  Dr.  Ral  h  Stockman. 
If  the  succeeding  volumes  of  this  work  are  brought  un  ta 
the  standard  attained  in  this  first  volume,  they  will  consti- 
tute a  work  that  will  be  a  most  valuable  addition  to  the 
library  of  every  physician  who  subscribes  for  it.     [j.h.l.] 


The  3Iedical  Press  and  Circular  states  Sir  Thornley 
Stoker  is  mentioned  as  a  probable  candidate  for  the  vacancy 
on  the  Council  of  the  Royal  College  of  Surgeons  in  Ireland^ 
created  by  the  death  of  Dr.  Jacob. 


364 


The  Philadelphia"! 
Mbdical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Febkcabt  23,  1901 


2lmertcan  Hcids  anb  Hotes. 


PHILADELPHIA  AND  PENNSYLVANIA. 

Professor  W.  W.  Keen  has  asked  for  a  leave  of 
absence  at  the  Jefferson  Medical  College  in  order  to  take  a 
long  trip  around  the  world.  He  will  start  next  June,  after 
the  meeting  of  the  American  Medical  Association,  and  will 
return  in  September,  1902,  to  resume  his  teaching  and 
practice. 

The  Mutual  Aid  As.socIation  of  the  Philadelphia 
•Coutity  Medical  Society  has  just  received  $3,110.55,  which  is 
a  part  of  the  legacy  under  the  will  of  the  late  Dr.  Albert 
Ericke.  This,  it  is  understood,  is  the  Association's  share  of 
the  amount  awarded  by  the  Orphans'  Court  at  the  first  dis- 
tribution made  by  the  executor. 

Dr.  John  D.  Ross,  of  Williamsburg,  Blair  Co.,  Pa.,  is 
the  oldest  medical  practician  in  the  Slate.  Dr.  Ross  gradu- 
ated from  the  Medical  Department  of  the  University  of 
Pennsylvania  in  1832.  He  is  now  in  his  ninety-fifth  year 
and  in  full  possession  of  his  ment  il  faculties.  Dr.  Ross  was 
president  of  the  Pennsylvania  State  Medioal  Association 
in  1863. 

Extracted  Wrong  Tooth. — Salt  for  $3,000  wa«  brought 
against  a  Philadelphia  dentist  for  the  extraction  of  a  wrong 
tooth.  The  plaintiff  alleges  that  the  dentist  had  maliciously 
«xtracted  the  tooth,  but  it  is  said  that  the  testimony  showed 
that  the  patient  was  taken  to  the  dentist's  office  by  his 
father,  that  he  pointed  out  the  tooth  to  the  dentist,  and  that 
!the  latter  had  by  mistake  extracted  another  tooth. 

Dr.  William  H.  Egle,  genealogist  and  historian,  died 
February  19,  at  Harriaburg  Pa.  He  was  graduated  from  the 
Medical  Department  of  the  University  of  Pennsylvania  in 
1859.  In  1863  he  was  appointed  surgeon  of  the  Forty- 
seventh  Pennsylvania  Regiment,  and  served  until  December, 
1865.  In  March,  1887,  he  was  appointed  State  Librarian, 
which  position  he  held  for  12  years.  He  was  the  author  of  a 
history  of  Pennsylvania,  and  a  large  number  of  other  his- 
.torical  publications. 

Free  Hospital  for  Consumptives. — The  Committee 
■on  Appropriations  at  Harrisburg,  has  decided  to  recommend 
:$50,000  for  the  establishment  of  a  free  sanitarium  at  White 
Haven,  near  Glen  Sammit.  The  appropriation,  it  is  pro- 
posed, shall  be  made  available  in  two  annual  installments  of 
$35,000  each.  These  recommended  appropriations  will  be 
in  addition  to  the  original  award  of  $10,000  for  the  treat- 
ment of  incipient  cases,  endorsed  by  the  Legislative  Com- 
mittee having  in  charge  the  apportioning  of  the  Slate's 
funds. 

Philadelphia  Neurological  Society.— .^t  the  stated 
meeting  to  be  held  February  25,  at  8.15  p  m.,  in  the  h^ll  of 
the  College  of  Paysicians  Drs  Wm.  H.  Zeller  and  F.  X. 
Dercum  will  exhibit  A  case  of  astereognosis  and  Drs. 
"George  L.  Walton  and  Walter  E  Paul,  of  Boston,  will,  by 
invitation,  read  a  paper  entitled  Astereognosis,  with  il- 
lustrative cases.  Tlie  presence  of  members  of  the  profes- 
sion is  cordially  invited.  At  the  close  of  the  meeting  a  re- 
ception will  be  tendered  Drs.  Walt)n  and  Paul  at  the  Uni- 
versity Club. 

Medical  Alumni  Meet.— Tne  Philadelphia  Alumni  of 
the  Medical  Department  of  the  University  of  Pennsylvania 
met  February  16  at  the  Bourse,  and  heard  a  lecture  given  by 
Ernest  W.  Kelsey,  of  the  Class  of  '94,  in  association  with 
William  C.  Henderson,  detailing  two  years'  experience  in  the 
Alaska  gold  fields.  The  lecture  was  illustrated  with  lantern 
islides.  A  communication  was  received  from  Provost  Har- 
rison advising  the  appointment  of  a  committee  to  consider 
the  best  way  of  raising  funds  for  the  building  and  endow- 
ment of  a  new  medical  laboratory.  A  committee  will  be 
appointed  by  the  executive  board  of  the  association. 

The  Kush  Hospital. — The  annual  meeting  of  the  cor- 
poration of  the  Rush  Hospital  for  Consumption  and  Allied 
Diseases,  of  Philadelphia,  was  held  February  19.  There  was 
JQO  opposition  to  the  ireelection  of  the  old  board  of  officers,  as 


follows :  President,  Hon.  William  N.  Ashman ;  Eecretary, 
Nathaniel  E  Janney ;  treasurer,  E.  A.  Sobernheimer  ;  trustees, 
Jeremiah  J.  Sillivan,  Samuel  Castner,  Jr.,  Rsv.  Thomas  J. 
Barry,  Frank  Read,  Dr.  James  Tyson,  Miss  Miry  S.  Buckley, 
Birclay  H.  Warburton,  W.  H.  Staake,  George  W.  Firr, 
Frank  A.  Sobernheimer,  Edmund  G.  Hamersly,  Emma  A. 
Duffield,  Mrs.  Gsorge  Pierce  and  Kenneth  M.  Blakiston. 

Berks  County  Medical  Society.— At  the  February 

meeting  of  the  society  Dr.  Hussbergee,  of  Blandon,  read  a 
paper  on  Delirium  tremens,  in  which  he  compared  the 
symptoms  in  a  measure  to  uremic  poisoning.  When  dia- 
phoresis could  be  established  the  patient  improved.  He 
cited  a  number  of  instances  of  men  who  were  heavy  and 
constant  drinkers,  who  did  not  have  the  delirium  simply 
because  they  were  working  before  a  hot  blast  furnace, 
which  caused  them  to  perspire  very  freely,  and  thus  to 
unload  the  poison  by  the  skin.  His  plan  of  treatment  is 
rest  in  a  dark  room,  diaphoresis,  purgation,  diuretics, 
hydrate  of  chloral,  only  in  a  few  doses  early,  and  digitalis 
in  a  few  doses.  Bromides  of  potassium  and  sodium  and 
morphia  to  produce  sleep  if  necessary. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 
February  16,  1901 : 

Total  mortality 522 

Cases.     Deaths. 
Inflammation  of  appendix  3,  bladder  1,  brain 
12,  bronchi  13,  kidneys  21,  lungs  94,  peri- 
toneum 4,  pleura  3,  stomach  and  bowel^  17, 

spine  2 170 

Inanition  17,  marasmus  8,  debility  4 29 

Tuberculosis  of  lungs 68 

Apoplexy  25,  paralysis  8 33 

Heart — disease  of  '63,  fatty  degeneration  of  3,  3C 

Uremia  12,  diabetes  2,  Brigbt's  disease  12  .        .  26 

Carcinoma  of  stomach   4,  uterus   2,  liver  2, 

pancreas  1,  rectum  1 10 

Convulsions  11,  puerperal  1 12 

Diphtheria 91  11 

Brain — softening  of  2,  congestion  of  2,  dis- 
ease of  2 6 

Typhoid  fever 61  7 

Old  age 17 

Suicide 5 

Alcoholism 2 

Cyanosis 7 

Scarlet  fever 62  10 

Influenza  16,  aneurysm  of  aorta  2,  asthma  2. 
casualties  6,  congestion  of  lungs  3,  childbirth 
2,  cirrhosis  of  the  liver  2.  croup  3,  membra- 
nous croup  3,  diarrhea  2,  dropsy  1,  dysen- 
tery 2,  epilepsy  1,  erysipelas  4,  hemorrhage 
from  stomach  1,  from  uterus  1,  hernia  2, 
leukemia  1,  poisoning  2,  arterial  sclerosis  2. 
spine  1,  shock  2,  septicemia  8,  suffocation  2, 
whooping-cough  3 73 

County  Medical  Society.— The  treatment  of  tu- 
berculosis of  the  glands  of  the  neck  with  minimal 
scarring,  by  Dr.  G.  Bettos  Massey,  was  the  first  piper  at 
the  meeting  of  February  13.  Because  of  the  author's  illness 
the  paper  was  read  by  Dr.  E.  R  Kirby.  The  method  is 
offered  as  a  substitute  for  cutting  operations,  which  leave 
unsightly  scars  and  is  a  modification  of  the  cataphoric 
method  for  treating  cancer.  The  destruction  of  the  tubercle 
bacilli  by  nascent  oxychloride  of  mercury  is  the  principle 
upon  which  the  operation  is  based.  A  small  opening  is 
made  through  the  skin  and  the  wound  cauterized  suffi  :ient!y 
to  keep  it  open  for  drainage.  Through  this  optning  is  intro- 
duced, at  intervals  of  a  few  days,  a  gold  electrode  amalga- 
mated to  hold  as  much  mercury  as  possible.  A  current  of  2 
to  10  milliamperes  is  passed  for  10  minutes.  The  sinus 
drains  the  products  of  the  dead  bacilli.  Two  cases  of  cure 
by  this  method  were  reported.  The  resulting  scar  is  a  mere 
point.  Dr.  J.  H.  Gibbon  said  that  two  points  seemed  worthy 
of  comment.  The  first  is  that  tuberculous  glands  are  rarely 
single  and  unless  the  results  of  this  treatment  extend  to 
others  than  the  one  to  which  application  is  made  its  efficacy 
is  not  assured.  Again,  simple  drainage  often  causes  such 
glands  to  shrink  without  any  applications.  Dr.  Hammont)  be- 
lieves the  condition  is  one  which  should  not  be  irritated  by 
such  a  method.  Tue  capsule  is  broken  down  and  spreading 
of  the  process  is  more  likely.  The  tuberculous  process  can 
be  spread  by  the  caseous  matter  formed,  as  well  as  by  the 
baoilli  themselves. 


FSBKDABT  23,   1901J 


AMERICAN  NEWS  AND  NOTES 


CThs  Phoadeu-hia 
msdical  jodbnal 


365 


Dr.  a.  R.  Moolton  reported  a  case  of  Rupture  of  the 
rectum  aud  beruia  of  tbe  iutestiue  iu  aa  iusaue 
man.  The  patient  was  a  man  of  34,  an  inmate  of  the  Penn- 
sylvania Hospital  for  the  Insane,  who  had  induced  a  rectal 
prolapse  by  means  of  his  hands.  On  November  20,  190O,  the 
rectum  ruptured  and  a  loop  of  small  intestine  and  mesen- 
tery, 2  feet  in  length,  protruded.  Shock  was  profound  and 
death  followed  in  30  hours. 

Pathological  Society. — The  meeting  of  February  14 
was  opened  with  a  paper  by  Dr  Albert  Woldert,  who 
showed  original  specimens  of  zygotes  of  estivo- 
autumual  malarial  parasites  iu  the  middle  intes- 
tine of  the  mosquito.  Specimens  of  the  anopheles 
were  secured  from  breeding  places  within  the  city  limits, 
allowed  to  bite  patients  having  malaria,  and  were  then  dis- 
sected after  4  or  5  days.  After  several  unsuccessful  trials, 
zygotes  were  found.  Search  for  mosquitoes  showed  that  the 
anoxiheles  was  present  in  every  locality  where  malaria  was 
endemic,  but  was  also  found  where  there  was  no  malaria, 
one  such  place  being  in  the  -Pocono  Mountains,  3,000  feet 
above  sea  level. 

Dr.  D.  L  Edsall  read  a  paper  on  The  diagnosis  of 
pancreatic  disease  by  the  estimation  of  the  urinary 
sulphates  and  of  the  fecal  fat.  Two  cases  were  re- 
ported. In  one  case  there  were  stomach  symptoms,  jaun- 
dice, and  other  signs  of  pancreatic  disease.  Examination  of 
the  urine  showed  that  the  ethereal  sulphates  were  less  than 
half  the  normal  quantity,  the  ratio  batween  the  ethereal  and 
the  preformed  being  1  to  20  or  29,  instead  of  1  to  10. 
Autopsy  showed  carcinoma  of  the  head  of  the  pancreas.  In 
the  second  case  the  ethereal  were  above  normal.  The 
patient  recovered  apparently  having  had  only  an  attack  of 
catarrhal  jaundice.  The  estimation  of  the  sulphates  is  of 
real  value  only  when  a  positive  result  is  obtained.  When 
the  test  is  negative,  very  little  attention  should  be  paid  to  it. 
When  positive  it  is  not  of  much  value  if  the  patient  be  on 
restricted  diet.  It  is  also  to  be  considered  in  relation  to  the 
conditions  which  so  often  accompany  pancreatic  disease — 
-constipation,  icterus,  cachexia,  etc.  These  all  tend  to  in- 
crease the  sulphates.  A  decrease  when  these  conditions 
are  present  is  of  diagnostic  importance.  Indicanuria  is  not 
considered  of  diagnostic  value  in  any  disease.  Regarding  the 
presence  of  fat  in  the  stools  there  is  a  widespread  belief 
among  students  and  even  practitioners  that  this  means  pan- 
creatic disease.  This  is  not  true,  as  there  is  fat  in  normal 
stools.  The  importance  of  icterus  as  a  cause  of  fatty  stools 
•was  emphasized.  In  the  second  case  before  mentioned  the 
stools  contained  a  very  high  percentage  of  fat.  The  con- 
clusion reached  is  that  fatty  stools  are  not  of  much  im- 
portance in  proving  the  existence  of  pancreatic  disease.  Dr. 
Wadsworth  believes  that  indisan  is  of  value  as  a  sign  and 
the  short  time  needed  to  make  the  test  is  in  its  favor.  The 
formation  of  sulphates  is  dependent  on  a  catarrhal  coating 
-of  the  jntestine.  The  amount  of  fermentation  present  de- 
pends on  the  rate  of  motion  in  the  intestines.  Sluggish 
motion  of  the  intestines,  catarrhal  coating,  etc.  must  be 
taken  into  account  when  studying  liver  or  pancreatic 
disease. 

Dr.  James  H.  Lloyd  reported  a  case  of  Extensive  sinus 
thrombosis  caused  by  long-standing  middle  ear 
disease.  The  case  was  reported  as  one  unusual  in  its 
etiology,  symptomatology,  and  pathology.  The  patient  was 
a  woman  of  34,  who  had  been  deaf  in  both  ears  since  an 
attack  of  measles  in  early  childhood.  The  case  was  an  ob- 
scure one,  having  been  sent  to  the  hospital  as  one  of  typhoid 
fever,  autopsy  showed  a  chicken-fat  clot  in  the  right  lateral 
sinus. 

Drs.  J.  H.  Girvin  and  J.  D.  Steele  reported  a  carcinoma 
■of  the  pleura  diagnosed  by  tissue  removed  in  tap- 
ping. The  patient  is  a  woman  of  50  who  had  pleurisy  3 
years  ago.  There  are  now  lumps  in  the  right  breast  and  the 
axillary  glands  are  enlarged.  Tapping  removed  27  ounces 
of  bloody  fluid  and  a  long  thin  piece  of  tissue,  which  on 
examination  proved  to  be  carcinoma. 

Dr.  Randle  C.  Rosenrerqer  showed  specimens  from  a 
«arcoma  of  the  mediastinum  of  a  rhinoceros.  The 
animal  had  died  recently  in  Zoological  Gardens,  presumably 
of  old  age,  as  it  was  nearly  100  years  old.  Examination 
«howed  a  small  round  cell  sarcoma  of  the  mediastinum.  It 
had  caused  no  symptoms  and  no  metastasis  was  noted. 


NEW  JERSEY. 

State  Board  of  Health. — The  New  Jersey  State  B^ard 
of  Health  is  considering  the  advisability  of  disinfecting  the 
books  used  in  circulating  libraries  of  that  State,  and  has 
decided  that  they  must  be  fumigated  at  regular  intervals. 

Atlantic  City  3Iedical  Society. — At  the  annual  meet- 
ing the  following  officers  were  elected  :  President,  Dr.  Theo- 
dore Boysen,  of  Egg  Harbor  City  ;  vice-president,  Dr.  W.  K. 
Darnall ;  secretary  and  treasurer.  Dr.  Theodore  Senseman  ; 
reporter,  Dr.  A.  B.  Shimer. 

Smallpox  in  Woodbury. — The  appearance  of  smallpox 
in  this  city  has  occasioned  a  feeling  of  alarm  among  the 
residents.  Two  cases  are  reported,  remote  from  each  other. 
Both  patients  are  school  boys.  A  special  meeting  of  the 
Board  of  Health  and  Board  of  Education  was  held,  and  it 
was  decided  to  recommend  a  general  vaccination. 

NEW  YORK. 

Appointment. — Dr.  Daniel  W.  Marston  has  been  ap- 
pointed visiting  surgeon  to  the  Randall's  Island  Hospital,  by 
the  New  York  Department  of  Public  Charities. 

Red  Cross  Hospital.— The  sum  of  $100,000  raised  by 
private  subscription  has  been  used  to  purchase  a  plot  of 
ground  in  New  York  City  on  which  a  Red  Cross  Hospital- 
and  Home  for  Red  Cross  Sisters  will  be  erected.  The  ad- 
ditional $60,000  required  to  build  the  hospital  and  home  will 
be  raised  in  the  same  way. 

New  Mount  Sinai  Hospital. — Preliminary  and  found- 
ation plans  for  nine  new  hospital  buildings,  to  be  erected  for 
Mount  Sinai  Hospital,  on  the  block  bounded  by  Fifth 
Avenue,  Madison  Avenue,  Oae  Hundredth  and  Oae  Hun- 
dred and  First  Streets,  were  submitted  to  the  Dapartment  of 
Buildings.  The  buildings  will  be  built  of  brick,  with  terra- 
cotta trimmings,  and  have  been  estimated  to  cost  $1,600,000. 

German  Hospital. — The  thirty-first  annual  report  of 
the  Board  of  Trustees  of  the  German  Hospital  and  Dispen- 
sary of  New  York  City  states  :  Daring  the  past  year,  accord- 
ing to  the  report,  3,352  patients  were  treated  at  the  hospital. 
Of  these  2,447  were  free  patients.  In  the  dispensary  22,595 
patients  received  treatment  free  of  charge.  Tne  expenses  at 
the  hospital  amounted  to  §79,405,  making  an  average  of 
$1.20  a  day  for  each  patient.  Daring  the  year  the  hospital 
received  $10,047.50  in  legacies  and  $4,963.80  in  donations. 

Albany  Hospital  for  Incurables. — A  tract  of  land 
was  purchased  recently  by  the  trustees  of  the  Albany  Hos- 
pital for  Incurables.  The  modern  pavilion  system  connected 
by  corridors  will  be  utilized.  The  work  has  been  incorporated 
under  the  direction  of  Messrs.  M.  T.  Hun,  L.  G.  Hun, 
Wheeler  B.  Melius,  Daniel  Casey,  with  the  approval  of  Judge 
William  L.  Learned.  The  incorporators  are  William  H. 
Murray,  M.D  ,  Robert  Geer,  John  W.  McNamara,  John  H. 
Farrell  and  Charles  N.  Phelps. 

New  York  Neurological  Society. — Stated  meeting 
February  5,  1901.     Dr.  Joseph  Collins,  President. 

A  Case  of  Locomotor  Ataxia  Trained  by  the 
Fraenkel  Method. — Dr.  A.  Wiener  presented  this  man. 
He  had  been  under  this  system  of  training  for  about  one 
year,  and  while  ataxia  was  still  present,  he  had  been  very 
greatly  improved,  and  was  now  able  to  go  about  even  at 
night  unaided.  There  had  been  no  other  treatment  for  the 
tabes. 

Sarcoma  of  the  Brain. — Dr.  A.  Wiener  also  preiented 
a  pathological  specimen  from  a  person,  17  years  of  age,  who 
had  first  come  to  him  about  November  1, 1898.  There  was 
an  absolutely  negative  history  of  alcoholism  and  syphilis. 
About  2  years  before  this  time  the  patient  had  suffered  from 
a  severe  fright,  and  almost  immediately  thereafter  had  had  a 
severe  convulsion.  Nothing  further  had  been  noticed  until 
the  summer  of  1898  when  she  had  suddenly  developed  a 
difficulty  of  speech,  with  right  facial  palsy.  She  had  suffered 
from  bad  headaches  frequently  for  3  months  previously.  On 
coming  under  observation,  there  had  been  excruciating  pain 
over  the  occipital  region,  complete  deafness  in  the  right  ear 
and  a  bulging  of  the  tympanic  membrane.    The  right  sterno- 


366 


UXOICAI.  JOUEHAL  J 


AMERICAN  NEWS  AND  NOTES 


[Fkbrdabt  23,  1(01 


mastoid  muscle  had  been  in  a  state  of  constant  contraction, 
and  there  had  been  a  doable  optic  neuritis,  most  marked  on 
the  right  side.  The  voice  was  hoarse.  Neither  the  upper 
nor  the  lower  extremities  had  suffered  any  loss  of  power. 
There  was  no  swaying  when  the  eyes  were  closed,  nor  was 
there  any  bladder  trouble.  Her  temperature  was  100°  F. 
The  seventh,  eighth,  ninth,  tenth,  eleventh  and  twelfth 
nerves  were  afiected  on  the  right  side,  and  the  sixth  nerve 
on  the  other  side.  On  November  8,  a  slight  ptosis  had  been 
noticed,  and  the  twelfth  nerve  palsy  had  become  more 
marked.  On  November  28,  there  had  been  vomiting,  vertigo 
and  an  increase  in  the  ptosis  of  the  left  eye.  On  December 
8  there  had  been  complete  third  nerve  palsy  on  the  left  side, 
and  the  headache  had  been  very  severe.  Having  diagnos- 
ticated a  tumor  of  the  brain,  the  patient  had  been  eent  to 
the  Mt.  Sinai  Hospital.  A  mass  had  developed  behind  the 
ear,  and  on  aspirating  this  it  had  been  found  that  the  case 
was  one  of  congenital  sarcoma.  On  January  11,  1899,  the 
third  palsy  had  entirely  disappeared  on  the  left  side,  and  the 
swelling  behind  the  ear  bad  grown  larger.  On  January  21, 
the  patient  had  suddenly  become  confused  and  blind  in  both 
eyes.  In  April  it  had  been  decided  to  open  the  mass  to  re- 
lieve the  pain.  By  June  30  the  patient  had  been  up  and 
around  again.  In  October  there  had  been  a  complete 
brachial  plexus  palsy  on  the  right  side.  The  tumor  had 
kept  on  growing  until  almost  the  size  of  the  patient's  head. 
The  patient  had  died  on  February  2,  1901,  and  an  autopsy 
had  been  performed.  The  whole  tumor  had  been  found 
below  and  outside  of  the  brain.  In  front  was  a  large  giant- 
cell  sarcoma  which  had  completely  destroyed  the  sphenoid 
bone.  At  the  back  the  tumor  had  destroyed  the  occipital 
bone.  The  brain  was  exhibited,  and  it  showed  that  only  the 
pons  had  suflFered  pressure.  The  tumor  had  apparently 
started  in  the  mastoid  portion  of  the  temporal  bone. 

Tendon  Transplantation  for  Deformity  of  the 
Hand. — Dr.  W.  R.  Townsend  presented  a  case  ot  this  kind, 
which  had  been  exhibited  to  the  society  ahout  1  year  ago. 
It  was  a  case  of  infantile  cerebral  palsy.  Instruments  had 
been  used  at  the  time  of  birth,  but  no  damage  had  apparently 
been  done  to  the  exterior  of  the  skull.  He  had  never  been 
able  to  use  his  right  hand,  and  it  was  a  typical  "  claw-hand  " 
when  the  boy  came  under  observation  at  the  age  of  15  years. 
On  December  21,  1899,  an  incision  had  been  made  over  the 
wrist,  exposing  the  tendons.  The  flexor  carpi  radialis,  the 
flexor  carpi  ulnaris,  and  the  palmaris  longus  were  divided 
just  above  the  annular  ligament.  The  hand  was  then  turned 
over  and  an  incision  made  on  the  dorsum  of  the  wrist,  and 
the  extensor  communis  digitorum  exposed.  A  dissection 
having  been  made  through  the  interosseous  space,  the  exten- 
sor tendon  was  pushed  through,  and  being  too  long,  was 
doubled  upon  itself.  It  was  then  attached  to  the  tendons 
previously  mentioned.  The  union  of  the  tendons  had  been 
satisfactory  and  permanent.  The  tendons  had  not  shown 
any  tendency  to  unite  to  the  surroundii  g  tissues.  He  was 
now  able  to  write  fairly  well,  whereas  formerly  he  could  not 
even  grasp  a  pen.  Dr.  B.  Sachs  said  that  he  had  been  deeply 
interested  in  this  subject,  and  it  was  certainly  the  best  proce- 
dure that  had  been  suggested  for  these  cases  of  contracture 
whether  of  spinal  or  cerebral  origin.  The  problem  was  to 
split  the  tendon  of  the  overacting  muscles  and  unite  them 
to  the  tendons  of  the  under-acting  muscles,  and  so  restore  the 
equilibrium  of  power.  It  had  been  found  prudent  not  to 
allow  the  patient  to  exercise  much  or  to  use  electricity  until 
the  tendinous  union  had  become  very  firm.  It  was  unfortu- 
nate that  this  boy  was  not  able  to  extend  his  fingers,  yet  he 
had  secured  good  extension  of  the  wrist.  In  spite  of  the  ten- 
don transplantation  the  boy  experienced  no  difficulty  in  pro- 
ducing flexion  when  he  desired  to  do  so.  Dr.  Schlapp 
remarked  that  it  seemed  to  him  that  the  boy's  hand  was 
decidedly  larger  now  than  when  he  had  seen  the  case  a  few 
months  ago. 

Dr.  Creiqhtox  presented  a  young  woman  of  neurotic  tem- 
perament who,  4  years  ago,  had  had  hysteria  and  typical  at- 
tacks of  grand  nial.  One  year  ago  she  had  had  the  grip, 
followed  by  pneumonia,  and  this  had  been  followed  by  head- 
aches, aching  spine,  and  numbness  in  the  left  side.  There 
were  severe  contractures  in  the  left  arm.  A  small  painful 
tumor  had  dppeared  in  the  left  palm,  and  had  been  removed 
by  the  family  physician  under  cocain.  It  had  returned  and 
had  been  again  removed.  A  galvanic  current  of  10  milliam- 
peres  had  brought  out  a  slight  redness  on  the  palm.    Three 


days  before  menstruation  a  large  red  spot  had  appeared  on  the 
back  of  the  forearm,  and  soon  afterward  several  similar  spots 
had  made  their  appearance  on  the  arm.  A  few  days  before 
the  next  menstruation  these  spots  had  returned,  and  in  addi- 
tion, a  number  of  large  blotches  on  the  left  shoulder,  and  on 
that  side  of  the  neck.  The  whole  side  was  very  hyperesthetic. 
There  was  slight  narrowing  of  the  visual  field,  and  there  was 
left-sided  sweating.  The  speaker  said  that  the  case  was  very 
similar  to  one  recently  reported  from  Erb's  clinic.  Dr.  Jo- 
seph Fraenkel  asked  whether  there  had  been  a  history  of 
malaria,  and  whether  the  case  might  not  be  looked  upon  as 
one  of  morphea.  Dr.  Ceeighton  replied  that  there  was  no 
history  of  malaria,  and  the  family  physician  had  stated  that 
the  tumor  which  he  had  removed  grew  on  the  nerve.  The 
microscopical  examination  had  been  made  at  the  laboratory 
of  the  Presbyterian  Hospital,  and  the  report  had  been  that 
there  was  a  slight  round- cell  infiltration  only;  no  nerve  de- 
generation was  found.  The  thyroid  gland  was  not  enlarged. 
Dr.  C.  L.  Dana  said  that  he  had  seen  cases  presenting  just 
this  appearance,  but  entirely  free  from  hysteria.  Db.  W.  B. 
NoYES  said  that  4  or  5  skin  lesions  were  closely  associated 
with  nervous  troubles.  Herpes  zoster,  erythema  multiforme, 
Reynaud's  disease,  all  were  distinctly  related  to  the  nervous 
system,  yet  it  was  very  difficult  to  state  the  exact  relation. 
It  had  occurred  to  him  that  the  element  of  suggestion  regard- 
ing the  connection  with  the  nerve  might  be  responsible  for 
some  of  the  phenomena  present.  Dr.  E.  D.  Fishee  said  that 
this  could  not  properly  be  described  as  simple  hysteria,  or  as 
the  result  of  mere  suggestion.  The  eruption  was  not  character- 
istic of  an  hysterical  state.  Dr.  M.  G  Schlapp  said  that  these 
cases  had  been  described  before ;  they  had  been  brought  on 
by  suggestion.  In  this  case  an  injection  had  been  given  in 
the  arm,  and  shortly  afterward  this  dermatitis  had  first  ap- 
peared. The  eruption  was  not  characteristic  of  any  particu- 
lar skin  lesion,  but  it  closely  resembled  cases  that  had  been 
described  as  hysterical  skin  manifestations.  In  typical  zoster 
there  was  frequently  a  degeneration  of  the  nerve  fiber  itself. 

Dr.  Sachs  said  that  the  case  was  a  very  unusual  one,  and 
he  did  not  regard  it  as  belonging  to  the  class  of  hysterical 
hyperemia.  It  was  certainly  a  distinct  form  of  skin  neurosis. 
The  closest  resemblance  in  the  anatomical  distribution  was 
to  herpes.  Dr.  Joseph  Colliss  said  that  if  the  girl  should 
develop  a  pneumonia  he  would  not  be  willing  to  call  it  a 
hysterical  pneumonia;  neither  was  he  willing  to  call  this  a 
hysterical  skin  disease.  He  was  inclined  to  think  it  was 
closely  related  to  morphea.  Dr.  Crkighton*  said  that  a  case 
had  been  reported  very  recently  in  which  the  gangrenous 
form  had  ultimately  developed.  This  case  had  been  de- 
scribed as  hysterical.  Dr.  J.  C.  Johnston,  the  dermatologist, 
had  seen  this  patient  and  looked  upon  her  as  hysterical. 

Paralysis  of  the  Spinal  Accessory.— Dr.  Peakce 
Bailey  read  this  paper.  He  said  that  the  chief  interest  of 
this  nerve  was  surgical.  Within  the  past  year  two  instances 
had  come  to  his  notice  of  accidental  section  of  the  nerve. 
In  most  cases  the  paralysis  which  results  from  section  was 
not  particularly  disabling,  but  such  had  not  been  the  case  in 
the  instances  referred  to.  When  the  stemomastoid  was 
completely  paralyzed  the  freedom  of  movement  of  the  head 
was  interfered  with,  but  not  totally  abolished.  In  the  two 
cases  referred  to  the  disability  had  been  unusually  great, 
and  had  led  him  to  study  more  carefully  the  nerve  supply. 
It  was  now  regarded  as  a  spinal  nerve,  pure  and  simple. 
The  spinal  portion  of  the  nerve,  represented  by  the  external 
branch,  springs  from  the  upper  five  segments  of  the  cord. 
Paralysis  of  the  nerve  presents  a  varying  symptomatology 
according  to  the  site  of  the  lesion.  An  injury  outside  of  the 
skull  to  cause  symptoms  referable  to  both  branches  must  be 
situated  directly  at  the  base  of  the  skull.  The  extracranial 
lesions  of  the  spinal  accessory  are  confined  to  the  external 
branch,  and  are  nearly  always  traumatic.  Neuritis  in  this 
nerve  is  rare.  A  case  was  cited  to  illustrate  the  possible 
traumatic  origin  of  spinal  accessory  palsy  by  injury  with  a 
blunt  instrument.  In  two  other  cases  reported  the  paralysis 
had  been  directly  the  result  of  operation.  In  the  second 
case  the  resulting  incapacity  had  been  so  great  that  the  right 
arm  had  been  rendered  practically  useless  for  any  heavy 
work.  Neurorrhaphy  had  been  performed  about  six  weeks 
after  the  operation  at  which  the  nerve  had  been  injured. and 
the  ends  of  the  divided  nerve  had  been  found  separated  over 
one  inch.  The  improvement  in  motor  power  haid  been  slow. 
A  reference  to  the  literature  showed  conflicting  views  re- 


Fkbedabt  23,  1901] 


AMERICAN  NEWS  AND  NOTES 


CThe  Philadelphia 
Medical  Joubnal 


367 


gardiug  the  nerve  supply.  Dr.  Bailey  said  that  the  spinal 
center  between  the  first  and  fifth  cervical  segments  of  the 
cord  was  fixed  and  constant,  but  occasionally  all  the  axons 
pass  to  the  muscle  by  the  spinal  accessory.  Under  these 
circumstances  the  motor  impulses  reach  the  trapezius 
through  the  spinal  accessory,  and  hence,  section  of  it  means 
total  palsy.  Dr.  W.  M.  Leszynsky  said  that  he  had  seen  a 
patient  two  months  ago  who  had  been  operated  upon  for 
torticollis.  Over  1  inch  of  spinal  accessory  nerve  had  been 
removed  on  the  left  side  without  relief,  and  the  function  of 
the  muscle  had  remained  perfectly  normal.  He  had  seen 
over  an  inch  of  the  other  spinal  accessory  nerve  removed 
subsequently,  yet  the  muscle  had  not  been  atfected  at  all ; 
hence  he  had  held  that  it  was  useless  in  these  cases  of  spasm 
to  operate  upon  the  spinal  accessory  nerve.  Dr.  J.  Arthur 
Booth  said  that  he  had  had  a  case  of  spasmodic  torticollis 
operated  upon  by  section  of  the  spinal  accessory  nerve.  A 
little  more  than  one  inch  had  been  excised,  and  the  sterno- 
mastoid  and  part  of  the  trapezius  had  been  paralyzed  as  a 
result. 

Congress  of  Nurses.— An  international  congress  of 
nurses  will  be  held  in  BufiFalo  next  September  to  strengthen 
the  national  and  international  organizations  which  the 
nurses  of  this  country,  Great  Britain,  the  English  colonies, 
Denmark,  and  Holland  have  for  the  last  few  years  been  in- 
tent upon  developing.  All  these  countries  have  now  national 
organizations  of  nurses,  based  upon  the  principles  of  self- 

fovernment  and  mutual  agreement,  pledged  to  uphold  the 
onor  and  best  interests  of  their  profession,  and  to  work  for 
a  steadily  advancing  educational  standard  and  ethical  devel- 
opment. The  national  association  of  the  United  States  has 
become  afiiliated  with  the  National  Council  of  Women,  aa 
the  others  purpose  doing  in  their  respective  countries.  The 
president  of  the  International  Council  is  Mrs.  Bedford  Fen- 
wick,  of  London,  and  the  vice-presidents  are  the  presidents 
of  the  respective  national  councils.  The  chairman  of  the 
congress  will  be  Miss  Mclsaac,  superintendent  of  nurses  in 
the  Illinois  Training  School,  Chicago,  and  the  secretary  is 
Miss  Banfield,  superintendent  of  the  Polyclinic  Hospital,  of 
Philadelphia. 

CHICAGO  AND   WESTERN  STATES. 

Dr.  John  Madden,  professor  of  physiology,  Milwaukee 
Medical  College,  has  resigned. 

Dr.  Murphy  has  been  appointed  oculist  to  the  Chicago, 
Milwaukee,  and  St.  Paul  Railway  at  Mason  City,  and  also  to 
the  Mason  City  and  Clear  Lake  Railway. 

Dr.  W.  A.  Jones  has  succeeded  Dr.  Alexander  J.  Stone, 
as  editor  of  the  NorthtoeMem  Lancet.  The  office  of  publica- 
tion has  heed  transferred  to  Minneapolis. 

Visiting  Nurses. — During  the  month  of  January,  4,287 
visits  were  made  by  the  nurses  of  the  Visiting  Nurses'  Asso- 
ciation of  Chicago.  This  is  the  largest  number  ever  cared 
for  by  the  association. 

New  Medical  Registration  Board. — A  new  State 
Board  of  Medical  Registration  has  been  appointed  in  Michi- 
gan— Drs.  Joseph  B.  Griswold,  Grand  Rapids;  George  E. 
Ranney,  Lansing ;  Walter  H.  Sawyer,  Hillsdale ;  Austin  W. 
Alvord,  Battle  Creek  ;  Henry  B.  Landon,  Bay  City,  and  five 
from  other  schools  of  medicine. 

The  Western  Ophthalmologic  and  Otolaryngo- 
logic Association  will  meet  in  its  next  annual  session  in 
Cincinnati,  Ohio,  April  11  and  12.  A  fine  program  has  been 
arranged  and  the  medical  profession  are  cordially  invited  to 
attend  the  sessions.  Dr.  C.  R.  Holmes,  of  Cincinnati,  is  chair- 
man of  the  local  committee  of  arrangements.  Dr.  M.  A. 
Goldstein,  of  St.  Louis,  is  the  president,  and  Dr.  W.  L.  Ballen- 
ger,  of  Chicago,  is  secretary. 

Union  State  Hospital. — The  stockholders  of  the  Union 
State  Hospital,  Indianapolis,  held  their  annual  meeting  and 
elected  the  following  directors  :  Deborah  Moore,  John  H. 
HoUiday,  Gen.  Benjamin  H.  Harrison,  Louis  HoUweg,  H.  H. 
Hanna,  S.  P.  Sheerin,  T.  C.  Day,  Victor  Hendricks,  Albert 
Lieber,  Nathan  Morris,  and  Bement  Lyman.    The  financial 


and  hospital  reports  were  submitted  and  approved.  The 
directors  elected  the  following  oflicers :  President,  H.  H. 
Hanna;  vice  president,  John  H.  Holliday;  treasurer,  Bement 
Lyman;  secretary,  Deborah  Moore. 

Medical  Examination  Before  Marriage. — The  Cleve 
land  Journal  of  Medicine,  February,  1901,  states  a  bill  provid- 
ing for  a  board  of  medical  examiners  to  decide  upon  the  fit- 
ness for  marriage  of  all  applicants  for  marriage  license  has 
been  introduced  in  the  Colorado  House  of  Representatives. 
The  bill  provides  that  the  license  may  not  be  issued  unless 
the  medical  board  recommends  it.  The  board  is  to  sit  10 
days  in  every  month.  A  number  of  diseases  and  certain 
defects  in  family  records  are  declared  to  be  bars  to  marriage 
in  Colorado  after  passage  of  this  act.  The  fee  for  the  exami- 
nation is  fixed  at  $15. 

Refuse  Further  Attendance.  —  Prisoners  at  the 
county  jail,  St.  Joseph,  Mo.,  are  without  medical  attention 
by  reason  of  the  increasing  numbers  of  smallpox  patients 
there,  which  caused  the  attending  physicians  to  give  up  the 
task  of  stamping  out  the  disease.  Sherifi"  Spencer  has  further 
complicated  matters  by  issuing  an  order  that  he  would 
permit  no  more  patients  to  be  removed  from  the  jail  to  the 
pest-house  unless  more  guards  were  placed  at  the  latter 
point.  By  reason  of  the  few  guards  at  the  pest-house  a  num- 
ber of  desperate  men  who  are  now  infected  with  the  disease 
might  make  their  escape  if  removed  from  the  jail.  An 
additional  pest-house  will,  in  all  probability,  be  built  during 
the  next  few  days. 

SOUTHERN  STATES. 

Virginia  State  Board.— A  bill  passed  the  Senate 
recently  which  directly  aflTects  all  the  students  of  this  State. 
Dr.  LeCato  introduced  the  measure  which  provides  that 
when  a  medical  student  has  passed  an  examination  on  any 
subject  before  the  State  Board,  he  shall  have  credit  for  it  evea 
if  he  fails  in  other  branches  at  the  same  time. 

Cancer  Home. — A  new  home  for  the  treatment  of  in- 
curable cancer  will  shortly  be  opened  in  Maryland  for  the 
benefit  of  the  poor,  through  a  gift  made  by  Mrs.  Rose  Haw- 
thorne Lathrop  to  the  Servants  of  Relief  for  Incurable  Can- 
cer. It  is  specifically  stated  that  the  corporation  shall  use 
the  donation  only  as  a  free  home  for  the  poor  persons  suffer- 
ing from  incurable  cancer. 

Gulf  Coast  Medical.— At  the  reorganization  of  the 
Gulf  Coast  Medical  Society,  at  Scranton,  the  fallowing  offi- 
cers were  elected  for  the  ensuing  term  :  Dr.  B.  F.  Duke,  of 
Pascagoula,  president;  Dr.  J.  J.  Washington,  of  Pass  Chris- 
tian, vice-president ;  Dr.  J.  N.  Rape,  of  Moss  Point,  secretary 
and  treasurer.  The  next  meeting  will  be  held  at  Pass  Chris- 
tian on  May  1. 

CANADA. 

Against  Tuberculosis.— A  conference  has  been  called 
by  the  Governor- General  of  Canada,  urging  all  governments 
to  adopt  organized  methods  for  diminishing  the  spread  of 
tuberculosis. 

French-Canadian  Medical  Congress.- The  French- 
Canadian  physicians  of  Qaebec  are  organizing  a  rnedical 
congress  of  the  French  practitioners  of  North  America,  to 
be  held  next  summer.  The  French  practitioners  of  Louis- 
iana have  expressed  their  intention  of  attending. 

MISCBLIiANY. 

Practising  Without  License.— Three  Chinese  doctors 
have  been  arrested  in  Kansas  City  for  practising  medicine 
without  a  license. 

Supernumerary  Digits An  infant  has  recently  been 

born  in  Cincinnati  with  6  toes  on  each  foot,  and  with  G  fingers 
on  the  right  hand  and  7  on  the  left. 

Dr.  Chapot  Prevost,  who  performed  the  operation  on 
the  xiphopagus,  has  been  awarded  a  sum  amounting  to 
about  $4,000  as  a  prize  by  the  Brazilian  government. 


368 


The  Philadelphia"! 
Medical  Jocrnal  J 


AMERICAN  NEWS  AND  NOTES 


(Februaet  23,  1901 


Obituary.— Dr.  N.  H.  Riddick,  at  Norfolk,  Va,,  on 
February  14,  aged  50  years.— Dr.  J.  W.  Elliot,  at  Yazoo  City, 
Mies.,  on  February  14. — Dr.  Thomas  Fridge  Muedcch,  at 
Baltimore,  Md.,  on  February  18,  aged  72  years.— Dr.  H.  B. 
Potter,  at  Orleans  Four  Corners,  N.  Y.,  on  February  18,  aged 
61  years.— Dr.  John  M.  Thomas,  at  Corry,  Pa.,  on  February 
19,  aged  75  years. — Dr.  Walworth  Marsh,  at  West  Point, 
Mies.,  on  February  15,  aged  29  years. — Dr;  George  L.  Kieby, 
Superintendent  of  the  Slate  Hospital  at  Raleigh,  N.  C. 

Election  of  OflQcers. —  The  following  officers  were 
elected  in  the  national  societies  which  recently  met  in 
Baltimore  :  American  Psychological  Association — Professor 
Joeiah  Royce,  president;  Dr.  Livingston  Farrand,  secretary. 
Society  for  Plant  Morphology  and  Physiology — Dr.  Edward 
F.  Smith,  president ;  Professors  F.  C.  Newcombe  and  L.  M 
Underwood,  vice-presidents.  Professor  W.F.Young,  secre- 
tary and  treasurer.  American  Morphological  Society — Pro 
fessor  J.  S.  Kingsley,  president ;  Professor  E.  A.  Andrews, 
vice-president ;  Professor  T.  H.  Montgomery,  Jr.,  secretary 
American  Association  of  Bacteriologists — Professor  William 
H.  Welch,  president;  Profeesor  E  O.  Jorden,  vice-president 
Professor  H.  W.  Conn,  secretary  and  treasurer. 

Health  Reports. — The  following  cases  of  smallpox 
cholera,  and  plague,  have  been  reported  to  the  Surgeon 
General  U.  S.  Marine- Hospital  Service,  during  the  week 
ended  February  16,  1901  : 

Smallpox— United  States. 

Cases.       Deaths. 


Califoknia  ; 

Oakland   .    .   . 

Jan. 12-26    .    . 

4 

Florida  : 

Jacksonville  . 

Feb.  2-9    ..   . 

2 

Georgia  : 

Jefferson  ville . 

Feb.  7    .... 

2 

Illinois  : 

Cairo 

Jan.  26-Feb.  9 

8 

" 

Chicago    .   .  . 

Feb. 2-9    .    .   . 

2 

" 

Pulaski  County 

Feb.  2-9    .    .   . 

5 

Iowa  : 

Ottuniwa  .   .    . 

Jan.  5-26.    .   . 

2 

Kansas  : 

Lawrence    .    . 

Feb.  2-9  .    .   . 

3 

" 

Wichita    ,    .   . 

Feb.  2-9  ..   . 

9 

Kkntccky  : 

Lexington   .    . 

Feb.  2-9  ..   . 

1 

Louisiana  : 

New  Orleans  . 

Jan. 2-9    ..  . 

14 

4 

Minnesota  : 

Minneapolis    . 

Jan.  26-Feb.  9 

9 

MissiesiPPi : 

Vieksburg   .    . 

Feb.  2-9  ..   . 

4 

2 

Nebraska  : 

Omaha.   .    .    . 

Feb.  2-9  ..   . 

8 

N.  Hampshire  : 

Manchester     . 

Feb.  2-9  ..   . 

26 

New  York : 

New  York   .    . 

Feb.  2-9  ..   . 

17 

6 

Ohio  ; 

Ashtabula  .    . 

Feb.  2-9  .    .   . 

2 

" 

Cleveland    .   . 

Feb.  ;-9  .    .   . 

48 

1 

" 

Toledo  .... 

Feb.  2-9  ..  . 

1 

Pennsylvania  : 

Pittsburg  .    .  . 

Feb.  2-9  ..   . 

5 

Tennessee  : 

Memphis.    .    . 

Feb.  2-9  ..   . 

16 

" 

Nashville     .    . 

Feb.  2-9  ..   . 

9 

Utah: 

Sail  I^ake  City 

Smallpox- 

Feb.  2-9  .    .   . 

— Foreign. 

32 

Austria  : 

Prague  .... 

Jan.  12-26    .    . 

27 

China  : 

Hongkong  .    . 

Jan. 8-12 .    .   . 

1 

EcDADOB : 

Guayaquil  .    . 

Nov.  24- Jan.  5 

25 

Egypt: 

Cairo  

Jan.  1-7   ..   . 

1 

England  : 

London    .   .  . 
New-Castle -on- 

Jan. 19-26   .    . 

3 

Tyne.  .   .  . 

Jan.  19-26    .    . 

6 

France : 

Paris  ..... 

Jan.  12-19  .    . 

6 

India  : 

Bombay   .    .   . 

Jan.  1-15  .   .    . 

6 

" 

Calcutta   .   .  . 

Dec.  29-Jan.  5 

96 

t( 

Karaclii    .    .   . 

Dec.  2-S-Jan.  6 

7 

3 

*' 

Madras     .   .  . 

Dec.  15-Jan.  4 

3 

Mexico: 

Merida  .... 

Dec.  20.   .   .  . 

Epidemic. 

" 

Tux pan    .    .   . 

Jan.  28- Feb.  4 

3 

Porto  Rico: 

Ponce    .... 

Feb.  8    .... 

22 

Russia  : 

Moscow    .    .   . 

Jan.  12-19    .    . 

4 

*' 

Odessa  .... 

Jan. 12-19    .    . 

31 

5 

*' 

St.  Petersburg 

Jan. 6-19 .   .  . 

6 

2 

Scotland  : 

Glasgow  .   .  . 

Jan.  25-Feb.  1 

180 

Cholera. 

India  : 

Bombay    .    .   . 

Jan. 1-5    .    .   . 

9 

*' 

Calcutta   .    .   . 

Dec.  29-Jan.  5 

31 

<i 

Madras     .   .   . 

Dec.  15-Jan.  4 

19 

PLAQDE.— 

-Foreign. 

China  : 

Hongkong  .   .   . 

Dec.  £9- Jan.  5 

0 

2 

England: 

Hull 

Jan., 30.   .   .  . 

2  deaths,  crew 

S.S. 

'Friary." 

Walks  : 

Cardiff     .   .  . 

Feb.  8    .    .   .  . 

1 

India  : 

Bombay    .    .   . 

Jan.  1-15  .    .   . 

550 

" 

Calcutta    .    .   . 

Dec.  29-Jan.  15 

28 

Chaoges  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  February  IG,  1901 : 

DcTCHER,  First  Lieutenant  Bash,  H.,  assistant  surgeon,  having  been 
discharged  from  hospital  in  ;Manila,  will  return  to  his  station 
at  Tayu,  Pangasinan. 


The  following  named  acting  assistant  surgeons  are  authorized  to 
proceed  to  Manila  and  report  to  the  president  of  the  Army 
medical  board,  for  examination  for  appointment  as  a-ssistant 
surgeons  :  Department  of  Northern  Luzon — George  M.  Ekwcb- 
ZEL,  IsinoR  M.  Ungee,  Ernest  F.  Slater,  Loein  B.  Ohlingee, 
James  F.  Edwards,  and  U.  8.  Grant  Deaton  ;  department  of 
Southern  Luzon — Frank  T.  Woodbury  and  Wilmot  E.  Brown  ; 
department  of  the  Visayas — Paul  R.  Fletchee.  ■-  sf> 

Stephenson.  Major  William,  surgeon,  will  report  to  the  command- 
ing general,  department  of  Southern  Luzon,  for  assignment  to 
duty. 

MuNSON,  Captain  Edward  L.,  assistant  surgeon,  is  granted  leave  of 
absence  for  2  months  on  account  of  sickness. 

Becker,  Max  A.,  acting  assistant  surgeon,  will  proceed  from  Log 
Angeles  to  San  Francisco,  Cal.,  for  as.signment  to  duty  with 
troops  en  route  to  the  Philippine  Islands,  where  he  will  report 
to  tlie  commanding  general,  division  of  the  Philippines,  for  as- 
signment to  duty. 

Santoire.  H.  a.,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  1  month  from  about  February  18. 

The  following  named  dental  surgeons  will  proceed  from  the  place» 
designated  to  Washington.  D.  C.  and  report  to  the  Surgeon- 
fjfneral  of  the  Army  for  instructions  :  John  S.  Marshall,  Chi- 
cago. III.  ;  Robert  T.  Oliver,  Indianapolis,  Ind. 

Ira  E.  Gates.  George  Griffith,  Ben.iamin  Hanson,  James 
Sweeney.  Paul  H.  Weyrauch  and  Amos  A.  Carter  hospital 
stewards  lappointed  February  8  from  privates  of  the  hospital 
corps )  now  in  Manila,  P.  I.,  are  assigned  to  duty  in  the  division 
of  the  Philippines. 

Frederick  W.  Boschen,  Austin  O.  Barber,  Louis  Frank,  Frank 
LuvE,  Herbert  Sharman.  Paul  L.  Stangl,  August  J.  Strom- 
berg,  Don  D.  Williams,  Thomas  J.  Walker.  Joseph  Waters, 
Gustave  Fonteene,  Will  G.  Butler  and  Harry  Meade,  hos- 
pital stewards  (appointed  February  8  from  acting  hospital 
stewards  of  the  hospital  corps )  now  at  Manila,  P.  I.,  are  assigned 
to  duty  in  the  division  of  the  Philippines. 

Morgan,  Robert  W.,  dental  surgeon,  will  proceed  from  Lynchburg, 
Va..  to  Washington.  D,  C,  and  report  to  the  Surgeon-General 
of  the  Army,  for  instructions. 

Arthur.  Major  William  H.,  surgeon,  will  proceed  to  Dagupan, 
province  of  Pangasinan,  and  assume  command  of  the  military 
hospital  at  that  point. 

ScHREiNER.  First  Lieutenant  Edward  R..  assistant  surgeon,  will 
proceed  to  San  Isidro,  province  of  Neuva  Ecija,  and  report  to 
the  chief  surgeon.  Fourth  division,  for  duty  at  the  hospital  at 
that  point. 

Penrose.  Major  George  H.,  surgeon,  upon  report  of  medical  ex- 
amining board,  will  proceed  to  San  Francisco.  Cal.,  and  report 
to  the  adjutant-general  of  the  Army,  with  a  view  to  discharge 
by  reason  of  disability. 

The  following-named  medical  oflBcers,  now  at  stations  designated, 
will  report  on  the  day  of  arrival  at  the  Presidio  of  volunteer 
troops  from  the  Philippine  Islands,  to  the  chief  mustering 
officer  for  temporary  duty  to  make  the  medical  examination  of 
olUcers  and  enlisted  men  belonging  to  volunteer  regiments,  re- 
<iuired  by  G.  O.  124,  series  1898.  H.  Q.  A.,  and  other  existing 
regulations:  Major  Robert  J.  (jibson,  surgeon,  San  Francisco, 
Cal.:  Acting  Assistant  Surgeon  Charles  H.  .-Andrews,  Army 
General  Hospital,  Presidio:  .Acting  Assistant  Surgeon  Fra.vk 
.v.  V,.  Disney,  Presidio.  This  duty  will  be  performed  by  Major 
Gibson,  surgeon,  in  addition  to  his  other  duties  at  these  head- 
quarters, and  he  will  make  immediate  request  for  such  clerical 
iissistance,  accommodations,  materials  and  appliances  as  may 
be  needed  in  the  work  to  be  performed  by  the  medical  officers 
uniler  this  order. 

Latimer,  Charles  H.,  acting  assistant  surgeon,  will  proceed  to  his 
home,  Washington,  D.  C.,  for  annulment  of  contract. 

James,  William  F.,  acting  assistant  surgeon,  is  granted  leave  of 
absence  for  1  month. 

Pitcher,  George  S.,  acting  assistant  surgeon,  will  proceed  to  his 
home,  Portland,  Me.,  for  annulment  of  contract. 

promotions. 

To  be  assistant  surgeons,  with  rank  of  captain — Clark  I.  Wertes- 
baker,  Ohio;  Frank  A.  E.  Disney^  New  York  :  Charles  H. 
Andrews,  New  York  ;  Robert  H.  Exders.  Sr.,  Arkansas:  Mat- 
thew Leepere,  Missouri:  Charles  Anderson,  California; 
James  S.  Kennedy,  Pennsylvania,  all  acting  assistant  surgeons, 
U.  S.  .\rmy  :  Frank  P.  Kenyon,  Kentucky,  late  major  and  sur- 
geon Fourth  Kentucky  Volunteers  :  Guy  G,  Bailey.  Michigan; 
(Jeorge  a.  McHenry.  Mississippi:  Edward  F.  Horr,  New 
York  :  Shannon  Richmond,  Missouri ;  Elmer  S.  Tknkky.  New 
Hampshire  :  Samuel  D.  Huntington,  California,  all  acting  as- 
sistant surgeons,  U.  S.  Array  :  James  J.  Erwin,  Ohio,  oaptain 
and  assistant  surgeon  Thirtieth  Infantry;  James  F.  Prksxkll. 
Iowa;  Frkdkrick  H.  Sparrenburgkr.  New  .Tersey ;  Irvin  E. 
Bennett,  Pennsylvania:  James  H.  McCall,  Tennesse,  all  act- 
ing assistant  surgeons,  V.  S.  Army:  Thomas  C.  Stunkabd,  In- 
diana, late  major  and  surgeon  One  Hundre^i  Fifty-ninth  Indi- 
ana Volunteers  and  acting  assistant  surgeon  V .  S.  Army  ;  Hab- 
rold  W.  Cowpkr,  New  York  ;  Dwight  B.  Taylor.  Ohio,  all 
acting  assistant  surgeons,  V.  S.  Army. 

To  be  assistant  surgeons,  with  rank  of  first  lieutenant — February  -I 
— Arthur  W.  Morse,  Illinois,  vice  Polhkmus.  promoted : 
Frank  C.  Baker,  District  of  Columbia,  vice  Borden,  promoted  ; 
Henry  S.  Kiersted,  Pennsylvania,  vice  Mearns,  promoted ; 
Allie  W.  Williams,  Georgia,  vice  Edie,  promoted:  John  J. 


FBBEnAHT    23,    1901] 


AMERICAN  NEWS  AND  NOTES 


FThk  Philadelphia 
L  Medical  Joukn al 


369 


Reilly,  New  York,  vice  Crosby,  promoted  ;  Jf.romk  Stewart 
Chaffee.  New  York,  vice  Kseedler,  promoted. 
To  be  assistant  surgeons  of  Volunteers,  with  rank  of  captain — Hae- 
BY  A.  LiTTLEFiELD.  Oregon,  late  acting  assistant  surgeon,  U.  S. 
Army,  February  9 ;  Frederick  W.  Cox,  S.  Dakota,  late  captain 
and  assistant  surgeon  First  South  Dakota  Volunteers,  February 
9  ;  Gerry  S.  Driver.  District  of  Columbia,  acting  assistant  sur- 
geon, U.  S.  Army,  February  9;  Justus  M.  Wheate,  Indiana, 
acting  assistant. 

Cbangres  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  February  14,  1901 : 

Sawtelle.  H.  W.,  surgeon,  granted  leave  of  absence  for  30  days 
from  February  20.     February  14. 

Kalloch,  p.  C.  surgeon,  granted  leave  of  absence  for  3  days  from 
February  17.     February  8. 

Geddixgs,  H.  D.,  passed  assistant  surgeon,  granted  leave  of  absence 
for  8  days  from  January  26,  on  account  of  sickness.  February 
12.  Granted  leave  of  absence  for  30  days  from  February  3. 
February  12. 

Gardner,  C.  H..  passed  assistant  surgeon,  granted  leave  of  absence 
for  7  days.     February  11. 

Parker,  H.  B.,  assistant  surgeon,  to  proceed  to  Gulf  Quarantine 
and  assume  temporary  command  of  the  service  during  the  ab- 
sence on  leave  of  the  medical  officer.     February  8. 

Moore,  Dumlop,  assistant  surgeon,  to  proceed  to  Port  Townsend, 
Wash.,  and  assume  temporary  command  during  the  absence  on 
leave  of  the  medical  officer  in  command.     February  11. 

McCoy,  G.  W.,  assistant  surgeon,  granted  leave  of  absence  for  14 
days  from  March  18.     February  12. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  February  16,  1901 : 

Bagg,  C.  p.,  passed  assistant  surgeon,  detached  from  the  Cavite 
Naval  Station  and  ordered  to  the  "  Culgoa." 

Alfred.  A.  R.,  passed  assistant  surgeon,  detached  from  the  "  Cul- 
goa "  and  ordered  to  the  Naval  Station.  Cavite,  February  7. 

BiDDLE,  C,  surgeon,  detached  from  the  Naval  Hospital,  Norfolk, 
Va.,  and  ordered  home  and  to  wait  orders. 

Lewis,  D.  0..  surgeon,  detached  from  the  "  Iowa"  and  ordered  to 
the  "  Philadelphia,"  February  13. 

Arnold.  \V.  F.,  surgeon,  detached  from  duty  at  the  Naval  Recruit- 
ing Rendezvous,  Chicago,  111-,  March  1,  and  ordered  to  the 
"  New  Orleans."  sailing  for  Manila,  March  1.5. 

Griffith,  S.  H.,  surgeon,  detached  from  the  "  Prairie"  when  put 
out  of  commission .  and  ordered  to  duty  under  the  Bureau  of 
Medicine  and  Surgery. 

Cordeibo.  F.J.  B..  surgeon,  detached  from  the  "New  Orleans" 
and  ordered  home  and  to  wait  orders. 

MooRE,  A.  M.,  surgeon,  retired,  ordered  to  duty  at  Naval  Recruit' 
ing  Rendezvous,  Chicago,  111.,  March  1. 


foreign  TX^ws  anb  Hotcs. 


GREAT  BRITAIN. 

Mr.  T.  P.  Legg,  ai.B.Lond.,  F.R.C.S.,  has  been 
appointed  assistant  surgeon  to  the  Royal  Free  Hospital. 

Election. — Dr.  Martin  J.  P.  Dempsey,  F.R.C.P.I.,  visit- 
ing physician  to  the  Mater  Misericordiae  Hospital,  Dublin, 
has  been  elected  to  the  chair  of  materia  medica  and  phar- 
macy in  the  Catholic  University  School  of  Medicine,  ren- 
dered vacant  by  the  death  of  Dr.  F.  J.  B.  Qainlan. 

Cancer  Laboratory. — A  research  laboratory  has  been 
opened  in  connection  with  the  Middlesex  Hospital,  London, 
England,  which  is  to  be  entirely  devoted  to  the  care  and  in- 
vestigation of  cancer.  In  the  hofpital  are  60  inoperable 
cases,  which  will  be  under  close  scientific  observation. 

Enteric  Fever  Among  British  Troops. — The  Secre- 
tary of  State  for  War  gave  a  statement  of  the  increasing 
number  of  cases  of  enteric  fever  among  the  troops  in  South 
Africa.  In  October  there  were  569  cases  and  98  deaths ;  in 
November,  1,213  cases  and  207  deaths ;  and  in  December, 
1,665  cases  and  286  deaths.  The  total  since  the  beginning  of 
the  war  to  December  is  19,101  cases  and  4,233  deaths. 

CONTINENTAL  EUROPE. 

Dr.  G.  Holzknecht  has  been  appointed  Rontgen  ray 
expert  in  Vienna.. 

Pirogoflf  Congress. — The  Eighth  PirogoflT  Congress  will 
be  opened  in  Moscow  in  December,  1901. 


Plague  Steadily  Spreading. — There  were  922  deaths 
from  the  plague  in  Bombay  during  the  past  week. 

Physicians  Rewarded. —The  Czar's  physioians  who 
were  in  attendance  upon  him  during  his  recent  attack  of 
typhoid  fever,  have  been  rewarded.  Prof.  Leo  PopofT  has 
been  appointed  body  physician  to  the  Czar,  Dr.  Tichskonofl 
honorary  physician  to  the  imperial  family,  and  upon  Dr. 
Hirsch  has  been  conferred  the  order  of  Alexander- Nevski. 

Autopsies  on  Suicides.— Professor  Meller,  of  Kiel  Uni- 
versity, the  renowned  expert  in  mental  diseases,  made 
autopsies  on  300  suicides  in  5  years,  and  now  states  that  he 
found  the  brains  of  43%  showed  distinct  malformation  ;  29% 
of  the  remainder  were  suffering  at  the  time  of  their  death 
from  acute  febiile  inflammation  ;  143  of  the  aggregate  had 
organs  diseased  by  alcoholism. 

Cheap  Modes  of  Transportation  Responsible  for 
Obesity. — The  multiplication  of  cheap  modes  of  transport, 
in  the  opinion  of  the  London  Medical  Press  and  Cirndar, 
favors  the  tendency  to  obesity,  so  that  with  the  rapid  de- 
velopment of  underground  and  fcuifice  electric  traction  in 
London  and  other  large  cities  the  next  generation  must  look 
out  for  an  increase  in  the  number  of  stout  individuals. 

Bubonic  Plague.— The  Daily  Mail  publishes  the  fol- 
lowing from  its  St.  Petersburg  correspondent :  Serious  reports 
■are  in  circulation  here  regarding  the  outbreak  of  what  was 
first  called  "  hunger  typhus,"  but  is  now  c  fficially  admitted 
to  be  bubonic  plague  in  the  Khirgiz  steppes  of  western 
Siberia.  Many  thousands  have  died.  The  Government  is 
sending  out  large  quantities  of  wheat  to  be  distributed  to  the 
starving  population  and  is  organizing  traveling  medical 
services  to  localize  the  outbreak. 


The  Influence  of  Neurectomy  upon  the  Union  of 
Fractures. — B.  G.  Muscatello  and  D.  Damascelli  {Archiv 
f.  klin.  Chir.,  Bd.  58,  H.  4.)  after  many  experiments  come  to 
the  conclusion  that  fractured  bones  may  unite  independent 
of  influence  from  the  nervous  system.  It  had  been  believed 
that  when  nerves  were  cut  in  cases  of  experimental  fracture, 
that  the  results  were  delayed  ossification,  larger  and  softer 
callus,  and  frequently  the  formation  of  pseudoarthroses. 
Experimenting  upon  guineapigs  the  authors  fractured  the 
ulna,  but  le't  the  radius  intact,  the  latter  acting  as  a  protec- 
tion. At  the  same  time  they  resected  a  portion  of  the 
brachial  plexus,    [m.e.d.] 

The  Relation  of  Appendicitis  to  Diseases  of  the 
Uterine  Appendages.— In  a  paper  read  before  the  X.  Y. 
State  Medical  Society,  January  29-31,  1899,  Dr.  Albert 
Beahan  says :  The  occurrence  of  right  side  pelvic  disease 
when  the  question  arises  as  to  the  diagnosis  between  disease 
of  appendix  and  appendages,  is  frequent,  and  sometimes  re- 
quires fine  distinction.  Gross  changes  in  the  appendages 
resulting  from  disease  coexisting  with  appendicitis  are  not 
uncommon.  There  has  not  been  shown  to  be  any  close  rela- 
tion, except  of  proximity.  Functional  disease,  with  disturb- 
ancs  of  menses — a  dysmenorrhea  exists  as  a  law  of  cause  and 
effect.  Four  cases  in  hospital  at  the  same  time  recently, 
unmarried  women  from  17  to  23  years,  had  had  irregular, 
painful  menses.  In  one  of  these  cases  where  an  aromaly 
existed  of  the  appendix,  passing  for  a  short  distance  between 
the  coats  of  the  intestine,  making  a  tight  stricture,  the  men- 
struation had  always  been  painful,  and  recently  a  local  peri- 
tonitis had  occurred  at  menstrual  epoch.  Our  case  records, 
other  than  these  4,  show  that  these  are  not  coincidences. 
A  locked  or  torpid  colon,  with  gas  accumulations,  an  exag- 
geration of  menstrual  phenomena,  increased  pallor,  cr 
muddy  complexion,  languor,  pains,  nausea  or  vomiting,  pro- 
nounced nervous  irritability,  peevishness  with  febrile  rise  to 
98J°  F.  or  100i°  F.,  especially  during  the  latter  part  of  the 
day,  if  a  tender,  enlarged  appendix  is  found,  establishes  the 
diagnosis.  A  recurrence  of  this  group  of  symptoms  at  one 
or  more  succeding  menstruations  may  be  expected.  The 
thermometer  showing  a  hovering  of  the  temperature  about 
the  991°  maik,  has  come  to  the  clinical  test.  The  tolerance 
of  the?emale  pelvis  to  disease  should  not  mask  the  diagnosis, 
nor  should  a  serious  attack  of  appendicitis  be  permitted. 
Remove  the  appendix  early ;  it  will  be  a  surprise  to  see  ita 
condition,  and  a  gratification  that  it  was  done. 


370 


THK    PHn.APgLPHI*"! 
MSDICAX  JODBKAL  J 


SPECIAL  ARTICLE 


[FXBEUAST23,  INl 


Special  21rticle. 


VIVISECTION  AND  ANTIVIVI SECTION. 

A  Correspondence  Between  Mr.  James  M.  Brown,  President 
of  the  American  Humane  Association,  and  Professor 
William  W.  Keen,  of  PhiladelpMa. 

The  following  correspondence  has  been  submitted  to  us  by 
Dr.  Keen.  It  speaks  for  itself  without  special  introduction. 
Our  comments  will  be  found  in  the  editorial  columns. 

Lbttee  From  the  President  of  the  American  Humane 

Association. 

Toledo,  0.,  October  4,  1900. 
Prof.   William  W.  Keen,   Late  President   of   the    American 
Medical  Association,  Jefferson  Medical  College,  Phila- 
delphia. 

Dear  Sir  : — My  attention  has  just  been 'called  to  a  pass- 
age in  the  published  "  Report  of  the  Hearing  "  before  the 
Senate  Committee,  held  at  Washington  last  February,  on  the 
Bill  for  Regulation  of  Vivisection.  In  this  volume,  the  fol- 
lowing conversation  between  Senator  Gallinger  and  yourself 
is  recorded. 

Senator  Gallinger.  "  What  knowledge  have  you  of  the 
advances  made  by  vivisectionists  that  have  led  them  to  pro- 
gress from  the  brute  creation  to  the  human  creation  in  mak- 
ing these  so-called  vivisection  experiments?" 

Dr.  Keen.  "  I  presume  that  you  refer  to  a  pamphlet 
issued  by  the  American  Humane  Society.  I  have  only  to 
say  in  reference  to  it  that  there  were  a  number  of  experi- 
ments which  I  would  utterly  condemn.  O.'  the  experiments 
narrated  in  that  pamphlet,  I  have  looked  up  every  one  that 
I  could.  Only  two  are  alleged  to  have  been  done  in  America. 
Many  of  them  are  so  vague  and  indefinite  that  I  could  not 
look  them  up,  but  as  to  those  that  I  could,  some  are  garbled 
and  inaccurate — not  all  of  them,  observe." 

Senator  Gallinger.    "  Some  of  them?  " 

Dr.  Keen.    "  Some  of  them." 

A  statement  of  this  character,  bised  upon  such  authority, 
it  is  impossible  to  ignore.  Proceeding  from  one  less  eminent 
than  yourself,  in  that  profession  which  you  represent  and 
adorn,  it  might  pass  without  notice  ;  but  coming  from  you, 
sir,  such  a  charge  must  be  investigated  and  probed  to  the 
fullest  extent.  Its  importance  is  evident,  and  in  testing  its 
accuracy,  you  will  give  me,  I  trust,  every  assistance  in  your 
power. 

First,  regarding  the  cases  of  experimentation  upon  human  beings 
recorded  In  our  pamphlet,  "  Human  Vivisection,"  you  inform^i 
the  Senate  Committee  that  many  of  them  are  so  vague  and  indefinite 
that  I  could  not  look  them  up. 

We  challenge  the  accuracy  of  that  statement,  and  ask  for  proof. 
Of  the  various  series  of  experiments  upon  human  beings,  made  for 
the  most  part  upon  women  and  children  in  hospitals  nnd  in- 
firmaries,— the  authorities  given  in  this  pamphlet  are  as  follows  : 

1.  Bulletin  of  the  Johns  Hopkim  Hospital  for  July,  1S97. 

2.  Boston  Medical  and  Surgical  Journal  for  Aug  6  and  13,  1896  • 

The  Philadelphia  Polyclinic  for  Sept.  5,  1896. 

3.  New  York  Medical  Record  for  Sept.  10.  1892. 

4.  The  British  Medical  Journal  for  July  3,   1897 ;   the  Xew  En- 

gland Medical  Monthly  for  March,  1898. 

5.  The  Medical  Press  for  IJecember  5,  1888 ;  the  British  Medical 

JournalfoT  Aug.  29,  1891  ;  the  London  Times  for  June  27, 
1891.  (and  other  journals). 

6.  The  Medical  Brief  (or  June,  1899. 

7.  "  Ringers  Therapeutics,"  pp.  585, 588,  590, 591,  498, 503  ;  the 

London  Lancet  for  Nov.  3,  1893. 

8.  The  Xewcastle  Daily  Chronicle  for  Sept.  21,  1888. 

9.  The  Medical  Pres.^  and  Circular  for  March  29,  1899 ;  the  Lou- 

don LaJicet  for  May  6.  1899,  p.  1261. 

10.  The  AUg.  Wiener  med.  Zeitung.  Nos.  50  and  51. 

11.  Deutsche  med.  Wocheiischrift,  Nos.  46  and  48  of  year  1891. 

12.  Deutsche  med.  Woehenschrift  of  Feb.  19,  1891. 

13.  Lecture  before  Medical  Society  of  Stockholm,  Sweden,  May 

12,  1891. 

14.  The  British  Medical  Journal  for  Oct.  15,  1881 :  Medical  Re- 

prints for  May  16,  1893 ;  the  Xineteenth  Century  for  Dec., 
1895. 

For  one  series  of  experiments  in  the  above  list. — those 
made  by  Dr.  Jansen  upon  children  of  the  Foundlings'  Home, 
(with  the  "kind  permission"  of  the  head  physician,  Prof. 
Medin)  because,  as  he  said,  "calves  were  so  expensive,"  it 


appears  that  the  only  authority  given  was  a  reference  to  his 
lecture,  delivered  before  a  Swedish  Medical  Society  upon  a 
certain  date.  Although,  so  far  as  known,  the  facta  there 
stated,  have  never  been  denied,  yet  the  reference  may,  per- 
haps, be  called  indefinite.  But  one  case  is  not  "  many."  To 
what  other  of  the  references  above  given,  did  you  refer  when 
you  informed  the  Senate  Committee  that  "  Many  of  them  are 
so  vagv^  and  indefinite  that  I  could  not  look  them  up"  f  Had 
you  stated  that  your  library, — ample  as  it  is,^-did  not  con- 
tain, and  could  not  be  expected  to  contain  all  of  the  foreign 
authorities  to  which  reference  was  made,  there  would  have 
been  nothing  to  criticise.  I  must  assume,  sir,  that  you  have 
not  put  forth  an  aspersion  of  another's  reliability  merely  to 
have  acknowledgment  of  the  inadequacy  of  your  sources  of 
reference ;  that  the  proofs  of  your  statement,  covering 
"  many  "  cases,  are  available,  and,  in  the  interest  of  accuracy, 
I  ask  you  to  produce  them. 

Second.  There  is  yet  another  point  to  which  I  ask  yoor 
attention.  You  made  the  statement  before  the  Senate  Com- 
mittee that  in  regard  to  our  published  account  of  cases  of 
human  vivisection,  "  many  of  Ihem  are  go  vague  and  indefinite 
that  I  could  not  look  them  up ;  but.  as  to  those  thai  I  could,  some 
are  garbled  and  inaccurate ;  not  all  of  them,  observe." 

Tnis,  sir,  is  a  most  serious  charge.  You  distinctly  declared 
that  of  the  cases  personally  investigated  by  yourself,  as 
quoted  in  the  pamphlet  on  "  Human  Vivisection,"  some  are 
"  garbled  and  inaccurate."  We  deny  the  charge,  and  again 
challenge  production  of  evidence  upon  which  it  is  made. 

A  "garbled"  quotation  is  one  which,  by  reason  of  omis- 
sion and  perversions,  is  essentially  unfair.  Sometimes  it  is  a 
statement  from  which  parts  are  omitted  or  transposed  for 
the  purpose  of  conveying  a  false  impression.  To  omit  qao- 
tation  of  parts,  not  directly  bearing  upon  the  question,  for 
sake  of  brevity, — this  is  not  "  garbling,"  for  all  quotations 
would  then  be  impossible.  We  assert  that  in  quoting 
accounts  of  the  cases  of  human  viviiection,  no  omissions  of 
essential  facts  have  been  made  sufficient  to  impair  the  a'MJu- 
racy  of  fairness  of  the  quotation.  Let  us  put  the  matter  to 
the  test.  Point  out,  if  you  can,  the  "some  cases  "  which 
you  found  "  garbled  and  inaccurate,"  and  in  proof  of  the 
charge,  quote  the  omitted  sentences  or  words,  uhich,  had  th^  been 
inserted,  would  cause  you  and  the  general  public  to  justify  and 
approve  the  eiperimenis  on  human  beings,  which  we  have  s» 
Severely  condemned 

Tnird.  You  stated,  sir.  before  the  Senate  Committee,  that 
only  two  experiments  upon  human  beings  "  are  alleged  to 
have  been  done  in  America,"  I  question,  sir,  whether  that 
remark  is  quite  in  accord  with  the  highest  ideals  of  truth;  it 
is  the  language  of  doubt ;  it  seems  to  signify  and  imply  that 
even  you  are  aware  of  no  other  experiments  upon  human 
beings  than  two  cases  which  are  thus  "  alleged."  I  am  very 
confident,  sir,  that  you  will  not  venture  formally  to  assert 
— what  you  have  seemed  to  imply — that  you  know  of  but  two 
experiments  upon  human  beings,  made  in  this  country,  and 
recorded  in  the  medical  literature  of  the  United  Slates. 
There  is,  indeed,  need  of  further  enlightenment,  if  the  med- 
ical profession  of  this  country,  so  worthily  represented  by 
yourself,  is  ignorant  of  what  has  been  done  by  men  without 
pity  and  without  conscience. 

Trusting  to  have  response  from  you  at  an  eirly  date,  I  am, 
Yours  most  truly, 
(Signed)  James  M.  Brows, 

President. 

Seplt  of  Dr.  Kekx. 

1729  Cheststt  Street,  Philadelphia,  Pa., 

January  21,  1901. 
James  M.   Broirn,  Esq ,   President  American  Humane  As- 
sociation, Toledo,  Ohio. 

Dear  Sir  : — Your  letter  of  October  fourth  reached  me 
promptly,  but  as  I  then  notified  you  would  be  the  case,  very 
pressing  engagements,  absence,  etc.,  prevented  an  earlier 
reply. 

Now  that  I  have  a  little  leisure,  I  caa  answer  your  letter 
and  furnish  you  in  detail  the  proofs  for  which  you  ask. 

There  are  two  pamphlets,  both  entitled  "  Human  Vivisec- 
tion." First,  one  of  SO  pages  "  printed  for  the  American 
Humane  Association,  1S99."  the  other  of  7  paces  "  published 
by  the  Humane  Society,  Washington,  D.  C,"  without  dat«, 
but  from  its  contents,  published  a  little  later,  as  it  is  chiefly 


Februart  23,  19011 


SPECIAL  ARTICLE 


rTHs  Philasblphia 
L  ALbdicax  Jodrhal 


Ol  1 


a  Bynopeis  of  the  same  instances  reported  more  fully  in  the 
larger  pamphlet.  Hereafter  when  I  speak  of  "  the  pam- 
phlet," I  mean  the  larger  one  unless  I  specifically  mention 
the  smaller  one. 

This  larger  pamphlet  consists  of  two  parts  :  first,  (pp.  3-12) 
a  reprint  of  a  poition  of  "  Senate  Document  No.  78  "  and  the 
rest  of  it  of  various  quotations,  translations  and  comments. 
No  name  is  attached  to  either  part  to  indicate  who  is  respon- 
sible for  the  accuracy  of  the  references,  the  translations  or  the 
quotations.  As  the  whole  is  preceded  by  an  open  letter 
signed  by  the  president  and  secretary  of  the  American 
Humane  Association,  and  as  you  refer  to  the  pamphlet  as 
"  ours,"  I  presume  the  Association  holds  itself  repponsible 
for  such  accuracy,  especially  as  you  as  its  new  President 
challenge  me  for  proof. 

The  pamphlet  purports  to  furnish  a  reprint  of  a  portion  of 
"  Senate  Document  No.  78  "  and  refers  to  this  document  in  a 
way  that  would  lead  uninformed  readers  to  suppose  that  this 
is  a  document  expressing  the  sentiments  of  the  United  States 
Senate.  It  is,  therefore,  important  to  call  your  attention  to 
the  fact  that  Senate  Document  No.  78  is  simply  a  collection 
of  statements  and  papers  by  various  persons  printed  by  order 
of  the  Senate,  but  in  no  sense  expressing  the  opinions  or 
convictions  of  that  body.  The  last  paper  in  this  document 
IB  one  on  "  Human  Vivisection,"  by  "  A.  Tracy." 

In  two  respects  "  A.  Tracy  "  has  a  right  to  complain  that 
the  reprint  is  inaccurate.  First,  it  omits  to  print  the  name 
of  the  author  "A.Tracy."  Surely  he  (or  she?)  should  re- 
ceive whatever  credit  there  is  attaching  to  his  work. 

Secondly,  on  page  30,  line  8  of  Senate  Document  No.  78,  I 
read  "  A.  Tracy's  "  comment.  ["  This  patient,  therefore,  was 
scientifically  murdered."]  This  statement  the  reprint  very 
wisely  omits — but  there  are  no  indications  of  the  omission. 
Of  this,  more  hereafter. 

Your  letter  challenges  the  accuracy  of  my  statements  in 
three  particulars. 

1.  I  stated  that  many  of  the  references  in  the  pamphlet 
are  "  vague  and  indefinite." 

2.  I  said  that  some  of  the  accounts  of  the  experiments  are 
"garbled  and  inaccurate." 

3.  I  stated  that  of  the  experiments  narrated  in  the 
pamphlet  only  two  were  alleged  to  have  been  performed  in 
America. 

You  will  pardon  me  if  I  indignantly  resent  your  imputa- 
tion of  untruthfulness  in  regard  to  this  last  statement.  You 
entirely  misinterpret  my  statement,  which  had  no  reference 
to  my  knowledge  or  ignorance  of  any  other  American  ex- 
periments. I  said  that  the  pamphlet  only  contained  two 
instances  of  such  experiments  which  were  alleged  to  have 
been  done  in  America.  These  are  recorded  on  pages  4  and 
5  of  the  pamphlet.  All  the  rest  were  done  in  Europe,  South 
America,  and  Hawaii,  years  before  it  came  into  our  posses- 
sion. If  you  still  question  the  accuracy  of  my  statement 
and  believe  that  there  is  a  third  instance  of  experiments 
done  in  America  and  described  in  the  pamphlet,  point  it  out 
by  page  and  paragraph. 

Turning  now  to  the  other  two  really  important  matters 
referred  to  in  your  letter,  let  me  again  state  clearly  the  ques- 
tion at  issue.  It  is  not  whether  the  experiments  meet  with 
my  approval,  but  solely  whether  the  reports  of  them  in  the 
pamphlet  issued  by  the  American  Humane  Association  are 
reliable  and  accurate  both  as  to  their  sources  and  their  sub- 
stance. 

I,  Many  of  the  References  are  Vague  and    Indefinite. 

The  references  are  so  vague  and  indefinite  in  many  cases 
that  the  statements  and  quotations  made  cannot  be  verified 
by  consulting  the  originals.  The  preface  of  your  president 
and  secretary  states  that :  "  In  each  case  the  authority  is 
given,"  and  what  sort  of  "  authority  "  do  you  depend  upon  ? 

Newspaper  medicine  and  surgery  are  notoriously  inac- 
curate. I  have  personally  had  so  much  experience  and  ob- 
servation of  this  that  I  am  always  certain  that  at  least  one- 
half  or  more  of  the  statements  in  newspapers  in  reference 
to  medical  matters  are  inaccurate,  not  purposely,  but  only 
because  the  writers  are  not  medical  men.  Yet  you  depend 
for  the  accuracy  of  your  statements  upon  newspapers  as 
follows.  (I  follow  the  inaccurate  spelling  of  foreign  names 
in  your  pamphlet) : 

1.  The  Vienna  correspondent  of  the  IjOndon  Morning  Leader, 
Jan.  26,  1899  (p.  3),  of  whom  more  hereafter. 


2.  Tlie  Deutsche  VnlhUatl.  .Jan.  25,  1899  (p.  3). 

3.  The  Washington   correspondent  of   the   Boston    Transcript, 

Sept.  24.  1897  (p.  9),  of  whom  more  hereafter. 

4.  The  Xew  York  Iiidrpandent,  Dec.  12,  1895  (p.  II). 

5.  Tlie  Ln„<hn  rinirs.  June  27,  1891  (p.  16). 

6.  The  Taglichc  Riuid.v/iau  of  Berlin,  (p.  17);  no  year,  month, 

or  day  being  given. 

7.  The    Vussixdic  Zcituiig  of   Berlin,  no  year,  month,  or  day 

being  given  (p   18). 

8.  The    Vonriirtr,.  no  year,  month,  or  day  being  given  (p.  18). 

9.  The  Daiizlgrr  Znlinig.  ,Iuly  23,  1891  (p.  18). 

10.  The  Schlesixrhr  VotkszcilMng,  July  21,  1891  (p.  18). 

11.  The    Hamburger    Xachric'hten,    July,   1891,   no  date  stated 

(p.  19). 

12.  A  correspondent  of  the  iVdifOfWite  (England?)  Daily  Chron- 

icle, Sept.  21,  1888  (p.  22). 

13.  Dr.  R.  E,  Dudgeon,  in  the  Abolitionist,  April  15, 1899  ♦p.  24). 

14.  A  letter  by  Dr.   Edward  Berdoe  to  the  London  Clironicle, 

without  year,  month,  or  day  (p.  29). 

Few  of  these  fourteen  newspaper  references  can  be  con- 
sulted in  this  country  ;  five  of  them  (Nos.  6,  7,  8,  11,  and  14) 
are  impossible  of  consultation  for  want  of  any  date  what- 
ever. 

In  no  case  would  I  be  willing  to  admit  a  newspaper  para- 
graph, a  nonprofessional  and  usually  unsigned  statemsnt 
(even  if  correctly  quoted)  as  a  sufficient  auhority  for  a  grave 
charge  against  an  individual  or  the  profession. 

Look  for  a  moment  what  stuflF  Senator  Gallinger  stated  at 
the  "  Hearing  "  he  had  himself  caused  to  be  printed.  It  is 
published  on  page  31  of  the  "  Hearing  "  and  on  page  3  of  the 
pamphlet.  It  consists  of  cable  dispatches  printed  ia  some 
newspaper — Senator  Gallinger  did  not  even  remember  its 
name.  The  author  of  the  dispatch  from  London  is  utterly 
unknown.  The  dispatch  states  that  "  the  Vienna  corre- 
spondent of  the  (London)  Morning  Leader  says  "  so  and  so. 
Who  and  how  reliable  is  the  Vienna  correspondent?  He 
says  that  "  the  physicians  in  the  free  hospitals  of  Vienna  " 
do  eo  and  so.  Who  are  the  physicians?  In  what  hospitals 
were  these  deeds  of  darkness  done? 

And  upon  such  evidence  it  is  seriously  proposed  to  indict 
the  medical  profession !  Whether  these  dispatches  are 
,  "  garbled  and  inaccurate  "  in  their  alleged  facts  who  can  find 
out? 

If  a  lawyer  tried  to  convict  a  man  of  petty  larceny  on  such 
testimony  he  would  be  laughed  out  of  court.  And  yet  a 
Senator  of  the  United  States  and  the  American  Humane  As- 
sociation actually  adduce  such  statements  as  evidences  of  the 
gravest  charges  and  spread  them  broadcast ! 

I  now  add  six  other  "  vague  and  indefinite  "  references  not 
to  newspapers. 

15.  On  page  13  there  is  a  quotation  from  Tertullian.  The  refer- 
ence in  the  footnote  Is  "  Tertullian,  De  Anima,  vol.  ii,  pp  430.  433, 
tran.  by  Holmes."  I  have  compared  the  quotation  with  Clark's 
Edinburgh  edition  of  the  "  Translation  of  Tertullian  by  Holme's," 
the  date  of  the  edition  being  1870.  No  such  quotation  exists  on 
pages  430,  4*3.  Possibly  it  may  be  that  the  quotation  is  from  another 
edition.  No  edition  is  named  in  the  pamphlet ;  another  instance 
of  a  "  vague  and  indefinite"  reference. 

16.  On  page  17  a  formal  accusation  is  quoted  as  made  by  a  Dr. 
Eugen  Leidig  against  certain  surgeons.  No  reference  wltatever  to  any 
book  orjotirnal  is  given  by  which  the  accuracy  of  the  quotation  can  be 
tested.    Is  not  this  again  "  vague  and  indefinite?'' 

17.  On  page  24  is  a  reference  to  a  paper  by  "  Professor  E.  Finger, 
of  Vienna  (Allg.  Wiener  med.  Zeitung,  Nos  50  and  51)."  No  year  is 
given,  a  somewhat  essential  part  of  the  reference,  as  there  are  over 
forty  volumes  of  this  journal,  each  with  the  weekly  numbers  50  and 
51.  No  such  paper  by  Finger  is  published  in  that  Journal  at  least 
from  1890  to  the  present  time.  The  reference  is  quoted  from  a  paper 
by  Dr.  R.  E.  Dudgeon  in  the  Abolitionist  (an  English  journal)  of 
April  15,  1899.  I  have  been  unable  to  consult  this  journal.  If 
Dudgeon  gave  the  year,  then  the  Humane  Association  pamphlet 
has  misquoted  him.  If  he  did  not,  then  both  the  Association's 
pamphlet  and  he  have  been  "  vague  and  indefinite." 

18.  On  page  25  again  is  a  reference  to  a  statement  in  a  "  lecture 
before  the  Medical  Society  of  Stockholm,"  by  Dr.  Jansen  of  the 
Charity  Hospital,  reporting  certain  experiments.  No  reference 
whatever  is  given  even  to  a  newspaper  much  less  to  any  medical 
journal.  As  the  statement  is  in  quotation  marks,  it  purports  to  be 
the  exact  words  used  and  ought  to  have  had  some  source  to  which 
a  reference  was  possible,  especially  as  the  preface  of  the  pamphlet 
says  "in  each  case  the  authority  is  given."  lam  glad  to  see  that 
in  your  letter  you  recognize  this  as  one  in  which  the  reference  is 
really  inadequate.  I  notice,  however,  that  even  in  your  letter  you 
do  not  supply  this  missing  reference.  You  say  the  facts  asserted  in 
the  Jansen  paragraph  have  never  been  denied.  Of  course  not.  The 
first  requisite  is  to  know  whether  they  are  correctly  quoted. 

Turning  now  from  the  larger  pamphlet  to  the  smaller  one,  which 
was  spread  broadcast  by  house  to  house  distribution  in  Washington, 
at  the  time  when  the  hearing  on  this  matter  tnuk  place  last  winter,  I 
find  repeated  in  this  a  number  of  the  same  vague  and  indefanite 


372 


Thk  Philadblphia"! 
Medical  JodbnalJ 


SPECIAL  ARTICLE 


[FSBBVAST  tZ,  im 


references  and  garbled  and  inaccurate  quotations  already  or  to  be 
described,  to  which  are  to  be  added  the  following : 

19.  On  page  3  an  extract  from  a  report  referring  to  experi- 
ments upon  insane  patients  is  printed  in  quotation  marks.  The 
only  reference  is  to  a  "published  report"  in  1890  of  the  "  Medical 
Staff  of  the  Public  Insane  Asylum  in  Voralberg,  Austria."  The 
librarian  of  the  Surgeon  General's  office  informs  me  that  there  are 
two  small  insane  asylums  in  the  Voralberg,  namely,— at  Hall  and 
Valduna.  Some  reports  of  tlie  former  are  in  the  Library  and  in 
them  no  account  of  the  experiments  referred  to  can  be  found.  No 
reply  has  been  received  to  a  letter  addressed  to  this  asylum  as 
named  in  the  pamphlet  and  written  over  a  year  ago.* 

20.  On  the  same  page  is  an  account  of  some  experiments  on  bac- 
teria from  boils  and  the  reference  is  to  the  Veulschcs  Vulkshlall,  no 
day,  no  month,  no  number,  no  page,  nor  even  the  year  is  given  If 
this  IS  not  "  vague  and  indefinite,"  what  is? 

21.  On  page  24  there  is  an  account  of  Kroenig's  experiments  (to 
which  I  shall  recur  later).  No  reference  whatever  is  given  to  the 
source  from  which  the  account  is  taken. 

II.  Some  of  the  Statements  abe  Garbled  and  Inaccueatf. 

To  be  vague  and  indefinite  in  charges  affecting  the  morals 
and  the  reputation  not  only  of  individuals,  but  in  fact  of  a 
whole  profession  is  bad  enough,  but  to  make  statementi  that 
are  "  garbled  and  inaccurate  "  is,  as  your  letter  recognizes,  a 
much  more  serioufl  matter.  Let  me  consider  the  instances 
in  detail. 

1.  "Vivisection  Experiments  upon  the  Insane,"  pages  4 
and  5. 

In  the  following  quotation,  the  words  of  the  original  which 
I  enclose  in  brackets  are  omitted.  "  To  these  patients  the 
thyroid  tablets  [each  pill  representing  5  grains  of  the  fresh 
sheep's  gland]  were  administered,"  etc.  This  omission  is  of 
moment,  because  any  one  familiar  with  the  administrations 
of  thyroid  eitract  knows  that  the  doses  used  by  Dr.  Berkley 
are  frequently  given  to  human  patients,  including  the  insane, 
without  producing  symptoms  dangerous  to  life,  but  on  the 
contrary  with  benefit.    I  have  myself  given  such  tablets  to 

SatientB  with  goiter  for  weeks  together  in  larger  doses  than 
>r.  Berkley  used. 

In  the  following  paragraph  the  quotation  is  garbled  by 
omitting  the  words  which  I  enclose  in  brackets :  "  Two 
patients  became  frenzied  and  of  these  one  died  before  the 
excitement  had  subsided  [the  immediate  cause  of  the  ezitus 
being  an  acute  disseminated  tuberculosis]."  And  again  in 
the  next  paragraph,  giving  a  report  of  the  same  case,  the 
pamphlet  quotes :  "  The  thyroid  extract  was  now  diecon- 
tinued,  but  the  excitement  kept  up  .  .  .  fjr  7  weeks,  at 
the  end  of  which  time  she  died."  Oae  would  think  this  was 
the  end  of  the  sentence  and  that  she  died  from  the  eflecta  of 
the  thyroid  tablets.  Not  at  all.  The  original  continues  as 
follows:  she  died  "with  the  clinical  evidences  of  acute 
miliary  tuberculosis,"  (galloping  consumption).  Does  this 
not  come  within  the  definition  of  garbling  given  in  your 
letter?  "A  'garbled'  quotation  is  one  which,  by  reason  of 
omission  and  perversions,  is  essentially  unfair." 

To  say  that  this  patient,  who  actually  died  of  galloping 
consumption  died  from  the  effects  of  the  thyroid  extract 
which  had  not  been  given  for  7  weeks  before  death  is  as  ab- 
surd as  it  wculd  be  to  say  she  had  died  from  the  eflects  of 
moderate  doees  of  laudanum  given  7  weeks  before.  Yet  "A. 
Tracy's"  comment  on  this  case  is  "  [This  patient,  was,  there- 
fore, scientifically  murdered]."  Your  Association  mutilates 
its  reprint  by  wisely  omitting  this  piece  of  absurdity  though 
the  omission  is  not  indicated.  Moreover,  the  pamphlet  states 
"  there  is  no  intimation  that  the  administration  of  the  poi- 
sonous substance  was  given  for  any  beneficial  purpose  to  the 
patients,  for  he  took  care  to  select  patients  that  were  prob- 
ably incurable."  On  the  contrary,  Berkley's  original  paper 
expressly  states  that  instead  of  being  incurable,  one  (Caae 
No.  1)  was  cured  and  another  (No.  3)  was  improved.  Besides 
this,  though  the  pamphlet  is  dated  1899.  it  omits  all  reference 
to  Dr.  Berkley's  letter  to  the  British  Medical  Journal  for  Octo- 
ber 30,  1897,  in  reply  to  your  friend  Dr.  Berdoe,  which  shows 
that,  as  a  result  of  the  administration  of  the  thyroid  tablets 
to  these  8  patients — a  well- recognized  remedy  for  insanity! — 

*  This  letter  was  written  by  myself  and  not  by  the  librarian  of  the  Surgeon- 
Genera^^  otfice. 

1 1  quote  the  following  from  the  eighth  edition  of  Hare's  "  Therapeutics  "  as 
to  the  use  ol  thyroid  extract  -  "  In  the  dose  of  from  5  to  tO  graitts  (0.35  to  1.3) 
three  times  a  dwy  {i.f.  ,  15  to  60  grains  a  day]  accordiug  to  the  degree  to  which  it 
produces  iLs  ettects,  it  has  proved  of  vaUie  lu  acute  mania  and   melancholia, 

Siierperal  and  climacteric  insanities,  and  in  stu|)orous  states  with  primary 
emeutia."    fierl^ley's  maximum  dose  was  IS  grains  a  day. 


not  one  died  from  the  effects  of  the  drug,  but  that  on  the 
contrary,  two  of  those  alleged  "  incurables  "  were  cured — 2-5  % ! 

In  his  admirable  letter  to  lAfe  (December  6,  19(X)),  Dr. 
Berkley  says:  "The  purpose  tor  which  the  article  was 
written  was  to  show  to  the  medical  profession  thit  a  certain 
■medicament  in  common  use  was  not  free  from  objection,  and 
should  net  be  given  in  unsuitable  cases.  In  proper  ones  the 
results  are  among  the  most  resplendent  attained  by  modem 
medicine,  converting  the  drooling  dwarf  into  an  intelligent, 
well-grown  man  or  woman ;  or,  in  other  instances,  as  in 
myxedematous  insanity,  affording  the  otherwise  hopelessly 
insane  with  almost  a  specific  to  recover  their  reason." 

2.  The  Cases  of  Lumbar  Puncture  by  Dr.  Wentworth,  of 
Boiton  (p.  5). 

"Lumbar  Puncture,"  I  may  remind  you,  is  the  simple  in- 
sertion of  a  hypodermatic  needle  between  the  vertebrae  into 
the  sheath  of  the  spinal  cord,  but  below  the  cord  itself,  to 
obtain  a  few  drops  of  the  cerebrospinal  fluid  for  diagnosis. 

The  pamphlet  gives  what  is  called  a  "  brief  abstract"  of 
five  of  the  experiments  related.  The  abstracts  are  indeed 
brief,  so  brief  as  to  give  a  wholly  erroneous  impression  as 
to  the  causes  of  the  patients'  death.  The  omissions  are 
glaring  instances  of  what  the  logicians  call  a  guppressio 
vert,  equivalent  to  a  sxiggesiio  falgi.  Let  me  point  this 
out  in  detail. 

Case  2. — It  is  correctly  quoted  that  the  last  puncture 
(where  there  were  several  punctures  I  only  give  the  last  date) 
was  made  "  February  16,  on  day  of  patient's  death."  The 
pamphlet  fails  to  add,  however,  the  important  fact  stated  by 
Dr.  Wentworth  that  the  postmortem  showed  an  empyema 
[abscess  in  the  chest]  which  had  burst  into  the  lung,  pneu- 
monia, and  inflammation  of  the  brain  with  pus  as  the  cause 
of  death. 

Case  3. — The  pamphlet  correctly  says,  "Puncture  January 
17,  1896;  patient  died  Jinuary  22"  WTiat  Dr.  Wentworth 
adds  is  omitted,  namely,  "  No  symptoms  attended  or  followed 
the  operation."  Moreover,  the  postmortem  showed  that  the 
patient  died  from  the  widespread  changes  common  to  infan- 
^  tile  wasting. 

Case  5. — The  pamphlet  says,  "  Puncture  February  3,  1896  ; 
patient  died  February  4."  It  omits  to  state  what  immedi- 
ately afterward  follows,  that  the  postmortem  showed 
"  primary  tuberculosis  of  the  intestines.  Double  pneu- 
monia," as  the  cause  of  death. 

Case  6. — The  pamphlet  quotes,  "  Punctured  February  1 ; 
patient  died  in  convulsions  three  weeks  later.'  It  neglects 
to  state  what  Dr.  Wentworth  particularly  mentions,  "  No 
reaction  on  the  part  of  the  patient  attended  the  operation," 
and  it  also  fails  to  state  that  the  child  was  seen  only  once 
and  that  the  diagnosis  then  made  was  tubercular  meningitis, 
which  was  clearly  the  cause  of  the  child's  death,  three  weeks 
later. 

Case  7. — The  pamphlet  quotes,  "  Punctured  February  27 ; 
patient  died  February  28."  It  omits  the  fact  that  the  post- 
mortem showed  that  the  child  died  from  defective  develop- 
ment of  the  brain  and  other  causes;  and  that  the  history 
showed  that  the  child,  who  was  7  months  of  age,  had  "  fre- 
quent convulsions,  which  began  when  he  was  about  3  months 
old.  While  in  the  hospital  the  convulsions  occurred  not  less 
than  20  times  a  day.    Oftentimes  he  had  several  in  an  hour." 

The  inference  from  the  pamphlet's  "brief  abstracts ''  of 
these  cases  is  clearly,  and  it  seems  to  me  by  these  omissions 
was  meant  to  be,  that  the  deaths  were  due  to  the  lumbar 
punctures,  whereas  the  evidence  is  that  the  deaths  were  due 
to  other  causes,  and  in  two  instances  the  operation  is  ex- 
pressly stated  not  to  have  done  any  harm.  Are  not  these 
abstracts  "  garbled  and  inacurate  "  ? 

8.  On  page  7  the  pamphlet  refers  to  some  experiments  on 
the  inoculation  of  lepers  with  syphilis,  made  in  Hawaii,  but 
published  in  the  Neiv  York  Medical  R-eord  of  September  10, 
1892.  It  is  stated  that  the  patients  "  were  already  suffering 
from  one  incurable  disease  and  the  object  of  the  experiment 
was  to  ascertain  whether  with  another,  and  even  worse  dis- 
order, they  might  not  be  infected."  This  statement  is  incor-' 
rect.  Most  writers  recognize  only  three  stages  of  syphilis, 
primary,  secondary,  and  tertiary.  The  writer  of  the  article 
in  question  believed  that  leprosy  was  a  fourth  and  final  stage 
of  syphilis  and  not  an  independent  disease.  It  is  a  well- 
recognized  fact  by  all  scientific  writers  that  a  patient  suffering 
from  syphilis  in  any  stage  is  immune  to  an  inoculation  of 
the  virus ;  that  is  to'  say,  the  inoculation  will  not  "  take  "  if 


February  23,  1901] 


SPECIAL  ARTICLE 


CrHB  Philadelphia 
Medical  Jocbnal 


373 


he  is  already  a  syphilitic.  It  was  for  the  purpose  of  deter- 
mining whether  leprosy  was  a  fourth  stage  of  syphilis  that 
the  attempt  was  made.  None  of  those  inoculated  took  the 
disease. 

4.  Sanarelli's  Experiments  on  the  Inoculation  of  Yellow 
Fever,  page  8. 

The  references  here  are  to  the  Britiih  Medical  Journal  for 
July  3,  1897,  and  the  New  England  Medical  Monthly,  March, 
1898.  The  extrartj  makfd  with  quctition  marks  are 
from  the  New  England  Medical  Monthly.  Between  the  first 
and  the  second  sentences  of  the  quotation  there  should  be 
some  stars  to  note  an  omission,  but  none  such  appear.  The 
omitted  words  state  that  not  the  germs  of  the  disease,  but 
the  carefully  filtered  and  sterilized  germ-free  fluid  was  used. 
Besides  this  and  many  other  minor  inaccuracies  many  of  the 
scientific  terms  are  changed  into  nonmedical  terms,  which 
is  not  objectionable  in  itself.  But  such  changes  and  inac- 
curacies should  exclude  quotation  marks,  for  when  used  they 
mean  that  the  words  quoted  are  the  ipsissima  verba  of  the 
author,  if  in  the  same  language,  or  an  exact  translation  if 
from  a  foreign  language. 

But  this  is  the  least  of  all.  The  pamphlet  says  that  the  in- 
jection produced  certain  symptoms,  among  which  are  men- 
tioned "the  jaundice,  the  delirium,  the  final  collapse"  the  last 
three  words  being  in  italics  in  the  pamphlet  to  call  special 
attention  to  them.  In  the  British  Medical  Journal  and  in  the 
New  England  Medical  Monthly,  the  words  "  the  final  "  are  not 
to  he  found.  We  see  not  a  few  patients  suffering  from  "jaun- 
dice, delirium,  and  collapse "  who  recover,  but  when  the 
expression  is  changed  to  "  the  final "  collapse,  it  means  to 
everyone  that  the  patient  died. 

Moreover,  the  end  of  the  quotation  is  as  follows :  "  I  have 
eeen  [the  symptoms  of  yellow  fever]  unrolled  before  my 
eyes  thanks  to  the  potent  influence  of  the  yellow  fever 
poison  made  in  my  laboratorv."  This  entire  sentence  does  not 
occur  ei'her  in  the  British  Medical  Journal  or  in  the  New 
England  Medical  Monthly.  Whether  it  is  quoted  from  some 
other  source  not  indicated,  or  has  been  deliberately  added,  I 
leave  you  or  "  A.  Tracy  "  to  explain. 

Moreover,  immediately  afterward  on  the  authority  of  the 
Washington  correspondent  of  the  Boston  Transcript  it  is 
stated  "it  is  understood  that  some  if  not  all  of  the  persons 
inoculated  died  of  the  disease  "  and  then  seven  times  after- 
ward are  repeated  "  the  final  collapse,"  the  "  unrolling  before 
the  eyes,"  "  scientific  assassination,"  "  death  "  and  "  murder  " 
quoted  from  a  public  speech  before  the  American  Humane 
Association.    Let  us  see  if  these  were  "  murders." 

In  the  two  references  given  there  is  no  indication  whether 
any  of  these  patients  died  or  not.  How,  therefore,  "  it  is 
understood  that  some,  if  not  all  of  them  died,"  I  do  not 
know.  As  a  matter  of  fa  ;t  none  of  the  human  heings  inoculated 
by  Sanarelli  died,  as  anyone  desirous  of  learning  the  truth 
could  have  ascertained  by  consulting  Sanarelli's  original 

fiublication    reporting    his    experiments  with    full    details. 
Annali  d'Igiene  Sperimentale,  1897,  vol.  vii,  Fascic.  iii,  pp. 
845  and  433 ) 

What  hysterical  oratory  about  "  the  final  collapse,"  which 
was  not  final;  "scientific  assassination,"  which  did  not  as- 
sassinate ;  and  "  murder  "  of  those  who  were  so  disobliging 
as  still  to  live  !  And  this  on  the  authority  of  the  Washing- 
ton correspondent  of  the  Boston  Transcript  who,  the  pamphlet 
assures  us,  is  a  person  "  who  would  seem  to  be  unusually 
well  informed  in  matters  of  science  !"  An  excellent  example 
of  "  newspaper  medicine  "  and  a  good  reason  for  my  refusal 
to  accept  it  as  evidence,  especially  from  other  correspond- 
ents who  may  not  be  as  "  unusually  well  informed."  May  I 
ask  whether  "  the  Vienna  correspondent  of  the  London 
Morning  Leader  "  is  also  one  of  those  who  in  your  opinion 
is  "  unumally  well  informed  in  matters  of  science "  and 
whether  his  testimony  is  as  wholly  false  as  the  one  under 
consideration  ? 

5.  On  page  28,  the  pamphlet  quotes  an  account  of  some 
experiments  by  Dr.  Neisser  from  the  Medical  Press  and  Cir- 
cular (England)  of  March  29,  1899."  This  is  an  instance 
again  of  misquotation  and  omission  which  can  ecarcely  be 
other  than  intentional.  The  last  sentence  of  the  first  quota- 
tion states :  "  Of  these  8  girls,  4  developed  syphilis."  No 
stars  indicate  that  any  words  have  been  omitted.  The  ori- 
ginal reads :  "  Of  these  8  girls,  [5  were  prostitutes,  and  of 
these  5]  4  developed  syphilis."  The  words  in  brackets  are 
entirely  omitted  in  the  pamphlet.    They  make  a  deal  of  dif- 


ference, for  what  ia  more  probable  than  that  4  out  of  5  pros- 
titutes should  develop  syphilis?  Whether  it  makes  any  dif- 
ference or  not,  however,  is  at  present  not  the  question.  The 
issue  is  whether  the  quotation  is  "  garbled  and  inaccurate." 
Does  it  not  fulfil  another  of  the  definitions  of  "garbling" 
given  in  your  letter,  viz.,  "  omissions  of  essential  facts  .  .  . 
suflicient  to  impair  the  accuracy  or  fairness  of  the  quota- 
tion ?  " 

Moreover,  the  pamphlet's  comment  upon  this  case  is  as 
follows:  "Does  the  London  journal  which  reports  these 
awful  experiments  denounce  them  as  a  crime  against  every 
law  of  morality  ?  Not  at  all.  It  simply  says  that  "  it  would 
b3  ditficult  to  acquit  Dr.  Neisser  of  a  large  measure  of  re- 
sponsibility in  respect  of  the  causation  of  syphilis  in  these 
cases  !"    Could  reproof  be  more  gentle  ? 

Is  that  really  all  that  the  Medical  Press  and  Circular  "  simply 
says  "  ?  On  turning  to  that  journal  after  the  above  sentence, 
which  is  correctly  quoted,  the  editorial  continues  thus  :  "  We, 
however,  are  less  concerned  in  establishing  the  culpability 
of  Dr.  Neisser  than  in  condemning  the  spirit  which  prompted 
such  experiments.  All  measures,  even  if  novel,  which  may 
reasonably  be  expected  to  assist  in  bringing  about  the  recov- 
ery of  the  patient  without  injury  to  his  health  may  legiti- 
mately be  resorted  to  with  the  consent  of  the  patient,  but 
measures,  whether  by  drugs  or  by  operation,  which  have  not 
for  direct  object  the  cure  of  the  patient  and  which  may  prove 
inimical  to  his  health  or  condition,  are  inadmissible  under  any 
circumstances  and  must  expose  the  perpetrator  to  professional 
ostracism  and  to  penal  rebuke." 

Is  "  professional  ostracism  and  penal  rebuke  "  a  reproof 
than  which  nothing  could  be  "  more  gentle  "  ?  If  this  state- 
ment is  not  "  garbled  and  inaccurate,"  what  do  words  mean? 
How  could  this  misrepresentation  be  otherwise  than  inten- 
tional ? 

6.  On  page  24,  again,  reference  is  made  to  the  experiments 
of  Menge.*  The  extracts  being  in  quotations  marks  would 
purport  to  be  exact  translations.  This  is  not  the  case.  The 
collocation  of  the  paragraphs,  also  (especially  in  the  smaller 
pamphlet),  is  such  that  it  would  be  supposed  even  by  a  careful 
reader  that  the  babies  experimented  upon  were  inoculated 
with  the  germs  taken  "  trom  the  pus  in  the  abdominal  cavity 
of  a  person  who  had  died  of  peritonitis,"  without  any  pre- 
cautions or  preliminary  experiments,  and  that,  therefore, 
these  babies  were  exposed  to  a  fatal  infection.  This  is  not 
true.  Four  columns  of  text  in  the  original  intervene  between 
the  first  and  the  second  paragraphs  alleged  to  be  quoted,  and 
these  detail  experiments  which  proved  that  the  inoculations 
which  he  then  carried  out  would  almost  certainly  be  harm- 
less. The  result  showed  that  he  was  right,  for  not  the 
slightest  ill-effects  followed.  I  have  only  words  of  condem- 
nation for  Menge's  experiments,  but  to  misrepresent  these 
experiments  is  scarcely  less  culpable  than  to  perform  them. 

7.  Then  follows  a  brief  account  of  Kroenig's  experiments. 
The  object  of  these  the  pamphlet  says  were  "  to  observe  the 
surest  way  of  breeding  purulent  bacteria."  This  is  not  true. 
On  the  contrary,  his  object,  like  Menge's,  Was  to  determine 
how  these  bacteria  are  normally  destroyed  in  the  part  of  the 
body  in  which  the  experiments  were  made.  In  only  a  single 
instance  did  any  ill  effects  follow,  and  in  this  case  the  inflim- 
mation  was  brief  and  not  dangerous  either  to  life  or  health. 
In  fact,  the  very  titles  of  these  two  papers  proclaim  the 
destruction  of  the  bacteria  and  not  the  surest  way  of  breed- 
ing them,  as  Menge's  title  reads,  "  On  a  quality  (Verhalten) 
of  the  vaginal  secretion  in  non-pregnant  females,  which  is 
hostile  to  bacteria,"  and  Kroenig's  is  on  the  same  peculiarity 
in  pregnant  women. 

In  the  comment  on  these  two  series  of  experiments,  they 
are  spoken  of  as  inoculations  "with  loathsome  diseases," 
which  would  suggest  to  any  one  that  the  patients  were  suc- 
cessfully inoculated  with  syphilis  or  other  similar  diseases. 
This  was  not  the  case.  Only  inflammation  would  follow  even 
had  the  inoculations  been  successful. 

Moreover,  to  show  the  vague  looseness  of  the  allf  ged  quo- 
tations, the  two  paragraphs  on  the  experiments  of  Menge 
are  in  quotation  marks  and  are  introduced  by  the  words 
'•  He  says  :  '  the  bacteria  I  used,  etc.,' "  as  if  they  were  exact 
continuous  translations.  "  He  says  "  nothing  of  the  kind. 
Instead  of  being  exact  translations,  the  first  paragraph  is 
made  up  of  partly  correct  and  partly  incorrect  translations 

•  DtMUcht  medicinische  Wochtnschrift ,  1894,  Nos.  46  to  48. 


374 


Thk  Philadelphia"] 
Medical  Journal  J 


SPECIAL  ARTICLE 


[Febsuabt  23,  1901 


from  page  891  near  the  top  of  the  second  column  and  near 
its  middle ;  and  the  second  paragraph  of  partly  correct  and 
partly  incorrect  translations  from  page  007  near  the  bottom 
of  the  first  column. 

No  reference  whatever  is  given  to  Kroenig's  paper  either 
by  number,  date,  or  page.  Is  not  this  "  vague  and  in- 
definite"? Asa  matter  of  fact  it  is  the  same  journal  (No. 
43,  p.  819)  as  Menge's  paper,  but  published  three  weeks 
earlier. 

8.  On  page  25  is  one  of  the  most  outrageous  instances  of 
garbling  and  mistranslation,  or  worse,  which  I  have  ever 
known  to  be  perpetrated  even  in  antivivisectionist  publica- 
tions. It  relates  to  observations  and  experiments  of  Profes- 
sor Schreiber,  reported  in  the  Deutsche  medicirmche  Wochen- 
schri/t  of  February  19, 1891. 

The  subject  is  introduced  with  the  startling  caption : 
"Inoculations  with  Tuberculin  and  Germs  of  Consumption." 
In  the  smaller  pamphlet  the  caption  is  simply ;  "  Injected 
Germs  of  Consumption."  What  was  injected  was  not  the 
"  germs  of  consumption  "  at  all,  but  tuberculin,  a  substance 
which  at  the  date  of  Professor  Schreiber's  publication  was 
engaging  the  attention  of  physicians  throughout  the  civil- 
ized world  as  a  therapeutic  and  diagnostic  agent.  To  de- 
scribe inoculations  with  tuberculin  as  "  inoculations  with  the 
germs  of  consumption  "  can  be  attributed  only  either  to  gross 
Ignorance  or  to  wilful  disregard  of  the  truth. 

In  the  first  paragraph  occurs  the  sentence :  "  He  began 
with  one  decimilligram  and  continued  to  inject  the  tubercu- 
lin in  ever-increasing  quantities,  until  he  at  last  injected  as 
much  as  5  centigrams,  about  50  times  as  much  as  Koch  said 
waa  the  maximum  dose  for  children  of  3  to  5  years  old." 
Any  fair  presentation  of  these  experiments  would  have  in- 
cluded Professor  Schreiber's  sentence  which  he  prints  in 
bold-faced  type  :  "  But  even  with  so  large  a  dose  injected  at 
one  time,  the  children  showed  no  trace  of  a  reaction."  It 
would,  perhaps,  be  too  much  to  expect  your  society  to  have 
indicated  on  what  grounds  Professor  Schreiber  was  led  to 
the  employment  of  such  large  doses,  and  that  his  observa- 
tions demonstrated  for  young  infants  an  exceptional  toler- 
ance of  tuberculin,  a  phenomenon  for  which  there  are 
analogies  with  other  drugs. 

But  the  worse  falsification  is  the  succeeding  account,  in  the 
form  of  what  purports  to  be  an  exact  translation  of  Schrei- 
ber's inoculation  of  a  boy  with  tuberculin.  The  alleged 
quotation  begins :  "  I  am  sorry  to  say  that  it  is  very  difficult 
to  obtain  subjects  for  such  experiments.  There  are,  of 
course,  plenty  of  healthy  children  in  consumptive  families, 
but  the  parents  are  not  always  willing  to  give  them  up."  The 
words  "  I  am  sorry  to  say  that,"  and  the  entire  next  sentence 
"  There  are,  of  course,  plenty  of  healthy  children,"  etc.  are 
not  in  the  original,  hut  are  additions  made  out  of  the  whole  cloth. 
The  next  following  sentences  contain  many  inaccuracies, 
such  as  the  translation  of  the  German  words  "  betriijhtlich 
anschwollen "  as  "  swelled  up  enormously,"  instead  of 
"  swelled  up  considerably."  But  the  worst  is  the  deliberate 
insertion  of  the  following  sentence  italicised  in  the  pamphlet 
which  also  does  not  occur  in  the  original :  "I  cannot  yet  say 
whether  the  boy  will  be  consumptive  in  consequence  of  my 
treatment."  The  correct  translation  of  Schreiber's  words  at 
the  point  where  this  closing  sentence  appears  in  tlie  pamph- 
let is  as  follows  :  "I  could  discover  no  other  alterations  in 
the  otherwise  apparently  healthy  boy."  [Andere  Veriinder- 
ungen  konnte  ich  an  dem  sonst  gesund  scneinenden  Knaben 
nicht  entdecken."  ] 

While  I  have  said  enough  about  this  case  to  substantiate 
my  charge  of  garbling  and  inaccuracy,  I  cannot  refrain  from 
utilizing  it  also  to  show  the  utter  misapprehension  which  the 
citation  of  detached  sentences  and  paragraphs  from  medical 
articles  is  calculated  to  create  in  the  mind  of  a  non  medical 
reader.  Even  when  the  words  are  quoted  correctly,  they  are 
likely,  when  detached  from  the  context,  to  give  rise  to 
entirely  false  impressions.  This  is  a  criticism  which  applies 
not  only  to  other  example^  cited  in  this  pamphlet,  but  to  a 
very  large  number  of  reports  of  experiments  and  of  quota- 
tions from  medical  journals  and  books  current  in  antivivisec- 
tionist writings,  and  the  resulting  dissemination  of  erroneous 
conceptions  is  often  greater  even  than  that  caused  by  inac- 
curate or  garbled  quotations.  A  brief  explanation  of  the 
present  example  will  show  the  justification  of  this  charge. 

For  what  purpose  did  Professor  Schreiber  inoculate  the 
boy  with  tuberculin  ?    His  article  leaves  no  doubt  as  to  the 


answer.  He  points  out  the  importance  of  the  earliest  pos- 
sible recognition  of  tuberculosis  in  a  patient  in  order  to 
secure  the  best  curative  results.  The  boy's  mother  had  con- 
sumption, and  the  author  calls  attention  to  the  frequency  of 
unrecognized  tuberculosis  in  the  oflfipring  of  tuberculous 
parents.  The  boy  received  a  small  dose  (1  milligram)  of 
tuberculin,  which,  if  he  were  free  from  tuberculosis,  would 
produce  no  eflFect,  but  which  if  he  had  unsuspected  tuberculosis 
would  produce  a  transient  (though  possibly  a  severe)  fever  and 
a  local  reaction,  indicative  of  tuberculosis.  Such  a  reaction 
followed  the  injection  of  tuberculin,  and  the  diagnosis  of 
tuberculosis,  which  had  not  been,  and  very  likely  could  not 
have  been  made  in  any  other  way,  was  established.  I  do  not 
know  what  could  have  been  more  fortunate  for  this  boy  than 
the  recognition  in  its  incipiency  of  a  disease  previously  un- 
suspected, and  which,  recognized  thus  early,  should  in  all 
probability  be  cured  by  proper  treatment.  This  tuberculin 
test  is  constantly  employed  to  prevent  the  spread  of  tubercu- 
losis in  our  cattle.  In  our  children  it  enables  us  to  discover 
the  same  disease  in  an  early,  curable  stage.  Shall  we  care 
for  our  cattle  better  than  for  our  children? 

Its  uf  e  is  not  properly  to  be  called  an  "  experiment "  at  all. 
As  I  write  this,  I  find  in  the  Journal  of  the  American  Medical 
Assodatiwi  for  January  12,  1901,  page  75,  3  cases  o(  the  use 
of  tuberculin  in  human  beings  by  Prof.  J.  M.  Anders,  who 
points  out  its  value  in  enabling  us  to  diagnosticate  consump- 
tion "  in  latent  forms  and  dubious  cases  however  incipient " 
long  before  percussion  or  the  stethoscope  will  reveal  the  dig- 
ease.  I  can  imagine  his  surprise  if  he  were  charged  with 
making  3  horribly  cruel  "  experiments "  and  injecting  the 
"  germs  of  consumption." 

It  is  euphemism  to  call  such  an  alleged  quotation,  in 
which  words  and  one  entire  sentence  are  iaterpolated  and 
another  wholly  changed  in  meaning,  a  "  mistranslation  "  or 
even  a  "  garbled  and  inaccurate  "  account.  Does  it  not 
amount  to  literary  forgery  ?  It  is  another  illustration  of  the 
fact  that  when  an  antivivisectionist  attempts  to  say  anything 
about  scientific  experiments  either  the  moral  sense  is  blunted 
or  the  truth-telling  faculty  is  in  abeyance.  A  good  English 
example  is  the  misstatements  in  Miss  Frances  Power  Cobbe's 
book  laid  bare  by  Victor  Horsley,  and  Schreiber's  and  San- 
arelli's  cases  will  serve  as  excellent  examples  of  American 
misrepresentation — if  so  long  a  word  is  needed  to  describe 
them. 

I  am  sorry  my  reply  is  so  long,  but  in  fewer  words  I  could 
not  explain  the  many  and  gross  errors  to  be  pointed  out.  I 
have  given  you  indeed  "  many  "  instances  in  which  the  refer- 
ences are  "  vague  and  indefinite  "  and  "  some  "  in  which  the 
accounts  are  "  garbled  and  inaccurate."  These  adjectives 
are,  I  submit,  very  mild  ones  to  apply  to  such  a  pamphlet. 

You  can  hardly  be  surprised  after  the  extraordinarj-  and 
repeated  interpolations,  mistranslations  and  worse  which  I 
have  demonstrated  in  this  letter  that  I  am  unwilling  to  ac- 
cept any  alleged  quotation  or  translation  emanating  from  the 
American  Humane  Association  sis  accurate  and  truthful  un- 
less I  can  compare  it  with  the  source  from  which  it  ia 
derived. 

In  conclusion  let  me  commend  to  the  "  Humane  "  Asso- 
ciation the  closing  words  of  President  Elliott's  letter  to  be 
found  on  pages  218-9  of  the  "  Hearing." 

"  Any  attempt  to  interfere  with  the  necessary  processes  of 
medical  investigation  is  in  my  judgment  in  the  highest  de- 
gree inexpedient  and  is  fundamentally  inhuman." 

I  shall  take  the  liberty  of  publishing  my  reply.    I  suppose 
that  you  will  not  object  to  the  publication  of  your  letter  with 
it  in  order  to  explain  the  reason  for  the  reply  ? 
Very  respectfully  yours, 

William  W.  Esen. 


Jenner  Institute  of  Preventive  Medicine. — The 

following  appointments  have  recently  been  made  at  this  in- 
stitution :  Dr.  S.  G.  Hedin,  of  the  University  of  Lund, 
Sweden,  has  been  appointed  Head  of  the  Department  of 
Pathological  Chemistry  ;  Mr.  J.  Beresford  Leather,  Lecturer 
on  Physiology  at  St.  Thomas's  Hospital  Medical  School,  as- 
sistant in  the  same  department;  and  W.  J.  Young,  of  Owens 
College,  Manchester,  assistant  in  the  Chemical  Department. 
Drs.  Moore,  Petrie.  and  Mackenzie  have  been  elected  to  fill 
the  three  Research  Studentships. 


Fkbrcabt  23,  1901] 


THE  LATEST  LITERATURE 


FThe  Philadelphia 
L  Medical  Journal 


375 


Ct^c  latest  literature. 


British  Medical  Journal. 

February  S,  1901.     [No.  2092.] 

1.  A  Clinical  Lecture  on  the  ComDlications  of  Gastric  Ulcer 

and  t^eir  Treatment.    A.  W.  Mayo  Robsos. 

2.  A  Case  Illustrating  the  Relief  of  Cnronic  Gastric  Disease 

by  Gastroenterostomy.    Arthur  E  Barker. 

3.  Remarks  on  a  Case  of  Retroperitoneal  Cyst.    John  Ward 

Cousins. 

4.  Strangulated  Femoral  Hernia;  Successful  Primary  Resec- 

tion of  the  Damaged  Gut.     Henry  Brtham  Robinson. 

5.  Some  Remarks  on  the  Ridical  Cure  of  Hernia  ;  Based  on 

190  Cases  of  Operation  for  the  Cure  of  Oblique  In- 
guinal Hernia.    A.  R  Anderson. 

6.  Carcinoma  of  the  Liver  at  the  Age  of  24  Years.    Dan 

McKenzie. 

7.  Remarks  on  Aneurysm  of  the  Coronary  Arteries  of  the 

Heart;  with  Notes  of  Two  Cases.    T.  Wakdkop  Grif- 
fith. 

1. — In  discussing  gastric  ulcer,  Robson  excludes  from 
his  remarks  ulcers  due  to  tubercle,  syphilis,  and  malignant 
disease.  Ulcers  are  divided  into  "  erosions  "  and  "  simple 
ulcers."  The  latter  is  subdivided  into  the  acute  round  ulcer, 
most  frequently  found  in  young  women  and  frequently  com- 
plicated by  hemorrhage  and  perforation,  and  the  chronic 
irregular  ulcer  more  frequently  seen  in  men,  but,  according 
to  Robson,  not  infrequently  found  in  the  female  sex.  Symp- 
toms and  diagnosis :  Pain  after  eating,  with  vomiting  and 
tecdernesa  in  the  epigastrium,  are  the  most  indicative  symp- 
toms of  ulcer.  In  many  cases  no  symptom  of  the  condition 
is  present  until  there  occurs  a  sudden  hemorrhage  or  perfo- 
ration. The  kind  of  pain  will  often  indicate  the  seat  of  the 
disease.  For  instance,  an  ulcer  on  the  posterior  wall  will 
give  rise  to  more  piin  when  the  patient  is  recumbent,  and  an 
ulcer  on  the  anterior  wall  will  be  most  painful  when  the  pa- 
tient is  prone.  When  the  ulcer  is  at  the  pylorus  the  patient 
is  more  comfortable  when  on  the  left  side,  and  the  reverse  is 
true  if  the  ulcer  is  at  the  cardia.  When  the  ulcer  is  situated 
in  the  anterior  of  the  wall  of  the  stomach  there  is  greater 
tenderness  over  the  epigastrium.  Vomiting  is  apt  to  give 
marked  relief  from  pain  in  cases  of  ulcer,  but  this  is  not 
true  of  cancer  of  the  etomach.  The  presence  of  hydrochloric 
acid  in  excess  favors  the  diagnosis  of  ulcer.  The  blood  in  the 
vomit  is  apt  to  be  free  or  clotted,  though  it  occasionally  re- 
sembles the  coffee-ground  vomit  of  cancer.  Distention  of 
the  stomach  by  the  evolution  of  carbonic  acid  gaa  will  show 
whether  or  not  dilatation  is  present.  In  chronic  ulcer  of  the 
stomach  a  tumor  may  not  infrequently  be  felt.  The  dura- 
tion of  the  chronic  ulcer,  which  is  usually  of  years,  as  com- 
pared with  the  short  duration  of  cancer,  will  frequently  aid 
in  a  differential  diagnosis.  When  there  is  doubt  as  to  the 
diagnosis,  an  exploratory  abdominal  section  may  be  made  if 
the  following  two  questions  can  be  answered  in  the  affirma- 
tive: First.  Can  an  exploratory  operation  be  performed  with- 
out adding  seriously  to  the  risk  of  loss  of  life  ?  Second.  Is  it 
possible  that  good  will  result  from  the  exploration  ?  Treatment 
should  be  medical,  but  if  the  ulcer  becomes  chronic,  does  not 
respond  to  treatment,  or  complications  arise,  surgical  treat- 
ment is  the  only  one  which  will  give  relief  Robson  thinks 
that  the  medical  treatment  ehould  be  kept  up  for  a  much 
longer  period  than  is  usual,  in  order  to  prevent  relapse. 
Surgical  treatment.  Robson's  mortality  in  opera' ions 
for  gastric  ulcer  is  below  5%,  and  he  thinks  this  mortality 
could  be  lowered  if  many  of  the  cases  were  operated  upon 
earlier  When  medically  treated  the  mortality  rate  is  from  20^ 
to  50%.  Gastroenterostomy  is  the  operation  which  Robson 
thinks  most  universally  applicable  to  these  cases,  and  he 
always  attaches  the  bowel  to  the  posterior  surface  of  the  stom- 
ach. His  last  20  cases  have  all  recovered  without  complication. 
Excision  of  the  ulcer  is  not  always  necessary.  Pyloro- 
plasty can  be  done  for  pyloric  ulcer  if  the  pylorus  is  free 
from  extensive  adhesion,  can  be  easily  drawn  forward,  and  is 
not  actively  ulcerated.  If  these  conditions  are  not  present, 
gastroenterostomy  is  to  be  preferred.  Pylorectomy  is  seldom 
necessary  for  simple  ulceration.  Dilatation  after  the 
method  of  Loreta  is  not  a  satisfactory  procedure.    Compli- 


cations. Perforation  occurs  in  about  15%  of  all  cases  of 
ulcer  of  the  stomach.  That  death  does  not  occur  in  all  cases 
of  perforation  is  due  to  the  fact  that  the  stomach  is  usually 
empty  and  that  the  omentum  becomes  adherent  at  the  point 
of  perforation.  Protecting  adhesions,  however,  are  rare  and 
cannot  be  depended  upon.  Perforation  not  infrequently 
results  in  the  formation  of  a  subphrenic  abscess.  Hemor- 
rhage occurs  in  about  80%  of  cases  of  gastric  ulcer.  Robson 
thinks  that  in  acute  hematemesis  the  treatment  should  be 
medical,  but  that  in  recurring  acute  as  well  as  chronic 
hemorrhage  surgical  treatment  should  be  instituted.  Cica- 
tricial contraction  of  the  pylorus  reeulting  in  dilatation 
of  the  stomach  is  not  an  infrequent  complication  of  gastric 
ulcer,  and  occasionally  gastroplication  is  necessary  as  well 
as  direct  treatment  of  the  stenosis.  Robson  has  operated 
upon  11  cases  of  hour-glass  contraction  of  the  stomach  as  a 
result  of  ulcer.  Perigastritis  with  adhesions  frequently  results 
from  ulcerations  of  the  pyloric  end  of  the  stomach,  produc- 
ing dilatation  and  requiring  surgical  interfence  fpr  its  relief. 

[j.H.G.] 

3. — Barker  describes  the  case  ef  a  woman,  aged  42  years, 
who  had  suffered  since  the  age  af  14  with  more  or  less  gastric 
disturbance  and  vomiting.  Six  years  before  admission  the 
diagnosis  of  gastric  ulcer  was  made.  For  the  past  16  months 
the  patient  had  used  a  stomach  tube  daily.  On  admission 
the  patient  was  extremely  weatand  anemic,  and  the  stomach 
was  largely  dilated,  a  diagnosis  was  made  of  nonmalignant 
pyloric  stenosis.  As  preparatory  treatment  for  operation,  the 
stomach  was  frequently  washed  out,  and  on  the  two  days 
preceding  the  operation  saline  solution  was  injected  subcu- 
taneously.  A  posterior  gastroenterostomy  was  performed  in 
the  usual  way,  but  before  closing  the  intestinal  opening 
liquid  food  was  thrown  into  the  bowel.  The  pylorus  was 
bound  down  by  adhesions  and  was  nearly  completely  closed. 
The  patient  recovered  promptly  from  her  operation  and 
gained  rapidly  in  flesh  and  health,     [j  h  g.] 

3.— Cousins  reports  a  case  of  retroperitoneal  cyst 
which  he  incised  and  drained  successfully.  He  does  not 
think  that  enucleation  of  these  cysts  can  often  be  accom- 
plished, and  that  the  undertaking  is  accompanied  by  con- 
siderable danger  to  life.  Where  the  pedicle  is  small,  how- 
ever, he  thinks  enucleation  should  be  done,    [j.h  g  ] 

4,— Robinson  reports  a  case  of  strangulated  femoral 
hernia  in  which  he  performed  a  resection  of  the  bowel  by 
the  Maunsell  method.  The  patient  made  a  good  recovery. 
[j.h  g.] 

5.— Anderson,  speaking  of  the  mortality  following  opera- 
tions for  the  radical  cure  of  hernia,  shows  the  percent  to 
be  about  one  in  100,  in  nonstrangulattd  cases.  Out  of  190 
operations,  including  cases  of  strangulation,  he  had  4  deaths, 
2  of  which  occurred  in  strangulated  cases.  He  thinks  that 
the  HalstedBassini  operation  is  the  best  method  of  obtain- 
ing a  radical  cure.  He  believes  that  with  this  operation, 
patients  can  be  assured  of  a  radical  cure.  Unless  the  cord  is 
large,  he  does  not  resect  the  veins,  and  thinks  this  should 
never  be  done  in  childien.  He  uses  silk  as  his  suturing 
material,  and  has  had  no  cause  to  regret  its  use.  In  60  oper- 
ations done  in  the  past  year,  in  which  silk  was  used,  he  has 
not  had  infection  to  take  place  in  a  single  case,  nor  has  he 
ever  seen  late  infection  follow  the  use  of  silk  sutures.  He 
does  not  advise  the  use  of  a  truss  after  the  operation,  as  it 
does  no  good,  and  is  apt  to  do  damage.  In  children  he 
thinks  the  radical  cure  should  be  undertaken  if  the  ring  is 
large,  and  the  hernia  is  not  successfuly  controlled  by  the 
truss.    [j.H.G.] 


Lancet. 

February  S,  1901.    [No.  4040.] 

1.  The  Baillie  Lectures  on  Considerations,  Touching  the 

Pathology  and  Relations  of  Diabetes.    W.  Howshif 
Dickinson. 

2.  A  Clinical   Lecture  (A.b8tract  of)  on  Femoral  Hernia. 

William  H.  Battle. 

3.  The  Hemorrhagic  Diathesis  in  Typhoid  Fever,  and  ite 

Relationship    to    Purpuric     Conditions    in     General. 
Albert  G.  Nicholls  and  G.  Everett  Lkarmonth. 

4.  The  Treatment  of  Typhoid  Fever.    Frederick  J.  Smith. 

5.  Filatow's  Spots  in  Morbilli.     L.  Falkener. 


376 


The  Philadelphia"! 
Mbdical  Journal  J 


THE  LATEST  LITERATURE 


LFkbbuabt  23,  1901 


6.  Laparotomy  and  Cleansing  of  the  Peritoneum  in  a  Case 

of  Tuberculous  Peritonitis.    Geobge  William  Davis. 

7.  Selenium  Compounds  as  Fnctors  in  the  Recent  Beer- 

poisoning  Epidemic.    F.  W.  Tunicuffe. 

8.  .An  Intraperitoneal  Method  for  the  Radical  Cure  of  In- 

guinal Hernia.    T.  H.  Wells. 

9.  A  Case  of  Primary  Carcinoma  of  the  Vermiform  Appen- 

dix, with  Remarks.    T.  R.  C.  Whipham. 
10.  Reflections  on  Therapeutics.    Habey  Campbell. 

1. — Dickinson  delivered  a  lecture  on  Considerations 
touching  the  patbolog-y  and  relations  of  diabetes,  at 

the  St.  George's  Hospital.  He  emphasizes  that  from  the  clin- 
ical standpoint  the  disease  is  well  defined,  but  that  from  the 
pathological  aspect  much  is  still  to  be  learned.  He  states 
that  an  uncommon  form  of  diabetes  is  associated  with  lesions 
of  the  pancreas  and  a  more  common  variety,  with  a  good 
lead  of  certainty,  is  associated  with  diseases  of  the  nervous 
system.  He  mentions  as  the  most  common  pathological 
change,  blood  extravasation  into  the  perivascular  canals  of  the 
brain,  particularly  about  the  deeper  arteries.  He  states  that 
he  has  preparations  showing  these  hemorrhages  in  8  out  of 
22  diabetic  brains.  He  also  refers  to  syringomyelia  which 
occurred  twice  in  8  diabetic  spinal  cords,  and  in  3  spinal 
cords  there  was  hyaline  modification  of  the  lateral  parts  of 
the  gray  horns.  Attention  is  directed  to  the  important  fact 
that  the  nervous  system  rapidly  undergoes  changes  after 
death,  also  that  the  saccharine  blood  may  have  an  influence 
upon  the  nerve  structures,  therefore  confusion  as  to  origin 
and  effect  necessarily  arises.  The  diabetic  liver  is  described 
as  being  enlarged,  congested,  red  and  firm.  He  refers  to  pul- 
niona.ry  consumption  in  relation  to  diabetes  with  particular 
mention  of  a  form  not  of  tuberculous  origin.  The  in- 
flamed kidney  and  other  changes  of  the  genito-urinary 
tract  are  probably  due  to  the  passage  of  saccharine 
urine,  and  that  diabetic  cataract  is  presumably  due  to 
the  saccharine  blood.  The  hemorrhages  in  the  brain, 
previously  defcribed,  are  probably  in  some  way  asso 
ciated  with  the  cause  of  the  disease,  and  not  due  to  the 
saccharine  blood.  Reference  is  made  to  the  discovery  of 
Claude  Bernard,  and  to  Baron  Larrey's  case  of  diabetes  (in 
1820)  in  a  man  of  22  years  of  age  who  developed  diabetes  after 
an  extensive  wound  of  the  brain  made  by  the  thrust  of  a  foil. 
He  states  that  reference  might  be  made  to  many  cases  of 
head  injuries  which  are  followed  by  glycosuria,  most  often  of 
a  temporary  nature.  Grief,  terror,  anxiety,  and  commercial 
disasters  are  frequently  followed  by  diabetes.  Diabetes,  as 
reported  by  Mr.  Herbert  Page,  surgeon  to  the  London  and 
Northwestern  R.  R.  Company,  is  twice  as  common  in  the 
engine-driver  as  in  the  ordinary  population.  The  close  as 
sociation  of  gout  and  diabetes  and  the  hereditary  tendency 
of  the  disease  are  set  forth.  The  occurrence  of  loss  of 
patellar  reflex  in  a  large  proportion  of  the  cases  and  periph- 
eral neuritis  as  clinical  manifestations  of  the  nervous  system 
are  mentioned.  He  also  states  that  the  appearance  of  earthy 
phosphates  in  the  urine  of  diabetics  shows  the  relation  of  the 
oisease  to  cerebral  irritation.  The  redness  of  the  mucous 
membranes  of  the  mouth,  particularly  of  the  tongue,  and 
the  dusky  redness  of  the  face  also  suggest  involvement  of 
the  nervous  system.  He  refers  to  glycosuria  as  being  a  con- 
comitant of  some  cases  of  insanity,  and  that  while  the 
pathology  of  both  remains  largely  a  problem  for  the  future, 
there  are  indications  of  cerebral  changes,  and  the  associa- 
tion between  the  two  conditions  seems  conclusive.  The  ad- 
dress is  concluded  by  mentioning  that  the  important  clinical 
observations  of  this  disease  are  the  following:  Mental  causes 
acting  as  an  origin ;  the  association  of  excessive  phospho- 
turia;  absence  of  patellar  reflex;  and  the  relation  of  glyco- 
suria and  insanity,     [f  j  k  ] 

2. — In  his  lecture  on  femoral  hernia.  Battle  discusses 
at  some  length  the  diagnosis  of  the  condition,  and  lays  great 
stress  upon  a  thorough  examination  for  hernia  in  allcases  of 
intestinal  obstruction.  He  recalls  two  instances  where  he 
had  been  called  in  to  operate  for  intestinal  obstruction,  when 
in  each  case  femoral  hernia  was  present  and  had  been  over- 
looked. Patients  should  be  examined  standing  as  well  as  in 
the  recumbent  position.  A  varix  of  the  internal  saphenous 
vein  is  sometimes  mistaken  for  femoral  hernia,  as  are  also 
enlarged  glands  and  lipomata  in  the  femoral  region.  A 
careful  examination  of  the  femoral  ring  will,  in  most  in- 
stances, suffice  to  difi"erentiate  these  conditions.    When  a 


femoral  hernia  is  irreducible,  it  should  be  operated  upon, 
unless  some  condition  exists  which  is  a  positive  contraindi- 
cation. In  speaking  of  the  radical  cure  of  these  cases. 
Battle  thinks  it  is  a  mistake  to  adhere  to  one  method  of 
operating,  and  that  it  is  better  to  change  the  technic  to  suit 
the  individual  case.  He  then  describes  a  method  which  he 
has  employed  on  three  occasions,  which  consists  in  the  im- 
plantation of  a  portion  of  the  aponeurosis  of  the  external 
oblique  muscle  into  the  femoral  ring.  This  h«s  been  fol- 
lowed in  each  case  with  very  satisfactory  result     [j  h  g  ] 

3. — Xicholls  acd  L?armorth  discuss  the  hemorrhagic 
diathesis  in  typhoid  fever  and  its  relationship  to 
purpuric  conditions  in  general.  The  authors  report  a 
case  of  hemorrhagic  enteric  fever.  They  mention  that  this 
term  should  be  used  in  referring  to  such  cases  of  enteric 
fever  that  show  purpuric  eruptions  of  the  skin,  bleeding 
from  the  mucous  membrane  such  as  hemoptysis,  hema- 
temesis,  metrorrhagia  and  eplstaxis.  Degeneration  of  the 
walls  of  the  bloodvessels  are  mentioned  as  factors  which  are 
produced  by  circulating  toxin.  They  state  that  4  cases  of 
hemorrhagic  typhoid  fever  have  occurred  in  a  series  of  200 
cases  at  the  Royal  Victoria  Hospital,  Montreal.  The  case 
reported  by  the  authors  is  that  of  a  female  of  21,  unmarried, 
and  a  school  teacher  by  occupation.  She  was  admitted  to  the 
Royal  Victoria  Hospital  on  June  19. 1900,  giving  a  history  of 
feeling  ill  for  6  days.  A  chill,  followed  by  fever,  marked 
the  onset  of  the  disease.  After  a  short  time  the  diagnosis  of 
enteric  fever  was  made,  rose  spots  appeared,  the  tongue 
was  dry  and  coated,  and  the  Widal  reaction  was  positive. 
The  spleen,  however,  was  not  enlarged.  Fourteen  days  after 
admission  a  purpuric  eruption  showed  itself  upon  the  skin  of 
the  abdomen.  These  hemorrhages  in  a  few  days  began  to  fade. 
Some  days  later  extensive  hemorrhages  showed  themselves. 
The  patient  had  2  hemorrhages  from  the  bowels,  there  were 
epistaxis,  bleeding  from  the  lips  and  gums,  hematuria  and 
hemorrhages  into  the  conjunctivae.  A  blood  examination 
at  this  time  showed  that  there  were  l.S.OOO  leukocytes.  At  a 
later  time  the  blood-count  showed  1,-540,000  erythrocytes  and 
35%  of  hemoglobin.  Death  occurred  on  the  third  of  Jaly. 
The  treatment  consisted  of  18  cold  baths,  these  were  stopped 
when  the  hemorrhages  appeared.  Bleeding  from  the  mucous 
surfaces  was  treated  with  suprarenal  powder,  and  spirit  of 
turpentine  and  liquor  calcis  chloridi  were  administered  in- 
ternally. The  case  is  interesting  on  account  of  the  sudden 
onset  and  absence  of  splenic  enlargement.  A  postmortem 
examination  made  2  hours  after  death  revealed  typhoidal 
ulceration  involving  pnncipally  the  large  intestine,  but  the 
small  bowel  was  also  implicated.  Hemorrhages  were  found 
in  the  skin,  lungs,  heart,  kidneys,  spleen,  intestines,  bladder, 
gallbladder,  and  connective  tissues.  There  was  an  old  healed 
duodenal  ulcer,  acute  diffused  nephritis  was  present,  the 
spleen  was  small  and  there  were  some  old  pleural  adhesions. 
Microscopical  examinations  revealed  fatty  degeneration  of 
the  capillaries  of  the  lungs  and  kidneys.  Tne  mos:  imo^runt 
fact  in  reference  to  the  pathological  findings  is  the  fatty  de- 
generation of  the  endothelial  cells  of  the  capillaries  in  the 
lungs  and  kidneys,  but  the  authors  emphasize  that  rupture  of 
the  capillaries  could  not  be  demonstrated.  A  bacteri  )logical 
examination  was  made,  cultures  being  taken  from  the  blo':>d  in 
the  heart,  peritoneal  cavity,  and  kidneys.  The  bacillus  typho- 
sus was  not  demonstrated,  but  the  staphylococcus  albus  was 
isiilated  from  the  blood  in  the  heart  and  peritoneal  cavity  as 
well  as  from  the  kidneys.  From  the  blood  in  the  heart  a  bacil- 
lus was  also  isolated ;  the  characteristics  of  this  organism  were 
the  following:  The  bacillus  showed  bipolar  staining  proper- 
ties ;  it  had  rounded  ends  and  was  four  times  as  long  as  it  was 
broad.  It  was  nonmotile,  gave  an  acid  reaction  in  litmus 
milk  and  also  produced  coagulation,  formed  gas  in  glucose 
broth,  and  was  nonpathogenic  whfn  inoculated  into  rabbits. 
A  bacillus  was  isolated  from  the  kidney,  which  was  regarded 
as  being  identical  with  the  bacillus  flaoroscens  liquffaciens. 
The  authors  have  tabulated  statistics  from  various  sources  to 
show  the  infrequency  of  hemorrhagic  typhoid  fever.  The 
total  number  of  cases  collected  were  12.000,  and  in  this 
number  there  were  only  18  cases  which  showed  the  gen- 
eral hemorrhagic  diathesis.  They  ne^t  refer  to  the  etiol- 
ogy of  this  condition,  pointing  out  as  an  important  fart 
that  scorbutic,  hemophiliac,  or  rheumatic  taint  does  not 
seem  to  have  been  noted  in  the  cases.  In  reviewing  the 
pathology  they  state  that  the  lesions  differ  little  from 
those  encovmtered  in  ordinary  typhoid  fever.    The  hem- 


Febbdabt  23,  1901] 


THE  LATEST  LITERATURE 


CTHK  PHmADSLFHIA 
Uedical  Jocsnajl 


377 


orrhages  into  the  tissues  and  from  the  free  surfaces 
show  considerable  diversity  as  to  character  and  distribution. 
From  the  information  that  can  be  gathered  the  bacterial 
origin  of  this  hemorrhagic  condition  is  provable,  but  that 
final  proof  is  still  lacking.  From  the  standpoint  of  onset 
and  symptoms  they  state  that  the  condition  usually  occurs 
in  well-developed  cases  of  enteric  fever,  and  that  the  pur- 
puric maiiifestations  are  most  frequent  in  the  third  week  of 
the  disease.  This  fact  strongly  suggests  that  secondary  infec- 
tion acts  as  the  most  important  cause.  They  regard  the 
prognosis  as  very  grave,  two-thirds  of  the  cases  ending  fatally. 
The  treatment  which  is  recommended  is  purely  symptomatic, 
stating  that  with  the  appearance  of  the  hemorrhagic  state, 
the  cold- bath  treatment  should  be  stopped.  They  mention 
the  treatment  recommended  by  Gerhard,  who  includes  vege- 
table juices  in  the  diet.  They  also  refer  to  the  many  plans 
of  treatment  adopted  to  check  the  hemorrhage.  The  authors 
conclude  the  article  by  giving  a  classification  of  purpuric 
conditions,     [fjk.] 

4. — Smith  in  discussing  the  treatment  of  typhoid  fever 
lays  particular  stress  upon  the  examination  of  the  stools,  and 
that  the  appetite  of  the  patient  must  be  carefully  watched. 
In  the  management  of  enteric  fever  he  states  that  he  has  laid 
down  a  golden  rule  to  examine  the  stools  at  least  once  in  24 
hours.  The  appearance  of  undigested  milk  or  other  food  in 
the  stools  has  led  the  author  to  diminish  the  quantity  of  food 
or  suspend  feeding  for  24  hours.  The  appearance  of  blood 
in  the  stools  he  states  is  an  indication  for  the  use  of  opium 
and  the  stopping  of  all  food  for  24  or  48  hours.  When 
sloughs  make  their  appearance  in  the  stools,  which  is  a 
natural  state  during  the  third  or  fourth  week  of  every  case, 
hemorrhage  may  be  feared,  so  that  feeding  should  be 
cautious.  Feculent  debris  is  a  desirable  constituent  of  the 
stools  and  should  indicate  the  persistence  in  the  line  of  treat- 
ment which  has  been  adopted.  He  believes  that  the 
appetite  of  the  patient  indicates  the  character  and 
amount  of  the  diet,  and  he  has  made  it  a  cardinal 
rule  to  allow  the  patient  to  be  the  sole  arbiter  of  his  diet, 
the  only  contrary  indications  to  feeding  being  vomiting, 
hemorrhage  and  tympanites.  He  advises  feeding  4  times 
during  the  24  hours.  Sleep,  however,  is  more  valuable  than 
feeding,  therefore  the  patient  should  never  be  aroused 
to  be  fed.  He  recommends  the  following  articles  in 
the  dietary:  Liquid  custard,  baked  custard  pudding,  junket, 
bread  and  milk,  eggs  lightly  boiled  or  poached,  jelly  and 
soups,  beef  tea,  beef  juice,  and  stale  bread.  He  does  not 
deny  the  patient  beer  or  stout.  In  the  treatment  of  compli- 
cations he  states  that  vomiting  should  be  controlled  by  with- 
holding the  food,  and  by  the  administration  of  hydrocyanic 
acid,  bicarbonate  of  soda  and  bismuth.  When  tympanites 
occurs  he  advises  the  withholding  of  all  food,  the  administra- 
tion of  sulphate  of  soda  until  the  bowels  are  acting  freely. 
He  also  recommends  that  an  ice-bag  should  be  placed  upon 
the  abdomen.  Constipation  is  treated  by  the  routine  admin- 
istration of  calomel.  As  a  rule  he  does  not  fear  excessive 
diarrhea,  but  when  undigested  particles  of  food  appear  in  the 
stools  food  should  be  stopped  for  a  while.  For  the  fever  he 
recommends  tepid  sponging  and  for  hemorrhage  from  the 
bowels  starvation  and  the  administration  of  opium.  He  ad- 
vises as  a  routine  treatment  the  administration  of  either 
caibolic  acid  or  chlorine  water,  and  in  some  cases  salol. 
Alcohol  he  believes  should  not  form  a  necessary  article  for 
the  treatment  of  this  disease.  He  concludes  the  article  by 
saying  that  with  this  method  of  treatment  he  believes  his 
results  as  regard  mortality  are  as  good  as  those  with  any 
other  plan  of  treatment  and  maintains  that  convalescence  is 
more  rapid  ;  relapses,  however,  are  not  prevented,   [fjk] 

6. — Filatow's  spots  in  morbilli  are  discussed  by  Falkener. 
He  states  that  Filatow  described  them  in  1895  and  Koplik  in 
1896,.  and  that  they  have  usually  been  called  Koplik's 
spots.  Koplik  described  them  as  bluish  white,  but  the 
author  states  that  these  spots  appear  as  fine  white  specks. 
They  are  easily  removed  by  rubbing.  After  these  spots  have 
persisted  for  a  short  while  they  are  surrounded  by  a  red 
areola.  The  buccal  mucous  membrane  is  the  commonest 
site  for  Filatow's  spot?,  appearing  opposite  to  the  lower 
molars  or  upper  molars  on  either  side.  They  are  also  found 
upon  the  inner  surface  of  the  lower  lip  and  upon  the  inner 
surface  of  the  upper  lip.  He  lays  stress  upon  the  fact  that  in 
every  one  of  his  cases  Filatow's  spots  were  observed.  From 
the  standpoint  of  differential   diagnosis  they  are  sometimes 


to  be  distinguished  from  permanent  spots  upon  the  mucous 
membrane,  also  from  curds  of  milk  which  collect  upon  the 
mucoea,  from  thrush  and  aphthous  stomatitis.  The  author 
has  never  noted  the  absence  of  Filatow's  spots  in  measles, 
and  he  has  never  observed  them  in  any  other  condition, 
having  examined  the  mucous  membrane  of  the  mouth  in 
from  3,000  to  4,000  cases.  They  are  of  great  importance 
from'the  standpoint  of  diagnosis,  for  when  they  appear  the 
case  is  most  certainly  one  of  morbilli.  From  the  standpoint 
of  early  treatment  and  isolation  this  sign  is  of  great  value. 
[fjk] 

6.— Davis  reports  a  case  of  tuberculous  peritonitis  in 
which  abdominal  section  and  toilet  of  the  peritoneum  re- 
sulted in  considerable  improvement.  He  thinks  it  a  mistake 
not  to  operate  in  these  cases  early  when  there  is  a  chance  of 
obtaining  beneficial  results,    [j  h  g.] 

7. — Tunniclitfe  and  Rosenheim  in  an  article  conclude  that 
after  an  investigation  relating  to  the  recent  beer-poisoning 
epidemic  that  selenium  compounds  would  explain  many 
anomalous  cases  in  which  the  dose  of  arsenic  was  very  small, 
and  feel  justified  in  stating  that  these  compounds  have 
played  an  important  role  with  the  arsenic,     [fjk] 

9.— Whipham  relates  a  case  of  primary  carcinoma  of 
tlie  vermiform  appendix  not  diagnosed  during  life  but 
found  postmortem.  The  peritQueum  was  studied  with  car- 
cinomatous masses,  and  one  ovary  also  was  the  seat  of  malig- 
nant disease.  The  mucous  membrane  of  the  appendix  waa 
seen  to  be  extensively  involved  by  spheroidal- celled  car- 
cinoma ;  the  muscular  coat  was  only  slightly  involved.  This 
was  the  only  portion  of  the  alimentary  canal  that  was  the 
seat  of  malignant  disease  and  Whipham  thinks  this  argues 
for  its  being  the  primary  seat.  Tne  cancerous  condition  of 
the  left  ovary  he  considers  to  be  due  to  dissemination. 
Microscopic  sections  of  the  appendix  are  shown  and  other 
reported  cases  referred  to.    [j.h.g.] 


New  York  Medical  Journal. 

February  16,  1901.     [Vol.  Ixxiii,  No.  7.] 

1.  Stethophonometry.    Albert  Abrams. 

2.  Septicemia  in  Young  Chickens.    Leo  F.  Rettger. 

3.  A    New    Portable    and    Inexpensive    Ophthalmometer. 

William  F.  Aiken. 

4.  Combined  Surgical  Operations  in  Female  Subjects  at  a 

Single  Seance.    R.  Stansbury  Sutton. 

5.  The    Normal    Declinations    of  the    Retinal    Meridians. 

George  T.  Stevens. 

6.  A  Study   of  Buboes  and  Their  Treatment.    Frederick 

Griffith. 

7.  Hysterical  Anesthesia  and  Analgesia.    B.  C.  Loveland. 

1.— Albert  Abrams,  in  an  article  on  stethophonometry, 
remarks  that  auscultation  of  the  heart- tone  in  the  con- 
ventional manner  not  infrequently  aflfords  us  no  indication 
of  cardiac  strength,  if  reliance  is  to  be  placed  on  the  intensity 
of  the  tones  in  their  selective  propagation  to  different  parts 
of  the  chest.  Abrams  has  devised  an  instrument  which  he 
calls  the  stethophonometer.  This  instrument  is  con- 
structed on  the  disc- valve  principle,  weighs  only  two  ounces, 
and  is  composed  wholly  of  hard  rubber.  He  believes  that 
the  employment  of  this  instrument  will  add  greater  scientific 
value  to  our  clinical  examinations,  in  recording  the  intensity 
of  the  acoustic  phenomena  associated  with  the  heart  and 
lungs,     [tl.o.] 

3. — Afier  considering  the  principles  of  some  of  the 
ophthalmometers  used  at  present,  Aiken  describes  a  new 
portable  and  inexpensive  ophthalmometer  devised 
by  him.  The  author  claims  that  ihe  instrument  has  proved 
reliable  for  measuring  the  corneal  convexity .  The  principle 
is  that  of  doubling  a  square  image  in  the  direction  of  one 
diagonal,  the  opposite  corners  touching  ;  the  opposite  sides  of 
the  square  thus  serve  as  mires.  In  the  absence  of  astigma- 
tism, a  perfect  cross  is  formed ;  when  astigmatism  is  present 
there  is  a  faulty  alignment  of  one  pair  of  sides  with  a  correct 
alignment  of  the  other  pair  at  right  angles.  No  counting  of 
"  steps  "  is  required  as  a  scale  of  the  draw-tube  indicates  each 
axis  when  the  arms  of  the  cross  in  the  correspondmg  meridiaa 
are  in  line.  The  spherometric  range  of  the  instrument  18 
from  a  curvature  i=5.5  millimetres  to  r=13  millimeters.  Tne 


378 


The  Philadelphia 
Mkdical  Journa 


'^ 


THE  LATEST  LITERATURE 


[FEBErABV  23,  1901 


instrument  can  be  employed  with  a  patient  in  the  position 
of  ophthalmoscopy  thus  enabling  the  examiner  to  determine 
the  astigmatism  and  make  the  ophthalmoscopic  examination 
with  the  patient  in  the  same  position.  The  article  is  com- 
prehensively illustrated  The  instrument  is  detachable  and 
easily  portable,    [m  R  d  ] 

4.— Sutton,  of  Pittaburg,  remarks  that  until  a  very  recent 
period  when  a  female  pitient  required  4  or  5  distinct  surgi- 
cal procedures,  many  months  were  frequently  required  for 
her  recovery.  Edebohls,  of  New  York,  has  encouraged  the 
practice  of  operating  at  one  time  upon  the  several  lesions 
without  regard  to  their  number.  Sutton  reports  15  cases  in 
which  several  operations  were  done  at  one  time  and  un- 
eventful recovery  followed,    [t  l.c  ] 

7. — Loveland  reports  a  case  of  hysterical  aaesthesia 
and  analgesia  in  an  unmarried  woman  of  24  years.  Tnis  case 
is  reported  as  one  of  hysteria  major.  The  sensation  was 
normal  in  the  head  and  neck  anteriorly  and  posteriorly. 
There  was  tactile,  thermic  and  pain  analgesia  from  the  collar- 
bone to  just  above  the  nipples  in  front,  and  over  an  equal 
area  in  the  back,  both  shoulders  and  arms  being  included  in 
anesthetic  area.  On  the  front  of  the  body  the  sensation  was 
normal  from  the  nipples  down,  along  the  line  of  the  body  to 
the  tenth  rib,  where  an  area  of  extreme  hyperesthesia 
began  and  extended  to  the  groins.  On  the  back  normal  een- 
sation  extended  from  the  lower  angles  of  the  scapula  to  the 
gluteal  folds,  except  at  two  small  points  just  below  the  scapula 
which  were  extremely  sensitive.  In  other  words  they  were 
hysterogenic  zones.  Electrical  stimulation  of  these  tpots 
immediately  developed  an  hysterical  attack.  Tne  limbs, 
including  the  feet,  were  devoid  of  all  sensation.  A  deep 
puncture  with  a  large  needle  produced  no  evidence  of  feeling. 
The  upper  limit  of  this  condition  being  the  groin  in  front  and 
the  gluteal  fold  in  the  back.  Contrary  to  what  is  usual  in 
such  caf-es,  puncture  with  a  surgical  needle  was  followed  by 
some  blood  ecchymosis,  though  the  skin  presented  the 
u?ual  pale  appearance.  The  line  between  the  sensitive  and 
insensitive  areas  was  sharply  defined,    [t.lc] 


Medical  Record, 

February  16,  1901.     [Vol.  59,  No.  7.] 

1.  The  Problem  of  Anpendjcitis  from  the  Medical  and  Sur- 

gical Points  of  View.     Robert  Abbe. 

2.  The  Causes  of  Failure  of  Compensation  in  Dieeaees  of  the 

Heart.    Morris  Manges. 
2.  Strabismus  and  its  Management.    J.  H.  Woodward. 

1.— Robert  Abbe  discusses  the  problem  of  appendicitis 
from  the  medical  and  sargrical  points  of  view.    He 

presents  for  careful  study  a  number  of  specimens  selected 
from  several  hundred  and  arranged  in  groups  of  10  to  illus- 
trate important  points  of  diflerence.  These  specimens  pre- 
sent respectively  single  strictures,  multiple  strictures,. those 
in  which  concretions  have  formed,  another  in  which  a 
partial  sealing  of  the  canal  had  occured  with,  however,  a 
remnant  of  the  canal  remaining,  to  produce  further  trouble. 
One  or  2  cases  of  the  series  are  interesting  in  illustrating  the 
fact  that  even  a  completely  obliterated  cavity  may  leave  an 
atrophied  appendix  which  is  the  seat  of  a  painful  neuralgia 
requiring  its  removal.  One  series  shows  a  f  mall  follicular 
ulcer.  The  idea  embodied  in  the  word  catarrhal  ap- 
pendicitis is  a  correct  one  in  the  very  early  stages  in  the 
morbid  condition.  Excluding  the  rarer  cases  when  foreign 
bodies  are  entrapped,  or  in  which  the  kinking  of  the 
appendix  from  its  short  mesentery,  the  origin  of  the 
stricture  is  found  in  1  of  2  causes,  septic  aud  linear 
ulcer  or  the  contraction  of  the  catarrhal  iutia- 
matlon,  antedating  this  stricture  by  many  years.  From 
this  study  it  may  be  said  with  certainty  that  the  first 
attack  of  appendicitis  recognized  by  the  patient  is  in  most 
cases  the  end  of  the  disease,  for  the  appendix  shows  the 
presence  of  a  stricture  which  may  have  existed  for  many 
years.  The  most  complete  experience  clinically  of  the  vari- 
ations in  the  symptoms  is  often  required  to  differentiate 
between  the  disease  in  question  and  so  unlike  a  malady  as 
typhoid  fever.  The  latter  study  of  leukocytosis  throws  much 
light  upon  the  differential  diagnosis.  Abbe  concludes  that 
attacks  may  often  be  cured  by  natural  methods ;  that  a  long 


respite  does  not  mean  a  cure,  and  that  it  is  impossible  to  pre- 
dict a  cure;  and  finally, that  unless  the  appendix  is  removed, 
the  disease  is  always  latent  where  once  it  is  begun,     [t.l  c] 

2. — Morris  Manges  discusses  the  causes  of  failure  of 
compensation  in  diseases  of  the  heart.  He  prefaces 
his  article  with  a  resum^  of  the  opinions  of  authorities  on 
this  Butject,  and  clinically  groups  the  causes  of  the  condition 
as  follows:  (1)  Failure  of  general  nutrition  of  the  body; 
(2)  disturbance  of  local  nutrition  of  the  heart ;  (3)  incresised 
work  of  the  heart ;  (4)  functional  cardiac  disorder ;  (5)  effects 
of  improper  treatment.  These  causes  are  discussied  under 
their  respective  captions,    [t.l  c] 


Medical  News. 
Febniary  16,  1901.     [Vol.  lixviii,  No.  7.] 

1.  A  Hair-Cast  of  the  Stomach ;  its  Successftil  Removal  by 

Laparotomy.    Nathas  Jaoobson. 

2.  Scurvv  and  Rickets  in  Young  Children.    H.  A.  Hare. 

3.  The  Relation   of  Tuberculosis    to    the  Tenement-house 

Problem.    Arthur  R.  Guerard. 

4.  Treatment  of  Lupus.    H.  Rockwell  Vabney. 

5.  A  Report  of  Some  Cases  of  Abdominal  Surgery,  with 

Remarks  on  the  Diagnosis  of  Carcinoma  of  the  Cecum 
and  the  Surgical  Treatment  of  Carcinoma  of  the  Liver 
and  Gallbladder.    Charles  Greese  Ccmston. 

1. — Jacobson  reports  a  very  interesting  case  of  a  young 
girl,  11  years  of  age  from  whose  stomach  he  removed  a 
large  hair-cast.  For  about  two  years  prior  to  the  operation 
the  patient  had  suffered  from  considerable  gastric  disturbance 
and  pain.  Frequent  vomiting  was  also  present.  About  a 
year  before  the  operation,  a  cucumber-shaped  swelling  was 
noticed  in  the  upper  pirt  of  the  abdomen  The  attacks  of 
pain  became  so  frequent  that  the  patient  lived  largely  on 
milk.  She  appeared  much  younger  than  she  was,  was  thin, 
ill-nourished  and  quite  nervous.  Nothing  abnormal  was 
found  about  the  abdominal  viscera,  but  a  large,  hard, 
slightly  nodular  tumor  could  be  palpated  above  the  um- 
bilicus. In  shape  it  was  somewhat  like  a  kidney  and  freely 
movable.  No  definite  diagnosis  was  made.  Tne  abdo- 
men was  opened  and  the  tumor  was  found  to  be  within  the 
stomach  which  was  opened  and  a  large  hair- cast  was  removed. 
Both  wounds  were  closed.  The  patient  recovered  from 
the  operation  and  admitted  that  during  all  her  life  she  had 
bitten  off  and  swallowed  her  hair.  At  first  she  did  this  be- 
cause she  was  nervous,  but  later  bscause  she  rather  liked  the 
tickling  sensation  produced  by  the  hair  in  its  transit  to  the 
stomach.  The  tumor  was  6  inches  long,  hswl  much  the  shape 
of  the  stomach,  was  about  i\  inches  thick  and  about  2J 
inches  in  breadth.  It  weighed  15  ounces.  The  pyloric  end 
extended  into  the  stomach.  Full-sized  photographs  of  the 
mass  accompany  the  article.  Jacobson  referred  to  the  fre- 
quency of  this  condition  in  animal.',  particularly  in  the  cow, 
and  then  discueses  19  cases  which  have  been  reported  as 
occurrirg  in  human  beings.  In  several  instances  intestinal 
obstruction  followed  the  presence  of  a  hair  ball,  with  perfo- 
ration and  death.  None  of  the  patients  were  insane,  but  a 
number  were  described  sis  hysterical.  The  stomach  in  a 
number  of  instances  tolerated  the  foreign  body  without  re- 
bellion. In  one  cafe  the  mass  of  hair  weighed  5  pounds  and  3 
ounces.  In  one  case  there  were  two  masses  of  hair  found  in  the 
stomach.  Of  the  19  rep"r:ed  cases  10  were  discovered  post- 
mortem and  9  upon  the  operating  table.  In  no  case  was  a 
diagnosis  made.  Because  of  the  movability  and  shape  of 
the  tumor  it  has  often  been  mistaken  for  a  movable  kidney. 
Jacobson  finds  in  one  other  Cise  the  regular  recurrence  of 
pain  at  n'ght  from  which  his  own  patient  suffered.  In  nearly 
every  case  it  was  not  discovered  that  the  patient  was  a 
hair  eater  until  after  the  foreign  mass  had  been  removed. 
In  most  of  the  fatal  cases  death  resulted  from  perforative 
peritonitis.  There  was  not  a  single  death  in  the  9  cases  oper- 
ated upon.     [j.H.Q  ] 

2. — H.  A.  Hare  mentions  the  frequency  with  which 
scurry  in  infancy  is  mistaken  for  acute  articular  rheu- 
matism and  mentions  as  a  point  of  differential  diagnoeis 
the  rarity  of  articular  rheumatism  in  the  first  5  years  of  life. 
A  frank  case  of  scurvy  is  easy  of  recognition,  but  many 
atypical  cases  are  found.    He  describes  3  cases,  the  first  in 


Febrcart  23,  1901] 


THE  LATEST  LITERATURP: 


PThk  Philadelfbia 
1_  Mkdical  Journal 


379 


which  the  child  cried  bitterly  every  time  it  was  moved,  par- 
ticularly if  the  movement  involved  the  change  in  the  position 
of  his  back;  An  orthopedic  surgeon  believed  that  spinal 
disease  was  present,  and  a  line  of  mechanical  treatment  was 
followed.  No  beaefit  was  observed,  but  after  a  time  scurvy 
was  diagnosed,  and  under  proper  treatment,  cure  followed. 
His  second  caae  also  presented  similar  symptoms  of  spinal 
trouble,  but  careful  examination  of  the  child  revealed  the 
fact  that  its  gums  were  slightly  spongy,  and  no  evidence  of 
disease  in  its  spine,  joints,  or  head  could  be  demonstrated, 
the  diagnosis  of  probably  ecurvy  was  made,  and  cure  rapidly 
followed  the  treatment  instituted.  The  third  case  was  that 
of  a  child  who  suflfered  at  the  end  of  its  first  year  with  almost 
complete  paraplegia.  It  was  plump,  but  pallid,  and  its  gums 
and  mouth  presented  the  characteristic  scorbutic  symptoms. 
This  child  had  been  fed  upon  the  best  cow's  milk  with  the 
addition  of  well  known  form  of  artificial  infant  food,  and 
scurvy  had  not  been  considered  possible.  However,  under 
the  proper  dietetic  regimen  a  speedy  cure  followed  with  total 
disappearance  of  all  the  paraplegic  symptoms.  Hare  points 
out  that  scorbutus  in  infancy  is  a  disease  of  the  children  of 
the  well- to-do,  in  distinction  from  rickets  which  on  the  other 
hand  seems  to  be  the  disease  of  the  poor,    [t  i.e.] 

3. — Guerard  discusses  the  relation  of  tuberculosis  to 
the  tenement- house  problem.  He  emphasizes  the 
deleterious  effects  of  poor  ventilation,  lack  of  sunlight  and 
the  effects  of  overcrowding.  He  points  out  the  repeatedly  ob- 
served fact  that  in  many  instances  tuberculosis  occurs  again 
and  again  in  the  same  house.  He  has  carefully  studied  the 
maps  and  records  of  the  New  York  City  Board  of  Health,  in 
the  Fourth  and  Sixth  Wards  of  the  City  and  he  found  that 
38%  of  the  total  number  of  dwellings  had  cases,  including 
deaths,  of  consumption  reported  from  them  during  the  years 
1894, 1895  and  1896.  Of  these  cases  one-half  occurred  in 
23%  of  the  affected  houses,  this  being  but  9%  of  all  the 
dwellings  in  the  wards.  One- fourth  of  the  houses  had 
apparently  become  permanently  infected  as  shown  by  a 
repetition  of  three  or  more  cases  in  them  in  the  three  years. 
In  some  houses  as  many  as  eight  cases  occurred.  Daring  a 
period  of  eight  years  previous  to  1897, 136  cases  were  reported 
in  12  houses,  and  he  estimates  that  200  or  more  cases  of  con- 
sumption, or  an  average  of  about  twenty  per  house,  had 
occurred  in  these  twelve  houses  in  the  eight  years.  These 
particular  wards  were  studied  on  account  of  the  dense  popu- 
lation and  poor  surroundings.  He  believes  that  much  can 
be  di)ne  by  enforcing  landlords  to  observe  the  following  re- 
quirements :  1  To  make  ample  and  suitable  water  closet 
provision  for  the  number  of  persons  to  occupy  the  house. 
2.  To  supply  each  set  of  apartments  with  a  separate  water 
Bupoly  and  bath.  3.  To  provide  separate  storage  for  coal. 
4.  To  provide  sufficient  means  for  was-hing  clothes.  5  To 
provide  pantry  accommodation  for  the  keeping  of  food.  The 
city  itself  can  do  much  to  ameliorate  the  condition  of  its 
poor  by  establishing  public  baths  and  wash-houses  as  well  as 
providing  public  squares  and  breathing  spacer.  The  infected 
nouses  should  be  razsd  and  building  laws  more  stringently 
enforced.  Iq  a  table  appsnded  to  this  article  it  appears  that 
the  deaths  from  phthisis  constitute  about  one  eighth  the 
deaths  in  New  York  City,  and  about  91  'fo  of  these  cases  occur 
between  the  ages  of  16  and  65.     [t.l  c.J 

4. — Varney  discusses  the  treatment  of  lupus  by  the 
x-ray.  In  passing  the  x  ray  through  the  spectroscope  one 
sees  at  the  chemical  end  of  the  spectrum  a  combination  of  2 
of  the  primary  colors,  red  and  blue  or  ultra  violet.  He  be- 
lieves that  it  is  by  the  action  of  the  strong  chemical  colors 
that  the  stimulating  influence  on  the  tissues  is  produced. 
This  is  the  same  principle  as  that  devised  by  Finsen  in  which 
he  uses  the  ultraviolet  rays  of  white  light  The  results  are 
about  the  same  except  the  x-ray  is  somewhat  more  rapid  in 
its  action  with  shorter  exposures,  and  larger  areas  may  by 
treated  at  a  sitting.  The  treatment  of  lupus  by  the  x  ray 
is  painless,  its  exposures  are  of  short  duration,  and  the  area 
treated  may  be  of  any  size  or  location.  There  is  no  scar  from 
the  treatment  if  the  exposure  is  properly  conducted.  The 
time  of  exposure  is  regulated  by  the  density  of  the  rays 
and  the  results  are  evident  with  much  less  scarred  tissue. 
[t.l  c] 

6. — The  next  case  reported  by  Cumtton  was  one  of  car- 
cinoma of  the  cecum  complicated  by  appendicitis. 
The  patient  was  a  woman,  48  years  of  age,  who  suffered  from 
attacks  of  appendicitis,  for  the  relief  of  which  a  diseased  and 


adherent  appendix  was  removed.  The  operation,  however, 
did  not  relieve  the  patient's  suffering,  but  the  symptoms 
increased  with  loss  of  flesh  and  symptoms  of  obstruction  of 
the  bowels.  A  second  operation  was  done,  an  annular  carci- 
noma of  the  colon  was  found,  but  the  patient's  condition  was 
not  such  as  to  stand  a  resection  and  an  anastomosis  and 
hence  an  artificial  anus  was  formed.  The  patient  died  a  few 
hours  later.  The  symptoms  of  carcinoma  are  summarized 
as  pain,  alternating  diarrhea  and  constipation,  loss  of  flesh, 
dyspeptic  disturbances,  and  intestinal  hemorrhage.  Physical 
signs  are  absent,  of  course,  at  the  onset  of  the  disease,  but 
later  a  movable  tumor  can  be  palpated  which  finally  becomes 
fixed.  Eiemaof  the  leg  may  follow  from  compression  of  the 
iliac  vein.  The  next  case  is  one  of  carcinoma  of  the 
gallbladder  with  secondary  deposits  in  the  liver,  which 
followed  within  a  year  an  operation  for  the  removal  of  gall- 
stones, which  was  entirely  satisfactory.  la  this  case  Cumstoa 
removed  the  gallbladder  and  a  large  portion  of  the  liver. 
About  two  years  after  the  operation,  the  patient  showed 
symptoms  of  extensive  malignant  disease  of  the  liver. 
Cumston  thinks  that  extirpation  of  the  gallbladder  is  justifi- 
able only  in  the  presence  of  malignant  disease  or  of  severe 
inflammatory  lesions,     [j.h  g.] 


Boston  Medical  and  Surgical  Journal. 

February  U,  1901.     [Vol.  cxliv,  No.  7.] 

1.  A  Case  of  Cesarean  Section  for  Complete  Placenta  Previa. 

C.  H.  Hare 

2.  The  Woolen  Yarn  Truss  in  Infantile  Inguinal  Hernia.    E. 

S.  BOI.AND. 

3.  Disinfection  Within  and  Without  the  Body  in  Diphtheria. 

M.  A.  Veeder. 

1. — Hare  reports  the  case  of  a  woman,  aged  27  years,  who 
was  having  alarming  hemorrhages  from  placenta  previa. 
A  cesarean  section  was  done,  and  a  living  female  fetus 
was  delivered.  The  patient  died  11  hours  after  the  opera- 
tion, and  the  baby  died  in  13  days  of  inanition,     [j  m  s  ] 

3. — Roland  advises  the  use  of  a  woolen  yarn  truss  for 
the  retention  of  infantile  inguinal  hernia,     [j.m  s  ] 


Journal  of  the  American  Medical  Association. 

February  16,  1901.    [Vol.  xxvi,  No.  7.] 

1.  The  Major  Obstetrical  Operations.    From  the  Standpoint 

of  the  General  Practitioner,  with  a  Tabular  Report  of 
23  Consecutive  Successful  Cases.    Edward  Reynolds. 

2.  Treatment  of  Sessile  and  Certain  other  Ofarian  Cysts. 

H.  B.  Stehman. 

3.  Paralysis  Agi tans  Without  Tumors.  AuQUSTOS  A.  Eshner. 

4.  New  Methods  for  the  Application  of  old  Principles  in  the 

Treatment  of  Fractures  and  Deformities   of   Limbs. 
James  G.  Hoghes. 

5.  Possibilities  of  Liquid  Air  to  the  Physicians.    A.  Camp- 

bell White. 

6.  Movements  of  the  Intestines.    Albert  Bernheim. 

7.  The  Etiologv  of  Yellow   Fever.    An  Additional    Note. 

Walter  Reed,  James  Carroll  and  Aristides  Agra- 

MONTE 

8.  The  Metric  System.    Frank  G  Wheatley. 

9.  Ewlution  and  Involutional  Types  of  Mental  and  Nervous 

Diseases.    Edward  E.  Mayer. 
10.  Anastomosis  of  the  Ureters  with  the  Intestine.    A  His- 
torical and  Experimental  Research.    Reuben  Peter- 
son. 

1.— Reynolds  discusses  the  major  obstetrical  opera- 
tions from  the  standpoint  of  the  neneral  practitioner.  The 
operations  to  be  considered  in  all  of  these  cases  of  pelvic 
contraction  are  forceps,  version,  induction  of  premature 
labor,  craniotomy,  the  cesarean  section  with  or  without 
extirpation  of  the  uterus,  and  symphysiotomy.  The  choice 
between  these  must  always  be  determined  by  a  consideration 
of  their  respective  maternal  and  fetal  mortality,  under  the 
conditions  of  the  individual  case.  The  conclusions  to  which 
he  has  been  forced  by  his  study  of  the  subject  are  as  follows  : 


380 


The  Philadelphia"! 
Medical  Jogbnal  J 


THE  LATEST  LITERATURE 


[Feeecaet  23,  1901 


1.  When  the  conditions  are  such  that  the  child  can  be 
delivered  with  anything  like  resonable  ease  by  forceps  or 
version  ;  one  of  these  operations  is  preferable  to  any  cutting 
operation.  2.  When  the  mechanical  relations  would  render 
forceps  or  version  unusually  difficult,  forcible,  and  prolonged  ; 
and  when  the  mother  is  in  the  favorable  class,  the  equally 
low  maternal  mortality  and  the  far  lower  fetal  mortality 
of  the  cesarean  section  render  it  the  operation  of  choice. 
3.  When  the  mechanical  conditions  make  the  intrapelvic 
delivery  of  an  intact  child  at  term  impossible,  or  unduly 
difficult,  the  great  superiority  of  the  cesarean  section  over 
the  induction  of  premature  labor  in  fetal  mortality,  and  its 
extremely  low  maternal  mortality,  render  it  again  the  prefer- 
able operation.  4.  When  the  ordinary  operations  fail  and 
the  woman  is  in  the  unfavorable  class,  symphysiotomy  is  the 
operation  of  choice,  and  may  be  eipectf  d  to  lead  to  a  favor- 
able result  for  both  mother  and  child  in  the  great  majority  of 
cases,  provided  always  that  the  deerree  of  mechanical  diffi- 
culty permits  of  its  application.  5.  When,  in  the  unfavorable 
class  of  cases,  the  degree  of  relative  disproportion  between 
head  and  pelvis  is  too  great  to  admit  of  a  safe  symphysi- 
otomy, craniotomy  to  the  living  child  should  be  unhesi- 
tatingly chosen,  since  the  maternal  mortality  of  either  form 
of  the  section  is  so  enormous,  and  because  the  life  of  the 
potential  mother  of  many  children  is  of  more  value  than  that 
of  any  unborn  fetus,    [wand.] 

2.— In  his  paper  on  the  treatment  of  sessile  and  other 
ovarian  cysts,  Stehman  gives  the  clinical  results  of  a 
method  which  he  claims  is  simple,  applicable  in  a  certain 
percentage  of  these  cases,  and,  so  far  as  he  knows,  not  usually 
employed.  Then  nonpedicular  cysta  of  the  female  adnexa 
as  a  rule  develop  either  from  the  ovary — paroophoron — or 
the  parovarium;  for  the  most  part  they  grow  between  the 
layers  of  the  broad  ligaments,  and  thus  are  in  intimate  rela- 
tion with  the  cellular  tissue,  vessels,  ureter,  and  bladder 
beneath  and  in  front;  the  muscular  and  serous  coats  of  the 
broad  ligaments  and  ovary  on  the  sides;  and  the  superim- 
posed tube  and  peritoneum  above.  His  method  includes 
the  following  steps:  After  carefully  walling  off  the  intestines, 
the  cy6t  is  afpirated  and  about  three-fourths  of  the  col- 
lapsed wall  removed ;  the  interior  of  the  remainder  is  thor- 
oughly painted  with  tincture  of  iodin  and,  by  the  aid  of  a 
long  dissecting  forceps  and  needle-holder,  the  marginal  ends 
are  turned  in  with  an  ovf  r-and-over  continuous  stitrh.  The 
abdominal  wound  is  then  sutured  and  sealed.  He  claims 
that  recovery  after  this  operation  is  ideal,     [w.a  n.d  ] 

3.— Eshner  in  an  article  on  paralysis  agitans  reports  2 
cases  in  whom  the  tremor  was  the  least  conspicuous  of  the 
Symptoms.  In  the  2  cases  the  tremor  was  almost  wholly 
absent  and  at  times  was  very  inconspicuous.  In  concluding 
the  article  he  states  that  this  disease  may  be  unaf.ended  by 
tremor,    [f  j  k  ] 

4.— Hughes  advocates  the  ambulatory  treatment  of 
fractures  of  the  thigh  and  leg  and  of  certain  cases  of 
coxalgia  and  illuftrates  his  article  with  cuts  of  an  apparatus 
which  he  has  devised  and  found  useful  in  these  cases. 
[j.H  G  ] 

6.— White,  in  discussing  the  possibilities  of  liquid  air 
to  the  physician,  tells  of  the  manifold  uses  of  this  new 
therapeutic  agent.  In  the  treatment  of  abscesses  the  author 
believes  that  liquid  air  is  to  be  preferred  to  any  other  form 
of  local  anesthesia.  He  also  recommends  it  in  the  treat- 
ment of  carbuncles,  in  the  treatment  of  lupus  and  as  a  ttini 
ulant  for  chronic  ulcers.  The  cauterizing  effect  is  especially 
to  be  applied  in  the  treatment  of  early  epithelioma  of  the 
lip  and  even  in  some  cases  of  nonoperative  epithelioma  cure 
may  follow  its  application,     [f  j  k.J 

6.— In  an  article  on  movement  of  intestines  by  Bern- 
heim  the  following  interetting  case  is  reported  :  An  enema  of 
cottonseed  oil  was  administered  to  a  woman  suffering  from 
floating    kidney,   nervousness  and   general   debility.      Five 
hours  after  the  injection  the  patient  vomited  the  oil.    He 
gives  an   account  of  the  work    performed  in  this  line  by 
various  investigators.    The  experiments  of  Bernheim  show 
that  antiperistaltic  motions  of  the  intestine  may  be   pro- 
duced by  the  injection  into  the  large  bowel  of  certain  sub- 
stances.   He  concludes  by  saying  that  nutritive  enemata  and 
the  irjection  rf  medicine  by  rectum  may  be  practised  with 
good  results,     [f  j  k  ] 
7, — Cnnsideied  fditorially. 
8.— Wheatley,  in  an  article  on  the  metric    system. 


gives  his  reasons  why  this  system  should  be  of  general  use 
in  medicine  and  pharmacy,     [p  j  k  ] 

9.— Evolutional  and  involutional  types  of  mental 
and  nervous  disease  are  discussed  by  Mayer.  He  described  at 
some  length  the  different  epochs  of  life  as  beins  of  import- 
ance in  the  production  of  nervous  instability.  He  considcra 
the  influence  of  childhood  from  many  points  of  view.  Then 
he  passes  to  the  influences  of  the  age  prior  to  puberty,  the 
period  of  puberty,  that  of  the  adult,  and  finally  considers  the 
changes  dependent  upon  the  senile,    [f.j.k.] 

lO. — To  be  treated  editorially  in  the  next  issue  of  the 

JODHNAL. 


Journal  of  Nervous  and  Mental  Diseases. 

January,  1901.    [Vol.  xiviii,  No.  1.] 

1.  Diffuse  Degeneration  of  the  Spinal  Cord.    James  J.  Pdt- 

NAM  and  E.  W.  Tayloe. 

2.  Report  of  a  Case  of  Brain  Injury,  with  Peculiar  Whist- 

ling Spells  Following  Operation.      William  C.  Kracs. 

3.  Brush  Massage.    Frank  R.  Fry. 

1. — Putnam  and  Taylor  present  Ba'tianelli's  classification, 
making  two  groups  of  degenerative  spinal  lesions  in  connec- 
tion either  with  pernicious  anemia  or  with  the  more  chronic 
forms  of  malnutrition,  between  which  the  line  of  separation 
is  not  to  be  too  sharply  drawn.  In  the  first  group  it  is  the 
anemia  which  dominates ;  the  spinal  lesions  mai^e  them- 
selves felt  only  towards  the  end  of  life,  when  they  develop 
with  great  rapidity.  In  the  second  group,  in  which  the  more 
chronic  cases  belong,  including  most  of  those  reported  by 
various  authors,  the  disease  is  one  of  the  nervous  system,  the 
malnutrition  being  of  secondary  importance.  Disease  of  the 
central  nervous  system,  in  cases  of  the  second  g^oup,  occa- 
sionally strikes  beyond  the  limits  of  the  spinal  cord,  involv- 
ing the  optic  nerves.  The  anatomical  lesions  differ  some- 
what in  character.  In  cases  of  the  first  group,  according  to 
Bastianelli,  they  are  relatively  slight  and  scattered,  and  the 
lateral  columns  in  particular  are  relatively  little  affected, 
while  in  the  second  group  they  are  more  pronounced  and 
the  lateral  columns  more  sharply  and  extensively  involved. 
Bastianelli  also  found  (hat  lesions  of  the  bloodvessels  are  less 
marked  in  the  typical,  quasisystematic,  whole  column  de- 
generations. Putnam  and  Taylor  do  not  altogether  agree 
with  Bastianelli,  saying  that  his  observations  are  not  ftilly 
maintained  by  theirs,  and  that  they  do  not  find  it  to  be  in- 
variably true  that  in  the  more  chronic  cases  in  which  the 
nervous  symptoms  have  played  an  important  part  for  manv 
years,  the  spinal  lesions  are  necessarily  most  marked. 
[t.m  t  ] 

3. — Kraus  reports  the  case  of  a  man  27  years  old,  a  herds- 
man in  a  stock}'ard,who  some  time  previous  to  the  accident, 
had  a  stroke  of  apoplexy,  resulting  in  hemiplegia  of  the  left 
side  of  the  body  with  partial  recovery.  He  was  struck  by  a 
train,  receiving  three  scalp  wounds,  one  2  inches  long  over 
the  occiput,  one  2J  inches  long  over  the  left  parietal  emi- 
nence, and  another  2  inches  long  over  the  left  frontal  region. 
In  addition,  he  sustained  a  depressed  fracture  of  the  skull, 
3  inches  above  and  1  inch  behind  the  left  ear.  After  tre- 
phining and  removing  the  depressed  bone  during  the  night 
the  patient  began  to  whistle  as  he  had  been  accustomed  to 
do  when  driving  cattle,  continuing  for  1  miLute  and  ceas- 
ing for  5  to  10  minutes,  keeping  it  up  at  regular  intervals 
until  he  died,  4  days  after  the  accident.  There  was  complete 
loss  of  control  over  bladder  and  rectum :  no  increase  in 
temperature,  and  pulse  slightly  lowered,    [t  m  t  ] 

3. — Fry  recommends  the  use  of  brush  massage  in  prefer- 
ence to  the  ordinary  massage,  and  says  that  in  this  method 
the  brush  is  kept  in  contact  with  the  skin  and  manipulated 
with  a  combined  circumlatory  and  creeping  movement,  with 
varying  degree  of  rapidity  and  pressure.  It  adheres  to  the 
skin,  drawing  with  it  the  superficial  structure  in  a  way  that 
can  hardly  be  described.  Amplitude  of  the  different  move- 
ment depends  much  on  the  length  of  bristles  and  spring  of 
the  brush.  The  combined  or  special  movement  almi">st  im- 
parts itself  to  the  hand  of  the  operator  or  can  be  easily 
acquired.  0.ie  of  the  advantages  of  this  massage  is  that  you 
can  obtain  operators,  and  even  people  of  mof^erate  means 
can  avail  themselves  of  the  trial.  It  is  also  effective  in  the 
heaviest  work  for  which  massage  is  used,    [t.m.t.] 


Fbbroary  23,  1901] 


THE  LATEST  LITERATURE 


The  Philadelphia"] 
Medical  Journal  J 


381 


Berliner  klinische  Wochenschrift. 

December  31,  1900.     [37.  Jabrg.  No.  53.] 

1.  Experimental  Contribution  to  our  Knowledge  of  Alopecia. 

A.  BrscHAE. 

2.  On  tbe  Transformation  in  the  Urine  of  Substances  Agglu- 

tinating the  Blood  Corpuscles.    E.  Friedberqer. 

8.  A  Grave  Spinal  Symptom-Complex  Caused  by  a  Serpen- 
tine Aneurysmal  Change  in  the  Spinal  Bloodvessels. 
E.  Brasch. 

4.  On  the  Simplification  of  the  Phenylhydrazin-Test  for 
Sugar.     A.  NEUMiNN. 

1. — Two  patients  who  had  been  given  thallium  acetate  for 
the  night  sweats  of  phthisis  developed  areas  of  alopecia. 
This  lead  the  author  to  make  some  experimental  investiga- 
tions with  this  drug.  He  found  that  feeding  white  mice  with 
thallium  acetate,  alopecia  could  be  produced,  but  only  by 
a  constitutional  effect,  as  local  application  of  the  drug  did 
not  produce  the  same  results,     [m.e  d.] 

3. — In  experimenting  upon  guineapigs,  Friedberger  found 
that  in  a  guineapig  whose  blood-serum  caused  the  ery- 
throcytes of  the  pigeon  to  agglutinate  and  then  dissolve,  that 
■the  urine  of  the  animal  also  possessed  that  power.  Also  in  a 
rabbit  that  had  been  immunized  against  pigeon  blood,  the 
urine  showed  this  property,  but  naturally  to  a  less  degree 
than  the  blood  of  the  animal.  The  experiments  are  still  in 
process,  but  so  far  it  appears  that  the  substances  of  the  blood 
causing  the  agglutination  also  enter  the  urine,  [m.r  d.] 

3. — The  author's  patient  presented  a  clinical  symotom- 
complex  which  was  strongly  suggestive  of  tabes.  Micro- 
scopic examination  showed  dilatation  and  tortuosity  of 
the  arteries  in  a  portion  of  the  spinal  cord  together  with 
hypertrophy  of  the  vessel  walls.  The  cord  itself  in  the 
lower  dorsal  and  lumbar  regions  was  the  eeat  of  chronic  de- 
generation, and  also  in  the  higher  portions  of  the  cord 
especially  in  the  posterior  and  lateral  tracts,  as  well  as  in  the 
anterior  cornua.  Together  with  these  changes  the  author  at  the 
postmortem  examination  found  a  cardiac  hypertrophy  with 
a  coexisting  conti  acted  kidney.  The  chronic  rise  in  arterial 
pressure  seemed  to  be  etiologically  responsible  for  the  thick- 
ening in  the  walls  of  the  vessels,  thus  influencing  the  nutri- 
tion of  the  spinal  cord.  ■  In  addition  to  these  spinal  lesions 
secondary  lesions  were  also  found,  and  were  recognized  as 
marked  ascending  degeneration  of  the  colums  of  Goll. 
[m.e.d  ] 

4.— See  Philadelphia  Medical  Journal,  Vol.  VII,  No.  5, 
page  211. 

January  7, 1901.    [38.  Jahrg.,  No.  1.] 

1.  Gallstones.    Riedel. 

2.  The  X  rays  in  Practical  Medicine.    H.  Kummell. 

3.  The  Modern  Efforts  at  Colonizition  and  the  Adaptability 

of  Europeans  to  the  Tropics.    F.  Hueppe. 

4.  Report  of  the  Roval  Policlinic  for  Pulmonary  Diseases  in 

Berlin  from  November  15,  1899,  to  November  15, 1900. 

M.  Wolff. 
1. — Will  be  abstracted  when  concluded. 
2. — Will  be  abstracted  when  concluded. 
3. — Will  be  abstracted  when  concluded. 


Wieaer  klinische  Wochenschrift, 

January  10, 1901.     [14.  Jahrg.,  No.  2.J 

1.  The  "Boas- Kaufmann  "  Bacilli  in  Diseases  of  the  Stom- 

ach,   with    Remarks    upon    other    Bacteria   Found. 
Rudolph  Schmidt. 

2.  The  Crossed  Sciatic  Phenomenon.    J.  Fajeesztajn. 

3.  The  Cardiorenal  Theory.    Otto  Gross. 

4.  Cod-Liver  Oil  with  Phosphorus.    Zweifel. 

5.  Reply    to     Dr.    Knapp's    "  Aseptic    Bougie."      Leopold 

Scherbek. 

1. — Schmidt  gives  a  detailed  description  of  the  Boas- 
Kaufmann  ba«illi,  long,  thread-like  microorganisms,  so 
often  found  in  stomachs  in  which  carcinoma  exists,  with  a 
review  of  the  literature.  Then  his  own  experiments  follow. 
When  blood  was  added  to  cultures  of  this  bacillus,  its  growth 
rapidly  increased.    That  it  is  rarely  found  in  the  stomach 


contents,  in  benign  conditions,  may  be  due  to  the  absence 
of  blood  in  the  stomach.  The  various  causes  which  seem  to 
favor  its  occurrence,  are  stagnation  of  the  stomach  contents; 
absence  or  decrease  in  the  production  of  hydrochloric  acid  ; 
absence  of  fermentation  ;  erosion  of  the  upper  surface  of  the 
stomach;  the  presence  of  albumin  detritus  and  blood,  fol- 
lowing ulceration.  He  reports  a  case,  a  laborer,  aged  37 
years,  who  had  had  stomach  symptoms  over  8  years.  He 
had  attacks  of  pain,  often  lasting  days,  generally  more  fre- 
quent in  the  winter.  The  pain  was  near  the  pylorus,  and 
worse  at  night,  and  he  could  not  lie  on  the  right  side  while 
it  lasted.  With  constipation  the  attacks  grew  worse ;  after 
vomiting  or  lavage,  they  improved.  This  was  undoubtedly  a 
case  of  benign  stenosis  of  the  pylorus,  probably  due  to  a 
cicatrizing  ulcer.  The  cultures  from  the  stomach  showed 
pseu do  lactic  acid  bacilli  and  other  flora.  Then  he  reports 
a  case  of  a  man  of  63,  who  suffered  from  stomach  trouble  for 
13  years,  accompanied  with  much  flatulence.  From  the 
stomach  contents  a  pure  culture  of  the  bacterium  coli  grew, 
but  no  lactic  acid  or  Boas  Kaufmann  bacilli.  The  case  was 
one  of  carcinoma  ventriculi.  The  colon  bacilli,  he  explains, 
may  have  come  from  the  oral  secretion,  following  their  in- 
gestion with  food  or  drink ;  or  they  might  have  come  from 
the  duodtnum.    [mo  ] 

2.— First  he  explains  that  "  Lisegue's  sign  "  in  sciatica 
is  the  fact  that  the  affected  thigh  can  be  flexed  at  the  hip 
without  pain,  when  the  lower  leg  is  flexed  at  the  same 
time;  but  when  the  lower  leg  is  kept  straight,  flexion  of 
the  thigh  at  the  hip  causes  intense  pain.  After  reviewing 
the  literature  of  the  suKject,  he  says  that  this  phenomenon 
is  due  to  the  stretching  of  the  sciatic  nerve.  Fajersztajn 
has  noted  that  besides,  a  crossed  phenomon  exists  in  most 
cases  of  sciatica;  when  the  well  leg  is  raised,  with  the 
lower  leg  straight,  pain  is  felt  in  the  sciatic  nerve  of  the 
other  side,  near  its  exit  in  the  buttock.  He  explains 
this  theoretically,  by  supposing  that  stretching  the  well 
nerve  causes  pain  in  the  affected  nerve.  Hs  details  experi- 
ments upon  the  cadaver  to  prove  this.  He  found^this  new 
sign  in  25  out  of  41  cases,  doubtful  in  5  others.  All  were 
rheumatic  sciatica,     [m.o.] 

3.— Gross  compares  the  Epstein-Schwalbe  work  with 
Norden's,  and  finds  that  they  disagree,  the  former  advocating 
the  ingestion  of  much  liquid  in  cardiorenal  affections, 
the  latter  restricting  the  liquid  relatively  to  the  amount  of 
heart  weakness.  Lavage  is  thus  a  two-eJged  sword,  increas- 
ing elimination,  but  overtaxing  the  heart-muscle.  He 
advises  lavage  only  when  the  heart  muscle  is  not  badly 
affected,    [mo] 

4.— Zweifel,  whose  feelings  seem  much  hurt  by  the  unjust 
criticism  of  Kassowitz,  whose  cod-liver  oil  with  phos- 
phorus, as  Zweifel  showed,  contained  very  little,  if  any, 
metallic  phosphorus,  reiterates  his  opinion,  with  quotations 
from  his  earlier  work.  He  states  his  arguments  v^ry  clearly 
to  prove  that  the  cod-liver  oil  alone  acts,  when  this  prepar- 
ation is  given  in  rachitis,  the  phosphorus  soon  becoming 
phosphoric  acid,     [m  o  ] 

5 Scherbek  describes  an    aseptic  bougie  made  by 

him  very  like  that  which  Dr.  Koapp  described.  But  he 
thinks  that  neither  Knapp's  nor  his  bougie  can  be  perfectly 
sterilized,    [m.o.] 


The  New  Osiris  Pavilion  in  the  Salpetrifere  Hos- 
pital.—Marcel  Baudouin  {Gazette  Mhlicale  de  Paris,  January 
19,  1901)  says  that  this  new  building,  erected  through  the 
munificence  of  M.  Osiris,  the  Paris  banker,  cost  over  $22,000. 
It  is  designed  especially  for  gynecology,  and  Dr.  Paul  Segond 
will  be  its  chief.  It  stacds  alone,  oppotite  the  chapel,  with  a 
garden  in  front  of  it.  Down  ftairs  are  5  single  rooms  for 
patients,  a  ward  with  6  beds,  and  cffice  for  the  superintend- 
ent, etc.,  and  the  operating  room,  with  an  anesthetizing 
room,  a  room  for  sterilizers  and  instruments,  a  small  r(>^^m 
ac'joining  for  electrical  apparatus,  and  a  dark  room.  Tne 
operating  room  is  large,  well  lighted,  with  a  chain  to  di- 
vide the  operator  from  the  students.  Bath-room  and  wate^ 
closets  are  at  the  extreme  other  end  of  the  building,  beyoncl 
the  ward.  Many  of  the  furnishiags  are  American,  the  steel 
bad-springs,  the  model  of  the  operating  table,  etc.  Dr. 
Segond,  to  whom  the  credit  of  finally  obtaining  this  pavilion 
is  due,  will  soon  tegin  his  course  in  operative  gynecology. 
[m.o  ] 


3B2 


Thb  Phtladblphia"] 
Medical  Jousnal  J 


RESECTION  OF  THE  RECTUM  PER  VAGINAM 


Febecaey  23,  1901) 


©riatnal  2irticlcs. 


THE    VALUE    OF    SPUTUM-EXAMINATIONS   TO  THE 
GENERAL  PRACTITIONER.' 

By  M.  HOWARD  FUSSELL,  M.D., 

of  Philadelphia. 

Instructor  in  Clinical  Medicine,  University  of  Pennsylvania. 

In  1887  I  had  the  honor  of  presenting  before  this 
eociety,  a  paper  upon  the  Diagnostic  Value  of  Tubercle 
in  the  Sputum. 

In  the  period  which  has  since  elapsed  the  propriety 
of  examining  the  sputum  in  cases  of  lung  disease,  not 
only  for  tubercle-bacilli  but  for  other  organisms,  has 
been  recognized  by  all  writers. 

The  methods  of  examination,  the  improvement  of 
the  technic  and  the  introduction  into  general  use  of  oil- 
immersion  lenses  have  made  the  detection  of  the  vari- 
ous organisms  a  matter  easily  performed  by  any  one 
at  all  skilled  in  the  use  of  the  microscope. 

The  demonstration  of  the  methods  of  examination  is 
now  a  part  of  the  curriculum  of  every  good  medical 
school. 

It  might  then  be  considered  a  gratuitous  act  to  write 
a  paper  upon  the  value  of  this  procedure. 

But  notwithstanding  the  fact  that  all  careful  diagnos- 
ticians recognize  that  in  many  instances  an  accurate 
diagnosis  of  lung  tuberculosis  cannot  be  made  without 
a  microscopic  examination  of  the  sputum,  and  while 
a  routii\e  examination  of  the  expectoration  is  made  in 
all  well-regulated  hospitals,  I  am  convinced  that  any- 
thing approaching  a  routine  sputum-examination  by 
the  general  practitioner  is  not  practised.  Indeed  I 
think  that  the  sputum  is  not  examined  at  all  by  the 
general  practitioner  except  in  rare  instances. 

It  is  with  the  idea  of  bringing  the  necessity  of 
sputum-examinations  before  the  family  doctor  that 
this  paper  was  prepared.  These  thoughts  present 
themselves  to  the  writer  on  this  subject: 

First.  The  necessity  of  sputum-examinations. 

Second.  The  value  of  sputum-examinations. 

Third.  The  technic. 

Fourth.  The  practicability  of  the  procedure. 

The  necessity  of  sputum-examinations  can  best  be 
presented,  it  seems  to  the  writer,  by  quoting  a  number 
of  cases  in  which  a  diagnosis  was  entirely  impossible 
without  the  light  shed  upon  the  case  by  the  examina- 
tion of  the  sputum. 

During  the  past  two  months  three  cases  have  pre- 
sented themselves  in  the  private  practice  of  the  writer 
in  which  the  examination  of  the  sputum  made  an 
otherwise  doubtful  examination  positive  in  two  and 
helped  much  in  the  third  case. 

Cas?  1. — Mrs.  H.,  aged  42  years,  mother  of  four  children. 
Family  history  was  e.xcellent,  there  being  no  case  of  tubercu- 
losis or  other  hereditary  disease  in  the  family.  The  lady  was 
of  extremely  nervous  temperament  and  first  came  under 
my  care  two  years  ago  while  sutVering  with  an  attack  of 
hysterical  dyspnea.  She  was  anemic,  having  about  70%  of 
hemoglobin  with  a  sliglit  diminution  in  the  number  of  red 
blood-cells.  She  was  emaciated,  afraid  to  venture  outdoors 
for  fear  she  would  die  of  heart-di>-ease.  In  a  word,  a  typical 
neurasthenic,  who  unfortunately  a  year  previously  had  been 
told  by  her  doctor  she  had  a  weak  heart.  This  fact  worried 
her  and  she  was  unable  to  dispossess  her  mind  of  the  fear 
of  sudden  death.  Careful  examinations  of  her  heart,  lungs, 
abdomen  and   urine,  revealed   only  a   rapidly-acting  heart 


>  Read  before  the  Philadelphia  County  Medical  Society,  February  IS,  1901. 


without  organic  lesion  Her  lungs  showed  no  sign  of  dis- 
ease. Under  a  carefully  regulated  life,  with  abundance  of 
outdoor  living,  driving,  walking,  etc,  which  she  willingly 
took  when  assured  she  Wf^uld  not  die,  she  rapidly  improved, 
gained  1.5  pounds  in  weight,  and  seemed  entirely  well  one 
year  ago.  In  August,  1900,  I  was  again  called  to  see  the 
patient.  She  was  suffering  from  exactly  the  same  symptoms 
as  previously,,  plus  a  very  slight  cough,  with  expectoration 
of  perhaps  half  an  ounce  of  sputum  in  the  morning.  Th  re 
was  no  fever,  as  evidenced  by  care  ul  thermometry.  Ex- 
amination showed  the  heart  normal  as  before,  with  a  very 
slight  impairment  of  resonance  at  the  apex  of  the  right  lung. 
Sputum-examination  showed  myriads  of  tubercle-bacilli, 
which  have  persisted  ever  since  and  which  were  present  in 
the  sputum  yesterday.  My  previous  knowledge  of  the  ex- 
treme hysterical  condition  of  my  patient,  together  with  the 
very  slight  physical  signs,  made  me  quite  certain  that  I  was 
dealing  again  simply  with  neurasthenia.  The  presence  of 
tubercle-bacilli  in  the  sputum,  was  practically  the  only  way 
in  which  I  was  enabled  to  make  a  correct  diagnosis. 

Case  2  — A  young  man  of  22  consulted  me  during  the 
recent  epidemic  of  la  grippe.  His  father  and  one  sister  died 
of  phthisis  several  years  ago  The  patient  had  always  been 
well  until  about  6  months  ago,  when  he  had  a  slight  cough  in- 
the  morning.  He  consulted  a  quack  contract  doctor  in  the 
city  and  for  6  months  had  been  dosed  with  medi  ine  at  $5  00 
per  month,  paid  in  advance  E.xamination  and  questioning 
revealed  that  except  for  the  morning  cough  the  patient  had 
been  perfectlj'  well  until  one  week  before  my  vist.  He  then 
had  coryza,  sore  throat,  aching  limbs  and  a  fever,  probably 
an  acute  attack  of  la  grippe.  On  examination  he  had  a 
temperature  of  100°.  His  throat  was  somewhat  red  and  in- 
flamed. In  the  region  of  the  left  nipple  there  was  a  distinct 
pleural  friction  with  a  slightly  marked  dull  note  on  percus- 
sion. I  made  a  diagnosis  of  inHuenza  with  some  pleurisy, 
believing  that  consumption,  which  had  been  so  glibly  diag- 
nosed by  my  brother  at  so  much  per  month,  was  not  present. 
Examination  of  the  sputum  at  first  revealed  no  tubercle- 
bacilli.  A  second  examination  showed  an  abundance  of  the 
organism  in  one  slide  and  none  in  another  taken  from 
another  portion  of  the  same  sputum.  Here  a  diagnosis  was 
surely  and  certainly  made  by  the  sputum-examination. 

Case  3. — L  C,  male,  16  years  of  age,  a  large  boy  weighing 
133  pounds,  was  seized  in  the  beginning  of  November  with 
one  of  the  most  virulent  attacks  of  pneumonia  it  has  been 
my  lot  to  see  in  a  boy  of  his  age.  A  chill  occurred  at  10  a  m. 
By  4  P.M.  he  was  semi-consci'  us,  had  a  pulse  of  130  and  a  tem- 
perature of  104°.  Consolidation  of  the  right  lower  lobe  of 
the  hmgs  rapidly  developed,  ftieumococci  were  abundant 
in  the  rather  scant  sputum.  A  blood  count  showed  22,000 
white  cells  to  the  cm  of  blood.  After  9  days  of  desperate 
illness,  a  crisis  occurred,  for  a  few  days  the  temperature  re- 
mained about  09J°  in  the  morning  to  100°  in  the  evening. 
Soon  the  fever  took  on  a  septic  type,  normal  or  nearly  so 
in  the  morning,  rising  to  102°  to  IOi°  in  the  evening.  A 
gradual  rise  in  the  number  of  leukocytes  occurred.  Con- 
stant, almost  daily,  examinations  of  the  sputum  failed  to 
show  tubercle-bacilli.  E.xamination  of  the  exudate  from  the 
lung  procured  by  puncture  also  failed  to  show  the  organism. 
Frequent  punctures  of  the  chest  wall  by  a  long  needle  failed 
to  show  pus.  The  physical  signs  denoted  the  absence  of  pus 
free  in  the  chest,  and  failed  to  demonstrate  a  collection  in 
the  lung  or  between  the  lobes  However,  on  the  strength  of 
the  increasing  leukocytes,  together  with  the  absence  of 
tubercle-bacilli  in  the  sputum,  confirmed  us  in  a  diagnosis  of 
iutrapulmonary  or  interlobular  abscess.  An  operation  was 
urged,  but  refused.  In  9  weeks  after  the  beginning  of  the 
illness,  a  diagnosis  of  iutrapulmonary  collection  of  pus  was 
confirmed  by  the  expectoration  on  three  occasions  of  S 
ounces  of  pus.  This  pus  showed  the  presence  of  streptococci 
and  pneumococci,  but  no  tubercle-bacilli.  The  patient  is 
now  entirely  well.  Here  the  negative  findings  in  the  sputum- 
examinations  went  a  great  way  against  a  diagnosis  of  tuber- 
culosis which  seemed  extremely  likely. 

Such  cases  as  these  might  be  multiplied  many  times, 
but  these  alone  will  suffice  to  make  my  point  of  the 
necessity  of  the  sputum-examination  in  making  a  diag- 
nosis which  at  the  time  would  have  been  impos.sible 
by  other  practicable  means.     The  value  of  this  pro- 


FSBRUABY  23,    1901] 


THE  VALUE  OF  SPUTUM-EXAMINATIONS 


[THR  PHIIJlDELPHLi 
Medical  Jodrhai. 


383 


cedure  is  demonstrated  by  the  above  cases  in  making 
the  diagnosis.  And  it  may  be  stated  as  a  fact  to  which 
there  are  no  exceptions,  that  the  presence  of  tubercle- 
bacilli  in  the  sputum  indicates  tuberculosis  in  the  pa- 
tient. The  absence  of  tubercle-bacilli  in  sputum  does 
not  unfortunately  always  mean  the  absence  of  tuber- 
culosis, but  when  repeated  examinations,  carefully 
made,  do  not  show  tubercle-bacilli,  it  is  a  valuable 
point  against  tuberculosis  in  the  patient. 

Sputum-examinations  are  of  value  in  making  an 
early  diagnosis.  Myriads  of  cases  are  yearly  overlooked 
in  the  early  stages  of  tuberculosis,  because  of  the  dearth 
of  physical  signs,  which  would  be  easily  marked  as 
tuberculosis  if  the  trouble  had  been  taken  to  make  a 
sputum  examination. 

The  value  of  an  early  diagnosis  in  tuberculosis  being 
made  is,  beside  the  object  of  this  paper,  but  one  of  its 
values.  The  possibility  of  destruction  of  sputa  con- 
taining tubercle-bacilli  as  a  prophylactic  measure  is 
beyond  computation.  A  detection  of  these  organisms 
in  the  early  stages — only  a  month  or  a  year  earlier  than 
a  diagnosis  would  otherwise  be  made — would  be  of 
incalculable  value  to  the  human  race. 

This  fact  alone,  it  seems  to  me,  must  appeal  to  every 
practising  physician.  It  is  the  family  doctor  who  first 
sees  the  case.  If  he  would  make  or  have  made  an 
examination  of  the  sputum  in  every  case  of  continued 
expectoration,  and  have  the  sputum  containing  tubercle- 
bacilli  destroyed,  in  a  few  years  the  cases  of  tubercu- 
losis in  the  world  would  be  greatly  lessened.  Instead 
of  this  trouble  the  patient  is  told  all  sorts  of  tales,  until 
continued  failing  health,  a  progress  of  the  physical 
signs,  so  that  he  who  runs  may  read,  at  last  suggests  a 
sputum-examination,  when  the  organisms  are  found. 
Can  anyone  calculate  the  new  cases  which  will  origi- 
nate from  such  a  neglected  case,  or  the  value  in  saving 
human  life,  by  the  expenditure  of  a  few  minutes  of  the 
doctor's  busy  life? 

From  the  nature  of  things  it  is  the  detection  of  cases 
of  tuberculosis  in  which  sputum-examinations  are  of 
the  greatest  value.  Besides,  the  detection  of  various 
parasites  in  the  sputum  is  also  of  value.  Recently 
Stiles,  of  the  Bureau  of  Agriculture,  read  a  thoughtful 
paper  upon  parasitic  hemoptysis,  which  shows  the  ne- 
cessity and  value  of  sputum-examinations  in  many  of 
the  tropical  regions. 

As  to  the  practicability  of  this  procedure  in  the 
busy,  rushing  life  of  the  general  practitioner. 

In  cities  such  as  Philadelphia  and  New  York, 
which  have  a  bacteriological  department  of  the  Board 
of  Health  in  which  examinations  of  the  various  ejecta 
including  sputum  will  be  made  at  short  notice  free 
of  charge,  there  is  not  the  slightest  excuse  for  the 
very  busiest  man  to  neglect  the  precaution  of  early 
sputum-examinations. 

That  the  privilege  is  not  taken  advantage  of  to 
any  extent  hflwever,  I  think  an  examination  of  the 
records  of  that  department  of  the  city's  government 
will  show.  Moreover,  doctors  who  live  far  from  such 
centers  as  Philadelphia  and  New  York  cannot  have 
the  advantage  of  such  departments.  To  them,  I  am 
sure,  such  an  examination  of  sputum  of  all  suspicious 
cases  is  a  practical  procedure. 

Necessarily  a  working  knowledge  of  a  microscope 
and  the  ability  to  recognize  various  organisms  when 
seen  under  the  microscope,  are  indispensable.  All 
recent  graduates  have  that  knowledge,  or  should  have 
it.    The  young  men   are  always  anxious  and  willing 


to  help  the  older  with  or  without  a  compensation, 
and  can  be  utilized  much  to  the  young  physician's 
benefit  as  well  as  that  of  the  patient.  Anyone,  how- 
ever, with  a  little  practice  can  learn  to  speedily  and 
accurately  examine  a  sputum-specimen. 

The  necessary  apparatus  is :  a  microscope,  prefera- 
ably  with  an  oil  immersion  lens,  though  lower  powers 
may  be  used,  an  alcohol  lamp,  a  bottle  of  fuchsin, 
a  bottle  of  Gabbet's  counter- stain,  some  cover-slips 
and  glass  slides.  Some  sputum  having  been  obtained, 
a  small  bit  of  the  sputum  is  put  upon  a  slide  and 
covered  with  a  slip,  this  is  examined  with  a  low 
power,  i  or  ^  inch  for  foreign  bodies  such  as  elastic 
tissue  or  the  various  larger  organisms.  Another  small 
bit,  preferably  a  small  caseous  mass,  is  spread  between 
two  slides  very  thin.  The  slides  are  separated  and 
allowed  to  dry  in  the  air.  One  is  then  passed  three 
or  four  times  rather  slowly  through  a  Bunsen  jet,  or, 
if  that  be  not  at  hand,  through  the  flame  of  an 
alcohol  lamp.  Upon  this  is  placed  some  carbol-fuchsin 
until  the  whole  part  of  the  slide  covered  with  sputum 
is  covered  with  the  stain. 

This  is  heated  very  slowly  and  gently  until  steam  is 
seen  rising  from  the  slide.  It  is  allowed  to  stand  one 
or  two  minutes.  The  stain  is  allowed  to  flow  oS"  the 
slide,  and  the  portion  previously  stained  with  fuchsin  is 
covered  with  Gabbet's  slain,  which  is  allowed  to  stand 
for  two  or  three  minutes.  This  is  then  washed  in 
water  and  dried  by  the  use  of  a  blotter.  Some  cedar 
oil  is  then  placed  directly  upon  the  stained  sputum  and 
the  oil-immersion  lens  run  down  until  the  particles  are 
in  focus.  The  specimen  will  be  seen  to  have  a  uniform 
blue  hue — cells,  bacteria  and  a  corpuscles  all  being 
stained  blue.  If  tubercle  bacilli  be  present  however, 
they  will  be  seen  as  small  red  rods  in  the  blue  field. 
Accurate  plates  of  this  can  be  seen  in  Mallory  and 
Wright  or  in  von  Jaksch. 

This  method  of  staining  for  tubercle-bacilli  is  prefer- 
able to  the  use  of  the  cover-slip.  There  is  no  danger 
in  the  various  manipulations  in  breaking  a  slide, 
whereas  a  cover  slip  cracks  except  in  the  expert  hands. 
The  whole  procedure  will  take  not  more  than  15  or 
20  minutes.     Surely  time  well  spent. 

It  appears  to  me  that  Austin  Flint's  statement  made 
in  1882  :  "  I  predict  that  the  time  will  soon  come  when 
in  order  to  corrobate  the  diagnosis  microscopical  ex- 
aminations of  the  sputa  will  be  considered  as  much  a 
matter  of  course  as  examinations  of  urine  for  evidence 
of  renal  disease,"  should  be  ever  present  to  all  of  us,  if 
for  no  other  reason  than  that  early  diagnosis  of  tuber- 
culosis can  thus  be  made  and  myriads  of  bacilli  be 
destroyed  that  would  otherwise  be  a  source  of  infection. 


RESECTION  OF  THE  RECTUM  PER  VAGINAM.* 
By  JOHN  B.  MURPHY,  A.M.,  M.D., 

of  Chicago,  III. 

Professor  of  Surgery,  Northwe>l«rn  University  ;  Professor  of  Surgery,  Chicago 
Postgraduate  School  and  Hospital;  Professor  ot  .Surgery,  Chicago  Clinical 
School ;  Attending  Surgeon.  (Jook  County  Hospital,  Mercy  Hos- 
pital, and  Alesian  Bruthers'  Hospital  ;  Cousultine  Sur- 
geon  to  St.  Joseph's  Hospital  and   Hospital 
for  Crippled    Children. 

It  is  not  the  purpose  of  this  paper  to  consider  in  detail 
the  pathological  conditions,  such  as  fibrous  stricture, 
tubercular  disease,  neoplasms,  and  so  forth,  which  may 

»  Prepared  for  the  Southern  Surgical  and  (Jynecological  Association,  AtlRBt*, 
Ga.,  1900. 


384 


Thb  Phiudklphia"] 
Mkdicai,  Jodbnal  J 


RESECTION  OF  THE  RECTUM  PER  VAGINAM 


[Fbbbuabt  23,  IMI 


demand  removal  of  the  rectum.  These  have  been  ad- 
mirably treated  in  the  recent  work  by  Quenu  and  Hart- 
niann,  and  involve  such  an  extensive  study  that  we 
w  ill  but  mention  them  here. 

The  profession  has  not  yet  agreed  upon  a  definite 
and  satisfactory  technic  in  the  performance  of  proctec- 
tomy, as  it  has  in  hysterectomy  and  many  other  pelvic 
operations.  The  posterior  operations,  such  as  the  trans- 
sacral and  ischiorectal,  have,  in  the  last  decade,  at- 
tracted most  attention  and  found  many  advocates,  but 


Flu.  1. 

that  they  are  difficult,  dangerous,  and  in  many  respects 
ultimately  unsatisfactory,  is  beyond  question.  The  mor- 
tality in  14  of  the  largest  European  clinics  is  21.2%. 
(Prutz.) 

The  perineal  proctectomy  of  Volkmann  is  applicable 
only  to  carcinoma  involving  the  third  and  lower  half 
of  "the  second  portion  of  the  rectum.  The  vaginal 
route  has  been  overlooked,  or  at  least  greatly  slighted, 
and  notwithstanding  the  fact  that  a  number  of  opera- 
tors have  been  forced  by  the  pathological  conditions 
present  to  make  use  of  it,  in  only  a  few  instances  has 
it  been  the  method  of  election. 

The  procedures  resorted  to  for  rectal  extirpation  may 
be  classified  as  follows,  partially  after  the  plan  of 
Renzaldt  and  Stintzing  : 

1.  Bloodless  dilation  of  the  sphincter.    (Simon.) 

2.  Circular  incision  around  the  anus.     (Lisfranc.) 

3.  Perineal  methods : 

a.  Posterior  division  of  sphincter.    (Dieffenbach.) 


6.  Posterior  longitudinal  incision  with  retention  of 

the  anus  and  sphincter.     (Kocher.) 
c.  Resection  of  coccyx.     (Kocher.) 

4.  Transsacral   method  with  resection  of  portions   of 

sacrum  : 
a.  One-sitting.    (Kraske  :  In  America.  Fenger.) 
6.  Transverse  section.     (Bardenheuer,  Rose.) 

c.  Oblique  section.     (Hochenegg.) 

d.  Transverse  resection  of  sacrum  and  coccyx.  (Hei- 

neke;  Schlange;  Kocher;  Hegar;  Kydygier; 
Marcy.) 

5.  Parasacral  methods,  division  of  soft  parts  on  side  of 

sacrum  without  section  or  excision  of  sacrum 
or  coccyx.    (Zuckerkandl ;  Wolfler;  Schelkly.) 

6.  Vaginal    extirpation.     (Des    Quins:    Norton;    L.  L. 

MacArthur;  Campenom;  Rehn;  Vautrin; 
Price;    Byford;  Bristow;   Julius  Sternberg.) 

7.  Primarj"  vaginal  celiotomy,  examination  of  extent  of 

disease  and  then  complete  division  and  later 
excision  with  end-to-end  union  of  intestine — 
retention  of  sphincter.  (Rehn ;  Murphy  after 
method  to  be  described  herein  1 


Flc.  2. 

Development  of  the  Vaginal  Opeeatios  ; 

1.  In  July,  1890.  DesQuins,'  in  a  case  of  carcinoma  of  the 
rectum  involving  the  rectovaginal  septum,  removed  tho 
septum  with  the  tumor,  drew  down  the  sigmoid  and  sutured 
it  t^  the  anal  portion  of  the  rectum,  which  he  had  retaineti. 
The  peritoneum  was  not  closed  by  suture.  The  defects  in 
the  perineum  and  vaginal  wall  were  closed  by  suture,  silver 
wire  being  used  for'the  former.  The  patient  died  shortJy 
after  operation,  but  it  was  noted  that  there  was  immediate 
continence  of  feces.    Cause  of  death  was  not  given. 

2.  December  17,1S90,  A.  T.  Norton-  removed  a  carcinoma 


FBBBCABT  23,  19(j1] 


RESECTION  OF  THE  RECTUM  PER  VAGINAM 


FThb  Philadrlphia 
L  Ukdicax  Jourhax. 


385 


of  the  anterior  rectal  wall,  not  invoU-ing  the  vaginal  mu- 
cosa, by  complete  division  of  the  perineum  without  opening 
the  peritoneal  cavit}'.  He  excised  the  entire  lower  segment 
of  the  rectum,  including  the  sphincter,  and  sutured  the 
proximal  end  of  the  bowel  to  the  skin.  The  patient  had 
fecal  continence  one  month  after  operation. 

3.  In  1891,  L.  L.  MacArthur'  in  a  secondary  operation  for 
recurrent  carcinoma  of  the  rectum,  removed  the  diseased 
portion  of  the  bowel  and  sutured  the  proximal  end  into  the 
upper  portion  of  the  vagina.  The  operation  was  followed  by 
good  results. 

4.  Campenom,    in   1894,*   performed  a    resection   of  the 


Fio.  3. 

rectum  for  nonmalignant  stricture,  not  involving  the  vaginal 
wall.  His  incision  was  in  the  rectovaginal  septum,  extend- 
ing out  onto  the  perineum,  which,  however,  was  not  com- 
Eletely  divided.  End  toend  approximation  ot  the  proximal 
owel  with  the  anal  portion,  which  had  been  left  intact,  was 
accomplished  by  means  of  sutures  Patient  recovered, 
stricture  did  not  return,  and  she  had  sphiucteric  control. 

5.  In  1895,  L.  Eehn '  removed  a  carcinoma  of  the  rectum 
by  division  of  the  perineum  and  later  opened  the  peritoneal 
cavity.     Death  from  peritonitis. 

6.  Yautrin,'  in  May,  1895,  removed  a  carcinoma  of  the 
rectum  per  vaginam.  The  details  of  the  operation  are  not 
given  in  the  report. 

7.  In  1896,  Joseph  Price'  reports  an  operation  performed 
by  himself,  for  carcinoma  of  the  uterus  and  rectum.  He  did 
an  anteroposterior  hysterectomy,  removing  the  rectum  with 
the  uterus,  and  subsequently  suturing  the  proximal  end  of 
the  bowel  iutothe  vaginal  wall.  The  patient  recovered  from 
the  immediate  effects  of  the  operation,  but  died  on  the 
seventh  day.  Subsequently  he  performed  an  operation  in 
which  he  utilized  the  button  as  a  means  of  approximation. 


The  case  recovered,  and  is  probably  the  first  case  of  a;prox- 
imation  of  this  kind  on  record. 

8.  In  November,  1896,  Dr.  H.  T.  Byford*  reported  a  case 
of  excision  of  a  rectal  carcinoma  by  incision  through  the 
upper  portion  of  the  vaginal  wall.  In  his  efforts  to  draw 
down  the  remaining  portion  of  the  rectum,  the  peritoneal 
cavity  was  torn  open.  The  j  roximal  end  of  the  bowel  was 
sutured  into  the  upper  part  of  the  posterior  vaginal  wall, 
with  the  intention  of  similarly  suturing  the  anal  segment 
into  the  lower  fart,  and  closing  the  vaginal  orifice,  thereby 
converting  the  vagina  into  a  portion  of  the  fecal  tract.  He 
does  not  state  the  result,  but  mentions  that  in  a  later  case 
he  successfully  performed  the  operation,  the  patient  surviv- 
ing for  1  year. 

9.  Bristow,'  in  1896,  removed  a  carcinoma  of  the  rectum 
through  the  posterior  vaginal  wall,  without  opening  the 
peritoneum  His  case  recovered,  and  in  comment  he  says  : 
"  Farther  than  6  inches  it  is  not  possible  to  go,  judging  from 
my  experience  in  this  case." 

10.  Julius  Sternberg'"  reports  fi-om  Gersuny's  Clinic  in 


Fig.  4. 

Vienna,  14  cases  of  reseetion  of  the  second  and  third 
portions  of  the  rectum  through  the  posterior  wall  of  the 
vagina.  All  were  cases  of  malignant  disease  His  results 
were  12  recoveries  and  2  deaths.  In  some  of  the  cases  where 
the  peritoneum  was  accidentally  opened,  it  was  closed  with 
sutures.  The  sphincter  was  retained  when  not  involved  in 
the  disease. 

11.  From  Rehn's  clinic,  Liermann  "  reports  2  cases,  1  oper- 
ated on  July,  1897,  in  which  the  rectum  and  uterus  were 
both  removed,  17  cm.  of  the  former,  and  in  the  other  case, 
ocerated  on  January,  1898,  the  rectum  alone  was  excised. 
Both  patients  recovered  and  both  had  sphincteric  control. 


386 


Thb  Philadelphia"! 
Mbdical  Joubnal  J 


RESECTION  OF  THE  RECTUM  PER  VAGINAM 


[FSBKCABY  23,   1901 


Thus  we  find  the  operation  of  vaginal  proctectomy 
advancing  in  the  direction  of  the  peritoneum  and  sig- 
moid, without  any  definite  plan  as  to  a  vaginal  celiot- 
omy for  the  removal  of  carcinoma  of  the  first  portion 
of  the  rectum  or  lower  portion  of  the  sigmoid. 

Anatomy. — A  few  details  of  the  anatomy  of  the  sig- 
moid and  rectum  may  be  considered  here  as  they  are 
important  in  the  performance  of  this  operation.  The 
normal  position  of  the  sigmoid  is  in  the  pelvis  and  not 
in  the  left  iliac  fossa  as  is  generally  supposed.     It  be- 


Fui.  5. 

gins  at  the  outer  border  of  the  left  psoas  muscle,  just 
above  the  brim  of  the  pelvis,  crosses  the  muscle  at  a 
right  angle,  descends  vertically  along  the  left  pelvic  wall 
sometimes  as  low  as  the  floor  of  the  pelvis,  then  passes 
horizontally  to  the  right  pelvic  wall  and  occasionally 
upward  into  the  right  iliac  fossa,  where  I  have  encoun- 
tered it  in  operating  for  appendicitis.  From  here,  after 
sharply  flexing  upon  itself,  it  passes  to  the  left  as  far  as 
the  median  line,  where  it  becomes  the  rectum  and 
descends  to  the  anus.  It  is  supported  by  a  meeosigmoid, 
whose  line  of  attachment  crosses  the  left  psoas  muscle, 
curves  upward,  passes  over  the  bifurcation  of  the  com- 
mon iliac  vessel  and  then  passes  downward  on  the  left 
side  of  the  pelvis  to  the  median  line. 

It  will  be  seen  from  the  attachments  of  the  mesosig- 
moid  that  this  portion  of  the  bowel  can  be  reached  and 
resected  from  below.  The  mesentery  .measures  from 
1^  to  3i  inches  in  length,  thus  permitting  great  freedom 


of  motion  in  the  pelvis,  which  is  necessary  in  the  per- 
formance of  one  of  its  great  functions  ;  that  of  guarding 
against  the  extension  of  pelvic  infections. 

The  sigmoid  may  rotate  on  its  axis  in  a  scroll-like 
manner  and  be  completely  surrounded  by  its  mesentery, 
this  being  possible  because  of  the  length  of  the  latter. 
It  occasionally  becomes  adherent  in  this  position  and 
produces  the  train  of  symptoms  known  as  ileus.  These 
symptoms  are  produced  in  the  presence  of  the  above 
condition,  when  the  bowel  becomes  over-distended  and 
forms  a  sharp  kink.  I  have  operated  upon  two  cases 
where  the  obstruction  was  caused  by  this  type  of 
adhesion. 

The  rectum  is  usually  described  as  having  three  dis- 
tinct portions,  but  more  correctly  there  are  but  two. 
The  first  portion  begins  at  the  third  piece  of  the  sacrum 
and  extends  to  the  tip  of  the  coccyx.  There  is  no 
mesorectum  and  it  is  covered  by  peritoneum  only  at  its 
upper  part  on  the  anterior  surface.  It  is  3i  inches  long, 


and  behind  is  in  relation  with  the  sacrum  and  coccyx, 
whose  curves  it  follows.  In  front  it  is  in  relation  with 
the  trigon  of  the  bladder  and  seminal  vesicles  in  the 
male,  and  in  the  female  with  the  vagina  and  cervix  uteri. 
The  peritoneum  in  the  male  comes:  to  within  3  inches 
of  the  anus.  I  found  on  the  male  cadaver  that  11 
inches  of  rectum  and  sigmoid  could  be  resected 
through  a  median  and  lateral  perineal  incision.  The 
second  portion,  formerly  described  as  the  third,  is  1^ 
inches  long,  and  extends  from  the  tip  of  the  coccyx  to 


Febrdakt  23,  1901) 


RESECTION  OF  THE  RECTUM  PER  VAGINAM 


[The    PHrLADKLPHIA 
Medical  Journal 


387 


the  anus.  Below  it  is  surrounded  by  the  external 
sphincter,  and  above,  about  1  inch  from  the  anus,  by 
the  internal  sphincter,  which  is  half  an  inch  broad. 

Case  1.— Referred  to  me  by  Col.  Nicholas  Senn  (then  iu 
the  service  at  Chattanooga),  Mrs.  M.  W.  S.,  aged  36,  occupa- 
tion, housewife.    Admitted  to  Mercy  Hospital  July  12,  1898. 

Present  illness  :  Ten  or  12  months  ago,  patient  began  com- 
plaining of  indefinite  pain  in  the  lower  abdomen  and  upper 
portion  of  the  vagina.  About  6  months  ago  she  first  noticed 
bloody  and  mucous  discharges  from  the  rectum,  and  the 
feces  assumed  a  ribbon  shape.  The  diagnosis  of  "  bleeding 
piles  "  was  made.  Ejcamination  reveajed  a  malignant  tumor 
of  the  first  and  second  portions  of  the  rectum,  for  the  re- 
moval of  which  operation  was  advised.  The  patient  was 
very  fleshy,  and  the  perineal,  hemorrhoidal,  and  vaginal 
veins  were"  enormously  distended.  Extent  of  disease  shown 
in  Fig.  1. 


Fig.  7. 

Operation,  July  16, 1898.  Lithotomy  position.  The  vagina 
was  dilated  with  broad  specuke,  the  cervix  draw  down,  and 
the  culdesac  opened  by  a  transverse  incision  similar  to  that 
used  in  vaginal  hysterectomy.  Large  laparotomy  sponges 
were  now  passed  into  the  peritoneal  cavity  to  displace  the 
intestines  out  of  the  field  of  operation.  The  tumor  was 
carefully  examined,  as  well  as  the  rectoperitoneal  lymph- 
glands,  which  latter  did  not  appear  to  be  involved  in  the_ 
disease  The  tumor  extended  upward  almost  to  the  brim  of 
the  pelvis.  The  rectovaginal  septum  was  now  divided  down 
to  the  rectum  by  a  vertical  incision  in  the  middle  line,  ex- 
tending from  the  postcervical  opening,  and  including  the 
sphincter  ani.  (Fig  2.)  The  hemorrhage,  which  was  quite 
profuse  from  the  dilated  veins,  was  controlled  by  conipresses 
and  forceps.  The  posterior  vaginal  wall  was  now  dissected 
laterally  from  its  attachments  to  the  rectum ;  lateral  and 
anterior  retractors  were  placed  in  position,  and  a  large  field 


for  operation  exposed.  (Fig.  3.)  The  sigmoid  could  be 
handled  throughout  its  entire  extent,  and  brought  well 
down  without  the  slightest  difficulty.  With  scissors  the 
anterior  rectal  wall,  including  the  sphincter,  was  divided  up 
to  the  lower  border  of  the  tumor,  and  the  anal  segment  of 
the  rectum  separated  from  that  just  above  it  by  a  complete 
transverse  incision  one  inch  below  the  lower  limit  of  the 
tumor,  the  incision  extending  into  the  postrectal  connective 
tissue.  (Fig.  4.)  The  proximal  end  of  the  rectum  was 
grasped  with  vulscllum  forceps,  closingit  completely  and,  by 
the  use  of  curved  scissors  separated  from  its  coccygeal  and 
postrectal  attachments,  upward  to  the  promontory  of  the 
sacrum,  thus  freeing  and  mobilizing  it.  (Fig.  5.)  The  hem- 
orrhage during  this  part  of  the  operation  was  easily  con- 
trolled. The  mesosignioid  was  now  loosened  sufficiently  to 
allow  the  healthy  portion  of  the  bowel  to  come  well  down. 
The  rectum  was"amputated  above  the  upper  border  of  the 
tumor  growth,  and  the  sigmoid  and  sphincteric  segment  of 
the  rectum  united  end  to-end  by  silk  sutures.  These  sutures 
were  passed  from  within  outward,  thereby  causing  all  the 
knots  to  be  on  the  inside  of  the  bowel ;  the  ends  were  left 
long  to  facilitate  removal.  The  incision  in  the  anterior 
rectal  wall  was  closed  with  silk  sutures,  introduced  in  the 
same  manner  as  those  last  described,  and  the  ends  of  the 
divided  sphincter  were  united  by  buried  sutures  of  catgut. 
(Fig.  6.)  The  laparotomy  sponges  were  removed  from  the 
peritoneal  cavity  and  the  peritoneum  on  the  floor  of  the 
l)elvis  closed  with  a  continuous  catgut  suture.  The  vaginal 
wall  was  sutured  to  the  cervix,  closing  the  transverse  incis- 
ion, and  the  edges  of  the  vertical  cut  united  in  the  central 
raphe  with  silkworm-gut  sutures.  (Fig.  7.)  A  large  rubber 
drainage  tube,  one  inch  in  diameter,  was  inserted  into  the 
rectum  and  sutured  in  place. 

When  the  patient  was  returned  to  her  room  the  pulse-rate 
was  86  and  temperature  97.6".  The  highest  temperature  and 
pulse-rate  occurred  28  hours  after  operation,  when  the  former 
registered  1(X)°  and  the  latter  101  per  minute.  Convalescence 
was  uneventful.  After  removal  of  the  rectal  tube  it  was 
noticed  that  there  was  a  slight  fecal  discharge  through  the 
vagina  when  the  bowels  were  loose.  This  sinus  was  operated 
upon  a  short  time  later,  and  the  patient  discharged,  cured, 
September  1.  ,  t  i    oa 

Pathological  report  on  specimen  of  rectal  tumor,  J  uly  M, 
1898,  by  Dr.  W.  A.  Evans,  was  as  follows  :  "  The  tumor  is 
malignant,  a  cylindrical-celled  carcinoma.  There  is  a  pihng 
up  of  the  epithelia  in  the  mucosa,  and  the  submucosa  is  occu- 
pied by  epithelial  cells.  The  muscularis  mucosae  cannot  be 
recognized.  The  epithelium  shows  abundant  traces  of  its 
glandular  antecedents.  In  places  the  invasion  of  the  mus- 
cular coats  by  the  epithelial  cells  is  evident,  and  there  are 
also  to  be  seen  in  this  layer  areas  of  round-celled  infiltration, 
showing  an  inflammatory  process." 

August  17,  1899,  I  received  a  letter  from  the  husband  of 
this  patient,  stating  that  she  had  suffered  considerably  since 
March  from  a  strictured  condition  of  the  rectum  and  prolapse 
of  the  uterus,  the  latter  organ  seeming  to  press  upon  the 
former.  After  a  few  dilations  with  the  bougie  and  tampon 
the  obstruction  disappeared  and  the  uterus  remained  in 
position.  In  a  still  later  letter  the  patient  states  that  the 
stricture  has  again  recurred.  At  the  present  time  I  have  not 
had  an  opportunity  to  examine  her,  but  expect  to  do  so  in 
the  near  future.  ,  .^        .  ,     .^^  j 

C.4SE  2.— Mrs.  D.  B.,  aged  67  years ;  housewife.  Admitted 
to  West  Side  Hospital  May  22, 1899. 

Present  illness  :  Three  years  ago  the  patient  began  to  have 
severe  "diarrhea,"  which  persisted  for  6  months.  Tne  pass- 
ages were  frequent,  often  20  a  day,  liquid  in  character,  and 
accompanied  bv  tenesmus.  After  6  months  some  improve- 
ment took  place,  but  during  the  next  year  she  had  frequent 
similar  attacks.  For  the  past  18  months  she  has  passed  con- 
siderable blood  and  mucus  from  the  bowels  and  the  stools 
have  been  verv  frequent.  Griping  pains  in  the  abdomen 
and  tenesmus  have  been  very  severe  duruig  the  same  lengtn 
of  time.     Has  lost  40  pounds   in  weight   during  the   past 

'Previous  historv  :  Patient  had  usual  diseases  of  childhood. 
The  menopause  o"ccurred  15  years  ago ;  has  had  10  chiiciren 
all  living  and  well.  Family  history:  Mother  died  of  cancer 
of  the  stomach."  Otherwise  negative.  Examination  ot 
patient :  Somewhat  emaciated.  Heart,  lungs,  and  abdomen 
negative.     Rectum:    Hard,  ulcerated  tumor  is  found  on 


388 


The  Philadelphia"] 

SiEDICAL  JOCRSAL  J 


RESECTION  OF  THE  RECTUM  PER  VAGIKAM 


[FEBECiRT  23,  an 


digital   examination,   involving  the    first   and   second  por- 
tions. 

Operation,  May  30, 1899 :  An  operation  exactly  similar  to 
that  described  in  Case  1  was  performed.  Time  of  operation, 
1  hour  and  15  minutes  Bowel-movement  through  the  rectal 
tube,  which  was  inserted  at  the  completion  of  the  operation, 
occurred  in  12  hours.  The  vaginal  packing  was  removed  in 
72  hours.  On  the  fifth  day  a  slight  fecal  discharge  through 
the  vaginal  wound  was  noted.  On  the  twelfth  day  the  rectal 
tube  was  removed.  Stitches  were  removed  on  the  fourteenth 
day  aft€r  operation,  and  on  the  fifteenth  day  the  patient  sat 
up  and  had  a  natural,  voluntary  bowel- movement.    There 


Fig.  8.- 


,  Gland  tubes  is  macosa.    b.  Submucosa. 


was  Still  some  fecal  discharge  into  the  vagina  at  this  time. 
On  the  twenty-ninth  day  following  operation,  as  the  fecal 
discharge  continued,  it  was  decided  to  close  the  rectovaginal 
fistula  by  operation.  The  edges  of  the  fistula  were  freshened 
and  approximated  by  means  of  interrupted  sutures  of  silk- 
worm-gut. Tube  inserted  into  rectum  and  retained  in  place 
by  a  suture.  After  second  operation,  convalescence  was. 
uneventful  and  patier  t  was  discharged  from  the  hospital, 
with  all  wounds  entirely  healed,  July  17,1899. 

Dr.  A.  W.  Chandler,  of  Compton,  111.,  who  referred  the 
case  to  me,  states  that  at  the  present  time  there  is  no  evi- 
dence of  recurrence  of  the  disease,  the  patient  is  in  excel- 
lent general  health  and  has  ftiU  control  of  the  bowels.  The 
rectovaginal  fistula  hiis  remained  closed. 

Case  3  — Mrs.  E.,  age  40  years,  housewife,  admitted  to  the 
Mercy  Hospital  January  24,  1S99.  Present  illness :  For 
some  time  patient  has  complained  of  slight  irritation  and 
pain  in  rectum  during  defecation.  The  general  health  is 
good.  Examination  of  the  patient  reveals  an  ulcerated  area 
with  raised  slightly  indurated  borders,  situated  on  the  pos- 
terior rectal  wall,  about  2  inches  above  the  sphincter  ani. 

Operation,  January  26,  1899.  The  sphincter  was  dilated, 
ulcer  brought  down  with  vulsellum  forceps  and  excised. 
The  edges  of  defect  united  bj'  means  of  silkworm-gut 
sutures,  perforated  shot  being  used  for  retention.  Patient 
was  discharged  from  the  hospital,  February  IS,  ,1899.  im- 
proved. Examination  of  tumor  showed  it  to  be'  a  simple 
adenoma.  ■ 

Readmitted  to  Mercy  Hospital  May  4,  1900,  suffering  from 
recurrence  of  the  symptoms  mentioned  above.  Examina- 
tion of  the  rectum  showed  an  ulcer,  situated  on  the  posterior 
wall  about  It  inches  above  the  internal  sphincter,  appar- 
ently involving  the  mucous  coat  only. 

Operation,  Mav  5,  1900.  Sphincter  dilated,  ulcer  drawn 
down  and  excised  by  cutting  well  outside  its  borders.  Edges 
of  rectal  wall  drawn  together  with  catgut  sutures.  A  gauze 
drain  was  left  in  rectum.     Patient  discharged  May  20,1900 

Admitted  to  Mercy  Hospital  for  the  third  time  September 
11,  1900,  complaining  of  the  same  symptoms  as  before,  with 
some  bloody  discharge  from  the  rectum.  Examination 
showed  an  indurated  mass  involving  the  posterior  wall  of  the 
rectum  at  site  of  former  operation  and  extending  upward. 


Operation  September  12,  1900.  The  diseased  portion  was 
resected  after  the  method  described  in  Case  1.  So  unpleas- 
ant symptoms  followed  the  operation,  except  a  rise  in  tem- 
perature which  took  place  36  hours  later  and  piersisted 
from  100°  to  101  5°  until  September  22.  A  slight  fecal  dis- 
charge into  the  vagina  was  noted  several  days  after  opera- 
tion, but  at  no  time  became  profuse.  Almost  immediately 
there  was  sphincteric  control,  weak  at  first,  but  gradually 
growing  stronger  during  convalescence,  until  date  of  dis- 
charge, Xovember  -5,  when  it  was  almost  complete.  Recto- 
vaginal fistula  had  closed  when  patient  left  hospital. 

Microscopic  examination  of  specimen  shows  it  to  be 
composed  principally  -of  adenomatous  tissue  (Fig.  8),  with 
beginning  proliferation  of  epithelial  cells  in  the  deeper  layer* 
of  the  rectal  wall.    (Fig.  9.)    Carcinoma. 

Case  4. — Mrs.  K.  P.,  age  31  vears,  housewife.  Admitted  to 
Cook  County  Hospital  October  16, 1900.  Present  illness :  About 
7  years  ago  patient  was  first  troubled  with  constipation,  which 
has  gradually  grown  worse  untO  the  present  time,  compel- 
ling her  to  use  cathartics  and  enemata  daily.  Has  consider- 
able pain  on  defecation.  Has  never  passed  blood  from  bowels. 
Two  years  ago,  after  confinement,  patient  had  "  childbed 
fever  "  which  kept  her  In  bed  for  nearly  4  months.  After 
this  she  experienced  bearing-down  pains  in  the  pelvis  and 
back,  aggravated  whenever  she  assumed  the  e  ect  position. 
States  that  her  "  womb  seems  to  fall  "  and  has  noticed  a  por- 
tion of  the  cervix  protruding  from  the  vulva. 

Previous  history:  Measles  in  childhood.  Rheumatism 
about  8  years  ago,  sick  fnr  1  year.  Xever  had  Revere  diar- 
rhea nor  dysentery.  Knows  of  nothing  that  might  have 
caused  her  constipation.  Denies  all  venereal  infection. 
Began  to  menstruate  at  sixteenth  year,  always  regular,  flows 
about  4  days  at  each  period.  Two  children,  first  about  1& 
years  ago,  second  about  2  years  ago,  after  which  patient  had 
the  fever.  One  miscarriage  about  5  years  ago.  no  trouble 
following. 

Habits :  Uses  liquors  and  morphin.  Family  history  : 
Negative.  Examination  :  Heart,  lungs,  and  abdomen  n»  ga- 
tive.  Vaginal :  Uterus  prolapsed,  anterior,  posterior  and 
la'eral  vaginal  walls  bulging  int-o  vagina,  and  entire  uterus 
low  and  poorly  supported.  An  old  laceration  of  the  perineum 
causes  the  lax  vaginal  outlet  and  is  evidently  responsible  for 
the  displacement.  Rectum :  About  2}  inches  above  anus  is  aa 


Fig.  9.- 


Small  arterr-proliftrratiog  intima.    b.  Denae  fibioos  lissne. 
c  Xre^ot  rouDd-cell  proUfentioD. 


annular  stricture  hard  and  movable:  cicatricial  tissue  com- 
pletely surrounds  the  rectum  and  the  opening  admits  only 
the  finger  tip  the  surface  is  not  ulcerated. 

Operation,  November  10  1900.  Stricture  removed  by  re- 
secting rectum  through  va^na  and  opening  the  peritoneal 
cavity.  Sp'  incter  was  retained  and  showed  firm  contraction 
at  completion  of  the  operation. 

At  the  present  date.  January  11. 1901.  there  is  partial  &il- 

ure  of  the  perineal  union,  but   an    excellent    end-to  end 

approximation  of  the  bowel.    The  perineum  will  be  repaired 

by  the  ordinar>-  method. 

"  Cask  5. — Miss  X.  E  .  .ige  26    years.    Occupation    clerk. 


Fbbrdary  23,  1901] 


SARCOMA  OF  THE  RIB3 


[Th«  Philadslphia 
Medical  Jouesal 


38» 


Sin2;le.  Admitted  to  Cook  County  Hospital,  December  3, 
1900. 

Present  Illness.  Three  and  one-half  years  ago  patient  fell 
from  a  bicycle,  severely  bruising  the  muscles  over  the  left 
ischeal  tuberosity  and  causing  an  abscess  near  the  rectum, 
which  ruptured  spontaneously.  It  remained  an  open  sore 
for  two  weeks,  then  the  wound  healed,  but  subsequently  a 
second  abscess  in  the  same  situation  had  to  be  opened 
by  a  physician.  After  this  a  small  opening,  the  size  of  a  pin- 
head,  remained  for  seven  months,  at  the  end  of  which  time 
an  operation  was  performed  and  the  sinus  was  incised  and 
drained.  Wound  healed  in  five  weeks.  One  year  later  a 
yellowish  discharge  began  to  flow  from  the  old  wound  ;  other 
openings  at  some  distance  from  the  anus  were  formed.  Pre- 
vious illnesses:  As  a  child  had  infectious  diseases.  Six  years 
ago  erysipelas.  Back  was  injured  by  being  shut  up  in  folding 
bed  five  years  ago.  Menstruation  began  at  13  years,  always 
normal,  until  one  year  ago  when  it  became  scanty.  Dtnies 
all  venereal  infection  and  gives  no  history  of  syphilis. 

E.xamination  :  Skin  over  left  ischial  tuberosity  is  perforated 
with  a  dozen  or  more  fine  openings  leading  into  sinuses 
which  communicate  freely.  Skin  is  indurated  and  thickened 
but  almost  painless  on  pressure.  Sinuses  do  not  extend  deeply 
into  muscular  tissue.  The  clinical  appearance  is  that  of 
lupus.  Rectal  examination  :  Reveals  a  narrow  circular  stric- 
ture of  the  rectum  about  2 J  or  3  inches  from  the  anal  open- 
ing.   Above  the  stricture  there  is  an  ulceration  extending 


.  Small  artery-proliferating  intiiua.    h.  Dense  fibrous  tissue. 
c.  Areas  o!  lound-cell  proliferation. 


upward  2i  inches.  The  stricture  is  movable.  Vaginal  ex- 
aminati'  n  negative.  Back  :  Several  vertebrae  in  the  lower 
dorsal  region  project,  though  there  is  no  tenderness  or  evi- 
dence of  inflammatory  processes.  Lungs  and  heart  negative. 
No  tubercle  bacilli  found  in  the  sputum. 

Operation  :  December  14, 1900  Rectum  resected  through 
the  vagina  by  the  method  described  under  Case  1,  2J  inches 
removed.     Peritoneum  closed.     Postrectal  drainage. 

Examination  cf  patient,  January  17,  1901.  For  past  four 
days  patient  has  had  complete  control  of  the  sphincter. 
Previous  to  that  it  was  partial.  Rectovaginal  septum  and 
perineal  body  have  united,  leaving  no  fistulous  communica- 
tions. Rectal  tube,  which  was  inserted  at  the  time  of  opera- 
tion, W!is  removed  after  eighteen  days  and  the  sutures  have 
been  taken  out  since.  Sphincter  contracts  on  the  linger  when 
inserted  into  the  rectum,  but  not  with  normal  vigor.  Skin 
lesion  w'hich  was  present  over  the  buttocks  before  operation, 
has  materially  improved.  Microscopic  examination  of  the 
tissue  removed  it  as  follows  :  The  mucous  membrane,  where 
present  above  stricture,  is  of  about  normal  thickness.  The 
tissue  producing  the  stricture  is  composed  principally  of 
dense  fibrous  bands,  with  scattered  areas  of  small  round- 
celled  infiltration.  No  epithelioid  or  giant  cells  found  and 
there  is  an  entire  absence  of  caseous  degeneration.  Endar- 
teritis obliterans  is  a  prominent  feature  throughout  the  sec- 
tions, which  would  lead  us  to  suspect  that  the  process  was 
syphilitic  rather  than  tubercular.    (See  Fig.  10.) 


Conclusions. — The  advantages  offered  by  the  vaginal 
route  are  : 

1.  The  sacrum  and  posterior  bony  wall  of  the  pelvis 
are  not  disturbed. 

2.  The  field  of  operation  is  as  extensive  and  the- 
anatomical  parts  as  accessible  as  in  the  transsacral 
operations. 

3.  The  peritoneal  cavity  is  opened  in  both  the  vaginal 
and  sacral  operations,  and  in  neither  is  it  a  source  of 
great  danger. 

4.  The  diseased  tissue  is  more  accessible  for  inspec- 
tion and  the  extent  to  which  the  operation  may  be 
carried  in  an  upward  direction  is  as  great,  if  not  greater, 
than  by  the  sacral  route. 

5.  The  peritoneum  may  be  drained  freely  through 
the  vagina. 

6.  A  perfect  end-to  end  approximation,  either  by 
suture  or  by  the  use  of  the  button,  may  be  secured. 
The  preferable  method  of  uniting  the  two  ends  is  by 
interrupted  sutures  of  silk,  because  as  there  is  no 
peritoneum  on  the  sphincteric  segment,  failure  of 
union  with  the  button  is  to  be  feared. 

7.  The  sphincter  is  retained  and  the  perineal  body 
is  restored.  There  is  diminished  action  of  the  levator 
ani  muscle. 

8.  When  the  operation  is  complete,  the  parts  are 
practically  in  their  normal  positions. 

I  have  performed  the  same  operation  on  the  male 
cadaver  and  find  that  by  splitting  the  sphincter  directly 
through  the  median  line,  anteriorly  and  posteriorly,  cut- 
tiiig  back  to  the  coccyx  and  opening  the  rectovesical  fold 
of  the  peritoneum,  practically  the  same  field  for  operation 
can  be  obtained  as  in  the  female.  Several  inches  of  the 
bowel  can  be  excised  and  end- to- end  union  secured. 
Either  anteprocteal  or  postprocteal  drainage  may  b& 
used.  The  cut  ends  of  the  sphincter  are  united  ante- 
riorly and  posteriorly.  The  lateral  nerve-supply  on 
either  side  is  not  disturbed. 

BIBLIOGRAPHY. 

•  .Inn.  <f«  la  Soc.  Med.  d'Anvers,  July,  1890. 

■  Trans.  Cliu.  Soi:  ,  London,  1890. 

'  Am.  Jour.  Obstetrics,  1891,  vol.  24,  p.  667. 

<  rnioiuVfif.,  October  25,  1894. 

•■■  Cenlr.  Chir.,  Berlin,  So.  10,  1895. 

«  Reported  by  Thuvien,  Gaz.llebdo.  de  Med.  el  Chir.,  March  27,  1896,  p.  283. 

'  Medical  and  Surgical  lieporter,  1896,  vol.  74,  p.  66. 

^  .innals  of  Surgery,  November,  1896. 

»  Medical  News.  March  5,  l.Sii6,  p  64». 

^0  Cenlr.  fur  Chir..  March  20, 1897,  |>.  305. 

"  .irchiv  fur  klin.  Chir.,  Langenbeck,  Berlin,  Bd.  58,  p.  263,  1S99. 


AMPUTATION   OF  BOTH  FEET  UNDER  SPINAL  AN- 
ESTHESIA WITH  COCAIN.* 

By  AUGUSTUS  C.  BEHLE,  M.D., 

of  Salt  Lake  City,  Utah. 

Mr.  President  and  Gentlemen  :^I  wish  to  report  to 
you  this  evening  a  case  of  amputation  of  both  feet  in 
which  I  used  a  subarachnoid  injection  of  cocain  for 
anesthesia.  My  patient,  Mr.  H.  A.  Woodmansee,  on 
New  Year's  Day  of  this  year,  was  thrown  from  his  horse 
while  returning  from  the  mountains  where  he  had  been 
locating  some  mining  claims.  It  was  about  2  a.m.  and 
the  night  intensely  cold,  there  being  4  or  5  feet  of  snow 
on  the  ground.  Mr.  Woodmansee  was  rendered  uncon- 
scious by  his  fall  and  does  not  remember  how  long  he^ 
remained  in  the  snow.  When  he  regained  conscious- 
ness he  did  not  know  where  he  was  and  wandered 


*  Read  before  the  Salt  Lake  County  Medical  Society,  February  U,  1901. 


390 


The  Philadelphia 

Medical  Journal 


] 


AMPUTATION  OF  BOTH  FEET 


IFkbbcaet  23,  1901 


around  until  daylight,  finally  reaching  Ophir.  His 
shoes  were  then  removed  by  cutting  them  to  pieces. 
The  feet  were  immersed  for  4  hours  in  snow  water,  fol- 
lowed by  rubbing  with  olive  oil,  from  11  p.m.  until  5 
A.M.  He  was  then  taken  to  Tooele,  where  he  remained 
under  the  care  of  a  physician  until  the  following  day. 
Being  removed  to  this  city  he  was  placed  under  my 
care;  I  advised.him  to  go  to  St.  Mark's  Hospital.  Both 
feet  were  badly  discolored  and  cold.  One  foot  was  cov- 
ered with  blebs  which  were  filled  with  a  bloody  serum ; 
the  legs  half  way  up  to  the  knees  were  intensely  red,  hot, 
swollen,  and  tender.  The  patient  was  poorly  nourished 
and  intensely  nervous  from  the  exhaustion  and  expo- 
sure. Sustaining  the  strength  of  the  patient,  attention 
to  the  partly  frozen  tissue,  and  avoiding  general  sepsis 
by  preventing  a  moist  decomposing  gangrene,  was  the 
treatment  instituted  for  the  next  three  weeks.  The  line 
of  demarcation  being  well  shown  at  the  end  of  this 
period  and  the  patient  realizing  that  he  could  not  save 
his  feet,  we  decided  upon  amputation. 

In  selected  cases  I  have  been  using  local  and  regional 
anesthesia  in  minor  and  major  surgery  in  place  of  gen- 
eral anesthesia.  The  immediate  deleterious  results  of 
a  general  anesthetic  are  only  too  common  in  our  rou- 
tine use  of  these  agents.  Of  the  remote  results  we  know 
too  little.  I  believe  that  many  chronic  inflammatory 
lesions  of  both  lungs  and  kidneys  could  be  avoided  by 
the  judicious  choice  of  anesthetic  agents.  The  latest 
form  of  regional  anesthesia  is  the  subarachnoid  injec- 
tion of  cocain  solution. 

This  method  has  had  the  careful  attention  of  our 
scientists  for  the  past  few  months  in  a  practical  way. 
"  It  has  been  weighed  in  the  balance,"  and,  in  my 
opinion,  has  not  been  found  wanting.  While  I  am  not 
here  to  advocate  its  use  in  every  case  where  it  can  be 
used,  I  firmly  believe  that  now  we  have  a  new  procedure 
that  will  prove  a  boon  to  suff'ering  humanity.  A 
skilled  anesthetist  is  a  necessary  factor  in  every  major 
surgical  operation,  if  you  wish  to  give  your  patient  the 
care  that  is  necessary  to  avoid  his  succumbing  from  the 
anesthetic  itself.  Gentlemen,  picture  to  yourselves  a 
country  practitioner  amputating  a  leg  with  one  eye  on 
the  knife  and  the  other  on  the  relative  or  friend  giving 
the  anesthetic  under  his  direction.  Probably  he  will 
have  to  leave  his  knife  and  pull  out  the  retracted  tongue 
of  the  patient,  then  wash  his  hands  again— of  course 
he  will  not  forget  this  in  his  haste  to  resume  his  work. 
On  the  other  hand,  think  of  the  same  practitioner  with 
his  hands  sterilized,  inserting  a  needle  into  the  lumbar 
subarachnoid  space,  injecting  a  little  solution,  with- 
drawing his  needle  and  then  proceeding  witli  his  ampu- 
tation with  his  hands  remaining  unsoiled.  No  fear  or 
worry  that  the  patient  will  not  regain  his  conscious- 
ness. When  Dr.  Leonard  Corning  announced  his  dis- 
covery of  this  mode  of  anesthesia  in  1885,  little  atten- 
tion was  paid  to  it,  as  he  did  not  make  a  practical  use 
of  this  method  in  surgical  work.  In  1899,  A.  Bier,  of 
Kiel,  used  the  subarachnoid  injection  of  cocain  by 
means  of  Quincke's  lumbar  puncture  upon  his  assistant, 
Hildebrand,  and  in  turn  was  himself  anesthetized  bv 
this  method.  Following  this,  Tuttier  took  up  this 
work  and  made  the  method  popular.  Experimenting 
for  some  time  with  minor  surgical  cases,  he  began  to 
■do  major  surgical  operations  under  this  anesthesia. 
Before  the  section  on  surgery  at  the  International 
Medical  Congress  at  Paris,  in  August,  1900.  many  major 
operations  were  reported,  and  this  mode  of  anesthesia 
and  operations  following  were  demonstrated.     Reports 


have  followed  each  other  rapidly,  some  writers  advising 
the  use  of  this  form  of  anesthesia  in  every  case  where  it 
can  be  used,  others  advising  its  use  in  selected  ca.se8. 
One  of  the  most  interesting  reports  that  I  have  seen  is 
from  the  pen  of  S.  Marx,  who  studied  its  action  in 
relieving  the  pain  of  labor.  As  he  expresses  it,  "  to 
see  the  parturient  woman  under  the  influence  of  cocain, 
lie  quietly  in  bed,  feeling  only  some  indescribable  sen- 
sation, but  without  pain ;  bearing  down  when  told  to, 
and  giving  birth  to  her  child  without  her  knowledge, 
and  only  cognizant  of  the  fact  when  the  cry  of  the 
newborn  was  heard,"  would  astonish  any  one  of  us  as 
it  did  him. 

To  avoid  the  shock  and  depressing  efifects  of  general 
anesthesia  and  having  had  experience  in  performing 
the  lumbar  puncture  for  diagnostic  purposes,  I  deter- 
mined to  use  this  method  of  anesthesia  on  my  patient. 
Stating  the  case  to  him  he  readily  consented,  as  he  feared 
the  general  anesthesia  more  than  the  operation  itself. 
I  injected  15  minims  of  a  sterile  2%  solution  of  cocain 
into  the  lumbar  subarachnoid  space  and  in  two  minutes 
had  a  profound  anesthesia  of  all  tissues  below  the  tenth 
rib  ;  the  anesthesia  lasting  almost  2  hours.  Assisted 
by  Dr.  Landenberger,  I  rapidly  amputated  the  limbs, 
the  patient  being  back  in  bed  some  time  before  the 
anesthesia  subsided.  I  am  pleased  to  state  very  little 
shock  followed  the  operation.  None  of  the  sequelae, 
such  as  nausea,  vomiting  and  headache,  which  some  sur- 
geons have  reported  after  the  use  of  this  method,  were 
observed.  My  patient  took  a  little  whisky  and  strychnia 
by  mouth  about  half  an  hour  after  the  operation  and  be- 
gan to  take  nourishment  immediately.  He  was  prepared 
the  same  as  for  general  anesthesia  by  having  empty 
bowels  and  stomach,  which  may  account  for  the  lack  of 
headache  and  nausea  in  my  case.  I  wished  to  be  pre- 
pared for  ether  or  chloroform  anesthesia  in  case  the 
regional  anesthesia  was  not  satisfactor}".  The  rise  of  tem- 
perature after  the  operation  was  very  slight,  being  only 
a  fraction  above  99°  F.  My  patient  made  a  rapid 
recovery,  the  stumps  healing  by  primary  intention. 
He  was  discharged  from  the  hospital  on  the  fifteenth 
day  after  the  operation  and  the  stumps  could  be 
handled  with  very  little  pain  to  the  patient.  I  cannot 
see  how  anything  more  could  be  desired. 


SARCOMA  OF  THE  RIBS. 
By  C.  C.  warden.  Ph.B.,  M.D., 

of  NasbTille,  Tenn. 

Professor  of  Anktomjr  and  Operative  Sun^rr  in  the  Medical  Departmeat  of 
the  UniTeraity  of  NasbTllU. 

T.  B  ,  aged  2*.  civil  enerineer.  Previous  health  good  until 
a  year  and  a  half  before  the  present  illness  when  he  was  sick 
for  two  weeks  with  malaria.  In  June.  1S99.  he  had  an  at- 
tack of  intercostal  neuralgia  on  the  left  side.  From  this 
attack  he  recovered  fairly  well,  but  within  a  month  another 
and  more  severe  attack  came  on.  During  August  there  were 
repeated  paroxysms  of  neuralgia  in  the  same  region,  and  in 
September  he  had  three  attacks  of  "  renal  colic,"  all  on  the 
same  side. 

Early  in  October  sciatica  developed  on  the  right  side.  The 
seizure  was  very  severe  and  the  patient  was  taken  to  Hot 
Springs  in  search  of  relief  He  returned  after  a  fortnight, 
unimproved.  There  was  extreme  p.ain  and  tenderness  along 
the  right  sciatic  aad  popliteal  nerves  with  numbness  in  the 
heel  and  some  anesthesia  in  the  leg.  The  t-eniperature  and 
pulse  were  normal. 

Pain  now  made  itself  felt  in  the  scalp  and  neck.  In  the 
middle  of  November  sciatica  set  in  on  the  left  side  and  for  a 


FBBRnART23,   ISOI] 


SARCOMA  OF  THE  RIBS 


TTHK   PHrLADEIJ»HIA 

L  Mhi>ical  Journal 


391 


week  the  man  sufiered  with  paroxysms  of  agonizing  pain, 
when  suddenly  the  sciatica  in  the  right  side  disappeared, 
never  to  return.  Late  in  the  mouth  a  firm,  immovable 
tumor-like  mass  was  made  out  over  the  eight,  ninth,  and 
tenth  ribs  on  the  left.  There  was  no  pain,  tenderness  or 
redness  and  the  overlying  skin  was  freely  movable.  Careful 
questioning  now  elicited  the  statement  that  an  injury  in  this 
region  was  received  from  a  fall  during  a  game  of  tenuis 
nearly  two  years  ago. 

In  December  the  patient  complained  of  failing  sight  in 
his  right  eye.  Emaciation  and  loss  of  strength  now  became 
progressive.      The  abdomen  became  distended  and  tympan- 


FlG.  1. — The  primary  sarcomatous  growth  on  the  ribs. 

itic.  There  was  no  pain,  but  some  tenderness  and  rigidity 
were  observed  in  the  right  iliac  fossa. 

The  patient's  condition  pi'ompted  the  suggestion  of  an  ex- 
ploratory operation,  which  was  accepted. 

The  abdomen  was  opened  on  December  14.  The  viscera 
everywhere  within  sight  and  touch  were  enormously  thick- 
ened, grumous  and  friable.  No  attempt  at  further  procedure 
was  made.     The  patient  died  the  following  day. 

The  autopsy  showed  the  following  conditions  :  Numerous 
hemorrhagic  spots  of  small  size  covered  the  abdomen  in 
irregular  distribution.  On  the  left  side  of  the  thorax  was  a 
mi  derately  firm  mass  elliptical  in  outline,  covering  portions 
of  the  eighth,  ninth  and  tenth  ribs  at  their  middle  third. 
The  right  eye  protruded  prominently  and  was  divergent. 
The  tissues  of  the  scalp  over  the  occiput  were  thickened. 
On  raising  the  scalp  the  tissues  covering  an  area  an  inch  or 
more  in  diameter  resembled  a  superficial  abscess,  exuding 
on  pressure  a  thick  white  substance.  The  thickened  mar- 
gins of  the  supposed  abscess  were  closely  adherent  to  the 
bone,  while  the  center  was  soft  and  communicated  with 
carious,  spongy  bone.  On  the  surface  of  the  dura  directly 
beneath  the  carious  bone  was  a  mass  two  inches  in  diameter 
and  a  half  an  inch  thick,  semisolid  and  grayish  white  in 
color.  The  dura  was  smooth  and  free  on  its  internal  surface. 
The  brain  was  normal.  Beneath  the  periosteal  covering  of 
the  right  orbital  roof  was  a  softened  mass  similar  in  color 
and  consistence  to  that  in  the  dura.  A  chain  of  enlarged 
mediastinal  glands  covered  the  anterior  aspect  of  the  peri- 
cardium, identical  in  appearance,  when  incised,  with  the 
growth  in  the  dura  mater  The  heart  showed  on  the  anterior 
surface  a  grayish-white,  slightly  elevated  spot,  three  quarters 
of  an  inch  in  diameter,  dipping  a  third  of  an  inch  into 
the  muscle.  A  few  small  atheromatous  patches  occupied 
the  first  two  inches  of  the  aortic  lining. 

In  the  left  side  of  the  thorax,  covering  the  middle  portions 
of  the  eiglith,  ninth,  and  tenth  ribs,  was  an  ovoid  mass  the 
size  of  a  child's  head,  adherent  throughout  to  the  visceral 
layer  of  pleura.  The  tumor,  together  with  portions  of  the 
ribs  to  which  it  was  attached,  was  removed  for  further  exam- 
ination.    The  bronchial  glands  were  enlarged. 

The  peritoneum  was  thickened  and  fibrous.  The  omen- 
tum, free  from  adhesions,  was  an  enormously  thickened, 
mottled,  grumous-lookhig  mass,  presenting  here  and  there 
whitish  areas  resembling  small  abscesses.  Many  of  the 
omental  veins  were  thrombosed.  The  mesentery  was  greatly 
thickened  and  some  of  its  glands  were  as  large  as  walnuts. 
The  proximal  portion  of  the  ileum  presented  a  firm  mass, 
about  an  inch  in  length,  involving  one  half  of  the  circum- 
ference of  the  gut  and  located  on  the  side  of  its  mesenteric 
attachment.  'Ihis  growth  involved  all  the  coats  of  the  bowel 
and  projected  a  half-inch  into  the  lumeu,  showing  on  sec- 


tion a  pinkish-white  color.  Further  toward  the  paroximal 
extremity  of  the  small  intestine  was  a  portion  sharply 
curved  on  itself,  uniformly  thickened  and  infiltrated.  On 
one  side,  near  the  mesenteric  border,  the  tissues  were  com- 
pletely disorganized  down  to  the  mucosa  where  the  necrosis 
terminated  in  a  yellow  patch  about  the  size  of  a  lentil. 

The  cecum  was  uniformly  |  of  an  inch  thick,  grayi.sh 
white  on  section  and  deeply  injected  on  its  mucous  surface. 
There  were  no  evidences  of  recent  or  old  ulceration.  The 
appendix  was  5  inches  long  and  sharply  kinked  from  thick- 
ening. Two  obliterating  strictures  were  found  in  it,  the 
dilated  lumen  between  the  cjnstrictions  being  filled  with  a 
translucent  jelly. 

The  liver,  gallbladder  and  ducts  and  the  stomach  were 
normal.  The  pancreas  was  enlarged  and  softened  almost  to 
disintegration.  The  external  appearance  of  the  spleen  sug- 
gested the  presence  in  its  center  of  a  spherical  body  like  a 
tennis  ball.  (Fig.  2.)  On  section  the  pulp  at  the  periphery 
was  normal  in  appearance.  The  center  of  the  organ  was 
filled  by  a  spherical  mass  two  inches  and  more  in  diameter, 
soft,  grayish  white  with  pinkish  and  hemorrhagic  areas  here 
and. there.  (Fig.  3.)  The  kidneys  were  enlarged  and  firm, 
with  capsules  slightly  thickened  and  adherent.  On  section 
the  cortices  presented  a  congested  appearance  and  the  con- 
trast between  cortices  and  pyramids  was  less  marked  than 
normal.  Numerous  grayish-white  masses  of  sizes  varying 
from  bird  shot  to  buck  shot  were  irregularly  scattered 
through  both  organs. 

The  spinal  canal  and  pelvic  contents  were  not  examined, 

Cultures  taken  from  the  softened  portions  of  the  growths 
in  the  dura,  orbit  and  elsewhere  produced  but  one  variety 
of  organism,  the  Bacillus  coli  communi-i. 

Microscopical  e.xamination  of  the  tumor  on  the  ribs  and 
tlie  various  disseminations  in  the  viscera  showed  small 
round-celled  sarcoma.     (Fig  4.) 

The  gross  specimen  of  the  tumor  on  the  ribs  was  of  con- 
siderable interest.  (Fig.  I.)  The  length  was  4J  inches, 
breadth  3|  inches,  the  third  diameter  measuring  2J  inches. 
Fully  two  thirds  of  the  mass  occupied  the  internal  surface, 
the  plane  of  the  ribs  passing  through  the  outer  third  of  the 
growth.  The  mass  was  semisolid  and  on  section  presented 
a  grayish-white  appearance  marbled  with  areas  of  a  delicate 
pink.  The  center  was  red  and  hemorrhagic.  The  growth 
was  of  the  periosteal  variety. 

A  review  of  the  literature  pertaining  to  this  interest- 
ing pathological  condition  gives  for  analysis  a  total  of 


Fig.  2. — Spleen,  showing  central  loc&tion  of  the  spherical  mass. 

73  cases,  including  the  one  herewith  reported.  The 
cases  are  so  few  in  number  that  the  task  of  sifting  out 
cross-references  and  identifying  those  twice  and  thrice 
reported  is  no  idle  one.  This  review  is  intended  to 
embrace  only  cases  of  the  type  imi)lied  in  the  title. 
Consequently  all  tumors  of  the  sternum,  spine  and 
soft  parts  have  been  excluded,  together  with  all  types  of 
tumor  other  than  sarcoma.  All  doubtful  cases  have 
been  omitted.  Gay's  case*  proves  to  be  a  chondroma 
and  is  not  included.     Out  of  the  total  number  of  cases 


392 


The  Philabelphia"! 
Medical  Journal  J 


SARCOMA  OF  THE  RIBS 


[FXBBCABT  23,   IMI 


65  came  to  operation.  By  far  the  ablest  reviews  of  the 
operative  treatment  of  tumors  in  the  chest-wall  are 
those  of  Campe/  Gerulanos,*  and  Parham'  of  New 
Orleans.  Parham's  valuable  monograph  discusses  fully 
all  cases  of  resection  for  tumors  of  all  types  growing 
from  the  bony  wall  of  the  chest.  Some  of  Konig's 
■cases,  rejjorted  by  Campe,  should  be  added  to  his  series. 
Of  the  8  inoperable  cases  one  recovered.  The  total 
mortality  is  48%.  In  operable  cases  a  slight  improve- 
iment  is  observed,  there  being  28  instances  of  recovery, 


Fio.  3. — Spleen  laid  open. 

or  a  mortality  of  38.3%.  If  we  add  to  the  list  of  deaths 
following  operation  the  doubtful  cases  and  those  the 
result-of  which  is  not  given  the  death-rate  rises  again 
to  46.7%.  It  will  be  safe  to  say  that  this  figure  is  not 
excessive,  since  many  of  the  patients  reported  cured  by 
operation  were  not  kept  under  observation  for  a  length 
of  time  sufficient  to  exclude  the  possibility  of  recur- 
rence. Five  cases  in  the  series  give  clear  histories  of 
recurrence,  3  of  which  were  subjected  to  secondary 
operation,  2  died  and  1  recovered.  Fully  5  of  the 
patients  were  males.  In  two  instances  the  sex  is  not 
given.  The  youngest  male  was  10  years  old  and  the 
oldest  66.  The  extremes  of  age  in  females  are  10  and 
45.  No  cases  appear  during  the  first  decade  of  life  or 
after  the  sixth.  Fully  i  of  the  cases  occur  between  the 
ages  of  20  and  30  and  over  §  between  10  and  30.  The 
relation  of  injury  to  the  morbid  process  is  difficult  to 
trace,  and  the  results  of  its  investigation  are  somewhat 
disappointing.  Gross  says  that  trauma  is  an  assignable 
cause  of  malignant  disease  in  i  the  cases.  Dennis  lays 
stress  upon  traumatism  as  being  a  distinct  causative 
factor  in  sarcoma.  There  is  a  clear  record  of  injury  in 
16  cases  only,  or  22%.  A  majority  of  the  writers  do 
not  mention  the  subject.  It  is  probable  that  this  per- 
centage index  is  far  too  low.  The  trivial  nature  of 
many  a  forgotten  injury  is  responsible.  Blows  and 
falls  upon  the  chest  are  causes  most  frequently  Hoted, 
and  fracture  of  the  ribs  comes  last  of  all. 

For  the  sake  of  convenience  the  conclusions  noted 
above  are  arranged  in  the  following  table : 

Whole  number  of  cases,  73. 
Operable  cases,  C5. 
Inoperable  cases,  8. 
Total  deaths,  35.     Mortality,  48%. 

Deaths  in  opernhle  cases,  28.    Mortality,  88.3%.  including 
•doubtful  cases,  4,  and  result  not  given,  2.    Mortality,  46.7  ft . 
Traumatism ,  1 6  —22.  % . 
Males,  47— 64.3%.    Youngest,  10;  oldest,  66. 


Females,  24,  32.8%.    Youngest,  10;  oldest,  45. 

Sex  not  given,  2. 

Ages,  first  decade,  none. 

"      second  decade,  2— 21%. 

"      third  decade,  2.5— 48%. 

"      fourth  decade,  7 — 13  5%. 

"      fifthdecade,  6— 11.5%. 

"      sixth  decade,  2— 3.8%. 

"      seventh  decade,  none. 

Gurlt'  gives  statistics  obtained  from  the  General  Hos- 
pital and  Rudolph  Institution  of  Vienna  covering  49 
cases  of  sarcoma  of  thorax,  ribs,  and  sternum,  of  which 
19  were  males,  21  were  females,  and  9  unknown.  A 
note  says  that  the  data  for  this  class  are  very  unsatis- 
factory, as  in  many  cases  it  is  not  known  whether  the 
soft  parts  or  the  bones  or  both  were  involved.  K 
atttempt  was  made  to  separate  the  cases  into  classe- 
and  it  is  also  stated  that  5  of  the  General  Hospital 
cases  were  in  all  probability  carcinoma.  The  whole 
series  is  accordingly  eliminated. 

My  thanks  are  due  to  Dr.  W.  G.  Ewing  for  many 
privileges  in  connection  with  the  case  above  reported, 
and  to  Dr.  Larkin  Smith  for  the  accompanying  illus- 
trations. 

Since  the  foregoing  review  was  written  the  history 
of  another  case  has  reached  me.  The  patient  was  under 
the  care  of  Drs.  C.  S.  and  S.  S.  Briggs,  of  Naahville. 
and  it  is  through  the  unfailing  courtesy  of  these  gentle- 
men that  I  am  permitted  to  report  it 

Mrs.  R,  Huntsvillp,  Ala.,  aged  35,   multipara,  young<-- 
child  6  years  old.     No  abortions  or  miscarriages.     Gener 
health  good.    Presented  a  hard,  fairly  smooth  tumor,  sess: 
and  firmly  attached  to  the   ribs,  situated  in  the  upper  Ir 
pectoral  or  subclavicular  space,  extending  half  way  to  the 


Fig.  4.— Photomicrograph  of  meiastas^is  in  the  kidney.     iDdlstmct  mnnantj 
of  tubules  may  be  9e«n  here  and  there. 

nipple  below  and  overlapping  the  clavicle  above.  The  inner 
niai-gin  reached  the  sternum  and  the  outer  border  was  lost 
in  the  axillary  space.  There  wa«  no  perceptible  glandular 
involvement."  The  left  arm  and  hand  were  edematous  ar.'l 
the  seat  of  dull  pain.  The  tumor  Wii*  first  noticed  in  Ft : 
ruary,  1900  It  was  painless  and  gave  no  trouble  until  th. 
swelling  in  the  arm  appeared.  She  gave  no  history  of  injurj-. 
X-ray  examination  resulted  negatively  as  no  light  pene- 
trated that  side.  There  were  no  chest  symptoms.  Heart- 
sounds  were  normal,  but  there  was  some  pulsation  in  the 
jugulars.  Operation  early  in  November,  1900.  Three  ounces 
of  A.  0.  E  mixture  were  used. 


Fkbeuart  23,  1901] 


CONGENITAL  UMBILICAL  HERNIA 


rrHE  Philadelphia 
L  Medical  Joubkal 


393 


A  curved  incision  was  made  over  the  tumor  and  carried 
through  the  pectoral  muscles,  exposing  the  neoplasm.  A  fter 
much  eflbrt  the  lower  and  inner  sides  were  freed,  then  the 
upper  side.  The  growth  was  found  to  spring  from  the  peri- 
osteum ot  the  first,  second  and  third  ribs.  In  freeing  the 
outer  portion  the  brachial  plexus,  axillary  artery  and  vein 
were  exposed  The  vein  was  involved  and  would  have 
require  1  resection.  The  tumor  tissus  was  cut  through  to 
relieve  the  vein  and  the  growth  removed  The  intercostal 
muscles  were  infiltrated  and  there  was  evidently  more 
growth  inside  the  thorax  The  wound  was  closed  with 
wormgut  sutures,  and  a  large  rubber  tube  was  used  for  drain- 
age. The  sutures  were  removed  on  the  seventh  daj',  the 
wound  having  healed  well.  The  patient  was  dismissed  on  the 
eleventh  day.  There  can  be  but  one  outcome  eventually 
in  the  case. 

Microscopical  examination  showed  the  growth  to  be  a  sar- 
coma undergoing  myxomatous  change. 

Another  case  has  been  reported  by  Whipple  and 
AVebber.^ 

BIBLIOGEAFHY. 

Aiiuar  ;  Op.  Hiverii,  Culpepper,  London,  1687,  p.  315. 

AlsbiTg:  Arch./,  klin.  Chir.,  Berlin,  1882-3,  xxviii,  p.  733.  By  Caro :  D  ul. 
med.  Woch..  1893,  No.  3,  p.  57. 

Bardelebeo  :  Bericht  u.  klin.  Chir.  TOn  Tillman,  Charitt  Annalen^  Berlin,  six, 
1894,  p.  820. 

Bardelebeo  ;  Ibxd. 

Bardeleben  :  Bt  Plitt,  Inaug.  Diss.,  Berlin,  1890. 

Bayer  :  amratbl./.  Chir..  lf-97.  So.  2. 

Brandl;  Ueber  tineo  Fall  von  Sarcom  der  Rippen,  J.  D.,  Miincben,  1886. 

Buscb,  F.:  Arch  /.  klin.  Chir.,  1872,  xiii,  p.  49. 

Camp:i  Ueber  Xumorei^  der  knochernea  Thoraxwand,  loaug.  Diss.,  Got- 
tlDgen.  1894. 

Cerne  ;  Sajoiu*  Annual,  1889. 

Citta  iini  :  Ann.  Univers.  dc  Med.,  Milano,  1826,  xxxvii,  p.  404. 

Caro,  J  :  Beitr.  z.  oper.  Entfero.  d.  malign.  Rippen-Tumoren,  Deut.  med. 
Woch.,  1893,  So.  3;  Centralbl.  /.  Chir.,  1882,  No.  4-';  ibid.,  1889,  No.  21;  ibid., 
1889.  No.  37. 

Coley  :  Jour.  Am.  Med.  Ass'n.,  August  20-27,  1898,  389  465. 

Dennis  :  Park's  System  of  S^irgery,  p.  293. 

Desquin:  La  Presse  Med.  Belg.,  Aiigust,  1887. 

Doyen :  By  Quenu  et  Longuet,  Eev.  de  Chir.,  May  10,  1898,  p.  399. 

Faure  :  Bv  same,  ibid.,  p.  402. 

Gautier  :  Rev.  Iiilrmat.  de  Med.  et  de  Chir.,  October  25,  1898,  ix.  No.  20. 

Gluck  ;  Experiment.  Beitr.  z.  Frage  d.  Lungenresect.,  Berl.  klin.    ICocA.,  1886. 

Gross:  Trans  Path.  Soc.  Phila.,  1871-3,  1874,  It.  14-18. 

Gurlt:5  Zur  Statist,  der  Geschwulste,  Arch./,  klin.  CIdr.,  1880,  xxv,  pp.  421- 
-467. 

Gay  :  *  Boit.  Med.  Jour.,  1886,  cxiv,  5. 

H.ihn  :  Deut.  med.  Woch.,  1888,  No.  50,  p.  1034. 

Hartley  :  N.  Y.  Med.  Jour.,  April  8,  1899,  p.  4S8. 

Heigl  :  Deut.  Arch./,  klin.  Med..  1889,  Bd.  xlx,  p.  27. 

Heinecke:  By  Meyer,  Inaug.  Diss.,  Erlangen,  18S9. 

Helferich  :  By  Plitt,  Inaug.  niss.,  B-rlin,  1890. 

Helferich:  =  By  Gerulanos,  Deut.  Zrilsch./.  Chir.,  October,  1598,  iliv,  p.  498. 

Helferich  :  Deut.  .irchiv /.  klin.  Med  ,  Leipzig,  1889,  xIt,  pp.  27-42. 

Heyfelder  :  Reject,  und  Amputat,  p.  120  ff.  Beitr.  z.  genauen  Kenntniss  d. 
Thoraigeschwul.,  Berl.  klin.  Woch.,  1868.  No.  9. 

Hueter  and  Langenbeek :  Archiv /.  klin.  Chit.,  1866. 

Humbert :  Ostesiircom  des  Coes,  Ber.  de  Chir.,  1SS6,  No.  4,  p.  297. 

Israel :  Langeiibeck's  .Arch./,  klin.  Chir.,  xx,  p.  26. 

Karevski :  By  Gerulanos,  Deut.  med.  Woch.,  1896,  No.  14. 

Konig  :  Paget's  Surgery  of  Chest,  1896. 

Konig  :  By  Camp*,  vid.  supra. 

Kronlein  :  By  MQIler,  Deut.  Zeitsch./.  Chir.,  1893,  xxxvii,  p.  41. 

Kuster  :  ZurBehandl.  d.  Geschwulst.  u.  s.  w.,  Berl.  klin.  Woch.,  1883,  No.  9. 

Langenbeek  :  By  Israel.  8th  Germ.  Cong,  for  Surg.,  1879,  p.  45. 

Leiserlnck  :  h-\ngeai>€ck^s  Archiv/.  klin.  CTir.,-B(l.  26. 

Maas;  Ueber  d.  Kesect.  d.  Brustw.  bei  Geschwul.,  Verhaadl  d.  Deut,  Gesellscb. 
(.  Chir,  xiT.  Cong.  1885,  pp.  447  ff.;  Archiv/.  klin.  Chir.,  Berlin,  1S86,  xixiii, 
pp.  314  ff. 

Mazzoni ;  Auszug  aus  dessen  "  Annu  secundo  di  clin.  Chir.  nella  Reale  Univ. 
di  Roma  ;"  Schmitt's  J.ihrljucher,  Bd.  167,  1875,  p.  105. 

Meyer,  L.:  Extirp.  d.  malig.  Brustwandtumor  mit  Eroffo.  d.  Pleurahohle,  J. 
D.  Wurtzburg.  1839. 

Mickulicz  :  By  von  Noorden,  Deul.  med.  Woch..  1893,  xix,  pp.  346  ff. 

Mills:  Med.  and  Phil.  Comment,  London,  1777,  v,  pp.  430  6. 

Muller,  W.:  Eiue  Thoraxw.  Resect,  mit  gOnst.  Ausgang,  Deul.  kitsch./.  Chir., 
xxxvii,  1893,  p    41. 

Parham,  F.  W,:  ^  Thoracic  Resection  for  Tumor  Growing  from  the  Bony  Wall 
■  of  Chest,  New  Orleans,  1899. 

Park  :  Annals  o/ Surgery,  1888,  viii,  p.  254. 

Pfeiffer:  Beitr. 'z.  K-^nnlnissd.  Sternaltum.,  Inaug.  Diss.,  Halle,  1834. 

Plitt ;  Zur  Casuist,  d.  Tumoren  d.  Brustw.,  Inaug.  Diss.,  Berlin,  1890. 

Quenu  et  Longuet  :  Rev.  de  Chir.,  May  10,  1898,  p.  400. 

Richerand  :  By  Maas,  .Archiv  f.  klin.  Chir.,  1886,  xxxiii,  314. 

Riesmeyer:  St.  Louis  Oour.  of  Med.,  xv,  p.  513,  1886. 

Sedillot :  By  Gerulanos,  Deul.  Zeitsch./.  Chir.,  October,  1898. 

Senn  :  Bv  Parham,  Gaston  in  Sajous'  Annual,  Bd.  xix. 

Steele:  tbid  ,  P.  and  S.  Plexus,  Chicago,  1898-9.  vol.  iv,  p.  197. 

Tietze:  Beitr.  z.   Resect,  d.   Thoraxw.  bei  Geschwul.,  Deut.  Zeitsch.  /.  Chir. 

Thompson  :  By  Davidson,  Tejas  Med.  Jour.,  1896,  xii,  p.  415. 

Tioniswood  :  Month.  Jour  ,  London,  July,  1344  ;  by  Campe,  vid.  supra. 

Tymaczkowsky  :  By  Campe,  vid.  supra. 

Warren  :  Boston  Med.  and  Surg.  Jour.,  1837,  vol.  xvi,  p.  203. 

Weinlecher  ;  By  Campe,  1876,  vid.  supra. 

Weinlecher :  Zur  Casuist,  der  Tum.  an  die  Brustw.  u.  d.  Behaadl.,  Wien.  med. 
Woch.,  1882,  XX,  xxi. 

Witzel :  Ein  Verlahr.  z.  Beseitie.  des  acut.  nach  Penetrat.  d.  Brustw.  ent- 
stand.  Pneumothor.,  Centralbl./.  Chir.,  1890,  No.  28. 

Wyne  Foote  :  By  Campe,  vid.  supra. 

Zwlcke  ;  Cliarite  Annalen,  18*2,  1884. 

Zarubln  :  Jacobson  Surg.  Oper.,  1897.  p.  581. 

Whipple  &  Webber  :•  Lancet,  November  10,  1900. 


CONGENITAL  UMBILICAL  HERNIA:  REPORT  OF  A 
CASE,  AND  TABLE  OF  CASES  HITHERTO  RE- 
PORTED.' 

By  homer  E.  SAFFORD,  Ph.B.,  M.D., 

of  Detroit,  Mich. 

My  attention  was  caUed  to  this  subject  by  a  case 
which  occurred  in  the  practice  of  Dr.  Geo.  E.  McKean, 
and  was  operated  upon  by  Dr.  F.  W.  Robbins. 

The  child,  a  boy  weighing  about  8  pounds,  had  been  bom 
at  3  o'clock  on  the  morning  of  July  16,  J899,  and  at  11 
o'clock  of  the  same  day  I  was  met  by  Dr.  McKean  at  the 
house  of  the  parents.  The  only  exception  to  the  boy's 
apparently  perfect  development  was  the  presence  in  the  um- 
bilical region  of  a  tumor  of  dark  red  or  purplish  color,  which 
at  its  upper  part  took  on  a  grayish  appearance,  suggestive 
of  the  tissue  of  the  cord.  The  circumference  of  the  tumor 
was  30  cm.  and  that  of  the  pedicle,  taken  externally,  was 
19.5  cm.,  and  the  protrusion  from  what  would  have  been  the 
norm  il  abdominal  surface  was  between  5  and  6  cm.  The 
walls  were  thio,  and,  except  where  the  grayish  appearance 
mentioned  was  present,  there  was  a  decided  transparency  and 
at  first  the  coils  of  intestine  could  be  seen.  Later  this  had  be- 
come clouded  by  the  drying  of  the  outer  covering  o' the  sac. 
When  first  the  child  was  delivered,  this  outer  layer  was 
smooth  and  glistening  like  the  surface  of  the  cord  itself,  and 
th3  area  thus  left  uncovered  by  skin,  almost  equ  1  to  that  of 
the  whole  tumor  The  skin  rose  perhaps  0.5  cm.  upon  the 
pedicle,  and  at  the  lower  border  this  cutaneous  margin  rose 
to  form  an  apron  of  about  3  cm.  width.  The  attachment  of 
the  cord  was  somewhat  t  >ward  the  left  of  the  median  line, 
and  slightly  above  the  center.  Its  structures  were  spread 
out  over  the  surface  after  running  a  little  distance  toward 
the  base  of  the  pedicle  where  its  proper  termination  seemed 
to  be  sought 

The  intestines,  plainly  visible,  could  be  largely  if  not 
completelj-  reduced  w.thout  seriously  affecting  the  child's 
breathing  or  circulation;  but  underneath  the  upper  grayish 
portion  of  the  sac  the  character  of  the  contents  was  less 
easily  determined  and  reduction  was  impossible.  This  por- 
tion was  presumabh'  liver,  and  so  it  proved  on  subsequent 
section  of  the  sac. 

In  the  afternoon  of  the  same  day  Dr.  Robbins  saw  the 
case,  and  the  conditions  were  recognized  as  presenting  littTe 
or  no  hope  for  the  reduction  of  the  hernia,  if,  indeed,  there 
were  any  for  saving  the  life  of  the  child,  under  expectant 
treatment  The  presence  of  adhesions  already  sufficient  to 
I  revent  reduction  was  suggestive  of  peritonitis,  which  must 
folios',  if  it  were  not  already  present.when  the  outer  surface  of 
the  hernia  should  become  gangrenous,  and  allow  the  further 
protusion  of  ihe  peritoneum  and  absolute  evisceration.  The 
intraabdominal  pressure,  it  was  recognized,  would  be  con- 
siderable when  the  contents  of  so  large  a  sac  were  emptied 
into  the  cavity ;  but  the  reduction  of  so  large  a  proportion 
of  the  hernial  contents,  and  the  hope  that  by  means  of  the 
apro  1  of  skin  mentioned,  it  would  be  possible  to  br  ng 
together  the  tissues  so  as  to  close  over  the  defect  when  the 
edges  should  be  vivified,  decided  the  matter  in  favor  of  an 
attempt  to  perform  the  laparotomy.  It  was  impossible  to 
proceed  to  the  operat  on  until  the  following  morning,  and 
the  child,  when  this  was  done,  was  30  hours  old.  After 
preparation  and  under  chl  roform  anesthesia,  the  hernia 
was  again  examined  and  reduction  still  found  impossible  to 
complete.  The  incision  into  the  sac  was  in  the  median  line 
through  the  lower  thinner  portion,  the  contents  being  found 
as  above  described.  Even  the  stomach  and  spleen  appeared 
at  the  hernial  opening.  This  opening  through  the  neck  of 
the  sac  was  about  4.5  by  5  5  cm.,  anS  the  liver,  which  had 
filled  in  its  upper  part,  making  a  definite  estimate  of  its 
size  impossible  before  section,  was  tied  to  the  inner  wall  of 
the  sac  by  broad  adhesions.  Another  previously  uncertain 
factor,  the  intraabdominal  pressure,  was  the  final  obstacle 
which  determined  the  necessity  of  withdrawing  from  thg 
operation.  So  long  as  the  external  opening  was  left  large 
enough  even  for  examination,  the  eventration  was  almost 
uncontrollable,  and  \\  was  finally  decided  that  it  would  be  a 
needless    proceeding  to    attempt  the  resection,  as  it  had 

^  Read  be.'ore  the  Detroit  Medical  Society,  October  81, 1900. 


394 


Thk  Philadklphla"! 
Medical  Journal  J 


CONGENITAL  UMBILICAL  HERNIA 


[Feeecaby  2»,  1901 


been  planned,  before  suturing.  The  wound-edges  were 
brought  together,  and  an  antiseptic  dressing  appHed.  The 
child  recovered,  took  nourishment,  and  had  a  number  of 
movements  of  the  bowels  before  the  peritonitis  developed, 
which  was  the  inevitable  end  of  the  picture.  The  outer 
membrane,  of  course,  became  gangrenous,  but  the  wound 
itself  made  marked  progress  in  the  matter  of  granulation  in 
the  4  days  before  death.     No  autopsy  was  obtained. 

It  was  not  possible  to  determine  any  other  case  of  arrested 
development  in  the  parents  or  relatives.  The  mother,  aged 
26,  was  a  primipara  and  had  had  a  favorable  term  of  preg- 
nancy with  no  unusual  disturbance,  physical  or  mental. 
Syphilis  was  not  an  element  in  the  case.  It  is,  perhaps, 
worth  noting  that,  on  April  12,  1900,  after  three  weeks  of 
albuminuria,  rapid  pulse,  and  marked  weakness,  the  mother 
bore  her  second  child  dead,  at  seven  months. 

In  general  this  class  of  cases  has  presented  a  prospect 
anything  but  favorable  to  the  practitioner  and  even  to 
the  skilled  surgeon  under  whose  observation  it  has  come. 
Up  to  the  coming  of  antiseptic  practice  there  was  little 
to  do  but  wait  and  hope.  The  expectant  treatment  had, 
with  a  few  exceptions,  been  the  only  method  adopted 
up  to  1882  ;  aside  from  this  the  most  common  being 
some  manner  of  ligature  ajjplied  to  the  sac  after  reduc- 
tion, although  two  or  three  cases  of  successful  laparot- 
omy followed  by  suturing  had  been  recorded  before  this 
date. 

Lindfbrs,  whose  table  of  cases  reported  as  cured  pre- 
vious to  1882  (Part  I  of  the  writer's  table),  is  accepted 
as  authoritative,  includes  34  such  cures.  Of  these  cases 
he  cites  two  as  having  had  the  radical  operation,  strictly 
speaking.  They  were  Berard's  case,  about  1836  (No.  9), 
and  that  known  as  the  Ferraracase(No.  13),  imperfectly 
reported  but  briefly  referred  to  by  Cruveilhier.  One 
other,  that  of  Treves  (No.  35  of  the  writer's  table),  is 
mentioned  by  Lindfors  but  not  included  in  his  table  be- 
cause the  child  died  shortly  after  what  Treves  claimed 
was  a  really  successful  treatment.  The  last  case  (No. 
36)  is  one  to  which  Treves  refers  in  the  report  of  his  own 
case  and  there  seems  to  be  no  reason  wh)'  it,  at  least, 
should  not  be  included.  Lindfors  himself  probably  did 
the  first  successful  operation  by  laparotomy  and  sutur- 
ing under  antiseptic  conditions  ;  and  so  he  believed  that 
a  new  era  in  treatment  and  a  new  series  of  cases  should 
be  considered  as  beginning  with  his  own.  His  first 
table  takes  account  only  of  those  cases  reported  cured 
up  to  the  time  he  began  his  work,  and  the  results  he 
found  may  be  briefiy  summarized  as  follows  : 

Cases  of  successful  treatment 34 

Cases  under  purely  expectant  treatment 22 

Cases  treated  by  simple  circular  ligature  of  the 

sac  after  reduction 6 

Cases  with  simple  ligature  combined  with  a  purse- 
string    suture  (No.  o) 1 

Cases  with  simple  ligature  after  opening  the  sac 

to  separate  adhesions  of  the  liver  (No.  19) 1 

Cases  with  pen-utsneous  ligature  (Nos.  83  and  34)  2 
Cases   with    laparotomy,    freshening   of   wound- 
edges,  and  sutering  (Nos.  9  and  13) 2 

The  expectant  treatment  in  this  earlier  period  consisted 
of  some  form  of  protective  dressing  to  aid  primarily  in  the 
reduction  and  support  of  the  tumor,  and  further,  it  was 
the  aim  to  prevent  the  gangrene  of  the  outer  membrane 
and  the  mucous  tissue  before  the  granulations  had  en- 
closed the  underlying  peritoneum.  In  more  recent  years 
some  few  cases  have  still  to  be  left  to  this  treatment,  and 
in  the  light  of  a  more  careful  aseptic  technic  such  cases 
should  not  be  considered  destitute  of  hope  with  respect 
to  life.  As  regards  the  ultimate  perfect  ctu'e  of  the  her- 
nia, of  course  less  can  be  expected.     It  is  to  be  the  aim, 


in  this  treatment,  to  avoid  irritation  at  all  hazards. 
Measures  that  cause  a  too  hasty  desiccation,  as  well  as 
anything  that  would  tend  to  macerate  the  coverings, 
are  to  be  avoided.  The  normal  mummification  of  the 
cord  should  be  considered  the  due  course  of  this  process, 
and  a  strict  asepsis  is  to  be  maintained. 

Operative  treatment  may  be  said  to  have  been  begun 
when  the  reduction  of  the  hernial  contents  was  followed 
by  a  simple  circular  ligature,  which  aimed  to  cause  suf- 
ficient adhesion  of  the  neck  of  the  sac  to  aid  in  bridging 
across  the  defect.  Another  step  was  taken  when  a  purse- 
string  suture  was  thrown  around  the  neck  of  the  hernia, 
and,  finally,  this  method  reached  its  climax  in  the  so- 
called  percutaneous  ligature,  usually  described  as  Breus' 
operation.  In  this  measure  the  particular  added  feature 
was  a  clamp  provisionally  appUed  to  the  pedicle  after 
reduction,  which  should  maintain  the  latter,  while  two 
needles  upon  the  same  thread  were  passed  about  1  cm. 
apart  immediately  below  it.  The  thread  or  ligature  was 
then  cut  at  each  of  the  needles  and  thus  three  sepa- 
rate ligatures  formed,  and  these  each  contained,  when 
tied,  its  own  portion  of  the  neck  of  the  sac.  Breus 
claimed  especial  advantage  for  his  operation  in  only  a 
limited  class  of  cases,  viz.,  those  where  not  too  wide  a 
defect  existed  in  the  abdominal  wall,  and  where  the  skin 
rose  far  enough  upon  the  tumor  to  furnish  a  cutaneous 
ring  upon  which  to  apply  the  clamp  and  through  which 
to  pass  the  ligatures.  It  could  be  applied  only  in  cases, 
too,  where  the  contents  of  the  sac  were  completely  redu- 
cible, or  exceptionally  where  a  small  loop  of  intestine 
remained  adherent  which  could  be  separated  and  re- 
duced by  incision  of  the  sac  after  the  clamp  was  appUed. 
In  one  of  Breus'  cases  he  found  a  persistent  adherent 
diverticulum  of  Meckel  which  he  included  in  the  hga- 
ture  and  carefully  tied  with  the  other  tissues.  This 
author  claims  for  his  operation  a  very  satisfactory  man- 
ner of  healing  and  a  firm  cicatrix,  but  the  critics  have 
largeh"  admitted  the  claim  that  the  method  holds  open 
the  possibility  of  setting  up  a  peritonitis  by  taking  up 
small  portions  of  only  partially  reduced  intestine. 
Fleischmann,  from  Breisky's  clinic  in  Prague,  reported 
that  the  vermiform  appendix  was  caught  upon  the  nee- 
dle. Breus  in  reply  says  "  this  rare  misfortune  is  not 
difficult  to  avoid  if  the  sac  is  opened  and  examined  "  after 
the  clamp  is  applied  and  before  the  ligatures  are  passed. 
He  certainly  accomplished  two  very  satisfactory  results 
and  in  another  the  wound  conditions  were  essentially 
perfect.  A  practical  point  he  offers  in  favor  of  the 
method  is  the  possibility  of  carrying  it  out  on  short  no- 
tice, under  conditions  unfavorable  for  elaborate  prepara- 
tion and  the  skilled  assistance  needed  for  laparotomy 
and  suturing.  It  is  needless  to  add  that  this  operation 
must  be  carried  out  under  conditions  as  rigidly  aseptic 
as  though  the  greater  surface  were  exposed.  It  is  not 
maintained  as  the  perfect  operation,  but  historically  it 
is  interesting,  and,  practically,  may  be  useful. 

In  Berard's  case  we  see  a  foreshadowing  of  the  prac- 
tice of  Lindfors  and  that  which  is  considered  proper 
for  all  favorable  cases  today.  That  his  case  recovered 
may  be  due  to  an  unusual  tolerance  on  the  part  of  his 
patient ;  but  to  Benird  must  be  given  the  credit  for  ap- 
proaching in  a  rational  manner  the  treatment  of  this 
condition  at  a  time  when  the  weight  of  opinion  was 
against  him.  Oken,  in  ISIO.  is  said  to  have  suggested 
the  idea  of  radical  operation,  but  no  claim  is  made  that 
he  knew  of  :uiy  cjise  where  it  had  been  successfully  j>er- 
formed.  Somering  in  ISll,  Malgaigne  in  1S40.  and, 
even  as  late  as  ISSO,  Konig  and  Vogel  are  quoted  as 


February  23, 1901] 


CONGENITAL  UMBILICAL  HERNIA 


TThe  Philadelphia  395 

L  Medical  Journal  ^^'J 


Recorded  Cases  of  Hernia  Funiculi  Umbilicalis. 

I.— LINFORDS"  table  OF  CASES    REPORTED   CURED,  PREVIOUS  TO  1882.     {Volkmann' s  Sammlung  Klinischer  Vortrdge,  N.  F.^  No.  6$,  189$.) 


1    Storeh. 


LobBtein, 


3  ,  Uerold. 


4    Hey. 


HamiltoD,  Cooper. 


Schneider. 


BBPERENCE. 


7    Ribke. 


8  Mailer. 

9  B6rard. 

P.  G.  CedeTBkjold. 

fin 
land). 


12 


Pau&roli. 


13  House-Surgeon    Id 

Hospital    in    Fer- 

rara, 

14  Regiiio. 


16  Goyrand. 

17  f  jet  to. 


18    Thelu. 


19    Pochhammer. 


Herrgott. 


Therap.  und  prakt. 
Abhandlungen  von 
Kindfcrht.,  Eise- 
nach, 1751. 

Buchholz :  Disser- 
tatio  de  hepat- 

omphalocele.  1768. 
Starke :     Archiv  fur 
Geburtshiife,  Jena, 
1787. 

Pract.  ObBerTatioijs 
in  Surg.,  London, 
1801. 

Case  XV  in  Cooper's 
Aoat.  EDd  Surgical 
Treatment  of  In- 
guinal and  Umbil- 
ical Hernia,  Vol.  11. 

Allgeriieine  med.  An- 
nalen,  Altenburg, 
1819. 

Rust's  Magazin  f.  die 
gesammte  H  eil- 
kunde,  1820. 


Rust's  Magazin,  1823. 


Schmidt's  Jahr- 
bucher,  1836 ;  and 
Jour,  des  connaiss. 
medic,  et  diet,  de 
medicin.  1840. 

Forlossningskonst, 
Stockholm.  1839, 
Vol.  Ill,  p.  162. 

Archiv.  gen.  d.  med. 
Also,  Mag.  d.  ausl. 
Litter,  d.  ges.  Heil- 
kunde,  Hamburg, 
1830. 


Cruveilhler:  In 
Cooper's  "  Path- 
oloiiie  generale," 
Vol.  1.  p.  604,  1849. 

Referred  to  by  Cru- 
Teilhier  in  "  Parh- 
ologie  generale." 

Gaz.  med.  de  Paris, 
October,  1832. 


Bulletin    de   Thera- 
peutique,  T.  53. 


Hale. 

Male. 
Male. 

Male. 

Female 


Female 


Male. 


Female 


Male. 


Male. 


DESCRIPTION. 


Lai^  as  a  me- 
d  i  u  m-si  zed 
apple.  Cord  at- 
tachment, cen- 
tral. 

Hernia,  3  inches 
in  diam eter. 
Contained  liver. 

As  large  as  a 
coffee-cup.  Cord 
aiiached  at  ihe 
lower  segment. 

As  large  as  a 
hen's  egg. 


Coils  ofintestine. 


Size  of  a  closed 
fist. 

Hernia,  2  inches 
in  diameter. 

Motion  of  intes- 
tines visible 
through  mem- 
branes. 


TBKATUEST. 


I 


Repression    and    com-   Healed  after  The  meconium  could  be  seen  through  the  coTcrings 
pressing  bandage.        '    6  weeks.        [    in    the   intestine.     Compression    maintained    by 

means  of  sirip<<  of  pla.ster  in  form  of  a  cross.  Child 
,    was  living  14  years  later. 

Simple  protectivedress-  Healed  after    On  the  third  day  the  outer  membrane  was  cast  oB. 
ing.  j    4  weeks.        ;    Cbild  died  some  time  later  of  whooping-cough. 


Simple  protective  dress-  Healed,    but 


ing. 


time 
given. 


Dressing  at  first  consisted  of  lead- water  compresses ; 
later,  of  linen  covered  with  cerate. 


Compressing  bandage.   'Healing  in  15'  Dressing  consisted  of  several  star-shaped  pieces  or 
j    days.   Cord  j    plaster  laid  one  upon  another,  and  over  this  a 
I    came  away      bandage  with  a  cushion-like  filling  in  one  end. 
on  eighth,     i 
Ligature   and  suturae    Healed  alter    After  hernia  was  reduced  and  sac  ligated,  edges  of 
circumvolutae.  !    some  days.       hernial  opening  were  brought  together  t>y  irana- 

I  fixion  wiih  silver  pins,  around  which  thin  strips 

of  adhe>ive  pla^ttr  were  wound.     Case  sometimes 
cited  under  name  of  A.  Cooper. 
Reduction    and    com- 1  Healed  after   Several  compresses  over  one  another  and  bandage 
pressing  bandage.        \    11  days.        I    applied  over  all. 

Simple  protective  dress-  Healed  after  ,  Reduction  not  attempted.    Sought  to  protect  hemi» 


IDg. 


As  large   as  a  |Reduction  and  ligature. 

closed  fist  and 

with    narrow 

neck. 
Adhesion  of  in-   Radical  operation. 

te^tine  to  sac. 


Hernia,  1  inch  in 
diameter. 


Ligature. 


4  weeks.  On 
second  day, 
opacity  of 
membranes; 
on  third, be- 
ginning des- 
quamation. 
Underlying 
gran  ula- 
tions. 
Healed  after 
3  weeks. 


from  all  pressure.  Cloth  wound  around  it,  and  a 
loosely-applied  bandage  over  it.  Child  died  a  year 
later  of  "dentition  fever,"  and  autopsy  showed  a 
separation  of  2%  inches  between  jhe  musculi  recti 


Largest  known  Reduction, ligature, and 
umbilical  cord  protective  dressing. 
hernia.  7  iuches 
(rhenish)  in  di- 
ameter. Con- 
tained "most  of 
the  abdominal 
viscera," 


When  reduction   Simpleprotectlvedress- 
w  a  s     effected,      ing. 
child  had  an  at-  , 
tack  of  syncope. 

Radical  operation 


Healed  after 
3  weeks. 


Healed  in  10 
weeks. 


Annates  de  chirurg, 
1844. 

Orliac  refers  to  this 
case  as  occurring  in 
1S60.  Also,  Lind- 
fors,  in  CentralbL 
f.Gyn.,1884,  No.  30. 

Jour,  de  Chirurg.  de 
M<ilgaigne.  1864. 


Casper's   W  o  c  h  e  n  - 

I    schrift,  1846. 


In  Debout'a  Memoire, 
com mu  n icated  i n 
1860.  (From  year 
1846.) 


Male. 


Female 


As  large   as  a    Simple  protective  dress- 
clo-^ed  fist.     At-      ing. 
tachment  of 
cord,  central. 

Snail   hernia,   Simple  protective  dress- 
projecting  4cm.      ing. 
Diameter,  7  mm. 


As  large  as  half 
an  apple. 


Circumference  ol 
hernia,  24  cm. 
Openiug  3  cm. 
in  diameter. 

Large  as  a  goose's 
eeg.  Liver  in 
the  hernia  and 
adherent. 

As  large  as  half 
an  ordinary 
apple.  Cord  at- 
tached at  the 
right  side. 


Simple  protective  dress- 

Simple  protective  dress- 
ing. 


Compressing  bandage. 


Radical  operation. 

Incision  of  sac. 

Separation  of  liver. 

Reduction. 

Ligature. 
Simple  prote«Uvedresa- 

ing. 


Healing,  but 
time  not 
given. 

Healing,  but 
time  not 
given. 

Healed  after 
more  than  | 
50  days.        \ 

On  thirteenth, 
day,  cord 
f  el  I  away, 
together 
with  the 
outer  mem- 
brane. Lay- 
er of  granu- 
lations be- 
neath. Beal- 
ing  on  for- 
tieth day. 

Healing. 

Healing  after 
7  weeks. 
Was  seen 
again  after 
17  vears. 

Healing  in  27 
days. 


Sac  incised.    Adhesion  separated.    Bowel  reduced. 
Skin-edges  approximated  with  sutures. 


When  the  ligature  was  applied,  the  area  uncovered 
by  skin  measured  2  inches  in  diameter.  Covered 
with  lint  dipped  in  red  wine  and  over  this  a 
bandage.  On  third  day,  when  the  swelling  had 
relaxed,  a  new  ligature  above  the  first  was  applied 
and  the  skin  drawn  together  with  adhesive  plaster. 
On  fifth  dav,  latter  was  renewed.  Then  the  outer 
membrane,'  at  the  edge,  began  to  desquamate. 
Some  pus  came  forth  and  granulations  showed 
beneath  it.  Later,  when  more  of  the  membrane 
was  shed  and  the  purulent  discharge  was  very  free, 
the  dressing  was  changed  to  compresses,  soaked  in 
a  decoction  of  willow-bark  with  alum. 

Over  the  hernia  the  omentum  of  an  animal  just 
killed  was  laid.  Sometimes  referred  to  as  Cru- 
veilhier's  case. 

First  case  reported  where  wound- edges  were  fresh- 
ened before  suturing.  This  treatment  is  not  counte- 
nanced by  Cruveilhier. 

After  hernia  was  reduced,  child  became  q"\«- 
Dressing  consisted  of  cerat**  plaster  spread  with 
almond-oil,  and  over  this  a  flannel  bandage. 

Child  showed  no  discomfort  from  pressure  on  sac 
Immediately  after  healing,  bilateral  inguinal 
heruia  appeared.  Child  died  3  months  later ;  cause 
unknown. 


Child  lived  2'4  months,  and  wound  neaaly  healed^ 
when  death  occurred  from  intercurrent  affecti  >n. 

Dyspnea  caused  bv  pressure  upon  the  sac;  also,  on 
nursing.  Dressing:  Pieces  of  lioen  covered  witb 
oil,  and  over  this  a  bandage. 

On  the  tenth  day  convulsions,  which  soon  ceased. 


Healing,  but    Cicatrix,  size  of  a  dollar  and  yielding,  so  that  a  pro- 
t  i  m  e   not      trusion  of  size  of  fist  remained, 
stated. 


Heating,  but 
time  not 
stated. 


Often  cited  as  Debout's  case. 


396 


The  PHILADKLPUliT 

Uedical  Jodbnal  J 


CONGENITAL  UMBILICAL  HERNIA 


[FSBBUAXT  23,  1901 


21 


22 


23 


BBFBBENCE. 


26 
27 

28 
29 

SO 

^1 

52 
33 


56 


Reutermann. 

Margariteau. 

Kraemer. 

Tbudicbum. 
Rose. 

Guersant. 
Raymondaud. 

Cooper,  Forster. 
Chamorro. 

6.  Aogers. 

Fear. 

Th.  Bryant. 

Tt).  Bryant. 

C.  Breus. 
Treves. 


Vifiik  (Malaga). 


Hygiea,  1861,  p.  747.    I  Male. 


First    in    commuui-    Male, 
caiiou    to    Bulletin 
de    Therajjeutique, 
1855.      (Kroui  year 
1847.) 


DBSCBIPTIOK. 


TBBATMBNT, 


Zeitscbrift  f.  ration. 
Med..  1853. 


Vierleljabrsachrift  f. 
prakt.  Heilkunde, 
1853. 

Monatsscbrifl  f.  Ge- 

burtskuude,  1868. 
Lindlors:  Centibl. 
t.Gyn.,1881,  No.30. 


Mentioned  by  Orliac, 
1877.  (From  year 
1860.) 


Published  in  "Bulle- 
tin de  la  Sou.  de 
Med.  de  la  Jlau  t- 
Tienne,"  1868.  \ 
(From   year  1861.) 

In  Holmes'  Surgical 
Diseases  of  CU  i  1- 
dren,  1869. 

Amfitreairo  anatom- 1 
ico  Kspanol,  1875. 


First  published  in 
OrUac's  Ihesif,  1877 
Also,  Lindfors'  ar- 
ticle in  Centrbl.  fiir 
Gyn.,1884,  No.30. 


Female 


As  large  as 
child's  bead. 
Contained  i  n- 
tes 1 1 n  es  and 
part  of  liver. 
Skin  spread  up- 
ward 1  inch  on 
the  hernia. 

Size   of  large 
beo's  egg. 


1 


Reduction 
ture. 


and     Itga- 


Healiog. 


Simple  protectivedress- 
ing. 


Operation  14  bour^  afu-r  birtb. 


Dressing:    Cerate-lint  and  bandage.    Patient  was 
seen  again  after  13  years. 


Male. 


CompressiDg  bandage. 


As  large  as  a 

closed    fist. 

Liver  adberetit 

in  the  sac   Cord 

attached   below 
I    and  at  left. 
Circumference,  I  Reduction     and     Uga- 

16  cm. ;  2%  cm.  I    ture. 

high. 


On  eighteenth 

day,    cord 

came  away. 

Recovery ; 

after  some- 1 

what   more  ■ 

than  on e  i 

month.  ' 

On    seventh  '  Dressing :  Long  adhesive  plaster  strips  over  a  piece 

day,  cord  of  linen  smeared  with  cerate.  Died  of  eclampsia 
3  weeks  after  healing.  Autopsy  showed  2^  inches 
separation  between  musculi  recti. 


Male. 


As  large  as  a 
child's  bead. 
Liver  in  sac. 
Irreducible  o  n 
accouiit  of  ad- 
hesions. 


As  large  as  half 
an  apple.  Open- 
i  n  g  measured 
6  cm. 


Female!  Stellate.  Circum- 
ference, 24  cm. 
Opening,  3  cm. 
Cord  inserted 
centrally. 


Brit.  Med.  Jour,  1878. 


Female 


Rat  her  large  her- 
nia. 


As  large  as  an 
orange.  Liver 
in  the  sac. 


Pract.  of  Surg.,ihird 
edition,  1879. 

Pract.  of  Surg.,  1879. 
(Operated  upon 
July,  1876.) 

Wiener  med.  Woch- 
enscbrift,lt*8l.  Also, 
8amm  In  nK  klin. 
Vortriige,  1893,  No. 
77. 


London  lancet,  1881, 
1, 3'23.  [Mentioned 
by  Lindfors,  but, 
not  included  lu  bis 
table  as  cured.] 


.  I  I^arge   hernia, 
I    containing  liver. 


Simple  protective  dress- 
ing. 


Simple  protective  dr..'] 
ing. 


Compressing  bandage. 


Simple  protective  dress- 
ing. 

Simple  protective  dress- 
ing. 


Simple  prot«ctiTedress- 
ing. 


came  away. 
Onthesiity- 
fifth,  heal- 
it.g 
Uealing  in  36 
days. 

Vain  attempt 
at  reduction 
by  another 
su  rgeon . 
Afterward, 
again  ex- 
pectant 
treatment. 

On  ninth  day. 
cord  and 
outer  mem- 
brane came 
away. 

U  e  a  1  e  d  on 
thirty-ninth 
day. 


Od  sixth  day, 
cord  came 
away.  Heal 
ing,  but 
time  not 
stated. 

On  sixteenth 
day,  cord 
came  away. 
Healing 
only  after 
11  weeks. 

Healing,  t^ut 
time  not 
stated. 

Healed. 


On  sixteenth  day  wound  cleared  up.  and  in  twelfth 
week  was  healed.  Dressing:  Zinc  ointuient  and 
bandage;  afterward,  solution  of  Fllver  nitrate. 
Child  died  of  diarrhea  3  weeks  after  healing.  Au> 
topsy  :  Separatiuii  of  almost  6  cm.  between  mus- 
culi  recti.  Cicatrix  2%  cm.  broad  ;  from  the  peri- 
toneum, to  which  the  liver  ai^o  was  firmly 
adherent,  it  was  not  to  be  separated. 

Cerate-linen  and  bandage. 


Dressing :  Cotton-tampon  and  disk  of  cork  with 
bandage.  After  one  dav,  pressure  symptom?  com- 
pelled the  removal  of  iKe  cork  disk.  No  bathing. 
On  sixth  day,  the  gangrenous  remains  of  the  outer 
membrane  were  removed  and  fresh  granulations 
found  covering  the  intier  one. 


The  course  was  "interrupted  by  an  attempt  at 
operation."  Local  phle>«iiis.  Fecal  Tomitiog.  Soor. 
Improvement  and  recovery. 


Compresses  with  "  vin  aromalique**  and  bandage. 


Male. 


Female 


Male. 


Idem,  1873,  I,  829. 
[Not  mentioned  by 
Lindfors.  J 


Large  as  a  hen's 
egg.  Contained 
cecum. 

Size  of  a  hen's 
egg.  Contained 
only  coils  of  in- 
testine. Open- 
ing, 3  cm.  in 
diameter.  i 

In  base  of  cord.  ; 
swelling  size  of 
bnnt;)m  s    egg. 
Almost  abso- 
lutely   irreduc   I 
ible.     Opening,  j 
size    ot    adult, 
thu  mb.     Con-  [ 
tents:  2  inches  i 
of  ileum,  whole  ' 
of  cecum,    and 
vermiform    ap 
p  e  n  d  i  X .     Ce-  ! 
cum  largely  ad- 
herent.  Firmly 
strangulated. 

Size  of  hen's  egg. 
Very  thin  and 
t  ransparen  t. 
Opening,  size  of 
a  pencil.  NVhen 
seen,  sac  was 
ruptured,  and 
eventration  in- 
cluded cecum 
and  appendix, 
ascending  and 
transverse  co- 
lon and  greater 
part  ol  small  io- 
teetioe. 


Ligature. 

Simple  protective  dress- 
ing. 

Reduction    and    per- .  Healed. 
cutaneous  ligature.      | 

I 
Reduction    and    per-  '  Healed. 

cutaneous  ligature. 


Radical  operation.  .\t 
first  incision  along 
the  whole  length  of 
tumor  in  median  line. 
Abdominal  opening  | 
enlarged.  Gas  In  in- 
testine relieved  by 
Suneture  with  hypo- 
ermic  needle.  Re- 
duction. Harelip-pins, 
including  i^eritoneum. 
Silk,  through  skin  , 
only. 


Recovery  in  7 
days,  wound 
healed,  but 
dit  d  after  3 
weeks  from 
d  iar  r  h  ea, 
followed  by 
convulsions. 
Had  left  hos- 
pital cured. 


The  serosa  gpranulated.  formed  a  cicatrix,  and  thus 
gradually  pressed  the  hernial  contents  b«ck. 

The  boy  was  living  2  years  later. 


Operation.  20  hours  after  birth.  After  reduction. 
temporary  closing  of  hernial  opening  by  means  of 
forceps;  afterwani.  perciiuneous  ligature  and  re- 
moval of  sac  with  Paquelln'c  thermocautery.  Anti- 
septic dressing. 


*een  day  after  birth.  Operation  refused,  but  granted 
next  day,  when  peritonitis  and  exhaustion  were 
advanced.  No  movement  of  l«owel!>.  Vomiting. 
Operation  under  chloroform  GO  hours  after  t>irth. 
laaprovement  began  within  12  bour^  Copious 
movement  of  bowels.  Took  nourishment  next  diy. 
No  vomiting.  Pins  removed  at  36  hour^.  Wound 
supponevi  bv  strapping.  Examinaiioo,  day  hefore 
death. showed  scar  tirm  and  well  healed,  iu  appear- 
ance like  normal  umbilicus.  Operaiion  was  with- 
out antiseptic  precautions. 


Reduction,  with  diffi- '  Wound  closed  Wound  healed  by  granulation,  which  for  a  time  w 
culty.    Skin-edges  se-      rapdly.  At       excessive,  and  the  fungous  growth  was  ticaled. 
curwi    by   tomiwrary      end    of    5 
clamp    and    sutured      weeks,    pa- 
with  wire.  tient  strong 

and  healthy. 


Fkbrdart  23,  1901] 


CONGENITAL  UMBILICAL  HERNIA 


TThe  P 
L  Medic 


DicAL  Journal  ' 


II.— LINDFORS'  TABLE  OF  CASE3  OF  HERJTIA  FUl^ICOLl  UilBILICALlS,  1332-1891.    {Volknann's  Sammlung  ktin,  Vortrdge,  N.  F.,  N0.6S,  1893.) 


1   A.  O.  LiDdfors. 


■2    Krukenberg. 


3   Bonaldson. 


4    Breisky,      Fleisch- 

mano. 


o   Pageostecher. 


6    Felsenreich. 


7    Good  lee. 

s    .Soud&D. 


9    C.  W.  RobinsoD. 


10    Harries, 
11 


13 


18 


S.  V.  Hofsten. 
Caldwell. 

ObhauseD. 


14  FleischmanD. 

15  R€ut«r. 

16  I  Stjpinski. 

17  RoberUon. 
I    18  j  Piperno. 

19  DuDlap. 

20  Dohrn,  EckerleiD. 


91 


Pbenomenoff ,  Stoly- 
pinekj. 


Auvard. 


REFERBNCB. 


Hygiea,  Stockholm, 
Jan.,  1882;  Jiord. 
Med.  Archiv.  IV, 
1883;  Centrbl.  fur 
Chirurgie,  1882, 
No.  49;  Centrbl.  fur 
Gynak.,1884,Xo.30; 
Centrbl.  fur  Gy  Dak., 
1889,  No.  23;  Samm- 
lung klin.  Vorlrg., 
1893.  N.F.,  No. 63. 


Arcbiv  fur  GynSk., 

1882,  II,  XV ;  Cen- 
trbl.   fur    Gynak., 

1883,  No.  1. 


Male. 


DBSCRIPTION. 


TREATMENT. 


Male. 


Tr.  Edin.  Obst.  Soc, 

1882-1883,  VIII,  101. 
I 
Pragermed.Wochen- '  Male. 

schrift,  1882;   Cen- 
trbl.   lur    Gynak., 

1883. 
Bulletin    gen.   de 

Therapeuiique,1883; 

Vircbow-  Hirscb 

Jahrbucher,  1SS3. 
Wiener  med.  Presse, 

18S3;    Lindfors, 

Centrbl.     f.    Gyn., 

1889,  No.  28. 


Med.  Times  and  Gaz., 
1883. 


Hygiea,  1883,  146; 
Lindfors,  Cfntrbl. 
fur  Gyn.,1889,  No. 


Lancet,  1883 ;  Vir- 
cbow-Hirsch  Jahr- 
bucher, 1883. 

Lancet,  1886,  II,  773. 


Hygiea,  1886.  Female 


Trans.  Gyn.  Soc.  of 
Chicago,  1886;  Cen- 
trbl. fur  Gynak., 
1887,  No.  2. 

Archiv  fur  Gyn5k.,    Female 
1887,  XXIX. 


Prager  med.  Woch-  Female 
enschr.,  1887;   Cen- 
trbl.   fUr    Gynak., 
1887. 

Geburtsh.  Gesell- 
achaii  von  Ham- 
burg ;  Centrbl.  fiir 
Gynak,,  1S87. 

Gaz.   lekaraska,  Bd.    Male. 
VI,  8;   C«ntrbl.  fur 
Gynak.,1887,  No.  13.! 


Male. 


Hernia,  size  of 
child's  head. 
Hernial  open- 
ing, 5cm.  in  di- 
ameter. Inser- 
tion of  cord  be- 
low and  at  left. 
Contents,  intes- 
tine. 


Liver  and  omen- 
tum adherent 
in  the  sac.  Her- 
nial opening, 
3.5  cm.  in  di- 
ameter. 

Large  hernia, 
with  adhesions. 

Size  of  walnut. 
Only  Intestines. 


Strangulated. 


Size  of  lemon. 
Skin    defect, 

8.4  ciu.  Con- 
teBts,iut«stiues 
and  edge  of 
liver. 

Contents,  small 
intestine  and 
cecum. 

Large  as  a  com- 
mon potato.  In- 
t est i n e  only. 
Cord,  centraL 
Hernial  open- 
ing, 1  cm.  in 
diameter. 

Intestines  only. 
No  adhesions. 

I  Size  of  hen's  egg. 

Adhesions. 
Size    of    goose's 

egg.    Intestines 

and  liver. 
Circumference 

of  hernia,  10 

inches. 

Hernial  opening 

4.5  cm.  wide. 


I  Laparotomy  and  sutur- 
ing, antiseptic.  Simple 
radical  operation. 


Laparotomy  and  sutur- 
ing. Simple  radical 
operation.  Antiseptic. 


Radical  operation. 


Progressive 
healing.  Su- 
perficial su- 
t  u  r  e  8  re- 
moved ,  sev- 
enth day. 
Deep,  tenth 
day.  Firm, 
deep  union. 
Superficial 
su  ppu  ra- 
tion. Union 
comple  te 
twenty- 
eigbth  dav. 

Healed  in  30 
days. 


Under  anesthesia  and  under  thymol  spray.  Reduc- 
tion. Excision  ot  sac  and  cord.  Sutuies — one  row 
deep,  one  superficial. 


Incision    of  sac.     Adhesions   broken.     Reduction. 
SKin-edges  freshened.    Compress.    Salicylic  acid. 


Percutaneous  ligature ;    Deatb. 
excision  of  sac  ;  cau- 
tery. 

I 

I  Radical    operation.    Cure. 
Antiseptic. 

!  Radical  operation.  Ex-  '  Cure. 
cision  of  sac.  Skm- 
edges  vivified.  Su- > 
tares.  Iodoform  com- 
presses. 

Radical  operation.  Re-  Died,  3  days 
duction.  Freshening,  after  opera- 
Sutures,  tion. 
Ligature.  Bandage  Cure  (time 
with  gentle  compres-  not  staled). 
sion.  Cord  cauie 
away  on 
tenth  day. 


Cure.  I  Incision  of  sac.    Adhesions  separated.    Reduction. 

[    Suture. 

I  Vermiform  appendix  was  caught  in  the  ligature 
;    and  tied. 


I  Death  after 
2  hours. 


Cure. 


Large. 


Male.      Abdominal  open- 
I    ing  4.5  cm.   Al- 
I    ready    peritcn- 
iiis. 


Radical  operation. 


Radical  operation.  Su- 
lurae  circumvolutae. 

Simple  protective  band- 
age. 


Herniotomy.      Reduc-  j  Cure, 
tion.  Freshening.  Su-  I 
tur<a. 

Modified  radical  opera-   Cure. 
tion.  Extraperitoneal.; 


Simple  protective  band-   Cure, 
age. 


Inc%ion  of  ring.    Reduction.    Suture  of  wound. 


Operation  at  age  of  2  days.    Primary  healing. 


Child  was  first  seen  at  2  days  old.  For  14  days, 
expectant  treatment.  Already  peritonitis  before 
operation.    Reduction  difficult.    Cecum  adherent. 

After  redn<;tion,  the  empty  sac  was  closely  wound 
with  strips  of  adhesive  plaster.  Over  this  a  gently- 
compressing  bandage. 


Operated  upon  the  day  after  birth. 


Glasgow  Med.  Jour., 
1887;  Centrbl.  fur 
Gyn.,  1887,  No.  47. 

Sperimentale,  Dec, 
1887:  Centrbl.  ftir 
Gynak.,1388,  No.28. 

Jour.  American  Med. 
Assoc,  188?: ;  Cen- 
trbl. fur  GynSk., 
1888,  No.  43. 

Zeits'chr.  fUr  Ge- 
burtsh. und  Gynak-, 
1888,  XV,  2. 


Diary  of  Kazan 
(Russia)  Med  Soc, 
VIII,  1888;  Cen- 
tralbl.  fur  Gvnak., 
1889,No.ll;  Annals 
of  Surgery,  188S. 

Revue  de  Gynecol., 
Paris,  1S88 ;  Cen- 
tralbl.  fUr  GynSk., 
1883,  No.  28. 


Male. 


Female 


;  Circumference, 

'  12  inches.  Lon- 
gitudinal diam- 
eter, 5  inches. 

I  Large  as  a  child's 
head.     Hernial 

I    opening  size  of 

I    a  dollar. 

[Defect ,  5  cm. 
long.  i 


Very  large.    In- 
testines in  the 


Size  of  hen's  egg. 
Patient  had  Bix 
fingers  on  each 
hand. 


Herniotomy.  Reduc- 
tion. Separation  of 
adherent  liver.  Skin- 
edges  freshened.  Su- 
tures. 

Compression  and  band- 
aj:e. 


Simple  protective  band- 
age. 


Child  only  a  few  hi)urs  old  at  time  of  operation. 

J  Ten  days  old  when  first  seen.     Died  next  day,  of 

i    peritonitis. 

I 

I  On  sixth  day,  fecal  discharge  from  wound.    Later, 

I    fistula  heaieu. 


Amnion  and  Wharton's  jelly  removed,  but  peri- 
toneum left  intact.  Incision  through  skin  along- 
side hernial  opening.  Sutured  over  the  infolded 
peritoneum.  Hemorrhage.  Healing,  but  not 
primary.  Granulation  filled  in  lower  third  of 
wound. 

The  defect  in  the  abdominal  wall  was  too  great  to 
bring  the  sutures  together.  Dressing  of  cotton 
covered  with  boric  add  and  vaselin. 


Cure. 


Death, in 
4  weeks. 


Heart  was  visible  and  palpable  among  intestines  in 
the  sac.     Defect  too  great  for  operation. 


Death,  on    Great  dilation  of  duodenum.    Small  intestine  open- 
ninth  day.       ing  directly  out  at  anus.    Colon  wanting. 


Radical  operation.  Re-    Death,  on 

duction.     difficult.;    second  day. 

.   Freshening.   Sutures. 


.   Size    of    goose's 
'    egg. 


Male.      Fecal  fistula 


Radical  operation. 
Freshening.  Sutures. 


Modified  radical  opera- 
tion. Extraperitoneal, 


Radical    operation. 
Freshening.   Sutures. 


Simpleprotective  baud- 
age. 


Cure. 


Cure. 


Cure. 


Deatb. 


Operation  without  preparation  and  without  skilled 
assistance,  in  unhealed  room,  in  farm-house. 
Directly  after  suturing,  bowels  underwent  even- 
tration. 

Child  an  hour  old.     Healing  by  primary  union. 


Five  hours  after  birth,  operation  accordine  to 
Olshausen's  method.  Carbolic  acid— 1  <— and  idio- 
form  during  operation.  Healing,  secondary. 
Afterward,  protrusion  of  umbilicus.  Died  atler 
6  weeks,  from  pneumonia. 

One  hour  after  birth,  operation  under  chloroform. 
Only  boiled  water,  by  way  of  prevention.  Hernial 
opening  enlarged.  Considerable  hemorrhaiie.  A 
portion  of  the  intestine  adhered  so  firmly  that  a 
part  of  the  peritoneum  of  the  ^c  waa  dropped  into 
abdominal  cavity  with  hernia.    Primary  union. 


398 


Tbk  Pbiuadblphia'1 
Medical  Jocsnal  J 


CONGENITAL  UMBILICAL  HERNIA 


[Fkbbuast  23,  ] 


24 


BartoD. 


Theims. 

25  '  Macdonald. 

26  Baum,  Colla. 


REFERBN'CB. 


Medical  Kews,  1889. 


DESCBEPTICMI. 


TBEATMEST. 


27 


Landerer. 


Larabrie. 


Salmon. 


Hinkiason. 


RuDge. 


Fraiienarzt,     Berlin, 

1889.  Vol.  X,  277. 
Am.  Jour.  Obst.,  1890. 

Centrbl.  fiir  GynSk., 

1890,  No.  21. 


Centrbl.  nir  Gjnfik., 
1890,  No.  31. 


Archiv  gen.  de  med., 
1891;  Centrbl.  fiir 
Chirurgie,  1891, 
No.  52. 

Gaz.desH6pit.,1891, 
No.  132. 


New  York  Med. 
Jour.,  1891  ;  Cen- 
tralbl.  fur  Cbirurg., 
1892,  No.  8. 

Archiv  fur  Gyna- 
kologie,  1891;  Cen- 
tralbl.  fur  Gyn., 
1892. 


Size ofclosed  fist;  I 
2  inches  in  di-  { 
ameter.  ■ 

....  I  Large  and  ad- ' 
herent,  ! 

Female'  Sizeofan  orange. ' 

Female  Pear-shaped 
,  tumor  with  ped- 1 
icte.  Contents,  I 
only  1  i ver.  I 
Strangulated,  i 
Irreducible.         ' 

Male.  Contents  :  Small 
intestine,  part 
of  stomach, 
transverse  co- 
lon, and  omen- 
tum. Adhesions 
to  stomach. 
Hernial  sac  rup- 
tured. Contents, 
intestine. 


Male. 


Female 


Size  of  an  orange. 
Contents: 
Bloody  ascitic 
fluid,  greater 
part  of  liver, 
and  cord  of 
omentum  size 
of  little  finger. 

Length  of  hernia, 
12  cm.  ;  width, 
6cm.  Contents, 
part  of  liver  and 
small  intestine. 

Size  of  lemon. 
Liver  and  in- 
testines. 


Radical  operation. 

Radical  operation. 

Radical  operation.  Su- 
turae  circumvolutae. 

Radical  operation.  Re- 
duction.   Suture. 


Radical  operation. 


Radical  operation. 


Simple  incision  of  sac. 
Freshening  of  wound- 
edges.  Deep  and 
superficial  sutures. 


Simple  incision  of  sac. 
Reduction.    Sutures. 


Simple  incision  of  sac. 
RcNluction.    Sutures. 


Cure. 

Cure. 

Cure. 


Operation  23  boars  after  birtli.   Already  peritonltk. 


Child  very  strong  2  months  later. 

Death,?  hours,  Oj>eration  15  hours  after  birth.    Chloroform 

later.  theaia.    S-ilicylic    acid   antisepsis.     Adhesions  of 

liver.     Hernial  opening  scarcely  the  size  of  Utile 
finger.    Opened  upward. 


Core. 


Core. 


Anesthesia.    Operation  16  bouTB  after  birth. 


'  Relief  of  constriction,  upward.  Adhesions  dissoiveA. 
Reduction.  Excision  uf  sac.  Suturing.  OperatiOB 
7  huurs  after  birth. 


Cure,  after    Cord  of  omentum  tied  ofi  and  excised.     Eed-ictioo 
14  days.  of  liver.   Chloroform  anesthestJL    Boric-acid  gauze 

'    dressing.  Two  sutures  cutthroagb  and  suppurated 
a  little. 


Cure.  I  Child  recovered  in  spite  of  the  fact  that,  when 

wound  was  dressed  the  first  time,  ibe  sutures 
j    out.     Repeated  under  anesthesia. 


Healed  in  20 
days. 


Broad  adhesions  with  liver.    Silver  sutures. 


111.— CASES  TABULATED   BY  BERGEB,  OCCURRING   UF  TO   1893.     {Merue  de  Chirurgie,  October,  1S9S.) 


32 

D*Arcy,  Power. 

Trans.  Path.  Soc.  of 

Transparent  sac.    Incision    of  sac      Be- 

Death,    after 

Peritonitis.    Reduction  impossible  without  opai»- 

Lon  don,     1  888, 

Contenis,  a  foot      duction.    Sutures. 

3  daya 

tion. 

XXXl.X,  108. 

of  small   intes- 
tine. 

33 

Jean  (de  Maubeuge). 

Routier:  Bulletin  et 
Mem.  de  la  Soc.  de 
Chiriirdie.  1891, 
N.  S.,  XVII,  17. 

Rupture  of  sac. 
Protrusion    of 
ileum    and   ce- 
cum. 

Reduction.    Expectant 
treatment. 

Cure. 

Vomiting,  fecal,  dae  to  cbiUiog. 

84 

Manour;  (Chartres). 

Salmon:  Gaz.  des 

Male. 

Size  of  mandarin. 

Radical  operation. 

Cure,  after 

No  antiseptic  precaution  taken  durine  24  hooia 
after  birth.    Operation  between  twenty-foarth  and 

Hupitaux,  1891, 

Transparent  at 
base.  Contents: 

Uver  reduced.    Deep 

5  days. 

No.  132. 

and    supt^rficial    su- 

thirtieth hour,     .\ntiscptic.    Two  stitches  cat  maA 

• 

The   liver,  a 

tures.    Omentum  ex- 

suppurated  slightly. 

band  of  omen-      cised. 

turn,  and  some 

ascitic  Quid. 

35 

KalUnbach. 

0.  Patz  :   Inaugural 
DisserUtion,  Halle, 
1891,  p.  32. 

Male. 

Size  of  closed  fist. 
With    pedicle. 
Intestinal   ad- 
hesions. 

Radical  operation.    In- 
cision   of    sac.      Ex- 
cision.    Separation  of 
adhesions.  Reduction. 
Suture. 

Cure. 

Operation,  11  houra  after  birth.  Anesthesia,  chkti^ 
Ibrm. 

36 

W.  Hogue  (Charles- 

Henry    Marcy; 

Male. 

Opening,  2  inches.  Expectant.  Support  by 

Cure,  after 

ton). 

Analom.  and  Surg. 
Treatment  of  Her- 
nia, New  York,  1892, 
p.  193. 
Idem,  p.  194. 

Tumor,de^cend-     adhesive  bandage. 
Ing  to  pubis. 

6  weeks. 

87 

Henry  0.  Marcy. 

Male. 

Tumor,     radius 

Olshausen'ft  operation. 

Oflr«. 

Operation  2  days  after  birth.  Chloroform.  PartW 
fiailure  of  union  and  suppuration.   Small  protubc^ 

2  inches.     Con- 

tents :    Part   of 

ance  when  child  cries. 

liver  and  spleen. 

38 

Angelo  Nanuoti. 

MnrKSgnl,    1892, 
XXXIV,  516. 

Male. 

Size  of  head  of 

Hernio-laparotomy.  In- 

Cure, after 

Operation  immediately  after  birth. 

fetus    at    term. 

cision   in    linca  alba. 

10  days. 

Sac  torn.  0|>en- 

Excision  of  sac.     Re- 

ing, 3  cm.  in  di- 

duction.    Deep    and 

ameter.     Con- 

superficial sutures. 

tents:    Large 

and    small    in- 

testine. 

39 

Samuel  C.  Benedict. 

Med.  Record,  N.  Y., 

Contents:  Spleen, 

Raised  amnion  and 

Cure. 

Chloroform.     Operation  4S  hours  sfter  birth.     D»> 

1892,  XLI,  262. 

part    of    liver, 

Wharton's  jelly,  sav- 

pen deuce  upon  silver  pins  ard  ff,:r^'-f  S  fuiun^ 
which  adhered  i.»  dr*sj.in^.      .  •                      ilure  m 

and  intestines. 

ing   peritoneum. 

Fre.d  skin  from  both 

part  of  wound.    Wound  ■*  iCv                            doeiA. 

sides  and  drew  over 

Small  pn>txusion  remained  «                        ed. 

opening. 

40 

Carl  Breus. 

Sammlung  klin.  Tor- 

Size  of  an  orange. 

Percutaneous  ligature. 

Death. 

Operation  under  <diloroform.  6  hours  after  Uitt. 
l*«aih,   uneipeciedlT.  on   tenth  day.      Not  tnm 

trSKe,  1893,  No.  77. 

Sessile.     With 

Very    dilficult      Im- 

p. 726. 

difficulty      re- 
ducible  'Open- 
ing a)>oui  7  cm. 
in  diameter. 
Contents:  Inies- 
ttne  and  liver. 
Pr'itrusiou.Scm. 

possible    to    satisfac- 
torily apply  the  for- 
ceps to  walls  of  the 
opening. 

peritonitis,  tauterv  not  used  as  in  Brau*s  ilM 
case— Table  I,  No.  34. 

41 

Carl  Breus. 

Idem,  p.  727. 

Percutaueous  ligature. 

Cure,  after 

Operation   under  cblorotorm    7  bcHirs  after  Urift. 

With    pedicle. 

Excision  of  the  diver- 

14 days. 

No    fistula.     Cicatrix    firm    and    smooth    aAv 

Incompletely  re- 

ticulum taken  up  by 

9  monthsw 

ducible.     Con- 

the  ligature. 

taineil  n  diver- 

tic  u  1  u  m     of 

Meckel. 

__ 

Fbbroart  23,  1901] 


CONGENITAL  UMBILICAL  HERNIA 


[The  Philadelphia 
Medical  Journal 


399 


c 

SURGEON. 

REFERENCE. 

SEX. 

DESCRIPTION. 

TREATMENT. 

COURSE. 

REMARKS. 

-42 
48 

P.  Berger. 
P.  Berger. 

ReTue  de  Chirurgie, 
1893,  p.  798. 

Revue  de  Chirurgie, 
1893,  p.  802. 

Female 
Female 

Size  of  hen's  egg. 
Contents:  Small 
intestine,     ce- 
cum, and  with 
transverse  colon 
adherent. 

Size  of  large  wal- 
nut. Contained 
Buiatl    intestine 
and    adherent 
cecum. 

Hernio-laparotomy.  In-  Cure,  after 
cision  in  iinea  alba.      10  days. 
Keductii^n.      >utured 
in  three  layers. 

Operation  as  for  No.42.   Cure. 

Operation  under  chloroform,  28  hours  after  birth. 
Iodoform  dressing  had  been  used.   Primary  union. 

Operation  under  chloroform,  3  days  after  birth.    No 
antiseptic  precaution  had  been  t&ken  meantime. 
Peritonitis  had  already  begun  before  operation. 
Cure,  18  days  after  removal  of  sutures.    Union  by 
first  intention. 

IV.— REMAINING   CASES   IN    BALLET'S   TABLE.     (Revue  de  Gi/necologie,  June,  1900.) 


44 

Breuss. 

Centrbl.  fur  GynSk., 
1883,  No.  30,  p.  478; 
Th&se  de  VienDC. 

Male. 

Size    of    lemon. 
Contents:   In- 
testine and  part 
of   liver.      Ab- 
dominal   opt-n- 
ing,    8   cm.   by 
4  cm.     Mem  - 
branes  very 
tense. 

Radical  operation. 

aire. 

Operation  7  hours  after  birth.    Primary  healing. 

Sutures  removed,  ninth  day. 

46 

Gluck. 

Berliner    klin.    Wo- 

.  .  .   . 

Signs   of  perito- 

Radical operation.  Re- 

Death. 

Child   born   at  7   mouths.     Died   in  30  hours,  o( 

chensehr.,  Jan.  19, 

nitis.    Strangu- 

section   of  diverticu- 

peritonitis. 

1885. 

lation, due  toan 
accessory    mes- 
enteric fold 
bound  to  diver- 
t  i  c  u 1 u  m    of 
Meckel   and 
passing  over  in- 
lehtine. 

him  and  of  the  mes- 
enteric fold. 

46 

Duc'hamp. 

Loire  Medical.  Nov. 

Size   i»f   «aluut. 

Diverticulum    tied    as 

Death. 

When    sac    burst,   small    intestine    appeared    and 

17,  1887  ;    Th&se  de 

Thin,    trans- 

far as  possilile   from                            | 

cecum,  with  its  appendix,  the  sigmoid  flexure, 

Vienne. 

parent  sac.    i;e- 
duction   easy. 
Just  as  opera- 
tion    was     to 
begin,  sac  sud- 
denly burst  and 
intestine  poured 
out  en  masse. 

intestine   wiib    silk 
thread,  to  hold  it  out- 
side t  he  ring.    Its 
middle  part  wos  then 
fixed  at  the  level  of 
the  umbilical  ring. 

and  a  diverticulum  of  Meckel,  of  2  cm.  in  length, 
adherent  to  hernial  sac  by  its  extremity. 

47 

Klaussner. 

MuDcb.  med.  Wo- 

Male. 

Size  of  an  apple. 

Radical   operation. 

Cure. 

No  anesthetic.    Age,  1  day.    Died  later,  of  diarrhea. 

chenschrifl,  18  89, 

Irreducible. 

Coils  of  intestine,  in- 

Postmortem, umbilicus  closed.    No  adhesions  to 

No.  3. 

Short  pedicle  of 
1  cm.  thickness. 
Hernia  5  cm. 
in    diameter. 
Easily  strangu- 
lated.   Turner 
tense. 

flamed    and    covered 
with  exudate. 

side  of  intestine. 

48 

PGan. 

Cliniques    Chirurgi- 

Size  of  head  of 

Radical  operation.   Re- 

Result un- 

Anesthesia diffiinilt.    Child  6  hours  old  and  very 

cale,  VIII,  717. 

*■ 

child  2  months 
old.    Coverings 
adherent  to 
liver  and  intes- 
tine. 

section  of  suspending 
ligamentof  liver.  Sep- 
aration of  large  and 
small    intestine,  and 
afterward  a  removal 
by  piecemeal  of  Whar- 
tou's  jelly.  Reduction 
difficult. 

known,  but 
it  does  not 
seem  that  a 
favorable 
re-^ult  conld 
have    fol- 
lowed. 

much  depressed  after  operation. 

49 

Uoseublaun. 

Alt  on  a,  18[il,  p.  8. 

Umbilical    her- 
nia   with  per- 

Radical  operation. 

Cure. 

(Quoted  by  Cahier.) 

si^entomphalo- 

meseniericdvict. 

50 

Bordeau. 

LiuQousiD  Medicale, 

Male. 

Size  of  an  "range. 
With   pedide. 

Radical   operation. 

Death. 

Child  2  days  old.  Already  peritonitis  at  operation. 
Its  extension  caused  death  18  hours  after  opera- 

1891, p.  148;  These 

Cleansing    with    bi- 

de  Vienne. 

Partly    redu- 
cible. Contents: 
Part  of  small 
intestine    and 
cecum  with  ap- 
pendix   closely 
adherent  to  the 
sac. 

chiorid  solution.    In- 
testines   came    out 
en  masse   and    more 
extensive  laparotomy 
necessary    to    reduce 
theu). 

tion. 

61 

Vanderroel. 

Jour,  de  medicine  de 
Bruxelles,  1S92. 

Size  of  fist.    Con- 

Reduction.   Suture  of 
the  ring  with  catgut. 

Cure. 

Operation  some  hours  after  birth. 

tents:     Liver 

and    other  vis- 

cera. 

62 

Wiirren. 

Lancet,  1893,  II,  1332. 

Large.     Opaque. 
Diameter,    6.5 
cm.    Contained 

entire  liver. 

Radical  operation. 

Cure. 

Operation  when  S-1  hours  old.    Anesthetic,  ether. 

53 

Warren. 

Idem. 

Pear -sb  H  ped. 
Length,?  inches 
Contained 
nearly    all    the 
small  intestine. 

Radical  operation. 

Cure. 

Child  at  tirst  very  much  depressed,  but  ultimately 
recovered. 

54 

Dolin^ki. 

Centrbl.  fur  Gynak., 
1893,  No.  40. 

Size  of  an  apple. 

Radical  operation. 

Cure. 

65 

L.  Hecht. 

Mil  u  cb.   med.   Wo- 
chenschr.,      1S94, 
No.  .">!,  p.  1D87. 

Of   small   size. 
M  c  ni  (t  r  a  n  e  s 
mummilied. 

Antiseptic  dressing. 

Cure. 

Child  first  seen  at  3  davs  of  age.  Cure  by  granu- 
lation. 

56 

Gener. 

Centrbl.  fiir  GyuUk., 
1894,  No.  42. 

Size  of  an  apple. 

Antiseptic  dressing. 

Cure,  in   4 
weekfl. 

Abdominal  walls  grew  together..  Umbilical  ring 
had  diameter  of  a  lead-pencil. 

67 

Bardelct)en,  Retlig. 

Reitig:    Inaugural 

Size   of  walnut. 

Radical  oi>eralion. 

Death. 

Age  at  operation,  2  days.  Hied  5  hours  afterward. 
Operation  without  anesthesia  and  lasted  one-half 

Dissert.,  Berlin,  1894 

Contents:    Ap- 

pendix,  lar^e 
part   of  small 

h<.ur.      Postmortem:    Adhesive    peritonitis    and 

punctiform  hemorrhagic  foci  in  the  peritoneum. 

intestine    and 

i^s  mesentery. 

Partly    irredu- 

cible. 

58 

Pdppelmann. 

Inaugural     Dissert. , 

.   .  •  * 



<  Sutures   through   skin 
1    and  amnion. 

Cure. 

Marburg,  1894. 

400  ^^^  PhiladelphiaT 

Medical  Jouknal  J 


CONGENITAL  UMBILICAL  HERNIA 


IFebrl-abt  23,  1901 


65 


72 


74 


75 


Timmer, 


Arodt. 
Arodt. 


REFER ENCE. 


JamesHarrey,  Ray- 
mond. 


N.  P.  Marjaotschik. 


Buist. 


0.  Piering. 


Knauer. 


Girard. 


Girard. 


E,  Patry. 


Boise. 


Church. 

A.  MacCosh. 


Rogier. 


Hildebrant 


Porak. 


Genotschter  bowerd. 
d.  Natur.  gener., 
1896. 


Arcbiv  fur    Gynak., 
1896. 

Centrlbl.riirGyDak., 
1896,  No.  24. 


Medical  Record, Sep-, 
tember  19,  1896,  p.  I 
425.  I 


Annalen  der  Russ. 
Chirargie,189G,Hft. 
3;  C«ntralhl.  fur 
Chirurgie,  1896,  No. 
42;  Centralbl.  fur 
GynSk.,  1816,  No. 
13. 

Brit-  Med.  Journa', 
1896. 


Prager  med.  Woch- 
enscbr.,  1896,  No. 
31. 


Centrbl.  fur  Gynfik., 
1897,  No.  2. 


Correspbl.  fiir  Scbw. 
Aerzle,  1897,  No.  13. 


Female! 


DESCRIPTXOM. 


TREATMENT. 


Loops    of    intes-   Radical  operation. 
tlDe    and    ad- 1 
herent  liver  in  | 
the  sac.  i 

Size  of  small  wal- 1  Radical  operation, 
nut.  I 

Umbilical  hernia  Radical  operation, 
vith  bemia  of 
heart.  Absence 
of  anterior  part 
of  diaphragm  at 
level  of  » ter- 
num.  Liverand 
intestines. 

Hernia,  large  and  ;  Radical  operation. 
'    firm.  Cuutained 
j    entire  liver.  Ah- 
I    solutely  irredu- 
cible. 

Size  of  lemon. 
Amnion  dry 
and  friable,  and 
partly  broken 
open.  In  places 
peritoneum  also 
torn. 


Idem,  1897,  No.  IS. 


Revue  Medicale  de 
la  Suisse  Komande, 
1896,  No.  7.  p.  851 


Am.    Jour.    Obst., 
1897,  p.  223. 


N.  Y.  Med.  Jour. 
Jan.,  1897. 


Idem.,  Feb.,  1897. 


Th^se  de  Paris,  1898, 
p.  79. 


P.  Busch  :  Inaugural 
Dissert.,  Berlin, 
lSij9. 

Presse  Medicale,  Dec 
80,  1899. 


Male. 


Male. 


Female 


Female 


Male. 


Male. 


Cure. 


Death. 
Death. 


Death. 


Excision    of   sac.    Death  on 5th 
Wound-edgee     fresh-      day. 
ened.  Sutures  through  ' 
the  whole  wall.  ' 


Opening  6  cm.  in    Radical  operation, 
diameter.  Coion 
and  liver  adhe- 
rent. 


Death. 


Radical  operation. 


Walls  of  hernia ; 
unusually  thick. 
Sac  ruptured  in 
labor.  Eventra- 
tion of  large  and 
small  intestine 
and  mesentery, 
except  duode- 
num and  rec- 
tum. 


Sizeof  mandarin.  I  Radical  operation. 
Cecum      audi 
small  intestine.  I 


Size  of  small  fist. 
Contents :  Pari 
of  left  lobe  of 
liver,  and  coils 
of  small  intes* 
tine.  Great  part 
of  liver  visible. 
Solidly  adher- 
ent to  sac. 

Size  of  fist.  Bad 
color  and  odor 
o  f  envelopes. 
Contents:  L-^rge 
part  of  small  in- 
testine, and  all 
of  left  lobe  of 
liver. 

Hepatocele. 


Hernial  opening 
Dearly  as  large 
as  silver  dollar. 
Contents:  I  n- 
t  e  s  t  i  n  e.  Re- 
ducible. Soft 
and  comprea- 
sible. 

Contained  colon. 
Reduction  im- 
possible. 


Size  of  an  orange 
Color,  purple. 
Contents :  In- 
testine. Partly 
irreducible. 

Sizeof  an  orange. 
With  pedicle. 
Contents ;  In- 
testine adher- 
ent .\giilutin- 
ation  by  peri- 
tonitis. 

Sizeof  an  orange. 
Contents ;  I  n- 
t  est  i  n  e.  Irre- 
ducible, 

Size  of  B  plum. 
Contents:  In- 
testlneand  part 
of  lower  border 
of  lirer. 


Radical  operation. 


Radical  operation.  I  n- 
t  est  ine  redu  ced. 
Lobe  of  liver  resected 
from  sac.  Excised 
gallblridder  after  ty- 
ing cystic  duct. 


Attempted  to  suture 
edges  of  resected  mem- 
braneover  liver  when 
reduced,  but  sutures 
did  not  hold,  the 
membrane  being  too 
triable.  Vivified  skin 
edges  and  sutured  ab- 
dominal walls  en  bloc. 

Radical  operation.  Kx 
cision  of  sac.  Suture, 
fascia  with  silk  ana 
skin  with  catgut. 


Cure. 


Cure. 


Age,  17  hours. 


Protrus-ion  of  small  intestine  outside  of  hernia. 
Age,  16  hours. 

Age  at  operation,  7  hours.    Death  from  compreaeioD 
of  the  heart. 


Died  shortly  after  operation.    Child  weighed  2  k.4]» 
and  the  liver  IVi  g. 


After  operation,  cognac  by  mouth  and  rectum  to 
overcome  depression.  Postmoitem :  Peritonitis 
and  gastritis,  the  latter  due  to  cognac;  fetal 
spleen,  left  lobe  of  liver'twice  the  size  of  ihe  right, 
and  a  tongue-shaped  lobe  behind. 


Age  7  days.  Died  the  following  d.^y.  From  birtb 
to  operation  a  boric-acid  dressing  had  bevo  used. 
Part  of  the  time  a  pad  uf  cork  also  used. 


Laparotomy.  Reduction  impossible.  Hernial  open- 
ing would  scarcely  admit  the  litile  finger.  Anes- 
thetic, chloroform,  well  borne. 


At  first,  an  attempt  to  employ  Olshsusen^s  method, 
but  reduction  impossible,  owing  to  adhesions. 


Age  36  hours.  Liver  separated  only  with  great 
difficulty.  Much  parenchymatous  hemorrhage. 
Died  some  weeks  after  leaving  huspitaL  Fhlrg- 
moD  of  scrotum. 


Death    after  '  Age  2>^  days.    Child  debilitated. 
36  hours. 


Cure  com 
plet ed  at 
end  of  6 
months. 


Cure  after  3 
weeks. 


'  I>eath     after 
36  hours. 


.\ge  of  child,  some  hours.  After  operation  inteoas 
icterus  for  6  days,  without  decoloration  of  stoolsL 
Child,  after  recovery,  was  robust.  Hernia,  sixv 
of  pigeon's  egg,  persisted,  appearing  only  wheo 
child  cried.  Evident  o:)  percussion.  King  allowed 
passage  of  two  fingera.  Bandage  maintains  redac- 
tion. 


Operation  on  child  at  age  of  7  hours, 
not  profound,  with  chloroform. 


.\neBibcsla, 


Radical  oporation. 
Radical  operation. 

Radical  operation. 
Radical  operation. 


Death    after    Operation  5   days  after  birth.*  Chloroform    aoc»- 
2  days.  ,    thesis  only  at 'moment  of  reduction.    Liver  cot- 

I    ered  with  exudate.    Parencbymatous  bemorrha^. 
I     Drainage  of  wound. 

Death.  Operation  second  day.     Died  same  day. 


Cure.  I  Age  at  operation,  S  hour&  Remnant  of  diverticulam 

of  Meckel,  a  cord  coming  out  to  be  inserted  Ln  tte 
sac 

Cure.  Operation  one  hour  after  birth.    Slight  protnakM 

1    on  coughing  or  crying  remained. 


FBBRDABT  23,  1901] 


CONGENITAL  UMBILICAL  HERNIA 


rxH 
Lm 


The  PUILADELPHIA 

EDiCAL  Journal 


401 


g 

SDROEON. 

REFERENCE. 

SEX. 

DESCRIPTION. 

TREATMENT. 

COURSE. 

RBUARKS. 

7fi 

Mnnti_ 

Arch,  mr  Kindhlkd., 

Circumference, 

Moist  dressing. 

Death. 

Died  from  peritonitis  on  the  fourth  day.  Colls  of 
intestine  bound  l-y  vascularized  membranous  de- 

1899. Bd.  xxvii,4l2. 

34cra.  Contents: 

Liver,  spleen, 

posit.     Liver  very  adherent. 

pancreas,  stom- 

ach,   small     in- 

testine,   large 

intestine,      ex-' 

cent  deacHiidiuK  ' 
colon.                    1 

77    Monti. 

Idem. 

Male. 

Small,     contain-    Antiseptic  dressinj-, 
in^;     intestinal  i 
coils. 

Death. 

Died  eighth  day  in  collapse.  Presented  abdoratno- 
pelvic  fissure,  exstrophy  of  bladder,  anal  atresia, 
and  spina  bilida. 

78    rzvzewicz. 

Wiener  med.  Woch- 

Half  size  of   an 

Protective  dressing. 

Death    after 

After  separation  of   cord,  wound  commenced  to 

eLSchr.,  Feb.,  1899. 

orange.     Open- 
ing very  large. 
Contained    in- 
testine. 

3  weeks. 

granulate. 

79 

C:(;yEewicz. 

Idem. 

.... 

Large  tumor,  in-    Protective  dressing, 
closing     intes- 
tine.                    ! 

Death. 

Died  after  some  hours.    Symptoms  of  peritonitis. 

80 

Bjlicki. 

Idem. 

Male. 

Size  of  an  apple. 

Protective  dressing. 

Cure. 

Seen  again  after  10  years.    At  level  of  umbilicus  a 

Contaioed     in- 

radiating cicatrix  of  size  of  4  krcutzt-r  piece.    No 

testine.     Open- 

separat on. 

ing  large. 

81 

Baracz. 

Idem. 

Male. 

Opening    10  em. 
by  8  cm.    Con- 
tents:   Liver, 
stomach,    and 
small  iDtesline. 

Radical  operation. 

Death. 

Age  at  operation,  a  lew  hours.  Hernial  sac  excised. 
Intestines  reduced  under  unclean  linen.  Reduc- 
tion ditficuU.  Sutures  very  tight.  L  ied  after 
some  hours. 

82 

Schramm. 

Idem. 

Female 

Size  of  a  goose's 
eg-.  Opei.iug,3 
cm.    Cootained 
small  intestine. 

Antiseptic  dressing. 

Cure. 

Seen  again  7  years  later.  At  level  of  umbilicus, 
radiating  scar.     No  separation. 

83 

Schramm. 

Idem. 

Female 

Size  of  an  apple. 
Op'g.,   scarcely 
4   mm.      Co  n 
tents:    Small 
intestine,      ce- 
cum,   and     as- 
cending  colon. 

Radical  operation. 

D  atb. 

At  first  wound  progressed  normally.  Wound  almost 
heiiled.  Erysipelas,  sixth  day.  Death  on  eighth 
day. 

81 

Coley. 

Medical     Record, 

Size    of    large 

Extraperitooeal  opera- 

Cure. 

Operation  under  chloroform  22  hours  afterbirth  ; 

November  4,  1899. 

orange.  Organs 

tion,  with  drainage. 

lasted  30  minutes.    Two  months  later,  slight  pro- 

adherent in  sac. 

trusion. 

Irreducible. 

85 

Coley. 

Medical  Recod,  No- 

Large as  a  child's 

Radical  operation. 

Healed. 

Incision  of  sac  allowed  about  250  gm.  of  straw- 

vember  4, 1899. 

head.  Contents: 

colored  fluid  to  tlow  out.     Reduction  impossible 

« 

Liquid,  liver, 
partoflargeand 
part  of   small 
intestine. 

on  account  of  extensive  eventration.  Three  weeks 
later  child  was  still  living. 

86 

Hallet. 

Revue  de    Gynecol., 
June,  1900. 

Female 

Sizeoffist.  Open- 
ing   narrow. 
Contents:  Small 
intestine,    with 
diverticulum  of 
Meckel,     adhe- 
rent,and  cecum. 
with  its  appen- 
dix.   Irredu- 
cible. 

Radical  operation. 

Cure. 

Child's  age,  2  hours.  Chloroform.  Resection  of 
appendix  and  of  diveriiculum.  Se?n  again  5 
months  later,  showed  radiating  scar  without  sep- 
aration. 

v.— CASES  NOT  IN  ANY  OF  THE  PREVIOUS  TABLES,  BUT  COLLECTED  BY  THE  AUTHOR  OF  THE  ACCOMPANYING  REPORT. 


87 

Hackney. 

Medical  and  Surgical 

....    Hernial    tumor. 

No  attempt  at  reduc-    Died      in    3 

Bowels  moved.    Child  took  nourishment.     Died  of 

Reporter,  Philadel- 

size of   adult 

tlou  nor  oi>eration.           days. 

general  peritonitis. 

phia,  1887,  vol.  56. 

tist.    Opening  2 

'    incliesin  diam- 

;    eter.  Transpar- 

ent    coverings. 

1    through    which 

1    could    be    seen 

large  and  small 
IniesIineB. 
....    Contained    liver 

88 

K.  Uedman. 

FinskaL£kares£llsk. 

Reduction.     Resection    Cure. 

Child  weighed  3,600  gm.    Anesthetic,  chloroform. 

Handlingar, Decem- 

and   small    in- 

of sac.    Suture  of  ab-  , 

Presented  no   other    abnormality.     Adhesions  of 

4 

ber,  1897;  Gaz.  Heb- 
domadaire  de  Med. 
etdeChirurg.,Mar. 
20,  1898.  Tome  iii, 
No,  23,  N.  S. 

testine,     which 
could    be    seen 
through    the 
transparent 
wall. 

dominal  walls. 

liver  to  aac  wall.    Body-cavity  relatively  small. 

89 

von  Habs. 

Med.  Geaellschaft  zu 

....    Entire    liver    in 

Radical  operation.  Ex-    Death    In    4 

Died  from  exhaustion.     Wound  conditions  fund 

Magdeburg;  Miinch. 
med.   Woch.,    1898, 

the  hernial  sac. 

cision  of  sac.     Liver      days. 

normal.    No  other  abnormality  except  patency  of 

Irreducible. 

reduced.     Urachus 

urachus,  discovered  during  operation  to  have  per- 

Bd. 45,    No.   11,   p. 

closed    by   a   suture. 

sisted. 

346. 

Suture  of  abdominal 
wall  by  layers. 

90 

Described  in  the  ac 

companying  report. 

Male.      Circumference, 
oOcm.  Grayish 

Radical    operation    at-    Death    after 
tempted    but    unsuc-      4  days. 

Operation  under  chloroform   at  age  of   30  hours. 
HealtbT.and  presented  otherwise  no  abnormality. 

above,  and  pur- 

cesslul owing  to  im- 

Adhesion  of  liver  to  sac  wall.    Body  cavity  rela- 

plish aud  more 

possibility  of  control- 

tively  small. 

transparent  be- 
low. Cord  at  left 

in  <;  eventration.    Su- 

tures. 

and  slightly 

above     middle. 

1 

Contents:    Part 

1 

of  liver,  part  of 

1 

small  and  large 

intestines.  Her- 

1 

nial      opening 

between  4.5  cm. 

1 

and  5.5  cm. 

1 

402 


THB  PH1LADBZ.PHIA 

MsDicAL  Journal 


] 


CONGENITAL  UMBILICAL  HERNIA 


[FSBBCABX  23,  IWl 


giving  little  encouragement  in  a  majority  of  cases  and 
accepting  death  as  inevitable. 

Lindfors  confines  his  use  of  the  term  "  radical  opera- 
tion," to  that  of  abdominal  section  together  with  fresh- 
ening of  the  cutaneous  edges  and  suturing,  although  the 
completed  operation  of  Breus  involves  an  opening  of 
the  abdomen.  Strictly  speaking  the  operation  by  Poch- 
hammer,  1846  (No.  19),  became  a  radical  operation  by 
reason  of  his  opening  the  sac  to  relieve  adhesions  of  the 
liver,  although  he  applied  only  simple  ligature  to  close 
the  hernial  opening. 

Lindfors'  second  table,  accompanying  his  article  in 
1893,  brought  together  31  cases  of  congenital  umbilical 
hernia,  reported  whether  cured  or  not,  all  before  1891.  He 
had  repeatedly  written  on  the  subject  and  in  1889  his 
table  contained  13  cases  up  to  that  date  since  1882.  In 
1890  Macdonald,  of  Albany,  N.  Y.,  published  a  table,  in- 
cluding his  own  case,  which  eniliraced  19  operative  cases, 
and  12  treated  expectantly.  Berger,  reporting  2  cases 
operated  upon  by  himself,  added  those  which  had  been 
reported  previous  to  1893.  Schramm  added  a  number 
of  cases  in  a  paper  with  a  table  published  in  Vienna  in 
1899 ;  and,  finally,  Hallet,  from  Paris,  published  in 
June  of  the  present  year  a  table  in  which  he  includes 
such  cases  as  he  has  gathered  from  the  literature  since 
1893,  and  this  last  is  the  most  satisfactory  statement  of 
the  subject  yet  made. 

In  adding  the  case  I  have  reported  herewith,  I  wish 
also  to  submit  those  other  cases  which  have  come  to  my 
notice  in  the  literature  of  the  subject.  The  table  as  pre- 
pared by  the  writer  comprises  90  cases,  the  treatment  of 
which,  with  results,  may  be  summarized  as  follows : 

Radical  operation :  Laparotomy,  freshening  wound- 
edges  and  suturing 64 

Healed 42  (=  &5.&%) 

Died 21 

Result  unknown 1 

Simple  ligature 1 

Healed 1 

Percutaneous  ligature 3 

Healed \ 

Died 2 

(Includiug  Breus'  first  case,  and 

Bryant's  second   case,  Nos.  33  and 

34  in  Table  1,  cases  healed  3.  =  60% ) 
Extraperitoneal  operation  of  Olshausen 5 

Healed 5  (=100%) 

Total  operative  cases 73 

Healed 49  (=67%) 

Died 23 

Kesult  unknown 1 

Expectant  treatment 15 

Healed 7  (=  47%) 

Died 8 

Treatment,  unknown  or  impossible 2 

Died 2 

Total  (1882-1900) 90 

In  this  summary  perhaps  the  most  striking  fact  is  the 
percentage  of  cases  healed  after  operation  by  Olshau- 
sen's  method,  and  of  this  it  is  jiroper  to  enter  a  word  of 
explanation,  as  well  as  some  detailing  of  the  method, 
before  proceeding  to  discuss  the  ordinary  radical  opera- 
tion. Olshausen's  report  appeared  in  1887,  and  he 
described  his  procedure  as  having  the  particular  advan- 
tage of  avoiding  the  opening  of  the  peritoneal  cavity. 
He  made  first  an  oval  incision  through  the  skin  near 
the  edge  of  the  defect  at  the  base  of  the  tumor  and  car- 
ried it  down  only  to  the  jieritoneum.  The  edge  of  skin 
toward  the  defect,  together  with  the  outer  membranous 
covering  of  the  hernia,  was  separated   from  the  under- 


lying sac  of  peritoneum.  Even  the  interposed  mucous 
tissue,  or  Wharton's  jelly,  is  removed,  until  the  peri- 
toneum is  as  free  as  possible  from  all  adherent  tissue. 
It  is  then  gathered  into  folds  by  a  few  stitches  to  ob- 
literate the  cavity  and  the  whole  is  dropped  into  the 
abdominal  wound  and  the  edges  and,  if  possible,  the 
deeper  tissues  drawn  together  over  the  opening  and 
sutured  with  silk.  In  Benedict's  case  (No.  39)  this  laat 
closing  was  effected  by  silver  pins  and  figure-of-eight 
sutures,  but  with  no  particular  advantage. 

This  operation  is  admitted  to  be  applicable  to  those 
cases  where  a  large  hernial  opening  makes  the  eventra- 
tion less  easy  to  control,  and  critics  have  generally  lim- 
ited its  special  recommendation  to  these  cases.  At  best 
the  treatment  by  Olshausen's  method  has  proved  itself 
a  means  for  lessening  the  probability  of  death  from 
peritonitis,  besides  making  a  smaller  cicatrix  than  would 
result  from  expectant  treatment.  In  these  cases  it  saves 
the  life  of  the  patient,  but  can  scarcely  be  said  to  have 
cured  the  hernia.  In  nearly  every  one  reported,  the 
course  of  the  case  was  that  of  failure  of  union,  suppura- 
tion, and  finally  a  cicatrix  which  after  healing  and  con- 
traction were  complete,  admitted  of  limited  protrusion 
of  the  bowel.  It  may  be  granted  that  even  this  is  a 
gain  in  that  class  of  cases  to  which  it  has  been  said  the 
operation  should  be  confined. 

Lindfors  recommended  the  following  technic :  After 
complete  anesthesia  under  chloroform  the  hernia  is  re- 
duced if  possible;  the  sac  is  then  opened:  adhesions 
separated  and  reduction  completed.  The  sac  is  then 
excised  and  the  skin-edges  \'i\'ified.  the  umbilical  ves- 
sels tied  and  separate  rows  of  deep  and  superficial 
sutures  passed.  His  most  particular  provision,  that  in 
regard  to  antisepsis,  becomes  to  us,  in  the  form  of 
asepsis,  a  matter  of  course.  He  dissects  around  large 
adhesions,  such  as  are  frequently  found  to  bind  down 
the  liver,  in  order  to  avoid  excessive  hemorrhage,  allow- 
ing the  excess  of  tissue  to  be  reduced  with  the  organ. 
Where  necessary  the  hernial  orifice  maj'  be  enlarged 
along  the  linea  alba  to  make  reduction  possible.  The 
diverticulum  of  Meckel  or  the  vermiform  appendix  may 
be  removed  in  the  manner  ordinarily  adopted. 

In  Hallet 's  conclusions  on  the  subject,  he  says :  ''  In- 
tervention should  be  as  early  as  possible  after  birth ; 
waiting  endangers  the  membranes  from  gangrene  and 
peritonitis ;  and  radical  operation  is  always  the  most 
rational  if  we  have  the  means  and  assistance  at  hand." 
In  his  analysis  of  the  cases  where  the  time  after  birth 
before  operation  is  given  in  the  reports,  he  supports  the 
above  statement  by  the  following  summary : 

In  58  cases  operated  upon  within  36  hours 

afterbirth,   15  deaths =    26% 

In  7  cases,  within  4S  hours,  3  deaths =    43% 

In  2  cases  on  third  day,  1  death =    50% 

In  4  cases  after  third  day,  4  deaths =  100% 

This  scale  of  percentages  surely  bears  testimony  to 
the  value  of  prompt  and  radical  action. 

Finally,  it  is  to  be  observed  that  a  rational  treatment 
of  congenital  umbilical  hernia  is  based  upon  two  ideas 
the  acceptance  of  which  is  comparatively  recent  and 
whose  absence  gave  the  condition  its  former  hopeless 
prospect.  These  two  things  are  aseptic  practice  in 
surgery  and  a  better  understanding  of  embryological 
development. 

Journal  on  Sea- Sickness. — A  unique  publication  hM 
recently  been  started  in  Patis,  entitled  /.<•  JoanM}  d(  Mal-d* 
M(r.    It  is  devoted  entirely  to  the  subject  of  sea-8ickne88. 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hendrik  Llotd,  A.M.,  M.D.,  Editor-in-Chief 
JuLira  L.  SALDfOBR,  M.D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kaltbykk,  M.D. 

D.  L.  EdSall,  M.D.  T.  L.  COLKY,  M.D. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dobland,  M.D. 

J.  H.  Gibbon,  M.D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.  Keprinta  (250)  of  Original  Articles  will  be  turnislied  gratis  to  Authors  making 
the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Hedloal  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  34. 


Vol.  VII,  No.  9 


MARCH  2,  1901 


.00  Per  Annum 


Surgical  Interference  in  Gastric  Ulcer. — Some 
idea  of  the  steady  advance  of  surgery  into  fields  for- 
merly considered  essentially  medical  can  be  had  by  read- 
ing the  excellent  results  recently  reported  as  obtained 
from  the  surgical  treatment  of  gastric  ulcer  by  a  num- 
ber of  different  surgeons.  We  recently  reported  in 
the  Journal  an  interesting  case  by  Dr.  Wharton  and 
Dr.  Musser.  Dr.  Mayo  Robson  in  a  clinical  lecture 
reported  in  the  British  Medical  Journal,  February  2, 
and  abstracted  in  this  Journal,  February  23,  shows 
the  wonderful  decrease  that  has  been  brought  about  in 
the  mortality  of  this  condition  by  surgical  intervention, 
not  only  in  cases  of  perforation  and  of  gastrorrhagia, 
which  threaten  to  be  fatal,  but  in  the  chronic  cases  as 
well.  Robson's  own  mortality  in  operations  for  gastric 
ulcer  is  below  5%,  which  includes  those  done  for  hem- 
orrhage and  perforation.  When  one  considers  that  the 
mortality  rate  of  gastric  ulcer  medically  treated  is 
variously  stated  as  from  20%  to  50%,  the  great  saving 
of  life  by  surgical  interference  is  very  apparent.  Of 
course  no  one  would  suppose  that  the  mortality  of  all 
operations  done  for  gastric  ulcer  and  its  complications 
would  be  found  to  be  as  low  as  that  of  Mr.  Robson,  who 
has  had  a  very  extensive  experience  in  this  particular 
branch  of  surgical  work ;  but,  there  is  no  reason  to  sup- 
pose that  with  greater  experience  and  improvement  in 
technic,  the  surgical  treatment  of  this  condition  may 
not  become  more  universally  employed  and  yield  in 
the  hands  of  others  the  good  results  shown  by  Robson. 
When  one  considers  the  immediate  and  remote  dangers 
of  ulcer  of  the  stomach ;  namely,  perforation  with 
general  peritonitis  or  subphrenic  abscess  ;  hemorrhage, 
which  may  prove  fatal ;  stenosis  of  the  pylorus  ;  hour- 
glass contraction,  and  dilatation,  then  it  would  seem 
that  if  surgery  offers  a  safeguard  against  these  dangers, 
it  should  be  called  to  the  patient's  aid.  A  patient  with 
a  chronic  gastric  ulcer  which  has  refused  to  respond  to 
treatment,  is  hardly  as  safe  as  one  with  an  irreducible 
hernia.  Undoubtedly  medical  treatment  should  take 
first  rank  in  the  treatment  of  ulcer  of  the  stomach,  and 
should  be  carefully  carried  out  for  a  reasonable  time,  but, 
in  cases  which  prove  obstinate,  which  bleed  repeatedly, 
or  which  recur  after  apparent  healing,  then  surgery,  it 
has  been  shown,  can  accomplish  a  great  deal.  The 
particular  surgical  operation  that  has  to  be  done  upon 
the  stomach  will  depend  upon  the  condition  and  situa- 
tion of  the  ulcer.     Where  the  ulcer  is  large  and  situated 


at  the  pylorus,  Robson  has  found  gastroenterostomy  to 
be  more  successful  than  pyloroplasty  or  pylorectomy, 
although  in  certain  cases  these  operations  are  to  be  pre- 
ferred. A  great  improvement  in  the  method  of  per- 
forming gastroenterostomy  is  the  attachment  of  the 
bowel  to  the  posterior  instead  of  to  the  anterior  wall  of 
the  stomach.  The  latter  is  easier  of  accomplishment, 
but  it  does  not  give  the  physiological  rest  to  the  stomach 
that  the  posterior  operation  affords,  and  where  a  button 
is  used  to  make  the  anastomosis  there  is  much  less 
likelihood  of  its  finding  its  way  into  the  stomach  instead 
of  into  the  bowel.  The  question  now  to  be  decided, 
since  surgical  interference  has  won  its  place  in  the  treat- 
ment of  gastric  ulcer,  is  the  time  at  which  it  is  best  to 
resort  to  surgical  operation.  Its  absolute  necessity  in 
cases  of  perforation  and  of  pyloric  stenosis  is  unques- 
tioned, and  as  regards  the  other  cases,  we  can  probably 
not  do  better  than  follow  the  ad\ace  of  Mr.  Robson,  who 
thinks  that  cases  of  gastric  ulcgr  which  do  not  yield  to 
careful  medical  treatment,  which  show  a  tendency  to 
bleed,  and  which  recur,  should  be  operated  upon.  The 
safety  of  the  operation  of  gastroenterostomy  in  the 
hands  of  experienced  surgeons  is  shown  by  the  fact 
that  in  his  last  20  cases,  Robson  has  not  had  a  single 
bad  or  fatal  result. 

The  Antiseptic  Treatment  of  Enteric  Fever. — 

It  is  now  generally  admitted  that  enteric  fever  is  a  self- 
limited  disease,  running  its  course  in  uncomplicated 
cases  in  from  21  to  28  days.  The  specific  bacterium, 
the  bacillus  of  Eberth,  is  conceded  to  be  the  exciting 
cause.  It  is  not  our  purpose  to  inquire  minutely  into 
the  pathology  and  the  course  of  the  specific  bacteria 
after  they  have  once  found  their  way  into  a  susceptible 
organism.  After  a  period  of  incubation  varying  be- 
tween two  and  three^weeks  (average  IS  days)  the  char- 
acteristic phenomena  of  the  disease  are  produced.  It 
is  quite  necessary  to  bear  this  in  mind  when  reflecting 
upon  a  treatment  which  has  for  its  purpose  the  ren- 
dering of  the  intestinal  tract  antiseptic.  Supposing 
this  were  possible  (it  is  well  known  that  under 
normal  circumstances  the  bowel  cannot  be  cleared 
of  bacteria,  which  under  many  conditions  may  take  on 
virulence),  what  effect  would  such  a  treatment  have 
upon  the  specific  bacteria  which  were  present  during 
the  period  of  incubation  and  which  had  already  pro- 
duced their  toxins,  which  after  their  absorption  had 


404 


Tms  Phii^dhlphia"! 

MEDICAL  JonllKAL  J 


EDITORIAL  COMMENT 


[March  2,  19*1 


given  rise  to  many  of  the  symptoms  of  the  disease,  such 
as  the  dilated  pupil,  the  dry  throat,  the  diarrhea,  the 
fever,  etc.?  How  can  a  so-called  antiseptic  treatment, 
at  least  three  weeks  after  the  effects  have  been  produced, 
control  such  manifestations  ? 

The  bacillus  of  Eberth  is  found  in  the  evacuations 
some  time  between  the  tenth  and  sixteenth  day  of  the 
disease.  It  is  found  in  the  spleen,  the  liver,  the 
bone  marrow,  the  blood,  etc.  While  so-called  intestinal 
antiseptics  may  serve  a  useful  purpose  in  the  control  of 
some  of  the  abdominal  symptoms  which  may  become 
unduly  prominent,  such  as  the  diarrhea,  tympanites, 
etc.,  they  cannot  under  any  circumstances  favorably  in- 
fluence or  abort  a  self-limited  disease,  in  which  a  long 
period  of  incubation  has  allowed  the  bacteria  and  their 
toxins  to  produce  these  harmful  effects. 

Our  only  hope  of  a  scientific  treatment,  which  will 
contain  all  the  essentials  of  an  antiseptic  and  abortive 
treatment,  rests  upon  an  antitoxin  serum. 

Problems  in  Fermentation  by  Yeast. — According 
to  the  Revue  Scientifique,  the  subject  of  the  fermentation 
of  sugar  by  the  action  of  the  yeast-plant  has  recently 
been  investigated,  with  some  interesting  results.  The 
subject  has  interest  for  physicians,  because,  as  will  be 
seen,  it  tends  to  throw  light  on  some  allied  problems  in 
bacteriology.  The  fermentation  of  sugar,  as  is  usually 
taught,  is  caused  by  a  low  vegetable  organism,  known 
as  the  yeast-plant.  This  plant  takes  in  the  sugar  and 
gives  off  carbonic  acid  and  alcohol.  In  1897,  Biichner, 
a  German  investigator,  announced  that  fermentation 
was  not  dependent  on  the  actual  presence  of  the  grow- 
ing yeast-plant,  but  that  the  process  was  maintained 
just  as  well  by  a  liquid  extract,  which  he  had  made 
from  the  yeast-plant  itself.  This  extract  is  called  a 
zymose.  More  recently  some  English  experimenters 
have  gone  over  this  ground,  in  order  to  determine 
whether  the  fermentation  caused  by  this  zymose  is 
identical  with  that  caused  by  the  yeast-plant  itself; 
and  especially  whether  the  usual  products — alcohol  and 
carbonic  acid — are  obtained  in  the  same  proportions, 
and  whether  the  amount  of  sugar  transformed  is  in 
exact  proportion  with  the  quantities  of  these  substances 
"produced.  They  have  found  that  the  proportion  be- 
tween the  alcohol  and  carbonic  acid  varies  greatly,  and 
that  the  exact  proportion  between  the  amount  of  sugar 
that  disappears  and  the  quantities  of  carbonic  acid  and 
alcohol  that  are  produced  is  not  maintained.  In  other 
words,  a  large  quantity  of  sugar  disappears  and  is  not 
accounted  for.  This  would  seem  to  show  that  the 
yeast-extract,  artificially  produced,  is  not  so  potent  as 
the  yeast-plant  itself,  and  that  its  potency  is  only  main- 
tained for  a  while.  This  whole  process,  as  can  be 
readily  perceived,  is  analogous  to  what  occurs  iii  the 
case  of  many  pathogenic  bacteria.  These  minute  organ- 
isms probably  act  by  producing  toxins,  which  are 
analogous  to  the  yeast-extract,  and  these  toxins  become 


gradually  reduced  in  strength.  By  taking  advantage  of 
these  facts  pathologists  are  able  to  obtain  a  preventive 
serum.  . 

Impositions  on  Medical  Witnesses. — Since  the 
recent  remarkable  utterance  of  one  of  the  judges  of  the  j, 
Philadelphia  bench,  which  was  referred  to  in  these  col-  I 
umns  on  February  9,  many  physicians  have  expressed 
their  opinions  to  us  about  their  treatment  by  lawyers 
when  called  as  witnesses  in  court.  Some  of  these 
opinions  have  been  favorable  to  the  legal  profession, 
while  others  have  been  decidedly  the  reverse.  Some  „ 
physicians  claim  that  medical  witnesses  are  greatly  im- 
posed upon  by  the  lawyers,  particularly  in  cases  of  civil 
suits  for  damages.  The  gist  of  these  complaints  is  about 
as  follows :  The  physician  receives  a  subpena,  which 
sets  forth  that,  laying  aside  all  his  routine  duties,  he  is 
to  appear  before  the  court  at  a  certain  hour  of  a  certain 
day  as  witness  in  a  certain  case.  This  case  is  placed 
on  the  court  calendar  for  that  day  in  company  with 
several  others.  The  physician  leaves  his  work,  and 
goes  to  the  court-room  at  the  appointed  hour  and  stays 
there  until  noon,  when  a  recess  is  declared  for  an  hour 
or  two  and  he,  as  a  witness,  is  excused  for  that  length 
of  time.  At  two  o'clock  the  court  reassembles  and  the 
physician  is  obliged  to  remain  in  the  court-room  for  two 
or  three  hours  more  listening  to  the  wearisome  details 
of  cases  that  do  not  concern  him.  This  may  be 
repeated  for  several  days,  until  the  case  is  so  far  behind 
that  it  cannot  be  reached  at  that  term  of  court,  and  the 
witness  is  excused  until  the  next  term.  A  physician  is 
very  likely  to  think  that  he  has  just  cause  for  complaint 
when  required  to  waste  almost  an  entire  day  listening 
to  the  arguments  of  learned  counsel  in  cases  that  do  not 
interest  him.  We  are  personally  aware  of  an  accident 
case  that  has  been  in  the  hands  of  a  lawyer  since  1895, 
in  which  the  medical  witness  has  been  summoned  twice 
a  year  for  three  years,  and  which  is  not  yet  settled. 
Some  lawyers  (not  all)  seem  to  have  no  consideration  for 
physicians,  especially  for  the  younger  ones,  in  this  mat- 
ter. If  the  lawyer  in  charge  of  the  case  would  always 
arrange  with  his  medical  witness  (as  is  often  really  done) 
for  the  accommodation  of  both,  that  when  the  case  is 
actually  called  for  trial  the  witness  should  be  telephoned 
for,  the  latter  could  get  to  court  and  give  his  testimony 
in  ample  time.  It  always  takes  time,  usually  more  than 
one-half  hour,  to  call  a  jury,  to  administer  the  oath,  to 
state  the  case  to  the  court,  and  to  examine  the  plaintifi, 
and  in  that  time  of  preliminaries  the  physician  can 
reach  the  court-room  from  almost  any  part  of  the  city. 
In  addition  to  the  element  of  waste  of  time  there  is  the 
question  of  compensation.  The  witness  fee  is  entirely 
inadequate  to  compensate  a  physician  for  a  day's  work. 
Of  course,  in  the  case  of  a  man  engaged  as  an  expert 
witness  the  fees  are  fixed  by  private  agreement,  but  evoi 
in  these  cases  there  is  no  reason  why  an  expert  should 
be  asked  to  waste  his  time  in  court 


March  2,  1*01] 


EDITORIAL  COMMENT 


TThb  Phii^dblphia 
|_  Medical  Journal 


405 


While  some  of  these  complaints  are  just,  there  is,  it 
must  be  freely  conceded,  another  side  to  this  question. 
Some  members  of  the  bar  are  exceedingly  courteous  and 
careful  in  endeavoring  to  put  expert  witnesses  to  as 
little  inconvenience  as  possible.  Of  this  we  have  fre- 
quently had  agreeable  personal  experience.  Lawyers 
claim  that  they  themselves  are  even  more  frequently 
than  physicians,  the  victims  of  the  law's  delays.  They 
too  have  to  waste  valuable  time  in  court.  The  truth  is 
that  there  are  many  kinds  of  lawyers,  just  as  there  are 
many  kinds  of  doctors,  and  all  are  not  equally  consider- 
ate of  other  men's  rights.  In  this  era  of  the  telephone 
we  think  there  is  less  excuse  than  formerly  for  robbing 
a  doctor  of  his  time,  and  we  are  sure  that  among  the 
better  class  of  lawyers  there  is  no  disposition  to  do  so. 

Physicians  and  Temperance. — The  National  Wo- 
man's Christian  Temperance  Union  is  out  in  a  circular 
to  physicians,  and  especially  to  the  editors  of  medical 
journals,  appealing  for  aid  in  its  crusade  against  the 
use  of  alcoholic  drinks.  The  authors  of  this  circular 
claim  that  their  most  effective  allies  are  those  physicians 
who  do  not  prescribe  alcoholic  liquors,  but  allow  alcohol 
a  very  limited  sphere  of  usefulness,  or  none  at  all,  in 
the  practice  of  medicine.  They  state  in  effect  that  they 
are  endeavoring  to  do  missionary  work  in  the  cause  of 
total  abstinence  by  using  the  teachings  of  such  phy- 
sicians, and  they  evidently  want  to  make  it  appear  that 
the  medical  profession  as  such  must  become  a  sort  of 
auxiliary  of  the  W.  C.  T.  U.  if  the  evils  of  liquor 
drinking  are  ever  to  be  fully  abated.  There  is  indeed 
in  the  tone  of  the  circular  a  little  suggestion  of  a  dis- 
position to  prescribe  to  the  medical  profession  what  it 
shall  prescribe  (or  not  prescribe)  in  the  way  of  alco- 
holic stimulants. 

We  think  the  day  is  probably  far  distant  when  the 
medical  profession  as  a  body  will  be  willing  to  sub- 
scribe to  all  the  dicta  that  underlie  the  crusade  against 
drink.  As  a  profession  it  allows  to  its  individual 
members  a  wide  latitude,  both  of  opinion  and  of  prac^ 
tice,  in  the  matter  of  the  use  of  alcohol.  As  a  profes- 
sion, moreover,  if  it  has  a  prejudice  on  any  one  subject, 
it  is  against  the  enforcing  of  the  extreme  views  of  indi- 
viduals upon  people  in  general,  and  against  taking  its 
cue  from  outside  sources  as  to  what  it  shall  prescribe 
in  the  treatment  of  disease.  The  whole  question  of 
alcohol — its  use,  its  abuse,  its  control,  its  place  in  med- 
icine— is  too  vast  for  discussion  within  the  limits  of  a 
circular  or  an  editorial ;  but  we  are  willing  to  say  that 
the  medical  profession  is  certainly  more  fully  alive  to 
this  question,  and  better  acquainted  with  some  of  its 
details,  than  any  other  body  of  men  in  the  world,  and 
yet  as  a  profession  it  would  not  endorse  many  of  the 
things  that  are  both  said  and  done  by  the  advocates  of 
prohibition.  Science  has  not  yet  demonstrated  that 
alcohol  is  an  unmixed  evil,  and  that  it  has  no  place  in 
the  treatment  of  disease.    Any  attempt  to  misrepresent 


the  medical  profession  on  this  subject,  or  to  try  to  make 
it  appear  that  it  has  formed  any  unnatural  alliances 
with  outside  crusading  organizations,  is  at  least  some- 
what premature. 

lafluenza  as  a  Cause  of  Aijpendieitis. — That  the 
poison,  or  germ,  of  influenza  sometimes  expends  its 
force  upon  the  intestine,  is  a  well-known  fact.  Intes- 
tinal catarrh,  with  or  without  bloody  discharges,  has 
been  observed  in  epidemics  of  grip,  and  has  been 
claimed  by  good  observers  to  be  one  of  the  effects  of 
the  disease.  From  this  conception  of  an  intestinal 
catarrh  it  is  but  a  step  to  the  conception  of  an  appendi- 
citis due  to  the  same  cause — the  grip.  This  idea  has  been 
held  and  advanced  by  some  clinicians,  and  is  in  accord 
with  the  idea  that  appendicitis  is  in  fact  always  an 
infectious  disease  rather  than  the  result  of  a  trauma  by 
a  foreign  body.  We  have  always  regarded  this  idea  as 
still  a  theoretical  one,  and  are  not  aware  of  any  statistics 
that  go  to  prove  that  appendicitis  is  more  prevalent 
during  or  just  after  an  epidemic  of  grip  than  at  other 
times.  A  cablegram  now  announces  as  a  piece  of  news 
that  M.  Lucas  Championniere  has  just  demonstrated  to 
the  French  Academy  of  Medicine  that  one  of  the  chief 
causes  of  appendicitis  is  the  grip.  For  a  piece  of  news, 
coming  all  the  way  from  Paris,  this  sounds  rather  stale 
in  the  ears  of  American  physicians. 

As  in  the  case  of  every  medical  announcement  that 
sifts  through  the  newspapers,  this  report  from  Paris  is 
tangled  up  with  a  lot  of  sensational  and  incredible 
nonsense.  One  statement  is  to  the  effect  that  a  well- 
known  Philadelphia  surgeon  had  said  that  at  least 
one- third  of  Philadelphia's  population  have  had  appen- 
dicitis due  to  grip  and  to  the  eating  of  meat.  As  this 
would  give  about  400,000  cases  of  appendicitis  in  this 
city,  the  size  of  this  canard  can  easily  be  estimated. 
It  is  clearly  in  the  domain  and  within  the  capacity  of 
the  city  editor  to  criticise  such  science,  and  to  edit  such 
cablegrams  before  they  reach  the  press. 

Eudoplilebitis.— In  a  recent  interesting  paper,  read 
before  the  Pathological  Society  of  Philadelphia,  Dr. 
Arthur  V.  Meigs  has  described  a  new  instance  of  this 
somewhat  rare  affection.  He  says  that  diseases  of  the 
veins  have  been  by  no  means  exhaustively  studied. 
The  word  itself,  while  not  new,  cannot  be  said  to  be  in 
common  use.  It  is  adopted  in  this  connection  in  dis- 
tinction from  the  ordinary  phlebitis,  so  often  used  in 
medicine  to  describe  the  disease  commonly  called 
'■milk-leg"  and  other  similar  inflammations  of  the 
veins.  The  endophlebitis  of  Meigs  corresponds  almost 
exactly  to  the  affection  known  as  endarteritis,  and  the 
term  serves  to  call  attention  to  the  similarity  of  the 
disease  in  the  two  kinds  of  bloodvessels.  In  Dr.  Meigs' 
case,  that  of  a  male  adult,  the  veins  in  some  places 
appeared  as  nearly  solid  cords  instead  of  being  thm- 
walled  tubes,  as  is  natural.     There  was  much  thicken- 


AQQ  TwB  Philadelphia"! 

Medical  Journal  J 


EDITORIAL  COMMENT 


(MaecU  2,  1961 


ing  of  the  intima,  but  the  muscular  coat  was  the  more 
affected,  while  in  the  adventitia  th^re  was  no  evidence 
of  disease.  The  intima  was  composed  of  fibrous  tissue 
and  presented  the  appearance  commonly  seen  in  dis- 
eased arteries.  On  the  other  hand  the  muscular  coat, 
which  occupied  two-thirds  of  the  entire  thickness  of 
the  vessel  wall,  was  unlike  anything  usually  described 
in  diseased  bloodvessels.  This  thickening  of  the  mus- 
cular coat  was  evidently  caused  by  an  overgrowth  of 
fibrous  tissue ;  hence  it  was  not  an  hypertrophy,  and 
instead  of  reinforcing  the  muscular  coat  had  the  effect 
of  destroying  it. 

These  changes  are  described  minutely  by  the  author 
in  his  paper,  and^should  be  studied  in  the  original  to 
be  fully  appreciated.  The  patient  in  whom  they  oc- 
curred was  an  Italian  stone-mason,  25  years  of  age, 
who  had  had  syphilitic  infection  1|-  years  previously ; 
otherwise  he  was|_in  good  health  and  had  been  a  man 
of  fairly  good  habits.  He  was  admitted  to  the  hospital 
with  an  attack  of  vomiting  and  diarrhea,  with  pain  in 
the  epigastrium  and  with  precordial  distress.  The 
heart's  action  was  slow  and  exceedingly  irregular,  but 
there  was  no  evidence  of  hypertrophy  or  valvular  dis- 
ease. There  was  some  stifiening  of  the  radial  arteries, 
but  the  most  noteworthy  changes  were  in  the  veins.  A 
small  vein,  for  instance,  extending  across  the  dorsum  of 
the  foot  was  felt  and  seen  to  be  distinctly  thickened. 
Its  unnatural  thickness  and  hardness  could  easily  be 
distinguished  by  passing  the  finger  back  and  forth 
across  it.  It  felt  like  a  minute  cord,  instead  of  almost 
disappearing  when  compressed  as  a  healthy  vein  does. 
This  vein  was  excised  and  was  the  object  of  micro- 
scopic study,  to  which  reference  has  been  made.  The 
patient  presented  no  evidence  of  kidney  disease,  but 
he  had  not  entirely  recovered  from  his  cardiac  symp- 
toms at  the  end  of  two  months  when  he  left  the  hos- 
pital 

In  describing  the  nature  of  these  changes,  Dr.  Meigs 
supposes  that  most  observers  would  attribute  this 
change  to  syphilis,  and  he  also  thinks  that  this  etiology 
is  probable.  Syphilis  undoubtedly  produces  vascular 
disease,  as  is  well  known,  hut  its  effects  have  mostly 
been  described  in  the  arteries;  and  changes  in  the  veins, 
such  as  those  described,  are  certainly  not  commonly 
reported.  This  observer  thinks,  however,  that  it  would 
be  a  mistake  to  believe  that  syphilis  is  the  only  cause 
of  such  changes.  He  has  been  a  careful  and  systematic 
student  of  diseases  of  the  vascular  system  and  has  ob- 
served similar  changes  in  the  veins  of  persons  suffer- 
ing with  other  disease.  He  calls  attention  to  the  fact 
that  diseases  of  the  veins  have  by  no  means  been  so 
thoroughly  studied  as  diseases  of  the  arteries,  and  that 
it  is  probable  that  the  veins  are  much  more  subject  to 
disease  than  is  commonly  supposed.  The  case  upon 
which  he  bases  his  observations  was  unique  from  the 
fact  that  the  specimen  was  taken  from  the  living  sub- 
ject. 


Leukocytosis. — The  doctrine  of  phagocytosis,  her- 
alded by  Metschnikoff,  the  principle  of  chemiotaxis, 
advanced  by  Pfefifer,  and  the  researches  of  Buchner, 
Deny,  Martin  Hahn,  Goldscheider  and  Jacob,  Lowy 
and  Richter,  and  others  upon  the  bactericidal  and 
antitoxic  secretions  of  the  leukocytes,  are  all  of  interest 
when  dealing  with  the  problem  of  leukocytosis.  Vir- 
chow  suggested  the  term  "  leukocytosis  '  as  meaning  a 
transient  increase  in  the  number  of  white  corpuscles  in 
the  blood.  In  our  opinion  Cabot's  comprehensive 
definition  is  well  worthy  of  general  acceptance  at  the 
present  time,  "  an  increase  in  the  number  of  leuko- 
cytes in  the  peripheral  blood  over  the  number  normal 
in  the  individual  case,  this  increase  never  involving  a 
diminution  in  the  polymorphonuclear  varieties,  but 
generally  a  marked  absolute  and  relative  gain  over  the 
number  previously  present."  Although  within  the 
last  decade  much  valuable  statistical  material  has  been 
collected,  yet  we  are  far  from  possessing  anything  like 
a  comprehensive  knowledge  of  leukocytosis  in  varied 
pathological  states.  As  a  striking  example  we  might 
refer  to  constant  leukopenia  present  in  enteric  fever  and 
the  value  of  repeated  blood-counts  through  the  course 
of  this  disease  which  will  indicate  the  subnormal  range 
in  a  given  case.  Thus  the  onset  of  beginning  peri- 
tonitis from  perforation  might  be  overlooked  from 
the  blood-count  alone  if  but  a  single  observation 
showed  an  apparently  normal  or  slightly  increased 
count,  whereas  if  such  a  count  was  one  of  a  series  the 
contrast  would  be  suggestive  of  an  inflammatory  com- 
plication. Thus,  again,  in  cases  of  malignant  disease 
which  should  give  rise  to  a  leukocytosis  we  frequently 
have  a  modifying  factor  which  complicates  the  clinical 
blood  picture.  We  refer  to  starvation,  which  may 
occasion  a  hypoleukocytosis  in  esophageal  cancer 
with  obstruction.  With  such  a  complication  the 
blood-count  is  modified  by  the  two  diverse  factors. 
In  our  present  state  of  knowledge  we  have  no 
measures  at  our  command  to  diflerentiate  b\'  the 
blood-count  alone  inflammatory  or  infectious  from  ma- 
lignant diseases.  The  condition  of  temporary  concen- 
tration due  to  the  sudden  loss  of  fluid  from  the  body 
through  excessive  sweating,  profuse  diarrhea  or  other 
allied  conditions  often  gives  rise  to  an  increase  in  the 
number  of  colorless  corpuscles  which  may  be  a  source 
of  error.  We  shall  not  attempt  to  point  out  the  vari- 
ous errors  arising  from  faulty  technic  which  are  patent 
to  the  experienced  hematologist,  but  it  may  be  men- 
tioned that  the  researches  of  Chantemesse  and  Ray  have 
showed  us  that  in  their  observations  the  number  of 
leukocytes,  when  the  blood  is  taken  from  the  cold 
finger  is  less  by  50%  than  in  a  count  made  from  the 
warm  finger. 

It  will  require  extended  study  and  the  compilation 
of  accurate  statistics  to  unravel  the  many-sided  ques- 
tion of  physiological  leukocytosis.  The  many  circum- 
stances giving  rise  to  the  increase  in  the  white  corpuscles 


March  2,  1901] 


REVIEWS 


rPHE  Philadelphia 
L  Medical  Joubnal 


407 


show  the  constant  association  of  this  change  with  sys- 
temic disturbances  and  its  consequent  importance.  The 
simplicity  of  the  method  of  determination  should 
stimulate  us  to  more  constant  and  careful  observation. 
The  value  of  leukocytosis  as  a  clinical  index  is  com- 
parable in  a  measure  to  that  afforded  by  the  range  of 
temperature.  The  classical  observations  of  Wunderlich 
established  for  us  the  value  of  the  clinical  thermometer 
and  threw  much  light  upon  that  which  was  hidden  and 
obscure.  Is  it  too  much  to  hope  that  the  thorough 
study  of  leukocytosis  may  afford  us  a  guide  of  equal 
value  ? 

Death  of  Professor  Pettenkofer. — The  news  of  the 
death  of  the  illustrious  bacteriologist  and  hygienist, 
Professor  v.  Pettenkofer,  will  be  received  by  the  scien- 
tific world  with  deepest  regrets.  The  Frankfurter 
Zeilung  states  that  Qr.  Pettenkofer,  who  was  a  diabetic, 
had  infected  himself  with  a  knife  with  which  he  opened 
an  abscess  on  his  neck.  Like  his  deceased  brother  he 
was  constantly  fearing  mental  derangement,  and  during 
a  spell  of  melancholia  shot  himself  during  the  night  in 
his  apartments  at  the  royal  residence.  A  man  of  pro- 
found learning,  indefatigable  energy  and  strength  of 
character,  he  gained  the  admiration  of  all  with  whom 
he  came  in  contact.  He  was  instrumental  in  elevating 
the  subject  of  hygiene,  and  he  endeared  himself  to  the 
inhabitants  of  Munich  by  his  scientific  devotion  to  all 
matters  pertaining  to  the  public  health.  At  the  age  of 
83,  beloved,  respected  and  preeminent,  Pettenkofer 
passed  away,  leaving  an  indelible  impression  for  future 
generations. 

Pistol  Shots. — Hough  gives  the  results  of  experimenis 
made  by  him  to  show  the  marks  produced  by  pistol  shots  at 
various  distances.  He  used  white  blotting-paper,  which  he 
confidered  took  about  the  same  amount  of  powder- mark  as 
the  human  skin.  He  found  that  it  is  not  possible  to  deter 
mine  with  absolute  accuracy  from  the  mark  alone  what  is 
the  caliber  of  the  weapon  used  or  the  dittance  from  which  it 
is  fired.  If  the  mark  is  a  smut  without  tattoo,  the  shot  was 
fired  at  a  distance  not  over  6  inches  ;  if  the  mark  consists  of 
a  tattoo  with  distinct  smut  at  the  center,  then  the  distatK  e 
was  not  over  2  feet;  if  the  mark  consists  of  a  bullet-hi  le 
alone,  the  range  was  not  less  than  4  to  6  feet,  if  a  22-caliber 
was  used  ;  7  to  9  if  a  32,  and  9  to  12  if  a  38  or  41. 

Scarlet  Fever. — Prof.  Gibert  (Revue  Medico  Pharmaceu- 
tique,  Jan.  15,1901)  divides  scarlet  fever  into  normal  cases,  nc  t 
necessarily  free  from  danger,  and  abnormal  or  complicated 
cases.  The  former  are  usually  seen,  with  angina,  fever, 
eruption,  desquamation  of  the  tongue,  followed  by  def  quam- 
ation  of  the  body,  taking  in  all  about  6  weeks.  The  abnor- 
mal cases  may  be  abortive,  as  is  so  common  in  France, 
severe,  or  hemorrhagic,  though  this  is  rare.  Among  the 
complications  are  severe  angina,  albuminuria,  edema,  etc. 
The  eruption  settles  the  diagnosis.  The  prognosis  should 
always  be  guarded.  Isolation  in  bed,  sponging,  should  the 
fever  persist,  and  milk  diet  constitute  the  main  treatment. 
All  cases  should  be  reported.  And,  finally,  disinfection  must 
be  carefully  done,     [mo.] 


2^Ct3icU?5. 


A  Manual  of  Medicine.  Edited  by  W.  H.  Allchiv, 
M.D.  Lond.,  F.R.C.P  F.R.S.  Ed.  Volume  II.  New  York 
and  London  :  The  Macmillan  Company.  Price,  %2SC) 
a  volume,  in  cloth. 
The  second  and  concluding  volume  of  this  manual  of 
medicine  sustains  the  excellence  of  the  first.  The  subjects 
have  been  treated  ablj'  and  as  briefly  as  is  consistent  with 
thoroughness.  The  editor  has  moulded  the  work  with 
painstaking  care,  and  we  have  failed  to  note  the  frequently 
observed  discrepancies  in  books  of  similar  character  in 
which  the  various  contributors  at  times  conflict.  The  fact 
that  the  work  is  in  two  volumes  may  militate  somewhat 
against  its  general  adoption  by  students,  but  this  inconven- 
ience is  more  than  compensated  by  its  satisfactory  character. 
This  volume,  from  the  pens  of  thirteen  contributors,  deals 
with  diseases  caused  by  parasites,  those  produced  by  p  isons 
introduced  into  the  body,  the  poisons  produced  by  perver- 
sion of  general  nutrition  as  uremia,  diseases  of  the  blood, 
diabetes,  gout,  chronic  rheumatism,  osteomalacia,  rickets, 
leontiasis  ossea,  ostitis  deformans,  akromegaly  and  rickets. 
This  in  general  serves  as  an  outline  of  the  contents.    [t.i.c.| 

Die  Therapie  beini  eng'en  Becken.    Die  Indikations- 
stellung  zu  operativen  Eingriffen  unter  Zugrundelegung 
der  in   den  Jahren  1891-99  an  der   UniversitatsFrauen- 
klinik  in  Leipzig  (Geheimrath  Prof  Dr.  Zweifel)  beobach- 
teten  Geburten  beim  engen  Becken.  Von  Dr.  B.  Keonig, 
Privatdocent  in  Leipzig.    Leipzig  :  Published  by  Arthur 
Georgi.    1901. 
The  author  in  this  little  brochure  of  213  pages  has  given  a 
comprehensive  description  of  the  treatment  of  contracted 
r  el  vis  which  is  largely  based  upon  statistics  taken  from  Dr. 
Zweifel's  Women's  Clinic  in  the  University  at  Leipzig.     The 
text  is  enriched  by  numerous  tables   of  labors  in  primipara 
and  multipara,  and  the  subject  is  so  grouped  as  to  be  ren- 
dered easily  accessible  for  pur:  oses  of  reference.    The  author 
illustrates  the  different   portions  of  the   work  with  descrip- 
tive cases,   and  from  the  point  of  view  of  the  management 
of  this  obstetric  complication,   he    considers  the    various 
operations  of  prophylactic  version,  craniotomy,  the  induction 
of  premature  labor,  symphysiotomy  and  Cesarean  section. 
A  large  list  of  authors  and  their  contributions  to  the  subject, 
the  conclusions  of  which  he  has  employed  in  his  work,  adds 
considerably  to  the  value  of  the  book,  which  should  find  a 
place  in  the  library  of  all  obstetricians,     [w.a  n.d.] 

Diseases  of  the  Heart ;  Their  Diagnosis  and  Treat- 
ment. By  Albei.t  Abramp,  A  M.,  M.D.,  Consulting 
Physician  for  Diseases  of  the  Chest,  Mt.  Zion  Hos- 
pital and  the  French  Hospital,  San  Frai  cisco.  Illus- 
trated. Pp.  172.  Chicago  :  G,  P.  Engelhard  &  Co. 
Price,  $1  00  net. 

Condensation  of  so  important  and  extensive  a  subject  as 
"  diseases  of  the  heart "  is  a  task  so  difficult  that  we  feel 
some  hesitancy  in  expressing  critici.sm  of  the  work  of  Abrams, 
which  would  be  obvious  in  a  more  elaborate  treatise.  In 
the  description  of  chronic  adhesive  pericarditis  we  fail  to 
find  mention  of  Broadbent's  sign.  On  page  54  the  author 
states  the  following:  "Mitral  Stenosis— Pulse  small,  irregu- 
lar, with  increased  frequency."  On  page  119,  in  dealing  with 
the  description  of  mitral  stenosis,  he  informs  us  that  'the 
pulse  is  smaller  in  volume  than  normal,  but  regular."  la 
the  discussion  of  mitral  stenosis  he  makes  the  following 
statement  (on  page  118):  "The  brunt  of  the  burden  is 
borne  by  the  right  auricle  and  ventricle  which  become  hyper- 
trophied."  Again,  on  page  3G,  we  find  the  following:  "In 
mitral  obstruction  it  is  the  left  auricle  which  primarily 
hypertrophies  to  overcome  the  narrowed  mitral  orifice. 
Later  the  right  ventricle  hypertrophies."  Such  contradic- 
tory statements  cannot  fail  to  impair  the  value  of  the 
work.  The  illustrations  appear  crude  and  typographical 
errors  are  also  found.  We  feel  that  the  brevity  of  the  work 
and  the  errors  would  greatly  mar  its  usefulness  as  a  work 
for  students.     [f..7.k.) 


408 


The  I*Hir,ADKLPHiA"| 
Medical  Jodbnal  J 


CORRESPONDENCE 


(Uaxcu  2,  1901 


International  Clinics.  Edited  by  Henry  W.  Cattell, 
A.M.,  M.D.  Philadelphia,  U  S.  A.  Volume  IV. 
Tenth  Series  1901.  Philadelphia  :  Published  by  Messrs. 
J.   B.  Lippiucott  &  Co.     Price,  $2.00  a  volume  in  cloth. 

This  volume  of  International  Clinics  contains  several  note- 
worthy contributions  and,  as  a  whole,  is  of  unusual  excel- 
lence. We  might  mention  especially  Professor  B.  Grassi's 
contribution  upon  "Mosquitoes  and  the  Prophylaxis  of 
Malaria,"  "  Massage  in  Raynaud's  Disease,"  by  Douglas 
Graham,  and  the  "  Role  of  the  Blastomycetes  or  Ferments 
in  the  Etiologj'  of  Cancer,"  by  Roncali".  John  B.  Deaver 
reports  several  interesting  operations  including  the  Kraske 
operation  for  carcinoma  of  the  rectum  and  neurectasy  of  the 
sciatic  nerve. 

One-third  of  this  volume  is  devoted  to  a  monograph  (by 
the  editor)  which  deals  with  the  etiology  and  morbid  anat- 
omy of  various  diseases.  The  letter  T  is  reached  in  this 
portion  of  the  entire  monograph.  It  is  designed  to  aid 
students  "  who  are  about  to  pass  examination  iu  medicine 
and  pathology  and  as  a  work  of  ready  reference  for  those 
interested  in  these  subjects." 

We  cannot  accept  the  value  of  such  a  work  in  the  Inter- 
national Clinics,  even  if  it  were  done  to  our  entire  satisfac- 
tion, but  in  the  present  instance  the  average  quiz  compend 
would  supply  the  student  with  far  better  material  than  is 
found  in  this  monograph.  There  is  scarcely  a  classification 
which  is  satisfactory,  and  many  are  wofully  behind  our 
present  knowledge  upon  their  respective  subjects.  We  may 
criticise  at  random.  Under  pernicious  anemia,  for  instance, 
in  the  description  of  blood-changes  it  is  stated  that  there  is 
an  increase  of  "  neutrophilic  whites."  Ihe  term  so  used  is 
a  poor  one.  Polynuclear  or  polymorphonuclear  neutrophiles 
•are  far  preferable.  Leukocytes  are  diminished  in  number. 
There  is  a  relative  increase  or  absolute  increase  in  the 
lymphocytes  and  a  small  percentage  of  myelocytes  are 
present  in  pernicious  anemia  No  mention  is  made  of  the 
presence  of  megalobhists  which  are  of  great  diagnostic 
value.  In  discussing  the  blood  in  the  anemias  no  mention 
is  made  of  the  gross  appearance  of  the  blood  which  is 
important.  Lloyd  Jones'  theory  is  not  mentioned  under  the 
etiology  of  chlorosis  The  etiology  of  malaria  is  disposed 
of  with  a  statement  that  it  is  "  a  true  hematozoon."  Jn  the 
definition  of  diabetes  the  continuous  presence  of  sugar  is  not 
regarded  as  noteworthy  of  mention.  It  seems  unfortunate 
to  mar  tlie  value  of  the  International  Clinics  with  such 
a  monograph  We  grant  that  the  editor  had  a  task  of 
unusual  difficulty  confronting  him,  but  we  believe  it  to  have 
been  an  entirely  gratuitous  one.     [t.l.c] 


Prophylactic  Pleasures  against  the  Pest.— In  the 

report  by  Prof.  v.  Ermengem  (^Rmie  Medu-o  Pharmaceuiique, 
Jan.  15,  1901)  upon  the  pest  epidemic  in  Glasgow,  August' 
1900,  he  says :  The  pest  probably  entered  upon  a  ship  from  a 
foreign  port,  which  showed  no  suspicious  signs  upon  reach- 
ing quarantine.  It  is  not  known  whether  persons  or  mer- 
chandise brought  in  the  infection.  The  epidemic  was  not 
widespread,  perhaps  because  the  rats  were  n  t  affected.  Nor 
were  the  cases,  on  the  whole,  severe.  The  diagnosis  was  not 
difficult  in  severe,  or  bubonic  cases.  Bacteriologie  examina- 
tion was  indispensable  in  pest  pneumonia  and  in  mild  cases. 
Anti-pest  serum  furnished  encouraging,  but  not  positive  re- 
sults. Where  isolation,  disinfection,  et"..,  are  well  carried 
out,  such  an  epidemic  is  soon  limited,    [m.o] 

Contribution  to  the  Clinical  Study  of  Osseous  and 
Osteoarticular  Tuberculosis  iu  Old  People.— Moret 

(Gaz    Heb.de  Med.  et  de  Chirur,  Feb..")    1901,  4Sme  Anno^ 
No.    10;    Paris   Thesis,    1900  1901,    No    31)    out    of   8,925 

{latients  has  found  178  cases  of  osseous  and  osteoarticu- 
ar  tuberculosis.  The  course  of  the  disease  appears  to  be 
chronic  and  its  evolution  slow.  The  prognosis  is,  however, 
rendered  more  grave  by  the  always  menacing  possibility  of  a 
propagation  to  another  organ.  The  gravity  of  the  disease  is 
etill  further  dependent  upon  the  localization  of  the  affection. 
The  seat  of  the  disease,  according  to  the  order  of  frequency, 
is  as  follows :  Foot,  ribs,  knee,  sternum,  wrist,  hand,  vertebral 
column.  While  conservative  treatment  is  the  rule  in  chil- 
liren,  in  old  people,  on  the  other  hand,  economic  operations 
enould  be  advised,     [j  MS.] 


dorresponbcncc. 


THE  INFLUENCE  OF  HEREDITY. 

By  JOHN  K.  MITCHELL,  M.D., 

of  Philadelpbia. 

To  the  Editor  of  The  Philadelphia  Medical  Jocenal  : — 

The  error  in  the  example  under  the  above  editorial  head- 
ing in  your  last  number  is  a  small  one — but  somewhat  vitiates 
the  result.  A  gelding  you  say  has  never  won  the  D^rby. 
This  might  argue  for  the  superiority  of  "  entire  "  horses  and 
mares  were  it  not  that  the  reason  why  a  gelding  has  never 
won  the  race  is  that  a  gelding  has  never  tried  to.  The  con- 
ditions of  the  race  limit  it  to  "  colts  and  fillies." 

Another  statement  there  made  is  of  more  moment. 
"  Mares  have  won  races  far  less  frequently  than  stallions." 
Having  regard  to  the  comparative  numbers  of  the  two  sexes 
in  training,  I  doubt  if  this  is  true.  But  if  it  refers  only  to 
the  Derby  a  glance  at  the  list  of  entries  for  any  year  will  sug- 
gest a  good  reason.  Counting  up  the  first  year's  record 
which  I  chance  upon  I  find  that  of  22  starters  for  the  Darby 
that  season,  but  2  were  mares. 

For  general  purposes  of  hard  and  steady  work  every  horse- 
man will  tell  you  a  mare  will  outwork  and  outlast  a  stallion 
or  a  gelding,  whether  the  work  is  for  a  day  or  a  year. 


SALINE  INFUSIONS  IN  THE  TREATMENT  OF 

PNEUMONU. 

By   CLARENCE  A.  PENROSE,  M.D., 

of  Baltimore,  Md. 

To  the  Editor  of  The  Philadelphia  Medical  Journal  : — 

In  your  February  16  number  an  article  by  Dr.  J^imes  K. 
Crcok  appeared  entitled  "  R  scent  Progress  in  the  Treatment 
of  Acute  Lobar  Pneumonia."  I  was  much  surprised  at  the 
little  emphasis  the  doctor  givss  to  saline  infusions  in  the 
treatment  of  this  disease,  and  felt  that  if  a  wrong  impression 
were  given  to  the  medical  profession  it  should  be  corrected. 

Salt  infusion  is  almost  a  routine  trea'.ment  in  desperate 
cases  at  the  Johns  Hopkins  Hospital  and  has  been  employed 
in  a  nifn-.ber  of  cases  of  pneumonia,  with  most  favorable 
results,  by  our  best  local  physicians  in  their  private  practice. 
As  I  had  the  honor  of  inaugurating  this  treament  of  pneu- 
monia while  on  the  staff  of  Dr.  Ojler,  and  published  the  first 
work  on  this  matter  {Johns  Hopkim  Hospital  BuUttin.  Ja!y, 
1899),  about  one  year  after  my  first  case,  "t  is  surprising  that 
Dr.  Crook  seems  unaware  of  that  article  and  of  recent  favor- 
able comments  on  t'ais  method  in  other  journals. 

All  articles  published  since  mine  seem  to  omit  what  I  con- 
sider to  be  a  very  striking  point  in  the  effect  of  salt- infusion 
in  pneumonia,  i.e.,  its  marked  action  as  a  respiratory  stimu- 
lant, proved  by  Dr.  Hunt's  work  on  dogs  in  Dr.  Howell's 
laboratory,  and  its  favoring  the  absorption  of  oxygen,  prob- 
ably for  this  reason. 

Since  my  first  case,  infused  February  IJ,  1S9S,  and  pub- 
lished later  with  two  others,  I  have  had  the  oppartunity  of 
seeing  saline  infusions  further  tested  and  have  probably  em- 
ployed this  method  more  in  private  work  than  anyone. 
This  additional  experienc?  only  confirms  me  more  and  more 
in  my  opinion,  that  such  infusions  are  most  valuable  in  the 
treatment  of  pneumonias  of  severe  grade,  when  employed 
by  one  conversant  with  the  method,  and  who  understands 
the  significance  of  the  second  pulmonic  heart-sound.  As 
stated  in  my  article,  bleeding  is  often  a  most  necessary  ad- 
junct to  infusion  and  sometimes  it  is  imperative.     I  take  the 


Uasch  : 


1901] 


AMERICAN  NEWS  AND  NOTES 


PThk  Philadblphia 
L  Medical  Jouk>'al 


409 


liberty  of  sending  you  a  reprint  of  my  article,  which  I 
scarcely  think  Dr.  Crook  should  overlook. 


QUEEN  VICTORIA  AND  THE  USE  OF  CHLOROFORM 
IN  OBSTETRICAL  PRACTICR 

By  J.  C.  REEVE,  M.D., 

of  DavtoD,  O. 

To  the  Editor  of  The  Philadelphia  Medical  Jouknal  : — 

In  all  the  notices  of  the  late  Queen  Victoria,  her  noble 
life,  and  her  influence  for  good,  I  have  failed  to  find  a  single 
word  in  regard  to  the  importance  of  her  example  in  accept- 
ing chloroform  during  labor,  until  the  article  in  your  issue  of 
February  9.  In  that  article,  due  appreciation  of  her  influ- 
ence in  promoting  the  use  of  anesthetics  in  obstetrical  prac- 
tice is  expressed.  May  I  be  permitted  to  call  attention  to  the  • 
fact  that  this  has  already  been  done,  and  several  years  ago, 
in  our  medical  literature.  In  Vol.  I,  of  Hirst's  American 
System  of  Obstetrics,  18S8,  article  "  On  the  Use  of  Anesthetics 
in  Labor,"  I  have  tried  to  give  due  expression  to  the  import- 
ance of  the  Queen's  action  in  this  matter,  and  appreciations 
of  its  great  influence  in  promoting  the  use  of  anesthetics  in 
labor.  The  date  was  1853,  but  a  very  few  years  after  chloro- 
form was  first  used  for  surgical  anesthesia,  and  when  the 
Lancet,  then  the  leading  medical  journal  of  the  world,  com- 
menting on  the  administration,  said  :  "  In  no  case  could  it 
be  justifiable  to  administer  chloroform  in  a  perfectly  ordinary 
labor."  In  that  article  I  close  by  sayiag :  "  The  illustrious 
sovereign,  whose  reign  has  seen  so  many  notable  achieve- 
ments, may  congratulate  herself  upon  a  personal  participa- 
tion in  the  greatest  one  of  the  age,  or  of  any  age,  so  far  as 
the  suSering  of  her  sex  is  concerned.  In  all  time  to  come 
homage  is  due  her  for  this  service  as  the  woman,  rather  than 
as  the  Queen."  

A  QUESTION  OF  ORIGINALITY. 

By  D.  T.  SMITH,  M.D., 
of  LouiSTille,  Ky. 

To  the  Editor  of  The  Philadelphia  Medical  Jouknal  : — 

I  SEND  you  today  a  copy  of  the  American  Practitioner  and 
News,  of  July  10,  1886,  containing  an  article  by  myself,  re- 
printed from  the  Southern  Pharmacist  of  February,  1884.  The 
article  was  read  to  the  Orleans  Parish  Medical  Society  in 
October,  1883,  and  shortly  afterward  submitted  to  Dr.  Rudolph 
Matas,  then  the  editor  of  the  Neio  Orleans  Medical  Journal,  for 
publication,  and  he  told  me  he  would  give  it  the  leading 
place  in  his  next  issue.  In  the  meantime  the  Journal  passed 
into  the  hands  of  a  coterie  of  physicians,  and  when  Dr. 
Matas  submitted  my  paper  they  unanimously  voted  it  too 
visionary  and  fanciful  for  a  scientific  journal  and  rejected  it. 
In  the  succeeding  February  it  was  published  in  the  Southern 
Pharmacist,  a  small  pharmaceutical  publication  conducted 
by  Ferdinand  Larcas,  Ph.D.  It  is  useless  to  say  how  long 
these  views  had  been  held  in  a  more  or  less  crude  form, 
but  I  may  say  that  at  that  time  I  had  never  heard  of  Metsch- 
nikofi"  nor  his  doctrine,  which  as  far  as  I  know  at  the  date  of 
the  rejection  of  my  article  had  not  been  published  in  America. 
His  observations,  I  believe,  began  in  1892.  The  article  con- 
tains a  number  of  errors  too  glaring  now  to  need  pointing 
out,  but  as  a  speculation  so  largely  borne  out  by  observations 
that  have  added  another  name  to  the  immortals,  I  may  be 
excused  the  selfish  desire  to  have  it  appear  in  the  columns  of 
the  Philadelphia  Medical  Journal. 

The  article  as  read  and  first  published  was  entitled,  "  The 
Role  of  the  Leukocyte,  or  the  Philosophy  of  Fever,"  and  is 
here  given. 


2lmcrtcan  Hctos  an5  Xloits. 


PHIIiADELPHIA  AND  PENNSYLVANIA. 

New  Editor, — Francis  R.  Packard,  of  Philadelphia,  has 
been  made  editor  of  the  American  Journal  of  Medical  Science, 
vice  Dr.  Alfred  Stengel,  resigned. 

The  Maternity  Hospital. — The  twenty-seventh  annual 
report  of  the  Maternity  Hospital, Tenth  and  Fitzwater  streets, 
which  has  jost  been  published,  states  that  there  were  90  appli- 
cants during  the  year,  of  whom  51  free  and  5  pay-patienta 
were  treated. 

Asatomy  Prizes, — At  the  annual  competitive  examina- 
tion just  held  at  the  Philadelphia  Sshool  of  Anatomy, 
Eighteenth  and  Buttonwood  streets,  by  Professor  W.  Wal- 
lace Fritz,  M.D.,  D.D.S.,  the  first  prize  was  awarded  to  Dr. 
Arthur  Pritz,  of  Australia,  for  the  best  paper  on  anatomy 
and  surgery.  The  second  prize  was  awarded  to  Dr.  Agnes 
W.  Howes,  of  New  York,  for  the  best  practical  anatomical 
work.  A  large  number  of  students  received  honorable  men- 
tion. 

Pennsylvania  Hospital. — A  committee  consisting  of 
John  B.  Garrett  and  John  Story  Jenks,  of  the  board  of  man- 
agers. Dr.  John  B.  Chapin,  superintendent  of  the  Penn- 
sylvania Hospital  for  the  Insane,  and  Dr.  Thomas  G.  Morton, 
president  of  the  medical  staff,  was  appointed  to  make  arrange- 
ments for  the  commemoration,  early  in  June,  of  the  one 
hundred  and  fiftieth  anniversary  of  the  founding  of  the 
Pennsylvania  Hospital.  Dr.  Francis  Olcott  AUen,  Jr.,  who 
graduated  last  year  from  the  University  of  Pennsylvania,  was 
appointed  a  resident  physician  of  the  hospital. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 

February  23,  1901 : 

Total  mortality 517 

CA3ES.       DKATBa. 

Inflammation  of  appendix  1,  bladder  2,  brain 
21,  bronchi  12,  heart  1,  kidneys  26,  larynx  1, 
lungs  74,  peritoneum  8,  pleura  2,  stomach 

and  bowels  19 167 

Inanition  20,  marasmos  10,  debility  -4 34 

Tuberculosis  of  lungs 64 

Apoplexy  16,  paralysis  6 22 

Heart — disease  of  41,  fatty  degeneration  of  4,  45 

Uremia  12,  diabetes  2,  Bright's  disease  5  .   .   .  19 

Carcinoma  of  breast  3,  stomach  4,  uterus  3  .   .  10 

Convulsions 18 

Diphtheria 59  11 

Brain — abscess  of  2,  dropsy  of  1,  softening  of  2  5 

Typhoid  fever 54  6 

Old  age 22 

Alcoholism 3 

Cyanosis 1 

Scarlet  fever 53  4 

Influenza  12,  asthma  3,  anemia  1,  aneurysm 
of  aorta  1,  burns  and  scalds  3,  casualties  11, 
congestion  of  lungs  3,  cirrhosis  of  the  liver 
9.  tuberculosis  of  the  bowels  1,  membranous 
croup  3,  diarrhea  1,  drowned  2,  dropsy  4, 
epilepsy  1,  erysipelas  1,  fistula  1,  gallstones 
1,  gangrene  1,  hemorrhage  from  nose  1, 
hernia  3,  jaundice  1,  obstruction  of  the 
bowels  2,  poisoning  1,  rheumatism  1,  ar- 
terial sclerosis  1,  surgical  shock  1,  septi- 
cemia 4,  sore  month  1,  suffocation  1,  syph- 
ilis 1,  teething  1,  brain  tumor  3,  ovarian  1, 
ulceration  of  stomach  1,  whooping-cough  3  36 

Neurological  Society, — The  stated  meeting,  held  Feb- 
ruary 25,  was  opened  by  Dbs.  William  H.  Teller  and  F.  X. 
Dercitm,  who  exhibited  A  case  of  astereognosis.  This 
condition  was  the  result  of  an  injury  by  a  blow  on  the  head, 
which  caused  a  depressed  fracture  and  a  large  subdural 
hemorrhage  in  the  parietal  lobule  posterior  to  the  fissure  of 
Rolando.  Astereognosis  of  the  right  hand  is  complete,  the 
patient,  a  colored  man,  30  years  of  age,  being  unable  to 
recognize  by  the  sense  of  touch  any  object  placed  in  that  hand. 
There  is  also  tactile  hypesthesia  over  the  whole  of  the  right 
side,  this  condition  being  more  marked  as  the  extremities 
are  reached.  Ability  to  locate  simultaneously  two  impres- 
sions is  lost  and  there  is  also  a  diminution  of  the  faculty  of 
locating  a  single  impression. 

Dbs.  Gkoroe  L.  Walton  and  Walter  E.  Paul,  of  Boston,  by 


410 


The  pHiLADELPEaAl 


AMERICAN  NEWS  AND  NOTES 


[Maeoj  2,  1901 


invitation,  read  an  admirable  paper  entitled  Astereognosis, 
with  Illustrative  cases.  The  value  of  this  condition  in  dif- 
ferentiating hysteria  from  organic  disease  was  pointed  out. 
Among  the  points  of  diflFerence  is  the  fact  that  in  astereog- 
nosis the  patient  cannot  touch  a  certain  point  on  the 
aflected  hand  with  the  well  hand  without  groping  when  the 
eyes  are  closed.  In  hysteria  this  is  not  present.  Astereog- 
nosis occurs  in  both  cortical  and  central  lesions  and  cannot 
alone  diflerentiate  between  these  locations.  In  none  of  the 
cases  seen  by  these  observers  has  pain  or  temperature  sense 
been  lost  when  the  lesion  was  in  the  Rolandic  areas.  In  one 
case  the  paralysis  was  limited  to  one  foot.  This  furnished 
an  opportunity  to  compare  results  with  those  obtained  in  the 
hands.  Tests  with  normal  subjects  showed  that  the  foot  gave 
little  reliability  in  distinguishing  the  size  of  objects  which  are 
round  or  square,  but  can  distinguish  long  objects.  In  the 
case  of  astereognosis  mentioned,  designated  points  could  be 
located  apparently  as  well  as  by  the  hand.  The  results  of 
locating  lesions  by  this  method  brings  up  the  question  of  the 
advisability  of  surgical  interference  in  cerebral  disease.  An 
occasional  success  indicates  that  the  patient  should  be  given 
the  benefit  of  the  chance  when  the  lesion  is  local  and  near 
the  cortex.  Experiments  on  animals  will  be  of  little  value  in 
advancing  the  knowledge  of  astereognosis  as  the  faculties 
concerned  are  not  well  enough  developed.  Control  experi- 
ments on  human  subjects  are  of  great  value.  In  cases  of 
hemiplegia  Ts-ithout  astereognosis  the  chances  are  in  favor  of 
a  capsular  lesion.  A  safe  working  plan  is  that  when  astere- 
ognosis only  is  present  the  lesion  is  at  a  point  in  the  central 
parietal  lobule.  Dr.  Deecum  thinks  it  is  justifiable  to  speak 
of  a  sensory  and  a  motor  astereognosis.  Dr.  Bubb  said  that 
it  was  wrong  to  speak  of  the  stereognostic  sense.  Faculty 
is  a  better  term.  He  believes  that  there  is  a  part  of  the  pos- 
terior parietal  lobule  which  stores  up,  so  to  speak,  the 
memory  of  things  felt  as  other  parts  do  the  memory  of  things 
seen.  The  term  stereognosis  is  a  more  accurate  expiession 
than  is  astereognosis.  The  subject  was  further  discussed  by 
De8.  Lloyd,  Spillee,  and  Walton.  Following  the  meeting 
a  reception  was  tendered  Drs.  Walton  and  Paul  at  the  Uni- 
Tersity  Club. 

College  of  Physicians — Section  on  Gynecology. — 

The  meeting  of  February  21  was  opened  by  Dr  John  B. 
Shober,  who  read  a  paper  on  Varicocele  of  the  broad 
ligrament.  The  etiology,  symptoms,  diagnosis,  and  treat 
ment  were  considered  and  a  case  reported.  The  treatment 
adopted  was  simple  ligation  of  the  veins  of  both  broad  liga- 
ments. The  condition  of  the  patient  after  16  months  is  fully 
as  bad  as  before  operation.  Catgut  ligatures  were  used, 
which  is  believed  to  be  largely  responsible  for  the  failure  to 
cure.  Dr.  Shober  also  exhibited  a  specimen  removed  from 
a  patient  having  primary  tuberculosis  of  the  fallopian  tubes. 
Operation  revealed  general  adhesions,  a  monolocular  cytt  of 
the  right  ovary,  double  pyosalpinx,  and  a  large  fibroid  of  the 
uterus. 

Dr.  Wilmer  Krusen  reported  a  case  of  Ovariotomy  in 
the  eightieth  year.  Cysts  of  both  ovaries  were  removed, 
the  patient  making  a  good  recovery.  An  interesting  point 
was  the  slow  growth  of  the  cysts,  a  tumor  having  first  been 
observed  26  years  before  operation. 

Dr.  H.  D.  Beyea  reported  The  occurrence  of  fibroid 
tumors  in  4  sisters,  their  mother,  and  grand- 
mother, a  maternal  aunt,  and  12  third  cousins. 
Dr.  E.  E.  Montgomery  believes  there  is  no  hereditary  tend- 
ency to  fibroids  of  the  uterus.  Dr.  J.  G.  Clark  thinks  that 
the  cases  reported  were  only  a  coincidence,  as  is  the  case 
with  any  growth  of  the  genitial  tract.  He  now  pays  but  little 
attention  to  the  family  history  in  cases  of  suspected  malig- 
nant disease. 

Dr.  John  B.  Deaver  read  a  paper  entitled  Three  dan- 
gerous operations— Repair  of  a  lacerated  cervix, 
dilatation,  and  curettement.  The  paper  was  directed 
mainly  to  general  practitioners  and  dealt  with  the  indications 
for  these  operations  and  their  danger  when  not  done  under 
proper  aseptic  precautions.  Lacerations  of  the  cervix  had 
better  be  let  alone  unless  there  are  special  indications  for 
treatment.  A  family  history  of  malignant  disea^ie  is  an  indi- 
cation for  operation  at  once.  Washing  out  the  uterus  and 
packing  with  gauze  are  to  be  done  only  in  infected  cases. 
Curettement  should  be  used  only  in  carefully  selected  cases. 
The  moral  effect  of  the  operation  is  nothing,  and  the  effect 


of  operations  per  te  should  be  relegated  to  the  realms  of 
Christian  science.  The  reliability  of  the  examination  of 
curetted  material  in  cases  of  suspected  malignant  disease  is 
doubtful.  Dilatation  of  the  cervix  or  curettement  should  never 
be  done  in  a  physician's  office.  They  should  only  be  done 
after  careful  disinfection  of  the  patient,  and  the  operator  and 
assistants  should  wear  rubber  gloves.  Operations  should  be 
confined  to  surgeons  and  not  be  a  prerogative  of  general 
practitioners.  De.  Montgomery  stated  that  he  considered  it 
a  crime  for  physicians  to  dilate  or  curet  a  uterus  in  their 
office.  He  does  not  permit  such  a  patient  to  be  up  in  less 
than  a  week.  Digital  examination  in  suipected  malignant 
disease  is  preferred  to  microscopic  examination  of  scrapings. 
The  hereditary  tendency  of  cancer  of  the  uterus  is  qnestion«L 
Dk.  Barton  Cooke  Hibst  has  had  a  satisfactory  experience 
with  the  examination  of  scrapings  by  expert  pathologista. 
Few  men  are  competent  to  give  authoritative  opinions  on 
such  tissues,  but  when  such  men  are  employed  the  results 
are  satisfactory.  Dr.  Hirst  has  been  observing  the  results  of 
operations  upon  the  cervix  until  he  is  convinc«l  that  primary 
operation  for  a  lacerated  cervix  is  not  warranted.  At  the  end 
of  2  weeks  a  certain  success  may  be  attained.  In  institutions 
this  time  should  be  selected,  the  woman  thus  convalescing 
from  the  puerperium  and  the  operation  at  the  same  time. 
Dr.  J.  G.  Clark  finds  microscopic  examination  of  curetted 
material  to  be  of  great  value.  The  diagnosis  of  such  material, 
however,  is  almost  a  special  line  of  pathology,  as  many  men 
who  are,  generally  speaking,  first-class  pathologists  will  make 
mistakes  in  these  instances.  Dilatation  of  the  cervix  is  a 
very  dangerous  procedure  in  old  cases  of  gonorrheal  iafec- 
tion.  Patients  with  gonorrheal  history  should  be  most  care- 
fully studied  before  the  operation  is  resorted  to.  Dr.  Dkaver 
has  obtained  distinct  history  of  heredity  in  some  cases  of 
cancer.  He  lakes  exceptions  to  the  statements  that  douch- 
ing of  the  uterus  is  advisable  after  ordinary  operations  upon 
the  cervix.  He  believes  that  fluid  can  be  thus  conveyed  to 
the  fallopian  tubes. 

Dr.  J'  'HN  H.  Gervin  reported  a  case  of  infectious  fever 
resulting  in  premature  labor,  peritonitis,  and 
death.  The  etiology  of  the  case  is  obscure.  Symptoms 
were  indefinite,  and  operation  at  no  time  seemed  to  be 
indicated. 

Dr  J.  M.  Baldy  read  a  paper  on  Results  in  treatment 
of  cancer  of  the  cervix  and  the  unreliability  of 
statistics  of  the  same.  The  reports  of  40  to  8li%  of 
curee  are  misleading  and  contrary  to  facts.  They  are  pub- 
lished before  a  sufficient  time  has  elapsed,  or  refer  only  to 
selected  cases  operated  upon,  the  great  majority  of  cafes  seen 
being  refused  operation  as  hopeless.  Statistics  of  Germans 
are  especially  unreliable.  Most  cases  of  cancer  of  the  cervix 
die,  whatever  be  done  for  them.  The  hope  of  the  future  is  a 
mere  careful  clinical  study  of  the  symytoms  and  earlier  diag- 
nosis. In  medical  schools  and  textbooks  too  much  stress  is 
put  upon  laboratory  diagnosis.  Clinical  manifestations  must 
be  studied,  especially  by  country  practitioners,  that  they  may 
send  cases  for  operation  earlier.  Dr.  Deaver  stated  that 
very  radical  surgery  was  advisable  only  in  cases  seen  early. 
The  same  rule  holds  good  in  these  cases  as  in  CAncer  of  the 
breast — when  the  surrounding  glands  are  involved  the  case 
is  hopeless.  In  cancer  of  the  breast,  when  the  glands  under 
the  clavicle  are  involved,  the  removal  of  the  entire  growth  is 
imp  wsible.  Dr.  E.  P.  Davis  believes  that  a  microscopic 
examination  should  be  made  in  cases  of  icc-'imnlete  abortion 
and  the  so-called  molar  pregnancies.  De.  J.  G.  Clark  con- 
siders the  statistics  of  German  writers  as  generally  very 
reliable. 

NEW  JERSEY. 

Appointed  Railroad  Surgeon. — Dr.  Paul  M.  Mecray, 
surueon  al  the  Cooper  H  spiLai,  nas  been  appointed  surgeon 
and  physician  to  the  Pennsylvania  Railroad  Company,  to 
succeed  Dr.  Dowling  Benjamin. 

NEW  YORK. 

New  Pavilion  at  Eye  and  Ear  Infirmary. — The 

new  Piatt  Pavilion,  fur  ttie  isolation  and  ire.-nmeut  of  cases 
of  coMagious  ophthalmia,  has  just  been  opened  at  the  New 
York  Eve  and  Ear  Infirmary.  The  building  was  erected  to 
the  memory  of  ttie  late  James  X.  Piatt,  and  presented  to  the 
institution. 


Maech  2,  1901J 


AMERICAN  NEWS  AND  NOTES 


FThb  Philadelphia 
L  Medical  Jodbhal 


411 


Professional  Secrecy.— A  bill  has  been  introduced  into 
the  New  York  legislature  to  include  nurses  within  the  scope 
of  sections  884  and  836  of  the  code  of  civil  procedure,  placing 
them  in  the  same  position  as  physicians,  regarding  revealing 
information  obtained  from  patients  while  serving  in  a  con- 
fidential and  professional  capacity. 

New  York  Skin  and  Cancer  Hospital.— The  Gov- 
ernors of  ihe  New  York  Skin  and  Cancer  Hospital  announce 
the  following  course  of  clinical  lectures  on  Syphilis  by  mem- 
bers of  the  Visiting  and  Consulting  Stafis,  on  Wednesday,  at 
4.15  P.M. : 

March  6. — Syphilis  as  a  Disease :  Modes  of  Infection : 
Extra-Genital  Syphilis,  by  L.  Duncan  Bulkley,  M.D. 

March  13.— Skin  Manifestations  of  Syphilis,  by  L.  Duncan 
Bulkley,  M.D. 

March  20  —Infantile  Syphilis,  by  A.  Jacobi,  M.D. 

March  27.— Syphilis  of  the  Mouth,  Nose,  Throat,  and 
Larynx,  by  D.  Bryson  Delavan,  M.D. 

April  3.— Syphilis  of  the  Eye  and  Ear,  by  David  Webster, 
M.D. 

April  10.— Syphilis  of  the  Nervous  System,  by  Edward  D. 
Fisher,  M.D. 

April  17. — Syphilis  of  Internal  Organs,  by  Edward  G. 
Janeway,  M.D. 

April  24. — Syphilis  of  the  Bones,  and  Surgical  Kelations  of 
Syphilis,  by  Willy  Meyer,  M.D. 

May  1. — Synopsis,  Conclusions,  and  Treatment  of  Syphilis, 
by  L.Duncan  Bulkley,  M.D. 

NEWIENGLAND. 

New  Eng^land  Baptist  Hospital. — The  New  England 
Baptist  Hospital  has  bought  a  piece  of  land  in  Roxbury, 
where  it  already  occupies  35,862  square  feet. 

Appointments.- F.  W.  Spalding,  M.D.,  has  been  ap- 
pointed visiting  ophthalmologist  to  the  Long  Island  Hospital, 
Boston  Harbor.  John  J.  Magrath,  M.D.,  has  been  appointed 
attending  surgeon  to  the  Harlem,  N.  Y.,  Hospital. 

Acute  Infectious  Diseases  in  Boston. — For  the  week 
ending  at  noon,  February  20,  1901,  there  were  reported  to 
the  Board  of  Health,  of  Boston,  the  following  cases  of  acute 
infectious  diseases  :  diphtheria  105,  scarlatina  31,  measles  48, 
typhoid  fever  4. 

Dr.  Samuel  Camp. — ^The  death  of  Dr.  Samuel  Camp, 
the  oldest  physician  and  surgeon  in  Southern  Berkshire, 
Mass.,  occurred  February  24.  He  was  72  years  of  age,  and  a 
native  of  Winsted,  Ct.  He  graduated  in  1851  from  the 
University  of  New  York.  He  served  during  the  Civil  War 
as  surgeon  of  the  27th  Massachusetts  regiment,  and  from 
1877  to  1892  was  Medical  Examiner  for  Southern  Berkshire. 
He  was  a  member  of  the  Massachusetts  and  Berkshire  medi- 
cal societies. 

CHICAGO  AND  WESTERN  STATES. 

Oakland  Medical  College. — The  new  building  of  the 
Oakland  M'  dical  College  will  be  ready  for  students  by  Sep- 
tember 1, 1901. 

Compulsory  Inoculation. — The  Council  of  Sioux  City 
has  piBotd  an  ordinance  compelling  the  inoculation  with 
antitoxin  of  all  members  of  families  in  which  there  is  a 
case  of  diphtheria. 

Professor  William  Pleen  Dead. — Dr.  William  Pleen, 
professor  of  physical  diagnosis,  at  Uamline  University,  and 
one  of  the  best  known  physicians  of  Minneapolis,  died 
February  21,  from  pneumonia. 

Value  of  Antitoxin, — It  has  been  estimated  by  the 
Henlih  Department  of  Chicago  that  4,500  lives  have  been 
saved  in  that  city  during  the  last  5  years  by  the  use  of  anti- 
toxin in  the  treatment  of  diphtheria. 

Mendota  Insane  Asylum. — The  state  board  of  control 
elened  Dr.  E  L.  Bullard  oi  Waukesha,  to  succeed  Dr.  W.  B. 
Lyman,  of  Eau  Claire,  as  superintendent  of  the  Mendota  In- 
sane Aaylum,  which  position  Dr.  Lyman  resigned  some  time 
ago. 


Omaha  Medical  Society. — The  following  officers  were 
elected:  Dr.  Bryon  B.  Davis,  president;  Drs.  Gertrude  Cus- 
caden  and  Rufus  D.  Mason,  vice-presidents  ;  Dr.  Joseph  M. 
Aikin,  secretary  ;  Dr.  Millard  Langfeld,  treasurer,  and  Drs. 
Harry  M.  McClanahan,  Benjamin  F.  Crummer  and  Andrew 
B.  Somers,  board  of  censors. 

Smallpox  in  Wisconsin. — The  village  of  Salem  is  the 
seat  of  a  smallpox  sensation  and  it  is  stated  that  over  700 
people  employed  in  the  hars'est  have  been  exposed  to  small- 
pox. The  village  is  used  by  ice  companies  for  cutting  ice  on 
the  lakes  and  a  few  days  ago  a  laborer  was  taken  ill  with 
what  was  supposed  to  be  influenza.  It  is  claimed,  however, 
that  the  man  nad  a  well  developed  case  of  smallpox  before 
leaving  the  village.  Cases  are  further  reported  at  Toma- 
hawk, Manitowoc  and  Neenah. 

Bacteria  in  Library  Books. — Dr.  F.  A.  Kufleweki, 
chairman  of  the  special  committee  appointed  by  the  public 
library  board  of  Chicago  to  consider  the  advisability  of  steril- 
izing the  books  in  the  library  for  the  purpose  of  prevent- 
ing the  spread  of  disease,  recommends  tnat  some  system  be 
adopted  for  freeing  the  pages  of  the  volumes  from  bacteria. 
He  said  that  all  of  the  50  books  examined  by  him  during 
the  investigation  were  found  to  be  more  or  less  infected.  He 
said  there  was  no  doubt  that  disease  was  spread  by  the  books, 
and  advised  that  a  system  of  sterilizing  the  volumes  by  the 
dry  process  be  adopted  immediately. 

Dr.  Smith  Dead. — Dr.  Maj[o  G.  Smith,  the  companion 
and  friend  of  Mark  Twain  and  inspiration  of  the  novelist's 
"  Doctor,"  "  Innocents  Abroad,"  is  dead  at  Colorado  Springs. 
Dr.  Smith  was  born  in  Newburyport,  Mass.,  August  19, 
1816.  He  was  one  of  the  first  graduates  of  Oberlin  College, 
and  was  an  intimate  friend  of  Horace  Greeley,  starting  life 
as  a  preacher  and  later  as  the  reporter  employed  by  Greeley 
on  the  Tribune.  He  went  to  California  in  1849,  joined  the 
regular  army ;  later  became  rich  and  traveled  with  Mark 
Twain.  He  was  master  and  part  owner  of  the  first  ship  that 
sailed  from  San  Francisco  to  Australia.  Dr.  Smith  was  the 
author  of  two  works  on  ether  and  chloroform  from  experi- 
ments he  conducted.  For  several  years  he  gave  his  attention 
to  medicine,  and  later  was  associated  with  Morse,  in  com- 
pleting the  telegraph  and  constructing  the  first  line  between 
Washington  and  Baltimore. 

Meeting  of  the  Chicago  Pathological    Society, 

February  11, 1901,  Dr.  L.  Hektoen,  President. 

Dr.  Thomas  R.  Ceowder  described  three  cases  of  osseous 
stylohyoid  arch.  The  stylohyoid  arch  is  a  constant  struc- 
ture in  the  higher  vertebrates.  In  many,  as  the  horse,  cow 
and  sheep,  it  is  completely  bony ;  in  man  it  is  largely  liga- 
mentous. Developmental  defects  with  more  or  less  ossifica- 
tion are  not  infrequently  found,  but  complete  bony  arch  is 
rare.  The  three  caaes  presented  were  not  recognized  before 
death.  The  anomaly  is  to  be  looked  upon  as  a  developmental 
defect  and  not  as  an  ossification  of  the  stylohyoid  ligament 
once  developed  in  the  normal  way.  It  has  no  clinical  signifi- 
cance beyond  the  possibility  of  fracture — an  unlikely  acci- 
dent. 

D.  F.  G.  Harris  reported  a  case  of  blastomycetic  derma- 
titis in  a  woman  78  years  old.  The  growth  was  located  on 
the  gluteal  region  and  commenced  four  years  ago  as  a  pim- 
ple, which  became  a  roughened  area  of  intense  itching  and 
later  became  apparently  denuded.  The  growth  was  11  centi- 
meters long  by  about  6  centimeters  wide,  having  an  elevated 
border  bearing  flattened  papillomatous  outgrowths  which 
overhung  the  floor,  the  latter  being  covered  with  villous-like 
epithelial  projections  interspersed  with  areas  of  ulceration. 
The  entire  growth  was  movable  on  the  underlying  tissues ; 
there  were  no  secondary  growths  on  any  part  of  the  body,  nor 
were  there  any  evidence  of  syphilitic  infection.  Microscopic 
examination  showed  a  hyperplasia  of  the  rete  murosum  which 
grew  down  into  the  conum  in  branching,  coral-hke  projec- 
tions. In  these  epithelial  downgrowths  were  miliary  abscesses 
containing  the  blastomycetic  organisms  which  were  present 
in  groups  of  3  or  more.  Many  of  them  were  in  the  process 
of  budding.  There  were  no  cultures  made  from  this  case  on 
account  of  the  diagnosis  not  having  been  made  clinically.  In 
the  discussion  of  Dr.  Harris'  paper.  Dr.  Lieberthal  referred 
to  a  case  recently  observed,  in  which  a  provisional  diagnosis 
of  syphilis  was  made,  where  the  blastomyces  were  found  in 


412 


The  Philadelphia"] 
Medical  Jodenal  J 


AMERICAN  NEWS  AND  NOTES 


[Makch  2,  IWl 


sections.  He  still  held  to  his  original  diagnosis.  H.  T. 
EiCKETS  said  that  the  histology  of  blastomycetic  dermatitis  is 
a  specific  one  and  entirely  different  from  that  of  tuberculosis 
and  syphilis.  H.  G.  Anthony  spoke  of  the  points  of  differ- 
ence between  blastomycetic  dermatitis  and  the  syphilitic  and 
tubercular  lesions  resembling  it.  L.  Loeb  called  attention 
to  the  fact  that  blastomycetic  dermatitis  has  not  been  pro- 
duced experimentally.  W.  E.  Coates  compared  blastomy- 
cetic dermatitis  to  certain  diseases  in  plants.  He  considers 
the  organisms  observed  in  the  skin  lesions  as  spores  of  fungi. 

F.  G.  Haeeis  stated  that  his  case  was  treated  with  iodids 
for  3  weeks  without  any  improvement. 

De.  Le  Count  demonstrated  diffuse  secondary  carcinoma 
confined  to  the  lymph-channels  of  both  lungs  of  a  man 
who  died  from  carcinoma  of  the  stomach  while  in  the  ser- 
vice of  Dr.  Kramps  at  the  St.  Elizabeth  Hospital ;  the  con- 
dition was  correctly  diagnosed  during  life.  At  the  necropsy 
the  usual  large  metastatic  tumor  nodules  were  found  in  the 
liver  together  with  an  extensive  involvement  of  the  peri- 
pancreatic,  retroperitoneal,  peribronchial  and  peritracheal 
lymph-glands;  the  adrenals  were  the  seat  of  a  very  ex- 
tensive carcinomatous  growth  ;  there  were  small  tumors  in 
the  outer  parts  of  both  kidneys.  The  primary  tumor  from 
which  all  these  metastatic  growths  arose  was  located  near 
the  pylorus  and  showed  no  features  other  than  are  often  ob- 
served in  gastric  carcinomata.  The  lungs  were  alike  in 
appearance;  both  possessed  very  exteneivesubpleural,  linear, 
branching  and  tortuous  carcinomatous  growths  in  the  lymph- 
channels  as  well  as  tumor  masses  in  the  lymph-channels  of 
the  deeper  parts  of  the  lungs.  There  were  no  nodular 
growths  in  the  lungs  as  are  observed  in  consequence  of  the 
embolism  of  tumor-cells.  The  lungs  were  fresh,  no  micro- 
scopic examination  having  been  made,  but  the  gross  appear- 
ance supported  in  all  its  details  the  opinion  that  a  retro- 
grade lymphatic  metastasis  had  occurred  in  these  channels 
from  the  lymph-glands  at  the  roots  of  the  lungs. 

Maetin  H.  Fisher  reported  the  results  obtained  from  a 
studj;  of  the  toxic  eflects  of  formaldehyde  and  its  aqueous 
solution,  formalin.  The  inhalation  of  formaldehyde  is  ac- 
companied by  marked  inflammatory  changes  throughout  the 
respiratory  system.  Dyspnea,  depression  of  temperature, 
tachycardia,  weak  pulse,  and  vomiting  follow  the  introduc- 
tion of  formalin  into  the  stomach.  Sudden  death  may  re- 
sult. The  severity  of  the  symptoms  and  the  degree  of 
histologic  disturbance  bear  no  relation  to  the  strength  or 
quantity  of  the  injected  formalin.  The  gastritis  is  charac- 
terized by  intense  congestion,  necrosis,  and  leukocytic  infil- 
tration. Intraperitoneal  injections  produce  a  fibrinohemor- 
rhagic  peritonitis  of  vary  ing  intensity  according  to  the  strength 
of  the  solution.  The  peritonitis  following  chronic  formalin 
poisoning,  produced  by  injecting  small  amounts  of  dilute 
formalin  intraperitoneally,  is  accompanied  by  great  con- 
nective-tissue proliferation  and  a  striking  eoeinophilia.  Sub- 
cutaneous formalin  iojections  produce  marked  exudation 
and  leukocytic  infiltration.  The  introduction  of  formalin 
into  the  conjunctival  sac  is  followed  by  an  iritis,  which,  when 
a  single  drop  of  the  concentrated  chemical  is  used,  may  be 
sufficient  to  permanently  injure  the  eye.  In  whatever  way 
formalin  is  introduced  into  the  body,  certain  systemic  changes 
result.  Degenerative  changes  and  focal  necroses  are  found 
in  the  liver  and  kidneys.  The  leukocytic  infiltration  follow- 
ing the  introduction  of  formalin  is  characterized  by  the 
eosinophiles  appearing  first ;  these  are  followed  by  the  other 
polynuclears ;  last  of  all  appear  the  mononuclears.  It  is 
believed  that  differences  in  osmotic  pressure  are  to  be  held 
accountable  for  the  exudation.  The  death  of  the  cell  is 
accounted  for  in  two  ways :  (1)  By  disturbances  in  osmotic 
pressure,  and  (2)  by  a  deleterious  chemical  action — probably 
the  reducing  power  of  formaldehyde. 

SOUTHERN  STATES. 

Dr.  John  B.  Haden  has  recently  been  elected  lecturer 
on  ophthalmology,  otology,  rhinology,  and  laryngology,  in 
the  medical  department  of  the  University  of  Texas. 

Baltimore    Connty    Medical    Association. — The 

February  meeting  of  the  Baltimore  County  Medical  Asso- 
ciation was  held,  February  21,  at  the  Baltimore  Medical  Col- 
lege. The  officers  are :  Dr.  H.  Burton  Stevenson,  president ; 
Dr.  R.  C.  Massenburg,  corresponding  secretary;  Dr.  H.  S. 


Jarrett,  treasurer.    Addresses  were  made  by  Drs.  L.  M.  Allen, 
L.  Gibbons  Smart,  H.  B.  Stevenson,  and  B.  F.  Bussy. 

Annaal  Meeting  of  the  Association  of  Medical 
Officers  of  the  Army  and  Navy  of  the  Confeder- 
acy.— The  annual  meeting  of  this  aatociation  will  be  held  in 
Memphis,  Tenn.,  in  connection  with  the  annual  reunion  of 
the  United  Confederate  Veterans,  May  2&-30,  1901.  Any 
further  information  desired  will  be  cheerfully  fumi-iked  by 
Drs.  Malone  orElcan,  of  Memphis,  or  Dr.  Deering  J.  Roberts, 
secretary  of  the  association,  of  Nashville,  Tenn.  It  is  stated 
that  considerable  preparation  is  under  way  in  Memphis  for 
this  meeting. 

Richmond  (Va.)  Notes.— The  next  annual  meeting  of 
the  Tri-State  Medical  Association,  embracing  Vir^nia,  North 
and  South  Carolina,  will  be  held  in  Richmond,  February  26, 
27,  and  28. 

The  State  Board  of  Health  at  its  recent  meeting  elected 
Dr.  R.  W.  Martin,  of  Lynchburg,  president,  and  Dr.  P.  A. 
Irving,  of  Richmond,  secretary. 

For  the  past  week  there  were  reported  to  the  city  health 
office  3  cases  of  diphtheria,  1  of  scarlet  fever  and  5  of 
smallpox.    Influenza  is  decidedly  on  the  decrease. 

CANADA. 

(From  Our  SpecUl  Correspondent.) 

The  extent  of  leprosy  in  Canada  is  shown  in  the  laot 
annual  report  of  the  Minister  of  Agriculture.  In  this  appears 
a  sub-report  from  the  medical  superintendent  of  the  Laza- 
retto at  Tracadie,  N.  B.,  Dr.  A.  C.  Smith,  for  the  12  months 
ending  the  Slst  of  October,  1900.  There  are  today  20  inmates 
at  the  Lazaretto,  13  males  and  7  females.  Their  ages  range 
from  19  to  64  years;  and  7  of  the  inmates  may  be  classified 
as  being  in  the  first  stage,  12  in  the  second,  and  1  in  the  final 
stage  of  the  malady.  There  were  4  deaths  during  the  past 
year ;  and  3  new  cases  were  admitted  from  the  surrounding 
districts,  in  New  Brunswick.  During  the  year  Dr.  Smith, 
having  received  favorable  reports  from  foreign  leper  institu- 
tions on  the  use  of  chaulmoogra  oil  and  creolin,  made  several 
trials  on  the  less  advanced  cases  with  encouraging  results. 
This,  however,  is  not  the  only  place  where  leprosy  exists  in 
Canada.  On  Darcy  Island,  off  the  coast  of  British  Columbia, 
there  are  confined  5  lepers — all  Chinese  males.  Oae  is  main- 
tained by  the  province  of  British  Columbia,  and  1  each  by 
the  municipalities  of  Victoria,  Vancouver,  Nanaimo  and 
Kamloops. 

The  latest  news  from  the  Yukon  shows  that  the 
citizens  of  Dawson  have  been  experiencing  some  pretty 
severe  weather  and  much  sickness.  On  January  9  the  ther- 
mometer stood  at  50.5  below  zero,  and  on  January  15  at 
68.5  below.  For  9  days  the  average  minimum  temperature 
was  60  below.  This  intense  cold  in  the  Yukon  valley  was 
accompanied  by  the  regular  dense  white  mist  peculiar  to  that 
country.  During  the  cold  spell  an  epidemic  of  rabies  broke 
out  among  the  dogs  of  the  town,  and  most  of  them  had  to 
be  impounded  to  preserve  the  citizens  from  being  bitten. 
Typhoid  and  pneumonia  have  been  very  prevalent  for  the 
past  two  months ;  and  a  complication  of  the  two,  "  typho- 
pneumonia,"  has  also  been  prevalent  and  has  proved  very 
fatal.  It  is  said  that  the  pneumonia  appears  first,  developing 
in  the  usual  way;  then  at  the  time  the  crisis  sbotild  occur, 
abdominal  troubles  with  other  marked  symptoms  of  typhoid 
set  in,  resulting  in  fatal  collapse.  Consequently,  during  those 
two  months  the  death-rate  has  been  very  high,  and  several 
well-known  and  popular  citizens  have  succumbed  to  the  fatal 
complication. 

Christian  Scientists,  both  in  the  province  of  Ontario 
and  British  Columbia,  have  come  in  recently  for  very  severe 
condemnation  at  the  hands  of  two  coroners'  juries.  At 
Peterboro,  Ont.,  a  death  occurred  recently  from  typhoid 
fever  under  treatment  by  these  people ;  and  in  returning 
their  verdict  on  the  investigation  into  the  cause  of  death  in 
this  case,  the  coroner's  jury  expressed  their  opinion  that  for 
the  safety  of  society,  further  legislation  is  necessary,  and 
stated  that  it  was  time  the  provincial  parliment  gave  this 
matter  their  serious  consideration.  They  further  expressed 
their  strongest  detestation  and  condemnation  of  the  practice. 
The  other  case  was  that  of  a  child  of  tender  years,  a  resident 


Uabcb  2,  IMl] 


AMERICAN  NEWS  AND  NOTES 


rrHE  Philadelphia 
Medical  Joubnal 


413 


of  Victoria,  B.  C,  whose  death  was  due  to  asphyxiation  from 
laryngeal  diphtheria.  In  this  verdict  the  jury  deliberately 
stated  that  the  "  Christian  Scientists  "  who  treated,  or  rather 
maltreated,  the  little  boy,  "  did  unlawfully  kill  and  slay  the 
said  child."  These  two  verdicta  are  indeed  healthy  indica- 
tions that  the  public  in  Canada  are  awakening  to  the  dangers 
of  permitting  these  dangerous  people  prosecuting  their 
practices  upon  deluded  and  helpless  victims.  The  intel- 
ligence of  these  two  juries  is  to  be  commended  in  thus 
endeavoring  to  preserve  the  health  of  the  community  from 
utter  disregard  of  isolation  in  communicable  diseases. 

War  on  the  white  plague  may  now  be  expected  to  be 
pushed  in  a  vigorous  and  systematic  manner  in  the  Dominion 
of  Canada.  In  response  to  a  call  of  the  Governor-General, 
Lord  Minto,  a  large  number  of  prominent  citizens  and  a 
great  many  of  the  most  eminent  medical  men  in  Canada  met 
in  conference  in  the  city  of  Ottawa  on  the  14th  and  15th  of 
February  and  formed  and  perfected  organization  for  the 
prosecution  of  this  most  important  work.  Several  resolu- 
tions of  importance  were  submitted  for  discussion  during  the 
progress  of  the  convention,  in  the  main  calling  upon  the 
central  government  and  the  governments  of  the  respective 
provinces  to  render  aid  to  municipalities  or  groups  of  muni- 
cipalities to  provide  for  the  erection  and  maintenance  of  suit- 
able sanitoria  for  consumptives.  Amongst  others  taking  part 
in  this  conference  were  Sir  William  Kingston,  Dr.  T.  G.  Red- 
dick,  M  P.,  and  Professor  Adami,  of  Montreal ;  Sir  James 
Grant,  Ottawa ;  Dr.  Fred.  Montizambert,  Director-General  of 
Public  Health  at  Ottawa;  Dr.  P.  H.  Bryce,  Toronto,  and  Dr. 
H.  H.  Chown,  president  of  the  Canadian  Medical  Associa- 
tion, Winnipeg.  A  constitution  was  adopted  and  the  name  of 
the  Association  decided  on  was  the  Canadian  Association  for 
the  Prevention  of  Tuberculosis.  Branches  will  be  formed 
immediately  in  those  provinces  where  similar  associations  do 
not  already  exist.  Honorary  life  patrons  will  pay  $1,000; 
honorary  life  members,  $50,  and  yearly  members,  $1.00.  The 
Earl  of  Slinto  was  elected  honorary  president,  and  Sir  James 
Grant,  president. 

The  National  Sanitarium  Association  is  handing 
around  its  third  annual  report.  Five  years  ago  Mr.  W.  J. 
Gage,  of  Toronto,  contributed  $25,000  for  this  work.  A  little 
later  on  Mr.  Hart  A.  Massey,  since  deceased,  contributed 
another  $25,000;  the  association  was  at  once  formed,  a 
splendid  tile  of  50  acres  at  Gravenhurst,  in  the  Muskeka 
region,  selected ;  a  charter  obtained  from  the  Dominion  Par- 
liament in  1896,  and  the  result  was  that  a  spacious  adminis- 
tration building  and  three  cottages  were  opened  in  the 
summer  of  1897.  A  free  department  for  the  poor  will  soon 
be  completed.  During  the  three  years  since  the  Sanitarium 
opened  it  haa  received  371  patients,  of  whom  47  are  still  in 
the  establishment.  It  haa  discharged  as  apparently  cured  57 
cases,  and  with  disease  arrested  95  cases,  while  78  others  have 
been  discharged  with  marked  improvement.  The  report  of 
the  Medical  Superintendent,  Dr.  E.  C.  Ashton,  for  the  year 
ending  October  1,  shows  that  48  were  in  residence  at  the  end 
of  1899;  admitted  during  the  year,  141 ;  total  treated  during 
the  year,  189;  47  remained  in  the  institution  at  the  end  of 
the  year,  thus  leaving  142  to  be  reported  on.  Of  these  one 
patient  was  twice  admitted,  leaving  141.  Of  these  24  were 
discharged  apparently  cured ;  40  with  disease  arrested ;  32 
with  marked  improvement ;  27  unimproved ;  16  failed  and  2 
died.  The  sites  of  the  pulmonary  lesions  shows  that  the 
apex  of  the  right  lung  only  was  affected  in  47  ;  the  base  in 
1;  general,  13;  left  lung  apex,  4;  base,  1;  general,  13;  both 
lungs — both  apices,  46 ;  both  bases,  3  ;  right  apex  and  left 
base,  6 ;  left  apex  and  right  base,  5 ;  and  general  infection,  3. 
Of  laryngeal  tuberculosis,  1  was  apparently  cured,  3  much 
improved,  2  stationary,  and  2  failed.  Patients  remaining  one 
month  or  under,  18  ;  14  of  these  gained  in  weight,  2  lost  and 
2  neither  gained  nor  lost.  Patients  remaining  from  two  to 
three  months,  51 ;  gained  in  weight,  31 ;  lost,  8 ;  and  neither 
gained  nor  lost,  12.  Patients  remaining  over  three  months, 
72 ;  gained  in  weight,  59 ;  lost,  6 ;  and  neither  gained  nor 
lost,  7.  It  is  considered  that  with  a  longer  stay  in  the  insti- 
tution even  better  results  can  be  obtained. 

Hospital  Burned.— News  has  been  received  from  Vic- 
toria, B.  C,  that  the  hospital  attached  to  Tokio  University 
was  burned  on  January  29  and  that  21  patients  were  burned 
to  death,  10  patients  and  11  nurses  injured. 


MISCELLANY. 

Miners'  Hospital. — Arrangements  have  been  made  to 
erect  a  handsome  hospital  at  Sclocan,  B.  C,  at  a  cost  of 
$5,000.  Dr.  Farin,  of  Nelson,  has  been  appointed  superin- 
tendent. 

Condemns  the  Indelible  Pencil. — A  Chicago  phy- 
sician has  protested  against  the  use  of  the  indelible  pencil, 
which  he  charges  has  been  the  cause  of  innumerable  sore  lips 
and  fingers.  The  doctor  says  the  coloring  matter  in  the  in- 
delible pencil  is  of  the  same  nature  as  that  which  caused 
the  death  of  Senator  Cushman  K.  Davis,  of  Minnesota,  in 
whose  case  the  dye  was  in  the  stockings. 

Obituary.  —  Dr.  Henry  F.  Batchelder,  at  Danvers, 
Mass. — Dr.  I.  N.  Bowser,  at  Millersville,  Pa.,  on  February  24. 
— Dr.  Pierce  B.  Fagin,  at  Santa  Cruz,  Cal.,  on  February  23, 
aged  82  years. — Dr.  S.  A.  Mercer  Given,  at  Clifton,  Pa.,  on 
February  23,  aged  41  years. — Dr.  William  Booze,  at  Car- 
thage, 111.,  on  February  20,  aged  73  years.— Dr.  George  L. 
KiRBY,  at  Raleigh,  N.  C,  on  February  19.— Dr.  B.  F.  Long- 
street,  at  Cincinnati,  O.,  on  February  21,  aged  51  years.— Dr. 
J.  H.  Rennee,  at  Lagro,  Ind.,  on  February  21,  aged  70  years. 
— Dr.  Daniel  Handel,  at  Onawa,  la.,  on  February  19. — Dr. 
C.  E.  GissY,  at  Breese,  111.,  on  February  21.— Dr.  Abbott 
HoDGMAN,  of  New  York  City,  on  February  26,  aged  69  years. 
— Dr.  Charles  P.  Amet,  at  Waukegan,  111.,  on  February  25, 
aged  88  years. — De  L.  T.  Brittingham,  at  Hannibal,  Mo.,  on 
February  24,  aged  80  years.— Dr.  E.  T.  Tidwell,  at  Camden, 
Ark.,  on  February  25 — Dr.  Thomas  O'Reilly,  at  St.  Louis, 
Mo.,  on  February  24,  aged  74  years. 

Health  Reports. — The  following  cases  of  smallpox, 
cholera,  yellow  fever  and  plague,  have  been  reported  to  the 
Surgeon-General  U.  S.  Marine-Hospital  Service,  during  the 
week  ended  February  23, 1901 : 

Smallpox- United  States, 


Cases. 

Deaths, 

Califoenia  : 

Los  Angeles  .   . 

Feb.  2-9   ..  . 

1 

San  Francisco   . 

Feb. 2-9   .   .   . 

7 

Floeida  : 

Jacksonville  .   . 

Feb.  9-16.   .  . 

5 

Illinois  : 

Chicago    .   .   .   . 

Feb.  9-16  .    .  . 

14 

Kansas  : 

Wichita       .  .   . 

Feb.  9-16.    .   . 

9 

Louisiana  : 

New  Orleans  .   . 

Feb.  9-16  .   .  . 

4 

4 

Michigan: 

Manistee  .    .   .    . 

Feb.  9-16.    .  . 

3 

Minnesota  : 

St.  Paul   .   .   .   . 

Jan.26-Peb.9 

8 

N.  Hampshiek  ; 

Manchester     .    . 

Feb.  9-16.   .  . 

1 

New  York : 

New  York   .   .   . 

Feb.  9-16.    .   . 

25 

6 

Ohio  : 

Ashtabula  .   .   . 

Feb.  9-16.   .  . 

3 

Cleveland    .   .   . 

Feb.  9-16.    .   . 

48 

" 

Youngstown  .    . 

Feb.  9-16.    .   . 

1 

Pennsylvania  : 

Allegheny    City 

Feb.  9-16.    .   . 

3 

Erie 

Feb.  9-16  .    .  . 

1 

South  Caeolina 

Greenville  .   .   . 

Feb.  9-16.   .  . 

1 

Tennessee  : 

Memphis .  .   .   . 

Feb.  9-16.    .   . 

19 

1 

Nashs-ille    .   .   . 

Feb.  9-16.    .   . 

9 

Wisconsin  : 

Green  Bay  .   .   . 

Feb.  10-17   .   . 

1 

Milwaukee .   .   . 

Feb.  9-16.    .   . 

1 

Smallpox- 

—Foreign. 

Belgium  : 

Antwerp  .   .  . 

.Tan.  19-26    .    . 

1 

England: 

Bradford  .    .   . 

Jan.  6-13  .   .    . 

'.       15 

2 

Italy  : 

Naples  .... 

Jan.  20-30    .    . 

.       26 

2 

Officiallyjrep'd 

Mexico  : 

Mexico     .    .  . 

Jan.  27-Feb.  3 

1 

Russia  : 

St.  Petersburg 

Jan.  19-26   .   . 

]         8 

1 

Odessa  .... 

Jan.  19-26  .    . 

.       13 

8 

Scotland : 

Glasgow  .   .  . 

Jan.  26-Feb.  3 

34 

Straits 

Settlements 

Singapore   .   . 
Yri.tow 

Dec.  22-29   .   . 
Fever. 

■ 

1 

Cuba  : 

Havana    .   .  .   . 
Plague.- 

Feb.  2-9   ..  . 
-Foreign. 

3 

1 

China  : 

Hongkong  .   . 

Jan.  5-12.  .  . 

2 

jAP.tN  : 

Formosa .   .  . 

Jan.  1-16  .   .  . 

'.       28 

22 

Steaits 

Settlements 

Singapore   .   . 

Dec.  22-29   .   . 

16 

Disposal  of  Booth's  Body.— At  the  monthly  diimer 
of  the  Medical- Legal  Society,  Dr.  George  L.  Porter,  of  Bridge- 
port, read  a  paper  entitled  "  Reminiscences  of  the  Assassi- 
nation of  President  Lincoln,"  and,  according  to  the  Washing- 
ton Post,  eaid  the  following  in  the  course  of  his  address  : 

"  I  was  in  medical  charge  in  Washington  after  the  murder 
of  Lincoln,  and  had  unequaled  opportunities  for  observation. 


414 


Thk  Philadklphia"! 
Medical  JonaNAt  J 


FOREIGN  NEWS  AND  NOTES 


[Mabch  2,  UOl 


The  descriptions  of  the  disposition  of  Booth's  body  are  most 
inaccurate. 

"  The  body  was  taken  to  Washington,  identified  by  many 
persons,  and  afterward  taken  in  a  rowboat  to  the  Washington 
Arsenal,  and  in  the  dead  of  night,  in  the  presence  of  the 
military  storekeeper,  four  enlisted  men,  and  myself,  the  only 
commissioned,  was  hidden  in  a  place  so  secret  that  never,  to 
this  day,  has  it  been  correctly  described.  We  were  requested 
by  Secretary  Stanton  to  keep  silent,  and  no  man  during  these 
36  years  has  yet  told.  I  believe  the  body  was  finally  given  to 
the  family  under  agreement  never  to  mark  by  mound  or 
monument  where  it  should  be  placed." 

Cbang-es  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  February  23, 1901 : 

Kendall,  Major  William  P.,  surgeon,  is  relieved  from  further  duty 
in  the  division  of  the  Philippines,  and  will  proceed  to  Fort 
Slocum,  to  relieve  Captain  Charles  M.  Gandy,  assistant  surgeon. 

Sakdy,  Captain  Charles  M.,  assistant  surgeon,  will  proceed  to  San 
Francisco,  Cal.,  and  report  for  transportation  to  Manila,  P.  I., 
where  he  will  report  for  assignment  to  duty. 

Bell,  Joseph  L.,  acting  assistant  surgeon,  will  proceed  to  Fort 
Cook  for  duty. 

Gbeenleaf,  Colonel  Chablhs  R.,  assistant  surgeon-general,  is  re- 
lieved from  duty  in  the  division  of  the  Philippines,  to  take 
effect  June  1,  and  will  then  proceed  to  San  Francisco,  Cal.,  and 
report  to  the  commanding  general,  department  of  California, 
for  duty  as  chief  surgeon  of  that  department. 

Jackson,  Fredeeick  C,  acting  assistant  surgeon,  now  at  San  Fran- 
cisco, Cal.,  will  report  to  the  commanding  general,  department 
of  California,  for  assignment  to  temporary  duty  in  that  depart- 
ment. 

GiLHDLEY,  John  J.,  acting  assistant  surgeon,  will  proceed  from 
Bridgeport,  Conn.,  to  Governors  Island,  N.  Y.,  and  report  in 
person  to  the  commanding  general,  department  of  the  East,  for 
assignment  to  temporary  duty. 

Reed,  Major  Walter,  surgeon,  is  detailed  as  a  member  of  the  board 
of  Medical  officers  appointed  February  2,  to  meet  at  the  Army 
Medical  Museum  building,  for  the  examination  of  candidate 
for  admission  to  the  medical  corps  of  the  Army. 

Moseley,  Major  Edward  B.,  surgeon,  now  at  San  Francisco,  Cal., 
is  relieved  from  further  duty  in  the  division  of  the  Philippines, 
and  upon  the  expiration  of  the  leave  of  absence  granted  him 
December  8,  will  proceed  to  Fort  Sheridan  for  duty,  to  reUeve 
Major  George  W.  Adair,  surgeon. 

Adair,  Major  George  W.,  surgeon,  will  proceed  to  ManUa,  P.  I., 
where  he  will  report  for  sissignment  to  duty. 

Penrose,  Major  Georoe  H.,  surgeon,  will  upon  the  expiration  of 
such  leave  of  absence  as  may  have  been  granted  him  by  the 
commanding  general,  department  of  California,  report  to  that 
officer  for  assignment  to  duty. 

Williams,  Allie  W.,  acting  assistant  surgeon,  is  assigned  to  duty 
at  Fort  Columbus. 

HoRNE,  Willis  S.,  acting  assistant  surgeon,  is  assigned  to  duty  at 
Fort  Sam  Houston. 

Cable,  George  L.,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  20  days. 

Williams,  Adrian  D.,  acting  assistant  surgeon,  upon  rehef  by  First 
Lieutenant  Weston  P.  Chamberlain,  assistant  surgeon,  wUl  pro- 
ceed to  Fort  Greble,  for  temporary  duty. 

Chamberlain,  First  Lieutenant  Weston  P.,  upon  expiration  of  his 
leave  of  absence,  wil  proceed  to  Fort  Adams  for  duty. 

Baohe,  Colonel  Dalas,  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  3  months  from  about  March  1,  on  surgeon's  certificate. 

The  following-named  dental  surgeons  will  proceed  from  Washing- 
ton, D.  C,  to  Philadelphia,  Pa.,  on  business  pertaining  to  the 
medical  department:  John  S.  Marshall,  Robert  T.  Oliver, 
and  Robert  W.  Morgan. 

Cox,  Shelby  G.,  hospital  steward.  Army  General  Hospital,  Presidio, 
will  be  sent  to  Fort  Crook  for  duty. 

McKee,  John,  hospital  steward,  San  Juan,  P.  R.,  is  transferred  to 
the  Army  General  Hospital,  Washington  Barracks,  for  duty. 

Bailey,  Guy-  G.,  acting  assistant  surgeon,  leave  of  absence  granted 
January  31  is  further  extended  10  days. 

Bamberger,  Raymond  S.,  hospital  steward,  (appointed  February 
18,  from  private,  hospital  corps),  San  Juan,  P.  R.,  is  assigned 
to  duty  at  his  present  station. 

Changes  in  the  Bledlcal  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  February  23, 1901 : 

Holcombe,  R.  C,  assistant  surgeon,  detached  from  the  "Glacier," 

and  ordered  to  duty  with  detachment  of  marines  at  PoUok,  P.I. 
Rosa,  J.  W.,  surgeon,  U.  S.  N.,  retired,  by  special  order,  department 

of  Cuba,  Feb.  15,  1901,  to  report  to  the  chief  sanitary  officer, 

city  of  Havana,  for  duty. 

Changes  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  February  21,  1901 : 

Gardner,  C.  H.,  passed  assistant  surgeon,  granted  leave  of  absence 

for  7  days. 
Kalloch,  p.  C,  surgeon,  granted  leave  of  absence  for  3  days  from 

February  17. 
Sawtellk,  H.  W.,  surgeon,  granted  leave  of  absence  for  30  days 

from  February  20. 


foreign  Zlevos  anb  Hotes. 

GREAT  BRITAIN. 

Appropriation  to  Combat  the  Plag-ae. — The  Lon- 
don county  council  has  decided  to  spend  £50,000  as  a  pre- 
cautionary measure  against  the  bubonic  plague  in  London.  • 

Presentation  to  Professor  Sch&fer. — A  silver  bowl 
and  platters  have  been  presented  to  Professor  Schafer, 
Jodrell  professor  of  physiology  at  University  College,  by  hia 
colleagues  and  his  pupils.  They  have  also  subscribed  funds 
for  the  endowment  of  a  Schafer  medal  to  be  awarded  for 
research  in  physiology. 

CONTINENTAL,  EUROPE. 

Obituary. — De.  Julius  Lahmann,  hygienest,  at  Copen- 
hagen.— Db.  W.  Paschutin,  at  Petersburg. 

Moscow. — Dr.  P.  A.  Minakow  was  appointed  extraordi- 
nary professor  of  jurisprudence  at  the  University  at  Moscow. 

Heidelberg. — Dr.  Braus,  demonstrator  of  comparative 
anatomy  in  Wiirzburg,  has  been  appointed  extraordinary 
professor  at  Heidelberg. 

Medical  Inspector.  —  Dr.  Brendan  MacCarthy  has 
been  appointed  medical  inspector  under  the  Local  Govern- 
ment Board  for  Ireland. 

Professor  Leopold  Weiss,  the  well-known  ophthal- 
mologist and  extraordinary  professor  at  the  University  at 
Heidelberg,  died  at  Manbeim,  aged  52  years. 

Suicide  of  Professor  Pettenkofer. — A  private  tele- 
gram to  the  Frankfurter  Zeiiung  states :  "  The  renowned 
hygienist  and  President  of  the  Academy  of  Sciences,  Profes- 
sor Pettenkofer,  shot  himself  during  the  night  at  his  lodgings 
in  the  Royal  residence.  Professor  Pettenkofer  was  a  diabetic. 
Recently  he  became  infected  by  cutting  an  abscess  from 
which  he  was  suffering,  with  an  unclean  fcnife.  He  was  83 
years  of  sige."  A  later  authentic  dispatch  states :  "  Profecsor 
Pettenkofer  suffered  from  an  abscess  in  the  neck,  and  had 
been  melancholic  for  some  time.  He  feared  psychical  disturb- 
ances similar  to  his  deceased  brother  ;  he  obtained  a  revolver 
and  shot  himself  in  the  temple  during  the  night,  while  in 
bed." 


Modern  Pathologry  of  Puerperal  Sepsis. — A.  Bass 
(CentralhlaU  fur  die  Grenzgehiete  der  Medizin  iind  ChirurgU, 
Vol.  3,  No.  22,  November  22, 1900)  comes  to  the  following  con- 
clusions :  1.  The  uterine  cavity  of  healthy  pregnant  and 
parturient  women  that  have  not  been  meddl^  with  is  free 
from  pathogenic  organisms;  this  is  likewise  true  in  most 
cases  of  healthy  women  during  the  puerperium.  2.  The  ques- 
tion as  to  whether  the  vagina  of  the  healthy  pregnant,  par- 
turient and  puerpurant  women  that  have  neither  been  exam- 
ined nor  douchea,  is  or  is  not  free  from  pathogenic  organisms 
cannot  as  yet  be  positively  answered,  notwithstanding  that  a 
series  of  observations  seems  to  indicate  the  affirmative.  3. 
Autoinfection  can  only  be  considered  when  every  probability 
of  an  external  infection  has  been  excluded ;  even  then  auto- 
infection contrary  to  Ahlfeld,  is  very  rare.  4.  The  follow- 
ing bacteria  have  been  shown  to  be  the  cause  of  puer- 
peral sepsis :  Streptococcus  pyogenes,  Staphylococcus 
pyogenes  aureus  and  albus.  Bacillus  coli  communis,  pneu- 
mococcus,  typhus,  and  diphtheria  bacilli,  and  various  ob- 
ligate anaerobes,  especially  the  Bacillus  aerogenes  capsn- 
latus  and  the  Vibrion  septique.  5.  The  portal  of  infection 
is  generally  the  endometrium  (the  placental  area)  where 
the  bacteria  not  only  directly  enter,  but  may  also  gain  access 
by  means  of  their  own  surface  growth.  6.  The  infection 
occurs  either  by  the  lymph-  or  blood-channels,  rarely  by  both 
simultaneously.  7.  A  certain  clinical  differentiation  in  re- 
gard to  the  various  forms  of  bacteria  c&nnot  vet  be  given ; 
nevertheless  the  anaerobic  infections  are  milder.  S.  The 
blood-examination,  with  the  exception  of  an  eventual  bacte- 
remia and  the  findings  of  Kaminer  (still  requiring  more  sub- 
stantiation), offers  nothing  characteristic  for  puerperal  sepsis. 
9.  Antibodies  are  probably  not  formed  in  the  blood  in  this 
condition ;  at  least  this  has  not  been  proved,    [m.rd.] 


March  2,  1901) 


THE  LATEST  LITERATURE 


The  Philadelphia"! 
Medical  Journal  J 


415 


CI^^  latest  literature. 


British  Medical  Journal. 

February  9,  1901.     [No.  2093.] 

1.  A  Clinical  Lecture  on  a  Case  of  Chronic  Cancer  of  the 

Face.    F.  T.  Paul. 

2.  On  Ringworm  Infection   in  Man   and  Animala.     J.  L. 

Bunch. 

3.  Remarks   on  Finsen's    Light- Treatment   of   Lupus   and 

Rodent  Ulcer.    Malcolm  Morris  and  8.  Ernest  Doee. 

4.  A  Preliminary  Communication    on    the    Treatment    of 

Rodent  Ulcer  by  the  X-rays.    James  H.  Sequeera. 

5.  An  Address  on  the  Need  of  Bacteriological  and  Patho- 

logical Laboratories  in  Dublin.    Sm  George  Duffey. 

6.  The  Surgical  Treatment  of  Migraine.    Walter  White- 

head. 

7.  A  Note  on  the  Results  Obtained  by  the  Antityphoid  In- 

oculations in  the  15th  Hussars,  Meerut,  India.    A.  E. 
Wright. 

8.  On  the  Treatment   of  Superficial  Syphilitic  Gummata. 

Roderick  Maclaren. 

1.— Paul  exhibits  a  patient,  aged  43  years,  suffering  from 
an  extensive  inoperable   cancer  of  the  face.    He  had 

operated  8  years  previously  upon  this  patient  for  a  rodent 
ulcer  of  the  face  which  had  resulted  from  an  injury  to  the 
skin  of  the  cheek  when  the  patient  was  19  years  old.  He 
thinks  the  present  epithelioma  started  in  the  scar  following 
the  former  operation.  The  appearances  and  histories  of 
rodent  ulcer  and  epithelioma,  as  well  as  their  pathology, 
are  carefully  contrasted,    [j.h.g.] 

2. — Bunch  reports  the  case  of  a  girl,  aged  3}  years,  who 
presented  a  small,  ringed  patch  on  the  right  forearm,  just 
above  the  wrist,  and  a  second  patch  on  the  right  shoulder. 
Microscopic  examination  of  scrapings  from  tnese  patches 
shows  chains  of  large,  squarish  spores  both|inside  and  outside 
the  hairs,  and,  in  preparations  treated  with  6.8^  liquor  potas- 
sae  solution,  a  segmented  coarse  mycelium  which  terminated 
in  a  fringe  above  the  bulb,  in  the  intrafollicular  portion  of  the 
hair  shafl:,  and  outside  the  hair  in  the  root  sheath  and  in  the 
connective  tissue  of  the  follicle.  Cultures  from  minute  portions 
of  the  afiected  hairs  and  from  the  scales  grown  on  French 
proof  agar  showed  a  network  of  coarse  aerial  hyphae,  radi- 
ating from  the  center,  white  in  color,  and  terminating  at_  the 
edge  in  tapering,  somewhat  pointed,  processes.  The  child's 
father  was  a  coachman  and  there  was  a  horse  in  his  stable 
that  had  been  certified  by  a  veterinary  surgeon  to  have  ring- 
worm. There  "were  two  patches  on  the  horse,  one  on  the 
neck  and  one  on  the  head,  both  of  which  were  scaly,  and 
covered  with  broken  and  twisted  hairs,  but  which  showed  no 
sign  of  vesiculation.  Microscopic  examination  of  scrapings 
from  these  patches  gave  the  same  results  that  were  obtained 
from  the  hairs  of  the  child  and  cultures  on  the  same  medium 
proved  to  be  almost  identical  with  those  obtained  from  the 
diseased  areas  of  the  child's  skin.  A  second  case  of  ring- 
worm in  man  due  to  infection  from  animals  was  in 
the  person  of  an  hostler,  aged  19  years,  who  presented  a  cir- 
cular, scaly  patch  on  the  right  side  of  the  neck.  Examina- 
tion of  scales  from  the  lesion  showed  a  network  of  abundant, 
fine,  branching,  irregularly  septate  mycelia,  and  mycelial 
threads  could  be  made  out  running  chiefly  in  the  direction  of 
the  long  axis  of  the  hair.  A  diagnosis  of  microsporon 
was  advanced  until  cultures  had  been  made  and  then 
the  opinion  as  to  the  character  of  the  organism  waa  con- 
firmed. 'The  hostler  had  been  looking  after  a  young  horse 
with  some  pimples  on  his  nose,  and,  on  going  to  the  mews, 
the  author  found  that  the  animal  had  some  indistinctly 
ringed  vesicles  above  the  right  nostril,  the  hairs  around 
which  appeared  to  be  irregular  and  broken.  Cultures  gave  a 
rapidly- growing,  white,  downy  mass,  similar  to  that  obtained 
from  the  lesion  of  the  patient.  In  a  third  patient,  a  boy, 
aged  3  years,  with  kerion  of  the  scalp,  cultures  showed 
alternate  concentric  rings  of  white  and  brown  growth,  with  a 
delicate  filiform  border  and  a  central  raised  prominence. 
Hairs  from  a  terrier  with  which  the  child  had  often  played 
proved  to  be  infiltrated  with  typical  microsporon,  and  cul- 
tures from  these  hairs  resembled  closely  those  obtained  from 
the  child's  scalp.    A  fourth  patient  was  a  child,  4  weeks  old, 


who  had  a  well-marked  patch  of  tinea  circinata  on  the  left 
cheek.  Cultures  made  from  the  patch  gave  a  somewhat 
coarse  growth  of  radiating,  aerial  hyphae,  of  a  dull  whitish 
color.  A  cat  in  the  house,  with  which  the  child  had  played, 
had  a  patch  on  the  neok  from  which  the  hairs  had  almost  all 
come  out.  Cultures  showed  the  same  organism,  with  some 
cultural  peculiarities  that  were  probably  due  to  difference  in 
the  medium  employed.  The  fifth  patient  was  a  youth,  aged 
16  years,  who  had  several  well-marked  patches  of  tinea 
circinata  on  the  left  arm  and  trunk.  A  large-spored  tricho- 
phyton was  found  both  within  and  without  the  hairs  of  the 
lesions,  which,  on  cultivation,  gave  a  somewhat  coarse, 
white  growth,  very  similar  to  that  already  described  by 
other  observers  as  being  derived  from  the  cat.  From  a 
patch  on  the  patient's  cat,  which  had  been  noticed  to  be 
mangy,  a  very  similar  culture  was  obtained.  The  sixth 
patient  was  a  boy,  aged  9  years,  who  presented  2  more  or  less 
circinate,  smooth,  almost  bald  patches  on  the  scalp.  Cul- 
tures gave  an  irregularly  plicated  growth,  somewhat  pow- 
dery, with  a  tendency  to  crack  on  the  surface.  Hairs  from  a 
cat  in  the  house  also  contained  an  endothrix  fungus. 
Cultures  from  these  lesions  on  the  cat  proved  to  be  very 
similar  to  those  obtained  from  the  boy.  The  seventh  case 
was  that  of  a  girl,  aged  13  years,  with  a  patch  of  tinea  cir- 
cinata on  the  forearm.  Cultures  gave  a  dull,  opaque,  whitish 
growth,  spreading  somewhat  irregularly  from  the  center, 
and  with  a  faviform  appearance.  The  child  had  a  pet  canary, 
whose  feathers  had  been  coming  out  in  patches  and  micro- 
scopic examination  of  these  feathers  showed  an  invasion 
by  a  fungus  similar  to  that  already  demonstrated  in  the 
patient.  Cultures  from  the  bird,  too,  were  faviform  in 
appearance,  and  only  differed  in  that  the  spreading  edge 
was  slightly  more  thickened.  The  eighth  example  was  a  case 
of  ringworm  of  the  beard  in  a  man  aged  29  years.  Cultures 
gave  a  whitish,  downy  growth  with  a  central  prominence, 
and  a  fine  striated  edge,  but  in  many  of  the  original  tube 
inoculations  the  growths  were  contaminated  by  staphylococci, 
and  it  was  only  with  difficulty  that  a  pure  culture  was 
obtained.  The  patient,  who  was  a  farm  laborer,  stated  that 
one  of  the  calves  had  ringworm.  Hairs  of  these  animals 
contained  an  endoectothrix  fungus,  somewhat  closely  packed, 
so  that  the  chain  formation  was  not  very  evident.  Cultures 
from  these  hairs  gave  a  white  aerial  growth  with  a  striated 
edge.  The  number  of  cases  of  ringworm  in  man  having  an 
animal  origin  must  always  be  a  very  small  percentage  of  the 
whole,  and  it  must  be  remembered  that  one  such  case  in  a 
child  is  capable  of  serving  as  a  source  of  infection  to  many 
more.  Valuable  though  microscopic  examination  is  for 
diagnosis,  greater  reliance  must  always  be  placed  upon  cul- 
tures.    [J.M.S.] 

3.— Morris  and  Dore  have  used  electric  light  rays  in 
the  treatment  of  lupus  vulgaris  and  rodent  ulcer 
after  the  method  of  Finsen.  They  give  some  practical  points 
concerning  the  technic.  These  points  bear  upon  current,  in- 
tensity of  light,  the  focus,  screens  and  pressure.  The  reaction 
varies  in  intensity  according  to  the  idiosyncrasy  of  the  pa- 
tient, but  largely  depends  upon  the  intensity  of  the  light  at 
the  time  of  exposure.  Lupus  vulgaris  is  the  disease  most 
benefited  by  this  treatment  and,  although  it  has  a  marked 
effect  upon  rodent  ulcer  and  other  diseases,  the  bactericidal 
theory  of  its  mode  of  action  is  not  thereby  disproved,  al- 
though it  negatives  the  supposition  that  it  is  specific  for  the 
tubercle  bacillus  alone.  Apparently,  however,  there  is  sotne 
chemical  or  nutritional  effect  upon  the  tissues  also  to  be 
taken  into  account.  In  all  the  cases  treated  by  the  authors 
the  improvement  has  been  marked  and  uniform,  though  in 
some  cases  very  slow.  In  several  cases  of  lupus  vulgaris  one 
application  has  been  sufficient  to  cause  the  disappearance  of 
a  small  isolated  superficial  nodule  for  the  time.  In  an  ex- 
tensive case  involving  both  sides  of  the  face,  a  year  with  in- 
tervals of  rest  maybe  given  as  a  rough  indication  of  the 
duration  of  the  treatment.  The  use  of  pyrogallic  acid  oint- 
ment, though  not  necessary  for  the  success  of  the  treatment, 
will,  in  cases  where  there  is  great  thickening  of  the  skin,  con- 
ersidably  lessen  its  duration.  In  the  case  of  an  extensive  rodent 
ulcer,  in  which  the  typical  hard  edge  was  in  part  absent^  the 
effect  of  a  single  application  was  apparently  to  stimulate  heal- 
ing of  the  part  to  which  the  light  was  applied  and  was  followed 
by  rapid  growth  of  healthy  epithelium  from  the  surrounding 
skin.  In  cases  in  which  there  was  no  ulceration,  reddening 
and  perhaps  slight  excoriation  of  the  skin  resulted  from  a 


416 


Thb  Philadklpuia 
Mbcicai,  Journal 


] 


THE  LATEST  LITERATURE 


[Mabch  2,  UOl 


few  applications  and  the  growth  gradually  became  softer, 
and  finally  disappeared  without  obvious  breaking  down  of 
tissue.  In  small  ulcers  entirely  surrounded  by  an  indurated 
rolled  edge,  there  was  no  visible  effect  at  first,  but  after  eev- 
eral  continuous  applications  the  discharge  increased,  and  an 
inflammatory  reaction  occurred  ;  at  the  same  time  the  indu- 
ration gradually  became  less  marked,  until  a  simple,  punched- 
out  ulcer  with  soft  edge  remained.  On  cessation  of  the  treat- 
ment, healing  took  place  with  great  rapidity  as  soon  as  the 
inflammation  had  subsided.  In  lupus  erythematosus  the 
effect  has  been  marked,  although  not  so  certain  as  in  lupus 
vulgaris.  Although  several  cases  have  been  treated  in  which 
the  inner  or  outer  canthi  or  lids  were  involved,  there  has 
not  been  any  deleterious  effect  upon  the  eye  itself.  In  one 
case  in  which  the  skin  of  the  nose  was  treated,  improvement 
took  place  in  the  mucous  membrane,  and  the  sensation  of 
smell  was  said  to  have  greatly  improved.  There  are  certain  con- 
ditions that  make  a  case  unfavorable  for  treatment ;  these  are 
scarring,  pigmentation,  great  vascularity,  great  depth  below 
the  surface,  the  situation  of  the  disease  near  the  eye,  on  the 
eyelid,  or  on  the  mucous  membranes,  and  great  extent  of 
the  lesions.    Notes  of  6  cases  are  given,     [j.m  s.] 

4. — Sequeira  has  treated  12  cases  of  rodent  ulcer  by 
x-rays.  The  immediate  result  of  the  treatment  is  all 
that  can  be  wished  for,  and  the  author  feels  justified  in  rec- 
ommending the  use  of  the  x-rays,  at  least  in  those  cases  of 
rodent  ulcer  in  which  complete  removal  by  the  knife  is 
impracticable,    [j.m.8.] 

6. — Whitehead  recommends  the  use  of  the  seton  in  the 
treatment  of  troublesome  cases  of  migraine,  and  reports 
most  satisfactory  results  from  its  employment,     [j.h.g.] 

7. — The  effects  of  antityphoid  inoculations  in  the 
15th  Hussars  have  been  encouraging.  The  incidence  of 
typhoid  fever  in  the  inoculated  was  represented  by  0.55^4 
and  the  mortality  by  0.27%;  while  the  incidence  in  the  un- 
inoculated  was  6.14%  and  the  death-rate  3.35%.     [j.m.s.I 

8. — Maclaren  recommends  the  careful  and  thorough 
excision  of  superficial  gumniata,  when  they  do  not 
respond  to  a  fair  trial  of  mercury  applied  locally  to  the 
surface  affected  and  by  inunctions,  or  to  increasing  doses  of 
potaeeium  iodid.  Very  extensive  dissection  of  fascia,  some- 
times extending  down  between  the  muscles,  is  necessary,  but 
his  results  have  been  very  satisfactory  from  this  treatment. 
[j.h.g.] 


Lancet. 

February  9,  1901.    [No.  4041.] 

1.  An  Address  on  Gastric  Hemorrhage   and   Its  Surgical 

Treatment.    A.  W.  Mayo  Robson. 

2.  The  Baillie  Lectures   on  Considerations  Touching  the 

Pathology  and  Relations  on  Diabetes.    W.  Howship 
Dickinson. 

3.  Three  Lectures  on  the  Surgery  of  Pregnancy  and  Labor 

Complicated  with  Tumors.    J.  Bland-Sutton. 

4.  A  Plea  for  the  More  Careful  Study  of  the  Symptoms  of 

Perforation  in  Typhoid  Fever,  with  a  View  to  Early 
Operation.    William  Oslkr. 

5.  Observations  Based  on  the  Probable  Mode  of  Formation 

of  Urinary  Stone,  Relative  to  Its  Recurrence  and  Pre- 
vention.   Reqinald  Harbison. 

6.  On  a  Case  of  Myasthenia  Gravis ;    Pseudo-paralytica ; 
'  Death ;  Necropsy ;  Remarks.    Leonard  R.  Guthrie. 

7.  Ptomaine  Poisoning  on  Perforation.   E.  Kkmpton  Brown. 

8.  A  Case    of   Cerebellar    Hemorrhage    Presentine  VVeli- 

Marked   Early  Cervical   Opisthotonos    and   Kernig's 
Sign.    William  Thyne. 

9.  A  Case  of  Pelvic  Sarcoma  with  Chylous  Ascites ;  Abdomi- 

nal Section  and  Drainage;  Patient  well  four  and  a  half 
Years  after  Operation.    Arnold  W.  W.  Lea. 
10.  Reflections  on  Therapeutics.    Harry  Campbell. 

1. — Robson  calls  attention  to  the  fact  that  gastric  ulcer 

occurs  in  5%  of  the  community  and  that  the  mortality  of 
this  condition  is  from  10%  to  50%.  As  soon  as  gastric  ulcer 
is  diagnosed  the  patient  should  be  informed  of  the  serious 
nature  and  the  necessity  of  careful  treatment,  rest  in  bed, 
and  long-continued  care  in  diet.  Robson's  mortality  from 
surgical  treatment  in  this  condition  is  about  5%.  Probably 
7%  represents  the  mortality  in  all  cases  of  gastrorrhagia. 


Vicarious  hematemesis  at  the  menstrual  period  and  post- 
operative hematemesis  usually  respond  to  medical  treatment. 
But  surgical  intervention  not  infrequently  is  to  be  considered 
in  these  cases,  though  its  results  have  n,ot  been  satisfactory. 
It  is  diflacult  to  account  for  postoperative  hematemesis, 
injury  of  the  omentum,  general  anesthesia,  and  sepsis  have 
all  been  suggested  as  causes,  and  yet  cases  occur  where  none 
of  these  conditions  exist.  R^obson  thinks  that  the  occurrence 
is  dependent  upon  a  reflex  nervous  influence.  Recurrent 
venous  hemorrhage,  Robson  thinks,  will  be  most  likely  to  be 
benefited  by  surgical  treatment.  The  arterial  bleeding  is 
most  responsible  for  the  fatal  cases,  and  may  arise  from 
small  arterioles  or  from  the  larger  vessels.  It  is  impossible 
to  tell  the  size  of  the  vessel  bleeding  either  from  the 
amount  of  blood  lost  or  from  the  length  of  the  survivaL 
The  only  help  in  such  a  case  would  oe  the  diagnosis  of 
the  situation  of  the  ulcer.  Treatment  should  always 
be  medical  at  first  in  cases  of  acute  hematemesis,  but 
if,  after  a  few  hours  of  medical  treatment  properly 
carried  out,  the  bleeding  is  not  arrested,  or  if,  being 
arrested,  it  recurs,  a  surgical  consultation  should  be  had, 
with  the  idea  of  opening  the  stomach.  In  cases  of  re- 
curring hemorrhage,  Robson  advises  operation,  even  during 
the  course  of  the  bleeding.  Technic :  It  is  undesirable  to 
wash  out  the  stomach  before  operating  on  a  bleeding  ulcer. 
After  the  abdomen  is  opened,  the  stomach  may  be  emptied 
by  pressing  the  contents  into  the  bowel.  Frequently  a  puck- 
ering of  the  surface  or  thickening  of  the  coats  will  indicate 
the  site  of  the  ulcer.  Examination  of  the  posterior  wall  is 
difiScult,  but  if  a  slit  be  made  in  the  omentum,  two  fingers 
can  be  pushed  through  it  and  the  posterior  wall  invaginated. 
When  no  ulcer  can  be  found  in  the  stomach,  the  duodenum 
should  be  carefully  examined.  If  an  ulcer  is  present,  it  should 
be  excised  and  its  edges  sutured.  The  cautery  may  be  used, 
if  excision  is  impracticable.  Robson  does  not  think  that  li- 
gation of  the  main  arteries  of  the  stomach,  as  has  been  sug- 
gested, is  advisable.  When  the  pylorus  is  adherent,  he  thinks 
it  advisable  to  do  a  gastroenterostomy,  but  if  the  pylorus  be 
extensively  ulcerated  and  free  from  adhesions,  pylorectomy 
can  be  done.  When  the  bleeding  is  general,  and  not  from 
any  vessel  which  can  be  ligated,  gastroenterostomy  by  secur- 
ing complete  physiological  rest  would  seem  to  offer  the  best 
chance  for  success.  Robson  strongly  recommends  the  pos- 
terior operation,  his  last  20  gastroenterostomies  done  in  this 
wav  having  recovered  without  any  untoward  symptoms. 
RoDson  reports  5  cases  operated  upon  for  hematemesis. 

[J.H.Q.] 

2. — Dickinson  delivered  the  second  lecture  on  Consid- 
erations touching  the  pathology  and  relations  of 
diabetes,  on  December  12, 1900.  Reference  is  made  to  the 
liver  as  the  organ  which  is  concerned  in  the  formation  of 
glycogen.  He  gives  the  theory  of  Bernard  stating  that  he 
believes  the  conversion  of  glycogen  into  sugar  takes  place  in 
the  liver,  the  latter  substance  then  finding  its  way  into  the 
circulation.  The  opinion  of  Pavy  is  also  mentioned,  who 
believes  that  the  liver  produces  glycogen  in  order  to  prevent 
the  passage  of  sugar  into  the  circulation.  Both  observers 
agree  that  in  diabetes  mellitus  the  blood  is  overloaded  with 
sugar.  Upon  theoretical  ground  the  author  mentions  that 
the  excess  is  due  either  to  improper  removal  or  excessive 
introduction  of  sugar  into  the  blood.  As  very  large  quanti- 
ties are  poured  out  with  the  urine  (as  much  as  2  pounds  per 
day)  the  idea  of  abundant  introduction  seems  to  be  sustained. 
As  a  provisional  theory  Dickinson  maintains  that  the  morbid 
influence  of  the  brain  upon  the  liver  (in  the  most  common 
form  of  diabetes)  is  the  important  factor  associated  with  this 
disease.  The  pathological  change  in  the  brain  appears 
rather  of  an  irritative  nature  than  a  paralytic  condition. 
Some  of  the  diseases  of  the  pancreas  must  not  be  over- 
looked in  the  consideration  of  the  etiology  of  this  disease, 
but,  as  he  has  previously  stated,  the  pancreas  produces  the  lees 
common  form  of  diabetes.  The  author  mentions  that  com- 
plete removal  of  the  pancreas  is  followed  by  fatal  glycosuria, 
while  partial  removal  of  the  gland  fails  to  produce  this  con- 
dition. After  complete  removal  of  the  pancreas,  followed  by 
implantation  of  the  portion  of  the  gland  into  some  part  of  the 
body,  glycosuria  does  not  develop.  That  diseased  condi- 
tions of  the  brain  are  more  frequently  the  cause  of  diabetes 
mellitus  than  pathological  changes  of  the  pancreas,  should 
at  the  present  time  be  upheld.  In  the  treatment  of  dia- 
betes the  chief  object  is  to  control  the  existing  symptoms. 


Mabch  2,  1961] 


THE  LATEST  LITERATURE 


[THS  PHIl.ADaLPHIA 
Mbdicax  Joitbhal 


417 


The  cause  is  beyond  our  reach.  Much  is  accomplished  by 
■withholding  sugar  and  starch  from  the  food,  especially  in 
the  mild  cases;  but  it  appears  that  in  the  more  severe  forms 
the  nitrogenous  principles  of  the  blood  are  broken  up  into 
urea  and  sugar,  therefore  depriving  the  system  of  nourish- 
ment. He  states  that  proper  dieting,  as  a  rule,  is  followed  by 
good  results,  with  very  few  exceptions.  A  full  list  of  the 
articles  included  in  the  diet  are  not  mentioned,  reference 
only  being  made  to  the  more  important  ones.  C  ire  must  be 
taken  not  to  institute  the  rigid  restriction  of  the  diet  too  sud- 
denly. The  patient  should  be  e  icouraged  to  partake  freely 
of  water.  Oncoming  coma  is  sometimes  prevented  by  the 
injection  of  aqueous  solution  into  the  veins.  As  to  the 
medicinal  treatment,  he  does  not  use  opium,  but  recom- 
mends strychnia,  sometimes  in  combination  with  tartrate  of 
potash  or  phosphate  of  soda.  Certain  mineral  waters,  espe- 
cially Carlsbid,  are  frequently  of  value  in  the  treatment. 
[fjk] 

3. — Bland-Sutton  in  his  first  lertnre  on  the  surgery  of 
pregnancy  and  labor  complicated  witli  tumors 
remarks  that  when  an  ovarian  tumor  occupies  the  p-lvis 
and  offers  mechanical  impediment  to  delivery,  the  fetus 
almost  invariably  dies  and  the  'ollowing  accidents  may 
happen  :  (1)  Rupture  of  the  cyst ;  (2)  rupture  of  the  uterus ; 
(3)  rupture  of  the  vagina;  (4)  excursion  of  the  tumor  into 
the  rectum.  Rupture  of  the  uteru^,  he  believes,  is  a  some- 
what exceptional  accident  under  these  conditions,  while 
rupture  of  the  vagina  is  an  unusual  accident  when  it  occurs 
as  a  result  of  the  efTorts  of  the  uterus  alone.  One  case  has 
been  observed  and  recorded  in  which  an  ovarian  dermoid 
obstructing  labor  had  been  pressed  into  the  rectum  and  the 
wall  of  the  bowel  had  become  invagiaated  and  the  tumc  r, 
invested  by  the  bowel,  had  been  excluded  throu;?h  the  anus. 
The  common  way  in  which  nature  overcomes  the  diffi  ;uUy 
is  by  rupture  of  the  cyst;  if  the  fluid  be  sterile  the  results 
are  not  necessarily  harmful,  but  when  the  tumor  has  thick 
walls  and  contains  dermoid  material  the  efftjcts  are  often 
very  grave.  Today  the  choice  of  treatment  of  this  condi- 
tion lies  between  two  methods:  1.  In  the  early  stage  to  push 
the  tumor  out  of  the  pelvis  and  allow  labor  to  be  completed, 
and  subsequently  to  perform  ovariotomy.  2.  To  perform 
ovariotomy  at  once  and  then  to  accelerate  labor  by  the  use 
•of  forceps.  It  is  now  a  well-atteh-ted  fact  that  ovariotomy 
can  be  successfully  performed  even  while  labor  is  in  progress, 
and  that  the  operation  in  no  way  interferes  with  the  con- 
traction of  the  uterus.  Single  and  even  double  ovariotomy 
can  be  successfully  performed  in  the  puerperium  without 
in  any  way  interfering  with  either  the  involution  of  the 
uterus  or  lactation.  Toerefore,  it  cannot  be  too  strongly 
urged  that  when  a  puerperal  woman  known  to  possess  an 
ovarian  tumor  exhibits  unfavorable  symptoms  ovariotomy 
should  be  resorted  to  without  delay,    [w.a.n  d.] 

4. — 0-tler  makes  a  plea  for  more  careful  study  of 
the  symptoms  of  perforation  in  typhoid  fever  with 
»  view  to  early  operation.  He  mnntions  that  tiie  m^  r- 
tality  of  enteric  tever  is  from  7%  to  14%.  Of  the  fatal  cases 
50%  of  the  deaths  are  due  to  asthenia,  2-5%  to  perforation 
and  25%  to  hemorrhage  and  other  accidents.  Of  the  deaths 
which  are  due  to  perforation,  he  states  that  with  early  oper- 
ation after  an  early  diagnosis  between  30%  and  40%  may  be 
saved.  Out  of  11  cases  operated  upon  in  the  Johns  Hopkins 
Hospital  since  January  1,  1900,  5  recovered.  The  classical 
description  of  perforation  as  we  see  it  is  really  the  picture  of 
the  consecutive  peritonitis.  He  gives  a  schedule  with  the 
view  of  aiding  the  resident  physicians  and  house  physicians 
in  the  study  of  early  symptoms  and  signs  of  perforation  in 
enteric  fever.  In  this  schedule  he  calls  attention  to  pain,  that 
we  should  be  careful  to  note  its  onset  and  its  locality ;  the 
state  of  the  abdomen,  its  contour,  the  respiratory  move- 
ments ;  the  signs  which  are  to  be  noted  upon  palpation,  per- 
cussion and  auscultation  ;  and  the  data  which  may  be  gained 
by  an  examination  of  the  rectum.  The  stools  and  the  urine 
should  also  be  carefully  studied.  The  general  condition  of 
the  patient  is  next  referred  to.  Under  this  heading  attention 
is  directed  to  the  facies,  the  pulse,  the  temperature,  the  re 
spiration,  hiccough  and  vomiting.  Tne  author  next  calls  our 
notice  to  the  constant  leukopenia,  an  1  that  it  is  of  imp  )rt mce 
to  note  any  rise  in  the  number  of  leukocytes.  He  states  that 
sudden  pain  is  perhaps  the  most  constant  symptom  of  per- 
foration, and  concludes  by  stating  that  in  a  doubtful  case  of 
perforation  the  patient  should  be  given  the  benefit  of  the 


doubt  and  operation  be  performed.  A  surgical  colleague 
should  always  be  called  as  soon  as  this  condition  is  suspected. 
[f  j  k.] 

5.— Of  101  cases  of  litholapaxy,  Harrison  had  a  mor- 
tality of  6,  and  a  recurrence  of  the  stone  to  some  degree 
in  23  cases.  In  most  of  the  recurrent  cases  the  patients  suf- 
fered from  enlargement  of  the  prostate  gland,  or  had 
pouched  bladders,  and  were  accustomed  to  use  the  catheter. 
Harrison  thinks  that  these  conditions  are  very  often  re- 
sponsible for  recurrences.  Recurrence,  however,  does  take 
place  in  people  who  do  not  suffer  from  any  disease  of  the 
prostate  or  the  bladder  itself.  In  many  of  these  the  recur- 
rence may  be  due  to  a  passage  of  a  stone  from  the  kidney 
and  this  is  as  apt  to  occur  after  lithotomy  as  after  lithotrity. 
Great  stress  is  laid  upon  the  after  treatment  of  the  bladder 
in  cases  of  litholapaxy.  This  should  be  carried  out  after  the 
patient  passes  from  the  hands  of  the  surgeon  into  those  of 
his  regular  medical  adviser.  So  long  as  the  urine  remains 
abnormal  or  unexpectedly  becomes  so,  as  indicated  by  the 
appearance,  smell,  or  microscopic  examination,  the  bladder 
should  be  carefully  attended  to  until  such  states  are  either 
explained  or  removed.  Irrigation  of  the  bladder  should  be 
regularly  kept  up,  so  long  as  the  condition  of  the  urine  indi- 
cates that  it  is  necessary.  For  this  purpose  boric  acid  or 
potassium  permanganate  may  be  used,  two  to  fcur  pints  being 
used  at  a  sitting.  Tue  catheter  should  be  a  large  one  so  that 
any  small  particles  may  come  away.  When  the  bladder  is 
sacculated  it.  is  well  occasionally  to  wash  out  with  the  evacu- 
ator  as  after  stone  crushing.  When  the  mucous  membrane 
remains  relaxed  and  spongy,  as  is  evident  from  an  excess  of 
mucus  in  the  urine,  H-irrison  recommends  that  a  solution  of 
nitrate  of  silver  (1  grain  to  12  ouncef)  should  be  thrown  into 
the  bladder  after  irrigation.  He  thinks  it  a  mistake  to  use 
nitrate  of  silver  in  the  stronger  solutions.  Raney's  theory 
of  the  formation  of  a  stone  by  molecular  coalescence  is 
next  diecusjed  in  detail.  Harrison  doubts  the  efficacy  of 
drugs  and  waters  to  dissolve  stone,  but  thinks  that  a  number 
of  these  are  useful  to  prevent  the  formation  of  a  stone  and  a 
recurrence  after  removal.  Hard  waters  produce  an  excessive 
amount  of  mucus  in  the  urine  and  are  hence  condemned. 
Among  the  drugs  mentioned  as  preventives  are  turpentine, 
sandal  and  copaiba  Boric  acid,  also,  is  highly  recommended 
because  of  its  antiseptic  qualities.  Erotropin  possesses  to  a 
marked  degree  the  valuable  power  of  clearing  the  urine  and 
keeping  it  so.  The  solution  of  nitrate  of  silver  prevents 
molecular  coalescence  and  hence  lessens  the  tendency  to  the 
formation  of  stone.  Hirrison's  paper  is  illustrated  by  the 
report  of  6  cases,    [j  h  g.] 

6.— Guthrie  reports  a  case  of  myasthenia  gravis.  The 
patient,  a  female,  aged  23,  a  waitress  by  occupation,  was  ad- 
mitted January  26,  1900.  to  the  Hospital  for  Epilepsy  and 
Piralysis,  Regent's  Park,  L-jndon.  The  only  point  of  in- 
terest in  the  family  history  is  that  an  aunt  suffered  from 
epilepsy,  and  a  sister  of  the  patient  had  an  attack  of  chorea. 
Tne  present  illness  began  very  gradually  a  number  of  months 
before  admission  to  the  hospital.  The  first  symptom  was 
difficulty  in  speaking,  owing  to  spasm  of  the  jaw,  as  She 
patient  says.  This  symptom  was  more  pronounced  towards 
the  end  of  the  day.  The  diSiculty  of  speaking  gradually 
increased  and  was  followed  by  difficulty  in  swallowing.  She 
had  considerable  trouble  in  swallowing  liquids  and  solids. 
Upon  admission  it  was  noticed  that  there  was  paresis  of  the 
orbicularis  oris  and  palpebrarum,  also  of  the  tongue,  soft 
palate,  and  probably  of  the  pharynx.  She  could  not  close  her 
eyes  and  could  not  whistle.  Ocular  movements  were  not  dis- 
turbed. The  pupillary  reaction  was  normil  and  there  was  no 
restriction  of  the  field  of  vision.  Speech  was  indistinct  and 
deglutition  was  rendered  difficult.  The  symptoms  always 
increased  in  severity  towards  the  end  of  the  day.  Only  after 
exertion  was  a':itual  loss  of  muscular  power  apparent.  The 
reflexes,  both  tendon  and  superficial,  were  normal.  Ttiere 
was  no  disturbance  of  sensation.  With  regard  to  the  myas- 
thenic reaction,  the  right  biceps  ceased  to  react  to  faradism 
in  about  one  minute,  while  the  left  biceps  required  about 
a  miniUe  and  a  half.  The  patient  gradually  improved  and 
in  three  moi.ths  was  sent  home.  The  treatment  con- 
sisted in  rest  and  the  administration  of  liquor  strychniae. 
The  patient  was  in  fair  health  until  June  15, 1900,  when  she 
suffered  a  severe  relapse.  All  of  the  symptoms  returned  with 
increased  severity.  There  were  also  weakness  of  the  muscles 
of  the  neck  and  marked  general  fatigue.    It  became  im- 


418 


Thb  PhiladblphiaT 
Medical  Joubnal  J 


THE  LATEST  LITERATURE 


[Makch  2,  1901 


possible  for  her  to  swallow  liquids,  and  she  was  therefore  fed 
with  nutrient  enemata.  Deatti  occurred  on  July  16,  probably 
due  to  respiratory  failure  and  gradual  exhaustion.  The  post- 
mortem examination  gave  no  clue  as  to  the  cause  of  this  con- 
dition, and  was  as  a  whole  negative.  The  author  states  that  he 
believes  that  myasthenia  gravis  is  due  to  a  toxin  which  is 
probably  elaborated  within  the  body.  He  gives  the  theory  of 
Its  origin  in  the  muscles,  but  states  that  Dr.  Bramwell,  by  an 
ingenious  experiment,  has  shown  that  this  is  not  the  seat  of 
origin.  He  also  mentions  that  the  origin  may  be  due  to  dis- 
turbances of  suprarenal  bodies,  or  the  poison  may  be  formed 
within  the  spleen.  He  then  gives  the  diagnosis  of  this  dis- 
ease, and  mentions  that  out  of  60  cases,  24  proved  fatal. 
Complete  recovery  may  follow.  The  author  then  gives  a 
careful  review  of  the  points  to  be  considered  in  the  differ- 
ential diagnosis  between  myasthenia  gravis  and  hysteria, 
bulbar  paralysis,  diphtheritic  paralysis,  Landry's  paralysis, 
multiple  neuritic,  and  postinfluenzal  neuroses.  He  mentions 
that  the  most  important  indication  in  the  treatment  is  com- 
plete rest  of  body  and  mind.  Drugs  have  proved  u-eless  in 
the  management  of  this  disease,     [f.j.k  ] 

7. — Brown  in  an  article  entitled  ptomaine  poisoning 
or  perforation,  states  that  on  November  19,  1900,  he  was 
called  to  see  a  woman,  27  years  of  age,  who  was  in  a  state  of 
unconsciousness,  the  eyes  were  open,  pupils  dilated,  irreg 
ular  movements  of  the  eyeballs,  and  the  temperature  was 
103°  F.  in  the  axilla.  Upon  examination  the  abdomen  was 
found  to  be  tympanitic.  After  an  hour  the  temperature 
rose  to  105°  and  the  pulse  was  140  per  minute.  In  a  short 
time  she  developed  rigors  and  the  temperature  fell  to  90" 
F.  The  extremities  were  cold,  the  skin  was  clammy,  and 
the  patient  dtveloped  hallucinations  with  general  nervous 
prostration,  diarrhea  and  vomiting.  Eighty  six  hours  after 
the  onset  of  the  disease  death  occurred.  From  the  history 
as  ascertained  from  her  friends,  it  was  learned  that  she 
had  partaken  of  2  beef  sausages  2  days  before  the  onset  of 
the  illness.  Three  other  persons  partook  of  these  sausages 
and  2  of  them  developed  diarrhea  and  vomiting.  The  post- 
mortem examination  revealed  an  exudation  of  lymph  in 
the  peritoneal  cavity  and  the  serous  lining,  the  small  in- 
testines were  intensely  inflamed.  The  petechiae  and  ecchy- 
moses  were  found  in  the  duodenum  and  stomach,  and  the 
gastric  miicosa  was  acutely  inflamed.  He  states  that  the 
points  of  interest  in  this  caee  are  the  sudden  onset,  high 
temperature,  abseace  of  muscular  weakness  and  inflamma- 
tion of  the  serous  coat  of  the  small  intestine  without  appar- 
ent inflammation  of  the  mucous  coat,     [f  i.k  ] 

8. — Tnyne  reports  a  case  of  cerebellar  hemorrhage 
presenting  well-marked  cervical  opisthotonos  and 
Kernig's  sign  occurring  in  a  man,  20  years  of  age.  Tne 
patient  gjves  an  epileptic  history,  and  was  suddenly  taken 
ill  after  partaking  of  a  hearty  meal.  The  onset  was  marked 
by  vomiting.  Six  hours  afterwards,  there  was  marked  re- 
traction of  the  heail,  and  the  patient  suflered  from  severe 
frontal  headache.  Kernig's  sign  was  present.  Taere  was  no 
motor  paralysis,  and  convulsions  and  twitchings  were  absent. 
Tendon  reflexes  were  exaggerated.  Consciousness  was  not 
impaired.  Upon  postmortem  examination,  a  subarachnoid 
serous  efi"usion  was  found,  also  a  thin  layer  of  coagulated 
blood  over  the  right  occipital  lobe  extending  down  to  the 
cerebellum,  and  the  fourth  ventricle  contained  a  blood- clot. 
The  lateral  left  lobe  of  the  cerebellum  was  the  seat  of  small 
hemorrhages.  No  evidence  of  meningitis  was  found.  The 
author  states  that  the  case  is  of  interest,  because  cervical  opis- 
thotonos and  Kernig's  sign  were  due  to  cerebellar  hemorrhage, 
and  not  to  meningitis,     [f  j  k  ] 

9. — Lea  records  a  case  of  pelvic  sarcoma  with  chy- 
lous ascites,  in  which,  after  abdominal  section  and  drainage, 
the  tumor  ceased  to  grow,  and,  4J  years  later,  had  shown  no 
tendency  to  increase  in  size.  Tne  lacteal  obstruction  also 
disappeared,  and  the  chylous  ascites  failed  to  reappear.  Lea 
offers  no  explanation  as  to  this  remarkable  occurrence,  which 
has  occasionally  been  noted  by  other  operators,    [w.an.d] 


New  York  Medical  Journal. 

February  2S,  1901.     [Vol.  Ixxiii,  No.  8.] 

1.  State  Care  of  the  Insane.    Hksry  Waldo  Coe. 

2.  The    Normal    Declinations    of   the    Ratinal    Meridians. 

George  T.  Stevens. 


3.  The  Relations  of  Scurvy  to  Recent  Methods  of  Artificial 

Feeding.    J.  P.  Cr^ziee  Griffith, 

4.  The  Pathology  of  Intra-uterine  Death.    Neil  Macphattee. 

5.  A  Simple  and  Accurate  Method  of  Substitute  Infant  Feed- 

ing.   Hesey  Dwight  Chapis. 

6.  A  Clinical  Ran  rt  of  the  Use  of  Chloretone  as  a  Hypnotic. 

A.  A.  Stevens. 

1.— Henry  Waldo  Coe  discusses  the  State  care  of 
the  Insane  and  deprecates  the  present  method  of  crowding 
together  insane  patients  as  well  as  the  system  which  the 
limits  of  State  appropriations  force  upon  those  having  charge 
of  these  patients.  He  believes  that  the  appointments  of 
physicians  should  be  by  merit  and  not  influenced  by  politics. 
His  idea  is  that  the  chief  physician  of  an  asylum  should  have 
the  appointment  of  his  assistants  as  well  as  full  discretionary 
power  in  the  management  of  the  institution.  He  beheves 
that  the  ideal  method  of  treatment  would  be  the  cottage- 
plan.  This  would  necessarily  imply  an  increase  in  the 
number  of  attendants,  yet  the  result  of  such  treatment  would 
certainly  be  more  favorable  to  restoration  of  mental  health 
in  many  cases.  Tne  care  of  the  insane  is  a  great  burden 
upon  the  State,  but  the  percentages  of  recovery  under  a 
liberal  and  thoroughly  modem  system  would  compensate  for 
the  additional  expense,    [t  l  c  ] 

2.— Stevens  defines  "normal  declinations  of  the  retinal 
meridians"  as  a  deviation  of  the  vertical,  horizontal,  or  any 
given  meridian  of  the  eye  from  the  corresponding  meridian 
of  external  space  when  the  line  of  regard  of  the  eye  is 
directed  parallel  to  the  median  plane  and  in  the  horizontal 
plane,  the  head  being  exactly  erect  or,  more  technically, 
in  the  primary  position.  The  definition  is  illustrated  by  an 
accompanying  diagram.  He  employs  the  term  "  anoma- 
lous "  in  designating  a  normal  declination  in  contradistinc- 
tion to  that  resulting  from  paralysis,  paresis,  or  insufficiency 
of  one  or  more  ocular  muscles.  Among  the  instruments 
employed  for  determining  declinations  there  are  mention^ 
the  "  clinoscope,"  and  the  "  lens  clinoscope."  One  of  the 
first  results  obtained  by  the  employment  of  the  clinoscope 
after  it  had  been  shown  that  normally  there  existed  for  the 
vertical  meridian  a  leaning  out  of  about  1J°  (while  the 
horizontal  meridian  was  supposed  to  exactly  c<:incide  with 
the  real  horizjn),  was  the  demonstration  of  the  fact  that 
when  either  of  the  meridians  leaned  that  the  position  of  the 
vertical  and  horizontal  meridian  leaned  in  corresponding 
directions  and  to  an  equal  amount.  Correction  of  declina- 
tion is  followed  in  a  large  number  of  cases  by  the  relief  of 
hyperphoria.  He  associates  a  number  of  symptoms  which 
appeared  to  result  from  hyperphoria,  with  declination.  The 
symptoms  are,  locally,  dryness  and  smarting  of  the  eyelids, 
with  the  sensation  in  them  cf  "grit,"  as  well  as  chronic 
hyperemia  of  the  lids.  Supraorbital  pain  is  frequently  com- 
plained of  and  careful  observation  in  these  cases  will  show, 
that  while  one  brow  is  arched  the  other  one  is  flattened 
against  the  eye-ball.  Stevens  emphasizes  the  fact  that  this 
supraorbital  pain  is  not  due  to  reflex  disturbance,  but 
is  an  expression  of  the  muscular  tension  beneath  in  the 
effort  to  elevate  or  depress  the  brow.  This  is  substantiated  by 
the  subsidence  of  the  symptom  upon  the  relief  of  declination. 
Variations  in  the  contour  of  the  brows  and  the  declinations 
of  the  meridians  are  in  relation  to  each  other.  The  author 
calls  attention  to  the  amblyopia  which  is  sometimes  found  in 
apparently  healthy  eyes  without  eqnint,  and  which  is  depend- 
ent on  declination.  When  refractive  errors  exist  or  erroro 
in  muscular  adjustment,  the  correction  of  these  disturbance* 
probably  gives  relief  by  lessening  the  diflBculty  in  the  mai»- 
agement  of  the  declination.  Correction  of  declination  can 
only  be  accomplished  by  surgical  intervention.  Opera- 
tive procedures  are  peritenotomy,  circum traction  (vertical  or 
lateral)  and  extendo-contraction.  By  the  'atter  operation  a 
change  in  the  direction  of  the  meridians  of  two  to  three  de- 
grees or  even  more  may  be  accomplished.  The  operation  is 
described  in  detail,  with  accompanying  illustrations  ot  the 
instruments  employed  in  its  technic.     [m.r  d] 

3.— J.  P.  Crozer  GriSltb  report*  16  CAses  of  infan- 
tile scurvy  under  his  care  during  the  last  IS  months.  A 
study  of  the^e  cases  supports  the  generally  accepts!  view 
that  the  patented  foods  often  produce  infantile  scurvy, 
and  some  of  them  show  that  recovery  may  follow  the  with- 
drawal of  these  foods  without  other  treatment  Griffith 
remarks  that  the  cause  of  this  action  of  these  foods  is  in 


Uazcb  2,  1901] 


THE  LATEST  LITERATURE 


rXHE  Philadelphia 

L  fllKDlCAL  JOUENAL 


419 


doubt.  It  may  be  that  they  are  so  commonly  derived 
from,  or  contain  starcb,  or  that  they  are  deficient  in  cer- 
tain ingredients.  Two  of  his  cases  throw  suspicion  on  barley 
water.  These  cases  indicate  also  that  the  sterilization  of 
milk  has  an  undoubted  power  to  produce  scurvy,  but  it  is  a 
less  prominent  factor  than  the  patented  foods.  It  is  seen 
that  scurvy  can  readily  develop  on  a  diet  of  milk  vfhich  is 
not  long  heated,  or  which  is  even  raw.  It  is  interesting  to 
note  that  in  some  of  his  cases  fruit  juice  may  be  given, 
and  improvement  noted,  without  any  change  in  the  food 
whatever.  He  concludes  that,  whereas  there  are  classes  of 
foods  which  are  particularly  apt  to  produce  scurvy  in  infants, 
yet  the  individual  element  is  remarkably  present  in  this 
disease,     [t  l  c  ] 

4. — Will  be  abstracted  when  concluded. 

6. — Henry  Dwight  Chapin  presents  a  simple,  accurate 
method  of  sub.stitute  infant  feeding.  In  preparing 
the  infant  food,  it  is  necessary  to  have  the  milk  bottled  at  the 
dairy,  and  kept  at  low  temperature.  He  then  dips  off  from 
9  to  16  ounces  from  the  top  of  the  bottle,  and  then  sets  aside 
the  milk  bottle  to  avoid  confusion.  He  advises  this  method 
rather  than  using  a  syphon.  He  then  prepares  dextrinized 
gruel  in  the  following  manner:  Beat  into  a  smooth,  thin 
paste  with  a  little  cold  water  two  heaping  tablespoonfuls  of 
wheat  or  barley  flour ;  and  a  quart  of  boiling  water, and  boil 
the  gruel  for  about  15  minutes.  It  is  then  cooled,  and  a  prepa- 
ration of  diastase  is  added.  He  recommends  that  an 
aqueous  solution  of  diastase  be  prepared  at  home  by 
soaking  malted  barley  grains  in  cold  water.  The  gruel 
is  stirred  and  kept  warm  until  it  becomes  thin  and  watery. 
Dilute  the  top  milk  taken  from  the  original  bottle  with  the 
digested  gruel  and  add  sugar.  The  food  for  a  young  infant 
should  contain  from  J  to  J  of  the  9  ounces  of  top  milk.  The 
food  for  an  older  infant  should  contain  i  to  |  of  the  16  ounces 
of  top  milk.  Sugar  is  added  to  make  up  for  the  amount  lost 
in  the  dilution.  He  recommends  that  when  the  milk  cannot 
be  kept  below  60°  F.,  it  will  have  to  be  pasteurized.  When 
there  is  vomiting  of  food,  the  digested  gruel  may  be  fed  tem- 
porarily, and  a  top  milk,  poorer  in  fat,  used  for  making  up 
the  next  feeding,     [t  l  c  ] 

6.— A.  A.  Stevens  has  used  chloretone  in  50  cases,  in 
which  sleeplessness  was  an  important  symptom.  Chlore- 
tone is  trichlor  tertiary  butyl  alcohol,  a  compound 
formed  by  tiie  addition  of  caustic  potash,  with  equal 
weights  of  chloroform  and  acetone.  It  possesses  \a,'\i- 
able  hypnotic  and  local  anesthetic  properties.  Stevens 
concludes  that  in  chlorotone  we  have  a  safe  hypnotic 
of  moderate  power,  which  rarely  gives  rise  to  unpeasant 
after-effects,  but  of  which  a  toleration  is  quite  rapidly  ac- 
quired. The  drug  is  especially  adapted  for  use  incases  of 
insomnia  unattended  with  pain,  high  fever,  or  pro- 
nounced nervous  excitement.  Tne  dose  is  from  10  to 
20  grains.  It  may  be  conveniently  administered  in  the  form 
of  powders  or  compressed  tablets,     [t.l.c] 


Medical  Record. 

Fibruary  23,  1901.     [Vol.  59,  No.  S.] 

1.  The  Necessity  for  a  More  Careful  Investigation  as  to  the 

Cause  of  Outbreaks  of  Infectious  Diseases.    Alvah  H. 
Doty. 

2.  A  Mpthod  of  Fixation  for  Loose  Kidneys.    Robert  T. 

MOERIS. 

3.  Convulsions  with  Scarlet  Fever,  and  the  Report  of  a  Very 

Severe  Case  with   Perfect  Recovery,  and   Important 
Daduclions  from  the  Treatment.    Herman  E.  Hayd. 

1. — Alvah  H,  Doty,  of  New  York,  discusses  the  neces- 
sity for  a  mure  ctreiul  investigation  as  to  the  cause  of  out- 
breaks of  infectious  diseases.  Dr.  Doty 'a  wide  experi- 
ence as  Health  Officer  of  the  Port  of  New  York  qualifies  him 
to  speak  with  authority  upon  this  subject.  In  the  first  place 
he  states  that  the  theory  of  contagion  from  clothing  worn  by 
well  persons  is  in  the  vast  msjjrity  of  cases  found  to  be 
unsupported.  Experience  teaches  that  epidemics  are  most 
frequently  carried  by  mild,  ambulant,  or  convalescent 
cases,  thence  the  necessity  of  tne  recognition  of  such  cases. 
Upon  the  ditcovery  of  a  case  of  infectious  disease  it  is  the  first 
and  most  important  duty  of  the  health  officer  to  ascertain,  if 
possible,  its  origin.    Whien  the  physician  is  called  to  such  a 


case,  he  should  at  once  require  that  all  the  clothing  of  the 
infectious  ca'<e  be  brought  together;  not  one  article  should 
be  missing.  This  material  should  be  subjected  to  a  thorough 
and  immediate  disinfection,  and  steam  should  be  used 
for  this  purpose.  In  marine  sanitation  the  crews  and  passen- 
gers from  an  infected  port  should  go  through  a  most  rigid 
examination.  For  the  past  3  years  Doty  has  required  that- 
all  of  the  passengers  and  crews  arriving  on  vessels  from 
infected  ports  shall  have  their  temperature  taken  bef  )re 
being  released  from  quarantine.  Many  cases  of  yellow 
fever  and  other  contagious  diseases  have  been  detected  in 
this  manner,     [t  l  c  ] 

3.— Robert  T.  Morris  details  a  method  of  fixation  for 
loose  kidneys.  In  this  operation  a  flap  of  capsule,  in- 
cluding the  larger  part  of  the  mesial  surface  of  the  kidney,  is 
incised  with  a  scalpel  and  the  flap  of  capsule  then  stripped  up 
from  the  parenchyma,  but  remaining  attached  to  the  convex 
border  of  the  kidney.  The  flip  of  capsule  is  drawn  through 
a  slit  in  the  psoas  muscle  or  the  quadratus.  This  brings  the 
parenchyma  also  in  contact  with  the  psoas  or  quadratus 
fascia,  where  it  forms  a  firm  connective  tissue  attachment. 
The  operation  avoids  the  necessity  of  passing  sutures  through 
the  parenchyma  of  the  kidney,     [t.l  c  ] 

3. — Herman  E.  Hayd  reports  a  case  of  scarlet  fever  with 
severe  convulsions,  followed  by  recovery.  Copious  clinical 
notes  of  his  case  are  given,  and  the  writer  concludes  with  the 
following  deductions :  Convulsions  may  occur  when  least 
expected,  and  every  case  of  scarlet  fever  should  be  closely 
watched  for  many  weeks.  The  frequent  examination  of  the 
urine  should  include  the  calculation  for  urea.  Mere  specific 
gravity  is  not  a  sufficient  index  as  to  the  amount  of  urea 
eliminated.  Albumin  need  not  be  present,  or  only  a  trace 
may  be  found,  yet  convulsions  may  occur.  The  increase  in 
the  albumin  will  generally  be  noted  after  the  convulsions 
occur.  Milk  is  the  ideal  food,  but  if  it  cannot  be  well  digested, 
the  author  advises  that  no  food  should  be  administered  for 
days  by  the  stomach,  simply  an  abundance  of  water  and  the 
patient  nourished  by  nutrient  enemata.  In  any  severe  case 
of  convulsions  very  small  amounts  of  nourishment  should  be 
given  at  one  time  and  the  urea  equivalent  must  be  deter- 
mined. He  recommends  hypodermoclysis  to  ihe  amount 
of  from  2  to  3  pints.  Enteroclysls  is  advised,  with  the 
water  at  a  temperature  of  80°,  once  or  twice  in  24  hours, 
if  much  fever  be  present.  Strychnin,  digitalln,  and 
brandy  are  recommended  as  heart  stimulants,     [t.l  c] 


Medical  News. 

February  S3, 1901.     [Vol.  Ixxviii,  No.  8.] 

1.  The  Value  and  Accuracy  of  the  Rontgen  Method  of  Diag- 

nosis in  Cases  of  Fracture.    Charles  Lester  Leonard-. 

2.  Pnaryngeal  Adenoids  and  Hypertrophied  Tonsils.    J.  H. 

Woodward. 

3.  The  Sustaining  Treatment  of  Typhoid  Fever,  with  Special 

Reference  to  the  Use  of   Hypnotics.     A.  H.  Buck- 
master. 

1.— Leonard  calls  attention  to  the  various  conditions  in 
which  the  Roatgen  ray  is  useful  for  diagnosis,  and  says  that 
(1)  many  fractures  that  were  considered  rare  exist  in  a  much 
greater  proportion  than  was  suspected  ;  that  the  functional 
loss  which  was  supposed  to  result  from  a  traumatism  or 
sprain,  and  was  termed  traumatic  arthritis,  or  a  bad  sprain, 
is  often  in  reality  the  result  of  an  undetected  fracture  which: 
it  is  impossible  to  diagnose  by  other  methods  of  examina- 
tion. The  Rontgen  ray  is  useful  for  (2)  detecting  unsus- 
pected fractures  and  multiple  fractures  when  only  one  waa 
suspected ;  (3)  exact  line  of  the  fracture  ;  (4)  to  guard  against 
the  production  of  deformities,  such  as  overlapping  and 
shortening  in  oblique  fractures;  in  transverse  fractures, 
angular  deformities ;  in  spinal  fractures,  a  rotation  of  one 
fragment  on  the  other,  while  in  fractures  involving  j  iint« 
a  restriction  of  motion  may  result  from  malposition  of  the 
fragments,  or  the  interference  of  motion  due  to  excessive 
callous  formation ;  (5)  accurate  information  is  obtained 
without  manipulation;  (G)  to  render  the  exact  coaptation 
of  the  fragments  more  certain  and  easier  or  determine  the 
impossibility  of  complete  reduction  mthout  operative  inter- 
ference; (7)  accuracy  of  the  setting  and  the  efficiency  of  the 
fixation  apparatus  or  other  methods  of  treatment.    [t.m.t.J 


420 


Thb  Philadelphia"! 
hsdical  jocbnal  j 


THE  LATEST  LITERATURE 


PlAECH  2,  1901 


2. — Woodward  divided  the  symptomatology  of  pharyngeal 
adenoids  into  :  1.  Symptoms  common  to  all  adenoids,  viz., 
hyperplasia  of  the  lymphoid  tissue  in  the  vault  of  the 
pharynx,  chronic  congestion  of  the  submucous  bloodvessels 
of  the  inferior  turbinated  body ;  a  more  or  less  profuse, 
mucopurulent  discharge.  2.  Symptoms  dependent  upon  the 
size  of  the  adenoid,  viz  ,  alteration  of  the  voice,  as  if  the  pa- 
tient was  suflering  from  a  cold  in  the  head ;  mouth  breath- 
ing; snoring  and  choking  in  sleep;  general  malnutrition; 
deafness;  chronic  headache  and  mental  dulness.  .3.  Occa- 
sional accessory  lymptoms  including  asthmatic  seizures; 
habit  (facial)  chorea  ;  epileptiform  attacks.  To  these  may  be 
added  the  state  of  deaf-mutism  as  one  of  the  consequences  of 
adenoids  in  infancy,  for  adenoid  vegetations  occur  in  the 
earliest  mcnths  of  infancy.  Adenoid  vegetations  are  very 
rarely  seen  in  persons  over  20  years,  and  retrogressive 
changes  of  the  hyperplasia  take  place  during  adolescence  if 
left  alone,  although  this  is  not  the  advised  course.  There 
seems  to  be  no  doubt  that  the  most  effectual  treatment  is 
their  removal,  although  in  special  cases  the  application  of 
tincture  of  iodin  and  nitrate  cf  silver  may  be  sufficient. 
The  author  also  gives  the  following  symptoms  of  hypertrophy 
of  the  faucial  tonsils;  alteration  of  the  voice  in  which  the 
tone  is  muffled  as  if  patient  were  holding  something  in  his 
mouth;  snoring  and  choking  in  sleep;  excessive  secretion  of 
mucus  in  the  throat;  frequent  attacks  of  acute  catarrhal  in- 
flammation in  the  throat  and  follicular  tonsillitis;  chronic 
enlargement  of  cervical  lymphatic  glands;  mouth  breathing; 
deafness;  general  malnutriii  )n.  This  condition  is  generally 
found  before  the  age  of  puberty,  especially  between  the  ages 
of  3  to  10  years.  The  treatment  depends  upon  the  degree  of 
hypertrophy  and  the  symptoms  present.  If  marked  they 
should  be  removed,  even  if  the  tonsils  are  not  markedly  en- 
larged, during  period  of  quiescence  or  reduced  in  size  by  the 
application  of  acute  cautery  or  astringent  alteratives. 
[t  m  t.] 

3. — Buckman  sums  up  hi.»  treatment  of  typhoid  fever 
with  special  reference  to  the  use  of  hypnotics,  and 
his  advice  to  pbysicians  is  as  follows:  1.  Ascertain  how  much 
food  is  necessary,  and  whether  patient  has  bad  enough  food, 
water  and  fresh  air  in  the  24  hours.  2.  Do  not  allow  the 
patient  to  wear  himself  out  by  continued  high  temperature 
or  by  lack  of  sleep.  The  amount  of  sleep  in  the  24  hours 
should  be  recorded.  3.  Examine  the  urine  frequently,  and 
ascertain  the  daily  quantity  ;  also  keep  posted  as  to  move- 
ments of  bowels  and  condition  of  skin,    [t  m.t.] 


Boston  Medical  and  Surgical  Jonrnal. 

February  SI,  1901.     [Vol.  cxliv,  No.  8.] 

1.  U.  S.  Army  Pathological  Laboratories  iu  the  Philippine 

Islands.    Jos.  J.  Curry. 

2.  Dysenteric  Diseases  of  the  Philippine  Islands,  with  Special 

Reference  to  the  Ameba  Coli  as  a  Causative  Agent  in 
Tropical  Dysentery.    J(  s.  J.  Curry. 

3.  Uterine  Fibroids.    Homer  Gage. 

4.  Dysbasia     Intermittens     Angiosclerntica     (Intermittent 

Lameness  of  Vascular  Origin).    J  as.  J.  Putnam. 

2. — Dysentery  is  responsible  for  the  highest  mortality 
among  our  trotips  in  service  in  the  East,  but  even  this  state- 
ment does  not  give  any  adequate  idea  of  the  gravity  of  the 
dieease.  Dysentery  in  the  Philippine  Islands  is  respon- 
sible for  more  permanent  disabilities  than  all  the  rest  of  the 
diseases  combined.  A  complete  permanent  recovery  in  the 
islands  is  the  exception  to  the  rule.  There  were  132  deaths 
from  dysentery  at  the  Fust  Reserve  Hospital  up  to  June  1, 
1900.  Ninety  eight  of  these  cases  of  dj  sentery  came  to  post- 
mortem. Of  these,  66  were  found  to  be  amebic  dysentery, 
20  acute  dysentery,  and  12  subacute  dysentery.  In  the  great 
majority  of  cases  among  our  troops  there  was  a  history  of 
drinking  polluted  or  uncertain  water.  Malaria  is  the  most 
frequent  complication  of  dysentery  in  the  Philippine  Islands. 
Typhoid  fever  and  amebic  dysentery  combined  occurred 
twice  and  acute  lobar  pneumonia  occurred  once  in  this 
series  of  66  cases  of  amebic  dysentery.  There  were  2  cases 
of  active  and  quite  extensive  pulmonary  tuberculosis.  As 
will  be  seen  from  reference  to  the  classification  of  the  98 
cases  autopsied,  amebic  dysentery  is  the  most  common  type. 


and  it  is  responsible  for  many  more  deaths  than  all  the  other 
types  combined.  Whether  the  ameba  coli  is  primary  or 
secondary,  we  have  the  strongest  evidence  that  it  is  certainly 
a  very  important  etiologic  factor.  In  several  of  the  cases  of 
acute  dysentery  that  came  to  autopsy  a  bacillus  apparently 
identical  with  that  described  by  Shiga  and  by  Flexner  was 
found  in  culture,    [j  m  s  ] 

4. — Putnam  reports  the  case  of  a  man  who  suffered  from 
dysbasia  intermittens  anglosclerotica,  first  described 
by  Charcot,  in  1854  Toe  patient  was  an  active  and  able 
business  man,  a  gentleman  of  70,  with  a  remarkably  good 
record  for  soundness  of  constitution,  temperance  of  habits, 
and  freedom  from  disease  and  exposure.  He  was  without 
signs  of  nephritis,  diabetes,  cardiac,  or  arterial  disease, 
unless  an  attack  of  sudden  giddiness  in  which  he  was  once 
precipitated  forcibly  and  suddenly  from  his  chair  to  the  floor 
was  due  to  a  cerebral  lesion  of  arterial  origin.  The  symp- 
toms of  chief  interest  in  the  present  connection  first  showed 
themselves,  2  months  before  the  author's  examination,  in 
the  form  of  an  intense  sense  of  muscular  fatigue  in  the  legs, 
amounting  almost  to  pain,  which  recurred  every  time  the 
patient  walked  more  than  i-mile,  but  quickly  passed  away 
with  repose.  Since  then  this  condition  has  remained  sub- 
stantially unchanged.  The  pain  is  usually  felt  first  in  the 
calf,  generally  that  of  the  left  leg  before  that  of  the  right,  and 
then  spreads  upward,  omitting  the  knees  and  centering  in 
the  neighborhood  of  the  hips.  The  patient  then  feels,  al- 
though a  man  of  great  resolution,  as  if  he  must  stop,  and 
that  if  he  went  on  his  joints  would  grow  rigid  and  he  could 
not  move.  After  a  rest,  or  on  waking  in  the  morning,  he 
feels  perfectly  fresh  and  "  as  well  as  ever  in  his  life."  Mental 
work  causes  no  fatigue,  and  he  is  singularly  free  from  neu- 
rasthenic symptoms  of  all  sorts.  The  treatment  consisted  cf 
galvanism,  which  was  carried  through  the  length  of  the  limb 
with  the  foot  resting  in  a  tub  of  warm  water.  Then  faradism 
was  used  in  a  similar  manner.  Finally,  a  deep  vessel  was 
obtained  so  that  the  legs  could  be  immersed  up  to  the  knees 
in  water,  and  this  was  charged  with  solutions  of  artificial 
Nauheim  salts  of  increasing  strength,  the  temperature  of  the 
water  being  at  the  same  time  lowered,  day  by  day,  or  week 
by  week.  G  !od  cutaneous  reactions  were  secured,  but  the 
mo-t  that  can  be  said  for  the  success  of  the  treatment  is  that 
the  patient  grew  no  worse  during  the  time  of  its  use.  The 
author  believes  that  a  vascular  spasm  is  perhaps  the  best 
explanation  of  the  pathology  of  the  disease,     [j.m.s.] 


Journal  of  the  American  Medical  Association. 

February  23,  1901.    [\o\.  xxvi,  No.  8.] 

1.  The  Bacterial  Toxins.    Victor  C.  Vaughn  and  Thomas  B. 

COOLEY. 

2.  Toe  True  Role  of  Drugs  in  the  Management  of  Consump- 

tion.    SOLOMOK  SOLIS  COHES. 

3.  The  Importance  of  an  Eu-ly  D.agnosis  of  Tuberculosis. 

A.  Mansfield  Holmes. 

4.  Three  Cases  illustrating  Cerebral  Complications  of  Otitis 

Media  Suppurativa.    Charles  W.  Richardson. 

5.  Suppurative  Tympano-Mastoiditis  in  Children.    Hbrmah 

Knapp. 

6.  Sjme  Observations  in  Mastoid  Operations.    A.  W.  Cal- 

houn. 

7.  Difi"erential  Diagnosis  between  Chickenpox  and  Smallpox. 

Herman  Spaldisq. 

8.  Misstatements  of  Antiviviseciion.    CorresDondence  with 

American  Humane  Association.    W.  W.  Kees. 

9.  Anastomosis  of  tie  Ureters  with  the  Intestine.    A  His- 

torical and  Experimental  Research.      Recbes  Pkkb- 
sos. 

1. — Vi>nphn  and  C  loley,  in  an  article  outlining  ihe  nature 
and  action  of  the  bacterial  toxins,  present  the  follow- 
ing theory :  Tnat  specific  poisons  constitute  a  part  of  bac- 
terial cells,  and  are  formed  within  the  microorganism  itself. 
They  also  state  that  the  pathogenic  principles  of  a  given  bac- 
terium are  dependent  upon  the  diffusibility  of  the  toxin,  the 
character  of  the  poison  in  the  cell,  and  the  permeabilitr  of 
the  cell  wall.  The  authors  mention  that  they  gained  little 
information  from  the  literature  upon  this  subject ;  they,  how- 
ever, refer  to  the  researches  of  Bachner  and  Pfeiffer.    The 


Ui.tcu2,  1901] 


THE  LATEST  LITERATURE 


rriiE  Philadelphia 
Medical  Journal 


421 


authors  have  carried  on  a  number  of  experimente  with  the 
bacillus  coli  communis,  and  have  reached  the  following  con- 
clusions :  The  colon  bacillus,  in  a  virulent  form,  contains  a 
toxin  within  the  cell.  This  poison  is  fatal  to  guineapigs, 
weighing  from  200  to  300  grams  in  the  dose  of  1  milligram. 
Aqueous  extracts  of  this  microorganism  grown  upon  agar 
are  inert.  The  bacillus  possesses  a  great  resistance  to  heat, 
dilute  acids,  and  alkalies.  Artificial  gastric  juice  will  digest 
the  cell-wall,  but  does  not  alter  the  toxin.  When  the  poison 
is  obtained  in  this  manner,  it  was  found  to  be  insoluble,  or 
but  slightly  soluble  in  dilute  acids,  but  more  readily  soluble 
in  dilute  alkalies,  and  slightly  soluble  in  water.  The  toxin 
gave  the  ordinary  proteid  reactions,  and  finally  it  was  found 
that  the  toxin  was  not  destroyed  by  boiling,     [f.j  k.] 

2. — In  an  article  on  the  management  of  consump- 
tives by  S.  SolisCohen  the  author  states  that  drugs  play  a 
secondary  part,  and  that  the  disease  is  curable  as  a  result  of 
the  natural  power  of  recovery.  He  carefully  outlines  the 
hygienic  management.  He  gives  the  progress  of  pulmonary 
tuberculosis,  dividing  the  disease  into  a  primary  stage,  a 
secondary  or  baoillary  stage  and  a  tertiary  stage.  In  the 
final  stage  various  microorganisms,  principally  streptococci 
and  staphylococci,  produce  degenerative  changes  and  mark- 
edly influence  and  modify  the  course  of  the  disease.  He 
mentions  the  important  drugs  which  are  to  be  used  as 
nervines,  digentants,  hematinics,  eliminants,  and  those  acting 
upon  the  circulation.  He  outlines  the  uses  of  the  iodine 
group,  and  the  creosote  group.  He  then  mentions  the  drugs 
which  influence  the  cough,  the  fever,  night-sweats,  diarrhea, 
outlines  the  treatment  of  hemorrhage  and  states  the  uses  of 
inhalants.  He  concludes  by  saying  that  hygienic  and  nutri- 
tional measures  are  to  be  preferred  to  the  use  of  drugs. 
[fjk.] 

3. — Holmes,  in  an  article  on  the  importance  of  early  diag- 
nosis of  tuberculosis,  classifies  the  disease  into  three  stages : 
(1)  The  pretubercular  stage,  which  is  associated  with  a  weak- 
ened state  of  the  system  and  therefore  furnishes  a  congenial 
soil  for  the  tubercle  bacillus;  (2)  the  stage  of  tubercular 
formation ;  and  (3)  the  stage  of  dettructive  tissue  changes. 

iThe  cog-wheel  respiration  he  believes  is  an  important  sign 
in  the  recognition  of  early  tuberculosis.  He  also  refers  to 
the  value  of  observing  the  temperature,  and  he  believes  that 
a  subnormal  temperature  is  one  of  the  earliest  signs.  The 
value  of  finding  the  bacillus  in  the  sputum,  from  the  stand- 
point of  diagnosis  and  future  treatment,  is  overestimated,  as 
It  only  appears  with  breaking  down  of  tissue.  The  tuberculin 
test  is  mentioned  as  being  of  value  in  the  early  stages  of  the 
disease,    [f.j  k  ] 

4.— Richardson's  first  case  is  one  of  sinus  throm- 
bosis in  a  man  60  years  of  age.  In  this  case  the  mastoid 
antrum  was  found  filled  with  a  rasty,  ofiensive  pus  which 
was  thoroughly  cleaned  out.  The  sinus  was  then  exposed 
throughout  its  whole  length  and  its  walls  found  to  be  gan- 
grenous. The  vessel  was  opened  and  found  filled  with 
broken  down  blood  clot  which  was  removed  until  circulation 
was  restored  from  above.  The  jugular  vein  was  then  expcsed 
in  the  neck  ;  it  was  collapsed  and  contained  some  organized 
blood  clot.  The  vessel  was  ligated  and  removed.  The  pa- 
tient was  in  an  intensely  septic  condition  before  operation 
and  died  of  sepsis  26  hours  after  operation.  The  second  case 
is  one  of  infective  thrombosis  in  a  man  aged  25.  This 
patient  had  all  the  symptoms  of  mastoid  disease  and  also  had 
a  cellulitis  of  the  cervical  tissues  below  the  mastoid.  The 
ordinary  mastoid  operation  greatly  relieved  this  condition,- 
the  patient's  temperature  became  normal  and  remained  so 
for  several  days.  In  about  2  weeks,  however,  the 
temperature  began  to  rise  and  pus  formation  showed 
itself  in  the  anterior  temporal  region.  This  was  freely 
liberated  by  incision,  the  pus  being  found  between 
the  temporal  fascia  and  the  periosteum  and  show- 
ing direct  communication  with  the  mastoid  cells.  At  one 
point  just  above  and  in  front  of  the  zyeoma  there  was 
a  carious  perforation  of  the  outer  table.  Upon  careful  ex- 
ploration of  this  condition  it  was  found  that  the  patient  was 
sufiering  from  a  decided  case  of  osteomyelitis,  the  probe 
passing  readily  for  some  distance  between  the  outer  and  inner 
tables  of  the  skull.  A  large  portion  of  the  outer  table  was 
removed.  The  patient  did  well  for  four  or  five  days  when  his 
temperature  again  rose,  due  to  a  collection  of  pus  in  the 
occipital  region,  but  subsided  again  upon  free  opening. 
About  a  week  later  ihe  patient  hid  sweat,  chill  and  a  rise  of 


temperature,  with  evidence  of  involvement  of  the  sigmoid 
sinus.  The  sinus  was  exposed,  found  to  be  filled  with  broken- 
down  clot  which  was  removf  d  until  a  return  circulation  was 
had  from  below,  but  no  return  circulation  could  be  obtained 
in  the  other  direction,  although  exploration  was  carried 
nearly  as  far  back  as  the  torcular.  The  patient  improved  a 
great  deal  after  this  operation,  the  temperature  falling,  his 
general  condition  appearing  better,  but  within  a  few  days 
symptoms  of  extension  of  the  infection  returned  and  the 
patient  died.  No  autopey  could  be  obtained.  Case  number 
three  is  that  of  a  man  aged  63  years,  who  had  suffered  for 
some  weeks  with  a  suppurating  ear  and  who  later 
developed  symptoms  of  cerebral  abscess  involving  the 
speech  center.  The  mastoid  cells  were  not  found  involved  at 
the  operation  and  an  exploration  of  the  temporosphen- 
oidal  lobe  through  a  trephine  opening,  made  one  inch  above 
the  external  auditory  meatus,  revealed  no  abscess,  although 
it  was  felt  sure  at  the  time  of  the  operation  that  such  was 
present.  The  patient  died  and  at  the  postmortem  a  small 
abscess  about  the  size  of  a  hickory  nut  was  discovered  on  the 
mesial  side  of  the  uncimate  convolution.  Richardson  thinks 
that  in  his  exploration  the  probe  must  have  passed  through 
this  abscess  cavity,  but  that  the  pus  was  too  thick  to  flow. 
In  cases  of  sigmoid  thrombosis  prompt  operation  is 
urged  as  soon  as  ttie  diagnosis  is  made.  Richardson  urges 
the  careful  consideration  by  the  general  practitioner  of 
symptoms  indicative  of  extension  of  the  disease  to  the  sinus. 
The  occurrence  of  a  chill,  a  high  temperature  and  a  sweat 
are  symptoms  of  extreme  gravity  and  should  suggest  in- 
volvement of  the  sinus.  In  operations  for  this  condition  he 
thinks  that  ligation  of  the  jugular  vein  should  be  done,  even 
though  a  return  circulation  may  be  had.  Richardson  thinks 
that  one  of  the  early  symptoms  of  cerebral  abscess  from 
disease  of  the  ear  is  an  alteration  in  the  general  demeanor 
of  the  patient,  such  as  irritability,  moroseness  and  attacks 
of  semihysteria.  To  these  should  be  added  also  some  form 
of  aphasia,     [j  h  c] 

6.— Knapp  shows  the  most  frequent  age  for  suppura- 
tive tympanomastoiditis  to  be  the  early  years  of  life, 
particularly  ttie  first  year.  He  gives  as  a  cause  for  this  the 
short  and  patulous  eustachian  tube  at  this  age,  and  the  fact  of 
the  great  prevalence  of  diseases,  particularly  adenoids,  in 
the  nasopharynx  of  children.  Tne  short  and  patulous  tube 
also  explains  the  quick  and  permanent  disappearance  of 
abscesses  of  the  middle  ear  in  children.  In  operations  upon 
the  mastoids  of  children  it  is  recommended  that  the  incision 
be  made  carefully,  and  layer  by  layer,  because  of  the  soft 
condition  of  the  bone  at  this  age.     [j.h  g  ] 

6.— Calhoun  discusses  disease  of  the  mastoid  cell* 
as  it  occurs  in  the  South.  He  does  not  think  that  middle 
ear  suppurations  are  as  prevalent  in  the  South  as  in  the 
colder  climates.  Daring  the  past  winter  he  has  observed  the 
disease  to  be  of  a  mild  type  and  unusually  free  from  cerebral 
and  other  complications.  He  has  found  it  as  frequent  in 
adults  as  in  children,  but  very  seldom  in  the  negro  race.  He 
also  calls  attention  to  the  possibility  of  serious  mastoid  dis- 
ease without  marked  outward  symptoms,  and  also  to  the 
occasional  occurrence  of  mastoid  disease  without  apparent 
middle  ear  involvement.  He  has  not  found  it  necessary  in 
the  treatment  of  these  caaes  to  pursue  the  radical  measures 
of  Stacke.     [j.h  g.] 

7.— In  an  article  bv  Spalding  the  differential  diagno- 
sis between  chickenpox  and  smallpox  is  given» 
The  author  states  that  he  has  seen  a  numoer  of  cases  of 
chickenpox  in  adults  and  he  gives  the  report  of  a  case  which 
occurred  in  a  male  22  years  of  age.  The  eruption  in  this 
case  appeared  first  on  the  body  and  then  on  the  face,  hjnbs 
and  hands.  There  were  no  prodromal  symptoms.  The 
eruption  consisted  of  vesicles  which  later  developed  into 
pustules  or  dried  scabs.  The  eruption  was  very  superficial. 
He  mentions  that  the  most  experienced  diagnostician  may 
sometimes  be  puzzled  in  the  diagnosis  of  varicella  from 
variola.  There  appear  3  illustrations  showing  the  character 
of  the  eruption  in  chickenpox,  also  3  showing  the  erup- 
tion in  smallpox.  He  believes  that  the  eruption  in  smallpox 
always  involves  the  cutis  vera,  while  in  chickenpox  the  lesion 
involves  only  the  outer  layer  of  the  skin.  He  emphasizes  the 
importance  of  the  prodromes  which  occur  even  in  the  mild- 
est cases  of  variola,  and  they  are  absent  in  varicella.  1  i^J^J 
8,— See  Philadei^phia  MEDirAL  Journal,  Feb.  23, 1901. 
9.— To  be  treated  editorially  later. 


422 


Thb  Philadelphia"] 

ilKDlCAL  JOUBNAL  J 


THE  LATEST  LITERATURE 


(Masch  2,  1901- 


Annals  of  Surgery. 

January  1,  1901.     [Vol.  xxxiii,  No.  1.] 
1.  Ventral  Hernia  Following  Abdominal  Section.    B.  Bbikd- 

LEY  EaD3. 

■2.  On  Traumatic  Keloid  of  the  Mf  dian  Nerve,  with  Observa- 
tions upon  Absorption  of  Silk  Sutures.    Otto  G.  I. 

KiLIANI. 

S.  An  Intestine  Holder.      Devised  for  Facilitating  the  Ead- 
t>E:jd  Suture  of  Intestine.     Edwaed  H.  Lee. 

4.  Laryngectomy  under  Eucaine  Anesthesia,  with  Remarks 

on  the  Technic  of  the  Operation.      Gwilym  G  Davis. 

5.  Double   Ureter.    Report  of  a   Nephrectomy  Done  upon 

a  Young  Child  with  this  Condition  Present.    John 
Edward  Scmalebs,  Je. 

1. — In  ventral  hernia  following  abdominal  section  Eada 
thinks  that  at  least  \bfc  of  all  cases  of  laparotomy  if  ex- 
amined five  or  more  years  afterward  will  present  evidences 
of  hernia,  Coley  has  pointed  out  that  relapses  after  operation 
for  ventral  hernia  take  place  in  more  than  one  half  of  the 
cases.  Eads  discusses  the  anatorr>y  of  the  abdominal  wall  in 
detail,  laying  particular  stress  upon  the  nerve-supply  of  the 
muscles.  If  a  nerve  supplying  muscle  is  severed  the  muscle 
loses  its  contractility,  it  becomes  wasted  and  weakened  and 
the  intraabdominal  pressure  produces  stretching,  and  finally 
hernia.  Close  suturing  and  accurate  approximate  of  like 
structures  will  not  prevent  this,  nor  will  prulonged  stay  in 
bed.  "Intact,  innervated  muscular  fiber  is  the  only  safe- 
guard against  hernia."  He  urges  that  all  muscular  section 
should  be  made  parallel  with  the  nerves  if  possible.  The 
vertical  incision  over  the  rectus  with  separalioa  of  the  mus- 
cular fibers,  so  highly  recommended,  is  a  failure  because  the 
inner  portion  of  the  muscle  is  deprived  of  its  motor  nerve- 
supply.  Incision  to  the  left  of  the  rectus  muscle  parallel  to 
and  a  little  below  the  costal  arch  gives  ready  access  to  the 
cardiac  end  of  the  stomach  and  permits  a  separation  of  the 
fibers  of  the  internal  oblique  and  of  the  motor  nerves,  be- 
sides giving  a  sphincteric  action  to  the  wound.  The  great 
advantage  of  the  McBjrney  incision  for  appendicitis  is  that 
it  permits  the  separation  of  the  nerve  fibers  instead  of  their 
■division.  The  author  suggests  a  lower  incision  than  that  of 
McBurney,  slightly  concave  with  the  concavity  upwards. 
Incision  in  the  linea  seaiilunaris  is  condemned  because  of 
the  resulting  paralysis  from  the  divisi  m  of  the  nerves  sup- 
plying the  rectus.  An  incision  through  the  rectus  is  but 
little  better.  In  making  an  incision  in  the  median  line  he 
insists  that  it  shall  be  accurately  placed  between  the  two 
recti  muscles.  Incision  through  the  umbilicus  shouM  be 
carried  to  the  left  in  order  to  avoid  the  suspensory  ligament 
of  the  liver.  In  discussing  the  treatment  of  ventral  hernia 
he  says  it  is  necessary  to  excise  the  redundant  and  atrophic 
tissues,  bringing  into  the  wound-area  as  much  muscular  fiber 
as  possible,     [j  h.g  ] 

2.— Kiliani  reports  a  case  of  division  of  the  median 
nerre  by  glass.  The  nerve  was  suturtd  3  or  4  weeks  after 
the  accident,  small  bulbi  being  excised  from  the  distal  and 
central  end.  The  wound  did  not  he.al  primarily,  and  there 
was  no  improvement  in  symptoms.  Six  weeks  later,  when 
he  first  saw  the  case,  a  good-sized  neurofibroma  was  found 
which  interrupted  completely  the  conduction  of  the  nerve. 
Tne  tumor  was  again  excised,  nerve  ends  sutured  with  cat- 
gut, primary  union  followed  with  immediate  restoration  of 
sensation,  and  very  soon  that  of  power.  Three  months  after 
this  operation  the  scar  on  the  skin  showed  a  keloid,  and  a 
email  tumor  was  felt  in  the  nerve.  O.ie  vear  after  the  oper- 
ation the  tumor  had  disaipeared  and  the  "hand  was  useful  for 
all  practical  purposes.  Kiliani  has  been  unable  to  find  a  case 
cited  where  neurofibroma  with  no  indication  of  sircomatous 
degeneration  had  occurred  after  extirpation.  He  believes 
the  growth  of  the  nerve  can  be  properlv  called  a  keloid.  At 
the  second  operation  he  found  the  silk  suture  employed  at 
the  first  operation  undergoing  absorption  as  is  shown  by  the 
microscopic  sections  which  illustrate  his  article,    [j  h  g.'] 

3,— Lee  describes  and  illustrates  the  use  of  a  new  intestinal 
anastomosis  appliance.  It  is  a  metal  instrument  avijasted 
to  ht  any  size  of  intestine,  and  when  the  anastomosis  is  com- 
pleted it  is  made  to  fold  upon  itself  and  can  be  withdrawn 
through  a  very  small  opening.  Tne  illustrations  explain  its 
«se.     [j  H.O.] 

4.— Davis  reports  the  case  of  a  man,  46  years  of  age,  suflfer- 


ing  from  a  carcinoma  of  the  larynx,  with  no  glandular 
involvement  and  in  which  he  performed  a  total  laryngec- 
tomy with  eacain  anesthesia.  No  preliminary  trache- 
otomy was  done.  Tne  patient  but  once  winced  with  pain 
and  then  when  the  superior  laryngeal  nerves  were  divided. 
The  growth  caused  considerable  stenosis  and  respiration  was 
diffisult.  The  trachea  was  divided  and  brought  forward,  and 
then  the  larynx  removed  by  careful  dissection  and  the 
wound  closed  without  drainage.  Patient  had  no  shock. 
Seventy  five  minims  of  a  1%  solution  of  eucain  B  were  used 
during  the  operation.  Oa  the  third  day  patient  could  speak 
in  a  whisper  and  was  able  to  swallow  small  amounts  of 
liquid.  His  temperature  rose,  he  had  considerable  cough, 
and  he  died  on  the  sixth  day.  Postmortem  examination 
showed  intense  congestion  of  tracheal  and  bronchial  mucous 
membrane  as  well  as  of  kidneys,  liver,  and  spleen.  The 
wound  above  trachea  healed  primarily.  About  the  tracheal 
opening  were  a  few  drops  of  pus.  Streptococcus  growths 
were  obtained  from  the  various  organs.  Davis  thinks  the 
main  objection  to  local  anesthesia  is  that  it  prolongs  the 
operation.  The  Trendelenburg  position  was  not  found 
necessary  in  the  operation.  The  subsequent  coughing  pro- 
duced considerable  irritation  about  the  tracheal  opening  and 
necessitated  the  cutting  of  some  of  the  sutures.  Divis  thinks 
this  a  great  objection  to  the  mode  of  operating,  and  attributes 
to  it  the  infection  in  his  case.  He  agrees  with  Delaven  that 
preliminary  tracheotomy  is  a  better  procedure.  He  thinks 
the  leaving  of  an  esophageal  tube  in  the  wound  is  probably 
unnecessary,  and  that  the  upper  wound  can  be  completely 
closed     [j.H  G  ] 

5. — Summers  discusses  first  the  several  varieties  of  an- 
omalous ureters  and  then  reports  the  following  case :  A 
child,  aged  2*  years,  suffered  from  a  tumor  of  left  kidney, 
which  c  )uld  be  easily  palpated.  The  urine  contained 
tubercle  bacilli.  Nephrectomy  was  done,  and  it  was  found 
that  the  organ  possessed  two  ureters,  proceeding  from  sepa- 
rate pelves.  Tne  upper  tube  was  the  larger,  and  the  seU  of 
tubercular  disease,  while  the  lower  and  smaller  was  normal. 
He  thinks  that  the  ureters  opened  into  the  bladder  separately, 
or  else  both  would  have  been  diseased.  The  patient  recovered 
from  operation,  and  when  last  heard  from  was  in  good  con- 
dition. He  remarks  on  the  difficulty  of  using  a  segregator 
in  ureteral  catheterization  in  such  a  case,    [j  h.g  ] 


Scottish  Medical  and  Surgical  Journal. 

February,  1901.     [Vol.  viii.  No.  2.] 

1.  The  Relation  of  Dentistry  to  Medical  Education.    W.  H. 

Williamson". 
2. -The  PfOgnofis  and    Treatment  of  Pulmonary  Phthisis. 

Alexander  James 

3.  A  Short  N  )te  on  Bilharzia  Hematobia,  with  Reports  of 

Turee  Cases.    David  Wallace. 

4.  The  Bacillus  Coli  Communis  in  Relation  to  Cystitis.   Kks- 

NBTH  M.  DouGi-ts. 

5.  A  Curious  Case  of  Disordered  Cerebral  Circulation.   PHmr 

G.  BOBROWMAX. 

6.  A  Cjse  of  Pseudohypertrophic  Muscular  Paralysis.    Geo. 

Rose. 

7.  A  Clinical  Note  on  a  Cise  of  Eclampsia  at  the  Sixth 

Month.    Michael  Dewar. 

1.— E^ery  practitioner  of  medicine  must  have  some 
dental  knowledge.  For  in  spite  of  the  fact  that  there 
are  specialists  for  each  separate  part  of  the  body,  every 
physician  should  know  the  correlation  of  the  ditlerent  parts, 
no  matter  what  specialty  he  practises.  Epecially  since  the 
development  of  bacteriology,  di  we  realize  how  splendid  an 
ini-ub.ator  the  mouth  makes.  Even  malignant  endocarditis 
may  come  from  defective  teeth.  Wi'liamson  suggests  a 
short  dental  course  for  medical  students.  The  student  should 
be  taught  how  to  examine  the  teeth,  to  find  cause  for  neu- 
ralgia. To  show  the  la-k  of  this  knowledge  in  older  physi- 
cians, he  reports  a  number  of  cases.  The  student  should  also 
be  able  to  recognize  the  milk  t*eth.  and  to  differentiate  them 
from  the  permanent  teeth.  He  should,  besides,  know  enough 
to  advise  a  visit  to  the  dentist  when  necessary;  or  to  say 
whether  a  tooth  should  be  extracted  or  not.  To  help  to 
make  this  clear  to  students.  Williams  m  suggests  the  use  of 
dental  models  in  the  dissecting  room.    Besides,  every  stu- 


Maech  2,  1901] 


THE  LATEST  LITERATURE 


fTHK  Philadelphia 
L  Medical  Jocenal 


423 


dent  should  have  practical  experience  in  extracting  teeth, 
and  a  knowledge  of  the  correct  instrument  to  be  used  in 
every  case.  And  the  students  should  know  how  to  admin- 
ister nitrous  oxid  gas.  With  such  an  education  the  result 
■wilj  be  a  hearty  cooperation  between  dentist  and  doctor,  fol- 
lowed by  the  amelioration,  or,  better  still,  the  prevention  of 
dental  decay,     [m.o  ] 

2. — lu  this  article  James  discusses  the  prognosis  and 
treatment  of  phthisis.  The  prognosis  depends  upon  5 
things :  Toe  family  history,  not  only  the  occurrence  of 
tuberculosis,  but  also  of  other  constitutional  diseases ;  the 
conditions  which  have  led  to  the  development  of  the  disease; 
the  general  condition  of  the  patient;  the  amount  of  lung 
tissue  involved  ;  and  the  complications,  such  as  laryngeal 
or  enteric  tuberculosis,  etc.  The  main  object  in  the  treatment 
is  to  put  the  patient  far  from  civilizition,  where  air  is  pure, 
where  freedom  of  movement,  of  body,  and  of  lungs  is  abso- 
lute, where  sunlight  is  abundant.  Yet  those  with  very  ex- 
tensive lung  disease,  those  with  very  slight  recuperative 
power,  and  those  who  cannot  leave  home,  will  not  be 
benefited  by  this  primitive  living.  For  these  James  advises 
the  sanatorium  as  the  best  place  for  treatment,  at  least  until 
the  patient  has  learned  how  he  should  live.  The  correct  food, 
cold  bathing,  menthol,  or  codein  for  the  cough,  morphin  for 
hemoptysis,  quinin,  antipyrin,  etc.,  and  ice  for  the  fever,  and 
cod-liver  oil,  form  the  most  necessary  modes  of  treatment. 
[m.o  ] 

3. — Wallace  reports  3  cases  of  this  rare  aflfection.  The 
first  case,  a  man  of  21,  went  to  South  A'rica  4  years  ago. 
Two  years  later  he  had  hematuria  which  has  continued 
since.  Treatment  has  been  of  no  avail.  The  second  case,  a 
South  African  of  21  years,  too,  had  had  hematuria  for  9 
years.  He  relates  that  all  the  boys  at  school  passed  red 
urine.  At  15  he  had  renal  colic.  Upon  diluents  and  salol, 
he  improved.  The  third  case  was  a  native  of  Natal,  also  21. 
He  had  no  symptoms  but  hematuria.  In  all  3  oases,  ova 
of  the  bilharzia  hematobia  were  found  in  the  clots  in 
the  urine.  They  were  absent  when  the  urine  was  clear. 
Only  youths  and  young  adults  were  affected.  Salol  alone 
seems  to  do  good.     [m.o. J 

4. — A.fter  a  review  of  the  literature,  Djuglas  sets  forth  the 
method  pursued  by  him  in  investigUins;  cystitis.  Cultures 
were  made  at  once,  either  after  catheterization  with  a  steril- 
ized catheter,  or  from  the  last  urine  to  flow,  collected  in  a 
sterilized  test-tube.  Of  the  20  cases  of  cystitis  examined, 
only  3  occurred  in  women.  Pure  cultures  of  the  bacillus 
coli  communis  were  obtained  in  12  cases,  associated  with 
other  microbes  in  2  cases.  In  3  cases  the  staphylococcus 
grew  alone,  in  2  cases  the  tubercle  baciHus  alone.  Afier  a 
description  of  his  experiments  upon  animals  and  an  account 
of  the  characteristics  of  these  colon  bacilli,  he  concludes  that 
the  bacillus  coli  communis  is  met  with  in  the  great  bulk  of 
casea  of  cystitis,  and  is  apparently  the  cause  of  the  disease; 
that  the  microorganism  may  be  present  in  the  bladder  for 
long  periods  of  time  without  causing  cystitis ;  that  it  may 
supplant  other  microbes,  rather  than  be  the  initiating  cause 
of  the  cystitis;  that  its  marked  polymorphism  and  patho- 
genicity account  for  the  conflicting  opinions  regarding  its 
identity  and  i6!e  in  cystitis,  and  that  no  one  reaction  enables 
it  to  be  certainly  recognized,  but  that  cultivation  upon  several 
media  is  needful,     [m  c] 

6.— Bjrrowman  reports  the  case  of  a  boy,  aged  9  years, 
who  had  measles  and  pertussis  a  year  previous.  With  other 
boys  he  had  for  some  weeks  practised  standing  upon  his 
head,  in  which  position  he  could  stay  about  a  half  hour. 
Headache  and  vomiting  occurred,  followed  by  6  weeks  of 
almost  constant  sleeping.  Whenever  he  tried  to  sit  up,  he 
felt  tired,  and  lay  down  at  once.  The  muscles  of  the  arms 
and  legs  had  wasted  considerably.  His  heart's  action  was 
very  feeble.  Under  digitalis  he  improved  immediately,  and 
recovered  wholly  in  four  weeks.  Borrowman  considers  the 
condition  due  to  passive  congestion  from  the  inverted  posi- 
tion, and  not  to  tubercular  meningitis,  the  only  other  pos- 
sible explanation  of  this  strange  case,     [m  c] 

6. — After  a  short  exposition  of  the  Bubjeit,  Rise  reports  a 
case  of  pseudohypertrophic  muscular  paralysis,  in 
a  boy  of  9J  years.  Tivo  years  ago  he  began  to  be  lazy. 
Then  he  had  difficulty  in  rising,  and  soon  became  helpless. 
Lordosis  was  marked  when  he  attempted  to  stand,  and  he 
could  not  stand  alone,  even  with  his  feet  wide  apart.  His 
jinethod  of  rising  from  the  floor    is   beautifully  shown   by 


photographs.  There  were  great  muscular  weakness;  enlarge- 
ment of  the  muscles  of  the  calf,  etc.,  with  wasting  of  the 
muscles  of  the  trunk,  etc. ;  loss  of  the  knefjerk,  with  diminu- 
tion of  other  reflexes,  and  hyperesthesia  to  pain.  Sections 
of  the  biceps  and  gastrocnemius  ehow  a  great  increase  in  the 
connective  tissue,  while  the  muscle  fibers  appear  to  be  com- 
paratively healthy,     [m-c] 

7. — Dewar  reports  a  ciiee  of  eclampsia  in  a  woman  aged 
28,  in  whom  convulsions  occurred  without  warning,  at  the 
sixth  month  of  pregnancy.  Ten  convulsions  occurred.  There 
was  no  albumin  in  the  urine.  Four  days  later  she  had  7 
more  convulsions,  and  albumin  was  found  in  the  urine. 
Three  more  convulsions  followed  4  days  later.  Chloral  and 
the  bromids  were  given.  Edema  and  varicose  veins  existed 
in  both  legs.  Three  months  later  the  baby  was  born  at  term 
in  excellent  condition.  At  this  time  albumin  was  absent 
from  the  urine.  As  there  was  no  cause  or  suspicion  of  epi- 
lepsy, he  believes  the  case  to  have  been  true  puerperal 
eclampsia,     [mo.] 


Berliner  klinische  Wochenschrift. 

January  U,  1901.     [38.  Jahrg.,  No.  2.] 

1.  Diphtheria.    Th.  Escherich. 

2.  Gallstones.    Riedel. 

3.  The  X  rays  in  Practical  Medicine.    H.  KCmmell. 

4.  The  Modern  Efforts  at  C  ^Ionization  and  the  Adaptability 

of  Europeans  to  the  Tropics.    F.  Hueppe. 

5.  Concerning  Saccussion  of  the  Kidneys.    S.  Goldflam. 

1. — The  author  extensively  reviews  the  history  of  diph- 
theria from  the  time  of  Aretseus  and  Aeitus  to  the  present 
ceutury.  E  ich  epoch  of  diphtheria  is  considered  and, 
especially,  the  researches  of  Bretonneau.  The  facts  upon 
which  the  etiological  significance  of  the  diphtheria  bacillus 
is  based,  are  the  following  :  1.  The  constant  presence  and 
the  great  quantity  of  bacilli  in  all  true  cases  of  diphtheria 
(Bretonneau).  2.  The  absence  of  the  bacillus  on  the  mucous 
membrane  of  healthy  individuals.  3.  The  specific  pathogenic 
influence  upon  animals.  4.  The  production  of  the  char- 
acteristic paralysis  caused  by  the  toxin  of  the  bacillus.  The 
older  authors  seem  to  have  neglected  the  toxic  efl'ect  of  diph- 
theria upon  the  circulatory  apparatus.  Of  great  historical 
note  is  that  epoch  in  medicine  during  which  the  character- 
istic symptoms  of  diphtheritic  nephritis,  its  pathological 
anatomy,  and  the  degenerative  changes  in  the  peripheral 
and  central  nervous  system  as  well  as  in  the  muscles  were 
established.  Tne  greatest  transformation,  however,  took  place 
in  the  therapy  of  diphtheria.  The  results  obtained  in  the 
past  6  years  show  the  astounding  reduction  of  mortality  due 
to  the  introduction  of  antitoxin,    [m  r.d.] 

2.— Will  be  abstracted  when  completed. 

3.— Kiijimell  describes  the  value  of  the  x-rays  in 
practical  medicine.  Iq  addition  to  their  value  for  the  detec- 
tion of  foreign  bodi?8  they  have  become  of  special  service  in 
military  surgery.  Pathological  dilatation  of  the  esophagus 
and  stomach  may  be  detected  by  the  Ro  atgen  rays.  B  jth  dila- 
tation and  stenosis  may  be  made  apparent  by  inserting  into 
the  organ  either  in  bulk  or  in  gelatine  capsules  some  metal 
salt  like  bismuth,  which  on  account  of  its  impermeability  to 
the  x-rays  reveals  the  existing  conditions.  Sounds  may  be 
also  emp'oyed  in  connection  with  the  x-rays  in  dilatation 
of  the  esophagis,  as  well  as  in  gastric  dilatation  if  the 
sound  lies  against  the  wall  of  the  esophagus  or  the 
greater  curvature.  Foreign  bodies  in  the  intestinal  tract 
may  also  be  located  by  means  of  the  x-rays  as  well 
as  Murphy  buttons  and  foreign  bodies  introduced  for 
therapeutic  purposes.  The  x  rays  are  of  value  when 
there  are  suspected  pathological  concretions,  although 
up  to  the  present  time  gallstones  have  been  detected 
but  twice  by  this  means.  Vesical  calculi  can  gen- 
erally be  easily  detected  by  the  x-rays.  Tiie  facility  with 
which  these  foreign  bodies  can  be  detected  varies  according 
to  the  chemical  constituency  of  the  concretion.  Concre- 
tions composed  of  urates  and  oxalates  are  less  translucent 
than  phosphatio  calculi.  Both  incrustated  as  well  ««  non- 
incrustated  bodie»,  hairpins,  etc.,  are  easily  demonstrable  by 
means  of  the  Ro  itgen  rays.  Considerable  progress  in  t.ie 
detection  of  renal  calculi  has  also  been  made,  and  ^lere 
also  the  thickness  of  the  soft  parts  as  well  as  the  translu- 


424 


The  Philadelphia"! 
Medical  Joubnal  J 


THE  LATEST  LITERATURE 


[Mabce  2,  um 


cency  of  the  concretion  renders  its  detection  more  or  less 
difficult.  The  triumphatt  success  of  the  x-rays  in  medi- 
cine is  well  known  to  have  been  due  to  the  detection  of 
fractures,  luxations,  and  diseases  of  bone.  Eijntxen- 
rays  have  been  of  great  value  in  diagnosing  and  treating 
congenital  luxations  of  the  hip.  The  differential  diagnosis 
between  cor  genital  luxstion  and  coxa  vara  is  presented  In 
an  interestirg  manner  by  the  x-rays.  Syphilitic,  tubercu- 
lous and  osteomyelitic  thickening  and  deposits  in  the 
large  and  small  long  bones  are  not  difficult  to  recognize 
by  means  of  the  x-rays,  and  it  is  interesting  to  observe 
how  under  treatment  a  tibia  that  before  medication 
appeared  as  a  narrow  shadow  upon  the  radiograph,  grad- 
ually increases  in  volume.  Similarly,  small  pathological 
changes,  such  as  tuberculous  deposits,  may  also  be  diag 
nosed.  Among  the  tumor- formations  large,  broad  osteosar- 
comata  are  characteristically  portrayed  by  the  x-rays.  Noth- 
ing of  account  has  yet  been  attained  in  detecting  other 
tumors  of  the  body  by  this  means,  as  the  contrast  of  in- 
dividual tissues  is  not  tuflficient  to  be  of  diagnostic  value  ex- 
ternally. The  shadows  of  the  liver  and  kidney  as  well  as  the 
convolutions  of  the  fetal  gut  may  be  plainly  seen,  but  less  so 
in  the  adult.  Fecal  masses  are  easily  recognized.  Chemical 
substances  introduced  from  without  for  therapeutic  or  diag- 
nostic purposes,  especially  the  iodine  compounds,  can  also  be 
plainly  seen.  Iodoform- glycerin  injected  into  tuberculous 
joints  remains  there  for  a  long  time  and  is  absorbed  slowly. 
Here  the  Koatgen  picture  teaches  us  that  it  is  not  necessary 
to  leave  a  great  amount  of  this  mixture  in  a  joint,  as  small 
quantities  being  also  slowly  absorbed,  fully  meet  the  thera- 
peutic requirements.  Iodoform  glycerin  injected  into  fistulous 
tracts  is  of  diagnostic  value  in  that  it  penetrates  to  the  bone 
and  permeates  extensive  sinuses.  Characteristic  results  have 
been  oHtained  in  the  recognition  of  myositis  ossificans. 
Arteriosclerotic  changes  in  the  bloodvessels  yield  very 
plain  x-ray  pictures.  Considerable  progress  has  been  made 
in  observing  the  intrathoracic  changes.  The  author  states 
that  the  dilated  lungs  of  emphysema,  and  the  lungs  in  pleurisy 
and  empyema  were  plainly  seen  by  the  x-rays  acd  a 
pneumothorax  which  clinically  could  not  be  established  with 
certainty  was  diagnosed  without  a  doubt  by  means  of  the 
Eouigen  picture.  Lung  cavities  are  easily  detected.  Peri- 
bronchial changes  appear  as  sharply  defined  nodules  of 
variable  size.  The  shadows  of  the  heart,  aorta,  and  aneurysms 
as  well  as  mediastinal  tumors  have  repeatedly  been  em- 
ployed for  diagnostic  purposes.  The  employment  of  the 
x-rays  for  therapeutic  purposes  has  yielded  excellent  results 
in  the  treatment  of  lupus.  It  is  to  the  treatment  of  skin 
diseases  that  the  therapeutic  efficiency  of  the  x  rays  has  been 
principally  confined.  Other  skin  diseases  that  have  been 
successfully  treated  by  this  means  are  chronic  eczema, 
vascular  nevus,  hypertrichosis,  favus,  and  sycosis.  Consider- 
able has  been  attained  since  5  years  by  this  epoch-making 
discovery  of  Rontgen,  but  much  more  will  be  required 
during  the  present  century,    [m.r.d  ] 

5.— Goldflam  in  addition  to  bimanual  examination  and 
ballottement  also  employs  the  following  method  :  While  the 
patient  stands  with  the  body  bent  forward  and  exposed,  the 
examiner  places  the  ulnar  side  of  the  clenched  fist  against 
the  lumbar  region  and  performs  a  series  of  mild  thrusts, 
which  in  the  healthy  individual  are  absolutely  painless  but 
which  give  rise  to  pain  of  more  or  less  intensity  in  certain 
renal  affections.  In  nephritis  there  is  no  pain,  but  on  the 
other  hand  there  is  in  nephrolithiasis,  pyelitis,  tuberculosis, 
abscess,  tumors  of  the  kidney,  in  short  all  those  conditions 
which  require  surgical  treatment.  The  author  states  that  he 
considers  this  method  of  procedure  of  use,  but  only  as  an 
accessory  to  the  other  important  methods  of  examination. 
[m.bd.] 

Deutsche  mediciuiscbe  Wochenschrift. 

January  17,  1901.     [27.  Jabrg.,  No.  3.] 

1.  Remarks  on  Tuberculosis  of  the  Female  Genitals  and 

Peritoneum.    A.  Sippel. 

2.  Vaginal  and  Abdominal  Section  in  Tubercular  Peritonitis. 

G.  Baumqart. 

3.  A  Case  of  Hydrocephalus  with  Recovery.    H.  Neumann. 

4.  A  New  Sensitive  Test  for  Sugar.     E.  Rieolar. 

6.  Contribution  to  the  Study  of  the  Renal  Function.    L.  Lip- 

MAN-WULF. 


3. — Neumann  reports  the  case  of  a  child  5  months  old  that 
was  brought  to  the  clinic  with  marked  hydrocephalus.  The 
increase  in  the  size  of  the  head  had  apparently  occurred 
chiefly  within  3  weeks.  There  was  a  distinct  history  of 
syphilis.  It  was  therefore  a  very  satisfactory  case  for  treat- 
meet,  both  because  it  was  syphilitic  and  because  the  hydro- 
cephalus was  of  very  recent  occurrence.  It  was  put  upon 
potassium  iodid  in  large  doses  (taking  in  9  months  nearly 
2J  ounces).  There  was  rapid  improvement  after  the  first  few 
days  of  treatment,  and  the  improvement  continued.  At  the 
end  of  9  months  the  child  seemed  practically  well.  Some- 
what over  a  year  after  the  treatment  was  begun  it  waa 
reported  that  the  child's  general  development,  both  physical 
and  psychic,  seemed  perfectly  normal,  and  the  head  showed 
no  abnormalities,     [d.l  E.] 

4. — The  teat  recommended  is  to  take  about  20  drops  of 
urine  in  a  test  tube,  add  a  small  amount  (about  j',;  gram)  of 
pure  hydrochlorid  of  phenylhydrazln,  about  J  gram  of  crys- 
tallizsd  sodium  aceta'e,  2  cc.  of  water.  Heat  over  a  flame 
ur-til  it  boils,  then  adi  10  cc.  of  a  10%  sodium  hydrate  solu- 
tion, inverting  the  tube  five  or  six  times  and  standing  aside. 
After  a  few  seconds  there  should  be  a  striking  reddish  violet 
color.  The  color  should  be  looked  for  by  holding  the  test 
tube  up  to  the  light  and  the  whole  flaid  should  be  colored, 
not  merely  the  deposit  upon  the  bottom  of  the  tube.  It  la 
essential  that  the  color  should  appear  within  5  minutes,  as 
some  color  is  seen  in  normal  urines  after  a  longer  time. 
[d  l.e,] 

6. — Lipman-Wulf  makes  some  rather  desultory  remarks 
concerning  his  work  with  methylene- blue  as  an  index  to  the 
functional  activity  of  the  kidneys.  He  tested  various  ani- 
mals with  methylene-blue  and  found  that  the  excretion  be- 
gan within  J  hour  to  6  hours,  and  lasted  from  24  to  52 
hours,  and  in  one  case  even  KX)  hours.  There  was  no  definite 
relation  between  the  excretion  of  the  dye  itself  and  of  the 
chromogen.  With  compensatory  hy  pertrophy  of  one  kidney 
it  was  evident  that  the  excretion  began  very  rapidly.  In  a 
woman,  from  whom  one  kidney  had  been  removed,  he  found 
that  the  dye  appeared  in  the  urine  during  the  first  half  hour, 
and  the  excretion  lasted  for  96  hours.  As  to  the  conditions 
in  nephritis.  Bard  has  stated  that  there  are  two  varieties  of 
disturbance.  In  one,  with  interstitial  nephritis,  the  dye  is 
slowly  excreted,  while  in  parenchymatous  nephritis  the  dye 
pafses  abnormally  readily.  Lipman-Walf  made  some  ex- 
periments upon  animals  chiefly  by  the  injection  of  can- 
tharidin  and  other  kidney  poisons,  and  found  that  the  dye 
was  rather  rapidly  excreted,  but  that  chromogen  was  still 
found  in  the  urine  as  long  as  70  hours  after  the  injection, 
and  in  some  cases  the  dye  it^^elf  was  not  ex  jreted  as  rapidly 
as  is  normal.  These  results  did  not,  therefore,  confirm  the 
statements  of  Bird.  It  is  quite  possible  that  there  are  cer- 
tain portions  of  the  kidney  parenchyma  which  have  the 
specific  function  of  excreting  the  coloring  matter,  and  that, 
therefore,  disease  of  these  portions  of  the  kidney  will  cause 
characteristic  changes  in  the  excretion.  He  attempted  to 
determine  some  characteristic  functions  of  various  portions 
of  the  kidney  by  administering  mixtures  of  dyes,  and  then 
observing  the  color  seen  in  subsequent  sections  of  the  kid- 
ney, but  had  no  satisfactory  result*.  He  thinks  that  this 
method  may,  however,  lead  to  better  results  through  its  more 
extensive  use.    [d  l.e  ] 

January  S4,  1901.     [27.  Jabrg.,  No.  4  ] 

1.  Instruction  in  the  History  of  Medicine  and  the  Modem 

S  heme  of  Medi -al  Examination.    E  Braatz. 

2.  A  New  Form  of  Hemoglobinuria.    L.  MirHAEUs, 

3.  A  Csse  of  B^nce  Jones  Albuminuria  in  Myeloma  of  the 

R'bs.    Kalischer. 

4.  Lieation  of  the  Irjured  Coronary  Artery.    Paoenstecher, 

5.  A  Method  for  Simultaneously  Staining  Dried  Blo'^d  Prep- 

arations with  Ejsin  and  Methylene  blue.    £.   A.  v. 

WiLLEBRAKD. 

6.  Disinfection  of  the  Hands.    G.  J.  MCixke. 

2. — The  case  which  gave  rise  to  the  present  report  was 
that  of  a  woman  of  41,  who  had  extrauterine  pregnancy  with 
rupture,  free  hemorrhage  into  the  peritoneal  civity.  collapse, 
and  a  rapid  reduction  of  the  hemoglobin  to  2o;f .  Tne  urine 
for  2  days  contained  a  marked  amount  of  hemoglobin;  5 
days  afterward  she  had  another  severe  attack  of  hemi>globin- 
luia,  which  lasted  for  4  days.    The  main  point  in  the  case 


UasCH  2,  1901] 


THE  LATEST  LITERATURE 


PThe  Philadelphia 
L  Medical  Jouknal 


425 


that  after  a  large  effusion  of  blood  in  the  peritoneal  cavity, 
2  attacks  of  hemoglobinuria  occurred.  It  was,  therefore, 
a    "  poBthemorrhagic    hemoglobinuria."    The    possible  ei- 

Elanations  of  its  occurrence  are  mere  absorption  of  the 
emoglobin  in  unchanged  form  and  its  excretion  as  such, 
and,  on  the  other  hand,  the  production  of  a  hemolysin 
through  the  absorption  of  the  blcod,  this  hemolysin  causing 
actual  solution  of  the  patient's  own  blood-corpuacles  and 
thus  producing  hemoglobinemia  and  hemoglobinuria.  The 
first  suggestion  seems  improbable.  If  it  were  correct  one 
would  expect  hemiglobinuria  frequently  after  hemorrhage, 
but  it  is  extremely  rare,  indeed  almost  unobserved.  The 
second  possibility  is  accepted  as  being  the  most  probable 
cause.  The  explanation  given  is  this  :  Normally  hemolysins 
are  not  active  because  they  are  combined  with  antihemoly- 
eins  in  the  red  blood-corpuscles  or  elsewhere.  It  is  quite 
possible  that  if  they  became  free  in  solution  they  would  be- 
come active  in  any  person.  In  the  case  reported  there  was  a 
large  abdominal  effusion  of  blood  which  was  very  rapidly 
absorbed.  It  seemed  probable,  therefore,  that  much  hemo- 
lysin was  rapidly  dissolved  out,  and  that  the  organism  was 
unable  to  provide  quickly  enough  a  sufficient  amount  of 
antihemolysin  and  some  solution  of  the  blood-corpuscles 
took  place  in  this  way.     [d  l.e  ] 

3. — The  case  reported  was  that  of  a  woman,  67  years  old, 
who  had  pains  about  the  thorax  and  disturbance  of  breath- 
ing, with  increase  of  these  disturbances,  cough,  loss  of 
strength,  and  other  indefiuite  symptoms,  which  were  at  first 
thought  to  be  hysterical.  Subsequently  she  came  under 
Kalischer's  observation,  and  it  was  found  that  she  had 
marked  tenderness  over  the  ribs  with  some  nodosities  of  the 
ribs,  and  that  the  urine  contained  considerable  amounts  of 
albumose  (Bence  Jones  bodies).  A  diagnosis  of  myeloma  of 
the  ribs  was  therefore  given,  and  a  fatal  prognosis  established. 
The  symptoms  increased,  and  the  patient  died  about  a  year 
and  a  half  after  the  beginning  of  her  pain.  The  postmortem 
examination  showed  that  the  ribs  were  filled  with  a  substance 
which  looked  much  like  a  semifluid  splenic  pulp,  the  spongy 
and  compact  bony  substance  had  almost  completely  vanished, 
the  bony  tissue  of  the  ribs  consisting  of  a  very  thin  shell, 
scarcely  thicker  than  paper.    The  ribs  were  broken  in  several 

Elates,  they  showed  numerous  swellings,  and  could  be  readily 
roken  to  pieces.  The  humerus  of  one  side  was  also  ex- 
amined, but  showed  scarcely  any  changes  in  the  marrow. 
The  case  was,  therefore,  one  of  myeloma  of  the  ribs.  Micro- 
scopic examination  showed  that  it  was  a  hyperplasia  of 
the  marrow  of  lymphoid  character.  The  marrow  of  the 
humerus  showed  practically  normal  conditions.  The  case 
ran  a  fairly  typical  course  for  this  disease,  and  the  urinary 
conditions  were  characteristic,  consisting  chiefly  in  pre- 
cipitation upon  gent'e  heating,  solution  of  the  precipi- 
tate upon  more  active  heating,  and  a  redeposit  of  the  precipi- 
tate upon  cooling.  No  Bence  Jones  bodies  were  found  in  the 
marrow  or  in  the  ribs  or  humerus.  Tne  amount  of  albumose 
in  the  urine  was  about  0  55  ^ .  According  to  the  recent  work 
of  Mignus  Levy  this  substance  is  midway  between  an  albu- 
mose and  an  albumin.  It  is  a  striking  fact  that  it  has  been 
observed  only  with  great  rarity  in  cases  of  pernicious  anemiaor 
leukemia  with  marked  involvement  of  the  bone  marrow.  In 
a  case  of  leukemia  and  one  of  pernicious  anemia  which  Kali- 
scher  observed  recently,  the  Bence  Jones  substance  was  not 

E resent  in  the  urine.  It  is  also  striking  that  myeloma  may 
e  present  for  a  long  time  and  may  involve  a  large  amount 
of  bone  marrow  without  causing  any  marked  blood  change. 
The  nervous  symptoms  frequently  seen  in  these  cases  may 
be  due  to  the  general  reduction  of  health  that  comes  with 
the  condition,  they  may  be  due  to  actual  pressure  of  growths, 
or  they  may  be  due  to  organic  lesions  of  the  nervous  system. 
Sometimes  there  are  paralytic  symptoms  which  are  not  ex- 
plained by  organic  changes  in  the  nervous  system,  [d  l  e.] 
5. — The  method  recommended  is  based  upon  the  fact  that 
if  one  adds  to  a  mixture  of  eosin  and  methylene  blue  an 
alkali,  the  staining  result  will  chiefly  be  due  to  nuthylene- 
blue,  while  with  the  addition  of  acid  the  eosin  stain  becomes 
more  marked  and  may  be  made  to  become  the  controlling 
stain  if  enough  acid  is  added.  The  mixture  recommended  is 
as  follows :  0  5%  eosin-solution  in  70%  alcohol,  and  an  eoual 
amount  of  concentrated  watery  solution  of  methylene-blue. 
This  mixture  ordinarily  causes  a  deep  blue  stain.  After  this 
a  dilute  (1%)  acetic  acid  is  added,  drop  by  drop,  and  the 
mixture  tested ;  after  each  addition  of  acid  it  will  be  found 


that  the  resulting  stain  shows  more  and  more  of  the  eosin 
element,  until  afi-er  the  addition  of  about  10  to  15  drops  of 
acid  to  50  cc.  of  the  stain  the  staining  result  finally  becomes 
a  satisfactory  mixture  of  the  eosin  and  methylene  blue,  affects 
and  does  well  for  staining  the  nuclei,  the  granules  of  the  leu- 
kocytes, and  the  protoplasm  simultaneously,    [d.l.e.] 


Wiener  kliuisclie  "Wochenschrift. 

January  17,  1901.    [14.  Jahrg.,  No.  3.] 

1.  The  Relation  Between  the  Nose  and  the  Female  Sexual 

Organs.    Arthur  Schiff. 

2.  A  Case  of  Uailateral  Hypertrophy  of  the  Breast.  Bebnabd 

Enolasder. 

3.  Remarks  upon  Phosphorus  in  the  Treatment  of  Rachitis. 

Monti. 

1. — Sjhiff  first  quotes  from  Fliess'  work  upon  this  subject, 
in  which  he  calls  two  areas  upon  the  mucous  mem- 
brane of  the  nostrils  (tbe  anterior  part  of  tbe  lower  tur- 
binate, and  the  tuberculum  septi),  "  genital  spots,"  since  they 
become  hyperemic  during  menstruation.  Besides,  in  cases 
of  dysmenorrhea,  he  says  that  cocaining  the  lower  turbinate 
causes  the  hypogastric  pain,  and  cocaining  the  tuberculuin 
causes  the  lumbar  pain,  to  disappear.  Further,  should  this 
be  so,  the  dysmenorrhea  can  be  permanently  cured  by  cau- 
terizing the  "genital  spots."  Not  only  is  this  true  in  ner- 
vous dysmenorrhea,  but  in  many  of  those  cases  associated 
with  disease  of  the  sexual  organs,  also.  In  pure  mechanical 
dysmenorrhea,  however,  associated  with  stenosis  of  the  cer- 
vix uteri,  anteflexion,  etc.,  this  is  not  the  case.  Snhiff  tested 
this  in  47  cases,  in  34  of  which  two  drops  of  a  20%  solution 
of  cocain  upon  these  genital  spots  caused  the  pain  of  dys- 
menorrhea to  disappear  temporarily,  not  only  once,  but 
whenever  applied.  Nine  of  the  13  negative  cases  showed 
gynecological  conditions.  His  tests  numbered  over  200. 
They  were  carefully  made,  suggestion  being  excluded.  When 
water  was  used,  and  not  cocain,  tbe  pain  persisted.  By  using 
other  anesthetics  (weaker  cocain  solutions,  suprarenal,  etc.) 
he  shows  that  this  is  due  to  anesthesia  of  the  "  genital  spots." 
In  12  out  of  17  cases  of  dysmenorrhea  cauterizing  the  gen- 
ital spots  was  followed  by  permanent  recovery.  Further  ex- 
periments showed  plainly  the  close  connection  between  the 
hypogastric  pain  and  the  mucous  membrane  over  the  lower 
turbinated  bone,     [m  o  ] 

2. — Engliinder  reports  a  very  rare  case,  a  woman  of  33, 
whose  right  breast  was  much  hypertrophied.  In  her 
mother,  also,  the  right  breast  was  much  larger  than  the  l^ft. 
During  two  pregnancies  her  breast  grew  much  larger.  Yet 
she  had  not  enough  milk  for  her  second  child.  She  refused 
operation,  in  spite  of  the  huge  size  of  her  breast.  A  detailed 
review  of  the  literature  is  given,     [m  o  ] 

3,_A.fter  a  det>iiled  exposition  of  the  suhjoot.  Monti  says 
that  phosphorus  was  first  used  for  rachitis  in  1838, 
and  in  186S  Trousseau's  prescription  was  widely  circulated. 
Wegner's  experiments  do  not  show  how  rickets  occurs,  nor 
that  it  can  be  cured  by  phosphorus.  Clinically,  phosphorus 
has  not  prevented  the  progress  of  rachitis,  nor  has  it  caused 
the  slightest  improvement.  Nor  does  phosphorus  act  any 
better  with  cod-liver  oil,  as  it  cannot  be  proved  how  much 
phosphorus  exists  in  each  dose,  nor  whether  the  phosphorus 
does  not  soon  become  phosphoric  acid.  Monti  agrees  with 
Zweifel  that  no  specific  action  of  unoxidized  metallic  phos- 
vhorus  has  been  proved  either  experimentally  or  clinically. 

Archiv  fiir  Pathologische  Anatomic  und  Physiolo- 
gie  und  fiir  klinische  Mediciu. 

[Band  162,  Heft  3.] 

18.  New  Methods,  Found  by  Experimentation,  for  the  Rec- 

ognition and    Treatment   of   Diseases    Produced    by 
Autointoxication.     F.  Bl.UM. 

19.  The  Morpbologv  of  Milk.     M.  Cohn. 

20.  The  Fibrinous  Inflammations  of  the  Intestmes  and  of 

the  Serous  Membranes.    Herxheimer. 

21.  The  Influence  cf  Chemical   M.iterials  Upon  the    Pro- 

cess of  the  Crystallization   of  Hemoglobin.    S.   von 
Stein. 


426 


The  Philadelphia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Habcb  2,  1901 


22.  Sircoma  of  the  Ileocecal  Region.    Blauel. 

23.  The  Histology  of    Acute    Suppurative    Peritonitis.    O. 

Walbaum. 

24.  Further  Investigations  Upon  the  Influence  of  Sterilizad 

Air  Upon  Animals.    J.  Kajinitzin. 

25.  L'.pochrom  of  the  Nerve  Cells.    Rosin  and  B.  von  Feny- 

VESSY. 

26.  Brief  Communications.    (1)  Connective   Tissues,  Mem- 

branes and  Lymph  Spaces;  Correspondence  Between 
R.  Krause  and  R.  Virchow.  (2)  A  Case  of  Atheroma 
of  the  Heart  Valves  in  a  Girl  of  15.  A.  Bkion.  (3) 
The  Idea  and  Nature  of  Anaplasia.    Hansemann. 

18. — Blum  has  performed  a  series  of  experiments  upon 
the  tliyroid  g-land,  that  appear  to  modify  our  views  of  the 
physiology  of  this  org-an  considerably,  and  to  indicate  to 
some  extent,  new  methods  of  research  and  treatment.  A 
large  number  of  dogs  were  sacrificed,  so  large  a  number  in 
fact  that  Blum  believes  that  accidental  features  are  prac- 
tically eliminated.  It  was  found  that  of  those  animals  that 
were  fed,  during  the  preliminary  period  and  after  the  experi- 
ment, exclusively  upon  meat,  9i5%  died,  the  great  majority 
from  tetany.  The  remaining  4fo  were  immune  to  the  re- 
eults  of  thyreo  priva,  and  also  to  all  other  forms  of  poison 
that  are  elaborated  from  the  food.  In  the  animals  which 
were  fed  exclusively  upon  milk  for  a  considerable  period  be- 
fore the  operation,  and  with  the  same  substance  after  the 
operation,  the  mortality  was  only  about  60% .  A  curious  fact 
was,  that  if  alter  they  remained  healthy  upon  the  milk  diet 
for  a  considerable  time  the  animals  were  given  meat,  they 
exhibited  all  the  symptoms  of  loss  of  thyroid.  If  the  animals 
were  kept  upon  a  mixture  of  milk,  bre.id  and  meat  they  re- 
mained perfectly  well.  Therefore  the  extractive  materials  in 
meat  are  certainly  not  concerned  in  the  poison  that  ij  pro- 
duced. Blum  therefore  believes  that  a  poison  is  manufac- 
tured in  the  gastrointestinal  tract  from  the  essential  con- 
stituents of  the  meat  that  is  consumed.  As  a  considerable 
proportion  of  animals  died  on  milk  diet  it  is  reasonable  to 
suppose  that  the  same  poison  is  produced  from  it  that  is 
produced  from  meat,  but  that  in  the  majority  of  cases  the 
quantity  is  considerably  less.  He  calls  this  poison  "  entero- 
toxin."  It  is  rather  difficult  to  explain,  however,  why  suck- 
ling puppies  invariably  died  after  tUe  removal  of  the  thyroid, 
although  they  were  always  nourished  exclusively  upon  milk. 
All  the  animals  that  survived  apparently  did  so  largely  as  a 
result  of  the  production  in  their  blood  eerum  of  some  anti- 
toxic substance;  for,  if  blood  serum  obtained  from  them  is 
injected  into  animals  manifesting  a  severe  form  of  thyroid 
cachexia,  it  is  often  possible  to  preserve  the  latter  for  some 
time.  The  function  of  the  thyroid  gland  appears  from  these 
studies  to  be  the  neutralization  of  toxic  substances  circulat- 
ing in  the  body.  From  these  it  manufactures  the  thyreo 
toxalburain,  a  substance  that  has  a  considerable  affinity  for 
iodin,  although  this  element  has  nothing  to  do  with  the  es- 
sential fuuclions  of  the  thyroid  glands,  as  is  proved  by  its 
total  absence  in  the  thyroid  glands  of  very  young  animals. 
The  thyreo  toxalbumin  is  itself,  under  certain  circumstances, 
toxic,  although  many  animals  either  possess  a  natural  im- 
munity to  it  or  are  capable  of  acquiring  it.  Such  animals, 
however,  do  not  possess  an  immunity  to  enterotoxin  alone. 
The  symptoms  of  thyreo  priva,  therefore,  are  not  due  so 
much  to  an  autointoxication  as  to  an  overwhelming  of  the 
system  with  the  poisonous  substances  produced  in  the  intes- 
tinal tract,  and  in  cases  of  this  condition,  in  order  to  dimin- 
ish this  poison  as  much  as  possible,  a  milk  diet  is  apparently 
indicated,     [j.s  ] 

19. — Cohn  having  had  his  su.'tpicions  aroused  regarding 
the  nature  of  the  colostrum  bodies  in  uiilk  by  the  fact 
that  they  manifest  ameboid  movements  when  upon  the  warm 
Stage,  has  endeavored  to  determine  this  point  by  micro- 
chemical  reactions,  that  is  to  say,  he  stained  them  with 
Earlich's  triacid  stain,  and  determined  that  they  possess 
neutrophilic  granules.  They  difler  from  leukocytes  chiefly 
iu  their  size,  and  in  the  possession  of  numerous  fat  granules, 
however  as  the  result  of  careful  studies  upon  the  milk  of 
women  in  the  process  of  weaning,  he  found  that  the  fat 
granules  were  simply  prestnt  in  the  protoplasm  as  the  result 
of  imbibition,  and  that  when  they  disappeared  the  leukocytes 
resumed  their  normal  appearance  The  nuclei  of  the  colos- 
trum-cells resembled  in  all  respects  the  nuclei  of  the  poly- 
morphonuclear leukocytes.    It  is  difficult  to  explain  why  at 


certain  periods  during  lactation,  particularly  the  very  begin- 
ning, the  colostrum  cells  should  be  present  in  euch  great 
excess.  We  can  explain  this  either  by  supposing  greater 
congestion  at  these  periods,  or  the  presence  of  the  products 
of  bacterial  metamorphosis  at  the  orifices  of  the  glands,  or 
the  secretion  of  some  chemotaclic  substance  from  the  blood. 
Cohn  believes  that  during  gestation  a  certain  amount  of 
secretion  collects  in  the  glands,  which,  after  parturition  is 
stimulated  by  the  greater  activity  of  the  bloodstream,  and 
manifests  then  its  chemotactic  qualities.  In  some  cases  it 
has  been  observed  that  after  the  ninth  day  there  may  be  an 
increased  secretion  of  colostrum-cells.  Tais,  Cohn  believes 
to  be  the  result  of  a  partial  aplasia  or  insuffinency  of  the 
glandular  tit^sue.  It  has  been  observed  in  support  of  this 
that  the  number  of  colostrum- cells  diminished  a<s  the  quantity 
of  milk  increased.  In  some  cases  there  is  unilateral  secre- 
tion of  colostrum  cells,  which  can  be  explained  by  partial 
insufficiency  of  the  glandular  tissue  on  that  side.  Cohn  also 
discusses  some  very  interesting  features  of  lactation,  which 
however,  Cinnot  properly  be  considered  in  an  abstract,  [j  8.] 

20. — Herxheimer  has  made  a  series  of  studies  upon  the 
fibriaous  infiaiuuiations  of  the  pleara  and  intos- 
tiue.  The  method  employed  was  staining  by  various 
methods,  but  chiefly  Weigert's  fibrin  method,  of  pleura  con- 
tents, postmortem  material  in  Go'.tingen.  The  object  waa 
to  determine  the  pari  which  the  endothelial  cells  take  in  the 
infl  immatory  process.  By  s'.aining  the  elastica  he  was  able 
to  determine  that  they  lay  beneath  the  fibrinous  layer,  and 
formed  a  continuous  layer,  covering  also  the  portions  upon 
which  no  fibrinous  exudate  existed.  Under  excep'ional  cir- 
cumstances a  few  cells  were  founl  on  the  outside  of  the 
exudate,  or  mixed  with  the  fibrin.  Tais  may  be  regarded  as 
accidental.  Many  of  these  endothtlialcells  were  swollen 
and  showed  distinct  signs  of  proliferation  similar  to  the 
changes  described  as  the  result  of  irritation  by  foreign  bodies. 
Above  the  cells,  clefts  were  not  infrequen'.ly  found,  but  these 
did  not  represent  lymph  spaces  because  they  were  not  lined 
by  endothe'ium.  The  signs  of  proliferation  consisted  in 
swelling  of  the  cells,  formation  of  giant  cells,  karyokioesis, 
and  the  arrangement  of  the  cells  in  several  superposed 
layers.  In  no  instance  did  they  show  any  signs  of  con- 
version into  connective  tissues.  The  explanation  for  the 
proliferation  was,  the  formation  of  clefts  that  needed 
covering,  the  replacement  of  discarded  cells,  or  the  action 
of  an  irritant.  Investigations  upon  the  intestine  were  made 
chiefly  for  the  purpose  of  determining  the  presence  of  true 
fibrin.  This  was  found  in  a  variety  of  cases,  and  always  most 
pronounced  in  the  submucosa.  In  one  case,  however,  diag- 
nosed as  a  pseudo  membranous  enteritis  following  pyemia, 
no  fibrin  was  found  and  the  membrane  present  determined 
to  be  due  to  the  numerous  emboli  of  microccocci.  Never- 
theless, Herxheimer  concludes  that  fibrin  formation  is  an 
important  element  in  intestinal  disease,     [j  s  ] 

21. — Von  Stein  has  carried  out  an  interesting  series  of  ex- 
periments with  the  object  of  determining  what  efl"ect  various 
chemical  solutions  have  upon  the  formation  of  crystals 
from  hemoglobin.  The  method  was  as  follows :  Blood 
was  obtained  from  guineapigs,  rapidly  defibrinated,  and  a 
drop  placed  upon  a  slide  and  then,  by  a  rather  delicate 
manipulation,  cavered  with  a  film  of  Canada  balsam.  At 
the  end  of  '2i  hours  it  was  examined,  and  the  crystallization 
was  usually  complete.  Various  saline  solutions  were  added 
to  the  drop  before  covering,  and  their  influence  upon  crys- 
tallizition  observed.  Distilled  water  in  small  proportions 
made  the  crystals  smaller  and  paler,  and  when  2  t  j  3  drops 
of  water  were  added  to  the  blood  they  failed  to  form.  Solu- 
tions of  sodium  chlorid  caused  at  first  blunting  of  the  edges 
of  the  crystals,  smaller  crystals,  and  finally  complete  disap- 
pearance of  them  S.milar  results  were  obtained  from  potas- 
sium chloride,  solium  sulphate,  potassium  chlorate,  ammo- 
nium sulphate.  Hydrogen  sulphide  prevented  the  formation 
of  crystals ;  carbon  monoxi  J  gave  rise  to  the  formation  of  blunt 
tetrahedrens  of  blood  red  color ;  nitrous  oxide  did  not  inter- 
fere with  the  formation  of  the  crystals,  and  anhydrous  sol- 
phnrous  acid  prevented  it  entirely. 

22.— B'auel  reports  2  cases  of' sarcoma  of  the  intes- 
tine. The  first,  a  man  of  33,  .at  the  age  of  2i5  conimeuoed  to 
have  gastric  disturbances  which  lasted  3  or  4  years.  At  the 
age  of  31  he  had  a  severe  influumation  of  the  appendix. 
Four  or  5  weeks  Later  he  noticed  a  tumor  the  size  of  a 
pigeon's  egg  in  the  right  iliac  region.    This  gradually  in- 


ItAKCH   2,    1901] 


THE  LATEST  LITERATURE 


L  Medical  Jodrnax. 


427 


creased  in  size.  Later  it  reached  the  size  of  a  child's  head. 
The  patient  had  an  eruption  of  blisters  all  over  the  body, 
that  suppurated.  The  tumor  from  this  time  increased  rapidly 
in  size,  and  soon  occupied  the  larger  portion  of  the  abdominal 
cavity.  It  became  infected  with  the  colon  bacillus  ;  was  in- 
cised, and  a  large  portion  of  necrotic  tissue  removed.  The 
patient  died  from  exhaustion.  At  the  autopsy  the  abdomi- 
nal organs  were  found  much  displaced,  and  the  tumor,  which 
was  larger  than  an  ordinary  man's  head,  involved  the  cecum 
and  the  commencing  portion  of  the  ascending  colon,  the 
walls  o' which  formed  a  rigid  tube.  Microscopically  it  was 
a  small  round  cell  sarcoma.  The  second  patient,  a  woman 
of  66,  had  suffered  for  about  6  months  with  pain  in  the  right 
side  of  the  abdomen.  At  an  operation  a  tumor  was  found  in 
the  ileocecal  region  that  had  formed  dense  adhesions  with 
the  right  adnexa.  The  patient  died  of  thrombosis  and  de- 
cubitus. At  the  autopsy  a  small  round-cell  sarcoma  of  the 
cecum  and  ileocecal  valve  was  found.  Blauel  calls  attention 
to  the  extreme  rarity  of  sarcoma  in  this  region.  Tney  are 
all  apparently  of  the  same  historical  construction,  and  in  the 
majority  of  cases  arise  from  the  serous  coat;  as  a  result,  a 
common  symptom  is  the  absence  of  the  ordinary  signs  of  in- 
testinal obstruction,     [j  s.] 

33. — Walbaum  has  undertaken  a  series  of  investigations 
upon  45  cases  of  purulent  peritonitis,  in  order  to  deter- 
mine how  much  of  the  actual  wall  of  the  intestine  was 
affected  by  the  inflimmatory  process,  and  what  changes  oc- 
curred in  the  ganglion  cells  of  the  intestinal  plexus.  He 
found  in  nearly  all  cases  that  the  muscular  coat  escapes,  but 
that  there  is  an  infiltration  around  the  bloodvessel  walls,  and 
round  cells  in  any  cases  extend  into  the  submucous  tissues. 
The  bloodvessels  passing  through  the  muscular  coat  also 
showed  perivascular  infiltration.  Tne  cellular  proliferation 
affects  chiefly  the  connective  tissue  cells.  Tnere  is  often 
fibrinous  exudate  in  the  intestinal  wall.  The  ganglion  cells 
of  the  intestinal  plexus  were  fixed  with  a  2%  formalin  solu- 
tion, and  then  stained,  either  with  osmic  acid  or  with  osmic 
acid  and  hemotoxin.  Even  in  normal  cells  a  few  fine  fat 
drops  could  be  found ;  but  in  the  pathological  cells  these 
were  often  considerably  increased.  The  absence  of  the  nu- 
cleus is  not  necessarily  a  pathological  sign.  Many  of  the  cells 
were  vacuolated  or  showed  hydropic  degeneration.  Chroma- 
tolysis  of  the  nucleus  was  not  infrequent.  He  concludes 
therefore,  that  the  inflammatory  process  extends  into  the  in- 
testinal wall  and  causes  alteration  in  the  protoplasm  and 
nuclei  of  the  ganglion  cells.     [J  *  ] 

24. — (See  editorial.) 

26. — Rosin  and  von  Fenyvessy  have  already  shown  by 
means  of  osmic  acid,  that  granular  pigment  in  the 
ganglion  cells  of  the  nerve  system  is  probably  fat. 
The  discovery  of  the  micro-chemical  reaction  with  sudan 
III,  however,  have  impelled  them  to  undertake  a  new  series 
of  investigations  in  order  to  determine  as  positively  as  pos- 
sible, that  their  previous  statement  was  correct.  The  sec- 
tions were  placed  in  formalin,  cut  on  the  freezing  mirotom 
and  placed  for  24  hours  in  a  saturated  solution  of  sudan  HI 
in  80^  alcohol,  and  then  mounted  in  glycerin.  The  granu- 
lar pigment  stained  an  intense  scarlet.  Certain  peculiar 
bodies  in  the  adventitia  of  the  bloodvessels  also  stained  a 
deep  scarlet,  and  the  myelin  sheaths  a  pale  red.  Iq  the  sec- 
tions treated  with  absolute  alcohol  and  ether  the  pigment 
completely  disappeared,  proving  its  true  fatty  nature. 

26. — 1.  Krause  having  written  to  Virchow  inquiring 
whether  he  agreed  with  the  principle  set  forth  by  Gegenbaur, 
that  the  various  tissues  arise  from  individual  embryonal  lay- 
ers, and  that  the  endothelium  represent  layers  of  connective 
tissue  cells,  received  from  Virchow  an  answer  in  which  he 
insists  upon  the  doctrine  of  metaplasia,  and  states  that  in 
endothelioma,  cells  with  epithelial  characteristics  may  occur. 
2.  Brion  reports  an  interesting  case  of  extensive  athe- 
roma occurring  in  a  girl  15  years  of  age,  who  had 
had  successive  attacks  of  articular  rheumatism  for  10  years. 
The  mitral  valve  was  stenosed,  the  aortic  valve  insufiicient, 
and  in  the  posterior  mitral  leaflets  there  was  a  cavity  con- 
taining an  emulsion  of  fat  with  some  calcium  crystal-*,  and  a 
few  compound  granular  cells.  It  represented  therefore,  an 
atheromatous  degeneration.  The  color  of  the  fluid  was  white 
instead  of  yellow.  The  interesting  features  are  that  the 
atheromatous  process  occurred  in  the  interior  of  the  valve, 
and  in  a  girl  of  1-5  years.  3.  Hanseraann  defends  his  hypoth- 
esis of  anaplasia  against  the  criticisms  of  Beneke.    He 


maintains  that  although  it  is  only  an  hypothesis,  it  ex- 
plains a  great  many  facts  that,  in  the  present  state  of  our 
knowledge,  cannot  be  better  elucidated,    [j.s.] 


Revue  de  Medecine. 

January  10,  1901.     [21me  Ann^e,  No.  2.] 

1.  The  Course  of  Gravid  Xephritis.    E.  Gaucher  and  E. 

Seegest. 

2.  The  Rsgulation  of  Cardiac  Movements  by  Systematic  Ex- 

ercise.   Fersand  Lageasge. 

3.  Two  Cases  of  Primitive  Progressive  Myopathy.    L.  Spill- 

mass. 

4.  Study  of  the  Localization  of  Symptoms  in  Sydenham's 

Chorea.    G.  Oddo. 

5.  Contribution   to   the  Study  of   the  Tendon  Reflexes  in 

Typhoid  Fever.    P.  Remlisger. 

6.  Traumatic   D.abetes,  Revealed  by  Anginoid  Symptoms; 

with  Some  Reflections  upon  Traumatic  Diabetes.    P. 
Vergely. 

7.  Purulent  Hygroma  Dae   to    Gonococcus  Infection.    V. 

Griffox  and  L.  Nattan-Laebier. 

1. — E  Gaucher  has  shown  in  previous  papers  that  all  the 
toxic  forms  of  nephritis,  toxic  infectious  and  autotoxic, 
while  primitively  epithelial  often  become  of  the  chronic  in- 
testinal form.  This  author,  in  conjunction  with  E.  Sergent, 
now  undertakes  to  prove  that  gravid  nephritis  becomes  also 
chronic  intestinal  nephritis  presenting  especially  the  bruit 
de  galop,  and  the  identical  anatomical  lesions.  Gravid 
nepbritis  becomes  identical  to  those  forms  of  nephritis  caused 
by  slow  and  prolonged  intoxication  and  should  be  classed 
with  them.    A  few  carefully  studied  cases  are  cited,    [t  l  c] 

2. — Lagrange  points  out  the  necessity  of  carefully  study- 
ing each  particular  case  of  cardiac  trouble  and  regulating 
any  systematic  exercise  upon  the  principle  t^^at  the  cardiac 
action  is  the  resultant  not  of  a  single  but  of  many  forces,  all 
of  which  must  be  taken  into  account.  Tne  article  (not  com- 
plete in  this  number)  discusses  with  judgment  the  pos- 
sibilities of  helping  certain  cardiac  cases  and  explains  the 
rationale  of  the  method.  TheeSact  of  massage  upon  en- 
gorged veins  is  familiar  to  all  and  the  eSect  also,  upon  the 
arterial  system  in  the  free  circulation  through  the  sluggish 
part,  which  must  benefijially  inflaence  cardiac  action.  In 
cases  of  complete  paralysis  of  one  side,  for  instance,  the  sys- 
tematic exercise  of  the  well  side  will  greatly  assist  in  adjust- 
ing the  circulation  to  the  changed  conditions.  The  influence 
of  groups  of  muscles  and  their  antagonists  and  the  possibility 
of  favorably  changing  the  arterial  tension  are  discussed.  The 
value  of  deep,  regular  breathing  upon  the  circulation  is  not 
underestimated,  and  the  keynote  of  moderation  in  all  sys- 
tematic exercises  to  bring  about  a  favorable  result  with  the 
lea*t  effort  is  insisted  upon,    [t.l.c  ] 

3.— Spillmann  reports  2  cases  of  primary,  progressive 
myopathy  in  girl  children  of  9  and  7  years  of  age  respec- 
tively. The  cases  present  some  interesting  features.  In  the 
second  case  the  atrophy  began  in  the  muscles  of  the  calves, 
then  invaded  the  thighs,  lumbar  region  and  trunk.  In  this 
cafe  the  atrophy  was  arrested  at  this  level,  hut  in  Cise  1  the 
muscles  of  the  upper  extremities  were  also  affected,  the  face 
alone  being  exempt.  These  2  cases  resemble  the  type  de- 
scribed by  Leyden,  Moiius,  and  Eichhorst.  There  seemed 
to  be  no  hereditary  tendency  in  these  cases.  In  testing  the 
electric  contractility  of  the  muscles,  the  excitability  to  the 
galvanic  current  was  found  diminished  in  both  cases,  but  in 
the  first  case  there  was  an  abolition  of  faradic  excitability  in 
the  extensors  of  both  arms.  This  absence  of  faradic  excita- 
bility of  muscles  which  is  present  generally  in  le^ioTls  of  the 
peripheril  nervous  system  shows  how  great  the  diffi  "ulty  is 
of  separating  these  myopathies  from  amyotrophic  conditions 
due  to  lesions  in  the  medulla,    [t  l.c] 

4.— Oddo  in  a  paper  (incomplete  in  the  present  number) 
ha*  made  an  elal>orate  ftudy  of  the  localization  of  the 
symptoms  in  Sydenham's  chorea.  He  summarizes 
the  opii  ions  as  to  the  localization  of  the  i  horeic  niovenients. 
The  movements  are  rarely  general  at  the  onset.  They  begin 
in  the  upper  extremity,  or  the  face;  or  rarely,  in  the  lower 
extremity.  They  epread  over  the  correspording  half  of  the 
body  and  finally  attack  the  opposite  side.  Pure  hemichorea 
is  very  rare.    In  Oido's  study  of  144  cases,  the  onset  was 


428 


The  Philadelphia"! 
Medical  Jodknal  J 


THE  LATEST  LITERATURE 


[Mabch  2,  19m 


general  in  25  oases  only.  It  was  hemilateral  in  111  cases  of 
his  series.  CoDS-dering  the  diseaEe  at  its  height,  Oddo  found 
hemichorea  in  24  cases;  general  symptoms  with  predomi- 
nence  of  hemilateial  tymptoms  were  seen  in  91  cases;  sym- 
metric general  involvtment  was  present  in  29  cases,     [tl.c] 

6.— In  a  valuable  coritribution  to  the  study  of  the  tendon 
reflexes  in  typhoid  fever  Kemlinger  has  found  that  in 
32  cases  out  of  100  they  are  exaggerated  ;  in  22  out  of  100  they 
undergo  no  chsnge;  they  are  diminished  in  17  cases  out  of 
100,  and  abolished  in  29  out  of  100.  There  does  not  seem  to 
be  any  cor  stant  relation  between  the  type  of  the  fever  and 
the  state  of  the  rtfltxes.  At  times  it  appeared  that  exag- 
geration was  prefent  in  grave  cast s,  especially  the  ataxic 
and  ataxo- dynamic  forms.  The  preservation  of  the  nor- 
mal rtfltxes  was  noted  especially  in  ttie  benign  cases  and 
these  with  pronounced  gastric  symptoms.  During  the  course 
of  convalescence  a  marked  tendency  to  exaggeration  of  the 
reflexes  was  observed.  The  epileptoid  trembling  of  the  feet 
was  found  in  20  caies  out  of  100,  but  it  was  less  frequent 
than  the  exaggeration  of  the  patellar  reflex.  It  is  often  uni- 
lateral and  often  coincides  with  exaggerated  tendon  reflexes 
but  it  was  observed  at  times  in  cases  of  normal,  diminished 
or  even  absent  reflexes.  This  tremulousness  was  observed 
especially  after  repeated  percussion  of  the  patellar  tendon. 
He  points  out  that  this  condition  does  net  seem  to  manifest 
itself  at  the  drop  of  the  temperature,  but  often  coincides  with 
profuse  sweats  and  polyuria  and  appears  to  deserve  notice 
as  a  true  critical  phenomenon.  The  percussion  of  the 
tendon  of  Achilles  sometimes  provokes  in  typhoid  fever 
an  epileptoid  trembling  of  the  foot,  which  the  author 
terms  Achillean  to  distinguish  it  form  the  ankle-clonus 
proper.  He  found  at  times  a  dissociation  between  the 
patellar  reflex  and  the  trepidation  elicited  from  the 
tendon  of  Achilles.  The  epileptoid  trembling  of  the  knee 
is  not  rare  in  typhoid  fever.  It  is  found  to  be  bilateral  and 
always  accompanies  an  increased  knee-jerk.  The  author 
observed  no  single  case  of  dissociation.  The  contralateral 
patellar-rtflex  (crossed  reflex),  the  vertical  shaking  of  the 
foot  and  toes  elicited  by  percussion  of  the  patellar  tendon,  is 
one  of  the  rare,  but  extremely  interesting,  phenomena  of 
typhoid  fever.  This  movement  is  most  maiked  in  the  limb 
percussed,  but  a  decided  movement  of  extension  is  also  seen 
m  the  opposite  leg.  The  cutaneous  reflexes  of  typhoid  fever 
present  no  particularly  interesting  changes.  Only  the  plantar 
cutaneous  reflex  has  been  studied.  The  dissociation  be- 
tween the  exaggeration  of  the  tendon  reflexes  and  the 
epileptoid  trembling  does  not  appear  to  be  explicable  upon 
the  ground  of  the  localization  of  tlie  hyper-excitability  of  the 
medullary  center  of  ankle-colonus ;  by  the  physiological 
abolition  of  the  tendon  reflexes  ;  or,  finally,  by  the  cortical 
origin  of  the  epileptoid  trembling  and  the  medullary  origin 
of  patellar  reflex.  That  the  tendon  reflexes  are  true  reflexes, 
the  contralateral  patellar  reflex  proves  conclusively.  Expla- 
nation of  the  epileptoid  trembling  is  simple,  if  we  regard 
them  as  simple  idiomuscular  contractions,     [t  l  c] 

6. — Vergely  reports  the  case  of  a  woman,  aged  68  years, 
of  good  family  histjry,  who  sustained  a  fall  upon  the  chest 
and  abdomen.  The  injury  was  slight  and  no  traces  were 
present  on  examination.  Some  3  years  before  the  accident 
she  had  lost  her  husband  and  the  shoe  k  had  proven  a  great 
one  to  her  nervous  system.  Some  hours  after  the  fall  the 
symptoms  of  angina  pectoris  set  in.  This  condition  was 
relieved  and  was  soon  followed  by  polyuria  and  great  thirst. 
Passive  congestion  of  the  lungs  also  developed.  Sugar  was 
present  in  considerable  quantity  and  the  nervous  symptoms 
mcreated  in  severity.  Tiiere  were  no  indications  of  glyco- 
suria before  the  accident,  although  the  urine  was  not  exam- 
ined. The  heart,  upon  examination,  presented  no  gross 
lesions,  but  the  arteries  were  somewhat  sclerosed.  Vergely 
gives  an  excellent  resume^  of  the  literature  of  traumatic 
diabetes  and  gives  copious  bibliography.  Vergely  concludes 
indirect  traumatism  often  induces  diabetes  in  predisposed 
persons.  The  onset  of  unusual  nervous  symptoms  following 
trauma  of  this  nature  should  lead  us  to  expect  traumatic 
diabetes  and  the  urine  should  be  examined  carefully. 
Anginoid  attacks  are  common  in  diabetes  and  also  demand 
careful  invest'gation  as  to  the  possibility  of  the  presence  of 
this  disease,    [t  l.c  ] 

7. — Griffon  and  Nattan-Larrie  r  report  from  Dieulafoy's 
clinic  a  rare  case  of  hygroma,  purulent  in  nature,  in  which 
the  presence  of  gonococci  was  established  definitely.    The 


patient,  a  woman  of  40  years,  entered  the  hospital  with  ago- 
nizing pain  in  the  lower  extremities ;  a  tumefaction  wa» 
present  in  the  region  of  left  hip.  It  was  found  by  careful, 
repeated  examinations  that  the  swelling  was  located  between 
the  fascia  lata  and  the  great  trochanter.  Fluctuation  wa» 
soon  observed  and  exploratory  puncture  performed.  The 
material  withdrawn  was  thick  and  purulent,  and  examina- 
tion by  cultivation  revealed  the  presence  of  the  gonococcnft 
in  pure  culture,     [t.l.c] 


Lia  Semaine  M^dicale. 

January  9,  1901. 

1.  General  Review:  The  Action  of  Yeasts  Introduced  into 

the  Digestive  Tract.    P.  Kobecouet. 

2.  Practical  Surgery  :  Technic  of  the  Operation  of  Empyema. 

Maueice  Cazin. 

1. — Attention  has  lately  been  recalled  to  former  observa- 
tions dealing  with  the  action  of  yeasts  introduced  into 
the  digestive  tract.  The  view  is  held  by  many  that 
the  yeasts  possess  favorable  action  upon  certain  conditions 
and  serve  as  valuable  therapeutic  agents.  Jfolecourt  has 
reviewed  the  experimental  work  done  upon  the  subject. 
Many  diffifulties  arise  in  the  prosecution  of  the  investiga- 
tions, but  there  is  a  certain  unanimity  of  opinion  upon  many 
points.  It  has  been  determined  that  the  best  range  of  tem- 
perature for  their  development  is  between  30°  C.  and  35°  C, 
but  fermentation  is  still  possible  at  45°  C,  so  that  the  body- 
temperature  is  satisfactory  for  their  action.  The  saliva  is 
found  to  have  no  unfavorable  influence.  However,  the  Action 
of  the  gastric  juice  presents  a  double  problem.  It  must 
be  determined  whether  the  gastric  juice  destroys  the  yeasta 
and  secondly  whether  they  are  able  to  produce  fermentation 
in  the  presence  of  the  gastric  juice.  The  alkalinity  of  the 
stomach  contents  after  a  meal  is  no  bar  to  the  action  of  fer- 
mentation which  we  know  can  proceed  in  an  alkaline 
medium.  It  has  been  determined  that  the  gastric  juice  ha» 
an  unfavorable  action  upon  the  yeasts,  but  not  to  the  point  of 
preventing  the  passage  of  a  certain  proportion  of  the  yeaeta, 
still  active,  into  the  intestine.  When  the  yeasts  reach  the 
intestines  we  have  to  consider  besides  the  alkalinity  above 
referred  to,  the  action  of  the  bile,  pancreatic  secretion,  and 
the  microorganisms  present  in  the  contents.  It  has  been 
proven  that  the  presence  of  the  bile  greatly  retards  the  action 
of  many  forms  of  yeasts ;  the  action  of  the  intestinal  juicee 
and  pancreatic  juice  is  not  as  certain.  Effects  of  microorgan- 
ism have  not  been  systematically  studied,  but  it  has  been  found 
generally  that  the  vitaUty  of  yeasts  is  not  sensibly  affected 
by  their  presence.  The  yeasts  are  able  to  supply  the  neces- 
sary oxygen  for  their  existence  by  deriving  it  from  the 
sugars.  It  is  to  be  remembered  that  oxygen  may  be  f  jund 
free  in  the  stomach.  It  is  found  necessary,  in  order  to  pro- 
vide the  most  advantageous  medium  for  the  development  of 
yeasts  in  the  digettive  tract,  to  give  a  liberal  supply  of  sugar 
with  the  yeasts.  After  ingestion  of  yeasts  it  is  found  that  the 
motor  activity  of  the  stomach  is  decreased,  that  the  produc- 
tion of  hydrochloric  acid  is  retarded,  but  that  pepsin  is 
present  in  sufficient  quantities.  The  effect  of  yeast  upon  the 
intestinal  contents  with  special  reference  to  the  utilizition  of 
sugar  is  of  importance  in  diabetes  for  the  reason  that 
in  the  presence  of  the  yeasts,  a  patient  may  partake  ot 
liberal  hydrocarbon  diet  without  increase  of  the  glycosuria. 
Certain  yeasts  are  found  to  act  unfavorably  upon  certain 
microorganisms  (in  experiments  performed  in  vitro),  to  have 
no  effect  upon  others,  and  to  even  increase  the  activity  of 
the  microorganisms  in  a  few,  as,  for  instance,  the  bacillus 
pyocyaneus.  Xolt^.^ourt  and  others  claim  a  decided  les- 
sening of  certain  toxins,  especially  of  diphtheria,  when 
yeasts  have  been  given.  Large  quantities  of  yeast  (witnessed 
in  beer  nciscning)  produce  diarrhea,  vomiting,  fever,  and 
coma.  This  is  probably  due  to  the  evolution  of  carbonic 
acid  gas  ancl  the  poisonous'effects  of  this  gas  In  animals  ab- 
dominal distention  and  asphyxia  are  observed.  Among  the 
diseases  attributed  to  the  effects  of  alcoholic  fermentation  are 
dilatation  of  the  stomach,  acute  gastrointestinal  catarrh, 
chronic  gastritis  and  anthrax.  Yeasts  have  been  used  thera- 
peuticaliy  in  furuuculosis,  with  or  without  diabetes,  in  en- 
teroptosis,  in  gastroentestinal  disorders  of  infant?  and  in  the 
infectious  fevers.    The  results  have  been  unsatisfactory  io 


March  2,  1901] 


THE  LATEST  LITERATURE 


["The  Philadelphia 
L  Medical  JocRyAL 


429 


many  cases.  The  necessity  arises  for  experimentation  as  to 
which  varieties  of  yeasts  are  to  be  employed  and  the  precise 
rationale  of  the  action,    [t.l.c  ] 

2. — Maurice  Cazin  contributes  a  paper  upon  the  technic 
■of  the  operation  of  empyema.  He  advocates  the  use 
of  local  anesthesia  and  employs  a,2fc  solution  of  cocain  in  a 
syringe  of  2  grams  capacity.  Perfect  local  anesthesia  is  ob- 
tained in  fifteen  minutes.  In  limited  sncysted  eflfusions  the 
area  of  dulness  itself  will  give  us  the  point  of  election  for 
operation.  In  general  effusion  the  polleurotomy  should  be 
performed  at  the  posterior  axillary  line  at  the  ninth  inter- 
space. The  technic  of  the  operation  follows.  The  writer 
points  out  the  importance  of  free  drainage  and  recommends 
flushing  the  pleural  cavity,  with  aseptic  or  mild  antiseptic 
solutions,  except  in  the  case  of  gangrene  of  the  pleura. 
[t.l.c] 

January  16,  1901. 

1.  Potain, — Obituary  Tribute.    P.  Teissier. 

2.  On  the  Semeiological  Value  of  the  Variations  in  Timbre 

and  Intensity  of  Abnormal  Heart-Sounds,  and  the  In- 
fluence of  the  Ventricular  Elasticity  on  the  Closure  of 
the  Mitral  Orifice.    Potain. 

3. — Potain  in  one  of  the  last  works  of  his  pf  n,  discusses 
the  semeiological  value  of  the  variations  of  timbre  and 
intensity  of  abnormal  cardiac  bruits,  with  especial 
reference  to  the  part  played  by  the  ventricular  elasticity  and 
the  closure  of  the  mitral  orifice.  He  briefly  narrates  the 
well-established  fact  that  valvular  lesions  give  rise  to  bruits 
which  serve  us  as  guides  of  the  precise  valvular  defects 
present,  and  mentions  the  part  played  in  the  modifica- 
tion of  these  murmurs  by  the  varied  states  of  the  super- 
imposed lung.  The  valvular  closure  is  produced  by  the 
systole  of  the  ventricles,  directly  for  the  auriculoventricular 
valves  and  indirectly  forthesigmoidal,  and  the  fall  and  shock 
of  the  sigmoidal  is  caused  by  the  arterial  pressure  which  acts 
upon  their  superior  surfaces,  and  this  arterial  pressure  being 
the  work  of  the  ventricular  systole  it  is  always  this  systole 
which  brings  about  the  closure  of  the  orifices  and  the  val- 
vular sounds,  and  by  the  intensity  of  this  ventricular  systole 
is  determined  the  intensity  of  the  bruit.  Potain  calls  atten- 
tion to  the  accessory  causes  not  generally  taken  into  account 
which  may  modify  the  bruits.  The  first  mitral  sound  espe- 
cially is  modified  by  the  cushion  of  blood  as  well  as  by  the  su- 
perimposed lung  interposed  between  the  heart  and  the  chest- 
wall.  It  is  generally  laid  down  that  hypertrophied  states  of  the 
ventricular  wall  attenuate  the  sounds,  while  simple  dilation 
augments  them.  Potain,  however,  shows  that  there  are 
manifold  variations  of  this  rule;  for  the  augmentations  or 
diminutions  are  often  transitory  and  cannot  be  attributed  to 
constant  organic  changes.  Again,  the  blood-wave  in  the  ves- 
sels is  often  strong,  while  the  valvular  sounds  appear  weak 
and  this  is  a  curious  alteration  which  the  state  of  the  ven- 
tricle will  not  explain.  Potain  seeks  the  cause  in  the  modi- 
'  fication  of  the  mechanism  of  valvular  closure.  He  holds 
that  the  closure  of  the  mitral  valves  is  determined  by  the 
elasticity  of  the  ventricle,  which  fact  accounts  for  the  varia- 
tion in  intensity  of  the  first  sound,  and  he  further  suggests 
that  an  analogous  explanation  may  be  given  for  alterations 
of  the  second  sound,    [t.l.c] 

January  23,  1901. 

1.  Thoracic  Pain  in  Peritonitis  Following  Perforation  of  the 
Stomach.    M.  J.  L.  Fadee. 

1. — Faure  has  observed  the  symptom  of  thoracic  pain 

in  the  peritonitis  followed  by  perforation  of  the  stomach.  In 
hia  first  case  the  pain  was  at  first  of  sharp,  violent  character, 
and  confined  to  the  stomach,  then  radiating  to  a  point  below 
the  left  shoulder.  The  patient  presented  signs  of  abdominal 
distention  with  general  abdominal  tenderness,  but  no  appreci- 
able point  of  maximum  intensity.  Laparotomy  was  per- 
formed, and  the  lesser  cavity  filled  with  pus,  which  appeared 
to  come  from  the  region  of  the  appendix.  Free  drainage 
was  established,  and  the  patient  died  5  hours  after  operation. 
At  postmortem  a  perforation  of  the  stomach  was  found.  In 
his  second  case,  sharp  pain  from  a  similar  condition  was  felt 
between  the  shoulders.  Autopsy  following  the  operation 
which  showed  the  presence  of  a  general  peritonitis,  con- 
firmed the  diagnosis  of  perforation  from  gastric  ulcer.    Faure 


concludes  that  acute  morbid  conditions  of  the  abdominal 
viscera  and,  in  particular,  perforation  of  the  stomach  are 
often  accompanied  by  thoracic  pain,  either  dorsal,  scapular, 
or  intrascapular.  In  cases  of  general  peritonitis  of  undeter- 
mined origin,  the  recoguition  of  this  symptom  is  of  the 
greatest  importance.  We  should  make  the  most  careful  in- 
quiries as  to  the  existence  of  this  pain  at  any  time  during 
the  disease.  Such  knowledge  would  indicate  the  point  of 
election  for  the  surgical  incision,     [t.l  c] 


R^vue  de  Chirurgie, 

Jamutry,  1901.    [21me  Annt'C,  No.  1.] 

1.  Ligation  of  the  Abdominal  Aorta.    P.  Tillaux  and  P. 

RiCHE. 

2.  The  Treatment  of  Infected  Wounds.    0=cak  Bloch. 

3.  The  Study  of  Osteomalacia.    G.  GAYETand  L.  M.  Bonnet. 

4.  Phlebitis  of   the  Left  Leg  with   Appendicitis.      Eugene 

ViLLARD  and  Paul  Viqnard. 

5.  E  ;tokelo8tomy.    Vitrac. 

6.  Some  Remarks  Upon  a  Case  of  Obturator  Hernia.  Piekre 

Fredet. 

2. — Oaly  since  Lister,  have  infected  wounds  been  well 
treated.  Naturally  in  every  case  the  best  result  would  be 
union  by  first  intention,  though  union  by  second  intention  ia 
often  the  best  result  obtained.  All  wounds  contain  microbes, 
yet  infected  wounds  often  heal  by  first  intention.  To  pre- 
vent the  growth  of  microbes  in  retained  secretions,  antisep- 
sis and  drainage  are  necessary.  Bloch  recommends  the 
use  of  carbolic  acid  as  an  antiseptic.  Dressings  applied 
should  always  be  Sterile,  and  drainage  should  always  be 
adequate.  After  being  dressed,  wounds  must  be  kept  im- 
mobile. The  only  general  treatment'  advised  is  the  use  of 
the  salicylates,  with  stimulants  when  necessary.  The  use  of 
Marmorek's  antistreptococcic  serum,  while  probably  innocu- 
ous, has  not  yet  been  proved  so.  Therefore  Bloch  does  not 
advocate  its  use.    [m.o.] 

4. — After  mentioning  the  occurrence  of  pleurisy,  hepatitis, 
and  psoitis  with  appendicitis,  Villard  and  Vignard  have 
recently  observed  two  cases  complicated  with  phlebitis  of 
the  leift  leg.  The  first  case  occurred  in  a  man  aged  26 
years.  Ttiree  months  before  he  had  had  his  first  attack  of 
appendicitis.  The  second  attack  lasted  5  days,  after  which 
he  was  operated,  the  appendix,  which  was  very  long,  being 
removed.  On  the  day  following  the  opera  ion  he  complained 
of  pain  in  the  left  leg.  The  next  day  dyspnea  and  fever  be- 
gan, followed,  a  day  later,  by  the  appearance  of  a  marked 
phlebitis.  Cough  with  bloody  expectoration  followed.  Soon 
all  the  signs  of  a  pulmonary  infarct  were  found.  The  second 
case  was  very  grave,  with  purulent  appendicitis  and  phlebitis 
of  the  left  leg  following  operation.  Two  other  cases  are  also 
reported.  Ot  these  four  cases  2  died.  There  would  be  noth- 
ing extraordinary  in  thrombosis  of  the  right  femoral  vein. 
But  it  occurs  more  frequently  on  the  left  side,  which  is  ex- 
plained as  a  distant  manifestation  of  the  general  infection, 
appendicitis.  It  is  evidently  metastasis  through  the  circula- 
tion. Its  occurrence  as  a  complication  in  appendicitis  makes 
the  prognosis  unfavorable.  Its  treatment  is  the  same  as  for 
ordinary  phlebitis.    Lm.o  ] 

6. — Ectokelostomy  is  an  operation  by  which  the  »ac  of 
a  hernia  is  kept  open  with  drainage,  the  whole  being  dis- 
placed through  a  counter-opening  in  the  abdominal  wall,  the 
hernia  being  then  cured  radicilly.  Vitrac  has  performed 
ectokelostomy  twice  in  women  aged  54  and  84  years.  Both 
had  strangulated  femoral  hernia,  and  both  recovered 
with  excellent  results.  Cucain  wa«  used  for  one,  the  other, 
however,  was  done  without  any  anesthetic.  Vitrac  describes 
the  technic  of  the  operation,  dividing  it  into  6  steps  ;  open- 
ing the  hernial  sac,  and  freeing  it  from  all  adhesions ;  making 
an  incision  into  the  abdominal  wall,  through  which  the  her- 
nial sac,  after  being  freed  from  the  anterior  abdominal  wall, 
is  drawn ;  placing  a  drainage  tube  in  the  sac,  protruding 
through  the  abdominal  wound  ;  performing  the  operation  for 
the  radical  cure ;  and  finally  removing  the  drainage  tube. 
By  this  method,  all  exudate  in  the  peritoneal  cavity  is  well 
drained  ofi",  and  at  the  same  time  the  drainage  does  not  in- 
terfere with  the  radical  cure  of  the  hernia.  Eight  illustra- 
tions explain  the  technic  of  the  operation,    [m  c] 

6.— This  obturator  hernia  waa  not  discovered  until 


430 


The  Phii.adki.phia'1 
Medical  Jooenal  J 


THE  LATEST  LITERATURE 


[Maech  2,  19M 


after  death,  upon  the  cadaver.  No  clinical  history  is  known. 
After  a  detailed  description  of  this  hernia,  Fredet  concludes 
that  obturator  hernia  may  have  a  double  sac.  If  this  is  the 
cafe,  they  are  produced  inside  of  the  umbilicri  artery.  The 
outer  sac  is  supplied  by  the  prevesical  fascia.  This  explains 
the  anatomic  connection  between  the  bladder  and  the  hernia. 
The  possibility  of  the  production  of  the  hernia  inside  the 
umbilical  artery  presupposes  the  presence  of  an  artery,  sorne- 
times  permeable,  above  and  outside  the  neck  of  the  hernia. 
The  hernial  sac,  when  in  the  subpubic  canal,  may  cause 
painful,  paralytic  phenomena  in  the  sphere  of  the  obturator 
nerve  ;  which  phenomena  decrease  when  the  hernia  emerges 
from  the  subpubic  canal ;  yet  the  external  obturator  nerve 
may  stop  the  hernia,  so  that  it  move  behind  the  external 
obturator  muscle,     [m.o.] 


P.  Heim. 


Archives  de  Medecine  des  Gafants. 

January,  1901.     [Vol.  iv.  No.  1.] 

1.  Lithemia  in  Children.    Jules  Com  by. 

2.  Leukocytosis  in  Pneumonia  and  in  Diphtheria. 

3.  Empyema  in  Children.     Bez^'  and  Bahby. 

1. — The  symptoms  of  lithemia  in  children  are  so  varied 
that  they  are  not  diagnosed  positively  without  study,  espe- 
cially with  reference  to  ancestry.  For  the  children  of  gouty 
parents  have  a  decided  tendency  toward  the  lithemic  dia- 
thesis. After  quoting  cases  reported  by  Ratchford  and  Whit- 
ney, Comby  details  15  case-hittories  showing  the  many  dif- 
ferent symptoms  found  in  lithemic  children.  He  then 
classifies  the  symptoms  under  7  headings,  considering  the 
most  important  periodic  headache,  and  cyclic  vomit- 
ing. The  symptoms  suggest  a  grave  autointoxication,  but 
the  history  of  eout  iil  the  parents  soon  leads  to  the  diagnosis 
of  lithemia.  The  urine  shows  high  specific  gravity,  with  an 
excess  of  urea  and  uric  acid.  Hygiene,  exercise,  regular 
meals  with  little  meat,  and  alkaline  waters  constitute  the  main 
treatment,     [m  o  ] 

2.— The  leukocytosis  in  croupoas  pneumonia  and 
diphtheria  in  children  depends  upcn  the  virulence  of  the 
microbes  and  their  toxins,  and  the  reaction  of  the  organism 
to  them;  From  19  cases  of  croupous  pneumonia,  in  which 
Heim  counted  the  leukocytes,  the  result  waa  a  constant  in- 
crease of  the  leukocytes  up  to  one  or  two  days  before  the  cri- 
sis, when  they  fell  suddenly  again  to  normal.  When  lysis 
occurred  rarely,  the  leukocytes  decreased  gradually  also. 
Hypoleukocytosis  is  always  a  serious  prognostic  sign,  though 
not  necessarily  fatal.  All  the  cases  showed  a  great  increase 
in  the  neutrophilic  polynuclears,  with  a  relative  decrease  in 
the  lymphocytes.  Eosiuophiles  are  absent  in  croupous 
pneumonia,  only  appearing  a  day  before  the  crisis.  This 
will  beip  to  differentiate  croupous  pneumonia,  meningitis, 
pleurisy,  and  tubercular  pneumonia,  in  which  diseases  the 
eosinophiles  are  abundant.  In  diphtheria  the  leukocytosis 
may  be  extreme,  Heim  having  seen  28,080  in  one  case.  The 
leukocytes  increase  very  rapidly,  even  before  the  membrane 
appears.  Then  they  decrease  gradually.  If  complications 
exist,  the  leukocytosis  persists.  Irjections  of  antidiphtheritic 
serum  decrease  it,  but  it  rises  again  later.  If  the  leukocytes 
do  not  decrease  in  number  after  a  serum  irjection,  enough 
serum  has  not  been  given.  The  polynuclear  leukocytes  are 
increased,  with  a  proportionate  decrease  in  the  lymphocytes. 
Eosinophiles  are  very  few  in  pure  diphtheria,  but  are  seen 
if  the  throat  condition  is  due  to  streptococcus.  If  the  poly- 
nuclear neutrophiles  remain  above  50^  the  day  after  the 
serum  injection,  the  prognosis  is  grave,     [mo.] 

3.— E^zy  and  Bauby  report  3  cases  of  empyema  in 
children.  The  first  case  occurred  in  a  boy  of  4,  who  had  a 
sudden  attack  of  dyspnea,  following  a  few  weeks  after  pneu- 
monia. As  there  was  distinct  movable  dulness  on  the  left 
side,  he  was  tapped,  two  liters  of  pus,  which  showed  pneu- 
mococci,  being  removed.  A  week  later  he  was  again  tapped 
and  a  liter  of  pus  removed.  Operation  followed,  with  drain- 
age, and  he  recovered  in  another  week.  The  second  case,  a 
boy  of  9,  had  empyema  on  the  left  side  following  typhoid 
fever.  He  was  tapped  and  operated  on  at  once.  The  yellow 
pus  contained  streptococci  and  colon  bacilli.  He  also  recov- 
ered. The  third  case,  a  boy  of  30  months,  had  had  diarrhea 
for  over  two  months  when  dulness  was  noted  upon  the  apex 
of  the  right  lung.    When  ready  to  tap  him,  he  vomited  a 


cupful  of  pua  which  contained  streptococci,  staphylococci, 
and  colon  bacilli.  He  continued  to  expectorate  pus,  but 
recovered  gradually  in  two  months  more.  These  histories 
are  discussed  in  full,     [m.o] 


Journal  de  Medecine  de  Bordeaux. 

Ftbruary  3,  1901.     [31me  Ann^e,  No.  5] 

1.  A  C-ise  of  Penetrating  Ganshot  Wound  of  the  Abdomen. 

M.  Hasslee. 

2.  Subdural  Serous  Cysts FoUowingCranial  Injury.  F.  Villas. 

3.  Mercurial  lojections  in  Syphilis.    A.  Gcebin. 

1. — The  patient,  a  native  bugler  of  the  Foureau-Lamy 
expedition  in  Africa,  received  his  first  wound  in  the  right 
leg,  and  his  second,  upon  the  Eame  day,  in  the  abdomen. 
The  wound  waa  dressed  at  once,  and  he  was  taken  to  camp 
in  a  canoe.  He  was  kept  at  rest  for  23  days.  Then,  as  camp 
was  moved,  he  started,  mounted  upon  an  ox,  which  method 
of  locomotion  caused  him  so  much  pain  that  he  got  down 
and  walked,  supporting  himself  upon  his  gun.  Six  weeks 
later  he  reached  Bordeaux.  A  probe  was  introduced 
into  the  fistula,  which  had  existed  since  he  had  been  shot, 
and  the  bullet  was  found.  No  skiagraplis  were  made.  He 
was  thin  and  anemic;  otherwise, however, in  good  condition. 
Toe  bullet,  weighing-  20  grams,  was  extracted  with 
d'fficulty.  The  intestines  were  not  opened,  the  entire 
fistulous  tract  being  dissected  out.  He  recovered  in 
6  weeks  and  left  for  his  African  home.  This  case  was  of  great 
interest,  because  the  bullet  had  a  steel  casing ;  because  its 
deformity  showed  that  it  had  already  struck  once  and  had 
then  been  deflected ;  and  because  calcareous  particles  and 
bits  of  clothing  were  found  in  the  aVdominal  fistula,     [m  o.] 

3. — Ciu(Srin  describes  the  different  preparations  of 
mercury  which  can  be  given  hypodermically.  He  also 
details  the  doses  and  the  technic  of  the  injections.  The 
soluble  salts  of  mercury,  the  blniodid,  benzoate,  and 
bichlorid  can  be  given  in  fractional  dosep,  or  calomel  may 
be  employed,  though  it  may  cause  intense  reaction  at  the 
eeat  of  injection.  Guerin  advises  the  administration 
of  mercury  in  subcutaneous  injections  as  a  routine 
practice,     [mo] 

February  10, 1901.     [31me  Ann^e,  No.  6] 

1.  Unrecognized  Cases  of  Whooping-cough.    R.  Saint  Phi- 

LirPE. 

2.  Subdural  Serous  Cysts   Following  Cranial    Injuries.    F. 

ViLLAR. 

3.  The  Leukocytes  in  Cises  of  Cancer,    kvcut  and  Vaillast. 

4.  A  Foreign  Body  in  the  Rectum.    A.  Fralkin. 

1. — Saint- Philippe  says  that  pertussis  may  exist  without 
the  spasmodic  cough,  or  the  typical  whoop.  Sneezing  may 
take  its  place,  often.  Rales  are  generally  heard,  and  naso- 
pharyngeal catarrh  may  be  present,  with  adenoids.  On 
account  of  its  extreme  contagion,  audits  ubiquity, he  advises 
that  every  child  with  a  longstanding  cough  be  carefully 
watched.  Children  who  expectorate  are  generally  far 
advanced  in  whooping-cough.  If  pertussis  be  present,  scratch- 
ing the  trachea  will  elicit  a  typical  paroxysm.  For  the  treat- 
ment, and  to  prevent  the  severe  seqrela,  especially,  minute 
scrutiny  of  all  suspicious  cases  must  be  routinely  practised. 
[M.o.] 

2.— Villar  details  2  cases  of  traumatic  epilepsy,  the 
attacks  having  occurred  for  the  first  time  14  and  4  years  afler 
the  cranial  injury.  In  both  cases  subdural  serous  cysts 
were  found.  They  were  caused  by  the  traumatism,  years 
before,  which  had  set  up  hemorrhagic  meningitis,  the  resu'ts 
of  which  these  circumscribed  serous  cysts  at  the  point  of 
hemorrhage.  The  only  treatment  is  trephining,  with  the 
evacuation  of  the  cysts.  In  neither  case  was  there  a  return 
of  symptoms  after  operation,     [m.o.] 

3. — Leukocytosis  is  an  acknowledged  fact  in  cancer. 
Four  cases  are  reported,  the  first,  epithelioma  of  the  tongue, 
gave  19,%4  leukocytes;  the  second,  scirrhous  cancer  of  the 
stomach,  showed  16,740  leukocytes  ;  the  third,  rodent  ulcer 
of  the  face  of  7  years'  duration,  5,S9<.i  leukocytes :  and  the 
fourth,  a  tumor  of  the  abdomen,  of  unknown  character, 
showed  21,7lX)  leukocytes.  The  blood-examination  in  the 
third  case,  the  rodent  ulcer,  showed  the  blood  to  be  normal 


liABcn  2,  1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
L  Medical  Jocknal 


431 


in  all  respects.  In  the  first  2  cases,  the  leukocytes  were 
markedly  increased  in  number,  with  a  relative  increase  in 
the  polynuclear  leukocytes,  and  the  lymphocytes.  The 
count  of  the  leukocytes  in  the  last  case  suggests  that  the  tumor 
may  be  cancerous,  from  the  evident  leukocytosis,  [m  o] 
4. — Fraikin  reports  the  case  of  a  farmer,  from  whose 
rectum  he  extracted  a  brush-handle,  without  causing 
him  any  pain  at  all.  After  dilating  the  sphincter,  with  the 
patient  in  the  knee-chest  position,  he  caught  one  end  of  the 
wooden  handle  with  difficuly,  and  slowly  withdrew  it.  The 
farmer  said  that  it  had  entered  when  he  fell  upon  it  from  a 
ladder.  He  had  had  no  symptom?,  but  the  foreign  body 
was  easily  felt  through  the  skin,    [m.o  ] 


Journal  des  Praticiens. 

February  2,  1901.    [15me  Ann6e,  No.  5.] 

1.  Intravenous  Irjections  of  Normal  Salt-Solution  in  Puer- 

peral Hemorrhage.    Chaeles  Mayqrier. 

2.  Post- Influenza  Polyneuritis.    Breton. 

1. — Maygrier  gives  detailed  histories  of  15  cases  of  hem- 
orrhage treated  by  normal  salt-solution  injected 
intravenously,  7  of  whom  recovered.  The  other  8  died. 
In  7  cases,  hemorrhage  was  due  to  vicious  insertion  of  the 
placenta,  to  abortion,  and  to  premature  detachment  of  the 
placenta,  each,  in  2  cases  ;  and  it  occurred  with  child-birth  in 
4  cflsps.  The  amount  injected  varied  from  700  to 
2000  grams.  In  many  cases,  subcutaneous  injections 
were  given  besides.  The  indication  for  the  injection  is  the 
severe  anemia,  the  lowered  general  condition.  Maygrier 
advises  intravenous  injections  when  subcutaneous 
injections  have  on  effect,  or  when  death  seems  im- 
minent.  They  should  even  be  repeated  if  necessary,     [m.o.] 

2. — Breton  reports  a  case  of  polyneuritis  in  a  cham- 
bermaid, aged  27  years,  who  was  always  nervous  and  ex- 
citable. She  had  had  a  distinct  attack  of  hysteria  some 
years  previous.  The  polyneuritis  appeared  3  months  after 
an  attack  of  influenza,  and  lasted  2  months.  During  the 
influenza,  paralysis  of  the  legs  existed,  but  then  disappeared. 
The  neuritis  affected  both  arms  and  legs.  The  left  side  was 
most  involved.  But  the  sphincters  were  at  no  time  affected, 
and  the  muscular  atrophy  was  slight,    [m.o] 


II  Policlinico. 

(Sezione  Pratica.) 

November  24,  1900.     [Anno  vii,  Fasc.  4.] 

1.  Transactions  of  Congresses. 

2.  Contribution  to  the  Study  of  the  Rhj  thmical  Shocks  Im- 

parted to  the  Head  in  Patients  Suffering  from  Aneu- 
rysm.    G.  COCORULLO. 

8.  Contribution  to  the  Diagnosis  of  Measles.    G.  Moeano. 

1. — D'Urso  (Italian  Surgical  Association,  Rome,  October, 
1900)  gave  an  account  of  experimental  researches  on 
the  pathogenesis  of  hydronephrosis  carried  out  on 
rabbits  and  dogs  by  ligature  of  the  ureter.  Rosa  showed  a 
case  in  which  he  had  sutured  with  complete  success  a  bra- 
chial artery  wounded  longitudinally  during  venesection  by  a 
phlebotomist.  Bagi  reported  on  6  cases  of  tubercular  peri- 
tonitis cured  by  the  iodoiodurate  injections  of  Durante.  Each 
injection  contained  from  1  to  2  cgr.  of  iodin,  and  from  22  to 
90  injections  were  required  to  complete  the  cure  in  the  dif 
ferent  cases.  Jaja  described  4  cases  of  vesical  exstrophy  and 
1  of  epispadias  treated  by  grafting  the  ureters  into  the  rec- 
tum. The  anal  sphincters  retained  the  urine  well  for  4  to  5 
hours  at  a  stretch.  It  was  not  found  possible,  however,  to 
avoid  ascending  renal  infection.  Betagh  presented  2  cases 
of  papilloma  of  the  urinary  bladder  diagnosed  by  aspiration 
of  the  vesical  contents  through  a  metal  catheter.  Diagnosis 
by  the  cystoscope  was  impossible  owing  to  the  turbidity  of 
the  urine  from  blood.  Rizzo,  arguing  from  the  results  of  ex- 
periments on  dogs,  recommended  the  ligature  of  the  sper- 
matic vessels  in  cases  of  enlarged  prostate,  in  place  of  division 
of  the  vas  deferens.  Pascale,  from  anatomical  observations 
and  experiments,  drew  the  conclusion  that  in  cases  of  hyste- 
rectomy for  fibromyomata  of  the  uterus,  the  ovaries,  having 
already  lost  their  function,  may  be  removed  in  most  cases 
without  doing  harm.  In  young  women,  however,  he  would 
leave  them.    At  the  Obstetrical  and  Gynecological  Congress 


(Naples,  October  20-23)  Pestalozza  related  2  cases  in  which 
there  was  a  recurrence  of  extrauterine  pregnancy  in  the  same 
patient,  in  1  case  for  a  second  time.  This  recurrence  is  com- 
paratively frequent  in  such  cases,  108  of  which  he  had  col- 
lected from  the  literature  of  the  subje<  t.  Ciivio  and  Ferrari 
spoke  on  the  subject  of  hematocele,    [o  s.b  ] 

2.— CocoruUo  describes  a  case  of  subclavian  aneurysm  ex- 
hibiting this  phenomenon.  The  patient,  a  man  3t>  years  of 
age,  showed  signs  and  symptoms  pointing  as  was  thought 
to  aneurysm  of  the  innominate  artery,  namely,  asynchronism 
of  the  two  radial  pulses,  an  area  of  dulness  higher  up  and 
more  to  the  right  than  that  usually  associated  with  aneurysm 
of  the  aortic  arch,  and  a  double  rhythmical  movement  of  the 
head,  vertical  and  rotatory.  The  autopsy  revealed  a  dissect- 
ing aneurysm  of  the  right  subclavian  and  first  part  of  the 
axillary  arteries,  proving  that  such  rhythmical  movements 
of  the  head  are  not  peculiar,  as  is  generally  supposed,  to 
aneurysms  of  the  arch  of  the  aorta.  As  to  the  cause  of  the 
movements,  this  varies  according  to  the  situation  of  the  pul- 
sating sac.  In  aneurysm  of  the  arch  they  are  due  in  part  tc> 
the  downward  push  given  to  the  right  bronchus  and  the 
backward  push  to  the  trachea  (nodding  movement) ;  in  that 
of  the  large  intrathoracic  vessels  they  result  from  the  jar  to 
the  costal  attachments  of  the  scalene  muscles  and  the  clav- 
icular attachment  of  the  sterno  cleido-mastoid  (lateral  rota^ 
tory  movement),     [g.s.b  ] 

3. — A  short  account  of  a  series  of  cases  of  measles  in 
which  Koplik's  sign  was  looked  for.  Of  15  infected  persons, 
10(06  %)  showed  the  characteristic  marks  on  the  mucous 
membrane  of  the  cheeks,  from  2  to  4  days  before  the  appear- 
ance of  the  general  eruption,     [g  s.b.] 

December  1, 1900.    [Anno  vii,  Fasc.  5.] 

1.  Why  Was  There  an  Increased  Mortality  from  Diphtheria 

Among  Children  in  Rome  During  "the  Present  Year  ? 
L.  M.  Spolverini. 

2.  On  (he  Discovery  of  the  Method  of  Rendering  Animal 

Vaccine  Bacteriologically  Pure.    T.  R.  Doria. 

1.— A  study  of  the  period  extending  from  July  1,  1895,  to 
May  31,  1900,  shows  that  the  introduction  of  the  serum 
treatment  of  diphtheria  into  Rome  reduced  the  case  mortality 
of  that  disease  from  60  or  70^  to  about  16%.  At  this  latter 
figure  the  death-rate  remained  almost  stationary  during  the 
first  four  years  under  consideration,  when  suddenly  a  sharp 
rise  took  place  not  only  in  the  death-rate,  which  increased  to- 
over  28% ,  but  also  in  the  number  of  cases  of  diphtheria.  The 
causes  of  this  increase  are  to  be  sought  in  (1)  previous  ill- 
nesses predisposing  to  infection ;  (2)  the  localization  of  the 
infection ;  (3)  the  association  with  the  bacillus  of  LofBer  of 
other  bacteria ;  (4)  complications,  especially  intercurrent 
affections ;  and  (5)  the  method  of  treatment.  The  pr^ispos- 
ing  disease  in  the  present  instance  was  measles,  as  is  clearly 
shown  in  the  statistical  tables  given,  which  also  exhibit  the 
marked  effect  it  had  upon  the  rate  of  mortality.  Owing 
probably  to  the  same  cause  there  was  an  unusual  percentage 
of  laryngeal  cases  with  a  mortality  of  31%.  In  the  mixed 
infections  (with  streptococci,  staphylococci,  pneumococci, 
etc)  the  mortality  reached  40%.  Of  acute  intercur- 
rent affections,  which,  owing  to  measles,  were  twice 
as  numerous  as  in  previous  years,  the  most  deadly  was 
bronchopneumonia  (with  a  mortality  of  70%).  Anti- 
diphtheritic  serum  was  employed  exclusively  in  the  treat- 
ment of  all  the  hospital  cases,  but  nevertheless  the  percentage 
of  deaths  was  high,  owing  to  delay  in  bringing  patients  to 
hospital  and  the  consequent  loss  of  time  in  commencing  the 
injections.  When  administered  on  the  first  day  of  the  attack, 
the  beneficial  effect  of  the  serum  is  unfailing,  but  after  the 
third  day  it  has  little  or  no  power  to  influence  the  course  of 
the  disease,    [qsb] 

3. — In  the  report  by  the  Lancet  commissioners  on  the 
conservation  of  vaccine  lymph,  April  28,  1900,  it  was  stated 
that  the  merit  of  this  discovery  of  the  best  method  was  due 
to  Copeman,  Chambon,  and  Saint  Yves- Menard.  By  Doria 
this  honor  is  claimed  for  Professor  Leoni,  formerly  Director 
of  the  Vaccine  Institute  of  Rame,  who  waa  the  first  to  de- 
monstrate that  vaccine  virus  in  the  fresh  state  is  contaminated 
by  germs,  and  that  these  germs  disappear  in  vaccine  virua 
preserved  with  glycerin  under  certain  conditions  of  tempera- 
ture, after  3  or  4  weeks.  Leoni's  experiments  determining 
this  important  fact  were  made,  it  is  stated,  in  1889.      [o  SB,] 


432 


The  Philadelphia"] 
Medical  Journal  J 


PRACTICAL  THERAPEUTICS 


[Masch  2,  IMl 


practical  CI]crapcutic5. 


Smokers'  Gingivitis; — 

R. — Salol 1  part. 

Tinct.  caiechu    4  parts. 

Spr.  menth.  pip 120  parte. 

M.  ft.  lotio.  S.  Teaspoonful  in  half  a  glass  of  tepid  water 
as  a  mouth- wash. — Inrlian  Medical  Journal,  Calcutta. 

Digitalis  and  its  Derivatives. — J.  P.  Arnold  and  H. 
C.  Wood,  Jr.,  Amer.  Jour.  Med  Set.,  Aug.,  1900,  found  that : 

1.  Digitalin  and  digitoxin  each  represent  the  full  circula- 
tory pt.wers  of  digitalis. 

2.  Digitalis,  digitalin  and  digitoxin  stimulate  the  cardio- 
inhibitory  mechanism,  both  centrally  and  peripherally.  In 
larger  doses  they  paralyze  the  intrinsic  cardioLnhibitory 
apparatus. 

3.  They  all  cause  a  rise  of  blood-pressure  by  stimulating 
the  heart  and  conetricting  the  bloodvessels. 

4.  Very  large  doses  paralyze  the  heart  muscle  of  the  mam- 
mal, the  organ  stopping  in  the  diastole. 

5.  Digitalm  of  M^rck  is  a  stable  compound,  1  gram  of  it 
being  equivalent  to  about  70  cubic  centimeters  (18  drame)  of 
tincture  of  digitalis. 

6.  Digitoxin  is  not  to  be  recommended  for  human  medica 
tion  on  account  of  its  irritant  action,  which  makes  it  liable 
to  upset  the  stomach  when  given  by  the  mouth,  or  to  cause 
abscesi-ee  when  given  hypodermirally,  and  on  account  of  its 
insolubility,  which  renders  it  slowly  absorbed  and  irregularly 
eliminated,  having  a  marked  tendency  to  cumulative  action 

Oiutment  for  External  Hemorrhoids. — 

U. — Chrysarobin  15  grains. 

Iodoform  5  grains. 

Ext.  belladonna  10  grains. 

Vaeelin  4  drams. 

M.  Ft.  unguentum.  Sig.  Apply  locally  n'ght  and  morn- 
ing, first  cleansing  the  parts  well  with  water. — New  York 
State  Journal  of  Mulicine. 

Use  and  Abuse  of  Potassium  Iodide  in  Oplitbalmic 
Practice. — Dr.  Alriert  Rufus  Baktr  (The  Juurnal  American 
Medical  Association,  November  17,  1900)  comes  to  the  follow- 
ing conclusions  : 

1.  Iodide  of  potassium  should  generally  be  administered  in 
rapidly  increasmg  doses  until  from  1  to  500  grains  are  given 
daily. 

2.  The  drug  should  always  be  given  after  eating,  and  well 
dilutfd  with  water. 

3.  Frequent  hot  baths  are  essential  to  the  best  resulta  in 
the  use  ot  the  remedy. 

P   4.  Not  infrequently  large   doses  will  be  tolerated    when 
smaller  ones  can  not  be  well  taken. 

5.  The  use  of  the  laige  dose  is  not  limited  to  syphilitic 
cases. 

6.  Large  doses  are  indicated  in  optic  neuritis,  ocular 
paralysis,  choroiditis,  serous  iritis  and  in  relapsing  iritis, 
cyolilis  and  interstitial  keratitis. 

7.  It  is  contraindicated  in  gray  atrophy  of  the  optic  nerve 
and  in  mostca-es  of  postneuritic  origin. 

8.  Albumin  in  the  urine,  generally  speaking,  is  a  contrain- 
dication for  large  doses  of  iodide. 

9.  Young  children  do  not  take  the  iodide  kindly  and  it 
should  be  administered  cautiously. 

10.  The  remedy  is  of  doubtful  value  in  early  syphilitic  iritis. 

11.  Large  doses  are  of  doubtful  utility  in  the  removal  of 
postoperative  exudates,  but  should  be  given  further  trial. 

Diuretic  in  Cardiac  and  Renal  Dropsy.— 

^-|l::xt.^Sns.}ofeach  4  drams. 

Fl.  ext.  iaborandi  1  ounce. 

Fl.  ext.  digitalis 30  drops. 

Nitrate  of  potash 5  drams. 

Angelica  wine 2  ounces. 

Sig. — A  teaspoonful  every  3  hours 

— Med.  Cycl.  oj  Prod.  Med. 


To  Preserve  Cocain. — 

B  . — Cocain  hydrochl  4  grains. 

Acid  salicylici  J  grain. 

Aqua  deetil 3  drams. 

— Jour,  de  Med.  de  Parit. 

The  Therapeutic  and  Diagnostic  Employment  of 
Suprarenal  Preparations  in  the  Upper  Respiratory 
Cavities. — Mosse  (Die  Therapie  der  G(genwart,  1900,  No.  12) 
has  emploj'ed  suprarenal  extract  in  various  cases  of  nose 
and  throat  diseasea.  Immediately  upon  application  of  the 
remedy  a  local  anemia  takes  place  which  lasts  but  a  few 
hours.  While  the  practical  value  of  the  remedy  in  these 
diseases  is  only  a  limited  one  as  far  as  therapeutics  are  con- 
cerned, it  i?,  however,  of  some  diagnostic  importance.  For 
this  purpose  it  can  be  used  in  conjunction  with  probes 
instead  of  cocain,  wherever  it  is  to  be  determined  whether 
the  disease  of  the  naaal  mucous  membrane  is  due  to 
hyperemia  or  to  increase  of  tissue. 

Early  Cough  and  Fever  in  Pneumonia.— 

K . — Potassium  citrate 6  drams. 

.Spirit  nitrous  ether 4  drams. 

Camphorated  tincture  opium  4  drams. 

Solution  potassium  citrate,  to  make 6  ounces. 

Dessertspoonful  every  3  hours. 

— Hughes  {St.  Louis  Clinic.) 

The  Treatment  of  the  Paroxysmal  Stage  of 
Whooping-cough.— Godson  {British  Mtdical  Journal,  No- 
vember 3,  1900),  as  the  result  of  a  collective  investigation, 
found  that  in  the  treatment  of  whooping-cough  the  drugs 
commonly  employed  and  chiefly  depended  upon  were  »nti- 
pyrin,  belladonna,  bromides,  carbolic  acid,  creosote,  and 
opium,  while  as  accessory  and  occasionally  useful  drugs 
chloral  hydrate,  quinin  and  butyl-chloral-hydrate  were  men- 
tioned. The  antispasmodics  are  always  combined  with  ex- 
pectorants, of  which  the  alkalies  are  the  greatest  favorites. 
Inhalants  appear  to  be  in  general  use,  the  ones  referred  to 
being  carbolic  acid,  creosote,  bromoform,  and  chloroform. 
None  of  the  answers  that  were  received  were  enthusiastic 
except  from  those  who  had  used  creosote.  The  simplest  and 
best  method  of  administration  is  to  sprinkle  the  drug  on  a 
cloth,  and  hang  the  cloth  in  the  sickroom  or  nursery  to  dry. 
The  method  of  treatment  that  the  author  has  found  most 
satisfactory  is  the  following :  Commence  at  once  with  the 
continuous  inhalation  of  creosote.  Ciear  the  lungs  of  bron- 
chitis as  much  as  possible  before  using  any  special  internal 
antispasmodic  remedies.  In  bronchopneumonia,  howtver, 
belladonna  appears  at  once  to  do  good.  In  all  cases,  if  or 
when  the  chest  is  fairly  clear,  and  the  circulation  is  good, 
antipyrin  may  be  given  in  suitable  doses.  Expectorants 
should  be  combined  with  the  antipyrin.  Good  air,  warm 
clothing,  sunlight,  and  wholesome  food  are  necessary  in  all 
cases. 

To  Remove  Cerumen. — Dr.  Godart,  of  Lyons,  recom- 
mends for  the  removal  of  pluglets  of  ear  wax  : 

K. — Pure  carbonate  of  sodium 1.00. 

Glycerin 20  cc. 

Distilled  water 20  c.c. 

A  few  drops  are  inserted  several  timee  a  day,  followed  by 
injections  of  water. 

Dyspepsia. — Sir  T.  Lauder  Brunton,  in  the  ClinicoJ  Jour- 
nal,  emphasizes  the  following  points  in  instructing  patients 
troubled  with  dyspepsia : 

1.  E  it  slowly,  masticate  and  insalivate  thoroughly.  And, 
if  necessary,  follow  Sir  Andrew  Clarke's  rule — coont  th« 
bites. 

2.  Take  the  solids  and  liquids  separately,  so  as  not  to  dilate 
the  gastric  juice  nor  weaken  the  digestive  ability  of  the 
stomach. 

3.  If  necessary,  let  the  patient  take  his  farinaceous  food 
and  the  proteins  at  diflferent  meals. 

4.  The  best  tluid  is  hot  water,  taken  early  in  the  morning 
and  an  hour  or  two  before  lunch  and  dinner. 

a.  Alkalies  before  meals  stimulate  secretion  of  gastric  juice. 
6.  .\cid8  before  meals  check  acid  secretions  of  the  stomach. 
c.  Where  the  food  remains  in  the  stomach  an  unusual 
length  of  time  lavage  should  be  resorted  to. 


Mabch  2,  1901] 


THREE  DANGEROUS  OPERATIONS 


[Thk  Philadelphia  4^^ 

Medical  Jodrnal  ^>Jt» 


©rtginal  2lrttclc5. 

THREE  DANGEROUS   OPERATIONS. 

Repair  of   Lacerated    Cervix,  Curettement   and    Rapid 
Dilatation  of  the  Cervix. 

By  JOHN  B.   DEAVER,   M.D., 

of  Philadelphia. 
Surgeon-in-Chief  to  the  German  Hospital. 

This  paper  is  intended  as  a  protest  against  the  in- 
discriminate use  and  abuse  of  three  operations  in 
surgery,  which  in  themselves  are  excellent  procedures 
and  capable  of  accomplishing  much  good  and  the  relief 
of  suffering.  We  cannot,  therefore,  condemn  the  oper- 
ations, but,  as  is  very  often  the  case,  they  are  performed 
without  due  deliberation  and  knowledge  of  the  indica- 
tions and  contraindications. 

Curettement,  rapid  dilatation  or  divulsion  of  the  cer- 
vical canal  and  repair  of  a  lacerated  cervix  call  for 
mature  judgment  and  skill  for  their  instigation  and  per- 
formance. It  would  be  difficult  to  say  from  which  one 
of  the  three  the  greatest  amount  of  harm  has  accrued, 
probably  from  curettement,  although  divulsion  is  very 
frequently  followed  by  untoward  symptoms. 

A  lacerated  cervix  in  women  who  have  bom  children 
is  so  common  that  it  may  be  considered  as  more  of  a 
normal  than  pathological  condition.  In  the  absence  of 
special  indications,  such  a  cervix  had  better  be  let  alone, 
for  to  operate  under  these  circumstances  subjects  the 
patient  to  useless  risks  without  a  commensurate  reward. 

If,  however,  a  lacerated  cervix  be  extensive  enough 
to  permit  gapping  of  the  edges  and  consequent  ex- 
posure of  the  cervical  mucous  membrane  to  injury,  or 
if  ulceration  be  present,  or  if  the  scar-tissue  is  hard 
and  in  excessive  amount,  or  if  any  of  these  conditions 
give  rise  to  subinvolution  or  marked  reflex  symptoms, 
then  operation  is  indicated.  If,  in  addition  to  any  of 
the  above  conditions,  there  is  a  history  of  hereditary 
tendencies  toward  malignancy,  we  have  the  strongest 
indication  for  operation.  A  patient  with  a  family  his- 
tory of  carcinoma  presenting  the  above  conditions 
should,  in  my  opinion,  be  operated  upon  at  the  earliest 
possible  moment,  and  this  should  be  repeated  after 
subsequent  labors  if  the  cervix  be  again  torn,  as  it  is 
likely  to  be. 

As  strong  as  these  indications  are  for  operative  inter- 
ference, we  are  not  justified  in  instituting  them  unless 
there  is  freedom  from  all  pelvic  inflammatory  processes 
or  their  results.  Salpingitis,  pyosalpinx  or  adhesions 
offer  strong  contraindications. 

Under  these  circumstances,  abdominal  section  for  the 
correction  of  the  intraabdominal  trouble  should  follow 
immediately  the  repairing  of  the  lacerated  cervix.  If 
the  cicatricial  tissue  in  a  lacerated  cervix  involve  the 
supravaginal  cervix,  it  may  be  sometimes  impossible 
to  remove  it  entirely  except  by  high  amputation  of  the 
cervix  with  freeing  of  the  bladder  and  rectum ;  if 
under  these  circumstances  there  is  a  history  of  a  hered- 
itary tendency  to  malignancy,  or  if  the  patient  be  near 
or  undergoing  the  menopause,  vaginal  hysterectomy 
may  be  considered  the  more  rational  procedure. 

In  the  presence  of  endometritis,  great  care  must  be 
exercised  to  prepare  the  endometrium  if  this  be  pos- 
sible prior  to  the  narrowing  of  the  cervical  canal,  so  as 
to  provide  adequate  drainage,  or  in  other  words,  to 
decrease  the  discharge  so  that  the  new  and  narrow 
canal  will  carry  it  off. 


Equally  as  important  is  it  to  carry  out  every  aseptic 
detail  during  the  operation  and  antiseptic  preparation 
of  the  field  of  operation  in  any  one  of  the  three  opera- 
tions under  discussion,  as  it  is  in  any  in  the  realm  of 
surgery. 

That  these  operations  are  capable  of  converting  a 
latent  salpingitis  into  an  active  one,  every  abdominal 
surgeon  of  experience  can  testify.  It  can  be  brought 
about  in  one  of  several  ways ;  first  and  most  impor- 
tant, by  the  introduction  of  sepsis  through  instruments 
or  intrauterine  douching,  or  the  spread  of  sepsis  from 
an  infected  uterine  cavity,  or  by  the  breaking  up  of  peri- 
uterine adhesions,  liberating  septic  foci  which  have 
been  imprisoned. 

Adhesions  can  be  torn  by  bringing  the  uterus  down 
to  the  vulvar  orifice  ;  the  tenaculum  should  only  be 
used  to  steady  the  uterus  and  not  to  make  traction 
during  dilatation  or  repairing  of  the  cervix. 

Washing  out  the  uterus,  except  in  septic  conditions, 
also  plugging  the  uterine  cavity  with  iodoform  gauze,  I 
regard  as  vicious  practices,  which  in  themselves  are  too 
often  capable  of  exciting  inflammation  in  the  fallopian 
tubes.  Even  in  septic  conditions  of  the  interior  of  the 
uterus,  the  intrauterine  douche  should  be  very  carefully 
done  and  the  packing  introduced  for  the  purpose  of 
drainage  and  not  to  its  exclusion.  Curettement  of  the 
uterine  canal  is  a  dangerous  operation  and  one  which 
calls  for  great  delicacy  of  touch  and  the  most  rigid 
observance  of  aseptic  and  antiseptic  details.  The  in- 
dications for  its  performance  are  positive,  although  one 
should  never  forget  the  contraindications. 

The  indications  are  for  the  correction  of  septic  con- 
ditions of  the  cavity  of  the  uterus,  both  acute  and 
chronic.  In  the  acute  form  of  endometritis,  which  is 
post-puerperal  infection  as  a  rule,  we  curet  with  pro- 
priety ;  to  remove  retained  foreign  matter,  we  must 
beware  of  the  great  danger  of  uterine  perforation,  an 
accident  which  can  and  does  happen  with  the  most 
startling  ease.  In  chronic  endometritis  curettement, 
the  persistence  of  the  disease  and  the  constant  danger 
of  tubal  infection  and  peritonitis,  or  lymphatic  infec- 
tion and  peritonitis,  makes  it  an  operation  of  wisdom  in 
many  cases.  We  should,  however,  have  in  mind  the 
likelihood  of  the  lightening  up  of  a  latent  salpingitis,  or 
latent  sepsis  in  some  other  locality  and  be  prepared  to 
complete  the  operation  by  removal  of  the  foci  of  pelvic 
inflammation. 

If  the  discharge  arising  from  an  endometritis  shows 
the  presence  of  gonococci,  curettement  is  positively 
contraindicated,  for  it  is  certain  that  such  a  procedure 
will  most  probably  lighten  up  an  active  gonorrhea 
which  shows  marked  tendency  to  spreading  and  con- 
sequent tubal  involvement. 

When  the  indications  for  curettement  are  established, 
then  the  operation  should  be  done  with  an  intelligent 
thoroughness  which  will  leave  no  portion  of  the  cavity 
untouched  by  the  curet.  The  so-called  moral  effect 
of  an  operation  accomplishing  good,  I  think  is  bosh ; 
certainly  any  improvement  is  but  temporary.  Again 
I  think  the  supposed  curative  effect  of  operations  per  se 
should  be  relegated  to  the  absurd  dogmas  of  the  Chris- 
tian Scientists.  If  the  surgeon  by  logical  reasoning 
cannot  arrive  at  the  conclusion  to  operate  in  a  given 
case,  then  he  had  better  let  it  alone;  an  operation 
should  be  attempted  only  to  remove  an  existing  patho- 
logical condition,  and  not  one  which  is  simply  supposed 
to  exist,  or  which  might  exist. 

There  is  a  doubt  in  my  mind  as  to  the  reliability  of 


434 


ThK  PHILiDELPHIAl 

Mkdicax  Jodbnal  J 


OPERATIONS  IN  PELVIC  AND  ABDOMINAL  SURGERY 


[JUbch  2,  1901 


the  information  derived  from  an  examination  of  speci- 
mens curetted  from  a  uterine  canal  in  which  malignant 
changes  are  suspected.  It  is  very  difficult  to  make  a 
positive  diagnosis,  ofttimes,  between  chronic  benign 
lesions  of  the  uterine  mucous  membrane  and  early 
malignant  changes  ;  and  then  the  specimens  are  neces- 
sarily small  and  fragmentary  and  interfere  with  a  satis- 
factory examination. 

The  advantage  of  such  knowledge,  when  reliable,  is 
inestimable,  but  nevertheless  it  can  only  serve  as  an  ad- 
junct to  the  clinical  diagnosis  and  must  of  necessity 
play  a  secondary  part.  The  ability  to  make  a  diagnosis 
from  a  curetted  specimen  is  only  acquired  by  a  highly 
specialized  training  of  brain,  eye  and  fingers. 

In  advanced  carcinoma  of  the  cervix,  where  other 
and  more  radical  measures  are  impossible,  curettement 
followed  by  the  application  of  the  cautery  is  indicated 
and  will  lessen  the  patient's  discomfort. 

Flexion  of  the  uterus  combined  with  endometritis 
in  the  absence  of  adhesions  indicates  dilatation  followed 
by  curettement. 

Dilatation  of  the  cervical  canal  is  an  operation  which 
offers  a  fruitful  field  for  the  ambitious  surgeon.  It  is 
devoid  of  cutting  and  is  practically  bloodless  and  there- 
fore appeals  to  a  patient.  If  it  was  not  so  dangerous 
and  inefficient,  I  might  be  induced  to  sanction  it  and 
perform  it  more  often  than  I  do.  Recently  America's 
greatest  gynecologist  said  to  me  that  a  dilatation  of  a 
cervix  caused  him  greater  anxiety  for  the  first  days 
following  an  operation  than  would  a  bad  pus  section  or 
hysterectomy. 

Slow  dilatation  by  sponge  tents,  even  though  protected 
by  a  sterilized  rubber  cot,  or  by  gauze  or  sponge  pack- 
ing, ofi"er,  no  advantages  over  divulsion  and  is  attended 
by  much  greater  risks  of  sepsis.  I  would  especially 
condemn  the  attempts,  and  I  say  attempts  advisedly, 
to  dilatation  in  the  physician's  office,  as  it  is  a  most 
dangerous  and  useless  practice.  Divulsion  should 
never  be  done  except  under  complete  anesthesia  and 
with  the  most  rigid  observance  of  aseptic  and  antiseptic 
precautions.  Antiseptic  preparation  of  the  vagina  is 
as  important  here  as  it  is  for  a  vaginal  hysterectomy  ; 
the  vulva  should  be  shaved,  and  the  vulva  and  vagina 
after  preparation  should  be  protected  by  iodoform  or 
sterile  gauze.  The  operator  and  all  assistants  and 
nurses  should  wear  sterile  rubber  gloves. 

Dilatation  is  indicated  in  dysmenorrhea  due  to 
cervical  stenosis,  as  a  preliminary  step  to  curettement 
when  there  is  a  displacement  of  the  uterus  which  is  not 
adherent,  and  when  there  is  an  absence  of  pelvic  or 
tubal  inflammation,  either  active  or  latent. 

Divulsion  for  stenosis  of  the  cervix  is  at  best  an 
unsatisfactory  measure,  as  it  frequently  fails  to  meet 
and  overcome  the  condition.  It  is  often  necessary 
to  repeat  the  operation  several  times  before  relief  is 
afforded.  After  the  first  divulsion,  in  addition  to  the 
stenosis,  we  have  the  rigid  scar-tissue  to  deal  with,  and 
here  it  is  comparatively  easy  to  lacerate  the  cervix. 

Frequently  relief  is  not  experienced  at  the  first 
menstrual  period  following  the  operation,  so  that  we 
should  not  be  too  hasty  in  repeating  the  measure,  but 
should  wait  until  the  evidence  of  failure  is  positive. 

Dilatation  as  a  method  for  the  correction  of  flexions 
of  the  uterus  must  be  classed  among  the  surgical 
failures.  I  have  never  been  able  to  satisfy  myself 
that  it  has  accomplished  the  slightest  bit  of  good. 

Upon  the  recognition  of  one  condition,  an  infantile 
uterus  in  a  woman  suflfering  from  dysmenorrhea  will 


or  should  demonstrate  the  futUity  of  attempting  to 
restore  a  cervical  canal  by  dilatation  in  an  organ  which 
is  congenitally  defective.  Operation  under  such  cir- 
cumstances is  always  attended  by  failure,  because  the 
source  of  the  trouble  is  the  result  of  the  abnormality  of 
the  uterus  itself  or  in  conjunction  with  its  adnexa. 
This  is  also  true  of  the  other  congenital  malformations 
of  the  uterus,  viz.,  the  bicornate  uterus,  etc. 

We  have  tried  to  point  out  the  various  dangers  and 
possible  contingencies  which  may  arise  in  the  perform- 
ance of  these  three  operations,  and  in  a  general  way  to 
show  the  methods  to  overcome  them  and  to  carry  the 
procedures  to  a  successful  issue. 

For  the  sake  of  emphasis,  allow  me  to  run  over  the 
points  again. 

First  of  all,  the  antiseptic  preparation  of  the  field  of 
operation ;  the  vulva  should  be  shaved  and  prepared 
by  soap  and  water,  permanganate  of  potash  and  oxalic 
acid,  bichloride  of  mercury,  and  carbolic  acid  solution, 
and  protected  by  a  pad  of  sterile  gauze.  The  vagina 
by  the  use  of  soap  and  water,  bichloride,  and  carbolic 
solution  and  iodoform  gauze  packing.  During  the 
operation  every  rule  of  aseptic  detail  must  be  adhered 
to  ;  sterile  instruments  and  gauze,  linen,  blankets,  etc., 
and  hands  protected  by  sterile  rubber  gloves. 

I  am  a  firm  beUever  in  rubber  gloves,  because  they 
not  only  diminish  the  risk  of  infection,  but  they  pro- 
tect the  surgeon  ;  you  cannot  boil  the  hands,  but  you 
can  boil  gloves,  and  thus  be  sure  of  the  only  absolutely 
reliable  method  of  sterilization.  If  it  be  necessary  to 
simultaneously  perform  a  vaginal  operation  and  ab- 
dominal section,  it  is  very  easy  to  change  gloves  and 
thus  be  sure  of  sterility. 

This  leads  me  to  a  renewed  warning  in  regard  to 
operations  on  the  cervix  or  its  canal  in  the  presence  of 
a  latent  or  active  inflammation  or  adhesions  binding 
the  uterus  down.  As  has  been  said,  it  is  the  part  of 
wisdom  to  correct  both  conditions  at  the  same  time. 

By  the  repeated  performance  of  surgical  operations, 
and  the  consequent  attention  to  aseptic  precautions, 
one  develops  a  habit  of  being  surgically  clean,  and  it 
seems  to  be  a  fair  proposition  that  such  a  habit  will  in- 
sure a  greater  degree  of  success  than  can  be  expected  by 
the  estimable  gentlemen  of  our  profession  who  operate 
occasionally,  and  who  are  in  constant  contact  with 
those  diseases  which  have  a  special  predilection  toward 
sepsis  and  septic  infection.  I  would  therefore  advise 
that  these  three  operations  should  be  confined  to  the 
realm  of  surgery,  and  not  be  classed  as  work  which  is 
the  duty  and  prerogative  of  the  general  practitioner  of 
medicine. 


ON  THE  DESIRABILITY  OF  COMBINED  OPERATIONS 
IN  PELVIC  AND  ABDOMINAL  SURGERY." 

ByW.  p.  MANTOX,  M.D., 
of  Detroit,  Mich. 

Professor  of  Clinical  Gynecoloey,  and  Adjunct  Professor  of  Obstetrics,  De- 
troit College  of  Medicine  ;  Cjynec^logist  to  Harper  Hospital,  and  U) 
the  Extern  and  Northern  AsThims  for  the  Insane :  Con- 
sulting Grnecologi^t  to  Si.".Tt-»seph's  Retreat:  Vice- 
President  Medical  Boftrd  Woman's  Hospital 
and  Infants'  Home,  etc  ,  etc 

T^VE^•TY-FIVE  years  ago,  when  pelvic  sui^ery  was  yet 
in  its  swaddling  clothes  and  the  terra  incopiita  abdotnin- 
alis  was  just  opening  up  new  fields  to  the  adventurous, 
all  operations  along  the  sexual  tract  were  viewed  with 

>  Transactions  of  Thiitl  Pan-American  Medical  Congress,  Harana,  Febraary 
4-8,  1901. 


March  2,  1901] 


URINARY  HYPERACIDITY 


[Thb  Philadelphia 
Medical  Journal 


435 


interest,  while  an  abdominal  section  was  recognized  as 
an  event  of  no  little  importance. 

The  advent  of  Listerism  and  the  subsequent  evolu- 
tion of  aseptic  surgery  revolutionized  methods  and 
rendered  undertakings  possible  which,  theretofore,  had 
hardly  entered  into  the  wildest  speculations  of  the 
ultra-radical,  until  today,  from  the  accumulated  experi- 
ence of  the  past,  nearly  every  part  and  organ  of  the 
body  may  be  invaded  with  greater  or  less  impunity. 
In  reviewing  the  history  of  the  development  of  ab- 
domino-pelvic  surgery  during  the  quarter  century  just 
closed,  however,  while  one  cannot  but  be  filled  with 
admiration  at  the  great  advancement  made  and  the 
wonderful  results  accomplished  in  this  particular  line 
of  work,  the  question  naturally  intrudes  itself,  Have  the 
achievements  of  the  immediate  past  led  to  an  overbold- 
ness  of  action,  and  has  enthusiasm  and  the  confidence 
begotten  of  fancied  security  in  anesthesia,  asepticism  and 
technic  betrayed  into  the  overlooking  or  ignoring  of  the 
best  interests  of  the  afflicted  individual  ? 

The  patient  resorts  to  the  surgeon  with  one  object  in 
view,  the  relief  of  somatic  sufifering  or  inconvenience, 
and  expects  from  him  honest  dealing  in  the  accom- 
plishment of  this  end.  Does  the  surgeon,  therefore, 
fulfil  his  duty  to  the  patient  if  he  but  partially  effects 
the  service  which  he  is  expected  to  render  ? 

There  is,  I  feel  sure,  no  one  of  experience  but  will 
answer  these  questions  in  the  negative  and  point  to  facts 
for  corroborating  evidence.  Assuming  then,  that  the 
surgeon  undertakes  only  that  which  he  is  authorized  to 
do  for  the  patient's  good,  in  his  endeavor  to  bring  about 
the  results  desired,  how  much  is  he  justified  in  attempt- 
ing, and  how  may  he  determine  the  limit  at  which 
safety  ends  and  danger  begins  to  assert  itself;  the  point 
where  benefit  shades  into  positive  injury  ? 

Among  gynecological  patients  it  is  usual  to  find  not 
one,  but  a  number  of  abnormal  conditions  or  defects 
'  present,  each  of  which  has  a  definite  bearing  on  the 
individual's  health  and  comfort,  and  demands  a  dis- 
tinct operation  for  its  relief  or  cure.  Shall  these  various 
conditions  be  attacked  successively  at  the  same  sitting, 
shall  the  different  operations  be  performed  at  intervals, 
or  shall  certain  parts  be  restored  while  others  are  left 
untouched  ?  Clinical  experience  and  pathology  have 
taught  that  the  best  results  cannot  be  awaited  from  the 
attempted  restoration  of  one  surgically  diseased  part 
when  lesions  of  associated  structures  are  allowed  to 
continue  undisturbed ;  in  other  words,  in  associated 
morbid  conditions,  the  harmony  and  adjustment  of  all 
the  disordered  elements  must  be  collectively  reestab- 
lished in  order  to  bring  about  the  perfect  restoration  of 
the  individual  defect.  Obviously,  then,  if  we  are  to 
effectuate  the  charge  placed  upon  us  by  the  patient,  the 
combined  operations  indicated  must  be  carried  out  in 
order  to  fulfil  the  requirements  of  the  case,  and  this  is, 
I  believe,  the  practice  of  most  operators  at  the  present 
time. 

By  the  unfamiliar,  however,  the  performance  of 
several  operations  at  the  same  sitting  is  often  looked 
upon  with  astonishment  and  doubt,  and  frequently 
censured  as  unwarrantable,  the  onus,  in  the  event  of 
untoward  result,  being  visited  upon  the  surgeon. 

In  order  that  this  question  may  be  definitely  settled 
by  weight  of  authority,  so  seemingly  unimportant  a 
subject  is  brought  to  the  attention  of  this  congress. 

In  summing  up  the  evidence  in  favor  of  combined 
operations  it  may  be  said,  experience  has  demonstrated 
on  the  one  hand,  that  several  operations  performed  at 


the  same  sitting  do  not  compromise  the  life  of  the 
patient  to  any  appreciable  degree  ;  that  the  extra  time, 
within  reasonable  limits,  required  for  the  execution  of 
the  various  procedures  does  not  necessarily  augment 
the  dangers  to  be  anticipated  from  any  surgical  act ; 
that  repair  in  the  individual  parts  involved  goes  on  as 
uninterruptedly  and  successfully  and  that  convalescence 
is  as  rapid  and  satisfactory  as  when  but  a  single  un- 
complicated operation  is  performed.  While,  on  the 
other  hand,  following  the  passing  of  the  ordeal,  the 
patient's  mind  remains  tranquil  and  undisturbed  by  the 
dread  of  possible  future  treatment  and  the  fear  of  the 
anesthetic,  convalescence  is  not  retarded  by  the  pres- 
ence of  morbid  structures  or  conditions  left  behind, 
and  recovery  is  not  partial  but  total  and  complete. 

In  the  opinion  of  the  writer,  therefore,  in  every  in- 
stance, whatever  is  necessary  should  be  done,  whether 
the  conditions  lie  within  the  pelvis,  the  abdomen,  or 
both ;  and  the  limit  of  execution  should  be  gauged  only 
by  the  general  condition  of  the  patient,  her  behavior 
under  the  anesthetic,  and  the  inherent  dangers  of  the 
operations  to  be  performed.  These,  together  with 
experience,  skilful  operating,  strict  asepticism  and 
watchful  care  of  the  patient,  are  the  sine  qua  non  of 
success. 


URINARY  HYPERACIDITY. 

A  Consideration  of  Cases  with  Symptoms  Suggestive  of 
Cystitis,  But  With  No  Infection,  Due  to  This  Cause. 

By  THOMAS  R.  BROWN,  M.D., 

of  Baltimore,  Md. 

Chief  of  Clinio,  Johns  Hopkins  Hospital  Medical  Dispensary ;  Associate  Pro- 
fessor of  Clinical  Medicine,  College  of  Physicians  and  Surgeons. 

It  is  of  course  a  well-known  fact  that  certain  symp- 
toms of  cystitis  are  found  in  a  variety  of  other  condi- 
tions in  which  there  is  no  vesical  infection.  Thus, 
increased  frequency  of  micturition  either  alone  or  asso- 
ciated with  somewhat  burning,  slightly  painful  mic- 
turition is  noted  during  the  use  of  a  number  of  drugs, 
such  as  copaiba,  cubebs,  camphor,  salicylic  acid, 
cantharides  in  small  doses  (large  doses  bring  about  acute 
cystitis),  etc.,  etc.,  and  also  during  the  course  of  many 
fevers  due  perhaps  to  the  noxious  substances  eliminated, 
perhaps  to  the  increased  concentration  of  the  urine. 
There  is  also  a  well-recognized  series  of  cases  in  which 
the  symptoms  are  distinctly  referable  to  certain  patho- 
logical conditions  in  the  organs  and  tissues  adjacent  to 
the  bladder.  Thus,  a  marked  relaxation  of  the  vaginal 
outlet,  the  presence  of  large  uterine  myomata  or 
ovarian  cystomata,  a  condition  of  pelvic  peritonitis  due 
to  a  variety  of  conditions  with  the  formation  of  adhe- 
sions between  other  organs  and  the  bladder,  these  and 
other  conditions  tend  to  produce  an  irritated  or  con- 
gested condition  of  the  bladder  which  in  its  turn  is 
productive  of  somewhat  frequent  and  occasionally 
painful  micturition,  often  associated  with  the  presence 
of  a  few  pus  or  red  blood-cells  in  the  urine. 

The  cause  of  the  urinary  symptoms,  however,  in  all 
these  cases  is  easily  recognizable  and  the  symptoms 
may  be  abated  by  proper  attention  to  the  causative 
agents ;  thus  in  the  former  series  of  cases  the  condition 
disappears  with  the  cessation  of  the  special  form  of 
medication,  while  in  the  second  series  of  cases  the 
removal  of  the  offending  tumor,  the  separation  of  ad- 
hesions, the  lifting  up  of  the  relaxed  outlet,  or  the 


436 


The  Philadelphia"! 
Medical  Journal  J 


URINARY  HYPERACIDITY 


IUabcu  2,  1901 


removal  of  a  protruding  uterine  polyp  will   cause  a 
complete  cessation  of  the  symptoms. 

There  is,  however,  another  class  of  cases  in  which  no 
definite  cause  for  the  suggestive  symptoms  other  than 
a  general  neurasthenic  or  neuropathic  tendency  can  be 
given,  and  it  is  in  reference  to  a  certain  class  of  cases  of 
this  nature  that  this  communication  will  treat.  In  these 
cases  the  vesical  irritability  is  produced  by  a  distinct 
hyperacidity  of  the  urine,  and  so  far  as  I  know  this  is 
the  first  communication  in  which  this  has  been  shown 
beyond  a  doubt  to  be  the  etiological  factor  in  the  pro- 
duction of  such  a  condition.  In  connection  with  my 
bacteriological  study  of  the  infections  of  the  bladder,  I 
was  frequently  struck  by  the  fact  that  many  of  the 
symptoms  of  cystitis,  frequent  burning  micturition 
often  associated  with  the  presence  of  a  few  pus  or  red 
blood-cells  in  the  urine,  was  found  in  a  certain  class  of 
cases  where  a  study  of  the  urine  demonstrated  that 
there  was  no  infection  present.  In  testing  the  reaction 
of  the  urine  in  the  first  of  these  cases  that  was  presented 
to  my  observation,  it  was  noted  that  the  blue  litmus 
was  colored  an  extremely  bright  red.  It  was  therefore 
regarded  as  possible  that  the  symptoms  might  be 
directly  referable  to  an  increase  of  the  acid  or  the  acid 
salts  in  the  urine ;  this  hyperacidity  in  turn  producing 
a  distinct  irritation  of  the  vesical  mucous  membrane 
and  the  symptoms  already  mentioned.  To  determine 
this  definitely,  I  have  made  a  quantitative  determina- 
tion of  the  total  acidity  of  the  urine  in  all  cases  pre- 
senting such  a  symptom-complex  without  any  definitely 
assignable  cause.  The  method  I  have  employed  has 
been  the  titration  of  10  ccm.  of  the  freshly  catheterized 
urine  with  a  one-tenth  normal  solution  of  sodium 
hydroxid,  phenol-phthalein  being  used  as  an  indicator. 
Although  this  method  is  not  quite  so  exact  as  the  more 
complicated  one  of  Freund,  where  the  estimation  is 
based  upon  the  quantitative  determination  of  the  acid 
phosphates  present,  nevertheless  it  is  comparatively 
quite  exact  and  furnishes  us  with  a  fairly  accurate 
criterion  of  the  total  quantity  of  acids  and  of  acid  salts 
present  in  a  given  quantity  of  urine. 

A  series  of  normal  cases  was  also  taken  to  determine 
the  average  acidity  of  nonnal  urine  which  we  have 
designated  as  10.  Since  the  inception  of  these  estima- 
tions, 9  cases  have  been  met  with,  in  all  of  which  the 
symptoms  were  distinctly  referable  to  a  hyperacid 
condition  of  the  urine.  All  these  cases  presented  the 
characteristic  symptom-complex,  although  the  symp- 
toms were  much  more  marked  in  some  cases  than  in 
others;  all  complained  of  frequent,  painful  burning 
micturition  of  greater  or  less  extent;  in  the  more 
marked  cases  quite  sufficient  to  absolutely  simulate  a 
true  cystitis  and  frequently  to  have  deceived  the  attend- 
ing physician  into  believing  it  to  be  of  such  a  nature. 

A  cystoscopic  examination  in  all  the  cases  in  which 
it  was  made  showed  a  marked  injection  and  hyperemia 
of  the  trigonal  area  in  the  bladder,  in  some  cases  of  a 
maximum  degree,  and  sometimes  in  these  cases  associ- 
ated with  a  lesser  hyperemia  of  the  mucous  membrane 
adjacent  to  that  of  the  trigonum ;  these  latter  cases 
were  those  in  which  the  symptoms  so  completely  simu- 
lated those  of  a  true  cystitis. 

The  urine  always  contained  pus  cells,  usually  in  very 
small  number,  although  occasionally  quite  a  consider- 
able number  were  present,  a  few  red  blood-cells  and 
some  bladder  epithelial  cells ;  cultures  of  the  urine 
were  always  sterile,  In  many  of  the  cases  the  upper 
portion  of  the  urethral  mucous  membrane  was  injected. 


The  acidity  of  the  urine  in  these  cases,  determined  by 
the  method  described  above,  and  upon  the  basis  of  10 
as  the  normal  acidity,  was  respectively  27.5,  30,  20,  31, 
30, 49, 2 1 , 3 1 ,  29 ;  that  is,  in  all  these  cases  the  acidity  was 
at  least  twice,  and  in  one,  nearly  five  times  as  great  as 
normal.  It  was  also  a  noteworthy  fact  that  the  gravity 
of  the  symptoms,  the  degree  of  the  injection  of  the 
trigonum,  and  the  number  of  pus  and  red  blood-cells 
present  in  the  urine  stood  in  direct  relationship  to  the 
degree  of  the  acidity.  Thus  in  those  cases  in  which 
the  acidity  was  49,  31,  31,  and  29,  the  symptoms  were 
such  as  to  distinctly  simulate  a  true  acute  cystitis  of  an 
infectious  nature ;  the  frequency  of  micturition  was  so 
great  as  to  necessitate  urination  every  1  to  3  hours  dur- 
ing the  night,  and  i  to  3  hours  during  the  day,  while 
the  painful  and  burning  sensation  in  these  cases  was 
very  marked.  In  several  of  the  cases,  the  patients 
definitely  localized  their  pain  in  the  trigonal  area  of  the 
bladder,  and  in  the  upper  portion  of  the  urethra.  Four 
of  this  series  of  cases  had  been  definitely  diagnosed  by 
their  physicians  as  cases  of  cystitis,  and  had  been  sent 
so  us  for  treatment  for  that  condition.  There  was  no 
local  pelvic  trouble  whatever  in  any  of  these  cases. 

Although  the  increased  acidity  seemed  to  be  the  un- 
doubted local  cause  of  the  condition,  the  cases  were 
carefully  considered  to  see  whether  some  general  cause 
could  not  be  found  which  in  turn  could  account  for  the 
hyperacidity.  Obviously  because  of  the  chronic  char- 
acter of  these  conditions,  peculiarities  of  diet  could  not 
be  regarded  as  a  cause,  and  this  was  also  shown  by  the 
very  slight  efifect  that  dififerent  varieties  of  diet  seemed 
to  have  upon  the  symptoms.  It  was  noted,  however, 
that  all  of  these  cases  occurred  in  young  girls,  or  in 
young  married  women,  in  all  of  whom  there  were 
marked  neurasthenical,  neurotic,  or  hysterical  manifes- 
tations, and  in  many  distinct  stigmata  of  these  condi- 
tions. It  was  also  noted  by  the  patients  themselves  that 
anything  which  tended  to  render  them  more  nervous, 
such  as  prolonged  excitement,  prolonged  mental  or  phys- 
ical strain,  or  violent  emotional  disturbances,  markedly 
increased  the  symptoms,  while  if  the  life  they  led 
bordered  upon  one  of  extreme  simplicity,  the  symp- 
toms were  much  ameliorated.  The  result  of  the  treat- 
ment of  these  cases  also  justified  us  in  the  belief  that, 
although  the  vesical  symptoms  were  distinctly  referable 
to  the  urinary  hyperacidity  (probably  somewhat  in- 
creased by  the  increased  irritability  of  the  bladder,  as 
well  as  all  the  other  organs  seen  in  neurotic  or  neuras- 
thenic conditions),  the  hyperacidity  in  turn  was  directly 
referable  to  the  general  neurasthenic,  neurotic,  or  hys- 
terical condition  ;  in  other  words,  this  hyperacidity  was  a 
urinarj'  neurosis  of  neuropathic  origin.  The  treatment  was 
designed  thus  both  to  counteract  the  local  hyperacidity 
of  the  urine  and  to  correct  as  far  as  possible  the  under- 
lying neurosis,  neurasthenia,  or  hysteria.  For  the  first, 
alkalies  were  administered  by  mouth  in  sufficient 
quantity  to  render  the  urine  neutral  or  alkaline ;  in 
some  cases  a  comparatively  small  amount  of  alkali  was 
all  that  was  required  for  this  purpose  (potassium  citrate 
or  potassium  bicarbonate,  15  to  20  grains,  3  times  a  day) ; 
in  other  cases,  however,  the  hyperacidity  was  so  great 
that  the  administration  of  as  much  as  100  grains  of  the 
alkali  daily  was  necessary'  to  render  the  urine  neutral ; 
to  correct  the  general  condition,  the  usual  treatment  of 
rest,  freedom  from  excitement,  plenty  of  sunshine  and 
fresh  air,  overfeeding,  and  a  general  attention  to  all 
the  various  bodily  functions  was  carried  out  Strychnia 
was  administ€red  in  most  of  the  cases,  while  in  some  a 


Mabch  2,  1901] 


MULTIPLE  BRAIN  ABSCESS  FOLLOWING  EMPYEMA 


[The  Philvldelphia 
L  Medical  Journal 


437 


veritable  rest  cure,   associated  with   cold   packs   and 
massage,  was  found  to  be  necessary. 

In  the  4  cases  in  which  this  treatment  was  carried 
out  in  full  the  symptoms  disappeared  quite  rapidly  ;  it 
is  highly  probable,  however,  if  the  patient  relapses  into 
her  previous  neurotic  condition,  that  the  symptoms, 
both  local  and  general,  will  reappear.  This  was  defi- 
nitely seen  in  one  case  who  was  entirely  free  from  all 
symptoms  for  6  months  subsequent  to  the  cessation  of 
the  treatment,  when,  after  a  prolonged  course  of  excite- 
ment and  social  dissipation,  the  symptoms  returned, 
although  less  marked  than  when  seen  the  first  time.  The 
patient  was  placed  upon  the  same  line  of  treatment  as 
before  and  the  symptoms  rapidly  abated. 

In  considering  this  neurosis  of  urinary  secretion,  it 
was  thought  probable  that  it  was,  in  a  certain  way, 
analogous  to  the  gastric  hyperchlorhydria  which  is 
often  associated  with  hysteria.  Although,  of  course, 
vesical  irritability  in  neurotic  individuals  has  been 
described  frequently,  hitherto,  so  far  as  I  know,  the 
determination  of  urinary  hyperacidity  as  an  etiologic 
factor  has  not  been  described  before. 

I  have  dwelt  upon  this  condition  not  only  because 
of  the  interest  attached  to  any  of  the  secretory  neuroses 
that  are  met  with,  but  also,  and  perhaps  mainly, 
because  of  the  absolute  necessity  of  correctly  diagnosing 
the  condition.  If  the  condition  is  correctly  diagnosed, 
proper  medical  treatment  can  bring  about  a  complete 
cure  in  the  majority  of  cases  without  any  local  treat- 
ment of  the  bladder  whatsoever ;  if,  on  the  other  hand, 
a  wrong  diagnosis  is  made,  and  the  condition  is  regarded 
as  a  cystitis  and  treated  as  such,  often  a  real  infection 
of  the  bladder  will  be  set  up  by  the  long-continued  use 
of  irrigations  and  local  applications,  that  are  so  usually 
employed,  and  the  second  state  of  that  woman  will  be 
much  worse  than  the  first.  To  show  that  this  is  no 
idle  warning,  I  need  simply  mention  that  at  least  5  of 
the  cases  of  chronic  cystitis  that  have  come  under  our 
observation  owe  their  origin  to  the  misinterpretation  of 
this  condition.  Two  of  these  cases  were  in  young  girls 
and,  in  them  both,  the  cystitis  which  was  directly  con- 
secutive to  the  treatment  for  what  was  undoubtedly  but 
a  simple  case  of  vesical  irritability  probably  due  to 
urinary  hyperacidity,  was  of  so  serious  a  nature  that 
life  had  been  rendered  practically  unbearable  in  both 
cases  for  many  years,  while  the  bladder  now  is  in  such 
a  condition  of  ulceration  and  contraction  that  a  cure,  if 
it  is  obtained  at  all,  will  only  be  reached  after  the  most 
protracted  and  painful  course  of  treatment. 

Cases  with  Symptoms  of  Cystitis  but  no  Infection,  Due  to 

HYPERACmiTY  of  THE  UrINE. 

Case  1. — Hysterical  young  woman,  extremely  nervous, 
teaches  school  and  has  to  be  on  her  feet  most  of  the  time  ; 
condition  persisting  for  3  years,  always  getting  markedly 
better  during  her  vacation.  Symptoms :  At  first,  only  fre- 
quent desire  to  urinate,  later  {for  past  year)  pain  and  burn- 
ing sensation  in  bladder.  Symptoms  are  aggravated  by  cold, 
overexertion  and  nervous  strain.  Examination  :  Trigonuni 
deeply  injected ;  right  floating  kidney.  Urine :  A  few  pus 
cells  and  epithelial  cells,  no  albumin,  extremely  acid 
(acidity,  27.5).  Bacterial  examination  :  Sterile.  Treatment : 
Alkalies  by  mouth ;  hygiene ;  rest  cure.  Result :  Cured. 
Patient  seen  6  months  later,  has  no  trouble  of  this  nature  ; 
whenever  any  tendency  towards  frequent  urination  appears, 
takes  alkalies  by  mouth  and  rests  more  and  condition  is  re- 
lieved. 

Case  2. — Neurasthenical  woman  of  28,  with  many  hyster- 
ical manifestations.  Symptoms :  Scalding  and  frequent 
urination  for  past  6  or  7  years  with  pain  in  bladder. 
Examination :  Intense  hyperemia  of  trigonum   and  upper 


urethra.  Urine :  A  few  pus  cells  and  epithelial  cells,  occa- 
sional red  blood-cells,  no  albumin,  very  acid  (acidity,  30.0). 
Bacterial  examination :  Sterile.  Treatment :  Alkalies  by 
mouth ;  cold  packs,  hygiene,  rest  cure,  scarification  of 
trigonum. 

Case  3. — Intensely  neurasthenical  married  woman  of  .S8,  with 
myomatous  uterus,  retroflexion  of  uterus,  and  right  floating 
kidney,  and  nervous  gastritis  with  hyperchlorhydria.  Bladder 
showed  intense  reddening  of  trigonum.  Urination  wa.s  fre- 
quent and  somewhat  painful  (in  mouth  of  urethra).  Urine: 
A  small  number  of  pus  cells,  no  albumin,  very  acid  (acidity, 
20),  specific  gravity,  1.005,  very  pale  in  color;  sterile.  Treat- 
ment :  Myomectomy,  suspension  of  uterus,  double  salping- 
ectomy. Subsequently  hygienic  treatment,  alkalies  by 
mouth.  Result :  Symptoms  entirely  disappeared  for  more 
than  6  months,  when  the  patient  attempted  to  do  too  much, 
when  the  symptoms  and  hyperacidity  returned.  She  was 
given  the  rest  cure  with  alkalies  by  mouth  and  the  symp- 
toms again  disappeared. 

Case  4. — Nervous  woman  of  31,  complaining  of  nervous- 
ness, headache,  and  pain  in  the  back  of  the  neck,  and  pain- 
ful and  frequent  micturition  (urinates  4  to  5  times  at  night), 
and  irritable  bladder.  Examination :  Hyperemia  of  trigo- 
num. Urine :  A  few  pus  cells,  no  albumin,  very  acid  (acid- 
ity, 31.00),  sterile. 

(Jase  5. — Complaint:  Irritable  bladder  and  frequency  of 
micturition.  Examination  :  Injected  trigonum.  Urine  :  Oc- 
casional pus  cells,  no  albumin,  very  acid  (acidity,  30.0); 
sterile. 

Case  6. — Married  woman  of  25,  very  neurotic.  Three 
years  ago,  six  days  after  marriage  complained  of  frequency 
of  urination,  and  later  also  of  a  tender  spot  in  the  bladder 
and  dysuria.  These  symptoms  have  continued  since  then, 
and  the  patient  has  had  the  urethral  sphincter  dilated,  the 
tender  spot  touched  with  various  substances,  and  the  bladder 
washed  out.  Examination:  Intense  scarlet  injection  of  the 
trigonum,  especially  on  left  side.  Urine :  A  few  pus  cells, 
occasional  red  blood-cells,  no  albumin  intensely  acid  (acid- 
ity, 49.0) ;  sterile.  Treatment :  General  hygienic  treatment, 
touching  spot  with  silver  nitrate,  alkalies  by  mouth  (it 
required  100  grains  of  potassium  citrate  per  day  to  render 
the  urine  neutral  or  alkaline).  Result :  Marked  improve- 
ment (patient  still  under  treatment). 

Case  7. — Married  woman  of  33.  Severe  instrumental 
delivery  three  years  previously,  since  which  time  she  has 
frequently  used  the  catheter  to  withdraw  her  urine.  During 
this  time  she  has  had  considerable  pain  on  urination,  in- 
creased by  cold,  with  a  severe  attack  of  vesical  pain  with 
fever  two  years  ago.  Examination :  Deep  injection  with 
some  ulceration  at  vertex  of  bladder.  Urine :  Very  occa- 
sional puscells,  no  albumin,  very  acid  (acidity,  21.0);  sterile. 

Cases  8  and  9. — Ofiice  patients  seen  but  once,  each  com- 
plaining of  frequent  and  somewhat  burning  micturition,  and 
in  each  of  whom  cystoscopic  examination  revealed  a  deeply 
injected  trigonum.  Urine :  A  few  pus  cells,  no  albumin, 
very  acid  (acidity  of  Case  8,  31.0;  acidity  of  Case  9,  29.0); 
sterile. 


MULTIPLE  BRAIN  ABSCESS  FOLLOWINCJ  EMPYEMA.* 
By  THOMAS  A.  CLAYTOR,  M.D., 

of  Washington,  D.  C, 

Professor  of  Clinical  Medicine,  Columbia  UniTerslty;  Attending  Physician  to 
Garfield  Hospital,  etc. 

Jdstification  for  this  report  is  sought,  first,  in  that 
brain  abscess  from  pulmonary  disease  is  not  very  com- 
mon, and  secondly,  in  that  while  an  abscess  may  be 
caused  by  disease  of  either  lung  or  pleura,  it  more 
usually  results  from  the  former. 

H.  P.,  male,  aged  22,  was  first  admitted  to  the  Garfield 
Memorial  Hospital  on  May  26,  1899. 

The  patient  had  had  the  usual  diseases  of  childhood,  and 
typhoid  fever  5  years  before  admission.  While  in  Cuba  dur- 
ing July,  1898,  ho  contracted  malaria,  from  which  he  thought 
he  had  never  fully  recovered.    In  September  of  the  same 

»  Read  before  the  Medical  Society  of  the  District  of  Columbia,  NoTember,  1900. 


4QS  Thk  Philadklphia"! 

MSDICAL  JODRHAL  J 


MULTIPLE  BRAIN  ABSCESS  FOLLOWING  EMPYEMA 


[Kasch  2,  1901 


year  he  began  to  have  a  dull  pain  in  the  left  side,  which  had 
not  left  him.  A  short  time  before  admission  (date  not 
noted),  he  awakened  one  morning  with  a  sharp,  piercing 
pain  in  the  left  side,  which  was  increased  by  motion  and  in- 
spiration.  'He  had  a  slight  chill,  and  a  dry  cough  set  in. 

On  admission  the  temperature  was  100.4°  F.,  pulse 
120,  respiration  52.  Dyspnea  marked,  pain  in  cardiac 
region  severe.  The  expression  was  anxious,  and  there  was 
slight  cyanosis.  The  tongue  was  lightly  coated.  The 
vessels  of  the  neck  pulsated  visibly,  and  there  was  marked 
pulsation  in  the  third,  fourth,  and  fifth  interspaces  on  the 
right  side  of  the  sternum,  which  could  be  seen  as  far  out  as  the 
right  nipple  line.  No  pulsation  could  either  be  seen  or  felt  to 
the  left  of  the  sternum.  Anteriorly,  on  the  right,  dulness 
began  at  the  third  rib  and  extended  downward  into  the  liver 
and  toward  the  right  for  3  inches  from  the  midstemal  line. 
On  the  left  dulness  began  at  the  third  rib  and  extended 
downward  to  costal  border.  The  axillary  region  was  so  ex- 
quisitely tender  as  to  render  examination  by  percussion  im- 
possible. Posteriorly  the  flatness  extended  from  2  inches 
above  the  angle  of  the  left  scapula  to  the  base  of  the  lung. 
The  upper  level  of  the  dulness  was  but  slightly,  if  at  all,  al- 
tered by  change  of  position. 

The  heart-sounds  were  distinct  over  the  sternum,  but  were 
very  faint  at  the  normal  position  of  the  apex.  The  respira- 
tory sounds  were  harsh  over  the  right  lung,  and  over  the 
apex  of  the  left,  becoming  tubular  over  the  normal  position 
of  the  heart.  There  was  also  tubular  breathing  over  the 
area  of  flatness  posteriorly.  The  diagnosis  of  left  pleural 
eflFusion  was  made.  The  patient's  condition  was  such  as  to 
demand  immediate  relief.  Therefore,  on  May  27,  paracen- 
tesis was  performed  in  the  seventh  interspace  midaxillary 
line.  There  seemed,  however,  to  be  some  obstruction  to  the 
flow,  and  only  a  small  amount  of  straw-colored  fluid  was 
drawn  off".  No  cultures  were  made.  The  patient  experienced 
slight  relief,  but  two  days  later  his  suSering  was  so  intense 
that  I  requested  my  colleague  on  the  surgical  side,  Dr.  A.  A. 
Snyder,  to  see  him.  We  decided  it  would  be  best  to  attempt 
paracentesis  again  and,  failing  in  that,  to  incise  and  drain. 

I  will  here  anticipate  criticism  by  saying  that  we  were 
fully  alive  to  the  great  probability  of  converting  a  serofibrin- 
ous pleurisy  into  an  empyema,  but  the  patient's  condition 
was  so  serious  that  it  seemed  to  be  but  a  choice  of  evils, 
the  left  chest  being  nearly  full  of  the  exudate,  and  the  heart 
pushed  over  until  it  occupied  the  position  on  the  right, 
which  it  normally  occupied  on  the  left.  There  was  extreme 
pain  in  the  cardiac  region,  with  cyanosis  and  dyspnea. 

Dr.  Snyder  found  it  necessary  to  resort  to  incision.  It 
would  seem  likely  from  the  facts  that  the  fluid  came  in 
such  small  quantities  through  the  canula  and  so  slowly 
even  through  the  drainage  tube,  that  there  must  have  been 
adhesions  which  allowed  the  fluid  to  escape  with  difficulty. 
The  following  day  the  patient  was  more  comfortable,  the 
temperature  and  pulse  had  fallen,  but  the  respirations  were 
still  frequent.  For  four  days  the  condition  was  somewhat 
improved,  the  temperature  not  rising  above  100  8°  F.  The 
fluid  also  gradually  decreased,  draining  slowly  into  the  dress- 
ing. The  pain  in  the  left  side  and  over  the  prajcordia,  how- 
ever, was  so  intense  as  to  require  morphia  almost  constantly. 
On  June  1  the  fever  increased,  took  on  the  hectic  type,  and 
it  was  found  that  the  wound  had  become  infected.  Two 
weeks  later  an  empyema  having  developed.  Dr.  Snyder 
under  chloroform-anesthesia  made  a  3i-inch  incision  over 
the  seventh  rib  midaxillary  line  on  the  left  side.  After  dis- 
secting the  periosteum  away  a  2-inch  section  was  removed 
without  injury  to  the  intercostal  artery.  The  pleural  sac 
was  opened  and  a  large  quantity  of  thin  pus  was  evacuated 
After  flushing  with  hot  salt^solution  a  tube  was  introduced 
and  the  wound  partially  closed  with  silkworm  gut.  Im- 
provement was  marked  and  the  course  of  the  case  unevent- 
ful until  June  24,  when  the  temperature  again  went  up  and 
became  hectic  in  type.  This  condition  of  aflairs  went  on 
until  September  20,  when  Dr.  J.  Ford  Thompson  performed 
the  Estlander  operation,  resecting  portions  of  the  fifth, 
sixth,  and  seventh  ribs  in  the  midaxillary  line.  The  sev- 
enth rib  which  had  been  resected  minus  the  periosteum 
by  Dr  Snyder  had  reformed.  Quite  a  large  pus  pocket  was 
evacuated  and  free  drainage  instituted.  In  three  days  the 
temperature  fell  to  normal  and  the  general  condition  rap- 
idly improved.  The  patient  was  discharged  on  November 
15,"  1899,  practically  cured,  except  for  a  small  sinus  which  he 


returned  to  have  dressed  every  few  days.  His  condition  was 
excellent,  flesh  was  rapidly  gained  and  he  began  to  drill  at 
the  armory. 

On  December  9,  H.  P.  was  again  admitted,  complaining 
of  having  had  on  December  6,  three  days  before,  a  chifl 
associated  with  headache,  high  fever,  nausea,  and  profuse 
sweating.  On  December  8  there  had  occurred  a  second  chill, 
fever,  headache,  etc.  Since  that  the  pain  in  his  head  had 
not  left  him  and  was  described  as  being  intense,  extending 
over  the  entire  cranium  and  down  into  the  back  of  the 
neck.  Vomiting  occurred  whenever  food  was  taken.  The 
bowels  were  constipated.  Temperature  was  103.2°  F.,  pulse 
120,  respirations  24.  The  patient  was  admitted  to  the  surgi- 
cal side  with  the  idea  that  the  existing  condition  was  due  to 
a  reaccumulation  of  pus  in  the  chest,  but  as  Dr.  1  hompson 
was  not  positive  upon  this  point  he  req^uested  me  to  see  the 
case  daily  until  we  could  come  to  a  definite  conclusion. 

Examination  showed  a  flushed  face,  anxious  expression 
and  a  clean  tongue.  The  heart-sounds  were  normal  and  the 
organ  had  returned  to  its  normal  position.  The  left  side  of 
the  chest  was  shrunken  somewhat  and  the  signs  indicated  a 
much  retracted  lung.  The  spleen  was  enlarged  and  there 
was  abdominal  tenderness.  The  urine  showed  a  specific 
gravnty  of  1.031,  acid  reaction,  albumin  one-third  by  bulk 
and  a  few  hyaline  casts.  The  usual  remedies  for  headache 
failed  to  reheve.    Morphia  produced  sleep. 

December  11. — Headache  intense,  nausea  continuous. 
Temperature,  100.2°  to  103°. 

December  12. — Delirious,  refused  nourishment,  vomited 
frequently.  Ice-cap  gave  no  relief  to  intense  headache. 
Temperature,  100°  to  102°  ;  pulse,  70  to  80. 

December  13. — Wildly  delirious,  tried  to  get  out  of  bed, 
headache  severe,  sweating  freely.  Temperature  at  8  p.m., 
98.4°  ;  pulse,  80 ;  resjjirations,  26. 

December  14. — Patient  seemed  much  worse.  Temperature. 
104.4°.  There  was  for  the  first  time  rigidity  of  the  neck. 
Death  occurred  at  3.40  p.m. 

During  the  attack  there  was'no  paralysis,  no  strabismus, 
no  inequality  of  the  pupils.  Unfortunately  there  was  no 
ophthalmoscopic  examination. 

The  autopsy  showed  multiple  abscess  of  the  brain,  a  very 
small  area  of  basal  meningitis,  parenchymatous  nephritis 
and  beginning  degenerative  change  in  the  liver-cells. 

Tlie  foregomg  nistory  well  illustrates  an  insidious  onset 
and  rapid  progress  to  a  fatal  result,  which  is  by  no  means 
uncommon  in  cases  of  brain  abscess. 

The  left  pleural  cavity  was  entirely  obliterated  except  for 
a  small  sinus  leading  backward  from  the  opening  in  the  side 
for  about  3  inches.  This  sinus  seemed  to  be  quite  clear  of 
any  discharge  save  a  thin  seropurulent  fluid.  The  adhesions 
were  so  firm  in  the  neighborhood  of  the  resected  ribs  as  to 
require  the  use  of  a  knife  to  separate  the  lung  from  the  ribs. 
From  about  the  sixth  rib  downward  the  diaphragm  was 
adherent  to  the  costal  pleura,  but  could  be  easily  separated. 

The  left  lung  was  congested  and  felt  solid,  containing  but 
little  air.  The  right  Tung  appeared  to  be  in  a  normal 
condition. 

The  pericardium  contained  about  100  cc.  of  clear  straw- 
colored  fluid.  The  heart  was  large  but  very  soft  and  flabby. 
Upon  the  mitral  valves  there  were  a  few  very  minute  areas 
which  macroscopically  suggested  a  beginning  endocarditis. 

The  stomach  and  "intestines  were  much  distended  but 
showed  nothing  worthy  of  note.  The  liver  was  pale  and 
rather  soft  but  no  abscesses  were  found.  The  spleen  was 
much  enlarged,  dark  and  fi-iable  and  was  adherent  to  the 
diaphragm  and  ribs. 

The  kidneys  were  very  large  and  deeply  congested. 

Upon  the  removal  of  the  calvarium  the  meninges  were 
found  to  be  deeply  congested,  but  there  were  no  signs  of  a 
meningitis  upon  the  vault.  In  remo\-ing  the  brain  as  the 
optic  nerves  were  being  severed,  yellowisli-gray  pus  gushed 
out  from  the  middle  fossa.  Upon  "turning  the  bram  upon  its 
superior  surface  and  pressing  upon  the  temporal  lobes  pus 
welled  out  of  a  ragged  opening  in  the  infeior  surface  of  the 
right  temporal  lobe.  Shaving  away  thin  sections  of  this  lobe 
disclosed  the  fact  that  the  ventricles  were  enormously  dis- 
tended with  pus.  The  velum  and  choroid  plexuses  were 
swollen,  congested  and  covered  with  pus.  The  excessive 
pressure  in  tlie  ventricles  had  evidently  caused  the  pus  to 
burrow  through  the  right  temporal  lobe  and  show  itself  iix 
the  middle  fossa  of  the  skull. 


AfAECH  2,   1901] 


PERSISTENT  EPISTAXIS 


[Thb  Philadklphia 
msdicai.  jourmal 


439 


The  brain  tissue  was  then  freely  incised  and  numerous 
abscesses  varying  in  size  from  a  small  shot  to  an  olive 
were  found.  The  abscesses  were  far  more  numerous  in  the 
frontal  than  in  the  middle  and  occipital  lobes,  whieh  prob- 
ably accounts  for  the  late  appearance  of  symptoms.  None 
was  found  in  the  pons  nor  in  the  cerebellum.  The  only  indi- 
cation of  basil  meningitis  was  about  the  optic  commissure. 

The  cerebral  tissue  was  soft,  deeply  congested  and  moist  in 
many  areas  of  varying  size.  Especially  was  this  the  case 
in  the  neighborhood  of  the  larger  collections  of  pus.  The 
staphylococcus  pyogenes  aureus  and  streptococcus  pyogenes 
were  found  associated  in  the  pus  from  the  abscesses  and 
also  in  blood  from  the  heart  cavities. 

Dr.  J.  B.  Nichols,  pathologist  to  the  Garfield  Hos- 
pital, has  furnished  me  with  the  microscopic  findings 
in  the  kidneys,  spleen  and  liver. 

The  kidneys  showed  a  marked  and  typical  condition  of 
parenchymatous  degeneration  or  cloudy  swelling.  The 
epithelial  cells  of  the  secreting  portions  of  the  uriniferous 
tubules  were  swollen,  granular,  and  showed  indistinct  out- 
lines and  their  nuclei  were  absent.  The  remaining  struc- 
tures were  normal.  The  spleen  was  practically  normal. 
The  liver  cells  showed  a  moderate  degree  of  cloudy  swelling, 
their  nuclei  not  staining  as  deeply  as  normally  and  the  cells 
being  in  places  somewhat  swollen. 

There  seems  no  reason  to  doubt  that  the  abscesses  in  the 
brain  were  metastatic  from  the  old  empyemic  fistula.  Why 
abscesses  should  form  in  the  white  matter  of  the  brain  and 
not  in  the  other  organs,  as  the  spleen,  liver,  kidneys,  etc.,  is 
difficult  to  explain.  There  is,  however,  in  these  cases  but 
little  tendency  to  the  general  pyemic  state.  As  to  the 
fretjuency  with  which  abscess  of  the  brain  becomes  a  compli- 
cation of  lung  disease,  we  read  that  of  76  cases  of  brain 
abscfss  collected  by  Gull  and  Sutton,  "Reynold's  System  of 
Medicine,"  Vol.  2,  page  568,  there  were  9  due  to  disease  of 
the  lungs  or  pleura.    Of  these  3  resulted  from  empyema. 

The  following  list  of  58  cases  of  brain  abscess  result- 
ing from  primary  lung  disease,  shows  that  empyema 
as  a  cause  is  second  only  to  bronchiectasis. 

1. — Bronchiectasis,  20  cases. 

Three  cases  reported  by  Naether,  Deulach.  Arch.  J.  klin. 

Med  ,  1883-84. 
One    each    by  Holzhausen,   Meyer,    Oppolzer,    Bath, 

Hutchinson,   Curshmann,   LShmann,   and   four  by 

Biermer,  quoted  by  Fuchs,  "  Gehirnabscesse  nach 

primaren  Lungenleiden." 
Two  by  Pfungen,  IVimer  med.  Blatter,  1883,  p.  181. 
One  by  Sainbury,  Lancft,  October  12,  1889. 
One  by  Caley,  Trans,  of  the  Path.  Soc  ,  London,  vol.  35. 
One  in  the  Jahr.  d   Wilier  K.  K.,  1895,  p.  456. 
One  by  R.  T.  Williamson,  Med.  Chronicle,  Manchester, 

1893-94,  p.  423. 
2. — Empyema,  10  cases. 

One  case  by  Nather,  he.  cit. 

One  by  Almgren  (von  C.  H.),  Schmidt's  Jahrbilcher,  vol. 

207-208. 
Two  by  Gull  and  Sutton,  loc.  cit. 

One  by  Bettenheim,  Dfutsch.  Arch.f.  klin.  ^/ed.,  1884. 
One  by  Chapt  (Jos.),  Bull,  de  la  Soc.  Anatom.  de  Paris, 

1892. 
Three    by    Hadden    (W.   B.),  St.    Thomas'  Hospital 

Reports,  vol.  17. 
My  own  case. 
3. — Purulent  bronchitis,  9  cases. 
Two  by  Nather,  loc  cit. 
One  each  by  De  Gaines,  Peterson,  Senator,  and  Meyer 

and  three  by  Pontoppidan,  quoted  by  Fuchs,  loc.  cit. 
4. — Gangrene,  7  cases. 
Naether,  two,  loc.  cit. 

Huguenin,  one,  Ziemssen's  Cyclopedia  of  the  Prac- 
tice of  Medicine,  vol.  12. 
Virchow,   Meyer,   Hoffmann,    each    one,  quoted    by 

Fuchs,  loc  cit. 
Brettner  (H.),  one,  "  Ein  Fall  von  Gehirnabscess  und 

Lungengangriin . " 
5. — Tuberculosis,  5  cases. 

Meyer,  Biermer  and  Robertson,  each  one,  quoted  by 

Fuchs,  loc.  cit. 


Gull  and  Sutton,  one,  loc.  cit. 
Fagge,  one,  quoted  by  Williamson,  loc.  cit. 
6. — Lung  abscess,  3  cases. 

Bottcher  and  Virchow,  one  each,  quoted  by  Fuchs, 

loc.  cit. 
Steese,    one,   Med.  and  Surg.   Report,    Presbyterian 
Hospital,  1898,  3. 
7. — Pneumonia,  2  cases. 

Bamberger,  one,  quoted  by  Huguenin,  loc.  cit. 
Finley  and  Adami,  one,  Montreal  Med.  Jour.,  1893-94. 
8. — Gunshot  wound  of  lung,  2  cases. 

V.  Mosetigmorf,  one,  quoted  by  Fuchs,  loc.  cit. 
Eskridge  and  Parkhill,  one.  New   York  Med.    Jour., 
1895,  Ixii. 

One  point  which  is  of  considerable  interest  from  a 
prognostic  point  of  view,  is  whether  in  these  cases  the 
abscess  is  more  likely  to  be  single  or  multiple. 

We  read  in  Allbutt's  "  System  of  Medicine,"  p.  363 : 
"  Abscess  of  the  brain  is  a  consequence,  not  very  un- 
common, of  empyema.  The  abscess  is  usually  single 
and  occupies  either  the  occipital  or  temporosphenoidal 
lobe;  in  a  few  rare  cases  many  abscesses  have  been 
found." 

Of  seven  cases,  the  reports  of  which  I  have  read, 
there  were  four  multiple  and  three  single.  Two  of  the 
cases  reported  by  Gull  and  Sutton  were  in  hospital 
records  which  were  not  obtainable  here.  With  the 
addition  of  my  case,  which  was  multiple,  the  balance 
would  seem  to  be  considerably  in  favor  of  the  multiple 
variety ;  making  five  multiple  to  three  single  in  eight 
cases.  In  case  of  multiple  abscess,  of  course,  surgical 
interference  becomes  practically  useless. 

I  am  indebted  to  Drs.  Snyder  and  Thompson  for  the 
history  of  the  case  while  under  their  care. 


THE    USE    OF    THE    AQUEOUS    EXTRACT    OF   THE 
SUPRARENAL  GLAND  IN  PERSISTENT  EPISTAXIS. 

By  lewis  S.  SOMERS,  M.D., 
of  Philadelpbifi. 

One  of  the  most  annoying  and  at  times  serious  inci- 
dents in  the  treatment  of  nasal  disorders  and  occurring  as 
a  symptom  during  the  course  of  some  general  diseases  is 
the  presence  of  continuous  or  intermittent  nasal  bleed- 
ing. In  the  majority  of  cases  of  epistaxis,  the  flow  of 
blood  is  readily  controlled  by  simple  measures  or  ceases 
of  itself  within  a  short  time,  while  in  a  much  smaller 
number  the  bleeding  is  apt  to  be  persistent  and  while 
local  applications  fail  to  modify  it  in  the  least  degree, 
packing  of  the  nares  will  apparently  control  the  bleed- 
ing as  long  as  the  mechanical  pressure  is  retained,  but 
when  it  is  removed  the  hemorrhage  quite  often  starts 
afresh.  When  the  bleeding  comes  from  a  definite  point 
on  the  septum  and  resists  the  ordinary  astringent 
applications,  the  actual  cautery  will  almost  instantly 
control  the  hemorrhage,  but  by  this  method  a  portion 
of  the  tissues  must  of  necessity  be  destroyed  and  it  is 
not  unusual  to  have  secondary  hemorrhage  when  the 
eschar  comes  away,  necessitating  further  applications 
for  an  indefinite  period.  The  iron  salts  have  probably 
been  used  more  than  any  other  remedies,  but  they  are 
irritating,  form  a  clot  and  are  decidedly  septic. 

It  is  not  my  purpose  to  mention  the  long  list  of  drugs 
and  procedures  used  with  varying  success  for  the  con- 
trol of  nasal  bleeding,  but  to  emphasize  the  results 
obtained  from  the  suprarenal  gland,  especially  in  those 
cases  of  epistaxis  extending  over  a  long  period  of  time, 


440  The  Philadelphia"! 

&i£DICAL  JOOKNAL  J 


PERSISTENT  EPI8TAXIS 


[MLasch  2,  IMi 


and  in  which  the  usual  gamut  of  procedures  have  been 
used  and  proved  unavailing.  The  desiccated  suprarenal 
gland  of  the  sheep,  being  composed  in  great  parts  of 
animal  matter,  readily  undergoes  putrefactive  changes 
when  moistened,  and  in  this  form  should  not  be  used 
in  the  nasal  cavities  unless  the  conditions  are  very 
urgent,  when  it  may  be  blown  in  the  bleeding  chamber 
either  dry  or  made  into  a  semifluid  mass  with  water. 
Under  any  circumstances,  however,  when  used  in  this 
form  it  should  not  remain  in  situ  for  more  than  10  or 
12  hours,  or  infection  with  local  and  systemic  disturb- 
ances will  take  place. 

This  has  previously  been  noted  by  Bates,'  who  states 
"  that  in  severe  nasal  hemorrhage  it  is  often  difficult  to 
reach  the  bleeding  surface  with  the  extract,  if  applied 
by  spray  or  cotton  on  a  probe,  and  in  some  cases  it  is 
necessary  to  syringe  a  iOfo  emulsion  into  the  nares 
before  the  bleeding  ceases.  Tampons  wet  with  the  solu- 
tion should  not  be  left  in  the  nose,  because  infection 
occurs  in  a  few  hours  with  vascular  disturbance  and 
secondary  hemorrhage."  I  have  not  in  any  of  my  cases 
seen  secondary  hemorrhage  occur  from  the  presence  of 
the  adrenal  extract  in  the  nose,  and  when  it  does  take 
place  one  cannot  ascribe  it  to  the  adrenal,  per  se,  but  it 
occurs  as  a  result  of  infection  from  putrefactive  changes 
in  the  aqueous  solution  or  desiccated  powder  which  has 
been  allowed  to  remain  in  the  nasal  cavity  for  too  long 
a  time.  These  untoward  results  should,  however,  not 
be  considered,  as  they  never  take  place  if  a  properly 
prepared  antiseptic  solution  be  employed  as  a  vehicle 
for  the  suprarenal.  Unfortunately,  the  addition  of  a 
number  of  antiseptics  or  preservatives  to  the  aqueous 
solution  of  the  gland  will  seriously  impair  its  efficiency 
and  its  maximum  physiological  results  will  not  be  ob- 
tained. However,  by  adding  1  grain  of  pure  carbolic 
acid  to  a  dram  of  sterile  water  containing  10  grains  of 
adrenal  and  then  filtering  through  paper,  a  solution  is 
obtained  that  retains  its  maximum  efficiency  and  is 
both  sterile  and  permanent.  I  have  used  this  formula 
for  nearly  2  years  and  always  find  it  reliable,  but  still 
more  preferable  is  the  same  solution  to  which  has  been 
added  a  sufficient  quantity  of  eucain  to  make  a  1,  2,  or 
3  %  solution.'  By  this  latter  one  attains  not  only  the  full 
vasoconstrictor  action  of  the  adrenal  but  an  anesthetic 
action  as  well. 

Theoretical  studies  of  the  suprarenal  gland  would 
indicate  that  it  possessed  qualifications  rendering  it 
superior  as  a  local  hemostatic  and  vasomotor  constrictor 
to  all  other  remedies,  and  on  practical  observation  this 
is  found  to  be  the  case.  It  has  no  effect  on  the  blood 
itself — that  is  it  does  not  produce  a  clot — but  within  a 
few  seconds  after  it  has  been  applied  to  the  mucous 
membrane,  blanching  of  the  surface  ensues  and  from 
its  remarkable  constricting  action  on  the  muscle  fibers 
of  the  vascular  walls,  the  small  arterioles  contract  to 
such  an  extent  that  it  is  impossible  for  the  blood  to 
flow  through  them. 

This  may  be  well  illustrated  by  the  following  case  in 
which  no  bleeding  had  previously  occurred,  therefore 
differing  from  the  class  especially  referred  to  here,  but 
which  I  wish  to  record  again  as  demonstrating  this 
phase  of  the  drug.'  The  patient  was  a  boy  of  14  years, 
who  came  to  my  clinic  with  a  severe  attack  of  epistaxis, 
commencing  but  a  few  moments  previously.  The  blood 
was  freely  escaping  from  nostrils  and  mouth  and  the 
patient  stated  that  it  had  commenced  from  the  left  nasal 
chamber.  Assuming  that  the  hemorrhage  was  due  to 
a  rupture  of  the  anterior  artery  of  the  septum,  as  is 


most  frequently  the  case,  a  small  pledget  of  cotton  satu- 
rated with  the  adrenal  solution  was  placed  over  this 
region,  as  the  parts  could  not  be  seen  on  account  of  the 
profuse  flow  of  blood.  This  was  allowed  to  remain  un- 
disturbed for  a  short  time  and  then  the  nostril  was 
thoroughly  sprayed  with  the  same  solution  and  at  the 
expiration  of  a  few  minutes  the  parts  were  cleansed 
with  a  simple  alkaline  solution,  the  flow  of  blood  hav- 
ing ceased  in  the  meanwhile.  It  could  then  be  seen 
that  all  evidence  of  hemorrhage  had  disappeared  and 
what  was  formerly  a  bleeding  area  was  completely  ex- 
sanguinated and  the  vessels  firmly  contracted,  no  clot 
remaining  to  later  become  detached  and  cause  secondary 
hemorrhage. 

What  one  may  designate  as  chronic  or  persistent 
epistaxis  is  exemplified  in  the  case  reported  by  Ler- 
mitte*  of  a  boy,  6  years  of  age,  who  had  epistaxis  at 
almost  daily  intervals  for  two  years ;  frequently  there 
would  be  several  attacks  a  day,  some  lasting  for  an  hour 
or  more.  A  long  list  of  measures  were  tried  on  this 
case  without  the  least  results  until  by  the  use  of  local 
applications  of  the  suprarenal  gland  the  bleeding  ceased 
and  did  not  return. 

These  cases  of  long-continued  nasal  bleeding  fre- 
quently assume  a  most  unfavorable  aspect,  the  general 
health  of  the  patient  becoming  seriously  impaired  and 
a  high  grade  of  anemia  developing.  In  addition  to  the 
general  impoverishment  of  the  system,  the  constant 
nasal  bleeding  and  especially  the  inefficient  measures 
used  for  its  relief,  produce  alterations  of  the  nasal 
mucosa,  and  on  the  slightest  irritation  the  hemorrhage 
is  renewed  afresh. 

The  following  case  is  of  considerable  interest  both 
on  account  of  the  duration  of  the  hemorrhage,  the  in- 
efficiency of  the  usual  remedies,  and  the  prompt  and 
permanent  results  obtained  from  the  local  appUcations 
of  the  suprarenal  gland. 

F.  M.,  salesman,  age  30  years,  was  first  seen  on  October 
26, 1899,  when  he  stated  that  his  nose  commenced  to  bleed 
on  July  1,  previous.  The  bleeding  was  from  the  right  side 
and  there  was  at  least  one  hemorrhage  every  day  and  very 
often  this  would  occur  two  and  three  times  daily.  He  would 
be  awakened  at  night  by  the  warm  blood  flowing  down  his 
throat,  and  the  attacks  of  bleeding  would  last  from  one  to 
four  hours.  A  number  of  drugs  and  various  measures  were 
used,  without  avail.  His  general  condition  was  poor,  he  was 
anemic,  weak,  and  at  times  had  attacks  of  vertigo,  especially 
marked  after  the  epistaxis  had  been  profuse  and  excessive. 
There  was  a  general  hypertrophic  C4it«rrhal  condition  of  the 
nasal  interior  and  pharynx  ;  the  left  side  of  the  septum  was 
normal  while  the  mucous  membrane  over  the  right  anterior 
cartilage  was  congested  and  irregular,  bleeding  on  the  slight- 
est touch.  The  vessels  of  this  portion  of  the  nasal  chamber 
were  larger  than  normal,  but  they  did  not  appear  to  be  of  an 
angiomatous  character  and  there  was  no  history  of  hemo- 
philia or  previous  attacks  of  epistaxis.  At  his  first  \-isit  a 
thin  pledget  of  cotton  was  saturated  with  the  adrenal  solu- 
tion and  placed  over  the  entire  bleeding  area  of  the  septum, 
without  pressure  and  without  interfering  with  respiration 
through  the  affected  nostril.  He  removed  the  cotton  the 
following  morning  and  bleeding  did  not  recur  until  five  days 
later,  when  he  had  a  profuse  hemorrhage  at  night,  lasting 
for  three  hours  and  finally  ceasing  spontaneously.  He  wm 
then  directed  to  place  a  small  piece  of  cotton  in  his  nostril 
eacli  evening,  saturated  with  the  solution.  From  tnis  time 
on  the  adrenal  was  applied  at  infrequent  int-ervals  and  the 
septum  became  pale  in  color,  and  tne  previously  enlarged 
vessels  were  hardly  perceptible.  He  reported  at  frequent 
intervals  with  no  bleeding,  until  November  21,  when  the 
septal  mucosa  had  entirely  changed  in  appearance  and  was 
covered  with  normal  epithelium,  and  aid  not  bleed  when 
touched  with  a  probe,  nor  was  it  unduly  sensitive.  He  h»8 
been  seen  at  intervals  during  the  past  year,  and  the  epistaxis 


MAacH2,  1901) 


BIO-CHEMICAL  BASIS  OF  PATHOLOGY 


rTHK  Philadelphia  441 

Mkdical  Jodbnal 


has  not  recurred,  while  his  general  health  has  decidedly  im- 
proved. 

Of  a  minor  grade  as  to  frequency,  duration,  and  the 
amount  of  nasal  bleeding,  is  the  following  case  which 
responded  admirably  to  the  adrenal  solution. 

E.  R.,  male,  age  7  years,  was  first  seen  May  2,  1900.  He 
had  never  had  any  nose  or  throat  symptoms,  nor  nasal 
bleeding  until' April  25,  1900,  when  he  had  a  profuse  epis- 
taxis  from  the  right  side.  This  took  place  during  the  night, 
and  the  week  previous  to  when  he  was  seen,  he  would  have 
from  2  to  3  attacks  daily.  With  but  slight  exceptions,  there 
was  an  almost  continuous  flow  of  blood  from  the  nose  for  1 
week.  At  times  it  would  only  be  a  few  drops,  but  mor^  fre- 
quently, a  steady  stream  would  flow  from  the  nostrils  His 
general  health  was  good,  except  for  the  anemia  already 
present  from  the  loss  of  blood,  and  the  rhinopharynx  was 
normal,  except  the  anterior  cartilaginous  portion  of  the 
septum,  which  was  red  and  granular,  the  vessrls  dilated  and 
bleeding  on  the  slightest  touch.  The  blood  appeared  to  ooze 
from  all  parts  of  this  portion  of  the  septum,  and  did  not 
come  from  any  large  vessel.  Adrenal  was  applied  on  cotton 
as  in  the  previous  case,  other  methods  having  been  used 
without  avail,  and  his  mother  was  instructed  to  drop  several 
minims  of  the  adrenal  solution  int )  the  affected  nostril 
twice  daily.  This  was  discontinued  in  a  few  days,  and  the 
bleeding  has  not  recurred,  while  the  affected  tissues  are  pale 
in  color,  perfectly  smooth,  and  can  be  handled  with  con- 
siderable roughness  without  the  least  evidence  of  bleeding. 

When  the  suprarenal  gland  is  used  in  these  cases 
and  in  any  nasal  pathological  condition  characterized 
by  congestion  and  erosion  of  the  mucous  lining,  the 
results  obtained  clearly  indicate  that  it  possesses  a  still 
further  action  than  that  of  vascular  constriction,  and 
this  is  shown  by  the  rapid  changes  taking  place  in  the 
physical  condition  of  the  parts.  The  erosions  heal  and 
a  general  nutritive  tone  is  given  to  the  tissues  that  no 
other  local  remedy  seems  to  possess.  This  has  been 
noticed  in  all  my  cases  in  which  the  nasal  conditions 
indicating  its  use  were  present  and,  therefore,  in  addi- 
tion to  the  drug  being  the  most  remarkable  vasomotor 
constrictor  that  we  possess,  it  is  also  of  great  value  for 
its  local  nutritional  efiFects,  and  its  power  of  acting  as  a 
pure  muscle  tonic. 

REFERENCES. 

'  Journal  AmerUan  Medical  Association.  August  11, 1900. 

*  Therapeutic  Gazette.  December  15,  1900. 
'  M'rci's  Archiia.  June,  1900. 

*  British  Medical  Journal,  February  25,  1899. 


THE  BIO-CHEMICAL  BASIS  OF  PATHOLOGY. 

By   HEXRY  a.  BU^'KER,  M.D., 

of  Brooklyn,  N.y. 

At  the  meeting  of  the  Hospital  Graduates'  Club,  held 
May  27,  1898,  I  had  the  honor  to  present  a  paper  bear- 
ing the  above  title,  in  which  paper  were  embodied 
certain  results  obtained  in  laboratory  work  in  the  field 
of  biological  chemistry,  together  with  some  deductions 
as  applied  to  pathological  conditions.  In  that  paper 
the  hope  was  expressed  that  the  outcome  of  researches 
then  under  way  might  warrant  the  early  presentation 
of  a  further  paper  under  the  same  title,  which  would 
substantiate  the  correctness  of  these  deductions.  That 
there  have  been  many  disappointments,  with  appar- 
ently meager  reward  for  much  hard  work,  may  go  with- 
out the  saying  for  those  of  my  fellow-members  who 
may  have  essayed  investigations  in  this  exacting  field 
in  conjunction  with  general  medical  practice.  A  pro- 
found faith  in  the  future  of  this  comparatively  new 


field  of  research  is  oSered  as  sufficient  justification  for 
presenting  this  paper. 

Until  within  the  past  few  years  our  knowledge  of 
pathological  conditions  has  been  limited  to  macroscopical 
and  microscopical  findings.  WhUe  such  knowledge  is 
essential — in  fact,  further  progress  would  be  impossible 
without  it — and  too  high  praise  cannot  be  awarded  to 
the  workers  in  that  field,  it  may  be  safely  stated  that, 
except  in  the  working  out  of  disputed  and,  in  the  main, 
minor  details,  morphology  has  practically  reached  its 
limit  in  the  field  of  research.  We  must  go  back  of 
structure  and  form  in  order  to  determine  the  causes  for 
the  now  well-recognized  variations  in  detail. 

If  we  accept  the  time-honored  teaching  that  all  patho- 
logical processes,  whether  those  involved  in  tissue  struc- 
ture or  in  the  modifications  in  composition  and  char- 
acter of  the  body-fluids,  are  originally  only  deviations 
from  normal  physiological  routine,  we  are  obliged  to 
conclude  that  the  real  secrets  of  disease-action  must  be 
sought  back  of  and  precedent  to  histological  and  mor- 
phological change.  In  other  words,  nutritional  dis- 
turbances and  perversions  must  antedate  change  of 
structure  from  the  normal. 

Therefore  we  must  look  to  the  cell  as  the  starting 
point  of  pathological  deviations  just  as  we  must  con- 
sider it  the  beginning  of  physiological  life,  for  in  so  far 
as  the  cell  is  perfect  in  activity  and  function,  just  so  far 
is  the  organ,  which  is  only  a  colony  of  similar  cells, 
perfect.  The  activity  of  the  cell,  its  very  existence  as 
a  ceU,  is  inherent  in  the  nucleus,  the  surrounding  ceU- 
protoplasm  being  apparently  a  nutritional  and  func- 
tional envelope. 

As  a  general  proposition  it  may  be  stated  that  any 
normal  cell  nucleus  resembles  in  every  respect,  morpho- 
logically and,  so  far  as  at  present  determined,  also 
chemically,  all  other  normal  cell  nuclei.  According  to 
Weisman  and  others,  the  amount  of  chromatin  sub- 
stance in  every  active  cell  among  the  millions  of  cells 
throughout  the  body  is  the  same  as  in  the  primitive 
cell  from  which  the  organism  sprang ;  and  further,  that 
in  any  given  species,  even  the  same  number  of  chro- 
matin filaments  persists  throughout,  under  whatever 
changed  conditions  normal  cell  proliferation  takes  place. 

From  the  nuclei  of  the  cells  then  are  formed  new 
nuclei  for  other  and  similar  cells  and  from  the  cell- 
protoplasm  are  constructed,  by  the  bio-chemical  activ- 
ity of  the  nuclei,  the  varied  connective  tissues  as 
reticula,  bone,  cartilage,  etc.,  etc.  In  this  process  in 
its  entirety,  whether  observed  in  the  life  history  of  uni- 
cellular organisms,  or  in  the  complex  structure  of  more 
highly  evolved  forms  of  life,  we  recognize  living  matter 
whose  vital  characteristics  as  opposed  to  matter  not 
living  are,  according  to  Huxley's  classical  definition, 
first :  "  universal  disintegration  by  oxidation  and  its 
reintegration  by  intussusception  of  new  matter,  giving 
rise  to  the  varied  forms  of  growth  and  repair,  and  sec- 
ond :  the  universal  tendency  to  cyclic  change  or  repro- 
duction." 

It  is  apparently  in  this  conception  of  cell  and  tissue 
growth  that  the  secret  of  normal  and  abnormal  action 
must  be  sought,  for  the  whole  problem  would  seem  to 
revolve  around  the  perfection  of  the  process  of  oxida- 
tion of  waste  and  of  the  preparation  of  new  matter  for 
reintegration  and  reproduction.  If  there  is  no  distin- 
guishable diflference  in  the  active  centers,  the  nuclei  of 
the  cells,  we  must  look  to  the  distinctive  characteristics 
of  the  varied  forms  of  new  material  built  up  by  their 
activity  out  of  the  cell-protoplasm— the  intercellular 


442 


The  Philadelphia"! 
Medical  Journal  J 


BIO  CHEMICAL  BASIS  OF  PATHOLOGY 


tHASCH  2,  19ei 


connective  tissues  being  considered  simply  as  cement 
substance  or  as  stroma — to  furnish  the  clue  to  the  char- 
acter of  the  vital  jjrocesses  by  which  they  are  pro- 
duced. 

Under  the  law  known  as  the  physiological  division  of 
labor  then,  we  find  that  the  life-energy,  as  embodied  in 
the  primitive  cell  and  which  insures  the  persistence  of 
all  living  things,  is  broken  up  into  the  difierent  mani- 
festations of  that  energy  which  marks  the  wide  distinc- 
tion between  the  primitive  cell  and  the  complete  phys- 
ical organism.  Under  the  action  of  this  law,  connective 
tissues  are  found  to  vary  so  widely  in  the  dififerent 
organs  and  structures  of  the  body,  both  in  character 
and  form,  that  we  are  obliged  to  assume  the  existence 
of  a  selective  affinity  on  the  part  of  the  active  nuclei 
for  the  various  elements  of  nutrition  required ;  for  all 
the  nutritive  material  needed  for  growth  and  function  is 
contained  in  the  fluids  in  which  the  cells,  organs  and 
tissues  are  constantly  bathed. 

Now  simple  protoplasm,  as  such,  cannot  continue  as 
living  matter,  if  deprived  of  the  nuclear  substance 
which  gives  it  life;  it  would  seem  to  be  simply  an  in- 
termediate material,  or,  perhaps,  rather  a  transition 
state  of  organic  matter  between  the  active,  directing 
and  selective  nucleus  and  the  connective  tissues  which 
determine  form  and  function.  In  other  words,  the 
character  of  an  organ  or  tissue  differs  from  that  of 
other  organs  and  tissues  by  virtue  of  the  ability  of  the 
cell-nuclei  to  pick  out  from  the  tissue  fluids  holding  it 
in  solution  the  material  which  will  build  into  the 
structure  required. 

As  the  composition  of  the  blood-plasma  throughout 
the  body  varies  slightly,  if  at  all,  and  as  the  specialized 
character  of  organic  structure  varies  within  wide  limits 
in  continuous  and  contiguous  tissues,  as  in  bone  and 
ligament,  muscle  and  aponeurosis,  etc.,  it  must  follow 
that  not  only  are  all  the  elements  of  nutrition  contained 
in  solution  in  the  tissue- fluids  derived  from  the  blood- 
plasma,  but  that  the  cell-nuclei  of  each  tissue  are  pos- 
sessed of  the  power  of  appropriating  just  what  is  wanted 
and  nothing  more.  Any  solution,  therefore,  of  the 
problems  involved  in  the  processes  of  growth,  waste, 
and  repair,  must  rest  i)rimarily  upon  :  (1)  the  quality 
of  building  material  required  and  the  method  or  meth- 
ods of  rendering  it  suitiible  for  the  purpose  ;  (2)  the 
character  of  structure  to  be  built;  and  (3)  efficient 
means  of  rendering  innocuous,  utilizing,  or  otherwise 
disposing  of,  waste-products. 

It  is  a  fairly  proven  proposition  in  biology  that  the 
living  cell  is  enabled  to  prepare  material  for  its  own 
nutrition,  by  means  of  a  secretion  or  emanation  from 
its  own  substance,  of  special  enzymes  which  seem  to 
act  universally  by  a  process  of  hydrolysis ;  by  simplify- 
ing and  splitting  up — by  the  introduction  into  its  chem- 
ical formula  of  the  elements  of  water — complex  material, 
so  that  the  subsequent  synthesis  which  appears  to  be 
the  distinctive  function  of  protoplasm,  may  be  possible. 
In  all  forms  of  cell  and  microorganic  life,  this  fact 
seems  to  be  fairly  well  established,  although  thus  far 
efforts  to  isolate  and  identify  such  enzymes  have  met 
with  but  partial  success. 

That  such  enzymes  do  exist,  however,  is  shown  in  the 
production  of  peptones  and  their  concomitants  in  bac- 
terial decomposition  of  proteids,  in  the  glycolytic  and 
emulsion  forming  powers  of  cells  and  other  microor- 
ganisms on  carbohydrates  and  fats  and  in  all  fermenta- 
tions. 

If  we  study,  for  example,  the  life  history  of  the  yeast 


cell  as  a  type  of  micro-organic  life,  many  interesting 
facts  may  be  noted.  This  cell  secretes  within  its  own 
substance  and  throws  off,  something  which  passes  into 
solution  in  the  surrounding  culture  medium,  or  even 
in  water,  which  possesses  the  power  of  hydrating  and 
splitting  up  carbohydrates  previous  to  assimilating 
them  to  its  own  needs  of  protoplasmic  growth.  Now, 
yeast  cells  contain  nitrogenous  matter  as  proteid,  car- 
bohydrate as  glycogen  and  cellulose,  fat  and  mineral 
matter.  In  the  classical  experiment  of  Pasteur,  it  is 
demonstrated  that  a  culture  medium  composed  of 
sugar,  tartrate  of  ammonia  and  the  ash  of  other  yeast 
cells  furnishes  a  sufficient  pabulum  for  the  continued 
and  extensive  growth  of  new  cells,  although  neither 
proteid  substance  nor  fat  are  contained  in  the  solution 
and  the  carbohydrate  supplied  as  sugar  is  of  a  much 
higher  degree  of  hydration  than  that  built  in  as  glyco- 
gen and  cellulose.  It  is  known  further,  that  prepara- 
tory to  the  synthetic  dehydration  by  which  it  is  built 
into  living  matter,  the  sugar  in  this  solution  undergoes 
a  radical  change  in  its  optical  properties  and  therefore 
in  its  molecular  structure.  This  inversion  or  division, 
which  as  far  as  my  investigations  have  led  me,  seems  tO' 
take  place  in  the  nutrition  of  all  living  cells,  not  only 
in  carbohydrates  but  in  all  their  derivatives,  is  a  fact  of 
such  far-reaching  importance  that  I  here  venture  to 
suggest,  by  way  of  digression,  that  upon  it  will  be  found 
to  hinge  some  of  the  deepest  problems  in  biology, 
pathology,  immunity  and  possibly  also,  heredity. 
There  is  no  evidence  of  any  such  change  taking  place 
in  the  other  constituents  of  Pasteur's  artificial  culture 
medium  for  yeast.  The  nitrogen  of  the  tartrate  and  the 
mineral  matter  of  the  ash  seem  to  enter  into  organic 
combination  without  material  change,  the  synthesis 
producing  proteid  in  its  union  with  one  half  of  the  car- 
bohydrate cleavage,  while  the  other  half  is  deposited 
as  cellulose  and  glycogen,  the  alcohol  produced  being 
apparently  an  accumulation  product  and.  on  account  of 
its  symmetrical  molecular  structure,  contributed  equally 
by  each  moiety. 

The  life  history  then,  of  the  yeast  cell,  whether 
grown  in  what  may  be  considered  its  natural  environ- 
ment or  in  one  artificially  provided,  is.  first :  prepara- 
tory hydrolysis  and  inversion  by  means  of  which  the 
nutritional  supply  may  be  built  into  proteid  already 
existing;  by,  second:  successive  dehydrations  and  syn- 
theses— the  formation  of  fat  being  apparently  inter- 
mediary ;  third:  the  building  up  out  of  the  carbohy- 
drate thus  incorporated  into  proteid.  of  cellulose  as 
tissue  structure,  and,  fourth  :  the  storage  of  unused 
carbohydrate  for  future  necessity,  as  glycogen.  The 
entire  process  of  synthesis  is  followed  by,  or.  as  is  more 
likely,  accompanied  at  each  step  by.  disintegration 
through  a  reverse  order  of  sequence— fat  being  again 
intermediary — to  the  close  of  the  reproductive  cycle. 
As  the  evolution  of  the  heat  of  vital  activity  is  continu- 
ous throughout,  there  must  be  an  equally  progressive 
oxidation  of  the  waste  of  each  stage  to  the  final  oxida- 
tion into  carbon  dioxid  ar.d  water. 

A  point  of  considerable  importance  in  the  subsequent 
consideration  of  the  subject  of  this  paper,  is  the  fact 
that  only  under  anaerobic  conditions  do  yeast  cells  pro- 
duce any  appreciable  amount  of  surplus  alcohol.  If,  as 
suggested  above,  alcohol  is  an  accumulation  product  of 
ferment  action — and  it  acts  as  do  all  such  accumulation 
products,  by  finally  destroying  its  producing  ferment — 
we  may  comprehend  how,  in  the  presence  of  the  free 
oxygen  of   the   atmospheric  air,   the   more    vigorous 


Mabch  2,  1901] 


BIO-CHEMICAL  BASIS  OF  PATHOLOGY 


["The    t^U.ADBlJ*HL& 
L  MKDICAL  JorRNAL 


443 


growth  and  multiplication  of  the  organism  compels  an 
equally  rapid  oxidation  to  aldehyde.  This  aldehyde  is 
the  soluble  carbohydrate  needed  for  reinteo:ration  as 
proteid  in  the  formation  of  new  cells.  The  invariable 
presence  of  succinic  acid  in  sugar  fermentation  and  also 
of  the  compound  ethers  under  special  condition?,  give 
some  weight  to  this  theory  as  to  the  origin  of  an  alcohol 
surplus.  This  outline  of  the  life  history  of  the  yeast 
cell  may  be  taken  as  the  type  of  all  cell  life,  in  so  far 
as  biology  is  unable  to  prove  to  the  contrary. 

As  in  the  yeast  cell,  so  in  all  organic  life,  there  is 
abundant  reason  for  believing  that  none  of  the  food- 
stuffs are  laid  down  in  the  body  as  such,  but  that  their 
appearance  as  body  stuffs  is  possible  only  by  a  process 
of  synthesis  into  the  proteid  of  the  cell,  for  analysis 
fails  to  show  that  fat,  for  instance,  is  ever  formed  in  the 
body  except  as  a  disintegration  product  of  proteid. 
This  is  certainly  true  of  the  albuminous  bodies,  for  it  is 
a  notable  fact  that  no  nitrogen  or  nitrogen-bearing  body 
is  stored  up  as  reserve  in  the  body,  but  that,  on  the 
contrary,  such  material  immediately  becomes  part  of 
the  active  bioplasm  and  as  such  is  at  once  used  up  by 
the  increased  activity  it  stimulates,  so  that  within  a  few 
hours  after  its  ingestion  a  corresponding  amount  of 
nitrogen  is  practically  wholly  eliminated  as  urea. 

It  is  far  different,  however,  with  the  fats  and  carbo- 
hydrates. Here  is  undoubted  storage  of  what  is  not 
required  for  immediate  use,  for  future  consumption,  to 
be  drawn  upon  as  may  be  demanded  and  converted,  the 
one  into  the  other,  according  to  the  exigencies  of  vital 
activity. 

The  fact  that  in  experiments  upon  animals  the  elim- 
ination of  urea  which  is  the  measure  of  the  extent  of 
proteid  metabolism,  does  not  show  a  uniform  decrease 
during  starvation,  would  certainly  indicate  that,  in  the 
absence  of  the  direct  incitement  to  increased  metab- 
olism brought  about  by  ingestion  of  nitrogen,  the 
source  of  supply  for  heat  production  is  a  stable  one. 
In  accord  with  this  is  the  further  fact  that  the  ultimate 
fate  of  fat  in  the  body  is  to  become  oxidized  through  a 
regular  sequence,  to  carbon  dioxide  and  water  with 
the  production  of  heat  and  energy,  whether  physical 
or  molecular ;  that  the  process  is  a  continuous  one  and 
that  the  seat  of  this  oxidation  is  throughout  living  pro- 
teid substance. 

The  gradual  disappearance  during  starvation  of  gly- 
cogen from  the  liver  and  muscle — muscles  showing  its 
presence  much  later  than  the  liver — the  acceleration  of 
its  disappearance  by  muscular  work;  the  small  amount 
of  dextrose  found  in  muscle  during  lifs  and  its  rapid 
increase  after  death,^  together  with  the  equally  rapid 
decrease  of  glycogen  and  the  appearance  of  dextrin  as 
an  intermediate  product,  are  all  in  full  accord  with  the 
view  that  the  transformation  of  waste  is  only  through 
the  medium  of  repair  and  that  this  takes  place  only 
through  the  production  of  proteid  substance. 

In  laboratory  experiments  on  mice,  by  injecting  solu- 
tions of  methylene-blue  and  of  indigo  carmine  under 
the  skin,  and  killing  the  mice  as  soon  as  color  showed 
in  the  urine,  I  found  that  the  cell-protoplasm  of  the 
excretory  glands  especially  had  taken  up  the  stain. 
The  stain  had  not  been  deposited  in  the  connective 
tissues  and,  if  the  mouse  was  not  killed  promptly,  the 
color  was  found  to  have  wholly  or  partially  disappeared 
according  to  the  time  after  injection.  While  admitting 
that  the  results  of  these  experiments  are  not  altogether 
conclusive,  they  are  respectfully  submitted  as  furnish- 
ing a  link  at  least,  in  the  chain   of  evidence  that  the 


entire  process  of  metabolism  takes  place  through  the 
formation  of  proteid. 

That  fat  and  tissue  carbohydrate  are  mutually  trans- 
formable through  the  medium  of  proteid  production 
would  seem  to  be  strongly  indicated  by  many  facts, 
among  which  may  be  noted  the  large  amount  of  fat 
together  with  the  small  amount  of  carbohydrate — none 
of  the  latter  as  glycogen,  so  far  as  I  am  able  to  find — 
as  found  in  the  egg ;  while  in  the  embryo  the  converse 
is  true.  In  the  embryo  there  is  an  enormous  amount 
of  glycogen  to  supply  the  rapidly  growing  tissues  and 
to  insure  during  early  infancy  a  sufficient  formation 
of  fat  to  act  as  a  reserve  from  which  may  be  drawn  the 
material  for  future  growth. 

On  the  other  hand,  the  inhabitants  of  the  arctic 
regions  and  the  carnivora,  from  whose  diet  carbo- 
hydrate— except  the  small  amount  obtainable  from 
proteids  by  digestive  cleavage — is  wholly  excluded,  do- 
not  lack  the  muscular  development  inseparable  from 
glycogenic  activity  either  as  embryos,  infants  or  adults. 
Finally,  in  breaking  down  proteid  material,  whether 
by  means  of  digestive  enzymes  or  by  chemical  hydro- 
lytic  agents,  we  always  find  split  off  carbohydrate  as  a 
glucose,  or  rather  as  an  aldehyde  or  a  ketone,  whose 
power  of  reducing  copper  oxide'  varies  apparently  with 
the  degree  of  dehydration  which  has  taken  place  in  its 
synthesis.  That  these  cleavage  carbohydrates  are  in 
every  case  aldehydes  or  ketones  may  be  easily  demon- 
strated by  the  usual  tests  for  these  bodies.  I  am  most 
familiar  with  the  ammoniated  silver  nitrate  solution  of 
Tollens,  from  which  the  metallic  silver  is  deposited  as 
a  mirror  on  the  glass  of  the  test  tube,  in  the  presence 
of  an  aldehyde.  I  have  done  little  with  the  ketones 
except  a  slight  study  of  their  phenylhydrazones.  That 
the  aldehydes  at  least  undergo  varying  degrees  of  dehy- 
dration in  proteid  synthesis,  the  degree  depending 
apparently  upon  the  tissue  from  which  they  are  split 
off,  is  shown  by  their  difi"erent  and  characteristic 
osazone  crystallizations  with  phenylhydrazine,  as  well 
as  by  their  varying  power  of  reducing  copper  oxide 
referred  to  above. 

While  the  carbohydrate  product  of  digestive  proteo- 
lysis is  always  an  aldehyde  or  a  ketone,  the  fat  that  is 
also  found  in  the  residue  has  been  considerably  modi- 
fied in  character  and,  aside  from  the  strictly  interstitial 
fat — which  is  still  storage  fat— is  never  the  so-called 
neutral  fat  which  serves  as  reserve. 

Thus  Dormeyer*  finds  "  that  after  muscle  has  been 
subjected  to  preliminary  gastric  digestion,  ether  extracts 
85%  more  of  the  total  fat  obtainable;  and  that  with- 
out such  preliminary  digestion,  extraction  with  ether 
is  useless  for  quantitative  purposes."'  E.  Bogdanow  be- 
lieves that  "the  fat  which  is  thus  soluble  in  ether  with 
difficultv,  is  a  real  constituent  of  muscle  plasma  and 
states  that  it  is  richer  in  volatile  fatty  acids  than  that 
from  the  surrounding  connective  tissues." 

It  would  seem,  therefore,  that  these  volatile  fatty 
acids  are  not  produced  by  proteolytic  action.  They  are 
apparently  acids  which  have  not  as  yet  been  built  into 
proteid,  for  the  acids  derived  from  the  breaking  down 
of  strictlv  albuminous  material  are  always  found  in 
combination  with  an  amidogen  group,  sometimes  two 
or  more,  and  vary  in  proportion  with  special  tissues. 
It  might  even  be  said  that  the  character  of  tissue  may 
be  determined  by  the  proportions  of  these  amido  acids 
relatively  to  each  other,  so  characteristic  does  this  pro- 
portion "seem  to  be.  For  instance,  the  predominant 
amido  acid  of  gelatine  and  its  mother  substance  collagen 


444 


Thk  Philadelphia"! 
Medical  Jodbnal  J 


BIO-CHEMICAL  BASIS  OF  PATHOLOGY 


(March  2,  1901 


is  amidoacetic  acid,  glycocoll,  although  with  it  are 
found  amidopyrotartaric  acid,  amidosuccinic  acid  and 
leucine  but  no  t^Tosine,  both  amido  compounds.  The 
only  other  connective  tissue  substance  in  which  gly- 
cocoll has  been  found  is  elastin,  but  here  there  is, 
according  to  Drechsel,  no  accompanying  amidosuccinic 
acid  or  amidopyrotartaric  acid,  but  a  small  amount 
of  tyrosine.  Lysatinine,*  but  no  lysine,  both  diamido- 
acids  were  also  found.  So  also,  Siegfried'  found  amido- 
valerianic  acid  in  reticulin  from  reticular  tissue  and 
from  no  other,  not  even  from  white  fibrous  connec- 
tive tissue  with  which  reticular  tissue  is  "  anatomically 
continuous  and  histologically  identical."  Amido- 
pyrotartaric acid  which  is  found  in  elastin  and  gelatin 
is  not  found  in  reticulin.  And  so  on  with  all  the 
tissues  which  have  thus  far  been  studied. 

It  is  noteworthy  that  the  so-called  antipeptone  which 
is  the  end  product  of  proteolytic  digestion  opposed  to 
the  group  of  amidoacids  which  constitutes  the  hemi-, 
or  more  acid  half  of  the  proteid  decomposition,  is  now 
found  by  Siegfried'  to  be  an  amido-,  or  perhaps  rather 
a  multiple  amidoacid  which  he  calls  carnic  acid  and 
which  is  capable  of  being  further  split  up  into  lysine 
and  lysatinine.  Without  wearying  you  further,  suf- 
ficient has  been  said,  I  am  sure,  to  indicate  the  rather 
strong  probability  that  the  particular  character  of  struc- 
ture may  be  dependent  upon  the  predominant  ami- 
dated  or  nitrogenized  fatty  acid  or  group  of  fatty  acids 
which  so  evidently  go  to  build  it  up. 

Now  the  question  arises  as  to  the  origin  of  these  acids. 
In  view  of  the  fact  that  the  neutral  or  storage  fat  of 
each  animal  species  is  characteristic,  regardless  of  the 
form  of  the  fat  taken  as  food,  or  where  fat  forms  no 
part  of  the  diet,  that  is,  that  pork  fat  is  always  lard 
and  beef  fat  is  always  tallow — differing  only  in  the  per- 
centage of  the  different  fatty  acids  combined  with 
glycerine — the  indication  is  rather  strong  that  fat  has 
its  origin  in  the  synthetic  activity  of  protoplasm.  The 
only  experimental  proof  of  this,  so  far  as  I  am  aware, 
is  that  of  Munk,  who  showed  that  free  fatty  acids  fed 
to  animals,  are  synthetized  into  and  deposited  as  re- 
serve like  the  neutral  fats  norm  il  to  the  animals  ex- 
perimented on. 

The  fact  that  the  higher  fatty  acids  are  easily 
oxidized  in  the  laboratory  into  acids  of  lower  carbon 
content ;  the  fact  that  aldehyde  and  ketones,  the  carbo- 
hydrate factors  in  tissue  construction,  are  direct  oxida- 
tion products  of  primary  and  secondary  alcohols, 
becoming  corresponding  acids  throu.;h  further  oxida- 
tion, and  finally,  the  fact  that  the  oxidation  processes 
of  the  body  must  be  continuous,  all  would  seem  to 
make  the  relation  of  these  acids  to  the  food  carbo- 
hydrates a  fairly  clear  one.  We  read  and  talk  of  the 
systern  of  drawing  on  the  reserve  of  storage  fat,  but 
very  little  is  known  of  the  methods  by  which  such 
stored  material  is  prepared  to  enter  the  circulation  or 
to  become  part  of  the  tissue  fluids.  It  is  known  that 
the  neutral  fats  are  not  and  can  not  be  absorbed  as 
such.  They  are  decomposed  for  absorption,  but  are  at 
once  reintegrated,  by  the  agency  of  the  lymphoid  cells 
of  the  intestinal  villi"  preparatory  to  being  laid  down 
as  reserve.  Investigation  suggests  that  perhaps  the 
manner  in  which  such  storage  takes  place  may  furnish 
the  clew  to  the  methods  by  which  the  fats  are  utilized. 
Such  high  authority  as  Hammarsten,'  while  admit- 
ting that  fatty  tissues  supply  a  "  depot  where  there  is 
stored  during  proper  alimentation,  a  subst;ince  of  great 
importance  in  the  development  of  heat  and  vital  force, 


which  on  insufficient  nutrition  is  given  ofif  as  needed," 
has  no  explanation  to  ofier  for  this  fact  further  than 
that  "  the  fatty  tissues,  on  account  of  their  low  conduct- 
ing power,  become  of  great  importance  in  regulating 
the  loss  of  heat  from  the  body.  They  also  serve  to  fill 
cavities  and  act  as  a  protection  and  support  to  certain 
internal  organs."  While  there  is  no  doubt  of  the  cor- 
rectness of  these  statements,  such  functions  of  the  fatty 
tissues  must  be  considered  as  purely  subsidiary. 

The  real  importance  of  the  general  plan  of  this 
physiological  storage  would  seem  to  lie  in  the  fact  that 
the  organs  so  supported  and  protected  are  organs  of 
intense  and  unceasing  activity,  requiring  for  their 
energy  incessant  and  heavy  drafts  upon  a  convenient 
and  stable  source  of  supply. 

Between  the  mass  of  fat  surrounding  or  lying  adja- 
cent to  such  organ  or  lymphatic,  or  other  gland  and  the 
organ  or  gland  itself,  there  is  a  fine  network  of  lym- 
phatic vessels.  Now  lymphoid  cells  are  notably  active 
in  all  the  processes  of  anabolism  and,  in  accordance 
with  the  general  proposition  that  all  metabolism  is  an 
alternate  process  of  breaking  down  and  building  up,  it 
would  not  be  a  violent  assumption  to  suppose  that  these 
cells  bring  about  just  such  chemical  changes  in  this 
stored  fat  as  would  be  necessary  to  form  the  various 
tissue  fluids  qualified  to  meet  the  specific  demands  of 
the  tissues  to  be  supplied  or  nourished. 

In  other  words,  given  the  base  or  bases  of  lysatinine, 
lysin,  or  antipeptone— one  or  more  of  which  being  ap- 
parently always  present  in  all  forms  of  proteid  sub- 
stances— special  character  of  tissue  would  depend  upon 
the  particular  fatty  acid  to  which  they,  as  bases,  are 
united.  As  the  only  source  of  such  acids  is  the  neutral 
storage  fat,  their  presence  as  acids,  must  depend  upon 
the  degree  of  hydrolysis  to  which  the  neutral  fat  is 
subjected  in  the  preparation  for  organic  or  cellular  as- 
similation. With  this  idea  in  view,  I  endeavored  a  few 
years  ago,  to  demonstrate  the  existence  of  a  fat-split- 
ting enzyme  in  bronchial  glands,  but  in  view  of  the 
elusive  nature  of  enzymes  in  general  and  the  limited 
acquirements  of  the  experimenter,  it  will  not  surprise 
you  to  learn  that  the  several  attempts  were  wholly 
futile.  The  frequent  appearance,  however,  as  observed 
with  the  microscope,  of  fatty  acid  crystals  in  fat  cells 
— particularly  in  those  cells  lying  in  closest  contact 
with  the  lymphatic  network  referred  to,  and  also  in  the 
lymph-spaces  of  the  organs  themselves,  gives  hope  that 
the  future  will  provide  a  more  fortunate  investigator. 

If  the  hypothesis  here  presented  be  true,  as  to  the 
origin  of  tissue  differentiation,  for  all  ti.*sues  are  sup- 
plied with  lymphatic  vessels  and  glands  and  also  with 
interstitial  spaces  filled  with  tissue  fiuids,  we  need  not 
feel  obliged  to  accept  without  reservation.  Waller "s  as- 
sumption of  an  "  interorganic  relation  ''  under  which 
"  the  waste  of  one  organ  serves  as  the  raw  material  for 
another,"  for  each  organ  and  tissue  is  seen  to  supply  a 
complete  metabolism  by  and  for  itself  and  pathological 
change  would  simply  be  the  result  of  deviations  in 
degree  or  sequence  of  anabolism  and  catabolism  in 
relation  to  each  other. 

Thus,  an  excessive  accumulation  through  too  active 
formation,  or  through  imperfect  oxidation  and  elimina- 
tion of  any  of  these  organic  acids  would  lead  to  hyper- 
plasias— the  special  type  depending  upon  the  particu- 
lar acid  involved, — their  perversion  to  metaplasias, 
etc.,  etc. 

The  waste  or  oxidation  products  of  each  tissue  or 
organ  need  not,  therefore,  be  the  end  products  of  met- 


Makch  2, 19(Jl] 


BIO-CHEMICAL  BASIS  OF  PATHOLOGY 


PThk  Philadblphu 
l  mxdica.1,  jodrhai. 


445 


abolism  of  the  body  as  a  whole — carbon  dioxid,  water 
and  urea — although  to  a  certain  extent  this  is  really  the 
case,  but  would  certainly  be  the  antecedents  of  these 
and  whose  retention  would  give  rise  to  such  toxemic 
conditions  as  the  acid  diathesis,  such  as  gout,  rheuma- 
tisms, etc.,  on  the  one  hand,  and  to  uremia  and  uremic 
conditions  on  the  other.  The  ready  production  by 
Drechsel  and  others  of  urea,  by  various  hydrations  and 
oxidations  of  the  different  basic  substances  derivable 
from  proteids,  together  with  the  fact  that  in  birds  and 
reptiles  the  nitrogenous  end  product  of  physiological 
waste  is  uric  acid  and  not  urea,  furnish  a  logical  reason 
for  this  assumption. 

The  different  forms  of  physiological  and  pathological 
degeneration  would  seem  to  point  to  imperfect  hydro- 
lysis, due  either  to  impaired  or  perverted  enzyme  action 
and  subsequent  faulty  dehydration  and  synthesis,  or  to 
imperfect  synthesis  of  properly  prepared  material.  In 
fatty  degeneration,  for  instance,  the  cells  seem  to  have 
lost  the  power  of  completing  the  proteid  anabolism 
from  carbohydrate  and  the  process  stops  at  the  fat  stage. 
The  cell  then  loses  its  protoplasm  through  ordinary  vital 
waste  and  deposits  the  fat  instead  of  new  protoplasm. 
This  deposited  fat,  not  having  reached  the  stage  of 
organic  combination  where  it  can  be  oxidized  with 
physiological  rapidity,  gradually  accumulates  to  the 
final  destruction  of  the  cell  as  such.  In  myxedema 
and  in  the  amyloid,  hyalin  and  colloid  types  of  degen- 
eration, it  would  seem  that  the  stops  occur  at  the 
different  stages  of  normal  cell  activity,  with  the  result 
that  in  each  case,  otherwise  normal  material  fails  of 
complete  metamorphosis  and  is  deposited  in  the  tissues. 
In  glycosuria,  however,  the  excess  of  glucose,  on  account 
of  its  solubility,  is  carried  off  in  the  body  fluids  and  is 
eliminated  as  such. 

However  this  may  be,  the  products  of  cytoplasmic 
degeneration  seem  ajways  to  be  normal  physiological 
substances,  their  excess,  location  and  environment 
making  them  pathological,  proving  Huxley's  definition 
of  dirt  as  "  matter  out  of  place  "  to  be  true  physiolog- 
ically as  well  as  physically. 

To  return  to  the  amido  acids.  We  never  find  them 
combined  with  glycerin  as  the  free  acids  themselves. 
It  would  seem  from  this,  in  view  of  the  abundance  of 
glycerin  in  the  body-fats  and  the  fact  that  it  is  never 
found  in  the  free  state,  that  at  the  instant  of  the  union 
of  the  acids  of  the  fat  with  the  amidogen,  the  glycerin 
is  at  once  set  free  as  triatomic  alcohol  and  as  promptly 
disposed  of  according  to  the  demands  of  normal  metab- 
olism. At  any  rate  it  disappears  immediately  it  is 
broken  off  from  its  combination  with  the  fatty  acids, 
apparently  either  by  (a)  union  with  whatever  free 
acid  may  be  available  to  serve  again  as  storage  fat,  or 
under  pathological  conditions  to  become  degenerative 
fat ;  or  (6)  by  oxidation  to  aldehydes  and  ketones,  for 
the  formation  of  new  proteid,  physiologically  or  patho- 
logically, to  pass  off  as  glucose  through  failure  of  normal 
synthesis,  or  (c)  by  oxidation  to  a  succession  of  acids 
whose  physiological  or  pathological  character  depends 
upon  the  orderly  sequence  and  completeness  of  the 
oxidation  processes. 

These  acids  cannot  exist  normally  in  the  body  in  a 
free  state  any  more  than  can  the  glycerin  from  which 
they  are  derived.  Their  appearance  implies  at  least  a 
partial  failure  of  metabolism.  Such  failure  gives  rise 
to  retention  acid  toxemias  either  as  the  acid  diatheses 
before  referred  to,  or  to  autotoxic  states  not  so  well 
recognized,   such   as  diabetic  coma,  due,  as  now  be- 


lieved, to  the  presence  in  the  body  fluids  of  B-oxybu- 
tyric  acid. 

The  physiological  disappearance  of  glycerin  by  oxida- 
tion to  aldehyde  for  the  formation  of  new  proteid,  as 
just  suggested,  is  rendered  extremely  probable  by  the 
fact  before  noted  that  aldehyde  is  always  a  cleavage  pro- 
duct of  proteid  decomposition  and  by  the  further  fact 
that  inseparable  from  aldehyde  as  a  result  of  such 
cleavage,  are  the  amido  acids. 

Like  glycerin  and  its  derivatives,  the  fatty  acids,  the 
amido  acids  are  never  found  free  under  normal  con- 
ditions. They  are  the  normal  body  acids  united  to  one 
or  more  amidogen  groups,  NHj.  This  union  is  of  such 
an  intimate  character  that  prolonged  boiling  in  caustic 
alkalies  does  not  destroy  it  and  under  normal  conditions, 
although  the  acid  half  of  the  amido  compound  is  suc- 
cessively oxidized  to  acids  of  progressively  decreasing 
carbon  content,  the  amidogen  appears  to  maintain  its 
relation  with  each  succeeding  acid  to  its  final  elimina- 
tion in  combination  with  carbonic  acid  as  urea,  car- 
bamid. 

The  fact  of  the  continuity  of  the  amidogen  or  nitro- 
genous half  of  the  different  amido  acids  would  indicate 
the  importance  of  the  grouping  and  gives  strong  con- 
firmation of  the  assumption  of  Waller  before  referred 
to  "  that  the  waste "  (meaning  the  oxidation  acids 
only)  "  of  one  organ  serves  as  the  raw  material  of 
another."  In  no  other  sense  may  the  amido  acids  be 
considered  as  waste  material,  and  then  only  as  they 
occupy  positions  lower  in  their  series  through  succes- 
sive oxidations  of  the  acid  radical. 

The  invariable  presence  of  amido  compounds — nota- 
bly the  monamids  of  aspartic  and  glutamic  acids  in 
germinating  plants'"  and  of  aspartic  and  glutamic  acids, 
both  amido  acids,  in  the  nutrient  material  of  animal 
embryos,  can  mean  only  that  they  are  necessary  for  pro- 
teid construction.  Hlaziwetz  and  Haberman"  have 
found  as  much  as  23.8%  of  aspartic  acid  in  egg-white. 

If  the  amido  acids  higher  in  the  series  are  of  such  im- 
portance in  the  normal  physiological  fibrosis  which  takes 
place  in  forming  the  embryo  and  are  such  important 
factors  in  maintaining  the  specialized  character  of  the 
different  body  tissues,  as  heretofore  cited,  why,  it  may 
be  asked,  should  they  not  be  of  equal  importance  in 
the  formation  of  new  tissues  and  cicatrizations  in  Na- 
ture's attempts  at  repair  after  degenerations  and  inju- 
ries ?  For  instance,  we  know  that  all  cures  of  the 
pulmonary  lesions  produced  by  tuberculosis  are  by 
fibrosis.  I  have  found  that  the  apparently  predomi- 
nant acid  in  this  fibrosis  is  the  amido-succinic  acid ; 
but  whether  it  is  the  most  important,  I  am  not  yet 
prepared  to  say.     Its  presence  is,  I  believe,  invariable. 

This  conclusion,  which  I  have  maintained  for  the  past 
four  years,  has  recently  received  grateful  confirmation 
in  a  paper  by  Dr.  Jonathan  Wright,"  of  this  city.  I 
take  the  liberty  of  abstracting  from  his  paper  a  quota- 
tion from  an  article  by  Viquerat,  in  Centralb.  f.  Bakt.  : 
"  Tuberculin,  glycerin  extract,  TO  or  TR  is  nothing  but  a 
watery  solution  of  an  alkaline  succinic  acid  salt,  .  .  . 
Further  researches,  which  will  soon  be  published,  show 
that  succinic  acid  plays  the  principal  part  in  the  tuber- 
culosis question ;  the  tubercle  bacillus,  or  rather  the 
succinic  acid  bacillus,  does  not  form  a  toxin  and  works 
in  this  connection  much  more  as  the  i)roducer  of  a 
diathesis  like  gout  than  as  a  true  toxin  forming  variety 
of  bacillus." 

The  result  of  the  further  reseaches  of  Viquerat,  the 
early   publication  of  which  is  promised,  will  doubtless 


446 


The  Philadelphia' 
Medical  Journal 


] 


CULTIVATION  OF  THE  ASPERGILLUS  IN  URINE 


[Maech2,  1991 


be  found  to  be  extremely  interesting.  I  do  not  know 
the  extent  of  his  researches  into  the  physical  properties 
of  tuberculin  extract,  but  I  venture  the  prediction,  based 
upon  my  own  investigations,  that  here  again,  as  sug- 
gested in  the  early  part  of  this  paper,  the  spatial  ar- 
rangement of  the  atoms  in  the  molecular  structure  will 
be  found  to  be  of  the  utmost  importance.  I  am  sorry 
to  say  that  I  have  nothing  sufficiently  definite  to  offer 
upon  this  point  now.  Unfortunately  my  notes  are  too 
incomplete  to  justify  any  conclusions  bearing  upon  this 
problem  as  relating  to  specific  biological  and  pathologi- 
cal conditions,  but  enough  has  been  learned  to  show 
conclusively  in  what  direction  the  distinction  between 
living  and  not-living  matter  lies. 

This  distinction  which  indicates  infallibly  the  direc- 
tion of  the  forces  which  tend  to  reintegration  on  the 
one  hand  and  to  disintegration  on  the  other,  is  so  funda- 
mental that  it  is  shown  in  the  earliest  and  most  primi- 
tive forms  of  life  and  is  seen  to  persist  throughout  to  the 
final  dissolution  of  organic  substance  into  its  primary 
elements.  What  may  be  the  nature  of  this  form  of 
energy  it  is  impossible  to  say  ;  as  in  other  forms  of  force, 
we  may  never  progress  further  than  recognition  of  them 
by  their  effect  upon  matter.  At  present  we  are  obliged 
to  conclude  with  Pasteur:"  "Is  it  not  necessary  and 
sufficient  to  admit  that  at  the  moment  of  the  elaboration 
of  the  primary  principles  in  the  vegetable  organism,  an 
asymmetric  force  is  present?  ...  Do  these  asym- 
metric actions,  possibly  placed  under  cosmic  influences, 
reside  in  light,  in  electricity,  in  magnetism  or  on  heat  ? 
Can  they  be  related  to  the  motion  of  the  earth,  or  to  the 
electric  currents  by  which  physicists  explain  the  terres- 
trial magnetic  poles  ?  It  is  not  even  possible  at  the 
present  time  to  express  the  slightest  conjecture  in  this 
direction. 

"  But  I  regard  as  necessary  the  conclusion  that  asym- 
metric forces  exist  at  the  moment  of  the  elaboration  of 
natural  organic  products ;  forces  which  would  be  absent 
or  ineffectual,  in  the  reactions  of  our  laboratories  either 
on  account  of  the  violent  course  of  these  phenomena, 
or  because  of  some  other  unknown  circumstance." 

Whether  we  accept  the  theories  of  Pasteur  or  those 
of  Le  Bel  and  van't  Hoff,  we  must  recognize  this  force 
or  these  forces  as  a  profound  modifier  of  chemical  affin- 
ities as  manifested  in  laboratory  reactions,  for  the  whole 
of  biological  chemistry  is  not  told  when  these  reactions 
are  noted. 

The  profound  and  far  reaching  bio-chemical  transfor- 
mations which  are  seen  to  occur  in  the  processes  of 
assimilation  and  also  of  disintegration  under  the  influ- 
ences of  normal  and  abnormal  cell  activity  are  brought 
about  by  the  collective  and  harmonious  action  of  the  in- 
dividual cells  of  each  gland  or  organ.  That  this  force 
is  the  determining  factor  in  the  biochemical  reactions 
which  take  place  within  the  cell,  is  evident  from  the 
uniformity  of  the  results  obtained.  Under  physiologi- 
cal conditions,  lines  of  cleavage,  synthetic  rearrange- 
ments and  successive  series  of  oxidations  are  seen  not 
to  vary,  but  to  follow  a  well  defined  and  symmetrical 
sequence,  disturbance  of  which  is  followed  by  a  more  or 
less  widely  distorted  condition  of  affairs  which  we 
recognize  as  pathological. 

If  we  consider  the  probable  size  of  the  proteid  mole- 
cule, we  must  realize  that  the  possible  lines  of  cleavage 
and  transformation  are  many.  If  after  normal  cleav- 
age, an  imperfect  oxidation  takes  place,  or  complete 
oxidation  follows  an  imperfect  cleavage,  or  imperfect 
cleavage  and  imperfect  oxidation  coexist,  we  see  that  the 


possible  modifications  of  metabolism  must  be  almost  in- 
finite. It  is  in  these  modifications  and  perversions  of 
normal  bio-chemical  relations — those  of  physiological  se- 
quence— that  the  cause  of  morphological  change  must 
be  sought ;  and  it  is  upon  the  recognition  and  under- 
standing of  the  chemistry  and  molecular  physics  in- 
volved in  tissue  structure  and  in  tissue  maintenance, 
that  the  pathology  and  therapeutics  of  the  future  must 
be  based. 

PARTEAL  BIBLIOGRAPHY. 

1  B.  Moore  :  Text  Book  of  Phvgiologry,  Schaefer,  vol.  i,  p.  319. 

2  W.  D.  Haliburton  :  Texl  Book  of  Physiology,  Schaefer,  vol.  i,  p.  15. 

3  Pavy  :  Physiology  of  the  Carbohydrates,  p.  28,  et  Kq. 
*  Schaefer:  Text  Book  ol  Physiologv,  vol.  i,  p.  105. 
»/6/d.,  vol.  i,  p.  72. 

8  Ihid  ,  vol.  i,  pp.  421,  426. 

0  Gamgee:  Physiological  Chemistry,  vol.  i,  p.  254,  tlseg. 

'  Schaefer:  Text  Book  of  Physiology,  vol.  i,  p.  163. 

»  Ibid. :  Text  B>ok  of  Physiology,  vol.  i,  p.  457. 

^  Pavy  :  Physiolotjy  of  the  Carhohydrates,  pp.  248,  121,  253. 

^  Hatnmarsteo  :  Physiological  Chemistry,  p.  250. 
'"  Ibid. :  Physiologicai  Chemistry,  p.  460. 
I"  Gamgee:  Physiologicai  Chemistry,  vol.  i,  p.  251. 
10  Pavy  :  Physiology  of  the  Carltuhydrales,  pp.  54,  55. 
ii  Gami^ee :  Physiological  Chemistry,  vol.  i,  p.  251. 
t2  N.  1'.  Mtdical  Journal,  April  7, 1900,  p.  505. 

18  Pasteur:  Researches  on  the  Molecular  Asymmetry  of  Natural  Organic  Pro- 
duets,  Lecture  2. 
"  J.  H.  vau't  Hoff:  The  Arrangement  of  Atoms  iu  Space. 


CULTIVATION  OF  THE  ASPERGILLUS  IN  URINK 
By  L.  napoleon  BOSTON,  M.D., 

Bacteriologist  to  the  Philadelphia  Hospital  and  to  the  Ayer  Clinical  Laboratory 

of  the  Pennsylvania  Hospital ;  I>emonstraior  in  charge  of  Clinical 

Laboratory,  MedicoChirurgical  College. 

(Contributed  from  Laboratory  of  the  Philadelphia  Hospital.) 

The  frequency  with  which  one  detects  the  presence 
of  yeast  and  mycelium  in  the  urine  voided  by  the 
inmates  of  this  institution  prompted  me  to  investigate 
the  apparent  relation  existing  between  these  and  other 
fungi,  which  are  in  many  respects  similiar.  For  this 
purpose  the  aspergillus  fumigatus  and  the  aspergillus 
nigra  were  cultivated  on  urine  as  follows  :  Acid,  alkaline, 
and  acid  diabetic  urines  were  placed  in  culture  tubes, 
in  quantities  of  10  to  15  c.c.  each.  Where  the  urine 
was  found  to  contain  albumin,  it  was  heated  sufficiently 
to  precipitate  this  body,  after  which  it  was  filtered  and 
placed  in  tubes,  as  above  stated.  One-half  of  all  the 
tubes  was  placed  in  a  temperature  of  212°  F.  for  45 
minutes.  Tubes  prepared  in  this  manner  were  inocu- 
lated with  the  A.  fumigatus,  care  being  taken  to  intro- 
duce, as  nearly  as  possible,  the  same  quantity  of  the 
growth  at  each  inoculation ;  always  cultivating  the 
organism  on  acid,  alkaline,  and  acid  diabetic  urines. 
To  acomplish  this,  6  tubes,  2  of  each  variety — 1  of 
which  was  sterile — were  employed.  The  same  precau- 
tions were  observed  in  the  stutly  ot  the  A.  nigra.  All 
inoculations  were  made  April  13,  1900,  and  the  follow- 
ing is  a  record  of  the  changes  observed — cultures  ex- 
amined daily  to  May  13,  1900. 

Series  No.  1.— A.  Fumigatits. 

Sterile  acid  urine,  kept  at  room-temperature,  4  days  after 
inoculation,  presented  a  surface-growth  which  was  easily 
broken  by  shaking  tbe  tube.  Microscopic  study  detected 
clumps  of  mycelium.  Many  spores  were  found  arranged  in 
large  clusters.  Mycelial  threads  crossing  one  another  were 
also  observed.  On  the  sixth  day  t  he  urine  was  alkaline,  of  an 
amber  color,  and  showed  a  heavy  precipitate. 

Acid  urine  (not  sterilized)  was  rendered  alkaline  in  4  days  — 
possibly  due  to  bacteria.  Growth  less  pronounced  than  on 
sterile  "urine.  Microscopically,  this  growth  appeared  to  be 
composed  of  amorphous  material  anj  spores.    Color,  amber. 

Sterile  alkaline  urine  presented  a  less  pronounced  growth 
than  did  acid  urine.    On  the  slightest  agitation  this  growth 


March  2, 1901] 


CULTIVATION  OF  THE  ASPERGILLUS  IN  URINE 


CThe  Philadelphia 
Medical  Journal 


447 


sinks  to  the  bottom  of  the  tube.  Alkalinity  was  increased  on 
the  sixth  day.  The  slight  surface- growth  contained  only  few- 
spores,  while  the  color  was  slightly  deepened.  On  the  twenty 
third  day  the  surface  and  upper  one  fourth  of  the  urine  were 
of  a  chocolate  color,  and  by  the  thirtieth  day  this  color  had 
extended  to  the  bottom  of  the  tube  The  sediment  and 
surface-growth  at  this  time  contained  only  few  spores.  To 
insure  iigainst  the  pussibility  of  contamination,  cultures  were 


Fig.  1. — Aspergillus  fumigatus  from  acid  diabetic  urine.    Objective  (Queen)  },. 
Eye-piece  iv. 

made  from  this  tube,  and  were  alike  in  giving  negative 
results. 

Alkaline  urine  (not  sterilized)  presented  a  more  marked 
growth,  which  was  found  to  be  largely  composed  of  spores. 
Alkalinity  was  not  increased  until  the  tenth  day,  when  a 
browning  was  observed  at  the  .surface  of  the  liquid,  which 
increased  gradually  to  the  sixteenth  day,  when  the  entire 
urine  was  of  a  brownish-black  color. 

Sterile  acid  diabetic  urine  presented  a  whitish  growth  in 
48  hours,  covering  the  surface  of  the  liquid ;  and  on  the 
fourth  day  tipping  and  shaking  of  the  tube  did  not  displace 


Flo.  2. — Penicillium  glaucum  from  potato  culture.    Objective  (Queen)  J.    Eye-- 

piece  iv. 

the  urine,  and  the  growth  was  beginning  to  acquire  a  greenish 
hue,  while  the  urine  reniaineil  of  an  amber  color.  Micro- 
scopic study  detected  many  mycelial  threads,  each  displaying 
its  individual  sporangium  at  one  extremity,  and  few  spores — 
the  usual  findings  when  A.  fumigatus  is  cultivated  on  potato 
■or  bread-paste.  On  the  ninth  day  the  growth  was  thickened, 
•wrinkled,  and  separated  from  the  side  of  the  tube,  while  its 
surface  was  studded  with  sporangia. 


There  was  practically  no  difference  in  the  reaction  of  the 
A.  fumigatus  when  grown  on  unsterilized  diabetic  urine. 

Series  No.  2.— A.  Nigra. 

Sterile  acid  urine  showed  a  marked  white  surface-growth 
on  the  fourth  day,-whi  h  prevented  the  urine  from  changing 
its  position  when  the  tube  was  inclined.  This  growth  was 
composed  of  mycelial  threads  and  many  spores.  Reaction 
neuiral.     Color  unchanged. 

Acid  urine  presented  both  a  surface-growth  and  a  heavy 
sediment.  The  surface-growth  was  composed  of  mycelial 
threads  and  spores.  Reaction,  alkaline.  Color  unchanged. 
No  further  changes  were  observed. 

Sterile  alkaline  urine  presented  but  slight  surface-growth 
on  the  fourth  day,  and  by  the  seventh  day  this  growth  had 
sunken  to  the  bottom  of  the  tube.  This  growth  wn.s  found  to 
be  composed  of  granular  material,  and  few  spores,  which 
presented  the  usual  dark  color.  Reaction  neutral,  after  the 
fourth  day,  and  at  the  surface  of  the  liquid  a  slight  reddening 
was  noticed,  which  increased  to  a  deep  cherry-red. 

Alkaline  urine  (not  sterilized)  differed  only  in  that  it  was 
rendered  highly  alkaline,  and  at  the  thirtieth  day  the  upper 
half  of  the  liquid  was  changed  to  a  dark  brown. 

Acid  diabetic  urine  presented  the  same  changes  noted  in 
the  studv  of  the  A.  fumigatus,  except  that  the  culture-medium 
acquired  a  dull  black  color,  which  was  first  observed  at  the 
surface  and  spread  rapidly,  discoloring  the  urine. 

A  review  of  the  literature  on  Aspergillosis,  made  by 
T.  A.  Rothwell,  of  Manchester,  England,  credits  R^non' 


Plate  3. — Mycelial  threads  (asperplllus  nigra)  from  acid  urine  as  shown  by 
both  ^  and  s  tenses,  6.  and  L. 

as  the  first  to  call  attention  to  the  presence  of  mycelial 
threads  and  spores  of  this  fungus  in  the  urine  of 
animals  suffering  from  experimental  aspergillosis 
(pseudo-tuberculosis).  This  author  found  that  in  from 
24  to  48  hours  after  inoculation,  he  was  able  to  culti- 
vate the  A.  fumigatus  from  the  animal's  urine,  and  in 
most  instances  he  found  mycelium  —  these  findings 
being  more  constant  as  the  disease  progressed.  At 
autopsy  these  animals  were  found  to  present  classical 
lesions  of  the  bladder  and  kidneys.  Renon  attributed 
these  findings  to  infection  through  the  venous  blood 
supply,  as  his  attempts  to  cultivate  the  aspergillus  on 
urine  proved  that  it  had  little  tendency  to  vegetate 
when  kept  at  incubating  temperature. 

Many  writers  have  called  attention  to  the  fact  that 
the  aspergillus  and  other  fungi  develop  best  on  acid 
medium,  at  a  low  temperature ;  and  the  same  has 
proven  true  in  my  study  of  the  organism  on  urine, 
which  probably  explains  the  wide  difference  between 
the  findings  of  R6non  and  those  of  the  writer.  My 
review  of  the  literature  has  been  rather  hastily  accom- 
plished and  possibly  some  records  have  escaped  my 
notice.  However,  I  have  been  unable  to  find  any 
special  record  of  the  efi"ect  of  this  organism  on  human 
urine. 

>  Compla  rmdiu  d«<  siancet  el  mtmoiret  de  la  toeiili  da  bMogie,  April  18, 1896. 


448  Thb  Phil*dki,phia"| 

Medical  Journal  J 


A  NEW  BLOOD-STAIN. 


[March  2,  1991 


A  NEW  BLOOD-STAIN. 
By  RANDLE  C.  ROSEXBERGER,  M.D., 

of  Philadelphia. 

Demonstrator  of  Bacteriology  and  Morbid  Anatomy  in  Jefferson  Medical 
College. 

(From  the  Laboratories  of  the  Jeflfereon  Medical  College  Hospital.) 

Every  year,  or  perhaps  more  frequently,  sorae  one 
publishes  a  new  blood-stain. 

One  of  the  latest  stains  is  that  made  according  to 
the  formula  of  Jenner,  the  only  objection  being  its 
tedious  procedure  and  uncertain  outcome.  After  it  is 
once  made  correctly,  it  keeps  indefinitely  and  stains 
very  well.  Ehrlich's  triacid,  Ehrlich's  triple-stain, 
Ehrlich-Biondi-Heidenhain  stain — these  all  have  their 
advantages,  yet  who  has  not  had  his  failures  with  these 
stains  to  probably  far  outnumber  his  successes.  The 
precipitation  of  the  stains  upon  coverglass  preparations 
is  also  a  great  disadvantage,  the  trouble  being  that  in 
some  formulae  filtering  is  recommended  and  in  others 
not. 

Plehn's  and  Prince's  stains  are  also  very  good  ones, 
both  for  the  malarial  parasite  and  for  the  leukocytes. 
These  are  also,  among  many,  easy  to  prepare.  So  many 
blood-stains  deteriorate  in  a  couple  of  weeks  or  some- 
times less,  that  when  you  wish  to  use  them  you  find 
they  have  spoiled.  It  stands  to  reason  that  a  freshly 
prepared  stain  stains  best,  but  when  in  a  laboratory  a 
couple  of  hundred  students  have  to  be  supplied,  then  a 
stain  easily  prepared  and  easily  kept  for  a  couple  of 
months  is  the  one  to  be  used.  While  performing 
Bremer's  tests  with  anilin  dyes  upon  diabetic  blood — 
phloxin,  congo-red,  benzo  purpurin,  and  methyl  blue — 
I  was  tempted  to  place  them  under  the  scope.  Phloxin 
showed  the  granules  of  the  leukocytes  beautifully,  and 
I  then  determined  to  prepare  a  blood- stain  in  combina- 
tion with  a  basic  dye. 

In  trying  to  perfect  the  stain,  discouragements  were 
repeatedly  encountered,  and  at  some  critical  moment 
hopes  were  always  blasted.  Methylerie-blue  being  one 
of  the  best  and  most  uniform  stains,  I  tried  this  in 
combination  with  the  phloxin.  Saturated  aqueous 
solutions  of  both  these  stains  were  made  and  the 
formula  which  has  worked  the  best  is  as  follows  : 

Saturated  aqueous  solution  of  metlivlene-blue 50  c.c 

of  phloxin  20  CO. 

Alcohol  (95%)    30  c.c. 

Water  (distilled) 60  c.c. 

These  are  all  mixed  indiscriminately  together  and  a 
bluish  solution  is  the  result. 

A  precipitate  generally  forms  and  the  stain  needs 
"shaking  before  using."  The  blood-films  can  either 
be  fixed  by  heat  (115°  to  120°  C.  for  20  minute.-^)  or  in 
equal  parts  of  alcohol  and  ether,  or  absolute  alcohol. 
The  stain  w6rks  well  in  either  case  of  fixation.  After 
the  preparation  is  dried  from  alcohol  and  ether,  or 
from  alcohol  alone,  the  stain  is  applied  and  allowed  to 
remain  from  1  to  3  or  4  minutes,  washed  freely  in 
water,  dried  and  mounted  in  balsam.  As  in  all  other 
blood-stains  the  nucleus  of  the  white  cell  stains  either 
a  deep  or  light  blue,  according  to  its  variety  ;  the  red 
cells  a  pinkish  color  or  a  reddish  green.  In  the  finely 
granular  oxyphiles,  the  nuclei  take  the  stain  quite 
darkly,  the  granules  either  a  dull  pinkish  color,  or  a 
bright  red,  denoting  that  they  are  slightly  acidophilic 
and  not  always  neutrophilic.  The  nuclei  of  the  lympho- 
cytes take  the  stain  deeply,  and  around  their  periphery 


numerous  basic  granules  are  demonstrable  as  a  rule, 
while  some  do  not  show  granules. 

In  the  coarsely  granular  oxyphiles  the  nucleus  takes 
a  light  blue  stain,  the  granules  are  bright  red,  almost 
brilliant. 

The  myelocytes  take  a  very  faint  blue  stain,  the 
nucleus  taking  up  nearly  the  whole  cell,  while  in  some, 
small  granules  exhibiting  a  slightly  acidophilic  reaction 
are  seen,  while  in  others  no  granules  are  demonstrable. 
These  cells  are,  of  course,  not  found  in  normal  blood, 
but  in  splenomedullary  leukemia  especially.  The  hya- 
lin  cell,  which  according  to  some  is  identical  with  the 
large  lymphocyte,  takes  a  uniformly  light  blue  stain 
and  no  granules  as  a  rule  are  demonstrable  ;  occasion- 
ally, however,  a  few  basophilic  granules  may  be 
present.  Finely  and  coarsely  granular  basophiles  take 
a  deep  blue  stain,  the  nucleus  and  granules  both  ex- 
hibiting an  aflBnity  for  the  basic  dye. 

The  red  corpuscles  in  normal  blood  generally  take 
a  pinkish  stain,  while  in  pernicious  anemia  and  leuke- 
mia they  take  a  reddish  green  or  a  yellowish  with  a 
faint  tinge  of  pink. 

The  nucleus  of  the  normoblast  takes  the  basic  stain. 

Not  only  is  this  stain  useful  for  blood-cells,  but  it  is 
also  a  fairly  good  one  for  the  malarial  parasite  of  any 
variety.  The  estivoautumnal  and  the  quartan  parasite 
stain  especially  well ;  in  any  variety  it  stains  a  bluish- 
green,  while  pigment  granules  show  up  very  decidedly 
upon  this  background. 


A  Case  of  .Spontaneous  Hemorrhag^e  frnin  the  Iris 
and  Ciliary  Body  Into  the  Anterior  Cliauiber  Due 
to  Splenomedullary  Leukemia.— Fr.  Sorger  (Munch. 
m*d.  U'och  ,  Jihrg.  -45,  No.  35)  reports  a  caoe  of  bypbemia 
occurring  in  a  patient  who  had  splenomedullary  leukemia 
for  6  months.  Upon  examination  there  was  a  hyphemia 
divided  into  3  layers.  As  spontaneous  absorpli  <ri  did  not 
take  place  under  medicinal  treatment,  paracenteisiB  of  the 
anterior  chamber  waa  performed.  Immediately  thereafter 
streaks  of  blood  emanated  from  the  anterior  surface  of  the 
iris  and  after  a  few  minutes  the  anterior  chamber  was  again 
half  filled  with  blocd.  This  phenomenon  reappeared  3  times 
before  the  hemorrhageB  ceased.  Hemorrhages  from  the  iris 
in  leukemia  have  not  yet  been  described,    [m  r.d.] 

A  Case  of  Tumor  of  the  Right  Cms   Cerebri. 

— Professor  A.  Pitres  (Journal  de  Mhiicine  lU  Bordeaux,  Janu- 
ary 13,  1901,  No.  2)  reports  a  woman  of  35  ye.irs  of  age,  mar- 
ried, with  two  healthy  children,  no  mifcarri^es,  and  no 
suspicion  of  syphilis,  who  began  two  years  ago  to  have  intermit- 
tent headache.  Her  husband  had  often  struck  her  on  the 
head,  when  under  the  influence  of  liquor.  About  a  year 
ago  the  headache  became  constant ;  and  for  the  past  3  months 
it  has  been  so  severe  that  she  could  do  nothing.  A  few  weeks 
ago  she  noticed  that  her  sight  was  failing,  that  the  left  side  of 
her  face  moved  less  than  the  right,  and  that  her  left  arm  was 
growing  weaker.  There  were  no  emaciation,  fever,  vomiting, 
or  constipation,  respiratory  or  urinary  troubles.  On  admission 
to  the  hospital  4  main  symptoms  were  found  which  formed 
the  positive  diagnosis  of  a  tumor  of  the  right  cms 
cerebri.  These  were  constant  headache,  worse  at  night, with 
exac^rbation8,  causing  the  hydrocephalic  cry  of  meningitis; 
bilateral  optic  neuritis ;  partial  paralysis  of  the 
third  cranial  nerve  on  the  right  side  (with  dilatation 
of  the  right  pupil,  and  paralysis  of  the  superior  rectus) ;  and 
slight  paresis  of  the  muscles  of  the  lower  half  of  the  leftside 
t  f  the  face  and  the  left  arm.  Tnese  last  two,  together,  form 
the  "  syndrome  of  Weber  " — positive  sign  of  a  peduncular 
lesicn.  The  patient  had  an  apoplectic  stroke  the  night 
before,  aud  died  upon  the  day  the  clinic  was  held.  Sudden 
death  is  the  rule  in  these  cases.  The  autopsy  showed  a 
glioma  the  size  of  a  small  apple  in  the  right  cms  cerebri  just 
where  it  enters  the  central  mass  of  the  right  hemisphere. 
[m.o] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hsndrik  Llotd,  A.M.,  M.D.,  £aitor-in-Cftic/ 
Julius  L.  Salixoer,  M.D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sahee,  M.D.  F.  J.  Kaltbtke,  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  Coley,  M.D. 

J.  M.  SWAS,  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  Gibbon,  M.D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.  Reprints  (250)  of  Original  Articles  will  be  lurnished  gratis  to  Authors  making 
the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Joamal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  AdTertising  Page  8. 


Vol.  VII,  No.  10 


MARCH  9,  1901 


$3.00  Per  Anjtom 


I  Infusion  of  Salt-Solution  in  the  Treatment  of 
Pneumonia. — Dr.  Clement  A.  Penrose,  of  the  Johns 
Hopkins  Hospital,  Baltimore,  calls  our  attention  to  the 
fact  that  he  recommended  this  treatment  in  several 
cases  of  extreme  severity  happening  in  Professor  Osier's 
wards  in  that  hospital.  He  says  that  it  had  been  a 
custom  in  the  hospital  (as  it  has  been  doubtless  in 
many  hospitals)  to  resort  to  infusion  of  normal  salt- 
solution  (.6%)  in  cases  of  collapse,  especially  during  or 
after  severe  surgical  operations.  In  gynecological  cases 
he  had  been  much  impressed  by  the  fact  that  stimula- 
tion to  respiration  was  more  marked  than  to  the  heart, 
and  this  led  him  to  suggest  the  use  of  this  solution  in 
several  cases  of  pneumonia.  His  personal  experience 
at  the  time  he  read  his  paper  was  limited  to  three  cases, 
of  which  two  were  fatal.  The  success  of  the  treatment, 
however,  should  not  be  gauged  strictly  by  these  facts, 
because  all  three  cases  had  reached  a  desperate  stage. 
The  infusion  of  salt-solution  was  given  in  the  usual 
manner,  at  a  little  above  body  temperature.  The 
needles  were  introduced  under  the  breast  or  in  the 
subcutaneous  tissue  of  the  thighs.  Care  was  taken  to 
examine  the  heart  at  frequent  intervals,  especial  atten- 
tion being  paid  to  the  pulmonary  second  sound,  and 
instruments  were  kept  in  readiness  for  instant  bleeding 
if  this  second  sound  should  have  become  too  accentuated 
in  qualit}\  Inhalation  of  oxygen  was  given  in  a  special 
manner  by  means  of  a  glass  funnel  instead  of  the  usual 
delivery  nozzle,  and  this  funnel  was  held  by  a  frame- 
work about  two  inches  above  the  patient's  face  and  thus 
supplied  the  oxygen  to  both  mouth  and  nostrils  without 
interfering  in  any  way  with  the  breathing.  The  gas 
was  passed  through  a  bottle  containing  a  pint  of  hot 
water  in  which  was  placed  a  mixture  composed  of 
creosote,  turpentine  and  benzoin.  Dr.  Penrose  states 
that  since  he  left  the  Hospital  this  treatment  has  been 
resorted  to  in  several  other  cases  with  most  gratifying 
success.  The  details  of  the  treatment  are  given  in  a 
paper  in  the  Johns  Hopkim  Hospital  Bulletin,  No.  100, 
July,  1899.  The  author  claims  that  the  infusion  is  a 
decided  advance  in  treatment,  but  requires  to  be  used 
with  careful  reference  to  the  pulmonary  second  heart- 
«ound.  He  thinks  that  infusion  is  preferable  to  trans- 
fusion. His  idea  seems  to  be  that  it  dilutes  the  toxins 
in  the  blood  and  promotes  their  elimination  through 
the  sweat  glands  and  the  kidneys.  He  says  that  it 
lowers  the    temperature,   stimulates    the    heart,    and 


renders  the  breathing  less  labored,  and  he  also  thinks 
that  it  renders  the  patient  more  susceptible  to  the  in- 
fluence of  oxygen. 

We  have  practically  quoted  here  his  own  statements 
in  his  paper  and  must  refer  the  readers  to  the  paper 
itself  for  details. 

Dr.  Penrose  says  that  Dr.  Reid  Hunt  made  experiments 
on  dogs  with  intravenous  injection  of  salt-solution,  and 
found  that  the  injection  of  this  solution  caused  a  marked 
increase  in  the  amplitude  of  the  respiratory  undula- 
tions of  the  blood-pressure.  The  theory  seems  to  be 
that  the  infusion  of  salt- solution  increases  the  circula- 
tion in  the  lungs  and  therefore  their  ability  to  take  up 
more  oxygen.  Not  sufficient  is  said,  however,  about 
the  possibility  of  such  treatment  causing  a  pulmonary 
edema,  a  risk  which  we  should  suppose  on '  purely 
theoretical  grounds  to  be  a  not  insignificant  one.  Dr. 
Penrose  does  well  to  call  attention  to  the  need  of  instant 
bleeding  in  case  the  pulmonary  second  heart-sound 
should  indicate  the  overdistention  of  the  lungs.  But 
this  sign  is  one  which  we  should  fear  might  not  be  suf- 
ficiently accurate  or,  at  least,  recognized  with  sufficient 
accuracy,  to  render  all  danger  on  this  account  un- 
important. The  value  of  the  treatment  can  only  be 
determined  by  a  wider  clinical  experience,  among  a 
larger  number  of  observers. 

The   Bio-Chemical   Basis   of    Pathology.  —  The 

paper  by  Dr.  Bunker,  in  the  last  number  of  the 
Journal,  is  worth  a  careful  reading  by  those  medical 
investigators  who  take  time  to  give  thought  to  the  deep- 
lying  foundations  of  the  science  of  pathology.  Dr. 
Bunker's  paper  is  not  an  arraignment  of  the  micro- 
scope, for  the  author  is  evidently  too  wise  to  take  such 
an  extreme  view  ;  but  it  contains  a  frank  criticism  of 
that  useful  instrument,  and  at  the  same  time  it  is  a  clear 
and  comprehensive  demonstration  of  the  grounds  for  its 
limitations.  It  must  be  apparent  to  the  man  who 
takes  the  time  and  opportunity  to  think  about  it, 
that  the  microscope,  as  an  instrument  of  precision,  is  an 
aid  merely  to  one  of  the  senses — the  eye — and  that 
what  is  not  revealed  to  the  eye  can  never  be  revealed 
by  the  microscope.  According  to  Dr.  Bunker,  mor- 
phology has  practically  reached  its  limit  in  the  field  of 
research.  This  concise  statement  will  not  be  welcome 
to  the  school  of  investigators  who  seek  to  find  in  dead 
matter  the  secrets  of  life  and  of  disease — and  it  may 


450 


Medical  Jocbsal  J 


EDITORIAL  COMMENT 


[Masch  »,  UM 


indeed  be  a  trifle  premature ;  but  it  expresses  a  truth 
which,  if  not  yet  realized,  must  be  forced  upon  the 
minds  of  students  of  medicine  in  the  not  remote 
future.  In  the  examination  of  diseased  structure  the 
microscope  reveals  not  what  is,  but  what  has  been  ;  not 
the  process  of  disease,  but  merely  the  wreckage  which 
it  has  left :  not  the  vital  facts,  but  only  the  dead  relics. 
The  structural  changes  in  a  cell,  pursued  to  the  remotest 
conceivable  subdivisions  of  dead  cytoplasm,  tell  only 
an  insignificant  part  of  the  story  of  disease.  The 
essential  factors  are  not  shown  to  the  eye,  for  they 
consist  essentially  of  bio-chemical  forces.  They  are  no 
more  to  be  seen  and  apprehended  under  the  lens  of  a 
microscope  than  is  the  combination  of  an  acid  with  a 
base. 

The  supreme  merit  in  Dr.  Bunker's  paper  is  that  it 
serves  to  call  the  minds  of  investigators  to  the  true  and 
ultimate  problems  of  pathology — those  problems  which 
lie  in  bio-chemistrj'.  It  serves  to  divert  them  from  their 
rather  crude  and  persistent  attempts  to  read  in  micro- 
scopic changes  the  true  science  of  pathology.  If  it  fully 
serves  this  purpose  it  wUl  do  well.  It  is  too  conserv- 
ative not  to  recognize  that  the  training  of  the  eye  by 
means  of  the  microscope  is  an  essential  correlative  factor 
in  the  study  of  disease,  but  at  the  same  time  it  expresses 
the  problems  of  disease  in  formula  that  cannot  be  solved 
by  the  eye  alone,  even  though  this  organ  were  har- 
nessed to  a  lens  a  hundred-fold  mightier  than  the  hand 
of  man  has  yet  evolved. 

A  Plea  for  the  Ophthalmoscope. — Although  oph- 
thalmology is  destined  to  remain  within  the  exclusive 
confines  of  specialism,  its  creation  as  a  major  branch  in 
many  medical  colleges  has  ofiFered  opportunities  to  the 
student-body  which  unfortunately  are  not  always  appre- 
ciated until  too  late.  It  is  remarkable,  but  true,  that 
many  otherwise  excellent  physicians  are  not  only  ignor- 
ant of  ordinary  external  ocular  affections,  but  are  abso- 
lutely unfitted  to  inspect  this  important  organ  as  an 
accessory  means  of  diagnosis.  It  seems  almost  in- 
credible that  an  organ  which  in  its  structure  practically 
represents  a  combination  of  almost  all  varieties  of 
normal  tissues,  which  permits  of  the  inspection  of  ex- 
posed nerves  and  bloodvessels  in  situ,  and  in  which 
there  arises  such  a  variety  of  pathological  changes,  in- 
dicative of  systemic  affections,  should  be  so  neglected 
by  the  general  practitioner.  How  often  is  the  ophthal- 
mologist consulted  as  the  last  court  of  appeal  when 
some  physician  has  been  instilling  a  mydriatic  into  a 
glaucomatous  eye.  and  how  seldom  is  he  approached  as 
a  first  court  of  appeal  when  the  detection  of  intraocular 
changes  might  have  elicited  many  valuable  diagnostic 
factors.  No  one,  of  course,  should  attempt  to  perform 
any  operations  upon  the  eye  unless  he  has  had  con- 
siderable experience;  but  this  does  not  apply  to 
the  treatment  of  simple  corneal  ulcers  and  uncompli- 
cated cases  of  conjunctivitis,  which  are  so  frequently 


unintelligently  treated  by  the  family  doctor.  The  ex- 
pressions of  students  and  even  practitioners  regarding 
their  distaste  for  ophthalmology  have  their  inception 
in  several  sources.  In  the  majority  of  cases  these  dis- 
likes are  due  to  the  fact  that  in  the  teaching  of  other 
branches  of  medicine  but  very  little  attention  is  paid  ix> 
the  eye.  Again,  the  subject  of  "  refraction  "  is  taught  to 
those  who  have  preconceived  intentions  of  forever  ban- 
ishing it  from  their  consideration  after  they  have  gradu- 
ated. Notwithstanding  that  the  eye  and  its  appendages- 
consist  of  fibrous,  adipose,  areolar,  muscular,  nervous, 
vascular,  glandular,  osseous  and  specialized  tissues,  to- 
gether with  serous  and  mucous  membranes,  hair,  skin, 
and  cartUage,  it  is  given  but  an  insignificant  position  in 
modem  treatises  on  pathology.  If  the  intelligent  use 
of  the  ophthalmoscope  by  the  general  practitioner  would 
take  the  place  of  his  frequent  unintelligent  use  of  the 
test  lenses,  much  would  be  gained  in  diagnosis  and 
treatment. 

The  Case  of  Major-General  Wood. — The  Xeic  York 
Medical  Journal,  commenting  on  our  reference  to  the 
recent  promotion  of  Dr.  Leonard  Wood  to  be  a  major- 
general,  tells  us  that  the  case  is  not  so  unprecedented 
as  we  had  supposed.  In  support  of  its  criticism  it 
mentions  two  instances  (and  only  two)  of  surgeons  being 
promoted  in  the  line ;  one,  the  case  of  "  a  veterinary 
officer  in  an  English  hussar  regiment"  serving  in  a  cam- 
paign in  Egypt,  and  the  other  that  of  General  Canonge. 
who  has  held  high  combatant  command  in  the  French 
army.  The  New  York  Medical  Journal  omits  to  give  the 
details  of  these  two  cases,  so  we  cannot  judge  how 
similar  they  are  to  the  case  of  General  Wood.  Anyhow, 
the  two  cases  serve  as  the  exceptions  that  prove  what 
seems  to  be  quite  a  general  rule.  The  special  features 
that  give  interest  to  General  Wood's  case  are  not  only 
his  promotion  in  the  line,  but  also  his  advance  to  such 
high  rank  in  so  short  a  time.  If  there  are  really  parallel 
cases  in  any  foreign  service,  we  should  be  pleased  to  be 
informed  about  them,  for  we  do  not  pretend  to  have 
made  any  extended  research  in  the  matter.  We  are 
under  the  impression  that  even  in  this  country  such 
cases  have  not  been  frequent  From  the  tone  of  the 
British  medical  periodicals  in  recent  years  in  their  com- 
ments on  the  unsatisfactory  status  of  their  army  medica) 
service,  we  should  be  much  surprised  to  hear  of  an 
English  army  surgeon  being  advanced,  for  any  gallant 
action  whatsoever,  to  the  rank  of  a  major-general  in 
the  line.  It  is  not  so  verj*  long  ago.  as  some  of  our 
readers  may  recall,  that  a  brave  English  army  surgeon 
in  India,  who  had  led  a  command  and  done  some 
gallant  fighting  in  an  emergency,  was  referred  to  by  the 
Duke  of  Cambridge,  Commander-in-Chief  of  the  British 
Army,  as  "  that  brave  civilian."' 

A  Bishop  on  Christian  Science. — Bishop  Fallows, 
of  Chicago,  is  to  be  commended  for  his  critical  genius 


March  9,  I90I] 


EDITORIAL  COMMENT 


CThk  Philadklphia 
Medical  Journal 


451 


as  well  as  for  his  capacity  to  manufacture  a  new 
nomenclature — if  the  latter  is  really  a  commendable 
thing.  He  tells  his  good  friends  in  the  church  who  are 
inclined  to  be  Christian  Scientists,  that  if  they  are  going 
to  start  a  new  religious  system  because  they  happen  to 
have  been  healed  at  some  time  through  the  influence 
of  a  mental  law  as  universal  as  gravitation,  then  the 
people  who  have  been  cured  by  patent  medicines  have 
just  as  good  reason  to  establish  medico-religious  cults 
as  they  have.  Thus  he  suggests  that  there  would  be 
Christian  Liver  Pillists,  Christian  Sarsaparillists,  Chris- 
tian Celery  Compoundists,  and  Christian  Cholera  Mix- 
turists.  He  might  have  added  a  good  many  more, 
especially  if  he  had  taken  their  names  from  the  quack 
advertisements  in  the  religious  press.  Bishop  Fal- 
lows is  doubtless  brought  into  contact  with  a  good 
many  persons  who  mix  their  theology  with  their  thera- 
peutics, and  therefore  his  suggestions  are  worth  heed- 
ing. Professor  Jastrow,  from  another  range  of  vision, 
points  out  that  the  doctrines  underlying  this  foolish 
system  are  not  characteristically  religious  ones,  but 
that  they  are  only  distorted  into  a  religious  guise. 
This  criticism  is  a  profound  one,  and  should  be  a 
source  of  comfort  to  those  alarmists  who  fear  that 
Christian  Science  will  overrun  the  laud.  It  means 
that  this  system  is  no  more  a  religion  than  it  is  a 
science,  and  therefore,  that  it  is  probably  destined  to 
an  ephemeral  existence.  Persecution  will  help  it  for 
a  while,  but  a  wise  and  forceful  administration  of  the 
laws  against  it  will  do  much  to  exterminate  it.  It  is 
an  illegal  practice  in  this  State. 

The  Therapeutic  Value  ot  Yeasts. — An  editorial 
in  our  last  number  dealt  with  some  of  the  phases  of 
the  complicated  problem  of  yeast  fermentation,  and 
this  subject  very  quickly  leads  to  one  of  practical  im- 
portance— the  current  question  as  to  the  value  of  yeasts 
as  therapeutic  agents.  For  a  number  of  years  a  few 
clinicians  have  employed  yeasts  in  the  treatment  of 
furunculosis.  Baron  has  recommended  this  treatment 
in  conjunction  with  fruit  juice  in  infantile  scurvy.  Lan- 
dau employs  an  injection  of  brewer's  yeast  in  vaginal 
gonorrhea,  basing  his  treatment  upon  the  fact  that  the 
yeast  organisms  have  greater  vitality  and  propagate 
more  rapidly  than  gonococci,  which  are  consequently 
crowded  out.  Most  important  are  the  observations  that 
yeasts  may  favorably  influence  the  course  of  diabetes. 
The  effects  of  yeast  upon  the  intestinal  contents,  with 
special  reference  to  the  utilization  of  sugar,  make  it 
possible,  at  least  experimentally,  for  a  patient  to  partake 
of  a  liberal  hydrocarbon  diet  without  increase  of  the 
glycosuria.  The  method  of  this  action  is  simple.  We 
know  that  the  yeast  causes  fermentation  of  the  sugars 
in  the  intestines  with  the  production  of  alcohol  and 
carbonic  acid.  However,  we  must  recognize  that  the 
yeast  so  introduced  has  the  power  of  acting  only  upon 
the  sugars   derived   from   the  food,  or,  in  other  words, 


those  present  in  the  alimentary  tract.  Nobecourt,  Hal- 
lion  and  others  claim  a  decided  lessening  of  certain, 
toxins,  especially  of  diphtheria,  when  yeast  has  beeni 
given.  For  instance,  Hallion  found  that  if  he  added  a 
pure  culture  of  yeast  in  the  must  of  beer  to  a  dose  of 
diphtheria  toxin  this  mixture  injected  into  the  skin  of 
the  guineapig  was  harmless ;  but,  when  the  toxin  and 
yeast  were  injected  unmixed  in  dififerent  parts  of  the 
body  of  the  guineapig,  the  action  of  the  toxin  was  not 
inhibited.  This  would  indicate  that  the  yeast  neutral- 
izes the  poison  directly.  The  author  has  concluded 
that  the  acidity  of  the  culture  medium  is  responsible 
for  the  neutralizing  action  on  the  toxin. 

Besides  the  conditions  named  in  which  the  use  of 
yeasts  is  recommended  we  may  also  mention  their  em- 
ployment in  enteroptosis,  the  gastrointestinal  disorders 
of  infancy,  the  infectious  fevers,  and  sepsis.  It  may  not 
be  unprofitable  to  summarize  rapidly  the  action  of" 
yeasts  introduced  into  the  digestive  tract.  We  know 
that  the  body  temperature  is  favorable  for  their  devel- 
opment, and  that  the  saliva  has  no  unfavorable  influence. 
The  gastric  juice  destroys  a  certain  proportion  of  the 
yeasts  introduced,  but  a  certain  amount  is  passed  on,. 
still  active,  into  the  intestine.  In  this  alkaline  medium, 
we  are  obliged  to  consider  the  action  of  the  bile,  pan- 
creatic secretion  and  the  microorganisms  present  in  the- 
contents.  It  has  been  found  that  microorganisms  do  not 
sensibly  affect  the  vitality  of  the  yeasts.  The  action  olT 
the  intestinal  juices  and  the  pancreatic  juices  is  not  as- 
certain, but  we  know  that  the  bile  exercises  a  retarding: 
influence.  It  is  found  necessary,  in  order  to  provide 
the  most  suitable  medium  for  the  development  of 
yeasts,  to  add  a  liberal  supply  of  sugar.  Large  quanti- 
ties of  yeast  produce  diarrhea,  vomiting,  fever  and: 
coma,  which,  it  has  been  pointed  out,  are  probably  due; 
to  the  toxic  action  of  the  carbonic  acid  gas  evolved. 
Before  we  can  intelligently  employ  yeasts  in  other 
than  an  empiric  manner  it  will  be  necessary  to  have- 
established  the  complete  action  of  the  several  varieties, 
of  yeasts  and  the  precise  rationale  of  this  action. 

Experimeuts  with  the  Milk  of  Tuberpulous  Cows. 

— According  to  the  Popular  Science  Monthly  (March,  1901^ 
some  interesting  observations  have  been  made  at  the- 
Storr's  Experiment  Station  in  Connecticut  on  the  use- 
of  the  milk  of  tuberculous  Cows.  Experiments,  extend- 
ing over  a  period  of  several  years,  were  made  by  using 
the  milk  of  a  group  of  diseased  cows  for  feeding  calves- 
During  the  first  two  years,  when  the  cows  had  the  dis- 
ease only  in  its  earlier  stages,  the  calves  and  young^ 
cattle  which  were  fed  on  their  milk  and  ran  with  them 
constantly,  presented  no  symptoms  of  tuberculosis  and 
showed  no  reaction  to  the  tuberculin  test.  During  the- 
next  year  and  a  half,  however,  the  results  were  quite- 
different.  By  this  time  the  disease  had  progressed  so  far 
in  three  of  the  cows  used  for  the  experiment  that  their 
failure  was  quite  apparent.    Five  calves  fed  on  the  milk 


452  "^^^  Philadelphia"] 

Medical  Jodbnal  J 


EDITORIAL  COMMENT 


[Habcb  9,  19«1 


from  these  animals,  now  well  advanced  in  tuberculosis, 
proved  to  be  diseased  and  responded  to  the  tuberculin 
test.  These  experiments  go  to  prove,  what  would 
almost  be  accepted  without  proof,  that  a  cow  far  ad- 
vanced in  tuberculosis  is  more  likely  to  transmit  the 
■disease  with  her  milk  than  a  cow  that  was  still  in  the 
incipient  or  early  stages  of  the  infection.  The  one 
practical  inference  to  be  drawn  is  that  the  danger  of  in- 
fection from  tuberculous  cows  is  probably  not  so  great 
as  some  persons  have  feared,  because  bovine  tuberculosis, 
at  least  when  transmitted  to  human  subjects  by  milk, 
is  not  likely  to  be  so  transmitted  until  the  disease  is  so 
recognizable  as  to  be  easily  detected.  Still,  these  ob- 
servations were  made  on  calves,  not  on  children,  and 
the  inference  is  rather  a  wide  one  that  is  drawn  from 
calves  to  children.  Experiments  seem  to  have  proved 
that  pasteurized  milk  from  tuberculous  cows  can  be 
safely  used  for  raising  calves,  but  this  is  no  argument 
in  favor  of  feeding  such  milk  to  children — or  to  people 
in  general.  Dairymen,  as  well  as  veterinarians,  cannot 
be  too  careful  to  take  no  risks  in  any  such  way. 
•"  Pure  "  milk  does  not  mean  "  pasteurized  "  milk. 

The  Care  of  "Neglected"  Children. — Crime  and 

vice  may  be  looked  upon  as  symptoms  of  disease  in  the 
)body  politic,  and  as  such  no  effort  can  be  too  great  that 
is  exerted  in  their  prevention,  not  less  than  cure.  That 
much  crime  and  vice  can  be  prevented  is  so  obvious  a 
truth  that  its  statement  seems  superfluous.  Unfortu- 
nately, we  cannot  go  back  200  years  in  our  influence 
upon  society,  but  we  can  at  least  start  200  years  in 
advance.  Inasmuch  as  "  the  child,"  in  truth,  "  is  father 
of  the  man,"  we  must,  in  order  to  diminish  crime  and 
Tice  in  later  life,  prevent  its  development  and  growth 
during  the  receptive  and  evolutionary  period.  Such  a 
noble  work  the  Children's  Aid  Society  of  Pennsylvania 
is  engaged  in,  and  it  is  done  most  admirably,  intelli- 
gently, and  practicably.  The  principle  followed  con- 
sists in  the  individual  treatment  in  homes  of  the  chil- 
dren that  come  under  the  care  of  the  Society,  which 
now,  after  an  active  existence  of  19  years,  has  on  its 
list  8,000  good  homes  that  have  been  carefully  investi- 
gated and  inspected,  into  which,  for  a  small  payment  at 
first,  the  children  will  be  received.  The  object  is  to 
provide  the  children,  not  with  the  reformation  that 
often  they  do  not  need,  but  with  the  personal  care  and 
attention  and  influence  of  foster-parents,  that  they  need 
most  of  all.  That  the  principle  is  correct  is  amply 
proved  by  its  successful  application.  The  efforts  of  the 
Society  are  directed  upon  three  main  lines :  The  care  of 
foundlings;  the  securing  of  work  in  country  families 
for  women  with  babies ;  and  the  care  of  neglected  chil- 
dren accused  of  delinquency  or  crime.  The  last  report 
of  the  Society,  just  issued,  shows  that  there  were  under 
its  care  at  the  beginning  of  the  year  1900,  803  children, 
and  that  during  the  year  140  were  additionally  received. 
These  are   clas.sified  as   follows :    Orphans,   33 ;    half 


orphans,  97 ;  deserted  children,  39 ;  from  dissolute 
parents,  63 ;  from  unmarried  parents,  43  ;  from  invalid 
and  insane  parents,  26 ;  rescued  from  ill-treatment,  88 ; 
from  parents  living,  but  separated,  93 ;  from  parents 
unable  to  control,  42 ;  vagrants,  10 ;  from  criminal 
courts  and  magistrates,  56  ;  from  almshouses,  335  ;  from 
other  charitable  societies,  18.  Depravity  and  immorality, 
like  weeds,  thrive  where  neglect  and  indifference  pre- 
vail ;  while  good  citizens,  like  choice  flowers,  must  be 
tenderly  watched  and  carefully  cultivated.  The  work 
of  this  Society  emphasizes  more  forcibly  than  any 
elaborate  argument  the  wisdom  and  the  economy,  as 
well  as  one  method  of  preventing  crime  and  vice,  and 
thus  by  so  much  lessening  the  later  need  for  reformatory, 
prison,  and  almshouse;  and  it  should  receive  unstinted 
support,  inasmuch  as  it  represents  an  inestimable  ser- 
vice both  to  the  individual  and  to  the  State. 

The  As.sociatlon  of  Appendicitis  and  Right-Sided 
Adnexal  Disease. — The  frequency  with  which  disease 
of  the  right  uterine  appendage  and  broad  ligament  is 
associated  with  an  adherent  and  inflamed  vermiform 
appendix  has  attracted  the  attention  of  abdominal 
surgeons  to  a  much  greater  extent  within  recent  years 
than  formerly.  Indeed,  the  gynecologist  is  now  arm- 
ing himself  for  any  intestinal  complication  of  the  kind 
when  the  symptoms  would  seem  to  indicate  right  pelvic 
disease.  It  is,  however,  verj'  often  when  such  a  com- 
plication is  least  expected  that  the  emergency  arises, 
and  the  field  of  operation  is  unexpectedly  transferred 
upward  to  the  right  iliac  region.  Persistent  bladder- 
symptoms — frequency  of  micturition,  dysuria,  and 
irritable  bladder — may  have  their  origin  in  the  adher- 
ence of  an  inflamed  appendix  to  the  body  of  that  organ, 
while  severe  paroxysmal  coUcky  pains,  closely  simulat- 
ing those  of  extrauterine  gestation  or  the  painful  con- 
tractions of  a  tubal  abscess,  may,  at  the  time  of  opera- 
tion, be  found  to  have  arisen  in  a  latent  appendicitis,  with 
dislocation  of  that  erratic  organ  to  the  pelvic  r^ion. 
Every  gynecologist  has  now  and  again  run  across  an 
elongated  vermiform  appendix — which  not  infrequently 
does  not  appear  to  be  inherently  diseased — attached 
firmly  to  the  uterine  fundus,  broad  ligament,  tube,  or 
ovarj',  with  extensive  pathological  involvement  of  the 
pelvic  viscera.  The  very  frequency  of  the  association 
would  seem  to  debar  the  accidental  element  and  to 
indicate  some  causal  relationship  between  the  two 
conditions. 

Is  the  appendix  attracted  to  a  primary  focus  of  dis- 
ease m  the  pelvic  organs,  drawn  thither  by  the  vascular 
engorgement  of  the  parts,  or  is  it  itself  the  offending 
agent,  and,  wandering  here  and  there  among  the  pelvic 
viscera,  does  it  attach  itself  arbitrarily  to  a  more  suscep- 
tible portion  of  these  organs,  and  through  transmission 
of  the  pathogenic  germs  that  normally  inh.ibit  its 
lumen,  excite  in  the  surrounding  tissues  an  inflamma- 
tory reaction  ? 


March  9,  IMl] 


REVIEWS 


["The  Philadelphia 
L  Medical  Jodbnal 


453 


The  tendency  for  the  bacillus  coli  communis  to 
penetrate  the  intestinal  walls  and  invade  the  sub- 
stance of  adherent  organs  and  tissues  has  repeatedly 
been  noted.  A  dermoid  cyst,  pus-tube,  or  ovarian  or 
uterine  tumor  may  thereby  be  transformed  into  a  sup- 
purating nidus  of  grave  disease  and  destruction  of 
tissue.  Is  it  not  quite  reasonable  to  suppose  in  certain 
of  these  associated  cases  of  pelvic  and  appendiceal  dis- 
ease in  which  the  greater  pathological  changes  are  to  be 
found  in  the  fallopian  tube  or  ovary,  in  the  absence  of 
the  history  of  septic  or  gonorrheal  disease  originating 
in  the  uterus  or  vagina,  that  the  pelvic  disease  is  the 
direct  result  of  infection  from  the  appendix  vermiformis 
through  bacterial  transmission  ?  On  the  other  hand, 
when  the  adherent  appendix  appears  to  be  more  ad- 
vanced in  the  pathological  process,  and  has  attached 
itself  by  bands  of  plastic  lymph  to  a  comparatively 
healthy  broad  ligament,  or  to  the  fundus  of  the  uterus 
or  to  the  bladder,  it  would  naturally  seem  to  be  the 
offending  organ  primarily  diseased  and  merely  attach- 
ing itself  to  whatever  chanced  to  be  most  in  apposition 
to  it. 

The  obscurity  that  is  unavoidably  associated  with 
the  etiology  of  appendicitis  necessarily  renders  any 
absolute  statement  as  to  the  primary  point  of  the  dis- 
ease in  these  pelvic  cases  impossible.  It  would  seem 
to  us,  however,  that  the  origin  of  pelvic  disease  from 
appendiceal  infection  is  more  than  merely  possible,  and 
indeed,  quite  probable  for  various  reasons,  as  follows: 
In  the  first  place,  the  well-recognized  source  of  infec- 
tion from  intestinal  adhesions  in  cases  of  suppurating 
cysts  and  tumors  arising  from  the  pelvis,  proves  the 
ready  transmissibility  of  the  pathogenic  intestinal 
germs  to  the  surrounding  structures.  If  this  complica- 
tion may  arise  from  ordinary  adherent  loops  of  intes- 
tine, it  is  just  as  reasonable  to  suppose  that  it  may 
follow  from  an  adherent  appendix  when  that  organ 
penetrates  into  the  pelvic  recesses.  In  the  second 
place,  the  frequency  of  the  greater  pathological  changes 
being  in  the  adherent  structures  and  not  in  the  appen- 
dix itself,  would  seem  to  prove  that  the  infection  has 
arisen  in  a  bacterial  invasion,  the  microorganisms  not 
producing  the  same  inflammatory  changes  in  their 
natural  habitat  as  they  would  in  any  adventitious 
structure  into  which  they  might  penetrate.  In  the 
third  place  and  finally,  the  aggravated  constipation, 
which  is  such  a  common  associated  condition  in  the 
various  pelvic  disorders  of  women,  by  lessening  the 
resisting  powers  of  the  body  through  the  resultant 
toxemia  and  by  markedly  increasing  the  virulence  of 
the  pathogenic  bacteria  resident  in  the  intestinal  tract, 
favor  their  dissemination  through  the  bowel-wall  ad- 
herent to  the  surrounding  organs  whereby  the  latter 
will  the  more  readily  become  the  seat  of  infection  and 
active  inflammatory  changes.  In  some  of  the  right- 
sided  pelvic  inflammations,  therefore,  the  possibility  of 
an  appendiceal  origin  should  not  be  overlooked. 


Hci?tcrr»5. 


An  Introduction  to  Physiology.  By  William  Town- 
send  Porter,  M.D.,  Associate  Professor  of  Physiology 
in  the  Harvard  Medical  School.  Pp.  314.  Cambridge, 
Mass.:  The  University  Press.    1901. 

The  readers  of  the  Philadelphia  Medical  Journal  will 
recall  the  admirable  paper  of  Professor  Porter  (published  in 
the  issue  of  September  5,  1900)  on  the  teaching  of  physi- 
ology. In  this  paper  the  advantages  of  a  properly  conducted 
laboratory  course  of  instruction  over  a  purely  didactic 
course,  though  illustrated  by  experiments,  were  clearly, 
forcibly,  and  convincingly  pointed  out. 

The  method  of  teaching  there  outlined  has  been  put  in 
practice  at  the  Harvard  Medical  School. 

In  this  paper  it  was  also  stated  that  at  the  very  beginning 
of  his  studies,  the  student  should  acquire  a  knowledge  of 
physiological  methods,  should  be  trained  in  technic  by  the 
study  of  one  or  more  tissues,  the  physiology  of  which  is  well 
advanced.  For  this  purpose  no  departments  of  physiology 
are  so  well  adapted  as  those  relating  to  the  physiology  of 
muscle  and  nerve,  and  the  physiology  of  the  circulation. 

The  "  Introduction  to  Physiology,"  recently  published  by 
Professor  Porter,  is  intended  to  meet  the  requirements  of 
the  method  advocated  by  him.  It  is  believed  that  the 
subject-matter  is  "at  present  that  best  adapted  to  form  the 
mind  in  habits  of  exact  observation  and  clear  reasoning." 
It  is  divided  into  two  parts :  1.  The  physiology  of  muscle  and 
nerve.     2.  The  physiology  of  the  circulation. 

In  Part  I,  under  the  title,  "  Methods  of  Electrical  Stimu- 
lation," there  is  a  description  of  a  new  form  of  that  valu- 
able instrument,  the  capillary  electrometer,  devised  by 
Professor  Porter,  a  new  form  of  rheocord  to  be  used  in  con- 
nection with  the  electrometer,  an  account  of  the  electric 
cell,  and  a  clear  presentation  of  the  scientific  principles 
underlying  their  construction,  their  mode  of  action  and  their 
mutual  adaptation  for  the  study  of  the  phenomena  exhib- 
ited by  muscle  and  nerve.  The  phenomena  of  induction, 
the  construction  of  the  inductorium,  the  induced  currents 
and  their  advantages  as  stimulating  agents,  are  clearly  and 
scientifically  presented. 

Then  follows  a  brief  account  of  the  graphic  method,  the 
apparatus  employed,  and  the  manner  in  which  it  is  used  in 
physiological  work.  The  remainder  of  Part  I,  pages  59  to 
235,  is  devoted  to  a  consideration  of  the  electrical  stimula- 
tion of  muscle  and  nerve,  chemical  and  mechanical  stimu- 
lation, irritability  and  conductivity,  the  electro-motive 
phenomena  of  muscle  and  nerve,  and  the  change  in  form  of 
muscle.  Under  each  heading  there  are  a  number  of  funda- 
mental experiments  logically  presented,  which,  if  thor- 
oughly and  accurately  performed,  will  not  only  give  the 
student  valuable  information,  but,  far  better,  will  train  his 
faculties  for  the  investigation  of  problems  in  other  fields  of 
physiology. 

Part  II  is  devoted  to  a  consideration  of  the  mechanics  of 
the  circulation.  The  cardinal  facts  are  made  clear  by  means 
of  a  new  artificial  scheme  also  devised  by  Professor  Porter. 
This,  taken  in  connection  with  a  number  of  experiments 
made  with  the  heart  of  the  frog,  and  observations  of  the 
heart  and  pulse  of  man,  will  give  the  student  an  admirable 
idea  of  the  phenomena  of  the  circulation.  An  objection  to 
the  use  of  this  Introduction  by  other  teachers,  might  be 
that  it  will  be  necessary  to  have  the  same  apparatus  in  order 
to  perform  the  experiments  here  detailed.  This  difficulty  is 
easily  overcome  by  buying  the  apparatus,  which  we  are  in- 
formed is  "  trustworthy  and  relatively  inexpensive."  The 
Introduction  is  cordially  recommended  to  all  those  inter- 
ested in  the  practical  teaching  of  physiology,    [a.p.b.] 


Society  of  Biology.— A  Society  of  Biology  has  been 
founded  in  Italy  for  the  purpose  of  studying  biological 
sciences.  The  society  is  divided  into  sectiona  on  anatomy, 
physiology,  pathological  anatomy,  general  pathology,  phar- 
macology, hygiene,  zoology,  and  botany. 


454 


The  Philadelphia"! 


AMERICAN  NEWS  AND  NOTES 


ruABCH  9,  un 


2lmertcan  Hcu?s  anb  Hotes. 


PHIIiAJ)ELPHIA  AND  PENNSYLVANIA. 

New  Department. — A  department  of  Laryngology  and 
Rhinology  has  been  established  by  the  Board  of  Trustees  at 
the  Presbyterian  Hospital,  51  North  Thirty-ninth  street,  under 
the  direction  of  Dr.  Arthur  H.  Cleveland. 

New  Duties  for  Pathologist. — Hereafter  the  patholo- 
gist at  the  State  Hospital  for  the  Insane  will  be  compelled  to 
examine  the  cattle  obtained  for  the  institution  to  ascertain 
whether  they  are  free  from  tuberculosis. 

Babies. — Dr.  N.  G.  Keirle,  resident  physician  of  the  Pas- 
teur department  of  the  City  Hospital,  nas  found  that  a  cat 
which  bit  several  members  of  a  family  at  Mahanoy  City,  Pa., 
nearly  a  month  ago  was  rabid.  The  cat,  which  had  been  a 
pet,  was  killed  and  a  portion  of  the  spinal  cord  was  sent  to 
the  Pasteur  laboratory.  Rabbits  inoculated  with  a  tincture 
made  from  the  spinal  cord  became  rabid. 

Practised  Medicine  68  Years.— Dr.  John  Dean  Roes, 
a  practising  physician,  died  at  his  home  in  Williamsburg, 
Pa.,  March  5th,  aged  95  years.  Dr.  Ross  was  graduated  from 
the  University  of  Pennsylvania  in  1832.  He  founded  the 
Blair  County  Medical  Society,  and  was  its  first  president.  He 
was  president  of  the  State  Medical  Society  in  1865,  and  was 
its  oldest  member  at  death.  He  waa  a  member  of  the  Amer- 
ican Medical  Society  47  years. 

St,  Joseph's  Hospital. — The  report  of  St.  Joseph's 
Hospital  for  February  shows  the  number  of  patients  admit- 
ted during  the  month  in  the  gynecological,  surgical  and 
medicinal  clinics  to  have  been  163 ;  remaining  from  Janu- 
ary, 120;  total  number  treated,  283;  patients  discharged  dur- 
ing the  month,  160;  patients  remaining  March  1,  123.  In 
the  medical  clinic  there  were  165  cases  treated ;  surgical,  394 ; 
gynecological,  107;  ear,  nose  and  throat,  22S;  children's 
clinics,  87 ;  nerve,  60.  There  were  34  ambulance  calls,  32 
patrol  cases  and  92  accident  cases. 

Assistant  Surgeon  of  the  Russian  Navy  Charged 
with  Desertion, — Leo  Alexandroff,  an^assistant  surgeon  cf 
the  Russian  cruiser  Variag,  who  was  arrested  aa  a  deserter, 
was  set  free  on  July  23, 1900,  by  a  decision  of  the  United 
States  Court  of  Appeals.  He  came  to  this  country  with  a 
crew  intended  for  the  Variag  while  the  veesel  was  building  at 
Cramps'  shipyards.  Shortly  after  his  arrival  he  took  out  his 
first  naturalization  papers,  and  was  later  arrested  as  a  de- 
serter. The  surgeon  claimed  that,  as  the  Variag  was  not  in 
commission,  he  could  not  desert  from  a  ship  that  did  not 
exist. 

Deaths  in  Philadelphia. — The  report  of  the  Bureau 

of  Health  for  1900  has  been  submitted.  It  states  that  2,717 
deaths  have  occurred  from  tuberculosis  during  1900.  'Ihis 
report  gives  interesting  statistics,  of  which,  perhaps,  the  most 
significant  is  the  number  of  deaths  resulting  from  consump- 
tion— 2,717.  The  Board  is  considering  the  advisability  of 
recommending  to  the  legislature  the  placing  of  this  malady 
on  the  list  of  contagious  diseases.  Pneumonia,  it  is  stated, 
caused  2,915  deaths  during  the  year  ;  but  there  was  a  marked 
decrease  in  the  number  of  fatal  cases  of  diphtheria,  ascribed 
to  the  use  of  antitoxin.  Attention  is  called  to  the  sanitary 
need  of  prohibiting  further  interments  in  cemeteries  in  the 
central  or  built-up  portions  of  the  city.  On  the  subject  of 
milk,  it  was  reported  that  1,684,768  quarts  were  irspected 
during  the  year;  and  21,384  were  found  to  contain  adultera- 
tion of  water.  Smaller  numbers  of  quarts  were  found  to  be 
adulterated  with  preservative,  or  to  contain  coloring  matter. 
It  is  recommended  that  many  improvementa  be  made  at  the 
Municipal  Hospital  in  the  way  of  interior  alterations. 

Death  of  Dr.  Richard  J.  Dunglison.— Dr.  Richard  J. 
Dunglison,  whose  reputation  in  medical  circles  need  hardly 
be  commented  upon,  died  on  March  4  at  his  home  in  Phila- 
delphia. Dr.  Dunglison  was  born  in  Baltimore,  Md.,  Nov- 
ember 13,  1834.  His  father  was  Dr.  Robley  Dunglison,  a 
well  known  physician,  and  his  grandfather,  John  Leadam, 
was  a  noted  surgeon  in  London,  England.  Dr.  Dunglison 
was  a  graduate  of  the  Central  High  School  and  the  Collegiate 


Department  of  the  University  of  Pennsylvania,  receiving  the 
degree  of  A.B.  in  1852  and  A.M.  in  1855.  In  1&52  he  took 
up  the  study  of  medicine  under  his  father's  direction,  and 
after  a  four  years'  course  in  the  Jefferson  Medical  College  grad- 
uated from  that  institution  in  1856.  He  was  the  editor  of 
"  Dunglison's  Medical  Dictionary  "  and  many  other  medical 
works  of  reference.  He  was  acting  assistant  surgeon  of  the 
army  from  1862  to  1865,  and  executive  oflBcer  of  a  local  army 
hospital  during  the  closing  years  of  the  Rebellion.  He  was 
a  member  of  the  County  Medical  Society,  Mutual  Aid  Asso- 
ciation, State  Medical  Society,  American  Medical  Associa- 
tion, International  Medical  Congress  and  many  other  organ- 
izations, in  nearly  all  of  which  he  held  oflBce. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 
March  2,  1901 : 

Total  mortality 5S8 

Casks.     Dbatbs. 
Inflammation  of  appendix  2,  brain  15,  bronchi 
11,    kidneys   27,    lungs  75.   peritoneum  8, 
pleura  1,  stomach  and  bowels  17,  spine  2  .  158 

Inanition  21,  marasmus  15,  debility  4 40 

Tuberculosis  of  lungs 62 

Apoplexy  29,  paralysis  8 37 

Heart — disease  of  29,  dropsy  of  1,  fatty  degen- 
eration of  1 31 

Uremia  12,  diabetes  4,  Bright's  disease  14    .    .  30 

Carcinoma  of  bladder  2,  stomach  3,  uterus  2, 

jaw  2,  Uver  1,  larynx  1,  esophagus  1  .   .  .   .  12 

Convulsions  18,  convulsions,  puerperal  1 .    .   .  19 

Diphtheria 108  20 

Brain — disease  of  1,  dropsy  of  2,  softening  of  3  6 

Typhoid  fever 18  6 

Old  age 10 

Cyanosis 4 

Scarlet  fever 91  9 

Influenza  14,  abscess  of  lung  1.  abortion  1. 
asthma  1,  anemia  1,  aneurysm  of  aorta  1, 
burns  and  scalds  4,  casualties  7,  cerebro- 
spinal meningitis  1,  congestion  of  brain  1, 
congestion  of  lungs  4.  pelvic  cellulitis  1, 
cirrhosis  of  liver  5,  childbirth  1.  tuberculo- 
sis of  the  bowels  1,  carbuncle  1,  croup  1, 
membranous  croup  7.  diarrhea  2.  drowned 
1,  dysentery  1,  erysipelas?,  catarrhal  fever  1, 
fistula  1 ,  gangrene  of  foot  1,  hemorrhage  from 
stomach  2,  neuralgia  of  heart  3,  obstruction 
of  bowels  2,  edema  of  lungs  1,  poisoning  1, 
rheumatism  3,  sclerosis  of  spine  1.  surgical 
shock  1,  septicemia  6.  sarcoma  of  breast  1, 
lung  1,  suicide  3,  teething  2.  brain  tumor  2, 
ulceration  of  stomach  1.  whooping-cough  1  94 

Pathological  Society. — At  the  meeting  of  February  28, 
Dr.  R.  N.  Wilson,  Jr.,  reported  for  himself  and  Dr.  R.  H. 
Harte  a  case  of  primary  carcinoma  limited  to  the 
vermiform  appendix.  The  patient  was  a  woman  of  24, 
with  a  negative  family  history,  who  had  had  several  attacks 
of  pain  over  the  appendix  and  also  in  the  right  lumbar 
region.  Diarrhea  with  bloody  stools  also  was  present  at 
times.  Operation  revealed  a  long  appendix,  apparently  nor- 
mal, and  no  adhesions.  The  appendix  was  removed  and  sec- 
tioned. The  lumen  was  obUterated  nearly  its  entire  length 
and  at  one  point  was  found  a  typical  carcinomatous  growth. 
Dr.  Wilson  believes  that  the  carcinoma  could  not  have  been 
diagnosticated.  The  blood-count  was  normal  and  no  tumor 
showed  even  when  the  appendix  was  removed.  The  prog- 
nosis in  these  cases  is  an  interesting  question.  Dr.  Wilson 
thinks  that  the  seriousness  attaching  to  them  has  been  ex- 
aggerated. If  the  prognosis  is  unfavorable  it  would  suggest 
the  propriety  of  removing  the  appendix  immediat€ly  in 
every  case  with  appendicular  symptoms. 

Drs.  D.  J.  M.  McCarthy  and  M.  P.  Ravkukl  exhibited  a 
specimen  of  melanosis  of  the  cerebrospinal  mem- 
branes  from  a  case  of  rabies.  The  specimen  was  from 
a  cow  that  had  died  of  hydrophobia.  All  the  membranes 
were  affected,  but  neither  the  cord  nor  brain  showed  any 
changes.  The  intense  deposit  of  melanin  was  not  considered 
to  have  any  connection  with  the  cause  of  death. 

Dr.  William  S.  Wadsworth  spoke  on  injuries  to  the 
brain.  The  relation  between  the  resisting  powers  of  indi- 
viduals and  the  injuries  received  was  discussed  and  their 
significance  pointed  out. 

Dr.  M.  B.  Hartzell  reported  a  case  of  lenticular  can- 
cer of  the  skin.  The  lesion  appeared  first  on  the  sole  of 
one  foot  and  was  removed.  It  afterward  spread  to  the  legs, 
trunk,  and  face,  death  of  the  patient  ensuing. 


MaBCU  9,  1901] 


AMERICAN  NEWS  AND  NOTES 


rTHE  Philadelphia 
Medical  Jodbnal 


455 


Dr.  John  B.  Roberts  showed  Bpecimens  of  multiple 
tumors  of  the  sciatic  nerve  which  he  had  recently 
removed  from  a  patient,  36  in  all  having  been  removed. 

Academy  of  Surgery. — At  the  stated  meeting  held 
March  4,  Dr.  Richard  H.  Harte  presented  a  patient  show- 
ing the  result  one  year  after  an  operation  for  sarcoma  of 
the  antrum  of  Highmore. 

Dr.  Charles  H.  Frazier  exhibited  a  patient  showing  a 
peculiar  neuropathic  affection  of  the  bones.  Skia- 
graphs showed  a  thickening  of  the  left  tibia  and  fibula  and 
exostoses  projecting  into  the  right  knee-joint  with  thickening 
of  the  enda  of  the  bones. 

Dr.  R.  H.  Haete  read  a  paper  entitled  some  observa- 
tions on  compound  fractures  of  the  skull  based  on 
146  cases.  In  doubtful  cases  of  fracture  an  incision  should 
be  made  through  the  skin  over  the  point  of  injury.  If  infec- 
tion has  taken  place  a  drainage  tube  may  be  inserted,  but  it 
should  seldom  extend  beneath  the  edge  of  the  bone.  Tre- 
phining is  not  a  serious  operation,  all  but  3  of  26  cases  recov- 
ering. Opium  is  one  of  the  most  useful  remedies  in  use  in 
these  cases.  Of  the  deaths  S7%  occurred  during  the  first  24 
hours. 

Dr.  John  H.  Gibbon  reported  two  cases  of  left  cecal 
hernia.  Both  patients  were  males.  From  a  resume  of 
the  literature  the  conclusion  is  reached  that  this  variety  of 
hernia  is  rare  in  women.  The  causes  are  believed  to  be  a 
small  movable  cecum  and  a  previous  hernia  of  the  small 
intestine. 

Dr.  Fkancis  T.  Stewabt  (by  invitation)  reported  a  case  of 
cecal  hernia  with  volvulus  of  the  ileum. 

Dr.  John  B.  Deaver  read  a  paper  entitled  mortality  in 
operations  for  obstructive  jaundice.  Hemorrhage, 
cholemia,  and  shock  are  the  causes  of  death  in  the  majority 
of  cases.  Peritonitis  is  not  a  common  cause.  To  prevent 
hemorrhage  chlorid  of  calcium  in  30  grain  doses  may  be 
given  for  several  days  before  and  after  operation,  although 
Dr.  Deaver  has  not  seen  any  great  benefit  from  its  use. 
Suprarenal  extract  seemed  of  value  in  one  case.  The  medi- 
cal treatment  of  these  cases  is  always  disappointing.  Early 
operation  is  the  best  preventive  ot  hemorrhage  and  other 
complications. 

Dr.  Thomas  S.  K.  Morton  read  a  paper  entitled :  Report 
of  a  case  of  strangulated  femoral  hernia ;  herni- 
otomy ;  acute  obstruction  3  weeks  later ;  enterec- 
tomy;  recovery.  The  case  brought  up  the  question  of 
deciding  what  bowel  to  return  and  what  to  excise  when 
operating  for  hernia.  Dr.  Morton  returns  all  bowel  that 
retains  its  endothelium. 

Dr.  George  Erety  Shoemaker  spoke  on  the  Treatment 
of  suppurating  hematocele  following  extrauterine 
pregnancy.  When  the  abdomen  is  opened  and  this  con- 
dition found,  the  abdomen  should  be  closed  and  the  collec- 
tion evacuated  through  the  vagina.  The  vaginal  route 
should  not  be  used  when  operating  for  extrauterine  preg- 
nancy. 

Kegistration  of  Tuberculosis^ — The  following  tract 
has  been  published  for  gratuitous  distribution  by  the  Penn- 
sylvania Society  for  the  Prevention  of  Tuberculosis : — Tuber- 
culosis, or  consumption,  as  it  is  usually  called,  is  a  contagious 
disease.  The  contagion  centers  around  the  person  who  has 
it,  so  that  he  as  well  as  the  place  in  which  he  dwells  are  liable 
to  give  the  disease  to  others.  But  the  contagion  is  confined 
to  the  matter  given  off  from  the  diseased  part,  such  as  sputum 
which  comes  from  diseased  lungs,  or  matter  which  comes 
from  a  sore ;  and  this  contagion  can  be  destroyed  when  such 
sputum  or  matter  is  given  off,  thus  making  the  person  of  the 
consumptive,  as  well  aa  the  place  in  which  he  lives,  harmless 
to  others. 

To  do  this,  certain  knowledge  and  means  are  necessary. 
Where  is  this  knowledge  and  means  to  come  from  1  Under 
our  system  of  government  from  the  Board  of  Health.  But 
how  18  the  Board  of  Health  to  know  who  needs  them  1  Only 
through  registration  of  every  case  of  tuberculosis. 

Now  there  are  a  great  many  people  who  seem  to  think  that 
registration  of  tuberculosis  means  putting  a  yellow  label  on 
every  consumptive's  house,  or  tying  a  yellow  ribbon  on  his 
coat,  so  that  the  poor  consumptive  may  be  branded  and 
shunned  like  Cain.  Nothing  could  be  farther  from  the 
truth. 


The  only  objects  which  can  be  obtained  by  registration  of 
tuberculosis  are :  1.  To  give  knowledge  and  help  to  the  con- 
sumptive and  his  family  for  their  protection  and  for  the  pro- 
tection of  the  public.  2.  To  protect  people  against  the 
danger  from  contaminated  houses  into  which  they  may  in- 
nocently move.  As  things  are  now,  a  family  may  run  into 
danger  which  they  cannot  see.  If  the  house  has  been  oc- 
cupied by  a  consumptive,  some  member  of  the  family  moving 
in  IS  very  likely  to  get  the  disease.  If  every  case  of  tubercu- 
losis were  registered,  the  Board  of  Health  could  watch  houses 
which  are  occupied  by  consumptives  and  require  their  disin- 
fection when  vacated.  To  properly  disinfect  a  house  is  rather 
an  expensive  operation,  and  this  being  the  case  few  landlords 
will  do  it  except  under  compulsion.  No  one  can  compel  a 
landlord  to  disinfect  such  a  house  except  the  Board  of  Health, 
and  the  Baard  of  Health  cannot  do  so  unless  it  knows  where 
the  house  is. 

Registration  of  tuberculosis  would  indeed  be  one  of  the 
greatest  blessings  possible  to  the  people,  and  especially  to  the 
poor  people.  There  would  be  no  publicity  in  the  matter. 
The  sufferings  of  the  consumptive  poor  would  be  lessened 
because  they  would  be  at  least  known  to  the  authorities. 
The  fact  is  we  have  all  grown  so  indiSerent  about  the  exist- 
ence of  consumption  and  so  callous  about  the  sufferings  of 
the  consumptive  that  we  seem  oblivious  of  them.  The  poor 
consumptive  could  not  be  more  completely  hidden  in  the 
desert  than  he  is  in  our  midst.  He  needs  to  be  discovered. 
He  needs  public  attention  and  only  through  registration  can 
he  get  it. 

If  you  desire  to  join  the  Pennsylvania  Society  for  the  Pre- 
vention of  Tuberculosis,  a  remittance  of  $1  to  the  Secretary, 
2024  Pine  street,  Philadelphia,  or  to  The  Commonwealth 
Title  Insurance  and  Trust  Co.,  Treasurer,  813  Chestnut 
street,  Philadelphia,  will  secure  membership. 

College  of  Physicians.— At  the  meeting  of  March  6, 
Dr.  W.  W.  Keen  exhibited  a  modification  of  Fell's  apparatus 
for  artificial  respiration.  The  bellows  has  an  opening  in 
which  a  funnel  containing  cotton  can  be  placed  for  the  pur- 
pose of  giving  an  anesthetic,  if  desired.  To  the  tube  leading 
from  the  bellows  can  be  attached  a  face-piece  or  a  modified 
O'Dwyer  intubation  apparatus,  which,  when  inserted,  closes 
the  opening  of  the  larynx.  A  thumb  is  held  over  the  end 
during  inspiration  (the  tube  being  attached  at  the  side)  and 
removed  during  expiration.  The  apparatus  is  believed  to  be 
extremely  useful  in  two  respects :  First,  in  surgical  operations 
about  the  chest ;  second,  in  cases  of  opium  poisoning,  etc. 

Dr.  George  W.  Crile,  of  Cleveland,  Ohio,  gave,  by  invita- 
tion, an  address  on  experimental  research  into  surgi- 
cal shock  and  collapse,  and  presented  stereopticon  views 
of  blood-presBure  charts,  etc.  The  experiments  were  made 
on  upward  of  250  dogs,  all  of  which  were  under  surgical 
anesthesia  and  were  killed  before  consciousness  was  regained. 
The  effects  on  blood-pressure  and  respiration,  of  cutting, 
bruising  or  burning  the  various  tissues  of  the  body  were 
detailed.  The  effect  produced  by  sawing  or  cutting  bone, 
cartilage  or  fascia  was  very  slight.  Wounds  of  muscle  gave 
more  change  and  in  nerve-trunks  the  effect  was  very  marked, 
there  being  an  immediate  rise  of  blood-pressure.  Opening 
joints  produced  little  effect.  In  amputations  and  disarticu- 
lations the  principal  change  was  caused  by  cutting  the  skin, 
muscles  and  nerve-trunks  and  not  by  sawing  the  bone  or 
opening  the  joint.  This  exactly  opposes  the  old  view.  Cut- 
ting the  skin  produced  everywhere  a  marked  effect  (greatest 
over  the  abdomen),  the  change  being  greater  than  for  any 
other  tissue  except  the  nerves.  Cutting  or  crushing  the 
tongue  produced  but  little  effect,  but  drawing  it  forward 
with  considerable  force,  particularly  if  toward  one  side, 
sometimes  caused  total  inhibition  of  the  heart.  The  clearing 
of  the  throat  by  vigorous  anesthetizers  and  the  inhibition  of 
respiration  which  sometimes  follows  and  is  supposedly 
remedied  by  drawing  forward  the  tongue,  suggested  the  above 
experiments.  Foreign  bodies  thrust  into  the  pharynx  and 
larynx  caused  marked  inhibition,  in  some  instances  collapse. 
Interference  with  the  laryngeal  mucosa  caused  respiratory 
inhibition  and,  if  marked,  cardiac  inhibition  also.  The  upper 
part  of  the  larynx  is  most  sensitive.  When  the  superior 
laryngeal  nerves  were  severed,  these  effects  were  not  proauced. 
Caaes  of  quick  death  from  drowning  are  believed  to  be  due 
to  circulatory  failure  and  not  to  asphyxia  In  positive  in- 
flation of  the  lungs  circulation  may  possibly  be  stopped,  an 


466 


Thb  Phiuj>klphia"1 
Mkdioai.  Joornal  J 


AMERICAN  NEWS  AND  NOTES 


[Maech  9,  1901 


important  point  in  cases  of  resuscitation.  Manipulation  of 
the  peritoneum  caused  marked  arrliythmia  of  respiration 
and,  when  long  continued,  complete  failure.  These  changes 
were  more  marked  as  the  region  of  the  diaphragm  wae 
approached.  Handling  the  omentum  caused  no  change. 
Opposite  effects  were  noted  in  the  male  and  female  genital 
tracts.  In  the  former  the  change,  if  any,  is  a  fall  of  blood- 
pressure.  In  the  latter  the  blood-pressure  rises.  Regarding 
the  effect  of  blows  upon  the  pit  of  the  stomach,  experimenta 
led  to  the  conclusion  that  no  amount  of  manipulation  of  the 
solar  plexus  could  produce  collapse.  The  effect  is  due 
to  action  upon  the  neart,  as  blows  upon  the  stomach, 
diaphragm,  or  intestines  will  not  produce  it.  The  symp- 
toms of  asphyxia  were  compared  with  those  of  inhib- 
ition. Asphyxia  is  generally  blamed  for  the  sudden  deaths 
which  occur  during  intubation  or  the  removal  of  a  foreign 
body  from  the  larynx.  Experiments  showed  that  it  is 
impossible  to  produce  sudden  death  by  asphyxia.  Respira- 
tions are  more  intense  when  true  asphyxia  comes  on  and  it 
takes  from  2  to  8  minutes  to  cause  death.  These  sudden 
deaths  are  caused  by  reflex  inhibition  of  respiration  and  the 
heart  through  the  superior  laryngeal  nerves.  Dr.  Crile  then 
spoke  of  the  various  causes  of  collapse.  Shock  is  believed 
to  be  caused  by  impairment  of  the  vasomotor  nervous 
system,  as  shock  cannot  occur  without  low  blood-pressure. 
The  heart  still  beats,  but  pressure  is  only  slightly  raised. 
The  pulse  is  small  because  the  blood  does  not  get  back  to  the 
heart  in  sufficient  amount  to  raise  venous  pressure  and  con- 
sequently arterial  pressure.  Dk.  Beinton  mentioned  having 
seen  very  great  collapse  from  division  of  the  thyroid  isthmus 
and  asked  if  experiments  regarding  it  had  been  made.  Db. 
Charles  Frazbee  asked  if  spinal  anesthesia  had  been  used 
in  any  of  the  experiments.  In  answering  these  and  other 
questions  Dr.  Crile  stated  that  he  had  found  nothing  in  the 
tnyroid  isthmus  to  cause  such  effects,  and  thought  they  were 
probably  due  to  the  traumatism  on  the  larynx  itself.  Experi- 
ments with  spinal  anesthesia  showed  that  no  changes  in 
blood-pressure  or  respiration  were  caused  by  operations  upon 
the  anesthetized  area.  The  experiments  had  led  to  no  plan 
of  treatment  for  shock,  as  they  were  more  suggestive  of  pre- 
vention than  of  cure.  As  to  the  part  played  by  hemorrhage 
in  causing  shock,  there  is  no  tall  in  blood-pressure  from 
hemorrhage  up  to  a  certain  point,  as  the  heart  and  vaso- 
motor system  compensate  for  the  loss  of  blood.  But  because 
of  the  diminished  stock  of  reserve  power,  shock  comes  on 
more  easily  after  hemorrhage.  The  continuance  of  shock 
after  abdominal  operations  depends  upon  the  amount  of 
raw  surfaces  left,  the  tension  of  stitches,  amount  of  blood- 
clot  left,  etc.  These  factors  probably  determine  why  one 
surgeon's  patients  recover  from  operative  shock  sooner  than 
do  those  of  another  operator.  The  statement  was  repeated 
that  the  cause  of  death  in  cases  of  auick  drowning  is  olock- 
ing  of  the  circulation  instead  of  aspnyxia. 

CoUegre  of  Physicians  of  Philadelphia — Section 
on  Ophthalmology. — Meeting,  February  19,  1901.  Dr. 
William  Thomson,  chairman,  in  the  chair. 

Dr.  Wm.  Zentmayee  exhibited  a  case  of  synchisis 
scintillans  occurring  in  a  woman,  aged  40  years.  The 
condition  was  monocular,  affecting  the  right  eye.  The 
crystals  were  diffused  throughout  the  entire  vitreous,  suid  in 
places  were  imbedded  in  the  retina.  The  fundus  was  other- 
wise normal.  Dr.  Zentmayer  also  showed  a  man,  aged  43 
years,  with  hyaline  formations  on  the  optic  nerve 
head.  The  entire  temporal  half  of  the  disc  and  the 
lower  inner  portion,  in  places,  was  covered  by  a  mass  com- 
posed of  clusters  of  brilliant  ^ayish-white  bodies.  There  were 
similar  bodies  in  the  choroid  surrrounding  the  lower  outer 
portion  of  the  disc.  The  left  eye  presented  the  same  condi- 
tion in  a  less  marked  degree.  Both  nerves  were  very  slightly 
atrophic.  In  the  discussion  Dr.  de  Schweinitz  showed  a 
microscopic  slide  of  an  optic  nerve  which  had  ophlhalmo- 
scopically  presented  all  the  appesrances  that  were  'pcn  in 
Dr.  Zentmayer's  case.  Dr.  Carpenter  referred  to  H  rasf>9 
which  he  had  reported  sevpral  years  .ago,  in  only  one  (,f 
which  wern  the  druecn  bodies  fdund  botti  in  the  macular 
legiou  ns  well  as  on  the  nerve  head. 

Dr.  G.  Oram  Ring  exhibited  a  young  girl,  9  yesra  of  agp. 
with  paresis  of  the  left  internal  rectus  foUowinjf 
diphtheria,  whicli  unlike  most  of  the  ctises  that  ho  had 
seen,  showed  no  improvement  after  9  months'  time. 


Dr.  John  T.  Carpenter  gave  the  clinical  history  of  a  case 
of  melanotic  sarcoma  of  the  choroid  in  a  woman,  aged 
64,  of  poor  health  and  with  probable  malignant  disease  of 
the  liver. 

Dr.  H.  F.  Hassell  read  a  paper  on  Binocular  hemian- 
opsia and  optic- nerve  atrophy  in  a  case  of  diabetes 
mellitas.  The  patient,  a  woman,  .56  years  of  age,  had  suf- 
fered for  a  number  of  years  with  diabetes  mellitus.  The  eye- 
symptoms  commenced  6  months  before  she  came  to  the  eye 
department  of  the  Jefferson  Hospital.  The  ophthalmoscope 
showed  marked  optic-nerve  atrophy  of  each  side  without 
signs  of  previous  papillitis.  The  perimetric  measurements 
disclosed  an  irregular  hemianopic  field  for  white  and  a 
definitely  outlined  hemianopic  field  for  colors.  Vision  had 
declined  to  ^.ft.  Dr.  Deeccm,  who  saw  the  patient  in  con- 
sultation, believed  that  the  diabetic  and  the  optic-nerve 
atrophy  were  both  due  to  the  same  cause,  namely,  intra- 
cranial lesion,  probably  of  the  floor  of  the  fourth  ventricle. 
The  urine  contained  J  %  glucose  and  was  of  high  specific 
gravity ;  it  was  free  from  albumin.  The  case  is  of  interest 
in  that  it  demonstrated  the  rare  form  of  eye  complication, 
namely,  optic  atrophy  with  hemianopsia  without  opacity  of 
the  media  or  history  of  inflammation.  Dr.  Hansell  reviewed 
the  recent  literature.  In  the  discussion,  Dr.  de  Schweinitz 
thought  that  the  symmetrical  changes  in  the  visual  fields  in 
diabetes  mellitus  might  be  explained  by  the  action  of  the 
toxin  of  this  disease  on  the  ganglionic  cells  of  the  retina. 
The  degeneration  in  the  ganglionic  cells  results  in  atrophy 
of  the  macular  fibers,  which  later  spreads  to  other  bundles. 
The  action  of  the  toxin  of  diabetes  under  these  circum- 
stances is  similar  to  that  of  certain  drugs ;  for  example, 
quinin,  filix  mas,  methyl  alcohol,  etc. 

Dr.  S.  D.  Risley,  under  the  title  of  Clinical  Memoranda, 
presented  Case  I,  hlack  cataract,  in  a  man,  aged  74,  a 
native  and  resident  of  the  island  of  Barbadoes.  Eight  years 
before,  an  unsuccessful  attempt  had  been  made  by  a  local 
surgeon  to  extract  the  lens  in  the  right  eye  after  an  iridec- 
tomy for  glaucoma.  Dr.  Risley  found  the  ball  shrunken, 
tencfer  to  palpation,  and  evidently  causing  sympathetic  irri- 
tation in  tne  fellow  eye,  a  contracted  field,  increased  tension, 
and  a  black  cataract.  The  right  eye  was  enucleated,  a  broad 
peripheral  preliminary  iridectomy  made  on  the  left,  and  6 
weeks  later  the  lens  successfully  extracted  in  its  capsule. 
The  eye  recovered  without  accident,  and  in  5  weeks,  with 
correcting-glasses,  +5.  C  +  8.c,  Ax.  180°,  V.  =  ^,  with 
some  difficulty.  Through  this  correcting- glass  a  distmct  but 
apparently  not  very  deep  glaucomatous  cup  of  the  optic 
nerve  could  be  made  out.  Case  II  was  that  of  a  man,  aged 
58,  a  patient  at  the  Wills  Eye  Hospital,  presenting  extraor- 
dinary calcareous  deposit  in  the  tarsal  conjunctiva. 
He  was  the  victim  of  chronic  trachoma,  erosion  of  the  bor- 
ders of  the  lids  and  closure  of  the  lacrimal  puncta  in  the 
upper  and  lower  lids  in  both  eyes.  The  entire  surface  of  the 
conjunctiva  was  occupied  by  a  pavement  of  yellowish- whit* 
masses  that  exuded  through  the  overlying  soft  tissue  under 
pressure.  A  portion  of  this  was  collected,  treated  with  dilute 
acetic  acid,  and  evaporated  to  dryness.  This  was  onc«more 
dissolved  with  dilute  acetic  acid,  filtered,  and  a  drop  of  am- 
monium oxalate  test-solution  added,  which  showed  the  char- 
acteristic precipitate  of  calcium  oxalate. 

Dr.  G.  E.  de  Schweinitz  described  some  unusual  cho- 
roidal lesions  associated  ^vith  pregnancy.  A  case  of 
unilateral  neuroretinitis  beginning  in  the  fifth  month  of 
pregnancy  resulted  in  complete  disappearance  of  the  neu- 
ritis, but  left  an  extensive  pigmented  retinochoroiditis.  He 
was  inclined  to  think  that  the  retinal  and  choroidal  lesions 
began  simultaneously,  although  it  was  possible  that  the 
retina  was  first  affected  and  the  choroid  coat  became  in- 
volved later,  as  in  several  other  similar  reported  CAses.  In 
the  second  case  the  lesions  were  those  of  a  oilateral  choroid- 
itis, or  rather  retinochoroiditis,  which  somewhat  resembled 
pigmentary  degeneration  of  the  retina,  and  were  ascribed  to 
the  influence  of  an  abortion  about  the  third  month.  It  was 
suggested,  however,  that  a  syphilitic  affection  prior  to  this 
date  might  have  been  the  cause  both  of  the  choroidal  lesions 
nod  of  the  abortion. 

r>R.  DE  Schweinitz  also  described  a  case  of  normal 
couibined  cataract  extraction  in  which  the  anterior 
chamber  was  not  reformed  until  the  thirty-second  day. 
Although  the  upper  part  of  the  cornea  was  slightly  haiy, 
vision  was  i^,  but  the  eye  remained  red  and  lacrimation  w»s 


MasOH  9,  1961] 


AMERICAN  NEWS  AND  NOTES 


PThk  Philadelphia 
L  Medical  Journal 


457 


excessive.  Two  and  one-half  months  later  keratoiritis  sud- 
denly developed,  followed  by  three  or  four  attacks  of  sec- 
ondary glaucoma,  in  one  of  which  the  anterior  chamber 
became  filled  with  blood.  Vision  was  reduced  to  light- per- 
ception. Under  the  influence  of  profuse  diaphoresis  pro- 
duced with  pilocarpin  and  large  doses  of  salicylate  of  sodium, 
all  inflammatory  symptoms  disappeared,  and  ultimately  the 
vision  rose  to  -frr,  with  proper  correction,  in  spite  of  exten- 
sive corneal  opacity.  The  slow  closure  was  attributed  to 
failure  of  reparative  power  due  to  the  mental  condition  of 
the  patient,  which  was  greatly  depressed.  The  late  kerato- 
iritis waa  ascribed  to  irritating  and  doubtless  infecting  secre- 
tions from  the  conjunctiva  which  obtained  entrance  through 
an  imperfectly  closed  wound,  because  even  when  the  anterior 
chamber  was  apparently  restored,  it  is  probable  that  the 
wound  was  not  perfectly  solid.  The  secondary  glaucoma 
was  doubtless  caused  by  sudden  complete  closure  of  the 
wound  as  follows  :  Slight  leaking  from  the  anterior  chamber 
through  an  insignificant  fistulous  opening  prevented  a  rise 
in  tension  ;  when  this  perforation  closed  there  was  complete 
restoration  of  the  anterior  chamber,  but  the  aqueous  could 
no  longer  find  an  outlet  through  Fontana's  spaces,  which 
had  become  impervious,  and  hence  the  rise  in  tension  and 
glaucoma.  Dr.  Knapp  has  reported  analogous  cases,  and 
suggested  such  an  explanation.  The  great  value  of  pilo- 
carpin diaphoresis  was  emphasized. 

County  Medical  Society.  —  The  first  paper  at  the 
meeting  of  February  27  was  read  by  Dr.  Elizabeth  L.  Peck, 
who  reported  two  cases  of  typlioid  fever  and  a  case  of 
suppurating  bronchial  glands,  with  recovery.    The 

first  case  of  typhoid  fever  reported  was  remarkable  because 
of  the  high  temperature,  the  limit  of  the  thermometer 
being  reached  and  maintained  for  some  days.  The  patient 
waa  a  very  nervous  woman,  the  high  temperature  being 
ascribed  to  that  cause.  Sponging  failed  to  reduce  it,  the 
patient  seeming  to  do  better  when  left  alone.  The  second 
case  was  that  of  an  epileptic,  the  convulsions  continuing 
throughout  the  attack. 

Dr.  Matthew  Woods  read  a  paper  on  the  Registration 
of  tuberculosis  from  the  standpoint  of  private 
practice.  Dr.  Woods  strongly  opposes  compulsory  regis- 
tration. He  believes  it  would  cause  a  disturbance  without 
being  a  benefit  to  either  the  sick  or  the  healthy.  Persona 
who  have  been  registered  may  be  denied  employment.  The 
keeping  of  a  knowledge  of  his  disease  from  a  sick  person  is 
often  the  most  beneficent  act  a  physician  can  do.  Registra- 
tion will  not  allow  this.  The  fear  of  registration  will  have  a 
tendency  to  keep  people  from  seeking  medical  advice,  until 
it  is  too  late.  Consumption  is  not  contagious.  Some  people 
have  tubercle  bacilli  in  their  sputum  and  not  the  disease, 
and  vice  versa.  The  Board  of  Health  can  accomplish  more 
by  eliminating  the  slums  of  the  city  than  by  making  regis- 
tration compulsory.  Physicians  can  accomplish  much  by 
inculcating  sanitary  laws. 

Dr.  Lawrence  F.  Flick  read  a  paper  entitled  Home 
treatment  of  tuberculosis.  In  the  treatment  of  this 
disease  three  points  are  to  be  aimed  at :  1.  The  restoration  of 
the  physiological  functions  of  the  body.  2.  The  securing  of 
hypemutrition.  3.  The  conferring  of  immunity.  These  can 
be  best  secured,  in  the  case  of  the  poor,  by  treatment  at 
home.  "  Close  "  treatment  refers  to  sanatoria  ;  "  open  " 
treatment  to  the  home.  The  paper  of  Dr.  Flick  was  an  out- 
line of  what  he  characterizes  close  treatment  at  home.  Early 
diagnosis  is  the  first  point  and  in  this  the  general  practitioner 
should  be  more  alert.  Indigestion  is  one  of  the  earliest 
symptoms  and  its  persistence  always  calls  for  physical  exam- 
ination of  the  lungs.  When  the  diagnosis  is  made  the  first 
step  should  be  to  inform  the  patient  of  his  condition.  This 
is  necessary  to  secure  his  cooperation  in  the  treatment  which 
he  should  understand  is  to  be  a  struggle — perhaps  from 
3  to  5  years  in  length.  Patients  are  often  not  cured 
when  they  seem  to  be,  and  treatment  should  be  kept 
up  for  some  time  after  a  favorable  result  is  obtained.  A 
daily  routine  of  life  as  to  food,  exercise,  etc.,  should  be  laid 
down.  Abundance  of  food  is  necessary — 3  to  6  quarts  of 
milk  and  6  to  12  raw  eggs  daily  can  be  taken  by  many 
patients.  The  foundation  principle  of  medication  for  these 
cases  is  that  whatever  builds  up  the  system  is  good  for  the 
patient.  In  Dr.  Flick's  experience  the  iodine  compounds 
are  first  in  value.    Next  is  creosote  given  in  hot  water  before 


meals,  a  maximum  of  50  drops  three  times  daily  being  at- 
tained in  some  cases.  Strychnin,  arsenic,  phosphorus,  digi- 
talis, and  iron  are  also  of  value.  Use  any  drug  that  will 
help  any  organ.  One  of  the  greatest  diSiculties  encountered 
in  the  treatment  of  tuberculosis  is  the  occurrence  of  compli- 
cations as  colds,  influenza,  or  pneumonia.  Taese  frequently 
cause  a  recrudescence.  When  they  occur,  absolute  rest  in 
bed  for  several  weeks  must  be  insisted  upon.  Dr.  Flick's 
results  for  the  past  6  years  have  been  18  %  of  cures,  with  arrest 
of  the  disease  in  10%,  very  great  improvement  in  26%,  and 
temporary  improvement  in  19  % . 

In  discussing  the  two  last  papers,  Dr.  J.  C.  Wilson  stated 
that  the  diametricallj'  opposed  views  of  the  speakers  was 
not  to  be  deplored,  as  a  controversial  spirit  served  to  bring 
out  the  subject  more  fully.    While  commending  the  treat- 
ment laid  down  by  Dr.  Flick,  he  believes  it  impossible  to 
carry  out  these  measures  among  many  of  the  inhabitants  of 
the  city,  especially  the  foreign  element  in  the  southeastern 
section.    Because  of  this,    the   profession    must    organize 
and  insist  that  the  municipality  provide  hospitals  for  poor 
consumptives.    The  drugs  used  today  are  the  same  aa  were 
formerly  employed,  but  their  application  is  difl'erent.    Three 
groups    are    included — the    phenol,    iodin,    and    arsenical. 
Regarding  registration  he  believes  the  way  to  meet  a  foe  is 
to  seek  it  and  thinks  that  Dr.  Woods   in  his  opposition 
overlooks  the  value  of  that  movement  to  society  at  large. 
Consumption  is  a  constant  menace  under  certain  circum- 
stances, and  registration  will  help  to  minimize  the  danger. 
Dr.  R.  G.  Curtin  uses  guaiacol,  quinin,  strychnin,  and  nux 
vomica  in  the  treatment  of  tuberculosis.    He  believes  the 
cases  of  contagion  are  few.    Instances  were  cited  from  the 
Philadelphia  hospital  where  men  had  lived  with  consurnp- 
tives  for  years,  one  man  who  had  an  ulcerated  throat  being 
there  for  10  years,  and  did  not  develop  the  disease.    Senti- 
ment against  consumptives  is  getting  so  great  that  they 
seem    to    have    no    place,    and    they    are    constantly  de- 
pressed   by    everybody    being  afraid  of  them.    Dr.  J.   M. 
Anders   said    that    a    certain    small    percentage    of   cases 
of  tuberculosis  get  well  without  any  treatment  or  change 
of   climate,    but   systematic    treatment   will    add    to    this 
number.    Considering  this  fact,  too  little  attention  is  being 
paid  to  cases  that  must  be  treated  at  home.    He  has  no 
experience  with  the  iodin  compounds.    Creosote  is  not  a 
specific,  but  it  controls  the  bronchitis,  fever,  and  cough  as  no 
other  drug  will  do  and  is  the  most  valuable  single  remedy. 
Fats,  as  cod-liver  oil,  are  of  great  value.    Arsenic  and  digi- 
talis are  of  service,  but  hygienic  measures  are  of  infinitely 
greater  importance.    The  patient  should  occupy  the  largest 
room    available   in    the    house    and   during  the    summer 
live    out   of  doors,    in  a    tent,  in    the    woods,  if  possible. 
Plants  and  flowers  in  the  sleeping  apartment  are  of  benefit. 
Dr.  Anders  is  in  favor  of  registration.    Although  pulmonary 
tuberculosis  is  feebly  contagious,  the  foci  of   the  disease 
should  be  located,  and  for  this  reason  registration  should  be 
secured.    Dr.  S.  SolisCohen  said  that  persistent  hopeful- 
ness on  the  part  of  the  physician  was  a  necessary  part  of  the 
treatment.    The  patient  should  be  told  exactly  what  his 
condition  is.    This  does  not  tend  to  depression,  as  hopeful- 
ness of  the  patient  is  characteristic  of  tuberculosis.     Dr. 
Cohen  is  not  convinced  that  registration  is  the  best  way  to 
accomplish  what   is  desired  in   the  way  of  hygiene,  etc., 
but  he  is  willing  to  be  convinced.    Prophylaxis  in  this  dis- 
ease is  not  so  much  a  medical  question  as  it  is  an  economic 
one.    There  are  three  easily  separable  main  stages  in  tuber- 
culosis—the trophic,  the  bacillary,  and  the  phthisis  or  con- 
sumptive.   Perfect  recoveries  from  each  stage  have  been 
seen.    Pneumatic  measures  are  of  great  value  in  the  treat- 
ment, simple  and  inexpensive  ones  being  readily  devised. 
Treatment  may  be  summed  up  in  one  word — nutrition.    Dr. 
A.  V.  Meigs  believes  that  compulsory  registration  would  not 
accomplish  what  is  claimed  for  it,  and  that  if  adopted  it 
will  sooner  or  later  fail  and  be  abandoned.    The  diagnosis 
of  tuberculosis  is  often  so  diflacult  that  physicians  can  exer- 
cise great  latitude  in  reporting  or  not  reporting  cises.    He 
believes  that  the  Board  of  Health  has  not  the  authority  to 
enforce  this  measure  at  present.    Dr.  Meigs  also  stated  that 
the  committee,  consisting  of  Drs.  Mitchell,  Tyson,  and  him- 
self, that  was  appointed  to  appeal  to  the  Board  of  Health  in 
regard  to  the  placarding  of  houses  containing  conUgious  dis- 
eases, had  been  unofficially  notified  by  the  president  that  the 
Board  had  receded  from  iU  position  and  that  in  the  future 


458 


The  Philadelphia"! 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[UaechS,  UM 


more  discretion  would  be  allowed  in  the  matter  of  placarding. 
It  has  been  found  that  this  rule  of  placarding  will  not  work, 
and  the  same  thing  will  be  true  of  compulsory  registration  of 
tuberculosis.  Tubercle  bacilli  in  the  sputum  are  not  an  abso- 
lute indication  of  pulmonary  tuberculosis. 

A  paper  by  Dr.  Leon  Brinkhun,  entitled  Observations : 
Results  of  160  operations  for  appendicitis,  was  read 
by  title. 

NEW  JERSEY. 

Physicians  Resign.— Dr.  Frank  H.  Glazebrook  and 
Dr.  Henry  P.  Merrill,  Jr.,  house  physicians  at  the  Orange 
Memorial  Hospital,  at  Orange,  N.  J.,  have  resigned.  They 
state  that  their  resignation  was  due  to  a  disagreement  with 
the  Board  of  Governors  of  the  hospital. 

Morris  Plains  Hospital.— A  resolution  haa  been  in- 
troduced in  the  legislature  of  New  Jersey,  calling  for  an 
investigation  of  the  Morris  Plains  Hospital  for  the  Insane. 
This  action  has  been  hastened  because  of  a  case  in  which  it 
was  charged  that  the  wife  of  a  citizen  has  been  committed  to 
the  aaylum  when  her  friends  believed  her  to  be  sane.  She 
has  recently  been  adjudged  in  possession  of  her  right  mind 
and  was  released. 

DELAWARE. 

An  amendment  has  been  introduced  in  Delaware  pro- 
viding that  whenever  a  physician  who  is  a  resident  of  the 
State  and  who  was  duly  qualified  to  vote  for  representatives 
in  the  General  Assembly  at  the  last  general  election  prior  to 
his  application  shall  apply  to  the  State  Board  of  Medical 
Examiners  for  a  certificate,  it  shall  grant  it  without  examina- 
tion upon  his  presenting  to  the  board  a  diploma  from  a  rep- 
utable medical  college,  and  on  satisfactory  proof  that  he  had 
been  in  active  practice  of  his  profession  at  least  ten  years  in 
any  other  State  of  the  United  States. 

NEW  YORK. 

Physician  for  Lunacy  Commission.— The  Senate 
has  passed  the  bill  of  Senator  Brackett  providing  that  the 
vacancy  in  the  Lunacy  Commission  now  existing  may  be 
filled  by  Gov.  Odell  from  the  ranks  of  physicians  who  are 
alienists  or  who  have  for  two  years  been  in  charge  of  the 
insane. 

Section  on  Railway  Surgery.— A  joint  session  of  the 
Section  on  Kailway  Surgery  with  the  Medico-Legal  Society 
of  New  York  will  be  held  on  Monday,  April  15,  1901,  in 
New  York  City,  under  the  chairmanship  of  Dr.  Charles  K. 
Cole,  of  Helena,  Montana.  An  attractive  program,  which 
includes  a  banquet,  is  being  arranged. 

Vaccinated  Burglar  and  the  Detectives.— A  burglar 
walked  into  a  quarantined  apartment-house  in  New  York 
City  last  week.  There  had  been  some  smallpox  in  the  build- 
ing and  two  Board  of  Health  doctors  were  in  charge  of  the 
house.  They  found  the  burglar  at  work,  and  before  turning 
him  over  to  the  authorities  they  vaccinated  him.  When  three 
detectives  arrived  at  the  house  the  Board  of  Health  doctors 
would  not  let  them  out  of  the  building  until  they  had  sub- 
mitted to  vaccination. 

Regulating-  Sale  of  Poisons.— The  following  restric- 
tions regarding  the  sale  of  poisons  have  been  introduced  in 
the  State  of  New  York :  No  substance  which,  in  the  words 
of  the  law,  "  according  to  standard  works  on  medicine  or 
materia  medica,  is  liable  to  be  destructive  to  human  life  in 
quantities  of  60  grains  or  less,  shall  be  sold  at  retail  or 
furnished  without  being  labeled  with  the  name  of  the  article 
and  the  word  '  poison  '  and  the  name  and  place  of  business 
of  the  seller  plainly  printed  in  red  ink."  A  record  must  be 
kept  of  the  more  dangerous  poisons,  as  arsenic,  cyanid  of 
potassium,  hydrocyanic  acid,  cocain,  morphin,  strychnin, 
and  all  other  vegetable  alkaloids  and  their  salts.  A  com- 
plete record,  including  the  name  of  the  purchaser,  his 
address,  the  amount  of  poison  sold  and  date  of  sale,  must  be 
kept  where  it  can  be  inspected  at  any  time  by  the  proper 
authorities,  and  must  be  preaerved  for  five  years. 

The  Bufifalo  Academy  of  Medicine  held    meetings 
during  the  month  of  February,  1901,  as  follows  : 


Section  on  Surgery. — ^Tuesday  evening,  February  5. 
Program  :  Conservative  Surgery  of  the  Extremity,  CHArKCEY 
Pelton  Smith.  Surgical  Complications  of  Typhoid  Fever, 
Veetnee  Keneeson.  Operative  Treatment  of  Tubercular 
Lymphomata  of  the  Neck,  Peescott  LeBeeton. 

Section  on  Medicine. — Tuesday  evening,  February  12. 
Program  :  Toe  Value  of  Clinical  Pathology,  A.  E.  Woeh- 
NEET.  Pemphigus,  with  the  Record  of  a  Case,  J.  W.  Geos- 
VENOE.  Discussion  by  Geo\t;e  Wende.  Report  of  a  Case  of 
Psychical  Equivalent  of  Epilepsy,  Chaeles  Caey  and  Julius 
Ullmann. 

Section  on  Ophthalmology,  Otologry,  Rhlnology 
and  Laryngology. — Monday  evening,  February  18.  Pro- 
gram :  Presentation  of  a  Case — Macular  Choroiditis,  with 
Cholesterin  Crystals,  J.  C.  Clemesha.  The  Eye  in  Nervous 
Diseases,  W.  C.  Keauss.  Certain  Diseases  of  the  Eye  Bene- 
fited by  Treatment  of  the  Nose  and  Nasopharynx,  B.  H. 
Geove. 

Section  on  Pathologry. — Tuesday  evening,  February  19. 
Program  :  Leukemia,  Charles  S.  Jewett.  House  Distribu- 
tion of  Cancer  in  Buffalo  Daring  the  Past  Twenty  Years. 
Irving  P.  Lyon.  Formaldehyd  Gas — Its  Most  Simple  Ap- 
plication and  its  Limitation  in  Household  Disinfection. 
William  G.  Bissell. 

Section  on  Obstetrics. — Tuesday  evening,  February 
26,  Program  :  The  Toxemia  of  Pregnancy,  M.  A.  Crockett. 
Symphj'siotomy,  P.  W.  VanPeyma. 

Manhattan  Dermatolog^cal  Society.— A  regular 
monthly  meeting  was  held  at  the  residence  of  Dr.  Jacxsb 
Sobel,  No.  1828  Madison  Avenue,  on  Friday  evening,  March 
1,  with  Dr.  William  S.  GottheU  in  the  chair. 

Dr.  L.  Weiss  presented  a  case  of  erythema  multiforme 
of  the  face,  showing  grouped  and  scattered  papules  assuming 
a  semivesicular  nature,  and  circular  patches  of  the  forehead. 
On  the  extensor  surface  of  the  right  leg  a  nodule  resembling 
erythema  nodosum  had  existed  for  two  weeks.  De.  Sobel 
agreed  with  the  diagnosis  of  exudativum  annulare  and  Dr. 
GtoiTHEiL  stated  that  the  face  was  commonly  involved  in 
erythema  multiforme. 

Dr.  Sobel  presented  two  cases  of  pruritus  hiemalis. 
Both  patients  attributed  the  itching  to  the  cold  weather,  one 
having  had  repeated  attacks.  The  urine  was  negative,  there 
was  no  gastrointestinal  disturbances  and  no  signs  of  pedicu- 
losis. The  body  above  the  umbilicus  was  free.  De.  Weibs 
concurred  in  the  diagnosis.  In  winter-itch  there  are  so-called 
prurigo  papules,  which  are  more  visible  to  the  touch  than  to 
the  eye.  Drs.  Gottheil  and  Abrahams  considered  the  first 
case  a  papular  eczema.  De.  Cocks  looked  upon  both  as 
pruritus. 

Dr.  Weiss  showed  a  patient  with  a  sycosis  simplex  of 
the  left  cheek  and  neck,  the  lesions  in  the  latter  region 
resembling  furunculosis.  De.  Abeaha.ms  looked  upon  the 
condition  as  sycosis  plus  furunculosis.  Des.  Blelmax  and 
Geysee  as  a  sycosis ;  and  Dr.  Gottheil  as  a  furunculosis. 

Dr.  Abrahams  presented  a  case  of  erythema  simplex 
of  the  face  in  a  highly  neurotic  woman.  The  condition 
assumes  a  butterfly  shape. 

Dr.  Abrahams  showed  a  case  of  rheumatic  purpura 
which  had  existed,  with  remissions,  for  20  years.  The  lesions 
respond  rapidly  to  salicyliites.  Dr.  Sobel  would  diagnose 
peliosis  rheumatica  and  give  salicylates.  Relapses  are  not 
at  all  uncommon  in  this  aflfection.  Dr.  GSotthkil  remarked 
that  most  cases  of  rheumatic  purpura  occur  in  children  and 
young  people. 

Dr.  Abrahams  presented  a  patient  who  showed  in  the  pre- 
patellar region  a  large,  firm,  bluish-colored,  flat  mass,  about 
the  size  of  a  child's  palm.  Six  years  previous  the  woman 
noticed  a  small  lump  around  a  varicose  vein ;  this  increased 
in  size,  remained  stationary  for  2  year?,  and  then  steadily  in- 
creased to  its  present  dimensions.  He  inclines  toward  a 
diagnosis  of  sarcoma  cutis.  Dr.  Obkrxdorfkr  thinks  it 
uonmalignant,  probably  a  fibroma.  Microscopical  examina- 
tion is  ad\-i8ed.  Dr.  Franklin  thinks  that  microscopical  ex- 
amination would  settle  matters,  and  with  the  aid  of  clinical 
observation  give  a  positive  diagnosis.  Dr.  Cocks  considers  it 
benign.  Dr.  Weiss  would  call  it  fibro-cavemosa,  and  D&. 
Gottheil  angiofibroma. 

Dr.  Abrahams  reported  a  lupus  erythematosus  of  the 
face,  followed  in  6  months  by  s  lupus  vulgaris  of  the 
left  breast,  the  latter  diagnosis  being  substantiated  by  micro- 


ttlBCH  9,  190IJ 


AMERICAN  NEWS  AND  NOTES 


rTHK   PomASEIf  HIA 
\_  MKmCAI,  JOimBAL 


459 


3Copical  examination.  Dr.  Gottheil  presented  photographs 
of  sarcoma  of  the  abdominal  wall  and  of  congenital  hyper- 
trophy of  all  structures  of  the  third  and  fourth  fingers  of  the 
right  hand.  Dr.  Meykowitz  remarked  that  such  anomalies 
were  usually  stigmata  of  degeneration. 

State  Health  Conmiissioner. — Gov.  Odell  appointed 
Dr.  Daniel  Lewis,  of  New  York  City,  State  Health  Commis- 
sioner on  February  28  and  sent  his  name  to  the  Senate  for 
confirmation.  Dr.  Lewis  was  president  of  the  State  Board  of 
Health,  which  has  been  legislated  out  of  office.  He  held  the 
presidency  of  the  board  for  three  terms,  serving  on  it  since 
1895.  His  appointment  as  State  Health  Commissioner  is 
for  the  term  ending  December  31,  1904.  The  salary  of  the 
office  is  $3,500  per  year.  He  will  have  entire  jurisdiction 
over  the  matters  which  have  hitherto  been  supervised  by  the 
State  Board  of  Health. 

NEW  ENGLAND. 

Resigrnation. — Dr.  B.  H.  Cheney,  for  3  years  chairman 
of  the  Board  of  Physicians  and  Surgeons  of  Grace  Hospital, 
of  New  Haven,  Conn.,  and  Mrs.  Cheney,  his  wife,  chairman 
of  the  Womea's  Board  of  the  institution,  resigned  their  posi- 
tions on  March  1,  1901. 

New  Haven  Hospital. — Plans  have  been  completed  for 
the  new  clinical  budding  to  be  erected  near  the  New  Haven 
Hospital.  The  new  building  will  be  situated  on  the  comer 
of  Congress  Avenue  and  Cedar  Street,  just  across  from  the 
City  Hospital.  The  frontage  on  Congress  Avenue  will  be  65 
feet,  and  the  depth  on  Cedar  Street,  90  feet. 

Prize  Essay. — Dr.  J.  B.  Learned,  of  Northampton, 
Mass.,  is  continuing  his  agitation  against  the  practice  of  ad- 
ministering drugs  to  induce  sleep.  He  believes  that  other 
methods,  more  natural  and  less  harmful  and  destructive,  are 
practicable,  and  offers,  through  the  Journal  of  the  American 
Medical  AssociatUm,  a  prize  of  $100  for  the  best  essay  on  the 
subject. 

CHICAGO   AND  WESTERN  STATES. 

Dr.  Sehaner  Resigns. — Dr.  J.  L.  Schauer,  professor  of 
dermatology  in  the  Milwaukee  Medical  College,  resigned  on 
March  1, 1901. 

The  American  Dermatological  Association The 

Association  will  hold  its  next  meeting  in  Chicago,  May  30 
and  31,  and  June  1, 1901. 

Medical  Socie£y  of  the  Missouri  Valley. — ^The  semi- 
annual meeting  of  this  society  will  be  held  in  the  city  of 
Omaha,  on  Thursday,  March  21. 

The  Western  Ophthalmologic  and  Oto-Laryn- 
gologic  Association. — The  Association  will  meet  in  its 
next  annual  session  in  Cincinnati,  Ohio,  April  11  and  12, 
1901. 

Association  of  Iowa  Physicians. — President,  Donald 
Macrae,  Council  Bluffs ;  vice-president,  F.  E.  Sampson,  Cres- 
ton ;  treasurer,  W.  B.  Small,  Waterloo ;  secretary,  J.  W. 
Kline,  Ft.  Dodge. 

Diphtheria  in  Springfield. — The  reeidenta  of  Spring- 
field, Dl.,  have  become  quite  alarmed  on  account  of  the 
spread  of  diphtheria  in  tnat  city.  The  disease  is  of  the 
malignant  type,  and  several  deaths  therefirom  are  reported. 

Chair  of  Casualty  Surgery.— Dr.  Gustavus  Blech 
has  been  appointed  professor  of  casualty  surgery  in  the 
Jenner  Medical  College.  This  is  the  first  institution  in  the 
West  to  establish  a  chair  for  this  branch  of  practical  surgery 
and  medicine. 

Hospital  at  Oshkosh.— Dr.  C.  W.  Oviatt,  house  surgeon 
at  St.  Mary's  Hospital  at  Oshkosh,  Wis.,  announces  today 
that  plans  have  been  completed  for  a  $50,000  hospital  to  be 
built  in  the  business  portion  of  the  city.  At  the  present  time 
$40,000  has  been  subscribed. 

Pomona  Valley  (Cal.)  Medical  Society. —At  the 

meeting  of  this  Society,  in  Pomona,  January  31,  the  follow- 
ing officers  were  elected :  Dr.  Conley  Heaton,  Pomona,  presi- 


dent; Drs.  William  A.  Lillie,  Oatario,  and  D.  Hardy  Smith, 
Pomona,  vice-presidents ;  and  Dr.  Edward  Henderson,  Po- 
mona, secretary  and  treasurer. 

Milwaukee  Hospital  for  the  Insane. — The  follow- 
ing officers  were  elected  for  the  ensuing  year  at  the  annual 
meeting  of  the  Board  of  Trustees  :  President,  B.  B.  Hopkins; 
vice-president,  A.  L.  Cary ;  secretary,  A.  F.  Wallschlaeger ; 
ex  officio  treasurer,  the  county  treasurer,  Schultz;  executive 
committee,  G.  E  Gustav  Kuechle,  David  Vance,  J.  W.  P. 
Lombard :  visiting  committee.  Christian  Wah),  John  F.  Burn- 
ham,  Miss  LiUian  Wall,  Mrs.  Anna  L.  Wall,  Dr.  Ernest 
Copeland. 

SOUTHERN  STATES. 

Kentucky  State  Medical  Society. — The  forty-sixth 
annual  session  of  the  Kentucky  State  Medical  Society  will 
be  held  in  Louisville,  May  22,  23,  24,  1901. 

The  Texas  Medical  Gazette.— 2%€  Texas  Medical 
Gkuette  made  its  appearance  in  January  of  the  present  year. 
It  is  printed  at  Fort  Worth,  and  edited  by  Drs.  F.  D.  Thomp- 
son, Bacon  Saunders,  Frank  Gray  and  W.  E.  Thompson. 

Tri-State  Medical  Society. — At  the  recent  meeting 
held  at  Kichmond,  Va.,  Dr.  J.  N.  Upsher,  of  Kichmond,  Va., 
was  elected  president,  and  Dr.  W.  R  Royston,  of  Charlotte, 
N.  C,  secretary.  The  next  meeting  will  be  held  at  Asheville, 
N.  C,  February,  1902. 

President  of  Johns  Hopkins  Resigns. — Dr.  Daniel 
Coit  Gilman,  president  of  the  Johns  Hopkins  University, 
Baltimore,  has  resigned,  the  resignation  to  go  into  effect  at 
the  close  of  the  academic  year,  September  Ist.  Dr.  Gilman 
has  been  with  the  university  since  its  foundation,  twenty- five 
years  ago. 

Conference  on  National  Liegislation. — The  second 
annual  conference  on  national  legislation  of  the  American 
Medical  Association  and  its  affiliated  societies  was  held  in 
Washington  on  February  20  and  21. 

There  were  present  delegates  from  Kentucky,  Michigan, 
New  York,  Minnesota,  Connecticut,  West  Virginia,  Ohio, 
Arkansas,  Wisconsin,  North  Dakota,  District  of  Columbia, 
Washington,  Pennsylvania,  Maryland,  Texas,  U.  S.  Army, 
and  U.  S.  Marine- Hospital  Service. 

The  chairman.  Dr.  H.  L.  E.  Johnson  and  the  sub-com- 
mittee appointed  at  the  last  conference  to  act  for  the  con- 
ference during  the  interim  of  meetings,  reported  the  results 
of  their  endeavors  to  carry  out  the  wishes  of  the  conference. 
The  report  showed  that' the  efforts  made  to  prevent  the 
passage  of  the  so-called  " Antivivisection  Bill"  had  been 
efficacious.  The  bill  providing  for  the  protection  of  the 
Florida  coast  from  fishing  boats  which  landed  yellow  fever 
suspects,  and  which  was  advocated  by  the  conference,  would, 
it  was  said,  probably  be  passed  at  this  session  of  Congress. 
The  Army  Reorganization  Bill,  which  had  recently  be- 
come a  law,  did  not,  however,  contain  the  provisions  which 
the  conference  had  desired  for  the  enlargement  and  better- 
ment of  the  Army  Medical  Corps.  The  protest  against 
changes  in  this  portion  of  the  Bill  as  originally  suggested 
by  the  Army  Medical  Department  had  been  unavaiUng.  A 
discussion  on  this  subject  showed,  however,  that  the  law  as 
enacted  did  no  injustice  to  the  present  rdembers  of  the  Army 
Medical  Corps,  and  was  not  as  unsatisfactory  to  the  medical 
profession  as  it  at  first  seemed.  It  was  thought  probable  that 
Congress  in  the  future  might  be  induced  to  give  further  con- 
sideration to  the  subject,  which  would  result  in  a  betterment 
in  the  direction  desired. 

The  conference  was  notified  that  one  of  the  provisions  of 
the  Post  Office  Bill  now  before  Congress  would  compel  pub- 
lishers to  affix  stamps  to  weekly  medical  journals  to  be 
delivered  in  large  cities.  A  resolution  was  adopted  to  have 
a  committee  of  the  Conference  protest  at  once  to  the  proper 
committee  of  the  Senate  against  the  passage  of  this  portion 
of  the  Act,  which  had  already  passed  the  House  of  Repre- 
sentatives. 

A  subcommittee  was  appointed  to  consider  the  whole  sub- 
ject of  medical  legislation  and  medical  education  in  order  to 
obviate  the  present  inconvenience  of  compelling  a  physi- 
cian who  moves  from  one  State  to  another  to  pass  an  exami- 
nation for  license,  though  a  licensed  practitioner. 


460  "^^  Phii^delphiaT 

msdicai,  jodbnal  j 


AMERICAN  NEWS  AND  NOTES 


[Mabcb  9,  190) 


The  importance  of  having  every  State  medical  gociety 
represented  in  the  Conference  was  recognized,  and  steps  were 
taken  to  call  the  attention  of  unrepresented  State  societies  to 
the  necessity  of  action  in  this  regard. 

CANADA. 

Postgraduate  Course.— The  corporation  of  McGill 
University  at  the  suggestion  of  the  medical  faculty  wUl  estab- 
lish a  new  postgraduate  course  in  legal  medicine. 

MISCELLAJfY. 

Marine  Hospital  Inquiry—Marine  Hospital  Service 
has  issued  a  letter  of  inquiry  regarding  influenza  or  grip,  with 
a  view  to  gathering  and  promulgating  some  correct  informa- 
tion regarding  its  prevalence  and  types. 

r«^„f  ?*?'/T'TP**2//««  has  been  consolidated  with  the 
Interstate  Medical  Journal  and  the  two  publications  continued 

!^?TO?«%''"^'"-,rj°^-    ^':  ^"'■^'^  Po^te'-  formerly  editor 
ot  Uieblylus,  will  be  associated  with  Drs.  W.  B.  Outten  R 

?f  ^'^r'^^?^^  ?r  ^•^•,^.-  ^*"' '°  *^e  editorial  management 
of  the  Interstate  Medical  Journal,  St.  Louis,  Mo. 

.^^^^^^^  ^^S&T».-^eB.d.\Bss  cigars  are  recommended, 
because  they  do  away  with  the  danger  from  the  pasted  end 
II^JIa  .P"?'    ''ll'^' J°u-  i»iffction.    Many  factory  operators 
are  said  to  have  the  habit  of  moistening  the  fingers  in  the 
mouth  before  making  the  end  twist.      The  discovery  by  the 

IZl^^^'^'^'tu  ^^''^'^  °^  ^^^"^^^  °^  '"bercle  bacilli  hi  cigars 
emphasizes  the  danger.— P«5&  Health  Journal. 

rn?,^*9A*'^T?o^-  ^^  ^^  ^*S™'  *'  Winchester,  Va.,  on  Feb- 

<^i7n^^'  ''^^Ji  y«*'-«--OR-  D.  W.  Scoir,  at  Oklahoma 

rl^'.n  F  -a""  ^^^^^'^  27  -Dr.  W.  F.  Aiken,  at  Savannah, 

Ga.,  on  February  27.-Dr.  Olivek  H.  McKittrick,  at  Wash- 

mgton,  Ind     on  February  28,  aged  61  years.-DE.  Ditten- 

HOEFER,  at  San  Francisco,  Cal,  on  February  22,   aged  40 

years.— Dr.  George  A.  Hamil,  at  Martinsburg,  W  Va.    on 

February  28.-DR.  E.  P.  Fraser,  at  Los  Anfdes,  Cal".',  on 

PnrtZ7  m'  "^"^  ^^  years-DR.  Edward  A.  F^sLxden,  a° 

Hat  Tp  '«f  r"  '"'Jif  ^"y  ^^'r,^^^^  56  years.-DR.  John 

W  ?^An^o     *^?®  ?'"j  ^?v  °°  February  28.-DR.  William 

H.  Gates,  at  Cleveland,  Ohio,  on  March  4.— Dr.  John  Syl- 

ctJECK,  at  Frederick,  Md.,  on  March  5,  aged  25  years.-DR 

Aloysids  X.  Whitford,  at  Parksville,  Md  ,  on  February  28  - 

Dr  Thomas  Riley,  at  North  Adams,  Mass.,  on  March  4,  aged 

58  years.-DR.  John  Sheldon,  at  Leroy,  111.  on  March  3,  aled 

68  years.-DR.  L    C.  Morgenstern,  at  Brooklyn,  N.  Y.,  on 

February  28,  aged  37  years.  ' 

Changes  in  the  Medical  Corps  of  the  U.  S.  Navy. 

for  the  week  ended  March  2, 1901 :  ^^tvy, 

PiCKKBKLL  G.,  surgeon,  detached  from  the  Cavite  Xaval  Station 
and  ordered  to  the  Mare  Island  Navy  Yard 

^"""nl^o'rdL^d'hreto^^aTlrTr^'^^'^'^^''  ''""^  ^"^  ■■«°'«<=«-" 
jTnroTd^erei-t^th^^^^lXc'e^'^^'^^'^ ''•°'"  '^^  •'Independence." 
CoEDERio,  F.  J    B.,  surgeon,  detached  from  the  "  New   Orleans  " 
and  ordered  home  via  the  "  Buffalo  "  "neans, 

^^^th^'e'^NeTbHeant^''^'''  """'  ''''  "^"'^^'°"  «""  ordered 
^°°n^kZ-A  wefical  inspector,  detached  from  recruiting  duty,  and 

iZ^^-  ?•  Pv- ™f;dical  inspector,  detached  from  duty  as  fleet  sur- 
Rusl   W  n'^'n"  Station  and  ordered  home  to  wait  orde^ 

"'la^;fnd'oX?dhf,[;[e'.'''*''^''''^'^*^'^  '"^^  ^^''^''-'^  ^'--^ 

Changes  in  the  U.  S.  Marine-Hospital  Service, 

for  the  week  ended  February  28,  1901 : 

^"^February  is""^'  ^'"'^^°"'  sr^'-'^d  leave  of  absence  for  1  day. 

°^''Fphr'?,'«^;  Tt  ^"'■e^O"-  granted  leave  of  absence  for  20  days  from 
February  17,  on  account  of  sickness.    February  19  •>'"™™ 

s^pt^r^^J'tbru^^r/^r''  ^  '"^^  ^'^"-  Quarant^e.^^^: 


^^°qnr!;£-  E-.  assistant  surgeon,  upon  being  relieved  by  Assistant 
Surgeon  T.  D.  Berry  to  proceed  to  Havana,  Cuba,  and  report  to 
the  chief  quarantme  officer  for  duty.  Fabniary  18 
,?^k^;P;'  assistant  surgeon,  reheved  from  duty  at  Havana,  and 
^Z^^  ^  W"^  to  Genfuegos,  Cuba,  reUeviug  Assistant  Sur- 
geon  F.  E.  Trotter.    February  18 

Habbis  B   Y.,  acting  assistanut  surgeon,  granted  leave  of  absence 
lor  10  days.     February  25. 

Maesh,  W.  H.  acting  assistant  surgeon,  granted  leave  of  absence 
for  4  days  from  February  27.    February  26.  •uw.ice 

Health  Reports.- The  following  cases  of  smallpox, 
yeUow  fever  and  plague,  have  been  reported  to  the  Surgeon- 
General  U.  S.  Manne-Hospital  Service,  during  the  week 
ended  March  2, 1901 : 


Alabama  : 
Califoesia  : 

DiSTBICT   OF 

Columbia 
Florida  : 
Illikoib  : 
Indiana: 
Kansas  : 

KEKTrCKY  : 

LomsiANA : 

Mabyland: 
Michigan: 
Minnesota  : 

MissocBi : 
Nebbaska  : 
N.  Hahpshibe  : 
New  Jebskt  : 
New  Yobk : 
Ohio  : 


Pennsylvania  : 


South  Caeolina 
Tennessee  : 

Texas: 
Utah  : 
WestViegihia  : 


Smallpox- United  States. 

Mobile Feb.  16-23 

Los  Angeles  .    .  Feb.  9-16  . 

:  Washington  .  .  Feb.  2-23  . 
Jacksonville  .  .  Feb.  16-23 
Chicago  ....  Feb.  16-23 
Delaware  Co.  Feb.  2  .  . 
Lawrence  .  .  .  Feb.  8-16  . 
Wichita  ...  Feb.  16-23 
Lexington  .  .  .  Feb.  8-23  . 
New  Orleans  .  .  Feb.  16-23 
Shreveport  .  .  .  Feb.  16-23 
Baltimore  .  .  .  Feb.  16-23 
West  Bay  Qty  .  Feb.  8-23  . 
Minneapolis  .  .  Feb.  8-^  . 
Winona  ....  Feb.  16-23 
St.  Joseph  .   .   .  Jan.  1-31  . 

Omaha Feb.  8-23  . 

Manchester  .  .  Feb.  16-23 
Newark  ....  Feb.  8-26  . 
New  York  .  .  .  Feb.  16-23 
Ashtabula  .  .  .  Feb.  16-23 
Cincinnati  .  .  .  Feb.  16-23 
Cleveland    .   .   .  Feb.  16-23 

Erie Feb.  16-23 

Pittsburg ....  Feb.  16-23 
Steelton  ....  Feb.  16-23  . 
Greenville  .  .  .  Feb.  16-23  . 
Memphis ....  Feb.  16-23  . 
Nashville  .  .  .  Feb.  16-23  . 
Galveston  ...  To  Feb.  16 
Salt  Lake  City  .  Feb.  8-23  .  , 
Huntington   .   .  Feb.  16-23    . 


Smallpox — Fobeion. 


Austbia  : 
Belgium  : 

Brazil: 


Cetlon : 

ECUADOB : 

France  : 
Great  Britain 


India  : 


Mexico  : 
Netherhnds  : 
Porto  Rico  : 
Russia  : 


Scotland  : 

Straits 

Settlements 


Prague  

Antwerp  .  .  .  . 
•ihent   .    . 

Bahia 

Pernambuco  .  . 
Rio  de  Janeiro  . 
Colombo  .  .  .  . 
Guayaquil  .    .   . 

Paris 

Bradford  .  .  .  . 
Liverpool  .  .  . 
London  .  .  .  . 
New    Castle    on 

Tyne .    . 
Bombay  .   .   .    . 
Calcutta   .... 
Karachi    .    .  .    . 

Madras 

Mexico 

Rotterdam  .  .  . 
Ponce  .... 
Moscow  .  .  . 
Odessa  .... 
St.  Petersburg 
Warsaw .... 
Dundee  .  .  . 
Glasgow  .   .   . 


Jan.  26-Feb.  9 
Jan.  26-Feb.  2 
Jan. 19-26    .    . 
Jan.  19-26    .    . 
Dec.  17- Jan.  15 
Dec.  16- Jan.  15 
Jan.  6-12  .    .   . 
Jan.  8-26  .    .  . 
Jan.  16-Feb.  9    , 
Feb.  2-9    .    .  .   . 
Feb.  2-9    ...    , 
Jan.  26-Feb.  9    . 

Jan.  26-Feb.  2  . 
Jan.  16-27  .  .  . 
Jan.  12-26  .  .  . 
Jan.  13-27    .    .   . 

Jan. 15  

Feb.  1-16  .  .  .  . 
Feb.  S-16  .  .  .  . 
Feb.  1-10  .  .  .  . 
Jan.  19-Feb.  2  . 
.Tan.  26-Feb.  9  . 
Jan.  26-Feb.  2  ■ 
Jan. 19-36  .  .  . 
Jan.  26-Feb.  9  . 
Feb.  8-15  .    .   .    . 


Bbazil: 
Cuba  ; 
Mexico: 


Africa: 
ISDIA  :| 


Rio  de  Janeiro 
Havana  .  .  . 
Vera  Cruz   .   . 


Dec.  8- Jan.  15 
Feb.  8-16  .  .  . 
Feb.  8-16  .   .   . 


Plagoe.— Foreign. 

Cape  Town  .  .   .  Feb.  S     .    . 
Bombav  ....  Jan.  16-29 
Calcutta   ....  Jan.  12-36 
Madras Jan.  19-26 


Cases. 

1 

12 

3 

10 

1 

1 

8 

3 

14 

2 

1 

2 

15 

13 

34 

12 

30 

3 

43 

3 

3 

48 

1 

3 

1 

2 

21 

6 

123 

46 

1 


Singapore    .   .   .  Dec.  29-Jan.  12  . 
Yellow   Fkvee. 


1 

32 
17 
35 

1 


DKATHas 

1 


62 
3» 
1 
11 
32 


1 
» 
186 
14 
6 
4 


2 
13 


12 
10 


10 


837 

89 

1 


March  9,  1901] 


THE  LATEST  LITERATURE 


CThk  Philadelphia 
Medical  Journal 


461 


^I?c  latest  itteraturc. 


British  Medical  Journal. 

February  16,  1901.     [No.  2094.] 

1.  Remarks  on  the  Heart- Index  Interval  in  Aortic  Regur- 

gitation.   Paul  M.  Chapm.4n. 

2.  The  Eflfecte  of  Severe  Muscular  Exertion,  Sudden  and 

Prolonged  in  Young  Adolescents.    W.Collier. 

3.  Caees  of  Adult  General  Paralysis  with  Congenital  Syphilis. 

Percy  Smith. 

4.  Wind  Exposure  and  Phthisis.    Charles  A.  Davies. 

5.  Thyroid  Extract  as  a  Remedy,  with  Illustrative  Cases. 

P.  Blaikie  Smith. 

6.  Cerebellar  Abscess  Successfully  Treated  by  Operation. 

Thomas  Barr  and  H.  Nicoll. 

7.  Trephining  in  Intracranial  Suppuration  and  Result  of 

Fracture.     D.  A.  McCurdy. 

8.  A    Report  on  Ten  Cases    of  Poisoning  by  Arsenetted 

Hydrogen.    J.  S.  Clayton. 

9.  The  Electrolytic  Deposit  of  Sulphur  from  the  Harrogate 

Sulphur   Waters   as    a   Therapeutic    Agent.    F.    W. 
Smith. 
10.  Amputation  Mortality  at  the  London  Temperance  Hos- 
pital.   W.  J.  Collins. 

1. — Chapman  publishes  a  tracing  from  a  case  of  aortic 
regurgitation  that  he  believes  furnishes  proof  of  the  pulse 
delay  and  of  its  modification  in  aortic  regurgitation.  He 
believes  that  this  pulse  delay  is  accounted  for  by  a  length- 
ened ventricular  systole  in  fully  compensated  cases  of  aortic 
regurgitation.  In  making  the  tracing  the  author  used  Dr. 
Augustus  Waller's  digital  sphygmograph.  The  normal  heart- 
radial  delay  is  about  0.18  second  and  the  delay  from  the 
radial  to  the  index  pulse  is,  at  the  very  most,  0.02  second. 
Allowing  for  errors  in  makiog  measurements  involving  hun- 
dredths of  a  second,  the  patient  had  a  heart- index  delay 
of  about  ;V  second,  which  was  probably  indistinguishable  by 
touch.  Later  the  heart-index  delay  was  0  185  second.  In 
the  former  case  the  blood-pressure  was  equal  to  16  mm.  of 
mercury ;  in  the  latter  instance  it  was  20  mm.  of  mercury. 
The  pulse- wave  produced  in  cases  of  aortic  regurgitation  is 
slow,  and  this,  the  author  believes,  is  the  principal  phenom- 
enon in  pulse  delay.  When  delay  is  observed  in  these 
cases  increased  arterial  tension  tends  to  obliterate  the  delay ; 
while  diminished  arterial  tension  makes  it  still  more  mani- 
fest. As  compensation  is  attained  the  arteries  are  better 
filled,  giving  to  the  patient  a  corresponding  sense  of  comfort 
and  well-being  and  then  the  pulse- wave  is  accelerated.  We 
see,  then,  that  the  attainment  of  a  normal  heart  radial  delay 
is  some  measure  of  the  correctness  of  the  compensation  and 
this  may  guide  us  to  aveid  further  interference,     [j  m  s  ] 

3. — The  most  important  factor  in  the  production  of  breath- 
lessness  is  the  saturation  of  the  blood  with  carbon  dioxid. 
The  respiratory  need  is  in  proportion  to  the  quantity  of  COj 
in  the  blood,  and  in  athletic  exercise  the  quantity  is  rapidly 
increased  by  increased  production.  If  muscular  work  in  a 
given  time  is  so  great  as  to  produce  a  quantity  of  CO^  greater 
than  the  lungs  are  able  to  eliminate,  the  gas  must  accumulate 
in  the  system  and  the  respiratory  distress  will  increase  pro- 
gressively. Further,  CO^  has  a  weakening  influence  on 
muscle  fiber  and  causes  its  contraction  to  be  less  effective. 
Severe  muscular  exercise,  either  sudden  or  pro- 
longed, throws  a  great  strain  on  the  air-vesicles,  leading  to 
that  which  may  be  described  as  physiologic  emphysema.  In 
the  case  of  a  young  university  athlete  the  signs  of  this 
physiologic  emphysema  are:  (1)  Absence  of  apex-beat 
while  at  rest ;  (2)  absence  of  superficial  cardiac  dulness ; 
and  (3)  a  hyperresonant  percussion-note  above  the  clavicles 
and  at  the  edges  of  the  sternum.  If  the  muscular  effort 
is  persisted  in,  this  physiologic  emphysema  may  beconie 
pathologic.  Again,  this  severe  muscular  exertion  throws 
a  great  strain  on  the  right  side  of  the  heait,  and  this 
danger  is  a  very  real  one  in  adolescents.  In  the  cases  of 
two  long-distance  runners,  exertion  produced  a  systolic  mur- 
mur in  the  right  side  of  the  heart  from  overdilation  of  the 
"ventricle.  There  is  a  form  of  heart-strain  in  girls  and  young 
women,  especially  in  those  who  do  much  stairclimbing,  that 
is  of  the  same  nature,  the  symptoms  of  which  disappear 


when  the  patients  are  required  to  rest  in  the  horizcntal  posi- 
tion. As  Allbutt  has  pointed  out,  oft  repeated  muscular 
eflfort  produces  hypertrophy  of  the  left  ventricle,  and  the  in- 
creased force  with  which  the  blood  is  thrown  into  the  aorta 
causes  that  vessel  to  lose  much  of  its  elasticity,  to  become 
dilated,  and  finally  causes  the  aortic  valves  to  become  incom- 
petent. A  symptom  of  these  changes,  which  are  of  very 
gradual  establishment,  is  sleeplessness.  In  order  to  prevent 
these  dangers,  all  boys  should  be  submitted  to  medical  in- 
spection before  being  allowed  to  compete  in  school  sports, 
and  the  badly  developed  subjects  should  not  be  permitted  to 
take  part.  Boys  who  are  obviously  growing  wiih  exceptional 
rapidity  should  be  advised  to  avoid  exercise  requiring  great 
muscular  exertion.  Healthy  and  strong  boys  who  are  in 
athletics  should  be  examined  once  or  twice  a  year  as  a  safe- 
guard against  overstrain.  Severe  muscular  exertion  un- 
doubtedly causes  intermittent  albuminuria,     [j.m.s  ] 

3. — Smith  gives  the  history  of  a  case  of  general  paral- 
ysis in  a  woman,  28  years  of  age,  in  whom  there  was  un- 
doubtedly inherited  syphilitic  taint  and  a  history  of 
paternal  general  paralysis.  The  case  was  referred  to  by  Mott 
in  the  Croonian  Lectures,  in  June,  1900.  He  also  gives  the 
history  of  a  married  woman,  aged  24  years,  who  broke  down 
with  general  paralysis.  There  was  a  history  of  paternal 
syphilis  and  general  paralysis,  although  there  were  none  of 
the  ordinary  signs  of  congenital  syphilis  in  the  patient  her- 
self and  she  had  never  acquired  syphilis.  In  neither  case 
was  there  any  history  of  alcoholism  or  of  sexual  excess.  There 
was  no  history  of  head  injury  nor  of  special  stress  or  worry 
in  either  patient.  Such  cases  seem  to  confirm  Mott's  opinion 
that  some  cases  of  general  paralysis  in  which  there  is  no 
history  of  acquired  syphilis  and  in  which  the  patient  can  no 
longer  be  classed  as  "juvenile"  may  owe  their  inception  to 
inherited  syphilis,    [j.m  s.] 

4, — After  careful  investigation,  covering  a  period  of  15 
years,  with  the  mortality  from  pulmonary  tuberculosis 
in  the  Isle  of  Man,  Davies  finds  that  the  results  obtained  can 
in  no  way  be  considered  to  support  the  theory  that  strong 
winds  are  accountable  for  the  peculiar  distribution  of  the 
disease  in  that  locality,     [j  m  s.] 

5. — Smith  reports  a  case  ot  widespread  carcinoma  in  a 
woman,  aged  44  years,  in  whom  thyroid  extract,  in 
5-grain  doses  varying  from  two  to  four  times  daily,  given 
for  6  months,  produced  great  amelioration  of  the  symptoms. 
The  symptoms  returned,  however,  in  spite  of  persistence^  of 
the  treatment.  In  the  case  of  a  child,  aged  3  years,  who  first 
presented  an  eruption  that  simulated  that  of  measles  and 
which  was  soon  cured  ;  but  in  whom  the  eruption  reappeared 
at  varying  intervals  and  became  edematous,  bullous,  ery- 
thematous, and  hemorrhagic,  the  administration  of  thyroid 
extract  was  followed  by  complete  cure.  In  the  case  of  a 
man,  aged  50  years,  who  was  suS'ering  from  chronic 
nephritis  and  who  was .  becoming  very  fat,  thyroid  extract 
was  beneficial  in  reducing  the  weight,     [j.m.s.] 

6. — Barr  and  Nicoll  report  a  very  interesting  case  of 
cerebellar  abscess  resulting  from  middle  ear  disease 
after  the  mastoid  operation  had  been  performed.  The  abscess 
was  drained  through  an  opening  made  in  the  floor  of  the 
posterior  fossa.  The  patient,  whose  condition  was  very  bad 
at  the  time  of  the  operation,  greatly  improved  afterwards 
excepting  that  the  abscess  cavity  did  not  seem  to  drain  well. 
A  second  operation  for  the  purpose  of  establishing  through- 
and-through  drainage  was  then  thought  advisable  and  an 
opening  was  made  through  the  mastoid  and  petrous  portions 
of  the  temporal  bone  and  counter- drainage  obtained  in  this 
way.  The  patient  made  an  excellent  recovery  and  two  and 
a  half  years  after  operation  showed  no  effect  of  his  trouble 
save  deafness  on  the  affected  side.  Facial  palsy,  which  was 
well  marked  before  the  operation,  entirely  disappeared  soon 
afterward,     [j  h.g.] 

7. — McCurdy  reports  a  case  of  fracture  of  the  skull  in 
the  frontal  region  which  was  not  recognized  at  the  time  of  its 
occurrence,  but  18  days  afterwards  the  patient  developed  an 
epileptiform  fit  and  three  days  later  another.  Operation  was 
decided  upon  and  when  a  button  of  bone  was  removed  at 
the  seat  of  fracture  it  was  found  that  there  was  a  consider- 
able collection  of  pus  between  the  dura  and  the  skull.  This  was 
evacuated  and  the  patient  recovered  well  from  the  operation. 
At  first  there  was  considerable  drainage,  but  four  days  after 
the  operation  he  became  irritable,  complained  of  pain  in 
the  head  and  on  the  fifth  day  became  unconscioas.    The 


462 


The  Philadelphia 
Medical  Jocenal 


] 


THE  LATEST  LITERATURE 


[M^BCB  9,  190> 


wound  waa  again  opened  and  the  frontal  lobe  of  the  brain 
thoroughly  explored  for  pus  but  none  found.  The  patient 
died  and  at  the  necropsy  it  was  found  that  the  pus  had  ex- 
tended downward  and  backward  into  the  neighborhood  of 
the  Sylvian  fi 'sure,    [j  h  g.J 

8. — Ten  men  who  were  engaged  in  manufacturing  zinc 
chlorid  from  crude  zinc  oxid  and  hydrochloric  acid  were 
poisoned  by  ar8«»iietted  hydrogen.  Both  the  hydro- 
chloric acid  and  the  zinc  oxid  were  known  to  contain  arsenic, 
but  the  exact  percentage  was  not  determined.  The  eymp- 
terns  were  nausea,  hot,  burning  pain  from  throat  to  stomach, 
intense  thirst,  violent  vomiting,  severe  diarrhea,  hemoglobin- 
uria, jaundice  of  an  intense  coppery  hue,  prostration,  cyanosis, 
and  thready  pu's3.  These  symptom?  gradually  diminished 
after  several  days,  and  the  feehng  of  depression,  anemia,  and 
pale- green  color  of  the  ekin  lasted  for  several  weeks  longer, 
and  the  man  who  was  most  severely  affecte  i  and  recovered, 
was  unible  to  go  to  work  for  5  weeks.  Oae  case  terminated 
fatally.     [jMs] 

9. — Smith  f  jund  a  yellow  deposit  that  looked  and  smelled 
like  sulphur  on  the  skin  of  many  patients  who  had  been 
treated  with  electricity  passed  thrr  ugh  Beckwith  Harrogate 
water  at  a  temperature  of  99°  F.  The  water  contains  a  large 
amount  of  alkaline  carbonates  and  a  considerable  amount  of 
sodium  eulphid.  Two  patients,  particularly,  who  presented 
this  deposit  recovered,  one  from  gouty  eczema,  rapidly.  It 
would  seem  then  from  these  clinical  refults,  as  well  as  from 
the  results  of  electrolytic  experiments,  that  nascent  sul- 
phar  is  deposited  in  the  Harrogate  sulphur  water 
by  electricity  at  the  positive  pole.  In  addition  to  the 
remedial  influence  of  nascent  sulphur,  electricity  stimulates 
the  peripheral  nerves  all  over  the  body  in  a  sulphur  bath  and 
thus  renders  the  action  of  sulphur  more  rapid  and  more 
efficacious  in  skin  and  gouty  affections,    [j.m.s] 


Lancet. 

February  16,  1901.    [No.  4042.] 

The  Hunterian  Oration.  An  Address  on  Craniology.  X. 
C.  Macs'amara. 

Three  Lectures  on  the  Surgery  of  Pregnancy  and  Labor 
Complicated  isith  Tumors.    J.  Blasd  Sctton. 

Remarks  on  Agglutination  by  P. ague  Blood.     E  Klein. 

Why  are  Both  Legs  of  the  Same  Length  ?  George  E. 
Wherry. 

A  Case  of  Subacute  Glanders.  John  Fawceit  and  Wal- 
ter C.  C  Paekes. 

Posterior  Basic  Meningitis.    Hugh  Thuesfield. 

Primary  Sarcoma  of  the  Stomach.    W.  S^ltau  Fenwicz. 

Foreign  B  >dy  in  the  Abdomen.    Ernest  H.  Ellison. 

A  Case  of  Cephalhematoma.    Hugh  Howle  Borland. 

Primary  Carcinoma  of  the  Ampulla  of  Vater,  with  Re- 
port of  a  Case  Presenting  S'>me  Special  Features  of 
Interest.    H.  D.  Rolleston. 

On  the  Uses  of  Formalin  in  Glycerin.  Alfred  C.  Jor- 
dan. 

Maternal  Impressions  in  L->wer  Life.      Andrew  Wilson. 

Reflections  on  Therapeutics.    Harky  Campbell. 

Oatbreak  of   Typhus    Fever    in    Manchester.    Harold 

COATES. 

1. — Macnamara delive-ed  the  Hunterian  ora'ion,  tiking 
as  his  subject  craniology  and  reviewed  the  labors  of  Hunter 
and  the  other  able  scientific  men  wh->  followed  him  in  that 
line  of  su-ly,  including  the  c'.ief  of  Eng'anl's  cranickgitts 
Thu-nam  and  Bana'd  Davis,  who  have  made  ma:niticent 
coUec'io-g  of  prehistoric  and  othe-  skulls.  He  remarks 
that  we  have  njw  come  to  know  that  the  size  and  f  irni  of 
the  skull  depends  to  a  large  ex' en',  on  the  growth  of  the 
bocei  of  which  it  is  formed  along  the  lines  of  the  various 
cranial  su'ures.  It  is  wdl  knowa  that  the  frontal  bone, 
which  forms  the  vault  of  the  anterior  pirt  of  the  cran'um  in 
ths  young  of  man  and  apes,  is  divided  by  a  suture,  and  so 
lorg  as  th"s  line  of  growth,  together  with  the  coronal  and 
other  sutures  by  which  the  fronta'  is  separated  from  sur 
rounding  bones,  remains  open,  the  fore  part  of  the  skull  and 
with  it  the  anterior  fo'sse  which  it  enc'oses  cm  expand. 
But  if  the  frontal  and  other  anterior  suture?  of  the  cranium 
ccmolidate  early  in  li^e  the  fore  part  of  the  skull  cannot  in- 
crease ia  capacity  beyond  the  size  it  had  reached   in   in- 


1. 

2. 

3. 

4. 

5. 

6. 
7. 

8. 

9. 

10. 

11. 

12. 
13. 
14. 


fancy.  Deneker  has  shown  that  ia  c  n  equence  of  the 
early  cljsur3  of  the  anteiior  suture?  of  the  skull  of 
anthropoid  ape?  the  fo-e  part  of  their  brain  does  not 
increise  beyond  the  size  it  had  attained  at  the  eni 
of  the  first  year  of  life,  but  in  man  these  sutures  do  not  con- 
solidate until  a  much  later  period,  so  that  the  anterior  lobes 
of  his  brain  are  enabled  to  become  far  more  perf-ctly  devel- 
oped than  the  correspondent  lobes  among  apes.  Men  of  the 
same  bulk  have  4  times  as  much  superficiil  brain-surface  as 
anthropoid  apes.  Whatever  functions  the  anterior  Icbes  of 
the  brain  perform,  their  cortical  nerve  elements  in  conjunc- 
tion with  those  of  the  other  lobes  of  the  brain  control  to  a 
large  extent  our  higher  intellectual  faculties.  If  we  com- 
pare the  skull  of  an  Englishman  with  that  of  one  of  the 
natives  of  Australia  a  wide  d  fference  may  be  noted  between 
the  development  of  their  frontal  regions  and  also  as  the  nature 
of  the  sections  of  many  of  their  skulls.  Schwalbe  has  arrived 
at  the  conclusion  that  the  Java  skull,  taking  its  capacity  and 
form  into  consideration,  is  on  the  border  line  between  that 
of  man  and  anthropoid  apes.  Until  the  J  iva  skuU  was 
found,  the  earliest  known  human  skulls  had  a  cranial 
capacity  of  about  1220  cu.cm.  The  postorbital  index  or 
narrowing  of  the  Java  skull  is  19  3,  as  compared  with  the 
average  of  living  Europeans,  which  is  12.  The  anterior  sur- 
face of  the  lower  j  iw  among  the  existing  races  of  E  irope 
projects  to  form  the  chin.  Among  apes  the  reverse  is  the 
case,  for  the  anterior  surface  of  their  mandibles  recedes. 
[w.A  N  D  ] 

2. — In  his  second  lecture  on  the  surgery  of  pregnancy 
and  of  labor  complicated  with  tumors,  B  and  Sutton 
treats  of  the  coexistence  of  pregnancy  and  fibroids,  and 
presents  illustrative  cases  of  this  complication.  He  remarks 
that  the  impaction  of  the  uterus  with  fibroids  secondary  to 
conception  is  not  only  responsible  for  pain,  and  in  a  certain 
proportion  of  cases  to  retention  of  urine  from  direct  pressure 
on  the  urethra,  but  it  probably  accounts  for  the  frequency 
with  which  abortion  occurs  under  these  conditions,  and  it  is 
interesting  to  observe  how  even  a  relatively  small  fibroid  will 
impede  the  ascension  of  the  uterus  as  it  enlarges  during 
pregnancy  and  gives  rise  to  much  trouble.  Tne  tumor  may 
likewise  obstruct  delivery  when  the  pregnancy  grows  to  full 
term.  Septic  endometritis  is  rendered  more  serious  when 
the  infected  uterus  contains  fibroids.  Necrosis  and  conse- 
quent gangrene  of  the  fibroid  arises  usually  from  irjury,  and 
may  even  result  from  the  efforts  of  the  utenis  itself  to  expel 
the  pedunculated  tumor.  It  does  not  necessarily  follow  that 
in  every  parturient  woman  with  a  fibroid  the  tumor  becomes 
septic  In  cases  complicated  by  tumor  which  have  reached 
term,  if  the  growth  cannot  be  pushed  cut  of  the  pelvis, 
cesarean  section  should  be  performpd.     [w  a  n.d  ] 

3.— Klein,  in  an  artii'le  entitled  Remarks  on  aggluti- 
nation by  plague  blood,  states  that  unfortunately  the 
plague  bacilli  show  a  tendency  to  adhere  together  in  broth 
cultures  which  vitiates  the  agglaiination  test  when  this 
media  is  employed.  1 1  the  cultures  upon  agar,  glycerin  agar 
or  serum  the  plague  bacilli  produce  a  sticky,  intercellular 
substance.  After  a  number  of  attempts  at  securing  a  good 
emulsion  of  the  plague  bacilli,  the  author  finally  tried  the 
following:  Tae  grow  h  upon  gelatin  (which  is  somewhat 
drier  than  the  growth  upon  other  artificial  cullu-e  media)  was 
mixed  ni'h  a  physiological  salt- solution.  This  solution  has  the 
property  oT  dissolving  globulin.  With  this  method  a  uniform 
distribution  of  the  bacilli  was  brought  about.  The  author 
found  that  by  adding  bouillon  in  the  proportion  of  1  to  20 
(■•f  the  emulsion)  agglutination  took  place  in  from  12  to  20^ 
minutes.  Eren  with  the  dilution  of  1  to  40  this  occurred. 
This  demonstrates  the  uselessnees  of  the  agglutination  test 
wh^n  using  a  bouillon  culture  of  plague  bacilli.  Normal 
human  blood  and  normal  mouse's  blood  mixed  in  the  pro- 
portion of  1  part  of  blood  to  20  parts  of  emulsion  failed  to 
give  the  agglutination  test  even  after  24  hours.  He  next 
injected  rats  with  Haffkine's  prophylactic  and  then  with 
living  plague  cultures.  In  all  the  animals  slight  tubo  forma- 
tion was  noted  and  a  general  illness  was  produced,  but 
recovery  followed.  After  2  or  3  weeks  the  blood  of  these 
^at^  was  tested,  and  agglutnat'on  was  present.  The  ant'ior 
concludes  by  saying  that  the  agglut  niton  test  is  positive 
with  the  blood  of  an  animal  convalescent  from  plague,  hut 
from  his  own  experience  he  cannot  mak^  the  same  state- 
ment in  regard  to  the  blood  of  a  human  individual  conva- 
lescing from  this  disease,     [fj.k.] 


March  9   1901 ) 


THE  LATEST  LITERATURE 


rXHK  Philadelphia 
L  Medical  Jookhal 


465 


4. — Wherry  discusaes  the  subject  of  asymmetry  in  both 
upper  and  lower  extremities  in  the  lower  animals  as  well  as 
in  man.  He  argues  that  by  proper  exercise  of  a  short  limb 
its  growth  can  be  encouraged  and  oftentimes  its  length  in- 
creased. He  thinks  it  is  a  mistake  to  simply  put  a  high- 
heeled  shoe  on  a  short  limb  and  allow  the  patient  to  go 
through  youth  without  any  attempt  being  made  to  develop 
the  part,     [j.h  g] 

5. — Fawcett  and  Pakes  report  an  interesting  case  of 
subacute  glanders  occurring  in  a  man,  45  years  of  age, 
in  whom  the  clinical  symptoms  were  not  very  marked  but 
the  bacteriological  examination  positive.  The  patient  had  a 
number  of  subcutaneous  swellings,  a  few  small  furuncles,  a 
small  abscess  in  the  left  forearm,  and  flaid  in  the  knee  j^int. 
There  were  no  typical  ulcers  of  the  skin,  no  bullous  or  pus- 
tular eruptions,  no  rhinorrhea,  and  no  intramuscular  ab- 
scesses. The  patient  died  and  postmortem  the  heart,  blood, 
spleen,  and  fluid  of  the  kneejomt  gave  cultures  of  the  bacil- 
lus mallei.  The  culture  injected  in  a  guineapig  produced 
the  disease,     [j  H  G  ] 

6. — Thursfield  reports  17  cases  of  posterior  basic 
meningitis  which  occurred  between  the  period  of  July, 
1899,  to  August,  1900,  in  the  medical  wards  at  Great  Ormond 
Street.  In  12  the  diagnosis  was  confirmed  by  autopsy.  Two 
cases  were  not  examined  after  death,  one  was  transferred 
from  the  wards  during  the  course  of  the  disease  on  account 
of  intercurrent  diphtheria,  and  2  cases  recovered.  The  bac- 
teriological examination  in  nine  instances  showed  that  in  8 
of  these  an  intracellular  diplococcus  was  present  in  the  exu- 
date. In  5  cases  inoculations  were  made  upon  artificial 
media,  6  giving  rise  to  a  distinct  growth  which  was,  however, 
always  of  1  )w  vitality.  In  1  of  the  cultures  a  mixed  infec- 
tion was  found.  The  principal  clinical  features  were  the  fol- 
lowing :  Seven  of  the  cases  occurred  in  'emales,  10  in  males. 
The  average  age  was  9  months,  excluding  4  cases  which 
occurred  in  their  fourth  year  and  over.  In  the  latter  cases 
there  was  some  difficulty  in  making  a  diagnosis.  The  onset 
of  the  disease  was  marked  by  retraction  of  the  head  in  3 
cases,  vomiting  in  9,  convulsions  in  4,  and  bulging  of  the 
fontanels  in  6  cases.  S  joner  or  later  retraction  of  thi^  head  ap- 
peared in  all  of  the  cases.  This  is  considered  one  of  the  cardi- 
nal symptoms.  The  author  next  mentions  a  case  of  retraction 
of  the  head  which  at  the  autopsy  did  not  show  signs  of  men- 
ingitis. Of  the  ocular  symptoms  he  frequently  noted  early 
strabismus  and  nystagmus.  In  13  out  of  the  17  cases  changes 
in  the  fundus  were  observed,  and  amaurosis  was  seen  in  7 
cases.  Retraction  of  the  upper  lid,  which  occurred  in  7  in- 
stances, is  regarded  as  the  most  constant  and  characteristic 
ocular  symptom  of  posterior  basic  meningitis.  Vomiting 
and  rapid  progressive  emaciation  were  present  in  all  of  the 
cases.  The  other  remaining  symptoms  are  those  common 
to  other  forms  of  meningitis.  He  mentions  that  a  clinical 
feature,  sometimes  present  in  posterior  meningitis,  is  hydro- 
cephalus, and  involvement  of  the  joints.  The  sudden  onset, 
the  head  retraction,  the  rapid  emaciation  and  the  chronic 
course  render  the  diagnosis  easy  as  a  rule.  Leukocytosis 
was  found  in  the  more  acute  form,  while  in  the  chronic 
variety  the  number  of  leukocytes  was  normal.  Lumbar 
puncture  was  performed  once  for  diagnostic  purposes.  The 
treatment  that  was  instituted  he  believes  was  ineffective.  In 
conclusion  he  mentions  that  there  are  a  number  of  clinical 
varieties  of  this  disease,  the  variation  depending  largely 
upon  the  age  of  the  patient  and  the  virulence  of  the  toxin. 
[fjk] 

7.— Fenwick  thinks  that  sarcoma  of  the  stomach  is 
much  more  frequent  than  is  commonly  supposed  and  that  it 
is  frfquently  mistaken  for  carcinoma.  He  thinks  that  it 
constitutes  probably  from  5  to  8%  of  all  primary  neoplasms 
of  the  stomach.  The  round-cell  sarcoma  is  the  most  fre- 
quently seen  variety  occurring  in  the  stomach  and  the 
spindle-cell  or  fibro-sarcoma  is  next  in  frequency  ;  these  latter 
growths  sometimes  reach  an  enormous  size  and  are  not  in- 
frequently pedunculated.  Myosarcomata  are  rare  in  the 
stomach,  but  they  frequently  reach  enormous  size  and  some- 
times undergo  cystic  degeneration.  Angiosarcoma  is  very 
rare  indeed.  All  varieties  of  sarcomata  are  apt  to  have 
secondary  growths  arising  in  organs  more  or  less  remote  from 
the  primary  disease.  Sarcomatous  nodules  are  frequently 
present  in  the  skin  of  the  abdomen.  In  almost  all  cases  the 
lymphatic  glands  of  the  stomach  are  enlarged  and  sometimes 
the  retroperitoneal,  mesenteric,  and  mediastinal  glands  are 


enlarged.  The  elongated  nodular  epigastric  tumor  so  fre- 
quently seen  in  carcinoma  of  the  stomach  and  due  to  the 
involvement  of  the  omentum  is  absent  in  sarcoma  of  the 
stomach.  In  about  15%  of  the  cases  of  round  cell  sarcoma 
the  spleen  is  considerably  enlarged.  Perforation  of  the 
stomach  is  much  more  frequent  in  sarcoma  than  in  carci- 
noma. Toe  two  conditions  have  twice  been  found  associated. 
Leukocytosis  is  not  infrequently  present  in  cases  of  sarcoma 
of  the  stomach.  Diarrhea  is  a  noticeable  feature  in  the 
round  cell  type.  Hematemesis  is  not  often  a  prominent 
symptom  in  round- cell  sarcoma.  The  Oppler-Bjas  bacillus 
has  been  demonstrated  in  these  case.  Unless  the  pylorus  is 
involved  death  usually  occurs  from  exhaui'tion,  though 
sometimes  from  perforation  and  peritonitis.  The  formation 
of  a  perigastric  abscess  is  rare  because  adhesions  are  not  apt 
to  form  before  perforation  takes  place.  In  many  cases  of 
sarcoma  of  the  stomach  there  is  a  slight  but  continuous 
pyrexia,     [j  h  g.] 

8. — E  lison  reports  the  case  of  a  man  who  presented  him- 
self with  a  foreign  body  protruding  from  the  abdomen  and 
whi?h  on  removal  proved  to  be  a  portion  of  a  hemostali; 
forceps.  This  had  been  left  in  the  patient's  abdomen  after 
an  operation  done  8  years  before,     [j  h.g.] 

9, — Borland  describes  a  case  of  cephalhematoma  in 
which  there  was  no  el^-vation  of  temperature,  no  dyspnea, 
and  no  cerebral  complications.  There  was  aho  no  history 
of  hemophilia,     [w.a.n  d  ] 

lO.— Rolleston  reports  a  case  of  primary  carcinoma 
of  the  ampulla  of  Vater.  The  patient  was  a  man,  6t> 
years  of  age,  and  was  admitted  to  the  hospital  deeply 
jaundiced,  with  an  enlarged  liver  and  gallbladder,  and  with 
some  tenderness  over  these  organs,  but  no  abdominal  dis- 
tention or  ascites.  The  urine  contained  albumin  and  bile 
but  no  sugar.  Oa  the  fourth  day  after  admission  the  patient 
suddenly  went  into  a  collapse  and  died  within  18  hours.  At 
the  necropsy  it  was  found  that  the  duct  formed  by  the  union  • 
of  the  common  bile  duct  and  the  duct  of  the  pancreas  was 
the  seat  of  a  carcinoma  completely  obstructing  its  caliber. 
The  hepatic  cystic  ducts  and  the  gallbladder  were  greatly 
distended  and  the  liver  enlarged.  There  was  a  large  cystic 
dilation  of  the  pancreatic  duct  which  contained  recent  blood- 
clot.  R  )lIeston  thinks  that  the  cause  of  death  in  this  case 
was  acute  pancreatitis  with  hemorrhage,    [j  h.g.] 

11. — Jordan  recommends  the  use  of  a  solution  of  for- 
malin and  glycerin,  the  strergth  of  the  formalin  vary- 
i  g  from  1%  to  4%,  and  he  adds  t'lat  t"ie  fo'ution  shoili 
always  be  fie  h'y  prepar  d.  It  is  recommer.ded  (I)  in  throat 
affeotio-^s,  such  as  t^nsillilis,  diphtheria, and  f  rtheery'.hem- 
atous  sora  throat  of  scarlet  fevor;  (2)  as  a  mouth  wash  in 
virioua  forms  of  stomatitis;  (3)  i  i  parasit'c  affections  of  the 
skin  such  as  tinea  tonsurais;  and  (4)  as  a  urathral  injection 
Th-^  author  cured  a  ewe  of  acute  gonorrhea  byal%  for- 
miliu  glycerin  sclati  m.  He  is  net  prepxred  to  advi  e  its 
g(n=ral  use  as  a  urethral  injection  on  account  of  the  pvin 
and  s-velling  of  the  mucous  membraoe  wh  ch  follows  its 
application. 

13.— Wilson  sfa'.es  his  belief  in  the  possibility  of  the  con- 
di  i  n  of  the  mother  ment .ally  and  otherwise  affectirg  the 
fetus  in  uteri,  and  givfs  anint'^resting  illustration  of  mater- 
nal impressions  in  1  jwer  life,  the  deformiiy  occurring  in  a 
bush-bock  ewe  (Tragelaphxis  sylvaticus).     [w.a.n  d.] 

14.— Coates  gives  a  report  of  an  outbreak  of  typhus 
fever  in  Manchester.  The  Health  Officer  of  Manchester 
was  informed,  on  January  8,  of  the  illness  of  7  women  and  a 
boy,  who  were  employed  in  a  rag  sorting  establishment.  It 
was  found  that  the  disease  was  typhus  fever.  In  this  estab- 
lishment 14  women  were  employed,  working  in  two  rooms. 
In  one  room  woolen  rags  were  sorted,  while  in  the  other 
cott^n  rags.  Of  those  stricken  with  the  disease  all  had 
handled  the  woolen  rags  and  no  case  developed  in  those  who 
handled  the  cotton  material.  The  disease  in  the  eight 
occurred  between  the  20.h  and  24th  of  December.  The  sud- 
den onset  was  marked  by  chills,  psiin  in  the  back  and  limbs, 
headache,  and  in  some  vomiting.  In  3  a  measly  rash  devel- 
oped. In  5  who  recovered  the  illness  terminated  by  crisis. 
The  infection  seemed  to  spread  from  this  focus.  Up  to  Jan- 
uary 10,  33  cases  with  8  deaths  were  reported.  On  February 
1  a  case  was  reported,  the  infection  of  which  was  traced  to 
June,  1900.  The  total  number  of  cases  from  June  to  Febru- 
ary 1  was  53.  The  management  of  the  outbreak  consisted 
in  removing  the  patients  to  the  HospiUl  for  Infectious  Dis- 


464 


The  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Mascb  9,  IMH 


eases,  disinfection  of  the  infected  houses,  isolation  of  those 
who  came  in  contact  with  the  sick  for  two  week?,  house-to- 
house  inspection,  dirty  and  filthy  quarters  were  disinfected, 
and  the  rag-sorting  establishment  from  which  the  epidemic 
probably  originated  was  also  disinfected,     [t.l.c] 


'    New  York  Medical  Journal. 

March  S,  1901.     [Vol.  Ixxiii,  No.  9.] 

1.  The  Axis-traction    Forceps,  with  Special  Reference    to 

Rotary  Axis-traction  in  the  Treatment   of  Posterior 
Positions  of  the  Anatomical  Head.    Simon  Maex. 

2.  Metrorrhagia  Due  to  Inflammatory  Processes  Within  the 

Pelvis.    Edwin  B.  Ceagin. 

3.  The  Pathology  of  Intrauterine  Death.    Neil  Macphatter. 

4.  The  Electrochemical  Action  of  the  X-Rij-s  in  Tubercu- 

losis.    J    RUDIS  JlCINSKY. 

5.  The  Palliative  Operative  Treatment  of  Carcinoma  of  the 

Poiterior  Wall  of   the  Stomach.     Albert  Vander- 
Veer. 

6.  Cancer  of  the  Uterus.    Andrew  F.  Cueeier. 

7.  Hemorrhage  from  a  Circumtonsillar  Abscess.    Walter 

F.  Chai'pei.l. 

1. — Simon  Marx  makes  a  plea  for  more  recognition  and 
more  frequent  employment  of  the  axis- traction  forceps. 

In  his  experience  he  has  found  the  axis-traction  forceps  of 
Tarnier  to  be  of  great  value  where  posterior  positions  of  the 
head  present.  The  length  of  the  forceps  which  render  steril- 
ization difficult  is  one  of  the  objections,  but  according  to  the 
author,  this  can  be  obviated  by  using  a  baby's  bathtub  as  a 
sterilizer.  In  unskillful  hands  there  is  more  danger  of  slip- 
ping than  with  the  ordinary  forceps.  The  danger  of  diefi  iure- 
ment  can  be  overcome  by  entirely  dispensing  with  the  fixa- 
tion screw.  It  having  been  shown  that  the  blades  are  kept 
in  place  by  the  pelvic  structures  and  the  impact  from  the 
fetal  head,  the  screw  can  be  discarded.  When  employing 
the  Tarnier  forceps,  unlike  with  ordinary  lorceps,  influence 
upon  moulding,  rotation  and  descent  of  the  head  does  not 
have  to  be  exerted  by  a  purchase  upon  the  handles,  and  by 
traction  and  pressure  on  the  head  ;  the  handles  of  the  for- 
ceps are  not  interfered  with,  and  are  simply  employed  as  an 
index  of  the  position  of  the  head  and  as  an  indicition  in 
which  direction  t-acion  is  to  lie  made.  The  force  cf  ex'rac- 
tion  being  directly  exercised  upon  the  cross  bar  attachtd  to 
the  tractioa  rods,  rolation  can  then  occur.  In  employing 
ordinary  foicsps  to  the  head,  the  more  powerful  the  extrac- 
tion force  the  greater  the  compression  upon  the  skull ;  this 
is  overcome  in  the  axis-traction  forceps  where  extraction  is 
applied  to  and  from  the  cross-bar.  The  savicg  of  exertion 
on  the  part  of  the  operator,  according  to  the  author,  is  the 
greatest  advantage  possessed  by  the  Tarnier  forceps.  The 
handles  of  the  instrument  must  be  taken  as  a  guide  as  to 
the  direction  of  traction,  no  matter  what  their  position, 
otherwise  pulling  directly  backward  as  is  done  in  employing 
the  ordinary  instruments  may  cau^e  an  improper  leverage, 
and  the  forcep.s  may  be  directly  pulled  off.  The  author  has 
given  the  name  rotary  axis  traction  to  a  procedure 
which  combines  ax's  traction  and  artilioial  rotation.  He 
states  that  as  rotation  in  the  majority  c  f  cases  occurs  at  the 
pelvic  floor,  he  ha?  fre(|uently,  in  occiput  posterior  positions, 
succeeded  in  rotating  the  hesd  anterloily  by  making  axis- 
traction,  and  relying  upon  the  resistance  of  the  pslvic  ttrac- 
tures  and  that  afforded  by  the  ischial  spines.  The  Tarnier 
forceps  by  their  fic3  mobility  rotat(»  with  the  head  and 
nature  ciu  thus  be  as-):s'cd  by  rotary  axii  (r,ictioa.  He  pre- 
ferably applies  the  blades  so  that  ihay  are  in  one  cf  the 
oblique  diameters  of  the  pelvis.  Traction  is  made  with  the 
right  hacd  and  wi  h  the  left  by  gentle  rotation,  the  forceps 
are  influenced  to  turn  ia  the  direction  of  the  presenting  part. 
The  author  refers  to  one  of  h  s  previous  articles  in  which  he 
quotes  the  following:  "To  my  ni'nd,  there  are  no  instru- 
ments that  we  are  called  upon  to  use  which  are  more,  if  I 
might  fay,  intelligent  than  thes3.  They  are  ttrength-saving 
to  the  accoucheur,  sife  for  the  mother,  and  eminectly  more 
safe  for  the  child.  Whilst  they  hjve  much,  very  much,  in 
their  favor,  yet  there  are  certain  objections  to  their  use  which, 
in  a  great  measure,  cannot  be  overcome,  and  these  objec- 
tions do  not  all  hold  good,  since  they  apply  with  equal  force 
to  the  ordinary  cbjtelric  forceps."     [m.r.d.] 


2. — Cragin  remarks  that  in  the  discussion  of  the  etiology 
of  metrorrhagia  due  lo  inflammatory  processes  within 
the  pelvis,  three  factors  must  be  considered  :  (1)  The  endo- 
metrium ;  (2)  the  muscular  wall  of  the  uterus ;  (.3)  the  blood- 
vessels of  the  uterus.  Hemorrhage  is  so  slight  in  amount 
during  an  acute  endometritis  that  this  disease  may  be 
dismissed  as  a  common  cause  of  metrorrhagia.  With 
chronic  endometritis,  however,  metrorrhagia  is  commonly 
associated,  and  in  this  condition  the  endometrium  is  rough 
and  hyper  trophied.  The  two  conditions  most  commonly  inter- 
fering with  the  normal  contractions  of  the  uterine  muscle 
in  the  nonpregnant  ttite  are :  (1)  Tumors  of  the  uterine 
wall ;  (2)  chronic  interstitial  inflammation  of  the  uterine 
wall  in  which  there  is  atrophy  of  the  muscular  tissue  and 
an  increase  of  new  connective  tissue.  Although  both  of 
these  conditions  most  often  produce  metrorrhagia  through 
the  mediam  of  a  chronic  endometritis,  occasionally  the 
endometrium  eeems  but  slightly  involved  and  the  bleeding 
appears  to  be  caused  by  a  lack  of  sufficient  elasticity  in  the 
uterine  muscle,  due  to  interference  with  the  normal  mus- 
cular contraction.  Interference  with  the  normal  contrac- 
tion of  the  arteries  themselves  favors  the  development  of 
metrorrhagia.  Thus,  a  condition  of  arterial  sclerosis  occa- 
sionally is  noted  at  or  near  the  time  of  the  menopause, 
which  results  in  an  insufficient  elasticity  of  the  vessels  either 
to  maintain  the  normal  balance  of  uterine  circulation  or  to 
check  the  flow  beginning  at  the  menstrual  period.  Conse- 
quently, a  metrorrhagia  will  be  produced.  If  the  bleeding 
be  associated  with  an  absence  of  hypertrophied  endome- 
trium, or  if  it  persist  after  repeated  curettage,  hysterectomy 
may  be  justified,     [w.a.n.d  ] 

3. — To  be  abstra'^ied  when  article  is  completed. 

4. — J.  Kudis-Jicinsky  di?cusees  the  electrochem- 
ical action  of  the  x-rays  in  tuberculosis.  The  appli- 
cation of  the  x-ray  to  early  cases  of  tuberculosis  is  highly 
recommended  by  certain  authorities.  The  author  has  found 
in  certain  early  cases  of  the  disease,  on  i-ray  examination,  a 
slight  haziness,  indicating  the  beginning  of  tuberculous  infil- 
tration in  the  apices.  He  has  not  only  attacked  the  seat  of 
the  disease  by  x-ray  treatment,  but  has  placed  his  patients  in 
pure  air,  at  suitable  temperature,  and  in  good  hygienic  sur- 
roundings. The  exposure  varies  in  these  cases  from  10  to  15 
minutes  at  each  sitting.  The  rays  are  to  be  observed  with  the 
fluoroscope  at  each  exposure,  the  tube  tested  to  see  that  it  ia 
working  at  its  best,  and  the  apparatus  must  be  under  full 
control  of  the  expert,  who,  with  the  help  of  the  x-ray,  is 
enabled  to  determine  the  limitations  of  the  diseased  portion 
of  the  lung.  His  results  have  been  most  encouraging,  and  he 
urges  that  this  method  of  treatment  should  receive  more 
attention  in  all  curable  cases,    [t.lc] 

6 — Albert  Vander  Veer  reports  four  cases  in  which 
the  palliative  operative  treatment  of  carcinoma  of 
the  posterior  wall  of  the  stomach  was  performed. 
From  these  cases  he  summarizes  as  follows :  Continued  gas- 
tric disturbances  that  do  not  yield  to  medical  treatment 
should  undergo  careful  examination  as  to  the  possibility  of 
malignancy  being  present.  Even  in  cases  where  a  positive 
diagnosis  of  malignancy  is  not  made,  and  the  patient  con- 
tinues to  emaciate  and  the  suffering  increases,  he  advoc^atea 
an  exploratory  incision,  and  if  there  is  no  malignant  growth 
a  gastrointestinal  anastomosis  should  he  made,  as 
recommended  by  Dr.  Weir.  Malignant  growths  in  the 
posterior  wall  of  the  stomach  are  more  difficult  to  diag- 
nose and  sometimes  escape  the  notice  of  the  most  careful  dii^- 
nostician.  When  an  exploratory  incision  has  been  made 
and  a  malignant  growth  is  found  in  the  posterior  walls  of 
the  stomach,  with  no  possibility  of  removal,  by  resection  or 
otherwise,  although  quite  deep,  yet  he  believes  that  the 
patient  should  submit  to  a  gastrointestinal  anastomoais. 
Finally  he  recommends  that  the  blood  of  such  patienta 
should  be  examined  most  carefully,     [t.l.c] 

7. — Walter  F.  Chappell  reports  a  case  of  hemor- 
rhage from  a  circumtonsillar  abscess.  Chappell 
finds  10  cases  reported  in  the  literature  with  2  recwveriee. 
His  own  case  recovered.  He  believes  that  the  spent  ineoua 
rupture  of  the  tonsillar  abscess  in  all  these  c^a8es  is  very  sug- 
gestive, and  expresses  the  opinion  that  an  early  incision 
would  have  prevented  the  extensive  ulceration  which  impli- 
cated one  of  the  large  vessels.  Immediate  ligation  of 
the  carotid  on  the  occurrence  of  tue  first  hemorrhage 
should   be   practised,  or  a  free   incision    through   the 


Makch  'J,  1901] 


THE  LATEST  LITERATURE 


The  Philadelphia"] 
Medical  Journal  J 


465 


anterior  wall  of  the  soft  palate  and  firm  packing  of  the 
abscesa  with  antiseptic  gauze.  The  latter  method  was 
followed  Bucceasfully  in  his  case,     [t.l.c] 


Medical  Record. 

March  S,  1901.    [Vol.  59,  No.  9.] 

1.  The  Treatment    of   Kheumatic  and  Allied   Diseases  of 

Joints  Complicated  by  Delormity.    Virgil  P.  Gibney. 

2.  An  Improved  Method  of  Examining  the  Female  Bladder, 

Admitting  Intravesical  Operations  and  Treatment  of 
the  Ureters.    William  R.  Pryor. 

3.  Some  Facts    Regarding    "  Ureine."      A.    F.  Chace  and 

William  J.  Gies. 

4.  A  Method  of  Reducing  Dislocations  of  the  Thumb.  John 

F.  Erdmann. 

5.  Tuberculosis  in  Prisons  and  Reformatories.    S.  A.  Knopf. 

1.  — Gibuey  of  New  York  reports  22  cases  of  rheumatic 
and  allied  diseases  of  joints  complicated  by  de- 
formity. He  states  that  his  experience  with  the  hot-air 
treatment  in  multiple  arthritis  with  deformity  has 

been  disappointing.  There  is  usually  a  temporary  relief,  but 
relapses  occur  in  which  the  deformity  must  be  corrected 
under  an  anesthetic,  and  prolonged  use  of  plaster  of  Paris. 
In  conclusion,  Gibney  states  that  it  is  difficult  to  fix  upon 
any  one  form  of  treatment  that  has  yielded  the  best  re- 
sult, but  he  commends  the  forcible  breaking  up  of 
adhesions  when  inflammatory  conditions  have  subsided, 
the  frequent  recurrence  to  these  operations  and  the  dis- 
criminate use  of  plaster  of  Paris.  Eich  year  his  belief 
grows  stronger  in  the  efficiency  of  absolute  immobiliza- 
tion as  a  promoter  of  absorption  of  chronic  in- 
flammatory products.  He  commends  also  the  pro- 
tection of  joints  with  a  limited  rangre  of  motion 
by  apparatus  within  the  bounds  of  this  motion. 
Recently  he  has  attempted  the  correction  of  deformity  in  a 
rigid  spiae  by  extension  with  moderate  force,  and  his  result 
up  to  this  writing  is  gratifying.  The  apparatus  employed  is 
that  used  in  the  correction  of  the  bones  in  the  deformity  of 
Pott's  disease  and  is  employed  without  an  anesthetic,  [t.l  c] 
2. — William  R.  Pryor  presents  an  improved  method  of 
examining  the  female  bladder,  admitting  intravesical  oper- 
ations and  treatment  of  the  ureter.  His  cystoscope  con- 
sists of  a  main  tube  for  inspection,  alongside  of  which  is 
attached  a  smaller  tube  for  carrying  a  lamp  and  the  stand 
which  holds  it.  The  tube  for  illumination  extends  beyond 
the  tube  for  inspection  and  consequently  the  rays  of  light 
project  beyond  and  outside  the  tube  for  inspection,  no  rays 
entering  the  latter.  The  light  illuminates  100°  of  the  blad- 
der circumference,  260°  being  in  the  shadow.  The  heat  from 
the  light  is  taken  up  from  the  metal  of  the  tube,  the  lamp, 
lamp-holder,  and  wiies  are  completely  insulated,  neither 
urine  nor  other  fluids  can  short-circuit  the  current  when  this 
apparatus  is  connected.  The  advantages  he  claims  for  the 
instrument  are  a  tube  for  inspection  free  from  obstruction 
and  free  from  light-rays,  either  direct  or  reflected ;  tlie 
absence  of  necessity  for  focussing  rays  of  light  which  em- 
barrass the  operator  in  his  maneuvers  when  a  head-mirror 
or  lamp  is  employed;  the  passage  of  the  rays  of  light  di- 
rectly to  the  object  to  be  inspected;  and  lastly,  the  perfect 
ease  with  which  demonstrations  can  be  made;  absence  of 
heat;  absence  of  urine  about  the  trigone;  absence  of  the  ne- 
cessity for  pumping  out  urine.  The  bladder  assumes  the 
shape  of  an  open  equilateral  triangle  with  rounded  corners. 
The  advantage  of  this  posture  over  the  knee-chest  is  due 
chiefly  to  the  straight  lines  which  the  vaginal  segment  (in 
which  the  ureteral  orifices  are  found)  and  the  pubic  segment 
assume.  He  first  examines  the  ureteral  orifices  and  the 
trigonum,  for  there  we  find  the  most  of  the  lesions.  He 
then  sweeps  the  instrument  over  the  lateral  vesical  walls 
and  by  turning  the  handle  down  the  light  illuminated  the 
pubic  segment.  In  catheterizing  the  ureters  for  the  purpose 
of  securing  separate  specimens  in  ureteral  and  kidney 
lesions  he  has  been  able  to  secure  sterile  urine  from  both 
ureters  even  when  an  acute  cystitis  existed.  He  first  detailed 
the  objections  to  the  ordinary  methods  of  examination  and 
then  advocates  placing  the  patient  on  her  back  in  the  lithot- 
omy position.  He  dilates  the  ureter  with  a  30  or  SG  (French) 
straight  sound,  but  states  that  no  dilatation  is  needed  when 


the  smaller  tube  of  the  endoscope  is  used  with  cocain.  He 
next  proceeds  to  introduce  the  obdurated  speculum  and 
evacuates  the  urine.  The  table  is  then  lowered  to  the 
requisite  angle  usually  to  about  45°.  The  uterus  now  sinks 
away  from  the  pubis  and  drags  with  it  that  portion  of  the 
bladder  which  is  covered  by  that  portion  of  the  peritoneum. 
[t.lc] 

3. — A.  F.  Chace  and  William  J.  Gies  present  a  com- 
prehensive criticism  of  the  recent  paper  by  Dr.  William 
Ovid  Moor  upon  the  discovery  of  ureine,  the  principal 
organic  conttituent  of  urine  and  the  true  cause  of  uremia. 
From  the  laboratory  of  physiological  chemistry  of  Columbia 
University  at  the  College  of  Physicians  and  Surgeons  of  New 
York.  The  fact  has  long  been  known  that  normal  urine 
contains  substances  of  a  very  toxic  character.  Potassium 
compounds  are  prominent  among  these,  but  more  poison- 
ous still  are  the  various  organic  bodies  of  an  alkaloidal 
nature,  present  in  only  minute  proportions.  These  writers 
believe  that  Moor's  method  of  preparing  ureine  fails  to  elimi- 
nate comnletely  either  potassium  salts  or  the  normal 
basic  alkaloidal  bodies  giving  the  typical  reactions  with 
potassium  ferricyanid  and  ferric  chlorid,  and  the 
toxicity  ascribed  to  ureine  must  be  referred  at  least  in  part 
to  these  substances  dissolved  in  it.  Summing  up  they  state  : 
Ureine  is  not  a  chemical  individual.  It  is  a  mixture  con- 
taining several  of  the  organic  substances  and  a  considerable 
proportion  of  inorganic  salts  ordinarily  found  in  normal 
urine.  Further,  its  toxicity  can  be  referred  to  some  of  these 
normal  urinary  constituents,     [t.l  c] 

4. — Erdmann  reviews  the  various  causes  of  irreducible 
dislocations  of  the  thumb  and  suggests  a  method  of 
reduction  which  he  ha?  never  failed  to  find  successful.  It 
consists  of  manipulation  and  is  free  from  all  danger  to  the 
parts.  The  two  thumbs  of  the  operator  are  placed  over  the 
dislocated  end  of  one  of  the  bones  and  the  forefinger  over 
the  other.  By  pressure  the  dislocation  is  reduced.  The 
article  is  illustrated  by  photographs  showing  the  method  of 
reduction,    [j  h  g.] 

5.— S.  A.  Knopf  discusees  the  subject  of  tuberculosis  in 
prisons  and  reformatories.  He  believes  the  spread  of  infec- 
tion should  be  prevented  by  separating  the  tuberculous 
prisoner  from  the  nontuberculous  in  the  workshop  as  well  a^ 
the  cell.  He  urges  the  necessity  of  careful  physical  exami- 
nation of  each  prisoner  on  admission,  which  should  include 
the  bacteriological  examination  of  the  sputum,  and  advises 
that  they  thould  be  reexamined  every  3  months.  This 
should  not  be  confined  to  prisoners  alone,  but  should  be 
obligatory  for  wardens,  iieepers,  officials,  and  help.  He  sug- 
gests tiie  feasibility  of  forming  convict  camps,  as  has  been 
done  in  Alabama,  and  advises  the  patients  to  be  carefully  in- 
structed as  to  the  danger  in  coughing  and  spitting  upon  the 
floors  and  corridors.  He  goes  so  far  as  to  recommend  that 
all  tuberculous  patients  should  be  forced  to  wear  mouth- 
masks.  Hygienic  surroundings  must  be  provided.  The 
author  in  conclusion  wisely  remarks  that  we  must  not  over- 
look the  fact  that  these  tuberculous  patients  will,  in  many 
cases,  soon  be  at  liberty  in  their  dis  aaed  state  and  act  aa 
agents  for  the  spread  of  tuberculosis,    [t.l  c] 


Medical  News. 

March  2,  1901.     [Vol.  Ixxviii,  No.  9.] 

1.  Veratrum  Viride;  Its  Value  in  Some  Conditions  of  Tox- 

emia.     A.  B    ISHAM. 

2.  The  Treatment  of  Delirium  Tremens  by  the  Intravenous 

Infusion  of  Saline  Solution.    James  P.  Warba?se. 

3.  Yohimbin  and  Its  Salts;  A  New  Aphrodisiac.    Roberts 

Bartholow. 

4.  Thymotal;  A  New  Remedy  for  AnkyloBtomiasis.    J.  E. 

Pool. 

5.  Belladonna  vs.  Scopolia.    Reynold  Webb  Wilcox. 

6.  Immunization   for  Typhoid  Fever;    A  Review.    H.  W. 

McLauthlin. 

7.  Malarial  Fever,  with  Special  Reference  to  the  Value  ot 

Blood  Examinations ;  Report  of  Cases.   Herbert  Old. 

1.— Isham  reports  the  following  cases^  in  which  vera- 
trum viride  was  used  with  marked  benefit :  (I)  Peritonitis ; 
(2)  uremia  ;  (3)  hepatic  colic  from  passing  of  gallstones.  The 
drug  affects  first  the  glandular  system,  including  the  sudo- 


466 


The   PHILiDELPHli"! 
MEDICiL  JotTESAI.  J 


THE  LATEST  LITERATURE 


llLi£CM  ■ 


riferous  and  salivary  glands,  although  the  latter  are  not  so 
much  aflected  if  there  is  profuse  sweating.  The  cells  of  the 
liver  are  undjubtedly  excited  to  increased  activity.  The 
author  thinks  that  activity  of  the  salivary  glands  is  much 
less  important  in  toxemia  than  that  of  either  the  liver  or 
sweat  glands,  although  the  organ  may  exercise  a  very  con- 
siderable power  in  neutralizing  and  removing  leukomaines 
and  toxins.  The  liver  is  a  factor  in  the  conservation  of  life 
nnder  conditions  of  toxemia  which  is  of  great  importance. 
The  re'.ching  and  vomiting  also  indirectly  spur  up  the  liver 
to  increased  secretion,  through  muscular  action  and  siphon 
age.  The  drug's  action  is  thought  to  be  due  to  the  effect 
upon  vasomotor  functions  and  the  exertion  of  some  stimu- 
lating influence  on  the  cells  of  the  liver,  salivary  and  sweat 
glands,     [t.m  T  ] 

2. — According  to  Warbasse,  treatment  of  delirium 
tremens  by  the  intravenous  infusion  of  saline 
solution  accomplishes  the  following :  1.  Increases  the 
amount  of  the  circulating  mediiim  in  which  the  toxic  mate- 
rials are  dissolved,  thertby  diluting  the  poison  and  bathing 
the  nerve  centers  with  a  more  attenuated  solution  of  the 
same.  2.  Tne  amount  of  circulating  fluid  is  increased  above 
the  normal,  so  that  the  excretion  of  fluids  through  all  the 
fluid-excreting  channels  is  increased,  thereby  carrying  cff  in 
solution  much  of  the  contained  toxins.  3.  The  action  of  the 
heart  is  improved  by  the  filling  of  the  relaxed  vessels.  These 
suffice  to  re-tore  the  physiological  equilibrium  and  turn  the 
balance  in  favor  of  recovery,     [t  si  t  ] 

3. — Bartholow,  in  his  experiments  with  yohinibin  on 
animals  indicates  that  it  is  a  central  paralyzer  of  mobility, 
but  not  of  sensibility.  With  the  muscular  paresis  occur 
spasms  of  the  muscles  and  nodding  movements  of  the  head, 
involving  the  neck  muscles.  It  t  fleets  respiration  by  action 
on  the  chest  muscle  and  diaphragm.  Heart  action  is  weak- 
ened by  it,  and  ultimately,  the  organ  is  paraljzed,  stopping 
in  diastole.  The  result  is  due  not  to  peripheral  impres- 
sions, but  to  an  ac.ion  of  the  caidiac  motor  ganglia.  It  is 
not  a  muscular  poison ;  the  muscles  themselves  react  to 
mechanical  and  electrical  excitation.  Dose,  -^  to  -^  grain. 
[t.m.t.] 

4. — Pool  advises  the  substitution  of  thymotal  for  thymol 
in  ankylostomiasis,  based  ou  the  following  reasons : 
(1)  Because  it  is  without  odor,  and  can  therefore  be  taken  by 
children  who  cannot  swallow  p:lU.  At  the  same  time  the 
danger  of  being  sufl"ocated  by  thymol  electuarium,  which 
occasionally  happens  in  infants,  is  avoided ;  (2)  because  it  is 
not  dissolved  in  tbe  stomach,  as  is  thymol,  and  is  not  vomited, 
as  is  often  the  case  with  thymol ;  (3)  because  thymotal  does 
not  cause  giddiness,  as  thymol  does  very  shortly  after  it  is 
taken  ;  (4)  because  the  danger  of  thymol  poisoning  is  reduced, 
especially  to  those  children  whose  bodies  are  weakened  by 
ankylostoma  ;  (5)  because  the  carbonate  of  thymol  is  broken 
up  in  the  body  by  the  influence  of  the  bile  and  the  mucus  of 
the  intestines,  and  thymol  is  formed  exactly  at  the  places 
where  the  ankylostomaa  are  found  in  the  body— i'.  #.,  duo- 
denum and  the  aciiicent  parts  of  the  intestines;  (6)  because 
it  cures  more  rapidly  than  thymol.  Dose :  Adult,  30  grains  ; 
children,  15  grains;  babies,  7.5  grains— 3  to  4  times  a  day. 
Treatment  kept  up  for  4  days,  and  on  fifth  day  a  purgative 
given,     [t.m.t  ] 

6. — Dr.  Mv  Liuthlin,  in  his  article  on  immunization  for 
typhoid  fever,  gives  a  detailed  account  of  Wright's  ob- 
servations of  typhoid  among  inoculated  and  uninoculated  in 
the  British  Indian  Army — period  of  observation,  about  nine 
months;  total  number  of  men  under  observation,  11.295; 
number  inoculated,  2  S35:  number  not  inoculated.  8.460  ; 
number  of  cases  of  typhoid  among  inoculated,  27,  or  0.95%  ; 
number  of  cases  of  typhoid  among  uninoculated,  213,  or  2.5  %  ; 
number  of  deaths  from  typhoid  among  inoculated,  5,  or  0  2%  ; 
number  cf  deaths  from  tvphoii  among  uninoculated,  l3,  or 
0.34%.     [t.mt] 


Boston  Medical  and  Sarg^ical  Journal. 

February  28, 1901.     [Vol.  cxliv,  No.  9.] 

1.  The  Use  and  Abuse  of  Spectacles.    Basket  Derby. 

2.  Avulsion  of  the  Finger,  with  a  Ciise  in  which  this  Acci- 

dent Occurred  to  an  Infint  20  Months  Old.    Gsohge 
H.  MosKS. 


3.  Two  Cases  of  Ligature  of  the  Internal  Jugular  Vein  for 
Infective  Tkirombosis  of  the  Sigmoid  Sinus  Due  to 
Purulent  O  itis  Media;  one  Eecovery  and  one  Death. 
Feeeerick  L  Jack. 

2. — Avulsion  of  a  finger  is  caused  by  firm  holding  of 
the  finger  in  something  moving  away  from  toe  person  or  by 
holding  of  the  finger  while  the  hand  is  pulled  away  from  it. 
The  bones  are  usually  separated  throug'n  one  of  the  joints. 
Avulsion  of  the  terminal  phalanx  is  the  most  common 
variety.  A  tendon,  usually  the  deep  flexer,  is,  as  a  rule, 
attached  to  the  avulsed  finger,  and  the  tendon  is  most  fre- 
quently pulled  off  at  itj  exit  from  the  muscle.  The  skin  is 
usually  paUed  ofi  at  a  higher  point  than  that  at  which  the 
bones  give  way.  Hemorrhage  is  seldom  troublesome.  Xo 
attempt  should  be  made  to  replace  the  avulsed  portion  of  the 
finger.  An  accident  of  this  kind  to  a  baby,  20  months  old,  is 
reported,    [j  M.S.  J 

3. — Jack  reports  2  cases  in  which  the  internal  jug-ular 
vein  was  ligated  for  infective  thrombosis  of  the 
sigmoid  sinus  due  to  purulent  otitis  media.  Oae  of  the 
patients  died  and  one  recovered.  la  acute  cases,  before 
ligating  the  vein,  remove  the  purulent  material  in  the  ainos 
until  a  healthy  clot  is  reached.  Afttr  this  operation,  if 
rigors  and  elevation  of  temperature  recur  immediately,  ligate 
the  jugular  vein  and  then  remove  the  entire  thrombus  until 
there  is  a  free  fl  ow  of  blood.  If  at  the  original  operation  no 
heilthy  clot  is  formed,  ligate  immediately.  In  chronic  cases 
no  time  should  be  lost  in  ligating  the  vein  and  completely 
removing  the  thrombus,     [j  m.s  ] 


Journal  of  the  American  Medical  Association. 

March  S,  1901.     [\o\.  iivi,  Xo.  I'.] 

1.  Nutrition  and  Stimulation.    I.  N.  Love. 

2.  Tee  Results  of  the  Surgical  Treatment  of  Inflammation 

of  the  Mastoid  Process.    Edward  Bradford  Desch. 

3.  Treatment  of  Chronic  Oiorrhea.    Frajsk  Allpoet. 

4.  Bony  Defects  and  Fistula  in  the  External  Meatus.    H. 

Geadle. 

5.  Aphasia  with  Letter- Blindness,  Without  Word- Blindneas, 

with  Right  Hemiplegia  and  Pulmonary  Tubsrculcsis, 
Guy  Hixsdale. 

6.  Combined  Sclerosis  of  Leichtheim  Putnam  Dana  Type 

Accompanying  Pernicious  Anemia.    M.  A.  Beows,  F. 

W.  LaSGIX)S,  D.  I.  WOLFSTEIX. 

7.  Croupous  Pneumonia.    J.  M.  A1.1.EX. 

S   Irrigation  of    the    Colon    as    a   Tnerapeutic    Measure. 

George  J.  Lochbokhler. 
9.  Protest  Against  the  Use  of  Proprietary  Remedies.  Dasekl 

R.  Beoweb. 

10.  Cultivation  of  the  Ejtivoautumnal  Malarial  Parasite  in 

the    Mosquito  .Anopheles    Qiadrimaculata.    Albebt 

WOLDEET. 

11.  Xq  Original  Chart  of  the  Neuronic  .Ajchitecture  of  the 

Visual  Apparatus.    Loris  Stricker. 

12.  Address  Before  the  New  York  State  Assembly  Committee 

on  Public  Health.  In  the  Discussion  of  the  Brll  Bill 
("  Cnristian  Science  Bill '')  Prohibiting  the  Practice  of 
Medicine    by  Unlicensed    Practitioners.    Robert   T. 

MOREIS. 

IS.  Anastomosis  of  the  Ureters  with  the  Intestine.    A  His- 
torical and  Experimental  Research.    Reibkx  Peteb- 

SOK. 

2. — Dench  thinks  that  wherever  there  is  the  sliehtest 
evidence  of  inflammation  of  the  mastoid  cells  a 
thorough  eiploraii  >n  should  be  made.  If  this  is  done  in  an 
aseptic  manner  the -danger  of  the  operation  is  practically 
nil.  The  incision  thould  be  made  as  close  to  the  ear  as  pos- 
sible. Exploration  of  the  entire  pneumatic  structure,  in- 
cluding the  cells  at  the  apex  of  the  process,  should  be  made. 
The  mastoid  antrum  should  be  entered  as  the  first  step  of 
the  procedure.  This  avoids  accidental  exposure  of  the 
meninges  or  of  the  lateral  sinus.  He  thinks  that  the  wound 
heals  as  rapidly  when  it  is  packed  as  when  it  is  partially 
sutured.     [,i  h.g  ] 

3. — All  port  discusses  at  some  length  the  diflferent  views 
held  bv  the  profession  recarding  the  treatment  of  chronic 
otorrhea.  Tne  great  diificulty  in  decidirg  upon  the  treat- 
ment of  this  condition  depends  upon  an  exact  diagnosis  of 


March  9,  1901J 


THE  LATEST  LITERATURE 


TThK   PlllLADKLPHlA 

L  Medical  Journal 


467 


the  extent  of  the  disease.  Oftentimes  the  symptoms  are  very 
slight  when  the  disease  is  very  extensive,  and  the  contrary  is 
not  infrequently  true.  Allport  thinks  that  as  soon  as  a 
diagncsis  of  extension  to  the  mastoid  has  been  made  the 
radical  operation  should  be  done.  If  the  aural  discharge 
continues  in  spite  of  proper  local  treatment  for  a  period  of 
3  months,  accompanied  by  recurrent  and  persistent  exubsr- 
ant  granulations  and  necrosis,  the  case  assumes  a  decidedly 
suspicious  aspect.  This  is  especially  true  if  the  opening  is  in 
Shrapneli's  membrane  or  in  the  posterior  superior  quadrant 
of  the  main  membrane,  and  if  carious  bone  is  found  in  the 
upper  and  posterior  wall  of  the  tympanic  cavit}'.  Other  indi- 
cations for  the  posterior  operation  are  a  cheesy  or  flaky  dis- 
charge, the  presence  of  the  streptococcus,  influenza,  or 
tubercle  bacilli,  and  also  the  condition  of  the  discharge  after 
•ossiculectomy  and  curettage,    [j.h  «.] 

4. — Gradle  has  met  with  20  instances  of  artificial  com- 
municating passages  between  the  meatus  and  the  attic  of  the 
middle  ear.  This  defect  was  usually  a  fissure  in  the  external 
wall  of  the  attic  but  in  some  instances  it  was  a  fistula.  In  a 
few  cases  the  membrana  tympani  was  totally  gone.  The 
patients  were  all  adu  ts  and  dated  their  trouble  back  to 
childhood.  The  origin  of  the  condition  is  due  to  necrosis  of 
bone.  All  of  the  patients  were  aiflering  from  a  chronic 
otorrhea.  Nineteen  of  the  twenty  patients  were  cured  with- 
out an  open.tion,  although  a  relapse  was  not  infrequent. 
Oradle  does  not  think  that  the  treatment  of  chronic  otitic 
supi^ oration  is  made  more  diffi  ult  by  the  presence  of  bony 
defects,     [j  h.g  ] 

6. — Hinsdale  reports  a  case  of  aphasia  with  letter- 
blindness  without  word-blindness  in  a  patient,  a 
phrsician  35  years  of  age.  He  wassuflering  from  pulmonary 
tuberculosis  and  suddenly  had  an  attack  of  paralysis  involv- 
ing the  right  side  of  the  face,  the  right  arm,  and  the  right 
leg.  The  paralysis  disappeared  rapidly  in  the  course  of  a 
few  days.  Speech  was  almost  completely  lost  during  the 
first  24  hours.  The  patient  could  only  speak  the  word 
"  No."  Sensation  was  not  disturbed  and  the  kneejerks  were 
normal.  Some  time  after  the  patient  could  not  name  objects 
although  he  could  recognize  them  (word-deafness).  The 
patient  also  mispronounced  some  words,  and  incorrectly 
substituted  words.  During  the  patient's  illness  he  regularly 
read  the  dailv  papers.  When  asked  to  read  the  alphabet, 
instead  of  saying  "  A,"  "  B,"  "  C,"  he  would  count  "  1,"  "  2," 
"  3,"  but  when  shown  the  words  "  boy  "  and  "  child  "  he 
pronounced  them.  He  therefore  had  letter-blindness  but 
not  word-blindnefs.  The  aphasia  persisted  for  nearly  a  year 
and  a  half,     [fj.k.] 

6. — Brown,  Langdon  and  Wolfatein  report  a  case  of  com- 
bined sclerosis  of  Liichtheini-Piitaaiu-Dana  type 
accompanying  pernicious  anemia.  The  patient,  31  years  of 
age,  was  the  proprietor  of  a  restaurant.  Dr.  Brown  first  saw 
the  patient  in  July,  1899.  He  had  complained  of  failing 
health  for  three  or  four  years.  After  careful  examination 
the  diagnosis  of  pernicious  anemia  was  made.  The  blood- 
count  showed  1,279,440  erythrocytes,  3,600  leukocytes  and 
32^  fc  of  hemoglobin  ;  the  color  index  was  1.3.  Microscopical 
examination  of  the  stain  films  disclosed  a  number  of  megal- 
oblasts,  a  pronounced  poikilocy tosis  and  marked  polychromat- 
ophilia.  The  patient  was  admitted  to  the  Cincinnati  Hospital 
in  January,  1900,  under  the  care  of  Dr.  Lmgdon.  He  com- 
plained of  stiflfQess  and  weakness  in  the  legs  and  inability  to 
walk.  A  blood  count  showed  1,661,805  red  blood  cells,  3,000 
white  blood  cells,  54^  of  hemoglobin  and  a  color  index  of 
1.54  A  differential  count  revealed  an  increase  in  the  lym- 
phocytes. Incoordination  was  apparent  in  the  upper  and 
lower  extremities.  He  could  not  walk  on  account  of  weak- 
ness and  rigidity,  the  kneejerks  were  exaggerated  and 
ankle-clonus  and  Babinski's  sign  were  noted.  There  was 
some  disturbance  of  sensation.  Death  occurred  on  April  11. 
The  autopsy  revealed  no  gross  lesions  of  the  organs.  Micro- 
scopically the  spinal  cord  exhibited  degeneration  in  the  pos- 
terior and  |in  the  lateral  tracts.  The  degeneration  in  the 
posterior  tracts  commenced  low  down  in  the  cord  about  the 
level  of  the  lower  lumbar  and  extended  as  high  up  as  the 
pyramidal  decussation.  The  pyramidal  tract  from  the  level 
of  the  olivarj'  bodies  showed  downward  degeneration,  ex- 
tending as  far  as  the  sacral  region.  The  posterior  nerve-root 
bundles  were  involved.  Hyaline  changes  of  the  smaller 
bloodvessels  were  also  noted,  but  no  evidences  of  inflamma- 
tion.   Dr.  Wolfstein  and  Dr.  Laugdon  believe  that  the  condi- 


tion was  a  primary  systemic  degeneration  dependent  upon 
the  pernicious  anemia,     [f  j  k.] 

7. — Allen  reviews  the  treatment  of  croupous 
pneumonia.  He  recommends  the  initial  use  of  calomel 
and  rhubarb,  and  during  the  course  of  the  disease  the  bowels 
are  to  be  kept  open  with  castor-oil  and  turpentine.  Sjdium 
salicylate  given  in  Phillip's  milk  of  magnesia  is  given  until 
the  fourth  to  the  sixth  day  of  the  disease.  During  the  ex- 
acerbation of  the  fever  Dover's  powder  is  recommended. 
During  the  middle  of  the  second  stage  of  the  disease  the  fol- 
lowing stimulants  are  used :  Digitalis,  strophanthu?,  and 
strychnin.  After  the  sixth  day,  instead  of  the  sodium  sali- 
cylate he  gives  tincture  of  the  chlorid  of  iron,  potassium 
iodid,  quinin,  and  nitroglycerin.  With  good  results  he  uses 
oxygen  inhalations,     [fj.k] 

8.— Irrigation  of  the  colon  as  a  therapeutic  measure 
is  discussed  by  Lochboehler.  Tne  introduction  of  water  into 
the  bowel  provokes  expulsion  of  its  contents,  acts  as  a  solvent 
for  catarrhal  product  and  when  large  qiantities  of  fluid  are 
used  thermal  changes  and  peristalsis  are  brought  about.  Ir- 
rigations may  act  mechanically  and  are  sometimes  indicated 
to  relieve  constriction  of  the  bowel  and  incarcerated  hernia. 
Irrigations  are  also  recommended  for  such  conditions  as 
hemorrhage,  cholera,  vellow  fever,  diabetes,  uremia,  shock 
and  CDllapse.  Normal  saline  solution  has  been  given  with 
the  best  results,  as  it  stimulates  the  nervous  system,  improves 
the  circulation  and  restores  the  temperature  to  the  normal. 
[fjk] 

9. — Brower  makes  a  protest  against  the  use  of  proprie- 
tary remedies.  The  author  found  that  three  leadmg 
dispensing  druggists  of  Chicago,  in  examining  the  last  1,000 
prescriptions  on  their  files,  respectively  20%,  21%,  and  26^ 
of  the  prescriptions  called  for  proprietary  remedies.  The 
author  sees  no  reason  why  physicians  should  not  prescribe 
liquor  chloralis  et  potassi  bromidi  compo3itus  instead  of  pre- 
scribing "  bromidia,"  and  pulvis  acetanilidi  compositus  in- 
stead of  antikamnia.  He  urges  the  Assoeiation  to  call  its 
members  back  to  the  more  conservative  way  of  prescribing. 
[fjk] 

lO.— Woldert  continued  his  observations  upon  the  culti- 
vation of  the  estivoautumnal  malarial  parasite  in 
the  mosquito  (anopheles  quadrimaculata)  during  the  past 
winter  and  summer.  In  the  neighborhood  of  the  League 
Island  Navy  Yard,  Philadelphi?,  on  June  19, 1900,  the  author 
found  both  the  larvae  of  the  anopheles  quadrimaculata  and 
the  anopheles  punctipennis  near  a  house  where  a  case  of 
malaria  developed.  From  June  19,  1900,  to  November  11, 
1900,  he  collected  larvae  of  the  anopheles  and  raised  200 
adult  mosquitoes.  He  also  visited  many  infected  localities, 
and  always  found  that  where  there  is  malaria  there  are 
mosquitoes.  The  reverse,  however,  does  not  hold,  for  where 
there  are  mosquitos  there  are  not  always  cases  of  malaria. 
He  found  some  larvae  of  anopheles  in  the  Pocono  Mountains 
of  Pennsylvania.  A  number  of  observations  were  conducted 
to  see  whether  the  anopheles  collected  around  Philadelphia 
were  susceptible  to  the  infection  from  the  malarial  parasite. 
In  only  one  out  of  10  observations  did  he  find  zygotes  in  the 
middle  intestine  of  one  mosquito,    [fjk] 

11. — Strieker  presents  a  diagram  showing  the  neuronic 
architecture  of  the  visual  apparatus,  the  chart  rep- 
resentirg  a  complete  cross  section  of  the  brain  at  a  level 
with  the  optic  thalami.  Beginning  with  the  eyeballs  the 
chart  portrays  the  optic  nerve,  chiasm,  optic  tracts,  tracing 
the  visual  apparatus  to  the  peduncles,  the  distribution  of  the 
fibers  to  the  primary  optic  centers,  and  the  dendrites,  which 
in  turn  are  in  apposition  with  those  given  off  by  the  ganglion 
cells  in  the  primary  centers.  Furthermore,  these  ganglion 
cells  give  off  dendrons  which  are  sent  out  to  the  visual 
centers  in  the  cortex  of  the  occipital  lobes.  The  association 
fibers,  the  fibers  from  the  motor  cortical  areas  to  the  motor 
ocular  nuclei  of  the  opposite  side  are  shown,  as  are  also  the 
fibers  which  pass  directly  from  the  optic  tracts  to  the  centers 
for  pupillary  reaction,  as  well  as  to  the  third  and  fourth  nerve. 
The  sixth  nerve  and  the  remaining  cranial  motor  nerves 
are  communicated  by  the  centripetal  and  centrifugal  fibers 
contained  in  the  posterior  longitudinal  bundle.  The  neu- 
ronic structure  of  the  retina  is  described.  The  various 
theories  regardinsr  decussation  are  considered,  as  are  also 
the  third,  fourth,  fifth,  sixth,  and  seventh  nerves  in  detail. 
Lesions  aflecting  the  association  filers  not  only  give  rise  to 
hemianopsia  but  also  to  other  manifestations,  such  as  optic 


468 


Thb  Philadelphia") 
Medical  Jocesal  J 


THE  LATEST  LITERATURE 


[SIabch  9,  1901 


aphasia,  alexia,  soul-blindness.  The  nerve  fibers  were  traced 
by  Weigert'a  stain,  and  their  origin  and  terminations  by 
Golgi's  stain,     [m.e.d] 

12. — To  be  considered  editorially. 

13. — To  be  treated  editorially  when  completed,     [j.h.g  ] 


MUnchener  mediciuiscbe   Wochenschrift. 

January  1,  1001.     [48.  Jahrg.,  Xo.  1.] 

1.  The  Treatment  of  Ciub  Foot  in  Adults.    Vulpius. 

2.  The  General  Distinction  Bstween  Cow's  Milk  and  Human 

Milk  and  the  Value  and  Significance  of  the  Substi- 
tutes for  Mother's  Milk.    Edlefsek. 

3.  The  Abscesses  of  the  Pancreas.    Marwedel. 

4.  The  Sensory  Disturbances  of  the  Skin  in  Diseases  of  the 

Internal   Organs,    Particularly    in    Diseases    of   the 
Stomach.    Haenel. 

5.  Contribution    to    the    Etiology    of    Primarily    Infected 

Kidneys.    Baumgahten. 

6.  The  Defects  of  Nursing  Bottles  and  Toeir  Prevention. 

Schmidt. 

7.  A  New    Test    for    Sugar    (NitroPropiol    Tablets.)    Von 

Gebbaet. 

8.  Azooaspermia  and  Paternity.    Eckstein. 

1. — Vulpius  believes  as  a  result  of  his  very  successful  ex- 
perience that  in  the  majority,  if  not  in  all  cases  of  club 
foot,  permanent  and  almost  complete  cure  can  be  obtained 
by  the  method  of  forcible  reduction  of  the  deformity,  fol- 
lowed by  the  application  of  a  plaster  cast,  that  is  to  be 
worn  for  at  least  4  months.  Even  in  adults  this  treatment 
has  produced  feet  that  are  almost  normal  in  appearance,  and 
apparently  quite  satisfactory  as  far  as  function  is  concerned. 
The  treatment  is  not  entirely  bloodless.  He  almost  invari- 
ably cuts  the  Achilles  tendon,  and  frequently  the  plantar 
aponeurosis,  and  in  some  cases,  n  ore  exteneive  operations 
are  required.  Iq  the  severe  cases  it  is  sometimes  necessary 
to  use  appliances  to  bring  the  bones  of  the  foot  into  approxi- 
mately normal  relation,  and  it  may  even  be  desirable  to 
overcorrect  slightly.  After  the  plaster  cast  has  been  removed, 
braces  are  often  required  for  some  time.  There  may  be  at 
first  intense  pain,  which  usually  does  not  last  more  than  3 
days,  but  if  it  should  persist  beyond  this  time,  it  indicates 
that  the  brace  has  not  been  properly  applied,  and  needs 
attention.  If,  before  the  operation,  the  leg  is  shorter  than 
its  fellow,  of  courie  no  elongation  is  produced,  and  in  nearly 
all  caees  the  calf  musclts  remain  small,  althougti  the  strength 
of  the  foot  is  usually  very  good.  Altogether  he  had  37  cases, 
ranging  from  13  to  35  years  of  age,  and  many  of  them  have 
now  been  under  observation  for  more  than  5  years  since  the 
operation.  There  have  been  no  relapses,  and  the  results 
have  been  uniformly  excellent.  Tne  only  danger  is  the  pos- 
sibility of  the  formation  of  a  pressure  ulcer  under  the 
bandage,  but  even  this  is  not  to  be  greatly  feired.     [j  s.] 

2.— Human  milk  contains  from  11  to  \2fc  of  solid  con- 
stituents ;  cow's  milk,  from  14  to  14  5%.  Human  milk 
contains  from  6to7fc  milk  sugar  ;  cow's  milk  from  3  to  4  5%  ; 
although  immediately  after  delivery  human  milk  contains  a 
smaller  proportion  of  sugar.  Citric  acid  occurs  in  human  milk 
in  a  very  much  smaller  proportion  than  it  does  in  cow's  milk. 
Both  contain  about  the  same  quantity  of  fat,  but  in  human 
milk  there  is  a  larger  proportion  of  the  heavy  fattv  acids, 
and  a  larger,  finer  emulsion  of  the  fat  than  in  cow's  milk. 
Human  milk  contains  very  much  lees  albumen  than  cow's 
milk,  and  a  proportion  of  nitrogenous  substance  from  7  to 
996,  whereas  in  cow's  milk  it  is  1  to  2.3^.  Curiously  enough 
the  quantity  of  albumen  is  greatest  immediately  after 
delivery,  and  then  steadily  diminishes,  so  that  tlie  to'.al 
quantity  taken  daily  by  the  child  remains  almost  tl.e  same. 
However,  the  proportion  of  lactalbumen  to  casein  is  greater 
in  human  milk  than  in  cow's  milk.  In  addition  there  are 
certain  nitrogenous  substances,  some  of  which  cottain  phos- 
phorus in  combination.  Cow's  milk  contains  a  larger  amount 
of  phosphorus,  but  most  of  it  is  in  the  form  of  inorganic  sal  :s. 
In  conclusion  Edlefsen  expresses  himself  as  rather  sceptical 
regarding  the  value  of  certain  substances,  that,  added  to 
cow's  milk,  modify  its  chemistry  in  the  direction  approximat- 
ing human  milk,  and  feels  that  in  general,  ordinary  cow's 
milk  diluted,  with  the  addition  of  a  small  amount  of  cream, 
albumen  and  sugar  of  milk,  fills  the   required  conditions. 

[JS.] 


3. — A  man,  60  years  of  age,  had  sufiered  from  pains  in  the 
right  upper  portion  of  the  abdomen  for  about  a  year,  and 
slight  icterua,  that  disappeared  after  the  employment  of 
Carlsbad  sails.  He  emaciated  rather  rapidly,  and  there  was 
a  distinct  globular  resistance  in  the  left  epigastrium,  that  was 
not  painful  upon  pressure,  and  became  verj'  much  less  dis- 
tinct when  the  stomach  was  inflated,  and  was  evidently  be- 
hind the  transverse  colon.  Tne  feces  did  not  c»ntain  any 
abnormal  quantity  of  fat,  but  there  was  a  distinct  trace  of 
sugar  in  the  urine.  A  diagnosis  of  tumor  of  the  tail  of  the 
pancreas  was  made,  and  an  operation  performed,  that  re- 
vealed an  abscess  contaioing  offeasive  pus,  about  twice  the 
size  of  a  fist.  Cultures  showed  the  presence  exclusively  of 
the  diplo-baciUus  of  Fried!aader.  The  3  forms  of  pancreatic 
disease  amenable  to  surgical  interference  are  tumor,  necrosis 
of  the  pancreas  a^  a  result  of  inflammatio!),  and  abscess. 
The  last  is  by  all  odds  the  rarest.  Only  8  cases  have  hitherto 
been  recordf  d  in  which  op?ration  has  been  performed,  [j.6.] 

4. — Haenel  has  mide  a  considerable  number  of  observations 
in  cases  of  gastric  disease,  in  order  to  determine  to  what 
extent  the  statements  of  Head  regarding  sensory  distarb- 
ances  in  certain  definite  areas  of  the  skin  in  affections  of 
this  order,  are  borne  out  by  observation.  In  42  cases  he  ob- 
tained positive  resul  s,  and  he  believes  that  these  constitute 
about  i  of  all  the  patients  examined.  The  changes  consist 
essentially  in  hyperilgesia  and  hyperesthesia.  There  was 
no  particular  difference  between  the  cases  of  gjstric  ulcer 
and  dyspepsia.  There  are  two  maximal  poin  s,  one  an'.erior 
and  one  posterior,  and  a  third  just  beneath  the  acromion  over 
the  deloid  muscle  was  presen'in37%  of  aM  cases  ofluag, 
hear,  and  s  omach  disease.  Wi  h  regaid  to  the  ex 'en',  22 
ca-e3  .showed  hypereuhesia  restric'.ed  to  the  u-ual  limitj, 
that  is  the  fojrth  a^d  sometimes  the  five  cerical  segment?, 
and  the  sevent'a  and  nin'h  dorsal  segments  T«"enty  cues 
showed  much  more  extensive  distribution  Wita  regard  to 
other  diseases  Haenel  calls  attention  to  the  interesting  fact 
that  diseases  of  the  seroos  membranes  give  ri^e  to  hyperes- 
thetic  araas.  usial  y  coextensive  wi'.h  ihe  membrane  and 
not  limited  to  any  particular  spinal  segments.  Tnis  he  is 
unable  to  expla'n  Therapeutically  it  seems  rea-onable  to 
suppose  tha',  suitable  simulation  of  those  sensorj-  areas  might 
act  reflexly  upon  the  organ?  invo'.ved.  He  coacludej  with 
brief  descr  ptions  of  five  of  the  moU  iit^r^sting  ca-es.    [J.s.] 

6. — Biiimearten  has  observed  220  casesof  primary  con- 
tracted kidneys,  158  in  men  and  62  in  women.  Tne  dis- 
ease is  proportionately  more  frequent  in  young  women  than 
in  j'ouDg  men,  9  women  being  affected  before  30  years  of 
age,  and  only  12  men.  It  is  probable  that  this  disease  can 
be  inherited,  that  is,  it  may  exist  at  birth,  or  there  may  be  a 
distinct  predisposition ;  the  existence  of  gout,  exposiue  to 
lead-poiaoning  and  indulgence  in  alcohol  are  probable  etio- 
logical factors,  but  it  seems  unlikely  that  diabetes  mellitusacts 
in  the  same  way.  Amyloid  disease,  especially  thit  following 
constitutional  syphilis,  is  also  a  potent  factor.  Tne  renal 
cxDndition  may  be  produced  either  by  direct  irritation  of  the 
kidney  or  secondarily  to  arterioecleroeie.  Baumgarten  ad- 
mits that  the  commmest  type  is  one  in  which  both  the 
parenchymatous  and  the  interstitial  tissues  are  affected,  but 
he  also  believes  that  there  are  other  forms  in  which  one 
tissue  is  involved  predominantly.  He  gives  two  valuable 
tables,  in  one  of  which  the  cases  are  classified  according  to 
age,  and  in  another  according  to  cause,     [j  s.] 

6. — Schmidt  believes  that  the  ordinary  nipple  of  the 
nursing- bottle  has  certain  serious  defects.  It  requires  too 
little  force  to  col 'apse  it,  and  therefore  it  does  not  sutB  :iently 
develop  the  baby's  muscles,  and  it  necessitates  the  frequent 
opening  of  the  mouth  in  order  to  allow  air  to  flow  into  the 
bottle,  so  that  the  child  is  obliged  to  swallow  more  or  le«  air. 
In  addition,  nipples  that  have  been  used  any  length  of  time 
usually  have  their  orifices  so  dilated  that  the  milk  flows 
rapidly  into  the  stomach  and  may  either  dilate  it  or  cause 
vomiting,  and  this  flow,  together  with  the  slight  amount  of 
work  required,  fails  to  fatigue  the  child  suflBiiently,  and  as  a 
result  it  does  not  sleep  after  nursing.  He  has  therefore 
devised  a  nipple  which  consists  essentially  of  the  ordinary 
finger  form  containing  slits  instead  of  holes  at  the  end.  which 
have  a  valve-like  action,  and  prevent  the  ingress  of  air.  and 
on  its  sides  an  openicg  that  e^in  be  regulated  by  a  screw- valve 
to  allow  air  to  get  into  the  bottle.  The  extent  to  which  this 
is  opened  regulates  the  amount  of  this  flow,  and  the  effort 
required  to  obtain  the  milk,    fj  8  ] 


Marcu  ' 


THE  LA.TEST  LTTERA.TURE 


PThk  Philadslphu 
L  Mbdical  Jodrnal 


469 


7,— Gsbbart  has  employed  nitropropiol  tablets  in 
order  to  detect  sugar  in  urine.  The  method  of  em- 
ployment is  to  drop  a  tablet  into  10  or  15  drops  of  urine, 
diluted  with  about  10  ccm.  of  distilled  water,  and  to  warm 
slightly.  If  sugar  is  present  the  solution  turns  first  green  and 
then  blue.  If  only  a  small  quantity  is  present,  this  can  be 
concentrated  by  shaking  with  chloroform,  as  in  the  indican 
reaction.  Tlie  reaction  does  not  occur  with  biliary  pigments, 
uric  acid,  albumin,  blood,  or  phosphates.  Neither  does  it 
occur  in  the  urine  of  patients  who  have  been  taking  benzoic 
acid,  chloral,  carbolic  acid,  guaiacol,  iodin,  the  salicylates, 
senna,  or  turpentine.  It  occurs  if  .03  part  of  dextrose  is 
dissolved  in  100  parts  of  water,    [j  s  J 

8. — The  plaintiff  had  contracted  gonorrhea,  followed  by 
epididymitis,  as  a  result  of  which  one  testicle  had  been 
removed.  He  subsequently  married  and  his  wife  bore  two 
children.  Certain  admissions  by  her  led  him  to  doubt  his 
paternity,  and  a  medical  expert,  ta  whom  the  case  was 
referred,  found  that  spermatozoa  were  absent  from  his  seminal 
fluid.  He  decided,  therefore,  that,  although  he  was  not  the 
father,  the  plaintiff  must  provide  for  the  children,  because  he 
had  not  suspected  their  illegitimacy  until  more  than  a  year 
after  birth.  The  author  criticises  this  judgment  because  the 
swelling  and  tenderness  of  the  other  epididymis  indicated  a 
recant  infection  and  suggested  a  lingering  possibility  that 
paternity  had  been  possible,     [j.s.] 

Jarmary  8,  1901.     [48.  Jahrg.,  No.  2.] 

1.  A  Remarkable  Case  of  Visibility  of  the  Ciliary  Processes 

in  the  Pupillary  Area.    Eversbusch. 

2.  New  Contribution  to  the    Knowledge  of   Bityric  Acid 

Forming  Bacteria  and   Their  Relation   to  Glanders. 
SCHATTENFROH  and  Gr^ssberger. 

3.  Tne  Test  for  Indican  in  Urine  Containing  Iodin.     Kuhn. 

4.  Steam  Dinnfection  in  Surgery.    Braatz 

5.  The  Influence    of  Subcutaneous    Injections    of  Gelatin 

Upon  Hemorrhage  from  the  Renal  Pelvis.    Gjssner. 

6.  A  Case  of  Prestu  re  Congestion.    Morian. 

7.  Engaging  the  Fetal  Head  in  Walcher's  Position  in  the 

Pelvis  by  Pressure.    Cramer. 

8.  Brief  Annual  Statistics  of  the  Royal  Gynecological  Uni- 

versity Dispensary  of  Prof.  Amann  for  1899     Braun. 

9.  Reply  to  the  Remarks  of  Prof.  Fraenkel  in  No.  51  of  this 

Journal.     Kopp. 

1. — Eversbusch  reports  a  case  of  visibility  of  the 
ciliary  processes  in  the  pupillary  area  occurring  in  a 
20-yearold  girl.  Dilatation  of  the  pupil  with  honiitropine 
showed  that  a  cataract  (two  corneal  scars  showed  that  a  pre- 
vious discission  had  been  done)  caused  a  diminution  in  the 
volume  of  the  lens  not  only  anteroposteriorly,  but  also  caused 
an  equatorial  shrinking.  There  resulted  a  lengthening  of  the 
ciliary  processes  in  the  whole  anterior  division  of  the  choroid, 
most  marked  at  the  lower  inner  quadrant,  and  least  marked 
up  and  out.  Most  careful  examination  of  the  eye  with  the 
loup  could  not  determine  whether  this  condition  was  due  to 
an  unequal  shrinking  of  the  lens  in  its  equatorial  diameter,  or 
to  the  fact  that  the  ciliary  processes  were  drawn  up  over  the 
anterior  surface  of  the  shrunken  lens  capsule.  The  operation, 
which  was  conducted  under  complete  cocain  anesthesia 
(fearing  loss  of  vitreous  on  account  of  retching  and  vomiting 
from  a  general  anesthetic),  consisted  of  a  corneal  section  at 
the  lower  outer  quadrant  of  the  limbus,  sufficiently  broad  so 
as  to  permit  the  introduction  of  Esberg's  discission-scissors. 
The  latter  were  introduced  into  a  small  gap  which  existed 
between  the  two  ciliary  processes.  Uninterrupted  recovery 
followed  with  black  and  regular  pupil  reacting  well  to  light, 
etc.  The  illuetratious  comprehensively  show  the  pre-  and 
postoperative  condition  of  the  eye.  The  literature  on  the  sub- 
ject is  considered,  with  special  reference  to  the  cases  of 
Siegrist  and  Schweigger.     [m  r  d  ] 

2. — The  authors,  in  continuation  of  their  work,  have  culti- 
vated a  number  of  bacteria,  found  in  various  places,  that 
have  the  following  characteristics  :  They  decompose  albumen  ; 
ferment  the  carbohydrates  with  production  of  butyric  acid 
and  lactic  acid  in  alcohol ;  they  are  of  obligate  anaerobes,  and 
the  group  contains  an  organism  that  is  nonmotile,  and  causes 
glanders  of  cattle.  Tliey  have  now  several  specimens  of 
tissue  from  animals  affected  with  glanders,  from  which  they 
have  obtained  this  organism,     [j.s.] 


3. — Kuhn  has  performed  a  number  of  investigations  upon 
the  urine  in  order  to  determine  the  presence  of  indican, 
using  the  reaction  of  Obermeyer  and  Jiffe.  He  was  impressed 
during  this  investigation  by  the  fact  that  the  chloroform  not 
infrequently  was  colored  red  or  violet.  Tliis  he  ascribes  to 
the  presence  of  iodin  in  the  urine.  In  order  to  overcome 
this  disturbance  it  is  only  necessary  to  add  a  crystal  of 
sodium  hyposulphite  in  order  to  convert  the  iodin  into 
sodium  iodid.  Suspecting  that  bromin  might  also  develop 
the  reaction,  tests  were  made  with  this,  but  they  showed  that 
it  had  no  influence.     [J  S  ] 

4.  — Braatz  calls  attention  to  the  fact  that  in  surgery  it  is 
exceedingly  important  not  only  to  sterilize  the  various 
materials  used,  but  to  keep  them  sterilizjd.  He  has  devised 
an  apparatus  by  which  this  can  be  done  very  quickly  and 
very  readily.  This  consists  essentially  of  a  metal  box  that 
is  air  tight,  and  in  which  a  wire  basket  is  enclosed  that  con- 
tains the  dressings,  and  permits  the  free  access  of  steam  to 
all  parts.  In  order  to  increase  the  effect,  he  is  in  the  haViit 
of  heating  the  dressings  first  in  a  hot  air  oven,  and  then 
introducing  into  them  steam  at  the  temoerature  of  100°  C. 

[J.S.] 

5. — Gossner  reports  the  case  of  a  man  who  had  severe 
hematuria,  associated  with  severe  pain  in  the  right  renal 
region.  All  treatment  proving  unavailing,  it  wis  decided 
to  give  him  a  subcutaneous  injection  of  gelatin, 
and  200  ccm.  of  a  sterilized  2  5^  solution  was  introduced 
into  the  right  breast.  The  injection  was  intensely  painful, 
and  associated  with  considerable  swelling,  but  the  hemor- 
rhage stopped  within  24  hours,  and  there  was  no  recur- 
rence,    [j.s] 

6.— Morian  reports  the  case  of  a  man,  42  years  of  age,  who 
was  rushed  by  a  heavy  bucket  in  a  mine.  He  was  rendered 
unconscious  for  some  time,  and  the  same  day,  when  inspected 
in  the  hospital,  it  was  noted  that  his  face  was  deep  blue  in 
color  and  swollen ;  there  were  hemorrhages  from  the  nose 
and  mouth;  minute  ecshymoses  in  the  skin,  covering  the 
upper  portion  of  the  body,  and  involving  also  the  mucous 
membranes,  with  the  exception  of  the  neck,  where  there  was 
a  white  mark  corresponding  to  the  pressure  of  a  collar.  Tne 
left  leg  was  completely  paralyzjd,  the  right  almost  com- 
pletely; the  kneejerk  was  lost,  and  it  was  necessary  to  use 
the  catheter  for  11  diys.  At  the  end  of  10  weeks  the  patient 
had  improved  considerably  and  commenced  to  wilk.  The 
author  has  collected  8  similar  cases  from  the  literature,  2  of 
which  died  in  a  very  short  time,  the  other  6  completely 
recovered.  He  believes  that  the  condition  was  produced  by 
pressure  upon  the  viscera  partially  equilized  by  closure  of 
the  glottis.  He  prefers  the  name  "  pressure  conges- 
tion" suggested  by  Berthes  to  "congestive  hemorrhage 
after  compression  of  the  body  "  suggested  by  Braun.     [j-s.] 

7.— Cramer  believes  that  in  those  cases  in  which  the  head 
refuses  to  engage  in  the  pelvis,  it  is  desirable  to  use  pressure 
through  the  abdominal  walls  in  order  to  compel  it  to  do  so. 
For  this  purpose  he  prefers  pressure  with  the  closed  fist  by 
which  it  is  possible  to  exert  a  force  equivalent  to  70  kilo- 
grams or  more.  He  has  used  this  procedure  in  6  cases  with 
excellent  results,  and  with  no  complications,     [j  s.] 


Berliner  klinische  Wochenschrift. 

January  21,  1901.      [38.  Jihrg.,  No.  3  ] 

1.  Diseases  of  the  Hip  Joint.    KosiG. 

2.  Mania  with  Depression.    Weygakdt. 

3.  Two  Cases  of  Rupture  of  the  Ductus  Arteriosus  Botalli. 

ROEDKR. 

4.  Gallstones.    Riedel. 

1 Koaig  describes  gonorrheal  coxitis  and  arthritis 

deformans  of  the  hip-joint.  He  beheves  that  the  former 
variety  is  a  peculiar  disease,  and  occurs  more  frequently 
than  has  been  supposed,  in  consequence  of  which  there  are 
many  errors  in  diagnosis  and  treatment.  Oaservatun  of  his 
twenty  cases  shows  that  gonorrheal  coxitis  occurred 
usually  between  the  ages  of  twenty  and  forty  ye&p,  eleven 
times  in  females  and  nine  times  in  males.  The  disease  oc- 
curred principally  during  the  acu'e  stage  of  the  gonorrhea, 
although  it  also  occurred  during  the  chronic  stage,  irauma 
preceded  the  affection  in  five  cases.  Pregnancy  appears  to 
favor  the  onset  of  gonorrheal  coxitis.     This  also  applies  to 


470 


TkE   PeiLADELPHLi 

Mkdical  Journal 


] 


THE  LATEST  LITERATURE 


[Mabch  3,  HOI 


the  puerperium,  an  observation  which  is  of  value,  as  it  may 
explain  many  cases  which  have  been  diagnosticated  as  due 
to  puerperal  sepsis.  Frequently  the  affection  is  bilateral ; 
varies  in  intensity;  frequently  there  is  simultaneous  in- 
volvement of  other  joints.  The  author  has  frequently  ob- 
served during  the  latter  stages  of  gonorrhea  that  the  pro- 
cess also  affected  the  vertebral  joints,  with  a  tendency  to 
ankylosis.  CUnically  there  are  two  varieties :  those  where 
the  onset  of  the  pam  is  gradual,  as  is  ako  the  restriction  of 
motion  in  the  affected  part,  and  those  in  which  the  oneet  is 
characterized  by  marked  disturbances  of  motion,  the  most 
severe  pain,  and  a  plainly  demonstrable  tumor.  In  the  stage 
of  the  process  in  which  the  patient  generally  presents  him- 
self at  the  hospital,  pain  is  the  predominant  symptom.  In  a 
relatively  small  percentage  of  cases  anomalies  in  the  position 
of  the  extremity  and  contracture  do  not  occur.  Much  more 
frequently,  however,  moderate  flexion  with  abduction  and 
external  rotation  are  present.  The  extremity  with  the 
patient  in  the  hor.'zontal  recumbent  position  appears  length- 
ened. This  was  observed  in  ore  half  of  the  author's  cases. 
In  one  quarter  of  the  author's  cases  there  existed  a  con- 
dition which  according  to  him  endangered  the  later  func- 
tional activity  of  the  joint,  namely,  flexion,  with  adduc- 
tion and  internal  rotation,  and  which  with  the  patient  in  the 
recumbent  position  showed  apparent  shortening  and  luxa- 
tion. The  author  has  noted  actual  shortening  in  these  cases  of 
from  2  to  5  cm.  A  very  constant  symptom  of  gonorrheal  coxitis 
is  the  swelling  of  the  joint,  most  marked  at  the  anterior  por- 
tion, often  fluctuating,  and  occasionally  assuming  a  phleg- 
monous character.  During  the  acute  stage  this  bwelling  is 
sometimes  accompanied  by  a  moderate  fever.  Without 
treatment  the  majority  of  cases  terminate  in  a  pitiful  manner. 
Almost  one- third  of  the  author's  patients  recovered  with 
mrre  or  less  shortening.  Impairment  of  mobility  regularly 
follows,  sometimes  hampering  the  ability  to  stand  or  sit. 
Occasionally  the  author  was  only  able  to  correct  the  de- 
formity by  force.  Tne  prognosis  as  far  as  function  is  con- 
cerned is  not  good.  Five  of  the  author's  cages  recovered 
without  disturbance  of  mobility.  Of  the  remaining  cases  one- 
half  recovered  wih  slight  impairment  of  mobility,  while  in 
the  balance  marked  disturbances  of  mobility,  shortening, 
ankylosis  and  abnormal  positions  resulted.  KiJiig  is  of  the 
opinion  that  the  latter  cases  would  have  terminated  more 
favorably  if  treatment  had  been  insiituted  very  soon  after 
the  onset  of  the  disease.  Although  the  author  has  had  no 
experience  in  the  application  of  plaster  of- Paris  bandages  to 
the  hip  joint,  he  is  of  the  opinion  that  an  accurately  applied 
plaster-of  Paiii  bandage  would  lessen  the  pain  and  hasten 
the  recovery,  as  it  does  in  the  elbow,  hand  and  knee.  During 
the  acute  stage  of  the  process  surgical  interventi  m  is  but 
rarely  required.  When  ankylosis  occurs,  indication  for 
surgical  interference  depends  upon  the  position  of  the  part. 
According  to  the  position,  either  osteotomy  or  resection 
may  have  to  be  done.  Kiiaig  believes  that  arthritis 
deformans  affecting  the  hip  joint  is  a  typical  affection, 
although  we  are  not  yel  in  the  position  to  demonstrate  its 
etiology  as  we  can  in  tubercu'osis  or  gonorrheal  arthritis. 
The  pathological  anatomy  shows  a  marked  panarthritis 
involving  the  joint  and  capsule.  Arthritis  def<>rman8 
of  the  hip  occurs  as  a  monarticular  process,  although 
beginning  changes  in  other  joints  are  also  frfquently 
found.  The  author  describes  20  cases  coming  under 
his  observation.  Among  these,  16  were  over  forty  years  of 
age,  12  were  over  fifty,  and  half  of  the  Litter  were 
sixty  and  over.  Among  the  younger  patients  observed  by 
the  author,  inflammatory  processes  (acute  osteomyelitis)  or 
trauma  had  preceded  the  arthritis  which,  however,  did 
not  occur  as  a  rule  in  the  typical  cases.  Among  Koaig's 
20  cases,  17  were  males  and  3  fecaales.  Hard-work- 
ing persons  like  farmers  and  laborers  seemed  to  be  more 
frequently  affected  by  this  disease  than  others.  The  begin- 
ning of  the  disease  is  usually  ushered  in  by  subjective  diffi- 
culties. Patients  complain  of  a  grating  sensation  in  the 
region  of  the  hip,  which  is  most  annoj-ing  in  the  morning 
upon  rising.  Disturbances  of  motion  soon  follow  which,  as 
a.  rule,  first  become  manifest  in  the  attempt  of  abduction. 
The  pedestrian  complains  that  le  experiences  great  diffi- 
culty in  stepping  over  ditches  which  he  previously  could 
cross  with  ease,  and  the  rider  finds  great  difficulty  in  swing- 
ing his  leg  over  the  saddle  when  mounting.  Abduction  and 
adduction  soon  increase  in  difficulty,  and  rotation  becomes 


almost  impossible.  Finally  the  members  can  be  bent  only 
in  one  horizontal  axis,  and,  as  a  rule,  the  foot  assumes  a 
position  midway  in  rotation.  Some  patients  experience 
great  pain  which  becomes  either  periodical  or  becomes  mani- 
fest at  every  moment.  In  time  there  occurs  more  or  leas 
ankylosis  of  the  hip.  The  disease  is  not  typical  as  far  as  its 
development  and  progress  is  concerned.  Tne  author  has 
never  seen  complete  recovery  in  a  case  of  arthritis  defor- 
mans of  the  hip-j  oint.  The  treatment  of  arthritis  deformans 
depends  upon  the  individuality  of  the  case.  Koaig  believes 
that  the  most  efficient  manner  of  treatment  is  to  begin  with 
regular  movements  of  brief  duration,  whose  purpose  is  to 
prevent  a  deformity  in  one  axis  This  treatment  must  be 
continued  for  some  time.  Should  symptoms  of  irritation 
with  increased  pain  occur,  the  exercises  are  to  be  stopped 
and  a  period  of  rest  advised.  The  symptoms  of  irritation  I 
are  relieved  by  extension  treatment.  In  some  cases  resec-  • 
tion  is  the  only  remedy  left.  The  author  reports  several 
cases  operated  upon,  the  technic  of  his  operation,  and  the 
histor  es  of  the  patients,     [me  d  ] 

2. — Weygandt  believes  ttiat  90%  of  rases  of  mania  with 
depression  are  hereditary.  The  patients  generally  mani- 
fest symptoms  of  disease  during  youth  by  certain  peciiliaritier 
of  character  and  spirits.  The  first  attacks  generally  occur  . 
during  puberty,  the  disease  then  showing  marked  periodic-  | 
ity.  The  maniacal  condition  is  characteriied  by  excitement 
and  flighty  ideas.  The  other  phase,  by  dejection,  and  inter- 
ference with  the  association  of  thought,     [m  e  d  ] 

3. — Roeder  reports  two  cases  of  rupture  of  the  ductus 
arteriosus  B^talli.  One  child  was  born  in  breech  presenta- 
tion and  in  the  other  there  was  an  enlargement  of  the 
thyroid  gland  up  to  three  times  its  norma!  size.  Tne  author 
believes  that  the  cause  in  most  of  the  cases  is  a  marked  dis- 
turbance of  the  circulation  occurring  in  his  two  ca^es  during 
birth.  From  a  histological  and  hemodynamic  point  of  view 
it  appears  that  the  opening  of  the  ductus  into  the  aorta  can 
normally  only  occur  at  acute  angles,    [m.r  d  ] 

4.— Riedel  reviews  the  literature  on  gallstones  since 
Soemmering  published,  in  179-3,  his  work  entitled  "  Di  Con-  . 
crementis  Biliariis  Corporis  Humani."  The  formation  of  I 
gallstones  is  a  harmless  process  as  long  as  the  cystic  duct 
remains  open  ;  the  bile  produced  in  the  liver  may  go  through 
the  gallbladder  and  flow  over  gallstones  without  producing 
any  troublesome  symptoms.  The  author  believes  that  hydrops 
is  not  caused  by  the  closure  of  the  cystic  duct,  but  by  im- 
paction from  a  stone  in  the  neck  of  the  gallbladder.  The 
clinical  course  of  the  afiection  is  not  dependent  upon  the 
nature  of  the  fluid  in  the  gallbladder;  seropurulent  fluid 
may  give  rise  to  severe  attacks  and  pure  pus  may  not  cause 
any  symptoms  for  weeks  or  months.  Among  151  cases  of 
"  gallstones  "  the  fluid  contents  in  76  cases  consisted  of  serum, 
mucus  in  16  cases,  and  pus  in  36  cases.  In  23  cases  in  which 
bile  was  present,  the  latter  was  inspissated  in  14  cases,  turbid 
in  7  cases,  and  clear  in  2  cases.  Most  of  these  151  cases  had 
a  large  and  the  longest  existing  stone  impacted  in  the  neck 
of  the  bladder;  this  was  sometimes  the  only  one,  but  most 
frequently  there  were  several  generations  of  stones  of  similar 
size  that  had  developed  in  the  direction  of  the  fundus.  As 
long  as  the  occluding  stone  remains  in  position  inflammatory 
exudates  may  be  absorbed, and  the  distended  gallbladder  again 
becomes  s  ofter  and  smaller.  We  now  know  that  primarily, 
in  violent  biliary  colic,  there  is  almost  always  serum  in  the 
gallbladder,  and  it  requires  a  rapidly  accumulating  seroos 
exudate,  with  a  wall  of  the  gallbladder  relatively  intact,  to 
permit  of  the  further  progress  of  the  gallstone.  The  author 
agrees  with  Soemmering  that  icterus  occurs  in  about  lOjt  to 
15%  of  cases  where  the  stone  remains  quiet  in  the  neck  of 
the  gallbladder.  Riedel  has  termed  this  variety  of  icterus 
as  inflammatory  in  contradistinction  to  that  variety 
caused  by  the  lithogenous  process,  when  there  is  an  impac- 
tion of  a  stone  in  the  ductus  choledochus  and  which  causes 
an  inflammation  of  the  gallbladder  extending  to  the  entire 
biliary  system.  Although  it  has  recently  been  attempted  to 
explain  this  variety  of  jaundice  as  due  to  the  distended  gall- 
bladder pressing  upon  the  ductus  choledochus.  this  explana- 
tion according  to  the  author  is  not  tenable  because  this 
icterus  is  also  seen  in  small  shrunken  gallbladders,  and  even 
after  operations  when  the  drainage  tube  has  been  removed 
too  early.  The  character  of  the  afiection  changes  sudienly 
when  a  more  or  less  harmless  local  process  develops  into  * 
general  afl"ection.    The  ordinary  everyday  onset  of  the  alfec 


MAECH9,   1901] 


THE  LATEST  LITERATURE 


rthe  puiladklphia         aj  i 
Medical  Journal 


tion  of  the  process  is  a  rapid  distention  of  tlie  anterior  ab- 
dominal wall,  vomiting  and  pain  radiating  to  the  right 
shoulder;  the  absence  of  icterus  may  then  give  rise  to  a 
suspicion  of  gastralgia  following  a  gastric  ulcer,  when  no  gall- 
bladder is  palpable,  and  a  floating  kidney  or  appendicitis 
may  be  diagnofcticated  when  a  tumor  is  present  below  the 
livtr.  Errors  are  also  made  when  there  is  a  palpable  gall- 
bladder. If  the  latter  decreases  in  size  with  an  abeyance  of 
the  symptoms,  many  physicians  still  suppose  that  the  dimin- 
ution in  the  size  of  the  tumor  is  due  to  the  passing  of  a  stone 
through  the  cystic  duct.  Furlhermore,  when  the  patients  do 
not  have  icterus  and  no  stones  are  found  in  the  df-jecta,  this 
statement  is  made ;  "  not  every  patient  has  icterus ;"  cr,  "  the 
stones  in  the  feces  have  been  overlooked."  As  a  matter  of  fact 
in  these  cases  the  stones  have  not  been  moved  in  the  slightest 
degree,  but  the  inflammatory  tumor  has  undergone  spontane- 
ous retrogression,  similar  to  that  process  seen  in  gouty  joints. 
Most  of  the  patients  have  a  watery  fluid  in  the  gallbladder,  not 
bile,  and  have  a  large  calculus,  not  a  small  one  inpacted  in  the 
neck  of  the  gallbladder.  The  older  view  on  this  subject  is  only 
applicable  in  the  minority  of  cases,  namely  in  those  where 
there  is  inspissated  bile  in  the  gallbladder  and  where  there 
is  a  small  stone ;  in  these  cases  an  effusion  of  serum  may 
push  the  stone  cut.  Regarding  the  indications  for  the  treat- 
ment of  these  afifections  the  author  is  of  the  opinion  that 
among  the  cases  not  to  be  operated  upon  are  those  where 
the  first  paroxysm  of  pain  is  succeeded  by  all  the  (ypical  mani- 
festations, where  the  patient  becomes  jaundiced  on  the 
second  to  the  third  day  and  passes  small  stones  per  vias 
naturales.  Even  repeated  attacks  are  not  indications  for 
operations  when  each  time  small  stones  are  passed.  When 
there  are  numerous  attacks  without  the  passage  of  small 
stones  then  the  question  of  operation  arises  on  account  of 
the  suspicion  tliat  besides  the  small  calculi  there  may  also  be 
large  ones  impacted  in  the  gallbladder.  Furthermore  those 
cases  should  not  be  operated  upon  in  which  after  repeated 
ineffectual  attacks  larger  calculi  have  been  pasted;  for  if  a 
large  stone  has  been  patsed  ethers  may  follow.  If  ineffectual 
attacks  continue  to  follow,  operation  is  indicated.  On  the 
other  hand,  a  single  ineffectual  attack  without  jaundice  indi- 
cates operation  ;  the  calculi  should  not  be  pushed  deeper  by 
further  attacks,  but  should  then  be  abstracted.  We  have  no 
one  single  remedy  to  bring  about  a  state  of  latency.  The 
latter  may  be  partially  at  times  brought  about  by  aperients,  but 
even  then  it  is  of  thort  duration.  Operation  is  indicated  in 
those  cases  when  after  repeated  ineffectual  attacks  the 
uppermost  stone  enters  and  becomes  impacted  in  the  ductus 
choledochuf .  Of  course  this  impaction  must  be  determined 
by  waiting  for  some  time;  from  2  to  3  weeks  is  sufficient, 
although  a  patient  rarely  permits  himself  to  be  operated 
upon  to  early,  because  he  still  hopes  of  a  spontaneous  evacu- 
ation cf  the  calculus.  The  earliest  choledochotomy  per- 
formed by  the  author  was  6  weeks  after  the  entrance  of  3 
stones  into  the  ductus  choledochus ;  one  of  these  was  spon- 
taneously evacuated  in  a  natural  manner,  and  the  two  others 
were  abttracted  from  a  ductus  choledochus  that  had  be- 
come as  thick  as  a  finger;  uninterrupted  recovery  followed. 
The  physician  must  not  only  make  a  general  diagnosis  of 
gallstones,  but  in  every  case  must  establish  the  posi- 
tion of  the  calculus,  its  presumable  size,  and  the 
nature  of  the  contents  of  the  g-allbladder.  In  this 
way  it  will  be  elicited  what  cases  to  leave  to  nature,  and 
upon  which  to  operate.  Some  of  the  literature  on  the  sur- 
gery of  gallstones  is  reviewed,    [m.rd.] 


Wiener  klinische  Wochenschrift, 

January  31,  1901.     [14.  Jahrg.,  No.  5  J 

1.  The  Umbilical  Cord  in  Newborn  Infants.     Max  Stolz. 

2.  Four  Cases  of  Plastic  Induration  of  the  Cavernous  Bodies 

of  the  Penis.    Otto  Sachs. 

3.  Further  Communications  upon  Operation  for  Volvulus. 

Joseph  Preindlsberqer. 

1. — Stolz  reports  his  results,  in  500  cases,  of  his  treatment 
upon  the  umbilical  cords  of  newborn  infants.  One 
hour  after  the  umbilical  cord  has  been  ligated  at  some  dis- 
tance from  the  navel,  he  Urates  the  cord  remaining-, 
<!lose  to  the  navel  with  a  fiue  silk  threa«l,  and  snips 
oflf  the  cord  a  half  centimeter  above  that  with  a 


sterile  scissors.  Sterile  gauze  is  then  applied,  and  a 
bandage  put  over  it  for  safety.  This  is  dressed  every  second 
day,  when  the  child  is  weighed,  the  dressing  being  continued 
even  a  few  days  after  the  cord  sloughs  off.  The  stump  ap- 
peared dry,  with  very  slight  secretion  at  any  time.  In  most 
cases  the  cord  dropped  off  upon  the  fifth,  sixth,  or  seventh 
day  (309  out  of  500).  The  average  time  was  6^  days.  It  was 
not  true  that  the  cord  healed  any  quicker  in  the  stronger  or 
heavier  children.  There  was  no  relation  between  body 
weight  and  the  time  the  cord  dropped  off.  Nor  did  the  char- 
acter of  the  food  make  any  difference.  But  it  was  striking 
that  in  the  children  of  parents  siifiering  from  slight  puer- 
peral diseases,  the  cord  dropped  off'  later,  after  7  days.  This 
was  possibly  due  to  slight  infection  of  the  stump,  with  secre- 
tion following.  The  after  care  may  have  caused  it,  however. 
Only  one  case  of  hemorrhage  occurred,  and  that  was  from 
the  slipping  of  a  ligature,  as  the  cord  had  been  cut  too  close 
to  it.  Finally,  he  advises  great  care  in  treatir  g  the  stump,  to 
keep  the  wound  aseptic  and  dry.     [mo.] 

2. — After  a  thorough  review  of  the  reported  cases  of 
induration  of  the  cavernous  bodies  of  the  penis, 
their  causes,  course,  and  treatment,  Sachs  gives  the  hiBtcjries 
of  his  4  cases,  the  causes  for  which  are  unknown.  In  all, 
when  past  middle  age,  circumscribed  hard  masses  appeared 
on  the  dorsal  surface  of  the  pi^nis,  near  the  median  line,  pre- 
venting complete  erection.  Notliing  showed  in  skiagraphs, 
so  that  they  were  probably  due  simply  to  connective  tissue. 
They  came  on  very  slowly,  during  two  years  or  more,  and 
caused  pain  only  upon  erection.  The  diagnosis  of  the  affec- 
tion is  easy.  No  local  treatment  has  had  any  effect  thus  far. 
Internally  arsenic  and  potassium  iodid  have  been  given. 
Patients  should  be  assured  that  the  affection  is  not  serious, 
as  it  may  lead  to  melancholia,     [m.o  ] 

3. — Preindlsberger  reports  two  cases  of  intestinal  ob- 
struction. The  first  was  a  farmer,  aged  25  years,  who  had 
had  gastroenterostomy  performed  for  stenosis  of  the  pylorus. 
Two  years  later  he  was  again  operated  on,  this  time  for 
intestinal  obstruction.  The  small  intestine  was  found  twisted 
upon  itself  beneath  the  site  of  the  former  operation,  proba- 
bly due  to  the  shrinking  of  the  cicatricial  tissue  of  the 
mesentery,  the  intestines,  or  both.  The  other  case  occurred 
in  a  man  51  years  old,  who  died  after  operation.  Meckel's 
diverticulum  existed,  was  very  long-,  and  had  become 
adherent  to  the  abdominal  wall.  Uuder  this  the  small 
intestine  was  twisted  upon  itself  and  incarcerated.  Though 
laparotomy  was  performed  with  local  anesthesia,  he  died  21 
hours  later.     Both  cases  occurred  in  Herzegovina,     [m.o.] 

February  7, 1901.    [14.  Jahrg.,  No.  6.] 

1.  Diseate  of  the  Nasal  Mucous  Membrane  a  Common  Occur- 

rence Among  Turners.    Rudolph  Blum. 

2.  Hysteric  Fa'.ial  Diplegia.     Huoo  Lukacs. 

3.  Foieign  Bodies  in  the  Male  Bladder.    Fritz  Pendl. 

4.  A  Method  of  Preventing  Clouding  of  the  Mirrcr  in  Najo- 

phaiyngeal  Examinations.    Ernst  Urbantschitsch. 

1.— In  sp'.te  of  the  dust  extractors,  and  other  modern  inven- 
tionj  emplf  yed  in  cane  fact&riee,  large  quantities  of  dust 
come  in  contact  with  the  nasal  mucous  membrane 
of  the  turners  i.t  work.  Beside?,  the  hazelwood  used  has 
first  bien  soaked  in  potassium  dichromaie,  which  bub.tance 
itself  cau-.es  inflammat  on  of  the  nasal  mucous  meiutraue. 
Small  blittars  tir^t  appear,  then  ulcera  fjllow,  after  which 
hemonhage  ocLUis.  Later  membranes  may  form,  or  rarely 
ozena  results.  As  a  rule  no  h.ng  is  noted  exte.nally,  but  in- 
ternaliv  an  advanced  atrophic  condition  is  finally  de- 
veloped. Besides  the  ca;e  ts>ken  \y  the  proprietors  cf  the 
factories  lo  prevent  the  accumulation  of  dus',  all  new  wr rk- 
men  should  be  made  to  wear  a  sponge,  moistened  with  vine- 
gar, over  the  mouth  and  no:e,  to  counterai  tthe  polaesium 
diehromate.  When  this  atrophic  coLdiiitn  exists,  daily 
local  treatment  will  do  good,  if  continued  regularly.      [m.o.| 

2.— Lukacs  reports  a  rare  case  of  hysteric  facial 
diplegia  in  a  girl  of  19.  Right  facial  paralysis  occurred  3 
years  ago,  with  pain  on  pressure  over  the  point  of  exit  of 
the  right  facial  nerve.  Electricity  cured  this  in  3}  months. 
S.x  months  later  the  right  facial  paralysis  again  appeared. 
This  was  also  treated  electrically.  A  week  later  the  left  side 
became  paraljzed.  Her  facial  expression  changed  almost 
like  the  "  mask  "  of  Parkinson's  disease.    She  was  easily 


472 


The  PhtladelphiaI 
Medical  Jodrsal  J 


THE  LATEST  LITERATURE 


[Mabch  9,  196) 


hypnotized,  but  presented  no  stigmata  of  hysteria.  Daring 
14  months'  treatment,  this  condition  has  varied  but  little,  at 
one  time  better,  then  worse  again.  Tonic  contractions  of 
the  muscles  of  the  mouth  have  appeared,  lasting  several 
minutes  at  a  time.  Voluntary  movements  are  carried  out, 
though  limited  in  extent.  They  are  done  better  when  she  is 
hypnotixed.  Xo  reactions  of  degeneration  have  appeared  at 
all.    A  review  of  the  literature  of  the  su'-ject  follows,     [mo.] 

3. — Pendl  reports  2  cases  of  foreign  bodies  in  the 
male  bladder.  In  the  first  case,  a  boy  of  2  year?,  he  ex- 
tracted a  needle,  its  eye  end  embedded  in  a  calculus, 
by  suprapubic  cystotomy.  He  believes  that  the  presence  of 
the  needle  in  the  bladder  is  most  probably  due  to  the  child 
having  swallowed  it,  the  needle  then  having  perforated  the 
intestine,  and  reached  the  bladder.  In  the  second  case,  a 
man,  of  38,  he  performed  lithotrity,  crushing  about  20 
pieces  of  paraffin.  Though  the  history  is  obscure,  it  is 
supposed  that  the  patient  had  introduced  paraffin  sticks  into 
the  urethra.  He  gives  the  literature  of  the  subject  in  full. 
[m  o.] 

4. — L'rbantschitsch  has  experimented  with  lasin,  a  sub- 
stance which,  when  spread  upon  the  mirror  to  be  used  in 
nasopharyngeal  examinations,  prevents  the  breath  from 
clouding  the  mirror,  and  does  away  with  the  necessity  of 
heating  the  mirror  before  introducing  it.  It  is  spread  upon 
the  mirror,  and  lightly  wiped  off,  so  that  the  mirror  remains 
bright,  yet  all  the  moisture  is  at  once  absorbed  by  the  lasin. 
To  disinfect  the  mirror,  a.  10  fc  solution  of  carbolic  acid  is 
used,  and  then  the  mirror  is  washed  in  water  before  the  lasin 
is  again  spread  upon  it.    [m.o  ] 


Centralblatt  fiir  Gynakologie. 

December  8, 1900. 

1.  F.  Ahlfeld  and  the  Tubingen  Method  of  Hand  Disinfec- 

tion.   Th.  Paul  and  O.  S-^rway. 

2.  Remarks  ou  the  Open  Letter  of  the  Geheim.  Medicin- 

rath  Professor  Dr.  Ahlfeld  to  Herr   Privatdocent  Dr. 
Kioaig.    Krosig 

3.  Kolpeurysis  and  Metreurysis.    Arthur  Mueller. 

1. — The  authors  object  to  the  criticism  of  Professor 
Ahlfeld  on  the  metbod  of  band  disinfection  as 
employed  at  the  University  of  Tiibingen.  Ahlfeld  prefers 
the  ho^  water  method  to  that  of  the  soap  and  alcohol  of  the 
latter  institution.  They  claim  that  Kioaig  had  not  spoken 
in  opposition  to  their  method,  as  Ahlfeld  had  stated,  and 
that  Professor  Ahlfeld  is  in  fact  the  only  authority  up  to 
date  who  has  found  fault  with  their  method  of  dieinfeciion 
of  the  hands.  Tuey  assert,  on  the  other  hand,  that  Professor 
Kiiiaig  was  astonished  at  the  results  obtained  by  their 
method,  and  openly  acknowledged  the  value  of  the  Tiibingen 
process.  Tney  emphatically  state  that  Ahlfeld's  criticism 
is  absolutely  unfounded.  It  is  difficult  to  say,  they  admit, 
which  method  of  disinfection  gives  the  best  resultp,  "namely  : 
the  method  as  employed  by  them  or  that  of  Hagler  and 
Kioaig.    [w.an.d] 

2, — Reinicke  stated  that  after  10  minutes  of  ininiersion 
of  the  baud  in  alcohol,  no  living  spores  could  be  found 
on  the  epithelium.  Kioaig  remarks  that  this  is  a  mistake, 
and  that  the  lacilli  will  be  found  without  a  doubt  after  this 
method  has  been  employed.  He  has  demonstrated  that 
after  15  minutes  immersion  of  the  hand  in  alcohol,  anthrax 
germs  were  still  present,  as  was  shown  by  inoculating  mice, 
the  animals  quickly  dying  of  ihe  infectious  disease.  He  be- 
lieves that  many  pathc genie  forms  of  bacilli  exist  which 
have  as  yet  not  been  recognized,  and  that  many  of  these 
geims  will  not  be  destroyed  by  this  method  of  disinfection. 

[w  A.N  D.] 

3. — Mueller  endorses  the  method  of  dilatation  o'  the 
vagina  and  uterus  by  meansof  elastic  balloons  or  bags  for  the 
induction  of  premature  labor  in  pieferenceto  the  per- 
formance of  the  m(.re  serious  operations  of  cesarean  section 
and  symphysiotomy  at  term  in  caies  of  pelvic  contraction. 
The  tags  may  be  retained  i)i  silu  for  frc  m  8  to  5  hovu-s,  or,  if 
necessary,  even  up  to  31  hours.  The  bags  that  he  prefers  are 
modelled  somewhat  after  those  of  Champetier  de  Ribes. 
fw  A  X.D  ] 


Dectrahtr  15,  1900. 

1.  Autocystop'sisty  and  Kolpocystoplasty  in  Marked  Defecte 

of  the  Vesico- vaginal  Wall.    O.  Witzel. 

2.  On  the  Favoring  Infiaence  of  Pregnancy  upon  Enterop- 

tosis.    Hector  Maillart. 

3.  Cure  of  a  Bilateral  Salpingitis — Probably  Tuberculous — 

Tnrough  an  Atropny  Secondary  to  Ligation  of  the 
Vessels.    Max  Naesauee. 

1. — Witzel  emphatically  condemns  the  operation  of 
kolpokleisis  for  the  cure  of  gross  defects  of  the  vesico- 
vaginal wall,  on  the  ground  of  the  ultimate  development 
of  serious  comphcations,  which  result  from  infections  orig- 
inating in  the  retained  vaginal  secretions.  He  remarks  that 
the  bladder  very  shortly  becomes  the  seat  of  a  chronic 
cjstitis  which,  sooner  or  later,  extends  up  the  ureters  to  the 
kidneys.  The  end  is  a  septic  pyelonephritis.  He  describes 
the  case  of  a  woman,  46  years  of  age,  who  presetted  a 
marked  vesico-vaginal  fistula  in  wiiich  3  unsucceeaful 
attempts  had  been  made  to  close  the  opening,  which  had 
resulted  from  attempts  at  the  removal  of  a  myomatoaa 
uterus.  His  examination  of  the  patient  convinied  him  that 
there  was  a  possibility  of  intravesical  transplantation  of  the 
ureters,  and  he  resorted  to  an  extensive  kolpocystoplastic 
operation  to  remedy  the  defect.  Full  exposure  of  the  seat 
of  operation  was  obtained  by  digit  il  retraction  of  the  anterior 
vaginal  wall  and  the  usepotteriorly  of  a  lirge-sized  speculum. 
It  was  found  that  the  destruction  of  tissue  had  paitlally 
involved  the  posterior  wall.  By  means  of  the  finger  the 
bladder  was  loosened  from  its  surrounding  tissues  after  a 
transverse  incision  had  been  made  into  the  vaginal  wall, 
and  the  organ  thus  rendered  more  accessible  for  the  further 
necessary  manipulations.  Slight  traction  was  then  succees- 
fuUy  exerted  upon  the  posterior  wall,  which  was  drawn 
forward  to  cover  the  deficiency  in  the  anterior  tissues,  a  few 
sti  tches  then  sufiBcing  to  bring  the  parts  into  active  apposition, 
Lembert's  sutures  being  employed  for  this  purpose.  A 
large-size  Xelaton  catheter  was  introduced  into  the  urethra 
and  retained  in  position  for  a  few  days.  Tne  wound  made 
an  uninterrupted  recovery.  There  was  but  little  discharge 
from  the  vagina  following  the  operation,    [w.a  x  d.] 

2. — Maillart  has  for  several  years  been  paying  consider- 
able attenti  n  to  the  association  existing  between  preg- 
nancy and  euteroptosis.  After  giv  ng  a  thoroogli 
review  of  the  literature  of  the  subjjct,  he  describes  everal 
cases  of  the  condition  which  had  occurred  in  his  own  prac- 
tice, and  finds  that  there  exists  a  certain  relationship  between 
the  enteroptosis  and  a  condition  of  congenital  neurasthenia. 
He  coccludes  that  since  in  cases  of  ptotic  individuals  be- 
coming pregnant,  the  intraabdominal  pressure  increases 
rapidly  as  soon  as  the  uterus  has  attained  a  certain  volume, 
and  since  pregnancy  under  these  circumstances  prcduces  a 
marked  improvement  in  the  digestive  functions  and  in  the 
general  neurasthenic  condition — an  improvement  wiiich 
gives  rise  to  an  increase  in  weight  of  from  i!i  to  6  kilograms 
from  the  time  of  conception  until  the  end  of  the  puerperium 
— it  follows  that  by  proper  treatment  this  improvement, 
which  seems  almost  to  amount  to  an  absolute  cure,  may  be 
made  lasting.  This  permanent  improvement  especially 
manifests  itself  in  the  latter  months  of  pregnancy,  and  in- 
duces a  further  incr.  ase  in  weight  of  several  kilograms.  In 
those  cases  in  which  from  some  other  cause,  such  as  albumin- 
uria or  neglect  of  a  proper  handling  of  the  case,  thi-  improve- 
ment (  f  the  general  condition  is  arrested,  even  then  a  nor- 
mal pregnancy  exerts  no  evil  icflueuce  upon  the  ptJtic  con- 
ditioi,  not  evea  in  the  cases  in  which  there  is  associated  a 
CO  stituted  neurasthenia,    [w.a.k.d  ] 

3. — Xassauer  takes  exception  to  the  statement  of  Lindfors 
published  in  Xo.  41  of  the  CentralhhH  /.  GyncilcoloffU.  that  a 
case  of  bilateral  salpiugitis,  probably  tuberculous 
in  nature,  had  been  cured  by  an  atrophic  process  resulting 
from  ligation  of  the  vessels  on  that  side  of  the  broad  liga- 
ment. He  prefers  to  believe  that  the  beneficial  result  was 
not  the  direct  outcome  of  the  arterial  ligation,  but  that  it  re- 
sulted from  the  alterative  effects  following  the  abdominal  inci- 
sion which,  as  is  recognized,  gives  rise  to  a  marked  improve- 
ment in  the  circulation  of  the  pelvic  tissues  in  tuberculous 
cases  whereby  there  follows  an  amelioration  and  in  many 
cases  an  absolute  cure  of  the  tuberculous  process.  This,  he 
believes,  results  from  the  improved  nutrition  consequent 
upon  the  increased  cirjalaticn  of  the  blood,     [w.a  s  r.J 


aiAECU  9,  19U1] 


FALSE  PREGNANCY  (PSEUDOCYESIS)  MYXEDEMA 


r^HB  Philadelphia 
Medical  Jouknal 


473 


Original  2lrticlc5. 


FALSE  PREGNANCY  (PSEUDOCYESIS)  AND 
MYXEDEMA. 

By  EDWARD  P.  DAVIS,  A.M.,  I\r.D., 

of  Philadelphia. 

Professor  of  Obstetrics  in  the  Jefferson  Medical  College;    Professor  of  Ob- 
stetrics and  Diseases  of  Infaaey  in  the  Pniladelphia  Polyclinic ; 
Visiting  Obstetrician  to  the  Jefler.son,  Philadelphia, 
and   Polyclinic  Hospitals,  etc. 

Genuine  pregnancy,  whether  entopic  or  ectopic,  is 
often  difficult  to  recognize.  Still  more  puzzling  are 
cases  of  false  pregnancy.  The  circumstances  under 
which  they  arise  are  calculated  to  mislead  the  practi- 
tioner. The  patient's  positive  assertion,  her  accurate 
description  of  symptoms,  the  abdominal  tumor,  in- 
definite mammary  changes,  and  the  preparations  made 
for  the  expected  confinement  render  an  error  easy. 
The  task  of  undeceiving  a  woman  strongly  desirous  of 
offspring  is  a  thankless  one.  But  the  resentment  which 
such  a  patient  feels  when  allowed  to  go  to  a  supposed 
labor  must  be  most  annoying  to  the  physician  and 
detrimental  to  his  reputation. 

Accusation  alleging  criminal  assault  by  innocent  per- 
sons are  not  infrequently  made  by  patients  who  assert 
that  they  are  pregnant.  Here  the  physician's  diagno- 
sis destroys  one  of  the  strongest  evidences  in  favor  of 
the  really  guilty  party.  The  following  cases  illustrate 
this  condition : 

Case  1.— A  robust  woman,  of  gouty  tendency,  married  later 
than  the  average  age  of  marriage.  Of  an  atiectionate  dis- 
position, the  birth  of  a  child  would  have  been  most  accept- 
able. After  marriage  menstruation  became  disordered, 
being  greatly  diminished  in  quantity  and  attended  with  far 
less  pain.  The  breasts  increased  considerably  in  size,  the 
patient  became  stouter  and  increased  markedly  in  the  de- 
velopment of  the  waist.  The  abdomen  increased  in  size  and 
the  patient  alleged  that  she  felt  movements  of  the  fetus. 
Her  married  sister,  the  mother  of  several  children,  had  a 
periodical  discharge  resembling  menstruation  throughout 
each  pregnancy.  This  led  the  patient  to  believe  that  men- 
struation in  her  case  was  no  proof  that  pregnancy  was  ab- 
sent. When  the  patient  was  first  examined,  the  womb  was 
slightly  enlarged,  the  cervix  softened.  She  was  informed 
that  pregnancy  might  be  present,  but  that  positive  evidence 
of  it  was  lacking.  Examinations  at  intervals  sufficiently 
long  to  recognize  growth  in  the  uterus  proved  that  such 
growth  was  not  taking  place.  The  patient  was  thoroughly 
convinced  that  she  was  pregnant  and  that  if  she  was  not 
pregnant  she  had  an  abdominal  tumor  of  considerable  size. 
At  the  suggestion  of  her  physician  she  was  examined  under 
ether  and  in  consultation  with  a  second  physician.  The 
pelvic  organs  were  found  normal  in  size,  position,  and  con- 
sistence. The  patient  accepted  the  result  of  the  examina- 
tion and  willingly  submitted  to  treatment  by  massage, 
regulated  feeding  and  exercise.  Her  increased  weight  di- 
minished to  normal,  the  abdominal  tumor  disappeared,  and 
she  speedily  became  convalescent. 

In  this  case  marriage  was  followed  by  increase  in 
general  physical  development,  a  result  not  infrequently 
seen.  The  patient  very  naturally  reasoned  from  the 
experience  of  her  sister,  and  from  incidents  which  she 
had  heard  from  other  women,  that  she  was  in  the  preg- 
nant condition  and  continued  so  to  think.  Her  recov- 
ery to  sound  health  was  greatly  hastened  by  her  good 
sense  in  accepting  the  result  of  the  examination  and 
in  cooperating  with  the  treatment  proposed. 

Case  2. — A  girl,  aged  16,  had  been  an  inmate  of  several  char- 
itable institutions,  giving  the  following  history.  She  had 
been  criminally  assaulted  and  had  become  pregnant.    The 


exact  period  of  gestation  she  could  not  describe  nor  remem- 
ber, but  her  statement  as  to  the  occurrence  was  positive  and 
she  was  prepared  to  make  a  charge  against  an  individual. 
She  described  minutely  the  symptoms  usual  to  pregnancy. 
On  examination  the  abdomen  was  enlarged  to  eight 
months'  gestation.  The  breasts  were  also  enlarged,  the  nip- 
ples more  prominent  tlian  usual,  secretion  was  not  present. 
Upon  palpation,  the  position  of  the  fetus  could  not  be  defi- 
nitely outlined  nor  could  much  be  learned  regarding  the 
nature  o(  the  abdominal  tumor.  Fetal  heart  sounds  were 
not  heard.  As  it  was  necessary  to  ascertain  definitely  the 
patient's  condition,  she  was  anesthetized.  As  the  anesthesia 
proceeded  the  abdominal  tumor  gradually  disappeared,  and 
it  was  possible  to  grasp  the  uterus  between  the  hands  in 
making  the  examination,  and  to  demonstrate  in  clinic  the 
fact  that  pregnancy  was  absent.  Prolonged  observation  of 
this  patient  proved  the  truth  of  the  diagnosis.  She  could  at 
will  produce  the  abdominal  tumor  and  did  so  whenever  she 
wished  to  attract  attention. 

This  patient  may  have  been  immoral,  and  was  cer- 
tainly malicious  in  so  far  as  her  declaration  that  preg- 
nancy existed  was  concerned.  She  evidently  used  this 
declaration  to  attract  attention,  to  secure  lodging  in 
charitable  institutions,  and  with  the  hope  of  ultimately 
getting  money. 

That  pseudocyesis  is  a  neurotic  state  has  long  been 
recognized.  Its  association  with  other  well-marked 
neurotic  symptoms  receives  abundant  illustration  in  the 
following: 

The  patient  was  a  stout  woman  of  pallid  complexion,  aged 
33.  She  gave  a  family  history  of  heart  disease.  When  thir- 
teen she  was  thrown  from  a  horse.  Her  menstruation  had 
never  been  attended  with  great  suflering.  She  gave  a  his- 
tory of  enteric  fever  and  also  of  so-called  brain  fever.  She 
had  been  married  twice.  In  the  first  marriage,  she  had  two 
miscarriages  at  about  seven  months.  Her  last  marriage  was 
three  years  ago.  Since  then  she  had  menstruated  regularly. 
For  almost  a  year  she  had  had  milk  in  the  breasts,  and  for  a 
number  of  months  she  had  felt  fetal  movem«nts.  Some 
time  before  she  experienced  well-marked  nausea.  Some 
eight  months  previously  she  had  labor-pains  and  was  sup- 
posed to  be  in  labor.  She  passed  nothing  but  clots.  Since 
that  time  she  has  felt  fetal  movements,  the  abdomen  has 
been  most  of  the  time  enlarged,  and  milk  has  been  present 
in  the  breasts.  She  has  had  headaches  for  years,  has  a  fair 
appetite,  her  bowels  move  regularly  and  she  sleeps  badly. 
She  would  be  glad  to  have  a  child,  and  when  supposed  to  be 
in  labor  recentlj',  she  had  a  nurse  in  attendance  and  a  physi- 
cian remained  in  the  house  during  the  night,  expecting  the 
birth  of  the  child.  She  asserts  that  she  had  strong  labor- 
pains  and  that  the  doctor  could  not  tell  what  had  become  of 
the  child. 

The  results  of  the  examination  of  this  patient  were 
as  follows : 

The  cranium  was  narrow  and  the  vertex  high  and  pointed. 
The  patient  was  evidentl}'  anemic  and  the  thyroid  was  found 
enlarged.  Upon  questioning  the  patient,  she  stated  that  she 
had  taken  tablets  for  that  condition.  The  left  half  of  the 
gland  was  larger  than  the  right.  The  intercostal  nerves  were 
tender  and  the  patient's  tissues  were  ilabby.  She  was  fat 
and  much  above  her  normal  weight.  In  the  left  breast  there 
was  a  small  portion  of  hard  glandular  tissue  from  which 
milky  fluid  exuded  No  fluid  came  from  the  right  breast. 
Both  breasts  were  flabby  and  there  was  no  increase  in  the 
pigment  about  the  nipples.  The  thoracic  organs  were 
normal.  The  abdomen  was  fat,  its  walls  flabby,  with  marked 
tympany  over  the  large  bowel  and  modified  tympany  over 
the  entire  abdomen.  The  urine  was  normal  and  the  blood- 
count  showed  a  slight  anemia. 

The  patient  was  seen  by  Dr.  Dercum,  who  examined 
the  nervous  system,  and  by  Dr.  Hansell,  who  examined 
her  eyes. 

Dr.  Dercum  found  her  a  neurotic  patient,  partially 
recovered  from  myxedema.     Dr.  Hansell  found  slight 


tl 


474 


The  Philadelphia 

Medical  Journal 


] 


ACTIONS  OP  MORPHIN  UPON  METABOLISM 


[Maech  9,  1901 


hypermetropia  in  both  eyes,  and  observed  that  the 
patient  was  wearing  glasses  which  did  not  fit  her. 

This  patient  was  examined  under  ether,  when  the 
genital  canal  was  found  relaxed,  the  womb  subinvoluted 
but  no  evidences  of  pregnancy  present.  Her  percep- 
tion of  fetal  movements  ceased  upon  learning  the  result 
of  the  examination. 

In  the  case  just  described,  the  history  of  abortion 
and  the  subinvolution  found  showed  that  a  center  of 
irritation  was  present  in  the  genital  organs.  'This  was 
probably  the  exciting  cause  for  the  imaginary  preg- 
nancy. The  predisposing  cause  which  rendered  this 
condition  possible  lay  in  the  patient's  malassimilation 
and  neurotic  state.  The  recognition  of  this  condition 
with  the  local  findings  made  the  case  readily  intelli- 
gible. 

In  diagnosticating  false  pregnancy,  the  physician  must 
not  be  misled  by  ectopic  gestation.  It  is  possible  for  a 
patient  to  have  an  ectopic  embryo,  to  manifest  many  of 
the  signs  of  pregnancy  and  yet  upon  vaginal  examina- 
tion to  be  pronounced  in  the  non-pregnant  state.  In 
such  a  case,  examination  under  ether  is  of  especial 
value,  as  it  enables  the  physician  to  map  out  the  pelvic 
contents  as  accurately  as  possible. 

In  patients  with  thick  abdominal  walls  or  with  those 
who  relax  badly  under  ether,  exact  diagnosis  may  be 
most  difficult.  Close  observation,  however,  will  usually 
show  that  the  patient  has  not  an  ectopic  pregnancy, 
while  if  such  be  present,  rupture  and  the  symptoms 
which  follow  it  must  soon  make  clear  the  diagnosis. 

Examinations  to  determine  the  existence  of  preg- 
nancy, and  especially  in  cases  of  false  pregnancy,  should 
invariably  be  made  in  the  presence  of  a  third  person 
and  whenever  possible  with  the  cooperation  of  a  trusted 
assistant.  In  cases  where  an  abdominal  tumor  has  been 
present  and  where  the  family  of  the  patient  may  be- 
lieve her  pregnant,  it  is  well  to  demonstrate  to  her  hus- 
band or  relative  the  fact  that  the  abdominal  tumor 
disappears  under  ether,  and  that  bimanual  examination 
proves  the  womb  to  be  empty. 

The  physician  can  act  the  part  of  a  friend  to  many 
of  these  patients  by  protecting  them,  if  possible,  from 
gossip.  If  the  supposed  condition  of  pregnancy  has 
become  known,  the  patient  may  be  greatly  mortified 
to  have  the  true  condition  announced.  The  physicfan 
should  not  only  absolutely  avoid  statements  of  any  sort 
regarding  the  case,  but  he  should  take  pains  to  dis- 
courage gossip  whenever  possible. 

It  is  a  mistake  to  allow  patients  having  false  preg- 
nancy to  go  with  an  examination  only  and  without 
treatment.  The  source  of  nervous  irritation  giving 
rise  to  the  supposed  pregnancy  should  be  removed,  the 
nutrition  of  the  patient  stimulated  as  vigorously  as 
possible  and  her  general  condition  brought  as  nearly  to 
the  normal  as  the  circumstances  permit.  The  exam- 
ination may  reveal  some  pelvic  disease,  which  must  be 
dealt  with  by  operative  or  other  treatment.  Where  the 
patient  can  afford  it,  rest  in  bed,  massage,  careful 
feeding,  electrical  treatment  and  a  selected  diet  are 
indicated. 


lustitute  for  Backward  Children.— An  Institute  for 
the  inetruction  of  children  ot  deleciive  intelligence  has  been 
opened  in  Rome. 

German  Congress  of  Otology. — The  German  Otologi- 
cal  Society  will  hold  its  annual  nieeliue  this  year  at  Breslau, 
M  ly  24  and  25.  The  arrangements  are  in  charge  of  Professor 
Kuemmel,  Thiergartenstrasse  53,  Berlin. 


THE  ACTIONS  OF  MORPHIN  UPON  METABOLISM,  WITH 
ESPECIAL  REFERENCE  TO  "INTERNAL  SECRE- 
TION '•  AND  ITS  BEARING  UPON  TOXICOLOGY. 

By  EDWARD  T.   REICHERT,  M.D., 

of  Philadelphia. 

Professor  of  Physiology  in  the  UDivereity  of  PeDneylTania. 

[From  the  Physiological  Laboratory  of  the  UniTersity  of  PennsrlTania.] 

For  nearly  fourscore  years  morphin  has  held  a  most 
important  place  in  the  armamentarium  of  the  clinician, 
yet  our  knowledge  of  its  physiological  properties  is 
fragmentary  and  unsatisfactory.  It  is  universally  recog- 
nized that  this  poison  kills  almost  invariably  by  para- 
lyzing the  respiratory  center,  but  to  what  extent  this 
paralysis  is  due  to  direct  and  indirect  actions  is  merely 
speculative.  If  it  be  conceded  that  morphin  acts 
directly  upon  the  metabolic  processes  of  the  center 
which  are  specifically  concerned  in  the  discharge  of 
respiratory  impulses,  it  must  also  be  admitted  that  this 
action  is  reinforced  by  the  enfeeblement  of  the  circula- 
tion, by  the  lowered  temperature,  and  probably  by  a 
universal  depression  of  metabolism  that  not  only 
directly  but  indirectly  afi'ects  both  its  anabolic  and 
katabolic  processes.  That  morphin  is  a  depressant  of 
nearly  all  forms  of  metabolic  activity,  both  special  and 
general,  is  evident  from  many  facts :  Its  power  to  annul 
the  pangs  of  hunger  and  lessen  the  quantity  of  food 
required  for  subsistence ;  its  lessening  of  the  body- 
weight;  its  weakening  of  the  reproductive  powers  of 
habitues;  its  enfeeblement  of  the  higher  mental  pro- 
cesses ;  and  its  depression  of  secretory,  circulatory, 
respiratory  and  muscular  activity,  and  of  body-tempera- 
ture, etc.,  all  point  to  a  decrease  of  metabolism  so  wide- 
spread as  to  extend  to  the  important  processes  which 
are  concerned  in  internal  secretion  and  in  repair.  If 
morphin  be  thus  so  extensive  a  depressant,  it  follows 
that  in  dealing  with  poisons  of  this  class  we  must  con- 
sider not  merely  the  direct  actions  upon  the  vital  centers, 
but  the' indirect  actions  which  result  from  the  metabolic 
depression  of  remote  and  apparently  unrelated  struc- 
tures, by  which  the  centers  may  no  longer  be  properly 
supjilied  with  some  special  forms  of  pabulum,  or  with 
other   substances   essential  to  their   normal  activities. 

While  our  knowledge  of  the  actions  of  internal  secre- 
tions* is  extremely  limited,  it  is  sufficient  to  warrant 
the  belief,  that  they  play  important  parts  in  many  or 
in  all  of  the  vital  processes ;  that  they  may  affect  either 
anabolism  or  katabolism ;  that  the  removal  of  the 
thyroids,  adrenals  or  pancreas  is  inimical  to  life  because 
of  the  loss  of  their  functions  of  internal  secretion,  and 
the  consequent  effects  upon  general  nutrition  ;  that  the 
respiratory  disturbances  in  uremia  are  not  due  to  the 
retention  of  urinary  constituents  in  the  blood,  but  to 
the  interference  with  internal  secretion  by  the  kidneys ; 
that  after  the  removal  of  three-fourths  of  the  total 
kidney-weight,  animals  may  live  for  weeks,  and  die  of 
asthenia  without  their  being  either  coma  or  convul- 
sions; that  the  marked  respiratory  excitement  caused 
by  muscular  activity  is  due  to  substances  given  to  the 
blood  by  the  muscles  ;  that  some  of  the  principles  are 
more  or  less  powerful  excitants  to  the  respiratory  center, 
to  the  heart,  to  the  cardiac  centers,  or  to  the  vasomotor 
centers  or  peripheries ;  that  some  are  apparently  dy- 
namogenics,  increasing  volitional  muscular  power  and 

•  The  lerm  *'  internal  secretions"  is  here  used  to  include  all  sut^tance*  wh>  ' 
are  specttically  or  incidentally  produced  by  the  various  structures  of  the  bo.-  ^ 
and  (lestined  to  aQect  the  metabolic  processes  of  other  structures  than  tbo»e  ■ 
which  they  ar«  formed. 


March  0,  1901] 


ACTIONS  OF  MORPHIN  UPON  METABOLISM 


rXHK    PHILADKLPHIA 

L  Mboicai.  Jodrhai. 


475 


lessening  fatigue;  that  several  are  of  great  toxicity,  one 
obtained  from  the  adrenals  being  among  the  most 
powerful  poisons  known,  0.00009  gram  causing  marked 
effects  upon  the  circulation  in  a  dog. 

The  manifest  importance  of  this  subject  led  me  to 
make  a  number  of  experiments  on  dogs  with  the  view 
of  studying  the  actions  of  morphin  not  only  upon 
general  metabolism,  but  their  bearing  upon  toxicology. 
The  calorimetric  method  was  chosen  because  of  its  being 
generally  preferable  to  the  others.  This  method  is 
based  on  the  fact  that  the  heat  produced  in  any  struc- 
ture is  proportionate  to  the  degree  of  metabolic  activity 
of  that  structure  ;  therefore,  the  heat  produced  by  the 
entire  organism  during  any  given  period  is  an  index  of 
the  mean  degree  of  activity  of  metabolism  in  all  of  the 
tissues.  Inasmuch,  however,  as  each  structure  is  to  a 
large  extent  independent  in  its  chemical  processes  of 
those  in  others,  this  index  can  be  applied  as  a  standard 
to  each  organ  only  in  conjunction  with  what  special 
evidence  exists  regarding  the  metabolism  in  that  organ. 

The  average  minimal  lethal  dose  of  morphin  for  dogs, 
when  injected  subcutaneously,  is  from  0.25  to  0.45  gram 
per  kilo  of  body-weight,  the  mean  minimal  lethal  dose 
being  about  0.35  gram  per  kilo.  Notwithstanding  the 
comparatively  large  quantity  required  to  kill,  fractional 
doses  are  sufficient  to  cause  decided  effects.  One  thirty- 
fifth  of  the  average  minimal  lethal  dose,  cr  0.01  gram 
per  kilo,  is  promptly  followed  by  stupor,  depression  of 
the  circulation  ;  marked  weakness,  especially  in  the  hind 
legs,  the  animal  often  being  unable  to  stand,  and  if  so, 
the  hind  legs  are  almost  if  not  completely  paralyzed  ; 
a  fall  of  body-temperature,  usually  as  much  as  1.5°  to 
3.5°  C.  (2.7°  to  6.3°  F.);  lessening  of  sensitivity;  and 
many  other  manifestations  of  nervous,  muscular  and 
secretory  depression,  although  in  many  instances  the 
respiratory  movements  are  for  a  time  increased  in  depth 
or  frequency,  or  in  both.  An  increase  of  the  repiratory 
rate  to  200-250  per  minute  is  not  rare.  A  dose  of  0.15 
gram  per  kilo  is  sufficient  to  cause  paralysis  of  the 
hind  legs,  which  may  last  for  two  days.  The  psychic 
depression,  the  slow  full  pulse,  the  lowered  arterial 
pressure,  the  slow  quiet  respirations,  the  intense  mus- 
cular weakness  and  the  decided  fall  of  body  tempera- 
ture are  among  the  most  marked  phenomena  com- 
monly observed  in  morphin  poisoning. 

Twelve  experiments  were  performed.  In  each  the 
heat  processes  were  studied  for  1  or  2  hours  before  giv- 
ing the  morphin,*  and  from  3  to  5  hours  after.  The 
results,  as  shown  in  the  accompanying  condensed 
records,  were  decided  and  quite  uniform.  In  the  first 
10  the  dose  was  0.01  gram  per  kilo  of  body-weight ;  in 
Experiment  II,  0.07  gram  per  kilo;  and  in  Experiment 
12,  0.15  gram  per  kilo.  In  every  experiment  a  fall  of 
temperature  occurred,  the  maxima  being  3.06°,  2.10°, 
0.91°,  1.57°,  0.93°,  2  30°,  3.76°,  1.69°,  1.24°,  0.93°, 
1.35°,  and  2.77°,  respectively,  and  the  average  1.93°. 
As  a  rule,  the  temperature  begins  declining  during  the 
first  hour  after  morphin,  falls  rapidly  during  the  second 
hour,  and  but  little  more  during  the  third  hour,  and 
sometimes  continues  downward  during  the  fourth  hour. 
In  every  case  the  temperature  fell  during  the  second 
hour.  In  4  experiments  (Nos.  8,  9,  11,  and  12)  there 
was  an  increase  during  the  first  hour,  notwithstanding 
the  occurrence  of  a  decrease  of  both  heat  production 
and  heat  dissipation,  the  former,  however,  not  being 
lessened  so  much  as  the  latter.  In  5  (Nos.  1,  5,  6,  7, 
and  10)  the  temperature  fell   continually  through cit 

*  The  sulfate  wa  .  used  ia  ihe^e  experiments. 


Experiment  l.f— Dog :  weight,  9.85  kilos ;  dose,  O.Ol  gram  per  kilo  of  body- 
weight. 


Wo 

li 

p  m 

§5 

RECTAL 

TEMPERITURE 

;.  p 

1^ 

SI'S 

■2| 

li 

CD 

-  •< 

First    hour    before   niorphiu. 

20.0  4 

19.434 

39.78 

39.86 

+  0.08 

2".2 

Second    "          "                " 

IS.WS 

19.572 

39. 8S 

39.73 

—0.13 

20.2 

First        "       after              '* 

7.47.i 

19.372 

39.73 

88.22 

-1.51 

19.9 

Second    '*          "                " 

5.1T6 

15.420 

38.22 

36.92 

—1.30 

20.1 

Third      "          "                " 

8.T61 

13.410 

36.92 

36.33 

—0,59 

19.8 

Fourth    "          "               *• 

12.069 

14.118 

36.33 

36.07 

—0.26 

23.S 

Experiment  2.— Dog :  weight,  11.84  kilos ;  dose,  0.01  gram  per  kilo  of  body- 
weight. 


First   hour  before  morphin. 

21.041 

23.598 

39.09 

38.82 

—0.27 

22.1 

Stcond    "         "              " 

25.731 

30.846 

38  82 

38.28 

-0.54 

21.7 

First       "      after 

16.715 

2.5.808 

38. 2S 

37.32 

—0.96 

21.4 

Second    '*          "                " 

12.602 

21.660 

37.:(2 

36.37 

—0  95 

21.2 

Third     " 

15.147 

16.936 

36.37 

36.18 

-0.19 

21.8 

Fourth   "          "                " 

12.591 

11.076 

36.18 

36.34 

+  0.16 

22.1 

Experiment  3, — Dog :  weight,  10.5  kilos ;  duse,  0.01  gram  per  kilo  of  body- 
weiifht. 


First   hour  befoie  morphin. 

23.934 

23.682 

38.56 

38  59 

+O.0J 

27.2 

Second    "          "                " 

16.650 

18.834 

38.59 

38.33 

—0.26 

26.7 

First        "      after             " 

13.632 

18.000 

38.33 

37.81 

-0.52 

26.0 

Second    "          "            .    " 

9.600 

12.876 

37.81 

37.42 

-0.39 

26.9 

Third      "          "                " 

10.416 

8.652 

37.42 

37.63 

+0.21 

26.6 

Fourth    "          "                " 

9.890 

11.058 

3:.63 

37.61 

-0  02 

25.2 

Experiment  4.— Dog;  weight,  12.97  kilos;  dose,  0.01  gram  rerkilo  of  body- 
weight. 


First    hour  before  morphin. 

27.485 

30.390 

38.84 

38.66 

-0.28 

23.3 

Second    "          '*               " 

25.895 

28  800 

38  56 

38.28 

-0.28 

23.6 

First       "      after 

27.630 

29.490 

38.28 

38  12 

—0.16 

23.6 

Second    "         "              *' 

10.508 

23.814 

3S.12 

36  98 

-1.24 

23.1 

Third      " 

21.564 

24.366 

36.98 

36.71 

-0.27 

23.6 

Fourth    "          "               " 

22.117 

20.976 

36.71 

36.82 

+0.11 

24.3 

Experiment  5.— Dog :  weight,  11.07  kilos ;  dose,  0.01  gram  per  kilo  of  body- 
weight. 


First    hour  before  morphin. 

18.227 

18.138 

38.4ii 

38.47 

—0.01 

24.3 

Second    "           "                 " 

13.278 

16.200 

38.47 

38.14 

-0.33 

24.2 

First       "      after 

12.728 

14.676 

38.14 

37.92 

-0.22 

24.3 

Second    "          "                " 

7.454 

11.528 

39.72 

37.46 

—0.46 

23.6 

Ttiird      ■'          " 

8.588 

10.182 

37.46 

37  28 

-0.18 

23.3 

Fourth    "          " 

9.928 

10.548 

37  28 

37.21 

-0.07 

23.1 

E.xrERiMEsi  6.— Dog:  weight,  13.75  kilos  ;  dose,  0.01  gi am  per  kilo  of  body- 
weight. 


First   hour  before  morphin.  I  27.049  S1.229 

Second    "  "              "  29.440  30.600 

First       "  after            "         1  7.414  21.219 

S.^cond    "  "               "         \  11.227  1«.377 

Third      "  "               ".  17-585  19.205 

Fourth    "  "              "  15.529  17  C19 

t  The  units  of  heat  prod\iclIon  and  heat  dissipation  are  in  kilogram  degrees; 

the  temperaiurc  records  in  the  cenli>:rade  ^c«!e. 


39.46 

39.08 

-0.38  1 

39.08 

39.02 

— 0.C6 

39.02 

87.74 

-1.28  ' 

37.74 

37i09 

—0.65 

37.09 

36.91 

—0.18 

86.91 

36  72 

-0  19 

1 

21.5 
21.4 
21.5 
21.4 


47  fi  Thk  Philadelphia"! 

'  Medical  Jocknal  J 


ACTIONS  OF  MORPHIN  UPON  METABOLISM 


[Mascb9,  I9f : 


EXPERUIEXT  7.— Dog :  wiigh',  10.3S  kilos;  dose,  0.01  gram  per  kilo  of  bodj- 
weight. 


II 

Si 

go 

BECIAL 

TKMPEBATCKE 

ttt 

=  >: 
=  1 

•o  2         a  S 
a'a       —  + 
o 

£5 

if 

First    hour 

before  morpbio. 

38.732 

40.980 

38. 8S 

38.59  1  —0.29 

23.9 

Second    " 

,. 

32.036 

33.780 

38.59 

E8.38 

—0.21 

242 

First 

after            " 

27.368 

35.688 

38.38 

37.  S8 

— I.OO 

21.5 

Second   " 

.. 

14.476 

31.914 

37.38 

35.28 

— ?.10 

239 

Third     " 

fC                           II 

17.571 

23.(52 

35.28 

34.62 

—0.66 

24.2 

ExPERiMKST  8.— Dog;  weight,  11.224  kiloa ;  dose,  0.01  gram  per  kilo  of  body- 
weight. 


Hoar  before  morphin  .... 

27.639 

28.896  \ 

39.38 

39.24 

—0  14 

20.9 

First  hour  after  morphin  .  . 

26.508 

26.149 

39.24 

39.28 

+0.04  1 

21.4 

Second  "         •           " 

4.105 

19.929 

39.28 

37.55 

-1.74 

22.3 

Third     '.'        "           "         .  . 

19.221 

18.50J 

37.55 

38.35 

+  0.80 

22.9 

Fourth  "        "            " 

24.904 

17.092  : 

38.35 

39.22 

+  0.87 

23.0 

Fif>h 

14.369 

14.728 

39.22 

39.18 

-0.04 

2.?.4 

£.'CPERiMEST  9.— Dog:  weight,  8.83  kilo;  dose,  0.01  gram  per  kilo  of  body- 
weight. 


Hour  before  morphin  .  .  . 

.      40.207 

38.309 

38.68 

£8.83     +0.27 

23.0 

Fin-t   hour  aAer  morph'n  . 

29.922 

27.378 

38  85 

39.21      .1036 

23.9 

Second  "        " 

6.411 

13.901 

39.21 

38.15     —1.06 

23.6 

Third 

17.C00 

21.476 

38  is" 

37.61     —0.51 

2<.5 

Fourth  " 

.       18.777 

16.445 

37.61 

37.94     +0.3S 

24.9 

Fifth 

.  ,     18.4.8 

1 

16.440 

37.94 

38.22  ,  4  0J» 

25.0 

ft».^.. 

Experiment  10. — Dog;  weight,  11.16  kilos;  dose,  0.01  gram  per  kilo  of  body- 
weight. 


First  hour  before   morphin. 

12.760 

13.928 

39.51 

39.38 

-0.13  ' 

19.5 

SecoLd    " 

U.56I 

16.883 

39.33 

39.12 

—0.26 

19.5 

First       "      after 

ll.lSi 

14.853 

39.12 

38.72 

-O40 

196 

Second    ■' 

11581 

14  616 

3S.72 

38.38 

—0.34 

21.6 

Third       • 

13.S63 

14  5S9 

38.38 

38.19 

-0.19 

22.6 

£XPEKIMENT  11.— Dog:  weight.  16.32  kilos ;  dcse.  0.075  gram  per  kilo  of  body- 
weight. 


Hour  before  moiphin  . 
First  hour  after  morphia  . 
Second  "        " 
Tliird     "        " 
Fourth  "        ' 
Fifth      ■' 


.   .       36.829 

42.707 

iS.90 

SS.45 

-0.43 

.   .       S8.306 

35.041 

38.45 

38.70 

+  025 

.   .       24.931 

38.043 

3S.70 

87.70 

—1.00 

.   .       31.084 

S2.S<0 

37.70 

37.60 

-0  10  ' 

.   .       27.;  66 

29  0T2 

37.60 

37.50 

-0.10 

.    .       27.305 

33  030 

37  50 

37.10 

-0  40  : 

19.7 
20.4 
22.2 
22.6 
21.2 
21.7 


EXPEBUIENT  12.— Dog: 

vtigbt,  Il.S  kilo ;  dose,  0.15  gram  per  kilo  of  bodf- 
Teigbu 

Hour  before  morphin  .   . 

44.718 

42.746 

SS.60 

33.82 

+  0.17 

21.1 

First  hour  after  morphia 

.  ,    32.972 

31  136 

33.82 

38.93 

+0.16 

•  22.0 

Second  " 

.       IS.OIS 

3U.04S 

33.98 

37.73 

—1.20 

22.3 

Third     •• 

.        14.642 

33.310 

37.73 

36  17 

—1.61 

22.6 

Fourth  "        " 

34  ;'.0T 

35.507 

36.17 

36.05 

—0.12 

24.2 

FifU» 

.  1     36.924 

36.924 

:6.0S       36  05 

1 

+  0.00 

24.9 

the  4  hours.  In  2  (Xos.  3  and  Sj  rises  of  0.21',  and 
0.8°,  respectively,  occurred  during  the  third  hour.  In 
4  (Nos.  2,  4,  8,  a'nd  9)  rises  of  0.16°,  0.11°,  0.87°.  and 
0.33°,  respectively,  were  recorded  during  the  fourth 
hour.  The  minimum  temperature  was  in  2  experi- 
ments noted  during  the  second  hour ;  in  5,  during  the 
third  hour;  in  4,  during  the  fourth  hour;  and  in  1, 
during  the  fifth  hour.  The  extent  of  the  decrea.«e  is 
due,  in  part,  to  idiosyncrasy,  as  will  be  apparent  by 
comparing  the  figures  of  the  10  experiments  in  which 
the  dose  was  the  same,  and  also  by  a  comparison  of 
these  with  the  results  in  Experiments  11  and  12,  in 
which  the  doses  were  very  much  larger. 

Heat  production  was  decreased  in  every  experiment, 
but  the  effects  were  decidedly  more  marked,  as  a  rule. 
during  the  first  2  hours  after  morphin.  The  ma.xima 
decreases  in  heat  production,  being  72, 51,  43,  60,44.75. 
55,  85,  84,  23,  32,  and  67%,  respectively,  or  on  an  aver- 
age about  58%.  The  average  in  the  10  experiments  in 
which  the  dose  was  O.Ol  gram  per  kilo  was  59.2%.  The 
maxima  decreases  were  recorded  in  1  experiment  dur- 
ing the  first  hour;  in  8,  during  the  second  hour;  in  2 
during  the  third  hour ;  and  in  1  during  the  fourth 
hour.  Heat  dissipation  was  also  decreased  in  every 
experiment,  and  the  maxima  decreases  were  31,  64.  54. 
27,  37.  42,  32,  49,  67.  14.  32,  and  29%,  respectively,  or 
an  average  of  not  quite  40%,  while  the  average  for  th 
first  10  experiments  was  41.7%.  The  maxima  de- 
creases occurred  in  2  experiments  during  the  second 
hour;  in  5,  during  the  third  hour;  in  4,  during  the 
fourth  hour;  and  in  1,  during  the  fifth  hour.  The  fall 
of  heat  production  sets  in  sooner,  progresses  more 
rapidly,  and  reaches  a  maximum  earlier  than  the  fell 
of  heat  dissipation.  The  mean  depression  of  heat  pro- 
duction was  about  20%  greater  than  that  of  heat  dissi- 
pation. 

The  actions  of  morphin  upon  thermogenesis  and 
thermolysis  can,  however,  be  understood  by  studying 
the  results  of  the  experiments  as  a  whole,  than  by  con- 
sidering each  experiment  separately.  If  we  find  the 
mean  heat  production,  heat  dissipation,  and  body-tem- 
perature of  all  10  experiments  for  each  hour,  and  from 
this  data  construct  composite  curves,  we  obtain  a  compo- 
site picture,  as  it  were,  of  the  typical  effects  of  a  dose 
of  0.01  gram  per  kilo  of  body- weight,  as  shown  in  the 
accompanying  cut  (Fig  1).  Examining  these  curves  it. 
will  be  noted  that  heat  production,  before  giving 
morphin,  was  increased  to  a  trifling  extent  (0.7  kilo- 
gram degree).  After  giving  morphin,  it  fell  6.339  kg., 
or  26%.  during  the  first  hour  ;  and  8.735  kg.,  or  36%, 
in  addition  during  the  second  hour,  thus  falling  15.074 
kg.,  or  about  62%,  or  to  38%  of  the  normal  in  2  hours. 
During  the  third  hour  an  increase  occurred  of  5.715 
kg.,  and  during  the  fourth  hour  a  further  increase  of 
0.696  kg.,  leaving  heat  production  at  the  end  of  the 
fourth  hour  at  only  65%  of  the  normal. 

Heat  dissipation  before  giving  morphin  was  some- 
what in  excess  of  heat  production,  and  was  increased 
l.OS  kg.  After  giving  morphin  it  fell  2.9S9  kg.,  or  about 
11%,  during  the  first  hour ;  5.S6  kg.,  or  about  22  % ,  dur- 
ing the  second  hour;  1.367.  kg.,  or  about  5%,  during 
the  third  hour:  and  5.143  kg.,  or  nearly  20%,  during 
the  fourth  hour,  the  total  fall  being  14.359  kg.,  or  about 
55%,  or  to  45%  of  the  normal.  It  will  thus  be  noted 
that  heat  production  fell  only  during  the  first  2  hours, 
while  heat  dissipation  continued  falling  throughout  the 
4  hours,  and  quite  r^ularly ;  but  it  w:vs  only  during 
the  fourth  hour  after  morphin  that  heat  dissipation  w.-is 


MxBCH  9, 1901] 


ACTIONS  OF  MORPHIN  UPON  METABOLISM 


TThe  Philadelphia  477 

L  Medical  JooENAL  *' 


reduced  more  than  heat  production.  During  the  first 
2  hours  heat  production  fell  about  double  as  much  as 
heat  dissipation. 

The  cause  of  the  decrease  of  temperature  is  rendered 
apparent  by  a  study  of  the  relations  of  the  curves  of 
heat  production  and  heat  dissipation,  as  exhibited  in 
Fig.  1.  Before  giving  morphin  heat  production  was  a 
little  less  than  heat  dissipation,  causing  a  fall  of  tem- 
perature of  0.19°.  During  the  first  hour  after  morphin 
both  heat  production  and  heat  dissipation  fell,  the 
former  26%  and  the  latter  11%,  causing  the  tempera- 
ture also  to  fall  0.39°.  During  the  second  hour  both 
heat  production  and  heat  dissipation  continued  decreas- 
ing, the  former  about  36%  and  the  latter  22%,  result- 
ing in  a  further  decrease  of  temperature  of  1.19°.  Dur- 
ing the  third  hour  heat  production  increased,  and  heat 
dissipation  fell  about  5%,  but  owing  to  the  continued 
deficit  of  heat  production  in  relation  to  heat  dissipation 
the  temperature  still  further  declined  0.18°.  During 
the  fourth  hour  an  increase  of  heat  production,  together 


HoBRS  OF  Experiment. 
Before  morphin.*                                    After  morphin. 

2                      12                      8                      4 

... 

~  -  --  -   m--  '=   '-^K- 

""! ^.                  ^-.. 

l>           1  >L                                 ■  itiTn 

■n                          mJ          irl 

-"L                                     SJ                r  4. 

2S               __ ■-_       5,                                      -'' 

£       _   ..     _  _^"%   _  ;   _ ,'       -  -     N_  - 

t                                           SL           Lm                rr 

S      .             _      1             V             2                    

in                                      •         N  J-rfl                      tH 

a  10      _        :_:::::;::      !''; —  

es                                                                                                                                                       -  -     -  - 

s3                                     - _-:...- 

0                                           ni  nTr   U  rn  1 1 

89° 


38°  a 


Fig.  1. — The  curve  of  heat  production  is  represented  L»y  a  solid  line 

{  ) ;  of  heat  dissipation,  by  a  broken  line  ( ); 

and  of  rectal  temperature  by  a  dotted  line  ( ). 

with  the  continued  decrease  of  heat  dissipation,  caused 
more  heat  to  be  produced  than  dissipated,  and  as  a 
consequence  there  occurred  a  rise  of  temperature,  this 
amounting  to  0.26°.  That  the  marked  fall  of  tempera- 
ture caused  by  morphin  is  due  to  a  lessening  of  heat 
production  is  obvious  from  the  fact  that  while  both  heat 
production  and  heat  dissipation  are  lessened,  the  former 
is  affected  the  more  decidedly. 

The  cause  of  the  decrease  of  heat  dissipation  is  doubt- 
less owing  chiefly  to  two  factors:  First,  to  compensating 
actions  of  the  thermolytic  mechanism  to  conserve  the 
body-heat;  and,  second,  to  a  direct  depression  of  the 
circulation. 

The  cause  of  the  decrease  of  heat  production  is  theo- 
retical, and  we  should  not  be  justified  in  attempting  to 
reach  conclusions  as  to  how  and  to  what  extent  each 
structure  shared  in  this  depression  until  after  a  detailed 
study  of  the  elTects  on  at  least  all  of  the  most  important 
metabolic  processes,  because  each  tissue  that  is  directly 
or  indirectly  affected  by  morphin  has  its  metabolic  ac- 
tivities increased  or  decreased,  as  the  case  may  be,  and 
thus  takes  part  in  the  alterations  of  the  mean  quantity 
of  heat  produced.     Under  ordinary  conditions,  prob- 


ably 5  %  of  the  total  heat  production,  in  the  absence  of 
volitional  movements,  shivering,  etc.,  is  contributed  by 
the  metabolic  processes  in  the  heart  and  respiratory 
apparatus,  the  remainder  coming  from  the  other  active 
structures  of  the  body,  and  varying  in  quantity  from 
each  in  accordance  with  the  degree  of  activity.  In  two 
of  the  experiments,  the  mean  metabolic  activity,  as 
shown  by  heat  production,  was  decreased  as  much  as 
84  and  85%,  thus  lowering  the  mean  metaboHc  activity 
of  the  body  to  about  15%,  oraboutA,  of  the  normal.  De- 
ducting from  this  the  heat  contributed  by  the  circulatory 
and  respiratory  mechanism,  the  remainder  is  so  small 
as  to  indicate  a  state  of  vitality  bordering  on  dissolution, 
and  one  which  must  of  necessity  directly  or  indirectly 
injuriously  affect  every  function.  It  would,  therefore, 
seera  unreasonable  to  assume  that  so  profound  a  depres- 
sion, apart  from  any  other  consideration,  is  not  shared 
to  an  important  degree  by  the  metabolic  processes  which 
are  concerned  in  internal  secretion,  and  with  consequent 
important  results. 

If  the  vital  centers  be  partially  or  wholly  deprived 
of  substances  essential  to  their  activities,  it  is  obvious 
that  the  most  important  indication  in  morphin  poison- 
ing is  not  merely  to  administer  specific  excitants  to  the 
respiratory  and  vascular  centers,  but  to  reach  the  causes 
of  the  depression,  and  therefore  to  direct  some  measures 
to  the  processes  which  are  concerned  in  internal  secre- 
tion and  in  repair.  In  fact,  it  is  more  than  probable 
that  most  of  the  agents  which  are,  or  appear  to  be,  of 
unquestionable  value  in  the  treatment  of  morphin  and 
opium  poisoning  have  proved  so,  in  part  at  least,  be- 
cause of  their  action  upon  these  processes,  although 
entirely  unrecognized.  Atropin,  caffein,  strychnin,  co- 
cain,  faradization,  cold  douches,  and  prolonged  very 
hot  baths,  will  doubtless  generally  be  regarded  as  the 
most  effective  physiological  antidotes,  and  with  the  ex- 
ception of  atropin  each  will  be  recognized  as  an  agent 
which  more  or  less  decidedly  excites  both  special  and 
general  metabolism. 

As  regards  atropin,  I  have  already  called  attention  to 
the  fact  that  clinical,  experimental  and  toxicological 
data  demonstrate  clearly  that  this  substance  cannot  be 
regarded  a  reliable  respiratory  stimulant  in  morphin 
poisoning.  (University  Medical  Magazine,  Februarj', 
1891.)  Furthermore  the  results  of  subsequent  in- 
vestigations not  only  fully  verify  this  statement,  but 
also  show  that  while  in  some  cases  atropin  is  of  value, 
in  most  cases  it  is  loorthless  or  positively  harviful.  Upon  the 
circulation  it  is  also  uncertain  in  its  actions,  therapeutic 
doses  sometimes  increasing  the  pulse  and  the  arterial 
pressure,  and  sometimes  decreasing  both,  etc.  The 
causes  of  these  vaTiations  I  have  also  shown  (loc.  cit). 
Atropin  is  claimed  to  be  in  therapeutic  doses  a  depres- 
sant to  the  cardioinhibitory  apparatus,  and  a  direct 
stimulant  to  the  heart ;  a  stimulant  to  the  vasomotor 
center  and  peripheries  ;  a  delirifacient ;  and  sometimes 
an  excitant  to  thermogenesis,  increasing  body  tempera- 
ture in  this  way.  There  is  very  little  evidence  which 
indicates  that  this  substance  is  to  any  marked  degree 
a  metaboUc  excitant.  In  fact,  apart  from  its  cardiac, 
vasomotor  and  cerebral  excitation,  and  its  direct  stimu- 
lation of  the  respiratory  center  (which  may  more  than 
be  offset  or  antagonized  by  the  effect  of  the  depression 
of  the  pulmonary  fibers  of  the  vagi  and  other  factors), 
it  is  probable  that  it  is  an  almost  universal  metabolic 
depressant,  and  that  its  reputed  value  in  opium  poison- 
ing is  owing  largely  to  the  circulatory  and  cerebral  ex- 
citation, coupled  at  times  with  a  more  or  less  important 


478 


Thx  Philadelphia! 
Mrdical  Joubhal  J 


PARESIS  SIMULATING  BRAIN  TUMOR 


[Habcb  9,  IMl 


increase  of  the  rate  or  depth,  or  of  both  rate  and  depth, 
of  the  respiratory  movements. 

CafFein  is  a  verj'  general  metabolic  excitant,  and  there 
is  evidence  which  leads  to  the  belief  that  in  opium 
poisoning,  besides  its  value  as  a  direct  respiratory,  car- 
diac and  psj'chic  stimulant,  it  is  of  indirect  value  by 
afifecting  internal  secretion  through  actions  on  the  nerv- 
ous, muscular  and  secretory  structures.  It  increases 
body-temperature  by  increasing  heat  production,  and  it 
in  some  obscure  way  affects  general  nutritive  processes, 
allaying  the  sense  of  hunger,  apparently  lessening  the 
quantity  of  urea  formed,  facilitating  assimilation,  and 
acting  directly  upon  the  muscles  to  increase  the  activi- 
ties of  their  chemical  processes. 

Strychnin  is  stated  to  be  a  powerful  and  certain 
respiratory  stimulant  in  morphin  poisoning,  but  the 
experimental  and  clinical  evidence  is  far  from  convinc- 
ing, excepting  when  strychnin  was  pushed  so  far  that  the 
individual  was  on  the  verge  of  convulsions,  and  in 
about  as  much  danger  from  one  poison  as  the  other. 
Elsewhere  (Therapeutic  Gazette,  April  15,  1892)  I  have 
shown  that  when  it  is  given  subcutaixeomly  to  normal 
dogs,  and  even  in  doses  so  large  as  nearly  one-half  the 
minimal  fatal  quantity,  it  is  without  any  specific  effect 
on  the  frequency  of  respiration  movements.  In  man,  in 
therapeutic  doses,  its  general  tonic  influence  is  simply 
shared  by  the  respirator}'  center  in  common  with  other 
structures,  and  its  effects  upon  the  respiratory  move- 
ments are  too  feeble  to  be  of  any  important  value  in  states 
of  depression  so  profound  as  in  morphin  poisoning.  That 
strychnin  will,  however,  powerfully  and  certainly  excite 
the  respiratory  center  when  injected  intravenowily  in 
doses  so  large  as  to  cause  dangerous  effects  is  without 
doubt.  But  entirely  apart  from  any  direct  action  upon 
the  respiratory  center,  suppositious  or  otherwise,  this 
substance  may  be  of  value  because  of  its  widespread 
tonic  powers  in  restoring  the  normal  activities  of  trophic 
and  allied  centers.  That  it  exercises  an  influence  upon 
internal  secretion  is  indicated  in  its  stimulation  of  the 
salivary  glands,  by  the  increase  of  heat  production  as 
shown  by  the  rise  of  body-temperature,  and  by  its 
favorable  effects  upon  nutritive  processes  generally. 

Cocain  is  among  the  most  powerful  of  respiratory 
excitants.  In  many  ways  it  is  apparently  a  powerful 
physiologic  antagonist  to  morphin.  It  is  a  psychic, 
respiratory,  cardiac,  vasomotor,  muscular  and  secretory 
excitant ;  and  it  decidedly  increases  body-temperature 
by  increasing  heat  production.  All  indications  point 
to  its  being  a  very  general  and  potent  metabolic  stimu- 
lant. 

Faradization,  is,  as  is  well  known,  an  excitant  to  both 
special  and  general  metabolism. 

Cold  douches  decidedly  afi"ect  the  metabolic  activities 
of  the  skeletal  muscles,  increasing  chemical  tonus  and 
heat  production. 

Prolonged  very  hot  baths  tend  powerfully  to  reflexly 
excite  the  respiratory  center  by  actions  upon  the 
cutaneous  nerves,  and  to  restore  the  normal  temperature 
of  the  body,  and  thus  favorably  influence  all  forms  of 
metabolic  processes. 

While  it  would  be  futile  to  contend  upon  a  basis  of 
such  generalities  that  the  antidotal  values  of  these 
several  agents  (not  considering  atropin)  are  due  in  any 
large  measure  to  their  actions  upon  the  metabolic  pro- 
cesses that  are  concerned  in  internal  secretion  and  in 
repair,  it  seems  equally  futile  to  assume  that  these  pro- 
cesses are  not  depressed,  and  therefore  take  part  directly 
and  indirectly  in  the  causation  and  intensification  of 


the  lethal  symptoms ;  but  what  degree  of  importance 
is  to  be  attached  to  the  consequent  effects  of  this  de- 
pression upon  the  respiratory  and  circulatory  mechan- 
isms is  of  course  problematical. 

This  subject  opens  a  wide  and  laborious  field  of  re- 
search, and  considerable  experimental  work  along  dif- 
ferent but  cooperative  lines  will  have  to  be  done  Vjefore 
we  can  hope  to  obtain  data  of  sufficient  scope  to  enable 
us  to  reach  satisfactory  conclusions.  Nevertheless,  it 
must  be  admitted  :  First,  that  the  profound  depression 
of  general  metabolism,  even  by  sublethal  doses,  together 
with  the  probable  involvement  of  the  processes  con- 
cerned in  internal  secretion  and  in  repair  and  their 
consequent  effects,  must  be  considered  among  the  im- 
portant factors  in  the  treatment  of  morphin  poisoning ; 
second,  that  further  research  will  probably  show  that 
we  have  in  this  depression  an  agent  in  explaining,  in 
part  at  least,  the  values  of  certain  physiological  anti- 
dotes, and,  on  the  other  hand,  the  ineffectiveness  of 
others  which  upon  theoretical  grounds  should  prove  of 
signal  power ;  and  third,  that  if  a  means  be  found  to 
restore  the  normal  processes  concerned  in  internal  secre- 
tion and  in  repair,  the  counteraction  of  the  direct 
actions  of  morphin  upon  the  metabolic  processes  which 
are  specifically  engaged  in  the  discharge  of  respiratory 
impulses  will  probably  be  accomplished  with  far  less 
difficulty  than  heretofore  experienced. 

In  the  near  future  I  will  supplement  this  article  by 
the  results  of  further  research. 


PARESIS  SIMULATING  BRAIN  TUMOR. 

By  AVHAKTOX  <I.\KLER,  M.D., 

of  FUladelphU. 

Phy-gician  to  the  Orthopedic  Hospital  &Dd  Infirmarr  for  Nerroiu  Duemaes. 

It  is  familiar  to  everyone  how  patients  suffering  from 
paresis  often  have  symptoms  which  resemble  so  closely 
those  which  arise  from  localized  disease  in  the  brain, 
that  one  can  scarcely  believe  that  there  is  not  some 
gross  lesion  present.  The  convulsive  seizures  which 
occur  as  a  late  symptom  of  paresis  frequently  begin  in 
or  may  be  confined  to  one  arm,  and  one  sometimes  sees 
in  a  paretic  almost  typical  Jacksonian  convulsions.  As 
the  disease  progresses,  the  convulsive  movements  may 
involve  the  entire  side,  and  consciousness  is  often  com- 
pletely lost  for  minutes  or  hours.  After  a  seizure  there 
may  be  more  or  less  complete  paralysis  in  the  arm  or 
whole  side  for  several  days,  and  in  cases  in  which  the 
hemiplegia  is  right-sided,  there  may  be  aphasia,  which 
is  generally  transient  but  may  be  more  or  less  perma- 
nent. ^^'hen  the  mental  and  other  symptoms  of  paresis 
are  not  pronounced,  it  is  difficult  to  convince  oneself 
that  there  is  not  a  tumor  or  other  gross  lesion  of  the 
brain  present.  The  following  cases  are  illustrative  of 
the  above  statements: 

Case  1. — \V.  A.  consulted  me  ou  September  1,  18S5  He 
was  35  years  of  age  and  gave  a  history  of  syphilis.  The  family 
history  was  bad;  three  brothers  were  or  had  been  insane, 
and  one  of  his  uncles  was  alleged  to  have  had  softening  of 
the  brain.  About  a  month  before  he  saw  me  he  awakened 
one  morning  with  violent  pain  in  the  left  eye.  A  day  or  two 
later  he  noticed  that  he  had  double  vision  and  consult^ed  Dr. 
Oliver,  who  referred  him  to  nie  Under  the  use  of  potassium 
iodid  and  faradism  to  the  external  rectus,  the  pain  .and 
double  vision  disappeared  in  the  course  of  a  few  weeks.  I 
did  not  see  the  patient  again  until  September,  1SS7,  two 
years  later,  when  I  was  sent  for  to  see  him  on  account  of  two 
epileptiform  convulsions  which  he  had  just  had.    He  had 


MaBCU  9,  1901] 


TUBERCULAR  LYMPHOMATA  OF  THE  NECK 


rTHE  Philadelphia  A'JQ 

L  Mbdioal  Jodbnal 


had  3  or  4  seizures  of  a  similar  character  during  the  few 
months  previous,  each  followed  by  severe  headache  but  no 
paralysis.  When  I  saw  him  he  was  incoherent,  the  speech 
thick,  and  he  was  unable  to  express  his  wants,  but  there  was 
uo  paralysis.  In  24  hours  he  entirely  recovered.  Two  or 
three  weeks  later  he  had  an  attack  of  excitement  brought  on 
without  sufficient  provocation.  He  had  delusions  of  perse- 
cution and  at  the  same  t  me  some  grandiose  ideas.  On 
January  7, 1888,  he  had  4  convulsive  attacks ;  following  these 
he  was  aphasic  and  there  was  ptosis  of  the  right  lid.  By 
January  24  the  aphasia  had  almost  entirely  disappeared, 
except  that  he  occasionally  misapplied  a  word.  On  March 
20  he  had  another  convulsion.  The  face  was  drawn  to  the 
left  and  both  arms  were  violently  convulsed.  This  attack 
was  also  followed  by  aphasia.  Convulsions  now  occurred  at 
intervals  of  from  one  to  two  weeks.  The  strength  of  the 
right  side  was  decidedly  less  than  the  left,  but  there  was  no 
distinct  paralysis.  The  ocular  conditions  were  as  follows : 
At  the  first  examination  there  was  paresis  of  the  right  ex- 
ternus  and  compound  myopic  astigmatism.  January,  1887, 
Dr.  Oliver  reported  that  "Fields  of  vision  were  normal, 
although  those  of  the  left  eye  were  somewhat  reduced  in 
area.  The  eye-grounds  gave  marked  evidences  of  regressive 
neuro- retinitis  and  this  was  more  pronounced  upon  the  left. 
Upon  individual  exposure,  the  left  pupil  was  the  larger,  al- 
though conjointly  both  became  equal.  In  associated  action 
the  irides  were  freely  mobile  to  light  stimulus  and  accom- 
modative reaction.  A  slight  paresis  of  the  right  externus 
could  be  made  out." 

About  the  end  of  May  he  had  another  seizure,  after  which 
the  entire  right  side  was  paretic  for  8  hours,  and  the  aphasia 
was  more  marked.  From  this  time  onward  the  patient's 
condition  grew  worse.  His  mental  state  deteriorated  and 
he  had  periods  of  excitement  which  caused  him  to  become 
violent.  He  was  finally  admitted  to  the  Pennsylvania  Hos- 
pital for  the  Insane,  where  he  remained  until  his  death,  which 
occurred  3  months  after  his  admission.  An  autopsy  was 
made  in  which  the  only  lesions  found  were  those  of  paresis ; 
that  is,  the  pia  arachnoid  was  opaque,  and  there  was  an 
unusual  amount  of  subarachnoid  serum,  but  there  were  no 
gross  changes  to  be  found  anywhere  in  the  brain.  Through 
an  accident  the  brain  became  unfit  for  microscopic  exam- 
ination. 

Case  2. — A.  J.  E.,  aged  32,  married.  Consulted  me  October 
6,  1898.  He  never  had  syphilis  and  had  always  been  tem- 
perate and  correct  in  all  of  his  habits.  No  history  of  any 
serious  illness.  His  occupation  was  that  of  a  bookkeeper, 
and  he  had  previously  been  for  a  time  employed  in  a  drug 
store,  but  had  to  give  up  the  work  because  he  was  not  strong 
enough.  He  is  the  father  of  5  children,  all  of  whom  are 
healthy  except  the  youngest  boy  who  is  2J  years  of  age, 
and  who  was  born  after  the  present  illne-ss  of  the  patient 
began.  The  child  is  a  deaf  mute  and  is  backward  in  every 
respect.  Four  years  ago  the  patient  got  into  an  altercation 
with  a  man,  who  struck  him  a  violent  blow  on  the  left  side 
of  the  head,  just  below  the  ear,  and  he  fell,  striking  against  a 
bulk  window  and  injuring  the  right  side  of  his  head.  When 
he  got  upon  his  feet  he  was  again  struck  on  the  side  of  the 
head  by  his  assailant.  He  was  stunned  and  dazed  when  he 
got  home,  but  there  was  no  external  injury.  For  about  2 
months  after  this  he  had  a  noise  in  the  right  ear  and  was 
somewhat  deafened.  He  then  saw  his  doctor  about  it.  He 
was  not  otherwise  affected,  except  that  his  wife  thought  he 
was  more  irritable  than  usual.  In  the  autumn  of  1897, 
about  3  years  after  the  injury,  he  seemed  to  get  worse. 
There  was  a  tendency  to  shaking  of  the  hands,  his  speech 
became  hesitating  and  his  memory  was  impaired.  He  con- 
tinued his  work,  however.  In  May,  1898,  he  suddenly  had 
a  sense  of  numbness  in  the  right  arm,  which  extended  to  the 
head  and  also  to  the  leg.  The  attack  lasted  about  15  min- 
utes, and  after  this  he  seemed  as  well  as  before.  He  had 
another  similar  attack  2  months  later  and  about  3  weeks 
before  seeing  me  he  had  had  a  third  attack.  In  addition  to 
the  numbness  in  the  arm  and  leg  and  drooping  of  the  lid, 
there  was  inability  to  swallow  and  thickened  tongue.  He 
was  not  unconscious  during  the  attacks,  but  after  one  he 
always  seemed  worse  than  before  ;  he  dragged  his  leg  more 
and  seemed  generally  feeble. 

On  examination  it  was  observed  that  the  expression  was 
vacant.  There  was  a  tendency  to  drooping  of  the  left  side 
(»f  the  mouth  and  the  speech  was  slow  and  inclined  to  be 


scanning,  his  memory  was  poor,  sleep  variable,  there  was  no 
nystagmus,  pupils  equal,  knee-jerks  markedly  exaggerated 
but  no  clonus.  The  patient's  mental  condition  was  evi- 
dently below  par,  although  he  had  no  delusions.  There  was 
a  tendency  to  tremor  in  the  hand  when  it  was  used,  and  in 
walking  his  whole  body  was  moved  stitily.  He  could  whistle 
and  there  was  no  marked  tremor,  but  his  tongue  trembled 
when  it  was  protruded.  He  had  no  headache,  and  there 
was  no  loss  of  power  in  the  arm,  but  he  was  inclined  to  drag 
the  right  leg  in  walking. 

The  patient's  mental  condition  grew  worse  from  this  time. 
He  became  delusional  and  at  times  was  greatly  excited  so 
that  it  was  difficult  to  manage  him.  He  finally  lost  strength 
and  fell  into  a  condition  of  dementia.  He  died  July,  1900. 
The  brain  was  sent  to  me  for  examination,  and  I  referred  it 
to  Dr.  Spiller,  who  found  no  gross  lesions,  and  who  has 
kindly  made  the  following  report  of  the  microscopic  ex- 
amination : 

"  Sections  from  the  left  paracentral  lobule  stained  with  a 
nuclear  stain  show  distinct  round-cell  infiltration  of  the  pia. 
Round-cell  infiltration  is  also  found  about  the  vessels  witnin 
the  brain-substance,  but  does  not  extend  beyond  the  perivas- 
cular spaces.  Numerous  spaces,  small  and  usually  round, 
arc  found  within  the  white  matter  beneath  the  cortex.  It 
is  difficult  to  say  whether  these  are  caused  by  a  gas-forming 
microorganism,  or  are  the  result  of  degeneration  of  nerve 
fibers  No  microorganisms  can  be  found  by  deep  staining 
with  thionine.  These  spaces  are  far  more  numerous  in  the 
white  matter  of  the  brain  and  in  the  medulla  oblongata  than 
they  are  in  the  cerebral  cortex,  and  are  not  separated  frorn 
the  surrounding  tissue  by  a  distinct  wall.  Many  of  the  peri- 
vascular spaces  are  much  enlarged.  It  is  diflicult  to  express 
an  opinion  in  regard  to  the  number  and  condition  of  the 
nerve-cell  bodies  and  of  the  medullated  fibers,  as  the  method 
employed  for  hardening  the  tissues  prevents  the  proper 
staining  with  thionine  and  Weigert's  hematoxylin.  The 
above  description  applies  also  to  sections  from  the  left  upper 
ascending  frontal  convolution,  from  the  right  frontal  lobe 
and  from  the  medulla  oblongata.  The  condition  is  one  of 
meningoencephalitis." 


OPERATIVE  TREATMENT  OF  TUBERCDLAR  LYM- 
PHOMATA OF  THE  NECK* 

By   PEESCOTT  LE  BRETON,  M.D., 
of  Buffalo,  N.  Y. 

Nature  has  provided  a  wonderful  barrier  to  certain 
diseases  and  infections  in  human  beings  by  the  elaborate 
system  of  lymphatic  channels  and  nodes  throughout 
the  body.  Due  warning  is  given  of  an  invasion  of 
septic  or  other  processes  by  the  swelling,  pain,  and 
tenderness  occurring  in  the  glands  and  noted  by  the 
patient.  Certainly  no  surgeons  think  of  removing  such 
able  sentinels  so  long  as  they  preserve  their  usefulness 
and  are  more  serviceable  than  damaging.  Wheri,  how- 
ever, the  infectious  process  overcomes  the  resistance 
met  with,  the  surgeon  must  interfere.  As  regards  opera- 
tion in  the  case  of  tuberculosis  of  the  lymph  nodes 
opinions  are  at  variance.  Schleich,  of  Berlin,  advises 
a  conservatism  almost  unsurgical,  because  of  unsatis- 
factory data  as  to  surgical  treatment.  Wheaton  states 
that  the  protection  aflforded  is  so  perfect  and  so  exten- 
sively exercised  that  removal  of  such  a  help  to  health 
is  often  a  crime.  Horace  Grant,  after  quoting  these 
men  in  a  recent  article,  has  summed  up  the  matter  and 
meets  the  objections  ofifered. 

1.  Although  there  is  a  loss  of  protection  for  a  time, 
the  remaining  glands  and  newly-formed  lymphatic 
channels  soon  perform  an  extra  duty,  just  as  one  kidney 
will  do  the  work  of  two,  or  as  one  part  of  the  brain  will 
do  the  work  of  a  part  previously  excised. 

"•Read  at  a  meetlmj  of  the  Surgical  Section  of  the  Buff»lo  Academr  «« 
Medicine,  February  5,  1901. 


480         "^^^  Philadelphia"! 
Medical  Joobnal  J 


TUBERCULAR  LYMPHOMATA  OF  THE  NECK 


[mabch  9,  i«n 


2.  The  difficulties  of  complete  removal  in  competent 
hands  are  never  insurmountable. 

3.  Dissemination  of  tubercle  bacilli  may  be  pre- 
vented by  careful  dissection  and  cleanliness  during  the 
operation. 

We  may  add  to  these  statements  that  operation  is 
indicated  because  general  infection  does  occur  in  a 
large  proportion  of  cases  of  tuberculosis  of  the  cervical 
glands.  Van  Noorden,  quoted  by  Dowd,  found  that  of 
149  cases  whose  histories  had  been  traced  for  3  years  or 
more,  28  died  of  general  tuberculosis  and  14  others 
had  pulmonary  tuberculosis,  but  were  alive  at  the  time 
of  the  report. 

Treves,  in  his  monograph,  written  as  early  as  1882, 
had  found  excision,  scooping  and  cautery  puncture  the 
best  treatment. 

Certainly  the  general  trend  of  opinion  among  surgeons 
in  this  country,  as  evidenced  in  the  latest  editions  of  Da 
Costa,  Roberts,  Stimson,  etc.,  is  towards  radical  operation 
in  all  cases  that  have  withstood  medical  treatment. 

The  great  frequency  of  cases  in  which  lymphomata 
of  the  neck  appear  renders  the  subject  an  important 
one.  In  children  tuberculosis  starts  most  often  in  this 
region  and  assumes  various  types,  Watson  Cheyne  in 
the  Harveian  lectures  in  1899  gives  the  most  practical 
classification  according  to  clinical  characteristics  and 
indications  for  treatment. 

1.  Cases  in  which  the  glands  remain  hard,  small  and 
movable,  with  no  marked  tendency  to  softening  or 
matting  together.  As  long  as  the  glands  are  quiescent 
they  may  be  left  alone  and  medical  treatment  alone 
instituted. 

2.  Cases  in  which  the  glands  enlarge  steadily  or  at 
intervals  until  the  whole  side  of  the  neck  is  involved 
in  a  mass  of  glands,  some  free  and  others  matted 
together,  and  in  all  stages,  from  those  which  are  fleshy 
in  appearance  to  those  which  are  cheesy  and  suppu- 
rating. Here  medical  treatment  is  contraindicated  and 
surgical  intervention  should  be  prompt  and  thorough, 
consisting  in  complete  excision. 

3.  Cases  in  which  the  inflammation  is  very  active. 
The  glands  enlarge  rapidly  and  soon  suppurate  while 
fresh  glands  become  involved.  Periadenitis  is  early, 
and  unless  the  case  is  operated  upon,  abscess  after  ab- 
scess forms,  and  numerous  ulcers  remain.  Again 
excision  is  indicated.  Although  many  surgeons  are 
content  with  scraping,  excision  is  the  better  plan,  with 
removal  of  capsules,  fat,  and  neighboring  glands. 

4.  Cases  in  which  there  are  unopened  abscesses,  and 
these  may  be  subdivided  according  to  the  position  of 
the  abscess.  If  1  or  2  glands  only  enlarge  and  suppu- 
rate, by  making  an  oval  incision  over  the  mass  and  dis- 
secting outside  the  abscess,  one  may  often  enucleate 
abscess  and  glands  in  toto.  If  the  abscess  is  accident- 
ally opened  while  dissecting,  the  pus  should  be  washed 
away  immediately,  ^\'here  the  abscess  has  broken 
through  the  deep  fascia  and  undermined  the  skin,  it  is 
sometimes  wise  to  incise  and  drain  3  to  4  weeks  and 
then  operate,  rather  than  excise  the  thin  skin  over  the 
abscess  and  leave  a  large  scar  that  may  stretch. 

5.  A  series  of  long-standing  cases  in  which  ulcers 
and  sinuses  remain  with  remnants  of  broken-down 
tubercular  tissues  and  glands  at  the  bottom.  The 
treatment  is  either  excision  or  scraping,  with  the  appli- 
cation of  iodoform  or  carbolic  acid. 

The  most  important  rule  to  remember  in  excising 
these  cervical  glands  is  to  remove  not  only  the  glands, 
but  their  capsules  and  other  surrounding    tissue,  in 


which  are  often  small  glands  already  infected.  In 
other  words,  to  go  wide  of  the  disease  as  in  operating 
upon  malignant  growths.  This  produces  the  best  re- 
sults, the  cleanest  wound,  and  the  quickest  healing. 
Cheyne  is  the  most  ardent  advocate  of  a  complete  and 
radical  operation,  leaving  the  least  chance  of  recurrence. 
Hartley  considers  it  best  to  identify  the  chief  structures 
in  the  neck  and  dissect  them  from  the  mass,  rather  than 
to  dissect  the  mass  from  them.  The  operation  must  be 
planned  beforehand  and  carried  out  systematically 
with  an  incision  large  enough  to  expose  the  field  and 
allow  complete  extirpation  without  cutting  important 
structures. 

Numerous  incisions  have  been  devised.  In  the  sub- 
maxillary region  an  incision  similar  to  Kocher's  for 
excision  of  the  tongue  is  the  one  preferred.  If  only  a 
few  glands  are  involved  in  the  anterior  triangle  a 
straight  incision  in  front  of  the  stemomastoid  will  be 
sufficient.  In  the  posterior  triangle  a  straight  incision 
behind  the  stemomastoid  or  an  incision  running  down 
behind  the  stemomastoid  and  curving  backward  above 
and  parallel  to  the  clavicle.  When  the  glands  in  both 
the  anterior  and  posterior  triangles  are  enlarged  some 
surgeons  incise  parallel  to  the  muscle  both  in  front  and 
behind  and  dissect,  lifting  the  muscle  up  from  its  bed. 
The  incisions  of  Hartley  and  Dowd  are  the  best  and 
afibrd  more  room,  each  being  followed  by  the  cross- sec- 
tion of  the  stemomastoid.  Hartley  formerly  used  the 
S  H  and  T  incisions  but  abandoned  these  in  1897  for 
the  following :  Beginning  just  below  the  mastoid  pro- 
cess in  front  of  the  stemomastoid,  incise  along  the 
anterior  margin  of  the  muscle  to  its  middle  point,  alter 
the  direction  to  run  downward  to  a  point  one  inch  above 
the  sternoclavicular  articulation,  then  curving  laterally 
with  a  rounded  angle,  pass  across  the  posterior  triangle 
till  a  line  joining  the  two  extremities  of  the  incision 
passes  behind  the  posterior  margin  of  the  mass.  Dowd's 
incision  is  the  reverse  of  this  in  position.  Starting  from 
under  the  lower  jaw,  running  backward  to  the  mastoid 
and  downward  along  the  hair  border,  the  incision  is 
continued  as  far  forward  and  downward  as  the  extent  of 
the  disease  renders  it  desirable.  The  scar  resulting  from 
this  is  the  least  noticeable  and  is  not  liable  to  stretch. 

Having  incised  through  superficial  fascia  and  pla- 
tysma,  the  flap  is  dissected  back.  The  external  jugular 
vein  is  tied  above  and  below  and  any  superficial  glands 
along  its  course  are  removed.  The  stemomastoid  is 
now  cut  transversely  below  the  exit  of  the  spinal  acces- 
sory nerve  and  its  ends  reflected,  in  this  way  uncovering 
the  great  vessels  from  the  mastoid  process  to  the  clavi- 
cle. Milton,  quoted  by  Dowd,  reports  two  cases  of 
torticollis  following  this  muscle  section,  but  no  other 
ill  effects  have  been  seen,  as  many  surgeons  testify.  The 
writer  has  cut  this  muscle  several  times  and  reunion 
and  return  of  power  have  resulted.  The  key  to  the 
situation  is  to  locate  the  internal  jugular  vein  at  the 
lower  end  of  the  woufld  and  foUow  it  as  one  finds  and 
follows  the  axillary  vein  in  the  axiUa.  If  the  disease 
is  continued  to  the  root  of  the  neck,  slow  and  patient 
work  is  insisted  upon  to  avoid  the  pleura  and  other 
important  structures  and  especially  the  thoracic  duct 
on  the  left  side.  Having  located  the  internal  jugular, 
by  blunt  dissection,  aided  by  snips  with  curved  scissors, 
the  contents  are  enucleated  en  masse.  In  managing 
the  tumor  violent  tearing  of  the  nodes  should  be  avoided 
and  the  tumor-hook  must  be  prevented  from  puncturing 
suppurating  foci  and  spreading  pus  over  the  wound. 

If  periadenitis  is  present  and  the  glands  are  adherent 


March  9,  1901] 


FRACTURE  OF  THE  METACARPAL  BONE  OF  THUMB 


fTHE  Philadelphia 
L  Medical  Jopbnal 


481 


to  the  internal  jugular,  it  is  best  to  ligate  it  and  remove 
it  with  the  glands.  The  dissection  is  facilitated  and  no 
harm  is  done  to  the  patient.  Watson  Cheyne  says : 
"  Probably  in  the  majority  of  cases — in  all  cases  where 
there  are  sinuses  and  practically  in  all  cases  where  sup- 
puration is  present — I  make  a  point  of  dividing  the  vein 
between  two  ligatures  and  taking  it  away  along  with  the 
mass  of  glands."  If  the  vein  is  removed  the  superior 
thyroid,  lingual,  and  facial  veins  are  met  with  above 
and  must  be  ligated.  A  final  ligature  is  applied  to  the 
internal  jugular  at  the  upper  end  of  the  wound.  The 
descendens  noni  is  recognized  and  saved.  As  the  mas- 
toid process  is  neared  the  spinal  accessory  is  looked  for 
at  its  entrance  into  the  sternomastoid  and  followed  up- 
ward, separating  the  glands  about  it.  Then  the  glands 
under  the  mastoid  may  be  freed,  care  being  taken  not 
to  cut  the  facial  nerve.  Rarely  there  are  glands  beneath 
the  common  carotid  which,  when  enlarged,  are  removed. 
After  defining  the  spinal  accessory  at  its  exit  from  the 
sternomastoid  and  freeing  it,  the  posterior  triangle  can 
be  cleared.  The  entire  field  should  now  be  clean.  The 
sternomastoid  is  sewed  with  catgut.  If  Hartley's  inci- 
sion is  used  a  puncture  at  the  base  of  the  flap  is  made 
and  a  small  drainage  tube  inserted  to  remain  48  hours. 
The  flap  is  sewed  in  place  unless  pus  has  smeared  the 
wound,  in  which  case  1  or  2  wicks  of  gauze  may  be 
added  at  the  corners  of  the  incision.  If  sinuses  have 
been  present  they  are  scraped  out  before  the  operation 
is  begun  and  the  edges  cut  away. 

The  lowest  branch  of  the  facial,  running  below  and 
parallel  to  the  lower  jaw,  is  often  cut.  This  causes  a 
temporary  drooping  of  the  lower  lip  near  the  angle  of 
the  mouth,  but  need  cause  no  alarm.  The  superficial 
branches  of  the  cervical  plexus  are  usually  injured,  re- 
sulting in  anesthesia  of  the  skin  supplied  by  them. 
The  deep  branches  can  be  avoided.  The  writer  has 
seen  one  case  in  which  the  thoracic  duct  was  cut.  Chyle 
flowed  freely  for  about  a  week,  then  the  discharge  grad- 
ually ceased,  pressure  being  applied  over  the  discharg- 
ing area.  A  frequent  use  of  hot  saline  solution  in  the 
wound  clears  it  of  blood  and  causes  the  tissue  to  stand 
out  in  bold  relief.  Many  small  vessels  are  wounded 
and  it  is  only  by  salt-solution  that  we  may  secure  an 
unstained  field. 

Patients  stand  this  extensive  operation  well,  being  up 
and  about  in  a  week  or  ten  days.  In  a  series  of  7  cases, 
operated  on  by  the  writer,  there  were  no  accidents  or 
complications.  The  writer  remembers  one  case  in  which 
the  common  carotid  sloughed  through  the  night  after 
operation,  at  a  point  where  it  was  infiltrated  with 
tubercular  tissue.  The  hemorrhage  was  severe,  but  a 
ligature  was  tied  about  the  artery  and  the  patient  lived. 
In  the  case  of  a  little  girl  in  which  the  submaxillary 
glands  were  excised,  death  followed  on  the  third  day 
from  what  was  apparently  an  ulcerative  endocarditis. 
No  autopsy  could  be  obtained. 

The  ultimate  results  are  encouraging.  Dowd  gives 
the  following  table  of  cases  whose  after-histories  were 
followed  in  most  instances  for  several  years. 

Total  number  of  cases 309 

Apparently  cured 202        65.4^ 

Living  with  local  or  general  tuber- 
culosis    57        18.4% 

Died  of  tuberculosis 50        16.2% 

Since  it  has  been  proved  that  the  bacilli  enter,  as  a 
rule,  through  the  mouth  and  pharynx,  an  important 
adjunct  to  the  treatment  is  the  removal  of  adenoids, 
and  hypertrophied  tonsils  and  the  care  of  carious  teeth. 


Eczema  of  the  scalp,  rhinitis  and  otitis  demand  atten- 
tion. 

BIBLIOGRAPHY. 

Dowd  ;  Annals  of  Sur<jery,  vol.  29,  p.  559. 

Hartley  :  Bo-ilon  Medicut  and  Surgical  Journal,  vol.  cxxxvii,  No.  17. 

Grant :  New  York  Medical  Juumal,  October  20,  1900. 

Laplace:  Journal  American  Medical  Association,  vol.  SO,  p.  1321, 

Treves;  Scrofula  aud  its  Gland  Diseases,  Philadelphia,  1883,  H.  C.  Lea,  Son 

4  Co.  ■=::= 

Cheyne;  British  Medical  Journal,  December  16,  1899. 
StimsoD  ;  Operative  Surgery.  1900. 
I)a  Costa;  Modern  Surgery,'  1900. 


A  SKIAGRAPH  OF  BENNETTS  FRACTURE  OF  THE 
METACARPAL  BONE  OF  THE  THUMB  OR  "  STAVE 
OF  THE  THUMB."* 

By  JOHN  B.  ROBERTS,  M.D., 

of  Philadelphia. 

Through  the  courtesy  of  Dr.  George  Thomas  Beat- 
son,  of  Glasgow,  Scotland,  I  am  able  to  show  a  Rontgen- 
ray  print  of  this  fracture.  The  injury  was  accurately 
described  in  1885  by  Professor  E.  H.  Bennett,  of  Dublin, 
Ireland,  but  has  not  attracted  as  much  attention  in  this 
country  as  it  should. 


Fio.  1. 

The  fracture  occurs  obliquely  at  the  base  of  the  meta- 
carpal bone  of  the  thumb  on  its  palmar  aspect,  detach- 
ing a  portion  of  the  base  of  the  bone.  It  runs  into  the 
joint  between  the  metacarpal  bone  and  the  trapezium. 
As  a  result  of  this  detachment  of  a  considerable  por- 
tion of  the  articular  surface,  the  metacarpal  bone  is 
displaced  backward  and  gives  a  deformity  similar  to 
that  of  a  posterior  subluxation.     The  injury  is  usually 

*  Read  before  the  College  of  Physicians  of  Philadelphia,  February  6, 1901. 


482  ^^^  Philadelphia"! 

"  Medical  Jocbnal  J 


FRA.CTURE  OF  LOWER  END  OF  RADIUS 


IMasch  9,  liw. 


Fig.  2. 


caused  by  a  blow  applied  in  the  long  axis  of  the 
thumb.  The  pain  causes  a  disability  in  opposing  the 
thumb  to  the  index  finger  and  probably  to  the  other 
fingers.     Grasping  small   objects  becomes  impossible 


and  pressure  on  the  ball  of  the  thumb  gives  pain.  The 
injur}-  is  likely  to  be  mistaken  for  subluxation,  sprain, 
or  contusion.  It  is  to  be  treated  by  extension  and  fall 
abduction  of  the  thumb,  Trhich  should  be  maintained 
by  a  gypsum  or  other  splint.  The  skiagraphs  of  Dr. 
Beatson's  case  were  taken  sixteen  days  after  the  injury 
and  at  the  conclusion  of  treatment.  The  fracture,  until 
seen  by  Dr.  Beatson,  had  been  unrecognized  and  had 
not  been  reduced. 

The  attention  of  the  Fellows  is  called  to  this  injury 
because  it  is  probable  that  it  is  overlooked.  I  have 
never  recognized  the  fracture,  though  the  inspection  of 
the  skiagraphs  calls  to  my  mind  an  injury  of  the  thumb 
seen  some  time  ago  which  was  not  clear  to  me.  It  is 
possible  that  it  was  a  case  of  this  kind. 


A  CAST  AND  SKIAGRAPH  OF  THE  SO-CALLED  SMITff  S 
FRACTURE  OF  THE  LOWER  END  OF  THE  RADIUS. 

Bt  JOHN  B.  ROBERTS,  M.D.. 
of  Ptuladelphia. 

Several  years  ago  I  showed  a  series  of  specimens 
from  the  Mutter  Museum  Ulustrating  fracture  of  the 


Flo.  3. 


MiRCH  9,  1901] 


NECESSITY  FOR  BACTERIOLOGICAL  COMMISSIONS 


CTbk  Philadklphli 
Mbdicai,  Joubsal 


483 


lower  end  of  the  radius  with  anterior  displacement. 
There  were  also  shown  at  that  time  skiagraphs  of  such 
fractures.  In  a  monograph  presented  to  the  Ameri- 
can Surgical  Association  in  1896,  I  recorded  a  number 
of  instances  occurring  in  my  own  practice  and  collected 
from  various  sources.  Experience  in,  and  study  of, 
this  injury  have  convinced  me  that  it  is  usually  over- 
looked. Of  the  five  or  six  cases  which  I  have  seen 
there  was  probably  not  one  in  which  the  character  of 
the  injury  was  clearly  understood  by  the  practitioner 
who  first  saw  it. 

It  is  a  great  pleasure,  to  be  able  to  present  to  the  col- 
lege at  this  time  a  cast  and  a  skiagraph  of  an  old  injury 
of  this  sort,  sent  me  by  Dr.  George  Thomas  Beatson  of 
Glasgow,  Scotland.  The  case  was  one  which  Dr.  Beat- 
son  did  not  see  until  a  year  after  the  accident.  It 
occurred  in  a  woman  of  46  years,  who  fell  from  a 
bicycle.  The  deformity  corresponds  with  that  usually 
seen,  and  the  skiagraph  is  an  almost  perfect  representa- 
tion of  the  specimen  in  the  museum  of  the  New  York 
Hospital,  a  picture  of  which  was  given  in  the  article  to 
which  reference  has  been  made.  It  is  unnecessary  to 
speak  of  the  treatment  in  full  at  this  time.  It  may, 
however,  be  said  that  it  requires  the  application  of 
force,  often  great  force,  to  break  up  the  impaction  and 
restore  the  fragments  to  their  normal  relations.  A 
moulded  splint,  made  of  metal,  gutta  percha,  or  gauze 
and  plaster  of  Paris,  should  then  be  applied  to  the 
palmar  surface.  In  some  cases  a  straight  splint  may  be 
applied  to  the  dorsal  surface  instead  of  the  moulded 
splint  to  the  palmar  surface. 


ON   THE  NECESSITY  FOR    THE  ORGANIZATION  OF 

»  BACTERIOLOGICAL     COMMISSIONS      FOR     THE 

STUDY  AND  INVESTIGATION  OF  QUARANTIN- 
ABLE  DISEASES  UNDER  THE  FORMATION  AND 
CONTROL  OF  THE  GOVERNING  AUTHORITIES 
OF  THE  COUNTRIES  INTERESTED— AN  ABSO- 
LUTE NECESSITY  FOR  THE  SCIENTIFIC  MAN- 
AGEMENT AND  BETTERMENT  OF  MARITIME 
HYGIENE  AND  QUARANTINE.* 

By  henry  B.  HORLBECK,  M.D., 

Health  Officer  of  Charleston,  S.  C. 

The  story  of  maritime  hygiene  and  quarantine  is  the 
tale  of  the  closing  years  of  the  nineteenth  century. 

It  is  the  history  of  one  of  the  great  problems  confront- 
ing civilized  mankind,  a  problem  to  solve,  whose  mis- 
sion it  is  to  protect  tens  of  millions  of  mankind  from 
the  transmission  of  diseases  of  fatal  tendencies  and  to 
permit  with  all  possible  freedom  the  interchanges  of 
commerce,  and  thus  secure  international  exchange. 

When  it  is  considered  how  absolutely  necessary  to 
the  well-being  and  happiness  of  mankind  is  the  un- 
limited and  unshackled  and  unchecked  intercourse  of 
nations  and  communities  on  the  great  highways  of  the 
sea,  it  will  be  seen  how  serious  and  momentous  is  the 
question  to  be  answered.  As  the  civilization  and  pros- 
perity of  the  world  have  advanced,  so  has  the  imperious 
demand  been  made  pari  passu,  for  the  minimization  of 
restraints  upon  commerce  and  for  some  practical  solu- 
tion of  the  world-wide  problem  of  holding  in  check  and 
fettering  the  great  leviathans  which  traverse  the  oceans 
of  the  world. 

The  maritime  hygiene  and  the  maritime  quarantine 

•  Bead  before  the  Section  of  Marine  Hygiene  and  Quarantine,  Pan-American 
Medical  Congress,  February  4, 1901. 


of  the  past  concerned  not  itself  with  the  hardships  of 
a  40-day  detention  ;  fleets  of  vessels  were  kept  infecting 
and  reinfecting  themselves  for  this  period,  this  con- 
finement ceasing  only  when  every  craft  had  been  sub- 
jected to  quarantinable  disease. 

From  the  quarantine  detention  of  40  days,  which  was 
the  recognized  period  of  detention  in  the  past,  to  the 
quarantine  restraint  of  5  days  now  prescribed  is  a  great 
leap  and  a  vast  progress. 

From  the  sulphur  pots  of  only  1.5  or  20  years  ago  to 
the  perfected  jacketed  steam  cylinder  is  a  far  greater 
bound  and  .shows  a  much  greater  growth. 

These  are  not  simply  advances  loosening  the  check- 
rein  that  has  hampered  commercial  prosperity  and 
progress,  but  they  are  methods  that  have  greatly  mini- 
mized a,nd  lessened  the  chances  and  dangers  of  the  in- 
troduction of  diseases  which  scourge  mankind  and 
desolate  the  households  and  habitations  of  human 
victims. 

These  steps  of  human  progress  have  been  accom- 
plished in  so  short  a  period  of  time  that  would  almost 
seem  incredible.  It  has  all  occurred  in  less  than  a 
generation  of  man,  and  during  the  official  life-terms  of 
some  of  us  who  are  engaged  in  the  daily  mission  of 
protecting  our  shores  from  the  introduction  of  danger- 
ous and  deadly  diseases.  With  a  better  knowledge  of 
the  diseases  most  to  be  dreaded  our  restraints  will  be 
surely  lessened,  and  our  ability  to  protect  our  shores 
increased. 

The  outlook,  the  standpoint,  and  the  responsibilities 
of  one  engaged  or  charged  with  the  duties  of  carrying 
out  a  safe  quarantine  vary  greatly  with  his  locale. 
While  each  and  every  quarantine  official  feels  to  a  cer- 
tain extent  the  requirement  of  protecting  his  community 
from  the  advent  of  all  dangerous  diseases  he  feels  that 
there  are  certain  diseases  which  are  to  him  most  im- 
portant, and  to  which  his  community  is  especially 
liable  and  which  he  must  guard  against  with  all  his 
main  and  all  his  soul.  The  health  official  of  one  of  our 
northern  ports  feels  every  pulse  quicken  at  the  reports 
of  cholera  and  plague. 

The  health  official  of  our  own  latitude  on  the  south 
Atlantic  coast  of  the  United  States,  and  to  the  south  of 
us  is  never  insensible  to  the  notice  and  warning  of  the 
presence  of  yellow  fever,  and  so  around  our  little  world 
there  will  be  found  on  the  borders  of  every  ocean  or  sea 
some  plague  or  pestilence  or  disease  that  prevails  in 
that  locality  with  a  tenacity  and  a  deadly  force  that 
must  be  accounted  with.  These  diseases  demand  every 
requirement  that  this  age  of  vitality  and  accountability 
has  furnished  and  provided  for  the  protection  of  the 
people  interested. 

All  of  us,  therefore,  that  are  engaged  in  this  all-im- 
portant work  must  look  to  such  dangerous  diseases  as  may 
when  introduced  injure  and  destroy  those  with  whose 
well-being  they  are  charged,  and  all  of  us,  it  is  to  be 
presumed,  have  perfected  ourselves  in  a  knowledge  of 
the  appliances  which  scientific  advance  has  furnished ; 
so  it  is  not  therefore  necessary  to  epitomize  what  tem- 
perature shall  be  employed  to  destroy  the  dangerous 
cocci,  or  this  pathogenic  bacillus,  or  tliat  perilous 
spirillum.  Our  health  associations  and  medical  organi- 
zations have  had  papers  and  papers  presented  on  such 
matters  explaining  tlioroughly  their  uses  and  advan- 
tages. 

What  is  the  all-absorbing  thought  in  entering  upon 
such  an  exciting  theme  or  subject  as  Maritime  Hygiene 
and  Maritime  Quarantine? 


484 


Trk  Phii.adklphia.~I 


NECESSITY  FOR  BACTERIOLOGICAL  COMMISSIONS 


[M^sca  9,  UOl 


We  all  know  that  a  temperature  of  230°  F.  will  surely 
kill  pathogenic  bacteria ;  this  much  we  know,  and  we  can 
surely  and  safely  use  this  temperature  with  confidence, 
and  we  have  the  jacketed  steam  cylinder  to  effect  the 
desired  result. 

We  may  also  use  with  more  or  less  confidence  and 
beiief  in  their  germicidal  value  certain  solutions  of  cer- 
tain chemical  salts  and  certain  vaporizations  which  are 
at  our  easy  command. 

We  are  thus  armed  and  equipped  with  the  materials 
for  warfare,  but  it  is  a  warfare  against  an  enemy  in 
many  cases  of  which  we  know  but  little. 

It  is  the  bludgeon's  work  and  not  the  rapier  thrust ; 
and  is  such  work  required  in  all  cases? 

The  dominant,  all-important,  ail-pervading  necessity 
in  the  work  of  maritime  hygiene  and  maritime  quaran- 
tine is  a  better  and  fuller  and  more  thorough  knowl- 
edge of  the  pathology  and  of  the  etiology  of  the 
diseases  against  which  our  quarantine  oflBcials  must 
contend  and  make  warfare. 

The  all-absorbing  necessity  is  a  better  and  a  fuller 
knowledge  of  the  causes,  and  we  can  in  no  way  better 
further  the  great  and  important  subject  of  maritime 
hygiene  and  quarantine  than  by  urging  upon  these 
earnest  gentlemen  of  this  Pan-American  Congress  the 
necessity  of  awakening  the  public  thought  and  interest 
among  the  people  they  represent  towards  the  more 
definite  and  closer  study  of  the  diseases  which  hamper 
commerce,  and  which  are  dangerous  to  the  lives  of  the 
communities  with  which  commerce  holds  intercourse. 

We  have  been  following  in  the  wake  of  ignorance, 
century  after  century,  until  the  two  last  decades. 

The  discovery  and  the  use  of  the  oil-immersion  lens 
and  other  mechanical  appliances  has  given  us  the  oppor- 
tunity of  acquiring  an  exact  knowledge  of  the  pathology 
of  the  diseases  which  are  ever  present  and  which  are  ever 
dangerous. 

The  exact  knowledge  of  the  raison  d^etre  of  these 
diseases  due  to  specific  origin  is  imperative,  and  mean- 
time maritime  hygiene  and  maritime  quarantine  will 
never  be  scientifically  fulfilled  until  this  is  obtained. 
To  acquire  such  sure  and  certain  information  there 
must  be  established  Government  commissions,  arranged 
for  bacteriological  research.  In  every  State  and  in 
every  community  where  there  are  diseases  that  exact 
constant  thraldom  to  commerce  and  that  are  of  ever- 
dangerous  importance,  there  should  be  established 
bacteriological  stations  for  constant,  unremitting,  and 
continuous  work ;  not  that  this  commission  should 
work  for  a  limited  period,  and  then  another  commission 
organized,  whose  first  duty  may  be  to  hunt  for  a  lost 
thread  of  a  predecessor's  labors,  but  an  organization  of 
trained  bacteriological  experts,  who  shall  be  so  equipped 
as  to  ensure  a  successful  investigation,  and  to  continue 
such  labors  until  the  work  that  has  been  assigned  to 
them  has  been  brought  to  a  successful  termination — 
mdla  dies  dn  sine  linea — following  the  heritage  of  Lord 
Bacon :  "  Its  law  is  progress ;  a  point  which  yesterday 
was  invisible  is  its  goal  today,  and  will  be  its  starting- 
point  tomorrow." 

For  two  and  a  half  years  Dr.  Ross,  with  unflagging 
interest  and  persistent  energy,  though  baffled  again  and 
again,  sought  the  malarial  organization  in  the  mosquito, 
and  he  finally  found  it. 

The  solution  of  the  cause  of  the  transmission  of 
malaria  among  the  nations  of  the  earth — the  certain 
knowledge — dissipating  the  superstitions  of  malaria  and 
malaqua,  is  of  such  incalculable  importance  and  benefit 


that  it  should  be  a  beacon-light  in  all  lands  and  in  aU 
countries. 

This  discovery  is  the  result  of  well-appointed,  well- 
organized,  and  long-sustained  bacteriological  investi- 
gation. 

Laveran  commenced  this  work  in  1889,  by  the  dis- 
covery and  description  of  the  plasmodium  malariae. 

It  has  taken  20  years  of  constant  and  assiduous 
work  to  fulfil  all  the  requirements,  so  that  full  fruition 
should  come  to  mankind,  and  today  the  picture  is  on 
the  wall. 

The  culmination  of  the  work  has  been  the  success  of 
the  procedures  undertaken  and  carried  out  during  the 
summer  of  the  year  1900,  at  Ostia.  Today  it  is  simply 
the  problem  of  the  destruction  of  the  anopheles  mos- 
quito. No  anopheles,  no  malaria.  It  has  taken  a  fifth 
of  a  century  of  continuous  scientific  work  to  accomplish 
this  result. 

What  of  the  malaria  and  the  malaqua  and  the 
miasms  and  the  vegetable  organizations  undergoing  de- 
cay or  decomposition  with  light  and  heat  and  moisture 
relegated  to  the  realms  of  the  shades  ?  Definite  knowledge 
has  assumed  leadership  and  physicians  and  sanitarians 
are  in  a  position  with  certain  and  definite  knowledge 
to  give  instructions  as  to  enlightened  methods  for  the 
protection  of  humanity. 

The  same  work  must  be  done  as  to  yellow  fever. 

For  over  two  centuries  have  the  nations  of  the  two 
continents  of  North  and  of  South  America  paid  tribute 
to  yellow  fever. 

In  a  recent  issue  of  the  N.  Y.  Herald  I  fimd  the  following 
report  as  to  yellow  fever ;  "  Medical  officers  in  Cuba 
admit  that  while  considerable  has  been  learned  about 
yellow  fever  since  American  occupation  began,  the  laws 
governing  the  disease  have  not  been  discovered.  Major 
Vallery  Harvard,  chief  surgeon  of  the  division  of  Cuba, 
says:  '  Yellow  fever  continues  to  strike  when  and  where 
it  liflteth,  regardless  of  our  most  reasonable  expectation 
and  best  hygienic  measures.  Why  the  germ  should 
remain  quiescent  and  inactive  one  or  two  seasons  in  the 
presence  of  susceptible  material  and  then  suddenly  be- 
come active  and  virulent  is  a  question  still  unanswered. 
The  outbreak  at  Santiago  last  year  was  attributed  on 
what  appeared  to  be  good  grounds  to  the  intensely  hot 
and  dry  spring,  while  the  outbreaks  of  this  year  at 
Santa  Clara  and  Quemados  are  attributed  on  equally 
good  grounds  to  the  unusually  heavy  rains  which  fell 
in  April  and  May.' '" 

What  tons  of  paper  and  what  gallons  of  ink  have 
been  sacrificed  in  giving  the  causes  of  yellow  fever  and 
what  is  the  situation  today  I  Theories  upon  theories. 
What  exact  certain  knowledge  have  we  of  the  etiology 
of  yellow  fever  ?     None. 

We  have,  however,  great  encouragement  from  the 
recent  investigations  of  Doctor  Walter  Reed  and  his 
colleagues.  Following  in  the  wake  of  Dr.  Carlos  Finlay, 
a  distinguished  investigator  of  the  city  of  Havana,  Dr. 
Reed  with  the  aid  of  the  microscope  has  given  us  a  clue 
to  the  labyrinth  which  has  so  fiir  baffled  all  investi- 
gators. 

Quoting  from  a  recent  exchange :  "  Dr.  Reed  says  the 
experiments  show  beyond  a  doubt  that  there  is  no  con- 
tagion from  an  infected  person  or  from  infected  cloth- 
ing, but  that  the  mosquitoes  alone  are  responsible  for 
the  spread  of  the  disease." 

What  a  vision  of  hope  this  discovery  affords, — that 
the  mosquito  (Culex  fasciatus)  is  the  conveyor  of  the 
maieries  morbi  of  yellow  fever.     It  is  a  source  of  con 


SfARCH  9,    1901] 


ALBUMINOUS  NUTRITION  AND  NUTRITIOUS  ALBUMEN 


("Thk  Philadrlphia 

L  Mkdical  Journal 


485 


gratulation  to  one  charged  with  the  great  and  grave  re- 
sponsibilities attaching  to  the  guardianship  of  the  pub- 
lic health  in  a  great  extent  of  territory.  What  an 
encouragement ! 

Only  one  having  such  duties  and  living  in  a  commu- 
nity susceptible  to  yellow  fever  can  realize  the  benefit 
of  such  a  boon.  With  the  exclusion  of  the  mosquito 
from  the  patient  the  dangers  of  the  transmission  of  the 
disease,  if  the  idea  proves  correct,  are  nil.  This  solu- 
tion, that  the  mosquito  is  the  factor  in  the  etiology  of 
yellow  fever,  explains  many  interesting  facts  :  its  pres- 
ence and  its  absence  in  various  communities,  the  immu- 
nity enjoyed  by  some  and  the  prev.alence  of  the  disease 
in  others,  as  the  mosquito  may  be  in  the  ascendancy, 
infecting  herself  and  conveying  the  poison  from  one 
patient  to  another  person. 

There  is  at  present,  at  this  period,  no  known  fact  estab- 
lished and  recognized  and  accepted  as  to  the  specific 
origin  of  yellow  fever  and  its  methods  or  modes  of 
transmission. 

What  has  the  maritime  hygienist  or  quarantine  offi- 
cer to  do  ?  Do  as  his  forefathers  have  done  for  gen- 
erations— proclaim  nonintercourse.  Certain  detention 
for  at  least  5  days  after  disinfection — a  sort  of  empirical 
quarantine  formula. 

We  are  holding  our  session  in  the  city  of  Havana, 
where  yellow  fever  has  been  more  or  less  present  for  two 
centuries,  summer  and  winter,  and,  judging  from  the 
records  of  the  past  summer,  its  inhabitants  are  as  pow- 
erless to  stay  its  ravages  as  they  were  when  the  holo- 
caust began — and  they  have  folios  and  folios  to  consult 
as  to  maritime  hygiene  and  maritime  quarantine.  Is  it 
not,  therefore,  becoming  in  us  and  proper  to  send  forth 
to  the  inhabitants  of  the  North  and  South  American 
Continents  from  this  Pan-American  Congress  our  urgent 
solicitation  and  recommendation  that  the  different  gov- 
erning and  representative  bodies  have  such  investigat- 
ing bacteriological  commissions  organized  as  we  have 
indicated  ? 

It  surely  does  not  want  a  lurid  pen  to  tell  of  the  tens 
and  tens  of  thousands  who  have  been  victims  and  whose 
homes  have  been  made  desolate.  It  does  not  require 
more  than  the  recital  to  tell  of  a  great  commerce  para- 
lyzed again  and  again. 

It  is  not  a  distant  past  to  recall  the  tragedies  and 
horrors  of  1878  in  the  Mississippi  Valley,  costing  16,000 
lives  and  $200,000,000  of  money.  These  facts  are  known 
to  us  all  and  require  but  the  reminder  to  bring  up  to 
us  the  picture  of  the  desolations  that  follow  upon  such 
visitations. 

And  as  to  yellow  fever  so  to  all  other  diseases  which 
come  within  the  purview  and  care  of  officials  charged 
with  the  administration  of  maritime  hygiene  and  mari- 
time quarantine. 

Without  a  scientific  knowledge  of  the  etiology  of 
plagues  and  pestilences  there  cannot  be  a  scientific  ad- 
ministration of  maritime  hygiene  and  quarantine. 

It  is  our  belief  that  the  good  health,  safety,  better- 
ment, and  happiness  of  mankind  require  that  constant 
effort  should  be  made  by  each  government  represented 
in  this  Pan-American  Congress  to  establish  properly 
equipped  bacteriological  stations  for  the  investigation 
of  dangerous  and  fatal  diseases,  so  that  quarantine  offi- 
cials may  have  such  exact  knowledge  that  they  may 
scientifically  fulfil  their  duties. 


Sir  Dyce  Duckworth  has  been  appointed  Consulting 
Physician  to  the  Italian  Hospital,  Qaeen  Square,  London. 


ALBUMINOUS  NUTRITION  AND  NUTRITIOUS 
ALBUMEN.* 

By  albert  BERNHEIM,  M.D., 

Instructor  in  Diseases  of  the  Stom.ich  and  Intestine  In  tlie  Philadelphia  Poly- 
clinic and  College  for  Graduates  in  Medicine. 

By  the  above  title  Dr.  Finkler,  professor  in  the  Uni- 
versity of  Bonn,  read  a  paper  before  the  Ninth  Inter- 
national Congress  for  Hygiene  and  Demograpl»y  at 
Madrid,  Spain,  April  10-17, 1898.  In  this  paper  Kink- 
ier discussed  elaborately  the  great  and  absolute  neces- 
sity of  providing  man,  in  order  that  he  be  able  to  work 
and  to  exist,  with  a  food  that  will  yield  muscle  and 
with  the  muscle,  strength  ;  strength  of  body  and  indi- 
rectly strength  of  mind.  At  the  same  time  he  comes 
to  the  conclusion  in  accordance  with  many  investigators 
and  in  contradiction  to  views,  formerly  and  partly  now 
regarded  as  valid,  that  albumen  alone  is  the  supporter  of 
the  muscle-substance;  he  quotes  Pfliiger,  by  whose 
exact  and  accurate  researches  the  maxim  has  been  es- 
tablished, that  the  albumen  is  the  nutriment  of  the  first 
order,  and  whose  thesis  is :  "  Full  muscular  energy 
though  fat  and  carbohydrates  being  absent,  no  muscular 
energy  without  disintegration  of  albumen.  Albumen 
can  perform  all  the  work.  The  materials  of  the  second 
order,  however,  the  fat  and  the  carbohydrates,  are  by 
themselves  never  able  to  sustain  life ;  all  work  of  life 
can  be  performed  by  albumen  alone,  while  no  other 
material  in  the  universe  can  do  it.  The  integral  ingre- 
dient of  the  living  and  working  cell  is  the  albumen, 
indeed  often  the  only  organic  part  of  it." 

Dr.  Finkler  gives  the  daily  amount  of  raw  albumen: 

1.  For  hard-working  man 145  grams. 

2    For  moderately  working  man 96  grams. 

3.  For  moderately  working  woman...  61  grams. 

Supposing  the  man's  weight  to  be  65  kilograms  and 
the  woman's  weight  to  be  55  kilograms,  the  daily 
amount  of  raw  albumen  for  each  kilogram  would  be: 

Por  1  2.23  grams. 

For  2  t.48  grams. 

For  3  1-11  grams. 

In  the  rations  of  the  armies  of  12  countries,  he  finds 
the  average  amount  of  raw  albumen  as  follows : 

1.  In  times  of  peace   117.92  grams. 

2.  In  times  of  war  130.49  grams. 

3.  In  the  navy  on  sea  duty    148.03  grams. 

But  the  difference  between  the  ingested  albumen  and 
the  albumen  really  consumed  in  the  body  is  great.  In 
every  food  mixture  a  certain  part  of  albumen  will  not 
be  resorbed,  that  is,  it  is  called  indigestible.  The  cor- 
rection for  this  uselessly  ingested  albumen  is  of  the 
greatest  importance.  Of  course  there  are  many  points 
to  be  considered  as  to  this  correction,  which  may  ofi"er 
difficulties,  such  as  the  individual  percentage  of  the 
resorbability  of  each  food,  and  the  mixture  of  the  vari- 
ous nutriments  for  the  meals  and  particularly  the  indi- 
vidual disposition  of  man,  perhaps  too  the  training  and 
habits. 

There  are,  however,  to  a  certain  extent,  a  few  hints 
for  this  correction.  By  frequent  researches  the  value  of 
the  resorbable  albumen  of  some  of  the  main  kinds  of 
foods,  such  as  bread,  meat,  leguminous  plants  and 
vegetables  has  been  found. 

•  Paper  read  at  llie  meeting  of  the  Philadelphia  County  M«Ji<;a|  f^^'^^J- 
.lauuary  23,  1901.  Re-read  on  invitation  before  tlie  Northern  Medical  A!.soci»- 
tiou,  .January  '25,  1901. 


486 


The  Philadelphia 
Medical  Journal 


]        ALBUMINOUS  NUTRITION  AND  NUTRITIOUS  ALBUMEN 


[March  9,  1901 


On  the  average  we  must  subtract  5%  from  the  animal 
albumen  and  35%  from  the  vegetable  albumen  ;  at  the 
same  time  man  takes  about  one-third  of  the  food  from 
the  animal  stuffs  and  two-thirds  from  the  vegetable 
stufifs: 

Correcting  according  to  that  the  above  mentioned 
figures  we  get: 

F^r  1 108.08  digestible  i.  e.,  resorbable  albumen. 

For  2 72.00        "  "  "  '  " 

For  3 45.00 

And  from  the  same  standpoint  for  the  armies  of  the 
12  countries: 

1 88.19  digestible  i.  e.,  resorbable  albumen. 

2 100.97 

3 108.00 

Only  the  resorbable  albumen  will  Ite  used  for  the 
repair  of  the  body  ;  the  not  resorbable  is  a  waste  in  the 
body  in  regard  as  to  the  work  to  be  performed  as  well 
as  to  the  money  value. 

By  further  investigations  Finkler  finds  that  per  kilo- 
gram and  24  hours  1.73  grams  albumen  are  necessary 
for  a  hardworking  man,  for  a  moderately  working  man 
1.42  grams ;  therefore  for  a  man  of  G5  kilogram  body 
weight: 

When  hardworking 112  45. 

When    moderiitcly   working 92.45,   and  that   only 

resorbable  albumen. 

For  the  hard-working  man  the  defect  shown  is  3.6 
grams,  or  3.2 /c,  of  the  albumen. 

For  the  moderate  workingman  the  defect  shown  is 
20.3  grams,  or  22%. 

By  the  same  figuring,  the  ration  of  the  armies  in 
times  of  war  compared  to  the  food  of  the  hard-working 
man,  has  a  defect  of  12.35  grams  of  resorbable  albumen, 
or  10.16%  ;  the  sailor  on  sea  duty  3  6  grams,  or  3.2%  ; 
and  the  soldier  in  time  of  peace  24.70  grams,  or  20.31  %, 
while  the  albumen  in  time  of  peace  amounts  to  7.2 
grams,  or  6.4%,  above  that  of  the  moderately  working 
man. 

A  remarkable  and  well-known  fact  is  that  the  lower 
social  classes  have  to  suffer  most  from  the  deficiency  of 
albumen,  a  fact  which  is  caused  by  the  proportionately 
more  expensive  albuminous  foods.  It  is  true,  records 
of  inquiries  from  1853  and  1891  show  an  improvement 
to  a  certain  extent,  and  that  in  all  classes.  The  differ- 
ence between  the  poorest  and  richest  class  is  40.0  grams 
of  albumen,  whereby  not  even  the  richest  class  reaches 
the  absolutely  necessary  amount  of  proteids. 

1.  The  proportion  of  the  daily  consumption  of  albu- 
men in  4  classes,  differentiated  as  to  pecuniary  circum- 
stances, is  100:117:153:159. 

2.  The  animal  ingredients  of  the  food  were  in  the 
proportion  of  100:  135: 180:236. 

3.  The  total  amount  of  food  was  in  the  proportion  of 
100:111:129:139. 

The  comparison  of  these  figures  shows  that  the  pre- 
vailuig  need  is  not  the  fulness  of  the  dinner-pail  in 
order  to  fill  the  stomach,  but  to  provide  the  body  with 
the  necessary  amount  of  the  best  nourishment,  namely 
albumen,  the  material  most  suitable  for  the  reproduc- 
tion of  flesh  and  muscle-substance.  Corresponding  to 
the  instinctive  want  and  the  social  conditions  improving, 
first  the  consumption  of  animal  food  increases,  then 
the  consumption  of  albumen  in  the  whole,  and  but  as 
third  the  total  amount  of  food. 

A   question   not  to   be   neglected   arises.     Can   the 


take-in  of  albumen  not  be  reduced  and  be  replaced  by 
anitrogenous  food? 

Many  investigators  believe  that  this  can  be  done,  and 
perhaps  it  can  be  done  under  certain  circumstances  and 
to  a  certain  extent. 

But  what  happens  if  the  amount  of  albumen  is  re- 
duced ?  The  first  thing  is  that  the  organism  begins  to 
economize  by  reducing  the  metabolism  of  the  body 
albumen,  and  conforming  to  a  lower  metabolic  equilib- 
rium. 

Maybe  it  is  possible  that  for  a  short  time  work,  that 
has  to  be  done  by  albumen,  may  be  performed  by  ani- 
trogenous food,  but  only  for  a  short  time ;  when  less 
albumen  is  introduced  into  the  body,  the  muscle-sub- 
stance will  be  reduced  in  weight,  and  that  very  soon 
and  very  considerably ;  the  result  of  it  is  a  hunger  for 
albumen. 

If  in  man,  when  hardworking,  but  a  small  amount 
of  albumen,  and  a  large  one  of  fat  and  carbohydrates, 
are  disintegrated  in  the  metabolic  process,  we  must  not 
conclude  that  its  reason  lies  in  the  large  amount  of  fat,, 
but  in  the  small  amount  of  albumen  disposable;  thi» 
means  that  either  simultaneously  less  albumen  is  pres- 
ent in  the  food,  or  that  on  account  of  a  previous  reduc- 
tion of  the  body  albumen,  the  food  albumen  must  be 
used  for  repairing  the  muscle-substance  before  a  normal 
level  of  the  disintegration  of  albumen  for  the  sake  of 
working  can  be  reached.  This  fact  is  markedly  pro- 
nounced in  the  growing  persons,  in  convalescents,  and 
in  persons  recovering  from  hunger. 

It  is  particularly  the  fat  that  has  been  supposed  to 
have  the  capability  of  reducing  the  disintegration  of 
albumen,  but  at  the  same  time  the  concession  has  been 
made  that  this  fact  is  not  markedlj'  evident  when  a 
large  amount  of  fat  has  been  ingested  rlong  with  a 
small  quantity  of  albumen.  But  under  such  circum- 
stances, in  case  of  subnutrition,  the  efficiency  of  fat  to 
save  albumen  would  be  just  the  real  desideratum.  If 
large  amounts  of  anitrogenous  foods  are  introduced, 
while  the  amount  of  albumen  is  reduced,  the.-e  anitro- 
genous foods  are  expected  to  perform  anything  and 
everything  in  the  body  ;  muscle  work,  however,  will  not 
be  performed  if  the  above-mentioned  maxim  of  Ptliiger 
is  correct,  namely,  that  the  muscle  consisting  of  albu- 
men ]ierforms  its  raeclianical  work  through  the  anabol- 
ism  of  albumen,  but  never  through  that  of  fat  or  car- 
bohydrates. Under  these  conditions  less  work  will  be 
performed  ;  for  the  laborer,  moderately  nourished  with 
smaller  amount  of  albumen,  is  not  able  to  perform  hard 
work,  because  for  this  purjtose  he  needs  the  largest 
amount  of  albumen,  as  shown  above.  With  a  defi- 
ciency of  albumen,  the  body  is  forced  to  conform  to  a 
lower  standard  of  proteid  metabolism.  This  lower 
standard  is  unavoidable  in  persons  who  are  continu- 
ously deprived  of  the  full  amount  of  nutritious  albu- 
men so  necessary  to  them.  Finkler  says  that  this  fact 
is  markedly  exhibited  by  the  proof — that  the  majority 
of  men  who  have  hard  work  and  but  scarce  nourish- 
ment, grow  prematurely  old  and  soon  become  ex- 
hausted, a  fact  which  is  daily  observable. 

It  is  true,  certain  amounts  of  fat  or  ciirliohydrates 
furnish  a  corresponding  number  of  calories  as  a  pro- 
portionate amount  of  albumen  does,  but  there  is  a 
deception  in  our  belief  that  the  one  can  replace  the 
other  for  any  length  of  time,  or  even  continuously.  For 
man  of  the  present  day,  in  his  strenuous  struggle  for 
life,  the  indispensable  amount  of  albumen  must  be  pro- 
vided for ;  it  cannot   be  reduced  unless  the  enduring 


March  9,  1901] 


ALBUMINOUS  NUTRITION  AND  NUTRITIOUS  ALBUMEN 


PThk  Philadelphla 
L  Medical  Journal 


487 


ability  of  the  worker  or  the  continuance  of  the  full 
amount  of  the  body  albumen  will  be  reduced.  Not 
only  the  provision  of  albumen  at  all,  but  also  the 
equality  of  the  daily  ingestion  of  albumen  is  necessary. 
In  the  course  of  the  7  days  of  a  week  Finkler  found  a 
difference  of  from  30%  to  40%  between  the  smallest 
and  largest  amount  of  the  digestible  albumen ;  physi- 
ological research  has  shown  that  under  such  circum- 
stances the  unequality  in  the  ingestion  of  the  albumen 
becomes  rather  a  waste  of  this  material,  because  the 
superfluence  of  the  one  day  will  not  be  used  up 
entirely  for  the  benefit  of  the  body,  and  will  not  by 
any  means  make  up  for  the  deficiency  of  the  other  day. 
Another  point  to  be  considered  in  regard  to  the  food 
is  the  digestibility.  The  loss  of  the  proteids  in  the 
bread  is  about  a  third  of  the  whole  amount,  in  the 
legumes  about  the  half.  It  is  true,  a  proper  prepara- 
tion of  this  kind  of  food  will  help  a  great  deal  for  the 
digestion,  but  nevertheless  a  large  part  of  the  albumen 
will  not  be  used,  and  this  unused  albumen  proves  a 
fertile  soil  for  putrefaction,  which  when  continuing  for  a 
longer  time  may  result  in  disturbances  of  the  alimen- 
tary canal  and  further  of  the  whole  body. 

Last  but  not  least  in  our  times  of  social  revolutions  is 
the  question  of  expense.  It  is  known  that  those  nour- 
ishments containing  the  most  nitrogen  and  being  the 
most  digestible  and  most  relishing  are  the  most  ex- 
pensive ones ;  and  since  mostly  the  less  well-situated 
people  have  to  perform  the  hardest  manual  work,  they 
will  have  to  come  to  an  ever  increasing  lower  condition 
of  wealth  and  work.  The  rich  people  have  less  manual 
work  and  more  nourishing  food,  the  poor  people  more 
work  and  less  nourishing  food. 

How  to  amend  these  conditions?  Fish,  very  nourish- 
ing, pretty  well  digestible  and  not  too  expensive,  may 
be  put  down  to  a  greater  extent  upon  the  daily  bill  of 
fare,  but  it  needs  training  of  the  people  for  the  daily 
use  of  fishes  (besides  the  best  ones  are  again  the  more 
expensive)  ;*  creamery  products  (cheese)  are  good  and 
may  be  furnished  rather  cheap,  at  least  in  country 
districts ;  but  the  preservation  of  milk  and  cheese  has 
its  limits.  Vegetable  albumen,  particularly  legumes, 
may  be  thought  of  in  this  respect,  but  the  digestibility 
or  rather  indigestibility  becomes  a  hindrance  and  be- 
sides they  are  not  cheap,  or  at  least  not  cheap  enough 
to  be  general  food  for  a  large  population. 

Many  and  various  investigations  have  shown  that  on 
an  average  60%  of  all  household  expenses  have  been 
spent  for  the  food,  and  the  albumen  of  the  food  costs 
more  than  the  half  of  the  food. 

There  remains  the  necessity  of  furnishing  good, 
resorbable,  and  cheap  albuminous  food. 

♦In  this  place  I  wish  to  say  a  few  words  on  fish  diet.  Many  may  regard  the 
albulDeu  nri^inatin^  in  fish-meat  as  a  disa'i vantage,  as  the  fish  is  considered  an 
inferior  food  from  the  sncial  standpoint.  I  cannot  admit  this.  Where  fish-food 
is  plenty  th**  people  like  it  not  only  as  a  nourishing  fijod,  but  also  asadelicatesse, 
especially  where  the  fishes  are  prepared  in  a  sensible  manner.  Fried  fishes  are 
certainly  not  pr»-terable  to  the  plain  boileti  fish.  That  fi^h-meat  is  proportionately 
cheaper  than  hutcher'a  meat  is  well  known,  particularly  as  it  is  more  easily 
digested.     Let  us  hear  what  Dr.  Kean  h  is  to  f-ay  aiiout  fish  diet  : 

Fresh  fish  is  abundant  and  cheap  in  almost  all  part^  of  our  new  tropical  posses- 
sions, and  it  is  somewhat  surprising  that  the  recent  authority  for  the  issue  of  this 
cheap,  excellent  and  wholesome  variation  of  tlie  meat  ration  is  not  more  taken 
advantage  of. 

I  am  inforin'Hl  that  the  men  eat  it  gladly  when  issuei.  Conservatism,  which 
is  so  characteristic  of  the  military  s»'rvice  and  in  matters  of  food,  of  the  Anglo- 
Saxon  race,  together  with  slight  administrative  ditficuUies  which  with  practice 
would  dis 'pp**ar,  seem  to  be  the  causes  of  its  comparatively  limited  use  at 
Columbia  Barracks.  It  has,  however,  been  more  regularly  used  at  other  posts 
In  this  dcpa'tinent. 

Routine  is  dear  alike  to  the  commissary-sergeant  and  company-cook,  and 
these  twi)  import  int  persons  have  more  influence  than  is  generally  recognized  in 
de'-iding  "hat  sh  ill  go  inti  the  company  kitchen.  When  the  gre  -ter  trouble  and 
labftr  to  the  latter  in  preparing  and  c>oking  fish  is  considered,  as  well  as  the  fact 
that  the  fish  ration  is  less  than  that  of  meat,  the  absence  of  fish  from  the  bill  of 
fare,  where  its  use  is  optional  withcorapinv  authorities,  is  largely  explained. 
Being  :i  less  satisfying  l^ood  than  beef,  and  the  w.iste-heads,  tails,  entrails,  etc., 
being  greater  than  the  proportion  of  bone  in  beef,  being  sometimes  as  much  as 


Can  such  food  be  furnished  ? 

Of  late  years,  all  the  scientists,  hygienists  and  social 
economists  have  looked  out  for  such  a  food ;  only 
recently  the  newspapers  were  full  of  a  report  how  the- 
president  of  the  Chicago  University  would  endeavor  to 
show  how  to  live  on  15  cents  a  day  ;  the  United  States 
Government  has  employed  scientists  to  make  researches 
as  to  the  value  of  foods  and  drinks  ;  not  only  in  America, 
but  also  in  Europe  the  governments  are  seeking  for  th& 
best  methods  of  feeding  large  masses,  be  it  for  the- 
inhabitants  of  prisons  or  for  the  soldiers  in  army  and 
navy.  Experiments  have  been  tried  ;  have  they  been 
successful?  Remember  the  preserved  meats,  the 
canned  meats  and  vegetables !  Can  we  say  that  they 
are  accompanied  by  success  ? 

Many  manufacturers,  many  packing  houses  have 
endeavored  to  furnish  the  long-desired  foods.  It  was- 
a  great  progress  when  meats  could  be  preserved  and 
shipped  all  over  the  world.  When  the  experiments  were- 
tried  to  furnish  meat  in  a  well  digestible  liquid  or 
powdered  form,  were  these  experiments  really  success- 
ful ?     An  unprejudiced  mind  has  to  say  "  No." 

Some  of  the  foods  have  been  cheap,  but  they  do  not 
keep  as  well  as  to  be  fit  for  the  human  body  ;  other 
foods  would  be  fit  for  the  body,  but  they  are  expen- 
sive ;  .they  are  either  luxuries  for  the  rich  or  drugs  for 
the  poor ;  many  are  nutritious,  keep  well,  but  they  are 
on  account  of  the  high  market  price  only  medicine  for 
the  sick,  and  often  if  they  should  be  continued,  only  for 
the  rich  sick. 

Finkler,'  after  long  and  many  labors  and  studies  in 
the  laboratory  of  the  University  of  Bonn,  was  the  first 
to  succeed  in  obtaining  a  food  which  has  all  the  re- 
quirements of  a  proteid  food  as  it  should  be.  He  made 
a  food  : 

1.  That  has  the  greatest  amount  of  albumen  possible,  up 
to  99%. 

2.  That  is  digestible  up  to  almost  its  entire  weight. 

3.  The  amount  of  which  can  be  made  equal  for  each  day. 

4.  That  keeps  well  indefinitely  in  all  climates. 

5    The  flavor  and  taste  of  which  does  not  interfere  with 
the  palate  of  man  in  combination  with  other  food. 
6.  The  price  of  which  is  the  lowest  possible. 

The  proteid  made  by  Finkler  consists  of  the  digest- 
ible albuminous  parts  of  meat,  fish  and  legumes,  is- 
odorless  and  tasteless,  of  a  light-yellowish  color,  and 
presents  a  very  fine,  sandy  powder. 

The  proteids,  as  a  rule,  possess  the  qualities  of  solu- 
tion and  coagulation,  a  fact  through  which  they  may 
be  separated  from  the  other  ingredients  of  the  food  ;  at 
the  same  time,  however,  they  have  disagreeable  quali- 
ties of  being  closely  combined  with  many  substances, 

35^,  no  reason  is  known  why  the  ration  should  be  less  than  that  of  beef,  viz.,  20- 

l-ish  is  largely  eaten  by  all  tropical  racea  near  the  source  of  supply,  and  is  un- 
doubtedly less  stimulating  and  more  easily  digested  than  butcher's  meats.  For 
this  cause,  and  to  secure  variety,  fresh  fish,  where  obtainable,  should  be  used 
twice  a  week,  no  savings  lieing  permitteu.  ,  „  ,  „  v  r  .o-  ~,» 
The  issue  of  the  meat  components  at  Columbia  Barracks,  Cuba,  lor  iso  con- 
secutive days  has  been  as  follows : 

Fresh  beef 124  days 

Mutton  ■•"<"'« 

Bacon  *1t^^ 

Fresh  fish •■' ""J- 

Other  issues '3  days 

Which  shows  well  the  monotony  of  the  issue,  the  only  iinportant  variant  being 

""ACTrta^infy  moTe^desirable  issue,  and  one  apparently  permissible  according 
to  the  paper  ration,  would  have  been,  for  example,  somewhat  as  follows: 

Fresh  beei  ^L'S  ?"" 

Fresh  mutton  2l!l*'° 

Fresh  fish  ^  ^ay» 

Other  issues  1»  ""^^ 

Asavingof  two  fiflhsof  the  fresh  meatbeing  authorized.  ,Ai,,,.h^„. 

As  fresh  fish  is  quite  cheap  at  Havana  the  difference  In  cost  would  have  beeir 
immaterial. 


488 


The  Philadelphia"] 
Medical  Journal  J 


ALBUMINOUS  NUTRITION  AND  NUTRITIOUS  ALBUMEN 


[Mabch  9,  1901 


such  as  fat,  coloring  matter,  odors  and  flavors,  the  sepa- 
ration from  which  is  a  very  difficult  task.  According 
to  the  origin  of  the  albumen  there  are  different  methods 
for  obtaining  the  digestible  albumen. 

It  is  one  thing  to  gain  the  animal  albumen  and 
another  thing  to  gain  the  vegetable  albumen  ;  but  the 
purification  of  the  albumen  of  various  origin  has  been 
done  after  one  uniform  method.  The  fatty  and  extrac- 
tive substances,  when  securing  the  albumen  of  animal 
origin,  must  be  brought  into  such  a  condition  that 
they  can  be  extracted,  and  especially  is  it  necessary 
that  all  and  even  the  smallest  fat  globules  are  removed, 
€lse  after  a  very  short  time  the  muscle  fibers  will 
acquire  a  particular  disturbing  odor  or  taste.  Besides 
the  use  of  ether  for  extraction  of  the  fat,  the  muscle 
fibers  have  to  be  treated  by  substances  which  allow 
peroxid  of  hydrogen  to  penetrate  into  the  interior  of 
the  fibrillae  in  order  to  decompose  the  fat ;  simultane- 
ously the  albumen  will  be  softened  without  being 
turned  to  albumoses  or  peptones.  It  is  not  enough  to 
-cover  the  odor  or  taste  of  the  albumen  with  certain 
substances,  as  such  experiments  will  not  yield  a  per- 
manent result.  Perfectly  pure  albumen  it  must  be,  if 
it  shall  have  the  qualities  of  keeping  for  a  longer  time 
and  remaining  free  from  any  disagreeable  odor  or 
taste. 

In  order  to  obtain  the  pure  vegetable  albumen  we 
must  be  able  to  remove  it  out  of  the  cells  of  the  plants. 
The  conditions  are  not  easy  because,  first,  the  cells  have 
to  be  broken  mechanically,  and  then  the  various  albu- 
minous substances  react  differently  in  regard  to  their 
solubility  in  water,  alcohol,  and  various  other  salt  solu 
tions.  In  extracting  fat  from  plants  it  may  happen  that 
simultaneously  the  albumen  is  extracted  also ;  the  diffi- 
culties are  especially  great  in  manufacturing  the  albumen 
in  large  quantities ;  and  this  has  to  be  done  for  the  sake 
of  the  uniform  qualities  and  the  expenses.  But  they 
succeeded  in  this  respect  too.  In  the  laboratories,  of 
course,  it  is  less  difficult  to  obtain  small  quantities  of 
pure  albumen  than  in  factories.  For  the  sake  of  cheap- 
ness the  choice  of  materials  to  be  used  for  the  manufac- 
turing must  be  limited,  and  for  the  purification  we  have 
only  the  resources  of  water  of  various  temperature  with 
weak  additions  of  alkalies  and  acids,  of  oxidizing  and 
reducing  substances. 

Among  the  different  contaminations  of  the  albumen 
are  not  the  least  ones  the  coloring  matters,  though  even 
the  pure  albumen  may  not  be  entirely  white,  but  accord- 
ing to  the  temperature  and  method  of  drying  may  have 
various  hues  of  yellow.  For  instance,  the  removal  of 
the  coloring  matter  of  albumen  gained  from  the  blood 
of  slaughtered  animals  is,  as  a  rule,  pretty  circumstan- 
tial and  expensive.  To  prevent  this,  a  special  method 
was  needed  and  was  found  in  the  oxidation  of  the 
blood- coloring  matters  by  means  of  peroxid  of  hydrogen. 
If  a  sufficient  amount  of  this  substance  is  used,  you  will 
succeed,  by  keeping  the  albumen  at  a  boiling  "heat,  in 
destroying  the  coloring  matters  and  along  with  them 
the  odorous  and  tlavoring  substances,  so  that  the  end 
product  will  be  an  absolute  sterile  and  pure  hematic 
albumen.  This  success  depends  largely  on  certain  cir- 
cumstances; thus,  it  must  not  be  forgotten  that  fresh 
blood  will  decompose  peroxid  of  hydrogen,  so  that  in 
order  to  become  discolored,  it  must  "first  be  prepared  in 
such  a  manner  that  its  oxyhemoglobin  will  be  altered. 
Another  point  is  the  fact  that  when  free  alkali  is  pres- 
ent the  albumen  itself  would  be  decomposed. 

Finkler,  in  order  to  prove  that  all  injurious  contami- 


nations of  the  albumen  have  been  destroyed  by  the 
methods  employed  by  him,  had,  in  his  laboratory,  fre- 
quently mixed  bacteria  as  well  as  bacteria  cultures  with 
the  toxins  contained  in  them  to  the  raw  materials,  and 
at  the  end  of  the  manufacturing  process  experimenting 
on  animals  convinced  himself  that  the  albumen  was 
entirely  rid  of  the  poisonous  substances  in  question. 

The  product  recovered  from  the  various  materials  is 
an  albumen  insoluble  in  water.  In  the  greater  majority 
of  the  cases  such  insoluble  albumen  is  preferable  to 
soluble  or  predigested  proteids.  Certainly  in  the  healthy 
person  and  in  the  greatest  number  of  the  sick,  too,  we 
need  not  a  totally  or  partially  digested  food ;  on  the 
contrary,  by  furnishing  such  food  lor  a  longer  time  we 
rather  put  the  individual  into  a  condition  not  beneficial 
at  all;  for  by  doing  so  we  take  from  him  the  work 
which  the  stomach  and  intestines  must  necessarily  per- 
form for  the  maintenance  of  their  respective  functions. 
Of  course,  there  may  sometimes  be  circumstances  where 
a  soluble  and  predigested  food  has  its  place,  particu- 
larly in  a  certain  number  of  diseases  in  which  the  ali- 
mentary canal  has  lost  its  power  of  action. 

Finkler  made  it  a  special  point  to  remove  the  gela- 
tinous substances  from  the  albumen,  because  gelatin  is 
of  a  considerably  inferior  nourishing  value  than  the  pure 
albumen.  This  albuminous  food,  consisting  of  animal 
as  well  as  vegetable  albumen,  contains  at  least  ^  animal 
albumen,  as  this  is  about  the  proportion  in  which  the 
animal  and  the  vegetable  albumen  are  united  in  the 
general  daily  food.  The  first  analysis  of  this  food  was 
published  by  Konig,"  as  follows : 

Proteids 89.87% 

Water 8.89% 

Ash 1.24% 

Fat 020% 

Some  other  analyses,  by  various  investigators,  are  about 
of  the  same  tenor. 

Lichtenfelt'  found  as  the  average  of  468  analyses : 

Proteids 90  57% 

Water 8.41% 

Ash 0  87% 

Fat 0.15% 

Cellulose  substance  has  been  found  to  the  amount 
of  0.01  to  0.03%. 

An  elementary  analysis  has  been  made  by  Kunz,* 
and  was  found  as  follows : 


AKIMAL  ORIGIN. 

C 51.498 

H 7.862 

S 0.788 

X 16.028 

O 23  184 

Ash 0.64 


VEGETABLE  OBIGCi. 
C 50.232 

H 7107 

S  0538 

X 16379 

O 23  004 

Ash 274 


These  analyses  represent  the  earlier  products  of  the 
manufacturing  process.  In  the  meantime  the  methods 
of  manufacturing  have  been  improved,  so  that  accord- 
ing to  the  more  recently-made  analyses  an  amount  of 
97  to  99  fc  of  chemicallv-pure  albumen  has  been  found.* 
(Finkler.  Plant.') 

In  a  paper  on  the  valuation  of  foods.  Dr.  Lewith' 
puts  forth  ver)'  interesting  observations.  Among  a 
number  of  various  foods  he  found  that  lor  the  price  of 
1  florin,  equal  to  about  50  cents,  he  could  obtain  the 
following  number  of  calories  out  of  the  albumen  (_fat 
and  carbohydrates  respectively) : 

»  More  of  recent  dale  are  two  other  albuminous  food-preparatioDS — the  one  of 
eniirel.v  animal  origin,  and  tiie  other  of  entirely  re^eiable  ori^n.  For  eitiier  it 
is  claimrti  to  possess  merits,  although  I  cannot  speak  llvm  experience,  as  I 
experimented  witli  the  first  oulv  in  small  quantities  ■  with  the  second,  not  at  all. 
Both  are  cheap,  too,  and  easllj-  resorbable,  and  would  deserre  a  thorough  trial. 


Mabch  0,  1901] 


ALBUMINOUS  NUTRITION  AND  NUTRITIOUS  ALBUMEN 


TThk  Philadblphia 
L  Medical  Jouknal 


489 


FOODS.  ALBUMEN.  FAT.  CAEBOHYDRATEa. 

Lard 12345 

Natural  butter ca20  S877  20.6 

Oleomargarine ca44  15443  45 

Sugar,  refmed 10470 

Beef 1152  1526 

Milk 10G3  2475  1396 

Milk,  skimmed 2804  1103  4652 

Eggs 791  1437 

Tropon 1200  (relatively  expensive  on  ac- 
count of  import  duties ; 
refers  to  tlii.s  country, 
too,  where  the  duties 
amount  to  25^  ad  val- 
orem) 

Potatoes 1476  619  34784 

Bread 1390  325  3092 

As  a  result  of  his  researches  he  recommends  on  the 
one  side  oleomargarine  as  preferable  to  lard  and  dairy 
butter  as  a  more  valuable  and  more  hygienic  product, 
provided  it  comes  from  a  good  source,  and  because  its 
production  may  be  easier  guarded  in  a  sanitary  sense 
than  the  other  products,  and  on  account  of  its  being 
cheaper ;  for  the  same  reasons  he  recommends  Finkler's 
food  as  a  clean  and  cheap  and  highly  nourishing 
albuminous  food.  The  indispensable  500  calories  de- 
riving from  albumen  are  obtainable  in — 

I  Tropon 110  grams,  •        3^  ounces. 

•  Lentils 550  "  18^ 

Peas 650  "  21t 

Beans 710  "  23f 

II  Meat 720  "  24         " 

f            Rice 1730  "  57? 

Bread 2500      "  83J 

Milk 3760  ccm.,  1   gallon. 

Milk,  skimmed 4450     "  1    gallon,  1  quart. 

Potatoes 14100grams,  30   lbs. 

Eggs,  21  pieces 1100      "  36§  ounces. 

This  albuminous  food  can  be  resorbed  at  almost  its 
entire  amount — certainly  to  an  extent  of  more  than 
90%  ;  even  as  high  as  95%  (Strauss,'  Finkler).  In  Ley- 
den's  Handbuch  fur  Ernahrungstherapie  we  find  a 
comparison  by  Klemperer  as  to  the  analysis  of  well- 
known  food-preparations,  whereby  he  makes  a  dis- 
tinction between  preparations  with  stimulating  effect 
(Genussmittel),  and  such  w^ith  nutritive  effect.  Among 
the  former  are : 

WATER.     ALb^MKN.     SALTS  ASH. 

Valentine  meat  juice ...  59.1  6  7        22.7        11.5 

Liebig's  beef-extract 17.72      20.5        38  29      22.74 

Among  the  latter: 

WATER.     ALBUMEN. 

Liebig's  pepton 33  3  47.13 

Somatose 9.2  8000 

Eucasin 80  9000 

Nutrose, 80  90.00 

•  Tropon 90.97 

But  we  will  immediately  become  aware  of  the  great 
difference  in  the  value  of  the  various  foods  of  this  kind 
when  we  consider  that  the  wholesale  prices  of  1  kg.  of 
albumen  amount  in — 

Tropon $1.00 

Eucasin 2  80 

Nutrose 500 

Somatose 12  50 

Valentine  meat  juice •. 41  50 

Pepton  Merck 5.25 

Pepton  Antweiler 10.00 

I  Pepton  Kemmerich 15.25 

I  Finkler's  nutritious  albumen  is  on  the  market  in  dif- 
ferent forms— the  food  plain,  and  combined  with  iron 
and  iron-mangan  and  with  sano  (a  25%  mixture  of  the 


albumen  and  finest  barley  flour),  as  wafers,  in  combina- 
tion with  cocoa  and  chocolate. 

The  food  in  question  had  been  used  in  the  feeding  of 
healthy  as  well  as  of  sick  people.  Time  would  not 
allow  me  to  give  the  growing  literature  on  the  use  of 
this  nutritious  albumen.  I  shall  only  mention  Pro- 
fessor Finkler,'  who  fed  a  large  number  of  consumptives 
and  hysterics  with  a  surprising  result;  thus  it  was  pos- 
sible in  the  case  of  a  hysteric  woman,  who  was  in  an 
excessive  state  of  inanition,  to  increase  her  weight  from 
56^  pounds  to  108  pounds,  by  administering  first  this 
pure  albumen  alone,  and  later  on  in  mixture  with  other 
food.  An  excellent  effect  was  exhibited  in  the  nourish- 
ment of  cases  of  phthisics,  anemics,  diseases  of  the  ali- 
mentary apparatus  and  in  acute  diseases.  Similar  good 
results  were  found  in  cases  of  consumption  by  Dr. 
Knopf,"  of  New  York,  and  Dr.  Martin,'"  of  St.  Louis. 

Dr.  Pannwitz,"  Regimental  Surgeon  in  the  German 
Army  and  Secretary-General  of  the  Central  Committee 
for  Sanitoria  for  Consumptives,  reports  experiments 
with  this  food  made  on  a  lieutenant  and  25  petty 
officers  and  privates.  The  experiment  lasted  for  3  days 
and  nights.  On  an  average  they  marched  daily  30  km. 
(19  miles),  and  they  camped  during  the  night  in  the 
open  air.  The  night  rest  was  never  more  than  3  or  4 
hours.  The  first  night  they  camped  at  a  temperature 
of  41°  F.,  covered  by  tents  around  a  fire  of  brush- 
wood. The  second  night  was  warmer,  but  the  rest  lasted 
only  2  hours.  In  the  third  night  they  rested  for  only 
3  hours  in  the  woods  without  any  campfire.  Each  man 
had  three  small  parcels,  each  containing  a  day's  ration 
of  the  wafers  and  the  chocolate.  Besides  this,  each  man 
had  2  days'  ration  of  a  mixture  of  pea-soup  or  bean- 
soup  in  his  bread  pocket.  The  participants  did  not  eat 
anything  but  this  nutritious  food  except  on  the  second 
evening  some  beer,  and  some  coffee  on  the  morning  of 
the  second  and  third  day.  On  the  evening  of  the 
third  day  they  ate  some  bread  and  butter.  The  ex- 
clusive feeding  with  this  proteid  food  was  strictly  en- 
forced for  2^  days. 

The  method  and  partition  of  the  food  was  as  follows: 
Breakfast,  coffee  and  the  wafers.  Until  dinner,  which 
was  at  10  or  11  a.m.,  each  participant  could  eat  of  the 
wafers  or  the  chocolate ;  dinner  consisted  of  the  mix- 
ture with  pea  or  bean-soup.  Supper,  the  prepared 
chocolate  cooked  in  water. 

The  nutrition  was  excellent,  the  digestisn  normal ;  in 
spite  of  the  cold  night  temperature,  no  diarrhea ;  neither 
obstipation  followed  thfe  change  in  the  manner  of  life. 

The  weight  of  the  3  days'  ration  was  1,200  grams, 
while  the  weight  of  the  common  3  days'  ration  amounts 
to  1,950  grams.  This  deficiency  of  weight  may  act  as 
a  relief  to  the  soldiers,  or  they  maj'  make  it  up  by 
carrying  more  cartridges. 

Dr.  Pannwitz  made  a  second  experiment  for  control- 
ling the  first.  During  the  more  extensive  fall-maneu- 
vers, 25  intelligent  privates  reported  voluntarily  for  the 
experiment.  They  received  as  daily  ration  100  grams 
of  the  wafers  with  sugar,  100  grams  without  sugar;  100 
grams  of  the  cocoa,  and  100  grams  of  the  peas  mixture 
— equal  to  400  grams;  for  3  days,  1,200  grams.  The 
food  contained  130  grams  albumen  in  the  daily  ration. 
The  result  was  highly  successful  in  spite  of  the  most 
unfavorable  circumstances  as  to  weather,  long  marches, 
and  irregular  night- rest. 

In  connection  with  these  experiments  I  like  to  men- 
tion two  articles  on  the  soldier's  diet  in  the  tropics,  the 
one  by  Major  and  Surgeon  W.  0.  Owen,"  and  the  other 


•490 


Thk  Philadkiphia' 
Medical  Jodrnal 


] 


ALBUMINOUS  NUTRITION  AND  NUTRITIOUS  ALBUMEN 


[Mabch  9,  1901 


by  Major  and  Surgeon  J.  R.  Kean."  These  two  writers 
stand  to  a  certain  degree  diametrically  opposite;  Owen 
is  for  increased  meat  diet — Kean  against  it.  Dr.  Owen 
«ays,  "  It  is  not  from  choice  that  the  laborer  of  the 
tropics  lives  on  rice,  bananas,  etc.,  or  the  Irish  cotter 
on  potatoes,  or  the  Eskimo  on  fat,  but  from  necessity." 
At  least  to  a  great  extent,  for  in  the  tropics  vegetables 
and  fruit  are  abundant  and  cheap  whereas  meat  is 
■expensive  and  hard  to  preserve,  while  in  the  Arctic 
regions  the  conditions  are  reversed.  Owen  reports  that 
for  several  months  he  had  charge  of  300  convalescents 
and  50  nurses  in  the  tropics,  and  found  that  they  con- 
sumed all  the  beef,  eggs,  chickens,  ducks,  etc.,  that  he 
could  obtain  for  them,  and  they  wanted  more.  At  the 
■end  of  the  period  they  were  in  as  good  a  condition  as 
that  of  the  inmates  of  any  of  the  other  hospitals  in  the 
neighborhood.  His  own  personal  experience  was  that 
so  long  as  he  tried  to  live  on  a  vegetable  diet  in  con- 
formity to  theory  and  tropical  natives'  custom,  he  was 
uncomfortable  and  despondent,  and  that  when  he  re- 
sumed his  full  meat  diet,  his  energy  returned.  More- 
over, his  native  servants  ate,  with  evident  relish  and 
benefit,  all  the  meat  that  could  be  spared  for  them  from 
the  mess. 

Dr.  Kean,  in  his  article  "  A  Tropical  Ration,"  says, 
"  The  digestion  is  weakened  in  hot  climates  and  the 
liver  is  more  inclined  to  torpidity.  Fats  are  more  diffi- 
cult of  digestion  and  absorption  normally  than  carbo- 
hydrates, and  when  freely  ingested  in  the  tropics  are 
extremely  apt  to  split  up  in  the  stomach  into  butyric, 
caproic,  lactic  and  other  irritating  acids,  producing  a 
condition  of  hyperacidity  of  the  stomach- contents 
which  the  diminished  secretion  of  the  torpid  liver  is 
unable  to  neutralize  and  render  alkaline." 

This  difficulty  of  the  digestion  of  fat  is  well-known 
in  the  tropic  and  subtropic  regions,  but  it  refers  only  to 
tha  animal  fat.  As  I  mentioned  elsewhere,*  vegetable 
fat,  as  olive  oil,  cottonseed  oil,  may  be  used  without  any 
impairment  of  alimentary  canal.  Dr.  Keen  quotes  Treille 
as  saying,  "  In  conclusion,  the  peoples  indigenous  to 
tropical  countries  are  above  all,  but  not  exclusively, 
vegetarians.  These  habits  do  not  proceed,  it  should  be 
observed,  from  a  backward  civilization.  For  the  great 
oriental  lawgivers,  who  were  true  hygienists,  took  care 
from  the  most  ancient  times  to  forbid  by  religious  laws 
the  abuse  of  animal  diet.  This  was  because  they  had 
cogent  reasons  for  doing  so,  and  these  were  drawn  from 
experience.  They  knew  that  too  carnivorous  a  diet  dis- 
poses in  warm  climates  to  certain  diseases,  and  they 
had  reason  to  fear  that  these  would  result  in  injury  to 
the  development  of  the  race  or  nation.  Hence,  we  find 
the  prohibitions  of  the  Mosaic  and  Mohammedan  law 
and  likewise  of  the  Vedic,  Brahmanic,  and  other  relig- 
ions of  India  where  the  Aryan  race  established  so 
enduring  a  foothold." 

As  to  the  "Mosaic  laws,  Treille  must  certainly  be  mis- 
taken, for  there  is  nothing  in  them  to  forbid  a  complete 
meat  diet.  It  only  forbids  certain  kinds  of  meat  that 
have  been  known  for  many  years  to  be  the  carrier  of 
noxious  agents  to  the  human  body.  Furthermore,  it 
forbids  the  use  of  the  blood  as  the  carrier  of  all  that 
which  is  necessary  to  life  on  the  one  side  and  of  the 
impurities  to  be  eliminated  on  the  other  side ;  it  for- 
bids the  eating  of  meat  combined  with  milk  or  butter. 
In  my  previously  quoted  article  I  recounted  the  experi- 
ence of  a  friend  of  mine  who  lived  for  many  years  in 
the  Island  of  Java  and  in  the  Philippine  Islands.     He 

*  CharMte  Medical  Journal,  January,  1899. 


told  me  that  he  never  could  understand  the  idea  of  the 
Mosaic  dietetic  laws  till  he  came  to  the  tropics,  where 
the  people  very  quickly  learn  to  stop  eating  meat  mixed 
with  animal  fat,  such  as  butter  or  cream. f 

I  do  not  doubt  that  an  addition  of  such  a  food,  which 
can  be  preserved  for  an  indefinite  time  without  deterio- 
ration, would  be  accompanied  by  an  excellent  result  in 
the  feeding  of  the  soldiers  in  the  army  as  well  as  navy, 
and  particularly  in  the  tropics  where  fresh  meat  is  very 
hard  to  keep  for  a  longer  time. 

As  to  my  experience  with  this  albumen-food,  I  have 
used  it  for  two  years,  and  that  in  27  cases^  of  healthy 
as  well  as  of  sick  people,  among  others  in  6  cases  of 
anemia ;  2  cases  of  pernicious  anemia  (1  case  in  the 
practice  of  a  colleague) ;  1  case  of  acute  vasomotor 
ataxia ;  2  cases  of  achylia  gastrica ;  1  case  of  chronic 
mucous  gastritis  with  large  dilatation  of  the  stomach ; 
1  case  of  neoplasma  of  the  rectum ;  1  case  of  renal  cal- 
culi and  cystitis ;  2  cases  of  neurasthenia ;  1  case  of 
gastritis  subacida  with  motor  insufficiency  ;  2  cases  of 
heart  trouble,  1  complicated  with  chronic  nephritis;  2 
cases  of  diabetes  mellitus,  and  others.  One  experi- 
ment I  wish  to  mention.  I  decided  to  live  on  this 
nutritious  albumen  for  one  month,  and  I  started  on 
August  24 ;  I  ate  for  the  following  month  no  meat  at 
all  and  replaced  it  hy  tropon  food.  I  ate  bread,  butter, 
vegetables,  potatoes,  cofi'ee,  and  I  added  at  every  meal 
from  one  teaspoonful  to  one  tablespoonful  of  the  prep- 
aration, mixing  it  with  the  food.  I  used  the  different 
kinds  of  the  preparation ;  the  best  as  to  taste  are  un- 
doubtedly the  combination  with  the  iron  and  iron 
mangan ;  then  the  wafers  and  sano-mixture,  the  latter 
particularly  adapted  to  soups.  At  the  end  of  the  ex- 
periment, on  September  23,  I  certainly  felt  in  as  good 
a  condition  as  if  I  would  have  eaten  meat,  and  since 
that  time  I  have  often  used  one  or  the  other  of  these 
food  preparations  as  a  meal.  This  experiment  provee, 
at  least  if  nothing  else,  that  this  food  can  be  injested  in 
pretty  large  doses  for  any  length  of  time  without  inter- 
fering in  the  least  with  the  digestion  and  the  well-being 
of  the  individuals.  In  cases  of  anemia  the  feeding 
of  this  nutritious  albumen  yielded  excellent  results; 
— better  conditions  of  the  blood  as  well  as  of  the  gen- 
eral health ;  loss  of  weight  was  never  recorded  even 
by  feeding  the  plain  albumen  alone,  except  where 
anemia  was  accompanied  by  the  so  frequent  state  of 
obesity ;  in  such  cases  I  found  flabbiness  of  the  skin 
and  muscles  giving  way  to  firmer  skin  and  muscles, 

t  The  Jewish  diet«Uc  laws  are  In  fact  Uosaic  oaly  to  a  certaia  extent :  they 
are  rather  originating  in  the  e,xpi>uaders  of  the  biblical  legislation,  but  un- 
doubieiily  ihey  must  have  understood  the  hygienic  laws  to  a  degree  tliat  is 
marvelous.  You  mitjht  say  they  anticiptted  tne  whole  bacteriology.  Meat 
was  not  forbidden  on  account  of  a  possi'ile  disagreement  with  the  alimen- 
tary app.Hr;itus,  but  bad  meat  was  forbidden,  meat  of  animals  which  were  not 
in  an  entirely  sound  C'lndillon.  To  begin  with,  only  animals  of  apparently 
good  health  could  be  killeil,  and  that  only  In  such  a  manner  that  the  blood 
could  flow  oil  as  much  as  possible.  The  meat  inspeclion  was  stricter  than 
it  was  erer  m.ide  by  any  other  legislature.  If  after  the  slaughtering  of  the 
animal  any  kiud  of  pathologic  condition  of  the  riscera  was  found,  the  me»t 
was  declared  unclean  in  a  religious  sense  and  therefore  not  fit  to  be  eaten. 
These  lawgivers  must  have  been  pathologists,  as  they  declare,  for  instance,  that 
when  the  pleura  is  adherent  to  the  lungs  the  m.  at  of  the  whole  animal  is  unfit 
for  use  unless  the  a-ihe^ions  can  he  loosened  without  tearing;  no'lules  in  the 
luugs  make  the  meat  unlit;  any  ulceration  on  any  of  the  viscera  makes  the  meat 
unclean  ;  kidneys  fs  the  carriers  >  f  the  matenal  of  elimination  were  unclean. 
Even  after  the  meat  was  declared  tit  to  eat,  it  had  to  undergo  a  purifying  pro- 
cess ;  it  had  to  l>e  rubbed  in  with  salt  and  to  he  covered  by  it  in  all  its  pans  for 
a  certain  time  and  t>  be  irrigated  for  anotiierdetinite  time ;  if  meat  was  to  be  kept 
for  a  few  days  it  had  to  he"  washi-d  off,  preferably  in  running  water  every  M 
hours,  ceremonies  that  show  the  wis  lorn  of  these  ancient  legislators.  Another 
hygienic  law  of  not  less  great  foresight  wa-^,  for  instance,  that  no  food  ought  to  he 
touched  with  a  hand  not  cleaned  just  for  this  purp^ise  ;  f  wd  standing;  unci.>vered 
overnight  was  declared  unclean.  Metallic  kitchin  utensils  were  to  be  cleaned  by 
exposure  to  fire,  wooden  utenS'ls  by  rubbing  with  sandstone  and  w.ster,  s  ich  of 
gla-'S  by  putting  them  under  water  and  replacing  the  stale  water  bv  fresh  water 
after  a'cert))in  duration  of  hours  uules-  it  was  a  runninc  water :  all  these  laws, 
which  are  easily  understood  nowadays,  when  we  know  of  the  attacks  of  the 
armies  of  bacteria,  were  given  as  religious  ceremonial  laws  in  those  olden  times. 

}  A  detailed  report  will  be  published  later  on. 


Mabcu  9,  1901] 


HYDROCHLORIC  ACID  IN  PROTEOLYTIC  DIGESTION 


TThb  Philadelphia  4QJ 

L  Medical  Jodhnal  ^ 


■with  subsequent  increase  of  flesh.  The  principal  rea- 
son for  this  improvement  was  no  doubt  dependent  on 
the  fact  that  the  body  was  nourished  without  being 
compelled  to  carry  along  a  large  ballast  of  water  and 
undigestible  remnants  present  more  or  less  in  all  our 
foods. 

The  greatest  amount  of  this  albumen,  about  3000 
grams,  was  taken  by  the  patient  suffering  from  the 
acute  vasomotor  ataxia  (S.  Soils  Cohen).  In  this  case, 
I  believe,  it  had  a  particularly  good  efi'ect  compared  to 
the  common  proteid  food,  animal  or  vegetable,  as  it 
took  away  with  the  large  bulk  of  indigestible  remnants, 
a  ready  soil  for  putrefaction  in  the  bowels,  a  fact  which 
is  not  to  be  neglected  in  cases  of  this  kind,  where  the 
etiology  may  be  of  the  nature  of  autointoxication. 
Such  autointoxication  with  symptoms  especially  of  a 
nervous  character  cannot  be  denied  after  the  elaborate 
researches  of  Bouchard,  Albu  and  others. 

In  cases  where  the  common  meat  diet  is  not  advis- 
able, as  in  uric-acid  diathesis,  this  proteid  food  may  be 
safely  administered,  since  in  the  plain  preparation  the 
salts  and  nucleins  have  been  removed ;  another  form,  to 
which  the  natural  salts  of  nutrition  have  been  added, 
has  been  put  on  the  market,  too,  and  used  in  many 
cases,  especially  in  little  children  and  where  the  food 
was  given  as  exclusive  food ;  this  latter  preparation 
has,  on  account  of  the  presence  of  the  various  salts  of 
nutrition,  a  more  palatable  taste  than  the  plain  prep- 
aration. In  our  times,  where  time  is  money,  and  in 
the  times  of  the  "  Quick  Lunch  Restaurant,"  a  more 
ideal  and  more  nourishing  food  than  these  prepared 
wafers  and  this  prepared  chocolate  cannot  be  thought  of. 

A  short  resume  of  the  nature  and  use  of  this  nutri- 
tious albumen  is  as  follows  : 

1.  This  food  is  a  powder  of  almost  chemically  pure 
albumen  of  animal  and  vegetable  origin  in  the  average 
proportion  in  which  the  daily  food  is  usually  mixed. 

2.  This  powder  is  of  slightly  brownish  color,  odor- 
less and  tasteless. 

3.  It  is  sterile,  and  can  be  kept  for  any  length  of  time 
under  any  climate  without  deterioration. 

4.  The  plain  preparation  is  not  soluble  in  water,  but 
is  readily  accessible  to  the  secretory  juices  of  the  ali- 
mentary apparatus.     The  iron  mixture  is  soluble. 

5.  It  is  resorbable  to  an  extent  of  more  than  90%  of 
its  weight  taken  into  the  body. 

6.  It  can  be  eaten  as  food  by  itself,  or  readily  be 
added  and  mixed  to  any  other  food  without  changing 
taste  or  flavor  of  the  food. 

7.  This  nutritious  albuminous  food,  because  of  its 
high  degree  of  resorbability,  is  an  exceedingly  cheap 
proteid  food  for  the  sick  as  well  as  for  the  healthy  per- 
son. Particularly  it  must  become  an  ideal  albuminous 
nourishment  for  the  soldier  in  army  and  navy,  and  for 
the  traveler  in  the  far  North  as  well  as  under  the  tropic 
sun. 

8.  This  food,  on  account  of  its  small  bulk  and  abso- 
lute digestibility,  yields  excellent  results  in  all  cases  of 
malnutrition  of  the  insane,  the  anemics,  the  consump- 
tives, the  sufferers  from  gastric  and  intestinal  diseases, 
and  the  acute  infections,  and  in  the  subsequent  conva- 
lescence ;  furthermore,  in  all  cases  of  disturbed  meta- 
bolism, such  as  diabetes  mellitus  and  gout. 

9.  Because  of  its  insolubility  in  water  it  does  not 
lose  any  of  its  good  qualities ;  on  the  contrary,  it  is 
preferable  to  soluble  and  predigested  foods  in  the 
greatest  number  of  cases  where  an  artificially  prepared 
ibod  is  necessary. 


10.  This  food,  like  several  other  artifically  manufac- 
tured foods,  including  oleomargarine  [sold  as  such]  will 
and  must  become  the  foods  of  future  periods,  especially 
when  the  number  of  the  population  shall  have  in- 
creased to  such  a  degree  that  all  available  space  must 
be  given  to  the  people,  and  the  factories,  where  all  the 
necessities  of  life  have  to  be  manufactured  ;  these  prep- 
arations must  become  the  food  wherever  the  success  of 
an  undertaking  is  dependent  upon  the  maintenance  of 
the  enterprising  parties  by  the  least  possible  ballast  and 
the  best  possible  nourishment. 

LITERATURE. 

I  Finkler:  Drulsche  med'cinische  Wochemchrifi ,  1898,  No.  17. 

'Koenig:  Landicirtschaftliche  Zntung  fiir  Wea'fulen  uiid  Lippe,  IHSS,  No.  87. 

^  Licht«Dfelt :  Berliner  kliiuscfi^  Woc/ieilsctirifl,  1>Q9.  No.  42. 

*  KuDz  :    Wiener  ktinische  IVochemckrift,  1899.  No.  19. 

'  Plant :  Zeilschrifl  fur  didlelische  viid  p/ii/sikaliscke  TlierapU),  1  Band,  1  Heft. 

'  Levrilh  :  Monalsschriflfar  Gesundheils/ijiege,  Wien,  1899,  No.  12. 

'  Stratiss  :  Therapeu/Uc/ie  .Monalshefte,  Mai,  1H9S. 

'  Finkler:  Berliner  kiinisilie  Wochenschrijt,  1898,  No.  30-33. 

5  S.  A.  Knopf:  Pulmonary  Tuberculosis,  P.  Blakiston's  Son  &  Co. 
l»  S.  C.  Marlin,  Jr. :  .imerinin  .hurnnl  of  Dermatolopy,  MarcU,  1900. 
"  Pannwitz;  Milildr  Wnehehblull,  1900.  No.  39. 
'>  Owen  :  New  York  Mcdiciil  .Journal,  1909,  October  27.     Editorial. 
'■■'  Kean  :  Philadelphia  Medical  Joornal,  1900,  December  8  and  IS. 


TaE  FUNCTION  AND  DISTRIBUTION  OP  COMBINED 
HYDROCHLORIC  ACID  IN  PROTEOLYTIC  DI- 
GESTION.* 

By  a.  E.  AUSTIN,  M.D., 
of  Boston. 

By  the  term  combined  hydrochloric  acid  is  meant, 
of  course,  that  portion  which  is  united  with  albumin 
or  albumose,  in  distinction  from  the  free,  and  that  por- 
tion which  is  more  firmly  combined  with  the  alkaline 
bases.  This  latter  is  a  true  chemical  combination, 
while  we  shall  be  able  to  show  in  the  experiments  which 
follow  that  the  loosely  combined  may  be  regarded  as 
simply  an  adherence  of  the  acid  to  the  albumin  which 
serves  the  purpose  of  base.  This  combination  in  fact 
is  so  unstable  that  it  can  be  disassociated  by  alcohol, 
heat,  and  all  bases  which  have  a  greater  affinity  for 
chlorin  than  the  albumin  itself.  Thus,  in  the  Sjoquist 
test,  barium  easily  combines  with  the  chlorin  wliich  is 
taken  from  the  albumin,  forming  barium  chlorid,  while 
in  Leo's  test  calcium  serves  the  same  purpose.  This 
combination  of  albumin  and  chlorin  seems  absolutely 
necessary  for  digestion  by  pepsin,  since  the  latter  ap- 
parently does  not  digest  albumin,  but  acid  albumin  or 
better  hydrochlorid  of  albumin,  the  formation  which 
seems  always  an  essential  preliminary  to  the  further 
disintegration  of  the  albumin  molecule. 

For  the  accomplishment  of  this  combination  it  is 
useless  to  talk  of  percentages  of  hydrochloric  acid  and 
water,  as  it  seems  to  make  but  little  difference,  as  re- 
gards the  ratio  of  hydrochloric  acid  and  water,  pro- 
vided that  there  is  enough  hydrochloric  acid  to  saturate 
the  albumin.  What  is  of  vastly  greater  importance  is 
the  ratio  of  the  albumin  to  water,  since  in  order  to 
affect  this  combination,  the  albumin  must  always  be  in 
solution.  The  problem  of  the  action  of  pepsin  is  a 
distinct  and  different  one,  for  we  know  that  we  may 
readily  provide  such  a  concentration  of  hydrochloric 
acid  that  it  has  an  inhibitory  effect  upon  the  activity 
of  pepsin.  If  digestion  by  pepsin  is  hydration,  then 
we  can  readily  conceive  why  excessive  dilution  of  the 
albumin  solution  upon  which  it  acts  is  so  necessary. 
Nor  is  hydrochloric  acid  the  only  one  which  can  form 
acid  albumin  upon  which   pepsin   may  act.     Lactic, 

»  From  the  Laboratory  of  Physiological  Chemistry,  Tufts  College,  Boaton. 


492 


THB  PHII»41)BLPHIa"1 

Mbdicai,  Joubhal  J 


HYDROCHLORIC  ACID  IN  PROTEOLYTIC  DIGESTION 


[Uabch  9,  1901 


acetic,  and  other  acids  may  perform  the  same  function. 
As  to  the  conditions  which  favor  the  production  of 
acid  albumin,  we  are  not  wholly  clear ;  the  first  essen- 
tial, of  course,  is  enough  hydrochloric  acid.  Simon  in 
his  "  Clinical  Diagnosis "  gives  a  list  of  albuminous 
substances,  and  the  amounts  of  hydrochloric  acid  which 
they  can  respectively  combine,  but  nothing  is  said  in 
this  of  other  modifying  conditions.  Temperature  ap- 
parently aids  this  combination,  as  does  also  persistent 
and  frequent  shaking.  Further,  hydrochloric  acid  does 
not  attack  albumin  well,  when  mixed  or  surrounded  by 
fat.  It  appeared  a  matter  of  sufficient  interest  to  in- 
vestigate at  length  the  conditions  which  modify  and 
affect  this  union  between  hydrochloric  acid  and  albu- 
min. One  of  the  first  ones  considered  was  that  of  con- 
centration. 

Effect  of   Concentration. 

In  order  to  demonstrate  this,  five  solutions  were  pre- 
pared, each  containing  respectively  1000,  .500,  250,  200, 
and  100  cc.  of  water,  with  2..5, 1.25,  .625,  .5  and  .25  gm. 
of  HCl.  To  each  of  these  was  now  added  10  gm.  of 
dried  egg  albumin,  and  all  were  digested  24  hours  at 
38°  F. 

The  free  hydrochloric  acid  was  now  determined  by 
dimethylamidoazobenzol  and  tenth  normal  NaOH,  and 
deducted  from  total  HCl  used,  whereupon  it  was  found 
that  each  gram  of  albumin  in  the  first  solution  had 
combined  21  mg.  HCl,  of  the  second  23  mg.,  of  the 
third  27  mg.,  fourth  25  mg.,  and  of  the  fifth  25  mg. 
It  is  of  interest  here  to  note  that  while  the  percentage 
of  hydrochloric  acid  always  remained  the  same,  and 
the  total  amount  of  HCl  steadily  diminished,  yet  with 
decreasing  amounts  of  water,  in  which  the  albumin  was 
dissolved,  the  latter  was  able  to  grasp  and  hold  more 
hydrochloric  acid. 

This  process  was  then  repeated,  but  in  a  somewhat 
different  manner.  An  insufficient  amount  of  hydro- 
chloric acid  for  saturation  as  determined  by  the  pre- 
vious experiments  was  added,  and  after  the  digestion 
was  completed,  tenth  normal  HCl  was  added  in  pres- 
ence of  demethyl  until  free  acid  was  present,  then  the 
total  HCl  obtained,  four  solutions  were  prepared  which 
contained  100  cc.  of  water,  10  grams  of  egg  albumin, 
and  respectively  250,  270,  275,  and  330  mg.  of  hydro- 
chloric acid.  After  adding  to  each  an  amount  neces- 
sary to  show  the  presence  of  free  acid,  it  was  found 
that  one  gram  of  albumin  had  combined  respectively 
with  28,  27.6,  33,  and  33  mg.  HCl.  In  other  words, 
while  not  enough  was  present  to  show  free  acid,  with 
gradually  increasing  percentages  of  HCl,  the  albumin 
had  taken  up  more  of  this  by  subsequent  addition  than 
in  the  previous  experiment.  In  fact  the  gradual  addi- 
tion of  hydrochloric  acid  will  cause  the  albumin  to 
absorb  more  than  though  it  is  placed  in  contact  with 
more  than  its  usual  quantity  of  combination.  As  the 
last  two  experiments  came  out  alike,  no  further  eS"ort 
was  made  to  increase  the  concentration  of  the  hydro- 
chloric acid. 

This  latter  experiment  is  not  fully  satisfactory,  be- 
cause the  eye  trained  to  observe  the  change  with  di- 
methyl, from  red  to  yellow  finds  great  difficulty  in  noting 
the  reverse  change  of  yellow  to  red.  and  the  exact  point 
at  which  all  of  the  albumin  is  saturated  is  difficult  to 
determine. 

Here  we  have  a  varying  concentration  of  HCl,  from 
2.5  to  3.3  per  thousand. 


Efficacy  of  Acid  Albumin  in  Digestion. 

It    was    now    considered    advisable    to    determine 
whether  acid  albumin  had  lost  its  efficacy  in  the  further 
digestion  of  native  albumin  with  the  acid  of  pepsin. 
Starting  from  our  previous  experience,  that  each  gram 
of  albumin  would  hold  about  30  mg.  of  HCl  in  com- 
bination, 50  grams  egg  albumin  were  dissolved  in  500 
cc.  water,  1.5  cc.  HCl  added,  and  the  whole  placed  in  a 
brood-oven  for  24  hours.     At  the  end  of  this  period  it 
was  removed,  filtered,  evaporated,  and  dried  at  a  low 
temperature.     It  is  necessarj'  to  add  that  no  free  acid 
could  be  detected  by  dimethyl.     This  preparation  kept 
perfectly  well,  but  was  redissolved   with  difficulty,  in 
fact  not  all  of  it  could  be  dissolved  even  upon  warming. 
The  addition  of  a  drop  or  two  of  tenth  normal  HCl, 
caused  reddening  with  dimethyl,  showing  that  it  was 
fully  saturated  with  HCl.    With  this  preparation  several 
digestions  were  preformed  in  the  following  manner :  Two 
similar  solutions  were  prepared,  one  containing  .1  gm. 
acid  albumin,  no  native  albumin,  .1  gm.  pepsin,  and 
100  cc.  of  water.     The  other  was  prepared  in  the  same 
way,  but  .5  gm.  of  native  albumin  was  added.    After  24 
hours  the  coagulable  and  acid  albumin  were  removed, 
the  albumose  peptone  in  each  was  determined  by  cen- 
trifugation,  and  also  in  some  cases  by  the  comparative 
amounts  of  nitrogen.     The  first  combination  contained 
.16%    albumose  peptone,  while  the  second  with  the 
native  albumin  contained  .26%  albumose  peptone.     In 
the  second  series  2  gm.  acid  albumin  were  used  in  the 
first,  while  the  second  contained  the  same  plus  .5  sni. 
native  albumin.     The  first  of  these  series  had  .23% 
albumose  peptone,  or  37  mg.  nitrogen,  while  the  second 
showed  .33%   albumose  peptone,  or  53  mg.  nitrogen. 
Of  the  third  series  No.   1    had  1   gm.  acid   albumin, 
while  No.  2  had  the  same  plus  1  gm.  native  albumin. 
The  result  of  this  digestion  was  .26%  albumose  peptone 
or  37.8  mg.  nitrogen  in  No.  1,  and  .43%  albumose  pep- 
tone or  42  mg.  nitrogen  in  No.  2.     Fourth  and  lasl 
series  had  1  gm.  acid  albumin  in  No.  1.  and  the  same 
with  .5  gm.  native  albumin  in  the  other.     The  result 
of  this  digestion  was  .9%  albumose  peptone,  or  109.2 
mg.  nitrogen,  and  1.06%   albumose  peptone,  or  120.0 
mg.  nitrogen  in  the  other.     In  everj-  case  a  marked  in- 
crease in  the  amount  of  albumose  peptone,  and  con- 
sequently of  nitrogen,  was  discovered  in  those  diges- 
tions to  which  native  albumin  had  been  added.     As 
the  theory  of  digestion    presupposes   that  the  native 
albumin  must  have  been  converted  to  acid  albumin,  it 
must  have  obtained  its  hydrochloric  acid  from  the  acid 
albumin.     Riegel  makes  the  statement  that  free  HCl 
can  do  still  further  digestive  work,  while  the  combined 
HCl  has  already  done  such  work.     It  would  seem  that 
acid  albumin  or  acid  peptone  before  absorption  could 
give  up  a  portion   of  its  HCl,  which  could  again  serve 
its  purpose  of  converting  native  to  acid  albumin.     In 
no  other  way  can  we  account  for  the  fact  that  stomach- 
contents  which  show  no  trace  of  free  HCl,  have  still 
quite  a  marked  digestive  power  when  brought  in  con- 
tact with  fibrin  or  egg  albumin.     This  has  been  the 
experience  of  the  author  in  several  cases  were  routine 
examinations  for  pepsin  have  been  made  in  stomach 
contents.     This  condition  is  distinctly   different  from 
those   where  alkalies   in   the  form    of  hile,   or  succus 
entericus  unite  with  the  HCl ;  there,  as  is  well  known, 
all  digestion  ceases.     It  is  also  noticeable  that  when 
2  gm.  acid  albumin  instend  of  1  were  used,  the  increase 
in  digestive  products  was  much  greater.     For  instance 


March  9,  1901] 


HYDROCHLORIC  ACID  IN  PROTEOLYTIC  DIGESTION 


[Thk  Philadelphia 
L  Medical  Journal 


493 


37.5  mg.  nitrogen  to  53.2  mg.  nitrogen  in  place  of  109 
mg.  to  120  mg.  nitrogen,  but  the  total  amount  of  nitro- 
gen in  the  form  of  albumose  peptone  was  much  greater 
in  the  latter  case.  An  amount  of  2  gm.  of  acid  albu- 
min when  digested  produces  less  nitrogen  than  1  gm. 
of  acid,  and  1  gm.  of  native  albumin,  by  nearly  6  mg. 
This  is  another  proof  that  the  native  albumin  must 
take  up  HCl  from  the  acid  albumin. 

Effect  of  Dialysis. 

It  is  a  well-known  fact  that  the  major  part  of  the 
digestive  products  pass  through  a  dialysing  membrane ; 
at  least  primary  and  secondary  albumoses  as  well  as 
peptones  do  this,  and,  while  it  is  not  generally  stated, 
my  experience  showed  that  acid  albumin  would  also 
pass  through  an  animal  parchment.  With  the  expecta- 
tion that  free  acid  with  digestive  products  would  pass 
through  such  a  membrane  to  a  large  extent,  leaving 
coagulable  albumin  and  acid  albumin  behind,  a  series 
of  digestions  was  prepared  in  the  inner  receptacle, 
while  the  outer  contained  only  distilled  water.  This 
then  remained  in  the  dialyser  24  hours  in  the  brood- 
oven.  At  the  end  of  that  time  free  hydrochloric  acid 
was  determined  both  in  the  inner  and  outer  fluids, 
after  being  measured,  by  N-10  NaOH  and  dimethyl 
while  the  total  free  and  combined  was  determined  by 
the  Sjoquist  method.  Efforts  were  made  to  separate  the 
free  acids  by  distillation,  and  also  to  separate  the  com- 
bined acid  by  precipitating  the  albumose  peptone,  with 
which  it  was  combined  by  alcohol.  Both  attempts  were 
utterly  futile.  Other  difficulties  were  also  met  with. 
It  was  found  that  there  was  no  surety  that  all  the  albu- 
mose peptone  would  pass  through  the  membrane,  even 
when  dialysed  against  running  water,  and  furthermore 
acid  albumin  was  repeatedly  found  in  the  outer  fluid. 
In  spite  of  these  difficulties  which  impaired  the  value 
of  the  work,  some  of  the  factors  are  worthy  of  mention. 
In  the  first  effort  5  gm.  of  dried  egg  albumin,  .2  gm. 
pepsin,  .6  gm.  HCl  and  250  cc.  water  were  placed  in 
the  inner  receptacle,  while  in  the  outer  there  were  550 
cc.  water.  At  the  end  of  24  hours  the  contents  were 
removed  from  both  vessels,  carefully  evaporated  to 
100  cc.  at  a  temperature  of  40°,  and  10  cc.  of  each  taken 
for  the  determination  of  free  and  total  HCl,  from  which 
the  combined  was  calculated.  In  the  inner  were  found 
174  mg.  free  HCl,  103  mg.  combined  and  140  mg. 
nitrogen;  in  the  outer  there  were  183  mg.  free  HCl, 
28  mg.  combined  and  65  mg.  nitrogen,  or  a  total  of 
488  mg.  HCl,  and  205  mg.  nitrogen.  In  digestion  No. 
2,  10  gm.  albumin,  .5  gm.  pepsin,  .4  gm.  HCl,  and 
water  as  before.  After  the  digestion  was  completed, 
the  inner  fluid  had  73  mg.  free  HCl,  46  mg.  combined, 
and  308  mg.  nitrogen,  while  the  outer  had  94  mg.  free, 
16  mg.  combined  HCl  and  210  mg.  nitrogen,  or  a 
total  229  mg.  HCl,  and  518  mg.  nitrogen.  The  enorm- 
ous loss  of  HCl  here  experienced,  can  only  be  ac- 
counted for  by  the  loss  in  evaporation  from  the 
dialyser.  Digestion  No.  3  had  5  gm.  albumin,  .2  gm. 
pepsin,  .2  gm.  HCl,  and  after  digestion  the  inner  had 
no  free  HCl  but  100.2  mg.  combined  HCl,  while  the 
outer  had  no  free  HCl  and  40.8  mg.  combined  HCl, 
making  a  total  of  141  mg.  No.  4  had  all  the  ingre- 
dients of  the  previous  digestion,  but  only  150  mg.  HCl ; 
at  the  close  of  the  digestion  the  inner  had  no  free  HCl, 
but  55.1  mg.  combined  HCl,  while  the  outer  had  no 
free  HCl,  but  25.2  mg.  combined  HCl,  or  a  total  of 
80.3  mg.  In  the  last  two  digestions  no  effort  was  made 
to  concentrate  the  solution  for  fear  of  loss  of  HCl,  and 


calculation  was  made  up  in  aliquot  parts  of  the  original 
solutions.  Among  the  points  which  were  here  noted 
was  this :  that  as  long  as  the  acid  was  in  excess  of  the 
combining  power  of  the  albumin,  it  passed  through 
the  membrane  freely,  but  not  until  the  demands  of  the 
albumin  were  satisfied.  As  soon,  however,  as  the  HCl 
approached  the  saturating  point  of  the  albumin,  no  free 
HCl  was  found  in  the  external  fluid.  It  appeared  that 
when  the  digestive  products  were  fully  or  even  partially 
removed  by  dialysis,  a  certain  amount  of  albumin  would 
take  up  no  more  HCl  than  when  simply  combined.  As, 
for  instance,  in  No.  3,  28.2  mg.  per  gram  of  albumin  in- 
stead of  30  mg.,  the  largest  amount  which  could  be  made 
to  combine  in  our  first  experience.  Another  explanation 
of  this  fact,  which  is  more  fully  brought  out  in  later 
experiments,  is  that  the  albumoses  and  peptones  will 
take  up  much  more  chlorin  in  the  proportion  to  the 
amount  of  nitrogen  contained,  than  the  simple  albumin. 
This  seems  opposed  to  pepsin,  by  which  more  albumin 
can  be  digested,  if  the  digestive  products  be  removed 
by  dialysis.  A  part  of  the  loss  of  HCl  as  compared 
with  the  original  amounts  used  can  perhaps  be  attrib- 
uted to  the  difficulty  of  filtering  barium  sulfate  in  the 
Sjoguist  test,  which  is  only  retained  with  difficulty  by 
the  finest  filter  paper.  These  experiments  lead  to  no 
definite  results  as  to  the  distribution  of  hydrochloric 
acid,  because  no  complete  separation  of  the  digestive 
product  could  be  made.* 

Separation  by  Metallic  Salts. 

This  effort  was  made  in  order  to  demonstrate,  if  pos- 
sible, the  greater  combining  power  of  albumose  and 
peptone  for  chlorin,  as  well  as  to  learn,  if  possible,  how 
the  chlorin  was  distributed  with  reference  to  the  differ- 
ent digestive  products  in  a  completed  digestion.  It 
was  assumed  naturally  that  each  of  the  digestive  pro- 
ducts when  separated  from  the  solution  carried  with  it 
the  chlorin  with  which  it  was  combined.  These  diges- 
tons  were  prepared,  and  after  24  or  more  hours  the 
coagulable  albmuin  was  removed  by  boiling  with  a  drop 
or  two  of  acetic  acid,  the  acid  albumin  by  sodium  car- 
bonate, the  primary  albumose  by  the  addition  of  copper 
acetate  in  solid  form  until  equal  to  2%  of  the  total 
solution.  The  precipitate  was  washed  by  a  saturated 
solution  of  copper  acetate,  while  the  secondary  albu- 
mose was  precipitated  by  adding  2  cc.  of  25%  sulfuric 
acid  to  each  100  cc.  of  fluid,  and  then  zinc  sulfate 
added  to  this  until  a  saturated  solution  was  obtained 
while  warm,  as  evidenced  by  deposition  of  some  of  the 
zinc  sulfate  when  cool.  This  precipitate  was  removed, 
washed  with  saturated  sulfate  solution,  and  the  filtrate, 
containing  peptone  and  certain  amido  acids,  was  pre- 
served. The  acid  albumin  was  suspended  in  water,  the 
copper  removed  from  the  albumose,  dissolved  in  water 
by  H2S.  The  secondary  albumose  was  redissolved 
and  the  peptone  in  solution  was  freed  from  zinc  by 
exact  neutralization,  and  then  each  solution  was  divided 
into  2  equal  parts,  the  one  half  was  evaporated  with  5 
grams  of  saltpeter  mixture  (3  parts  nitrate  of  potash 
and  1  part  of  sodium  carbonate)  and  burned,  and  the 
other  half  reduced  in  volume,  and  its  nitrogen  was  de- 
termined by  the  Kjeldahl  method.  By  this  method  the 
portions  which  were  burned  were  freed  from  organic 
matter  and  the  chlorin,  after  neutralization  with  HNOj, 
could  be  determined  by  a  standard  solution  of  silver 

*  After  completing  this  work  to  this  point,  my  attention  was  called  to  the  fact 
that  (jillespife  had  done  similar  work,  piiblished'iu  Journal  of  Anatomy  and  Phy^ 
sioloiji/,  vol.  xxvii,  p.  201,  to  whom  credit  for  priority  Is  due,  but  not  for  any 
suggestion  to  me. 


494  Ta^  Philadelphia"! 

Medical  Journal  J 


HYDROCHLORIC  ACID  IN  PROTEOLYTIC  DIGESTION 


[MiECB  9,  1900 


nitrate.  The  5  grams  of  saltpeter  mixture  contained 
quite  uniformly  as  an  impurity,  3  mg.  of  chlorin, 
■which  were  deducted  from  the  total  found  in  each  case. 
The  amount  of  hydrochloric  acid  used  in  each  diges- 
tion was  600  mg.  of  dilute,  which,  as  determined  by 
the  standard  silver  solution,  contained  164  mg.  of 
chlorin.  The  egg  albumin  used  was  found  free  from 
chlorin,  but  contained  465.5  mg.  nitrogen  per  5  gm. 
albumin.  Digestion  No.  1  consisted  of  5  gm.  albumin, 
600  mg.  HCl  dilute,  200  mg.  pepsin,  and  200  cc.  of 
water.  Period  of  digestion  was  25.5  hours.  There 
were  found  combined  with  the  acid  albumin  20.4  mg. 
chlorin,  with  the  primary  albumose  24  mg.  chlorin, 
with  the  secondary  albumose  18  mg.  chloriu,  and  with 
the  peptone  100.8  mg.,  or  a  total  of  163.2  mg.  The 
respective  amounts  of  nitrogen  in  these  separate  pro- 
ducts were  16.2,  12.3,  5.6,  and  12.6  mg.  nitrogen,  or  a 
total  of  46.7  mg.  No.  2  was  similar  to  the  former  ex- 
cept that  150  cc.  of  water  was  used.  Period  of  diges- 
tion, 24  hours.  There  were  combined  as  acid  albumin 
24  mg.  with  primary  albumose  15.6  mg.,  with  secondary 
albumose  40.8  mg.,  and  with  peptone  81  mg.  chlorin, 
making  a  total  of  162  mg.  The  corresponding  amounts 
of  nitrogen  were  22.9,  1.9,  5.6,  and  21  mg.  nitrogen, 
making  a  total  of  51.4.     No.  3  same  as   former,  but 


thing  is  that  the  acid  albumin,  so  called,  appears  to 
have  no  regular  formula  for  its  composition.  We  find 
in  this  form  16.2  mg.  nitrogen  combined  in  one  instance 
with  20.4  mg.  chlorin,  and  in  another  instance  6.1  mg. 
nitrogen  in  the  form  of  acid  albumin  combined  with 
18.  mg.  chlorin.  This  amount  of  chlorin  is  so  very 
much  larger  than  we  can  cause  to  unite  with  native 
albumin  without  the  aid  of  pepsin,  that  this  must  rep- 
resent a  rest  or  residue  of  the  albumin  molecules  from 
which  the  more  easily  spUt-off  portion  undergoes  further 
change  into  albumose  peptone,  which  contains  much 
stronger  basic  properties.  This  is  found  pretty  generally 
throughout.  For  instance,  12.3  and  11.2  mg.  nitrogen 
as  primary  albumose  combined  with  24  mg.  of  chlorin. 
In  one  of  these  the  nitrogen  in  the  albumose  was  found 
to  be  about  12%,  so  that  we  find  an  equivalent  of  102.5 
and  93.8  mg.  of  primary  albumose  uniting  with  this 
amount  of  chlorin,  making  vastly  more  than  can  be 
made  to  combine  when  these  two  are  brought  together 
apart  from  digestion.  For  instance.  Otto  Cohnheim 
could  only  make  one  gram  of  protoalbumose  in  2.5 '/c 
solution  take  up  43  mg.  of  HCl,  while  heteroalbumose 
takes  up  81  gm.  to  the  gram,  and  in  a  1.25%  solution 
protoalbumose  took  up  35  mg.  HCl,  and  heteroalbu- 
mose took  up  45  mg.  to  the  gram.     We  can  therefore 


ACID   ALBUMIN. 

PBIHARY 

ILBOMOSB. 

BECOKDABT 

ALBUMOSB. 

PEPTOSK. 

Percent 

Percent 

Percent 

Percent 

Percent 

Percent 

Percent 

Percent 

T»tal 

Total 

Total 

ToUl 

Tolal 

Toul 

Total 

Total 

CL. 

N. 

CL. 

N. 

CL. 

N. 

CL. 

N. 

CL. 

N. 

CL. 

N. 

CL. 

N. 

CL. 

N. 

Mgms. 

Mgms. 

Mgms. 

Mgms. 

- 

j". 

Mgms. 

Mgms. 

Mgms. 

Mgms.    j 

20.4 

16.2 

12.5 

34.7 

24. 

12.3 

14.7 

.  26.3 

IS. 

S.6 

11. 

11.9 

100.8 

IXS 

61.7 

24.8 

24. 

22.9 

14.8 

44.6 

15.6 

1.96 

9.6 

3.7 

40.8 

5.6 

25.1 

las 

81.6 

21. 

50.3 

40.8 

18. 

6.1 

9.8 

12.7 

89.0 

3.6 

21.7 

7.1 

10.8 

1.6 

5.8 

3.1 

111. 

39.2 

62.6 

77.6 

10. 

10. 

6.1 

14.7 

24. 

11.2 

14.7 

16.4 

18.6 

7.5 

11.1 

11.4 

113.4 

89.2 

67.9 

57.7 

100  cc.  of  water  was  used.  Period  of  digestion,  96 
hours.  There  were  found  combined  as  acid  albumin 
18  mg.,  as  primary  albumose,  39  mg.,  as  secondary 
albumose  10  mg.,  and  as  peptone  114  mg.  chlorin,  or  a 
total  of  181  mg.  Corresponding  amounts  of  nitrogen 
were  6.1,  3.6,  1.6,  39.2  mg.,  or  a  total  of  0.5  mg.  No.  4 
same  as  former,  but  with  50  cc.  water,  acid  albumin  had 
10.2  mg.,  primary  albumose  24.6  mg.,  secondary  albu- 
mose 18.6  mg.,  and  peptone  113.4  mg.  chlorin,  or  a  total 
of  166.8  mg.  Corresponding  to  each  of  these  were 
respectively  10  mg.,  11.2  mg.,  7.5  mg.,  39.2  mg.  nitrogen, 
or  a  total  of  67.9  mg.  In  none  of  these  was  free  acid 
ever  discovered  by  dimethyl.  These  factors  are  here 
shown  in  tabular  form. 

The  most  noticeable  thing  about  these  digestions  is 
the  inefficient  nature  of  the  digestive  process.  There 
was  by  actual  estimation  455.5  mg.  nitrogen  in  the  ori- 
ginal albumin,  but  only  from  46.4  to  67.9  mg.  could  be 
found  in  the  sum  of  the  digestive  products.  This  was 
probably  due  to  the  great  ratio  of  albumin  to  water  in 
the  solution.  The  inhibitory  action  of  albumose  pep- 
tone upon  the  farther  digestion  by  pepsin  was  appar- 
ently increased  by  their  greater  concentration.  The 
major  part  of  the  nitrogen  was,  of  course,  removed  in 
the  coagulable  albumin,  which  was  not  taken  into  ac- 
count because  not  a  part  of  the  digestive  products,  con- 
taining no  chlorin  in  combination.     Another  noticeable 


conclude  that  they  have  vastly  stronger  basic  properties 
than  the  native  albumin,  and  in  general  we  may  say 
that  each  stage  of  the  digestive  process  enabled  the 
nitrogenous  substance  to  increase  its  chlorin-containing 
powers  until  the  acme  is  reached  in  the  peptone.  The 
relative  amounts  of  the  difi'erent  albumoses  in  the  vari- 
ous digestions  vary  so  greatly  that  it  is  liard  to  draw 
any  conclusions  as  to  distribution  of  the  nitrogen.  In 
the  first  two  the  major  part  of  the  nitrogen  is  found  in 
the  two  extremes,  acid  albumin  and  peptone,  but  in  the 
latter  the  nitrogen  gravitates  more  toward  the  peptone 
end  of  the  line.  E.  Zuntz  (^Zeitschr.f.  physiologische  Chemie. 
vol.  xxviii,  p.  141)  finds  in  a  digestion  1.12%  of  the  total 
nitrogen  as  primary  albumose,  11.7%  as  secondan.-  albu- 
mose, and  87.18%  of  the  total  in  other  nitrogen-con- 
taining products.  He  used  serum  albumin  and  much 
larger  quantities  of  water,  275  cc.  to  5  grams.  My  most 
favorable  results  only  approximated  this  after  96  hours 
digestion  with  still  i.7%  as  acid  albumin,  and  77.6% 
as  other  nitrogen-containing  products.  Zuntz  does  not 
regard  all  of  the  remainder,  nonprecipitable  by  zinc  sul- 
fate, as  peptone,  for  an  amount  of  nitrogen  varying  at 
different  periods  of  digestion  from  34.8  to  62.47%  of 
this  is  not  precipitable  by  phosphomolybic  acid  and 
sulfuric  acid.  This  substance  was  probably  of  the 
nature  of  amido  acids,  for  they  could  be  precipitated  by 
tannic  acid  and  other  alkaloidal  reagents. 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articlea,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  flolicited 
for  publication.  Reprints  (250)  of  Original  Articles  will  be  turnished  gratis  to  Authors  making 
the  request. 

The  ISditorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  FhiladelpUia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa, 

See  Advertising:  Pages  8  and  30. 


James  Hendrie  Lloyd,  A.M.,  M. D.,  Editor-in-Chief 
Julius  L.  Salinger,  M.D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyer,  M.D. 

D.  h.  Edsall,  M.D.  T.  L.  Colet,  M.D. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  Gibbon,  M.D. 


Vol.  VII,  No.  11 


MARCH  16,  1901 


$3.00  Per  Annum 


Recent  Phases  of  Medical  Legislation. — State 
Legislatures  and  Governors  in  various  parts  of  the 
United  States  are  having  opportunities  at  present  to 
display  the  degree  of  natural  intelligence  with  which 
they  are  endowed  with  reference  to  the  greater  ques- 
tions of  public  health.  In  New  York  at  the  time  of 
the  present  writing  we  are  glad  to  know  that  there  is  a 
prospect  of  a  passage  of  the  so-called  Bell  bill  by  the 
Legislature.  This  bill  will  compel  all  such  so-called 
practitioners  of  medicine  as  osteopaths  and  Christian 
Scientists  to  submit  to  the  same  regulations  and  take 
the  same  examinations  as  are  required  by  the  gradu- 
ates of  recognized  medical  schools.  The  justice  of  this 
measure  is  so  obvious  as  to  need  no  comment.  It  is 
in  our  opinion  the  most  practicable,  if  not  the  only 
practicable,  way  to  suppress  these  unqualified  practi- 
tioners. It  obviates  the  necessity  of  any  criticisms  of 
their  various  tenets  and  beliefs.  It  merely  requires  of 
them  a  demonstration  of  their  fitness  to  practise  medi- 
cine, and  it  effectually  suppresses  them  if  they  are 
^    found  not  to  be  competent. 

\  In  some  of  the  Western  States,  we  are  sorry  to  see  that 
I  this  subject  of  State  control  of  the  practice  of  medicine  is 
not  receiving  the  intelligent  consideration  which  it  de- 
mands. Some  Governors  of  States  as  well  as  legislators 
show  with  reference  to  this  question  that  they  have  lit- 
tle appreciation  of  the  duties  imposed  upon  them  as 
guardians  of  the  public  welfare.  It  is  very  evident,  as 
we  said  in  these  columns  in  discussing  Dr.  Wyman's 
recent  address  before  the  Pan-American  Medical  Con- 
gress, that  the  public  and  the  servants  of  the  public  in 
this  country  require  a  more  careful  education  in  the 
subjects  of  hygiene  and  medicine.  For  crass  ignorance 
and  perversion  of  judgment,  the  Governor  of  the  State 
of  Washington  (Rogers,  by  name)  has  shown  that  he  is 
preeminent.  He  has  just  vetoed  an  act  passed  by  the 
Legislature  to  control  medical  practice  in  that  State, 
because  it  ruled  out  the  osteopaths.  In  addition  to 
this  pernicious  exercise  of  his  prerogative  he  has  in- 
dulged in  a  senseless  tirade  against  the  medical  pro- 
fession. He  professes  to  believe  that  the  osteopaths  are 
teaching  educated  physicians  the  way  to  cure  diseases 
without  the  use  of  deleterious  drugs,  and  he  claims 
that  the  contents  of  the  drug  stores  are  perhaps  more 
dangerous  to  the  future  well-being  of  the  human  race 
than  are  the  saloons.  To  criticise  such  a  public  official 
is  useless :  it  is  sufficient  to  quote  him. 


In  California  the  Legislature  has  persisted  in  putting 
Christian  Scientists  on  an  equality  with  graduates  of 
the  recognized  schools  of  medicine.  Its  motives  for  so 
doing  seem  to  have  been  that  these  sectarians  are 
numerous  and  a  good  class  of  people ;  a  reason  which 
the  Sacramento  Bee  (quoted  by  the  Journal  of  the  Ameri- 
can Medical  Association)  says  would  have  been  as  perti- 
nent if  applied  to  the  inmates  of  the  various  lunatic 
asylums  of  the  country.  In  connection  with  this  class 
of  legislation  the  recent  eruption  of  Mark  Twain  is  per- 
haps worthy  of  a  passing  notice.  He  has  appeared  before 
a  committee  of  the  New  York  Legislature  in  favor  of 
legalizing  osteopathy.  Fortunately  Mark  Twain's  entire 
reputation  is  that  of  a  so-called  humorist,  but  his  recent 
championing  of  osteopathy  is  as  devoid  of  judgment 
and  knowledge  as  some  of  his  more  recent  productions 
are  lacking,  in  the  estimation  of  men  of  good  taste,  in 
the  essential  qualities  of  humor. 

The  Liverpool  Tropical  School  on  Yellow  Fever. 

— In  the  British  Medical  Journal  of  February  23,  1901, 
appears  the  abtract  of  the  interim  report  of  the  Yellow 
Fever  Expedition  of  the  Liverpool  School  of  Tropical 
Medicine.  The  investigations  were  conducted  by  Dr. 
Herbert  E.  Durham  and  Walter  Myers,  M.B.  They 
were,  unfortunately,  interrupted  by  both  of  these 
observers  suffering  from  attacks  of  the  disease.  Most 
regrettably,  Mr.  Myers'  case  proved  fatal,  and  it  was 
deemed  wise  to  publish  the  incomplete  report.  This 
furnishes  us  with  a  valuable  contribution  on  the  subject 
of  the  etiology  of  yellow  fever.  The  investigators  have 
found  in  all  fatal  cases  of  the  disease,  after  thorough 
search,  a  small  bacillus  somewhat  resembling  that  of 
influenza.  They  have  been  able,  upon  examining  the 
organs  after  death,  to  discover  this  bacillus  in  the  kidneys 
and  spleen,  and  in  the  mesenteric,  portal,  axillary  and 
lymphatic  glands.  Apparently  the  same  bacillus  is 
often  found  in  extraordinary  preponderance  over  the 
other  microorganisms  in  the  lower  intestine.  Prepara- 
tions of  the  organs  fail  usually  to  show  the  presence 
of  any  other  bacteria.  They  believe  that  this  bacillus 
has  been  observed  by  Dr.  Sternberg  and  two  others, 
and  they  attribute  the  fact  that  no  etiological  import- 
ance was  attached  to  the  bacillus,  to  the  employment 
of  insufficiently  stringent  staining  technique,  owing  to 
which  it  was  not  found  constantly.  They  have  not 
been  able  to  obtain  pure  cultures  of  the  organism  in 


496 


Thb  Philadelphia"] 
Medical  Jousxtal  J 


EDITORIAL  COMMENT 


[Hascu  16,  19e> 


either  aerobic  or  anaerobic  culture  tubes.  They  have, 
however,  obtained  pure  cultures  by  placing  whole 
mesenteric  glands  cut  out  by  means  of  the  thermo- 
cautery in  broth,  under  strict  hydrogen  atmosphere. 
Most  careful  search  was  made  for  parasites  of  the  nature 
of  protozoa,  but  none  were  found.  They  conclude, 
consequently,  that  yellow  fever  is  not  due  to  this  class 
of  parasites.  Durham  and  Myers  were  not  familiar 
with  the  concluding  report  of  the  American  Commis- 
sion, but  they  were  far  from  being  convinced  of  the 
commission's  logic  in  the  deductions  of  its  preliminary 
report. 

The  concluding  Report  of  the  American  Commission 
read  recently  before  the  Havana  Pan-American  Con- 
gress (and  which  we  have  commented  upon  editorially) 
has  received  wide  support,  and  would  probably  satisfy 
certain  objections  which  Durham  and  Myers  found  in 
the  preliminary  work.  These  authors  conclude  by 
stating  that  there  is  much  etiological  importance  to  be 
attached  to  the  fine,  small  bacillus  which  they  describe, 
and  they  suggest  that  the  acquisition  of  a  new  intes- 
tinal bacterium  would  explain  the  immunity  of  the 
"  acclimatized."  They  have  examined  the  blood  and 
organs  of  fourteen  fatal  cases  of  yellow  fever,  with 
painstaking  care,  and  the  report  of  their  studies  is  en- 
titled to  respect.  They  may  be  criticized,  however, 
for  a  lack  of  thoroughness  in  their  deductions.  No 
experiments  seem  to  have  been  performed  upon  animals 
and  the  etiological  relation  between  this  fine,  small 
bacillus  and  yellow  fever  cannot  be  considered  by  any 
means  as  definitely  established.  At  the  present  writing, 
while  we  must  suspend  judgment,  it  would  appear  that 
the  views  of  the  American  Commission  are  far  more 
conclusive  than  the  abstract  quoted,  yet  it  is  but  fair 
for  us  to  await  the  promised  completion  of  the  Report 
of  the  Expedition  of  the  I>iverpool  School  of  Tropical 
Medicine  before  attempting  a  judgment  of  its  work. 

The  Influence  of  Sterilized  Air  Upon  Animal  Life. 

— "  Therefore  as  a  result  of  the  experiments  made  by 
me  in  1893  and  1894,  and  during  the  present  year,  upon 
the  influence  of  sterilized  air  upon  animals,  I  maintain 
that,  besides  the  oxygen  of  the  air,  certain  microorgan- 
isms of  the  air  are  also  necessary  to  maintain  life  and 
the  normal  metabolism  in  the  tissues.  These  microorgan- 
isms enter  the  blood  during  the  interchange  of  gases  and 
are  devoured  by  the  leukocytes  (hence  they  are  not 
found  in  normal  blood),  then,  after  they  have  been  di- 
gested by  them,  they  give  rise  to  the  formation  of  fer- 
ments without  which  the  normal  process  of  oxygenation 
in  the  organs  rapidly  diminishes,  and  is  replaced  by  the 
formation  and  accumulation  of  a  large  quantitj'  of  in- 
complete intermediary  products  of  tissue  metamorphosis, 
that  is,  by  leukomaines,  which  cause  the  death  of  the 
animal." 

This  is,  to  say  the  least,  a  startling  assertion.  Kijan- 
itzin  (Virchoiv's  Archiv,   162,    p.    515).    who    has   done 


much  work  with  sterilized  air,  has  performed  a  number 
of  experiments  by  placing  sterile  newly  born  and 
other  animals  in  sterile  vessels,  and  supplying  them 
with  a  sterile  atmosphere.  Under  these  conditions 
the  animals  emaciate,  as  a  result  of  a  marked  in- 
crease in  the  nitrogenous  excretion  compared  with 
the  nitrogenous  intake,  and  a  large  proportion  of  them 
die  in  five  days,  or  less.  It  does  not  appear  possible 
that  this  is  due  to  the  formation  of  any  jjoisonous  ele- 
ment in  the  air,  as  a  result  of  the  intense  heat  to  which 
it  has  been  subjected ;  and  CO  was  not  present  in  the 
blood  of  the  animals  after  they  died.  Therefore  it  seems 
reasonable  to  suppose  that  the  mere  fact  that  the  air  was 
sterile,  that  is,  contained  no  microorganisms,  must  be 
the  true  explanation. 

The  author  supports  his  doctrine  by  the  following 
arguments.  First,  that  most  of  the  normal  ferments  of  the 
blood  are  found  in  the  leukocytes.  Second,  in  certain 
pathological  states  certain  of  the  pathogenic  microbes  are 
digested  by  the  leukocytes  and  give  rise  to  the  forma- 
tion of  substances  that  possess  the  characters  of  ferments. 
Third,  the  non- pathogenic  microbes,  instead  of  being 
absolutely  neutral,  exert,  under  certain  circumstances, 
considerable  influence  upon  the  tissue,  especially  upon 
the  leukocytes.  Fourth,  the  fact  that  the  animals  sub- 
jected to  the  experiment  died  not  only  in  the  apparatus, 
but  frequently  from  ten  minutes  to  an  hour  and  a  half 
after  their  removal  from  it,  when  they  had  been  sup- 
plied with  ample  nourishment  and  everything  to  enable 
them  to  recover,  is  an  indication  that  some  profound 
alteration  in  their  economy  had  taken  place. 

In  order  to  determine  what  this  alteration  was  he 
made  careful  e.'<timatinn  of  the  nitrogenous  metabolism, 
and  found  that  the  proportion  of  the  total  nitrogen  in 
the  urine  to  the  nitrogen  in  the  urea,  which,  in  normal 
animals  is  about  100  to  90,  in  the  animals  subjected  to 
this  experiment  was  altered  to  100  to  55,  and  even  less, 
as  a  result  of  the  enormous  increase  in  the  proportion 
of  leukomaines. 

The  interesting  feature  about  this  paper  is  the  light 
it  throws  upon  the  moot  question  of  the  advantage  of 
bacteria  in  the  economy  of  the  higher  animals.  It  has 
been  supposed,  in  fact  it  has  been  accepted,  that  the 
bacteria  of  the  intestine  are  concerned  in  the  digestion 
or  at  least  in  the  disintegration  of  cellulose,  hut,  aside 
from  this,  no  actual  benefit  derived  from  their  action 
has  ever  been  definitely  proven,  excepting  of  course 
those  very  indirect  benefits  that  result  from  the  forma- 
tion of  antitoxins. 

If  Kijanitzin  is  correct  we  must  modify  our  views,  or 
rather  agree  to  believe  that  the  ferments  of  the  blood, 
which  by.  the  way  are  not  as  well  known  as  they  should 
be,  but  whose  functions  are  undoubtedly  of  the  greatest 
importance,  are  produced  largely,  if  not  exclusively,  as 
a  result  of  the  conversion  of  the  bodies  of  bacteria  ob- 
tained from  the  atmosphere  by  the  action  of  leukocytes. 

If  one  should  allow  one's  imagination  to  run  riot  it 


March  16,  1901) 


EDITORIAL  COMMENT 


FThe  Philadelphia 
L  Medical  Jopenal 


497 


might  dream  of  the  treatment  of  various  dyscrasias  by 
saturating  the  air  in  which  the  patient  should  be  placed, 
with  certain  forms  of  bacteria  whose  bodies  should  sup- 
ply the  missing  ferments. 

The  Registration  of  Tuberculosis. — Amid  the 
controversy  which  this  subject  is  bound  to  excite — a 
few  tones  of  which  can  already  be  distinguished  in 
the  columns  of  the  Journal — it  were  well  for  every  one 
to  pause  long  enough  to  endeavor  to  gain  a  clear  view 
of  what  after  all  is  the  vital  question.  This,  it  seems  to 
us,  is  the  old  and  ever  recurring  question,  in  hygiene 
as  in  every  other  sociological  science,  of  what  is  the 
greatest  good  to  all.  It  is  not  a  question  that  is  to  be 
argued  on  purely  sentimental  grounds,  or  even  exclu- 
sively.on  the  ground  of  the  sensitiveness  and  welfare 
of  the  individual,  but  of  the  one  imperative  consider- 
ation of  the  public  welfare.  Is  this  infectious  disease 
controllable,  and,  if  so,  how  is  it  to  be  best  controlled  ?  Is 
it  to  be  allowed  to  go  about  unrestrained,  slaying  yearly 
its  thousands  and  tens  of  thousands,  lesi,  perchance, 
an  effort  to  control  it  should  wound  the  feelings  or  the 
scruples  of  a  minority  ?  In  other  words,  is  the  majority 
to  be  exposed  to  a  constantly  active  risk  rather  than 
that  the  invalided  minority  should  be  in  some  remote 
way  put  to  inconvenience  or  exposure  ?  The  question 
needs  but  to  be  put  in  order  to  answer  itself.  The 
principle  involved  is  already  acted  on  in  the  case  of 
every  contagious  disease,  and  human  society  for  its 
own  good  can  and  will  be  satisfied  with  nothing 
less  than  protection.  It  is  absolutely  needless  to  dwell 
upon  the  so-called  hardships  of  the  law.  They  are 
greatly  exaggerated,  and  such  as  they  are  they  can  be 
practically  ameliorated  in  many  ways. 

The  force  of  all  arguments,  pro  and  con,  bears  eventu- 
ally upon  the  question  simply  of  public  welfare.  Prac- 
tically the  problem  resolves  itself  into  this  :  If  this  or 
any  disease  is  to  be  subject  to  State  control,  there  must 
be  a  way  to  allow  the  State  to  gain  knowledge  of  its 
whereabouts,  and  in  the  case  of  tuberculosis  there 
seems  no  practicable  way  but  by  means  of  registration. 

The  New  Medical  Bulletin  of  the  University  of 
Pennsylvania. — The  medical  faculty  and  graduates  of 
the  University  of  Pennsylvania  are  to  be  congratulated 
on  the  appearance  of  the  new  medical  periodical  which 
comes  out  this  month  under  the  title  of  The  Unirersity 
of  Pennsylvania  Medical  Bulletin.  This  first  number  is 
very  attractive  in  appearance  and  in  its  table  of  con- 
tents. Dr.  Francis  R.  Packard  contributes  the  first  of 
a  series  of  papers  on  medical  men  prominent  in  civil 
and  military  affairs  in  revolutionary  times.  This  paper 
has  all  the  interest  which  attaches  to  Dr.  Packard's 
literary  and  historical  work.  Dr.  J.  William  White 
publishes  a  valuable  paper  on  the  Treatment  of  Tri- 
facial Neuralgia,  with  the  report  of  a  case  of  evulsion  of 
the  second  and  third  divisions  and  of  the  Gasserian 


ganglion.  At  the  end  of  11  months  the  patient  remained 
free  from  pain.  Dr.  Charles  H.  Frazier  and  Dr.  Mont- 
gomery H.  Bigs  contribute  an  important  paper  on  the 
Value  of  the  Tuberculin  Test.  'Their  conclusions  are 
given  at  length,  and  .should  be  read  in  the  original. 
Dr.  John  H.  Jopson  contributes  a  digest  of  recent  litera- 
ture on  Perforation  of  the  Intestine  in  Typhoid  Fever. 
The  number  concludes  with  copious  alumni  notes, 
which  will  be  of  great  interest  to  the  graduates  of  the 
University. 

This  new  Bulletin  is  to  be  published  once  a  month, 
and  is  to  take  the  place  of  the  former  University  Medical 
Magazine.  It  is  to  represent  exclusively  the  University, 
not  the  work  of  those  only  who  are  actively  connected 
with  the  faculty,  but  of  the  whole  alumni  body.  It  is 
to  be  a  purely  scientific  periodical,  without  advertise- 
ments, and  promises  under  the  able  editorial  care  of 
Dr.  Frazier  to  be  in  every  way  a  worthy  exponent  of 
the  oldest  medical  school  in  the  United  States. 

The  Assault  on  the  Kaiser. — If  the  earlier  reports 
are  accurate  the  recent  assault  on  the  German  Emperor 
was  made  by  an  epileptic,  and  the  case  has  therefore 
more  medico- legal  than  political  interest.  It  is  said 
that  the  assailant,  after  throwing  a  piece  of  iron  at  his 
Majesty  and  wounding  him  slightly  on  the  cheek,  had 
several  fits,  and  that  he  was  found,  on  investigation,  to 
be  the  victim  of  chronic  epilepsy.  It  is  premature 
perhaps  to  comment  on  the  case,  but  it  may  not  be 
inappropriate  to  express  the  hope  that  the  assault  may 
be  found  to  have  been  the  act  of  an  irresponsible  man. 
Epilepsy,  as  is  well  known,  predisposes  its  victims  to 
just  such  impulsive  and  maniacal  outbursts  as  this  act 
of  Weiland  seems  to  have  been.  Such  patients  some- 
times act  in  an  automatic  or  seemingly  purposive 
manner,  when  in  fact  they  are  quite  unconscious  of  the 
nature  of  their  acts,  and  have  no  memory  of  them. 
This  is  especially  true  of  the  post-epileptic  maniac,  who 
may  continue  to  display  a  true  psychosis  for  hours  or 
even  days  after  a  convulsion.  It  is  also  true  of  the 
victim  of  those  curious  substitutional  attacks  which 
replace  the  fit  itself,  and,  as  the  name  implies,  substi- 
tute for  it  a  delirium  in  which  delusions  and  wild 
impulses  have  full  sway.  In  the  Ipilepsie  larvee,  or  con- 
cealed epilepsy,  of  Morel,  the  motor  crisis  may  never 
or  rarely  occur,  but  a  periodical  or  occasional  furore 
may  be  the  sole  symptom.  This  is  ope  of  the  most 
involved  of  all  the  vexed  questions  in  medical  juris- 
prudence, and  it  is  to  be  hoped  that  this  assault  on  the 
Kaiser  may  have  at  least  the  one  good  effect  of  subject- 
ing the  whole  question  to  renewed  investigation  and 
profitable  criticism. 

The  Treatment  of  Cancer. — Professor  L.  Lewshin 
remarks  that  during  the  last  33  years  of  his  surgical 
practice  no  material  improvement  has  taken  place  in 
the  treatment  of  cancer.     The  percentage  of  complete 


498 


The  Phii.adbi.phL4 "I 

MSDICU.  JOXIXSil,  J 


EDITORIAL  COMMENT 


[Hascb  16,  uei 


recoveries  following  surgical  intervention,  as  attested 
by  Eiiropean  surgeons,  is  still  very  small  even  in  oper- 
able carcinomas.  On  the  other  hand,  the  statistics  of 
Massey,  Heyman,  Czemy  and  others  establish  beyond 
doubt  the  alarming  fact  that  cancer,  especially  of  the 
digestive  organs,  is  on  a  progressive  increase.  In 
Moscow  there  occurred  in  1880  411  deaths  from  cancer, 
while  in  1896  the  number  of  deaths  from  this  disease 
reached  892,  almost  doubled.  It  is  to  be  regretted  that 
the  author  does  not  state  the  extent  of  the  increase  in 
population  during  the  same  period,  but  it  may  be 
assumed  that  he  has  taken  this  into  account  in  making 
his  deductions.  To  the  hundreds  who  die  there  are 
thousands  who  drag  out  a  miserable  existence,  a  burden 
to  themselves  and  their  families  and  a  ready  prey  to 
the  quack.  These  unfortunate  sufferers  should  be  taken 
care  of  Moreover,  the  rapid  increase  of  an  incurable 
and  fatal  malady  renders  of  paramount  importance  the 
study  of  the  disease  in  all  its  phases.  Both  the  humani- 
tarian and  scientific  purposes  could  only  be  accom- 
plished by  the  establishment  of  proper  sanitaria.  Such 
an  one  is  being  established  in  Moscow  through  the  efiPorts 
of  Professor  Lewshin,  who  has  already  received  private 
contributions  to  the  amount  of  300,000  roubles  (about 
S  150,000).  The  city  council  of  Moscow  pledged  itself 
to  pay  for  the  maintenance  of  50  patients  for  10  years, 
while  the  medical  faculty  of  the  Moscow  University  has 
taken  the  sanitarium  under  its  protection  as  an  addition 
to  the  university  clinics. 

Plague  News. — According  to  the  Marine  Hospital 
Health  Reports,  India  is  still  the  great  theater  of  plague. 
In  some  districts  of  the  vast  Hindu  empire  cases  were 
being  reported  in  the  early  part  of  the  winter  by  the 
hundreds,  and  even  thousands.  In  the  Patna  city  and 
district,  in  Bengal,  5,506  cases  occurred  during  Novem- 
ber, December,  and  January,  ami  of  this  number  4.810 
cases  were  fatal.  A  glance  at  the  list  of  infected  regions 
in  India,  with  the  tabulated  figures  of  cases  and  deaths, 
showing  as  usual  a  very  high  mortality,  does  not  inspire 
the  reader  with  the  belief  that  the  disease  is  under  any 
sort  of  control  in  that  country,  or  with  the  hope  that 
even  with  serum-therapy  and  prophylaxis  its  spread 
wiU  be  checked  before  the  onset  of  summer.  India  is 
at  present  the  most  active  focus  of  plague  on  the  face  of 
the  earth,  and  her  condition  is  a  grave  menace  to  man- 
kind in  general.  If  the  disease  does  not  spread  from 
her  territory  to  ©ther  countries,  and  become  as  unman- 
ageable in  them  as  it  is  in  her,  it  will  be  almost  mirac- 
ulous. In  Japan,  China,  and  Formosa  there  is  very 
little  plague  that  is  being  reported.  In  Japan  espe- 
cially the  disease  seems  to  have  been  fought  with  great 
intelligence  and  success.  In  Brazil  there  is  still  some 
of  it  lurking  in  Rio  de  Janeiro,  and  the  mortality  is 
high,  but  the  number  of  cases  is  not  great.  The  reports 
contain  no  mention  of  plague  in  San  Francisco,  so  we 
might  hopefuUy  and  charitably  suppose  there  is  none 


there,  if  we  did  not  believe  that  the  truth  has  been  sup- 
pressed— a  state  of  things  for  which  the  U.  S.  Marine- 
Hospital  service  is  not  responsible.  It  is  unfortunate 
that  that  citj'  has  aroused  a  suspicion  that  the  disease 
has  been  concealed  by  the  local  authorities.  A  dele- 
gation of  San  Francisco  citizens  in  Washington  have 
just  given  out  a  remarkable  statement  that  no  case  of 
infectious  bubo-pneumonic  plague  has  been  found  in 
California,  but  that  all  the  cases  have  been  of  a  "  non- 
contagious character."  This  is  a  truly  alarming  state- 
ment, for  it  acknowledges  the  presence  of  plague  while 
it  attempts  to  mitigate  the  fact  by  claiming  that  the 
disease  is  •'  non-contagious  " — a  self-evident  contradic- 
tion that  goes  far  to  discredit  either  the  knowledge  or 
sincerity  of  those  who  made  it — or  both.  In  Cape 
Town,  South  Africa,  15  new  cases  were  reported  on 
the  11th  inst.  In  the  Philippine  Islands  there  were 
but  2  cases.  There  is  plague  in  Eussia  (more  than  100 
cases  of  it)  and  in  Smyrna  in  Turkey.  From  this  latter 
port  a  steamer  arrived  at  Bristol,  Eng.,  on  January  2  let. 
laden  with  barley,  with  a  clean  bill  of  health.  The  fol- 
lowing day  dead  rats  were  found  in  the  hold,  and  in 
their  bodies  were  found  the  plague  bacilli.  Extra  pre- 
cautions had  been  taken  to  keep  rats  from  leaving  this 
ship,  and  it  was  believed  that  none  of  the  animals  had 
escaped.  The  crew  were  kept  under  medical  inspection 
and  the  vessel  was  disinfected  and  allowed  to  depart. 
A  fatal  case  occurred  at  Cardifi"  in  Wales  in  a  man  who 
had  been  employed  in  gathering  up  dead  rats  and  de- 
stroying their  bodies,  but  where  the  rata  came  from  and 
how  they  had  contracted  the  plague  are  mysteries. 
From  these  various  items  of  plague  news  it  is  evident 
that  the  disease  is  still  active,  and  that  great  watchful- 
ness is  required  to  meet  it 

Astereognosis. — ^At  a  recent  meeting  of  the  Phil- 
adelphia Neurological  Society  an  interesting  paper  on 
this  subject,  written  by  Dr.  Walton  and  Dr.  Paul,  of 
Boston,  brought  out  a  discussion  of  this  rather  obscure 
symptom  of  nervous  disorder.  The  term  itself  is  derived 
from  two  Greek  words,  meaning  a  knowledge  of  solid 
objects,  and,  in  its  negative  form,  is  meant  to  apply  to 
that  pecuUar  loss  of  the  ability  to  recognize  the  shape, 
size  and  locality  of  a  solid  body  which  is  displayed  by 
some  patients  in  certain  forms  of  cerebral  disease.  In 
attempting  an  analysis  of  this  subject,  as  was  pointed  out 
in  this  discussion,  the  clinician  should  begin  by  recog- 
nizing the  fact  that  there  are  certain  elementary  proper- 
ties of  the  sensory  nerve  cell  which  we  generally  speak 
of  as  the  various  modes  of  sensation,  or  the  pain,  tactile, 
and  thermal  senses.  These  elementary  properties  are 
probably  inherent  in  every  sensor\-  nerve  cell.  In  the 
lower  forms  of  life  we  have  every  reason  to  believe  that 
they  are  all  present.  When  we  come  to  the  higher  ani- 
mal forms,in  which  there  is  elaborated  a  complex  psychi- 
cal Ufe,  we  have  a  much  more  complex  matter  to  deal 
with.    We  have  here  to  consider  the  activity  of  the  brain 


March  IB,  1901] 


EDITORIAL  COMMENT 


CThe  Philadelphia  4QQ 

Mkdical  .Todrnal  ^oi^ 


cortex,  and  we  must  recognize  certain  psychological 
problems  more  complex  than  those  that  are  presented 
by  the  sensations  of  pain,  heat  and  cold.  It  requires 
quite  an  elaborated  psychological  perception  to  ap- 
prehend the  qualities  of  a  solid  body,  such  as  its  size, 
shape  and  location  in  space ;  and  it  is  not  probable 
that  among  the  very  lowest  forms  of  life  there  can  be 
any  such  conception  unless  in  a  very  rudimentary  way. 
In  the  higher  forms  of  life,  these  conceptions  are  not 
only  present  but  are  essential. 

This  is,  therefore,  a  psychological  and  physiological 
as  well  as  a  pathological  question.  Looking  at  it  from 
the  practical  standpoint  of  pathology,  we  have  very 
good  grounds  for  knowing  the  course  in  the  spinal  cord 
for  these  elementary  qualities  of  sensation,  such  as  the 
pain,  tactile  and  thermal  modes  of  sense.  We  know 
that  they  run  in  different  tracts  through  the  cord. 
These  facts  have  been  proved  in  certain  cases  by  patho- 
logical conditions,  as,  for  instance,  syringomyelia  and 
traumata  of  the  cervical  region  of  the  spinal  cord. 

When,  however,  we  come  to  lesions  of  the  cortex  or 
of  the  cerebral  hemispheres,  then  we  come  into  the 
region  where  there  is  necessarily  present  the  "  gnosis," 
the  knowledge  or  judgment;  and  in  such  cases  the  dis. 
turbances  of  sensation  may  present  highly  complex 
problems. 

A  rare  form  of  aphasia,  which  has  occasionally  been 
seen,  illustrates  this  fact.  A  woman,  for  instance,  could 
not  name  an  object  which  was  presented  to  her  sight, 
but  if  the  object  was  placed  in  her  hand  she  would 
name  it  instantly.  In  this  case  there  was  evidently  a 
breaking  up  of  the  fibers  that  proceeded  to  the  speech- 
center  by  way  of  the  visual  sense,  but  the  fibers  that 
approached  by  way  of  the  stereognostic  sense  remained 
intact. 

In  a  case  of  brain  tumor  reported  by  Dr.  Mills  and 
Dr.  Keen,  a  diagnosis  of  a  tumor  in  the  superior  pari- 
etal lobule  had  been  made.  This  diagnosis  was  based 
in  part  on  the  fact  that  there  was  here  a  peculiar  form 
of  incoordination  due  to  a  sort  of  astereognosis  which 
was  practically  identical  with  what  had  been  seen  in  a 
previous  case  in  the  wards  at  Blockley,  in  this  city,  and 
shown  by  .autopsy  to  be  due  to  a  lesion  in  the  superior 
parietal  lobule.  It  would  not  be  proper  to  assert  that 
the  superior  parietal  lobule  is  the  seat  of  all  astereog- 
nostic  symptoms,  but  a  number  of  cases  have  been  seen 
in  which  astereognosis,  associated  with  a  form  of  inco- 
ordination, has  been  caused  by  a  lesion  of  this  region 
of  the  brain.  The  case  of  Dr.  Mills  and  Dr.  Keen 
had  been  of  extraordinary  interest,  because  it  was  a 
practical,  pathological  demonstration  of  some  of  these 
rather  fine  distinctions. 

Literary  Piracy. — The  Indian  Aredical  Record  pos- 
sibly thinks  that  it  is  published  so  near  the  antipodes 
that  it  can  safely  rifle  the  columns  of  The  Phil.v- 
DELPHi.\    Medical  Journal  without   being    detected. 


Living  on  the  other  side  of  the  earth,  the  Record 
stands  constantly  on  its  head,  and  may  therefore 
naturally  have  a  perverted  view  of  morals  in  gen- 
eral. It  printed  verbatim,  on  .January  30,  1901,  Dr. 
Howard  A.  Kelly's  paper,  "On  Methods  of  Teach- 
ing Gynecology,"  which  was  first  published  as  an 
original  article  by  this  .Jourxal  on  September  1,  1900 ; 
but  the  Record  omitted  to  mention  this  latter  fact.  Again, 
in  its  Volume  XX,  February  6, 1901,  it  published  Dr.  A. 
0.  J.  Kelly's  paper  on  the  "  Relation  between  Cardio- 
vascular and  Renal  Disease,"  as  an  original  article  with- 
out giving  us  credit  for  having  originally  published 
this  paper  on  October  27, 1900.  There  is  an  old  saying 
that  imitation  is  the  sincerest  flattery,  and  there  is  also 
an  old  fable  about  a  Spartan  boy  being  blamed  not  for 
stealing  a  fox  but  for  being  caught  at  it.  The  Indian 
Medical  Record  can  now  sympathize  with  that  Lacede- 
monian youth. 


The  Influence  of  Climate  on  the  Evolution  of  Ex- 
perimental Pleuropulnionary  Tuberculosis.—  Lan- 
nelongue,  Achard  and  Gaillard  (Gaz.  Heb.  de  Med.  etde  Chinir., 
January  31,  1901,  4Sme  Ann^e,  No.  9)  have  experimented 
by  inoculating  into  the  pleura  of  300  male  guiceapigg, 
equal  quantities  of  an  emulsion  of  tuberculosis  and  imme- 
diately submitting  groups  of  equal  numbers  to  different 
climatic  influences.  The  conditions  of  the  injection  were 
in  all  cases  the  same  and  the  conditions  of  lodgment  and  food 
in  each  group  were  as  nearly  alike  as  possible.  Two  series  of 
experiments  were  made.  In  the  first  series  150  guineapigs 
were  divided  into  3  groups.  One  group  was  kept  at  the 
laboratory  of  External  Pathology  of  the  Faculty  of  Medicine, 
at  Paris,  another  group  was  sent  to  the  seashore  at  Grandes- 
Dalles,  and  the  third  group  was  sent  to  the  country  at  Val- 
mont.  In  the  second  experiment,  one  group  was  retained 
at  the  laboratory,  a  second  group  was  sent  to  the  mountains, 
and  the  third  group  to  a  forest  on  the  Isle- Adam.  In  the 
two  experiments  the  groups  retained  at  the  laboratory  pre- 
sented the  advantage  of  condition,  in  spite  of  the  apparent 
unfavorable  surroundings  produced  by  lack  of  space,  poor 
ventilation,  absence  of  light,  the  high  degree  of  humidity, 
and  the  abundance  of  ammoniacal  vapors.  Cold  and  change 
of  temperature  appeared  to  have  acted  unfavorably,  while 
the  equality  of  temperature  and  the  greater  quiet  in  the 
laboratory  animals  seemed  to  have  operated  favorably.  The 
evolution  of  the  lesions  in  the  animals  of  each  group  pre- 
sented great  variations.  While  certain  guineapigs  died  of 
tuberculosis  at  the  ecd  of  6  weeks,  in  certain  others  at  the 
end  of  15  or  18  months,  the  lesions  were  very  few  and  small 
and  were  entirely  localized  to  the  thorax.  This  was  the  end 
of  the  experiment  in  3  animals  of  the  group  sent  to  the  sea- 
shore, 3  of  the  group  sent  to  the  country  and  4  of  the 
laboratory  group  of  the  first  experiment.  In  the  second  ex- 
periment the  same  condition  was  found  in  1  animal  sent 
to  the  mountains  and  in  3  of  those  kept  in  the  laboratory. 
Whether  or  not  the  remarkable  resistance  of  certain  guinea- 
pigs  to  the  generalization  of  tuberculous  lesions  might  go  on 
to  complete  cure  and  to  the  disappearance  of  virulence  is 
doubtful.  These  experimental  facts  have  certain  definite 
relations  to  conditions  observed  in  human  pathology.  The 
evolution  of  tuberculosis  in  man  is  eminently  variable  ac- 
cording to  the  subject  and  very  diverse  forms  of  the  disease 
are  met  with  independent  of  climate  or  of  altitude.  Cure 
and  resistance  to  infection  are  observed  with  greater  fre- 
quency in  man  than  in  the  animals  experimented  upon. 
This  observation  is  explained  sufficiently  by  the  fact  that  the 
guineapigs  received  a  larger  dose  of  the  virup,  and  by  the  fact 
that  this  animal  presents  a  high  degree  of  susceptibility  to 
the  infection.     [j.M.e.] 


500 


THK  PBOLADKLPHLi"] 

Mbdicai.  Jocrsax  J 


CORRESPONDENCE 


[Habc-b  IC,  1901 


(£orrc5pon6crtcc. 


PAROTITIS  IN  PNEUMONIA. 

By  T.  C.  MORRIS,  M.D., 
of  Loch  Leveo,  Ta. 

To  the  Editor  of  The  Philadexphia  Medical  Journal  : — 

I  HAVE  noticed  in  the  past  few  months  a  limited  number  of 
cases  of  parotitis  reported,  complicating  pneumonia.  I 
wish  to  add  one  to  the  list.  The  patient  was  a  man,  79 
years  of  age,  who  was  taken  with  the  grip.  Four  days  later 
bronchopneumonia  set  in.  Five  days  from  the  onset  of  the 
pneumonia  I  noticed  the  patient  constantly  placing  his  hand 
near  his  left  ear,  and  examination  revealed  the  presence  of 
a  parotitis  of  the  left  side.  The  patient  made  no  complaint 
of  it  owing  to  his  mental  condition,  which  waa  very  bad  at 
this  time.  There  was  no  rise  in  the  temperature,  which  ranged 
from  99  to  101.  But  there  was  a  marked  change  in  the  char- 
acter of  his  pulse  which,  prior  to  this,  had  been  remarkable, 
ranging  from  90  to  100,  full  and  strong.  Now  it  ranged 
from  130  to  140,  soft,  compressible,  and  intermittent.  There 
waa  no  appreciable  change  in  any  of  the  other  symptoms, 
he  case  terminated  fatally  6  days  later.  Whether  the  paro- 
titis had  anything  to  do  with  the  change  in  the  circulation 
I  am  unable  to  say. 


PULMONARY  TUBERCULOSIS  AND  THE   BOARD 
OP  HEALTH. 
By  WM.  M.  CAPP,  M.D., 
of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Jodbnal  : — 

Before  the  Board  of  Health  should  be  so  unwise  as  to 
require  the  registration  of  all  cases  of  pulmonary  tuberculosis, 
it  should  first  clearly  appear  that  some  practical  benefit  will 
thereby  be  gained  to  the  public.  Registration  of  itaelf  is  an 
idle  form  and  does  not  give  as  useful  information  as  the 
physician's  usual  death-reports.  In  New  York,  where  this 
requirement  is  in  force,  no  public  action  other  than  the  regis- 
tration is  taken  as  to  private  houses  and  iu  cases  reported  by 
private  physicians.  To  this  extent,  at  least,  registration,  then, 
has  no  value  whatever ;  and  besides,  it  may  do  much  harm 
to  the  individuals  reported  and  their  friends.  To  be  of  value 
In  protecting  public  health  a  registry  of  consumptives'  names 
should  be  an  open  book  and  proclaimed  abroad  to  all  for 
their  personal  safety ;  for,  certainly,  registration  must  be 
thought  of  as  devised  for  the  protection  of  the  public  rather 
than  of  the  patient.  But  this  public  exposure  of  private 
distress  is  an  idea  so  shocking  to  all  sense  of  propriety  and 
humane  sentiment  that  we  are  told  the  register  is  to  be  kept 
with  the  utmost  secrecy.  Registration,  as  such,  therefore, 
can  accomplish  nothing  in  the  way  of  protection  to  the  public 
health.  A  knowledge  of  the  particular  house  or  locality 
in  which  germs  of  consumption  exist  is  what  the  public 
authorities  reallj-  need,  and  that  only,  if  it  is  the  bona  fide 
intention  to  follow  the  matter  up  by  officially  conducting 
efiective  sanitary  measures  by  destroying  the  threatening 
germs  of  the  disease  wherever  they  may  be  found.  In  fact, 
prompt  and  thorough  disinfection  of  infected  abodes  of  the 
ejected  bacillus  of  consumption  is  the  only  paternal  intrusion 
of  the  government  upon  individual  rights  which  is  called  for 
in  these  cases,  or  which  will  be  in  any  sense  valuable  for  the 
protection  of  the  public.  And  this  should  not  be  undertaken 
until  liberal  and  sufficient  arrangements  for  the  efficient 


prosecution  of  the  work  are  mapped  out  and  provided  for. 
Disinfection  is  a  more  or  less  costly  operation  and  needs  to 
be  done  aright  by  properly  qualified  agents,  and  will  not  be 
strictly  attended  to  if  left  in  the  hands  of  the  average  landlord 
or  tenant  of  means,  and  cannot  be  exacted  of  the  poorer 
tenant,  who  often  lives  in  quarters  most  requiring  it.  The 
public  authorities  should  not  proceed  against  the  individual, 
but  against  the  disease,  in  infected  premises.  Meanwhile,  let 
the  health  boards  also  prosecute  a  more  vigorous  and  intelli- 
gent campaign  of  education  and  enlightenment  of  the  public 
upon  the  nature  of  the  disease  under  consideration  and  the 
proper  means  to  prevent  its  spread  among  the  people,  among 
whom,  in  the  very  nature  of  things,  the  unfortunate  victims 
of  the  disease  must  associate  with  more  or  less  freedom. 


TWO   CASES   OF  PAROTITIS  COMPLICATING 
CROUPOUS  PNEUMONL^. 

By  D.  J.  MILTOX  MILLER,  M.D., 

of  Philadelphia. 

To  the  Editor  of  The  Philadelphia  Medical  Jouesal  : — 

Apropos  of  several  cases  of  parotitis  complicating  pneu- 
monia, which  appeared  in  your  correspondence  columns  last 
winter  (1900),  and  of  the  case  of  bilateral  parotitis  reported 
by  Dr.  Eshner  in  your  issue  of  February  16,  1899, 1  desire  to 
briefly  record  two  additional  instances  of  this  unusual  com- 
plication of  croupous  pneumonia,  occurring  in  my  service 
and  in  that  of  my  colleague.  Dr.  D.  D.  Stewart,  at  the  Epis- 
copal Hospital,  during  the  winter  and  spring  of  1900.  My 
case  was  that  of  a  young  woman  of  18,  who,  while  at  the 
height  of  an  attack  of  chorea,  the  last  of  many  similar  out- 
breaks, was  seized  with  acute  croupous  pneumonia,  limited 
to  the  whole  of  the  upper  and  adjacent  portion  of  the  middle 
lobe  of  the  left  lung.  The  disease  ran  a  severe  course,  with 
high  temperature  (104°  to  105°  F.),  intense  delirium,  and 
great  resilessness,  the  patient's  limbs  and  body  being  con- 
stantly tossed  from  side  to  side  by  the  exaggerated  choreic 
movements.  In  addition,  there  waa  a  loud,  blowing,  systolic 
murmur,  heard  at  the  apex  and  transmitted  to  the  axilla  and 
to  the  left  scapular  angle.  The  second  pulmonary  sound  was 
sharply  accentuated.  Tuese  signs  were  regarded  at  the  time  as 
indicating  an  associated  endocarditis.  On  the  ninth  day,  while 
the  constitutional  and  local  symptoms  were  abating  (the 
temperature  fell  by  lysis),  enlargement  of  the  left  parotid 
gland  wM  observed.  Suppuration  rapidly  supervened,  neces- 
sitating incision  and  free  drainsige  three  days  later.  Bacteri- 
ological examination  of  the  evacuated  pus  gave  a  pure 
culture  of  the  staphylococcus  aureus.  With  the  establish- 
ment of  drainage  the  temperature,  which  had  risen  with  the 
onset  of  the  parotitis,  fell  almost  to  normal  (9S.5°  to  99°),  and 
continued  so  until  the  seventeenth  day,  when  it  again  aroee, 
owing  to  the  development  of  an  empyema  in  the  right 
pleural  cavity.  Aspiration  was  performed  on  the  twenty- 
third  day,  and  a  pint  of  thick,  creamy  pus  removed,  from  which 
a  pure  culture  of  the  streptococcus  pyogenes  was  obtained. 
After  this  the  patient  gradually  sank  into  a  typhoid  condi- 
tion, and  died  on  the  twenty-seventh  day.  No  autopsy  was 
permitted.  The  leukocytes,  which  on  admission  numbered 
17,000,  increased  with  the  parotitis  to  27.000,  then  fell  almost 
to  normal,  to  rise  again  to  18,000  at  the  height  of  the  em- 
pyema. 

The  second  case  (reported  through  the  courtesy  of  Dr. 
Stewart),  a  woman  of  71,  on  the  eighteenth  day  of  an  acute 
pneumonia  of  the  left  upper  lobe,  while  the  temperature  was 


JUkch  IC,  1901] 


CORRESPONDENCE 


rTHE  Philadelphia 
L  Medical  Journal 


501 


falling  and  the  other  syinptoins  abating,  developed  a  left- 
sided  parotitis,  which  .quicklj'  suppurated,  and  was  opened 
and  drained  four  days  later.  The  wound  healed  readily  in 
about  10  days,  and  the  lung  cleared  up  entirely,  but  a  severe 
cystitis  developed  and  she  died  on  the  thirty-seventh  day. 
No  autopsy  could  be  obtained,  nor  was  a  bacteriological  ex- 
amination of  the  parotid  pus  made.  The  leukocytes,  at  the 
height  of  the  parotitis,  numbered  22,000.  Tlie  association  of 
the  first  case  with  endocarditis  is  worthy  of  note  in  ^^ew  of 
the  statement  of  Oaler  that  parotitis  in  pneumonia  is  com- 
monly accompanied  by  this  form  of  heart  disease.  About 
one  year  ago,  however,  when  I  looked  this  matter  up  with 
the  intention  of  publishing  a  more  elaborate  paper  in  con- 
nection with  these  cases  (the  material  for  which  has  since 
been  lost),  I  did  not  find  the  associations  at  all  frequent. 
Another  point  of  interest  in  the  same  case  is  the  different 
bacteriology  of  the  two  suppurative  processes,  the  parotitis 
giving  a  pure  culture  of  the  staphylococcus,  while  in  the  em- 
pyema the  streptococcus  only  was  found,  the  pneumococcus 
not  being  present  in  either.  This  does  not  necessarily  indi- 
cate that  the  pneumonia  was  of  streptococcal  origin,  as  in 
pneumonias,  owing  to  a  mixed  infection,  the  streptococcus 
alone  may  find  access  to  the  pleura.  The  presence  of  the 
staphylococcus  in  the  parotid  pus,  however,  may  be  regarded 
as  an  evidence  that  the  infection  reached  the  gland  by  way 
of  the  parotid  duct,  as  is  usually  the  case  in  one-sided  par- 
otitis, la  the  bUateral  variety,  as  in  Dr.  Eshner's  case,  it  is 
more  likely  that  the  inflammation  is  induced  by  an  infection 
through  the  blood. 


THE  TREATMENT  OF  PURULENT  ENDOMETRITIS'  BY 

INJECTIONS  OF  IODOFORM- GLYCERIN  EMULSION. 

By  JAY  G.  ROBERTS,  M.D., 

of  Hastings,  Nebraska. 

To  the  Editor  of  The  Philadelphia  Medical  Jouknal  : — 

In  presenting  this  article  I  wish  simply  to  call  attention  to 
a  new  application  of  that  old  and  tried  remedy,  iodoform. 

It  is  possible  that  this  method  of  treatment  may  not  be 
entirely  new,  but  a  careful  perusal  of  all  the  literature  at  my 
command  fails  to  disclose  any  reference  to  such  a  method  of 
treatment  of  endometritis. 

I  have  always  been  a  firm  advocate  of  iodoform  in  the 
treatment  of  all  those  conditions  attended  with  pus  forma- 
tion, in  spite  of  its  unsavory  odor,  which  has  led  into  many 
a  vain  experiment  with  other  numerous  substitutes  with 
which  the  market  is  flooded,  for  all  of  which  are  claimed  all 
the  advantages  with  none  of  the  disadvantages  of  the  drug 
which  they  seek  to  replace. 

After  having  gone  the  rounds,  I  have  yet  to  find  a  drug 
which  will  clear  up  a  suppurating  surface  and  replace  foul, 
unhealthy  granulations  so  well,  and  in  so  short  a  time  as 
iodoform. 

The  possibilities  of  such  a  method  of  treatment  were  first 
suggested  by  a  consideration  of  the  close  resemblance  of  the 
infected  uterine  cavity  to  a  tubercular  or  other  abscess  cavity, 
the  custom  of  which  it  has  long  been  to  treat  by  injections  of 
iodoform-glycerin  emulsion.  Other  methods  having  given 
such  unsatisfactory  results  as  almost  to  lead  to  despair,  I 
determined  to  put  it  to  a  test. 

The  method  of  application,  which  is  very  simple,  is  as 
follows  :  An  emulsion  is  prepared  according  to  the  following 
formula,  the  small  amount  of  creolin  very  eflfectually  dis- 
guising the  odor  without  aflfecting  its  eflScacy  to  which  most 
patients  object  very  strenuously. 


R.— lodofjrm  2.00. 

Amyl  1.00. 

Mix  and  add 

Glycerin 20.00. 

Water 12.00. 

Creolin 80. 

M.    Stirring  graduahj ,  heal  .  ,/  to  about  27°  F. 

This  makes  a  more  stable  c.-uulsion  than  that  made  by  the 
usual  method. 

For  the  injection  the  _rJinary  long-nozzled  intrauterine 
syringe  may  be  used.  I  have  found  a  small  glass  syringe 
with  a  soft  rubber  nozz'e,  some  two  inches  in  length,  and  of 
sufficient  firmness  to  answer  admirably. 

Toe  cervical  canal  in  these  cases  being  quite  patulous,  aa  a 
rale,  little  difficulty  is  experienced  in  inserting. 

The  patient  is  placed  in  the  dorsal  position  with  the  hipa 
well  elevated. 

The  cervix  is  exposed  by  means  of  the  ordinary  bivalve 
speculum,  and  with  dressing  forceps  and  pledgets  of  absorb- 
ent cotton,  all  discharge  is  carefully  wiped  from  the  cervix 
and  vaginal  fornices,  which  are  then  thoroughly  mopped 
with  sinol  or  other  antiseptic,  and  then  with  hydrogen  dioxid. 

About  4  cc.  of  the  emulsion  is  then  drawn  into  the  syringe, 
all  the  air  expelled,  the  nozzle  gently  inserted  well  up  into 
the  uterine  cavity,  and  the  emulsion  slowly  injected.  The 
syringe  is  withdrawn  and  the  cervix  plugged  with  absorbent 
cotton. 

It  is  a  good  plan  to  have  the  patient  retain  her  position  for 
a  few  minutes  before  arising,  thus  keeping  the  fluid  in  more 
prolonged  contact  with  the  upper  portion  of  the  uterine 
cavity. 

As  high  as  8  or  10  cc.  may  be  used  at  a  time,  but  it  is 
better  to  start  a  smaller  amount,  evea  as  low  as  2  cc,  and 
gradually  increase  the  quantity  to  guard  against  any  sus- 
ceptibility or  idiosyncrasy  to  the  action  of  the  drug,  the 
uterine  mucosa,  as  is  well  known,  possessing  great  absorbent 
properties.  The  injections  should  be  repeated  every  other 
day  or  every  third  day. 

The  following  case,  the  first  in  which  I  had  occasion  to 
resort  to  this  method,  well  illustrates  its  efficacy.  I  have 
since  used  it  in  numerous  cases  of  both  simple  and  purulent 
endometritis  with.uaiformly  satisfactory  results  : 

Case. — Anna  T.,  age  21,  waitress.  Came  under  treatment 
September  21.  History  of  painful  menses,  constant  dragging 
pain  in  the  pelvis,  and  leukorrheal  discharge. 

Examination  revealed  a  somewhat  enlarged  and  painfu 
uterus.    Cervix  enlarged,  everted,   and   eroded.    Red  and 
painful,  bleeding  readily,  with  an  abundant,  thick,  purulent 
discharge. 

Applications  of  iodized  phenol  were  made  to  the  uterus 
with  tampons  of  ichthyol  and  glycerin  to  the  cervix  every 
other  day,  and  hot  vaginal  injections  twice  daily. 

Under  this  treatment  the  acute  symptoms  rapidly  subsided, 
bu  t  the  discharge  continued  with  little  decrease  in  amount. 
At  the  end  of  6  weeks  silver  nitrate  applications  were  sub- 
stituted for  the  iodized-phenol  with  no  benefit.  Discharge 
increased  in  amount. 

November  3.  Curetted  lightly  and  douched  out  uterus,, 
which  seemed  only  to  aggravate  the  disorder. 

November  IS.  Injected  4  cc.  iodoform-glycerin  emulsion. 

November  20.  Discharge  less  abundant.  Injected  6  cc. 
iodoform-glycerin  emulsion. 

November  22.  Discharge  markedly  diminished.  Treat- 
ment continued. 

November  28.  Discharge  absent.  Cervix  almost  normal  in 
appearance. 

December  6.  Discharge  absent  for  over  a  week.  Cervix 
normal.    Consistency  not  painful. 

Patient  has  been  seen  at  intervals  since,  and  has  been 
entirely  free  from  discharge,  pain,  or  other  symptoms. 
Menses  regular  and  painless. 


502 


The  Philadelphia"] 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


(StAEtH   16,   1901 


2imcrican  Hems  anb  Xloks. 


PHILADELPHIA  AND  PENNSYLVANIA. 

Chester  Hospital. — A  nurses'  home  and  laundry  will  be 
built  as  an  addition  to  the  Chester  Hospital. 

Dr.  B.  a;  Randall  Kesigns.— Dr.  B.  A.  Randall  has 
resigned  the  position  of  Eye  and  Ear  Surgeon  to  the  Method- 
ist Hospital.  Applicants,  who  must  possess  the  B.  A.  degree, 
should  communicate  promptly  with  the  Board  of  Managers. 

Death  of  Dr.  Emil  Schnizler. — After  two  weeks  ill- 
ness Dr.  Schnizler  died  at  his  home  in  Philadelphia  on  March 
6.  He  had  practised  in  this  city  for  twelve  years  and  had 
devoted  considerable  time  to  the  study  of  rheumatism  and 
gout.  He  was  born  at  Frankfort-on-the-Main,  Germany, 
and  received  his  medical  education  at  Heidelberg  University. 
On  graduating  there,  in  1868,  he  became  head  professor  at 
the  Vienna  Hospital,  where  he  remained  for  fifteen  years. 

University  of  Pennsylvania  Medical  Bulletin.— 

We  note  that  the  changes  in  the  Univfrsity  Medical  Maga- 
zine, which  were  announced  in  February,  appear  with  the 
March  issue.  The  title  has  been  changed  to  read  Univer- 
sity of  Pennsylvania  Medical  Bulletin,  the  reading 
matter  is  printed  in  double  instead  of  single  column,  and, 
what  is  particularly  creditable,  all  advertising  matter  has 
been  excluded.  The  policy  and  scope  of  the  publication  are 
in  no  way  affected  by  these  changes,  as  it  still  continues  to 
be  the  official  organ  of  the  Medical  Department  of  the  Uni- 
versity of  Pennsylvania.  In  its  present  form  the  publication 
is  both  attractive  and  dignified  in  appearance. 

Nurse  Obtains  a  Mandamus.  —  Miss  Mariane  H. 
Wood,  a  nurse  at  the  Pennsylvania  Hospital,  was  awarded  an 
alternative  writ  of  mandamus  returnable  March  25,  com- 
pelling the  Pennsylvania  Hospital  to  reinstate  her  as  nurse 
in  that  institution.  Miss  Wood  was  admitted  to  the  Pennsyl- 
vania Hospital  Training  School  for  nurses  on  March  28, 1898, 
and  it  is  reported  that  before  her  term  of  three  years  was 
completed,  she  was  expelled  on  August  15,  1900,  for  slapping 
a  patient.  The  nurse  claims  that  she  had  received  peremp- 
tory instructions  to  keep  a  powerful  colored  woman  who  had 
undergone  abdominal  operation  on  her  back,  and  that  the 
patient  resisted  by  clutching  the  nurse's  hair  threatening  to 
do  herself  injury.  The  impact  of  the  nurse's  hand  against 
the  patient's  cheek  in  the  attempt  to  keep  the  latter  in  a  re- 
cumbent position  is  the  "  slap  "  which  she  says  she  is  accused 
of  inflicting. 

TheSesqui-Centennial  of  the  Pennsylvania  Hos- 
pital.— The  150th  anniversary  of  the  founding  of  the  Penn- 
sylvania Hospital  in  this  city  will  be  celebrated  in  May  of 
this  year.  On  the  15th  of  that  month  an  address  will  be 
delivered  by  Mr.  John  B.  Garrett  in  the  new  assembly  room 
in  the  old  Pine  Street  institution.  On  the  18th  of  the  month 
the  contributors  and  invited  guests  will  enjoy  a  visit  to  the 
departmei  t  for  the  insane  in  West  Philadelphia.  The  com- 
mittee having  charge  of  the  anniversary  is  composed  of  Mr. 
Benjamin  H.  Shoemaker,  chairman;  Mr.  John  B.Garrett, 
Mr.  J.  Stewart  Jenks,  Dr.  Thomas  Q.  IMoiton,  and  Dr.  John 
B.  Chapin.  The  Pennsylvania  Hospital  is  one  of  the  most 
important  and  interesting  of  our  pre-Revolutionary  institu- 
tions, and  its  coming  anniversary  will  doubtless  attract  wide 
attention.    The  occasion,  it  is  hoped,  will  be  a  great  success. 

Obstetrical  Society.— Dr.  Guy  L.  Hunner,  of  Johns 
Hopkins  Hospital,  by  invitation  addressed  the  meeting  of 
March  7.  Dr.  Hunner  gave  a  thoroughly  practical  talk  on 
Streptococcus  In  Gynecology.  The  localized  forms  of 
this  infection  were  the  types  discussed.  The  various  foci  of 
infection,  within  the  uterus,  in  the  perimetric  tissues,  etc., 
and  the  modes  of  infection  were  detailed  and  histories  of 
cases  given.  Most  of  the  infections  from  the  uterine  con- 
tents occur  not  through  the  medium  of  the  tubes  but  through 
the  uterine  wall.  Hence  abscesses  may  be  found  anywhere 
in  the  pelvis.  The  diagnosis  of  streptococcic  infection  is 
considered  to  be  sufficiently  easy  to  render  a  mistake  inex- 
cusable. The  history  of  the  case  is  of  the  greatest  import- 
ance in  diagnosis,  as  streptococcic  infection  is  almost  always 
connected  with  the  puerperium.   Examination  then  confirms 


the  diagnosis  which  can  be  at  least  provisionally  made  from 
the  history  alone.  Streptococcic  infections  are  usually  cellu- 
litic  in  character.  When  operating  to  evacuate  abscesses  a 
cardinal  rule  to  be  observed  is  to  keep  out  of  the  peritoneal 
cavity.  The  inguinal  incision  should  be  used,  thus  avoiding 
the  peritoneum,  or  vaginal  puncture  anterior  or  posterior  to 
the  uterus.  Dr.  Wilmer  Krdsen  spoke  of  the  conservative 
operations  of  the  present  day  and  their  efficacy  in  preserving 
the  functions  of  the  patient.  The  possibility  of  the  reaccu- 
mulation  of  pus  if  only  a  vaginal  puncture  waa  made  was 
mentioned.  He  aaked  Dr.  Hunner  if  antistreptococcic  serum 
was  used  at  the  Johns  Hopkins  Hospital  and  also  how  strep- 
tococcic was  differentiated  from  gonorrheal  infection.  Dr. 
Honner  stated  that  antistreptococcic  serum  had  been  used 
but  it  is  not  considered  of  much  value.  Many  cases  get  well 
without  it  and  a  favorable  change  may  occur  almost  syn- 
chronous with  its  use  and  yet  not  be  due  to  its  effect.  "The 
user  must  be  careful  in  drawing  conclusions.  Regarding  the 
inefficiency  of  puncture  to  fully  drain  abscess  cavities  it  was 
stated  that  when  the  abscess  is  between  the  uterus  and  bladder 
an  incision  is  made ;  when  posterior  to  the  uterus  or  laterally 
a  puncture  is  made  and  then  enlarged  by  dilators.  No  irri- 
gation is  used  in  these  cases,  the  operation  being  done  by  the 
dry  method.  Streptococcic  and  gonorrheal  infections  cannot 
be  diflerentiated  except  by  the  history  of  the  case.  The  sub- 
ject was  also  discussed  by  Drs.  Downes,  Ro.sesthal,  Wxlsos, 
Hirst,  Boyd,  and  Nassau. 

Dr.  a.  J.  Downes  read  a  paper  on  Spinal  anesthesia  in 
cases  stroDgrly  coutraindicating^  general  anesthe- 
sia. Five  cases,  including  a  gastroenterostomy,  two  hyster- 
ectomies, ana  an  extrauterine  pregnancy  were  reported.  The 
results  warrant  tbe  use  of  this  method  in  selected 
cases.  Dr.  George  Erety  Shoemaker  stated  that  until 
surer  methods  of  sterilizing  the  anesthetic  were  in  use  it  waa 
wiser  to  retain  the  old  anesthetics.  Very  few  cases  will  not 
bear  general  anesthesia.  Dr.  Frask  Hammosd  expressed 
the  same  view.  General  anesthetics,  particularly  chloroform 
and  oxygen,  can  be  used  in  practically  every  case  which 
may  seem  to  contraindicate  them. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 

March  9,  1901  : 

Total  mortality 495 

CA3BS.      Deaths. 
luflammation  of  appendix  1,  bladder  1,  brain 
11,  bronchi  y,  heart  2,  kidneys  15,  larynx  1, 
liver  1,  lungs  80.  pericardium  1,  peritoneum 
a,  pleura  3,  stomach  and  bowels  IV,  spine  2  150 

Inanition  9,  marasmus  13,  debihty  9 31 

Tuberculosis  of  lungs 77 

Apoplexy  14,  paralysis  5    . 19 

Heart — disease  of  33,  fatty  degeneration  of  3, 

dropsy  of  1 37 

Uremia  10,  diabetes  3,  Bright's  disease  10    .    .  23 

Carcinoma  of  colon  1,  breast  2,  stomach  7, 
uterus  2,  liver  1,  pancreas  2,  rectum  2    .    .   .  17 

Convtilsions 21 

Diphtheria 68  9 

Brain — congestion  of  1,  disease  of  1,  hemor- 
rliage  from  1,  softening  of  4,  tumor  2    .    .   .  9 

Typhoid  fever 86  7 

Old  age 9 

Cyanosis 6 

Scarlet  fever 29  5 

Influenza  9,  abscess,  back  1,  abortion  2,  alco- 
holism 1,  asthma  3,  anemia  1,  atheroma  I, 
burns  and  scalds  3,  casualties  7,  congestion 
of  lungs  5,  cirrliosis  of  liver  2,  membranous 
croup  2,  erysipelas  2,  fracture  of  skull  1, 
gangrene  of  foot  2,  intussusception  2,  indi- 
gfstiou  2,  jaundice  1,  neuralgia  of  heart  4, 
obstruction  of  bowels  I,  edema  of  lungs  3, 
purpura  hemorrhagica  1,  rheumatism  1,  scle- 
rosis of  liver  1,  surgical  shock  1,  sepiicemia 
3,  suffocation  1,  suicide  3.  teething  2,  tumor, 
uterus  1,  neck  1,  ulceration  of  stomach  1, 
whoopiug-cough  3 74 

NEW  JERSEr. 

Beverly. — Scarlet  fever  has  again  made  its  appearance 
at  Beverly,  and  all  cases  are  being  quarantined. 

Muhlenberg  Hospital.  —  A  plot  of  ground  with  a 
frontage  of  500  feet  and  300  feet  deep  has  been  given  to 
the  Muhlenberg  Hospital  at  Plainfield  by  James  A.  Martine. 
The  value  of  the  land  is  estimated  at  $10,000. 


Mabcii  1G,  1901] 


AMERICAN  NEWS  AND  NOTES 


TTiiE  Philadelphia  503 

L  Medical  Journal 


Quarantine  Kemoved. — For  the  first  time  in  2  weeks 
the  churches  and  schools  were  again  opened  in  Woodbury. 
Vaccination  is  being  enforced. 

Medical  Library. — The  medical  and  surgical  library  of 
the  late  Dr.  William  Pierson,  of  Orange,  numbering  8,000 
volumes,  has  been  presented  by  Mrs.  Pierson  to  the  physi- 
cians of  Orange,  who  have  decided  to  organize  the  William 
Pierson  Medical  Library  Association. 

NEW  YORK. 

Acquitted. — The  nurse  in  Bellevue  Hospital  who  was 
charged  with  hiving  been  responsible  for  the  death  of  one 
of  the  insane  inmates,  has  been  acquitted. 

Clianged  to  a  Periodical. — The  Annual  Circular  of 
the  New  York  University  will  now  be  issued  twice  a  month 
as  a  periodical  containing  in  addition  recent  progress  in  the 
university. 

New  Scientific  Quarterly. — A  new  scientifio  bulletin 
under  the  title  of  New  York  University  Bulletin  of  the  Medical 
Sciences  will  appear  for  the  first  tune  this  month,  edited 
under  the  auspices  of  the  New  York  University  Medical 
Society. 

Nurses'  Home. — Plans  were  filed  for  the  nurses'  home 
to  be  erected  for  the  Presbyterian  Hospital  in  New  York. 
The  structure  will  be  8  stories  in  height.  Several  months  ago 
a  benefactor,  whose  name  was  not  disclosed,  gave  the  hos- 
pital $300,000  for  the  erection  of  this  home,  provided  the 
institution  would  assume  the  maintenance  of  it. 

Bellevue  Maternity. — The  Medical  College  and  Dis- 
pensary Building  of  the  Bellevue  Hospital  will  be  altered 
into  a  maternity  hospital,  dispensary  and  dormitory.  The 
expense  for  altering  the  interior  of  the  building  has  been 
estimated  at  $20,000.  The  object  of  these  alterations  is  to 
bring  about  a  closer  approximation  of  the  various  depart- 
ments of  the  hospital. 

New  York  Obstetrical  Society.  —  Stated  meeting, 
February  13,  1901.  The  president.  Dr.  H.  J.  Boldt,  in  the 
chair. 

Dr.  Boldt  presented  a  case  of  persistent  amenorrhea, 
the  trouble  dating  back  to  the  time  of  her  first  menstruation 
at  the  age  of  13.  Before  marriage  she  menstruated  at  inter- 
vals of  3  or  4  months,  since  that  time  (3  years)  she  has 
menstruated  only  twice.  The  pelvic  organs  are  normal,  with 
the  exception  that  the  uterus  is  slightly  smaller  than  it 
should  be.  Dr.  H.  N.  Vineberg  remarked  that  in  some  cases, 
after  marriage,  small  uteri  seem  to  diminish  in  size  and  lose 
their  function  rather  than  develop,  as  one  might  expect. 

Dr.  George  L.  Brodhead  reported  a  case  of  cesarean 
section  for  fibrocystic  uterine  tumor.  The  specimen 
here  presented  is  one  of  fibrocystic  growth  of  the  uterus, 
removed  from  a  patient  upon  whom  the  operation  of  cesarean 
section  was  performed  February  2,  1901,  11  days  ago.  The 
history  of  the  case  was  as  follows  :  The  woman  first  came 
under  my  observation  on  November  20, 1900,  when  she  pre- 
sented herself  for  examination  in  the  lying-in  service  of  the 
New  York  Postgraduate  Hospital.  The  patient  was  34  years 
of  age,  she  had  been  married  2|  years,  and  her  menstrual 
history  prior  to  marriage  and  up  to  the  time  of  the  present 
pregnancy  had  been  normal  in  every  respect.  There  have 
been  no  symptoms  at  any  time  of  uterine  growth,  and  her 
general  condition  was  very  good.  The  last  menstruation  had 
begun  on  May  6,  and  had  continued  for  3  days,  the  usual 
amount  of  blood  having  been  lost.  Abdominal  examination 
showed  a  uterus  enlarged  to  the  size  of  about  7  months' 
gestation,  the  fundus  being  higher  than  it  should  have 
been  to  correspond  to  the  period  of  pregnancy  as  based 
upon  the  date  of  the  last  menstruation,  namely,  6  months 
or  a  little  over.  The  presentation  was  vertex,  the  head 
being  high  above  the  brim,  and  the  position  left  occi- 
put anterior.  The  fetal  heart- rate  was  148,  and  a  loud 
uterine  soullle  was  heard  in  the  right  upper  quadrant. 
The  pelvis  was  justo  minor,  the  woman  being  of  small 
stature,  about  5  feet  2  inches  in  height,  and  weighing  about 
109  pounds.  Vagioal  examination  revealed  a  tumor  the  sizs 
of  an  orange,  of  moderately  firm  consistency,  well  down  in 


the  culdesac  of  Douglas,  pressing  the  cervix  well  forward 
behind  the  symphysis.  Thinking  that  the  tumor  might  be 
one  of  the  ovary,  or  a  pediculated  fibroid,  which  might  be 
made  to  slip  back  into  the  abdominal  cavity,  the  patient  was 
placed  in  the  knee-chest  position,  but  the  growth  was  so  ad- 
herent that  it  could  not  be  replaced.  The  patient  was 
extremely  anxious  to  have  a  living  child,  and  therefore  sec- 
tion at  or  near  full  term  seemed  indicated.  Dr.  Dudley,  who 
very  kindly  saw  the  case  with  me,  concurred  both  in  the 
diagnosis  of  fibrocystic  growth,  and  the  advisability  of  per- 
forming cesarean  section.  On  January  19,  the  position  was 
found  to  be  left  sacro-anterior,  the  breech  being  well  above 
the  brim,  and  a  loud,  umbilical  souffla  was  heard  in  the 
left  lower  quadrant  of  the  uterus.  On  February  2,  1901,  the 
operation  was  performed  at  the  New  York  Post  Graduate 
Hospital,  the  patient  being  within  10  days  of  full  term.  It 
seemed  best  to  elect  this  time,  for  the  reason  that  the  child 
was  of  good  size,  and  the  uterus  already  well  distended.  In 
the  operation,  able  assistance  was  rendered  by  Dr.  Dudley 
and  the  house  staff  of  the  hospital,  Doctors  Boldt  and  Ward 
being  present  also.  The  technic  of  the  section  was  that  de- 
scribed by  Dr.  Dudley  in  the  New  York  Medical  Journal  of 
November  3,  1900,  in  his  article  "  The  Modern  Cesarean  Sec- 
tion. An  Ideal  Method  of  Treatment  for  Placenta  Previa." 
Under  constant  irrigation  with  a  hot  normal  saline  solution, 
an  incision  G  inches  in  length  was  made  in  the  median  line, 
from  a  point  just  below  the  navel  to  just  above  the  symphysis, 
and  the  uterus  exposed.  A  rubber  ligature  was  then  passed 
over  the  fundus,  and  carried  down  to  the  lower  segment  of 
the  uterus,  just  above  the  fibroid.  While  the  uterus  was 
held  up  and  the  ligature  tightened  by  an  assistant  sitting  be- 
tween the  legs  of  the  patient,  and  while  the  abdominal  walls 
were  kept  closely  applied  to  the  uterus  above,  an  incision 
about  6  inches  in  length  was  quickly  made  through  the 
uterine  wall  and  the  fetal  sac  opening.  The  breech  of  the 
child,  found  lying  just  beneath  the  incision  was  seized,  the 
child  lifted  out  and  the  cord  clamped  and  cut.  Tae  amount  of 
amniotic  fluid  was  small.  The  uterus  was  followed  down, 
and  lifted  out  of  the  abdominal  cavity,  while  the  intestines 
were  protected  above.  The  child,  a  male,  weighing  sis  pounds 
seven  ounces,  was  born  five  minutes  after  the  operation  was 
commenced,  in  good  condition,  and  soon  cried  lustily.  The 
placenta  was  found  lying  loosely  in  the  uterine  cavity,  and 
was  removed  with  its  membranes,  manually.  Tbe  tumor 
was  adherent  to  the  rectum,  but  the  adhesions  were  soon 
separated,  and  the  growth  lifted  up  out  of  the  abdominal 
cavity.  It  was  then  found  that  during  its  removal,  the  cyst 
had  ruptured,  allowing  a  small  quantity  of  yellowish  brown 
fluid  to  escipe.  The  mass  was  about  the  size  of  an  orange, 
and  was  attached  to  the.  posterior  wall  of  the  uterus  by  a 
thin  pedicle  about  IJ  inches  in  width.  The  growth  was 
enucleated  and  the  uterine  wall  closed  with  several  layers  of 
nae  catgut  sutures.  Ten  minutes  had  been  occupied  in  the 
removal  of  the  fibroid.  A  finger  was  then  passed  through 
the  cervix  from  the  uterine  side,  and  the  incision  closed  in 
layers  with  a  continuous  suture  of  fine  No.  1  ten  day  chromi- 
cized  catgut.  Baginniug  above,  the  mucosa  was  first  closed, 
then  from  below  upward,  the  muscular  layer,  and  finally  the 
peritoneal  coat  united.  The  ligature  was  now  loosened,  and 
several  sutures  passed  to  control  slight  oozing.  As  (here  was 
a  moderate  amount  of  bleeding  from  torn  adbesions,  a  strip 
of  iodoform  gauze  was  placed  in  the  culdesac,  and  the  end 
drawn  out  of" the  vagina.  The  incision  in  the  abdomen  was 
closed  in  layers  with  catgut,  and  the  patient  put  to  bed  in 
excellent  condition,  a  little  less  than  an  hour  having  been 
consumed  in  the  entire  operation,  and  the  blood  loss  having 
been  very  small.  The  child  was  well  developed,  and  since 
birth  has  done  well.  The  mother's  recovery  has  been  unin- 
terrupted from  the  first.  I  take  this  opportunity  to  thamc 
Dr.  Dudley  and  the  house  staff  for  their  valuable  assistance 
and  kindly  interest  in  the  case.  Dr.  Vineberq  asked  if  it 
would  not  have  been  feasible  to  remove  the  growth  per 
vaginam.  Dr.  Brodhead  stated  that  the  patient  was  a 
primipara,  35  years  of  age,  exceedingly  anxious  to  have  a 
living  child  and  perfectly  willing  to  undergo  the  operation  at 
fall  term.  Under  these  circumstances  it  seemed  best  to  wait, 
as  operation  per  vaginam  would  almost  certainly  have  in- 
duced premature  labor  with  the  probable  loss  of  the  child. 

Dr  E  H.  Gr.\sihn  read  a  few  Notes  relating  to  cases 
of  ectopic  gestation.  Dr.  Gramiia  gave  a  most  inter- 
esting tolk  on  this  subject,  relating  the  clinical  history  of 


504 


The  Philadklphia"! 
Medical  Joubkal  J 


AMERICAN  NEWS  AND  NOTES 


(Mabch  16,  1901 


many  of  his  cases,  seen  both  in  his  own  and  in  consultation 
practice.  It  falls  to  the  lot  of  comparatively  few  men  to 
possess  such  a  wealth  of  material  from  which  to  draw  deduc- 
tions which  will  be  helpful  to  those  interested  in  this  most 
absorbing  subject.  His  experiecce  teaches  him  that  many 
of  the  patients  with  whom  he  had  to  deal,  give  histories 
which  are  decidedly  atypical,  judging  by  the  classic  symp- 
toms epoken  of  in  the  majority  of  textbooks.  Dr.  Grandin 
believed  that  when  in  doubt,  it  was  advisable  to  make 
a  posterior  incision  in  the  culdesac,  for  the  purpose  of 
establishing  the  diagnosis.  The  abdominal  section  could 
then  be  resorted  to  for  the  removal  of  the  mass,  if  the  pos- 
terior section  were  insufficient  for  the  purpose.  De.  George 
T.  HAREIS0^f  in  discussing  the  paper  said  that  he  thought  the 
reader  of  the  paper  should  have  made  a  clearer  distinction 
between  cases  where  the  ovum  is  dead,  and  those  in  which 
the  ovum  is  living.  In  the  latter  class  of  cases,  the  extreme 
softness  of  the  tumor  lying  near  the  uterus  was  a  very  char- 
acteristic symptom.  Again,  where  the  ovum  is  dead,  the 
uterus  is  hard,  whereas  if  the  ovum  is  living  the  uterus  is 
usually  soft.  He  believed  all  cases  of  ectopic  gestation 
should  be  attacked  through  the  abdominal  wall,  and  not  by 
a  posterior  colpotomy.  He  thought  that  the  rupture  of  the 
tube  was  a  rare  termination,  while  tubal  abortion  is  a  fre- 
quent termination.  At  least  SOfo  of  the  cases  terminate  that 
way.  After  death  of  the  ovum  the  picture  change?,  and 
the  tumor  becomes  harder.  He  strongly  advocated  the 
abdominal  section  for  such  cases.  Dr,  H.  N.  Vineberg 
thought  that  in  certain  cases  the  incision  in  the  culdesac 
for  the  purpose  of  diagnosis  was  a  valuable  one.  In 
one  instance  he  had  removed  a  cystic  ovary  in  that 
way  where  ectopic  pregnancy  was  suspected.  He  believed 
that  Dr.  Mann  had  reported  a  case  in  which  he  lost  the 
patient  by  making  an  incision  in  the  culdesac.  The  patient 
bled  so  profusely  that  before  he  could  find  and  catch  the 
bleeding  vessel ,  the  patient  died.  In  the  second  case,  the  right 
tube  was  removed  by  posterior  section  and  bleeding  was  so 
great  from  the  whole  surface  of  the  cavity  where  the  maas 
had  been  lying  that  it  was  necessary  to  pack  the  cavity. 
Bleeding  continued  and  it  required  very  thorough  tampon- 
ing to  arrest  the  hemorrhage.  After  this  she  did  well,  but 
the  case  emphasized  the  point  that  the  lower  route  is  not  a 
safe  one  through  which  to  remove  a  tubal  pregnancy.  In 
the  third  case,  the  patient  had  been  curetted  twice,  it  being 
supposed  that  the  case  was  of  incomplete  abortion.  Dr. 
Cleveland  diagnosed  the  condition  as  that  of  ectopic  preg- 
nancy and  on  operating  he  found  an  unruptured  tubal 
pregnancy  of  3J  to  4  months.  In  removing  the  tube  he  had 
used  Skene's  electric  clamp,  for  he  prefers  it  because  of  the 
liability  of  ligatures  to  cut  through  the  soft  tissues.  The 
patient  recovered.  Dr.  A.  Brothers  said  that  the  pregnancy 
of  ectopic  gestation  was  to  him  alarming.  He  had  had  a 
case  some  weeks  before  in  which  the  mass  was  so  bound  down 
by  adhesions  that  it  was  necessary  to  remove  the  uterus. 
The  patient  made  a  good  recovery. 


NKW  ENGLAND. 

Donation.— The  Yale  Medical  School,  New  Haven,  has 
received  an  anonymous  donation  of  $100,000  to  be  devoted  to 
the  construction  of  a  building  consisting  of  a  laboratory  of 
clinical  medicine  and  surgery. 

Cbange  of  Meeting.— The  State  Medical  Association 
of  Maine,  on  account  of  the  conflict  of  dates  with  the  meeting 
of  the  American  Medical  Association,  has  changed  the  time 
of  its  annual  session  to  June  12  to  14. 

Donation  to  Au<ia  Jaques  Hospital.  —  The  Anna 
Jaques  Hospital,  Newburyport,  which  for  some  years  has 
been  seriously  cramped  for  room,  will  have  a  new  and  com- 
modious structure  through  the  munificence  of  the  Hon. 
William  C.  Todd.  Toe  trustees  received  a  letter  from 
Mr.  Todd  in  which  he  makes  the  oflfer  of  $50,000  for  a  new 
building,  and  ateo  offers  as  a  gift  a  sightly  and  commodious 
site,  valued  at  $5,000.  The  trustees,  in  acknowledging  the 
gift,  state  that  the  diiBculty  of  providing  better  accommo- 
dations has  long  perplexed  them,  and  that  no  gift  would  have 
been  more  generally  and  deeply  appreciated  than  this.  The 
gift  will  be  used  solely  for  the  erection  of  a  new  building. 


Hospital  Site  Proposed. — There  appears  to  be  con- 
siderable controversy  among  the  citizens  of  Roxbury  relative 
to  the  establishment  of  a  hospital  for  consumptives  on 
grounds  in  Marcella  Street.  The  following  resolutions  were 
adoDted  and  a  committee  appointed  to  wait  upon  the  Mayor : 

Whereas,  the  Mayor  in  recommending  the  transfer  to  the 
board  of  health  department  of  the  Marcella  Street  Home, 
Roxbury,  for  the  purposes  of  a  hospital  for  consumptives, 
and,  whereas,  the  said  property  is  unfit  for  such  use,  because 
of  its  unhealthy  location,  it«  low  level,  its  proxitnity  to  a 
large  city  stable  and  its  unsanitary  condition,  besides  being 
a  menace  to  the  health  of  nearby  residents  and  a  cause  for 
the  decrease  in  the  value  of  surrounding  property;  therefore, 

Resolved,  that,  while  we  are  heartily  in  favor  of  a  hospital 
in  the  proper  place,  we  are  opposed  to  the  site  of  the  Mar- 
cella Street  Home  for  such  purpose. 

Resolved,  that  we  request  the  members  of  the  city  govern- 
ment to  oppose  this  proposed  location  for  a  consumptives' 
hospital. 

CHICAGO  AND  WESTERN  STATES. 

Appointment. — Dr.  Z.  T.  Martin,  of  Lathrop,  Mo.,  has 
been  appointed  physician  to  the  penitentiary  at  Jefferson 
City,  Mo. 

Fined. — A  magnetic  healer  of  Moloine,  111.,  was  fined 

$100  and  costs  for  practising  medicine  without  a  license. 
He  refused  to  pay  the  fine  and  was  committed  to  jail. 

Death  of  Dr.  Fernand  Bazaa.— It  is  reported  that 
Dr.  Fernand  Bazin,  a  prominent  physician  who  practitei  for 
many  years  in  San  Francisco,  died  in  Glion  sur  Montreaux, 
Switzerland,  on  March  6. 

Smallpox  in  Kansas. — Doctor  W.  B.  Swan,  secretary 
of  the  State  B3ard  of  Health,  issued  a  bulletin  stating  that 
there  are  more  than  1,000  cases  of  smallooi  in  the  State. 
The  worst  infected  district  is  Crawford  and  Caerokee  counties. 
In  these  two  counties  there  are  not  less  than  .500  cases  of  the 
disease. 

The  Western  Ophthalmologic  and  Otolaryngo- 
logic Association  wiil  meet  in  its  next  annual  session  in 
Cincinnati,  Ohio,  April  11  and  12.  A  fine  program  has  been 
arranged  and  the  medical  profession  are  cordially  invited  to 
attend  the  sessions.  Dr.  C.  K.  Holmes,  of  Cincinnati,  is 
chairman  of  the  local  committee  of  arrangements.  Dr.  M. 
A  Goldstein,  of  St.  Louis,  is  the  president,  and  Dr.  W.  L. 
Ballenger.  of  Chicago,  is  secretary. 

Bequests  to  the  .University  of   Michigan.— Mrs. 

Love  M.  Palmer,  widow  of  Dr.  A.  B.  P.ilmer,  who  was  pro- 
fessor in  the  medical  department  of  the  Uaiversity  of  Michi- 
gan from  18-52  up  to  the  time  of  his  death,  15  years  ago,  died 
March  8.  By  the  term  of  her  will,  she  leaves  $5-5,000  to  the 
university.  It  is  understood  that  $20,000  will  go  to  build  a 
new  ward  for  the  ho>pital,  and  $15,000  'o  maintain  free  beds 
in  that  institution.  Mrs.  Palmer  left  $10,000  with  which  to 
build  a  tower  for  St.  Andrew's  Episcopal  Church  in  Ann 
Arbor,  Mich. 

Bubonic    Plague   in    California. — The  commission 

selected  by  Secretaiy  Gage  to  investigate  the  plague  situation 
in  behalf  of  the  Government  has  returned  to  Washington, 
but  their  report  as  yet  has  not  been  published.  The  commis- 
sioners are  Prof.  F.  G.  Nery,  Prof.  Simon  FJexner,  of  the 
University  of  Pennsylvania,  and  Prof.  L.  T.  Barker:  the  other 
commissioners  being  also  attached  to  institutions  of  learning. 
They  are  in  no  way  connected  with  the  Federal  service  and 
were  chosen  because  of  their  recognized  ability  as  experts. 
The  committee  of  citizens  of  S.iu  Francisco  that  had  been  in 
consultation  with  the  Treasury  Department  regarding  the 
bubonic  plague  in  that  city  deny  that  the  health  atlairs  of 
San  Francisco  have  been  taken  charge  of  bj-  the  Surgeon- 
General's  Department.  Tcey  furthermore  state  that  the 
death  list  in  Chinatown  is  now  lower  than  it  has  been  for 
years. 

SOUTHERN  STATES. 

Buxley  Professorship. — The  professorship  endowed 
several  years  ago  by  Dr.  Henry  Willis  Buxley,  of  Baltimore 
has  been  designated  "  the  Bjxley  professorship  of  pathol' 


SIabch  1G,  1901] 


AMERICAN  NEWS  AND  NOTES 


rfHE  PhII-ADELPHIA 
Medical  Journal 


505 


ogy."    The  present  incumbent  is  Prof.  William  H.  Welch  of 
the  Medical  School. 

Charity  Hospital. — An  unconditional  donation  of 
<50,000  has  been  received  by  the  Charity  Hospital,  New 
Orleans,  from  an  unknown  source  through  Dr.  Rudolph 
Matas.  The  money  was  donated  for  the  purpose  of  increas- 
ing the  nursing  staff  and  providing  a  home  for  trained 
nurses. 

Verdict  of  $7000  for  the  Loss  of  an  Eye.— In  the 
case  of  the  De  La  Vergne  Refrigerating  Machine  Company 
vs.  Stab),  in  which  a  verdict  of  SSOOO  was  returned,  the  judge 
said  that  he  will  affirm  the  judgment  if  a  remittitur  of  $1000 
be  made  from  the  $S000,  as  the  later  is  larger  than  in  any  dis- 
coverable case  of  a  similar  nature. 

Memorial  Tribute. — The  Jledical  Society  of  the  Dis- 
trict of  Columbia  met  on  March  5  for  the  purpose  of  devot- 
ing a  memorial  tribute  to  the  life  and  character  of  the  late 
Dr.  Samuel  Busey.  A  memoir  was  read  by  Dr.  W.  W.  Johns- 
ton, giving  a  sketch  of  Dr.  Bueey's  life  and  an  appreciative 
estimate  of  his  life  as  a  man,  citizen,  and  physician. 

Death  of  Dr.  John  Randolph  Page. — Dr.  John 
Randolph  Page  died  at  his  home  at  the  University  of  Vir- 
ginia on  March  11  of  acute  Bright's  disease,  aged  70  years. 
Dr.  Page  was  educated  at  the  University  of  Virginia,  being 
graduated  in  18.50  with  the  degree  of  doctor  of  medicine, 
after  which  he  was  for  some  years  a  student  in  Paris.  He 
was  chief  surgeon  in  the  Confederate  service,  first  with  Ma- 
gruder,  on  the  Peninsula,  and  afterward  in  Lynhburg.  After 
the  war  he  practised  medicine  in  Baltimore,  and  later  he 
became  professor  in  the  Louisiana  Military  Academy.  From 
1872  to  1882  he  was  professor  of  agriculture  in  the  University 
of  Virginia.  Resigning  his  chair  he  went  to  Birmingham, 
Ala.,  and  again  entered  upon  the  practice  of  his  profession. 


CANADA. 

(From  Our  Special  Corrfsponilent.) 

To  Combine  Toronto  Medical  Schools. — Steps  are 
being  taken  to  bring  about  the  amalgamation  of  Trinity 
Medical  College,  Toronto,  and  Toronto  Medical  CoUege.  A 
committee  composed  of  three  members  of  each  faculty  was 
appointed  to  draft  a  definite  basis  of  amalgamation. 

The  3Iedical  Alliance  of  America,  now  attempting 
to  do  business  with  the  medical  profession  in  Toronto, 
Montreal,  and  other  Canadian  cities,  has  been  disapproved 
of  by  the  Toronto  Clinical  Society.  One  year  ago  the  corpo- 
ration secured  a  charter  from  the  Dominion  Parliament  and 
at  once  set  about  exploiting  the  profession  of  medicine.  The 
doctor  is  secured  as  an  ordinary  member  of  the  Alliance,  the 
same  as  any  other  individual,  at  the  rate  of  15  centa  per 
week.  He  is  then  appointed  by  the  Company  one  of  the 
medical  advisers  of  the  Alliance.  When  an  ordinary  member 
falls  ill,  if  he  wishes  to  secure  the  benefits  of  the  Alliance,  he 
must  call  in  one  of  the  Alliance's  physicians  to  attend  him. 
The  Company  pays  the  doctor  at  the  rate  of  $1.00  per  office 
consultation  and  $1.50  for  each  house-visit  paid — that  is,  if 
the  fund  set  apart  for  that  specific  purpose  will  permit  of 
such  lavish  distribution.  At  the  regular  stated  meeting  of 
the  Toronto  Clinical  Society,  on  the  evening  of  the  6th  inst., 
the  Society  unanimously  adopted  a  resolution  unfavorable  to 
the  methods  of  the  Alliance. 

Winnipeg  General  Hospital  has  just  published  its 
annual  report.  The  number  of  patients  treated  in  the  hos- 
pital during  the  past  year  amounted  to  2,(549 ;  and  in  the 
out- door  department  there  were  1,435  consultations.  Of  the 
in-door  patients,  1,684  came  from  the  City  of  Winnipeg,  785 
from  other  places  in  the  province  of  Manitoba,  150  from  the 
other  provinces  and  30  from  the  United  States.  In  the  finan- 
cial report  appeared  a  deficit  of  $4,510.50,  which  could  be  ac- 
counted for  by  the  fact  that  the  hospital  had  to  contend  with 
an  outbreak  of  smallpox  within  its  walls  at  the  beginning  of 
the  year.  Reference  was  made  in  the  report  expressing  deep 
regret  at  the  death  of  one  of  the  nurses.  Miss  Lynch,  who 
had  contracted  the  disease  while  in  the  discharge  of  her 
■duties ;  and  also  to  the  generosity  of  the  Lake  of  the  Woods 
Milling  Company  which  donated  $2,,500  to  the  institution. 


The  nursing  staflf  of  this  hospital  now  consiets  of  a  lady 
superintendent,  5  head  nurses,  1  district  nurse  and  50 
pupil  nurses.  During  the  year  223  applications  were  received 
for  admission  to  the  hospital  training  school.  Of  these  23 
were  accepted  on  probation  and  16  as  pupils  of  the  school. 

Nova  Scotia  is  to  Have  a  Consumption  Sani- 
tarium.— A  year  ago  the  Legislature  of  the  province 
passed  a  Sanitarium  Act  and  appointed  a  committee  to  look 
into  the  matter  during  the  recess  of  the  House  and  make 
recommendations  at  an  early  date.  Through  sickness  and 
other  misfortunes  this  committee  has  not  been  able  to  report 
until  the  present  time ;  and  the  other  day  Premier  Murray 
laid  before  the  Legislative  Assembly,  now  in  session,  the  re- 
port of  the  committee.  It  recommends  that  a  single  sani- 
tarium be  constructed  on  the  congregate  plan,  capable  of 
accommodating  20  patients ;  that  no  resident  medical  officer 
be  appointed,  but  that  there  shall  be  regular  specified  visits 
made  by  two  properly  qualified  medical  men ;  that  the 
site  be  "either  at  Dutch  Village  near  the  city  of  Halifax,  or 
else  on  the  shores  of  Bedford  Basin  near  the  village  of  Bed- 
ford. The  committee  considers  it  avisable  that  any  sani- 
tarium for  the  treatment  of  consumption  should  be  erected 
near  the  large  centers  of  population;  and  that  the  Sani- 
tarium Act  of  the  province  be  amended  so  as  to  provide  for 
municipalities  wishing  to  construct  and  carry  on  these  insti- 
tutions, may  receive  aid  from  the  Government.  Dr.  A.  P. 
Reid,  the  secretary  of  the  provincial  Board  of  Health,  favors 
the  recommendations,  but  prefers  to  see  a  regular  medical 
officer  in  charge;  he  also  objects  to  the  site  on  the  Atlantic 
seaboard. 

A  new  civic  hospital  for  Sloutreal  has  long  been 
contemplated,  but  after  struggling  with  this  question  for  the 
past  one  or  two  years,  the  city  is  no  nearer  the  goal.  Smallpox 
is  even  now  on  the  outskirts  of  the  city  and  there  is  no  place 
provided  for  the  reception  of  these  patients.  The  present 
Civic  Hospital  is  old  and  dilapidated,  in  fact,  water-logged, 
has  been  universally  condemned,  by  both  prominent  medical 
men  and  influential  citizens,  and  even  if  available,  could  not 
be  used  as  it  is  now  full  of  scarlet  fever  patients,  a  disease 
which  has  been  epidemic  in  Montreal  almost  since  last  Sep- 
tember. The  old  smallpox  pavilion  contains  four  beds,  and 
both  it  and  the  Civic  Hospital  are  little  better  than  ordinary 
barns.  There  are  now  two  propositions  before  Council  for 
the  adjustment  of  this  important  question.  One  is  for  a 
single  hospital  for  contagious  diseases,  to  be  under  civic  con- 
trol, financially,  but  to  be  under  the  medical  control  of  the 
leading  French  hospital,  the  Hotel  Dieu,  and  the  leading 
English  hospital,  the  Royal  Victoria.  The  other  proposition 
favors  two  hospitals,  one  for  the  French  and  one  for  the  Eng- 
lish practitioners.  Alderman  Ames,  who  by  the  way  is  an 
advanced  hygienist,  now  favors  building  one  hospital,  but  so 
far  has  been  unable  to  get  Council  to  adopt  any  plan  what- 
ever. The  Montreal  Medical  Society,  composed  of  French 
practitioners,  favors  one  hospital. 

Gynecological    surgery  among    the  insane    has 

reached  the  end  of  its  sixth  year  in  the  London,  Ont.,  Asylum, 
during  which  time  the  work  has  been  carried  on  in  a  sys- 
tematic manner,  but  without  much  encouragement  from 
the  profession  or  the  alienists  in  Canada.  In  the  annual 
report  on  the  asylums  of  Ontario  just  issued  a  summary  is 
given  of  this  work.  During  the  year  closed  55  of  these  cases 
have  been  operated  on.  Of  these  patients,  17  have  recovered, 
16  have  improved,  none  have  died,  and  so  far  as  yet  heard 
from  22  of  the  cases  are  unimproved  mentally.  It  is  fully 
expected  that  several  of  the  16  improved  will  get  quite  well. 
During  the  period  of  this  work  at  London,  286  female  patients 
have  been  examined,  generally  under  an  anesthetic,  and 
organic  diseases  have  been  found  in  some  one  or  more  of  the 
pelvic  organs  in  243  of  them.  Only  43  of  the  entire  number 
subjected  to  an  examination  have  been  found  free  from 
pelvic  diseases.  A  total  of  564  diseased  conditions  were 
found  in  226  patients.  "  In  the  women's  halls  the  average 
recovery  rate,  including  cases  improved,  for  the  five  years, 
1886-91,  calculated  on  me  admissions,  was  37.2%;  in  the  next 
five  years,  1891-95,  it  was  37.5% .  But  in  the  next  five  years, 
during  which  the  gynecological  work  was  a  factor,  that  is, 
in  1896-1900,  the  recovery  rate  rose  to  52.7^."  The  chief 
credit  of  this  work  belongs  to  Dr.  A.  T.  Hobbs,  who  has 
recently  resigned  from  the  stafi'  to  en'.er  private  practice. 


506 


Thb  PhiladklphiaI 
Mbi>ical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


(Habcb  le,  lan 


The  operations  were  never  performed  merely  for  the  insanity, 
but  always  f  jr  some  actual,  existing  disease. 

Lodge  practice  in  British  Columbia  about  a  year 

ago  seemed  to  be  on  the  wane  when  the  Victoria  Medical 
SDciety  adopted  a  strong  resolution  disapproving  of  the  prac- 
tice and  deciding  that  they  collectively  and  individually- 
should  have  nothing  more  to  do  with  it  whatever.  This  of 
course  raised  a  storm  amongst  the  fraternal  societies,  and 
efTorts  were  made  to  induce  practitioners  to  come  from  the 
East,  particularly  from  the  province  of  Ontario,  as  well  as 
from  Eagland.  This  proved  ineffectual,  as  the  Medical  Act 
of  British  Columbia  required  that  an  examination  had  to  be 
passed  before  any  one  could  practise  in  the  Pacific  province. 
During  the  past  summer,  however,  the  fraternals  have  not 
been  idle.  They  appointed  a  special  committee  to  take  the 
matter  in  hand,  and  as  a  result  petitions  were  circulated 
throughout  the  province  praying  that  the  Government  would 
cancel  the  Medical  Act,  and  permit  of  practitioners  S3ltling 
in  British  Columbia,  provided  they  had  an  English  degreee, 
or  a  license  to  practise  in  any  of  the  other  provinces  of  the 
Dominion.  This  proved  too  much  for  the  Victoria  Medical 
Society,  and  they  are  now  said  to  be  seeking  to  propitiate 
the  fraterna's.  It  would  certainly  be  an  indirect  act  of 
coercion  if  the  Legislature,  before  whom  the  petitions  now 
lie,  should  grant  the  prayer  of  these  petitioners  ;  and  for  the 
sake  of  the  honor  of  the  profession  of  medicine  in  the 
province  of  British  Columbia  it  is  sincerely  hoped  that  the 
Medical  Society  of  Victoria  will  continue  to  exhibit  their 
Spartan  courage. 

MISCELLANF. 

Scarlet  Fever  aniong  Yale  Students.— Two  cases  of 
scarlet  fever  have  been  discovered  in  a  Yale  University 
boarding-house. 

Fellow  Students  of  Bismarck.— Dr.  Mitchell  King, 
who  recently  died  in  Charleston,  S.  C  ,  aged  86  years,  was  a 
fellow  student  of  Bismarck,  at  the  Univer.sity  of  Gottingen, 
together  with  two  Americans,  John  Lathrop  Motley  and 
Amory  Coffin,  of  South  Carolina.  The  three  Americans  ate  a 
Fourth  of  July  dinner  at  (id'.tingen  in  1832  with  Bismarck  as 
their  guest.  Bismarck  said  that  Germany  would  be  united  in 
30  years.  Coffin  disagreed  with  him  and  a  bet  was  made  of  a 
bottle  of  champagne  which  the  loser  waa  to  carry  to  the 
country  of  the  winner  and  drink  with  him.  Bismarck  lost, 
but  as  civil  war  was  raging  at  the  time,  the  whereabouts  of 
Coffin  could  not  be  determined. 

Obituary.— Dr.  John  B.  McDonald,  nt  Spnkane,  Wash., 
on  March  3,  aged  63  years.— Dr.  Jason  Walker  ai  Minot, 
Me.,  on  March  7,  aeed  (56  years —Dr.  William  Davison,  at 
Kenosha,  Wis.,  on  March  2.— Dr.  Asa  Bowman,  in  Cnristian 
County,  111.,  on  March  6,  aged  82year8.— Dr  R.  L  Mayfield, 
at  Marble  Hill,  Mo.,  on  March  5. — Dr.  Samuel  Mequire,  at 
Trenton,  111  ,  on  Maroh  6,  aged  76  years. — Dr.  Alonzo  T. 
Smith,  at  Syracuse,  N.  Y.,  on  March  8,  aged  81  years.— Dr. 
Jonas  C.  Raymond,  at  Oakland,  Cal.,  on  March  3,  aged  77 
years.— Dr.  William  Stiyes,  at  Washington,  N.  J  ,  on  March 
8.— Dr.  Ribert  Heath  Dodge,  at  Bsthesda,  Md.,  on  March 
11,  aged  29  years.- Dr.  J,  A.  Swartz,  at  Harrisburg,  Pa.,  on 
March  10,  aged  76  years— Dr.  R.  Wilson  Carr,  ait  Sedalia, 
Mo.,  on  March  4,  aged  70  vears.— Dr.  J  D  Scott,  en  route  to 
Villisca,  on  March  11  — Dr  Lloyd  Zaner,  at  Wilkes'barre, 
Pa.,  on  March  12.— Dr.  H.  B  Hall,  at  R  verton.  Pa.,  on 
March  8. 

To  the  Medical  Profession  of  the  United  States. 

— The  undersigned  constitute  a  committee  similar  to  those 
forrned  in  several  Earopean  countries  for  the  purpose  of  re- 
ceiving subscriptions  for  a  monument  commemorative  of 
the  distinguished  scientific  services  of  Prof.  Leopold  Oilier. 
Among  the  members  of  these  committees  are  Lord  Lister, 
Profs,  von  Bcrgmann,  Czerny,  Durante,  and  other  leading 
men.  The  municipality,  of  the  city  of  Lyons  has  dedicated 
an  open  space  adjacent  to  quarters  of  the  various  academic 
faculties  on  the  border  of  the  Rhone  named  in  hia  honor, 
"  Place  Leopold  Oilier." 

The  profession  of  this  country  are  well  aware  of  the  great 
services  rendered  by  Prof  Oilier,  especially  in  the  domam  of 
plaetic  and  osseous  surgery.    His  labors  have  been  most 


fruitful  in  the  domains  of  surgery,  of  physiology,  and^of 
pathology. 

The  committee  hopes  to  raise  not  less  than  one  thousand 
dollars  ($l,OWi)  as  a  testimonial  from  the  profession  *of 
America.  Checks  should  be  forwarded  to  W.  W.  Keen,  1729 
Chestnut  Street,  Philadelphia,  Pa.,  and  at  as  early  a  date  as 
possible. 

f  Robert  Abbe.  New  York. 
I  William  T.  Bull,  New  York. 

P.  S  Conner,  Cincinnati. 
'  A.  T.  Cabot,  Boston. 
I  Howard  A.  Kelly%  Biltimore. 
I  W.  W.  Keen,  Philadelphia. 
Committee  -|  Rudolph  Matas.  New  Orleans. 
Wm.  j.  Mayo,  Rochester. 
W.  F.  McSutt,  Sin  Francisco. 
RoswELL  Park,  BafFalo. 
Clay'ton  Pabkhill,  Denver. 
I  Maurice  H.  Richardson,  Boston. 
[  Nicholas  Senn,  Chicago. 

Health  Reports. — The  following  cases  of  smallpox, 
and  yellow  fever,  have  been  reported  to  the  Surgeon- 
General  U.  S.  Marine-Hoepital  Service,  during  the  week 
ended  March  9, 1901 : 

Smallpox— United  Statkf. 


Cabbs. 

Dkatbe 

Alabama: 

Mobile 

Feb.  22-Mar. 

2 

1 

California  : 

San  Francisco  . 

Feb. 18  .    .  . 

8 

District  of 

COLDMBIA 

Washington  .   . 

Feb.  23-Mar. 

2 

7 

Florida  : 

Jacksonville  .    . 

Feb.  23-Mar. 

2 

3 

Illinois: 

Cairo 

Feb. 16-23    . 

6 

Iowa  : 

Ottumwa.  .   . 

Feb. 2-9    .    . 

1 

Kaksab  : 

Lawrence    .    .    . 

Feb.  23-Mar. 

2 

2 

'* 

Wichita       .  . 

Feb.  23-Mar. 

2 

12 

Kentucky: 

Lexington   .   . 

Feb.  23-Mar. 

2 

2 

LopisiANA  : 

New  Orleans  . 

Feb.  23-Mar. 

2 

7 

2 

Michigan: 

West  Bay  City  . 

Feb.  23-Mar. 

2 

5 

Minnesota  : 

■Winona    .    .   .    . 

Feb.  23-Mar. 

2 

12 

Xebk.^ska  ; 

Omaha 

Feb.  a3-Mar. 

i 

5 

X.  Hampshire  : 

Manchester    .    . 

Feb.  23-Mar. 

2 

27 

New  York : 

Elmlra         .    . 

Feb.  23-Mar. 

2 

1 

'• 

Xew  York  .   .   . 

Feb.  23-Mar. 

2 

64 

11 

*' 

Yonkers  .    .   .    . 

Feb.  23-Mar. 

1 

1 

N.  Carolina  : 

Charlotte     .    . 

Feb.  1-2S.    . 

16 

Ohio  : 

Ashtabula  .    . 

Feb.  23-Mar. 

2 

2 

" 

Cincinnati  .   . 

Feb.  -ii-Mar. 

1 

2 

" 

Toledo  .... 

Feb.  23-Mar. 

2 

i 

" 

Youngstown 

Feb.  23-Mar. 

2 

'7 

Pennsylvania ; 

Alleghany  .    . 

Feb.  23-Mar. 

2 

2 

" 

Philadelphia.    . 

Feb.  23-Mar. 

2 

1 

" 

Pittsburg.   .    . 

Feb.  23-Mar. 

2 

4 

Tennessee  : 

Memphis .   .    . 

Feb.  23-Mar. 

0 

16 

'* 

Nashville     .    . 

Feb.  23-Mar. 

2 

17 

Utah: 

Sail  Lake  City   . 

Feb.  23-Mar. 

2 

31 

West  Virginia  : 

Huntington    .    . 

Smallpox- 

Feb.  23-Mar. 
— Foreign. 

2 

1 

China  : 

Hongkong  .    . 

Jan.  15-22    . 

1 

England  : 

Liverpool    .    .    . 

Feb.  8-16  .    . 

2 

" 

lAindon     .    .  . 

Feb.  S-16.    . 

1 

Scotland  : 

Dundee    .    .   .    . 

Feb.  8-16.    . 

6 

" 

Glasgow  .   .   .    . 

Feb.  1.5-22  . 

20 

Mexico  : 

Vera  Cruz    .   . 

Feb.  19     .    . 

.     300 

•■ 

Yucatan  .    .   . 

Feb.  20    .    . 

.  Epidemic. 

RossiA : 

St.  Petersburg 

Feb.  2-9  .    . 

4 

1 

" 

Warsaw    . 

.Ian.  26-Feb.C 

S 

Torkey  in  Asia 

.Taffa 

Jan. 1-15 

.  Epidemic. 

Yellow 

Fevkb. 

Cuba  : 

Havana    .   .  .   . 

Feb. 17-24    . 

3 

Doctors  Must  Not  Leave  Patient. — Tht  ifedicai 
Record  publishes  the  following  :  Dr.  P.  H.  Flood  was  ordered 
to  pay  $'2,O0O  damages  by  the  Supreme  C-ourt  recently.  Evi- 
dence showed  that  over  a  year  ago  he  was  called  to  attend 
Mrs.  Margaret  A.  Lathrope.  An  operation  was  deemed 
necessary  by  him.  Her  screams  interfered  with  his  appUca- 
tion  of  the  necessary  instruments.  He  finally  said  that  if 
she  "  did  not  quit  he  would  quit."  And  leave  he  did,  although 
the  patient  waa  in  agony.  The  husband  followed  the  phy- 
sician to  the  door,  begging  him  not  to  go.  He  refused  to 
come  back,  and  it  was  over  an  hour  before  another  doctor 
was  obtAined,  the  woman  in  the  me.sntime  suflering  dread- 
fully. The  other  surgeon  performed  the  operation,  saving  the 
mother's  life  at  the  expense  of  that  of  the  child.    Mr.  and 


ilblCH  16,  1901 J 


FOREIGN  NEWS  AND  NOTES 


TThe  Philadelphia         5Q7 
L  Medical  JocKNAL 


_re.  Lathrope  sued  Dr.  Flood  and  got  a  verdict  for  $2,000  in 
|the  Superior  Court.  Dr.  Flood  appealed  the  case  to  the 
{Supreme  Court,  and  the  latter  affirmed  the  lower  court's 
jjclion,  saying,  in  part :  "  It  is  the  undoubted  law  that  a  phy- 
Isiciftn  may  elect  whether  or  not  he  will  give  his  services  to  a 
ijsaae,  but  having  accepted  his  employment,  and  entered  upon 
(the  discharge  of  his  duties,  he  is  bound  to  devote  to  the 
iipatient  his  best  skill  and  attention,  and  to  abandon  the  case 
tDnly  under  one  or  two  conditions.  First,  when  the  contract 
(is  terminated  by  the  employer,  which  termination  may  be 
(made  immediately.  Second,  when  it  is  terminated  by  the  pby- 
(sician,  which  can  be  done  only  after  due  notice  and  an  ample 
(opportunity  afforded  to  secure  the  presence  of  other  medical 
iittendance,  .  .  He  can  never  be  justified  in  abandoning 
it  (case)  as  did  this  defendant,  and  the  circumstances  show  a 
[ifgligence  in  its  character  amounting  wellnigh  to  brutality." 
—iSan  Francisco  Examiner.'] 

Changes  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  M  irch  9,  1901 : 

Rahd,  Captain  Irving  W.,  assistant  surgeon,  is  relieved  from  duty 
at  Santa  Mesa  Hospital,  Manila,  and  will  proceed  to  Nagasaki, 
Japan,  for  the  purpose  of  establishing  a  military  hospital  at 
thai  place. 

DtracHER,  First  Lieutenant  Basil  H.,  assistant  surgeon,  U.  S.  Army, 
is  relieved  from  duty  at  present  station  and  will  report  to  Cap- 
tain Irving  W.  Rand,  assistant  surgeon,  for  duty. 

P1B8ONS,  First  Lieutenant  Elbert  E.,  assistant  surgeon,  U.  S. 
Army,  is  relieved  from  duty  at  present  station,  and  will  report 
to  Captain  Irving  W.  Rand,  assistant  surgeon,  for  duty. 

3teaub,  Major  Paul  F.,  surgeon,  now  at  San  Francisco,  Cal.*  is  re- 
lieved from  further  duty  in  the  division  of  the  Philippines,  and 
will  proceed  to  Fort  Crook  for  duty. 

Thomason,  Major  Henry  D.,  surgeon,  recently  appointed,  will  pro- 
ceed from  Albion,  Mich.,  to  San  Francisco,  Cal.,  for  temporary 
duty,  upon  the  completion  of  which  he  will  proceed  to  Manila, 
P.  I.,  and  report  for  assignment  to  duty. 

ZotJNER,  Major  Robert  H,  surgeon,  is  relieved  from  temporary 
duty  at  Columbus  Barracks,  and  will  rejoin  his  station  at  Fort 
Du  Pont. 

30WPEK,  Captain  Harold  W.,  assistant  surgeon,  recently  appointed, 
now  at  San  Francisco,  Cal.,  will  report  for  transportation  to 
Manila,  P.  I  ,  where  he  will  report  for  assianment  to  duty. 

Jabe,  Major  L.  C.  surgeon,  will  proceed  to  Santiago,  Cuba,  for 
assignment  to  duty. 

Iabes,  H.  M.,  acting  assistant  surgeon,  is  granted  leave  of  absence 
for  1  month,  with  leave  to  apply  for  an  extension  of  1  month, 
and  to  go  beyond  the  limits  of  the  department  of  Cuba. 

Leepkre,  Captain  Matthew,  assistant  surgeon,  recently  appointed, 
now  at  Fort  Crook,  will  proceed  to  San  Francisco,  Cat.,  and  re- 
port for  transportation  to  Manila,  P.  I.,  where  he  will  report 
for  assignment  to  duty. 

The  following-named  assistant  surgeons,  XT.  S.  Volunteers,  recently 
appointed,  will  proceed  from  the  places  hereinafter  specified  to 
Ban  Francisco,  Cal.,  and  report  for  transportation  to  Manila,  P. 
1.,  where  they  will  report  for  assignment  to  duty  :  Captains 
James  S.  Kennedy,  Fort  Sam  Houston  ;  Frank  P.  Kenyon, 
(Joplin,  Mo.,  DwiGHT  B.  Taylor,  Columbus  Barracks. 


LDel 
|j 


Changes  in  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  March  9,  1901 : 

Baeins,  0.  M.,  assistant  surgeon,  detached  from  the  "  Ajax,"  when 
put  out  of  commission,  and  ordered  home  to  wait  orders. 

OoBDEiRO,  F.  J.  B.,  surgeon,  detached  from  the  "  New  Orleans  "  and 
ordered  to  the  "  Buffalo." 

Spear,  R.,  passed  assistant  surgeon,  detached  from  the  "Buffalo" 
and  ordered  to  the  "  Isla  du  Luzon." 

!|Cennedy,   R  M.,    passed  assistant   surgeon,    detached  from    the 
"  Newark  "  and  ordered  to  the  "  Bennington." 
Tone,  M.  v.,  assistant  surgeon,  detached  from  the  "Isla  de  Lu- 
zon "  and  ordered  to  the  "  Buffalo." 
IjjFYDER,  J.  J.,  assistant  surgeon,  detached  from  the  "  Isla  de  Cuba," 
and  ordered  to  Pollock,  P.  I.,  with  marines. 

Patne,  Jr  ,  J.  H.,  assistant  surgeon,  detached  from  duty  at  Pollock, 
P.  I.,  and  ordered  to  the  "Isla  de  Cuba." 

tfuNTiNGTON,  E.  0.,  assistant  surgeon,  detached  from  the  "Ben- 
nington "  and  ordered  to  the  "  Newark." 

)>  Changes  in  the  U.  S.  Marine-Hospital  Service, 

(([or  the  week  ended  March  7,  1901 : 

jPebry,  T.  B.,  passed  assistant  surgeon,  granted   leave  of  absence 
1       for  30  days  from  March  12.    March  2. 

Brown,  B.  W.,  passed  assistant  surgeon,  directed  to  report  at  Wash- 
ington, D.  C,  for  special  temporary  duty.     March  5. 
^viiEGQKR,  J.  A.,  passed   assistant  surgeon,  to  assume  temporary 
romraand  of  the  Cape  Charles  Quarantine  Station  during   the 
ahsence  of  Assistant  Surgeon  C.  W.  Wille.     March  2. 
i.\RK,  Taliaferro,  assistant  surgeon,  granted  7  days'  extension  of 
II       sick  leave  from  March  8.    March  7. 

IIIBOTTER,  F.  E.,  assistant  surgeon,  relieved  from  duty  as  quarantine 
oflBcer  at  the  port  of  Cienfuegos,  Cuba.    March  1. 


Wille,  C.  W.,  assistant  surgeon,  granted  leave  of  absence  for  7 
days  from  March  4.     March  2. 

Berry,  T.  D..  assistant  surgeon,  detailed  as  quarantine  officer  at 
the  port  of  Cienfuegos,  Cuba.     March  I. 

Long,  J.  D..  assistant  surgeon,  relieved  from  duty  in  the  Hygienic 
Laboratory,  Washington,  D.  C,  and  directed  to  proceed  to  New 
York,  N.  Y.,  and  report  to  Surgeon  L.  L.  Williams,  Immigra- 
tion Depot,  for  duty.     March  3. 

Macdowell,  W.  F,,  hospital  steward,  granted  leave  of  absence  for 
30  days  from  March  20.     February  26. 

GooD.MAN,  F.  S.,  hospital  steward,  relieved  from  duty  at  Havana, 
Cuba,  and  directed  to  proceed  to  Washington,  D.  C,  and  await 
orders.     March  6. 

Newbern,  Jr.,  Walter,  hospital  steward,'granted  leave  of  absence 
for  20  days  from  March  5.     February  27. 


Joreign  Hctns  anb  Hotes 


GRE.A.T  BKITAIN. 

Physician  Honored.— Sir  James  Raid,  Bart.,  K.C.B., 
has  been  appointed  a  Knight  Grand  Cross  of  the  Royal 
Victorian  Order,  in  recognition  of  his  services  to  her  late 
Majesty. 

British  Congress  on  Tuberculosis.— Professor  Robert 
Koch,  of  Berlin,  Professor  Brouardel,  of  Paris,  and  Professor 
McFadyean,  of  London,  have  promised  to  hold  addresses 
at  the  Congress. 

Decorations  Conferred  upon  Nurses,  —  King 
Eiward  has  conferred  the  decorations  of  the  Royal  Red 
Cross  upon  Miss  Marian  Lambert,  of  the  Church  of  England 
Mission,  Sister  Jessie  Molyneux  Rinaome,  Miss  Lillie  Emma 
Saville,  M.D.,  London  Mission,  and  Miss  Abbie  Goodrich 
Chapin,  in  recognition  of  their  services  at  the  International 
Hospital  during  the  siege  of  the  legations  at  Pekin. 

Medical  Appointments  to  the  King  of  England. 

— The  following  appointments  are  announced  : 

Honorary  Physicians  to  the  A'l/i.g.— Dugal  McEwan,  M.D. ; 
Sir  James  J.  L.  Denuet,  K.C.B  ,  M  D.,  Inspeotor-Gfineral  of 
Hospitals  and  Fleets;  Sir  John  Watt  Reid,  K.C.B.,  M.D., 
LL  D.,  Director  General  of  the  Medical  Department  of  the 
Navy  (retired);  Adam  B.  Messer,  M  D.,  Inspector- General  of 
Hospitals  and  Fieets;  Henry  C.  Woods,  C.V.O.,  M.D.,  In- 
spector General  of  Hospitals  and  Fleets  (extra). 

Honorary  Surgeons  to  the  King. — Sir  James  Jenkins,  K.C.B. , 
M.D.,  Inspector  General  of  Hospitals  and  Fleets ;  Timotheus 
J.  Haran,  Inspector  General  of  Hospitals  and  Fleets;  Sir 
James  N.  Dick,  K.C.B.,  Director-General  of  the  Medical  De- 
partment of  the  Navy  (retired);  William  H.  Lloyd,  M.D., 
Inspector  General  of  Hospitals  and  Fleets;  Alfred  G.  Del- 
mege,  M.VC,  M.D.,  Deputy  Inspector-General  oi  Hospitals 
and  Fleets  (extra). 

CONTINENTAL  EUROPE. 

Influenza  in  Sweden. — The  influenza  epidemic  is  be- 
coming more  severe.  Prince  Barnadotte,  second  son  of 
King  Ojcar,  is  among  the  sufferers. 

Virchow  Collection  Destroyed. — Fire  recently  broke 
out  in  the  Pathological  Institute  at  Berlin,  during  which  the 
remarkable  Virchow  collection  was  entirely  destroyed. 

Anti-tuberculosis  Society. — A  society  for  the  preven- 
tion of  tuberculosis  in  the  Baltic  provinces  of  Russia  has 
recently  been  founded.  Professor  Dehio  is  president,  and  the 
headquarters  of  the  society  are  at  Dorpat. 

Italian  Pediatric  Congress. — The  subjects  selected  for 
discussion  at  the  Italian  Pediatric  Congress,  to  be  held  at 
Florence  from  October  15th  to  20lh,  1901,  are  :  Infantile 
Atrophy  (Athrepsia),  to  be  introduced  by  Professor  Fede,  of 
Naples,  and  Professor  G.  Berti,  of  Bologna;  the  Respiratory 
System  of  Early  Infancy,  by  Professor  C.  Mya,  of  Florence, 
and  Professor  Mensi,  of  Turin ;  and  the  Acute  Affections  of 
the  Digestive  Apparatus  in  Sucklings,  by  Professor  Concetti, 
of  Rome,  and  Professor  R.  Gtiaita,  of  Milan. 


508 


The  Philadelphia"] 
Medical  Jocrjial  J 


FOREIGN  NEWS  AND  NOTES 


TMascB  16,  I 


OermaB  Surgical  Congress. — The  German  Sureical 
Society  will  hold  iu  thirteenth  congresa  in  BerUn  from  April 
10  to  13.  Among  the  general  addresses  are  t-ie  following: 
Renal  Surgery  in  the  Nineteenth  Century — a  Retrospect  and 
a  Prospect,  by  Professor  Kiister,  of  Marburg;  Castration  in 
Tuberoulosia  of  the  Testis,  by  Professor  von  B.uns,  of  Tiibin- 
gen  ;  A  Report  on  the  Second  Series  of  a  Thousand  Excisions 
of  Goiter;  On  the  Operation  for  Struma  I  Qtrathoracica;  and 
on  the  Treatment  of  G  liter  WithoHt  Operation,  by  Professor 
Th.  Kocher,  of  Berne ;  The  Wounds  Caused  by  Modem  Fire- 
arms, by  Dr.  Schjerning,  of  Berlin  ;  The  Various  Methods  of 
Anesthesia  and  their  ludications,  by  Professors  von  Mikulicz, 
of  Breslau,  and  Bier,  of  Greifswald ;  Pneumonia  after  Lapar 
otomy,  by  Professor  Henle,  of  Breslau ;  The  ladicatioas  for 
Extirpation  of  the  Uterus  by  the  Vaginal  and  Abdominal 
Routes,  by  Drs.  M.  Jordan,  of  Heidelberg,  and  Schuchardt, 
of  Stettin;  The  Building  Up  of  Carcinoma,  by  Dr.  W.  Peter- 
sen, of  Heidelberg ;  Cancer  Parasites,  by  Professor  Nils 
Sjobring,  of  Lund ;  The  Surgical  Treatment  of  Appendicitis, 
by  Dr.  Rehn,  of  Frankfort  on-the-Main  ;  and  the  After-TreaV- 
ment  of  War  Invalids  aad  Victims  of  Accident  in  Watering 
Places,  by  Dr.  Z  emsssn,  of  Wiesbaden. 

The  Imperial  Council  of  Hygiene.— The  regulations 
for  the  new  Reichsgesundheitsrath  (Imperial  Council  of  Hy- 
giene) have  been  published  by  the  Federal  Council.  The 
Council  has  been  instituted  Ln  conformity  with  the  new  laws 
relative  to  epidemic  diseases  to  be  a  conaulting  body  in  con- 
nection with  the  Imperial  Health  Offi  e.  The  members  are 
elected  by  the  Federal  Council,  and  the  president  and  vice- 
president  are  appointed  by  the  Imperial  Chancellor.  The 
membership  is  an  honorary  office  and  is  tenable  for  only 
5  years,  after  which  time  fresh  elections  will  take  place.  The 
Imperial  authorities  and  also  the  authorities  of  the  individual 
confederated  Slates  have  the  right  to  send  representatives  to 
the  meetings.  The  Council  is  authorized  to  send  commis- 
sioners to  make  inquiries  in  any  part  of  the  Empire  where 
intervention  in  hygienic  matters  seems  to  be  necessary. 
There  will  be  nine  special  committees  of  the  Council,  the 
functions  of  which  will  be  to  take  cognizince  of  the  following 
subjects :  (1)  Public  health,  including  hygiene  of  dwellings, 
ventilation,  etc. ;  (2)  hj-giene  of  food ;  (3)  water  supply ; 
(4)  hygiene  of  factories  ;  (5)  epidemic  diseases ;  (6)h}giene 
of  hospitals ;  (7)  the  pharmacopeia ;  (8)  hygiene  of  shipping ; 
and  (9)  veterinary  hygiene.  The  ''plenum''  of  the  Council 
will  meet  only  when  convoked  by  the  Imperial  Secretary  of 
State  for  the  Interior.  The  proceedings  are  not  public.  It 
lemains  to  be  seen  whether  this  program  will  be  realized 
and  how  often  the  Imperial  Government  will  think  it  requisite 
to  convoke  the  Council.  Care  must  be  taken  to  prevent  the 
Council  from  coming  into  collision  with  the  medical  depart- 
ments of  the  individual  States,  which  are  very  anxious  to 
maintain  their  prerogatives  in  this  respect,  and  whose  influ- 
ence is  the  greater,  as  the  executive  is  entirely  under  their 
control,  whilst  the  Imperial  Council  of  Health  is  only  a  con- 
sulting body,  without  executive  functions.  Of  the  members 
of  the  Council  the  following  prominent  names  may  be  men- 
tioned :  Professor  von  Bergmann,  honorary  F.R  C.S.  Eng., 
the  well-known  professor  of  surgery  in  Berlin  University ; 
Professor  Binz,  of  Bonn ;  Professor  Buchner,  of  Munich ; 
Professor  Fliijge,  of  Breslau;  Professor  F.iiikel,  of  Halle; 
Professor  GafTky,  of  Giessen  ;  Professor  Gerhardt,  of  Berlin ; 
Professor  Robert  Koch,  the  bacteriologist;  Professor  Loffler, 
of  Greifswald  ;  Professor  van  Noorden.  of  Frankfurt ;  Pro- 
fessor Rubner,  of  Berlin ;  Professor  von  Ziem8sen,of  Munich ; 
and  many  others. —  {^London  Lancet"] 

MISCELLANY. 

Acetic  Acid. — Acetic  acid  is  now  made  in  Gsrmany  from 
the  refuse  material  obtained  from  the  sauerkraut  factories. 
The  enormously  increased  production  will  reduce  the  price 
of  the  acid  to  a  merely  nominal  sum. 

Appoiutmeuts.  —  Basle  :  Dr.  Karl  Haegler,  Privat- 
docent  of  Surgery,  and  Dr.  Friedrich  Egger,  Privat-docent 
of  Medicine,  have  been  appointed  extraordinary  professors. 
— Cjpenhagex:  Dr.  J.  Fibiger  has  been  appointed  to  the 
chair  of  pathological  anatomy  in  succession  to  the  late  Dr. 
Lange.— Kiel  :  Dr.  Theodor  Kirchoff,  Privat-docent  of  psy- 
chiatry, has  been  granted  the  title  of  professor.— ^Lkip^ic  : 
A  new  dermatolog^cal  clinic  has  been  opened  ;  it  is  replete 
with   apparatus  for  Rojtgen  rays  for  urethroscopy,  cyeto- 


X- 


scopy,  and  the  Finsen  light  treatment,  and  it  is  under  tl 
charge  of  Professor  G  Riehl.— Kiew  :  Professor  A.  Murato 
of  Dorpat,  professor  of  obstetrics  and  gynecology. — Viesh. 
Dr.  Anton  Freiherr  v.  Eiselsberg,  ordinary  professor  of  tl 
University  of  Koaigsberg,  has  been  appointed  ordinary  pr 
fessor  of  eurgery  and  head  of  the  first  surgical  clinic  Ln  tl 
University  of  Vienna. 

Plague  In  Cape  Town.— Bubonic  plaerue  is  developiu 
to  a  considerable  extent  in  Cape  Town.  Fifteen  new  caat 
and  97  old  ones  were  offi;ially  reported  on  March  11.  Th 
disease  is  extending  to  the  better  classes.  Several  peraor 
have  died  from  the  plague  on  the  streets  of  Cape  Town.  It : 
reported  that  the  German  Government  has  establis'ied 
plague  quarantine  against  vessels  coming  from  C*pe  Town. 

Obituary. — Dr.  Theodore  HrsEMASS,  professor  of  phs 
macology,  aged  68  years,  at  Go.tingen. — Da.  Wn.HBL; 
ZoLLER,  aged  75,  at  Heidelberg — Dr.  Hermak  Pfkiff£R,  f 
Darmstadt. — Dr.  San  Cristobal,  rector  of  and  formerly  pic 
feasor  in  the  medical  faculty  of  the  University  of  Santiaei 
Chili. — Dr.  Ignacio  Qcnjn-ixo  de  Avkller,  surgeon  to  hi 
Hospital  de  S.  Jose,  of  Lisbon,  aged  82  years.— Dr  Heikbici 
ScHAPiRo.  profesEorin  the  Grand  Dachess  Helena  Pawlown 
Clinical  Institute,  St.  Petersburg,  aged  4S  years. — Dr.  Lkc 
POLD  Weiss,  extraoidinary  professor  of  ophthalmology  in  th 
Uaiversity  of  Heidelberg,  aged  51  years. — Dr.  JcruD 
HoMAXS,  assistant  in  the  Hygienic  Institute  of  Kiel.— Wn 
LLAM  Pope  Meaes,  M  A.,  M.D.,  MR  C.S,  in  Edinburgh,  a 
February  22,  aeed  46  vears. — Ms.  Baros  Alfred  BuoI 
M.R.CS.,  LRCP,  at"  London.— Mr  Hesry  WiluM 
SiRATCHLEY,  MR  C.S  ,  LRCP.,  at  Poole,  on  February  f 
ased  38  years. — Professor  Victor  PASCHtnrs,  Chief  of  th 
Military  Medical  Academy  of  St.  Petersburg,  aged  56  yean 

Postmortem  Vitality  of  Bacteria. — In  a  receo 
number  of  a  German  journal,  devoted  to  bacteriology,  n' 
interesting  summary  is  presented  of  certain  results  attaint-" 
by  Dr.  Klein  in  the  course  of  a  long  series  of  expeiimen 
made  lately  in  which  Dr.  Klein  endeavored  su  cessfuUy  : 
ascertain  what  becomes  of  disease  germs  af.er  the  deatu  < 
their  victim.  These  experimentj  had  a  very  decided  praci; 
cal  value,  as  the  conditions  which  they  proved  to  exist  dig 
pose  eflfectually  of  one  of  the  arguments  which  ha«  beei 
often  used  by  aidvocates  of  cremation. 

Tnese  latter  have  held  that  disease  germs  could  retail  I 
their  vitality  for  an  indefinitely  long  period  in  the  burie>  i 
body,  and  that,  therefore,  cemeteries,  in  addition  to  bein^  I 
harmful  because  of  the  decaying  organic  matter  which  the;  I 
contained,  were  positively  dangerous  because  they  acted  a  ( 
immense  storage  reservoirs  for  the  bacteria  of  the  differen  t 
diseases. 

Dr.  Klein's  results  correct  this  mistaken  idea.    In  order  U  t 
carry  out  his  experiments  satisfactorily  he  buried  animali  I 
which  had  died  from  certain  known  diseases,  disinterred  th» 
bodies  at  the  end  of  varying  periods,  and  examined  th« 
organs  for  bacteria. 

Ttie  bacillus  of  Asiatic  cholera  was  still  living  at  the  enc 
of  19  days,  but  after  being  buried  for  28  no  living  specimer 
could  be  found.  The  typhoid  fever  bacillus  was  able  to  exisi 
for  about  the  same  length  of  time,  while  the  ger  n  whict 
causes  the  bubonic  plague  was  able  to  survive  an  intermen' 
of  17  days,  but  was  never  found  living  at  the  end  of  8  week- 

The  bacillus  of  tuberculosis  lives  but  a  short  time  after  t: 
death  of  its  victim.  Dr.  Klein  always  found  it  withe 
difficulty  in  the  organs,  but  was  never  able  to  obtain  a  er. 
cessful  culture.  What  is  perhaps  of  even  greater  importac' 
he  was  never  able  to  cause  tuberculosis  by  injecting  the  b.< 
teria  thus  found  into  the  system  of  a  healthy  animal.— [.V-u 
York  Herald]  

Treatment  of  Senile  Pruritus. — Jaenicke  (Omira'' 

f  innere  Med.,  Dee.  1,  ItKXI)  finds  that  in  this  condition  t: 
skin  showed  a  peculiar  dryness,  was  ill-nourished,  and  shir.} 
He  concludes  that  the  condition  might  be  due  chiefly  to  > 
collection  of  ill-nourished  superficial  epithelium,  and  ireited 
one  case  by  actively  rubbiog  the  surface  with  a  soft  brnab 
in  order  to  remove  the  superficial  epithelium.  This  wte 
repeated  three  times  a  day,  being  earned  out  for  from  10  tc 
llO  minutes.  The  results  "in  this  case  and  in  others  were 
extremely  good,    [d.l  e.J 


iiBCB   It!,   1901] 


THE  LATEST  LITERATURE 


TThk  Philadelphia 
L  Medical  Journal 


509 


Ct?e  latest  iitcrature. 


British  Medical  Journal. 

February  S3, 1901.    [N.o.  2095  ] 

1.  Remarks  on  the  Conclusions  of  the  Report  of  the  Anes- 

thetics Committee  of  the  British  Medical  Association. 
Geo.  Eastes. 

2.  A  Criticism  of  the  Report  of  the  Anesthetics  Committee 

of   the    British    Medical  Association.     AuaosTUS  D. 
Waller. 
3   A  Prehminary  Note  on  the  Etiological  Agent  in  Vaccinia 
and  Variola.    M.  Funck. 

4.  A  Preliminary  Note  on  the  Cultivation  of  the  Microbes 

of  Vaccinia  and  Variola.    S.  Monckton  Copeman. 

5.  Liverpool  School  of  Tropical  Medicine  Yellow  Fever  Ex- 

pedition.   (Abstract  of   Interim   Report.)     Herbert 
E.  Durham  and  the  Late  Walter  Myers. 

6.  The  Margin  of  Error  in  Bacteriological  Diagnosis.    J. 

Odery  Symks. 

7.  The  Protection  of  the  Observers  in  Cases  of  Infectious 

Sore  Throat.    Ernest  Wagqett. 

8.  Two  Cases  of  Typhoid  Fever,  with  Abscess  of  Lung  and 

Empyema.    Sidney  Phillips. 

9.  A  Note  on  the  Phenylhydrazin  Test  for  Sugar.   G.  Leslie 

Eastes. 
10.  A  Note  on  the  Phenylhydrazin  Test  for  Sugar.    Walker 
Hall. 

1. — The  report  of  the  anesthetics  committee  of  the  British 
Medical  Association  is  based  on  25,920  cases,  and  includes 
the  records  of  the  administration  of  43  distinct  anesthetics, 
mixtures,  or  successions  of  anesthetics.  But  the  administra- 
tions in  over  21,000  cases  were  confined  to  chloroform,  ether, 
gas  and  ether,  A.  C.  E.  mixture,  and  mixtures  of  chloroform 
and  ether  in  various  proportions.  The  complications  under 
chloroform,  and  mixtures  of  chloroform  and  ether  were 
more  frequently  of  a  dangerous  character.  Cases  of  danger 
were  divided  into  two  classes ;  those  that  recovered,  153  ;  and 
those  that  died,  29.  Under  ether,  gas  and  ether,  and  A.  C. 
E ,  the  proportion  of  complicated  cases  classed  as  cases  of 
danger  was,  especially  under  ether  alone,  very  far  below  the 
proportion  of  cages  so  classified  under  chloroform  and  mix- 
tures of  chloroform  and  ether.  In  1,176  cases  of  the  ether 
group,  there  was  an  average  of  1  case  of  danger,  due  entirely 
to  the  anesthetic,  whilst  in  the  same  number  of  cases  of  the 
chloroform  group  there  were  at  least  6  cases  of  danger 
caused  solely  by  the  anesthetic.  Probably  the  chief  lesson 
taught  by  the  report  is  that  chloroform  alone,  or  in  combi- 
nation, caused  in  the  reported  cases  a  danger-rate  sixfold 
higher  than  the  danger-rate  produced  by  ether.  The  tend- 
ency for  cases  of  complications  and  danger  to  arise  was 
rather  greater  in  the  winter  than  during  the  rest  of  the  year, 
especially  under  ether.  This  latter  fact  may  possibly  be  due 
to  the  circumstance  that  bronchitis  is  far  more  prevalent 
after  ether  than  after  chloroform,  and  that  bronchitis  usually 
flourishes  when  the  thermometer  is  low.  The  percentage  of 
complications  under  all  anesthetics  together  was  greater  in 
males  than  in  females,  whilst  the  percentage  of  danger  cases 
was  still  higher  in  males  than  in  females.  The  age  period,  from 
11  to  15  years,  had  the  lowest  complication  rates  and  danger 
rates  under  all  anesthetics  taken  together;  from  this  age 
onward  there  was  a  steady  rise  for  each  decennial  period 
until  the  age  of  50  in  the  complication-rate,  and  80  in  the 
danger- rate.  Under  chloroform  the  percentage  of  danger 
cases  in  the  first  10  years  of  age  was  distinctly  higher  than  in 
the  second  and  third  decennial  periods.  Of  the  18  chloro- 
form deaths,  3  were  considered  to  have  been  due  en- 
tirely to  the  anesthetic  and  4  to  the  anesthetic  princi- 
pally, and  the  patient's  condition  secondarily.  In  the 
others,  the  patient's  condition  and  the  operation  were 
held  to  be  more  or  less  contributory  factors  to  the  fatal 
termination.  Of  the  6  ether  deaths  not  one  was  considered 
to  be  due  entirely  to  the  anesthetic.  No  method  of 
administration  of  chloroform  is  free  from  danger,  but  an 
examination  of  the  complicated  cases  appears  to  show  that 
the  occurrence  of  danger  depends  largely  upon  the  admin- 
istrator. In  conditions  of  good  health,  chloroform  is  very 
much  more  dangerous  than  other  anesthetics.    In  grave  con- 


ditions, chloroform  still  remains  the  least  safe  anesthetic, 
but  the  disparity  between  it  and  other  anesthetics  is  far  less 
marked  than  in  health.  Vomiting  during  anesthesia,  which 
may  lead  to  danger,  seems  to  be  more  frequent  under  chloro- 
form than  under  other  anesthetics.  The  tendency  for  circu- 
latory complications  to  appear  increases  directly  with  the 
relative  amount  of  chloroform  in  the  anesthetic  employed. 
While  vomiting  is  more  common  after  administration  of 
ether,  severe  and  prolonged  vomiting  is  more  common  when 
chloroform  has  been  used.  Circulatory  depression  following 
the  administration  of  anesthetics  is  more  common  after 
chloroform  than  after  ether.  While  the  respiratory  compli- 
cations of  anesthesia,  as  a  whole,  are  of  equal  frequency  in 
the  ether  and  the  chloroform  groups  respectively,  yet  those 
that  occur  under  ether  are  mostly  of  a  trifling  and  transitory 
nature,  while  those  that  occur  under  chloroform  are  more 
grave  and  persistent.  After- vomiting  is  more  common  with 
ether  than  with  other  anesthetics,  but  it  is  usually  transient. 
Bronchitis  is  much  more  common  as  an  after-efiect  of  ether 
than  of  chloroform,     [j  M.s  ] 

2.— The  article  is  a  criticism  of  the  report  of  the  work  of 
the  anesthetics  committee,     [j.m.s.]  ...         * 

3. — Funck  believes  that  vaccinia  is  not  a  microbic  disease 
and  that  the  etiologic  cause  of  vaccinia  is  a  protozoon,  which 
he  names  sporidium  vaccinale.  In  certain  specimens  of 
vaccine  virus  he  took  advantage  of  the  large  size  of  the  cysts 
filled  with  spores  to  fish  the  latter  out  with  a  platinum  wire 
onto  discs  of  agar,  and  to  make  them  into  an  emulsion  with 
a  sterile  liquid.  If  under  these  conditions  the  author  suc- 
ceeded in  reproducing  the  disease,  it  could  no  longer  be 
doubted  that  he  really  had  found  the  protozoon  sought  for. 
The  spores  were  made  into  an  emulsion  with  a  drop  of  bouil- 
lon, and  a  calf  was  inoculated.  About  the  sixth  day,  when 
the  experiment  was  properly  conducted,  the  characteristic 
pustules  were  observed.  When  calves  are  inoculated  with 
fresh  emulsions  of  the  protozDon  they  are  found  to  have  be- 
come refractory  to  subsequent  inoculations  with  vaccine. 
He  also  found  that  the  variolous  pustule  contains  a  protozoon 
similar  to  tne  sporidium  vaccinale,  and  concludes  that  the 
etiologic  agent  of  vaccinia  is  identical  with  that  of 
variola,     [jms.] 

4,— Copeman  attempted  to  cultivate  the  micro- 
organisms of  vaccinia  and  variola  by  employing 
collodion  capsules,  which,  after  being  filled  with  beef  broth 
and  inoculated  with  a  trace  of  glycerinated  vaccine  lymph, 
free  from  extraneous  microorganisms,  were  sealed  up  and 
placed  within  the  peritoneal  cavities  of  rabbits  and  dogs. 
In  successful  cases  the  fluid  contained  no  leukocytes,  but  it 
could  be  demonstrated,  by  the  presence  of  an  appreciable 
amount  of  serum  albumin,  that  body  lymph  had  managed  to 
dialyze  through  the  walls  of  the  capsule.  Oa  making  film 
preparations  of  the  contents  of  an  unruptured  capsule,  and 
examining  them  microscopically  after  staining  with  methy- 
lene-blue,  in  addition  to  flakes  of  epithelium  numerous  zooglea 
masses  were  visible,  made  up  of  bodies  resembling  spores, 
only  the  periphery  of  which  took  the  stain.  Apparently  they 
represent  the  resting  stage  of  the  specific  microorganism. 
The  fluid  contents  of  these  capsules  was,  however,  found  to 
be  capable  of  producing  a  typical  eruption  of  vaccinia  in  the 
calf,  although  the  contents  of  control  capsules  placed  in  test- 
tubes  partially  filled  with  beef  broth  and  incubated  at  the 
body  temperature  for  periods  varying  from  a  week  to  a  fort- 
night gave  no  results.  Dr.  Fremlin  and  the  author  have 
recently  demonstrated  the  presence  of  what  appear  to  be 
similar  microorganisms,  often  in  extraordinary  numbers,  in 
the  epithelium  of  vesicles  in  vaccinia  of  the  calf  and  also  in 
human  smallpox,  [j  M.S.] 
6.— Will  be  treated  editorially. 

6.— All  the  cases  of  typhoid  fever  do  not  give  the  serum 
reaction,  and  the  agglutinating  property  may  not  present 
itself  until  late  in  the  disease  ;  again  it  may  be  present  at  one 
period  of  the  disease  and  absent  at  another.  Horton-Smith 
estimates  that  it  is  absent  in  about3%  of  all  cases.  The  find- 
ing of  the  Klebs  Lofflsr  bacillus  is  of  value  in  cases  present- 
ing doubtful  clinical  symptoms,  but  is  of  less  importance 
when  symptoms  of  disease  are  absent,  or  when  the  exact 
nature  of  the  organism  is  doubtful.  Failure  to  find  the 
specific  bacillus  is  only  of  value  when  confirmed  by  repeated 
examinations.  In  the  case  of  blood -examinations  failure  to 
detect  microorganisms  cannot  be  accepted  as  proof  of  their 
absence,  for  the  quantity  of  material  examined  is  relatively 


i 


510 


Thk  Philadelphia"! 
Medical  Jocenal  J 


THE  LATEST  LITERATURE 


[Mabcb  16, 


4 


small.  The  chances  of  error  with  a  positive  result  are,  bow- 
ever,  small  and  depend  solely  on  the  care  and  attention  be- 
stowed upon  the  sterilization  of  the  syringe  and  skin.  Error 
iu  bacteriologic  diagnosis  is  frequently  due  to  the  fact 
that  cultures  only  are  taken  and  no  films  prepared.  For 
example,  an  abscess  is  incised  and  some  of  the  pus  inoculated 
on  culture  tubes  ;  no  growth  results,  and  the  pus  is  regarded 
as  having  been  sterile,  whilst  in  reality  it  has  been  caused  by 
an  organism  that  does  not  grow  on  ordinary  media,  or  that 
only  grows  under  anaerobic  conditions.  Whenever  possible, 
therefore,  films  should  be  prepared  and  stab  cultures  made 
in  glucose  medium.  From  neglect  of  these  precautions,  Symes 
has  more  than  once  failed  to  elucidate  the  cause  of  lesions 
that  were  probably  due  to  such  organisms  as  the  B.  tuber- 
culosis and  B.  capsulatus  aerogenes.  Some  organisms,  too, 
such  as  the  diplococcus  of  Fiiiakel,  are  far  easier  to  recognize 
in  fresh  films  than  in  cultures,      [j  m  s.] 

7. — Waggett  describes  an  instrument  for  the  protection 
of  the  observers  in  cases  of  infectious  sore  throat. 

[j  M  S  ] 

8. — Phillips  reports  two  cases  of  typhoid  fever,  with 
abscess  of  the  lung  and  empyema,     [j.m  s.] 

9. — The  chief  use  of  the   phenylhydrazin- test  for 

sugar  is  a  confirmation  or  otherwise  of  the  presence  of 
sugar  in  urines,  of  which  the  total  reducing  power  is 
equivalent  to  5  parts  per  1,000  or  less.  Before  proceed- 
ing, however,  to  apply  confirmatory  tests  the  presence 
or  absence  of  albumin  should  be  ascertained.  If  more 
than  a  cloud  is  observed  the  coagulated  proteid  should  be 
filtered  off  and  Fehling's  test  again  applied.  This  is  essen- 
tial, as  Bastes  has  occasionally  met  with  proteid-containing 
urines  that  react  with  Fehling's  solution,  the  reaction  not 
occurring  after  the  separation  of  the  proteid  by  heat  and 
filtration.  Should  the  reduction  still  take  place  we  can  then 
proceed  with  the  phenylhydrazin  test.  Take  of  the  filtered 
urine  about  60  ccm.  in  a  beaker  of  100  ccm.  capacity.  Add 
1  gram  of  sodic  acetate  and  rather  less  of  the  phenylhy- 
drazin hydrochlorate.  Stir  with  a  glass  rod,  which  remains 
in  the  beaker  throughout  the  entire  operation.  The  beaker 
is  then  placed  on  a  water  bath  and  the  urine  gradually 
evaporated  down  to  from  10  to  15  ccm.  During  this  process 
the  beaker  should  be  occasionally  removed,  and  any  sedi- 
ment collected  on  the  sides  of  the  vessel  scraped  off  with  the 
glass  rod  into  the  fluid.  In  this  way  none  of  the  sugar  is 
left  by  evaporation  on  the  sides  of  the  beaker.  When  re- 
duced to  the  bulk  above  indicated  the  flame  should  be 
removed  and  the  beaker,  remaining  on  the  bath,  should  be 
allowed  to  cool.  This  will  take  2  hours  or  longer.  When 
quite  cold  stir  up  all  the  sediment  and  with  a  pipette  place 
some  on  a  glass  slide  for  microscopic  examination.  O  lazone 
crystals  will  have  formed  if  there  is  one  part  per  1,000  or 
more  of  sugar  in  the  urine.  If  no  crystals  are  found  it  may 
be  safely  concluded  that  sugar  (that  is  glucose)  is  absent. 

[JM.S.] 

10. — Hall  describes  a  series  of  experiments  to  determine 
the  exact  times  and  quantities  necessary  to  produce  good 
crystals,  and  at  the  same  time  be  sufficiently  sensitive.  From 
these  it  appears  that  0  5  gram  (7  to  Sgrs.)  of  phenylhydra- 
zin, 1.5  gram  (22  grs.)  of  sodium  acetate,  and  5  ccm.  (2  dramf) 
of  urine  give  the  most  rapid  and  satisfactory  results  with 
glucose,  but  that  10  ccm.  should  be  taken  if  the  solution 
contains  maltose  or  lactose.  Before  adding  the  urine,  the 
reagents  should  be  dissolved  by  gently  warming  in  a  few 
cubic  centimeters  of  water.  When  the  urine  is  added  the 
mixture  is  brought  to  the  boiling  point,  and  there  maintained 
for  fully  3  minutes  with  strong,  and  5  minutes  with  weak 
solutions.  The  test  tube  need  not  be  placed  in  cold  water ; 
it  should  be  simply  placed  at  rest.  Within  2  to  10  minutes 
the  crystals  will  be  formed,    [j.m.s.] 


Lancet. 

February  SS,  1901.    [No.  4043.] 

1.  A  Clinical  Lecture  on  a  Quiet  Effusion  into  the  Knee- 

joints  Occurring  in  Women  and  Young  Girls.      Wil- 
lAKti  H.  Bennett. 

2.  Three  Lectures  on  the  Surgery  of  Pregnancy  and  Labor 

Cjmplicated  with  Tumors.  "  J.  BLAND-SirrroN. 

3.  The  Diagnosis  and  Treatment  of  Abscess  in  Connection 


with  the  Vermiform  Appendix.    Ruthkefobd  Moei 

SON. 

4.  Points  in  the  Classification  and  Diagnosis  of  Some  Join 

Affections.    Gilbert  A.  Basnatyne. 

5.  Oa   Protective  Inoculation  and  Serum-Therapy.     J.   L 

Bunch. 

6.  Persistent  Metrorrhagia.    J.  Inglis  Pabsons. 

7.  Abstract  of  an  Interim  Report  on  Yellow  Fever,  by  th< 

Yellow  Fever  Commission  of  the  Liverpool  School  o 
Tropical  Msdicine.  Herbert  E.  Ddeham  and  the  lat« 
Walter  Myers. 

1. — Bennett  describesa  condition  of  quiet  effusion  intc 
the  knee-joint  occurring  in  women  and  young  girls 
Although  the  effusion  is  greater  on  one  side  than  on  th« 
other  it  is  usually  bilateral.  Unless  the  part  is  injured  ther« 
is  very  little  pain.  Excepting  for  a  sense  of  weakness  th« 
patient  is  unaware  of  the  existence  of  the  swelling.  Th« 
condition  is  limited  to  girls  and  women  and  is  always  asso 
ciated  with  menstrual  irregularity  or  uterine  trouble,  hence 
it  is  most  common  at  puberty  and  at  the  climac'.eric.  When 
the  patient  is  standing  the  fluid  occupies  the  lower  part  ol 
the  knee-joint  and  produces  oftentimes  a  pouch  like  swell- 
ing at  the  lower  and  an'erior  part  of  the  joint.  Sometimes 
a  slight  injury  will  call  attention  to  the  existencs  of  the  eflfu- 
sion,  and  hence  a  diagnosis  of  traumatic  synovitis  is  fre- 
quently made.  Bennett  reports  a  number  of  cases  to  illus- 
trate his  remarks.  Daring  the  past  four  years  he  has  see? 
20  typical  examples  of  this  condition.  It  is  practically  never 
seen  m  other  than  the  knee  joints.  No  case  recovered  until 
the  menstrual  or  uteriuBi  trouble  had  been  CDrrected,  but 
when  this  had  been  accomplished  absorption  of  the  fliid 
took  place.  Bennett  bases  a  diagnosis  on  the  presence  of  a 
painless  eff'usion  into  both  knee  joints  occurring  in  women 
associated  with  menstrual  irregularity  or  uterine  trouble,  in 
which  traumatism  and  other  causes  may  be  excluded,  [j.h.g.] 

2. — Bland-Sutton  in  his  third  lecture  on  The  surgery 
of  pregnancy  and  labor  complicated  with  tumors 
takes  up  tiie  subject  of  cancer -of  tne  neck  of   ihe  uteru?, 
tumors  of  the  pelvis,  misplaced  viscera,  and  sequestered  and 
quick  extrauterine  fetuses.    He  regards  cancer  of  the  neck 
of  the  uterus  as  the  most  appalling  of  all  the  complications  of 
pregnancy.    It  is  difficult  to  understand  how  a  woman  with 
this  disease  can  conceive,  but  it  is  quite  certain  that  it  hap 
pens,  and  even  when  the  disease  is  well  advanced.   He  believi 
that  cases  in  which  uterine  cancer  offers  obitruction  to  d 
livery  are  rare,  and  this  for  two  reasons,  namely  :  cancer 
the  neck  of  the  uterus  predisposes  to  abortion,  and  when 
has  advanced  to  such  a  stage  as  to  occupy  the  vagina  wita 
an  obstructive  mass  the  effect  of  it  upon  the  patient  is  such 
as  endangers  and  often  kills  the  fetus.    It  occasionally  hap- 
pens that  even  when  the  child  'is  dead  cancer  may  induce 
such  changes  at  the  neck  of  the  womb  as  to  render  surgical 
interference  indispensable.    Wnen  pregnancy  goes  to  term 
in  such  cases,  cesarean  section  is  the  proper  procedure  to 
adopt.    Tumors  of  the  pelvis  must  be  considered  among;  the 
rare  obstructions  to  labor.    The  ovoid  shape  of  the  tumsrs 
and  their  elliptical  outlines  are  characteristic  of  all  tumors 
which  mould  themselves  in  the  true  pelvis.    Usually  such 
tumors  are  chrondromatous  in  nature.    D.slocated  kidneys 
and  postrectal  dermoids  are  occasionally  encountered  in  ad- 
vanced pregnancy  or  in  labor  at  term.  Taey  may,  and  usually 
do,  necessitate  cesarean  section.    An  enlarged  and  movable 
spleen  is  one  of  the  rarest  complications  of  pregnancy.    I:  > 
a  well-established  fact  that  uterine  and  tubal  pregnancy  mi 
run  concurrently  and  both  go  to  term.  Tnis  may  be  describeu 
as  the  most  dangerous  combination  to  which  child-bearing 
women  are  liable.    In  dealing  with  the  question  of  concur- 
rent, intra-  and  extrauterine  gestation  the  cases  require  con- 
sideration in  three  categories:    1.  Cases  in  which  uterine 
pregnancy  supervenes  on  a  quiescent  (sequestered)  extra 
uterine  fetus  and  goes  to  full  term.    In  these  circumstance- 
it  may  end  happily  and  even  be  successfully  repeated.    '- 
An   extrauterine    and  a  uterine    pregnancy  begin    simul- 
taneously, but  the  complication  is  recognized  in  the  e.arly 
months  and  terminated  by  surgical  intervention.    3.  U;erine 
and  extrauterine  pregnancy  running  concurrently  to  term. 
All  the  recorded  examples  of  this  extremely  rare  combina- 
tion have,  with  one  exception,  ended  in  disaster  to  the  mother. 

[W.A  N.D.] 

3. — Morison,  discussing  the  diagnosis  of  appendicitis 


I 


March  16,  1901] 


THE  LATEST  LITERATURE 


[ 


Phk  Philadelphia 
Medical  Journal 


511 


with  pus,  urges  the  necessity  of  localizing,  as  far  as  pos- 
sible, ttie  exact  position  of  the  abscess,  as  the  treatment  to 
be  instituted,  as  well  as  the  prognosis,  will  depend  upon  the 
situation  of  the  pus.  In  the  diagnosis  of  pelvic  cases  of 
appendicitis,  especially  in  women,  difficulty  is  often  met 
with,  and  the  rectal  and  vaginal  examination  of  such  cases  is 
strongly  urged.  When  a  diagnosis  of  pelvic  abscess  due  to 
appendicitis  has  been  made,  Morison  thinks  that  it  is  safer 
to  drain  such  through  the  rectum  in  men,  and  through  the 
vagina  in  women.  When  it  is  posaible  to  do  so  in  cases 
operated  upon  ihtraperitoneally,  he  thinks  that  not  only  the 
abscess  should  be  drained,  but  the  appendix  should  be 
removed  in  every  case.  When  the  abscess  is  found  adherent 
to  the  parietal  peritoneum,  he  prefers  to  open  the  abdomen 
above  the  abscess,  to  wall  it  off  with  gauze,  and  then  open 
the  abscess.  In  ligating  the  appendix  and  suturing  it,  he 
uses  catgut.  Drainage  is  always  obtained  through  the  pos- 
terior angle  of  the  wound.  Morison  gives  the  mortality  of 
appendicular  abscess  as  8%  in  the  cases  operated  upon, 
[j.h.q] 

4. — Bannatyne,  in  an  article  entitled  Points  in  the 
classification  and  diagnosis  of  some  joint  affec- 
tions, states  that  no  two  men  seem  to  agree  as  to  the  diag- 
nosis of  certain  classes  of  disease.  The  author  suggests  the 
following  classification:  "(1)  The  bacterial  or  toxic  arthrop- 
athies ;  (2)  the  nerve  arthropathies  and  (3)  the  senile  degen- 
erative arthropathies."      He  divides  all  cases  into  two  essen- 

:  tial  groups  :  (1)  Those  in  which  the  principal  symptom  of  the 
disease  is  the  joint  trouble,  and  (2)  accidental  arthropathies, 
the  joint  troutile  not  being  the  essential  feature  of  the  dis- 
ease.   In  the  first  group  may  be  included  rheumatism,  rheu- 

:  matoid  arthritis,  gout,  senile  arthritis  and  pulmonary  osteo- 

:  arthropathy.  In  the  second  class  he  mentions  the  arthritis 
accidental  to  gonorrhea,  scarlet  fever,  malaria  and  certain 
nervous  diseases.  He  believes  that  microorganisms  act  as 
I ;  causes  in  nearly  all  forms  of  arthritis.  From  our  present 
■■.  knowledge,  the  following  classification  is  suggested:  "  (1) 
Bacterial  or  toxic  arthropathies ;  (a)  bacterial  rheumatism, 
rheumatoid  arthritis,  gonorrheal  and  scarlatinal  arthritis 
(and  probably  malarial  arthritis) ;  and  (b)  toxic,  gout  and 

:  pulmonary  osteoarthropathy  ;  (2)  nerve  degenerative  arthrop- 
athies, such  as  occur  in  tabes,  ataxic  paraplegia,  etc;  (3) 
senile  degenerative  arthropathies,  such  as  senile  arthritis." 
Attention  is  directed  to  4  separate  kinds  of  swellings  or 
nodules  which  occur  in  various  structures.  Muscular  rheu- 
matism is  regarded  as  a  manifestation  of  the  rheumatic 
poison.  In  this  affection  indurated  patches  in  certain  muscles 
are  frequently  observed  ;  these  areas  represent  interstitial 
changes  in  the  muscle.  In  rheumatism,  rheumatoid  gout, 
etc.,  fibrous  masses  are  not  infrequently  observed  in  the 
subcutaneous  tissues.  The  subcutaneous  masses  have  also 
been  found  in  gonorrheal  arthritis  and  maltese  fever;  the 
third  variety  of  nodules  consists  of  bursal  swellings  in  con- 
nection with  joint  affections  and  occurs  most  frequently  in 

,  chronic  gout  and  chronic  rheumatism ;  sometimes  in 
rheumatism.  Occasionally  these  swellings  apparently  have 
no  relation  to  the  joint.  The  fourth  variety  of  swellings 
coneiets  of  osseous  nodes,  principally  at  the  end  of  the 
phalangeal  bones ;  these  nodules  occur  in  chronic  rheu- 
matoid arthritis  and  gout.  Reference  is  made  to  the  re- 
searches of  Dr.  Poynton  and  Dr.  Piine,  who  have  isolated 
a  diplccoccus  from  the  joint  fluids  and  joint-structures, 
incases  of  rheumatism.  Inoculation  of  this  organism  into 
animals  gave  rise  to  arthritis  and  other  joint  manifestations, 
as  well  as  other  symptoms.  The  diplococcus  was  again 
found  in  the  inflammatory  lesions  of  the  animal.  The  author 
believes  that  rheumatism  is  due  to  a  specific  bacterium. 
Two  varieties  of  rheumatoid  arthritis  are  mentioned ;  one 
being  acute  and  the  other  chronic.  Children  and  compara- 
tively young  adults  are  susceptible  to  the  acute  form ;  fe- 
males being  more  frequently  attacked  than  males,  and  the 
disease  often  follows  such  disorders  as  influenza,  rheumatism, 
or  tonsillitis.  The  clinical  manifestations  of  the  acute  variety 
are  swelling  of  the  joints  and  an  increase  in  the  tempera- 
ture. The  joint  becomes  soft,  or  is  distended  with  synovial 
fluid  and  bony  formations  do  not  appear.  Vasomotor  dis- 
turbances may  develop  in  the  neighborhood  of  the  joint; 
pain  in  the  varying  grades  of  severity  may  be  present  and 
glandular  enlargements  are  seen  in  the  neighborhood  of  the 
involved  joints.  The  chronic  variety  may  follow  the  acute 
or  develop  insidiously.    The  joints  gradually  become  crip- 


pled, show  great  deformity,  become  enlarged  and  bony  out- 
growths develop.  The  affection  may  spread  to  many  joints, 
thereby  causing  pain,  stiffness  and  deformity  ;  in  some  cases 
even  dislocation  occurs.  He  mentions  that  von  Dungern 
and  Schneider  have  isolated  a  microorganism  from  the  joints 
in  cases  of  rheumatoid  arthritis.  When  this  bacterium  was 
injected  into  animals  the  disease  was  reproduced  and  the 
microorganism  was  found  in  the  joints.  Dr.  A.  S.  Wolmann 
and  the  author  have  isolated  a  specific  bacterium.  In  the  acute 
variety  of  rheumatoid  arthritis  muscular  atrophy,  which 
occurs  in  relation  to  muscles  or  certain  groups  of  muscles, 
and  increase  in  the  tendon  reflexes,  have  been  observed.  In 
the  chronic  forin,  the  muscular  atrophy  was  due  to  disuse, 
and  tendon  rt flexes  were  not  exaggerated.  He  believes  that 
the  joint  manifestations  of  rheumatoid  arthritis  are  not  pre- 
ceded by  nerve  troubles  but  arise  secondarily ;  therefore, 
muscular  atrophy  seems  to  develop  through  reflex  impulses. 
From  a  diagnostic  standpoint,  gonorrheal  arthritis  presents 
the  following  points  of  interest :  The  affection  is  always  pre- 
ceded by  a  gonorrheal  attack  elsewhere,  most  frequently  in 
the  urethra;  the  goaococcus  produces  the  lesions  in  the 
joints  and  can  be  found  in  these  structures.  The  severity  of 
the  primary  attack  has  no  relationship  to  the  severity  of  the 
joint  troubles.  The  join's  of  the  lower  extremities,  particu- 
larly the  knee-joints,  are  most  frequently  involved;  great 
swelling  without  redness  is  the  common  character  of  the 
lesion,  and  cardiac  complication  is  rare  in  gonorrheal 
arthritis.  The  diagnosis  as  a  rule  is  epsy  when  the  gonor- 
rheal discharge  has  been  discovered,  but  it  should  be  remem- 
btred  that  a  vaginal  discharge  in  women  may  be  misinter- 
preted.and  that  gonorrhea  may  accompany  gout;  and  it  should 
not  be  mistaken  for  rheumaiism.  The  salicylates, when  admin- 
istered, as  a  rule,  point  out  the  true  nature  of  the  affection. 
The  arthritis,  which  is  occasionally  associated  with  scarlet 
fever,  develops  with  the  disappearance  of  the  rash.  The 
joints  of  the  knee  and  elbows  are  most  often  involved 
in  this  8  flection  and  the  disease  rapidly  subsides  with 
the  administration  of  salicylates.  Arthritis,  which  occa- 
sionally develops  with  malaria,  may  have  its  origin  either  as 
true  rheumatism,  probably  developing  with  the  malarial 
affection,  or  it  may  be  of  malarial  origin.  He  states  that  a 
point  of  interest  is,  that  the  occurrence  of  a  gouty  attack 
may  cause  one  of  ague  ;  and  further,  that  the  administration 
of  quinin  in  some  cases  of  malaria  seems  to  provoke  a  gouty 
paroxysm.  The  diagnosis  of  pulmonary  osteoarthropathy 
may  be  attended  with  some  difficulty,  owing  to  its  rarity  and 
also  because  it  may  be  confounded  with  akromegaly.  In 
pulmonary  osteoarthropathy  the  finger  ends  are  clubbed  and 
the  carpal  and  metacarpal  bones  are  thickened,  and  the  dis- 
ease is  associated  with  such  pulmonary  affections  as  phthisis, 
chronic  bronchitis  and  empyema.  The  author  believes  that 
the  theory  of  a  toxic  condition  of  the  blood  or  tissues  seetns 
to  be  the  most  likely  solution  of  the  determining  agent  in 
gout.  The  diagnosis  of  chronic  gout  from  subacute  and 
chronic  rheumatism  often  presents  difficulty.  The  joint  in- 
volvement in  gout  is  rarely  symmetrical  and  is  more  liable 
to  affect  the  joints  of  the  lower  limbs  than  those  of  the 
upper.  The  disease  is  more  common  in  males,  especially  in 
the  well-to-do,  and  often  there  are  in  association,  digestive 
disturbances  and  irritability  of  temper.  Little  difliculty 
attends  the  diagnosis  of  arthritis  which  is  due  to  tabes  or 
other  similar  nervous  affections.  The  arthritis  of  the  senile 
is  essentially  a  monarticular  disease,  especially  afiecting 
men  and  frequently  following  some  injury ;  swelling  is 
slight  and  redness  does  not  occur.  The  author  concludes  the 
article  by  saying  that  arthritic  troubles  may  develop  from 
bacterial  poison  ;  from  bacteria  themselves  acting  upon  the 
joint  structures;  from  toxic  poison,  and  from  nerve  degen- 
erations and  senile  changes,     [f  j  k.] 

5.— Bunch  delivered  a  lecture  on  "Protective  Inocu- 
lation and  Seruiutherapy,"  before  the  North  London 
Medical  Society,  on  February  14,  1901.  Reference  is  made 
to  congenital  immunity  against  scarlet  fever,  measles,  and 
syphilis  in  animals ;  also  that  dogs  are  not  susceptible  to 
tuberculcsis,  and  that  fowls,  rats,  and  pigeons  are  not  sus- 
ceptible to  anthrax.  He  further  states  that  field  mice  are 
susceptible  to  tuberculosis,  while  white  mice  are  immune  to 
this  disease.  Congenital  immunity  occasionally  exists  in 
some  individuals  as  they  may  pass  through  epidemics  of 
measles,  scarlet  fever,  or  smallpox,  without  contracting  these 
diseases.    It  is  also  shown  in  the  case  of  the  negro,  who 


512 


The  PHILADELPHLi"! 

Mkdical  Jocksal  J 


THE  LATEST  LITERATURE 


[MiBCH  16,  1 


is  not  80  liable  to  malaria.  Attention  ia  directed  to  ^he  fact 
that  immunity  may  be  abolished  or  lessened  in  certain  ani- 
mals ;  for  example,  Cnarrin  and  Roger  have  shown  that  rate 
may  lose  their  immunity  to  acthrax  by  exposing  the  animals 
to  prolonged  work,  and  thereby  causing  fatigue.  Acquired 
immunity  is  brought  about  by  passing  through  an  attack  of  a 
disease,  or  experimentally  by  the  inoculation  of  wekk  cultures 
which  protect  against  more  virulent  cultures.  Acquired  im- 
munity develops  after  smallpox,  scarlet  fever,  and  measles. 
Diphtheria,  pneumonia,  and  gonorrhea,  on  the  contrary,  do 
not  render  an  individual  immune  to  subsequent  attacks  of 
these  diseases.  The  various  theories  of  immunity  are  consid- 
ered. That  of  Pasteur  and  Klebs  who  believed  that  immunity 
to  particular  micro arganisms  is  brought  about  because  certain 
substances  necessary  for  their  growth  were  used  up  in  the 
infected  individual,  thereby  preventing  a  subsequent  attack 
of  a  disease.  Cbauveau  and  Wernich  hold  that  microorgan- 
isms produce  certain  substances  which  hinder  the  subse- 
quent growth  of  these  organisms.  In  this  way  the  theory 
explains  that  diseases  are  brought  to  an  end  and  subsequent 
attacks  prevented.  Buchner  and  Wo.ifberg  believe  that  in 
certain  iafecfious  diseases,  destruction  of  the  weaker  cell 
elements  look  place,  the  stronger  cells  being  able  to  resist 
the  invasion  of  the  snecific  microorganism.  Mention  is 
made  of  MetschnikoflTs  phagocytic  theory ;  also  the  re- 
searches of  Xuttall,  who  demonstrated  that  certain  fluids  in 
the  ser^m  cavities  of  dogs  have  the  property  of  killing  an- 
thrax bacilli.  Tne  blood  serum  of  white  rats  rendered  im- 
mune to  anthrax  was  shown  by  Behring  to  have  lost  the 
property  of  allowing  anthrax  bacilli  to  thrive  unless  large 
numbers  are  inoculated.  Attention  is  also  called  to  E^r- 
lich,  who  believes  that  antitoxins  act  by  combining  with 
toxins,  similar  to  the  chemical  combinations  of  acids  and 
alkalies  The  author  mentions  that  of  late  the  phagocytic 
theory  has  been  somewhat  modified  in  that  the  leukocytes  are 
believed  to  secrete  a  bactericidal  substance  which  may  inhibit 
the  growth  or  destroy  bacteria.  The  experiments  of  Bachner 
strongly  support  this  view.  In  discussing  the  practical  side 
of  this  question,  !h3  author  mentions  that  artificial  inocu- 
lation Was  probably  practised  thousands  of  years  ago  by  the 
Chinese.  R^ferencs  is  made  to  the  discovery  of  the  protec- 
tive action  of  cow-pox  agiinst  smallpox,  by  Jenner,  in  1798. 
This  method  has  stamped  out  smallpox  in  many  communi- 
ties. Vaccination  against  swine  fever  by  attenuated  virus 
has  stamped  out  this  disease  ia  some  localities.  In  a  similar 
manner  anthrax  vaccination  has  also  been  prictised  during 
the  last  three  years  with  considerable  success.  Attention  is 
also  directed  to  the  treatment  of  rabies.  Injection  of  pro- 
ducts elaborated  during  the  growth  of  microorganisms  has 
been  attempted  with  the  hope  of  curing  certain  diseases; 
tuberculin  is  given  as  an  example ;  the  treatment  of  tuber- 
culosis with  tuberculin  has  not,  however,  met  with  success. 
Recently  protective  inoculation  has  been  tried  with  enteric 
fever.  The  method  of  Wright  and  Netley  is  mentioned. 
The  observers  use  a  culture  of  the  bacillus  typhosus  which 
is  rendered  sterile  by  heating  to  a  temperature  of  60°  C. 
and  then  adding  a  small  amount  of  lysol  to  the  sterilized 
broth-culture.  The  clear  fluid  is  decanted  and  this  is 
used  for  injections.  The  dose  for  an  adult  is  2  ccm.;  a 
second  irj action  is  given  as  a  rule,  the  dose  being  doubled. 
The  symptoms  following  the  injection  of  this  fluid  are 
frontal  headache,  shooting  pains,  rigors  and  syncope ;  at 
the  site  of  the  inocula  ijn  a  certain  amount  of  in- 
flammation develops  and  some  fever  foUjws  the  inocula- 
tion. The  inoculation  cannot  be  considered  satisfactory 
unless  the  agglutination  test  is  positive  afterwards.  The 
author  gives  the  statistics  of  Wright.  Out  of  11.295  individ- 
uals, one  quarter  were  inoculated  against  enteric  fever;  only 
0.95%  of  the  inoculated  developed  enteric  fever  and  the 
death-rate  among  these  was  0.92%.  Ationgst  the  uninocu- 
lated2  05%  developed  typhoid  fever;  the  mortality  in  this 
group  was0.3i/o.  Raference  is  also  made  to  "IS  soldiers, 
out  of  which  number  539  were  inccalated  ;  amongst  the  u;i- 
inoculated  6.14%  developed  enteric  fever,  while  amongst  the 
inoculated  ones  the  disease  developed  in  0.55%  ;  the  death- 
rate  amongst  the  uninoculated  was  3.35%  against  0.27  of 
those  who  were  subjected  to  protective  inoculation.  Mention 
is  made  of  the  researches  of  Behring  and  Kitasato  on  diph- 
theria immunity,  and  the  statistics  of  Sidney  Martin  and 
Hunt  are  given,  who  have  shown  that  the  death-rate  of  diph- 
theria has  been   reduced  from  28%  to  17%.    The   author 


states  that  the  antitoxic  serum  treatment  of  plague  has  bei 
followed  with  success  by  Calmette  and  other  observers.  Tl 
death  rate  at  Oporto  amongst  1-12  patients  treated  with  an 
plague  serum  was  15%  ;  63  was  the  mortality  percentage 
those  not  treated  wi'-h  the  serum,    [f  j  k.] 

6. — Parsons  remarks  that  there  are  certain  well-recogniz< 
causes  for  metrorrhag'ia,  such  as  fibromyoma,  polypo 
retained  products  of  conception,  diseased  appendages,  ar 
cancer.  In  this  paper  he  discusses  another  class  of  ca* 
which  he  says  is  not  very  uncommon,  but  about  which  vei 
little  is  said  in  the  text-books,  namely,  metrorrhagia,  for  whic 
there  is  no  obvious  cause.  Even  when  patients  are  examine 
under  an  anesthetic  the  surgeon  fails  to  find  anything  wrot 
in  the  pelvis,  and  when  the  uterus  is  dilated  there  is  nothir 
apparent  to  account  for  so  prominent  a  symptom.  Cndi 
these  conditions  thfe  indication  is  to  use  the  curet.  In  ce 
tain  numbers  of  cases  very  little  thickening  of  the  end. 
metrium  is  found,  and  then  the  metrorrhagia  will  ofle 
persist  and  perhaps  be  worse  after  the  curetting  thin  befor 
In  such  c^ases  Parsons  has  been  able  to  stop  the  hemorrhaj 
permanently  by  the  use  of  the  constant  current,  and  he  advi 
cates  this  method  of  treatment  in  preference  to  the  risk  an 
mutilation  involved  by  hysterectomy.  In  those  caees  whic 
are  benefited  by  cure. ting  the  microscope  shows  the  endi 
metrium  to  be  considerably  thickened  by  an  excessi^ 
glandular  proliferation.  Tne  condition  corresponds  to  thi 
described  by  Wyder,  of  Berlin,  as  "  interstitial  endometritig. 
There  is  one  other  cause  of  menorrhagia  to  which  Pargot 
refers,  namely,  retroversion  of  the  uterus.  The  first  ind 
cation  here  is  to  replace  the  uterus  and  keep  it  in  its  prop( 
position,     [w  A.x  d  ] 

7, — Durham  and  Myers  have  discovered  a  small  bacilli 
in  the  organs  of  14  yellow  fever  cadavers.  The  bacillus  wt 
found  in  the  spleen,  kidney,  mesenteric,  portal,  and  axilla: 
lymphatic  glands  ;  also  in  great  numbers  in  the  lower  ini- 
tine.  0:her  microorganisms  were  not  found  in  the  orgau 
It  is  probable  that  S:«rnberg  and  other  observers  have  n< 
recognized  this  bacillus  because  it  takes  up  stains  with  difi 
culty,  and  because  it  is  also  with  difficulty  cultivated  o 
artificial  culture  media.  Successful  staining  was  accomj: 
lished  with  carbolic  fucbsin  solution  diluted  with  5%  phenc 
solution.  The  bacilli  stained  after  the  solution  had  bee 
applied  for  from  12  to  18  hours.  Pure  cultures  were  obtair. 
in  broth  by  inoculating  this  media  with  mesenteric  glanu 
the  growth  developed  under  a  strict  hydrogen  atmospheit 
The  authors  believe  that  the  evidence  in  favor  of  this  smal 
bacillus,  as  being  of  etiological  significance  in  yellow  fever,  i 
stronger  than  any  that  has  been  presented  for  any  of  tb 
so  called  yellow  fever  germs,     [f  j  k.] 


New  York  Medical  JourBal. 

March  9,  1901.     [Vol.  Ixxiii,  No.  10  ] 

1.  Blood  in  the  Urine  as  a  Symptom,  and  the  Diagnosis  c 

its  Source.    Joseph  Wieser,  Jr. 

2.  The  Specific  Treatment  of  Acute  Dysentery.    William  J 

Crcikshask. 

3.  The  Pathology  of  Intrauterine  Death.  Neil  Macphattki 

4.  Ichthvol    in  Treatment   of  Deep-seated  Inflammations 

Walter  T.  Slevik. 

5.  Rssorcin  as  a  Preservative  for  S.iprirenal  Extract  Solu 

tion.    Seymour  Ofpesheimer. 

6.  The  Radical  Treatment    of   Malignant  Disease    of  th 

Larynx.    Ersest  Waggett. 

7.  The  Surgery  of  the  Turbinal  Bodies,  with  a  New  Methot 

of  Operating.    J.  E.  Boylax. 

I. — Joseph  Wiener,  Jr.,  contributes  an  article  upon  blooi 
in  the  urine  as  a  symptom,  and  the  diagnosis  of  it 
source.  Alio  ises  c  f  hematuria  pre^sent  a  double  pri  b'.en 
for  solution.  F.rst,  the  location  of  the  bleeding  point  in  th 
urinsry  tract,  and,  second,  the  cause.  Tne  family  hist-  ■ 
frequently  lends  us  valuable  aid.  For  instance,  in  showi: 
the  tendency  to  tubsrculosis  or  to  the  uric  acid  diathesis 
The  frequency  and  duration  of  the  attacks  should  be  de 

'  termined.  In  renal  hematuria  the  blood  often  appears  end 
denly  and  just  as  suddenly  disappears.  In  cases  of  moT»bl> 
kidney  and  renal  stone  the  hemorrhage  follows  a  simila 
course.    Long-standing  attacks  tend  to  exclude  malignan 

1  disease.    Theeflects  of  exercise,  or  rest,  in  the  course  of  ai 


L4KCH   IG,    1901] 


THE  LATEST  LITERATURE 


[Thb  Philadelphia 
Medical  Jouhnal 


513 


ittack  should  be  ascertained.  In  tuberculosis  of  the  bladder 
here  is  a  sudden  appearance  of  bright  blood  which  is  not 
nfluenced  by  rest,  while  the  hemorihage  due  to  calculi  in 
he  prostate  bladder  or  kidney  is  generally  more  or  lees  re- 
ieved  by  rest.  A  perjistent  hemorrhage,  especially  if  it  is 
nore  profuse  at  night,  suggests  tuberculosip,  earcoma  or 
larcinoma.  The  author  furnishes  valuable  tables  of  ditfer- 
mtial  diagnosis  between  vesical  tuberculosis  and  cal- 
julus.  Also  between  primary  renal  tuberculosis  and 
renal  calculus.  A  table  is  also  supplied  giving  the  prin- 
;ipal  points  of  difference  between  the  diagnoses  of  hemor- 
•hage  from  the  prostate,  stone  in  the  bladder,  tuberculosis  of 
be  bladder,  tumor  of  the  bladder,  stone  in  the  kidney, 
,uberculou8  kidney  and  tumor  of  the  kidney.  An  excellent 
libliography  is  appended,     [t.l.c] 

2. — Will  be  abstracted  when  concluded. 

3. — To  be  abstracted  when  concluded. 

4. — Walter  D.  Slevin  recommends  the  following  formula 
OT  the  relief  of  superficial,  as  well  as  deep-seated  inflam- 
mations. It  consists  of  ichthyol,  45  grains;  lead  iodid,  45 
grains;  ammonium  chlorid,  10  grains;  petroleum,  enough 
to  make  1  ounce.  It  should  be  applied  by  rubbing  upon  the 
tflamed  parts.  The  author  has  found  the  formula  to  be 
moBt  effective  when  used  in  chronic  conditions,  inflamma- 
;ion,  glandular  enlargements,  and  ulceration,  whether  of 
ipecifir  nature  or  otherwise,    [t.l  c  ] 

6. — Seymour  Oppenheimer  recommends  a  1%  solution 
»f  resorcin  in  sterile  water  as  a  preservative  for  supra- 
renal extract.  The  desiccated  gland  is  added  in  the  pro- 
portion (  f  60  grains  to  the  ounce,     [t.l.c] 

6. — Waggett  discusses  at  great  length  the  comparative 
merits  of  total  laryngectomy  and  the  operation  of  tby- 
reotomy.  He  very  much  opposes  the  total  removal  of  the 
arynx  in  cases  of  beginning  malignant  disease,  as  recom- 
mended by  J.  N.  Mackenzie.  He  thinks  that  the  less  severe 
operation  of  thyreotomy  is  much  to  be  preferred  in  these 
sases.  Tables  of  statistics  are  given  to  show  that  both  the 
Jeath-rate  and  cures  are  better  in  this  operation.  He  does 
DOt  deny  the  use  of  the  total  extirpation  in  cases  of  far 
idvanced  cancer.  He  thicks  that  improvement  in  the  treat- 
ment of  malignant  disease  of  the  larynx  will  come  with 
advancement  in  diagnosis,  and  the  early  institution  of  surgi- 
cal treatment  by  opening  the  larynx  and  removing  the 
diseased  area,    [j.h  q  J 

7. — Boylan  thinks  that  the  best  method  of  treating  byper- 
tropby  of  the  turbinals  is  by  removing  them  by  means  of 
a  cold  wire  snare  or  scissors  or  with  a  saw,  rather  than  by 
the  use  of  the  cautery.  In  using  the  cautery  more  tissue  is 
injured  than  that  which  is  removed.  He  prefers  a  thin  stiff 
wire  and  with  this  the  tissues  cut  smoothly  and  with  ease. 
[jh.g] 


Medical  Record. 

March  9,  1901.     [Vol.  59,  No.  10  ] 

1.  The  Period  of  Incubation  of  Yellow  Fever.  A  Study  from 
Unpublished  Observations.    Heney  R  Carter 

-.  A  Contribution  to  the  Bottini  Operation  for  the  Radical 
Relief  of  Prostatic  Obstruction.    L.  Bolton  Bangs 

5.  Acute  Gastric  Ulceration.    H.  Newton  Heineman. 

4.  Treatment  cf  Acute  Serofibrinous  Pleurisy.  Charles  E. 
Nammack. 

1.— Henry  R.  Carter,  of  the  U.  S.  Marine-Hospital 
Service,  contributes  a  valuable  paper  upon  the  period  of 
incubation  of  yellow  fever.  In  a  study  of  80  cases  he 
tias  found  that  the  shortest  period  of  incubation  recorded  is 
3  days ;  the  longest  8}  days,  while  very  few  of  the  cases 
jhow  over  6  days.  Great  pains  has  been  taken  to  eliminate 
all  sources  of  error  in  these  deductions  and  they  seem  to  be 
entirely  trustworthy,    [t.l  c  ] 

2. — Bangs  in  discussing  the  radical  relief  of  prostatic 
obstruction  relates  his  experience  with  the  Bottini  opera- 
tion. He  thinks  the  operation  should  always  be  regarded  as 
a  serious  one  and  careful  preparation  should  precede  it.  He 
thinks  the  operation  can  best  be  done  with  general  anesthe- 
sia. Arnocg  the  symptoms  which  follow  the  operation  fre- 
quent urination  is  invariable.  Hematuria  is  not  infrequent, 
but  usually  subsides  within  two  or  three  days.    Particles  of 


burned  tissue  may  be  expected  to  appear  in  the  urine  after 
the  first  week.  Fever  is  more  or  less  frequent  after  the  oper- 
ation. Epididymitis  occurs  in  a  small  number  of  cases. 
Bangs  thinks  that  the  post  operative  period  is  more  nearly 
three  than  two  weeks  and  emphasizes  the  fact  that  the  after- 
treatment  of  these  cases  is  as  important  as  the  operation  it- 
self. The  patient  should  not  be  allowed  to  pass  from  observ- 
ation until  the  urine  is  clear  and  all  symptoms  of  irritation 
have  passed,  and  if  possible  the  bladder  should  be  explored 
with  the  oystoscope.  Among  the  complications  which  follow 
the  operation  incontinence  of  urine  must  be  mentioned.  It 
occurred  in  two  cases  out  of  Bangs'  36.  Sixty  per  cent,  of 
his  cases  have  discontinued  the  use  of  the  catheter;  20% 
have  an  increased  amount  of  spontaneous  urination  and  are 
able  to  reduce  the  use  of  the  catheter  from  one  half  to  only 
that  which  is  required  for  occasional  treatment;  20%  re- 
ceived no  benefi  t,  or  if  any,  but  very  little.  The  largest  perceL  t- 
age  of  cures  was  among  the  patients  wholly  dependent  upon 
the  catheter.  The  time  for  voluntary  urination  to  appear 
after  operation  varies.  In  some  it  occurred  immediately  fol- 
lowing the  operation,  and  the  longest  period  was  two  months 
after  operation,     [j.h  G  ] 

3.— H.  N.  Heineman  discusses  the  subject  of  acute  gas- 
tric ulceration,  basing  the  term  upon  the  description  of 
Dieulafoy  to  distinguish  it  from  the  well  known  gastric 
ulcer.  Even  when  an  arteriole  only  is  involved,  the  hem- 
orrhage may  become  serious.  The  great  source  of  danger 
arises  from  the  fact  that  the  arteriole  is  eroded  only  to  a 
small  extent  of  its  circumference,  thus  keeping  it  patulous 
and  preventing  retraction  within  the  sheath  of  the  vessel  or 
formation  of  clot  which  would  arrest  hemorrhage.  The 
arteries  involved  in  23  cases  were  the  coronary  gastric  arteries 
in  6,  and  the  splenic  in  17  cases.  The  lesion  can  be  described 
only  as  an  acute  ulceration  of  the  mucous  membrane,  or  of 
this,  and  the  muscularis  mucosae,  unaccompanied  by  any 
bacterial  invasion,  and  without  other  recognizable  lesions  of 
the  walls  of  the  stomach.  The  seat  of  the  ulceration  in- 
volves an  area  ranging  in  size  of  a  pea  to  nearly  J  of  an  inch. 
It  is  most  often  found  near  the  cardiac  end  in  the  grand  cul- 
de-sac  or  the  anterior  wall  near  the  greater  curvature.  As  to 
etiology,  gastric  hyperacidity  has  been  ascribed  as  the  cause. 
It  is  regarded  by  others  as  an  early  stage  of  the  chronic 
ulcer.  Usually  the  sudden  and  excessive  hemorrhage  is  the 
first  sign.  Exceptional  nausea  and  gastric  pain,  vertigo,  and 
syncope  immediately  precede  and  accompany  the  hemor- 
rhage, the  patient  being  previously  in  good  health.  Some- 
times gastric  pain,  accompanied  by  nausea  and  vomiting, 
precedes  the  hemorrhage,  while  a  alight  elevation  of  temper- 
ature may  also  occur.  As  to  treatment,  the  patient  should 
be  placed  at  absolute  rest,  and  rectal  alimentation  resorted  to 
for  3  or  4  weeks.  An  ice  bag  may  be  appUed  to  the  stomach, 
while  nothing,  not  even  water,  should  be  given  by  the  mouth. 
Intravenous  or  subcutaneous  iijection  of  serum  should  be 
used.  Dieulafoy  recommends  8  gm.  of  chloride  of  sodium 
and  10  cm.  of  nitrobenzaate  of  caffein  added  to  one  litre  of 
distilled  water.  The  indications  for  operation  are  rather 
ditficult  to  determine.  If  a  patient  has  lost  a  half  to  one  litre 
of  blood  upon  several  occasions  within  24  hours,  he  is  cer- 
tainly in  danger  if  not  operated  upon.  The  amount  of  blood 
lost  is  our  best  indication,  but  all  clinical  signs  and  symp- 
toms should  be  considered.  The  author  appends  a  valuable 
list  of  all  surgical  interventions  for  gastric  hemorrhages 
bearing  upon  the  condition  described,  and  for  chronic  ulcer. 
[t.l.c] 

4.— Charles  E.  Nammack  discusses  the  treatment  of 
acute  serofibrinous  pleurisy  with  especial  reference 
for  the  indications  of  tapping.  He  recommends  this  pro- 
cedure, first,  when  life  is  directly  thre.atened  by  asphyxia 
from  compression  or  by  cardiac  weakness;  second,  when 
fluid  has  risen  to  the  third  interspace  in  front;  third,  in  all 
lesser  eS^usions  when  spontaneous  absorption  is  unduly  de- 
layed. His  medical  treatment  includes  the  local  application 
of  guaiacol,  or  of  iodin  when  the  eS'ect  of  guaiacol  on  the 
heat- regulating  and  vasomotor  centers  is  too  pronounced. 
Internally  he  gives  sulphate  of  magnesium  in  concen- 
trated solution  in  suflioient  doses  to  produce  mild  catharsis. 
It  is  important  that  the  ingested  liquids  should  be  kept  at 
as  low  a  point  as  possible,  and  the  consumption  of  as  much 
table  salt  as  the  patient  can  be  induced  to  take  is  recom- 
mended. Nammack  states  that  in  his  experience  progres 
is  more  rapid  in  those  cases  which  are  not  tapped.    [t.l.o. 


514 


Thk  Philadelphia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Mabcb  16,  1 


Medical  News. 

March  9,  1901.     [Vol.  Ixxviii,  No.  10.] 

1.  Oar  Duties  Toward  the  Consumotive  Poor.    S.  k.  Knopf. 

2.  The  Intravesical  Evidence8  of  Perivesical  Inflimmatory 

Processes  in  the  Female.    Frederick  Bierhoff. 

3.  The  Prevention  of  Insanity.    Heney  Waldo  Coe. 

4.  The  Tonometer  and  Its  Value  in  Determining  Arterial 

Tension.    Henry  L.  K.  Shaw. 

5.  The  Present  Status  of  the  Subarachnoidean  Injection  of 
•    ■      Cocaine  for  Anesthesia  (Corning- Bier  Method).    John 

S.  Miller. 

1. — Knopf  in  his  article  advises  the  early  isolation  of 
persons  suffering  from  consumption  in  sanatpriums  not  only 
for  the  cure  of  the  disease,  but  also  to  school  them  in  the 
hygienic  measures  that  actual  experience  gives  in  taking 
care  of  expectoration,  how  to  protect  themselves  from  rein- 
fection, and  what  to  do  to  get  well  and  remain  well.  He 
also  objects  to  institutions  in  which  there  are  large  numbers 
of  these  patients,  and  advises  that  a  number  of  smaller 
sanatoriums  would  be  better  whether  in  the  city  or  country. 
He  also  agrees  with  some  authorities  that  there  should  be 
hospitals  in' the  city  used  for  the  isolation  of  these  cises  and 
their  treatment,  and  only  the  sanatoria  situated  at  a  diftance 
should  receive  the  incipient  and  more  hopeful  ca^es.   [t.m.t.] 

2.— Bierhoff  calls  attention  to  a  peculiar  change  which  is 
noted  in  bladder-walls  under  cystoscopic  examination,  which 
he  regards  as  intravesical  evidences  of  perivesical 
inflammatory  processes.  These  changes  are  invariably 
confined  to  limited  portions  of  the  bladder  wall,  and  occur  in 
patients  who  present  absolutely  no  obstruction  to,  nor  diffi- 
culty in,  urination.  In  the  majority  of  ca^es,  however,  the 
patients,  who  were  all  women,  had  at  some  previous  period 
suffered  from  parametritis  or  allied  conditions.  In  a  total 
number  of  413  cases  examined,  in  214  a  history  of  such 
an  affection  preceding  the  bladder-change  could  be  obtained. 
In  cases  of  perivesical  inflammation  of  recent  origin  the 
bladder-wall  will  be  seen  to  bulge  inward  over  the  side  of  the 
exudate.  When  the  process  is  an  old  one  and  the  exudate 
has  gone  on  to  organization,  the  cystoscopic  picture  is  an 
entirely  different  one.  The  most  characteristic  appearance 
in  these  caees  is  the  presence  over  parte  of  the  bladder- wall 
of  sharp  scar-like  formations,  which  arise  to  a  greater  or  less 
extent  above  the  surrounding  wall,  have  a  yellowish  white 
color,  and  tend  to  fimbriate  at  the  end.  The  parts  usually 
affected  are  the  lower  lateral  and  the  upper  posterior  and 
postero- lateral  portions  of  the  bladder.  These  structures 
Bierhoff  terms  "  pericystitic  strands."  Treatment  of  the 
recent  processes  usually  results  in  the  disappearance  of  the 
vesical  changes.  In  the  older  cases  the  full  resorption  of 
the  strands  is  yet  undecided,     [w.a  n.d.] 

4.— Shaw  states  that  the  tonometer  is  by  far  the  simplest 
and  most  satisfactory  instrument  yet  devised  for  the  estima- 
tion of  the  blood- pressure  and  describes  it  as  follows:  It 
consists  of  a  pneumatic  ring,  mercury  manometer,  rubber 
ball  and  rubber  tubing.  The  ring  is  made  of  metal  and  large 
enough  to  slip  easily  over  and  cover  one  of  the  phalanges. 
There  is  a  hole  in  one  side  where  the  rubber  tube  is  attached. 
The  inside  of  the  ring  is  covered  with  a  thin  rubber  mem- 
brane and  is  air-tight,  the  only  place  that  air  can  enter  or 
escape  being  through  the  opening  in  the  side.  The  man- 
ometer is  simply  a  glass  tube  with  a  bulb  filled  with  quick- 
silver. A  scale  is  attached  which  registers  up  to  260  mm. 
The  tubing  is  T-shaped  with  the  ring,  manometer  and  rubber 
ball  attached  on  the  free  ends.  These  parts  are  separable, 
but  by  the  use  of  leather  washers  the  joints  are  made  air- 
tight. Pressure  on  the  ball  forces  the  air  into  the  mercury 
bulb  and  pneumatic  ring,  raising  the  mercury  in  the  one  end 
and  distending  the  membrane  in  the  other.  "To  slowly  regu- 
late the  pressure  on  the  ball  there  is  a  small  wooden  press 
with  a  thumbscrew  in  which  the  ball  is  placed.  The  technic 
is  simple.  The  pneumatic  ring  is  slipped  over  the  second 
phalanx  of  one  of  the  fingers  and  the  blood  removed  from 
the  finger-tip  by  rolling  a  small  rubber  band  down  to  the 
joint.  The  rubber  ball  is  then  compressed  until  the  pressure 
exerted  upon  the  digital  arteries  by  the  ring  is  greater  than 
that  of  the  blood  in  the  arteries.  The  rubber  band  is  with- 
drawn and  the  finger-tip  should  remain  anemic.  The  pressure 
on  the  ball  is  slowly  and  evenly  diminished  until  the  finger- 
tip becomes  intensely  red.  The  height  of  the  mercury  in 
the  tube  is  then  recorded,    [t.m.t.] 


5. — Miller  givf s  the  following  advantages  and  disadva 
tages  of  subarachnoidean  injection  of  cocain  ov 

general  anesthesia:  (a)  that  it  has  no  tffect  on  respiratoi 
cardiac  and  renal  organs ;  (6)  that  there  is  no  danger  fro 
pneumonia  in  an  old  person  after  his  prolonged  etherizatioi 
(c)  that  there  is  no  nausea  or  vomiting,  inducing  seconds 
hemorrhage  in  abdominal  sections,  brain  or  neck  operatioi 
overcDme  in  a  great  measure  by  careful  preparation  of  tl 
patient  and  by  an  intelligent  technic;  (d)  that  the  patient  a 
confer  with  the  surgeon  during  operation,  if  a  modificatic 
of  the  original  method  is  necessary.  The  di;advantage8  a 
(a)  uncontrollable  headache,  lasting  sometimes  a  week ;  ( 
nausea;  (c)  vomiting;  (d)  vertigo;  (e)  cyanosis;  (/)  elevaiu 
of  temperature ;  {g)  weakness ;  (A)  relaxation  of  the  sphio 
ters,  sometimes  lasting  seven  days;  (O  during  operatic 
patient  may  become  rettless.  The  drug  must  be  sterilise 
and  Keen's  dose  is  15  minims  of  a  2^  solution  of  eucai 
[tmt  J 


Boston  Medical  and  Surgical  Journal. 

March  7,  1901.    [Vol.  cxliv,  No.  10.] 

1.  Clinical  Notes  and  Comments  ;  Cancer  of  the  Extremi 

of  the  Common  Bile  Duct.    Robert  T  Edes. 

2.  The  Interpretations  of  Bacteriological  Findings  in  Dip 

theria  Diagnosis.     Summary  of  Examinations — Intie 
pretation  of  Results.    Hibbeet  Winslow  Hax. 

3.  Destruction  of  Lefc  E/e  and  Frontal  Lobe  of  Brain  firo: 

a  Shotgun  Explosion.    Edward  Swasey. 

4.  Convulsions    in    Children.    William    N.    Bcllasd 

Chables  W.  Towksend. 

1. — Edes  reports  the  case  of  a  single  woman,  aged  48  y^ 
who  had  enjoyed  good  health  up  to  June,  1898, 
appetite  and  digestion  had  been  excellent,  and  repeated 
quiries  failed  to  disclose  anything  like  attacks  of  gallstoi 
The  patient  had  been  in  the  country  riding  a  bicycle 
enj  lying  herself.  One  day  she  came  home  saying  she  i 
very  tired  and  was  going  to  bed.  Within  a  day  or  two  th 
was  a  loss  of  appetite,  intense  jaundice,  and  light- colon 
stools.  Neither  then  nor  at  any  other  time  was  there  u 
severe  pain  or  tenderness  on  pressure.  This  condiiion  lastt 
essentially  unchanged  until  her  death.  During  the  course  • 
the  disease,  which  was  more  than  a  year,  there  was  soit 
swelling  of  the  legs,  which,  however,  later  disappearei 
Ascites  was  also  present  for  which  she  was  tapped  18  time 
about  12  or  14  quarts  being  drawn  at  each  operation 
the  autopsy,  the  gallbladder  was  found  to  be  enlarged  and  1 
contain  many  choleslerin  gallstones.  Tne  biliary  passagi 
were  enormously  dilated  within  the  liver,  and  the  hepi^ 
duct  and  the  common  bile  duct  were  also  dilated  to  a  poii 
2  inches  from  the  duodenum,  where  there  was  an  abra; 
narrowing.  At  the  point  of  narrowing  there  was  a  sm* 
rounded  tumor,  which  proved  to  be  an  enlarged  lymph-nod 
There  was  a  very  small  carcinoma  of  the  papilla  at  tk 
orifice  of  the  common  bile-duct.  A  rapid,  compleb 
nonfebrile  jaundice  in  a  person  over  40  or  4-5  years  of  age,  pi» 
ceded  or  accompanied  by  no  severe  and  painful  paroxysm 
and  succeeded  by  a  moderate  amount  of  diffuse  pain  an 
tenderness,  especially  after  it  has  lasted  long  enough  t 
exclude  catarrhal  jaundice,  is  an  adequate  basis  for  a  highl 
probable  diagnosis  of  carcinoma  of  tne  bile  duct.  If,  l»to 
the  smooth  nonnodular  edge  i  f  the  liver,  with  the  gallbladdc 
tense  but  not  tender,  presents  below  the  rib?,  it  is  al«o  hig^ 
probable  that  the  lesion  of  the  ducts  was  primary.  Unfortor 
ately,  the  presence  of  painful  paroxysms  is  not  so  decisive! 
one  direction  as  their  complete  absence  is  in  the  other,  fa 
even  if  significant  of  gallstones,  this  does  not  exclude  cart 
nom*.  A  distinction  between  a  growth  originating  in  tk 
walls  of  the  duct  itself  and  a  small  malignant  or  other  tame 
in  the  head  of  the  pancreas  pressing  upon  it,  and  produdi 
total  occlusion  there  before  giving  rise  to  symptoms  dii 
where,  would  certainly  be  very  ditJicult  to  make.  Toe  itt 
portant  point  is  to  determine  as  early  as  possible  the  exat 
location  of  the  growth,  and  this  cannot  be  done  without  a: 
operation,     [j.m.s  ] 

3.— In  the  city  of  Boston,  in  the  management  o 
diphtheria  cases,  2  consecutive  negative  cultures  fo 
release  from  quarantine  are  required  instead  of  one.  Fm 
ther,  each  of  the  2  consecutive  negative  cultures  for  leleaa 


Mabch  16,  1901] 


THE  LATEST  LITERATURE 


tTHE  Philadelphia 
Medical  Jocknal 


515 


must  be  taken  from  both  the  nose  and  the  throat  of  the  con- 
valescent patient.  The  Board  of  Health  does  not  take  the 
position  that  a  sick  person  is  necessarily  sutfering  from  diph- 
theria simply  because  a  positive  culture  has  been  obtained, 
although  this  is  usually  true.  The  board  does  insist,  how- 
ever, that  such  a  person  is  a  nucleus  from  which  the  bacilli 
may  be  spread,  and  remains  euch  until  the  bacilli  disappear. 
The  board  recognizes  that  the  patient  ,may  be  harmless,  de- 
spite the  positive  culture,  if  the  bacilli  in  his  nose  or  throat 
are  not  actively  producing  toxins.  But  since  the  methods 
for  determining  that  the  bacilli  fail  to  produce  toxins  are  im- 
possible of  application  in  practice  to  large  numbers  of  cases, 
the  board  feels  justified  in  assuming  that  they  are  virulent 
on  the  strength  of  much  evidence  that  shows  that  the  error 
involved  in  the  assumption  is  small.  Hence  it  is,  that  a  posi- 
tive report  on  a  case  for  diagnosis  is  considered  sufficient 
evidence  for  the  isolation  of  the  sick  person  as  infective. 
While  a  positive  report  indicates  clearly  the  presence  of 
diphtheria  bacilli,  a  negative  report  is  by  no  means  such 
good  evidence  of  their  absence,  particularly  in  laryngeal  cases. 
A  no  growth  report  is  used  when  for  any  technical  reason 
the  examination  of  the  culture  is  a  failure.  The  principle  of 
release  by  culture  in  diphtheria  is  analogous  to  that  of  wait- 
ing for  the  desquamation  to  cease  before  release  in  scarlet 
fever.  Release  on  one  negative  culture  allows  30%  of  the  total 
positive  persons  released  to  go  out  of  isolation  while  the 
bacilli  are  still  present.  Extensive  investigation  has  shown 
that  Lf  two  consecutive  negative  cultures  for  release  be  de- 
manded only  1  %  to  Sfe  of  those  released  will  be  still  infec- 
tive.     [j.M.S.] 

3. — Swasey  repoiite  the  case  of  a  boy,  16  years  of  age,  who 
sustained  a  large,  ragged  wound,  involving  the  left  eye, 

eyebrow,  and  part  of  the  frontal  bones,  the  result  of  a  gun- 
shot explosion.  The  eye  was  enucleated  and  it  was  then 
found  that  the  superior  orbital  plate  was  pushed  down,  and 
nearly  filled  the  orbit.  The  breech  pin  and  screw  were  im- 
pacted in  the  wound  in  the  frontal  bone,  and  when  they  were 
withdrawn  they  were  followed  by  a  good  deal  of  soft  brain 
matter  and  blood.  For  a  time  the  patient  did  very  well  and 
then  headache,  pain  in  the  back  of  the  neck,  restlessness, 
convulsions,  a  state  of  stupor,  and  twitching  of  arm  and  leg 
developed.  The  left  arm  became  paralyzed  and  the  patient 
died.  At  the  postmortem  examination  the  whole  frontal 
lobe  of  the  cerebrum  was  found  to  be  practicall}^  de- 
stroyed. The  remaining  portion  of  the  brain  appeared  quite 
healthy,  except  that  the  left  lateral  ventricle  contained  pus 
and  that  there  was  evidence  of  a  basilar  meningitis.  The 
author  believes  that  the  last  two  lesions  were  the  sole  cause 
of  the  fatal  termination,    [j.m  s.] 

4. — A  certain  proportion  of  cases  of  convulsions  in 
early  childhood  are  but  the  beginning  of  true  epilepsy.  Bul- 
lard  and  Townsend  conclude  from  a  study  of  7,180  case 
records:  1.  Thatl%  of  the  children  applying  for  treatment 
at  the  Boston  Children's  Hospital  came  for  convulsions.  2. 
That  10%  of  children  between  5  and  12  years  of  age  gave  a 
history  of  convulsions.  3.  Cases  that  appear  to  be  due  to  some 
manifest  reflex  cause  may  turn  out  to  be  true  epilepsy.  4. 
Other  cases  in  which  the  attacks  occur  frequently  and  with- 
out apparent  cause,  may  suddenly  recover,  at  least,  for  a 
considerable  period.  5.  Tnat  children  who  have  had  con- 
vulsions may  be  strong  and  free  from  nervous  tendencies  in 
later  life,  although  the  proportion  who  have  nervous  ten- 
dencies seems  to  be  greater  than  in  those  that  have  not  had 
convulsions,     [j.m. 8.] 


Journal  of  the  American  Medical  Association. 

March  9, 1901.    [Vol.  xxvi,  No.  10.] 

1.  Sanitation  and  Progress.    Walter  Wyman. 

2.  Results  of  Surgery  in  the  Aged.    James  P.  Tuttle. 

3.  Sarcoma  of  the  Intestines,  with  Tables  of  15  Cases  of 

Resection.    C.  Van  Zwalenbukg. 

4.  Rest   Treatment   for    Hysterical    Diseases.     John    K. 

Mitchell. 

5.  Hereditary   Subnormal    Color-Perception.     F.   Savary 

Peaece. 

6.  The    Simplest    Explanation    of   the  Functions  of   the 

Nervous  System,    ii.  W.  Drake. 

7.  Psychic  Therapeutics.    J.  C.  Culbeetson. 


8.  Treatment  of  Deflection  of  the  Naaal  Septum,  Compli- 

cated with  Traumatic  Deformity  ol  the  External  Nose. 
E.  B.  Gleason. 

9.  Extensive  Laceration  of  the  External  Ocular  Muscles ; 

Diplopia ;  Spontaneous  Recovery.    Walter  L.  Pyle. 
10.  Anastomosis  of  the  Ureters  with  the  Intestine.    A  His- 
torical and  Experimental  Research.  Reuben  Peterson. 

2. — Tuttle  gives  an  interesting  and  instructive  account  of 
operations  done  in  the  aged.  He  reports  131  opera- 
tions done  in  patients  over  60  years  of  age,  with  a  mortality 
of  three.  Two  of  these  deaths  were  caused  by  pneumonia 
due  to  unavoidable  exposure  after  operation,  and  the  third 
was  due  to  Bright's  disease.  The  majority  of  the  operations 
might  be  clasied  as  major,  30  being  for  inguinal  hernia; 
the  three  deaths  occurred  in  this  class.  Thirty- five  opera- 
tions were  done  for  hemorrhoids.  There  were  two  cases  of 
appendicitis  and  two  of  resections  of  the  intestine,  both  of 
these  latter  patients  being  about  70  years  of  age,  and  in  one 
patient  21  inches  of  the  small  intestine  were  removed. 
Ether  was  used  83  times,  chloroform  13  times  and  cocain  30 
times.  Tuttle  does  not  think  that  a  small  amount  of  albumen 
in  the  uriue  should  be  taken  as  a  contraindication  to  opera- 
tion, but  that  patients  with  fatty  and  epithelial  casts  should 
be  rejected  for  operations  of  election.  Organic  valvular 
diseases  of  the  heart,  unless  of  the  most  marked  character, 
are  not  a  bar  to  ordinary  surgical  procedures,  but  fatt}-  heart 
and  degeneration  of  the  muscles  are  contraindications.  Fat, 
flabby  old  people  are  not  good  subjects  for  operation.  He 
thinks  that  the  utmost  celerity  consistent  with  good  work 
should  be  had  in  operatic  ns  upon  old  people.  Shock  was 
very  seldom  seen  in  his  cases.  The  patients  in  this  series 
were  in  a  county  institution  and  were  not  selected  cases. 

[j.H.G.] 

3. — Van  Zwalenburg  reports  a  case  of  sarcoma  of  the 
intestine,  occurring  in  a  5-year  old  boy,  and  apparently 
having  its  origin  in  a  traumatism.  He  resected  the  entire 
ascending  colon  with  5  or  6  inches  of  the  ileum.  At  the 
time  of  operation  the  patient  was  in  a  very  bad  condition, 
emaciated  and  very  anemic  and  running  some  temperature. 
Six  months  after  the  operation  the  patient  was  perfectly  well, 
and  had  gained  17  pounds.  The  growth  was  a  small  round- 
cell  sarcoma.  It  was  about  the  size  of  a  hen's  egg,  and  sur- 
rounded the  ileocecal  valve.  There  was  another  groivth 
which  was  smaller  and  occupied  the  small  intestine  4  or  5 
inches  from  the  cecum.  Van  Zwalenburg  presents  a  table 
classifying  15  cases  of  sarcoma  of  the  intestine  in  which 
resection  was  done,  all  of  which  have  occurred  since  1882. 
He  concludes  that  sarcoma  of  the  intestine  is  more  common 
than  is  generally  supposed,  and  that  it  more  frequently 
affects  the  small  than  the  large  intestine,  the  ileum  being  the 
favoiite  location,  and  that  stenosis  is  rare,  but  dilatation  is 
more  frequent,    [j.h.g.] 

4. — Mitchell  outlines  the  rest  treatment  for  hysteria.  He 
advises  this  plan  of  treatment  in  all  cases  of  hysteria,  except 
when  complicated  with  certain  acute  diseases,  especially 
uterine  and  periuterine.  The  earlier  the  treatment  is  insti- 
tuted the  more  favorable  the  results,  and,  as  a  rule,  well- 
marked  cases  of  hysteria  receive  the  most  benefit  by  this 
treatment.  Mitchell  prefers  to  send  patients  to  a  private 
house  rather  than  to  a  hospital  or  sanitarium.  Great  care 
should  be  exercised  in  the  selection  of  a  nurse ;  she  must 
have  certain  personal  accomplishments,  such  as  being  able 
to  read  aloud,  which  are  not  a  necessary  part  of  a  nurse's 
education.  Isolation  he  regards  as  a  most  important 
measure  in  the  treatment.  Only  the  physician,  the  nurse, 
the  masseur  and  the  servant  should  see  the  patient.  If  the 
patient  be  in  a  private  room  of  the  hospital,  the  resident 
physician  should  only  make  one  daily  visit.  Isolation  must 
be  continued  from  six  to  eight  weeks  in  an  ordinary  case, 
but  the  calenc  ar  must  not  be  the  index  which  regulates  the 
duration,  as  some  cases  may  require  a  much  longer  rest. 
Absolute  rett  in  bed  should  be  instituted.  The  ordinary  diet 
may  be  given,  but  at  the  beginning  milk  is  the  best  article 
of  food.  Massage  is  advised  once  daily,  preferably  given  by 
some  other  person  than  the  nurse.  Daily  use  of  electricity 
is  recommended,  more  because  it  fills  an  hour  or  so  of  the 
day,  which  helps  to  keep  the  patient  occupied.  He  treats 
insomnia  with  the  cold-dip,  the  wetpack,  or  an  abdominal 
compress.  At  times  massage  at  night,  or  the  application  of 
electricity,  induces  sleep.    The  use  of  drugs  must  be  avoided 


516 


The  PhiladelphiaI 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[M^BCH  16,  1901 


as  much  as  possible.  He  emphasizes  that  the  after-care  of 
ihe  patient  is  of  great  importance,  and  he  hag  made  it  a 
rule  to  follow  such  cases  for  about  six  months,    [f  j  k.] 

5. — F.  Savary  Pearce  reports  a  contribution  to  the  study  of 
hereditary  subuornial  color-perception.  The  patient, 
a  man,  could  not  dittinguish  red  from  green.  Excepting 
chronic  cystitis  following  hypertrophy  of  the  prostate  gland, 
and  arteriosclerosis,  no  organic  lesions  could  be  demon- 
strated. There  was  slight  accentuation  of  the  aortic  second 
sound.  There  was  hypochondriasis  and  recurrent  melan- 
cholia. Ophthalmoscopic  examination  was  negative.  Visual 
fields  were  neither  contracted  nor  reversed.  There  were  no 
optical  defects.  The  patient  had  first  noticed  the  abnormal 
color- perception  while  performing  his  duties  as  a  seaman. 
The  family  history  showed  that  one  of  the  children  had 
chorea,  one  daughter  was  very  nervous,  and  another  suffered 
from  lateral  curvature.  A  daughter  of  15  years  of  age  was 
the  only  discoverable  case  of  diminished  appreciation  of 
red  and  green  in  the  family.  The  patient's  mental  condition 
had  always  been  peculiar.  A  year  after  he  was  first  seen  by 
the  author  he  became  afflicted  with  delusions  of  insanity, 
and  died  eight  months  thereafter  in  an  insane  asylum. 
[m.r  D  ] 

6. — Drake  suggests  that  the  name  neuricity  be  applied 
to  the  specific  energy  peculiar  to  nervous  tissue.  He  believes 
that  giving  this  form  of  energy  a  distinctive  name  emphasizes 
its  importance,  and  that  it  will  simplify  the  study  of  its 
action,  and  the  formulation  of  its  laws,    [f  j  k.] 

7. — Culbertson,  in  an  article  on  psychic  therapeutics, 
states  that  the  treatment  by  suggestion  should  form  a  part  of 
a  reputable  physician's  armameatarium,  jusf  as  certain 
books,  instruments,  medicines,  and  surgical  appliances  form 
a  part.  Personal  influence,  he  believes,  is  so  powerful  and 
important  a  therapeutic  agent  that  it  cannot  go  unrecog- 
nized,    [p  J  K.] 

8. — Oleason  discusses  the  various  operations  for  the 
correction  of  deflections  of  the  nasal  seittuni.  He 
thinks  that  septal  resiliency  does  more  to  prevent  success 
than  any  other  one  factor.  He  then  describes  an  operation 
which  he  has  found  very  successful  in  6  cases  of  lateral  de- 
flection of  the  whole  tip  of  the  nose,     [j.h  g.] 

9. — Pyle  reports  a  case  of  extensive  laceration  of  the 
external  ocular  muscles,  diplopia,  spontaneous 
recovery,  occurring  in  a  physician,  aged  44,  in  good  general 
health.  The  injury  occurred  while  the  patient  was  riding  a  bi- 
cycle, and  was  due  to  the  end  of  a  blunt  splicing  hook  of 'No. 
10  telephone  wire  penetrating  the  conjunctiva  of  the  right  eye 
near  the  inner  canthus,  and  making  its  exit  toward  the  ex- 
ternal canthus,  the  line  of  injury  keeping  below  the  cornea. 
The  sclera  was  not  perforated.  The  wound  healed  kindly 
under  antiseptic  treatment.  Diplopia  followed,  which  a  local 
optician  could  not  relieve  by  any  prismatic  correction. 
There  was  crossed  diplopia,  due  to  injury  of  the  inferior 
rectus,  and  homonymous  diplopia  pointing  to  injury  of  the 
inferior  oblique  muscle.  Fusion  of  the  images  and  single 
binocular  vision  were  obtained  while  the  patient  was  sitting 
erect  in  a  straight  position  facing  a  small  circle  of  light  at 
about  the  level  of  his  eyes,  slightly  lowering  the  chin  and 
rotating  the  latter  to  the  right  until  the  head  was  inclined  to 
the  left  at  an  angle  of  about  75  degrees.  Removal  of  the 
blinder  from  the  right  eye,  which  the  patient  had  been  wear- 
ing, partially  relieved  the  diplopia.  Repeated  attempts  at 
correction  finally  resulted  iu  obtaining  comfort  for  the 
patient  by  prismatic  correction,     [m  r.d.^ 


Wiener  kliuische  Wochenschrift. 

February  I4, 1901.     [14.  Jahrg.,  No.  7.] 

1.  Transitory  Absence  of  the  Knee-jerk  after  Cerebral  Injury. 

A.  Pick. 

2.  The  Mechanical  Treatment  of  Certain  Forms  of  Vertigo. 

V.  Urbantschitsch. 

3.  lodipin  as  a  Means  of  Diagnosis.    Franz  Werner. 

1. — Pick  reports  4  cases  in  which  the  knee-jerk 
was  absent  for  some  time  following  an  injury  to 

the  head.  The  first  man  was  kicked  in  the  face  by  a  horse ; 
in  his  case  knee  jerks  were  obtained  only  a  week  later,  for 
the  first  time.    The  second  man  had  been  struck  in  the  head 


by  a  locomotive.  In  this  case  the  knee  jerks  were  not  found 
until  5  days  later.  Tne  third  case  received  a  stab-wound  in 
the  right  parietal  bone,  after  which  the  left  knee  jerk  failed 
until  death  6  months  afterward,  though  left  hemiplegia  fol- 
lowed. In  the  fourth  case,  a  man  who  had  been  shot  in  the 
mouth,  both  knee-jerks  were  absent  for  12  days.  Pick  con- 
siders that  the  amount  of  shock  is  the  probable  cause  of  the 
failure  to  elicit  knee  jerks  for  some  days  after  cranial  injury. 

[M.O.] 

2. — Urbantschitsch  reports  the  case  of  a  man  in  whom, 
following  operation  for  caries,  with  otitis  media,  the  semi- 
circular canals  were  opened.  His  vertigo  was  so  great  that 
he  could  not  even  go  upstairs.  Hearing  was  unaffected.  As 
the  vertigo  was  no  better  10  weeks  after  operation,  Urbant- 
schitsch started  rhythmic  head  exercises.  Methodic 
movements  of  the  head  were  begun  and  kept  up.  Then  they 
were  increased  in  frequency  until  but  a  slight  instability 
remained,  which  the  patient  did  not  notice  himself.  Urbant- 
schitsch has  tried  this  treatment  with  much  success,  in  many 
cases  of  vertigo  due  to  ear  disease,    [m  o.] 

3.— In  using  iodipin  for  diagnosis,  the  preparation 
must  not  contain  free  iodin.  It  must  therefore  be  kept 
away  from  light,  air,  or  heat.  While,  ordinarily,  the  saliva 
will  not  react  with  iodipin,  causing  the  formation  of  free 
iodin,  this  reaction  does  rarely  occur,  though  only  after  a 
long  time.  Nor  is  iodipin  absorbed  by  the  mucous  mem- 
brane of  the  esophagus  during  its  passage  into  the  stomach. 
The  normal  stomach  secretions,  being  acid,  do  not  break  up 
iodipin.  Therefore,  when  iodipin  is  employed  medicinally, 
no  alkali  should  be  given.  From  the  fact  that  iodipin 
reaches  the  pyloruo  intact,  and  is  only  later  broken  up  and 
absorbed  in  the  intestines,  in  the  presence  of  bacteria  and 
the  secretions  of  the  glands  of  the  intestinal  mucous  mem- 
brane, by  the  fluids  from  the  gallbladder  and  the  pancreas, 
comes  the  possibility  of  the  use  of  iodipin  as  a  means  of 
diagnosis  in  6  distinct  affections.  It  is  used  to  ascertain  the 
gastric  motor  activity,  iodipin  appearing  in  the  saliva  in  45 
minutes  at  the  most  (an  average  of  27  minutes),  when  the 
stomach  is  normal.  The  cause  of  its  appearing  after  45 
minutes,  due  to  a  sluggish  action  of  the  motor  function  of  the 
stomach,  is  generally  gastric  catarrh,  from  congestion  in 
heart  disease,  fever,  gastroptosis,  etc.  Motor  activity  is 
normal  when  the  heart  affection  has  not  caused  congestion, 
lodipin  will  be  especially  useful  here,  in  cases  in  which  the 
use  of  the  stomach  tube  is  contraindicated.  Secondly,  in 
insufiiciency  or  incontinence  of  the  pylorus,  from  cancer  or 
ulcer,  iodin  will  appear  in  the  saliva  in  from  10  to  20  minutes 
after  iodipin  has  been  taken.  When  the  bile  or  pancreatic 
juice  is  absent  from  the  duodenum  from  any  cause,  the  time 
before  the  appearance  of  iodin  in  the  saliva  is  directlj* 
proportionate  to  the  amount  of  jaundice  present.  In  cases 
of  total  closure  of  the  common  bile  duct,  iodin  only  appears 
several  hours  after  the  iodipin  has  been  ingested.  Fourthly, 
widespread  inability  of  absorption  in  the  intestinal  mucous 
membrane  or  mesenteric  lymph  system,  from  atrophy, 
amyloid  disease,  tuberculosis,  peritonitis,  or  enteritis,  will 
also  be  shown  by  the  length  of  time  after  which  iodin 
appears  in  the  saliva.  On  tapping,  in  ascites,  the  presence 
of  iodin  in  the  fluid  withdrawn  will  make  the  diagnosis 
ascites  chylosus.  Besides,  the  failure  of  iodin  in  the  saliva 
and  urine,  after  taking  iodipin,  with  other  causes  excluded, 
will  point  to  closure  of  the  thoracic  duct.  Finally,  in 
chyluria,  whether  from  parasites  or  not,  iodipin  given  per 
OS  will  cause  the  appearance  of  iodin-fat  in  the  urine. 
Five  tables  sum  up  the  statistics  of  the  102  cases  used  in 
these  experiments.  On  account  of  its  unpleasant  taste, 
iodipin  should  be  given  in  capsule,  or  with  peppermint. 
The  article  is  full  of  details,  with  many  references  cited. 
[mo.]  

Deutsche  medieinische  Wochenschrift. 

January  SI,  1901.     [27.  Jahrg.,  No.  5-1 

1.  Wooden'y  Cellulitis.    Vox  R.  MChs.*.m. 

2.  A  Case  uf  Fatal  Scaldirg  of  the  Pharynx  and  Larynx. 

E.  Schmidt. 

3.  Concerning  Basaphile  Granulaticns  of  the  Rad  BloDd- 

Corpascles.    G.  Moritz. 

4.  The  Development  of  Lactic  Acid  Bacilli  from  Granules. 

Prelimiaary  Communic«tioa.    A.  P.  Fokkkr. 


March  16,  19(1 1 


THE  LATEST  LITERATURE 


PThk  Philadslphia 
L  Mbdicai.  Jockrai. 


517 


5.  Investigations  of  the  Bactericidal  Action  of  Light  from 

H'gh  Tension  Currents,  and  an  ImproTcd  Method  of 
Making  Use  of  the  Bictericiial  Action  of  Light  from 
Voltaic  Current.     H.  Steebel. 

6.  Mastitis  Adolescentium.    R.  Adlee. 

2. — Schmidt  reports  a  case  of  fatal  scalding  of  the 
pharynx  and  larynx  occurring  in  a  child,  3  years  of 
age,  which  had  attempted  to  drink  from  the  tpout  of  a 
fei-kettle  containing  boiling  water.  A  remarkable  feature 
of  the  cas3  was  that  immeiiately  afcer  the  accident  no 
local  manifestations  were  present.  During  the  night,  how- 
ever, there  were  evidences  of  dyspnea  and  dysphagia. 
Cutaneous  emphysema  next  oc3urred,  the  dyspnea  in- 
creased, requiring  the  performance  of  tracheotomy.  The 
patient  died  on  the  following  day  from  cardiac  failure 
following  a  left-sided  pneumonia,  death  occurring  with 
high  fever,  accelerated  pulse  and  coma.  Postmortem  exam- 
ination confirmed  the  clinical  diagnosis  of  pneumonia.  The 
epiglottis  was  thickened  and  rigid.  The  mucous  membrane 
on  the  laryngeal  suiface  of  the  epiglottis  as  well  as  the 
mucous  membrane  of  the  larynx  were  necrotic  as  far  as  the 
false  vocal  cords.  On  a  level  with  the  endolaryngeal  necrosis 
there  was  also  found  an  area  of  necrosis  at  the  point  of  tran- 
sition between  the  pharynx  and  the  esophagus.  The  ring  of 
necrosis  throughout  showed  an  elevation  of  about  1  cm. 
The  fact  that  the  scalding  was  not  followed  by  simultaneous 
pathological  manifestations  in  the  mouth  and  pharynx  is  ex- 
plained as  being  due  to  the  deep  introduction  of  the  spout 
of  the  kettle  into  the  mouth,  the  bending  backwards  of  the 
head  in  the  attempt  at  suction  and  the  entrance  of  the  steam 
or  the  boiling  water  by  reason  of  the  deep  inspiration  caused 
in  the  attempt  to  scream.  The  frequency  of  tea-drinking  in 
England  has  caused  a  number  of  these  accidents  and  the 
author  states  that  English  literature  on  this  subject  shows  an 
appalling  amount  of  such  cases.  The  complicating  cutane- 
ous emphysema  is  explained  by  the  pathological  findings  in 
the  larynx  and  the  pharynx.  In  consequence  of  the  necrosis 
of  the  mucous  membrane  at  the  transition  from  the  pharynx 
to  the  esophagus  the  emphysema,  analogous  to  similarly 
observed  cases,  may  have  originated  from  here  as  well  as 
from  the  larynx.  At  all  events,  on  account  of  the  inflamma- 
tory swelling  and  constriction  of  the  larynx,  the  resulting 
spasmodic,  deep  inspiration  may  have  afforded  the  possi- 
bility for  the  entrance  of  air  into  the  submucous  tissue  and 
still  further  through  the  interstitial  tissue  to  the  skin. 
[m.e.d.] 

3.— Moritz  has  administered  acetate  of  lead  to 
rabbits,  and  after  various  doses  has  been  able  to  produce 
basophile  granulations  in  the  red  blood- cells.  He  also  found 
that  of  6  workers  in  a  lead  factory  all  showed  typical  granu- 
lations, and  only  one  had  any  suspicion  of  intoxication.  One 
had  previously  had  lead  poisoning.  He  csnsiders  that  these 
granulations  are  of  marked  diagnostic  value  in  the  diagnosis 
of  lead  intoxication.  He  has  also  seen  them  in  leukemia, 
malaria,  sepsis,  and  the  cachexia  of  carcinoma,     [d  l.e  ] 

4.— Fokker  states  that  more  colonies  develop 
from  sour  milk  than  one  would  expect  from  the  number 
of  bacilli  visible  upon  microscopic  examination,  and  the 
number  of  bacilli  present  is  much  larger  when  the  sour  milk 
is  filtered  hot ;  he  considers  therefore  that  there  is  some 
albuminous  substance  which  has  a  vicarious  action.  This  is 
very  similar  to  casein.  If  heated  to  22°  or  higher  it  coagu- 
lates, and  produces  soluble  granules  in  alkaline  fluids.  The 
bacilli  continue  to  increase  on  the  second  day,  and  since  ex- 
isting bacilli  cannot  reproduce  by  simple  division,  and  since 
if  the  casein  is  filtered  no  further  development  occurs,  he 
reaches  the  conclusion  that  the  bacilli  were  developed  from 
the  casein.  Af'.er  the  second  day  fermentative  processes 
hinder  the  development  of  the  bacilli,     [d.l.e.] 

6. — Strebel  gives  an  elaborate  discussion  of  the  Finsen 
therapy  and  his  own  method,  together  with  a  technical 
discussion  of  the  best  method  of  accomplishing  results. 
[d.l.e.] 

6. — Adler  describes  an  affection  of  the  mammary  glands, 
attended  by  considerable  pain,  swelling  of  one  or  both  glands, 
and  the  development  of  considerable  sensitiveness  to  touch. 
The  malady  usually  occurs  at  the  time  of  puberty.  The  treat- 
ment consists  of  applying  tincture  of  iodin,  mercurial  oint- 
ment, and  a  protective  bandage,  and,  in  very  marked  cases, 
extirpation  of  the  gland.  The  author  recommends  that,  when 


extirpation  has  to  be  resorted  to,  the  nipple  be  left  intact 
for  cosmetic  purposes,     [m  e  d.] 


Berliner  klinische  Wochenschrift. 

January  28, 1901.     [38.  Jahrg.,  No.  4.] 

1.  Hygiene  of  the  Eye  in  the  Nineteenth  Century.    H.  Cohs. 

2.  Two  Cases  of  Rectal  Gonorrhea  FoUowirg  Evacuation  of 

Gonorrheal  Pus  into  the  Rectum.     W.  Kaeo. 

3.  Concerning  the  Frequency  of  Sugar  in  the  Urine  of  Obese 

Individuals.    F.  Wolksee. 

4.  Mania  with  Depression.    W.  Weygasdt. 

1. — Will  be  abstracted  when  concluded. 

'£. — Karo  describes  two  cases  of  rectal  gonorrhea  fol- 
lowtng  the  evacaation  of  gonorrheal  pus  into  the 
rectum.  The  author  concluded  from  the  clinical  course  of 
his  two  cases  that  gonorrheal  suppuration  of  the  prostate 
gland  may,  upon  spontaneous  perforation  into  the  rectum, 
give  rise  to  rectal  gonorrhea.  This  should  be  taken  into  con- 
sideration when  an  insision  into  such  abscesses  is  contem- 
plated. In  one  of  the  author's  cases  there  was  an  acute 
spermato-cystitis  which  later  also  perforated  into  the  rectum, 
causing  rectal  gonorrhea  which,  however,  occurred  without 
subjective  difficuUiss. 

3. — Wclfner  examined  the  urine  of  996  obese  patients  and 
found  sugar  present  in  10^  of  them.  He  believes  that  the 
percentage  of  diibatics  increases  with  the  degres  of  obesity. 
[m.e.d.] 

4. — See  Philadelphia  Medical  Jouenal,  March  9, 1901. 


Journal  de  Medecine  de  Bordeaux. 

February  17,  1901.     [31me  Ann^e,  No.  7.] 

1.  Insane  or  Criminal?    E.  Regis. 

2.  General  "  Tics  Convulsifs  "  Cured  by  Respiratory  Gymnas- 

tics.    A.  PiTEES. 

1, — In  this  article  Re^s  comments  upon  a  communication 
by  Coriveaud  and  S3bileau,who,  after  examining  an  individual 
accused  of  having  attempted  murder,  concluded  that  he 
was  an  alcoholic,  irresponsible  at  the  time,  from  alcoholic 
delirium  ;  that  he  had  recovered  when  they  saw  him ;  and 
that  he  could  be  liberated.  A  few  months  later  he  had  an- 
other acute  attack,  gravely  injured  three  people  (one  of 
whom  died),  and  attempted  suicide.  At  this  examination  he 
was  found  irresponsible,  and  taken  to  an  insane  asylum. 
Regis  thinks  these  experts  were  correct  in  all  but  one  par- 
ticular, that  is,  that  the  patient  should  be  observed  for  a  long 
time  before  being  liberated,  in  order  to  be  sure  that  he  is 
cured.  Even  then  a  return  of  the  delirium  is  probable.  He 
says  that  most  insane  patients  are  liberated  too  soon  nowa- 
days from  the  private  institutions,    [mo.] 

2. — Pitres  presented  a  case  of  general  "tic,"  occurring  in 
a  man  aged  20  years.  There  had  been  no  nervous  diseases 
in  his  ancestors,  but  he  had  had  convulsions  with  unconscious- 
ness up  to  7  years  of  age.  The  convulsive  movements  began 
at  9  years,  after  a  fright.  They  were  present  in  the  body  and 
grew  gradually  worse.  At  10  years  he  had  some  internal 
treatment,  after  which  he  improved,  the  amelioration  lasting 
to  his  seventeenth  year.  Then  the  "  tic  "  began  again  and 
grew  worse.  Tne  movements  existed  in  the  head,  body,  and 
eltremities,  from  1  to  20  a  minute.  With  each  movement  a 
shrill  cry  was  associated.  They  ceased  during  sleep.  Regular 
breathing,  singing,  reading  aloud,  and  lying  down  diminish 
them.  He  could  not  be  hypnotized.  For  a  month,  with 
his  back  to  the  wall,  for  10  minutes  thrice  daily,  he  tried 
respiratory  gymnastics,  breathing  deeply  and  slowly, 
elevating  both  arms  at  the  same  time.  The  movements 
gradually  decreased  and  he  left  the  hospital.  Since  then  he 
has  kept  this  exercise  up  and  is  now  cured.  Even  his  fear 
and  love  of  solitude,  which  had  been  so  noticeable  before, 
have  disappeared,    [m.c] 


Rattlesnake  Venom  as  a  Cure  for  Leprosy.— A 

BraziUan  physician  claims  to  have  cured  several  cases  of 
leprosy  with  rattlesnake  poison.  Several  cases  of  leprosy 
that  were  claimed  to  have  been  cured  by  rattlesnake  bites  led 
him  to  make  these  investigations. 


518 


The  Philadelphia"! 
Medical  Journal  J 


STRANGULATED  AND  GANGRENOUS  HERNIA 


[M^ECH  ic,  i9n 


(Dvxqinal  Tivticks. 


STRANGULATED  AND  GANGRENOUS  HERNIA.  KE- 
LOTOMY  AND  LAPAROTOMY  IN  STRANGULATION, 
EXTERNAL  AND  INTERNAL:  ARTIFICIAL  ANUS 
—ENTEROSTOMY,  PRIMARY  OR  SECONDARY 
RESECTION— ENTERECTOMY.  AND  END-TO-END 
OR  LATERAL  JOINTING  IN  GANGRENOUS 
HERNIA* 

By  THOMAS  II.  MANLEY,  Ph.D.,  M.D., 

of  New  York. 

DuRi.vG  the  past  20  years  no  single  branch  of  surgical 
pathology  has  had  so  much  attention  bestowed  upon  it 
as  visceral  hernia  of  the  reducible  or  incarcerated  type. 

Its  etiology  has  engaged  the  attention  of  some  of  our 
most  noted  master-minds,  as  has  also  its  clinical  his- 
tory, its  course,  treatment  and  termination.  Almost 
numberless  procedures  have  been  devised  for  its  opera- 
tive cure. 

It  is  somewhat  remarkable,  however,  to  note  that 
while  advance  has  been  made  in  the  therapy  of  reduci- 
ble forms  of  hernia,  but  little  if  any  departure  is  noted 
from  antiquated  methods  in  the  treatment  of  that  type 
of  hernia  that  kills,  the  strangulated,  in  many  modern 
textbooks  and  systems  of  surgery. 

Radical  revolutionary  methods  are  adopted,  very 
properly,  by  the  profession,  with  great  reserve,  and  the 
more  ancient  procedures,  established  and  promulgated 
by  eminent  authority,  are  set  aside  with  reluctance. 
We  have  not  yet  fully  outlived  that  strange  dread  of  the 
peritoneal  membrane,  nor,  in  strangulated  hernia,  can 
we  forbear  the  vivid  recollection  of  the  harrowing  mor- 
tality which  so  often  followed  kelotomy  for  its  relief,  in 
our  student  days.  Of  some  7  cases  of  kelotomy  wit- 
nessed by  myself  in  my  own  school  and  hospital 
courses,  every  one  of  them  sank  within  48  hours.  So 
great,  indeed,  was  the  mortality  from  operative  effort 
that  every  resource  was  exhausted  before  kelotomy  was 
tried ;  hence  the  patient  was  often  in  mortal  collapse  before 
the  scalpel  was  taken  in  hand.  And  though  the  patient 
realized  the  desperate  chances  he  was  taking,  it  is  evi- 
dent that  the  surgeon  was  also  keenly  alive  to  the  trying 
ordeal  before  him,  as  Abernethy  tells  us  that  always 
before  an  operation  for  strangulated  hernia,  he  felt  like 
a  man  about  to  be  hanged.  The  introduction  of  anes- 
thetics seemed  to  make  little  impress  on  mortality,  as 
,the  late  Dr.  Frank  H.  Hamilton,  as  recently  as  1880, 
affirmed  that  the  mortality  from  strangulation  remained 
about  the  same  as  in  the  time  of  Hey  ;  viz..  60  to  70%. 

Practitioners  yet  held  their  patients  back  until  sur- 
gery was  nearly  powerless  to  resuscitate  dying  individ- 
uals ;  the  faulty,  timid,  imperfect  methods  in  vogue  in 
operating  left  a  large  number  unrelieved,  to  die  from 
adhesions  of  the  coils,  stricture,  kinking,  asphyxia, 
gangrene  or  perforation  of  the  gut.  In  those  days  sur- 
geons knew  nothing  of  the  technic  of  intestinal  sur- 
gery, nor  of  aseptic  methods ;  experimental  surgery  on 
modern  lines  was  quite  unknown,  and,  moreover,  the 
echo  of  the  warning  of  Peyronie,  Richter  and  Duverger 
yet  dinned  in  their  ears ;  that  ''  ihe  deductions  derived 
from  animal  experiments  had  no  application  on  the 
human  being." 

*  Read  at  the  Pan-American  Medical  Congress,  Havana,  Cuba,  February  4, 
1901,  before  the  Section  on  Gynecology. 


PART  I. 

Mortality  ix  Straxgulatiox  and  Some  of  its  Causes. 

It  strikes  one  as  rather  incomprehensible  how  so  emi- 
nent a  surgeon  as  the  elder  Gross  should  advise  against 
early  kelotomy.  and  that  he  should  allege  that  operation 
was  often  premature  and  taxis  would  save  more  than 
the  incision.  The  older  authors  regarded  kelotomy,  in 
a  large  measure,  in  the  same  light  and  submitted  fig- 
ures to  prove  it.  Thus,  Gosselin  treated  53  cases  by 
taxis  and  lost  but  two.     He  kelotomized  61  and  lost  31. 

At  about  this  time  Heusser,  of  Paris  (1861-1865) 
recorded  227  cases  operated,  with  172  deaths,  a  mortal- 
ity of  75.08%.  Later,  Tschering  and  McCready,  in 
1888,  published  statistics  on  this  aspect  of  the  subject; 
the  former,  524  operated — 29%  mortality;  the  latter, 
cases  collected  from  1869-1888,  operated — 36%  mortal- 
ity. Hennegeler,  in  1896,  2^6  kelotoraies  —  23.02  % 
mortality.  Bochard,  same  year,  86  kelotomies  16 
deaths— 17.97%  mortality.  Hagedorn  (1883-1890)  170 
kelotomies — 14%  mortality. 

The  Causes  of  Fatal  Changes  in  Strangulation  of  the  In- 
testine.— Conditions  which  lead  to  grave  or  fatal  symp- 
toms in  strangulation  arise  from  numerous  sources. 
Primarily,  they  are  anatomical. 

1.  Enteroptosis,  compression  of  the  gut,  with  alimen- 
tary impediment,  or  asphyxia. 

2.  Torsion  of  the  gut. 

3.  Stricture  or  partial  stenosis. 

The  intestine,  forced  out  of  the  abdominal  cavity  in 
slow  stages,  accommodates  itself  to  its  new  abode ;  but 
when  this  occurs  suddenly,  as  after  a  strain  at  stool  or 
in  making  any  violent  effort,  distressing  symptoms  may 
follow.  Dupiay  and  several  other  noted  surgeons  have 
insisted  that  a  torsion  or  a  twist  in  the  coils  of  gut  was 
one  of  the  most  prolific  causes  of  strangulation  ;  and  it 
is  noted  in  these  cases,  that  the  constriction  at  the  neck 
of  the  sac  is  seldom  great  and  that  the  circulation  is  not 
completely  strangled.  These  are  evidently  the  class  in 
which  the  intestine  preserves  its  vitality  for  several  days 
after  strangulation. 

Direct  stenosis  with  torsion  of  the  coils  or  not,  from 
constricting  pressure  at  the  neck,  plays  a  wider  role  than 
any  other  anatomical  factor. 

The  parts  most  actively  concerned  in  nipping  the 
bowel  are  all  fibrous ;  but  the  aponeurotic  structures 
above  are  all  continuous  with  muscular  elements,  and 
are  by  them  more  or  less  influenced.  Heretofore,  but 
little  attention  has  been  bestowed  on  the  consideration 
of  the  part  which  the  intestine  itself  plays  in  the  etiol- 
ogy of  strangulation.  The  intestine  is  a  muscular  tube, 
highly  vascular,  with  a  tiiick  mucous  lining  and  serous 
investment.  Its  movements  are  serpentine  and  it  will 
permit  of  more  manipulation  and  abuse  than  any 
other  organ,  in  a  serous  cavity.  Its  muscular  energy 
is  extraordinary,  for  an  oi^an  apparently  so  frag- 
ile and  delicate.  In  many  cases  of  strangulation,  if  not 
crushed  and  crippled  by  violent  manipulation,  it  will 
tend  to  draw  the  coil  which  has  slipped  out.  back  into 
the  abdomen ;  and  when  the  grip  is  tight,  it  will  yet 
maintain  a  tug  on  the  trapped  parts  at  the  ring  until  it 
has  totally  freed  itself  from  the  herniated  segment. 

The  small  intestine  is  supplied  by  blood  through 
the  mesenteric  ligament — a  large,  movable,  loosely- 
organized  structure,  conveying  numerous  arteries  and  a 
great  number  of  large  veins.  In  all  cases  of  strangu- 
lation the  condition  of  the  mesentery  is  a  matter  of 
dominant  importance,  as  it  is  only  when  this  is  com- 


Mabcb  16,  1901] 


STRANGULATED  AND  GANGRENOUS  HERNIA 


[THI  PHlLiDELFHIA 
Mkdical  JorRaxi. 


519 


promised  by  great  or  protracted  pressure  that  the 
vitality  of  the  intestine  is  threatened,  and  much  de- 
pends on  the  state  of  the  vessels  in  this  structure  at  the 
time  of  operative  reduction  whether  the  gut  is  to  perish 
or  recover  function. 

Sex  in  Strangulation. — Berger,  in  the  Bureau  Centrale, 
of  Paris,  in  the  examination  and  record  of  10,000  hernia 
cases  in  both  sexes,  found  that  strangulation  occurred 
three  times  more  frequently  in  the  female  than  in  the 
male ;  its  symptoms  were  more  grave,  gangrene  was 
more  frequent,  and  its  mortality  was  larger.  Gibson 
observes  that  while  women  bear  abdominal  surgery 
with  remarkable  impunity,  in  resection  for  gangrenous 
hernia  the  mortality  is  larger  than  in  men. 

He  collected  3-54  cases  of  gangrenous  hernia  operated 
between  1SS8  and  1898.  One  hundred  and  twenty 
died— 34%.  Males,  123  ;  34  deaths  ;  mortality,  28%. 
Females.  209;  82  deaths;  mortality,  39%.  Dr." Gibson 
is  inclined  to  believe  that  the  anatomical  difiference  in 
the  structures  of  the  female  may  account  for  the  greater 
mortality,  but  this  impression  is  lacking  a  rational  con- 
firmation, though  clinically  every  surgeon  well  knows 
that  every  phase  of  strangulation  in  women  is  of  a  very 
grave  character,  and  operative  mortality  has  been  very 
large.  With  women,  the  onset  is  more  sudden  and  its 
progress  towards  death  very  often  terribly  rapid.  This 
has  been  often  verified  in  my  own  practice.  In  one  case 
coming  under  my  care,  the  woman,  in  the  morning, 
while  out  in  her  garden,  stooped  to  pick  up  a  rake 
which  had  fallen  from  her  hands.  In  an  instant  she 
was  seized  with  all  the  symptoms  of  strangulation.  In 
the  evening  of  the  same  day  she  was  sent  to  the  hos- 
pital in  a  state  of  grave  collapse. 

Two  hours  after  admission,  while  she  was  in  a  state 
of  desperate  exhaustion,  she  was  operated  under  ether- 
anesthesia.  But  already  the  gut  was  the  seat  of  gan- 
grenous rupture  and  the  sac  filled  with  feces;  before 
it  was  possible  to  divide  the  stricture  and  fix  the  broken- 
down  bowel  in  the  wound,  she  expired,  11  hours  after 
the  first  symptoms. 

Delay  in  Operating.  Forcible  and  Protracted  Taxis. — 
The  statistics  of  Madelung  and  other  investigators 
clearly  demonstrate  that  the  mortality  after  kelotomy 
is  in  direct  proportion  to  the  extent  of  delay  in  oper- 
ating, and  that  sanguinous  intervention  offers  little 
hope  after  symptoms  of  mortal  collapse  set  in. 

In  former  times  when  every  description  of  peritoneal 
surgery  was  availed  of  only  as  a  dernier  resort  this  delay 
was  perhaps  justified,  but  at  the  present  such  a  course 
is  cruel,  is  indefensible,  and  places  the  responsible 
attendant  particeps  criminis,  and  reponsible  in  a  great 
degree  for  the  consequences.  Some  of  the  most  har- 
rowing examples  of  this  have  come  to  my  own  knowl- 
edge. In  one  instance  the  unfortunate  woman  was 
jostled  into  a  cab  in  extremis  and  reached  the  hospital  a 
corpse.  In  another,  after  three  practitioners  had  ex- 
hausted themselves'  on  the  strangulated  hernia  of  an 
old  man,  of  ample  means,  he  was  hustled  off  in  a 
driving  snowstorm  at  midnight  to  a  hospital,  to  sink, 
before  hasty  preparations  for  a  kelotomy  could  be 
made.  Another  case  was  sent  in,  the  patient,  a  middle- 
aged  man,  who  sufi'ered  three  days  from  .strangulation 
with  repeated  and  forcible  taxis.  When  I  saw  him  he 
was  in  profound  morphin  narcosis  and  moribund  ;  but 
the  hernia  was  reduced. 

On  autopsy  the  following  day,  it  was  found  that  a 
gangrenous  gut  had  been  ruptured  and  forced  into  the 
abdominal  cavity,  which  was  now  flooded  with  feces. 


Many  other  cases  might  be  cited  of  a  similar  character. 
Certain  it  is  that  in  some  of  this  class  of  cases  one  is  in 
a  quandary  to  know  what  to  do  when  operation  is  de- 
clined by  the  patient  or  family  ;  but  it  should  be  plainly 
stated  that  at  the  proper  time,  in  skilled  hands  it- 
dangers  are  insignificant,  and  that  protracted  dela 
involves  new  risks  and  may  remove  all  hope  from  any 
effort  of  relief.  Protracted,  or  maladroit  taxis  probably 
more  than  any  other  cause  augments  the  mortality  in 
strangulation.  Southam  well  observes  that,  "  the  high 
mortality  in  strangulated  hernia  is  largely  due  to  two 
causes  :  First,  delay  in  operating,  and,  second,  from  the 
injury  previously  inflicted  on  the  contents  of  the 
hernial  sac  by  forcible,  prolonged  and  repeated  taxis. 
■  And  yet,  with  our  knowledge  of  the  great  harm  inflicted 
by  violent  manipulation,  it  is  curious  to  note  that  so 
distinguished  an  authority  as  Mr.  Jonathan  Hutchinson 
is  still  a  champion  of  it;  though,  of  course,  since  he  i- 
no  longer  an  operator  his  views  have  little  weight  in  th; 
branch  of  surgery. 

The  Limitation  of  laxis. — There  are  several  eminent 
surgeons  who  go  so  far  as  to  discount  taxis  altogether 
in  strangulation.  When  there  is  no  evidence  of  organic 
disease  present  and  proper  facilities  are  at  hand  for 
operating,  in  no  case  should  taxis  be  employed  in  any 
stage  of  strangulation,  but  every  time,  there  and  then, 
the  intestine  should  be  liberated  and  the  hernia  radi- 
cally cured  by  one  of  the  many  available  methods. 
With  patients  averse  to  radical  surgery,  or  other  cogent 
reasons,  judicious  taxis  alone,  or  combined  with  other 
resources,  will  often  effect  the  reduction. 

In  nearly  all  cases  sent  to  a  hospital  for  operative 
relief,  the  most  determined  taxis  has  been  employed, 
the  extruded  intestine  has  been  crushed  or  lacerated, 
the  mesentery  has  suffered  in  its  nerve  and  vascular 
structures,  the  gut  is  crippled  and  palsied,  reduced  to 
a  state  bordering  on  gangrene  if  it  is  not  already  sphace- 
lated in  patches.  On  this  head,  a  recent  writer  truly 
observes  :  '■  That  in  these  modem  days  a  strangulated 
hernia  delayed  for  operation  till,  on  an  average,  more 
than  four  days  have  elapsed,  shows  that  there  is  still 
much  missionary  work  to  be  done." 

Incomplete  or  Antiquated  Methods  in  Operation. — The 
mortality  succeeding  kelotomy  for  strangulated  hernia 
in  the  past  was  greatly  augmented  by  operating  by 
methods  which  were  established  on  mistaken,  erroneous 
principles,  or  a  lack  of  knowledge  of  the  pathological 
changes.  In  the  preanesthetic  period  we  can  well 
imagine  the  supreme  importance  of  rapidity  in  operat- 
ing ;  but  since  operating  has  become  painless,  and  since 
wound-infection  can  be  eliminated,  it  seems  incompre- 
hensible how  any  relic  of  an  ancient  kelotomy  can  yet 
survive;  how  anything  can  still  justify  the  use  of 
Cooper's  herniatome,  the  blind  incision,  the  una- - 
countable  fear  of  hemorrhage,  the  leaving  of  a  c/os 
sac  or  the  practice  of  pushing  en  masse  the  whole  ad- 
herent or  tangled,  perchance  devitalized  intestinal  loop 
back  into  the  abdomen.  No  wonder,  indeed,  an  enor- 
mous mortality  is  recorded. 

The  time  has  now  arrived  when  the  whole  superstruc- 
ture of  surgical  technic  in  operations  for  strangulated 
hernia  must  be  remodelled,  and  one  who  operates  here 
should  be  thoroughly  trained  in  the  art  of  intestinal 
surgery.  Operations  for  simple,  strangulated  hernia, 
performed  early  and  properly  should  have  no  mortality 
whatever ;  those  late  and  complicated,  in  patients  whose 
condition  warrants  it,  should  be  followed  by  a  mortality 
under  10%. 


520 


The  Philadklphia*) 
Mbdical  Jouknal  J 


STRANGULATED  AND  GANGRENOUS  HERNIA 


(Mabch  16,  1901 


In  every  instance  when  symptoms  point  to  complete 
stricture  of  the  intestine,  with  systemic  toxemia,  the 
surgeon  should  have  ample  preparations  made  before  he 
begins,  to  make  an  intestinal  resection,  a  partial  or 
complete  enterorrhaphy,  to  laparotomize  and  freely  ex- 
plore the  abdominal  cavity.  When  we  proceed  to  oper- 
ate, Riedel  advises  that  we  must  cast  aside  the  hernia- 
tome  and  cut  freely  down  on  the  constriction  with  a 
scalpel ;  and  that  no  attempt  at  reduction  should  be 
made  in  gangrenous  cases,  until  the  intestine  is  freely 
exposed. 

PART  II. 

Morbid  Anatomy  and  Pathology. 

In  a  general  way  it  may  be  said  that  strangulation 
occurs  in  two  varieties  of  ruptures ;  in  those  which 
were  reducible  and  those  which  were  irreducible  before 
the  accident ;  in  the  former,  on  exceptional  occasions, 
in  femoral  hernia  on  its  tirst  appearance. 

What  is  understood  here  as  irreducible  or  incarcer- 
ated herniae  are  those  not  coercible  to  the  truss  or  hav- 
ing adhesions. 

Of  strangulation  we  have  essentially  two  types.  One 
primary,  or  external,  and  secondly,  the  consecutive  or 
internal,  which  may  follow  operative  reduction,  and 
which  has  so  largely  augmented  mortality. 

The  primary  dangers  in  hernial  strangulation  are 
from  (a)  a  sudden  interruption  of  a  physiological  pro- 
cess, a  double  occlusion  of  the  alimentary  canal,  with 
fecal  stagnation;  (6)  the  interruption  or  arrest  of  the 
vascular  supply  to  the  trapped  intestine ;  and  (c)  from 
gangrene  or  mortification  of  it. 

The  temporary  occlusion  of  the  alimentary  current  in  a 
hernia  is  seldom  productive  of  marked  pathological 
changes,  either  local  or  general,  except  where  the  degree 
of  constriction  is  so  great  as  to  induce  violent  reflex 
disturbances ;  something  singularly  common  in  female 
strangulation. 

The  contents  of  the  intestine — it  being  quite  invari- 
ably the  ileum — in  groin  ruptures,  are  gases  and  liquids, 
sometimes  pure  blood.  The  impediment  to  the  intes- 
tinal current,  in  itself,  either  through  impeding  diges- 
tion or  inducing  coprostasis,  per  se,  cannot  be  regarded 
as  a  grave  accident  immediately  imperilling  life ;  the 
harm  comes  later,  through  the  violent  reflex  disturb- 
ances ;  the  reversing  of  the  peristaltic  wave,  with  agon- 
izing distress  and  profound  cardiac  depression.  But 
symptoms  of  grave  omen  are  seldom  in  evidence  until 
secondary  changes  have  commenced  in  the  hernia, 
which  ultimately  lead  to  partial  or  complete  death  of 
the  intestine.  ' 

Pathological  changes  are  accentuated  through  the 
mesenteric  structures  involved,  through  considerable 
and  long-continued  pressure  on  the  bloodvessels,  which 
lead : 

1.  To  an  intense  engorgement  of  the  walls  of  the 
intestine,  very  considerably  increasing  its  volume. 

2.  By  inflammation  with  large  serous  efifusion  into 
the  sac  or  a  fibro-plastic  exudate  firmly  gluing  the  walls 
of  the  intestine  together  above,  as  well  as  below,  the  site 
of  stenosis. 

3.  Unrelieved  inflammation  passes  on  into  gangrenous 
changes ;  but  we  never  find  any  considerable  segment 
of  intestine  entirely  mortified,  though  gangrenoue  pro- 
cesses are  widespread.  Here  and  there  is  thrombotic 
occlusion  of  an  arterial  radical  in  the  mesentery  ;  or 
those  ramifications  of  it  nearest  to  the  convex  surface 


cease  to  convey  blood,  and  mark  the  site  of  mortified 
patches. 

The  mucosum,  the  layer  calling  for  the  greatest  vas- 
cular supply,  is  the  first  to  part  with  its  vitality,  to 
erode  and  ulcerate,  and,  lying  in  immediate  contact 
with  decomposing  ingesta,  is  a  prolific  source  of  infec- 
tion, of  inflammatorj'  and  gangrenous  changes. 

The  free  hemorrhage  into  the  bowel  before  or  after 
kelotomy,  the  uncontrollable  diarrhea  from  ulceration, 
the  stenotic  contraction  and  subsequent  stricture  some- 
times observed  after  herniotomies,  usually  result  from 
a  lesion  of  this  delicate  structure. 

Lesio'ns  of  the  Mesentery  and  Intestinal  Muscle.— The 
mesentery  is  the  bond. which  unites  the  alimentary 
tube  over  its  greatest  length,  conveying  the  blood  and 
lymph  vessels  and  nerves.  It  is  a  membranous  struc- 
ture made  up  of  elastic  fibrous  tissue  and  smooth 
muscular  elements.  That  it  possesses  contractile  energy 
is  apparent  to  anyone  who  has  observed  its  move- 
ments in  the  living  animal.  In  various  pathological 
and  traumatic  conditions  its  tonicity  is  impaired  or 
lost,  when  it  permits  of  varying  degrees  of  enterop- 
tosis  or  derangement  in  the  movements  of  the  intestine. 
Mr.  Treves  has  called  attention  to  the  great  role  of  the 
mesenter3'  as  an  etiological  factor  in  hernia  ;  and  again, 
we  may  observe  here  with  advantage,  the  part  a  trau- 
matized mesentery  plays  in  some  of  those  fatal  cases 
recorded  after  kelotomy.  A  turgescent,  edematous, 
pulseless  mesentery,  of  a  bronzed  color  and  a  granular 
or  leathery  feel,  possesses  but  little  if  any  functional 
activity.  It  is  in  very  much  the  same  state  of  vitality 
which  we  observe  after  the  main  arterial  trunk  of  a 
limb  has  been  suddenly  occluded  by  a  ligature  or 
damaged  by  an  injury.  There  is  a  very  large  and  free 
anastomosis  between  the  vessels  of  the  mesentery,  so 
that  when  one  area  of  supply  to  the  intestine  does  not 
exceed  six  or  eight  centimeters,  the  vitality  of  the 
segment  cut  off  is  supplied  by  the  excess  at  either 
healthy  end.  When  this  fails,  or  reestablishment  of 
the  arterial  current  is  too  long  delayed,  the  organ  on 
the  distal  end  is  slowly,  but  surely,  deprived  of  its 
vitality  ;  it  lies  in  the  sac,  or  reduced  in  the  abdominal 
cavity,  as  a  foreign  body. 

In  some  types  of  strangulation  the  mesentery  may 
sufler  greater  tension  or  compression  than  the  intestine ; 
so  that  on  its  return  to  the  abdomen  it  is  in  a  function- 
less,  enfeebled  state,  permitting  of  a  sagging,  kinking 
or  twisting  of  the  bowel.  It  is,  therefore,  obvious  that 
the  mesentery  deserves  a  critical  consideration  in  aggra- 
vated varieties  of  strangulation  ;  that  the  diseased  part 
should  be  resected,  that  its  elongation  be  obviated  by 
tucking  or  imbricating  its  folds,  and  so  adjusting  it 
that  its  circulation  may  be  unencumbered  and  it  may 
promise  the  greatest  support  to  the  intestine. 

The  intestinal  muscle,  next  to  the  mucosum.  consti- 
tutes the  most  important  anatomo  physiological  struc- 
ture of  the  alimentary  canal.  If  we  examine  under 
the  microscope,  a  sagittal  section  of  an  injected  speci- 
men of  gut,  we  will  find  that  as  the  arteries  split  up 
in  the  submucosum  numerous  and  large  divisions 
pierce  and  ramify  through  the  muscular  fibers.  In  the 
full  circulation  of  life  we  will  find  the  muscularis  about 
twice  as  thick  as  it  is  after  death,  when  the  arteries  are 
emptied  ;  and  hence  the  reason  that  intestinal  suturing 
is  much  easier  on  the  living  than  the  dead  intestine  in 
the  human  being.  Physiologically  the  musculature  of 
the  intestine,  its  motor  power,  must  be  regarded  as  of 
vital  importance  in  alimentation ;  in  (ii~)  in  maintain- 


March  16,  1901] 


STRANGULATED  AND  GANGRENOUS  HERNIA 


CThe  Philadelphia 
Medical  Journal 


521 


ing  the  open  lumen,  (6)  in  moving  on  and  reducing 
the  ailment. 

It  is  curious  to  note  clinically,  that  inflammation  in- 
volving its  inner  lining,  the  mucous  memtrane,  accel- 
erates its  peristaltic  activity,  while  peritonitis,  or  inflam- 
mation of  its  serosa,  induces  a  diminution  of  peristalsis 
or  entirely  suppresses  it.  Traumatic  muscular  inertia, 
inflammation  or  gangrene  of  gut  after  section  of  the 
constriction  and  reduction,  are  those  pathological  con- 
ditions of  a  post-operative  character  which  have  so 
largely  contributed  to  a  fatal  termination  in  strangu- 
lated hernia. 

Paralyzed  and  powerless  to  contract,  the  damaged 
coil  permits  of  no  passage  of  the  alimentary  contents 
through  it.  Its  now  vitiated,  pent-up  contents,  un- 
dergoing decomposition,  set  free  infective  bacteria, 
which  readily  penetrate  the  intestinal  wall  and  invade 
the  peritoneal  cavity.  In  the  greater  number  of  cases, 
general  invasion  by  infection  is  arrested  by  processes  of 
nature,  by  the  fibro-serous  exudate  of  the  peritoneum 
which  seeks  first  to  localize  infection  by  adhesions,  by 
a  gluing  and  binding  together  of  the  condemned  struc- 
tures preparatory  to  their  final  destruction  by  suppura- 
tive or  gangrenous  processes. 

In  external,  or  primary  strangulation  nature's  inter- 
vention may  prolong  life  or  even  effect  a  cure ;  but  in 
secondary  or  internal,  after  reduction,  her  efibrts  in  this 
direction  are  practically  abortive  and  in  most  cases  only 
hasten  the  end.  In  all  cases  of  recently  acquired  her- 
nia there  is  no  force  so  constant  and  effective  in  reduc- 
tion of  the  extruded  coil,  as  muscular  retraction  of  the 
healthy,  free  ends  within  the  abdomen.  This  is  a 
potent  influence  in  strangulated  cases.  Immediately 
on  the  nipping  or  occlusion  of  the  intestine  it  is  thrown 
into  a  state  of  tonic  spasm  with  a  great  strain  put  on  the 
neck  of  the  imprisoned  loop. 

One  case  came  under  my  care  in  the  person  of  a 
young  man,  which  again  illustrated  how  this  aid  of 
nature  may  have  disastrous  consequences.  A  man  of 
24,  was  sent  to  the  hospital  by  his  family  for  the  treat- 
ment of  a  strangulated  hernia  of  10  hours'  duration.  On 
entrance,  a  strangulated  inguinal  hernia  was  discovered. 
He  begged  not  to  be  operated  till  the  following  day. 
No  taxis  was  at  any  time  employed.  The  following 
morning  the  hernia  had  disappeared,  but  he  had  all  the 
signs  of  general  peritonitis  and  sank  two  days  later. 

On  autopsy,  a  perforated,  gangrenous  knuckle  of  the 
ileum  was  found,  with  large  fecal  leakage  into  the 
peritoneal  cavity. 

In  one  of  my  own  cases  of  successful  intestinal  resec- 
tion of  gangrenous  hernia,  a  30-inch  loop  was  spontane- 
ously detached  on  one  side,  and  nearly  so  on  the  other. 
Pressure,  no  doubt,  was  the  main  factor  in  efi'ecting  this 
spontaneous  excision,  but  there  can  be  no  question  that 
the  severance  was  accelerated  by  intestinal  retraction 
from  above. 

Tumultuous  spasm  or  inflammation  of  the  intestinal 
coils  promptly  induce  what  the  French  designate  peri- 
tonisme,  or  muscular  rigidity  of  the  abdominal  walls. 

Rigidity  or  simidtaneous  clonic  spasm  of  the  smooth 
and  striped  muscle,  therefore,  comes  into  action  as  the 
first  pathological  phenomenon  in  actual  cases  of  stran- 
gulation. 

The  Peritoneal  Exudate. — The  serous  secretion  of  an 
aqueous  consistence,  from  the  peritoneum  in  health 
in  various  pathological  states  provoked  by  trauma, 
becomes  of  a  glairy,  gluey  consistency  and  finally 
serves  the  purpose   of  a  veritable  cement  or  solder. 


This  gives  rise  to  adhesions,  that  salutary  provision 
of  the  economy  for  walling  oS"  the  healthy  from  dis- 
eased tissue,  but  which  so  often  in  hernia  involves 
troublesome  complications,  though  plastic  operations  on 
the  peritoneum,  or  intestinal  jointing  would  be  im- 
possible without  it ;  the  rapid  transmutation  of  this 
plastic  exudate  into  solidly  organized  tissue,  has  no 
analogy  in  any  other  tissue  of  the  body.  The  plastic- 
ity and  effectiveness  of  the  peritoneal  secretion  or  exu- 
date depends  on  a  free  circulation  in  the  substratum  of 
its  endothelial  layers,  and  hence  the  reason,  that  helow 
the  point  of  constriction  in  the  sac  of  a  strangulated 
rupture,  although  there  is  commonly  a  considerable 
quantity  of  serous  efi'usion,  there  are  rarely  adhesions 
of  the  omentum  and  intestine  or  the  coils  themselves ; 
though  when  pressure  at  the  neck  of  the  sac  is  not  great 
or  the  stenosis  of  intestine  is  largely  dependent  on  a 
torsion  of  the  bowel  in  the  upper  segment  of  the  sac, 
the  hernial  contents  may  be  more  or  less  glued  to- 
gether. 

External  and  Internal  Strangulation. — The  fatal  defect 
in  the  older  operations  for  strangulation  was  largely 
dependent  on  the  erroneous  conclusion  that  all  the 
danger  attaching  to  this  state  emanated  from  the  im- 
prisoned intestine  outside  the  abdomen,  and  that  when 
the  constriction  was  released  and  the  protruding  loop 
was  pressed  up  inside  the  abdominal  cavity,  the  re- 
sources of  art  were  exhausted ;  when  fatalities  were  set 
down  as  due  to  "  shock  or  peritonitis." 

In  all  cases  of  strangulation  the  primary,  gross  lesion 
is  limited  to  the  parts  of  the  alimentary  canal  caught 
in  the  constriction  and  below  it.  But,  when  consider- 
able delay  is  permitted,  when  there  is  torsion  of  the 
bowel  and  a  large  segment  of  the  mesentery  is  carried 
down,  having  attachment  to  a  portion  of  the  gut  above, 
this  may  sufler  from  the  effects  of  ischemia  equally 
with  that  projected  outwards;  therefore  why  so  often 
symptoms  of  strangulation  persisted  after  the  ring  of 
constriction  had  been  freely  divided,  and  an  ap- 
parently healthy  intestine  had  been  reduced ;  coils  of 
intestine  above  were  matted  together,  were  palsied  and 
partly  asphyxiated  or  on  the  verge  of  gangrenous  per- 
foration. But,  unsurgical  methods  in  the  absence  of 
better,  in  dealing  with  external  strangulation,  were  the 
most  fruitful  source  of  the  harrowing  mortality  after  the 
antiquated  kelotomy  of  the  past ;  as  now,  at  times  ;  and 
what  had  been  an  external  strangulation  was  soon  con- 
verted into  an  internal,  which  became  a  grave  post- 
operative lesion. 

Simple  external  strangulation,  dealt  with  promptly 
by  skilled  hands,  has  a  low  mortality,  if  any  at  all  in 
healthy  individuals.  On  the  contrary,  the  jiost-operative 
or  internnl  is  a  state  of  great  gravity,  quickly  fatal  very 
frequently  in  spite  of  all  resources  of  modern  surgery. 

In  internal  or  post-operative  consecutive  strangulation, 
when  the  element  of  collapse  is  absent,  "  toxine  absorp- 
tion or  enteric  paresis  "  are  often  makeshifts  which  will 
not  explain  its  mortality.  Delayed  or  incomplete  sur- 
gical treatment  in  a  larger  measure  than  any  other 
agency  explains  the  former  heavy  death-rate  in  these 
cases  resulting  from  incomplete  reduction  of  the  hernia, 
or  the  forcing  up,  into  the  abdomen  of  kinked,  adher- 
ent, asphyxiated  or  gangrenous  coils  of  intestine.  Mr. 
Frederick  Treves  gives  us  a  graphic  and  faithful  descrip- 
tion of  some  of  these  post  operative  complications,  in  a 
recent  contribution.  After  reduction,  he  says :  "  In  the 
first  place,  the  gut  may  lie  in  the  abdomen  hors  de  com- 
bat, so  damaged  that  its  coats  are  quite  inert ;  it  is  an 


522 


The  PHTUDElPHIi"! 
ilZDICAL  JorBXAI,  J 


STRANGULATED  AND  GANGRENOUS  HERNIA 


[Mabcb  16,  1901 


irritant  to  the  peritoneal  nerves,  it  interrupts  peristalsis 
and  acts  as  an  obstructing  agent,  as  would  a  piece  of 
rubber  tubing  introduced  in  the  line  of  the  living  intes- 
tine. .  .  .  Perhaps  a  laparotomy  is  performed  and 
nothing  is  found  to  account  for  the  persisting  symp- 
toms, and  nothing  abnormal  save  the  listless  dead  or 
dying  loop  of  ititestine."  He  adds,  that  Mr.  Potts  re- 
cords two  cases  in  which,  after  reduction,  he  performed 
laparotomy  for  persisting  symptoms  and  found  no  cause 
save  that  presented  by  the  free  but  listless  coils  that 
had  been  treated  too  late. 

From  the  testimony  of  this  noted  authority,  as  above 
stated,  those  lives  were  lost  not  only  by  delay,  but  also 
because  a  crippled  hernia,  an  asjjhyxiated,  a,' '•  desid  or 
dying"  intestinal  loop,  supersaturated  with  septic  elements, 
was  carried  up  into  the  abdomen,  which  should  have 
been  freely  resected,  and  nothing  but  freely  vascular  and 
highly  animated  parts  reduced.  This  would  have 
obviated  internal  mortal  strangulation. 

Southam,  in  1S91,  published  the  statistics  in  85 
cases  keletomized  for  strangulated  hernia.  There  were 
but  27  deaths.  In  16  of  these,  postmortevi  examination 
was  made.  In  4  the  bowel  was  found  to  be  the  seat  of 
gangrene ;  in  10  ulceration  and  perforation  had  taken 
place  at  the  site  of  constriction  ;  1  died  of  general  per- 
itonitis and  one  of  diabetic  coma.  Here  we  find  ample 
confirmation  of  the  view  taken  of  the  most  common 
cause  of  death  after  operation  for  the  relief  of  stran- 
gulation ;  that  it  frequently  results  from  preventable 
causes,  viz.,  the  return  to  the  abdomen  of  infected, 
diseased  segments  of  the  intestine  which  at  the  time  of 
operation  should  have  been  excluded  or  resected. 

Incomplete  Reduction  and  Atypical  Anatomical  Vari- 
eties.—Ineomj)\ete  reduction  may  occur  with  a  timid  or 
inexperienced  operator.  Some  years  ago  such  a  case 
was  recorded  by  myself,  in  which  I  was  called  to  see 
if  anything  could  be  done  for  a  young  man,  dying  3 
days  after  a  kelotomy  for  strangulation.  The  case  was 
reported  in  detail  in  "the  Xeic  York  Medical  Record  Mav 
1894. 

On  examination  it  was  found  that  the  unopened  sac 
and  contents  were  pushed  up  and  fixed  in  the  inguinal 
canal,  the  constriction  not  yet  divided.  Happily  the 
opening  of  the  sac  under  cocain  and  free  incision 
through  the  neck  promply  relieved  all  symptoms. 

Another  case  came  under  my  notice  on  autopsy  in 
which  a  middle  aged  man  died  on  the  dav  following 
kelotomy.  The  operator,  finding  on  exposure  of  the 
parts  nothing  save  an  apparently  adherent  epiplocele, 
di^-ided  the  stenosis,  leaving  the.  omentum  undisturbed. 
There  was  no  amelioration  in  the  symptoms,  thence 
on  to  death.  Freely  exposing  the  part  post  mortem,  a 
concealed  gangrenous  loop  of  intestine  was  found,  just 
protruding  through  the  ring  and  nearly  divided  bv  the 
tight  constriction,  undiscovered.  This  was  another 
example  of  ''shock  and  peritonitis."  In  the  old  davs 
of  blind  cutting  and  hasty  manipulation,  similar  cases 
were,  no  doubt,  not  uncommon. 

Van  Buren  Knott  has  collected  66  cases  of  peritoneal 
and  intestinal  hernia.  He  observes  that  in  all  cases  in 
which  the  tumor  is  of  an  unusual  situation  and  form, 
inconaplete  reduction  may  occur,  and,  unless  we  observe 
special  caution,  we  may  assume  reduction,  yet  strangu- 
lation remains.  In  all  this  class,  we  shouW  operate,  he 
says,  whether  they  are  strangulated  or  not.  In  this, 
certainly  all  surgeons  are  in  full  accord. 

A  complete  reduction  of  a  strangulated  intestinal  loop 
alu-ays  presupposes  a  complete  liberation  of  it  from  adhe- 


sions. In  a  strangulated,  old,  large,  incarcerated  hernia 
both  free  liberation  and  reduction  may  be  injudicious 
because  of  the  menace  to  the  vascular  supply  of  the 
bowel  in  its'  new  abode.  But  in  all  other  than  these 
exceptions,  in  old  people,  the  freest  possible  liberation 
of  the  intestine  is  essential  as  a  prerequisite  to  its 
reduction.  Robaix  and  Duplay  have  at  length  de- 
scribed the  complex  character  of  these  adhesions,  so 
often  formed  in  simple  irreducible  and  strangulated 
hernia.  Rather  than  risk  the  return  of  the  volvulus, 
we  should  resect  and  joint. 

In  hernia  en  bisac  we  will  often  discover  in  old, 
chronic  cases  of  the  irreducible  or  incarcerated,  that 
when  they  become  strangulated  they  are  a  most  com- 
plex and  difficult  class  to  deal  with  in  a  hurried  opera- 
tion. In  one  case  of  the  femoral  type  coming  under 
my  care,  the  patient  of  Dr.  John  Gillespie,  of  this 
city,  besides  a  small  protrusion  containing  a  short 
loop — a  Richter  hernia — there  was  an  old,  thick  sac, 
nearly  as  large  as  a  fetal  head,  containing  the  cecum 
and  several  loops  of  small  intestine,  not  only  deeply 
congested  and  bound  together  but  also  united  firmly  to 
the  base  and  walls  of  the  sac  by  organized  adhesions 
and  bridles  of  new  tissue.  In  this  case  the  ring  was 
freely  opened,  all  the  adhesions  removed  and  the  wan- 
dering coUs  returned.  Death  followed  on  the  third 
day,  the  symptoms  of  strangulation  remaining  unre- 
lieved, the  result  of  imperfect  surgical  methods.  In  the 
same  season,  the  winter  of  1893,  a  somewhat  similar 
case  of  strangulation  came  under  my  care  in  the  practice 
of  Dr.  John  Plunkett,  also  of  New  York.  The  case  was 
one  of  strangulation  of  a  large,  old  exomphocele  with- 
out a  true  peritoneal  investment,  in  a  woman  of  60,  in 
deep  collapse.  Here  a  free  liberation  of  the  adhesions 
at  the  ring  was  all  that  was  ventured  ;  a  free  drainage 
provided  for  the  escape  of  peccant  fluids  and  a  loose 
dressing  applied.  Immediate  relief  of  symptoms  fol- 
lowed. 

These  two  cases  illustrate  a  large  class  of  adherent 
hernia  in  strangulation,  in  which  consecutive  or  post- 
operative symptoms  of  a  grave  character  may  be  usually 
entirely  obviated  by  limiting  our  intervention  to  intestinal 
liberation  and  in  no  manner  disturbing  widespread  ad- 
hesions through  which,  now.  the  intestine  derives  its 
nutritive  supply,  in  its  ilew  abode.  However,  in  young 
subjects,  invalided  by  their  infirmity,  a  resection  of  the 
omentum  and  intestine  is  a  justifiable  means  of  core. 

PART  III. 
Symptomatology. 

One  of  the  most  prolific  causes  of  dangerous  changes 
in  strangulated  hernia  is  a  tardy  recognition  of  it ;  as 
there  are  no  pathognomonic  symptoms  of  this  condi- 
tion, and  no  features  of  a  clinical  character  which  dis- 
tinguish internal  enteric  obstruction  from  stenosis  of 
external  constriction  in  strangulation ;  nay.  more, 
acute  gastric,  hepatic  or  renal  colic  may  simulate  the 
agony  of  strangulation. 

Dr.  Gibson's  tables  on  this  subject  include  several 
desperate  cases  of  strangulation  in  advanced  pr^nancy, 
wherein  one  certainly  might  be  led  to  confound  or  mis- 
take the  hernial  distress  for  labor-pains.  Many  a  prac- 
titioner is,  indeed,  quite  in  the  dark  when  he  first  sees 
one  of  these  case",  until  the  patient  calls  his  attention 
to  a  "  sore  lump  "  at  the  navel  or  groin. 

I  have  seen  an  aged  lady  in  the  moribund  state  froni 


Masch  16,  1901] 


STRANGULATED  AND  GANGRENOUS  HERNIA 


r?as  Philadelphia  c05 

Uedical  Jouesal  vi'^ 


an  unrelieved,  strangulated  umbilical  hernia,  who  was 
supposed  to  be  suffering  from  "  gastritis." 

In  those  advanced  in  years,  and  notably  in  females, 
there  may  be  an  absence  of  symptoms  or  they  may  be 
of  a  complex  character.  Mr.  Carle,  of  Lyons,  notes  an 
interesting  case  of  this  kind  in  a  man  of  72  years,  with 
no  redoubtable  symptoms,  and  yet,  on  exposure  of  the 
hernial  tumor,  a  gangrenous  patch  of  the  cecum  was 
found  requiring  resection,  the  size  of  a  five-franc  piece. 
A  huge  abscess  had  formed  and  from  this  a  ball  of 
feces  as  large  as  a  hazelnut  escaped.  This  indefinite 
symptomatology  in  strangulation  also  applies  to  its 
complications.  Thus,  in  a  recent  case  of  gangrene  of  19 
inches  of  gut  requiring  resection,  in  my  service  at  Har- 
lem Hospital,  the  patient  had  no  vomiting  whatever. 
In  another  case  seen  by  me  in  Dr.  George  V.  Hahn's 
practice,  in  the  aged  father  of  a  physician,  the  patient 
had  no  pain  ;  but,  recurring  fecal  vomiting  led  to  a  search 
for  rupture,  when  a  small  inguinal  hernia  was  found 
strangulated — Richter's.  On  division  of  the  parts,  a 
fecal  abscess  with  a  rotten  intestine  was  found.  In  the 
greater  number,  acute  constipation  with  violent  colicky 
pains  and  vomiting  lead  us  to  suspect  strangulation. 

Diagnosis. — An  early  and  accurate  diagnosis  is  as 
important  in  strangulation  as  rational  and  definite 
therapy ;  and  what  leads  up  to  this  in  a  larger  degree 
than  any  other  aid,  is  a  searching  investigation  into  the 
history  of  the  case  and  a  careful  examination  of  the 
abdominal  portals.  Hernial  tumors  are  seldom  pain- 
ful, hence  the  patient  deceives  himself  and  others,  not 
infrequently.  For  this  reason,  we  must  accept  with 
reserve  any  statement  of  the  patient  not  confirmed  by 
a  physical  examination.  Occasionally,  we  will  en- 
counter tumors  in  the  groin,  so  similar  to  hernia  that 
nothing  less  than  an  examination  through  an  incision 
will  reveal  their  true  character.  I  have  seen  a  young 
man  who  had  a  strangulated  hernia  which  was  opened 
by  the  scalpel  under  the  mistaken  impression  that  it 
was  a  bubo.  This  mistake  cost  the  poor  fellow  his  life. 
In  another  instance  I  was  called  to  the  hospital  to 
operate  for  "  acute  internal  obstruction "  in  a  young 
woman.  She  was  in  deep  collapse  and  everything  was 
in  readiness  for  a  laparotomy  when  I  arrived.  A 
strangulated  femoral  hernia  was  easily  made  out ;  but 
she  assured  me  she  had  the  fulness  from  childhood 
and  that  a  physician  had  informed  her  that  it  con- 
sisted of  enlarged  glands.  A  kelotomy  under  cocain 
saved  her  life. 

Certainly,  we  may  have  inguinal  adenitis  or  abscess 
with  a  strangulation,  as  we  may  also  have  neoplasmata 
— hydrocele,  spermatocele,  etc.  In  a  case  of  a  mixed 
character  with  complex  symptoms,  diagnosis  should  be 
definitely  determined  when  urgent  symptoms  are  pres- 
ent, by  an  exploratory  incision. 

In  gangrenous  strangulation  with  perforation  of  the 
intestine,  lasting  over  several  hours,  there  is  certain  to 
be  diffuse  cellulitis  which  may  be  accompanied  with 
an  extensive  edema  of  the  parts,  purulent  infiltration, 
and  a  pointing  over  the  tumefaction  with  a  gangrenous 
plaque  of  the  integument  on  the  point  of  giving  way ; 
in  fact,  the  parts  present  all  the  common  characters  of 
a  huge  abscess.  We  can  always  readily  differentiate 
here,  if  we  take  the  precaution  to  carefully  percuss  the 
tumors,  as  invariably  in  gangrenous  hernia  we  have  an 
infiltrated  loop  of  intestine  which  emits  a  tympanitic 
note. 

In  the  femoral  hernia  of  the  female,  with  a  large 
adipose  development,  the  projecting  knuckle  of  intes- 


tine may  be  so  small  and  so  deep  seated  that  it  will 
elude  detection  in  many  cases,  unless  a  most  painstak- 
ing examination  is  made  when  the  first  symptoms  of 
abdominal  colic  set  in.  In  those  advanced  in  years, 
devoid  of  acute  sensation,  any  sudden,  violent  disturb- 
ance of  digestion  attended  with  colic  should  lead  us  to 
suspect  strangulation. 

Treatment  of  Strangulation ;  Palliative  and  Radical. — 
In  simple,  reducible,  congenital  or  acquired  liernia  the 
natural  tendency  in  nearly  all  types  is  towards  spon- 
taneous return  to  the  abdomen,  or  with  but  moderate 
mechanical  aid.  The  same  holds  true  in  a  considerable 
number  of  cases  of  strangulated.  A  loop  of  intestine 
is  suddenly  thrust  out  of  the  abdomen  and  tightly 
caught  by  parts  acted  on  by  muscles.  The  whole  in- 
testinal canal  is  immediately  thrown  into  violent, 
tumultuous  contractions  with  convulsive  agony  and 
great  depression  of  the  vital  powers,  the  whole  physical 
equilibrium  has  sustained  a  violent  shock.  Now,  if  the 
patient  be  placed  on  a  comfortable  couch  and  given  a 
small  dose  of  morphine  hypodermically  and  left  severely 
quiet,  with  free  warmth  to  the  body  until  immediate 
agitation  passes  off — say,  for  from  two  to  six  hours — in 
all  other  than  exceptional  cases  moderate  taxis  wiU 
effect  reduction  in  a  large  number  ;  many  will  reduce 
themselves.  But  immediate,  repeated  and  forcible 
taxis  is  disastrous  in  a  large  number  and  frequently 
fails.  I  have  seen  a  case  that  resisted  violent  and 
repeated  taxis,  which  was  sent  to  the  hospital  for 
operation,  and  which,  after  a  small  opiate  and  a  few 
hours  rest  disappeared  of  itself,  and  again  others  after 
anesthesia  return  with  the  greatest  ease,  on  taxis.  Some, 
surely  enough,  had  disappeared  to  the  chagrin  of  the 
operator  before  they  were  brought  to  the  table.  The 
relief  of  intestinal  and  muscular  spasm  should,  there- 
fore, be  our  primary  aim  ;  then,  after  reaction  has  set  in, 
we  may  try  taxis  if  operation  is  refused.  Some  cases 
of  strangulation,  however,  are  quickly  mortal  if  not 
operated  without  any  delay  whatever,  and  even  then 
thej^  may  not  rally  from  shock  and  sink.  An  example 
of  this  lethal  type  I  recently  saw  in  a  young  man 
seized  with  strangulation  on  the  sidewalk  on  his  way 
from  dinner.  His  agony  was  so  great  that  he  had  to 
sit  on  a  step  until  an  ambulance  was  called.  He  was 
operated  the  same  day  at  5  o'clock  and  died  before 
midnight.  Deepening  shock  and  fecal  vomiting  call 
for  immediate  operation.  Local  application  of  ether  or 
ice  on  the  seat  of  the  strangulation  are  expedients  of 
doubtful  efficacy.  They  are  supposed  to  overcome 
spasm  and  subdue  inflammatory  changes,  but  they 
depress  the  circulation  and  endanger  the  vitality  of  the 
intestine ;  they  are  really  makeshifts  of  the  incompetent. 
Inversion  of  the  body,  large  clysters  and  violent  force 
applied  over  the  hernia  are  brutal  and  barbarous 
measures,  the  relics  of  ancient  surgery  which  cannot 
now  be  permitted  under  any  circumstances  whatever. 

Our  responsibility  with  this  accident  is  always  great, 
and  hence,  in  order  to  proceed  with  that  course  the 
most  advantageous  to  our  patient,  we  should  resort  to 
those  expedients  which  have  been  well  proven  to  be 
the  safest  as  a  general  rule.  And  here,  we  must  turn 
to  operative  surgery  early  or  not  at  all.  No  reputable 
surgeon  should  attempt  operation  on  the  moribund 
sent  in,  in  his  dying  moments,  by  the  practitioner.  He 
should  simply  do  his  duty  and  leave  the  case  in  the 
coroner's  hands. 

Kelotomy  and  Laparotomy. — The  modern  operation  for 
strangulation  is  essentiallv  a  new  creation,  based  on 


524 


Thb  Prrrr.  a  pwt  .pttt  a  H 
ICSDICAI.  JOUKNAL  J 


STRA.NGULA.TED  AND  GANGRENOUS  HERNIA 


[Mascb  16,  1901 


scientific  knowledge  and  extraordinary  advances,  espe- 
cially in  the  art  of  intestinal  surgerj-.  It  aims  not 
only  at  relieving  the  constriction,  but  also  at  repairing  the 
damaged  intestine  and  permanently  curing  the  hernia. 

Preparation  of  the  Patient. — The  room  chosen  to 
operate  in  should  be  thoroughly  cleansed,  well  lighted 
and  warmed.  Besides  the  anesthetizer,  the  operator 
needs  at  least  two  capable  assistants.  It  is  needless  to 
say  that  the  most  scrupulous  antisepsis  must  be  em- 
ployed and  every  possible  complication  provided  for 
before  the  first  incision  is  made. 

In  exceptional,  unusual  cases,  attended  with  pro- 
found collapse,  wherein  we  venture  only  to  quickly 
relieve  the  constriction,  cocaine  analgesia  can  be  sub- 
stituted for  pulmonary  anesthetics,  greatly  to  the  advan- 
tage of  the  patient,  or  we  may  cocainize  up  to  the 
division  of  the  stricture  and  then  continue  with  pul- 
monary anesthesia. 

It  is  important  to  remember  that  in  most  cases, 
immediately  on  liberation  of  the  intestine  the  most 
alarming  symptoms  pass  ofiF.  Dr.  Lewis  {Columbus 
Medical  Journal,  1884,  p.  156)  records  an  illustrative 
example  of  this  in  a  case  of  inguinal  strangulation. 
The  patient,  he  says,  "  was  delirious,  wearing  the  ex- 
pression of  great  pain  and  anxiety  so  commonly  noted 
in  advanced  cases ;  all  of  which  disappeared  on  open- 
ing the  sac  and  dividing  the  ring." 

Inasmuch,  however,  as  troublesome  complications 
accompany  the  most  of  these  cases,  and  much  time 
will  be  consumed  in  making  a  complete  operation, 
we  should  have  a  pulmonary  anesthetic  at  hand. 

A  preliminary  irrigation  of  the  stomach  provides  us 
greater  security  against  the  inspiration  of  vomited  fluids 
of  a  septic  character ;  but  I  believe  that  this  is  a  rare 
accident,  and,  moreover,  free  gastric  irrigation  with  a 
patient  bordering  on  the  moribund  state  is  by  no  means 
a  simple  or  safe  procedure.  The  patient  should  be 
catheterized  and  given  an  enema  as  large  and  hot  as 
can  be  borne,  before  the  operation  is  begun. 

Technic  in  Operating. — Anything  like  hasty,  hap- 
hazard operating  on  parts  within  the  peritoneal  mem- 
brane is  to  be  deprecated,  while  on  the  other  hand, 
unduly  prolonged  anesthesia  greatly  depresses  the 
vital  powers ;  besides  awkward,  unskilful  or  long  exposure 
of  the  peritoneum  tends  to  deepen  shock  and  paralyze 
the  intestine. 

It  is,  therefore,  presupposed  that  one  properly 
equipped  to  operate  for  strangulated  hernia  has  mas- 
tered the  technic  of  intestinal  surgerj-,  by  practice  on 
the  cadaver,  or,  what  is  much  better,  by  experimenta- 
tion on  the  anesthetized  animal. 

Everything  in  readiness,  we  begin  by  making  a  long, 
free  incision  passing  down  over  the  tumor,  in  an  oblique 
direction.  This  cut  should  begin  from  3  to  4  inches 
above  the  internal  ring  in  inguinal  hernia.  It  should 
extend  far  enough  down  to  permit  easy  manipulation 
of  the  sac.  McBurney's  advice  to  commence  the  deep 
dissection  close  to  the  neck  of  the  sac  and  work  down- 
ward, is  a  good  one.  When  the  general  condition 
warrants  it,  the  whole  distended  sac  should  be  isolated 
and  turned  out  before  it  is  opened.  This  is  usually  a 
rapid  and  simple  procedure.  We  now  come  to  dealing 
with  the  structures  after  opening  the  sac.  In  several 
cases  I  have  found  that  the  constriction  was  not  so 
tight,  but  the  trouble  rather  depended  on  torsion  of  the 
bowel ;  though,  again,  we  may  sometimes  find  the 
constriction  so  extreme  as  to  more  or  less  completely 
cut  through  one  or  both  coils ;  in  some  cases  we  will 


find  that  the  pressure  has  been  so  great  as  to  quite 
freely  induce  an  annular  erosion  through  the  fibro- 
serous  coat,  or  even  open  the  intestine.  The  division 
of  the  constriction  should  always  be  from  without  in, 
freely  exposing  this  to  the  naked  eye.  There  should 
be  no  more  moping  and  cutting  blindly  with  so-called 
"hernia-bistouries."  All  the  divided  vessels  should  be 
separately  secured  and  ligated  until  the  peritoneum 
comes  into  view,  when  the  inner  aperture — miscalled  a 
"  ring  " — is  divided  with  a  blunt-pointed  scissors.  We 
now  lay  the  neck  of  the  sac  widely  open  and  draw  the 
intestine  well  out  and  critically  examine  it.  If  there  are 
any  adhesions,  they  should  be  freely  liberated ;  then,  if 
the  intestine  possess  full  vitality,  it  should  be  care- 
fully pressed  up  into  the  abdomen,  the  sac  cut  away, 
and  a  radical  cure  superadded,  the  latter  prolonging  the 
operation  but  a  few  moments  and  accomplishing  the 
double  purpose  of  relieving  the  strangulation  and 
obliterating  the  hernia. 

The  second  step  of  the  technic  for  radical  cure 
should  be  as  simple  as  possible,  as  it  appears  from 
statistics  that  those  who  have  survived  the  operation 
for  strangulation  at  any  time,  have  rarely,  if  ever,  had 
hernia  again.  Ample  drainage  with  scrupulous  asep- 
tic precautions  will  usually  secure  prompt  union  in 
recent,  noncomplicated  cases. 

Laparotomy  Incision. — In  aU  cases  of  strangulation, 
in  order  that  we  may  ascertain  a  full  knowledge  of  the 
condition  of  the  intestine,  above  the  constriction,  or  in- 
ternal to  it,  besides  for  the  purpose  of  aiding  manipula- 
tion in  dealing  with  complications  and  rendering  re- 
duction easy,  the  scalpel  must  be  carried  freely  up 
through  the  ring  into  the  abdominal  wall.  Neglect  to 
more  freely  explore  in  former  times,  cost  the  lives  of  a 
large  number.  Mr.  Knaggs  impresses  the  importance 
of  completeness  in  operation  in  these,  and  records  two 
instances  within  his  own  observation,  in  which  failure 
resulted  through  neglect  to  examine  and  liberate  the 
upper  segment  of  the  intestine.  In  one,  gangrene  from 
volvulus  of  the  distal  coil  was  found  on  autopsy.  In 
another,  a  distended  unrelieved  loop  was  found  which 
remained  after  operation. 

A  large,  free  incision  has  been  avoided  heretofore  be- 
cause it  was  thought  to  augment  shock  and  favor  ventral 
hernia,  but  there  is  no  evidence  to  show  that,  when 
properly  closed  at  the  time  of  kelotomy,  it  is  responsi- 
ble for  either. 

Complicatiotis  and  Varieties  of  Strangulation  and  Their 
Ireatment. — The  great  mortality  following  kelotomy  in 
former  times  resulted  from  incomplete  operative  treat- 
ment in  complicated  cases ;  and  strangulated  hernia  at 
any  stage  may  be  complicated.  The  diminished  mor- 
tality of  our  time  comes  from  earlier  intervention  with 
aseptic  precautions  and  the  deliberate  and  precise 
management  of  complications.  As  an  evidence  of  re- 
duction of  mortality,  a  few  recent  statistics  may  be 
cited  from  recent  contributors. 

One  writer  has  collected  227  cases  of  strangulated 
hernia  operated  from  1861  to  1864,  giving  a  mortality 
of  75%.  Benno  Schmidt,  in  1883,  reported  that  at 
that  time  in  the  German  hospitals  there  was  36%  mor- 
tality. Tschering.  of  Copenhagen,  in  524  cases,  gives 
the  death-rate  as  29%.  Southam  and  Bolby.  in  1S95, 
in  the  London  hospitals,  found  that  mortality  ranged 
from  40  to  43%.  Borchard  and  Dagot,  of  France,  the 
former  17%,  the  latter  14%,  when  not  complicated. 
Borchard  sets  the  present  mortality  at  7%  after  kel- 
otomy for  strangulation.     Gussenhaur  said  that  anti- 


March  16,  1901] 


STR.^NGULATED  AND  GANGRENOUS  HERNIA 


FThe  Philadelphia 
L  Medical  Journal 


525 


septics  had  reduced  the  mortality  to  39%.  Hengeler, 
for  15  years  prior  to  1897,  collected  1,491  casges  of  kel- 
otomy,  mortality  16.5%.  I  am  sorry  to  say  that  no 
recent  statistics  under  this  head  are  published  in 
America,  as  I  am  confident  that  they  would  show  an 
average  of  less  than  5%  in  noncomplicated  cases.  In 
my  own  early  experience,  fully  75%  sank  after  opera- 
tion ;  now,  unless  the  patient  is  in  deep  collapse  at  the 
time  of  operation,  recovery  in  all  is  quite  the  invariable 
rule. 

Complications.  —  The  complications  attendant  on 
strangulation  are  constitutional  and  local. 

In  many,  especially  the  female,  they  are  of  an  alarm- 
ing character,  from  the  beginning ;  pain  is  agonizing, 
vomiting  is  incessant,  the  circulation  is  enfeebled  and 
great  exhaustion  sets  in  early.  In  others,  again,  stran- 
gulation runs  into  gangrene  or  even  perforation  with- 
out any  violent  disturbances  of  the  system,  until  late. 

General  Condition. — The  sudden  and  complete  occlu- 
sion of  the  intestinal  canal  usually  produces  profound 
disturbances  of  the  system  ;  but  fortunately  in  stran- 
gulated hernia,  the  obstruction  is  seldom  immediate  or 
total ;  when  it  is,  mortal  changes  set  in  early. 

The  patient  is  first  seized  with  agonizing  pain  over 
the  abdomen,  vomiting  begins,  the  pulse  quickens  and  is 
weak,  signs  of  prostration  set  in  early,  the  extremities 
become  cold  and  damp.  As  the  condition  continues, 
reverse  of  peristalsis  sets  in  and  fecal  vomiting  com- 
mences, with  great  thirst ;  the  tongue  is  livid,  dry  and 
crusted  and  the  gums  besmeared  with  sordes.  The 
patient  lies  on  his  back,  in  deep  melancholy  or  in  a 
state  of  indifference. 

To  the  inexperienced,  many  of  these  cases  at  first 
sight  strike  one  as  past  any  hope  of  relief  or  in  no  con- 
dition to  warrant  radical  surgery.  But  I  am  acquainted 
with  no  serious  condition  that  is  so  susceptible  of  eS"ec- 
tive  and  prompt  remedy  by  judicious  operative  inter- 
vention, provided  only  that  the  pulse  is  regular  and 
can  be  felt  at  the  wrist.  In  extreme  cases  their  trans- 
port to  hospital  by  any  sort  of  conveyance  is  a  trying 
ordeal  which  greatly  augments  their  exhausted  state. 

Pain  has  greatly  enfeebled  the  heart,  fecal  toxemia 
is  in  operation,  and  the  task  before  us  is  to  release  the 
intestine  and  restore  the  free  movement  of  the  intestinal 
current  without  augmenting  shock. 

Next  to  the  rough  transport  of  the  body  in  a  grave 
case  of  strangulation,  the  most  potent  cause  of  deepen- 
ing shock  is  full,  pulmonary  anesthesia.  With  a 
knowledge  of  these  facts,  it  therefore  behooves  us  to 
send  these  cases  into  hospital  early,  revive  the  sinking 
powers  by  very  warm,  large,  stimulating  enemata  and 
proceed  with  the  first  stages  of  the  operation  until  the 
intestine  is  fully  liberated,  under  ethyl  chlorid  and 
cocainization. 

The  fullest  measure  of  success  in  the  operative  treat- 
ment will  only  be  realized  when  special  remedial 
measures  are  primarily  directed  toward  combating 
grave  constitutional  conditions. 

Unrelieved  Strangulation  Leads  to  Local  Changes  and 
Lesions  in  the  Imprisoned  Intestine. — 1.  Deep  asphyxia 
or  incipient  gangrene.  2.  Plaques  of  gangrene  or 
ulceration  of  intestine.  3.  The  entire  circumference 
of  gut  may  be  mortified.  4.  Gangrenous  perforation 
with  fecal  extravasation  into  the  sac. 

Intestinal  Asphyxia. — What  is  the  most  embarrassing 
of  all,  is  that  comparatively  large  class  of  cases  in  which 
we  are  in  doubt  as  to  the  vitality  of  the  intestine.  It 
is  of  a   deep   brown   chocolate   color,   congested    and 


thickened  ;  it  has  a  leathery  feel  and  seems  to  be  devoid 
of  circulation.  The  application  of  very  warm  water 
fails  to  elicit  any  positive  evidence  of  circulatory  stabil- 
ity. The  gut  is  not  healthy  nor  is  it  dead ;  but,  as 
Treves  says,  is  hors  de  combat,  or  rather,  "  knocked  out." 
It  is  in  a  state  of  deep  asphyxia  and  may  recover  its 
full  functions,  or  may  not.  The  intestine  is  in  a  state 
of  impending  gangrene,  or  is  rather  in  the  incipient 
stages  of  mortification.  Jordon  Lloyd  well  observes  in 
this  connection,  that  "  the  recognition  of  gangrene  in  a 
coil  of  intestine  lying  before  us  in  an  open  sac  is  not 
always  an  easy  matter.  Few  surgical  complications 
are  more  perplexing  than  that  of  determing  whether  a 
coil  of  gut  shall  be  returned  to  the  abdomen  or  be 
treated  where  it  lies.  No  judgment  can  be  formed 
merely  by  the  color  of  the  coils,  nor  can  any  analogy 
be  drawn  from  one's  experience  of  gangrene  of  the 
outer  surface  of  the  body." 

But  we  certainly  cannot  agree  with  this  eminent  sur- 
geon when  he  continues  and  adds  that,  "  the  same 
amount  of  functional  disturbance  in  the  nutrition  of  an 
external  part,  as  a  finger  or  toe,  for  example,  which 
necessarily  will  be  followed  by  local  death  and  putre- 
faction, may  be  entirely  recovered  from  in  the  case  of 
the  intestine,  if  the  cause  of  the  disturbance  be  removed 
and  the  gut  be  returned  to  the  peritoneal  cavity  under 
aseptic  precautions." 

We  cannot  remove  the  cause  by  the  reduction  of  a 
mortally  asphyxiated  coil  of  gut,  and  function  never 
returns  to  mortified  tissues  in  any  part  of  the  body. 
The  damaged  intestine  certainly  does  possess  most  re- 
markable properties  in  the  way  of  spontaneous  repair ; 
but  to  return  a  strictured,  crippled,  dying  or  dead  in- 
testine, a  foreign  body,  a  septic  structure  into  the  peri- 
toneal cavity  is  certainly  to  invite  disaster.  And  there- 
fore, we  regard  the  advice  of  Mr.  Carwardine  as  cer- 
tainly not  en  rapport  with  modern  rational  treatment, 
when  he  says,  in  speaking  of  these  doubtful  cases, 
"  When  in  doubt  in  strangulation,  the  belly  is  the  best 
place  for  the  gut." 

There  can  be  no  question  but  resuscitation  may  occur 
in  rare  cases,  that  gangrenous  patches  may  become  in- 
nocuous by  adhesions,  that  spontaneous  anastomosis 
may  occur,  or,  what  is  more  remarkable  yet,  the  dead 
segment  of  gut  may  find  its  way  out  through  the  anus. 

What  then  should  be  our  line  of  action  in  this  class 
of  doubtful  cases '?  Clearly,  with  our  knowledge  of  the 
physiology  of  the  alimentary  canal,  that  large  segments 
of  it  may  be  removed  with  perfect  impunity,  we  need 
not  hesitate  to  amputate  the  suspicious  part.  And  now 
that  the  technic  of  resection  and  jointing  have  become 
au  courant  procedures  there  should  be  no  hesitation  as 
to  our  decision.  Only  one  thing  will  at  all  justify  the 
return  of  a  suspicious  coil  into  the  peritoneal  cavity ; 
and  that  will  be  lack  of  skill,  or  want  of  a  practical 
knowledge  of  intestinal  surgery,  assuming  of  course,  that 
the  general  condition  warrants  it. 

Localized  Patches  of  Ecchymosis,  Abrasions,  Contusions, 
or  Gangrene  of  the  Intestine. — In  nearly  all  cases,  which 
a  surgeon  is  called  on  to  operate  for  strangulated  hernia, 
the  patient  has  been  subjected  to  repeated  and  per- 
chance violent  taxis  before  he  sees  the  case.  Many  are 
only  sent  to  the  hospital  when  they  are  close  to  the 
moribund  state.  Happily  these  are  much  less  frequently 
seen  now  than  20  years  ago.  In  all  these,  with  few  ex- 
ceptions, we  will  find  the  bowel  more  or  less  trauma- 
tized. 

Deqj  Congestion  or  Incipient  Gangrene. — In  all  cases  of 


626 


The  Philadeuhia"! 
Medical  Jooknal  J 


PERCENTAGE  AND  LABORATORY  FEEDING 


[Ma«ch  16,  19W. 


acute  hernial  strangulation,  there  promptly  sets .  in 
simultaneously,  a  double  stasis ;  first,  of  the  fecal  cur- 
rent, and  second,  of  the  circulation.  In  the  first,  tem- 
porary' intestinal  exclusion  is  induced,  a  condition 
which  of  itself,  if  not  protracted,  is  not  a  serious 
accident;  its  lethal  influence  only  becomes  obvious 
when  the  obstruction  is  maintained,  when  decom- 
position of  the  imprisoned,  stagnant,  alimentary  con- 
tents begins,  when  an  excess  of  gas  is  liberated  and 
a  fresh  strain  is  put  on  the  intestine  from  below.  Actual 
intestinal  asphyxia,  or  gangrene,  can  be  said  to  only 
begin  when  vascular  stasis  is  established  ;  when  the 
arterial  feeders  yet  send  the  blood  into  the  capillaries, 
but  the  efferent  vessels  are  hopelessly  obstructed  ;  a  con- 
dition gradually  extending  in  a  retrograde  direction, 
and  later  inducing  a  general  thrombosis  of  all  the 
mesenteric  radicles.  When  this  stage  is  reached  incipi- 
ent gangrene  is  in  operation,  now  in  the  presence  of  this 
condition  in  which  the  intestine  is  not  completely  killed, 
in  which  the  gut  is  not  dead,  not  mortified,  and  yet  not 
sufficiently  vitalized  to  functionate  with  certainty, 
should  we,  if  in  doubt,  adopt  the  current  custom  and 
return  it  to  the  peritoneal  cavity  after  complete  relief 
of  the  strangulation?  In  this  connection  it  may  be 
well  to  note  that  in  consequence  of  the  complete  and 
double  stenosis  of  the  intestinal  and  vascular  canals, 
decomposition  has  begun,  and  the  exuded  serum  in  the 
sac  emits  an  odor  which  assures  us  that  the  bacterium 
termo  has  commenced  the  work  of  decomposition  and 
the  extruded  loop  is  septic ;  it  is  certainly  temporarily 
crippled  and  functionless. 

This  is  one  of  the  most  numerous  class  of  cases  in 
the  past,  which  led  to  the  appalling  mortality  ;  and 
what,  indeed,  can  warrant  or  justify  the  practice  of 
forcing  these  dead  or  dying  structures  up  into  the 
healthy  peritoneal  cavity  seems  beyond  comprehension. 

Immediate  Resection. — In  these  dubious  cases,  the  gen- 
eral condition  of  the  patient  permitting  it,  there  is  but 
one  course  to  pursue ;  and  that  is  an  immediate  and 
complete  resection  of  the  suspected  loop,  whether  it  be 
an  inch  or  a  yard  in  length,  with  simultaneous  jointing 
of  the  divided  ends.  This  course  is  simple,  rational, 
and  safe  in  skilled  hands  and  a  proper  environment. 

Intestinal  Paralysis,  Intestinal  Toxemia,  etc. — In  Gib- 
son's recent  able  contribution  (Annals  of  Surgery,  Oc- 
tober and  November,  1900),  the  author  observes  that 
the  above  terms  "  are  usually  used  as  a  mask  for  peri- 
tonitis," the  functionless,  infected  coil,  with  its  wall  col- 
lapsed, its  musculature  without  tone,  its  mucous  mem- 
brane edematous  and  detached, and  its  fetid,  decomposed 
contents  transuding  through  its  destroyed  serosa,  lies 
doubled  up  as  a  block  in  the  path  of  the  alimentary 
canal,  infecting  and  spreading  widely  its  septic  ele- 
ments through  every  tissue  it  touches.  Experimental 
investigation  and  clinical  observation  conclusively 
prove  that  full  physiological  function  in  digestioii  may 
be  preserved  with  the  total  exclusion  of  a  full  third  of 
the  small  intestine ;  and,  moreover,  we  have  ample  evi- 
dence that  the  mortality  of  resection  is  in  no  manner 
dependent  on  the  extent  removed,  provided  it  does  not 
exceed  the  physiological  limit. 

Stricture,  Ukeration,  Hemorrhage,  and  Perforation  after 
lleductiun  of  Damaged  Intestine. — The  intestine  may 
suffer  serious  pathological  changes  and  yet  not  have 
advanced  to  gross  gangrenous  changes;  in  fact,  if  the 
mesentery  escape  very  great  compression,  without  a 
certain  inspection,  we  may  overlook  mottled  patches  or 
compressed  areas,  the  seat  of  subtle  but  positive  or- 


ganic changes.  At  the  point  of  compression  at  the 
inner  aperture  all  the  coats  of  the  intestine  may  have 
become  so  crushed  as  to  later  undergo  repair,  by  leav- 
ing a  cicatricial  contraction.  Persistent  diarrhea  from 
ulceration  of  a  compromised  loop  has  followed  with  a 
fatal  ending  in  some  cases  (Malgaigne).  Persistent  and 
fatal  hemorrhage  per  rectum  has,  too,  occurred  (Paget). 
In  one  of  my  own  cases  of  resection  the  intestine  was 
found  filled  with  coagulated  and  fluid  blood. 

Mr.  Kough  {London  Lancet,  1884,  p.  636,  vol.  ii) 
records  a- case  of  death  from  enteric  hemorrhage  two 
hours. after  reduction  of  the  intestine.  The  sac  con- 
tained six  feet  of  ileum  with  the  cecum.  On  autopsy, 
when  the  bowel  was  opened,  a  pint  of  fluid  blood 
escaped.  The  inner  surface  of  the  bowel  presented 
several  dark,  slate- colored  patches.  Death  from  ulcer- 
ative perforation  and  peritonitis  in  former  time  was  not 
an  infrequent  postoperative  sequela  in  kelotomy,  when 
the  intestine  of  "  doubtful "  vitality  was  reduced. 

Gangrene  of  the  Intestine. — W'hen  gangrenous  changes 
have  advanced  to  the  unequivocal  mortification  or  death 
of  the  extruded  loop,  whether  it  appear  in  patches,  in- 
volve the  entire  circumference  of  the  intestine,  or  has 
advanced  to  perforation,  the  part  involved  must  be 
isolated  from  the  peritoneum.  How  this  may  be  at- 
tained to  the  best  advantage  of  the  patient  embraces 
one  of  the  most  important  chapters  in  the  history  of 
intestinal  surgery. 

Twenty-five  years  ago  resection  for  gangrenous  hernia 
was  comparatively  unknown  as  a  practical  procedure, 
though  there  were  some  few  rare  cases  recorded  since 
the  seventeenth  centurj'.  At  that  time  and  until  later, 
there  was  only  one  alternative  in  cases  of  complications 
in  strangulation,  when  the  intestine  was  not  immedi- 
ately reduced,  which  was,  to  secure  it  to  the  groin  and 
make  an  artificial  anus. 

(To  be  continued.) 


PERCENTAGE  AND  LABORATORY  FEEDING.* 
By  J.  P.  CROZER  GRIFFITH,  M.D., 

Clinical  Professor  of  Diseases  of  Children  in  the  University  of  PennsylraniA, 
Pbiiadelpbia. 

It  is  safe  to  say  that  those  physicians  who  have 
once  accustomed  themselves  to  what  is  known  as  per- 
centage feeding,  will  never,  if  they  can  avoid  it,  use 
any  other  method.  Yet  considerable  misconception 
exists,  and  mistakes  often  arise  through  a  lack  of 
understanding  of  what  percentage  feeding  really  is.  and 
through  a  lack  of  the  easily  acquired  knowledge  of 
how  to  employ  the  method  properly. 

Let  us  contrast  for  a  moment  the  old  and  the  new, 
the  empirical  and  the  scientific  plans  of  feeding.  In 
the  old  way — the  excellent  way  which  we  all  followed 
with  more  or  less  success  until  we  had  a  better  plan — 
a  physician  thought  of  his  milk  mixture  as  consisting 
of  so  many  tablespoonfuls  of  milk,  so  many  of  cream, 
so  many  of  water,  and  so  on.  In  his  mind  he  had 
stored  up  a  certain  formula  of  this  kind  which  repre- 
sented what  he  considered  about  the  proper  food  for 
a  nursing  child.  A\'hy  we  used  this  or  another  formula, 
the  majority  of  us  scarcely  knew.  We  had  merely 
learned  it  empirically,  or  oftener  we  had  learned  from 
some  one  else's  experience  that  upon  this  formula  the 
majority  of  children  could  be  expected  to  thrive.  As 
the  babies  grew  older  some  of  us  often  increased  the 

»  Read  before  the  Philadelphia  County  Medical  Society,  May  lS,  1900. 


Habch  16,  1901] 


PERCENTAGE  AND  LABORATORY  FEEDING 


CThe  Philadelphia 
Medical  Journal 


527 


proportion  of  milk  or  cream  and  diminished  that  of 
water  in  an  absolutely  unscientific  way,  forgetting  that 
in  human  milk  no  such  alteration  occurs  as  time  goes 
on,  yet  realizing  that  this  change  was  sometimes  neces- 
sary in  our  milk  mixture.  The  real  reason  for  the 
change  we  did  not  understand,  and  too  many  of  us 
degenerated  into  the  condition  of  mere  manipulators  of 
quantities  by  rule-of-thumb  methods,  saying  to  our- 
selves that  at  one  week  we  would  put  so  many  table- 
spoonfuls  of  milk  in  the  mixture,  at  3  months  so  many 
more,  at  6  months  so  many  more,  and  so  on,  absolutely 
regardless  of  the  individuality  of  the  baby  or  its  actual 
needs. 

When  the  babies  did  not  thrive  upon  the  mixtures 
which  rules  said  they  should  have,  we  made  certain 
changes  which  again  experience  had  taught  to  be  useful 
in  illness,  but  the  reason  for  which  we  scarcely  under- 
stood. For  instance,  we  used  whey,  or  barley  water,  or 
egg  water  as  diluents  instead  of  water,  or  we  increased 
or  diminished  the  cream  or  the  milk  in  our  mixture. 
Some  of  us  were  guided  by  a  knowledge  that  curds  in 
the  stools  perhaps  suggested  too  much  milk,  sour  vom- 
iting perhaps  too  much  cr^am,  and  so  on,  but  this  was 
about  as  far  as  we  could  go.  In  fact,  it  was  impossible  to 
go  much  farther.  One  family  used  cream  of  one  strength 
from  one  sort  of  cow,  while  another  had  furnished 
them  cream  of  another  strength  from  another  breed  of 
cows.  There  was  no  certainty  that  the  cream  and  milk 
furnished  to  a  bab}'  did  not  vary  even  from  day  to  day. 
There  was  no  knowledge  of  or  control  over  the  purity 
of  the  dairy  product.  It  is  evident  that  all  a  physician 
could  do,  and  in  many  cases  still  can  do,  was  to  feel 
his  way  empirically,  shifting  numbers  of  tablespoonfuls 
up  and  down  as  seemed  to  him  best.  We  all  did  it. 
Most  of  us  do  it  yet.  Often  we  are  forced  to  do  so. 
But,  as  I  said,  any  one  who  has  used  the  newer  plan 
wants  always  to  avoid  this  older  one  because  the  newer 
is  so  much  more  satisfactory  in  its  results. 

Yet  studies  meantime  were  constantly  being  made 
by  scientific  investigators  into  the  relative  composition 
of  human  milk  and  cow's  milk,  and  all  these  results 
were  published  and  were  read  by  us  without,  it  would 
seem,  it  even  occurring  to  us  that,  since  the  results  of 
analyses  made  were  all  expressed  in  percentages  of  fat 
and  proteid,  solids,  salts,  water  and  sugar,  and  not  in 
quantities  of  milk  and  cream,  it  would  be  very  much 
easier  for  us  could  we  work  directly  with  the  decimal 
proportions  these  analytical  studies  had  given  us. 
This  simply  is  what  the  percentage  method  of  feeding 
is ;  the  transferring  of  scientific  analyses  to  practical 
feeding.  One  merely  learns  to  think  in  decimal  pro- 
portions instead  of  in  teaspoonfuls  or  ounces.  One 
says,  "  I  will  give  the  baby  such  a  percentage  of  fat  and 
such  of  proteids,"  instead  of  saying,  "  I  will  use  so 
much  of  milk  and  of  cream."  This  method  greatly 
simplifies  the  whole  process  as  well  as  making  feeding 
more  scientific  and  effectual.  In  the  old  way  we  might, 
for  instance,  have  concluded  that  a  child  needed  a 
richer  food,  but  that  it  could  not  digest  more  curd. 
If,  now,  we  added  more  cream  to  the  mixture,  we  were 
at  the  same  time  increasing  the  curd  strength  and  this 
we  did  not  want,  whereas  if  we  substituted  a  certain 
part  of  milk  by  cream,  we  could  in  no  way  tell  just 
what  effect  we  had  produced  upon  the  proportions  of 
the  ultimate  ingredients  of  the  mixture.  All  is  differ- 
ent if  we  think  and  work  in  percentages.  We  say  we 
will  increase  the  fat  in  the  mixture  from  3%  to  4%, 
but  leave  everything  else  unchanged — and  then  we  do 


it  accurately.  Now  should  the  mixture  disagree,  we 
know  exactly  what  is  wrong.  Surely,  the  advantages 
of  this  must  appeal  to  every  one.  Having  tried  both 
the  old  and  the  new,  I  can  assure  you  that  I  get  much 
better  practical  results  with  percentage  feeding. 

The  method  of  calculation  is  easy.  Any  one  with 
the  slightest  knowledge  of  figures  can  manage  it.  Sev- 
eral simple  methods  have  been  published.  One  bf  the 
most  convenient  and,  for  practical  purposes,  accurate, 
is  that  published  by  Dr.  Baner,  of  New  York.  I  carry 
his  few  equations  with  me,  written  on  a  card  and  kept 
in  my  pocket  book  in  case  I  should  forget  them.  Dr. 
Taylor,  of  New  York,  has  a  modification  of  Baner's 
which  is  more  accurate,  and  Dr.  Westcott,  of  Philadel- 
phia, has  still  another  method.  I  will  not  occupy  the 
time  of  the  Society  by  going  into  the  calculation.  The 
papers  of  these  writers  explain  it  very  clearly.  For 
those  physicians  who  would  rather  avoid  even  the  sim- 
ple calculations  convenient  tables  may  be  found  in  the 
text  books  of  Rotch  and  of  Holt,  showing  at  a  glance 
exactly  how  much  milk,  cream  and  sugar  are  required 
for  many  of  the  percentage  formuke  oftenest  used.  One 
can  readily  make  a  copy  of  these  and  have  it  always  at 
hand. 

But  to  work  in  percentages  it  is  necessary  to  have 
milk  and  cream  of  a  definite  percentage  strength,  and 
this  is  not  always  easy  to  obtain.  We  may,  however, 
assume  that  in  "ordering  herd  milk  the  percentages  of 
sugar  and  of  proteid  vary  very  little.  The  variable  in- 
gredient is  the  fat.  In  these  days  when  the  centrifuge 
for  the  examination  of  urine  has  become  so  cheap  and 
so  convenient,  it  is  very  easy  for  any  of  us  to  test  a  few 
times  the  fat  strength  of  "herd  milk  and  cream,  and 
then  to  calculate  a  formula  which  we  can  readily  modify 
according  to  the  needs  of  the  baby.  I  do  this  myself 
repeatedly  and  yet  am  devoid  of  special  knowledge  of 
chemistry  or  mathematics.  It  is  mere  mechanical 
work. 

Where  cream  and  milk  of  definite  guaranteed  strength 
can  be  obtained,  all  the  trouble  of  home  analysis  can  be 
saved,  and  where  a  milk  laboratory  is  accessible  the 
physician  may  be  spared  even  the  labor  of  a  calculation 
or  the  trouble  of  consulting  a  table. 

This  brings  us  to  the  consideration  of  the  milk  labor- 
atories as  managed  by  the  Walker-Gordon  Company  in 
various  of  our  larger  cities.  There  is  to  some  extent  a 
misconception  of  the  purpose  and  nature  of  these  in- 
stitutions. Some  have  even  imagined  that  a  sj)ecial 
sort  of  milk-food  is  prepared  there,  like  a  patented 
food;  and  others  talk  of  laboratory  milk  agreeing  or 
disagreeing  as  though  it  were  an  entity,  with  its  com- 
position always  the  same.  A  milk  laboratory  is  simply 
a  place  where  you  order  for  a  baby  anything  you  want 
in  the  way  of  a  food,  put  up  in  any  way  you  please. 
There  is  nothing  whatever  special  or  peculiar  about  it. 
The  milk  is  just  like  all  other  milk  except  that  unusual 
care  is  taken  to  have  it  clean  and  free  from  germs,  and 
that  its  strength  in  the  different  ingredients  is  deter- 
mined daily  by  analysis  and  is  guaranteed.  Such  milk 
and  cream  can  be  procured  by  families  at  little  above 
the  ordinary  rates,  and  the  milk  mixture  made  at  home 
by  the  mother  or  nurse  according  to  the  directions  of 
the  physician  and  according  to  the  formula  furnished 
by  him.  Such  guaranteed  milk  and  cream  can  be  ob- 
tained in  some  places  from  other  dairies  than  those  of 
the  Walker-Gordon  Company.  The  Philadelphia  Pedi- 
atric Society  is  looking  forward  to  a  near  future  when  it 
shall  have  completed  arrangements  by  which  guaran- 


528 


ThK  PHILADEt-PHIA"] 

Medical  Joornai.  J 


PERCENTAGE  AND  LABORATORY  FEEDING 


[Mabch  IC,  1901 


teed  milk  and  cream  can  be  obtained  from  many  dairies 
of  Philadelphia.* 

But  since  even  with  definite-strength  milk  and  cream 
the  calculation  of  a  formula  by  the  physician  is  neces- 
sary, with  a  milk  laboratory  handy  he  can  even,  as  I 
said,  save  himself  this,  and  the  mother  the  trouble  of 
preparing  the  food,  by  having  the  mixture  made  at  the 
laboratory,  put  into  the  different  feeding  bottles  there 
and  delivered  at  the  home  all  ready  for  use.  The  phy- 
sician in  this  case  must  write  a  prescription  ordering 
the  percentage  of  fat  and  of  jiroteid,  etc.,  and  specify 
how  many  bottles  are  to  be  supplied  and  how  many 
ounces  these  shall  contain.  Anything  you  please  may 
be  ordered  in  the  mixture.  Barley  water  or  oatmeal 
water,  malt  extract,  pancreatic  extract,  even  patented 
foods  if  you  wish.  It  is  the  laboratory's  business  to 
follow  your  directions  just  as  a  drug  store  would. 

There  has  been  some  little  talked  and  written  about 
the  milk  and  cream  of  the  laboratory  being  "  Separa- 
tor" products  and  therefore,  it  was  said,  inferior.  One 
should  not  forget  that  all  cream  from  large  dairies  is 
nowadays  separator  cream.  Milk-men  do  not  any  longer 
skim  with  spoons  and  hand  skimmers  and  the  like. 
The  triviality  of  such  an  objection  is  therefore  evident. 
Nevertheless,  if  you  want  skimmed  cream  from  the 
laboratory,  order  it  and  you  get  it. 

Finally,  it  is,  of  course,  necessary,  as  with  all  infant 
feeding,  to  know  what  to  expect  from  the  different  ingre- 
dients of  the  food,  and  to  acquire  by  actual  experience 
a  little  knowledge  of  the  proportions  which  a  baby  is 
liable  to  require,  and  what  changes  a  certain  baby  needs 
at  any  time. 

One  of  the  secrets,  if  we  may  call  it  this,  of  successful 
feeding  of  very  young  infants  is  to  begin  with  low  per- 
centages. Woman's  milk  contains:  Fat  4%,  proteids 
1  to  1^%,  and  sugar  7%.  Yet,  it  is  by  no  means  advis- 
able to  start  any  baby  upon  this  strength  of  a  milk  mix- 
ture. We  must  remember  that  we  are  not  dealing  with 
the  natural  food  of  the  child.  The  proteid  of  milk  is 
a  complex  substance  which  varies  in  different  animals. 
That  of  the  cow  is  distinctly  different  from  that  of  the 
woman.  It  is  unreasonable  to  expect,  then,  that  a  baby 
can  take  it  in  just  the  proportions  found  in  human 
milk.  This  is  the  mistake  which  some  physicians  have 
made  in  their  first  efforts  at  percentage  feeding. 

The  child  in  the  first  two  weeks  of  life  should  not  be 
started  with  over  .50%  proteids.  In  fact,  even  much 
later  in  the  first  year  it  is  wise  to  begin  percentage 
feeding  with  low  proteids  in  the  case  of  children  who 
have  been  fed  on  food  other  than  milk  or  who  have 
been  subjects  of  indigestion.  In  all  cases  where  we 
find  the  existence  of  diarrhea  with  numerous  curds  in 
the  stools,  it  is  well  to  consider  whether  the  proteids 
had  not  better  be  reduced  at  least  for  a  time,  although 
it  is  well  to  remember  in  this  connection  that  these  ap- 
pearances are  not  infrequently  composed  of  fat.  It  is 
the  proteid  element  which  is  the  hardest  for  most  chil- 
dren to  manage. 

Then  with  regard  to  the  percentage  of  fat.  Here,  too, 
it  is  well  to  begin  with  small  amounts — 2%,  perhaps, 
instead  of  the  normal  4%.  When  we  find  a  constant 
tendency  to  rancid  vomiting  it  is  very  probable  that  the 
fat  is  too  high  even  though  the  vomit  may  contain 
curds.  The  sugar  sometimes  acts  upon  the  bowels  and 
in  other  cases  causes  gastric  indigestion.  Less  than  the 
normal  7%  of  sugar  is  good,  then,  for  a  beginning — 
possibly  5  or  6%. 

*  since  lliis  jnper  was  written  four  dairies  of  tbe  vicinity  of  Philadelpliia  are 
receiving  ccrtiiicates  from  tlie  Piiiladelpiiiu  Pediatric  Society. 


For  a  very  young  baby,  therefore,  without  signs  of 
disease,  or  for  a  marantic  child  who  has  had  constant 
sj'mptoms  of  indigestion,  such  a  percentage  formula  as 
fat,  2%,  sugar,  ofo,  proteids,  .50%,  would  not  be  amiss. 
Of  course,  it  is  not  to  be  expected  that  this  weak  mix- 
ture will  answer  long.  It  must  soon  be  increased  and 
the  method  of  increase  will  depend  largely  on  circum- 
stances. Other  things  being  equal,  it  is  generally  my 
plan  first  to  increase  the  fat  by  steps  up  to  about  3%, 
then  the  proteids  to  .75  or  1  % ,  and  perhaps  meantime  the 
sugar  as  well,  watching  constantly  for  the  development 
of  any  unfavorable  symptoms  and  altering  the  formula 
according  to  the  nature  of  these.  Most  important  is  it 
to  weigh  the  child  weekly  or  semi  weekly.  If  increase 
in  weight  does  not  go  on  properly  in  spite  of  the  exist- 
ence of  no  symptoms  of  indigestion,  it  is  nearly  certain 
that  the  food  is  either  not  strong  enough  or  not  large 
enough  in  quantity.  On  the  other  hand,  we  must  re- 
member that  there  is  no  reason  to  increase  the  strength 
of  the  food  when  the  child  is  gaining  nicely.  There 
should  be  absolutely  no  rule  of  thumb  increase  of  the 
percentages  of  any  of  the  ingredients  dependent  upon 
age  alone.  It  is  the  condition  of  the  individual  child 
which  must  determine  this.  I  cannot  too  strongly  em- 
phasize this  point.  Your  rule  should  be,  "  Let  well 
enough  alone."  Of  course,  one  does  not  wait  for  actual 
failure  of  good  condition  to  develop.  But  a  little  ex- 
perience and  judgment  will  soon  teach  how  to  proceed 
in  most  cases.  One  must  remember,  too,  that  failure 
to  increase  in  weight  may  depend,  not  so  much  on 
trouble  with  the  percentage  formula,  as  upon  the  fact 
that  the  baby  needs  a  larger  quantity  of  nourishment. 
The  baby  at  the  breast,  although  it  does  not  get  stronger 
food,  takes  a  larger  quantitj'  as  it  gets  older. 

An  eminent  writer,  for  whose  knowledge  of  the  dis- 
eases of  children  I  have  much  respect,  has  recently  ex- 
pressed the  belief  that  children  raised  upon  milk  mix- 
tures furnished  by  a  laboratory  experienced  difficulty 
in  tolerating  an  increase  in  the  percentage  of  proteids. 
As  already  stated,  very  many  children  have  difficulty 
in  digesting  the  proteids  of  cow"s  milk  given  in  any 
way  whatever ;  and,  in  any  case,  before  these  are  in- 
creased we  should  be  sure  that  such  an  increase  is  really 
indicated.  That  there  should  be  any  such  special  dif- 
ficulty in  the  digestion  of  proteids  in  the  case  of 
laboratory  milk,  I  find  it  impossible  to  conceive.  My 
own  experience  is  in  accord  with  that  of  those  physicians 
who  have  used  milk  laboratories  very  extensively  in 
other  cities,  viz  :  that  there  is  no  special  difiiculty  in 
increasing  proteids  or  any  other  ingredients  of  labora- 
tory milk  mixtures  more  than  with  any  other  milk. 
That  laboratory  milk  offers  any  especial  difficulties 
seems  to  me  to  be  an  assumption  lacking  proof 

Of  course  idiosyncrasies  of  all  sorts  exist  and  all 
sorts  of  changes  have  to  be  made  and  expedients  used 
in  infant  feeding,  as  we  all  know,  but  these  are  excep- 
tions and  not  the  rule.  I  once  knew  a  baby  who 
thrived  only  after  its  mother  fed  it  exclusively  on  corn- 
meal  mush.  But  this  could  hardly  be  our  guide  in 
practice. 

After  all,  before  we  can  come  to  any  conclusion  that 
percentage  feeding  or  any  other  feeding  is  not  succeed- 
ing in  a  given  case,  we  must  be  sure  that  the  error  is 
not  with  our  own  formula  or  method.  The  following 
case  illustrates  my  meaning  : 

I  was  called  to  see  a  baby  in  consultation  with  a 
well  known  and  able  obstetrician  of  this  city,  who 
frankly  acknowledged  thaf  the  feeding  of  such  a  case 


MaBCII  16,  19011 


PERCENTAGE  AND  LABORATORY  FEEDING 


CThe  Philadelphia 
Medical  Jodrsal 


529 


was  out  of  his  line  and  asked  me  to  take  it  in  charge. 
The  history  is  as  follows : 

F.  W.,  born  June  16,  1899.  He  weighed  over  9  pounds  at 
birtii.  Feedins?  had  always  been  difficult.  He  had  had 
malted  milk  aiid  peptonized  milk,  but  neither  suited.  Then 
he  was  put  upon  a  laboratory  perccntagje  mixture  at  first  of 
fat  3%  sugar  6%,  proteid  0.80%  ;  then  fat  2fo,  sugar  5.o0%i, 
proteid  .50 fo  ;  then  fat  8.50%,  sugar  6%,  proteid  .28%  ;  then 
fat  3.75% ,  sugar  6% ,  proteid  .50% .  But  whenever  the  pro- 
teids  exceeded  .50%  the  child  vomited.  Colic  was  trouble- 
some I  saw  him  for  the  first  time  on  November  15,  1899, 
and  found  a  vcrv  thin  child  of  5  months  (22  weeks),  weigh- 
ino-  about  as  much  as  when  born.  His  face  was  bright  and 
his  strength  seemed  very  good.  After  some  study  of  his 
history  a^ld  condition,  I  gave  it  as  my  opinion  that  the 
trouble  was  not  with  the  proteids,  but  with  the  fat  being  m 
excess.  This  seemed  likely  from  the  fact  that  the  cluld 
showed  a  tendency  to  vomit,  but  never  had  diarrhea  or  the 
passage  of  undigested  milk.  I  advised  that  the  fet  be 
reduced  to  3%  and  the  proteids  increased  to  .6H%  ;  a  greater 
amount  ti.an  had  been  given  for  a  long  time.  I  also  advised 
adding  some  barlev  water  to  the  mixture,  since  experience 
shows  that  this  often  seems  to  render  proteids  more  easily 
digestible.  The  sugar  was  also  increased  slightly  in  order  to 
aid  in  overcoming  constipation.  The  formula  then  read  :  fat 
3%,  sugar  0.50%,  proteids  .66%,  i  barley  water,  J  water. 

The  further  history  of  the  child  is  one  of  almost 
uninterrupted  gain  except  for  a  short  time  when  it  suf- 
fered from  an  intercurrent  malady. 


Weeks. 
23  26  27  28  29  303132333435363 


"3839  +041+2434445+6 


^ 

^- 

^ 

^ 

^ 

^ 

— 

— 

— 

—^ 

_^ 

^ 

" 

" 

^ 

^ 

, 

/ 

.' 

/ 

A 

/ 

/ 

^ 

/ 

1 

/ 

V 

- 

/ 

-' 

y 

^ 

^ 

<■ 

y 

H 

J---' 

s 

/ 

■^ 

1 

-N 

1 

Weight  Chart  of  F.  W. 

The  changes  in  the  food  formula  were  as  follows : 

F.  S.  P. 

23    weeks  3  6.5  .66 

29        "       3  6.5  .75 

29J      "      3  65  1. 

34        "      3.5  7.  1. 

39        •'      4.  7.  1. 

Studying  these  and  the  weight  chart  conjointly  is  in- 
teresting. The  loss  in  weight  at  26  weeks  was  the  result 
of  a  too  great  temporary  dilution  of  food  done  through 
a  misunderstanding  on  the  part  of  the  family.  The 
cessation  of  increase  about  the  2yth  week  was  followed 
by  immediate  gain  after  the  food-strength  was  increased. 
The  same  renewed  gain  occurred  at  34th  week.  The 
cessation  of  gain  from  the  39th  to  the  42d  week  was 
the  result  of  the  intercurrent  affection. 

The  following  case  is  another  instance  of  the  folly  of 
condemning  a  good  thing  which  we  have  not  learned  to 
appreciate : 


Mary  C,  born  September  17,  1899.  First  seen  December 
29,  1899,  when  n  months  (16  weeks)  old.  The  4  preceding 
children  had  all  been  cases  of  inanition,  and  had  all  died  in 
the  first  7  months  of  life.  Only  the  first  2  children  born, 
which  had  been  breast-fed,  survived.  The  child  Mary, 
weighed  it  was  .said,  11  pounds  when  born.  This  is  certainly 
an  overestimate,  but  it  mu.st  have  been  a  large  and  plump 
baby.  She  was  fed  at  first  on  barley  water  and  milk,  but 
did  not  grow,  then  was  given  a  percentage  mixture  from  the 
Walker-Gordon  Laboratory,  but  did  not  <lo  well,  suffering 
either  from  diarrhea  or  vomiting  Four  different  formute 
were  tried.  It  should  be  stated,  however,  that  the  physician  in 
charge  had  never  prescribed  percentage  milk  before,  and  did 
■so  now  only  on  the  insistence  of  the  family.  It  seems  likely 
from  the  bad  results  that  he  did  not  cfinsiderthe  relation  of 
the  different  ingreilients  to  the  symptoms.  At  last,  another 
physician  was  called  in  who  ;)rescribed  Robinson's  barley 
with  condensed  milk.  With  this  food  constipation  replaced 
diarrhea  and  there  was  much  colic,  but  there  was  no  gam  in 
weight.  The  child  weighed  only  8  pounds  and  1  ounce 
when  I  first  saw  it.  It  was  in  a  wretched  condition,  wrinkled, 
puny,  and  crying  constantly  from  pain.  I  strongly  urged  the 
employment  of  a  wet  nurse,  as  I  was  doubtful  about  the  re- 
covery on  other  milk.  The  mother,  however  did  not  con- 
sent, owing  to  her  prejudice  in  the  matter.  She  had  in  any 
case  made  up  her  mind  from  her  past  sad  experience 
that  the  recovery  of  tiie  child  was  absolutely  hopeless.  I 
ordered  for  it  a  percentage  mixture  from  the  laboratory  of 
the  strength  of  F.  2%,  S.  6%  P.,  .50%  ;  8  four  ounce  bottles. 
Although  this  mixture  was  weak,  I  warned  the  mother  that 
it  might  disagree  badly,  which  it  did,  causing  severe  vomit- 
ing. After  24  hours'  treatment  with  alternate  egg  water  and 
barley  water,  the  formula  was  changed  to  F.  150%,S.  5% 
P.  .50%,  with  barley  water.  The  fats  were  reduced  on 
account  of  the  tendency  to  vomit.  This  formula  agreed 
nicely,  colic  nearly  ceased  and  constipation  was  much  less. 
The  improvement  has  been  nearly  con.stant  and  brilliant, 
barring  a  few  times  when  the  child  suffered  from  a  bron- 
chial catarrh. 


Lbs. 
18- 


Weeks. 


16  17  IS  19  20  21  2 

2  2 

3  24  25  26  2 

7  2 

S  2 

93 

■)  313; 

>3 

^ 

4 

^ 

^ 

^ 

-^ 

^ 

r^ 

^ 

^ 

; 

,^ 

y 

y 

y 

■^ 

••' 

-^ 

^ 

y 

-' 

^ 

/ 

^ 

^ 

/ 

■-, 

.^ 

y 

' 

Weight  Chart  o£  Mary  C. 


Changes  in  the  formula 
time  as  follows : 


were  made  from  time  to 


16   weeks 

16J     ." 

19 

20 

24 

26 

30 

33 


F.  S.  P. 

2  6  .50 

1.50  5  .50 

..2  5  .50 

2  5  .75 

2.50  6  1. 

;■": 3.  7  1. 

3.  7  1.25 

increased  quantity  merely. 


Comparing  this  with  the  weight  chart  we  notice  no 
crain  of  weight  during  the  first  three  weeks  of  treat- 
ment. The  only  eflbrt  at  this  time  was  to  accustom, 
the  child  to  milk.  Of  course,  the  formula  was  too 
weak  for  any  material  improvement  to  be  expected.^  It 
is  interesting  to  note  the  decided  increase  ot  weight 
which  followed  the  slight  increase  of  the  fat  percentage 


530  Th^  PHn_»DELPHLA"| 

ilEDICiL  JOCRNAL  J 


TECHNIC  OF  THE  WIDAL  TEST 


[Mabch  16,  190: 


at  19  weeks.  The  growth  was  now  fairly  satisfactory, 
the  strength  of  the  food  being  gradually  increased 
toward  the  normal  human  milk  percentages.  The  de- 
cided gain  at  the  33d  week  followed  an  increase  in 
the  amount  of  milk  given  without  any  alteration  of  the 
formula.  The  little  girl  now  is  like  a  different  child. 
She  is  well  filled  out  and  gaining  constantly.  My  plan 
is  to  increase  the  fat  up  to  3.50  or  even  4  and  the  pro- 
teids  possibly  up  to  1..50  according  to  the  needs  of  the 
case.  Later  the  proteids  will  require  a  still  greater 
increase. 

Still  another  case  may  be  cited  in  illustration  of  the 
point  I  wish  to  make,  viz  :  That  we  must  bring  our 
common  sense  to  bear  in  feeding  an  infant  by  any  plan, 
and  not  hastily  condemn  any  method  because  it  seems 
to  fail.  The  following  case  was  by  far  the  most  un- 
compromising of  any  I  have  attempted  to  feed  for  some 
time. 

L.  M..  born  June  12,  1899.  Seen  by  me  January  27,  1900* 
at  the  age  of  7i  months  (33  weeks).  The  child  was  said  to 
have  weighed  11  pounds  when  born ;  doubtless  an  overesti 
mate,  but  an  indication  of  his  excellent  size  and  condition. 
He  wasfed  on  the  breast  and  the  bottle  for  thefirst  two  months 
and  then  was  given  the  bottle  alone,  first  of  malted  milk  and 
then  of  condensed  milk,  but  always  suffered  from  diarrhea. 
Kext  he  was  fed  upon  some  "sterilized  milk,"  and  then  upon 
percentage  milk  prepared  at  the  Walker-Gordon  Laboratory. 
This  was  given  for  several  weeks,  but  disagreed.  I  do  not  know 
the  formula  employed.  The  child  then  received  a  rather 
strong  cows-milk-and-water  mixture,  which  he  vomited 
Next,  for  two  months,  be  had  barley  water,  brandy,  and  white 
of  egg,  and  for  the  last  month  had  Mellin"s  Food.  With 
every  sort  of  feeding  he  had  diarrhea,  and  always  passed 
curds  if  there  was  any  milk  in  the  food.  He  had  lost  weight 
constantly  since  birth,  and  for  the  last  few  weeks  had  some 
edema  of  the  cheeks  and  feet. 

Examination  showed  a  wretched-looking  marantic  speci- 
men. The  abdomen  was  distended,  the  limbs  very  thin,  the 
cheeks  unnaturally  plump  from  edema,  and  the  feet  and  legs 
distinctly  dropsical.  I  ordered  him  a  formula  from  the  lab- 
oratory of  F.  1.-50^,  S.  0%,  P.  50%,  with  the  water  one-half 
barley  water,  and  of  an  alkalinity  of  10%,  i.  e.,  ■j',  of  the 
whole  mixture  was  lime  water.  The  low  percentages  were 
chosen  on  account  of  the  child's  extremely  weak  digestion. 
An  astringent  mixture  was  also  prescribed.  By  February  2  the 
child  seemed  better  in  every  way.  There  were  but  two  stools 
a  day,  but  there  was  no  gain  in  weight.  An  increase  in  the 
formula  was  made  to  F.  2% .  S.  •'i% ,  JP.  .50%.  By  February  7, 
the  child  seemed  clearly  better  and  the  tlesh  fuller,  although 
the  weight  was  apparently  no  greater.  At  this  date  it 
weighed  7  pounds  10  ounces.  It  is  probable  that  the  earlier 
weighings  were  incorrect  and  that  the  weight  at  the  thirty- 
third  week  was  little  over  7  pounds. 

Improvement  was  doubtless  interfered  with  by  the  devel- 


Lba. 


Weeks. 


3 

43 

53 

63 

"3 

83 

94 

04 

14 

24 

3444 

S4 

S4 

74 

S4 

9j 

(^ 

'^ 

^ 

^ 

<■ 

" 

-- 

- 

/ 

J 

/ 

s 

r- 

--■ 

*'"■■-» 

/ 

V 

— 

r^ 

• 

' 

.. 

. 

Weight  Chart  of  L.  M. 


opment,  about  Februarj-  17  (36  weeks),  of  a  very  severe 
bronchitis  with  high  fever,  possibly  a  bronchopneumonia, 
and  then  a  few  days  later  of  symptoms  of  scurvy.  In  spite 
of  this,  gain  in  weight  went  on,  as  the  chart  shows.  The- 
baby  has  improved  wonderfully  and  is  now  in  excellent  con- 
dition, with  every  prospect  of  a  complete  recovery.  It  is, 
of  course,  still  far  below  the  normal  weight  for  its  age.  The 
food  is  still  weak  for  fts  age,  as  it  is  now  almost  a  year  old. 
I  shall  now  increase  the  proteids  of  the  food  as  raoidly  as 
the  digestion  permits  and  the  rate  of  growth  indicates  it 
necessary. 

The  various  changes  in  the  formula  were  as  follows  : 

F.  S.  P. 

33    weeks 1.50  5  0.50 

33i       •       2  5  050 

35  "       2.-50  5  0.75 

36  "       2.75  5  1 

37  "      3  5  1 

37*       "       3.50  6  1 

38i       "       4  7  1 

47        "       3.50  7  125 

Comparison  of  this  table  and  of  the  weight  chart 
requires  some  explanation  in  view  of  certain  symp- 
toms. From  the  3Sth  week  to  the  42d,  gain  in  weight, 
though  steady,  was  not  as  great  as  it  had  been,  in  spite 
of  the  increase  in  the  strength  of  the  formula.  Thi-; 
appears  to  have  been  due  to  a  continued  slight  indiges- 
tion following  a  severe  attack  of  vomiting  and  diarrhea 
at  3Si  weeks.  After  this  was  over  the  gain  was  strik- 
ing with  no  alteration  of  the  food  formula.  The  loss  in 
weight  at  the  45th  week  was  the  result  of  a  very  severe 
cold  with  diminution  of  the  appetite.  The  diminished 
rate  of  gain  up  to  the  47th  week  seems  clearly  due  to 
diluting  the  milk  with  water,  not  advised  by  me,  but 
done  by  the  mother  on  account  of  a  tendency  to  vomit 
which  the  baby  showed.  I  consequently  ordered  this 
dilution  .^topped  and  reduced  the  percentage  of  fat 
slightly  although  increasing  the  proteid.  The  resulting 
gain  is  shown  in  the  chart. 

I  could  detail  many  other  cases  showing  how  well 
children  do  either  on  percentage  formula?  as  prepared 
by  the  laboratory  or  on  percentage  mixtures  made  at 
home  from  definite-strength  milk  and  cream  ;  some  of 
the  children  being  fed  from  birth  on  percentage-milk, 
some  doing  finely  after  little  success  with  other 
methods;  many  of  them  with  weight -charts  in  which 
the  curve  is  up  to  or  even  above  the  normal  curve  of 
healtliy.  breastfed  children.  But  I  have  limited  mysel ' 
to  these  three  cases,  partly  because  the  children  were 
such  absolutely  unpromising  specimens  which  had 
been  doing  badly  on  all  methods  tried,  largely,  too.  be- 
cause all  three  of  them  had  at  different  times  been  fed 
on  laboratory  prescription  milk  before  I  saw  them  and 
had  done  ven,'  badly  indeed.  One  could  easily  have 
claimed  that  this  was  the  fault  of  laboratory  feeding. 
As  a  matter  of  fact  it  must  have  been  the  fault  of  the 
prescriptions  which  had  been  ordered.  What  I  suc- 
ceeded in  doing  for  them  of  course  any  physician  can 
accomplish.  All  that  is  needed  is  that  he  go  about  it 
with  some  common-sense  idea  of  what  he  is  trying 
to  do.  • 


A  CONTRIBUTION  TO  THE  TECHNIC  OF  THE  WIDAL 

TEST. 
Bv  A.  ROBIX,  M.D., 

of  Xeirark,  Del. 

Pathologist  »Dd  Bacteriologist  to  the  r>ebiw«re  State  Board  of  Hea'th. 

(From  the  State  Burd  of  Health  laboratory.  > 

The  Widal  test  has  already  passed  the  experimental 
stage,  and  now  is  universallv  recognized  as  an  ahnost 


March  16,  1901 1 


TECHNIC  OF  THE  WIDAL  TEST 


TThb  Philadklphla. 
L  Medical  Jocrnal 


531 


pathognomonic  sign  of  typhoid  fever.  It  is  also  being 
utilized  for  the  recognition  of  infection  with  virulent 
coli  communis,  pneumonia  and  tuberculosis,  and  hog 
cholera  in  animals.  The  conditions  necessary  for  the 
successful  application  of  the  test  are  a  motile  organism, 
or  one  which  is  capable  of  clumping  either  when  the 
blood  is  added  to  a  test-tube  culture  (macroscopic  test) 
or  a  hanging-drop  (microscopic  test).  Whenever  these 
conditions  are  present  the  test  can  be  employed  for 
diagnostic  purposes.  The  opmion  is  gaining  ground 
that  the  reaction  is  one  of  immunity  and  not  infection. 
Personal  observations  fully  corroborate  this  view.  The 
reaction  has  been  observed  in  mild  or  so-called  walking 
cases  of  typhoid  fever,  while  on  the  other  hand  it  bears 
no  relation  to  the  severity  of  the  disease,  and  in  one 
•case  submitted  to  the  laboratory  it  was  absent  24  houi-s 
before  death  occurred.  It  may  also  be  absent  imtil  con- 
valescence is  well  established.  Add  to  this  the  fact  that 
it  is  frequently  observed  in  healthy  individuals  when 
the  blood  is  diluted  1:5  or  even  1:10  and  that  it  persists 
for  months  and  even  years  in  persons  who  have  suffered 
from  an  attack  of  typhoid  fever,  and  we  have  an  incon- 
testable array  of  arguments  in  favor  of  the  above  view. 

Those  who  still  believe  that  they  can  make  a  diagnosis 
of  typhoid  fever  without  the  aid  of  the  Widal  test  will 
probably  be  surprised  at  the  assurance  that  typical 
cases,  as  pictured  in  our  text-books,  are  not  met  with 
frequently.  Many  lack  one  or  more  of  the  pathogno- 
monic symptoms  of  the  disease,  making  it  impossible 
to  arrive  at  a  correct  diagnosis  during  the  first  week  or 
two  of  the  attack.  From  the  blanks  filled  out  by  the 
attending  physicians,  when  submitting  a  specimen  of 
blood  for  examination  to  this  laboratory,  we  gather  the 
following  interesting  data  :  Of  the  cases  submitted  dur- 
ing the  first,  second  and  a  few  the  third  week  of  the 
disease  there  was  diarrhea  in  30%,  enlarged  spleen  in 
32%,  iliac  tenderness  in  46%,  rose-spots  in  27%,  and 
delirium  in  20%.  We  have  no  record  of  epistaxis,  but 
it  is  well  known  how  infrequent  the  occurrence  of  this 
symptom  is.  It  is  thus  seen  how  difficult,  nay  impos- 
sible, it  may  be  to  make  a  correct  diagnosis  from  clinical 
sj'mptoms  alone.' 

We  often  hear  it  stated  that  typhoid  fever  has  undergone 
considerable  modification  within  the  last  few  years ;  the 
disease  is  milder  than  it  used  to  be  and  the  mortaUty  is 
less.  Is  it  not  probable  that  besides  the  improved  sani- 
tation and  treatment,  the  cause  may  be  sought  in  im- 
proved methods  of  diagnosis  ?  At  present  we  recognize 
mild  cases  which  in  the  olden  times  passed  under  the 
name  of  bilious  fever,  bilious  remittent,  or  remittent  fever, 
not  to  mention  the  cases  frequently  encountered  in 
which  the  typhoid  lesion  is  confined  to  some  other  part 
of  the  body  besides  the  intestines,  and  which  in  times 
happily  gone  by  formed  medical  puzzles.  There  are 
still  physicians  in  Delaware  who  claim  that  they  have 
never  seen  a  genuine  case  of  typhoid  fever ;  their  patients 
suffered  fi'om  remittent  fever,  and  yet  during  an  experi- 
ence of  almost  two  years  plasmodium  malariae  was 
demonstrated  in  the  Delaware  State  Board  of  Health 
Laboratory  only  in  half  a  dozen  cases,  while  on  the 
other  hand  every  case  of  so-called  remittent  gave  the 
Widal  reaction. 

The  usefulness  of  the  test,  however,  depends  entirely 
on  the  viodus  operandi.     Were  we  able  to  use  both  the 

*  Dr.  Kalteyer  has  kindly  called  my  attentluu  to  the  fact  that  the  al>ove statis- 
tics are  not  in  accord  witfi  the  observations  of  vCurchison,  Osier,  Wilson  and 
others.  I  am  in  no  way  responsible  for  the  statistics  above  },'iveu.  They  were 
compiled  from  the  blanks  filled  out  by  the  attending  physicians.  I  do  not  quote 
the  statistics  of  the  gt^iirlemen  nieutloned,  for  the  reason  that  I  intended  to  give 
luy  personal  observalions  only. 


macroscopic  and  microscopic  methods  in  every  case,  an 
error  would  lie  almost  impossible,  but  the  difficulties  con- 
nected with  the  macroscopic  method  are  sufficientlj' 
great  to  form  a  permanent  barrier  to  its  employment, 
and  we  must,  therefore,  rely  upon  the  microscopic 
method,  especially  Ln  municipal  laboratories.  This 
being  the  case,  the  technic  must  be  faultless,  or  mis- 
takes will  occur  with  sufficient  fret|Uency  to  make  the 
results  unreliable.  In  municipal  laboratories  the  chance 
for  error  is  still  greater,  since  the  bacteriologists  are 
mostly  overcrowded  with  work  and  can  devote  but  a 
few  minutes  to  each  specimen. 

The  problems  confronting  us  in  applying  the  test 
are  :  1.  The  dilution.  2.  The  best  way  of  obtaining  a 
motile  culture  free  from  "  natural  "  clumps.  3.  The 
differentiation  between  a  true  and  a  pseudo-reaction. 
4.  The  time  limit. 

1.  The  necessity  for  high  dilutions  (1 :  20  to  1 :  40)  is 
made  evident  by  the  observations  of  bacteriologists  in  this 
country  and  abroad  that  the  difference  between  normal 
blood  and  that  of  typhoid  patients  is  one  of  degree  and 
not  of  kind.  In  dilution  of  1 :  5  or  1 :  10  even  normal 
blood  will  at  times  produce  agglutination.  The  typhoid 
reaction  has  also  been  obtained  with  the  blood  of  tuber- 
culous patients,  even  when  diluted  1 :  25.  On  the  other 
hand,  no  case  is  on  record  in  which  a  posi- 
tive reaction  occurred  with  a  dilution  of 
1:40.  It  is  thus  seen  that  the  question  of 
dilution  is  not  a  matter  of  indifference  as 
some  authorities  claim.  To  obtain  accu- 
rate dilutions  various  methods  have  been 
devised  from  time  to  time.  It  is  hardly 
necessary  to  describe  them.  Suffice  it  to 
say  that  those  which  do  possess  a  claim 
to  accuracy  are  either  cumbersome  or  ap- 
plicable to  bedside  diagnosis  only,  while 
aU  the  others  are  not  free  from  error,  which 
makes  their  raison-d'-ctre  doubtful.  The 
method  recently  de\'ised  bj'  F.  D.  Chester 
and  myself  meets  all  the  requirements, 
combinins;  as  it  does  accuracv  with  sim- ^J''- ^\~-^pp''^°'=^ 

^  .  %.  ,         .  ,    tor   drawing     up 

plicity.  It  IS  essentially  a  modification  ot  one  drop  of  wood. 
Cabot's  medicine-dropper  method  from  which  it  differs 
in  the  substitution  of  a  mechanical  appliance  for  the 
fingers  and,  what  is  more  important,  is  being  utilized 
for  making  dried-blood  specimens.  It  consists  of  an 
ordinary  medicine-dropper,  a  V-shaped  piece  of  spring 
brass  or  nickel-plated  steel  and  a  medium-sized  Hoffman 
clamp  (see  Fig.  1).  The  rubber  bulb  of  the  dropper  is 
placed  in  the  brass  plate  and  the  latter  into  the  clamp. 
Each  inward  movement  of  the  screw  releases  the  bulb 
and  draws  up  the  blood,  while  an  outward  movement 
has  the  opposite  efl"ect.  The  advantages  of  the  mechan- 
ical appliance  are  :  t^l)  Not  more  than  one  drop  of  blood  is 
required ;  (2)  a  single  drop  of  blood  can  be  drawn  up 
without  the  formation  of  air  bubbles,  as  is  the  case  when 
the  fingers  are  used ;  (3)  if  the  puncture  is  not  sufficient 
to  cause  a  free  flow  of  blood,  a  part  of  a  drop  may  be 
drawn  up,  the  dropper  laid  aside,  the  finger  or  lobe  of 
the  ear  squeezed  until  more  blood  exudes,  the  addi- 
tional portion  again  taken  up,  and  the  process  repeated 
if  necessary  until  a  full  drop  is  obtained.  All  this  can 
be  done  without  breaking  the  continuity  of  the  column 
of  blood  in  the  dropper.  (4)  The  parts  of  the  appli- 
ance are  to  be  found  in  eveiy  laboratory  or  easily 
obtained,  and  can  be  put  together  in  a  few  minutes. 
The  drop  of  blood  thus  obtained  is  expelled  upon  a 

2  Journal  of  Applied  Microseopr,  19t0. 


632 


Tbk  Philadelphia' 
Ukdical  Jor&KAL 


] 


TECHNIC  OF  THE  WIDAL  TEST 


[Uabcu  16,  Wti 


piece  of  heavy  filter  paper.  The  drop  should  be  allowed 
to  fall  of  its  own  weight.  \V|ien  the  test  is  made  the 
spot  formed  by  the  blood  is  cut  out,  placed  in  a  watch 
glass  provided  with  an  accurately  fitting  cover  made 
air-tight  b}'  a  layer  of  vaseUn,  ai.-l  10,  20,  or  more 
drops  of  normal  salt-sol. lion,  bouillon  or  distilled  water 
added.  In  a  few  muiutes  all  the  constitufuts  cf  the 
blood,  except  the  fibrin,  will  be  completely  dissolved  o\'.t 
and  ready  for  the  test. 

2.  To  obtain  a  motile  organism  is  not  difficult.  All 
one  needs  to  do  is  to  get  fi-om  any  of  our  bacteriologists 
a  pure  culture  of  typhoid  bacilli  well  tried  as  to  their 
motility.  Such  cultures  may  be  kept  in  hermetically 
sealed  tubes  without  impairing  their  motiUty.  We  keep 
our  cultures  in  tubes  sealed  in  the  flame.  The  last  one 
opened  was  sealed  S  months  ago  and  the  bacilli  were 
found  none  the  worse  for  this  long  confinement.  To 
make  the  test  it  is  necessaiy  to  have  a  fresh  agar  or 
bouillon  culture  which  is  made  from  the  stock-culture 
and  kept  in  the  incubator  for  18  to  24  hours.  I  found, 
however,  that  the  incubator  temperature  is  unnecessary 
and  that  just  as  good,  if  not  better,  results  are  obtained 
when  the  organism  is  grown  at  the  temperature  of  a 
fairly  warmed  room.  In  the  latter  case  the  bacilli  are 
longer  and  have  a  greater  motility.  Jly  experience  with 
the  bouillon  culture  has  been  rather  unsatisfactory,  and 
I  have  long  abandoned  it,  using  a  combination  of  both 
the  bouillon  and  agar  cultures,  in  the  following  manner : 
An  agar  culture  is  made  and  placed  in  the  incubator  or 
kept   at   room -temperature   for  12  to  IS  hours,   when 


Fia.  2. — A.  Pure  coiture  of  typhoid  bacilli  in  hanginc  drop.  B.  Bouillou  cul* 
ture,  24  hours,  showing  'false  clumps.  G  Pseiuio-reaction.  D.  Typical 
W^dal  reaction. 

either  2  or  3  loopfuls  are  transferred  into  bouillon  until 
a  marked  turbidity  results,  or  a  small  quantity  of  bouil- 
lon added  to  the  agar  culture,  and  enough  of  the  growth 
scraped  off  to  produce  a  uniform  cloudiness.  By  this 
method  the  natural  clumps  so  frequently  observed  in 
bouillon  cultures  (see  Fig.  2  B)  are  entirely  avoided. 
The  addition  of  the  bouillon  to  the  agar  culture  is  pref- 
erable to  mixing  a  portion  of  the  latter  in  a  watch-glass 
for  obvious  reasons. 


3.  The  differentiation  between  a  true  and  pseudo- 
reaction  forms  the  most  important  and  the  most  difficult 
part  of  the  test.  Natural  clumps,  as  stated  above,  will 
form  in  bouillon  even  without  any  admixture  of  blood, 
and  again  some  clumping  will  result  upon  the  additioi 
of  normal  blood.  When  the  latter  possesses,  as  it  oftei 
does,  bactericidal  properties,  the  bacilli  wiU  be  rendere'i 
immotile  and  a  number  of  them  will  gather  around 
debris,  clumps  of  fibrin  or  blood-corpuscles,  thus  simu- 
lating a  clump-reaction  very  closely.  Only  an  expert  eye 
is  able  to  cope  with  such  deceptive  appearances.  How- 
ever, when  the  methods  outlined  al)ove  are  followed. 


Fig.  %. — Gla-s  sliJe  wi'.h  two  concavilies. 

the  natural  clumps  will  not  be  present  nor  will  the 
fibrm  and  other  foreign  material  which  remain  entangled 
within  the  meshes  of  the  filter  paper.  To  still  ftirther 
insure  against  the  possibUity  of  error  the  following 
method  has  been  adopted  :  A  sUde  with  two  concavities 
is  employed  (see  Fig.  3),  the  edges  of  the  latter  being 
sun'ounded  with  a  layer  of  vaselin.  On  each  of  two 
clean  cover  glasses  is  dejxisited  a  loopful  of  the  culture : 
to  one  a  loopful  of  the  blood  diluted  1 :  20  to  1 :  40 
is  added,  while  the  other  serves  as  a  control.  By  shift- 
ing the  slide  from  one  cover  glass  to  the  other  the 
shghtest  difference  in  the  behavior  of  the  bacilli  can  be 
eiisily  noted.  Furthermore,  the  lens  is  focused  on  the 
edge  of  the  hanging-drop  where  the  bacilU  are  more 
numerous  and  being  nearer  to  the  objective  are  seen 
more  clearly.  If  the  reaction  is  positive  all  or  nearly 
all  the  baciUi  will  be  found  tp  gather  in  clumps  of  two, 
three  or  a  dozen  and  will  soon  lose  their  motility 
while  in  a  pseudo-reaction  only  a  few  clumps  will  form, 
the  rest  of  the  bacilli  remaining  separated.  If  killed 
by  non-typhoid  blood  they  become  motionless  but  still 
remain  single.  The  difference  between  the  true  and 
false  reactions  is  well  illustrated  in  Fig.  2,  C  and  D.  In 
case  of  doubt,  or  when  the  bacilli  are  very  small,  an  oil- 
immersion  lens  will  render  valuable  aid.  In  fact,  the 
Widal  test  can  generally  be  more  satisfactorily  performed 
with  an  oil  immersion.  The  individual  bacilli,  the 
clumps  and  the  entire  field  of  vision  can  be  seen  to 
better  advantage. 

4.  The  time  limit  which  determines  a  positive  reaction 
is  another  very  important  point.  Bacteriologists  abroad 
make  tlieir  dilutions  1 :  100  to  1 :  600  and  extend  the 
time  of  obsers-ation  to  2  hours.  If  within  that  time 
clumping  and  loss  of  motility  does  not  take  place,  the 
reaction  is  negative.  In  this  cotmtry.  where  no  accurate 
dilutions  are  practised,  considerable  difference  of  opinion 
exists  as  to  time.  Thus,  while  visiting  some  of  our 
bacteriologic  laboratories,  the  author  found  that  in  a 
few  of  them  the  time  during  which  a  positive  reaction 
is  to  take  place  is  set  at  1  to  2  raintites,  while  in  others 
it  is  extended  to  1  hour.  Such  a  divergence  of  opinion 
cannot  but  lead  to  erroneous  results.  Uniform  results  can 
only  be  the  outcome  of  uniform  methods,  and  it  is  to  be 
hoped  that  before  long  a  certain  time  limit  wiU  be  imi- 
vers;illy  adopted.  The  author  would  propose  the  fol- 
lowing :  Dilution  1 :  10,  time  hmit  6  to  15  minutes : 
1 :  20,"^  15  to  30  minutes  ;  1 :  40  to  1  :  IQO.  30  to  60 
minutes  ;  1 :  100  to  1 :  200,  1  to  2  houre.     That  would 


Mabch  16,  1901] 


RUPTURE  OF  RECTUM— GLAUCOMA.  SIMPLEX 


[Thk  I*hiladelphia 
Medical  Jouesal 


533 


mean  tRat  if  within  the  specified  time  a  considerable 
number  of  bacilli  are  found  activeh'  motile  or,  if  dead, 
fail  to  arrange  themselves  in  clumps,  the  reaction  is  to 
be  pronounced  negative,  irrespective  of  the  clumps 
■which  have  already  formed. 

In  conclusion  it  may  be  stated  that  there  is  no  reason 
why  the  general  practitioner  who  is  removed  from 
municipal  laboratories  could  not  perform  the  Widal 
test  himself.  The  culture  tubes  and  other  accessories 
can  be  purchased  in  any  supply  store,  no  incubator  is 
necessary,  and  the  skill  is  just  such  as  should  be  jjos- 
sessed  by  any  intelligent  phj-sician  who  had  received 
his  instructions  in  an  up  to-date  medical  institution. 


RUPTURE  OF  THE  RECTUM   AND   HERNIA  OF  THE 
INTESTINES  IN  AN  INSANE  MAI>f.* 

Bv  A.  R.  MOULTOX,  M.D., 

of  Philadelphia. 

First  Assistant  Physician  for  Men.  Pennsylvania  Hospital  for  the  lusane 

The  case  which  I  report  is  that  of  a  man  34  years  of 
age  who  was  admitted  to  the  Pennsylvania  Hospital  for 
the  Insane  during  the  summer  of  1S92.  His  excite- 
ment, which  was  very  intense,  was  followed  in  a  few 
weeks  by  a  condition  of  melancholia  with  stupor,  which 
in  turn  was  succeeded  by  dementia.  His  physical 
health  was  not  good,  and  his  vitality  was  low.  The 
habits  of  the  patient  were  uncleanly,  and  he  acquired 
the  ability  to  produce  rectal  prolapse,  which  he  did  by 
introducing  his  fingers  through  his  anus  and  withdraw- 
ing them  with  the  tips  widely  separated.  Then,  if  he 
had  the  opportunity,  he  would  cause  an  inversion  of 
the  rectum,  sometimes  fully  6  inches  in  length.  The 
replacement  of  the  parts  was  done  with  difficulty  by 
manipulation,  but  they  would  return  readily  by  the 
application  of  moist  heat  with  rest  in  bed. 

On  the  morning  of  November  20,  1900,  the  patient 
got  up,  was  dressed,  and  took  breakfast  as  usual,  after 
which  he  went  to  the  water  closet.  In  a  few  minutes 
he  was  seen  to  cross  the  corridor,  coming  from  the  bath- 


room, and  to  sit  down  on  a  sofa.  He  was  pale,  and^his 
trousers  appeared  wet.  Supposing  he  had  soiled  hi,m- 
self,  the  attendent  was  in  the  act  of  removing  the 
patient's  clothes  when  he  discovered  a  loop  of  small 
intestine  fully  2  feet  long  hanging  from  the  man's  anus. 
There  was  also  protruding  considerable  mesentery.    He 

*Bead  at  Philadelphia  County  Medicil  Sxiety,  February  IS,  1901, 


had  ruptured  the  walls  of  his  rectum,  and  through  the 
opening  the  small  intestines  and  mesentery  had  es- 
caped. No  inflammation  occurred,  but  the  shock  was 
profound  and  death  occurred  36  hours  after  the  receipt 
of  the  injury. 


The  accompanying  photographs,  one  taken  before 
and  one  after  death,  show  quite  plainly  the  magnitude 
of  the  protruding  mass. 


REMOVAL  OF  THE  RIGHT  UPPER  CERVICAL  SYM- 
PATHETIC GANGLION  FOR  THE  RELIEF  OF 
GLAUCOMA  SmPLEX. 

By  D.  H.  COOVER,  M.D., 

Denver,  Colorado. 

Professor  of  Ophthalmology  in  Gross  Medical  College ;  Oculist  and  Aurist  to 

the  Arapahoe  County  Hospital,  St.  .-Vnthony's  Hospital  and  to 

the  National  Jewish  Hospital  for  Consumptives, 

Denver,  Colorado. 

John  L.,  aged  65  years,  consulted  me  March  15,  1900, 
T\-ith  the  following  history  :  For  the  past  year  his  vision  had 
been  failing  very  rapidly  until  at  this  time  vision  was  reduced 
in  right  eye  to  only  light-preception  in  the  extreme  nasal 
side  of  retina  (temporal  field),  tension  +  3,  optic  nerve 
cupped,  pupils  slightly  dilated  and  fixed,  arterial  pulsation, 
and  retinal  vessels  contracted.  Left  eye,  vision  j-/,,  tension 
+  2,  nerve  cupped,  pupil  slightly  dilated,  field  contracted. 

He  never  complained  of  pain  or  inflammation  in  either 
eye.  Myotics  were  tried  but  had  no  effect  upon  the  vision. 
l"  suggested  the  operation  of  sympathectomy  to  him,  but 
before  he  consented  I  called  in  Dr.  Melville  Black  ;  he  agreed 
that  it  was  a  case  of  glaucoma  simplex  and  would  be  a  good 
case  for  the  operation.  I  explained  to  my  patient  the  oper- 
ation and  its  possibilities.  Dr.  Leonard  Freeman,  of  this 
city,  removed  the  right  upper  cervical  sympathetic  ganglion. 
The  operation  was  rather  difficult,  as  the  patient,  a  black- 
smith, had  a  very  short  thick  neck,  the  muscles  being  very 
large  and  the  veins  numerous  and  dilated  almost  to  a  condi- 
tion of  varicosity.  The  nerve  was  reached  by  dissecting 
down  behind  the  sternomastoid  muscles  and  turning  up  the 
sheath  of  the  great  vessels. 

Resu'ti  of  the  Operation. — It  was  performed  at  5  p.m.  of  the 
31st  day  of  March,  1900.  Immediately  after  the  operation 
tension  was  lowered  in  both  eyes.  The  following  morning 
right  pupil  slightly  contracted,  slight  lacrimation,  which 
was  noticeable  during  the  day.  Tension  -|- 1  and  more  light- 
perception  in  the  eye. 

Second  day— Tension  +  1.  Pupil  slightly  coutracted  and 
slight  reaction.  No  pulsation  of  retinal  arteries,  vessels 
fuller,  no  lacrimation,  counted  fingers  at  three  feet. 

Third  day— Tension  + 1.  Counted  fingers  at  five  feet,  field 
of  vision  increased. 

Fourth  day— Tension  + 1.  Field  of  ^-ision  increased  to 
median  line,  pupil  reacted  slightly. 


Medical  Jocrsal 


]     INDIGENT  VISITORS  TREATED  AT  HOT  SPRINGS,  ARK. 


[Mabcb  16,  1901 


Fifth  day — Tension  + 1  •    Vision  ^. 

Sixth  day— Tension  + 1.    Vision  ^gj. 

Seventh  iay— Tension  + 1.  Vision  ,^iy,  and  could  catch  a 
letter  on  the  70-foot  line.  Field  of  vision  increased  a  little 
beyond  the  median  line  on  temporal  side. 

Eighth  day— Tension  + 1.  Vision  ^fj.  More  Ught-per- 
ception  in  temporal  side  of  retina  (nasal  field). 

Twelfth  day — Tension +  1.  Vision  not  so  good,  slight 
cloudiness  of  the  aqueous.  Vision  jlj.  Complained  of 
lobe  of  the  right  ear  and  face  along  the  jaw  being  numb. 

Fourteenth  daj- —  ( he  aqueous  cleared.     Vision  j'/s- 

Eighteenth  day — Tension +1.  Vision  ^°j.  Pupil  reacted 
slightly. 

On  the  nineteenth  day  he  returned  to  his  home.  At  in- 
tervals of  a  few  weeks  I  would  hear  from  him  in  which  he 
stated  that  his  vision  was  getting  better  and  his  range  of 
vision  was  wider.  In  the  latter  part  of  July  I  received  a 
letter  stating  that  his  vision  was  very  poor,  and  failing 
rapidly.  He  supposed  it  was  due  to  a  cold  that  he  had  con- 
tracted. 

On  August  2  I  went  to  see  him.  On  examination  I  found 
tension  +  3,  vision  reduced  to  light-perception  and  field  of 
vision  .contracted  to  where  it  was  at  the  date  of  operation, 
pupil  dilated  and  fixed.  No  congestion  or  pain.  The  vision 
in  the  left  eye  was  reduced  from  ^\%  to  j^  and  field  of  vision 
very  much  contracted.  The  immediate  results  of  the  opera- 
tion were  very  encouraging  and  were  as  follows :  1.  That 
tension  was  lowered  to  almost  normal.  2.  Contraction  of  the 
pupil  and  slight  reaction.  3.  Increase  of  the  visual  field  and 
visual  acuteness,  and  the  temporal  field  or  nasal  side  of 
the  retina  improved,  while  the  nasal  field  or  temporal  side 
of  retina  did  not  improve  These  conditions  remained  until 
the  attack  of  supposed  "  cold  in  the  eyes,"  which  proved  to 
be  nothing  more  than  the  return  of  the  former  disease, 
glaucoma. 

Jonnesco,  in  September,  1S97,  was  the  first  to  perform 
this  operation  for  the  relief  of  glaucoma  and  from  the 
cases  that  he  had  operated  upon  he  concluded  that  the 
best  results  are  to  be  expected  in  those  cases  where 
iridectomy  had  failed  to  arrest  the  disease,  and  in  all 
cases  of  glaucoma  except  the  acute  inflammatory  and 
hemorrhagic  form. 

Dr.  James  M.  Ball,  of  St.  Louis,  concludes  from  the 
cases  that  he  has  operated  upon  that  the  operation  is 
more  valuable  in  glaucoma  simplex  than  any  other 
form  of  the  disease. 

My  conclusions  from  this  case  are  that  the  operation 
is  of  no  service  in  glaucoma  simplex  where  vision  has 
been  reduced  to  zero,  as  the  final  outcome  of  this  case 
has  demonstrated,  but  may  be  of  service  in  arresting 
the  disease  in  the  earlier  stages  and  retain  vision  before 
atrophic  changes  have  taken  place  in  the  nerve,  retina, 
and  choroid. 

After  myotics  and  iridectomies  have  failed  to  relieve 
the  disease,  it  is  then  when  we  are  justified  to  advise 
sympathectomy  in  hope  of  relief  from  permanent 
blindness.  Even  then  we  have  no  assurance  that  the 
glaucomatous  attacks  will  not  return  months  afterwards 
and  destroy  what  has  been  gained. 

The  operation  in  skilful  hands  is  not  a  dangerous 
one,  nor  has  there  been  any  deleterious  effects  upon  the 
patient,  except  the  numbness  of  the  lobe  of  the  right 
ear  and  along  the  inferior  maxillary. 


Examining  Board.— The  Medical  Board  which  met  at 
Washington  for  the  purpose  of  examining  candidates  for 
admission  to  the  Medical  Corps  of  the  Army  consisted  of 
Col.  Alfred  A.  Woodhull,  assistant  surgeon-general,  U.  S.  A.; 
Major  Louis  A.  Ls  Garde,  surgeon,  U.  S.  A.;  Captain  William 
C.  Borden,  assistant  surgeon,  U.  S.  A.;  and  Captain  Frank 
E.  Keefer,  assistant  surgeon,  U.  S.  A. 


A  SYNOPTICAL  REPORT  OF  1141  CASES  OF  INDIGENT 
VISITORS  TREATED  AT  HOT  SPRINGS.  ARK.* 

By  HOWARD  PAXTON  COLLIXGS,  B.S.,  M.D., 

of  Hot  Springs. 

My  object  in  submitting  this  report  to  the  Society  is 
that  we  may  see,  by  investigating  a  considerable  num- 
ber of  this  class  of  patients,  taken  as  they  present 
themselves  for  treatment,  what  the  greater  portion  visit 
the  Springs  for,  and  at  the  same  time  to  note  the  great 
diversity  of  ills  in  a  limited  number  ;  to  report  in  a  very 
brief  manner  a  few  cases  that  were  of  especial  interest 
and  lastly  to  refer  more  minutely  to  some  special 
features  in  connection  with  the  not  infrequent  diseases 
— syphilis  and  gonorrhea. 

I  give  below  in  the  first  chart  a  list  of  all  the  dis- 
eases met  with,  which  in  numbers  is  slightly  in  excess 
of  the  patients;  but  in  some  cases,  there  being  two 
separate  and  distinct  diseases,  each  was  tabulated  sepa- 
rately. 

Chart  No,  L 

LIST  OF  ALL  DISEASES. 


Acne  rosacea 

*'      vulgaris 

Anemia 

Aneurysm  of  left  femoral  artery  . 

Abscess,  cold 

AlcoholL^m       

Bubo,  inflamed  and  suppuraliog  . 

BroDcbiiis,  chronic 

Brighi's  disease 

Balanitis 

Chloasma 

CoDJunciivitis 

"  goDorrbeal  .... 

Cystitis  ...  

Catarrh,  na^al 

"        (typhilitic 

Constipation,  chronic 

CocaiD  habit 

Consumption 

Cellulitis 

Chorea 

Condylomata 

Chancroids 

Cyst  from  female  urethra    .... 

Dyspepsia  .   .       

I^ermaiitts,  chronic 

Dysentery,  chronic 

Eczema 

Epilepsy 

Elephantiasis 

Epididymitis 

Eu'lomeiritis 

Fistula  in  ano 

Fracture,  nonunion 

Furuncutosis  

Fistula,  urethral 

Gleet  and  gouorrhea 

Gt*ut  

Herpes  preputialis 

"       zoster 

Hematuria 

Hydrocele 

acut«  syphilitic      .   .   . 

Hemiplegia 

Hyperidroais  

Hemorrhoids 

Jaundice 


Locomotor  ataxia 

Lipomas,  multiple 

Lead  pai^y 

Lupus  vulgaris 

Malaria,  chronic 13 

Masiurbation 

Morphin  habit 

Neurasthenia 

Sexual  neurasthenia 

Neuralgia  . 

Nephritis,  syphilitic 

'  Psoriasis 18 

Paralysis,  agitans 

'*         spastic 

'*         syphilitic 15 

Foliations,  nocturnal 

Proctitis 

Prostatorrhea 

Periostitis,  nonsypbilitic     .... 

Poison  oak    .   .  ' 

Paresis  trom  urethral  stricture 

Pemphigus  vulgaris,  acute: .... 

Prosutitis 

Pleurisy,  chronic    .   .  .... 

Rbeumatiisxn,  chrooic  ......    12- 

••  acute 16 

"  gonorrheal    ....     27 

Stricture,  rectal 

Semioal  vesiculitis 

ajcosis 

Sciatica      

Se^rrhea 

Subinvolution 

Svphilis 831 

Tuberculous  arthritis 4 

•*  glands    ......      10 

'*  osteitis  and  caries  .  . 

Tonsillitis,  chronic 

ricer  of  leg,  nonsypbilitie    .  .  . 

Clcer  of  rectum 

Venereal  warts 15 

Varicose  veins  of  legs ' 

Valval«r  heatt  disease 3 

Vertigo I 


Total 1485 


We  see  by  referring  to  the  above  table,  that  while 
the  greater  number  are  patients  who  have  contracted 
venereal  diseases,  yet  there  are  many  diseases  rep- 
resented, some  of  these  it  is  true  that  would  not  be 
benefited  directly  by  the  use  of  the  waters  here,  but 
most  of  them  would.  Many  patients  were  seen  that 
came  to  be  treated  for  syphilis,  they  having  made  their 
own  diagnosis,  who  had  only  some  trivial  affection,  but 
the  delusion  proved  beneficial  in  that  they  were  enabled 
to  take  a  few  much-needed  baths.  A  number  of  dis- 
eases are  sparingly  represented  owing  to  the  class  of 
patients  I  had  to  deal  with — it  being  unladylike  for  a 
woman,  for  example,  to  run  the  risks  incidental   to  a 

*Read  at  a  meeting  of  the  Hot  brings  Medical  Society,  Aagost  1,  1S99. 


.VrARCH   16,  1901] 


INDIGENT  VISITORS  TREATED  AT  HOT  SPRINGS,  ARK. 


MSDICAL  JOUBN&L 


535 


ride  of  hundreds  of  miles,  perhaps,  on  the  trucks  of  a 
fast-going  passenger  coach,  the  front  end  of  a  freight 
car,  or  even  to  withstand  the  luxuries  of  an  empty  hox 
oar.  Thus  is  accounted  for  the  paucity  of  all  the  diseases 
peculiar  to  the  female,  which  are  so  satisfactorily 
treated  here.  Again  the  same  can  be  said  of  the  poor 
rheumatics  and  paralytics  and  those  suffering  with 
stomach,  liver,  kidney,  intestinal  and  bladder  diseases, 
in  fact,  an  absence  of  most  all  patient  whose  strength 
and  vitality  were  well  nigh  exhausted  from  disease. 

In  this  Chart  are  included  2  cases  which  have  already 
been  reported  separately.  One,  that  of  a  case  of  re- 
infection of  syphilis,  published  in  the  Journal  of  Cuta- 
neoi.(s  and  Genito- Urinary  Diseases,  in  August,  1896;  and 
the  other  a  case  of  acute  double  hydrocele,  due  to 
secondarj'  syphilis,  published  in  The  Hot  Spritujs  Medi- 
calJournal,  in  March,  1898. 

Among  the  interesting  and  unusual  cases,  of  which 
there  were  many,  I  have  selected  the  following  6  which 
seem  of  sufficient  importance  to  bear  special  mention. 
A  detailed  report  of  cases  not  being  admissible  at  this 
time,  I  trust  that  in  practising  brevity  it  has  not  entirely 
robbed  them  of  value. 

Case  No.  715  was  partial  paralysis  of  the  lower  limbs,  in- 
coutinence  of  urine,  severe  pain  in  the  back,  almost  entire 
loss  of  power  of  erection,  and  a  generally  nervous  and 
weakened  condition  of  the  entire  sj'stem.  A  stricture  at 
one-fourth  of  an  inch  from  the  meatus,  which  admitted  a 
No.  18  French  bulb,  was  cut.  which  on  the  following  day  en- 
abled him  to  walk  better  than  he  had  in  4  >  ears,  and  in  a 
short  time  all  symptoms  were  relieved.  The  remainder  of 
the  urethra  was  entirely  free  from  abnormal  iibrous  tissue. 

Case  No.  149  was  one  of  chronic  serpiginous  phagedena 
supplanted  upon  a  chancroidal  ulcer  which  had  existed 
for  2  years  when  I  saw  him  The  integument  of  all  the 
lower  part  of  the  abdomen  and  pubes  and  probably  some  of 
the  muscular  tissue  had  been  destroyed,  but  had  granulated 
and  healed.  The  penis  was  entirely  gone,  with  an  ulcer  still 
remaining  at  the  opening  o  the  urethra,  which  was  then  at 
the  scrotal  junction.  The  scrotum  and  testicles  were  un- 
injured. 

Case  No.  737  was  also  a  venereal  ulcer  which  began  3 
years  previous  to  his  visit  here.  It  had  its  beginning  in  the 
meatus  and  gradually,  in  spite  of  all  medication,  eroded  its 
way  through  the  dorsal  portion  of  the  glans  penis,  layin^r 
the  entire  glans  wide  open,  then  attacked  the  prepuce  and 
had  destroyed  this  tissue  nearly  around  the  entire  organ  to  a 
distance  of  li  inches  from  the  corona.  This  maj-  have  been 
a  case  of  mixed  infection  at  the  beginning,  but  1  am  of  the 
opinion  that  it  was  a  true  chancre,  as  a  clear  sj'philitic  his- 
tory dated  fi-om  it,  including  the  length  of  time  after  exposure 
before  the  appearance  of  the  sore,  and  to  this  then  was  added 
the  chronic  serpiginous  phagedena. 

Case  No.  1040. — A  strong  healthy  man  ;  muscular  system 
unusually  well  developed ;  very  short  in  stature ;  with  his- 
tory of  having  had  a  bubo  which  was  removed  in  its  entirety 
8  months  before  I  saw  him.  While  yet  in  the  hospital  he 
said  a  sore  developed  in  his  mouth,  the  exact  location  not 
known.  He  was  given  no  medicine  then  and  had  taken 
none  since.  There  had  been  no  skin  eruption  so  far  as 
noticed.  When  seen  the  gums  were  swollen  down  on  a  level 
with  the  cutting  edge  of  the  teeth,  and  at  places  even  be^'ond, 
were  tender  and  had  the  appearance,  especially  behind  the 
molars,  of  severe  ptyalism.  This  condition  had  been  grad- 
ually developing  since  he  left  the  hospital.  The  gums  were 
quite  firm,  were  not  ulcerated,  no  granulations  and  no  tend 
ency  to  bleed  except  where  they  came  in  contact  with  the 
teeth ;  congested,  bluish  in  color,  and  to  a  certain  extent 
fibrous-like  in  appearance.  The  teeth  were  firm  and  con- 
tinued so.  Mercury  and  potassium  iodid  in  enormous 
doses,  with  some  local  astringent  applications,  persisted  in 
for  4  months,  had  relieved  the  trouble  almost  entirely  when 
he  left  the  city.  I  am  unable  to  find  this  condition  described  ; 
it  was  certainly  syphilis,  but  was  not  a  gingivitis  gummosa 
as  described  by  Morrow.  It  was  a  diffuse  hyperplasia,  a 
gingivitis  interstitialis. 


Case  No.  901. — Male ;  was  one  of  most  extensive  condylo- 
mata about  the  anus.  This  condition  followed  a  gonorrhea 
of  the  rectum  which  was  contracted  from  a  male  friend. 
The  growths  were  removed  under  anesthesia  by  the  clamp 
and  cautery  where  pcissible,  and  by  the  cautery  alone  where 
impcssible  to  use  both.     There  was  no  return. 

Case  No.  886,  with  diagnosis  of  acute  pemphigus  vulgaris. 
The  patient  was  a  laliorer,  aged  31,  who  gave  a  possible  his- 
tory of  syphilis  10  years  previously  ;  was  not  strong.  From 
the  time  the  eruption  began  until  death  occurred  only  10 
days  elapsed.  This  condition  is  stated  by  all  authors  to  be 
extremely  rare,  and  by  Zeisler  to  be  classified  rather  as  a 
febris  bullosa,  while  Morrow  in  his  Atlas  describes  it  and 
classifies  it  as  pemphigus,  and  reports  a  case  in  a  man  aged 
33,  but  in  his  SysUm  of  Genilo-  Urinary  Diseases,  Syphilology 
and  Dermatolngy  lie  says  :  "  They  would  better  lie  termed 
unprejudicedly  as  febris  bullosa." 

Below  are  given  Charts  II  and  III,  in  which  is  tab- 
ulated information  that  will  show,  to  say  the  least,  that 
gonorrhea  is  a  very  prevalent  disease,  and  that  it  is 
contracted  early  in  life. 

Chart  No.  II. 


NHMBEE. 

PER  CBNT. 

— 

818 

.337 
229 
27 

Number  of  males  who  had  when  seen,  existing  gonor- 
rhea, or  at  some  previous  time  had  had  the  disease  . 
Number  ot  males  who  h-id  never  had  an  attack  of  gon- 

70.8 
29.2 

Total                                         

1411 

100 

Number  of  attacks  of  gonorrhea  as  ascertained  in  784 

1886 
2.4 

.\verage  number  of  attacks  to  each  indivi'lual    .... 

Chart  No.  III. 


AGE. 

NUMBER  OF 

INDIVIDUALS. 

The  age  at  which  each  individual  first  contracted  gonorrhea 

10 
12 
IS 

1 
1 

3 

14 

2 

l.'i 

13 

16 

38 

17 

61 

18 

93 

19 

85 

20 

75 

21 

77 

22 

62 

2S 

49 

24 

39 

2,'i 

33 

26 

20 

27 

19 

28 

14 

29 

n 

SO 

10 

•ll 

6 

it2 

6 

3S 

4 

34 

4 

3.5 

/ 

36 

4 

37 

38 

I 

39 

I 

40 

1 

41 

1 

42 

S 

43 

1 

44 

2 

4."! 

1 

47 

3 

48 

1 

f>i 

1 

57 

1 

Nuniberof  attacks  not  ascertained  in  .   .». 

68 

Total  number  of  individuals     ...          

813 

The  average  age  at  which  gonorrhea  was  first  contracted 

21.8 

The  information  given  in  these  tables  was  so  unsatis- 
factorily obtained   in  some  and   seemed  so  unreliable 


536 


Thb  Philadklphia 
Mkdical  Jocesal 


]        INDIGENT  VISITORS  TREATED  AT  HOT  SPRINGS.  ARK. 


[Masch  16,  19*1 


that   the   numbers   were    necessarily   cut    down   con- 
siderablj'. 

On  a  basis  of  1,155  cases  there  were  818,  or  70.8%, 
who  had  when  seen  or  at  some  previous  time  had  had 
an  attack  of  gonorrhea,  and  337,  or  29.2%,  had  re- 
mained free  from  an  infection  by  the  gonococcus  up  to 
that  time.  In  229  the  fact  was  either  not  ascertained 
or  was  deemed  unreliable  and  in  the  27  females  it  was 
not  attempted ;  however,  there  were  17  out  of  the  27 
women  that  were  syphilitic  subjects. 

An  attempt  was  also  made  to  determine  the  number 
of  attacks  to  each  individual,  from  which  it  was  de- 
duced, that  in  784  men  there  had  been  1,886  cases  of 
gonorrhea,  an  average  of  2.4  attacks  to  each  man.  As 
these  patients  were  of  all  ages,  from  puberty  to  old  age, 
this  gives,  I  think,  a  fairness  in  the  average.  Again, 
taking  as  a  basis  the  784  cases  in  whom  the  number  of 
attacks  was  ascertained  and  the  337  who  were  found, 
if  not  virtuous,  to  at  least  have  escaped  gonorrheal  in- 
fection, which  seems  to  be  abundantly  liberal,  there 
having  been  34  discarded  who  were  known  to  have  had 
gonorrhea  but  the  number  of  times  not  ascertained,  we 
still  have  the  appalling  average  of  nearly  1.7  attacks  to 
each  individual. 

It  would  seem  that  the  memory'  of  the  first  attack  of 
gonorrhea  would  have  impressed  itself  so  indelibly 
upon  the  minds  of  each  that  the  age  at  which  it  oc- 
curred could  have  been  recalled  at  will ;  however,  there 
were  58  discarded  as  being  unsatisfactor}\  This  leaves 
760  to  determine  the  average  time  of  Ufe  at  which  the 
disease  was  first  contracted,  which  gives  us  the  age  of 
21.8  years.  It  will  be  noticed  by  referring  to  the  chart 
that  the  age  of  10  is  the  first  on  the  list ;  I  have  seen 
one  case  in  private  practice,  of  a  little  boy  8  years  old 
who  had  contracted  the  disease  from  a  girl  aged  12. 
We  have  another  recorded  at  12,  three  at  13,  two  at  14, 
and  then  the  list  rapidly  swells  until  we  reach  IS,  at 
which  age  the  largest  number  of  victims  are  recorded. 
It  is  a  picture  to  the  mind's  eye  of  a  perfect  avalanche 
of  boys,  rushing  peU-meU,  in  their  eagerness  to  be  the 
first  to  receive,  to  nurture  and  to  propagate  in  the 
interests  of  posterity,  the  trouble-making  germ  known 
as  the  gonococcus.  From  18  to  22  there  is  an  apparent 
wavering,  haste  and  eagerness  have  been  partially  sup- 
planted by  caution  and  fear.  The  early  and  unbounded 
passions  of  youth  have  been,  to  some  extent,  superseded 
by  thoughts  of  employment,  of  gaining  a  livelihood,  of 
the  general  responsibilities  attendant  upon  manhood 
and  finally  of  marriage.  From  22  on  down  the  list,  as 
age  increases,  the  number  of  first  attacks  rapidly  de- 
crease; however,  we  still  have  examples  even  up  to  the 
age  of  57,  and  I  may  add  that  nearly  all  of  the  older 
patients  recorded  are  of  men  who  had  contracted  the 
disease  after  losing  by  death  or  otherwise  their  life-- 
companions. 

Many  of  the  cases  seen  were  lingering  attacks  that 
had  existed  oftentimes  for  years,  in  fact  most  aU  of  the 
cases  that  come  here  for  treatment  do  so  because  they 
have  failed  to  be  cured  elsewhere.  It  will  be  noticed 
that  in  Chart  I  there  were  76  cases  of  gleet  and  gonor- 
rhea, the  proportion  of  chronic  cases  were  so  much  in 
advance  of  the  acute  that  it  is  scarcely  worth  our  while 
to  mention  the  latter.  Experience  teaches  us  that  a 
gonorrheal  inflammation  of  the  urethra,  continued  over 
a  long  period  of  time,  or  even  but  a  comparatively 
brief  time,  if  very  severe,  will  and  does  cause  granula- 
tions which  as  time  passes  become  fibrQlated  and  later 
begin  to  shorten  or  contract  as  in  an  ordinary  scar.    The 


urethral  caliber  is  then  encroached  upon  and  the  bal- 
ance existing  between  the  expulsive  force  of  the  bladder 
and  the  friction  of  the  stream  along  the  urethra  is  dis- 
turbed and  symptoms  follow.  A  constant  irritation 
and  inflammation  is  then  kept  up  by  this  beginning 
contraction  as  I  have  pointed  out'  I  referred  then  to 
the  mechanical  obstruction,  the  chemical  irritation, 
and  to  a  mechanical  irritation  and  "by  mechanical 
irritation  I  mean  the  encroaching  upon  and  squeering 
of  the  nerve-endings  in  the  mucous  membrane  by  the 
newly  formed  fibrous  tissue."  As  the  urethra  is  claimed 
by  Civiale  to  possess  a  sympathetic  sensitiveness  inde- 
pendent of  the  local,  then  through  the  third  agent — 
mechanical  irritation — we  ascribe  as  being  the  principal, 
if  not  the  entire  cause,  when  he  refers  to  this  sensitive- 
ness "  being  aggravated  it  may  awaken  sympathetic 
response  in  every  organ  and  function  of  the  body." 
Aside  then  from  the  suffering  and  inconvenience 
attendant  upon  the  disease  per  se  we  have  a  grave  com- 
plication, or  result,  in  stricture  as  evidenced  by  the 
simple  case  No.  715  reported  above,  in  which,  even  the 
act  of  urination  should  not  have  been  interfered  with  to 
a  noticeable  degree.  This  case  was  an  example  in  which 
the  mechanical  irritation  "  awakened  the  sympathetic 
response '"  and  produced  the  symptoms  he  had  and  relief 
began  as  soon  as  the  hard,  fibrous  tissue  was  divided 
which  allowed  of  the  relaxation  of  each  fiber  and  a 
consequent  inability  to  produce  pressure.  The  question 
arises  then  why  we  do  not  have  these  or  similar  respon- 
sive symptoms  in  every  case  of  stricture,  and  I  would 
answer  that  we  do  almost  invariably  and  more  especially 
if  the  stricture  be  an  annular  one  and  located  in  the 
fossa  navicularis.  It  is  rare  that  we  have  a  stricture 
within  one-half  inch  of  the  meatus  that  we  do  not  have 
symptoms  other  than  the  interference  with  the  passage 
of  the  urine.  To  determine  the  validity  of  this  point 
I  made  several  examinations  and  found,  that  out  of  194 
patients  examined  for  stricture,  that  condition  existed 
in  184.  Some  of  these  had  discharges  at  the  time  and 
others  were  only  suffering  from  the  resultant  conditions 
of  that  discharge,  but  all  had  symptoms  pointing  to  a 
urethral  stricture,  otherwise  the  examination  would  not 
have  been  made. 

A  word  here  may  not  be  out  of  place  in  reference  to 
the  treatment  of  chronic  gonorrhea  at  this  resort  and 
why  it  is  successful.  It  is  not  an  uncommon  occur- 
rence, in  fact  a  very  frequent  one,  for  visitors  who  have 
been  here  a  few  days,  using  the  waters,  to  call  the 
attention  of  their  physician  to  a  slight  urethral  dis- 
charge, making  the  statement,  that  several  weeks  or 
months  before  they  had  had  an  attack  of  gonorrhea,  but 
thought  it  entirely  cured.  In  others  a  slight,  but 
noticeable  discharge  would  be  increased.  I  would  ac- 
count for  this  by  the  well-known  fact  that  these  waters 
are  stimulating  to  the  urethra  and  during  the  first  few 
days  of  its  internal  use  decidedly  so.  In  an  acute  case 
the  hot  water  is  to  some  extent  harmful,  although  that 
from  many  of  the  cold  springs  is  very  beneficial  as 
soothing  diluents.  It  is  also  an  established  fact,  that  a 
low-grade  inflammation,  such  as  we  have  in  gleet,  de- 
mands a  stimulant  to  bring  about  a  healthy  reaction, 
and  this  we  get,  in  various  degrees,  from  the  use  of  the 
hot  waters,  by  increasing  or  decreasing  the  amount  used 
as  the  case  m,\v  demand,  and  to  this  then  is  added  the 
local  treatment. 


I  •'  The  ReUiion  of  Organic  Slriclare  to  HTpensthesim  of  the  ProstMic  Vre- 

thra,''  puhlishfd  in  the  Lancfl-Oimie,  August  15,  1896. 


March  16,  1901] 


INDIGENT  VISITORS  TREATED  AT  HOT  SPRINGS,  ARK. 


(Thi  Philadklphia 
L  Medicai.  Joukhal 


537 


In  taking  up  the  remaining  subject,  that  of  syphilis, 
we  will  begin  by  giving  Charts  IV,  V,  and  VI. 

Chart  No.  IV. 


-- 

AOB. 

NDMBBK  OF 

ISDIVIDUALS. 

The  age  .-it  wbiL-li  eacli  patient  contracted  syphilis 

15 

3 

16 

8 

Vi 

20 

18 

41 

19 

38 

20 

51 

21 

77 

22 

84 

23 

65 

24 

51 

2S 

59 

26 

38 

27 

42 

28 

43 

29 

30 

30 

27 

31 

27 

32 

12 

33 

10 

34 

13 

.35 

17 

36 

13 

37 

9 

38 

9 

39 

6 

40 

4 

41 

5 

42 

3 

43 

1 

44 

3 

45 

1 

46 

4 

47 

2 

48 

3 

49 

1 

52 

2 

53 

2 

54 

1 

57 

1 

60 

1 

63 

1 

65 

1 

Inherited  syphilis 

2 

Total 

25.7 

831 

The  average  age  at  which  syphilis  was  contracted 

In  comparing  Chart  IV  with  the  similar  one  for  gon- 
orrhea we  see  that  infection  begins  at  the  age  of  15  in- 
stead of  10,  it  reaches  its  greatest  number  at  22  instead 
of  18,  and  is  also  continued  to  a  more  advanced  age, 
65  instead  of  57.  The  ratio  we  find  to  be  pretty  con- 
stant all  the  way  through.  The  reason  for  this  being 
so,  can  be  accounted  for  by  gonorrhea  being  of  more 
frequent  occurrence ;  by  boys  in  their  first  amours  be- 
ing led  by  the  bolder  women  that  frequent  the  streets. 
These  women  take  little  care  of  their  persons  and  prac- 
tically all  have  a  partially  cured  gonorrhea,  while  they 
do  not  all  have  syphilis,  being  trained  in  the  art  of  ob- 
serving their  victims  for  their  own  protection,  which 
can  be  done  better  ordinarily  in  syphilis  than  in  gon- 
orrhea, hence  they  become  sources  of  great  danger. 
Later,  too,  the  men  become  more  bold  and  make  vic- 
tims of  comparatively  innocent  parties,  and  these 
women  from  ignorance,  and  real  or  assumed  modesty, 
are  unable  to  protect  themselves,  hence  contract  syph- 
ilis easily  and  likewise  distribute  it  as  easily  among 
other  "  special  friends."  Care  also  in  postamour  ablu- 
tions and  a  lesser  susceptibility  of  the  urethra  to  the 
action  of  the  gonococcus  in  the  older  subjects  has  its 
influence. 

In  Chart  V  is  given  the  most  important  data  we  have 
to  ofier.  When  we  glance  at  it  and  see  the  great  num- 
ber who  have  had  syphilis  for  so  many  years,  and  to 
know  that  the  greater  proportion  of  them  were  still 
suffering  from  the  activity  of  the  disease,  it  is,  to  say 
the  least,  discouraging.  I  am  not  willing  to  say  that 
they  were  all  suffering  from  syphilis  direct,  many  were 


Chart  No.  V. 


LENGTH 

KDMBBR  OF 

OF  TIME. 

INDIVmUAIS. 

The  leu^th  of  time  syphilis  had  exi.stud  in  each  pa- 
tient when  seen,  counting  as  accurately  as  possiole 

1  week. 

2 

2  weeks. 

4 

3 
4 

1 

10 

5 

4 

6        " 

10 

2  months. 

28 

3       ," 

41 

4       " 

40 

5       " 

31 

6 

24 

7 

22 

8 

24 

9 

11 

10       " 

17 

12 

53 

14 

16 

16 

11 

18 

28 

20 

14 

2  years. 

64 

2ii" 

28 

3      " 

65 

4      " 

50 

5      " 

31 

6      " 

22 

7      " 

28 

8      " 

16 

9       " 

10 

10      " 

26 

11       " 

8 

12       " 

12 

13       " 

7 

14       " 

5 

16      " 

4 

16       " 

6 

17       " 

2 

IS       " 

4 

19       " 

1 

20       " 

9 

22       " 

1 

23       " 

2 

24      " 

2 

25      " 

2 

29       " 

1 

30      ■■ 

1 

34      " 

1 

Number  in  whom  there  was  no  certain  knowledge 

of  a  chancre 

30 

2 

Total 

831 

The  average  time  that  each  patient  had  been  affected 

3  years  and 
7.8  months. 

Chart  No.  VI. 


Urethral  chancres  seen,  inchiding  those  of  meatus                  10 

Number  of  syphilitic  patients  in  whom  there  was  no  certain  knowl- 
edge of  a  chancre ^0 

Extragenital  Chancres. 

Chancre  on  tongue • • 

"         "    tonsil * 

"        "lip I 

*'        "    chin ' 

Multiple  Ciiasckes. 

Two  chancres      ^ 

Three     "         ■• 


suffering  from  the  effects  of  its  poison,  possibly  more 
from  the  effects  of  its  irrational  treatment,  and  still 
others  from  the  thoughts  of  having  had  it.  To  at  once 
appreciate  the  magnitude  of  the  working  forces  of  this 
disease,  let  us  make  some  deductions  from  the  cases  I 
present,  taken  as  a  standard.  There  were  799  cases 
whose  average  time  of  battling  with  the  infection  was 
over  3  years  and  7  months.  Reduce  this  to  years  for 
the  whole  number  and  we  have  a  little  oyer  2,916 
years.  Again,  taking  the  data  furnished  by  Gihon,  who 
estimated  that  there  are  at  one  time  2,000,000  cases  of 
syjihilis  in  the  United  States,  and  from  this  at  the  same 
ratio  of  existence  in  each  case  of  the  disease,  we  have 
7,300,000  years ;  and  as  Buret  has  traced  the  disease 
back  nearly  7,000   years,  and  we  come  to  compute  for 


538  ^*^    PHrLADELPHIAl 

Medical  Journal  J 


INDIGENT  VISITORS  TREATED  AT  HOT  SPRINGS,  ARK. 


[Mabch  in,  1901 


the  whole  world  for  that  length  of  time  including  the 
terrific  ravages  of  the  plagues,  we  find  ourselves  com- 
pletely lost  in  the  immensity  of  numbers — and  yet  this 
little  something  that  has  given  so  much  trouble  and  for 
such  a  great  length  of  time  is  not  even  known.  By 
stealth  these  victims  keep  the  knowledge  of  their  suffer- 
ing from  the  public  gaze,  but  that  monstrous  reaper — 
tuberculosis — almost  pales  into  insignificance  in  com- 
parison. After  years  of  constant  attack  of  the  poison 
of  sj'philis  upon  the  system,  whatever  it  is,  it  is  true 
its  forces  are  depleted  and  attenuated,  but  likewise  are 
the  opposing  forces  in  the  human  victim,  and  we  have 
left  a  constitution  eminently  fitted  for  furthering  mor- 
tality. 

The  fact,  of  course,  is  to  be  considered  that  many 
of  the  older  cases  we  see  here  are  the  exceptions,  and 
that  we  must  not  lose  sight  of  the  fact  that  there  are 
hundreds  who  never  see  and  apparently  never  know  of 
any  inconvenience  from  the  disease  a  few  months  after 
infection,  and  it  will  again  be  necessary  to  keep  in  mind 
the  class  of  patients  reported.  Neglect  in  the  early  and 
proper  treatment,  continued  over  a  sufficient  length  of 
time,  even  in  the  absence  of  symptoms,  is  so  often  neg- 
lected by  these  people  that  it  becomes  a  greater  factor 
of  harm  than  in  private  practice. 

I  also  tabulated  the  special  features  of  those  cases 
that  had  had  the  disease  for  4  years  and  over,  to  see 
what  the  prevailing  ailments  might  be,  and  while  I 
found  a  great  variety  of  results  there  were  special  lines 
very  noticeable,  and  at  the  same  time  convincing  proof 
that  the  man  who  contracts  syphilis  may  indeed  be  im- 
pressed with  the  idea  that  his  troubles  in  life  have  well 
begun,  and  as  time  goes  on,  he  too  often  is  further  made 
to  believe,  from  experience,  that  they  increase  as  he 
grows  older.  Among  these  features  were  gummatous 
ulcers  in  various  locations,  indefinite  pains,  rheumatism, 
anemia,  many  bad  stomachs,  necrosis  of  bone,  rupia, 
and  a  point  noticed  particularly  was  the  number  in 
whom  the  glands  were  markedly  enlarged,  even  for  a 
period  of  8  or  10  years  or  more.  Ulcers  were  seen  in 
great  numbers,  and  small  multiple  sores  well  distrib- 
uted over  the  entire  body  were  much  more  frequent 
than  I  had  been  led  to  believe  they  would  be.  The 
points  other  than  enlarged  glands,  weakened  stomachs, 
anemia,  and  indefinite  pains  will  be  passed  by,  merely 
having  been  mentioned. 

A  marked  glandular  enlargement,  noticeable  several 
years  after  infection,  is  quite  frequent  and  possibly  more 
so  among  these  patients  than  in  private  practice,  and 
is  probably  due,  when  dependent  upon  this  disease,  to 
the  fact  that  treatment  in  the  early  stages  is  not  per- 
sisted in  until  they  are  reduced,  they  then  become  per- 
manently enlarged  from  a  new  growth  of  interstitial 
fibrous  tissue  which  resists,  to  a  great  extent,  all  treat- 
ment. These  glands  are  not  of  especial  value  as  a 
diagnostic  sign,  so  late  in  the  disease,  in  determining 
whether  it  is  still  present  or  not,  and,  of  themselves,  do 
not  demand  treatment.  In  the  laboring  classes  the  in- 
guinal and  epitrochlear  glands  are  often  enlarged,  hard 
labor  itself  being  the  only  tangible  cause,  and  the 
former  are  most  always  permanently  enlarged  in  patients 
who  have  had  protracted  attacks  of  gonorrhea. 

The  other  conditions — weakened  stomach,  anemia, 
and  indefinite  pains  —  follow  each  other  naturally. 
It  is  the  custom  of  many  physicians  to  prescribe 
potassium  iodid  in  the  early  disease,  even  in  large 
doses,  along  with  mercury  in  some  form  as  a  routine 
treatment.     If  this  is  not  done,  often  the  patient  him- 


self, especially  the  dispensary  patient,  goes  to  the  drug- 
gist and  obtains  a  bottle  of  iodid  and  begins  to  treat 
himself.  He  has  heard  of  what  a  wonderful  walking 
barometer  he  may  become,  by  mercury  being  deposited 
in  his  bones,  should  he  take  that  drug.  He  soon  finds 
by  experience  that  potash  will  produce  pimples  on  the 
skin,  and  concludes  at  once  that  it  is  "  ridding  the  sys- 
tem of  bad  blood."  Every  tramp  you  see  basking  in 
the  sunshine  on  the  mountainside  has  a  small  pocket 
mirror  which  he  consults  frequently  to  see  the  progress 
of  his  pimples.  Like  the  ancient  Sun  Worshipers  they 
worship  them  because  they  can  see  them.  A  few  weeks 
or  months  after  experiencing  this  eruptive  process  for  a 
considerable  time,  some  real  or  imaginary  symptom 
causes  him  to  reproduce  it.  Again  and  again  this  is 
repeated  until  his  stomach  begins  to  rebel  under  the 
weight  of  the  potash  habit.  From  a  generally  inactive 
stomach,  the  proper  amount  of  nourishment  is  not 
supplied  to  the  sj'stem  and  anemia  follows.  In  the 
trail  of  anemia  may  then  revive  the  latent  forces  of 
syphilis,  and  attack  any  organ  or  tissue  of  the  body. 
The  mental  capacity  is  lessened,  the  nerves  assert  them- 
selves, and  we  have  the  indefinite  pains  spoken  of 
above.  These  pains  are  indefinite  as  to  intensity,  loca- 
tion and  time  of  occurrence.  The  intensity  of  the  pain 
varies  very  much,  but  is  usually  not  severe  and  is  ach- 
ing in  character ;  they  are  inconstant  as  to  their  per- 
sistency in  any  one  part ;  they  are  not  influenced  to 
any  extent  by  the  hour  of  the  day.  but  the  changes  in 
the  weather  have  much  to  do  with  their  occurrence  and 
severity.  That  the  potassium  iodid  is  the  prime 
factor  indirectly  in  developing  these  conditions  I  do 
not  doubt,  but  that  it  is  a  cause  direct.  I  do  doubt,  for 
mercury  will  relieve  them  ;  however,  this  may  be  due 
to  some  extent  to  its  rapid  tonic  action  on  the  blood  in 
this  condition.  By  avoiding  mercury  and  by  abus- 
ing the  use  of  the  potassium  iodid  this  condition  is 
brought  about,  yet  is  always,  by  the  patient,  attributed 
to  mercury.  He  connects  it  with  mercury  from  the  fact 
that  the  pains  are  more  severe  during  dnmp  and  cloudy 
weather.  The  pain  often  seems  deep-seated,  his  bones 
ache  and  he  imagines  the  barometric  state  has  been 
reached.  He  comes  here  to  bathe  for  the  purpose  of 
getting  rid  of  the  mercury,  of  which  he  has  taken  a 
little  perhaps  years  before,  but  always  includes  his  usual 
course  of  potassium  iodid.  which  seems  as  essential  to 
him  as  does  the  cocktail  to  the  habitual  rounder. 
Finally,  when  he  is  disappointed  at  not  obtaining  relief, 
he  consults  a  physician  and  usually  refuses  to  take 
mercury,  but  when  it  is  given  to  him  secretly  he  is  re- 
lieved. This  may  be  an  example  of  simUia  similibus 
curantur,  but  I  think  instead,  it  is  a  case  of  syphilis 
meeting  with  its  proper  antidote.  Where  we  may 
possibly  see  one  injured  by  the  use  of  mercur}-  we  see 
hundreds  that  are  injured  irreparably  by  the  uncalled 
for  and  irrational  use  of  the  potassium  iodid. 


Healtb  of  the  Army. — The  Surgeon-General  has  re- 
ceived a  report  from  Co!.  Green'.eaf,  chief  surgeon  of  the 
division  of  the  Philippines,  regarding  the  health  of  the  army 
in  that  locality.  The  report  which  was  dated  Manila.  Jan- 
uary 15,  1901,  showed  tnat  at  that  time  the  strength  of  the 
command  was  67,415,  and  the  percentage  of  the  sick  waa 
7.49.  The  consolidated  weekly  report  of  hospitals  in  Manila 
and  the  military  hospitals  in  the  division  shows  2,400  sick,  of 
which  390  were  cases  of  malaria,  1  fever,  826  dysentery,  25S 
wounds  and  injuries,  etc.  There  were  S3  deaths  among  the 
troops  during  the  month  ended  January  15. 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articlea,  Clinical  Memoranda.  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.  Reprints  (250)  of  Original  Articles  will  be  turnished  gratis  to  Authors  making 
the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestoat  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8. 


James  Hendrik  I^loyd,  A.M.,  M.D.,  Editor-in-Chief 
Jrucs  L.  Saldjgkr,  M.D.,  Assoeiale  Editor 
AsMtant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyer,  M.D. 

D.  L.  Kdsall,  M.D.  T.  L.  Coley,  M.D. 

J.  M.  SWA>-,  M.D.  W.  A.  N.  DoRLAND,  M.D. 

J.  H.  Gibbon.  M.D. 


Vol.  VII,  No.  12 


MARCH  23,  1901 


5.00  Per  Annum 


I 


The  Oxytocic  Action  of  Lumbar  iDJeetion  of 
Cocain. — Since  the  startling  innovation  of  lumbar 
puncture  with  subarachnoid  injection  of  cocain  for  pur- 
poses of  general  anesthesia  the  medical  journals  have 
from  time  to  time  published  reports  of  cases  so  oper- 
ated upon.  This  method  of  anesthesia  has  especially 
received  support  on  the  continent  and  by  the  French 
surgeons  in  particular.  The  records  of  TufEer,  who 
has  probably  experimented  on  the  subject  more  ex- 
tensively than  any  other  individual  operator,  are  not 
encouraging.  The  very  decided  mortality  attendant 
upon  cocain-injections  into  the  spinal  canal  would  not 
warrant  the  general  adoption  of  such  an  apparently 
dangerous  method  of  anesthesia  save  in  those  cases  in 
which  other  anesthetics  should  be  contraindicated. 

Following  shortly  upon  the  general  surgical  use  of 
lumbar  injections  of  cocain  came  the  suggestion  of  its 
employment  in  labor  for  purposes  of  anesthesia.  Under 
the  action  of  the  drug  the  labors  were  found  to  pro- 
gress without  suffering  on  the  part  of  the  patients  and, 
according  to  the  published  reports,  without  any  evil 
consequences  to  mother  or  child.  It  was  noted,  how- 
ever, by  several  of  the  experimenters  that  there  devel- 
oped a  tendency  to  uterine  and  abdominal  inertia,  the 
former  from  a  direct  benumbing  action  on  the  uterine 
muscles  and  the  latter  probably  as  a  consequence  of 
the  loss  of  suffering  on  the  part  of  the  patient  who  ex- 
perienced no  stimulus  to  bear  down  and  thereby  hasten 
the  delivery  of  the  fetus.  Thus,  Marx,  of  New  York, 
in  a  series  of  40  cases  thus  treated,  was  compelled  to 
hasten  delivery  by  the  application  of  forceps  in  16  in- 
stances,— an  unusually  high  percentage  of  operative 
cases. 

Recently,  however,  the  distinguished  French  obstet- 
rician and  gynecologist,  Doleris,  has  presented  papers 
before  various  well-known  societies,  including  the 
Academie  de  Medecine,  the  Paris  Society  of  Obstetrics 
and  Gynecology,  and  the  MedicoChirurgical  Society  of 
Paris,  in  which  he  strongly  advocates  the  use  of  lumbar 
injections  of  cocain  as  an  efficient  oxytocic.  Coming 
from  such  a  source,  and  directly  antagonizing  the 
former  published  records  as  to  the  action  of  the  drug 
thus  administered,  these  communications  must  elicit 
considerable  interest  the  world  over.  Doleris  states 
that  while  anesthesia  is  complete,  there  is  no  diminu- 
tion in  the  intensity  of  the  uterine  contractions,  which 
are   of    rapid    occurrence   and    normal    duration,   and 


produce  a  speedy  and  progressive  dilatation  of  the 
OS  with  normal  obliteration  of  the  cervix.  After  de- 
livery of  the  fetus  has  been  accomplished  in  these 
cases,  the  uteriae  retraction  and  contraction  are  normal. 
This  was  especially  noted  in  a  case  of  Cesarean  section 
for  pelvic  contraction,  which  waa  performed  by  Doleris 
on  the  eighth  of  October  last,  the  Sanger  operation 
being  selected  and  the  results  being  all  that  could  be 
desired.  In  fact,  Doleris  remarks  that  in  no  other 
Cesarean  operation  performed  by  him  had  he  noted 
such  complete  and  persistent  uterine  contraction,  and 
he  further  suggests  that  in  cases  of  labor  in  which  the 
operation  of  version  would  have  to  be  performed,  this 
firm  contraction  resulting  from  the  action  of  the  drug 
might  contraindicate  its  use. 

Kreis,  however,  who  had  performed  version  under 
cocain  anesthesia  secured  through  lumbar  puncture, 
experienced  no  difficulty  from  this  source.  Contrary 
to  the  general  experience  of  the  experimenters  thus  far 
DoKris  would  suggest  the  use  of  cocain-injections  as 
the  proper  course  to  pursue  in  the  treatment  of  uterine 
inertia.  He  maintains  that  even  in  small  doses  of  one 
centigram  of  the  cocain  solution  there  follows  a  posi- 
tive action  on  the  motor  uterine  nerves  whereby  efiBcient 
labor-pains  are  induced.  He  even  goes  so  far  as  to  say 
this  might  eventually  become  the  accepted  method  of 
induction  of  labor. 

Remarkable  as  are  these  statements  of  the  eminent 
French  obstetrician  we  feel  that  without  further  con- 
firmation from  other  equally  reliable  sources  this  method 
of  treatment  cannot  conscientiously  receive  the  endorse- 
ment of  obstetricians  any  more  than  could  the  sugges- 
tion of  Lawson  Tait,  published  immediately  prior  to 
his  death,  that  Cesarean  section  should  be  adopted  as 
the  proper  treatment  for  placenta  previa.  With  the 
evident  mortality  that  has  attended  the  use  of  sub- 
arachnoid injections  of  cocain  in  general  surgery  one 
would  hardly  feel  justified  in  exposing  his  parturient 
patients  to  risks  that  legally  as  well  as  morally  would 
not  seem  warranted.  The  profession  will  await  with 
interest  the  future  developments  in  this  line  of  experi- 
mentation. 

The  Differential  Determination  of  Human  Blood 
from  that  of  Animals. — The  determination  of  a  satis- 
factory method  of  differentiating  human  blood  from 
that  of  animals  is  a  problem  of  recognized  medico-legal 


540 


Medical  Journal  J 


EDITORIAL  COMMENT 


[XaBCH  23,  IMl 


importance.     The  spectroscopic  examination  will  prove 
merely  the  presence  of  hemoglobin,  but  will  furnish  no 
clue  as  to  the  derivation  of  the  blood.     The  character 
of  the  crystals  of  hemoglobin  varies  in  different  animals, 
but  from  a  medico-legal  point  of  view,  this  difference 
cannot  be  utilized  owing  to  the  fact  that  a  considerable 
quantity  of  fresh  blood  is  required.     The  study  of  the 
relative  differences  between  the  red  blood-corpuscles  is 
comparatively  fruitless,  for  within  the  limits  of  size  of 
a  human  red  blood-cell  there  might  be  included  those 
of  the  dog,  rabbit,  and  perhaps  other  domestic  animals. 
Equally  uncertain  is  the  test  of  the  time  of  coagulation 
of  fresh  blood.     We  are  indebted  to  a  French  observer, 
Bordet,  for  a  decidedly  practical  advance  in  this  direc- 
tion.    In  1898  he  showed  that  after  injecting  into  an 
animal    the  defibrinated  blood  of  a  different    species 
there  were  developed   in  the  blood  of  this  animal  two 
substances  which  he  termed  agglutinin  and  hemolysin. 
The  former  of  these  possesses  the  property  of  agglutinat- 
ing the  red  cells;  the  latter  disintegrates  them.     Their 
peculiar  projjerties  are  exerted  only  upon  the  particular 
blood  with  which  the  animal  was  inoculated.     Follow- 
ing this  investigator   Uhlenhuth,    of  the    Institute    of 
Hygiene  of  the  Faculty  of  Medicine  of  Greifswald,  per- 
formed  a   series   of    experiments   upon    rabbits,    first 
with  bovine  blood,  then  with  human  blood.     He  in- 
ected  into  the  peritoneal  cavity  of  these  animals  10  cc.  of 
defibrinated  beef  blood,  and  afterfive  injections  theserum 
of  the  rabbits'  blood  was  so  modified  as  to  cause  agglu- 
tination and  to  possess  hemolytic  properties  towards 
the  blood   of  beef  exclusively.     He    then    prepared  a 
series  of  dilutions  of  human  blood  and  the  blood   of 
nineteen    different  animals,    principally  the   domestic 
animals.     This  was  allowed  to  settle,  or  was  filtered  and 
an  equal  quantity  of  saline  solution  was  added  to  each 
tube.     By  means  of  a  pipette,  six  to  eight  drops  of  serum 
of  the  rabbit,  which  had  received  the  injections  of  the 
defibrinated  beef  blood,  were  added  to  each  tube.  In  all 
the  tubes  save  the  one  containing  the  blood  of  beef,  the 
liquid  remained  absolutely  clear,  but  in  the  tube  con- 
taining this  blood   a  flocculent  precipitate  was  formed. 
The  same  experiment  was  repeated  with  the  serum  of 
rabbits  which  had  received  injections   of   defibrinated 
human  blood.     It  was  found  upon  adding  a  dilution  of 
human  blood  to  tubes  similarly  prepared  that  no  pre- 
cipitate was  formed  except  in  that  containing  the  serum 
of  the   rabbit  which    had    received    the   injections   of 
human   blood.      More  recently   and    independent  of 
Uhlenhuth's  work,  Wasserman  and  Schiit/.e,  of  the  In- 
stitute for  the  Study  of  Infectious   Diseases  in   Berlin, 
pursued   similar   investigations.     At   intervals  of  two 
days  they  injected  into  the  peritoneal  cavity  of  rabbits 
10  cc.  of  human  blood-serum  deprived   of  its  cellular 
elements.     After  five  or  six  injections  the  animals  were 
bled  from  the  carotid.     The  blood  was  collected  care- 
fully and  allowed  to  separate  at  low  temperature.    Upon 
adding  to  the  serum  of  the   rabbit  a  weak  solution  of 


human  blood  diluted  with  physiological  salt-solution, 
or  distilled  water,  a  precipitate  was  immediately  formed. 
These  observers  declare  that  the  action  of  the  serum  of 
rabbits  so  treated  is  specific,  for  the  reaction  is  not  ob- 
served with  any  other  than  human  blood.  Uhlenhuth 
has  found  that  this  specific  reaction  may  be  obtained 
with  a  drop  of  blood  which  had  been  dried  for  four 
weeks  upon  a  board. 

We  hope  that  these  investigations  may  have  an  im- 
portant medico-legal  bearing  and  may  furnish  us  finally 
with  an  absolute,  as  well  as  thoroughly  practical,  differ- 
ential test.  A  resume  of  these  experiments  from  the 
pen  of  L,  Cheinisse  appears  in  La  Semaine  Medicale  of 
February  27,  1901.  Bordet's  original  paper  was  pub- 
lished in  the  Annales  de  VInstitut  Pasteur,  October,  1898; 
Uhlenhuth's  in  Deutsche  medicini^he  Wochenschrift,  Feb- 
ruary 7,  1901 ;  and  the  paper  of  Wassermann  and 
Schiitze  will  be  found  in  Berliner  klinische  Wocken- 
schrifi,  of  February  18,  1901. 

The  Crusade  Against  Cigarettes. — According  to 
The  Outlook,  measures  directed  against  the  sale  of  cigar- 
ettes have  occupied  much  attention  in  the  various  State 
Legislatures  this  past  winter.  One  of  the  most  radical 
measures  is  that  adopted  by  the  lower  house  of  the  New 
Hampshire  Legislature.  This  law  provides  that  here- 
after no  person,  firm  or  corporation  shall  make,  sell  or 
keep  for  sale  any  form  of  cigarette.  It  makes  even  the  ' 
gift  of  a  cigarette  to  a  minora  misdemeanor.  The  pen- 
alty is  a  fine  of  ten  dollars  for  a  first  offense  and  fifty  dol- 
lars forany  subsequentoffense.  The  magazine  from  which 
we  quote  says  that  this  act  is  a  sample  of  those  which 
have  been  presented  to  most  of  the  State  Legislatures. 
It  seems  that  eleven  States  have  already  passed  laws 
against  the  cigarette,  and  that  only  two  States — Louis- 
iana and  Wyoming — have  not  given  the  subject  some 
attention.  These  measures  seem  to  win  support  very 
largely  from  the  fact  that  there  is  such  a  widespread 
belief  that  this  particular  use  of  tobacco  is  especially 
prevalent  among  boys  and  young  men,  and  that  it  is 
doing  incalculable  injury  to  many  of  the  rising  genera- 
tion. Even  among  legislators  who  are  themselves 
smokers  it  is  not  difficult  to  win  support  for  such  bills, 
because  the_v  put  this  abuse  on  the  same  plane  as  the 
sale  of  liquor  to  minors.  The  more  rational  reformers 
who  are  frankly  opposed  to  the  use  of  cigarettes 
(not  only  by  minors  but  also  by  adults,  and  especially 
by  women)  will  very  much  doubt  the  expediency  of 
such  stringent  legislation  as  that  adopted  in  New 
Hampshire.  It  is  notorious  that  sumptuary  and  pro- 
hibitory legislation  generally  over-reaches  itself,  and  in 
the  end  falls  a  dead  letter.  We  ourselves  doubt 
whether  men  and  young  society  women  can  be  legis- 
lated out  of  the  use  of  cigarettes.  We  even  believe  that 
such  a  law,  when  aimed  at  adults,  is  essentially  tyran- 
nous and  that  it  is  a  specimen  of  the  worst  form  of 
paternalism.     In  the  case  of  minors  the  question  is,  of 


Mabch  23,  1901] 


EDITORIAL  COMMENT 


("The  Pu 
L  Mbdicj 


ILADELPUIA 
-AL  JOCRHAL 


541 


course,  different ;  and  the  attention  of  law-makers 
should  be  limited  to  devising  means  to  stop  the  sale  of 
cigarettes  to  this  class,  just  as  the  law  aims  to  stop  the 
sale  of  liquors  to  it.  The  best  preventive  after  all  is  a 
sound  public  sentiment,  and  this  can  be  directed  against 
adults  of  both  sexes,  as  well  as  against  boys.  There  is 
doubtless  a  prejudice  abroad  against  cigarettes,  but  it 
seems  to  be  based  in  part  upon  nothing  higher  than 
the  dislike  which  most  normal  persons  have  for  the 
fumes  of  burning  paper. 

The  Antitoxin-Treatment  of  Diphtheria. — While 
it  is  within  the  bounds  of  moderation  to  state  that  the 
mortality  from  diphtheria  has  been  reduced  about  one- 
half  in  consequence  of  the  employment  of  the  antitoxin 
in  treatment,  it  is  generally  recognized  that  the  best  re- 
sults are  obtained  the  earlier  in  the  progress  of  the  disease 
the  treatment  is  instituted.  It  has  also  been  learned  that 
maximum  doses  should  be  injected  at  once  and  be  re- 
peated in  accordance  with  the  indications  in  the  indi- 
vidual case.  Certain  differences  are  observed,  also,  if 
the  cases  are  classified  in  accordance  with  their  charac- 
ter. Thus,  Escherich  {Berliner  klinische  Wochensrhrift, 
1901,  No.  2,  p.  38)  recognizes  three  varieties  of  diph- 
theria :  (1)  The  local  variety,  with  slight  susceptibility 
to  the  action  of  the  toxin,  and  locally  limited  superfi- 
cial predisposition  ;  (2)  the  progressive  variety,  with 
slight  susceptibility  to  the  action  of  the  toxin,  extensive 
superficial  predisposition,  and  extension  to  the  air- 
passages  ;  (3)  the  toxic-septic  variety,  (A)  with  marked 
susceptibility  to  the  action  of  the  toxin,  and  circum- 
scribed local  lesions  (hypertoxic  variety),  (B)  with 
marked  susceptibility  to  the  action  of  the  toxin  and 
local  mixed  infection,  (a)  with  pyogenic  cocci  (phleg- 
monous, necrotic,  septic  variety),  (/))  with  putrefactive 
processes  (fetid  variety),  (c)  with  gangrene  (gangrenous 
variety),  (d)  with  the  hemorrhagic  diathesis  (hemor- 
rhagic variety).  An  analysis  of  the  cases  under  ob- 
servation, classified  according  to  this  plan,  shows  that 
in  the  preantitoxin  period,  from  1890  to  1894,  there 
were  treated  115  cases  of  diphtheria,  with  a  mortality 
of  45.2%.  Of  these  cases,  30  were  classified  as  local- 
ized, 74  as  progressive  (croup);  11  as  septic-toxic,  the 
mortality  in  each  group  being,  respectively,  nil,  55A'/c 
and  100%.  In  the  succeeding,  antitoxin,  period,  from 
1894  to  1899,  there  were  treated  1,147  cases,  with  a 
mortality  of  13,08%.  Of  these,  593  were  localized, 
378  progressive,  176  septic-toxic,  and  the  mortality  was, 
respectively,  0.17%,  19.58%,  and  4262%. 

Anti-Diphtheritic  Serum. — In  a  recent  article  in 
the  Munchener  medicinische  Wochenschrifl,  .January  15, 
1901,  by  Trumpp,  certain  facts  regarding  the  action  of 
anti-diphtheritic  serum  are  stated  that  are  not  gener- 
ally known,  and,  if  true,  are  of  considerable  importance. 

Trumpp  had  under  his  care  a  child  to  whom  3  doses, 
each   containing    1,500   units,  were  given  without  the 


least  influence  upon  the  rapid  course  and  fatal  ter- 
mination of  the  disease,  and  as  the  first  dose  was  given 
at  the  very  commencement  of  the  symptoms,  it  seemed 
to  him  that  there  should  be  some  reason  why  in  this 
particular  instance  the  effect  had  been  so  entirely  neg- 
ative. There  could  be  no  doubt  about  the  diagnosis 
because  the  organisms  were  found  in  considerable 
numbers,  and  there  was  no  reason  to  suppose  that 
mixed  infection  existed,  for  nothing  in  the  bacterio- 
logical examinations  or  in  the  clinical  course  of  the 
disease  suggested  this.  Then  it  occurred  to  him  that 
possibly  the  serum  might  be  at  fault.  Upon  inspection, 
however,  it  seemed  normal,  and  there  was  no  local 
reaction  at  the  point  of  injection.  On  examining  the 
label,  however,  he  found  that  the  serum  had  been  pre- 
pared 10  months  previously,  and  he  suspected  that 
possibly  it  had  lost  its  potency  on  account  of  prolonged 
keeping;  but  upon  inquiry  he  found  that  it  was  still 
legally  efficient,  as  it  was  not  yet  time  to  retire  it  in 
accordance  with  the  German  law  upon  this  subject. 
He,  therefore,  applied  to  the  "  Hochster  Farbwerke," 
where  the  serum  had  been  prepared,  and  received  a 
reply  from  Dr.  Libbertz,  in  charge  of  the  protective 
serum  department.  In  this  Libbertz  states  that  although 
it  is  true  that  serums  do  diminish  in  effectiveness  after 
keeping,  this  diminution  occurs  in  the  first  two  or 
three  months  and  is  probably  due  to  the  action  of  the 
antiseptics.  Later,  they  can  be  kept  for  years  without 
any  impairment  of  their  potency.  He  also  stated  that 
in  view  of  this  diminution  it  is  customary  to  mark  the 
serums  with  a  rather  lower  potency  than  they  actually 
possess  so  that  the  minimum  value  always  exceeds  tbat 
stated  upon  the  label.  In  conclusion,  however,  Libbertz 
states  that  in  consequence  of  the  impairment  in  anti- 
diphtheritic  serum,  quantities  of  it  are  from  time  to 
time  withdrawn  from  commerce. 

Trumpp  very  pertinently  inquires  whether  these 
experiments  upon  which  the  first  statements  are  based, 
were  made  upon  animals  or  human  beings  ?  and  further, 
what  conditions  give  rise  to  the  loss  of  potency  ? 

The  whole  question  is  an  exceedingly  interesting 
one,  and  of  the  gravest  importance  to  clinical  medicine, 
because  upon  the  efifectiveness  of  the  first  dose  of 
serum  depends,  in  all  probability,  the  outcome  of  the 

case. 

It  is  a  pity  that  some  of  our  bacteriological  labora- 
tories in  America,  which,  on  the  whole,  produce  such 
a  relatively  small  amount  of  original  work,  can  not 
thoroughly  thrash  out  this  subject. 

The  Vahie  of  Alcohol  as  Food.— This  subject  is 
apparently  one  that  will  not  stay  settled.  Not  long  ago 
Prof.  Atwater  thought  he  had  settled  it  for  a  while 
when  he  stated  that  alcohol  is  a  food  in  the  sense  that 
it  supplies  energy  to  the  body,  although  not  in  the 
sense  that  it  goes  to  form  tissue.  This,  in  fact,  has 
been  the  teaching  of  physiology,  if  we  mistake  not,  for 


512 


Thb  Philadelphia"! 
Medical  Jocrn 


lphia"] 

RNAL  J 


EDITORIAL  COMMENT 


[Mabch  23,  IMl 


a  good  many  years.  Now  M.  Chauveau,  a  French 
physiologist,  reports  a  series  of  experiments  which 
he  had  made,  and  which,  he  claims,  tend  to  prove 
that  the  value  of  alcohol  as  a  food  has  been  much 
overestimated.  He  thinks  (Revue  Sdentifiqne,  Janu- 
ary 12  abstracted  in  the  Literary  Digest)  that  he  has 
established  that  very  little  energy,  if  any,  is  derived 
from  ingested  alcohol.  We  are  not  prepared  to  criticise 
M.  Chauveau's  opinion,  but  we  cannot  help  suspecting 
that  a  little  of  the  uncertainty  that  clings  to  this  sub- 
ject comes  from  the  ambiguity  of  this  term  "  energy." 
His  object,  apparently,  was  to  discover  whether  in  the 
case  of  a  laboring  man  the  muscles  are  caused  to  con- 
tract by  deriving  the  necessary  energy  from  the  com- 
bustion of  alcohol.  This  seems  to  us  to  be  somehow  a 
rather  inadequate  statement  of  the  question.  We  should 
suppose  that  a  muscle's  "  energy  "  was  not  derived  from 
an  outside  source  but  from  its  own  inherent  nutritive 
function.  For  the  sustaining  of  this  nutritive  function 
it,  of  course,  requires  a  food  from  a  source  outside  of 
itself.  M.  Chauveau  seems  to  think  that  ingested  alco- 
hol can  participate  only  in  a  feeble  degree  in  this  pro- 
cess. He,  therefore,  thinks  that  alcohol  is  not  a  food 
so  far  as  the  production  of  force  is  concerned,  and  its 
introduction  into  the  ration  of  a  worker  is  a  physio- 
logical contradiction.  He  contends  also  that  the  organ- 
ism, even  when  not  actively  at  work,  does  not  use  alco- 
hol as  a  food  in  any  of  its  physiological  processes. 
The  results  of  all  experiments,  he  says,  show  this ; 
especially  the  enormous  deficit  in  its  combustion  shown 
by  its  elimination,  especially  through  the  lungs.  After 
all,  these  profound  and  somewhat  obscure  physiological 
speculations  do  not  invalidate  the  conclusions  of  prac- 
tical clinical  observers  that  in  some  particular  way 
alcohol  has  distinct  value  as  a  therapeutic  agent.  Call 
it  a  food,  an  energy,  or  merely  a  stimulant,  its  place  is 
probably  quite  definitely  fixed  in  practical  therapeutics. 

A  Study  of  British  Genius.— Mr.  Havelock  Ellis 
has  been  publishing  in  the  Popular  Science  Monthly  a 
paper  on  this  subject  which  contains  some  items  of 
special  interest  for  medical  readers.  As  a  study  in 
heredity  and  environment  the  paper  has,  of  course,  a 
general  interest  for  the  limited  class  of  physicians  who 
concern  themselves  with  these  topics ;  but  it  also  con- 
tains things  here  and  there  which  challenge  the  atten- 
tion of  all  medical  men  because  of  what  we  may  call  a 
personal  or  professional  bearing.  Mr.  Ellis'  first  care, 
of  course,  in  making  a  statistical  study  was  to  select 
his  material,  and  it  is  right  at  this  point  that  he 
excites  criticism.  He  proceeded,  according  to  a  law 
of  his  own,  by  picking  from  the  "  Dictionary  of  Na- 
tional Biography"  the  names  of  such  Britons,  in 
all  fields  of  mental  activity,  as  seemed  to  himself 
to  have  been  endowed  with  genius.  He  finds  that 
the  doctors  make  an  "  unexpectedly  small  group."  He 
discovered  that  Great  Britain  has  produced  no  fewer 


than  859  men  of  more  or  lees  genius  (according  to 
Havelock  Ellis  and  the  aforesaid  "  Dictionary  "),  but  in 
this  goodly  sized  group  there  were  only  7  doctors.  This 
alleged  fact  is  all  the  more  depressing  because  the  group 
is  not  confined  to  moderns  but  goes  all  the  way  back 
to  St.  Boniface  and  Duns  Scotus.  These  7  doctors  are 
Linacre,  Caius,  Mead,  Pott,  Sydenham,  Cheselden,  and 
Cullen.  We  know  not  what  assistance  Mr.  Ellis  had,  if 
he  had  any,  in  making  this  selection,  and  we  must 
acknowledge  that  these  names  are  fairly  representative, 
but  we  cannot  see  by  what  principle  of  exclusion  the 
names  of  Harvey,  Jenner,  John  Hunter,  and  Lister,  not 
to  mention  a  few  others,  were  left  out  of  this  list  of  medical 
men.  Mr.  Ellis  explains  that  eminent  physicians  some- 
times win  fame  in  the  domains  of  pure  science,  and  can- 
not be  strictly  classed  with  their  profession.  This  was 
true  of  Huxley,  who  is  not  included  anywhere  in  the  lists, 
but  it  certainly  was  not  true  of  the  four  just  named,  all 
of  whom  are  listed  by  Mr.  Ellis  with  the  men  of  science. 
Sir  Thomas  Browne  is  placed  among  the  men  of  letters, 
but  his  profession  will  not  let  him  go  without  a  remon- 
strance. Erasmus  Darwin  also  was  an  M.D.  We  pro- 
test that  all  this  is  unjust  to  the  medical  profession,  and 
goes  far  to  invalidate  Mr.  Ellis'  conclusions. 

Among  these  conclusions  is  one  respecting  the  par- 
entage of  640  of  these  men  of  genius.  But  2.9^^  of  them 
had  physicians  for  fathers,  while  12.5%  were  the  sons 
of  clergymen,  and  5.4%  were  sons  of  lawyers.  The 
inferences  to  be  drawn  from  these  figures  are  somewhat 
problematical,  but  the  figures  should  not  be  taken  to 
imply  (as  Mr  Ellis  might  lead  one  to  do)  that  doctors 
do  not  procreate  as  brainy  sons  as  do  clergymen  and 
lawyers.  This  inference,  based  on  such  figures,  would 
be  preposterous.  The  social  status  and  customs  in 
England  probably  influence  these  results.  This  is 
shown  by  the  fact  that  the  church  outnumbers  all  the 
other  professions  together — law,  medicine,  and  the  army 
— in  this  matter  of  begetting  men  of  genius.  It  is 
curious,  perhaps,  that  not  an  eminent  doctor  was  the 
son  of  a  doctor,  although  army  oflBcers  and  clergymen 
are  often  the  fathers  of  sons  eminent  in  these  respective 
professions.  But  Charles  Darwin  was  the  son  of  a  physi- 
cian, as  was  also  Landor,  the  man  of  letters — at  least,  so 
we  infer  from  Mr.  Ellis.  Edward  Forbes,  the  naturalist, 
was  a  student  of  medicine.  In  the  case  of  Oliver  Gold- 
smith, who  was  a  physician,  we  perhaps  have  no  right 
to  set  up  much  of  a  claim. 

Medical  College  Libraries. — There  can  be  no  ques- 
tion that  a  well-stocked  medical  library  is  a  most  im- 
portant adjunct  to  a  medical  college.  Neither  is  there 
any  doubt  that  such  a  librarj'  should  be  housed  in  a 
convenient  and  attractive  way  so  that  medical  students 
in  their  odd  and  leisure  hours  would  feel  inclined  to 
patronize  it,  A  collection  of  old  medical  books  in  a 
cold  and  barren  room  is  not  the  ideal  for  such  a 
library.      We    learn    from    the    Jfffersonian   that   the 


HaRCU  23,  1901] 


REVIEWS 


LXhe  Fuiladklphia 
Medical  Journal 


513 


library  in  Jefferson  Medical  College  (which  attains 
a  proper  ideal)  is  thoroughly  appreciated  by  the  stu- 
dents. This  is  evident  from  the  rapid  month-by-month 
increase  in  the  number  of  books  taken  out.  The  li- 
brary report  shows  an  average  of  more  than  50  volumes 
a  day  for  each  working  day  of  the  month,  while  the 
largest  number  was  100  on  one  day.  This  indicates 
the  cultivation  of  a  studious  habit  and  the  formation 
of  a  literary  taste  which  from  Eome  standpoints  are  just 
as  important  as  the  results  obtained  from  routine  work. 
In  our  great  universities  the  library  is  properly  made 
the  central  figure  of  the  campus  ;  it  is  the  central  lumi- 
nary about  which  the  intellectual  life  of  the  university 
revolves.  The  University  of  Pennsylvania  well  sup- 
plies this  want,  while  at  Harvard  and  Princeton  it  is  as 
good  as  giving  an  education  to  give  a  student  free  ac- 
cess to  the  University  Library.  Our  medical  colleges 
would  all  be  fortunate  to  have  such  advantages. 


"The  Clinical  Value  of  Astereognosis,  and  its 
Bearing  on  Cerebral  Localization." — (Abstract  of  Dr. 
Walton's  paper  before  the  Philadelphia  Neurological  Society, 
February  25). 

The  writer  dwelt  on  the  importance  of  testing  the  stereog- 
nostic  sense  in  cerebral  disease.  Impairment  of  this  sense  is 
not  rare.  Lasting  astereognojis  is  common  in  hemiplegia. 
(Abba  found  },  Dercum  nearly  J,  the  writer  J  ) 

Four  cases  were  reported  of  lesion  in  the  Rolandic  area, 
three  with  operation.  Astereognosis  was  present  in  all  with 
no  loss  of  pain  or  temperature  senses,  and  in  only  one  case, 
slight  impairment  of  touch  sense.  In  one  case  motor  paral- 
ysis, previously  limited  to  the  lower  extremities,  spread  after 
operation  to  the  hand  which  then  became  astereognostic. 
The  astereognostic  patient  cannot  tell,  if  the  foot  is  affected, 
whether  the  pencil  is  applied  transversely  to  the  sole  or  only 
the  point  is  used,  though  the  touch  sense  may  be  normal. 

These  cases,  with  others  reported,  tend  to  show  that  the 
Rolandic  region  is  an  important  seat  of  the  stereognostic 
sense.  This  assumption  is  not  contradicted  by  the  numerous 
cases  reported  of  Rolandic  injury  unaccompanied  by  sensory 
loss,  for  in  such  cases  the  examination  has  not,  as  a  rule, 
included  the  stereognostic  sense.  When  this  sense  has  been 
tested  in  such  cases  it  has  been  found  defective. 

In  view  of  the  strong  evidence  for  both  the  Rolandic  region 
and  the  parietal  lobes  and  gyrus  fornicatus  as  sensory  areas 
it  seems  desirable  to  reconcile,  if  possible,  the  views  of  Mills 
and  Dana.  The  writer  suggested  a  theory  adaptable  to  clin- 
ical experience  and  analogous  to  a  mechanism  already  ac- 
cepted, namely  that  of  language. 

In  studying  this  question  we  need  not  limit  the  number  of 
neurons  involved,  for  it  is  as  logical  to  suppose  these  pro- 
cesses complicated  as  to  assume  that  they  are  simple.  The 
theory  suggested  included : 

1.  Structures  receiving  simple  cutaneous  sensations. 

2.  Centers  for  appreciating  the  qualities  of  the  objects 
touched  (corresponding  to  the  center  for  mind  vision). 

3.  Kinesthetic  centers  assembling  these  and  other  sensory 
stimuli.  The  centers  of  the  third  order  are  probably  seated 
principally  in  the  postcentral  gyrus.  For  diagrammatic  pur- 
poses the  writer  placed  the  centers  of  the  lower  order  in  the 
parietal  lobes  and  gyrus  fornicatus  for  the  upper  and  lower  ex- 
tremities respectively.  Astereognosis  might  result  from  lesic n 
in  the  parietal  region  through  disturbing  the  mental  picture. 

The  fibers  conveying  muscle  sense  probably  follow  a  more 
direct  course  from  the  internal  capsule  or  thalamus  to  the 
kinesthetic  centers.  These  centers  may  represent  the  aggre- 
gation of  associative  memcries  stimulating  so-called  volun- 
tary movements.  Though  the  whoie  hemisphere  may  take 
part  in  mental  processes,  lesions  in  certain  regions  are  perhaps 
specially  liable  to  disturb  these  processes  when  exercised  in 
certain  directions  on  account  of  the  aggregation  of  associative 
memories.  From  this  point  of  view  cerebral  localization  is 
not  altogether  incompatible  with  the  psychology  of  Loeb. 


HepictDs. 


Therapeutics:    Its    Principles    and    Practice.     By 

Horatio  C.  Wood,  M.D.,  LL.D.,  Professor  of  Materia 
Medica  and  Therapeutics,  and  Clinical  Professor  of  Dis- 
eases of  the  Nervous  System  in  the  University  of  Penna  , 
etc.  Eleventh  edition.  Remodelled  and  in  greater 
part  rewritten  by  Horatio  C.  Wood,  M.D.,  and  Horatio 
C.  Wood,  Jr.,  M.D.,  Demonstrator  of  Pharmacodynamics 
in  the  University  of  Pennsylvania.  8vo,  pp.  xxxi,  850. 
Philadelphia  and  London  :  J.  B.  Lippincott  Co.,  1900. 

Dr.  Wood's  Therapeutics,  which  for  25  years  has  been  a 
standard  work,  appears  in  the  present  edition  very  much 
altered  in  appearance  and  in  the  arrangement  of  the  subject 
matter.  The  authors  have  done  a  great  service  to  the  stu- 
dent by  endeavoring  to  present  the  articles  according  to  a 
uniform  plan,  and  by  putting  the  less  important  portions  in 
smaller  type.  The  text  also  has  been  made  more  readable 
by  removing  the  references  to  the  end  of  each  chapter.  The 
doses  are  given  according  to  the  metric  system  and  in 
apothecaries'  weights  and  measures.  Of  course  there  are 
new  articles  on  the  newer  drugs.  Moreover,  by  judicious 
excision,  conciseness  of  statement,  and  rearrangement 
of  the  text  it  has  been  possible  to  reduce  the  size  of  the  vol- 
ume. There  can  be  no  question  that  the  changes  have  im- 
proved the  book,  good  as  it  has  always  been,  and  that  it  will 
continue  to  be  a  trustworthy  guide  to  therapeutics,   [h.b..*..] 

The  Year- Book  of  the  Nose,  Throat,  and  Ear.   The 

Nose  and  Throat  edited  by  G.  P.  Head,  M.D.  The  Ear 
edited  by  Albert  H.  Andrews,  M.D.  Chicago:  The 
Year-Book  Publishers. 

This  volume  is  one  that  should  meet  the  approval  and 
encouragement  of  those  working  in  the  specialty  indicated 
by  its  title  It  comprises  a  resume  of  the  more  recent  ar- 
ticles on  the  subjects  with  which  it  purports  to  deal,  and 
contains  a  large  amount  of  information  of  value  both  to  the 
specialist  and  to  the  generiil  practitioner.  In  its  prepara- 
tion the  editors  have  culled  from  over  three  hundred  period- 
icals and  reports  and  they  have  succeeded  in  giving  a  very 
fair  resume  of  the  year's  literature.  No  attempt  is  made 
to  argue  pro  or  con  on  the  various  articles  abstracted,  and 
when  authorities  differ  equal  credit  is  given  to  all.  There  is 
a  good  working  index  of  twenty  pages. 

The  book  bears  much  evidence  of  either  haste  in  prepara- 
tion or  carelessness  in  editing.  It  is  far  from  being  an  up- 
to-date  specimen  of  the  printer's  and  bookbinder's  art  and 
there  is  not  shown  the  care  in  systematizing  the  various  sub- 
titles that  there  .should  be.  Some  of  the  English,  particu- 
larly in  translated  articles,  is  not  as  smoo  h  and  accurate  as 
one  has  a  right  t )  expect.  There  is  no  excuse  f.ir  such  a 
sentence  as  "  Recurrence  in  five  months,  which  was  re- 
moved" (page  174),  or  "The  patient  could  swallow  good, 
.  .  ."  (pages  175-176).  It  is  to  be  hoped  that  in  f.ture 
editions  these  more  glaring  faults  will  be  eradicated  and  also 
that  there  will  be  added  a  table  of  contents,  almost  a  neces- 
sity in  a  book  of  this  character,     [d.b.k.] 

Handatlas  der  Anatoniie  des  Meuschen.  Bear- 
beitet  von  Werner  Spalteholz  mit  Unterstiitzung  von 
WiLHELM  His.    3te  Auftage.     Leipzig  :  1901. 

The  favorable  reception  accorded  the  first  volume  of  Spalte- 
holz's  admirable  •' Handatlas  "  on  its  first  appearance,  now 
something  over  three  years  ago,  was  by  no  means  limited  to 
Germany,  and  its  excellence  was  promptly  appreciated  by 
American  teachers  of  aiiaomy.  The  subsequent  issue  of  the 
second  and  the  first  part  of  the  third  volume  strengthened 
this  estimate  and  widely  extended  the  circles  in  which  the 
work  has  become  a  favorite.  The  purpose  of  the  editor  is 
to  cover  in  about  800  drawings  the  most  important  parts  of 
descriptive  anatomy  ;  to  this  end  a  large  number  of  original 
drawings  have  been  made  from  special  dissections  and  prep- 
arations, the  illustrations  of  the  '  Handatlas  "  representing 
a  selection  of  those  which  seemed  most  instructive  and  help- 
ful to  the  student. 


544 


Thb  PhiladblpsxaI 
Medzca-L  JojnasAJL  J 


REVIEWS 


[MiECH   „, 


Tlie  first  200  illustrations  of  Vol.  I,  representing  the  bones, 
are,  taken  as  a  whole,  the  least  satisfactory  ;  not  from  lack 
of  faithftil  or  capable  drawing,  but  rather  from  the  unsuit- 
ableness  of  the  half-tone  process  to  preserve  the  rugged  \-igor 
of  line  essential  in  conveying  a  true  impression  of  bony 
masses.  In  addition  to  lack  of  spirit,  the  pictures  of  the 
bones,  in  not  a  few  eases,  are  marred  by  unnecessarily  intense 
shadows  which  add  nothing  to  plasticity  and  certainly  mask 
details.  The  areas  of  muscular  attachment  are  very  clearly 
indicated  in  color  on  supplementary  outline  sketches  of  the 
more  important  bones.  An  excellent  feature  is  the  repre- 
sentation of  the  smaller  skull- bones  in  sitv,  the  surrounding 
osseous  parts  in  relation  being  indicated  in  outline. 

The  illustrations  of  the  joints  are  especially  good,  unusual 
clearness  being  imparted  to  the  ligaments  by  the  delicate 
contrast-tint  laid  over  the  bones.  While,  probably,  the  stu- 
dent may  be  disappointed  in  some  instances  in  failing  to  find 
the  ligaments  on  his  subject  presenting  the  sharply  defined 
forms  that  the  drawings  portray,  he  will  have,  nevertheless, 
before  him  a  most  clear  and  comprehensive  guide  to  their 
study. 

Vol.  II,  including  the  muscles,  the  heart,  and  the  blood- 
vessels, is  very  satisfactory  by  reason  not  only  of  the 
attractive  and  artistic  drawings,  but  also  of  the  excellent 
judgment  with  which  the  dissections  have  been  made,  and 
the  views  selected  to  illustrate  the  parts  under  consideration. 
The  representations  of  the  arteries  are  particularly  good ; 
those  of  the  veins  are  somewhat  less  successfiil,  since  they 
are  often  marred  by  unwarranted  depth  of  shadows.  An 
interesting  section  across  the  cavernous  sinus  shows  the 
arterj-  about  midway  between  the  lateral  and  mesial  walls  of 
the  venous  space,  the  sixth  nerve  lying  in  close  relation  to  the 
artery  below,  with  the  ophthalmic  division  of  the  fifth, 
within  the  lateral  wall,  extending  corsiderably  below  the 
level  of  the  sixth  ner\e. 

It  is,  however,  to  Vol.  Ill,  devoted  to  the  thoracic  and 
abdominal  viscera,  that  we  turn  with  greatest  interest,  since 
the  close  association  of  the  author  with  Prof  His,  whose 
work  has  advanced  so  materially  our  appreciation  of  the 
true  form  and  relations  of  the  organs,  naturally  suggests  the 
exercise  of  unusual  critical  judgment  in  the  preparation  of 
this  part  of  the  subject.  Nor  have  we  reason  for  disappoint- 
ment, since  the  drawings,  wiih  very  few  exceptions,  are  ex- 
cellent, interesting,  and  well  chosen.  They  faithfiilly  repre- 
sent the  digestive,  respiratory,  and  genitourinary  organs  as 
these  appear  after  careful  hardening  in  sUu.  by  which  their 
true  iorm  and  relations  are  preserved  with,  at  least,  a  fair 
degree  of  accuracy.  That  viscera  so  treated  should  appear 
very  different  from  the  representations  accepted  without 
challenge  before  the  missonary  work  of  the  His  models 
is  to  be  expected ;  that  anatomists  should  have  failed  so 
long  to  appretiate  what  now  is  so  evident  seems  incredible. 
Another  valuable  feature  is  the  reproduction  of  the  st  mi- 
microscopical  appearances,  as  seen  under  the  hand  lens,  as 
those  of  the  mucous  membrane  of  the  various  parts  of  the 
digestive  tube.  Such  pictures  are  most  instructive  and 
emphasize  the  close  relations  between  the  gross  appearances 
and  the  histological  details. 

The  text  accompanying  the  illustrations  is  not  only  de- 
scriptive of  the  particular  drawing  under  consideration,  but 
includes  the  salient  points  in  the  anatomy  of  the  parts  rep- 
resented, so  that  it  is,  in  many  cases,  an  acceptable  epitome. 
The  terniino'ogy  is  that  of  the  B  N  A. — Nomina  Aiialomica  — 
adopted  by  the  Anatomische  Gesellscriaft  at  its  meeting  at 
Basel  in  1S95.  now  generally  followed  in  all  recent  German 
works.  In  this  connection  it  may  be  of  interest  to  note  that 
W.  Krause,  with  the  collaboration  of  Professors  His  and 
Waldeyer,  has  undertaken  a  systematic  text,  based  on  C. 
Kjause's  '"  Handbuch  der  Anatomic,"  especially  intended 
for  use  with  Spalteholz's  "  Handatlas ;  "  an  additional  and 
broader  purpose  was  the  demonstration  of  the  advantages 
of  the  new  nomenclature  by  putting  it  to  consistent  use  in  a 
brief  although  systematic  textbook.  Reinke  is  accomplish- 
ing a  similar  object  in  the  text  which  he  is  preparing  to 
be  used  with  the  recent  atlas  edited  by  Toldt.  The  appear- 
ance of  the  tnglish  translation  of  Spalteholz's  Handatl.<»s, 
by  Professor  Barker,  has  brought  the  B  X  A  terminology  to 
our  American  students  in  such  an  attractive  form  that  its 
advantages,  with  slight  encouragement  on  the  part  of 
teachers,  cannot  fail  to  be  appreciated. 

In  its  full  classical  form,  as  seen  in  Krause's  text,  it  is  | 


doubtful  whether  the  B  X  A  will  make  marked  headway  in 
■America  and  England,  since  the  often  apparently  formid 
able  and  truly  cumbersome  array  of  words  appeaJs  neither 
to  student  nor  teacher  seeking  the  most  convenient  and 
concise  mode  of  expression.  Xeither,  as  a  matter  of  fact . 
does  the  German  student  often  resort  to  the  Latin  term  - 
when  his  native  language  is  so  rich  in  simpler,  and  often 
most  expressive,  synonyms.  As  is  weU  known,  for  a  number 
of  years  the  efforts  of  the  Association  of  American  A  nato- 
mists  have  been  directed  towards  the  f  implification  of  ana- 
tomical terminology  by  the  pruning  of  all  superfluous  words  : 
this  worthy  desideratum,  however,  it  seems  t->  us,  is  not 
incompatible  with  profiting  bj-  the  many  desirable  feature:^ 
of  the  new  terminology.  Notwithstanding  the  truism, 
"Names  but  stand  for  things, "  there  is  every  reason  for  pre- 
ferring terms  that  shall  be  consistent  and  logical  and,  as  far 
as  possible,  universally  used.  That  the  terminology  at 
present  followed  in  our  anatomical  textbooks  only  imper- 
fectly meets  such  requirements  few  will  deny.  Careful 
study  of  the  B  N  A  shows  that  when  shorn  of  their  some- 
what formidable  appearance  by  being  Anglicized,  the  terma 
in  the  great  majority  of  ca^^es  correspond  closely  with  those 
usually  employed  by  our  own  students ;  that  In  those  case- 
where  more  radical  differences  do  exist,  the  newer  terms,  in 
the  Anglicized  form,  might  be  adopted  with  profit  and  great 
gam  in  accuracy.  One  important  advantage  of  the  B  N  A 
IS  the  substitution  of  terms  indicating  the  location  and  rela- 
tions of  parts  for  those  embodying  the  surnames  of  Investi- 
gators. The  reaction  against  this  growing  evil— and  non' 
have  been  greater  offenders  In  this  respect  than  our  Teuton; ; 
colleagues  -  is  most  timely.  While  some  may  be  loath  t 
abandon  such  a  time  honored  friend  as  Poupart's  ligament 
in  favor  of  inguinal  tignment,  there  is  little  doubt  as  to  which 
best  expresses  the  general  position  of  the  structure.  Associ- 
ation suggests  an  example  of  the  greater  consistency  of  the 
newer  terminology  in  the  case  of  the  bloodvessels  and  closely 
related  nerves  of  the  thigh.  While  we  have  abandoned  the 
name  •'  crural  "  as  applied  to  the  femoral  artery  and  vein,  it 
is  still  retained  in  connection  with  the  anterior  crural  nerve 
and  the  crural  branch  of  the  genitocrural  nerve.  These 
nerves  according  to  the  B  N  A  consistently  become  the 
femoral  nerve  and  the  femoral  branch  of  the  genitofemoral. 

This  digression  is  offe'ed  in  no  sense  as  a  defense  of  the 
new  terminology,  which,  although  it  has  defects  as  well  as 
merits,  is  established  on  a  lasting  foundation  It  has  been 
rather  with  the  purpose  of  suggesting  to  those '  f  our  readers 
who  are  Interested  in  anatomy  and  surgery  the  desirability 
of  acquainting  then>selves  with  the  undoubted  advantages 
to  be  derived  from  the  adoption,  in  a  modified  form,  of  many 
terms  of  the  B  N  A  which  will  add  to  the  uniformity  and 
accuracy  of  our  anatomical  nomenclature. 

The  last  part  of  Spalteholz,  including  the  nervous  system 
and  the  organs  of  special  sense,  is  yet  to  appear.  The  beauty 
and  clearness  of  the  work,  as  far  as  published,  warrant  the 
anticipations  of  a  most  interesting  and  instructive  fascicu- 
lus when  the  remaining  section  is  issued.  While  the  Ger- 
man student  is  to  be  congratulated  on  possessing  so  admir- 
able an  atlas,  the  completion  of  Dr.  Barker's  translation  of 
the  book  will  introduce,  before  long,  into  our  own  dissecting 
rooms  a  guide  which  will  surely  become  a  favorite,    [g.a.p.] 


Uterine  Fibromyoma. — Dr.  Kiewaky  (G-iztta  Ltkanlca, 
November  and  December,  1900)  employed  intraspinal  cc- 
cainization  (2^  solution)  in  eleven  cases.  The  ages  of  the 
patients  varied  from  IS  to  60.  Only  in  one  case  of  uterine 
fibromyoma  did  the  method  result  in  failure,  in  spite  of  an 
injection  of  1  5  cc.  In  all  others  anesthesia  was  produced  in 
from  4  to  S  minutes  and  lasted  from  1  to  3J  hours.  In  three 
cases  no  untoward  effects  whatever  were  observed ;  in  the 
others  vomiting  and  frequency  of  the  pulse  were  the  only 
unpleasant  complicationB.     [a.r.] 

A    New    Cause    of  Intestinal    Obstrnction. — Dr. 

Krawtehenko  calls  attention  In  the  iffdieal  Chronicit  o/  the 
Qoitrnnifnt  of  Ch^son  to  the  frequent  attacks  of  Intestinal 
occlusions  otwerved  among  peasants,  owing  to  their  habit 
of  swallowing  shells  and  seeds  of  fruits.  He  cites  four  cases. 
In  two  the  large  intestine  was  occluded  by  grape  seeds,  while 
in  the  other  watermelon  seeds  formed  the  offending  cause- 

[A.R.] 


MiB.  H  2S,  1901] 


CORRESPONDENCE 


CThe  Pheladblphia 
Medical  Jodbnal 


545 


(lorrcsponbcncc. 


THE   USE   OF  NITROGLYCERIN   IN   AFFECTIONS  OF 
THE  NEWBORN. 

By  SAMUEL  WOLFE,  M.D., 

of  Philadelphia. 

To  the  Editor  o/The  Philadelphia  Medical  Journal:— 

In  the  publication  of  my  paper  on  "  The  Causes  and  Treat- 
ment of  Urgent  and  Serious  Condition  of  the  Newborn,"  I 
appear  to  advise  the  use  of  doses  of  ^  J^j  of  a  drop  of  10  fc 
solution  of  nitroglycerin.  My  intention  was  to  advocate  in  of 
a  drop  of  1  ^  solution.  The  error  most  probably  occurred 
in  the  original  manuscript,  and  was  overlooked  in  the  proof- 
reading. If  you  will  publish  this  in  correction,  I  shall  appre- 
ciate the  favor. 


I 


THE  CASE  OF  GENERAL  CRAWFORD,  U.  S.  A.,  SIMI- 
LAR TO  THE  CASE  OF  GENERAL  WOOD. 

Bv  G.  TOTTEN  McMASTER,  M.D., 

of  New  HaveD,  Code. 

To  the  Editor  o/The  Philadelphia  Medical  Journal: — 

In  your  issue  of  February  23,  1901,  page  358,  second 
column  right,  you  say  under  the  section  "  A  Doctor  a  Major 
General,"  "  This  is  noteworthy  because  the  appointment  is  in 
the  line,"  further  "  it  is  unprecedented  so  far  as  we  can  recall." 

Now  this  is  wrong  One  of  the  best  officers  of  the  U.  S. 
Regular  Service  during  the  Civil  War  was  Brevet  Major- 
General  S.  W.  Crawford,  U.  S.  Army,  who  was  a  surgeon. 

Assistant  Surgeon  S.  W.  Crawford  was  appointed  from 
Pinnsylvania.  For  gallant  services  at  the  bombardment  of 
Fort  Sumter  he  was  raised  to  Major  of  the  13th  U.  S.  Infantry 
(line),  and  served  under  Major-  General  Eosecrans  in  the  West 
Virginia  campaign.  He  served  upon  his  staff  as  Inspector- 
General  of  the  Department  until  Floyd  retreated  and  the 
campaign  closed  with  success  to  the  United  States. 

S.  W.  Crawford  (major)  was  one  of  the  two  officers  named 
by  General  Rosecrans  in  response  to  a  request  from  Wash- 
ington for  promotion  to  the  rank  of  Brigadier-General  and 
was  assigned  to  duty  in  the  Army  of  the  Shenandoah.  He 
was  present  at  the  second  battle  of  Winchester  and  com- 
manded the  advance  to  Culpeper,  and  to  Cedar  Mountain, 
where  in  the  attack  upon  it  he  lost  one-half  of  his  brigade. 
His  corps  being  incorporated  with  the  Army  of  the  Potomac, 
he  was  present  at  South  Mountain,  and  commanded  a  divi- 
sion at  the  battle  of  Antietam  after  the  death  of  General 
Mansfield — his  corps  commander — and  was  severely  woun- 
ded. 

He  rejoined  the  army  on  the  march  to  Gettysburg,  having 
been  placed  in  command  of  the  Third  Division  of  the  Fifth 
Corps  (Pennsylvania  Reserves),  participating  in  the  battle 
upon  the  left  of  the  line  at  the  Round  Top. 

Upon  the  expiration  of  the  term  of  Eervice  in  this  organiza- 
tion he  was  placed  in  command  of  the  regiments  of  the  old 
(reliable)  First  Corps,  then  incorporated  with  the  Fifth  as  the 
Third  Division  of  that  corps. 

This  division  he  commanded  through  the  Rapidan  cam- 
paign, from  Bethesda  Church  through  the  siege  of  Peters- 
burg, the  battle  of  Five  Forks  and  the  surrender  of  Lee's 
army  at  Appomattox. 

For  gallant  and  meritorious  services  at  the  battle  of  Gettys- 
burg he  was  breveted  Colonel  in  the  regular  army ;  Briga- 


dier General  for  gallant  and  meritorious  service  at  the  battle 
of  Five  Forks,  Major  G;neral  of  Volunteers  for  conspicuous 
gallantry  in  the  battles  of  the  Wilderness,  Spotsylvania 
Court  House,  Jericho  Mills,  Bethesda  Church,  Petersburg 
and  Globe  Tavern  (Weldon  Railroad)  and  for  faithful  service 
in  the  campaign  ;  Major  General  in  the  regular  army  for  gal- 
lant and  meritorious  service  in  the  field  during  the  war. 

He  became  Colonel  of  the  16th  U.  S.  Infantry  in  18G9,  and 
upon  the  reduction  of  the  army,  which  immediately  followed, 
he  was  transferred  to  the  2d  Reg.  U.  S.  Infantry,  and  was  on 
duty  at  Huntsville,  Ala.,  under  the  Reconstruction  Act,  for 
3  years. 

His  disability  increasing,  he  made  application  for  retire- 
ment, when  he  by  a  special  enactment  was  retired  Brigadier- 
General  U.  S.  A.,  February  19, 1873. 


21merican  Xl^ws  anb  Xloks. 


PHILADELPHIA  AND  PENNSYLVANIA. 

Opening  of  New  Building.— The  new  building  at  the 
State  Hospital  for  the  Insane  at  Harrisburg,  Pa.,  has  been 
opened  with  an  accommodation  for  800  patients. 

St.  Joseph's  Hospital,— Drs.  Randle  C.  Rosenberger 
and  Alfred  Hand,  Jr ,  have  been  appointed  pathologists  to 
St.  Joseph's  Hospital,  each  to  serve  6  months  yearly. 

Tetanus  Following-  Vaccination.— A  man  in  Harris- 
burg recently  died  from  tetanus,  wh.oh  it  is  said  was  caused 
by  vaccination.  After  he  was  vaccinated  the  arm  became 
very  much  swollen  and  shortly  thereafter  tetanus  occurred. 

Philadelphia  Academy  of  Medicine. — A  meeting 
and  dinner  of  the  Philadelphia  members  and  those  of  neigh- 
boring localities  were  held  at  the  Stratford  Hotel,  March  16, 
1901.  The  object  of  the  meeting  was  to  promote  the  local 
interest  in  the  association,  and  to  enlarge  the  local  member- 
ship. 

Proceeds  of  Charity  Ball.— A  balance  of  $11,200  left 
after  the  payment  of  all  expenses  connected  with  the  twenty- 
first  annual  Charity  Ball  will  be  equally  distributed  among  the 
hospitals  of  the  University  of  Pennsylvania,  the  Jefferson 
Maternity,  the  Philadelphia  Orthopaedic  Hospital  and  In- 
firmary for  Nervous  Diseases  and  the  Samatarian  Hospital. 

A  Private  Hospital.— Ground  has  been  broken  at  the 
core er  of  North  Second  and  Hamilton  streets  for  a  private 
hospital  which  is  being  built  by  Dr.  E.  L.  Sh  pe,  of  Green  and 
Hamilton  Streets,  this  city.  The  new  hospital  will  De  44  feet 
front  on  Second  street  and  extend  back  68  feet,  will  be  3 
stories  high  and  will  have  accommodations  for  the  treat- 
ment of  from  30  to  40  patients. 

Wills'  Hospital  Ophthalmic  Society.— At  the  sug- 
gestion of  Dr  Charles  A.  Oliver,  the  suigeons  and  assistant- 
surgeons  of  Wills'  Hospital,  met  on  the  evening  of  February 
26,  1901,  and  formed  a  society  for  the  presentation  and  dis- 
cussion of  ophthalmic  cases.  It  was  decided  to  admit  to 
membership  the  surgical  stafi  and  all  the  clinical  assistants. 
Meetings  will  be  held  at  8  15  p  m.  in  the  Hospital  building 
on  the  second  and  fourth  Mondays  of  each  month.  They 
will  be  open  to  physicians  who  may  be  invited  by  members. 

Philadelphia  Academy  of  Surgery. — At  the  meeting 
of  the  Philadelphia  Academy  of  Surgery  to  be  held  April  1, 
Doctor  John  A.  Wyeth  of  New  York  will  read  a  paper  en- 
titled "  Amputation  at  the  Hip  Jcint  for  Sarcoma;  the  Ten- 
dency to  Recurrence."  The  meeting  will  be  held  at  the 
Hall  of  the  College  of  Physicians,  13th  and  Locust  streets, 
and  any  of  the  members  of  the  medical  profession  who  will 
be  interested  in  the  subject  are  invited. 

Death  of  Dr.  Given. — Dr.  S.  A.  Mercer  Given,  superin- 
tendett  of  the  Burn  Brae  Sanitarium  for  Mental  and  Nervous 
Diseases,  near  Clifton  Heights,  in  Delaware  County,  Pa.,  died 


546 


THB  PHttADEI.PBIA'l 

Uedicai.  Jocbnai.  J 


AMERICAN  NEWS  AND  NOTES 


[Mabcu  23,1901 


Kcenilyin  diabetic  coma.  Dr.  Givtn  had  been  aeeociated 
with  the  late  Dr.  J.  Willoughby  Ph-.Uipa,  acd  succeeded  his 
father,  the  late  Dr.  Eabert  A.  Given,  in  charge  of  the  Bum 
Brae  Sanitarium.  He  wa«  born  in  Carlisle  in  1860,  and  gradu- 
ated from  the  University  of  Pennsylvania  in  1887.  His  father, 
the  elder  Dr.  Given,  founded  the  Sanitarium  many  years  8g<^, 
and  was  widtly  known  in  the  Unittd  States  for  the  success 
with  which  he  managed  this  useful  institution.  The  son  suc- 
ceeded to  many  of  h  s  father's  admirable  personal  qualities, 
and  his  death,  at  the  eaily  age  of  41,  will  be  greatly  regretted 
by  all  who  knew  him.  His  brother-in-law.  Dr.  Phillips,  ditd 
only  recently. 

A  Century  of  Medicine  in  America. — In  an  address 
at  Houston  Hall  en  March  15,  before  the  John  B.  Deaver 
Surgical  Society  of  the  University,  Professor  James  C.  Wil- 
son, of  Jefferson  College,  spoke  of  "  A  Century  of  Medicine 
in  America,"  and  told  of  the  great  work  accomplished  by  the 
leaders  in  that  science  for  its  development  to  a  high  position. 
The  address  was  remarkable  for  its  literary  treatment  of  a 
scientific  subject.  Though  the  past  century  was  conspicuous 
for  advance  in  many  lines  of  thought,  he  said,  medicine 
probably  accomplished  greater  progress  than  any  other 
science.  The  New  World  is  now  in  a  position  to  repay  the 
Old  for  many  points  of  advance  granted  in  former  years,  and 
is  in  many  respects  a  leader.  America's  great  surgeons  and 
physicians  of  the  last  century  were  compared  favorably  with 
the  great  names  of  the  Eastern  Continent.  In  a  historical 
sketch  of  the  American  Medical  Association,  Dr.  Wilson  ex- 
horted his  hcartra  to  strive  for  membership  in  it,  as  one  of 
the  greatest  of  assistances  to  a  young  practitioner. 

Vital  Statistics  of  Philadelpliia  for  the  week  ended 
March  16, 1901: 

Total  mortaUty 526 

Casks.      Deaths. 
Inflammation  of  appendix  6,  bladder  4,  brain 
14,  bronchi  l(j,  heart  1,  kidneys  21,  larynx 

3,  liver  1,  lungs  72,  pericardium  1,  perito- 
neum 5,  pleura  5,  stomach  and  bowels  16, 

spine    2 167 

Inanition  15,  marasmus  13,  debility  9 39 

Tuberculosis  of  lungs 83 

Apoplexy  19,  paralysis  15 34 

Hearts— disease  of  27,  fatty  degeneration  of  I, 

neuralgia  of  1 29 

Uremia  15,  diabetes  3,  Bright's  disease  7    .   .   .  25 

Carcinoma  of  breast  1,  stomach  i,  uterus  2, 

jaw  1,  liver  1,  rectum  1 , 10 

Convulsions  13,  puerperal  convulsions  1  .   .   .  16 

Diphtheria 93  0 

Brain — congestion  of  I,  disease  of  1,  soften- 
ing of  3 7 

Typhoid  fever 28  3 

Old  age II 

Cyanosis 3 

Scarlet  fever 114  9 

Influenza  12,  abscess  of  liver  1,  aneurysm  of 
aorta  1,  alcoholism  2,  asthma  2,  anemia  1, 
atheroma  2,  burns  aud  scalds  2,  casualties 
11,  congestion  of  lungs  5,  childbirth  1,  cir- 
rhosis of  liver  4,  membranous  croup  3,  diar- 
rhea 1,  drowned  2,  extrauterine  pregnancy 
1,  erysipelas  5,  catarrhal  fever  1,  gangrene 
of  leg  2,  homicide  1,  hemorrhage  from 
bowels  1.  hemorrhage  from  uterus  1,  ob- 
struction of  bowels  2,  edema  of  lungs  1, 
creosote  poisoning  1,  purpura  hemorrhagica 
1,  pyemia  2,  rheumatism  1,  sarcoma  of 
stomach  1,  sclerosis  of  spine  1,  septicemia 

4,  suicide  2,  teething  3,  ulceration  of  stom- 
ach 1,  ulceration  of  foot  1,  whooping-cough  2  85 

Pediatric  Society. — The  regular  monthly  meeting  was 
held  March  12,  with  the  president,  Dr.  T.  S.  Westcott,  in  the 
chair. 

Dr.  J.  A.  Scott  read  a  paper  upon  intestinal  sand. 
The  literature  of  this  comparatively  rare  pathological  condi- 
tion was  reviewed  and  three  cases  reported.  The  first  case 
was  a  woman  of  40.  The  feces  contained  small  regular  sand- 
like bodies  which  were  partially  crystalline  and  somewhat 
resembled  uric  acid.  There  was  also  some  resemblance  to 
bile  but  no  cholesterin  was  found.  It  was  thought  that  the 
appearance  of  these  bodies  bore  some  relation  to  fruit  eaten 
by  the  patient.  The  theory  of  fruit  formition  was  not  borne 
out  by  the  second  case,  however,  which  occurred  in  a  child 
of  Si  years.  The  child  had  periodical  attacks  of  catarrh  of 
the  "duodenum  and  ileum  and  for  three  or  four  days  afier 


these  attacks  the  stools  would  contain  fine,  reddish,  sandlike 
particles.  In  the  third  case  what  is  commonly  termed  biliary 
sand  was  ''ound.  Dr  Scott  believes  that  a  careful  examination 
of  the  stools  of  persots  having  gastrointestinal  or  liver 
disease  will  finally  show  the  origin  of  these  materials.  The 
pathology  is  supposed  to  be  practically  the  same  as  that  of 
gallstones  or  urinary  calculi. 

Dr.  Geo.  McClellas  read  an  instructive  paper  on  the 
Anatomy  of  childliood,  and  afterward  illustrated  his  re- 
marks by  stereopticon  views.  Dr.  McClellan  spoke  of  the 
modifications  which  occur  in  the  anatomy  from  birth  to 
puberty.  The  most  important  periods  in  the  infant  are  from 
birth  to  the  seventh  month,  and  from  the  seventh  month  to 
the  end  of  the  second  year.  In  childhood  the  important 
changes  are  confined  to  the  periods  between  the  second  and 
seventh  years,  and  from  the  seventh  year  to  puberty. 
Special  stress  was  laid  upon  the  differences  in  the  abdominal 
contents  as  found  in  children  and  adults.  It  is  a  mistake  to 
suppoi  e  that  the  intestines  in  a  child  are  merely  the  repro- 
duction in  miniature  of  the  arrangement  found  in  the  adult. 
Tne  colon  is  differently  placed,  and  the  sigmoid  flexure 
especially  is  totally  unlike  tbat  found  in  older  individuals. 
The  stereopticon  views  illustrated  graphically  the  relations 
of  the  thoracic  and  abdominal  organs. 

Pathological  Society.— The  first  scientific  business  at 
the  meeting  of  March  14  was  an  address  by  Dr.  Joseph  Mc- 
Farlan'd,  whose  subject  was  Some  remarks  on  snake- 
venom.  A  brief  review  of  the  researches  into  the  nature  of 
venom  and  immunizing  serums  was  given,  the  work  of  Cal- 
mette  being  dwelt  upon  particularly.  Dr.  McFarland  then 
gave  the  results  of  his  experiments  upon  3  horses  with  c»bra 
and  rattlesnake  venoms.  Heated  venom  was  first  used,  then 
unhealed  venom  subcutaneously,  and  finally,  unhealed 
venom  was  injected  into  a  vein.  One  horse  died  from  local 
symptoms,  a  slough  being  caused.  The  tests  made  with  the 
serum  showed  that  it  yielded  the  best  results  when  large 
doses  of  venom  were  used  intravenously.  It  seems  proven 
that  it  is  impossible  to  immunize  against  the  local  effects  of 
the  globulins  of  venom,  but  with  the  peptones  it  is  possible. 
The  possibility  of  the  interchange  of  serums  was  also  proven. 
It  was  not  proven  that  antivenene  will  protect  against  the 
globulins  of  venom.  Dr.  Packard  asked  if  the  effect  on  the 
heart  produced  by  the  venom  was  such  as  to  justify  the  pop- 
ular belief  that  whisky  is  a  valuable  antidi  te  in  cases  of 
snake  bite.  De.  McFarlasd  said  that  death  generally  was 
due  to  paralysis  of  the  respiratory  centers.  He  also  stated 
that  it  was  safe  to  say  that  whisky  did  more  harm  than  good 
in  cases  of  rattlesnake  bites.  These  cases  are  not  often  fatal 
in  this  country  under  any  circumstances,  not  more  than  5% 
of  them  proving  fatal.  Whisky  is  not  a  physiological  anti- 
dote>,  strychnin  better  fulfilling  the  indic;ations.  The  treat- 
ment of  snake  bite  as  determined  by  Calmette  is  to  ligate 
the  part,  suck,  or  draw  out  the  poison,  irject  chloride  of 
lime  solution,  4  drops  in  each  of  at  least  10  different  places 
near  the  wound,  give  strychnin  and  other  stimulants  as 
needed. 

Dr.  David  EtsAix  read  a  paper  on  Tlie  carbohydrates 
of  the  urine  in  diabetes  insipidus.  The  case  studied 
was  a  man  of  27  who  was  brought  to  the  hospital  in  the  early 
stages  of  typheid  fever.  Marked  polyuria  was  proved  to  be 
due  to  diabetes  itsipidus.  The  ben zo  esters  of  the  urine 
were  estimated  daily  for  2  weeks.  There  was  no  increase  in 
the  unfermentable  carbohydrates.  Experiments  were  then 
made  to  determine  if  the  amount  of  the  benzo-esters  was 
caused  by  diuresis  itself.  To  this  end  the  liquids  ingested 
were  reduced  until  only  63%  of  the  usual  amount  of  urine 
was  secreted.  The  benzo  esters  then  fell  to  62%  of  their 
former  quantity,  thus  showing  a  causative  relation.  The 
amount  of  urinary  nitrogen  also  fluctuated  fairly  regularly 
with  the  benzo  esters.  Tne  influence  of  water  drinking  on 
the  nitrogen  of  the  urine  was  then  studied,  the  i.iirogen  being 
reduced  when  the  water  was  reduced  in  quantity.  An  im- 
portant conclusion  reached  is  that  diet  plays  the  largest  part 
in  determining  the  excretion  of  carbohydrates. 

Dr.  W.  M.  L.  Coplis  spoke  on : '  1.  A  convenient 
method  of  staining  a  number  of  sections  on  one 
slide.  Four  or  more  sections  are  mounted  on  one  slide  and 
stained.  When  counterstaining,  one  or  two  of  the  sections 
are  immersed  in  one  stain,  washed,  and  then  the  slide  re- 
versed and  other  stains  used.    In  this  way  each  of  the  sec- 


Mabch  23,  1901] 


AMERICAN  NEWS  AND  NOTES 


FThe  Philadelphia 
L  Medical  Journal 


547 


tiona  are  stained  by  a  different  method.  Care  must  be  taken 
to  wash  the  slide  with  alcohol  before  counterstaining  to  pre- 
vent the  stain  spreading  to  the  next  section.  2  A  modifi- 
cation of  the  staining  methods  of  Claudius  and 
A'an  Gieson,  The  former  method  is  employed  first  and 
Van  Gieson's  used  as  a  counteratain. 

County  Medical  Society. — The  meeting  of  March  13 
was  devoted  to  the  consideration  of  obstetrical  topics. 

Dr.  Walter  L.  Pyi.e  read  a  paper  on  Postpartum  me- 
tastatic panophthalmitis  with  a  clinical  and  path- 
ological study  of  a  case.  This  condition  is  rare  since 
the  days  of  asepsis.  It  usually  comes  on  from  5  to  15  days 
after  labor,  loss  of  vision  often  being  the  first  symptom. 
Enucleation  during  the  activity  of  the  process  is  not  without 
danger  of  meningitis  and  should  be  deferred.  The  case  re- 
ported had  developed  10  days  after  forceps  delivery  of  a 
woman  who  had  been  in  labor  55  hours.  Rupture  had  taken 
place  before  enucleation  was  done,  a  notable  point  being  that 
it  was  so  far  posterior  that  the  front  of  the  eye  was  left  intact. 

Dr.  Richard  C.  Norris  r  ad  a  paper  entitled  Remarks 
on  the  obstetrical  forceps  employed  by  the  general 
practitioner.  The  technic  of  forceps  deliveries  was  first 
considered.  Forceps  should  be  boiled  in  water  for  as  least 
10  minutes.  The  toilet  of  the  patient  should  be  preparation 
as  for  a  surgical  operation.  The  vagina  should  not  be 
douched  unless  there  is  a  known  virulent  discharge.  The 
operator's  hands  should  be  thoroughly  disinfected  and  then 
covered  !by  rubber  gloves.  The  special  topic  of  the  paper 
was  the  management  of  arrested  posterior  posi- 
tions of  the  vertex.  An  accurate  diagnosis  is  the  first 
step,  insuffieient  flexion  of  the  head  being  the  most  usual 
cause  of  delay.  When  the  head  is  above  the  brim  of  the 
pelvis  one  of  four  procedures  is  to  be  chosen :  1.  External 
manipulation,  with  posture,  etc.  2.  Internal  manipulation, 
with  posture,  etc.  3.  The  application  of  forceps.  4.  Podalic 
version.  In  the  hands  of  the  general  obstetric  practitioner 
podalic  version  will,  as  a  working  rule,  give  the  best  results. 
Forceps  must  be  used  in  some  cases.  la  cases  where  the 
occiput  is  arrested  in  front  of  the  sacrum,  Dr.  Norris  has 
during  the  past  3  years  used  forceps  as  rotators  with  satisfac- 
tory results.  This  manipulation  has  been  done  repeatedly 
without  producing  extensive  lacerations  of  the  soft  parts  and 
with  no  greater  danger  to  the  child  than  is  incurred  in  other 
procedures.  Reversed  forceps  applications  should  not  be 
made  even  by  skilled  operators.  Rotation  by  forceps  has 
been  condemned  very  generally,  but  three  years'  use  has 
proven  its  practicability.  Dr.  Norris  uses  the  Tucker  solid 
blade  instrument  for  this  purpose.  The  handles  are  deflected 
toward  the  side  enough  to  keep  the  tips  of  the  blades  always 
in  the  median  line  of  the  pelvis.  Rotation  and  traction  are 
used  until  the  R.  0.  A.  position  is  reached.  The  forceps  are 
then  unlocked  and  readjusted  if  necessary.  In  cases  where 
the  head  is  low  down  the  solid  blades  are  applied  to  the  sides 
of  the  head  and  gradual  rotation  applied,  taking  care  to 
keep  the  head  w -11  flaxed.  The  danger  in  these  cases  is 
that  the  trunk  will  not  rotate.  The  head  must  be  held  after 
rotation  until  several  expulsive  efforts  have  been  made  and 
the  trunk  rotated.  These  manipulations  were  demonstrated 
on  a  manikin. 

Dr.  Chas  p.  Noble  presented  a  paper  on  General  con- 
siderations of  the  treatment  of  placenta  previa. 
Toe  three  dangers  of  placenta  previa  are  sudden  profuse 
hemorrhage,  moderate  loss  of  blood  long- continued,  and  in- 
fection. 'The  induction  of  premature  labor  is  the  most 
important  single  step  in  the  treatment.  Prior  to  the  seventh 
month  of  gestation  there  is  but  little  danger  to  the  mother 
and  viability  of  the  child  should  be  waited  for  unless  in 
special  cases.  Bipolar  version  is  of  greit  value  in  cases  of 
severe  hemorrhage.  A  tampon  is  to  be  used  only  as  a 
temporary  expedient  while  further  preparations  are  being 
made  or  assistance  summoned.  The  moat  rigid  asepsis 
should  be  used,  rubber  gloves  being  especially  commended. 

Dr.  Geo.  M.  Boyd,  presented  a  piper  on  Indications 
for  cesarean  section  in  placenta  previa.  Placenta 
previa  at  present  seems  to  be  more  frequent  than  during  the 
past,  judging  from  the  statistics  of  some  of  the  older  writers. 
Of  the  2,887  deliveries  at  the  Poiladelphia  Lying  in  Charity 
there  has  been  1  placenta  previa  to  every  107  cases.  This 
large  proportion  may  be  due  to  the  fact  that  this  institution 
treats  a  great  many  emergency  cases.    Dr.  Boyd  places  the 


maternal  mortality  at  from  10  to  12%.  The  fetal  mortality 
at  the  Lying  in  Charity  has  been  81.5%.  Any  measure 
which  will  decrease  this  high  fetal  mortality  without  increas- 
ing the  danger  to  the  mother  is  justifiable.  Cesarean  section 
will  lower  fetal  mortality  and  at  the  same  time  check  hemor- 
rhage from  the  mother.  If  hemorrhage  c:)mes  on  before  the 
period  of  viability,  forceps  delivery  or  version  may  suffice; 
after  viability  cesarean  section  is  indicated. 

The  discussion  on  the  papers  of  Drs.  Norris,  Noble,  and 
Bjyd  was  opened  by  Dr.  Barton  Cooke  Hirst.  D-.  Hirst 
considers  it  rather  unfortunate  to  exaggerate  the  dangers  of 
occiput  posterior  presentations.  The  general  practitioner 
has  a  dread  of  this  condition  which  is  unfounded.  It  occurs 
in  but  25%  of  all  cases,  and  rotation  fails  finally  to  occur  in 
only  4%.  Dr.  Hirst  does  not  agree  with  the  principle  of 
securing  rotation  by  forceps.  He  would  rather  deliver  the 
child  by  forceps  with  injury  to  the  soft  parts  than  to  rotate 
by  them  first.  It  is  possible  for  the  head  to  rotate  without 
the  trunk  and  not  injure  the  child,  but  the  injury  produced 
by  this  torsion  of  the  neck  has  proved  fatal  in  some  cases. 
Regarding  placenta  previa.  Dr.  Hirst  has  met  with  24  cases 
with  no  fatalities  to  the  mothers.  The  percentage  of  mor- 
talities, as  given  by  previous  speakers,  seem  too  high.  Any 
one  who  attends  enough  cases  to  be  cUled  a  specialist  should 
look  for  a  mortality  in  mothers  of  less  than  1%,  and  the 
infant  mortality  should  be  under  50%.  Cesarean  section  on 
account  of  the  infant  mortality  alone  is  not  justifiable,  and 
he  would  not  at  present  consider  it  as  a  treatment  for  placenta 
previa,  because  it  increases  the  risk  to  the  mother.  Dr. 
Reynolds  Wilson  said  that  forceps  blades  as  no¥  made  allow 
motility  of  the  child's  head  within  their  grasp,  hence  it  is 
immaterial  whether  they  are  applied  to  the  sides  of  the  head 
or  the  sides  of  the  pelvis.  The  rota'ion  of  the  head  in  occi- 
put posterior  presentations  by  high  application  of  the  f  jr  jeps 
is  not  a  safe  procedure  in  every  instance.  Tne  injury  to  the 
mother  is  perhaps  greater  than  to  the  child.  Clinically, 
placenta  previa  are  of  2  kinds:  1.  Tuose  seen  early  in 
pregnancy  in  which  the  management  is  fairly  easy.  2.  Tuose 
seen  as  emergency  cases  where  a  total  placenta  previa  haa 
been  bleeding  for  perhaps  a  week.  The  majority  of  the 
latter  are  fatal.  Full  surgical  procedure  seems  dangerous. 
In  these  cases  the  shock  of  the  delivery  of  the  child  is  a 
cause  of  death  as  well  as  the  hemorrhage.  In  such  a  case  if 
the  patient  was  not  in  too  serious  a  condition.  Dr.  Wilson 
would  not  attempt  to  separate  the  placenta,  but  would  pene- 
trate it,  do  version  and  use  the  child  as  a  tampon.  When 
this  is  accomplished  it  is  advisable  to  give  ergot.  Dr. 
Norris  stated  that  his  remarks  did  not  apply  to  cases  of 
occiput  posterior  that  finally  rotated,  but  to  arrested  cases 
where  something  had  to  be  done.  The  two  dangers  of  for- 
ceps rotation  are  failure  of  the  trunk  to  rotate  and  lacera- 
tion of  the  soft  parts,  but  the  procedure  can  be  successfully 
accomplished.  He  does  not  commend  cesarean  section  for 
placenta  previa.  In  cases  of  total  or  nearly  total  placenta 
previa  use  the  tampon  only  as  a  temporary  expedient,  but 
do  not  leave  the  woman  until  she  has  been  delivered.  The 
statistics  of  specialists  regarding  cesarean  section  have  a  bad 
inflaence  on  general  practitioners.  The  subject  was  further 
discussed  by  Drs.  Price,  Fisher,  Coles,  Noble,  and  Boyd. 

Wills'  Hospital  Ophthalmic  Society.— Meeting  was 
held  March  11,  1901.     Dr.  S.  D.  Risley  in  the  chair. 

Dr.  Frank  Fisher  presented  a  case  of  sympathetic  opthal- 
mitis  coming  on  after  a  panophthalmitis  which  had  followed 
a  cataract  extraction,  the  patient  being  64  years  of  age.  He 
laid  especial  stress  on  the  age  at  which  the  ophthalmitis  had 
developed  and  the  long  period  of  time  eLapsing  between  the 
condition  and  the  cataract  extraction.  Dr,  William  Zbnt- 
mayer  inquired  whether  it  is  not  rare  for  the  dissase  to  evi- 
dence itself  in  cases  in  which  there  is  panophthalmitis.  In 
answer  to  Dr  John  T.  Karll's  question  whether  the  ftj.°^"* 
of  the  sympathizing  eye  had  been  examined.  Dr.  Fisher 
stated  that  when  he  saw  the  case  the  eyeground  had  bee  ime 
invisible.  Dr.  Risley  asked  whether  subconjunctival  injec- 
tions of  solutions  of  chloride  of  sodium  had  ever  been  tried 
by  any  of  the  members  of  the  staff.  Db  Walter  L.  Pylk 
believed  that  the  occurrence  of  sympathetic  inflammatioa 
after  panophthalmitis  depended  upon  the  amount  of  destruc- 
tion of  the  globe.  He  believed  that  if  there  was  decided 
scleral  rupture  and  escape  of  most  of  intraocular  contents, 
sympathetic  ophthalmitis  was  not  likely  to  follow.      Dr. 


548 


The  PHrLADELPHii"! 
Medical  Jocrnal  J 


AMERICAN  NEWS  AND  NOTES 


[ifARCH  23,  1901 


Charles  A.  Ouver  had  found  that  all  attempts  to  do  useful 
iridectomy  in  euch  cases  were  futile,  the  iris-tiseue  being 
brittle  and  friable,  while  any  obtained  good  results  are  rapidly 
lost.  He  had  been  successlul  in  several  instances  by  either 
the  Critchett Story  operation  or  Tyrrell's  method  of  (irilling. 
He  had  never  employed  eubconjunctival  injections  to  any 
advantage,  nor  as  yet  had  made  use  of  large  doses  of  the 
alkalies,  but  thought  if  lymph- formation  and  circulation  are 
good,  the  former  method"  might  be  of  assistance. 

De.  George  C.  Harlas  presented  a  case  of  false  maculae. 
The  patient,  a  white  man  of  23  years  of  age,  whose  family  and 
personal  histories  were  negative,  had  squinted  since  child- 
hood. He  could  me  either  eye.  On  February  2S,  1900,  he 
was  admitted  to  the  hospital  with  an  esotropia  of  40°  prefer- 
ably fixing  with  the  left  eye.  A  tenotomy  of  the  right  inter- 
nal rectus  muscle  with  an  advancement  of  the  corresponding 
external  rectus  was  done,  leaving  a  residual  squint  of  about 
10°.  Two  weeks  later  similar  operations  were  performed  on 
the  left  eye  with  the  result  of  an  overcorrection  of  10°.  On 
January  l'3  of  this  year,  the  perimeter  showed  10°  of  eso- 
tropia. Maddox  rod  gave  20°  of  crossed  diplopia.  At  this 
time  a  tenotomy  of  the  right  external  rectus  muscle  waa 
done  allowing  both  eyes  to  fix  centrally,  but  the  crested 
diplopia  remained  the  same.  One  week  later  it  waa  found 
that  the  esotropia  of  10°  still  persisted.  There  was  not  any 
monocular  polyopia.  During  fixation  with  both  eyes  a 
crossed  diplopia  ot  between  S°  and  16°  with  a  hypophoria  of 
one-half  to  two  degrees  could  be  determined.  Dr.  Zest- 
MAYEE  made  mention  of  a  case  of  divergent  squint  with 
homonymous  diplopia  occurring  in  a  bright  student.  Dr. 
KiSLEY  stated  that  it  was  not  infrequent  to  find  diplopia  after 
the  correction  of  a  divergent  squint.  He  reported  a  case  of 
citaract  extraction  on  an  amblyopic  convergent  eye  in  which 
vision  after  the  operation  equalled  six  twelfths  of  normal. 
A  liter  operation  upon  the  fellow  previously  fixing  eye  in 
which  psion  was  brought  to  more  nearly  normal,  resulted  in 
the  patient  afterwards  having  diplopia.  Dr.  Fisher  reported 
a  case  in  which  a  patient  with  marked  divergence  could  at 
will  associate  the  images  of  the  two  eyes  and  dislodge  them 
to  his  greater  comfort.  Dr  Olh^er  gave  the  details  of  a  case 
of  marked  esotropia  in  early  life  with  want  of  binocular  fusion 
that  through  operative  interference  and  want  of  prop3r  cor- 
recting lenses  was  transferred  in  early  adult  life  into  a  case  of 
pronounced  though  comfortable  divergence  with  good  vision 
in  each  eye.  Recently,  for  cosmetic  purposes,  a  colleague 
had  so  successfully  attempted  to  bring  about  a  parellelism  in 
the  two  organs  that  a  most  troublesome  series  of  diplopias 
took  place,  necessitating  an  operation  to  restore  the  origin- 
ally induced  condition  of  comfortable  divergence.  Dr. 
Berens  mentioned  neuro-muscular  memory  as  being  one  of 
the  factors  in  this  type  of  cases  and  desired  to  see  careful 
studies  from  the  standpoint  of  the  psychologist  made. 

Dr.  Berens  presented  a  case  of  successful  extraction  of  a 
foreign  body  from  the  vitreous  chamber  with  a  resultant 
vision  of  f  of  normal.  The  patient,  a  38  year- old  man, 
came  to  the  hospital  on  February  12,  1901,  with  the 
history  of  having  been  struck  in  the  left  eye  one  hour  pre- 
viously by  a  clipping  from  a  hammer.  The  external  wound, 
which  was  vertical  and  3  millimeters  in  size,  was  situated  in 
the  cort:ea  5  millimeters  distance  from  the  nasal  limbus. 
There  was  a  corresponding  wound  in  the  iris.  The  pupil 
was  4  millimeters  in  size,  and  central,  and  the  iris  reacted 
well.  Under  atropin  the  pupil  enlarged  to  S  millimeters. 
There  were  numerous  vitreous  opacities  anteriorly,  and  some 
posteriorly.  The  details  of  the  eyeground  were  slightly 
veiled.  Far  down  and  to  the  inside  two  semilunar  areas, 
one  of  which  at  first  showed  a  suspiciously  bright  point 
could  be  seen.  Under  Dr.  Berens'  guidance,  the  senior 
residence  surgeon  enlarged  the  corneal  wound  down  and  in, 
did  an  iridectomy,  and  placed  a  magnet  tip  towards  the  side 
of  the  retinal  laceration.  Three  unsuccessful  attempts  being 
made  in  this  direction.  Dr.  Berens  took  the  tip  and  inserted 
it  twice,  the  second  time  down  and  out,  recovering  a  piece  of 
steel  from  that  locality.  Atropin  was  instilled  ar>d  a  band- 
age was  applied.  On  the  next  day  there  was  slight  reaction 
but  there  was  not  any  pain.  Two  days  later  there  was  a 
moderate  injection.  At  this  time  the  patient  could  tell  time 
on  a  watch  at  J  meter's  distance.  In  8  days'  time  the  eye 
was  quiet,  and  vision  equalled  ,',  of  normal.  The  eyeground 
could  be  distinctly  seen.  Four  days  after  this,  vision  had 
risen  to  i  of  normal,  and  the  eye  was  quiet. 


Dr.  Oliver  exhibited  a  case  of  double  coloboma  of  the 
iris,  choroid,  and  optic  nerve,  with  unusually  small  cornea  in 
a  16  year-old  Italian  girl.  As  far  as  could  be  ascertained, 
there  was  not  any  history  of  inheritance,  nor  were  there 
any  other  signs  of  congenital  malformation  present,  llie 
colobomata  were  in  their  usual  positions  downward  and 
slightly  inwards,  those  of  the  right  eye  being  the  larger. 
The  characteristic  curvilinear  extension  of  the  retinal  vessels 
along  the  borders  of  the  colobomatous  areas  could  be  plainly 
seen.  The  surfaces  of  the  fundus  colobomata,  which  were 
on  a  much  deeper  level  than  the  rest  of  the  eyegrounds,  were 
quite  ectatic  in  places.  Refraction  in  the  uninvolved 
macular  regions  was  myopic  and  slightly  astigmatic.  Cor- 
rected vision  equalled  about  two- thirds  of  normal.  The 
visual  fields  showed  defects  corresponding  with  the  fundus 
abnormalities.  Both  optic  nerve  heads  were  considerably 
enlarged.  The  retina  in  the  colobomatous  areas  were  visible 
as  thin,  almost  transparent  membranes  over  and  in  which  a 
few  small  vessels  could  be  traced.  The  case  was  particularly 
interesting  in  the  fact  that  in  spite  of  t'ne  apparent  microph- 
thalmus,  the  eyeballs  were  enormously  lengthened  in  their 
anteroposterior  diameters,  giving  high  degrees  of  myopic 
refraction.  Dr.  Oliver  also  showed  a  patient  from  whom  a 
chip  of  iron  had  been  spontineously  extruded  from  the  eye- 
ball two  years  after  its  entrance  into  the  crystalline  lens 
through  the  cornga  and  the  irie.  Xo  reaction  followed  the 
expulsion  of  the  foreign  body.  The  lens  itself  had  been 
studded  with  brilliant  cholesterine  crystals  for  more  than  a 
year's  time. 

Dr.  Beress  presented  a  case  showing  the  recent  effects  of 
a  plastic  operation  for  symblepharcn  in  which  the  conjunc- 
tiva of  the  upper  lid  had  been  adherent  to  the  cornea  over 
more  than  two- thirds  of  its  surface,  entire  freedom  of  motion 
being  restored  to  the  globe. 

Dr.  Olives  gave  a  brief  accctint  of  a  case  of  interstitial 
keratitis  occurring  in  the  left  eye  of  a  24  year-old- man,  suf- 
fering from  other  stigmata  of  hereditary  syphilis.  He  had 
treated  and  cured  the  patient's  right  eye  for  a  similar  attack 
of  keratitis  some  six  months  previously.  The  point  of  in- 
terest in  the  case  consisted  in  the  fact  that  at  the  time  of  the 
patient's  second  admission  to  the  hospital,  some  three  weeks 
previously,  the  senior  resident  surgeon.  Dr.  Van  Epps,  dis- 
covered a  sloughing  chancroid  involving  almost  the  entire 
foreskin  of  the  patient's  penis,  necessitating  excision  of  the 
sloughing  part  of  the  organ. 

SEW  JERSEY. 

Appointed  Railroad  Surgeon.— Dr  Francis  W.  Ben- 
nett has  been  appointed  surgeon  and  physician  to  the  Peon- 
sylvacii  Railroad  Company,  at  Atlantic  City,  X.J. 

DEL  .\  WARE. 

Resignation. — Dr.  Jean  M.  Wilson,  pathologist  to  the 
Delaware  Hospital  for  the  Insane,  has  sent  in  his  resigna- 
tion. 

Varioloid. — An  epidemic  is  raging  in  the  lower  part  of 
Delaware,  in  Dover  and  vicinity.  Dr.  Knowls,  of  Dover,  is 
among  the  victims.  The  epidemic  is  mild,  the  disease  last- 
ing only  3  or  4  days. 

Licensing  Without  Examination. — The  bill  provid- 
ing for  licensing  without  an  examination  grsiduates  Irom  the 
University  of  Pennsylvania  and  other  reputable  institutions 
was  killed  by  the  general  assembly  of  Delawswe. 

Delaware  State  Hospital. — The  Legislature  passed  a 
bill  appropriating  $125,000  to  the  Delaware  Sute  Hospital 
for  the  Insane,  at  Famhurst ;  also  a  bill  increasing  the  appro- 
priation for  the  State  Pathological  and  Bacteriological  Lab- 
oratory, located  at  Delaware  College.  Newark,  to  $2,500. 

NEW  YORK. 

Appointment. — Dr.  William  Browning  has  been  ap- 
pointed consulting  neurologist  lo  the  Long  Island  State 
Hospital  at  Fiatbush. 

New  Hospital. — A  new  brick  and  brownstone  hospital 
building,  live  stcnies  in  height,  will  be  erected  in  One  Hun- 
dred and  Thirty-sixth  Street,  near  Amsterdam  Avenue,  for 


March  23,  1901] 


AMERICAN  NEWS  AND  NOTES 


PThe  Philadklphia 
L  Medical  Journal 


549 


the  Hebrew  Benevolent  and  Orphan  Asylum  Society,  at  an 
estimated  cost  of  $70,000.  The  new  hospital  will  be  used  for 
emergency  purposes. 

Dr.  Delafield  will  Resign.— Dr.  Francis  Delafield,  one 
of  the  leading  pathologists  in  the  country,  will  give  up  the 
chair  of  the  practice  of  medicine  in  the  College  of  Physi- 
cians and  Surgeons,  on  June  1.  He  asked  to  be  relieved 
of  the  professorship  some  time  ago.  Dr.  Walter  Belknap 
Jones  has  been  appointed  lecturer  on  the  practice  of  medi- 
cine. 

Female  Nurse  Appointed.— Secretary  Root  has  ap- 
pointed Mrs.  Dita  Hopkins  Kinney,  of  New  York  City, 
superintendent  of  the  female  nurse  corps  under  the  army 
reorganization  act.  Mrs.  Kinney  has  been  superintendent 
of  the  nurses  in  the  Long  Island  Hospital,  at  Bnston.and  has 
been  connected  with  hospitals  in  St.  Paul,  San  Francisco  and 
New  Mexico.  Sae  was  selected  to  be  superintendent  of  the 
hospital  that  was  proposed  to  be  established  at  Nagasaki 
during  the  Chinese  troubles.  Recently  she  has  been  in 
charge  of  the  army  nurse  corps  in  the  War  Department. 

New  York  Academy  of  Medicine— Section  on  Or- 
thopedic Surgery, — Meeting  of  February  15, 1901,  Dr.  Geo. 
R.  Elliott,  Chairman.  The  subject  of  the  evening's  discus- 
sion was  a  symposium  on  Clubfoot.  Dr.  H.  W.  Berg  read  a 
paper  entitled  "  The  Etiology  of  Congenital  Talipes  Equino- 
Varus."  He  devoted  a  part  of  his  paper  to  again  calling 
attention  to  views  elaborated  and  published  by  him  in  1881. 
He  said  it  was  a  fact  that  talipes  equinovarus  was  a  morpho 
logical  stage  in  the  normal  development  of  the  lower  e.x- 
tremity  of  every  human  fetus.  In  early  fetal  life  the  leg  as 
a  whole  rotated  outwards  and  this  outward  rotation  was 
accompanied  by  an  exaggerated  varus  and  later  an  equino- 
varus. Tuis  outward  rotation  reached  its  maximum  as  soon 
as  the  joints  were  formed.  The  thighs  were  flexed  upon  the 
body  and  the  legs  partially  flexed  upon  the  thighs.  The  wide 
border  of  the  thigh  and  the  tibial  border  of  the  leg  pressed 
against  the  abdomen  of  the  fetus,  the  legs  crossing  each 
other.  All  intrauterine  pressure  was  thus  brought  to  bear 
directly  upon  the  outer  border  of  the  thigh  and  leg.  As  a 
resul .  the  foot  was  rotated  iu  and  extended  (equinovarus). 
This  then  was  a  stage  in  the  normal  development  of  every 
healthy  fetus,  and  were  the  extremities  to  remain  in  this 
position  all  children  would  be  born  club-footed.  Nature 
provided  against  this  by  an  inward  rotation  of  the  extremity 
carrying  the  leg  away  from  ics  position  against  the  abdomen 
of  the  fetus.  The  soles  of  the  feet  came  to  lie  against  the 
uterine  walls  and  intrauterine  pressure  waa  exerted  directly 
upon  them  producing  extreme  flexion  and  outward  rotation 
of  the  foot — thus  was  antagonized  the  varus  or  equinovarus 
which  had  hitherto  existed.  This  inward  rotation  began 
about  the  second  month,  was  to  a  great  extent  accomplished 
by  the  fourth  month,  but  not  complete  till  the  fifth  or  begin- 
ning of  the  sixth  month.  Now  if  this  inward  rotation,  this 
second  rotation  stage  did  not  occur  or  was  incomplete  the 
child  was  born  more  or  less  club-footed.  The  difi'erent  stages 
of  rotation  were  illustrated  by  fetal  specimens  from  the 
museum  of  the  New  York  Hospital.  Dr.  Berg  denied  that 
his  views  were  those  of  Eicbricht  as  some  had  claimed.  He 
said  Eschricht  himself  had  said  that  talipes  equinovarus  was 
a  stage  in  the  development  of  the  lower  extremities  of  the 
human  fetus,  but  Eschricht  had  not  explained  how  it  was 
produced.  There  was  no  embryological  data  at  that  time 
(1851). 

Dr.  J.  E.  Kelly's  paper  dealt  with  the  mechanism  of  the 
foot  and  the  advantages  to  be  derived  from  the  anatomical 
study  of  the  factors  and  treatment  of  talipes.  He  called  at- 
tention to  the  erroneous  idea  which  persisted  as  to  the  exist- 
ence of  a  transverse  arch  in  the  foot.  We  said  it  was  impos- 
sible, as  it  had  no  internal  abutment ;  it  bore  a  greater  resem- 
blance to  a  "  flying  buttress,"  the  upper  and  inner  extremity 
of  which  was  supported  by  the  so-called  longitudinal  arch. 
In  reality  it  was  a  semi-dome  which,  with  its  fellow  foot,  con- 
stituted a  dome  upon  the  apex  of  which  the  weight  of  the 
body  rested.  He  called  attention  to  the  benefits  obtained  by 
utilizing  the  stability  of  the  margins  of  the  semi-dome  in 
walking,  especially  in  those  tending  to  pes  planum  and 
talipes  valgus.  He  dwelt  on  the  fact  that  the  factors  in  the 
third  and  fourth  degrees  of  talipes  equinus,  varus  and  equi- 
novarus had  best  be  divided  into  hyperextention,  adduction, 


torsion,  and  longitudinal  folding,  and  with  the  exception  of 
the  last,  which  results  from  the  simple  approximation  of  the 
internal  and  external  margins  of  the  foot,  each  of  these  fac- 
tors is  complex,  and  may  occur  in  two  or  more  anatomical 
sites  and  in  diflferent  degrees,  thus  accounting  for  the  infinite 
variety  of  talipes.  He  reviewed  the  different  factors  in 
detail — action  of  the  muscles  and  resistance  of  ligaments, 
and  observed  as  a  summary  that  the  factors  in  hyperexten- 
sion,  or  ivertical  deformity,  are  the  retraction  of  the  heel, 
luxation  downwards  and  forwards  of  the  astragalus  and  the 
plantar  flexion  at  Chopart's  articulation.  Adduction  is  due 
to  the  curvature  in  the  neck  of  the  astragalus,  displacement 
of  the  scaphoid  and  the  traction  exercised  by  the  severed 
tendons  and  muscles  on  the  inner  aspect  of  the  foot.  The 
torsion  is  caused  by  the  rotation  of  the  scaphoid  on  its 
anteroposterior  axis,  the  traction  of  the  tibialis  anticus  on 
the  inner  margin.  He  pointed  out  that  the  peculiar  facilities 
of  section,  resection  and  dissection  were  afi'orded  in  the  two 
margins  of  the  foot,  and  indicated  the  positions  from  which 
the  difleient  structures  could  be  most  easily  reached.  He 
said,  owing  to  the  direction  of  fibers  of  the  plantar  fascia, 
it  was  best  to  divide  it  posteriorly  near  the  tubercle  of  the  os 
calcie,  where  the  flexor  dig.  brevis,  the  flexor  accessorius  and 
the  long  plantar  ligament  might  be  divided.  The  division 
should  be  obliquely  forward  and  outward,  parallel  to  the 
ext.  plantar  vessels  and  nerves.  Should  the  external 
septum  need  special  section,  it  could  best  be  approached 
from  the  external  margin.  He  advocated  the  division  of 
tendons  close  to  their  insertion.  Owing  to  the  slight  import- 
ance of  toes  in  ordinary  locomotion,  he  suggested  dividing 
the  numerous  digital  tendons  close  to  the  metatarsophalan- 
geal articulation.  Owing  to  his  observation  on  the  perfect 
restoration  of  ligaments  of  great  mechanical  importance,  he 
thought  it  expedient  in  subluxation  of  the  astragalus  to  con- 
sider as  an  alternative  to  resection,  the  free  division  of  the 
lateral  and  posterior  ligaments  and  the  replacement  of  the 
bones  which  should,  under  the  persistent  influence  of  the 
modelling  pressure  and  adaptive  shortening,  result  in  a 
restoration  of  the  articular  functions. 

Dr.  E.  D.  Fisher,  in  speaking  of  the  neurological  aspect  of 
talipes,  said,  that  the  only  class  of  talipes  interesting  to  the 
neurologist  was  that  class  originating  from  lesions  of  the 
brain,  spinal  cord,  or  peripheral  nervous  system.  The  two 
main  causes  of  talipes  of  this  class  were  diseases  of  the  motor 
tracts  of  the  brain  and  spinal  cord.  Another  form  of  talipes 
was  that  due  to  infantile  spinal  paralysis.  Certain  definite 
symptoms  difi'erentiate  true  congenital  clubfoot  from  that  of 
cerebral  or  spinal  origin.  In  the  deformity  resulting  fi-om 
central  nerve  disease  were  found  reflex  disturbances,  usually 
exaggerated  reflexes  associated  with  spastic  conditions  of  the 
muscles,  and  commonly  the  Babinski  symptom — the  exten- 
sion of  the  toes  on  irritation.  This  latter  phenomenon  asso- 
ciated with  exaggeration  of  the  patellar  and  knee-jerk  always 
pointed  to  disease  of  the  pyramidal  tracts  and  present  when- 
ever there  was  disease  of  the  lateral  tracts ;  in  cerebral  hem- 
iplegia in  the  later  stages ;  in  the  secondary  changes  follow- 
ing myelitis;  iu  lateral  and  multiple  sclerosis.  In  congenital 
clubfoot,  on  the  contrary,  there  was  no  central  nerve  disease, 
therefore  no  disturbances  of  the  ordinary  physiological  actions 
of  the  spinal  cord  and  brain,  hence  no  disturbances  of  the 
reflexes.  In  making  a  difierential  diagnosis  between  the  con- 
genital type  of  clubfoot  and  clubfoot  due  to  infantile  spinal 
paralysis  he  said  the  muscular  electrical  reaction  determined 
the  diagnosis.  Referring  to  treatment,  he  said  of  late  years 
interesting  exnerimental  work  had  been  done.  In  cases  of 
spastic  paraplegia  for  a  long  time  neurologists  were  opposed  to 
operation,  but  now  he  recommended  section  of  tendons,  and 
putting  patients  in  a  condition  to  walk.  He  referred  to 
transplantation  of  tendons  to  opposite  muscles  or  muscles  of 
opposed  functions,  such  as  transplanting  a  flexor  tendon  to 
an  "extensor  muscle  or  vice  versa.  He  referred  to  a  boy  with 
central  hemiplegia  who  could  not  extend  his  hand.  The 
extensor  tendon  was  transplanted  with  the  result  of  giving 
boy  a  useful  hand. 

Dr.  Newton  M.  Shaffer  spoke  of  the  nonoperative  treat- 
ment of  clubfoot.  He  said  he  was  accustomed  to  divide  his 
clubfoot  patients  into  three  classes :  Vertical,  antero  pos- 
terior, and  transverse.  By  careful  study  of  each  case  and  by 
making  each  instrument  an  individual  prescription  to  fit  the 
given  case,  he  had  achieved  results  which  at  first  appeared 
impossible.    The  necessity  for  operation  was  gHting  further 


550 


Thb  Philadelphia^ 
Medical  Journal 


] 


AMERICAN  NEWS  AND  NOTES 


[MiBCH  23,  19M 


and  further  away.  He  said  in  the  first  class  of  cases  of  ordi- 
nary clubfoot,  without  much  deformity,  good  results  could 
be  accomplished  by  manipulation,  massage,  electricity,  or 
perhaps  some  form  of  walking  apparatus.  The  careful  carry- 
ing out  of  nonoperative  treatment  in  these  cases  should  result 
in  cure  in  a  year's  time.  In  the  second  class,  where  the 
deformity  is  greater,  especially  in  equinovarus,  we  meet  with 
resistance  which  may  be  osseous,  or  fibrous.  Experience 
here  was  necessary  to  determine  whether  operative  or  non- 
operative  measures  should  be  adopted.  It  was  diflacult  to 
give  any  positive  rule,  however ;  he  was  inclined  to  agree 
with  the  elder  Doctor  Say  re  and  not  operate  if  we  could  trace 
our  lesion  to  cerebral  source.  The  rule  had  exceptions.  In 
the  third  class — the  resistant — usually  some  form  of  oper- 
ative procedure  was  indicated.  This  class  fell  into  the  hands 
of  the  general  surgeon.  Referring  to  cutting  the  tendo 
Achilles,  he  said  he  did  not  cut  when,  in  taking  hold  of  the 
foot,  he  felt  the  resistance  gradually  give  away. 

De.  a.  M.  Phelps  in  speaking  of  the  operative  treatment 
of  clubfoot  said  that  in  considering  when  and  why  to  operate 
nothing  had  been  said  regarding  age  of  patient.  If  a  rigid 
foot  occurred  in  a  child  two  months  of  age,  and  that  same 
rigid  foot  in  a  child  of  six  years,  there  wa?  a  vast  difference. 
In  the  two  rnonths'  old  baby  the  condition  could  be  cured  by 
the  mechanical  nonoperative  treatment ;  in  the  older  child 
Buch  a  thing  was  impossible.  For  that  reason  be  believed 
all  cases  should  be  divided  into  classes  according  to  age  and 
deformity.  In  a  certain  type  of  talipes  in  newborn  children 
the  human  hand  was  the  beat  instrument,  and  the  deformity 
could  be  cured  by  manipulation  before  the  child  was  nine 
years  old.  In  other  cases,  even  after  four  months,  there  was 
great  resistance  and  operation  was  required  the  same  as  at 
the  age  of  six  years.  Operations  on  the  soft  parts  are  all 
that  were  indicated  up  to  a  certain  age  and  to  a  certain 
degree.  In  a  child  of  four  months  a  subcutaneous  tenotomy 
was  all  that  would  be  required  in  the  majority  of  cases,  but 
having  once  commenced  to  operate  the  foot  must  be 
straightened  at  the  expense  of  a  more  extensive  operation. 
At  the  age  of  two  or  three  years,  instead  of  applying  appa- 
ratus for  a  year  or  so,  he  advised  subcutaneous  tenotomy 
observing  the  rule  to  get  the  foot  straight.  Regarding  open 
operation  he  said  frequently  surgeons  neglected  to  carry  out 
the  necessary  after-treatment.  He  objected  to  the  opera- 
tions when  bone  was  removed,  such  as  removing  the  astrag- 
alus which  caused  shortening  of  the  leg  ;  or  the  removal  of 
a  V-shaped  portion  from  the  tarsus  which  shortened  the 
foot.  He  said  he  resorted  to  subcutaneous  tenotomy,  and  if 
this  was  not  sufficient  to  allow  of  straightening  the  foot,  he 
made  an  open  wound  and  cut  whatever  resisted.  Occasion- 
ally he  found  it  necessary  to  take  a  V  out  of  the  os  calcis  ; 
occasionally  the  deformity  was  so  great  that  nothing  short 
of  amputation  was  indicated.  He  advocated  thorough  oper- 
ative measures  rather  than  spending  years  with  mechanical 
appliances  and  subcutaneous  tenotomies. 

Dr.  Phelps  presented  a  boy,  16  years  old,  upon  whom  he 
had  performed  the  open  incision  operation  four  weeks  pre 
viously.  The  boy  was  born  with  extreme  equinovarus  of  the 
right  foot  and  had  worn  various  mechanical  appliances.  He 
cut  the  tendons  necessary  to  straighten  the  foot  and  pulled 
it  into  position. 

Dr.  Sayre  cited  a  case  of  his  own  some  years  ago  in  which 
both  feet  were  deformed.  He  operated  on  one,  taking  out 
the  astragalus.  Later,  he  did  not  like  the  condition  of  the 
foot  and  when  he  cime  to  operate  on  the  other,  the  worst 
one,  he  did  not  remove  the  astragalus  but  divided  by  sub- 
cutaneous incision  and  wrenched  the  foot  into  place,  getting 
a  better  result  than  by  taking  out  the  astragalus.  The 
patient  was  a  man  26  years  old,  who  was  deformed  since 
birth.  Toe  question  then  came  up  as  to  whether  the  foot 
should  he  brought  to  a  right  angle  by  means  of  an  operation 
through  the  bone  of  the  tarsus  or  by  going  above  the  tarsus. 
The  idea  of  going  through  the  tarsus  was  abandoned  f  jr  the 
reason  that  by  years  of  walking  in  an  abnormal  position  the 
foot  had  adjastf  d  itself  to  a  peculiar  formation  of  the  facets 
of  articulation  of  the  bone,  and  it  seemed  better  to  allow  this 
confirmation  to  remain  and  to  cut  through  above  the  mal- 
leolus, taking  out  a  piece  of  the  tibia  and  fibula.  A  wedge  of 
the  tibia  was  therefore  removed  and  the  result  has  enabled 
the  patient  to  walk  very  comfortably. 

In  the  discussion,  Dr.  Elliott  said  he  agreed  with  Dr. 
Shaffer  that  in  certain  forms  of  congenital  clubfoot  delayed 


muscular  growth  seemed  to  call  for  some  cause  beyond  the 
mechanical  one  described  by  Dr.  Berg.  Dr.  Berg  had  clearly 
demonfitrated  that  equinovarus  was  a  stage  in  the  develop- 
ment of  every  human  fetus.  He  failed  to  believe  that  nature 
80  frequently  failed  in  her  unfolding  process,  without  some 
pathological  reason,  as  the  great  number  of  clubfeet  would 
indicate.  This  lack  on  the  part  of  nature  to  unfold  properly 
was  contrary  to  her  workings  throughout  the  animal  and 
vegetable  kingdom.  Regarding  the  treatment  of  clubfoot  he 
thought  Dr.  Phelps  had  struck  the  keynote  to  the  successfnl 
treatment  in  dwelling  upon  the  advisability  of  dealing  with 
resistance  which  could  not  be  overcome  by  manipulation  by 
operation.  Those  who  had  seen  many  cases  of  clubfoot  in 
babies  could  not  fail  to  have  noticed  that  many  were  easily 
cured  by  manipulation  whils  others  resisted  all  manipulative 
procedures.  Any  foot  left  short  of  the  flaccid  state  was  cer- 
tain to  relapse. 

Dr.  Berg  said  he  considered  Dr.  Shaffer's  lateral  traction 
shoe  a  most  admirable  device  and  he  thought  Dr.  Phelps' 
Of)en  incision  was  also  the  treatment  par  excellence  for  cer- 
tain cases.  In  regard  to  Dr.  Sayers'  question  as  to  why 
external  rotation  of  the  lower  extremity  remains  and  why 
internal  rotation  does  not  occur,  he  did  not  think  it  applied 
at  all.  It  made  no  difference  why  it  happened  thus ;  the  fact 
remained  just  the  same.  We  are  satisfied  to  know  what 
form  of  arrested  development  causes  hare  Up  or  spina  bifida 
without  inquiring  why  such  arrest  of  development  occurs. 
In  his  paper  he  had  purposely  avoided  theory  as  much  as 
possible. 

Dr.  Phelps  eaid  in  regard  to  the  traction  shoe  that  if  a 
muscle  was  pulled  upon  for  years  atrophy  was  sure  to  follow 
and  said  further  that  he  had  observed  atrophy  so  produced 
in  hundreds  of  cases.  Oa  the  other  hand  if  you  divided  a 
tendon  the  normal  nutrition  of  the  muscle  was  preserved. 

Dr.  Shaffer  stated  that  he  hid  kept  records  of  a  series  of 
cases  that  had  been  stretched  as  to  muec'.es  and  he  wished 
to  say  that  Dr.  Pnelps  was  entirely  mistaken.  In  his  ex- 
perience the  muscles  had  become  stronger  by  stretching. 
He  wished  this  remark  recorded.  He  stated  that  in  a  long 
series  of  cases  extending  over  years  of  practice  he  had  not 
once  seen  atrophy.  In  regard  to  Dr.  Pnelps'  statement 
about  "stretching  muscles  for  years"  he  would  like  to  ask 
who  did  such  a  thing.  He  also  said  that  he  had  patients 
who  wore  the  traction  shoe  for  a  short  time  in  the  morning 
in  the  winter  because  after  it  the  foot  kept  warm  all  day ;  he 
did  not  think  that  the  state  of  things  indicated  atrophy. 


NEW  ENGL.\ND. 

Smallpox  at  St.  Alban's. — Dr.  A.  H.  Barbe,  secretary 
of  the  State  Bjard  of  Health,  received  an  cffisial  report  of 
49  cases  of  sm.illpox  and  4  recent  deaths  from  the  disease  at 
St.  Alban's.    Toe  epidemic  has  existed  for  3  weeks. 

CHICAGO  A  SO   WESTERN   STATES. 

Appointment.— Dr.  W.  D.  Zoethout  has  been  appointed 
labor.itory  professor  of  neurology  in  Rush  Medical  College, 
Chicago,  III. 

American  Medico-Psychological  Association  will 
hold  its  annual  meeting;  in  Milwaukee,  Wis.,  June  11. 12,  IS 
and  14,  1901. 

Indians  Dying  of  Diphtheria. — It  is  reported  that 
7  deaths  from  diphtheria  have  occurrel  among  the  Indiana 
at  the  Fiathead  Reservation.  Tae  Indians  are  ignorant  of 
the  nature  of  the  affection  and  consequently  intermingle 
indiscriminately. 

Cleveland  German  Medical  Society. — Toe  following 
officers  were  ele  ted  for  the  ensuing  year :  President,  Dr.  C. 
Sihraitz;  vi.'.e  pre.-ident,  Dr.  I.  Bjllowski ;  secretary.  Dr.  M. 
Kahn;  correspondiuj  secretary,  Dr.  Leo  Reich;  and  treas- 
urer, D..  I.  J.  Propper. 

Endowment  for  a  Library  and  Pathological 
Laboratory. — Dr.  William  E.  Q  line  gave  $25,000  to  endow 
a  library  for  the  College  of  Poysici.ins  and  Surgeons  of 
Illinois,  and  Dr.  D.  A..  K.  Steel  $25,000  for  tbe  establishment 
of  a  pathological  laboratory. 


UaBCB  23,  1901] 


AMERICAN  NEWS  AND  NOTES 


CThe  Philaoelpbu. 
XlKDICAL  JOCHNAL 


551 


Appoiatmeut. — Dr.  Frf  derick  C.  Schaefer  haa  been  ap- 
pointed gynecologist  to  St.  Elizabeth's  Hospital,  and  surgeon 
in  chief  to  St.  Hedwig's  Hospital,  Chicago. 

Death  of  Dr.  James  A.  Ewingr^ — Dr.  James  A.  Ewirg, 
Irtasurtr  of  the  St.  Louis  Hospiinl  Association.  St.  Louis, 
died  on  March  16,  at  the  hrspital,  aged  33  years.  He  returned 
two  weeks  sgo  from  Las  V(gas,  N.  JI.,  whither  he  went  lasi 
geptembtr  to  recuperate. 

Medical  Practice  Bill  Passed. — The  Senate  of  Mis- 
eouii  has  passed  the  Hall  medicine  practice  bill,  which  has 
been  strongly  opposed  by  the  Christian  Scientists  of  Missouri 
since  it  began  its  course  early  in  the  session.  The  bill  has 
been  signed  by  the  Governor. 

Village  for  Epileptics.— A  bill  introduced  in  the  House 
of  Representatives  of  Indiana  provides  for  a  villase  for  epi- 
leptics, to  be  erected  by  the  State.  The  sum  of  $40,000  is  to 
be  appropriated  for  the  purpose  of  purchasing  a  tract  of  not 
less  than  1,000  acres  of  land,  and  not  more  than  $160,000  ''or 
the  erection  of  buildings.    No  site  has  yet  been  selected. 

Exposed  Himself  to  Contagion. —A  physician  of 
Appleton,  Wisconsin,  has  made  himself  notorious  by  visiting 
smallpox  patients,  breaking  the  pustules,  and  smearing  the 
contents  over  his  face,  hands,  and  clothing,  in  an  attempt  to 
prove  that  the  disease  is  not  contagious.  He  was  caught  by 
the  health  authorities,  confined,  and  quarantined.  There 
was  so  much  public  excitement  in  Appleton  that  he  came 
very  nearly  being  mobbed. 

Hospital  for  the  Treatment  of  Incipient  Tubercu- 
losis.— A  bill  has  been  introduced  into  the  legislature  of 
Wisconsin  providing  for  the  establishment  of  a  hospital  for 
the  treatment  of  incipient  tuberculosis  to  he  known  as  the 
Wisconsin  State  Sanitarium.  The  bill  provides  that  "  All 
persons  afllicted  with  incipient  pulmonary  tuberculosis  may 
be  admitted  to  said  hospital  after  such  examination  into 
their  condition  as  is  required  to  be  made  to  determine  the 
condition  of  persons  who  are  alleged  to  be  insane  and  for 
whom  admission  is  sought  to  the  State  hospitals  or  county 
asylums  for  the  insane.  All  the  provisions  of  law  relating 
to  the  examination  and  commitment  of  such  alleged  insane 
persons,  shall,  so  far  as  practicable,  apply  to  persons  whom 
It  is  sought  to  have  committed  to  the  hospital  for  those 
afflicted  with  incipient  pulmonary  tuberculosis ;  and  all 
powers  conferred  upon  the  judges  of  the  several  courts  as  to 
auch  alleged  diseased  persons,  and  all  duties  devolving  upon 
such  judges  in  relation  to  their  examination  and  commit- 
ment shall  be  exercised  in  the  examination  and  commitment 
of  persons  to  said  hospital,  so  far  as  such  powers  and  duties 
are  applicable. 

SOUTHERN  STATES. 

New  Central  State  Hospital. — The  new  Central  State 
Hospital  at  Petersburg,  Va.,  has  recently  been  opened,  with 
accommodations  for  160  patients. 

Old  Dominion  Hospital. — This  hospital  in  Richmond 
connected  with  the  Medical  College  of  Virginia,  is  about  to 
be  enlarged  so  as  to  accommodate  forty  more  patients. 

Orphans'  Home. — An  Orphans'  Home  for  physicians' 
children  is  being  established  at  Bristol,  Tenn.  Dr.  N.  H. 
Reeve,  of  tliat  place,  is  the  secretary  of  the  board  of 
trustees. 

Legislature  on  Cocaiu.  —  The  State  Legislature  of 
Georgia,  at  its  last  session,  passed  a  law  imposing  a  fine  on 
any  dealer  guilty  of  selling  cocain  except  on  a  prescription  of 
a  physician. 

Plan  Revised  for  a  Municipal  Hospital.— Health 

Commiesiouer  Bosley's  ordinance  appropriating  $25,000  for 
the  establishment  of  a  municipal  hospital  for  infectious  dis- 
eases was  introduced  in  both  branches  of  the  Baltimore  City 
Council  and  referred  to  the  Committee  on  Health. 

University  College  of   Medicine    Hospital.- This 

hospital,  adjoining  the  Virginia  Hospital  of  Richmond,  is 
nearly  completed.  It  will  have  a  capacity  of  some  sixty  or 
more  patients.      Ita   clinical  amphitheater  is  built  on  t'  e 


most  approved  plans,  havirg  all  the  convenient  arrange- 
ments for  demonstrations,  etc. 

Death  of  Dr.  George  C.  Venable.— Dr.  George  Car- 
rington  Venable  died  at  his  home  in  Lynchburg,  Va,,  on 
March  13,  aged  73  years.  He  was  born  in  Charlotte  county 
and  wa«  the  only  son  of  Dr.  Paul  C.  Venable  and  Emily 
Eaton  Carrington.  After  his  graduation  in  medicine  at  the 
University  of  Pennsylvania  in  1847  he  practised  in  his  native 
county  and  continued  there  until  10  years  ago,  when  he  came 
to  Lynchburg. 

Death  of  Dr.  J.  W.  H.  Lovejoy Dr.  James  W.  H. 

Lovfjoy,  one  of  the  best- known  members  of  the  medical  fra- 
ternity cf  Washington,  died  at  his  residence  in  Washington, 
aged  76  years.  Dr.  Lovejoy  was  chairman  of  the  executive 
committee  of  the  Children's  Hospital,  and  also  served  several 
terms  as  president  of  the  Medical  Society  of  the  District.  He 
was  one  of  the  incorporators  of  Garfield  Hospital,  and  had 
been  president  of  the  faculty  of  Georgetown  University 
Medical  School.  Dr.  Lovejoy  came  from  one  of  the  oldest 
families  in  the  District,  and  his  father  and  grandfather  lived 
in  the  house  in  which  he  died.  At  an  early  age  he  took 
up  the  study  of  medicine  and  graduated  from  Jefferson  Col- 
lege in  Philadelphia.  He  practised  in  Washington  for  a 
good  many  years. 

Louisiana  State  Medical  Society. — The  Pillowing  is 
the  list  of  officers  for  1901  :  President,  Dr.  F.  W.  Parhara, 
New  Orleans  ;  vice  presidents,  First  Congressional  District,  Dr. 
C.J  Landfried,  New  Orleans;  Second  Congressional  District, 
Dr.  John  Callan,  New  Orleans;  Third  Congressional  District, 
Dr.  C.  M.  Smith,  Franklin  ;  Fourth  Congressional  District,  Dr. 
T.  G.  Ford,  Shreveport ;  Fifth  Congressional  District,  Dr.  0. 
M.  Patterson,  Bastrop ;  Sixth  Congressional  District,  Dr.  R. 
C.  Webb,  Rayne ;  recording  secretary,  Dr.  H.  B.  Gessner, 
New  Orleans;  corresponding  secretary.  Dr.  A.  G.  Friedriehs, 
New  Orleans  ;  treasurer  and  librarian.  Dr.  H.  S.  Cocram,  New 
Orleans. 

Sections. 

Surgery- — Dr.  E.  D.  Martin,  chairman.  New  Orleans.  Sab- 
ject  for  discussion.  Treatment  of  Fractures  of  the  Long  Bones 
of  the  Upper  and  Lower  Extremities. 

Genito-Urinary  Surgery. — Dr.  Charles  Chassoignac,  chair- 
man, New  Orleans.  Subject  for  discussion.  Treatment  of 
Cystitis. 

Materia  Medica  and  Therapeutics. — Dr.  L.  Sexton,  chairman. 
New  Orleans.  Subject  for  discussion.  Is  the  Tendency 
Toward  Prescribing  Proprietary  Medicines  Increasing ;  Its 
Final  Etfect  upon  the  Professions  of  Medicines  and  Phar- 
macy. 

Ear,  Nose  and  Throat. — Dr.  0.  Joachim,  chairman.  New 
Orleans.  S  ibject  for  discussion,  The  Middle  Eir  Inflamma- 
tions of  Childtiood  and  their  Consequences. 

Ophthalmology  —  Dr.  E.  A.  Robin,  chairman,  New  Orleans. 
Subject  for  discussion.  When  Not  to  Operate  in  Anomalies 
of  the  Extrinsic  Muscles  of  the  Eye. 

Dental  and  Oral  Surgery. — Dr.  A.  G.  Friedriehs,  chairman, 
New  Orleans.  Subject  for  discussion.  The  Care  of  Children's 
Teeth. 

Nervous  Diseases. — Dr.  P.  E.  Archinard,  chairman,  New 
New  Orleans.  Subject  for  discussion,  Alcohol  in  Its  Relation 
to  Nervous  Diseases. 

Sanitary  Scitnce. — Dr.  E  Souchon,  New  Orleans,  chairman. 
Subject  for  discussion,  The  Prevention  of  the  Spread  of  Con- 
tagious Diseases. 

Quarantine.— Dr.  J.  N.  Thomas,  Port  Eads,  chairman. 
Subject  for  discussion,  The  Period  of  Incubation  of  Yellow 
Fever.  » 

Dermatology. — Dr.  J.  N.  Roussel,  chairman.  New  Orleans. 
Subject  for  discussion,  Dandruff. 

Practice  of  Medicine.— Dr.  W.  Glendower  Owen,  White 
Castle,  chairman.    Subject  for  discussion.  Scarlet  Fever. 

Medical  Jurisprudence.— Dr.  C.  D.  Simmons,  Dutchtown, 
chairman.  Subject  for  discussion.  Board  of  Lunacy,  with 
Especial  Reference  to  the  Examination  of  Patients  for  Com- 
mitment in  the  Insane  Asylum. 

Obstetrics  and  Gynecology.— Dr.  E.  S.  Lewis,  New  Orleans, 
chairman.  Sutject  for  discussion.  Lacerations  of  the  Cervix 
and  their  Consequences. 


552 


Thk  Philadelphia"! 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


(MiECH  23,  1901 


I 


Miscellaneous  Subjects. 

In  the  final  program  it  is  the  object  of  the  committee  of 
arrangements  to  have  these  topics  called  for  at  any  session 
where  the  general  discussion  on  any  section  has  been  com- 
pleted, thereby  adding  to  the  interest  of  each  session  of  the 
Society. 

1.  Overaction  of  the  Heart  from  Administration  of 
Hyosoin,  by  Dr.  Parsons,  of  Minden,  La. 

2.  Thirty  cases  of  Acute  Lobar  Pneumonia,  with  29 
Recoveries,  by  Dr.  Edward  D.  Xewell.  St.  Joseph,  La. 

S  Otitis  Media  Neonatorum,  by  Dr.  O.  Joachim,  Xew 
Orleans. 

4.  Affections  of  the  Nose  and  Throat  as  Factors  in  Diseases 
of  the  Bronchi  and  Lungs,  by  Dr.  W.  Scheppegrell,  New 
Orleans. 

CANADA. 

Vital  Statistics.— Winnipeg's  vital  statistics  for  Febru- 
ary were  :  110  births,  62  male  and  48  female  ;  71  deaths,  40 
male  and  31  female;  marriages,  39. 

Held  on  the  Charge  of  Graveyard  Desecration.— 

The  Canai/'i  Lancet  states  that  a  third  year  medical  student 
in  Queen's  College,  Kingston,  was  recently  arrested  at  Peter- 
borough fcr  robbing  a  grave  in  order  to  secure  a  body  for 
dissection.  The  charge  of  robbery  was  withdrawn  by  the 
prosecution,  as  there  was  nothing  in  Canadian  law  govern- 
ing such  an  ofience,  thf  re  being  no  property  in  a  dead  body. 
He  is  held  for  trial,  however,  at  the  Assizss,  in  bonds  of 
$2,000,  on  the  charge  of  graveyard  desecration  and  offering 
indignity  to  the  dead.  The  police  magistrate,  in  giving 
judgment,  held  that  while  Canadian  law  did  not  cover  this 
point,  English  law,  which  makes  it  a  punishable  offence, 
would  probably  be  applicable  in  the  present  instance.  Since 
more  ample  provision  of  dissecting  material  has  been  made 
under  the  Anatomy  Act,  cases  of  this  kind  in  Ontario  have 
fortunately  teen  of  very  rare  occurrence. 

MISCELLANY. 

A  Useful  Millionaire Alexander  Graham  Bell,  the 

inventor  of  the  telephone,  has  been  serving  as  a  spesial 
agent  of  the  Census  Bureau  in  charge  of  the  enumeration  of 
the  deaf,  dumb,  and  blind  population  of  the  country,  and  is 
now  preparing  his  report,  Mr.  Bell  is  a  millionaire  several 
times  over,  but  is  entitled  to  $6  a  day  from  the  Government 
while  he  is  employed  in  this  work.  In  his  early  life  he  was 
an  instructor  in  a  deaf  and  dumb  asylum,  and  a  large  part 
of  his  time  is  now  spent  in  the  investigation  of  means  for 
promoting  the  education  of  deaf-mutes  and  sightless  people. 

Obituary.— Dr.  Charles  H.  Bowen,  at  Washington, 
D.  C,  on  March  12,  aged  65  years.— Dr.  K.  R.  Hall,  at 
Fayette  County,  Ky.,  on  March  14,  aged  85  years. — De.  E. 
H.  Davis,  at  Plainfield.  Conn.,  on  March  15,  aged  56  years. — 
Dr.  Hesrv  N.  Lovelace,  at  Apex,  Mo.,  on  March  15,  aged  60 
years.— Dr  Henry  M.  S.mith,  at  Escondido,  Cal.,  on  March 
16 —Dk.  S.  R.  McCla.vahan,  at  Culneper,  Va.,  on  March  J9, 
aged  70  years.— Dr.  J.  J.  S.vith,  at  LiCrosse,  Wis.,  on  March 
16,  aged  63  years.— Dr.  John  Sargent,  at  Jefferson  County, 
N.  Y.,  aged  87  years. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  Mirch  16,  1901 : 

Xoticc— Candidates  for  appointment  as  Dental  Surgeons  in  U.  S. 
Array  will  be  examined  in  the  following-named  branches  : — Anat- 
omy ;    physiology  ;    histology  ;    physics  :    chemistry  :    metallurgy  ; 
dental  anatomy  and  physiology  :  dental  materia  medica  and  thera- 
peutics ;    dental   pathology   and   bacteriology;    orthodontia;     oral 
surgery;    operative    dentistry,    theoretical;    prosthetic    dentistry, 
tlieoretieal ;  operative  dentistry,    practicral ;     prosthetic    dentistry, 
practical.     An  average  of  75'f  will  be  required  in  each  subject  for 
theoretical  examination,  and  SSCi  in  the  practical  examinations. 
Knapp,  Gustav,  hospital  steward,  a  patient  in  the  Army  General 
Hospital,  Presidio,  will  be  sent  to  the  Army  and  Navy  General 
Hospital,  Hot  Springs. 
Skinxee,  First    Lieutenant  Ira  A.,  assistant  surgeon,  is  granted 
leave  of  absence  for  1  month,  with  permission  to  apply  for  an 
extension  of  1  month. 
Hali,,  Henry  M.,  acting  assistant  surgeon,  is  relieved  from  tempo- 
rary duty  at  the  Army  General  Hospital,  Presidio,  and  will   re- 
port for  temporiiry  duty  at  Major  Lockwood's  camp  of  recruits 
and  casuals  on  the  Presidio  reservation,  awaiting  transporta- 
tion to  the  Philippine  Islands. 


ScMMERALL.  W.  B  ,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  1  month,  with  permission  to  go  beyond  the  limit*  of 
the  department  of  Cuba. 

PuMMER.  George  R..  acting  assistant  surgeon,  now  on  duty  at  Bat- 
tery Xo.  5,  Havana,  Cuba,  will  proceed   to  Hamilton  Barrack" 
Matanzas,  Cuba,  for  temporary  duty  during  the  absence  of  Act 
ing  Assistant  Surgeon  W.  B  .Suramerall. 

Erck,  Philip  F..  hospital  steward,  will  be  granted  a  furlough  for  6 
months,  by  the  commanding  otBcer  of  Fort  Monroe,  with  per- 
mission to  leave  the  Cnited  States,  to  take  effect  about  April  10. 

Mitchell.  James,  acting  assistant  surgeon,  will  proceed  to  his 
home.  Lancaster,  Pa.,  for  annulment  of  contract. 

LeHardy,  Jclics  C,  acting  assistant  surgeon,  will  proceed  to  his 
home  Savannah,  Ga.,  for  annulment  of  contract. 

Athey.  Wiley  L.,  acting  assistant  surgeon,  will  proceed  to  his 
home.  N'ew  York,  X.  Y.,  for  annulment  of  contract. 

.Adair,  Major  George  W.,  surgeon,  is  granted  leave  of  absence  for  1 
month,  upon  being  relieved  from  duty  at  Fort  Sheridan. 

The  following-named  assistant  surgeons,  U.  S.  Volunteers,  recently 
appointed,  now  in  San  Francisco,  Cal..  will  report  to  the  com- 
manding general,  department  of  California,  for  transportation 
to  Manila,  P.  I.,  where  they  will  report  to  the  commanding 
general,  division  of  the  Philippines,  for  assignment  to  duty: 
Captains  Elmer  S.  Tes.sey,  and  Clark  I.  Wertesbakkb. 

Williams,  Charles  F.,  acting  assistant  surgeon,  will  proceed  from, 
Yorkville,  S.  C,  to  Fort  Screven,  for  temporary  duty. 

Andrews,  Captain  Charles  H.,  assistant  surgeon,  recently  ap 
pointed,  now  at  the  Presidio,  will  report  for  transportation  tc 
Manila,  P.  I.,  where  he  will  report  for  assignment  to  duty. 

Chaffee,  First  Lieutenant  Jerome  S.,  assistant  surgeon,  recentlj 
appointed,  will  proceed  from  Dover  Plains,  X.  Y.,  to  Colambat 
Barracks,  for  duty. 

Hicks,  John  R.,  acting  assistant  surgeon,  is  granted  leave  of  absence 
for  21  days,  with  permission  to  apply  for  an  extension  of  7  days. 

BoYiE,  Newton  J.,  actins  assistant  surgeon,  is  relieved  from  duty 
on  the  transport  "  McClellan."  and    will   proceed  from   New! 
York  City  to  San  Francisco,  Cal.,  and  report  for  assignment  to 
duty  with  troops  en  route  to  the  Philippine  Islands,  where  he 
will  report  for  assignment  to  duty. 

Driver,  G.  S.,  acting  assistant  surgeon,  is  granted  leave  of  absence 
for  6  days. 

Laine,  Major  Da.maso  T.,  surgeon,  is  granted  leave  of  absence  for  10 
days,  on  surgeon's  certificate. 

GoRGAS,  Major  Willia.m  C,  surgeon,  is  granted  leave  of  absence  for 
14  days,  with  peimission  to  go  beyond  the  limits  of  the  depart- 
ment of  Cuba. 

Gilhuley.  John  J.,  acting  assistant  surgeon,  is  relieved  from  tem- 
porary duty  at  Fort  Columbus  and  will  proceed  to  Fort  Terry, 
and  relieve  Acting  Assistant  Surgeon  Arthur  I.  Boyer. 

Boyer,  Arthde  I.,  acting  assistant  surgeon,  will  proceed  to  Fort 
Columbus  for  duty. 

Penrose,  Major  George  H.,  surgeon,  leave  of  absence  grante<l  Feb- 
ruary 11  is  extended  1  month,  on  surgeon's  certificate. 

Cox,  Captain  Frederick  W..  sssistant  surgeon,  recently  appointed, 
will  proceed  from  Vermillion,  S.  D.,  to  San  Francisco.  Cal.,  for 
transportation  to  Manila,  P.  I.,  where  he  will  report  for  duty. 

Conn.  Frederick  A.  W,  acting  assistant  surgeon,  is  granted  leave 
of  absence  for  1  month 

Whitney,  Major  Walter,  surgeon,  recently  appointed,  will  report 
at  Fort  Walla  Walla,  for  duty. 

Pond,  Major  Arlington,  surgeon,  recently  appointed,  will  report 
at  Fort  Preble,  for  duty. 

Pond.  Major  .Arlington,  surgeon,  is  relieved  fnim  duty  at  Fort 
Preble  to  take  etfect  ni>on  the  arrival  at  that  post  of  Acting  As- 
sistant Surgeon  Ernest  W.  Fowler,  and  will  then  proceed  to 
San  Francisco,  Cal  ,  and  report  for  transportation  to  Manila,  P. 
I.,  where  he  will  report  for  assignment  to  duty. 

Pond,  M^or  Arlington,  surgeon,  is  granted  leave  of  absence  for  14 
davs.  to  take  effect  upon  his  being  relieved  from  duty  at  Fort 
Preble. 

Disney.  Captain  Fr.\nk  A.  E.,  assistant  surgeon,  recently  appointed, 
now  at  San  Francisco.  Cal.,  will  report  for  transportation  to 
Manila,  P,  I  ,  where  he  will  report  for  assignment  to  duty. 

Shimkr,  First  Lieutenant  Ira  A.,  orders  of  February  25  relating  to 
him  are  revoked. 

HrTTON,  First  Lieutenant  Paul  C,  recently  appointed,  now  in 
Washington,  D.  C,  will  proceed  to  Fort  Thomas,  for  duty. 

Fowler,  Ernest  W.,  acting  assistant  surgeon,  will  proceed  from 
Xew  York  City  to  Fort  Preble,  for  duty,  to  relieve  Major  Ar- 
lington Pond,  surgeon. 

Changres  in  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  March  16,  1901 : 

McClannahan.  R.  K.,  assistant  sufireon,  detached  from  the  "In- 
diana" and  ordered  to  wait  orders  for  sea  duty. 

Eakins,  0.  M.,  assistant  surgeon,  resignation  accepted,  to  take  eSect 
from  April  15. 

Morse,  E.  T.,  pharmacist,  detached  from  the  Boston  Xavy  Yard, 
and  order«l  to  the  "  Michigan.'' 

HiRD,  I.  N.,  pharmacist,  detached  from  the  "  Wabiish  '  and  ordered 
to  the  Boston  Xavy  Yard. 

Changres  in  the  U.  S.  Marine-Hospital  Serrice. 

for  the  week  ended  M*rch  17,  1901 : 

Bailuachk,  Prestun  H.,  surgeon,  is  relieved  from  duty  at  the 
bureau  and  directeii  to  Stapleton,  X.  Y.,  and  assume  command 
of  the  service,  relieving  Surgeon  G.  W.  Stoner.    March  8. 


March  23,  1901 J 


FOREIGN  NEWS  AND  NOTES 


CThe  Philadelphia 
Medical  Journal 


553 


Stoner.  O.  W,,  surgeon,  upon  being  relieved  by  Surgeon  Preston  H. 
Bailhache,  is  to  proceed  to  immigration  depot,  New  York.  N.Y,. 
and  assume  command  of  the  service,  relieving  Surgeon  L.  L. 
Williams.     March  8. 

Carter,  H.  R..  surgeon,  upon  being  relieved  by  Past  Assistant  Sur- 
geon G.  B.  Young,  is  to  proceed  to  Baltimore.  Md..  and  assume 
command  of  the  service,  relieving  Passed  Assistant  Surgeon  B, 
W.  Brown,     March  8. 

Glknnan,  a.  H.,  surgeon,  is  granted  leave  of  absence  for  U  days 
from  March  6.     March  8. 

Williams,  L.  L.,  surgeon,  upon  being  relieved  by  Surgeon  G.  W. 
Stoner,  is  to  proceed  to  Washington,  D.  C,  and  report  at  bureau 
for  duty.     March  8. 

YotNG,  G.  B..  passed  assistant  surgeon,  upon  being  relieved  by 
Assistant  .Surgeon  C.  H.  Lavinder,  is  to  proceed  to  Louisville, 
Ky.,  and  assume  command  of  the  service,  relieving  Surgeon  H. 
R.  Carter.     March  8. 

Brown,  B.  W.,  passed  assistant  surgeon,  upon  being  relieved  by 
Surgeon  H.  R.  Carter,  is  to  proceed  to  Evansville.  Ind.,  and 
assume  command  of  the  service,  relieving  Passed  Assistant  Sur- 
geon J.  H.  Oakley.     March  8. 

NvDEGGKR,  J.  A.,  passed  assistant  surgeon,  is  relieved  from  duty  at 
Chicago.  III.,  and  directed  to  assume  command  of  the  Cape 
Charles  (Quarantine  Station,  relieving  Assistant  Surgeon  C.  W. 
Wille.  March  11. 

The  official  list  of  changes  dated  January  17.  1901,  is  amended  so 
that  leave  of  absence  granted  Passed  Assistant  Surgeon  Nydeg- 
ger  for  30  days  shall  read,  "  leave  of  absence  on  account  of  sick- 
ness."    March  13. 

Oakley,  J.  H.,  passed  assistant  surgeon,  upon  being  relieved  by 
Passed  Assistant  Surgeon  B.  W.  Brown,  is  to  proceed  to  Cairo, 
111.,  and  assume  command  of  the  service,  relieving  Assistant 
Surgeon  J.  M.  Holt.     March  8. 

Mathewsox,  H.  S.,  assistant  surgeon,  is  to  proceed  to  Washington, 
U.  C,  for  examination  for  promotion.     March  8. 

Lavinder,  C.  H.,  assistant  surgeon,  is  to  proceed  to  Delaware  Break- 
water and  assume  command  of  the  service,  relieving  Passed 
Assistant  Surgeon  G.  B.  Y'oung.    March  8. 

Foster,  M.  H.,  assistant  surgeon,  is  granted  leave  of  absence  for  20 
days  from  April  1.     March  11. 

King,  W.  W.,  assistant  surgeon,  is  to  proceed  to  San  Juan,  Porto 
Rica,  for  special  temporary  duty.    March  8. 

Holt,  J.  M.,  assistant  surgeon,  upon  being  relieved  by  Passed 
Assistant  Surgeon  J.  H.  Oakley,  is  to  report  to  him  for  duty. 
March  11. 

Trotter,  F.  E.,  assistant  surgeon,  is  granted  leave  of  absence  for  26 
days  from  April  9.     March  11. 

Wille,  C.  W.,  assistant  surgeon,  upon  being  relieved  by  Passed 
Assistant  Surgeon  J.  A.  Xydegger.  is  to  report  to  him  for  duty. 
March  11. 

Dudley,  I).  E.,  acting  assistant  surgeon,  is  relieved  from  duty  at 
Havana,  Cuba,  and  assigned  to  duty  in  the  office  of  the  United 
States  Consul  at  Vera  Cruz,  Mexico.     March  1. 

Hodgson,  S.  H.,  acting  assistant  surgeon,  is  relieved  from  duty  at 
Vera  Cruz,  Me-^iico,  and  assigned  to  duty  in  the  office  of  the 
United  Stats  Consul  at  Proeresso,  Mexico.    March  1. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera  and  plague,  have  been  reported  to  the 
Surgeon-General  U.  S.  Marine-Hospital  Service,  during  the 
week  ended  March  16,  1901 : 

Smaixpox— United  States. 


3A3ES.       Deaths 

Alabama  : 

Mobile  .... 

.  March  2-9    .    . 

1 

California  : 

Los  Angeles  . 

.   Feb.  24-March  i 

5 

'* 

Oakland  .   .  . 

.  Feb.  24-March  £ 

1 

Sacramento    . 

.   Feb.  24-Marcli  2 

1 

Illinois  : 

Chicago    .   .  . 

.  March  2-9    .    . 

7 

Indiana  : 

Evansville  .   . 

.  Feb.  24-March  i 

2 

Kansas  : 

Wichita       .  . 

.  March  2-9    .    . 

23 

Kentucky  : 

Lexington  .   . 

.  March  2-9    .   . 

1 

Louisiana: 

New  Orleans  . 

.  March  2-9    .    . 

14           3 

Massachscetts 

Lowe'l      .  .   . 

.  March  2-9    .    . 

1 

" 

.  Somerville  .   . 

.  March  2-9    .    . 

1 

Michigan  : 

Detroit  .... 

.  March  2-9    .    . 

1 

*' 

Grand  Rapids 

.  March  2-9    .    . 

1 

Minnesota  : 

Minneapolis  . 

.   Feb.  24-March  C 

4 

" 

Winona   .    .   . 

.  March  2-9    .   . 

2 

Nebraska  : 

South  Omaha 

.   Dec.  28-Feb.  5 

5 

N.  Hampshire  : 

Manchester    . 

.   March  2-9    .    . 

21 

New  Y'ork  : 

New  Y'ork   .    . 

.   March  2-9    .    . 

54           10 

Ohio  : 

Cincinnati  .    . 

.  March  2-9    .    . 

2 

" 

Cleveland 

.   March  2-9    .    . 

52 

" 

Dayton .... 

.   Nov.  2-9   .    .   . 

1 

Oregon  : 

Portland  .    .   . 

.   Feb.  1-2S  .    .  . 

2 

Pennsylvania  : 

Erie 

.  March  2-9    .    . 

2 

" 

Philadelphia  . 

.  JIarch  2-9    .    . 

1 

*' 

Steelton    .   .  . 

.   March  2-9    .    . 

1 

Tennessee  : 

Jackson     .    .   . 

.  Jan.  1-31  .    .   . 

20           2 

'* 

Memphis  .   .    . 

.  March  2-9    .    . 

10 

'* 

Nashville     .   . 

.   March  2-9    .    . 

U 

" 

San  Autonio  . 

.  Feb.  1-28  .    .   . 

16 

Utah  : 

Ogden  .... 

.   March  2-9    .    . 

18 

Washington  : 

Tacoma    .   .  . 

.   Feb.  25  ...    . 

6 

West  Virginia 

Huntington    . 

.  March  2-9    .    . 

11 

"           " 

Wheeling     .    . 

.   Feb.  24-March  9 

4 

Wisconsin  : 

Milwaukee  .   . 

.   March  2-9    .    . 

2 

Smallpox— FoBEioN . 


Austria  : 

Belgium  : 
Canada : 
Ceylon  : 
Egypt  ; 
Great  Britain 


Scotland : 

India  : 


Italy  : 
Malta  : 
Mexico  : 
Philippines  : 
Rdssla  :. 


colu.mbia  : 
Cuba  : 
Mexico  : 

India  : 
Straits 


Prague  .  . 
Vienna .  . 
Antwerp  . 
Sudbury  . 


Cairo".  .  .  . 
I  London  .  . 
New  Castle 
Tyne  .  .  . 
Dundee  .  . 
Edinburgh  . 
Glasgow  .  . 
Bombay  .  . 
Calcutta  .  . 
Karichi  .  . 
Madras  .  . 
Naples  .   .  . 


Progresso  .  . 
Manila  .... 
Moscow  .  .  . 
Odessa  .... 
St.  Petersburg 
Warsaw   .   .  . 


Jan.  9-23  .... 
Feb.  16-23  .  .  . 
Feb.  9-23  .... 

Feb.  22  

Jan.  2fi-Feb.  2  . 
Jan. 28-Feb. 4  . 
Feb. 16-23    .    .    . 

Feb. 16-23  .  .  . 
Feb.  16-23  .  .  . 
Feb,  16-23  .  .  . 
Feb.  22- March  1 
Jan. 29-Feb.  12  . 
Jan.  26- Feb.  9  . 
Jan.  »7-Feb.  10  . 
Jan.  26-Feb.  8    . 

Feb.  20 

Feb. ie-28  .  .  . 
Feb. 19-28  .  .  . 
Jan.  5-19  .  .  . 
Feb.  2-66  .... 
Feb.  8-23  .... 
Feb.  8-16  .... 
Feb.  8-16  .... 


14 


Prevalent. 
1  1 

2 
1 

1 


13 

6 

235 

7 

8 

Present. 

1 


15 


16 

4 

10 

26 


Yellow   Fever. 


Honda  .  .  . 
Guaduas  .  . 
Cienfuegos  . 
Havana   .   . 

Vera  Cruz    . 


Jan. 7    . 
Jan. 7    . 
March  4 
Feb.  2S-Marcl: 
Feb.  16-23 


1  4 


Cholera. 

Bombay   ....  Jan.  29-Feb.  12 
Calcutta  ....  Jan.  26-Feb.  9    , 
Madras Jan.  26-Feb.  8    , 


Epidemic. 
Epidemic. 
1 

2  1 

2 


12 
33 
22 


Settlements  :  Singapore 


Jan. 12-26 


Africa  : 
China  : 
India  . 

Philippines  : 


Plague— Foreign  and  Insular. 

Cape  Town      .       Feb.  16-26    .    .    . 
Hongkong  .    .    .  Jan.  19-26    . 
Bombay  ....  Jan.  i9-Feb.  12  . 
Calcutta  ....  Jan.  26-Feb.  9    . 
Manila Jan.  5-19  .... 


44 


35 


6 

2 

1711 

176 

2 


Jorei^n  Heirs  anb  Hotcs. 


GREAT  BRITAIN. 

Appoiatnient. — Lord  Lister  has  been  appointed  Ser- 
geant-Surgeon in  Ordinary  to  His  Majesty. 

Reelection.— Dr.  Parry  has  been  reelected  president  of 
the  Royal  Medical  and  Chirurgical  Society  for  the  ensuing 
year. 

Honors  for  Americans. — The  appointments  of  Mmes. 
George  Cornwallis  Vi'^est  and  Jennie  Blow  as  Ladies  of  Grace 
of  the  Order  of  St.  John  of  Jerusalem,  and  Mr.  J.  J.  Van 
Alen  as  an  honorary  Knight  of  Grace  is  announced,  on 
account  of  their  work  in  connection  with  fitting  out  the 
American  hospital  ship  Maine,  and  a  field  hospital  for  South 
Africa. 

Astley  Cooper  Prize. — Under  the  will  of  the  late  Sir 
Astley  Cooper,  Bart.,  a  sum  of  money  was  left  in  trust,  which 
should  yield  £300,  to  be  awarded  to  the  author  of  the  best 
essay  or  treatise  on  "  The  Pathology  of  Carcinoma,  and  the 
Distribution  and  Frequency  of  the  Secondary  Deposits  Cor- 
responding to  the  Various  Primary  Growths."  This  prize  is 
awarded  triennially,  full  particulars  of  which  will  be  found 
on  reference  to  the  advertising  columns  of  the  Medical  Press 
and  Circular.  The  competition  is  open  to  all  members  of  the 
medical  profession,  except  to  the  staffs  of  Guy's  and  St. 
Thomas'  Hospitals,  Particulars  regarding  other  conditions 
to  be  complied  with  can  be  obtained  on  application  to  Dr. 
Newton  Pitt,  Guy's  Hospital,  London. 

Two  Dispensing  Accidents. — A  terrible  triple  mishap 
is  reported  from  Normanton  (Yorks),  where  three  children 
have  succumbed  after  taking  powders  supposed  to  contain 
santonin,  but  which  there  is  reason  to  suspect  contained 


Medical  Journal 


] 


FOREIGN  NEWS  AND  NOTES 


FMabch  23,  1101 


strychnin.  The  powders  were  dispensed  in  the  surgery 
of  a  local  practitioner,  and,  on  suspicion  being  raised, 
it  was  found  that  the  strychnin  bottle  stood  in  close 
proximity  to  that  containing  santonin.  The  dispenser  de- 
clares, however,  that  he  made  no  mistake,  and  the  inquest 
has  been  adjourned  for  an  analysis  of  the  viscera.  A  some- 
what similar  accident  is  reported  from  Sketty,  near  Swansea, 
where  a  young  mining  engineer  died  from  the  effects  of  car- 
bolic acid  sent  out  in  error  for  medicine. 

Lead  in  Drinking  Water. — A.t  a  recent  meeting 
of  the  Hunslet  Rural  District  Council,  the  principal  sub- 
ject discussed  was  the  alleged  presence  of  lead  in  the  water- 
supply  of  Middleton.  The  question  had  been  raised  by  Dr. 
Buck  in  his  annual  report,  which  stated  that  the  Middleton 
water,  supplied  from  Morley,  still  acts  on  the  lead  when 
standing  in  the  pipes  overnight.  Various  samples  had  been 
taken  during  the  year,  and  no  improvement  had  been  per 
ceptible,  and  he  was  of  the  opinion  that  the  matter  should 
be  brought  before  the  Morley  Corporation,  with  a  view  to  its 
abatement.  After  discussion,  it  was  agreed  that  the  inhabit- 
ants of  the  district  be  informed  that  it  was  not  desirable  to 
use  the  water  in  the  morning  without  first  opening  the  tap 
and  letting  it  run  some  time.  The  chairman  said  they  must 
prepare  themselves  for  a  considerable  waste  of  water, 

CONTINENTAL  EUROPE. 

Appointment. — Dr.  Karl  Haeger  and  Dr.  Frederick 
Egger  have  heen  appointed  extraordinary  professors  of  medi- 
cine in  the  University  of  Basel. 

Hospital  for  Slcin  Diseases.— Through  the  liberality 
of  Madame  Andre  Nottebohn  a  liospital  for  skin  diseases, 
which  included  a  department  for  light- treatment,  has  been 
established  at  Antwerp.  Dr.  Francois  has  been  appointed 
directing  physician. 

A  Woman- physician  Leads  in  tlie  Race. — In  the 

province  of  Novosibkow,  Russia,  occurred  four  vacancies  for 
district  physicians.  Over  80  applications  were  received. 
Among  those  selected  was  also  a  woman,  Mrs.  Lishin,  who 
graduated  from  the  Medical  Faculty  of  Paris. 

Italian  Recognition. — The  Italian  Government  has 
tendered  Dr.  Eugene  Wasdin,  of  the  United  States  Marine- 
Hospital  Service,  the  Cross  of  OfiBcer  of  the  S.  S.  Maurizio  et 
Lazzaro,  in  recognition  of  his  services  in  verifying  and  con- 
firming the  Italian  studies  and  discoveries  regarding  the 
nature  of  yellow  fever. 

Death  of  Dr.  liocha. — Dr.  Augusto  Rocha,  professor 
of  clinical  medicine  in  the  University  of  Coimbra,  and  editor 
of  the  Coimbra  Medica,  has  recently  died  of  aneurysm  of  the 
ascending  aorta.  He  was  born  at  Coimbra  in  1849,  studied 
medicine  in  the  university  of  that  city,  and  took  the  degrees 
of  licentiate,  and  a  few  months  later  of  doctor,  in  187('>.  He 
was  appointed  professor  in  1882.  He  was  the  author  of  nu- 
merous contributions  to  medical  literature,  among  which  may 
be  mentioned  monographs  on  the  Intravenous  Injections  of 
Chloral  in  the  Treatment  of  Tetanus,  an  Investigation  of  the 
Typhoid  Bacillus  in  the  Drinking-water  of  Coimbra,  Studies 
on  the  Nervous  System,  and  papers  on  medicolegal  subjects 

Meeting  of  the  Medical  Society  of  the  City  of 

Zurich,  held  on  February  2,  1901 Prof.   Schlatter 

presented  a  17-year-old  girl  on  whom,  on  October  5,  1894, 
(that  is,  more  than  0  years  before)  he  had  resfcted  a  10  cm. 
piece  of  the  lower  jaw  because  of  a  myelogenous  sarcoma. 
At  that  time  a  prothesis  modelled  according  to  Claude 
Martin's  suggestions  of  vulcanized,  hard  rubber  fitted  to  the 
natural  jaw  was  inserted  and  fastened  at  either  end  by  outer 
and  inner  platinum  plates  screwed  to  the  bone.  Tnis  first 
prothesis  {prothise  immediaie)  was  removed  on  November 
3.  Then  on  December  3,  1891,  the  patient  received — after 
wearing  a  substitute  prothesis  for  several  weeks — a  definite 
prothesis  with  teeth.  This  grasped  at  either  end  the  rear 
molar  Iceth  which  alone  were  left.  The  fastening  showed 
itself  secure.  After  each  meal  the  prothesis  was  removed 
(at  first  by  the  nurse,  later  by  the  patient  herself),  cleaned 
and  replaced.  This  final  prothesis  has  been  renewed  4 
times  during  the  G  years  in  order  to  keep  pace  with   the 


growth  of  the  surrounding  bones.  The  present  results,  both 
from  a  cosmetic  and  medical  standpoint,  are  excellent.  The 
only  thing  noticeable  is  the  scar  in  the  submental  region. 
The  functional  results  are  so  good  that  the  patient  can  bite 
through  an  apple.  Professor  Schlatter,  in  discussing  the 
advantages  and  disadvantages  of  the  Martin  prothese  imme- 
diate, coEsidered  that  its  wordt  point  was  not  so  much  the 
difficuliy  of  disinfection  as  the  dependence  of  the  surgeon 
upon  the  dentist.  The  Boanecken,  Baitsah,  and  Sloppani 
models  of  jaw  supports  were  then  exhibited  and  discussed. 
Professor  Schlatter  prefers  the  Stoppani  aluminum  model. 
This  is  not  simply  composed  of  metal  plates,  but  pierced 
strips,  the  lower  edges  of  which  are  bent, — to  give  chin  a  sup- 
port and  to  prevent  its  falling  in.  The  advantages  of  the 
Stoppani  prothesis  are  :  (1)  The  surgeon  is  always  prepared 
without  the  help  of  a  dentist  to  insert  the  primary  pjiece,  no 
matter  how  great  the  resection  ;  (2)  it  prevents  the  falling  in 
of  the  chin  ;  (3)  it  permits  easy  cleaning  and  supervision  of 
the  wound  surface  ;  (4)  it  permits  the  taking  of  a  caat  of  the 
jaw  without  removal. 

In  conclusion  Prof  Schlatter  presented  a  34  year-old 
patient  on  whom  he  resected  both  maxillary  bones  on  Ssp- 
tember  7,  1897.  The  cause  was  sarcoma,  from  which  there 
has  appeared  no  recidive.  The  peculiarity  of  the  operation 
was  that  the  right  common  artery  was  temporarily  ligated 
to  perform  the  operation.  (Prof.  Schlatter's  article  on  this 
operation  is  soon  to  appear  in  the  PHiLADELPHii  Medi- 
cal Journal).  The  patient  has  wore  for  three  years  without 
trouble  a  prothesis  which  acted  as  substitute  for  the  right 
and  part  of  the  left  hard  palate,  which  supported  the  left 
bulbus  and  to  which  was  attached  a  Schiltaky  obturatur.  The 
result  has  been  excellent.  The  nasal  cavity  is  completely 
separated  from  the  mouth.  The  double  seeing  due  to  the  sink- 
ing of  the  left  eye  was  cured  by  the  projections  on  the  proth- 
esis. The  "lallend"  speech,  due  to  a  drawing  of  the  soft 
palate  to  the  front,  was  also  cured  by  the  prothesis.  Prof. 
Schlatter  has  ligated  the  carotids  in  two  other  maxillary  re- 
sections. Once  the  ligature  of  the  external  carotid  sufficed 
to  stop  the  bleeding ;  in  the  other  case  the  ligating  of  the 
internal  carotid  was  also  necessary. 

Further,  Prof.  Schlatter  reported  a  case  of  true  bone  growth 
in  the  thyroid  (struma  calcarea),  in  which  he  performed 
strumectomy.  The  45  year-old  patient  (woman)  had 
suffered  since  her  twelfth  year  with  a  hard  goiter.  Because 
of  the  terrible  dyspnea  she  was  forced  to  seek  surgical  aid. 
Because  of  the  severity  of  the  attack  the  operation  was 
hurried  as  much  as  possible.  Local  anesthesia  by  4  Pravaz 
syringesful  of  1%  cocain-eucain  solution,  and  1.01  of 
morphium.  Patient  was  in  silting  position.  Incision  from 
one  sterno-cleido  to  the  other.  The  upper  thoracal  aperture 
was  entirely  filled  by  the  bone-like  tumor.  While  seeking  to 
draw  this  up  and  out  the  patient  became  so  asphyxiated  that 
her  head  fell  back,  the  face  became  pale,  and  the  breathing 
ceased,  the  pupils  dilated,  the  pulse  became  small.  There- 
upon tracheotomy  was  performed  with  difficulty,  the 
operator  piercing  the  goiter,  and  found  the  trachea,  which 
was  compressed  into  a  ribbon  against  the  spinal  column. 
A  Kiinig  canula  was  inserted  and  pushed  behind  the  tumor- 
mass  down  into  the  thorax  and  artificial  respiration  accord- 
ing to  Silvester  was  begun.  With  the  spontaneous  respiration 
(after  about  6  minutes)  a  hemorrh^e  occurred,  which  was 
stopped  by  ligatures.  'The  goiter  was  now  literally  dragged 
up  out  of  the  thorax,  which  caused  a  fearful  venous  hemor- 
rhage from  the  jugular.  By  manual  compression  and  finally 
ligatures  this  was  controlled  and  the  operation  completed, 
leaving  the  tracheal  canula  in  place.  The  patient  made  an 
uninterrupted  recovery.  The  examination  of  the  goiter 
showed  therein  a  dissemination  of  true  bone. 

Professor  Schlatter  reported  further  3  cases  sent  to  him 
for  operation  as  appendicitis  and  which  proved  to  be  (1) 
perforated  pyosalpinx ;  (2)  duodenal  ulcer,  and  (3)  extra- 
uterine pregnancy.  The  first  and  third  were  cured.  In  the 
second  case  the  perforation  was  not  found  and  the  patient 
died.  An  old  appendicitis  had  caused  the  intestines  to  be- 
come so  attached  to  each  other  and  to  the  peritoneum  that  a 
clear  conception  of  the  c*8e  was  impossible  and  the  trouble 
was  believed  to  have  been  due  to  these  old  processes.  The  Bode 
drainflge  was  used,  but  in  spite  of  this  the  patient  died  afler 
about  24  hours.  This  is  the  third  case  in  Zurich  where  the 
Bode  drainage  for  diffuse  purulent  peritomtis  has  proven  in- 
eflective. 


Maech  23,  1901] 


THE  LATEST  LITERATURE 


(Thb  Philadelpioa 
L  Mbdical  Jodknal 


555 


tm^  latest  literature. 


British  Medical  Journal. 

March  S.     [No.  2096.] 

1.  A  Clinical  Lecture  on  Some  Points  Relating  to  Varicocele. 

William  H  Bennett 

2.  Ad  Terra-n.    II.— The  Earth  and  the  Soil.    Sir  Fkancis 

Seymour  Haden. 

3.  The  Milroy  Lectures  on  the  Influence  of  the  Dwelling 

upon  Health.    John  F.  J.  Sykes. 

4.  Painless  Ca'culous  Pyonephrosis  without  Fever;  Nephrec-  ; 

tomy  ;  Recovery.    Alban  Doran.  I 

5.  The  Trea'ment  of  Puerpera'  Eolampsia  by  Sa'ine  Diuretic 

Infusions.    Robert  Jardine. 

6.  Case  of  Puerperal  E^laiipsia  and  its  Trea'/inent  by  Mor- 

phin.    George  Elder. 

7.  A  Case  of  Multilocular  Cystoma  of  the  Omentum ;  Re- 

moval ;    Recovery.      N.    Percy    Marsh    and    Keith 
Monsareat. 

8.  The  Campaign  Against  Ague.    Herbert  E.  Durham. 

1. — Bennett  in  this  lecture  discusses  particularly  varico- 
cele associated  with  certain  nervous  symptoms.  As  to  the 
frequency  of  varicocele  it  is  found  to  occur  in  about  7  ^  of 
all  males.  Eighty  per  cent,  are  affected  on  the  left  side  only, 
limitation  to  the  right  side  only  is  extremely  rare.  The  vari- 
cocele itself  usually  produces  no  inconvenience  and  no  pain 
unless  injured.  Tne  distressing  symptoms  and  those  which 
make  operation  most  frequently  necessary  are  the  melan- 
choly states  of  the  patient's  mind.  Bjnnett  finds  these 
patients  to  be  always  unmarried,  and  to  whatever  class  they 
belong  they  are  sensitive  and  intelligent  beyond  the  average. 
He  has  never  known  a  dull,  stupid,  or  uneducated  person  to 
suffer  from  these  83'mptoms.  Masturbation  cannot  be  con- 
sidered a  cause  of  varicocele.  He  describes  varicocele  as  of 
two  kinds :  First,  that  consisting  of  large  tortuous  veins  gen- 
erally confined  to  the  cord,  and,  second,  that  consisting  of 
masses  of  small  veins  clustered  around  the  testicle?.  This 
latter  variety  checks  the  growth  of  the  testicle.  The  small 
testicle  is  often  thought  to  be  due  to  atrophy,  but  this  is  not 
the  case,  for  the  organ  has  never  been  developed.  In  the 
hypochondriacal  cases  arguments  from  the  moral  point  of 
view  are  of  little  benefit  unless  "in  the  first  instance  the 
conditions  of  life  ordinarily  led  are  entirely  changed."  If  the 
patient  himself  is  convinced  that  operation  and  cure  of  the 
defect  will  bring  about  relief,  operation  can  generally  be 
recommended  without  hesitation  and  with  a  good  prospect 
of  cure  in  60  fo  of  cases.  If  relief  does  not  follow  the  first 
operation  no  secondary  one  should  be  done.  At  the  earnest 
written  solicitation  of  two  patients  and  their  friends,  Bennett 
has  twice  performed  castration  after  operating  for  varicocele, 
but  in  each  case,  as  he  predicted,  the  patients  were  not  bene- 
fited, la  operating  for  varicocele  the  veins  are  not  denuded 
of  the  fascia  covering  them,  but  are  tied  en  masse.  He  advo- 
cates very  strongly  the  ligation  of  the  spermatic  artery,  main- 
taining that  the  vessels  which  accompany  the  vas  deferens, 
together  with  the  few  small  vessels  which  are  derived  from 
the  subvaginal  tissue,  are  suflicient  to  nourish  the  testicle. 
Bennett  thinks  that  the  ligation  of  the  spermatic  artery  tends 
to  prevent  the  fatty  degeneration  which  is  occasionally  eeen 
after  operation  for  varicocele,    [j.h  g.] 

3. — It  may  be  assumed  that  beyond  a  certain  point,  in- 
creasing density  of  population  upon  a  given  area,  in  the 
absence  of  hygienic  measures,  would  result  in  increasing 
mortality,  and  that  in  propoition  to  the  application  of  these 
measures,  the  mortality  would  diminish.  It  is  recognized 
that  the  most  important  factor  in  the  spread  of  pulmonary 
tuberculosis  is  predisposition,  and  predisposition  can  be 
acquired  as  well  as  be  innate,  and  further  that  by  hygienic 
measures  the  acquired  predisposition  and  the  innate  disposi- 
tion, and  even  the  communicable  entity  of  tbe  disease  itself, 
can  be  so  controlled  as  to  be  kept  in  abeyance,  and  even  to 
be  permanently  subdued.  It  is  further  recognized  that  the 
conditions  under  which  it  may  be  acquired  are  residence  in 
impure  air,  particularly  such  as  is  not  renewed  often  enough, 
crowding  of  persons  together,  absence  of  sunlight,  and 
dampness.  In  susceptibility  to  phthisis,  the  power  of  resist- 
ance appears  to  be  even  more  important  than  the  power  of 


infection,  or  in  other  word-",  the  prevention  of  loss  of  vitalitj' 
or  energy  is  most  important.  In  cities  the  average  dwell- 
ing space  of  the  inhabitants  has  a  closer  relation- 
ship to  their  health  than  any  other  condition  of  health 
which  is  capable  of  statistical  expression.  If  we  could  obtain 
a  classification  of  only  a  portion  of  the  population  according 
to  the  amount  of  measured  cubic  space  occupied  and  the 
ages  and  causes  of  mortality,  we  should  perhaps  be  able  to 
draw  m'ore  definite  and  exact  conclusions  still.  Typhus  was 
formerly  very  prevalent  under  conditions  of  gro  s  over- 
crowding, and  not  only  typhus,  but  other  infectious  diseases 
tend  to  diminish  in  prevalence  with  increase  of  cubic  dwell- 
ing space.  The  phthisis  death-rate  shows  a  close  relation- 
ship to  density  of  persons  in  cubic  spice,  and  phthisis 
appears  to  stand  almost  in  the  same  relationship  to  respira- 
tory pollution  as  typhoid  does  to  filth  pollution.  The  respira- 
tory diseases,  apart  from  phthisis,  are  also  influenced  by 
impurities  of  the  air,  and  afford  some  measure  of  their 
effects,  just  as  diarrheal  diseases,  apart  from  typhoid,  are 
regarded  as  bearing  a  relationship  to  impurities  of  the  soil. 
The  effects  of  insufliciently  separating  street  blocks  from 
each  other — that  is,  of  allowing  streets  to  be  made  too  nar- 
row, displays  itself  as  one  of  tne  causes  of  unhealthiness  of 
unsanitary  areas.  The  occupants  of  stable  dwellings  have  a 
high  birth-rate,  a  high  mortality  at  all  ages,  and  high  death- 
rates  from  pulmonary  diseases  both  of  infants  and  adults, 
and  from  th«!  zymotic  diseases,  especially  diarrhea  and 
diphtheria.  These  facts  point  to  the  effects  of  the  vicissi- 
tudes of  temperature  affecting  adults,  and  unheaUhy  condi- 
tions at  home  affecting  young  children  in  tropical  countries. 

[j.M.S.] 

4. — Doran  reports  a  very  interesting  case  of  pyoneph- 
rosis, occurring  in  a  woman,  38  years  of  age,  in  which  the 
usual  symptoms  of  pain  and  fever  were  entirely  absent.  The 
patient"  was  well  nourished,  able  to  do  all  her  housework,  and 
only  suflered  pain  and  nausea  when  she  put  on  her  corsets. 
Blood  had  never  been  passed  in  the  urine,  and  she  had  never 
had  any  symptoms  of  renal  colic.  Esamination  ravealed  a 
large  movable  kidney,  not  tender,  and  apparently  contain- 
ing fluid.  This  organ  was  removed  through  the  peritoneal 
cavity  and  upon  examination  was  found  to  be  filled  with  pus, 
to  contain  a  free  calculus  in  the  pelvis  and  several  others  in 
the  calices.  Tnere  was  complete  obhteration  of  the  ureter. 
The  oatient  made  an  excellent  recovery.  Doran  does  not 
think  that  this  is  a  case  of  an  original  floating  kidney  with 
kinking  of  the  ureter,    [j.h.g  ] 

5. — Jardine  repeats  his  former  statement  that  in  the 
treatment  of  puerperal  eclampsia  by  saline  diu- 
retic infusions  the  essential  part  ot  the  method  is  the  in- 
fusion. His  aim  is  to  dilute  the  poison  and  get  rid  of  it  as 
quickly  as  possible — that  is  to  treat  the  cause  and  not  a  mere 
symptom.  He  has  recently  had  under  treatment  some  half 
dozen  cases  of  marked  dropsy  and  albuminuria  of  preg- 
nancy. By  prompt  purging  with  salts  and  the  use  of  diu- 
retics and  milk  diet  they  all  except  one  escaped  eclampsia. 
If  by  the  establishment  of  diuresis  one  can  prevent  the  fits, 
it  is"  reasonable  to  suppose  that  they  can  be  cured  by  the 
same  method.  Besides  the  diuretic  effect  when  the  drugs 
are  given  subcutaneously,  there  is  obtained  a  dilution  of  the 
poison  and  a  stimulation  of  the  patient.  In  other  words  the 
same  effect  is  obtained  as  in  the  treatment  of  septicemia  by 
saline  infusions.  As  to  the  obstetric  treatment  of  the  condi- 
tion, Jardine's  experience  teaches  him  not  to  interfere  if 
labor  has  not  begun.  During  the  first  stage,  if  the  fits  cease, 
dilatation  may  be  left  to  nature,  but  if  they  recur  the  uterus 
should  be  emptied  as  quickly  as  possible.  During  the  sec- 
ond stage  delivery  should  be  effected  at  once.  Kerr  has 
collected  all  the  cases  of  puerperal  eclampsia  treated  in  the 
Glasgow  Maternity  Hospital  during  the  last  fifteen  years. 
The  death-rate  among  the  cases  treated  by  chloroform, 
chloral  bromide,  and  veratum  viride,  was  47/c.  Since  the 
saline- in  fusion  has  been  added  to  the  treatment  the  rate  has 
fallen  to  17/0.    [w  a.n  d  ] 

6.— Eder  records  a  case  of  puerperal  eclampsia 
treated  by  morphin  successfully.  He  claims  that  when 
the  medical  attendant  is  brought  face  to  face  with  a  patient 
in  convulsions,  whether  these  be  before,  during,  or  after  labor, 
no  remedy  is  so  quickly  and  certainly  sedative  as  morphin 
hvDodermically  administered.    \_v;  a  n.d  ] 

"7.— M*rsh  and  Monearrat  report  a  case  of  multilocular 
cystoma  of  the  omentum,  occurring  in  a  child  aged  one 


556 


The  Philadelphia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[K4BCH  28,   1901 


year  and  eight  months.  This  case  was  at  first  looked  upon 
88  one  of  tuberculous  peritonitis,  as  the  fluid  seemed  to  be 
free  in  the  peritoneal  cavity,  producing  dulness  in  both  flmks. 
The  abdomen  was  tapped  repeatedly  and  quantities  of  light 
colored  serum  removed.  At  the  list  two  tappings  blood  was 
found  in  the  fluid.  After  the  last  tapping  the  fianks  were 
found  resonant,  although  there  was  still  the  evidence  of  fluid 
in  the  upper  part  of  the  abdomen,  hence,  laparotomy  was 
advised  and  done.  There  was  found  a  large  cyst  of  the  omen- 
tum with  many  smaller  ones  invf  Iving  nearly  the  whole  of 
this  portion  of  the  peritoneufn.  The  child  made  a  very  good 
recovery,    [j  h.g  ] 

8. — In  undertaking  the  use  of  chemical  culicicidal  agents 
it  appears  that  the  most  profitable  time  for  their  employ- 
ment would  be  during  the  dry  season.  During  the  wet 
season,  with  heavy  rains  much  actual  washing  away  or  dilu- 
tion would  occur;  however,  nature's  own  culicicides,  in  the 
form  of  tadpoles,  water  beetles,  etc.,  may  be  enabled  to 
spread  from  pool  to  pool,  and  assitt  in  the  "destruction  of 
anox)beles  larva.  Koch  has  been  the  chief  advocate  of 
the  proposal  to  effect  the  riddance  of  ague  by  means  of 
quinin.  It  is  geaerally  admitted  that  although  the  admin- 
istration of  quinin  causes  a  rapid  disappearance  of  the  mal- 
aria parasite  in  its  asexual  form  from  the  blood,  the  sexual 
forms  can  still  be  found,  even  after  long  periods  of  quinin- 
taking.  It  is  clear,  therefore,  that  some  better  drug  than 
quinin  is  needed  for  stamping  out  ague,  inasmuch  as  it  is  by 
the  sexual  forms  that  the  disease  is  spread  by  means  of  the 
gnat.  Durham  believes  that  arsenic  is  the  drug  that  has 
best  repute  for  compassing  the  destruction  of  these  forms. 
In  the  treatment  of  an  individual  suffering  from  ague  in  a 
region  where  he  is  likely  to  be  a  danger  to  his  fellow  men, 
every  endeavor  should  be  made  to  prevent  the  development 
of  sexual  parasites  in  his  system.  For  the  patient's  own 
safety  he  must  be  given  quinin  in  some  form  or  other ;  at  the 
same  time,  for  the  safety  of  the  community,  the  administra- 
tion of  some  drug,  such  as  arsenic,  should  be  commenced. 
[j.M  s.] 


Lancet. 

March  S,  1901.     [No.  4044  ] 

1.  The  Milroy  Lectures  on  Public  Health  and   Housing; 

the  Influence  of  the  Dwelling  Upon  Health  in  RelatioD 
to  the  Changing  Style  of  Habitation.  John  F.  J. 
Sykes. 

2.  On  the  Influence  of  Ozine  on  the  Vitality  of  Some  Path- 

ogenic and  Other  Bicteria.  Arthur  Ransome  and 
Alexander  G.  R.  Foulerton. 

3.  On  the  Q  nantitative  Estimation  of  the  Bictericidal  Power 

of  the  Blood.    A.E.Wright. 

4.  Result  of  Major  Amputations  Treated  Antiseptically  in 

the  Royal  Infirmary,  New  Castle  upon -Tyne,  during 
the  Year  1899,  and  for  a  period  of  21  Years  and  9 
Months— viz.,  from  April  1,  1878,  to  December  31, 
1899,  Inclusive.    H.  Bounton  Angus 

5.  A  Method  of  Distinguishing  Bicillus  Coli  Communis  from 

Bicillus  Typhosus  by  the  Use  of  Neutral  Red. 
William  Hunter. 

6.  Note  on  a  Case  of  Influenza  with  Meningitis  as  a  Com- 

plication.   Arthur  Foster. 

7.  Three  Cisea  of  Cervical  Spina   Bifida   Treated   as   Out- 

patients by  Open  Operations.    James  H.  Nicoll. 

8.  A  Case  of   Fracture  of    the  Sternum.      J.  Sackville 

Martin. 

9.  A  Case  of  Cerebrospinal  Meningitis.    Francis  Riley. 

10.  Four  Cases  in  which  Pain  was  Relieved  by  Suprarenal 

Extract.    E  A  Peters. 

11.  History  of  Renal  Surgery.    David  New.man. 

12.  Ad  Terram.    Sir  Francis  Seymour  Haden. 

!• — The  abstract  will  appear  when  the  lectures  are  com- 
pleted. 

2.— Ransome  and  Foulerton  in  an  article  defined  "  the 
influence  of  ozone  on  the  vitality  of  some  patho- 
genic and  other  bacteria."  They  review  the  literature 
of  the  bactericidal  action  of  ozsne,  laying  special  promi- 
nence on  the  work  of  Downes  and  Bluet,  who  have  shown 
that  the  blue  and  violet  rays  of  the  spectrum  have  a  greater 
influence  upon  destroying  the  vitality  of  the  bacteria  than  the 
red  rays.    The  authors  have  conducted  a  number  of  experi- 


ments, first  to  determine  the  action  of  ozone  upon  the  vitality 
of  certain  bacteria,  and  second  to  ascertain  whether  the 
virulence  of  t^^e  tubercle  bacillus  is  influenced.  The  first  expe- 
riment consisted  of  subjecting  cultures  of  various  bacteria  to  a 
current  of  ozone  and  atmospheric  air.  Control  testa  were 
made  at  the  same  time.  These  experimente  showed  that 
the  growth  of  two  out  of  seven  species  of  bacteria  waa 
slightly  retarded  upon  exposure  to  the  ozone.  Toe  second 
experiment  consisted  of  exposing  bacteria  to  ozone  in  the 
absence  of  organic  matter.  Small  blocks  of  plaster-of  Paris 
were  inoculated  witb  stock  cultures  of  different  bacteria. 
The  blocks  were  then  placed  in  culture  tubes  and  suljected 
to  a  current  of  ozone.  Control  experiments  were  also  made 
by  inoculating  plaster-of- Paris  blocks;  then  placing  these  in 
culture  tubes,  and  subjecting  them  to  a  current  of  air.  The 
ozone  had  no  effect  upon  the  vitality  of  the  microorganiems. 
The  third  experiment  consisted  in  exposing  various  cultures 
of  bacteria,  after  having  placed  these  upon  porcelain,  to  the 
action  of  tzone,  produced  by  pasting  oxygen  under  pressure 
from  a  cylinder  over  a  powerful  ozonizer.  The  bacteria  were 
not  affected  ;  their  growth  was  not  iropiired,  and  the  chro- 
mogenic  organisms  did  not  lose  their  power  of  producing 
pigments.  The  fourth  expsriment  consisted  of  passing  czine 
through  fluid  cultures  of  microtrganisms.  Milk  was  used  as 
the  culture  media.  This  experiment  showed  that  the  bacteria 
lost  their  vitality.  The  fifth  experiment  waa  made  in  order 
to  determine  whether  or  not  ozone  had  any  influence  upon 
modifying  the  virulence  of  the  bacillus  tuberculosis.  It  was 
shown  that  the  virulence  was  not  changed.  The  authors 
have  drawn  the  following  conclusion  :  That  ozone  in  a  dry 
state  does  not  affect  the  vitality  of  the  bacteiiiexperimented 
with  to  any  appreciible  degree  ;  nor  does  the  action  of  ozone 
modify  the  pathogenic  virulence  of  the  badllus  tuberculosis; 
and,  finally,  the  activity  of  bacteria  is  hindered  when  c  zone 
is  passed  through  a  fluid  medium  containing  the  micro- 
organisms in  suspension,     [f  j  k.] 

3. — Will  be  considered  editorially. 

4. — Angus  gives  the  results  of  major  amputations  in 
the  Royal  Infirmary,  Newcastle- upon  Tyne,  during  the  year 
1899  Toere  were  G7  amputations,  32  for  injury  and  35  for 
disease.  The  mortality  for  the  whole  was  9  03% .  Of  the  32 
cases  of  injury  four  died,  a  mortality  of  12  05%.  Of  the  35 
amputations  for  disease  two  died,  a  mortality  5  07%.  [j  h  g  ] 

6. — Hurter  in  an  article  entitled  The  method  of  dis- 
tinguishing bacillus  coli  communis  from  bacillus 
typhosus,  by  the  use  of  neutral  red,  comes  to  the 
following  coLclusions  :  (1)  That  the  power  of  reducing  neu- 
tral red  is  possessed  by  the  bacillus  coli  communis  to  a 
marked  degree,  and  superb  canary  yellow  fluorescent  color 
of  the  culture  media  is  produced  ;  (2)  this  s»me  reaction  is 
produced  by  the  so  called  bacillus  euteritidis  of  Oiertner; 
(3)  this  reducing  power  is  not  possessed  by  the  bacillus 
typhosus;  (4)  the  r- action  is  not  given  by  otber  pathogenic 
microorganisms ;  (-5)  with  accuracy,  the  diagnosis  as  to  the 
presence  of  bacillus  coli  communis  is  possible  within  from 
12  to  21  hours,  by  means  of  the  neutral  red  reaction.  The 
author,  so  far  as  his  experience  goes,  states  that  by  means  of 
the  neutral  red  it  is  possible  to  diagnose  the  true  coli  group 
from  the  typhoid  group  of  microorganisms,     [f  j  K  ] 

6. — Foster  reports  a  case  of  influenza  complicated 
with  meningitis  in  a  woman  54  years  of  age.  Tne  illness 
began  on  January  29,  with  pains  in  the  back  and  legs, 
sore  throat,  and  headache.  Oa  the  following  day  the  symp- 
toms were  more  pronounced,  the  temperature  wa?  105.-,°  F., 
the  pulse-rate  was  95  per  minute,  and  the  respirations  were 
25  per  minute.  Oj  February  1  the  heidache  became  mire 
intense,  and  nausea  and  vomiting  developed;  the  tempera- 
ture was  104-  F.,  pulse  rate  90,  and  the  respiratory  f.^eqaency 
36.  On  the  evening  of  the  same  day  the  temperature  fell  to 
97°  F.,  and  the  patient  had  some  d.ffi;ulty  in  fp?>»king  and 
swallowing.  Oq  the  following '  day  the  temperature  again 
rose  to  103  5°  F.,  the  pulse-rate  was  72,  and  the  respiratory 
rate  50  Rigidity  of  the  muscles  of  the  neck  developed,  the 
patient  was  unable  to  talk  or  swallow,  and  a  state  of  stupor 
set  in.  There  was  partial  paralysis  of  one  half  of  the  face, 
strabismus  appeared,  and  there  was  a  muscular  tremor  in- 
volving the  face,  arms,  and  legs  ;  retraction  of  the  head  waa 
striking;  de<th  occurred  on  the  morning  of  the  third  of 
February.  The  author  states  that  ttiere  was  no  doubt  as  to 
the  diagnosis  of  influenza,  followed  by  meningitis.  A  post- 
mortem examinatioa  waa  not  made.    Tf  •'  k.] 


MaeCH  23,  1901] 


THE  LATEST  LITERATURE 


[The  Philadblphia 
Medical  Journal 


557 


7. — Treated  editorially. 

8.— Sackville  reports  an  interesting  case  of  fracture  of  the 
sternum,  due  to  pressure  exerted  on  the  two  shoulders.  He 
calls  attention  to  the  peculiarity  of  the  force  which  produced 
this  fracture.  The  line  of  fracture  was  obliquely  across  the 
manubrium  and  only  gave  rise  to  pain  when  the  pectoral 
muscle  was  in  action,     [jho] 

9.— Riley  reported  a  case  of  cerebrospinal  meniii- 
gitis  in  a  girl  of  5  years  of  age,  who  had  always  been  in 
fairly  good  health.  The  disease  developed  suddenly  with 
the  symptoms  of  vomiting  and  headache  followed  by  con- 
vulsions; the  temperature  rose  to  103.5°  F.  and  remained 
high  several  days.  On  the  fourth  day  retraction  of  the  head 
and  slight  opisthotonos  developed.  The  superficial  and  deep 
reflexes  were  abolished  except  that  Babinski's  sign  was 
present.  The  spleen  was  not  enlarged  and  the  abdomen 
was  retracted.  A  mixed  erythematous  and  petechial  rash 
appeared  on  the  trunk  and  extremities.  This  rash  appeared 
on  the  fifth  day.  The  patient  complained  of  pain  in  one  knee 
and  there  was  a  slight  swelling  of  the  dorsum  of  the  foot. 
The  optic  discs  were  congested  and  pupillary  reaction  to 
light  was  somewhat  retarded.  During  the  acute  stage  of  the 
disease  the  temperature  range  was  of  the  inverse  type,  but 
as  the  patient  began  to  improve,  the  morning  temperature 
was  lower  than  the  evening  temperature.  For  a  while  the 
respirations  were  of  the  CheyneStokes  type.  Slight  ptosis 
of  the  left  eyelid  and  photophobia  developed.  As  the  disease 
progressed  the  reflexes  returned,  and  the  skin  became 
hyperesthetic,  but  retraction  of  the  head  increased ;  vomit- 
ing was  an  occasional  symptom.  The  symptoms  began  to 
subside  4  weeks  after  the  onset ;  during  this  period  great 
emaciation  developed ;  the  total  duration  of  the  disease 
was  3  months.  The  treatment  consisted  in  the  application 
of  ice-bags  to  the  head  and  neck  and  in  the  administration  cf 
potassium  bromid  and  iodid  ;  small  quantities  of  brandy 
were  given  as  a  stimulant,  and  during  the  period  of  vomitng, 
food  was  administered  per  rectum,  small  doses  of  calomel 
were  used  to  keep  the  bowels  opened.  The  case  is  of  interest 
because  Babinsk/s  sign  was  present,  herpes  labialis  and 
headache  were  absent  after  the  onset  of  the  disease.  The 
origin  of  the  illness  was  very  obscure,    [f  j  k.] 

10. — Peters  advocates  the  use  of  suprarenal  extract 
for  the  relief  of  pain  in  some  conditions.  He  reports 
4  cases  in  which  pain  was  relieved  by  the  administration  of 
this  animal  extract.  He  found  that  the  most  efficient  prep- 
aration was  obtained  by  dissolving  tabloids  of  the  dried  gland 
in  boiled  water ;  the  solution  was  then  filtered  and  this  was 
administered.  The  author  advocates  a  10^  watery  extract ; 
the  first  case  in  which  he  used  this  preparation  was  one  of 
recurrent  scirrhus  of  the  breast  in  a  woman,  89  years  of  age  ; 
the  local  application  of  suprarenal  extract  in  this  case  gave 
the  patient  much  relief.  The  second  ease  was  one  of  stric- 
ture of  the  esophagus  occurring  in  a  woman;  pain  devel- 
oped after  the  passage  of  a  bougie,  which  was  relieved  by  a 
teaspoonful  of  the  10%  aqueous  extract  of  suprarenal 
capsule;  the  dose  was  repeated  every  evening  before  going 
to  bed.  The  third  case  was  one  cf  tuberculosis  of  the 
larynx,  occurring  in  a  man  34  years  of  age  ;  the  suprarenal 
extract  was  used  in  the  form  of  a  spray.  The  fourth  case 
was  one  of  periodontitis  ;  the  extract  was  applied  every  two 
to  six  hours  ;  the  patient  in  this  way  was  given  much  relief. 
[fj.k  ] 


New  York  Medical  Journal. 

March  16, 1901.    [Vol.  Ixxiii,  No.  11.] 

Congenital  Dislocation  of  the  Shoulder  with  Report  of 
Two  Cases  of  Dislocation  Posteriorly.  Daniel  W. 
Marston. 

The  Representation  of  Biliary  Calculi  by  the  Rontgen 
Rays.    Carl  Beck. 

Substitute  Feeding  of  Infants  upon  Milk  Modified  Accord- 
ing to  Prescription  in  Laboratories.    W.  P.  Northehp. 

The  Specific   Treatment  of  Acute  Dysentery.    William 

J.    CEtllKSHANK. 

The  Pathology  of  Intra-  Uterine  Death.  Neil  Macphatter. 
Angeioma  Cysticum  of  the  Nose.    Henry  Lewis  Wagner. 
A  Simple  Apparatus  for  Modifying  Cow's  Milk.    Charles 
Hebrman. 


1. — Marston  discusses  the  pathology  of  congenital 
dislocations  of  the  shoulder,  and  reports  2  cases  of 
posterior  dislocation.  He  thinks  this  condition  due  to  trau- 
matism at  birth  or  ia  utero,  or  to  some  prenatal  diseased 
condition  of  the  joint.  He  does  not  think  that  paralysis  is  a 
primary  etiological  factor  of  the  dislocation,  but  rather  a 
result  of  the  condition.  When  the  patient  is  under  3  years 
of  age  reduction  by  manipulation  should  be  attempted. 
Failing  in  this,  the  operation  suggested  by  Phelps  (Transac- 
tions American  Orthopedic  Association,  1898)  should  be 
employed,    [j  h  g  ] 

2,— Carl  Beck,  of  New  York,  claims  to  have  showed  the 
first  undisputed  skiagraph  of  cholelithiasis  in  living 
patients.  A  further  experience  in  making  these  skiagraphs 
has  enabled  him  to  modify  the  principles  he  originally  set 
forth.  The  corrf  ctness  of  the  statement  that  the  chemical 
composition  of  the  calculi  will  have  much  to  do  with 
their  clearness  of  definition  has  been  found  to  be  correct  to 
some  extent  only.  He  has  succeeded  in  fixing  the  com- 
mon biliary  calculi  even  when  they  are  as  small  as  the 
head  of  a  pin.  Even  calculi  of  the  hepatic  ducts  are  shown. 
The  mixed  bilirubin  calculi  are  less  permeable  to  the  rays 
than  all  the  other  varieties.  Those  of  pure  cholesterin  show 
well,  while  the  stratified  cholesterin  calculi  show  less 
permeability  to  the  rays.  He  attributes  this  success  to  the 
excellent  quality  of  the  tubes  he  employs.  They  must  bear 
a  15  inch  spaik  for  5  minutes  without  coming  too  hot.  The 
tubes  he  has  used  for  reproducing  biliary  calculi  display  their 
energy  only  as  long  as  they  are  new.  The  position  of  the 
patient  is  an  important  factor.  He  should  lie  on  his  abdomen 
with  three  pillows  under  the  clavicles,  for  this  elevation  per- 
mits the  protrusion  of  the  gallbladder,  and  brings  the  calculi 
nearer  to  the  photographic  plate.  The  direction  of  the  rays 
should  be  such  that  they  should  form  an  angle  of  about  70° 
with  the  plate,  and  the  tube  should  be  as  near  the  abdomen 
as  possible.  The  disadvantage  of  oblique  irridiation  is  that 
the  calculi  appear  larger  than  their  natural  size.  When  a 
protrusion  palpable  in  the  region  of  the  gallbladder  indicates 
that  it  projects  from  the  liver,  direct  irridiation  is  to  be  pre- 
ferred. The  bowels  should  be  thoroughly  evacuated  before 
irridiation.    [t.lc] 

3.— Northrup  publishes  his  views  upon  the  substitute  feed- 
ing of  infants  with  milk  modified  according  to  the  prescrip- 
tion in  laboratories.  He  emphasizes  the  necessity  for  a 
thorough  examination  of  the  sources  of  all  milk  for  general 
use  and  insists  that  the  laboratories  supplying  this  milk 
should  be  under  the  most  careful  supervision.  The  modifi- 
cation of  milk  consists  in  the  transfornr  ation  of  the  propor- 
tion of  cow's  milk  to  the  proportions  of  woman's  milk,  and 
in  transforming  a  slightly  acid  milk  to  ore  of  slightly  alka- 
line reaction,  in  preserving  it  from  contamination  and 
making  it  as  nearly  as  possible  like  a  mother's  milk.  It  is 
to  be  remembered  that  cow's  milk  is  appioximately  4%  of 
fat,  4%  of  sugar,  and  4%  of  proteids.  In  consequence  then 
it  is  necessary  to  remember  three  formulas  :  (1)  Feeding  for 
the  newborn,  adapted  to  the  majority,  should  comprise  -2% 
of  fat,  5%  of  sugar,  0.75%  of  proteids;  (2)  "Low-average 
breast- milk"  should  contain  3%  of  fat,  6%  of  sugar,  and  1% 
of  proteids;  (3)  "high- average  breast-milk,"  4%  of  fat,  7% 
of  sugar,  and  2%  of  proteids.  These  modifipations  should  be 
changed  gradually  and  frequently  by  small  fractions  from 
one  to  another.  At  the  age  of  from  8  to  10  months  it  is  time 
to  make  the  proportions  approximate  that  of  the  whole  cow's 
milk  ;  in  other  words,  wean  the  child.  The  feedirg  should  be 
all  milk  for  the  first  year,  and  mostly  milk  for  second  year. 

Ft  l  c  1 

4._W.  J.  Cruikshank  concludes  his  paper  upon  the 
specific  treatment  of  acute  dysentery.  His  con- 
clusions are  that  dysentery  is  a  disease  of  great  gravity,  and 
that  it  is  both  contagious  and  infectious;  that  it  is  caused  by 
the  introduction  to  the  system  through  food,  drink,  and  also 
through  the  air,  of  a  specific  microorganism,  the  identity  of 
which  seems  to  be  still  in  doubt.  He  states  that  dysentery  is 
one  and  the  same  disease  in  whatever  latitude  it  may  be 
found  and  its  varieties  represent  merely  the  dififtrence  of 
intensity  of  the  morbid  process.  The  majority  of  thera- 
peutic agents  which  have  been  employed  are  useless,  and 
even  harmful.  Sulphate  of  magnesium,  properly  adminis- 
tered, in  the  acute  form   of  dysentery  acts  as  a  specific. 

Tt  l  c  1 
Is.—Henry  Lewis  Wagner  has  devoted  considerable 


558 


The  Philadelphia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[IUbch  23,  1903 


time  to  the  study  of  the  claesification  of  the  various  cystj  of 
the  nose.  His  cases  were  studied  in  a  boy  of  9  years  and  a 
woman  of  28.  Both  presented  practically  the  same  condi- 
tion. Microscopically  the  nasal  passages  present  no  path- 
ological condition  other  than  a  single  bluish  gray  tumor 
obstructing  the  entire  posterior  portion  of  one  side  of  the 
nose  and  protruding  somewhat  into  the  nasopharyngeal 
vault.  The  tumor  shows  greater  elasticity  to  the  touch  than 
any  other  found  within  these  limits.  It  is  movable  and 
attached  to  a  small  base.  It  will  rapidly  form  again  after 
removal  unless  the  seat  of  the  cyst  is  thorojghly  destroyed, 
as  with  the  galvanocautery.  Microscopically  the  ciliated 
columnar  epithelium  covered  nearly  the  whole  of  the  ex- 
ternal part  of  the  growth  with  the  exception  of  a  small  por- 
tion which  consisted  in  squamous  epithelium,  p-obably  pro- 
duced by  pressure  or  by  continuation  of  the  mother-stratum. 
No  glands  are  to  be  found  in  any  of  the  sec -ions,  but  there 
are  a  large  number  of  venous  bloodvessels,  some  of  them 
enlarged  and  running  parallel  with  the  sac.  Some  large 
venous  sinuses  are  also  seen.  Oa  this  account  he  terms  this 
growth  angeioma  cysticum.  Upon  chemical  analysis  the 
fluid  of  the  cyst  is  found  to  possess  an  alkaline  reaction  and 
a  specific  gravity  slightly  lower  than  that  of  blood-serum. 
It  has  a  brown  color  that  is  partly  due  to  lupien  and  partly 
derivative  from  hemoglobin.  Serum  albumin  was  found  in 
larger  quantities  ;  only  a  few  red  blood-corpuscles  were  de- 
tected. A  coagulation  of  the  whole  fluid  occurred  a  very 
short  time  after  removal,     [t.l  c] 


Medical  Record. 

March  16,  1901.     fVol.  59,  No.  11.] 

1.  The  Treatment  of  Gonorrhea  with  Frequent  Irrigations  of 

Hot  Decinormal  Salt  Solution.    Chas.  E.  Woodruff. 

2.  A  Whistle  in  the  Esophagus.    A.  E  Isaacs. 

3.  The  Treatment  of  C  ililis  by  Valvular  Colostomy  and  Irri- 

gation.    P.  R.  Bolton. 

4.  The  Ovary  ;  1(8  Relation  to  Normal   Functions  and  to 

Pathological  States.    S.  W.  Bandler. 

5.  The  Use  of  Suprarenal  Capsule  in  Hemaptysis.    William 

B.  Kenworthey. 

1.— Charles  B.  Woodruff' recommends  frequent  irriga- 
tion with  hot  deciuoriual  salt-solution  in  the  treat- 
ment of  gonorrhea.  He  employs  a  eimple  short  glass  tube 
and  has  seen  no  harm  come  from  using  as  much  as  a  quart  of 
hot  salt-solution  every  hour.  He  has  found  that  if  the  dis- 
charge keeps  up  for  more  than  10  days  under  this  treatment, 
the  irrigations  are  not  properly  done.  In  a  study  of  9S 
cases  he  has  found  that  the  average  time  of  cure  is  12J  days  ■ 
about  30%  lasts  7  days;  30%  11  days;  20%  17  days;  10% 
20  days,  and  10%  over  3  weeks.  Tnough  the  actual  duration 
of  the  symptoms  is  less  than  this,  as  each  case  remained  in 
the  hospital  2  or  more  days  after  the  symptoms  disappeared. 
In  5%  all  symptoms  disappeared  within  2  days.  As  a  rule 
there  was  marked  reduction  within  a  week  and  total  cessa- 
tion in  from  10  to  14  days.  It  is  well  known  that  early  ces- 
sation of  the  discbarge  is  really  a  danger  in  any  treatment, 
but  it  may  be  overcome  by  carefully  explaining  the  condi- 
tions to  every  man.  Woodruff  gives  each  patient  an  astrin- 
gent injection  to  use  for  2  or  3  weeks  after  leaving  the  hospi- 
tal. Iq  his  98  cases  there  were  not  more  than  6  or  8  relapses. 
[tl.c] 

2.  —A.  E.  Isaacs,  of  New  York,  reports  a  case  of  a  child 
who  swallowed  a  whistle  2  days  before  he  saw  him.  At 
first  the  symptoms  had  been  very  urgent,  but  when  seen 
they  had  so  much  improved  that  what  remained  CDuld  be 
very  well  accounted  for  by  the  irritation  from  previous 
attempts  to  dislodge  the  foreign  body.  A  radiograph 
showed  that  the  whistle  was  lodged  in  the  esophagus, 
although  an  esophageal  bougie  and  a  bristle  brobang  weri- 
used  without  revealing  the  foreign  body.  After  expere 
mentiog  with  various  instrumenta,  Isaacs  succeeded  in 
remov-ing the  whistle  with  a  "coin-catcher"  or  a  "  hineed- 
burket  "    [t.l  c  ] 

3.— P.  B,  Bolton  discusses  the  treatment  of  colitis 
by  valvular  colostomy  and  irrigation.  In  1885, 
Keith  recommended  the  treatment  of  some  forms  of  colitis 
by    diverting;  the    fecal   current  and  sparing   the   mucous 


membrane  of  this  part  of  the  intestine  from  contact  with  it 
by  establishing  an  artificial  anus  in  the  cecum,  whifh  should 
also  facilitate  local  applications  to  the  mucous  membrane. 
Tois  plan  has  been  carried  out  with  gratifying  results  in  a 
number  of  cases.  The  treatment,  however,  is  radical  and 
there  are  positive  risks  entailed.  The  writer  reports  the  fol- 
lowing case,  in  which  a  modified  form  of  the  treatment  out- 
lined was  employed.  The  patient  was  a  male,  of  42  years,  with 
negative  family  history.  E^ght  weeks  before  being  admitted  to 
the  hospital,  and  without  assignable  cause,  he  developed  a 
severe  diarrhea  accompanied  by  fever  and  pros- 
tration. This  persisted  in  spite  of  all  treatment.  The 
stools  were  bloodstained  and  contained  a  great  deal  of 
mucus,  and  numbered  from  16  to  23  in  the  24  hours.  No 
amebae  were  found.  The  pitient  lost  31  pounds  in  weight. 
The  first  step  in  the  treatment  consisted  in  performing 
of  a  cecal  colostomy.  A  IJ  inch  incision  was  carried 
through  the  abdominal  wall  parallel  with  the  right 
Poupart's  ligament,  and  an  inch  internal  to  its  outer 
part.  Tne  cecum  at  once  presented.  A  point  was  chosen 
in  its  anterior  band  and  the  intestine  opened  sufficiently 
to  admit  a  fair-sized  soft-rubber  catheter.  Three  tiers  of 
sutures  placed  above  and  bel  jw  this  orifice  served  to  enclose 
the  cecal  wall.  Tne  ends  of  those  last  introduced  left  long 
and  carried  through  the  margin  of  the  abd  jminal  incision, 
brought  the  cecum  forward  into  close  contact  with  the  ab- 
dominal wall,  and  were  utilized  to  close  the  external  wouad, 
being  reinforced  by  a  silkworm  gut  suture  at  each  angle. 
Healing  of  the  abdominal  wound  occurred  promptly.  The 
after  treatment  occupied  4  weeks,  but  the  patient  waa  con- 
fined to  bed  for  only  half  this  time.  The  diet  at  first  was 
composed  entirely  of  proteids,  and  salol  and  castor  oil 
were  given  every  3  hours  in  smiU  coses.  Toward  the  close 
of  the  treatment  a  mixed  diet  waa  allowed.  Irrigation  of  the 
colon  was  begun  at  once.  Ssveral  quarts  of  .01%  solution 
of  silvernitrate  were  injected  through  the  catheter.  This 
was  followed  by  a  .5%  salt-solution.  For  the  first  3  days 
this  washing  was  done  twice  a  day,  for  the  next  11  days  once 
a  day,  and  the  strength  of  the  silver  solution  increased  to 
.02%  for  the  remaining  time  every  other  day.  The  catheter 
was  removed  after  the  seventh  day  except  at  the  periods  of 
washirg.  and  in  the  intervals  there  waa  absolu'ely  no  leakage. 
His  weight  increased  10  pounds.  Complete  recovery  fol- 
lowed. A  small  ventral  hernia  has  appeared  at  the  site  of  the 
operation,  which  ha^  led  to  the  author's  decision  to  adopt  in 
future  the  intermusc  ilar  incision  of  the  abdominal  wall. 
[t.l  c  ] 

4. — Bandley  has  made  an  exhaustive  study  of  the  ovary 
and  its  relation  to  the  normal  functions  and  to 
pathological  states.  He  remarks  that  one  of  the  func- 
tions of  the  normal  ovary  is  the  production  and  expulsion  of 
ova  capable  of  being  fecundated.  It  is  probaMe  that  after 
birth  no  new  ova  are  formed  from  the  germinal  epithelium. 
After  puberty  the  vitality  of  the  ovary  is  revealed  by  its  abil- 
ity to  bring  these  ova  to  a  stage  which  may  be  called  right. 
For  the  expulsion  of  an  ovum  from  the  graflian  follicle  a 
gradual  increase  in  size  of  the  follicle  tikes  place  depending 
partly  on  an  increase  in  the  amount  of  liquor  folliculi.  The 
cells  of  the  follicle  epithelium  undergo  fatty  degeneration, 
and  the  internal  layer  (the  tunica  interna)  shows  an  increase 
in  the  size  of  the  cells  and  a  decided  development  of  the 
bloodvessels.  As  a  result  of  this  fatty  degeneration  the  ovum 
is  freed  from  the  cumulus  oophorus.  The  most  prominent 
point  of  the  follicle  is  poor  in  blood-supply  and  furnishes  the 
so-called  stigma  folliculi,  at  which  place  an  opening  is  formed 
for  the  escape  of  the  ovum.  After  ovulation  the  ovum  is 
thrown  cut  into  the  abdominal  cavity,  ultimately  finding  ita 
way  into  the  uterus.  It  is  not  necessary  that  the  tube  should 
grasp  or  surround  the  ovary.  Lode  haa  shown  that  an  ovum 
finds  its  way  through  the  tube  into  the  uterus  in  SO  hours. 
Menstruation  is  the  perifidic  loss  of  hlood  from  the  uterus  or 
trom  any  mucous  membrane  and  may  be  divided  into  three 
periods:  the  premenstrual,  the  menstrual,  and  the  pos'.men- 
strual.  The  premenstrual  period  is  characterized  by  a  swell- 
ing of  the  erdometrium,.^,which  may  measure  from  0  to  7 
mm.  in  thickness.  During  "the  Tire'fistrual  perioi  the  super- 
ficial capillaries  are  greatly  dilated,  and  an  exit  of  blood- 
elements  not  dependent  upon  a  bursting  of  the  capillaries 
goes  on  for  several  days.  The  bleeding  occurs  partly  througli 
diapedesis,  and  in  strong  bleedings  through  rhexi*.  There  ia 
little  or  no  destruction  of  the  mucosa,  only  a  very  alight  fatty 


March  : 


THE  LATEST  LITERATURE 


rpHE  Philadelphia 
L  Medical  Journal 


559 


degeneration  of  the  epithelium  of  the  uppermost  layer.  The 
changes  in  the  tubes,  if  any,  are  slight.  The  postraenstrual 
period  comprises  14  days,  during  which  the  mucous  mem- 
brane returns  to  a  thickness  of  3  mm.  During  this  time  all  cells 
not  capable  of  further  growth  are  thrown  off,  and  the  epithe- 
lium, only  partially  denuded,  is  regenerated.  A  regenera- 
tion concerns  the  stroma,  the  glande,and  surface  epithelium, 
reaching  its  height  on  the  fourteenth  or  fifteenth  day  after 
the  beginning  of  menstruation.  Ovarian  secretion  is  the  direct 
cause  of  this  periodic  swelling  of  the  mucosa,  and  it  continues, 
if  fecundation  has  not|  taken  place,  to  exert  not  only  a  local 
but  likewise  a  stimulating  influence  on  the  general  and  sexual 
organs.  On  the  occurrence  of  pregnancy  this  secretion  causes 
a  further  development  of  the  uterus  and  the  decidua  and 
plays  an  important  part  in  the  process  of  labor.  It  stimulates 
the  functions  of  the  breasts,  exerts  a  decided  constitutional 
stimulation  and  is  the  cause  of  many  of  the  pathological  con- 
ditions occurring  before  and  during  labor.  Ovulation  and 
menstruation  are  related  only  in  that  both  are  the  result  of 
the  secreting  functions  of  the  ovary,  and  are  in  no  wise  con- 
nected as  regards  cause  and  effect.  Ovulation  as  a  rule 
occurs  from  4  to  8  days  before  menstruation,  but  it  may 
occur  at  other  periods,  as  ripe  ova  may  be  present  at  almost 
any  time.  Since  ovulation  may  occur  without  menstruation, 
but  the  latter  never  without  the  former,  we  have  here  an  evi- 
dence that  a  certain  functional  activity  of  the  ovary  is  neces 
sary  to  stimulate  the  mucous  membrane  from  its  periodic 
changes.  Menstruation  is  simply  an  evidence  that  a  fecun- 
dated ovum  is  not  present  in  the  tube  or  in  the  uterus.  A 
proof  of  the  direct  influence  which  the  ovum  exerts  upon  the 
decidua  is  shown  by  the  manner  in  which  the  space  formed 
by  the  embedding  of  the  ovum  is  filled  up.  It  may  be  tiken 
for  granted  that  the  ovum  embeds  itself  in  the  decidua,  and 
that  an  active  growth  of  the  latter  up  to  and  surrounding  the 
ovum,  with  a  formation  of  the  so-called  decidua  reflexa,  by 
no  means  takes  place.  Another  of  the  fanctions,  then,  of 
ovariaa  secretion  is  to  be  found  in  its  slinulation  of  the 
round  cells  of  the  stroma  to  growth  and  to  the  f  jrmation  of 
decidua  cells.  This  secretiou  is  a  stimulus  likewise  to  ute- 
rine contrac.ions,  and  is  the  probable  cau^e  of  the  con- 
tractions normally  occurring  during  labor.  The  action  upon 
the  uterus  at  the  end  of  pregnancy  of  this  accumulated  secre- 
tion is  probably  the  cause  of  labor-pains.  The  action  of 
the  ovarian  secretions  upon  pulse-tension  and  its  effest 
upon  the  mucous  membranes  of  the  body  generally  are 
evidenced  by  the  congestion  of  the  vocal  cords  during  men- 
Btruation,  so  that  during  this  time  the  singing  voice  is  poor. 
The  secretion  of  intestinal  mucosa  is  also  greater,  there  is 
increased  perspiration,  the  lower  turbinated  bones  are 
swollen,  and  the  eyes  suffer  limitations  in  power.  Bandley 
also  emphasizes  the  trophic  action  of  the  ovarian  secretion  as 
evidenced  by  the  numerous  experiments  upon  transplanta- 
tion of  the  ovaries.  It  is  also  shown  in  the  various  disorders 
of  menstruation,  such  as  amenorrhea,  in  which  case  there 
are  frequently  found  poorly-developed  ovaries ;  menstruation, 
if  present,  is  unaccompanied  by  pain,  and  the  girls  have 
irregular,  weak,  or  eventually  no  menstruation.  Although 
these  persons  may  be  well-developed,  yet  they  show  poorly 
developed  genitalia.  The  frequent  occurrence  of  amenorrhea 
and  uterine  hypoplasia  in  chlorotic  girls  is  an  interesting 
link,  associating  the  ovary  as  a  secreting  organ  with  the  vital 
functions  of  the  body.  A  farther  evidence  of  the  influence 
of  ovarian  secretion  upon  the  body  in  general  may  be  found 
in  its  relation  to  osteomalacia,  occurring  as  the  disease  does 
80  frequently  in  pregnancy.  Bendley  also  believes  that  the 
ovarian  secretion  is  responsible  for  the  developm'ent  of 
eclampsia,  and  for  the  occurrence  of  chorea,  especially  de 
veloping  at  the  period  of  puberty  and  in  the  early  months  of 
pregnancy.     [w.A  N.D.] 

6.— William  B.  Keuworthey  reports  a  case  of 
hemoptysis  treated  by  suprarenal  extract.  Keu- 
worthey states  that  in  the  14  cases  ia  which  this  remedy 
has  been  used  to  control  hemoptysis  in  no  case  did  it  fail 
to  accomplish  its  purpose,  and  in  only  one  case  did  the 
hemorrhage  continue  for  15  minutes  after  the  administra- 
tion of  the  first  powder.  In  his  own  case  he  administered 
the  drug  in  3-grain  capsules,  one  every  half  hour  until 
8  were  taken.  Then  one  every  two  hours  until  3  more 
were  taken,  then  one  three  times  a  day  for  a  week,  to  be 
taken  dry  on  the  tongue,  chewed  and  swallowed  without 
water,     [t.l.c] 


Medical  News. 

March  16,  1901.     [Vol.  Ixxviii,  No.  11.] 

1.  Kecent    Eiperience    with    Erythromelalgia.    Henry  L. 

Elsner. 

2.  The  Treatment  of  the  Heart  in  Typhoid  Fever  and  Ooher 

Infectious  Diseases.    Albert  Abrams. 

3.  A  Report  of  Tliree  Cases  of  Thoracic  Aneurysm  Treated 

by  Subcutaneous  Injections  of   Gelatin.     Lewis  A. 
Conner. 

4.  Observations  upon  the  Amebae  Coli  and  Their  Staining 

Rsactions.    Charles  F.  Craig 

5.  A  Preliminary  Note  on  the  Relation  of  the  Farm  of  the 

Tubercle  Bacillus  to  the  Clinical  Aspects  of  Pulmonary 
Tuberculosis.    Henry  Sewall. 

6.  Rhinoscleroma.    H.  Jarecky. 

1. — Eisner,  in  his  recent  experience  with  erythro- 
melalgia, reports  3  cases  associated  with  Riynaud's  disease, 
and  gives  the  great  variety  of  diseases  which  claim  erythro- 
melalgia as  an  attendant.  Sahwenck's  cise,  with  ascending 
degeneration  of  the  posterior  columns  of  the  cord  ;  VVoodnut's 
case  was  associated  with  myelitis ;  Collier  reports  10  cases  asso- 
ciated with  various  spinal,  system,  and  indiscriminate  lesions  ; 
Auerbach  reports  2  cases,  in  one  of  which  a  postmortem 
examination  revtaled  degenerative  changes  in  the  posterior 
nerve-roots  of  the  lumbar  and  sacral  nerves  without  degener- 
ation in  the  cord  substance,  while  the  bloodvessels  were  found 
normal.  This  is  the  only  postmortem  of  a  case  of  erythro- 
melalgia on  record.  Neider  reports  a  case  of  erythromelalgia 
with  eye  symptoms  prominent,  choked  disc  with  vascular 
dilatation ;  Eulenberg,  one  case  of  brain  tumor  with  hemor- 
rhagic retinitis  and  consequent  changed  visual  field;  Hoff- 
man mentions  an  interesting  case  of  akromegaly  associated 
with  erythromelalgia,  in  which  the  patient  was  23  years  of 
age.  She  had  had  erythromelalgia  since  her  sixth  year,  when 
fiually  the  characteristic  cbaiges  in  the  hands  and  feet 
followed  ;  Henoch's  case  was  one  of  erythromelalgia  follow- 
ing hemiplegia  and  hemihyperidrosis,  death  finally  resulting 
from  angina  pectoris ;  and  Levy  reports  a  case  resting  on  a 
hysterical  bisis,  cured  by  hypnosis,  in  which  erythromelalgia 
was  associated  with  Raynaud's  disease,    [t  m  t.] 

3,— In  Abrams's  treatment  of  the  heart  in  typhoid 
fever  he  seta  forth  the  following  theories  in  explaining  the 
action  of  the  cold  bath  treatment :  (1)  It  possesses  a  powerful 
stimulating  action  on  the  circulatory  apparatus  and  nervous 
system ;  (2)  it  exerts  an  antipyretic  action ;  (3)  it  stimulates 
the  nerve  centers  presiding  over  the  functions  of  respiration, 
circulation,  digestion  and  excretion ;  (4)  the  flux  and  reflux 
of  blood  between  the  periphery  and  viscera  are  facilitated ; 
(•5)  leukocytosis  is  produced.  He  advocates  the  use  of  the 
carbonated  bath  (S;hott  mtthod)  in  place  of  the  cold  bath 
and  knows  no  means  better  adapted  for  maintaining  the 
vigor  of  the  heart  in  typhoid  fever,  pneumonia  and  other 
infectious  diseases  The  reduction  of  temperature  after  the 
carbonated  baths  is  relatively  slight,  and  such  reduction  is 
evoked  by  dilatation  of  the  subcutaneous  vessels.  If,  how- 
ever, we  regard  temperature  redaction  as  a  necessity,  then 
we  miy  alternate  the  carbonated  with  the  cold  baths,  or  we 
may  even  incorporate  the  ingredients  necessary  for  generat- 
ing the  carbonic  acid  'in  the  Cold  bath.  He  also  desci  ibes 
the  friction  bath  as  follows:    The  patient  is  first  rubbed  or 


bath  the  temperature  reduction  was  slight,  but  the  stimulat- 
ing effect  upon  the  heart  and  nervous  system  was  pro- 
nounced. Another  treatment  \i  the  siphon  method  in 
which  the  patient  is  prepared  in  the  usual  manner  f  )r  taking" 
a  sponge  bath.  Tne  siphon  bottle  containing  the  carbonated 
liquid  is  gradually  discharged  over  the  surface  of  the  body, 
notably  in  the  thoracic  region.  The  siphon  may  be  im- 
mersed in  hot  water  if  desired.  Tbis  method  has  reduced 
the  pulse  10  to  20  beats  a  minute,  which  rate  is  mamtamed  for 
a  varying  period  of  time,    [t.m.t  ] 

3._jhe  results  of  Connor's  study  of  three  cases  ot 
thoracic  aneurysm  treated  by  subcutaneous  injec- 
tion of  gelatin  have  not  been  very  satisfactory.  In  two  of 
these  cases  three  injections  were  given,  in  the  other  seven. 
In  the  first  two  it  was  discontinued  on  account  of  the  severe 
pain  following.     In  the  other  the  pain  was  only  slight.    In 


560 


The  Philadklpuia 
Ubdical  Jodsnal 


J 


THE  LATEST  LITERATURE 


LMakcb  23,  IMl 


the  case  that  received  seven  irjections  there  was  very  slight 
improvement.  In  one  case  athjiht  increase  in  the  symptoms 
was  noted,  while  the  third  case  died  of  rupture  of  the  aneur- 
ysm while  under  treatment  and  the  autopsy  showed  no  evi- 
dence of  recent  thrombosis  formation,  although  the  condi- 
tion, that  of  large  sac  with  a  small  communicition  with  the 
aorta,  was  an  especially  favorable  one  for  clotting.  His 
experience  in  these  three  cases  has  convinced  him  that, 
whatever  the  curative  value  of  the  treatment,  its  usefulness 
is  seriously  impaired  by  the  severe  pain  which  frequently 
follows  the  injection,    fx  m.t  ] 

4. — Craig  in  his  observations  upon  the  aiuebae 
coli  and  their  staining  reactions  demonstrates  the  fol- 
lowing :  (1)  That  vacuolization  is  a  degenerative  process,  as 
the  young  amebae  show  no  vacuoles,  the  full  grown  healihy 
ones,  few,  while  the  amebae  in  which  they  are  the  most 
numerous  are  degenerate  bodies,  showing  neither  a  nucleus 
nor  inclusions  of  any  kind ;  (2)  that  there  occur  in  all  but 
the  degenerate  forms  of  amebae,  small,  round,  or  oval  un- 
stained areas,  uniform  in  appearance,  and  most  numerous  in 
the  large  full  grown  forms,  and  entirely  absent  in  the  vacuo- 
lated shells  of  amebae.  The  areas  resemble  similar  areas 
observed  in  stained,  segmenting  malarial  Plasmodia,  which 
are,  in  them,  due  to  the  young  spores,  which  take  the  stain 
but  faintly,  iieasoning  from  analogy,  it  may  be  that  these 
areas  in  the  amebae  are  also  spores ;  (3)  that  in  the  proto- 
plasm of  the  amebae  there  occur  peculiar  structures,  evi- 
dently not  bacterial  in  nature,  the  significance  of  which  it  is 
impossible  to  decide.  It  may  be  that  they  are  certain  crys- 
tals which  occur  in  the  feces  and  which  have  been  absorbed 
by  the  amebae;  (4)  that  degeneration  of  the  amebae  takes 
place  in  two  ways,  i  e.,  by  vacuolizition  and  by  fragmenta- 
tion,   [t.m  t  ] 

5. — Sewall,  in  his  studies  on  the  relation  of  the  form 
of  the  tubercle  bacillus  to  the  clinical  aspects  of 
pulmonary  tuberculosis,  comes  to  the  following  conclu- 
sions :  That  short,  deeply  staining  rod  or  chain  of  rods  of 
moderate  length  is  the  usual  form  in  many  active  cases.  The 
long  rode,  particularly  if  irregularly  broken,  betoken  a  milder 
process,  and  the  chains  of  sporelike  beads  characterize  the 
very  chronic  cases  which  make  us  wonder  at  their  tenacious 
hold  on  life.  If  there  be  a  good  form  of  the  tubercle  bacillus 
it  is,  as  seems  to  us,  a  rather  long,  slender  rod,  ill-staining, 
or  staining  irregularly,  as  if  the  oody  of  the  microbe  were 
irregularly  corroded  on  the  sides.  It  is  found  in  cases  appar- 
ently passing  on  to  cure.  Sputs  of  the  same  individuals 
examined  month  after  month  have  seemed  to  me  to  vary  in 
their  bacillary  characters  with  the  state  of  the  patient  as  re- 
gards the  disease,    [t.m.t.] 


Boston  Medical  and  Surgical  Journal. 

March  U,  1901.     [Vol.  cxliv,  No.  11.] 

1.  The  Story  rf  the  Boston  Society  for  Medical  Improve- 

ment.    J.  G.  MUMFORD. 

2.  Notes  from  the  Neurological  Denartment  of  the  Ma*sa- 

ehusetts  General  Hospital.    \V.  E  Paul. 

3.  Intestinal  Anastornosis.    Charles  G.  Cumston. 

2.— Paul  reports  the  case  of  a  woman,  51  years  old,  who 
was  sufiering  from  bulbar  paralysis  with  hemiplegia 
and  astereoguosis.  Eleven  years  previous  to  the  author's 
examination,  the  woman  suddenly  became  unable  to  talk, 
but  in  brief  lime  the  disability  disappeared,  leaving  no  traces 
of  the  attack.  A  year  later,  speech  was  arrested  in  the 
middle  of  a  sentence,  she  felt  dizzy,  and  the  left  arm  became 
numb  and  powerless.  Consciousness  was  retained,  vision 
was  not  disturbed,  and  there  was  no  vomiiing.  At  the  end 
of  3  months  she  was  up  and  about  with  some  improvement 
in  all  her  symptoms.  Ten  years  after  the  attack,  the  patient 
talks  in  a  mumbling  fjshion ;  she  cannot  whistle,  and  she 
drools  on  her  pillow  at  night.  There  is  typical  bulbar  speech ; 
the  left  hand  cannot  make  fine  movements ;  pain  sense  is 
decidedly  blunted  over  the  left  uppsr  extremity;  space 
sense  is  not  lost  but  is  impaired  ;  pressure  sense  is  altered ; 
muscle  sense  is  preserved  ;  objects  are  unrecognized  by  the 
left  hand;  the  knee  jerks  are  normal,  there  is  no  ankle 
clonus,  and  the  plantar  reflex  is  absent  in  both  feet,     [j  M.S.] 


Journal  of  the  American  Medical  Association. 

March  10,  1901.    [Vol.  xxxvi,  No.  11  ] 

1.  The  Study  of  Anatomy.    Lewellyn  F.  Barker. 

2.  Paresis  of  the  External  Recti  Associated  with  Irregular 

Tabes.    G.  Oram  Rikg. 

3.  The  Amount  of  Myopia  Corrected  by  Removal  of  the 

Crysta.ltne  Lens.    Edward  Jackson. 

4.  On  Certain  CUnical  Features  of  the  Epidemic  of  Influ- 

enza.   Howard  S.  Axders. 

5.  Surgical  Circumcision.    Ferd.  C.  Valestise. 

6.  Treatment  of  Laryngeal  Tuberculosis  at  the  Montefiore 

H'  me  for  Chronic  Invalids.    W.  Freudesthai-. 

7.  Treatment  of  Atrophic  Rhinitis  by  E:ecir-  Ivsis.     And 

Some  Experiments  to   Determine  the  Ediciency  of 
Needles  of  Different  Metals.    Caroli's  M.  Cobb. 

8.  The  Nature  and  Treatment  of  Vertigo.      J.   Leonard 

CORNI.VG. 

9.  The  Pnarmacologic  Assay  of  Drugs  and  its  Importance 

in  Therapeutics.    E  M.  Hocghton. 

10.  The  United  States  Pharmacopeia  for  1900.    Prof.  Jos.  P. 

Remington. 

11.  Astigmatism,  its  Detection  and  Correction.     H.  Bert 

Ellis 

12.  Urine.    Experiments  to  Determine  the  Truth  of  the  Re- 

cently Announced  D'scovery  by  Moor  of  the  True 
Cause  of  Uremia.    John  Weatheeson. 

13.  Anastomosis  of  the  Ureters  with  the  Intestine.    A  His- 

torical and  E.xperimeatal  Research.    Reuben  Peter- 
son. 

2.— G.  Oram  Ring  reports  a  case  of  paresis  of  the  ex- 
ternal recti  associated  with  irregular  tabes  occurring 
in  a  man,  aged  30,  otherwise  healthy  and  with  a  negative 
family  history.  Within  a  period  of  two  years  the  only  ocu- 
lar manifestation  was  paresis  of  the  left,  external  rectus  mus- 
cle. The  affection  was  supposed  to  be  dependent  upon  a 
specific  infection,  although  the  iodides  had  but  little  effect. 
The  best  result,  although  only  palliative,  was  obtained  from 
chloride  of  gold  and  sodium,    [m.r  d.] 

3. — Edward  Jackson  makes  a  plea  for  a  more  complete 
and  exact  study  of  ocular  refraction  and  corneal  curvature 
before  and  after  extraction  of  the  lens  for  myopia.  He 
presents  a  table  showing  the  diopters  of  myopia  before  opera- 
tion, the  anticipated  theoretical  change  for  axial  myopia, 
the  average  change  noted,  the  maximum  and  minimum 
changes,  and  a  number  of  cases  of  each  degree  of  myopia, 
the  cases  varying  from  10  diopters  to  35  diopters.  The  author 
furthermore  discusses  the  optical  changes  produced  by 
removal  of  the  crystalline  lens  in  myopia  due  to  excessive 
corneal  curvature,  in  that  due  to  excessive  refractive  influ- 
ence of  lens,  and  in  myopia  due  to  increased  length  of  axis. 
[m.r.d] 

4. — Howard  S.  Anders,  in  an  article  on  the  clinical 
features  of  epidemic  inlluenza,  gives  his  observations, 
which  are  based  upon  an  analysis  of  128  cases.  The  most 
common  onset  includes  certain  symptoms  common  to  the 
cerebrospinal  and  respiratory  forms.  The  early  symptoms 
are  headache,  pain  in  the  back  and  limbs,  and  extreme  pros- 
tration for  the  first  5  or  7  days.  Especially  those  cases  char- 
acterized by  symptoms  relative  to  the  respiratory  tract 
showed  intense  prostration.  Congestion  of  the  conjunctivae 
was  a  symptom  well  characterized  at  the  onset.  In  the  mild 
cases  there  was  no  fever,  while  in  the  more  severe  form  the 
temperature  rose  above  102*  F.,  its  elevation  continuing  dur- 
ing the  first  2  or  3  days.  The  highest  temperature  reached 
was  105°  F.,  occurring  in  2  uncomplicated  cases,  one  in  an 
infant  14  months  old,  the  other  in  a  woman  72  years  of  age. 
The  decline  of  the  fever  was  by  rapid  lysis,  and  in  only  one 
case  was  the  fever  continuous  for  a  period  covering  10  days. 
During  convalescence,  subnormal  temperature  was  of  fre- 
quent occurrence.  The  symptoms  referable  to  the  cerebro- 
spinal system  were  the  following :  Severe  pains  in  the  loin- 
nerves,  and  muscles;  soreness  of  the  sternocleido-mastoid 
and  other  muscles  of  the  neck  ;  cephalalgia ;  inflammation  of 
one  or  more  of  the  intercostal  nerves,  suggesting  pleurisy; 
and  in  one  case,  there  was  enteralgia.  Neuritis,  affecting  the 
plantar  nerves  of  the  left  foot,  occurred  in  one  CAse ;  otalgia, 
facial  neuralgia,  and  mental  disorders  were  also  observed. 
Conjunctivitis  was  a  frequent  concomitant  of  the  influenia 
epidemic ;  13  cases  showed  hyperemia  and  watering  of  the 


March  23,  19011 


THE  LATEST  LITERATURE 


[The  Philjidelpuia 
Medical  Jocbnal 


561 


eyelids;  in  4  there  was  suppuration.  In  2  cases  purulent 
otitis  media  occurred  ;  one  developed  in  an  infant,  the  other 
in  an  adult  male.  Many  of  the  cases  began  with  faucial, 
tonsillar  and  pharyngeal  inflammation  ;  severe  laryngitis 
was  the  prominent  manifestation  in  7  of  the  cases ; 
in  almost  every  instance  bronchitis  developed,  being 
especially  severe  in  23  cases ;  bronchopneumonia  was  asso- 
ciated in  5  cases,  and  dry  pleurisy  also  in  5  of  the  cases. 
The  symptoms  referable  to  the  gastrointestinal  tract  were 
the  following :  Anorexia  was  associated  in  nearly  all  the 
cases  ;  the  less  important  manifestations  were  coated  tongue, 
nervous  irritability  of  the  gullet  and  stomach,  precardial  and 
epigastric  distre-^s,  flatulency  and  sluggishness  of  the  bowels. 
Palpitation  of  the  heart,  with  signs  of  dilatation,  occurred 
in  two  children  and  in  an  adult ;  bradycardia  was  frequently 
noted  during  the  period  of  convalescence  ;  vasomotor  disturb- 
ance, in  the  form  of  depressing  flushes,  was  a  symptom 
observed  in  3  women  ;  only  2  cases  of  acute  nephritis  devel- 
oped ;  herpes  labialis  was  noted  in  30%  of  the  cases.  The 
most  important  complications  were  lobar  pneumonia,  nephri- 
tis, peripheral  neuritis,  emphysema  and  cardiac  dilatation. 
Dry  tubercular  pleuritis  was  of  rare  occurrence.  Intermit- 
tent tertian  malarial  fever  developed  during  the  height  of 
the  disease  in  two  instances,  and  recurrence  of  ihe  attack  of 
iifluenza  occurred  in  4  persons.  The  important  sequels 
were  the  following  :  Unilateral  sweating  of  the  right  side  of 
the  face  occurred  in  one  case ;  phlyctenular  keratitis  in  a 
boy  3  years  of  age;  erysipelas  of  the  face  in  a  middle-aged 
woman  ;  melancholia  in  a  female  52  years  of  age ;  total  deaf- 
ness in  a  girl  3  years  of  age ;  neuritis  in  one  case.  Many  of 
the  patients  complained  of  marked  physical  prostration  and 
lack  of  ambition  after  convalescence  was  established.  From 
the  standpoint  of  diagnosis,  it  was  found  necessary  in  some 
cases  to  exclude  acute  muscular  rheumatism,  follicular  ton- 
sillitis, measles,  intermittent  malarial  fever,  cerebrospinal 
meningitis  and  enteric  fever.  The  author  concludes  the 
article  by  mentioning  the  climatic  conditions  favorable  to 
the  epidemicity  of  influenza,     [f  j  k.J 

6.— Valentine  thinks  that  general  anesthesia  should  be 
employed  in  all  children  under  the  fifth  year  unless  some 
cardiac  or  pulmonary  condition  exists  which  is  a  contra- 
indication. In  older  children  local  anesthesia  is  often  very 
kjititfactory.  In  the  Hebrew  race  he  thinks  it  would  be 
much  better  if  the  operation  were  performed  by  a  Hebrew 
doctor  capable  of  observing  the  proper  aseptic  precautions, 
[j  H  G  ] 

6. — Freudenthal  suggests  the  following  plan  of  treatment 
for  laryngeal  tuberculosis:  Relief  may  be  given  by  the  ap- 
plication of  saccharated  suprarenal  gland  to  produce  local 
anesthesia.  Menthol-orthoform  prcducee  a  longer  local 
anesthesia,  and  has  also  curative  properties.  F«_r  the  relief 
of  dysphagia  he  recommends  olive,  almond  or  sesame  oil ; 
he  has  not  as  yet  reached  final  conclusions  as  to  the  efficacy 
of  phototherapy ;  heroin  is  recommended  for  the  bronchial 
cough.  He  concludes  the  article  by  urging  further  investi- 
gation in  this  large  field,     [f  j.k  ] 

7.— Cobb  mentions  the  value  of  electrolysis  in  the 
treatmeut  of  atrophic  rhinitis.  lu  typical  cases  it  has 
a  curative  action  so  far  as  preventing  the  tendency  to  crust- 
formation  and  lessening  the  odor,  but  the  discharge  or  the 
odor  is  not  modified  when  nasal  empyema  is  present.  The 
best  results  are  obtained  by  placing  the  needles  compara- 
tively near  together;  improvement  in  the  condition  is 
especially  noticeable  in  the  area  corresponding  to  the  appli- 
cation of  the  positive  pole,  and  that  improvement  is  due  to 
the  liberation  of  oxygen  and  chlorin  or  the  acid  reaction 
produced  thereby  ;  and  finally,  he  cautions  us  never  to  iniro- 
duce  the  needle  of  the  negative  pole  beneath  the  membrane 
of  the  septum,     [f  j.k  ] 

8. — The  nature  and  treatment  of  vertigo  are  inves- 
tigated by  Corning.  After  a  number  of  experiments,  the 
author  draws  the  following  conclusions:  1.  Primarily,  ver- 
tigo is  a  deracgement  of  perception.  2.  Some  impair- 
ment of  consciousness  is  always  associated  with  a  de- 
rangement of  perception.  3.  Confusional  conditions  engen- 
dered in  contiguous  centers  of  higher  mental  action — cortical 
centers — produce  the  impairment  of  consciousness  by  the 
impairment  of  the  functions.  4.  Direct  impairment  of  func- 
tional t  fficiency  of  the  (enters  of  perception  without  inter- 
vention of  the  aflerent  nerves,  may  produce  vert'go.  5.  The 
clinical  causes  of  vertigo  have  this  in  common  :  that  they  are 


capable  of  interfering  directly  or  indirectly  with  the  cortical 
function.  6.  From  experimental  and  clinical  data,  vertigo 
is  regarded  as  essentially  a  cortical  derangement,  of  either 
direct  or  indirect  origin.  7.  Vivid  impressions,  particularly 
those  of  sound,  may  inhibit  milder  forms  of  rotary  vertigo 
8.  Impairment  of  consciousness,  caused  by  the  interference 
with  cortical  function,  is  in  direct  ratio  to  the  severity  of  the 
vertigo.  From  a  standpoint  of  treatment,  the  author  believes 
that  we  should  use  such  drugs  that  will  cope  directly  with 
the  vertigo  itself,    [f  j  k.] 

9.— Houghton  advocates  the  use  of  animal  experiments 
in  determining  the  dosage  of  certain  drugs,  when  the  chem- 
ical active  principles  can  not  be  isolated.  He  emphasizes  the 
fact  that  the  strength  of  certain  drugs  varies,  on  account  of 
the  different  processes  of  manufacture  ;  also,  for  the  reason 
that  the  amount  of  active  constituents  contained  in  the 
crude  drugs  varies  fmm  season  to  season,  and  is  modified  by 
habitat,  climatic  inflaences,  and  the  method  of  handling, 
collecting,  storing  and  curing,     [f  j  k.] 

10 — Remington  states  that  tne  decennial  convention 
for  the  revision  of  pharmacopeia  assembled  in  Wash- 
inton  on  May  2,  1900.  Delegates  were  present  from  28 
States,  representing  various  medical,  pharmaceutical  and 
national  organization8,and  delegates  from  the  Navy, Army  and 
Marine  Hospital  Service.  Fifty-seven  medical  colleges  and 
89  colleges  of  pharmacy  sent  delegates.  The  following  offi- 
cers were  elected  to  preside :  President,  Dr.  Horatio  C. 
Wood,  Philadelphia.  Vice  Presidents,  Professors  A.  B.  Pres- 
cott,  Ann  Arbor,  Michigan;  O.  A.  Wall,  Drs.  R.  W.  Wilcox, 
New  York  ;  N.  8.  Davis,  Jr.,  Chicago,  and  A.  L.  Langfeld,  of 
San  Francisco.  Secretary,  Dr.  H.  M.  Whelpley,  St.  Louis. 
Assistant  Secretary,  Dr.  W.  G.  Hotter,  District  of  dlumbia, 
and  Treasurer,  Wm.  M.  Mew,  of  Washington.  The  Commit- 
tee on  Revision  consisted  of  Charles  R\ce,  of  New  York, 
chairman;  Dr.  H.  C.  Wood;  H.  A.  Hare;  John  Marshall; 
Profs.  Remington,  Sadtler  and  Kraemer,  of  Philadelphia; 
Drs.  J  J.  Absl;  R.  W.  Wilcox;  Profs.  Virgil  Coblentz,  Greg- 
ory, E.  H.  Squibb,  of  New  York ;  W.  R.  Scoville,  of  Boston ; 
Prof.  Caspari  and  Dr.  Dohme,  of  Baltimore ;  Drs.  N.  S.  Davis, 
Jr.,  W.  S.  Haines;  Profs.  Oldberg  and  Helberg,  of  Caicago; 
Prof.  Jas.  M.  Wood,  of  Si.  Louis  ;  Dr.  George  F.  Payne,  of 
Atlanta ;  Prof.  Kremers,  of  Madison,  Wisconsin  ;  Prof.  L.  E. 
Sayre,  of  Lawrence,  Kansas;  Prof.  A.  B  Stevens,  of  Ann 
Arbor,  Michigan,  and  Prof.  C.  Louis  Dsal,  of  Louisville. 
The  author  concludes  the  article  by  saying  that  a  very  suc- 
cessful meeting  was  held,  and  that  the  Paarmacopeia  of 
1900  will  probably  appear  in  three  years  from  now  and  will 
receive  the  same  welcome  as  has  been  accorded  to  its  pre- 
decessors,   [f  J  K  ]  . 

13.— Weaiherson  concludes  that  by  hie  own  experimental 
research  he  could  not  confirm  the  discovery  of  ureine  by 
Moor.  He  closely  followed  the  method  advanced  by  Moor ; 
not  being  successful,  he  began  a  series  of  experiments  by 
more  improved  methods  of  research,  and  finally  made  inves- 
tigations to  prove  that  ureine  is  not  a  constituent  of  urine ; 
he  was  more  successful  in  proving  the  latter,     [f  j.k.1 


Wiener  klinische  Wochenschrift, 

February  21, 1901.    [14.  Jahrg.,  No.  8  ] 

1.  The  Question  of  Phosphorus  in  Oily  Solution.    Konrad 

Stick. 

2.  Carcinoma  Following  Pyloiio  Ulcer.     Anton  Krokiewicz. 

3.  Lipoma  of  the  Small  Intestine.    Ernst  Fuchsig. 

1.— Stich's  experiments  to  decide  whether  the  solution  of 
phosphorus  in  oil,  generally  cod  liver  oil,  is  really  useful 
or  not,  are  divided  into  four  sections.  Firat.— He  found  that, 
with  air  added,  0.0002  gram  of  phosphorus  is  shown  by  Mit- 
scherlich's  method.  Ssrondly.— Weak  solutions  (1 :  1000)  will 
keep  their  phosphorus  for  some  time ;  but  in  strong  solution 
(1  :  100)  the  phosphc  rus  will  diminish,  oxidation  and  the  pro- 
duction of  yellow  phosphorus  lowering  the  strength.  To 
keep  phosphorus,  it  should  be  dissolved  in  oil  (1 :  100)  and  the 
bottle  then  filled  with  carbon  dioxide.  After  cooling,  the  so- 
lution should  be  diluted  1 :  1000,  and  put  away  in  sniail  bottles. 
These  will  keep  well,  and  will  always  be  ready  for  use. 
Thirdly.— To  determine  the  amount  of  phosphorus  in  a  given 
sample  of  oil  containing  phosphoius,  benzol  is  added,  and 
the  I  h  w|  h^rus  precipitst'id  with  argentic  acetone  so  ution. 


562 


Thb  Phii^dblphiaI 
Medical  Joubnai.  J 


THE  LATEST  LITERATURE 


[ILi^CU  23,  un 


The  superfluous  pilver  can  be  withdrawn  by  the  aldition  of 
hydrochloric  acid.  Finally. — When  phosphorus  in  oil  is  kept 
in  half  filled  bottles,  oxidation  will  occur,  with  the  production 
of  amorphous  phosphorus,     [mo] 

2. — Krokiewicz  reports  a  case  of  cancer  following 
gastric  ulcer,  in  a  laborer,  aged  34  years.  First  he  had  the 
typical  symptoms  of  pyloric  ulcer.  Five  months  later  he 
grew  much  worse,  from  which  time  the  cancerous  cachexia 
started  increasing  till  death,  after  6  weeks  more.  His  ags, 
the  evident  connection  between  the  pyloric  ulcer  and  tbe 
succeeding  carcinoma,  the  early  marked  acidity  of  the  gastric 
contents,  with  the  presence  of  free  hydrochloric  acid,  and 
the  rapid  development  of  the  tumor  and  its  cachexia,  all 
make  this  case  one  of  great  interest.  The  literature  is  given. 
[m  o.] 

3.— Fuchsig  reports  an  interesting  case  of  lipoma  occur- 
ring in  the  small  intestine,  causing  invagination,  cured 
by  laparotomy.  A  man,  47  years  old,  had  abdominal  pain 
ofT  and  on  for  a  year.  Acute  attacks  of  colic  then  began, 
with  constipation  and  great  distention  of  the  abdomen. 
Vomiting  followed.  Laparotomy  for  invagination  was  per- 
formed 3  days  later,  showing  ciear  fluid  in  the  peritoneum. 
All  the  folds  of  the  intestines  were  dilated.  The  invagination 
was  easily  reduced,  and  a  tumor,  about  the  size  of  a  walnut, 
found  in  the  small  intestine,  which  on  removal  was  diagnosed 
a  submucous  lipoma.  The  patient  recovered  slowly. 
The  etiology  is  unknown.  Diagnosis  and  prognosis  depend 
upon  the  symptoms  of  invagination,  etc.,  should  they  occur. 
Operation  alone  will  settle  this.  He  cites  the  literature  of  the 
subject,     [m  o] 

Deutsche  medicinische  Wochenschrift. 

February  7, 1901.     [27.  Jahrg.,  No.  6] 

1.  On  the  Bacteriology  of  Acute  Articular  Rheumatism.    F. 

Meyer. 

2.  A  Method  for  Distinguishing  Different  Forms  of  Blocd; 

in  Particular  for  Determining  the  Presence  of  Human 
Blood.    H.  Uhlenhuth. 

3.  A  Case  of  Volvulus  of  the  Stomach  which  had  Produced 

Complete  Closure  of  the  Cardia  and  Pylorus,  and 
Acute  Fat  Necrosis.    Wiesinger. 

4.  Pathology  and  Treatment  of  Cicatricial  Contraction  of  the 

Bladder. 

5.  Concerning  Some  Gouty  Phenomena.     Adler. 

6.  The  Bactericidal  Action  of  Light  from  High  Tension  Cur- 

rents, and  an  Improved  Method  of  Making  Use  of  the 
Bactericidal  Action  of  Light  from  the  Voltaic  Current. 
H  Strebkl. 

1.— Meyer,  after  having  witioui  success  investigated  the 
joint  exudate  in  cases  of  rheumatism,  turned  his  attention 
to  the  tonsils  and  founi  in  the  mucus  from  the  tonsils 
diplococci  wbi  h  grew  as  stn  ptococti,  and  which  producfd 
in  animals  a  pe<"uliar  arthritic  affection  which  had  cl  )8e  re- 
semblance to  rheumatism.  The  diplococci  were  very  similar 
to  those  described  by  Wassermann,  but  were  apparently  not 
absolutely  identical  with  them.  The  conclusions  which  he 
reaches  are,  that  he  was  able  to  find  these  organisms  in  the 
tonsillar  mucus  in  cases  of  rheumatism,  but  not  in  other 
cases;  that  they  produced  a  eeropuruUnt,  usually  sterile, 
exudate  in  the  joirits  which  did  not  proceed  to  sepsis;  that 
the  bacteria  have  a  peculiar  affinity  to  the  serous  membranes 
and  the  endocardium  in  particular,  and  that  this  makes  it 
probable  that  they  have  a  close  relation  to  actual  articular 
rheumatism,  but  that  the  number  of  cases  as  yet  investi- 
gated has  bsen  too  small  to  allow  of  any  definite  decision 
conce  rnirg  this  matter,  and  there  is  as  yet  no  justification  for 
stating  whether  or  not  we  have  in  this  organisii  the  only 
cause  of  rheuma  ism.     [d  l  e.] 

2.— Uhlenhuth  makes  the  interesting  statement  that  by 
injecting  cows*  blood  into  rabbits  at  intervals  of  6  to 
8  days  he  found  that  after  about  5  injections  the  serum  of  the 
rabbits  was  found  to  contain  some  substance  which,  wlien 
added  to  a  perfect'y  clear,  very  dilu'.e,  solution  of  cows' 
blood,  caused  a  turbidity  in  this  solution.  The  reaction  was 
found  to  be  absent  ia  experiments  on  a  large  series  of  blood 
from  other  animals,  and  was  evidently  specific  for  cows' 
blood.  A  similarly  specific  action  was  found  after  injecting 
various  other  forms  of  blood  into  rabbits,  and  af.er  injecting 
human    blood  the  reaction  was  specific  for  human  blood 


alone.  The  reaction  was  also  observed  with  human  blood 
that  had  been  dried  for  weeks  and  subsequently  dissolved  in 
physiological  saltsolution.  Uhlenhuth  considers  it  a  specific 
reaction  for  various  forms  of  blood.     [d.l.e.J 

3. — The  interesting  case  occurred  in  a  man  of  41,  who  was 
taken  ill,  immediately  after  a  dietetic  indiscretion,  with  the 
clinical  appearances  of  Intestinal  obstruction  associ- 
ated with  enormous  distention  of  the  epigastrium  and  left 
hypochondrium.  There  were  attempts  at  vomiting,  but  noth- 
ing was  brought  forth.  The  distention  increased,  and  opera- 
tion was  undertaken  on  the  fourth  day  while  the  patient  wae 
in  extremely  bad  condition.  The  large  mass  in  the  epigas- 
trium proved  to  be  the  stomach.  It  was  suspected  at  first 
that  this  was  merely  pressed  forward  by  a  cyst  (possibly  pan- 
creatic) lying  behind  the  stomach,  as  the  mass  felt  like  a 
cyst.  The  stomach  was  punctured  and  the  contents  drawn 
off",  and  it  was  found  that  the  whole  mass  consisted  of  the 
tensely  distended  stomach.  The  pancreas  itself  was  found  to 
be  normal  excepting  for  perhaps  some  enlargement.  There 
were  widespread  areas  of  fat  necrosis.  The  stomach  was 
found  twisted  at  an  angle  of  about  180°  and  fixed  in  this  posi- 
tion. The  cardia  and  pylorus  were  completely  closed.  There 
was  beginning  peritonitis.  Tne  stomach  was  replaced  in 
proper  position,  and  the  wound  closed.  The  patient  re- 
covered completely,  and  had  subsequently  no  digestive  dis- 
turbances. The  case  was  notable  for  the  complete  cure  of 
the  fat  necrosis.  The  latter  condition  was  probably  due  to 
pressure  upon  the  pancreas  by  the  enormously  distended 
stomach.  The  occurrence  of  volvulus  of  the  stomach  was 
attributed  to  the  displacement  of  the  colon  above  the  stomach 
resulting  to  the  abnormal  length  of  the  mesocolon ;  after  a 
partial  volvulus  had  orcurred  this  was  increased  by  the 
enormous  secretion  which  took  place  in  the  stomach.  [d.l.e  ] 

6. — Adler  makes  some  remarks  on  gout,  based  upon  pure 
theory.  He  thinks  that  the  reason  the  deposits  occur 
in  the  cartilages  about  the  joints  is  due  less  to  the  fact  that 
the  circulation  is  poor  than  to  the  tendency  that  cartilage; 
have  to  attract  deposits.  Tbey  normally  attract  a  deposit  <  : 
calcium  salts,  and  Adler  thinks  this  natural  tendency  is  aU 
exerted  upon  uric  acid.  He  considers  that  perhaps  diar- 
rhea, the  free  secretion  of  saliva  seen  in  gout,  may  be  due  t 
an  effort  to  rid  the  blood  of  an  excess  of  uric  acid.     [d.l.e 

C— Strebel  presents  reasons  for  believing  that  only  th- 
uUraviolet  rays  and  the  rays  beyond  kill   bacteria,  and  tha 
it  is  the  invisible  rays  that  are  chiefly  active.    He  describe,- 
vaiioQs  experiments  which  he  has  carried  out  with  the  ultra- 
violet rays,  using  various  lenses,    [d.l  e.] 


Milnchener  medicinische  Wochenschrift. 

January  15,  1901.     [4S.  Jahrg.,  No.  3.] 

1.  A  Case  of  Cerebrospinal  Meningitis  and  the  Diplococcus 

Intracellularis.     Boxhoff. 

2.  Free  Openings  in  Operations  for  GiUstones     Kuhs. 

3.  Subcutaneous  Rupture  of  the  Spleen  and  Its  Treatment. 

Jordan. 

4.  A  Case  of  Use'ulness  of  Both  Stumps  After  R?amputation 

of  the  L-'gs  Without  Osteoplasty.    Gojskkr 

5.  Contribution  to  Diphtheria  of  the  Conjunctiva  (Conjuncti- 

vitis Crouposa,  Caused  by  Diphtheria  Bacilli)  Pem- 
phigus Serum.    Schlesisger. 

6.  Progressive  Fatal  Diphtheria  with   Eirly   Serum   Treat- 

ment.   Trumpp. 

7.  The  Employment  of  Sand  for  the  Ripid  Filtration  of 

Nutrient  Agar.    Paul. 

8.  The  Corset  Treatment  of  Tabes  Dorsalis.    Bade. 

9.  Dessener's  System  of  Riiatgen  Instruments.    Wiesker. 

1. — BonhofT  reports  the  case  of  a  woman,  b~  years  of  age, 
who  was  attacked  with  sudden  pain  in  the  back  of  the  head. 
Sbe  became  delirious,  had  fever,  and  retraction  in  the  neck. 
A  lumbar  puncture  showed  the  presence  of  pus  cells  and 
bacteria  in  the  fluid.  The  patient  died,  and  at  the  autopsy 
there  was  found  that  aside  from  a  very  slight  congestion,  the 
membranes  of  the  brain  were  normal,  but  there  was  a  con- 
siderable amount  of  yellowish-green  turbid  fluid  in  the  mem- 
branes of  the  cord,  and  a  grayish  green  infiltration  of  the  pi* 
about  2  mm.  in  thickness.  It  is  interesting  to  note  that  there 
were  no  other  cases  in  the  patient's  neighborhood  either 
before  or  after  her  sickness.    Cultures  upon  Loftl  »r"s  blood 


Makcb  23,  1901] 


THE  LATEST  LITERATURE 


tTHE  PaiI.AI>KLPHlA 
Medical  Journal 


563 


serum  caused  a  growth  of  typical  meningococci.  Tnese 
Bonhoflf  believes  to  be  perfectly  distinct  from  other  forms, 
partly  by  their  morphological  and  cultural  peculiarities,  and 
partly  hv  their  very  limited  pathogenicity.  They  have  a  very 
slight  effect  upon  guineapigs,  kill  mice  very  readily,  and  it  is 
practically  impossible  to  immunize  rabbits,  although  in  those 
animals  to  whom  ascending  doses  of  the  cultures  were  given, 
some  protective  power  existed  in  the  blood-serum.  In  ad- 
dition, a  peculiar  bacillus  was  found,  which  occurred  quite 
frequently  in  the  cultures,  and  somewhat  resembled  the  one 
described  by  Stadelmann.  This  appeared  first  on  the  fifth 
day,  but  later  appeared  48  hours  after  reiaoculation.  They 
are  non-motile,  and  do  not  ferment  grape  sugar.  Although 
he  is  not  certain  that  they  are  the  same  as  Stadelmann's 
bacillus,  he  regards  them  as  a  form  of  pseudo  diphtheria  bacil- 
lus that  has  no  influence  upon  the  disease,     [rs.] 

3. — Kuhn  calls  attention  to  the  great  importance  of  secur- 
ing free  openings  in  all  operations  for  the  removal 
of  gallstones.  He  mentions  a  case  in  which  the  patient 
was  apparently  relieved,  but  at  the  second  operation  the 
gallbladder  was  found  filled  with  clear  bile,  and  a  single 
facetted  stone,  evidently  overlooked  at  the  previous  opera- 
tion, blocked  the  opening  of  the  cystic  duct.  He  also  men- 
tions another  case  in  which  only  after  prolonged  palpation  a 
similar  concrement  lying  in  the  neighborhood  of  the  duo- 
deum  and  completely  blocking  the  duct  was  found.  Finally 
he  describes  the  case  of  a  woman  in  whom  a  permanent 
biliary  fistula  occurred  as  a  result  of  adhesion  of  the  con- 
nective tissue  bands  including  the  common  duct.  At  the 
third  operation  it  was  found  that  there  was  stenosis  at  the 
pylorus,  and  a  fistula  between  the  gallbladder  and  the  duo- 
denum was  made,  as  a  result  of  which  the  patient  readilj'  re- 
covered. In  these  cases  he  used  a  spiral  sound  having  a 
bulbous  extremity  with  great  success,    [j.s.] 

3. — Jordan  reports  the  case  of  an  oflicer,  23  years  of  age, 
who  was  thrown  from  his  horse  and  received  a  severe  blow 
in  the  left  side  from  the  handle  of  his  sword.  There  was  im- 
mediate, intense  pain  and  a  feeling  of  weakness,  requiring 
his  immediate  removal  to  the  hospital.  Here  he  was  seized 
with  vomiting,  progressive  collapse,  severe  anemia,  and  con- 
traction of  the  muscles  of  the  abdomen.  As  these  indicated 
internal  hemorrhage,  it  was  decided  to  perform  immedi- 
ate laparotomy,  when  a  considerable  effusion  of  blood  was 
found  in  the  peritoneal  cavity,  evidently  a  result  of  a  rup- 
ture of  the  spleen,  from  which  blood  was  still  pouring. 
The  spleen  was,  therefore,  extirpated,  and  the  wound  closed. 
It  was  noted  that  part  of  the  intestines  were  still  in  a  state 
of  spasm  as  a  result  of  the  injury.  In  the  course  of  2  months 
the  patient  had  recovered  sutfisiently  to  leave  the  hospital, 
and  undertake  a  bath-cure.  Four  months  after  the  injury 
the  leukocytes  were  slightly  increased,  the  hemoglobin  and 
red  blood-cells,  slightly  decreased.  There  were  no  evidences 
during  recovery  of  vicarious  hypertrophy  of  the  lymph- 
glands  or  the  bone  marrow.  Exammation  of  the  spleen  showed 
that  ihe  rupture  had  occurred  upon  the  concave  side.  One 
hundred  and  thirty- five  cases  of  this  injury  are  on  record, 
with  the  following  results  :  5  healed  spontaneously ;  16  were 
saved  by  extirpation  of  the  spleen ;  and  104  died.  Of  these, 
3  died  from  abscess,  and  the  rest  from  hemorrhage.  Jordan 
draws  the  conclusion  that,  if  after  severe  secondary  anemia 
produced  by  hemorrhage,  a  man  can  recover  almost  com- 
pletely, although  his  spleen  has  been  removed,  it  is  not 
likely  that  this  organ  is  of  great  importance  in  the  forma- 
tion of  blood,     [j.s.] 

4. — Gjssner  reports  the  case  of  a  man  who  attempted 
suicide  by  starvation.  At  the  end  of  the  twelfth  day  pain 
drove  him  from  his  place  of  concealment  and  he  was  carried 
to  the  hospital  unconscious.  Both  legs  became  gangrenous 
and  were  amputated  above  the  ankles.  The  stumps  suppu- 
rated, and  some  months  later  another  amputation  was 
performed,  without  forming  any  periosteal  riaps.  Suppura- 
tion again  occurred  in  the  stumps,  but  gradually  the  surface 
granulated  and  healed,  and  the  patient  was  able  to  walk 
without  support  of  any  kind,  and  even  to  go  up  and  down 
stairs.  Gossner  reports  the  case  as  an  illustration  of  the 
hopefulness  of  amputation  through  the  legs,  in  spite  of  the 
most  untoward  complications,     [j.s] 

6. — Sohlesinger  reports  2  cases  of  pseudo- membranous 
conjunctivitis.  In  the  first  case  diphtheria  bacilli  were 
not  obtained  in  the  cultures;  nevertheless,  an  injection  of 
antitoxic  serum  was  given,  and  in  addition  vigorous  local 


therapy  with  antiseptic  solutions  was  employed.  The  patient 
recovered  completely.  In  the  second  case  numerous  diph- 
theria bacilli  were  found.  The  same  treatment  was  employed, 
and  the  results  were  again  excellent.  The  advantage  in  the 
employment  of  the  antidiphtheritic  serum  was  that  it  hastens 
the  separation  of  the  membrane,  as  well  as  that  it  improves 
the  general  condition  of  the  patient.  It  should  be  used 
in  this  condition,  as  in  all  others,  at  the  earliest  possible 
moment,     [j.s.] 

6. — See  editorial. 

7. — The  difficulty  of  the  filtration  of  agar  has  caused 
many  ingenious  schemes  to  be  devised,  the  majority  of  which 
depend  either  upon  using  pressure  or  suction  force,  or  the 
employment  of  some  filtering  substance  with  larger  pores.  A 
few  have  endeavored  by  various  means  to  render  the  agar 
solution  more  fluid.  To  the  second  group  belongs  the 
method  of  Paul.  It  occurred  to  him  that  sand,  on  account 
of  the  fixity  of  the  size  of  its  pores,  would  probably  be  a 
most  desirable  substance.  His  apparatus  consists  of  2  vessels, 
one  containing  a  perforated  bottom  resting  upon  the  rim  of 
the  other.  The  sand,  of  course,  is  placed  in  the  upper  one, 
a  layer  of  gauze  retaining  it  in  position.  Tne  arrangement 
is  rather  peculiar.  There  is  first  a  layer  of  large  pebbles  3 
cm.  in  thickness,  then  one  of  small  pebbles,  2  cm.  in 
thickness,  then  6  cm.  of  sand,  and  the  2  Uyers  of  peb- 
bles in  inverse  order.  Eich  layer  is  separated  by  gauze. 
The  filter  is  first  thoroughly  washed  with  boiling  water,  is 
then  placed  in  an  ordinary  steam  sterilizer  and  heated  until 
it  reaches  100^  throughout.  The  agar  is  then  poured  upon  it 
and  filtration  commences.  With  this  apparatus  Paul  has 
filtered  30  litres  of  agar  in  2  hours,  and  the  amount  of  loss  is 
very  slight,     [j  s.] 

8. — Bade  beliives  that  a  properly  fitting  corset  exercises 
a  favorable  influence  upon  the  course  of  tabes  dorsalis  ; 
why,  he  is  not  clear.  The  corset,  as  usually  prepared,  has 
certain  unpleasant  features,  particularly  the  supports  of  the 
arms,  and  the  portions  over  the  hip'.  Unless  the;e  fit  exact  y 
they  cau?e  great  discomfort  and  often  the  formation  of  serious 
Eores.  All  these  disadvantages  Bade  has  endeavo  ei  to  over- 
come by  the  employment  of  a  corset  made  of  leather,  care- 
fully fitted  so  that  it  rests  firmly  upon  the  hips.  There  is 
also  a  special  band  made  for  the  waist,  which  binds  firmly 
the  upper  and  lower  portions  of  the  corset  together,  and 
enables  the  body  to  move  freely  at  this  pciat.  A  partial  sup- 
p  irt  is  given  to  the  back  by  springs,    [j  s.] 

9. — Wiesner  describes  the  Rontgen-ray  apparatus  of  Des- 
sauer,  which  is  distinguished  for  its  simplicity  and  effective- 
ness. The  reproductions  of  the  pictures  that  have  been 
taken  with  it  tiave,  unfortunately,  been  omitted.  [They  are 
given  in  the  following  number,    j.s.] 


Berliner  klinische  Wocbenscbrift. 

February  4,  1901.      [38.  Jahrg.,  No.  5.] 

1.  Fatigue  and  Recreation.    M.  Verworx. 

2.  Observations  on  the  Treatment  of  Puerperal  Fever  with 

Marmorek's  Antistreptococcus  Serum.    M.  Bld.mbeeg. 

3.  A  Case  of  Hysterical  Sensory  Aphasia  in  a  Child.    L. 

Mann. 

4.  Hygiene  of  the  Eye  in  the  Xineteenth  Century.    H.  Cohn. 

*£. — Will  be  abstracted  when  concluded. 

3. — Mann  reports  a  case  of  hysterical  sensory  aphasia 

occurring  in  a  girl  7  years  of  age,  with  negative  family  and 
personal  history.  It  was  elicited,  however,  that  within  2  days 
previous  to  the  onset  of  the  affection  the  child  had  become 
vexed  and  cried  considerably.  The  mother  stated  that  for  4 
weeks  she  had  noticed  that  the  child  had  been  speaking 
indistinctly,  and  this  progressed  so  rapidlj'  that  within  3  days 
the  child's  utterances  became  unintelligible.  According  to 
the  mother  the  child  became  at  the  same  time  completely 
deaf.  The  author  upon  examination  coincided  with  the 
physicians  who  had  previously  examined  the  patient,  namely, 
that  the  child  was  completely  deaf.  She  would  not  respond 
when  addressed,  no  matter  how  loud  she  was  spoken  to,  peered 
into  vacancy  or  shook  her  head,  at  the  same  time  speaking  un- 
intelligently  in  a  manner  that  seemed  to  indicate  that  she  did 
not  understand.  A  noticeable  feature,  however,  was  the  intel- 
ligent, attentive,  and  interested  expression,  and  also,  accord- 
ing to  the  mother,  there  seemed  to  have  been  no  diminution 


564 


Thk  Philadelphia 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


[Maech  23,  1901 


in  the  intelligence  of  the  child  while  performing  her  daily  du 
ties.  After  a  few  days,  when  the  confidence  of  the  child  was 
obtained,  the  author  found  that  no  real  deafness  was  present, 
but  that  the  child  was  unable  to  understand  spoken  words, 
and  that  the  perception  of  ordinary  noises  was  fully  pre- 
served, it  being,  therefore,  a  condition  of  eocalled  "  word 
deafness "  or  sensory  apliasia.  In  the  absence  of  other 
cerebral  symptoms  and  on  account  of  the  peculiarities  of 
those  present  the  author  believes  that  this  was  an  hysterical 
manifestation  with  a  not  yet  described  symptom-complex. 
Upon  isolation,  painful  faradization  and  systematic  practice 
in  articulation,  improvement  soon  set  in  with  complete  re- 
covery. The  persistent  suggestive  treatment  applied  for 
some  time  before  a  result  was  obtained,  seems  to  indicate 
that  an  isolated  symptom  of  hysteria  may  persist  for  some 
time,  to  ultimately  disappear  under  suggestive  treatment. 

[M.R.D.] 

4. — Cohn  reviews  the  hygiene  of  the  eye  in  the 
nineteenth  century  and  could  not  find  anything  in 
literature  before  1800  on  the  suVject,  with  the  excep- 
tion of  Bartisch's  work  which  contains  a  few  facts  that  are 
recognized  even  at  the  present  time.  AU  the  years  of  con- 
sequence in  ophthalmic  hygiene  are  considered  seriatim. 
[m  ED.] 


Ceutralblatt  fiir  Gyu^kologie. 

December  23,  1901.     [No.  51.] 

1.  The  Prevention  of  Purulent  Inflammation  of  the  Eyes  in 

Newborn  Children.    P.  Zweifel. 

2.  Test  of  Lysoform  as  a  Method  of  Hand-Disinfection.    F. 

Ahi.keld. 

3.  Gangrene  of  the  Lower  Extremities  in  the  Puerperium. 

George  Bcrckhard. 

1. — Zweifel  presents  an  exhaustive  paper  upon  the  pro- 
phylaxis of  purulent  inflammation  of  the  eyes  in 
newborn  children,  with  especial  reference  to  Credo's 
treatment  by  silver  nitrate  solution,  2%,  and  the  more  re- 
cent silver  salts  which  have  been  employed  in  this  disease. 
He  draws  attention  to  the  diflference  experienced  between 
patients  as  met  with  in  clinics  and  in  private  practice,  the 
greater  number  of  cases  occurring  in  children  delivered  by 
midwives.  He  agrees  with  the  other  obstetricians  in  attrib- 
uting the  vast  majority  of  cases  of  the  ophthalmia  of  the 
newborn  children  to  Neieser's  gonococcus.  The  secret  of  the 
prevention  consists  in  an  immediate  cleansing  of  the  eyes 
after  birth  with  sterile  water  followed  by  the  instillation  of 
the  remedy  that  is  to  be  employed.  He  remarks  tliat  in  a 
number  of  these  cases  the  lochial  secretion  will  not  show 
the  characteristic  gonococci,  but  every  mother  whose  va- 
ginal secretion  appears  in  the  slightest  degree  suspicious 
should  be  placed  on  prophylactic  douches  and  the  eyes  of 
the  child  be  treated  in  the  manner  mentioned.  For  some 
years  Zweifel  had  employed  a  3%  solution  of  boric  acid  as 
an  eye-wash  and  had  obtained  very  satisfactory  results.  In 
another  group  of  cases  he  employed  a  1%  solution  of 
formalin,  one  drop  being  instilled  into  each  eye  at  birth  ;  of 
120  childi  en  so  treated,  but  4  presented  inflammatory  changes 
in  the  eyes,  that  is  3  3  ^ .  Since  1895  the  newer  silver  salts 
have  been  employed,  also  such  solutions  as  salicylic  acid 
by  BischoflT,  chlorin-water  by  SchmidtRimpler,  thymol  by 
Schirmer,  boric  acid  by  Gredt'-Wecker,  potassium  perman- 
ganate by  Valenta,  and  carbolic  acid,  mercuric  chlorid,  and 
sulpho-carbolate  of  zinc.  Olshausen  while  using  a  1%  solu- 
tion of  carbolic  acid  had  Sfc  of  ophthalmia;  with  the  2% 
solution  he  had  but  3^  of  ophthalmia.  Sfiith  with  \%  car- 
bolic acid  had  1.4  of  ophthalmia,  while  Krukenberg  with  a 
2%  solution  had  13.4  of  ophthalmia.  Schnider  with  a  subli- 
mate solution  had  from  4%  to  Q>%  ophthalmia  and  with 
eulpho-carbolate  of  zinc  he  had  but  3%  ophthalmia;  finally 
Erdberg  with  a  1  to  7000  sublimate  solution  had  but  4%  of 
ophthalmia.  The  acetate  of  silver  has  been  employed  witli 
boiled  water  with  comparatively  satisfactory  results,  as  has 
also  silver  nitrate;  thus  he  treated  43  children  with  this  salt 
and  had  but  two  cases  of  ophthalmia,  or  ■i&'ft,.  Zweifel 
gives  the  results  of  some  experiments  which  were  made  by 
him  with  these  newer  preparations,     [w  a.n.d  ] 

2, — Ahlfeld  has  instituted  a  series  of  experiments  upon 
disinfection  of  the  hands  by  lysoform.  Eighteen  of 
his  pupils  have  repeatedly  made  use  of  this  substance,  6  with 


a  3%  solution  and  12  with  a  4%  solution.  The  entire  18 
have  primarily  employed  the  usual  methods  of  cleansing  the 
hand  followed  by  the  use  of  hot  water,  soap  and  brush  for  5 
minutes.  The  lysoform  is  then  rubbed  in  with  a  brush  fjr 
5  minutes,  after  which  the  hands  are  immersed  in  sterile 
warm  water.  Notwithstanding  this  thorough  testing,  Ahlfeld 
is  inclined  to  believe  that  the  method  is  no  better  than  the 
methods  usually  employed,  although  the  germs  are  destroyed 
probably  as  well  as  by  the  methods  generally  recommended. 
[w.A  N  D  ] 

3. — Burckhard  ha?  been  able  to  collect  from  literature  14 
cases  of  gangrene  of  the  lower  extremities  during 
the  puerperium.  He  reports  2  cases  which  have  come 
under  his  own  observation.  The  first  patient,  38  years  of  age, 
passed  through  a  difficult  birth  at  the  end  of  the  seventh 
pregnancy,  the  child  occupying  a  transverse  position.  Ex- 
amination showed  that  the  lower  uterine  segment  was  con- 
siderably distended  and  uterine  rupture  threatened.  The 
right  shoulder  lay  deep  within  the  pelvis,  whOe  the  right 
arm  of  the  child  had  prolapsed  and  protruded  in  a  deeply 
cyanosed  condition  from  the  pelvis.  The  back  of  the  child 
was  directed  posteiiorly  while  the  head  projected  over  the 
symphysis.  Decapitation  was  performed  by  Braun's  hook 
and  after  the  extraction  of  the  child  there  was  a  profuse 
hemorrhage  from  the  placental  site.  An  incomplete  uterine 
ruj)ture  was  found  on  the  left  side,  the  hemorrhage  from 
which  was  arrested  by  means  of  an  intrauterine  tamponade. 
The  puerperium  was  practically  normal  until  the  twelfth 
day,  when  the  temperature  arose  and  the  toes  of  the  left  foot 
became  anesthetic.  The  latter  condition  steadily  progressed 
up  the  foot  to  the  ankle  and  gangrene  began,  which  necessi- 
tated an  amputation  after  the  method  of  Gritti.  Examina- 
tion showed  that  the  popliteal  vein  had  been  thrombosed. 
The  second  patient  was  32  years  old  in  her  fifth  labor. 
Kolpurysis  was  employed  and  the  child  extracted  by  version. 
The  maternal  pelvis  was  flattened  and  the  child,  which  was 
stillborn,  presented  a  spoon-shaped  depression  on  the  right 
parietal  bone.  On  the  second  day  of  the  puerperium  the 
patient  experienced  severe  pain  from  the  symphysis  down 
the  left  limb;  the  foot  became  cyanotic  and  anesthetic,  aline 
of  demarkation  formed  across  the  malleoli,  and  amputation 
was  required  of  the  left  leg  in  its  upper  third.  Examination 
showed  that  thrombosis  of  the  posterior  tibial  artery  had 
occurred.  Burckhard  remarks  that  in  the  17  cases  of  this 
complication  collected  from  literature  endocarditis  was  ob- 
served twice.    [w.A  N  D  ] 


Centralblatt  fiir  innere  3Iedicin. 

January  IS,  1901.     [25.  Jahrg.,  No.  2.] 

1.  Concerning  the  Influence  of  Morphia  upon  the  Stomach. 

Alfred  Hiesch. 

2.  The  ESect  of  Thyroidin  Preparations  in    Certain  Rare 

Cases.    Arthitr  Jaksicke. 

1. — Hirsch  found  that  the  subcutaneous  injection  of 
1  eg.  of  morphia  per  kilo  of  body-weight  in  dogs  resulted 
in  the  complete  retention  of  fluids  In  the  stomach, 

while  under  normal  circumstances  these  left  the  organ 
within  an  hour  and  a  quarter.  The  secretion  of  HCI  con- 
tinued. The  expulsion  of  the  fluid  was  still  markedly  de- 
creased 10  or  11  hours  after  the  injection,  while  the  secretion 
of  HCI  had  much  increased.  While  listening  over  the 
stomach  it  was  found  that  there  was  a  loud  noise  in  the 
region  of  the  pylorus  similar  to  that  made  when  the  pyloric 
portion  of  the  stomach  is  attempting  to  drive  air  or  fluid 
through  the  pylorus.  This  indicated  peristalsis  of  the 
stomach,  but  since,  in  spite  of  this  marked  activity  of  peri- 
stalsis, no  gas  or  fluid  escaped,  it  seemed  evident  that  the 
cause  of  the  condition  was  a  tonic  contraction  of  the  pylorus 
producing  temporary  obstruction.  The  fundus  of  the  stomach 
seemed  to  remain  quiet.  The  condition  of  the  pvlorus  and 
the  marked  increase  of  the  peristalsis  were  considered  to  be 
due  to  excitation  of  the  contraction  centers  per  the  pylorus 
and  pars  pylorica  in  the  corpora  quadrigemina.  The  HCI 
secretion  was  decreased  in  the  beginning,  probably  from  the 
fact  that  the  morphia  injected  subcutaneously  is  excreted  by 
the  gastric  mucosa.  The  subsequent  hypersecretion  was 
thought  to  have  a  central  origin.  The  results,  then,  of 
morphia  injection   were  to  produce  difficulty  in  emptying 


lABCH  23,  1901] 


THE  LATEST  LITERATURE 


[Thk  Philadelphia 
Medical  Journal 


565 


the  stomach  ;  first  a  decrease  and  then  a  marked  increase  in 
theHCl;  the  influence  of  the  drug  increased  progressively 
with  increase  in  the  dose ;  the  use  of  the  drug  subcutane- 
ously  produced  more  marked  effects  than  use  by  the 
mouth.  As  to  atropin  he  found  that  it  produced  less  marked 
but  still  notable  disturbance  of  expulsion  which  lasted  for  at 
least  6  hours.  HCl  was  completely  absent  during  the  first 
hour,  but  was  again  normal  after  6  hours.  There  was  at  the 
latter  period  a  marked  fl  iw  of  bile  which  is  never  observed 
after  morphia.  Hirsch  also  observed  in  narcotizing  a  dog 
with  ether  that  the  ether  and  morphia  seemed  to  act  antag- 
onistically. 

2. — The  first  case  described  was  that  of  a  woniin  who  had 
a  mamillary  tumor  which  was  at  first  thought  to  be  malig- 
nant. Thyroidin  was  given  and  there  was  a  rapid  decrease 
in  the  size  of  the  tumor,  and  it  ultimately  practically  dis- 
appeared. Similar  effects  were  observed  in  2  cases  in  which 
there  were  large  lymphomata,  and  also  in  3  cases  of 
marked  splenic  enlargement  without  increase  of  leu- 
kocytes. The  histories  are  given  somewhat  in  detail.  It  is 
noted  that  one  patient  took  within  6  years  more  than  4,000 
tablets,  containing  5  grains  each,  of  thyreoidin,  without  bad 
effects,    [d  l.e  ] 

Vratch. 

January  6,  1901.     [Vol.  xxii,  No.  1.] 

1.  The  Participation  of  the  Spleen  in  the  Formation  of  the 

Albumin  Ferment  of  the  Pancreas.    A.  A.  Gertsen. 

2.  On  Writer's  Cramps.    I.  W.  Zabludowsky. 

3.  The  Diagnostic  and  Prophylactic  Significance  of  Koch's 

Tuberculin.    Ph.  A.  Dombrovs'sky. 

4.  Electrolysis  in  Cicatricial  Stricture  of  the  Esophagus.    N. 

W.  Sletow  and  P.  I.  Postnicow. 

1. — Gertsen  devotes  his  paper  to  a  critical  reply  to  Dr. 
Popelsky,  who  published  in  the  Vratch  of  1899,  Nj.  25,  the 
results  of  some  of  his  experiments  intended  to  disprove  the 
aseerlions  of  Shiff,  Pachon  and  the  author  to  the  effect  that 
the  spleen  is  intimately  associated  in  the  formation  of  tryp- 
sin from  protrypsin.  The  author,  who  has  done  considerable 
experimental  work  on  the  subject,  finds  no  difficulty  in  show- 
ing that  not  only  were  the  experiments  of  Popelsky  useless 
but  that  they  actually  establish  the  very  facts  against  which 
they  were  directed.  Gertsen's  contentions  are :  1.  The 
amount  of  trypsin  in  the  pancreatic  juice  or  an  infusion  of 
the  pancreas  is  proportionate  to  the  swelling  of  the  spleen 
which  takes  place  at  the  height  of  digestion.  2.  In  dogs  and 
cats,  receiving  their  food  only  once  in  24  hours,  the  swelling 
of  the  spleen  and  the  increased  formation  of  trypsin  begin 
simultaneously  five  hours  after  the  ingestion  of  food,  reach- 
ing the  maximum  at  the  seventh  hour,  when  they  disappear 
gradually.  3.  Animals  from  which  the  spleen  has  been  re- 
moved not  only  do  not  show  such  increase  in  the  secretion 
of  trypsin,  but  the  latter  disappears  entirely  from  the  pan- 
creatic juice  or  an  infusion  of  the  pancreas.  4.  By  adding 
to  a  solution  of  trypsin,  i.  e.,  an  infusion  of  the  pancreas  in  a 
state  of  rest,  an  equal  quantity  of  an  extract  of  spleen  in  a 
state  of  physiologic  activity,  the  protrypsin  is  at  once  con- 
verted into  active  trypsin.  5.  The  same  results  are  obtained 
with  the  venous  blood  of  the  swollen  spleen.  6.  If  half  of 
the  pancreas  be  removed  from  a  dog  from  which  the  spleen 
had  been  removed,  and  an  intravenous  injection  made  of  a 
watery  extract  of  a  swollen  spleen,  i.  e.,  one  removed  at  the 
height  of  digestive  activity,  and  20  minutes  later  the  second 
half  of  the  pancreas  be  removed,  an  infusion  of  the  first  half 
will  not  digest  any  albumin  while  the  second  half  will  show 
great  digestive  powers.  These  claims  are  substantiated  by  a 
considerable  number  of  careful  experiments,  some  of  which 
are  described  by  the  author,     [a.r.] 

2. — Will  be  abstracted  when  completed. 

3. — Dombrowsky  has  employed  Koch's  tuberculin  for 
diagnostic  purposes  with  very  satisfactory  results.  The  re- 
action when  present  was  always  marked,  the  temperature- 
elevation  varying  from  0  7  to  1.5  C.  Of  12  patients  3  reacted 
after  the  first,  6  after  the  second  and  3  after  the  third  injec- 
tion. No  albuminuria  or  diazo- reaction  followed.  The 
method  employed  by  the  author  is  one  described  by  Friiakel 
and  is  essentially  as  follows :  0  1  c.c.  of  tuberculin  is  mixed 
with  10  c.c.  of  sterile  water.  Of  this  mixture  one  division  of 
a  Pravaz  syringe,  i.e.,  0.1  c.c.  of  the  mixture,  or  0.001   of 


tuberculin,  is  irjected  subcu'aneously.  If  no  reaction  takes 
place  the  injection  is  repeated  on  the  third  day,  increasing 
the  dose  to  five  divisions  of  the  syringe  or  0.5  c.c. ;  if  still  no 
reaction  follows  the  entire  contents  of  tlie  syringe,  or  0.01  of 
tuberculin,  are  inj^ct^d.  The  reaction  is  considered  posit-ve 
when  the  elevation  of  temperature  reaches  at  least  0  5  C. 
Both  prior  and  after  the  injection  the  temperature  is  taken 
every  three  hours,  except  between  9  in  the  evening  and  6  in 
the  morning,  for  three  consecutive  days.  Tne  prophylactic 
value  of  the  tuberculin  test  the  author  sees  in  the  early 
recognition  of  the  disease  afforded  by  it.  A  claim  for  its 
perfect  harmlessnees  is  made,     [a.r.] 

4. — Sletcw  and  Postnikow  treated  successfully  by  elec- 
trolysis two  severe  cases  of  stricture  of  the  esophagus,  result- 
ing from  taking  ammonia.  Tne  diagnosis  was  established 
bevond  doubt  by  several  specialists,  and  the  various  mechani- 
cal means  employed  to  dilate  the  stricture  resulted  in  fail- 
ure. Tne  authors  achieved  success  promptly  by  means  of 
olive  shaped  electrodes  introduced  into  the  esophagus,  using 
a  current  of  5  to  10  m.a.  for  1  to  5  minutes.  The  bene  filial 
effects  of  electricity  in  such  cases  the  authors  explain  by  the 
theory  ihat  the  current,  coming  in  contact  with  the  cicatrix, 
produces  certain  chemical  changes  which  soften  and  dissolve 
the  newforaied  tissue.  The  assertion  of  some  authorities 
that  the  effect  is  due  to  cauterizition  is  proven  to  be  errone- 
ous by  a  simple  mathemitical  calculation  of  the  thermic  value 
of  the  current  as  well  as  by  the  fact  that  the  electrode  is 
practically  cold  when  removed.  The  authors  prefer  an 
olive-shaped  electrode,  as  it  is  much  more  certain  to  come  in 
intimate  contact  with  the  cicatricial  tissue.  This  should  be 
made  of  brass,  nickel  or  silver  plats,  J  ti  2  cm.  in  diameter. 
The  method  employed  is  des3ribed,  but  does  not  differ  essen- 
tially from  those  generally  practised,     [a.r  ] 

January  IS,  1901.     [Vol.  xxii,  No.  2.] 

1.  On  the  Collection  of  Thorough  Information  about  Can- 

cerous Patients  by  the  Aid  of  Q  xestion-Blanks.    L.  L. 
Lewshin. 

2.  Poisoning  by  Cream- Tarts  in  Charkow.   P.  N.  Lashenkow. 

3.  On  the  Questi  jn  of  Determining  the  Oxidizability  of  Water 

by  Means  of  Permanganate  of  Potash.    A.  Ph.  Drshe- 

WETSKY. 

4.  On  Writer's  Cramps.    I.  W.  Zabludowsky. 

1. — Considered  editorially. 

2. — AViil  be  abstracted  when  completed. 

3. — Will  be  abstracted  when  completed. 

4. — Zibludowsky  devotes  an  exhaustive  paper  to  the  sub- 
ject of  the  etiology  and  treatment  of  writer's  cramp.  He 
deprecates  the  indiscriminate  use  of  the  term,  irrespective  of 
the  cause  or  extent  of  the  abnormality  present.  Many  of  the 
so-called  cures  may  be  ascribed  to  the  laxity  of  nomenclature. 
He  divides  the  affection  into  the  following  forms  :  1.  Ascend- 
ing form,  due  to  diseased  conditions  of  the  muscles  and  nerves 
of  the  upper  extremity.  Under  this  heading  he  considers 
(a)  Paralytic  manifestations,  such  as  partial  or  complete 
paralysis ;  (6)  inflammatory  conditions,  such  as  neuritis, 
neuralgia,  and  myositis  ;  (c)  tremor;  and  (rf)  spasms.  2  De- 
scending form,  brought  about  by  diseases  of  the  central 
nervous  system,  such  as  apoplexy,  tabes,  unilateral  degener- 
ations of  the  spinal  cord.  3.  Disturbances  of  the  central 
nervous  system  produced  by  such  conditions  as  hysteria, 
neurasthenia.  Graves'  disease,  senile  degenerations,  and 
cardiac  diseases.  4.  Mixed  forms.  In  making  a  diagnosis, 
the  patient  should  be  subjected  to  a  careful  physical  exami- 
nation to  ascertain  the  cause.  He  is  then  told  to  write  in  the 
presence  of  the  physician,  as  well  as  bring  several  specimens 
of  his  writing  done  at  home  under  more  favorable  circum- 
stances. Tne  treatment  and  prognosis  vary,  of  course,  with 
the  form  of  the  affection.  Generally,  however,  it  resolves 
itself  into  writing  exercises,  massage,  Swedish  movements, 
and  in  the  correction  of  any  faulty  habits  of  writing,  such  as 
improper  position,  manner  of  holding  the  pen,  etc.  In  the 
graver  forms  the  use  of  mechanical  appliances  intended  to 
relieve  the  strain  on  the  digital  muscles  or  do  away  altogether 
with  the  use  of  the  fingers  is  to  be  recommended.  The 
employment  of  the  types^•riter  is  advisable,  especially  since  it 
affords  a  gentle  exercise  to  the  fingers.  As  a  prophylaxis, 
the  author  lays  stress  on  the  proper  position  to  be  assumed 
while  writing,  and  other  details  pertaining  to  calligraphic 
hygiene,     [a.r.] 


568 


The  PHirADELPHiA"! 
.Mbdical  Jooesal  J 


THE  TOXICOLOGY  OF  TELLURIUM  COMPOUNDS 


[Mabch  23,  1901 


(Driginal  Tivticks. 


THE  TOXICOLOGY  OF  TELLURIUM  COMPOUNDS,  WITH 
SOME  NOTES  ON  THE  THERAPEUTIC  VALUE  OF 
TELLURATES. 

By  WILLIAM  J.  GIES,  M.S.,  Ph.D., 

of  New  York. 

Instructor  of  Physiological  Chemistry,  Columbia  Uuiversity. 

A.  Action  on  Plants  and  Microorganisms. — The  earliest 
as  well  as  most  important  researches  on  the  biological 
influence  of  tellurium  compounds  were  conducted  on 
domestic  animals  and  on  man.  It  was  not  until  1885 
that  the  results  of  a  study  of  their  action  on  plants  was 
announced.  Knop,  in  that  year,  after  an  investigation 
of  the  influence  of  various  substances  on  growing  plants 
(maize)  by  the  water-culture  method,  reported  that 
telluric  acid'  to  the  amount  of  0.05  to  0.1  gm.  per  litre 
of  nutrient  fluid,  (0.005-0.01%),  exerted  no  observable 
influence  on  their  development,  although  analysis  of 
the  plants  showed  that  tellurium  had  been  absorbed. 

Bokorny,  a  few  years  later,  working  with  tellurous 
oxide  and  potassium  tellurite,  found  that  aqueous  solu- 
tions containing  only  a  trace  of  the  very  insoluble  oxide 
had  no  eS'ect  whatever  on  algae  and  infusoria,  even  after 
5  days'  treatment,  and  that  0.02  %  solutions  of  pota.ssium 
tellurite  (containing,  also,  0.1%  of  dipotassium  phos- 
phate) were  likewise  without  toxic  influence,  although 
the  algae  had  been  kept  in  the  fluid  for  a  week.  Under 
the  microscope  the  cells  were  seen  to  be  perfectly  nor- 
mal in  all  outward  aspects.  Even  with  a  0  1%  solution 
of  potassium  tellurite  (containing  a  trace  of  potassium 
hydroxide),  only  one  form  of  spirogyra  seemed  to  be 
affected.  All  of  the  rest  vegetated  normally,  even  at  the 
end  of  a  week  of  treatment.  Continuing  his  experi- 
ments, Bokorny,  in  the  following  year,  reported  that 
when  various  algae,  such  as  Spirogyra  communis,  S. 
nitida,  conferveae,  diatomaceae,  etc.,  and  also  infusoria, 
were  placed  in  0.1%  solution  of  telluric  acid  and  kept 
there  in  diffused  light  for  some  time,  little,  if  any,  in- 
fluence was  exerted.  At  the  end  of  48  hours  the  Algae 
remained  perfectly  normal,  and  the  infusoria  swam 
about  in  very  lively  fashion.  Even  after  14  days  some 
of  the  algae  were  still  growing,  in  spite  of  the  fact  that 
the  faintly  acid  solution  contained  no  mineral  or  other 
nutrient  material.  Potassium  tellurate  (slightly  alka- 
line in  reaction),  in  like  quantity,  was  just  as  in- 
nocuous.^ 

Scheurlen,  very  recently,  wishing  to  grow  bacillus  an- 
thracis  in  pure  cultures,  and  in  the  absence  of  atmos- 
pheric oxygen,  sought  a  medium  which,  containing 
loosely  bound  oxygen  in  oxyhemoglobin-like  combina- 


•Tellurium  was  discovered  in  1782  by  MBllerTon  Reicbcnstein,  and  identified 
and  named  (from  leUus,  the  earth)  by  Klaprotb  in  1798.  The  uietal  is  silrer- 
white,  of  markedly  crystalline  structure,  with  strong  metallic  lustre.  Its  atomic 
weight  is  still  uncertain,  but  closely  appro.ximates  1J8.  Tellurium  is  very  nearly 
related  chenaically  to  sulphur  and  sfleiiium.  Its  chemical  qualities  liave  made 
it  a  dithcult  problem  from  the  time  of  its  discovery,  and  at  first  it  was  called  aitrinn 
pnradoxum  and  melallum  problfmu/icutn.  It  is  one  of  the  rarer  elements  and 
occurs  in  nature  mostly  as  tclluride  in  combination  with  hisnuith,  lead,  mercury, 
silver,  and  goid.  The  followinL*  formulae  show  the  composition  and  relation- 
ahips  of  the  tellurium  compounds  referred  to  in  this  paper : 

Tellurous  oxide TeOa. 

Telluric  oxide TeO,. 

Tellurous  acid HjTeOj. 

Tell  iric  acid H^TeO,. 

:^odium  teluirite      Na^TeOa. 

Sodium  tellurate NaaTeO^. 

Hydrogen  telluride li^Te. 

Methvl  telluride (CH,)jTe. 

Ethyi  tt-iluride (CjHj),Te. 

Tellurium  tartrate  ...  Te  (C^HjOcl,. 

>  {'"urther  reference  to  edect-s  on  lower  animals  is  made  farther  on  in  the  re- 
views of  Hofmeister's  and  Czapek  and  Weil's  work. 


tion,  would  be  almost  as  favorable  to  their  growth  as 
blood  itself.  Having  previously  found  that  selenious 
acid  on  warming  with  organic  substances  is  reduced 
and  red  selenium  deposited,  he  experimented  with  so- 
dium selenite  and  also  with  sodium  tellurite,  which  on 
similar  treatment  yields  grayish  black  metallic  tellu- 
rium. He  found  that  not  only  B.  anthracia  but  also 
all  of  the  growing  bacteria  he  worked  with  were  col- 
ored by  retluced  metal  in  the  presence  of  sodium  salts 
of  these  acids.  The  bacteria  themselves  were  colored, 
not  the  nutrient  medium.  Thej'  were  grown  on  10  cc. 
of  a  meat  infusion  peptone  agar  with  1  to  3  loopfuls 
of  a  2%  solution  of  the  salts. 

These  results  led  directly  to  the  detailed  work  con- 
ducted by  Klett,  who  studied  the  growth  of  numerous 
species  of  bacteria  and  some  moulds  under  the  influ- 
ence of  selenium  and  tellurium  compounds,  and  found 
that  the  development  of  various  forms,  such  as  slnphyl- 
ococcm  pyogenes  aureus  and  B.  meseatericus  vulgatus,  as 
well  as  the  various  moulds,  was  not  materially  hin- 
dered by  slight  quantities  of  sodium  tellurite,  although 
several  others,  such  as  B.  fluoresceas  liquefaciens,  were 
strongly  retarded  in  growth  by  only  traces  of  the  tellu- 
rite, which  seems  to  be  more  inhibitory  than  the 
selenite.  Yet  a  few,  such  as  the  bacillus  of  malignant 
edema  and  of  symptomatic  anthrax,  wnich  are 
markedly  arrested  in  growth  by  selenite,  not  only  re- 
duce tellurite,  but  appear  to  continue  their  develop- 
ment in  the  presence  of  a  larger  proportion  of  the  latter 
salt.  Most  of  the  experiments  were  made  on  10  to  12 
cc.  of  nutrient  medium  (gelatin,  agar-agar),  containing 
1  to  3  loopfuls  of  2%  solution  of  the  tellurite.  Increasing 
amounts  of  tellurite  wrought  more  destructive  effects, 
of  course.  The  colonies  in  all  cases,  as  in  Scheurlen's 
experiments,  were  colored  grayish  black  by  metallic 
tellurium,  the  intensity  of  the  coloration  having  been 
proportional  to  growth.  Grayish  particles  were  de- 
posited within  the  bacteria.  Since  the  colonies  only 
were  pigmented  by  the  metal  and  the  surrounding  me- 
dium was  left  entirely  colorless.  Klett  concluded  that 
the  reduction  took  place  in  the  protoplasm  of  the 
bacterial  cell  and  not  outside  the  cell  by  secondary  ac- 
tion of  metabolic  products.  For  this  reason,  then,  he 
considers  tellurites,  with  selenites,  the  most  satisfactory 
reagents  for  detecting  and  determining  accurately  re- 
ducing action  on  the  part  of  bacteria.  It  was  observed, 
further,  that  the  oxygen  set  free  from  tellurite  during 
the  reduction  could  not  be  utilized  by  aerobic  bacteria 
in  anaerobic  environment,  nor  was  the  presence  of 
tellurite  favorable  to  the  growth  of  anaerobic  forms. 
Klett  found,  also,  that  tellurite,  in  the  quantities  used, 
did  not  decrease  the  virulence  of  such  forms  as  B. 
anthracis.  Sodium  tellurite  was  the  only  tellurium 
compound  tried  in  this  connection.  Sodium  selenate 
in  slight  quantity  was  found  to  have  little  or  no  effect 
on  the  growth  of  bacteria  and  was  not  reduced.  Klett 
appears  to  have  concluded,  from  analogy,  that  tellurates, 
also,  would  not  be  reduced  by  them.' 

B.  Effect  on  Cold- Blooded  and  on  Domestic  Animals. — 
Chr.  Gmelin  appears  to  have  been  the  first  to  give 
special  attention  to  the  action  of  tellurium  compounds 
in  the  animal  body.  Early  in  the  last  century  he 
experimented  with  tellurous  acid  on  a  dog  and  a  rabbit. 
The  former  he  gave  3  grains  (0.2  gram)  in  a  single 
dose;  the  latter,  14  grains  (0.9  gram)  in  the  course  of 
three  days.     The  dog  lost  its  sprightliness  at  first  and 

'The  author  is  greatly  indebted  to  Dr.  P.  H.  Hiss  for  the  refrrenc«s  to  tlM 
work  of  Scheurlen  and  Klett,  and  for  suggestions  in  conneciioD  with  this  rtview 
of  their  results. 


March  23,  IJOl] 


THE  TOXICOLOGY  OF  TELLURIUM  COMPOUNDS 


CrHB  PHII.ASSLPBIA 
Medical  Jocsnal 


567 


also  its  appetite,  but  in  a  few  days  recovered  both. 
The  rabbit's  appetite  remained  normal  throughout  the 
experiment,  but  on  the  fourth  da}'  it  died.  On  post- 
mortem examination  of  the  poisoned  animals  Gmelin 
noted  that  a  peculiar  garlicky  odor  proceeded  from  the 
abdominal  cavity  ;  that  the  mucous  membrane  of  the 
stomach  and  intestines  was  much  swollen  and  covered 
with  a  thick  layer  of  tough  mucus ;  and  that  from  the 
j)ylorus  to  the  rectum  the  walls  of  the  intestines  were 
very  black.  The  liver  was  covered  with  minute  red 
spots,  the  blood-serum  colored  violet,  the  gallbladder 
widely  distended  and  the  heart  full  of  coagulum. 

A  more  extended  series  of  experiments  was  next 
carried  out  by  Hansen,  who,  working  in  Wohler's  labor- 
atory, found  that  0.3  gm.  of  potassium  tellurite, 
introduced  directly  into  the  stomach  of  a  medium-sized 
dog,  was  followed  almost  immediately  by  an  unpleas- 
ant, garlicky  odor  in  the  breath,  similar  to  that  which 
Gmelin  had  noted  on  opening  the  bodies  of  the  pois- 
oned animals  and  which  Wohler  and  his  pupils  had 
attributed  to  ethyl  telluride.  Twenty  minutes  after 
dosage  repeated  vomiting  ensued.  The  symptoms 
noted  by  Gmelin  (languor  and  loss  of  appetite)  were 
also  observed  and  recovery  was  not  long  delayed.  The 
same  dose  twice  on  the  following  days,  morning  and 
afternoon,  induced  identical  results,  while  the  odor  in 
the  breath  became  stronger  each  day  and  persisted  long 
after  the  conclusion  of  the  experiment.  The  vomit 
and  feces  were  slimy  and  black  with  tellurium  granules. 

In  a  second  experiment  on  a  dog  of  average  size,  0.5 
gm.  of  tellurous  a.cid  per  o.son  two  succeeding  days  caused 
no  toxic  symptoms,  although  the  odor  of  the  breath 
became  more  and  more  marked,  and  the  feces  were 
blackened  by  metallic  tellurium.  On  the  third  day, 
0.7  gm.  of  acid  potassium  tellurite  induced  vomiting  of 
grayish-black  slimy,  material  in  addition  to  the  previous 
results,  and  the  odor  of  the  breath  rapidly  grew  stronger. 
On  the  fourth  day  another  dose  of  0.7  gm.  of  the  tellurite 
caused  vomiting,  and  considerable  thick  mucus  ran 
from  the  mouth.  On  the  seventh  day  0.5  gm.  of  the 
same  potassium  salt,  in  solution,  was  injected  into  the 
jugular  vein.  Convulsions  resulted  at  once  and  death 
followed  in  four  minutes.  The  body  cavity  gave  off 
the  characteristic  odor  and  the  alimentary  tract  as  well 
as  the  kidneys  and  all  other  glands,  except  the  spleen 
and  parotids,  were  colored  bluish-black.  The  liver  was 
not  covered  with  the  inflammatory  spots,  nor  was  the 
blood-serum  colored  violet,  as  Gmelin  had  previously 
found.  The  lungs,  brain  and  spinal  cord  retained 
their  normal  appearance.  The  pigmentation  of  the 
glands,  etc.,  was  caused  by  deposition  of  microscopic 
granules  which  were  shown  to  consist  of  tellurium. 
The  peritoneal  cavity  contained  a  small  quantity  of 
serous  fluid,  but  neither  hyperemia  nor  inflammation 
was  observed.  The  wall  of  the  urinary  bladder  was 
bluish  in  color  and  the  urine,  acid  in  reaction,  con- 
tained the  odoriferous  compound.  The  right  side  of 
the  heart  and  the  vena  cavae  were  swollen  with  blood. 
In  the  crystalline  lens  of  each  eye,  as  reported  by 
Hansen's  friend.  Dr.  Schrader,  there  was  a  depbsit  of 
chalky  granules  of  varying  size.  They  were  least  in 
quantity  in  the  center.  The  cataract  was  greatest  in  the 
left  eye.  The  humours  of  the  eye  gave  off  the  odor  of 
garlic.  Tellurium  was  separated  from  the  urine,  liver, 
stomach  and  intestines.  Two  additional  experiments 
on  dogs  gave  results  that  were  identical  with  the  above 
in  practically  all  particulars.  The  blood-serum  was 
normal  in  color  in  each  case. 


Hansen  concluded  his  paper  with  the  opinion  that 
the  pigmentation  of  the  contents  of  the  gastrointestinal 
tract  was  due  to  deposition  of  tellurium  by  a  process 
of  reduction  and  that  direct  absorption  of  the  metal 
through  the  intestinal  wall  was  indicated  by  the  bluish- 
black  color  of  the  mucous  membrane.  He  suggested, 
further,  that  the  violet  color  of  the  blood-serum,  noted 
by  Gmelin,  was  due  to  the  presence  of  absorbed  metal 
in  suspension,  and  that  it  was  not  observed  in  his 
own  experiments  because  there  had  been  time  in 
each   for  the  tellurium   to  be   deposited  in  the  tissues. 

Kletzinsky,*  also,  in  experiments  on  animals  noted 
that  administered  tellurium  was  eliminated,  in  part,  in 
the  urine.  Rabuteau,  15  years  after  Hansen's  results  had 
been  recorded,  found  tellurium  to  be  exceedingly 
poisonous  and  considered  it  very  similar  in  its  action 
to  selenium,  although  stronger.  This  deduction  was 
based  on  the  results  of  only  one  experiment,  however, 
with  sodium  tellurite.  Following  an  intravenous  injec- 
tion of  0.08  gram  of  that  substance  in  a  dog,  vomiting 
ensued  within  2  hours,  after  which  profound  dyspnea 
set  in,  with  anesthesia,  opisthotonus,  and  finally  death 
from  asphyxia  in  4  hours.  Postmortem  examination 
12  hours  after  death  showed  marked  congestion  and 
ecchymosis  of  the  whole  of  the  intestinal  canal ;  also  of 
the  liver,  spleen,  lungs  and  especially  the  kidneys. 
The  latter  were  almost  black  as  a  consequence  and  the 
tubuli  were  studded  with  fat  globules.  In  the  heart 
the  right  side  was  filled  with  blood,  the  left  side  on  the 
contrary  was  empty. 

The  contents  of  the  right  side  of  the  heart,  and  also 
of  the  larger  bloodvessels,  held  a  multitude  of  small 
prismatic  crystals  of  unknown  chemical  composition — 
0.002  to  0.004  mm.  in  width  and  from  5  to  10  times  as 
long — which,  in  the  opinion  of  Rabuteau,  presented  a 
mechanical  obstacle  to  the  movement  of  the  blood  and 
thus  eventually  caused  the  death  of  the  animal_  in 
asphyxia.  These  crystals  were  apparently  identical 
with  those  Rabuteau  reported  he  had  found  under  simi- 
lar conditions  after  intravenous  injections  of  sodium 
selenite  and  administrations  of  the  same  per  (w.  They 
were  not  produced,  he  says,  by  selenates— only  by 
selenites  and  tellurites.  Rabuteau  states,  further,  that 
they  were  more  numerous  than  the  corpuscles.  He  says 
nothing  about  their  color,  but  his  sketch  of  them  suggests 
that  they  may  have  been  hemoglobin  or  some  deriva- 
tive of  it.    Radziejewski^  seems  to  entertain  this  opinion. 

It  should  be  remarked,  in  passing,  that  Chabrie  and 
Lapicque"  were  unable  to  find  these  crystals  in  the  blood 
of  animals  poisoned  with  sodium  selenite  and,  also,  that 
Czapek  and  Weil,  whose  work  with  tellurium  is  sum- 
marized farther  on,  obtained  the  same  negative  result, 
both  with  selenites  and  tellurites,  after  intravenous  in- 
jections. Rabuteau's  observations  in  this  connection 
have  never  been  confirmed.  Consequently,  his  theory 
that  death  after  injection  of  tellurites  results  from  a 
"mechanical  poisoning,"  which  produces  asphyxia, 
cannot  be  accepted.  Rabuteau  makes  no  reference 
whatever  to  the  work  of  Hansen,  or  any  of  his  prede- 
cessors, and  says  nothing  definite  about  odor  in  the 
expired  air  of  the  dog  to  which  he  had  given  tellurite.' 

*  Klftzinsky:  Ueher  die  Ausacheidung  der  Metalle  in  den  Stcreten,  Wiener 

med.  Ifoc/ieiiscAr.,  1858.  viii,  355.  ^„ 

=  Halz.iej  wski :  In  abstractor  Rabuteau's  paper,  Cent.  f.  a.  men.  Mi-ss.,  ibov, 

^"'cha'briiT-  et  Lipicque:     Sur  I'action    physiologique   de  I'acide  sC-I6nieux, 
Cbmi.Menrf  ,  1890.  ex,  152.  ,  .,    ■    .      i      .„.^„ 

I  Tlie  odor  ciuscd  bv  selenates  Rabuteau  mistalienly  ascribed  to  lij-drogen 
selenide  instead  of  uieth"yl  selenide.  Ilofmcister,  whose  expenuienis  are  referred 
to  on  a  subsequent  pane,  assumes  tliat  the  usualodor  was  recogniz.-d  bv  Kabule.iu, 
and  from  analogy  apparently,  that  It  was  referred  in  error  to  hydrogen  te.lurlde 


568 


The  Philadelphia 

Medical  Journal 


]         THE  TOXICOLOGY  OF  TELLURIUM  COMPOUNDS 


[Mabch  23,  1900 


Czapek  and  Weil,  in  perhaps  a  more  thorough 
research  than  any  of  the  preceding,  learned  that,  in  its 
toxicological  influence,  tellurium  behaves  very  much  as 
does  its  close  chemical  relative,  selenium,  although  the 
symptoms  it  induces  appear  later  and  are,  for  the  most 
part,  weaker — ^just  the  reverse,  in  the  latter  respect,  of 
Rabuteau's  deduction.  Sodium  tellurite,  in  quantities 
of  0.002  gm.,  under  the  skin,  caused  the  death  of  frogs 
within  48  hours ;  0.01  gm.  of  sodium  tellurate  was 
required  to  produce  the  same  result.  In  cold-blooded 
animals  these  quantities  of  tellurium  gradually  brought 
about  paralysis  of  the  central  nervous  system  and  death. 
The  heart  was  arrested  in  diastole,  apparently  because 
of  paralysis  of  the  so-called  excito-motor  ganglia. 
Atropin  did  not  restore  the  beats,  and  the  heart-tissue 
itself  remained  susceptible  to  mechanical  and  electrical 
stimulation.  The  garlic  odor  was  detected  about  the 
animal  in  most  of  these  cases.  Muscular  fibrillations 
were  almost  always  observed  in  frogs  into  which  tel- 
lurium had  been  injected,  but  neither  clonic  nor  tetanic 
convulsions  followed  its  introduction  in  the  quantities 
employed. 

In  warm-blooded  animals  these  same  observers  found 
that  0.02  gm.  of  sodium  tellurite,  and  0.0-5  gm.  of 
sodium  tellurate,  per  kilo  of  body- weight,  gave  very 
toxic  eflFects.'  Dogs  very  soon  became  restless.  Vomit- 
ing quickly  ensued,  followed  by  diarrhea,  weakening 
of  the  reflexes,  somnolence,  unconsciousness,  general 
paralysis,  stoppage  of  respiration,  and  death  after  con- 
vulsions. Within  five  minutes  of  the  time  of  adminis- 
tration of  the  poison,  the  garlic  odor  in  the  expired  air 
was  intense.  There  was  no  muscular  fibrillation  as  in 
the  case  of  frogs,  and,  with  the  exception  of  the  spasm 
just  before  death,  no  clonic  or  tetanic  convulsions.  In 
all  cases  a  lowering  of  blood-pressure  followed  the  in- 
jection of  tellurium  salts.  This  was  due,  not  to  central 
influences,  but  to  direct  peripheral  action  on  the  blood- 
vessels, resulting  in  impaired  tonic  contraction,  for  the 
vasomotor  center  remained  sensitive  to  stimulation  and 
the  vagi  were  able  to  carry  impulses.  The  abdominal 
capillaries,  particularly,  were  very  greatly  distended. 

The  blood  from  animals  poisoned  with  tellurium  was 
dark-colored  and  had  a  distinct  garlic  odor.  Spectro- 
scopically  it  was  normal  and  the  corpuscles  showed  no 
change.  Czapek  and  Weil  could  not  confirm  Rabuteau's 
observation  in  this  connection.  Postmortem  exami- 
nation showed  profound  changes  in  the  intestinal 
mucous  membrane,  in  which  edema,  congestion,  and 
extravasations  were  especially  prominent.  Desqua- 
mation of  the  villi  was  also  observed  in  most  cases. 
Destructive  changes  were  the  rule  in  the  tubules  of 
the  kidneys.  The  urine  was  bloody  now  and  then, 
and  frequently  tellurium  could  be  detected  in  it. 
Nearly  all  of  the  body  parts,  in  the  cold  as  well  as 
warm-blooded  animals  experimented  on,  were  colored 
grayish  by  metallic  tellurium,  but  no  deposit  of  the 
metal  in  granules  was  observed,  on  microscopic  exam- 
ination, in  any  of  the  tissues.  It  seemed  to  be  in  solu- 
tion. The  muscles  of  the  poisoned  animals  retained 
their  susceptibility  to  stimulation. 

Tellurium  was  found  to  diSer  from  selenium,  in  toxi- 
city, mainly  quantitatively .°  Czatiek  and  Weil  concluded 
that  the  difference  between  the  two  lies  in  the  different 
modes  of  elimination.  Tellurium  salts  are  less  toxic,  they 
think,  because  the  tellurium  is  quickly  transformed  by 

'  We  are  left  to  infer  the  manner  of  introiinclinn  of  telliirimu  lu  these  expori- 
me-its.     It  seems  to  have  lieen  both  by  way  ot  the  muiith  and  under  the  skin. 

"  Al8D  In  having  anidrotio  action. '  See'fojtnote  further  ou,  wliere  additional 
res-tlts  of  Czapek  and  Weil's  work  are  given. 


reduction  to  the  metallic  state  and  so  is  rendered 
comparatively  passive  at  once.  The  results  of  their 
experiments  indicate  that  in  its  toxic  action  tellurium 
behaves  much  as  do  selenium,  arsenic  and  antimony."' 

Although  the  garlic  odor  in  the  breath  and  about  the 
organs  of  animals  to  which  tellurium  salts  had  been 
administered  was  thought  at  first  to  be  due  to  ethyl 
telluride,  its  resemblance  to  methyl  telluride,  when 
that  substance  was  first  made,  satisfied  Wohler  and  his 
pupils  that  it  resulted  from  a  formation  of  that  organic 
compound.  This  conclusion  was  generally  accepted  for 
some  time.  Hofmeister,  in  some  very  exact  experi- 
ments, finally  determined  in  a  chemical  way  that  the 
methyl  synthesis,  assumed  by  previous  investigators, 
really  does  take  place  when  tellurium  is  administered 
and  that  the  garlic  odor  arising  as  a  consequence  is 
caused  by  methyl  telluride." 

In  experiments  on  warm  and  cold-blooded  animals 
he  confirmed  the  observations  of  previous  workers  that 
the  various  body  parts  take  on  the  same  odor,  and 
showed  that  it  is  strongesst,  or  in  other  words  the 
methyl  synthesis  is  relatively  greatest,  in  the  testes  and 
the  lungs,  and  pronounced  in  the  blood,  liver  and 
kidneys.  He  found  that  when  the  organs  of  an  animal 
into  which  sodium  tellurite  had  been  injected  intraven- 
ously, are  put  in  a  warm  place  (at  36°  C.),  the  smell  of 
methyl  telluride  is  intensified  about  those  having  that 
odor  to  begin  with  and  is  gradually  made  distinct  in 
others.  Under  the  same  conditions,  blood  loses  it, 
however.  Time  and  intensity  vary,  of  course.  These 
facts  show  that  the  cells  of  the  glands  are  able  to 
absorb  tellurium  and  that  they  also  have  the  power,  at 
the  body  temperature,  of  forming  methyl  telluride  from 
it.  This  substance  is  formed  also  by  minced  fresh 
organs  from  dogs  and  rabbits  when  they  are  treated 
with  the  same  substance  at  the  body  temperature. 
Hofmeister  proved  that  this  synthesis,  with  production 
of  the  characteristic  odor,  takes  place,  also,  in  frogs, 
fishes,  crabs,  and  even  in  earthworms,  when  small 
quantities  of  tellurite  are  given  them."  The  tellurium 
was  deposited  in  the  animals  experimented  on  in  large 
part  in  metallic  form  in  many  parts  of  the  body,  the 
reduction,  judging  from  the  discoloration,  varying  con- 
siderably. 

In  the  body  of  a  dog  weighing  850  gms.,  into  which 
0.04  gm.  of  sodium  tellurite  had  been  injected  intra- 
venously, and  which  after  bleeding  to  death  had  been 
kept  at  normal  temperature  for  four  hours,  practically 
all  parts  were  pigmented  by  tellurium  except  cartilage, 
bone  and  the  white  matter  of  the  nervous  system. 
When  dosage  was  not  too  great,  however,  it  was  found 
that  in  the  lungs  and  testes  the  tellurium,  instead  of 
having  been  deposited  was  transformed  wholly  into 
methyl  telluride,  which  accounts  for  the  fact  that  these 
organs  are  rarely  colored  by  the  bluish-black  metallic 
deposits  usually  found  in  practically  all  of  the  glands. 
The  long-continued  elimination  of  methyl  telluride  in 
the  breath,  Hofmeister  shows,  is  due  to  gradual  syn- 

•^  It  is  Interesting  to  note,  in  this  connection,  that  telluriutn  is  believed  by 
sotne  cheniisis  to  be  in  reality  a  mixture  of  elements,  containing  an  aniimooj 
arsenic-like  bkniy.  Brauner  calls  one  of  the  presumed  constituenu  of  the  tellu- 
rium complex,  austriacum,  which  appears  to  be  the  dxcitfilurium  predicted  bj 
Mendelcetr. 

"  Solium  tellurate,  0.05—0,05  gram,  was  injected  subcutaneously  into  dogs 
and  cats.  .\s  soon  as  the  garlic  odor  became  evj.Ient  in  the  ex:i'r-d  air.  the 
latter  was  passed  through  saturated  sohitioa  of  iodine  in  pjta^ssium  iodide  for  20 
to  48  hours.  The  solution  decomposed  the  methyl  telluride,  but  retained  each 
group  and  from  it  methyl  was  sep-irated  in  the  lofui  of  methyl  sulphide  by  treat- 
tue'ii  with  sodtum  sulphide.  Tellurium  af:er  evaporation  of  the  s.ilution  and 
treatment  with  nitric  and  hydrochloric  acids,  was  precipitated  in  metallic  flak«s 
with  sodiutn  sulphite, 

1=  t)f  the  other  iniluences  of  telluriura  sails  on  these  animals.  Hofraeiater  says 
nothingox?ept  that  injection  of  sodium  tellurite  into  the  soft  parts  of  crabs  is 
followi-d  by  paralysis  and  death. 


Mabch  28,  1901] 


THE  TOXICOLOGY  OF  TELLURIUM  COMPOUNDS 


TThe  Philadelphia 
L  Medical  Jodbnal 


569 


thetic  transformation  of  the  tellurium  which  had  been 
deposited  in  the  tissues  in  metallic  form  soon  after  its 
introduction.  He  suggests  that  the  reduced  tellurium 
is  slowly  transformed  into  the  soluble  sodium  tellurate 
by  the  action  of  the  alkaline  tissue  fluids  before  it 
reaches  the  lungs,  and  that  it  is  there  changed  to  the 
methyl  compound.  In  this  way  he  explains  the  persis- 
tence of  the  odor  in  the  breath. 

Hofmeister  was  unable  to  determine  the  specific 
source  of  the  methyl  for  this  synthesis,  but,  as  the 
liberation  of  methyl  groups,  and  also  their  incorpora- 
tion in  other  substances  like  cholin  and  creatin,  seem 
to  be  intermediate  processes  in  general  metabolism, 
he  concluded,  from  his  experiments,  that  the  tellurium 
unites  with  methyl  groups  set  free  in  some  manner  in 
the  cells.  He  showed  that  this  conversion  of  tellurium 
to  methyl  telluride,  and  the  process  of  reduction  of 
tellurium  compounds,  may  take  place  quite  inde- 
pendently of  each  other,  for  when  fresh  normal  glands 
after  maceration  are  warmed  a  few  minutes,  at  50  to 
55°  C,  and  then  treated  with  sodium  tellurite,  their 
power  to  reduce  is  undiminished,  although  no  methyl 
telluride  is  formed  by  them.  The  synthetic  process  is 
entirely  prevented,  also,  after  treatment  of  the  tissues 
with  solutions  of  various  chemicals — -even  physiolog- 
ical salt  solution. 

Beyer,  following  the  general  suggestions  of  Ludwig, 
demonstrated,  in  some  transfusion  experiments  on  per- 
fectly fresh  kidneys  with  oxygen  free  and  arterial 
blood  containing  sodium  tellurate,  that  the  methyl 
synthesis  does  not  take  place  in  the  absence  of  oxygen, 
although  reduction  to  the  metallic  state  occurs  in  the 
cells  quite  independently  of  the  character  of  the  trans- 
fused blood.  He  sought  also,  by  histological  methods, 
to  determine  just  where  in  the  tissues  the  reduction  of 
tellurium  from  its  salts  occurs.  He  injected  small 
quantities  of  sodium  tellurate,  dissolved  in  physiolog- 
ical salt  solution,  into  the  jugular  veins  of  dogs  and 
rabbits,  and  found  that  granular  metallic  tellurium 
was  deposited  only  in  form  elements  ;  in  nerve  and 
glandular  cells,  leukocytes  and  striated  muscle  espe- 
cially. Endothelium,  unstriated  muscle,  nerve  and  con- 
nective tissue  fibers,  on  the  other  hand,  were  found  to 
have  no  affinity  for  tellurium.  The  deposit  of  metallic 
element  in  the  cells  did  not  appear  to  cause  their 
degeneration.  Destruction  occurred  only  occasionally. 
The  cells,  for  the  most  part,  seemed  to  have  the  power 
of  gradually  removing  the  foreign  material  without  loss 
of  normal  function,  and  even  when  quite  full  of  the 
deposit  behaved  toward  all  the  various  staining  re- 
agents exactly  as  normal  cells  do.  Even  three  weeks 
after  injection  of  tellurate,  while  the  breath  still  smelled 
strongly  of  methyl  telluride,  Beyer  found  metallic 
tellurium  in  the  glandular  cells.  Its  transformation 
must,  therefore,  have  been  gradual,  as  Hofmeister  has 
shown  was  the  case  in  other  connections. 

Increasing  amounts  of  sodium  tellurate  injected  into 
the  blood  of  rabbits  induced  clonic  convulsions,  respir- 
atory paralysis  and  death.  The  blood  became  laky. 
Lakiness  was  not  produced  by  tellurate  in  rabbit's  blood 
outside  the  body,  which  fact  suggests  that  a  tellurium 
transformation  product  caused  it  in  Beyer's  experi- 
ments. Intravenous  injections,  in  dogs,  of  quantities  of 
sodium  tellurate  ranging  from  0.025  to  0.04  gm.  per  kilo 
of  body-weight  were  (juickly  followed  by  death  in  some 
cases  ;  at  other  times,  by  vomiting  and  loss  of  appetite, 
with  recovery  in  several  days.  These  quantities  also 
brought  about  general  paralysis  ;  sometimes  only  of  the 


hind  legs  and  masseters,  but  usually  also  of  the  inter- 
costals,  making  respiration  very  labored.  Fatty  degen- 
eration of  the  hepatic  cells  and  destructive  changes  in 
the  uriniferous  tubules  also  resulted.  The  lymphatic 
vessels  of  the  liver  were  found  to  be  much  enlarged 
and  other  structural  changes  were  observed.  In  one 
case  lymph  from  the  thoracic  duct  had  a  grayish  color, 
due  to  suspended  tellurium. 

The  urine  under  these  same  conditions  was  turbid, 
greenish  brown  to  a  dark  green  in  color,  and  gave  off 
the  odor  of  methyl  telluride.  It  contained  metallic 
tellurium,  crystals  of  urocanic  acid  and  triple  phos- 
phate ;  also,  blood-corpuscles,  albumin  and  bile  pig- 
ment. The  latter  appeared  in  the  blood-serum  also. 
From  the  urine  of  a  dog,  collected  during  the  first  24 
hours  after  intravenous  injection  of  0.75  gm.  of  sodium 
tellurate  (0.27  gm.  Te),  Beyer  separated  0.062  gm.  of 
metallic  tellurium.  From  the  urine  of  the  second  day, 
0.081  gm.  There  was  only  a  trace  in  that  of  the  third. 
None  in  the  fourth.  More  than  one-half  of  the  tellu- 
rium administered  was,  therefore,  eliminated  through 
the  kidneys. 

Until  recently,  a  brief  and  imperfect  experiment  by 
Beyer,  on  the  excretion  of  urea  after  intravenous  injec- 
tion of  sodium  tellurate,  had  been  the  only  one  to  sug- 
gest the  metabolic  influence  of  tellurium.  Beyer  found 
that  the  normal  amount  of  urea  eliminated  in  the  urine 
of  a  healthy  dog,  during  three  preliminary  days,  was 
9.45,  10.41  and  7.62%  respectively,  an  average  of  9.16%. 
After  injection  of  0.75  gm.  of  sodium  tellurate  into  the 
jugular  vein,  the  urea  in  the  urine  on  five  successive 
days  was  1.79,  6.06,  8.50,  7.98,  9.00%,  an  average  of 
6.67%.  This  marked  falling-ofF  in  the  amount  of  urea 
was  due  mainly  to  the  refusal  of  the  dog  to  eat  on  the 
first  and  second  days  of  the  tellurium  period,  and  as 
Beyer  does  not  give  any  analytic  data  regarding  the 
food,  it  is  impossible  to  attach  any  special  importance 
to  his  results  in  this  connection. 

The  author,  very  ably  assisted  by  Mr.  L.  D.  Mead, 
recently  completed  a  series  of  experiments  on  dogs  in 
which  an  attempt  was  made  to  ascertain,  among  other 
things,  the  effects  of  continued  dosage  of  tellurium 
compounds.  It  was  found  that  nontoxic  doses  of  tellu- 
rium (in  quantities  several  times  as  great  as  therapeutic 
doses  and  in  the  forms  of  oxide,  tellurite,  tartrate  and 
tellurate)  did  not  materially  affect  metabolism  in  dogs 
brought  to  a  state  of  nitrogenous  equilibrium,  even 
when  dosage  was  continued  for  a  week.  These  sub- 
stances appeared  to  stimulate  proteid  catabolism  only 
slightly.  They  mcreased  somewhat  the  weight  of  dry 
matter  in  the  feces  and  diminished,  in  small  degree,  the 
absorption  of  fat.  The  urine  was  unag'ected  in  volume, 
specific  gravity,  and  reaction,  but  became  dark  brown 
in  color  during  the  dosage  periods. 

Excesive  doses  retarded  gastric  digestion;  induced 
violent  vomiting,  loss  of  appetite  and  somnolence.  They 
caused,  besides,  inflammation  and  disintegration  of  the 
mucous  membrane  of  the  gastrointestinal  tract  and, 
also,  intestinal  hemorrhage.  Introduced  under  the 
skin,  tellurium  (tartrate)  caused  restlessness,  tremor, 
weakening  of  the  reflexes,  somnolence,  diarrhea,  paral- 
ysis, unconsciousness,  stoppage  of  respiration  and  death, 
in  convulsions  from  asphyxia.  At  the  point  of  injection 
much  of  the  tellurium  was  deposited  in  metallic  form, 
but  it  was  also  distributed  in  large  quantity  to  most  of 
the  organs  and  tissues. 

It  was  found,  also,  that  tellurium  compounds,  even 
in  small  proportion,  markedly  arrested  the  secretion  of 


570 


Thk  Philadelphia") 
Medical  Journal  J 


THE  TOXICOLOGY  OF  TELLURIUM  COMPOUNDS 


[Mabch  23,  1»«1 


acid  in  the  stomach — the  direct  cause,  probably,  of  the 
indigestion  brought  about,  not  only  in  dogs  but,  as 
will  be  pointed  out  later,  by  tellurium  compounds  in 
man,  also.  Intestinal  putrefaction  was  not  influenced 
in  any  degree.  The  action  of  trypsin  and  pepsin  out- 
side the  body  was  not  very  perceptibly  diminished  by 
quantities  of  tellurium  compounds  underO.6%.  Zymol- 
ysis  was  almost  unaffected  in  the  presence  of  as  much 
as  1.25%  of  some  of  the  salts.  Ptyalin  was  more  easily 
affected,  even  by  the  faintly  alkaline  tellurate.  Trypsin 
appeared  to  be  least  sensitive  to  destructive  influence, 
acting  rapidly  in  the  presence  of  even  2.5%  of  tellurite. 
Tellurium  was  eliminated  in  metallic  form  in  the 
feces;  as  methyl  telluride  in  the  breath,  urine,  feces, 
and  epidermal  secretions  ;  in  a  soluble  form,  in  small 
quantity,  in  the  urine  and  in  the  bile.  The  urine  was 
colored  brown  to  yellowish  green  after  heavy  dosage 
with  tellurium  compounds,  but  return  to  normal  colora- 
tion was  rapid  after  administration  had  been  discon- 
tinued. Albumin  and  bile  pigment,  besides  tellurium, 
were  the  abnormal  constituents  of  the  urine  found  after 
subcutaneous  injections.  Toxic  quantities  given  by  the 
mouth  caused  the  appearance  of  coagulable  proteid,  but 
no  bile  pigment,  in  the  urine. 

C.  Influence  on  Man.  (o)  GmeraL— Berzelius."  who 
led  the  way  for  so  long  in  chemical  studies  of  tellurium, 
f9und,  from  personal  experience,  that  hydrogen  tellu- 
ride is  irritant  in  its  action  and  more  poisonous  in  effect 
than  the  corresponding  compound  of  sulphur.  Ber- 
zelius  and  Kolreuter'*  have  reported  that  the  oxides  of 
tellurium,  as  well  as  a  number  of  salts  of  telluric  and 
tellurous  acids,  have  a  very  unpleasant  metallic  taste 
resembling  that  of  compounds  of  antimony  and  that 
some  have  a  nauseating  action  and  are  strongly  emetic. 

Wohler,  at  the  time  of  his  discovery  of  ethyl  tellu- 
ride,"^ referred  to  the  disagreeable  odor  of  that  substance, 
and  stated  that  it  is  very  poisonous.  At  that  time,  and 
subsequently,  while  engaged  in  his  chemical  researches 
on  ethyl  telluride,  Wohler  observed  that  his  sweat  and 
breath  took  on  an  odor  closely  resembling  that  of  the 
substance  he  was  working  with."^  One  night,  while 
perspiring  very  freely,  the  garlic  odor  in  his  sweat  be- 
came so  great  that  he  himself  could  hardlv  bear  it.  It 
persisted  in  his  breath  for  weeks.  These  facts  led 
^Y6hler  to  suggest  the  physiological  researches  made  in 
his  laboratory  by  his  pupil,  Hansen. 

The  latter  was  the  first  to  experiment  systematically 
on  man  with  tellurium  compounds.  For  7  successive 
days  he  himself  took  neutral  potassium  tellurite  an 
hour  before  dinner.  On  the  first  4  days  0.04  gm.,  on 
the  2  following  days  0.05  gm.,  and  on  the  last  day  O.OS 
gm. — a  total  of  0.34  gm.  During  the  first  two  days  very 
unusual  sleepiness  was  the  main  symptom.  Later  it 
disappeared.  At  the  beginning  there  was  increased 
appetite,  but  later  the  appetite  was  reduced.  After 
dosage  on  the  last  day  there  was  a  sense  of  oppression 
in  the  cardiac  region,  also  nausea  and  abundant  saliva- 
tion. The  tongue  was  heavily  coated  with  a  white 
deposit,  and  there  was  complete  loss  of  appetite.  The 
gastric  symptoms  did  not  disappear  completely  until 
after  a  lapse  of  2  weeks,  and  the  alliaceous  odor  of 
the  breath  continued  7  weeks. 

The  charaateristic  odor  of  the  breath  was  noticed 
within  a  few  minutes  after  the  first  dose  had  been  taken, 

"  rh.  Hiiseiuann  und  .^V.  Husemann  :  Handbuch  der  Toxikologie,  1S62  77S 
.,    H,*^!,""^''"'  '• '"''book  of  Chemistry  (Walt.-*),  is:i»,  iv,  »98,  SS9,  402   403 
A  so  /!)id.,  lS5t;,  X,  309,  and  Berzelius  :  Traitf  rte  Chimie,  1,<46,  ii,  225  230 
"Wohler:  Tolluraethyl,  .4jiji,  rf.  CVifm.  «,  /'/win,,     1S40  xxxv   11> 
"Gnup-Besauez:  Lehrlmch  der  phTsiol.  Chemie,  1878  65-'. 


and  soon  became  so  strong  and  so  oVjnoxions  to  others 
that  his  own  seclusion  was  necessary  for  their  comfort. 
At  that  time  the  odor  was  attributed  to  a  volatile  com- 
pound of  tellurium  identical  with  or  similar  to  ethyl- 
telluride.  Hansen  was  unable  to  separate  any  tellurium 
from  the  urine ;  not  even  from  that  passed  during  the 
first  24  hours  after  the  last  dosage.  Experiments  on 
his  friend,  von  Roder,  who  took  0.04  gm.  of  acid  potas- 
sium tellurite  before  dinner  one  day,  and  nearly  0  05 
gm.  at  the  same  time  the  next,  presented  assentially  the 
same  results.  Hansen  refers  to  Wohler's  previous 
experience  and  says  that  during  these  later  experi- 
ments in  the  latter's  laboratory  Wohler  observed  the 
same  phenomena,  with  regard  to  himself,  a  second  time. 
Heeren,"  also  working  under  Wohler's  direction,  on 
the  chemical  nature  of  various  compounds  of  ethyl 
and  methyl  tellurides,  noted  that  the  garlic  odor  of  the 
breath  was  especially  strong  in  his  own  experience 
when  methyl  telluride  or  any  of  its  derivatives  was 
under  examination.  He  states  that  even  when  these 
products  are  merely  touched  with  the  fingers  their 
characteristic  odor  is  carried  to  all  parts  of  the  body 
and  in  a  few  days  the  breath  also  acquires  it,  the  odor 
quickly  becoming  so  obnoxious  that,  as  he  puts  it,  "  one 
must  avoid  all  social  life  for  months,  so  as  not  to  annoy 
others." 

Sir  J.  Simpson  records  a  case"  in  which  a  student 
inadvertently  swallowed  a  dose  of  tellurium,  which  was 
followed  by  the  evolution  of  such  a  persistent  odor  that 
for  the  remainder  of  the  session  he  had  to  sit  apart 
from  his  fellow  students. 

Prof.  Victor  Lenher,  who  for  several  years  has  been 
engaged  in  chemical  studies  of  tellurium,  greatly  favored 
the  author  with  a  statement  of  his  toxicological  experi- 
ences for  use  in  this  connection.  After  inhalations  of 
the  volatile  tellurous  oxide,  which  he  formed  repeatedly 
in  preparing  metallic  tellurium  by  the  fusion  method, 
Prof.  Lenher's  breath  and  the  excretions  from  his  skin 
took  on  the  usual  garlic  odor.  Metallic  taste  was  noted 
and  nausea  also  frequently  experienced.  The  odor  of 
the  breath  in  one  case  persisted  for  about  a  year. 
General  depression  followed  continuous  inhalation  of 
the  oxide,  and  in  one  instance  a  prolonged  period  of 
somnolence  resulted,  an  experience  similar  to  Hansen's 
after  ingestion  of  tellurite.  Severe  constipation  was  also 
a  marked  symptom  following  tellurium  inhalation.  At 
no  time  could  Prof.  Lenher  detect  any  tellurium  in 
his  urine,  not  even  during  the  periods  of  his  worst 
experiences. 

The  author  has  found  in  his  own  experience  that 
when  the  methyl  telluride  which  had  been  exhaled  by 
the  dogs  he  experimented  with  was  taken  into  his  own 
lungs,  an  alliaceous  odor  of  the  breath  and  excretions 
from  the  skin  soon  became  noticeable  and  continued 
persistently.  Also,  that  such  inhalation  was  accom- 
panied frequently  by  short  periods  of  drowsiness  and 
nausea. 

(6)  The  cause  of  ^' bismuth  breath"  and  the  minimal 
quantiti/  of  tell uri urn  (hat  will  produce  it.  As  early  as  1875 
tellurium  had  been  suspected  in  commercial  prepara- 
tions of  bismuth."  The  evidence  on  this  point  at  that 
time  was  not  of  an  analytical  character,  but  was  based 
upon  the  observation  that  people  to  whom  certain  bis- 
muth preparations  had  been  administered  suffered  from 
fetid  breath.     The  presence  of  tellurium  in  bismuth 


>'  Hwren  :  Ueher  Tellurilhvl  uod  TellamiethTl-Verhindungen,  C*«i>.  (.>■- 
/ra;^;.,  isijl.  Ti.  916  (N.  F.) 
"  Qaottd  from  Blyih  :  Poi.sons.  their  Effects  and  Detection,  1SS5,  5S9. 
"  lily  th  :  A  Manual  of  Practical  Chemistry,  1879,  43S, 


March  23,  1901] 


THE  TOXICOLOGY  OF  TELLURIUM  COMPOUNDS 


CThe  Philadelphia 
Medical  Jocesal 


571 


preparations  has  since  been  repeatedly  shown,*  and 
their  medicinal  use  implies  frequent  incidental  action 
of  this  tellurium  impurity. 

Reisert.  in  1884.  after  an  investigation  of  the  cause  of 
the  so-called  bismuth  breath,  ascertained  that  it  was 
due,  as  had  been  supposed  by  some,  to  the  minute  tel- 
lurium impurities  often  found  in  the  commercial  bis- 
muth compounds  used  in  medicine,  and  not  to  arsenic 
or  bismuth  itself,  as  had  been  assumed  by  others."^  He 
not  only  demonstrated,  in  some  experiments  on  himself 
and  friends,  that  the  '"  bismuth  breath  "  did  not  follow 
dosage  with  chemically  pure  bismuth  sesquioxide,  or 
arsenious  oxide,  but  also  determined  the  minimal 
amount  of  tellurium  which  would  produce  the  alli- 
aceous odor  in  the  breath.  He  found  that  as  little  as 
0.000,000,5  gm.  of  tellurous  oxide,  given  in  solution  to 
men,  was  followed  by  the  smell  of  garlic  in  75  minutes, 
and  that  it  continued  for  about  30  hours ;  0.000,000,3 
gm.,  given  to  three  different  individuals,  failed  to  pro- 
duce a  detectable  quantity  of  the  odor.  In  one  experi- 
ment, three  doses  of  0.005  gm.  each  were  taken  on  the 
-ame  day  at  intervals  of  3  hours.  "  In  15  minutes  after 
the  first  dose  the  breath  had  a  strong  garlic-like  odor, 
and  in  an  hour  a  metallic  taste  was  observed.  An  hour 
after  the  second  dose  the  urine  and  sweat  had  the  garlic- 
like odor,  which  was  also  observed  in  the  feces,  4  days 
later.  The  metallic  taste  was  observed  for  72  hours; 
and  the  garlic- like  odor  in  the  urine  for  382  hours,  in 
the  sweat  for  452  hours,  in  the  feces  for  79  days,  and 
in  the  breath  it  was  still  present,  though  verv  faintlv, 
after  237  days." 

Reisert  passed  his  breath  through  a  tall  column  of 
distilled  water  for  several  hours,  in  the  hope  of  catching 
the  odoriferous  compound  which  seemed  to  be  elimi- 
nated from  the  lungs  in  appreciable  quantity,  but  analy- 
sis of  this  water  afterwards  gave  negative  results.  He 
assumed,  therefore,  that  the  quantity  of  substance 
responsible  for  the  odor  was  too  small  to  be  detected  by 
known  chemical  means  and  suggested  that  the  "  physio- 
logical test  "  is  much  more  delicate  than  any  purely 
chemical  one  for  this  purpose."'  Reisert  concluded  his 
paper  with  the  remark  that  idiosyncrasy  did  not  seem 
to  have  any  influence  in  'his  experiments,  since  the 
breath  of  every  one  to  whom  the  tellurous  oxide  had 
been  administered,  in  quantities  not  less  than  0.000,- 
000,5  gm.,  was  affected  with  the  alliaceous  odor. 

(c)  Antihydrolic  Action  and  Therapeutic  Use. — Xeusser 
was  the  first  to  show  that  tellurium  compounds  are  of 
therapeutic  value.  In  about  fifty  clinical  experiments, 
on  as  many  consumptives,  he  observed  that  the  night- 
sweats  were  very  perceptibly  reduced  after  administra- 
tions of  potassium  tellurate  in  daily  doses  of  0.02  to  0.06 
gm."    In  a  majority  of  cases  0.02  gm.  was  suflScient, 

-'''  Lately  again;  Druggists'  Circular  arid  Chemical  Gazitte,  1894,  xxxriii,  256, 
referriDg  to  xliservations  of  Janzon  in  Pharm.  Zcitschr. 

-^  The  author  is  greatly  indebted  to  Prof.  John  Marshall  for  calling  his  atten- 
tion to  Reisert's  work.  It  stents  that  subsequent  foreign  investigators  of  the 
behavior  of  tellurium  in  the  animal  body  were  unaware  of  Reisen's  results.  It  is 
probab'e,  however,  that  Kuukel  refers  to  these  results  when  he  says,  "  The  odor. 
(of  methyl  telluride)  has  been  deiecteti  in  the  fects  of  man  over  two  months,  and 
in  the  breath  more  than  a  half  vear,  after  the  last  dose  of  tellurium."  Handbuck 
dcr  ToiikJoytf,  1899,  365. 

^  Refereuce  has  already  been  made  to  Hofmeister's  method  for  separating 
tellurium  eliminated  in  tie  form  of  methyl  telluride  in  the  expired  air.  This 
was  not  applied,  of  course,  until  after  Reisen's  work  had  t>een  reported.  Reisert 
knew,  however,  that  Wr.hler  and  his  pupils  attributed  this  odor  to  methyl  tellu- 
ride, but  he  failel  to  use  adequate  means  for  the  retention  and  chemical  detec- 
tion of  such  a  volatile  compound. 

^  In  order  to  test  the  anidroiic  action  of  tellurium,  Czapek  and  Weil,  whose 
work  has  already  been  revitwed,  made  careful  expt-riments  in  this  connection 
on  kittens  with  results  that  entirely  confirmed  Neusser's  original  observation. 
Jloderate  nontoxic  doses  (presumably  of  telhirates*  were  given  and  before  any 
of  the  usual  sickening  induences  had  manifested  themselves  the  moisture  on 
the  soles  of  the  hind  paw>  became  less  and  less,  until  they  were  quite  drv,  when 
even  the  strongest  electrical  stimulation  of  the  peripheral  end  of  the  divided 
sciatic  nerve  was  insuUicient  to  call  forth  secretion  ;  after  the  tellurium  had 


although  cumulative  dosage  was  necessary  at  times  to 
effect  continued  results.  He  noted,  also,  that  these 
amounts  did  not  cause  any  particularly  toxic  symptoms, 
although  mild  dyspepsia  (eructations,  coated  tongue, 
loss  of  appetite)  was  produced  now  and  then  by  the'use 
of  the  largest  dose.  In  some  cases  there  appeared  to 
be  stimulation  of  appetite  at  first  and,  in  quite  a  num- 
ber of  instances,  Neusser  received  the  impression  that 
slight  narcotic  action  had  been  manifested.  The  breath 
of  each  individual  experimented  on  always  quickly 
assumed  the  characteristic  alliaceous  odor  even  with  the 
smallest  quantities  of  the  tellurate.  This  was  the  only 
undesirable  feature  that  occurred  regularly.  Neusser 
stated  that  the  odor  was  not  noticed  by  the  patients 
themselves  except  in  a  few  cases.  Sulphurous  and 
camphoraceous  odors  in  eructations  were  sometimes 
complained  of  His  experiments  were  conducted  on 
patients  in  advanced  stages  of  phthisis,  but  with  none 
of  these  was  any  favorable  influence  of  the  tellurium 
observed  on  the  disease  itself. 

Pohorecki,  following  Xeusser's  lead,  confirmed,  in  a 
large  number  of  clinical  experiments,  the  latter's  re- 
sults in  practically  all  particulars.  He  reported  that 
increased  appetite  and  better  general  nutrition  resulted 
from  dosage  with  0.01—0.02  gm.  of  potassium  tellurate 
in  the  earlier  stages  of  phthisis.  Anidrotic  action  was 
manifested  in  fifteen  minutes  to  an  hour,  and  continued 
five  to  seven  hours.  The  garlic  odor  of  the  breath  could 
be  detected  fifteen  minutes  after  administration  and 
continued  four  to  eight  weeks.  Even  in  people  who 
were  perfectly  well  it  was  observed  that  potassium 
tellurate  greatly  hindered  the  secretion  of  sweat. 

Combemale  and  Dubiquet  found  that  sodium  tellurate 
in  daily  doses  of  0.02  to  0.05  gm.  had  a  pronounced 
antidiaphoretic  action  and  was  more  effective  in  this 
respect  .than  even  camphoric  acid.  Anidrosis  was 
obtained  not  only  with  patients  suffering  from  phthisis, 
but  also  in  other  cases  in  which  sweating  is  often  pro- 
fuse (rheumatism,  dyspepsia,  etc.).  .\dministration  of 
sodium  tellurate  was  followed  by  diminished  perspira- 
tion in  18  of  20  cases.  In  6  of" the  IS  it  was  arrested 
completely.  0.02  gm.  was  found  to  be  the  minimal 
dose  which  would  induce  anidrosis  ;  0.05  gm.  the  most 
effective  quantity.  Repeated  dosage  with  this  amount 
for  a  few  days  brought  about  the  result,  if  it  was  not 
manifested  immediately  after  the  first  administration. 
These  observers,  unlike  Xeusser  in  his  experiences  with 
the  potassium  salt,  did  not  find  that  any  gastrointestinal 
disturbances  were  set  up  and  report  the  alliaceous  odor 
of  the  breath  in  but  a  few  instances  as  the  only  objec- 
tionable feature  following  its  administr?  tion  in  the 
doses  indicated  and  for  reasonable  lengths  of  time.-' 
Combemale  and  Dubiquet  consider  sodium  tellurate 
the  very  best  anidrotic  agent  and  prefer  it  as  a  result  of 
their  experiments  to  camphoric  acid,  white  agaric, 
atropin,  phosphate  of  lime,  etc.  Combemale  favors  the 
view  that  excessive  sweating,  in  such  disorders  as 
phthisis,  is  due  to  the  action  of  ptomaines  elaborated 
by  the  specific  germs  of  the  disease  and  he  supposes 
that  sodium  tellurate  exerts  an  antihydrotic  influence 
by  rendering  these  soluble  septic  products  innocuous. 

reached  its  fullest  efiect,  pilocarpine,  however,  was  able  ro  induce  secretion. 
These  iuvestigatora  were  unable  to  determine  anv  pathological  changes  in  the 
structure  of  the  sweat  glands  and  concluded  that  the  interference  with  secre- 
tion was  a  direct  peripheral  action  of  the  tellariuin  and  not  one  upon  the  central 
nervous  system. 

-*  The  reported  absence  of  the  garlic  odor  in  the  breath  in  a  large  majorilv  of 
t  hese  cases  is  in  direct  disagreement  with  the  results  of  Reisert's  quantitative 
experiments  and  the  observations  of  all  previous  and  subsequent  investigators, 
except  Rabuteau,  each  of  whom  has  found  that  it  inrariably  follows  the  intro- 
duction of  very  small  quantities  of  tellurium  compounds  both  In  man  and 
lower  animals. 


572 


The  Philadelphia' 
Medical  Jodrnal 


] 


SOME  MODERN  GYNECOLOGICAL  RESOURCES 


[Hascb  23,  19«1 


He  presents  nothing,  however,  in  direct  evidence  to  sub- 
stantiate this  deduction.  His  theory  would  not  explain 
the  reduced  sweating  in  perfectly  well  people,  which 
Pohorecki  observed  after  administration  of  potassium 
tellurate. 

Mr.  Mead  and  the  author  have  shown,  as  has  already 
been  pointed  out,  that  tellurates,  in  quantities  not  ex- 
cessive and  yet  much  greater  than  the  therapeutic 
doses  in  man,  exerted  no  particularly  deleterious  effects 
on  the  nutritional  processes  in  dogs,  even  when  dosage 
was  continued  for  a  week,  although  proteid  catabolism 
seemed  to  be  slightly  stimulated  after  a  time,  and 
secretion  of  acid  in  the  stomach  retarded.  The 
alliaceous  odor  imparted  to  the  breath  appears,  there- 
fore, to  be  the  chief  objectionable  feature  constantly  fol- 
lowing the  use  of  therapeutic  amounts  of  tellurates. 

BIBLIOGRAPHY. 

Chr.  Gmelin.  1824.  Versuche  uber  die  Wirkungen  des  Baryts,  Strontians, 
u.s   w.,  auf  den  ihierischen  Organismus.     TiihingeD,  43. 

Hansen.  1853.  Versuche  uber  die  Wirkung  des  Tellurs  auf  den  lebenden 
Organismus.    Ami.  d.  Chem.  u.  Pfiann.,  IxxxTi,  208. 

Rabuteau.  1369.  Recherches  sur  les  propriet^s  et  sur  I'glimination  des 
composes  oxygL'nes  du  s&l^nium  et  du  teliure.  Gas.  hebd.  de  Med,  et  de  Cliir., 
XTJ.  194:  241. 

Reisert.  18S4.  The  so-called  bismuth  breath.  American  Journal  of  Pharm.^ 
Ivi,  177. 

Knop.  1835.  Ueber  die  Aufnahme  verschiedener  Subslimzen  durch  die 
Pfianze,  welchenicht  zu  den  Nahrstoflen  gehoren.    BoOin.  QintraibL,  xxii,  Zb. 

Neusser,  1890.  Ueber  lellursaures  Kalium  als  Mittel  gegen  die  Nacht- 
scliweisseder  Phthlsiker.     \Vi>^n.  kiin.  Wochetiscfir.,  iii,  437. 

Pohorecki.  1891.  Ueber  den  Eintiuss  des  Kali  tellurlcum  auf  die  Schwelase 
der  Phthisiker.    yu/ir«ter.  iV.  rf.  ;/es.  /Ved.,  xxvi,  (i),  398. 

Couit)emale  et  Dublquet.  1891.  ije  tellurate  de  sonde  comme  medicament 
antisudoral.    Sem.  medic,  xi,  .\unexe8,  24. 

Combemale.  1S91.  Recherches  cliniques  sur  deux  agents  antisudoraux  ; 
I'acide  camphorique  et  le  (elluraie  de  soude.    Bull,  gen,  de,  Therap.,  cxx,  14. 

Czapek  und  Weil.  1393.  Ueber  die  Wirkung  des  Selens  und  Tellurs  auf  den 
thierischen  Organismus.     Archiv,  j,  erp.   Path,  u,  Pharm.,  xxxii,  438. 

Bokorny,  (a).  1893.  Ueber  die  physiologische  Wirkung  der  telhirigen  .^aure. 
Chem.  Zeitnng,  xvii,  (ii),  1598;  (b).  1894.  Toxikologische  Nutizen  iiber  einige 
Verbindungen  des  Tellur,  Wolfram,  u.  s.  w.,  Ibid,,  xviii,  (ii),  1739. 

Hofmeister.  1894.  Ueber  Methylirungim  Thierk.'.rper.  Archiv. /.  erp.  Path. 
V.  Pharm.,  xxxiii,  198. 

Beyer.  1895.  Durch  welchen  Bestandtheil  der  lebendigen  Zellen  wird  die 
Tellursiiure  reducirt?    Archiv  J  Anat.  n.  PAyaio/.,  Physiol.  Abth'l'g.  225. 

Scheurlen.  1900.  Die  Verwendung  der  selenigen  und  tellurigen  S;iure  in 
der  Bakteriologie.     Zeitschr.J.  Ht/g.u.  In/.-krank.,xx^\u,  V'5. 

Klett.  1900.  Zur  Kenntniss  der  reducirenden  Eigenschaften  der  Bakterien. 
Zeilschr.j.  Hug-  «•  Inf.-krank,  xxxiii,  137. 

Mead  and  Gies.  1901.  Physiological  and  toxicological  effects  of  tellurium 
compounds,  with  a  special  study  ol  their  influence  on  nutrition.  .4mer.  Jour. 
0/  Physiol.,  T,  104. 


SOME  MODERN  GYNECOLOGICAL  RESOURCES. 

Bv  AUGUSTIX  H.  GOELET,  M.D., 

of  New  York. 

Professor  of  Gynecology,  New  York  School  of  Clinical  Medicine;  Consulting 

Professor  of  Gynecological  Electro-Therapeutics,  International 

Correspondence  Schools,  Scranlon,  Pa.;  elc. 

The  accompanying  illustrations  were  inadvertently 
omitted  when  my  paper  on  "The  Resources  of  Modern 
Minor  Gynecology "  appeared  in  this  Journal,  Janu- 
ary 5. 

Fig.  1  represents  a  four-branch  dilator  for  extending 
the  degree  of  dilation  of  the  cervix  uteri  beyond  what 
is  possible  with  the  two-branch  instrument.  It  is  the 
only  satisfactory  dilator  expanding  in  more  than  two 
directions  that  I  have  seen  or  used,  and  is  a  very  use- 
ful instrument  where  extensive  dilatation  of  the  cervix 
is  required.  It  is  a  very  powerful  instrument,  however, 
and  used  carelessly  will  rupture  the  cervix.  A  stop 
which  may  be  adjusted  at  any  point  is  arranged  so  as 
to  limit  the  dilatation  to  any  degree  required,  thus  lim- 
iting the  amount  of  force  applied. 

Figs.  2  and  3  represent  a  rubber  cover  for  sponge  or 
laminaria  tents  wherebj'  this  very  useful  means  of  di- 
lating the  cervical  canal  may  be  employed  in  a  per- 
fectly aseptic  manner.  It  was  because  of  the  impos- 
sibility of  effecting  aseptic  dilatation  with  these  tents 
that  they  were  abandoned.     The  tents  could  of  course 


be  rendered  aseptic,  but  their  expansion  when  placed 
in  the  canal  depended  upon  the  absorption  of  secretion 
from  the  surface  and  glands  beneath.  Hence  this  secre- 
tion which  so  olten  harbors  bacteria  is  taken  up  by  the 
tent  and  conveyed  to  the  endometrium  of  the  cavity 
above  where  the  bacteria  find  a  fertile  field  for  devel- 
opment. 

By  using  the  tent-covers  the  tent  does  not  come  in 


I 


Open. 
Fig.  ].— Author's  four-brancb  dilator. 

contact  with  the  surface,  but  expands  within  the  cover 
by  absorption  of  moisture  from  gauze  placed  in  the 
vagina. 

Fig.  2  represents  the  cover. 

Fig.  3  represents  the  cover  with  the  tent  within  it 
and  a  piece  of  gauze  covering  the   tent,  one  end  of 


Fig.: 


-.Author's  tent  cover. 


which  projects  from  the  opening  of  the  cover  so  as  to 
come  in  contact  with  the  moist  gauze  placed  in  the 
vagina  after  the  tent  has  been  inserted.  They  are 
sterilized  either  by  boiling  or  by  emersion  for  20 
minutes  in  synol  soap,  full  strength. 

The  method  of  using  the  tent  is  as  follows,  viz.,  the 


Fig.  3. — -Author's  tent  cover  over  tent  ready  for  use.    Showing  strip  of  gauM 
surroundiDg  teot  with  one  end  projecting. 

tent  is  drawn  over  a  pair  of  sterile  dressing  forceps 
closed  and  rolled  in  the  same  manner  as  the  finger  cot, 
from  the  opening  to  the  closed  end.  to  facilitate  getting 
it  over  the  tent ;  the  tent  is  then  covered  with  a  narrow 
strip  of  absorbent  gauze  placed  lengthways  with  one 
end  projecting  considerably  beyond  the  lower  end  of 
the  cover.     The  gauze  is  now  made  thoroushlv  wet  bv 


Uabch  23,  1901] 


SOME  MODERN  GYNECOLOGICAL  RESOURCES 


[The  Philadelphia 

L  Medical  Jocrnal 


573 


dipping  it,  tent  and  all,  into  water.  Then  the  cover  is 
unrolled  over  it,  leaving  the  long  end  of  the  gauze  strip 
projecting  beyond  the  opening  of  the  cover. 

The  tent  with  cover  over  it  is  grasped  with  a  pair  of 
uterine  dressing  forceps  and  dipped  into  synol  anti- 
septic liquid  soap  to  lubricate  it,  then  fixing  the  cervix 
(exposed  through  a  vaginal  speculum),  by  means  of  a 
pair  of  atigular  tenaculum  forceps  the  tent  is  inserted 


irrigator 


■^ 


OBTURATOR 


=*&^ 


MCOAVOSCOPf 


Fi(-.  4. — Author's  uterine  endoscope,  tbowing  the  diUeretit  parts  det:tched 


into  the  cervix  up  to  its  full  length,  and  the  vagina  is 
filled  loosely  with  absorbent  gauze  to  retain  the  tent 
in  position.  The  gauze  in  the  vagina  is  then  thoroughly 
moistened  with  sterile  water  before  the  speculum  is 
withdrawn.  The  vagina  and  vulva  are  to  be  previ- 
ously sterilized  as  for  curettage. 

For  the  benefit  of  the  younger  members 
of  the  profession  who  are  unfamiliar  with 
the  use  of  sponge  tents,  I  will  say  that 
about  24  hours  are  required  for  the  com- 
plete expansion  of  these  tents  and  during 
that  time  the  patient  should  be  kept  in 
bed  in  the  recumbent  position. 

Figs.  4  and  5  represent  the  uterine  en- 
doscope for  inspecting  the  interior  of  the 
uterus  which  I  introduced  about  2  years 
ago. 

Fig.  4  represents  the  instrument  with  the  several 
parts  detached  and  shows  the  small  electric  lamp 
near  the  extremity  of  the  endoscope  tube  where  the 
light  is  placed  for  direct  illumination  of  the  cavity. 

Fig.  5  represents  the  endoscope  tube  in  position  in 


afforded  by  the  uterine  endoscope.  With  this  instru- 
ment it  is  possible  to  determine  whether  it  is  necessary 
or  not  to  employ  the  curet,  and  after  curettage  to  decide 
if  the  work  has  been  properly  and  thoroughly  done. 
Without  such  aid  these  points  are  often  only  a  matter 
of  conjecture. 

Fig.  6  represents  a  clinical  double  current  uterine 
which  possesses  many  advantages.  The 
stream  is  projected  from  the  end  of  the 
tube  in  a  fan-shaped  jet  and  the  opening 
is  so  arranged  that  if  the  extreme  point 
is  pressed  against  the  fundus  the  stream 
can  escape  from  the  sides,  thus  the  flow 
does  not  become  obstructed.  The  outer 
tube  is  conical,  enlarging  from  the  end 
to  the  point  of  exit  so  as  to  obviate  ob- 
struction of  the  return  flow  from  the 
cavity. 

The  end  of  the  tube  is  small  enough  to 
he  introduced  through  the  canal  of  the 
cervix  and  internal  os  in  most  cases  with- 
out previous  dilatation  of  the  canal. 
Hence  the  instrument  is  useful  for  clin- 
ical irrigation  of  the  uterus  both  previous  to  and  after 
dilatation  and  curettage.  (There  is  a  larger  size  of  the 
instrument  for  use  when  the  cervix  is  dilated,  known 
as  the  operating  irrigator.) 

When  the  clinical  irrigator  encounters  obstruction  in 


Fig.  5. — The  uterine  euddsc-upe  in  positiou. 

the  uterus  with  megaloscope  in  position  for  magnify- 
ing the  field.  Illumination  of  the  lamp  is  secured  by 
4  dry  Leclanche  cells  arranged  in  series  and  placed  in  a 
box  for  tranportation,  in  the  top  of  which  may  be 
stored  the  different  size  endoscope  tubes  (3  in  number) 
with  their  obturators,  the  connecting  cords,  etc. 

The  diagnosis  of  disease  involving  the  endometrium 
is  obviously  imperfect  without  the  aid  of  inspection 


Fig.  6. — Author's  clinical  double  curreut  uteriue  irrit:ator. 

the  canal  and  does  not  enter  readily  it  may  be  converted 
temporarily  into  an  electrode  by  slipping  over  it  a  piec^ 
of   rubber  tubing  for  insulation,   extending  from  the 
projection  for  the  outflow  on  the  outer  tube  to  within 
2i-  or  3  inches  of  the  end.     There  is  an  attachment  on 
the  handle  near  where  the  tube  from  the 
reservoir  is  attached    for    connecting  the 
cord   from   the   battery.     If  this   irrigator 
thus  arranged  is  connected  with  the  nega- 
tive pole  of  the  galvanic  battery  and  a  dis- 
persing electrode  connected  with  the  posi- 
tive is  placed  on  the  abdomen  or  over  the 
sacrum  and  10  M.  of  current  is  turned  on 
the  action  of  the  current  will  so  soften  the 
structure    of  the  cervix  within  a  minute 
that  the  irrigator  will  slip  through  or  by 
the  obstruction.     By  permitting  the  cur- 
rent to  remain  on  while  the  irrigation  of 
the  cavity  is  going  on,  thorough  relaxation 
of  the  canal  will  be  secured,  sufi&cient  for 
subsequent  drainage. 

This  irrigator  is  positively  indispensable  in  treating 
endometritis,  to  preserve  cleanliness  of  the  cavity  and 
for  making  applications  thereto. 


Coiigress  of  Gynecology.— The  Congress  de  Gynecol- 
ogie  of  France  will  meet  this  year  at  Nantes,  September  23 
to  30.    Foreign  gynecologists  are  invited  to  attend. 


574        '^"^  Philadelphia! 
Medical  Journal  J 


MULTIPLE  NEURITIS— TUBERCULOUS  GLANDS 


[ilAKCH  23,  IMl 


DEJERINEERB  TYPE   OF  UPPER-ARM    PALSY  FOL- 
LOWING MULTIPLE  NEURITIS.* 

By  d.  J.  McCarthy,  m.d., 

of  Philadelphia. 

Instructor  in  Nervous   Diseases,   Philadelphia  Polyclinic;  Associate  in  Medi- 
cine William  Pepper  Clinical  Laboratory,  University  of  PeunMlvania. 

Multiple  neuritis,  caused  by  alcohol,  is  not  an 
uncommon  affection.  Bilateral  wrist-drop  in  workers 
in  lead,  caused  by  the  toxic  action  of  the  lead  on  the 
peripheral  nerves,  is  of  rather  frequent  occurrence.  The 
probable  action  of  both  of  these  poisons  in  the  pro- 
duction of  the  symptoms  in  the  case  here  reported, 
makes  it  one  of  considerable  interest. 

J.  G.,  age  28,  compositor  by  occupation,  was  admitted  to 
the  clinic  October  15,  1900.  suffering  with  paralysis  of  both 
arms  and  weakness  of  both  legs.  His  family  history  and 
previous  history  revealed  nothing  of  importance.  For  sev- 
eral months  he  had  been  drinking  heavily,  and  3  weeks 
previous  to  the  time  of  his  admission  had  an  attack  of 
abdominal  pain  with  marked  constipation.  He  thinks  this 
was  an  attack  of  lead  colic.  Following  this  attack  he  became 
very  nervous  and  during  tlie  following  week  rapidly  lost 
power  in  both  arms.  At  the  end  of  the  week  the  paralysis 
of  the  arms  was  so  complete  that  he  was  unable  to  lift  them 
to  the  horizontal  position,  or  to  dress  or  feed  himself  During 
the  following  week  he  rapidly  lost  power  in  the  legs  and  was 
compelled  to  go  to  bed.  There  was  at  that  time  dull,  aching 
pains  in  the  arms  and  shoulders  worse  at  night.  He  re- 
mained in  bed  2  weeks.  The  legs  rapidly  regained  their 
tone  and  he  is  now  able  to  walk  with  comfort.  There  has 
been  no  numbness,  no  parasthesia,  and  no  bladder  or  rectal 
trouble. 

Examination  reveals  almost  complete  loss  of  power,  with 
marked  wasting  in  all  the  shoulder  muscles  of  both  sides. 
The  supra  and  infraspinatus  fossae  are  verj-  prominent  and 
show  marked  wasting  The  forf  arm  and  hand  is  not  wasted, 
but  there  is  marked  bilateral  wristdrop.  The  grip  is  weaker 
than  normal,  but  when  the  wrist  is  supported  in  e.xtension, 
power  is  fairly  well  preserved  in  the  median  distribution. 
Reflexes  are  lost ;  and  there  is  tenderness  alone;  the  course 
of  the  nerve-trunks.  In  the  lower  extremities  there  is  a 
very  marked  diminution  of  power  in  all  the  muscles,  with 
loss  of  reflexes,  tenderness  over  the  nerve-trunks  and 
muscles,  but  with  practically  no  wasting  atrophy  of  any 
muscles.  The  electrical  examination  shows  reactions  of 
degenerations  in  all  the  muscles  about  the  shoulder  girdle, 
with  partial  reactions  and  delayed  contraction  in  the  fore- 
arms and  hands.  The  eye  examination  revealed  diplopia 
due  to  palsy  of  the  right  iuternal  rectus.  A  distinctly 
marked  blue  line  is  present  on  the  gums. 

This  case  should  be  considered  as  representing  the 
double  etiology  of  alcohol  and  lead  in  the  production 
of  multiple  neuritis  for  the  following  reasons:  In  the 
first  place,  the  presence  of  the  blue  line  on  the  gums 
and  the  history  of  an  attack  of  lead  colic,  is  sufficient 
evidence  of  the  presence  of  lead  in  the  system  in  suf- 
ficient quantity  to  produce  changes  in  the  nervous 
system.  In  the  second  place,  the  predominance  of 
extensor  involvement  as  exhibited  in  the  bilateral  wrist- 
drop, with  a  fair  preservation  of  the  grip,  and  all  forms 
of  sensation,  follows  the  usual  clinical  picture  of  lead 
palsy  of  the  upper  extremities.  The  evidence  in  favor 
of  the  presence  of  the  alcohol  as  a  factor  in  the  pro- 
duction of  the  neuritis  is  found  in  the  predominance  of 
the  changes  in  the  peripheral,  intramuscular  nerve  fila- 
ments in  the  lower  extremities,  over  the  trunk  changes. 
The  muscles  were  very  sensitive  to  pressure  even  after 
the  acute  symptoms  had  subsided,  while  the  nerve- 
trunks  were  only  moderately  sensitive,  and  only  deep 
pressure  elicited  pain. 

Sensitive  and  painful  nauscles  are  as  rare  in  cases  of 

•  Read  at  the  Philadelphia  Neurological  Society,  November,  1900. 


lead  neuritis  as  they  are  common  in  alcoholic  neuritis. 
Wrist- drop,  on  the  other  hand,  is  so  frequent  in  lead. 
neuritis  that  it  is  looked  on  as  the  typical  clinical  pic- 
ture of  that  disease.  The  intense  atrophy  coming  on 
so  rapidly  after  the  development  of  the  neuritis,  less 
than  four  weeks,  is  rare  in  either  form  of  neuritis,  and 
is  practicaUy  never  met  with  in  lead.  We  must  look 
on  it  as  an  evidence  of  an  intense  change  takfng  place 
either  in  the  peripheral  nerves,  or  the  anterior  horn 
cells  of  the  spinal  cord,  or  both,  induced  by  the  double 
intoxication. 

The  patient  continued  to  improve  under  rest,  gal- 
vanism and  small  doses  of  strychnin,  and  at  the  end  of 
three  months  presented  the  clinical  picture  of  the  so- 
called  Duchenne-Erb  type  of  combined  shoulder  paral- 
ysis. To  this  was  added  extensor  palsy  of  both  fore- 
arms producing  bilateral  wristdrop.  Erb  considers 
this  type  of  palsy  to  be  due  to  a  lesion  afifecting  the 
fifth  and  sixth  cervical  roots.  It  is  usually  the  result 
of  direct  or  indirect  trauma,  although  Erh  saw  it  re- 
sult from  the  intoxication  of  tainted  meat.  Heyse 
reports  a  case  in  a  tuberculous  patient  and  Kraft- Ebing 
and  Oppenheim  have  seen  it  the  result  of  intoxication 
as  in  our  case.  The  involvement  of  the  deltoid,  bi- 
ceps, supraspinatus,  infraspinatus,  triceps,  supinator 
longus,  and  the  extensor  carpi  radiaUs  and  ulnaris  cor- 
responds closely  to  the  type  described  by  Erb.  While 
the  other  muscles  of  the  upper  extremities  were  at  first 
afi'ected,  they  recovered  their  tone  in  a  short  time,  and 
were  not  involved  in  the  intense  atrophy  present  about 
the  shoulder. 

Lead  intoxication  from  tj'pe,  at  one  time  so  common, 
is  at  present  of  infrequent,  even  rare,  occurrence.  This 
is  due  to  the  fact  that  the  type  of  today  contains  but 
little  lead ;  zinc  and  other  metals  are  employed  to 
harden  the  type,  and  the  small  percentage  of  lead  is  not 
usually  deleterious  in  its  eflfects. 

The  combined  effect  of  lead  and  alcohol  on  the  nerv- 
ous system  can  rarely  be  differentiated  with  such  clear- 
ness as  in  the  present  case.  The  lead  had  probably 
little  to  do  with  the  manifestations  in  the  lower  ex- 
tremities ;  the  paralysis  and  sensory  changes  following 
here  the  alcoholic  type.  The  intense  wasting  about  the 
shoulder  girdle  is  probably  the  result  of  the  combined 
effect  of  both  the  alcohol  and  lead,  as  the  palsy  of  the 
forearm  followed  clearly  the  lead  type,  to  which  was 
added  in  the  upper  arm  the  tenderness  over  the  nerves 
and  the  reactions  of  degeneration. 

I  am  indebted  to  Dr.  Wm.  G.  Spiller,  fiom  whose 
clinic  at  the  Philadelphia  Polyclinic  this  case  is  pub- 
lished. 


A  NEW  TREATMENT  FOR  TUBERCULOUS  GLANDS  OF 
THE  NECK  WITH  MINDHAL  SCARRING.  INVOLV- 
ING A  METHOD  OF  STERILIZING  A  TUBERCU- 
LOUS REGION  THROUGH  THE  LYMPH  CHANNELS. 

Bv  G.  BETTOX  MAS.vEY,  .M.D., 
of  Philadelphia. 

Thk  recognition  of  the  tuberculous  nature  of  what 
were  formerly  known  as  scrofulous  enlargements  of  the 
lymphatic  glands  of  the  neck  has  opened  a  new  vista 
in  the  treatment  of  this  afifection.  The  disease  should 
no  longer  be  looked  upon  as  a  constitutional  affection, 
controllable  only  by  general  treatment,  but  should  be 
understood   as   a  local   implantation   of   the   bacillus 

*  Read  before  tbe  Philadelphia  County  Medical  Society,  February  IS,  IMl. 


MaECH  23,  1901) 


lUBEKCULOUS  GLANDS  OF  TBE  NECK 


pTHE  Phiudelphia 
L  liEDiCAL  Journal 


575 


tuberculosis  in  an  individual  whose  inherited  type  of 
cell  constitution  is  not  preof  against  its  implantation. 
In  these  particular  cases,  the  tuberculous  germs  doubt- 
less gain  entrance  into  the  lymphatic  vessels  of  the 
neck  through  an  infection  atrium  in  the  tonsils,  and 
are  arrested  in  the  first  gland  reached  by  them,  there 
to  multiply  until  the  gland  is  eroded,  permitting  the 
next  one  in  the  chain  to  be  infected,  and  so  on,  through- 
out the  chain. 

It  is  evident  that  mere  constitutional  treatment  of 
this  condition,  while  both  appropriate  and  valuable  in 
strengthening  the  phagocytic  powers  of  the  body  cells 
and  fluids,  is  but  a  sorrj'  method  of  reaching  an  in- 
trenched colony  already  in  vigorous  growth.  Moreover, 
these  colonies  of  germ  growth  are  just  beneath  the 
skin,  and  therefore  are  more  accessible  than  tubercular 
deposits  in  the  inner  organs  of  the  body. 

The  removal  of  the  infected  glands  by  the  ordinary 
cutting  operation  has  the  disadvantage  of  leaving  un- 
sightly scars,  which  are  seriously  objected  to  by  patients 
for  cosmetic  reasons.  When  the  capsules  of  the  glands 
are  eroded  through,  their  removal  is  more  difficult,  and 
gives  rise  to  a  more  extensive  scar. 

Efforts  to  cause  absorption  of  these  enlargements  by 
the  percutaneous  application  of  electricity,  or  by  per- 
cutaneous cataphoresis,  have  been  equally  unsuccessful 
in  my  hands,  and  the  reason  is  evident  when  we  con- 
sider that  the  vital  resistance  of  these  germs,  though 
not  great,  is  quite  sufficient  to  resist  any  agents  or  in- 
fluences that  are  transmissible  through  an  intact  skin. 
When  applied  to  more  than  a  year  ago  by  a  physician 
to  treat  such  a  case,  therefore,  I  immediately  deter- 
mined to  try  a  modification  of  my  cataphoric  method 
for  the  destruction  of  cancer,  and  as  the  application  of 
this  modified  method  was  an  unqualified  success  in 
this  case  and  in  that  of  another  case  in  which  it  has 
since  been  employed,  its  presentation  to  the  medical  pro- 
fession is  now  made  with  much  confidence  in  its  value. 

The  object  of  the  method  is  the  destruction  of  the 
bacilli  by  the  cataphoric  diffusion  among  them  of 
nascent  oxychlorid  of  mercury,  developed  in  their 
midst  by  the  electrolysis  of  metallic  mercury  held  in 
contact  with  a  small  gold  electrode.  A  small  opening 
is  made  through  the  skin  and  into  the  gland  by  a  nar- 
row bistoury,  under  a  chlorid  of  ethyl  spray,  and  into 
the  opening  is  thrust  a  sliver  of  amalgamated  zinc  to 
act  as  an  anode,  not  insulated,  of  a  weak  galvanic  cur- 
rent— one  to  three  milliamperes — which  is  turned  on 
gradually  and  maintained  for  a  few  minutes  to  cauter- 
ize the  tract  and  keep  it  patulous  for  the  treatment 
proper.  When  the  tract  has  received  a  sufficient  im- 
pregnation with  the  mixed  oxychlorids  of  zinc  and 
mercury  thus  developed  to  keep  it  patulous  for  a  few 
days,  the  zinc  electrode  is  withdrawn  and  an  insulated 
gold  electrode  about  the  caliber  of  a  piece  of  No,  IS 
wire  is  inserted,  its  point  having  previously  been  amal- 
gamated and  made  to  hold  as  much  mercury  as  pos- 
sible. This  instrument  is  left  bare  for  J  inch  from 
the  point  only,  in  order  that  all  the  current  action  shall 
be  expended  within  the  gland,  the  remainder  of  the 
instrument  being  insulated  with  fused  hard  rubber  or 
fused  shellac.  From  2  to  10  milliamperes  is  now 
turned  on  and  maintained  for  10  minutes,  or  until  all 
the  mercury  has  been  dissipated  from  the  gold  surface, 
after  which  a  piece  of  absorbent  cotton  or  lint  is  placed 
over  the  opening,  topped  by  a  piece  of  plaster,  and  the 
patient  returns  at  intervals  of  two  or  three  days  for  a 
repetition  of  the  application.     The  endermic  applica- 


tion of  cocain  may  be  used  to  deaden  the  slight  pain 
of  these  applications,  a  mere  drop  of  a  10%  solution 
placed  in  the  opening  being  an  excellent  preliminary 
to  the  later  applications. 

The  purpose  of  the  sinus  thus  formed  is  the  drainage 
of  the  products  of  the  dead  bacilli  and  deposited 
chemicals  as  well  as  for  a  direct  application  to  the 
germ  colony.  Small  doses  and  the  gradual  method  of 
treatment  are  adopted  to  avoid  unnecessary  destruction 
of  the  gland  tissue  or  the  production  of  solid  eschars 
that  would  not  readily  drain  away,  the  repeated  appli- 
cations acting  in  a  cumulative  way  on  the  protoplasm, 
finally  destroying  all  pathogenic  germs  by  the  com- 
bined effects  of  the  direct  action  of  the  germicide  and 
the  indirect  action  of  the  aroused  trophic  forces  of  the 
surrounding  normal  cells. 

Observation  of  the  two  cases  to  be  reported  has 
caused  me  to  believe  that  the  germicidal  action  is  not 
confined  entirely  to  the  gland  to  which  the  application 
is  made,  but  that  the  chemicals  deposited  in  this  situa- 
tion drain  downwards  to  the  next  glands  in  the  chain 
and  favorably  influence  any  infection  in  these  glands. 

The  final  result  is  the  destruction  of  the  tuberculous 
bacilli,  without  necessarily  destroying  all  the  gland  tis- 
sue not  destroyed  by  the  disease,  and  when  the  opening 
is  allowed  to  close  the  scar  left  is  a  mere  point,  and  the 
general  health  of  the  patient  will  be  found  to  be  im- 
proved. The  sinus  requires  no  special  precautions 
against  septic  infection  while  open,  by  reason  of  the 
powerfully  antiseptic  chemicals  deposited  within  and 
about  it. 

Case  I. — Mr.  B.,  a  stenographer,  was  referred  to  me  by  Dr* 
E.  E.  Johnson,  of  Philadelphia,  February  15,  1899.  The 
family  history  was  good.  In  July,  1898,  a  tuberculous  gland 
was  removed" bv  means  of  a  cutting  operation  by  a  physician 
of  York,  Pa.  The  wound  failed  to  heal,  and  Dr.  Johnson 
cauterized  it  the  following  month.  When  first  seen  by  me 
there  was  a  large  scar  on  the  left  side  of  the  neck,  near 
which  a  tuberculous  gland  of  large  size  was  located.  The 
patient's  color  was  pale. 

A  small  opening  was  made  under  chlorid  of  ethyl  spray, 
the  opening  was  made  patulous  by  means  of  the  zinc  mer- 
cury sliver  "as  an  anode,  and  subdermic  mercuric  cataphore 
sis  was  applied  by  means  of  the  insulated  gold  instrument 
about  twice  a  week,  the  patient  covering  the  spot  between 
times  with  a  bit  of  adhesive  plaster  and  continuing  at  his 
usual  occupation.  In  all,  11  applications  were  made  in  7 
weeks,  when  the  gland  itself  seemed  to  be  softened  and  hol- 
low, surrounded  by  an  area  of  treatment  induration.  The 
opening  was  now  allowed  to  close,  subsequent  observation 
showing  a  progressive  shrinkage  of  the  induration. 

This  patient  was  not  seen  again  until  4  months  after  the 
cessation  of  the  treatment,  when  the  induration  had  disap- 
peared, leaving  a  minute  round  scar  in  the  skin,  and  he 
seemed  to  be  in  decidedly  more  robust  health.  He  states  at 
present  that  he  is  in  better  health  than  for  fifteen  years 

Case  2.— Miss  G.,  also  a  stenographer,  applied  for  treat- 
ment in  May,  1899.  Her  parents  are  healthy,  but  there  was 
consumption  on  both  sides  in  the  grandparents'  generation, 
and  a  sister  and  brother  now  have  pulmonary  tubercu'osis. 
Examination  showed  two  enlarged  glands  on  the  right  side  of 
the  neck,  rather  alongside  of  each  other  than  in  the  same 
chain.  Below  these  glands  there  were  a  number  of  smaller 
ones.  The  patient  complained  of  some  stiffness  and  pain  in 
the  neck  when  tired,  and  was  anemic  and  menorrhalgic. 

The  method  detailed  above  was  employed  19  times  to 
August  22,  1899,  when  one  gland  was  shrivelled,  and  it  was 
evident  that  the  glands  below  were  smaller.  Treatment  was 
then  stopped  in  this  focus  of  the  disease,  and  she  was 
placed  under  a  brief  similar  treatment  for  the  other  gland. 

After  but  a  few  applications  were  made,  the  patient 
noticed  that  she  no  lons^er  had  the  stiffness  and  dull  ache  in 
ihe  neck.  Her  general  health  was  immediately  miproved 
bv  the  treatment,  so  much  s?,  indeed,  that  she  cea  ed  attend- 


576 


The  Philadklpuia"! 

flALJ 


Medical  Journj 


STRANGULATED  AND  GANGRE^fOUS  HERNIA 


[Mabch  23,  1901 


ance  before  I  thought  the  second  gland,  to  which  I  was 
making  applications,  had  received  enough  of  the  cataphoric 
salts  Her  weight  increased,  the  menstrual  pain  ceased,  and 
she  very  shortly  showed  the  evidences  of  blooming  health 
which  you  will  notice  tonight. 

On  examining  the  neck  tonight,  a  year  and  a  half 
after  the  brief  treatment  described,  you  will  notice  a 
small,  white  scar  less  than  an  eighth  of  an  inch  in  diam- 
eter at  the  site  of  the  first  gland  punctured,  and  beneath 
it,  what  is  apparently  a  healthy  gland,  but  slightly 
larger  than  normal,  the  other  scar  is  equally  indis- 
tinct, and  seems  to  overlie  an  equally  healthy  gland. 
But  probably  the  most  interesting  fact  of  all  is  the 
shrinkage  of  the  other  glands  of  the  neck  below  those 
treated,  these  being  today  but  remnants  of  the  knobby 
chain  that  extended  down  the  neck  into  the  supra- 
clavicular region.  It  is  evident  that  the  sterilizing 
mercurials  that  were  cataphorically  diffused  into  the 
uppermost  gland  also  sterilized  those  below  in  the 
lymphatic  channels  while  flowing  through  them.  The 
importance  of  this  observation  in  indicating  one 
method  of  actually  curing  a  form  of  tuberculosis  is 
quite  evident. 


STRANGULATED  AND  GANGRENOUS  HERNIA.  KE- 
LOTOMY  AND  LAPAROTOMY  IN  STRANGULATION 
EXTERNAL  AND  INTERNAL:  ARTIFICIAL  ANUS 
—ENTEROSTOMY,  PRIMARY  OR  SECONDARY 
RESECTION— ENTERECTOMY,  AND  END-TOEND 
OR  LATERAL  JOINTING  IN  GANGRENOUS 
HERNIA.* 

By  THOMAS  li,  MANLEY,  I'li  D.,  M.D, 

of  New  York, 

(CoDtimied  from  page  526.) 

PART  IV. 

A  Brief  Resume  on   the   Evolutio.v    of   Intestinal 
Surgery  as  it  Applies  to  Strangulated  Hernia. 

The  first  cases  recorded  in  surgical  literature  in  which 
efforts  were  made  to  remove  a  section  of  diseased  intes- 
tine were  those  of  strangulated  hernia.  Littre,  in  1699, 
closed  a  chasm  in  the  intestine  after  gangrene,  refresh- 
ing the  edges  and  closing  by  circular  suture.  Von 
Bamdohr,  surgeon  to  the  Duke  of  Brunswick  in  1727, 
resected  successfully  two  feet  of  gangrenous  intestine  ; 
operating  by  invaginating  one  divided  end  into  the 
other.  Twenty  years  later  Durverger  removed  two 
inches  of  a  gangrenous  gut  and  joined  the  ends  over  a 
4-inch  section  of  the  dried  trachea  of  a  calf;  this  com- 
ing away  on  the  twentieth  day,  per  rectum,  and  the 
patient  recovering— 1747.  Peyronia  again  successfully 
resected  four  inches  of  the  intestine  in  1753.  These 
pioneers  were  not  without  imitators  and  zealous  disci- 
ples, but  the  mortality  was  so  great  that  Lewis,  writing 
late  in  the  last  century,  formally  condemned  every  de- 
scription of  intestinal  surgery  in  strangulation,  except 
the  formation  of  an  artificial  anus.  This  eminent  au- 
thority, however,  bestows  great  praise  on  Littrt-,  and 
pronounces  his  achievement  "  d'une  merveille  de  Part." 

In  the  first  half  of  the  present  centurv  there  are  but 
two  cases  recorded  of  successful  resection  and  jointing 
for  mortified  intestine;  one  by  Levielle,  1812,  and  one 
by  DiiTenbach,  1836. 

Animal  Experimentation,  Etc.— The  foundation  of 
rational  and  scientific  surgery  of  the  intestine  rests  on 

.nn,"*!"?  "*  the  Pan-American  Medical  Congress,  Havana,  Cuba,  February  4 
1901,  before  the  Section  on  Gynecology. 


modern  animal  experimentation  ;  nay,  a  mastery  of  its 
art  and  technic  are  possible,  chiefly  by  resort  to  this 
means. 

In  pre-anesthetic  times  it  was,  in  a  large  measure,  a 
failure.  For  example,  as  early  as  1740  Moebus  and 
Farcy,  after  enumerating  a  large  number  of  experi- 
ments on  the  intestine  of  the  dog,  conclude  from  this 
experience  and  results,  that  intestinal  resection  is  utterly 
impracticable  on  the  human  being.  Early  in  the 
century  (nineteenth)  there  was  a  notable  re-awaken- 
ing in  the  French  school  on  the  subject  of  intestinal 
surgery,  -Tolly,  Joubert  and  Lambert  instituted  a 
large  number  of  experiments  on  the  lower  animals' 
intestine ;  several  devices  for  jointing  were  devised. 
Lambert,  a  young  hospital  interne,  described  his  suture 
before  the  French  Academy  in  1824.  In  182-5.  Ricb- 
erand  tested  the  utility  of  the  new  modes  of  eff"ecting 
enterorrhaphy  in  man,  with  disastrous  results.  Rey- 
berd,  in  1843,  undertook  to  unite  the  divided  ends  of 
the  colon  after  resection  of  a  cancerous  ma^s  involving 
its  ascending  portion.  His  patient  survived,  but  union 
failed  and  a  large  fecal  fistula  followed. 

The  results  thus  far  were  so  unsatisfactory  and  the 
mortality  so  great  that  the  best  surgeons  in  Europe 
looked  with  disfavor  on  any  description  of  surgery 
which  entailed  a  section  or  resection  of  the  intestine. 
In  the  brief  space  of  five  years  after  Reyberd's  failure, 
the  discovery  of  pulmonary  anesthesia  in  America  was 
announced,  an  event  of  incalculable  magnitude  to 
operative  surgery  ;  and  yet  we  find  that  the  deeply 
grounded,  superstitious  fear  of  opening  or  manipulating 
the  peritoneum,  stayed  the  hand  of  the  surgeon.  Not 
until  the  antiseptic  treatment  of  wounds  was  generally 
adopted  did  intestinal  surgery  share  in  the  impetus  of 
modern  advance,  although  this  is  of  secondary  import- 
ance in  surgery,  to  anesthesia  with  ether  or  chloroform 
narcosis. 

In  1873,  Liicke,  of  Strasburg,  again  revived  the  oper- 
ation of  intestinal  resection  for  gangrenous  hernia,  re- 
moving 6  centimeters  of  gut  and  losing  his  patient. 

In  Germany,  notably  after  Thiersch's  failure  in  1879, 
the  surgery  of  the  intestine  made  surprising  advances. 
To  the  Germans  are  we  indebted  for  a  large  part  of  the 
knowledge  we  now  possess  on  the  art  of  intestinal  sur- 
gery. Dr.  Carl  Beck,  of  New  York,  in  1879,  made  an 
extended  series  of  experiments  on  induced  gangrenous 
hernia,  the  deductions  from  which  have  since  been 
utilized  with  signal  advantage. 

It  is.  as  Bouilly  has  observed,  remarkable  to  note  that 
in  France  where  intestinal  surgery  was  first  made  the 
subject  of  a  most  extended  experimental  investigation, 
surgeons  were  skeptical  and  were  verj'  reluctant  in 
sharing  in  the  revival  of  this  phase  of  operative  sur- 
gery. Thus,  in  1883,  Dr.  Bouilly  was  able  to  collect  38 
cases  of  primary  resection  for  gangrenous  hernia  re- 
ported from  1873  to  this  date :  but  one  of  which  came 
from  French  sources.  Serrc,  writing  on  this  topic,  says 
that  "  we  may  date  the  real  advance  in  intestinal  sur- 
gery' from  1873.  I  must  repeat  that  we  can  only  regret 
that  these  operations  founded  by  the  experimentations 
of  French  surgeons,  the  glory  of  the  achievement  is 
ours,  executed  by  principles  conceived  by  us  and 
abandoned  by  the  country  that  gave  them  birth,  so  that 
it  is  now  quite  exclusively  from  foreign  sources  that 
recent  cases  are  reported."  This  author  pronounces 
successful  primary  resection  of  the  gangrenous  bowel 
with  effective  jointing  the  greatest  triumph  of  modem 
surgery. 


March  23,  1901  ] 


STRANGULATED  AND  GANGRENOUS  HERNIA 


["The  Philadelphia 
L  Medical  Jouknal 


577 


America  was  destined  to  play  a  rule  of  stupendous 
importance  along  this  line  of  advance.  In  1888,  the 
illustrious  Senn,  of  Milwaukee,  at  the  International 
Medical  Congress  held  in  Washington,  D.  C,  submitted 
the  most  extraordinary  essay  that  ever  was  written  on 
intestinal  surgery.  It  was  based  entirely  on  exhaustive 
experimentation  and  yet  the  logical  convictions  deduced 
from  so  large  and  diversified  a  number  of  experiments, 
their  general  success,  their  scientific  foundation,  their 
precision  and  skiU  in  execution,  promptly  assured  sur- 
geons of  their  applicability  to  the  human  being.  The 
presentation  of  this  great,  unrivalled  essay  was  hailed 
as  the  dawn  of  a  new  era  in  the  surgery  of  the  alimen- 
tary canal,  and  at  an  early  date  the  fundamental  prin- 
ciples it  inculcated  were  successfully  established  on  a 
large  scale  bj'  the  leading  surgeons  of  the  civilized  world. 
In  1891,  Dr.  John  B.  Murphy,  a  brilliant  young  surgeon 
of  Chicago,  published  a  description  of  his  anastomotic 
disc,  the  "  Murphy  button,"  a  most  extraordinary  piece 
of  ingenuity  which  it  appears  no  description  of  modifi- 
cation can  ever  improve.  It  is  generally  conceded  that 
no  device  ever  invented  has  imparted  the  enormous 
impetus  to  the  intestinal  surgery  that  this  has.  For 
end-to-end  jointing  of  the  intestine  it  is  simply  un- 
rivalled. 

Gibson  pronounces  it  the  best  and  safest  of  all  the 
various  expedients  at  our  command.  A  large  number 
of  other  devices  have  been  employed  to  assist  in  effect- 
ing union  of  the  divided  intestine.  The  last,  and  one 
of  the  most  valuable  of  all  measures  yet  suggested  for 
jointing  the  divided  intestine,  was  devised  by  Dr.  M.  E. 
Connell,  of  Milwaukee,  now  of  Chicago.  It  displaces 
every  description  of  apparatus  or  mechanical  appliance, 
consisting  of  nothing  more  than  a  simple  suture, 
specially  employed. 

In  all  of  the  above  advances  their  success  was  only 
possible  by  animal  experimentation.  Lambert,  on 
whose  conception  the  initiatory  was  instituted,  and  whose 
principles  yet  hold  with  the  vast  majority,  in  his  life- 
time, never  had  an  opportunity  to  test  them  on  man, 
and  Senn,  Murphy,  and  Connell  all  published  their 
essays  before  this  method  had  yet  been  tested  in  resec- 
tion of  the  intestine  in  the  human  being,  their  conclu- 
sions being  entirely  drawn  from  vivisection  experiments. 

PART  V. 

Artificial  Anus,   Resection  op  the  Intestine,   Pri- 
mary AND  Secondary. 

In  cases  of  advanced  gangrenous  hernia,  with  or 
without  perforation  of  the  intestine,  there  are  practi- 
cally but  two  courses  open  to  us  for  adoption ;  the  one 
is  to  fix  the  dead  parts  in  situ  and  drain  the  fecal  con- 
tents through  the  inguinal  or  crural  incision,  when  we 
have  groin  ruptures;  the  other  is  to  resect  the  morti- 
fied parts  and  reconstruct  the  intestinal  canal,  and  the 
time  has  now  arrived  when  the  "  doubtful "  cases 
should  be  dealt  with  in  a  similar  manner. 

Artificial  Anus. — The  attitude  of  our  most  noted 
surgical  authorities  widely  varies  on  the  choice  of  leav- 
ing an  opening  in  the  bowel  involved  by  gangrene,  or 
performing  an  immediate  resection.  Brief  comments 
and  statistics  from  various  sources  will  be  submitted  on 
this  aspect  of  the  subject. 

The  establishment  of  an  artificial  anus  is  an  imita- 
tion of  nature's  mode  of  relief,  and  cure  also,  when  but 
a  limited  area  of  the  gut  is  involved.  In  gangrenous 
cases  the  intestine  above  the  stricture  has  usually  con- 


tracted adhesions,  so  that  there  is  little  to  do  in  apply- 
ing technic  when  an  artificial  anus  is  to  be  hurriedly 
made.  Frequently,  though  not  always,  a  patient  with 
gangrenous  hernia  is  in  a  state  of  great  prostration,  and 
there  are  signs  of  invasion  of  the  general  peritoneum. 
In  G  cases  of  artificial  anus  left  after  gangrenous  hernia,  in 
my  own  practice,  in  all  the  intestine  was  found  ruptured. 
One  had  the  gut  opened  for  what  was  supposed  to  be  a 
suppurating  bubo.  In  3,  the  general  condition  was 
not  alarming  at  the  time  of  kelotomy,  but  none  sur- 
vived more  than  10  days.  At  the  French  Congress  of 
Surgeons,  in  1898,  this  subject  was  exhaustively  dis- 
cussed, and  it  was  the  opinion  of  the  greater  number 
that  in  gangrenous  hernia  the  proper  course  to  pursue 
was  to  fast  tap  the  bowel,  and  later,  when  reaction  was 
well  reestablished,  perform  a  resection,  a  course  which, 
from  a  theoretical  standpoint  at  least,  is  unassailable. 
But  the  establishment  of  an  artificial  anus  in  strangu- 
lated hernia  at  best  must  be  regarded  as  a  confession 
of  surgical  irapotency,  and  is  a  relic  of  antiquated 
methods,  as  Treves  says:  "  The  history  of  enterostomy 
is  as  old  as  strangulation  itself"  Dr.  Carl  Beck,  of  New 
York,  was  the  first  to  decide  the  relative  value  of  enter- 
ostomy and  enterectomy  from  an  experimental  stand- 
point in  induced  strangulation  in  55  vivisections.  In 
21  resections  he  had  14  cures ;  in  20  cases  of  artificial 
anus,  9  recoveries  and  11  deaths.  Though  we  do  carry 
our  patients  over  the  breach  with  an  artificial  anus,  a 
danger  yet  awaits  him  in  a  future  jointing  of  the  bowel, 
as  no  hope  of  cure  may  be  looked  fur  by  the  unaided 
powers  of  nature  in  artificial  anus,  when  a  section  of 
the  gut  is  done.  Bouilly  observes  that  '•  although  we 
may  find  vestiges  of  fortunate  tentatives  which  have 
been  effected  in  the  management  of  gangrenous  hernia 
in  the  vast  literature  of  ancient  surgery,  no  mention  is 
made  of  any  means  of  cure  of  artificial  anus.  Richter 
alone,  in  1700,  thought  it  possible  by  anastomosis,  but 
regarded  it  as  altogether  too  dangerous  an  undertaking." 
Mr.  Spencer  cites  McCready  as  stating  that  at  the 
present  time,  of  21  London  surgeons,  17  favor  artificial 
anus  and  but  4  the  primary  suture.  Julliard's  expe- 
rience has  been  quite  unique,  as  he  records  20  cases  of 
anastomosis  for  artificial  anus  with  no  deaths,  after 
gangrenous  hernia.  Mr.  Lockwood  was  able  to  collect 
40  cases  of  gangrenous  hernia  treated  after  the  method 
of  Lawrence ;  viz.,  by  a  free  incision  through  the  morti- 
fied part  in  order  to  relieve  the  intestinal  canal ;  or,  if 
the  intestine  had  already  given  way,  to  divide  freely 
the  integument  and  sac  and  leave  the  subsequent  pro- 
gress of  the  case  entirely  to  nature,  practically  leaving 
an  artificial  anus.  Thirty-six  of  these  died — 90%  ; 
4  survived  after  a  long  and  tedious  convalescence, 
and  had  submitted  to  repeated  operations  to  close  their 
fistulae.  This  author  regards  incising  the  bowel  as  the 
most  fatal ;  primary  resection  and  suture  the  next  in 
order  of  fatality,  and  the  least,  the  enterotome.  Kendall 
Franks,  of  Dublin,  collected  202  cases  of  gangrenous 
hernia  from  various  sources  and  in  this  number  the 
mortality  after  artificial  anus  was  80.7%  ;  after  primary 
reaction,  47%.  Ill  collected  notes  on  29  cases  of  arti- 
ficial anus  in  the  United  States  ;  25  died,  86%  mortality. 
Mr.  Wallace,  of  the  Royal  Manchester  Infirmary, 
records  4  cases  of  artificial  anus  posthernial.  all  ending 
fatally.  Chaput  gives  80%  as  the  primary  mortality 
in  above  condition.     Korte,  85.5%  ;  Mikulicz,  76%. 

Duplay  fully  describes  the  dangers,  immediate  and 
remote,  "connected  with  enterostomy  of  gangrenous 
hernia,   and   says  :  "  Artificial   anus    may    heal    spon- 


578 


Thk  Philadklphia"] 
Mbdical  Journal  J 


STRANGULATED  AND  GANGRENOUS  HERNIA 


[Makch  23,  1901 


taneously,  it  may  give  temporary  amelioration ;  but  it 
most  frequently  tends  toward  death  by  inducing  inani- 
tion, or,  what  is  more  frequent,  death  follows  early  from 
a  persistence  of  symptoms  and  an  extension  of  peri- 
toneal invasion.  But,  more,  in  order  to  cure  this  re- 
pulsive state  a  fresh  operation  is  involved,  difficult  of 
execution,  grave  in  character  and  uncertain  in  results." 
The  above  well  epitomizes  this  important  subject ;  for 
look  on  it  as  we  may,  the  construction  of  an  artificial 
anus  in  gangrenous  hernia  can  only  be  regarded  as  a 
dernier  res.sort,  justified  only  when  the  patient  is  border- 
ing on  the  moribund  state  or  is  in  the  hands  of  an  in- 
competent surgeon.  The  economy  of  time  in  its  con- 
struction has  constituted  one  of  its  strongest  claims ; 
but  M.  Chaput  pertinently  observes  that  this  has  been 
exaggerated,  that  a  resection  and  jointing  may  be 
effected  in  30  minutes,  a  limit  no  greater  than  required 
in  the  formation  of  an  enterostomy. 

The  repair  of  a  fecal  fklula — sometimes  miscalled  arti- 
ficial anus — may  occur  of  itself  when  the  sphacelated 
patch  is  of  an  area  which  involves  less  than  half  the 
diameter  of  the  intestine.  Harrington  records  such  a 
case,  in  a  Littrt's  hernia ;  they  are  not  very  rare  in  this 
anatomical  type  of  occlusion. 

Localized  or  superficial,  small  plaques  of  gangrene  we 
may  sometimes  encounter  in  kelotomies  for  strangula- 
tion. These  are  most  frequently  induced  by  violent 
taxis,  the  bowel  has  been  severely  crushed,  the  muscu- 
losa  lacerated,  the  mucous  lining  detached,  but  the 
fibroserous  layer  is  intact.  In  these  cases,  the  whole  ex- 
truded coil  has  sustained  serious  damage,  though  there 
are  only  local  expressions  of  it.  These  may  often  be 
grouped  in  the  category  of  "  doubtful  "  cases.  We  may 
treat  them  by  (a)  leaving  the  loop  outside  and  waiting 
for  time  to  decide;  (h)  we  may  resect  the  gangrenous 
patches  and  suture,  or  bury  them  under  a  row  of  Lem- 
bert  sutures  and  reduce  the  affected  loop;  or  (c)  we 
may  at  once  proceed  to  more  radical  measures  and  re- 
sect the  entire  extruded  loop.  We  here  must  decide  on 
that  course  which  promise.s  the  best  results,  the  least 
danger  of  peritoneal  infection  or  loss  of  life  by  shock 
and  exhaustion.  When  the  vascular  supply  is  not 
compromised,  and  the  full  vitality  of  the  intestine  is 
preserved,  the  exclusion  of  the  small,  ulcerated  patches 
with  a  complete  disinfection  of  the  intestine  will 
warrant  immediate  return  of  it  to  the  abdominal 
cavity  ;  caution,  however,  will  require  here  that  ample 
drainage  is  maintained  until  the  danger  of  peritonitis 
is  past.  When,  however,  in  conjunction  with  these 
localized  contusions  there  is  evidence  of  incipient  gan- 
grenous changes  in  the  entire  loop,  free  resection  is 
called  for. 

PART  VI. 

Pki.marv    Resection   and   Reestablishment   of    the 
Intestinal  Canal  in  Gangrenous  Hernia. 

The  successful  resection  of  diseased  intestine  and  the 
jointing  of  the  divided  ends  certainly  constitutes  one  of 
the  very  greatest  triumphs  of  operative  surgery. 

Theoretically  viewed,  it  appears  like  a  procedure  im- 
possible of  accomplishment.  We  know  that  a  finger 
cleanly  severed  may  sometimes  be  reim planted;  a  part 
of  the  ear,  the  nose,  or  the  integument  may  likewise  be 
restored  and  take  on  vitality.  Homologous  reimplan- 
tation of  various  structures  under  aseptic  precautions 
is  frequently  resorted  to  with  satisfactory  results.  But 
to  resect  part  of  a  tubular  organ  like  the  intestine,  of 


so  complex  a  structure,  and  to  unite  it  in  such  a  man- 
ner as  to  ensure  union  and  immediate  recovery  of 
function  within  a  cavity  so  exquisitel}'  sensitive  to  ex- 
posure or  irritation  as  the  peritoneal,  seems  to  border 
on  the  miraculous  ;  as  Louis  expressed  it,  "  a  marvel  of 
surgical  art."  No  wonder  that  it  was  only  after  the 
progress  of  ages  and  the  futile  efforts  of  numerous  in- 
vestigators, that  in  our  time,  with  the  aid  of  modem 
discoveries,  intestinal  jointing  has  come  to  be  regarded 
as  a  legitimate  and  a  life-saving  operation.  In  gan- 
grenous hernia,  it  is  only  within  the  last  10  years  that 
enterectomy  has  generally  been  re.=orted  to  as  a  proced- 
ure at  all  warranted.  It  is  only  about  25  years  since 
its  great  value  here  was  first  forcibly  impressed  on  the 
profession. 

The  underlying  principle  of  intestinal  anastomosis  or 
jointing  is  embodied  in  the  discovery  announced  by 
Lembert,  the  seroserous  fusion  of  the  intestinal  walls  ; 
although  the  mode  of  introducing  the  suture  in  such  a 
manner  that  only  the  serous  and  muscular  layers  be 
included,  experiment  and  experience  have  proven  of  ho 
essential  consequence,  as  two  of  the  latest  and  most 
efifective  modes  of  securing  junction  entirely  ignore  it 
— Murphy's  and  Connell's. 

In  gangrenous  hernia  calling  for  exclusion  or  the 
separation  of  the  diseased  from  the  healthy,  immediate 
resection  and  jointing  has  the  sanction  of  the  majority 
of  surgeons ;  want  of  accord  is  only  noted  in  technic. 
It  is  well,  however,  to  observe  that  in  the  near  past 
many  were  hostile  to  primary  resection.  Deaver,  of 
Philadelphia,  e.  g.,  states  it  as  his  belief  that  '"  anasto- 
motic operations  are  of  value  in  but  a  few  cases  of 
strangulated  hernia,  ...  in  hernia  the  condition  of 
the  patient  does  not  warrant  the  procedure  of  anasto- 
mosis, and  under  the  most  favorable  circumstances,  the 
operation  is  anything  but  favorable."  He  had  tried 
it  more  as  an  experiment,  and  lost  all  his  patients. 
Resection  and  an  anastomosis  should  not  be  "  experi- 
mental "  affairs  any  more  than  the  performance  of  an 
appendectomy,  but  should  be  governed  by  well-estab- 
lished surgical  principles ;  performed  on  patients 
in  exlremis  it  is  a  barbarity.  Jaboulaj'  pronounces 
"  resection  of  the  intestine  as  a  difficult  and  grave 
procedure."  Mr.  F.  Treves  says  that  "  in  cases  in  which 
gangrene  exists  experience  is  against  any  attempt  to 
unite  the  divided  ends  of  the  bowel  immediately  after 
the  necrosed  portion  is  excised.  Such  measures  have 
been  carried  out  with  success  in  a  lew  recorded  cases, 
but  it  is  a  very  hazardous  procedure  and  neither  the 
state  of  the  patient  nor  the  intestine  will  usually  sanc- 
tion the  somewhat  elaborate  and  possibly  protracted 
operation."  Mr.  Treves  is  certainly  in  error  when  he 
speaks  of  "  a  few  recorded  cases"  succeeding,  as  these 
are  now  comparatively  numerous,  in  fact  of  such  fre- 
quent occurrence,  that  many  of  them  are  not  reported. 
With  the  proper  preparation,  the  procedure  is  not  at  all 
perilous  nor  does  it  involve  fresh  risks.  The  only  seri- 
ous drawback  is  the  frequent  exhausted  state  of  the 
patient,  to  such  a  degree  as  to  justify  no  description  of 
radical  surgery. 

Stad-'^-tics  from  Various  Author.^ — Within  the  past  ten 
years  there  have  appeared  extensive  statistical  tables  on 
the  subject  of  the  relative  value  of  resection  of  the  in- 
testine for  various  pathological  conditions.  The  first  in 
this  country,  as  it  applied  to  gangrenous  hernia  by  Dr. 
A.  J.  McCosh.  1 889,  the  latest  in  the  recent  valuable 
contribution  of  Dr.  Gibson.  The  latter  collected  226 
cases  of  primary  enterorrhaphy  with  oS  deaths,  mor- 


March  23,  1901] 


STRANGULATED  AND  GANGRENOUS  HERNIA 


riHK  Philadelphia 
L  Medical  Journal 


579 


tality  26%.  Croft,  in  1894,  recorded  13  treated  by  arti- 
ficial anus  ;  all  died.  Kendall  Franks  the  year  before 
reported  220  cases  gathered  from  various  sources,  of 
primary  resection,  of  which  Croft  declares  but  very  few 
belonged  to  English  surgeons.  Segond,  in  1894,  pub- 
lished details  of  three  cases  of  primary  resection  under 
his  own  care.  All  died.  Up  to  1883  Reichel  could  find 
but  56  recorded  cases  of  j)riniary  resection  ;  29  deaths  ; 
51.44%  mortality.  Carson  from  this  date  to  1887  added 
21  more;  8  died,  13  recovered,  one  with  artificial  anus 
or  large  fistula.  Czerny  and  Hahn,  in  1898,  set  the 
mortality  at  47%,  Mickulicz,  33%,  Borchard,  36%. 
McCosh,  in  1889,  collected  113  cases  of  primary  resec- 
tion in  gangrenous  hernia  which  gave  a  mortality  of 
50%.  Five  years  later,  the  same  author  recorded  three 
more  of  the  same  class,  all  recovering,  in  his  own  ser- 
vice. Ziedler  gives  the  mortality  as  49%  from  primary 
resection  and  74%  from  artificial  anus.  Frank,  mor- 
tality, 48%  primary  resection,  80%  artificial  anus. 
Madyl,  mortality,  22%  primary  resection.  Wal- 
lace, mortality,  25%  primary  resection,  90%  arti- 
ficial anus.  Serru  in  October,  1893,  reported  37  cases 
of  resection  in  hernia ;  9  complete  cures ;  cured 
after  fistula,  8  ;  artificial  anus  left  in  one ;  there  were 
18  deaths.  Madelung,  44  cases  resection  in  hernia,  23 
recovered,  53%  ;  22  cases  of  artificial  anus  later  closed 
by  suture;  there  were  8  deaths,  36%.  Dr.  Bovis  re- 
corded 17  cases  of  resection  and  anastomosis  for  same 
condition  before  1889;  10  deaths,  69%;  since  188S- 
1891,  51  cases,  19  deaths,  37%. 

Makins,  39  cases  resection  and  anastomosis,  15  deaths, 
38%.  Bouilly,  29  cases  resection  and  anastomosis,  11 
deaths,  37%.  Korte,  28  artificial  anus,  16  deaths,  57%. 
Friederichshain,  26  artificial  anus,  20  deaths,  76%. 
Poulsen,  54  artificial  anus,  mortality  86%.  Chaput, 51 
artificial  anus.  Recovered  86%.  Chaput,  67  primary 
jointing.     Recovered  46%. 

Lock  wood's  statistics  show  88%  mortality  for  artifi- 
cial anus.  In  1894  combined  statistics  of  Czerny, 
Reidel,  Kocher,  Hagedorn  and  Hahn,  64  cases  of 
primary  resection,  32  deaths,  50%.  Barette's  statistics, 
49  cases  primary  resection,  23  deaths,  47%. 

Gibson  sets  down  failure  of  technic  as  responsible  for 
13%  of  deaths  after  resection. 

My  own  experimental  work  wherein  I  was  able  to 
verify  the  cause  of  death,  by  autopsy,  in  every  instance, 
it  was  proved  conclusively  that  faulty  technic  was 
always  responsible  for  the  fatal  ending.  This  has  been 
well  borne  out,  too,  in  my  unfortunate  first  cases  of 
resection  in  the  human  being,  and  my  later  cases  which 
survived. 

Recorded  statistics  conclusively  prove  that  the  opera- 
tion of  primary  resection  with  its  larger  application  has 
a  steadily  reduced  mortality,  in  general,  much  less  than 
the  production  of  an  artificial  anus,  although  it  is  well 
to  remember  that  an  enterostomy  of  late  years  is  only 
resorted  to  in  very  desperate  cases ;  those  in  which,  as 
Moyenhan  well  observes,  "  resection  of  the  loop  and 
suture  of  the  ends  is  most  satisfactory,  but  there  are 
not  a  few  patients  in  whom  such  a  course  would  be 
wholly  unjustifiable." 

These  statistics  include  96  cases,  several  with  incom- 
plete data.  There  were  68  recoveries,  21  deaths,  in  7 
result  not  stated — mortality  general,  30.88.  Mortality 
in  end-to-end  enterorrhaphy  by  suture— 57  cases;  14 
deaths,  25.25.  Murphy  button,  16  cases,  3  deaths, 
20.20.  Senn  plate,  5  cases,  1  death,  20.00.  Connell 
suture,   4   cases,    0   deaths.     Twelve   cases   of    mixed 


methods  treated.  There  were  45  females,  32  males,  in 
19  sex  not  stated. 

The  Senn  plate  was  first  described  in  1889.  It  was 
soon  discarded  as  unsatisfactory  in  gangrenous  hernia. 
Murphy  pul)lished  the  description  of  his  metallic  double 
disc  in  1894.  It  has  proved  unrivalled  as  a  means  of 
jointing  for  various  pathological  states  of  the  intestine, 
but  after  resection  for  gangrenous  hernia  it  has  been 
largely  set  aside  as  inferior  to  the  suture,  the  Connell 
mode  of  adjustment  having  the  preference  with  those 
who  are  familiar  with  its  technic. 

Temporary  Evisceration  with  Lateral  Anastomosis  in  Situ, 
in  Gangrenous  Hernia. — In  certain  cases  of  gangrenous 
hernia  rather  than  form  an  artificial  anus  or  do  a  resec- 
tion, some  authors  have  recommended  the  withdrawal 
of  the  suspected  loop  after  relieving  the  constriction, 
imbedding  it  in  warm,  aseptic  dressings  and  delay  for 
24  hours  or  more,  in  order  to  determine  if  the  death  of 
the  part  is  complete,  or  to  what  limit  it  may  have  ex- 
tended. Although  this  procedure  has  been  suggested, 
I  am  unable  to  find  any  recorded  cases  wherein  it  has 
succeeded,  nor  does  it  appear  to  be  a  means  that  is 
without  serious  drawbacks.  A  strangulated  loop  at  all 
approaching  the  mortified  condition  is  in  a  paralyzed, 
crippled  state,  outside  the  abdomen  the  mesentery  is 
placed  in  a  condition  of  tension  with  a  languid  circula- 
tion. The  endothelial  investment  of  the  intestine  is 
endowed  with  a  most  exquisite  sensibility  to  irritation ; 
hence,  on  exposure,  it  quickly  presents  evidences  of 
inflammatory  changes,  loses  its  gloss  and  becomes 
granular.  Therefore,  even  though  the  intestine  were 
found  to  have  preserved  its  full  vitality,  its  return  to 
the  cavity  of  the  peritoneum  after  an  abode  of  24  to  48 
hours  outside  of  it,  would  be  quite  certain  to  involve 
free  adhesions  and  more  peril  than  had  it  been  reduced 
in  the  first  place.  The  loss  of  the  serous  tunic  in  the 
repair  and  reduction  of  a  healthy  intestine,  the  former 
seat  of  an  artificial  outlet,  is,  without  doubt,  a  more 
serious  impediment  to  union  and  restored  function  than 
the  temporary  spur  formed ;  and  reasoning  from  an 
analogy  we  must  anticipate  the  same  difficulties  from 
temporary  evisceration  in  gangrenous  hernia. 

The  procedure  of  Helferich,  of  anastomosing  the  healthy 
intestine  on  either  side  above  the  gangrenous  loop,  the 
latter  to  remain  in  the  wound  until  the  patient  has 
fully  reacted,  when  it  is  resected  has  nothing  to  recom- 
mend it.  It  has  all  the  objections  of  temporary  evis- 
ceration ;  it  is  a  more  serious  procedure  than  the 
formation  of  an  artificial  anus  without  its  advantages. 
The  temporary  anastomosis  will  occupy  quite  as  much 
time  as  to  effect  a  clean  resection  jointing  and  reduc- 
tion ;  and  in  any  event  involves  later,  another  difficult 
and  dangerous  operation.  It  is  at  the  present  time 
quite  generally  discarded. 

Seco)idary  Resection. — Fecal  fistula,  artificial  anus  and 
physiological  exclusion  with  lateral  jointing  in  gangren- 
ous hernia,  all  call  for  consecutive  intestinal  resection, 
after  the  patient  has  recovered  from  their  immediate 
dangers.  At  this  stage  one  would  expect  that  there 
should  be  a  low  mortality,  but  in  resection  and  joint- 
ing, as  has  been  seen,  the  latest  writer  on  the  subject, 
Gibson,  has  rated  it  the  same  as  primary  resection. 
Reichel  places  the  mortality  as  37.8,  Hartzburg,  27,  and 
Makins,  28.4.  Lockwood  very  pertinently  observes 
that  "  we  must  bear  in  mind  that  those  on  whom  sec- 
ondary suture  is  performed  are  the  rare  survivors  of  a 
most  fatal  class  of  cases ;  moreover,  the  successful  cases 
recorded  are  of  fecal  fistula  rather   than   gangrenous 


^QQ  The  Phii^dei^hia"] 

Medical  Joce>'al  J 


STRANGULATED  AND  GANGRENOUS  HERNIA 


[Masch  23,  19C1 


hernia."  Newman  believed  that  secondary  resection 
was  less  mortal,  but  noted  that  this  was  only  resorted 
to  in  those  who  had  survived  a  most  dangerous  disease. 


Richter,  in  1788,  first  successfully  resected  the  bowel 
secondarily  for  gangrenous  hernia.  Seventy-five  year- 
later,  in  1863,  Kinloch,  of  South  Carolina,  U.  S.,  per- 


Statistics  on  Cases  of  Gaxgrenods  Hebxia  Treated  by  Resectios,  is  Decade  from  1891  to  1901. 


AfTHOE. 

YEAR. 

1900 

SE.T. 
F. 

AGE. 

HERMA. 

mode  of  jonr-mfG. 

EESCI.T. 

UTEEATUItK. 

DATK. 

C.  S   Hamilton  (4). 

7 

? 

;  End  to-end  suture. 

Three  recov'd,  1  died- 

Columbus  Medical  JoumaL 

Sept.,  1900 
Kov.,  1899 

C.  Morean. 

lgi«y 

M. 

33 

Inguinal. 

•'       '*       " 

EecoTered. 

Bull,  de  !■  Acad,  de  Med.,  Belgium. 

A.  J.  McCosh  (SJ. 

,    1897 

1 

2  F. 

25,  43, 
66 

• 

>4                tt                •• 

** 

Annals  of  Surgery. 

1897 

aPage. 

1894 

F. 

•> 

Crural. 

End-to-end  satare. 

Death. 

London  Lancet,  p.  901 ,  voL  i. 

1894 

1893 

F. 

45 

XoguLnal. 

11        It        i( 

Rec  very. 

SchlaDge. 

1S93 

M. 

50 

Umbilical. 

41              <l              H 

Klin.  Cbir.,  p.  674. 

1893 

Sacbs. 

1893 

F. 

64 

Crural. 

11              l(              il 

•• 

Arch,  fur  k.  Chir. 

1894 

HeDgeler. 

1893 

F. 

9 

*' 

*•              ••              " 

«« 

1894 

Nammack. 

1893 

F. 

'    as 

" 

•  (              ••              (1 

«< 

•.         11         .1 

1894 

A.  Lane 

1893 

F. 

39 

IngiiinaL 

Senn-plates. 

" 

Tr.  Med.  Chir.  Sot,  Edinburgh. 

Laks. 

1391 

? 

1            7 

1  „ 

End-to-end  suture. 

" 

Cvnt.  fur  Chir.,  So.  41. 

1891 

Souiham  (3;. 

1891 

F. 
F. 

1           9 

Doibilical. 

<(        ti        <( 

Death. 

London  Lancet,  voL  il 

1891 

Lock  wood. 

1891 

F. 
M. 

•> 

17 

Inguinal. 

!!        \\        !i 

Recovery. 

Med. -Chir.  Trans..  voL  xiv. 

1891 

Uoyot  (2). 

1S95 

F. 

43 

;Cmral. 

"        "        " 

" 

Arch.  Prov.  de  Chir. 

Haahs. 

I>92 

F. 
F. 

41 
47 

''• 

«. 

Death. 

<'.             1,                u 

1835 
1895 

Duchamps. 

1893 

M. 

52 

Inguinal. 

"                    •!                    tt 

" 

Gaz.  Heb.,  12. 

189S 

0.  P.  Thomas. 

1900 

F. 

42 

Inguinal  Strang. 

Murpbj  button. 

Recovery. 

Am.  Jour.  Gynec.  and  %urg. 

1833 

B.  M.  Eicketts. 

1900 

It 

30 

Inguinal. 

'•            " 

Death. 

Cincinnati  Lancet  Clinic. 

Dec.,  1900 

C.  E   Brewer. 

1899 

M. 

'.' 

" 

M                        It 

Recovery. 

Medical  Etcord,  p  58. 

1900 

Newboldt  (2j. 

1900 

F 
M. 

70 
41 

Crural. 

"                        \\ 

" 

London  Lancet. 

IMW 
IIUD 

R.  W.  Marrav. 

1900 

M. 

? 

? 

End-to-end  suture. 

•  ■ 

Gaz.  Med.  Juin. 

Nov.,  1900 

Temier. 

1898 

F. 

60 

Cmbilical. 

"        "        •' 

189S 

Herman. 

1898 

F. 

75 

Crural. 

Through-and -through  suture. 

»' 

Medico-Cbir.  Trans. 

1891 

Kendall  Fnuiks. 

189S 

F. 

3« 

CmbUical. 

End-to-end  suture; 

•• 

Rev.  de  la  Suisse,  45. 

1896 

Patry. 

1895 

M. 

80 

Inguinal. 

ti        .. 

*' 

Gaz.  des  H6p.,  Paris,  212. 

183S 

Gro«. 

189S 

M. 

20 

" 

"        "        " 

Death. 

Boston  M.  and  S.  Jour.,  p.  207. 

1893 

Gay  (2). 

1892 

F. 
F. 

60 
55 

Cmbilical. 
Crural. 

\\   \\   w 

Eecoverr. 

1S92 
1S9Z 

Richardson. 

1892 
1891 

M. 
M. 

22 
40 

InguinaL 

Fistnla  foUn»ed. 

Lincet,  p.  988. 
LaScien.  Med.,  Mai. 

1831 

Coller.  D. 

Recovery. 

1891 

Delbel. 

1892 

H. 

40 

** 

End-to  end  suture. 

Death. 

K.  A  Med.  Journal,  p.  64S. 

1892 

Watkins  (3) 

1894 

M. 

M. 

19 
26 

•> 

**        **        " 

Recovery. 

18»l 

I8»4 

F. 

".' 

? 

11        (t        1. 

Two  deaths. 

Wiener  Woch_,  p.  920. 

I8»l 

Rydygier  (4) 

J894 

Recovery. 

Lehigh  Valley  Med.  Mar. 

1894 

E^tes,  W.  L. 

1897 

M. 

'65" 

loguinal. 

End-to^nd  suture. 

Death. 

Aui^a  s  of  Surgery,  p.  515. 

1897 

Abbe,  S. 

1895 

M. 

40 

•• 

*■        "        ** 

Kecoverv. 

Giz.Mt:d.,p.  95. 

189S 

Elefleiades. 

1896 

F. 

65 

Crural. 

"        .1        It 

Drath. 

Jour.  Am.  Med.  Assn,  p.  .•597. 

1896 

Davis,  T. 

1897 

M. 

36 

logulnal. 

Lateral  anastomosis. 

Recovery. 

Med.  Woho  ,  St.  Petersburg. 

IMS 

Rudolff. 

1092 

F. 

3S 

•* 

End-to-end  suture. 

Annals  .il  Surgerv,  p.  340. 

1830 

RausataofT. 

1892 

F. 

56 

'* 

>{       ti       (. 

»' 

Bull  della  \cad.  M.,  Roma. 

18*2 

Paoii. 

1892 

M. 

SO 

Crural. 

li             II             11 

«i 

N.  W.  Lancet,  p.  131. 

\tat 

Graff  {2'. 

1892 

F. 
F. 

58 
40 

'•'. 

Senn-plate. 

Lateral  anastomosis. 

*• 

1892 
1893 

RawdoD  (2). 

1898 

M. 

M. 

38 
39 

InguinaL 

Uurpbj  button. 

Recovered. 

Liverpool  Med.-Chir.  Jour. 

1838 
1898 

Felicia 

1898 

M. 

65 

" 

End-to-end  suture. 

" 

La  Riforma  Medica. 

1898 

Bennekp. 

1897 

M. 

•; 

ti 

il       It       II 

Death. 

L'Ann^  Chir. 

1898 

Alb  ni  (4). 

18S7 

4 

9 

•> 

1.       It       11 

Three  recov'd,  1  death. 

1898 

Frederi'^i 

1898 

M. 

47 

Umbilical. 

II       ti       II 

Recovery. 

Rilbrma  Medica. 

1898 

Henzel  (7). 

1899 

? 

* 

Revue  de  Chir. 

1839 

Manley,  T.  H.  (2) 

1896 
1901 

M. 
M. 

'it' 

29 

Inguinal. 

Lateral  anastomosis. 
Connell  suture. 

Recovery. 

(1)  Annals  of  Surgery. 

1897 

Gatui. 

1892 

F. 

51 

Cmbilical. 

" 

Sperimentale  Firenze. 

1832 

Daniels. 

1891 

M. 

46 

Inguinal. 

Eod-to-end  suture. 

Death. 

Texas  Med.  Jour. 

1891 

Walker,  H.  0. 

1894 

F. 

50 

CruraL 

11       It       II 

Recoverv. 

Med.  Record,  p.  661. 

1834 

Segond  ri) 

1894 

F. 

F 

39 
60 

t 

11       11        il 

Dath. 

Bull,  et  Mem.  de  la  Sac.  de  Chir. 

1894 

JI. 

40 

• 

11 

.i 

Bull,  et  Mem.  de  la  Soc.  de  Chir. 

1834 

Beck,  Carl   2). 

1892 

F. 
M. 

57 
45 

Umbilical. 
Inguinal 

!!     i!     W 

Eecorery. 

Medical  Record,  p.  416. 

189S 
1838 

Andrews,  A.  F.  (2). 

1892 

-> 

? 

t 

Murphy  button. 

•  ' 

Jour.  .Am.  Ued.  Aai*n. 

I89S 

Bouffleur. 

1893 

F. 

57 

Umbilicai. 

Eod-io-end  suture. 

t< 

Rogers. 

1893 

M. 

50 

loguinal. 

'. 

Memphis  Med. 

189« 

Graff.  W.  W. 

1893 

M. 

47 

Crural 

Senn-plate. 

Death. 

London  Lancet. 

IS9S 

Jaboiilar. 

1895 

? 

V 

lagiiiual. 

End-to-end  suture. 

Recovery. 

Revue  de  Chir. 

Jan.,  1896 

Jouillard  (2). 

ll>95 

M. 

U. 

56 
6.: 

\\ 

II                    11                    •! 

1893 
1896 

VUliard  (4). 

1893 

4F. 

56,  iiO, 

42,66 

40 

Crural. 

nio-colic.    M.  B.,  3 ;  suture,  I. 

All  recovered. 

Tr.  Asa'n  Fran^ais  de  Oiir. 

1836 

Martin.  F.  H. 

19(10 

F. 

Tntest.  obstruction. 

Council  suture. 

Recovery. 

Jour.  Am.  Med.  Aas'n,  Kov.  3. 

19M 

Kowler.                     i 

1898 

F. 

? 

Umbilical. 

Murphy  button. 

" 

*.            ..             •• 

1838 

McGuire. 

1898 

F. 

? 

" 

It            .. 

1. 

•t            ..             .1 

18*3 

O.ieT. 

1897 

F. 

^o 

loguinaL 

End-to-^Dd  sutures. 

Death. 

PeraotuI  communication. 

1838 

Meyer. 

1893 

F. 

68 

** 

II       11       It 

Recovery. 

Annals  of  Surgery. 

1898 

Morris,  R. 

1897 

M. 

70 

" 

Murphy  button. 

•* 

Per^onU  communication. 

1897 

Lavoise. 

1898 

F. 

49 

Crural. 

End  to-end  suture. 

•* 

Rev.  Med.  de  la  S.,  Rom. 

1836 

Marchand  (2). 

M. 

35 

iDguioaL 

(. 

1838 

Montgomery  (2). 

1897 

2F. 

29,35 

Crural. 

It        11        1. 

•• 

Brlu  Med.  Jour.,  voL  i,  p. 72. 

1997 

Williamson. 

1899 

F. 

62 

UmbUicaL 

Murphy  button. 

•' 

1899 

Barker  (2). 

1899 

F. 

46 

CruraL 

End-to-end  suture. 

" 

M. 

20 

laguinaL 

Through  and-ihreugh  suture: 

■• 

BidwelL 

1900 

F. 

60 

" 

Lateral  anastomosis. 

•* 

London  LanceL 

JuB«,19W 

Comberraale. 

1900 

F. 

40 

CruraL 

End-to-end  suture. 

" 

L>  Nord-Medicale.  15  ka. 

1906 

Kaijar  (3). 

1898 

? 

It        11        It 

Hygiea.  Stockholm,  p.  1S9. 

1898 

.Spencer. 

1895 

F. 

77 

rVaraL 

Murphy  button. 

Death. 

Loudon  Lancet,  May  11. 

lS9o 

Neely. 

1900 

M. 

19 

InguinaL 

11 

Recovery. 

Memphis  Med.  Die. 

19M 

1895 

F. 

44 

CruraL 

End-to-end  suture. 

Glasgow  Med.  Jour,,  p.  S5. 

1895 

Dalton,  H.  C. 

1S97 

M. 

45 

InguinaL 

«i 

Trans.  Mo.  Med.  Ass'n. 

1887 

Douglas. 

189S 

M. 

55 

Crural. 

Murphy  button. 

it 

Brit.  Mei.  Jour.,p.  S2S. 

1836 

AahhorsL 

1897    1 

U. 

■• 

Inguinal. 

••            II 

Death. 

Jour.  An.  Med.  Ass'o. 

1897 

Sampter. 

189S 

F. 

45 

CruraL 

Ead-to-end  suture. 

Recovery. 

Cent,  fiir  Chir.,  p.  195. 

1S3S 

Mari  a  ' 


i90j| 


STRANGULATED  AND  GANGRENOUS  HERNIA 


EThe  Philadelphia 
Medical  Journal 


581 


formed  successfully  the  first  secondary  resection  of  the 
bowel  in  America.  It  was  not  for  hernia,  however,  but 
a  gunshot  wound,  and  it  appears  too,  that  a  small  fecal 
fistula  remained  for  some  time  after  the  bowel  was 
resected . 

Bouilly  and  Assaky,  up  to  1883,  could  find  on  record 
but  27  operations  for  the  closure  of  artificial  anus  ;  26 
after  gangrenous  hernia  ;   17  were  successful. 

In  1881,  Rydygier  reported  18  cases ;  in  1882,  Made- 
lung  22,  from  various  sources,  the  same  ratio  of  re- 
coveries noted,  as  by  Bouilly. 

In  order  to  ensure  the  best  results  after  secondary 
resection,  the  patient  should  l)e  in  a  state  to  promptly 
recuperate  from  the  shock  of  the  operation,  as  little 
blood  as  possible  should  be  wasted.  A  free  resection 
should  be  made  widely  from  parts  the  seat  of  patholo- 
gical changes.  This  favors  early  union  and  an  escape 
from  the  dangers  of  necrosis  at  the  site  of  suture. 

PART  VII. 

On  the  Mode  of  Jointing  the  Divided  Ends  of  the 
Intestine  after  Resection  of  a  Gangrenous  Loop. 

Up  to  the  time  of  the  report  of  my  own  case  of  re- 
section of  a  gangrenous  loop — 30  inches  long — after 
strangulation,  my  patient  making  a  prompt  recovery, 
I  can  find  no  case  on  record  in  which  any  other  pro- 
cedure was  adopted  to  unite  the  divided  intestine  and 
reestablish  the  alimentary  canal,  than  by  invagination, 
or  end-to-end  junction,  in  gangrenous  hernia. 

The  end-to-end  mode  of  junction  appealed  to  sur- 
geons as  the  most  rational  because  it  restored  the  direct 
continuity  of  the  canal.  Mr.  Thomas  Bryant,  in  writing 
on  the  technic  of  end-to-end  enterorrhaphy,  and  the 
obstacles  in  the  way,  said  "  he  could  not  conceive  any- 
thing more  difficult  than  to  unite  the  separate  segments 
of  the  bowel,  one  infiltrated  and  distended  and  the 
other  patulous  and  collapsed." 

The  various  mechanical  appliances  and  sutures  have, 
scarcely  without  exception,  in  intestinal  resection  for 
mortified  hernia,  been  utilized  in  efTecting  end-to-end 
union.  But  its  range  of  applicability  was  found  limited 
until  Murphy's  button  was  invented  in  1894.  This 
contrivance  enormously  simplified  end-to-end  junction 
and  greatly  reduced  its  mortality  from  leakage  at  the 
mesenteric  border. 

Dr.  William  Evans,  of  Chicago,  in  a  recent  study  of 
the  question  of  stenotic  contraction  after  union  or 
circular  enterorrhaphy,  denies  that  stricture  ever  follows 
the  line  of  junction.  Stricture  of  a  tubular  passage 
only  occurs  in  a  permanent  form,  after  an  extensive 
loss  of  mucous  membrane,  something  entirely  absent 
on  reconstructed  intestine. 

Lateral  anastomosis  as  a  substitute  for  end-to-end 
enterorrhaphy,  after  intestinal  resection,  was  first 
brought  to  the  notice  of  the  profession  by  Dr.  M.  E. 
Connell,  another  Chicago  surgeon,  the  pioneer  in  experi- 
mental intestinal  surgery  in  America.  At  the  time 
when  he  published  a  description  of  the  suture  which 
bears  his  name,  he  called  attention  to  the  greater  safety 
and  security  of  lateral  anastomosis  as  contrasted  with 
end-to-end  jointing.  He  claimed  for  it,  an  escape  from 
the  dangers  of  leakage  at  the  mesenteric  border,  in  the 
facility  of  execution  with  intestines  not  corresponding 
in  caliber,  and  finally  the  prompt  and  full  restoration  of 
function  after  this  mode  of  jointing.  But  his  deduc- 
tions were  based,  like  Lembert's  original,  entirely  on 
experimental    research   and    on    theoretical    grounds. 


This  substitute  for  jointing,  together  with  his  new  suture, 
were  rejected  for  a  time  by  the  profession. 

From  a  speculative  standpoint,  there  stood  out  three 
glaring  objections  to  lateral  jointing.  The  first  was, 
that  it  entailed  the  closure  of  4  openings  instead  of  2  ; 
second,  it  left  two  blind  pouches,  or  diverticula  ;  third, 
it  forced  a  deflection  of  the  course  of  the  fecal  current 
from  one  loop  of  intestine  into  another.  It  would 
certainly  seem  to  involve  a  positive  disturbance  in  the 
physiology  of  digestion.  But,  practically,  we  find 
nothing  farther  from  the  fact.  In  my  first  case  with 
a  large  resection — lateral  anastomosis  near  the  distal 
end  of  the  ileum — my  patient,  now  4  years  since  the 
operation,  has  gained  30  pounds  in  weight  and  has  per- 
fect digestion.  In  my  second  case  the  ileum  was  divided 
close  to  the  distal  end  and  was  laterally  implanted  on 
the  cecal  wall — ileocecal  anastomosis  lateral.  In  2 
months  my  man  weighed  15  pounds  more  than  before 
the  operation,  and,  notwithstanding  the  functionless 
state  of  the  ileocecal  valve,  he  has  vigorous  digestion. 

Bidwell,  in  recording  his  experience  in  resection  for 
gangrenous  hernia,  expresses  his  belief  that  lateral 
anastomosis  is  much  safer  than  end-to-end. 

Mr.  Greig  Smith  did  not  favor  lateral  anastomosis, 
he  alleged,  "  as  there  is  as  much  time  consumed  in 
closing  the  two  ends  as  is  necessary  to  make  a  circular 
enterorrhaphy."  As  far  as  function  was  concerned,  he 
regarded  it  of  little  importance,  as  to  the  axes  of  the 
bowels,"  whether  they  were  jointed  end-to-end  or  later- 
ally, the  question  being  quite  wholly  a  practical  one." 

In  1889,  Jessett  laterally  anastomosed  the  divided 
ileum  with  the  cecum,  after  the  excision  of  a  new 
growth,  the  patient  sinking  on  the  fourteenth  day. 
There  are  several  cases  scattered  through  surgical  litera- 
ture of  successful  lateral  anastomosis  after  resections  for 
neoplasms  ;  while  for  unilateral  exclusion  or  mechanical 
obstruction  no  operation  on  the  intestinal  canal  is  more 
common  or  more  effective. 

In  a  recent  valuable  contribution  by  MM.  Terrier 
and  Gosset  it  is  maintained  that  in  bilateral  exclusion 
of  the  bowel  with  resection  of  the  intestine  for  gan- 
grenous hernia,  end-to-end  junction  with  Murphy's 
button  is  a  great  saver  of  time ;  but  that  in  the  reestab- 
lishment  of  the  tractus  intestinalis  lateral  enteroanasto- 
mosis  may  be  performed  with  great  facility  and  its 
functional  results  are  perfect.  Reichel  has  demonstrated 
that  here  the  diverticula  at  the  ends  atrophy  and  con- 
tract. Von  Frey,  by  a  series  of  experiments  on  animals, 
pointed  out  that  after  6  months,  in  lateral  anastomosis, 
the  intestinal  current  assumes  a  perfectly  straight  direc- 
tion. This  view  is  supported  by  von  Haecker,  who 
found  that  the  closed  ends  have  so  apposed  that  the 
afterent  coil  will  continue  in  the  direction  of  the  eflerent. 
Gibson  remarks  that  some  resort  to  this  means  to  do 
away  with  the  danger  of  necrosis  of  the  suture  line,  as 
well  as  to  effect  perfect  union  when  dealing  with  seg- 
ments of  uneven  caliber. 

The  special  advantages  of  lateral  anastomosis,  in  cases  oj 
gangrenous  hernia,  are : 

First  and  greatest,  it  obviates  that  lurking  danger, 
always  present  in  end-to-end  circular  enterorrhaphy, 
viz.,  consecutive  leakage  at  the  dead  space  in  the  mesen- 
teric border. 

Secondly,  it  secures  the  jointing  of  the  segment  of 
the  intestine  in  full  vascular  activity. 

Thirdly,  it  permits  of  the  greatest  rapidity  and  facility 
of  execution. 

Fourthly,  it  completely  obviates  the  possibility  of 


5S2 


The  Philu>klphia'1 
MsDiCAL  Journal  J 


STRANGULATED  AND  GANGRENOUS  HERNIA 


[Uabcu  23,    1901 


ultimate  annular  stenosis  or  a  contractured  narrowing 
of  the  aperture. 

My  own  experience  with  this  mode  of  jointing  after 
resection,  based  on  an  extended  series  of  experiments 
on  the  lower  animals,  and  in  two  aggravated  cases  of 
gangrenous  hernia  employed  after  the  method  of  Con- 
nell,  induces  me  to  recommend  it  in  all  cases,  as  simpler, 
safer,  and  more  effective  than  end-to-end  union  by  any 
of  the  numerous  devices  now  employed. 

On  the  Technic  Employed  in  Uaitinf/  the  Divided  or 
Excluded  Intestine. — The  elements  which  are  essential  to 
success  in  intestinal  resection  in  gangrenous  hernia, 
besides  asepsis  and  proper  preparation,  are: 

1.  Those  means  which  effectively  restore  the  contin- 
uity of  the  intestine  and  securely  wall  off  the  intestinal 
from  the  peritoneal  cavity. 

2.  The  economy  of  time. 

3.  The  fullest  possible  circulation  to  the  traumatized 
parts. 

The  Law  of  Lemberl. — The  principle  laid  down  by 
Lembert,  that  in  order  to  secure  the  firmest  possible 
adhesions  between  the  divided  intestine,  it  is  only 
necessary  to  appose  their  serous  surfaces,  remains  unas- 
sailable ;  but  he  certainly  was  in  error  when  he  taught 
that  in  the  introduction  of  the  suture,  danger  was  in- 
vited if  we  carried  it  through  all  the  coats  of  the 
intestine.  In  fact,  the  modern  stupendous  advances  in 
intestinal  surgery  only  began  when  this  precept  was  cast 
aside.  Senn's  celebrated  essay  in  1889  marked  the 
beginning  of  the  new  epoch.  The  adjustment  of  his 
decalcified  bone  plate  required  the  suture  to  pass 
through  all  the  coats  of  the  gut. 

In  the  preliminary  purse-string  suture,  in  the  Murphy 
button  operation,  it  is  a  matter  of  no  importance 
whether  the  needle  pass  through  all  the  coats  of  the 
intestine  or  not.  In  Connell's  suture  the  needle  passes 
in  and  out  through  all  the  coats.  The  mythical  objec- 
tion, that  a  through-and-through  suture  necessarily 
involves  a  fistulous  passage  from  the  mucosum  out,  has 
absolutely  nothing  to  support  it.  The  fatal  defect  in 
intestinal  jointing  before  Senn's  plates  were  invented 
was  that  the  peristaltic  movement  of  the  intestine  began 
be/ore  the  seroplastic  cement  was  sufficiently  organized  to 
hold  the  ends  of  the  bowel  in  position  ;  and  the  sutures 
being  numerously  applied,  they  superficially  reduced 
the  vitality  of  the  parts,  readily  tore  out  and  permitted 
of  a  fatal  extravasation.  Senn's  plates  impressed  one 
as  large  and  clums}',  but  they  were  strong  and  resistant ; 
however,  their  introduction  required  special  skill,  they 
were  not  time  savers,  and  they  were  a  foreign  bodj' ; 
nevertheless,  they  were  a  distinct  gain  over  any  means 
in  use  before  their  time,  because  they  maintained  a  firm 
grip  on  the  ends  of  the  gut  and  held  it  in  position  until 
union  was  secure. 

Various  devices  were  invented  after  the  Senn  plates, 
but  none  of  them  possessed  any  especial  advantage  over 
them  until  Murphy  perfected  his  wonderful  invention, 
a  double  disc  whicli  not  only  holds  the  ends  of  the  in- 
testine securely  compressed  against  each  other,  but  at 
the  same  time  affords  a  continuous  lumen,  takes  a  bite 
out  of  each  end  of  the  intestine,  finally  the  machine  be- 
coming detached  and  thrown  off  by  the  rectum,  when 
it  may  be  cleansed  and  immediately  sterilized  for 
another  bout. 

But  perfect  as  this  apparatus  is,  it  has  many  serious 
drawbacks ;  it  requires  both  skill  and  tact  to  readily 
employ  it  to  advantage.  It  must  be  properly  con- 
structed and  of  such  diameters  as  correspond  with  the 


lumina  of  the  divided  intestine.  The  rim  of  the  button 
may  cut  unevenly  or  it  may  become  clogged  with  feces. 
A  heavy  button,  segmenting  the  small  intestine,  dropped 
into  the  abdominal  cavity  may  cause  a  kinking  of  the 
coil  and   thus  induce  obstruction. 

Three  years  ago.  Prof.  Senn  informed  me  that  he  had 
discarded  all  apparatus  and  depended  on  the  suture 
alone.  Villard  says  that  in  gangrenous  hernia,  an 
anastomotic  button  constructed  on  Murphy's  model 
should  be  the  method  of  choice  on  jointing.  .lonathan 
Hutchinson,  Jr..  says,  on  the  contrary,  he  has  been 
working  on  the  statistics  of  resection  of  the  intestine  for 
gangrenous  hernia  and  had  found  that  when  the  Murphy 
button  had  been  used  there  were  only  7  %  recoveries, 
and  40%  when  the  direct  suture  was  employed. 

On  the  Mode  of  Suturing  and  Suture  Materials. — If  we 
discard  anastomotic  apparatus,  what  method  of  suture 
must  commend  itself?  .Jaennell  observes  that  "  suture 
must  fulfil  two  conditions;  it  must  close  the  wound 
in  the  intestine  and  it  must  preserve  sufficient  caliber 
of  the  intestine.  But  it  must  do  very  much  more  than 
this ;  it  must  hold  the  ends  of  the  intestine  firmly 
together  not  only  until  they  have  adhered,  but  until 
they  are  soundly  healed.  The  fatal  error  in  the  past 
was  in  assuming  that  after  temporary  adhesions  were 
formed  all  danger  of  subsequent  leakage  was  over. 
Stanhope  Bishop  collected  no  less  than  33  different 
modes  of  uniting  the  intestine ;  to  this  number,  in  1896, 
the  late  Greig  Smith  added  33  modifications  or  new 
methods.  Next  to  the  Lembert  suture,  the  modification 
of  Czerny,  in  the  past,  is  the  best  known,  the  -mture  en 
etneje.  the  two  or  three  row  suture,  the  muco-mucous, 
the  muscular  and  the  sero-serous.  Its  purpose  was  to 
give  greater  firmness  to  the  bond  of  union  and  to  pre- 
vent leakage ;  but  the  multiplicity  of  sutures  defeated 
the  object  in  view  in  many  cases.  The  Czerny- Lembert 
suture  involved  a  most  trying  task  ;  one  American  sur- 
geon who  reported  a  successful  result  with  it,  says  "  it 
required  from  '■  three  to  four  hours  "  to  complete  the 
suture  of  the  intestine." 

The  multiplicity  of  knot-s  strangle  the  circulation  and 
favor  gangrene.  It  was  believed,  however,  that  the 
homologous  apposition  and  union  separately  of  the  three 
tunics  of  the  divided  intestine  insured  a  more  complete 
and  stronger  bond  than  the  simple  adhesion  of  the 
serous  surfaces. 

Both  the  Senn  decalcified  bone  plates  and  the 
Murphy  button,  the  two  best  known  mechanical  ex- 
pedients in  jointing,  require  the  employment  of  a 
suture  as  a  preliminary  in  their  adjustment ;  both  entail 
an  infolding  or  an  inversion  of  the  divided  ends  of  the 
intestine,  their  serous  surfaces  only  coming  into  im- 
mediate contact  when  the  twin  segments  of  the  appa- 
ratus are  fixed.  Senn's  discs,  in  its  application,  were 
the  first  to  involve  a  departure  from  the  law  of  Lem- 
bert in  effecting  an  intestinal  anastomosis,  as  a  fixation 
suture  in  its  insertion,  passed  through  all  the  coatt)  of  the 
intestine.  The  results  following  the  employment  of 
Senn's  jilates  were  highly  unsatisfactory  in  anastomosis 
after  resection  in  gangrenous  hernia. 

The  Connell  Suture. — Dr.  M.  E.  Connell,  who  was  a 
collaborator  with  Prof.  Senn  in  his  early  experimental 
work  on  the  intestines  of  animals  in  Milwaukee,  ia 
September,  1892.  published  the  technic  of  a  suture 
which  he  had  devised  as  a  means  of  joining  the  divide! 
intestine  by  end-to-end  enterorrhaphy  or  by  lateral  an- 
astomosis, when  required  for  any  condition  whatever. 
Like  all  original  investigators,  his  experience  was  con- 


March  23,  1901] 


STRANGULATED  AND  GANGRENOUS  HERNIA 


TThe  Philadelphia 
L  Medical  Journal 


583 


fined  to  animal  experimentation.  In  his  essay  he 
limited  its  application  to  end  to-end  enterorrhaphy,  but 
one  of  his  pupils,  a  talented  young  physician,  Dr.  A. 
D.  Davidow,  informed  me  that  Connell  subsequently 
insisted  that  the  fullest  measure  of  usefulness  and 
security  for  his  suture  was  best  realized  in  the  lateral 
jointing  of  the  intestine,  as  his  mode  of  dividing  the 
bowel  and  treating  the  mesentery  were  important  fac- 
tors in  success.  Connell  claimed  for  his  suture,  that  it 
involved  the  employment  of  no  foreign  body,  that  it 
could  be  introduced  as  quickly  as  any  description  of  a 
disc,  that  its  material — -a  round  needle  and  a  silk 
thread — could  be  found  in  every  household,  and  that 
used  by  an  experienced  hand  it  is  a  simple,  safe,  and 
effective  expedient. 

Mr.  Greig  Smith,  in  the  last  edition  of  liis  work  pub- 
lished in  1896,  in  noting  some  of  the  later  devised 
sutures,  mentions  Connell's,  but  said  as  there  were  no  re- 
corded cases  of  its  use,  he  would  not  describe  it.  In 
the  autumn  of  the  same  year,  after  a  thorough  testing 
of  it  on  the  lower  animals,  with  the  able  assistance  of 
Dr.  Davidow,  it  was  ray  good  fortune  to  employ  this 
suture  for  the  first  time  on  a  human  being,  my  patient 
being  a  young  Chinaman  with  gangrenous  hernia, 
requiring  the  removal  of  30  inches  of  the  intestine ; 
speedy  recovery  following.  My  later  case,  in  which  19 
inches  of  gut  were  removed,  my  patient  being  able  to 
return  to  his  position  as  a  shipping  clerk  just  6  weeks 
from  the  time  of  operation. 

The  suture  of  Connell  embraces  a  radical  departure 
from  all  others. 

1.  In  resection  of  gangrenous  intestine,  lateral  anasto- 
mosis is  preferred ;  this  was  employed  in  both  of  my 
cases. 

2.  It  is  a  continuous,  longitudinal  suture,  silk  always 
preferred. 

3.  The  suture  passes  through  all  the  coats  of  the 
intestine. 

4.  The  suture  is  everywhere  turned  in  except  where 
the  knots  are  tied. 

In  gangrenous  hernia  requiring  resection  and  joint- 
ing, it  is,  par  excellence,  an  ideal  method,  in  extra  or 
intraperitoneal  cases. 

No  description  of  apparatus  can  be  applied  with 
greater  ease  or  economy  of  time ;  but  there  are  situa- 
tions within  the  abdomen  where  the  ^lurphy  button 
may  be  more  expeditiously  employed. 

Used  in  lateral  anastomosis,  its  greatest  utility  is 
realized  through  the  manner  in  which  the  full  vascular 
supply  is  maintained,  the  large  aperture  which  is  made 
and  the  firm  bond  of  union  secured. 

It  is  certainly  my  conviction  that  when  the  technic 
of  its  application  is  better  understood,  it  will  be  ac- 
cepted by  all  surgeons  as  the  simplest  and  safest  of  any 
suture  yet  devised. 

In  a  recent  contribution  on  a  valuable  contrivance  for 
holding  the  intestine  in  position  while  doing  an  end-to- 
end  jointing.  Dr.  H.  Lee,  of  Chicago,  says  that  he  pre- 
fers the  Connell  suture  above  all  others,  as  when  prop- 
erly inserted  it  is  followed  by  ideal  results. 

Suture  Material. — Suture  material  for  intestinal  work 
is  an  important  element  in  technic.  Two  varieties  of 
suture  are  generally  selected  ;  the  absorbable  and  the 
nonabsorbable.  With  many,  catgut  has  had  the  pre- 
ference, because,  when  properly  prepared,  it  will  main- 
tain the  divided  parts  in  contact  sufficient  time  to  en- 
sure union,  and  later,  undergo  complete  resorption. 
But   properly    prepared,    fresh    catgut   is    not    always 


accessible;  some  claim  that  its  complete  sterilization 
is  impossible  without  impairment  of  its  integrity. 
At  all  events,  it  requires  a  spear-pointed  needle  to  carry  it, 
it  entails  an  excess  of  trauma  in  its  introduction,  it  may 
often  stretch  and  slip  at  a  dangerous  stage,  and  permit 
a  fatal  leakage  from  the  bowel ;  in  a  word,  in  intestinal 
surgery,  it  is  the  general  consensus  of  surgical  opinion 
that  it  is  not  the  most  desirable  material. 

The  silk  suture  possesses  the  most  necessary  qualities 
for  an  intestinal  suture. 

1.  It  is  the  strongest  and  most  durable;  these  are 
the  primary  essentials.  It  is  true  that  it  cannot  be 
effectively  sterilized,  but  this  is  a  consideration  of  sec- 
ondary importance  if  it  count  for  anything  at  all,  in 
intestinal  jointing,  as  anything  like  an  aseptic  wound 
here  is  a  myth,  for  by  the  most  approved  and  effective 
methods  here  employed,  the  widely  divided  ends  of  the 
intestine  are  left  exposed  to  free  irrigation  by  stagnant, 
decomposed  feces,  which  immediately  begins  as  soon 
as  the  continuity  of  the  intestinal  canal  is  re-established 
and  the  enteric  contents  begin  to  move  on. 

2.  We  can  employ  a  fairly  fine  silk  suture  which  may 
be  introduced  with  a  round  cambric  needle,  one  which 
acts  on  the  principle  of  the  wedge  and  divides  the 
walls  of  the  intestine  without  cutting. 

The  ultimate  course  of  the  silk  suture  after  introduc- 
tion is  not  known ;  it  probably  rarely,  if  ever,  is  ab- 
sorbed ;  it  either  becomes  imbedded  in  the  tissues  or  is 
thrown  off  by  the  intestinal  canal.  In  dogs  killed  six 
months  after  the  silk  sutures  were  employed  on  the 
intestine,  I  have  found  them  buried  under  adhesions, 
entirely  unchanged. 

Tamponage  and  Drainage. — Everyone  who  has  oper- 
ated for  strangulated  hernia  is  aware  that  even  after  the 
constriction  is  removed  and  the  stricture  is  relieved,  the 
reduction  of  the  intestine  is  often  tedious  and  difficult ; 
after  the  resection  of  a  gangrenous  loop  and  anast- 
omosis by  an  apparatus  or  the  suture,  the  difficulty  is 
greater  yet ;  the  mass  is  bulky  and  awkward  to  manip- 
ulate, a  considerable  degree  of  force  must  be  employed 
to  return  the  overdistended  coils,  and  great  caution  is 
needful  that  the  jointing  is  not  disturbed.  Hence  the 
reason  why  a  large,  free  opening  must  be  made  up 
through  Poupart's  or  Gimbernat's  ligament,  that  no 
undue  strain  be  put  on  the  herniated  bowel. 

In  all  these  cases  a  tampon  drain  is  necessary.  The 
Mickulicz  gauze  or  cigarette  tampon  is  probably  the  best. 
There  is  always  some  serous  oozing,  and  there  may  be 
some  leakage.  My  practice  has  been  to  pass  a  drain 
down  to  the  site  where  the  intestine  is  joined,  and  not 
around  the  bond  of  union.  Immediately  on  the  re- 
duction of  the  united  loop  temporary  adhesions  wall  it 
off  from  the  cavity  of  the  peritoneum,  but  the  gauze 
drain  establishes  and  maintains  a  passage  from  this, 
now  extraperitoneal  loop,  with  the  exterior  of  the  body. 
If  everything  goes  well,  the  tampon  is  not  removed 
until  the  second  day.  By  this  time,  intestinal  paresis 
will  have  passed  off,  and  peristalsis  have  begun.  At 
this  stage  there  may  be  a  varying  degree  of  leakage. 
Gentle  irrigation  is  now  practised,  and  the  wound  is 
again  freshly  tamponed  with  a  small  gauze  drain.  In 
both  of  my  cases  it  continued  for  a  week,  and  within 
three  weeks  the  wounds  had  solidly  closed. 

Ziedler  observes  that  "  the  most  frequent  cause  of 
death  in  the  eases  of  gangrenous  hernia  is  leakage  at 
the  site  of  suture  with  resulting  peritonitis ;  hence  we 
should  always  tampon  so  that  a  way  of  escape  is  freely 
provided." 


I5g4  T^HK  Philadelphia"] 

Medical  Journal  J 


STRANGULATED  AND  GANGRENOUS  HERNIA 


[Uabch  23,  IMl 


Ventral  hernia  we  might  expect  after  large  incisions 
necessary  in  resection  wherein  so  large  a  breach  must 
be  made  in  the  abdomen,  which  later  closes  in  by 
scar  tissue;  but  it  has  not  occurred  in  my  two  cases, 
nor  do  statistics  show  that  it  is  a  frequent  sequela. 
Probably  the  adhesions  which  environ  the  reduced 
intestine  tend  to  fix  it,  so  that  its  subsequent  descent 
is  imjieded  and  recurrence  prevented. 

LITERATURE. 

Conuell,  Meilical  Record,  September  17,  1892. 

Traus.  Int.  Med.  Congress,  188il,  vnl,  ii,  p.  715. 

Ziedler,  Cenl.f.  Chir.,  January  21,  1893,  p.  63. 

Moulin,  M.,  Treatise  on  Surgery,  p.  217. 

Smith,  G.,  Intestinal  Surgery.  3ii  E.I.,  p.  212. 

R.  L.  Knaggs,  London  Lancet,  i,  p.  17C0. 

Reidel,  Vortriige,  No.  147. 

Bryant,  Thoma.s,  Treatise  on  S  irgery,  5th  Ed  ,  p.  419. 

Mery,  Mem.  Acad,  des  .Science,  No.  1701,  j).  285. 

Boullly,  Rev.  de  Chir.,  i,  1881,  p.  W. 

Lambert,  Arch.  Gen.  de  Med.,  182li. 

Ludwig,  Wien.  med.  Presse.  1880. 

Beck,  Carl,  Arch.  f.  klin.  Chir.,  \i.  73,  IgSO. 

Beck,  Carl,  New  Yorii  Medical  Journal,  \>.  287. 

Wallace,  C,  St.  Thomiis  Hospital  Report,  vol.  xxv,  p.  123,  1897. 

Le  Dentu  et  Delbert,  Trail,  de  Chir.,  vol.  vii,  p.  034, 1899. 

Croft,  Am.  Jour.  Med.  i^eirnres,  p.  87.'5,  1894. 

Segond,  P.,  Bull,  el  Mem.  de  Chir.,  p.  384,  1894. 

Martinet,  Hull,  de  la  Sac.  de  Chir.,  p.  247,  1891. 

Poulscn,  Deul.  med.  Woch.,  320,  188S. 

Kocher,  IJeu/.  Zeit.f.  Chir  ,  171,   1891. 

De  Bouvls,  K'v.  de  Chir.,  October  10,  1900. 

Guillemaln,  Rev.  de  Chir.,  1898,  p.  112.''>. 

Abbe,  R  ,  Annuls  ofSurr/eri/,  1895,  p.  ."ilS. 

McCosh,  A.  ,T.,  Medical  Record,  1889,  p.  285. 

McCosh,  A.  .1.,  Am.  Surgerii,  1894,  p.  657. 

Hiiter,  Deul.  Zeil./.  Chir.,  1875,  p.  621. 

Schade.  Verhand.  der  Deutschen  Chir.,  187 S,  p.  20. 

Curie,  Deut.  med.   MWA..  1868,  p.  829. 

Gibson,. 4  nno(s  of  Suraei-y,  19011,  p  892. 

LUcke,  Rev.  de  Chir.,  1883,  p.  317. 

Moyenhara,  The  Practitioner,  November,  1900. 

Carle,  M^  Li/on  Med..  1899,  p.  170. 

Treves,  R,  iRtestinal  Obstruction,  p.  492. 

Deaver,  Int.  Med  Mat/..  IS'.il. 

.Taboulay,  Prov.  Medimle,  189.'),  p.  457. 

Gassenbanr,  Beitrdge  ztir  klin.  Chir.,  vol.  Xli,  1890. 

hoyd,  J.,  Birmingham  Med.  Rev.,lSSS,p.  24. 

Berger,  P.,  Essai  sur  les  Ileruies,  Paris,  1897. 

McCready,  Treatise  on  Hernia,  p.  327. 

Treves,  K.,  London  Lancet,  p.  1012,  1884. 

Carwardine,  Manual  of  Surgery,  191)0,  p.  230. 

.Southam,  London  Lancet,  vol.  ii,  p.  1217,  1891. 

Karprinskl,  Gaz.  Cek    Warzava,  p.  1605, 1891. 

Duplay,  Path.  Externa,  Tome  vi,  p  62. 

llerriugton.  Annals  of  Surgery ,  p.  248,  l>i97. 

Madelung,  Arch.  f.  klin.  Chir.,  B.  xxvii,  1882. 

Cohn,  Be;'/iner  J-im.  It'ocA  ,  p.  317,  1887. 

Jaeunel,  Sut.  Intes.  Chir.  de  Lintes,  p.  41,  1898. 

Terrier  et  Gosset,  Rev.  de  Chir.,  November  10.  1900. 

Frey,  Beitrtige  zur  klin.  Chir.,  vol.  xvi,  1895. 

Evans,  V/.,Jour.  .4m.  Med.  Ass'n.,  December  8,  1900. 

Hutchinson,  J.,  .Jr.,  Bril.  Med.  Jour.,  i).  1547. 

Treves,  F.,  Trans.  Roy.  Med.  et  Chir,  Soc,  vol.  1,  18*2. 

Villard,  Trans  Cong.  F.anraise,  p.  200,  1895. 

Bishop,  Med.  Chronicle,  .Septeml)er  1,  1885. 

Lawrence,  Treatise  on  Ruptures,  p  179,  1898. 

Franks,  K.,  Medico  Chir.  Trans.,  1893,  vol.  Ixxli,p.  il5. 


Albumin  Transformatiou  and  Sugar  Excretion. 

— Rumpf  {Deutsche  Med  Woch  ,  O^t.  4,  1900)  reviews  the 
work  which  has  been  done  in  the  attempt  to  prove  that  fat 
may  furnish  sugar.  No  one  ha8  yet  demonstrated  this 
satisfactorily.  It  has  been  generally  an  accepted  statement 
that  it  is  possible  for  sugar  to  be  formed  from  albumins, 
and  that  so  long  as  the  sugar  excreted  was  not  more  than  6 
or  7  times  greater  than  the  amount  of  nitrogen  excreted  the 
whole  amount  of  sugar  may  reasonably  be  thought  to  be 
derived  from  albumins.  Rumpf  and  his  assistant  experi- 
mented with  dogs,  first  accustoming  them  to  a  special  diet 
which  contained  only  a  small  amount  of  albumin  but  a  large 
amount  of  fat,  and  then  producing  phloridzin  glycosuria. 
They  determined  the  sugar  nitrogen  excretion  through 
periods  of  5  days  each,  and  demonstrated  that  in  one  of 
these  periods  the  average  sugar  excretion  was  8  9  times 
greater  than  the  nitrogen  excretion.  During  this  period 
the  relation  of  nitrogen  to  sugar  was  as  follows :  On  the 
first  day  1  :  9.7 ;  on  the  second  day  1  :  7.1 ;  on  the  third 
1:85;  on  the  fourth  1 :  9.9 ;  on  the  fifth  1 :  12.2.  He  decided, 
therefore,  that  the  sugar  formed  could  not  have  come  en- 
tirely from  the  albumins,  and  that  some  of  it  must  have  been 
produced  by  fats.  There  was  no  evidence  of  a  nephritis 
which  could  have  caused  retention  of  nitrogen.    Also  he  in- 


vestigated the  excretion  of  SOj  and  P2O5.  He  found  that 
there  was  no  relative  increase  in  the  phosphorus  excretion, 
a  fact  which  was  against  the  theory  of  Blumenthal,  that 
albumin,  which  is  especially  rich  in  phosphorus,  is  destroyed 
in  diabetes,     [d  l.e.] 

Dysentery  as  a  Human  Disease  and  Its  Cause. 

— Kruee  {Dtutsche  Med.  Woch.,  Oct.  4, 1900)  directs  attention 
to  the  fact  that  dysentery  is  constantly  endemic  in  certain 
regions  in  Germany,  and  at  times  has  broken  out  in  large 
epidemics;  in  the  last  few  years  it  has  been  increasing  in 
frequency  until,  in  1898  and  1899,  there  were  in  one  locality 
100  fatal  cases,  and  in  the  year  1899  alone,  in  Barmen  there 
were  600  cases  with  66  fatalities.  In  one  region  in  which 
there  were  300  cases  with  80  fitalities  he  made  extensive 
bacteriologic  studies.  In  the  first  place  he  found  in  the 
fresh  dejections  no  amebae,  but  small  clumps  of  pus  which 
contained  practically  only  one  f-Drm  of  organism.  This  was 
a  short  plump  bacillus.  Its  cultural  peculiarities  were  al- 
most the  same  as  those  of  the  bacillus  of  Saiga  and  Fiexner, 
it  being  chiefly  distinguished  by  the  fact  that  it  was  not 
motile.  Agglutination-tests  with  the  blood-serum  of  patients 
who  had  been  ill  for  more  than  7  days  with  dysentery 
showed  regularly  an  agglutination  in  a  dilution  of  at  least 
1  :  50,  and  in  some  instances  in  dilutions  as  great  as  1 :  1000. 
The  serum  of  healthy  persons  very  rarely  showed  such  action 
in  a  dilution  greater  than  1 :  10  or  1 :  20.  Oiher  intestinal 
bacteria  were  tested,  but  they  showed  no  agglutination.  The 
dysentery  apparently  caused  by  this  bacillus  also  differed 
from  that  described  by  Shiga  and  Fiexner  in  that  the  chief 
gross  anatomic  change  consisted  in  a  widespread  pseudo- 
membrane  formation  on  the  mucous  membrane  of  the 
colon,    [d.le.] 

The    Duty  of  the  Physician  to  the  State.— Tne 

recent  utterance  of  a  Philadelphia  judge  to  the  eflect  that  it 
would  be  better  that  a  patient  should  die  rather  than  that  a 
physician  should  neglect  a  judicial  summons,  has  stirred  up 
the  lawyers  as  well  as  the  doctors.  The  physician's  stand- 
point has  already  been  given  editorially  in  the  Joubsal,  but 
it  may  be  of  interest  to  note  how  it  is  viewed  by  the  legal 
profession.  The  NiW  Orleans  Times  Democrat  has  taken  the 
trouble  to  obtain  the  opinion  of  a  number  of  leading  mem- 
bers of  the  Bar  and  judges  upon  the  course  of  the  judge,  and 
their  unanimity  in  condemnation  of  the  opinion  is  striking. 
The  expressions,  "unreasonable  and  arbitrary,"  "not  rul^ 
by  the  ordinary  law  of  common  sense,"  "  absurd,"  "  in- 
human," "  brutal  in  its  effects,"  are  some  indications  of  how 
the  judge's  action  and  statements  are  appreciated  by  his  legal 
brethren.  If  he  is  at  all  sensitive  to  public  opinion  he  will 
not  be  likely  to  repeat  his  action,  which  one  can  hardly  be- 
lieve was  prompted  by  any  deliberate  consideration  of  the 
facts.  Judges,  however,  are  the  men  who,  more  than  others, 
should  guard  their  speech  and  action  from  any  suspicion  of 
inconsiderateness,  and  if  they  make  mistakes  such  as  that  of 
this  Philadelphia  jurist,  must  suffer  for  it  accordingly  in 
public  and  professional  estimation. — [Jounioi  of  the  Artterican 
Medical  Association.] 

Contribution    to    the    Study  of   the  Connective 
Tissue  Tumors  of  the  Kidney  of  the  Adult.     (Qaz. 

Heb.  de  Mid.  el  de  Chirur.,  Februarv  3,  1901.  4Sme  Annee, 
No.  10;  Paris  Thesis,  1900-1901,  No.  60)  According  to 
Bahuand  the  embryonal  connective  tissue  neoplasm  is 
represented  in  the  kidney  by  sarcoma.  Sometimes  round- 
celled  sarcoma  is  found,  again  the  spindle- celled  variety  is 
met  with,  quite  often  the  two  elements  are  united  in  variable 
proportion,  and  sometimes  myxosarcoma  has  been  observed. 
From  the  point  of  view  of  its  structure,  a  great  development 
of  the  connective  tissue  ground  substance  is  sometimes  noted 
which  may  go  on  to  the  production  of  a  fibrosarcoma.  The 
vascular  element  is  often  very  well  developed  which  accounts 
for  the  frequence  and  the  volume  of  the  blood  cysts.  Some- 
times smooth  muscle  fibers  are  found  which  have  no  impor- 
tance from  the  viewpoint  of  the  histologic  value  of  the  tumor. 
The  adult  connective  tissue  tumor  is  represented  in  the  kidney 
by  fibroma  and  lipoma.  These  tumors  spring  from  the  inter- 
stitial connective  tissue  of  the  organ,  in  the  neighborhood  of 
the  hilum,  beneath  the  capsule,  or  in  the  fibrous  capsule 
itself.  Other  tumors  of  this  nature  spring  from  the  supra- 
renal capsule  or  from  suprarenal  rests,    [j.m.s.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and   Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.    Reprints  (250)  of  Original  Articles  will  be  iuraished  gratis  to  Authors  making 
the  request. 
The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Pliiladelphia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising:  Pages  8,  18  and  19. 


James  Hendrib  Lloyd,  A.M.,  M.D.,  Editor-in-Chief 
Juiiiua  L.  Salinqkr,  M.D.,  Associate  Editor 
AssUtant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteykr,  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  Colky,  M.D. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  Gibbon,  M.D. 


Vol.  VII,  No.  13 


MARCH  30,  1901 


$3.00  Per  Annum 


Tlie  Report  of  the  Committee  ou  Anesthetics. — 

The  ninth  and  final  report  of  the  anesthetic  committee 
of  the  British  IMedical  Association,  appointed  10  years 
ago  to  inquire  into  the  relative  safety  of  various  anes- 
thetics, the  best  methods  of  administration  and  of  res- 
toration, has  recently  been  published.  The  report  is 
based  upon  an  analysis  of  25,920  cases  from  hospital 
and  private  practice,  of  which  13,393  were  cases  of 
chloroform-anesthesia,  4,595  ether,  2,911  nitrous  oxide, 
2,071  gas  and  ether,  678  A.  C.  E.  mixture,  and  the 
balance  various  combinations  of,  as,  for  example,  mix- 
tures of  chloroform  and  ether,  chloroform  followed  by 
ether,  and  vice  versa,  nitrous  oxide  and  oxygen,  etc. 
Although  an  immense  amount  of  time  and  energy  have 
been  unselfishly  expended  by  the  committee  in  the 
pursuance  of  these  investigations  and  the  collaboration 
of  these  statistics,  the  report  is,  on  the  whole,  disap- 
pointing. Of  the  35  conclusions  of  the  sub-committee 
but  few  have  been  drawn  upon  a  strictly  numerical 
basis,  the  majority  are  expressions  of  opinion  the  value 
of  which  depends  upon  the  judicial  capabilities  of  the 
committee  and  many  are  negative  in  that  no  conclu- 
sions are  warrantable.  For  purposes  of  analysis  and 
comparison  the  total  number  was  divided  into  two 
general  classes,  the  uncomplicated  and  the  complicated, 
and  the  latter  subdivided  into  (1)  cases  with  minor 
complications,  (2)  cases  of  anxiety,  (3)  cases  of  danger, 
(4)  cases  of  death.  As  in  such  a  large  majority  of  cases 
chloroform  or  ether  was  the  anesthetic  employed,  "  the 
conclusions  of  the  report  frequently  resolve  themselves 
into  various  phases  of  the  chloroform  vs.  ether  contro- 
versy." As  to  the  relative  safety  of  these  anesthetics, 
taking  into  consideration  only  those  cases  of  danger 
(including  death)  for  which  the  anesthesia  was  held 
wholly  responsible,  under  chloroform  there  were  78  or 
€.582%  as  compared  with  3  under  ether,  or  0.065%. 
The  observation  is  made  that  "  although  (excluding 
nitrous  oxide)  ether  may  be  accepted  as  the  safest 
routine  agent,  certain  circumstances  determined  by 
the  state  of  the  patient,  the  nature  of  the  operation, 
etc.,  may  render  the  use  of  some  other  anesthetic  or 
combination  of  anesthetics  both  safer  and  easier." 
The  committee  were  able  from  the  clinical  evidence  to 
draw  no  conclusion  as  to  the  best  method  of  adminis- 
tering ether ;  and  as  to  chloroform,  we  are  told  that 
■while  no  method  is  free  from  danger,  inexperience  on 
the  part  of  the  administrator  rather  than  any  particular 


method  must  be  held  accountable  for  the  occurrence  of 
complications,  fatal  or  otherwise,  in  the  great  majority 
of  cases.  As  to  the  best  method  of  restoration,  here 
again  the  committee  humbly  confess  their  inability  to 
draw  any  conclusion  from  the  material  at  their  dis- 
posal. Many  of  the  conclusions  that  particularly  con- 
cern chloroform-anesthesia  are  simply  confirmatory  of 
opinions  in  vogue  for  some  time  past.  The  alarming 
symptoms  are  those  of  primary  circulatory  failure; 
many  have,  however,  been  traced  to  imperfect  anesthesia. 
Prolonged  vomiting  and  circulatory  depression  are  more 
common  after  chloroform  than  ether,  while  respiratory 
complications,  though  occurring  with  equal  frequency 
under  ether  and  chloroform,  were  apt  to  be  "  transient 
and  trifling  "  after  ether  and  "  grave  and  persistent  " 
after  chloroform.  Perhaps  the  most  practical  conclu- 
sion from  the  standpoint  of  the  anesthetizer  is  the  last, 
namely,  that  by  far  the  most  important  factor  in  the 
administration  of  anesthesia  is  the  experience  of  the 
administrator  and  that  in  many  cases  the  anesthetiza- 
tion so  completely  transcends  the  operation  in  gravity 
and  importance,  that  it  is  absolutely  essential  to  con- 
sign that  duty  to  an  experienced  anesthetizer. 

The  committee  were  unable  to  throw  any  light  upon 
two  important  subjects  :  the  safest  method  of  adminis- 
tration and  the  most  reliable  method  of  restoration. 
Whether  or  not  the  committee  in  charge  could  have 
used  to  better  advantage  the  mass  of  clinical  evidence 
which  passed  through  their  hands  we  are  not  in  a 
position  to  judge,  suffice  it  to  say  that  they  have  con- 
tributed little  if  anything  to  the  knowledge  of  anes- 
thetics already  acquired.  That  ether  is  the  safest 
anesthetic  for  routine  work;  that  the  alarming  symptoms 
of  chloroform-narcosis  are  due  primarily  to  circulatory 
failure ;  that  no  method  of  administration  of  chloroform 
is  free  from  danger ;  that,  excluding  infancy,  the  com- 
plications and  alarming  conditions  of  narcosis  increase 
pari  passu  with  advancing  age ;  that  the  tendency  for 
these  complications  to  occur  increases  pari  passu  with 
the  gravity  of  the  operation ;  these,  as  most  of  the  other 
conclusions,  are  but  confirmatory  of  long-established 
views.  As  an  exception  to  this  general  statement  we 
might  call  attention  to  their  observations  on  the  respi- 
ratory complications  of  anesthesia.  In  their  experience 
the  complications  that  occurred  under  ether  were  mostly 
of  a  trifling  and  transitory  nature,  while  those  occurring 
under  chloroform  were  grave  and  persistent. 


586 


The  Philadelphia"! 
Medical  Journal  J 


EDITORIAL  COMMENT 


[Hasch  30,  un 


The  Diagnosis  of  Malaria  from  the  Standpoint 
of  the  General  Practitioner. — From  the  standpoint  of 
accuracy,  simplicity,  and  practicability,  the  diagnosis 
of  malaria  by  determining  the  presence  of  the  specific 
parasite  in  the  blood  must  be  looked  upon  as  the  most 
approved  clinical  method,  perhaps   outranking  every 
other  clinical  microscopical  test  in  point  of  usefulness. 
The  vague  expression  of  such   an  inaccurate  term  as 
"  a  touch  of  malaria,"  so  commonly  employed  by  many 
phj'sicians,  finds  its  origin  chiefly  in  the  lack  of  more 
constant  and    systematic  blood-examination   in  every 
suspected  case,  and  in  part  to  the  indiscriminate  and 
hasty  use  of  quinin  as  a  therapeutic   test.     Many  of 
these  periodical  ailments,  loosely  designated  "  a  touch 
of  malaria,"  undoubtedly  subside  quite  independent  of 
the  drug  when  it  is  administered.     Aside  from  the  gross 
misrepresentation  of  statistics  brought  about  by  such 
a  method,  the  life  of  the  patient  is  sometimes  jeopard- 
ized.    The  question  of  immediate  recognition  of  such 
a  condition  as  a  deep-seated  suppurative  process  pre- 
senting symptoms  resembling  those  of  malaria,  is  often 
of  vital  importance  for  the  early   establishment  of  a 
plan  of  treatment.     The  delay  caused  by  the  adminis- 
tration of  quinin,  in  order  to  exclude  malaria,  is,  as  a 
rule,  inexcusable,  for  we  have  at  our  command  that 
more  reliable  resource,  the  microscopical  examination. 
It  is  well  known  that  malaria  may  sometimes  coexist 
with  some  other  febrile    condition,   for  instance,    en- 
teric fever.     In  such  a  case,  of  what  possible  value  is 
the    administration  of   the  therapeutic  test?     In  the 
event,  however,  of  malaria  not  complicating  the  con- 
dition the  harm    that    might  arise  is   manifest.     The 
similarity  of  malarial  fever  to  many  other  diseases  in- 
dicates the  necessity  of  difi"erentiating  by  a  search  for 
the  Plasmodium.     Under  exceptional  circumstances  the 
therapeutic  test  has  its  place,  but  never  when  the  clin- 
ical method  can  be  pursued.     The  advantages  of  the 
latter  are  so  apparent  as  to  hardly  require  comparison. 
A  single  droplet  of  blood  will  not  only  determine  the 
presence  of  the  disease,  its  type,  or  combinations  of 
types,  the  relations  of  the  time  of  examination  to  the 
time  of  the  paroxysm,  with  some  degree  of  certaintj- ; 
but  will  also  indicate  the  manner  of  administration  of 
our  therapeutic  measures,  and   the  necessity  of  proper 
isolation  to  prevent  the  spread  of  the  disease  by  means 
of  mosquitoes.     The  early  recognition  of  some  of  the 
pernicious  types  without  the  aid  of  the  microscope  is 
so  difficult  that  the  most  expert  clinician  may  err. 
From   the   prognostic  standpoint,  early  and   vigorous 
treatment  constitutes  in  many  instances  the  only  means 
by  which  life  may  be  saved.     The  negative  value  of 
the  clinical  test  is  equally  important.     It  is  a  well- 
known  fact  that  considerable  experience  is  necessary  to 
distinguish  some  of  the  forms  of  the  malarial  parasite, 
especially  the  hyaline,  non-pigmented  bodies;  but  this 
should  in  no  way  constitute  a  valid  excuse  for  its  non- 
employment     In   the   present  state  of  our  scientific 


knowledge  a  microscope,  slides  and  cover-glasses  should 
constitute  a  part  of  the  armamentarium  of  the  well- 
equipped,  practical  physician. 

Symptoms  of  Disseminated  Sclerosis  Occurring- 
in  Malarial  Infection. — Dr.  William  G.  Spiller  has 
published  an  interesting  paper  {American  Journal  of  the 
Medical  Sciences,  December,  1900)  on  this  subject,  based 
upon  a  case  which  occurred  in  Dercum's  clinic  at  the 
Philadelphia  HospitaL  The  patient  was  a  man  who 
had  had  syphilis  and  who  became  slightly  hemiplegic 
on  the  right  side  in  1890.  The  hemiplegia  was  tran- 
sient, but  five  years  later  the  patient  began  to  have 
headache,  vertigo,  drowsiness  and  diplopia.  Left  tran- 
sient hemiplegia  also  occurred.  The  left  leg  remained 
ataxic,  the  Romberg  symptom  was  present,  and  there 
was  intention  tremor  of  the  left  upper  extremity.  The 
patient  had  vertical  nystagmus  and  scanning  speech, 
and  the  knee-jerk  was  increased  on  the  right  side,  on 
which  side  also  there  was  ankle  clonus.  He  presented  a 
somnolent  appearance,  and  died  from  an  intercurrent 
diarrhea  nine  years  after  the  beginning  of  his  disease. 
At  the  autopsy  the  right  crossed  pyramidal  tract  was 
found  sclerosed,  but  not  extensively  so.  An  interesting 
finding  was  enlargement  of  the  spleen.  No  true  dis- 
seminated sclerosis  was  found  anywhere  in  the  central 
nervous  system,  but  numerous  small  recent  hemor- 
rhages were  found  in  the  left  paracentral  lobule  and 
other  parts  of  the  cortex.  Dr.  Spiller  was  not  able  to 
discover  any  distinct  syphilitic  lesions,  such  as  prolifer- 
ation of  the  walls  of  the  bloodvessels.  The  small  blood- 
vessels throughout  the  brain  and  cord  were  filled  with 
the  malarial  parasites.  The  patient  had  not  presented, 
so  far  as  was  known,  any  of  the  ordinan.'  symptoms  of 
malarial  infection.  The  identity  of  the  parasites  was 
established  by  Dr.  A.  Stengel  and  Dr.  W.  S.  Thayer. 

Dr.  Spiller  points  out  that  the  malarial  parasite,  of 
the  estivoautumnal  type,  may  exist  as  a  larvated  form 
for  an  indefinite  time,  and  he  includes  his  case  among 
cases  of  this  variety.  He  presents  the  literature  of  the 
subject,  from  which  we  learn  that  symptoms  of  a 
pseudosclerosis  have  been  observed  by  some  of  the  best 
investigators  in  cases  of  undoubted  malarial  infection. 
Among  these  observers  are  TriantaphylUdes,  Forti. 
AngeUni,  Bignami,  and  Bastianelli.  The  symptoms  in 
some  cases  have  disappeared  under  antimalarial  treat- 
ment. Dr.  Spiller's  case  has  a  unique  importance  as 
being  the  first  in  which  the  malarial  parasite  has  been 
demonstrated  postmortem  in  such  a  long-standing  CAse. 
although  the  plasmodium  had  been  observed  during 
life  in  some  other  reported  cases.  The  facts  that  Dr. 
Spiller's  patient  had  had  syphilis,  and  that  some  of  his 
earlier  symptoms,  such  as  transient  hemiplegia,  diplo- 
pia and  headache,  strongly  suggested  a  syphilitic  infec- 
tion, have  not  been  ignored  in  this  study  of  the  case, 
but  Dr.  Spiller  reports  that  distinct  syphilitic  lesions 
were  not  discovered. 


HabcH  30,  1901] 


EDITORIAL  COMMENT 


TThe  Philadelphia 
L  Medical  Jodkical 


587 


The  Treatment  of  Spina  Bifida. — When  one  con- 
aiders  that  the  large  majority  of  cases  of  infants  suffering 
from  spina  bifida  run  a  rapid  course  to  death  from  rupture 
and  convulsions,  or  spinal  meningitis,  it  is  gratifying  to 
observe  the  good  results  being  obtained  by  surgical  in- 
terference in  these  hopeless  cases.  Palliative  treatment, 
the  seton,  and  the  injection  of  Morton's  fluid  have  all 
been  tried  and  have  accomplished  practically  nothing. 
A  spontaneous  cure  is  of  the  rarest  occurrence.  Res- 
toration of  the  cord,  when  present  in  the  sac,  to  the 
spinal  canal,  and  excision  of  the  sac,  although  at  first 
productive  of  a  large  mortality,  certainly  seem  justifi- 
able in  the  light  of  the  necessarily  fatal  nature  of  the 
disease  and  the  infinitesimal  chances  of  spontaneous 
cure.  The  method  of  treatment  which  was  strongly 
urged  by  Bayer,  Robson,  and  others  has  been  perfected, 
and  good  results  are  frequently  being  reported.  Mr. 
Nicholl,  in  the  Lancet  of  March  3,  adds  to  his  other 
contributions  on  this  subject  a  brief  report  of  three 
cases  of  young  infants  operated  upon  for  cervical  spina 
bifida,  and  returned  to  their  homes  the  same  day  under 
the  care  of  a  nurse.  These  infants  all  made  complete 
recoveries,  and  the  wound  in  each  case  healed  by  pri- 
mary union.  Of  course,  the  surgical  treatment  of 
spina  bifida  occurring  in  the  cervical  region  is  much 
more  hopeful  than  in  the  forms  met  with  in  the  lower 
portions  of  the  spine,  and  the  results  which  Nicholl 
has  had  ought  certainly  to  encourage  the  surgeon  to 
further  effort  in  the  treatment  of  this  distressing  con- 
dition. 

Surgeons  in  discussing  this  subject  as  well  as  in 
treating  these  cases,  do  not,  as  a  rule  sufficiently  dis- 
tinguish the  several  forms  of  spina  bifida.  The  simple 
meningocele,  in  which  there  is  no  portion  of  the  spinal 
cord  included  in  the  sac,  is  naturally  much  more  easily 
cured,  and  with  far  better  results,  than  the  meningo- 
myelocele, in  which  the  sac  contains  portions  of  the 
undeveloped  spinal  cord.  An  excision  or  obliteration 
of  the  sac  in  this  latter  form  cannot  cure  the  child  in 
any  sense  because  it  leaves  the  patient  permanently 
crippled.     Some  cases  are  even  left  paraplegic. 

Recent  Notes  on  Plague. — We  are  indebted  to 
Captain  R.  H.  Jackson  for  an  original  communication 
of  great  interest  in  his  Notes  on  Plague  at  the  General 
Plague  Hospital,  Balgaum,  India,  1899,  which  appeared 
in  the  Dublin  Journal  of  Medical  Science  for  February, 
1901.  The  spread  of  this  disease  is  favored  by  those 
arch-enemies  of  health,  overcrowding,  deficiency  of 
ventilation  and  sunlight.  The  poorer  classes  suffer 
greatest  from  its  ravages.  Infection  is  caused  either  by 
inoculation,  or  through  the  digestive  tract,  or  the  res- 
piratory organs.  Two  distinct  forms  of  plague  are 
•described  :  Pestis  major  (severe  or  ordinary  plague); 
and  Pestis  minor  (abortive  or  larval  plague).  The 
varieties  of  the  Pestis  major  are:  («)  Bubonic;  (6) 
pneumonic;  (c)  septicemic;  (rf)  pyemic;  (e)  local  inoc- 


ulation. It  is  interesting  to  follow  the  course  of  an 
average  attack  of  ordinary  bubonic  plague,  as  described 
by  Dr.  Jackson.  The  period  of  incubation  is  given  as 
from  3  to  7  days ;  the  period  of  invasion,  or  the  pro- 
dromal stage,  varies  greatly  in  length.  Sometimes  there 
is  a  sudden  onset,  but  usually  24  to  48  hours  pass  before 
the  disease  shows  any  of  its  characteristic  symptoms. 
During  this  prodromal  stage  the  patient  has  chills  with 
fever,  and  suffers  from  lassitude,  weakness,  headache, 
vertigo  and  vomiting.  Then  follows  the  stage  of  bubo 
development,  with  a  characteristic  staggering  gait,  great 
restlessness  and  tremulous  speech.  The  temperature  at 
this  time  is  104°  F.  or  higher.  The  pulse  is  full  and 
quick  and  averages  about  130 ;  the  tongue  is  typical. 
It  is  dry,  granular,  velvety,  with  yellow  fur  and  a  bright 
red  margin.  The  face  is  anxious  and  pallid  and  the 
conjunctiva;  are  deeply  injected.  The  diagnosis  at  this 
stage  is  easy.  The  buboes  or  glandular  swellings,  ex- 
tremely painful,  develop  with  great  rapidity  in  the 
groins,  axilla  or  neck.  The  bowels  are  usually  consti- 
pated. There  is  generally  a  fall  of  temperature  and 
pulse-rate  with  the  appearances  of  buboes,  and  this 
usually  occurs  on  the  second  or  third  days  of  the  dis- 
ease. With  this  remission  the  patient  appeare  much 
improved,  but  in  52  hours  there  is  a  return  of  the  fever, 
which  ranges  between  103*  and  105°  for  7  days,  when 
the  bubo  has  become  developed.  In  10  days  the  tem- 
perature and  pulse-rate  drop  gradually  to  normal.  The 
emaciation  and  exhaustion  are  extreme,  and  the  great 
danger  of  heart-failure  still  threatens.  A  protracted 
recovery,  usually  occupying  two  months,  may  now  be 
expected,  should  the  patient  be  fortunate  enough  to 
avoid  the  many  sequels  of  the  disease.  Among  these 
may  be  mentioned  cardiac  syncope,  probably jnduced 
by  the  action  of  the  toxins  upon  the  heart-muscle. 
Hemorrhages  are  common  and  are  regarded  as  most 
unfavorable  symptoms.  Pregnant  women  usually  abort, 
and  there  were  but  two  exceptions  to  this  general  rule 
in  Jackson's  series  of  cases.  Peritonitis,  jaundice,  reten- 
tion of  urine,  mental  complications  and  hyperpyrexia, 
are  common.  The  eye-complications  are  frequent.  In 
the  early  stages  the  conjunctiva  are  congested,  but  with 
the  appearance  of  the  bubo  this  congestion  may  disap- 
pear. In  the  later  stages  severe  conjunctivitis,  with 
iritis  and  ulceration,  may  lead  to  total  loss  of  vision. 
As  to  treatment,  it  is  comforting  to  know  that  inocula- 
tion with  Haffkine's  prophylactic  serum  has^proven  of 
great  value.  Fifteen  per  cent,  increase  in  recoveries 
followed  its  use.  Furthermore,  the  value  of  this  as  a 
preventive  treatment  is  unquestioned,  and  a  compara- 
tively small  number  of  plague  cases  occurred  among 
the  inoculated.  In  the  298  cases  treated  in  the  Belgaum 
Hospital  there  were  183  deaths,  a  mortality  of  61.4^. 
Plague  is  clearly  one  of  those  dread  diseases  which  by 
improved  methods  of  sanitation  may  by  its  disappear- 
ance mark  an  epoch  in  preventive  medicine.  It  is  an 
object-lesson  of  great  magnitude. 


688 


MsDiCAL  Journal  J 


EDITORIAL  COMMENT 


[]£ucH  30,  IWl 


Hereditary  Tuberculosis. — Since  Hauser's  excel- 
lent study  of  hereditary  tuberculosis,  in  which  he 
reached  the  conclusion  that  there  were  really  no  satis- 
factory instances  on  record  of  the  transmission  of  tuber- 
culosis from  parent  to  child,  excepting  in  a  few  cases  in 
which  the  mother  was  suffering  from  miliary  tubercu- 
losis during  pregnancy,  it  has  been  rather  the  custom 
to  discredit  the  influence  of  heredity  upon  the  devel- 
opmeat  of  the  disease,  and  particularly  to  discredit  the 
possibility  of  infection  from  the  father  before  birth.  In 
view  of  the  beautiful  studies  that  have  been  made  in 
certain  hereditary  forms  of  nervous  disease  in  which 
sometimes  as  many  as  six  generations  hare  been  traced, 
and  elaborate  family  trees  prepared  (we  have  particu- 
larly in  mind  Huntingdon's  chorea),  it  seems  strange 
that  similar  studies  have  been  so  rarely  undertaken  for 
tuberculosis.  It  is  therefore  with  considerable  satisfac- 
tion that  we  call  attention  to  the  recent  article  of  Edwin 
Klebs  (Munchener  medic inische  Wochenschrift,  January 
22,  1901). 

He  gives  two  elaborate  family  trees,  the  first  includ- 
ing five,  and  the  second  six  generations.  It  seems  de- 
sirable to  give  briefiy  the  general  data  concerning  these 
two  families. 

Concerning  the  original  pair  of  family  "  A,"  dating 
from  1757,  there  is  no  information  excepting  that  the 
father  died  at  the  age  of  81.  Five  children  were  born, 
of  whom  four  died  of  tuberculosis,  and  the  fifth  is  doubt- 
ful. Of  these  five  children,  one,  a  chronic  drunkard, 
married  and  had  eight  children,  of  whom  five  died  of 
tuberculosis  and  the  infection  of  the  others  was  doubt- 
ful. One  of  these  five,  a  woman,  who  died  at  the  age  of 
twenty-five  of  tuberculosis,  married,  and  had  two  chil- 
dren, both  of  whom  died  in  early  life  of  tuberculosis.  Two 
of  the  doubtful  males  married,  one  having  three  chil- 
dren, two  of  whom  died  of  tuberculosis;  but  the  other 
three  had  five  children,  all  of  whom  are  at  present 
healthy.  The  other  doubtful  male  married  and  had  two 
male  children  ;  both  were  married,  one  to  a  woman  who 
had  already  been  married  to  a  tuberculous  man,  and 
had  had  one  tuberculous  child.  The  eight  children 
of  her  second  marriage,  however,  were  all  healthv. 

The  second  ancestral  pair,  also  dating  from  1757,  had 
two  descendants,  one  dying  of  tuberculosis.  The  latter 
had  two  children,  one  of  whom  was  married  twice, 
and  had  six  children,  all  dying  of  tuberculosis ;  but 
three  of  these  six  married  and  had  three  seta  of 
children — three,  three,  and  one,  all  of  them  at  present 
healthy.  The  other  married  and  had  five  children,  four 
of  whom  were  certainly  tuberculous.  Four  of  these  five 
married,  one  having  a  tuberculous  child,  who  also  had 
a  tuberculous  child.  Another  had  one  tuberculous 
child.  His  widow  afterward  married  one  of  the  healthy 
descendants  of  family  "  A,"'  and  had  eight  healthy  chil- 
dren. Another  marriage  resulted  in  one  doubtful  child, 
and  the  last  was  sterile. 

From  the  study  of  these  tables  and  some  other  in- 


stances that  he  has  observed,  Klebs  reaches  the  con- 
clusion that  tuberculosis  in  the  father  is  ten  times  as 
dangerous  as  tuberculosis  in  the  mother,  and  that  if 
both  parents  are  tuberculous,  all  the  children  wUl  cer- 
tainly be  so.  In  the  two  families  in  which  the  disease 
was  traced  for  five  generations  or  more,  there  were  fifty- 
five  children,  of  whom  thirty-three  were  tuberculous, 
and  twenty-two  were  apparently  free.  That  is,  more 
than  50%  of  the  children  were  infected.  In  ad- 
dition to  this,  many  of  the  marriages  of  these  children 
were  sterile,  showing  the  disastrous  effects  upon  the 
race  of  tuberculosis  in  the  parents. 

No  Universal  Lianguage  for  Science. — Of  all  the 

men  who  have  yearned  for  a  common  tongue  the  men 
of  science  perhaps  have  yearned  the  most.  Medical 
scientists  have  certainly  as  good  cause  as  any  others  to 
wish  that  there  was  a  universal  language.  Diversity  of 
tongues  is  an  obstacle  to  science,  and  the  Tower  of 
Babel  was  the  first  barrier  to  the  rapid  diffusion  of 
knowledge.  Considering  these  facts,  it  is  rather  curious 
to  note  that  Hermann  Diele,  in  a  recent  number  of  the 
Deutsche  Revue,  says  that  he  has  no  faith  in  the  scheme  ' 
of  a  universal  language,  and  that  such  a  language 
would  not  be  of  much  value  except  in  commerce,  and 
not  much  even  there.  Diele  says  that  Latin  is  the  only 
language  adapted  to  universal  use  (just  as  it  was  in  the 
Middle  Ages),  but  he  evidently  believes  that  the  revival 
even  of  Latin  for  such  a  purpose  is  only  a  Utopian 
dream.  He  thinks  that  the  agitation  for  a  universal 
language  for  the  use  of  the  learned  haa  subsided  of  late 
years.  French  seemed  to  take  the  lead  for  a  century  or 
two  after  the  time  of  Richelieu,  but  it  certainly  does 
not  hold  it  now  in  competition  with  English  and  Ger- 
man. Diele  thinks  that  an  exclusive  patriotism  now 
actuates  the  several  great  nations  of  the  world,  and  re- 
acts against  foreign  languages.  This  evidently  is  true 
of  English,  French  and  German,  and  there  is  no  pros- 
pect of  this  spirit  diminishing.  This  whole  subject  is 
of  direct  personal  concern  to  medical  scientists,  for  it 
means  that  they  must  continue  to  cultivate  not  one  but 
several  foreign  tongues.  Of  recent  years,  indeed, 
Italian  and  even  Spanish  have  assumed  great  import- 
ance as  languages  of  science.  From  the  medical  stand- 
point some  of  these  facts  are  to  be  deplored,  for  medical 
science  now  demands  nearly  all  a  man's  time  and 
energy  without  leaving  him  much  for  the  cultivation  of 
foreign  languages.  Moreover,  the  command  which  a 
man  acquires  over  a  foreign  language  when  he  pursues 
it  merely  for  the  acquisition  of  scientific  facts,  is  usually 
not  sufiicient  to  give  him  much  facility  or  pleasure  in 
it.  He  in  no  sense  becomes  a  skilled  linguist.  Xo  one 
knows  this  fact  better  than  the  medical  toilers  who 
delve  in  German  and  French.  But  there  seems  to  be 
no  prospect  of  a  remedy  for  the  polyglot  evils  of  our 
daj',  as  the  following  figures,  compiled  by  Carnac,  the 
English  statistician,  clearly  show : 


March  30,  1901] 


REVIEWS 


TTHE  PHILiDKLPHlA 

L  Medical  Joubnal 


589 


DATS. 

ENGLISH. 

GERMAN. 

RUSSIAN. 

FRENCH. 

ITALIAN. 

SPANISH. 

Millions. 

MilliODB. 

Millions. 

Millions. 

Millions. 

Millions. 

1500      

4 

10 

8 

10 

0% 

^% 

1600 

6 

10 

3 

14 

^% 

8;. 

1700 

S'A 

10 

3 

20 

9J^ 

i% 

1800      

20 

81 

30 

31 

15 

26 

1900.   $ 

116 

80 

85 

52 

54 

44 

A  New  Therapeutic  Journal. — Beginning  about 
the  Ist  of  May  The  Medical  .Journal  Union,  limited,  of 
this  city,  will  issue  a  new  medical  journal  to  be  called  the 
Iherapeutic  Monthly.  We  are  glad  to  announce  that  this 
new  journal  will  be  under  the  editorial  care  of  Professor 
James  Tyson,  who  will  have  as  his  associate  editor  Dr. 
Thomas  L.  Coley.  The  Therapeutic  Monthly  will  have 
absolutely  no  connection  with  any  pharmaceutical  or 
drug  firm,  but  will  be  an  entirely  independent  journal, 
devoted  to  the  interests  of  its  readers  alone.  It  will 
contain  original  papers  by  therapeutists  of  recognized 
reputation,  abstracts  of  therapeutic  literature,  and  edi- 
torial matter  relating  to  therapeutics  in  general.  It 
will  consist  of  40  pages  each  month,  of  the  size  of  the 
Philadelphia  Medical  Journal.  We  believe  that  the 
profession  will  welcome  this  new  monthly,  which 
promises  to  meet  accurately  and  conscientiously  the 
wants  of  practitioners  in  a  particularly  changeable  and 
difficult  field.  The  character  and  attainments  of  the 
editor  are  guarantees  that  these  wants  will  be  ade- 
quately met. 


An  Interesting  Case  of  Self-inflicted  Injury  of 
the  Urethra  and  Bladder. — Sianosheasky  (Fra<c A.,  Vol. 
22,  No.  2)  reported  before  the  Society  of  Physicians  of  Kiew 
the  case  of  a  peasant  woman,  who  suffered  from  pruritus 
vulvae  and,  by  the  advise  of  some  neighbors,  applied  garlic. 
Not  obtaining  any  relief,  she  cut  the  urethra  with  a  small 
knife  and  continued  these  applications.  There  still  being  no 
relief,  the  bladder  was  cut  in  a  similar  manner,  and  the  ap- 
plication of  the  garlic  kept  up.  This  was  followed  by  com- 
plete recovery  from  the  pruritus,  but  a  condition  of  incon- 
tinence was  established  for  which  she  sought  medical  advice. 
On  examination,  both  the  urethra  and  the  neck  of  the 
bladder  were  found  severed  with  the  edges  of  the  wound 
gaping.  A  plastic  operation  was  performed,  and  the  woman 
made  a  rapid  and  complete  recovery,     [a  r  ] 

Soft  Chancre  Treated  by  the  Cautery.— Zydlovitz 
{Gazeta  Lekarska,  December  16,  1900),  ^treated  26  cases  by 
Andry's  method,  which  consists  in  holding  a  Pacquelin 
cautery  at  a  distance  of  from  3  to  4  mm.  from  the  ulcer. 
The  heat  kills  the  virus,  and  the  chancre  is  transformed  into 
a  simple  granulating  ulcer.  The  results  obtained  by  the 
author  are  all  that  could  be  desired.  Not  in  a  single  case 
did  adenitis  or  any  other  complications  follow.  The  irjec- 
tion  of  a  2%  solution  in  the  neighborhood  of  the  chancre 
was  found  to  produce  complete  anesthesia.  It  was  also  ob- 
served that  by  applying  the  curet  to  the  floor  and  edges  of 
the  ulcer  before  applying  the  cautery,  recovery  was  greatly 
hastened.  An  application  of  the  cautery  for  one  minute  will 
destroy  the  chancre  at  a  single  sitting.  The  subsequent 
treatment  is  the  same  as  that  of  a  simple  ulcer,    [a.b.] 


Hcrtctrs. 


The  Practice  of  Medicine.  A  Textljook  for  Practition- 
ers and  Students,  witli  Special  Reference  to  Diagnosis 
and  Treatment.  By  James  Tyson,  M.D.,  Professor  of 
Medicine  in  the  University  of  Pennsylvania,  and  Physi- 
cian to  the  Ho.spital  of  the  University ;  Physician  to 
the  Philadelphia  Hospital;  Fellow  of  the  College  of 
Physicians  of  Philadelphia;  Member  of  the  Association 
of  American  Physicians,  etc.  Second  edition,  thor- 
oughly revised  and  in  parts  rewritten,  with  127  illustra- 
tions including  colored  plates.  Philadelphia  :  P.  Blakis- 
ton's  Son  &  Co.,  1900.    Cloth,  $5.50. 

The  many  years  of  experience  in  the  teaching  of  the 
practice  of  medicine  to  students  that  have  accumulated  in 
the  lifetime  of  Dr.  Tyson  ought  to  result  in  the  production, 
out  of  that  experience,  of  a  most  valuable  textbook  to  the 
general  practitioner  as  well  as  to  the  student.  The  verdict 
of  the  profession  is  in  favor  of  Dr.  Tyson's  book,  since,  in  the 
space  of  four  years,  the  first  edition  lias  been  exhausted  and 
a  second  edition  made  necessary.  Dr.  Tyson's  reputation  is 
that  of  a  practical  and  conservative  teacher,  and  those  who 
learn  from  him  may  be  sure  that  they  will  not  be  led  astray 
by  recommendations  to  adopt  new  methods  merely  because 
they  are  new ;  but  rather  that  new  methods  are  recom- 
mended because  they  have  been  tried  and  not  found  want- 
ing. 

The  special  department  of  medical  investigation  with 
which  the  author's  name  is  habitually  associated  is  that  re- 
lating to  diseases  of  the  kidneys  and  the  examination  of 
the  urine.  And  here  we  find  a  concise  and  practical  exposi- 
tion of  the  facts  relating  to  the  diseases  of  these  important 
organs.  We  think  that  a  more  precise  statement  of  the 
author's  own  views  concerning  the  nature  of  cylindroids 
would  have  been  appreciated  by  Dr.  Tyson's  many  students. 

It  would  be  beyond  the  limits  of  the  space  allowed  for  a 
review  to  treat  of  each  section  of  the  work  separately.  But 
we  may  mention  two  points  on  which,  like  the  significance 
of  cylindroids,  the  profession  in  general  would  be  pleased  to 
have  a  more  definite  statement  from  the  author.  These  are, 
first,  the  value  of  antitoxin  in  the  treatment  of  diphtheria ; 
and  second,  the  diagnostic  value  of  lumbar  puncture.  It 
would  also  be  of  value  to  have  a  tabular  arrangement  of 
the  difl'erential  points  in  the  diagnosis  of  organic  and  hys- 
terical hemiplegia.  The  chapter  on  tuberculosis  is  very 
complete  and  admirably  arranged,  and  the  section  on  the 
gonorrheal  infection  is  very  timely  and  in  the  right  place. 

In  revising  the  section  on  the  diseases  of  the  nervous  sys- 
tem, the  author  has  had  the  assistance  of  Dr.  William  G. 
Spiller.  The  chapter  on  general  symptomatology  will  serve 
as  an  excellent  model  for  the  investigation  of  nervous  dis- 
eases. The  neuron  theory  of  the  composition  of  the  nervous 
system  is  set  forth  in  language  devoid  of  technicalities  and 
is  admirably  adapted  to  the  needs  of  the  general  practi- 
tioner.    [.I. M.S.] 

The  Treatment  of  Fractures.  By  Charles  Locke 
ScuDDEB,  M.D.,  Surgeon  to  the  Massachusetts  General 
Hospital,  Out-patient  Department,  assisted  by  Fred- 
eric J.  Cotton,  M.D.  Second  Edition,  Revised.  With 
611  illustrations,  8vo,  pp.  457.  Philadelphia  and  Lon- 
don :  W.  B.  Saunders  &  Co.,  1901. 

This  book  is  conspicuously  attractive  because  of  the  un- 
usual number  and  beauty  of  its  illustrations.  Half-tones, 
skiagraphs,  tracings  from"  skiagraphs,  and  diagrams  crowd 
its  pages.  A  good  many  of  these  pictures  have  comparatively 
little  real  practical  usefulness,  but  ihey  are  worthy  of  study 
bv  the  scientific  student  of  osseous  lesions. 

"The  author's  method  of  presenting  the  subject  shows 
originality,  and  as  a  result  his  book  has  a  fresh  flavor,  which 
inspires  the  reader's  interest.  There  is,  liowever,  little 
originality  in  the  methods  of  treating  fractures.  Indeed,  the 
dressings  are  uiuisualiv  complicated  and  cumbersome.  This 
is  probably  due  to  the  author's  familiarity  with  the  recog- 


590 


The  Philadelphia"] 
Medical  Journal  J 


REVIEWS 


(UaBCH  30,  1901 


nized  methods  of  his  seniors  in  the  Surgical  Department  of 
the  Massachusetts  General  Hospital.  An  illustration  is  seen 
in  his  statements  that  a  patient  with  a  fractured  femur  should 
always  be  anesthetized  before  putting  the  thigh  up  perma- 
nently, that  about  one  hour  will  be  consumed  in  applying 
the  fracture  dressing ;  and  that  an  extension  apparatus, 
an  external  axillarj-  splint,  a  ham  splint,  coaptation  splints, 
and  sandbags  are  to  be  employed  in  the  treatment  of  this 
usually  not  very  troublesome  injury.  It  is  little  wonder  that 
the  patient  requires  general  anesthesia.  One  would  think 
that  the  surgeon  and  nurses  would  need  general  stimulation 
to  stand  the  strain  ! 

The  title  is  scarcely  just  to  the  work,  because  the  volume 
is  much  more  than  a  treatise  on  treatment.  Many  pages  are 
devoted  to  the  pathology  and  diagnosis  of  fractures.  In  the 
discussion  of  fractures  at  the  elbow,  some  twenty  odd  pages 
are  occupied  by  these  matters  before  the  treatment  is  taken 
up  In  fractures  of  the  lower  end  of  the  radius,  about  a 
dozen  pages  ar-e  used  in  a  similar  manner;  and,  in  the  chap- 
ter on  cranial  fractures,  eighteen  pages  are  given  up  to  these 
prelimina'y  details.      * 

The  more  recent  improvements  in  fracture  treatment  are 
mentioned  in  an  almost  too  cursory  manner.  A  special 
chapter  towards  the  end  of  the  volume  is,  for  instance, 
devoted  to  the  use  of  gypsum  in  fractures,  instead  of  discuss- 
ing the  use  of  splints  made  of  this  material  and  gauze  in  the 
sections  devoted  to  special  fractures  or  in  a  general  state- 
ment at  the  beginning  of  the  work.  This  circumstance  gives 
one  the  impression  that  the  author  prefers  wooden  splints  to 
the  perfectly  fitting  plastic  splints  which  are  becoming  the 
preference  of  so  many  surgeons  of  today.  Again,  the  opera- 
tive treatment  of  cranial  and  other  fractures  is  scarcely 
more  than  mentioned. 

The  book  nevertheless  contains  many  practical  sugges- 
tions which  are  often  overlooked  by  practitioners  treating 
fractures.  Some  of  these  suggestions  are  novel ;  many  are 
none  the  less  valuable,  though  old. 

Within  recent  months  American  surgeons  seem  to  have 
felt  a  renewed  interest  in  the  treatment  of  fractures,  for 
Scudder  and  Hopkins  have  published  large  books  on  the 
subject  and  Estes  and  Roberts  small  ones.  This  is  a  hopeful 
sign,  for  these  lesions  are  important  and  are  often  badiv 
treated,    [j.b.r.] 

The  Treatment  of  Fractures.  By  W.  L.  Estep,  A.M., 
M.D.,  Surgeon-in-Chief  of  St.  Luke's  Hospital,  South 
Bethlehem,  Pa  8vo,  illustrated,  cloth,  pp.  216.  New 
York  :    International  Journal  of  Surgery  Company. 

This  volume  has  the  same  title  as  that  just  noticed,  but  it 
is  physically  and  scieutilically  of  a  different  type.  It  is 
plam  in  appearance,  small  in  size,  and  illustrated  by  cuts 
which  are  far  from  artistic  in  appearance.  The  abundance 
and  beauty  of  Scudder's  illustrations  are  missing,  though  the 
figures  introduced  serve  to  give,  as  a  rule,  the  information 
desired  by  the  author. 

Examination  of  the  volume  soon  makes  it  evident  that 
the  author  is  speaking  from  personal  experience  in  the  treat- 
ment of  fractures  and  that  he  has  not  been  bound  by  surgical 
traditions,  or  the  older  writers  and  teachers.  He  speaks 
as  if  he  had  made  good  use  of  his  opportunities  to  studv 
traumatisms  of  bone,  and  had  not  failed  to  draw  his  own 
deductions  and  formulate  his  own  methods  of  treatment. 
His  frequent  employment  of  plastic  splints  of  gvpsum,  and 
of  mechanical  devices  applied  directly  to  the  bone  after  in- 
cision of  the  soft  tissues,  and  his  willingness  to  split  open  the 
whole  perineum  in  bad  fractures  of  the  pelvis  show  the  thor- 
oughness of  his  appreciation  of  modern  surgical  principles. 

Dr.  Estes  lays  perhaps  more  stress  than  most  surgeons  on 
the  necessity  of  verifying  with  the  RSntgenray  the  apposi- 
tion of  fractures  after  i-eduction,  and  in  some  o"ther  respects 
he  may  have  individual  views  which  are  not  in  accordance 
with  the  opinions  of  other  writers.  In  the  main,  however, 
his  statements  will  scarcely  be  challenged. 

It  may  seem  invidious  to  make  comparisons  between  two 
good  books  on  the  same  subject,  but  it  is  part  of  a  reviewer's 
duty  to  do  so.  In  the  ojnnion  of  the  present  writer  this 
small  book  is  more  up  to-date  than  Dr.  Scudder's  handsome 
big  volume,  and  a  better  practical  guide  for  the  professional 
attendant  on  cases  of  fracture  to  follow.  In  both  books  the 
authors  could  with  benefit  have  given  more   attention  to 


writing  accurate  English.  Scientific  works  deserve  the  same 
painstaking  care  in  the  grammatical  structure  of  sentences 
as  they  require  in  the  interpretation  of  fact.?,     [j.b  r.] 

Pulmonary  Consumption,  Pneumonia,  and  Allied 
Diseases  of  the  Lung's.  Their  Etiologj-,  Pathology, 
and  Treatment,  with  a  Chapter  on  Physical  Diagnosis. 
By  Thomas  J.  Mays,  A.M.,  M.D.,  Professor  of  Diseases 
of  the  Chest  in  the  Philadelphia  Polyclinic ;  Visiting 
Physician  to  the  Rush  Hospital  for  Consumptian.  Il- 
lustrated. New  York  :  E.  B.  Treat  &  Co.,  1901.  Price, 
.$3.00. 

It  is  with  mingled  feelings  of  satisfaction  and  regret  that 
we  notice  that  Dr.  Mays  has  given  to  the  profession  in  sys- 
tematic form  his  well-known  views  upon  "Pulmonary  Con- 
sumption, Pneumonia,  and  Allied  Diseases  of  the  Lungs." 
Our  satisfaction  arises  from  the  fact  that  we  are  now  able  to 
studj'  the  whole  work  carefully  and  draw  our  conclusions  as 
to  its  value.  Our  regret  is  that  these  conclusions  cannot  '' 
agree  with  those  of  the  author  of  the  work.  His  point  of 
view  has  been  developed  with  painstaking  care  and  unques- 
tioned conviction  during  thirty  years,  and  he  is  surely  en- 
titled to  that  respectful  consideration  which  he  requests  in 
his  preface.  To  quote  the  author  :  "  The  fundamental  con- 
cepts of  the  work  may  be  formulated  into  the  following 
proposition:  1.  That  pulmonary  phthisis  is  primarily  a 
neurosis,  and  that  the  pulmonary  disintegration  is  second- 
ary. 2.  i'hat  any  agent,  influence,  or  condition  which  under- 
mines the  integrity  of  the  nervous  system  will  engender 
pulmonary  phthisis  or  some  other  form  of  pulmonary  dis- 
order. 3.  That  the  only  remedies  of  value  in  the  treatment 
of  pulmonary  phthisis  are  those  which  appeal  to,  and  act 
through,  the  nervous  system.  4.  That  of  special  value  in  the 
treatment  of  phthisis  is  the  counterirritant  action  of  silver 
nitrate  introduced  hypodermically  over  the  vagi  in  the 
neck.  5.  That  acute  pneumonia  and  other  forms  of  acute 
pulmonary  disease  are  closely  affiliated  with  disorders  of  the 
nervous  system." 

The  exposition  of  Dr.  Mays'  views  is  extremely  readable,  if 
atavistic  in  its  tendency.  We  believe,  however,  that  the  logic 
of  the  author's  work  is  at  fault  in  the  essential  point  that 
he  reasons  from  a  few  particulars  to  universals,  a  common 
enough  error,  but  not  to  be  condoned  in  a  work  of  essayed 
scientific  character.  The  fact  is  incontrovertible  that  certain 
diseased  states  of  the  vagus  will  cause  pulmonary  lesions, 
but  after  our  reading  of  Dr.  Mays'  work  we  cannot  alter  our 
conviction  that  because  this  relationship  is  present  in  certain 
cases  it  does  not  argue  for  the  universal  existence  of  a 
primary  nervous  disorder,  central  or  peripheral.  Indeed,  we 
believe  that  the  opposite  state  of  affairs  is  much  more  likely : 
that  diseased  nervous  processes  frequently  occur  secondary 
to  bacterial  affection.  Again,  we  believe  that  the  reasoning 
of  the  work  is  faulty  in  that  it  overlooks  the  clear  distinction 
between  the  predisposing  and  exciting  cause.  The  wide 
prevalence  of  tuberculosis  makes  its  association  with  inter- 
current diseases  of  many  varieties  most  common,  and  of 
these  we  grant  the  importance  of  nervous  disorder.  The 
effort,  however,  to  prove  the  nervous  affection  primary  is  not 
in  accord  with  accepted  teaching ;  and  neither  has  the  exposi- 
tion of  the  theory  proven  convincing  even  though  it  has 
been  cleverly  and  entertainingly  presented.  We  are  prepared 
to  grant  that  in  a  certain  number  of  cases  in  which  clinically 
pulmonary  lesions  develop,  there  is  excellent  reason  to  believe 
that  the  predisposition  culminating  in  the  specific  infection 
is  due  directly  to  the  derangement  of  the  nervous  mechan- 
ism of  respiration ;  but  to  our  mind  it  by  no  means  follows 
that  every  case  of  pulmonary  disease  must  have  this  ante- 
cedent cause.  In  attempting  to  throw  the  entire  onus  of 
pulmonary  pathologv'  upon  the  nervous  system  we  seem  to 
assume  tar  more  than  our  knowledge  of  the  subject  warrants. 
The  complex  functions  of  the  vagus  are  but  partially  under- 
stood and  its  physiological  relations  with  other  organs  than 
the  lungs  seem  to  be  too  little  taken  into  account  in  Dr. 
Mays'  theory. 

He  goes  to  great  length  to  disapprove  the  contagiousness 
of  tuberculosis,  but  we  believe  in  all  sincerity  that  many  of 
the  cases  brought  forward  to  adduce  this  fact  argue  strongly 
for  the  more  generally  adopted  view.  In  the  author's  opinion 
there  is  no  \ital  difference  between  the  pneumonias.    He 


Mabch  30,  1901] 


CORRESPONDENCE 


PThe  Phizadklphia  591 

[_  Medical  Journal  ' 


recognizes  the  general  difference  between  the  croupous  and 
the  catarrhal  varieties,  but  goes  on  to  say  that :  ''  This  differ- 
ence is  neither  vital  nor  essentially  fundamental ;  that  both 
are  in  a  great  measure  the  products  of  the  same  pathological 
principle ;  that  clinically  one  cannot  be  separated  from  the 
other.     ..." 

Dr.  Mays  lays  great  stress  upon  his  interpretation  of  this 
word  "  clinical."  It  carries  to  him  a  practical  meaning,  a 
meaning  which  he  has  derived  from  his  own  observation,  and 
to  which  he  is  inclined  to  attach  much  more  value  than 
to  the  results  of  the  laboratory  study  of  disease.  His  views 
upon  pathology  are  by  no  means  in  accord  with  modern 
authorities  upon  this  major  subject.  From  a  study  of  his 
work  we  conclude  that  he  ascribes  to  bacteriology  but  a 
minor  role  in  the  etiology  of  disease. 

Basing  his  methods  of  treatment  upon  his  "  neurotic  " 
theory  (the  term  is  the  author's),  which  he  has  expounded, 
Dr.  Mays  has  injected  from  4  to  7  miniins  of  a  2*%  to  even 
a  5%  solution  of  silver  nitrate  into  the  tissues  of  the  neck. 
'•  The  place  which  has  been  selected  for  its  administration  is 
immediately  over,  or  slightly  behind,  the  pulsating  carotid 
artery  in  the  region  of  the  neck,  in  a  line  near  between  the 
angle  of  the  jaw  and  the  clavicle,  and  nearer  the  latter  than 
the  former  point.  Points  higher  up  along  the  course  of  the 
nerve  niaj'  also  be  chosen."  In  the  past  two  years  Dr.  Mays 
has  employed  this  treatment  in  250  cases  with  surprisingly 
good  results.  Other  remedial  measures  do  not  seem  to  have 
been  neglected  during  this  time,  and  it  must  appeal  to  many 
minds  that  they  are  the  more  reasonable  explanation  for 
the  betterment  of  the  symptom.  Empirically  this  method 
does  not  seem  to  have  wrought  any  serious  damage.  Ab- 
scesses have  occurred  about  50  times  in  some  i;,0(K)  injec- 
tions. Theoretically  we  hold  the  measure  would  appear  to 
be  fraught  with  danger  both  upon  anatomical  and  physi- 
ological grounds,    [t.l.c] 


dorrcsponbcncc. 

ALBUMINODS  NUTRITION  AND  NUTRITIOUS  ALB  OMEN, 
BY  DR.  BERNHEUa. 

By  a.  L.  BENEDICT,  A.M.,  M.D., 

of  Buff.>Io,  S.  Y. 

To  the  Editor  of  The  Philadelphia  Medical  Jourxal  : — 

It  has  always  seemed  to  me  that  a  published  article  should 
be  subject  to  the  same  full,  free,  and  more  or  less  informal 
discussion  as  one  that  is  read  before  a  society.  In  this  spirit 
I  should  like  to  make  a  few  remarks  regarding  the  paper  by 
Dr.  Albert  Bernheim  and  that  by  Dr.  A.  E.  Austin,  in  your 
issue  of  March  9. 

It  seems  doubtful  whether  Pfliiger's  dictum  concerning 
the  importance  of  proteid  food  can  be  accepted  in  the  clin- 
ical sense.  Most  exhaustive  experiments  (see  Gamgee  and 
other  authorities)  have  shown  that  muscular  exercise  does  not 
actually  destroy  much  albumin,  either  of  the  muscle  itself  or 
of  the  circulating  plasma.  Exercise,  and  in  fact,  all  bodily 
work  involves  a  comparatively  slight  wear  and  tear  of  tissue 
and  an  enormous  (relative)  combustion  of  carbohydrates  and 
fats  to  produce  the  needed  energy.  There  is,  I  believe, 
some  evidence  to  show  that  brain  work  requires  relatively 
more  proteid  than  muscle  work,  comparing  equal  weights  of 
brain  and  muscle  for  strenuous  effort  for  the  same  time.  No 
one  can  seriously  question  the  appropriateness  of  the  term 
"proteid  "  as  iadicating  that  this  kind  of  food  is  absolutely 
indispensable.  Oa  the  other  hand,  the  implication  of  the 
quotation  of  Pfliijer  through  Finkler,  is  misleading  as  mini- 
mizing the  importance  of  carbohydrate  food,  of  which  the 
normal  adult  organism  needs  at  least  four  times  a3  much 
as  of  proteid.  The  conditions  in  Europe  undoubtedly  are 
such  that  the  poorer  classes  eat  too  little  meat,  but  this  con- 


dition does  not  obtain  in  America,  except  among  recent  immi- 
grants, and  in  some  parts  of  the  rural  districts.  The  average 
American  laborer  has  an  abundance  of  meat,  and  his  diet 
needs  improvement  rather  in  the  way  of  a  greater  variety  of 
vegetable  food,  and  of  having  his  principal  meal  in  the  even- 
ing, when  it  can  be  served  hot  and  eaten  at  leisure.  Com- 
parisons of  dietaries  of  diflferent  classes  are  also  somewhat 
misleading  on  account  of  the  greater  waste  among  the  rich. 
Again,  it  seems  remarkable  that  the  waste  by  failure  of  non- 
absorption  amounts  to  5%  for  animal  proteid,  and  35%  for 
vegetable  proteid.  I  da  not  pretend  to  be  a  physiologic 
chemist,  but  if  this  enormous  waste  exists,  why  do  not  our 
clinical  analysis  of  feces  show  notable  quantities  of  proteid 
at  all  times?  Possibly  the  discrepancy  is  due  to  the 
fact  that  Dr.  Bernheim  includes  tendon  ends,  coarse  bits  of 
vegetable  tissue,  ets.,  yet  he  seems  to  refer  especially  to 
vegetable  flours  and  meals.  These  latter  ought  to  furnish 
feces  as  rich  in  proteid  as  stomach  contents,  if  35%  of 
albumin  is  unabsorbed. 

Probably  Dr.  Bernheim  can  point  out  the  error  of  our 
clinical  tests,  but  I  believe  the  clinical  fact  remains  that 
most  of  our  patients  in  private  practice  consume  too  much 
meat  and  too  much  proteid  as  compared  with  carbohydrate. 
Furthermore,  I  want  to  protest  against  the  idea  that  any 
artificial  nutriment  can  supplant,  except  for  special  purposes 
and  for  a  limited  time,  natural  food,  selected  in  acjordance 
with  a  healthy  appetite  guarded  by  common  seose. 

THE  FUNCTION  AND  DISTRIBUTION  OF  COMBINED 
HYDROCHLORIC  ACID  IN  PROTEOLYTIC  DIGES- 
TION, BY  DR.  AUSTm. 

These  experiments  are  interesting  and  confirm  the  clinical 
experience  that  combined  HCl  varies  widely  in  amount  as 
compared  with  proteid,  in  chyme.  They  may  also  serve  as 
a  ba.3is  for  explaining  the  fact  that  the  common  practice  of 
administering  pepsin  when  HCl  is  indicated,  often  seems  to 
increase  digestive  power.  I  trust  that  Dr.  Austin  will  con- 
tinue his  experiments,  using  solutions  and  time  limits  more 
readily  CDmparable  with  gastric  digestion  in  man.  I  take  it 
for  granted  that  his  percentages  of  HCi  refer  to  the  gaseous 
acid,  though  some  of  his  formulas  suggest  that  the  official 
strong  acid — containing  about  31%  HCl — is  meant.  This 
point  is  of  practical  importance  and  should  be  distinctly 
stated.  The  distinction  of  coagulable  from  acid  albumin  is 
one  that  can  not  be  made  in  examinations  of  stomach-con- 
tents, after  ordinary  test  meals,  as  all  albumin  is  ingested 
coagulated  and  any  liquefaction  must,  I  suppose,  be  due 
primarily  to  acidification.  Was  the  egg  albumin  used  simply 
the  dried  material  or  was  it  previously  boiled  and  then  dried 
or  estimated  as  water-free  proteid  ?  In  my  clinical  method 
of  quantitating  proteolysis  in  stomach  contents  (now  await- 
ing publication  in  the  Jour.  Am.  3Ied.  Ass'n.)  1  have  called 
all  proteid  precipitated  by  heat,  acid  albumin  and  have  suc- 
cessively precipitated  albumoses  by  ammonium  sulphate  and 
peptones  with  phospho-molybdic  acid.  Dr.  Austin's  method 
makes  a  four-fold  division  of  proteolysis,  or  a  five- fold,  if  his 
albumin  was  first  coagulated  before  being  first  subjected  to 
digestion.  I  should  be  pleased  to  learn  more  fully,  to  what 
extent  he  has  used  the  centrifuge  in  his  experiments,  so  as 
to  give  credit  for  his  work  so  far  as  it  has  anticipated  mine. 

In  this  d'Ecussion  I  have  tried  to  write  much  as  one  would 
talk  extemporaneously,  after  hearing  two  interesting  and 
valuable  papers,  and  wou'd  be  pleased  to  receive  the  criticism 
and  explanation,  as  the  readers  would  have  replied  in  the 
verbil  summicg  up.  Doubtless,  many  of  the  apparent  differ- 
ences of  opinioa  ar3  due  to  the  fact  that  the  authors  have 


592 


The  Philadelphia"] 
Medical  Journal  J 


CORRESPONDENCE 


[Mabch  3e,  UOl 


taken  the  standpoint  of  laboratory  research,  while  mine  is 
entirely  that  of  the  cUniciau,  with  leisure  and  apparatus 
adapted  only  to  clinical  investigation  of  cases. 

In  conclusion,  I  should  like  t3  suggest  that  while  this  par- 
ticular discussion  may  have  little  value,  it  would  add  im- 
mensely to  the  interest  and  ussfuluess  of  medical  periodicals 
if  printed  papers  were  as  freely  discussed  as  those  presented 
veiba'ly  to  societies ;  also  to  urge  that  all  such  discuEsion 
should  be  preceded  or  accompanied  by  notice  to  the  authors, 
as  a  matter  of  courtesy. 


INFUSION  OF  SALT-SOLUTION   IN  THE  TREATMENT 
OF  PNEUMONIA.— A  CRITICISM. 

By  D.  E.  KEEFE,  M.D., 
of  Springfield,  Mass. 

To  the  Editor  o/The  Philadelphia  Medical  Journal  :— 

In  the  Jodrnal  of  March  9,  1901,  appeared  a  lucid  and 
timely  editorial,  giving  a  synopsis  of  a  paper  by  Dr.  Clement 
A.  Penrose,*  of  the  Johns  Hopkins  Hospital,  advocating  the 
use  of  saline  infusion  in  conjunction  with  inhalation  of  oxy- 
gen passed  through  water  containing  antiseptics,  in  the  treat- 
ment of  pneumonia.  By  way  of  preface,  let  me  say  that  I 
am  entirely  opposed  to  the  routine  use  of  this  solution  "  in 
cases  of  collapse  during  and  after  operations,  so  common  in 
our  hospitals,"  except  only  when  the  collapse  is  preceded  by 
and  is  consequent  on  blood-loss.  Oxygen,  with  or  without 
antiseptics,  has  a  certain  value  in  a  number  of  cases  of 
pneumonia.  But  I  am  certain  that  very  little  can  be  ad- 
duced in  favor  of  saline  infusion  in  pneumonia,  but,  on  the 
contrary,  much  in  opposition.  Indeed,  its  use  before  the 
stage  of  gray  hepatization  is  wholly  indefensible.  Busy 
physicians  are,  I  fear,  too  apt  to  take  post  hoc  for  propter 
hoc  in  such  matters.  For  example,  in  syncope  and  collapse, 
while  the  regular  physician  prescribes  diffusive  stimulant?, 
his  confrere  of  the  Hahnemannian  persuasion  employs 
aconite.  In  both  cases,  and  with  medicines  acting  in  dia- 
metrically opposite  directions,  the  heart  responds  and  the 
patient  is  resuscitated.  The  physicians  of  both  schools  are 
firmly  convinced  that  the  reaction  is  proof  positive  of  the 
correctness  of  their  medication,  each  believing  he  has  saved 
a  life.  But  they  have  entirely  overlooked  the  fact  that,  in  a 
third  case,  where  no  medicine  was  given,  a  like  recovery  took 
place.  The  difficulty  is  that  they  did  not  calculate  on  that 
great  power  in  medicine  of  which  we  hear  so  much,  the  vis 
medicatrix  naturae.  They  should  remember  that  the  heart  is 
prone  to  make  just  such  responses,  and  that,  too,  without 
medication  and  where  least  expected. 

Both  the  saline  infusion  and  the  stimulant  plan  of  treat- 
ment, now  in  vogue,  are  unphysiological  as  applied  to  pneu- 
monia. They  promote  activity,  and  seek  to  send  more  blood 
to  the  affected  in  common  with  all  other  parts,  whereas  cor- 
rect physiological  teaching  demands  rest  and  abstraction  of 
blood.  They  fail  in  pneumonia  because  in  the  inflamed  lung 
there  is  almost  complete  stasis,  by  reason  of  the  exudate 
outside  and  the  clotting  within  the  vessels.  No  matter  what 
the  degree  of  stimulation,  this  impediment  cannot  be  over- 
come, and  the  blood  cannot  be  forced  through.  In  conse- 
quence of  this  the  treatment  accomplishes  nothing,  and, 
indeed,  may  be  carried  so  far  that  the  heart,  already  over- 
acting, becomes  exhausted  and  strikes  work.  Moreover,  the 
sending  of  more  blood  to  the  nonpneumouic  lung,  which  is, 
under  such  circumstances,  always  congested,  tends  to  pro- 

*  By  the  kindness  of  Dr.  Penrose  I  have  read  his  original  paper. 


duce  edema,  as  very  properly  pointed  out  in  your  editorial, 
and  also  pneumonia.  Until  an  equivalent  for  the  added 
saline  infusion  is  eliminated,  by  the  skia  and  kidneys,  and 
although  the  heart  may  not  be  stimulated  to  the  extent  ob- 
taining when  medicinal  stimulants  are  used,  the  great  addi- 
tion to  the  circulating  fluid  and  consequent  increase  in 
pre? sure  sends  a  greater  quantity  of  blood  in  every  direction, 
and  especially  toward  the  lungs.  Thus  is  stimulation  by 
medication  and  by  saline  infusion,  in  so  far  as  they  affect  the 
circulation,  tantamount  to  the  same  thing,  the  only  differ- 
ence being  that  the  infusion  places  an  additional  burden 
upon  the  heart,  and  one  of  which  it  must  be  relieved.  Ex- 
periment and  observation  have  established  as  a  fact  that  the 
heart  promptly  responds  to  irritants  or  stimuli  whether  ex- 
ternally or  internally  applied.  Thus,  dashing  cold  water  on 
the  face  is  followed  by  a  gasp,  then  increase  in  the  depth 
and  number  of  respirations  and  increased  heart  action.  So, 
also,  a  cold  bath,  physical  exercise,  the  ingestion  of  a  con- 
siderable quantity  of  food  or  drink,  whether  introdueed 
through  the  alimentary  canal,  the  skin,  or  directly  into  a 
bloodvessel,  elicits  a  like  response.  The  degree  of  reaction 
varies  with  temperature,  and  many  other  circumstances. 
As  a  matter  of  course,  the  same  phenomenon  follows  the 
ingestion  of  saline  solution,  but  is  not  inherent  to  it  any 
more  than  to  a  like  quantity  of  water  or  milk.  If  it  ia 
justifiable  to  inject  any  fluid  in  this  manner  during  an  attack 
of  pneumonia,  that  fluid  is  antipneumotoxin  serum.  Then 
we  would  at  least  get  the  specific  effect,  and  if  largely  di- 
luted, all  the  good  effects  claimed  for  saline  infusion.  Dr. 
Penrose  prefers  infusion  to  transfusion,  but  the  difference  ia 
rather  one  of  degree  than  of  kind.  The  more  rapid  the  in- 
gestion, the  larger  the  quantity  thrown  into  the  circulation 
within  a  given  time,  the  greater  reaction  and  the  greater  the 
danger.  So  that,  while  infusion  is  safer,  it  is  also  less  prompt 
and,  so  far  as  inducing  reaction,  less  efficient. 

With  regard  to  "  diluting  the  toxins  and  promoting  their 
elimination,"  I  should  say  that  whatever  may  be  thought 
of  eliminating  them  through  the  skin,  and  I  for  one  am 
sceptical,  as  to  the  kidneys  I  say  nothing,  but  in  the  lungs, 
where  they  are  mostly  situated  and  where  most  of  the  dam- 
age is  wrought,  they  are  inaccessible  to  the  saline  solution  by 
reason  of  the  stasis,  clotting  exudate,  etc.,  as  before  ex- 
plained. Suppose  that,  for  the  sake  of  argument,  we  admit 
that  the  blood  and  saline  solution  could  circulate  freely 
through  the  pneumonic  lung,  by  just  so  much  as  it  diluted 
the  blood  and  toxins,  would  it  also  dilute  the  hemoglobin,  and, 
hence,  lessen  the  ability  of  the  blood  to  carry  oxygen  at  joat 
the  time  it  is  most  needed.  I  am  aware  of  the  small  quan- 
tity of  free  oxygen  found  in  the  blood,  but  it  is  of  no  conse- 
quence for  purposes  of  oxygenating  the  tissues.  Regarding 
the  cardiac  second  sound  and  its  accentuation  being  an  index 
for  bloodletting ;  it  is  always  too  accentuated  in  a  pneumonia 
of  any  extent  by  reason  of  the  pulmonary  artery's  inability 
to  empty  iteelf,  hence  this  sign  has  no  value. 

Considering  the  matter,  then,  from  every  point  of  view,  we 
cannot  agree  that  "  saline  infusion  is  a  decided  advance  in 
treatment."  Neither  are  we  familiar  with  smything  in  the 
chemis'.ry  of  oxygen  that  would  lead  us  to  expect  any  as- 
sistance from  saline  infusion  iii  promoting  its  absorption  or 
utility.  Had  the  doctor  proposed  to  first  abstract  a  quantity 
of  blood  equal  to  the  saline  solution  to  be  infused,  then  he 
could  reasonably  claim  he  was  gettnj  lid  of  so  much  at  least 
of  the  toxins  as  the  withdrawn  blocd  contained,  just  as  we 
do  in  uremia,  and  of  diluting  those  remaining  in  the  blood. 
At  least  he  could  not  be  held  accountable  for  adding  to  the 


Masch  30,  1901) 


AMERICAN  NEWS  AND  NOTES 


TTbe  Philadelphia 
L  Medical  Jocbsal 


5S3 


labor  of  a  heart  already  working  at  a  disadvantage  and  at 
the  point  of  exhauiticn. 

In  conclusion,  I  contend  it  is  never  safe  or  justifiable  to 
suddenly  make  any  considerable  addition  to  the  circulatory 
fluids  at  the  acme  of  an  acute  diEease  like  pneumonia,  (a) 
The  added  fluid  cannat  circulate  through  the  aflected  lung 
to  any  extent;  (6)  it  tends  to  cause  edema  and  pneumonia 
in  the  unafiected  lung ;  (c)  it  dilutes  the  hemoglobin,  and 
so  is  an  impediment  at  a  moment  when  this  is  mott  needed ; 
(d)  it  places  an  additional  burden  on  the  heart  (its  propul- 
sion and  elimination) ;  and,  finally,  it  tends  to  paralyse  the 
capillaries,  destroy  vessel  tonus,  and  overwhelm  the  heart, 
while  all  the  good  it  accomplishes  may  be  efiecttd  by  other 
agents  not  involving  like  objections  and  dangers. 


American  Xl^vos  anb  Hotes. 


PHILADELPHIA  AXD  PENNSYLVANIA. 

British  Society  of  Public  Analysts. — Dr.  Henry 
Leffmann  of  Philadelphia  has  been  elected  a  vice  president 
of  the  British  Society  of  Public  Analysts. 

Charity  Hospital. — In  the  dispensary  clinics  of  the 
Charity  Hospital,  1731  Vine  street,  there  were  treated  last 
month  322  medical  cases,  53  surgical,  and  162  of  women  and 
children,  and  775  prescriptions  were  dispensed. 

West  Philadelphia  Hospital  for  Women.— The  re- 
port of  the  West  Philadelphia  Hospital  for  Women  for  Feb- 
ruary shows  that  on  February  1  there  were  20  patients  in  the 
hospital;  received  during  the  month,  17;  registered  in  dis- 
pensary, 60  ;  registered  in  out  practice  visits,  246 ;  operations 
in  hospital,  8;  operations  in  out- practice,  6. 

Death  of  Dr.  Edward  Clarence  Fraser.— Dr.  Ed- 
ward Clarence  Fraser,  who  was  at  one  time  attached  to  the 
staflfs  of  the  Polyclinic  and  Jeflferson  Hospitals,  died  at  his 
home,  616  North  Eighth  street,  Thursday,  of  heart  failure. 
Dr.  Fraser  was  61  years  of  age,  and  was  a  graduate  of  the 
University  of  Maryland  and  Jefferson  Medical  College.  He 
also  took  a  post-graduate  course  in  the  New  York  Medical 
School  and  Hospital. 

Surg-ical  Treatment  of  Cirrhosis  of  the  Liver. — 

Cases  continue  to  multiply  of  the  so-called  operation  of  epi- 
plopexy.  This  is  an  operation  for  establishing  a  collateral 
circulation,  by  which  the  abdominal  dropsy  in  cirrhosis  of 
the  liver  is  absorbed.  Of  course,  it  is  merely  a  palliative 
operation,  and  does  not,  and  cannot,  influence  the  patho- 
logical process  in  the  liver  itself.  It  consists  essentially  in 
stitching  the  omentum  to  a  denuded,  parietal  surface  of  the 
peritoneum.  Dr.  Frazier,  of  Philadelphia,  was  one  of  the 
early  operators,  and  published  a  statistical  paper,  based  on 
all  recorded  cases  up  to  December,  1900.  Recently,  Dr. 
Jelks,  of  Hot  Springs,  Ark.,  has  reported  a  case  with  satis- 
factory results  {iledkal  Record,  March  23).  In  the  Phila- 
delphia Medical  Jouesal  for  January  26,  Dr.  John  B.  Rob- 
erts reported  2  cases,  in  a  paper  entitled  "  Epiplopexy  in  Cir- 
rhosis of  the  Liver."  These  cases  are  inadvertently  omitted 
by  Dr.  Jelks  in  his  references  to  reported  cases. 

Neurological  Society. — A  stated  meeting  of  the  society 
was  held  March  25.  the  president,  De.  James  Tyson,  in  the 
chair.  Dr.  F.  X  Dekcum  exhibited  a  man  of  37,  who  has  a 
combined  surgical  and  nervous  lesion.  The  upper  part  of 
the  left  arm  is  more  than  2  inches  shorter  than  the  right, 
supposedly  due  to  an  early  epiphysitis  of  the  upper  end  of 
the  humerus  and  consequent  lack  of  development.  There  is 
also  pain  in  that  shoulder  which  radiates  to  the  neck  and 
at  times  involves  the  eyes.  Tae  condition  is  apparently  one 
of  hysterical  joint  superimposed  upon  the  old  lesion.  This 
is  the  third  case  of  epiphysitis  seen  by  Dr.  Dercum. 

Dr.  a.  R.  Moulton  reported  A  case  of  fracture  of  a 
thin  skull  and  hemorrhage  into  the  brain.  The 
subject  was  a  patient  at  the  Pennsylvania  Hospital  for  the 


Insane  who  was  found  dead  in  his  room.  The  tkull  was 
fractured,  apparently  by  a  fall  from  the  bed,  and  was  found 
to  be  very  thin,  from  .02  to  .04  inches,  and  exceedingly 
brittle. 

Dr.  Alfred  Gordon  read  a  paper  entitled  The  role  of 
infection  and  intoxication  in  diseases  of  the  spinal 
cord.  The  frequency  with  which  microorganisms  are  found 
in  connection  with  various  lesions  of  the  cord  was  stated. 
Serumtherapy  will  probably  play  an  important  part  in  future 
treatment. 

Dr  Chas.  S.  Potts  exhibited  a  case  of  multiple  scler- 
osis with  unilateral  ascending  progressive  paraly- 
sis. An  interesting  point  in  this  case  of  multiple  sclerosis 
of  unusual  t.^pe  was  the  history  of  attacks  of  rheumatism 
before  and  during  the  presence  of  the  disease. 

Dr.  William  C.  Pickett  read  a  paper  on  the  Scapulo- 
humeral reflex  of  Von  Bechterew.  The  paper  was  a 
report  of  the  study  of  this  sign  in  122  cases  at  the  Philadel- 
phia Ho8pi'.al.  The  reflex  was  entirely  absent  in  40  cases. 
The  frequency  of  its  occurrence  in  various  lesions  of  the 
nervous  system  was  detailed.  Adduction  and  external  rota- 
tion of  the  arm  were  found  to  be  less  constant  than  abduc- 
tion with  slight  flexion  of  the  elbow.  The  presence  of  the 
reflex  is  considered  to  be  significant,  while  its  absence  is  of 
uncertain  value. 

Dr.  Mcses  Behrexd  (by  Invitation)  read  a  paper  on  The 
biceps-  tendon  jerk  in  locomotor  ataxia.  The  results 
of  the  s;udy  of  29  cases  of  tabes  were  given.  The  biceps 
jerk  was  present  in  9  caies,  the  triceps  jerk  on  both  sides  in 
2  cases,  and  on  one  side  in  2  cases.  When  the  biceps  tendon 
jeikis  absent  there  was  generally  marked  ataxia  in  the  arms. 
The  intensity  of  shooting  pains  seemed  to  have  no  relation 
to  the  degree  of  ataxia  present.  The  intensity  cf  the  symp- 
toms were  not  found  to  be  dependent  on  the  duration  of  the 
case. 

Vital  Statistics  of  Philadelphia  for  the  week  ended 
March  23,  1901 : 

Total  mortality 487 

Cases.     Dkaths. 
Inflammation  of  appendix  3,  brain  15.  bronchi 
S,  kidneys  27,  liver  3,  lungs  86.  pericardium 
1,  peritoneum  2,  pleura  5,    stomach   and 

bowels  14 164 

Inanition  12,  marasmus  13,  debility  6 31 

Tuberculosis  of  lungs 70 

Apoplexy  15,  paralysis  11 26 

Heart— disease  of  31,  fatty  degeneration  of  2, 

neuralgia  of  2 35 

Uremia  8,  diabetes  G,  Bright's  disease  4  .   .  .   .  18 

Carcinoma  of  bladder  1,  breast  1,  stomach  3, 
uterus  2,  face  2,  rectum  1,  tongue  1    .   .  .   .  11 

Convulsions 14 

Diphtheria 73  15 

Brain — congestion  of  1,  disease  of  4,  hemor- 
rhage from,  softening  of  4 10 

Typhoid  fever 30  3 

Old  age 20 

Cyanosis 1 

Scarlet  fever 85  5 

Influenza  12,  abscess  of  neck  1,  aneurysm  of 
aorta  1,  alcoholism  1,  asthma  3,  atheroma  1, 
burns  and  scalds  1,  casualties  4,  congestion 
of  lungs  4.  cirrhosis  of  liver  3,  membranous 
croup  2,  diarrhea  2,  dropsy  1,  dysentery  2, 
erysipelas  1,  hernia  1,  obstruction  of  bowels 
3,  edema  of  lungs  1,  rheamatism  5.  sarcoma 
of  neck  2,  arteriosclerosis  1,  septicemia  1, 
suicide  2,  teething  1,  abdominal  tumor  1, 
of  liver  1 ,  unknown  coroner  case  1,  whoop- 
ing-cough 4,  dropsy  of  brain  1 64 

College  of  Physicians— Section  on  Gynecology.— 

A  stated  meeting  of  the  Section  was  held  March  21,  the  Pres- 
ident, Dr.  John  C.  DaCosta,  in  the  chair.  Dr.  W.  Reynolds 
Wilson  read  the  report  of  a  Cesarean  section  in  a  case 
of  obliquely  contracted  pelvis.  The  case  belonged  to 
that  class  in  which  the  diagnosis  may  be  overlooked  when 
only  the  pelvic  measurements  are  considered,  the  distance 
between  the  spines  and  between  the  crests  being  2S  cm. 
There  was  a  history  of  progressive  deformity,  2  of  the  4  pre- 
vious children  having  been  delivered  by  decapitation.  A 
previous  lumbar  abscess  and  the  progressive  deformity  sug- 
gested tuberculosis,  but  this  condition  was  finally  excluded, 
the  history  and  condition  together  pointing  to  an  original 
rachitic  deformity.  Dr.  E.  P.  Davis  said  that  there  were 
occasional  cases  in  which  the  causes  of  oblique  pelvis  were 


gQ4-  The  Philad.  lphia"! 

Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[M&BCB  30,  isn 


injuries  during  adolescence.  Two  cases  were  cited,  one  due 
to  disease  of  the  knee-joint  with  fiaal  ankylosis,  the  other 
caused  by  a  temporary  injury  to  the  lower  extremity.  Ce- 
sarean section  is  the  choice  of  operation  in  these  cases,  and 
in  instances  of  a  second  confinement  it  is  hardly  wise  to 
induce  labor  even  at  the  end  of  8  months. 

De.  Barton  Cooke  Hirst  gave  clinical  memoranda  of  sev- 
eral cases :  1.  Partial  hysterectomy  for  necrosis  of 
the  uterus  due  to  streptococcus  infection.  Tutai 
hysterectomy  was  formerly  performed  in  cases  where  a  por- 
tion of  the  uterus  was  found  to  ba  softened  and  necrotic.  la 
2  recent  cases  recovery  is  believed  to  have  been  due  to  the 
removal  of  only  a  part  of  the  uterus.  The  method  is  sug- 
gested as  being  more  quickly  and  easily  done  than  a  total 
hysterectomy  and  as  one  causing  less  shock  to  the  patient. 
2.  The  removal  of  ovarian  cysts  under  conditions 
seemingly  unfavorable.  The  case  reported  was  that  of 
the  removal  of  an  intraligamentary  cyst  from  a  woman  over 
50  years  of  age  who  had  an  aneurysm  of  the  arch  of  the 
aorta.  Recovery  was  uneventful.  To  prevent  infection  from 
the  large  raw  surface  left,  a  puncture  through  the  vaginal 
vault  was  made  for  drainage  and  peritoneum  sutured  over 
the  area  in  such  a  way  as  to  exclude  it  from  the  abdominal 
cavity.  3.  The  treatment  of  lacerated  cervices 
directly  after  labor.  Dr.  Hirst's  experience  is  that 
primary  operations  directly  after  labor  are  not  satisfactory. 
In  4  days  involution  is  so  far  advanced  that  sutures  will  hold, 
but  it  is  better  on  account  of  the  lochial  discharge  to  wait  2 
weeks.  Laceration  of  the  cervix  is  often  complicated  by 
laceration  of  the  perineum.  In  such  cases  when  repair  of 
the  cervix  has  been  decided  upon  the  perineum  is  allowed  to 
go  for  2  weeks  and  both  operations  done  at  one  sitting.  Dr. 
E.  P.  Davis  stated  that  his  experience  with  immediate  closure 
of  the  wounded  cervix  had  not  been  distinctly  unsatisfac- 
tory. Hemorrhage  sometimes  demands  the  insertion  of 
sutures  and  these  often  give  good  results.  Tne  danger  of  in- 
fection may  be  increased  by  waiting.  If  the  operation  is 
postponed  for  2  weeks,  lactation  may  be  interfered  with  in 
patients  of  a  certiin  temperament.  Dr.  Davis  asked  if 
choice  of  suture  material  had  any  influence  in  causing  poor 
results  in  early  operations.  Dr.  J.  B.  Deaver,  while  not  a 
believer  in  intraspinal  cocain- anesthesia,  stated  that  the 
woman  with  the  aneurysm  would  seem  to  have  been  a  proper 
case  if  it  should  be  used  at  all.  He  has  tried  it  in  a  case  of 
suppression  of  urine  due  to  a  stone  in  the  pelvis  of  the  kid- 
ney, the  other  kidney  having  previously  been  removed.  The 
trial  resulted  in  failure,  and  chloroform  was  successfully  used. 
Dr.  Hirst  stated  that  he  used  silkwormgut  sutures  in  repair- 
ing the  cervix.  In  the  case  referred  to,  spinal  anesthesia  had 
been  strongly  urged  by  the  physician  of  the  patient,  but  ow- 
ing to  the  discouraging  nature  of  inquiry  regarding  its  results 
Dr.  Hirst  decided  against  it.  He  is  confident  that  the 
woman  did  better  under  ether  and  prefers  that  anesthetic  as 
a  routine. 

Dr  R  p.  McReynolds  reported  a  case  of  Ruptured 
interstitial  ectopic  gestation.  The  symptoms  of 
ectopic  gestation  were  typical.  The  woman  died  12  hours 
after  operation  in  whicli  the  portion  of  the  uterus  involved 
was  removed  by  means  of  a  V-shaped  incision.  Intra- 
venous infusion  of  saline  solution  was  given  after  opera- 
tion. From  the  results  in  this  and  other  cases  Dr. 
McReynolds  believes  that  intravenous  infusion  is  a  some- 
what dangerous  proceeding  in  patients  having  such  general 
condition.  Dr.  Hirst  said  that  interstitial  pregnancy  must 
be  a  rare  condition  since  in  his  42  cases  of  ectopic  gesta- 
tion only  1  was  anything  like  interstitial  in  location.  He 
prefers  submammary  hypodermoclysis  of  salt  solution.  If 
a  vessel  were  used  he  would  prefer  the  radial  artery  instead 
of  a  vein,  as  the  solution  would  not  go  so  directly  to  the 
heart,  and  the  danger  of  air  embolism  would  not  be  so 
great.  Dr.  E.  P.  Davis  stated  that  he  had  used  intravenous 
infusion  of  saline  solution  in  several  cases  and  no  accident 
could  be  traced  directly  to  it.  Dr.  J.  B.  Shobek  considers 
submammary  injection  satisfactory  and  less  dangerous  than 
intravenous.  Dr.  J.  B.  Deaver  recommends  intravenous 
infusion  and  considers  it  one  of  the  greatest  boons  of 
modern  surgery.  It  finds  its  best  application  in  cases  of 
hemorrhage,  but  is  of  value  in  general  sepsis.  In  some 
cases  the  residents  at  the  German  hospital  do  not  sew  up 
the  wound  in  the  arm,  but  use  it  for  a  second  infusion.  Dr. 
Deaver  believes  there  is  more  risk   of  infection  from  the 


submammary  method  and  would  not  advise  the  arterial 
route.  Dr.  John  C.  Da  Costa  has  found  the  intravenous 
method  satisfactory  in  every  case  in  which  he  has  used  it. 
He  has  seen  abscesses  result  from  submammary  injection 
and  does  not  like  that  method.  Da.  McReynolds  stated  that 
intravenous  infusion  of  saline  solution  is  of  value  in  recent 
injuries  as  crushes,  etc.,  but  where  bleeding  has  kept  up  for 
a  period  of  days,  as  in  the  case  reported,  the  heart  accus- 
toms itself  tj  the  condition  present  and  infusion  may  do 
damage. 

NEW  JEKSEY. 

Legislation  for  Undertakers.— An  ordinance,  drawn 
similar  to  the  one  operative  in  Pniladelphia,  placing  restric- 
tions on  persons  engaged  in  the  undertaking  business,  was 
under  consideration  by  the  Camden  Board  of  Health.  It 
provides  that  all  persons  now  engaged  in  the  business  shall 
pay  a  license  fee,  to  be  fixed  later,  and  that  hereafter  all  per- 
sons desiring  to  enter  the  business  must  undergo  an  exami- 
nation as  to  their  fitness.  The  ordinance  also  prohibits  non- 
resident undertakers  from  conducting  a  city  burial  unless 
they  have  a  license,  and  instructs  the  nuisance  inspector  to 
inspect  all  undertaking  establishments. 

NEW  YORK, 

Elected    Professor    of    Internal    Medicine.— Dr. 

Heinrich  Stern  has  been  elected  professor  of  internal  medi- 
cine in  the  New  York  School  of  Medicine. 

Dr.  S.  A.  Knopf  Receives  First  Prize. — The  De- 
partment of  State  has  been  informed  tnat  the  Berlin  tuber- 
culosis congress  has  awarded  the  fir?t  prize  for  papers  on  the 
subject  of  tuberculosis  to  D.-.  S.  A.  Knopf,  of  New  York,  and 
has  arranged  for  the  publication  and  distribution  of  his 
paper  with  a  view  to  using  the  proceeds  in  the  establishment 
of  sanitariums  for  the  treatment  of  that  disease. 

Change  of  Date  of  Annual  Meeting.— Owing  to  an 

oversight  the  dates  selected  for  the  annuil  meeting  of  the 
American  Laryngological,  Rhinological  and  0:ological  So- 
ciety are  the  same  as  those  of  the  American  Climatological 
Society.  The  American  Climatological  Soclely  is  to  meet  in 
Buffalo,  and  owiag  to  the  crowded  condition  of  Buffalo  dur- 
ing the  Expofition  it  would  be  diflicult  for  them  to  change 
their  date.  The  annuil  meeting  will  beheld  at  the  N.  Y. 
Academy  of  Medicine  in  the  city  of  New  York  on  May 
23,  24  and  2-5,  1901. 

New  Yorli  Obstetrical  Society. — Stated  meeting  held 
March  12, 1901.    The  president,  De  H.  J.  Boldt,  in  the  chair. 

Dr.  Bache  Emmet  presented  a  specimen  of  sarcoma  of  the 
ovary.  The  tumor  was  removed  2  weeks  ago  from  a  patient 
having  the  following  history  :  aged  49,  multipara,  married, 
menopause  6  years  ago.  One  brother  had  cancer  in  the 
abdomen,  one  sister  had  a  tumor  of  the  lower  abdomen. 
Within  the  last  3  or  4  years  the  mass  has  grown  until  now  it 
is  the  size  of  a  football.  The  mass  was  attached  by  its  own 
ligament,  and  had  a  few  thre-idlike  adhesions.  There  was 
no  derangement  of  the  general  health,  and  the  woman  has  not 
suffered.  The  tumor  proved  to  be  of  the  round  celled  variety. 
As  the  growth  was  essentially  IocaI,  and  the  attach  men',  so 
small,  he  felt  like  encouraging  the  patient  to  feel  no  appre- 
hension. He  was  aware,  however,  of  the  fact  that  there  might 
be  a  return  of  the  malignancy  in  a  few  years. 

Dr.  Viseberg  could  recall  2  cases  of  spindle-celled  sarcoma, 
operated  upon  by  him,  one  2,  the  other  3  years  ago.  Both 
patients  are  in  good  health  today.  During  the  past  summer 
he  had  operated  upon  a  patient,  the  tumor  proving  to  be  a 
round-celled  sarcoma.  It  is  more  than  9  months  since  opera- 
tion, and  as  yet  there  has  been  no  recurrence.  Dr.  Boldt 
said  that  one  of  the  cases  he  had  reported  had  died  shortly 
after  operation,  and  that  the  second  had  a  recurrence  in  the 
abdominal  wall  which  he  had  operated  upon  a  year  later. 
Dr.  Waldo  said  that  the  last  patient  referred  to  by  Dr.  Boldt 
was  alive  and  well  2  years  after,  without  recurrence.  He  had 
operated  upon  a  case  —  years  ago.  and  during  the  past  year 
he  had  opened  the  patient's  abdomen  again,  finding  the 
growth  too  extensive  to  remove. 

Dr.  Grandis  presented  a  specimen  of  ectopic  gestation, 
removed  from  a  patient  23  years  old,  who  had  had  2  children, 


Uabch  30,  1901] 


AMERICAN  NEWS  AND  NOTES 


FThe  Philadelphia 
L  Medical  Joubsal 


595 


the  last  2  years  ago.  She  menBtruated  every  4  weeks,  the 
flow  lasting  7  to  10  days.  She  menstruated  last  on  February 
15,  the  flow  lasting  12  days.  On  March  1,  she  again  began 
to  flow  and  continued.  There  were  no  colicky  pains  or  data 
to  suggest  pregnancy.  There  was  a  mass  behind  and  to  the 
left  of  the  uterus.  Under  ether  the  uterus  was  curetted. 
There  was  no  enlargement.  Postvaginal  section  gave  exit 
to  blood  and  clots.  Abdominal  section  was  made  for 
removal  of  left  ruptured  tube.  There  was  almost  a  quart  of 
clots  and  blood  in  the  peritoneal  cavity. 

Dr  George  G.  Ward,  Jr.,  read  the  paper  of  the  evening. 
His  subject  was  The  Prevention  of  Postoperative  ad- 
hesions of  the  peritoneum.  The  author  remarked  that 
ore  who  comes  in  contact  with  patients  after  they  have  been 
subjected  to  peritoneal  operations  must  surely  be  impressed 
with  the  fact  that  we  have  ttill  much  to  learn  before  we  can 
invade  the  peritoneal  cavity  without  leaving  that  delicate 
membrane  in  a  crippled  condition  ;  in  a  large  per  cent  of 
cases,  as  is  evidenced  by  cottinued  pain,  constipation,  and  in 
some  cases  such  bands  cf  adhesion  that  subsequent  opera- 
tion is  necessary.  He  called  attention  to  the  fact  that  more 
is  necessary  for  the  welfare  of  the  patient  than  simply  to  be 
able  to  open  the  abdomen,  remove  an  organ  or  g  owth,  and 
suture  the  wound  without  loss  of  life  from  hemorrhage  or 
sepsis. 

A  summary  of  the  means  of  prevention  he  advocates  is  as 
follows : 

1.  The  attainment  of  asepsis  as  perfect  as  is  possible  by 
the  rigid  adherence  to  the  most  modern  methods  of  securing 
surgical  cleanliness.  2.  The  avoidance  of  raw  surfaces  and 
pedicle  stumps  by  covering  them  with  peritoneum,  or  grafts 
of  omentum,  and  the  abandonment  of  the  ligature  en  masse. 
3.  Protection  from  dry  air  contact  by  the  employment  of 
moist  asepsis  instead  of  dry  asepsis,  and  keeping  the  exposed 
parts  covered  whenever  possible.  4.  The  time  element — 
rapidity  of  operating  by  technical  skill,  thorough  prepara- 
tion, and  trained  assistants.  5.  Keeping  up  the  heat  of  the 
peritoneal  cavity  by  frequent  renewal  of  the  hot  salt-solution 
(11&''  F.),  and  by  protection  of  the  exposed  parts.  6.  Avoid- 
ance of  excessive  manipulations  of  the  intestines  by  technical 
skill,  proper  anteoperative  preparation  of  the  bowels  and 
posture  to  prevent  pseudoileuB.  7.  Replacement  of  the  loops  of 
intestine  and  omentum  by  filling  the  abdominal  cavity  with 
hot  saltrsolution  before  closing,  and  thus  floaticg  them  that 
they  may  more  readily  adjust  themselves  in  their  proper 
relations.  8.  Free  motion  of  the  patient  after  the  operation 
to  be  encouraged  instead  of  prohibited.  9.  Early  use  of  the 
high  enema  during  the  first  12  hours  in  cor  junction  with 
cathartics,  and  on  failure  the  prompt  use  of  oxygen  in  the 
exaggerated  Trendelenburg  posture. 

Conclusions  — My  study  of  adhesion  formation  and  the  best 
means  cf  their  prevention  leads  me  to  the  following  conclu- 
sions :  1.  That  peritoneal  adhesions  after  operation  result 
from  several  causes.  2.  That  therefore  we  can  not  depend 
upon  any  one  preventive  method,  but,  recognizing  their 
multiple  etiology,  we  must  employ  all  the  details  of  opera- 
tive technic  that  are  necessary  to  ofTset  the  various  causes. 
3.  That  this  necessitates  a  technical  skill  that  can  only  be  at- 
tained by  a  long  apprenticeship  and  a  thorough  training  in 
abdominal  surgery.  In  closing,  the  speaker  said  that  in  his 
opinion,  the  surgeon  who  most  conscientiously  looks  after 
all  the  details  will  have  the  fewest  pottoperative  cases  of 
adhesions  with  their  unfortunate  sequelae. 

NEW  ENGLAND. 

American     Laryngological      Association.  —  Tlie 

Twenty- third  Annual  Congress  of  the  association  will  be 
held  at  New  Haven,  Conn.,  Monday,  Tuesday  and  Wedues- 
day,  May  27-29,  1901.  The  president  of  the  Congress  is 
Dr.  Henry  L.  Swain,  of  New  Haven. 

CHICAGO  AND   WESTERN   STATES. 

Convicts  Vaccinated.— The  1,000  convicts  in  the  Illi- 
nois penitentiary  at  Joliet,  are  being  vaccinated,  and  the 
utmost  care  is  being  taken  to  prevent  smallpox  from  break- 
ing out  among  the  prisoners. 

Minnesota  Senate  Passes  Marriage    Bill.  —  The 

State  Senate  passed  Senator  Chilton's  bill  prohibiting  the 


marriage  of  insane,  epileptic  and  idiotic  persons,  and  requir- 
ing a  medical  certificate  of  all  applicants  for  marriage 
licenses.  Amendments  were  adopted  making  the  physi- 
cian's certificate  not  quite  so  sweeping  and  to  permit 
marriage  of  any  feeble  minded  person  over  45,  ttie  bill 
originally  having  extended  such  permission  only  to  women. 

Siiccus  Capricornus. — All  the  way  from  California 
comes  the  news  that  there  is  a  "  regular  "  doctor  out  there 
somewhere  who  is  exploiting  a  brand-new  lymph  treatment. 
He  has  even  bought  the  exclusive  right  to  this  alleged  ther- 
apy. The  lymph,  we  are  credibly  told,  is  "  straight  Rocky 
Mountain  Goat  Juice."  This  doctor  is  soliciting  and  practis- 
ing business  in  the  treatment  of  chronic  and  wasting  dis- 
eases, especially  tuberculosis,  locomotor  ataxia  and  prema- 
ture senility,  by  the  use  of  this  wonderful  lymph,  which  a 
local  observer  calls  a  "  hircine  balm  of  Gilead."  This  juice 
is  elaborated  with  such  care  and  such  unique  skill  as  to  pre- 
serve, with  ever  increasing  potency,  the  original  "  cell  life." 
It  causes  marvelous  changes  for  the  better  to  take  place  in 
the  structure  and  chemical  composition  of  bones  previously 
diseased  within  two  months  and  a  half  after  beginning  a 
twice  a  day  injection.  This  was  demonstrated  in  the  labora- 
tory and  under  the  microscope  upon  an  aged  dog  that  had 
been  rejuvenated  capricornically.  And  the  impression  is 
somehow  created  that  so  strenuous  and  exuberant  was  the 
physical  vigor  and  vital  tenacity  of  that  canine  compromise 
twixt  Job  and  Methuselah,  transmogrified  by  the  Succus  Capri- 
cornus, that  it  was  only  wth  the  extremes!  difficulty  that  the 
creature  was  killed  sufficiently  dead  to  make  it  safe  for 
chemist  and  microscopist  to  trifle  with  his  remains.  From 
all  this  it  appears  that  serumtherapy  is  well  advanced  on  the 
Pacific  coast. 

Chicago  Pathological  Society.— Meeting  held  March 
11,  1901,  Dr.  L  Hekton,  president. 

Dr.  Maximilian  HEUzro  read  a  paper  on  Primitive 
splenomegaly,  or  anemia  splenica.  The  paper  was 
based  upon  a  study  of  the  literature  of  the  subject,  and  upon 
two  cases  in  which  Dr.  M.  L.  Harris  had  performed  splenec- 
tomy. Particularly  one  of  the  two  cases,  both  of  which  got 
well  after  the  removal  of  the  spleen,  had  been  studied  care- 
fully since ;  two  years  had  elapsed  since  the  operation. 
Before  the  operation  there  had  been  present  in  this  case  a 
marked  diminution  of  the  erythrocytes,  a  low  color  index, 
and  an  absolute  and  relative  reduction  in  the  number  of  the 
leukocytes.  The  blood  had  improved  very  much  since 
splenectomy,  and  there  had  developed  a  marked  esinophilia. 
An  examination  of  the  spleens  removed  showed  a  marked 
endothelial  proliferation  with  enlargement  of  the  blood 
lymph  spaces  (pulp  spaces).  Heizog  stated  that  he  had  in 
vain  sought  for  many  destroyed  blood- corpuscles  inside  of 
lymphmdothelia,  a  picture  as  it  is,  for  instance,  found  in 
typhoid  fever.  Considering  the  fact  that  the  blood  condition 
had  always  improved  in  all  cases  of  splenomegaly  in  which 
splenectomy  had  heen  performed,  provided  the  patient  did 
not  die  from  the  operation,  it  appeared  conclusive  that  the 
changes  in  the  spleen  must  be  looked  upon  as  the  primary 
factor  in  the  disease.  We  therefore  must  look  to  the 
pathological  changes  in  the  spleen,  as  the  cause  of  the 
blood- destruction.  From  an  examination  of  the  two  cases 
as  well  as  from  a  study  of  the  literature  it  appears 
that  no  evidence  can  be  found  that  lymphatic  endo- 
thelia  destroy  the  blood  by  directly  taking  up  blood- 
corpuscles.  Herzog,  therefore,  advances  the  theory  that 
lymphatic  endothelia  of  the  spleen  and  of  lymph  glands 
secrete  an  erjthrolytic  ferment  and  in  this  manner  destroy 
old  and  worthless  blood-corpuscles.  We  have  in  spleno- 
megaly an  enormous  endothelial  proliferation  and  probably 
in  consequence  an  enormously  increased  production  of  the 
erythrolytic  ferment,  which  when  present  in  such  a  large 
amount  destroys  many  healthy  blood-corpuscles.  If  the 
spleen  is  removed  the  source  of  the  increased  production  of 
the  erythrolytic  euzym  is  removed  and  the  blood  improves 
rapidly  and  permanently.  In  the  discussion  Dr.  W.  A. 
EvASS  referred  to  the  case  of  Dr.  Ferguson  in  which  there 
occurred  petechial  spots  in  the  skin  and  where  the  spleen 
became  smaller  before  death.  He  spoke  of  a  case  reported 
by  Dr.  Dalton  before  the  London  Clinical  Society,  which  was 
clinically  one  of  splenic  anemia,  but  at  autopsy  the  enlarge- 
ment of  the  spleen  was  discovered  to  depend  upon  passive 


596 


THB  PHn.ADELPHU.~l 

Mkdicai,  Joubnal  J 


AMERICAN  NEWS  AND  NOTES 


[Uabch  30,  un 


coDgestion,  due  to  constriction  by  an  anomalous  colon.  Dr 
Leo  Loeb  declined  to  accept  the  theory  of  an  enzyme  which 
destroys  the  red  blood-cells  in  the  spleen.  Dr.  E.  H. 
OcHSSER  referred  to  a  case  which  clinically  wassplenic  anemia, 
and  which  improved  for  a  time  after  the  spleen  was  removed, 
but  subsequently  died.  There  were  a  few  small  peritracheal 
glands  found  at  autopsy  which  were  tuberculous.  A  possible 
infection  in  such  cases  must  always  be  considered.  Dr.  B.  W. 
SiPPY  spoke  of  the  similarity  of  these  cases  to  the  ordinary 
lymphatic  pseudoleukemia  as  regards  blood  changes,  general 
asthenia,  etc  ,  a  similar  enlargement  of  the  spleen  also  being 
observed.  In  manj^  cases  of  splenic  anemia  there  is  enlarge- 
ment of  the  lymph  glands,  although  it  may  be  slight.  In  all 
cases  the  bone  marrow  has  been  converted  into  a  fetal  con- 
dition, like  that  found  in  many  cases  of  pseudoleukemia 
lymphatics.  He  objects  to  the  term  splenic  anemia,  and 
considers  the  one  splenic  pseudoleukemia  to  be  the  proper 
one.  He  believes  the  primary  cause  cannot  be  positively 
located  in  the  enlargement  of  the  spleen.  In  the  case  de- 
scribed by  himself,  the  fibrous  changes  were  much  more 
marked  than  in  Dr.  Herzog's.  This  he  thinks  mav  depend 
upon  the  longer  duration  of  the  disease.  Dr.  P.  Kyes  said 
that  in  the  specimens  of  Dr.  HerzDg,  the  proliferation  in- 
volves all  the  structures  of  the  spleen,  and  such  a  condition 
cannot  be  due  to  a  primarv  proliferation  of  any  one  element,  as 
the  endothelium.  De.  T.  R  Crowder  presented  sections  of  an 
amyloid  spleen  with  unusually  distinct  endothelial  linings  in 
the  vascular  spaces.  Dr.  Herzog  in  closing  said  that  he  did 
not  claim  that  there  was  proliferation  of  the  endothelium 
alone,  but  that  the  incieise  in  the  endothelium  wa?  enormous, 
80  much  so  that  the  condition  had  been  mistaken  for  an 
endothelioma.  Dalton's  case  had  not  been  considered  as  it 
was  too  indefinite.  Oae  reason  for  separating  these  cases 
from  lymphatic  pseudoleukemia  is  because  they  are  curable 
by  operation. 

Dr.  Theo.  Tiekes  exhibited  a  specimen  of  pancreas 
annulare,  with  resulting  constriction  of  the  duodenum  so 
that  a  large  fus'form  sacculation  of  the  latter  had  formed. 

Dr  H.  M.  Ricketts  presented  specimens  of  experi- 
mental general  blastomycosis  in  the  dogr  produced 
by  an  intravenous  inoculation  of  aa  organism  obtained  fr^m 
a  case  of  blastomycosis  of  the  human  skin. 

The  Chicago  Hospital-School  for  Nervous  and 
Delicate  Children. — This  school  was  criminally  incor- 
porated in  1899  as  the  Chicago  Physiological  School ;  it  has 
now  16  children  under  treatment  and  care.  Tae  hospita'.- 
s^hool  is  located  on  Drexel  avenue,  Chicago,  near  Drexel 
square.  Owing  to  the  capacity  being  overtaxed  a  movement 
is  now  on  foot  to  arrange  for  more  commodious  quarters. 

The  incorporators  of  the  school  were  Dr.  W.  R  Harper, 
president  of  the  University  of  Cnicago;  Prof  George  H. 
Mead,  associate  professor  in  philosophy  of  the  University  of 
Chicago,  and  Miss  Mary  Campbell,  founder  of  the  school. 

Toe  executive  committee  consists  of  Prof.  George  H. 
Mead,  president;  Dr.  Henry  H.  Donaldson,  vice-president ; 
and  Miss  Mary  Campoell,  secretary  and  treasurer. 

The  Board  of  Trustees  also  include  Mr.  A.  C.  Bartlett,  Dr. 
Nicholas  Senn,  Dr.  John  Dewey,  head  of  the  department  of 
philosophy  and  psychology,  Mrs.  A.  C.  McCIurg,  Mrs.  C.  R. 
Crane,  and  Mrs.  J.  Young  Scammon. 

The  institution  was  established  for  the  cire  and  treatment 
of  children  incapacitated  from  receiving  regular  instruction 
owing  to  slight  physical  defects,  such  as  stammering,  stutter- 
ing, nervous  troubles,  minor  ear  and  eye  trouble,  for  children 
obliged  to  be  under  medical  care  and  yet  capable  of  receiv- 
iag  a  certain  amount  of  educational  work,  and  for  those 
needing  corrective  work  in  speech,  etc.  Children  from  4  to 
15  years  are  accepted  for  treatment. 

The  school  has  three  regular  nurses,  a  faculty  of  eight 
teachers,  and  a  regular  consulting  stafTof  physicians,  among 
whom  are  Dr.  Frank  Billings,  Dr.  Archibald  Church,  Dr. 
Hugh  T.  Patrick,  Dr.  D.  R.  Brower,  Dr.  Nicholas  Senn,  D,-. 
N.  B  Delamater,  Dr.  Frank  Allport,  Dr.  Eugene  S.  Talbot, 
Dr.  John  Ridlon,  P/.  Llewellyn  Birker,  and  others. 

The  School  has  recently  been  affi'iated  with  Rush  Medical 
College  and  the  educational  work  is  supervised  by  the  De- 
pirtment  of  Nsurology  and  Poilosophy  of  the  University  of 
Chicago,  the  University  advisor  being  Dr.  H.  H.  Donaldson. 

The  Hospital-Sihool  is  to  be  used  as  a  l.iboratory  for  the 
study  of  mental  phenomena  of  subnormal  children. 


SOUTHERN  STATES. 

New  Morgue.— Plans  for  the  erection  of  a  new  morgue 
at  Washington  have  been  submitted  to  the  Commissioners.  In 
addition  to  the  mortuary,  there  will  be  a  room  for  postmor- 
tem examinations  and  a  capacious  room  for  laboratory  pur- 
poses. 

Health   Officers'    Association   Organized. — At    a 

meeting  of  State,  county  and  city  health  officers  held  on 
March  21,  the  organization  of  the  Hsalth  Officers'  Associa- 
tion of  Texas  was  efiFected.  The  following  offi  lers  were  elected : 
President,  Dr.  J.  B.  Misaie,  of  Houston;  vice-president.  Dr. 
I.  J.  Jones,  of  Austin ;  secretary  and  treasurer.  Dr.  J.  M. 
McCutcheon,  of  Temple. 

Defence  of  Dr.  Loeb. — In  the  Corporation  Court  of 
Newport  News,  the  case  of  Louis  Loeb,  the  well-known  phys- 
ician, will  be  tried.  Dr.  Loeb  was  indicted  several  months 
ago  on  the  charge  of  practising  medicine  without  a  license 
or  a  certificate  from  the  State  Board  of  Medicil  Examiners. 
It  is  said  that  the  doctor  will  admit  everything  charged  by 
the  Commonwealth,  but  will  contend  thai  the  law  is  uncon- 
stitutional. 

CANADA. 

(From  Oar  Special  Correspondeol.) 

McGill  University  is  the  fortunate  possessor  of  many 
good  friends — friends  in  deed  and  action  as  well  as  in  name. 
Sir  William  Macdonald  has  again  loosened  his  purae-strings 
and  McGill  is  the  richer  by  $150,000.  Of  this  sum  $75,000 
will  be  taken  to  endow  the  chair  of  chemistry,  $-32,-500  for  the 
chair  of  botany,  and  $12,500  will  be  added  to  the  chair  of 
physics.  Prior  to  this  donation.  Sir  William  had  already 
given  the  University  $2,500,000.  Another  eift  is  also  an- 
nounced, Miss  Jessie  Dow  having  given  $60,000  for  a  chair  of 
political  economy.  Nor,  indeed,  is  the  Medical  Faculty  for- 
gotten. Another  large  addition  will  be  made  to  the  medical 
building  this  summer.  It  will  be  four  stories  in  height,  and 
be  provided  with  a  large  number  of  lecture  rooms,  museums, 
and  chemical  laboratories.  The  cost  of  this  proposed  addi- 
tion will  be  borne  by  Lady  Stratbcona  and  the  Hon.  Mrs. 
Howard. 

The  Extent  of  Cancer  in  Ontario. — The  report 
of  the  provincial  board  of  health  shows  that  from  the 
years  18S6  to  1899  inclusive  there  were  deaths  from  this  cause 
a«  follows:  410,  614,  635.  714,  6S5,  579,  676,  678,  621,  620,  731, 
927,  975,  and  1,041  in  1899.  These  figures  indicate  that  those 
diseases  included  under  the  name  of  cancer  are  on  the  in- 
crease in  the  province  of  Ontario.  Prior  to  1S96  it  will  be 
noticed  that  these  returns  show  no  notable  increase,  but 
since  that  time  there  has  been  a  remarkable  increase.  Prob- 
ably this  may  be  due  to  the  fact  that  many  deaths  formerly 
included  under  "  tumors,"  are  now  set  down  to  cancer, 
through  more  description  in  death  returns.  Another  cause 
may  be  set  down  tj  the  great  increase  in  the  hospital  popu- 
lation of  the  province,  which  in  1835  numbered  5  00 J,  now 
amounts  to  20,000 ;  and  the  increase  in  hospital  accommoda- 
tion bringing  with  it  bett-er  accuracy  in  diagnosis  would  also 
tend  to  augment  the  statistics  of  cancer. 

The  bill  for  the  treatment  of  inebriates  in 
Ontario  has  apparently  very  little  chance  of  going  through 
the  Legislature  this  session,  although  it  was  prepared  in  the 
early  part  of  last  session,  at  which  time  it  was  lully  expected 
that  the  Government  would  introduce  it.  Notwithstanding 
that  the  bill  has  been  approved  by  the  Premier,  by  the  in- 
spectors of  prisons,  and  by  the  Warden  of  the  Central  Prison, 
himself  a  medical  man,  as  well  as  by  many  of  the  members  of 
the  Gjvernment,  the  Government  continues  to  dally  with 
this  legislation.  The  Ojtario  Medical  Association  and  the 
Toronto  Medical  Societies  have  sent  deputations  to  interview 
the  Government  on  the  matter  time  and  again,  and  although 
the  G:)vernment  has  been  great  in  promises,  it  has  also  been 
very  small  in  action.  In  this  matter  the  Government  is 
wofully  dilatory :  but  an  election  is  near  at  hand,  and  a  long- 
sufllering  profession  and  public  may  be  expected  to  take 
advantage  of  the  opportunity  for  getting  even  on  many  an 
old  score  through  the  triumph  at  "the  polls  of  a  progressive 
Opposition. 


MaBCB  30,  1901) 


AMERICAN  NEWS  AND  NOTES 


rXHK  Phtlabelphia 
I_  Medical  Jocesal 


597 


A  Bledical  Council  for  the  whole  Dominion,  the  Bill 
concerning  which  has  recently  been  introduced  into  the 
Dominion  Parliamect  by  Dr.  T.  G.  Roddick,  M.P.,  will  soon 
be  consummated,  providing  the  present  Bill  goes  through  the 
House.  It  provides  for  a  central  medical  council,  upon 
•which  will  be  three  representatives  from  each  of  the  eight 
provinces  in  the  Dominion  ;  and  the  homeopaths  will  also  be 
given  three  representatives,  appointed  by  that  body  through- 
out the  conntry.  The  composition  of  this  council  will  be 
the  President  of  each  Medical  Council  of  every  province, 
eioflScio,  one  member  elected  from  the  Medical  Council  of 
each  province,  and  one  from  each  province  elected  by  the 
Governor-General  in  Council.  It  provides  also  for  examina- 
tions and  a  course  of  study  of  5  years  as  already  existing  in 
the  province  of  Ontario.  During  the  course  of  his  address 
to  the  House,  Dr.  Roddick  gave  some  interesting  details  of 
the  history  of  medical  education  in  Canada,  and  also  con- 
cerning the  medical  population  of  each  province.  Prince 
Edward  Island  his  90  medical  practitioners;  Nova  Scotia, 
476;  New  Brunswick,  2i3 ;  Qiebec,  1,400  ;  Ontario,  2,5'00  ; 
Manitoba,  344;  North  West  Territories,  95,  and  British 
Columbia,  214. 

The  Annual  Report  of  the  Quebec  Board  of 
Health  gives  some  interesting  information  in  connection 
with  the  health  of  that  province.  Notably  is  the  law  in  re- 
gard to  cases  of  tuberculosis  of  the  lungs  in  advance  of  that 
of  any  of  the  other  provinces.  There,  every  householder  in 
whose  household  a  death  occurs  from  pulmonary  consump- 
tion must  notify  the  secretary  of  the  local  board  of  health  of 
such  death  within  48  hours  of  its  occurrence.  Upon  such 
notification  being  given  the  municipality  is  bound  to  cause 
the  disinfection  of  the  apartments  which  may  have  been  con- 
taminated by  the  patient.  The  rate  of  death  in  diflFerent 
Canadian  cities  from  tuberculosis  is  set  down  as  follows : 
Qaebec  City,  1.99  in  1,000;  O.tawa.  312;  Montreal,  2.87; 
Kingston,  2.17 ;  Toronto,  2.41,  and  London,  2  67.  It  would 
thus  appear  that  Quebec  City  was  the  most  free  of  the  dread 
disease  and  Ottawa  the  most  infected.  Qaebec  can  point 
with  unalloyed  J3y  and  pride  to  her  birth  rate.  In  the  year 
1898  the  birth  rate  was  35.70,  which,  compared  with  that  of 
Ontario,  is  greatly  in  excess  of  the  latter,  which  was  20.4  for 
the  same  year.  In  1899  the  birth-rate  was  33  46,  which 
meant  a  decrease  of  3,5i5.  Still  with  this  decrease,  Qiebec 
can  be  consoled,  as  she  has  the  highest  birth-rate  of  any 
country  except  Germany. 

Government  aid  for  Toronto  University  is  promised 

in  a  measure  laid  before  the  Ontario  Legislature  last  week  by 
ihe  Hon.  Mr.  Harcourt,  the  Minister  of  Education  for  the 
Province.  The  particulars  of  the  bill,  however,  do  not  meet 
the  entire  approval  of  the  friends  of  the  provincial  university. 
They  had  expected  a  great  deal  more  than  will  be  given. 
Although  the  university  has  gone  behind  to  the  extent  of 
$30,000  or  $40  000  during  the  past  three  years,  they  are  now 
only  promised  $20,000,  which  must  be  devoted  exclusively  to 
the  chemical  atd  physical  branches.  The  friends  of  the  uni- 
versity had  fully  expected  $50,000  at  the  very  least.  An  item 
of  great  importance  in  the  bill  takes  the  control  of  the  insti- 
tution out  of  the  hands  of  the  Government  and  invests  it  in 
a  board  of  trustees.  This  is  a  sort  of  sop  to  the  moneyed 
men  of  Toronto,  who  heretofore  would  not  indulge  in  dona- 
tions in  aid  of  the  work  of  the  university  so  long  as  it  was 
under  the  direct  control  of  the  Ontario  Government.  Pro- 
visions are  also  made  in  regard  to  the  proposed  federation  of 
Trinity  and  Toronto  Universit'es,  and  incidentally  the  medi- 
cal faculties  in  affiliation  therewith.  This  latter,  however, 
now  seems  to  bs  ofiF  the  boards  for  some  time,  as  Trinity 
Medical  College,  through  Dean  Geikie,  has  given  out  that 
they  will  not  amalgamate  on  the  lines  proposed,  which  in  the 
main  amounted  to  the  fact  that  all  the  professors,  lecturers, 
and  demonstrators  were  to  be  kept  on  for  two  years  by  the 
united  institution,  and  then  a  new  faculty  formed  therefrom. 
Amalgamation  of  Trinitj-  and  Toronto  may  then  be  said  to 
be  as  far  off  as  ever  it  was.  The  Government  has  promised 
to  erect  during  the  next  two  years  a  new  building  for  the 
science  departments  at  a  cost  of  $200,000,  but  this  is  taken 
by  many  of  the  friends  of  the  university  as  a  mere  election 
dodge. 


MISCELL,.\NY. 

Obituary.— Dr.  Wkesn,  Bridgeport,  Conn.,  on  March  23. 
— Dr.  Ecwaed  S.  Fawcett,  at  Alexandria,  Va.,  on  March  21. 
— Dr.  p.  a.  Holohan.  at  Springtield,  Mass.,  on  March  11. — 
Dr.  Oliver  P  Wolcott,  at  Milwaukee,  Wis.,  on  March  16. — 
Dr.  George  M.  Fisher,  at  Denton,  Md..  on  March  20. — Dr. 
H.  G.  HoLLESBECK,  at  Willow  Springs,  Mo.,  on  March  22. — 
Dr.  Alfred  R.  Greex,  at  Greely,  Col,  on  March  22,  aged  79 
years. — Dr.  Joseph  Tellyesnecky,  at  Chicago,  111.,  on  March 
14,  aged  40  years. — Dr.  J.  S.  Scofield,  at  HUlsboro,  Tex.,  on 
March  23,  aged  75  years. — Dr.  Ralph  J.  Hess,  at  North 
Brother  Island,  near  New  York,  on  March  24,  aged  27  years. 

Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported  to  the 
Surgeon-General  U.  S.  Marine- Hospital  Service,  during  the 
week  ended  March  23,  1901 : 

Smallpox — United  Statbb. 


Cases. 


Dbathi. 


DiETElCT  OF 

Columbia 

:  Washington    . 

.  March  2-16  .   . 

10 

Florida: 

Jacksonrille  . 

.  March  9-16      .    . 

4 

Ilusois  : 

Chicago    .   .  . 

.   March  9-16  .    . 

8 

ISDIAXA  : 

Terre  Haute   . 

.  Feb.  4-U  .    .   . 

2 

Kansas  : 

Wichita    .    .  . 

.  March  8-16  .   . 

15 

Kektuckt  ; 

Lexington   .    . 

.  March  S-lf.  .   . 

1 

LouisiAKA : 

Xew  Orleans  . 

.  March  8-16  .   . 

14 

4 

Maeyland  : 

Bahimore   .   . 

.  March  8-16  .    . 

1 

Michigak; 

Bay  City  .    .   . 

.  March  8-16  .    . 

o 

'* 

Detroit  .    .  .   . 

.  March  S-16  .    . 

4 

" 

West  Bay  City 

.  March  1-16  .   . 

1 

StlSNESOTA  : 

Minneapolis 

.  March  8-16  .   . 

U 

Winona    .   . 

.   March  8-16  .    . 

26 

Xebkaska  : 

Omaha  .    .   . 

.  March  2-9    .    . 

5 

S.  Hampshire  : 

Manchester 

.  March  8-16.    . 

3 

New  York  : 

Elmira  .    .  . 

.  March  2-9    .   . 

1 

.1         11 

New  York  . 

.  March  8-16  .   . 

37 

6 

Ohio: 

Cleveland 

.  March  8-16  .    . 

46 

Toledo  .   .  . 

.  March  8-16.    . 

3 

Pkkkstlvakia  : 

Erie   .... 

.  March  8-16  .    . 

1 

McKeesport 

.  March  8-16  .   . 

3 

" 

Pittsburg  .   . 

.  March  8-16.   . 

2 

'^ 

Steelton    .   . 

.  March  8-16  .    . 

5 

Tkkkesske  : 

Memphis .   . 

.  March  8-16.    . 

£0 

Nash\nlle 

.  March  8-16.    . 

14 

Utah  : 

Salt  Lake  aty 

.  March  S-16     . 

97 

Porto  Rico  : 

Aguas  Buenas 

.   Feb.  8-March5 

2 

Bayamon     . 

.  Feb.  8-March  5 

2 

" 

Caguas  .   .  . 

.  Feb.  S-March  5 

2 

'»          * 

Ciales    .   . 

.  Feb.  8-March  5 

2 

.1         I 

Morovis    .    . 

.  Feb.  8-March  5 

2 

•  >         1 

Ponce    .   .  . 

.  Feb.  8-March  5 

98 

1 

" 

Quebradillas 

.  Feb.  8-March  5 

4 

1.         I 

Rio  Piedars 

.  Feb.  8-March  5 

1 

t.         t 

San  Juan  .   . 

.    .  Feb.  8-March  5 

7 

PmLiPPisES : 

Manila  .   .  . 
Smam.PC 

.   .  Jan.  29-Feb.  9 
X— Foreign. 

.       11 

BR.4ZII, : 

Pernambuco 

.  Jan. 17-31    .   . 

25 

Rio  de  Janein 

)  .  Feb.  16-28    .    . 

36 

Canada : 

Bracebridge 

.  March  2    .    .   . 

2 

Georgian  Bay 

.  March  2    .   .  . 

Prevalent 

'• 

Orillfa  .    .  . 

.  March  2    .    .   . 

1 

" 

Penetanguishi 

ne  March  2    .    .   . 

1 

" 

Toronto    .   . 

.  March  2    .    .   . 

4 

Egypt  : 

Cairo .... 

.  Feb.  11-2.5    .    . 

3 

France  : 

Paris  .... 

.  Feb.  8-March  2 

21 

Gee.\t  Britain 

:  London    .   . 

.  Feb.  23-March  i 

!         1 

Glaso'OW 

March  1-S    .    . 

46 

12 

India  : 

Bombay   .    . 

.  Feb.  12-19    .    . 

Madras     .   . 

.  Feb.  9-15  .    .   . 

5 

Mexico  : 

Tuxpan    .    . 

.  Feb.  25-Marcb  ^ 

1 

Russia  : 

Moscow    .   . 

.  Feb.  14-23    .    . 

4 

St.  Petersburg 

.   Feb.  16-23    .    . 

3 

" 

Moscow    .   . 

.  Feb. 16-23    .    . 

.       12 

Spain : 

Barcelona   . 

.  Jan.  1-March  2 

253 

Corunna  .   . 

.  Feb.  23-March  i 

1 

" 

Valencia  .   . 

.  Feb.  8-24  .    .   . 

'.         1 

Ykt.txi 

w   Fever. 

Cuba  : 

Havana   .   . 
Ch 

.  March  4-11  .    . 
OLERA. 

1 

India  : 

Bombay   .   . 

.  Feb.  12-19    .    . 

3 

Madras .  .   . 

.  Feb.  9-15  .       . 

12 

Straits 

Settlements  :  Singapore    .   .   .  Jan.  26- Feb.  2    . 

Pi  AGUE— Foreign  and  Insular. 

Cape  Town  Feb.  16-26    .    .   . 

Bombay  ....  Feb.  12-19    .    .   . 
Manila" Jan.  19-Feb.  9    . 


Africa  : 
India  . 
Philippines  : 
Straits 

Settlements  :  Singapore 


44 


10 


6 

897 

4 


Jan.  26-Ftb.  2 


598 


The  Philadelphia  "I 
Mbdical  Jocbnal  J 


AMERICAN  NEWS  AND  NOTES 


[Habch  30,  1901 


General  Wood's  Case   Not   the   Only  One.— Our 

recent  referecce  to  General,  or  Doctor,  Leonard  Wood's 
promotion  in  the  U.  S.  Army  has  aroused  the  interest  of 
many  persDns.  We  have  received  information  about  the 
following  army  officers,  which  is  worth  knowing: 

Brigadier  General  Ainswortb,  at  present  chief  of  the  Record 
and  Pension  Division,  War  Department,  Washington,  D.  C, 
was  promoted  to  that  place  from  the  position  of  major  and 
surgeon,  U.  S.  Army,  as  a  result  of  bringing  the  aflairs  of  that 
division,  while  temporarily  acting  in  charge,  into  a  most 
admirable  condition  of  efficiency.  He  was  first  promoted  to 
a  colonelcy,  and  was  subsequently  raised,  in  1898,  to  the  rank 
of  brigadier-general  as  a  result  of  his  admirable  administra- 
tion of  the  affairs  of  his  bureau. 

Brigadier  General  Myer,  late  Chief  S'gaal  Officer,  U.  S. 
Army,  invented  and  perfected  the  Myer  code  of  military 
signalling,  now  used  in  all  the  armies  of  the  world,  while 
serving  as  an  assistant  surgeon,  U.  S.  Army.  For  his  work  in 
connection  with  military  signalling  he  was  made  a  br'gadier- 
general  and  appointed  the  chief  of  the  Signal  Corps. 

The  case  of  Major-General  Crawford  was  given  in  the  last 
number  of  the  Journal.  It  is  a  curious  fact,  illustrative  of 
the  difficulty  of  obtaining  accurate  information  on  these 
subjects,  that  from  one  source  we  learn  that  Gen.  Crawford 
was  killed  in  action  during  the  Civil  War,  while  from  another 
we  learn  that  he  was  retired  with  honor  in  1873. 

Surgeon  General  Lawson,  who  was  chief  of  the  Medical 
Department  of  the  Army  prior  to  the  Civil  War,  had  served 
with  much  credit  during  the  Seminole  War  in  Florida  as 
lieutenant-colonel  of  an  infantry  regiment. 

The  moral  of  these  promotions,  together  with  that  of  Gen- 
eral Wood,  seems  to  be  that  the  Medical  Department  of  the 
Army  is  fully  as  much  a  military  as  a  professional  organiza- 
tion, that  a  large  proportion  of  its  members  possess  mili'ary 
qualifications  of  a  high  order,  and  that  a  medical  training 
and  executive  ability  are  far  from  incompatible. 

Further,  it  would  appear  that  the  line,  when  an  unusually 
good  man  is  needed  to  fill  a  position  of  emergency,  have 
sometimes  to  go  to  the  Medical  Department  of  the  Army  to 
get  him.  Edward  L  Whenson, 

Capt.  Asst.  Surg.  U.  S.  A. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Army, 

for  the  week  ended  Mirch  23,  1901 : 

DE  NiEDKMAN,  Major  William  F.,  surgeon,  is  relieved  from  duty 
with  the  Thirtieth  Infantry,  U.  S.  Volunteers.,  upon  the  depar- 
ture of  that  regiment  for  Manila  from  its  present  station,  for 
muster  out  in  the  United  States,  and  will  report  to  the  com- 
manding general,  department  of  Southern  Luzon,  for  assign- 
ment to  duty  in  that  department. 

Tekney,  Captain  Elmer  S.,  assistant  surgeon,  is  relieved  from  tem- 
porary duty  at  the  Army  General  Hospital,  Presidio,  and  will 
report  to  the  commanding  otiicer.  First  Squadron,  Fifteenth 
Cavalry,  in  camp  on  the  Presidio,  for  temporary  duty  with  that 
squadron,  awaiting  transportation  to  the  Philippine  Islands. 

Pitcher.  George  S  ,  acting  assistant  surgeon,  is  relieved  from  tem- 
porary duty  with  the  First  Squadron,  Fifteenth  Cavalry,  in 
casip  on  the  Presidio,  and  will  proceed  to  his  home,  Portland, 
Me.,  for  annulment  of  contract. 

Leepere,  Captain  Matthew,  assistant  surgeon,  7  days'  leave  granted 
March  7  is  extended  15  days. 

TAKY-un-DKEN.  Najib,  acting  assistant  surgeon,  will  proceed  from 
Washington,  D.  C,  to  Columbus  Barracks  for  duty. 

Dillon,  G.  Parker,  acting  assistant  surgeon,  will  proceed  from 
Grand  Rapids,  Mich.,  to  Fort  Sheridan  for  duty. 

UsDKKWOOD,  Fred  R..  acting  assistant  surgeon,  will  proceed  from 
London,  Ohio,  to  Fort  Leavenworth  for  dnty. 

Williams,  Ciurles  F.,  acting  assistant  surgeon,  is  relieved  from 
temporary  duty  at  Fort  Screven,  to  take  etiect  upon  the  return 
to  duty  at  that  post  of  Acting  .\ssistant  Surgeon  John  R.  Hicks, 
and  will  then  proceed  to  Fort  McPherson  for  duly. 

Whitney,  Major  Walter,  surgeon,  is  relieved  from  further  dnty  at 
Fort  Walla  Walla  and  will  proceed  to  San  Francisco,  Cal.,  and 
report  for  transportation  to  Manila,  P.  I  .  where  he  will  report 
for  assignment  to  duty. 

McHenry,  Captain  Geo.  A.,  assistant  surgeon,  recently  appointed, 
now  on  duty  at  Santiago,  Cuba,  will  as  soon  jis  his  services  can 
be  spared  by  the  commanding  general,  department  of  Cuba, 
proceed  to  San  Francisco.  Cal.,  and  report  for  transportation  to 
Manila,  P.  I.,  where  he  will  report  for  assignment  to  duty. 

Anpersdn.  Joh.v  B,,  hospital  steward,  (appointed  March  J3  from 
actiuj  hospital  steward  hospital  corps).  Fort  Mackenzie,  is 
assigned  to  duty  at  his  present  station. 

Richards,  Josiah  W.,  acting  assistant  surgeon,  is  relieved  from  duty 
on  the  transport  "  Buford  "  and  will  proceed  from  San  Fran- 
cisco, Cal ,  to  Fort  Mott  for  duty. 

Williams.  Charles  F.,  acting  assistant  surgeon,  is  detailed  as  a 
member  of  the  e.tamining  board  at  Fort  McPherson,  vice  Acting 
Assistant  Surgeon  Francis  A.  Halliday,  relieved. 


Werner,  Max,  hospital  steward,  Frankford  Arsenal,  Pa.,  will  be 
sent  to  the  Army  and  Navy  General  HospitaL  Hot  Springs, 
Ark.,  for  treatment  in  the  hospital. 

Plcmmer,  Captain  George  R.,  assistant  surgeon,  recently  appointed, 
is  reheved  from  further  duty  in  the  department  of  Cuba,  to  take 
effect  when  his  services  can  be  spared  by  the  commanding 
general  of  that  department,  and  will  then  proceed  to  San  Fran- 
cisco, Cal.,  and  report  for  transportation  to  Manila,  P.  I.,  where 
he  will  report  for  assignment  to  duty. 

Williams,  Adrian  D.,  acting  assistant  surgeon,  now  at  Governor's 
Island,  is  relieved  from  farther  duty  at  Fort  Adams  and  will 
report  to  the  commanding  general,  department  of  the  East,  for 
assignment  to  duty  with  the  first  battalion  of  the  Eleventh  In- 
fantry, and  will  accompany  that  battalion  to  the  Philippine 
Islands   where  he  will  report  for  assignment  to  duty. 

Simmel,  Martin,  hospital  steward,  Columbus  Barracks,  is  trans- 
ferred to  Fort  McDowell,  for  duty  with  the  hospital  corps  school 
of  instruction. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  Mirch  23,  1901 : 

Parker,  J.  B.,  medical  director,  detached  as  president  of  medical 
examining  boards,  Washington,  and  ordered  to  the  Naval 
Home,  Philadelphia. 

Mabmion,  R.  a.,  medical  director,  detached  from  Naval  Home,  and 
to  duty  at  the  Washington  Xavy  Yard,  as  president  of  the  ex- 
amining board. 

Moore,  J.  M.,  passed  assistant  surgeon,  detached  from  the  Port 
Royal  N'aval  Station,  and  ordered  to  the  "  Franklin,"  April  2. 

BoGEBT,  E.  S.,  passed  assistant  surgeon,  detached  from  the  "  Mas- 
sachusetts," and  ordered  home  to  wait  orders. 

Shiffebt,  H.  C,  assistant  surgeon,  detached  from  the  "  Franklin," 
and  ordered  to  the  "  Solace,"  April  1,  and  to  the  Asiatic  Sta- 
tion. 

Thompson,  J.  C,  assistant  surgeon,  ordered  to  the  Port  Royal  Sta- 
tion. 

Thompson,  E..  assistant  surgeon,  detached  from  the  "XashviUe," 
and  to  the  "  Solace." 

Hess,  H.  H..  ordered  to  the  Naval  Hospital,  New  York. 

Grove,  W.  B..  assistant  surgeon,  ordered  from  Naval  Hospital,  New 
York,  to  the  Naval  Hospital,  Norfolk.  Va. 

Bbansford.  J.  P.,  surgeon,  retired  in  accordance  with  Act  of  Con- 
gress, approved  February  5,  IDi)!. 

Rodman,  S.  S.,  assistant  surgeon,  detached  from  Naval  Hospital, 
.Mare  Island,  and  to  the  "  Adams." 

Obvis,  R.  T.,  assistant  surgeon,  detached  from  the  "  Adams,"  and 
ordered  to  Naval  Hospital,  Mare  Island. 

BoGERT.  E.  S.,  medical  director,  retired,  detached  from  recruiting 
rendezvous.  New  York,  and  home. 

Law,  H.  L.,  surgeon,  retired,  ordered  to  recruiting  rendezvous,  Buf- 
falo, N.  Y. 

Cbawfoed,  M.  R.,  surgeon,  detached  from  recruiting  rendezvous, 
Butfalo,  N.  Y.,  and  to  Marine  recruiting  rendezvous,  New  York 
City. 

Leach,  P.,  surgeon,  detached  from  the  "Oregon"  and  to  the 
"  Monoca:;y." 

Evans,  S.  G.,  passed  assistant  surgeon,  from  the  "Kentucky"  to 
the  "Concord." 

Faeenholt.  a.,  passed  assistant  surgeon,  from  the  "  Concord  "  to 
the  "  Oregon." 

Hk;h.  W.  B.  C.  assistant  surgeon,  from  the  "Oregon"  to  the 
"  Kentucky." 

Changes  in  the  U.  S.  Marine- Hospital  Serric«, 

for  the  week  ended  March  21,  1901 : 

McDowell,  A.  B.,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  10  days.    March  9. 

Peckham,  C.  T.,  surgeon,  granted  leave  of  absence  on  account  of 
sickness,  for  20  days  from  March  9.    March  ;9. 

WoonwARD,  R.  M.,  surgeon,  detailed  as  inspector  of  unserviceable 
property  in  the  Hygienic  laboratory,  Washington,  D.  C. 
March  21. 

Nydkogkb,  J.  .\..  passed  assistant  surgeon,  to  proceed  to  Norfolk, 
Portsmouth,  and  Newport  News,  Va.,  on  special  temporary 
duty.     March  19. 

Gardnke,  C.  H.,  passed  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  3  days  from  April  4.     March  lH. 

Holt,  J.  M.,  assistant  surgeon.  Bureau  order  of  March  8  is 
amended,  and  he  is  directe<l  to  proceed  to  Chicago.  III.,  and  re- 
port to  medical  otiicer  in  command  for  duty  and  assignment  to 
quarters.    March  20. 

Walklky,  W.  S  ,  acting  assistant  surgeon,  is  granted  leave  of  ab- 
sence for  2  days.     March  19. 

Carlton.  C.  G  .  hospital  steward,  to  proceed  to  Mobile.  Ala.,  and 
report  to  the  medical  officer  in  command  for  temporary  duty. 

Board  Convened. 

Board  convenetl  to  meet  at  Washington,  D.  C.  on  or  about  March 
19,  ISWl,  to  examine  Assistant  Surgeon  H.  S.  Mathewson,  to  de- 
termine his  fitness  for  promotion  to  the  grade  of  passed  assistant 
surgeon.  Detail  for  the  board: — Surgeon  P.  H.  Bailhaohe, 
chairman;  Surgeon  G.  T.  Vatghax.  Passed  Assistant  Surgeon 
H.  D.  Geddings.  recorder. 


SUBCH  so,  1901] 


FOREIGN  NEWS  AND  NOTES 


PThb  Philadelphia 
L  Medical  JotTRifAL 


599 


Assistant  Surgeons  Appointed.— The  Secretary  of 
the  Treasury  ha-i  appointed  tae  following  as  assistant  sur- 
geons, to  serve  during  the  quarantine  season  at  the  several 
fruit  ports  of  Central  America,  their  principal  duty  being  that 
■of  inspecting  fruit  to  be  exported  to  the  United  States  : 

Bocas  Del  Tore,  Colombia. — Paul  Osterhout. 

Port  Limon,  Costa  Rica. — D.  W.  Goodman. 

Livingston,  Guatemala. — W.  K   F^rt. 

Puerto  Cjrtez,  Honduras. — 3.  H.  Backus. 

Ceiba,  Honduras. — R.  H.  Peters. 

Belize,  Britih  Honduras.— J.  G.  Thomas. 

Bluf  fields,  Nicaragua. — W.  H.  Carson. 
The   appc  iatees  will  serve  in  the  office  of  the  American 
consuls  at  the  places  mentioned. 


Jorcign  HetDs  anb  Hotcs. 


GREAT  BRITAIN. 

Elected. — Dr.  R.  B.  Wild  has  been  elected  to  the  Leech 
professorsnip  of  materia  medica  and  therapeutics  at  Owens 
College,  Manchester. 

Change  in  Editorship. — Dr.  Henry  Kellet  has  been 
appointed  editor  of  the  Medical  Press  and  Circular,  to  succeed 
the  late  Dr.  Archibald  Hamilton  Jacob. 

Professorship  of  Surgery.  —  The  professorship  of 
surgery  in  the  R  lyal  College  of  Surgeons,  Ireland,  vacant  by 
the  death  of  Sir  William  Stokes,  will  be  filled  in  April. 


COXTINEXTAL  EUROPE. 

Petroleum  Drinking, — The  Mfdical  Society  of  Paris 
has  expressed  the  opmion  that  it  is  necessary  to  adopt  some 
measures  against  the  alarming  spread  of  petroleum  drinking. 
At  firct,  it  was  thought  that  this  habit  had  sprung  up  from 
the  increased  taxation  on  alcohol  imposed  by  the  French 
government,  but  an  investigation  showed  that  this  was  not 
the  case ;  the  habit  has  been  prevalent,  some  time  previously, 
in  certain  districts,  and  had  spread  with  great  rapidity.  The 
victim  of  the  petroleum  habit  does  not  become  brutal,  only 
morose. 

Marble  Bust  for  the  Discoverer  of  the   Lepra 

Bacillus. — The  sixtieth  anniversary  of  the  birthday  of  Dr. 
Gerhard  Armauer  Hansen,  the  discoverer  of  the  lepra  bacil- 
lus, will  be  celebrated  on  July  29,1901.  His  numerous  friends 
and  admirers,  both  among  the  medical  profession  and  the 
laity,  will  commemorate  the  occasion  by  the  erection  of  a 
marble  bust  of  Dr.  Hansen  in  the  Lungegaard  Hospital, 
Bergen,  where  he  discovered  the  lepra  bacillus.  A  committee 
of  N  irsvegians  is  active  in  the  solicitation  of  subscriptions 
for  this  object.  ; ^^  1:_'S  ,7^  -^  .   --'  -  j^    i-i.?   ..^ 

"  Legislation  for  the  Prevention  of  Malaria  in 
Italy. — Tne  Lancet  publishes  an  account  of  the  law  drawn 
up  fur  the  purpose  of  preventing  malaria  in  Italy.  The 
articles  provide  for  an  official  declaration  of  the  affected 
areas,  for  the  gratuitous  distribution  of  quinin  to  the  poor 
from  municipal  sources,  and  the  taxation  of  property  to  raise 
funds.  Another  article  compels  the  Government  to  supply 
qiiinin  free  of  cha  rge  whenever  it  is  responsible  for  the  execu- 
tion of  a  public  work  giving  rise  to  malaria.  The  protection 
of  all  homes  in  the  affected  district  sgainst  the  entrance  of 
insects  and  the  empowerment  of  the  Government  to  take  any 
fiirther  measures  necessary  for  the  execution  of  the  legal 
provisions,  are  included.  In  his  new  work  entitled  "  La 
Mtlaria"  Celli  announces  an  annual  mortality  in  Italy  of 
15,000  due  to  ma'aria,  and  that  5,000,000  acres  of  good  land 
remain  uncultivated. 

MISCELL.YNY. 

Kussmaul's  Respiration. — This  variety  of  respiration 
is  characteristic  of  diabetic  coma,  and  consists  in  a  deep, 
abrupt  inspiration,  followed  by  a  pause,  then  a  quick  expira- 
tion and  another  pause. 


Medical    Practice    in    New    South   "Wales.— The 

Western  Medical  Review  stales  that  the  new  practice  act  for 
New  South  Wales  calls  for  a  term  of  5  years'  study  of  medi- 
cine. This  would,  therefore,  exclude  an  American  from 
practice  because  he  is  supposed  to  have  graduated  from  a 
school  of  but  4  years.  However,  it  seems  that  the  first  of  the 
5  years  is  similar  to  the  last  year  usually  spent  in  an  Ameri- 
can preparatory  school  before  entering  an  American  medical 
college,  and  the  regulations  of  the  British  Medical  Council 
says :  "  Graduates  in  the  arts  and  sciences  of  any  university 
recognized  by  the  medical  council,  who  shall  have  spent  a 
year  in  the  study  of  physics,  chemistry,  and  biology,  and 
have  passed  an  examination  in  these  studies  for  the  degrees 
in  question,  shall  be  held  to  have  completed  the  first  of  the 
5  years  of  medical  study." 

History  of  Hospitals — The  institution  of  the  hospital 
as  we  know  it  at  the  present  day,  with  its  regulations  and 
rules,  did  not  exist  in  the  earliest  times,  nevertheless  houses 
or  establishments  for  the  reception  of  the  sick  can  be  traced 
back  to  the  early  Jewish  period.  The  earliast  of  these  weie 
known  as  Beth  Holem,  or  houses  of  the  sick ;  such  a  Beth 
Holem  was  Beth  Saida,  famous  in  the  New  Testament  Scrip- 
tures. This  institution  was  supported  by  voluntary  contri- 
butions, as  the  word  "  Saida  " — charity — naturally  expresses. 
Tnese  hospitals  were  mostly  situated  round  a  pocl,  the 
waters  of  which  were  con.-idered  to  be  efficacious  for  various 
diseaf  63,  especially  gout  and  rheumatism.  According  to  the 
writer,  the  a'teadants  in  charge  of  tbese  establishments 
were,  as  we  know  frcm  the  Scriptures  (John  5  :  2-7),  expected 
to  help  the  paiients  into  the  water.  This  kird  of  institution 
may  be  looked  upon  as  the  foundation  of  hospitals.  They 
were,  however,  usually  of  a  very  primitive  construction, 
mostly  cotsisting  of  a  few  wooden  huts. 

In  ancient  E^ypt  hospitals  were  unknown,  the  sick  being 
mostly  attended  to  in  their  own  homes,  or,  in  the  case  of  the 
very  poor,  at  the  various  temples  in  the  city  to  which  they 
belong.  Tne  Greeks,  however,  appear  to  have  been  better 
supplied  with  institutions  of  this  kind.  Plato  says  that  there 
existed  in  various  parts  of  the  country  shelter  houses  for  the 
sick.  Tnese  institutions  were,  as  Thucydides  has  observed, 
supplied  wi  h  attendants,  who  waited  upon  the  sick.  It  has 
been  asserted  that  the  ancients  had  no  such  attendants,  be- 
cause no  pa?an  would  wait  upon  a  stranger  in  case  of  sick- 
ness; this,  however,  seems  to  be  contradicted  by  the  well- 
known  case  of  the  Samaritan  (Luke  10 :  30-35).  Here  was  a 
man  who  had  bsen  attacked  by  thieves  left  by  his  own 
countrymen,  and,  moreover,  priests,  to  die  by  the  wayside, 
who  was  seen  by  a  man  of  a  country  with  whom  his  own 
kindred  were  at  enmity.  The  foreigner  seeing  the  man  from 
Jadea  in  trouble,  not  only  attended  him,  but  even  helped 
him  to  mount  his  own  ass.  Many  instances  of  a  similar 
kind  could  be  cited  from  ancient  authorities.  It  is  probable 
that  the  hpst  hospitals  of  antiquity  were  those  established  in 
Rjme.  For  some  years  it  was  doubted  whether  the  Romans 
had  such  institutions,  but  a  large  tablet  which  was  discovered 
near  Placenza,  dated  in  the  reign  of  Trajan,  has  shown  that 
not  only  did  they  possess  such  institutions,  but  that  they 
were  actually  endowed.  One  of  the  earliest  hospitals  on 
record  was  probahlv  that  founded  by  Valens  in  Cfe-<area  be- 
;wpen  the  years  370  and  380  A.  D. — ^London  Physician  and 
Surg  f  on.} 

The  Good  Effects  of  Methylene-blue  in  Acut« 
Parenchymatous  Nephritis.— Nj-btah  (Sapisky  Ekat- 
frinoslauskago  Me>iicinskago  Ooshestu-a,  1900;  Vratch,  Vol.  iiii, 
No.  4)  reports  4  cases  of  acute  parenchymatous  nephritis,  in 
which  the  methylene  blue  had  a  curative  e  ffect.  The  nephritis 
was  secondary  to  scarlet  fever.  In  one  case,  that  of  a  girl  of 
7,  the  administration  of  the  methylene-blue  aborted  what 
promised  a  severe  attack  of  acute  nephritis.  In  the  other, 
that  of  a  boy  of  3  years,  the  usual  treatment  failed  to  im- 
prove the  condition  of  the  kidneys.  The  methylene  blue,  on 
the  other  hand,  at  once  relieved  the  anasarca,  and  freed  the 
urine  from  blood  and,  later,  albumin.  Similar  results  were 
obtained  in  the  other  2  cases.  The  author  treated  IS  cases 
of  scarlet  fever  and  6  of  primary  parenchymatous  nephritis 
with  this  drug.  The  results  in  all  were  most  gratifying. 
The  beneficial  effects  of  the  methylene  blue  are  explained 
by  its  chemical  combination  with  the  renal  cells  or  the 
toxins  generated  by  the  microorganisms,    [a.r.] 


600 


The  PHILADKLPHIi"] 

Mbdical  Jodesal  J 


THE  LATEST  LITERATURE 


[MaBCH  30.  1901 


CI?c  latest  iitcraturc. 


British  Medical  Journal. 

March  9, 1901.     [No.  2097.] 

1.  An  Address  on  the  Neglect  of  the  Actual  Cautery  in  Sur- 

gery, and  its  Value  in  the  Treatment  of  Pruritus  Ani. 
William  M.  Banks. 

2.  The  Lettsomian  Lectures  on  Diseases  and  Disorders  of  the 

Heart  and  Arteries  in  Middle  and  Advanced  Life.     J. 
Mitchell  Bruce. 

3.  The  Milroy  Lectures  on  the  Inflaence  of  the  Dwelling  upon 

Health.    John  F.  J.  Sykes. 

4.  The  Histoloey  of  the  Urinary  Tract  in  its  Relationship  to 

Morbid  Urinary  Deposits.    G.  Leslie  Estes. 

5.  Remarks  on  a  Case  of  Electric  Shock.    Henry  Smurth- 

WAITE. 

1. — Banks  thinks  that  the  actual  cautery  is  at  present 
too  little  used  in  certain  surgical  conditions.  In  syphilitic 
periostitis,  where  the  pain  is  very  severe,  preventing  sleep, 
and  where  the  ordinary  antisyphilitic  remedies  fail  to  relieve 
pain,  he  has  found  that  the  thorough  application  of  the  actual 
cautery  will  give  permanent  relief.  The  instrument  should 
be  at  a  white  heat,  and  should  be  passed  many  times  over 
the  same  tracks.  In  certain  cases  of  arthritis,  due  to  trau- 
matism occurring  in  adults  and  not  associated  with  tubercu- 
losis, and  in  which  rest,  blistering,  etc.,  have  been  of  no  avail, 
he  has  found  the  application  of  the  actual  cautery  will  give 
maiked  relief  from  pain  and  cau^e  absorption  of  fluid.  He 
gives  a  number  of  case?,  illustrating  the  advantage  of  the 
actual  cautery  in  this  condition.  In  some  spinal  inflam- 
mations after  injury,  this  method  of  treatment  has  also 
been  of  great  advantage.  Finally,  Banks  refers  particularly 
to  the  use  of  the  cautery  in  the  treatment  of  pruritus  ani. 
It  is  only  to  be  recommended  for  this  condition  where  the 
cause  of  the  condition  cannot  be  found  and  removed,  and 
where  other  treatments  have  failed.  He  records  a  number 
of  cases  where  patients  have  suflered  from  marked  exhaus- 
tion from  loss  of  sleep,  produced  by  the  itching,  in  which 
destruction  of  the  affected  skin  by  the  cautery  has  given  per- 
manent relief,    [j.h  q  ] 

2. — Between  ttie  ages  of  20  and  45  years  the  blood-pressure 
is  relatively  high,  the  aorta  and  the  other  large  arteries  in- 
crease in  diameter  from  the  stress  of  the  blood-pressure  on 
their  elastic  walls,  and  the  heart  increases  in  size  year  after 
year  at  a  nearly  uniform  rate.  We  have  in  these  facts  ana- 
tomic evidence  of  the  great  functional  vigor  and  activity  of 
the  circulation  in  manhood.  At  45,  while  the  arteries  con- 
tinue to  increase  in  circumference,  the  blood-p)re8sure  falls 
and  the  heart  begins,  almost  suddenly,  to  diminish  in  size. 
These  3  features  characterize  the  circulation  for  the  next 
20  years.  This  fall  in  the  size  of  the  heait  is  to  be  accounted 
for,  partly  by  the  widening  of  the  arterial  trunks  and  the 
consequent  fall  of  pressure  ;  and  partly  by  the  reduction  of 
mechanical  stress,  due  to  comparative  bodily  relaxation, 
loss  of  vasomotor  tone  in  the  splanchnic  area,  and  the 
chronic  diseases  from  which  the  patient  may  suffer.  The 
blood  becomes  more  venous  in  quality  and  its  hemoglobin 
value  is  lowered.  At  65,  the  decline  of  circulatory  energy 
and  the  effects  of  time  on  the  protoplasm  of  the  cells  of  the 
body  have  so  lowered  the  metabolic  and  functional  energy 
of  the  tissues  and  organs  and  the  activity  of  the  blood-supply 
that  a  considerable  propoition  of  the  capillary  network 
becomes  obsolete.  The  peripheral  resistance  is  thus  in- 
creased ;  the  blood-pressure  rises ;  therefore,  the  heart  once 
more  increases  in  siza,  so  that  at  the  end  of  10  years 
it  is  found  as  large  as  it  was  at  45,  and  at  the  same  time 
the  hemoglobin  value  of  the  blood  again  proves  to  be 
higher.  In  other  words,  as  age  advances,  the  arteries 
naturally  become  wider,  longer,  and  thicker,  and  altogether 
larger  than  in  early  life,  and  we  must  not  speak  of  vascular 
degeneration  in  an  evil  sense  as  often  as  we  find  these  con- 
ditions present.  The  heart  may  remain  structurally  sound, 
and  is  more  often  regular  than  irregular,  to  the  most  advanced 
years  of  life.  Conversely,  these  facts  suggest  that  actual  dis- 
eases of  the  arteries  and  heart  are  not  properly  senile  in  their 
nature.  Physical  stress  is  a  definite  cause  of  cardiac  and 
vascular  damag'e  in  the  second  half  of  life,  in  the 
forms  both  of  sadden,  violent  exertion  and  of   ordinary 


laborious  occupations.  Bruce  has  met  with  instances  of 
acute  and  serious  strain  at  all  ages  over  40,  up  to  and  even 
after  70.  In  some  cases  there  was  no  reas3n  to  believe  that 
the  heart  was  other  than  sound  before  the  strain ;  but  in  the 
majority  of  instances  one  or  more  of  the  safeguards  of  the 
circulation  against  strain  were  already  defective  or  wanting. 
So  far  as  the  heart  is  concerned  the  principal  safeguard  is 
the  presence  of  well- nourished,  healthy  cardiac  walls.  Two- 
thirds  of  the  cases  of  cardiac  strain  in  the  second  half  of  life 
presented  a  history  of  perverted  metabolism.  In  many  cases 
the  occurrence  of  strain  was  but  the  latest  of  a  series  of 
similar  events;  the  heart  had  been  strained  originally  in 
youth  or  early  manhood,  and  had  given  serious  trouble  as 
often  as  it  was  taxed  again.  Rowing  or  running  at  college 
was  in  a  good  many  instances  given  as  the  cause  of  the  first 
strain.  Previous  valvular  disease,  usually  of  rheumatic 
origin,  is  a  condition  powerfully  predisposing  to  cardi&c 
injury  by  physical  exertion.  Again,  the  metabolic  disorders, 
including  gout,  that  weaken  the  cardiac  walls,  are  among  the 
common  causes  of  arterial  degeneration,  and  the  two  influ- 
ences, rheumatism  and  perverted  metabolism,  acting  together 
no  doubt  are  accountable  for  a  considerable  number  of  cases 
of  atheroma  and  chronic  arteritis.  It  is  unwise,  ill-timed, 
ill-planned  muscular  exercise  that  injures  the  circulation, 
usually  on  the  part  of  the  middle-aged  man,  who,  awaking  to 
the  consciousness  of  growing  fat  and  gouty,  rushes  incon- 
siderately to  violent  exercise  for  relief.  Many  cases  of  dis- 
order and  disease  of  the  walls  of  the  heart  and  arteries 
originate  in  distress,  worry,  anxiety,  and  protracted  suspense ; 
and  the  connection  is  most  often  seen  in  middle  and  advanced 
life  because  these  depressing  emotions  fall  most  heavily  upon 
mankind  at  this  period.  Alcohol  undoubtedly  plays  an  im- 
portant part  in  many  cases  of  cardiac  failure  that  are  regarded 
as  due  to  overwork,  worry,  and  nervous  exhaustion  both  in 
men  and  in  women.  Many  of  the  complaints  of  nervous 
depression,  lowness,  and  worry  are  really  due  to  gout  and  to 
ir.fluenza.  Disturbances  of  metabolism,  including  gout,  are 
by  far  the  most  prolific  cause  of  cardiovascular  disorder  and 
disease  after  40,  at  any  rate  amongst  the  middle  and  higher 
classes.  Whatever  the  date  of  the  primary  infection,  syphilis 
is  a  standing  danger  to  the  heart  and  arteries  in  the  middle- 
aged  man,  and  even  in  declining  years.  Acute  and  chronic 
diseases  explain  many  cases,  while  the  origin  of  other  cases 
of  cardiovascular  disease  is  explained  by  the  existence  of 
emphysema  and  other  chronic  diseases  of  the  lungs  and 
pleura.  Chronic  Bright's  disease  threatens  the  function  and 
structure  of  the  heart  and  the  arteries,  and  in  many  instances 
the  different  influences  that  threaten  the  circulatory  organs 
act  together  in  different  combinations.  There  are  some  per- 
sons whose  hearts  and  arteries  cannot  carry  them  through 
the  wear  and  tear  of  what  may  be  called  everyday  life  for 
more  than  40  or  50  years.  This  type  of  case  is  described  aa 
family  heart,  for  it  runs  in  families,  3,  4,  5,  or  more  members 
of  which  may  have  all  died  suddenly  of  cardiac  disease,  some 
o'"  them  at  an  early  age.    [j  m  s.] 

3. — See  abstract  for  Lancfi  of  March  9. 

4. — In  the  course  of  over  6,000  microscopical  exami- 
nations of  urine  from  cases  of  nephritis,  E$te$  has 
never  been  able  to  convince  himself  that  he  has  seen  the 
clear,  flattened  epithelial  cells  peculiar  to  the  Malpighian 
corpuscles.  He  haa  been  able  to  recognize  the  granular, 
rodded  epithelium  of  the  convoluted  tubules  because  the 
cells  are  polygonal  with  somewhat  extended  processes.  The 
cubical  or  columnar  epithelium  of  the  latter  part  of  the 
tubules  is  not  diflicult  to  recognize  and  is  the  kind  most 
commonly  found  when  renal  epithelium  is  present.  In  a 
case  in  which  urine  from  a  carcinomatous  kidney 
was  examined  there  was  an  abundance  of  renal  epithelium 
in  the  sediment.  The  epithelial  cells  did  not  appear  iso- 
lated, as  is  almost  invariably  the  case  in  tubal  nephritis,  but 
were  frequently  to  be  found"  in  clumps,  numbering  from  4  to 
20  cells,  grouped  together  with  some  dovetailing ;  they  were 
cubical  in  shape,  griinular  in  appearance  throughout,  except 
for  a  large  and  evident  nucleus.  These  appearances  pointed 
to  rapid  proliferation,  and  the  tumor  was  a  rapidly-growing 
carcinoma.  There  was  much  blood,  a  few  blood-cast^,  and 
there  was  some  renal  pelvic  epithelium.  In  cases  of  buried 
calculus  the  deposit  usually  contains  blood,  a  few  hyaline 
casts,  no  epithelial  cells,  although  blood  caste  are  present. 
In  every  case  there  was  much  free  uric  acid  in  the  deposit, 
and    the    crystals    were  aggregated    together.    Epithelium 


MaBCH  30,   ISUll 


THE  LA.TEST  LITERATURE 


[The  Philadelphia 
Medical  Journal 


601 


from  the  pelvis  of  the  kidney  was  wanting  or  present 
only  in  very  small  quantity.  Chemic  examination  showed 
the  presence  of  more  albumin  than  was  accounted  for  by  the 
quantity  of  blood  present.  The  epithelium  lining  the 
whole  of  the  renal  pelvis  and  the  upper  part  of  the  uieter 
belongs  to  the  type  of  ep.thelium  known  as  transitional. 
The  cells  of  the  deeper  layer  are  those  that  are  mott  easily 
recognized  in  morbid  deposits,  and  the  commonest  forms 
present  a  rounded  body  with  granular  contents  and  an  evi- 
dent nucleus.  The  body  usually  tails  off  rapidly  into  a  pro- 
longation, whose  length  may  be  twice  or  thrice  that  of  the 
body.  Some  of  these  cells  possess  a  prolongation  at  either 
end.  They  are  only  shed  when  there  is  extent-ive  damage  to 
the  renal  pelvis,  and  are  mott  characteristic  when  that  dam- 
age is  due  to  mechanical  causes,  particularly  the  existence  of 
a  calculus  in  the  pelvis.  Blood  and  hyaline  casts,  and  a  slight 
though  constant  leukocytotis,  not  amounting  to  pus,  with 
the  almost  invariable  accompaniment  of  crystals.  In  cases 
of  pyelitis  due  to  causes  other  than  calculus,  the  deposit  con- 
tains casts,  and  when  tVie  pyelitis  is  due  to  any  other  infec- 
tion than  tuberculos  s,  the  urine  contains  numerous  bacttria. 
The  caf-ts  are  broad,  because  they  are  derived  from  the  ducts 
of  Bellini  and  the  collecticg  tubules,  and  sometimes  they 
contain  pus  cells.  In  all  lesions  of  the  renal  pelvis,  whether 
due  to  calculus  or  not,  it  is  usual  to  find  more  albumin  than 
the  microscopic  exammation  eeemed  to  warrant.  The  renal 
pelvis  may  contain  neoplasms,  and  in  such  cases  the  deposit 
will  contain  groups  of  cells  and  isolated  cells  in  large  num- 
bers, accnmpanitd  by  blocd.  The  cells  will  be  of  a  most 
pleomorphic  chaiatter,  but  usually  are  fusiform  or  spindle 
shape.  The  disease  of  the  bladder  that  cannot  be  diag- 
nosed by  an  examination  of  the  depcsit  are  very  few.  Cys- 
titis can  be  distinguished  from  localized  ulceration,  papillo- 
matous and  epitheliomatous  neoplasms  recoenized,  and 
vesical  calculus  strongly  suspected.  In  cystitis,  the  cells  are 
usually  derived  from  the  surface  of  the  epithelium.  In 
epithelioma  the  cells  are  highly  pleomorphic,  smaller  than 
in  either  diseases,  but,  on  the  average,  larger  than  those  of  the 
renal  pelvis  ;  they  tend  to  come  away  in  groups,  are  granu- 
lar, and  contain  a  large  and  evident  nucleus.  But  the  most 
characteristic  cells  are  found  in  cases  of  villous  growth.  The 
cells  in  these  cases  are  of  exceptional  lengih  of  a  remark- 
able thinness,  the  greater  thickness  being  that  of  the  nucleus, 
with  other  cells  which  are  shorter  and  more  pleomorphic  in 
the  urine  of  lads  between  the  ages  of  14  and  20,  clumps  of 
clear,  luminous,  pear-shaped  cells  embedded  in  a  mucoid 
material  are  ofcen  found.  The  author  has  never  seen  similar 
cells  or  groups  of  cells  in  urine  Irom  girls,  so  he  believes  they 
may  be  derived  from  the  prostate,     [j.m.s.] 

5. — Smurthwaite  reports  the  case  of  a  man,  aged  29  years, 
who  wafl  admitted  to  hospital  in  a  semiconscious  condition, 
with  severe  burns  of  the  right  hand  and  thigh.  The  patient 
was  employed  by  the  local  electric  works,  where  he  had  sus- 
tained the  injuries.  On  admission,  he  was  pale  and  almost 
pulseless,  with  pupils  dilated,  respiration  very  shallow,  and 
extremities  cold  and  clammy.    His  right  hand  and  upper 

Eart  of  right  thigh  were  very  much  burnt.  There  was  a 
unch  of  keys  in  his  right  trousers  pocket,  which  were  un- 
doubtedly the  indirect  cause  of  the  accident.  The  bunch  was 
a  very  big  one  and  bulged  out  the  pocket  so  that  the  thigh 
was  brought  into  contact  with  the  screws  in  a  water-contact 
switch,  thus  completing  the  circuit  with  the  motor,  which 
he  was  adjusting,  producing  the  severe  electric  shock. 
[j.m.s  ] 


Lancet. 

March  9.     [No.  4015] 

1.  The  Milroy  Lectures  on  Public  Health   and  Housing. 

John  F.  P.  Sykks. 

2.  A  Clinical  Lecture  on  the  Statistics  of  Gastric  Ulcer,  with 

Special  Reference  to    Gastric  Hemorrhage,  its  Fre- 
quency and  Fatality.    Btrom  Bramwell. 

3.  Lettsomian  Lectures  on  Diseases  and  Disorders  of  the 

Heart  and  Arteries  in  Middle  and  Advanced  Life.    J. 
Mitchell  Bruce. 

4.  Pure  Urea  in  the  Treatment   of  Tuberculosis.    Henry 

Harper. 

5.  A  C««e  of  Pemphigus  Neonatorum  in  an  Infant  Three 

Days  Old.    Charles  J.  Glasson. 


6.  A  Few  Cases  of  Ethyl  Chloride  Narcosis.    W.  J.  McCar- 

DIE. 

7.  A  Further  Note  on  the  Production  of  Local  Anesthesia 

in  the  Ear,  Nose  and  Toroat.    Albert  A.  Gray. 

8.  Two  Cases  Illustrating  the  Use  of  the  XEays  in  Surgery. 

G.  P.  Newbolt  and  C.  Thurston  Holland. 

9.  The  Yesterday  and  Today  of  Aural  Surgery.  Sir  William 

Dalby. 

10.  History  of  Renal  Surgery.    David  Newman. 

11.  Nomenclature    and     Classification.      Charles    Powell 

White. 

1. — The  abstract  will  appear  when  the  article  is  completed. 

2. — Bramwell  delivered  a  lecture  before  the  Edinburgh 
Royal  Infirmary  on  February  12,  1901,  on  The  statistics 
of  gastric  ulcer,  with  special  reference  to  gastric 
hemorrhage,  its  frequency  and  fatality.  The  author 
does  not  agree  with  Mr.  Mayo  Robson,  as  to  the  mortality  of 
gastric  ulcer  and  its  frequency;  and  he  fears  thht  the  mor- 
tality would  be  increased  rather  than  decreased  by  opera- 
tions for  the  arrest  of  hemorrhage  in  cases  of  gastric  ulcer. 
Perhaps  in  no  other  disease  are  statistics  so  misleading  as 
those  pertaining  to  the  subject  of  gastric  ulcer,  and  the 
author  believes  that  Mr.  Mayo  Robson  has  overestimated 
the  total  mortality  and  the  mortality  from  hemorrhage  in 
gastric  ulcer.  The  frequency  of  gastric  ulcer  in  the  general 
population  is  estimated  as  being  about  5^  of  the  whole  popu- 
lation (who  suS'er  at  some  period  of  their  lives).  Bramwell 
states  that  this  is  probably  an  exaggerated  estimate.  The 
frequency  of  gastric  ulcer  is  approximately  arrived  at  in  two 
ways :  (1)  By  postmortem  examinations ;  (2)  from  the 
clinical  standpoint.  The  statistics  collected  by  Welch  show 
that  out  of  32,052  autopsies,  gastric  ulcers  were  found  in 
about  5%  of  the  number.  The  objections  to  the  post- 
mortem method  are  the  following:  1.  The  frequency 
of  gastric  ulcer  may  be  underestimated,  because  the  stom- 
ach may  not  be  opened  in  all  cases.  2.  Cicatrices  of 
former  ulcerations  may  be  overlooked ;  the  proportion  of 
open  ulcers  to  cicatrices  is  generally  given  as  being  1 
to  3.  3.  It  is  questionable  whether  a  superficial  ulceration 
in  the  stomach,  when  healed,  leaves  a  recognizable  cicatrix, 
and  the  author  mentions  that  there  are  cases  of  gastric  ulcer 
presenting  well-defined  characteristic  symptoms,  which  may 
heal  without  leaving  any  obvious  or  recognizable  cicatrix.  4. 
Another  objection  to  the  postmortem  method  is  that  other 
lesions  may  produce  scars  ;  for  example,  syphilitic  gummata 
and  tuberculous  ulcerations.  The  author  concludes,  therefore, 
that  probably  more  than  5^  of  the  cases  collected  and  ana- 
Ij  zed  by  Welch  suffered  from  gastric  ulcer.  It  is  unreasonable 
to  suppose  that  because  5  %  of  the  autopsies  made  in  hospitals 
revealed  ulcerations,  that  we  should,  therefore,  conclude  that 
this  applies  to  the  general  population ;  postmortem  examina- 
tions in  hospitals  are  mostly  made  on  adults,  or,  at  all 
events,  on  individuals  over  5  years  of  age ;  gastric  ulcer  is  a  very 
rare  disease  in  early  life  (up  to  the  fifth  year).  Therefore,  it  is 
unreasonable  to  suppose  that  because  5%  of  the  autopsies  in 
hospitals  presented  gastric  ulcer,  that  5%  of  the  whole  popu- 
lation suffers  from  this  condition.  The  author  states  that 
gastric  ulcer  is  very  much  more  common  in  the  class  of  pa- 
tients found  in  hospitals,  and  that  this  condition  occurs  less 
frequently  in  the  middle  and  upper  classes,  and  probably  to 
a  less  degree  in  the  same  class  of  persons  living  in  rural  dis- 
tricts. Hospital  patients  are,  as  a  rule,  drawn  from  towns ; 
therefore,  it  would  seem  unreasonable  to  conclude  that  be- 
cause 5%  of  the  inmates  of  hospitals  suffer  from  gastric  ulcer, 
that  the  percentage  is  the  same  when  dealing  with  the  gen- 
eral population.  Approximately,  13^  of  the  general  popula- 
tion is  composed  of  children  under  5  years  of  age  ;  gastric 
ulcer  being  very  rare  in  children  under  this  age,  and  because 
autopsies  are,  as  a  rule,  not  made  upon  children,  it  is  alto- 
gether unjustifiable  to  conclude,  therefore,  that  because  5  % 
of  the  persons  examined  postmortem  in  hospitals  suffer 
from  gastric  ulcer,  that  the  general  conimunity  should  be 
affected  to  the  same  extent.  The  death-rate  from  gas- 
tric ulcer  in  hospitals  is  much  greater  than  the  death- 
rate  outside  of  hospitals ;  he  concludes,  therefore,  that 
the  estimate  of  5%  for  the  whole  population  is  probably 
excessive.  The  frequency  of  gastric  ulcer,  as  deter- 
mined by  the  clinical  method  is  less  satisfactory  than 
the  postmortem  method.  The  author  gives  a  number  of 
reasons  for  this;  he  has  only  observed  27  cases  (or  0.44%), 


602 


THS   PHn-ADBLPHIA"! 

Medical  Journal  J 


THE  LATEST  LITERATURE 


[March  30,  ISOl 


out  of  6,123  cases,  seen  in  his  own  private  consulting  prac- 
tice. It  is  extremely  difficult  to  draw  reliable  conclusions  as 
to  the  total  mortality  of  gastric  ulcer.  If  hospital  patients 
form  the  basis  of  the  calculation,  the  conclusions  will  be 
misleading,  for  the  worst  cases  find  their  way  into  hospitals. 
The  author  mentions  that,  according  to  Mr.  Mayo  Robson, 
81.25  (above  5  years  of  age),  constitutes  the  annual  mortality 
from  gastric  ulcer  in  Leeds  (estimating  the  population  at 
500,000).  An  analysis  of  the  number  of  deaths,  which  were 
registered  from  this  cause  in  Leeds  during  the  last  year, 
showed  that  there  were  14  deaths  from  gastric  ulcer  and  4 
from  hematemesis  (probably  due  to  ulcer),  making  a  total  of 
18  cases ;  this  is  making  a  very  libpral  allowance.  Eitimating 
the  population  of  Leeds  as  500  000,  20.08  deaths  would  have 
been  due  to  gastric  ulcer  last  year.  Bramwell  believes  that 
Mr.  Mayo  Robson's  conclusions,  regarding  the  total  mortality 
from  gastric  ulcer  in  Leeds,  mu>t  be  incorrect.  Bramwell 
also  states  that  according  to  Mr.  Mayo  Robson,  the  deaths 
due  to  hemorrhflge  from  gastric  ulcer  last  j'ear  in  Leeds 
amounted  to  2277.  Upon  examining  the  registration  of 
deaths,  he  found  that  8.1  deaths  were  due  to  hemorrhage. 
He  believes  that  death  from  hemorrhage  in  cises  of  gastric 
ulcer  is  of  rare  occurrence  ;  he  only  recalls  a  single  instance 
in  his  own  practice,    [f  j.k  ] 

3. — See  abstract  of  British  Medical  Journal  of  Mirch  9. 

4. — Harper  advocates  the  use  of  pure  urea  in  the 
treatment  of  tuberculosis,  and  believes  tbe  remedy  to 
be  superior  to  any  oiher  that  is  in  use  fc  r  this  disease  at  the 
present  time.  The  author's  experience  lends  him  to  believe 
that  more  radical  measures  will  be  needed  in  the  treatment 
of  this  disease  than  fresh  air  and  the  ordinary  sanitarium, 
and  that  a  careful  revision  of  our  diet  list  will  form  the  key- 
note in  the  management  of  tuberculosis.  Over  one-half  of 
his  own  cases  of  tuberculosis  come  from  the  country  ;  there- 
fore, it  is  hard  to  reconcile  with  the  view  that  country  air  is 
the  remedy  for  tuberculosis.  He  has  urged  tuberculous 
patients  to  partake  of  as  much  animal  food  as  possible.  The 
immunity  of  certain  animals  to  tuberculosis  may  be  ascribed 
to  the  character  of  their  food  ;  and  in  the  author's  opinion, 
urea  and  uric  acid  play  an  important  part  in  rendering 
animals  immune,  or  the  reverse.  The  carnivora  rarely 
become  tuberculous,  whilst  the  herbivora  show  a  marked 
tendency  to  tuberculosis.  The  author  finds,  upon  review- 
ing h's  notes  of  cases,  that  those  individuals  showing  a 
marked  tendency  to  gout,  gravel  and  calculus  very  rarely 
suflfer  from  tuberculosis.  The  negro,  althoi'g'a  lead- 
ing an  outdoor  life,  is  especially  liable  to  tuberculosis, 
probably  for  the  reason  that  his  food  largely  consists  of 
starchy  foods,  such  as  rice,  vegetables  and  fruits,  and  par- 
takes sparingly  of  meat.  The  author  applied  the  following 
treatment  in  his  own  cases:  plenty  of  nutritious  food,  espe- 
cially that  rich  in  albumins  (1  kidney  well  cooked,  daily, 
with  one  half  pint  of  beef  tea) ;  in  cirefully  selected  cases, 
he  advised  exercise  in  the  fresh  air;  the  medicinal  treatment 
comprised  drugs  of  recognized  value,  such  as  iron,  cod-liver 
oil,  hydrochloric  acid,  strychnia,  pepsin,  creosote,  and  urea 
has  been  added  to  the  remedies  mentioned.  By  partaking 
of  a  superabundance  of  rich  food,  containing  a  large  per- 
centage of  urea,  the  tissues,  and  fluids  of  the  body  are  ren- 
dered less  susceptible  to  the  invasion  of  the  tubercle- bacilli; 
in  short,  they  act  as  an  antitoxin.  A  report  of  9  cases  of 
tuberculosis  is  given.  In  all  of  these  urea  was  administered 
with  very  favorable  results.  The  remedy  is  of  special  value 
when  the  disease  is  uncomplicated  by  various  species  of 
cocci.  From  the  standpoitt  of  a  laboratory  investigation, 
the  author  failed  to  obtain  a  growth  of  tubercle-bacilli  in 
meat  broth  containing  a  small  percentage  of  urea,  whilst  in 
the  control  tubes  which  did  not  contain  urea  tbe  bacilli 
grew,    [f.j  k.] 

6.— Glasson  reports  an  interesting  case  of  pemphigus 
occurring  on  the  third  day  after  birth,  in  an  otherwise  iiealthy 
child.  The  disease  first  appeared  as  a  bullous  rash  over  the 
occipital  region  and  then  spread  over  the  entire  body,  ac- 
companied by  fever,  constipation  and  restlestnfsj.  E.-ich 
spot  was  pricked  with  an  aseptic  needle,  the  child  was  kept 
in  a  warm  rain-water  bath  for  five  minutes  each  day,  and 
then  anointed  with  boracic  ointment.  An  interesting  feature 
in  the  case  lies  in  the  fact  that  there  is  no  history  of  syphilis 
in  any  member  of  the  family  and  nothing  to  cause  one  to 
suspect  this  disease  as  being  the  cause  of  the  pemphigus. 
The  mother  nursed  the  child  throughout  the  entire  attack. 


During  convalescence  there  was  a  complete  exfoliation  of  the 
entire  cuticle,  leaving  no  blemish  of  the  skin,    [f  j  k  | 

6. — McCardie  reports  10  cases  of  ethyl  chloride  nar- 
cosis. He  is  very  much  impressed  with  the  usefulne84  of 
this  anesthetic.  The  anesthesia  is  produced  in  about  2  min- 
utes and  passes  away  in  about  the  same  time.  It  has  no  irri- 
tating action  and  can  be  administered  in  heart,  lung,  or  kid- 
ney diseases  where  ether  and  chloroform  are  contraindicated. 
The  only  objection  to  its  use  is  that  complete  musnular  relax- 
ation is  difficult  to  obtain.  McCardie  uses  the  Breuer  appa- 
ratus, which  consists  of  a  close  fitting  ma;k  with  inspiratory 
and  expiratory  valves  and  a  chamber  above  the  former  to 
hold  the  gauze  on  which  the  drug  is  sprayed.  All  the  cases 
he  ha;  used  it  in  have  been  short  operations,  such  as  the 
extraction  of  teeth,  removal  of  tonsils,  etc.     [j  h  o  ] 

7. — Gray  recommends  as  a  local  anesthetic  in  the  ear, 
no-ie  and  throat  a  combination  consisting  of  equal  parts  of  a 
20^  solution  of  cocainina  mixture  of  equal  parts  of  anilin  oil 
and  rectified  spirit,  and  a  20%  solution  of  eucain  Bin  anilin 
oil.  The  latter  is  not  a  true  solution,  as  eucain  is  only  soluble 
to  about  the  extent  of  10%  in  anilin  oil,  therefore,  before  the 
solutions  are  mixed  the  eucain  solution  should  be  thoroughly 
shaken.  Of  the  combined  solutions  he  uses  never  more  than 
20  minims.  Gray  thinks  that  this  combination  of  cocain  and 
eucain  in  anilin  oil  is  much  more  anesthetic  than  either  of 
these  drugs  used  alone,  and  much  more  so  than  an  aqueous 
solution  of  them.  He  allows  seven  minutes  to  elapse  after 
the  application  of  the  anesthetic  agent  before  beginning  his 
operation.  Where  chromic  acid  is  used  after  the  application 
of  this  solution  the  eschar  will  be  of  a  dark  green  color,  ow- 
ing to  the  formation  of  an  ani'in  dye.  This,  however,  pro- 
duces no  deleterious  effects.  He  never  sees  'he  intoxication 
from  the  use  of  these  drug?  which  is  not  infrequent  when 
used  in  aqueous  solution.  A  blueness  of  the  lips  has  some- 
times followed  the  use  of  this  anesthetic,  but  is  never  accom- 
panied by  any  other  svmptoms.     [j  h  o  ] 

8. — Ntwbold  and  Holland  report  two  cases  in  which 
x-rays  were  used  for  the  location  of  foreign  bodies : 
one,  a  gun  shot  wound  of  the  face  in  which  tbe  bullet  was 
easily  located,  and  the  other  one  of  a  plate  with  a  single 
tooth  which  was  readily  located  in  the  esophaeu*',  and  sub- 
sequently successfully  removed  through  the  mouth. 

9. — Dalby  calls  attention  to  the  great  change  which 
has  taken  place  in  recent  years  in  aural  surgery,  showing 
that  today  the  specialists,  instead  of  discussing  me  minor 
ailments  of  the  ear,  are  exercised  over  such  subjects  as  cere- 
bral abscess,  thrombosis  of  the  lateral  sinus,  mast  nd  inflam- 
mations, etc.,  and  the  wonderful  advance  made  in  the 
treatment  of  these  conditions,    [j  h  g.] 


New  York  Medical  Journal. 

March  gS,  1901.     [Vol.  Ixxiii,  No.  12.] 

1.  Some  R-^trospects  and  Prospecte  in  Genitourinary  Surgery. 

Reginai  d  Harrison. 

2.  The   Pnyoical   Examination  of   the  Stomach.    Mask  I. 

Knapp. 

3.  Infective  Sigmoid  Sinus  Thrombosis.    Clarencb  R.  Du- 

FOUR. 

4.  The  Pathology  of  Intrauterine  Death.  Xeil  Macphratter. 

5.  Emphj'sema  of  the  Eyelid  from  Nasal  Causes.    Beamas 

Douglass. 

1. — Harrison,  in  spfaVine  of  the  advance  made  dur- 
ing the  century  in  genitourinary  surgery,  mentions  first 
the  great  improvement  in  the  treatment  of  stone,  brought 
about  by  the  work  of  B  gelow  of  Boston.  He  remarks  upon 
the  completeness  of  Bigelow's  work  and  how  little  improve- 
ment has  been  brought  about  in  the  operauon  of  lithoUpaxy 
since  its  introduction.  He  refers  to  Rainey's  views  on  the 
formation  of  urinary  stone  as  being  of  the  utmost  prac- 
tical importince.  In  discussing  prostatic  hypertrophy 
he  urges  tiat  at  least  three  varieties  of  this  condition  should 
be  recognized  and  difierentiated,  as  each  requires  individual 
treatment.  The  cyst'vicope  here  is  of  the  greatest  import- 
ance. The  possible  damage  to  the  kidney,  due  to  pres- 
sure from  tension,  is  next  taken  up  and  Harrison  suggests 
the  possibility  of  relief  in  this  condition  from  an  exposure 
of  ttie  kidney,  and  incising  itj  capsule.  Lastlv,  reference  is 
made  to  the  progress  of  urinary  antiseptics,     [j.h  q.] 


HaBCU  30    1901] 


THE  LATEST  LITERATURE 


CPhe  Philadelphla 
Medical  Journal 


60S 


3.— Clarence  R.  Dufour  presents  an  able  paper  upon 
infective  sigmoid  sinus  throniljosis.  The  sigmoid 
ainuB  is  more  often  affected  with  thrombosis  than  any  other 
of  the  sinuEes  on  account  of  its  nearness  to  the  middle  ear, 
mastoid  cells  and  antrum,  cavities  that  are  so  liable  to  puru- 
lent inflammation.  The  etiology  of  this  condition  is  by  ex- 
tension from  chronic  purulent  otitis  media,  extension  of 
thrombosis  from  other  sinuses,  traumatism  such  as  a  fracture 
paseing  from  the  base  of  the  skull  to  the  middle  ear,  infection 
from  eeptic  wounds  of  the  head,  neck  or  mastoid  region  and 
inflammatory  secretion  from  throat  or  nasopharynx  into  the 
middle  ear,  antrum  and  mastoid  cell.  A  large  number  of 
persona  are  affected  with  chronic  middle  ear  disease,  and 
it  is  from  this  class  that  a  large  number  of  cases  of  in- 
fected intracranial  diseaae  comes.  The  beginning  of  a  throm- 
bus of  the  sigmoid  sinus  rarely  has  any  symptoms  pointing 
directly  to  it  other  than  the  mastoid  symptoms  which  demand 
the  opening  of  the  bone.  There  are  no  uniform  or  specific 
symptoms  which  determine  the  presence  of  a  thrombosis  of 
thia  sinus  that  may  not  vary  in  such  a  manner  as  to  cause 
a  doubt  of  the  condition  present.  The  writer  regards  the 
fluctuating  temperature  as  important.  The  pulse  rate  is 
high — from  150  to  175— respiration  soon  becomes  rapid  and 
labored,  vomiting  and  dizziness  may  or  may  not  be  present ; 
meningitis  may  occur.  When  it  does,  these  last  two  symp- 
toms are  usually  present.  The  patient  may  become  uncon- 
scious or  delirious,  or  consciousness  may  be  retained  up  to 
the  time  of  death.  There  is  often  present  an  edema  of  the 
occipital  region  extending  down  the  neck,  which  is  caused 
by  an  obstruction  of  the  occipital  and  mastoid  veins,  and  by 
phlebitis  of  the  same  vessels.  This  is  known  as  Grie- 
singer's  symptom,  and  when  present  is  significant.  Pain 
and  pressure  a  ong  the  course  of  the  internal  jugular  vein, 
and  on  the  upper  third  of  the  posterior  cervical  triangle  can 
often  be  elicited.  Comparison  of  the  two  sides  as  to  the  de- 
gree of  pain  produced  by  pressure  will  often  give  valuable 
information  when  in  doubt  as  to  the  condition  of  the  sinuses. 
The  most  serious  stage  of  the  disease  is  that  of  the  breaking 
down  of  the  thrombus,  at  which  time  metastasis  occurs.  The 
writer  closes  with  a  detailed  account  of  the  technic  of  the 
operation,    [t.l  c] 

5. — Beaman  Douglass  reports  several  caaea  of  emphy- 
sema of  the  eyelid  from  nasal  causes.  The  condition 
often  results  after  a  Bowman  operation  and  the  question  then 
sometimes  arises  whether  the  aurgeon  is  at  fault.  The  con- 
dition may  occur  from  any  wound  from  the  lachrymal  duct 
as  well  as  from  disease  when  the  wall  of  the  lachrymal  duct 
haa  been  weakened.  In  an  operation  upon  the  lachrymal 
duct,  if  the  wall  of  the  duct  ia  incised  to  such  an  extent  as  to 
permit  a  deep  introduction  of  the  knife  into  the  wall,  the 
cellular  tissue  around  the  upper  wall  of  the  duct  is  cut.  If 
the  patient  subsequently  blows  his  nose  a  rise  of  pressure 
causes  air  to  be  forced  through  the  incision  into  the  cellular 
tissue  and  into  the  wall  of  the  eyelid.  In  operating  the  author 
advises  the  following  precautions :  Avoid  as  much  as  possible 
the  use  of  the  curet,  never  amputate  any  part  of  the  middle 
turbinate  during  an  ethmoid  operation,  as  it  subsequently  can 
be  removed  if  neceaaary.     [m.r.d.] 


Medical  Record. 

March  23, 1901.     [Vol.  59,  No.  12.] 

1.  1.  A  Case  of  Ambulatory  Typhoid  Fever  with  Intestinal 

Perforation.    2.  A  Case  of  Traumatic  Rupture  of  the 
Intestine  ;  Operation  ;  Recoveries.    A.  A.  Berg. 

2.  Chronic  Gonorrhea  and  Marriage.    Ludwig  Weiss. 

3.  Excision  of  Aneurysm,  with  the  Report  of  Two  Cases  of 

Femoral  Aneurysm    so  Treated.      George  Ryeeson 
Fowler. 

4.  Conpervatism  in  the  Diagnosis  and  Treatment  of  Proatatic 

Hypertrophy.    James  R.  Hayden. 

5.  Subphrenic  Abscesa  as  a  Complication   of  Appendicitis. 

J.  McF.  Gaston,  Jr. 

6.  Surgical  Treatpient  of  Abdominal  Dropsy  Following  Cir- 

rhosis of  the  Liver.    James  T.  Jelks. 

1. — A,  A.  Berg  reports  a  case  of  ambulatory  typhoid 
fever  with  intestinal  perforation,  and  case  of  trau- 
matic rupture  of  the  intestine  in  which  oper- 
ation was  performed,  and  both  recovered.    The    writer 


has  carefully  studied  the  question  of  operation  in  cases  of 
typhoid  fever  with  intestinal  perforation.  His  personal  ex- 
perience as  to  how  major  operations  are  borne  by  typhoid 
patients  extends  over  three  cases.  He  concludes  that  the 
early  surgical  intervention  will  show  between  nature's  and 
man's  surgical  efforts  such  a  marked  difference  in  favor  of 
the  latter  that  the  question  of  the  propriety  of  operations  for 
intestinal  perforation  with  extravasation,  occurring  in  the 
case  of  typhoid  fever,  will  very  soon  be  settled  in  favor  of 
operation.  As  to  operation  in  the  preperforative  stage, 
when  our  diagnostic  acumen  will  have  reached  the  highest 
stage  of  development,  and  when  we  are  able  to  foretell  an 
impending  perforation,  operation  will  clearly  be  indicated. 
But  until  then  the  writer  agrees  with  Gushing  that  such 
symptoms  of  a  localized  peritonitis  should  place  the  attend- 
ant upon  his  guard  so  that  the  patient  may  be  kept  abso- 
lutely quiet,  and  tubs  omitted,  especially  if  they  are  dis- 
agreeable and  resisted.  The  necessity  of  calling  in  a  surgeon 
in  this  stage  of  the  course  of  the  fever  is  urgent.  Tae  aymp- 
toma  of  the  preperforative  atage  are  local  rigidity  of  the 
abdominal  wall,  usually  an  increased  leukocytosis,  local  pain 
and  tenderness  of  the  abdomen,  possibly  nausea  and  vomit- 
ing, possibly  an  increased  rise  in  the  pulse  and  temperature. 
The  symptoms  of  the  perforative  stage  depend  in  almost  all 
cases  upon  the  extravasation  of  the  cavity  into  the  peritoneal 
cavity.  With  those  rare  exceptions  in  which  a  large  blood- 
vessel of  the  intestine  is  eroded  by  the  ulcer  and  in  which 
the  signs  of  internal  hemorrhage  are  constantly  present, 
the  perforation  per  se  does  not  give  rise  to  any  symptoms. 
If,  however,  the  perforation  is  large,  permitting  of  extensive 
extravasation,  the  reflex  symptoms  of  shock  will  be  very 
marked.  They  are  collapse,  fall  of  temperature,  cold, 
clammy  skin,  rapid  feeble  pulse.  The  author  concludes  that 
it  is  of  the  utmost  importance  to  examine  the  abdomen  fre- 
quently for  evidence  of  local  rigidity  and  to  make  examina- 
tions of  the  blood  every  24  to  48  hours.  In  patients  with  a 
distinct  preperforative  stage  the  sudden  appearance  of  symp- 
toms of  shock  when  present  clearly  indicates  perforation 
with  extravasation.  In  those  patients  with  a  distinct  pre- 
perforative stage,  a  decreasing  leukocytosis  and  increasing 
abdominal  rigidity  with  or  without  the  previous  signs  of  col- 
lapse demand  immediate  surgical  interference.  The  author 
recommends  a  general  anesthetic  in  those  cases  in  which  it 
can  be  borne.  The  existence  of  typhoid  fever  does  not 
counterindicate  an  operation.  The  repair  of  the  ruptured 
typhoid  ulcer  should  be  undertaken  as  soon  after  the  perfora- 
tion as  the  patient  can  stand  the  necessary  laparotomy  and 
possible  eventration.  Operation  in  the  preperforative  stage 
is  not  to  be  considered.  Extravasation  can  usually  be  early 
diagnosed  if  strict  attention  is  paid  to  the  recognition  of  ita 
symptomatology-,     [t.l.c] 

2. — Ludwig  Weiss  discusses  the  familiar  question  of 
chronic  gonorrhea  and  marriage,  and  he  concludes  that 
we  should  only  give  permission  to  marry  to  those  who  have 
had  gonorrhea  when  after  repeated  and  careful  microscopical 
examination  of  elide  specimens  and  an  exhaustive  bacterio- 
logical and  microscopical  investigation  of  the  threads  and  of 
the  secretions  of  the  prostate  and  seminal  vesicles  done  under 
the  strictest  rules  and  with  the  aid  of  Graham's  method  the 
presence  of  gonococci  cannot  be  demonstrated,    [t.c.l.] 

3. — George  R  Fowler  reports  two  cases  of  femoral  an- 
eurysm treated  hy  excision.  By  means  of  this  opera- 
tion the  vessel  is  ligated  at  its  end  instead  of  in  its  continuity, 
and  by  the  process  of  ablation  of  the  sac  and  the  adj  lining 
portions  of  the  vessel  provision  is  made  against  the  two  moat 
active  factors  concerned  in  the  relapse,  namely,  the  existence 
of  the  portion  of  the  diseased  or  injured  vessel  and  the  pres- 
ence of  one  or  more  branches  concerned  in  the  recurrent  cir- 
culation. One  of  the  old-time  dangers  following  ligation  for 
aneurysm,  namely,  inflammaiory  suppuration  of  the  sac  and 
its  consequent  rupture  with  hemorrhage  from  collateral 
branches ;  following  displacement  of  the  clots  at  their  points 
of  communication  with  the  sac,  is  rendered  impossible  by 
this  operation.  His  first  case  made  a  good  recovery  and 
3  years  after  the  last  operation  has  experience!  no  trouble. 
In  the  second  case  everything  went  on  well  until  the  end  of 
the  second  day,  when  pulmonary  congestion  followed  by  a 
rapid  edema  terminated  the  patient's  life,    [t.l.c  ] 

4.— James  R.  Hayden  discusses  conservatism  in  the 
diagnosis  and  treatment  of  prostatic  hypertrophy.  He 
has  been  very  forcibly  impressed  by  the  following  facts :  A 


604 


The  Philadelphia"! 

AL  J 


Medical  Journal 


THE  LATEST  LITERATURE 


[H&BCU  30,  1901 


large  number  of  patients  now  being  operated  upon  whose 
symptoms  judging  from  their  recorded  histories,  hardly 
warrant  such  heroic  methods,  especially  in  these  days  of 
improved  technic,  as  to  catheterization  and  urethrovesical 
irrigation  as  well  as  internal  medication,  improved  soft 
rubber  and  woven  catheters  and  the  employment  of  local 
treatment  to  the  prostate  by  way  of  the  rectal  route.  Hay- 
den  points  out  the  fact  that  in  a  large  number  of  these  cases 
of  prostatic  hypertrophy  there  is  considerable  pos- 
terior urethritis,  compressor  spasm,  urethrocystitis 
and  true  prostatitis,  with  temporary  swelling  ot  the  gland, 
and  in  these  conditions  much  can  be  done  in  the  way  of 
palliative  treatment.  In  those  cases  in  which  operative 
treatment  is  demanded  the  writer  believes  that  the  most 
satisfactory  method  is  the  partial  or  complete  removal  of  the 
gland,  either  by  the  suprapubic,  or  by  the  peroneal  route,  or 
by  a  combination  of  these  methods.  He  does  not  believe 
that  the  Bottini  operation  will  give  as  immediate  and 
free  vesical  drainage  as  does  prostatectomy,  which  is  a  strong 
argument  against  its  general  adoption.  Castration, 
vasectomy  and  lig^ation  of  the  internal  iliac  arteries 
are  not  to  be  recommended,    [t.l  c] 

5. — J.  McF.  CJaston  has  coilectea  a  number  of  cases  of 
subphrenic  abscess  as  a  complication  of  appen- 
dicitis, and  reports  a  case  of  his  own  in  detail.  This  com- 
plication is  a  very  rare  one.  Many  of  the  cases — there  are 
some  45  collected — were  not  diagnosed  until  after  the  death 
of  the  patient.  Pathological  examination  has  shown  that  these 
cases  may  be  extraperitoneal  or  intraperitoneal.  Gaston's 
case  had  its  onset  on  the  first  of  June,  when  operation  was 
performed.    The  recovery  was  complete  on  July  31.     [t.lc] 

6. — James  J.  Jelks  discusses  the  surgical  treatment  of 
abdominal  dropsy  following  cirrhosis  of  the  liver. 
The  operation  consists  of  abdominal  section  preferably  between 
the  umbilicus  and  ensiform  cartilage,  evacuation  of  the  accu- 
mulation of  fluid,  and  scraping  of  the  parietal  peritoneum  with 
a  curette  or  rubbing  off  the  epithelium  with  a  gauze  sponge. 
The  superior  surface  of  the  liver  and  the  peritoneum  cover- 
ing the  diaphragm  are  also  to  be  rubbed.  The  omentum  for 
3  or  4  inches  around  the  incision  is  then  to  be  stitched  to  the 
parietal  wall.  It  is  also  included  in  the  sutures  which  close 
the  abdominal  incision.  Thus  a  broad  surface  is  presented 
for  adhesions,  and  it  is  this  additional  collateral  circulation 
which  has  saved  the  patient  operated  upon.  It  is  frequently 
necessary  to  tap  these  patients  several  times  after  operation, 
before  the  collateral  circulation  is  complete.  The  writer  be- 
lieves that  all  well-attested  cases  of  cirrhosis  pre- 
senting: ascites  should  be  operated  upon,  and  local  anes- 
thesia is  recommended.  He  reproduces  Frazier's  table  of  15 
cases,  his  own  being  the  fifteenth  in  the  table.  Three  of 
these  cases  died  within  2  weeks  of  the  operation,  1  from  con- 
tracted kidneys,  1  from  septic  peritonitis,  and  1  from  delirium 
tremens,  who  while  delirious  tore  off  the  dressings  and  in- 
fected the  wound.  In  discussing  I  he  results  of  the  operations 
from  Frazier's  tables  he  shows  that  75^  of  recoveries  has 
taken  place,    [t.l.c  ] 

Medical  News. 

March  S3,  1901.     [Vol.  Ixxviii,  No.  12.] 

1.  Retrospects  and   Prospects    in    Qenitj  Urinary    Sargery. 

Reginald  Harrison. 

2.  Cerebrospinal  Meningitis  ( Weiohselbaum,  Jaeeer)  Treated 

by  Repeated  Lumbar  Puncture.     Henry  Koplik. 

3.  Drainage  in  Abdominal  Surgery.    J.  W.  Long. 

4.  Veriigo;  A  Stomach  Lesion.   "Martin  A.  H.  THELnERG. 

1. — Harrison  mentions  in  his  article  on  retrospects 
and  prospects  in  ^enito-urinary  surgery  some  of 
the  prominent  features  in  the  progress  of  genito-uriuary  sur- 
gery: (1)  litholapaxv,  (2)  Otis'  urethrometry,  (3)  etiology  of 
vesical  calculus;  (4)  prostatic  hypertrophy;  (5)  surgery  of 
kiduey.  In  prostatic  enlargement  he  mentions  3  forms:  (1) 
the  simple  enlarged  prostate  which  bulges  upward  and  back- 
ward into  the  bladder,  more  generally  cured  than  any  other 
form  by  castration,  vasectomy,  or  by  the  Bottini  operation;  (2) 
a  form  in  which  a  tongue  of  prostatic  tissue,  or  a  median  lobe 
of  the  prostata,  is  the  active  agency  that  interferes  with  the 
emptying  of  the  bladder.  C.istration  and  vasectomy,  as  a 
rule,  do  no  good.  The  median  tongue  of  tissue  must  be  re- 
moved ;  (3)  that  form  in  which  there  occur  in  the  midst  of 


the  enlarged  prostate  hard  glandular  growths.  Gistration 
and  vasectomy  always  fail,  and  also  does  Bottini's  operation. 
He  also  suggests  that  for  the  condition  of  congestive  tension 
on  the  kidney,  an  aseptic  exploration  with  puncture  of  the 
capsule  might  easily  be  done  without  great  danger  and  that 
this  operation  might  serve  as  a  prophylactic  against  the 
development  of  kidney  disease  in  later  life,     [x  m.t.] 

2. — Koplik  in  his  treatment  of  cerebrospinal  menin- 
gitis by  repeated  lumbar  puncture  gives  the  follow- 
ing facts:  QiiQcke  mettioJ  was  employed  and  from  3  to  50 
cc.  of  the  tiaid  was  withdrawn.  Tae  nuncturej  were  made 
on  5th,  6th,  8th,  9th,  10th,  13th,  16th,  19:h,  24th,  28;h,  36th, 
37th  days  of  the  disease.  The  fluid  withdrawn  on  the  5th 
day  was  turbid;  on  6th,  cloudy;  on  8th,  turbid;  10;h, 
turbid  and  flaky;  13th,  turbid,  thick  and  purulent,  and 
continued  to  ■  be  turbid  up  to  the  37th  day.  This  shows 
that  there  may  be  marked  exudate  even  at  an  early  period, 
and  later  puncture  after  chill  may  give  a  turbid,  flaky,  or 
even  purulent-looking  fluid.  Councilman  found  in  his  ex- 
amination that  a  diminution  of  turbidity  went  often  hand  in 
hand  with  absence  of  microorganisms.  In  Koplik's  cases 
microorganisms  were  found  in  turbid,  opalescent  and  less 
turbid  fluids,  and  that  also  microorganisms  grew  in  turbid 
fluids.  In  opalescent  or  clear  fluids  they  were  found  by 
staining  and  sometimes  were  absent  by  culture.  Only  in 
one  of  his  cases  were  the  microorganisms  absent  by  culture. 
On  the  other  hand,  they  were  positive  in  all  stained  speci- 
mens except  one  and  in  this  the  culture  showed  the  diplo- 
coccus.  It  seems  to  Koplik  that  the  difficulty  of  culture  is 
rather  the  obstacle  to  a  positive  result,  in  some  cases,  than 
the  abundance  of  microorganisms.  In  reviewing  the  treat- 
ment by  the  puncture,  he  found  that  such  symptoms  as 
persistent  headache,  somnolence,  coma,  delirium,  and  con- 
vulsions due  to  an  accumulation  of  fluid  in  and  about  the 
brain  and  cord,  and  to  a  certain  amount  of  toxemia  result- 
ing from  the  absorption  of  inflimmatory  products,  were 
relieved  for  a  time,  at  least.  The  puncture  was  carried  out 
with  antiseptic  precaution,  most  of  the  patients  receiving 
three  punctures,  although  in  one  more  were  given.  The 
operation  was  only  performed  when  symptoms  of  pressure 
or  accumulation  of  exudate  appeared,  and  the  procedure  was 
only  repeated  if  there  was  an  exacerbation  of  the  symptoms. 
If  there  was  continued  improvement,  the  patient  waa  not 
disturbed,  and  by  this  method  no  harmful  results  appeared. 
There  seemed  to  be  no  marked  effect  on  the  pulee  and  res- 
piration, even  if  a  considerable  amount  of  fluid  waa  with- 
drawn,    [t  M.T.] 

3 In  drainage  in  abdominal  surgery  Long  states: 

(1)  Objects  of  drainage  ;  (2)  objections  to  drainage.  Drainage 
is  employed  (a)  to  dram  away  existing  septic  material;  (6) 
to  afford  an  exit  for  the  sepsis  wtien  the  operator  fears  thai 
he  has  possibly  infected  his  patient ;  (c)  to  provoke  adhe- 
sions and  thereby  wall  off  weak  spDts  from  the  remainder  of 
the  abdominal  contents ;  (d)  to  keep  the  peritoneal  cavity 
free  of  blood  and  other  fluids ;  (e)  to  allow  of  a  more  certain 
knowledge  of  the  conditions  present  in  the  abdomen ;  (/) 
gauze  drains  are  sometimes  employed  as  tampons  to  control 
hemorrhage.  The  objections  are  (a)  it  is  deceptive  ;  (6)  cases 
not  drained  do  better  ;  (t)  drainage  is  neither  scientific  nor 
workmanlike,     [t  m  t.] 

4. — Thelberg  believes  that  vertigo  is  brought  about  by 
either  or  all  of  the  following  cause* :  1.  Reflexly  through 
direct  irritation  of  the  gastric  branches  of  the  pneumogastric 
and  thence  by  the  lower  cervical  ganglion  to  the  vasomotor 
nerves  of  the  vertebral  artery  winch  supplies  the  internal 
ear.  2.  By  toxemia  from  amnion  and  other  ptomaines, 
nicotin,  alcohol,  reabsorption,  etc.  3.  By  direct  pressure 
upon  the  heart  through  distention  of  the  stomach  and  intes- 
tines by  gases,  resulting  principally  from  so-called  amylace- 
ous indigestion  and  hyperchylia.  Treatment,  administration 
of  a  glass  or  two  of  hot  water  half  an  hour  before  meals,  and 
some  sodium  bicarbonate  before  breakfast,  and  3  to  5  grains 
of  diastase  with  each  meal,  combined  with  strychnin,  ,\,  to  ^  j 
grain,  and  in  some  instances  a  pepsin  ferment,     [t  m  t  ] 


Boston  Medical  and  Surgical  Jouroal. 

March  SI,  1901.    [Vol.  cxliv,  No.  12.] 

1.  Piierpersl  Iu>anity.     .Arthur  C.  Jfu.y. 

2.  Meat  Rstions  in  the  Tropics.     P.  R.  Egan. 


ILiBCH  SO,  1901] 


THE  LATEST  LITERATURE 


FThe  Philadelphia 
L  Mbdical  Journal 


605 


3.  Bubonic  Plague.  Report  on  the  Plague  in  Manila,  P.  I.> 
from  January  1,  1900  to  June  30,  1900.  Joseph  J- 
Curry. 

1. — Two  hundred  and  fifty  cases  of  puerperal  insanity 

were  found  on  the  records  of  the  Institution's  Registration 
Depirtment  of  Boston,  between  1872  and  1900.  Jelly  excluded 
50  of  these,  so  that  200  cases  remained  in  which  the  puer- 
peral state  was  the  alleged  cause  of  the  insanity  and  in  which 
the  hospital  records  were  at  the  disposal  of  the  author. 
From  an  etiologic  standpoint  the  cases  may  be  di^^ded  into 
2  groups:  (1)  those  in  which  the  puerperal  condition  ap- 
peared to  be  the  sole  cause  of  the  insanity,  and  (2)  those  in 
which  the  preparations  were  already  made  and  in  which  the 
puerperal  state  opened  the  door.  Heredity  is  the  great  pre- 
disposing cause,  although  tuberculosis,  alcoholism,  epilepsy, 
hysteria,  grief,  fright,  worry,  domestic  unhappiness,  ille- 
gitimacy, sepsis,  autointoxication,  or  several  of  these  com- 
bined, play  important  parts  in  the  etiology  of  the  disease. 
In  cases  of  graidual  onset  the  first  symptoms  noted  are  a 
change  of  manner,  so  that  the  patient  becomes  somewhat  in- 
different and  neglectful  of  the  child  and  of  her  household 
duties.  She  grows  reticent  and  her  face  shows  a  peculiar 
expression  cf  watchfulness,  as  if  she  were  anxious  and  yet 
unwilling  to  reveal  her  state  of  mind.  Loss  of  appetite  and 
inability  to  sleep  occur  early.  Later,  a  patient  may  be  con- 
fused, suspicious,  resistive,  depressed  or,  less  often,  excited; 
frequently  she  has  impulses  to  suicide,  or  she  makes  attempts 
at  suicide  in  an  impulsive  way ;  less  often,  impulses  or 
attempts  to  injure  the  child  are  recorded.  Hallucinations 
occur  and  distressing  delusions  are  also  recorded,  which  are 
frequently  concerned  with  religion.  After  a  short  period 
many  of  the  most  eicited  cases  become  comparatively  quiel 
and  no  longer  suffer  from  hallucinations  and  delusions. 
Many  septic  caees  are  of  short  duration  and  end  in  death. 
Others  improve  after  removal  of  the  source  of  sepsis.  Some 
cases  of  exhaustion  live  only  a  few  days.  Thirty  patients 
had  more  than  one  attack.  The  prognosis  as  to  life  is  very 
good.  Of  the  200  eases  studied,  13  died  in  the  first  attack 
and  3  in  the  second  ;  of  the  chronic  cases,  14.  The  return 
of  menstruation  is  a  good  sign,  not  because  it  in  any  way 
leads  to  recovery,  but  because  it  indicates  a  return  to  the 
normal  condition  on  the  part  of  the  bodily  functions. 
Recovery  once  well  started  usually  progresses  steadily. 
When  the  physician  has  reason  to  suspect  the  existence 
of  conditions  favorable  to  the  development  of  insanity, 
he  should  instruct  the  patient  to  establish  the  most  per- 
fect hygiene  possible  in  her  home  during  her  pregnancy, 
and  if  danger  signals,  pointing  to  instability,  appear  at 
any  time,  he  should  at  once  seek  to  remove  the  cause  if 
possible,  and  endeavor  in  every  suitable  way  to  restore  the 
balance.  Special  attention  should  be  paid  to  the  digestive 
and  eliminative  functions ;  exercise  in  the  open  air  should  be 
ordered  ;  excitement  should  be  avoided ;  and  sources  of  an- 
noyance should  be  removed.  When  mental  disturbance 
appears  after  delivery  wait  until  it  is  clear  that  the  patient 
is  suffering  from  something  more  than  a  mere  temporary 
affair  before  deciding  the  question  whether  she  shall  remain 
at  home  or  be  sent  away  for  treatment.  In  cases  of  profound 
sepsis  or  rapidly  progressive  exhaustion,  death  is  liable  to 
occur  within  a  few  days  and  it  is  especially  unfortunate  to 
remove  such  a  patient  to  an  insane  hospital  and  have  her  die 
there  in  24  hours.  It  is  usually  desirable  and  frequently 
necessary  to  separate  the  mother  and  child  because  of  danger 
to  the  latter.  Measures  should  be  taken  to  prevent  suicide, 
to  maintain  strength,  to  improve  nutrition,  and  to  insure 
sleep.  It  is  usually  necessary  to  give  more  or  less  alcohol. 
Hjpnotics  should  be  used  freely  if  necessary  and  close  at- 
tention should  be  paid  to  the  functions  of  the  bladder  and 
the  rectum.  In  the  treatment  of  lactational  cases  nursing 
should  be  stopped  and  the  attending  debility  and  anemia 
should  receive  proper  treatment,     [j.m  s  ] 

<S, — Dr.  E»an's  paper  on  the  meat- ration  iu  the 
tropics,  is  a  ciiticism  of  the  statements  made  by  certain 
army  surgeons,  that  the  soldier  in  the  tropics  should  have 
the  amount  of  fat  and  proteid  in  his  diet  reduced,    [j.m.s.] 

3. — For  an  early  diagnosis  of  bubonic  plague  the  most 
satisfactory  method  is  that  of  aspiration  of  one  of  the  recent 
swollen  glands  by  means  of  a  hypodermic  syringe.  With 
the  material  in  the  syringe  :  1.  A  drop  is  used  to  make  cult 
ture  in  melted  agar  tubes  or  in  bouillon  from  which  dilu 


tions,  cultures,  and  plates  can  be  made.  2.  A  drop  is 
allowed  to  fall  on  a  slide,  which  is  then  smeared  by  a  plati- 
num needle,  to  be  used  for  direct  examination.  3.  The  re- 
mainder is  injected  into  a  mouse  or  a  rat.  If  examination 
of  the  specimens  on  the  glass  slides  shows  the  presence  of 
large  numbers  of  characteristic,  short,  bipolar  staining  bacilli, 
that  decolorize  by  Gram's  method,  the  case  at  once  becomes 
more  than  suspicious.  By  the  second  day  the  inoculated 
animal  is  either  dead  or  very  ill,  and  an  absolute  diagnosis 
can  be  made.  In  every  instance  in  which  the  direct  cover- 
slip  examination  showed  large  numbers  of  short  thick  bacilli 
that  decolorized  by  Gram,  the  subsequent  history  of  the  case, 
the  cultures,  and  the  inoculations  of  animals  proved  the  case 
to  be  one  of  bubonic  plague.  In  some  cases  bubonic  plague 
is  ushered  in  by  a  sudden  chill,  and  this  onset  is  followed  by 
a  fever  closely  simulating  a  malarial  attack.  If  the  examina- 
tion of  the  blood  in  such  cases  fails  to  reveal  the  malarial 
parasite,  but  does  show  an  early  and  marked  leukocytosis, 
suspicion  of  a  septic  process  of  some  kind  should  be  aroused 
and  the  observer  should  look  carefully  for  the  cause  of  the  leu- 
kocytosis. From  January  1  to  June  30, 1900,  in  Manila,  there 
were  225  cases  of  bubonic  plague  with  167  deaths,  a  mortality 
of  74% .  The  right  femoral  and  the  right  inguinal  glands  were 
the  first  glands  to  enlarge  in  considerably  over  one-half  of  all 
cases.  It  was  unusual  to  be  able  to  locate  any  fresh  wounds  of 
the  extremity  which  appeared  to  be  the  point  of  entry  of  the 
infection.  It  was  very  common,  however,  to  find  skin 
lesions  involving  legs  and  thighs.  There  is  the  possibility  of 
introduction  of  the  plague  bacilli  through  infection  of  these 
areas  in  which  the  epidermis  is  broken  :  as  most  people  are 
right-handed,  it  may  be  possible  that  they  are  more  inclined 
to  scratch  the  right  thigh  than  the  left.  Almost  all  cases  of 
plague  which  came  to  autopsy  showed  evidence  of  bites  by 
fleas  and  mosquitoes.  It  does  not  seem  probable,  however, 
that  mosquitoes  play  any  part  in  the  dissemination  of 
plague.  Objection  has  been  made  by  some  to  the  puncture 
of  a  plague  gland  with  the  hypodermic  needle.  These  ob- 
servers claim  that  there  is  danger  of  infection  by  this  method 
from  rupture  or  injury  of  a  bloodvessel  which  would  allow 
the  plague  bacilli  to  enter  the  vessel  and  by  it  to  enter  the  gen- 
eral circulation.  Cuiry  thinks  that  this  objection  to  the  use 
of  the  aspiration  method  for  diagnostic  purposes  is  based 
more  on  theoretic  than  on  practical  grounds.  He  believes 
it  is  much  safer  for  both  the  patient  and  the  operator  than 
the  incision  method  advocated  by  some,    [j.m.s.] 


Journal  of  the  American  Medical  Association. 

March  S3, 1901.    [Vol.  xxxvi.  No.  12.] 

1.  Elbow  Fractures  and  the  X-Riys.    W.  W.  Geast. 

2.  General  Bodily  Resistance  as  a  Factor  in  Nose  and  Throat 

Disease.    Frank  Lewis  Stlllman. 
S.  Systemic  Factors  in  Catarrhal  Deafness.      Sargent  E. 
Snow. 

4.  Diagnosis  and  Prognosis   of   the    Ear  Disease.    Alex. 

Randall. 

5.  Effects  of  Alcohol  on  the  Nervous  System,  the  Mind  and 

Heredity.    Albert  E.  Sternt:. 

6.  A  Case  of  Combined  Gastric  and  Aural  Vertigo,  with  a 

Discussion  of  the  Pathology  of  such  Cases.    J.  W. 
McCaskey. 

7.  Heart  Tonics.    John  N.  Upshub. 

8.  The  Therapeutic  Application  of  the  Organic  Extracts. 

0.  T.  Osborne. 

9.  Treatment  of  Addison's  Disease.    With  Case.    John  V. 

Shoemaker. 

10.  Quantitative  Tests  for  Proteolysis.    A.  L.  Benedict. 

11.  Anastomosis  of  the  Ureters  with  the  Intestines.     A  His- 

torical and  Experimental  Research.    Reuben  Petbr- 

SON. 

1.— Grant  reports  several  cases  of  fracture  at  the  elbow- 
joint  illustrated  by  x-ray  pictures.  These  cases  were  all 
treated  in  the  flexed  position,  which  he  thinks  gives  better 
results  than  in  the  extended  position  as  recommended  by 
Allis  and  Roberts.  His  article  is  illustrated  by  x-ray  pictures 
of  fractures  occurring  in  other  parts  of  the  body,  showmg 
marked  deformity,  and  yet  the  patients  exhibited  the  most 
excellent  functional  results.  In  discussing  the  x-rays  Grant 
calls  attention  to  the  great  misconception  which  can  be  had 


606 


Thk  Philadelphia"] 
Medical  Jocbnal  J 


THE  LATEST  LITERATURE 


[SIaecb  30,  1901 


from  examining  skiagraphs  of  the  injured  part  taken  in  dif- 
ferent positions  and  by  different  operators.  He  thinks  that 
it  is  a  mistake  to  give  the  x-rays  the  prominent  place  which 
some  have  given  them  as  a  diagnostic  and  prognostic 
measure,    [j  h  g.] 

2. — Stillman  discusses  general  bodily  resistance  as 
a  factor  in  nose  and  throat  diseases.  As  the  cases 
coming  to  the  specialist  are  usually  chronic,  the  object  of  the 
treatment  is  to  remove  the  effect  of  the  long-standing  patho- 
logical action.  The  author  makes  a  plea  for  more  constant 
study  of  the  history  of  the  patient  in  regard  to  the  &mily 
history,  the  previous  and  personal  history,  and  the  mode  of 
life  of  the  patient  and  the  environments,  as  well  as  the  mani- 
festations of  the  local  disease.  In  order  to  properly  advise 
and  institute  treatment,  the  specialist  should  always  remem- 
ber that  he  is  a  physician  first  and  a  specialist  afterwards. 
[f.j  k.] 

3.— Regarding  the  systemic  factor  as  the  cause  of 
catarrhal  deafness.  Snow  states  that  particular  stress 
should  be  laid  upon  the  following  conditions :  (1)  Sluggish 
reaction  of  the  skin ;  (2)  low  vital  resisting  powers ;  (3) 
torpid  liver ;  and  (4)  improper  exercise.  For  the  sluggish 
reaction  of  the  skin,  which  plays  an  important  part  in  the 
etiology  of  catarrhal  deafness,  he  recommends  cold  baths 
and  friction.  The  problem  of  avoiding  frequent  colds,  the 
author  believes,  is  not  to  be  solved  by  the  excessive 
amount  of  clothing,  but  in  stimulating  the  skin  to  proper 
and  rapid  reaction ;  lack  of  exercise,  torpid  liver,  and  diges- 
tive disorders  also  assist  in  the  causations  of  catarrhal  deaf- 
ness. Many  causes  or  conditions  of  causes  participate  in  the 
production  of  this  condition  ;  therefore,  the  specialist  should 
not  only  be  well  trained  in  the  diagnosis  of  diseases  of  the 
nose,  throat,  and  ear,  but  he  should  also  have  had  a  training 
as  a  general  practitioner.  Snow  states  that  the  prognosis 
should  depend  largely  upon  the  physical  condition  of  the 
patient  and  the  ability  to  have  skillful  attention.  While  the 
surgical  treatment  is  important,  it  is  no  more  so  than  the 
proper  attention  to  the  functional  equilibrium,  especially 
after  the  operation,     [f.j.k.] 

4.— Randall  states  that,  in  order  to  come  to  the  proper 
conclusions  as  to  the  diagnosis  and  prognasis  of  the  ear  dis- 
eases, a  detailed  family  history  should  be  obtained  and  the 
following  objective  findings  added  to  the  record:  Ascertain 
the  degree  of  hearing  for  whispered  or  conversational 
speech,  for  the  tuning  forks  (use  the  forks  which  produce  50 
vibrations  per  second,  then  200,  500,  and  2,000)  and  for  the 
Gallon  whistle;  also,  test  the  hearing  with  the  200  fork  by 
bone  conduction  (from  the  nose  and  mastoid  bone) ;  Pol- 
itzer's  test  should  be  performed  in  order  to  determine 
whether  or  not  the  Eustachian  tube  is  patulous,  and  for 
lateralizition  from  the  middle  line ;  finally,  otoscopic  and 
rhinoscopic  examinations  must  be  made  and  the  degree  of 
response  to  inflation  and  pneumatic  maasage  ascertained. 
[fj.k.] 

6.— Stern  mentions  that  the  effect  of  alcohol  upon  the 
nervous  system  is  either  direct  (primary)  or  indirect  (sec- 
ondary). From  a  physiological  or  functional  standpoint  it 
may  be  either  direct  or  indirect,  and  from  a  pathological  or 
structural  view  it  may  also  be  primary  or  secondary.  The 
author  refers  to  a  paper  of  Dehio,  who  has  shown  that  acute 
alcoholism  produces  a  diminution  in  the  chromophilic  gran- 
ules of  the  nfrve  cells  of  the  cerebral  cortex,  of  the  large 
multipolar  cells  of  the  spinal  gray  matter,  and  of  the  Pur- 
kirje  cells  of  the  cerebellum.  Mention  is  made  of  a  case 
which  may  bear  relation  to  the  observations  of  Dehio ;  this 
case  was  that  of  a  lad  aged  19,  a  farmer  by  occupation.  The 
symptoms  developed  a  year  after  he  began  the  use  of  alco- 
holic beverages.  The  symptoms  consisted  of  peculiar  spas- 
modic seizures,  which  were  motor  in  character  and  increased 
in  frequency  as  the  disease  progressed.  When  the  disease 
was  at  its  height,  the  seizures  occurred  every  few  minutes 
and  involved  the  greater  portion  of  the  body.  Voluntary 
movements,  however,  were  not  markedly  aflTected  during  the 
attacks.  The  deep  tendon  reflexes  were  somewhat  exagger- 
ated. After  9  weeks  of  treatment  the  patient  recovered; 
the  seizures  gradually  decreased  in  frequency  and  intensity 
and  finally  ceased  altogether.  The  etiological  factor  was 
apparently  alcohol.  The  changes  of  the  nervous  system, 
caused  by  chronic  alcoholism,  are  secondary  and  depend 
upon  vascular  derangements.  The  author  states  that  the 
chronic  use  of  alcohol  is  a  most  important,  constant  con- 


tributing factor  of  bloodvessel  diseases.  The  author  hae 
long  held  the  view  that  chronic  alcoholism  never  develops 
unless  a  neurotic  basis  previously  exists.  He  emphasizes 
the  fact  that  the  alcohol  habit  is  a  great  social  evil,  [f.j  z.] 
6, — McCaskey  reports  a  case  of  combined  gastric  and 
aural  vertigo.  He  concludes  that,  from  the  clinical  point  of 
view,  the  stomach  must  be  regarded  as  a  necessary  cause  in 
the  reported  case.  He  has  observed  several  hundred  cases 
of  chronic  gastric  diseases,  in  which  vertigo  was  a  symptom. 

[f  J.K.] 

7. — Upshur  discusses  heart- tonics  in  the  broadest  sense, 
from  the  standpoint  of  the  clinician  and  therapeutist,  rather 
than  from  a  technical  ground  of  physiological  action.  Heart- 
tonics  are  defined  as  remedies  having  power  to  regulate  the 
action  of  the  heart,  whether  due  to  functional  or  organic 
irregularities,  or  to  that  modification  of  its  condition  which 
produces  a  source  of  discomfort  and  danger  to  the  patient. 
In  dealing  with  the  therapeutic  value  of  digitalis,  he  empha- 
sizes that  this  remedy  in  mitral  stenosis  is  of  transient  bene- 
fit, and  ultimately  may  be  harmful  in  its  results.  In  fatty 
heart,  the  danger  of  rupture  of  the  cardiac  wall  is  increased 
by  its  administration ;  its  use  is  contraindicated  in  fevers, 
septicemia,  and  similar  conditions;  the  pulse  tension  in 
pneumonia  is  not  increased  by  digitalis.  He  refers  to  the 
clangers  which  follow  its  use  in  aortic  insufiiciency  for 
reason  of  prolongation  of  the  diastole,  and  the  danger  of 
rupture  of  the  heart  in  aortic  stenosis  for  reason  of  more 
forcible  contraction  of  the  ventricle  during  systole.  Mention 
is  made  of  the  advantage  of  convallaria  over  digitalis,  but 
the  latter  drug  is  more  powerful  and  more  reliable  in  its 
action.  The  slow  elimination  of  spartein  and  for  reasan  of 
ita  true  stimulating  action  upon  the  cardiac  muscle,  makes 
it  a  reliable  drug  in  the  treatment  of  weak,  flabby  heart-  walla. 
SirophanthuB  combined  with  strychnia  is  of  value  in  the 
threatened  heart-failure  of  enteric  fever.  The  greatest  bene- 
fit of  atropin  is  found  in  tiding  a  patient  over  an  emergency, 
such  as  sudden  collapse,  or  threatened  heart-failure ;  this 
drug  should  be  combined  with  strychnia ;  he  recommends 
caffein  for  the  dropsy  due  to  pEU-enchymatous  nephritis, 
associated  with  heart  involvement.  Strychnia  is  placed  at 
the  head  of  heart  tonics,  its  usefulness  is  especially  mani- 
fested in  the  enfeebled  heart  of  enteric  fever,  of  pneumonia 
and  of  septicemia ;  nitroglycerin  is  indicated  for  angina- 
pectoris  (true  or  pseudo).  It  is  contraindicated  in  the  en- 
feebled heart  due  to  septicemia  and  surgical  shock.  Under 
some  circumstances,  opium  is  a  heart  tonic.  He  mentions 
as  an  example  the  coma  vigil  of  enteric  fever,  the  aspect  of 
the  case  may  be  greatly  changed  and  a  favorable  termina- 
tion depend  upon  the  use  of  this  drug,    [f  j.k.] 

8. — Oibome  reviews  some  of  the  literature  pertaining  to 
organotherapy.  He  mentions  the  therapeutic  indications  for 
thyroid  extract,  thymus  extract,  pituitary  extract  and  supra- 
renal extract.  The  important  use  of  thyroid  extract  is  found 
in  the  treatment  of  myxedema ;  it  is  contraindicated  in 
Graves'  disease,  unless  the  patient  is  apathetic,  sleepy,  does 
not  complain  of  headache  and  is  gaining  weight  Mention 
is  made  of  its  value  in  obesity,  and  such  skin  diseases  as  dry 
eczema  or  psoriasis.  Thyroid  extract  seems  to  be  indicated 
in  certain  cases  of  melancholia,  in  order  to  prc>duce  cerebral 
stimulation.  The  mental  depression  occurring  at  the  time 
of  menopause  may,  perhaps,  be  benefited  by  ita  administra- 
tion. The  author  has  used  thymus  extract  In  the  treatment 
of  Graves'  disease  and  feels  convinced  of  its  value,  but  that 
it  does  twt  possess  a  curative  action.  Osborne  mentions  that 
it  is  fairly  suppoeable  that  the  administration  of  pituitary 
body  extract  in  akromegaly  can  prevent  the  continued  growth 
of  the  body  and  obviate  some  of  the  symptoms.  Ttie  local 
action  of  suprarenal  extract  is  positive,  but  the  advantages 
derived  by  its  internal  administration  are  as  yet  doubtful. 
In  Addison's  disease  it  should  always  be  tried  for  the  possible 
good  that  might  follow,    [f  j.k.1 

9.— Shoemaker  reports  a  case  of  Addison's  disease  and 
discusses  the  treatment.  He  advises  a  trial  of  suprarenal 
extract  in  all  cases.  Tnere  is  little  hope  in  those  cases  of 
tuberculous  origin ;  in  the  cases  due  to  atrophy,  sclerotic 
or  inflammatory  changes,  if  a  portion  of  the  gland  is  still 
active,  suprarenal  extract  will  probably  be  found  useful. 
[fjk  j 

10. — The  abstract  will  appear  when  the  article  is  com- 
pleted. 

11. — To  be  treated  editorially  when  concluded. 


MlRca  30,  1901] 


THE  LATEST  LITERATURE 


CThb  Philadblphia 
msdical  jodknai. 


607 


University  Medical  Magazine. 

February,  1901. 

1.  Dysentery  (in  the  Tropics) :  Its  Symptomatology,  Compli- 

cations and  Treatment.    B  L.  Wright. 

2.  The  Aggociation  of  Chronic  Jaundice  with  Gastroptosis. 

Report  of  a  Case.    J.  Dqtton  Steele. 

3.  A  Clinical  and  Histological  Study  of  a  Case  of  Melano- 

sarcoma  of  the  Chorioid.    Charles  A.  Oliver. 

4.  A  Note  on  the  Disinfectant  and  Deodorant  Action  of  Am- 

monium Persulphate.     M.   P.   Ravenel  and    S.    M. 

GiLLILAND. 

1. — B.  li.  Wright,  assistant  surgeon  U.  S.  N.,  writing 
from  the  Pnilippines,  furnishes  us  with  a  practical  article 
upon  Tropical  dysentery,  its  symptomatology,  com- 
plications and  treatment.  Dysentery,  as  met  with 
in  the  tropics,  is  epidemic  in  character  and  most  virulent 
in  form.  It  seldom  stops  at  the  catarrhal  stage,  but 
rapidly  passes  to  that  of  ulceration.  If  the  patient  does 
not  die  from  exhaustion  or  complications  the  disease  may 
slowly  progress,  finally  becoming  gangrenous.  Wright 
believes  that  the  cause  is  undoubtedly  introduced  into  the 
intestinal  tract  by  means  of  the  drinking  water,  and  in  sup- 
port of  this  generally  accepted  view  describes  an  outbreak 
which  was  traced  to  neglect  on  the  part  of  the  cooks  to  boil 
the  water  which  had  been  used  after  long  transportation. 
For  several  weeks  in  which  the  water  was  boiled  no  cases 
developed.  Immediately  upon  the  cessation  of  this  precau- 
tion the  outbreaks  occurred,  and  disappeared  upon  the  con- 
dition being  corrected.  Another  similar  outbreak  was  traced 
to  the  contaminated  water.  In  this  case  it  was  found  that 
the  sterilizer,  which  had  been  relied  upon,  was  worthless. 
Dysentery  in  the  Phihppines  begins  usually  with  moderate 
fever,  coated  tongue  and  diarrhea.  The  character  of  the 
watery  stools  changes  in  the  course  of  a  few  days  to  the  mu- 
cous stool  of  the  catarrhal  stage.  At  this  time  griping  pains 
in  the  abdomen  are  prominent.  There  is  tenderness  along 
the  line  of  the  colon,  rectal  tenesmus  and  frequent  nausea. 
The  stools  are  small,  averaging  about  4  grams  in  weight  in 
number  from.  10  to  35  per  day.  Gangrenous  dysentery 
is  but  a  late  etage  of  the  acute  condition.  Wright  calls  par- 
ticular attention  to  the  fact  that  out  of  80  cases  of  dysentery 
observed  3  developed  appendicitis  during  the  fifth  or  sixth 
week  of  the  disease.     [t.l.c.J 

2.— J.  Dutton  Steele  reports  a  case  of  chronic 
jaundice  associated  with  gastroptosis.  When  the 
gastroptosis  was  corrected  by  fitting  the  patient  with  an 
abdominal  support  the  signs  of  gastric  insufficiency  began  to 
disappear  quickly,  and  the  jaundice  also  slowly  disappeared. 
A  study  of  the  literature  reveals  no  report  of  a  case  of  gas- 
troptosis unaccompanied  by  adhesions  in  which  j  iundice 
was  present.  From  a  number  of  experiments  performed 
upon  a  number  of  bodies,  Steele  found  that  while  the  descent 
of  the  pylorus  alone  cannot  produce  obstructive  jaundice, 
if  the  ducts  are  bound  down  by  adhesion  to  the  under  sur- 
face of  the  liver  a  very  moderate  degree  of  traction  produced 
by  a  displaced  pylorus  might  bring  about  such  a  result.  In 
the  case  in  question  Steele  concludes  that  there  were  some 
conditions  causing  a  perihepatitis  or  some  form  of  peri- 
toneal inflammation,  and  that  adhesions  bound  down 
the  common  or  hepatic  ducts  in  such  a  manner  that  the 
apparently  slight  amount  of  traction  from  the  prolapsed 
stomach  caused  kinking,  obstruction  and  jaundice,     [t.l.c] 

3. — Charles  A.  Oliver  reports  a  clinical  and  histological 
study  of  a  case  of  melanosarcoma  of  the  chorioid. 
The  patient  presented  a  nodular  mass  of  the  left  eye  which 
could  be  seen  protruding  between  the  widely  opened  eyelids. 
The  nodule,  which  was  somewhat  mobile,  was  vascular  and 
pigmented.  Its  internal  surface  was  covered  with  numerous 
scabs  beneath  which  bleeding  areas  could  be  exposed.  The 
skin  of  the  lower  lid  was  excoriated  and  excreted  a  thin, 
sauious  fluid.  The  mass  was  painless,  and  the  right  eye  was 
normal  in  every  respect.  The  orbital  contents  were  removed 
and  the  patient  made  uneventful  recovery.  A  very  careful 
microscopic  examination  of  a  large  number  of  sections  from 
the  removed  mass  was  made.  The  preponderance  of  the 
cells  over  the  intercellular  substance,  as  is  usual  in  such 
growths,  the  gross  infiltration  into  the  surrounding  tissues 
and  the  thorough  destruction  of  all  the  soft  ocular  elements 
are  of  the  utmost  importance.    The  long  period  of  time, 


possibly  more  than  26  years  in  this  case,  that  the  growth  had 
been  in  existence  and  the  almost  certain  surety  of  the  failure 
of  extension  or  metastasis  for  a  period  of  more  than  3  years' 
time  after  the  removal  of  the  orbital  mass  are  of  great  im- 
portance in  the  prognosi'i  of  such  an  affection,     [t.lc] 

4. — Ravenel  and  Gilliland  have  conducted  a  series  of 
experiments  upon  the  disinfectant  and  deodorant 
action  of  ammonium  persulphate.  They  conclude  that 
it  has  little,  if  any,  value  as  either,     [t.l.c] 


University  ot  Pennsylvania  Medical  Bulletin. 

March,  1901. 

1.  A  Series  of  Twelve  Articles  on  Medical  Men  Prominent  in 

the  Civil  and  Military  Affairs  of  Revolutionary  Times. 
Francis  R.  Packard. 

2.  The  Treatment  of  Trifacial  Neuralgia,  with  the  Report  of 

a  Case  of  Evulsion  of  the  Second  and  Third  Divisions, 
and  of  the  Gasserian  Ganglion.    J.  William  White. 

3.  The  Value  of  the  Tuberculin  Test  in  the  Recognition  of 

Latency  or  Quiescence  in  Tuberculosis  of  the  Bones 
and  Joints.  Charles  H.  Frazier  and  Montgomery 
H.  Biggs. 

4.  A  Digest  of  Recent  Literature  Upon  Perforation  of  the 

Intestine  in  Typhoid  Fever.    John  J.  Jopson. 

1. — Francis  R.  Packard  contributes  a  noteworthy  historical 
article  upon  General  Joseph  Warren,  one  of  the  lead- 
ing medical  lights  of  his  day,  and  a  staunch  patriot.  This  is 
the  first  of  a  series  of  twelve  articles  on  medical  men  promi- 
nent in  the  civil  and  military  aS'airs  of  revolutionary  times. 
It  is  replete  with  anecdote  and  characterized  by  evident  his- 
torical accuracy,     [t  lc] 

2. — J.  William  White  reports  a  case  of  evulsion  of 
the  second  and  third  division  of  the  gasserian 
ganglion  for  the  medical  treatment  of  trifacial  neu- 
ralgia. White  states  that  the  etiology  of  the  condition, 
as  in  his  case,  is  too  often  hypothetical,  or  absolutely  un- 
known. The  medical  treatment  should  include  the  removal 
of  the  reflex  sources  of  irritation,  though  well  developed  it 
is  rarely  found  to  have  such  origin.  Dana  divides  the 
period  of  treatment,  as  to  curative  value,  into  two  cases : 
First,  a  neurotic  type  occurring  early  in  life,  aflfecting 
women  much  more  often  than  men,  running  a  long,  tedious 
course  with  no  tendency  to  recovery  allied  to  ordinary  mi- 
graine and  due  probably  to  central  disease — a  disorder  of 
the  sensory  neuron — and  not  to  disease  of  the  gasserian 
ganglion.  The  second,  a  more  common  type,  occurs  later 
in  life,  after  the  age  of  forty,  affecting  men  at  least  half  as 
often  as  women,  sometimes  beginning  as  a  definite,  infective 
neuritis,  and  a  disease  either  of  the  peripheral  nerves  or  of 
the  ganglion.  In  the  first  classifijation  Dana  believes  that 
operative  procedure  is  of  no  avail.  In  the  second  class  he 
maintains  that  nothing  short  of  a  complete  removal  of  the 
gasserian  ganglion  will  produce  anything  more  than  tem- 
porary relief,  and  this,  he  urges,  may  also  be  secured  by 
medical  means.  White,  however,  believes  that  in  men 
cases  of  tic  which  have  resisted  medical  measures  for  from 
six  months  to  a  year  should  be  regarded  as  requiring  sur- 
gical interference.  Operations  on  the  peripheral  nerves  are 
hkely  to  do  good,  when  the  disease  is  distinctly  limited  to 
either  the  second  or  third  division  of  the  nerve  and  where  the 
evidence  shows  that  there  is  a  peripheral  neuritis.  In  view 
of  the  atrophy  of  the  cerebral  center  which  must  follow  the 
excision  or  destruction  of  the  nerve  trunk  peripheral  opera- 
tions might  still  eflfect  a  cure  even  if  the  cause  were  central. 
The  intracranial  operation  may  be  considered  as  a  primary 
operative  procedure  in  those  very  severe  cases  affecting  all 
the  divisions  of  the  nerve  with  frequently  recurring  parox- 
ysms and  with  no  immediate  relief  from  medical  treatment. 
White  recommends  Cushing's  modification  of  the  Hartley- 
Krause  operation  as  the  method  of  approach. .  He  believes 
that  this  method  will  reduce  the  present  mortality  of  20% 
and  will  increase  the  percentage  of  cures  90%.  The  surgeon 
may  limit  his  interference  to  evulsion  of  the  second  and  third 
division  between  the  ganglion  and  the  foramina,  knowing 
that  this  has  been  followed  by  cure  in  a  number  of  cases. 
This  course  of  action  is  favored  by  the  knowledge  that  pri- 
mary and  exclusive  disease  of  the  first  division  has  never 
been  known  to  occur.    There  is  also  less  risk  of  injury  to  the 


608 


The  Philadelphia ~| 
Medical  Joubnal  J 


THE  LATEST  LITERATURE 


[Mascb  20,  IMI 


abducens  nerves  and  to  the  cavernous  avernus  sinus,  and  by 
leaving  the  first  division  untouched  diminishes  the  later 
danger  of  trophic  changes  in  the  eye.  The  latter  course  of 
treatment  was  followed  in  a  case  which  White  now  reports 
and  the  patient  was  free  from  pain  11  months  after  the  oper- 
ation,   [t.l  c] 

3. — Charles  H.  Frazier  and  M.  H.  Biggs  publish  a 
preliminary  report  on  the  value  of  the  tuberculin  test 
in  the  recognition  of  latency,  or  quiescence,  in  tuberculosis 
of  the  bones  and  joints.  The  object  of  the  investigation  was 
to  determine  solely  whether  tuberculin  could  be  employed 
to  advantage,  not  as  a  means  as  revealing  the  presence  of  a 
focus  in  the  incipiency  of  the  disease,  but  as  a  means  of  de- 
termining whether  the  disease  has  apparently  run  its  course 
and  subsided,  whether  the  process  is  in  a  state  of  quiescence, 
of  latency,  or  whether  resolution  with  total  disappearance  of 
all  tuberculous  material  has  occurred.  Carefully  prepared 
tables  are  furnished  by  these  writers  showing  the  results  of  the 
reactions  they  have  obtained.  The  table  of  pc  siti  ve  reactions 
is  deserving  of  attention;  of  the  "recovered"  78%;  of  the 
"  quiescent "  100% ;  and  of  the  "  active  "  80%  responded  in  a 
positive  manner.  Those  cases  in  which  for  periods  varying 
from  one  to  seven  jears  there  had  been  no  clinical  evidence 
of  active  tuberculosis  gave  positive  reaction.  Some  of  the 
patients  classified  as  "  recovered "  had  submitted  to  a 
radical  operation  for  the  removal  of  the  affected  joint, 
or  the  affected  area  in  the  bone.  The  writers  inquire 
"  what  is  the  interpretation  of  the  figures  these  tables 
supply  ?  "  They  might  be  accounted  for  in  one  of  3  ways : 
(1)  Tli«  general  unreliability  of  the  test:  (2)  misinterpreta- 
tion of  the  clinical  phenomena;  and  (3)  the  existence  of 
tuberculous  foci  elsewhere.  The  first  supposition  may  be 
ruled  out.  The  positive  reaction  in  answer  to  (2)  might  be 
accounted  for  by  the  presence  about  the  seat  of  the  old  tuber- 
culous disease  of  small  areas  in  which  were  imbedded  the 
bacilli  of  tuberculosis  in  a  dormant  state.  It  is  possible  that 
these  minute  areas  might  account  for  the  positive  reaction. 
The  existence  of  tuberculous  foci  elsewhere  than  at  the  seat 
of  the  so  called  primary  bone  and  joint  tuberculosis  may 
be  relatively  frequent.  For  instance,  in  the  intrathoracic 
or  intraperineal  chains  of  lymphatics.  The  positive 
reactions  which  are  obtained,  therefore,  in  so  large  a  per- 
centage of  cases  that  have  recovered  would  seem  to  vitiate 
the  value  of  the  tuberculin  test  when  employed  for  the 
demonstration  of  the  presence  or  absence  of  tuberculous 
lesions  in  other  tissues  of  the  body,     [t.l.c  ] 

4.— John  H.  Jopson  supplies  a  digest  of  recent  litera- 
ture upon  perforation  of  intestine  in  typhoid  fever. 
This  is  based  upon  7  resent  papers  which  have  appeared 
upon  this  subject,  those  by  J.  M.  T.  Finney,  Harvey  \V. 
Gushing,  W.  W.  Keen,  J.  Collins  Warren,  G.  G.  Davis, 
William  Qjler,  and  H.  A.  Hare,     [t  l c] 


The  Journal  of  Nervous  and  Mental  Disease. 

February,  1901.     [Vol.  xxviii,  No.  2.] 

1.  A  Case  of  Cortical  Sclerosis,  Hemiplegia  and  Epilepsy, 

with  Autopsy.    Charles  L.  D.\n.v. 

2.  Diffuse    Degeneration    of   the    Spinal    Cord.      James  J. 

Putnam  and  E.  W.  Taylor. 

1. — Dana  gives  a  summary  of  his  case  of  cortical  scle- 
rosis, etc.,  as  follows :  Child,  aged  4}  years,  forceps  delivery, 
right  hemiplegiafrom  birth,  general  epilepsy  from  six  months, 
operation,  death,  meningeal  thickening,  general  cortical  scler- 
osis in  area  of  distribution  of  Sylvian  artery,  atrophy,  degen- 
eration of  pyramidal  tract,  no  degeneration  of  lemniscus  or 
atrophy  of  cerebellum,  considerable  deficiency  of  tangential 
fibers.  This  ca«e,  he  states,  furnishes  a  contribution  to  the 
pathological  anatomy  of  infantile  hemiplegia  with  epilepsy 
and  helps  to  throw  light  upon  the  origin  of,  at  least,  some 
cases  of  this  disease.  He  also  mentions  lesions  which  are 
found  causing  similar  conditions:  (1)  Diffuse  sclerosis;  (2) 
Lobar  sclerosis;  (3)  Atrophic  sclerosis;  (4)  Hynertrophic 
sclerosis;  (5)  Porpucephaly ;  (6)  Agenesis;  (7)  Cysts;  (8) 
Simple  atrophy.  These  various  anatomical  defects  have  as 
a  cause  (o)  simple  developmental  defects;  (6)  chronic  hydro- 
cephalus; (c)  meningo-cephalus ;  (rf)  vascular  lesions,  such 
as  hemorrhage,  embolism,  thrombosis  of  veins  and  infl:i,mma- 
tory  lesions  such  as  polioencephalitis.    Tae  .author  thinks 


that  in  the  case  mentioned  the  anatomical  defect  is  atrophy 
due  to  a  vascular  defect  or  disease  and  that  during  intra- 
uterine life,  partial  stoppage  of  the  left  middle  cerebral 
artery  and  its  branches  leading  to  the  incomplete  develop- 
ment of  the  brain  which  it  nourished.  The  obliteration 
could  not  have  been  complete  without  leading  to  a  more 
massive  and  localized  lesion,    [t  m.t.] 

2. — In  5  cases  of  diffuse  degeneration  of  the  spinal 
cord  studied  pathologically  by  Taylor,  the  features  common 
to  the  general  group  of  lesions  were ;  1.  A  diifose  degenera- 
tion for  the  most  part  limited  to  the  cord,  often  in  more  or 
less  discrete  patches.  2.  A  constant  involvement  of  the 
dorsal  and  lateral  columns,  without  strict  regard  to  neurone 
symptoms.  3.  A  predominance  of  the  lesion  in  the  cervical 
and  thoracic  regions.  4.  The  common  freedom  from  degene- 
ration of  nerve-roots,  both  motor  and  sensory,  and  of  per- 
ipheral nerves.  5.  The  practical  noninvolvement  of  gray 
matter.  6.  Insignificant  vessel- changes.  Putnam  and  Tay- 
lor's general  conclusions  derived  from  the  study  of  this 
condition  are :  1.  That  a  well-defined  lesion  of  the  nervous 
system  particularly  localized  in  the  cord  exists,  which  may 
for  the  present  be  termed  simply  "  difi'use  degeneration."  2 
That  no  fundamental  characteristics  of  the  lesion  have  been 
found  depending  on  diflerent  causes.  3.  That  anemic  states 
have  been  shown  at  times  to  be  a  concomitant  condition,  but 
not  necessarily  a  cause.  4.  That  actual  causes  are  still 
wholly  obscure,     [t.m.t.] 


The  Practitioner. 

February,  1901. 

1.  The  Special  Functions  of  the  Medical  Examiner.    T.  Col- 

coTT  Fox. 

2.  Medical  Examination  Forms  for  Life  Assurance.    Thob. 

Glover  Lyox. 

3.  The  Medical  Aspects  of  Life  Assurance.    J.  J.  Perkiss. 

4.  The  Surgical  Aspects  of  Insurance.    J.  Jackson  Clarkje. 

5.  The  Medical  Examiner  and  Insurance  Company.    James 

Chisholm. 

6.  Heroes  of  Medicine.    Thomas  Syeeham. 

7.  The  Influence  of  Soil  on  the  Prevalence  of  Pulmonary 

Phthisis.    Arthur  Newsholme. 

3. — Perkins  discusses  the  facts  which  lead  the  larger 
life  assurance  companies  to  accept  so  few  women  as  risks. 
In  the  population  at  large  the  average  mortality  for  women 
is  about  two  per  thousand  less  than  that  for  men — a  differ- 
ence largely  due  to  the  protection  from  the  occupation  ritka 
to  which  men  are  liable.  This  difference  is  not  equally  dis- 
tributed through  the  whole  period  of  life,  as  between  the 
ages  of  5  and  35  the  mortality  between  the  two  sexes  is 
nearly  equal,  while  from  10  to  20  years  the  deaths  are  more 
numerous  among  women.  Among  assured  lives,  however, 
the  reverse  holds,  instead  of  a  less  mortality  a  marked  ex- 
cess over  the  death-rate  among  men  is  found  up  to  the  age 
of  45  and  50,  due  partly  to  incomplete  medical  examination, 
partly  to  the  motive  for  assurance.  The  increased  mortality 
among  women  before  20  is  largely  due  to  phthisis,  which  has 
an  earlier  age  incidence  among  women  than  among  men, 
and  from  the  early  age  has  little  interest  for  assurance  par- 
poses.  After  20  the  increased  mortality  among  women  arises 
from  the  accidents  of  childbirth.  Between  the  ages  of  25 
and  45  childbirth  is  held  accountable  for  nearly  one  in  ten  of 
the  total  deaths  of  women,  and  if  the  deaths  from  this  cause 
were  removed  the  mortality  would  fall  well  below  that  of  men. 
The  death-rate  for  married  women  is  less  than  for  the  un- 
married except  at  the  age  when  the  risk  of  childbijth  is  the 
highest.  As  to  cancer  the  evidence  of  heredity  is  much 
stronger  in  females  than  in  males.  Perkins  sums  up  by 
concluding  that  the  death  of  the  mother  from  cancer  re 
quires  a  substantial  increase  in  premium.  If  one  other 
female  relative  has  been  affected  the  risk  becomes  serious 
and  in  some  cases  prohibitive.  The  death  of  a  male  relative 
from  cancer  is  less  serious,  but  no  female  life  with  a  well- 
established  family  history  of  CAncer  should  be  accepted  at 
the  ordinary  rate,    [t.l  c  ] 

'  7. — Arthur  Newsholme  contributes  an  exhaustive  piper 
upon  the  theory  of  the  intluence  of  soil  on  the  prev- 
alence of  piiliuoHiiry  phthijiis.  He  nas  nude  .i  care- 
ful study  of  the  death-rate  m  various  towns  in  Great  Britain 


Much  30,  1901] 


THE  LATEST  LITERATURE 


PThk  {Philadelphia 
l  msdical  joukhal 


609 


in  which  there  were  different  degrees  of  drying  of  the  sub- 
soil. His  statistics,  which  are  based  upon  a  comparative 
study  of  the  death-rate  before  and  after  proper  sewage  facili- 
ties were  introduced,  suggest  a  number  of  considerations.  It 
appears  probable  that  much  of  the  benefit  ascribed  to  the 
drying  of  the  soil  has  really  been  due  to  other  factors  of  im- 
provement. Buchanan's  results  show  the  benefit  of  altitude 
in  lowering  the  mortality  from  phthisis,  even  when  the  per- 
meability is  the  same  at  the  two  levels.  It  may  be  that  as 
the  dry  soils  are  usually  higher  than  the  wet,  altitude  may 
be  as  important  a  factor  as  dryness  of  site  of  house.  Holland, 
for  instance,  has  been  already  mentioned.  It  has  been  very 
malarious  and  yet  not  excessively  phthisical.  Indeed  there 
is  a  widespread  impression  that  ague  is  antagonistic  to 
phthi  is.  The  fact  that  such  a  widespread  impression  exist* 
and  that  ague  is  most  common  in  marshy  districts  does  not 
support  the  view  that  there  is  a  causative  relationship  be- 
tween phthisis  and  wet  soil.  Newsholme  concludes  that 
personal  infection  is  the  main  cause  of  the  spread  of  phthisis, 
and  that  this  occurs  chiefly  where  people  are  most  closely 
agglomerated  and  live  an  indoor  life.  That  deficient  nutri- 
tion is  an  important  favoring  cause  of  phthisis,  and  that 
wetness  of  soil  operates  in  a  minor  degree  by  favoring 
catarrhal  conditions  of  the  respiratory  mucous  membrane. 
[t.l.c] 


The  Quarterly  Medical  Journal. 

[Vol.  IX.    Part  II.] 

1.  The  Limits  of  Discovery.    Alexander  Macalister. 

2.  A  PleaforSympithetic  Relations  between  Members  of  the 

Medical  Prufession.    J.  Gordon  Black. 

3.  On  Three  Cases  of  Primary  Amenorrhea.    J.  B.  Hellier. 

4.  Two  Cases  of  Fracture  of  the  Base  of  the  Skull,  with  Re- 

covery.   Trafpord  Mitchell. 

5.  Two  Cases  of  Acute  Yellow  Atrophy  of  the  Liver,  with 

Remarks.    Arthur  Hall. 

6.  Case  of  Calculous  Pyonephrosis — Nephrectomy — Recov- 

ery.   James  Menzies. 

7.  The  International  Congress  of  Medicine  at  Paris,  August, 

1900.    J.  B.  Hellier. 

8.  Operations    in  Acute  Intestinal    Obstruction.     Sinclair 

White. 

3. — Hellier  reports  three  cases  of  this  very  uncommon 
condition  and  gives  the  following  important  facts  :  The  in- 
cision of  an  imperforate  hymen  to  evacuate  retained  menses 
is  beset  with  serious  dangers  and  that  antiseptic  methods 
have  not  diminished  the  danger.  He  states  that  the  most 
serious  danger  arises  when  the  hematosalpinx  is  present  as 
well  as  hematocolpus  and  hematometra  :  («)  the  thinned  out, 
distended  oviduct  has  often  contracted  adhesions,  and  may 
rupture  when  the  great  mass  of  accumulation  is  liberated; 
(6)  the  hematosalpinx  is  apt  to  become  septic.  This  is  due 
to  the  fact  that  it  does  not  contract  and  empty.  A  hemato- 
colpus can  be  easily  drawn  and  irrigated.  A  distended  uterus 
contracts  well,  but  a  distended  oviduct  has  little  power  to  ex- 
pel its  contents.  Hence,  if  hematosalpinx  is  present  it  is 
better  to  perform  abdominal  section  and  to  remove  the 
tubes.  Their  removal  greatly  improves  the  patient,     [t  M  t  ] 

5. — In  reporting  two  cases  of  acute  yellow  atrophy 
of  liver,  Hall  concludes  that  yellow  atropny  of  the  liver 
seems  to  be  due  to  a  toxin  formed,  possibly  in  the  alimen- 
tary canal,  but  as  to  its  origin  or  nature  very  little  is  known. 
The  likeness  of  symptoms  lo  those  in  cases  known  to  be  the 
result  of  toxic  action,  such  as  phosphorus  poisoning,  seems 
to  suggest  similarity  in  origin.  Jaundice  is  probably  due  to 
a  catarrhal  inflammation  and  consequent  obstruction  of  the 
smaller  ducts,  caused,  possibly,  by  secretion  of  the  irritating 
toxin  "  toxemic  catarrti "  (Hunter).  What  relation,  if  any, 
such  cases  hpar  to  various  cases  of  cirrhosis  of  the  liver  is 
unknown.  Toe  treatment  is  to  check  the  formation  of  toxin 
in  the  alimentary  canal  by  intestinal  antiseptics  and  keep  up 
the  patient's  strength.  Diagnosis  is  generally  not  made  until 
symptoms  of  the  last  stage  have  commenced,  when  treat- 
ment is  of  no  avail,     [t.m  t] 

G. — Menzies  notes  in  his  case  of  calculous  pyonephro- 
sis ;  (1)  Complete  absence  of  hematuria  throughout  the 
course  of  the  case ;  (2)  no  history  of  the  passage  of  gravel ; 


(3)  pain  not  paroxysmal ;  (4)  pain  not  influenced  by  exer- 
cise ;  (5)  pain  not  especially  referred  to  the  affected  side ;  (6) 
long  period  of  tolerance  (6  years)  before  the  advent  of  alarm- 
ing symptoms,     [t.m.t.] 


Miinchener  uiedicinische  Wochenschrift. 

January  3S,  1901.     [48.  Jahrg.,  No.  4.] 

1.  The  Treatment  of  Tuberculosis.  Hereditary  Transmission 

and  Other  ISIethods  of  Infection.    Klebs. 

2.  The  Disinfectant  Action  of  Alcohol,  Particularly  of  Al- 

cohol Steam.    Frank. 

3.  Is  it  Possible  to  Draw  any  Conclusion  Concerning  the 

Condition  of  the  Blood-forming  Organs  from  Decom- 
position of  Anemic  Blood  ?    Engel. 

4.  A    Cise  of  Acute  Leukemia    without  Microscopically 

Recognizable  Pathological  Alterations  of  the   Blood- 
torming  Organs.     Dennig. 

5.  A  C*se  of  Cnronio  Pemphigus  of  the  External  Skin  and 

Mucous  Membranes,  witti  Epidermal  Cystic  Forma- 
tions.   Mertens. 

6.  The  Significance  of  an  Exact  Definition  of  Character  for 

the  Judgment  of  Patients  Suffering  from  Mental  Dis- 
ease.   Tesdorpf. 

7.  The  Opening  of  Peritiphlitic  Abscesses  of  Douglas'  Pouch 

by  an  Incision  in  the  Parisacral  Region.    Port. 

8.  The  Removal  of   an  Artificial   Set  of  Teeth  from  the 

Esophagus  by  Gastrotomy.     Qcadflieq. 

9.  Six  Cases  of  Ejhinoooccus  of  tue  Liver,  with  Rupture 

into  the  Lungs.    Zervos. 
10.  Personal  Prophylaxis  and  Abortive  Treatment  of  Gon- 
orrhea.   Fraenkkl. 

1. — Part  1.  (See  Editorial.)  Part  2.  Klebs  is  of  the  opinion 
that  inhalation  tuberculosis  is  very  rare.  In  between 
4,000  and  5,C00  autopsies  he  was  able  to  discover  but  one  in- 
stance, which  occurred  in  a  young  girl,  who  had  nursed  a 
tuberculous  patient.  He  thinks  the  reason  for  this  is  that 
the  tubercle  bacilli  are  very  rapidly  killed  by  drying.  Cer- 
tain experiments  that  he  has  undertaken  prove  this  fact  con- 
clusively. He  believes  that  the  frequent  involvement  of  the 
apices  of  the  lungs  is  probably  due  to  original  lymphatic  in- 
fection. He  also  believes  that  laryngeal  tuberculosis  may 
arise  in  the  same  way.     [j  s.] 

2. — Frank  has  undertaken  a  number  of  experiments  in 
order  to  determine  the  efficacy  of  alcohol  as  a  disinfect- 
ant, as  it  was  necessary  to  discover  some  disinfecting  agent 
that,  in  the  form  of  gas,  would  disinfect  brushes,  hair,  etc., 
with  certainty.  He  found  that  in  the  various  preparations 
of  alcohol,  those  with  a  higher  specific  weight  have  more 
energetic  disinfectant  action.  As  a  matter  of  fact,  the  most 
energetic  preparation  is  40^  alcohol,  which  boils  at  about 
90°  C.  He  believes  that  in  addition  to  the  disinfection  of 
various  objects  requiring  penetration,  alcohol  may  also  be 
useful  for  hygienic  purposes,  sach  as  the  disinfection  of 
houses,  etc.     [j  s.] 

3.— Engel,  as  a  result  of  careful  studies  of  the  red  blood- 
corpuscles  in  cases  of  anemia,  particularly  in  view  of  the 
fact  that  the  non  nucleated  red  blood-cell  is  derived  from 
the  nucleated  cell  of  the  marrow,  believes  that  we  are  able  to 
predicate  four  types  of  bone  marrow  as  a  cause  of 
the  blood-chang-es.  First,  normal  bone  marrow  in  which 
the  biood  contains  only  the  normal  ortho-chromatic  erythro- 
cytes ;  second,  the  insufficient  bone  marrow  characterized  by 
excess  of  nucleated  red  cells  with  the  following  changes  in 
the  blood.  Normal  number  of  red  cells,  with  diminished 
hemoglobin,  that  is  chlorosis;  or  the  diminished  number  of 
red  cells  with  proportionate  or  disproportionate  diminution 
of  hemoglobin ;  or,  occasionally,  pathologic  red  blood  cells  of 
normal  size  showing  peculiar  color  reactions,  and  occasion- 
ally nucleated.  Third,  metaplastic  bone  marrow  of  the  red 
or  embryonal  type.  AH  types  of  abnormal  red  blood-cells 
are  found  in  the  circulation.  Fourth,  the  aplastic  bone  mar- 
row characterized  by  nothing  but  fat  even  in  the  epiphyses. 
The  red  blood-cells  are  normal,  but  rapidly  diminish;  granu- 
lated leukocytes  are  absent.    [J  s.] 

4.— Dennig  reports  a  case  of  leukemia  in  a  girl,  19 
years  of  age.  There  was  marked  leukocytosis,  and  an 
excessive  number  of  mononucleated  cells.    The  red  blood- 


610 


The  Philadelphia 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


[Mabcb  30,  UM 


cells  were  diminished.  The  patient  had  all  the  character- 
istic symptoms  of  leukemia,  with  the  exception  of  enlarge- 
ment of  the  spleen  and  lymph  glands.  Death  occurred, 
and  at  the  autopsy  all  the  organs  were  normal,  both 
macroscopically  and  mirro8Copi<'ally,  and  even  the  bone 
marrow  showed  no  alterations,     f J.s  ] 

6. — Mertens  reports  the  case  of  a  woman,  who  at  the  age 
of  15  had  had  a  severe  attack  of  coughing,  followed  by  an 
expulsion  of  a  yellowish-white  membrane,  and  a  considerable 
quantity  of  clear  blood.  This  attack  was  repeated  several 
times,  and  from  time  to  time  there  were  also  attacks  of  severe 
hoarseneBs,  blisters  upon  the  lips  and  tongue,  and  occasion- 
ally ulcers  upon  the  skin  that  healed  very  slowly.  When 
admitted  to  the  hospital  it  was  observed  that  she  was  pale, 
not  very  well  nourished,  there  was  a  patch  of  membrane  in 
the  throat  surrounded  by  an  area  of  hyperemia,  and  a  few 
ulcers,  bluish  in  color,  and  covered  with  a  membrane,  were 
found  in  various  parts  of  the  body.  The  tonsils  were  always 
intact.  Very  rarely  blisters  appeared  in  the  mucous  mem- 
branes of  the  mouth  that  apparently  contained  no  micro- 
organisms, that  is  to  say,  on  only  one  occasion  was  a  culture 
obtained  of  the  staphylococcus  aureus  and  smear  prepara- 
tions were  always  negative.  On  one  occasion,  the  patient 
had  an  attack  of  acute  edema  of  the  larynx.  Treatment  was 
entirely  useless.  Local  applications  of  chromic  acid  appeared 
to  produce  improvement  but  it  was  temporary.  A  diagnosis 
was  made  of  chronic  pemphigus.  An  interesting  feature 
was  the  presence  of  numerous  cysts  in  the  skin  beneath  one 
of  the  affected  parts.  The  differences  between  the  lesions  in 
the  mucous  membranes  and  the  ekin  were  also  remarkable. 

[J.S.] 

6. — Tesdorpf,  after  considf  ring  the  desirability,  on  various 
grounds,  of  an  exact  defiuitiou  of  character,  suggests 
the  following :  "  We  speak  of  a  diseased  character  in  cases 
in  which  all  or  some  of  the  psychical  qualities  present  in  a 
human  being,  in  as  far  as  these,  either  as  conscious  or  as 
unconscious  factors,  influence  the  inner  psychical  activities 
and  the  external  actions,  have  either  undergone  some  chanee 
as  a  result  of  disease,  or  have  been  influenced  previously  by 
disease.  The  morbid  changes,  or  perhaps  better,  morbid 
influences,  may  affect  the  number,  the  intensity  or  the  vari- 
ability of  the  relation  of  the  qualities  of  the  character;  cr 
the  mutual  relations  of  the  qualities  of  the  character  to  one 
another."  This  he  regaids  as  a  considerable  improvement 
upon  the  previous  definitions,     [j.s.] 

7. — Port  reports  the  case  of  a  man  40  years  of  age  who 
developed  appendicitis  followed  by  considerable  accumula- 
tion of  pus  in  the  perityphlitic  space.  It  was  decided  to  evac- 
uate this  through  an  incision  alongside  the  anus.  By 
careful  dissection  it  was  possible  to  reach  the  abscess  cav- 
ity, and  about  }  of  a  liter  of  pus  was  evacuated.  The  in- 
cision was  10  cm.  deep,  funnel-shaped,  and  therefore  readily 
cleaned.  Several  days  later  a  large  fragment  of  necrotic 
tissue  was  expelled,  and  thereafter  granulations  filled  the 
cavity  very  rapidly,  and  in  the  course  of  4  weeks  the  patient 
was  discharged  entirely  well,    [j  s  ] 

8.— Quadflieg  reports  an  interesting  case.  A  woman  of 
44  swallowed  her  plate  containing  2  artificial  teeth.  She 
felt  severe  pain  in  the  thorax,  but  daily  explorations  with  the 
esophageal  sound  failed  to  reveal  any  obstruction.  An  ex- 
amination with  the  Eontgen-rays  apparently  showed  a  mass 
in  the  email  intestines.  As  the  condition  of  the  patient  be- 
came alarming  an  exploratory  incision  was  made  followed  by 
gastrotomy,  and  the  removal  of  the  plate  from  the  esopha- 
gus through  the  cardia.  There  was  considerable  bleeding, 
and  a  gastric  fistula  was  left  which  was  subsequently  cured 
by  another  operation,     [j  s.] 

O. — Zervos  reports  6  cases  of  echinococcusof  theliver, 
all  of  which  ruptured  into  the  lung-,  causing  death  in  5 
cases.  In  the  sixth  <use  there  was  tevere  coughmg  with  an 
expectoration  (ontainirg  numerous  eel  inococcus cysts.  The 
patient,  however,  recovered.  In  4  of  the  fatal  cases  the  diag- 
nosis was  confirmed  by  autopsy.  All  these  cases  were  pre- 
viously operated  upon  by  the  method  of  capitonage,  and  the 
author  draws  the  conclusion  that  this  operation  is  net  cn'y 
useless  but  actually  dangerous,  because  after  the  occlusion 
of  the  cysts  by  suture,  new  ones  are  formed,  acd  meeting 
dense  scar  tissue  anteiiorly,  usually  extend  in  the  direction 
c)f  least  resistance,  that  is  toward  the  convex  surface  of  the 
Ji  ver,  and  eventually  rupture  through  the  diaphragm.    [J.s  ] 


Deutsche  niedicinische  Wochenschrift. 

February  I4,  1901.     [27.  Jahr^.,  No.  7.] 

1.  On    the     Etiology    of    Acute    Articular     Bbeamatism. 

Menzee. 

2.  A   Contrbjti.n    to    the    E'iolo^y    of   Hay    Fever.      C. 

DiETSCH. 

3.  Op 'rating  During  th?  First  E'her  Anesthesia.    P  Sudeck. 

4.  Toe  Operitive  Treatment  of  Pulmona  y  Tuberculosis     H. 

Sarfert 

5.  Conce  ning  the  Decomposition  of  Albumins  by  Boiling. 

K  Oppenheimee. 

6.  Pathology  and  Treitmen';  of  Cica'ricial  Con'.raction  of  the 

Bladder.    A.  Rothschild.  ^ 

1. — Menzer  first  reports  his  own  work,  which  coningted  in     1 
the  disBovery  of  streptococci  in  the  joint  exudate  in 

2  cases  of  rheumatism,  and  in  the  tonsils  in  3  cases.  His 
method  of  investigating  the  tonsils  was  to  excise  a  portion, 
and  to  make  bacteriological  examiaations  of  the  cut  surface, 
thus  looking  only  for  bacteria  that  were  present  in  the  sub- 
stance of  the  tonsil.  The  bacteria  found  producsd  ioflam- 
mation  of  and  exudation  into  the  joints  in  animals  and  in 
some  cases  caused  endocardial  changes.  He  then  discusses 
the  work  reported  by  Meyer  in  the  last  number  of  the  same 
j  jurnal,  and  directs  attention  to  the  fact  that  the  discoveries 
reported  by  Meyer  are  by  no  means  new,  for  there  have  been 
repeated  reports  of  the  presence  of  streptococci  in  the  joints 
and  in  the  tonsils  in  rheumatism.  The  streptococcus 
discovered  by  Meyer  differed  in  some  ways  from  that 
found  by  Wassermann,  and  the  one  which  Menzer  re- 
ports also  showed  some  variations  from  either  of  these. 
The  conclusions  which  Menzer  reaches  are,  that  the  dis- 
covery of  streptococci  in  rheumatism  is  by  no  means 
new,  but  this  does  not  mean  that  it  is  entirely  without 
importance.  It  is  true  that  one  can  find  s'.reptococci  and 
staphylococci  frequently  in  almost  any  infectious  disease, 
and  particularly  in  the  mouth  and  throat ;  in  the  latter  places 
even  under  normal  circumstances.  The  importance  of  cer- 
tain streptococci  is,  however,  that  they  tend  to  cause  joint 
changes  in  animals.  He  considers  it  a  question  whether  we 
shall  ultimately  find  streptococci  to  be  the  sole  cause  of 
rheumatism;  also  whether  the  streptococci  which  are  at 
times  found  on  the  normal  tennis  will  prove  always  to  lack 
the  peculiarity  of  producing  joint  changes  in  animals.  He 
considers  it  impossible  as  yet  to  make  any  definite  stite- 
ments  concerning  the  bacteriology  of  rheumatism.  A  num- 
ber of  forms  of  bacteria  have  been  discovered,  chiefly 
streptococci,  staphylococci,  and  pneumococci,  and  some  of 
these  have  the  power  of  producing  joint  changes.  It  is 
possible  that  some  one  of  these  changes  may  be  shown  to  be 
the  actual  and  constant  cause  of  typical  rheumatism,  though 
this  is  certainly  questionable  considering  the  close  relation 
of  typical  acute  rheumatism  to  rheumatoid  and  pyemic 
affections.  From  a  clinical  standpoint,  however,  rheumatism 
seems  to  Menzer  to  present  the  characteristics  of  a  morbus 
sui  generis,     [d  le  ] 

2. — Dietsch  discusses  the  two  chief  theories  of  the 
causation  of  hay  fever, — the  one  being  that  it  is  due  to 
con'Stitutional  factors  and  irritation,  the  other  attributing  it 
to  infection.  Those  holding  to  the  theory  that  it  is  spread 
by  infection  belong  to  two  classes ;  certain  authors  consider 
that  it  is  spread  by  dust,  pollen,  etc.,  which  carry  the  infec- 
tion ;  others  that  the  infection  is  not  related  to  pollen,  etc., 
but  that  these  latter  bodies  act  merely  as  irritants,  and  pre- 
pare the  way.  Dietsch  gives  a  review  of  the  reasons  for  con- 
sidering that  pollen  is  actually  connected  with  the  causation 
of  the  disease.  He  strongly  holds  to  this  belief  because  of 
the  occurrence  of  the  disease  almost  entirely  at  the  period 
when  pollen  is  present  and  plants  are  blossoming.  There  are 
many  points  against  the  view  that  the  disease  is  due  to  in- 
fection. In  the  firsit  place  fever,  if  it  occurs,  is  very  slight. 
Second,  the  sense  of  smell  is  almost  always  uninvolved  ;  the 
contrary  is  otten  true  of  other  infections  which  involve  the 
nasal  cavities.  Further,  infectious  diseases  which  continue 
for  j'ears  practically  always  leave  behind  some  important 
sequels.  There  is  absolutely  no  evidence  of  any  sequel 
in  hay  fever,  cr  any  involvement  of  other  organs  than 
the  respiratory.  Also  the  predisposition  to  the  disease 
is  so  pecul  ar  that  it  could  scaicely  be  the  result 
of    an     iafec;ion.      Some     perscns    are     predisposed     to 


March  ?0,  1901] 


THE  LATEST  LITERATURE 


[Thb  Philadelphia 
Medical  Journal 


611 


the  disease  for  life,  whilq  the  grpat  majority  of  per- 
sons have  absolute  irnmuni'v.  If  it  is  iafpcti  lus.  thee 
mut  e  an  enormous  p  s  i  i'itv  of  infe  t  on,  since  ihe  pre 
dispo  ed  regularly  have  ihe  dis  ase,  and  un  ler  such  rir  urn- 
Stan  'fS  it  wou'd  be  ex  rem'^ly  p-tiuliar  if  thife  who  we^e  not 
great  y  p  edi  poeed  d  d  riot  (  cc-s  ona'ly  acqnie  ih-  d  sease 
and  -iibseqiiently  ss  well  »s  previously  rtma  n  free  fr  ni  t 
He  th  nks  that  the  d  s'-asn  is  a  cata-rh  resulting  from 
meihanical,  chemiial  ani  ihermic  irrna  ion  of  the  na«al 
cavil  es,  which  is  prel  spos3d  to  by  a  g.  n^ra'-  sensitivenes* 
of  organism,  irii'abil  ty  of  the  nervous  system,  prol  mgfd 
nsbtd  citarrh,  ani  probably  arthriiijm  in  tne  pwen  s. 
[d  LE.] 

3. — Sudeck  states  that  there  are  a  number  of  operations 
that  can  be  performed  in  a  short  time  but  in  which  local 
anesthesia  is  not  applicable.  He  recommendi  in  minor 
operations,  and  the  more  serious  ones  that  can  be  quickly  per 
formed,  the  etaployment  of  the  very  first  stage  of  etner- 
anesthesia.  The  following  points  are  to  be  observed  :  1.  The 
patients  are  instructed  to  take  deep  inspirations  at  the  begin- 
ning of  ether-administration.  2.  The  patients  should  be  im- 
pressed with  the  fact  to  concentrate  their  minds  upon  the 
aneethesia.  The  instruments  should  be  kept  from  the  view 
of  the  patient  and  the  latter  should  be  kept  in  ignorance  of 
the  fact  that  the  operation  ia  soon  to  be  performed.  3.  The 
operation  should  be  immediately  performed  at  the  first  or 
second  ether- inhalation  and  should  last  but  a  few  minutes. 
The  advantages  of  this  method  of  anesthesia  are  the  absence 
of  danger,  prevention  of  disturbances  to  the  respiratory 
organs,  and  the  rapid  recovery  from  the  narcosis,    [m.r.d  ] 

4. — H.  Sarff  rt  believes  that  there  are  many  casts  of  pul- 
monary tuberculosis  tbat  can  be  benefited  by  surgical  pro- 
cedures. Theauthor  has  experimenteii  upon  150  cadavers, 
and  finding  that  apical  cavities  are  best  reached  by  the 
operation  by  resection  of  the  second  rib,  proposes  the  fol- 
lowing operation :  An  incision  is  made  into  the  skin  at  the 
external  extremity  of  the  rib  and  is  extended  outward  about 
4  inches.  An  incision  is  made  into  the  periosteum,  the 
cartilage  cut  through  and  an  entrance  obtained  at  the  axi  lary 
end.  The  parietal  pleura  is  separated  from  the  chest  with 
the  fingers.  The  apex  cf  the  lung  is  brought  out  without 
opening  the  pleural  cavity.  An  opening  is  obtained  into  the 
cavity  either  by  the  knife  or  Paquelin  cautery.  Exposed 
bloodvessels  may  now  be  I'gUed  and  several  communicating 
cavities  should  be  opened  and  the  whole  converted  into  one 
cavity.  In  one  of  the  author's  cases  where  the  size  and  ex- 
tent of  the  cavity  were  determined  by  palpation  and  the 
above  operation  performed,  the  hectic  fever  and  hemoptysis 
ceased,     [mrd] 

5.— Opperiheimer  brefly  reports  that  bntt^es  rf  milk  stop- 
ped with  CLtt  n  or  rutber,  and  containing  hanging  from  the 
top  filer  paper  which  had  bten  moistened  with  acid  of  lead 
were  heated  for  various  lengths  of  time.  Aftsr  sufficient 
heating  there  was  alwi-ys  a  brown  dii-colorati  n  of  the  lead 
paper  indicating  the  presence  of  H,  S.  Ttiis  he  considers 
a  definite  demonstration  ih.t  the  albumin  of  the  milk  was 
broken  up  with  ihe  heating.  Boiling  the  miln  for  5  min- 
utes give  «n  extrcnely  s  ight  reaction.  The  reaction  was 
distiiict  after  10  minute  and  increapel  after  this  time.  It 
was  very  marked  after  20  minutfs.  The  import<nce  of  this 
in  com  ec'.ion  with  steriliziii  n  of  milk  is  evijeit,  and  a 
further  ciacussion  of  the  matter  will  appear  elsewhere. 
[dle.] 


La  Seniaiue  Medicale. 

January  30,  1901. 

1.  The  Application  of  the  Method  of  "  Sufficient  Dose  "  in 
the  Treatment  of  Some  Maladies  of  the  Nervous 
System  :  Those  Grave  Forms  Associated  with  Migraine, 
Meniere's  Vertigo,  Nr-uralgia  and  Tic  douloureux. 
De.  Gilles  de  la  Toueette. 

!  1. — This  paper  presents  studies  upon  the  method  of  treat- 
I  ment  originally  expounded  by  Charcot,  based  upon  the  ad- 
ministration of  sufficient  dose  of  broniid  in  epilepsy. 
Having  determined  the  personal  equation  ol  the  patient  by 
I  the  establishment  of  his  point  of  toleration  for  the  bromid, 
a  dose  is  maintained  for  a  period  of  time  which  is  found  to 
be  sufficient  to  lessen  the  cortical  motor  excitability. 


and  to  cause  the  disappearance  of  the  attacks.  The  treat- 
ment was  originally  used  in  epilepsy,  but  the  writer  believes 
that  it  has  equal  value  in  Meniere's  vertigfo  and  cases  of 
severe  neuralgia  and  tic  douloureux,  fhe  amhor  first 
discusses  the  treatment  of  grave  forms  of  nervous  dis- 
orders associated  witli  migraine.  It  is  applicable  to 
all  forms,  from  the  simple  migraine  to  the  severe  types  with 
accoinpanying  scintillating  scotoma,  hemiopia  and  even 
transitory  aphasia.  A  case  is  reported  of  a  young  woman  of 
34  years,  who  had  suffered  for  a  long  period  from  attacks  which 
lasted  3  full  days  of  each  week,  compelling  her  to  remain  in 
bed  and  to  abstain  from  all  fo  id.  After  some  5  months  of 
treatment  by  the  bromids  there  was  a  great  improvement. 
The  second  case  in  a  patient  of  58  years,  who  had  suflfered 
ffir  a  long  time  from  a  grave  migraine  accompanied  by  a 
right  hemiplegia  after  a  very  severe  attack,  which  dis- 
appeared after  8  aayb'  treatment  with  bromid  of  potas- 
sium. This  case  was  followed  for  2  years,  tne  paiient  took 
progressingly  increasing  and  decreasing  doses  of  bromid. 
There  was  a  gradual  restoration  to  health.  His  third  case 
was  one  of  ophthalmoplegic  migraine  in  a  young  man 
of  35  years.  A  cure  Wds  brougnt  about  by  prescribing 
rapidly  increasing  doses  of  bromids  up  to  7,  8  and  9  grams. 
The  pupillary  phenomena  from  this  treatment  showed  them- 
selves in  the  third  week  R^erardingthe  treatment  of  Meuifere's 
vertigo,  he  beheves  with  Charcot  that  the  disease  depends 
upon  a  hyperexcitability  of  the  labyrinth  analogous  to 
corticomoior  excitability,  and  he  rea^Dos  thit  as  br  imids 
lessen  the  latter  condition,  sulfate  of  quinin  ought  to 
suppress  the  labyrinthine  hyperexcitability.  Quinin  is 
given  to  the  point  of  toleration,  then  the  dose  is  decreased 
and  finally  increased  again.  After  a  period  of  2  or  3  months, 
sometimes  longer,  a  comolete  cure  will  be  brought  about. 
For  the  treatment  of  tic  douloureux,  he  recommends  .06 
cm.  of  extract  of  opium  per  day.  This  is  increased 
every  day  or  every  other  day  by  a  pill  of  .02  cm.  and  the 
point  of  toleration  will  indicate  when  suffiiMent  dose  has 
been  attained.  The  toxic  influence  of  the  drug  mu-<t  be 
carefully  watched.  In  the  first  period  of  treatment  30  to  40 
cm.  may  be  given  in  from  5  to  7  days,  after  which  time 
it  is  necessary  to  increase  it  with  care.  The  patient  should 
be  carefully  guarded  against  cold  and  the  chamber  kept  at 
an  fqual  temperature.  After  this  first  period  the  dose 
should  be  diminished  daily  and  very  gradually,    [t.l.c] 

February  6,  1901. 

1.  Typhoid  Fever  Simulating  Appendicitis.  Operation. 
Death.    M.  Rendu. 

1. — The  patient  was  a  young  woman  of  29  years  who 
entered  the  hospital  having  suffered  from  a  headache  for  5 
days.  There  were  no  abdominal  symptoms  or  vomiting,  but 
there  was  a  loss  of  aopetite,  and  an  evening  rise  of  tempera- 
ture. She  had  piiS^ered  from  typhoid  fever  at  5  years 
and  a  grave  metritis  at,  19.  Alter  several  days  thore  was 
pain  in  the  right  iliac  fossa  and  a  diagnosis  of  salpingi- 
tis was  tentatively  made.  Rest,  injections  of  pennauganate 
of  potash,  applications  of  hot  compresses  over  the  ahdomen, 
a  semi-solid  diet  and  the  application  of  several  lee  ihes  over 
the  painful  region  improved  her  condition.  The  tempe  riture 
(ell  to  normal.  For  several  days  the  apyrexia  was  com- 
plete. Then  the  temperature  suddenly  roie  1 1 39.6  0.  There 
was  vomiting  and  abdominal  tenderness  as  well  as  profound 
induration  in  the  region  of  the  appendix.  Operation  was 
performed,  but  the  appendix  was  found  to  be  perfectly  nor- 
mal. Tne  patient's  condition  continued  to  grow  worse  and 
death  ensued.  A  postmortpm  examination  showed  the  case 
to  be  one  of  typhoid  fever.  The  Widal  reaction  had 
not  been  employed,     [t.lc] 

February  13,  1901. 

1.  On  the  Assimilation  of  Inorginic  Preparations  of  Iron 
and  their  Role  in  the  Treatment  of  Cnlorosis.  A. 
Jaquet. 

1. — Jaquet  furnishes  us  with  a  comprehensive  resumtS  of 
the  studies  made  during  the  pa-t  25  years  as  to  the  value  of 
the  various  organic  and  inorganic  iron  preparations.  With 
reference  to  chlorosis,  experience  has  proven  the  good  to 
be  derived  from  certain  organic  preparations,  but  he  recom- 


612 


Th^  Philadelphia  1 
Medical  Jousnax  J 


THE  LATEST  LITEKATURE 


[Mabcb  3«,  19M 


mends  in  our  present  state  of  knowledge  that  the  prepara- 
tions of  the  pharmacopeia  be  employed  rather  than  many  of 
the  much  vaunted  "  assimilable  "  preparations  which  lack 
the  test  of  time  to  determine  their  value,     [t  l.o  ] 


Joarnal  des  Praticiens. 

February  9,  1901,     [ISme  Ann6,  No.  6] 

1.  A  Case  of  Tuberous  Xephriti?.  with  Epileptic  ConvulsionB 

and  Sudden  Blindness.    Chauffard. 

2.  Symptoms  of  Lithemia  in  Cnildren.    Jules  Combre. 

3.  Convulsions  with  Hemiplegia  in  an  Infant  of  15  Months. 

Le  Gendee. 

1. — ChauflFard  reports  the  case  of  a  woman  aged  32  years, 
whose  urine  contained  albumin  for  the  three  years  prior  to 
her  death.  She  had  had  a  miscarriage,  with  retained  placenta, 
double  phlebitis,  and  peritonitis,  and  repeated  attacks  of 
bronchitis,  earlier.  Typical  epileptic  convolsions  oc- 
curred as  often  as  twice  a  week.  There  were  edema  of  both 
legs,  ascites,  edema  of  the  lungs,  and  a  slight  pleural  eflFu- 
sion.  The  left  ventricle  of  the  heart  was  hypertrophied,  and 
there  was  marked  arteriosclerosis.  In  the  urine  were 
albumin,  granular,  fatty,  and  hyaline  casts.  The 
day  after  admission,  she  suddenly  became  blind,  and 
had  a  very  severe  convulsion.  After  being  bled  700  grams, 
vision  returned.  The  ascites  increased,  and  she  died  of  edema 
of  the  lungs,  after  600  grams  of  liquid  had  been  withdrawn 
from  her  abdomen.  The  autopsy  showed  the  right  kidney 
weighing  15  grams,  while  the  left  weighed  150  grams.  Both 
were  sclerotic.  In  the  left  were  some  hypertrophied  tubules, 
still  able  to  function,  while  none  were  found  in  the  much- 
atrophied  right  kidney.  Cbauflard  considers  the  convul- 
sions uremic,  and  the  sudden  loes  of  vision  due  to  inhibi- 
tion of  the  cortical  optic  centers  by  the  uremic  convulsion. 
The  renal  condition,  he  calls  tuberous  nephritis,     [m  o.] 

2.— The  lithemic  diathesis  is  generally  hereditary. 
Among  the  many  manifestations  of  gout  (arthritis)  seen  m 
children,  Combre  enumerates  pallor,  anemia,  enlarged  lymph- 
glands,  convulsions,  headache,  neuralgia,  neurasthenia, 
coryza,  epistaxis,  spasmodic  laryngitis,  asthma,  adenoids, 
palpitation,  arrhythmia,functional  murmurs,  syncope,  edema, 
gastrointestinal  symptoms,  jaundice,  albuminuria,  enuresis, 
glycosuria,  rheumatism,  urticaria,  eczema,  and  many  more. 
Then  he  calls  particular  attention  to  three  other  symptoms : 
(1)  Periodic  headache,  severe,  coming  on  suddenly,  with- 
out other  symptoms ;  (2)  cyclic  vomiting,  severe,  sudden, 
lasting  days,  with  fever,  and  followed  by  headache ;  and  (3) 
arthritic  fever,  intermittent,  quotidian,  with  no  suspicion 
of  malaria.  To  explain  all  these  diflFerent  symptoms,  Combre 
mentions  that  there  are  probably  grave  autointoxications  in 
Uthemia.  As  treatment  he  advises  rest  in  bed,  baths,  and 
injections  of  normal  salt-solution.  All  children  of  gouty  an- 
cestry should  be  brought  up  in  the  open  air,  with  exercise, 
and  massage.  They  should  drink  much  water,  and  eat  little 
meat,  but  many  vegetables.  Meals  should  be  regular.  They 
should  have  no  alcohol.  Alkaline  waters  should  be  given 
from  time  to  time.     [m.o.J 

3. — A  baby  of  15  months,  hereditarily  syphilitic,  sud- 
denly had  convulsions.  They  were  epileptic  in  character, 
the  right  side  moving  more  than  the  left.  Right  hemiplegia 
followed,  more  marked  in  the  leg.  Sensation  remained 
normal.  Babinski's  reflex  was  present.  Both  pupils  were 
contracted.  Le  Gendre  gave  two  grams  of  mercurial  oint- 
ment externally,  and  one  gram  of  potassium  iodid  in  rectal 
injection,  daily.  For  two  weeks  treatment  was  of  no  avail, 
then  the  convulsions  ceased.  From  that  time  the  child  im- 
proved continually.  The  cause  of  the  convulsions  was 
undoubtedly  syphilitic,  agumms,  a  circumscribed  menin- 
gitis, or  encephalitis,  in  the  left  Uolaudic  region,    [m.o.] 


Vratch. 

January  SO,  1901.    [Vol.  xxii,  No.  S.] 

1,  Corporal  Punishment  in  K'lssia  in  the  Twentieth  Century. 

D.  N.  Shbankow. 

2.  Toe  Public  Importance  of  Skin  Diseases.    0.  W.  Peter 

SEN. 


3.  On  the  Injection  of  Sodium  Cinnamylate  in  Tuberculosis. 

L.  A.  Fiskelsteis. 

4.  On  the  Question  of   Determining   the    OiidizibLlity  of 

Water  by  Means  of  Permanganate  of  Potash.    A  Ph. 
Drshewetsky. 

2. — Petersen  shows  how  infectious  skin  diseases  are 
widespread  in  Russia,  and  recommends  as  a  prophylaxis 
the  infusion  of  the  knowledge  of  hygiene  into  the  masses  as 
well  as  the  establishment  of  pubhc  baths  constructed  on 
modem  sanitary  principles,    [a.e.] 

3. — Will  be  abstracted  when  completed. 

4. — Drshewetsky  points  out  an  error  in  the  determination 
of  oxygen  consumed  in  water,  hitherto  unnoticed,  namely, 
the  oxidizing  properties  of  the  salts  of  chlorine  and  bromine. 
As  a  result  of  carefully  conducted  experiments,  he  arrives  at 
the  following  conclusions :  1.  In  determining  the  oxygen 
consumed  by  means  of  permanganate  of  potash,  a  correction 
should  be  made  for  chlorine  by  deducting  0.15  mg.  of  oxygen 
(per  litre)  if  the  permanganate  solution  is  normal,  and  a  cor- 
responding amount  if  weaker  than  normal.  2.  This  correc- 
tion can  only  be  made  with  waters  containing  not  more  than 
0.1  gm.  of  chlorine  per  litre.  3.  The  salts  of  bromine  oxidize 
permanganate  nf  potash  according  to  the  following  equa- 
tion:  2HBr— 0=Br.— HO,  t.  «.,  in  proportion  of  160:16. 
4.  The  determination  of  organic  substances  in  mineral 
waters  rich  in  salts  of  chlorine  and  bromine  is  impossible. 

[A.B.] 

JanvMry  27, 1901.     [\'ol.  xxii,  No.  4.] 

1.  On  the  Question  of  the  Significance  of  the  So-called  Para- 

lytic Chest  (Thorax  Paralyticus).  I.  G.  GABRiKLOvrrcH. 

2.  Corporal  Punishment  in  Russia  in  the  Twentieth  Century. 

D.  N.  SCHBASKOW. 

3.  On  the  Injection   of  Sodium   Cinnamylate   ( Natri  Cin- 

namylici)  into  Tuberculous  Patients.    L.  A.  Fiskel- 

STEIlf. 

1. — Gabrielovitch  has  made  the  tuberculous  chest,  or  the 
"  paralytic  chest,"  of  Engel's,  the  subject  of  special  study. 
He  justly  considers  the  chest  measurements  hitherto  applied 
unreliable,  inasmuch  as  they  vary  considerably  with  the  indi- 
vidual. Much  more  accurate  he  finds  the  relative  measure- 
ments between  the  chest  and  other  parts  of  the  body  in  the 
same  individual.  To  establish  the  normal  average,  he  took 
the  measurements  of  31  perfectly  healthy  individuals  between 
the  ages  of  20  and  30,  the  mode  of  life  and  occupation  being 
nearly  the  same  in  all.  The  measurements  taken  were  as 
follows :  (1)  Height ;  (2)  the  circumference  of  the  cheet  on  a 
level  with  the  nipples,  both  at  inspiration  and  expiration, 
only  the  median  being  noted :  (3)  the  circumference  of  the 
abdomen  on  a  level  with  the  umbilicus,  both  at  expiration 
and  inspiration,  only  the  median  being  noted ;  (4)  the  length 
of  the  trunk  from  the  upper  border  of  the  sternum  to  tho 
pubes ;  (5)  the  antero-posterior  diameter  on  a  level  with  the 
fifth  dorsal  vertebra,  and  the  lateral  diameter  on  the  same 
level  (by  means  of  a  pelvimeter).  Having  thus  determined 
the  normtl  average,  the  author  subjected  to  the  same 
measurements  75  tuberculous  patients  of  about  the  same 
conditions  and  stage  of  the  disease,  none  of  them  being  very 
far  advanced.    The  results  are  tabulated,  as  follows; 


KELATIOS. 


HKALrHV 

PEBSO^S. 


IS 

TrBKBcr- 

Lors 


Of  the  circamference  of  the  chest  to  the  height  .... 

Oi  the  circumference  of  the  chest  to  the  circumference 
of  ihe  abdomen 

Of  the  circumferenoe  of  the  cheet  to  the  length  ol  the 
trunt  

Of  the  lateral  to  the  aDtero-posterior  diameter  .... 


1:1.8  1:2.0 

1  :  0,S9  1  :  0.S6 


1:0.  £2 
1 : 0.70 


i:ae7 

f  1:0.7» 
I  l:0.?S 


It  is  thus  seen  that  the  tuberculous  chest  may  be  chantctef' 
ized  as  long  and  narrow,  the  circumference  being  equal  to 
half  the  height.  The  narrowiLg,  however,  is  lateral  instead 
of  antero-posterior,  as  is  commonly  believed.  The  "  paralytic 
chest,"  as  described  by  Engel,  Rokit&nsky.  and  othe-rsj  iL 
according  to  the  author's  observations,  rare  in  the  first  and 
second  stages  of  the  disease,  [a.r.] 
3. — Will  be  abstracted  when  completed. 


March  30,  1901] 


ATMOKAUSIS 


rTHE  Philadelphia 
Medical  Jocenal 


613 


©rtginal  2ivi\cks. 


ATMOKAUSIS :  ITS  VALUE  DJ  THE  TREATMENT  OF 
SEVERE  AND  UNCONTROLLABLE  UTERINE  BLEED- 
INGS (UTERINE  ARTERIOSCLEROSIS). 

By  SAMUEL  AV.  BANDLER,  M.D., 
of  New  York  City. 

Prof.  Snegirjoff,  in  Moskau,  has  for  years  used  steam 
at  a  temperature  of  100°  C.  in  controlling  uterine  bleed- 
ings. In  his  opinion  steam  cauterizes,  stops  hemor- 
rhage, removes  every  odor,  and  diminishes  the  sensi- 
tiveness of  the  inner  lining  of  the  uterus. 

Pincus  introduced  this  method  into  Germany.  His 
first  experience  was  with  an  inoperable  corpus  carci- 
noma, with  endometritis  hyperplastica,  and  with  endo- 
metritis cervicis,  obtaining  good  results.  Since  then 
the  method  has  been  used  on  many  sides  and  for  quite 
a  series  of  gynecological  affections.  Kahn  used  this 
precedure  in  many  cases  of  septic  postpartum  endo- 
metritis with  very  quick  benefit.  He  found  that  the 
sensitiveness  of  the  uterus  was  diminished  and  that  good 
contractions  resulted.  The  steam  had  a  bactericidal 
effect  and  the  disagreeable  odor  disappeared.  Through 
thrombosis,  the  blood-  and  lymph-vessels  were  closed 
and  a  protecting  cover  was  formed  for  the  development 
of  fresh  granulations.  Clinically,  temperature  fell, 
usually  by  crisis.  Only  in  those  cases  where  action  was 
delayed,  or  where  placenta  or  membranes  were  retained, 
did  an  immediate  improvement  fail  to  result.  Pincus 
obtained  good  results  in  putrid  abortions  and  in  climac- 
teric hemorrhages  where  abrasio  failed,  in  subinvolu- 
tion uteri  and  gonorrheal  infections.  In  the  clinic  of 
Pawlik,  in  Prague,  about  50  cases  were  treated  with  this 
method  and  with  excellent  results,  especially  cases  of 
abortion  with  large  bleedings  due  to  atonic  uteri,  and 
chronic  hemorrhagic  endometritis. 

Diihrssen  also  has  used  this  method  for  some  time, 
and  it  is  my  purpose  to  prove  the  value  of  this  method, 
for  my  results  were  uniformly  excellent.  The  improve- 
ments which  Diihrssen  made  in  the  apparatus  used  for 
this  purpose  are  undoubtedly  responsible,  in  a  great 
measure,  for  the  good  results.  Originally,  Pincus  used 
metallic  catheters  for  the  intrauterine  introduction  of 
steam.  Later  he  added  a  tube  which  permitted  the 
outflow  of  the  liquefied  steam.  Since  the  metal  tubes 
caused  deep  cauterization  and  stenosis  of  the  cervix, 
through  direct  contact  of  the  hot  catheter,  he  used  gauze 
to  protect  this  part  of  the  uterus.  Later  he  used  tubu- 
lar wooden  plates  to  protect  the  lining  of  the  cervix 
from  cauterization. 

Unfavorable  results  were  reported,  among  others,  by 
Czempin,  who  mentioned  an  atrophia  uteri  with  climac- 
terium prcecox  in  a  patient  who,  6h  months  postpar- 
tum, was  treated  by  this  method  for  a  hemorrhage  last- 
ing 8  weeks.  A  death  was  reported  from  the  clinic  of 
Traube,  due  to  necrosis  and  perforation  of  the  uterus 
resulting  in  peritonitis.  V.  Weiss  recorded  an  obliter- 
atio  uteri  in  a  nonpuerperal  case  treated  for  continued 
uterine  bleeding. 

These  failures  and  poor  results  occurred  for  the  fol- 
lowing reasons  : 

1.  The  introduced  catheter  permitted  no  outlet  for 
the  vapor,  so  that  a  continued  action  of  the  same  re- 
sulted. 

2.  The  heated  metal  catheter  caused  a  deep  cauteri- 
zation, through  direct  contact  with  the  cervix  and  uterus. 


3.  On  contraction  of  the  uterus  the  tip  of  the  metal 
catheter  exerted  a  local  and  deeply  cauterizing  action. 

The  advantages  of  the  apparatus  of  Diihrssen  are  as 
follows : 

1.  The  uterine  tube  consists  of  fiber  stuS"  which  does 
not  transmit  heat,  so  that  the  cervix  is  protected. 

2.  This  tube  is  centrally  perforated  and  its  lumen  is 
so  large  that  when  the  metal  tube  through  which  the 
steam  enters  the  uterus  is  introduced  there  is  sufficient 
room  for  an  outflow  of  steam  and  coagulated  blood. 

3.  This  metal  tube,  through  which  the  steam  passes, 
does  not  come  in  contact  at  any  point  with  the  mucous 
lining  of  the  uterus. 

I  have  used  this  method  mostly  for  bleedings  which 
could  not  be  overcome  by  other  methods.  Frequent 
cases  were  climacteric  bleeding  where  our  purpose  was 
to  cause  a  destruction  of  the  endometrium  with  result- 
ing obliteratio  cavi.  At  the  same  time  the  future  de- 
velopment of  a  corpus  carcinoma  is  in  such  cases  impos- 
sible. A  dilatation  of  the  cervix  is  a  preliminary  in  all 
cases,  not  alone  to  permit  of  an  easy  introduction  of 
the  uterine  tube  and  to  furnish  subsequently  good 
drainage,  but  also  to  permit  of  a  tactile  examination  of 
the  uterine  cavity  in  all  cases.  In  one  case,  treated  for 
continued  bleedings,  in  spite  of  the  good  results  ob- 
tained by  this  method  in  other  patients,  I  was  compelled 
to  perform  a  hysterectomia  uteri.  These  are  the  cases 
where  the  natural  sclerosis  of  the  uterine  vessels  during 
climacterium  reaches  a  very  high  grade.  In  general 
this  method  is  absolutely  specific  for  these  forms  and 
especially  valuable  when  other  means  fail.  What  is  the 
pathological  condition  in  such  a  case  ?     Bleeding  ? 

In  gynecological  hemorrhages,  if  such  from  the  vulva, 
vagina  and  portio  vaginalis  be  excluded,  visible  bleed- 
ings are  limited  to  the  cervix  and  the  uterus.  Acute  in- 
fections cause  a  certain  amount  of  hemorrhage,  but  large 
losses  of  blood  from  the  cervix  are  due  either  to  carci- 
noma, sarcoma,  myoma,  or  polyps,  conditions  easily 
diagnosed  on  proper  examination.  The  intact  lining  of 
the  cervix  does  not  bleed,  taking  no  part  in  menstrua- 
tion. An  affected  lining  of  the  cervix  bleeds  less  fre- 
quently than  the  lining  of  the  corpus  uteri,  for  it  takes 
but  slight  part  in  the  physiological  swelling  of  men- 
struation. 

Bleeding  from  the  corpus  uteri  may  be  due  to  local 
conditions,  to  affections  of  the  adnexa,  to  general  phys- 
ical disturbances,  to  nervous  or  temporary  circulatory 
phenomena.  The  only  normal  uterine  bleeding  is  men- 
struation. Every  very  strong  menstruation  or  every 
irregular  bleeding  must  be  viewed  as  pathological.  If 
the  uterus  on  examination  be  found  enlarged  the  fol- 
lowing conditions  must  be  looked  for :  myoma  or  sar- 
coma of  the  uterine  wall,  carcinoma,  sarcoma  or  polyp 
of  the  endometrium,  chronic  metritis  with  endome- 
tritis, the  complications  of  pregnancy,  such  as  endome- 
tritis, placenta  prajvia,  abortion,  retention  of  placenta 
or  decidua,  trauma,  subinvolution.  If  the  uterus  be 
not  enlarged,  there  may  be  present  endometritis  or  a 
malignant  change  or  degeneration  of  the  endometrium. 
If,  on  examination  with  a  sound,  the  inner  lining  feels 
smooth  and  even,  the  endometrium  is  probably  normal. 
Of  the  secondary  hemorrhages  from  the  uterus,  a  not 
infrequent  cause  is  acute  pyosalpinx.  In  this  category, 
above  all,  extrauterine  gestation  must  be  taken  into 
consideration.  Bleedings  due  to  tumors  of  the  ovary 
are  rare,  and  if  they  do  occur  are  the  result  of  bilateral 
tumors,  especially  carcinomata.  The  peritoneal  causes 
of  uterine  bleedings  come  under  the  head  of  pelveo- 


614 


TJtt  Philadelphia 
Mbdical  Jouknal 


] 


ATMOKAUSIS 


[MaecH  80,  1901 


peritonitis  in  that  case  the  associated  endometritis  is 
the  probable  cause.  This  holds  true  likewise  of  the 
bleedings  complicating  parametritis. 

Among  the  other  forms  of  decided  uterine  hemor- 
rhage, the  most  important  are  the  so-called  bleedings 
of  menopause.  At  the  climacterium  a  gradual  disap- 
pearance of  menstruation,  becoming  less  and  less  at 
each  period,  is  rare.  Without  a  previous  diminution  in 
the  amount  of  blood  lost  periodically,  the  menses,  as  a 
rule,  are  absent  for  one  or  two  periods,  they  then  re- 
turn at  the  regular  time,  usually  increased.  The  inter- 
val between  the  individual  bleedings  is  rarely  more 
than  five  or  six  months.  The  loss  of  blood  as  a  rule 
does  not  reach  a  dangerous  height,  but  these  bleedings 
may  occur  often  and  last  long.  We  may  have  at  first 
a  too  early  appearance  of  increased  menstruation,  and 
then  later  a  delayed  appearance  of  increased  menstrua- 
tion. In  other  cases  there  is  a  constant  oozing  of  blood 
until  the  next  flow  appears.  Even  after  a  disappear- 
ance of  menstruation  for  half  a  year  or  a  year  a  bleed- 
ing may  again  occur,  so  that  it  is  difficult  to  say  when 
a  final  cessation  has  taken  place.  In  such  cases  endo- 
metritis, myoma  and  carcinoma  must  be  excluded,  for 
if  after  an  absence  of  six  or  more  months  a  bleeding 
occurs,  it  should  be  considered  pathological  until 
proven  otherwise.  Not  infrequently  there  occur  at  the 
natural  climacteric  age,  and  likewise  much  earlier,  the 
so-called  climacterium  prtecox,  most  decided  and  long- 
continued  bleedings,  for  which  no  apparent  cause  can 
be  found. 

We  have  at  the  menopause  hemorrhages  without  de- 
cided changes  in  the  endometrium,  and  without  the 
presence  of  new  growths.  The  bleedings  are  frequently 
stopped  with  difficulty  and  recur.  These  often  con- 
tinue in  spite  of  rest  in  bed  and  the  use  of  stypticin, 
hydrastin,  ergotol.  Even  curetting  and  tamponing 
have  no  effect,  and  not  so  very  rarely  hysterectomy  is 
necessary.  Why  do  these  profuse  bleedings  occur,  and 
why  is  this  condition  found  in  younger  women  ?  What 
is  the  cause,  what  is  the  treatment  ?  This  form  of  de- 
cided hemorrhage  is  due  to  local  uterine  trophic  changes 
caused  by  a  cessation  of  function  on  the  part  of  the  ovary 
and  its  secretion.  Even  though  the  only  symptom  is 
profuse  hemorrhage,  since  the  same  changes  are  found 
in  the  uterus  in  unexplainable  bleedings  in  younger 
women,  we  must  view  these  later  cases  as  climacterium 
preecox.  The  pathological  cause  of  these  bleedings  is 
the  uterine  arteriosclerosis. 

Halban  found  that  castrated  newly-born  guineapigs 
showed  no  future  development  of  the  genitalia,  and  no 
development  of  the  uterine  muscle.  Knauer  found, 
after  castrating  rabbits,  that  the  uterus  atrophied,  and 
that  the  intermuscular  connective  tissue  was  increased. 
SokolofiF  castrated  dogs  and  found  that  the  uterus, 
especially  the  circular  layer,  became  atrophied,  the 
vessels  were  thickened  and  their  lumen  smaller.  Jent- 
zer  and  Beuttner,  on  castrating  cows,  found  an  atrophy 
of  the  muscle  and  of  the  glands  of  the  uterus,  an  in- 
creased growth  of  the  connective  tissue,  and  changes  in 
the  stratum  vasculare.  Glaevecke  and  many  others 
have  found  that  after  castration  the  uterus  of  women 
atrophies.  Benkisser  found  that  the  vessels  of  a  uterus, 
removed  3  months  after  castration,  showed  a  sclerosis 
and  an  endarteritis  obliterans.  Eckhardt  found,  one 
year  after  castration,  that  the  uterus  of  a  woman  was 
atrophied,  the  endometrium  likewise,  and  that  the  con- 
nective tissue  was  increased.  Gottschalk  found  1^ 
years  after  castration  that,  although  the  muscle  of  the 


uterus  was  well  retained,  the  mucosa  was  atrophied  and 
that  the  large  vessels  showed  a  folding  of  the  intima. 
Therefore,  after  castration,  the  changes  are  like  those 
occurring  at  the  menopause.  At  and  after  menopause 
the  uterus  undergoes  regressive  changes,  the  portio 
shrinks,  and  we  have  the  so-called  senile  uterus.  The 
wall  is  thin  and  dry,  contains  much  connective  tissue ; 
the  vessels  are  thickened,  narrow,  and  calcified.  The 
mucous  membrane  is  thin,  flattened,  and  indurated. 
This  change  occurs  likewise  in  younger  women,  and  is 
due  to  an  early  cessation  of  ovulation  and  functional 
activity  on  the  part  of  the  ovary,  and  is  therefore  an 
early  senescens,  so  that  in  cUmacterium  prsecox  we  have 
an  early  atrophy  of  the  uterine  genitalia,  often  going 
hand  in  hand  with  increasing  obesity.  Why  this  early 
change  in  the  ovary  should  occur  in  certain  ca^es  we 
do  not  know,  for  in  our  discussion  we  exclude  those 
atrophic  conditions  resulting  from  acute  infectious  dis- 
eases. Do  these  normal  changes  at  climacterium,  and  do 
increased  changes  of  this  kind  in  individual  cases  ex- 
plain the  irregular  and  profuse  hemorrhages  in  some 
patients,  and  the  uncontrollable  hemorrhages  in  others? 
The  recent  investigation  of  Pick  upon  the  amount  and 
character  of  the  elastic  fibers  of  the  uterus  throw  de- 
cided light  upon  this  question. 

Under  the  serosa,  or  peritoneal  covering  of  the  uterus, 
is  a  subserosa  which  is  absent,  however,  at  the  fundus 
and  on  most  of  the  corpus  uteri,  the  peritoneum  being 
for  that  reason  very  adherent  at  these  points.  A  mem- 
brane of  elastic  fibers  is  found  under  the  serosa  (or 
under  the  subserosa)  which  separates  it  from  the  outer 
muscular  layer  of  the  uterus  ;  this  membrane  at  times 
lies  under  the  external  muscular  layer  or  both  above  and 
below  it.  From  this  membrane  go  out  the  elastic 
fibers  found  in  the  two  outer  muscular  strata.  Between 
the  uterine  serosa  and  the  mucosa  we  distinguish  four 
layers  of  muscle-fibers  :  A,  the  stratum  subserosum, 
longitudinal ;  B,  stratum  supravasculare,  longitudinal, 
and  circular ;  C,  stratum  vasculare,  the  main  layer,  with 
its  fibers  arranged  circularly  and  about  the  vessels ;  D 
stratum  submucosum,  longitudinal.  As  said  before, 
the  elastic  fibers  of  A  and  B  are  derived  from  the 
membrane  of  elastic  fibers  usually  found  under  the 
serosa,  while  those  of  the  stratum  vasculare  are  derived 
from  the  elastic  fibers  of  the  adventitia  of  the  vessels. 
In  the  stratum  submucosum  the  elastic  fibers  are  few 
in  number.  The  elastic  fibers  of  .-1  and  B  run  at  right 
angles  to  the  muscle  fasciculi,  i.  e.,  the  muscle-fibers 
run  up  and  down,  to  the  right  and  left,  while  the  elastic 
fibers  run  dorsoveutrally,  ;'.  e.  radially,  sending  out  an- 
astamosing  branches  in  all  directions.  They  thus  form 
a  framework  or  a  collection  of  septa,  like  the  fingers  of 
the  two  hands  crossed  at  right  angles.  The  vessel  an- 
astomoses run  up  and  down,  and  the  elastic  fibers,  the 
muscle  bundles  and  the  vessels  therefore  cross  in  a 
longitudinal,  transverse,  and  sagittal  direction.  In  the 
cervix  there  is  no  such  framework.  We  have  here  two 
layers,  one  under  the  squamous  epithelium,  the  other 
about  the  vessels ;  these  layers  communicate.  It  has 
been  said  that  a  disappearance  of  the  elastic  fibers  is 
responsible  for  rigidity  of  the  cervix.  It  is,  however, 
really  due  to  a  disappearance  of  the  muscle  elements, 
and  to  their  replacement  by  sclerotic  connective  tissue, 
so  that  rigidity  is  present  in  spite  of  the  elastic  fibers. 

The  ends  of  the  elastic  fibers  of  the  uterus  run  be- 
tween the  muscle-bundles,  upon  the  surface  of  the 
bundles ;  they  may  surround  a  fasciculus  or  they  may 
perforate  it.     In  the  stratum  vasculare,  where  the  elas- 


Uabch  so,  1901] 


ATMOKAUSIS 


PThe  Philadhlphia 

L  MKDICAIi  JOUBKAL 


615 


tic  fibers  come  from  the  adventitia,  finer  fibers  are  found 
in  the  interfascicular  connective  tissue,  but  most  of 
these  are  not  connected  with  the  main  fibers.  They 
are  sometimes  absent  in  the  virgin  uterus.  Elastic  and 
fibrous  tissue,  situated  between  the  muscle-bundles, 
sends  branches  between  and  around  every  muscle- cell, 
but  always  at  right  angles  to  the  long  axis  of  the  cell. 
The  individual  muscle-cells  of  the  stratum  subserosum 
have  therefore  a  perimysium  elasticum,  and  a  peri- 
mysium fibrosum ;  the  muscle- cells  of  the  stratum 
supravasculare  and  the  stratum  vasculare  have  a  peri- 
mysium fibrosum  and  often  a  perimysium  elasticum. 
The  fibers  of  the  stratum  submucosum  have  only  a 
perimysium  fibrosum.  The  important  muscle  fasciculi 
are  thus  furnished  with  a  framework  or  elastic  support 
which  protects  the  fibers  from  over- stretching  and  per- 
mits their  return  to  normal  position  on  contraction. 
This  elastic  framework  is  especially  well  developed  in 
the  outer  layer  and  permits  any  change  of  form  on  the 
part  of  the  fibers.  We  thus  have  a  perimysium  inter- 
fasciculare  and  pericellulare.  The  circumcellular  peri- 
mysium of  the  strata  supravasculare  and  vasculare  is 
not  so  regularly  defined  or  so  rich  as  in  the  outer  layer, 
and  is  much  less  so  in  the  inner  layer.  A  perimysium 
elasticum  is  present  in  the  external  layer  of  the  cervix. 
This  arrangement  whereby  the  main  amount  of  elastic 
tissue  is  placed  in  the  outer  two  layers  of  the  uterus 
has  the  advantage  that  it  does  not  interfere  with  the 
contraction  of  the  vessels ;  besides,  any  two  points  in 
the  periphery  are  further  separated,  on  dilatation  of 
the  uterus,  than  two  points  near  the  center,  so  that  this 
supply  is  adapted  to  subsequent  demands.  The  arrange- 
ment whereby  the  elastic  fibers  are  arranged  at  right 
angles  to  the  muscle-fibers  prevents  any  interference 
with  contraction  of  the  muscle  and  the  vessels.  The  above- 
mentioned  is  the  natural  condition  found  between  birth 
and  the  climacterium,  namely,  elastic  fibers  in  the 
interstices  of  the  muscle-bundles  and  the  muscle-fibers. 

In  the  first  half  of  pregnancy,  so  long  as  the  myome- 
trium grows,  the  elastic  fibers  undergo  hyperplasia.  The 
same  is  true  of  the  parauterine  and  periuterine  elastic 
fibers.  In  the  second  half  there  is  a  diminution,  prob- 
ably relative,  through  stretching;  possibly,  however, 
there  is  an  absolute  diminution.  This  seems  to  be  irra- 
tional in  view  of  the  future  stretching  to  which  the  lower 
uterine  segment  is  to  be  subjected  during  labor;  but  in 
pregnancy  there  is  a  huge  increase  in  the  elastic  struc- 
tures situated  at  the  sides  of  the  uterus  and  around  the 
lower  uterine  segment,  so  that  on  subsequent  dilatation 
there  is  no  interference  with  the  muscle  fibers  of  the 
uterine  wall.  This  vicarious  growth  of  powerful  para- 
and  perimetritic  elastic  fibers,  the  course  of  the  uterine 
fibers  at  right  angles  to  the  line  of  contraction  of  the 
muscle-bundles,  the  network  of  elastic  and  fibrous 
perimysium  about  the  individual  fibers,  the  equal  dis- 
tribution of  the  coarse  and  fine  elastic  fibers  in  the 
external  wall  of  the  uterus,  are  ideal  conditions  ;  yet  this 
typical  arrangement  is  somewhat  lost  in  pregnancy  and 
the  vessels  of  the  stratum  vasculare  show  proliferation, 
in  places,  of  the  elastic  fibers  of  the  intima. 

During  the  puerperium,  however,  there  is  a  decidedly 
increased  formation  of  elastics,  and  after  labor  their 
increase  is  permanent,  hand  in  hand  with  an  increase 
of  the  muscle  fibers  and  a  thickening  of  the  vessels. 

The  typical  arrangement  of  the  elastic  fibers  is  lost 
in  pregnancy,  at  the  climacterium  and  likewise  in  the 
presence  of  myomata  and  in  chronic  metritis.  The 
fibers  are  thickened  and  increased  in  number,  and  we 


might  say  that  the  typical  arrangement  is  heightened, 
in  chronic  inflammations,  in  the  first  half  of  pregnancy 
and  at  the  puerperium.  The  fibers  are  swollen  through 
serous  infiltration  in  pregnancy  in  the  puerperium  and 
in  metritis  exudativa.  The  fibers  are  degenerated  in 
pus  infiltrations.  The  fibers  increase  in  thickness  up 
to  the  age  of  50.  After  50  they  lose  their  continuity 
and  become  brittle  and  irregular.  In  old  age  they  form 
lumpy  groups  in  which  the  individual  elastic  fibers  are 
to  be  scarcely  recognized,  and  form  groups  around  the 
arteriosclerotic  vessels  which  are  likewise  grouped 
together.  The  elastic  fibers  disappear  from  the  inter- 
fascicular connective-tissue  interstices,  so  that  the  cir- 
cum vascular  islands  of  elastic  fibers  lose  all  connection 
with  each  other. 

It  may  with  truth  be  said  that  the  thinner  the  wall 
of  the  uterus  and  the  more  shrunken  the  cervix  the 
larger  is  the  amount  of  elastic  fibers,  so  that  in  the 
senile  uterus  the  elastic  fibers  of  the  corpus  and 
cervix  are  increased.  A  like  condition  is  found  in  cas- 
tration atrophy,  and  in  addition  the  walls  of  the  vessels 
are  thickened  and  the  elastic  fibers  in  the  adventitia  are 
increased  in  amount.  In  atrophia  uteri  there  is  then 
an  increased  supply  of  elastic  fibers.  This  is  not  alone 
a  local  condition,  but  is  part  of  a  general  increase,  such 
as  takes  place  in  the  kidney,  liver,  testicle,  heart,  spleen, 
etc.,  and  is  an  attempt  at  compensation  for  the  disturbed 
mechanical  relations  due  to  the  loss  of  epithelial  and 
muscular  tissues.  It  is  true  then  that  the  greater  the 
atrophy  the  larger  is  the  number  of  elastic  elements, 
and  that  an  increase  of  elastic  elements  is  present  in  all 
atrophies  of  the  uterus,  whether  natural,  artificial,  or  as 
a  result  of  disease.  The  elastic  fibers  in  the  arterioscle- 
rotic vessel  walls  of  the  stratum  vasculare  are  increased 
and,  passing  out  into  the  myometrium,  they  substitute 
the  muscle-bundles,  which  is  of  itself  a  proof  that  the 
adventitia  is  a  source  for  their  formation.  We  have 
therefore  a  hyperplasia  of  the  connective  tissue  hand- 
inhand  with  a  gradual  degeneration  of  the  muscle-fibers 
at  menopause  and  in  climacterium  pr;ecox,  so  that  a 
framework  is  formed  in  the  uterine  wall,  in  the  meshes 
of  which  lie  the  degenerating  muscle-cells,  accompanied 
by  an  increase  of  the  fibrous  perimysium,  especially  in 
the  external  layers.  The  elastic  elements  are  thickened 
and  lumped,  likewise  in  the  pericellular  and  interfas- 
cicular spaces.  The  stratum  submucosum  has  natu- 
rally few  elastic  fibers,  and  we  have  here  an  elastose  of 
the"  bloodvessels.  Therefore  in  atrophy  we  have  a 
diminution  of  the  muscle  elements,  an  increased 
amount  of  fibrous  connective  tissue,  and  increased 
amount  of  elastic  elements  of  poor  quality.  Even  if 
the  latter  are  not  increased  in  amount  they  are  thick- 
ened, brittle,  and  form  polyp  like  groups.  The  greater 
the  hyaline  and  sclerotic  changes  in  the  vessel- walls  the 
greater  is  the  amount  of  the  elastic  elements.  So  much 
for  the  valuable  investigations  of  Pick. 

Pichevin  and  Petit  curetted  a  41  year-old  multipara 
for  continued  uterine  bleedings,  with  no  improvement. 
While  performing  a  second  curettage  the  bleeding  frop 
the  uterus  was  so  profuse  that  it  was  necessary  to  extir- 
pate it.  Examination  showed  an  increase  in  the  num- 
ber of  vessels  which  showed  very  much  thickened 
walls,  especially  in  the  middle  layer  of  the  uterus.  The 
muscularis  was  found  almost  substituted  by  vessels. 

Marches!  reported  a  case  of  a  32-year-old  multipara 
who  had  aborted  several  times.  For  great  bleedings 
abrasio  was  done,  but  the  bleedings  increased  and  an 
hysterectomy  was  performed.     The  uterus  was  found 


616  "^^^  Philadelphia"! 

Medical  Journal  J 


ATMOKAUSIS 


[Makch  3*',  19«1 


to  be  increased  in  size,  and  its  walls  were  filled  with  the 
gaping  lumina  of  blood-  and  lymph-vessels.  Towards 
the  mucosa  the  bloodvessels  were  increased  so  that  at 
this  part  the  uterine  stucture  had  the  appearance  of 
cavernous  tissue.  The  adventitia  of  the  arteries  showed 
an  increase  of  connective  tissue,  the  intima  was  thick- 
ened and  uneven.  Marchesi  observes  the  occurrence  of 
bleedings  which  are  not  controlled  by  abrasio,  and 
where  the  endometrium  shows  no  great  changes.  The 
pathological  condition  is  therefore  a  change  in  the 
vessels  themselves.  He  quotes  from  the  French  litera- 
ture 6  recent  cases  of  this  character  showing  no  affection 
of  the  glands,  of  the  interstitial  tissue,  or  of  the  uterine 
parenclayma,  but  decided  changes  in  the  vessels  of  the 
mucous  membrane  and  the  muscularis. 

Keinicke  reported  4  cases,  2  of  which  suffered  from 
uterine  bleedings  which  could  not  be  controlled,  the 
other  2,  in  addition,  showed,  on  examination  of  the 
scrapings,  suspicious  areas.  In  these  cases,  secale  and 
ergotin  were  of  no  value,  dilatation  of  the  cervix  and  the 
application  of  liquor  ferri  brought  only  temporary  re- 
lief, and  extirpation  was  necessary.  Examination 
showed  that,  with  degeneration  of  the  muscularis,  the 
arteries  became  stiff  tubes.  All  four  cases  showed  a 
thickened  media  of  the  vessels  and  a  growth  of  peri- 
vascular and  intermuscular  connective  tissue.  This  con- 
dition is  viewed  as  an  arteriosclerosis. 

Cholmogoroff  reports  2  cases,  where  the  severity  of  the 
bleedings  endangered  life.  No  new  growths  or  decided 
changes  of  the  endometrium  were  present,  and  curetting 
brought  no  relief.  The  first  case,  a  42-year  old  XIpara, 
had  aborted  six  times.  Her  menstruation  had  become 
gradually  stronger,  returning  every  3  weeks,  and  lasting 
8  days,  with  a  loss  of  much  blood  and  many  coagula. 
In  the  intervals  fluor  albus  was  present.  Hydrastis 
and  ergotin  being  of  no  avail,  an  abrasio  was  per- 
formed and  showed  no  abnormal  condition  of  the  endo- 
metrium. After  a  bleeding  which  nothing  could  con- 
trol, the  uterus  was  extirpated.  On  section,  the  vessels 
of  the  wall  gaped.  The  mucosa  was  normal,  the  small 
vessels  showed  the  intima  to  be  thickened  in  spots,  and 
almost  obliterated.  The  muscularis  showed  an  increase 
in  the  number  of  vessels,  but  this  was  possibly  an  illu- 
sion due  to  their  twisted  course.  All  the  vessel  walls 
were  thickened  with  a  diminution  of  the  lumen.  The 
connective  tissue  was  increased. 

The  second  case  was  a  patient,  31  years  old,  who  had 
aborted  twice.  Her  menstruation  lasted  8  to  10  days, 
and  was  very  profuse,  recurring  every  3  and,  later,  every 
2  weeks.  Leukorrhea  was  also  present.  An  abrasio 
showed  a  normal  mucous  membrane  with  hemorrhagic 
areas.  The  bleedings  recurred  so  often,  and  were  so 
profuse  that  an  extirpatio  uteri  was  performed.  The 
muscularis  was  firm  and  grated  on  incision.  The  ves- 
sels looked  like  pale  strips  on  the  cut  surface,  and  their 
lumina  gaped.  The  connective  tissue  was  increased. 
There  was  a  thickening  of  the  arterial  walls  in  the 
muscularis,  especially  of  the  media  and  the  intima. 
There  was  an  increase  in  the  connective  iissne,  especially 
that  seeming  to  come  from  the  adventitia  of  the  vessels. 

We  have,  therefore,  a  very  clear  picture  of  the  path- 
ological changes  and  several  distinct  conditions  which 
make  a  diagnosis  positive.  When  menstruation  becomes 
severe,  menorrhagia,  or  metrorrhagia,  and  no  local 
changes  in  the  endometrium  can  be  observed  with  a 
sound  or  with  the  examining  finger,  we  may  take  it  for 
granted  that  the  following  conditions  are  present :  (1) 
Degenerating  muscle-fibers  poor  in  contractile  power ; 


(2)  an  increased  amount  of  fibrous  connective  tissue ; 

(3)  an  increased  amount  of  elastic  fibers  thickened  and 
brittle  ;  (4j  arteriosclerotic  vessels.  Age  is  no  criterion, 
since  these  changes  may  occur  long  before  the  natural 
climacteric  period.  If  ergotin,  stypticin,  etc.,  are  of 
no  avail ;  if  no  decided  changes  in  the  adnexa,  suflS- 
cient  to  warrant  their  being  considered  the  cause  of  the 
hemorrhage  be  present ;  if  an  abrasio  shows  no  altered 
condition  of  the  endometrium ;  and  if,  above  all,  an 
abrasio  does  not  control  the  hemorrhage,  then  the  diag- 
nosis of  arteriosclerosis  must  be  made.  It  is  scarcely 
necessary  to  mention  that  myomata,  sarcomata,  and 
other  local  conditions  are  to  be  excluded  on  examination. 
What  is  the  best  method  of  treatment  in  these  cases  ? 

Among  the  cases  reported  by  Diihrssen  are  the  fol- 
lowing :  A  37-year-old  bleeder,  decidedly  weakened  by 
profuse  and  long  menstruations,  and  referred  for 
hysterectomy,  was  atmokaused  for  2  minutes.  Nine 
days  later  a  tubular  membrane  consisting  of  the  entire 
mucous  lining  and  the  adjoining  muscular  layer  was 
expelled.  Twenty  days  after  the  first  vaporization  a 
second  was  performed  lasting  H  minutes.  There  re- 
sulted an  atrophy  of  the  uterus  ^  cm.  above  the 
external  os. 

Another  patient  suffered  for  4  years  with  almost 
daily  hemorrhages  and  was  curetted  four  times  and 
treated  locally  without  result.  Gradual  expulsion  of 
the  mucous  membrane  occurred  after  atmokausis.  In 
the  next  three  months  normal  menstruation  occurred 
twice  ;  then  atrophy  of  the  uterus  and  obliteratio  cavi 
as  in  case  one. 

In  a  third  case  treated  in  the  same  manner  an  oblit- 
eratio oavi  likewise  resulted,  in  all  probability,  for 
amenorrhea  was  present  6  months.  A  fourth  patient 
menstruated  profuselj'  for  4  years  as  the  result  of  the 
presence  of  an  interstitial  myoma,  the  size  of  an 
apple.  Curetting  brought  only  temporary  benefit 
Because  of  a  decided  bleeding  lasting  2.5  days,  she  waa 
vaporized  for  1  minute.  Bleeding  ceased  at  once.  The 
next  menstruation  occurred  after  9  weeks,  lasting  only 
1  day.  Decided  diminution  in  the  size  of  the  uterus 
and  its  cavity  was  observed. 

Pincus  mentioned,  among  his  first  cases,  a  patient 
suffering  from  climacteric  hemorrhages.  The  uterus 
was  diffusely  fibromatous.  Large  dose  of  stypticin, 
tamponade  of  the  uterus  and  curettage  were  without 
effect.  After  vaporizing  one  minute,  at  a  temperature 
of  105°  C,  bleeding  stopped.  Fluor  lasted  12  days. 
Even  after  a  period  of  11  weeks  there  was  no  return  of 
bleeding.  His  results  in  the  treatment  of  post-climac- 
teric fluor  were  excellent,  since  an  obliteration  of  the 
uterine  lining  resulted.  In  IS  cases  of  climacteric 
bleedings  from  the  uterus,  treated  by  this  method,  13 
showed  permanent  benefit,  evidenced  by  a  cessation  of 
bleeding  lasting  in  the  various  cases  at  the  time  of 
writing  from  2  years  to  5  months.  In  5  cases  the 
period  of  observation  was  not  sufficiently  long  to 
decide  whether  the  cessation  was  permanent.  In  2 
cases  the  procedure  was  repeated  after  S  to  11  weeks. 
In  3  of  his  own  cases,  which  had  been  advised  to 
undergo  a  total  extirpation,  obliteratio  was  obtained  by 
this  method,  and  this  result  was  frequently  obtained 
in  other  cases  reported  to  him.  so  that  Pincus  believes 
an  extirpatio  uteri  to  be  no  longer  a  necessity  in  these 
cases, 

Czempin  reported  a  case  vaporized  by  other  hands. 
The  patient,  27  years  old,  menstuated  for  the  first  time 
after  labor  after  4^  months.     The  menstruation   lasted 


March  30,  1901] 


ATMOKAUSIS 


rPHK  PHILABBUHIA 

1_  Mbdic&x  Jovsjsax. 


617 


8  weeks.  Atmokausis  stopped  the  bleeding  at  once. 
Menstruation,  however,  did  not  recur  and  the  patient 
suffered  from  symptoms  of  climacterium  pnpcox.  The 
uterus  was  found  to  be  small  and  hard,  the  cervix  was 
obliterated  by  cicatricial  adhesions. 

V.  Weiss  atmokaused  at  100°  C.  for  f  of  a  minute  a 
19-year-old  nullipara  who  menstruated  profusely  for 
8  to  12  days,  sometimes  twice  a  month.  E.Kamined 
after  4  weeks,  the  uterus  lining  was  insensitive,  a  sound 
was  easily  passed.  Later,  no  menstruation  occurred 
and  the  patient  suffered  with  headache  and  bleedings 
from  the  nose.  Several  months  later  the  uterus  was 
found  to  be  small,  hard  and  shrunken ;  the  cervix  was 
closed  by  cicatrices  and  a  sound  could  not  be  passed. 
Two  months  later  a  protrusion  at  the  external  os  was 
seen  and  was  cut  with  scissors.  Only  the  cervix  was 
then  passable  for  the  sound,  a  distance  of  3  cm.  The 
body  of  the  uterus  was  flat  and  shrunken. 

It  is  to  be  understood  that  I  have  mentioned  the  cases 
of  Czempin  and  v.  Weiss  not  as  instances  of  arterio- 
sclerosis, nor  simply  as  an  evidence  of  the  value  of  this 
method  in  these  two  individual  case.  I  have  included 
them  in  this  portion  of  the  paper  to  show  what  the 
effects  of  atmokausis  may  be,  and  the  fact  that  the  sad 
results  above  mentioned  were  due  to  this  method  speaks 
by  no  means  against  it,  for,  on  the  other  hand,  they 
have  served  to  define  the  limit  of  time  for  an  atmokausis 
where  no  obliteratio  cavi  is  desired.  It  should  be 
known  that  vaporization  is  used  for  a  large  number  of 
gynecological  affections,  in  addition  to  uterine  bleed- 
ings due  to  endometrial  changes,  and  to  climacteric 
local  processes.  Pincus  and  others  use  this  method  in 
quite  an  extended  class  of  cases.  For  ordinary  use  the 
duration  of  vaporization  is  10  to  30  seconds  ;  for  oblitera- 
tion, 2  minutes  or  more  at  a  temperature  of  100  to  110°  C. 
Pincus  finds  as  indications  for  this  method  the  follow- 
ing forms  of  affection  :  Endometritis,  especially  hem- 
orrhagic and  gonorrheal,  incipient  puerperal  endo- 
metritis, uterine  atony,  bleeding  due  to  interstitial  my- 
oma, subinvolution,  as  a  preliminary  to  hysterectomy, 
as  a  palliative  in  inoperable  carcinoma,  in  putrid  abor- 
tion. To  this  treatment  of  the  last  mentioned  affection 
decided  objection  has  been  raised  on  many  sides.  In 
addition,  the  method  is  used  by  Pincus  very  frequently 
in  the  treatment  of  climacteric  bleedings  and  senile 
catarrh,  in  both  of  which  cases  an  obliteration  of  the 
uterine  cavity  is  desired.  He  finds  the  contraindica- 
tions to  be  malignant  growths  of  the  uterus,  tumor 
conditions  of  the  tubes,  and  adnex  abscesses. 

The  limits  and  absolute  indications  for  this  method 
are  not  yet  defined.  The  generally  accepted  indications 
are  those  followed  by  Fehling,  who  has  obtained  good 
results  in  bleedings  due  to  endometrial  changes,  and  in 
climacteric  bleedings.  On  the  fourth  to  sixth  day 
after  curettage  he  atmokauses  for  five  to  twenty  seconds 
at  a  temperature  of  110-115°  C.  As  said  before,  we 
used  this  method  in  the  clinic  Diihrssen  generally  for 
uterine  bleedings,  not  controlled  by  the  curette  and  bj' 
local  treatment.  That  excellent  results  are  obtained, 
and  that  an  obliteration  of  the  uterine  cavity  is  not  its 
only  value,  may  be  seen  from  the  following  cases  treated 
by  atmokausis:  A  newly  married  patient  suffering 
from  gonorrheal  endometritis  became  pregnant  five 
moHths  after  vaporization  by  Diihrssen,  giving  birth  to 
a  child  later  at  full  term.  In  this  case,  metal  catheters 
being  then  in  use,  a  beginning  cervical  stenosis,  result- 
ing from  direct  contact  of  the  heated  catheter,  was  over- 
come by  dilatation.     The  second  case  was  a  34-year-old 


I  Vpara,  who  later  aborted  twice.  After  the  last  abortion 
two  menstrual  periods  were  accompanied  by  a  decided 
loss  of  blood.  After  curettage,  the  next  menstruation 
was  normal,  but  recurred  later  at  intervals  of  23  days, 
the  menorrhagia  lasting  six  days.  Vaporization  lasting 
one-half  minute  was  followed  for  a  few  days  by  a  decided 
serous,  yellow  fluor,  perfectly  odorless.  After  regular 
menstruation  for  three  months,  it  disappeared  for  three 
months,  when  its  place  was  taken  by  a  brown  discharge 
which  returned  for  four  consecutive  months.  Examina- 
tion showed  the  patient  to  be  in  good  condition  with  a 
uterus  the  size  of  a  fist,  evidencing  in  addition  Hegar's 
sign.  Diagnosis,  gravidity.  Three  weeks  later  she 
aborted.  In  these  two  cases  atmokausis  stopped  the 
bleeding  when  local  treatment  and  curettage  faOed. 
The  normal  character  of  the  regenerated  mucous  mem- 
brane was  evidenced  subsequently,  by  the  history  of  the 
cases  and  subsequent  pregnancy. 

The  procedure  in  treating  patients  with  this  method 
is  as  follows  :  A  positive  diagnosis  of  the  condition  at 
hand  must  be  made  in  all  cases.  Dilatation  of  the  cer- 
vix is  an  all-important  preliminary  for  many  reasons.  It 
permits  of  the  examination  of  the  uterine  cavity  with 
the  finger.  If  no  local  changes  are  present,  and 
if  there  is  no  retention  of  fetal  membranes,  not  infre- 
quently vaporization  suflices  without  previous  curet- 
tage. Retained  membranes  and  malignant  changes 
must  be  excluded  before  using  this  method.  Only  the 
finger  can  prove  absolutely  that  the  uterus  is  empty, 
and  only  curettage  aided  by  examination  with  the 
finger  makes  it  certain  that  we  have  removed  those 
portions  of  the  endometrium  which  are  abnormal,  and 
which  are  to  be  examined  for  malignant  changes.  In 
addition,  dilatation  of  the  cervix  changes  the  three- 
cornered  uterus  into  a  circular  canal  so  that  subsequent 
use  of  steam  affects"  all  parts  of  its  lining  equally.  In 
addition,  dilatation  of  the  cervix  permits  of  the  use  of 
a  large  uterine  tube,  so  that  when  the  metal  catheter, 
through  which  the  steam  passes,  is  introduced  there  is 
sufficient  room  in  the  uterine  tube  for  the  exit  of  the 
liquefied  steam,  and  coagulated  blood  and  serum. 
Lastly  and  equally  important  is  the  fact  that  a  dilated 
cervix  permits  of  a  readier  natural  drainage  of  the 
uterus  during  the  subsequent  period.  A  necessary 
preliminary,  then,  not  alone  for  the  sake  of  a  positive 
diagnosis,  but  for  the  other  reasons  mentioned,  is  dila- 
tation of  the  cervix,  for  which,  in  all  cases  when  feasi- 
ble, laminaria  are  used.  For  performing  vaporization 
narcosis  is  never  necessary,  since  the  uterus  loses  its 
sensitiveness  on  the  contact  of  steam.  It  is  only  when  this 
is  applied  to  the  cervix  that  some  pain  is  experienced. 
As  a  rule,  the  cervix  must  not  be  treated,  for  atresia 
is  possible  before  obliteration  of  the  uterine  canal,  in 
those  cases  where  obliteration  is  desired.  If,  however, 
the  cervix  be  likewise  vaporized,  in  such  cases  attention 
must  be  paid  to  the  prevention  of  too  early  atresia.  On 
the  introduction  of  two  Simon's  specula,  after  disinfec- 
tion of  the  vagina  and  cervix  with  lysol,  the  posterior 
lip  of  the  cervtx  is  grasped  with  volsellum  forceps.  The 
uterine  tube,  having  been  previously  boiled,  is  then 
introduced  in  the  cervix.  This  tube  is  marked  so  that 
it  can  be  easily  determined  how  far  it  has  been  intro- 
duced. If  the  entire  uterine  cavity  is  to  be  treated  for 
onlv  a  few  seconds,  the  uterine  tube  is  introduced  as 
far  as  the  internal  os.  If  the  entire  uterine  cavity  is  to 
be  treated  for  several  minutes  with  the  purpose  of  oblit- 
erating it,  the  uterine  tube  after  previous  measurement 
of  the°ut«ru3  with  the  sound  is  introduced  to  within 


618 


Tme  Philadelphia 
Medical  Journal 


] 


COEXISTENCE  OF  CARCINOMA  AND  FIBROMA 


[MlBCH  SO,  1901 


2  cm.  of  the  fundus,  the  markings  on  the  uterine  tube 
permitting  this  to  be  done  with  exactness.  The  metal 
tube  which  carries  the  steam  is  then  introduced,  a  bulb 
at  its  lower  end  closing  the  opening  at  the  external 
end  of  the  uterine  tube.  During  the  process  of  treat- 
ment this  inner  metal  catheter  is  moved  occasionally 
to  permit  the  outflow  of  liquefied  steam  and  coagu- 
lated blood,  and  to  prevent  too  high  pressure  in  the 
uterus.  Shortly  after  contact  of  the  steam  the  uterus 
contracts,  and  during  the  following  minutes  the  uterine 
tube  is  slowly  and  gradually  drawn  out  until,  when  it 
reaches  the  internal  os,  the  entire  inner  surface  of  the 
uterus  has  been  affected.  If  desired,  the  tube  is  drawn 
out  up  to  the  external  os,  whereby  action  on  the  lining 
of  the  cervix  likewise  takes  place.  The  inner  metal 
catheter  does  not  extend  fully  up  to  the  end  of  the 
uterine  tube,  so  that  at  no  time  is  it  in  contact  with  the 
uterus  or  cervix.  The  uterine  tube  being  made  of  fiber 
stuff  and  transmitting  no  heat  protects  the  cervix  fully 
from  contact  with  the  heated  metal  inner  tube.  After 
treatment,  rest  in  bed  for  lO  to  14  days  is  necessary;  no 
irrigations  being  given  except  a  vaginal  irrigation  after 
several  days,  if  a  large  serous  flow  make  the  patient 
uncomfortable. 

The  duration  of  the  application  of  steam  is  as  a 
rule  15  to  20  seconds  in  younger  women,  where  no 
obliteration  is  desired ;  4  to  8  minutes  if  total  oblitera- 
tion be  intended.  The  temperature  used  is  100°  C.  in 
the  boiler  of  the  instrument,  which  temperature  is  there 
registered  by  a  thermometer.  The  boiler  of  the  instru- 
ment is  covered  by  a  safety-valve  which  eliminates  all 
danger,  for  the  outlet  tube  is  controlled  by  a  stop-cock 
for  two  purposes.  Firstly,  it  may  be  desired  to  use 
steam  of  a  higher  temperature  which  can  readily  be 
obtained  if  the  stop-cock  be  closed.  Secondly,  before 
introducing  the  metal  catheter,  conveying  the  steam 
into  the  uterine  tube,  the  stop-cock  is  opened  to  eee  if 
the  steam  appears  and  to  remove  from  the  metal  cathe- 
ter any  water.  The  stop- cock  is  then  closed  for  a  sec- 
ond or  two  until  the  catheter  is  introduced  into  the 
uterine  tube.  At  any  time,  if  desired,  the  supply  of 
steam  may  thereby  be  shut  off. 

It  has  been  found  experimentally  that  the  steam 
when  it  enters  the  uterus  is  probably  of  a  temperature 
of  about  70°  C,  if  the  thermometer  in  the  boiler 
registers  100°.  Whether  this  be  true  or  not,  con- 
tinued practice  with  this  apparatus  has  shown  that  the 
above-named  limits  are  absolute.  There  is  generally  a 
serous  discharge  for  days  or  weeks  after  this  treatment. 
The  action  upon  the  uterus  and  its  lining  may  be 
judged  by  the  character  of  the  necrotic  tissue  which  is 
thrown  off"  in  bits,  or  as  a  whole.  This  necrotic  tissue 
makes  its  appearance  in  from  6  to  10  days  if  the  action 
has  been  superficial,  and  in  10  or  more  days  if  a  deeper 
cauterization  has  resulted.  If  this  method  is  to  be  re- 
peated, it  should  be  done  only  after  a  lapse  of  4 
weeks,  when  the  mucous  lining  has  been  regenerated. 
Not  infrequently  after  this  treatment,  irregular  bleed- 
ings or  one  or  two  increased  menstrual  bleedings  may 
occur.  The  former  are  the  result  of  the  throwing  off 
of  necrotic  tissue,  the  latter  gradually  go  over  into 
natural  menstruation.  The  action  of  this  method  in 
causing  involution  may  be  seen  from  the  fact  that 
in  a  case  of  metritis  chronica,  with  a  uterine  cavity  12 
cm.  in  length,  six  months  after  vaporization  the  uterine 
cavity  measured  6  cm.  This  patient  had  been  curetted 
twice,  had  been  treated  with  local  application  of  iodin, 
and  with  numerous  internal  remedies.     The  contrain- 


dications to  the  use  of  this  method  in  cases  not  de- 
manding operation  for  other  conditions  are  malignant 
changes  of  the  endometrium,  and  the  presence  of  re- 
tained placentae  or  membranes.  Other  contraindica- 
tions are  those  affections  of  the  tubes,  and  those 
inflammatory  conditions  which  are  generally  recognized 
as  contraindications  to  curettage.  While  the  value  of 
atmokausis  in  other  conditions  is  still  a  question  of 
personal  experience,  there  is  no  doubt  that  uterine 
bleedings,  especially  the  bleedings  of  climacterium, 
and  the  uncontrollable  hemorrhages  occurring  at  thia 
period,  and  in  earlier  years,  are  positive  indications  for 
its  use,  especially  when  curettage  and  other  local 
methods  are  of  no  avail.  Since  our  experience  and  the 
investigations  mentioned  above  have  proven  the  larger 
proportion  of  such  cases  to  be  due  to  local  degener- 
ative changes,  we  may  say  that  atmokausis,  if  not  a 
specific,  is  at  least  the  best  method  of  treatment  for 
uterine  arteriosclerosis. 


THE  COEXISTENCE   OF   CARCINOMA  AND  FIBROMA 
IN  THE  CORPUS  UTERI.' 

By  W.  a.  NEWMAN  BORLAND,  A.M.,  M.D, 

of  Philadelphia. 

Associate  in  Gynecology,  Philadelphia   Polyclinic;  Assistant  Obstetr'ciac   to 
the  Ho>i)italof  the  Unireisity  of  Penosylvania,  etc. 

I. — The  Frequency  of  Uterine  Fibroma. 

Two  years  ago  I  had  the  honor  of  reading  before 
this  society  a  paper  on  the  modern  methods  of  treat- 
ment of  fibroma  of  the  uterus,  which,  as  you  know,  is 
one  of  the  commonest  pathologic  conditions  of  woman- 
kind, and  one  of  divers  clinical  aspect.  Thus,  accord- 
ing to  the  investigations  of  Champneys'  based  upon 
the  records  of  St.  Bartholomew's  Hospital,  of  all  the 
patients  seen  in  the  Department  for  Diseases  of  Women 
from  January,  1866,  to  July  13,  1899 — a  little  over 
40,000  women — together  with  almost  6,000  patients 
admitted  to  the  wards  of  that  hospital,  from  3  to  IS^fc 
of  these  cases  showed  the  presence  of  uterine  fibroids 
in  varying  degrees  of  development.  Pozzi  claims  that 
one-fifth  of  all  women  who  arrive  at  the  age  of  35  are  so 
afllicted,  while  Klob  states  that  40%  of  the  uteri  of 
females  who  die  after  the  fiftieth  year  contain  fibroid 
tumors.  Bayle  asserts  that  20%  of  all  women  over  35 
years  of  age  present  uterine  fibroids,  while  Winckle  in 
575  autopsies  upon  females  found  only  12%  fibroma- 
tous.  Of  135  women  dead  under  35  years  of  age  ex- 
amined by  Martin  only  5%  had  fibroids.  Senn  claims 
that  marriage  increases  the  frequency  of  the  disease, 
and  that  in  33%  of  the  married  women  the  tumors 
cause  sterility.  According  to  Twombly"  another  set  of 
statistics  show  that  these  growths  occur  in  the  unmar- 
ried 25%  and  in  the  married  75%.  and  that  30%  of 
the  married  remain  sterile.  As  you  will  note  from  the 
foregoing  statistics  my  original  assertion  that  this  is  one 
of  the  commonest  afflictions  of  womankind  may  be 
amply  verified. 

II. — Cancerous  Degeneration  of  Fibroid  Tumor  of 
the  Uterus. 

To-night  I  shall  present  to  you  one  of  the  rarer 
manifestation  of  the  diseases — a  form  of  degeneration 


•  Read  before  the  Barton  Cooke  Hirst  Obstetrical  Society  of  the  Unirersitjr  of 
Pennsylvania,  February  28,  1901,  and  the  .ludson  Daland  Society  of  tlie  U«l- 
rerdty  of  Pennsylvania.  March  IS,  19C1. 


March  30,  1901] 


COEXISTENCE  OF  CARCINOMA  AND  FIBROMA 


TThe  Philadelphia  619 

L  Mp:ihcal  J(jurnal 


which,  it  is  claimed  by  many  writers  in  gynecology, 
fibroid  tumor  has  never  been  conclusively  demonstrated 
to  have  undergone.  I  refer  to  carcinomatous  changes 
in  the  fibroid  tumor  itself  and  in  the  corporeal  endo- 
metrium— a  condition  quite  distinct  from  carcinoma 
of  the  cervix  of  a  fibromatous  uterus.  The  association 
of  carcinoma  of  the  cervix  with  uterine  fibroids  is  of 
comparatively  frequent  occurrence,  and  will  not  receive 
extensive  consideration  at  this  time.  It  is  now  very 
generally  admitted  by  scientific  investigators  that  the 
combination  of  malignant  and  benign  tumors  in  the 
uterus  is  quite  possible,  Roger  Williams*'  stating  that 
fibroids  coexist  with  uterine  cancer  at  some  point  in 
that  organ  in  9%  of  necropsies,  and  that  uterine 
fibroma  and  cancer  of  other  localities  coexist  to  the 
extent  of  18.5%,  while  Chiari''  claimed  that  uterine 
fibroma  predisposed  to  the  development  of  carcinoma 
either  in  that  organ  or  elsewhere.  Williams  and  others, 
however,  reject  this  statement  as  unfounded  in  fact. 
Carcinomatous  degeneration  of  a  fibromyoma,  on  the 
contrary,  is  quite  a  rare  occurrence. 

Last  summer  I  performed  a  hysterectomy  upon  a 
patient  primarily  for  the  relief  of  carcinoma  of  the 
fundus  uteri,  the  diagnosis  having  been  made  from  a 
microscopic  examination  of  scrapings  removed  two 
weeks  before  the  major  operation.  The  uterus  at  the 
time  of  the  abdominal  section  was  found  to  be  infil- 
trated with  small,  nodular,  fibromatous  growths,  one 
of  which,  submucous  in  situation  and  projecting  well 
into  the  uterine  cavity,  had  become  involved  in  a 
cancerous  process.  I  present  the  result  of  the  patho- 
logic examination  of  the  specimen  which  was  made  by 
Drs.  Kirkbride  and  Deal,  of  the  Polyclinic  Hospital. 
A  pathetic  incident  associated  with  this  report  is,  that 
it  was  probably  the  last  examination  ever  made  by  Dr. 
Kirkbride,  who  succumbed  shortly  afterwards  to  an 
attack  of  typhoid  fever.  Drs.  Kirkbride  and  Deal 
write  as  follows : 

Microscopic  examination  shows  the  uterus  fairly 
normal  in  shape  with  the  presence  of  numerous  fibroids 
in  its  walls.  It  measures  15x14x13  cm.  in  diameter, 
and  is  of  very  firm  consistence.  The  external  surface 
is  studded  here  and  there  with  small,  round,  firm 
masses.  The  cut-surface  shows  the  uterine  cavity  to 
be  of  fairly  normal  size,  and  the  uterine  walls  are  thick- 
ened from  the  presence  of  numerous  fibroids.  The 
internal  surface  of  the  uterus  is  studded  with  small 
fibroid  nodules  and  three  millimeters  from  the  line  of 
the  cervical  incision  is  a  thickening  of  the  endome- 
trium, of  oval  shape,  measuring  10x6  mm.,  and  elevated 
2  mm.  above  the  surface  of  the  surrounding  tissue. 
Extending  into  the  uterine  cavity  are  two  small  fibroids 
and  a  polyp  measuring  2^x1^  cm.  in  diameter.  In 
the  upper  right  cornua  of  the  uterus  is  seen  a  slough- 
ing mass,  measuring  4x4  cm.,  evidently  a  degenerating 
fibroid  nodule.  This  area  is  quite  necrotic,  and  from 
it  a  yellowish-white  semifluid  juice  can  be  expressed. 
Cutting  into  the  fibroid  one  encounters  some  calcifica- 
tion. The  microscopic  examination  gives  the  following 
results  : 

Slide  1. — A  section  taken  from  the  thickening  3  mm. 
above  the  cervical  incision,  stained  in  hematoxylin- 
eosin,  shows  the  tissue  to  be  composed  mainly  of  mus- 
cular fibers,  with  the  presence  of  the  uterine  mucosa  on 
its  internal  surface.  The  mucosa  measures  2i-  mm.  in 
its  greatest  width,  and  decreases  at  one  end  until  noth- 
ing but  the  muscular  coat  is  seen.  The  glands,  where 
present,  show  but  little  of  their  normal  arrangement, 


and  in  these  places  they  are  somewhat  dilated  and 
show  proliferation  of  their  lining  epithelium.  Else- 
where the  whole  mucosa  has  been  replaced  by  a  mass 
of  large  sized  epithelial  cells,  with  large,  oval,  paleh'- 
staining  nuclei,  which  arrange  themselves  atypically  in 
relation  to  themselves  and  the  surrounding  connective- 
tissue  stroma.  Many  of  the  nuclei  show  karyokinetic 
figures,  and  there  is  very  little,  if  any,  intercellular  sub- 
stance. There  is  a  marked  infiltration  of  small,  round 
cells,  with  a  few  polymorphonuclear  leukocytes.  Blood- 
vessels are  fairly  abundant,  and  hemorrhagic  areas  are 
seen  in  the  mucosa  between  the  cells.  Some  distance 
beneath  the  mucosa,  one  sees  in  the  muscle-tissue 
small  nests  of  these  large  epithelial  cells  separated  from 
one  another  by  bands  of  normal  muscle- tissue.  The 
whole  muscular  wall  is  markedly  infiltrated  with  small, 
round  leukocytes.     Diagnosis — Glandular  carcinoma. 

Slide  2. — A  section  of  the  uterine  polyp  stained  in 
hematoxylon-eosin  shows  a  great  proliferation  of  the 
glandular  elements  of  the  uterus  within  a  fairly  loose 
edematous  connective-tissue  stroma.  These  glands 
show  dilatation  of  the  lumen  and  some  proliferation  of 
their  lining  epithelium,  and  in  many  places  the  lumen 
is  completely  filled  with  a  homogeneous  mucoid 
material  which  is  stained  blue  with  the  hematoxylin. 
The  proliferation  is  apparently  confined  to  the  glands, 
and  shows  no  tendency  to  invade  the  surrounding 
tissue.  The  stroma  shows  some  infiltration  of  leuko- 
cytes, and  the  bloodvessels  are  fairly  abundant,  with 
here  and  there  small  hemorrhages  into  the  surround- 
ing tissue.     i)wi(/)iosi'.5  — Glandular  polyp. 

Slide  S. — A  section  taken  from  the  degenerated 
fibroid  nodule,  stained  in  hematoxylin- eosin,  shows  the 
presence  of  large  bundles  of  connective  tissue  inter- 
lacing with  one  another.  There  is  a  round-cell  infiltra- 
tion, and  the  bloodvessels  are  only  fairly  abundant ; 
no  hemorrhages  are  present.  The  bundles  are  made 
up  of  connective-tissue  fibrils  with  spindle  cells  which 
contain  elongated  nuclei.  The  surface  shows  the  same 
carcinomatous  degeneration  as  noted  in  the  first  slide. 
Diagnosis — Fibroid  polyp  with  carcinomatous  degenera- 
tion of  its  surface. 

The  foregoing  report  confirms  the  diagnosis  as  made 
at  the  time  of  the  hysterectomy  of  malignant  degener- 
ation of  a  fibroid  tumor  of  the  uterus. 

III. — The  Literature   of  Cancerous  Degeneration 
OF  Uterine  Fibroids. 

Reference  to  the  literature  of  this  extremely  interest- 
ing subject  establishes  the  fact  that  the  opinions  of 
gynecologic  surgeons  and  pathologists  still  largely  vary 
as  to  the  possibility  of  the  association  of  the  malignant 
with  the  benign  growth  in  the  uterine  tissues  above  the 
cervix.  Thus,  Champneys^  remarks  that  "  malignant 
degeneration,  though  often  talked  of,  is  seen  very  rarely 
indeed.  Its  chief  sign  would  be  rapid  growth."  He 
has  never  seen  a  case  in  which  a  well-marked  fibroid 
has  taken  a  malignant  growth.  Franklin  H.  Martin" 
likewise  says  :  "  I  have  had  an  opportunity  of  examin- 
ing and  having  under  observation  for  long  periods  an 
unusually  large  number  of  fibroid  tumors  of  the  uterus, 
and  I  have  never  known  one  to  undergo. carcinomatous 
degeneration.  Fibroid  tumors  do  not  predispose  to 
carcinomatous  degeneration.  Cancerous  change  may 
occur,  however,  in  a  fibroid  uterus  as  a  coincidental 
disease,  but  in  no  way  as  a  direct  result  of  the  fibroid." 

Harrison'"  remarks  that  degeneration  of  a  fibroid  into 
sarcoma  has  been  observed,  and  even  rarely  into  carci- 


620 


Thk  Philadelphia"! 
Medical  Joursa.l  J 


COEXISTENCE  OF  CARCINOMA  AND  FIBROMA 


CMiECH  30,  1901 


noma,  while  Palmer'*  states  that  "  the  weight  of  opin- 
ion is  that  fibroids  do  not  become  malignant,  although 
malignant  growths  may  be  associated." 

Wallace,"  in  speaking  of  the  degenerative  changes  to 
which  fibroid  tumors  are  subject,  gives  their  order  of 
frequency  as  follows  :  "  Fatty  (the  most  frequent),  myxo- 
matous and  cystic  (the  next  frequent),  the  sarcomatous 
(which  probably  existed  from  the  beginning),  and  the 
calcareous — the  rarest  of  all  if  we  except  the  carci- 
nomatous," which  he  has  never  met. 

Ash  ton'  states  that  '•  fibroid  tumors  may  be  the  seat 
of  cancerous  or  sarcomatous  degeneration.  Whether  or 
not  a  fibroma  can  become  a  malignant  tumor  is  as  yet 
undecided.  It  is  a  clinical  fact,  however,  that  these 
degenerations  are  frequently  observed  associated  with 
fibroid  tumors  of  the  uterus."  Homans,"  on  the  other 
hand,  admits  that  the  fibroid  tumor  may  develop  a  can- 
cerous character,  while  Goffe'^  remarks  that  "carcino- 
matous and  sarcomatous  degenerations  have  been 
attributed  to  fibroid  tumors,  but  this  is  still  a  disputed 
point." 

According  to  Madden,'"  the  theory  of  Sir  James 
Simpson,  which  was  subsequently  adopted  by  Professor 
Klebs,  was  that  while  fibroid  tumors  have  nothing  car- 
cinomatous in  their  nature,  nor  any  tendency  to  undergo 
malignant  degeneration,  they  may  secondarily  become 
the  seat  of  carcinomatous  deposits,  or,  as  Klebs  expresses 
it,  with  the  hyperplastic  new-formations  (the  fibromata) 
heteroplastic  new-formations  become  associated,  within 
which  myxomatous  and  sarcomatous  developments 
occur. 

A.  P.  Clarke'  writes  that  "the  record  of  cases  coming 
in  my  own  practice  shows  unmistakeably  that  the 
malignant  degenerative  changes  to  which  these  growths 
are  prone  are  not  of  rare  occurrence ; "  while  C.  P.  Noble," 
in  the  discussion  of  Clarke's  paper,  remarks  that  "  we 
may  find  carcinomatous  changes  after  fibroids,  but  I 
have  not  seen  a  carcinomatous  change  in  the  tumor 
itself"  He  believes  such  a  change  is  extremely  rare. 
He  has  seen  a  number  of  cases  of  carcinoma  of  the 
cervix  as  a  complication  of  fibroid  in  the  uterus. 

Twombly"  positively  asserts  that  the  transformation 
of  intrauterine  myomata  into  carcinoma  has  never  been 
demonstrated,  while  Anderson'  diametrically  states  that 
carcinomatous  or  sarcomatous  degeneration  may  take 
place  in  a  fibroid  or  in  the  uterine  tissue  adjacent.  In 
one  case  which  he  saw  there  was  a  new-formation  of  a 
cancer,  or  a  degeneration  of  the  tumor  itself,  which 
seemed  to  have  been  the  result  of  the  frequent  irritation 
produced  by  puncturing  the  parts  with  an  electric 
needle.  He  also  remarks^  that  Martin,  of  Berlin,  as 
quoted  by  Irish,"  in  205  cases  of  extirpation  of  myo- 
matous uteri,  found  9  cases  which  showed  carcino- 
matous, and  6  cases  sarcomatous,  degeneration.  Leopold 
claims  that  fibromata  may  become  fibrosarcomata,  and 
in  one  of  his  cases  he  observed  a  carcinomatous  for- 
mation within  the  myoma.  Ehrendorfer'"  held  that 
the  mucosa  of  a  fibroid  uterus  may  become  carcino- 
matous. D.  Tod  Gilliam'*  says  that  he  has  never 
attended  a  patient  whose  death  could  be  traced  to 
malignant  degeneration  of  the  growth.  He  has  removed 
several  uterine  fibroids  that  gave  strong  evidence  of 
malignant  degeneration,  but  these  were  rare  as  com- 
pared with  the  number  of  cases  in  which  no  such  indi- 
cations existed. 

Lockhart"  admits  the  possibility  of  carcinomatous 
degeneration,  especially  when  the  tumor  is  of  large  size 
and  the  patient  is  near  the  menopause.     On  the  other 


hand,  De  Boncaud^  denies  the  occurrence  of  cancerous 
degeneration  of  uterine  fibroids,  and  affirms  that  the 
simultaneous  development  of  both  neoplasms  in  the 
same  uterus  is  purely  accidental,  while  H.  Macnaugh- 
ton  Jones''  states  that  carcinoma  of  a  fibroid  uterus 
is  a  much  rarer  complication  than  sarcoma.  Ford" 
remarks  that  a  very  practical  question  arises  as  to 
whether  myoma  does  not  occasionally  become  cancerous. 
The  answer  of  the  pathologist,  he  admits,  is  that  it  may 
become  carcinomatous.  Landau,"  in  criticising  the  rea- 
sons generally  ad  vanced  in  favor  of  treating  fibroid  tumors 
symptomatically,  states  that  though  a  myoma  is  usually 
a  benign  tumor  it  does  not  necessarily  remain  so.  Apart 
from  the  possibility  of  its  breaking  down  and  slough- 
ing, metaplastic  processes — sarcomatous  or  carcino- 
matous degeneration — are  not  uncommon,  and  death 
from  metastasis  has  been  known  to  occur,  though  the 
tumor  was,  histologically,  a  simple  myoma.  This  ma- 
lignant degeneration  is  especially  apt  to  occur  at  the 
climacteric  period,  or  after  that  time  in  cases  in  which 
the  menopause  has  been  postponed  owing  to  the  pres- 
ence of  the  fibromyomatous  growth. 

Oliver^'  writes  as  follows  :  •'  There  has  been  of  late 
some  discussion  in  the  medical  journals  as  to  the  asso- 
ciation and  relation  of  fibrous  tumors  of  the  womb  and 
cancer.  It  is  maintained  by  some  physicians  that  under 
certain  cirumstances  a  fibroma  of  the  uterus  may  take 
on  malignant  action.  The  denial  of  such  a  possibility 
is  just  as  stoutly  made.  I  have  a  faint  recollection  that 
I  have  seen  this  transformation  occur,  but  I  hesitate  to 
express  myself  absolutely  on  this  matter."  Finally,  Cul- 
len,*  in  his  recent  admirable  work  on  "  Cancer  of  the 
Uterus,"  states,  ''  in  spite  of  a  rigid  search  I  have  failed 
to  find  among  our  own  cases  a  single  instance  in  which 
an  adenomyoma  has  become  carcinomatous."  He  has 
found,  however,  two  instances  in  which  a  pure  myoma 
had  become  invaded  by  the  disease.  Such,  in  short,  is 
the  more  recent  expression  of  opinion  of  eminent  gyne- 
cologists at  home  and  abroad,  as  to  the  possibility  of 
the  supraim plantation  of  a  malignant  upon  a  benign 
growth  in  the  uterine  wall. 

IV. — The    Histology    and    Pathology    of    Uterine 
FiBROiL^TA  a:nd  Myomata. 

A  brief  study  of  the  microscopic  features  of  uterine 
fibromyomata  will  explain  the  great  rarity  of  this  form 
of  malignant  degeneration  of  such  neoplasms,  and  the 
evident  reluctance  of  the  scientific  gynecologists  to 
admit  the  possibility  of  such  a  change.  As  Madden" 
has  clearly  indicated,  uterine  tumors  are  at  the  outstart 
almost  entirely  myomatous  in  nature,  but  sooner  or 
later  in  most  cases  they  become  modified  by  the  in- 
creasing development  of  the  connective-tissue  sheaths 
of  the  muscular  fibers,  so  that  more  or  less  of  a  fibrous 
nature  is  superimposed  on  the  original  tumor.  Klebs 
pointed  out  that  during  this  process  of  transformation 
into  a  fibrous  growth  the  lymph-spaces  and  bloodves- 
sels within  the  tumor  are  obliterated  in  part,  and  the 
line  of  demarkation  between  the  individual  muscle- 
fibers  becomes  indistinct  or  even  totally  lost.  In  the 
small  minority  of  the  cases  the  origin,il  tumor  retains 
its  myomatous  tissue,  appearing  as  a  growth  composed 
of  smooth  muscular  fibers  of  a  greyish  red  transparent 
color  and  evidently  contractile  in  nature.  In  either 
case  epithelial  formations  are  completely  wanting  and 
the  development  of  a  carcinoma  is.  histologically, 
impossible.  On  the  contrary,  the  development  of 
myxomatous  and  sarcomatous  degenerations  would  be 


Maech  30,    1901] 


COEXISTENCE  OF  CARCINOMA  AND  FIBROMA 


TThe  Philadelphia        621 
L  Medical  Journal        'J^a 


expected  to  occur  if  the  tumor  malignantly  degenerated 
at  all,  and  clinical  experience  has  amply  demonstrated 
this  to  be  the  usual,  though  rare,  form  of  malignant 
degeneration  of  uterine  fibroids,  the  process  proceeding 
from  the  neighborhood  of  the  bloodvessels,  and  invad- 
ing only  the  muscular  tissue,  which  undergoes  a  speedy 
proliferation  with  the  production  of  a  rapidly-growing 
one-sided  malignant  tumor. 

As  to  the  nature  of  the  muscular  tissue  from  which 
the  uterine  myoma  develops,  the  theories  are  again  at 
variance.  Can  they  develop  from  the  mature  muscular 
fibers  of  the  adult  womb?  Senn  maintains  that  they 
cannot,  while  Winckle  inclines  to  the  belief  that  they 
do  not  come  from  muscle-tissue  at  all,  but  that  they 
spring  from  the  uterine  interparietal  bloodvessels,  and 
Klebs  from  the  connective  tissue  of  the  bloodvessels. 
Velpeau's  theory  that  they  develop  from  small  clots  in 
the  uterine  walls  has  been  disproved  by  Pozzi,  and 
Kleinwiichter's  belief  in  their  origin  in  a  round-cell 
formation  along  the  course  of  the  capillaries  has  not 
been  substantiated.  There  seems  to  be  much  reason 
in  the  arguments  advanced  by  Anderson'  that  these 
fibroid  tumors  are  localized  or  diffuse  hypertrophies  of 
embryonic  (mesoblastic)  uterine  parenchymatous  tissue, 
and  composed,  therefore,  of  unstriped  muscular  fibers. 

Whichever  of  the  foregoing  theories  we  may  be  in- 
clined to  accept  as  the  most  plausible,  it  remains  true 
that  from  their  histologic  formation  carcinomatous  de- 
generation would  seem  to  be  an  imijossible  occurrence. 
How,  then,  are  the  undoubted  cases  of  this  rare  compli- 
cation that  have  been  recorded  to  be  explained  ?  Mad- 
den'* claims  that  genuine  carcinomata  can  only  pro- 
ceed out  of  fibromy  omata  in  cases  in  which  the  formation 
of  the  tumor  extends  to  the  surface  of  the  mucous 
membrane ;  secondary  extension  of  the  carcinoma  into 
a  myoma  may  then  happen  in  the  same  way  as  into  the 
normal  uterine  muscular  tissue  from  the  endometrium, 
either  continuously  or  discontinuously. 

Such  seems  to  have  been  attempted  in  one  of  the 
cases  reported  by  Babcock*  from  the  clinical  service  of 
Dr.  Noble,  of  this  city,  in  which  the  capsule  only  of  the 
fibromyoma  had  been  invaded  by  an  epitheliomatous 
growth  originating  in  the  cervix.  Roger  Williams,"  in 
his  most  admirable  paper  on  "  The  Question  of  the 
Origin  of  Malignant  from  Nonmalignant  Uterine  Ne- 
oplasms," claims  that  in  cases  of  this  kind  the  cancer- 
ous disease  usually  spreads  from  the  mucosa  to  the 
fibroid  by  the  way  of  the  perivascular  lymphatics,  and 
goes  on  to  say  that  "  in  like  manner  uterine  fibroids 
projecting  into  the  abdomen  sometimes  become  can- 
cerous through  extension  of  the  disease  from  adherent 
neighboring  organs,  as  the  ovar}^  intestine,  and 
omentum."  Kiimmel"  records  a  case  of  secondary 
cancerous  involvement  of  a  subperitoneal  fibroid,  the 
primary  disease  originating  in  an  adherent  ovary. 
"  A  number  of  instances  have  been  recorded,"  Williams 
proceeds  to  state,  "  of  fibroids  projecting  into  the  uterine 
cavity  and  bearing  on  their  surface  a  cancerous  growth 
or  ulcer."  Examples  of  this  kind  have  been  reported 
by  Schramm"  and  Ehrendorfer'"  in  corporeal  polyps, 
while  Frank,"  Wahrendorfif,'*  and  J.  Williams''  have 
recorded  instances  in  which  the  polyp  was  attached  to 
the  cervix. 

A  second  method,  not  so  common  as  the  foregoing, 
by  which  a  uterine  fibroid  tumor  may  become  the  seat 
of  secondary  cancerous  degeneration  is  by  metastatic 
■dissemination  of  the  malignant  disease  from  a  primary 
focus  at  some  remote  portion  of  the  body.    An  incident 


of  this  rare  accident  is  recorded  by  Schopter,"  the 
patient  suffering  from  a  primary  cancer  of  the  lung, 
a  uterine  fibroma  ultimately  presenting  a  secondary 
nodule  of  the  disease. 

Finally,  the  rarest  method  of  all  by  which  a  fibroid 
tumor  may  become  the  seat  of  malignant  changes  is  by 
primary  involvement  of  the  tumor  itself  Roger 
Williams"  claims  that  hitherto  only  about  a  dozen  in- 
stances of  this  occurrence  have  been  recorded,  and  in 
most  of  these  the  evidence  is  far  from  being  thoroughly 
convincing. 

He  reports  an  undoubted  case  of  this  rare  condition. 
As  a  primary  carcinomatous  change  would  seem  to 
indicate  the  presence  of  epithelial  tissue,  some  other 
explanation  than  already  given  must  be  sought  in  order 
to  understand  this  phenomenon.  Fortunately,  in  1896 
new  light  was  thrown  upon  the  matter  by  the  paper  of 
von  Recklinghausen,  who  observed  in  addition  to  the 
ordinary  fibromas,  myomas,  and  fibromyomas  of  the 
uterus,  certain  muscle-tumors  in  which  glands  and 
cysts  were  present. 

These  neoplasms  he  termed  "  organoid  myomas," 
and  he  then  stated  his  belief  that  the  epithelium  of  these 
glands  and  cysts  was  derived  from  parental  inclusion 
of  fragments  of  the  Wolffian  bodies  within  the  tissues 
of  the  coalescing  tubes  of  Miiller,  or  from  cut-off  postfetal 
outshoots  of  epithelium,  growing  from  the  uterine 
mucosa  deep  into  the  muscularis.  Landau,"  in  com- 
menting on  this  statement  of  von  Recklinghausen, 
recalls  "  that  the  tubes  of  Miiller  are  so  situated  in 
the  embryo  that  the  upper  segment  of  each  tube  lies 
laterally  to  the  Wolffian  body  of  the  same  side ;  also 
that  at  a  lower  point,  which  corresponds  to  the  tubo- 
uterine  junction  of  postfetal  life,  the  tube  of  Miiller 
crosses  the  Wolffian  duct,  coursing  in  a  median  ventral 
direction,  and  that  the  lowest  or  vaginal  section  lies 
median  to  the  duct  of  the  Wolffian  body."  These 
relations  being  borne  in  mind,  it  is  not  difficult  to  under- 
stand how  fetal  inclusion  of  epithelium  from  the 
Wolffian  ducts  within  the  muscularis  uteri  or  in  the 
inner  extremity  of  the  Fallopian  tube  could  be  accom- 
plished. 

A  strong  confirmation  of  von  Recklinghausen's 
theory,  as  pointed  out  by  Landau,  is  the  fact  that 
these  adenomyomas  are  very  frequently  bilaterally 
symmetric,  and  are  much  more  common  in  the  per- 
ipheral layers  of  the  uterine  muscularis  near  the  tubo- 
uterine  junction.  An  additional  confirmation  is  to  be 
found  in  the  striking  similarity  in  the  epithelial  tissue 
of  the  Wolffian  ducts  and  the  gland  tubules  of  the 
ad  enomy  omata. 

On  the  other  hand,  this  theory  of  von  Reckling- 
hausen is  combated  by  investigators  of  equal  ability 
and  powers  of  observation.  Thus,  Lockstaedt"  de- 
scribes seven  specimens  of  fibromyoma  in  which  he 
found  follicles  or  cysts  lined  with  epithelium.  The 
tumors  were  nearly  all  subserous  and  were  attached  in 
the  neighborhood  of  the  Fallopian  tube,  so  that  it  seemed 
to  him  more  plausible  to  infer  that  the  epithelial  ele- 
ments were  derived  from  the  glands  in  the  tubal  mucosa, 
rather  than  from  remains  of  the  Wolffian  body,  as  in- 
ferred by  von  Recklinghausen.  He  also  opposes  Orlof's 
view  that  the  tumor  may  grow  around  and  include 
epithelial  pouches.  Legnen'^  calls  attention  to  the 
fact  that  the  epithelial  cells  which  are  sometimes  found 
between  the  muscular  fibers  and  in  the  meshes  of  the 
connective  tissue  in  fibromyomata  are  more  common 
in  those  which  are  adjacent  to  the  endometrium.   These 


g90        Thb  Philadelphia"! 
Medical  Jouexal  J 


SHOCK  IN  ABDOMINAL  OPERATIONS 


[JLarch  30,  ISOl 


cells  usually  appear  as  single,  irregular  layers  lining 
blind  follicles.  He  believes  that  they  are  derived  bj- 
proliferation  of  the  glands  of  the  uterine  mucosa. 
Ivanofifs  "  inaugural  thesis  upon  this  subject  is  based 
upon  an  examination  of  77  fibromyomata  of  the  uterus, 
the  majority  of  which  were  of  the  subserous  variety. 
He  was  able  to  find  glandular  elements  in  only  a  single 
case,  hence  he  concludes  that  uterine  adenomyoma  is 
very  rare.  He  does  not  believe  that  embryonic  re- 
mains which  have  been  present  for  many  years  in  the 
uterus  can  suddenly  develop  into  a  fibromuscular 
neoplasm.  In  the  specimen  he  examined  a  zone  of 
irritation  was  present  around  the  epithelial  tubes  and 
cystic  cavities,  as  shown  by  dilatation  of  the  vessels 
and  round-cell  infiltration,  the  sathe  as  in  cases  of 
localized  obstruction  of  the  circulation. 

These  two  distinct  theories  as  to  the  origin  of  cancer 
of  a  uterine  fibroid  therefore  exist,  and  must  claim 
consideration.  However,  what  the  source  of  the  glands 
and  glandular  tissue  may  be,  it  remains  evident  that 
it  is  in  this  tL-sue  and  in  this  tissue  only  that  primary 
cancerous  changes  of  fibroid  tumors  must  originate. 

We  conclude,  therefore,  from  the  foregoing  study  of  the 
clinical  and  histologic  manifestations  of  reported  cases, 
that  it  is  possible  for  fibroma  and  carcinoma  of  the  uterus 
to  coexist,  and  that  this  coexistence  may  manifest  itself 
in  one  of  three  distinct  ways  as  follows,  given  in  their 
order  of  frequency:  1.  Fibromyoma  of  the  corpus 
uteri  with  carcinoma  of  the  cervix,  the  increased  vas- 
cularity of  the  uterus  and  the  irritant  leukorrheal  dis- 
charges attendant  upon  the  benign  tumor  favoring  in 
those  women  so  predisposed  the  development  of  cervical 
malignancy.  2.  Fibromyoma  of  the  corpus  uteri  with 
associated  adenocarcinoma  of  the  endometrium,  the 
malignant  disease  not  invading  the  benign  tumor,  but 
originating  either  in  the  tubular  utricular  glands  or  in 
the  included  glandular  vestiges  which  may  be  present. 
3.  True  cancerous  degeneration  of  an  adenomyoma,  the 
malignant  change  originating  in  glandular  vestiges,  in- 
cluded in  the  uterine  growth,  or  the  carcinomatous  dis- 
ease invading  the  benign  growth  by  extension  from  an 
endometrial  adenocarcinoma  through  contiguity  of 
tissue. 

V. — Tabulated  Cases. 

I  append  a  series  of  authentic  cases  collected  from 
literature  in  which  the  fibroid  tumor  itself  was  invaded 
by  the  cancerous  growth  either  primarily  or  second- 
arily, as  proved  by  careful  macroscopic  and  microscopic 
examination.     They  are  as  follows  : 

1.  Schramm,'*  a  cancerous  involvement  of  au  intrauterine 
fibroid  polyp. 

2.  Ehreudorfer,'"  a  cancerous  involvement  of  an  intra- 
uterine fibroid  poh'p. 

3.  Frank,'-  a  c^mcerous  degeneration  of  a  cervical  fibroid 
polyp  projecting  into  the  vagina. 

4.  Wahrendorfl',''  a  cancerous  degeneration  of  a  cervical 
fibroid  polyp  projecting  into  the  vagina. 

5.  John  Williams,*'  a  case  of  fibromyomatous  polypus  pro- 
jecting into  the  vagina,  and  bearing  on  it«  surface  a  squamous- 
celled  cancerous  ulcer,  processes  of  which  had  invaded  the 
substance  of  the  fibroid. 

6.  Jessett,*'  a  case  of  fibromyoma  of  the  uterus  taking  on 
malignant  action ;  panhysterectomy ;  recovery. 

7.  Kiinimel,"  a  secondary  cancerous  degeneration  of  an 
intraabdominal  uterine  polyp  by  extension  from  cancer  of 
the  ovary. 

8.  Sehopt«r,*'  a  case  of  metastatic  involvement  of  a  uterine 
fibroid  from  a  primary  cancer  of  the  lung. 

9.  W.  Roger  Williams,*'  a  case  of  intramural  fibromyoma 
infiltrated  with  colloid  cancer,  occurring  in  a  single  woman, 
43  years  of  age. 


10, 11, 12, 13.  Klob,  Glaeser,  Liebmann,  and  Coe,  reported 
bv  Seuer,*^  each  a  case  of  cancer  originating  in  uterine 
fibroids  without  primary  involvement  elsewhere. 

14.  Thorn,''  a  case  of  cancerous  degeneration  of  an  intra- 
uterine fibroid. 

15  Babcock,'  a  case  of  squamous  epithelioma  of  the  cer- 
vix uteri  in  which  the  disease  had  invaded  the  capsule  of  a 
fibromyoma. 

16,  17,  18,  19.  Geuer,"  four  cases  of  primary  cancerous  de- 
generation of  a  myoma. 

20.  Dorland,  the  case  reported  above. 

BIBLIOGEAPHy. 

■  Anderson,  Winslow,  Patifie  Medical  Journal,  September,  1897. 

-  Anderson,  Winslow,   Jlci'Cat  B-eord,  January  26, 1895. 

3  AsbtoD,  W.  Easterly,  Am^ru:an  Gyn.  and  OhsUt.  Jour.,  December,  1896. 

*  Babc-xrk.  W.  Warne,  Ibid.,  XoTeiuber,  IS&S. 

»  Cbampneys,  F.  H.  C,  Lancet,  January  2li,  1900. 

«  Ciiiari,  Klinikder  Gtburuh.,  Erlangen,  18)3. 

^  Cl^ke,  Alonzo  P.,  Journal  of  the  American  Medical  Auociation,  Aaeust  1, 
1896. 

»  Cullen,  F.  S.,  Cancer  of  Ihe  Ulerus,  1900. 

''  DeBoiicaud,  Ber.  Inttmat.  dt  Jf»d.  el  <fe  Giir.,  Ko.  14,  1893. 
10  Ebrend.rfer,  ^rcAir  (.  Gyndk..  Bd.  lUi,  H.  2. 
»  Ford,  W.  E..  Amer.  Gvn.  and  Obikt.  Juur.,  June,lS03. 
^  Frank,  M'len.  mtd.  \V<,chenichri/t,  So.  50, 1892. 
"  Geuer,  OnxUf.  Gyndk.,  Xo.  14,  1S3L 

**  Gilliam,  D.  Tod,  y&uma/ Jm^rwM-    "  rio/ion,  July  22,  1899. 

«  G  ffe,  J.  P.iddle,  Am.  Jour.  ObsUt 

»  Harrison,  Geo.  T..  JnKr.  Gyn.ar.:  _  _ -.,  Febroary,  1896. 

1'  HomaDS,  Jobn,  Boston  Med.  and  ,>u,'y.  Jour..  March  7,'  1895 ;  Amerieam 
JotjmaJ  of  the  Medical  Sciencet,  September,  IS97. 

1-  Iri-h,  J.  C.,Amer.  Gyn.  and  Obstet  .lournal,  December,  18M. 

1'  Ivanoff,  La  Gw'C  .  December  15, 1898. 

•-«  Jessett,  B.,  Brit.  Med.  Jour.,  July  a,  1899. 

S'  Jones,  H.  Macoaughton.  ^:".'y.  Med.  Jour.,  Jxnaxry,  1901. 

~  Kaoimel,  DeulicU  .'/■  7  *,  '895. 

25  Landau,  I^eopold,  /-*<-  -  Gegmu^irt.  Janaary,  1899. 

:•  Landau,  I^eopold.  Be  .1  liy  3,  1899. 

2*  Legnen,  C>»/.  f.  Gi;inii  ,  >'■  -   - 

»  Lockhart,  F.  A.,  .4"fji.  6<m.  '  'r.,  December,  1899. 

"  lyocksuedl,  Mona'tcl..  If.  G        .  \.  ri;.  H.  2.  1893. 

3  Madden,  Toonia*  Mo^irV,  Med.  P  r  21,  1891. 

»  Martin,  Fraaklm  H.,  .V.  Amer.  r  .  -96. 

*>  Noble,  Chas.  V..  Journal  A  ne Hear,  .';  riaticn,  August  1.  1S96- 

"  Oliver,  Thos.,  Bnl.  Med.  Jour..  Januar,  Ij,  IWl. 

»-  Palmer,  S.  E.,  BoHon  Med.  and  Suri.  J.,ur.,  Ap-il  14,  IS98. 

»  Schopter,  Areh.  f.  Palhntov   Anal ,  Bd.  129,  S.  61. 

«  Schramm,  Cent.  /.  Gi/n-it,  No.  12.  189-2. 

5^  Seuer,  Ctnl,  (.  Gvnai..  No.  14,  1694. 

*  Thorn.  Zeitich.  f.  Griurlih.  ..    '-.niv..  Bd.  iiTii,  H.  1. 

•■'TvambU.Z..  Boston  Md  -  ,  May  20,  IS9T. 

^  WahrendoriT,  Fibrome  und  :—  Ulenis.  Inaug.  Dis.,  BerUn.  18S7. 

"  Wallace,  John,  Brit.  Med. .'        .  r  31,  1896. 

»  Williams.  John,  Cancer  of  lh«  Ltexua,  1S88,  p.  29. 

"  Williams,  W.  Roger,  AmtaU  o/  Surpery,  September,  1896. 


SHOCK  IN   ABDOMINAL  OPERATIONS.* 

Bv  FEXTOX  B.  TCECK,  M.D., 

of  Chicago. 

The  use  of  the  term  "  shock  "  usually  demands  an 
apology.  In  the  absence  of  knowledge  of  the  pathol- 
ogy of  this  complex  symptom  we  recognize  only  the 
phenomena,  the  efifects  of  certain  changes  that  seem  to 
occur  through  the  medium  of  the  nervous  mechanism. 
The  study  of  the  innumerable  ways  we  may  excite 
this  remarkable  phenomenon  "shock"  has  added  much 
to  our  knowledge  both  from  a  scientific  and  practical 
standpoint.  The  distinction  made  between  shock  and 
collapse  (loss  of  the  fluid  of  the  blood}  is  valuable  as 
a  classification,  but  brings  us  no  nearer  to  a  knowledge 
of  the  pathology. 

The  recent  work  of  Crile  (Cartwright  Lectures.  New 
York,  1897)  adds  much  to  the  value  of  the  older  ob- 
servers on  the  methods  of  inducing  shock,  and  the 
effects  upon  blood- pressure,  respiration,  etc. 

Boise's  conclusions  (Transactions.  Amer.  Association 
of  Obstetricians  and  Gynecologists,  1S9S)  on  the 
theory  of  hyperirritation  of  the  sympathetic  system, 
instead  of  a  paresis  of  the  nerves  governing  the  heart, 
circulation,  respiration,  etc.,  are  in  accordance  with 
many  recognized  facts,  and  have  been  alluded  to  by 
other  observers. 


*  Presented  before  the  Pan-Amerlcao  Medical  Oongnss,  Harana,  IMl. 


March  30.  1901] 


SHOCK  IN  ABDOMINAL  OPERATIONS 


CThb  Philadelphia 
Medical  Joubnal 


623 


In  recognizing  the  nervous  phenomena  we  are  still 
shrouded  in  mj'stery,  and  while  each  observer  may  add 
something  of  value  to  our  present  knowledge,  we  must 
admit  that  the  pathology  remains  obscure. 

I  have  reported  many  observations  and  experiments 
on  this  interesting  subject,  and  the  results  seem  to  in- 
dicate two  important  factors  not  investigated  sufficiently 
by  other  experimenters.  One  is  the  decreased  resist- 
ance against  infection  when  shock  is  present.  The  sec- 
ond is  increased  resistance  against  infection,  produced 
by  the  internal  application  of  heat  while  preventing 
shock,  or  reducing  shock  when  present.  Especially  is 
this  most  marked  when  the  heat  is  applied  within  the 
colon,  stomach,  or  within  the  abdominal  cavity,  the  two 
latter  locations  being  the  most  effectual.  No  such 
marked  effect  was  produced  when  the  heat  was  applied 
to  the  skin.  In  these  experiments  it  was  shown  that 
even  virulent  staphylococci  and  streptococci  would  not 
develop  when  inoculated  into  the  peritoneal  cavity  of 
animals  (dogs,  guineapigs,  rabbits),  providing  the  heat 
stimulation  continued  for  one  hour.  On  the  other 
hand,  if  the  viscera  were  exposed  to  the  air  for  a  cer- 
tain length  of  time,  and  shock  thus  produced,  even 
what  we  term  nonpathogenic  microoganisms  intro- 
duced into  the  abdominal  cavity  rapidly  develop,  re- 
sulting in  death  of  the  animal. 

It  will  thus  be  seen  that  one  of  the  important  factors 
in  shock  is  a  lessened  resistance  to  infection,  while  an 
increased  resistance  is  obtained  in  the  reduction  of  the 
shock  by  the  application  of  heat  to  the  splanchnic  area. 

I  have  shown  by  my  own  experiments  and  those  of 
other  observers,  that  the  skin  of  the  abdomen  is  a 
source  of  infection.  It  was  shown  that  these  germs 
cannot  be  removed  even  by  our  most  painstaking 
aseptic  procedures.  That  the  microorganisms  found 
are  in  a  measure  "  nonpathogenic,"  but  if  the  vi- 
tality is  reduced  by  shock  or  otherwise,  these  so- 
called  non- pathogenic  microorganisms  may  produce 
infection  and  death.  To  prevent  these  germs  from 
gaining  access  to  or  infecting  the  abdominal  cavity, 
I  described  a  method  of  covering  the  abdomen  with  an 
"  artificial  skin "  or  thin  rubber  dam  sheet  that  is 
made  to  adhere  fast  to  the  skin ;  hence,  I  designated 
the  method  by  the  appropriate  name,  "  artificial 
skin."  (Xew  York  Medical  Record,  August  11,  1900, 
p.  208).  I  have  also  had  rubber  sheets  made,  with  an 
opening  already  formed,  to  fit  closely  to  the  body  and 
securely  fastened  so  that  the  same  sheet  may  be  used 
over  again.  For  practical  purposes,  the  artificial  skin 
which  I  previously  described  is  more  simple,  as  all 
that  is  necessary  is  to  take  a  piece  of  this  rubber  dam 
and  cement  it  to  the  skin  like  a  surgeon's  adhesive 
plaster.  I  have  used  various  cements ;  simple  bisul- 
phide of  carbon  will  dissolve  the  rubber  and  cause  a 
sheet  of  rubber  to  adhere  to  the  skin.  I  have  had  several 
special  cements  made  for  the  purpose.  A  thin  rubber 
cement  is  useful.  I  have  tried  a  cement  made  of  gal- 
vanum.  Rubber  and  balsam,  when  sterilized,  forms  a 
firm  adhesive  sterile  pla.ster  to  fix  the  rubber  to  the 
skin.     It  can  be  easil_y  removed. 

When  the  artificial  skin  is  thus  cemented  over  the 
skin  of  the  abdomen  or  any  other  operation  area,  it 
forms  a  perfect  protection  from  infection  and  lessens 
the  danger  of  shock  that  may  result  partly  from  the 
evaporation  of  the  wet  skin. 

The  rubber  protector  may  be  cut  to  the  size  required. 
After  this  protective  artificial  skin  has  been  made  ad- 
herent to  the  real  skin,  it  can  be  left  to  be  opened  by 


the  surgeon,  the  incision  being  made  the  same  as  if  the 
rubber  covering  was  not  there. 

The  methods  of  preventing  shock,  or  reducing  it 
when  present,  have  been  previously  described  by  the 
author.  (Paper  presented  to  the  Thirteenth  International 
Medical  Congress,  Paris,  August  2-9,  1900  ;  published  in 
Medical  Record,  August  11,  1900,  under  the  title,  "The 
Care  of  Patients  During  Surgical  Operations."  Also, 
"  Improved  Methods  and  Details  in  the  Care  of  Patients 
During  Surgical  Operations,"  Journal  of  the  American 
Medical  Association,  June  9, 1900.)  One  method  consists 
of  introducing  into  the  stomach  a  thin  rubber  bag 
attached  to  the  author's  double  current  stomach-tube, 
which  is  provided  with  an  inlet  and  outlet  tube.  When 
in  the  stomach  one  side  of  the  double  tube  is  connected 
with  an  irrigator,  and  the  water  at  a  temperature  of 
50°  C.  (122°  F.)  is  allowed  to  flow  into  the  bag  within 
the  stomach.  About  500  cc.  is  used  and  allowed  to 
remain  a  few  minutes,  when  the  water  is  permitted  to 
flow  out  through  the  outlet  tube.  Where  it  is  desirable, 
a  continuous  flow  is  permitted,  allowing  300  or  400  cc. 
of  water  to  remain  in  the  stomach  throughout  the  treat- 
ment. Within  20  minutes  this  produces  the  profound 
effects  previously  shown  by  experiments  on  animals 
and  numerous  observations  on  patient.=,  made  by  the 
author.  If  the  temperature  of  the  water  introduced 
into  the  intragastric  bag  is  gradually  raised  to  55°  C. 
(131°  F.),  the  highest  physiologic  action  is  obtained, 
and  this  is  used,  not  only  to  prevent  shock,  but  more 
especially  to  reduce  profound  shock  when  present. 

The  second  method  of  preventing  or  reducing  shock, 
previously  described  by  the  author,  is  that  of  the 
introduction  of  small  and  thin  rubber  hot^water 
bags  covered  with  the  flat  gauze  sponges  into  the 
abdominal  cavity  during  operations  for  laparotomy. 
The  temperature  of  the  water  in  the  bag  is  48°  C. 
These  bags  are  partly  filled  with  sterile  water,  tied,  and 
kept  in  a  hot-water  receptacle  at  48°  C,  ready  for  use. 
These  heated  flat  sponge  bags  are  not  only  useful  in 
holding  back  the  viscera  from  the  operative  field,  but 
supply  the  necessary  constant  heat  to  prevent  shock, 
and  consequently,  as  I  have  previously  shown,  prevent 
the  infection  that  results  from  the  lowered  resistance 
accompanying  shock. 

To  determine  the  changes  of  the  blood  during  shock, 
I  injected  the  serum  of  animals  in  shock  into  healthy 
animals,  and  by  increasing  the  dosage  I  found  that 
animals  so  injected  soon  manifested  the  symptoms  of 
shock.  These  experiments  were  repeated  a  sufficient 
number  of  times,  and  the  results  were  constant  in  the 
disturbance  of  circulation,  respiration,  lowered  tem- 
perature, resulting  in  collapse.  Thirty  animals  were 
used,  including  guineapigs,  rabbits,  and  dogs.  The 
following  experiment  will  illustrate  : 

Two  dogs,  brothers,  11  months  old. 

Dog  No.  1.  The  abdomen  was  opened  and  the  vis- 
cera exposed  to  a  cool  draught  of  air  ;  at  the  same  time 
the  viscera  were  frequently  manipulated  until  profound 
shock  was  produced.  Loss  of  reflexes,  lowered  blood- 
pressure,  failing  respiration,  temperature  reduced  to 
95°  F.,  marked  congestion  of  the  splanchnic  vessels  and 
marked  anemia  of  the  periphery.  Time,  one  hour  and 
55  minutes.  The  animal  was  then  bled  and  the  serum 
used  to  inject  into  Dog  No.  2.  Injection  of  5  cc.  pro- 
duced but  little  noticeable  effect.  When  50  cc.  had 
been  used  the  animal  showed  marked  fatigue.  When 
150  cc.  was  injected  the  animal  was  in  a  state  of  col- 
lapse. 


624 


Thb  Philadklphia"! 


PHENYLHYDRAZIN  TEST  FOR  GLYCOSURIA 


[March  30,  1901 


The  blood  from  the  animal  in  shock  was  injected 
into  two  guineapigs,  injection  being  made  subcu- 
taneously  into  the  back  of  one  animal  and  into  the  ab- 
dominal cavity  of  the  other.  One  lived  8  hours  and 
the  other  12,  but  both  died  from  shock.  These  two  ex- 
periments were  controlled  by  animals  injected  with  water 
and  with  blood  from  an  animal  not  suffering  from 
shock ;  neither  of  the  controls  showed  any  symptoms 
of  shock. 

Rabbits  and  guineapigs  are  far  more  susceptible  to 
the  injection  of  serum  from  an  animal  in  shock  than  a 
larger  animal.  A  rabbit  will  sometimes  go  into  con- 
vulsions and  manifest  all  the  evidences  of  suffering 
by  snake  poisoning.  Small  injections,  frequently  re- 
peated, will  establish  the  phenomena  of  shock  without 
convulsions.  I  have  also  found  that  those  animals  thus 
injected  are  rendered  more  susceptible  to  infection,  but 
this  point  requires  more  experimental  work  to  establish 
it  beyond  a  doubt.  The  conclusions  are  well  shown 
that  in  shock  there  are  tissue  and  blood  changes  that 
are  produced,  and  when  the  serum  of  animals  in  shock 
is  injected  into  a  healthy  animal,  it  produces  shock  in 
the  second  animal.  This  corresponds  to  Mosso's  experi- 
ments on  fatigue,  in  which  fatigue  was  produced  in  one 
animal  and  the  injection  of  the  fatigued  animal's  blood 
into  a  healthy  animal  resulted  in  fatigue  in  the  second 
animal. 

In  another  series  of  experiments,  I  found  that  when 
an  animal  is  stimulated  by  heat  for  one  hour  or  more, 
the  heat  applied  within  the  splanchnic  area  by  methods 
previously  described,  immunity  or  resistance  against 
infection  was  thus  produced.  When  the  serum  of  such 
an  animal  was  injected  into  another  animal,  there  was 
an  increased  resistance  produced,  or  a  partial  immunity 
to  infection.  Animals  so  protected  could  not  always  be 
saved,  but  the  death  from  infection  was  retarded  some- 
times for  one  or  two  weeks.  These  facts  establish  a 
most  important  point  in  the  pathology  of  shock,  namely, 
the  alteration  of  the  tissue-cells  and  blood  in  shock. 
The  nerves  seem  to  act  here  as  a  transmitter  of  impulses 
that  result  in  these  tissue  changes  that  we  call  shock. 
The  chemical  changes  in  muscle  contraction,  with  re- 
sulting fatigue,  may  illustrate  the  part  that  nerves  play 
in  fatigue,  so  in  shock.  The  phenomena  of  shock  are 
too  complex  to  explain  by  a  single  theory,  but  we  must 
regard  it  as  connected  closely  with  the  phenomena  of 
altered  metabolism.  When  metabolism  is  more  satis- 
factorily worked  out  we  may  more  clearly  understand 
the  phenomena  we  call  shock. 


A  PRACTICAL  MODIFICATION   OF  THE  PHENYLHY- 
DRAZIN TEST  FOR  GLYCOSURIA. 

By  ROBERT  N.  WILLSON,  M.D., 

of  Philadelphia. 

So  MANY  urinologists  have  found  it  easy  to  criticise 
and  discard  as  too  intricate  or  liable  to  error  the  so-called 
phenylhydrazin  test  for  glucose  in  the  urine,  that  I  have 
been  led  to  offer  a  suggestion  that  may  bring  it  within 
the  reach  of  even  the  least  skilled  experimenters.  Be- 
fore describing  the  moditications  that  render  it  both 
practical  and  expeditious,  and,  what  is  still  more  impor- 
tant, almost  free  from  error,  it  may  be  well  to  give  the 
main  steps  of  the  test  as  usually  performed.  These 
consist  in  boiling  a  certain  quantity  of  the  suspected 
urine  (usually  50  to  100  cc.)  in  a  beaker  in  a   water 


bath,  after  adding  a  small  quantity  of  sodium  acetate, 
and  one-half  as  much  phenylhydrazin  hydrochlorid. 
Fischer  and  von  Jaksch  allow  the  above  mixture  to  boil 
for  half  an  hour,  but  use  such  a  small  quantity  of  urine 
(especially  von  Jaksch,  who  recommends  6  to  8  cc.)  that 
their  followers  in  imitating  the  method  have  frequently 
failed  to  demonstrate  glucose,  although  shown  by  other 
tests  as  present  in  large  quantities.  Sahli  ad\'ises  10  cc. 
of  urine,  to  which  two  drops  of  a  concentrated  lead 
acetate  solution  have  first  been  added,  and  the  urine 
then  carefully  filtered  to  remove  the  albumin.  He  then 
renders  the  filtrate  acid  with  a  drop  of  acetic  acid.  I 
would  say  here  that  while  the  use  of  lead  acetate  solu- 
tion and  the  subsequent  filtration  are  measures  condu- 
cive to  a  more  cosmetically  perfect  test,  the  albumin  in 
no  way  interferes  with  the  execution  of  the  method,  and 
so  far  as  concerns  the  final  outcome  need  not  be 
removed.  This  being  true,  and  providing  the  urine  is 
already  acid,  nothing  need  be  added  except  the  essential 
reagents,  thus  saving  to  the  experimenter  two  steps  in 
Sahli's  method.  Both  von  Jaksch  and  Sahli  have  sug- 
gested the  use  of  a  test-tube  in  the  place  of  a  beaker  as 
a  handy  substitute  for  the  more  bulky  glass  dish  that 
requires  a  large  water  bath.  R.  T.  WiUiamson,  in  an 
excellent  article  on  the  phenylhydrazin  method  {Man- 
chester Med.  Chron.,  1899),  suggested  an  even  quicker 
plan  for  the  preparation  of  the  phenylhydrazin- urine 
solution,  and  yet  the  majority  of  observers  have  held  to 
the  water  bath,  and  have  at  last  become  weary  of  the 
procedure  and  discarded  the  test  altogether.  WiUiam- 
Eon  makes  a  decided  advance  in  modifying  the  old  sug- 
gestion of  Hoffman  and  Ultzman  (Atlas  der  Harnsedi- 
mente,  Wien,  1872),  by  heating  equal  parts  of  sodium 
acetiite  and  phenylhydrazin  hydrochlorid  (i  inch  of  each 
in  an  ordinary  test-tube)  with  the  urine  over  a  spirit 
lamp  for  two  minulei  after  the  solution  has  reached  the 
boiling  point.  He  then  places  the  test-tube  in  the 
rack  and  leaves  it  there  for  from  half  an  hour  to  twelve 
houi-s  or  more  before  examining.  As  he  says  the  crys- 
tals are  "  frequently  found  after  the  tube  has  been  stand- 
ing half  an  hour,  but  after  boiling  the  tube  I  have  gen- 
erally placed  it  in  a  test-stand  and  did  not  examine 
the  deposit  until  next  day,  or  at  least  until  6  or  S 
hours  afterwards."  Thus,  although  he  has  rendered 
easy  and  speedy  the  first  step  in  the  method,  even  Wil- 
liamson fails  to  furnish  a  test  that  will  always  react 
within  a  practically  short  space  of  time.  If  the  phenyl- 
hydrazin test  is  to  be  of  advantage  it  must  be  rendered 
prompt,  aud  in  the  following  suggestions  I  believe  I  can 
bring  it  decidedly  within  the  reach  of  even  the  most 
exacting  requirements. 

Method  I. — The  test  may  be  carried  out  according  to 
Williamson's  method  up  to  the  point  at  which  he  places 
the  tube  in  the  rack,  after  boiling  for  two  minutes.  At  this 
stage,  instead  of  allowing  the  solution  to  cool  gradually 
in  the  tube,  or  to  stand  for  hours,  I  have  found  it 
practicable  to  place  a  drop  directly  upon  the  slide  and  ex- 
amine it  under  the  low  power  (AA  Zeiss)  of  the 
microscope.  In  from  i  to  2  or  3  minutes  depending 
upon  the  temperature  of  the  room,  and  the  quantity  of 
sugar  present,  (/'  the  reagents  have  been  thoroughly  mii^d 
mid  dissolved  in  the  urine  before  boding,  t\-pical  crystals  of 
phenylglucosazone  can  be  seen  forming  beneath  the 
eye  of  the  observer.  The  character  of  these  crystals  can 
be  readily  seen  fi-om  the  accompanying  figures.  It  need 
only  be  mentioned  that  the  color  is  a  brilliant  yellow, 
contn\sting  strongly  with  the  brown  globules  and  dark 
yellow  granules  that  often  appear  in  the  precipitate,  and 


March  30,  1901] 


PHENYLHYDRAZIN  TEST  FOR  GLYCOSURIA 


TTBE   PHII.ACELPHU 

L  Medical  Jodbnai, 


625 


especially  when  the  urine  is  rich  in  uric  acid  or  in 
urates. 

Method  II. — I  prefer  to  the  direct  application  of  the 
flame  to  the  test-tube,  as  rather  more  certain  and  slightly 
more  sensitive,  the  use  of  a  small  beaker  as  an  impro- 
vised water  bath.  I  make  it  a  rule  to  boil  the  solution 
in  the  test-tul)e  in  this  bath,  for  5  to  10  minutes 
over  a  Bunsen  burner,  and  then  to  examine  immediately 
as  before,  with  a  single  drop  on  the  slide,  and  with  the 
low-power  lens.  The  slightly  slower  heating  insures  a 
perfect  solution  of  the  reagents  before  boiling,  and  avoids 
a  source  of  error  that  with  this  rapid  method  may  prove 
of  decided  moment.  This  method  requires  but  little 
longer,  and  the  whole  examination  is  complete  within 
10  or  12  minutes. 

I  have  believed,  since  my  first  attempt  and  failure  to 
demonstrate  the  presence  of  5  %  of  glucose  in  a  specimen 
of  urine,  that  my  error  and  that  of  a  large  number  of 
observers  laj'  in  the  use  of  a  too  small  quantity  of  phenyl- 
hydrazin  hydrochlorid,  and  at  the  same  time  of  too 
little  urine.  Not  more  than  a  few  weeks  ago,  while 
demonstrating  the  test  to  a  class  of  medical  men,  a 
physician,  himself  a  laboratory  teacher,  remarked  to 
me  that  either  "  my  phenylhydrazin  was  spoiled,  or  else 


Fig.  1— Phenylglucosazone  c^5•(^taIs,  as  they  appear  when  first  formiiig  in  the 
drop  of  urine  under  the  lens  (DD  Zeiss). 

the  test  was  of  no  use."  He  had  placed  glucose  in 
normal  urine,  tested  as  he  thought  properly  for  the 
crystals,  and  had  obtained  nothing  but  the  customary 
normal  flaking  of  the  phenylhydrazin  salt,  and  no 
crystals.  In  the  first  place  I  may  say  that  very  rarely,  if 
ever,  does  the  phenylhydrazin  salt  "  spoil."  In  the 
second,  the  opportunity  was  too  good  to  be  lost.  So, 
before  the  class,  and  with  his  own  materials  that  had  in 
his  hands  failed,  I  carried  out  what  I  have  described  as 
Method  II.  Within  10  minutes  of  the  preparation  of 
the  first  solution  I  had  typical  phenylglucosazone  crys- 
tals in  abundance,  and  forming  fast  under  the  lens  of 
my  microscope.  Where  the  doctor  had  erred  I  do  not 
know.  Either  the  heating  had  been  too  hurried,  the 
mixing  had  not  been  thorough,  or  his  proportions  of  the 
salts  used  had  been  inaccurate  or  too  meager.  The  eye 
soon  learns  the  quantity  necessary,  and  no  measure  is 
required.  Until  practice  aii'ords  this  accuracy,  however, 
no  more  frequent  source  of  error  will  be  found  than  the 
lack  of  suflicient  salt  of  one  kind  or  the  other.  The 
directions  that  I  have  given,  however,  are  exact,  and 
if  glucose  is  present  the  test  as  described  will  not  fliil  to 
produce  the  crystals.  The  test-tube  method  is  undoubt- 
edly the  practical  one.  with  or  without  the  water  bath. 


To  the  tube,  half  full  of  urine,  I  add  one  gram  '  (equiv- 
alent to  the  amount  that  will  heap  a  silver  quarter  dollar 
piece)  of  sodium  acetate  and  as  much  phenylhydrazin 
hydrochlorid.  The  amount  of  these  reagents  mentioned 
by  Williamson,  while  vitiating  the  accuracy  of  the  test  in 
no  way,  is  unnecessarily  large,  and  as  the  phenylhy- 
drazin salt  is  somewhat  costly,  its  lavish  use  will  prove 
somewhat  of  an  item  in  the  laboratory  account. 

If  sugar  is  present  in  large  quantities,  large  yellow 


Fig.  2.— Final  formation  of  crystals  in  ordinary  (1-5^)  percentages  of  glycosuria 
(DD   Zeiss) 

crystals  will  form  in  the  field  as  the  drop  cools.  ^  The 
long  slender  spicules  and  the  tendency  to  a  rosette  or 
cluster  form,  will  differentiate  the  phenylglucosazone 
crystals  from  any  others  that  may  form  from  other  sub- 
stances. (Fig.  2.)  In  high  percentages  of  glycosuria  the 
formation  of  crystals  is  so  profuse  that  there  is  no  dif- 
ficulty in  their  detection  with  the  low-power  lens.*;  I 
prefer,  however,  to  use  no  coverglass  in  the  method, 
since  in  this  fashion  the  urine  cools  both  gradually  and 
quickly,  and  presents  a  concentrated  field  for  observa- 
tion. Just  here  can  occur  a  source  of  error.  In  the 
event  of  a  minute  tjuantity  of  glucose  being  present. 


Fig    3. — Final  formation  of  crvstals  in  very  low  percentages  of  glycosuria. 
(DD   Zeiss.) 

minute  crystals  only  may  form  that  cannot  be  clearly 
seen  with  "the  low-power  lens.  These,  however,  can  be 
easily  recognized  with  the  higher  power  (DD  Zeiss)  as 
characteristic  though  tiny  crystals  of  the  same  nature 
as  the  larger  ones.  (Fig.  3.)  By  this  method  I  ha\  e 
repeatedly  discovered  glucose  in  quantities  far  less  than 

1  Attention  has  repeatedly  been  called  by  different  authorities  to  the  tendency 
of  this  salt  to  produce  ecze'uia  of  the  skin.  My  personal  eiperience  has  covered 
no  such  cases. 


€26 


The  Phu^adklphia"! 
Mboica^l  Journal  J 


PHENYLHYDRAZIN  TEST  FOR  GLYCOSURIA 


[Uakch  jo,  1901 


0.1%  in  the  urine.  Williamson  claims  accuracy  for  the 
test  in  the  presence  of  0.0 1 9^  of  sugar,  and  my  experi- 
ence tends  rather  to  confirm  than  to  doubt  his  state- 
ment. A  comparison  of  the  phenylhydrazin  test  with 
the  ordinary  tests  for  glycosuria  can  be  made  in  the 
following  recent  experience.  I  was  examining  a  speci- 
men of  urine  sent  to  me  for  analysis  in  which  I  later 
demonstrated  about  0.1%  glucose  in  the  evening  speci- 
men and  a  still  more  delicate  quantity  in  that  of  the 
morning.  In  both  specimens  I  obtained  a  negative 
reaction  with  Fehling's  solution,  although  a  few  weeks 
previously  the  evening  specimen  had  contained  5%  of 
glucose.  After  standing  between  5  and  10  minutes  the 
Fehling  test  began  to  give  a  suspicious  color- reaction, 
that  never  went  beyond  a  yellowing  of  the  blue,  and 
gave  no  precipitate.  I  then  instituted  the  phenylhy- 
drazin test  after  the  above  method  (11),  boiling  the 
solution  10  minutes ;  and  in  less  than  a  minute  after 
placing  the  drop  on  the  slide  saw  tiny  crystals  of  phenyl- 
glycosazone  begin  to  form.  These  I  could  see,  but 
barely  distinguish  with  the  A  A  lens.  Fehling's  test  re- 
quired 5  to  10  minutes  to  give  a  very  doubtful  reaction; 
the  fermentation  test  would  have  required  several  hours, 
had  it  responded  at  all;  while  the  phenylhydrazin 
method  as  I  have  described  it  was  practically  conclu- 
sive in  less  than  a  minute  after  the  boiling  was  com- 
plete. Altogether  the  latter  test  requires  under  the  most 
disadvantageous  circumstances  between  10  minutes  and 
•^  hour.  In  my  own  hands  I  can  be  confident  of  its 
success  within  a  time  limit  of  10  minutes. 

Of  course  the  question  arises  here  (1)  as  to  the  un- 
variableness  of  the  appearance  of  the  crystals  when 
glucose  is  present ;  (2)  whether  other  substances  than 
glucose  will  produce  with  phenylhydrazin  similar 
•crystal  formations  ;  and  (3)  as  to  whether  or  not  the  test 
is  so  delicate  as  claimed  by  some,  no  matter  how  exe- 
cuted, as  to  cause  the  formation  of  crystals  from  the 
small  quantity  of  glucose  supposedly  present  in  normal 
urine.  In  answer  to  the  first  point  I  will  simply  sub- 
mit the  instance  already  mentioned  as  one  of  a  large 
number  in  which  the  phenylhydrazin  test  has  been  the 
•only  one  apart  from  the  clinical  symptoms  to  conclu- 
sively demonstrate  the  presence  of  sugar.  I  have  never 
met  with  an  instance  in  which  the  customary  tests 
(Fehling's,  bismuth,  fermentation)  all  agreed  in  reacting 
to  the  glucose  and  yet  the  phenylhydrazin  test  registered 
a  negative  decision.  In  regard  to  the  second  point  I 
must  answer  that  certain  substances  do  at  times  form 
with  phenylhydrazin  hydrochlorid  crystals  similar  to 
those  of  phenylglucosazone.  Glycuronic  acid  or  alkapton, 
(of  which  traces  may  be  normally  present  in  the  urine, 
but  never  in  quantity  sufficient  to  give  this  reaction) 
may  as  a  result  of  the  ingestion  of  certain  drugs'  appear  in 
(juantity  in  the  urine,  and  lead  to  the  reduction  of 
■copper  oxide  in  Fehling's  test,  bismuth,  silver  salts,  and 
also  to  the  formation  of  crystals  somewhat  similar  in 
appearance  to  those  under  discussion.  Usually  they 
.are  smaller  and  the  spicules  are  shorter  and  less  rich  in 
number.  The  occurrence  of  alkapton  is,  however,  a  rare 
one,  and  can  be  determined  at  once  by  its  disappearance 
on  discontinuance  of  the  use  of  the  drug. 

Crystals  should  then  no  longer  form  with  the  phenyl- 
hydrazin salt.  Alkapton  fails  to  give  the  bismuth  reac- 
tion (Nylander's  solution),  and  does  not  ferment  with 
yeast.  Its  crystals,  moreover,  melt  at  114°  to  115°  C. 
Williamson  mentions  the  fact  that  sodium  salicylate  and 

*  Among  these  are   opium  antl  its  alkaloids,  curare,    camphor,  chloroforni, 
<bloraI,  etc. 


salol  may  cause  a  Uke  reaction,  probably  due  again  to 
glycuronic  acid  formation  in  the  urine.  Salkowski  states 
also  that  the  pentoses  may  form  crystals.  The  pentoses 
are,  however,  rare  forms  of  sugar,  and  as  their  crystals 
melt  at  159°  C,  they  also  can  be  separated  from  those  of 
phenylhydrazin  which  melt  first  at  or  about  205°.  Lev- 
ulose  may  also  rarely  form  a  crystalline  sediment,  but 
is  again  such  a  rare  occurrence,  except  in  company  with 
glucose,  that  it  hardly  enters  into  consideration.  Finally 
with  regard  to  the  oft-claimed  oversensitiveness  of  the 
phenylhydrazin  test,  I  can  present  an  unbroken  indi- 
vidual experience.  I  have  tested  many  times  what  I  be- 
lieve to  have  been  normal  (glucose  free)  urine,  and  by 
all  of  the  methods  above  mentioned,  and  have  never 
obtained  crystals  that  were  in  any  way  liable  to  be  con- 
fused with  those  of  the  phenylhydrazin  salt.  William- 
son quotes  a  series  of  50  specimens  of  urine  tested  in 
the  same  way  and  with  a  like  conclusion.  In  the  same 
specimens  he  tested  with  the  method  of  Moritz  (boiling 
for  one  hour  or  more)  and  obtained  crystals  somewhat 
similar  in  appearance  in  many  of  the  cases.  Moritz's 
method  seems  undoubtedly  oversensitive.  On  the  other 
hand  those  facts  appear  to  me  to  prove  conclusively  the 
value  of  the  phenylhydrazin  test  when  executed  accord- 
ing to  the  above  suggestions,  which  outline  a  procedure 
so  much  simpler  than  the  one  that  is  liable  to  error  that 
the  latter  can  be  chosen  only  through  ignorance  or  in- 
tention. I  feel  safe  in  recommending  it  as  the  most  ac- 
curate, and  at  the  same  time  one  of  the  most  expeditious 
of  methods  of  examination  for  glucose  in  the  urine.  Cer- 
tainly as  a  negative  test  it  is  unimpeachable,  while  as  a 
positive  indication  of  the  presence  of  glucose  in  large  or 
small  quantities  (0.01  %  +)  I  believe  it  shows  so  few 
sources  of  error  as  to  make  it  preferable  to  any  of  the 
other  resources  at  our  command.  Bismuth  and  copper 
react  with  uric  acid,  kreatinin,  and  other  normal  con- 
stituents of  the  urine,  and  often  their  reactions  with 
glucose  ars  obscured  by  the  presence  of  albumin  in  one 
of  its  many  forms.  Phenylhydrazin  hydrochlorid  re- 
sponds to  none  of  these  substances,  nor  does  albumin 
interfere  with  its  reaction.  Even  in  the  case  of  the 
polariscope  is  the  latter  recommendation  in  a  measure 
wanting.  In  the  presence  of  less  than  0.1%  glucose  the 
much-relied-on  fermentation  fails,  while  phenylhydrazin 
has  demonstrated  so  much  smaller  a  tjuantity  that  it  has 
suffered  the  accusation  of  such  a  delicacy  as  the  demon- 
stration of  a  possible  normal  amount.  We  have,  there- 
fore, in  the  modified  phenylhydrazin  test  not  only  one 
that  can  lie  used  with  satisfaction  by  those  skilled  in 
labor,atorv  methods,  but  one  that  is  within  the  ability  of 
the  veriest  tyro,  or  the  humdrum  doctor  of  the  oldest 
school,  provided  he  has  advanced  to  the  use  of  a  micro- 
scope and  test  tube.  For  accurate  work  I  would  sug- 
gest the  routine  use  of  three  tests — phenylhydrazin, 
Fehling's,  and  fermentation  (the  latter  always  done  with 
a  control  test  of  glucose-free  urine).  The  polariscope, 
when  within  the  means  of  the  worker,  forms  a  valuable 
adjunct.  Rubner's  test  with  lead  acetate  and  ammonia 
is  also  an  excellent  one.  But  for  practical  results,  I 
believe  of  all  these  the  modified  phenylhydrazin  test  com- 
bines the  most  valuable  qualities  and  assures  the  greatest 
accuracy.  Permanent  specimens  of  the  crystals  may 
be  mounted  directly  in  balsam  after  drying  upon  the 
cover  glass  or  slide. 


Awarded  Golden  Crown. — Professor  Gras?i  has  been 
awarded  the  distinction  cf  the  Golden  Crown  by  the  Si>ciety 
of  Italian  Agriculturist*,  in  recognition  cf  the  valuable 
services  rendered  by  him  in  the  investigation  of  malaria. 


March  SO,  1901  ] 


HOW  TO  PREVENT  STAMMERING 


[ 


The  Philadelphia 
Medical  Jocbnal 


627 


HOW  TO  PREVENT  STAMMERING* 

By  G.  HUDSON  MAKUEN,  M.D., 

of  Philadelphia. 

Professor  of  Defects  of  Speech  at  the  Philadelphia  Polyclinic. 

The  old  adage,  "  An  ounce  of  prevention  is  worth 
a  pound  of  cure,"  was  never  more  applicable  than  it  is 
in  the  consideration  of  the  treatment  of  stammering. 
The  time  to  cure  stammering  is  before  it  begins.  Few, 
if  any,  children  stammer  from  the  very  outset.  Speech 
is  an  acquired  faculty  and  stammering  is  an  acquired 
defect.  The  tendency  to  stammer  is  inherited  in  many 
cases,  and  children  having  ancestors  who  stammered 
should  be  very  carefully  guarded.  The  inherited  tend- 
ency consists  in  a  transmitted  defective  nervous 
organization,  the  exact  character  of  which  has  not  yet 
been  differentiated. 

So  complex  are  the  mechanisms  of  speech  that  the 
wonder  is  that  we  do  not  all  stammer.  In  no  other 
faculty  of  the  human  organization  is  so  great  precision 
of  coordinate  muscle-action  required,  and  not  only  must 
there  be  a  perfect  coordination  between  the  numerous 
muscles,  but  there  must  also  be  a  perfect  harmony  and 
coordination  of  action  between  the  mechanisms  them- 
selves. Indeed,  it  is  the  lack  of  this  latter  coordination 
that  causes  stammering  in  the  great  majority  of  cases. 

The  three  mechanisms  of  speech  are  the  respiratory, 
the  vocal  and  the  oral  mechanisms,  and  there  are  few 
stammerers  who  cannot  employ  any  one  of  these 
mechanisms  separately.  They  can  breathe,  they  can 
vocalize  and  they  can  articulate,  but  they  have  trouble 
when  they  attempt  to  do  these  three  things  at  the  same 
time.  In  other  words,  they  are  unable  to  coordinate 
the  action  of  the  three  mechanisms  of  speech. 

The  first  act  of  the  child  on  coming  into  the  world  is 
to  breathe.  This  breathing  is  instinctive,  automatic 
and  involuntary.  Its  function  is  to  aerate  the  blood 
and  it  is  therefore  necessary  to  life.  Its  physiology  is 
well-known,  and  it  differs  very  materially  from  the 
physiology  of  the  breathing  employed  in  the  production 
of  speech.  This  latter  breathing  incidentally  performs 
the  function  of  the  former  during  the  speech-processes, 
but  its  own  and  chief  function  is  to  supply  the  vocal 
organs  with  a  column  of  breath  which,  in  turn,  becomes 
voice,  the  material  out  of  which  speech  is  made.  In 
other  words,  while  the  breathing  of  speech  production 
incidentally  aerates  the  blood,  its  chief  function  is  to 
produce  voice. 

The  management  of  the  breath  for  speaking  and 
singing  is  an  art  and  it  should  be  taught  in  the  schools. 
Its  physiology,  I  explained  several  years  ago  in  a  paper 
entitled,  "  Artistic  Breathing,"  presented  before  the 
American  Laryngological  Association,  and  published 
in  the  Philadelphia  Medical  Journal.  Good  vocali- 
zation is  also  an  art,  and,  although  it  is  the  product  of 
a  separate  and  distinct  mechanism,  it  should  be  studied 
in  connection  with  breathing. 

I  have  defined  voice  elsewhere  as  being  a  moving 
column  of  breath  set  in  vibration  by  its  own  impact 
with  the  vocal  bands  and  reinforced  by  its  diffusion 
through  the  various  resonant  chambers  into  the  sur- 
rounding atmosphere.  The  production  of  voice,  there- 
fore, requires  not  only  a  precise  coordinate  action  of  the 
muscles  of  each  of  the  two  mechanisms,  the  respiratory 
and  the  vocal,  but  it  also  requires  a  precise  coordinate 
action  of  the  mechanisms  themselves,  and  defects  of  vo- 


*  Bsad  before  the  Third  Pan-AmericaQ  Medical  Congress  in  Havana,  Cuba. 


calization  are  often  due  to  a  lack  of  this  harmony  of 
coordinate  action. 

The  vocal  element  of  speech  depends  for  its  perfec- 
tion upon  the  moving  column  of  breath,  upon  its  den- 
sity, its  rate  of  motion,  and  its  accurate  control  by 
means  of  the  respiratory  muscles.  One  child  will  stam- 
mer because  the  column  of  breath  is  not  sufficiently 
dense;  another  because  it  moves  too  rapidly  or  too 
slowly ;  and  another  because  it  moves  in  the  wrong  di- 
rection, the  attempt  to  vocalize  being  made  on  the  inspi- 
ratory effort.  There  is  a  faulty  action  of  the  respiratory- 
muscles  and  a  lack  of  coordination  between  the  respi- 
ratory and  vocal  mechanisms  which  necessarily  result 
in  a  faulty  production  of  voice.  And  it  is  here  that  the 
trouble  with  many  stammerers  exists.  Voice,  the  mate- 
rial out  of  which  speech  is  made,  is  not  forthcoming  at 
the  exact  time  at  which  it  is  required  for  purposes  of 
articulation  into  syllables  and  words,  and  there  is,  there- 
fore, a  lack  of  coordination  also  between  the  vocal  and 
the  oral  mechanisms. 

An  apt  illustration  of  the  relation  between  these  two 
mechanisms  is  given  by  Dr.  Wyllie  in  his  book  on 
"  Disorders  of  Speech,"  in  which  he  likens  the  vocal 
mechanism  to  the  bow  hand,  and  the  oral  mechanism 
to  the  string  hand  of  the  violinist.  Just  as  the  most 
precise  harmony  of  action  must  exist  between  the  two 
hands  of  the  violinist,  so  must  there  be  perfect  har- 
mony of  action  between  the  vocal  and  oral  mechanisms 
of  speech.  If  you  imagine  for  a  moment  a  failure  on 
the  part  of  the  bow  hand  to  perform  its  functions  and 
an  effort  on  the  part  of  the  string  hand,  not  only  to  do 
its  own  work,  but  also,  at  the  same  time,  to  supply  the 
deficiency  of  the  bow  hand,  you  will  have  a  good  illus- 
tration of  what  takes  place  in  the  case  of  the  stammerer. 
The  vocal  mechanism  is  defective  in  its  action.  It  may 
be  lacking  in  promptitude,  as  it  is  in  many  instances, 
and  the  oral  mechanism  tries  to  articulate  something 
that  does  not  exist,  and  the  result  is  necessarily  a  fail- 
ure. The  word  will  not  come  out  and  the  first  impulse 
is  toward  greater  effort.  This  greater  effort  generally 
takes  place  in  the  acting  mechanism  and  results  in  an 
overflow  of  nerve-energy  into  this  mechanism  and 
sometimes  into  other  portions  of  the  muscular  system 
and  gives  rise,  not  only  to  the  grimaces  of  the  stam- 
merer, but  also  to  the  spasmodic  contortions  of  the  mus- 
cles sometimes  observed  in  other  portions  of  the  body. 

The  proximate  cause  of  stammering,  therefore,  is  a 
faulty  coordination  of  the  three  mechanisms  of  speech, 
viz.,  the  respiratory,  the  vocal,  and  the  oral.  This  faulty 
coordination  in  turn  is  generally  due  to  a  faulty  action 
of  one  of  these  mechanisms  which  always  results  in  a 
faulty  action  of  them  all. 

The  trouble  does  not  often  appear  first  in  the  oral 
mechanism,  where  the  muscle-spasms,  characteristic  of 
the  stammerer,  are  so  manifest,  but  rather  in  the  re- 
spiratory and  vocal  mechanisms,  and  the  spasms  of  the 
articulating  muscles,  as  I  have  shown  above,  are  due  to 
the  overflow  of  nerve-energy  into  these  parts. 

Having  considered  the  immediate  causes  of  this  afflic- 
tion, let  us  now  look  for  the  more  remote,  or  first  cause. 
What  is  it  that  causes  the  faulty  coordination  of  the 
muscles  and  the  mechanisms  of  speech  ?  This  we  nat- 
urally look  for  in  that  portion  of  the  nervous  system  sup- 
plying these  muscles  and  mechanisms.  It  may  exist 
in  any  portion  of  the  nerve-tracts  running  from  the 
peripheral  organs  of  speech  to  the  centers  in  the  cere- 
bral cortex.  In  the  majority  of  cases,  however,  it  is 
probably  in  the  motor  speech-centers  of  the  bulbous 


628 


Thk  Philadelphia 

Medical  Journal 


] 


BELL'S  PALSY 


[Mascb  30,  INl 


portion  of  the  spinal  cord.  It  is  not  a  gross  anatomical 
lesion ;  that  is  to  say,  one  that  may  be  differentiated  by 
any  methods  at  our  command ;  but  that  it  is  a  struc- 
ural  condition,  differing,  however,  slightly  from  the 
normal,  is  quite  probable,  and  I  am  looking  forward  to 
the  time  when  a  more  minute  study  of  the  pathology 
of  the  nervous  system  may  enable  us  to  demonstrate  it. 
The  fact  that  this  peculiarity  of  the  nervous  system 
is  transmitted  according  to  the  laws  of  heredity,  tends 
to  suggest  and  confirm  the  above  theory.  If  stammer- 
ing were  the  result  of  a  mere  functional  derangement 
of  the  nervous  system,  heredity  would  not  figure  so  con- 
spicuously as  a  contributory  cause.  There  is  something 
more  definite  than  we  have  yet  discovered,  which 
is  handed  from  one  generation  to  another,  and  which 
predisposes  those  possessing  it  to  this  distressing  afflic- 
tion. Children  who  acquire  the  habit  of  stammering, 
whatever  may  be  the  exciting  cause,  generally  have 
within  their  own  nervous  organizations  the  germs  of  the 
disease.  Hence  it  is  that  they  should  have  the  most 
careful  management  during  the  period  of  the  develop- 
ment of  speech.  Prophylactic  measures  should  be  in- 
stituted before  the  stammering  actually  begins.  In  the 
majority  of  cases  these  measures  should  be  wholly 
educational.  The  little  patients  merely  require  to  be 
taught  how  to  think  calmly  and  connectedly  and  how 
to  speak,  and  this  is  not  a  difficult  thing  to  do. 

Stammering  is  not  generally  of  sudden  onset,  but  it 
is  of  slow  development  and  begins  during  a  period  of 
great  excitement.  A  child  attempts  to  describe  some 
little  incident  that  may  have  happened  during  his  play 
hour  and  which  seems  to  him  of  overwhelming  im- 
portance. He  is  anxious  to  make  his  description  as 
vivid  as  possible  and  he  thinks  there  is  no  time  to  lose. 
In  his  haste,  various  details  of  the  incident  become 
confused  in  his  mind  and  he  has  difficulty  in  selecting 
the  proper  words  and  in  enunciating  them  as  rapidly 
as  appears  to  him  to  be  fitting  to  the  occasion.  His 
excitement,  moreover,  increases  his  heart's  action  and 
his  breathing  and  they  become  wholly  inadequate  to 
the  requirements  of  normal  speech.  The  result  is  a 
repetition  of  the  initial  sound  or  syllable  of  some  word 
that  may  be  uppermost  in  his  mind.  This  is  what 
is  known  as  stuttering.  It  is  a  prodrome  of  stammer- 
ing ;  and  it  is  at  this  stage  that  the  treatment  should 
begin. 

What  not  to  do  is  quite  as  important  as  what  to  do, 
and  therefore,  it  may  be  well  to  begin  with  a  few 
"  don'ts."  In  the  first  place  don't  scold  the  child.  He 
is  already  in  an  excited  condition  and  scolding  will 
merely  add  fuel  to  the  flame.  Don't  make  fun  of  him 
or  call  his  attention  to  his  defect  or  use  the  word  stam- 
mering or  stuttering  in  his  presence,  for  all  this  will 
embarrass  him  and  lead  to  a  nervous  dread  of  future 
trouble  of  a  similar  kind.  Don't  allow  him  to  associate 
with  stammerers  or  even  to  hear  another  stammer,  for 
unconscious  imitation  is  an  important  causal  factor  at 
this  stage  of  the  affliction. 

Always  keep  in  mind  the  fact  that  the  child  begins 
to  stutter  because  he  has  not  yet  learned  to  combine 
the  art  of  ideation  with  that  of  oral  expression.  His 
thoughts  come  rapidly  and  in  confusion  and  the  words 
with  which  he  attempts  to  clothe  them  tumble  out 
spasmodically,  somewhat  as  water  comes  out  of  a  bottle. 
He  tries  to  say  everj'thing  at  once.  He  cannot  arrange 
his  thoughts  in  order  and  he  has  difficulty  in  selecting 
suitable  words  for  their  expression.  The  vocal  and 
articulating  organs  share  in  the  general  confusion  and 


they  soon  begin  to  lose  their  normal  automatic  action. 
An  effort  is  made  to  control  them  by  will  power  and 
this  usually  results  in  failure.  These  organs  cannot  be 
forced  into  proper  action. 

Inasmuch,  therefore,  as  the  trouble  often  arises  in  a 
faulty  mental  action,  the  first  indication  is  to  direct  the 
mental  processes  into  normal  channels.  We  must  dis- 
entangle the  somewhat  twisted  thoughts  and  to  do  this 
the  attention  of  the  patient  should  be  unconsciously 
diverted  from  the  all-absorbing  subject  at  hand  until 
he  has  regained  his  mental  equilibrium  and  then  he 
should  be  led  gradually  back  to  the  main  subject  and 
given  a  clear  conception  of  exactly  what  it  is  that  he 
desires  to  say  and  shown  how  to  say  it  in  a  deliberate 
and  clear  manner.  It  is  quite  possible  to  do  this,  and 
careful  direction  and  management  at  the  very  inception 
of  the  trouble  will  almost  surely  prevent  the  formation 
of  the  stammering  habit.  It  is  after  the  habit  has  been 
formed  that  the  difficulty  in  curing  stammering  arises. 
The  treatment  then  is  not  only  more  difficult,  but  it  is 
much  more  complicated  because  of  the  many  new  fac- 
tors entering  into  the  problem. 

Children  never  should  be  allowed  to  stammer  and 
the  habit  never  should  be  formed.  It  is  quite  probable 
that  the  above  treatment,  if  properly  carried  out  dur- 
ing the  prodromal  period,  would  result  in  completely 
stamping  out  this  dreaded  disease. 


BELL'S  PALSY  ASSOCIATED  WITH  COMPLETE  ANES- 
THESIA IN  THE  TERRITORY  OF  THE  FIFTH 
NERVE.' 

By  .tames  HEXDRIE  LLOYD,  A.M.,  M.T)., 
of  Philadelphia. 

Physician  to  the  Methodist  Episcopal  Hospital  and  to  the  Home  for  Crippled 

Children  ;  Consulting  Neurologist  to  the  State  Hospital  for  the  Chronic 

lusane  at  Werner?rille,  Pa.,  and  to  the  Pennsylv-aola  Training 

School  for  Feeble-Minded  Cuildren  at  Eliryn. 

Involvement  of  sensation  in  a  minor  degree  is  not 
uncommon  in  ordinary  cases  of  peripheral  paralysis  of 
the  seventh  nerve.  This  implication  of  the  fifth  nerve 
in  such  cases  is,  however,  merely  shown,  as  a  rule,  by 
pain  in  and  around  the  point  of  exit  of  the  seventh  nerve 
from  the  skull.  This  pain  is  usually  not  severe  and 
not  long  continued.  On  the  other  hand,  a  true  anes- 
thesia in  ordinary  Bell's  palsy  is  very  rare,  and  even 
when  present  is  usually  but  limited  in  extent  and 
quite  evanescent.  In  my  own  observation  of  per- 
ipheral paralysis  of  the  seventh  nerve,  of  the  ordinary 
type  due  to  cold,  and  known  as  Bell's  palsy,  I  have 
never  seen  until  now  a  well-marked  anesthesia.  I 
have,  of  course,  seen  a  conjoint  paralysis  of  the  fifth 
and  seventh  nerves,  due  to  a  gross  lesion,  such  as  a 
tumor,  within  the  cranium,  but  of  such  cases  I  am 
not  speaking  here. 

There  is  apparently  very  little  recorded  about  anes- 
thesia or  other  involvement  of  the  fifth  nerve  in 
cases  of  Bell's  palsy.  The  reason  must  be  that  such 
involvement  is  rare.  Erb  regards  it  as  remarkable, 
considering  the  intimate  association  that  exists  between 
the  fibers  of  the  fifth  nerve  and  those  of  the  pes  anser- 
inus,  that  sensibility  is  not  oftener  involved,  and 
regards  this  exemption  as  proof  that  in  ordinary 
facial  paralysis  the  inflammation  is  usually  higher 
up  in  the  trunk  of  the  facial.  Gowers  says  he  has 
seen  a  few  cases  of  diminished  sensibility  on  the  cheek, 

1  Bead  before  the  FhUalelphia  Neurological  Society,  October.  1900 


March  30, 19«1] 


BELL'S  PALSY 


CTHB  PHII.ASBLPHU 
MSDICAI,  JODSHAI. 


629 


but  his  explanation  that  this  is  due  to  diminished 
sensibility  of  the  nucleus  of  the  fifth  nerve  due  to  the 
diminution  of  the  number  of  muscular  impressions,  is 
quite  unsatisfactory.  Mills  says  that  occasionally  one 
or  more  branches  of  the  trifacial  may  be  involved  in 
Bell's  palsy,  and  this  is  due  to  a  spread  of  the  inflam- 
mation by  contiguous  structures.  Eulenberg  and 
others  have  recorded  the  occurrence  of  herpes  zoster  in 
cases  of  paralysis  of  the  seventh  nerve,  but  in  such 
•cases  I  should  suspect  a  deep-seated  lesion  probably 
acting  as  an  irritant  to  the  Gasserian  ganglion.  Notta, 
in  1860,  described  a  form  of  neuralgic  Bell's  palsy  in 
which  the  first  symptom  was  pain  in  the  suboccipital 
and  auriculotemporal  nerves,  followed  after  a  period  of 
eight  days  by  the  facial  paralysis.  But  in  this  aflfec- 
tion  there  was  no  anesthesia.  The  affection  was  a  most 
anomalous  one  and  suggests  a  resemblance  to  oph- 
thalmic migraine,  in  which  paralysis  of  the  ocular 
muscles  follows  a  severe  bout  of  pain  in  the  ophthalmic 
division  of  the  fifth  nerve.  It  was  certainly  not  like 
an  ordinary  Bell's  palsy,  and  I  have  never  seen  any 
record  of  other  cases  like  it. 

Webber,  of  Boston,  wrote  a  paper  on  pain  (not  anes- 
thesia) in  Bell's  palsy.  He  suggests,  somewhat  as  Mills 
has  done,  that  a  "  rheumatoid  "  inflammation  of  the 
trunk  of  the  fifth  nerve  might  occur  at  the  points  of 
exit  of  the  nerve  from  the  skull,  just  as  occurs  in  the 
case  of  the  seventh  nerve.  But  in  such  an  affection,  I 
should  think  anesthesia  would  be  present  as  well  as 
pain.  The  occurrence  of  pain  in  Bell's  palsy  is,  in  fact, 
not  difficult  to  understand ;  it  may  readily  be  caused 
by  the  swelling  of  the  trunk  of  the  seventh  and  con- 
sequent involvement  of  the  small  fibers  of  the  fifth 
with  which  the  trunk  of  the  seventh  is  doubtles  sup- 
plied. But  the  problem  of  a  complete  anesthesia  in 
these  cases  is  a  far  different  one. 

I  have  to  present  this  evening  a  case  of  peripheral 
paralysis  of  the  seventh  nerve  associated  with  complete 
anesthesia  in  the  whole  territory  of  the  fifth  nerve. 

The  clinical  notes  of  the  case,  as  taken  by  Dr. 
Cohen,  resident  physician,  are  as  follows  : 

A.  W.,  female,  aged  20  years,  has  a  negative  family  and 
personal  history.  The  patient  says  she  has  always  been 
Bervolis,  but  gives  no  historj'  of  hysterical  crises  prior  to 
onset  of  present  illness.  Xo  specific  history  is  attainable, 
and  there  is  no  evidence  of  specific  infection.  On  Monday, 
July  8,  1900,  the  patient  slept  in  a  draft.  On  Tuesday  she 
had  pain— occipital,  frontal  and  on  the  vertex.  She  was 
dizzy  and  nauseated,  but  there  was  no  emesis.  On  Friday 
morning  the  patient  felt  nauseated.  Suddenly,  while  con- 
versing, she  felt  her  mouth  draw  to  the  left  and  she  could 
not  see  out  of  her  right  eye.  There  was  lateral  flexion  of 
the  head  to  the  right,  and  deafness  in  the  right  ear.  Violent 
headache  was  present.  The  patient  says  she  fainted.  There 
was  marked  epiphora  from  the  right  eye.  The  patient  grew 
worse  on  Saturday  and  Sunday.  Her  mouth  became  more 
distorted,  the  left  angle  being  situated  about  half  way 
between  the  ear  and  its  normal  position.  She  was  admitted 
to  the  hospital  on  July  21. 

Physical  Examination  — Dull  mentally.  Pain  severe  in 
right  ear  and  down  the  right  side  of  the  neck,  over  the  mas- 
toid process,  temporal  region,  and  ramus  of  the  inferior 
maxilla.  Eyes;  Sight  poor,  especially  of  right  eye.  Pupils: 
Uneven,  right  larger  than  left,  dead  to  light  and  accommo- 
dation, movement  of  eyeballs  good  in  all  directions,  orth- 
ophoria, no  ocular  palsies,  conjunctival  reflex  absent  in  the 
right  eye— also  corneal.  Eye  grounds :  No  gross  lesion, 
form  field  roughly  taken  under  cover.  Right  eye  con- 
tracted to  fixation  point;  left  eye  markedly  limited,  but  no 
central  scotoma  Fifth  nerve  :  Motor  branches  uninvolved. 
Patient  cannot  open  mouth  to  full  extent  On  account  of  pain  ; 
the  temporal,  masseter,  and  pterygoid  muscles  act  perfectly. 


Sensory  branches :  Complete  anesthesia  of  the  right  side  of 
the  head,  neck,  and  face,  including  the  buccal  surface  (see 
Figure).  Tactile,  temperature,  pain,  and  muscular  senses 
absent  over  large  area  on  right  side  of  the  head,  neck,  face 
and  mouth.  The  special  senses  :  Taste  absent  on  the  right 
side  of  tongue  Smell  absent  in  the  right  nostril.  Hearing 
diminished  on  the  right  side.  Ear  (right),  membrane  thick- 
ened ;  light  spot  slightly  broken ;  pain  on  pressure  over  pos- 
terior auricular  nerve.  Seventh  nerve :  All  branches  in- 
volved ;  right  side  of  face  expressionless ;  lagophthalmus  ; 
escape  of  saliva  from  mouth;  the  faradic  contractility  of  the 
afifected  muscles  is  almost  completely  abolished.  Eleventh, 
spinal  accessory :  Contraction  of  the  muscles  on  the  right  side ; 
chin  deflected  to  the  left ;  pharyngeal  reflex  absent.  Tongue 
protruded  with  difficulty,  but  not  deflected  from  median 
line.  No  other  part  of  the  body  is  paralyzed ;  kneejerks 
sluggish ;  sensation  elsewhere  normal ;  some  difficulty  in 
urination — tendency  to  retention.  Heart  and  lungs  nor- 
mal.    Abdomen  normal. 

Abstract  from  Clinical  Notes. —  Since  admission  to  the  hos- 
pital the  patient  has  had  4  distinctly  hysterical  crises  charac- 
terized by  weeping,  globus,  varying  degrees  of  anesthesia  of 
trunk  and  upper  extremities,  aphonia,  muscular  twitchings, 
semiconscious  state,  partial  anesthesia  of  left,  or  sound,  side 
of  the  face,  and  dropping  of  the  lower  jaw.  There  was  no 
relaxation  of  the  sphincters.  These  additional  anesthesias 
have  been  temporary,  passing  off  in  a  day  or  so.  The  anes- 
thesia of  the  right  side  of  the  head,  face,  buccal  surface  and 
neck  has  remained  constant.  The  patient  steadily  improved 
and  regained  considerable  facial  control.    She  could  nearly 


Anesthesia  complicating  a  case  of  Bell's  palsy. 

close  the  right  eye  at  the  end  of  two  months.  There  has 
been  a  gradual  increase  in  response  to  the  faradic  current. 
At  the  end  of  three  months  the  patient's  condition  was  as 
follows:  She  still  presented  the  above- described  sensory  dis- 
turbances, viz.,  abolition  of  tactile,  pain,  temperature,  and 
muscular  senses  over  a  large  area  of  the  right  side  of  the  head, 
face,  buccal  surface  and  neck.  Absence  of  the  special  senses 
of  taste  and  smell  on  the  right  side.  Considerable  deafness 
in  the  right  ear,  diminished  vision  in  the  right  eye.  Con- 
tracted visual  fields.  Slight  or  partial  reaction  of  degen- 
eration. Electrical  sense  has  gradually  increased.  At  no 
time  has  there  been  any  disturbance  of  speech  apart  from 
hysterical  aphonia. 

In  seeking  for  an  explanation  of  this  involvement  of 
the  fifth  nerve  we  have  to  consider  several  points.  In 
the  first  place,  the  escape  of  the  motor  branch  of  the 
fifth  seems  to  indicate  that  the  lesion  is  not  at  any 
point  within  the  cranium.  It  is  difficult  to  see  how  a 
lesion  at  the  base  of  the  brain,  involving  both  the 
seventh  and  fifth  nerves,  would  allow  the  motor  branch 
to  escape,  and  also  how  the  sixth  nerve  would  escape. 
The  intense  pain  at  the  beginning,  with  stiffness  of  the 
neck  muscles,  might  suggest  a  meningitis,  but  the  sub- 
sequent favorable  progress  of  the  case  is  against  this 
theory.  Besides,  there  has  been  no  optic  neuritis  or 
other  evidence  of  intracranial  lesion.  The  case  hardly 
presents  the  history  or  appearance  of  brain  tumor.  The 
involvement  of  taste  is  doubtless  due  to  implication  of 


630 


The  Philadelphi 
Medical  Journal 


'1 


BELL'S  PALSY 


[itLBCB   30,  19<ll 


the  chorda  tympani,  hut  the  involvement  of  smell  sug- 
gests an  hysterical  complication,  and  this  leads  to  a 
consideration  of  the  theory  of  hysteria. 

Hysterical  complications  in  organic  nervous  disease 
have  been  ohserved  now  so  often  by  me  that  I  have 
come  to  look  upon  them  quite  as  matters  of  course. 
In  the  present  case  the  evidence  in  favor  of  hysteria  is 
both  negative  and  positive.  The  negative  evidence 
consists  in  the  absence  of  any  clear  indication  of  an 
organic  lesion  to  explain  the  anesthesia.  The  positive 
proof  is  briefly  as  follows  :  The  association  of  the  anes- 
thesia with  loss  of  the  special  senses,  even  sight,  on  the 
affected  side.  The  loss  of  taste  could,  of  course,  be 
otherwise  explained  as  due  to  involvement  of  the  chorda 
tympani  in  the  inflammation  of  the  seventh  nerve ;  it 
being  now  pretty  well  agreed  upon  that  the  chorda 
tympani  and  the  intermediary  nerve  of  Wrisberg  are  one 
and  the  same  sensory  nerve — called  by  Sapolini  the 
thirteenth  cranial  nerve — and  that  this  is  the  nerve  of 
taste  for  the  anterior  half  o''  the  tongue.  Favoring 
hysteria  also  are  the  hysterical  crises,  the  fugitive  anes- 
thesia on  the  sound  side  of  the  face  and  elsewhere,  the 
contracted  visual  fields,  and  the  patient's  occasional 
mental  states.  Rather  against  this  theory,  perhaps,  is 
the  permanency  of  the  anesthesia  on  the  affected  side — 
nothing  has  served  to  dispel  it.  It  has  persisted  now 
for  three  months,  and  is  as  obstinately  fixed  and  as  com- 
plete as  an  organic  anesthesia. 

Finally,  in  favor  of  hysteria  is  the  fact  that  the  anes- 
thesia is  not  strictly  limited  to  the  territory  of  the  fifth 
nerve.  It  overlaps  this  territory  considerably  except 
at  the  median  line.  As  seen  in  the  figure,  the  anes- 
thesia extends  down  on  the  neck,  below  the  territory  of 
the  fifth  nerve,  and  back  toward  the  occiput  in  the 
territories  of  the  great  and  lesser  occipital  nerves  and 
the  auricularis  magnus.  It  would  be  difficult  to  ac- 
count for  such  an  anesthesia  by  an  organic  lesion. 

As  to  the  paralysis  of  the  seventh  nerve,  it  is  unques- 
tionably due  to  an  organic  lesion — evidently  a  neuritis. 
The  paralysis  is  not  like  an  hysterical  paralysis  of  the 
seventh  in  which  blepharospasm  is  usually  seen  to  take 
place  of  lagophthalmus.  Besides,  the  reactions  of  degen- 
eration are  an  unmistakable  proof  of  its  organic  origin. 


Black-Water  Fever. —  Ziemann  {Deutsche  med.  Woch., 
October  4, 1900)  gives  tbe  following  statements  as  the  result 
of  his  experience  in  black-water  fever.  1.  In  some 
regions  severely  affected  with  malaria  there  are  found  people 
who,  after  having  had  one  or  more  attacks  of  malaria  have 
a  tendency  to  black- water  fever  which  varies  from  time  to 
time.  As  a  rule  the  intensity  increases  with  the  number  of 
attacks  of  malaria,  but  this  is  not  always  the  case.  It  is  not 
necessarily  associated  with  a  general  hemorrhagic  diathesis. 
2.  This  disposition  to  black-water  fever  is  seen  chiefly  in 
people  who  have  been  infected  with  the  small  parasites  of 
the  tropics,  or  with  estivoautumnal  fever,  though  ordinary 
tertian  or  quartan  fever  may  produce  it.  3.  It  is  possible  that 
there  an  especial  virulence  of  the  parasites  is  produced  by 
local  conditions,  and  that  this  leads  to  the  hemoglobinuria. 
As  a  result  of  these  observations  he  concludes  that  black- 
water  fever  may  appear  as  a  result  of  a  new  outbreak  of 
malaria ;  it  may  be  the  result  of  a  new  outbreak  of  malaria 
with  the  coincident  use  of  quinin  ;  it  may  also  appear  in 
people  who  are  predisposed  thereto  owing  to  earlier  attacks 
of  malaria  by  the  mere  use  of  quinin  without  any  new  attack 
of  malaria.  The  latter  cases  are  rare.  Black- water  fever 
has  been  observed  in  Togos  negroes  when  they  have  never 
taken  quinin.  The  same  has  been  seen  in  other  regions.  It 
may  be  seen  in  very  mild  forms  with  only  a  slight  brownish 
tinge  of  the  urine.  One  case,  which  is  worthy  of  attention, 
was  observed  by  Ziemann.    In  this  tropical  malaria  was 


present.  A  dose  of  J  of  a  grain  of  quinin  produced  hemo- 
globinuria, and  about  J  this  amount  produced  albuminuria. 
[d.l  e.] 

£xtra- genital  Syphilis  Transmitted  to  Several 
Members  of  the  Family.— Tulinow  ( Vraich,  Vol.  22,  Xo. 
2)  related  before  the  Pediatric  Society  of  Moscow  the  follow- 
ing interesting  cases :  To  the  Hospital  of  St.  O'ga  were  ad- 
mitted a  brother  and  sister,  5  years  and  11  months  respec- 
tively, both  suffering  from  sjpbilitic  affection  of  the  buccal 
mucous  membrane.  From  the  history  it  was  learned  that 
the  gill  was  infected  by  her  brother  through  kissing,  and  he, 
in  turn,  was  infec  ed  by  a  syphilitic  janitor  who  occupied  the 
same  room.  The  little  girl  infected  her  mother  who  devel- 
oped a  hard  chancre  of  the  nipple.  The  father  of  these 
children  also  developed  a  hard  chancre  of  the  left  tonsiL  In 
the  same  hospital  was  received  a,  boy  3  years  old  with  a 
hard  chancre  of  the  lower  lip.  This  boy  infected  two  other 
children  and  his  father  and  mother.  At  the  same  time  the 
landlord's  children,  living  in  the  same  house,  developed 
extragenital  syphilis,    [a  r  ] 

Polyneuritis  Due  to  Influenza. — Diemer  (Gaz  Heb. 
de  Med  et  de  Chirur.,  January  IS,  1901,  43nie  Ancee.  Xo.  4; 
Paris  Thesis,  1900)  refers  to  a  case  of  polyneuritis  follow- 
ing influenza  that  occurred  in  the  service  of  Lt-pine. 
The  nerves  were  examined  histologically  after  death  and  the 
presence  of  parenchymatous  neuritis  was  demonstrated  and 
not  interstitial  neuritis.  This  complication  of  influenza 
ordinarily  begins  during  the  period  of  convalescence,  like 
diphtheritic  neuritis,  tD  which  it  hsis  often  been  compared. 
Motor  troubles  are  constant  in  this  condition,  which  is  pri- 
marily a  motor  polyneuritis.  The  motor  phenomena  consist 
of  paralyses  of  so  very  variable  location  that  it  is  impossible 
to  assign  to  this  form  of  polyneuritis  a  predilection  for  suiy 
particular  group  of  muscles.  It  may  be  said  that  all  the 
muscles  may  be  paralyzed  and  that  consequently  the  func- 
tional troubles  that  originate  from  the  paralysis  vary  accord- 
ing to  the  localization  of  the  lesions.  Usually  the  paralysis 
is  isolated  either  to  the  upper  or  the  lower  extremity  with 
predominance  on  one  side.  Whatever  their  seat  these  par- 
alyses present  common  characters  which,  however,  are  not 
pathognomonic.  Among  the  peculiarities  of  this  form  of 
paralysis  are :  1.  The  predilection  for  the  distal  segment  of 
the  limb,  which  predilection  diminishes  in  its  intensity 
as  the  proximal  segment  is  approached.  2.  The  extensor 
mugcles  are  usually  the  ones  that  are  involved.  3.  The 
course  of  the  affection  is  irreuglar.  4.  The  paralyses  are 
always  flaccid.  In  addition  to  the  paralytic  phenomena 
ataxic  symptoms  are  often  observed  which  are  due  to  the 
paralysis  of  the  extensor  muscles  of  the  leg.  Disorders  of 
sensation  are  not  very  well  marked  in  polyneuritis  due  to 
influenza,  and  they  never  attain  the  intensity  observed  in 
cases  of  polyneuritis  due  to  alcohol.  Atrophic  and  vaso- 
motor phenomena  are  usually  slight.  Muscular  atrophy  was 
noted  in  nearly  all  cases.  The  psychic  condition  of  the  pa- 
tient is  not  altered.  The  course  of  the  disease  may  be  acute 
or  subacute;  no  case  of  chronic  influenial  polyneuritis  has 
been  observed.  The  disease  is  nearly  always  cured  without 
leaving  traces  of  its  existence,  but  in  some  instances  in- 
curable atrophies  in  certain  groups  of  muscles  have  been 
noted.  In  the  treatment  of  the  condition  the  element  of 
pain  ij  the  one  most  clamorous  for  relief.  Absolute  re«t  in 
bed  is  an  essential  in  the  treatment.  If  morphin  is  given  its 
administration  should  be  very  short  and  it  should  never  be 
used  without  first  determining  that  cardiac  lesions  or  in- 
volvement of  vagus  nerve  are  wanting.  Antipyrin  and 
sodium  salicylate  render  great  service.  A  very  gratelul  ap- 
plication to  the  painful  parts  consists  of  circular  bandages 
of  linen  wrung  out  of  cold  water  which,  in  turn,  should  be 
covered  with  a  layer  of  dry  cotton,  wool,  and  surrounded, 
finally,  by  a  layer  of  impermeable  tissue.  When  the  disease 
is  localized  in  the  lower  extremities  prolonged  refrigeration 
in  the  dorsolumbar  region  will  be  found  of  benefit.  After 
the  spontaneous  suffering  of  the  patient  has  disappeared ; 
when  the  signs  of  the  reaction  of  degeneration  no  longer 
exist,  and  when  the  examiuaticn  of  the  nerves  and  the 
muscles  shows  a  simple  diminution  of  excitability  of  those 
organs,  curative  treatment  should  be  instituted.  In  order 
that  this  treatment  may  be  etticacious  it  should  aim  at  the 
anatomic  restoration  as  well  as  at  the  functional  restoration 
of  the  altered  muscles  and  nerves,    [j.m.s  ] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hendrie  Lloyd,  A.M.,  M.D.,  Editor-in-ChUJ 
Julius  L.  Salinger,  M.D.,  Associate  Editor 
Astistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyer,  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  CoLET,  M.D. 

J.  M.  Swan,  M.D.  W.  A.  N.  Dorland,  M.D. 

J.  H.  Gibbon,  M.D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession  are  solicited 
for  publication.    Reprints  (260)  of  Original  Articles  will  be  lurnlshed  gratis  to  Authors  making 
the  request. 
The  liklitorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising;  Pages  8,  26  and  27. 


Vol.  VII,  No.  14 


APRIL  6,  1901 


$3.00  Per  Annum 


The  Plague  in  San  Francisco. — The  truth  on  this 
subject  seems  likely  to  come  to  light  in  due  time.  Some 
of  the  exact  facts  are  stated  in  the  last  number  of  the 
Public  Health  Reports  issued  by  the  Marine-Hospital 
Service,  and  are  printed  in  our  news  columns  today. 
The  commission  appointed  by  the  Secretary  of  the 
Treasury  was  supposed  to  have  made  up  its  report 
and  sent  it  in  to  the  Secretary  some  weeks  ago,  but  for 
reasons  which  doubtless  seemed  good  to  Mr.  Gage  this 
report  was  not  promptly  made  public.  We  cannot  too 
strongly  protest  against  any  further  attempt  to  keep  the 
plague  situation  in  San  Francisco  a  mystery.  The 
local  authorities  in  California  have  been  guilty  of  sup- 
pressing the  truth,  and  the  United  States  Government 
should  not  tolerate  this  abuse  any  longer.  Much  less 
should  it  keep  back  any  reports  of  commissions  or 
government  agents  relating  to  this  subject.  The  public 
is  vitally  interested,  and  all  alike  have  an  equal  right 
to  know  the  exact  facts.  It  is  unnecessary  here  to  re- 
peat the  facts  and  figures  given  in  another  column. 
The  announcement  that  42  fatal  cases  of  bubonic 
plague  have  occurred  in  San  Francisco  will  be  startling 
news  to  the  vast  majority  of  persons  both  within  and 
without  the  profession.  It  heralds  a  serious  situation, 
and  it  is  a  reproach  to  those  public  persons  from  San 
Francisco  who  were  announced  recently  to  have  said  in 
Washington  that  the  only  kind  of  plague  existing  on 
the  Pacific  Coast  was  of  a  "  noncontagious  "  character. 
The  general  demand  of  the  public— both  lay  and  profes- 
sional— ought  to  be  for  the  United  States  Government 
to  take  the  situation  vigorously  in  hand,  with  the  co- 
operation of  the  local  government,  if  possible,  but 
without  that  co-operation  if  need  be.  There  is  getting 
to  be  a  sort  of  optimism  about  plague  being  easily  con- 
trolled and  eradicated — but  the  facts  in  India  do  not 
prove  this,  and  at  any  rate  we  do  not  want  to  be  driven 
to  the  proof  of  it  by  a  widespread  epidemic  in  this 
country. 

Treatment    of  Malignant  Tumors  With   Serum. 

— The  di.'covery  of  a  specific  has  long  been  the  object 
of  those  engaged  in  studying  the  treatment  of  disease. 
Unfortunately,  while  belief  in  the  existence  of  a  specific 
for  each  morbid  entity  is  reasonable,  even  as  is  the 
belief  that  there  must  be  an  antidote  for  every  poison, 
the  true  specifics  at  our  command  are  very  few.  Even 
in  the  cases  of  quinin  we  find  cases  of  the  disease  for 


which  this  drug  is  supposed  to  be  a  specific,  in 
which  it  is  devoid  of  action ;  and  the  same  may  be  said 
of  mercury.  The  specific  action  of  antidiphtheritic 
serum  has  led  investigators  to  turn  their  attention 
to  serumtherapy  as  a  means  of  solving  the  problem  of 
obtaining  a  specific  for  diseases  that,  up  to  the  present 
time,  have  been  considered  incurable.  Some  of  the 
recent  experiments  in  the  line  of  curative  serums  have 
been  made  in  connection  with  sarcoma.  During  1899, 
Louis  Dor  (Gazette  Hebdomadaire  de  Medecine  el  de  Chi- 
rurgie,  February  14,  1901)  introduced  a  piece  of  a  chon- 
drosarcoma of  the  shoulder,  about  the  size  of  an  egg, 
into  the  peritoneal  cavity  of  a  rabbit.  At  first  a  large 
mass  developed  in  the  abdomen  of  the  rabbit ;  but  after 
about  a  year  the  mass  was  so  reduced  in  size  that  only 
a  small  nucleus  remained.  Then  a  larger  piece  of  a 
chondrosarcoma  from  a  human  subject  wag  introduced 
into  the  peritoneum  of  the  same  rabbit.  After  this  opera- 
tion the  fragment  was  absorbed  in  less  than  two  months. 
This  experiment  seems  to  show  that  the  serum  of  the 
rabbit  may  become  cytolytic  for  certain  sarcoma  cells  of 
man.  In  the  next  experiment  a  goat  was  operated 
upon.  A  bouillon  was  made  from  a  melanotic  sarcoma 
and  injected  subcutaneously.  There  was  some  reaction 
following  the  mjection  that  lasted  for  about  three  days. 
Three  months  later  the  same  goat  received  subcu- 
taneously an  entire  melanotic  sarcoma  of  the  eye.  The 
serum  of  the  goat  was  then  used  in  the  treatment  of 
two  patients  ;  one  of  whpm  presented  general-  melanotic 
sarcoma  of  the  lymph  nodes  of  the  axilla  and  neighbor- 
ing regions  with  a  presternal  cutaneous  tumor,  and  the 
other  of  whom  was  suffering  from  melanotic  sarcoma 
of  the  leg.  The  first  patient,  twelve  days  after  the  in- 
stitution of  the  treatment,  had  improved  in  general 
appearance  and  the  tumors  were  smaller.  In  the  second 
patient,  after  three  weeks,  during  which  about  100  ccm. 
of  the  serum  were  injected,  the  tumor  was  much  modi- 
fied in  appearance.  Reynier  (Gazette  Hebdomadaire  de 
Medecine  et  de  Chirurgie,  February  21,  1901)  has  used  a 
serum  obtained  by  Wlaeff  by  inoculating  birds  with 
blastomycetes  isolated  from  human  carcinomatous 
tumors.  The  patient  on  whom  this  serum  was  used 
was  suffering  from  an  inoperable  carcinoma  of  the 
tongue.  The  first  injections  of  the  serum  were  made 
July,  1900,  and  after  ten  injections  the  patient  was  able 
to  resume  his  ordinary  occupation.  The  lymph  nodes 
in  the  neck  remained  large,  however,  and  the  tumor  of 


632 


TffK  Philadelphia' 
Medical  Journal 


] 


EDITORIAL  COMMENT 


[April  6,  1981 


the  tongue  was  still  present  in  spite  of  the  amelioration 
of  the  general  condition  of  the  patient.  A  second 
patient,  who  was  suffering  from  a  cylindrical  epithelioma 
of  the  mammary  gland,  was  much  benefited  after  the 
administration  of  the  serum,  and  the  tumor  appeared  of 
the  nature  of  a  nonmalignant  growth.  Reynier  admits 
that  if  the  injections  are  stopped  the  disease  will  resume 
its  course  and  the  patient  will  finally  succumb.  Here, 
then,  are  two  serums,  both  in  the  experimental  stage.  The 
first  is  produced  by  transplanting  fragments  of  malig- 
nant tumor  or  by  injecting  a  bouillon  representing  the 
entire  tumor ;  the  second,  by  inoculating  blastomycetes 
obtained  from  malignant  tumors.  The  great  objection 
to  the  second  method  is  that  we  are  not  sure  that  blas- 
tomycetes are  the  cause  of  carcinoma  or  of  sarcoma. 
The  first  method  would  seem  to  stand  more  chance  of 
success  in  the  production  of  an  anticarcinomatous  or 
antisarcomatous  serum,  because,  since  the  entire  tumor 
is  used,  the  pathogenic  factor  of  the  disease,  whatever 
that  may  be,  must  surely  be  introduced  into  the  animal 
operated  on.  It  is  not  possible,  however,  at  the  present 
writing,  to  say  that  either  of  the  serums  advocated  in  the 
papers  under  review  is  a  specific ;  because  of  the  four 
patients  treated  not  one  was  actually  cured  of  his  dis- 
ease, and  Reynier  admits  that  the  result  of  the  adminis- 
tration of  the  bird's  serum  is  merely  palliative. 

Some  Timely  Words  About  the  Social  Evil. — Dr. 

Prince  A.  Morrow,  of  New  York,  is  a  surgeon  whose 
words  carry  weight  with  all  men  when  he  speaks  on  this 
wellnigh  forbidden  topic.  He  has  both  the  personality 
and  the  professional  experience,  as  well  as  the  balanced 
judgment  and  fine  ethical  sense,  which  constitute  him 
an  excellent  instructor  for  the  people  as  well  as  for  the 
profession  on  the  delicate  and  extremely  responsible 
question  of  the  public  recognition  and  control  of  the 
venereal  diseases.  In  the  present  number  of  the 
Journal  Dr.  Morrow  presents  a  paper  in  which  he 
traverses  rapidly,  fearlessly  and  completely  this  entire 
field.  The  author  of  the  paper  has  no  illusions,  yet  he 
is  not  pessimistic;  while  on  the  other  hand  he  has 
scruples,  but  he  is  not  puritanical.  He  sees  in  the  social 
evil,  as  he  aptly  expresses  it,  a  necessary  evil,  not  in  the 
sense  that  it  is  indispensable,  but  that  it  is  inevitable. 
The  drift  of  his  paper  is  to  make  clear  a  few  essential 
facts.  Its  worth  consists  in  its  not  attempting  to  say  too 
much.  The  regulation  of  prostitution  is,  at  best,  a 
dubious  and  imperfect  way  of  controlling  the  propaga- 
tion of  the  venereal  poisons.  In  this  country  such 
regulation  is  practically  impossible,  because  public 
opinion  will  not  tolerate  it.  This  was  made  clear  in 
Missouri  in  1871 — and  that  State  is  the  only  one  that 
has  ever  had  the  temerity  to  try  to  license  prostitution. 
Sanitarians  must  reckon  in  this  matter  with  public 
sentiment,  whether  they  wish  to  or  not,  and  in  the 
meanwhile  should  not  lose  valuable  time  in  vainly 
arguing  this  question  from  the  standpoint  of  hygiene 


versus  morality.  They  should  follow  the  course  that 
Dr.  Morrow  points  out,  and  try  in  some  practical  way 
to  at  least  control  and  curtail  the  evil.  That  it  can  ever 
be  entirely  eradicated  the  history  of  mankind  disproves; 
and  while  it  is  a  fine  thing  to  have  enthusiasm  in  a 
good  cause,  it  is  somewhat  Quixotic  to  believe  that  such 
a  sordid  and  debauched  curse  as  harlotry  can  ever  be 
banished  by  the  decrees  of  legislatures.  The  great  merit 
of  Dr.  Morrow's  paper  is  that  it  minimizes  the  purely 
ethical  and  sociological  aspects  of  this  subject,  and  treats 
it  largely  as  a  wise  physician  should,  upon  a  purely 
pathological  basis.  His  paper  is  fully  up-to-date  in  the 
way  it  demonstrates  the  grounds  for  our  enlarged  views 
about  the  far-reaching  effects  of  gonorrhea  and  syphilis, 
and  his  suggestions  for  meeting  the  evil  are,  we  believe, 
about  the  only  practical  ones  that  can  be  devised.  His 
arraignment  of  our  hospitals  for  shutting  their  doors  in 
the  faces  of  venereal  victims  is  timely  and  deserved, 
for  their  policy  in  this  matter  is  worse  than  inhuman — 
it  is  short-sighted. 

The  Influence  of  Intemperance  Upon  the  Death- 
Kate. — Whether  alcohol  be  a  food  or  a  poison  is  a 
question  that  will  be  answered  somewhat  in  accordance 
with  the  individual  point  of  view.  To  the  judicial 
mind  it  would  appear — paradoxic  as  it  may  sound — 
that  it  may  be  either  or  neither  or  even  both.  The 
best  disposition  of  alcohol  is  to  place  it — with  its  con- 
geners, ether,  chloroform,  etc., — in  the  category  of  drugs, 
with  definite  physiological  and  pathological  activities,  in 
accordance  with  the  dosage  employed,  the  frequency, 
mode  and  time  of  administration  and  the  susceptibility 
of  the  individual  who  receives  it.  Like  other  agenta 
and  agencies  capable  of  doing  good,  alcohol  is — as  might 
be  expected — capable  also  of  doing  harm,  and  no  one  can 
appreciate  better  than  the  physician  the  evil  results  of 
alcoholic  intoxication.  These  can  be  seen  directly  in 
various  disorders  of  the  digestive  organs  and  in  the 
more  remote  and  widespread  manifestation  of  arterio- 
sclerosis and  visceral  fibrosis.  In  addition  the  impress 
of  alcoholic  excess  can  be  observed  upon  the  mortality- 
rate  and  there  appears  an  intimate  relation  between 
alcoholic  excess  and  vice  and  crime.  Thus,  in  the 
United  Kingdom,  while  the  average  mortality-rate  has 
fallen  from  22.5  to  17.2  per  1000  since  1872,  the  rate 
from  alcoholic  intemperance  increased  from  45  per 
million  in  1875  to  77  per  million  in  1897.  It  is  found 
also  that  the  number  of  criminal  offences  is  smaller  in 
parts  where  alcoholic  intemperance  is  less  prevalent. 
Upon  the  physician  as  the  conservator  of  the  public 
health,  therefore,  it  would  seem  incumbent  to  prevent 
and  to  correct  so  far  as  possible  any  tendency  to 
alcoholic  addiction,  with  the  same  earnestness  as  he 
strives  to  prevent  and  correct  habituation  to  tlie  use  of 
chloral,  cocain,  opium  or  any  other  substance  pre- 
judicial to  health.  A  share  of  responsibility  rests  upon 
every  physician  in  this  matter. 


April  6,  1901) 


EDITORIAL  COMMENT 


[The  Philadelphia 
Medical  Journal 


633 


The  Business  Outlook  in  Medical  Practice. — The 

ratio  of  physicians  to  total  population  in  the  United 
States  is  rather  more  than  1  in  600.  The  120,000  physi- 
cians are  dying  at  the  rate  of  about  25  to  1000.  To 
make  good  the  deficit  of  physicians  by  death,  about 
3,000  should  be  graduated  annually.  The  population 
is  also  increasing  at  the  rate  of  about  1,300,000  an- 
nually, and  this  increase  could  accommodate  some 
2,100  additional  graduates  in  medicine  annually.  In 
1899,  according  to  statistics  of  the  Bureau  of  Educa- 
tion, all  of  the  medical  schools  of  the  country  gradu- 
ated not  quite  5,000.  Thus,  statistically  considered, 
there  is  a  very  slight  favorable  tendency  toward  the 
reduction  of  a  tremendously  overcrowded  profession. 

On  the  other  hand,  it  should  be  remembered  that  as 
a  country  increases  in  density  of  population,  it  can 
support  fewer  physicians.  For  instance,  European 
countries  with  a  ratio  of  approximately  1  to  2000  of 
physicians  to  population,  support  their  medical  profes- 
sions even  more  poorly  than  does  the  United  States. 
Moreover,  sanitary  science  and  medical  and  surgical 
skill,  as  well  as  more  wholesome  modes  of  living,  are 
markedly  reducing  the  work  of  the  profession.  The 
well  known  fact  that  a  fifth  or  sixth  of  graduates  do  not 
practise  is  little  comfort,  as  this  has  always  been  the  case, 
and  it  simply  denotes  the  unfavorable  conditions  against 
which  the  medical  man  has  to  contend.  Thus  it  is  the 
urgent  duty  of  every  physician,  by  fair  argument  and 
reasonable  means,  to  create  a  sentiment  against  the  en- 
trance of  young  men  upon  medical  studies,  unless  they 
are  especially  fitted  for  their  pursuit. 

The  Antitoxin  Unit. — The  antitoxin  unit  is  defined 
as  the  amount  of  antitoxin  which,  when  inoculated  into 
a  guineapig  of  250  grams  weight,  will  neutralize  100 
times  the  minimum  fatal  dose  of  toxin  of  standard 
strength.  Antitoxin  may  be  present  in  varying 
amounts  in  the  serum  employed,  and  it  is  an  important 
point  to  remember  that  the  number  of  cubic  centi- 
meters of  the  serum  injected  is  no  index  to  the  strength 
of  the  solution  in  antitoxin  units.  Until  1896  the  defi- 
nition of  antitoxin  unit  above  given  was  regarded  as 
reliable,  but  in  that  year  Ehrlich  found  that  the  same 
antitoxin  is  capable  of  neutralizing  varying  numbers 
of  fatal  doses  of  toxin  according  to  the  cultures  used, 
and  perhaps  the  method  of  preparing  the  toxin.  For 
example,  he  found  that  the  same  amount  of  the  same 
antitoxin  might  neutralize  from  less  than  30  to  130 
doses,  according  to  the  source  of  the  toxin.  A  diffi- 
culty to  be  overcome  was  to  maintain  the  standard 
strength  of  the  toxin  and  antitoxin  for  testing  purposes. 
Ehrlich  prepared  both  toxins  and  antitoxins  dried,  in 
powder  form,  and  kept  them  in  vacuum  tubes  at  a  low 
temperature  and  protected  from  the  light.  The  standard 
dilution  of  antitoxin  which  Ehrlich  employs  consists  of 
equal  parts  of  glycerin  and  10%  salt-solution.  This 
mixture   will  maintain  the  strength  of  the  antitoxin 


dissolved  in  it  for  several  months.  The  technique  of  the 
preparation  of  antitoxin  was  further  modified  by 
Ehrlich  in  that  he  mixed  both  the  toxin  and  the  anti- 
toxin before  injecting  them  into  the  guineapig  instead 
of  injecting  them  separately,  as  was  at  first  practised. 
Ehrlich  also  employed  the  whole  unit  in  the  operation 
of  standardizing  instead  of  one-tenth  unit,  and  the  most 
important  modification,  that  in  place  of  making  complete 
neutralization  the  end  to  be  obtained,  he  shifted  the  end 
reaction  to  the  death  or  survival  of  the  guineapig  used. 
For  example,  if  we  wish  to  standardize  a  certain  toxin 
with  the  unit  antitoxin  we  add  to  the  antitoxin  such 
excess  of  toxin  that  the  resulting  mixture  will  just 
prove  fatal  to  a  guineapig  on  the  fourth  day.  By  this 
procedure  we  have  not  only  neutralized  the  antitoxin, 
but  also  added  one  minimum  fatal  dose.  Theobald 
Smith  for  the  past  three  years  has  employed  Ehrlich's 
improved  method,  and  with  the  test-serum  obtained 
from  Ehrlich  has  prepared  all  of  the  antitoxin  for  the 
Massachusetts  State  Board  of  Health.  In  the  Journal 
of  the  Boston  Society  of  Medical  Sciences,  Vol.  5,  No.  1,  he 
has  presented  a  critical  analysis  of  the  combining 
power  of  antitoxins  and  toxins  so  prepared,  and  con- 
cludes that  up  to  the  present  time  Ehrlich's  method  is 
by  all  means  the  most  satisfactory  and  accurate.  It 
has  been  claimed  by  Park  and  Atkinson  that  if  toxins 
are  prepared  in  an  absolutely  uniform  manner  from 
the  same  cultures  their  neutralizing  power  is  likely  to 
be  the  same.  Smith  has  demonstrated  in  a  number  of 
experiments  that  this  may  or  may  not  be  the  case.  The 
studies  of  Ehrlich  and  Madsen  have  revealed  how  intri- 
cate is  the  process  of  the  neutralization  phenomena, 
and  up  to  the  present  time  all  hypotheses  fail  to  explain 
them.  Ehrlich  has  found  that  if  he  added  to  a  definite 
quantity  of  toxin,  different  fractions  of  the  antitoxin 
unit  the  results  indicate  that  the  neutralizing  and  the 
toxic  power  of  the  same  toxin  do  not  go  hand  in  hand. 
Ehrlich  (quoted  by  Smith)  from  his  study  of  the 
various  toxins  infers  from  these  results  the  presence  in 
them  of  substances  of  different  degrees  of  toxicity,  as 
well  as  neutralizing  power,  towards  antitoxins.  He 
explains  the  multiplicity  of  variations  which  occur  by 
the  numerous  combinations  of  these  substances.  Ehrlich 
has  called  these  substances  which  appear  in  the  fresh 
toxins,  toxins  and  toxones.  The  latter  have  but  little 
toxic  power,  but  they  neutralize  antitoxin,  and  Ehrlich 
is  inclined  to  look  upon  them  as  the  feeble  poisons 
which  cause  paralysis.  According  to  their  affinity  to 
antitoxins  he  classifies  the  antitoxins  present  in  any 
culture  fluid  into  proto-,  deutero-,  and  trito-toxins.  The 
proto-toxins  have  the  strongest,  the  toxones  the  least 
affinity  for  antitoxins.  These  break  up  after  a  time 
into  toxoids.  Some  of  these  secondary  products  are 
more  stable  than  others.  We  are  indebted  to  Dr.  Smith 
for  a  convincing  demonstration  of  the  superiority  of 
Ehrlich's  method  over  others  employed.  The  variable 
factors  to  be  considered  in  the  preparation  of  antitoxin 


634 


The  Philadelphia"! 
Medical  Journal  J 


EDITORIAL  COMMENT 


[APRIL  6,  IMl 


are :  a  uniform  culture  medium,  the  preservation  of 
cultures  so  that  deterioration  may  be  minimized,  and 
the  effects  of  inoculations  upon  guineapigs.  Smith 
has  found  a  few  animals  out  of  the  great  number  em- 
ployed for  experimental  purposes  who  have  withstood 
a  single  fatal  dose  without  any  local  reaction  whatever. 
He  also  mentions  that  the  animals  are  apparently  more 
susceptible  in  winter  than  in  summer. 

Must  the  Family  Doctor  Go  ? — Obliquity  of  view 
and  extravagance  of  expression  are  among  the  venial 
sins  of  some  of  the  modern  newspapers.  To  deal  in 
paradox  is  their  specialty,  and  they  exercise  this  privi- 
lege nowhere  more  rashly  than  on  the  subject  of  medi- 
cal practice.  For  instance,  one  of  our  metropolitan 
dailies  (by  which  expression  we  mean,  of  course,  a 
New  York  newspaper),  recently  wrote  a  sort  of  obituary 
notice  on  the  family  doctor.  On  the  authority  of  a 
fashionable  specialist,  this  newspaper  announced  that 
the  days  of  the  general  practitioner  are  numbered,  and 
that  in  the  near  future  the  specialist  and  the  trained 
nurse  will  monopolize  the  field.  Even  as  it  is,  the 
functions  of  the  family  doctor,  it  thinks,  can  be  per- 
formed just  as  well,  if  not  a  little  better,  by  a  well- 
trained  nurse.  Moreover,  the  specialist  to  occupy  the 
field,  will  be  the  surgical  specialist — the  man  who 
stands  ever  ready  with  knife  in  hand,  because,  accord- 
ing to  our  New  York  newspaper,  the  day  is  rapidly 
approaching  when  all,  or  nearly  all,  diseases  will  be 
cut  out  bodily.  In  this  promised  golden  age,  aU  that 
■will  be  necessary  will  be  for  a  well-trained  nurse  to 
recognize  the  disease  and  call  in  the  surgical  specialist, 
who  will  proceed  to  cut  it  out  and  hand  over  the  patient 
again  to  the  nurse,  who  will  keep  him  aseptic  and  re- 
turn him  to  business  in  due  time. 

All  this  sounds  like  persidage,  and  was  probably 
written  by  a  man  with  his  tongue  in  his  cheek,  but  we 
take  note  of  it  because  it  represents  superficially  a  kind 
of  criticism  that  is  growing  too  common.  The  family 
doctor  is  not  doomed  to  extinction.  Far  from  the  day 
of  his  decline  having  come,  the  day  of  his  greatest 
usefulness  is  only  just  beginning.  It  is  evident,  how- 
ever, that  he  must,  in  one  sense,  be  a  specialist  him- 
self, i.  e.,  he  must  have  special  alertness  of  mind  to 
recognize  disease,  and  to  know  what  remedy  is  needed. 
But  the]  field  of  preventive  and  domestic  medicine 
is  largely  his  own,  and  will  continue  to  be  his.  He 
will  always  occupy  a  position  of  great  advantage,  for 
he  stands  at  the  threshold.  He  will  continue  to  dis- 
pense his  patronage  to  the  specialists,  and  they  will 
know  him  when  they  see  him.  But  he  must  be 
thoroughly  trained  for  this  work. 

The  Treatment  of  Varicocele. — Surgeon- General 
Sternberg  has  sent  out  from  his  otfice  an  interesting 
circular  on  the  treatment  of  varicocele  in  which  the 
experience  of  a  number  of  army  surgeons  is  given. 


These  observers  all  recommend  the  recently  devised 
high  operation,  and  since  its  employment  they  have  had 
the  most  uniformly  good  results,  particularly  as  regards 
the  primary  healing  of  the  wound.  As  varicocele  is 
considered  a  bar  to  enlistment  and  when  occurring  after- 
ward a  partial  disability,  the  recruiting  stations  and  the 
army  furnish  a  large  majority  of  the  cases  of  varicocele 
which  are  operated  upon.  In  civil  life  this  condition 
is  not  looked  upon  as  one  of  any  moment  unless,  as  is 
not  infrequently  the  case,  the  patient  has  developed  a 
distressingly  hypochondriacal  state  of  mind.  It  can 
be  truly  said  that,  excepting  in  applicants  for  the  army 
and  navy  and  for  positions  in  some  of  our  police  and 
fire  departments,  operations  for  varicocele  are  seldom 
necessary.  The  circular  concludes  with  some  very  wise 
remarks  on  the  subject  by  Nicholas  Senn.  His  observa- 
tions regarding  the  usually  innocent  nature  of  this 
condition  and  the  infrequent  necessity  for  operation 
coincide  with  those  expressed  by  William  H.  Bennett, 
in  a  recent  lecture  published  in  the  London  Lancet, 
March  2  (abstracted  in  Philadelphia  Medical  Jourxal, 
March  23).  Senn,  in  examining  9,815  recruits,  found 
varicocele  present  in  2,078.  One-half  of  these  men  were 
ignorant  of  the  condition  and  only  three  or  four  ac- 
knowledged the  slightest  discomfort  or  pain.  Undoubt- 
edly it  is  true  that  the  recruiting  stations  of  the  army 
and  navy  discover  for  most  of  these  patients  the 
presence  of  this  condition,  which  Senn  believes  to  exist 
in  one  out  of  every  three  or  four  males  between  the 
ages  of  18  and  30  years.  One  point  of  difiference  in  the 
operative  technique  of  Mr.  Bennett  is  that  he  urges  the 
ligation  of  the  spermatic  arter}'  with  the  veins,  main- 
taining that  the  artery  of  the  vas  deferens  and  other 
small  vessels  from  the  tunica  vaginalis  are  suflBcient  to 
suppl}'  the  testis.  He  suggests  that  the  fatty  degenera- 
tion of  the  testis  which  sometimes  follows  the  operation 
might  possibly  be  due  to  an  over-supply  of  blood  with- 
out the  proper  means  of  its  return. 

One  can  but  be  pleased  with  the  satifactory  reports 
found  in  the  Surgeon- General's  circular,  but  in  the  light 
of  the  experience  of  men  like  Bennett  one  must  also 
conclude  that  many  cases  of  varicocele  are  unnecessarily 
subjected  to  operation.  In  the  absence  of  local  and 
mental  symptoms  we  are  inclined  to  doubt  the  necessity 
for  operation  in  civil  life.  In  a  soldier,  particularly  a 
cavalryman,  it  is  somewhat  different,  as  a  large  varico- 
cele would  certainly  predispose  to  traumatism. 

The    Control   of    Marriage   by   the   State. — The 

right  of  the  State  to  regulate  marriage  has  always  been 
recognized  in  some  form  as  a  fundamental  principle  of 
law.  Marriage,  considered  purely  from  the  historical 
standpoint,  is  an  artificial  institution ;  that  is  to  say, 
its  very  existence  depends  upon  legal  recognition.  It 
is  created  by  law,  and  in  the  eye  of  the  law  it  is  merely 
a  contract  of  a  special  and  peculiar  kind.  In  the  evo- 
lution of  society  the  institution  of  marriage  has  passed 


April  6,  1901] 


EDITORIAL  COMMENT 


rxH 

LMl 


E  Philadelphia 

EDICAL  JOUBNAL 


635 


through  several  recognizable  phases,  but  there  has  never 
been  a  time  when  it  was  not  in  some  way  or  other  the 
creature  of  the  law.  The  culmination  of  this  process 
of  social  evolution  has  been  when  marriage  has  come 
to  be  regarded  in  the  canonical  law  of  most  races  as  a 
sacrament  of  the  Church.  But  this  is  only  a  late  phase 
of  its  development.  Considering  all  these  facts  it  is 
somewhat  remarkable  how  really  little  the  lawmakers 
of  various  nations  and  ages  have  interfered  with  the 
natural  process  of  marriage.  No  civil  institution,  per- 
haps, has  been  less  trammelled  in  its  initial  stage  by 
the  law— although  the  contract  once  made  it  has,  as  a 
rule,  been  jealously  guarded.  But  the  widest  liberty  in 
entering  into  the  bonds  of  matrimony  has,  as  a  rule, 
been  granted.  Where  restrictions  have  been  imposed 
they  have  been  usually  for  social,  not  for  hygienic, 
reasons ;  as,  for  instance,  when  the  marriage  of  slaves 
has  been  prohibited.  But  that  natural  prejudices,  as 
well  as  the  welfare  of  posterity,  have  also  imposed  restric- 
tions is  seen  in  the  Levitical  law  against  consanguineous 
marriage  within  certain  limits,  and  in  the  interdiction 
by  most  countries  of  the  marriage  of  lunatics  and  idiots. 

There  must  be  some  reason  why  a  contract  so  jealously 
guarded  when  once  established,  should  be  left  so  com- 
paratively free  from  restrictions  for  almost  all  persons 
who  choose  to  enter  into  it.  The  ancient  Spartans,  we 
believe,  came  the  nearest  of  all  really  civilized  nations  to 
putting  the  entrance  into  marriage  under  the  control  of 
the  State ;  in  other  words,  to  using  marriage  merely  as 
a  method  for  breeding  healthy  men  and  women.  But 
Sparta  was  the  least  civilized  of  all  the  Greek  States, 
and  her  example  has  never  been  followed.  It  has 
remained  for  the  State  of  Minnesota  to  play  this  inter- 
esting role  of  imitating  ancient  Sparta.  If  the  reports 
of  the  new  law  regulating  marriage  in  thatState  are  cor- 
rect, Minnesota  is  approaching  perilously  near  Sparta. 
We  are  much  impressed  with  the  futility,  not  to  say 
folly,  of  the  proposed  law,  and  wish  to  chronicle  a 
prophecy  that  it  will  fail,  as  it  deserves  to  do. 

This  new  and  preposterous  law  would  make  it  illegal 
to  marry  without  a  physician's  certificate  as  to  the 
mental  soundness  of  the  contracting  parties  as  well  as 
of  the  families  of  both  of  them.  It  is  difficult  to  know 
where  to  begin  to  criticise  such  a  law.  The  crusade 
against  cigarettes  is  as  the  wisdom  of  Solon  compared 
with  it.  We  do  not  stop  for  a  moment  to  condemn  it 
on  ethical  and  humane  grounds ;  it  condemns  itself 
there.  To  say  that  any  person  who  had  had  a  parent 
a  grandparent,  or  a  brother  or  sister,  the  victim  at  some 
time  of  an  attack  of  insanity,  or  epilepsy,  should  be 
debarred  from  marriage  by  the  certificate  of  a  phy- 
sician, is  too  wantonly  barbarous  and  too  crudely  un- 
scientific to  need  to  be  criticised  at  all.  We  simply 
point  to  the  utter  impracticability  of  such  a  law  on  the 
ground  that  the  proof  of  insanity  in  a  family  is  the 
hardest  to  establish  and  the  easiest  to  conceal  of  any 
kinds  of  proof.  All  psychiatrists  know  this  from  almost 


daily  experience.  Such  a  law  apparentlj'  places  the 
happiness  of  two  individuals  for  life  on  the  scientific 
acumen  and  psychiatrical  skill  of  the  average  practi- 
tioner of  medicine  in  Minnesota,  or  leaves  the  law  itself 
to  die  a  natural  death  from  the  inability  or  unwilling- 
ness of  a  doctor  to  step  in  and  forbid  the  banns  in  the 
case  of  some  young  man  or  young  woman  whose  mother 
may  have  had  puerperal  insanity,  or  whose  grandfather 
may  have  had  senile  dementia,  or  whose  wayward 
brother  may  have  just  recently  died  of  general  paresis. 
The  general  sense  of  mankind  will  condemn  such  laws 
as  it  has  condemned  them  since  the  time  of  the  Spartans. 

The  Bacterial  Treatment  of  Sewage. — The  dis- 
posal of  the  sewage  of  large  towns  and  cities  is  a  prob- 
lem that  has  long  engaged  the  attention  of  public  health 
officials  throughout  the  world.  When  a  town  is  situated 
on  the  banks  of  a  river  the  natural  outlet  for  the  waste 
from  the  dwellings  and  from  the  manufacturing  estab- 
lishments of  that  community  is  into  the  river  which, 
provided  there  is  sufficient  current,  will  carry  the  efiete 
matter  away  from  its  origin.  If,  however,  there  is  a 
second  city  situated  on  the  same  river  below  the  one 
seeking  to  dispose  of  its  sewage,  the  refuse  of  the  first 
will  flow  through  the  second  community,  giving  rise  at 
least  to  noxious  odors.  Again,  if  the  second  community 
seeks  to  obtain  its  water-supply  from  this  stream,  polluted 
with  the  drainage  from  the  first,  disease  will  surely  follow, 
and  in  numerous  authentic  instances  has  resulted. 
Experiments  have  been  made  at  Barking  and  at  Cross- 
ness, in  England,  with  the  treatment  of  sewage  by 
allowing  it  to  flow  by  intermittent  contact  through  beds 
made  of  coke  or  of  ragstone  so  as  to  produce  in  the 
fluid  drainage  a  series  of  changes  comparable  to  those 
found  in  nature.  The  object  of  inducing  these  changes 
is  to  produce  an  effluent  that  shall  not  do  harm  to  the 
inhabitants  when  flowing  through  a  stream  that  is  used 
for  the  water-supply  of  a  town.  The  results  of  these 
experiments  have  been  reported  by  Houston  (Edinburgh 
Medical  Journal,  February,  1901).  In  nature  the  follow- 
ing cycle  of  transformation  takes  place  :  Dead  organic, 
matter  decays  as  the  result  of  the  vital  activity  of  bac- 
teria, and  ammonia  is  liberated.  The  nitrifying  organ- 
isms bring  about  the  oxidation  of  the  ammonia,  first 
to  nitrous  and  then  to  nitric  acid.  These  acids,  by 
reaction  upon  the  bases  always  present,  form  nitrites 
and  nitrates,  and  these  nourish  the  living  plant.  While 
the  nitrogen  is  undergoing  these  changes,  the  carbon  of 
the  organic  matter  is  converted  into  carbonic  acid  and 
the  hydrogen  mainly  into  water.  To  some  extent,  also, 
the  nitrogen  and  hydrogen  are  liberated  in  the  free 
gaseous  state.  Now  the  organic  matters  found  in  sew- 
age are  partly  in  suspension  and  partly  in  solution,  and 
sewage  contains  in  itself  the  necessary  living  germs  for 
the  destruction  of  both  these  forms  of  organic  matter. 
The  object  of  the  biological  treatment  of  sewage 
is  to  render  the  solid   matters  soluble,  by  microbial 


636 


Thk  Phii.adblphia~| 
msdical  joubkal  j 


EDITORIAL  COMMENT 


[Apbil  e,  1901 


agencies,  and  to  split  up  both  the  matter  thus  dis- 
solved and  the  organic  compounds  that  were  originally 
in  solution  into  their  simpler  elements  by  the  action  of 
living  bacteria.  In  the  final  process  of  purification 
these  substances  should  undergo  oxidation,  induced  by 
the  life  processes  of  nitrifying  organisms,  and  an  effluent 
should  be  produced  that  is  free  from  putrescible  matter 
and  that  contains  only  inorganic  or  mineral  substances. 
As  compared  with  the  present  process  of  chemical  pre- 
cipitation and  sedimentation,  the  bacterial  process  pre- 
sents the  following  advantages  :  (1)  It  requires  no 
chemicals ;  (2)  it  produces  no  offensive  sludge,  but  onl^ 
a  deposit  of  sand  or  vegetable  tissue  that  is  free  from 
odor ;  (3)  it  removes  the  whole  of  the  suspended  matter, 
instead  of  only  about  80%  thereof;  (4)  it  effects  the 
removal  of  51.3%  of  the  dissolved  oxidizable  and 
putrescible  matter,  as  compared  with  the  removal  of  17% 
by  the  present  chemical  treatment;  (5)  the  resultant 
liquid  is  entirely  free  from  objectionable  smell,  does  not 
become  foul  when  it  is  kept,  and  maintains  the  life  of 
fish.  Although  the  effluents  from  the  bacterial  beds 
contained  on  an  average  fewer  bacteria,  liquefying 
microorganisms,  spores  of  aerobic  bacteria,  B.  coli,  and 
spores  of  B.  enteritidis  sporogenes,  than  the  raw  sewage, 
the  reduction  was  not  well  marked,  and  indeed  was 
immaterial,  considering  the  large  number  of  organisms 
still  remaining.  It  was  discovered  that  the  sewage 
capacity  of  the  coke  beds  decreased  and,  in  one  case, 
the  decrease  was  determined  to  be  proceeding  at  the 
rapid  rate  of  1  %  of  the  original  capacity  per  week. 
The  coke  was  found  to  be  coated  with  a  black-colored, 
slimy  deposit,  free  from  objectionable  smell.  When 
looked  at  under  a  low  power  of  the  microscope,  it  was 
seen  to  be  composed  largely  of  minute  particles  of  sand 
and  coke,  together  with  apparently  imperfectly  disin- 
tegrated animal  and  vegetable  matter.  In  crude  sew- 
age, in  bacterial  coke  beds,  and  in  the  effluent 
from  bacterial  beds,  there  are  certain  bacteria,  which, 
after  being  stained  with  hot  carbol-fuchsin,  resist  de- 
colorization  with  33%  nitric  acid.  Some  of  these 
acid- fast  bacteria  cannot  with  certainty  be  morpho- 
logically distinguished  from  the  tubercle-bacillus.  In 
one  instance,  a  guineapig,  inoculated  with  the  deposit 
accumulating  on  the  coke  of  a  bacterial  bed,  died  and 
presented,  on  examination,  the  appearance  of  death 
from  tuberculous  infection.  Furthermore,  sections 
of  the  organs  of  this  animal,  when  appropriately 
stained,  showed  the  presence  of  numerous  tubercle- 
bacill.  In  one  experiment  the  cholera  bacillus  seemed 
to  have  lost  its  vitality  in  less  than  a  fortnight;  in 
another  experiment  it  remained  alive  for  nearly  4 
weeks.  Up  to  the  twenty-fourth  day  after  the  original 
inoculation,  the  presence  of  Staphylococcus  pyogenes 
aureus  was  readily  demonstrated.  After  experiments 
with  other  microorganisms  Houston  concludes  that 
liowever  satisfactory  the  process  may  be  from  the  chem- 
cal  and  practical  point  of  view,  the  effluents  from  the 


bacterial  beds  cannot  reasonably  be  assumed  to  be 
more  safe  in  their  possible  relation  to  disease  than  raw 
sewage. 

The  Therai)eiitlc  Monthly. — We  called  attention  in 
our  last  number  to  the  fact  that  a  new  -Journal,  devoted 
exclusively  to  Therapeutics,  would  be  issued  in  May 
under  the  editorial  care  of  Dr.  James  Tyson,  with  whom 
are  associated  Dr.  Thomas  L.  Coley  and  Dr.  T.  Mellor 
Tyson.  The  prospects  for  the  new  .Journal  are  most 
favorable,  and  we  predict  success  for  it. 


A  Metastatic  Tumor  Composed  of  Healthy  Tissae 
of  the  Thyroid  Gland.— Oderfeld  and  Steingaus  (Medy- 
cyna,  January  6,  1901),  report  the  interesting  case  of  a  wo- 
man, 58  years  dd,  who  presented  a  tumor  on  the  '.eft  side  of 
forehead  the  size  of  a  hen's  egg.  An  incision  disclosed  a 
firm  mass  very  rich  in  bloodvessels,  connected  with  the  dura 
and  passing  out  through  the  tkull.  The  growth  was  removed 
and  a  microscopic  examination  showed  it  to  consist  of 
glandular  tissue  identical  with  that  found  in  the  thyroid 
gland.  No  tumor  of  the  thyroid  was  found.  The  woman 
made  a  good  recovery,  and  no  return  of  the  growth  was  no- 
ticed half  a  year  later.  The  supposition  is  made  that  this 
tumor  was  the  result  of  metastasis  of  a  piece  of  healthy  thy- 
roid which  was  carried  by  the  blood  to  the  skull  and'there 
developed,     [a  k.] 

Treatment  of  Pneumonia  by  Antidiphtheritic 
Serum. — Ch.  Talamon  {Gaz.  Heb.  de  Med.  d  de  Chirur., 
February  28, 1901,  48me  Anni-e,  No.  17)  at  a  meeliog  of  the 
Soci6t6  M^dicaledes  Hopitaux,  held  January  2, 1901,  reported 
the  results  of  the  treatment  of  .W  cases  of  pneumonia  by 
the  lEJection  of  antidiphtheritic  serum.  Oat  of  these 
50  cases,  7,  or  14^,  died.  Formerly  in  the  Hospital  Bichet 
the  mortaUty  was  at  least  24%,  and  in  1899  it  was  37^. 
The  author  then  gives  statistics  concerning  the  ages  of  the 
patients  and  the  number  in  which  a  history  of  alcoholism 
could  be  obtained.  Out  of  the  cases  treated  before  the  sixth 
day,  the  mean  duration  of  the  disease  has  been  6  days. 
Twenty- live  patients  were  not  treated  until  after  the  sixth 
day  of  the  disease.  Six  of  these  patients  died.  Out  of  the 
number  who  recovered,  in  14,  a  single  irjection  sufficed  to 
produce  defervescence.  The  mean  duration  of  the  disease 
in  18  patients  who  recovered  when  treatment  was  not  estab- 
lished until  after  thesixth  day  of  the  disease,  was  20  days.  Tne 
author  has  injected  enormous  doses  of  antidiph'.heritic 
serum,  even  as  much  as  200  ccm.  or  260  ccm.  during  several 
days,  and  he  has  never  noticed  any  deleterious  results  other 
than  erythematous  eruption  and  articular  pains  and  these 
sequelae  were  noted  only  5  times  in  the  50  cases.  Renal 
lesions,  cardiac  lesions  and  arteriosclerosis  are  organic  defects 
that  demand  great  reserve  in  serumtherapy.  In  this  series  of 
cases,  however,  almost  all  the  patients  above  40  years  of  age 
eutfered  from  arteriosclerosis,  and  the  author  has  never  ob- 
served the  least  cardiac  trouble  that  could  be  imputed  to  the 
serum  ;  there  was  no  sign  of  cardiac  failure,  even  in  patients 
between  60  and  75  years  of  age.  The  author  has  never  seen 
an  increase  of  albuminuria  after  the  injections,  nor  has  he 
observed  cases  in  which  that  symptom  was  more  persistent 
than  usual :  it  disappeared,  as  a  rule,  assocu  as  the  fever  fell. 
Two  or  three  injections  of  20  ccm.  each  should  be  given.  Ordi- 
narily eacli  injection  is  followed  by  a  lowering  of  the  morn- 
ing temperature.  If  the  temperature  is  high  again  in  the 
evening  a  second  injection  should  be  made.  In  cates  of 
adynamic  pneumonia  with  a  typhoid  aspect,  2  injections 
ought  to  be  given  in  the  same  day,  and  repeated  the  next 
day  if  the  temperature  is  not  modified.  In  any  case  the 
double  injection  ought  to  be  used  if  the  patient  is  not  seen  be- 
fore the  third  day  of  the  disease.  The  author  considers  that, 
by  following  these  rules,  it  is  possible  to  shorten  the  duration 
of  pneumonia,  to  suppress  or  at  least  to  reduce  the  chances 
of  complications,  and  to  lower  the  mortality  of  that  disease 
to  about  10%.    [JM.S.] 


Aprii.  fi,  19011 


AMERICAN  NEWS  AND  NOTES 


["The  Philadelphia 
L  Medical  Jooenal 


637 


21mcrican  Hems  anb  Xloks. 


PHILA.DELPHIA  AND  PENNSYLVANIA. 

Dead  in  His  Chair. — Dr.  Jacob  E.  Hoffer,  of  Columbia, 
Pa.,  died  sitting  in  his  chair  in  the  laboratory,  death  having 
resulted  from  heart  disease.    Diceased  was  75  years  old. 

Farntaurst  State  Hospital  for  the  Insane.— The 

Trustees  of  the  State  Hospital  for  the  Insane  at  Farnhurst 
elected  Dr.  Florence  H.  Watson,  formerly  of  the  hospital  at 
Norristown,  Pd.,  to  be  Assistant  Superintendent,  to  succeed 
Dr.  John  H.  Hammond,  resigned. 

Duhring  Dermatolog-ical  Society. — The  Duhring 
Dermatological  Society  hos  recently  been  formed  with  the 
following  membership :  Drs.  L.  A.  Duhring,  Arthur  Van 
Harlingen,  H.  W.  Stelwagon,  J.  V.  Shoemaker,  M.  B.  Hart- 
zell,  J.  F.  Schamberi,  E.  S.  Gans,  C.  N.  Davis,  E.W.  Stout,  I. 
M.  Koch  and  J.  F.  Wallis.  Meetings  are  held  on  the  third 
Tuesday  of  each  month  at  the  various  centrally  located  hos- 
pitals. No  papers  are  read,  but  cases  of  rare  interest  are  ex- 
hibited and  discussed.  Dr.  H.  W.  Stelwagon  is  chairman  of 
the  Society,  and  Dr.  J.  F.  Schamberg,  secretary. 

Vital  Statistics  of  Philadelphia  for  the  week   ended 

March  30,  1901 : 

Total  mortaUty 532 

CA3ES.        DKATBS. 

Inflammation  of  appendix  3,  bladder  3,  brain 
15,  bronchi  17,  kidneys  22,  heart  3,  liver  1, 
hings    78,    pericardium    1,    peritoneum   7, 

pleura  1,  stomach  and  bowels  21 172 

Inanition  17,  marasmus  7,  debility  5 29 

Tuberculosis  of  lungs 74 

Apoplexy  19,  paralysis  9    .    .       28 

Heart — disease  of  42,  fatty  degeneration  of  4, 

neuralgia  of  2 48 

Uremia  11,  diabetes  2,  Bright's  disease  10  .   .   .  23 
Carcinoma  of  breast  3,  liver  1,  rectum  2,  stom- 
ach 6,  uterus  1,  face  1 13 

Convulsions  15,  convulsions,  puerperal  1     .   .  16 

Diphtheria 72  12 

Brain — disease  of  2,  abscess  of  1,  dropsy  of  1, 

softening  of  3,  tumor  of  1 8 

Typhoid  fever 47  4 

Old  age   7 

Cyanosis 3 

Scarlet  fever 97  8 

Influenza  9,  alcoholism  1,  asthma  4,  anemia  1, 
aneurysm  of  aorta  1,  burns  and  scalds  2, 
casualties  9,  congestion  of  brain  4,  conges- 
tion of  lungs  5,  childbirth  1,  cirrhosis  of 
liver  2,  cellulitis  of  leg  1,  membranous 
croup  2,  diarrhea  1,  dropsy  3,  erysipelas  1, 
extrauterine  pregnancy  1,  puerperal  fever 
1,  fracture  of  femur  1,  gallstones  1,  gangrene, 
leg  1,  hemorrhsige,  uterus  1,  jaundice  3,  ob- 
struction of  bowels  1,  edema  of  lungs  3, 
poisoning  1,  rheumatism  1,  retention  of 
urine  1,  arteriosclerosis  1,  surgical  shock  2, 
septicemia  6,  sarcoma  of  larynx  1,  suffoca- 
tion 2,  teething  4,  ulceration  of  stomach  1, 
unknown  coroner  case  1,  whooping-cough  3  86 

Pathological  Society. — The  first  paper  read  at  the 
meeting  of  March  28  was  by  Dr.  William  G.  Spiller  on 
Cerebellar  lesions  without  cerebellar  symptoms. 

Several  cases  were  cited  as  instances  of  the  condition  men- 
tioned. Among  them  were  cases  of  sclerosis  of  one  cere- 
bellar hemisphere,  a  glionaa  filling  the  fourth  ventricle  with 
a  cyst  situated  above  the  tumor,  a  fibroma  above  the  corpora 
quadrigemina,  sclerosis  of  nearly  the  entire  cerebellum,  etc. 
None  of  them  produced  symptoms  that  were  referable  to 
the  cerebellum.  The  point  was  made  that  tumors  and 
abscesses  in  connection  with  the  cerebellum  by  pressure  on 
other  parts  cause  symptoms  which  are  not  due  to  the  cere- 
bellar lesion.  For  this  reason  they  are  not  good  cases  from 
which  to  determine  the  function  of  the  cerebellum.  Dr  D. 
J.  McCarthy  mentioned  a  case  in  which  practically  all  the 
cerebellum  was  diseased,  but  no  symptoms  developed. 

Dr.  D.  L.  Edsall  reported  A  case  of  malignant  endo- 
carditis. The  patient  was  a  girl  of  18  who  came  to  the 
hospital  with  symptoms  of  thyroid  intoxication.  Afterward 
symptoms  developed  which  pointed  to  malignant  endocar- 
ditis or  a  collection  of  pus  in  the  region  of  the  kidney.    A 


definite  diagnosis  of  malignant  endocarditis  was  not  made 
until  5  or  6  days  before  death  when  cutaneous  and  visceral 
embolism  occurred.  Streptococci  had  been  found  in  the 
blood.  Attention  was  called  to  the  fact  that  a  large  quantity 
of  blood  should  be  used  when  making  inoculitiona.  A  few 
drops  in  agar  gave  no  growth  in  the  above  case,  but  3  cc.  in 
bouillon  gave  a  culture  of  streptococci.  Dr.  Robertson 
spoke  of  a  case  of  malign int  endocarditis  in  which  the  only 
lesion  was  on  the  pulmonary  valve. 

Dr.  Milton  B.  Hartzell  exhibited  :  1.  A  pigmented 
epithelioma  or  alveolar  melanotic  sarcoma,  2.  A 
chronic  ulcer  showing  marked  degeneration  of  epi- 
thelium. 

Dr.  W.  B.  Eaton  read  a  preliminary  note  on  the  histo- 
genesis of  myomata.  The  various  theories  of  origin  were 
briefly  considered.  The  inclusion  theory  answers  in  but  few 
cases,  as  inclueion  is  the  origin  in  only  about  yV  of  adeno- 
myomata  and  that  variety  is  only  a  small  proportion  of  the 
whole  number  of  myomata.  A  study  of  a  number  of  tumors 
has  been  made  by  Dr.  Eaton  and  in  at  least  3  of  them  there 
was  found  a  genetic  relation  between  the  walls  of  arteries 
and  the  tumor.  The  conclusion  reached  from  the  studies 
thus  far  made  is  that  many  myomata  have  their  origin  in 
the  musculature  of  vessels. 

Academy  of  Surgery. — The  meeting  of  April  1  was 
addressed  by  Dr  John  A.  Wyeth,  of  New  York,  his  subject 
being  amputation  at  the  hip- joint  for  sarcoma ;  the 
tendency  to  recurrence.  Dr.  Wyeth  spoke  of  the  ex- 
tremely malignant  character  of  sarcoma  and  its  liability  to 
recurrence,  this  being  true  whether  it  be  the  round,  spindle, 
or  giant-cell  variety.  The  address  dealt  largely  with  statistics 
of  cases  of  amputation,  the  percentages  of  recurrence,  the 
seat  of  recurrence,  etc.  Of  131  collected  cases  of  amputa- 
tion at  the  hip-joint  for  sarcoma,  14  resulted  in  death  follow- 
ing operation.  Some  of  these  were  complicated,  however. 
Leaving  out  complications  the  immediate  mortality  was  6%. 
Histories  of  83  survivors  were  obtained  and  in  these  there 
were  61  recurrences.  Whether  the  tumor  involves  the  soft 
parts  or  the  bone  has  little  to  do  with  the  safety  of  the  pa- 
tient. A  table  giving  the  length  of  time  after  operation  of 
the  recurrence  was  read.  The  time  varied  from  a  few  months 
to  9  years.  The  study  of  a  case  in  which  Fowler's  solution 
was  injected  led  to  the  belief  that  streptococcic  infection 
would  cure  cases.  One  exceedingly  large  recurrence  was 
cured  by  an  attack  of  erysipelas,  the  patient  now  being  in 
health  after  a  lapse  of  16  years.  Cases  of  infection  were  then 
caused  by  packing  the  wound  with  nonsterile  gauze  and  by 
inoculating  with  virulent  cultures  of  streptococci.  Cises  of 
sarcoma  in  the  abdomen,  at  the  hip  and  shoulder  were  thus 
treated  and  some  of  them  are  well  after  the  lapse  of  8  years. 
It  is  difficult  to  infect  these  cases  even  with  the  streptococcus 
of  Fehleieen.  The  use  of  this  method  is  believed  to  inhibit 
the  growth  of  some  cases  of  sarcoma,  and  Dr.  Wyeth  recom- 
mends it  in  every  case.  For  at  least  6  years  after  operation  in- 
fection should  be  induced  at  intervals  not  exceeding  6  months. 
Dr.  W.  W.  Keen  spoke  of  the  great  mortality  of  sarcomata 
and  reported  6  cases  of  amputation,  4  of  the  upper  and  2  of 
the  lower  extremity.  All  died  sooner  or  later.  One  case,  a 
woman  in  the  fifth  month  of  pregnancy,  survived  3J  years. 
Dr.  Keen  believes  operation  should  be  done  in  every  case. 
Recurrences  are  often  internal,  and  ara  less  annoying  and 
painful  than  the  original  growth.  No  operation  in  continuity 
should  be  done.  If  the  tumor  be  at  the  lower  end  of  the 
femur,  amputate  at  the  hip-joint.  No  operation  should  be 
done,  however,  if  the  hemoglobin  be  lower  than  bOfc.  Dr. 
W.  B.  Coley,  of  New  York,  reported  6  cases  of  amputation 
at  the  hip-joint.  One  operated  upon  in  August,  1900,  has  no 
recurrence  as  yet ;  one  could  not  be  traced,  and  4  died  of 
recurrence.  Operation  is  advised  in  all  cases,  and  the  toxin 
treatment  by  induced  infection  should  be  instituted  in  every 
case.  It  is  as  well  to  get  the  patient  over  the  efl'acts  of  the 
operation  and  then  give  systematic  treatment  for  fi-om  1  to  2 
years.  Cases  were  cited  in  which  the  patients  is  well  8  years 
or  less  after  this  treatment.  Four  cases  of  ronnd-cell  sar- 
coma have  been  cured  by  this  method.  Dr  John  B  Deavek 
favors  treating  these  cases  as  open  wounds  and  allowing  in- 
fection from  the  start.  Of  2  hip  joint  and  2  shoulder  ampu- 
tations, all  died.  Of  the  osteosarcomata,  those  of  the  jaw 
are  most  favorable.  Dr.  Bloodgood,  of  Baltimore,  thinks 
there  may  be  a  ditference  in   malignancy  of  the  various 


638 


The  Philadelphia^ 
Medical  Jocbxal   , 


AMERICAN  NEWS  AND  NOTES 


[APHIL  C,   IMl 


varieties,  the  giant  cell  form  being  the  least  likely  to  give 
metastasis.  Dr  Yocng,  of  Baltimore,  cited  a  case  of  sarcoma 
of  the  inguinal  region  and  omentum,  in  which  there  were 
recurrent  nodules  in  the  chest  and  other  parta  of  the  be dy. 
After  a  time  the  nodules  disappeared,  and  the  patient  was 
found  to  have  pernicious  anemia.  Dr.  Rodman  has  seen 
only  one  case  successful — the  exlirpation  of  the  lower  jaw. 
Toxins  should  be  used  in  all  cases,  at  once,  and  not  wait  for 
a  recurrence.  Dr.  Wyeth  said  that  in  anemic  and  run- 
down cases  he  would  not  care  to  use  primary  infection  by 
streptococci,  but  that  in  robust  people  he  would  insist  on 
immediate  infection. 

Philadelphia    County    Medical    Society. — At    the 

stated  meeting,  held  March  27,  Dr.  C.  A.  E.  CoDiiAy  read  a 
paper  on  The  acquired  form  of  funnel  chest.  Occu- 
pation is  not  considered  to  be  an  important  factor  in  the 
production  of  this  deformity.  Some  underlying  consti- 
tutional condition  probably  aids  in  cases  ascribed  to  the 
above  cause.  Diseases  of  the  respiratory  organs,  especially 
obstructive  ones,  causing  pronounced  respiratory  efforts, 
have  not  been  given  the  prominence  they  deterve  as  caus 
ative  factors.  Of  the  8  cases  reported,  only  one  could  be 
ascribed  to  occupation. 

Dr.  M.  G.  Tull  reported  a  case  of  Arthritis  defor- 
mans successfully  treated  by  application  of  ice  to 
the  spinal  column.  The  patient  was  a  female,  21  years 
of  age,  who  had  for  months  been  skilfully  treated  by  other 
physicians,  but  with  no  results.  Long  ice  caps  were  applied 
to  the  spine  2  hours  during  morning  and  afternoon  at  first, 
afterward  1  hour  each  time.  Guaiacol  carbonate  was  given, 
and  later  the  iodides.  The  result  was  great  improvement. 
The  wrist  deformities  disappeared  and  the  patient  can  now 
walk  2  miles.  This  treatment  was  also  tried  in  one  case  of 
ordinary  inflammatory  rheumatism  with  marked  improve- 
mect  in  the  patient.  A  notable  point  was  the  production  of 
somnolence,  insomnia  having  previously  existed.  Dr. 
RuGH  spoke  of  the  use  of  hot  air  in  cases  of  arthritis 
deformans.  He  has  used  it  in  several  cases,  some  of  them 
for  more  than  a  year,  with  not  the  slightest  beneficial  effect. 

Dr.  W.  C.  Hollopeter  read  a  paper  on  Fangotherapy. 
Fango  is  a  grayish-brown  slime  or  mud  obtained  from  certain 
Italian  lakes.  It  contains  iron,  sulphur,  magnesium,  lime, 
etc.,  and  its  properties  are  not  lost  by  transportation.  Its 
use  is  indicated  in  diseases  of  the  muscles,  rheumatism,  gout, 
neuralgias,  paralysis,  etc.  Local  application  to  the  part 
affected  is  made,  a  layer  3  cm.  thick,  at  a  temperature  of 
98°  to  120°  being  used,  the  patient  being  placed  between 
blankets  to  maintain  the  heat.  After  one-half  to  one  hour 
the  fango  is  easily  removed  by  a  tepid  bath.  Several  cases 
in  which  this  treatment  gave  gocd  results  were  reported. 
Among  them  were  cases  of  rheumatism,  synovial  swelling 
of  the  knee,  gastric  disturbance,  etc.  Dr.  C.  W.  Bcrr  said 
that  the  indications  for  the  employment  of  this  material 
were  the  same  as  those  for  a  hct  poultice.  He  considers  it 
of  no  value  in  diphtheritic  or  spinal-cord  palsies.  The  chem- 
ical composition  of  the  mud  probably  plays  but  little  part  in 
the  efiect  produced. 

Dr.  I.  Newtos  Ssively  read  a  paper  on  the  treatment 
of  croupous  pneumonia  by  autipueumococcic 
serum.  Several  cases  were  detailed  to  show  the  favorable 
results  of  this  treatment.  The  serum  was  given  in  doses  of 
20  CO.  every  3  hours  in  some  cases  until  the  temperature  was 
under  control.  The  temperature  usually  fell  by  rapid  lysis 
as  early  as  the  fifth  day  in  some  instances,  an  J  was  under 
control  even  earlier.  The  use  of  serum  is  bslieved  to  be  of 
the  greatest  value  in  private  practice  where  the  cases  are 
seen  earlier  than  in  hospitals.  Statistics  of  106  cases  with 
13  deaths  have  been  collect,  d.  The  conclusions  reached  are 
that  the  serum  is  haroaiess,  and  that  it  gives  fivorable 
results,  especially  in  early  cases  and  in  those  of  single 
infection.  Freshly  drawn  serum  should  be  used  if  possible. 
Its  use  is  believed  to  hasten  the  crisis.  Dr.  Skively  urges 
all  physicians  to  report  their  results.  Dr.  J.  M.  Fisher 
reported  two  case?.  Two  injections  of  the  serum  were  given 
daily.  One  patient,  an  alcoholic,  died  the  seventh  day.  Tne 
other,  a  woman,  who  had  croupous  pneumonia  of  one  side 
and  some  catarrhal  involvement  of  the  other  is  now  con- 
valescent. An  interesting  point  in  the  latter  case  was  the 
appearance  of  a  rash,  a  rise  of  temperature,  swelling  of  some 
of  the  joints,  etc  .  after  the  temperature  had  been  normal. 


this  undoubtedly  being  caused  by  the  serum.  De.  Edwin 
Rosenthal  uses  the  serum  in  large  doses  even  in  infants. 
The  symptoms  mentioned  by  Dr.  Fisher  are  often  met  with. 
In  mixed  infections  the  serum  is  alternated  with  antistrepto- 
coccic serum.  It  shortens  the  attack  of  pneumonia  only  in 
cases  that  are  seen  early. 

DELAWARE. 

Delaware  Hospital.— The  Delaware  Hospital,  at  Wil- 
mington, has  received  $5,000  by  the  will  of  Mrs.  Sarah  Cum- 
mins, of  Smjraa. 

Vigorous  Opposition  Against  the  Abbot  Bill. — 

The  Abbot  bill,  which  permits  physicians  who  have  practised 
for  10  years  in  another  State,  and  have  resided  one  year  in 
Delaware,  to  practise  in  De!awar3  without  undergoing  an 
examination,  is  being  vigorously  opposed  by  the  reputable 
physicians  of  that  State. 

Smallpox. — There  are  a  number  of  new  cases  of  small- 
pox reported  from  the  lower  part  of  the  State.  In  Bethel 
one  colored  woman  died  and  another  (white)  dying.  There 
are  two  new  cases  at  Seaford  and  one  at  Concord.  In  Laurel 
pickets  are  patrolling  all  the  town  entrances  and  no  one  from 
the  stricken  towns  is  permitted  to  enter.  It  is  believed,  how- 
ever, that  the  epidemic  is  abating. 

NEW  YOKK. 

Acciuitted. — Tne  nurse  in  Bellevue  Hospitil  who  was 
charged  with  being  responsible  for  the  death  of  one  of  the 
insane  inmates,  has  been  acquitted. 

Smallpox  on  an  Ocean  Steamer.— The  Anchor  Line 
steamer  BaiUana,  which  arrived  on  March  26  from  Marseilles 
and  other  Italian  ports,  was  quarantined  on  account  of  a  case 
of  smallpox  which  existed  among  the  passengers,  the  patient 
is  convalescent  and  ha?  been  removed  to  North  Brother 
Island.  The  New  York  authorities  are  to  be  commended 
for  their  promptness  in  discovering  the  disease. 

Loomis  Sanitarium. — The  Charitable  Annex  in  con- 
nection with  the  Loomis  Sanitarium,  at  Liberty  Heights, 
Liberty,  Sullivan  county.  New  York,  was  opened  on  Friday, 
March  22,  1901,  with  12  patients.  The  present  capacity  of 
this  annex  is  24  patients.  The  patients  are  charged  $-5  a 
week,  for  whi  h  they  receive  their  board,  lodging,  medical 
atten lance,  medicines,  and  laundry;  they  also  derive  all  the 
benefits  of  the  main  sanitarium  in  the  way  of  scientific  care 
and  oversight.  The  deficit  between  the  $^5  a  week  charged 
to  patients,  and  the  actual  cost  of  maintenance,  is  made  up 
by  a  maintenance  fiind  raised  annually  by  subscription. 
While  the  financial  afifairs  of  the  annex  are  administered 
from  the  main  sanitarium,  there  is  a  superintendent  in 
(hirge  there.  Dr.  J.  Eiward  Stubbert,  physician  in  charge 
at  the  main  sanitarium,  visits  the  annex  once  a  week  a?  con- 
sulting physician,  while  Dr.  Stephen  W.  Wells,  resident 
house  physician,  and  Dr.  Thomas  I.  Shannon,  resident  as- 
sistant house  physician  at  the  main  sanitarium,  constitute 
the  regular  visiting  staff  of  the  annex,  visiting  it  daily  and 
keeping  daily  office  hours.  Tne  nurses  are  furnished  from 
the  training  school  of  the  main  sanitarium.  This  annex  has 
a  thoroughly  equipped  treatment  room,  and  the  patients 
receive  practically  the  same  treatment  that  is  g^ven  at  the 
main  sanitarium.  At  present  there  is  one  large  3  story 
building,  and  it  is  the  hope  of  the  management  to  be  able  to 
raise  sufficient  funds  in  a  short  time  to  enlarge  the  institu- 
tion, so  that  many  more  patients  may  he  cared  for.  The 
various  medical  examiners  for  the  main  sanitarium  will  also 
examine  applicants  for  admission  to  the  annex,  but  the  rulee 
for  receiving  only  incipient  cases  are  even  more  rigidly  en- 
forced here  than  at  the  main  institution.  ' 


NEW^ENGL.AND.  ""^ 

Donation  to  Yale  Medical  College.— $100,000  was 
recently  given  to  Yale  University  for  the  purpose  of  cvin- 
structing  a  building  for  the  medical  school.  Tne  name  of 
the  donor  has  not  been  made  public. 


April  6,  1901) 


AMERICAN  NEWS  AND  NOTES 


CThe  Philadelphia 
Medical  Joubital 


639 


WESTERN  STATES. 

Unique  Bill. — A  bill  was  recently  intrcduced  in  tiie  legis- 
lature 01  Arkansas  preventing  physicians  from  practising  if 
they  use  intoxicating  liquors  in  beverages. 

Senator  Chilton's  Bill  Passed. — By  the  passage  of 
this  bill  the  State  of  Minnesota  prohibits  the  marriage  of  the 
insane,  the  epileptic,  and  the  idiotic,  and  requires  a  medical 
certificate  from  all  applicants  for  marriage  licenses.  Amend- 
ments were  adopted  permitting  the  marriage  of  all  feeble- 
minded persons  over  45,  the  bill  originally  reading  that  this 
permission  was  only  to  be  extended  to  women. 

Bubonic  Plague  in  San  Francisco. — Not  long  ago  a 
Government  commission,  consisting  of  Professor  Flexner,  of 
the  University  of  Pennsylvania,  Prcfeesor  Barker,  of  the 
Chicago  University,  and  Professor  Novy,  of  Ann  Arbor  Uni- 
versity, was  sent  to  San  Francitco  by  the  Government  to 
investigate  the  reports  of  bubonic  plague.  Six  fatal  cases 
were  reported  between  February  5  and  12  by  this  special 
commission.  The  report  of  the  commission  confirms  the 
presence  of  the  plague  which  occurred  among  Chinamen  in 
San  Francisco.  In  the  report,  under  the  heading  of  remarks 
it  is  stated  :  "  Plague  has  been  reported  in  San  Francisco 
officially  in  the  Public  Health  Reports  since  March  6,  1900, 
32  cases  (all  fatal)  having  been  reported  and  published  in 
previous  numbers  of  the  Public  Health  Reports,  and  the  facts 
were  reported  in  the  annual  report  to  Conrress  of  the  Secre- 
retary  of  the  Treasury,  dated  December  4, 1900." 

The  San  Francisco  Medico- Chirurgical  Society. 

— Regular  meeting  February  4,  1901,  Dr.  Jos.  O.  Hirsch- 
felder  in  the  chair. 

Leprosy — Mixed  Variety. — De.  C.  F.  Griffin  presented 
a  young  patient  and  gave  the  following  history  of  the  case  : 
Boy,  13  years  old,  French  parentage ;  native  of  Papeete, 
Tahiti.  Was  brought  from  the  islands  5  months  ago  for 
treatment  for  "  general  weakness."  Patient  perfectly  well 
until  two  years  ago,  when  he  stepped  upon  a  dirty  white  coral 
with  the  left  foot,  making  a  cut  through  the  skin  about  an 
inch  long.  The  wound  bled  freely  ;  patient  applied  a  native 
plaster  dressing  of  herbs,  for  about  6  months.  The  foot 
swelled,  requiring  constant  dressing  of  cloths  around  it. 
He  walked  for  about  6  months ;  then  saw  a  European 
doctor,  from  a  French  war  ship,  who  cut  the  wound, 
and  sponged  out  one-half  teaspoonful  of  some  black 
material,  leaving  a  hole  about  the  size  of  a  10  cent  piece, 
running  down  to  the  bone  of  the  end  of  the  second  toe. 

During  this  time  the  spots  now  present  on  the  extremities 
and  the  face  began  to  appear  ;  first  behind  the  ears,  and  the 
ears  began  to  grow  larger.  The  sequence  of  these  events  is 
unknown.  No  spots  appeared  upon  the  chest,  back  nor  ab- 
domen. The  toes  and  foot  swelled,  but  the  legs  and  thighs 
did  not  swell.  Cough,  and  loss  of  weight,  and  night  sweats 
began  two  years  ago,  at  which  time,  also,  the  nose  began  to 
be  sore  and  somewhat  swollen.  Has  had  at  irregular  times 
since,  bloody  nasal  discharges.  No  other  illneas  in  family. 
The  maternal  grandmother  died  at  the  age  of  58,  after  hav- 
ing some  operation  upon  the  nose. 

Physical  Examinalion. — Boy  about  medium  size,  and  de- 
velopment to  be  expected  at  his  age.  Face  presents  nothing 
of  note  except  a  purplish  discoloration  over  the  left  malar 
eminence.  The  skin  over  and  around  the  spot  feels  smooth, 
indurated,  much  as  would  be  felt  in  a  malignant  tumor  in- 
volving the  skin  previous  to  ulceration.  The  ears  are  un- 
usually large,  stand  out  from  the  iiead,  having  about  them 
the  suggestion  of  akromegaly.  Upon  the  ears  and  about  the 
forearms  are  a  few  spots  resembling  psoriasis.  Impaired 
resonance  and  bronchial  breathing  of  both  apices.  Weight 
absolute,  61  f  pounds.  Diagnosis:  Tuberculosis  pulmonalis 
and  psoriasis.  Tonic  and  supportive  treatment  resulted  in 
increase  of  weight,  subsidence  of  cough,  and  discontinuance 
of  night  sweats.  Local  treatment  for  the  spots,  chrysophanic 
acid  in  ointment. 

From  time  to  time  the  case  was  seen.  The  spots  becoming 
not  smaller,  but  increasing  in  number,  called  special  attention 
to  them,  when  wide  areas  of  analgesia  and  anesthesia  were 
found  over  the  arms,  parts  of  the  face  and  lower  extremities. 
Coverslip  smear  preparations  were  then  made  and  stained, 
establishing  a  diagnosis  of  tubercular  leprosy,  which  diagnosis 
was  confirmed  by  sections  cut  from  a  papule  on  the  forearm. 


This  case  is  brought  before  you  for  three  reasons  :  First,  to 
sliow  what,  here  ia  San  Francisco,  is  a  somewhat  infre- 
quently seen  disease — lepropsy ;  second,  to  call  attention  to 
the  ease  with  which  the  disease  may  be  unthinkingly  or  care- 
lessly diagnosed  as  pEoria«is ;  third,  the  ease  with  which, 
when  once  attention  is  drawn  in  that  direction,  the  diagnosis 
may  be  made  by  the  aid  of  the  microscope. 

The  following  is  the  simple  technic  followed,  and  is  usually 
successful  because  the  bacillus  of  leprosy  is  found  in  the 
ulcerating  skin  lesions,  in  the  discharge  from  them,  and  in 
the  bloody  serum  from  them,  and  not  in  the  general  blood- 
stream of  the  patient.  The  crust  or  superficial  layers  of  skin 
over  a  papule,  being  gently  removed,  a  clean  coverslip  is 
touched  lightly  to  the  oozing  surface,  it  is  then  dried  and 
stained  with  carbolfuchsin,  in  the  same  manner  as  for 
tubercle  bacilli.  The  lepra  bacilli,  are  easily  decolorized  by 
subsequent  washing  in  alcohol,  or  in  weak  solutions  of 
mineral  acids.  This  characteristic  distinguishes  them  from 
tubercle  bacilli.  Essentially  the  same  technic  may  be 
applied  to  discharges  from  the  nose. 

SOUTHERN  STATES. 

Pasteur  Department  of  the  Baltimore  City  Hos- 
pital.— A  report  from  the  Pasteur  Department  of  the  Balti- 
more City  Hospital  states  that  up  to  date  200  cases  have  been 
treated,  in  120  of  which  the  animal  had  been  demonstrated 
rabid  by  subdural  inoculations  of  rabies.  There  has  been  but 
one  death  from  any  cause ;  that  was  rabies.  The  Pasteur  De- 
partment of  the  City  Hospital  was  founded  by  the  College  of 
Physician?  and  Surgeons  for  the  preventive  treatment  of 
hydrophobia  according  to  the  Pasteur  method.  It  is  modeled 
after  the  "  Institut  Pasteur,"  of  Paris.  The  method  is  the 
result  of  personal  investigation  at  that  institute  and  is  identi- 
cal with  that  used  in  Paris.  Without  the  Pasteur  preventive 
treatment  tiie  mortality  from  bites  of  rabid  animals  is  16  to 
25  % .  Of  those  treated  by  the  Pasteur  method,  the  mortality 
is  about  Jj  of  1  % . 

Program  of  American  Gastroenterological  So- 
ciety.— The  fourth  annual  meeting  of  the  American  Gastro- 
enterological Association  will  be  held  in  the  banquet  hall  of 
the  "Shoreham,"  Washington,  D.  C,  Wednesday,  May  1, 
1901.    Council  meets  at  9  a.m.    Morning  session  at  10  a.m. 

1.  Address  by  the  president.  Dr.  Max  Einhorn. 

2.  "  The  German  Clinics  of  Today,"  Dr.  J.  C.  Hemmeter. 

3.  "The  Etiology  of  Hepatic  Sclerosis,"  Dr.  A.  L.  Bene- 
dict. 

4.  "Treatment  of  Gastric  Ulcer,"  Dr.  D.  D.  Stewart. 

5.  "  The  State  of  the  Gastric  Secretions  in  Chronic  Rheu- 
matism and  Rheumatoid  Arthritis,"  Dr.  Frank  H. 
Murdoch. 

6.  "  Some  Cases  of  Tetany,"  Dr.  Willian  Geary  Morgan. 

7.  "  The  Report  of  Two  Cises  of  Acute  Dilatation  of  the 
Stomach,"  Dr.  Julius  Friedenwald. 

1  p.  M.    Luncheon.    2.30  p  m.    Afternoon  Session. 

8.  "Experiments  in  Peristalsis,"  Dr.  Fenton  B.  Turck. 

9.  "Some  Clinical  Studies  in  Gastric  Secretion,"  Dr.  G. 
W.  McCaskey. 

10.  "  Treatment  of  Antonia  Gastrica  Splanchnoptosis  by 
Means  of  Abdominal  Strapping,"  Dr.  A.  Rose. 

11.  "  Hyperchlorhydria,"  Dr.  John  A.  Lichty. 

12.  "  Report  of  a  Case  of  Cancer  of  the  Cardiac  Ead  of 
the  Esophagus  at  a  Distance  of  Twenty  Inches  from 
the  Incisor  Teeth  in  a  Man  Five  Feet  and  Three 
Inches  Tall,"  Dr.  C.  D.  Spivak. 

13.  "  Digestive  Disturbances  in  Formes  Foustes,"  Dr.  John 
P.  Sawyer. 

Vital  Statistics  of  Havana. — In  his  report  of  the  vital 
statistics  of  Havana  for  the  month  of  February,  Major  W.  C. 
Gorgas,  Chief  Sanitary  Oflicer  of  the  Department  of  Cuba, 
states  that  the  mortality  in  Havana  for  that  month  is  less 
than  it  has  been  for  any  February  of  which  any  reliable 
record  is  at  hand.  The  minimum  was  in  1893,  when  there 
were  446  deaths,  and  the  maximum  in  1898.  when  there  were 
1,602  deaths.  The  rate  per  thousand— 19  32— makes  even  a 
better  showing.  The  last  February  of  the  Spanish  rule,  1898, 
gave  us  a  death-rate  of  82  32  per  thousand.  February  tf 
1901— the  third  February  under  American  rule— gives  us  a 
death-rate  of  19.32.    This  is  a  very  creditable  death-rate,  and 


640 


The  Pbiladblphia 
Medical  Johknal 


] 


AMERICAN  NEWS  AND  NOTES 


[Apeil  6,  19W 


places  Havana  in  the  class  of  healthy  cities  of  the  world. 
Many  of  the  cities  of  the  United  States  and  Europe  have  a 
higher  mortality  than  this.  According  to  the  latest  figures 
of  Marine-Hospital  reports  Biltimore.  with  a  population  of 
33i,4S9,  for  the  week  ending  January  26,  had  225  deaths — a 
death-rate  of  26  93;  Cincinnati,  population  326  000,  for  the 
week  endihg  January  25,  had  142  deaths — death  rate  22.65; 
Boston,  population  560,892,  for  the  week  ending  January  26, 
had  260  deaths — death-rate  24.10;  Jacksonville,  population 
17,201,  for  the  week  ending  January  19,  had  16  deaths — 
death-rate  48.37  ;  Newark,  N.  J.,  population  246  070,  for  the 
week  ending  January  19  had  107  deaths — death-rate  22  61; 
New  Orleans,  population  287,000,  for  the  week  ending  January 
19,  had  156  deaths — death-rate  28.26;  New  York,  population 
3,437,202,  for  the  week  ending  January  26,  had  1,432  deaths — 
death-rate  22  42 ;  Washington,  population  278,719,  for  the 
week  ending  January  19,  had  141  deaths — death-rate,  26  60 ; 
Belfast,  Ireland,  for  the  week  ending  January  5,  had  165 
deaths,  with  a  death-rate  of  23  90;  and  Mobile,  population 
88,469,  for  the  week  ending  January  16.  had  22  deaths — 
death-rate  29.73.  It  will  be  seen  that  most  of  the  cities  have 
a  much  higher  death-rate  than  Havana.  Major  Gorgas 
states :  "  Jacksonville,  Mobile,  and  New  Orleans,  all  have 
a  higher  death  rate  than  Havana,  and  I  have  no  doubt 
that  we  would  find  such  to  be  the  case  with  other  Gulf 
cities  if  we  could  get  statistics  on  the  subject.  At  present 
they  look  upon  Havana  with  suspicion,  but  I  think  that 
in  the  near  future,  Havana  will  have  to  guard  against 
them.  Taking  cities  in  the  yellow-fever  area,  such  as  New 
Orleans,  Mobile,  Pensacola,  Tampa,  Key  West  and  Havana ; 
those  in  bad  sanitary  condition,  as  shown  by  their  high 
death-rate,  would  be  more  likely  to  become  infected  than 
a  city  such  as  Havana,  which  is  in  first  class  condition 
as  shown  by  its  low  death-rate.  I  think  it  probable  that 
within  a  year  or  two,  Havana  will  have  to  take  steps  to 
protect  itself  from  the  above  mentioned  cities.  During  Feb- 
ruary of  1900,  we  had  17  new  cases  of  yellow  fever ;  in  Feb- 
ruary of  1901,  we  had  8  new  cases.  As  the  number  of 
nonimmunes  was  very  much  larger  in  February  of  this  than 
in  that  of  last  year,  I  think  the  showing  is  very  encouraging. 
Besides  disinfecting  the  houses  with  formalin  and  other  dis- 
infectants, we  now  screen  the  rooms  occupied  by  a  yellow- 
fever  patient  as  soon  a«  his  case  is  reported,  and  kill  all  the 
mosquitoes  in  the  building  with  the  fumes  of  pyrethrum 
powder,  at  the  same  time  covering  with  kerosene  oil  all 
places  where  mosquitoes  can  breed  about  the  building.  We 
also  kill  the  mosquitoes  in  all  the  adjoining  buildings  in  the 
same  way.  With  these  measures  and  the  steps  we  are  taking 
to  kill  the  mosquitoes  in  the  suburbs,  I  hope  to  markedly  de- 
crease the  yellow  fever  during  the  coming  summer." 


MISCELLANY. 

Correction. — In  the  abstract  in  the  article  of  Drs. 
Ravenel  and  Gilliland  {University  Medical  Magazine,  February, 
1901),  which  appeared  on  page  607  of  our  last  issue,  the 
statement  was  made,  concerning  the  disinfectant  and  de- 
odorant action  of  ammonium  persulphate,  that  it  has  little, 
if  any  value  as  either.  This  conclusion  applied  to  potas- 
sium persulphate.  The  studies  of  the  investigators  have 
demonstrated  that  aninionium  persulphate  possesses 
most  decided  germicidal  properties,  and  is  a  most  excellent 
deodorizar.  In  some  ways  it  is  superior  to  carbolic  acid  as  a 
germicide. 

Obituary. — Dr.  Edwin  C.  Baldwin,  at  Dover,  N.  J ,  on 
March  25  — Dr.  P.  H.  Cook,  at  Vicksburg,  Miss  ,  on  March 
26,  aged  87  years. — Dr.  S.  Edgar  Mortimore.  at  Jackson- 
ville, Fla.,  on  March  21,  aged  56  vears. — Dr.  Montqomery 
Lawrekce,  at  Baltimore,  Md.,  on  March  26,  aged  70  years. 
— Dr.  Charles  Edward  Coaxes,  at  Abilene,  Tex.,  on  March 
25,  aged  73  years.— Dr.  G.  M.  Mavghs.  at  St.  Louis,  Mo.,  on 
March  23,  aged  80  years. — Dr.  John  W.  Hankins,  at  Carlin- 
ville.  111.,  on  March  18,  aged  75  years. — Dr.  John  H.  H. 
Bdrge,  at  Brooklyn,  N.  Y.,  on  March  24 — Dr.  Richard  K. 
Valentine,  at  Brooklyn,  N.  Y..  on  March  22.  aged  50  years. 
— Dr.  Myron  H.  Parkhill.  at  Howard,  N.  Y.,  on  March  26, 
aged  35  years. — Dr.  E.  B.  Liqhthill,  at  Newark,  N.  J.,  on 
March  25,  aged  70  years. — Dr.  Alfred  Spearman,  at  Mil- 
waukee, Wis.,  on  April  1,  aged  69  years. 


Health  Reports. — The  following  cases  of  smallpox, 
yellow  fever,  cholera,  and  plague  have  been  reported  to  the 
Surgeon-General  U.  S.  Marine-Hospital  Service,  during  the 
week  ended  March  30,  1901 : 

Smallpox— Unitkd  States. 


CA£ES. 

Deaths. 

California  : 

Los  Angeles    .    . 

March  19  ...    . 

15 

*' 

San  Francisco    . 

March  2-9    ..    . 

8 

DiSTEICT  OF 

Columbia 

Washington    .    . 

March  18  .    .   .    . 

16 

Florida  : 

Jacksonville  .    . 

March  16-23    .    . 

2 

Illinois  : 

Anna 

Dec-March  18  . 

50 

Chicago    .... 

ilarch  16-23    .    . 

10 

Kansas  : 

Wichita    .... 

March  16-23    .    . 

12 

Kentucky: 

Lexington  .   .   . 

March  16-23    .    . 

2 

LOCIBIANA  : 

New  Orleans  .    . 

March  16-23    .    . 

14 

Michigan: 

Bayaty  .... 

March  16-23    .    . 

2 

" 

Detroit 

March  16-23    .    . 

6 

" 

Minneapolis   .    . 

March  16-23    .    . 

6 

" 

Winona    .... 

March  16-23    .    . 

10 

Nebeaska : 

Omaha 

March  9-23  .    .    . 

12 

N.  Hampshire  : 

Manchester     .    . 

March  16-23    .    . 

3 

New  Jeesey  : 

Hudson  County 

March  21  ...    . 

6 

'■ 

Newark    .... 

March  16-23    .    . 

1 

New  Yoek  : 

New  York  .   .    . 

March  16-23    .    . 

41 

6 

Ohio  : 

Cincinnati   .    .    . 

March  16-23    .   . 

2 

" 

Cleveland        .    . 

March  1&-23    . 

43 

1 

" 

Toledo  .... 

March  16-23    .   . 

1 

Pekbstlvania  : 

Pittsburg .   .    . 

March  16-23    .   . 

9 

*' 

Steelton    .... 

March  16-23    . 

6 

S.  Carolina  : 

Greenville   .   . 

March  8-16.    . 

2 

Tennessee  : 

Memphis .... 

March  16-23    . 

26 

*' 

Nashville     .    . 

March  16-23    . 

13 

Utah  : 

Salt  Lake  aty 

March  16-23    . 

40 

W.  Virginia: 

Huntington    . 

March  8-16  .    . 

12 

"           ** 

WlieeUne    .   . 

March  8-23  .    . 

2 

Wisconsin  : 

Milwaukee .   . 

March  16-23    . 

2 

PoBTO  Rico  : 

Ponce    .... 
Smallpox 

March  11  .    .  . 
— FOEKIGH. 

13 

Austria  : 

Prague  .... 

Feb.  23-March  £ 

10 

•' 

Trieste  .... 

March  2-9    .    . 

2 

Brazil  : 

Rio  de  Janeiro 

Jan.  1-31  .    .  . 

36 

Belgio-v: 

Antwerp  .    .  . 

Feb.  23-March  E 

8 

Ceylon  : 

Colombo  .    .   . 

Feb.  8-16  .    .  . 

1 

1 

Ecuador : 

Guayaquil  .    . 

Feb.  2-March  2 

14 

Egypt: 

Cairo 

Feb.  25  ...    . 

I 

France  : 

Paris 

March  2-9    .   . 

7 

" 

Roubaix  .    .   . 

Jan. 1-31  .    .  . 

1 

Germany : 

Leipsic  .... 

Feb.  16-23    .   . 

1 

Great  Britain 

:  London     .    .  . 
New    Castle    on 

March  2-9   .   . 

1 

Tyne      ... 

March  2-9    .   . 

2 

" 

Edinburgh  .    . 

Feb.  2-9    .    .   . 

3 

" 

Glasgow   .    .  . 

March  8-15  .   . 

20 

India  : 

Bombay  .    .  . 

Feb.  19-26    .    . 

7 

Calcutta    .    .   . 

Feb.  8-23.    .    . 

243 

" 

Karachi    .    .   . 

Feb.  10-24    .    . 

23 

10 

" 

Madras     .  -   . 

Feb. 16-23    .    . 

i 

Japan  : 

Yokohama .   . 

Feb.  16-23    .    . 

1 

Korea  : 

Seoul 

Feb.  2-9    ..  . 

Prevalent. 

RossiA : 

Odessa  .... 

Feb.  23-March  8 

20 

3 

" 

Riga 

Jan.  1-Dec.  31 

174 

" 

St.  Petersburg 

Feb.  23-March  S 

12 

1 

" 

Warsaw    .   .  . 

Feb.  23-March  2 

8 

Straits 

Settlements 

:  Singapore    .   . 

Feb.  8-16  .    .  . 

2 

Syria  : 

Jaffa 

Aug.,1900-Mar.( 

>        4 
in 

4 

German 

-1 

•  1 

Jerusalem   .   . 

Ang.,1900-Feb.  i 

COiuu>, 

1600 
and  35 or 40" 
deaths. 

Yellow 

Fevkk. 

Cdba  : 

Havana    .   .  . 

March  8-16.   . 

2 

2 

Cholera. 

India  ; 

Bombay   .   .  . 

Feb. 16-23    .   . 

6 

'• 

Calcutta    .    .   . 

Feb.  S-23  .       . 

44 

" 

Madras 

Feb. 16-22    .    . 

2 

Straits 

Settlements 

:  Singapore    .   .   . 

Feb.  8-16  .   .  . 

4 

Plague — United  States. 

California  : 

San  Francisco    . 
Plague - 

Jan.  6-Mar;h  2 . 
FoBEIGN. 

10 

10 

Africa  : 

Cape  Town 

Feb.  16-Maich  4 

55 

11 

Brazil  : 

Rio  de  Janeiro  . 

Jan.  1-31  .    .  .    . 

15 

9 

China: 

Hongkong  .   .   . 

Feb.  2-9    ...    . 

2 

India  . 

Bombay  .... 

Feb.  19-26    .   .   . 

1118 

sao 


Straits 
I        Settlkments  :  Singapore 


Feb.  4 


April  B,  1901] 


FOREIGN  NEWS  AND  NOTES 


tXHK  Philadelphia 
Mkdical  Journal 


641 


Changes  in  the  Medical  Corps  of  the  U.  S.  Navy, 

for  the  week  ended  March  30,  1901 : 

Lbdbettkr,  R.  F.,  assistant  surgeon,  detached  from  ihe  "  Constella- 
tion," April  1,  and  ordered  to  the  "  Chicago,"  via  the  "  Dixie," 
April  3,  as  relief  of  Assistant  Surgeon  J.  R.  Whiting. 

Crawford,  G.  A.,  assistant  surgeon,  detached  from  the  "  Dixie," 
March  28,  and  ordered  to  the  "  Constellation,"  April  1,  as  relief 
of  Assistant  Surgeon  R.  E.  Ledbetter. 

Whiting,  J.  R.,  assistant  surgeon,  detached  from  the  "Chicago," 
upon  reporting  of  relief,  and  ordered  to  the  "  Dixie." 

PicKRELL,  G.,  surgeon,  detached  from  the  Naval  Hospital,  Mare 
Island,  Cal.,  and  ordered  home. 

Evans,  E.,  assistant  surgeon,  detached  from  the  Naval  Hospital, 
Mare  Fsland,  Cal.,  with  permission  to  delay  en  route  home. 

McClanahan,  R.  K.,  assistant  surgeon,  ordered  to  the  Asiatic  Sta- 
tion, via  the  "Solace,"  April  12. 

Decker,  C.  J.,  surgeon  order  detaching  from  the  "  Monocacy  "  and 
ordering  to  the  "  Oregon  "  revoked  ;  ordered  to  the  "  Newark." 

Leach,  P.,  surgeon,  order  detaching  from  the  "Oregon"  and  to 
the  "  Monocacy"  revoked. 

HiBBETT,  U.  T.,  surgeon,  detached  from  the  "Newark"  and  ordered 
to  the  Naval  Hospital,  Cavite,  P.  I. 

Spear,  R.,  passed  assistant  surgeon,  detached  from  the  "  Isla  de 
Luzon  "  and  ordered  to  the  "  Concord." 

Evans,  S.  G.,  passed  assistant  surgeon,  detached  from  the  "Con- 
cord," and  ordered  to  the  "  Monocacy." 

Grow,  E.  J.,  assistant  surgeon,  detached  from  the  "Glacier,"  and 
ordered  to  the  "  Isla  de  Luzon." 

Changes  in  the  U.  S.  Mariue^Hospital  Service, 

for  the  week  ended  March  28,  1901 : 

Mdrrav.  R.  D.,  surgeon,  granted  leave  of  absence  for  5  days  from 
April  9,  1901.     March  23. 

Austin,  H.  W.,  surgeon,  detailed  chairman  of  a  board,  to  be  con- 
vened from  time  to  time  as  necessary,  for  the  purpose  of  reex- 
amining rejected  immigrants.     March  28. 

Eager,  J.  M.,  passed  assistant  surgeon,  upon  expiration  of  leave  of 
absence  to  proceed  to  Naples,  Italy,  for  duty,  relieving  Assistant 
Surgeon  V.  G.  Heiser.      March  25. 

Mathewsun,  H.  S.,  assistant  surgeon,  granted  leave  of  absence  for  3 
days  from  March  29.     March  26. 

Clark,  Taliaferro,  assistant  surgeon,  granted  leave  of  absence  for 
30  days,  on  account  of  sickness.    March  22. 

Lavinder,  C.  H.,  assistant  surgeon,  granted  leave  of  absence  for  10 
days  from  March  28.    Marcli  27. 

McMuLLEN,  John,  assistant  surgeon,  upon  being  relieved  from  duty 
at  Wilmington,  N.  C,  to  proceed  to  the  Mullet  Key  Detention 
Camp,  Florida,  and  assume  command,  reporting,  en  route,  at 
Washington,  D.  0.     March  28. 

RnssELL,  H.  C.  assistant  surgeon,  granted  leave  of  absence  for  28 
days  from  February  21,  on  account  of  sickness.     March  22. 

Heiser,  V.  G.,  assistant  surgeon,  upon  being  relieved  from  duty  at 
Naples,  Italy,  to  proceed  to  Washington,  D.  C,  and  report  in 
person  for  duty.     March  25. 

Goodman,  P.  S.,  hospital  steward,  to  report  to  the  Director  of  the 
Hygienic  Laboratory,  Washington,  D.  C,  for  duty.    March  20. 


The  Use  of  Tiokol  in  Tuberculosis. — Achwlediani 
(  Woenno  Medicinski  Journal,  December,  1900)  determined  to 
try  this  new  remedy  so  extravagantly  lauded  by  Shwarts, 
J  de  Ret  zi,  Maramoldi  and  others.  He  made  careful  observa- 
tions in  eight  cases  in  which  incipient  tuberculosis  was 
present.  The  following  results  were  obtained :  (1)  The 
temperature,  pulse,  respiration  and  urine  were  in  no  way 
modified  by  the  drug ;  (2)  the  amount  of  expectoration  did 
not  diminish;  (3)  the  weight  was  reduced;  (4)  no  changes 
in  percussion  or  auscultation  were  observed  ;  (5)  the  number 
of  tubercle  bacilli  increased  ;  (6)  the  night-sweats  remained 
the  Bsme ;  (7)  the  debility  and  cough  remained  in  statu  quo. 

[AR.] 

Two  Cases  in  which  Dead  Fetuses  Remained  in 
the  Uterus  for  a  Considerable  Time.— A.  P.  Petrow 
(Russki  Medicinski  Vieilnic,  February,  1901)  reports  the  fol- 
lowing interesting  cases :  In  one  the  woman,  34  years 
old,  had  a  number  of  miscarriages  as  a  result  of  syph- 
ilis contracted  from  her  husband.  Her  last  pregnancy  led  to 
a  division  of  opinion  among  the  physicians,  some  claiming 
that  she  was  pregnant  while  others  diagnosed  a  fibroid.  On 
the  seventh  month,  after  a  considerable  period  of  exhaustion 
accompanied  by  other  alarming  symptoms,  the  woman  was 
delivered  cf  a  male  fetus  partially  mummified,  presenting  the 
developments  of  8*  months.  In  the  second  case  a  macerated 
fetus  of  5  months  was  delivered  2 J  months  after  it  died. 
This  woman  was  also  syphilitic.  In  both  cases  the  mothers 
recovered,     [a.r.] 


foreign  Hcu?5  anb  Xloks. 


GUEAT  BRITAIN, 

Royal  College  of  Surgeons. — At  a  meeting  of  the 
Fellows  of  the  Rjyal  CoUeee  of  Surgeons  in  Ireland,  held  on 
Tuesday,  March  19th,  Sir  William  Thomson  and  Mr.  Robert 
H.  Woods  were  elected  members  of  the  Council. 

World's  Tuberculosis  Congress. — American  medi- 
cal scientists  will  be  both  numerous  and  prominent  at 
the  World's  Tuberculosis  Congress,  to  be  held  in  London 
during  the  last  week  in  July.  Professor  William  Ojler,  of 
Johns  Hopkins  University,  has  been  invited  by  the  manage- 
ment of  the  congress  to  organize  the  American  contingent. 
Among  those  who  liave  already  signified  their  intention  of 
coming  are  Professor  Truedeau  of  Massachusetts,  Professor 
S  )lly  of  Colorado,  Dr.  Herman  Biggs  of  New  York,  Dr.  J. 
G.  Adami  of  Ontario,  and  Professor  McEachran  of  Quebec. 
Professor  Koch  of  Berlin  and  Dr.  Brcuardel  of  Paris, 
Europe's  great  bacilli  authorities,  have  announced  their  in- 
tention of  actively  participating.  Dr.  Malcolm  Morris,  of 
London,  the  originator  and  secretary  general  of  the  congress, 
said  recently  :  "  Certainly  tuberculosis  never  called  together 
so  distinguished  a  body  of  international  experts.  Delegates 
will  attend  from  probably  every  civilized  country  of  the 
world." 

Plague. — The  British  Medical  Journal  says  plague  seems 
to  be  obtaining  a  serious  hold  upon  Capetown.  Fresh  cases, 
varying  in  number  from  2  to  17,  have  occurred  daily  during 
the  last  fortnight.  The  information  is  incomplete,  and  a 
compilation  from  telegrams  gives  the  number  of  fresh  cases 
on  March  7,  9, 10,  12,  15,  and  18  as  8,  G,  10,  17,  11,  and  5  re- 
spectively. The  importance  of  the  outbreak  of  plague  at 
the  Cape  is  surely  sufficiently  great  to  make  it  reasonable  to 
ask  the  Government  for  exact  information.  A  telegram, 
dated  March  19,  from  the  Governor  of  Cape  Colony  to  the 
Colonial  Secretary  states  that  the  plague  report  for  the  week 
ending  March  16  is  as  follows:  "Cases  admitted  81,  deaths 
29,  suspects  17,  contacts  402."  The  report,  it  would  appear, 
applies  to  the  whole  Colony,  but  contains  no  information  as 
to  where  the  deaths  or  cases  have  occurred,  nor  as  to  whether 
the  patients  are  white,  negro,  Indian,  or  Malay.  Plague  at 
the  Cape  has  struck  the  empire  in  a  most  vital  spot,  and  any 
failure  to  issue  adequate  ofBcial  information  as  to  the  preva- 
lence of  the  disease  is  not  consistent  with  imperial  necessity. 
We  would  urge  the  Government  to  keep  nothing  tack,  but  to 
let  the  people  in  this  country  know  the  exact  state  of  affairs 
in  regard  to  the  plague  at  the  Cape  and  in  South  Africa 
generally.  The  Malay  laborers  have  been  giving  trouble,  re- 
fusing to  go  to  hospital,  to  live  in  isolation  camps,  or  to  have 
their  houses  inspected.  As  there  are  several  thousand 
Malay  males  in  the  city,  their  turbulence  is  calculated  to 
cause  trouble  and  difficulty.  The  Kaffirs  have  already  been 
sent  to  isolation  camps,  and  as  the  Government  has  pro- 
hibited the  meeting  of  more  than  25  persons,  the  proposed 
meeting  of  natives  to  protest  against  the  plague  measures  is 
prevented. 

More  About  Huxley. — The  anecdotal  side  of  a  great 
man's  biography  is,  if  tot  the  most  important,  at  least  the 
moat  attractive.  Professor  John  Fiske,  in  a  recent  number 
of  the  Atlanlic  Monthly, gives  seme  interesting  reminiscences 
of  Huxley.  The  following  anecdotes  will  be  appreciated  by 
all  medical  readers : 

A  clergyman,  who  had  no  knowledge  cf  biology,  wrote  a 
foolish  attack  on  the  Darwinian  theory  and  was  rather 
piqued  that  Huxley  took  no  notice  of  him.  He  thereupon 
wrote  to  the  latter  calling  his  attention  to  the  article  and 
asking  his  advice  as  to  further  study  of  these  deep  questions, 
whereupon  Huxley  answered  briefly  and  to  the  point,  "  Take 
a  cockroach  and  dissect  it." 

One  evening  Professor  Fiske  discussed  with  Huxley  the 
celebrated  murder  of  Dr.  Parkman  by  Dr.  Webster.  It  will 
be  recalled  that  Webster  murdered  Parkman  in  his  lecture 
room  in  Harvard  Medical  College  about  1819  and  attempted 
to  destroy  the  remains  by  chemical  reagents.  Fiske  ex- 
pressed surprise  that  Webster,  who  was  an  expert  chemist, 
should  have  been  so  slow  and  bungling  in  getting  rid  of  the 


642 


Thb  Phii.adblphia~| 


FOREIGN  NEWS  AND  NOTES 


[Afeil  6,  UM 


remains;  whereupon  Huxley  said,  "Well,  there  is  a  good 
deal  of  substance  in  a  human  body.  It  is  hard  to  dispose  of 
so  much  corpus  delicti.  I  have  often  thought  this  when  I 
felt  like  killing  somebody." 

Oj  another  occasion  he  examined  a  student  who  insisted 
on  placing  the  mitral  valve  in  the  right  side  of  the  heart. 
HtLxley  expressed  sympathy  with  him  and  told  him  that 
he  had  himself  always  made  the  same  mistake  until  it  oc- 
curred to  him  one  time  that  a  bishop  was  never  In  the  right. 

At  the  close  of  a  lecture  he  once  asked  a  student  if  he 
understood  it  all.  "  All,  sir,"  answered  the  student,  "  but 
one  part,  diuing  which  you  stood  between  me  and  the  black- 
board." "Ah,"  replied  Huxley,  "  I  tried  my  best  to  make 
myself  clear,  but  evidently  I  did  not  make  myself  trans- 
parent." 

COXTLNTEXTAL  EUROPE. 

Inflaenza  in  Copenhagen* — There  were  1700  cases  of 
influenza  reported  in  Copennagen  last  week.  Several  deaths 
have  been  reported.  In  general,  however,  the  eflfect  of  the 
disease  is  similar  to  that  seen  in  America,  most  of  the  cases 
being  of  a  rather  mild  character. 

Student  Kiots  in  Russia. — On  account  of  the  student 
riots  which  have  lately  occurred  in  Russia,  the  courses  for 
women  medical  students  have  been  stopped. 

Postmortem  Examination  of  the  late  Prof.  Pet- 
tenkofer. — The  British  Medical  Journal  states  than  an 
autopsy  performed  on  the  late  Prof,  von  Peltenkofer  by  Prof. 
Bollinger  showed  the  presence  of  chronic  inflammation  of 
the  dura  mater,  considerable  calcareous  deposits  in  the 
cerebral  arteries,  and  chronic  arthritis  deformans;  gallstones 
were  found  in  the  gallbladder. 

Turpentine  Poisoning. — Schulz  in  studyicg  the  toxi- 
cological  eflfects  of  turpentine  states  that  the  inhalation  of  a 
small  amouct  of  turpentine  is  liable  to  be  poisonous  sls 
small  quantities  are  very  rapidly  absorbed.  The  poisoning 
generally  aflFecta  the  central  nervous  system.  The  symptoms 
produced  were  extreme  muscular  fat'gue,  headache,  low 
pulse,  digestive  disturbances,  constipation,  and  in  two  cases 
marked  acne. 

Cocain  Hahit. — The  cojain  habit  is  becoming  quite 
prevalent  in  Bengal,  and  eflbrts  are  being  made  to  restrict 
the  sale  of  the  drug,  which  the  Hindus  are  using  as  a  sub- 
stitute for  opium. 

University  of  Warsaw. — The  total  number  of  students 
in  the  University  of  Warsaw  in  the  current  semester  is  1,169. 
Of  these  367  belong  to  the  Faculty  of  Medicine. 

Italian  Medical  Congress. — The  Italian  Congress  of 
Internal  iledicine  will  this  year  hold  its  aimual  meeting  at 
Pisa  in  the  latter  half  of  October. 


MISCELLANY. 

A  Typical  Russian  Episode. — The  Vratch  quotes  from 
the  Kurier  the  following  characteristic  story :  An  archi- 
tect and  a  physician  accused  of  disturbing  the  peace  and  in- 
sulting the  police  appeared  before  the  justic*  of  the  peace  in 
Moscow.  The  circumstances  of  the  case  were  that  a  woman 
was  run  over  by  a  car  which  crushed  her  leg.  Two  police- 
men who  happened  to  be  present  sent  for  the  ambulance. 
Meanwhile  the  woman  was  lying  on  the  track,  bleed- 
ing profusely.  The  ambulance  was  slow  in  coming.  The 
Seople  who  gathered  around  became  indignant  at  the  in- 
ifierence  of  the  policemen.  The  prisoners  were  especially 
demonstrative  and  one  of  them,  the  physician,  took  out  a 
handkerchief  and  tied  it  around  the  woman's  leg.  The 
ambulance  arrived  only  half  an  hour  later  and  removed  the 
almost  exsanguinated  woman  to  the  hospital,  while  the  two 
gentlemen  who  were  "  disturbing  the  peace  "  were  taken  to 
the  police  station.  They  were  discharged,  however,  their 
excited  state  of  mind  being  considered  as  an  extenuating 
circumstance. 

Professor  W.  A.  Manasein,  the  disticguished  editor  of 
the  Vraich,  died  Februiry  13,  from  thrombosis  of  the  cerebral 
bloodvessels,  caused  by  a  chronic  nephritis.    The  deceased  I 


had  been  editor  of  this  excellent  Russian  weekly  for  over 
21  years.  In  him  the  Russian  medical  profession  loees  aa 
able  teacher,  a  noble  man,  an  upright  and  fearless  editor, 
and  a  leading  spirit.  Medical  journalism,  not  only  in  R'ossia, 
but  all  over  the  civilized  world,  will  surely  miss  in  him  one 
who  had  succeeded  in  making  bis  JDumal  the  representative 
organ  of  universal  medicine  in  general,  and  R'lesian  in  par- 
ticular. By  his  will  the  Vratch  is  to  be  issued  until  the  ead 
of  the  year  and  then  discontinued,  he  having  been  alao 
the  publisher  for  the  past  6  years.  Until  then  Dr.  S.  Wladis- 
lawlew  is  to  be  the  editor. 


The  Effects  of  Canadian  Hemp  in  Heart  Disease. 

— Golubinin  {Klinitghtski  Journal,  December,  l&CO;  Vraich, 
Vol.  xxii,  Xo.  4)  found  as  a  result  of  a  number  of  observations, 
f  jur  of  which  are  described  in  detaO,  that  a  fluid  extract  of 
Canadian  hemp  diminishes  the  frequency  of  the  pulse-rate 
in  severe  cases,  while  the  organism  is  under  ita  influence,  but 
in  milder  cardiac  affections,  even  after  its  use  has  been  dis- 
continued, the  blood-pressure  is  raised,  the  secretion  of 
urine,  in  favorable  cases,  is  considerably  increased  and  the 
albuminuria,  in  so  far  as  it  depends  on  the  blood-pressure, 
disappears.  The  number  of  respirations  also  diminish  in 
proportion  to  the  improved  circulation.  The  fluid  extract 
should  be  administered  in  doses  of  5  drof)6  3  to  4  times  daily. 
Xd  untoward  effects  take  place.  The  slight  irritation  of  the 
stomach  quickly  disappears  after  the  drug  has  been  discon- 
tinued for  one  or  two  days.  To  prevent  the  gastric  irritation, 
an  equal  amount  of  an  infusion  of  cai:nabis  indica  should  be 
administered.  Tlie  author  concludes  by  stating  that  in 
Canadian  hemp  we  have  a  most  valuable  remedy  which 
gives  relief  in  many  severe  cases  not  benefited  by  other  car- 
diac remedies,     [a.k.] 

Tuberculosis  of  the  Submaxillary  Gland.— Arcoleo 

(ilorgagni,  September,  ICOO)  states  that  tubercles  in  the  sub- 
maxillary gland  are  particularly  liable  to  become  fibrous. 
Whether  the  bacillus  gains  ingreas  by  lymph-  or  bliX)d- 
channele,  there  is  always  a  firm  encapsulation  due  to  chemo- 
taxis,  the  leukocytes  becoming  deposited  in  the  connective 
tissue  stroma  of  the  gland.  These  leukocytes,  as  well  as  the 
connective  tissue  ceils,  subsequently  assume  the  character 
of  epithelial  cells.  It  is  difficult  to  artificially  in-'ect  the 
gland  with  tubercle  bacilli  by  inoculation  through  the  sali- 
vary duct.  Toe  tuberculous  nodes  form  in  the  center  of  the 
lobule  ;  the  sclerotic  change  begins  in  the  perilobular  tissue 
and  extends  towards  the  center.  Direct  inoculation  of 
tubercle  bacilli  causes  tuberctdar  abscesses  aad  Usiona, 
which  quickly  result  in  scleroeia  of  the  gland.    [m.b,d  J 

On  Moore's  Ureine  and  its  Physiologic  Action. — 

Xuliabko  (Vratch.  Vol.  xxii,  Xo.  4)  pre?enttd  before  the 
Russian  Society  for  the  Preserva'.ion  of  PubUc  Health  the 
results  of  his  investigations  of  urein,  a  substance  claimed  by 
Dr.  Moore  to  be  a  newly. discovered  important  urinary  con- 
stituent. The  author  found  that  this  so-called  tireice  possesses 
no  chemi(!al  entity.  The  meihcxl  of  obtaining  it  is  extremely 
inaccurate,  and  there  is  no  assurance  of  the  purity  of  the 
substance  obtained.  "  Ureine  "  contains  a  great  deal  of  water, 
ure^,  and  other  urinary  constituents,  representing  practically 
a  watery-alcoholic  extract  of  luine.  The  toxic  etfecta  of 
'■  ureine  "  on  animals  resemble  generally  the  action  of  urinaiy 
extractives.  It  aflects  the  nervous  system  and,  principaDy, 
the  respiratory  center,  the  immediate  cause  of  death  being 
due  to  paralysis  of  respiration.  When  injected  directly  into 
the  blood-current  it  lowers  the  blood- pressure,  diminishes  and 
finally  paralyzes  respiration,  producing  general  convulsiona. 
The  latter,  however,  are  due  to  the  respiratory  difficulty  and 
are  not  observed  when  artificial  respiration  is  used.  In  this 
case  there  take  place  increased  secretion  of  the  glands,  fre- 
quent urination,  diminished  sensibility,  disturbances  of  res- 
piration and  dilatation  of  the  pupil.  Owing  to  the  larce 
amount  of  urea  this  sub>stance  contains,  it  is  eitrem^ 
irritating  to  the  muscles  or  nerves  when  applied  locally.  Dr. 
Dzershowski,  one  of  the  members  of  the  society,  remarked 
that  in  his  opinion  "  ureine  "  does  not  merit  the  attention  it 
received.  In  its  preparation  Dr.  Moore  employs  oxalic  acid, 
mercury,  ammonia,  etc.  These  substances  are  not  removed 
and  the  preparation  therefore  is  impure.    [a.k.] 


Apeii.  6,  1901] 


THE  LATEST  LITERATURE 


CThk  Philadelphia 
Medical  Jocrnal 


643 


Ctje  latest  literature. 


British  Medical  Journal. 

March  16,  1901.     [No.  2098.1 

1.  An   Address  on  tbe  Causation  of  Cancerous  and  O.lier 

New  Growths.    J  George  Adami. 

2.  On  the  O.currence  of  Pyrexia  in  Cancer  and  Other  DIs- 

exsfs  of  the  Liver  and  in  Cases  of  Gallstone.      C.  O. 
Hawthoene. 

3.  Digestion  Leukocyto;isin  Cancer  of  the  Stomach.      Cab- 

stairs  Douglas. 

4.  The  Palliative  Treatmen'.  of  Carcinomj.  Uteri.    Gerald 

R  Leighton. 

5.  Toe  App'ication   of   Romanowsky's    Stiin    in    Malaria. 

Major  W.  B.  Leishman. 

6.  The  Milrov  Lectures  on  the  Influence  of  the  Dwelling 

Upon  Health.    John  F.  J.  Sykes. 

1. — After  a  consideration  of  the  diS'erent  theories  to  ac- 
count for  the  causation  of  cancerous  and  other  new 
growths,  Adami  concludes  that  whatever  the  origin  of  a 
tumor,  however  it  is  started,  that  which  makes  the  tumor  is 
the  assumption  by  the  primary  cells  of  that  tumor  of  the 
habit  of  growth  in  place  of  the  habit  of  work,  and  according 
to  the  extent  of  this  replacement,  we  get  the  various  grades 
of  tumor  formation  from  the  mo&t  bsnign  to  the  most  malig- 
nant. The  katabolic  activities  of  the  cell  are  of  two  orders  : 
those  that  determine  the  relationship  of  the  cell  to  the  ex- 
terior, and  those  that  are  vegetative  and  that  determine  the 
continued  existence  and  multiplication  of  the  cell.  The 
former  activities  are  excited  by  stimuli  of  various  orders 
from  without ;  the  latter  are  only  indirectly  so  excited,  but 
are  more  directly  called  into  play  by  conditions  obtaining 
within  .the  cell.  The  nucleus  is  the  controlling  agency  in  the 
higher  katabolic  activities  of  the  cell  at  least,  both  fanctional 
and  vegetative,  and  nuclear  activity  is  accompanied  by 
breaking  down  and  discharge  or  by  rearrangement  of  the 
nuclear  molecules.  The  changes  that  occur  in  the  nucleus 
during  the  active  performance  of  the  specific  functions  of 
the  cell  are  of  a  character  so  diflerent  from  those  observed 
during  the  process  of  cell  division  that  proliferation  and  ac- 
tive performance  of  specific  function  are  incompatible  to  a 
great  degree.  It  follows,  therefore,  that  active  cell  division 
and  cell  proliferation  occur  only  in  canditions  in  which  the 
cell  cannot  fully  utilize  the  assimilated  material  and  the 
energy  stored  up  in  the  assimilation  of  that  material  in  the 
performance  of  its  specific  functions.  Such  conditions  are 
to  be  met  with  when  the  tensions  acting  on  the  cell  are  re- 
duced and  certain  energies  that  were  formerly  necessary  to 
counteract  opposing  forces  are  freed  and  thus  become  capa- 
ble of  diversion  from  their  purpose,  or  when  stimulation 
from  without  results  in  increased  assimilation  and  storage 
of  nuclear  and  cell  material  which  from  any  cause  cannot 
be  utilized  in  the  performance  of  specific  function.  In  either 
case,  the  cells  will  continue  to  proliferate  so  long  as  the 
primary  modification  of  physical  relationships  or  the 
primary  stimulus  continues  to  act,  so  long  as  there  is  ade- 
quate nutriment,  and  so  long  as  the  tensions  exerted  upon 
the  cells  do  not  become  excessive.  Provided  that  these  con- 
ditions are  observed,  the  greater  the  amount  of  cell  prolifer- 
ation, the  greater  the  tendency  for  certain  at  least  of  the 
newly  formed  cells  to  be  projected  from  the  relations  proper 
to  cells  of  the  tissue  giving  them  origin,  and  the  less  will  be 
the  opportunity  for  such  cells  to  carry  on  their  primordial 
function.  The  longer  the  cells  are  diverted  from  their  proper 
extrinsic  functions  to  proliferative  activity,  the  greater  the 
momentum  acquired  by  them  to  continue  performing  the 
proliferative  act  until  the  functional  activities  become  largely 
suspended  and  the  habit  of  growtli  is  set  up.  When  this 
habit  of  growth  is  inaugurated  the  cells  can  continue  to  grow 
and  multiply  in  the  complete  absence  of  those  conditions 
that  initiated  their  proliferation  in  the  first  place,  and  we  ob- 
tain that  purposeless,  functionleas  cell  growth  characteristic 
of  the  true  tumor.  According  to  the  stage  of  cell  develop- 
ment in  which  this  habit  becomes  impressed  upon  the  cell, 
we  have  the  various  grades  of  benign  and  malignant  tumors. 
According  to  this  theory,  microorganisms  and  their  products 
may  be  one  of  the  causes  originating  localized  cell  prolifera- 


tion, provided  that  they  bring  about  stimulation  rather  than 
irritation,  or  irritation  of  so  mild  a  type  that  the  cells  are 
stimulated  to  an  increased  metabolism  which,  however,  does 
not  go  on  to  exhaustion  and  excessive  breaking  down  of 
protoplasm,  and  provided  also,  that  the  microorganisms  and 
their  products  continue  in  action  for  a  sufficiently  long  time 
to  set  up  the  habit  of  growth.  It  is  quite  conceivable  that 
such  microorganisms  may  continue  to  exist  in  the  tumors 
they  originated,  exerting  a  cumulative  effect.  The  more 
the  cells  depart  from  the  type  the  greater  the  eflfect  of  these 
microorganisms  and  their  products  in  producing  a  tis- 
sue of  rapidly  proliferative  and  malignant  type.  This  con- 
tinuance and  persistence  of  microorganismal  acti  n,  how- 
ever, must  not  be  regarded  as  essential.  The  very  fact  that 
after  all  these  years  and  after  the  hosts  of  careful  observa- 
tions, we  are  still  in  very  grave  doubt  as  to  whether  any  of 
the  bodies  seen  in  tumors  are  really  parasites,  the  fact  that 
no  growth  of  these  bodies  have  surely  been  obtained  outside 
the  organism  and  then,  upon  injection,  have  induced  tumor 
formation,  although  by  no  means  proof  absolute,  may  be 
quoted  in  favor  of  the  view  that  if  microorganisms  originate 
malignant  tumors,  they  do  not  continue  in  them  in  the  liv- 
ing state.  It  is  quite  possible,  according  to  this  theory,  that 
certain  specific  forms  of  microorganismal  life  originate  cer- 
tain forms  of  tumor  growth  and  that,  like  other  pathogenic 
microorganisms,  these  may  show  a  predilection  to  attack 
special  tissues  under  special  conditions ;  and,  if  it  be  true 
that  malignant  growths  are  specially  common  in  ceitiin 
localities,  then  such  microorganismal  origin  becomes  emi- 
nently probable.  But  if  this  theory  be  true,  it  does  not  fol- 
low that,  discovering  the  causative  microorganism,  we  shall 
be  able  to  arrest  the  development  of  carcinoma  by  antimi- 
crobic  or  antitoxic  means.  But  above  all,  the  author  feels 
that  the  greatest  benefit  to  the  patient  and  the  greatest 
triumph  and  satisfaction  to  the  practitioner  will,  for  some 
years  to  come,  be  the  recognition  and  successful  removal  of 
malignant  tumors  at  the  earliest  possible  date,  and  the 
removal  of  benign  tumors,  in  general,  before  they  have  taken 
on  possible  malignant  characters,    [j  m  s.] 

2. — Hawthorne  publishes  abstracts  of  the  course  of  several 
cases  that  show  that  a  considerable  degree  of  pyrexia  may  at- 
tend carcinoma  of  the  liver.  As  a  result  of  these  clinical 
observations  it  follows  that  the  distinction  of  carcinoma  of 
the  liver  from  impacted  gallstone,  abscess,  and  other 
hepatic  conditions  in  which  febrile  disturbances  more  or 
less  frequently  occur,  is  not  facilitated.  But  the  recognition 
of  this  clinical  truth  may  at  least  save  the  physician  from  an 
inclination  to  place  undue  stress  upon  the  existence  of 
pyrexia  as  a  reason  for  excluding  carcinoma  from  the  diag- 
nosis. A  combination  of  jaundice,  intermittent  fever,  and 
hepatic  enlargement  should  demand  very  careful  considera- 
tion before  the  diagnostician  decides  to  cast  the  verdict  for 
gallstone,  on  the  one  hand,  or  malignant  disease  on  the 
other.  In  the  various  forms  of  abssess  of  the  liver,  rigors 
and  remittent  or  intermittent  fever  is  to  be  expected,  but 
this  expectation  is  not  always  realized.  Identical  symptoms 
have  followed  the  bursting  of  an  hydatid  cyst  with  the  pass- 
age of  secondary  cysts  into  the  bile-duct.  The  same  associ- 
ation of  eveats  has  followed  the  entrance  of  iumbricoid 
worms  into  the  biliary  passages.  Pyrexia  occasionally  exists 
as  a  symptom  of  hepatic  cirrhosis,     [j  m  s.] 

3. — Douglas  reports  the  result  of  a  study  of  the  blood- 
formula  in  11  cases  of  malignant  disease  involving  the  stom- 
ach. It  would  appear  from  the  results  of  the  investigation  that 
digestion  leukocytosis  is  a  broken  reed  on  which  to  lean 
in  the  diagnosis  of  carcinoma  of  the  stomach,  since 
only  a  trifle  over  51%  of  the  cases  give  a  positive  reaction. 
Out  of  the  11  cases,  digestion  leukocytosis  was  absent  in  6, 
or  54  54^  ;  present  in  4,  or  36.36%  ;  and  inconstant  in  1,  or 
9.10%.    [j  M.S.J 

4. — Leighton  considers  the  palliative  treatment  of 
carcinoma  uteri  as  illustrated  by  a  case  which  had  been 
under  almost  daily  observation  for  2J  years  from  the  first 
diagnosis  of  the  disease  to  its  fatal  termination.  His  main 
treatment  consisted  in  the  administration  of  the  solution  of 
the  hydrochlorate  of  morphin  alternating  with  chloral 
hydrate  and  morphin  suppositories.  Subsequently  the 
liquor  morphica;  was  discarded  for  the  tincture  which  was 
carried  to  its  limit,  and  was  associated  with  tincture  of  bella- 
donna. The  suffering  of  the  patient  was  inconsiderable. 
[w.A  N.D.] 


6U 


Thk  Phii.asklphia'I 
Ubdicai.  Joushax  J 


THE  LATEST  LITERATURE 


lAfRU.  6,  1101 


5. — Leisbman  describes  a  modification  of  Roman- 
owsky's  method  of  staining  for  the  demonstration  of 
the  presence  of  malarial  parasites  in  the  blood  and,  in 
particular,  for  the  differential  diagnosis  of  the  tertian  para- 
site. The  chief  advantages  of  the  method  are  :  1.  The  specific 
action  of  the  stain  upon  all  red  blood- corpuscles  infected  by 
the  tertian  parasite.  2.  The  greater  certainty  of  the  detec- 
tion of  very  young  intracorpuscular  forms  of  all  varieties  of 
the  malarial  parasite.  3.  The  facility  with  which  the  occur- 
rence of  a  mixed  infection  may  be  detected.  4.  The  ease  of 
application,  after  a  little  practice,  and  the  certainty  of  the 
results  obtained.  In  the  preparation  of  the  blood  film  care 
should  be  taken  that  the  cover  glasses  are  never  subsequently 
handled  except  with  a  pair  of  forceps,  as  the  slightest  trace 
of  moisture  from  the  fingers  will  et danger  the  result.  A 
thin  even  film  is  necessary  and  this  should  be  fixed  in  equal 
parts  of  ether  and  absolute  alcohol.  The  fixed  film  should 
be  washed  well  in  water  and  dried  in  the  air  before  staining. 
Two  stock  solutions  are  prepared  ;  the  first  is  a  1%  solution 
of  methylene- blue  in  distilled  water  which  is  rendered  alka- 
line by  the  addition  of  0.5  fo  of  sodium  carbonate.  This  solu- 
tion should  be  heated  for  some  time  before  use.  To  prevent 
the  growth  of  moulds  0.25%  of  formalin  may  be  added.  The 
second  solution  is  a  1  to  1,000  solution  of  eosin  in  distilled 
water.  A  portion  of  each  of  these  solutions  is  further  diluted 
with  24  parts  of  distilled  water  and  an  equal  volume  of  each 
diluted  solution  is  poured  on  to  the  cover-glass  in  such  a  way 
that  they  come  in  contact  with  the  film  at  the  moment  of 
mixing.  At  the  end  of  half  an  hour,  the  film  is  removed 
from  the  stain  and  examined  in  water  by  a  J  or  J  inch 
objective.  If,  instead  of  a  deep,  red  color,  the  nuclei  and 
blood  plates  are  only  purple  or  deep  violet,  the  staining  is 
insufficient,  and  the  films  must  be  replaced  in  the  solution 
for  a  short  time.  The  deep,  red  color  represents  a  slight 
degree  of  over  staining  and  the  preparation  should  be  de- 
colorized, after  washing  in  water,  by  rinsing  in  absolute 
alcohol  for  2  or  3  seconds,  the  cover  glass  should  then  be 
immediately  transferred  to  water  until  all  traces  of  alcohol  are 
removed.  Decolorization  may  be  accomplished  by  holding 
the  film  under  running  water  for  some  time,  or  by  leaving  it 
to  soak  in  water  for  from  J  hour  to  an  hour.  The  appear- 
ance of  the  film  when  it  is  ready  to  mount  should  be  as  fol- 
lows: The  red  cells  are  transparent  and  nearly  colorless,  or, 
perhaps,  slightly  green  or  pink.  The  polymorphonuclear 
leukocytes  have  their  nuclei  stained  ruby  red  or  magenta, 
the  extranuclear  portion  being  colorless  or  containing  a  few 
reddish  granules.  The  nuclei  of  the  mononuclear  leukocytes 
and  lymphocytes  are  of  the  same  color  as  those  of  the  poly- 
morphonuclears, and  their  margins  are  very  clearly  defined, 
while  the  extranuclear  portion  is  stained  a  beautiful  eaude- 
nil  or  pale  blue  color.  The  blood  plates  are  ruby  red,  with 
definite  involuted  margins.  The  films  are  now  dried  in  the 
air  or  by  gentle  heat  and  mounted,     [j.m.s  ] 

6. — Will  be  abstracted  when  finished. 


Lancet. 

March  16,  1901.    [No.  4016  ] 

1.  The  Hunterian  Lectures  on  the  Topographical  Anatomy 

of  the  Abdominal   Viscera    in    Man.     Christopher 
Addison. 

2.  A  Clinical  Lecture  on  the  Treatment  of  Tuberculous  Peri- 

tonitie.    I.  Bueney  Yeo. 

3.  Some  Personal  Experiences  of  the  Epidemic  of  Enteric 

Fever  Among  the  Troops   in  South  Africa,  in  the 
Orange  River  Colony.    H.  H.  Tooth. 

4.  The  Clinical  and  Pathological  Relations  of  the  Chronic 

Rheumatic  and  Rheumatoid  Affections  to  Acute  In- 
fective Rheumatism.    Archibald  E.  Garrod. 

5.  The  Toxicolcgical  Detection  of  Arsenic  and  the  Influence 

of  Selenium  on  its  Tests.   William  Hexry  Wili.cox. 

6.  Septic  Disease  in  Graduated  Attacks  in  the  Same  Patient. 

J.  Snowman. 

7.  The  Status  of  the  "Country  Doctor."    Harry  Roberts. 

1. — Addison,  in  his  lecture  on  the  topographical 
anatomy  of  the  abdominal  viscera,  goes  carefully 
into  the  posiion  and  relations  of  each  organ  and  presenta 
several  excellent  illustrations,     [j.h  a  "J 

2. — Yeo  delivered    a  lecture  on   the   treatment   of 


tubercalous  peritonitis  at  the  Medical  Graduates'  Col- 
lege and  Polyclinic,  on  December  19,  1900.  The  author 
states  that  it  has  been  shown  that  tuberculous  peritonitis 
may  be  a  primary  as  well  as  a  secondary  condition  ;  when 
primary,  the  tubercle  bacilli,  as  a  rule,  gain  entrance  into 
the  intestinal  canal,  from  infected  meat  and  infected  milk  ;  the 
bacilli  pass  through  the  walls  of  the  intestine  without  pro- 
ducing a  lesion,  and  in  this  way  Involve  the  peritoneum.  It 
frequently  happens  that  lesions  are  first  set  up  in  the  intes- 
tine and  the  peritoneum  involved  subsequently.  The  author 
reports  4  cases  of  tuberculous  peritonitis;  all  of  these  cases 
were  treated  with  an  ointment  containing  iodine  or  iodoform, 
applied  freely  to  the  abdominal  surface ;  iodoform,  combined 
with  creosote,  was  also  administred  internally ;  all  of  the 
cases  made  a  good  recovery,     [f.j.k] 

3.— Tooth  read  the  opening  pep^r,  entitled  "Some  per- 
sonal experiences  of  the  epidemic  of  enteric  fever 
among  the  troops  in  South  Africa,  in  the  Orange  River 
colony,"  before  the  Clinical  Society  in  London,  on  March  8, 
1901 .  The  obj  ect  of  the  occasion  being  to  discuss  this  re  cent 
epidemic.  The  author  believes  that  the  epidemic  originated 
in  tbe  Modder  River  camp  ;  the  dissemination  of  the  disease 
was  probably  largely  due  to  contaminated  water  supply  and 
atmospheric  disturbances.  Sand  storms  are  frequent  in 
South  Africa,  and  Tooth  states  that  the  sand  was  distributed 
broadcast,  and  therefore  contaminated  almost  every  article 
cf  food.  He  also  believes  that  it  is  reasonable  to  suppose 
that  the  spread  of  the  disease  was  in  part  due  to  flies  and  to 
a  lees  extent  by  personal  infection.  Almost  every  prcciution 
was  taken  to  prevent  the  spread  of  enteric  fever ;  the  carry- 
ing out  of  sanitary  laws  was  very  difficult,  and  sometimes 
impossible,  as  these  laws  are  always  subservient  to  the  exi- 
gencies of  warfare.  Preventive  inoculation  was  produced 
with  rather  favorable  results.  From  a  standpoint  of  treatment, 
nourishment  was  given  liberally  when  it  could  be  done 
safely  ;  digitalis  and  strychnia  were  found  to  be  of  great 
value,  and  alcohol,  as  a  rule,  was  used  sparingly.  Hesulache 
was  controlled  by  pbenacetin,  and  sometimes  antipyrin  was 
administered;  insomnia  was,  fs  a  rule,  treated  with  pbena- 
cetin. A  solution  containing  potassium  chlorate,  glycerin 
and  perchloride  of  iron  was  used  to  cleanse  the  mouth ;  potas- 
sium chlorate  and  scdium  bicarbonate  were  given  3  times  a 
day ;  these  drugs  seemed  to  hhve  a  favorable  action  upon 
keeping  the  buccal  mucous  membrane  and  tbe  tongue  moist. 
[k  J  K  ] 

4.— Garrc  d  discusses  The  clinical  and  pathological 
relations  of  the  chronic,  rheumatic  and  rheumatoid 
affections  to  acute,  infective  rheumatism.  Tl:e 
most  important  consideration  in  his  article  is  whether  there 
is  any  direct  relationship  between  rheumatoid  arthritis  and 
£cute  rheumatism.  The  author  states  that  iheuma'.oid 
arthritis  in  the  majority  of  instances  appears  to  be  a  primary 
malady  with  characteristic  features  from  tbe  onset.  Infre- 
quently the  patient  suffericg  from  ttis  form  of  arthritis  has 
previously  been  affetted  with  acute  rheumatism.  He  con- 
cludes the  article  by  saying  that  from  a  cUnical  and  patho- 
logical standpoirt,  theie  is  still  much  room  for  the 
accumulat'on  of  facts  bearing  upon  rheumatoid  aithrit's, 
and  for  the  present  we  should  take  an  expe.tint  attitude  in 
this  matter,     [f  j.k  ] 

5. — Wilcox,  in  an  article  entitled  "The  to.vicological 
detection  of  arsenic  and  the  influence  of  selenium  on 
its  tests,'  concludes  as  follows :  That  from  his  experiments 
he  conclusively  proves  that  the  poisoning  was  not  due  to 
selenium  primarily  and  to  arsenic  secondarily,     [f  j  k  ] 

6. — Snowman  describes  a  patient  who  suffered  after 
childbirth  from  septic  infection.  Several  years  later  the 
patient  suffered  from  septicemia,  and  only  a  year  subse- 
quent to  this  attack  she  had  pyemia,  from  which  she  again 
reccvere.''.     [j.h.g] 


New  York  Medical  Journal. 

March  SO,  1901.    [Vol.  Ixxiii,  No.  13.] 

1.  Congenital  Dislocation  of  the  Shoulder,  with  Report  of 

Two  Cases  of   Dislocation    Posteriorly.    Dakikl  W. 
Marstok. 

2.  The  Pathology  of  Intrauterine  Death.   Nkil  MacPhattkr. 

3.  The  Comparative  Pathology  of  the  Jews.    Morris  Fkh- 

bero. 


April  6,  1901) 


THE  LATEST  LITERATURE 


TTHK   PHn.ADKLFHlA 

L  Mkdical  Jouksal 


645 


4.  The  Causes  and  the  Significance  of  the  Obsietric  Hemor- 

rhages.   J.  Cliftos  Edjar. 

5.  Tropical  Dysenteries.    Stephen-  M.  Long. 

6.  A  Dressing  for  C  Mies' Fracture.    Charles  L    DeMeritt. 

7.  A  Requisite  to  Increase  the  Uaefulness  of  Ambulances. 

Frederick  Griffith. 

1, — In  concluding  his  article,  D.  W.  Marston  comes  to  the 
following  conclusions :  1.  It  is  of  the  utmost  importance  to 
distinguish  between  cbsbs  of  dislocation  and  true  ob- 
stetrical paralysis.  2.  The  treatment  of  the  former  con- 
dition is  immediate  reduction ;  by  manipulation  if  possible, 
otherwise,  operative.  3.  Every  infant  should  be  carefully 
examined  at  birth,  for  it  is  at  this  time  that  reduction  is 
easiest  performed.  4  From  the  facts  that  a  fracture  of  the 
glenoid  cavity  was  found  in  three  of  Dr.  Phelps'  cases,  and 
•  that  the  historj-  of  nearly  all  cases  shows  difficult  labor,  I 
am  led  to  believe  that  these  cases  are  not  cf  paralytic  origin, 
or  due  to  nondevelopment,  as  affirmed  by  Ssudder,  but  are 
due  to  traction  made  in  the  axilla  by  the  finger  or  vectis,  or 
to  the  arm  being  caught  in  some  unusual  position  and  dislo- 
cated by  the  contraction  of  the  uterus.  Paralysis  may  be 
coincident,  but  it  cannot  be  a  primary  factor  in  causing  dis- 
location posteriorly.  5.  The  prognosis  of  the  operative  treat- 
ment is  excellent.  The  earlier  the  operation  the  more  hope- 
ful the  outlook.  6.  Like  congenital  dislocation  of  the  hip, 
these  cases  of  the  shoulder  are  little  benefited  by  mechanical 
treatment.  In  connection  with  the  desiription  of  the  oper- 
ation here  advocated  for  this  deformity,  he  recommends  the 
new  excavator  of  DiJDn,  which  will  be  found  almost  indis- 
pensable in  the  process  of  cleaning  out  the  glenoid  cavity  for 
the  reception  of  the  head  of  the  humerus.  It  is  also  of  value 
in  the  open  operation  for  the  reduction  of  congenital  dislo- 
cation of  the  hip.  The  instrument  is  made  in  three  sizes, 
and  consists  of  a  cylindrical  steel  tube,  conical  at  one  end, 
furnished  with  cutting  edges  like  the  old-time  pot  auger  used 
by  carpenters.  These  instruments  leave  the  glenoid  cavity 
with  perfectly  smooth  and  regular  edges,    [m  e  d  ] 

2. — Will  be  abstracted  when  completed. 

4, — J.  Cliftoa  E  igar  divides  obstetric  metrorrhagia 
into  three  classes:  L  The  metrorrhagia  of  pregnancy  or 
antepirtum  hemorrhages.  2.  The  metrorrhagia  of  labor  or 
intrapartum  hemorrhages.  3.  Puerperal  metrorrhagia 
proper,  or  secondary  postpartum  hemorrhiges.  He  believes 
that  the  most  frequently  occurring  antepartum  hemorrhages 
are  indicative  of  bleeding  due  to  a  sudden  or  inevitable  abor- 
tion caused  by  a  partial  separation  of  the  fetal  structures 
before  complete  formation  of  the  placenta.  0;her  conditions 
causing  antepartum  hemorrhages  such  as  placenta  previa, 
premature  separation  of  a  normally  located  placenta  (acci- 
dental hemorrhage),  ectopic  gestation,  rupture  of  the  uterus, 
and  menstruation  occurring  during  pregnancy,  are  discussed, 
as  well  as  the  causes  giving  rise  to  each  of  these  conditions. 
The  causes  and  significance  of  intrapartum  and  postpartum 
hemorrhages  are  also  described,    [m  r  d.] 

5.— Stephen  M  Long  believes  that  dysenteryshouM  be 
more  thoroughly  investigated  by  the  profession  living  outside 
of  the  territories  where  it  ii  prevalent.  Hemenlionet  le  futility 
of  any  treatment  devised  up  to  the  present  time  for  fulminat- 
ing catarrhal  dysentery.  The  second  type  discussed  is  the 
simple,  a:u'e  dysentery  starting  as  a  diarrhea  and  frequently 
associated  with  maLtria.  After  discussing  the  third  typ3  gener- 
ally called  the  amebic  one,  and  subdivided  into  the  amebic, 
the  trichomon-idic,  the  cercomonadic,  and  the  mixed  forms, 
chr  jnic  dysentery  as  well  as  the  gangrenous  and  diphtheric 
forms  are  considered.  The  author  states  that  the  ssquelae 
of  the  disease  as  met  with  in  the  Philippine  Islands  are  the 
following  :  (1)  Its  chronicity  ;  (2)  chronic  gastritis  and  indi- 
gestion ;  (3)  obstinate  constipation  ;  (4)  paralysis  (partial)  of 
the  large  intsstines,  due  either  to  obliteration  of  the  glands 
and  lack  of  secret  on  or  to  la^k  of  innervation  and  blood- 
sapply ;  (5)  anemia,  from  lack  of  assimilation  of  food ;  (6) 
the  association  with  it  of  malarial  fever;  (7)  typhoid  fever  ; 
(8)  neuritis ;  (9)  atrophic  cirrhosis  of  the  liver ;  (10)  chronic 
parenchymatous  nephritis;  (U)  abscess  of  the  liver;  (12) 
metastatic  abscessss  of  other  organs,  as  of  the  lungs  and 
kidneys;  (13)  inanitiDn  ;  (14)  toxemia;  (15)  dilatation  of  the 
stomach  and  intestines.  He  emphasizes  the  necessity  of 
cleanliness  as  a  prophylactic  measure  and  the  avoidance  of 
anything  as  he  terms  it  "  which  has  not  seen  the  baptism  of 
fire."    iHe  does  not  believe  in  the  employment  of  alcoholic 


drinks  as  p-ophylaxis  against  dysentery,  but  bjlieves  that 
blackberry  brandy,  sherry  or  claret  judiciously  and  cautiously 
used  in  the  chronic  stiges,  are  of  value.  Sulphate  of  magne- 
sium, calomel,  pecacuanha,  opium  and  bismuth  subnitrate 
are  each  disousjed  as  to  their  respective  value.  Enemata, 
composed  of  various  drugs  that  are  described  individually 
are  extremely  valuable  when  medicines  taken  per  os  prove 
futile.  Abdominal  massage,  turpentine  stupjs  and  hot 
fomentation!  should  alsD  be  taken  into  consideration. 
[m  r  d.] 

6. — 0.  L.  DeMeritt  describes  a  dressing  for  CoUes' 
fracture,  consisting  of  a  thin  piece  of  board  previously 
marked  out  in  the  desired  shape.  The  ulnar  side  of  the  dis- 
tal end  is  rounded  off,  thus  permitting  the  hand  to  turn  in 
the  desired  direction.  A  rounded  piece  of  board  with  its 
convex  surface  above  fills  out  the  hollow  in  the  hand.  The 
upper  surface  of  the  splint  is  padded  and  covered  with  a 
roller  bandage,    [m.e  d.] 


Medical  Record. 

March  SO,  1901.     [Vol.  59,  No.  13.] 

1.  Some  Fallacies  of  Therapeutics.    George  L.  Peabody. 

2.  Ionization  in  its  Physiologial  and  Pathological  Duration. 

'    iMARTiN  H.  Fisher. 

3.  Creosote  in  Pneumonia;  A  ReiumI     I.  L.  Van  Zvndt. 

4.  Orchid  Culture  in  its  Rslation  to  a  iNew,  Improved,  and 

Completely  Effective  iMethod  of  Disinfection.    J.  iil. 
W.  Kitchen. 

1.— George  L.  Peabody  contributes  a  suggestive  article 
upon  some  fallacies  of  therapeutics.  He  calls  atten- 
tion to  that  class  of  mixtures  known  as  "  tonics "  and 
"bitters"  which  are  l.irgely  consumed  by  the  laity.  He 
has  found  these  very  generally  to  contain  a  large  percentage 
of  alcohol.  Almost  all  of  these  compounds  are  sold  as 
being  nonalcoholic.  The  writer  believes  that  in  a  vast 
majority  of  cases  in  which  bitter  substances  actually  do 
increase  the  appetite  this  is  due  to  the  fact  that  the  mixture 
contains  alcohol.  He  states  the  boric  acid  is  another 
drug  which  furnishes  an  illustration  of  the  authority  of 
tradition  and  the  consequent  propagation  of  error.  He 
believes  that  the  disinfecting  power  of  boric  acid  is  so  trifling 
that  for  practical  purposes  in  this  application  it  must  be 
disregarded  entirely.  iNeither  is  it  to  be  considered  as 
quite  harmless.  The  use  of  tannic  acid  is  another 
agent  which  may  be  considered  of  doubtful  value.  He 
believes  that  there  is  no  warrant  for  the  very  convenient 
opinion  that  after  its  absorption  it  can  produce  styptic  or 
hemostatic  effects  upon  remote  organs.  iErgot  is  known 
to  produce  a  primary  fall  of  blood-pressure,  which  is  fal- 
lowed almost  at  once  fcy  an  enormous  and  persistent  rise  of 
pressure  in  the  arteries.  Taere  is  na  proof  that  ergot  causes 
any  contraction  of  pulmonary  vessels,  and  it  is  known  to 
cause  a  rise  in  pressure  in  the  pulmonary  artery,  yet  in  spite 
of  these  facts  it  is  recommended  t )  arrest  pulmonary  hem- 
orrhage by  some  authors  Lithium  is  a  drug  in  regard  to 
which  much  false  impression  exists.  It  is  practically  value- 
less as  a  solvent  in  gout,  even  when  given  in  reasonably  large 
amounts,  and  it  is  especially  likely  to  disorder  digestion. 
Speaking  of  arsenic,  the  author  mentions  the  fallacy  that  a 
tDxic  dose  which  causes  death,  must  necessarily  act  as  a  pre- 
servative of  the  body.  Calomel,  he  says,  is  still  given  to 
stimulate  the  liver,  whereas  experiment  has  long  since  proved 
it  to  be  an  hepatic  sedative.  It  is  at  the  same  time  a 
cholagogue,  and  so  is  any  laxative  which  acts  upon  the 
upper  part  of  the  small  intestine,  and  thus  causes  a  discharge 
of  bile  that  might  otherwise  be  reabsorbed.  His  conclusions 
regarding  the  '^usefulness  of  the  iodids  are  that  except  in 
syphilitic  disease  they  have  no  power  of  removing  hyper- 
plastic connective  tissue  or  absorbing  exudation.  Ha  does 
not  believe  that  it  is  of  any  value  in  chronic  lead  poisomng. 
This  writer  also  believes  that  the  sphere  of  usefubiess  of 
oxygen  inhalation  under  ordinary  oxygen  pressure  is 
reallv  very  lim'ted.     [t.l  c.l  . 

2.— Martin  H.  Fischer  discusses  the  subject  of  ionization 
in  its  physiological  and  pathological  relations. 
The  properties  of  the  aqueous  solutions  of  electrolytes 
seem  to  be  well  explained  by  the  assumption  that  in  these 
solutions  the  dissolved  substances  are  split  up  into  ions. 


646 


Thk  PuiladhlphiaI 
Urdical  Journal  J 


THE  LATEST  LITERATURE 


[Apbil  6,  1901 


and  the  properties  of  the  Bolution  are  due  to  the  properties 
of  the  ions  contained  in  them.  For  example,  HCl  dissoci- 
ates into  H-ions  and  Cl-ions  and  NaCl  disaEsociates 
N-ions  and  Cl-ions.  These  solutions  are  the  same  in  so 
far  as  they  contain  Cl-ions  and  different  because  oae  con- 
tains H-ions  and  the  other  Na-ions.  These  differences 
determine  the  differences  in  the  properties  of  the  two  solu- 
tions. The  physiological  action  of  any  substance  is  due  to 
its  chemical  character.  The  chemical  character  of  the  solu- 
tion of  an  electrolyte  is  due  to  the  properties  of  its  ions 
plus  the  propeities  of  its  undissociated  molecules.  The 
poisonous  properties  of  a  dilute  solution  are  due  to  the  ions 
they  contain,  and  if  at  the  particular  concentration  under  con- 
sideration, toxic  ions  of  only  one  kind  are  present,  the  behavior 
of  the  solution  is  to  be  attributed  to  those  ions.  The  change  in 
the  irritability  of  the  gastrocnemius  muscle  of  the  frog  and 
the  amount  of  water  absorbed  by  it  may  be  taken  as  an  in- 
dex of  the  toxicity  of  the  solution  of  an  electrolyte  in  which 
the  muscle  was  immersed.  The  increase  in  the  weight  of 
the  muscle  is  due  to  an  absorption  of  water,  explainable  on 
the  ground  that  the  Hions  of  the  acids  or  the  Oh-ions  of 
the  alkalies  have  a  fermented  action,  which  causes  hydroljtic 
splittings  in  the  muscles  and  an  increase  in  its  osmotic  pres- 
sure. The  ta^te  of  the  solution  of  an  electrolyte  is  depend- 
ent upon  the  ions  contained  in  it.  This  theory  of  ioniza- 
tion, which  the  author  presents  in  a  comprehensive  and 
scientific  manner,  offers,  he  believes,  a  new  field  for  investi- 
gation in  the  realm  of  medicine.  He  haa  endeavored  to 
show  that  in  dealing  with  the  action  of  dilute  solution  of 
inorganic  substances  we  are  dealing  with  the  action  of  their 
constituent  ions,  and  this  fact  should  be  borne  in  mind 
when  we  consider  physiological,  pathological,  and  pharma- 
cological problems  which  involve  the  presence  of  inorganic 
substance j.    [t.lc] 

3. — I.  L  Van  Zmdt  presents  a  re  um6  of  the  treat- 
ment of  pneumonia  by  creosote.  He  believes  that  it 
cuts  short  tae  disease  in  the  most  remarkable  manner,  and 
thatitcau-es  complete  resolution  of  the  diseased  focus,  so 
that  the  sequelae  are  less  likely  to  follow.  Furthermore,  it  is 
his  opinion  that  the  sputum  and  excreta  are  voided  dis- 
infected,   [t.lc] 

4. — J.  M.  W.  Kitchen  contributes  a  paper  upon  orchid 
culture  in  its  relation  to  a  new,  improved  and  complete 
method  of  disinfection.  The  author  in  the  course  of 
his  experience  of  raising  orchids  was  met  by  the  diffioulty 
of  destroying  the  insects  which  interfered  with  the  growth  of 
his  plants.  He  has  found  that  the  formaldehyde  is  the 
most  valuable  agent  at  our  command.  He  believes  that  a 
number  c  f  small  generators  placed  in  the  several  parts  of 
a  room  are  more  effective  than  one  l.irge  apparatus,     [t.l  c  ] 


Medical  News. 

March  SO,  1901.     [Vol.  Ixxviii,  No.  13.] 

1.  Report  of  the  Committee  of  the  Medical  Board  of  Bellevue 

Hospital,  Appointed  January  2,  liWl,  to  Investigate 
and  Report  upon  Questions  Relating  to  the  General 
Administration  of  the  Hospital. 

2.  Vaccination,  Clinically  Considered.    Frank  S.  Fielder 

3.  The  Method  of  Preparation  of  Vaccine  Virus  in  the  Vac- 

cine Labjratory  of  the  New  York  City  Health  Departr 
ment.    J.  H.  HuDrLESTON. 

2. — Fielder,  in  his  article  on  Vaccination,  emphasizes  the 
following  points  :  1.  Complete  natural  immunity  to  vaccina- 
tion is  practically  unknown.  2.  la  primary  cases,  delayed 
vesiculation,  raspberry  excrescence,  and  abortive  course, 
mean  poor  virus.  8.  Among  the  complications,  there  is  now 
no  danger  of  transmitting  syphilis  or  tuberculosis,  and  other 
infectious  diseases.  4  Daring  the  second  week  cf  vaccinia, 
a  large  juinful  areola  may  be  considered  normal  if  it  be 
bright  red,  and  if  the  vesicle  be  of  typical  appearance.  If 
the  vesicle  be  irregular,  tilled  with  greenish  pus,  and  the  are- 
ola be  of  a  dark  livid,  purplish  hue,  the  case  is  one  of  mixed 
infection.  5.  Generalized  vaccinia,  aside  from  cases  in  which 
the  eruption  is  spread  by  autoinoculation,  is  rare.  Cases  of 
doubtful  diagnosis  may  be  tested  by  the  inoculation  of 
lymph  from  one  of  the  vesicles  into  another  subject.  If 
it  be  true  generalized  vacc!nii>,  a  localized  pock  will  develop 
in  the  inoculated  person.      G.  The  destruction  of  the  vac- 


cine vesicle  does  not  interfere  with  the  immunity  (X)nferred 
by  the  vaccination.  7.  Immunity  is  acquired  about  the  time 
the  areola  is  at  its  height — 8  to  10  days  after  vaccination.  If 
smallpox  appears  at  this  time  it  will  be  mild.  If  the  eruption 
appears  before  the  vaccination  has  reached  the  areolar  stage, 
the  disease  will  not  te  much  modified  by  the  vaccination.  8. 
Vaccination  of  the  pregnant  woman  does  not  protect  her  child. 
9.  The  fetus  in  utero  may  have  smallpox,  if  the  mother  has 
it,  and  may  be  born  with  an  active  rash  or  with  healed  scars. 
A  child  born  while  the  mother  has  smallpox  is  not  only  not 
protected,  but  has  been  exposed  in  utero,  and  will  probably 
develop  the  disease  before  there  is  time  to  secure  protection 
by  vaccination.  10.  The  duration  of  immunity  to  smallpox 
which  is  conferred  by  vaccination  is  extremely  variable,  and 
in  the  presence  of  an  epidemic,  the  fact  of  recent  successful 
vaccinotion  is  only  presumptive  evidence  of  immunity.  Of 
persons  successfully  vaccinated  within  5  years,  very  few  will, 
contract  the  disease  ;  but  some  will,  though  they  will  prob- 
ably have  varioloid  instead  of  severe  smallpox.  11.  The 
duration  of  immunity  to  revaccination  which  is  (Mjnferred  by 
vaccination  is  also  extremely  variable,  and  is  probably  short 
(two  years  or  under)  in  a  larger  proportion  of  cases  than  has 
been  supposed.  12.  The  protective  power  of  vaccination  is 
in  direct  proportion  to  its  excellence  and  completeness  as 
shown  by  the  number  and  quality  of  the  resulting  scars.  Of 
the  two  elements  which  enter  into  this  pro'.e3tive  value, 
quality  of  scars  is  more  important  than  number.  13.  While 
the  quality  of  a  scar  is  a  fair  indication  of  its  protective 
power  against  smallpox,  it  is  an  untrustworthy  guide  in  de- 
ciding whether  the  individual  is  susceptible  to  revaccination. 
14.  A  person  who  is  immune  to  smallpox  can  often  be  suc- 
cessfully revaccinated.  15.  Revaccination  protects  against 
smallpox  as  fully  as  an  attack  of  the  disease  protects  against 
a  subsequent  attack.  16.  A  person  who  has  been  successfully 
revaccinated  is  much  less  likely  to  contract  or  to  die  of 
smallpox  than  a  person  who  has  been  vaccinated  only  once. 
The  more  successful  vaccinations  one  has  had  at  dif- 
ferent times,  the  more  certain  is  his  immunity,  and 
the  better  his  chance  of  recovery  if  he  does  contract 
the  disease.  17.  Revac:icalion,  therefore,  shculd  be  con- 
sidered as  impcrtant  as  primary  vaccination,  and  should  be 
just  as  syst3mat!cally  pract's£d.  18.  Primary  vaccination 
should  be  performed  in  mfancy,  revaccination  at  school  age. 
In  the  preeence  of  an  epidemic,  however,  revaccination 
should  ba  performed  even  though  the  primary  vaccination 
was  of  CDmpara'ively  recent  date.  19.  The  eruption  in 
revaccination  is  more  likely  to  f  )llow  the  type  of  vaccinoid 
than  that  of  typical  vaccinia.  20.  Vaccinoid  protects  if  the 
virus  used  is  of  high  grade  sufficiency.  If  the  virus  is  poor, 
only  partial  immunity  is  ccnferied  21.  All  vacciEC  virus 
shou'd  be  subjected  to  rigid  physiological  tests  tefore  issu- 
ance. It  should  be  refc3tei  monthly,  so  long  as  it  is  on 
s.ile.  The  virus  from  each  animal  thould  be  kept  by  itself 
and  numbered.  It  should  be  known  by  this  number  when 
issued  so  that  it  can  be  calhd  in  if  retests  show  that  its 
cITiciency  has  expired.  22.  Vaccination  should  be  performed 
under  aseptic  precautions.  23.  It  is  not  sufficient  merely 
to  smear  the  virus  upon  the  scarified  areas.  It  must  be 
thoroughly  rubbed  or  scrat.;hed  or  pricked  in.  24  Vaccina- 
tion shields  often  do  more  harm  than  gcod.  25.  Cases  of 
infected  vaccination  ghoul  1  be  cared  for  by  the  physician 
and  not  by  the  mother.  26  Remembertbat  the  destruction 
of  the  vesicle  does  not  impair  the  protective  power  of  vacci- 
nation, and  in  signs  of  mixed  infection  appear,  open  the  ves- 
icle, cleanse  the  wound  andtre.it  it  upm  general  surgical 
princip'ej. 


Boston  Medical  and  Surgical  Journal. 

March  SS,  1901.    [Vol.  ciliv,  No.  13.] 

1.  The  Embrvological  Bisis  of  Pathology.    Charles  Skdq- 

WICK  MiSCT. 

2.  A   New   Method    of   Treatirg  Fractures.      Leonard    F. 

Hatch. 

1.— The  ovum  is  a  cell  every  part  of  the  protoplasm  of 
which  is  to  be  regarded  as  potentialli'  capable  of  producing 
any  or  all  of  the  tissues  of  the  adult.  Differentiation  in  cells 
resulting  from  the  segmentation  of  the  ovum  acts  as  a  pro- 
gressive restriction  of  further  development.  Each  successive 


APEIL6    1901] 


THE  LATEST  LITERATURE 


CThe  Philadkiphia 
Medical  Joobnaj. 


647 


etage  of  differentiation  puts  a  narrower  limitation  upon  the 
possibilities  of  further  advance.     Applied  to  pathology  this 
law  means  that  the  range  of  possible  pathologic  changes  is 
determined  not  merely  by  the  nature  or  kind,  but  also  by  the 
stage  or  degree  of  the  previous  differentiation  of  the  tissue. 
The  eggs  of  all  animals  pass  through  two  well  marked  phases 
of   development.    During    the  earlier  and    much    shorter 
phase,  the  nuclei  are  multiplying  rapidly,  while  the  cyto- 
plasm is  growing  but  little,  if  at  all.    During  the  second  and 
longer  period  of  development,  the  multiplication  of  nuclei 
lags  behind  the  growth  of  the  cytoplasm,  which  no  longer 
multiplies ;  the  increase  is  gradual   and  often  shows  itself 
through  successive  generations  of  cells.    Of  the  first  method 
of  protoplasmic  growth,  embryonic  bloodcells  offer  a  good 
illustration ;  of  the  second,  the  neuroblasts  or  young  nerve 
cells  afford  a  striking  example.    Now  cells  of  the  embryonic 
type  show  little  if  any  capacity  for  differentiation,  and  the 
increase  of  the  cytoplasm  ia  the  single  cell  is,  so  far  as  we 
can  judge,  a  necessary  preliminary  step  to  cell  differentia- 
tion.   Tne  embryonic  cells  have  yet  another  characteristic  of 
basal  significance ;    they    are    capable    of   rapid    multipli- 
cation. Hence,we  conclude,  that  the  growth  of  the  cytoplasm 
impedes  the  multiplication  of  cells,  and,  therefore,  ultimately 
retards  the  growth  of  the  body  as  a  whole,  while  on  the  other 
hand  it  favors  differentiation.  Accordingly,  the  growth  of  cells 
and  their  diflferentiation   are  essentially  antagonistic   pro- 
cesses, which  are  necessarily  more  or  lefs  mutually  exclu- 
sive.   We  should  conceive  of  differentiation  as  a  change  in 
the  intimate  and  eseential  structure  of  the  individual  cell, 
more  specifically  of  its  cytoplasm,  and  perhaps  of  its  nucleus 
also.    It  seems  probable  that  the  cells  of  the  germ  layers  are 
at  first  quite  indifferent,  so  that  if  it  were  possible  to  graft  a 
young  mesodermic  cell  on  to  the  ectcderm  or  entoderm,  it 
would  become  a  true  ectodermic  or  entodermic  cell.    Bat, 
in  the  embryo,  each  germ  layer  has  its  definite,  specific 
value.    It  is  more  than  probable  that  all  pathologic  tissues 
are  as  strictly  governed  by  the  law  of  the  specific  value  of 
germ  layers  as  are  the  normal  tissues.    There  are  2  distinct 
types  of  cell  difierentiation,  for  both  of  which  types  the 
starting  point  is  the  undifierentiated  embryonic  cell.    In  one 
tjpe  we  find  that  as  the  cells  proliferate  a  portion  of  them 
only  undergoes  differentiation  ;  and  another  portion  remains 
more  or  less  undifferentiated  and  retains  more  or  less  fully 
the  power  of  continued  proliferation.    The  second  type  is 
characterized  by  its  inclusion  of  all  the  cells.    Differentiation 
is  a  slowly  progressive  and  wholly  gradual  change  in  the 
cell,  and  we  must  look   upon  each  step  in  the  process  of 
differentiation  as  establishing    narrower  limits  for  future 
changes.    So  in  the  mesenchyma,  after  the  embryonic  cells 
have  changed  and  large  numbers  of  them  have  become  con- 
nective tissue  cells,  these  last  still  are  capable  of  various 
further  differentiation,  and  may,  therefore,  be  said  to  have 
been  arrested  in  their  development  at  a  stage  of  partial 
differentiation.    This  quality  of  the  connective  tissue  cells 
is,  from  the  pathologic  standpoint,  one  of  the  most  import- 
ant facts  known  to  us  concerning  the  structure  of  the  body. 
The  changes  that  succeed  differentiation  are  destructive  and 
fall  into  3  main  groups :  (1)  Changes  of  direct  cell-death  ;  (2) 
necrobiosis,  or  indirect  cell-death,  preceded  by  changes  in 
cell  structure;  and  (-3)  hypertrophic  degeneration,  or  indirect 
cell-death,  preceded  by  growth  and  structural  change  of  the 
cell.    Necrobiosis  and  hypertrophic  degeneration  are  normal 
processes  that  invariably  occur  in  the  normal  body  and  play, 
in  many  cases,  important  roles  in  the  life  history  of  the  in- 
dividual.   For  example,  the  thymus  and  the  fetal  kidney 
first  attain  their  full  differentiation;  their  elements  die  f  if 
during  the  next  phase,  and  finally  are  resorbed,  the  greater 
part  of  the  organ  disappearing.    In  the  same  category  of 
change  belong  the  histories  of  the  senile  ovary  and  testis. 
Oell-death  on  a  large  scale  is  a  common  phenomenon  of  the 
tissues.    Degeneration,  in  the  stricter  sense  of  an  antemortem 
hypertrophic  change  of  cell  structure,  is  also  of  widespread 
occurrence  in    the  healthy    body.    The  various   kinds    of 
changes  in  dying  cells,  with  which  the  pathologist  is  most 
familiar,  recur  in  healthy  tissues.    Granulation  of  the  bodies 
of  the  cartilage  cells  and  of  the  notochord  cells  may  be  ob- 
served to  precede  their  resorption.    Hyaline  transformation 
is  conspicuous  in  the  decidua  reflexa.    Imbibition  or  cellular 
edema  occurs  in  the  epidermis  of  the  lips,  in  the  cells  of  the 
uterine  glands  during  pregnancy,  after  they  have  detached 
themselves  from  the  gland  walls,  and  in  the  endothelium 


of  the  placental  bloodvessels  of  the  rabbit.    Desiccation  is 
the  usual  accompaniment  of  cornification.    Plasmatosis  is 
seen  in  the  cells  of  the  secreting  milk  gland,  and  also,  as  an 
unpublished  research  of  Minot's  indicates,  to  the  cells  of  the 
secreting  glands  of  the  cervix  uteri.    Karyolysis  is,  according 
to  present  probabilities,  the  method  by  which  nucleated  red 
bloodcells  are  converted  into  nonnucleated  blood- corpuscles. 
Karyorhexis,  or  the  fragmentation  of  the  nucleus,  occurs  in 
the  cells  of  the  disappearing  follicles  of  the  ovary.    The 
sloughing  off  of  cells  is  one  of  the  most  familiar  phenomena. 
On  the  other  hand,  cells  without  access  to  the  external  world 
must  be  got  rid  of  by  resorption,  which  seems  to  take  place 
either  with  or  without  the  cooperation  of  leukocytes.    In  the 
latter  case  we  must,  for  lack  of  a  better  hypothesis,  attribute 
the  resorption  to  chemical  means.    Tne  author  proposes  the 
new  term,  "cytomorphosis,"  to  designate  comprehensively 
all  the  structural  alterations  which  cells,  or  successive  genera- 
tions of  cells,  may  undergo  from  the  earliest  undifferentiated 
stage  to  their  final  destruction.    This  review  of  normal  eni- 
bryologic  conditions  furnishes  us  with  3  general  concep- 
tions that  are  valuable  for  their  pathologic  applications, 
namely :  (1)  That  each  germ  layer  has  a  specific  and  exclu- 
sive share  in  the  production  of  tissues;  (2)  that  undifferen- 
tiated cells,  characterized  by  having  only  a  small  amount  of 
unspecialized  protoplasm,  exist  not  only  in  the  embryo,  but 
also  throughout  life  in  certain  parts  of  all  3  germ  layers ;  and 
(3)  that  differentiated  cells,  characterized  by  having  a  larger 
amount  of  specialized  protoplasm,  form  most  of  the  organs  of 
the  adult,  and  are  incapable  of  undergoing  any  new  unUke 
differentiation,  though  they  are  still  capable  of  completing 
their  cytomorphosis,  by  necrobiosis  or  degeneration.    We 
must  apply  these  conceptions  as  rigidly  to  pathologic  as  to 
normal  development.    From  this  viewpoint  epitheliotnata 
should  be  studied  in  relation  to  their  layership,  and  it  is 
reasonable  to  expect  that  they  will  be  found  to  have  very 
distinctive  characteristics,  according  to  the  germ  layer  from 
which  they  take  origin,  for  the  layership  of  a  tissue  governs 
the  normal   differentiation    and    probably,    therefore,    the 
abnormal  also.    The  author  especially  urges  the  study  of 
the   layership  of  the  various  carcinomata.    Can  we  safely 
assume  that  there  is  only  one  kind  of  carcinoma?    May  it 
not  well  be  that  ectodermal,  mesothelial  and  entodermal 
carcinomata  are  separate  kinds '?    Undifferentiated  cells  have 
the  power  of  multiplication  in  a  high  degree,  and  they  have 
the  possib'lities  of  increasing  their  size  and  of  undergoing 
further  differentiation,  acd  their  occurrence  in  the  adult  is 
of  the  utmost  pathologic  significince.    Such  cells  exist  in  4 
important  parts  :  (1)  In  the  basal  layer  of  the  epidermis  and 
in  corresponding  portions  of   the  epidermal  appendages; 
(2)  in  the  adult  mesenchyma  or  connective  tissue;  (3)  in 
many  parts  of  the  adult  mesothelium,  especially  of   the 
epithelia  of  the  genitourinary  tracts;  and  (4)  in  the  ento- 
dermal epithelium  of  the  gastrointestinal  tract.    It  is  signi- 
ficant that  it  is  precisely  from  these  parts  that  the  develop- 
ment of  many  rapidly  growing  tumors  takes  place,  and  it  is 
further  significant  that  the  least  differentiated  or  specialized 
of  all,  namely,  the  mesenchymal  cells,  are  the  ones  that  pro- 
duce the  greatest  variety  of  tumors.    The  mesenchyma  still 
exhibits,  by  the  formation  of  its  characteristic  tumors  in 
the  adult,  its  embryonic  capacity  to  transform  itself  in  varied 
ways.  Minot  would,  from  the  enchyologic  standpoint,  classify 
new  formations  into  two  msia  groups  :  (1)  Those  with  marked 
cytomorphosis,  or  change  in  cell  structure,  as,  for  exf  mple, 
myoma,  lipoma,  and   chondroma ;  and  (2)  those  without 
cytomorphosis,  the  cells  of  the  new  growth  resembling  those 
of  the  parent  tissue,  as,  for  example,  angioma  and  glioma. 
Members  of  the  first  group  have  been  termed  heteroplastic ; 
members  of  the  second  group  have  been  termed  home  plastic. 
Accepting  these  terms,  we  may  say  that  tumors  are  either 
heteroplastic   or  homoplastic.    It  is  probable  that  highly 
differentiated  cells,  such  as  the  nerve  cells  or  the  neurons, 
the  liver  cells,  and  the  striated  muscles,  cannot  produce 
tumors.    The  author  concludes  (1)  that  pathologic  differ- 
entiation in  its  essential  features  is  identical  with  the  process 
of  normal  differentiation  ;  (2)  that  the  character  of  a  tumor 
depends  primarily  upon  the  layership  of  the  cells  prcducing 
it;  (3)  that  normal  differentiation  impedes  and  limits  the 
formation  of  tumors,  precisely  as  it  does  of  further  normal 
structures,  so  that  tumors  arise  most  readily  from  ucdiffer- 
entiated  tissues  and  may  then  be  heteroplastic;   arise  less 
readily  from  differentiated  tissues  and  are  then  always  homo- 


648 


The  Philadelphia 
Medical  Journal 


] 


THE  LATEST  LITERATURE 


(Apbil  6,  tMf 


plastic ;  and  arise  unreadily  or  not  at  all  from  the  most 
highly  specialized  tissues.  Probably  all  pathologic  necrobiosis 
and  degeneration  of  cells  are  essentially  identical  with  normal 
processes  and  are  pathologic,  owing  to  the  abnormality  of 
their  occurrence  in  time  and  site,    [j.m  s  ] 

<4. — Hatch  reports  a  new  method  for  the  treatment 
of  fractures,  ba«ei  on  modern  surgery.  The  principle  is 
to  convert  all  compound  fractures  into  simple  one?,  and  to 
operate  on  simple  fractures,  making  them  compound,  and 
then  make  them  simple.  Tne  techcic  of  the  operation  U  the 
same  for  simple  and  compound  fractures,  with  this  exception, 
that  in  simple  fracture  there  is  a  point  of  selection  for  the 
incision,  while  in  a  compound  fracture  the  wound  is  simply 
enlarged.  There  must  be  the  most  perfect  antiseptic  prep- 
aration. The  site  of  operation  must  be  shaved  and  then 
scrubbed  thoroughly  with  soap  and  water,  bichlorid  solution, 
and  permanganate  and  oxalic  acid  solutions ;  all  other  parts 
of  the  patient  must  be  carefully  covered  with  sterile  sheets 
and  towels.  Hold  the  extremity  in  a  vertical  position  for  a 
few  minutes,  then  apply  a  rubber  constrictor.  Fit  a  sterile 
posterior  and  anterior  splint  of  any  suitahle  material.  The 
points  of  selection  for  incision  are  for  the  tibia  along  the 
crest,  for  the  femur  along  the  outer  side  of  the  thigh,  for  the 
radius  behind  the  supinator  longus,  for  the  ulna  along  the 
ulnar  side  of  the  arm  where  the  bone  is  most  superficial,  for 
the  humerus  along  the  outer  side  of  the  arm.  A  good  free 
incision  should  be  made,  as  it  is  important  to  have  plenty  of 
room,  and  the  size  of  the  incision  does  not  complicate  the 
case.  Wash  out  thoroughly  all  clots  and  debris,  removing 
all  shreds  of  soft  tissue  and  loose  pieces  of  bone.  If  any 
sharp  points  of  bone  prevent  perfect  coaptation  remove 
them.  Remove  rubber  band.  Tie  all  bleeding  points,  and 
be  sure  that  the  wound  is  dry.  If  in  a  case  of  a  compound 
fracture  the  periosteum  is  stripped  up,  carefully  replace  it. 
Secure  perfect  coaptation.  Apply  one  of  the  splints  bofore 
closing  the  wound,  to  make  sure  of  holding  the  fragments  in 
place.  Close  the  wound  with  catgut  sutures  without  drain- 
age, and  lay  a  thin  pad  of  iodoform  gauze  over  the  wound  ; 
apply  the  second  splint  and  bandage  quite  firmly,  as  there 
will  not  be  any  swelling  like  that  which  occurs  after  a  frac- 
ture treated  in  the  usual  manner.  Remove  dressings  on  the 
seventh  or  eighth  day  and  apply  plaster  cast  or  ambulatory 
splint,  according  to  the  requirements  of  the  case.  With  this 
method  it  is  safe  to  discontinue  splints  at  least  one  week 
earlier  than  in  fractures  treated  by  former  methods.  With 
the  advance  made  in  modern  surgery,  where  we  do  not  hesi- 
tate to  enter  the  abdominal  or  cranial  cavities,  in  some  cases 
even,  simply  to  establish  a  diagnosis,  we  surely  should  not  be 
deterred  from  operating  on  fractures  by  fear  of  sepsis,  and  it 
certainly  is  unscientific  to  adopt  a  blind  way  when  a  better 
presents.  The  method  would  be  warranted  if  it  did  nothing 
more  than  to  relieve  the  pain  and  swelling,  which  i".  ceriaialy 
does.  It  shortens  the  repair  process  at  least  one  week.  It 
reduces  the  chances  of  deformity  and  nonunion  to  a 
minimum,     [j  M.S.] 


Journal  of  the  American  Medical  Association, 

March  SO,  1901.   [Vol.  xxvi.  No.  13  ] 

1.  Recent  Advances  in  Dermatology  which  are  of  Service  to 

the  General  Practitioner.    L  Di'Ncas  Bulkley. 

2.  Hyperacidity  a  Came    of  Skin   Disease.     W.  R.  Inge 

Dalton. 

3.  Acute    Suppurative  Folliculitis   of  the  Scalp.    Wm.  S. 

GOTTHEIL. 

4.  Operations  for  Injuries  to  the  Median  and  Ulnar  Nerves. 

R.  Brindley  Eads. 

5.  Patbologicil    Conditions    Found    in    Meat    Injpec'ion. 

D  E  Salmon. 

6.  The  Treatment  of  Prolapse  of  the  R>ctum.    Joseph  M. 

Mathews 

7.  Sinitary  Conditions  of  Peking.    John  Inglis. 

8.  Thyroid  Tissue  in  the  Larynx  and  Trachea.    Otto  T. 

Feeek. 

9.  Open  Treatment    of  Suppuration    of  the    Knee-Joint. 

W.  J.  Mayo. 
10   Qjantitative  Tests  for  Proteolysis.    A.  L.  Benedict. 

11.  Tne  R'ge  of  Rapid  Operating  and  the  Importance  of 

Saving  Time  in  Surgical  Op=!ration8.    John  S.  Miller. 

12.  Venereal  Disease  as  a  Social  Problem.    W.  C  Gates 


13.  Circumcision  in  Restricting  the  Spread  of  Syphilis.  How- 

ard N.  MOYER. 

14.  Report  of  Special  Committee  of  the  Section  on  State  Medi- 

cine of  the  American  Medical  Association,  Appointed 
to  Inquire  Whether  and  When  the  Gonorrheic  majr 
be  Permitted  to  Marry,  and  Whether  the  Matter  is  a 
Proper  one  f  jr  Regulation  by  Statute. 

15.  Purulent  Otitis :   Its  Treatment  and  Prevention  by  the 

Family  Physician.    H.  Geadle. 

1. — Bulkley  reviews  the  important  recent  advances  in 
dermatology  which  are  of  service  to  the  general  practitioner 
from  the  standpoint  of  diagnosis,  pathology  and  therapeutics. 

[FJK.] 

2. — Dalton  holds  that  hyperacidity  of  the  contents 

of  the  duodenum,  due  to  the  hyperacid  condition  of  the 
stomach,  produces  derangement  of  physiologic  metabolism, 
and  is  the  starting-point  of  nearly  all  the  diseases  of  the  skin, 
except  the  contagious  exinthemata.     [f  j.k.] 

3. — Gottheil  reports  two  cases  of  acute  suppurative 
folliculitis  of  the  scalp.  Oae  of  the  cases  is  described 
in  detail ;  this  case  terminated  in  reiovery  and  the  affected 
parts  returned  to  a  normal  condition.  The  author  does  not 
venture  to  explain  the  causes  which  give  rise  to  this  acute 
suppurativa  process. 

4. — Eads  reports  a  number  of  operitions  for  injuries  to 
the  median  and  ulnar  nerves  with  a  good  resul:  in  each 
cafe.  For  nerve  suture  Eids  prefers  silk  rather  than  citgut, 
or  eli-e  chromicized  ca'gut.  In  suturing  a  nerve  care  should 
be  taken  that  it  is  so  placed  as  n3t  to  be  caught  and  pressed 
upon  by  cicatrices,     [j  h  g  ] 

5.— Silmon  gives  adetailed  accountof  the  pathological 
conditions  found  in  meat  inspection.  He  mentions 
the  various  statistics  in  reference  to  the  number  of  carcasses 
thit  were  condemned  and  the  reasons  for  such  action.  Refer- 
ence is  made  in  regard  to  the  limitations  of  authority  of  the 
inspectors.  Finally,  he  emphasizes  the  fact  that  no  public 
work  can  be  carried  to  the  highest  degree  of  etficiency  un- 
less its  object  and  value  are  understood  by  the  people  of  the 
countrj-.    [f  J  k.] 

6. — Mathews  describes  a  very  severe  case  of  prolapse  of 
the  rectum  in  an  adult,  in  which  he  obtained  an  excellent 
result  aftsr  opening  the  abdomen  and  sut  iring  the  bowel  to 
the  abdominal  wall.  When  he  performed  t'lis  operation  he 
was  not  aware  t'lat  it  had  ever  been  don  3  by  any  other 
surgeon.  He  thinks  that  colopecia  in  case  of  prolapse  of 
the  rectum  of  the  second  or  third  degree  is  preferable  to 
other  methods  of  operation  for  this  condition,  and  that  it  is 
accompanied  by  less  danger.  In  suturing  the  bowel  to  the 
abiominal  wall  he  prefers  a  continuous  suture,    [j.h.g  ] 

7. — Inglis  writes  upon  the  sanitary  conditions  of 
Peking,  aid  concludes  by  saying  that  before  China  is 
admitted  to  the  society  of  enlightened  nationi,  she  should 
make  her  capital  less  danger  jus  a?  a  pla^e  of  resideace,  by 
instituting  proper  sanitary  measures,  thereby  checking  the 
prevalence  of  those  diseases  which  are  due  to  the  products 
of  filth,     [f  J.K.] 

8.— I  a  an  article  on  thyroid  tissue  in  the  larynx  and 
trachea.  Freer  gives  an  account  of  the  symptons  of  the 
condition,  the  theories  regarding  the  entrance  of  a  thyroid 
tissue  into  the  larynx  and  trachea,  the  prognceis,  the  diag- 
nosis and  the  treatment.  In  the  article  is  included  a  report 
of  a  cas9,  and  mention  is  also  made  that  nine  other  cases 
have  previously  been  recorded. 

9. — Mayo  strongly  urges  the  open  treatment  for  severe 
suppurations  involving  the  knee  joint,  maintaining  that 
he  has  see  a  limbs  saved  by  this  method  of  treatmen'.  where 
amputation  was  thought  to  be  necessary  in  order  to  save  life. 
Tne  incision  extends  across  the  front  of  the  knee  joint  and 
gives  most  satisfactory  drainage.  Ankylosis  nearly  always 
follows,     [j  H  G.] 

10. — Benedict  discusses  the  quanta'ive  test  for  proteolysis, 
and  formulates  the  following  conclusions  (so  far  as  the  test 
breakfast  is  concerned,  the  stomach  being  evacuated  after  60 
and  90  minutes) :  1.  In  individuals  who  are  normal,  the 
pr.iportions  of  the  three  stipes  of  proteids  do  not  vary 
materially  during  the  third  half-hour  of  digestion,  nor  accord- 
ing to  moderate  variations  in  other  respects.  '2  A  mere 
trace  of  syntonin,  not  exceeding  j'/j  cc.  in  10  cc.  of  filtered 
chyme,  is'  most  typically  represented.  8.  Albumoee  (by 
ammonium  sulphate)  is  most  typically  represented  by  5>j% 


Apkil  6,  1901) 


THE  LATEST  LITERATURE 


["Thb  Philadblphia 
L  Medical  Journal 


649 


cc.  in  10  cc.  4.  Most  typically  peptone  is  represented  by  }j§ 
to  f§g  cc.  in  10  cc,  but  there  may  be  variation  between 
m  and  ??§.     [F.J.K.J 

14. — Tuckerman  submits  a  "  Report  of  the  Special  Com- 
mittee of  the  Section  on  State  Medicine,  of  the  American 
Medical  Association,  appointed  to  inquire  whether  and  when 
the  gonorrheic  may  be  permitted  to  marry,  and  whether  the 
matter  is  a  proper  one  for  regulation  by  statute."  Various 
questions  pertaining  to  this  subject  were  submitted  to 
prominent  gynecologists  and  genitourinary  specialists.  Their 
answers  are  given  in  tne  report ;  no  final  conclusions  are, 
however,  drawn,    [f.j.k.] 

16.— Gradle  urges  the  importance  upon  the  general  prac- 
titioner of  early  incision  of  the  drum  in  purulent  otitis.  He 
condemns  most  strongly  the  use  of  the  popular  remedy  for 
earache,  such  as  opium  and  sweet  oil  and  camphorated  oil. 
The  only  local  application  which  can  be  of  any  service  is  a 
10  to  12^  solution  of  carbolic  acid  in  glycerin,  and  opium 
internally  is  the  only  remedy  which  will  control  the  pain. 
Tae  improper  use  of  the  nasal  douche  Gradle  thinks  is  a 
prevalent  cause  of  otitis,     [j.h.g.] 


Journal  of  Experimental  Medicine. 

January  15, 1901.    [Vol.  v.  No.  3.] 

1.  The  Superficial  Glands  of  the  Esophagus.   Albion  Walter 

Hewlett. 

2.  False  Diverticula  of  the  Intestine.    Martin  H.  Fischer. 

3.  Some   Theoretical  Considerations   Upon  the   Nature  of 

Agglutinins  Together  with  Further  Observations  upon 
Bacillus  typhi  abdomiaalis,  Bacillus  enteritidis,  Bacil- 
lus coli  communis.  Bacillus  lactis  aerogenes,  and  some 
other  Bacilli  of  Allied  Character.  Herbert  E.  Dor- 
ham. 

4.  Report  of  a    Laboratory  Epizootic  among    Guineapigs, 

Associated  with  Gaseous  Emphysema  of  the  Liver, 
Spleen,  and  Kidneys,  due  to  Bacillus  mucosus  capsu- 
latus.    R.  G.  Perkins. 

5.  On  the  Relation  of  Chronic  Interstitial  Pancreatitis  to  the 

Islands  of  Langerhans  and  to  Diabetes  Mellitus. 
Eugene  L.  Opie. 

1, — The  esophageal  glands,  which  have  long  been  known, 
are  situated  in  the  submucous  tissue  of  the  esophagus. 
Hewlett  describes  a  second  group  of  glands  situated  entirely 
within  the  mucous  membrane  of  the  esopliagus,  above 
the  muscularis  mucosae,  which  were  originally  described  by 
Kiidinger,  in  1879.  These  glands  are  of  the  tuberacemose 
type  and  are  found  in  small  circumscribed  areas  in  the  upper 
third  and  the  lower  third  of  the  tube.  They  produce  oval 
defects  in  the  mucous  membrane  that  may  readily  be  mis- 
taken for  ulcers.  The  superficial  glands  present  many 
cyst-like  dilations.  The  acini  are  lined  by  low  columnar  cells 
and  by  cells  that  are  identical  with  the  parietal  cells  in  the 
cardiac  glands  of  the  stomach.  The  morphologic  significance 
of  the  glands  is  not  clear.  The  pathologic  relations  of  the 
glands  are  of  interest  on  account  of  the  possibility  that  they 
may  act  as  a  nidus  for  the  development  of  a  pulsion  diverticu- 
lum of  the  esophagus.  They  may  be  a  source  of  origin  of 
esophageal  cysts  and  they  may  give  rise  to  carcinomata. 

[j.M.S.] 

2. — A  false  diverticulum  of  the  intestines   is  a 

hernia  of  the  mucosa  and  submucoja  through  the  muscular 
wall  so  that  the  wall  of  the  pouch  is  formed  of  the  two  layers 
forming  the  protrusion  covered  by  the  serous  coat  of  the 
bowel.  Fischer  describes  a  case  of  single  diverticulum  of 
the  jejunum;  a  case  of  multiple  diverticula  of  the  ileum  ;  a 
case  of  diverticula  of  the  rectum,  omega  loop,  and  descend- 
ing colon,  and  a  case  of  diverticulum  of  the  appendix.  These 
diverticula  are  usually  found  in  the  position  of  a  dilated 
bloodvessel  and  extend  in  the  course  of  this  bloodvessel  either 
between  the  layers  of  the  mesentery  or  on  one  side  of  that 
structure.  The  force  producing  the  outpouching  of  the 
mucous  membrane  apparently  comes  from  within  tde  bowel 
and,  as  the  hernia  passes  through  the  muscular  coat,  that 
tissue  is  broken  and  then  crowded  to  either  side.  Doubtless 
the  chronic  passive  congestion  of  the  viscera  due  to  hyper- 
trophy and  dilation  of  the  heart  and  arteriosclerosis  is  an  im- 
portant factor  in  the  causation  of  the  diverticula.  The  walls 
of  the  diverticula  often  present  inflammatory  changes.    The 


diverticulum  of  the  appendix  described  in  the  paper  occurred 
on  the  side  opposite  to  the  mesoappendix.  Its  wall  was  com- 
posed of  serosa  only,  so  that  it  is  possible  that  the  condition 
was  originally  one  of  true  diverticulum  produced  by  traction 
of  an  old  adhesion  and  that  the  accumulation  and  stagnation 
of  feces  in  the  pouch  caused  pressure  atrophy  of  the  mucosa 
and  muscularis  in  the  wall  of  the  sac.    [j.m.s.] 

3. — Further  experience  with  the  differential  actions  of 
serums  of  treated  animals  leads  Durham  to  confirm  the  con- 
clusion that,  so  far  as  bacteriolytic  and  agglutinating  actions 
are  concerned,  the  word  specific  is  inapplicable  and  special 
would  be  a  better  term  to  employ.  It  has  been  found  that 
the  serum  reactions  are  not  uniform  within  the  species  vib- 
rio cholerae  asiaticae.  From  this  and  other  observations  it 
would  seem  as  though  the  serum  test  could  not  be  considered 
a  final  criterion  for  the  diagnosis  of  species.  The  author's 
experience  is  contrary  to  that  of  Baumgarten  concerning 
the  power  of  the  serum  of  rabbits  to  agglutinate  colon  bacilli. 
He  attributes  Baumgarten's  results  to  the  fact  that  cultures 
in  broth  made  with  muscle  sugar  were  used.  Such  broths 
when  mixed  with  fresh  broth  or  serum  may  give  precipita- 
tion of  proteid  matters  that  produce  an  apparent  agglutina- 
tion. The  author  believes  that  the  bacillary  agglutination 
process  is  not  due  purely  to  an  entanglement  of  the  bacilli 
in  coagula  formed  in  the  free  fluid.  The  microscopic  obser- 
vation of  bacilli  mixed  with  very  dilute  special  sera  is  most 
suggestive  of  some  alteration  of  the  surfaces  of  the  bacilli  in 
the  direction  of  increased  stickiness.  It  may  be  that 
this  surface  alteration  is  due  to  a  precipitation  or  more  or 
less  nascent  precipitation  upon  the  surfaces  of  the  individual 
susceptible  bacilli;  such  bacilli  as  are  secreting  more  of 
appropriate  substances  will  be  more  susceptible  to  the  action 
of  the  serum  and  become  more  profoundly  aSected.  It  is 
always  a  striking  phenomenon  that  all  the  bacilli  are  not 
equally  influenced  in  a  given  dilute  mixture.  In  order  to 
explain  the  perplexing  partial  and  mutual  reactions  of  agglu- 
tinating sera  upon  different  races  or  t roups  of  bacteria,  the 
author  supposes  that  a  given  ag'glutinin  is  not  a  single 
substance,  but  a  complex  one,  while  the  bacillary  compo- 
nents that  are  capable  of  giving  rise  to  the  formation  of 
agglutinins  are  also  variable  and  not  produced  in  the  same 
amount  in  all  species  or  in  all  races.  It  is  possible  that  the 
agglutinin  producing  substances  and  the  agglutinin  overlap 
in  organisms,  such  as  bacillus  typhosus  and  bacillus  enteri- 
tidis. Moreover,  any  given  race  does  not  necessarily  pro- 
duce the  same  quantities  of  the  different  constituents  at 
different  times,  and  hence  the  variations  of  agglutinabil- 
ity,  virulence,  etc.  It  is  further  supposed  that  the  bacteri- 
olytic, inhibitory,  and  protective  or  preventive  substances 
have  a  similarly  complex  constitution,  the  amount  of 
each  unit  being  to  some  degree  independent  of  the 
others,  although  all  the  substances  tend  to  be  grouped 
together  more  or  less  dependently.  From  numerous  ex- 
periments, it  seems  that  the  most  satisfactory  method 
of  producing  clumping  sera  is  to  give  considerable  quantities 
of  killed  bacilli  by  the  intraperitoneal  route.  It  is  possible 
to  get  moderate  potency  by  giving  sterile  filtrates  of  cultures 
and  to  induce  some  power  by  giving  killed  cultures  by  the 
mouth.  These  facts  seem  further  evidence  that  agglutina- 
tion is  no  reaction  of  infection.  Agar  cultures  should  be 
used  because  broth  is  unsuitable  on  account  of  the  precipi- 
tation of  the  peptone  from  the  broth  by  the  serum  of  ttie 
animals,  as  shown  by  Myers.  The  effect  of  a  given  injection 
probably  reaches  its  height,  when  killed  bacilli  are  given,  in 
about  10  days  or  2  weeks.  The  author  concludes  that  the 
clumping'  reaction  is  of  little  value  for  differen- 
tiating and  classifying  these  bacilli  in  a  satisfactory 
manner.  It  appears  that  we  can  only  find  whether  the 
products  of  bacilli  that  are  capable  of  giving  rise  to  agglu- 
tinins are  the  same  in  2  or  more  cases.  Even  then, 
although  these  may  be  the  same  substances  qualitatively, 
these  may  not  necessarily  be  present  quantitatively  to  the 
same  extent.  Again,  by  taking  the  same  race  of  bacilli  and 
its  own  serum,  we  find  that  the  susceptibility  of  cultures 
made  at  different  times  is  not  necessarily  the  same.  A 
classification  of  the  types  that  have  been  studied  follows, 
with  a  consideration  of  the  ordinary  characteristics,  and  an 
account  of  the  media  that  may  be  useful  for  further  work. 
[j.m.s.] 

4. — Perkins  describes  an  epidemic  of  epizootic  that 
occurred  among  his  laboratory  guineapigs.    The  fatal  cases 


650 


The  Philadelphia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[APEIL  C,  1901 


terminated  with  coma  and  muscular  twitchings  in  from  12 
to  48  hours  after  the  onset  of  the  disease.  Two  animals  re- 
covered after  infection.  Among  the  fatal  cases  65%  pre- 
sented a  well-marked  peritonitis  of  the  seropurulent  type. 
The  liver  in  every  case  showed  marked  congestion  and  cloudy 
swelling,  and  in  60%  there  was  a  general  gaeeous  empliy- 
senia  of  the  organ.  In  39%  of  the  animals  a  similar  condi- 
tion of  the  spleen  was  associated  with  the  empbysema 
of  the  liver  ;  while  the  spleen  was  markedly  congested  in 
all  cases.  The  kidneys  and  the  adrenals  showed  congestion 
and  cloudy  swelling  only.  The  gastrointestinal  tract  con- 
tained gas,  but  no  lesion  could  be  demonstrated.  With  two 
exceptions  each  autopsy  gave  pure  cultures  of  a  pleomorphic 
non-motile  organism,  most  frequently  occurring  in  the  form 
of  a  short  bacillus  with  rounded  ends.  There  was  no  cap- 
sule. The  organism  stained  readily  with  the  aniline  dyes, 
and  decolorized  rapidly  with  Gram's  stain.  The  organism 
was  not  like  the  bacillus  areogenes  capsulatus,  although  it  un- 
doubtedly belongs  in  the  bacillus  luucosus  capsalatus 
group.  The  2  animals  that  recovered  possessed  a  high  degree 
of  immunity  to  the  organism  causing  the  disease,     [j.m.s.] 

5. — Opie  has  studied  17  cases  of  pancreatitis.  In  con- 
genital syphilitic  pancreatitis  he  finds  that  the  development 
of  the  glandular  acini  is  retarded  but  that  the  islands  of 
Langerhans  are  not  affected.  These  bodies  are  embedded  in 
the  stroma,  but  they  are  not  invaded  by  it  and  they  maintain 
their  continuity  with  the  small  ducts  and  acini  with  which 
they  have  a  common  origin.  There  are  two  types  of  chronic 
interstitial  inflammation  :  (1)  Interlobular  pancreatitis  and 
(2)  interacinar  pancreatitis.  In  the  interlobular  variety  the 
inflammatory  process  is  localized  chiefly  at  the  periphery  of 
the  lobule  and  implicates  the  islands  of  Langerhans  only 
when  the  sclerotic  process  has  reached  a  very  advanced 
grade.  When  pancreatitis  has  followed  obstruction  of  the 
ducts,  the  islands  remain  unaltered  for  a  long  time,  although 
they  are  embedded  in  dense  scar-like  tissue.  In  tbe  inter- 
acinar type  the  process  is  difl'use,  invading  the  lobulea  and 
separating  individual  acini.  The  inflammatory  change  in- 
vades the  islands  of  Langerhans.  The  author  has  observed 
a  relationship  between  the  lesions  of  the  islands  of  Langer- 
hans and  the  occurrence  of  diabetes  mellitus.  In  one  of  11 
cases  of  interlobular  pancreatitis,  diabetes  of  mild  intensity 
occurred.  The  sclerosis,  which  in  this  case  followed  obstruc- 
tion of  the  ducts  by  calculi,  was  far  advanced  and  afiected 
the  islands  of  Langerhans.  In  2  of  3  cases  of  interacinar 
pancreatitis,  diabetes  was  present.  The  third  case  was  asso- 
ciated with  hemochromatosis,  which  at  a  later  stage  is 
associated  with  diabetes,  the  result  of  pancreatic  lesion.  In 
a  fourth  case  of  diabetes,  hyaline  deposit  betwen  the  capil- 
laries and  the  parenchymatous  cells  had  so  completely 
altered  the  islands  of  Langerhans  that  they  were  no  longer 
recognizable,    [j.m  s.] 


American  Journal  of  Medical  Sciences. 

February,  1901. 

1.  A  Clinical  Study  of  Diphtheria.  Fred  Grant  Burrows. 

2.  Observations  on  the  Character  of  the  Cells  in  the  Exuda- 

tion in  Acute  Interstitial  Nephritis,  with  Special  Ref- 
erence to  the  Presence  of  Cells  with  Eosinophilic 
Granulations.    W.  T.  Howard,  Jr. 

3.  Rare  Cardiac  Anomalies.    Ludvig  Hektoen. 

4.  Report  of  a  Case  of  Blastomycetic  Dermatitis. 

5.  Refractory  Syphilis,  with  Report  of  a  Ciise  Utterly  Resist- 

ant to  Specific  Treatment.    Jay  F.  Schamberg. 

6.  Physiological  Dilation  and  the  Mitral  Sphincter  as  Factors 

in  Functional  and  Organic  Disturbances  of  the  Heart. 
Morton  Prince. 

1. — Burrows,  during  his  service  in  the  department  for  con- 
tagious diseases  in  the  Boston  City  Hospital  collected  records 
of  2,093  cases  of  diphtheria,  all  of  which  were  treated 
by  antitoxin.  From  these  records  he  has  attempted  to 
give  a  clinical  picture  of  the  disease  as  it  has  been  modified 
by  the  antitoxin  treatment.  There  were  slightly  more  females 
than  males.  The  death-rate  decreased  with  the  age  of  the 
patient,  being  14%  of  all  patients  under  15,  and  2  85^  of 
patients  above  that  age.  The  greatest  proportion  of  deaths, 
87  ^ ,  occurred  in  the  first  two  years  ;  and  only  2  occurred  in 
the  127  patients  over  30  years  of  age.    As,  however,  69  pa- 


tients were  moribund  when  admitted,  and  died  within  24 
hours,  the  true  death-rate  of  the  disease  when  properly 
treated  was  not  over  9%.  An  interesting  factor  was  the 
variability  in  the  cases  grouped  by  hundreds  according  to  the 
order  of  admission.  The  death-rate  under  theee  circum- 
stances varied  from  5  to  19%,  showing  the  extreme  inaccuracy 
of  statistics  based  upon  small  numbers  of  cases.  In  the 
great  majority  of  cases  the  membrane  showed  the  ordinary 
distribution  upon  both  tonsils.  In  71  there  was  diphtheritic 
membrane  in  the  tonsils,  and  in  a  number  of  others  a  dis- 
charge which  suggested  nasal  infection.  Cultures  were 
always  taken  from  the  throat  and  nose.  They  were  positive 
from  both  nose  and  throat  in  632  cases.  From  the  nose  159, 
and  from  the  throat  954.  In  228  cases  of  undoubted  diph- 
theria the  cultures  were  negative.  The  other  organs  showed 
the  following  alterations  in  the  course  of  the  disease.  The 
heart  frequently  developed  a  soft  systolic  murmur, 
usually  most  distinct  over  the  mitral  area,  but  occa- 
sionally heard  loudest  at  the  base.  Irregularity  waa 
common,  and  in  a  considerable  proportion  of  cases  both 
irregularity  and  murmurs  developed.  Cardiac  lesions  were 
usually  present  when  the  patient  entered  the  hospital,  but 
sometimes  did  not  develop  for  several  days.  One-half  of  the 
cases  gave  murmurs,  and  one-third  irregularity.  There  waa 
usually  tachycardia,  the  pulse  ranging  from  100  to  200.  The 
proportion  of  deaths  was  very  much  increased  when  the 
maximum  pulse  exceeded  170.  Albuminuria  was  exceed- 
ingly rare,  and  this  is,  perhaps,  the  most  significant  result  of 
the  antitoxin  treatment.  The  albumin  never  exceeded  \  of 
1  %  by  weight,  and  in  considerably  more  than  half  of  the 
cases  was  not  found.  Three  hundred  and  thirty-seven  of  the 
1962  cases  had  symptoms  of  laryngeal  stenosis ;  213  of  theee 
required  intubation ;  and  96  died,  37  being  moribund  when 
admitted.  Three  cases  subsequently  requiring  tracheotomy, 
and  all  died.  Two  required  tracheotomy,  and  recovered.  It 
is  interesting  to  note  that  in  both  the  cases  of  tracheotomy 
that  recovered  the  constriction  was  due  not  to  membrane, 
but  to  peritracheal  abscesses.  Burrows  believes  that  primary 
tracheotomy  is  no  longer  required  in  diphtheria.  Among 
the  other  complications  were  vomiting,  middle  ear  disease, 
suppuration  of  the  cervical  glands,  and  the  post-diphtheritic 
paralyses.  These,  however,  were  not  especially  common, 
occurring  in  only  102  cases.  The  majority  of  them  occurred 
during  the  acute  stage  of  the  disease,  and  many  were  due  to 
mixed  infection.  The  most  striking  portion  of  the  paper  is 
the  brief  section  devoted  to  treatment.  Burrows  and  his  col- 
leagues have  reached  the  conclusion,  as  the  result  of  their  ex- 
tended experience,  that  the  antitoxin  is  not  under  any  circum- 
stances injurious,  and  should  be  given  until  the  symptoms  are 
relieved.  The  routine  treatment,  therefore,  consisted  in  the 
administration  of  4,000  units  every  4  hours,  or  in  severe  cases, 
every  2  hours.  He  believes  that  by  this  vigorous  adminis- 
tration, cases  apparently  moribund  have  been  saved.  He 
mentions  in  particular  patients  that  received  from  40,000  to 
110,000  units  in  the  course  of  the  disease.  Comparing  the 
statistics  in  the  hospital  before  and  after  the  introduction  of 
the  antitoxin  treatment,  he  believes  that  the  death-rate  has 
been  lowered  33%.  The  other  therapeutic  points  are  the 
use  of  alcohol,  feeding  intubated  patients  through  the  eso- 
phageal tube,  and  rectal  feeding  when  the  vomiting  waa 
annoying.     [J.s.] 

2.  —  Howard  examined  3  cases  of  acute  intestitial 
nephritis.  One  wjis  a  case  of  general  streptococcus  infec- 
tion, the  other  2  without  demonstrable  microorganisms  in  the 
kidneys,  although  in  one  of  these  a  large  number  of  strepto- 
cocci were  found  in  the  other  organs.  The  interesting  features 
were  the  discovery  of  plasma  cells,  lymphocytes,  and  poly- 
morphonuclear leukocytes  in  the  tissues  and'  in  the  dilated 
vessels.  The  plasma  cells  showed  evidence  of  ameboid 
activity,  and  some  of  them  had  mitotic  nuclei.  In  addition 
he  found  great  numbers  of  typical  eosinophilic  leukocytes. 

[J.S.] 

3.  —  Hektoen  reports  the  following  cases  of  cardiac 
anomalies :  One  in  a  child  recently  born,  that  died  of 
general  infection  with  tte  Bacillus  mucosis  CApsulatus.  He 
found  a  large  defect  in  the  septum  between  the  pulmonary 
artery  and  the  aorta,  consisting  of  an  oval  opening  about 
1.5  cm.  in  diameter.  The  ductus  arteriosus  was  patent :  the 
veins  were  normal.  He  has  collected  10  other  cases  of  this 
condition.  It  is  interesting  that  some  of  these  patients  lived 
for  a  considerable  time.    They  all  gave  marked  evidences  of 


ApKIL  6,  1901] 


THE  LATEST  LITERATURE 


rTHK  Philadelphia 
ilKDICAL  JOCSSAL 


651 


heart-disease,  the  physical  signs  varying  from  a  systolic  bruit 
at  the  base  to  both  diastolic  and  systolic  murmurs,  frequently 
changing  in  character.  The  second  sound  was  accentuated 
in  one  case.  There  was  usually  hypertrophy  of  the  right 
ventricle  that  could  sometimes  be  diagnosed  during  life.  In 
one  or  two  cases  there  was  cyanosis.  The  second  patient  had 
a  curious  depression  under  the  base  of  the  anterior  aortic 
valve  connecting  with  the  ventricle,  through  which  regurgi- 
tation occurred.  This  is  unique,  and  it  is  difficult  to  under- 
stand by  what  freak  of  embryological  development  it  was 
caused,    [j.s.] 

4.— The  patient,  a  man  49  years  of  age,  had  had  the  back 
of  his  right  hand  scratched  by  the  teeth  of  a  cat.  He  also 
caressed  very  frequently  his  dog  which  was  suffering  from 
mange.  A  few  weeks  later  he  developed  a  small  pustule 
which  broke  down,  healed,  and  a  crust  formed  over  the 
opening.  Then  other  pustules  appeared,  and  the  condition 
gradually  extended  until  the  whole  back  of  the  hand  was 
involved.  Cover-glass  preparation  showed  the  presence  of 
staphylococci,  long  streptococci,  and  a  few  yeast  fungi. 
Cultures  of  the  yeast  plant  were  obtained  on  glycerin  agar, 
and  a  diagnosis  of  blastomycetic  dermatitis  was  made. 
Mild  antiseptic  treatment  appeared  to  improve  the  disease. 
5. — Schamberg  reports  the  case  of  a  woman,  39  years  of 
age,  who  had  been  inoculated  8  years  previously  with 
syphilis.  Since  then  she  has  had  a  great  number  of  syph- 
ilitic skin  lesions  which  have  resisted  all  forms  of  anti- 
syphilitic  treatment.  Her  general  health  remains  good,  and 
she  has  gained  in  weight. 

6. — Prince,  in  an  article  with  numerous  numbered  para- 
graphs, discusses  functional  mitral  regurgitation.    He 
I    considers  that  the  mitral  ring  probably  dilates  and  contracts 
I    with  the  dilatation  and  contraction  of  the  ventricle,  and  is 
not  rigid  as  is  the  aortic  ring.    The  sphincter-like  band  of 
muscles  around  the  ring  is  essential  for  maintaining  its  com- 
petence.   When,  however,  the  tonus  of  the  sphincter  is 
diminished  the  ring  may  dilate  to  such  an  extent  that  re- 
gurgitation can  occur.    The  work  of  Roy  and  Adami  has 
shown  that  irritation  of  the  various  nerves  leading  to  the 
heart  may  have  great  influence  upon  the  size  of  the  organ, 
j    and  the  completeness  of  the  muscular  contraction.    Prince 
:    has  observed  that  in  men  apparently  healthy,  who  were  ex- 
amined under  conditions  tending  to  produce  considerable 
■    excitement,  murmurs  not  infrequently  developed.  These  mur- 
murs have  all  the  physical  characteristics  of  mitral  mur- 
murs.   Examination  of  some  of  these  cases  have  shown  that 
.    the  heart  is  considerably  increased  in  size,  and  it  is  probable 
that  the  murmurs  were  merely  functional  in  character.    He 
quotes  the  results  of  the  investigations  of  various  other  in- 
vestigators in  support  of  his  views.     [J.s] 

March,  1901. 

1.  Surgical  Treatment  of  Ascites  Due  to  Cirrhosis  of  the  Liver 

with  Report  of  Two  Cases.    F.  Packard  and  Le  Cokte- 

2.  Splenic  Myelogenous  Leukemia  with  Pulmonary  Tuber- 

culosis.   EsHNER  and  Groat. 

3.  Hemorrhagic  Typhoid  Fever.    Eshner  and  Weisenberg. 

4.  A  Study  of  Congenital  Sarcoma  of  the  Liver  and  Supra- 

renal.   W.  Pepper. 

5.  A  Case  of  Sarcoma  of  the  Thigh  for  which  Disarticula- 

tion was  Performed  Through  the  Hip  Joint,  with  the 
Formation  of  a  Posterior  Flap.    DaCosta. 

6.  Stereognosis  and  Allied  Conditions.    Bcrr. 

7.  Clinical  Study  of  Acute  Myocarditis.    Roblssox. 

1. — Packard  and  Le  Conte  report  2  cases  of  cirrhosis  of 
the  liver  in  which  the  operation  of  stitching  the 
mesentery  to  the  abdominal  wall  was  performed  in 
order  to  promote  the  establisnment  of  a  collateral  circula- 
tion. The  first  patient,  a  man  of  63,  was  operated  upon 
only  after  repeated  tapping  had  failed  to  relieve  the  ascites, 
and  the  symptoms  were  rather  alarming.  After  the  opera- 
tion, the  patient  was  very  depressed  and  weak,  and  he  died 
in  53  days  of  heart- failure  and  pulmonary  edema.  The 
autopsy  confirmed  the  diagnosis.  The  second  patient,  a 
man  of  52,  had  practically  the  same  indications  for  opera- 
tion, but  afterward  became  delirious  and  died  with  symptoms 
of  uremia.  There  was  no  fever  and  no  signs  of  infec- 
tion. The  authors  give  a  general  discussion  of  the  subject, 
quoting  extensively  from  the  literature.    They  believe  that 


the  operation  may  be  of  benefit  in  two  ways :  First,  by  dimin- 
ishing the  congestion  of  the  liver ;  secondly,  by  increasing 
the  vascular  supply  of  the  surface  cells  so  that  they  may 
undergo  compensatory  hyperplasia.  They  regard  the  ascites, 
therefore,  as  due  almost  exclusively  to  the  portal  obstruction. 
Le  Conte  gives  the  following  suggestions  in  regard  to  the 
operation.  He  objects  to  etherization,  preferring  chloroform 
and  local  anesthesia.  A  primary  incision  is  made  above  the 
umbilicus  and  a  little  to  the  left  of  the  median  liae,  and  the 
liver  palpated.  A  small  opening  is  then  made  in  the  median 
line  just  above  the  pubis  and  the  fluid  siphoned  off  through 
it.  The  parietal  peritoneum  over  the  omentum,  liver,  and 
spleen  is  then  rubbed  with  a  gauze  sponge,  and  the  surface  of 
those  organs  is  treated  in  the  same  way.  The  omentum  is 
then  stitched  to  the  anterior  abdominal  wall,  and  the  incition 
closed.  Drainage  may  be  made  through  the  larger  opening. 
The  abdomen  should  be  encircled  with  broad  adhesive  strips. 
Twenty-two  cases  have  been  recorded,  giving  the  following 
results  :  Immediate  death,  5  ;  ultimate  death,  3  ;  unimproved, 
3 ;  improved,  2 ;  recovered,  9.  As  the  operation  has  been 
chiefly  performed  upon  cases  that  were  otherwise  hopeless, 
and  after  repeated  tapping  had  failed  to  make  any  impression 
on  the  peritoneal  accumulation  of  fluid  Le  Conte  regards 
these  results  as  encouraging,  in  fact  some  authors  are  already 
urging  an  early  operation.  The  authors  strongly  recommend 
the  operation,    [j  s.] 

3. — A  man,  -10  years  of  age,  had  complained  for  some 
months  of  a  sense  of  fulness  in  the  abdomen,  also  progres- 
sive emaciation  and  severe  cough,  with  night  sweats.  He 
had  fever,  was  anemic,  and  had  a  rapid  pulse.  Tubercle 
bacilli  were  found  in  the  sputum,  the  spleen  was  enormously 
enlarged,  and  the  liver  moderately  so.  Repeated  examina- 
tions of  the  blood  showed  progressive  diminution  in  the  red 
blood-cells  and  a  very  considerable  leukocytosis,  at  one  time 
exceeding  300,000  whites  per  ccm.,  considerable  reduction 
in  hemoglobin,  and  a  very  large  proportion  of  myelocytes, 
sometimes  amounting  to  nearly  40^.  In  the  course  of  the 
disease  the  general  changes  in  the  white  cells  were  a  steady 
decrease  in  their  number,  an  increase  in  the  percentage  of 
polymorphonuclear  neutrophiles  and  the  lymphocytes,  and 
a  decrease  in  the  number  of  myelocytes.  During  all  this 
period  the  tubercular  process  was  advancing.  The  case  is 
reported  as  one  of  tuberculosis  associated  with  splenic 
myelogenous  leukemia,    [j.s.] 

3. — Eshner  and  Weisenberg  report  the  following  cases.  A 
man  of  39,  who  had  been  a  heavy  drinker,  was  admitted  to 
the  hospital  delirious.  He  developed  characteristic  symp- 
toms of  typhoid  fever,  and  on  the  sixth  day  after  admis- 
sion, a  rose-red  eruption  appeared  that  did  not  disappear 
upon  pressure.  The  same  day  he  had  hematuria  and  a 
bluish  papular  eruption  over  nearly  the  whole  body,  severe 
hemorrhage  from  the  bowels,  and  an  extravasation  of  blood 
in  the  cornea  of  the  left  eye.  He  died,  and  at  the  autcpsy, 
blood  was  found  in  the  serous  cavities.  The  intestine  showed 
the  characteristic  ulcers.  The  second  patient,  a  man  of  2S, 
also  an  alcoholic,  gave  the  characteristic  symptoms  of 
typhoid  fever.  He  also  developed  a  peculiar  red  papular 
eruption  that  did  not  disappear  upon  pressure.  He  had 
symptoms  of  meningitis ;  that  is,  divergent  strabismus,  re- 
traction of  the  head,  and  later  Kernig's  sign.  He  became 
comatose  and  died.  The  autopsy  showed  only  the  lesions  of 
typhoid  fever,    [j.s.] 

4. — Pepper  reports  the  following  interesting  cases :  A 
female  child,  born  August  19,  remained  well  until  September 
14.  At  this  date  the  abdomen  began  to  enlarge  ;  there  was 
emaciation  and  diarrhea.  The  distention  was  evidently 
due  to  an  enormous  enlargement  of  the  liver.  A  few  days  be- 
fore death  there  were  small  hemorrhagic  petechiae.  At  the 
autopsy  the  enormously  enlarged  liver,  upon  section,  was 
yellowish  white  in  color  with  a  few  hemorrhagic  areas. 
The  right  suprarenal  was  enlarged,  and  bad  the  same  appear- 
ance. Microscopic  examinations  showed  that  both  the  liver 
and  right  adrenal  were  infiltrated  with  lymphosar- 
comatous  tissue.  Pepper  has  been  able  to  collect  5  cases 
of  this  nature  from  the  literature,  which  give  the  following 
interesting  points  of  resemblance :  Swelling  of  the  abdomen 
at  a  very  early  age,  varying  from  birth  to  5  weeks ;  death  a 
short  time  afterwards,  from  10  days  to  16  weeks.  The  very 
rapid  growth  of  the  liver;  the  fact  that  all  the  cases  except- 
ing one  were  females,  and  in  this  one  case  the  sex  was  not 
mentioned.    The  clinical  symptoms  were,    in    addition  to 


652 


The  PhiladblphiaH 
Medical  Jgubnal  J 


THE  LATEST  LITERATURE 


[Apbu,  6,  UO 


distention  of  the  abdomei,  moderate  wasting,  but  there  was 
no  jaundice  nor  ascites,  nor  pigmentation  of  the  skin.  The 
children  did  not  appear  to  suffer  pain.  There  was  no  fever 
and  they  all  nursed  well  until  shortly  before  death.  Tnere 
was  no  history  nor  sign  of  syphilis.  The  changes  were 
practically  identical  in  all,  nor  were  any  other  organs  except- 
ing the  liver  and  suprarenal  involved.  The  kidneys  were 
always  normal.  The  disease  differs  considerably  from  pri- 
mary sarcoma  of  the  suprarenal,  of  which  Pepper  has  collected 
46  cases,  given  in  tabulated  form.  Primary  sarcoma  of  the 
liver  appears  to  be  very  doubtful,     [j  s] 

6. — DaCosta  reports  a  case  of  rapidly  growing  sarcoma  of 
the  thigh  occurring  in  a  girl  of  15  years.  This  ruptured 
through  the  skia,  fungated,  and  bled  profusely.  Amputation 
was  therefore  indicated,  and  hemorrhage  was  controlled  ac- 
cording to  McBurney's  method  of  opening  the  abdomen  and 
compressing  the  iliac  vein  and  artery  against  the  psoas 
muscle.  As  the  anterior  portion  of  the  thigh  was  involved  it 
was  necessary  to  make  a  long  posterior  flap.  Tne  operation 
was  entirely  successful,  with  the  exception  of  the  fact  that 
the  weight  of  the  fat  caused  gaping  in  the  external  fourth  of 
the  wound.  Six  weeks  later  recurrence  appeared.  Da  Costa 
states  that  in  future  cases  he  would  make  the  posterior  flap 
consist  almost  exclusively  of  skin  in  order  to  decrease  ite 
weight.    The  growth  was  a  small  cell  sarcoma,     [j  s,] 

6. — Burr  reports  several  interesting  cases.  The  first,  a 
man,  had  received  as  a  boy  a  fracture  of  the  right  parietal 
bone.  Subsequently,  although  there  was  no  paralysis,  he 
could  not  locate  sensation,  and  had  persistent  stereog'- 
nosis.  The  second  patient  had  tumor  of  the  brain  localized 
in  the  right  parietal  region.  There  was  slight  hemiparesis. 
In  the  right  side  muEcilar  sense  was  apparently  fair,  but  the 
localization  sense  was  greatly  impaired.  He  also  had  com- 
plete stereognosis.  The  third  patient  had  a  fracture  of  the 
right  parietal  bone.  Subsequently  had  impairment  in  the 
movements  of  the  left  hand,  with  a  good  deal  of  pain  when 
they  were  moved.  There  was  loss  of  sensation  of  position, 
and  partial  stereognosis,  which  apparently  was  not  limited  j 
to  any  particular  class  of  objects.  The  fourth  patient,  a  man 
of  52,  had  hemiparesis  of  the  right  side.  There  was  tremor 
of  both  arms,  ataxia  of  the  right  arm,  and  hypesthesia. 
There  was  some  impairment  of  motion,  but  complete  stere- 
ognosis in  the  right  arm,  and  later  some  sensory  aphaaia. 
The  diagnosis  was  made  of  tumor  in,  or  near,  the  left  angu- 
lar gyrus,  and  this  was  confirmed  at  the  autopsy.  The  last 
patient,  a  woman  of  30,  had  sluggish  movements,  and  there 
waa  complete  paralysis  of  the  right  side  of  the  face,  atrophy 
of  both  optic  nerves,  and  complete  loss  of  all  sensation  in 
the  left  arm.  Nevertheless,  she  recognized  and  correctly 
named  all  sorts  of  objects  placed  in  the  left  hand.  The  diag- 
nosis of  this  case  Burr  leaves  in  doubt.  Burr  believes  that 
stereognosis  is  produced  by  disease  either  of  the  cortical 
area  for  perception  or  its  afferent  or  efferent  tracts.  He  ac 
cepts  lbs  cortical  sensory  area  for  the  recognition  of  objects 
by  handling  them,  and  calls  attention  to  the  analogies  be- 
tween this  condition  and  the  various  forms  of  aphasia.  He 
suggests  that  in  the  last  case,  the  tactile  sensory  area  is  not 
the  same  as  the  cortical  area  for  perception,  and  that  a  lesion 
in  the  tract  uniting  them  might  cause  the  symptoms.     |  J  s  ] 

7. — Robinson  discussses  the  various  fjrms  of  inflamuia- 
tion  of  the  heart- luuscle.  He  tpsaks  of  the  symptoms 
of  heart  failure  that  may  occur  in  acute  infectious  processes, 
and  in  which  a  soft  flabby  heart  is  found  at  the  autopsy.  He 
thinks  that  potassium  iocii  is  lets  used  in  such  affections 
than  it  should  be.  He  also  thinks  that  oxygen,  to  which  a 
small  proportion  cf  nitrogen  monoxide  has  been  added 
should  be  given  continuously.  He  also  makes  warm,  moist 
applicatioES  to  the  pericardium,  and  if  necessary  small 
amounts  of  opium  may  be  given  for  a  soothing  effect.  Of 
all  cardiac  stimulants  he  is  most  impressed  with  the  value  of 
coffee  and  cocoa.  After  recovery  from  an  acute  condition, 
enlargement  of  the  heart  iiny  sometimes  occur,    [j  B.] 


Archives  of  Pediatrics. 

M,.  rch,  1901, 

1.  Hemorrhage  into  the  S.iprarenal  Capsule  in  Still-born 
Children  and  Infants  :  Report  of  a  Case  Showing  Rup- 
ture  of  the  S.<c  ar.d  Escape  of  Blood  into  the  Peri- 


renal Tissues  and    the  Peritoneal    Cavity.     S.  McC 
Hamill. 

2.  The  Diagnosis  and  Treatment  of  Adenoids  by  the  Gsnera 

Practitioner.    Francis  Hubee. 

3.  Some  Observations  upon  the  Temperatures  of  Apparently 

Healthy  Children;  An  Experimental  Study.    W.  M. 
Donald. 

4.  Case  of  Apparent  Recovery  from  a  Congenital  Abnor- 

mality of   the  Heart  (?  Patent    Ductus    Arteriosus). 
John  Thomson. 

5.  Tumor  of  the  Cerebellum  in  a  Boy  of  Seven  Years.    S. 


R.  Ketcham  and  L.  C.  Peter. 
7.  Report  of  a  Case  of  Diabetes  in  an  Infant. 
Young. 


William  E. 


» 


1. — Hamill's  article  on  hemorrhag-e  into  the  sapra- 
renal  capsule  in  stillbora  chUdren  and  infants  is 

concluded  by  a  review  of  the  literature,     [j.m  s.] 

2.— The  diagnosis  of  adenoids  may  be  made  (1)  from 
the  symptoms,  (2)  by  means  of  the  rhinal  mirror,  or  (3)  by 
digital  exploration  of  the  nasopharynx.  The  symptoms  are 
often  so  plain  that  no  one  cin  fail  to  interpret  them  correctly. 
The  use  of  the  mirror  for  posterior  rhinoscopy  is  impossible,  ■ 
as  a  rule,  in  children.  Digital  exploration  after  a  little  prac- 
tice is  readily  performed  and  yields  the  desired  information. 
For  one  reason  or  other  it  may  not  be  desirable  at  the  time 
to  resort  to  a  digital  examination.  Under  such  circumstances, 
reliance  may  be  placed  on  two  symptoms.  Either  one  or  the 
two  jointly  offer  a  ready  and  easy  method  for  a  correct  diag- 
nosis. 1.  The  presence  of  two  small  lymph  nodes,  painless 
and  freely  movable  at  the  angle  of  the  lower  jiw,  one  on 
either  side.  2.  Upon  oral  examination  and  inspection,  if  the 
size  of  the  tonsils  does  not  obstruct  the  view,  numerous  small 
hypertrophies  will  be  found  upon  the  mucous  membrane  of 
the  posterior  pharynx,  now  and  then,  at  the  level  of  the  soft 
palate,  larger  masses  are  present.  In  the  treatment  two 
points  must  be  considered :  (1)  The  removal  of  the  lymphoid 
hypertrophies  constituting  the  tonsillar  ring;  and  (2)  the 
effects,  local  and  general,  of  the  interference  with  normal 
nasal  respiration.  Tne  earlier  the  treatment  is  instituted  the 
greater  the  success  in  preventing  secondary  changes.  In  case 
decided  symptoms  are  associated  with  adenoids,  the  growth 
should  be  removed.  This  may  be  accomplished  by  the  finger, 
forceps  or  curet.  Huber  prefers  to  operate  without  narcosis. 
The  existence  of  an  acute  otitis,  bronchitis,  or  inflammatory 
process  in  any  part  of  the  respiratory  tract  is  a  contraindica- 
tion to  operative  interference.  Bleeders,  or  those  who  have 
had  petechise,  are  best  left  alone,     [j  m  s.] 

3. — Donald  selected  20  children  and  the  temperature 
of  each  was  taken  twice  daily,  at  about  8.30  a.m.  and  6  p.m., 
for  a  period  of  14  days.  During  the  14  days  in  which  the 
tests  were  conducted,  he  had  28  collective  readings,  and  out 
of  these  28,  12  readings,  or  42%,  gave  a  mean  or  average 
temperature  of  99°  F.  or  over.  The  nigher  readings  occurred 
at  the  afternoon  tests  in  the  majority  of  cases;  9  of  these 
being  recorded  in  the  afternoon,  and  but  3  in  the  morning. 
On  five  difierent  occasions,  or  about  18?f-,  the  mean  temper- 
ature on  the  collective  reading  showed  a  higher  range  in  the 
morning  than  in  the  evening  of  the  same  day.  There  was  a 
tendency  toward  a  constant  high  temperature  in  about  30* 
of  the  cases  examined.  The  children  were  especially 
selected  from  nearly  100  in  an  asylum  on  account  of  their 
perfect  condition  of  health.  Xo  one  of  them  was  sick 
a*,  any  time  during  the  tests  and  none  of  them  has  devel- 
oped any  illness  since,     [j  m  s.] 

4. — Thomson  reports  the  case  of  a  girl,  9  weeks  old,  who 
was  suffering  from  blueness  of  the  face  and  hands.  The 
child's  cyanosis  had  been  noticed  b}-  the  parents  from  birth, 
but,  as  the  patient  seemed  well  in  other  respects,  they  had 
not  been  concerned  about  it.  The  hands,  the  feet,  and  the 
face,  especially  the  lif)s,  were  distinctly  cyanotic.  Tne  pulse 
was  very  rapid,  156.  and  small  but  regular ;  the  respirationa 
were  36  in  the  minute.  The  lungs  and  the  abdominal  or» 
gans  appeared  to  be  normal.  The  heart's  apex  beat  was 
very  indistinct,  and  was  situated  in  the  fourth  left  interspace 
about  J  inch  outside  the  nipple  line.  No  thrill  could  be  felt 
in  any  area.  There  was  no  increase  of  the  cardiiic  dulneai 
and  no  sign  of  enlargement  of  the  right  side  of  the  heart. 
On  auscultation,  a  loud  systolic  murmur  was  heard,  which 
was  most  marked  over  the  base  of  the  heart,  especially  to 
the  left  of  the  sternum,  but  was  also  audible  in  the  other 


April  6,  1901) 


THE  LATEST  LITERATURE 


rruK  Philadelphia 

L  USDICAL  JOUKKAL 


653 


areas,  in  the  axilla,  and  in  the  interscapular  regions.  The 
pulmonary  second  sound  was  normal  and  not  accentuated. 
There  was  no  clubbing  of  the  finger  ends.  Two  months  later, 
only  very  slight  cyanosis  of  the  feet  and  legs  was  noticed. 
The  murmur  was  distinctly  less  loud,  and  over  the  tricuepid 
area  it  was  quite  inaudible.  The  puhe  was  152.  Seven  years 
afterward,  the  child,  who  had  been  tolerably  well  since  last 
examined,  was  fairly  healthy  in  appearance.  She  showed 
no  trace  of  cyanosis  and  had  no  clubbing  of  the  fingers. 
Her  pulse  was  normal  in  rate  and  rhythm.  While  the  facts 
given  above  are  hardly  enough  to  found  a  sure  diagnosis 
upon,  it  seems  probable  to  the  author  that  the  murmur  and 
other  signs  of  circulatory  disturbance  in  this  patient  may 
have  been  due  to  a  patent  and  perhaps  dilated  ductus 
arteriosus,  while  the  disappearance  of  the  symptoms 
points  to  the  closure  of  the  lumen  of  the  vessel,     [j.m.s.] 

6. — Ketcham  and  Peter  report  the  case  of  a  boy  in  whom 
nystagmus  was  noticed  soon  after  birth,  followed  in  a  few 
years  by  a  titubating  gait,  static  ataxia,  incoordination  of  the 
upper  extremities,  headache,  vomiting,  and  choked  disc.  The 
symptoms  are  clearly  those  of  tumor  of  the  cerebellum. 
[j.m.s.] 

6. — Young  reports  the  case  of  a  boy,  6  months  old,  who 
commenced  to  vomit.  His  stools  were  green  and  contained 
undigested  material.  At  every  weighing  a  loss  of  several 
ounces  was  noted,  the  child  was  emaciated,  and  his  skin  was 
very  dry  and  wrinkled.  An  examination  of  the  urine  showed  a 
specific  gravity  of  1.030,  about  5  %  of  sugar,  very  little  albumin, 
and  a  few  casts.  The  child  died  of  pneumonia.  At  autopsy 
the  cortex  of  the  kidneys  was  grayish-white  and  indurated. 
There  were  marked  hyperemia  and  inflammation  of  the 
parenchyma,     [j.m  s.] 

Journal  of  Nervous  and  Mental  Disease. 

March,  1901.    [Vol.  xxviii.  No.  3.] 

1.  The  Amelioration  of  Paralysis  Agitans  and  Other  Forms 

of  Tremor  by  Systematic  Exercises.    John  Madison 
Tayloe. 

2.  A  Case  with  the  Symptoms  of  Cerebrospinal  Meningitis, 

with  Intense  and  General  Alteration  of  the  Nerve- 
Cell  Bodies,  but  with  Little  Evidence  of  Inflammation. 
William  G.  Spiller. 
S.  A  Ca«e  of  Muscular  Dystrophy.    Charles  Gilbert  Chad- 
dock. 


♦ 


1. — Taylor  is  convinced  that  in  this  form  of  tremor,  what- 
soever the  cause,  we  may  hope  to  obtain  fair  amelioration  of 
symptoms,  and  it  may  be  in  some  instances  a  cure,  by  care- 
fully regulated  and  systematized  movements.  These  should 
be  such  as  shall  reestablish  the  largest  degree  of  elasticity  in 
the  tissues  which  have  suffered  contractures.  They  should 
always  include  passive  extensions  and  flexions,  followed  by 
active  repetitions  of  these  acts.  The  most  important  move- 
ments to  overcome  the  milder  forms  of  tremor,  as  the  senile 
form,  are  slow,  full,  forcible  extensions.  An  important  part 
of  the  treatment  is  the  attainment  of  normal  attitudes.  Along 
with  this  should  be  continued  conscientious  efi'orts  on  the 
part  of  the  patient  to  acquire  full  thoracic  capacity  and  as 
much  elasticity  of  the  lungs  as  possible,     [t  m  t] 

3. — Spiller  reports  a  case  with  symptoms  of  cerebro- 
spinal meningitis  existing  for  six  days  without  lesions 
sufficient  to  explain  them  at  necropsy.  A  very  slight  round- 
cell  infiltration  was  observed  in  some  parts  of  the  pia  and 
about  some  of  the  intramedullary  blcodvessels,  but  the 
smaller  vessels  of  the  pia  and  anterior  and  posterior  roots 
were  much  distende  1  with  blood.  Numerous  small  bacilli 
were  found  within  the  nervous  tissues.  Some  authorities 
think  that  this  same  condition  is  found  in  cases  of  amaurotic 
family  idiocy,  but  Spiller  does  not  agree  with  them,  and 
reports  cellular  infiltration  in  two  cases  of  children  of  feeble 
mental  development,  one  the  above  reported  case  and  the 
other  of  internal  hemorrhagic  pachymeningitis.  A  theory 
of  a  toxic  condition  in  the  first  ca^e  could  be  well  supported 
l>y  the  clinical  history,  but  not  so  well  in  the  case  of  internal 
hemorrhagic  pachymeningitis,  although  even  in  this  it  could 
not  be  absolutely  rejected.  The  alteration  of  the  nerve-cell 
bodies  throughout  the  central  nervous  system  was  extra- 
ordinary, although  the  secondary  degeneration  had  not 
occurred,    [t.m.t.] 


3.— In  a  case  of  muscular  dystrophy  Chaddock  notes 
that  the  beginning  of  the  trouble  was  in  the  face,  and  it  siib- 
sequently  attacked  the  arms,  and  later  the  lower  extremities 
became  involved,  and  finally  the  hands  With  atrophy  far 
advanced  and  quite  generalized,  the  wasting  at  the  roots  of 
the  extremities  predominates  decidedly  over  that  at  the  dis- 
tal extremities  of  the  members.  The  characteristic  prom- 
inence of  the  middle  third  of  the  wasted  deltoids  is  also 
worthy  of  note.  Absence  of  all  fibrillary  contractions  as  well 
as  the  absence  of  all  sensory  and  central  disturbances  are 
points  which  render  a  diagnosis  of  myopathic  atrophy  cer- 
tain,    [t.m.t.] 

Edinburgh  Medical  Journal. 

February,  1901.    [N.  S.,  Vol.  ix.  No.  2.] 

1.  Oa  Bad  Positions  of  Pelvis  Productive  of  Spinal  Carvature. 

Richard  Bar  well. 

2.  The  Borderland.    Lecture  IL    G.W.  Balfocr. 

3.  Oa  Intraperitoneal  Rupture  of  Simple  Ovarian  Cystf^,  with 

Special  Reference  to  Operative  Treatment.    F.  W.  N. 
Haultaen. 

4.  The  Bacterial  Treatment  of  London  Crude  Sewage  at 

Barking  and  Crossness.  A.  C.  Houston. 
6.  Medico-Legal  Notes.  Harvey  Littlejohn. 
6.  Cholesteatoma  of  the  Temporal  Bone  and  Its  Treatment. 

H.  J.  Waring. 

1.— Barwellhas  seen  no  cases  of  scoliosis  in  which,  either 
while  sitting,  standing,  or  both,  the  pelvis  was  normally  and 
properly  placed.  Tne  pelvic  malpostures  with  which  we 
have  to  do  are  3  in  number  :  obliquity,  amesiality,  and  ver- 
sion. Pelvic  obliquity  means  that  one  side  of  the  pelvis  lies 
on  a  higher  level  than  the  other.  It  is,  unlike  the  other  two, 
not  dependent  on  a  trick  or  habit,  but  on  a  difi'erence  in 
length  of  the  lower  limbs.  For  the  diagnosis  of  this  con- 
dition the  patient,  having  the  garments  let  down  to  a  level 
with  the  hips,  standing  with  feet  together  and  knees  straight, 
is  so  arranged  that  there  is  some  straight  horizontal  line  in 
the  decoration  or  furniture  of  the  room  in  front  of  him  that 
may  serve  as  the  gauge  of  level.  The  surgeon,  behind  the 
patient,  places  the  index  finger  of  each  hand  on  the  crest 
of  one  ilium  at  the  side  outline,  and  gets  his  eye  at  such  a 
level  that  one  of  his  fingers  corresponds  with  the  horizontal ; 
unless  the  other  finger  also  corresponds  with  the  horizontal 
line  the  pelvis  is  oblique.  Amesiality  of  the  pelvis  is  a  term 
indicating  that  the  patient  in  standing  erect  habitually  places 
the  pelvis  to  one  side  of  what  should  be  the  central  mesial 
line  of  his  figure.  In  order  to  diagnose  this  condition  the 
patient  should  stand  in  drill  posture,  unless  that  position 
produces  a  swaying  of  the  figure.  In  such  a  condition  he  may 
be  allowed  to  stand  with  the  feet  slightly  separated  but  at 
exactly  equal  distances  from  a  carpet  pin  or  other  mark 
on  the  floor.  Placing  himself  absolutely  square  behind, 
the  surgeon  so  holds  a  plummet  that  it  or  its  cord  cuta 
the  mark  on  the  floor.  If  when  traced  upwards  by  the 
eye  the  cord  does  not  fall  over  the  intergluteal  fissure, 
the  pelvis  is  (probably)  amesial.  In  order  to  carry  out 
this  method,  the  patient's  back  and  hips  must  be  bare 
and  the  feet  must  also  be  easily  visible.  The  camera 
affords  a  much  more  certain  diagnostic  method,  since  the 
image  can  be  accurately  triangulated  and  measured.  Version 
of  the  pelvis  is  a  fault  of  posture  that  is  very  frequently  met 
with.  It  is  to  be  determined  by  measuring  the  distance  from 
the  rima  natium  to  the  pelvic  side  outline.  Let  a  piece  of 
white  tape  be  pinned  to  the  floor,  and  the  patient  ar- 
ranged with  the  garments  dropped  a  little  below  the 
level  of  the  trochanters  so  that  the  heels  touch  its  edge. 
The  surgeon  then  holds  some  straight  rod  or  sufficiently 
narrow  strip  of  wood  horizontally,  and  places  its  edge 
in  equal  contact  against  the  patient's  glutei  muscles,  then, 
stooping  his  head  so  that  with  the  right  eye  he  can 
look  along  the  epine  from  between  the  scapulae  downward, 
he  notes  whether  his  rod  lies  parallel  to  the  tape,  or  cuts  it 
at  an  angle  somewhere  between  the  heels.  If  one  end  of  the 
rod  lies  behind  and  the  other  in  front  of  the  white  line,  the 
pelvis  is  verted  toward  the  side  on  which  the  rod  is  posterior. 
The  condition  may  be  diagnosed  while  the  patient  is  sitting. 
Of  these  three  faulty  postures  obliquity  very  often  occurs 
alone,  the  other  two  are  less  frequent :  while  occasionally  all 


654 


Thk  Philadblphia"] 
Medical  Jodenal  J 


THE  LATEST  LITERATURE 


(APBiL  0.  1901 


three  coincide  in  the  same  person.  In  the  last  case  rapid 
and  severe  deformity  is  always  produced.  Pelvic  malpos- 
tures  do  not  originate  in  erect  but  in  sedentary  postures.  A 
habit  thus  inaugurated  in  sitting  very  easily  extends  into  the 
standing  posture,  and,  although  such  juveniles  aa  delight  in 
athletic  amusements  may  obviate  the  evil  effects,  yet 
naany  even  of  these  suffer,  while  the  more  physically 
inert  are  certain  to  do  so.  A  child  detected  by  the  means 
described  sitting  or  standing  askew  should  be  intelli- 
gently corrected.  Later  curvature  may  be  thus  forestalled 
or,  if  incipient  curvature  is  present,  it  may  be  redressed. 

[JMS.] 

3. — In  the  majority  of  instances  intraperitoneal  rup- 
ture of  simple  ovarian  cysts  is  apparently  unassociated 
with  discomfort.  It  is  probable,  therefore,  that  this  condi- 
tion is  common  in  small  cysts  that  have  not  given  rise  to 
any  symptoms.  The  absence  of  symptoms  is  doubtless  due 
to  the  innocuous  contents  of  the  cyst  and  to  its  slow  escape, 
a  sudden  gush  being  prevented  by  the  intraabdominal  pres- 
sure. In  a  large  proportion  of  recorded  cases  severe  and 
dangerous  symptoms  supervened  after  rupture.  In  these 
instances  the  contents  of  the  cyst  must  have  been  intensely 
irritating,  and  in  many  cases  probably  septic,  while  in  a  cer- 
tain proportion  death  was  produced  by  hemorrhage.  The 
causes  of  rupture  are  numerous  and  include  violence  and 
morbid  processes  in  the  cyst  wall  due  to  thrombus  and  intra- 
cystic  hemorrhage.  Nutritive  disturbances  in  the  cyst  wall, 
the  result  of  tension  of  the  pedicle,  is  a  further  frequent 
cause.  Perhaps  the  commonest  variety  of  cyst  to  rupture 
spontaneously  is  that  with  gelatinous  contents.  The  gelatin- 
ous contents  are,  aa  a  rule,  more  irritative  and  at  the 
same  time  are  but  slowly  absorbable  by  the  peritoneum 
and  may  continue  to  distend  the  abdomen.  It  is,  there- 
fore, possible  that  this  accounts  for  the  greater  fre- 
quency with  which  such  cysts  are  found  ruptured,  because 
when  the  contents  of  a  cyst  are  more  fluid  and  more 
readily  absorbed,  operation  is  seldom  undertaken  after  col- 
lapse of  the  cyst  and  the  disappearance  of  the  abdominal 
swelling.  In  a  certain  proportion  of  cysts  with  innocuous 
contents,  in  which,  after  rupture,  no  abdominal  symptoms 
supervene,  ready  absorption  of  the  extravasated  contents 
occurs  and  permanent  obliteration  of  the  cyst  follows. 
This  occurs  more  frequently  in  unilocular  cysts  of  the  broad 
ligament,  the  fluid  of  which  is  practically  normal  saline 
solution  and  is  absorbed  rapidly,  giving  rise  to  temporary 
polyuria.  In  another  series  of  cases  there  is  a  ready  absorp- 
tion of  the  escaped  fluid,  without  peritoneal  irritation,  but 
the  tumor  reappears  from  redistention  of  the  cyst  or  growth 
of  secondary  cysts.  When,  however,  the  contents  of  the 
cyst,  though  absorbable,  tend  to  cause  a  subacute  type  of 
irritation  of  the  peritoneum,  we  have  inflammatory  adhe- 
sions formed  between  the  cyst  wall  and  surrounding  struc- 
tures, which,  on  redistention  of  the  cyst,  may  form  an 
almost  insuperable  barrier  to  subsequent  removal.  In  a 
fourth  group  of  cases,  practically  lacerated  cysts  with 
gelatinous  contents,  no  absorption  tikes  place.  At  the 
same  time,  from  mucoid  degeneration  of  the  cyst  wall,  the 
seat  of  rupture  remains  patent,  and  active  secretion  con- 
tinues, which  results  in  a  steady  increase  of  abdominal 
distention  from  free  intraperitoneal  fluid.  According  to 
Haultain,  ruptured  cysts  should  in  all  cases  be  removed  as 
soon  as  possible.  Having  been  certain  of  the  presence  of  an 
ovarian  tumor,  its  sudden  or  gradual  disappearance  should 
be  an  incentive  to  operation.  The  treatment  of  perforated 
cyst  associated  with  acute  symptoms  must  be  operative. 
From  our  inability  to  diagnose  the  papillomatous  variety 
without  visual  examination,  and  appreciating  their  tend- 
ency to  secondary  peritoneal  infection,  an  additional  incen- 
tive is  added  to  the  immediate  removal  of  all  ovarian  cystic 
growths.  Notes  of  6  cases  of  ruptured  ovarian  cysta  are 
given.     [3.M.S.] 

4.— Will  be  treated  editorially. 

6.— Littlejohn  concludes  that  the  hydrostatic  test  applied 
to  the  lungs  is  not  an  absolute  means  of  determining  that 
respiration  has  taken  place,  since  in  those  exceptional  cases 
of  persistent  atelectasis  it  may  afl^ord  negative  results,  and 
yet  the  child  may  have  respired  for  a  considerable  time. 

[.I.M  S  J 

6.— Waring  reports  one  case  of  primary  and  one  case 
of  Heroadary  cholesteatoma  of  tUe  temporal  bone. 

[jMS] 


Mtincheuer  medicinische  Wochenschrift. 

January  29,  1901.     [48.  Jahrg.,  No.  5.] 


1.  A 


Contribution  to    the    Knowledge    of   Clitoris    Crises. 

KOSTEE. 

2.  Anterior  Chronic  Poliomyelitis  after  Injury.    Meyer.        I 

3.  The  Action    of  High  Temperature  upon  the  Casein  of  | 

Milk.      CONEADI. 

4.  A  Contribution  to  the  Pathology  of   L%chrynal  Olanda.' 

Stoewee. 

5.  The  Diagnosis  and  Prognosis  of  Gonorrhea  in    the  Maid 

KOPPEN. 

6.  The  Struggle  Against  Venereal   Diseases  among  the  Sti^ 

dents.    ScHOLTz. 

7.  A  New  Contribution  to  Disinfection  with  Formalin,  Esp 

cially  in  Urology.    Loeb 

8.  A  Case  of  Ischiopagus.    Steenbeeg. 

9.  Difficulty  in  Delivery  aa  a  Result  of  a  Double  Monstrosity. 

Palmedo. 

1. — Koster  reports  the  case  of  a  woman,  49  years  of  age, 
who  had  probably  had  luetic  infection,  and  first  manifested 
disease  by  lancilated  pains  in  the  legs,  with  numbness  of  the 
feet,  some  uncertainty  in  gait,  etc.  Ten  years  after  the  first 
symptoms  she  had  at  the  menstrual  periods  crises  in  which 
she  suffered  from  intense  voluptuous  sensations  in  the  region 
of  the  clitoris,  followed  occasionally  by  a  slight  mucous  dis- 
charge. Tnese  attacks  were  always  followed  by  severe  paina 
in  the  pelvic  region,  lasting  for  24  hours,  and  afterwards  by 
pains  in  the  legs.  The  case  has  been  steadily  but  very  slowly 
progressing,  and  these  symptoms  have  persisted  for  10  years. 
The  frequency  with  which  the  attacks  occur  varies  consider- 
ably, sometimes  every  day  or  two;  at  others,  only  at  inter- 
vals of  a  month.  There  were  also  crises  in  the  larynx  associ- 
ated with  pain  and  severe  dypsnea.  Treatment  with  bromidea 
and  baths  produced  considerable  improvement.  There  were 
also  severe  pains  in  the  left  heel,  which  gave  the  patient 
much  discomfort,  and  were  resistent  to  all  forms  of  treal/- 
ment.  These  clitoridiau  crises  are  either  very  rare  or 
have  escaped  observation.  Two  forms  only  have  been  de- 
scribed. One  by  Pitres,  in  which  they  are  quite  typical ; 
another  by  Morselli,  in  which  they  are  replaced  by  intense 
pains  in  the  genitalia.  The  present  case  appears  to  combine 
both  types,    [j  s.] 

2. — Meyer  reports  the  case  of  a  man  59  years  of  age,  who 
sprained  his  right  ankle.  Tnis  troubled  him  for  several  days, 
although  the  pain  was  not  severe.  Fourteen  days  later  a 
physician  observed  a  distinct  weakness  in  the  right  leg  that 
gradually  progressed  until  there  was  distinct  paralysis.  Liter 
the  left  leg  was  involved  ;  there  were  paresthesia,  the  reflexes 
were  diminished  or  absent,  but  there  was  no  disturbance  of 
the  bladder  or  rectum.  It  was  observed  that  the  muscles 
became  weak  and  atrophic ;  there  were  no  fibrillary  twitch- 
ings,  and  there  were  distinct  reactions  of  degeneration. 
Tnere  was  no  tenderness  over  the  muscles  or  the  nerves,  and 
a  diagnosis  of  anterior  poliomyelitis  was  made  on 
account  of  the  regular  progressive  course  of  the  disease,  the 
fact  that  both  legs  were  not  affected  simultaneously,  the  loss 
of  the  skin  and  tendon  reflexes,  the  alteration  in  the  elec- 
trical reactions,  and  the  absence  of  objective  disturbances  or 
sensation.  Slight  paresthesia  are  not  uncommon  in  anterior 
poliomyelitis.  A  diagnosis  of  ascending  neuritis  does  not 
seem  justified  on  account  of  the  very  slight  pains  in  the  be- 
ginning of  the  attack,    [j  s.] 

3. — Conradi  has  perfcrmed  a  number  of  experiments  in 
order  to  determine  what  effect  the  temperatures  used 
ordinarily  in  sterilizition  have  upon  the  chemistry  of 
luilk.  He  found  that  the  addition  of  calciuai  chloride  favors 
coigulation  consilerably  at  a  temperature  of  55°  until  a  con- 
siderable quantity  is  added,  1  part  in  4  of  a  10%  solution, 
whea  it  prevents  coagulation  completely.  Tnis  action  of 
calcium  chloride  is  aitagonized  by  the  addition  of  sodium 
bicarbonate.  Under  these  circumstaujes  the  temperature  at 
which  coagulation  occurs  can  be  considerably  elevat  ?d,  and 
after  enough  of  the  a'kali  has  been  added  it  will  not  coag- 
ulate, even  at  a  temperature  of  boiling.  In  general  it  may 
be  Slid  that  from  0.2  to  0.6%  of  calcium  chlorid  in  cow's 
milk  causes  coagulation  between  45°  and  65°.  If,  however, 
the  milk  haa  first  been  heated  above  SO",  the  temperature  at 
which  coagulation  occurs  is  reduced  from  S°  to  12°,  indicating 
ai  alteration  in  the  casein.    Toe  period  required  for  coagu- 


April  6,  1901| 


THE  LATEST  LITERATURE 


CThb  Philadblphia 
Medical  Joubmal 


655 


lation  may  vary  considerably.  With  ordinary  rennet  it  was 
found  for  normal  milk  to  occupy  from  5  to  7  minutes.  If, 
however,  the  milk  had  been  heated  to  80°  the  period  was 
greatly  prolonged,  and  if  it  had  been  boiled,  it  sometimes 
required  many  hours  before  coagulation  occurred,  if  at  all. 
Conradi  therefore  recommends  that  in  sterilization  tempera- 
tures of  less  than  75°  be  employed,    [j  s  ] 

5. — Koppen  reports  some  interesting  eases  bearing  upon 
the  diagnosis  of  gonorrhea.  One  of  these,  a  boy  of  17 
who  had  been  exposed,  wa?  found  to  have,  not  gonorrhea, 
but  tuberculosis  of  the  testicles.  Another,  a  man  of  60,  with 
tuberculosis,  was  found  to  be  suffering  from  acute  urethritis. 
He  reports  several  other  cases  in  which  infectious  processes 
had  remained  latent  for  a  number  of  years,  and  then,  as  a 
result  of  some  irritation,  had  suddenly  developed.  He  calls 
attention  to  the  great  importance  of  careful  microscopical 
examination,  and  believes  that  by  it  we  are  frequently  in  a 
position  to  make  a  diagnosis  even  although  a  urethroscope 
18  not  available.  No  case  is  to  be  recorded  as  cured  until  all 
discharge  ceases,    [j.s,] 

6. — Scholtz  believes  that  the  present  agitation  concerning 
venereal  infection  is  having  considerable  success  among  the 
German  students,  particularly  in  regard  to  leading  them  to 
seek  treatment  promptly,     [j.s.l 

7. — Loeb  has  performed  some  experiments  in  order  to  de- 
termine the  efficacy  of  formalin  disinfection,  particularly 
for  catheters  and  similar  instruments.  For  this  purpose 
he  used  cultures  in  gelatine  in  order  to  render  the  access  of 
the  disinfecting  agent  to  the  germs  as  difficult  as  possible. 
He  found  that  mercuric  cyanide  solution  acted  in  6  hours 
upon  the  spores  of  anthrax  at  a  temperature  of  over  70°,  but 
failed  to  act  in  7  days  at  normal  temperature.  He  found 
that  formalin  vapor  destroyed  these  spores  in  6  hours,  al- 
though this  did  not  occur  if  the  tubes  were  plugged  with 
cotton.  Bouillon  cultures  were  destroyed  in  2  hours.  He 
believes  that  it  is  important  to  use  some  method  of  mechani- 
cal cleansing  before  the  application  of  the  disinfectant. 
Catheters  he  sterilized  by  allowing  a  solution  of  corrosive 
sublimate,  1  to  1,000,  to  run  through  them  for  about  24  hours. 
This  invariably  destroyed  all  spores,    [j  s.] 

8. — Sternberg  reports  a  case  of  ischiopagus.  Delivery 
was  accomplished  by  extracting  first  one  child  and  then 
doing  version  upon  the  other.  Both  portions  of  the  monster 
died  at  birth,  although  one  made  a  few  efforts  to  breathe 
after  delivery.  The  monster  consisted  of  two  heads  and 
necks,  four  well-proportioned  arms,  two  well-developed  legs, 
and  a  single,  considerably  shrunken  limb.  There  were  two 
spinal  columns,  and  two  thoraces,  which,  however,  were  in- 
cluded in  the  common  skin  covering,  but  only  one  pelvis. 

[J  8.1 

9. — Palmedo  reports  another  case  of  double  mon- 
strosity, which  was  delivered  with  great  difficulty,  one 
child  living  about  an  hour,  the  other  dying  at  birth.  The 
children  were  apparently  united  along  the  ventral  sur- 
faces.    [J  s.] 

February  5, 1901.     [48.  Jahrg.,  No.  6.] 

1.  Total  Abdominal  Extirpation  of  the  Uterus  in  Carcinoma 

and  Sarcoma,  with  Reference  to  the  Permanence  of 
the  Results.    Funke. 

2.  What  are  the  Results  of  Tetanus  Antitoxin  in  Tetanus  in 

Human  Beings?    Wilms. 
8.  Epityphlitis    and    the   Present  Position  Concerning  Its 

Treatment.    Berndt. 
4.  The  Treatment  of  Eczema.    Kromayer. 
6.  The  Method  of  Determining  the  Freezing  Point  of  the 

Blood,  with  Reference  to  Its  Freezing  Point  in  Typhoid 

Fever.    Rumpel. 

6.  Intermittent  Fever  as  a  Symptom  of  Mediastinal  Tumors. 

WiTTHAUER. 

7.  Medical  and  BDtanical   Notes.      (2)  Further  Studies  of 

Menabea  Veneata  Baillon.    Model. 

8.  A  Simple  Support    for  the  Uterus   and  Vagina    (Hys- 

terophor).    Reismann. 

9.  Remarks  Upon  the  Article  of  Prof.  Paul,  "The  Employ- 

ment of  Smd  for  the  Rapid  Filtration  of  Nutrient 

Agar."    Wilde. 
1. — Funke  reports  19  cases  in  which  he  performed  total 
extirpation  of  the  uterus  on  account  of  malignant 
tumor.     Tnree  died  within  a  few  days  of  the  operation, 


and  the  others  recovered,  but  it  is  still  too  early  to  speak 
positively  of  the  absence  of  recurrence.  He  discusses  par- 
ticularly the  indications  that  are  given  by  enlargement  of  the 
glands.  In  16  cases  out  of  40,  those  upon  which  the  opera- 
tions have  been  performed  moat  recently,  this  enlargement 
was  carefully  sought  for  and  found  in  8.  Of  these  8,  two 
showed  such  extensive  metastasis  that  a  radical  operation  was 
not  possible.  In  2  others  the  glands  could  not  be  removed 
on  account  of  extensive  adhesions.  In  another  2,  both 
young  women  with  carcinoma  of  the  cervix,  in  spite  of  ex- 
tensive removal  of  the  glands,  recurrence  appeared  within  5 
months,  showing  that  the  operations  had  not  been  radical 
enough.  In  one  of  these  the  recurrence  appeared  on  the  side 
from  which  the  glands  had  been  removed.  Of  the  remaining  2 
cases,  one  has  shown  no  recurrence  since  1896,  and  1  had  only 
recently  undergone  operation.  Funke  prefers  the  combined 
vaginal  and  abdominal  routes.  He  believes  that  the  opera- 
tion should  not  last  longer  than  any  other  severe  laparotomy, 
that  lit  should  be  very  thorough  and  involve  the  removal 
of  the  chain  of  glands  along  the  iliac  arteries  and  the 
ureters,  and  the  complete  removal  of  the  parametrium  and 
the  lymphatics  connected  with  it.  The  prognosis  of  carci- 
noma in  young  women,  that  is  to  say,  those  about  30  years 
of  age,  is  very  doubtful,  on  account  of  the  extremely  rapid 
growth  of  the  tumor,  and  the  fact  that  metastases  may  occur 
before  adhesions  may  have  formed.  In  older  women  the 
progress  is  more  gradual.  It  is  very  difficult  therefore,  to 
say  which  cases  are  adapted  to  a  radical  operation,  and  which 
to  a  palliative  one.  The  higher  mortality  of  Frend's  oper- 
ation, which  was  the  one  used  by  Funke,  is  apparently  due 
in  part  to  defective  technic,  for  in  his  own  experience  the 
percentage  of  deaths  has  steadily  decreased.  As  for  the  pos- 
sibility of  permanent  cure  the  following  figures  show  that  it 
is  not  inconsiderable.  In  11  cases  operated  upon  before 
1896,  2  died  immediately  after  the  operation ;  4  of  recur- 
rence, and  5  are  still  living  and  apparently  well.  Of  these 
cases  2  were  sarcomas,  1  carcinoma  of  the  cervix,  1  of  the 
body  of  the  uterus,  and  1  of  the  entire  organ,    [j.s.] 

3. — Wilms  reports  the  following  cases  of  tetanus  in 
which  the  antitoxin  was  employed.  A  man  of  26  re- 
ceived a  severe  wound  in  the  knee-joint  requiring  amputa- 
tion six  days  later.  Eight  days  after  the  injury  there  were 
symptoms  of  tetanus,  and  250  units  of  antitoxin  were  injected 
on  that  day,  and  on  each  of  the  following  three  days.  The 
patient  died  on  the  fourth  day  of  the  disease  without  any 
improvement.  A  man  of  39  received  a  severe  crush  of  the 
skin  of  the  left  leg.  On  the  eighth  day  symptoms  of  tetanus 
appeared,  and  on  the  following  day  an  injestion  of  250  units 
was  made.  The  patient  died  the  same  day.  The  third  case, 
a  boy  of  18,  was  injured  upon  the  right  foot.  On  the  seventh 
day  the  symptoms  appeared  and  20  hours  later  125  units  of 
antitoxin  were  injected,  and  a  similar  amount  in  three  hours. 
The  next  day  250  units  more  were  injected  and  on  the  third 
day  death  occurred.  The  fourth  patient,  a  man  of  22,  re- 
ceived aa  injury  to  his  hand ;  on  the  ninth  day  the  symptoms 
appeared  and  on  the  same  day  1,000,000  units  were  injected, 
and  within  the  first  30  hours  altogether  4,000,000  units.  No 
improvement  of  any  kind  was  observed,  and  the  patient  died. 
In  all  these  cases  the  conditions  which  Bshring  requires  to 
be  fulfilled  were  carefully  observed,  that  is  that  the  serum 
treatment  shall  be  commenced  in  30  hours  afcer  the  first 
symptoms  have  appeared,  and  that  not  less  than  100  units 
shall  be  injected.  Nevertheless  all  the  patients  died.  Wilms 
reports  also  two  cases  of  chronic  tetanus  in  both  of  which 
the  serum  was  employed,  and  both  of  which  recovered.  In 
both  cases,  however,  the  serum  was  not  employed  until  the 
third  day.     [j.s.] 

3._B3rn(lt,  in  the  first  portion  of  a  valuable  paper  on 
appendicitis,  or,  as  he  prefers  to  call  it,  epityphlitis, 
speaking  of  the  etiology  of  the  disease,  discards  entirely  the 
idea  of  stercoral  typhlitis,  that  is  to  say  appendicitis  caused 
by  an  accumulation  of  feces  in  the  cecum  ;  however,  he  ad- 
heres to  the  view  that  the  majority  of  cases  are  caused  by 
some  fecal  conorement  or  foreign  body  in  the  lumen  of  the 
appendix  itself,  which  may  cause  perforation  by  pressure,  or 
by  setting  up  an  inflammation  that  distends  the  appendix 
and  finally  ruptures  it.  In  a  series  of  operations  he  obtained 
a  number  of  specimens  which  show  practically  all  stages  ot 
the  disease,  and  curiously  enough,  vary  in  length  from  4  to 
20  cm.  He  accepts  the  conclusions  of  Sonuenberg,  who 
recognized  the  following  types:  First,  acute  catarrhal  epi- 


656 


Thk  Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Apeil  0,  1901 


typhlitis ;  second,  chronic  catarrhal  epityphlitia  ;  third,  per- 
forative ulcerated  epityphlitis  (a.  with  circumscribed  perito- 
nitis, 6.  with  diffuse  peritonitis).  He  gives  the  symptoms  of 
the  three  types  as  follows  :  Acute  catarrhal  epityphlitis  not 
infrequently  accompanies  acute  gastroenteritis;  it  is  charac- 
terized by  moderate  pains  in  the  iliac  region,  tenderness 
over  McBuraey's  point,  and  in  some  cases  a  palpable  appen- 
dix which  may  be  felt  as  a  cord  and  is  recognized  by  the 
patient  as  the  seat  of  pain ;  chronic  epityphlitis  usually 
occurs  in  patients  who  have  suffered  from  digestive  disturb- 
ances for  years.  They  have  loss  of  appetite,  occasionally 
vomiting,  diffuse  abdominal  pains,  and  constipation  or  a 
tendency  to  diarrhea.  The  disease  not  infrequently  occurs 
in  young  girls,  and  may  be  confused  with  chlorosis. 
Upon  physical  examination  the  appendix  may  sometimes 
be  felt  as  a  painful  cord,  and  there  is  nearly  always 
tenderness  over  McBurney's  point.  To  this  class  be- 
longs a  group  of  cases  characterized  by  frequently 
repeated  attacks  of  pain  usually  localized  in  the  right 
iliac  region,  and  accompanied  by  vomiting  and  fever,  and 
either  constipation  or  diarrhea.  These  attacks  last  usu- 
ally only  a  few  days.  Then  finally  the  patient  has  a  very 
severe  attack  characterized  by  high  fever,  weak  and  rapid 
pulse,  and  then  the  formation  of  an  exudate  in  the  region  of 
the  appendix.  If  the  symptoms  persist,  the  difierential  diag- 
nosis from  perforative  epityphlitis  is  difficult.  Ordinarily, 
however,  the  symptoms  rapidly  diminish,  the  exudate  disap- 
pears, and  in  8  days  there  are  no  further  traces  of  disease. 
If  an  operation  is  performed  the  appendix  is  usually  found 
slightly  adherent,  with  thickened  and  rigid  walls.  Perfora- 
tive epityphlitis  usually  occurs  in  patients  who  have  had 
numerous  typical  attacks,  or  at  least  occasional  pains  in  the 
abdomen.  In  a  few  cases  no  previous  symptoms  have  oc- 
curred ;  these  patients  are  usually  robust.  The  symptoms 
are  a  sudden  pain  in  the  abdomen,  vomiting  and  high  fever 
often  associated  with  chills,  superficial  respiration,  and  small 
rapid  pulse,  with  an  expression  of  extreme  anxiety  upon  the 
face,  which  is  often  covered  with  sweat,  and  a  retracted  and 
rigid  abdomen.  In  the  course  of  a  few  hours  or  days  the 
pain  becomes  localized  in  the  right  iliac  region ;  the  abdomen 
is  slightly  distended,  there  is  resistance  in  the  region  of  the 
appendix,  distinct  dulness  on  percussion  and  exquisite  ten- 
derness. From  this  point  different  cases  pursue  different 
courses.  In  some,  symptoms  of  septicemia  develop,  and  the 
patient  dies  within  24  hours ;  in  others,  they  become  mild, 
and  in  spite  of  perforation  the  patients  gradually  improve. 
Berndt  believes  that  this  is  not  due  to  previous  walling  off 
of  the  appendix  by  adhesions,  but  rather  to  the  different 
degrees  of  virulence  of  the  microorganisms,  for  in  his 
opinion  the  contents  of  the  appendix  are  always  expelled 
into  the  free  peritoneal  cavity.  In  a  few  cases  the  pain  is 
felt  on  the  left  and  not  on  the  right  side.  In  all  cases  it  is 
extremely  important  to  watch  the  pulse  and  the  tempera- 
ture in  order  to  control  as  far  as  possible  the  condition  of  the 
patient.  In  regard  to  treatment  his  opinions  are  interesting. 
The  first  form  does  not  require  operative  interference.  The 
second  form,  the  chronic  catarrnal,  can  be  cured  only  by 
removal  of  the  appendix.  The  operation  is  best  performed 
during  an  interval.  The  third  form  may  occasionally  heal 
spontaneously,  but  no  physician  should  depend  upon  this. 
Nevertheless,  as  the  great  majority  of  the  cases  of  perforative 
epityphlitis  pass  into  a  latent  stage  if  treated  expectantly,  it 
is  obvious  that  every  case  should  not  be  subjected  to  an  opera- 
tion as  soon  as  the  diagnwis  is  made.  The  choice,  of  course, 
depends  entirely  upon  the  experience  cf  the  surgeon.  If  the 
symptoms  are  grave  from  the  first,  an  immediate  operation 
is  demanded.  If,  on  the  other  hand,  they  are  mild  and 
steadily  improve,  expectant  treatment  is  probably  the  best. 

[J.S.] 

4.— Kromayer  and  Giiinebcrg  believe  that  in  eczema  the 
following  indications  should  be  met.  Rest  of  the  skin,  the 
removal  of  the  chronic  changes  in  the  tissue,  and  the  cauter- 
ization of  the  inflammatory  areas.  The  latter  procedure  is 
one  that  most  frequently,  if  improperly  uied,  causes  disaster. 
Lenigallol  is  the  best  drug  for  the  treatment  of  eczema  that 
has  hitherto  been  introduced.  It  is  the  triacetate  of  pyro- 
gallic-acid,  and  occurs  in  the  form  of  a  white  crystalline 
powder,  insoluble  in  water.  Brought  into  contact  with  skin 
in  a  seat  of  chronic  inflammation,  it  gradually  yields  free 
pyrogallic  acid.  On  healthy  skin  it  is  entirely  nonirritatiug. 
The  authors  have  used  it  in  about  6C0  cases  with  very  excel- 


lent results.  They  employ  either  20  parts  in  8  parts  of  zinc 
paste,  or  10  parts  mixed  with  tar  and  zinc  paste,  or  mixed 
with  Wilkinson's  ointment.  The  zinc  pa«te  mixture  is  used 
in  the  milder  cases  and  ordinarily  all  the  inflammatory  parts 
are  colored  black  at  the  end  of  the  first  day.  In  the  deeper 
cases  one  of  the  other  preparations  is  used.  In  a  few  cases 
the  results  are  unsatisfactory  because  the  caustic  action  is 
too  slight,     [j.s.] 

6.— Rumpel  criticizes  the  statements  of  Waldvogel  who 
discovered  a  remarkable  reduction  in  the  freezing  point 
of  blood  obtained  from  typhoid  fever  cases.  He 
has  repeated  these  experiments  and  found  that  by  various 
technical  procedures,  or  by  the  dilution  of  normal  blood- 
serum,  an  artificial  reduction  could  be  obtained.  In  llcaaes 
of  typhoid  fever  with  varying  temperatures  he  has  carefully 
estimated  the  freezing  point  of  the  blood,  and  found  that  it 
was  exactly  normal,    [j  s  ] 

6. — Witthauer  reports  a  remarkable  case,  a  woman  24 
years  of  age,  who  was  attacked  with  pains  in  the  side,  cough, 
and  fever.  Examination  showed  an  area  of  dulness  on  the 
left  side  in  the  region  of  the  lower  lobe,  in  which  the  breath 
sounds  were  weak.  Exploratory  puncture  gave  a  clear  fluid. 
There  was  some  hectic  fever.  A  second  aspiration  gave 
again  a  small  quantity  of  fluid.  For  a  period  of  5  months 
the  patient  had  a  regularly  relapsing  fever,  the  remissions 
lasting  3,  rarely  4  days.  Then  on  the  fifth  day  the  tempera- 
ture rose  te  39°  or  40°,  fell  the  following  day  to  38°,  and  the 
next  day  became  normal.  Careful  examination  of  the  blood 
for  malarial  parasites  was  negative.  No  antiseptic  measures 
nor  specific  treatment  had  any  effect  whatever.  In  the  last 
month  the  patient  showed  slight  cyanosis  of  the  face,  pulsa- 
tion of  the  vessels  in  the  neck,  and  then  gradually  increasing 
symptoms  of  bronchial  stenosis  that  led  to  death.  At  the 
autopsy  a  large  tumor  was  found  in  the  posterior  medi- 
astinum about  the  size  of  two  fists.  It  had  invaded  the 
posterior  walls  of  both  auricles.  It  also  compressed  both 
bronchi  and  the  left  branch  of  the  pulmonary  artery  and 
had  invaded  a  considerable  portion  of  the  right  lung. 
Microscopically,  it  proved  to  be  a  round-celled  sarcoma. 
The  interesting  features  were  the  regularly  recurring  fever 
and  the  invasion  of  the  heart,     [j.s.] 

7. — Model,  after  a  careful  analysis  of  the  facts  regarding 
the  existence  of  the  menabea  veneata  baillon,  reaches 
the  conclusion  that  this  plant  does  exist,  belongs  to  the 
ordalia,  and  that  it  is  exceedingly  important  that  fresh  speci- 
mens should  be  obtained  from  Madagascar  and  carefully 
studied  in  relation  to  their  toxicity.     [J  s] 

8. — Reismann  suggests  a  simple  apparatus  for  sup- 
porting the  uterus,  consisting  of  a  rubber  tube  stuffed 
with  cotton,  and  supported  at  its  lower  end  by  2  other  tubes 
that  fasten  into  tie  belt.  For  more  accurate  dtecriptioa  we 
refer  the  reader  to  the  original  article,     [j.s.] 

9. — Wilde  clears  agar  with  the  white  of  egg-,  thev,  after 
prolonged  boiling,  is  able  to  filter  it  quite  rapidly.  He 
believes  this  method  is  quite  as  good  as  that  of  Paul.    [JS.] 

February  IS,  1901.    [48.  Jahrg.,  No.  7.] 

1.  The  Function  il  Results  of  the  Transplanting  «f  Tendons 

in  Paralytic  Deformities,  especially  in  the  Paralysis  of 
Children,    jvunik. 

2.  The  Upper  Temperature  Limit  of  Life.    Stecdel. 

3.  Acute  Puerperal  Inversion  of  the  Uterus.    FLKiscHMA>Tf. 

4.  The  Indications  for  Palliative  and  for  Operative  Treat- 

ment of  Myomota  of  the  Uterus.    Schaixkr. 
g.  The  Perineuriiic  Diseases  of  the  Sacral  Plexus.    GtrrxEJi- 

BERO. 

C).  China  Acid  :  a  New  Remedy  for  Gout.    Stersfeld. 
7.  Epityphlitis,  and   the  Present    Opinions  Regarding    Its 
Treatment.    Berndt. 

5.  Remarks  upon  the  Article  of  Dr.  Trumpp  :  "  Progressive 

Diphtheria  with  Prompt  Serum  Treatment.''  Schmidt- 

MOSNARD. 

9.  Remarks  upon  the  Article  of  Dr.  Frank  :  "  The  Disinfectr 
ant  Action  of  Alcohol,  EJspecially  of  Alcohol  Steam." 
V.  Brunx. 

1. — Kunik  discusses  the  technical  points  involved  in  the 
transplantation  of  tendons  for  the  correction  of 
deformities  of  the  feet  and  hands.  The  various  proced- 
ures may  be  roughly  grouped  as  follows :  First,  the  trans- 
plantation of  the  central  portion  of  a  healthy  muscle  into 


APRIL  n,  1901) 


THE  LATEST  LITERATURE 


[The  Philadklphia 
Mjckical  Joubnal 


657 


the  tendon  of  a  paralyzed  muscle  ;  second,  the  division  of 
the  tendon  of  a  paralyzed  muscle  and  the  implantation  of  its 
peripheral  portion  in  the  healthy  muscle,  sometimes  called 
"passive  transplantation  ";  third,  splitting  of  the  tendon  of 
a  healthy  muscle  and  the  implantation  of  one  half  into  the 
tendon  of  a  paralyzed  muscle,  gometimes  called  "active 
transplantation"  ;  fourth,  the  implantation  of  a  healthy  ten- 
don in  the  periosteum.  In  addition  to  the  transplantation 
of  the  tendons  it  is  often  necessary  to  employ  other  operative 
measures,  such  as  correction  of  the  position,  etc.,  before  the 
transplantation  is  undertaken.  In  those  cases  in  which  con- 
traction of  the  muscles  antagonistic  to  the  paralyzed  muscles 
has  occurred,  it  is  necessary  to  elongate  the  tendons  by 
making  a  series  of  step-like  incisions.  Another  impor- 
tant procedure  is  the  resection  of  the  tendons  of  healthy 
muscles  that  as  a  result  of  vicious  position  of  the  extremity 
have  become  abnormally  elongated.  Of  course,  in  many 
cases  it  requires  a  combination  of  all  methods  in  order  to 
secure  the  desired  result.  In  addition  to  infantile  spinal 
paralysis  deformities  due  to  injury,  or  those  that  are  con- 
genital, may  be  operated  upon  by  these  measures.  The 
operation  should  be  undertaken  only  when  cure  by  any 
other  measure  is  manifestly  hopeless,  and  as  long  as  traces 
of  spontaneous  improvement  appear  it  should  be  delayed. 
After  the  operation  the  extremity  is  placed  in  the  position 
of  over-correction  and  fixed  in  a  plaster  cast.     [j.s.  | 

2. — Steudel  calls  attention  to  the  fact  that  certain  of  the 
lower  forms  of  life,  particularly  bacteria,  are  capable  of 
living:  at  temperatures  nearly  as  bigrh  as  those 
that  coagulate  albumin,  that  i^  to  say,  they  not  only 
maintain  lite,  but  actually  multiply  actively  at  from  60° 
to  70*  C.  These  microorganisms  under  anaerobic  con- 
ditions, particularly  if  associated  with  other  forms,  can 
multiply  at  other  temperatures.  It  is  interesting  to  note 
that  certain  other  lower  forms  of  life  can  resist  high  tem- 
peratures if  sufficient  water  has  been  abstracted  from  them. 
This  is  particularly  true  of  the  rhizophods.  Certain  rhizo- 
phods  are  capable,  as  a  result  of  careful  cultivation,  of  sup- 
porting a  temperature  of  70°  C. 

3. — Fleischmann  reports  a  case  of  inversion  of  the 
uterus  occurring  in  a  primipara.  After  delivery  the  uterus 
remained  relaxed,  and  during  an  effort  to  expel  the  placenta 
by  Credo's  method,  the  uterus  suddenly  became  completely 
inverted,  and  the  patient  immediately  went  into  collapse. 
Upon  an  attempt  to  replace  it,  it  was  found  that  the  cervix 
opposed  an  obstacle,  but  this  was  overcome  by  gentle  force. 
After  replacement,  the  uterus  remained  relaxed  until  a 
warm  injection  was  given,  when  it  immediately  contracted, 
and  the  subsequent  course  was  normal.  He  also  reports 
another  case  that  occurred  in  th^  service  of  Dr.  Becker,  in  a 
multipara,  which,  however,  was  easily  replaced.  In  a  few 
remaiks  upon  this  condition  Fleischmann  mentions  the 
collapse  that  is  so  common,  and  is  peculiar  in  that  it  dis- 
appears almost  immediately  after  reposition.  The  chief 
obstacle  to  this  is  the  cervix.  This  can  best  be  overcome 
by  inserting  the  fingers,  then  gradually  distending  them,  and 
at  the  same  time  pressing  upon  the  fundus  with  the  hollow 
of  the  hand.  The  placenta  probably  always  should  be  re- 
moved before  reposition  is  attempted,  partly  because  if  this 
is  not  done  inversion  is  apt  to  recur  and,  moreover,  reposi- 
tion is  always  more  difficult,    [j.  s] 

4. — Schaller  states  that  in  those  cases  in  which  the  patient 
has  a  small  myoma  of  the  uterus  that  does  not  produce 
symptoms,  he  does  not  advise  an  operation,  nor  does  he  even 
tell  the  patients  that  they  have  a  tumor.  Large  myomata 
produce  merely  mechanical  disturbances;  small,  intramural 
myomata  frequently  cause  an  obstinate  dysmenorrhea.  In  a 
few  cases  the  myomata  become  malignant,  and  then  endan- 
ger the  life  of  the  patient.  In  all  cases  in  which  they  un- 
dergo suppuration,  gangrene,  or  sarcomatous  changes,  they 
should  be  removed.  In  case  the  patient  should  become  preg- 
nant, they  usually  develop  very  rapidly.  Schaller  believes 
that  a  conservative  treatment  is  often  of  great  advantage. 
Tnus,  the  patients  can  be  considerably  improved  by  rest  in 
bed  during  menstruation,  moderate  purgation,  ice-bag  upon 
the  abdomen,  and  a  general  improvement  in  the  nutrition. 
Certain  hemostyptics  are  of  value,  especially  hydrastis,  and 
occasionally  ergotin.  Locally,  hot  douches  to  the  vagina 
may  be  employed,  or  certain  escarotica  to  the  mucous  mem- 
branes, such  as  tincture  of  iodin,  carbolic  acid,  etc.  Elec- 
tricity does  not  appear  to  be  of  value.    Ovariotomy  is  some- 


times of  value,  particularly  in  patients  suflfering  extreme 
cachexia,  in  whom  an  operation  might  be  dangerous.  In 
submucous  myomata,  a  vaginal  enucleation  may  be  em- 
ployed, although  in  these  cases  recurrence  may  appear.  In 
the  more  severe  forms,  the  combined  vaginal  and  abdominal 
operation  is  probably  the  best.    [J.s.] 

6.— Guttenberg  reports  5  cases  occurring  in  women,  in 
which  the  symptoms  were  pain  in  the  lower  portion  of  the 
abdomen,  and  in  whom,  upon  careful  examination,  small 
nodules  were  found  along  the  cord  of  the  sacral  plexus,  that, 
according  to  Rindfleisch,  who  examined  a  similar  case,  con- 
sist of  an  accumulation  of  small  cells  with  round  or  oval 
nuclei ;  that  is,  a  form  of  neuritis  nodosa.  In  all  these  eases 
cure  was  obtained  by  careful  attention  to  the  general  con- 
ditioB,  and  systematic  massage  of  the  nerves,  with  hyper- 
fiexion  of  the  thighs  upon  the  abdomen.  Cure  usually  re- 
quired se  veral  weeks .     [ J.s  ] 

6. — Sternfeld  highly  recommends  china  acid,  obtained 
from  various  fruits,  in  the  treatment  of  uric-acid  diathesis. 
This  is  converted  into  benzoic  acid,  and  finally  into  hippuric 
acid  in  the  body,  and  when  combined  with  the  uric  acid  pro- 
motes the  elimination  of  the  latter.  The  great  objection  to 
it  at  present  is  its  high  price,    [j.s.] 

7. — Berndt,  in  continuation  of  his  article  upon  epityph- 
litis,  discusses  the  methods  of  operation.  The  object  snouid 
always  be  to  reach  the  site  of  the  primary  abscess.  The 
operation  is  always  serious,  and  is  not  to  be  undertaken 
unless  absolutely  indicated.  A  double  operation  is  entirely 
irrational.  When  a  typical  attack  has  occurred,  should  the 
patient  recover,  operation  should  be  performed  3  or  4  days 
after  the  disappearance  of  the  fever.  In  cases  with  a  mild 
course,  there  may  sometimes  persist  a  remittent  fever,  rising 
in  the  evening.  This  usually  indicates  the  existence  of  a 
large  encapsulated  abscess.  When  this  is  opened  the  appen- 
dix should  be  removed  if  easily  found,  but  it  is  undesirable 
to  take  great  pains  to  search  for  it.  Berndt  prefers  an  oblique 
incision  parallel  to  Poupart's  ligament,  and  passing  through 
McBurney's  point.  Tnis  is  continued  through  the  muscles 
and  fascia  until  the  site  of  the  operation  is  reached.  During 
an  interval  the  operation  is  usually  more  difficult  because 
the  adhesions  are  denser.  If  the  operation  is  done  during  an 
attack,  it  is  usually  desirable  to  tampon  the  entire  wound. 
The  results  in  40  cases  were  as  follows  :  Operation  during  an 
interval — 15  cases,  all  cured ;  made  after  an  acute  attack — 
7  cases,  all  cured ;  opening  of  a  large  encapsulated  abscess 
after  a  long  febrile  period — 5  cases,  all  cured  operated  upon 
during  an  attack  (I)  without  perforation  of  the  appendix — 2 
cases,  both  cured;  (2)  with  perforation  or  gangrene  of  the 
appendix — 11  cases,  5  cured  and  6  died.  Three  of  these  were 
operated  on  in  a  state  of  collapse.  Twenty- four  of  these  pa- 
tients were  subsequently  observed,  3  had  hernia  in  the  wound ; 
all  were  operated  upon  during  an  attack.  The  others  were 
normal  with  the  exception  of  1  who  had  a  very  email  tumor 
upon  coughing.  Two  patients  had  intestinal  fistulas ;  one  of 
these  closed  spontaneously,  the  other  was  not  closed  by  two 
operations.  The  histories  of  the  cases  are  given  in  detail. 
[J  si 

8. — Schmidt-Monnard  has  observed  several  cases  of  diph- 
theria in  which  he  was  obliged  to  use  old  serum,  and  his 
impression  has  been  that  it  acted  much  less  efficiently  than 
fresh  serum,    [j.s.] 

9. — Von  Brun  believes  that  in  disinfection  with  alcohol 
the  vapor  is  the  effective  element.  He  is  delighted  that  his 
results  have  been  confirmed  by  Frank,     [j.s.] 


Centralblatt  filr  Gynakologie. 

December  29,  1900. 

1.  Total  Extirpation  of  the  Vagina  Through  tho  Abdomen. 

Ernst  Wertheim. 

2.  Remarks  upon  Total  Extirpation  for  Myoma  Through  an 

Abdominal  Incision.    H.  A.  v.  Guerard. 

3.  Contribution  to  the  Etiology  of  Sactosalpinx  with  Torsion 

of  the  Pedicle.    J.  Harpoth. 

4.  Critical  Reports  on  the  Speculum  of  Professor  Dr.  Drag- 

hiescu.    Z.  Sintenis. 

1. — Wertheim  reports  2  cases  of  total  extirpation  of 
the  vagina  through  the  abdominal  incision  for  cancer  of 
ttiat  organ  secondary  to  carcinoma  of  the  cervix.    His  first 


658 


The  Philadelphia' 
Mbdical  Journal 


] 


THE  LATEST  LITERATURE 


[APEIL  6,  1901 


patient  wae  a  woman,  56  years  of  age,  who  presented  a  can- 
cerous ulcer  the  size  of  a  walnut  upon  the  anterior  vaginal 
wall,  which  was  accompanied  by  a  slight  hemorrhagic  dis- 
charge. He  performed  the  radical  operation  through  a 
sagittal  median  incision,  extirpating  not  only  the  uterus,  but 
the  upper  portion  of  the  vagina  and  a  portion  of  the  pos- 
terior vaginal  wall.  No  prophylactic  catheterization  of  the 
ureters  was  resorted  to.  Considerable  venous  hemorrhage 
from  the  paravaginal  cellular  tissue  followed  the  extirpation, 
but  this  was  easily- controlled  by  ligature.  The  lymph-glands 
in  the  vicinity  were  also  extirpated,  the  peritoneal  edges 
were  closely  coaptated,  and  subperitoneal  drainage  into  the 
vagina  was  established  by  idoform  gauze.  The  patient  made 
an  excellent  recovery.  The  second  case  was  a  woman,  51 
years  of  age,  upon  whose  portio  vaginae  existed  a  white  car- 
cinomatous growth  the  size  of  an  apple.  The  posterior 
vaginal  wall  also  presented  multiple  small  and  large  capillary 
outgrowths.  A  similar  operation  as  in  the  foregoing  case 
was  performed.  The  carcinoma  had  descended  pretty  close 
to  the  bladder-wall  and  had  surrounded  the  ureter ;  as  a 
result  a  left-sided  uretero-vaginal  fistula  followed,  otherwise 
the  operation  resulted  well.  Three  months  later  a  nephrec- 
tomy was  nerformed  for  the  relief  of  the  fistula,  [w.a  n.d  ] 
2. — Guurard  considers  the  question  of  extirpation  of 
myomata  throug:h  the  abdoniiual  incision  versus 
total  extirpation  of  the  myomatous  uterus,  which 
was  first  discussed  by  Hofmeier.  He  is  inclined  to  prefer 
the  total  extirpation  of  the  uterus  through  the  abdomen  to 
the  mere  amputation  of  that  organ  at  the  cervical  junction. 
The  operation  consists,  after  opening  the  abdomen,  in 
enucleating  the  tumor  and  then  opening  into  the  vaginal 
fornices  anteriorly  and  posteriorly  and  securing  the  vaginal 
wall  to  the  peritoneal  edges.  The  hemorrhage  ii  but  slight, 
and  the  operation  takes  from  but  30  to  36  minutes,  requiring 
not  more  than  three  ligatures  in  some  cases.  He  has  removed 
by  this  method  tumors  weighing  11  pounds  or  more  and 
varying  in  size  from  that  of  a  child's  head  to  a  man's  head. 

[W.A.N.D.] 

3. — Harpoth  records  a  case  of  sactosalpiax  with  tor- 
sion of  the  pedicle  in  addition  to  the  22  cases  of  this  con- 
dition recorded  in  1899  by  Praeger  in  the  Archives  fiir  Gymi- 
kologie,  Bd.  Iviii,  Hft.  3.  His  case  was  a  young  woman,  26 
years  of  age,  who  suffered  from  severe  pains  in  the  right  side 
of  the  abdomen,  the  pains  localizing  themselves  in  the  right 
iliac  fossa.  In  the  intervals  between  the  pains  the  patient 
felt  quite  well.  Menstruation  had  always  been  regular,  last- 
ing four  days  and  was  unattended  with  pain.  The  patient 
had  been  suffering  for  some  time  from  metrorrhagia.  Ab- 
dominal palpation  revealed  a  tumor  extending  above  Pou- 
part's  ligament,  wliile  vaginal  examination  showed  the 
uterus  lying  well  up  in  the  pelvis  and  small  in  size.  The 
tumor  could  be  felt  lying  on  the  right  side  and  extending 
posteriorly  into  Douglas's  culdesac.  It  fluctuated  on  per- 
cussion, was  sensitive  to  the  touch  and  was  about  the  size  of 
a  small  child's  head.  It  had  a  broad  pedicle.  The  ovaries 
could  not  be  detected,  and  there  was  no  ascites.  Operation 
revealed  a  tubal  tumor  which  was  slightly  adherent 
and  which  had  twisted  upon  itself,  producing  torsion  of  the 
pedicle.  The  tube  was  ligated  and  extirpated.  Harpoth 
remarks  that  sactosalpinx  usually  occurs  in  a  tube  which  is 
quite  free  or  but  slightly  adherent  to  the  surrounding  tis- 
sues ;  this  was  the  case  in  his  own  instance  of  the  complica- 
tion.    [W.A.N.D.J 

JaniMry  5,  1901. 

1.  Operation  for  Hernia  of  the  Umbilical  Cord  with  Resec- 

tion of  the  Prolapsed  Lobes  of  the  Liver.    Otto  KOst- 

NEB. 

2.  Additional  Remarks  on  the  Use  of  Protargol  by  Credo's 

Eye  Instillation- Method.    Fritz  Englemann. 

3.  Another  Case  of  Hypertrophy  of  the  Female  Mammary 

Glands.    A.  GrasmCck. 

1. — Kiistner  reports  an  interesting  case  of  a  male  child 
admitted  to  the  Polyclinic  in  Breslau  presenting  a  large-sized 
umbilical  hernia,  as  large  as  an  apple,  associated  with 
prolapse  of  the  liver.  A  portion  of  the  latter  organ  pro- 
jected through  the  opening  in  the  abdominal  wall  and 
into  the  hernial  sac.  The  umbilical  cord  was  inserted  into 
the  lower  half  of  the  sac.  It  was  34  cm.  in  length  and 
showed  3  vessels,  2  arteries,  and  1   vein.    The  operation 


which  was  performed  for  the  relief  of  this  condition  con-  i 
sisted  in  drawing  the  sac  out,  cutting  it  off  with  sciBsora, 
and  suturing  the  edge  of  the  sac  to  the  thin  periton^ 
covering  of  the  abdominal  wall.  It  was  found  necessary  to 
remove  a  portion  of  the  prolapsed  liver.  The  vermiform 
appendix,  together  with  a  portion  of  the  ascending  colon, 
lay  in  view  under  the  thinned- out  peritoneal  covering.  The 
adhesions  to  the  liver  were  separated  and  the  liver  as  far 
as  possible  restored  to  its  normal  position.  Although  not 
narcotized,  the  child  during  the  operation  did  not  suffer  any 
pain,  except  when  extra  pressure  was  exerted  upon  the  pro- 
lapsed organ.    A  normal  convalescence  followed,    [w.a.n.d.] 

2. — Englemann  gives  a  brief  critical  review  of  Zweifel'e 
article,  published  in  No.  51  of  this  journal,  1900,  on  the 
prophylaxis  of  ophthalmia  neonatorum  by  Credo's 
method.  He  especially  speaks  of  the  results  obtained  by  the 
use  of  silver  salt,  protargol,  which  he  claims  are  very  bad  in 
a  number  of  cases,  silver  catarrh  being  produced  in  over  48 
children,    [w.a.n.d.] 

3. — In  the  Centralbl.  /.  Gyn/lk.,  No.  35,  Donati  reported  an 
interesting  case  of  mammary  hypertrophy  from  Ehren- 
dorfer's  clmic  at  Innsbruck.  Grassmuck  records  an  addi- 
tional case,  giving  the  following  history :  The  patient,  a  peasant 
woman,  18  years  of  age,  presented  herself  at  their  clinic  in 
the  last  month  of  her  first  pregnancy.  As  a  girl  she  had  al- 
ways been  healthy ;  menstruation  began  when  ehe  was  16, 
and  was  regular.  "The  mammary  glands  were  of  normal  size. 
The  patient  married  10  months  before  she  presented  herself 
for  treatment.  In  the  second  month  of  her  pregnancy  she 
had,  for  the  first  time,  noticed  an  unusual  size  of  the  breasts, 
which  became  so  large  and  heavy  as  to  fall  down  to  and  rest 
upon  the  abdominal  enlargement.  They  were  so  large  as 
to  require  constant  support  from  a  mammary  binder.  The 
subcutaneous  veins  were  distended,  but  not  varicose.  Toe 
right  breast  was  considerably  smaller  than  the  left,  although 
the  tissues  were  firmer.  Grasmiick  regards  this  case  as  one 
of  true  mammary  hypertrophy,    [w.a.n.d.] 


Neurologisches  Centralblatt. 

February  1,  1901.    [No.  8.] 

1.  A  New  Method  of  Silver  Impregnation  for  Staining  the 

Axis  CyKnders.  (Preliminary  Communication.)  Fajkk- 

SZTAJN. 

2.  The  Value  of  the  Measurement  of  Blood  Pressure  in  the 

Diagnosis  of  Traumatic  Neurasthenias  and  Hysterias. 
Strauss. 

3.  A  Case  of  Myasthenia  Pseudoparalytica  Gravis.   Mendel. 

1. — The  principle  of  this  new  silver  stain  is  as  follows: 
Ammonia  added  to  a  solution  of  silver  nitrate  causes  a  pre- 
cipitate that  is  soluble  in  excess  of  ammonia.  If  to  the  lat- 
ter an  aldehyd  is  added,  the  liquid  becomes  cloudy,  and  after 
some  time  the  sides  of  the  test  tube  are  covered  with  a  mir- 
ror, or  if  the  reaction  occurs  very  energetically  a  black 
precipitate  is  thrown  down.  The  tissue  is  hardened  in  a  5  to 
10%  solution  of  formalin  for  several  days  to  several  months. 
It  is  not  necessary  that  the  tissue  should  be  very  fresh.  The 
tissues  are  best  cut  in  the  freezing  microtone,  and  then  thor- 
oughly washed  in  water.  A  2%  solution  of  nitrate  of  silver 
is  prepared,  and  to  this  ammonia  is  added  drop  by  drop  un- 
til the  preliminary  cloudiness  has  completely  disappeared. 
Then  some  of  the  2%  solution  of  silver  is  added  to  this  un- 
til a  yellow  precipitate  appears,  the  solution  is  then  filtered 
through  an  analytic  filter.  No  free  ammonia  now  exists  in 
it,  and  it  stains  very  effectively.  It  is  usually  advisable  to 
add  a  small  quantity  of  baryta  water  to  this.  Various  mix- 
tures are  prepared  with  a  mother  solution  conUiining  1  to  2 
drops  of  ammonia,  of  sodium  hydrate,  or  of  baryta  water, 
and  several  sections  placed  in  them.  Impregnation  usually 
occurs  in  from  5  to  20  minutes.  Tne  sections  are  then  plac«d 
immediately  in  a  5%  solution  of  formalin,  and  allowed  to 
remain  for  an  instant,  and  then  examined  in  a  drop  of  for- 
malin under  a  microscope.  The  axis  cylinders  are  stained 
an  intense  brown  or  black,  the  nerve-cells  are  either  invis- 
ible or  stained  a  faint  yellowish  brown.  Sometimes  the 
nuclei,  and  sometimes  the  red  blood-cells  are  also  stiined, 
and  occasionally  the  glii  cells  and  glia  fibers  are  slightly 
colored.  If  there  is  too  much  alkali  present  the  sections 
are  stained  a  diffuse  brown,  and  if  there  is  too  much  ammonia 


April  6,  1901] 


THE  LATEST  LITERATURE 


[Thb  Philadelphia 
Medical  Jodrnal 


659 


they  do  not  stain  at  all.  K  this  is  the  cate  the  procesb  can 
be  repeated  several  times.  If  necessary  to  diSerentiate  the 
sections,  and  this  may  be  the  case  in  tissue  hardened  in 
Miiller's  fluid,  it  can  be  done  by  placing  them  in  10  to  15 
ccm.  of  95%  alcohol  solution,  to  which  1  to  3  drops  of  a  0.3% 
solution  of  chlorid  of  gold  has  been  added.  They  are 
allowed  to  remain  in  this  in  the  dark  for  about  24  hours. 
Platinum  chlorid  may  also  be  used.  The  sections  are  then 
mounted  in  Canada  balsam.  The  author  describes  the  re- 
sults he  obtained  in  sections  from  various  parts  of  the  body. 
Certain  modifications  are  required  if  the  tissue  has  been 
hardened  in  Miiller's  fluid.  He  expresses  the  hope  that  the 
method  may  in  time  be  so  greatly  improved  as  to  add  a 
valuable  microchemical  test  to  our  laboratory  methods.  fj-S.] 

2. — Strauss  calls  attention  to  the  fact  that  the  elevation 
of  blood- pressure  as  a  result  of  peripheral  stimulation, 
may  be  of  considerable  value  in  the  diagnosis  of  trau- 
matic neurosis.  He  used  chiefly  the  method  of  Gerhardt, 
and  performed  the  experiments  between  10  and  12  in  the 
morning,  upon  the  left  index  finger  which  was  held  at  the 
level  of  the  heart.  In  normal  human  beings  the  aver- 
age pressure  was  between  90  and  100  mm.  of  mercury.  In  9 
cases  of  uncomplicated  traumatic  neurosis  he  found  in  25 
investigations  that  in  21  the  pressure  was  between  100  and 
120  mm.,  in  3  cases  below  100  mm.,  and  in  one  case  over  130 
mm.  When  the  sensitive  point  of  which  these  patients 
complained  was  pressed  upon  there  was  an  increase  in  blood- 
pressure  of  from  15  to  40  mm.  In  normal  human  beings 
this  increase  in  pressure  is  considerably  less,    [j.s.] 

3. — A  servant,  21  years  of  age,  developed  pain  in  the  left 
leg,  then  difficulty  in  speaking,  and  swallowing.  She  was 
easily  fatigued  and  often  had  cramps  in  the  calves.  When 
examined  it  was  found  that  the  pupillary  contraction  to 
light  was  very  transient,  and  soon  disappeared  ;  all  the  mus 
cles  became  readily  fatigued,  there  was  slight  paresis  of  the 
right  facial  nerve.  The  .pharyngeal  reflex  was  absent,  the 
speech  was  bulbar  in  type,  and  there  was  rapid  fatigue  of  the 
extremities.  The  pulse  was  extremely  irregular,  and  there 
was  often  dropping  of  one  beat.  Later  a  typical  myasthenic 
reaction  occurred,  and  the  diagnosis  of  niyastlienia 
pseudoparalytica  was  made.  The  only  etiological  fac- 
tor that  could  he  discovered  was  a  very  pronounced  tuber- 
culous family  history,    [j.s.] 


Journal  des  Praticiens. 

February  23,  1901.    [15me  Ann^e,  No.  8.] 

1.  The  Symptoms  of  Dyspepsia  in  Older  Children.    Sevestre. 

2.  The  Pathogeny  of  Gallstones.    G.  Llnossier. 

3.  The  Association  of  Dyspnea  and  Angina  Pectoris.    H. 

HnCHARD. 

1. — The  main  symptom,  headache,  is  almost  con- 
stant in  children  suffering'  from  dyspepsia  during 
the  period  from  7  to  15  years.  There  is  also  present  a  tired 
feeling,  with  perhaps  fever,  palpitation,  or  nervous  symp- 
t/mis.  The  headache  is  generally  frontal,  and  persists. 
While  the  headache  is  absent  at  night,  insomnia  or  night- 
mares occur.  Palpitation  is  common  upon  the  slightest 
exertion,  and  arrhythmia,  with  an  occasional  functional  mur- 
mur, is  also  observed.  Vomiting  may  appear,  with  fever, 
off  and  on.  The  stomach  and  colon  are  both  found  dilated. 
The  liver  may  be  enlarged,  and  constipation  is  the  rule. 
The  tongue  may  be  coated  and  the  breath  foul.  These  chil- 
dren eat  quickly,  and  often  drink  too  much  liquid  at  meals. 
Sevestre  believes  the  headache  to  be  due  to  an  in- 
toxication from  indigestion.  Therefore,  treatment  should 
be  directed  toward  preventing  the  formation  of  such  toxins, 
and  toward  destroying  them  if  already  formed.  Diet  is  to  be 
insisted  upon,  and  all  food  properly  masticated.  Meals  must 
be  regular ;  bowel  movements  also.  Tincture  of  nux  vomica 
should  be  given  before  meals.  Finally  daily  bathing  and 
exercise  in  the  open  air  are  necessary,    [m.o.] 

2. — It  has  been  shown  by  experiment  lately,  that  gall- 
stones may  be  due  to  microorganisms.  The  two 
bacteria  which  are  known  to  have  caused  them  are  the 
colon  bacillus  and  the  typhoid  bacillus.  The  latter  will  cause 
the  renewed  production  of  gallstones  in  a  person  whose 
gallbladder  was  affected  before  taking  typhoid  fever.  Thus, 
the  condition  of  the  part  atfected  will  often  favor  the  inva- 


sion of  bacteria.  To  keep  otf  such  disastrous  efl'ects,  in  those 
predisposed  to  gallstones,  by  heredity,  gout,  etc.,  Linossier 
advises  regular  yearly  visits  to  some  alkaline  springs,  in 
order  to  maintain  a  good  condition  of  general  health,  [m.o.] 
3. — Huchard  reports  the  case  of  a  man  of  63,  who  neither 
smoked,  drank,  nor  had  had  syphilis.  For  18  months  he  has 
suflfered  from  dyspnea  upon  the  slightest  exertion,  accom- 
panied by  a  feeling  of  oppression.  During  the  last  3  months 
this  has  increased  so  that  he  can  only  sleep  with  difficulty. 
There  is  a  little  albumin  in  the  urine.  During  th's  time  he 
has  had  a  few  attacks  of  true  ang^ina  pectoris,  first  with 
exertion,  later  even  at  night.  They  are  severe  and  of  short 
duration.  Besides,  during  the  past  few  weeks,  he  has  had 
pseudostenocardia,  the  pain  persisting,  localized  to  the 
second  intercostal  spaces  on  both  sides,  and  to  the  right 
shoulder.  Upon  auscultation  the  diastolic  shock  of  the  aorta 
is  heard,  and  some  arrhythmia.  The  pseudostenocardia 
Huchard  believes  to  be  neuralgic  or  neuritic,  secondary  to 
the  periaortitis  evidently  existing  there.  But  true  angina 
pestoris  also  exists,  due  to  probable  endoaortitis.  The  "  toxi- 
alimentary  "  dyspnea  depends  upon  the  renal  sclerosis,  just 
as  true  angina  depends  upon  aortic  and  coronory  sclerosis. 
As  treatment  he  advises  exclusive  milk  diet  and  theobromin 
for  two  weeks.  Then  for  one  week  every  month,  milk  diet 
and  sodium  iodid.  During  the  rest  of  the  month,  special 
diet,  with  the  theobromin  continued.  Huchard  considers 
this  alimentary  treatment  most  necessary  in  this  complex 
case  of  mixed  angina  pectoris  with  pseudosteno- 
cardia.    [m  o.] 

March  2, 1901.    [15me  Ann^e,  No.  9.] 

1.  Typhoid  Fever  and  Pleurisy.    Paul  Remlinger. 

2.  Seven  Cases  of  Shoe-Polish  Poisoning.   Laurent  and  Guil- 

LEinN. 

3.  Heteroplasty  of  the  Orbit,  with  the  Use  of  a  Rabbit's  Eye. 

F.  Lagrange. 

4.  The  Treatment  of  Syphilis  During  Pregnancy.    Gaucher 

AND  Bernard. 

1.— Pleurisy  may  occur  with  typhoid  in  four  dif- 
ferent ways.  First,  the  pleurisy  may  be  but  the  first  symp- 
tom of  beginning  typhoid,  the  diagnosis  only  being  settled  by 
the  Widal  reaction,  after  epistaxis  or  spots  have  appeared. 
This  the  French  call  "pleurotyphus."  Then  pleurisy 
may  occur  as  a  complication,  late  in  tynboid,  with  a  serous, 
hemorrhagic,  or  purulent  effusion.  While  three-quarters 
of  the  cases  recover,  the  development  of  pleurisy  is  always 
serious.  Rarely  a  pleurisy  in  typhoid  will  be  due,  not  to 
the  bacillus  of  Eberth,  but  to  some  secondary  infection. 
Rarer  still  is  a  pleurisy  caused  by  the  typhoid  bacillus, 
in  the  terminal  stage  of  acute  phthisis,  of  which  2  cases  are 
reported,  no  signs  of  typhoid  fever  being  found  at  the  autop- 
sies,   [m.o.] 

2. — Six  children  in  one  family,  all  of  whom  had  worn 
shoes  fresh  from  the  shoemaker,  upon  which  the  aniline 
polish  had  not  yet  dried,  were  attacked  suddenly  with  symp- 
toms of  poisoning.  Their  ages  ranged  from  2  to  14  years, 
the  youngest  being  the  earliest  affected.  First,  pallor  of  the 
face,  a  bluish  discoloration  of  the  skin,  and  a  violet  color  of 
the  lips  and  nails  were  noted ;  then  dilatation  of  the  pupils, 
headache,  vertigo,  absolute  muscular  weakness,  transitory 
paralysis,  followed  by  unconsciousness,  slowing  of  the  pulse, 
and  arrhythmia,  with  cold  extremities.  Slight  convulsive 
movements  occurred  in  2  cases,  besides.  In  from  1  to  3 
days  all  signs  disappeared,  including  the  faint  trace  of  albu- 
min found  in  the  urine.  Another  case  occurred  later,  in  a 
child  of  6.  A  thorough  investigation  revealed  the  fact  that 
in  each  case  the  shoes  worn  had  but  just  come  from  the 
shop,  and  the  polish  was  not  yet  dry.  Chemical  examina- 
tion of  the  polish  used  showed  aniline.  Experiments  were 
made  upon  guineapigs,  in  which  the  polish  produced  pre- 
cisely the  same  symptoms  as  in  man.     [m.o.] 

3._Ligrange  reports  4  cases  of  operation  for  loss  of 
vision  following  traumatism.  Three  have  been  quite  suc- 
cessful. In  each  case  the  eye  was  enucleated,  a  thread 
lef;  in  the  muscles.  The  hemorrhage  was  then  stopped, 
either  by  irrigating  with  ice-water,  hydrogen  peroxide,  or  by 
a  tampon  left  some  time  in  the  capsule  of  Tenon.  Then  a 
rabbit's  eye,  preferably  of  a  young  animal,  is  enucleated, 
and  sutured  in  the  patient's  empty  capsule.    Then 


660 


Thb  PhilasblphiaI 
Medical  Jocrsal  J 


THE  LATEST  LITERATURE 


[Apeil  6,  ISOl 


the  conjunctiva  is  sutured  at  fjur  psints.  and  an  ordinary 
ojclusive  dressing  applied.  At  the  end  of  a  week,  the  con- 
janctival  stitcties  are  removed,     [mo] 

4, — Gaucher  and  Barnard  say  that  preg'aaacy  occur- 
ring- in  gyphilitlcs  who  are  ivell  treated  is  not  as 
serious  as  it  is  generally  considered.  If  specifij  treatment 
be  begun  early  enough,  and  given  in  large  enough  amounts, 
regularly,  well  children  will  be  borne  at  term.  Such  children 
should  be  nursed  by  their  mothers,  and  treated,  to  prevent 
later  syphilitic  manifestations.  The  treatment  advised 
consists  of  icjections  of  two  centigrams  of  benzoate  of  mer 
cury,  daily,  alternating  with  pills  containing  two  centigrams 
of  bichloride  of  mercury,  the  number  of  injections  being 
continued  over  a  period  twice  as  long  as  that  of  the  pilis. 
The  intensity  of  this  treatment,  if  the  woman  should  show 
albumin  in  the  urine,  should  be  subordinated  to  the  renal 
function,  which  can  be  watched  by  determining  the  urinary 
toxicity,  and  the  elimination  of  the  mercury,    [m.o.] 


Gazette  Hebdoniadaire  de  M^decine  et  de 
Chirurg'ie. 

February  10,  1901. 

1.  Dyspeptic  Glycosuria  and  Diabetes.    Robin. 

2.  The  Role  of  the  Renal  Plexus  in  the  Pathogenesis  of  the 

Edema  of  Bright's  Disease,  and  of  Some  of  the  Symp- 
toms of  Nephritis.    M.  F.  Semeril. 

3.  Treatment  of  Infantile  Tuberculosis  by  Thiocol.      Ka- 

PLANSKY. 

1. — At  the  meeting  of  the  Academic,  de  Medecine  held  Feb- 
ruary 5,  1901,  Robin  read  a  paper  on  dyspeptic  glyco- 
suria and  diabetes.  As  a  complication  of  dy.-pepsia, 
simple  glycosuria  is  met  with  in  5%  of  the  hypersthenic 
cases.  It  is  irregular,  always  small,  varying  from  0.05  to  6 
grams  per  liter.  It  only  exists  in  the  urine  during  the  pro 
cess  of  digestion  and  is  wanting  in  the  fasting  urine.  In 
half  the  caaes  it  coincides  with  digestive  albuminuria.  Toe 
elementary  nutrition  is  characterized  in  these  patients  by  an 
exaggeration  of  the  nutritive  changes  and  of  the  dissimil* 
tion  of  nitrogen  and  by  the  excitation  of  the  nervous  sys- 
tem. There  are  no  symptoms  of  diabetes.  The  patient  has 
only  an  exaggerated  appetite,  a  distended  stomach,  an  hyper- 
trophied  liver,  and  gastric  hyperchlorbydria.  One  finds  also 
vertigo,  phosphaturia,  dermatoses,  hyperidroses,  ocular  and 
auricular  troubles.  If,  in  a  certain  number  of  cases,  gastric 
troubles  are  secondary  to  diabetes,  the  rule  is  for  diabe  ea  to 
be  consecutive  to  dyspepsia.  This  distinction  is  important 
because  dyspeptic  diabetes  may  yield  to  treatment  while 
primary  diabetes  ordinarily  resists  treatment.  This  diabetes, 
as  has  already  been  demonstrated,  is  not  a  disease  charac- 
terized by  a  depressioa  of  nutrition,  but,  on  the  contrary,  by 
an  excitation  of  nutrition  and  an  increase  in  the  activity  of 
the  liver.  In  fact,  all  the  medicines  that  excite  nutrition 
aggravate  diabetes;  whilst  those  medicines  that  moderaie 
nutrition  ameliorate  diabetes.  For  example,  antipyrin  di- 
minishes glycosuria,  pyramidon  augments  it.  Glycosuria 
always  indicates  an  hyperactivity  of  the  hepatic  function;  it 
is  in  relation  with  gastric  hypersthenia  of  the  dyspeptic  sub- 
jects in  whom  it  is  observed.  The  excitation  of  the  liver,  at 
first  intermittent,  may  become  permanent,  and  true  diabetes 
of  dyspeptic  origin  is  then  set  up.  Glycosuria  of  dyspeptic 
origin  is  cured  by  the  treatment  of  the  hypersthenic  dys- 
pepsia; the  administration  of  powders  of  the  alkaline  earths 
after  meals  often  suffice.  In  cases  that  are  more  severe,  abso- 
lute milk-diet  gives  good  results,  whilst,  on  the  other  hand,  it 
is  well  known  that  milk  diet  is  unfavorable  in  cases  of  true 
diabetes.  When  dyspeptic  diabetes  is  established  the  treat- 
ment is  commenced  by  decreasing  the  quantity  of  sugar  by 
diet.    Then  the  dyspepsia  should  be  treated,     [j.m  s.] 

2. — Irritation  of  the  renal  nerves  is  proved  by  hist- 
ologic examination  which  suows  the  existence  of  degener- 
ative lesions  or  simple  irritations  of  the  nerve  fibers.  Renal 
edema,  as  well  as  being  of  the  nature  of  a  dyscrasia,  may 
also  be  a  reflex  nervous  edema.  The  cases  of  hemianas.arci 
consecutive  to  traumatic  nephritis  furnish  an  undoubted 
proof  of  this  statement.  This  nervous  action  alone  allows  of 
an  explanation  of  the  char.-icter  of  the  variability  and  the 
localization  of  the  edema  on  one  side  of  the  bodj-  or  in  a 
special  region,  aa  is  sometimes  seen  in  cases  of  nephritis. 


Tnis  nervous  accion  is  in  the  nature  of  a  reflex  stimulation 
of  the  vasomotor  centers.  Reflex  edema  is  not  confined  to 
the  kidney.  It  has  been  ooserved  in  cases  in  which  the 
point  of  origin  of  the  reflex  producing  the  edema  was  the 
pleuropulmonary  nerves  and  the  uterine  nervous  plexus. 
This  same  nervous  irritation  may  account  for  lumbar  paine 
and  the  polyuria  of  cases  of  nephritis.  It  also  is  concerned 
in  the  pathogenesis  of  intermittent  glycosuria,  and  to  it  also 
certain  cases  of  sudden  death  supervening  in  the  course  of 
Bright's  disease  may  be  attributed.  Opposed  to  the  preceding 
symptoms,  which  are  attributable  entirely  or  partially  to 
nervous  action,  it  is  convenient  to  place  those  that  are  mani- 
festly the  result  of  uremic  intoxication.  These  are  the  ner- 
vous troubles,  such  as  convulsions,  delirium,  coma,  ocular 
and  auditory  troubles,  nervous  dyspnea  of  toxic  origin,  and 
finally  gastrointestinal  disorders.  It  is  necessary  to  note, 
however,  that  the  nervous  action  may  intervene  in  the 
beginning  in  producing  the  congestive  processes  found  in  the 
nervous  centers,  the  lungs,  or  the  digestive  apparatus,  [j.m  8.] 
3. — ^The  results  of  experiments  on  animals  show  that 
tliiocol  has  an  antituberculous  action  in  the  animal  organ- 
ism and  not  merely  a  favorable  effect  on  the  general  nutri- 
tion and  on  certain  symptoms  of  tuberculosis.  Experimental 
facts  as  well  as  clinical  experience  authorize  the  use  of  thio- 
col not  only  in  pulmonary  tuberculosis  but  also  in  other 
forms  of  tuberculous  disease  such  as  tuberculous  pleuritis 
and  tuberculous  peritonitis,    [j  M.S.] 


Archives  de  Medecine  des  Enfants. 

February,  1901.    [VoL  iv,  No.  2.] 

1.  -A.  Case  of  Diphtheritic  Stomatitis  Due  to  OOspora.    A. 

Trasibcsti. 

2.  The  Clinical  Forms  of  Infantile  Tuberculosis.  A.  Motjssous. 

3.  A  Savere  Case  of  Athrepsia  Neonatorum.    Bacmel  and 

SCHEYDT. 

4.  A    Case  of   Tetany   Occurring    in   Acute    Eaterocolitia. 

Charles  Leroi-x. 

5.  A  Case  of  Adhesion  of  the  Labia  Minora.    E.  Cazal. 

1. — Trambusti  reports  a  case  of  stomatitis  occurring  in 
a  child  of  3  years.  The  gums  and  roof  of  tQe  palate  were 
covered  with  an  exudate  in  plates,  looking  exactly  like 
diphtheria.  Tue  temperature  remained  high.  Preparations 
examined  bacteriologicaily  gave  quantities  of  filamentous 
microorganism*,  and  a  few  cocci,  but  no  diphtheria  bacilli. 
Beside  a  few  colonies  of  staphylococci,  the  great  number  of 
colonies  showed  the  filamentous  masses,  very  like  lepto- 
thrices,  yet  evidently  oSspora.  They  were  not  pathogenic 
when  inoculated  into  animals.  Trambusti  describes  their 
actions  upon  different  media,  and  suggests  that  other  condi- 
tions, thus  far  attributed  to  leptothricea,  as  noma,  etc.,  may 
be  due  to  oospora.     [m  o] 

3. — In  this  article  .Moussous  discusses  general  tubercu- 
losis in  young  children.  Tuberculosis  before  the  third  year 
is  either  thoracic  or  general,  much  more  frequently  the 
latter.  While  very  few  children  of  tubercular  parents  are 
born  with  tuberculosis,  there  are  bom  many  children  with  so 
debilitated  a  system  that,  if  kept  among  tubercular  p>eople, 
they  will  inevitably  develop  consumption.  The  fact  that 
they  have  a  good  chance  of  escaping  this  result,  should  they 
be  at  once  removed  from  their  tainted  surroundings  and 
brought  up  in  the  co'ntry,  seems  often  forgott€n,  even  by  the 
medical  profession.  In  nealthy-looking  children  the  disease 
may  remiin  latent  for  weeks,  as  it  is  rarely  seen  before  the 
third  month  of  life.  Whether  hereditary  or  acquired,  its 
course  may  be  chronic  or  acute.  Chronic  generalized 
tuberculosis  may  be  divided  into  3  periods;  firit.avery 
short  initial  stage,  with  bronchitis  or  bronchopneumonia 
alone,  or  folloTing  an  infectious  disease,  or  gasiroenteritis. 
Then,  instead  of  recovering,  the  child  remains  ill,  without 
fever,  weak,  with  an  ever- increasing  cachexia.  The  spleen, 
liver,  and  general  lymphatic  system  enlarge.  This  is  the 
second  stage,  and  lasts  a  long  time.  The  last  stage  is  death, 
occurring  quietly  in  a  fewhou.-s.  Or  the  disease  may  b« 
complicatea  by  pneumonia,  Pott's  diseise,  pleurisy,  otitis, 
etc.  It  may  last  even  up  to  4  or  5  years,  but  generally  only 
until  the  fifteenth  month.  Acute  miliary  tuberculosis, 
on  the  otner  hand,  runs  a  rapid  course,  witD  high  fever, 
diarrhea,    enlarged    spleen,  tympany,   bronchopneumonia. 


April  G,  19011 


THE  LATEST  LITERATURE 


TThk  Philadelphia 
L  Medical  Journal 


661 


etc.,  and  death.  But  the  chronic  form  may  suddenly  end 
with  raeaingitic  symptoms,  either  convulaiona  or  hemiplegia, 
with  death  in  from  2  to  4  days.  After  detailing  the  differen- 
tial diagnosis  between  general  tuberculosis  and  the  many 
other  infautile  c.ichexia?,  Moussoui  speaks  in  high  terms  of 
the  serum  reac'.ion  as  obtained  bv  Baard,  and  hopes  that  thij 
method  of  forming  a  positive  diigaoiis  will  soon  bs  per 
fect<:d.    [m  o.] 

3, — Baumel  and  Saheydt  report  the  case  of  a  child  who 
first  had  couvulsious  when  1  month  old.  Stomatitis  and 
constipation  next  appeared.  Vomiting  had  always  existed, 
though  the  wet-nurse  nursed  him  regularly  every  3  hours. 
The  child  was  kept  in  an  incubator,  and  given  large  doses  of 
bromide  and  chloral.  At  4  months  the  convulsions  decreised 
in  frequency,  and  the  vomiting  began  to  grow  less.  A  month 
later  the  child  went  to  the  country  cured.  At  the  ajj^e  of  3 
luontbH,  he  had  lost  680  grams.  At  6  months  he 
g'ained  03  grams  daily  for  four  days.  Taese  weights 
show  what  a  baby  can  lose  and  gain,     [m  o  ] 

4. — Lftroux  reports  the  case  of  a  boy  of  2  years,  with  dis- 
tinct tetany  in  the  course  of  a  severe  acute  enterocolitis. 
In  spite  of  the  frequency  and  severity  of  the  convulsions,  the 
child  recovered.    He  showed  no  signs  at  of  rachitis,    [mo.] 

5. — Cazal  reports  the  cate  of  a  girl  of  19  months,  whose 
labia  minora  were  adherent.  A  tiny  opening  for  the 
passage  of  urine  was  seen  just  below  the  clitoris.  As  there 
had  been  no  vulvitis,  this  condition  must  have  been  con- 
genital. It  was  easily  divided  with  very  little  bleeding.  No 
dressing  was  necessary  as  it  healed  at  once.  The  rest  of  the 
genitalia  were  found  normal  beneath,    [mo  ] 


Kevue  de  Chirurgie. 

February,  1901.     [21me  Ann^'e,  No.  2.] 

1.  Peritonization  in  Laparotomy.    E.  Quenu  and  Judex. 

2.  The  Surgical  Treatment  of  Purulent  Peritonitis  Following 

Perforation  in  Typhoid  Fever.    Ed  Loisdn. 

3.  Ligation  of  the  Abdominal  Aorta.    P.  Tillaux  and  P. 

RiCHE. 

4.  An  Experimental  Study  of  Fracture  of  the  Upper  Jaw. 

R.  Le  Foet. 
5   The  Study  of  Osteomalacia.    G.  Gayet  and  L.  M.  Bonnet. 
fi.  Chopart's  Amputation.    A.  La  Pointe. 
7.  Torsion  in  Hydrosalpinx.    F.  Cathelin. 

1.— Qu6nu  and  Judet  use  the  term  peritonization,  or 
peritoneal  autoplasty,  for  their  method  of  suturing  the 
cut  or  torn  ends  of  the  peritoneum  to  the  intestine,  in  oper- 
ating, so  that  the  intestines  only  touch  the  endothelium,  and 
all  raw  surfaces  have  a  serous  covering.  Besides,  covering  a 
denuded  surface  with  peritoneum  prevents  exudation  and 
hemorrhage,  and  further  diminishes  the  possibility  of  infec- 
tion. It  also  hinders  the  formation  of  adhesions,  which  are 
so  often  followed  by  intestinal  occlusion.  This  method  was 
first  practised  by  Hegar,  whose  name  it  bears.  It  should  be 
especially  applied  in  laparotomv  for  appendicitis,  salpingitis, 
ovarian  cysts,  and  fibromata.  The  technic  in  each  case  is 
described,  with  14  case  histories.  During  5  years  they  have 
performed  129  laparotomies  with  5  deaths,  3.8%.  When 
operation  is  done  by  this  method,  colicky  pains  rarely  ocnur; 
drainage  is  necessary  only  fi-om  2  to  4  days;  and  micturition 
and  defecation  are  never  affected.  Nor  do  these  patients, 
operated  some  time  before,  return  with  digestive  disturb 
ances,  or  abdominal  pain.  During  tliese  five  years,  onlv  one 
caf>e  has  developed  postoperative  intestinal  occlusion,   [m.o.] 

2. — Thouijh  peritonitis  may  arise  outside  of  a  typhoid 
ulcer  in  the  small  intestine,  the  m-ijority  of  cases  follow 
perforation  of  such  an  ulcer.  A  diflfuse,  purulent  peri- 
tonitis follows,  fatal  in  95% ,  in  3  to  6  d».ys.  Of  the  90  cases 
of  perforation  surgically  treated,  which  Loisou  h*s  collected, 
36  recovered,  21.6%.  His  own  case  is  described  in  fall. 
Perforation  generally  occurs  in  the  second,  third,  or  fourth 
weeks  of  the  disease,  and  cases  operated  within  24  hours 
after  the  occurrence  of  perforation  generally  recover.  Bat 
it  is  always  difficult  to  diagnose  positive  perforation;  the 
ganeral  condition  of  the  patient  may  not  warrant  opera- 
tion; the  8  tfi  of  the  perforation  may  not  be  found,  or 
multiple  perfjrations  may  exist.  Liison  describes  lapar- 
otomy in  such  cases,  when  and  how  it  should  be  performed, 
the  method  of  finding  and  suturing  the  perforation,  drainage, 
etc.,  in  full,    [m.o] 


6. — Osteomalacia  is  a  disturbance  of  the  nutrition  of 
the  bones,  making  it  impossible  for  the  bones  to  keep  their 
lime  salts,  rtsulting  in  a  softening  of  the  skeleton.  This  dis- 
turbance of  nutrition  may  be  local  or  general.  Local  osteo- 
malacia may  be  traumatic,  infectious,  or  due  to  certain 
nervous  affections.  Traumatic  osteomalacia  is  more  frequent 
in  the  vertebral  column,  and  the  tibia;  it  is  usually  due  to 
direct  violence,  and  it  is  rather  more  common  past  middle 
age.  Pain  and  softening  follow  rapidly.  The  infectious 
theory  is  not  as  yet  positively  proved,  yet  influenza,  tubercu- 
losis, and  syphilis,  probably,  c.iuse  osteomalacia.  The  lesions 
found  in  osteomalacia  are  the  same,  whether  the  process  be 
generalized  or  local.  These  lesions  vary  much,  and  show 
nothing  specific.  After  discussing  the  various  theories,  and 
reporting  13  cases,  Gayet  and  Bonnet  conclude  that  different 
disturbances  of  the  nervous  system  probably  play  an  import- 
ant role  in  the  etiology  of  osteomalacia.  A  possible  explan- 
ation of  the  good  results  following  ovariotomy  may  rest  in 
the  fact  that  the  ovarian  secretion  causes  an  active  elimina- 
tion of  the  phosphates,  after  the  removal  of  which  the 
softening  gradually  disappears,    [m.o.] 


Gazette  M^dicale  de  Paris. 

February  9,  1901.     [  Vol.  i,  No.  6  ] 

1.  The  Winsum  Skull,  a  Cranial  Malformation.  Feenasd 
Delisle. 
1. — This  is  a  reply  to  Dr.  Folmer's  article  upon  the  skull 
found  at  Winsum,  in  Holland,  20  years  ago.  Folmer  con- 
sidered it  a  macrocephalic  head  deformed  artificially.  De- 
lisle,  on  the  other  hand,  believes  the  skull  to  be  a  malforma- 
tion. Its  height  is  striking  compared  with  its  length  and 
breadth.  The  frontal  region  slopes  greatly  and  the  occiput 
is  almost  vertical.  A  study  of  the  sutures  and  the  two  teeth 
remaining  lead  to  the  conclusion  that  the  individual,  at  the 
time  of  death,  was  over  30  years  old.  The  synostosis  of  the 
sagittal  and  frontal  sutures  show  malformation,  and  not 
deformity  due  to  pressure.  The  bones  of  the  top  of  the  head 
had  to  give  way  as  the  brain  grew  beneath,  especially  as  the 
bones  were  fast  below.  That  explains  the  bulging  of  the 
upper  part,  just  as  in  hydrocephalus.  Besides,  the  frontal 
and  temporal  bones  show  no  signs  of  pressure.  Delisle  con- 
siders the  Winsum  skull  acrocephalic,  a  malformation  due 
to  development,  the  lower  sutures  having  been  obliterated, 
the  head  grew  where  it  could.  All  the  measurements  of  the 
skull  are  given,    [m.o  ] 

Journal  de  M^decine  de  Bordeaux. 

March  3,  1901.     [31me  Annce,  No.  9.] 

1.  A  Case  of  Traumatic  Hysteria.    Goyot  and  Peey. 

2.  Regeneration  in  the  L'ver.    M.  B.  Adche. 

3.  A  Case  of  Congenital  Unilateral  Microphthalmia.    Gines- 

TOUS. 

1.— Guyot  and  Pery  report  a  case  of  traumatic  hysteria 
in  a  girl  of  13.  A  month  ago  she  fell  from  a  ladder,  from  a 
height  of  about  6  feet,  striking  upon  her  forehead.  There 
was  no  loss  of  consciousness  or  convulsions.  She  was  all 
right  for  2  weeks,  then  during  2  or  3  days  her  cheeks  became 
flibby,  and  trismus  occurred.  This  condition  of  lockjaw 
persisted  for  2  weeks.  As  she  was  a  foundling,  her  ancestry 
was  unknown.  Paralysis  of  both  branches  of  the  facial 
nerve  existed  on  the  right  side.  At  night,  however,  she  shut 
her  right  eye  too.  There  were  found  scattered  areas  of  anes- 
thesia and  hvpoesthesia.  The  application  of  electricity 
cured  the  condition  very  quickly.  Guyot  and  Pery  com- 
ment upon  the  fact  that  the  few  cases  of  hysteria  or  neuras- 
thenia reported  in  children,  followed  falls  upon  the  head. 
A  diflerential  diagnosis  is  given  between  facial  paralysis  due 
to  traumatism,  or  true  facial  paralysis,  and  that  from  trau- 
matic hysteria,     [m.o  | 

2. — It  has  been  shown  by  raanv  experiments  that  when 
degeneration  occurs  in  the  liver,  the  cells  of  the  liver 
regenerate,  producing  tissue  to  take  the  place  of  that 
destroyed.  Chaufl'ard  says  that  compensatory  hypertro- 
phy always  occurs  in  the  liver.  This  is  the  condition 
ordinarily  found  in  diflfuse  or  nodular  parenchymatous 
hypertrophy  of  the  liver.  In  acute  yellow  atrophy,  also,  the 
regenerating  cells  are  found  in  great  numbers  with  those 
that  have  degenerated.    When  this  regeneration  exists  in 


662 


The  Philadelphia  "I 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[April  6,  IMl 


very  small  amount,  Chauffard  calls  it  "radiate  compensatory 
hypertrophy."  This  Auch6  found  in  a  case  of  purulent 
angiocholitia  and  periangiocholiti8,which  is  described  in  full. 
A  case  of  congestion  of  the  liver  in  heart  disease  is  then 
detailed,  in  which  regeneration  of  the  liver-cells  was  ob- 
served,    [m.o.] 

3. — Ginestous  reports  the  case  of  a  child  of  3  months, 
with  unilateral  microphthalmia.  When  the  mother  was 
4  months  pregnant,  an  older  child  kicked  her  violently  in 
the  abdomen.  This  hurt  severely,  but  the  pregnancy  went 
on  to  term.  At  birth,  the  left  side  of  the  baby's  face  was  still 
embryonic  in  character,  the  eye-lids  being  very  small. 
When  the  baby  opened  its  eyes,  at  2  months,  the  left  eye 
wa,s  the  size  of  a  small  bean  only.  A  congenital  cataracit 
existed  also.  The  right  eye  was  normal,  as  was  the  body, 
with  the  exception  of  a  dermoid  cyst  under  the  tip  of  the 
tongue.  Ginestous  believes  that  the  injury  to  the  pregnant 
mother  probably  caused  the  occurrence  of  the  unilateral 
microphthalmia,     [m.o.] 

Vratch. 

February  3, 1901.    [Vol.  xxii,  No.  5.] 

1.  A  Discharge  of  a  Watery  Fluid  from  the  Nose  (Hydror- 

rhea nasalis).    A.  Ph.  Ekkert. 

2.  The  Spleen  and  the  Albumin  Ferment  of  the  Pancreatic 

Gland.    L.  B.  Popelsky. 

3.  Difficulties  Encountered  in  the  Restriction  of  Diphtheria. 

E.  M.  WOLFSON. 

4.  Corporeal  Punishment  in  Russia  in  the  Twentieth  Cen- 

tury.     D.  N.  SCHBANKOW. 

5.  On  the  Injection  of  Sodium  Cinnamylate  (Natri  cinnamy- 

lici)  in  Tuberculous  Patients.    L.  A.  Finkelstein. 

1. — Will  be  abstracted  when  completed. 

2.— Popelsky  takes  up  the  polemic  incited  by  Dr.  Gertsen 
(See  Vratch,  Vol.  xxii.  No.  11,  recently  abstracted  in  the 
Philadelphia  Medical  Journal)  and  devotes  a  lengthy  article 
to  the  exposition  of  the  fallacies  with  which  Gertsen's  ex- 
periments were  surrounded  and  the  erroneous  conclusions 
deduced  from  them.  He  claims  that  his  experiments  were 
performed  strictly  in  accordance  with  the  directions  given 
by  Schiff,  and  that  they  prove  only  one  thing,  namely,  that 
Schiff's  theory,  modified  by  Gertsen,  is  wrong.  The  spleen, 
according  to  his  observations,  has  no  specific  effect  on  the 
formation  of  trypsin.  The  results  obtained  by  Schiff,  Gert- 
sen, Pachon,  and  Gachet  the  author  explains  in  the  following 
manner:  It  has  been  demonstrated  that  there  exist  in  the 
organism  bodies  in  the  nature  of  ferments,  possessing  oxi- 
dizing properties.  These  bodies  are  present  in  the  formative 
elements  of  the  blood  and  are  derived  mainly  from  the  de- 
struction of  leukocytes.  Their  presence,  therefore,  in  the 
spleen  is  due  to  the  blood  and  not  to  the  splenic  tisrae  per  se. 
During  the  height  of  digestion  digestive  leukocytosis  takes 
place  ;  in  other  words,  an  increased  destruction  of  the  leuko- 
cytes and  consequently  an  increased  formation  of  these 
oxidizing  bodies,  the  latter  aiding  in  the  oxidation  of  the 
protrypain  into  trypsin — hence  the  fact  that  a  swollen  or 
hyperhemic  spleen  is  concomitant  with  an  increased  forma- 
tion of  trypsin,     [a.r.] 

3  — Wolfson  points  out  the  impossibility  of  isolatiag  those 
cases  of  diphtheria  in  wliich  a  brief  attack  of  sore  throat  is 
followed  by  complete  recovery,  and  yet  the  diphtheria  bacilli 
persist  for  a  long  time,  rendering  the  hosts  a  menace  to  the 
public.  The  following  cases  are  cited  as  illustrations  :  A  wo- 
man suffered  from  a  slight  sore  throat  without  any  glandular 
involvement.  On  the  third  day  the  throat  was  clear  and  the 
temperature  normal.  A  bacteriologic  examination,  repeated 
3  times,  showed  the  presence  of  diphtheria  bacilli.  The 
patient  could  not  be  kept  in  her  room  for  more  than  a  week. 
She  went  to  concerts,  m.ide  calls,  etc.  In  another  case  the 
daughter  of  a  physician  engaged  to  be  married  to  a  physician 
had  an  attack  of  mild  sore  throat  a  few  days  before  the  wed- 
ding was  to  take  place.  A  bacteriologic  examination  showed 
the  presence  of  diphtheria  bacilli.  On  the  fourth  day  the 
patient  was  perfectly  well.  She  refused  to  be  isolated  or 
postpone  the  wedding.  In  another  family,  two  children  took 
sick  with  diphtheria  and  were  sent  to  the  hospital.  The 
throats  of  the  other  members  of  the  family  were  examined 
and  diphtheria  bacilli  found.    No  isolation  was  permitted. 


The  fourth  case  is  of  special  interest.  A  servant,  23  years 
old,  had  an  attack  of  diphtheria  while  nursing  her  diph- 
theritic child  in  a  foundliag  asylum.  She  kept  her  affection 
secret,  and  2  weeks  later,  after  the  child  died  of  laryngeal 
diphtheria,  came  to  the  author,  presenting  postdiphtheritic 
paralysis  of  the  palate.  A  bacteriologic  eximlnation  dis- 
closed the  presence  of  diphtheria  bacilli.  The  latter  per- 
sisted for  a  period  of  13  months,  and  were  still  to  be  found  at 
the  present  writing.  However,  while  morphologically  they 
were  proven  to  be  true  Klebs-Loffler  bacilli,  they  were  found 
avirulent  on  two  different  occasions,  when  inoculated  into 
guineapigs.  The  author  emphasizes  the  importance  of  using 
local  antiseptics,  believing  that  in  cases  in  which  the  bacilli 
persist  in  the  completely  recovered  or  the  healthy,  the 
persons  may  be  allowed  to  go  about,  providing  they  observe 
the  same  precautions  with  regard  to  expectoration,  utensils, 
etc.,  as  are  recommended  in  tuberculosis,    [a.r  ] 

6. — Finkelstein  devotes  an  extensive  paper  to  the  subje^Jt 
of  the  eflect  of  cinnamylic  acid  or  its  salts  on  tuberculosis. 
After  a  thorough  review  of  the  subject,  quoting  in  extenso 
the  observations  of  others  pro  and  con,  he  reports  his  own 
observation  made  in  the  sanitarium  for  consumptives.  In 
all  20  cases  were  studied.  The  history  of  each  is  given,  but 
the  cardinal  points,  as  well  as  the  results  of  the  treatment, 
are  summarized  as  follows:  1.  The  ages  of  the  patients  varied 
from  19  to  42,  the  majority  from  20  to  -30.  2.  One  of  the 
patients  was  at  the  time  of  admission  in  the  first  stage  of  the 
disease,  the  other  in  the  second.  By  the  "  first  stage  "  the 
author  understands  a  condition  in  which  one  or  both  apices, 
not  below  the  second  rib,  are  affected,  and  there  is  no  catarrh. 
In  the  "  second  stage "  there  are  marked  changes  accom 
panied  by  catarrh,  but  without  any  signs  of  destruction  of 
lung-tissue.  3.  The  number  of  injections  was  from  10  to  45. 
4.  The  duration  during  which  the  injections  were  made  was 
from  1  to  5J  months.  The  duration  of  the  observations  made 
prior  to  the  injections  was  from  10  days  to  14J  montha.  5. 
The  cough  diminished  during  the  injections  in  5  patients,  in 
11  it  remained  as  before,  in  -4  it  became  either  worse  or  bet 
ter.  Prior  to  the  injections  it  diminished  in  14,  remained 
stationary  in  2,  and  was  either  better  or  worse  in  4.  6.  Toe 
sputum  has  undertone  no  change,  either  in  quality  or  quan- 
tity, in  16;  in  2  it  oecame  less,  in  1  more  profuse  ana  in  1 
lighter  in  consistency.  Prior  to  the  injections  it  became  less 
in  9,  remained  station<irv  in  8,  changed  in  character  in  2  and 
was  irrezular  in  1.  7.  The  tubercle  bacilli  remiined  as  be- 
fore in  13,  became  less  in  number  in  3  and  increased  in  4. 
8.  No  special  improvement  of  the  subjective  symptoms  was 
noticed  during  the  injections.  9.  The  night-sweats  disap- 
peared also  before  the  injections.  Only  in  one  case  did  they 
disappear  during  the  treatment,  while  in  the  other  they  per- 
sisted in  spite  of  it.  10.  The  weight  was  reduced  in  4;  in 
the  other  it  increased  from  \  to  37J  pounds.  Prior  to 
the  treatment  it  was  decreased  in  3  and  increiised  from  \\  to 
43  pounds  in  the  others.  11.  The  enlarged  lymphatic  glands 
remained  as  before.  In  1  patient  with  a  fistula  of  a  lym- 
phatic gland  the  opening  did  not  close.  12  In  1  patient 
with  laryngeal  tuberculosis  an  improvement  was  observed 
during  the  injections,  but  this  improvement  is  to  be  credited 
more  to  the  general  hygienic  and  dietetic  treatment  than  to 
the  sodium  cinnamylate.  A  number  of  similar  cases  im- 
proved in  the  sanitarium  prior  to  the  use  of  this  drug,  and 
many  even  recovered.  13.  The  areas  of  dulness  did  not  di- 
minish during  the  injections.  On  the  contrary,  in  2  c-ases  the 
tympanitic  sound  reappeared.  14.  In  1  case  the  breathing 
became  weiker,  in  2  it  changed  from  bronchial,  and  in  1 
from  weak  to  amphoric.  In  2  it  assumed  a  marked  bronchial 
character,  and  only  in  1  did  it  become  less  raspy.  In  all 
others  the  conditions  remained  the  same.  15.  Two  patients 
had  hemoptysis  twice  (1  had  it  twice  prior  to  the  injec- 
tions, the  other  4  times).  In  1  case  hemoptysis  occurred 
once,  in  the  other  5  times  prior  to  the  injections,  but  in 
neither  case  was  blood  found  in  the  sputum  during  the  treatr 
ment.  16.  The  treatment  exerted  no  influence  on  the  tem- 
perature. 17.  In  1  patient  somnolence  was  observed  for 
from  half  to  one  hour  ;if:er  the  injection.  It  thus  appears 
that  the  results  obtained  could  not  be  considered  either 
favorable  or  encouraging.  The  slight  improvement  which 
took  plac«  in  some  of  the  cases  could  be  very  well  attributed 
to  general  treatment  and  other  favorable  conditions  under 
which  the  patients  in  sanitaria  are  placed.  The  best  that 
could  be  said  about  this  drug  is  that  it  did  no  harm.    [a.e.] 


April  e,  1901] 


PROPHYLAXIS  OF  VENEREAL  DISEASES 


[Thb  Phiuldrlphu 
Mkdical  Jousnai, 


663 


(Drtginal  ^Irttclcs. 


THE  PROPHYLAXIS  OF  VENEREAL  DISEASES. 
Medical  Aspects  of  the  Social  Evil  in  New  York.* 

By  prince  a.  MORROW,  M.D., 

of  New  York. 

Attending  Surgeon  to  the  City  Hospital ;  Attending  Physician  to  the  Depai  truent 
of  Skin  and  Venereal  Diseases,  New  York  Hospital ;  etc. 

It  would  hardly  seem  necessary  in  a  paper  before  a 
learned  society  of  medical  men  to  pass  in  review  the 
pathological  significance  of  the  class  of  diseases  com- 
prehended under  the  general  term — venereal — or  the 
important  relations  which  these  diseases  bear  to  the 
public  health. 

There  is  reason  to  believe,  however,  that  the  enormous 
extent  to  which  these  diseases  prevail  and  their  far- 
reaching  and  pernicious  influence  upon  the  health  of 
the  community  are  not  sufficiently  appreciated  by  the 
general  profession.  Unfortunately,  our  perceptions  of 
the  significance  of  certain  evils  become  blunted  by 
habituation,  and  we  accept  them  as  natural  and  among 
the  established  order  of  things. 

While  we  view  with  lively  concern  those  epidemic 
waves  of  disease  which  from  time  to  time  sweep  over 
the  community,  wo  are  apt  to  regard  with  indifference, 
diseases  which  are  of  common  occurrence  and  exist  in 
a  state  of  permanence  in  our  midst.  We  take  alarm 
and  employ  active  means  of  defense  against  the  threat- 
ened invasion  of  the  cholera,  the  plague,  yellow  fever, 
etc.,  while  we  are  insensible  to  the  ravages  of  a  disease — 
syphilis — which  is  vastly  more  destructive  to  the  health 
of  the  community  than  all  the  foreign  pestilences  that 
have  visited  our  shores. 

It  has  been  estimated  by  a  competent  and  careful 
authority  that  fully  one- eighth  of  all  human  suff'ering 
is  caused  by  venereal  diseases  or  their  sequela-.  As 
regards  their  prevalence  in  this  city  it  may  be  said  that 
there  are  no  data  upon  which  we  can  base  conclusions 
possessing  definite  scientific  value.  Venereal  statistics 
cannot  be  computed  by  the  methods  ordinarily  em- 
ployed for  the  detection  and  registration  of  diseases. 
Unfortunately,  they  belong  to  the  category  of  "  shame- 
ful diseases,"  the  avowal  of  which  would,  to  employ  a 
legal  phrase,  tend  "to  incriminate  or  degrade  the 
bearer,"  so  that  the  actual  number  of  such  cases  in  any 
city  or  community  must  always  remain  an  unknown 
and  unknowable  quantity. 

It  is  well  known  that  material  as  well  as  moral  and 
sanitary  conditions  modify  venereal  morbidity ;  it  is 
much  larger  among  urban  than  among  rural  popula- 
tions. Then  again,  even  in  our  large  centers  of  popula- 
tion oscillations  occur  just  as  in  other  current  diseases, 
the  explanation  of  which  escapes  us. 

According  to  Neisser,  the  discoverer  of  the  gonococ- 
cus,  gonorrhea  is  with  the  exception,  perhaps,  of  measles, 
the  most  universal  and  widespread  of  all  diseases.  Other 
German  authorities  have  computed  that  fully  three- 
quarters  of  the  adult  male  population  and  one- sixth  or 
more  of  adult  females  have  contracted  gonorrhea. 

As  regards  the  prevalence  of  syphilis,  Fournier  found 
in  careful  personal  investigations,  extending  over  a  num- 
ber of  years,  of  the  general  hospitals  of  Paris  from  15% 
to  23%  cases  of  syphilitic  origin.     From  these  figures, 

»  Read  before  the  New  York  County  Medical  Society,  February  26, 1901. 


taken  in  connection  with  the  enormous  number  treated 
in  the  special  hospitals,  in  dispensaries  and  in  private 
practice,  he  estimates  that  one-seventh  of  the  population 
of  Paris  is  syphilitic.  When  we  consider  the  cosmo- 
politan character  of  the  population  of  New  York,  the 
large  foreign  colonies  of  Bohemians,  Italians,  Russian 
and  Polish  Jews,  many  of  whom  bring  their  social  vices 
and  sordid,  communistic  modes  of  living,  it  is  quite 
possible  that  Fournier's  figures,  with  some  modification, 
may  apply  to  this  city  as  well  as  Paris. 

The  following  statistics  of  five  of  the  principal  dis- 
pensaries in  New  York  City  give  some  idea  of  the  pro- 
portion of  venereal  morbidity  to  general  diseases. 

The  records  of  the  out-patient  departments  of  the 
following  hospitals  for  1900  show  : 

The  New  York  Hospital,  total  number 11,.550 

Number  of  venereal  cases 1,054 

The  Vanderbilt  Clinic,  total  number 43,967 

Number  of  venereal  cases 2,935 

New  York  Dispensary,  total  number  of  cases  42,531 

Number  of  venereal  cases 3,895 

The  Good  Samaritan  Dispensary,  total  number  86,916 

Surgical  and  venereal  cases 20,530 

(25  to  50^  venereal.) 
Belle%aie  Out-Patient  Department 67,470 

Venereal  cases 7,320 

Averaging  all  together  nearly  10^  of  venereal  cases. 

These  figures  by  no  means  represent  the  actual  num- 
ber of  cases  of  venereal  disease,  as  a  large  proportion 
of  the  cases  treated  in  the  skin  departments  were 
syphilodermata. 

Furthermore,  venereal  cases  undoubtedly  furnish  a 
certain  contingent  of  the  classes  in  the  eye,  throat, 
gynecological  and  other  departments. 

It  is  not  claimed  that  these  few  statistical  data  afford 
any  correct  indication  of  the  amount  of  venereal  mor- 
bidity in  this  city,  they  simply  show  that  it  exists  to  a 
larger  extent  perhaps  than  is  generally  realized. 

Venereal  morbidity  may  best  be  studied  in  taking 
large  bodies  of  men,  such  as  the  army  and  navy,  where 
every  case  of  disease  is  carefully  tabulated  and  the 
results  analyzed.  To  take  an  extreme  case.  Sir  H.  S. 
Cunningham's  report  of  the  health  of  the  British  Army 
in  India  for  the  year  1895  shows  that  out  of  68,331 
British  soldiers  stationed  in  India,  the  admissions  to 
the  hospital  for  venereal  diseases  were  no  less  than 
36,881  cases,  or  53.7%.  Of  these  17,702,  or  25.9%,  were 
cases  of  syphilis.  During  this  year  15  died  from  syph- 
ilis, 348  were  invalided  and  130  finally  discharged  as 
unfit  for  service  from  the  same  cause.  Of  economic 
interest  is  the  fact  that  these  diseases  occasioned  a  loss 
of  1,155,451  days  of  active  service. 

These  figures  did  not  in  the  opinion  of  the  official 
experts  represent  the  whole  amount  of  venereal  dis- 
eases, many  cases  being  treated  without  admission  to  the 
hospitals.  Moreover,  the  report  shows  that  of  the  en- 
tire army  in  India,  13,000  of  whom  are  annually  sent 
home  to  England,  25%  were  syphilitic.  It  is  to  be 
hoped  that  of  our  returning  forces  from  the  Philip- 
pines, no  such  percentage  will  bring  back  syphilis  as  a 
souvenir  of  their  sojourn  in  these  islands. 

While  venereal  diseases  are  rarely  fatal  in  their  im- 
mediate effects,  yet  in  their  remote  consequences  they 
contribute  largely  to  the  bills  of  mortality.  Our  mor- 
tuary statistics  throw  a  misleading  hght  upon  the  mor- 
tality from  these  diseases.  The  deaths  from  the  sequelae 
of  gonorrhea  are  rarely  referred  to  their  true  etiological 
factor.  The  deaths  from  syphilis  are  conveniently 
grouped  under  affections^of  the  viscera,  diseases  of  the 


664 


Thk  Phtladklphia"! 
Medical  Joprnal  J 


PROPHYLAXIS  OF  VENEREAL  DISEASES 


[APBIL  6,  19« 


brain,  cord,  liver,  etc.,  while  the  determiniag  cause  is 
chastely  concealed. 

Gonorrhea. 

In  the  estimation  of  the  laity  the  relations  of  gonor- 
rhea to  the  public  health  would  be  regarded  as  of  no 
more  significance  than  a  catarrhal  inflammation  of  any 
other  mucous  membrane,  and,  less  than  a  quarter  of  a 
century  ago,  this  opinion  would,  perhaps,  have  been 
shared  by  many  medical  men.  But  within  recent  years 
our  conception  of  the  pathological  import  of  gonorrhea 
has  been  singularly  amplified,  not  only  as  regards  its 
chronicity,  but  especiallj'  its  etiological  relationship  to 
many  morbid  states  of  the  general  system.  To-day  we 
recognize  it  not  only  as  the  most  widespread  but  also 
as  one  of  the  most  serious  of  infective  diseases ;  it  has 
risen  to  the  dignity  of  a  public  peril. 

Since  the  discovery  of  the  gonococcus,  new  facts  have 
been  developed  showing  that  instead  of  being  limited 
to  the  genito-urinary  tract  the  range  of  its  morbid  action 
is  much  more  extensive  and,  not  infrequently,  is  radi- 
ated to  important  visceral  organs.  Staining  and  culture 
experiments  have  demonstrated  its  presence,  not  only 
in  the  ovaries,  tubes  and  peritoneal  cavity,  but  also  in 
the  pleura,  the  endocardium  and  pericardium,  the 
bloodvessels,  joints  and  tendon-sheaths,  etc.  Moreover, 
it  has  been  demonstrated  that  it  stands  in  the  relation 
of  causal  factor  to  visceral  lesions  which  often  termi- 
nate fatally.  An  analysis  of  the  recent  literature  of  the 
subject  shows  a  surprisingly  large  number  of  such 
fatal  complications. 

I  will  pass  over  briefly  the  common  complications  of 
gonorrhea,  the  afi'ections  of  glandular  structures,  the 
acute  and  chronic  inflammations  of  the  prostate  and 
bladder,  of  the  seminal  ducts  and  vesicles,  the  cord, 
epididj'mis,  testes,  etc.  These  latter  afi'ections  are  most 
important,  as  they  may  entirely  destroy  the  fecundat- 
ing capacity  of  the  individual.  The  sequelae  of  gonor- 
rhea, stricture  and  ascending  inflammations  of  the 
ureters  and  kidney  causing  pyelitis,  etc.,  which  not 
only  seriously  compromise  the  health  but  may  endanger 
the  life  of  the  individual,  need  only  be  mentioned. 

In  the  female,  the  local  and  general  eflects  of  gonor- 
rhea are  apt  to  be  much  more  serious  and  permanent 
owing  to  the  extent  and  character  of  the  structures 
exposed.  In  addition  to  vagmitis  and  vulvitis,  the 
virus  may  penetrate  the  uterine  cavity  with  result- 
ing endometritis,  ascend  the  tubes,  causing  painful  and 
suppurative  swellings,  with  acute  exacerbations  not  in- 
frequently necessitating  laparotomy.  Most  cases  of 
salpingitis  must  be  classed  as  gonorrheal.  Sanger  found 
that  about  one-eighth  of  all  his  gynecological  cases  were 
due  to  gonorrheal  infection.  As  more  permanent  results 
may  be  mentioned  chronic  inflammation  of  the  uterus 
and  its  adnexes,  resulting  in  fixation  of  these  organs, 
various  disorders  of  menstruation,  anemia,  neurasthenia, 
etc.  German  authorities  state  that  80%  of  all  deaths 
from  diseases  of  the  uterus  and  its  adnexes  are  of 
gonorrheal  origin. 

The  virus  spreading  through  the  lymph  and  vascular 
channels  may  cause  generalized  metastases.  General 
septicemia  and  pyemia  from  foci  of  suppuration  in  the 
genito-urinary  tract  are  bj'  no  means  uncommon. 

Many  other  grave  manifestations  of  gonorrhea  in  both 
sexes  might  be  referred  to,  such  as  its  frequently  de- 
structive effect  upon  the  sight  from  inoculation  of  the 
child  at  birth.  Blennorrhea  neonatorum  contributes  a 
large  contingent  to  our  blind  asylums,  estimated  from 


10  to  20%  ;  from  40  to  60%  before  the  Crede  method 
was  instituted.  Neisser  thinks  that  of  the  30,000  bUnd 
in  Germany  from  this  cause,  a  large  proportion  might 
have  been  saved  by  the  employment  of  this  prophylac- 
tic measure.  The  prominent  role  which  the  gonococcus 
plays  in  the  etiology  of  joint-affections  of  a  serious  and 
intractable  character  should  not  be  overlooked. 

It  is,  however,  the  destructive  effect  of  gonorrhea  upon 
the  procreative  functions  that  I  would  especially 
emphasize  as  of  interest  in  this  connection.  Neisser 
contends  that  gonorrhea  is  a  more  potent  factor  in  the 
depopulation  of  countries  than  syphilis  even.  He 
regards  gonorrheal  infection  of  the  male  responsible  for 
30%  of  sterile  marriages.  Busch,  Fiirbringer  and 
others  have  demonstrated  that  90%  of  all  cases  of 
azoospermia  may  be  traced  to  antecedent  inflammation 
of  the  epididymis  and  cord. 

A  percentage  variously  estimated  at  from  40  to  80% 
of  endo-,  meso,-  and  perimetritis  is  of  gonorrheal  origin 
and  a  cause  of  sterility  in  women.  Xoeggerath  found 
in  81  gonorrheal  women,  49  entirely  sterile.  In  96 
sterile  marriages  Kehrer  found  30%  due  to  azoosper- 
mia, 33%  to  perimetritic  inflammatory  changes,  8.3% 
to  amenorrhea,  4.1  to  vaginismus — all  of  gonorrheal 
origin. 

Syphilis. 

Syphilis,  as  we  comprehend  it  to-day,  has  a  much 
graver  significance  in  its  relation  to  the  public  health 
than  was  formerly  supposed  ;  not  that  the  disease 
exhibits  a  severer  type,  but  that  its  pathological  domain 
has  been  greatly  enlarged  with  our  increased  knowledge 
of  the  vast  number,  the  complexity,  and  the  far-reach- 
ing character  of  its  morbid  processes.  That  our  con- 
ception of  syphilis  has  entirely  changed  will  be  evident 
from  comparing  the  older  textbooks  with  a  modern 
treatise  on  syphilis.  In  the  -former  almost  the  entire 
symptomatology  of  the  disease  was  made  up  of  the 
visible  accidents  on  the  external  surface  of  the  body 
and  for  the  cure  of  which  a  few  months'  treatment  was 
all  that  was  deemed  essential.  In  the  modern  treatises 
these  surface  accidents  are  considered  of  subsidiary 
importance,  as  they  rarely  aff"ect  the  integrity  of  any 
important  organ,  while  the  visceral  determinations  of 
the  disease,  the  cerebral,  spinal,  vascular,  ocular,  artic- 
ular, pulmonary,  intestinal,  hepatic  and  renal  affections 
constitute  its  chief  significance.  We  now  recognize  that 
the  infection  of  syphilis  is  of  a  more  profound  and 
permanent  character,  that  it  may  attect  every  constit- 
uent element  of  the  body,  and  that  these  systemic  com- 
plications are  serious  and  often  fatal. 

Of  the  tertiary  determinations  syphilis  of  the  brain 
and  cord  occupies  the  first  rank  in  frequency  as  well  as 
gravity.  Fournier  declares  that  the  nervous  system  is 
the  preferred  victim  of  tertiarism.  His  personal  statis- 
tics, extending  over  a  period  of  39  years,  and  embracing 
4,000  Ciises  of  tertiary  syphilis,  show  that  next  to  the 
skin  the  brain  and  cord  were  the  organs  most  frequently 
afi'ected.  The  cutiineous  accidents  number  1.145.  while 
affections  of  the  brain  number  758  :  of  the  spinal  cord 
1,098 ;  giving  a  total  of  1,857  cases  in  which  the  brain 
and  cord  were  involved. 

It  is  interesting  to  note  th.at  354  of  these  cases  of 
cerebral  syphilis  were  followed  up  to  a  known  termina- 
tion ;  77  were  cured ;  OS  died,  while  ihe  remaining  209 
survived,  but  with  various  infirmities  of  a  grave  char- 
acter and  in  every  case  irremediable. 

Want  of  space   forbids  the  mention  of  the  almost 


April  6,  19011 


PROPHYLAXIS  OF  VENEREAL  DISEASES 


CThe  Philadelphia 
Medical  Journal 


665 


innnumerable  manifestations  of  syphilis.  Among  them 
may  be  classed  oculomotor  paralyses,  hemiplegia,  para- 
plegia, epilepsy,  chorea,  multiple  neuritis,  progressive 
muscular  atrophy,  locomotor  ataxia,  general  paraly- 
sis, etc. 

We  come  now  to  consider  certain  irradiations  of 
syphilis  which  constitute  a  grave  social  danger  and 
which  emphasize  the  importance  of  prophylaxis  from 
a  humane  as  well  as  a  sanitary  standpoint.  I  refer  to 
syphilis  imontium,  or  syphilis  of  the  innocents.  Unfor- 
tunately, the  risks  of  this  disease  are  by  no  means 
limited  to  the  offender  against  morality,  but  are  trans- 
mitted to  innocent  wives  and  helpless  children  by  its 
introduction  into  the  family.  The  infected  wife  is  not 
only  made  to  incur  all  the  individual  risks  we  have 
been  considering,  which  in  her  case  are  much  greater  as 
she  is  most  often  ignorant  of  the  nature  of  her  disease 
and  does  not  receive  the  benefit  of  prompt  and  efficient 
treatment.  Incredible  as  it  may  appear,  many  husbands 
who  infect  their  wives  employ  every  possible  means  to 
prevent  them  consulting  a  physician  from  a  fear  of  the 
detection  of  their  infidelity  which  would  come  from 
the  woman's  knowledge  of  the  nature  of  the  trouble. 

The  frequency  of  marital  syphilis,  the  enormous  ex- 
tent to  which  it  prevails,  is  not  generally  known  or 
even  suspected.  Fournier's  statistics  embracing  only 
those  cases  in  which  the  origin  of  the  infection  could 
be  positively  traced,  show  that  out  of  every  100  syphi- 
litic women  19,  or  nearly  5%,  are  conjugally  contam- 
inated. 

During  the  past  year  I  have  carefully  investigated 
the  origin  of  the  infection  in  every  syphilitic  woman 
who  appplied  for  treatment  in  my  service  at  the  New 
York  Hospital.  Fully  90%  were  enrolled  as  married 
women.  Excluding  all  cases  in  which  there  was  a  sus- 
picion of  irregularity,  and  including  only  those  in  which 
the  statement  of  the  woman  that  she  lived  with  and 
was  supported  by  her  husband  was  borne  out  by  every 
appearance  of  truth,  fully  70%  appeared  to  be  cases 
of  conjugal  infection.  This  percentage  is  large,  but  it 
will  be  remembered  that  few  public  women  come  to  this 
hospital  for  treatment. 

The  number  of  cases  of  syphilis  insontium  is  not  to 
be  measured  by  the  number  of  victims  of  marital 
syphilis.  Innocent  inoculations  occur  in  the  daily 
occupations  and  intercourse  of  life.  Infection  of  children 
and  other  members  of  a  family  take  place  in  the  thou- 
sand and  one  intimacies  of  family  life,  children  infect 
their  nurses  and  nurses  contaminate  children. 

The  irradiations  of  syphilis  can  be  traced  not  only 
through  the  family,  but  through  various  industrial 
occupations  and  professional  relations.  Professional 
syphilis,  that  of  physicians,  surgeons,  and  accoucheurs, 
is  vastly  more  common  than  generally  supposed  ;  more 
than  50  such  cases  have  come  under  my  personal  obser- 
vation. We  hear  little  of  them,  as  the  victims  have 
every  motive  to  conceal  the  nature  of  their  trouble. 

The  hereditary  consequences  of  this  disease  will  be 
only  briefly  referred  to.  Syphilis  stands  as  the  per- 
fected type  of  an  hereditary  disease.  No  other  disease 
is  so  susceptible  of  hereditary  transmission,  nor  so  pro- 
nounced in  its  effects,  and  fatal  to  the  offspring.  Statistics 
show  that  from  60  to  86%  of  all  syphilitic  pregnancies 
terminate  in  death  in  ulero,  or  stillborn  children.  Of 
children  born  alive  and  viable,  a  large  proportion  of 
those  who  survive  the  first  year  suffer  from  a  category 
of  infirmities  which  can  only  be  briefly  recapitulated. 
Dystrophies  and  degenerations,  cranial  and  nasal  mal- 


formations, hydrocephalus,  osseus  lesions,  various  affec- 
tions of  the  brain  and  cord,  lesions  of  the  organs  of 
special  sense,  deaf-mutism,  idiocy,  etc.  Rickets  has  its 
almost  exclusive  etiology  in  syphilis.  The  predisposi- 
tion to  abortion  may  be  manifest  in  the  third  genera- 
tion. From  the  stastics  of  Pinard,  Gibert,  Tarnowsky, 
and  others,  we  find  that  of  81  pregnancies  occurring  in 
households  in  which  one  of  the  parents  had  inherited 
-syphilis,  there  were  28  abortions,  13  stillborn,  7  died 
soon  after  birth,  while  only  33  finally  survived. 

The  social  misery  caused  by  venereal  diseases  cannot 
be  overlooked  ;  the  separations,  divorces,  the  breaking 
up  of  families,  the  dishonor  of  children,  are  deplorable 
consequences  which  can  be  too  often  traced  to  the  in- 
troduction of  these  diseases  into  the  family. 

We  have  thus  seen  that  there  exists  in  our  midst  a 
large  and  important  class  of  diseases  which  have  the 
most  intimate  relations  to  the  public  health  ;  they  entail 
suffering,  they  destroy  life,  they  are  the  fruitful  source 
of  a  vast  deal  of  social  misery.  In  addition  they  have 
important  socio-economic  relations  in  their  incapacitat- 
ing effect  upon  the  wage-earner,  army  and  navy  inva- 
lidism, and  also  in  their  undoubted  influence  as  a 
factor  in  the  depopulation  of  countries.  No  disease 
has  such  a  devitalizing  influence  upon  the  procreative 
function  as  gonorrhea,  no  disease  has  such  a  murderous 
influence  upon  the  offspring  as  syphilis,  they  literally 
poison  the  fountains  of  life. 

In  passing,  one  distinctive  peculiarity  of  venereal  dis- 
eases may  be  referred  to.  The  germs  of  many  infectious 
diseases  cannot  be  guarded  against,  the  recipient  is  a 
passive  victim  ;  infection  is  inevitable.  The  contagion 
of  venereal  diseases,  exception  being  made  of  accidental 
inoculations,  is  always  evitable ;  it  is  effected  by  the 
voluntary  act  of  individuals.  The  communication  of 
venereal  disease  is  therefore  to  a  certain  degree  wilful. 

Prophylaxis. 

We  cannot  well  consider  the  prophylaxis  of  any  dis- 
ease without  reference  to  our  sanitary  authorities  who 
are  the  accredited  representatives  of  the  State  in  all 
matters  relating  to  the  protection  of  the  public  health. 
At  the  present  day  the  extermination  of  every  con- 
tagious disease  is  the  watchword  of  sanitary  science. 
In  an  address  before  the  Congress  of  American  Physi- 
cians and  Surgeons,  in  1894,  a  high  Government  official 
proclaimed  "  that  the  controlling  movement,  so  far  as 
medical  science  is  concerned,  which  will  mark  the  closing 
of  the  present  century  and  the  beginning  of  the  next,  is 
the  settled  resolution  to  exterminate  every  contagious 
disease."  And  yet  the  dawn  of  the  twentieth  century 
witnesses  the  spectacle  of  a  large  class  of  diseases,  dan- 
gerous to  the  public  health,  confessedly  contagious, 
essentially  evitable,  and  yet  absolutely  ignored  by  our 
sanitary  authorities.  There  is  not  a  single  city  or  com- 
munity in  the  United  States  in  which  these  diseases  are 
subject  to  sanitary  supervision. 

We  may  ask  why  this  apparent  indifference,  this  ab- 
solute inaction  upon  the  part  of  the  guardians  of  the 
public  health  ?  Is  it  from  the  traditional  conception 
that  these  diseases  do  not  come  within  the  legitimate 
sphere  of  preventive  medicine  ?  But  at  the  present  day 
our  sanitarians  do  not  restrict  their  work  upon  approved 
traditional  lines,  they  are  constantly  enlarging  the 
sphere  of  its  application.  They  have  attacked  the 
modern  Sampson  of  tuberculosis  upon  the  grounds  of 
its  contagiousness,  but  the  syphilitic  is  20  times  more 
active  as  a  spreader  of  contagion  than  the  consumptive. 


666 


Thk  Philadelphia"! 
Medical  Journal  J 


PROPHYLAXIS  OF  VENEREAL  DISEASES 


[Apbil  6,  1901 


Is  it  from  a  conviction  that  since  these  diseases  are 
commonly  due  to  voluntary  exposure  they  are  in  a 
certain  sense  merited  and  that  society  is  under  no  obli- 
gation to  protect  those  who  are  able  to  protect  them- 
selves? But  is  it  not  the  manifest  duty  of  society  to 
protect  the  army  of  innocents  who  are  infected  through 
no  fault  of  their  own  ?  Besides,  the  large  pjroportion  of 
the  victims  of  venereal  disease  are  not  the  seasoned 
sinners,  the  confirmed  debauchees,  but  the  young,  the 
immature,  and  the  inexperienced.  An  analysis  of  sta- 
tistics shows  that  the  average  at  which  syphilis  is  con- 
tracted by  women  is  from  18  to  20,  in  men  from  20  to  25. 

Is  it  not  rather  true  that  this  policy  of  inaction  is  a 
confession  of  inability  to  cope  with  the  evil  by  any 
methods  known  to  sanitary  science? 

We  must  admit  that  the  sanitary  control  of  venereal 
diseases  is  much  more  difficult  than  would  at  first 
appear ;  the  problem  is  so  complicated  by  the  nature  of 
the  cause  and  the  mode  of  contagion,  so  interwoven 
with  questions  of  infringement  of  private  rights,  restric- 
tions of  individual  liberty,  and,  finally,  with  questions 
of  morality,  that  there  appears  no  clear  way  in  which 
the  evil  can  be  touched  by  the  strong  hand  of  repression. 

Undoubtedly  the  chief  obstacle  to  sanitary  interven- 
tion in  this  country  is  the  inhibitory  influence  of  pub- 
lic sentiment  against  the  legal  recognition  or  license  of 
prostitution. 

Prostitution  is  the  fo7is  et  origo — the  baleful  source  of 
the  diseases  under  consideration.  While  not  directly 
concerned  in  the  transmission  of  syphilis  in  the  family, 
it  is  the  fountain  head  to  which  all  innocent  inocula- 
tions may  be  traced.  Hence  the  suppression  of  prosti- 
tution and  the  prevention  of  venereal  diseases  are  in- 
dissolubly  linked. 

But  the  suppression  of  prostitution  is  a  Utopian  idea. 
It  has  existed  in  all  ages  and  under  all  conditions  of 
civilization.  The  most  severe  and  drastic  measures 
carried  out  under  the  most  despotic  authority  have 
failed  to  crush  it.  Almost  every  conceivable  punish- 
ment, flogging,  branding,  shaving  the  head,  banishment 
and  death  have  been  employed  in  vain.  It  cannot  be 
annihilated  by  force.  In  the  exifting  economic  and 
moral  conditions  of  society  it  is  a  necessary  evil,  not  in 
the  sense  of  being  indispensable,  but  inevitable. 

Now  the  law  takes  cognizance  of  certain  forms  of 
prostitution.  It  has  made  the  keeping  of  disorderly 
houses  a  crime  ;  it  has  made  open  public  provocation 
a  misdemeanor.  It  can  sentence  the  keeper  of  a 
brothel  to  the  penitentiary,  it  can  send  the  inmates  to 
the  workhouse;  but  the  law  has  its  limitations.  There 
are  certain  forms  of  the  evil  which  are  intangible,  the 
prostitute  can  solicit  in  the  streets  by  signs,  which 
though  subtle  are  no  less  significant  than  the  voiced 
invitation.  She  can  make  whatever  disposition  she 
pleases  of  her  body  in  her  private  apartments,  and  in 
this  stronghold  of  individual  liberty  the  law  cannot 
touch  her. 

In  this  city  the  crusades  against  vice  have  been  too 
often  campaigns  of  force.  From  time  to  time  a  cry  of 
alarm  is  raised  against  the  public  peril  created  Ijy  the 
appalling  conditions  of  the  social  evil  in  certain  locali- 
ties. The  strong  arm  of  the  law  is  invoked,  the  police 
are  stimulated  to  do  their  duty,  and  the  city  is  declared 
purified.  Such  a  movement  took  place  five  or  six  years 
ago,  but  the  ultimate  result  of  the  harsh  and  punitive 
measures  employed  was  simply  to  disperse  and  scatter 
the  evil,  which  was  comparatively  isolated  in  certain 
quarters.     Unfortunately,  dissemination  ia  not  destruc- 


tion. From  an  exclusively  medical  standpoint,  segre- 
gation represents  the  least  objectionable  form  of  the 
social  evil.  To  change  the  locale  of  a  shameless  traflBc 
from  one  precinct  to  another,  to  drive  it  to  Harlem,  or 
even  to  Hoboken,  is  not  to  break  it  up.  The  inmates 
of  disorderly  houses  when  turned  into  the  streets  are 
confronted  by  the  stern  necessity  of  living.  They  carry 
in  their  depraved  and  often  diseased  bodies  their  only 
means  of  subsistence — they  simply  ply  their  demoral- 
izing trade  elsewhere.  These  crusades  can  make  vice 
less  flagrant,  less  scandalous ;  they  can  render  the  streets 
more  orderly  and  more  decent;  but  the  volume  of  vice 
is  not  diminished- — it  is  simply  directed  into  other 
channels.  Too  often  it  takes  refuge  in  the  crowded 
tenements  of  the  poor,  or  in  the  apartment-houses  of 
the  better  class,  and  becomes  a  co-dweller  with  virtue 
and  respectability. 

Violent  measures  must  always  defeat  the  object  in 
view,  because  they  are  of  necessity  intermittent  and 
spasmodic.  Violence  is  incompatible  with  the  sus- 
tained and  continuous  effort  required  to  combat  this 
evil.  The  social  reformer  can  accomplish  more  by 
measures  for  the  amelioration  of  the  social  condition  of 
women  ;  by  throwing  stronger  safeguards  around  minors, 
especially  the  orphans  and  unprotected;  by  establishing 
homes  for  the  reception  and  reclaiming  of  faUen 
women;  and  by  furnishing  means  and  opportunities  for 
the  rehabilitation  of  those  wishing  to  reform. 

While  the  most  stringent  legislation  can  never  accom- 
plish social  reforms,  yet  the  arm  of  the  law  may  be 
effectively  invoked  in  preventing  scandalous  public 
provocation;  in  suppressing  the  afBuents  of  vice — the 
wine-shops,  low  concert  and  dance-halls,  and  other  dis- 
reputable resorts ;  in  making  the  punishment  for  the 
seduction  of  minors  more  sweeping  by  raising  the  age 
of  consent  to  21  years ;  and  by  meting  out  the  severest 
punishment  against  the  purveyors  of  vice — men  and 
women  who  make  a  trade  of  dealing  in  human  flesh  by 
enticing  and  selling  into  the  slavery  of  prostitution 
innocent  and  unprotected  young  women. 

Regulation  of  Prostitctiox. 

Recognizing  prostitution  not  only  as  an  ineradicable 
feature  of  our  social  order,  but  as  a  fruitful  source  of 
disease,  what  are  the  best  methods  of  dealing  with  it 
from  the  standpoint  of  public  hygiene?  The  system 
known  as  the  "  Regulation  of  Prostitution  "  has  been 
tried  in  various  countries  of  Europe.  It  is  now  in 
force  in  France,  Belgium,  Germany,  Austro-Hungary, 
Russia,  Spain  and  Portugal.  It  was  introduced  in  Eng- 
land in  1860  and  abandoned  in  1881.  In  Norway  it 
was  tried  from  1860  to  1888.  In  Switzerland  it  has 
been  abolished  in  many  communes,  but  still  exists  in 
Geneva.  It  was  introduced  in  Italv  in  1860,  suppressed 
in  1888,  and  reestabUshed  in  1891." 

In  all  these  countries  the  system  is  essentially  the 
same  with  slight  modifications.  It  has  for  its  essential 
features  the  registration  or  inscription  of  all  prostitutes 
that  can  be  brought  within  the  jurisdiction  of  the 
police,  and  the  medical  examination  of  these  women 
at  stated  intervals.  Any  woman  found  suffering  from 
venereal  disease  is  sent  to  the  hospital,  where  she  is 
forcibly  detained  until  the  contagious  accidents  are 
cured.  The  object  is  to  hygienize  an  insalubrious  oc- 
cupation by  the  retiring  from  circulation  of  all  sources 
of  contagion.  Men  are  not  subjected  to  surveillance.  The 
only  plea  for  this  discrimination  is  that  the  woman  who 
sells  her  body  for  money  is  engaged  in  a  commerce  or 


Al-KIL  6,  1901] 


PROPHYLAXIS  OF  VENEREAL  DISEASES 


PThb  Philadelphia 
L  Medical  Journal 


667 


traffic,  and  that  the  interests  of  public  hygiene  demand 
that  what  she  offers  for  sale  should  not  be  tainted  or 
contaminating  to  health.  Besides,  as  the  woman  is  the 
more  active  spreader  of  disease^  she  is  the  greater 
offender. 

Like  any  other  system,  its  value  depends  upon  the 
thoroughness  with  which  it  is  organized  and  the  activ- 
ity and  energy  with  which  its  regulations  are  carried 
out.  A  number  of  statistics  might  be  cited  to  show 
that  the  regulation  of  prostitution  has  an  undoubted  in- 
fluence in  limiting  the  dissemination  of  disease,  such 
for  example  as  the  vastly  larger  proportions  of  cases  of 
contagion  that  can  be  traced  to  the  unregistered  prosti- 
tutes who  are  not  subjected  to  surveillance.  Without 
reference  to  statistics  it  stands  to  reason  that  a  public 
woman  who  is  diseased  will  almost  inevitably  infect 
every  comer,  it  may  be  four  or  five  a  night,  while  if 
she  is  quarantined  in  a  hospital,  so  many  men  will 
e.scape.  The  more  public  women  that  can  be  brought 
under  the  operation  of  this  measure,  the  more  sources 
of  contagion  will  be  suppressed  and  the  greater  the 
protection  of  the  public. 

But  right  here  comes  in  the  limitation  of  its  useful- 
ness. Women  do  not  like  to  be  registered  as  prosti- 
tutes, they  do  not  willingly  submit  to  medical  examina- 
tion, they  have  a  horror  of  imprisonment  In  a  hospital. 
The  result  is  they  abandon  public  houses  and  become 
clandestine  prostitutes,  so  that  the  maison.s  dc  tolerance 
in  which  vice  is  collective  and  centralized  and  can  be 
most  effectively  superviged  and  controlled  are  in  pro- 
cess of  extinction. 

In  Paris  the  number  of  such  houses  has  diminished 
from  250  to  less  than  40,  although  within  this  time  the 
population  has  quadrupled.  In  Marseilles  there  were 
in  1875,  120  brothels  with  600  inmates,  20  years  later 
there  were  only  12  with  90  inmates.  In  Bordeaux  the 
number  has  decreased  from  60  to  21,  and  so  in  all 
cities  where  regulation  has  been  enforced.  Regulation 
has  conclusively  demonstrated  that  the  surest  way  to 
break  up  disorderly  houses  is  to  subject  them  to  sani- 
tary surveillance.  But  with  the  passing  of  the  brothels, 
there  have  sprung  up  hundreds  of  houses  of  rendez- 
vous, in  which  public  women  do  not  reside,  but  to 
which  they  go  when  sent  for.  Vice  takes  refuge  in 
theaters,  music  halls,  dance  halls,  it  seeks  cover  in  pri- 
vate lodgings.  The  industry  simply  ehanges  its  form 
and  methods  of  business  ;  it  becomes  clandestine,  more 
elusive,  less  susceptible  of  control  and  infinitely  more 
dangerous  to  the  public  health. 

To  my  mind  one  objection  to  this  system  is  that  it 
takes  cognizance  of  only  one  factor  in  the  spread  of 
disease.  It  is  a  rank  inequality  of  justice  to  subject  the 
female  offender  to  surveillance  and  allow  the  equally 
guilty  male  spreader  of  contagion  to  go  free.  Another  ob- 
jection is  the  inquisitorial  character  of  this  surveillance ; 
moreover,  when  the  police  are  armed  with  discretion- 
ary power,  in  the  matter  of  arrests,  they  are  apt  to 
abuse  this  authority. 

In  countries  where  regulation  is  employed  it  has  its 
partisans  and  opponents,  ^^'hile  generally  sustained 
by  the  medical  profession  it  is  condemned  by  others  as 
defective  and  inefficient.  The  most  violent  opposition 
comes  from  the  religious  and  moral  elements  of  society 
on  the  ground  that  in  hygienizing  prostitution  by 
sterilizing  sources  of  contagion,  it  is  rendered  safe,  and 
that  this  safety,  however  illusory  it  may  prove,  is  a 
direct  incitement,  a  provocation  to  debauch. 

Without  confuting  the  fallacy  of  this  charge  it  may 


be  said  that  it  is  unfortunate  that  there  should  be  such  an 
irreconcilable  conflict  of  opinion  between  the  hygienist 
and  the  moralist  upon  this  important  question.  The 
medical  man  and  the  moralist  are  both  interested  in 
the  correction  of  the  social  evil.  Instead  of  working 
independently,  and  often  antagonistically,  there  should 
be  cooperation  and  concert  of  action.  The  former  looks 
only  upon  the  effects  of  prostitution,  the  diseases  it  en- 
genders, to  prevent  which  appears  to  him  the  para- 
mount issue.  The  moralist  looks  upon  the  social  evil 
as  a  vice,  an  ofience  against  morality,  which  should  be 
combated  by  moral  means  alone. 

Whatever  may  be  the  value  of  the  system  of  regu- 
lation, as  employed  in  Continental  Europe,  it  is  safe  to 
say  that  it  cannot  be  utilized  in  this  country.  Public 
opinion,  which  often  has  a  force  quite  irrespective  of  its 
merits,  forbids  its  establishment  in  this  country,  on  the 
ground  that  it  is  equivalent  to  a  licensing  of  vice.  The 
experiment  has  been  tried  but  once  in  the  United 
States.  In  1872  the  Missouri  Legislature  enacted  a  law 
for  the  regulation  of  prostitution,  modeled  on  the  Conti- 
nental plan.  The  system  was  introduced  in  St.  Louis, 
but  was  in  operation  scarcely  over  a  year  when  the 
obnoxious  law  was  swept  from  the  statute-books  by  an 
avalanche  of  protests,  principally  from  women  and  the 
clergy. 

Again,  regulation  is  impracticable  in  this  city,  because 
the  conditions  essential  to  its  successful  application 
and  working  are  wanting.  This  sanitary  scheme  con 
templates  the  hospitalization  of  diseased  public  women 
and  their  quarantine  during  a  period  more  or  less  pro- 
longed, certainly  until  their  contagious  accidents  are 
cured.  Now,  incredible  as  it  may  appear,  there  are  not 
hospital  accommodations  for  one  in  2000  of  the  prosti- 
tutes in  this  city.  The  great  city  of  New  York  provides 
for  the  reception  and  treatment  of  women  suffering 
from  venereal  diseases  just  26  beds  in  the  City  Hospital 
on  Blackwell's  Island.  There  is  not  a  single  hospital 
on  Manhattan  Island  where  a  syphilitic  woman,  whether 
she  be  a  prostitute  or  an  innocent  victim  of  the  disease, 
may  be  treated.  She  may  be  received  in  Bellevue 
Hospital,  but  she  is  promptly  transported  to  the  Island. 

Such  is  the  situation.  Prostitution,  the  root  of  the 
evil,  cannot  be  extirpated,  it  will  continue  to  bring 
forth  its  crop  of  dangerous  diseases ;  any  proposition 
for  their  prevention,  based  upon  the  regulation  of  pros- 
stitution,  is  impracticable.  Can  nothing  be  done  to 
restrict  or  limit  their  spread  ? 

Prophylaxis  by  Treatment. 

What  has  been  termed  prophylaxis  by  treatment, 
appears  to  be  the  only  practicable  measure.  In  dealing 
with  diseases  in  which  there  has  been  a  comparative 
failure  of  the  sanitary  measures  employed  for  their 
prophylaxis  the  value  of  treatment  becomes  magnified 
in  importance.  In  the  case  of  inoculable  diseases, 
treatment  constitutes  the  best  prophylaxis,  by  steriliz- 
ing sources  of  contagion  and  limiting  the  period  of 
their  contagious  activity.  Prophylaxis  by  treatment  is 
by  no  means  a  new  idea.  It  was  advocated  as  the  only 
solution  of  the  problem  in  the  article  on  "  The  Relations 
of  Syphilis  to  the  Public  Health  "'  (Morrow's  System, 
Vol.11,  Syphilology,  1894).  Its  value  and  possibilities 
have  been  since  more  fully  elaborated  by  Fournier, 
Barthelt'my  and  others. 

Indeed  the  basic  principle  of  any  system  of  regula- 
tion is  to  hospitalize  and  treat  as  many  sources  of  con- 
tagion as  possible.     Its  chief  defect  lies  in  the  fact  that 


668 


ThK   PlIILAJ>Kt.PHIA~| 

Medical  Journal  J 


PROPHYLAXIS  OP  VENEREAL  DISEASES 


[Apbil  6,  1901 


the  number  of  cases  which  can  be  subjected  to  treat- 
ment is  limited.  The  feature  of  forced  detention  in  a 
hospital  excites  an  invincible  repugnance.  Treatment 
should  be  free  and  patients  allowed  to  come  and  go  at 
their  will.  Experience  proves  that  more  patients  can  be 
treated  by  liberty  than  by  force,  and  the  more  patients 
we  can  treat  the  greater  the  protection  to  the  public 
health. 

Now  it  is  a  notorious  fact  that  the  vast  majority  of 
syphilitica  do  not  receive  proper  treatment,  not  one  in 
20,  certainly  not  one  in  10  receives  a  treatment 
sufficiently  prolonged.  Statistics  show  that  the  larger 
proportion  of  the  dreaded  accidents  of  tertiarism  occurs 
in  this  class  of  cases. 

Reference  has  already  been  made  to  the  lack  of 
hospital  accommodations  for  female  venereals  in  this 
city.  A  slightly  more  generous  provision  is  made  for 
men.  There  are  56  beds  in  the  male  venereal  wards  of 
the  City  Hospital  and  a  small  number  in  the  Metro- 
politan Hospital.  This  provision  is  notoriously  inade- 
quate. What  is  needed  is  the  removal  of  the  ban  of 
ostracism  which  dishonors  this  class  of  diseases. 
Venereal  patients  should  not  be  discriminated  against. 
Admit  that  we  owe  no  duty  to  the  debauchees,  but  if 
society  cannot  protect  the  innocent  from  contamination, 
it  owes  them  at  least  the  recompense  of  free  and  skill- 
ful treatment.  Moreover,  morality  should  not  qualify 
disease,  medical  science  is  sufficiently  broad,  charitable 
and  humane  to  ignore  such  a  petty  qualification.  The 
plea  that  these  diseases  are  excluded  from  all  general 
hospitals  in  this  city  on  the  ground  that  they  are  "  con- 
tagious diseases "  is  a  mere  pretext.  They  are  con- 
tagious only  by  inoculative  contact,  and  in  no  hospital 
conducted  on  modern  asejjtic  principles  can  there  be 
any  chance  of  contagion  in  this  way.  I  would  urge 
then  that  every  general  hospital  in  this  city,  receiving 
State  or  municipal  assistance,  should  be  required  to 
open  its  doors  to  this  class  of  diseases.  Special  wards 
or  services  should  be  organized  for  their  reception  and 
treatment. 

Free  hospital  treatment  is  but  one  of  the  agencies  and 
by  no  means  the  most  important  for  the  suppression  of 
sources  of  contagion.  Its  application  is  limited  to  a 
small  number  and  for  a  brief  period.  The  contagious 
activity  of  venereal  diseases  is  manifest  during  a  long 
period,  that  of  sypliilis  for  two  or  three  years.  The 
large  proportion  of  syphilitics  are  ambulatory  cases, 
they  do  not  reijuire  hospital  care,  they  are  quite  able  to 
go  about  and  attend  to  their  duties  and  employment. 
What  they  require  is  the  prolonged  treatment"  which 
the  well-to-do  syphilitic  can  procure  at  the  office  of  his 
physician. 

There  are  seven  dispensaries  in  this  city  in  which 
there  is  a  venereal  orgenito-urinary  service;  in  addition 
there  are  a  few  cases  treated  in  the  Harlem  and  Ford- 
ham  Hospital  dispensaries.  There  are  ten  others  in 
which  there  is  a  skin  or  dermatological  class  in  which, 
presumably,  the  syphilodermata  may  be  treated.  The 
dispensaries  with  venereal  services  should  be  mul- 
tiplied. They  should  be  located  in  convenient  quar- 
ters of  the  city,  readily  accessible,  so  as  not  to  involve 
too  much  loss  of  time  to  the  patients  in  going  and  com- 
ing. Loss  of  time  means  to  many  patients  the  alterna- 
tive of  losing  their  employment  or  giving  uji  treatment. 
Night  classes  should  be  established  for  jiatients  unable 
to  come  during  the  regular  day  hours.  In  the  surgical 
night  class  of  the  New  York  Hospital  when  these  cases 
are  admitted  more  than  70^  are  venereal. 


These  services  should  be  organized  and  conducted 
with  especial  reference  to  the  nature  of  the  disease,  due 
regard  being  had  to  the  fact  that  the  patient,  whatever 
may  he  his  position  in  the  social  scale  is  conscious 
that  he  has  a  shameful  disease,  the  avowal  of  which  is 
more  or  less  humiliating ;  especially  is  this  the  case 
with  women.  These  services  should  be  conducted  with 
all  the  privacy  possible.  There  should  be  separate 
rooms  for  women.  Time  and  time  again  innocently 
infected  women  have  declared  that  they  could  not  con- 
tinue their  attendance  at  my  class  because  their  entrance 
into  this  particular  room,  in  which  men  are  also  re- 
ceived, would  convict  them  of  having  a  shameful 
disease. 

These  cases  should  be  treated  not  only  with  reference 
to  the  individual  ri.sks  of  the  patient,  but  with  the  car- 
dinal consideration  in  view  that  every  case  is  a  focus  for 
the  spread  of  disease ;  and  that  measures  of  prophylaxis 
are  quite  as  important  as  the  cure  of  the  disease.  With 
the  object  of  suppressing  as  promptly  as  possible  all 
sources  of  contagion,  the  now  obsolete  practice  of  de- 
structive cauterization  of  venereal  sores,  and  the  excision 
of  chancres,  whenever  practicable,  should  be  revived. 
Mucous  patches  which,  with  the  chancre,  constitute 
the  almost  exclusive  sources  of  contagion  should  be 
subjected  to  the  same  sterilizing  medication.  For  years 
I  have  employed  the  acid  nitrate  of  mercury  for  this 
purpose. 

Conjoined  with  the  enlarged  and  improved  facilities 
for  treatment  there  should  be  a  campaign  of  education. 
Patients  should  in  everj'  case  be  enlightened  not  only 
as  to  their  individual  risks  but  the  risks  they  convey 
to  others  and  the  necessity  of  prolonged  treatment. 
Time  and  time  again  patients  who  have  infected  their 
wives  and  children  with  syphilis  have  declared  to  me, 
with  every  indication  of  honesty  as  well  as  remorse,  "  I 
thought  that  I  was  cured  ;  I  did  not  dream  that  there  was 
any  danger."  Now  the  average  patient  is  ignorant  of 
the  varied  and  multiple  modes  of  syphilitic  contagion, 
and  it  is  the  duty  of  the  physician  to  instruct  him.  In 
public  practice  this  is  difficult.  A  dispensary  phy- 
.sician  who  sees  from  50  to  60  patients  or  more  in  two 
hours  cannot  give  the  necessary  time  for  such  instruc- 
tion. The  same  plan  that  is  employed  in  many  foreign 
clinics  should  be  adopted  here,  viz.,  each  syphilitic 
patient  should  be  handed  a  printed  slip,  stating,  in  plain 
language,  the  nature  of  the  disease,  the  modes  of  con- 
tagion, the  risks  of  personal  contact  from  erosions  or 
mucous  patches,  the  possible  contamination  of  house- 
hold articles,  towels,  spoons,  drinking  utensils,  etc.,  the 
risks  of  hereditary  transmission  and  also  emphasize 
the  necessity  of  thorough  treatment. 

The  gonorrheal  patients  should  be  instructed  as  to 
the  details  of  the  technic  to  be  employed  in  local  treat- 
ment, the  possible  gravity  of  the  disease,  the  danger  of 
contagion  even  when  the  discharge  may  have  apparently 
ceased,  the  significance  of  shreds  in  the  urine  as  an 
indication  that  the  disease,  though  latent,  is  still 
uncured,  etc. 

Physicians  should  never  sanction  marriage  until  all 
possible  danger  of  infection  is  jiassed.  Too  much  care 
and  circumspection  cannot  be  employed  in  this  regard. 
Patients  are  too  prone  to  take  advantage  of  a  guarded 
or  qualified  ;vssent  on  the  part  of  the  physician,  but 
thev  invariably  throw  upon  him  the  responsibility  for 
unfortunate  results. 

The  medical  profession  should  be  better  equipped  for 
this  prophylactic  work  by  a  more  thorough  knowledge 


April  6,  1901] 


ON  CERTAIN  DISORDERS  OF  SLEEP 


PThe  Philadelphia 
Medical  Jouknal 


669 


of  venereology.  The  system  of  instruction  as  at  pres- 
ent organized  in  most  of  our  medical  colleges  is  defective 
in  this  regard.  In  the  presidential  address  before  the 
American  Dermatological  Association,  in  1890,  I  called 
attention  to  these  defects  and  urged  that  the  study  of 
venereal  diseases  should  be  made  an  integral,  necessary 
part  of  the  course  of  medical  education,  and  that  a 
practical  as  well  as  a  theoretical  knowledge  of  these  dis- 
eases should  be  made  an  indispensable  requisite  for 
graduation  in  medicine. 

Physicians  can  do  much  in  their  professional  capacity 
in  instructing  the  young  men  of  their  clientele  as  to  the 
dangers  of  licentious  living.  Too  often  the  charge  has 
been  made  against  the  profession  that  they  recommend 
or  sanction  illicit  indulgence  as  a  means  of  health.  On 
the  contrary,  the  opinion  of  all  medical  men  entitled  to 
respect  is  that  continence  is  not  incompatible  with 
health,  and  that  harlotry  is  not  a  safe  substitute  for 
marriage. 

This  campaign  of  education  should  be  extended  to 
the  high  schools  and  colleges  for  young  men.  Unfor- 
tunately this  has  always  been  a  forbidden  topic.  There 
is  no  reason  why  young  men  should  not  be  forewarned 
of  the  pitfalls  and  dangers  which  beset  their  pathway 
— dangers  into  which  they  often  ignorantly  and  uncon- 
sciously rush.  Whatever  may  be  thought  of  the  innoc- 
uity  of  "  sowing  wild  oats,"  its  consequences  are  most 
often  disastrous  to  the  health  of  the  individual.  They 
should  also  be  taught  that  self-restraint,  personal 
purity,  and  respect  for  women  are  among  the  surest 
foundations  of  character.  This  education,  it  seems  to 
me,  should  enlist  the  interest  and  cooperation  of  the 
moralist.  For  after  all  we  must  look  to  the  education 
and  training  which  will  develop  a  higher  order  of 
morality  in  men  as  among  the  surest  means  of  checking 
the  evil. 

Finally,  the  public  should  he  educated  to  a  recogni- 
tion of  the  fact  that  the  prostitute  is  largely  the  product 
of  her  environment.  The  vast  majority  of  fallen  women 
become  so — not  from  choice  or  from  innate  depravity — 
but  because  of  the  hard  and  unjust  social  laws  which 
force  many  of  them  into  this  life.  Society  should  deal 
with  them  as  unfortunates  rather  than  criminals. 


ON  CERTAIN  DISORDERS  OF  SLEEP." 
By  CHARLES  A.  DANA,  A.M.,  M.D., 

of  New  York. 

Professor  of  Nervous  Diseases,  Cornell  University  Medical  College ;   Visiting 

Physician  to  Believue  Hospital ;  Nt-urologist  to  the  Montetiore 

Hospital ;  Curresjtunding  Member  of  Society  de 

Neurologie  de  Paris. 

Nature  of  Sleep. — Whether  or  not  the  neuron  moves 
or  the  neuroglia  fibrils  contract,  this  doctrine  is 
true  that  sleep  is  the  period  during  which  the  brain 
rests  from  its  conscious  activities,  empties  itself  of  the 
products  accumulated  by  this  activity  and  builds 
itself  up  for  the  work  of  awakening.  There  is  much 
truth  in  the  homology  between  sleep  and  the  diastole 
of  the  heart,  or  the  resting  stage  of  a  gland,  and 
also  in  the  suggestion  that  excessive  sleep  is  like  a  flux, 
ill  whicli  too  much  is  carried  away,  while  insomnia  is 
a  constipation  in  which  morbid  products  are  retained 
in  the  system. 

Different  Forms  of  Sleeplessness. — The  most  common  dis- 

1  Read  at  a  meeting  of  the  Believue  Hospital  Alumni  Association,  December 
I'.iQO.  ' 


order  of  sleep  is  insomnia,  but  this  is  only  a  very 
general  term,  for  there  are  many  kinds  and  degrees  of 
sleeplessness.  The  approach  of  sleep  may  be  accom- 
panied with  a  strain  and  stress  which  are  very  uncom- 
fortable; during  sleep  there  may  be  an  unnatural 
activity  of  the  sensory  and  association  centers  causing 
dreams,  or  of  the  motor  centers  causing  shocks,  starts, 
and  spasmodic  symptoms.  Ordinary  control  of  the 
visceral  centers  may  be  lessened,  causing  discharges 
from  the  bladder,  sexual  organs  and  intestines  ;  or  the 
vagus  may  let  go  its  hold  and  the  patient  be  wakened 
by  palpitations  and  dyspnea.  The  sensory  centers  may 
be  stirred  up  causing  the  patient  to  waken  with  sensa- 
tions of  light,  colored  scotomata,  thundering  noises, 
violent  vertigo,  or  terrific  pain.  In  fine,  the  ordinary 
smooth  current  of  the  subconscious  activities  breaks 
against  some  pathological  condition,  and  now  one 
symptom,  now  another  is  thrust  out  and  so  unpleas- 
antly disturbs  the  sleep  and  wakens  the  sleeper. 

It  is  to  some  of  these  phenomena  that  I  wish  to  call 
your  attention  this  evening. 

The  Fear  of  Insomnia. — I  would  like  to  say  a  word  in 
the  begining  about  the  seriousness  of  insomnia.  It  is 
sometimes  a  much  overrated  and  overtreated  symptom. 
Nervous  people  who  cannot  sleep  well  often  get  the 
idea  that  that  they  must  sleep  or  they  will  get  ill,  pos- 
sibly crazy.  Hence,  an  artificial  apprehension  is  cre- 
ated, and  the  patient  becomes  as  solicitous  about  his 
8  hours  of  sleep  as  the  constipated  hypochondriac  is 
about  the  daily  movement  of  his  bowels.  He  makes 
his  whole  life  and  that  of  his  family  conform  to  the 
acquisition  of  nocturnal  quiet.  He  restricts  his  even- 
ing meal,  gives  up  all  study,  social  life,  and  evening 
amusements,  takes  the  back  room,  puts  blankets  over 
the  doors,  stops  the  clock,  and  poisons  the  back-yard 
cats,  all  to  secure  his  eu-hypnosis. 

As  a  matter  of  fact,  adults  can  get  along  very  fairly 
for  a  long  time  with  from  one-half  to  two-thirds  the 
regular  hours  of  sleep  if  they  nightly  rest  in  bed  for 
10  or  12  hours,  and  therefore,  I  hesitate  before  I  treat 
insomnia  in  the  sane,  and  never  treat  it  with  drugs, 
except  temporarily,  for  there  are  no  good  drugs  for  the 
trouble. 

Morniwi  Insomnia. — Insomnia  has  all  kinds  of  phases 
and,  as  is  found  by  questioning  those  who  suffer,  it  does 
not  always  mean  the  same  thing.  There  is  a  very 
common  type  which  is  extremely  annoying,  and  which 
has  a  rather  distinct  etiology  and  therapeutics.  It  is 
what  I  term  "  morning  insomnia."  In  these  cases  the 
patients  go  to  bed  at  the  ordinary  hour  and  go  to  sleep 
without  any  trouble,  but  wake  up  at  2  or  3  o'clock  and 
then  lie  awake,  or,  at  best,  have  only  a  little  imperfect 
slumber  for  the  rest  of  the  night.  Such  cases  occur 
most  often  in  persons  over  the  age  of  4.5  or  50,  and  are 
associated  with  the  development  of  degenerative  changes 
in  the  arteries  to  which  is  the  added  factor  of  ill-health 
or  worry.  It  may  be  an  accentuation  of  a  habit  formed 
in  youth,  of  very  early  rising.  It  is  natural  in  old 
people  to  wake  up  early  in  the  morning.  When  this 
symptom  comes  on,  however,  in  middle  or  shortly 
after  middle  life,  it  is  a  very  annoying  and  a  morbid 
condition.  Such  patients  often  are  helped  by  general 
tonic  treatment,  and  by  giving  the  heart  tonics  and 
arterial  depressants,  such  as  glonoin,  potassium  iod  de, 
and  strophanthus.  They  often  also  get  some  relief  by 
getting  up  and  taking  a  drink  of  hot  milk  or  hot  water, 
or  some  simple  food.  A  small  dose  of  bromide  (10  gr.) 
or  of  trional  (  5  gr.)  at  bedtime  helps  them. 


670 


ThB  PhILA  DELPHI  a  1 

Medical  Journal  J 


ON  CERTAIN  DISORDERS  OP  SLEEP 


[Apbil  6, 1901 


A  man  of  61  came  to  me  complaining  of  morning  insom- 
nia. He  had  a  slight  apex  systolic  bruit  and  signs  of  arterial 
sclerosis  but  no  other  organic  disease  For  the  past  15  years  he 
had  had  morning  insomnia,  and  for  G  years  had  kept  a  daily 
record  of  the  number  of  hours  he  slept.  This  averaged  5 
hours  and  20  minutes,  and  had  not  varied  half  an  hour  in 
any  month,  summer  or  winter,  by  the  sea  or  in  the  moun- 
tains.   The  range  was  from  5  to  6  hours. 

There  is  another  form,  however,  of  morning  insomnia. 
When  this  occurs  in  younger  people,  generally  in  the 
thirties,  the  symptoms  are,  if  anything,  rather  more 
marked  and  distressing.  The  patient  goes  to  sleep 
satisfactorily,  but  wakes  up  at  about  2  or  3  o'clock 
and  lies  awake  in  a  state  of  nervousness  and  discomfort 
until  the  daylight  comes. 

Mr.  L  A.,  33  years  of  age,  came  to  me  with  tliis  type  of 
insomnia.  He  was  a  man  of  good  physique,  and  sound 
in  all  his  organs,  except  that  his  heart  was  not  a  very 
strong  one.  He  was  of  a  nervous  temperament :  one  sister 
was  insane  and  one  brother  neurasthenic,  but  he,  himself, 
was  an  intelligent,  well-balanced  man.  His  habits  were  good, 
he  was  careful  of  his  diet,  and  as  regards  indulgences  of  all 
kinds.  There  was  a  slight  rheumatic  factor  in  his  history 
and  he  had  a  rather  irrital)le  heart.  He  was  treated  by  me  for 
his  morning  insomnia  witli  very  little  relief  for  considerable 
time.  He  did  not  i-espond  to  tonic  measures,  to  anti-rheu- 
matic measures  or  to  the  ordinary  hypnotics.  He  would  go 
to  sleep  at  11  and  wake  at  2  or  3  a.m.,  no  matter  what  I  gave 
him.  1  discovered,  however,  finally,  that  he  was  carrying  a 
very  heavy  burden  domestically  and  financially  and  that  he 
had,  although  he  did  not  confess  it,  feelings  of  depression 
nearly  all  the  time  and  that  a  fixed  idea  of  a  worrying 
character  was  with  him.  When  circumstances  I'hanged  so 
that  this  disappeared  he  promptly  got  over  his  insonniia 

A  very  similar  case  uniler  my  care  is  that  of  a  man, 
aged  .'iO,  whose  bodily  organs  were  .sound  except  that  he 
had  a  slight  blowing  murmur  at  the  base  of  the  heart 
over  the  aortic  valve.  He  had  been  very  well,  until  he  found 
that  his  family  and  children  were  beginning  to  suffer. 
Although  he  ate  well  and  looked  well,  his  sleep  became  im- 
paireil.  He  would  go  to  bed  at  9,  go  to  sleep  in  about  an 
hour,  wake  up  at  2  or  3  o'clock  in  the  morning  and 
stay  awake  all  the  morning  thinking  of  his  troubles. 

In  tliis,  as  in  other  similar  cases,  a  fixed  idea  of  a  depress- 
ing character  is  working  upon  the  br:iin  all  the  time,  and  it 
is  the  important  factor  in  finally  waking  the  person  up  after 
he  has  gone  to  sleep,  there  being  a  sort  of  subconscious 
activity  of  the  brain  which  finally  bursts  into  consciousness 
and  rouses  the  patient.  No  doubt  the  other  awakening 
factors  are  defective  heart  and  some  neurasthenia  entering 
into  the  cases ;  but  happiness  is  the  cure  and  is  the  best 
hypnotic  in  these  cases. 

Motor  Shocks.— Sometimes  persons  go  to  sleep  nor- 
mally, but  have  their  sleep  disturbed  by  a  succession  of 
wakenings  due  to  motor,  sensory  or  psychical  dis- 
charges. One  very  distinct  form  of  intermittent  awaken- 
ing is  by  motor  shocks. 

Just  as  the  patient  is  dropping  asleep  he  suddenly 
wakes  with  a  start.  There  is  usually  a  very  decided 
spasmodic  extension  of  the  legs  and  sometimes  a  jump- 
ing of  the  whole  body.  The  patient  is  at  once  awake 
and  the  spasm  is  not  repeated  and  he  soon  falls  off  to 
sleep  again.  The  attack  may  occur  several  times  be- 
fore sleep  is  permanently  secured.  It  is  usually  simply 
an  evidence  of  fatigue  and  nervous  irritability  and 
rarely  requires  anything  more  than  rest.  In  some  in- 
stances, however,  this  condition  continues  through  the 
night  and  becomes  very  annoying.  It  may  even  end  in 
some  serious  condition. 

A  man  of  35  had  sufi'ered  from  neunisthenic  insomnia  for 
3  years  and  had  ,got  in  the  habit  of  taking  trional  in  'JO-grain 
doses  at  night.  Under  advice  he  stopped  it,  and  or  a  long 
time  was  annoyed  by  these  motor  shocks.  A  return  to  tri- 
onal stopped  it  and  another  attempt  to  break  oft  the  habit, 
led  to  the  same  result. 


I  have  a  patient  whose  case  shows  that  motor  shocks  may 
end  seriously.  She  is  a  single  woman ;  age,  about  38,  who 
for  10  years  has  suffered  from  neurasthenic  troubles  of  a 
mild  but  persistent  type,  t^he  suffered  from  general  weak- 
ness so  that  she  could  not  walk  far  or  sit  up  long  nor  do  any 
physical  labor.  She  had  rather  frequently  some  slight 
amount  of  vertigo,  she  often  had  attacks  of  migraine,  and 
slight  exertion  would  bring  on  feelings  of  weakness  and  dizzi- 
ness and  pain  in  the  head  and  back  ;  when  quiet,  however, 
her  symptoms  were  very  few.  She  had  always  been  accus- 
tomed to  sleeping  well  and  her  appetite,  digestion,  and 
nutrition  were  good.  She  was  of  a  nervous  temperament 
and  one  brother  had  been  a  sleep-walker  in  early  life  She 
herself  had  always  been  a  very  sound  sleeper  until  the 
last  two  years  of  illness.  Objectively  she  showed  noth- 
ing but  a  rather  weak  heart  with  a  functional  murmur 
over  the  pulmonic  valve.  In  the  last  two  years  she 
had  had  attacks  of  intermittent  heart-beat  which  annoyed 
her  a  great  deal.  She  had  never  had  any  fainting  turns  or 
any  spasmodic  troubles  of  any  kind.  The  heart  intermis- 
sions would  occur  during  the  daytime  and  in  later  periods 
annoyed  her  when  beginning  to  go  to  sleep  at  night.  About 
two  years  before  her  severest  symptom  developed,  she  suf- 
fered from  startings  just  as  she  dropped  off  to  sleep.  These 
occurred  only  rarely,  were  not  often  repeated,  and  gave  her 
but  little  annoyance.  In  the  summer  of  1900,  however,  both 
the  sense  of  ihe  intermission  of  the  heart  and  the  startings 
at  night  increased  in  frequency  until  finally  when  she  went 
to  bed  she  would  be  annoyed  for  3  or  4  hours  by  repeated 
st.artings,  it  being  12,  1,  or  2  o'clock  before  she  finally  got  to 
sleep  She  would  have  20  or  30  successive  starts  during  the 
night.  All  of  this  broke  up  her  rest  and  disturbed  her  gen- 
erally. On  July  5  she  retired  as  usual,  but  the  startings  con- 
tinued througli  the  night  and  until  5  o'clock  in  the  morning. 
The  skippings  of  the  heart  annoyed  her  occa.sionally  also. 
At  5  A.M.,  just  as  daylight  was  bre  <king,  she  started  up  again 
and  felt  at  the  same  time  a  cold  sensation  on  her  left  side. 
She  sat  up  suddenly  in  bed  and  felt  a  profound  sense  of  ob- 
jective vertigo.  She  called  for  h^r  maid  and  then  fell  back 
and  lost  consciousness  for  about  a  minute  After  this  she 
felt  dizzy  and  uncomfortable,  but  had  no  more  starts  until 
half-past  10  in  t'le  forenoon.  She  then  had  another  severe 
one ;  sat  up,  got  extremely  dizzy  and  lost  consciousness.  At 
the  same  time  she  was  found  by  the  nurse  in  a  state  of  slight, 
general  clonic  spasm.  These  spasms  lasted  onlj-  for  a  few 
seconds.  She  became  conscious  after  a  few  moments.  After 
coming  out  of  this  she  was  very  dizzy  again  and  vomited  a 
good  deal  during  the  day.  In  the  evening  she  had  two  more 
of  these  seizures.  She  was  then  seen  by  a  physician  who 
gave  her  bromide  and  she  slept  She  was  seen  by  me  next 
day  and  ])laced  upon  iodide  of  potassium  and  small  doses  of 
bromide  of  potassium,  not  larger,  however,  than  she  had  had 
on  previous  occasions.  She  was  kept  upon  this  for  several 
months  and  had  no  recurrence  of  the  attacks  in  any  way. 
For  several  weeks  she  passed  very  bilious  passages. 

The  whole  history  of  the  case  would  suggest  that  out 
of  a  simple,  persistent  and  predormitial  start  there 
had  developed  some  att;vcks  of  an  epileptic  characier. 
Still,  I  am  loath  to  believe  that  they  were  genuine 
epilepsy,  for  the  patient  had  never  had  any  signs  of  any 
type  of  petit  mal  before  and  inherited  no  tendency  in 
that  direction.  They  were  more  likely  symptomatic  of 
the  weak  and  intermittent  heart-action. 

It  seems  to  me  that  "  motor  shocks  "  are  due  to  the 
change  in  the  circulation  of  the  brain  that  occurs  while 
[passing  from  the  waking  to  the  sleeping  state.  When 
this  takes  place  in  very  irritable  and  tired-out  brains,  a 
slight  motor  explosion  is  brought  about.  In  fact,  the 
cardiac  mechanism  seems  to  be  a  very  important  one  in 
the  production  of  bizarre  type^  of  sleep  disorder.  The 
condition  of  the  liver  is  also  an  important  factor.  One 
of  the  causes  of  the  predormitial  starts  is  perhaps  the 
removal  of  the  inhibition  exercised  on  the  motor 
cortex  by  sensory  stimuli  from  the  outride  world, 
especially  from  the  visual  organs.  -\  girl  of  12  who 
has  frequent  abortive  attacks  of  epilepsy,  has  always 


APSIL  6,  1901] 


ON  CERTAIN  DISORDERS  OF  SLEEP 


PThk  PhiIuISBLFhia 
L  Mbsical  JeUBHAI. 


671 


starts  and  slight  seizures,  when  she  goes  suddenly  into 
a  dark  room  and  even  when  she  closes  her  eyes.  She 
has  to  have  a  light  in  her  bedroom  at  night  and  has  had 
to  give  up  closing  her  eyes  when  she  says  her  prayers  at 
church. 

Psychical  and  Sen^<xry  Shocks. — At  times  persons  are 
disturbed  by  sudden  wakings  from  sleep  accompanied 
with  a  sense  of  anxiety  or  distress  over  some  partic- 
ular idea;  generally  some  work  forgotten  or  duty 
neglected  or  apprehension  which  seems  about  to  be 
realized.  In  these  cases  there  is  no  sensory  shock  and 
no  muscular  starts  or  particular  motor  disturbance. 
The  patient  simply  wakes  suddenly  and  sits  up  in  bed 
with  a  fear  upon  him  that  something  should  be  done  or 
ought  to  be  done.  Upon  realizing  the  real  state  of 
affairs  he  falls  to  sleep  and  then,  after  a  time,  starts 
again  with  the  same  apprehensive  idea. 

A  lady,  35  years  of  age,  married,  childless,  of  nervous 
temperament,  had  alwas  been  a  good  sleeper.  She  had  had 
weak  digestion  and  was  rather  neurasthenic.  She  under- 
went a  severe  strain  in  organizing  certain  charitable  work 
involving  much  responsibility.  While  doing  this,  and  for 
two  years  afterwards,  she  became  subject  to  disturbances  of 
sleep  of  the  above  character.  After  sleeping  an  hour  or  two 
.she  would  suddenly  become  quite  wide  awake  and  sit  up  in 
bed  with  a  sense  of  fear  that  she  had  left  something  undone 
about  her  work.  After  a  moment  she  would  realize  the 
state  of  things  and  go  to  sleep  again,  to  be  again  awakened ; 
and  this  was  jepeated  through  the  night.  The  sudden 
awakenings  were  not  convulsive  starts  or  associated  with 
aurae.  They  continued  as  a  kind  of  nervous  habit  two  years 
after  she  had  been  relieved  of  her  responsibilities  and  when 
she  had  regained  comparative  health.  They  returned  a  year 
later  wBen  she  had  again  become  neurasthenic. 

Sensory  Shocks. — Dr.  Weir  Mitchell,  in  his  book  on 
nervous  disorders,  18S1,  describes  a  condition  some- 
what analogous  to  this  which  I  have  described,  but  not 
identical  with  it.  He  refers  to  his  cases  as  illustrations 
of  sensory  shock  and  finds  them  much  more  frequently 
in  women  than  in  men. 

"  When  just  falling  asleep,  one  of  his  patients  became 
conscious  of  something  like  an  aura  passing  up  from 
his  feet.  When  it  reached  his  head  he  felt  what  he 
described  as  an  explosion.  The  sensation  was  that  of  a 
pistol  shot,  or  as  of  a  bursting  of  something,  followed 
by  a  momentary  sense  of  deadly  fear.  These  sensory 
shocks  may  be  accompanied  by  a  flash  of  light  or  a 
sense  of  odor,  or  an  abrupt  and  general  motion,  such  as 
the  ordinary  attack  of  any  violent  and  sudden  sensa- 
tion." 

In  the  patient  whose  case  I  have  described,  there 
was  nothing  in  the  shape  of  an  aura,  nor  in  most  of  the 
cases  which  I  know  has  there  been  anything  like  a  seni- 
sory  shock.  These  shocks,  whether  of  psychical  sen- 
sory or  motor  character,  occur  in  neurasthenic  and 
hysterical  persons  and  are  not  associated  with  epi- 
lepsy. 

Waking  Vertigo. — A  condition  belonging  to  the  class 
of  sensory  shocks  may  be  termed  "  waking  vertigo." 

A  man,  58  years  of  age,  suffered  from  recurrent  vertigo 
which  he  had  had  at  various  periods  iu  the  previous  15 
years.  His  father  had  been  very  deaf,  and  he  had  a  sister 
who  suffered  from  Meniere's  disease.  He  himself  had  always 
been  a  healthy  man  with  no  specific  history  and  no  history 
of  excesses  of  any  kind,  except  that  he  had  been  a  very  hard 
worker.  He  had  never  had  headaches,  but  had  some  incli- 
nation to  sluggishness  of  the  liver  and  sutfered  from  bleeding 
piles.  He  was  always  a  sound  sleeper.  In  the  earlier 
periods  of  the  vertigo  he  used  to  be  suddenly  wakened  up  at 
night  with  an  intense  feeling  of  objective  dizziness.  This 
always  occurred  when  he  lay  upon  the  right  side.  If,  during 


sleep,  he  turned  over  on  this  side  for  a  time,  he  would  sud- 
denly be  roused  and  sit  up  in  bed  with  a  feeling  of  dizziness 
and  a  sense  of  alarm  in  connection  with  it.  This  speedilj- 
disappeared,  and  if  he  turned  over  upon  his  left  side  he  had 
no  more  trouble.  The  attacks  were  especially  apt  to  occur 
when  he  suffered  from  what  he  termed  "  biliousness."  At 
this  time  also  he  wakened  with  numb  fingers  and  sometimes, 
sleep  palsy.  The  attacks  were,  as  he  said,  "  verj-  dreadful." 
They  disappeared  under  tonic  regimen  and  attention  to  the 
condition  of  the  liver.  When  examined  by  me  he  presented 
no  objective  signs  except  a  rather  large  heart  and  a  systoUc 
murmur  at  the  apex,  but  tie  had  no  subjective  symptoms  of 
cardiac  trouble  and  could  ride  a  bicycle  and  go  up  stairs 
without  any  difficulty.  Whether  he  had  the  heart  trouble 
at  the  time  of  his  pre\uous  attacks,  or.  at  least,  whether  it 
was  of  any  serious  consequence,  is  very  doubtful  in  my 
mind.  The  attacks  must  be  ascribed  to  some  mechanical 
cause.  Theories  as  regards  it  could  easily  be  developed,  but 
I  know  of  none  that  is  perfectly  satisfactory.  That  the  posi- 
tion in  some  way  interferes  with  the  portal  circulation  and 
disturbs  the  hepatic  function  is  perhaps  the  most  likely  ex- 
planation. 

This  waking  vertigo  is  a  condition  not  very  rare  in 
those  who  have  chronic  vertiginous  troubles.  Usually 
they  suffer  from  an  unpleasant  dream  of  falling  or  of 
being  carried  swiftly  along,  an  unpleasant  sensation 
finally  awakening  them,  and  they  sit  up  finding  them- 
selves in  the  midst  of  an  attack  of  vertigo.  It  some- 
times occurs  as  an  awakening  aura  of  epilepsy. 

Migrainous  Seizures  in  Sleep. — Migraine  sometimes  pro- 
duces sensory  shocks  or  perhaps  less  explosive  disturb- 
ances that  lead  to  sudden  awakenings  and  broken 
sleep.  The  migraine  occasionally  takes  a  fulgurating 
type  in  which  the  patient,  with  hardly  a  moment's 
warning,  is  taken  with  a  terrific  pain  in  the  head 
accompanied  with  nausea  and  eventually  all  the  classi- 
cal symptoms  of  the  disease. 

One  of  my  patients,  a  man  of  55,  is  often  waked 
without  warning  from  a  sound  sleep  by  a  terrific  tem- 
poral pain,  which  keeps  him  in  agony  for  several  hours, 
then  gradually  abates.  This  nocturnal  attack  of 
migraine  is  precisely  similar  to  nocturnal  spasms  of 
epilepsy,  and  is  measurably  helped  by  antiepileptic 
remedies.  The  less  sudden  arousal  of  a  patient  with 
migrainous  pains  is  quite  common. 

Waking  Paresthesia. — A  neurasthenic  woman  of  30, 
anemic,  and  overworked,  was  constantly  wakened  from 
sleep  by  her  arms  and  legs  going  to  sleep.  The  sensa- 
tions would  arouse  her ;  she  would  wake,  rub  her  limbs 
till  they  felt  normal,  and  drop  off  to  sleep  again, 
and  again  be  awakened.  Sleep  thus  became  im- 
perfect and  distressing.  Two  patients,  reported  by 
Schurster,  would  go  to  sleep  quietly,  but  soon  after 
would  awake  with  a  feeling  that  they  had  lost  their 
muscle-sense  and  sense  of  position.  The  attacks  came 
on  successively  during  the  night  and  allowed  no  sleep. 

The  condition  here  is  similar  to  that  of  waking-palsy 
or  waking-numbness,"  only  in  the  cases  referred  to,  the 
sensations  of  numbness  and  anasthesia  come  first  and 
are  the  cause  of  the  awakening.  They  soon  disappear 
but  recur  repeatedly,  breaking  up  the  sleep.  Such 
attacks  are  more  apt  to  occur  toward  morning,  while  the 
motor  shocks  occur  often  in  the  earlier  part  of  the  night. 
It  is  as  though  the  motor  cells  lose  their  irritability 
more  slowly  and  go  to  sleep  later,  while  the  sensory 
cells  begin  to  become  irritable  sooner  as  the  morning 
comes  on.  They  precede  the  motor  cells  both  in  going 
to  sleep  and  awakening. 

-  Waking-palsy  and  waking-nunibDess  are  very  •ommon  symptoms  and  are 
generally  and  rightly  considered  in  most  cases  to  be  due  to  a  rbeumatic  or 
lithemic  condition. 


Mksical  Joubnal  J 


ON  CERTAIN  DISORDERS  OF  SLEEP 


(April  6,  uoi 


This  is,  in  a  measure,  similar  to  the  phenomena 
observed  in  diseases  which  cut  off  the  peripheral  nerves 
or  injure  the  conductivity  of  the  spinal  cord,  when 
sensory  symptoms  come  on  first  and  disappear  first. 

Painful  Sleep. — (Hypnalgia,  dysoneiria.)  A  chapter 
might  be  written  upon  the  psychoses  of  the  night ;  by 
which  I  mean  those  peculiar  and  unnatural  mental  states 
which  come  on  as  bedtime  approaches  and  which  mingle 
with  or  disturb  the  sleep.  The  period  of  retiring  gets  to  be 
with  some  people  who  sleep  ill,  an  event  looked  forward 
to  with  despondency  and  dread  almost  amounting  to  ter- 
ror. On  retiring  they  toss  about,  the  mind  jaded  with 
worries  and  depressing  emotions.  They  get  up,  walk 
about  the  room,  read,  take  their  medicine,  go  to  bed 
again,  still  with  no  relief  until  perhaps  toward  morn- 
ing, under  the  influence  of  some  drug,  they  finally 
drop  oif.  This  is  a  state,  of  course,  which  is  to  a  cer- 
tain extent  experienced  by  all  sufferers  from  insomnia, 
but  in  some  instances  the  condition  during  the  night 
amounts  to  an  acute  melancholia,  while  in  the  daytime 
they  are  fairly  comfortable. 

Mr.  J.  H.  R.,  a  married  man  and  traveling  salesman,  came 
to  me  some  time  ago  with  such  a  storj-.  He  had  been  well 
until  about  three  years  ago.  He  had  always  been  a  hard- 
working man,  a  moderate  drinker  and  smoker.  He  showed 
no  distinct  objective  symptoms,  but  gave  the  rather  ordinary 
history  of  an  irritable  type  of  neurasthenia.  His  worst 
trouble  was  at  night,  during  which  time  he  suffered  from 
disturbed  sleep  and  a  mental  depression  which  was  most 
excessive  and  to  him  alarming.  He  looked  upon  tbe  ap- 
proach of  night  with  absolute  horror.  The  condition  I 
characterized  by  the  term  of  ''night  despondency"  because 
it  was  so  sharply  marked  and  acute. 

The  condition  in  which  sleep  is  not  refreshing  or  enjoyable, 
but  actually  a  pain,  has  been  called  hypnalgia. 

Dysoneiria. — Absolutely  healthful  and  restful  sleep  is 
dreamless ;  and  hard  dreaming  is  largely  a  product  of 
modern  civilization ;  yet  dreaming,  like  drinking,  in 
moderation  is  harmless  and  not  even  disagreeable.  This 
is  the  common  experience  and  is  confirmed  by  system- 
atic observation.  In  an  analysis  of  11 8  consecutive  dreams 
(Strong,  Avierican  Jonrnnl  of  Psychology,  October,  1900) 
there  was  an  unpleasant  emotional  element  in  only  29 
and  here  it  was  not  acute.  Painful  dreams  are  usually 
incidents  in  early  sleep  and  are  often  readily  traced  to 
indiscretions  accounted  sufficiently  enjoyable  to  over- 
balance the  nightmare.  The  sleep  of  early  life  is  pecu- 
liarly sensitive  to  irritations  from  below  the  diaphragm. 
In  later  life  it  is  more  affected  by  the  heart,  bloodves- 
sels and  lungs.  It  is  rare  for  an  adult  to  be  disturbed 
by  disagreeable  dreams. 

There  are,  however,  conditions  in  which  sleep  is  a 
continuous  succession  of  painful  or  disagreeable  dreams. 
The  moment  sleep  begins  dreams  begin,  and  when  the 
patient  awakens  it  is  with  a  feeling  that  the  whole 
night  has  been  a  series  of  fretting,  depressing  and  an- 
noyingly  incoherent  incidents. 

A  lady  of  35  has  had  about  seven  attacks  of  epilepsy 
annually  in  the  past  si.x  years;  she  has  some  chronic  head- 
aches but  is  otherwise  well.  She  takes  about  40  grains  of 
bromide  a  day.  She  says  that  every  night  the  moment  she 
goes  to  sleep  she  begins  to  dream,  and  slie  keeps  it  up  till 
morning  when  she  wakes  up  tired  and  unrested  ;  the  dreams 
are  unpleasant  but  not  frightful.  They  make  her  sleep  a 
burden. 

A  neurasthenic  man  of  30  years,  sound  of  body,  sensitive 
ana  inclined  to  despondency,  tells  the  same  story.  He  goes 
to  sleep  instantly,  but  begins  at  once  to  dream  of  trivial  but 
unpleasant  things,  and  wakens  tired  out.  He  agrees  that 
the  free  play  of  fancies  in  dreaming  is  more  wearying  than 
systematic  mental  effort. 


Such  people  are  never  quite  well.  They  are  usually 
tired  out  and  have  poisoned  or  degenerate  brains. 

The  condition  of  unpleasant  dream-slumber  is  called 
dysoneiria.  It  can  be  artificially  and  acutely  induced 
by  tobacco,  coffee,  and  other  poisons. 

Waking  Syncvpe. — It  is  a  pretty  safe  general  clinical 
rule  to  say  that  all  serious  spasmodic  disturbances  that 
occur  in  sleep  are  of  an  epileptic  character.  There  are, 
however,  a  good  many  minor  disturbances  not  of  a 
convulsive  character  but  associated  with  mental  aber- 
ration or  fainting  turns  which  are  often  very  puzzling 
and  which  belong,  perhaps,  sometimes  to  the  epileptic 
class  and  very  often  may  be  considered  simple  evidences 
of  a  hysteria  or  neurasthenia,  or  of  some  temporary- 
disturbance  of  the  vascular  mechanism. 

A  lady  of  45,  married,  and  the  mother  of  several  children, 
came  to  me  in  great  distress  of  mind  because  it  had  been 
intimated  to  her  by  her  nurse  that  she  had  nocturnal 
epilepsy.  She  was  a  woman  of  nervous  temperament,  but 
ver}'  intelligent  and  usually  self-controlled ;  still,  she  was 
inclined  to  fits  of  depression  and  at  times  to  hysterical 
outbreaks.  As  a  girl  she  would  often  faint ;  once  when 
vaccinated,  again  after  taking  a  verj-  large  or  powerful 
cathartic,  again  once  when  riding  in  a  verj-  hot  car  while 
pregnant  with  her  first  child.  These  attacks  were  simple 
fainting  turns  without  any  convulsions.  When  about  30, 
while  nursing  her  baby,  she  would  sometimes  be  wakened 
up  suddenly  at  night  by  his  cries  ;  she  would  jump  out  of 
bed.  run  quickly  to  him  and  then  faint  awaj- :  she  would 
remain  unconscious  for  a  short  time,  then  get  up  and  attend 
to  her  task.  These  nocturnal  fainting  turns  ceased  as  the 
baby  got  older.  Some  10  j-ears  later  she  became  very  much 
depressed  and  neurasthenic  and  took  the  rest-cure  under  my 
care  for  a  period  of  several  weeks.  Twice  during  that  time 
she  wakened  up  suddenly  at  night  and  then  went  off  into  a 
fainting  turn  without  any  observed  spasm,  however.  Four 
years  later,  while  sleeping  at  night,  her  hoy  being  in  a  neigh- 
boring room,  called  to  her  in  a  hurrj'.  She  jumped  out  of 
bed  and  had  this  same  fainting  turn.  It  seemed  to  me  that 
1  was  not  justified  in  calling  these  attacks  epileptic,  although 
I  regarded  them  with  some  suspicion.  The  patient  had  a 
rather  weak  heart  and  was  not  a  strong  woman  and  it  might 
easily  be,  it  seems  to  me,  that  the  sudden  shock  of  being 
roused  from  sleep  and  getting  up  on  the  feet  would  cause  a 
fainting  turn,  owing  to  the  sudden  change  from  a  horizontal 
to  a  vertical  position  and  the  sudden  demand  upon  the  exer- 
cise of  the  mental  faculties  before  the  heart  had  time  to 
adjust  itself  to  the  new  situation. 

Nocturnal  Oratory. — Automatic  disturbances  of  sleep 
such  as  sleep-walking  and  talking,  are  seen  rarely  and 
almost  always  in  children.  They  are  not  of  any  serious 
significance,  and  rarely  come  to  the  attention  of  the 
neurologist. 

Automatic  phenomena  occurring  in  the  adult  during 
sleep  are  of  importance.  They  are  not  seen  often  in 
frankly  developed  epilepsy  and  yet  they  are  usually 
significant  of  this. 

A  common  form  of  this  trouble  is  one  called  noctur- 
nal oratory. 

A  man  of  35  and  lawyer  by  profession ;  a  healthy,  strong, 
vigorous  man,  came  to  me  complaining  that  his  wife  did  not 
like  the  way  in  which  he  pjvssed  the  nights.  He  would  go 
to  bed  and  go  to  sleep  like  a  normal  individual,  but  in  the 
early  morning  hours  he  would  suddenly  sit  up  in  bed  and 
say  :  ''  boo  !  boo!  boo  !  "  This  would  be  followed  by  a  short 
oratorical  display  upon  some  p.assing  topic.  For  a  short  time 
he  would  quiet  down  and  then  go  to  sleep  .igain.  In  the  morn- 
ing he  would  sometimes  remember  these  attacks,  but  this 
was  not  always  the  case.  At  one  time  his  wife,  being  a  little 
irritated  by  his  habit,  tried  to  persuade  him  to  stop,  when  he 
jumped  at"  her  and  held  her  rather  violently,  quickly,  how- 
ever, quieting  down  and  resuming  his  elocution. 

I  assumed  the  attacks  were  not  associated  with  anv 


ApBIL  6,  1901] 


GENERAL  METABOLISM  IN  DIABETES  MELLITUS 


tTHB   PmLADKLPHIA 
Mbdical  Journal 


673 


nightmares  or  dreams  or  any  emotions  of  terror  of  any 
kind,  nor  could  they  be  related  to  any  habits  of  self- 
indulgence.  I  took  them  to  be  of  an  epileptic  character 
and  under  the  use  of  bromides  they  gradually  ceased. 

In  the  foregoing  I  have  considered  a  special  type  of 
insomnia^morning  insomnia. 

Disturbing  phenomena  of  sleep  causing  more  or  less 
insomnia,  and  these  I  classify  as  : 

Motor  shocks,  psychical  and  sensory  shocks,  including 
waking  in  fright,  waking  sensory  shocks  of  various 
kinds,  and  waking  parasthesia. 

Painful  sleep,  in  which  there  is  a  kind  of  nocturnal 
melancholia,  and  in  other  instances  a  series  of  painful 
dreams  (dysoneiria). 

Certain  epileptoid  and  automatic  disturbances  of 
sleep. 

A  large  part  of  the  above  phenomena  occur  from 
somewhat  similar  causes,  viz.,  neurasthenia,  lithemia, 
arterial  sclerosis,  and  cardiac  weakness,  and  a  few  can 
be  attributed  to  digestive  disturbances,  and  a  few  per- 
haps to  abortive  forms  of  epilepsy. 

The  treatment  of  these  symptoms  is  the  treatment  of 
the  underlying  condition.  They  are  usually  easily 
helped  by  bromides  and  hypnotics,  but  these  drugs  are 
not  often  curative.  It  is  especially  dangerous  to  use 
the  ordinary  hypnotics ;  and  I  have  come  to  the  belief 
that  all  sleep-producing  drugs  are  bad  and  useless  in 
dealing  with  chronic  and  established  neuroses.  More 
can  be  accomplished  by  heart  and  general  tonics,  by 
dealing  with  the  lithemia  and  arterial  sclerosis  and 
thus  promoting  the  patient's  general  health.  Exercise 
in  moderation  and  long  drives  or  long  exposure  to  the 
fresh  blowing  air,  are  the  best  hypnotics  given,  also 
peace  of  mind,  and  especially  a  removal  of  that  dread 
awakener — fear  of  not  sleeping.  The  safest  medicinal 
agent,  if  any  is  to  be  used,  is  single  small  doses  of 
bromide,  persistently  kept  up. 


GENERAL  METABOLISM  IN  DL^ETES  MELLITUS.* 

By  DAVID  L.  EDSALL,  M.D., 

of  Philadelphia. 

Instructor  in  Clinical  Medicine  in  the  University  of  Pennsylvania,  and  Assist, 

ant  Physician  to  the  University  Hospital ;    Associate  of  the 

William  Pepper  Laboratory  of  Clinical  Medicine. 

The  fact  that  my  discussion  is  to  be  limited  purely 
to  metabolism  in  diabetes,  without  considering  the  rela- 
tions of  the  metabolic  disturbance  to  various  organs, 
will  necessitate  omission  of  some  jjoints  which  are 
apparently  of  extreme  importance  in  connection  with 
the  portion  of  the  subject  assigned  to  me.  In  the  case 
of  the  pancreas  in  particular  valuable  discoveries  have 
been  recorded,  and  knowledge  of  these  is  practically 
essential  to  a  proper  conception  of  present  views  con- 
cerning the  nature  of  the  metabolic  abnormalities  in 
this  disease.  Such  matters  will,  however,  be  more 
properly  discussed  by  other  speakers. 

Since  so  large  a  number  of  points  must  be  touched 
upon  in  discussing  the  general  metabolism,  I  must 
repeatedly  throw  together  facts  which  are  rather  dis- 
tantly related  in  order  to  accomplish  the  duty  which 
has  been  assigned  to  me  within  the  limit  of  time. 

The  whole  nutritional  difficulty  in  diabetes,  so  far  as 
is  definitely  known,  is  one  that  in  an  ordinary  case 
relates,  primarily,  solely  to  the  carbohydrates.     The  sum 

•  A  part  of  a  Symposium  on  Diabetes.    Read  at  a  meeting  of  the  Philadelphia 
Pathological  Society,  January  24,  1901. 


total  of  the  activity  of  the  metabolic  processes  is  prac- 
tically normal ;  and  the  demand  for  and  expenditure  of 
energy  are  normal,  except  in  so  far  as  these  are  in- 
fluenced by  the  disturbance  of  the  carbohydrate 
'■  mechanism."  Speaking  freely,  we  may  say  that  the 
diabetic  expends  the  same  amount  of  energy  and  suf- 
fers the  same  daily  amount  of  tissue  loss  as  a  normal 
person,  and  requires  in  his  food  the  same  amount  of 
energy  and  of  material  for  repair  as  does  the  normal 
man.  In  one  small  way,  to  be  sure,  the  diabetic  does 
use,  and  therefore  does  demand,  more  energy  than  a 
normal  man  under  the  same  circumstances.  He  goes 
through  the  labor  of  digesting  carbohydrates,  he  pro- 
duces carbohydrates  within  himself,  and  he,  perhaps, 
constantly  builds  up  glycogen  and  then  produces 
glucose  from  it.  All  these  processes  serve  a  useful  pur- 
pose in  the  normal  subject  and  yield  far  more  energy 
than  they  consume.  In  the  diabetic,  on  the  contrary, 
the  energy  of  this  labor  is  wasted,  the  partially  prepared 
food  is  cast  out  without  being  used  and  without  having 
furnished  in  return  even  the  energy  which  it  has  itself 
demanded.  Modifying  the  previous  statement,  there- 
fore, in  slight  degree,  a  diabetic  may,  in  regard  to  his 
nutritional  demands,  be  looked  upon  as  differing  from 
the  normal  person  only  in  that  he  uses  slightly  more 
energy  in  accomplishing  the  same  amount  of  work.  It 
is,  however,  essential  to  recognize  that  his  real  fault  does 
not  lie  in  a  pathologically  increased  expenditure  of 
energy  and  a  consequently  increased  demand,  such  as 
is  seen  in  many  febrile  and  toxic  states ;  it  is  a  fault 
which  does  not  lie  in  the  demand  for  food  or  in  the 
quantity  of  food  ingested,  but  in  a  more  or  less  com- 
plete loss  of  the  normal  ability  to  derive  energy  from 
carbohydrate  food,  and  a  consequent  necessity  for  the 
vicarious  assumption  by  the  protein  and  fat  of  the  role 
in  producing  energy  normally  taken  by  the  carbohy- 
drates. 

It  has  always  been  known  that  diabetics  hunger  and 
emaciate ;  it  has  also  long  been  known  that  a  diabetic 
practically  always  excretes  much  more  nitrogen  than  a 
normal  man.  The  first  impression  that  these  facts  give 
is  that  there  is  some  essential  factor  in  the  disease  which 
causes  abnormal  activity  of  tissue  destruction,  and  that 
the  excess  in  nitrogen  excretion  is  direct  evidence  of 
excessively  active  protein  metabolism.  It  was  taught 
for  many  years  by  authorities  that  an  essential  feature 
of  the  disease  was  azoturia,  and  that  the  nitrogen  ex- 
cretion regularly  exceeds  the  intake  ;  and,  indeed,  the 
same  statement  is  still  often  made  or  implied.  As  re- 
gards the  fats,  too,  it  may  usually  be  observed  that  the 
loss  in  weight  is  more  than  the  nitrogen  loss  will  ex- 
plain, and  it  is  known  that  a  diabetic  early  loses  prac- 
tically all  his  reserve  store  of  carbohydrates.  The  con- 
clusion is,  therefore,  justified  that  the  man  is  losing  fat, 
and  his  tissues  themselves  show  this.  Hence,  wasting 
of  the  fatty  tissues  is  often  accepted  as  an  essential  part 
of  the  disease.  In  neither  instance,  however,  is  such 
a  conclusion  justified.  The  losses  of  fat  and  of  nitro- 
genous tissues  may  be  shown  to  be,  in  ordinary  cases, 
purely  secondary  and  due  to  the  fact  that  the  subject 
of  the  disease,  though  taking  large  amounts  of  food,  is 
excreting  so  much  of  it  practically  unchanged  that  he 
is  actually  using  for  the  production  of  energy  an 
amount  which  is  decidedly  below  the  demand.  The 
continuance  of  the  demand  for  energy  necessitates  a 
proper  supply,  however,  and  the  protein  tissues  and  fat 
are  broken  down  in  order  that  they  may  yield  this 
energy  and  not  because  their  functions  are  abnormal. 


674 


The  Philadelphia"! 
Medical  Joobnal  J 


GENERAL  METABOLISM  IN  DIABETES  MELLITUS 


[April  6,  1»M 


The  unusual  appetite  exhibittd  by  a  diabetic  is  then  a 
reall\'  normal  appetite  in  that  his  tissues  show  no 
abnormal  excitation  of  their  food  demands.  Large 
amounts  of  food  must  be  ingested  merely  because  much 
of  the  food  is  wasted ;  and  the  subject  emaciates  only 
because  he  does  not,  as  a  rule,  take  a  sufficient  amount 
of  the  proper  kind  of  food,  that  is,  the  kind  that  he  can 
use ;  his  supply  of  energy  is  below  the  demand,  and 
his  body  protein  and  fat  must  fill  the  gap  so  far  as  pos- 
sible. To  appreciate  the  correctness  of  this  view  and 
the  fact  that  the  contrary  teaching  is  erroneous,  one 
must  remember  certain  facts  relating  especially  to  the 
metabolism  of  the  proteins  in  a  healthy  subject  when 
the  food  supply  is  normal  and  when  too  little  or  too 
much  food  is  given.  There  is  not  a  sufficient  gen- 
eral understanding  of  certain  well-established  facts 
which  are  all-important  in  this  relation.  In  the  first 
place,  it  should  be  more  generally  recognized  that 
under  normal  circumstances  the  excretion  of  nitro- 
gen is  regulated  almost  entirely  by  the  char- 
acter and  amount  of  food  that  a  man  takes  and  not 
by  his  manner  of  life  as  regards  exercise,  etc.  If  a 
mixed  diet  of  normal  quantity  be  given  a  man  his  tis- 
sues will  in  a  very  short  time,  usually  a  very  few  days, 
accustom  themselves  to  the  diet,  and  it  may  then  be 
seen  that  whatever  the  amount  of  protein  contained 
therein,  his  nitrogen  excretion  during  a  given  period 
will  be  equivalent  to  the  amount  of  nitrogenous  food 
he  absorbed  during  that  period  ;  in  other  words,  that 
he  maintains  a  nitrogen  balance.  It  is  necessary  only 
to  see  that  the  total  value  of  his  food  in  units  of  energy 
is  sufficient  to  meet  the  demand  for  energy,  and  that 
the  daily  ration  does  contain  a  certain  amount  of  pro- 
tein. The  active  tissues  of  the  body  are  nitrogenous, 
and  their  activity  means  a  certain  amount  of  wear  and 
tear,  and  consequently  some  protein  is  necessary  to  re- 
place the  loss.  But  this  loss  is  small,  and  the  protein 
may  be  reduced  to  as  low  as  30  to  50  grams  a  day 
without  causing  any  loss  of  body  protein  during  an  ex- 
tended experiment.  Even  active  muscular  exercise 
causes  practically  no  increase  in  the  nitrogen  excre- 
tion if  only  the  other  foods  are  increased  so  that  the 
total  intake  meets  the  increased  demand ;  and  a 
reduction  of  exercise,  while  the  protein  is  still 
given  in  large  amounts,  does  not  cause  any  distinct 
reduction  in  the  nitrogen  excretion  though  it  may 
cause  the  subject  to  grow  fat.  If  food  is  given  in  very 
large  amounts,  more  than  necessary  for  the  body  needs, 
the  subject  will  generally  grow  fat,  but  a  nitrogen  bal- 
ance is  again  soon  reached  even  if  very  large  amounts 
of  protein  are  given.  If,  however,  the  food  is  reduced 
in  total  quantity  below  the  amount  which  is  necessi- 
tated by  the  man's  expenditure  of  energy,  a  loss  of 
nitrogen  will  be  seen  almost  at  once  if  the  excretion  be 
compared  with  the  intake.  This  loss  will  occur  even 
though  a  relatively  large  amount  of  protein  is  taken. 
If  the  man  be  now  given  an  amount  of  food  which 
will  bring  the  total  food  value  up  to  the  point  de- 
manded by  his  circumstances,  he  will  reach  a  nitrogen 
balance  again.  The  increase  in  foods  need  not  be  in 
protein,  providing  the  protein  has  not  been  reduced  be- 
low the  relatively  low  limit  of  absolute  demand,  for  it 
has  been  conclusively  sliown  that  protein  loss  can  be 
easily  controlled  by  giving  more  carbohydrate  and,  to 
a  less  complete  and  satisfactory  extent,  by  giving  fats. 
There  are  a  number  of  conclusions  that  "can  be  drawn 
from  these  facts,  which  are  of  importance  in  connection 
with  diabetes.     In  the  first  place,  protein  is  evidently 


not  stored  in  the  body.  This  conclusion  is  not  wholly 
justified,  as  Krug's  work  seems  to  show  that  overfeeding 
with  protein  may,  under  favorable  circumstances,  cause 
some  .storage.  His  results,  however,  are  justly  ques- 
tioned, and  even  if  accepted  they  show  extremely 
slight  protein  storage  (producing  only  5%  of  the  increase 
in  weight  as  compared  with  95%  due  to  increase  in  fat), 
and  it  is  probable  that  the  conditions  producing  such  a 
storage  could  not  be  long  maintained.  Secondly,  the  pro- 
tein both  of  the  food  and  of  the  tissues  is  evidently 
readily  broken  down ;  with  a  general  excess  of  foods 
or  with  an  excess  of  any  kind  of  food,  even  of  protein, 
the  protein  is  broken  down  at  once,  the  fats  and  car- 
bohydrates being  stored  ;  while  if  there  be  a  demand 
for  more  food  than  is  given  the  body-protein  practi- 
cally always  suffers.  And  thirdlj',  and  much  more  im- 
portant in  direct  connection  with  the  question  under 
discussion,  it  is  evident  that  a  negative  nitrogen  bal- 
ance, while  it  may  mean  excess  in  the  activity  of  pro- 
tein metabolism,  may  mean  merely  that  the  subject  is 
taking  too  little  food,  all  told.  In  health  this  is  evi- 
dently the  explanation,  and  in  disease  it  is  the  first 
thing  to  be  thought  of.  Fourthly,  and  quite  as  import- 
ant in  diabetes,  it  is  evident  that  a  nitrogen  loss  may, 
with  healthy  nitrogen  metabolism,  be  converted  into  a 
nitrogen  balance  if  more  food  is  given,  and  that  it 
matters  little  what  form  of  food  is  given  so  long  as  the 
protein  is  not  extremely  low  and  the  total  value  in 
energy  units  is  normal  under  the  circumstances.  The 
possible  explanations  for  the  increased  nitrogen  elimi- 
nation in  diabetes  are,  therefore,  three.  It  may  be  due 
to  an  increase  in  the  ingestion,  to  a  lack  of  sufficient 
food,  or  to  a  pathological  essential  increase  in  protein 
metabolism.  The  diabetic  takes  enormous  quantities  of 
food,  hence  the  first  factor  evidently  explains  some  of 
the  increase  in  urinary  nitrogen.  It  is  not  this  alone, 
however,  for  the  loss  exceeds  the  intake.  Of  the  other 
two,  then,  it  may,  in  the  ordinary  uncomplicated  case, 
be  readily  shown  that  a  lack  of  proper  food  is  at  fault 
A  pathological  increase  of  protein  metabolism  does  some- 
times occur  in  the  late  stages  of  diabetes,  particularly 
when  the  patient  is  in  danger  of  coma ;  but  under  ordi- 
narj'  circumstances,  if  the  total  caloric  value  of  the  food 
be  calculated,  and  the  loss  in  the  sugar  excreted  be  de- 
ducted, it  will  be  found  that  the  diabetic  is  making  use  of 
food  only  in  amounts  too  small  to  meet  the  necessities  of 
the  occasion.  If  now  his  fats  and  proteins  be  increased  to 
such  a  point  that  the  total  food  value,  after  deducting 
the  excreted  sugar,  is  equal  to  or  greater  than  the 
amount  he  needs,  it  will  be  found  that  the  nitrogen 
balance  is  normal,  and  he  may  even  retain  nitrogen 
until  the  previous  loss  is  replaced.  Evidently,  then, 
the  protein  metabolism  is  normal.  As  to  the  fat.  con- 
clusions are  much  more  difficult  to  reach,  except  by  in- 
ference. As  has  been  stated,  however,  if  a  diabetic  is 
given  sufficient  food,  with  consideration  of  the  sugar 
loss,  he  will  cease  to  lose  weight,  and  with  more  food 
will  gain  weight,  more  even  than  the  protein  retention 
will  explain.  He  tends,  therefore,  to  retain  fat  and  not 
to  destroy  it,  if  given  the  opportunity  by  being  fur- 
nished enough  total  food,  for  a  carbohydrate  retention 
cannot  explain  the  increase  in  weight.  Further,  there 
is  no  evidence  of  any  increase  in  the  oxidation  of  fats 
in  studies  of  the  respiratory  quotient.  There  is  also  no 
good  evidence  that  fats  can  contribute  largely  to  the  for- 
mation of  carbohydrates  in  the  body,  indeed,  the  most 
satisfactory  evidence  points  against  this ;  there  is,  there- 
fore, no  opportunity  for  an  indirect  increase  of  fat  de- 


April  6,   1901] 


GENERAL  METABOLISM  IN  DIABETES  MELLITUS 


["The  Philadelphia       fi75 
L  Medical  Journal 


struction  through  contributing  to  the  sugar  production 
and  loss.  And  finally,  many  cases  of  diabetes  even  show 
a  distinct  tendency  to  obesity.  There  is,  therefore,  no 
reason  for  believing  that  there  is  any  increase  in  the 
oxidation  of  fats,  either  direct  or  indirect,  excepting  in 
an  attempt  to  replace  a  deficit  in  the  food. 

But  while  there  is  no  destruction  of  fats  and  protein 
in  diabetes,  excepting  that  which  has  the  normal  pur- 
pose of  supplying  the  energy  demanded,  there  is  an 
evident  disturbance  of  the  metabolism  of  the  carbo- 
hydrates, which  is  most  easily  seen  in  the  characteristic 
and  generally  known  symptom,  glycosuria.  The  primary 
reason  for  this  disturbance  is  both  the  most  important 
and  the  most  obscure  question  in  diabetes,  but  valuable 
facts  concerning  the  abnormality  are  known.  Normally, 
we  take  the  carbohydrates  of  our  food  chiefly  in  the 
form  of  hexoses,  i  e.,  their  molecules  contain  six  atoms 
of  carbon,  or  a  multiple  of  six.  It  is  now  known  that 
our  food  does  contain  pentoses  in  considerable  quanti- 
ties, and  that  they  play  some  part  in  our  nutrition.  It 
is  not  improbable  that  they  are  of  decidedly  greater 
importance  in  this  way  than  is  even  now  admitted,  but 
they  are  probably  largely  transformed  into  hexoses  after 
their  absorption  before  they  are  used  by  the  tissues. 
At  present  our  interest  certainly  attaches  chiefly  to  the 
hexoses.  These  are  absorbed  largely  as  glucose,  though 
to  some  extent  as  levulose  and  also,  in  small  amounts,  as 
polysaccharids.  Absorption  takes  place  into  the  portal 
circulation  almost  exclusively.  After  this  point  the 
changes  in  the  sugar  are  somewhat  uncertain  as  to  the 
main  facts  and  entirely  obscure  in  many  details.  It  is 
quite  possible  that  all  the  sugars,  including  glucose, 
pass  through  the  glycogen  stage  before  they  are  ad- 
mitted to  the  general  circulation.  It  is  certain,  at  any 
rate,  that  practically  speaking  all  the  sugar  normally 
admitted  to  the  general  circulation  is  in  a  form  which 
gives  the  chemical  and  physical  reactions  of  glucose, 
and  that  normally  the  amount  in  the  general  circulation 
is  kept  at  a  fairly  constant  but  low  level,  the  percentage 
being  about  0.12  or  0.15.  Any  excess  taken  as  food  or 
formed  in  the  organism  is  stored  in  the  liver  and 
muscles  as  glycogen,  or  if  these  reservoirs  are  filled  to 
the  limit,  is  changed  into  fat  and  deposited  as  such.  If 
the  supply  is  low  the  glycogen  reservoirs  are  called  upon 
and  the  glycogen  is  transformed  into  glucose  and  fur- 
nished to  the  circulation  as  such  and  not  as  glycogen. 
The  existence  of  the  glycogen  reservoirs  makes  it  pos- 
sible to  keep  the  percentage  of  sugar  in  the  blood  at 
the  normal  level  in  the  long  periods  between  meals,  and 
in  spite  of  temporary  starvation  or  other  unusual  de- 
mands ;  the  glycogen  lost  is  soon  replaced  from  a  new 
supply  of  food,  so  that  the  total  quantity  of  glycogen 
shows  only  temporary  variations  and  a  reserve  is  always 
on  hand.  The  sugar  admitted  to  the  blood  is,  practi- 
cally speaking,  entirely  used  in  the  economy,  the  excre- 
tions containing  only  end  products  of  its  breakdown. 
The  normal  urine  does  contain  a  small  amount  of 
carbohydrate,  and  some  of  this  seems  to  be  glucose, 
but  the  quantity  is  too  small  to  be  considered  of  any 
practical  importance. 

The  alterations  in  diabetes  manifest  themselves  in 
all  these  main  points — in  the  storage  of  glycogen,  in 
the  quantity  of  sugar  in  the  blood,  and  in  the  striking 
change  in  excretion.  The  glycogen  becomes  reduced 
in  amount  and  may  almost  disappear  ;  sugar  is  found 
in  the  blood  in  abnormal  amounts,  constituting  a  so- 
called  hyperglycemia,  and  more  or  less  of  this  sugar  is 
excreted  in  the  urine  as  glucose,  and  the  energy  con- 


tained in  it  is  lost.  The  characteristic  and  distinguish- 
ing feature  of  diabetes  is  that  these  conditions  are  not 
dependent  upon  temporar\'  causes,  but  are  persistent 
and  usually  tend  to  increase.  Any  of  the  changes 
mentioned  may  occur  temporarily  as  the  result  of 
numerous  causes.  The  store  of  glycogen  may  be  more 
or  less  completely  reduced  by  starvation,  particularly 
when  associated  with  active  muscular  exercise ;  various 
nervous  insults,  particularly  the  piqure  of  Claude 
Bernard,  and  many  operative  procedures  will  have  a 
similar  result,  the  latter  probably  acting  largely  through 
the  nervous  shock  which  they  produce.  Undoubtedly 
a  hyperglycemia  results  in  most  of  these  instances, 
except  in  starvation,  from  the  sudden  flooding  of  the 
circulation  with  glucose  formed  from  the  glycogen,  and 
hyperglycemia  results  in  most  if  not  in  all  of  those 
conditions  in  which  we  observe  so-called  alimentary 
glycosuria.  As  to  temporary  glycosuria,  this  is  a  prac- 
tically inevitable  sequel  of  hyperglycemia  when  this 
reaches  any  notable  degree,  and  consequently  occurs 
in  any  of  the  conditions  mentioned  in  which  the  per- 
centage of  sugar  in  the  blood  rises  distinctly  above  the 
normal.  It  is  in  this  way  that  the  glycosuria  may 
probably  be  explained  when  it  occurs  after  trauma, 
experimental  nervous  insults,  shocks  in  various  dis- 
eases (as  in  gallstones),  and  in  so-called  alimentary 
glycosuria.  In  some  cases  a  glycosuria  is,  however, 
independent  of  any  mere  sudden  excessive  production 
of  glucose  from  glycogen  or  of  a  flooding  of  the  blood 
with  sugar  by  other  means,  such  as  the  ingestion  of 
large  amounts  of  sugar.  In  some  poisonings,  parti- 
cularly that  produced  by  phloridzin,  there  is,  without 
any  hyperglycemia,  a  more  or  less  decided  glycosuria. 
In  these  instances  the  glycosuria  is  evidently  not  due 
to  increase  in  the  amount  of  sugar  in  the  circulation, 
but  to  either  a  change  in  the  chemical  character  of  the 
sugar  itself,  or  a  change  in  the  kidney  permitting  of 
the  passage  of  the  sugar.  Infections  also  may  cause 
glycosuria.  They  probably  act  as  a  rule  through  the 
production  of  a  "hyperglycemia,  but  may  possibly  act 
at  times  by  alteration  of  the  sugar  or  of  the  kidneys. 
But  while"  it  is  possible  that  all  the  factors  mentioned 
— poisonings,  infections,  shocks  of  various  kinds,  over- 
ingestion  of  carbohydrates  (when  protracted  and 
particularly  when  largely  of  sugars),  and  even  starva- 
tion,— may  cause  diabetes,  and  it  is  certain  that  some  of 
these  factors  do  at  times  produce  the  disease,  the 
usual  characteristic  of  the  changes  which  they  set  up  is 
that  they  are  but  temporary  and  disappear  at  once  when 
the  cause  ceases  to  act,  or  at  most  soon  afterward.  If 
this  is  not  the  case  the  abnormality  is  actual  diabetes. 
Of  the  conditions  mentioned  the  one  that  most  closely 
approaches  diabetes  is  alimentary  glycosuria,  when 
this  occurs  persistently  and  after  taking  only  moderate 
amounts  of  sugar.  A  normal  person  is  evidently  limited 
in  his  power  of  making  immediate  use  of  the  carbohy- 
drates which  are  absorbed  from  his  gastrointestinal 
tract.  Under  normal  circumstances  the  sugars  absorbed 
are  formed  gradually  during  the  process  of  digestion, 
and  hence  are  absorbed  in  only  small  amounts  within 
a  given  time.  Only  small  amounts  need  to  be  dealt 
with,  therefore,  at  one  time.  If,  however,  a  normal  per- 
son is  given  readily  absorbable  sugar  in  large  amounts 
he  absorbs  large  quantities  within  a  brief  period,  par- 
ticularly if  his  stomach  and  small  intestine  are  practi- 
cally empty  when  the  sugar  is  taken.  If  the  quantity 
given  is  large  enough,  any  normal  person  will  react  by 
the  excretion  of  some  of  "the  sugar  in  the  urine.    The 


676 


Thk  Phzladrlphia"] 
Medicai,  Jocrnal  J 


GENERAL  METABOLISM  IN  DIABETES  MELLITUS 


[APBIL  6,  19»1 


most  evident  reason  for  this,  and  the  one  generally 
accepted,  is  that  he  is  unable  to  consume  or  store 
quickly  such  large  amounts  of  sugar,  his  general  cir- 
culation is  flooded  with  sugar,  and  his  kidneys  excrete 
the  excess.  In  other  words,  the  normal  ability  to  con- 
sume or  store  sugar  quickl_y  is  limited.  It  "may  be 
observed  in  a  large  series  of  abnormal  conditions"  that 
while  there  is  no  actual  diabetes,  an  alimentary  gly- 
cosuria may  be  produced  much  more  readily  than  nor- 
mally, i.  e.,  the  ingestion  of  quantities  of  sugar  that  are 
normally  fully  used  in  the  economy  results  in  glycosu- 
ria. Among  the  prominent  conditions  in  which  this 
occurs  may  be  mentioned  neuroses  (traumatic  and 
other  forms),  organic  nervous  diseases,  chronic  or  acute 
alcoholism,  infectious  diseases,  pancreatic  disease,  and 
exophthalmic  goiter.  It  is  found  in  disease  of  the  liver 
at  times,  but  not  in  the  large  percentage  of  cases  at  one 
time  thought.  The  essential  point  of  distinction  be- 
tween a  pure  alimentary  glycosuria  and  diabetic  gly- 
cosuria is  that  the  former  occurs  only  after  taking  sugars 
and  ceases  when  the  excess  is  excreted,  while  the  latter 
occurs  after  taking  carbohydrates  in  any  form,  and  often 
even  when  no  carbohydrates  are  taken,  it  is  more  or 
less  constantly  present,  even  under  normal  conditions 
of  life,  and  it  is  persistent  and  shows  a  strong  tendency 
to  increase.  Alimentary  glycosuria  is  present  in  dia- 
betes, but  does  not  necessarily  mean  diabetes.  When 
the  assimilative  power  is  decidedly  low,  however,  there 
is  a  dangerously  close  resemblance  to  diabetes  in  that 
in  both  conditions  the  normal  power  of  making  use  of 
carbohydrates  is  reduced;  but  in  pure  alimentary  gly- 
cosuria the  alteration  is  quantitative  only,  while  in  dia- 
betes it  is  both  qualitative  and  quantitative.  One 
striking  difference  between  alimentary  glycosuria  and 
diabetes  is  that  in  the  former  the  sugar  excreted  is 
practically  always  purely  the  kind  ingested,  while 
in  diabetes  the  sugar  found  in  the  urine  is,  with 
very  rare  exceptions,  glucose.  But  while  the  sugar  ex- 
creted in  diabetes  is  nearly  always  glucose,  there  is  a 
distinct  difference  usually  seen  iii  the  effects  of  the  in- 
gestion of  different  sugars.  While  all  forms  of  sugars 
almost  always  increase  the  glycosuria,  glucose  is  always 
badly  tolerated  and  more  or  less  completely  eliminated, 
and  the  various  polysaccharids  are  also"  but  poorly 
borne.  There  is,  as  a  rule,  some  power  of  using  lac- 
tose, and  levulose  is  frequently  consumed  to  a  very  con- 
siderable extent,  and  may  even  cause  an  accumulation 
of  glycogen,  and  the  latter  point  is  one  of  importance  in 
attempting  to  make  the  course  of  diabetes  clear.  Besides 
the  effect  of  the  carbohydrates  of  the  food,  a  striking 
effect  may  be  seen  from  the  food  protein  and  the  protein 
of  the  body.  It  is  now  certainly  known  that  both  these 
forms  of  protein  furnish  some  carbohydrate  normally, 
though  whether  it  is  a  mere  splitting  off  of  a  carbohy- 
drate molecule  already  present  in  the  protein,  or  the  car- 
bohydrate is  formed  "by  a  more  complex  synthetic  pro- 
cess after  the  partial  breakdown  of  the  protein  mole- 
cule, is  not  known.  Normally,  this  carbohydrate,  like 
that  already  found  as  such,  is  completely  used  in  the 
economy,  but  in  diabetes  it  frequently"  increases  the 
difficulty  and  is  more  or  less  completely  excreted.  But 
certainly  the  carbohydrate  formed  from  protein  is 
more  readily  assimilated  than  that  taken  as  carbohy- 
drate, as  the  exclusion  of  the  preformed  carbohydrates 
from  the  food  will  frequently  cause  the  glycosuria  to 
cease,  and  it  is  only  in  severe  grades  of  the  disease  that 
the  carbohydrate  formed  from  protein  is  excreted  in 
large  percentage.     Fats   do   not.  from  all  satisfactorj' 


work  on  the  question,  seem  to  increase  the  glycosuria, 
or  indeed  to  form  sugar  at  all.  Bouchard  and  Desgrez 
have  claimed  recently  that  they  may  cause  increase  of 
the  muscle  glycogen,  however,  and  this  may  possibly 
prove  to  be  true. 

The  power  of  using  preformed  carbohydrate  of  any 
variety  is  rarely  or  perhaps  never  completely  lost. 
Rumpf  has  recently  claimed  to  have  shown  its  absolute 
loss,  and  some  other  writers  agree  with  him  that  this  may 
occur,  though  no  conclusive  evidence  of  it  has  ever  been 
offered.  There  are  a  number  of  cases  on  record,  how- 
ever, in  which  the  loss  was  almost  complete,  and  there 
seems  no  good  reason  that  it  should  not  occur  at  times. 
There  is,  however,  never  an  entire  loss  of  the  abilit}'  to 
use  carbohydrates  in  general,  whether  preformed  or 
produced  from  protein.  The  possible  variations  are 
from  the  almost  complete  (or  possibly  complete)  loss  of 
the  use  of  preformed  carbohydrates,  to  a  very  slight  and 
variable  loss.  In  general  there  is  a  tendency  for  in- 
crease in  the  disability,  and  if  carbohydrates  are  taken 
in  any  considerable  amount  this  tendency  is  usually 
increased,  often  strikingly  so.  The  most  rational  ex- 
planation of  this  is  that  the  carbohydrate  function, 
already  weak,  becomes  overtaxed  and  still  further  re- 
duced if  excited  to  any  degree.  The  abnormality  also 
shows  a  decided  tendency  to  more  or  less  protracted 
fluctuations  in  degree,  and  may  even  spontaneously 
disappear  for  varying  periods.  Daily  fluctuations  are 
also  seen  in  the  sugar  excretion,  but  these  are  probably 
due,  as  a  rule,  chieflj'  to  the  pauses  between  meals  and 
consequent  variations  in  the  amount  of  sugar  absorbed 
from  the  gastrointestinal  tract. 

Turning  now  from  the  characteristics  of  the  metabolic 
disability  to  its  effects — the  chief  immediate  changes 
which  can  be  determined  are.  as  stated,  an  accumulation 
of  sugar  in  the  blood,  a  reduction  of  the  glycogen  in 
the  liver,  and  to  a  lesser  extent  of  that  in  the  muscles, 
and  a  loss  of  sugar  in  the  urine.  The  most  striking 
clinical  effects  are  largely  secondan,'  to  those  mentioned  ; 
they  are  chiefly  hunger,  emaciation,  thirst  and  polyuria. 
The  hunger  and  emaciation  are,  as  previously  stated,  evi- 
dently due  to  food  loss  through  the  excretion  of  sugar  in 
the  urine.  They  are  due  to  the  fact  that  while  the  subject 
of  diabetes  takes  a  normal  amount  of  what  to  a  normal 
man  is  useful  food,  a  very  considerable  portion  of  this 
is  actually  not  food  to  the  diabetic  and  cannot  be  used 
as  such,  and  is  excreted  practically  untouched.  Hence 
he  provides  his  tissues  with  an  abnormally  small 
amount  of  the  substances  which  they  can  use  as  food. 
The  hunger  and  emaciation  are  then  their  expression  of 
a  lack  of  sufficient  food.  An  explanation  of  the  thirst 
is  usually  simple  enough.  It  is  entirely  or  almost  en- 
tirely dependent  upon  the  polyuria :  the  loss  of  water, 
in  the  excessive  excretion  through  the  kidneys,  makes 
the  tissues  poor  in  fluid,  and  the  symptomatic  expres- 
sion of  this  is  thirst.  The  polyuria  is  not  quite  so  read- 
ily explained.  It  is  certainly  in  chief  part  and  in  most 
cases  explainable  through  the  existence  of  a  hypergly- 
cemia. The  kidneys  are  so  constituted  that  they  will 
not  allow  of  the  passage  of  sugar  unless  it  be  present 
in  the  blood  in  abnormal  amounts.  When  it  is  present 
in  abnormal  amounts,  however,  the  kidneys  practically 
always  make  an  attempt  to  excrete  the  excess.  The 
sugar  must  pass  the  kidneys  in  solution,  and  for  the 
solution  of  large  amounts  of  sugar,  large  quantities  of 
water  are  nece-ssary,  hence  polyuria  is  an  almost  inevi- 
table accompaniment  of  glycosuria. 

The  fact  that  the  kidneys  allow  the  sugar  to  pass 


APKIL6,  1901] 


GENERAL  METABOLISM  IN  DIABETES  MELLITUS 


r^HE   PHTT.AT>BLPHIA 
MSDICAL  JOUKSAL 


67: 


when  it  is  present  in  the  blood  in  excessive  amounts  is 
commonly  spoken  of  as  if  it  were  an  overtaxing  of  the 
kidneys,  and  the  glycosuria  is  apparently  usually  thought 
of  as  an  unfortunate  occurrence.  It  is,  of  course,  gen- 
erally recognized  that  the  glycosuria  is  not  of  itself 
the  cause  of  symptoms,  but  is  the  expression  of  some 
abnormality  further  back  in  metabolism  ;  but  it  should 
be  recognized  also  that  instead  of  being  a  misfortune  in 
itself,  the  excretion  of  sugar  through  the  kidneys  in 
hyperglycemia  may  be  looked  upon  as  a  happy  event ; 
it  must  be  largely  an  altruistic  and  purposeful  act 
of  the  kidneys  rather  than  the  mere  expression 
of  a  limit  of  power  in  retaining  sugar.  Hypergly- 
ycemia  is  an  unfortunate  condition  in  many  ways,  and 
were  there  no  attempt  on  the  part  of  the  kidneys  to 
reduce  the  excess  of  blood-sugar  so  far  as  possible, 
the  results  upon  the  tissues  of  the  mere  hyperglycemia 
itself  would  probably  soon  become  grave  in  nearly  all 
cases  of  diabetes.  These  results  of  hyperglycemia  are 
among  the  most  important  of  the  secondary  effects  of 
the  metabolic  disturbance.  They  consist  chiefly  in 
a  striking  tendency  to  infection  and  necrosis  of  the 
tissues.  It  is  generally  known  that  the  subjects  of  dia- 
betes have  a  very  marked  tendency  to  pyemia,  to  tuber- 
culosis in  particular,  to  sepsis,  to  gangrene,  and  to  many 
other  infections.  The  gangrene  can  be  explained  to  a 
considerable  extent  through  the  arteriosclerosis ;  but 
considering  the  strong  tendency  that  diabetics  show  to 
other  forms  of  infection,  it  is  rash  to  follow  the  recent 
tendency  of  some  surgeons  and  medical  clinicians,  and 
attribute  the  liability  to  gangrene  almost  exclusively 
to  the  arteriosclerosis  that  is  often  present.  As  to  the 
tendency  to  tuberculosis,  to  pyogenic  sepsis,  and  to 
many  other  infections,  there  is  fairly  general  acceptance 
of  the  idea  that  these  are  largely  due  to  the  hypergly- 
cemia. The  existence  of  an  excess  of  sugar  in  the 
blood  and  other  body  fluids  makes  this  a  much  more 
favorable  culture  medium  for  bacteria,  and  it  is  per- 
fectly reasonable  to  consider  that  the  peculiar  liability 
of  diabetics  to  infection  is  largely  due  to  this  altera- 
tion of  the  body  fluids.  There  are  two  other  factors 
which  must  be  considered,  however.  A  diabetic  is 
often  an  extremely  ill-nourished  person,  and  his  very 
severe  reduction  of  nutrition  certainly  favors  infection, 
as  infection  is  favored  in  other  conditions  of  malnutri- 
tion. The  third  possible  cause  has  recently  been  insisted 
upon  by  Teissier, who  found  that  the  presence  of  glycogen 
in  culture  tubes  largely  or  completely  hindered  the 
growth  of  various  forms  of  bacteria.  He  considers  these  ob- 
servations added  testimony  of  th«  correctness  of  the  view 
previously  expressed  by  Roger  and  Amato  that  the  re- 
duction of  the  glycogen  of  the  liver  so  commonly  seen 
in  diabetes  favors  infection  by  reducing  ihe  bactericidal 
power  of  the  liver.  This  is  a  somewhat  theoretical 
explanation  which  may  have  considerable  truth  in  it, 
but  the  actual  knowledge  of  the  role  played  by  the 
liver  in  the  prevention  of  infections  is  not  yet  sufficiently 
accurate  to  base  ideas  chiefly  upon  that,  and  it  is  cer- 
tainly not  yet  sufficiently  proved  that  the  glycogen  in 
the  liver  prevents  bacterial  growth  and  activity.  The 
hyperglycemia  is  almost  certainly  the  most  important 
factor  in  favoring  infection ;  one  fact  which  seems  to 
make  this  very  definitely  evident  is  that  v.  Mering  and 
Minkowski  in  their  original  communication  on  experi- 
mental pancreatic  diabetes  strongly  emphasized  the 
tendency  exhibited  by  the  animals  experimented  upon 
to  acquire  infection  almost  at  once.  This  infection 
usually  took  place  locally  through  the  wound  made  in 


operating,  and  this  seems  much  more  like  local  infec- 
tion due  to  a  proper  condition  of  the  body  tissues  and 
fluids  than  a  tendency  to  general  infection  through  re- 
duction of  the  bactericidal  power  of  the  liver ;  the  ten- 
dency to  infection  was  also  so  rapidly  developed  in  these 
animals  that  the  reduction  in  nutrition  does  not  seem 
to  have  played  a  very  important  role.  In  closing 
this  portion  of  the  subject  it  may  be  mentioned 
that  it  is  claimed  that  diabetes  is  demonstrable  by 
certain  methods  which  consist  in  observing  the  reaction 
of  the  blood  to  dyes,  particularly  to  methylene  blue. 
These  reactions  probably  depend  almost  exclusively 
upon  the  existence  of  hyperglycemia.  The  tests  which 
have  been  used  in  this  connection  are  those  of  Bremer 
and  Williamson.  Bremer  has  two  reactions  :  one  of 
them  consists  in  a  peculiar  behavior  of  diabetic  urine 
to  stains,  the  other  in  alterations  in  the  staining  reac- 
tions of  diabetic  blood.  Williamson's  test  consists  in  a 
rapid  decolorization  of  a  weak  alkaline  methylene-blue 
solution  when  diabetic  blood  is  added  to  it.  In- 
vestigation of  Bremer's  reactions  has  shown,  as  might 
have  been  postulated  without  special  study,  that 
while  it  is  almost  always  present  in  diabetes  when 
hyperglycemia  and  glycosuria  are  marked,  there  are 
other  conditions  of  the  blood  and  urine  that  may  give 
an  apparent  reaction,  and  there  are  also  so  many  possi- 
bilities of  error  in  the  technic  of  the  preparation  of  the 
blood  that  the  reaction  is  of  no  serious  consequence  in 
actual  diagnosis.  As  to  Williamson's  test,  it  is,  in  the 
first  place,  necessary  to  carry  out  the  reaction  with  the 
utmost  care  as  to  details,  and  errors  in  technic  are  very 
likely  to  occur.  Furthermore,  the  only  instances  in 
which  the  reaction  is  likely  to  be  of  any  real  value  are 
in  cases  in  which  there  is  no  opportunity  to  determine 
the  existence  of  glycosuria,  for  glycosuria,  if  present,  is 
a  sign  which  is  much  more  readily  and  certainly  demon- 
strated. Such  conditions  are  probably  at  most  two. 
One  of  them  is  the  absence  of  glycosuria,  while  hyper- 
glycemia is  present.  If  such  a  condition  exists  it  is  ex- 
tremely rare,  and  even  if  the  possibility  of  its  occurrence 
be  admitted,  certainly  hyperglycemia  can  be  present 
in  only  extremely  slight  degree  without  a  coexistent 
glycosuria,  and  it  is  questionable  whether  a  very  slight 
degree  of  hyperglycemia  could  be  determined  by  this 
rough  test ;  probably  it  could  not.  The  condition  in 
which  Williamson  thinks  the  test  is  more  likely  to  give 
useful  results  is  in  diabetic  coma,  when  urine  cannot  be 
obtained  for  examination,  and  when  one  desires  imme- 
diate security  in  his  diagnosis.  A  negative  result,  how- 
ever, under  such  conditions,  could  never  be  depended 
upon  as  indicating  the  absence  of  diabetes,  as  it  is  well 
known  that  preceding  or  during  coma,  glycosuria  and 
hyperglycemia  not  very  infrequently  disappear  more  or 
less  completely.  For  this  reason  alone  it  is  probable 
that  Williamson's  test  would  be  negative  in  a  certain 
proportion  of  cases  of  diabetic  coma,  if  glycosuria  were 
absent.  There  are  instances  in  which  the  bladder  con- 
tains no  urine,  and  yet  glycosuria  and  hyperglycemia 
are  present.  In  these  extremely  rare  cases  Williamson's 
test  might  be  of  value.  It  must  be  remembered,  how- 
ever, that  up  to  the  present  the  test  has  not  been  well 
studied  in  relation  to  the  other  conditions  which  might 
possibly  give  a  reaction.  From  some  investigations  that 
have  been  made  it  appears  that  the  reaction,  or  some- 
thing practically  undistinguishable  from  the  reaction, 
may  occasionally  appear  in  other  conditions.  It  would 
seem,  therefore,  that  the  possibilities  of  a  negative  result 
in  actual  diabetes  and  of  a  positive  result  in  other  con- 


678 


Thk  Phiijj>blphia"| 
Medical  JonENAt  J 


GENERAL  METABOLISM  IN  DIABETES  MELLITUS 


[APBII.  C,  1901 


ditions  make  the  test  so  far  unreliable  that  it  is  a  very 
insecure  basis  of  diagnosis.  The  proper  observation  of 
the  symptoms,  together  with  the  investigation  of  the 
urine,  if  this  is  possible,  and  the  discovery  in  it  of  large 
amounts  of  acetone,  diacetic  acid,  and,  perhaps  of 
;5-oxybutyric  acid,  afford  much  more  satisfactory  and 
far  more  reliable  methods  of  diagnosing  diabetic  coma. 
The  discussion  of  metabolism  in  diabetes  would,  of 
course,  be  incomplete  without  a  mention  of  the  condi- 
tions in  coma  ;  but  the  questions  arising  in  connection 
with  this  complication  are  so  intricate  and  have  given 
rise  to  such  extensive  discussion  that  only  the  most 
notable  points  and  those  which  seem  fairly  well  estab- 
lished can  be  given.  So  far  as  nitrogen  metabolism  has 
been  studied,  it  seems,  while  somewhat  variable,  to  be 
very  likely  to  suffer  an  abnormal  excitation  with  the 
approach  of  coma.  The  subject  of  the  disease,  while 
previously  in  nitrogen  equilibrium  if  properly  fed, 
shows  with  approaching  coma  a  loss  of  nitrogen  which 
cannot  be  replaced  by  increasing  the  protein  food 
within  safe  limits.  The  cause  of  this  increase  in  meta- 
bolism is  not  clearly  evident,  though  it  is  certainly  an 
expression  of  toxemia.  With  the  nitrogen  loss  the 
patient  commonly  suffers  a  loss  of  fat.  The  carbohy- 
drate disturbance  usually  continues,  and  at  the  period 
when  coma  is  approaching,  has  generally  become  of 
severe  degree.  One  striking  point,  however,  which  is 
always  worthy  of  being  remembered,  is  that,  as 
previously  noted,  in  some  cases  the  sugar  excre- 
tion disappears  as  coma  approaches  and  during 
the  course  of  coma.  This  is  perhaps  due  chiefly  to 
reduction  in  the  amount  of  food  taken,  and  a  conse- 
quent reduction  in  the  amount  of  carbohydrates  sup- 
plied to  the  circulation,  though  this  is  by  no  means  a 
complete  and  satisfactory  explanation.  But  the  most 
notable  facts  about  diabetic  coma,  so  far  as  one  is 
directly  concerned  with  questions  of  metabolism,  are 
the  evidences  of  intoxication  that  precede  or  accom- 
pany the  coma.  The  facts  best  known  to  the  clinician 
are  that  acetone  and  diacetic  acid  are  found  in  the  urine 
in  more  or  less  considerable  amounts.  It  has  also  been 
shown  chemically,  and  is  evident  upon  mere  observa- 
tion, that  acetone  is  given  off  in  large  quantities  from 
the  lungs.  Acetone  is  known  to  be  toxic,  and  it  was 
long  taught,  and  is  still  widely  believed,  that  diabetic 
coma  is  actually  an  intoxication  with  acetone.  It  has, 
however,  been  shown  satisfactorily  that  acetone,  while 
it  may  and  probably  does  play  some  part  in  the  pro- 
duction of  coma,  is  far  from  being  the  sole  or  even  the 
chief  cause  of  the  coma.  Acetone  is  really  an  end  pro- 
duct of  the  acids  which  cause  the  coma  rather  than 
itself  the  cause  ;  and  although  acetone  may  readily  be 
conceived  of  as  contributing  to  the  production  of  in- 
toxication, it  cannot  be  considered  to  be  chiefly  active 
in  causing  the  peculiar  s3'mptoms  seen  in  diabetic 
coma.  In  the  first  place,  acetone  is  but  mildly  poi- 
sonous, and  when  given  to  man  or  animals,  even  in  the 
amounts  excreted  during  the  course  of  diabetic  coma, 
produces  only  mild  symptoms,  if  indeed  it  causes 
any  ;  also,  the  amount  excreted  shows  no  regular  pa- 
rallelism with  the  progress  of  the  intoxication ;  and 
further,  the  symptoms  produced  by  poisonous  doses 
are  not  those  of  diabetic  coma.  It  may  properly  be 
said,  also,  that  it  has  never  been  quite  conclusively 
proved  that  acetone  is  ever  found  in  large  amounts  in 
the  body,  and  a  number  of  observers  contend  that  all 
the  acetone  found  in  the  urine  is  excreted  as  diacetic 
acid,  and  this  is  subsequently  oxidized  to  acetone.  This 


view  is  probably  not  correct ;  the  reasons  given  are  suf- 
ficient, however,  to  show  that  acetone  can  not  be  con- 
sidered to  be  the  cause  of  the  peculiar  coma.  But  a 
still  better  reason  is  found  in  the  fact  that  other  sub- 
stances are  present  in  diabetic  coma  and  preceding  its 
onset,  which  show  a  close  and  almost  constant  relation 
to  the  symptoms,  and  which  may,  from  analogy  with 
the  results  of  experiments,  be  fairly  considered  to  be 
the  cause  of  the  coma.  It  is  now  well  known  that  pre- 
ceding and  during  coma  there  is  so  large  a  production 
of  acids  as  to  flood  the  blood  and  tissues  with  these,  to 
reduce  greatly  the  alkalinity  of  the  blood,  and  to  cause 
the  excretion  of  large  amounts  of  alkalies  combined 
with  the  excess  of  acid.  It  is  also  well  known  to  ex- 
perimenters that  adminiBtering  large  amounts  of  acids 
of  various  kinds  will  result  in  the  appearance  of  a  con- 
dition which  resembles  diabetic  coma  in  several  of  its 
most  distinctive  features.  Somewhat  similar  symptoms 
of  intoxication  may  also  be  produced  by  giving  to 
animals  large  quantities  of  those  forms  of  food  which 
will  produce  acids  in  large  amount  in  the  process  of 
the  breakdown  c.f  the  food,  providing  that  the  animals 
are  not  accustomed  to  such  a  method  of  feeding. 

The  most  satisfactory  explanation  of  typical  coma 
then,  so  far  as  our  present  knowledge  goes,  is  to  con- 
sider it  a  form  of  irrtense  acid  intoxication,  due  not  to 
any  special  toxic  agent,  in  its  typical  form,  but  to 
the  mere  excess  of  acid,  and  to  the  consequent  reduc- 
tion of  the  alkalies  of  the  blood  and  tissues  through 
their  neutralization  by  the  acid.  The  substance  which 
is  undoubtedly  chiefly  active  in  the  production  of  the  in- 
toxication is  ,J-oxybutyric  acid.  This  has  been  shown, 
since  the  work  of  Minkowski  and  Kiilz  first  demon- 
strated that  it  may  be  found  in  this  condition,  to  be 
present  in  large  quantities  during  coma  or  preceding  its 
onset  in  the  great  majority  of  cases.  It  has  not  any 
severe  toxic  action  which  is  peculiar  to  itself;  it  is, 
however,  present  in  such  large  quantities  as  to  be 
capable  of  producing  acid  intoxication  through  its 
action  simply  as  an  acid.  Diacetic  acid  is  also  found 
in  large  amounts  when  coma  is  imminent  or  present; 
it  is  very  probably  derived  from  the  ;i-ox}'butyric  acid, 
though  it  is  possibly  separately  produced.  It  is  almost 
devoid  of  any  special  toxic  properties  and  is  active  in 
the  production  of  diabetic  coma  only  through  its  acid 
properties,  but  it  is  almost  certainly  present  in  suffi- 
cient amounts  in  many  cases  to  aid,  at  least,  in  the  pro- 
duction of  the  acid  intoxication ;  it  is  impossible  to 
state  this  absolutely,  since  the  amount  of  diacetic  acid 
cannot  be  satisfactorily  determined  quantitatively. 
(Joxy butyric  acid  is,  however,  present  in  much  larger 
amounts  and  is  of  itself  somewhat  toxic ;  it  is  certainly 
much  the  more  prominent  factor  in  the  production  of 
the  coma.  Acetone  is  a  derivative  of  ,;-oxybutyric  acid 
and  diacetic  acid,  and  is  therefore  chiefly  the  expression 
of  the  conditions  causing  the  coma  rather  than  itself 
the  cause,  though  as  previously  stated  its  toxicity  is 
sufficient  to  make  it  probable  that  it  aids  in  the  pro- 
duction of  intoxication  though  not  directly  in  the  pro- 
duction of  the  peculiar  symptoms  of  diabetic  coma. 
There  has  recently  been  an  attempt  to  demonstrate 
the  possibility  that  diabetic  coma  is  due  to  a  sub- 
stance which,  besides  its  mere  acid  influence,  has  a 
special  toxic  efi'ect,  and  which  through  this  latter  action 
produces  the  special  symptoms  of  diabetic  coma. 
Sternberg,  assuming  that  ,i-amidobutyric  acid  might  be 
present  in  diabetic  coma,  has  investigated  the  effect  of 
this  acid  upon  animals,  and  claims  to  have  produced 


April  6,  ISOl] 


GENERAL  METABOLISM  IN  DIABETES  MELLITUS 


["Thk  Philadblphu 
L  Medical  Joushal 


679 


with  it  a  condition  practically  identical  with  the 
peculiar  coma  of  diabetes,  and  Grube  states  that  he  has 
confirmed  Sternberg's  results.  Magnus-Levy  very  prop- 
erly objects  to  the  acceptance  of  these  results,  however, 
upon  the  ground  that  the  amido-acidg  found  in  the 
human  organism  are  of  the  alpha,  not  the  beta,  series, 
and  that  the  theoretical  assumption  of  the  existence  of 
/?-amidobutyric  acid  is  unjustified.  There  is  also  ques- 
tion whether  the  conditions  produced  were  really  those 
seen  in  diabetic  coma.  While  it  may  be  true  that  some 
special  toxic  agent  produces  the  peculiar  symptoms,  this 
does  not  from  our  present  knowledge  seem  at  all  essential. 
The  conditions  in  true  diabetic  coma  vary  to  a  certain 
degree,  and  other  acids  beside  /J-oxybutyric  and  diacetic 
acids  (lactic,  volatile  fatty  acids,  etc.)  have  been  demon- 
strated to  be  present  in  large  amounts  in  some  instances, 
and  were  very  possibly  the  cause  of  the  coma  in  these 
cases ;  hence  coma  seems  to  be  produced  by  a  flooding 
with  acids  of  various  kinds.  Also  a  condition  practically 
indistinguishable  from  diabetic  coma  has  been  observed 
in  a  number  of  other  diseases,  such  as  carcinoma  and 
pernicious  anemia,  when  there  was  evidence  of  pro- 
found acid  intoxication.  These  facts,  together  with  the 
observation  of  experimenters  that  various  kinds  of  acids 
produce  a  similar  condition  when  the  amount  given  is 
large  enough,  demonstrate  with  a  considerable  degree  of 
certainty  that  the  coma  is  at  least  in  chief  part  due  to 
the  action  of  the  acids  as  such,  and  not  to  any  special 
toxic  substance. 

The  source  of  the  acids  has  been  a  matter  of  great  con- 
troversy. It  is  demonstrated  by  both  experimental  work 
and  by  clinical  observation  that  the  use  of  carbohydrate 
food  not  only  does  not  produce  these  acids,  but  tends  to 
decrease  any  existing  acid  intoxication.  It  has  until 
recently  been  very  generally  accepted  that  the  acid 
intoxication  is  produced  by  destruction  of  proteins. 
It  is  well  known  that  the  destruction  of  proteins  does 
produce  considerable  quantities  of  acid,  and,  further,  one 
of  the  most  striking  reasons  for  accepting  this  source  of 
the  intoxication  is  that  when  acid  intoxication  occurs 
the  subject  is  usually  losing  large  quantities  of  nitrogen 
in  spite  of  the  large  intake,  and  is  therefore  breaking 
down  large  quantities  of  the  protein  of  the  body  tissues 
as  well  as  of  the  food.  It  has,  however,  not  been  satisfac- 
torily established  that  /5-oxybutyric  acid,  diacetic  acid, 
or  acetone  can  be  produced  from  protein,  though  the 
recent  work  of  Blumenthal  and  Neuberg  makes  it 
seem  probable  that  this  may  actually  be  accom- 
plished in  the  human  organism  as  well  as  artificially. 
Their  work,  however,  is  not  yet  confirmed.  In  the 
absence  of  thorough  proof  of  production  of  these  sub- 
stances from  protein,  and  in  the  very  satisfactory  de- 
monstration, by  Geelmuyden  and  Magnus-Levy  in 
particular,  that  they  may  be  produced  from  fats,  the 
belief  has  become  quite  generally  accepted  that  the  fats 
of  the  food  or  the  body,  or  both,  are  probably  the  source 
of  the  acids  producing  the  intoxication.  One  must  at 
present  therefore  consider  the  source  of  these  acids 
to  be  chiefly  the  fats ;  though  it  is  highly  probable 
that  the  protein  also  contributes  to  their  produc- 
tion, and  it  must  be  accepted  as  practically  certain  that 
proteins  at  any  rate  contribute  to  the  acid  intoxication 
through  the  production  of  other  acids,  since  the  break- 
ing down  of  [jrotein  food  always  produces  a  consider- 
able amount  of  acid.  It  has  been  very  definitely 
demonstrated  by  both  clinical  observation  and  experi- 
ment that  the  acid  intoxication  occurring  in  diabetes 
may  be  due  to  the  use  of  a  protein-fat  diet,  or  to  break- 


down of  similar  body  tissues.  A  complete  or  almost 
complete  restriction  of  carbohydrates  from  the  food  is 
very  likely  to  be  followed  by  the  appearance  of  acetone 
and  diacetic  acid  in  the  urine  in  diabetes,  as  is  well 
known  to  clinicians,  and  the  experiments  of  Gerhardt 
and  Schlesinger  show  that  a  similar  result  may  be  pro- 
duced in  normal  persons  ;  while  the  substitution  of  car- 
bohydrates for  some  of  the  protein  and  fat  frequently 
causes  the  disappearance  of  the  acetone  and  the  diacetic 
and  oxybutyric  acids  and  the  symptoms  of  approaching 
coma  if  they  were  present.  In  what  way  the  carbo- 
hydrates exert  this  action  is  not  fully  understood,  as 
such  an  effect  may  sometimes  be  seen  when  compara- 
tively little  carbohydrate  is  given.  It  seems  probable 
that  the  carbohydrates  in  some  way  influence  the  meta- 
bolism of  the  protein  and  fat,  besides  reducing  the 
quantity  of  the  latter  which  it  is  necessary  to  give. 
While  the  appearance  of  large  quantities  of  acetone, 
and  more  particularly  of  diacetic  acid,  in  the  urine  fur- 
nishes what  must  continue  to  be  the  best  general  clin- 
ical index  of  the  danger  of  the  onset  of  coma,  a  more 
exact  method  of  determining  the  degree  of  acid  intoxi- 
cation and  its  progress  is  by  estimating  the  ammonia 
of  the  urine ;  one  may  practically  always  see  that 
with  increasing  acid  intoxication  the  ammonia  excre- 
tion in  the  urine  coincidently  increases  and  in  most  cases 
this  increase  is  practically  proportionate  to  the  degree 
of  intoxication  with  acids.  The  reason  for  this  is  that 
the  acids  produced  in  the  body  are  normally  neutral- 
ized largely  by  the  fixed  alkalies,  only  small  amounts 
of  ammonia  being  excreted.  If,  however,  the  amount 
of  acid  to  be  neutralized  becomes  much  larger  than  the 
normal,  the  fixed  alkalies  do  not  suffice  to  neutralize  the 
acids  or  they  cannot  be  so  largely  used  without  causing 
a  dangerous  reduction  in  the  alkalinity  of  the  body 
fluids.  Under  such  circumstances,  according  to  the 
teaching  of  the  Schmiedeberg  school,  which  is  the  most 
satisfactory,  the  ammonia  formed  in  the  body,  instead 
of  being  excreted  as  urea,  unites  so  far  as  necessary 
with  the  acids  and  is  excreted  in  combination  with 
them. 

An  interesting  fact  which  has  been  well  shown  re- 
cently by  Gerhardt  and  Schlesinger,  and  has  previously 
been  indicated  by  the  work  of  others,  is  that  the  excre- 
tion of  calcium  and  magnesium,  particularly  of  the 
former,  is  increased  during  acid  intoxication,  and  there 
may  even  be  a  decided  calcium  loss  which  may  be  con- 
trolled to  a  considerable  extent  by  modifying  the  diet 
or  by  giving  alkalies.  This  fact  is  of  great  abstract  in- 
terest, and  it  is  wholly  probable  that  it  may  have  a 
good  deal  of  actual  clinical  importance.  The  calcium 
salts  play  an  extremely  important  role  in  organic  chem- 
istry in  numerous  ways,  one  of  the  most  important 
of  which  in  animal  physiology  is  their  influence 
upon  coagulation  of  the  blood.  An  influence  similar 
to  that  just  mentioned  is  exerted  by  calcium  salts 
upon  the  action  of  other  ferments  than  the  fibrin 
ferment,  and  it  seems  not  at  all  impossible  that  re- 
duction of  the  calcium  salts  in  acid  intoxication  may 
have  an  important  relation  to  the  symptoms  produced 
during  such  intoxication.  The  results  of  metabolic  ex- 
periments make  it  wholly  worth  while  to  investigate 
more  thoroughly  the  effects  of  calcium  upon  the  disease, 
particularly  when  there  are  evidences  of  acid  intoxica- 
tion. 

In  conclusion,  the  main  theories  concerning  the  defi- 
nite nature  of  the  disturbance  in  metabolism  which 
produces    diabetes    may    be    mentioned.     These     are 


680 


Thk  Phti-adklphia"] 
Mkdical  Jocbkax  J 


STUDY  OF  TWO  BRAINS 


[April  6,  1901 


that  the  disease  is  due  to  overproduction  of  sugar; 
that  it  is  due  to  imperfect  oxidation  of  sugar 
and  its  consequent  accumulation;  that  it  is  due 
to  insufficiency  in  the  production  of  glycogen  so 
that  the  sugars  absorbed  from  the  digestive  tract  or 
formed  in  the  body  constantly  reach  the  circulation  at 
once,  and  the  excess,  instead  of  being  stored,  is  con- 
stantly being  excreted ;  and  that  some  special  toxic 
agent  is  the  primary  cause.  The  first  and  last  theories 
at  present  deserve  little  consideration.  There  has 
never  been  any  proof  offered  that  there  is  an  over- 
production of  sugar;  indeed,  the  testimony  is  wholl_y 
against  such  a  belief.  The  whole  amount  of  sugar  ex- 
creted is  never  continuously  greater  than  the  amount 
absorbed,  plus  the  amount  that  we  know  can  be  pro- 
duced from  the  food-protein  and  body-protein  which 
are  being  destroyed  at  the  time.  The  theory  of  a 
special  diabetic  toxemia,  which  has  recently  been  put 
forth  by  Leo,  is  based  upon  inconclusive  experiments, 
which  amount  to  nothing  more  than  the  production  of 
glycosuria  in  a  small  number  of  dogs  by  injecting  the 
urine  of  diabetic  subjects.  Urine  from  other  diabetics 
did  not  give  the  same  results,  and  there  was  no  demon- 
stration that  actual  diabetes  occurred  in  the  animals,  or 
that  a  special  toxic  agent  caused  the  glycosuria.  The 
choice  lies  between  the  other  theories — the  disease 
seems  to  be  either  a  loss  of  the  normal  power  of  de- 
stroying sugars,  or  a  lack  of  the  normal  power  of 
producing  glycogen,  and  of  controlling  thereby  the 
amount  of  sugar  supplied  to  the  blood.  Either  of  these 
theories  would  satisfactorily  explain  the  facts  observed 
in  most  instances.  The  general  tendency,  more  partic- 
ularly of  the  V.  Noorden  school,  is  to  put  faith  in  the 
theory  of  imperfect  oxidation  of  the  sugars.  The 
most  important  point  upon  which  such  a  belief  is  based 
is  that  the  respirator^'  quotient  (the  amount  of  oxygen 
taken  in  in  respiration  divided  by  the  amount  of  CO, 
given  off)  is  low  in  diabetes.  Under  normal  circum- 
stances the  oxidation  of  carbohydrates  in  large  amounts 
increases  this  quotient,  while  when  the  amount  of  fats 
being  oxidized  is  relatively  high,  the  quotient  decreases. 
It  would  seem,  therefore,  that  in  diabetes  the  amount 
of  oxidization  of  carbohydrates  is  below  the  normal. 

This  is  serious  testimony,  but  it  is  based  upon  a  verj' 
small  number  of  observations,  and  hence  the  influence 
of  chance  factors  cannot  well  be  excluded  ;  and  against 
such  results  may  be  adduced  the  fact  that  oxidative 
processes  in  general  are  certaibly  not  reduced  in  dia- 
betes, as  it  has  been  shown  that  many  substances  which 
are  difficult  of  oxidation  may  he  oxidized  in  large 
amounts  by  the  organism  of  the  diabetic.  Further, 
under  ordinary  circumstances  levulose  and  glucose  are 
oxidized  with  about  the  same  facility,  but  in  diabetes 
levxilose  is  assimilated  but  glucose  is  not.  This  points 
against  suboxidation  as  the  cause.  Chauveau  and 
Kauffman  also  found  that  comparing  the  venous  and 
arterial  bloods  of  the  diabetic  with  those  of  the  normal 
subject  there  was  evidence  of  oxidation  of  the  sugars  in 
the  diabetic  subject  as  well  as  in  the  normal  one.  Their 
methods  were  subject  to  question,  however.  The  work 
that  has  been  done  on  glycolysis  has  not  demonstrated 
anything  clearly,  unless  it  be,  as  Biernacki  has  recently 
claimed,  that  glycolysis  is  very  variable  in  diabetes ; 
Lepine's  attempts,  and  those  of  others,  to  demonstrate 
the  absence  of  the  glycolytic  ferment  or  reduction  in 
its  activity  have  not  been  successful,  and  his  sugges- 
tion of  a  loss  of  glycolytic  action  of  the  body  fluids 
in  diabetes  is  therefore  not  at  all  supported  by  experi- 


mental work.  The  theory  of  imperfect  glycogen  pro- 
duction is  suggested  by  a  number  of  facts,  the  most  im- 
portant of  which  is  perhaps  the  observation  that 
levulose  is  frequently  made  use  of  in  large  amounts  by 
the  diabetic  organism  when  glucose  is  largely  or  com- 
pletely excreted  unused  ;  and  more  particularly  that 
levulose  will  frequently  produce  an  accumulation  of 
glycogen  in  the  liver  while  glucose  will  not.  This 
would  seem  to  indicate  that  it  is  impossible  in  diabetes 
to  produce  glycogen  from  glucose,  while  this  occurs 
normally  with  levulose.  It  seems  improbable  when 
viewed  in  this  connection  that  the  oxidation  of  glucose 
is  at  fault,  because  the  levulose  after  producing  glyco- 
gen in  the  liver  is  normally  furnished  to  the  circulation 
in  the  form  of  glucose ;  in  spite  of  this  it  is  largely  or  com- 
pletely oxidized  thereafter,  apparently  even  by  the  dia- 
betic in  many  instances.  Further  testimony  of  the  pos- 
sible correctness  of  this  view  has  been  recently  furnished 
by  the  results  of  Sachs  who  found  that  extirpation  of  the 
liver  in  frogs  did  not  alter  the  power  of  these  animals 
to  assimilate  glucose,  but  did  produce  a  strong  tendency 
to  alimentary  levulosuria.  He  uses  these  results  as 
testimony  of  the  lack  of  importance  of  the  liver  in  the 
production  of  diabetes  ;  but  since,  as  has  been  repeatedly 
stated,  levulose  is  often  satisfactorily  assimilated  by  the 
diabetic  while  glucose  is  not,  and  since  extirpation  of 
the  liver  produces  exactly  the  contrary  conditions  to 
those  seen  in  diabetes,  these  results  would  seem  to  indi- 
cate also  that  if  levulose  passes  the  stage  of  glycogen  pro- 
duction in  the  liver,  it  is  properly  used  by  the  organism, 
and  that  the  reason  that  levulose  is  well  assimilated  in 
diabetes  is  that  there  is  still  power  of  transforming  it 
to  glycogen  while  glucose  cannot  be  so  transformed. 


A  PRELIMINARY  COMMUNICATION  OF  A  STUDY  OF 
THE  BRAINS  OF  TWO  DISTINGUISHED  PHYSI- 
CIANS. FATHER  AND  SON.* 

Bt  EDWARD  ANTHONY  SPITZKA, 

of  Kew  York  Citj. 

Student  of  Medicine,  College  of  Ptiysici&ns  and  Surgeon& 

To  a  great  extent,  the  more  recent  studies  of  human 
brain  anatomy  may  be  termed  one-sided,  inasmuch  as 
the  numerous  examinations  made  of  individual  cerebra 
were  of  such  derived  from  criminals,  lunatics,  and  other 
defectives,  nay,  most  frequently  from  subjects  whose 
Ul'e-history  and  characteristics  were  and  remained  un- 
known, or  were  unworthy  of  record.  On  the  other  hand, 
the  brains  of  public  men  of  professional  or  scientific 
eminence,  whose  actions  and  attainments  were  "  writ 
large  upon  the  pages  of  history  '"  are  seldom  obtainable. 
In  the  words  of  Wilder,  this  is  '•  both  illogical  and  un- 
profitable.'' .  .  .  "'It  is  at  once  a  reproach  and  an 
irreparable  loss  to  science  that  the  community  has  not 
yet  been  convinced  that  the  preservation  and  study  of 
ones  brain  is  an  honor  to  be  coveted.  Who  can  set  a 
limit  to  the  result  that  might  have  been  attained  from 
the  examination  of  the  brains  of  soldiers  like  Grant, 
Sherman,  and  Sheridan;  of  preachers  like  Beecher, 
Brooks,  and  Howard  Crosby ;  of  naturalists  like  Agas- 
siz,  Gray,  and  Jefifries  W'j-man ;  of  lawyers  like  Tilden. 
Conkling,  and  Benjamin  Butler.     How  long  must  sci- 

*  Read  before  the  Association  of  Amarican  Aaalomists.  at  Baltimore.  Decem- 
ber, 1900;  and  before  the  Section  on  .\iilhri>po!ogT  and  Psychology,  Kew  York 
Academy  of  Sciences,  Febrttary  15,  1901.  In  riew  oi  a  monographic  study,  the 
publication  of  which  is  contemplated,  the  writer  refrains  Irom  an  enumeration 
of  those  details  essentia]  to  the  latter  and  whose  reproduction  were  unnecetssarilr 
repetitious. 


April  6,  1901] 


STUDY  OF  TWO  BRAINS 


[The  fHn.ADSLPHiA 


681 


ence  wait  for  a  general  sentiment  such  as  is  embodied 
in  the  declaration  of  an  eminent  historian,  that  science 
is  as  welcome  to  his  brain  as  his  old  hat,  and  that  he 
wishes  he  had  ten  of  them."     .     . 

To  this  day  only  a  few  brains  of  eminent  men  have 
been  studied  and  described  :  that  of  C  hauncey  Wright,  a 
philosophical  writer;  that  of  George  Grote,  the  well- 
known  historian  of  Greece,  and  those  of  five  or  six  mem- 
bers of  the  French  "Society  Mutuelle  d'Autopsie."  I 
might  add  that  of  a  woman,  Laura  Bridgman,  who, 
though  bereft  of  the  powers  of  language,  sight,  and  hear- 
ing, displayed  an  intelligence  and  education  of  a  remark- 
able degree.  Less  detailed  descriptions  were  made  of 
the  brains  of  the  mathematician  Gauss,  Dr.  Fuchs  and 
a  few  others. 

In  this  view  of  the  subject  the  writer  ventures  to  as- 
sume that  the  presentation  of  the  following  preliminary 
account  may  not  be  uninteresting  when  it  is  learned  that 
it  is  based  on  the  examination  of  the  brains  of  two  emi- 
nent physicians,  which  liave  been  "  saved  for  scientific 
uses  rather  than  wasted  upon  worms."  But  what  is  of 
especial  importance  and  without  precedent  is  that  one 
is  the  descendant  of  the  other,  and  furthermore,  that 
their  ancestors  and  several  relatives  of  the  same  name 
had  been  for  several  generations  physicians,  chemists, 
engineers,  and  architects,  and  that  the  ancestral  history 
is  marked  by  many  meritorious  achievements.  The 
brains  of  which  I  speak  are  those  of  Dr.  Edouard  Seguin, 
and  his  son,  Prof.  Edward  V.  Seguin,  both  of  whom  were 
distinguished  for  high  scholarship  and  lirilliant  attain- 
ments. 

Brief  Biographical  Sketches. 

The  elder  Seguin  was  born  at  Clamecy,  Department 
of  Nievre,  in  France,  on  January  20,  1812.    As  I  alluded 


Dr.  Edouard  Seguin. 

to  above,  his  ancestors  for  several  generations  were  emi- 
nent as  physicians,  architects,  etc.,  ranking  at  the  head 
of  their  professions  in  the  department.  Dr.  Edouard 
Seguin    received   a  very    thorough    education    at   the 


college  of  Auxerre,  and  at  that  of  St.  Louis,  in  Paris. 
He  then  couniieuced  the  study  of  medicine  with  the 
celebrated  Itard  as  iireceptor,  ar\d  was  subfequently 
associated  witli  Esnuirol.  the  distinguished  alienist  and 


Dr.  Edward  Constant  .Seguiu. 

psychologist,  in  his  investigations.  Tlie  study  of  what 
is  now  known  as  arrested  mental  development  began  with 
Sequin's  devotion  of  his  young  life  and  talents  to  the 
welfare  of  the  idiot  children  at  the  Hospice  de  Bicetre, 
and  for  over  40  years  he  remained  devoted  to  the  cause 
he  had  made  his  own.  The  works  he  published  have 
been  recognized  as  authorities  to  the  present  time.  In 
this  country  he  was  the  pioneer  in  advocating  the  intro- 
duction of  "the  metric  system,  and  lie  is  ecjually  noted 
for  his  contributions  to  the  subject  of  medical  ther- 
mometry. His  son,  Dr.  Edward  C.  Seguin,  departed 
this  life'so  recently  that  it  and  his  work  are  yet  a  fresh 
reminiscence.  With  the  favoring  ancestry  already 
alluded  to,  it  is  not  surprising  that  the  younger  Seguin 
should  attain  his  prominent  position.  Born  in  1843  in 
Paris,  and  coming  to  the  United  States  with  his  father 
in  1850,  he  received  a  pubhc  and  high-school  education 
in  Cleveland,  Ohio.  In  18G1  he  began  the  study  of 
medicine  with  his  father  and  after  a  3  years'  course  at 
the  New  York  College  of  Physicians  and  Surgeons- 
showing  his  brilliant  (jualities  even  as  a  student — he 
graduated  in  1864,  being  then  only  21  years  of  age,  and 
after  having  at  that  early  age  served  as  a  medical  cadet 
in  the  regular  army.  Among  other  appointments  which 
he  received,  was  "that  of  house-pliysician  at  the  New- 
York  Hospital.  He  developed  a  pulmonary  trouble 
which  was  recovered  from  during  a  sojourn  at  Forts 
•Craig  and  Selden,  in  New  Mexico.  Froin  1871  to  1885 
he  was  lecturer  at  the  College  of  Physicians  and  Sur- 
geons on  diseases  of  the  nervous  system  and  insanity. 
In  1873  he  founded  the  clinic  for  "nervous  diseases  in 
that  college.  He  was  a  member  of  many  societies  in 
both  hemispheres,  and  his  contributions  to  the  pathology 
and   therapeutics   of  nervous   disorders   are   especially 


682 


The  Philadelphia"! 
Medical  Jodrnal  J 


STUDY  OF  TWO  BRAINS 


[April  6,  1901 


valuable  and  rendered  his  position  in  the  literature  of 
the  medical  world  a  very  prominent  one.  He  will 
always  l^e  distinguislied  as  one  of  the  pioneers  of  Ameri- 
•can  neurology.  An  indefatigable  worker,  his  labors 
were  all  characterized  l)y  a  methodicity  which  has  be- 
come tradional  among  his  friends  and  pupils.  He  died 
on  February  19,  1898. 

Brain  of  Dr.  Edouard  Seguin. 

The  elder  Seguin's  brain  was  removed  within  24  hours 
after  death  by  Dr.  E.  C.  Spitzka,  assisted  by  Dr.  R.  W. 
Amidon,  on  October  29,  1880.  Its  appearance  and 
texture  were  normal,  but  there  appeared  to  be  a  trifle 
less  cerebrospinal  fluid  than  usual.  The  brain-weight 
was  recorded  as  2  pounds,  1 2  ounces,  51-  drams,  equiva- 
lent to  44.344  ounces  or  1,257  grams."  At  the  present 
time,  after  over  20  years'  immersion  in  alcohol,  this 
weight  is  reduced  to  880  grams,  the  lo.ss  amounting  to 
377  grams,  or  30%  of  the  original  weight. 

The  weights  of  the  different  parts  of  the  brain*  on  De- 
cember 3,  1900,  were  as  follows  : 

Left  hemicerebrum  365  grains. 

Right  hemicerebrum  367  grams. 

('erebeHuni 84      " 

Isthmus    64:      " 

Total, 880  grams. 

According  to  Marshall's  tables  the  average  brain- 
weight  for  a  man  of  the  height  of  6.5  inches  or  under,  and 
between  the  ages  of  40  and  70,  is  45.74  ounces  (=  1,296 
grams).  It  must  not  be  forgotten,  however,  that 'the 
brain- weights  of  the  French  are  somewhat  less  than 
those  of  the  English  which  Marshall's  figures  represent ; 
and  if  we  remember  that  Dr.  Edouard  Seguin  was  about 
64_  inches  in  height  and  was  in  poor  health  for  some  time 
prior  to  h is _  decease,  his  brain- weight  of  1,257  grams 
cannot  be  said  to  deviate  much  from  the  normal  figures, 
and,  if  anything,  would  point  to  the  occurrence  of"some 
■wasting  of  the  brain- tissue  from  disease,  or  age,  or  both. 
Various  estimates  of  Dr.  Seguin's  body  weight  range  be- 
tween 125  and  145  pounds,  giving  ratios,  as  compared 
with  tlie  brain- weight,  ranging  between  1  :  45  and  1  :  52. 
The  latter  ratio  was  also  found  in  the  case  of  George 
Orote  by  Marshall,  and  was  ])robably  due  to  the  same 
or  similar  causes. 

In  the  following  list  of  brain- weights  of  eminent  men 
compiled  liy  the  writer  from  various  sources,  Dr.  Edou- 
ard Seguin's  position  is  rather  a  low'one,  but  the  idea  that 
intellectuality  always  presupposes  a  heavv  brain  has  long 
ago  been  demonstrated  as  groundless.  Still,  such  a  tal)le 
has  its  value  in  showing  that  the  maximum  frequency 
of  brain-weights  of  eminent  men  occupies  a  distinctly 
superior  position  as  conqiared  with  those  of  ordinary 
individuals,  and  that  the  significance  of  brain- weight  a"s 
an  index  of  intellectual  ca])acity  must  depend  upon  the 
proper  collation  of  a  sufficiently  large  number  of  cases, 
4ind  the  correlation  of  contributory  and  complicating 
factors.  '  '^ 

Brain-\\'i.:ights  of  Eminent  Men. 
[This  table  is  only  ijrovisionally  arranged,  as  a  few  of 
the  figures  have  not  yet  been  verified  by  the  writer.  The 

wftn'M^tlyiH™  °/  ""?  "frebral  segments  was  not  made  strictly  in  accordance 

border  of  tlie  oirtic  tract,  and  the  t.v-nia  tlialami  (rlpa)as  guides  for  a  slnRle 
.^H,^  m"""'  V'TI^ '"•H''^*''<'''  converge  forvvard  to  nfeet  in  front  of  tie 
frlZl^i^  H'o  "-"'lal  cut  through  the  cilllosum  and  la.nina  termlnalis  complete  a 
thrid  T  "'"'^''J'"""'*  "'«  l»o»ncephalon  and  brain-axis  separated  as  nearly 


authorities  for  these  weights  have  been  omitted  here,  but 
will  be  fully  supplied  in  the  final  report.] 


Ivan  Turgenleff  .  .  . 

G.  Cuvier 

E.  II.  Olney 

E.  H.  Knight  .... 
von  Bismarck  .... 
AljfTcrombie    .... 

B.  F.  Butler 

Olney     .... 

W,  M.  Thackeray  .  . 
John  Goodsir      .   ,   . 

F,  B.  W.  V.  Hermann 
.T.  K.  Ribbeck  .... 
K.  Spurzheim  .... 
J-  Y.  Simpson  .... 
P.  G.  Dirichlet    .  .   . 

C.  A.  De  Morny  .  .   . 

D.  Webster 

John  Campbell  .  .  . 
Chauncey  Wright  ,  . 

.Schleich    .  .  , 

Thos.  Chalmers  .  .  . 

E.  C.  Seguin 

von  Helmholtz  .  .  . 
Napoleon  III    .... 

K.  H.  Fuchs 

L.  Agassiz 

De  Morgan 

K.  F.  Gauss 

Babbage    .   .   . 

K.  von  Pfeufer    .  . 

Paul  Broca 

L'>ui8  Asseline  .  .  . 
M.  D.  Skobtleff  .  .  . 
C.  H.  E.  Bischoff  .  . 
J.  A.  H.  Gylden  .  .  . 
Lamarque    .  . 

F.  H.  von  Kobell     .   . 

Dupuytren  .   , 

J.  E.  Oliver 

MelchiorMeyr  .  .  . 
George  Grot«    .... 

J.  Iluber    , 

J.  Assezat  ...... 

BertiUon  .  .  . 

W.  Whewell 

C'judereau    .   . 

n.  T.  von  Schiiiid  .  . 
.1.  G.  .1.  Hermann  .  . 
K.  I-'.  Hermann  .  .  . 
von  Scblagintweit  .  . 
.T.  von  Liebig    .... 

l.udwig  II 

.T.  P.  Fallmerayer  .  . 
J.  H.  Bennett .... 

Seizel 

R.  E.  Grant 

Walt  Whitman  .  .  . 
]:^douard  Seguin  .  .  . 

V.  Lasaulx 

F„  Harless 

I.,  von  Buhl 

J.  F.  L.  Hausmann  . 
I.  von  Dullinger  .  .  . 

F.  J.  Gall 

L6on  Gambetta   .  ,  . 


OOCnPATIOK. 


Pot  t  and  novelist 

Naturalist 

Mechaoician  and  author  . 

Mechanician 

Statesman 

Physician     

General  and  lawyer  .   .   .   , 

College  professor 

Humorist 

Anatomist 

Economist 

(Industr.) 

Phrenologist 

Physician 

Mathematician 

Statesman 

Statesman 

Lord  Chancellor 

Philosopher 

Writer 

Theologian 

Physician 

Physiologist 

Sovereign 

Patholo^t 

Naturalist 

Mathematician 

Mathematician 

Mathematician 

Physician 

Anthropologist 

.Tournaiist 

General 

Physician 

Astronomer 

General 

Poet  and  geologist    .  .  .  . 

Surgeon    

Matuematician 

Poet  and  philosopher  .  .  . 

Historian 

Philosopher 

Journalist 

Anth-opologist 

Philosopher 

Physician , 

Writer 

Philologist       

Archa;jlogist 

Explorer 

Chemist 

Sovereign  (insane)       .  .  . 

Historian 

Physician 

Sculptor    

Anatomist 

Poet 

Physician 

Physician 

Physiologist 

Physiologist 

Mineralogist 

Physiologist 

Phrenologist 

I  Statesman 


62 
S3 
73 
61 
S6 
59 
51 
54 
70 
82 
45 
S< 
67 
55 
73 
65 
52 
6« 
73 
78 
79 
63 
56 
49 


63 

79 

58 

65 

61 

75 

49 

45 

62 

72 

50 

6i 

76 

51 

51 

70 

41 

71 

63 

5(?) 

80 

72  ( 

68 

67 

42 

6< 

77 

71 

70 

44 


2012 

1830 

1816 

1813 

1807 

1786 

1758 

1701 

16.;8 

1629 

1590 

1580 

1559 

1931 

1520 

1520 

1518 

1517 

1517 

1903 

1502 

1502 

1500 

1500 

14»9 

1495 

1494 

1492 

1488 

1488 

1484 

1468 

1457 

1452 

1452 

1449 

1445 

1437 

1416 

1415 

1410 

1409 

1403 

189S 

1389 

1378 

1374 

1870 

1358 

13S3 

1352 

1349 

1349 

1332 

1312 

1290 

12S2 

12  J7 

12S0 

12S8t 

1229 

1226 

1207t 

1198 

1160t 


Concerning  the  general  form  of  the  cerebrum  the 
reader  is  reminded  that  during  its  immersion  in  alcohol 
for  a  score  of  years  there  has  naturally  been  consider- 
able shrinkage  and  flattening.  Giving  due  allowance  to 
this  unavoidable  distortion,  its  striking  features  can  be 
enumerated  as  follows  : 

Marked  development,  with  great  breadth  and  fulness 
of  the  frontal  lobes. 

A  great  width  and  ample  development  of  the  parietal 
and  temporal  lobes, 

Relative  smallness  of  the  cuneus  in  both  halves,  espe- 
cially tlie  left. 

General  tortuosity  of  the  fissures  and  gyres. 

A  full  and  ample  development  of  the  left  insula,  espe- 
cially of  its  cephalic  (anterior)  portion,  the  insular  pole 
being  very  fully  tleveloped.  and  far  better  than  on  the 
riglit  side.     A  portion  of  the  left  preinsula  is  visible. 

The  sylvian  cleft  is  more  horizontally  directed  than  in 
most  brains.  This  approach  to  tlie  horizontal  is  more 
marked  on  the  left  side,  and  is  generally  considered  an 
important  indication  of  superior  development 

t  The  weight  of  these  brains  when  fre^h  will  always  remain  unknown. 


April  g,  1901] 


STUDY  OF  TWO  BRAINS 


TThb  Philadelphia 
L  Medical  Journal 


683 


The  left  parietal  and  paroccipital  fissures  are  sepa- 
rated while  on  the  right  side  they  are  confluent.  This 
arrangement  is  quite  rare,  having  been  found  in  6%  of 
cases  by  Wilder'  and  the  writer.^ 

The  fissures  on  the  whole  are  characterized  by  their 
ienerally  tortuous  paths,  by  their  great  depth,  and  per- 
haps by  a  greater  frequency  in  their  deep  interruptions 
liy  vadums  andinterdigitatingsubgyres.  In  general  the 
iryres  are  neither  of  maximum  nor  minimum  width ; 
their  size  seeming  to  be  determined  by  a  tendency  to 
crowd  the  greatest  number — more  or  less  regularly  and 
evenly — into  the  available  space.  They  are  bold  and 
I  iiassive,  so  that  in  spite  of  the  intricate  fissuration  the 
configurations  of  the  brain  are  neither  "  overcrowded" 
nor  "  cramped  looking."  There  is  that  in  the  "  physiog- 
nomy "  of  the  brain  as  in  the  son's,  which  it  is  impos- 
sible to  describe,  otherwise  than  in  terms  the  very  use  of 
which  would  suggest  the  having  preconceived  notions  nf 
u  relation  between  structure  and  function,  to  say  that 
it  portrays  the  culture,  refinement  and  intellectual  capa- 
city of  its  erstwhile  owner  when  living. 

The  indices  of  the  lobes*  of  the  left  hemicerebrum  are  : 

Frontal  index 60.4 

Parietal  index 22.2 

Occipital  index 17.4 

On  the  right  hemicerebrum  : 

Frontal  index 5S 

Parietal  index  20.6 

Occipital  index  214 

These  figures  indicate  in  a  measure  the  better  devel- 
opment of  the  left  frontal  and  parietal  lobes, 
f-  The  frontal  gyres  are  the  most  complex  of  the  entire 
brain,  being  particularly  rich  in  their  windings,  though 
the  parietal  gyres  are  almost  as  rich  in  their  develop- 
ment.    The  subfrontal  gyrus  (Broca's  convolution)  of 


|i 


Fig:1.— Frontal  portion  of  the  left  hemicerebrum  of  Edouard  Seguin  (father) 
showing  exposed  area  of  the  preinsula,  and  also  the  well-deTeloped  opercula. 


the    lefl    half 
expected,    in 
speech  center. 


is   very    well    developed,  as   might    be 
a   right-handed   individual  with    a   left 


(See  Fig.  1.) 


*  These'iDdices  are  caeasured  along  the  dorsiraeaal  border  of  the  heniicerettrum, 
f^om  pole  to  pole,  and  aie  expressed  in  terms  regarding  the  entire  length  &o 
measured  as  equivalent  to  100. 


Upon  the  left  half  the  "  intraparittal  fissural  com- 
plex "  is  remarkable  in  that  all  four  of  the  so-called 
segments  are  distinctly  separated  from  each  other,  a 
condition  rarely  observed  and  found  by  Cunningham ' 
in  only  four  hemicerebrums  out  of  sixty-xwo  ;  once  on 
the  left,  once  on  the  right,  and  once  on  both  halves. 


Fig  2  —Occipital  portion  01  left  hemiceiebnim  of  Edouard  Seguin  (father) 
showing  the  remarkably  distinct  exoccipital  fissure  (EOP)  :is  well  as  the 
paroccipital  isthmus,  marked  by  the  cross  (Xl-  OC  marks  the  occipital 
fissure.    (Photograph  by  Dr.  E  Learning.) 

Mickle  *  regards  such  bridging  of  the  so  called  "  intra- 
parietal  sulcus"  as  a  mark  of  superiority  in  brain 
evolution.  The  paroccipital  fissure,  which  is  of  the 
true  zygal  type,  is  absolutely  separated  from  the  pari- 
etal fiss\ire  ijy  a  well-developed  "  paroccipital  isthmus." 
(See  Figs.  2  and  3.)  Upon  the  right  half  there  is  a 
confluence  of  the  corresponding  fissures.  This  brain, 
therefore,  presents  an  additional  example  of  a  rare 
arrangement  hitherto  unnoticed  in  the  brains  of  moral 
and  educated  persons,  at  least  so  far  as  the  writer  knows. 
Of  the  six  cases  recorded  by  Wilder' there  were  three 
of  unknown  history,  while  the  remaining  three  whose 
history  was  known,  were  insane,  one  a  Swiss  woman, 
one  an  engineer,  and  one  a  negro.  The  writer'  has 
since  found  a  similar  arrangement  in  six  of  the  one 
hundred  brains  of  dissecting-room  subjects,  derived 
mainly  from  the  pauper  class  dying  in  the  municipal 
hospitals  and  charitable  institutions. 

As  stated  above,  the  occipital  index  on  the  left  half 
is  as  17.4:100,  and  on  the  right  half  as  21.4:100, 
according  to  Cunningham's  method.  1  his  index  aver- 
ages 20.8  for  human  adult  males,  and  21.7  for  females; 
and  it  increases  as  we  descend  to  the  anthropoids  and 
apes.     The  following  are  Cunningham's  figures  : 

Orang    f^ 

Chimpanzee 24.2 

Hamadryas 29.5 

Cynocephalus 29.7 

Mangaby  3'^-5 

Macaque  ^1. 

Cercopithecus ^'--^ 

Cebus 33.1 


684 


Thk  PhiladklphiaI 
Medical  Journal  J 


STUDY  OF  TWO  BRA.INS 


[April  6,  UO 


It  was  recognized  as  being  of  considerable  import- 
ance by  even  so  early  an  observer  as  Gratiolet,  and 
it  would  seem  to  indicate,  other  things  being  equal,  that 
relative  smallness  of  the  cuneus,  measured  in  this 
manner,  signified  superiority.  Its  exemplification  upon 
the  better  developed  left  half  of  both  of  the  Seguins' 
brains  would  seem  to  lend  force  to  this  hypothesis. 

Notable  for  its  extent  and  well-marked  course  is 
the  exoccipital  fissure  on  the  left  side.  (Fig.  2.)  It 
begins  very  near  the  zygon  of  the  paroccipital,  at  its 
caudal  part  and  separated  from  it  by  a  narrow  (3  mm.) 
"  deuxieme  pli  de  passage."  Morphologically  speaking, 
therefore,  the  fissure  falls  into  the  first  class  of 
Wernicke's  descriptions,^  a  condition  occurring  nor- 
mally in  some  apes.  As  the  fissure  passes  ventrad  a 
notalDle  fact  is  the  nature  of  the  slope  of  its  walls, 
which,  as  in  the  right  half,  incline  distinctly  caudo- 
mesad.  It  resembles  a  cleft  rather  than  an  ordinary 
fissure,  and  in  its 
depths  can  be  seen 
several  interdigitat- 
ing  subgyres.  As  the 
fissure  approaches 
the  ventro  -  lateral 
border  it  takes  an 
abrupt  caudal  direc- 
tion and  terminates 
just  at  the  border. 
Around  this  end 
curves  a  narrow 
"  quatrieme  pli  de 
passage."  The  "  troi- 
sieme  pli "  may  be 
any  one  of  the  sev- 
eral interdigitating 
subgyres  alluded  to 
above. 

Upon  the  right 
half  the  '•  troisieme 
])li  "  instead  of  being 
totally  submerged, 
approaches  to  within 
7  mm.  of  the  surface 
and  is  capped  by  the 
lip  of  the  poma  (oc- 
cipital operculum), 
so  that  it  may  proper^ 


removed  about  30  hours  after  death,  also  by  Dr.  E.  C 
Spitzka,  my  father,  and  to  him  I  am  indebted  for  tli« 
opportunity  of  studying  and  describing  both  of  theB<' 
valuable  brains,  unprecedented  in  so  far  as  I  can  fine 
no  other  instance  where  the  brains  of  father  and  soi 
were  available  (both  being  of  marked  characteristics) 
and  the  nearest  approach  being  the  case  of  the  brother 
Leidy,  of  Philadelphia,  undescribed  as  yet — and  a 
present  in  the  collection  of  the  Anthropometric  Sociel; 
of  that  city. 

The  appearance  and  texture  of  the  younger  Segiiin^ 
brain  were  normal.  After  dissection  draining  the  toti 
weight  was  1,502  grams,  or  52.98  ounces.     The  parted 


the  brain  while  still  fresh  weighed  as  follows  : 

Right  hemicerebrum 642  grams. 

Left  "  6,53 

Cerebellum 140 

Isthmus  67 


1 


Total  1,502  grams. 

The  brain  wa 
again  weighed  oi 
December  3,  190( 
after  nearly  3  yean 
immersion  in  for 
maldehvde  solution 


Right  hemi- 
cerebrum 

Left  hemi- 
cerebrum 

Cerebellum 


555grmf 

563 
109 


Isthmus 57 


Fio.  3.— View  of  the  occipital  regions  of  both  hemicerebrums  of  Dr.  Edouard  Seguin  (father).  On 
the  left  a  dijliiict  paroccipital  isthmus  (PAROC.  ISM.)  sfparates  the  parietal  from  the  parocci- 
pital ;  on  the  right  these  tissures  are  conHiieut  over  a  vadum  at  a  depth  of  11  millimeters. 


y  be  termed  a  subgyre.  The  ex- 
occipital  fissure  consists,  therefore,  of  two  segments,  a 
superior  (EOP')  and  an  inferior  (KOP"),  superficially 
confluent  with  each  other. 

In  both  hemicerebrums  the  occipital  lobe  exhibits  a 
distinct  tendency  to  overlap  the  ]iarietal  gyres  ;  the  walls 
of  the  exoccipital  fissure  slope  distinctly  mesocaudad, 
suggesting  the  pomatic  homology  and  derivation  of  the 
occipital  lobe. 

The  insula  on  the  left  side  is  lar  better  developoil  than 
its  fellow  on  the  right  half,  corroborating  the  statement 
made  by  Waldsclunidt,"  that  in  educated  men  the 
left  insula  is  "incomparably  richer"  in  its  development 
than  the  right.  Upon  close  insjiection,  and  by  means  of 
soundings  made  in  the  sylvian  cleft,  this  redundancy  is 
found  to  be  most  marked  in  the  preinsular  region. 

Br.\in  of  Dr.  Ei)W.\rd  C.  Seguin. 

The  autopsy  upon  the  younger  Seguin  took  place  on 
February  21,  1898,  and  was  made  by  Dr.  J.  S.  Thacher, 
assisted  by  Drs.  J.  Arthur  Booth  and  E.  C.  Sjiitzka. 
Drs.  Hallock  and  Pooley  were  present.     The  brain  was 


Total 1,284  grmi 

The  loss  in  weigh 
amounted  to  21 
grams,  or  13%  c 
the  original   weight 

This  brain-weigh 
(53  ounces  in  roun^ 
numbers)  is  about 
ounces,  or  about  12 
grams  above  th 
average  for  one  c 
Dr.  E.  C.  Seguin' 
in  the  list  of  brain 


age  and  height,  and  his  position 

weights  of  eminent  men  is  comparatively  high 

Owing  to  the  excellent  preservative  qualities  of  foi 
maldehvde,  this  brain  is  only  slightly  flattened,  and  th 
shrinkage  amounts  to  very  little.  As  in  the  father 
brain  there  is  a  slight  but  untiuestionable  exposure  t 
the  left  preinsula.  The  left  sylvian  fissure  more  neail 
approaches  the  horizontal,  and  there  is  a  similar  ampl 
development  of  the  frontal  lobes  characteristic  of  th 
father's  brain.  The  indices  of  the  lobes  are : 
Left  he.micer'hrum : 

Frontal  index 61 

Parietal  index 23.6 

Occipital  inde.x 15.3 

Right  hemirfrehnim  : 

Frontal  index 57.2 

Pariet^d  index 26  S 

Occipital  index ItVS 

The  relatively  small  index  of  the  occipital  lobe  i 
particularly  noteworthy  in  both  halves  of  this  brain. 

The  letl  separation  and  right  continuity  of  "ft 
parietal-paroccipital  fissures  s}x>ken  of  in  the  father 
brain  are  in   the  son's  brain  reversed  as  to  sides.     & 


.  .PBIL  6,  1901] 


STUDY  OF  TWO  BRAIKS 


CThk  Philadelphia 
MsDiCAL  Journal 


685 


he  right  side  a  well-marked  isthmus  separates  the  fis- 
lures,  on  the  left  they  are  confluent  over  a  vadum. 

On  the  right  half  the   exoccipital  fissural  complex 

ices  not  differ  very  much  in  its  appearances  from  the 

eft  half  of  the  father's  brain,  except  that  the  "  troisieme 

:  jli  "  is  flush   with   the  cerebral  surface  and  not  sub- 

nerged. 

The  left  insula  as  in  the  father's  is  far  better  developed 
than  the  right,  and  the  preinsular  portion  is  so  redun- 
dant that  the  surrounding  opercular  parts  have  been 
crowded  apart  and  a  small  triangular  jiortion  of  the 
insular  pole  is  thus  made  visible  upon  the  lateral  aspect. 

If  one  be  permitted  to  indulge  in  such  an  expression 
I  would  say  that  the  physiognomy  of  each  of  these  Ijrains 
reproduces  that  of  the  other,  much  as  the  outer  phy- 
siognomy of  their  bearers  did  in  life.  By  the  nieta- 
phoric  term  "  physiognomy  "  used  in  this  connection,  I 
mean  the  general  feature  of  the  arrangement,  relations 
and  molding  of  the  convolutions,  difficult  to  describe  in 
so  many  words  and  renderable  only  through  photo- 
graphic or  other  reproduction,  and  even  through  these 
imperfectly.  Every  brain  I  have  yet  examined  had  its 
•distinct  features,  as  much  distinct  as  the  outer  ones  of 
its  owner.  One  ma}^  distinguish  brains  resembling 
•each  other  as  a  group,  and  as  distinguishable  from  other 
.groups  as  are  different  families  and  races  of  men.  No 
imore  striking  instance  of  a  prevailing  typical  difference 
•can  be  adduced  than  that  of  the  Mongolian  brains 
recently  studied  by  Dercum  and  others.  It  were  futile 
to  attempt  basing  a  discrimination  on  any  single  factor, 
it  is  the  general  physiognomy  that  seems  to  be  so 
peculiar  to  the  race,  but  by  this  I  do  not  mean  that 
.given  a  certain  brain  an  investigator  could  declare  it  to 
belong  to  such  and  such  a  race  or  sex.  We  are  not 
•ulvanced  far  enough  for  that  yet,  if  we  ever  attain  such 
;i  point ;  and  how  mistaken  we  may  be  in  regard  to  the 
•outer  features  I  need  not  remind  the  reader.  We  are 
much  like  the  traveler  who  merely  touching  the 
shores  of  a  new  land  is  struck  by  the,  to  him,  strangely 
and  strikingly  uniform  character  of  a  new  race — yet 
whose  individuals  are  as  distinguishable  to  their  fellow- 
tribesmen  as  that  traveler's  companions  are  to  him. 

Perhaps  the  most  significant  feature  common  to  both 
Ibrains  is  the  exposure  of  the  insula,  and  although  this 
feature  formed  the  theme  of  a  special  paper'  a  brief 
•Bummary  thereof  may  not  be  out  of  place  here. 

Heretofore  it  was  only  in  the  brains  of  deaf-mutes,  of 
negroes,  of  idiots,  and  of  the  defective  classes  generally, 
where  the  opercula  are  commonly  atrophied,  that  the 
insula  has  been  found  visible.  It  was  therefore  regarded 
as  an  indication  of  inferior  development.  The  brains  of 
the  Seguins,  however,  present  the  very  reverse  of  low 
form  or  defective  type.  Nor  are  the  opercular  regions 
at  all  defective,  though  they  fail  to  come  into  typical  ap- 
position. The  explanation  of  this  anomaly  is  that  the 
left  preinsula  is  far  better  developed  than  its  fellow  on  the 
right  side,  corroborating  the  findings  of  ^^'aldschmidt 
(in  1887)  upon  the  brains  of  two  professors  of  the  Uni- 
versity of  Freiburg.  But  in  the  Seguin  brains  this  re- 
dundancy of  development  upon  the  left  side  is  so  pro- 
nounced, that  the  insula  in  a  gj^asi- struggle  to  reach  the 
general  cerebral  surface,  has  virtually  thrust  apart  the 
•opercula  and  made  itself  visible. 

The  interpretation  of  this  exposure  as  due  to  the  rela- 
tive hypertrophy  of  the  insula  is  sustained  by  the  results 
of  "  soundings  "  taken  at  various  points,  and  given  in 
millimeters  in  the  following  table. 

The  terms  pre-,  medi-,  and  post-insular  depth  refer  to 


the  three  points  at  which  the  Sylvian  cleft  was  soimded, 
the  preinsular  point  being  the  junction  of  the  Sylvian 
with  its  presylvian  ramus,  the  medi-insular  point  being 
at  the  middle  of  the  course  of  the  Sylvian,  the  postinsu- 
lar  being  at  the  junction  of  the  Sylvian  cleft  with  its 
episylvian  ramus. 

Depths  of  the  Sylvi.\n  Fissure  in  the  Four  Hemi- 

CEREBRUMS    OF   THE    TwO   SegUINS. 

Edodard  Seguin  (Father). 

Left.  Right. 

Pre-insular  depth 11  mm.  18  mm. 

Medi-insular     "     11     "  22     " 

Post-insular     " 24    "  22    " 

Edward  C.  Seguin  (Son). 

Left.  Right. 

Pre-insular  depth 7  mm.  15  mm. 

Medi-insular     "     20     "  23     " 

Post-insular     "    25    "  25    " 

The  conclusions  naturally  to  be  drawn  from  the  above 
are  that  the  causes  potential  in  insular  exposure  must 
be  discriminated  or  classified  as  follows  : 

Class  1. — In  the  highly  intellectual  (for  example,  the 
two  Seguins),  owing  to  the  excessive  growth  and  devel- 
opment of  the  left  preinsula,  causing  a  displacement  of 
the  opercula,  thrusting  them  apart,  as  it  were,  and  even 
though  the  latter  be  very  well  developed. 

Class  2. — In  the  defective,  exposure  of  the  preinsula 
is  due  to  deficient  development  of  the  opercula  and  be- 
cause these  fail  to  approach  each  other.  In  such  cases 
the  insula  itself  is,  without  a  single  exception  in  the 
series  that  I  have  studied,  of  inferior  development,  indi- 
cated not  only  by  the  soundings  of  the  Sylvian  cleft,  but 
also  by  the  flatness  of  configuration  and  lesser  area  of 
the  insular  cortex. 

In  the  paper  referred  to,  the  writer  said  :  "  Among  the 
reflections  which  occur  in  the  course  of  such  a  study,  is 
the  possibility  of  some  paternal  influence  exerted  on  the 
brain  of  the  oft"spring  under  circumstances  such  as  the 
following  :  Dr.  Edouard  Seguin  (the  father)  was  most 
actively  engaged  in  the  teaching  of  the  idiot  children  at 
the  Hospice  de  Bicetre,  wrote  many  treatises,  and  deliv- 
ered many  lectures  upon  the  subject  in  the  six  years 
prior  to  the  younger  Seguin's  birth.  If  physiological 
tendencies  are  transmitted  from  father  to  son,  and  if 
such  transmission  of  function  finds  structural  expression, 
one  would  expect  it  to  be  demonstrated  where  the  cir- 
cumstances are  so  favorable  as  here.  Of  course,  all  such 
statements  are  made  tentatively ;  yet  what  would  be  a 
more  natural  conception  when  we  view  the  circum- 
stances, the  visible  evidences  in  the  two  brains,  and  the 
corroborative  soundings  of  the  S3'lvian  fissure  of  both 
sides.  Both  men  were  of  high  intellectual  capacity ; 
both  were  facile  writers  and  speakers — if  anything  the 
son  excelled  the  father ;  and  both  were  polylinguists, 
speaking  and  writing  three  languages  fluently.  The 
teaching  capacities  of  both  men  were  remarkable,  in  the 
one  case  being  especially  devoted  to  the  patient  efforts 
required  in  the  training  of  the  feeble-minded,  in  the 
olher  developed  in  the  highest  degree  in  didactic  lectur- 
ing and  clinical  teaching." 

This  unexpected  exposure  of  the  insula  has  been 
noted  on  both  sides  in  the  brain  of  Chauncey  Wright,  now 
in  the  care  of  Prof.  Burt  G.  Wilder.  In  his  Handbook 
article,'  written  in  1889,  Wilder  called  attention  to  the 
fiict  that  possibly  pressure  may  have  caused  sufficient 
displacement  to  artificially  expose  the  insula.  In  a  letter 
to  me  (March  12, 1901)  in  response  to  a  communication 


686 


The  PHIIiiDELPHIA"] 


STUDY  OF  TWO  BRAINS 


lApBtL  6,  UO] 


in  which  I  suggested  the  explanation  here  advanced, 
Dr.  Wilder  states  that  probably  the  exposure  of  Wright's 
insula  was  also  natural.  This  investigator  proposes  to 
review  the  matter  as  soon  as  he  returns  to  Ithaca. 

There  are  a  number  of  facts  which,  naturally  group- 
ing themselves  together,  justify  as  a  strong  surmise, 
if  not  a  scientific  probability,  this  anticipation :  that 
hereditarily  transmitted  and  identifiable  individualities 
in  gyral  disposition  will  be  first  satisfactorily  determined 
in  the  region  of  the  insula.  To  attempt  sustaining  this 
proposition  by  the  experience  of  the  single  case  here 
presented  were  absurd  ;  it  simply  points  in  the  direc- 
tion of  the  following  logical  chain — partly  of  obtained 
facts,  partly  of  natural  conclusions  from  these. 

In  a  study  made  of  heredity,  whose  results  were 
placed  at  my  disposal,  covering  the  parentage  and 
descent  of  indi^'iduals  prominent  in  various  fields  of 


The  speech  faculty  in  its  intimate  relations  to  thought- 
expression,  to  memory — in  its  reading-form  to  sight,  in 
writing  to  manual  muscular  innervation,  exquisitely 
hereditar}'  as  it  is  in  life,  and  most  accurately  localizable 
in  the  ravages  of  disease,  as  shown  after  death,  appeals 
one  whose  transmission  is  most  likely  to  be  expressed 
by  morphological  signs — be  they  relative  and  quantita- 
tive or  purely  morphological — and  these  in  and  abont 
the  Island  of  Reil. 

I  have  said  that  there  exists  a  resemblance  between 
the  "  physiognomies  " — if  I  may  use  that  term — it 
these  brains.  But  if  the  various  features  of  these  spe^^ 
mens  be  separately  analyzed  and  compared  this  reseiBr 
blance  becomes  a  striking  one.  The  view  that  a  coinci- 
dence of  features  in  the  brains  of  parent  and  child  i- 
due  to  an  actual  transmission,  as  that  term  is  now  under- 
stood, gains  in  plausibility  in  proportion  as  such  feature^ 


Fig.  4. — Lateral  view  of  the  left  hemicerebrum  of  Dr.  Edward  C.  Seguln  (son).  Aside  from  the  redundant  derelopmeDt  of  the  operculum,  andjthe 
nearly  horizontal  course  of  the  Sylriau  tissure,  the  most  striking  feature  is  the  risibility  of  the  preinsula,  wbo^  summit  approaches  within 
7  mm.  of  the  cerebral  surface.    X  .83  natural  size.    From  a  drawing  by  the  author. 


science,  politics,  art,  and  handicraft,  it  is  found  that  the 
cases  where  both  father  and  son  attained  distinction 
sufficiently  to  merit  place  (in  the  biographical  encyclo- 
pedias), in  intellectual  fields  of  labor,  they  had  been 
of  those  in  which  skilled  motor  innervations  in  their 
association  with  sensory  impressions  and  registrations 
are  prerequisites.  Preeminently  is  this  the  case  with 
two  professions;  that  of  the  composer-musician  and 
that  of  the  philologist.  As  defects  in  speech  are  so 
likely  to  be  repeated  in  a  family  lino,  it  seems  tliat  its 
skilled  employment  by  the  ancestor  is  similarly  refiected 
in  the  way  of  focile  ac(juirability  on  the  part  of  the 
descendant.  Not  unrelated  may  be  the  fact  that  among 
those  recruited  for  the  ranks  of  linguists  of  other  than 
philologist  parentage,  there  largely  predominate  those 
whose  parents  had  emigrated  or  who  were  born  on 
islands,  in  seaport  towns  or  in  lands  where  two  dialects 
are  spoken,  not  to  mention  those  in  whose  families  it 
has  been  the  custom  to  maintain  an  ancient  tongue  for 
sacerdotal  reasons. 


are  marked  or  exceptional,  and  most  so.  as  in  the  brain.- 
before  us,  where  they  approach  the  atypical. 

The  tenii  atypical  as  here  used  is  so  in  a  morphologi- 
cal sense  only,  and  not  as  equivalent  to  the  sense  of 
aberrant  atypy — heterotypy — found  in  grossly  asym- 
metrical and  jiathological  brains.  Just  as  it  is  the 
simplest  brains  that  are  more  symmetrical  than  the 
higher  ones,  so  the  simjilest  arrangement  of  gyres  is 
also  the  one  which  is  most  purely  and  symmetrioidly 
typical.  With  higher  development,  a  certain  degree  of 
deviation  from  the  type  seems  an  insepamble  accom- 
paniment of  the  luxuriant  development,  contorted  fold- 
ings, and  deep  as  well  as  conipUcated  fissuration,  which 
represent  a  struggle  for  surface  and  expansion,  in 
which  the  interests  of  neighboring  formations  oftai 
balance  unevenly.  This  irregularity  is  regular  even  in 
its  irregularity,  however ;  of  the  surfoce  only  and  in 
this  respect  i>arallel  to  those  perhaps  not  unrelated 
manifestations  of  the  living  organ  of  the  mind,  which 
in  the  shape  of  originality  or  ingenuity  are  ofl(?n  mis- 


April  6,  1901J 


STUDY  OF  TWO  BRAINS 


[■ 


The   PUILADBLPHIA 

Medical  Journal 


687 


apprehended  and  interpreted  as  evidence  of  unbalanc- 
ing and  eccentricity.  It  is  because  the  simple  mind  has 
not  breadth  enough  that  it  neither  indulges  in  excur- 
sions into  a  field  of  original  thought,  nor  understands 
such  when  hidulged  in  by  others.  So  it  is  because  there 
is  little  rivalry  of  growth  interests  in  an  unexpansive 
organ  that  its  simple  gyres  repose  in  the  rough  and  com- 
prehensible simplicity  of  the  Bechuana  folds. 

"To  certain  miuds  fate  narrow  bounds  has  set, 
In  vain  they  try  beyond  those  bounds  to  get." 

In  reality  all  these  qualities  are  but  expressions  of  a 
strong  individuality ;  and  individuality  is  not  conceiv- 
able otherwise  than  as  an  expansion  beyond  the  aver- 
age mediocrity, — expansion  in  the  direction  of  deviation 
from  that  of  the  common  rut. 

In  the  case  of  the  two  Seguin  brains  it  is  safe  to  say 
that  if  they  had  been  scattered  among  a  hundred  other 
brains,  and  these  had  been  grouped  according  to  the 
type  of  gyral  disposition,  they  would  have  come  to- 
gether as  the  classification  became  finer  and  finer  until 
ultimately  they  probably  would  have  constituted  a 
group  by  themselves. 

The  asymmetry  of  the  halves  of  highly-developed 
brains  must  therefore  form  the  basis  for  demonstrating 
hereditary  transmission  in  the  brains  of  jiarent  and 
child  before  us ;  and  it  is  for  such  unilateral  features 
that  we  must  search.  They  are  present  in  sufficient 
number  to  establish  the  jiroposition,  and  while  I  am 
prepared  to  enumerate  these  at  length,  their  presenta- 
tion and  discussion  would  require  more  space  than  it  is 
my  privilege  to  occupy.  Briefly  stated,  the  most  im- 
portant of  these  features  common  to  both  brains  are : 
The  left  insula  exhibits  an  incomparably  richer  devel- 
opment than  the  right. 

The  left  occipital  index  is  smaller  than  the  right. 
The  left  frontal  index  is  larger  than  the  right. 
The  left  subfrontal  gyrus  is  larger  than  the  right. 
On  both  right  operculums  there  is  a  single  isolated 
fissure  embraced  by  the  limbs  of  the  presylvian  fissui-e. 
The  left  medifrontal  fissure  is  in  two  segments  (in  one 
case  separated  by  a  superficial  isthmus,  in  the  other  by 
a   slight  vadum  of  4  mm.).     Furthermore,   the  medi- 
frontal is  poorly  represented  on  the  right  sides. 

The  left  cephalic  limb  of  the  paracentral  fissure  is 
short ;  long  on  the  right. 

The  left  episylvian  fissure,  and  also  the  hyposylvian 
are  longer  than  on  the  right  half. 

The  left  fronto-marginal  fissural  segments  are  easily 
traced  ;  they  are  absent  on  the  right  sides. 

The  left  olfactory  fissure  is  shorter  than  the  right. 
The  left  Sylvian  fissure  more  nearly  a]iproaches  the 
horizontal  than  does  the  right. 

The  existence  of  these  and  other  facts  give  strong 
evidence  of  direct  hereditary  transmisdon.  In  addition, 
however,  there  are  other  interesting  points  of  resem- 
blance in  attributing  which  to  such  transmission,  one 
strange  apparent  difficulty  is  encountered,  namely : 
their  reversed  position  as  to  sides.  This  "  crossed 
heredity,"  or  the  reproduction  of  unilateral  asymmet- 
rical peculiarities  of  one  side  in  the  father "s  brain  upon 
the  opposite  side  in  the  son's,  would  constitute  an  inter- 
esting chapter  in  itself  An  enumeration  of  the  facts  in 
support  of  this  mode  of  crossed  hereditary  traTismission 
can  only  be  briefly  made  here. 

Father's  Brain.  Son's  Brain. 

I.  Left  parietal  f.  and  par-  Left  parietal  f  and  paroc- 

occipital   f.   separated ;  con-  cipital   f.   continuous ;   sepa- 

tinuous  on  right.  rated  on  right. 


II.  Postcalcarine  f.  bifur- 
cated on  right  only. 

III.  Right  occipitocal  ca- 
rine  angle=70° ;  left  60° 
(circa). 

IV.  Father's  right  "  exoc- 
cipital  complex  "  almost 
identical  with  .»on's  left. 

V.  Left  {)arietal  f  joins 
supertemporal  f.  and  inter- 
medial f 

VI.  Mode  of  junction  of 
right  medifrontal  (.  with' 
orbitofrontal  f  exactly  as  in 
son's  left. 

VII.  Father's  right  half 
heavier. 


Postcalcarine  f.  bifurcated 

on  left  only. 

Eight  occipitocalc  a  r  i  n  e 
angle=60° ;  left=70°  (circa). 

Son's  left  "exoccipital 
complex  "  almost  identical 
with  father's  right. 

Right  parietal  f  joins 
supertemporal  f.  and  inter- 
medial f 

Mode  of  junction  of  left 
medifrontal  f  with  orbito- 
frontal f.  exactly  as  in  father's 
right. 

Son's  left  half  heavier. 


The  last  item  is  one  to  which  I  am  not  prepared  to 
attach  too  much  importance,  for  observations  upon 
the  weight  of  the  halves  of  a  dissected  brain  come 
within  the  range  of  error  usually  ascribed  to  the  "  per- 
sonal e<|uation." 

The  history  of  inheritable  peculiarities,  such  as  sex, 
polydactylism,  abnormalities  of  the  external  ear,  and 
the  like,  show  that  the  problematical  mechanism  of 
their  transmission  acts  without  regard  to  any  other  plan, 
in  this  respect,  than  that  of  "  symmetry  in  asym- 
metry :"  namely,  it  impresses  the  same  or  similar  varia- 
tion from  the  typical,  if  not  on  both  sides,  on  either 
side  alone,  and  indifl'erently  as  to  correspondence  with 
the  one  parentally  involved. 

Any  declaratory  explanation  for  the  contralateral 
situation  of  the  same  or  similar  atyp}^  in  the  brains  of 
parent  and  child  must  rest  on  conjecture.  The  influ- 
ences at  work  in  molding  organic  forms  are  profoundly 
mysterious ;  particularly  is  this  the  case  where  sym- 
metrical relations  are  in  question.  I  need  but  refer  to 
the  possible  relations  of  this  fact  to  the  more  familiar 
ones  just  referred  to,  such  as  onesided  peculiarities  of 
the  pinna,  the  digits,  or  the  orbits;  and  that  these  influ- 
ences act  contralaterally  as  well  as  unilaterally,  and  as 
harmoniously  in  their  inversion  as  in  those  rare  cases 
of  complete  transposition  of  the  viscera.  Let  me  in- 
stance an  authentic  case  of  maternal  impression  reported 
by  Dr.  W.  L.  Swift  (New  York  Medical  Journnl,  October 
9,  1886,  p.  407),  where  the  birthmark  not  only  repeated 
the  original  one-sided  maternal  impression,  but  was 
also  duplicated,  both  sides  of  the  body  showing  it.  .  .  . 
Brown- Sequard  demonstrated  the  hereditary  transmis- 
sions of  lesions  in  the  nervous  system  of  guineapigs,  the 
change  in  the  descendants  often  being  bilateral  where 
they  had  been  unilateral  in  the  anunals  experimented 
upon.  (Oompies  rendits,  vol.  xciv,  627).  The  defor- 
mities of"  hammer-toe  "  and  "  syndactylism  "  may  Uke- 
wise  exhibit  unilateral,  bilateral  or  even  contralateral 
transmission.  Lastly,  I  would  allude  to  the  mirror  like 
reproductions  of  physiological  ami  pathological  phenom- 
ena on  opposite  sides  in  certain  forms  of  hysteria. 

If  such  modes  of  transmission  be  wonderful  and 
mysterious  how  much  more  so  is  that  of  the  hereditary 
influences  of  which  we  speak.  'When  we  remember  that 
we  are  dealing  here  with  the  one  organ  of  the  body  that 
is  so  variable  that  no  two  individuals  possess  it  exactly 
alike,  so  far  as  external  appearances  are  concerned,  the 
importance  of  determining  as  nearly  as  possible  the  in- 
fluences of  heredity  will  be  undei-stood  readily  enough. 
More  material  of  this  kind,  and  extended  observations 
upon  this  line  are  necessary  before  we  can  arrive  at  any 
satisfactory  conception  of  the  external  appearances  of 
this  most  important  organ.     Anatomists  and  scientists 


688 


Teb  Philadelphia") 
Medical  Jocrsal  J 


SANTIAGO  AS  A  YELLOW  FEVER  CENTER 


[April  6,  1901 


in  general  cannot  urge  too  strongly  upon  their  fellow- 
men  and  women  the  importance  of  be(jueathing  their 
brains  to  the  uses  of  a  science  which  might  well  regard 
such  bequests,  if  not  as  invaluable  as  the  legated  brains 
once  had  been  to  their  original  owners,  of  the  very 
highest  one,  such  being  indispensable  to  progress  in 
psychological  phj'siology. 

For  valuable  aid  and  information  cheerfully  given  while 
pursuing  this  study,  the  writer  wishes  to  express  his  sincere 
thanks  to  Mrs.  E.  il.  Seguin,  and  to  Drs.  J.  Arthur  Booth,  E. 
Learning,  and  Professor  B.  G.  Wilder. 

Abbbeviatioss. 

Fin-iureg. 

ANT.  PEC "  Anterior  precentral." 

C Central. 

DG Diagonal. 

EOP  Exoceipital. 

EPS  Episvlvian. 

MFE Medifrontal. 

OC Occipital. 

OLF Olfactory-. 

PAKOC Paroccipital. 

PAEOC.  VDM  Paroccipital  vaduni. 

PEC Precentral. 

PES  Presylvian. 

EDT Eadiate. 

S Svlvian. 

SBFE    Siibfrontal. 

SPC   Supercentral. 

SPFE    Superfrontal. 

SPTMP Supertemporal. 

TPEC   Transprecentral. 

TEPC  Transpostcentral. 

MFR.  G    Medifrontal  g. 

MTMP.  G Meditemporal  g. 

PAROC.  G Paroccipital  g. 

PAEOC.  ISM Paroccipital  isthmus. 

PC.  G Postcentral  g. 

PEC.  G Precentral  g. 

SBFE.  G Suhfrontal  g. 

SPFE.  G Superfrontal  g. 

SPTMP.  G Supertemporal  g. 

REFERESCES. 

>  B.  G.  Wilder :  Neurology  Lecture  Note?,  Cornell  University,  1899-1900,  p.  28. 

^E.  A.  Spitzka  :  "  A  contribution  to  the  question  of  fissural' integrality  of  Uie 
paroccipital ;  observaUons  upon  100  brains.*'  Proceeding's  of  AssociaUon  of 
American  Anatomists,  December,  1930.  To  be  published  io  Joumai  <tf  Mental 
Pathology. 

•D.  J.  Cunningham;  "The  intraparietal  sulcus,"  pp.  135-155,  Journal  of 
Anatomy  and  Physiology,  vol.  XX. t. 

*W.  Julius  Mickle:  "Brain  forms  in  relation  to  mental  status."  Joumai  of 
Mental  Science,  January,  1S97,  p.  25. 

*C.  Wernicke:  Lchrbuch  der  Gehimkrankheiten,  ISSl,  p.  11. 

"Jul.  WaUischuiidt ;  "  Beitra^  ziir  Anatomie  des  Taubstummen  Gebims." 
Allg.  ZeiUchriji  j.  Psychialne,  ISST,  pp.  371-379. 

•  E  A.  Spitzka :  "  The  rednmiancy  of  the  preinsula  in  the  brains  of  dislin- 
-ftuished  educated  men."  To  be  published  in  the  current  volume  of  the  Medical 
Record. 

3  B.  G.  Wilder :  Brain,  gross  or  macroscopic  anatomy.  Reference  Handbook  of 
the  Medical  Sciences.    A.  U.  Buck,  editor,  viii,  ISSd.    Also  vol.  ix.    (Supplement.) 


SANHAGO  AS  A  YELLOW  FEVER  CENTER. 
Bv  MAJOE  L.  C.  CARE,  Surgeon,  U.S.A. 

Chief  Surgeon,  Department  ot  Eastern  Cuba. 

Ik  1S98  I  frequently  heard  the  statement  made,  that  for 
many  years  Santiago  de  Cuba  and  Santos,  Brazil,  had  been  in 
a  class  of  their  own,  universally  at  cepted  without  question 
as  the  two  filthiest  and  most  unhealthy  cities  on  the  globe. 

The  death-rate  here  given  for  Santiago  is  made  from 
records  for  the  years  1888 — 1897,  both  inclusive;  they  were 
-compiled  by  Dr.  M.  J.  Bosenau,  Marine-Hospital  Service, 
who  says  in  submitting  his  report : 


"  S.45Ti.iGO  DE  Ctba,  May  8,  1899. 
"Sie: — I  have  the  honor  to  transmit  herewith,  moitoary  statistics 
for  the  city  of  Santiago  de  Cuba  daring  the  past  ten  years.  These 
interesting  figures  were  kindly  collected  for  us  by  3r.  Eduardo  Yero, 
the  .\lcalde's  clerk,  after  much  searching  through  musty  recorda. 
The  figures  were  taken  from  official  reports," 

It  is  fair  to  presume  that  these  records  are  favdty,  and  that 
the  number  of  deaths  given  is  less  than  those  tliat  occurred. 
The  popidation  of  Santiago  during  these  years  can  be  only 
approximately  determined,  after  exhausting  all  sources  of 
information.  I  have  taken  45,000  as  a  standard,  upon  which 
the  following  calculations  are  based  : 


« 

M 

• 

■s 

1   ' 

1 

ill 

1 

= 

_2 

%>  ? 

— 

2 

^ 

i 

a 

't 

S 

"S 

".3 

>■ 

:  ^ 

S 

!-   1 

g 

s 

^ 

s 

1888.  .  . 

4 

139 

151 

109 

83 

701 

1187 

25.37 

1889.  .  . 

7 

139 

131 

92 

S« 

702 

1157 

25.71 

1890.  .  . 

2 

121 

51 

5S 

44 

730 

1009 

22.42 

1S91  .  .  . 

1 

169 

119 

58 

149 

878 

1374 

3a  sa 

1892.  .  . 

0 

126 

6 

96 

54 

817 

1099 

24.41 

1S93.  .  . 

0 

136 

4 

57 

79 

911 

1187 

26  37 

1894.  .  . 

0 

132 

55 

53 

68 

723 

1031 

32.91 

1895 .  .  . 

0 

221 

631 

251 

306 

1451 

2S10 

£2.44 

1893  .  .  . 

859 

316 

363 

177 

457 

1840 

4012 

89.15 

1897.  .  . 

4 

410 

325 

239 

423 

3091 

4497 

99.33 

During  this  period  it  will  be  noted  that  tuberculosis  and 
yellow  fever  caused  about  one-tifth  of  the  total  deaths,  also 
that  the  death-rate  for  1895,  1896  and  1897  is  abnormally 
high,  even  for  a  filthv  tropical  citv ;  this  rate  reached  an 
alarming  height  in  1S9S.  The  statistics  for  1898, 1899  and 
1900  are  fairly  accurate ;  yet  there  can  be  no  question  but 
that  there  were  many  more  cases  of  yellow  fever  in  Santiago 
during  1898  than  were  officially  reported,  and  also,  that  dur- 
ing July,  August  and  September  of  that  year  the  population 
was  well  over  45,000,  but  the  confusion  owing  to  the  cam- 
paign is  responsible  for  lack  of  data. 


. 

^ 

1 

£ 

O 

1 

s 

1°  = 

i 

s 
= 

|__. 

a 

M 

J 

o 

o 

K  £  =: 

o 

1 

3 

^3 

1S9S.  .  . 

1 

415 

20 

m 

5S1 

3393 

1179 

6017 

\a.n 

1S99.  .  . 

.   4 

173 

o3 

138 

163 

8U 

43 

1383 

so.  73 

Tuberculosis  attracts  but  little  attention  here.  The  same 
remark  applies  to  yellow  fever,  so  far  as  natives  are  con- 
cerned, and  yet  the  natives  sutfer  from  the  former,  while 
free  from  the  latter ;  their  calenturiis  are  accepted  as  a 
necessary  evU,  and  judging  from  my  experience  here  during 
a  perioda  28  months,  80*  if  not  more  of  the  population 
are  subject  to  recurrent  attacks. 

In  the  tables  will  be  noted  deaths  under  the  heading 
"  diagnosis  unknown  " :  this  is  a  relic  of  past  Ciireles.sness, 
which  will  not  he  permitted  in  the  future. 

With  all  of  her  drawbacks,  the  Santiago  of  today  is  very 
far  removed  from  the  Santiago  of  1898  :  her  principal  trou- 
ble at  the  present  time  is  malaria,  which  prevails  in  all  of 
its  forms,  but  it  is  not  so  serious  as  formerly,  nor  is  the  per- 
nicious form  found  so  frequently.  With  the  exception  of 
eleven  cases  of  diphtheria,  from  which  disease  we  are  now 
free,  there  have  been  no  contagious  or  infectious  diseases 
this  year. 

Incomplete  as  the  records  are,  they  show  yearly  visitations 


ApRn.  6,  1901] 


SANTIAGO  AS  A  YELLOW  FEVER  CENTER 


["The  Philadelphia 
L  Medical  Jocrnal 


689 


of  yellow  fever ;  these  records  can  be  traced  to  the  year  1S40. 
It  is  within  reason  to  say  that  yellow  fever  has  existed  here 
continuously  for  over  100  years;  many  of  these  annual 
visitations  were  epidemics  and  were  very  severe,  but  the 
data  obtainable  are  too  unreliable  to  quote. 

The  fever  has  frequently  visited  El  Cristo,  10  miles,  and 
San  Luis,  26  miles  north,  also  Palma  Soriano,  42  miles  north- 
west ;  all  of  these  points  are  about  650  feet  above  the  sea 
level.  On  the  east,  Guantanamo  has  had  many  visits  ;  the 
city  is  14  miles  from  its  harbor,  Caminera  ;  little  hamlets 
within  a  radius  of  15  miles  of  Santiago  have  also  reported 
frequent  visitations.  Santiago  never  having  been  free  from 
the  disease,  was  always  considered  the  source  of  infection. 
The  results  this  year  establish  the  justness  of  the  claim,  for 
while  no  such  precautions  were  taken  at  other  places  as 
were  taken  here,  there  was  no  yellow  fever  within  150  miles 
of  Santiago. 

The  Provinces  of  Santiago  and  Puerto  Principe  comprise 
nearly  one-half  the  extent  of  the  Island,  and  the  following 
harbors,  large  and  small,  are  on  their  sea-coasts  :  Nue vitas, 
Puerto  Padre,  Banes,  Gibara,  Mayari,  Sagua  de  Tanamo, 
Baracoa,  Guantanamo,  Santiago,  Manzanillo,  Santa  Cruz 
and  Jucaro.  These  harbors  are  visited  by  vessels  of  all  sizes 
from  every  part  of  the  world. 

During  "the  year  of  1900,  the  following  has  been  the  report 
from  Nuevitas  in  the  Province  of  Puerto  Principe  : 

Three  cases  of  yellow  fever  occurring  as  follows  : 

The  first,  a  Spaniard,  on  April  14,  1900;  the  second  on 
April  27 ;  this  case  I  saw  on  May  6,  and  did  not  agree  with 
the  diagnosis ;  it  was  the  case  of  a  discharged  soldier  who 
had  been  on  a  prolonged  spree;  my  diagnosis  was  acute 
alcoholism,  with  malarial  complications  and  a  prognosis  of  a 
fatal  termination  ;  after-results  did  not  bear  out  a  diagnosis 
of  yellow  fever.  A  sporadic  case  at  that  season  of  the  year 
was  out  of  the  question  :  it  was  the  time  for  an  epidemic  ; 
the  season  of  the  year,  climatic  conditions  and  materials 
were  there— nonimmunes  from  La  Gloria,  discharged  sol- 
diers and  newly  arrived  Spaniards  to  the  number  of  90 
— and  no  other"  case  was  reported  until  June  21,  55  days 
later;  this  latter  case  was  also  a  Spaniard,  and  a  study  of  the 
temperature,  pulse  and  symptoms  which  had  been  received 
hy  telegram  and  from  which  a  chart  had  been  made,  made  a 
diagnosis  in  this  case  by  no  means  certain.  Cuban  physi- 
cians, as  a  rule,  are  not  accustomed  to  meeting  cases  of 
drunken  and  worthless  fair-skinned  foreigners  who  may  be 
taken  sick  from  the  effects  of  alcohol,  climate  and  neglect ; 
such  cases  have  been  frequent  since  American  occupation 
(and  noticeably,  drunkenness  is  not  a  failing  of  the  Cuban 
race).  Given  such  a  case  as  above  stated,  you  have  a  con- 
gested face,  ^^olent  frontal  headache,  congested  eyes,  jaun- 
dice, epigastric  tenderness,  vomiting  and  nearly  always 
albumin,  all  of  which  are  pronounced  symptoms  of  yellow 
fever ;  add  to  this  malarial  complications,  and  a  diagnosis 
of  yellow  fever  is  easily  made. 

HoLGUis. — The  town  is  situated  about  thirty  miles  from 
the  coast ;  yellow  fever  had  not  visited  there  for  several 
years ;  on  May  17,  1900,  a  case  was  reported,  an  American 
six  months  on" the  Island,  the  last  two  months  of  this  period 
spent  in  Holguin,  from  which  place  he  had  not  been  absent 
during  that  time.  He  reported  to  the  post  surgeon  sick,  was 
admitted,  and  six  days  after  admission  a  diagnosis  of  yellow 
fever  was  made.  Symptoms,  temperature  and  pulse-rate, 
three  observations  were  asked  for  by  wire ;  from  these  tele- 
grams a  chart  was  made  ;  a  study  of  that  chart  and  the  fact 
that  in  the  face  of  exposure  from  this  patient  and  the  place 
of  his  supposed  infection  no  other  case  occurred  in  Holguin, 
rendered  the  diagnosis  in  this  case  extremely  doubtful. 

On  October  13  a  Spanish  passenger  from  Havana  took  sick 
on  the  Steamer  Julio  three  days  out  from  Havana;  he 
was  left  at  Gibara,  the  diagnosis  was  yellow  fever;  all  pre- 
cautions were  taken  against  its  spread.  The  case  resulted 
fatally ;  of  this  case  I  have  received  no  data  ;  there  were  no 
other  cases. 

In  all,  four  cases  have  been  reported  as  occurring  in 
these  two  provinces,  three  in  Puerto  Principe  province  and 
one  in  Santiago  province,  one  was  not  yellow  fever,  and 
in  the  three  other  cases  there  was  sufficient  reason  for 
doubt. 


MORTUARY  STATISTICS  — SANTIAGO  DE  CUBA. 

(Based  on  a  population  of  4->,000.) 

Tear  189S. 


at  o 

3 

2  ► 

S  s 


January. 

0 

69 

4 

76 

45 

315 

7 

516 

February. 

0 

S8 

0 

50 

35 

275 

1 

399 

March. 

0 

60 

1 

22 

15 

283 

3 

374 

AprU. 

0 

SI 

0 

23 

13 

193 

2 

262 

May. 

0 

28 

5 

17 

IS 

188 

1 

254 

June. 

0 

38 

2 

22 

12 

174 

5 

263 

July. 

0 

25 

0 

26 

11 

271 

98 

431 

August. 

0 

33 

8 

86 

239 

772 

414 

1552 

September. 

0 

21 

0 

U 

35 

277 

619 

863 

October. 

1 

31 

0 

24 

46 

296 

118 

516 

November. 

0 

29 

0 

21 

68 

178 

5 

301 

December. 

0 

22 

0 

SO 

47 

171 

6 

296 

Total. 

1 

415 

20 

428 

SSl 

3393 

1179 

6017 

Annual  death-rate,  133.71. 
Tear  1899. 


I   give   in   extenso, 
October  31. 


tables  for  1898—1899  and  for  1900  to 


C  i 

a 

t. 

. 

o 

h"^ 

S 

M 

tA 

1 

■3 

1 

1 

E  °- 

V  »  =J 

s 

go 
1 

3 

1 

i 

S 

? 

1 

1*"° 

N 

3 
o 

m 

S 

Jan. 

» 

0  . 

23 

0 

29 

45 

117 

1 

215 

Feb. 

0 

0 

10 

0 

21 

19 

92 

5 

147 

March. 

0 

0 

17 

0 

16 

18 

74 

3 

128 

April. 

0 

16 

0 

6 

7 

89 

4 

122 

May. 

0 

0 

18 

0 

5 

9 

63 

6 

101 

June. 

0 

0 

13 

14 

9 

7 

73 

5 

121 

July. 

0 

0 

14 

27 

12 

7 

51 

5 

116 

August. 

« 

0 

17 

6 

9 

8 

54 

2 

96 

Sept. 

3 

0 

9 

3 

4 

12 

44 

3 

78 

Oct. 

0 

0 

10 

1 

8 

6 

46 

3 

74 

Nov. 

0 

0 

14 

0 

4 

18 

64 

4 

S9 

Dec. 

1 

0 

12 

2 

IS 

12 

54 

2 

96 

Total. 

4 

0 

178 

53 

136 

163 

811 

43 

1383 

Annual  death-iate,  30.73. 
Year  1900. 


Jan. 

0 

0 

11 

0 

16 

9 

S3 

1 

120 

Feb. 

0 

0 

16 

0 

12 

1 

70 

2 

101 

March. 

0 

0 

14 

0 

10 

5 

72 

S 

104 

April. 

0 

0 

14 

0 

7 

8 

6S 

S 

100 

May. 

0 

0 

14 

0 

IS 

7 

SO 

1 

117 

June. 

0 

0 

16 

0 

17 

9 

49 

4 

95 

Total. 

0 

0 

86 

0 

77 

39 

422 

14 

6S7 

Annual  death-rate  for  the  six  months,  28.S0. 


690 


The  Philadelphla~| 
Medical  Journal  J 


SANTIAGO  AS  A  YELLOW  FEVER  CENTER 


[APRIL  6,  19«1 


Year  1900. 


^ 

3 

■i4 

C 

S 

g 

S 

1 

"a 
g 

1 

> 

1 

o 

a 

£ 

J3 

a 

S 

1 

BO 

Q 

a 
1 

a 

£ 

2 

a 

2 
"C 

5 

1 

3 

•a 

1 

a 

1 

a 

M 

^ 

i 

1 

§• 

o 

1 

July. 

13 

1 

13 

3 

0 

" 

2 

10 

s 

3 

0 

2 

15 

70 

August. 

11 

2 

16 

1 

e 

4 

1 

S 

4 

7 

0 

4 

13 

71 

September. 

10 

1 

7 

0 

0 

1 

1 

4 

9 

8 

4 

4 

24 

73 

Total. 

37 

4 

36 

4 

0 

s 

4 

19 

18 

18 

4 

10 

52 

214 

Annual  death-rate  for  the  above  three  months,  19.00. 

CAUSES  OF  DEATHS  FOR  THE  MONTH  OF  OCTOBER,  1900. 
(Estimated  population,  43,000.    Bate  mortality,  14.93.) 


!2:iz; 


—  z 


18   2 


S6 


Death-rate  for  the  ten  months  ending  October  31, 1900,  21.18. 


BIRTHS  FOR  OCTOBER,  1900. 


MALE. 

FEMALE. 

TOTAL. 

a 

While. 

Colored. 

White. 

Colored. 

■ 

Male.          Female. 

E 

< 

11 

22 

13 

13 

33                  26 

69 

This  is  the  first  month  in  which  the  aboye  statistics  have  been  kept 


For  1900  the  vital  stati.stics  are  given  in  more  complete 
form,  showing  the  changes  that  American  methods  nave 
made  in  the  manner  of  their  keeping ;  all  of  these  changes 
are  new  innovations,  and  much  time  and  labor  has  been 
given  to  introduce  them  and  accustom  physician  and  officials 
to  their  use. 

The  following  tables  are  self-explanatory,  and  the  con- 
sideration of  the  generally  accepted  theory,  that  heat  and 
moisture  under  certain  conditions  have  a  definite  influence 
on  the  propagation  of  yellow  fever,  gives  to  these  tables  a 
peculiar  interest. 

In  accordance  with  that  theory,  other  things  being  equal, 
the  season  of  the  year  1900  was  for  more  favorable  for  a 
yellow  fever  epidemic  than  the  season  of  1S99. 

For  ten  days  preceding  June  15,  19(X)  (date  of  outbreak  in 
1899),  the  temperature  was  higher  with  slightly  less  moisture 
than  for  the  same  period  in  1899,  and  for  the  ten  days  fol- 
lowing June  \ri,  the  temperature  was  higher,  and  there  was 
a  greater  rainfall  in  1900  than  in  1899. 

From  the  11th  to  the  20th  of  June,  1900,  both  dates  inclu- 
sive, the  nia.ximum  was  but  once  below  90",  and  the  minimum 
ranged  from  75°  to  77°,  dropping  to  74°  but  once  in  that 
period,  June  18th. 

The  height  of  the  epidemic  in  1899  was  in  July.  During 
July  of  1900,  the  maximum  temperature  was  1.1°  higher  and 
the  minimum  .3°  lower  than  in  July,  1899.  The  precipitation 
was  .03°  higher  in  1899  than  in  1900. 


Tempera- 
ture. 


Max.  Mln. 


f  Yellow 
Fever. 


Rain- 
fall. 


3 

4 

5 

6 

7 

8 

9 

10 

U 

12 

13 

14 

15 

16 

17 

IS 

19 

20 

21 

22 

23 

24 

26 

26 

27 

28 

29 

30 

SI 


S 


1 

2 
3 
4 

.T 

6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
26 
27 
28 
29 
30 
31 


84 
83 
85 
86 
85 
85 
85 
86 
88 
90 
90 
87 
88 


87 
87 
88 
90 
89 
90 
91 
91 
91 
89 
87 
89 
85 


66 
70 
71 
70 
70 
'  70 
70 
71 
70 
72 

I  '2 
70 
72 

I  71 

I  72 
'  71 
'  71 
I  72 
70 

I  '9 
71 

I  71 
72 
73 

I  72 
74 
72 

'1 
72 


1 
2 
3 
4 
S 
6 
7 
8 
9 
10 
11 
12 
13 
14 
16 
16 
17 
18 
19 
20 

22 
2.1 
21 


86 
88 
88 
87 
88 
87 
87 
88 
87 
87 
91 
90 
88 
89 
88 
88 
89 
90 
89 
90 
91 
93 
89 
90 

25  I  91 

26  :  91 


27 
28 


89 
90 
91 
92 


91 
91 
91 
94 
91 
89 
89 
90 
90 
92 
90 
91 
91 
92 
91 
89 
90 
S9 
91 
91 
89 
89 
93 
91 
90 
90 
91 
91 
87 
91 
92 


.26 

.0 
.22 
.06 
.18 
.87 
.02 
Tr. 
.0 
.0 
.0 
.0 
.0 
.25 
.30 
Tr. 
.0 
.01 
.58 
.0 
.0 


MAY,  1900. 


Date. 


.0 

.0 

.0 

.0 

.e 

.01 

\ 

1.27 

1 

.15 

1 

.01 

Tr. 

1 

1 

2 
3 

4 
5 
6 
7 
8 
9 

I  10 
I  11 
1  12 
I  13 
I  14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
23 
26 
27 
28 
29 
30 
31 


Tempera- 

Yellow 

ture. 

Fever. 

fall. 

K 

Mai. 

Min. 

5 

"3 

87 

70 

.0 

i» 

73 

2.31 

87 

78 

.0 

86 

77 

.0 

89 

72 

.0 

90 

74 

Tr. 

90 

73 

.03 

90         73 

.02 

89 

74 

.01 

90 

72 

.0 

84 

74 

.01     , 

80 

72 

.20    1 

8« 

73 

Tr.    1 

88 

73 

.01 

87 

73 

.80 

84 

76 

.49 

M 

75 

.28 

84 

76 

.03 

86 

75 

.17 

89 

74 

.0 

89 

74 

.0 

89 

75 

.0      , 

89 

73 

.01 

90 

73 

.0       1 

91 

73 

.0 

91 

74 

.0 

92 

74 

.0 

91 

75 

.0 

94 

74 

.49 

90 

74 

.23 

89 

72 

.14 

JI7SE,  1899. 


.0 
.0 
.0 
.04 
Tr. 
.86 
.35 
.01 
.02 
.0 
.03 
.12 
.49 
Tr. 
Tr. 
.0 
.0 
.0 
.0 
.0 
Tr. 
.11 
.01 
.11 
.0 
Tr. 
.16 
.0 
.0 
.0 


JtniE,  1900. 

1 

89 

67 

L78 

2 

88 

71 

.20 

3 

88 

73 

.19 

4 

91 

71 

.09 

5 

91 

71 

.0 

6 

90 

74 

.0 

7 

87 

73 

Tr. 

8 

88 

74 

.29 

9 

89 

rt 

Tr. 

10 

91 

78 

.0 

11 

88 

75 

.0 

12 

90 

76 

.0 

13 

90 

76 

.0 

14 

90 

77 

.0 

1.1 

93 

77 

.0 

16 

93 

76 

.0 

17 

91 

76 

.0 

la 

91 

74 

.0 

19 

92 

76 

.0 

20 

92 

75 

.26 

21 

91 

74 

.0 

22 

90 

74 

.05 

23 

91 

73 

.0 

24 

90 

73 

.0 

Vi 

92 

;s 

.0 

26 

93 

74 

.0 

27 

91 

76 

.05 

28 

91 

75 

.0 

29 

88 

7S 

.10 

30 

83 

74 

.14 

JULY,  1899. 


JULT,  1900. 


74 

.0 

75 

.0 

75 

.0 

75 

.0 

74 

.03 

73 

.03 

75 

.0 

76 
72 
74 
73 
T4 
74 
73 
74 
7S 
74 
75 
7S 
71 
72 
72 
75 
li 
76 
75 
75 
75 
74 
74 
TS 


Tr. 
.0 
.03 
.03 
.0 
.02 
.0 
.07 
.21 
.« 
.0 
.0 
.12 
Tr. 
.0 
.0 
.0 
.0 
.0 
.05 
.52 
.23 
.0 


5 
20 

13  I 

8  I 
«  I 

9  I 

2  I 

3  ■ 
6  ■ 
5 

6 
8 
3 
5 


1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

IS 

19 

20 


89 
92 
90 
91 
92 
S2 
89 
92 
91 
92 
92 
92 
91 
93 
92 
92 
91 
93 
92 


73 
72 


Tr. 
.01 
.19 


74 

.0 

74 

.0 

73 

.02 

73 

.01 

74 

.08 

74 

.0 

75 

.0 

76 

.0 

74 

.0 

ti 

.0 

22 

92- 

2.^ 

94 

24 

91 

2-. 

S9 

2r. 

92 

27 

94 

2S 

94 

29 

90 

SO 

91 

31 

91 

77 
76 
75 
74 
73 
75 

r.ii 

73 
73 
TS 
73 
72 
70 
7S 
75 
74 
74 
73 


.0 
.0 
.0 
.0 
.0 
.14 
.37 
Tr. 
.02 
Tr. 
.28 
.04 
.09 
.01 
.04 
.0 
Tr 
:'\ 


AIKIL  6,  1901] 


SANTIAGO  AS  A  YELLOW  FEVER  CENTER 


PThe  Philabelphia 
L  Medical  Joobsal 


691 


ACGDST,  1899. 

1 

Tempera- 
ture. 

Rain- 
fall. 

Yellow 
Fever. 

Date. 

Max. 

90 
92 
91 
90 
90 
90 
92 
96 
94 
88 
84 
86 
89 
90 
92 
90 
91 
90 
90 
92 
91 
90 
92 
92 
91 
91 
92 
91 
92 
93 
96 

Min. 

i 

•> 

1 

I 

2 

3 

4 

5 

6 

7 

8 

9 

1* 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

30 

31 

74 
74 
73 
74 
73 
71 
74 
74 
75 
75 
68 

-6 
(6 

74 

73 

75 

?^ 
75 
74 
74 
73 
73 
76 
75 
74 
73 
74 

It 
76 

.0 
.0 
.01 

.11 

0 
.0 
.0 
.0 

0 

.67 
4.38 
.03 
.0 
.0 
.0 
.0 
.0 
.0 
.0 
.0 
.0 
.0 
.0 
.0 
.0 
.06 
.0 
.0 
.0 
.0 
.0 

2 

•  •  ; 

1 ' 

• 

1 
1 
1 

1 

l' 

AUGUST,  1900. 


SEPTEMBER,  1899. 


SEPTEMBKK,  1!  00, 


1 

92 

77 

.03 

2 

94 

75 

.0 

S 

90 

74 

.03 

4 

92 

76 

.26 

5 

91 

76 

.0 

fi 

91 

74 

.15 

7 

91 

75 

.30 

8 

89 

74 

.11 

9 

91 

75 

.06 

10 

92 

75 

.12 

11 

90 

73 

.28 

12 

88 

74 

1.88 

Vii 

86 

70 

1.15 

14 

89 

72 

.0 

15 

90 

74 

.0 

16 

91 

75 

.02 

17 

90 

74 

.0 

18 

90 

74 

.0 

19 

91 

75 

.0 

20 

91 

75 

.0 

21 

91 

75 

.0 

22 

87 

73 

.05 

23 

91 

73 

.0 

24 

91 

73 

.01 

25 

92 

75 

.0 

26 

90 

76 

.0 

27 

90 

75 

.52 

28 

92 

73 

.63 

29 

90 

74 

.01 

30 

90 

74 

.04 

2 

1 

1 
1 

1 

1 

'.    '.    .     .   '.    '. 

1 

2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
23 
26 
27 
28 
29 
30 


OCTOBEK,  1899. 


OCTOBER,  1900. 


1 

90 

74 

.14 

2 

2 

90 

74 

.03 

.  .  . 

3 

86 

73 

.16 

4 

85 

74 

.69 

5 

85 

73 

.01 

G 

89 

73 

.0 

7 

90 

75 

Tr. 

8 

91 

74 

Tr. 

9 

89 

72 

Tr. 

10 

91 

72 

Tr. 

11 

88 

74 

.15 

12 

90 

74 

.03 

13 

R7 

69 

.50 

14 

B4 

70 

.06 

15 

83 

71 

.41 

16 

84 

73 

.23 

17 

88 

69 

.0 

IS 

90 

74 

.26 

19 

90 

74 

.36 

20 

■  88 

74 

.?5 

21 

88 

72 

Tr. 

22 

88 

72 

.25 

23 

85 

72 

12 

24 

87 

-.2 

125 

1 

25 

81 

73 

.09 

26 

84 

71 

.88 

27 

74 

71 

6.09 

28 

78 

71 

2.73 

29 

82 

72 

2.5S 

30 

85 

74 

2.29 

31 

85 

70 

.0 

1 

2 
3 
4 

5 
6 
7 
8 
9 
10 
11 


91 
90 
90 
92 
89 


12 

90 

13 

90 

14 

90 

15 

88 

16 

89 

17 

90 

18 

90 

19 

90 

20 

89 

21 

92 

,    22 

89 

23 

89 

24 

89 

25 

87 

26 

84 

27 

81 

28 

86 

29 

86 

30 

81 

31 

89 

73 

.0 

71 

.82 

71 

'1-r. 

73 

.29 

72 

.0 

72 

.0 

72 

.0 

73 

.0 

73 

.0 

74 

.06 

75 

.0 

72 

.0 

72 

.03 

71 

.0 

70 

.95 

72 

.0 

71 

.0 

72 

.0 

73 

.0 

75 

.0 

72 

1.17 

73 

.14 

74 

Tr. 

72 

.0 

71 

Tr. 

69 

.14 

72 

.62 

71 

.0 

71 

.03 

74 

.07 

74 

.02 

Tempera- 

Yellow 

ture. 

Bain- 

Fever. 

^ 

fall. 

-/. 

Max. 

92 

Min. 

73 

1 

1 

.0 

2 

91 

76 

.0 

3 

91 

74 

Tr. 

4 

94 

74 

.0 

5 

94 

75 

Tr. 

fi 

92 

74 

.36 

7 

90 

74 

.10 

8 

91 

74 

Tr. 

9 

91 

72 

Tr. 

10 

92 

74 

.0 

11 

9S 

74 

.40 

12 

92 

74 

.0 

13 

99 

74 

.01 

14 

92 

74 

.SO 

15 

91 

73 

Tr. 

IB 

94 

75 

.0 

17 

93 

7R 

.0 

18 

92 

75 

Tr. 

19 

93 

73 

2.11 

20 

90 

75 

.12 

21 

90 

75 

.0 

22 

92 

72 

.06 

23 

93 

73 

.0 

24 

91 

75 

.31 

25 

95 

76 

.0 

26 

92 

75 

Tr. 

27 

91 

75 

.17 

28 

92 

74 

.75 

29 

88 

73 

Tr. 

80 

87 

74 

.64 

31 

89 

75 

,o6 

91 

74 

.68 

89 

73 

.54 

80 

72 

10.89 

76 

6a 

7.22 

86 

72 

1.78 

86 

72 

2.29 

77 

71 

3.25 

82 

74 

.29 

86 

71 

1.24 

89 

73 

.14 

89 

73 

.0 

90 

75 

.0 

91 

73 

.0 

91 

72 

.63 

89 

73 

.02 

89 

72 

.0 

90 

73 

.0 

92 

70 

.0 

92 

74 

.0 

92 

73 

.0 

91 

73 

.0 

90 

73 

.19 

91 

73 

.0 

1 

92 

73 

.0 

94 

75  , 

..-53 

91 

74 

.0 

90 

73 

.0 

92 

73 

.0 

93 

74 

.0 

90 

71 

.0 

A  C0.MP.\RAT1VE  STCDY  OF  THE  CONDITIOX.S  EXISTING  DURING 
THE  YELLOW  FEVER  SEASONS  IN  HAVANA  AND  SANTIAGO 
GIVES  THE  FOLLOWING  TABLES: 


TEMPKRATORE, 

YELLOW 

FEVER. 

1899. 

Max. 

Min. 

Cases. 

Deatlis. 

Ha-      San- 

Ha-      San- 

Ha- 

San- 

Ha- 

San- 

Ha- 

Sm- 

vana. 

tiago. 

vana. 

tiago. 

vana. 

tiago. 

vana. 

tiago. 

vana. 

tiago. 

May. 

89.0 

87.6 

66.0 

71.1 

1.64 

3.92 

2 

0 

0 

0 

June. 

90.0 

89.1 

68.0 

73.1 

2.79 

2.20 

4 

66 

1 

14 

July. 

91.0 

90.5 

69.0 

74.1 

S.87 

1.84 

6 

131 

2 

30 

Aug. 

92.0 

90.9 

73.0 

74.0 

0.14 

5.16 

34 

19 

13 

6 

Sept. 

90.0 

90.4 

73.0 

74.2 

2.97 

5.35 

St 

14 

18 

3 

Oct. 

89.0 

86.3 

68.0 

72.5 

5.82 

19.06 

63 

5 

25 

0 

TEMPERATURE 

RAINFALL. 

YELLOW 

FEVER. 

1900. 

Max. 

Min. 

Cases. 

Deatlis. 

Ha- 
vana. 

San- 
tiago. 

Ha- 
■vana. 

San- 
tiago. 

Ha- 
vana. 

San- 
tiago. 

Ha- 
vana. 

San- 
tiago. 

Ha- 
vana. 

San- 
tiago. 

May. 

88.0 

8L1 

69.0 

73.9 

9.96 

5.23 

5 

0 

2           0 

June. 

91.0 

90.1 

68.0 

73.9 

3.43 

3.15 

19 

0 

8 

0 

July. 

90.0 

91.6 

71.0 

73.8 

5.40 

1.31 

96 

0 

30 

0 

Aug. 

90.0 

91.7 

72.0 

74.2 

1.72 

5.89 

219 

0 

49     '         0 

Sept. 

90.0 

88.7 

710 

72.7 

4.25 

29.49 

269 

0 

62             0 

Oct. 

90.0 

88.3 

70.0 

72.3 

1.95 

4.34 

308 

0 

74             0 

AVERAGE  FOR  SIX  MONTHS. 


TEMPERATURE. 

YELLOW  FKVER. 

1899 

190(1 

Cases. 

Deaths. 

Max. 

Min. 

Max. 

Min.   1899. 

1900. 

1899. 

190O. 

1899.    1900. 

Havana  .... 
Santiago.  .  .  . 

90.01 
89.13 

69.50 
73  13 

89  83 
89.90 

70.16 
73.46 

17.23 
37.03 

26.71 
49  41 

163 
235 

916 
0 

59       215 
53          0 

Jilanson  on  tropical  diseases,  voices  the  accepted  view  of 
experts,  when  he  says  : 

"  For  its  development  in  epidemic  form,  yellow  fever  re- 
quires a  temperature  of  over  75°  F.  It  ceases  to  e.xtend  its 
area  when  the  thermometer  sinks  below  this  point,  and  it 
stops  abruptly  as  an  epidemic  when  the  freezing  point  is 
reached  ;  although— as  proved  by  the  recurrence  of  the  dis- 
ease two  years  in  succession  in  one  of  the  Spanish  epidemics, 
and  that  without  a  fresh  introduction- the  vitality  of  the 
germ  may  not  be  extinguished  and  killed  outright  by  frost. 
Dampness  favors  yellow  fever;  it  is  therefore  most  prone  to 
occur  during  the  rainy  seasons. 

"  Conditio'^ns  of  soil  required.— Further,  it  is  not  every  spot 
that  aftbrds  the  extracorporeal  conditions  demanded  by  the 
germ.  It  would  appear  that  an  admixture  of  animal  matter 
must  enter  into  the  composition  of  the  nidus  ;  decomposing 
vegetable  matter  does  not  suffice." 

If  this  means  that  a  case  of  yellow  fever  must  exist,  before 
these  conditions  will  have  any  eflect  in  causing  an  epidemic, 
I  have  not  been  so  taught.  In  a  city  wherein  yellow  fever 
is  due  to  importation,  a  case  must  be  brought  before  any 
meteorological  condition  can  be  considered  as  bearing  on 
its  spread.  It  is  also  true  that  these  conditions  are  coex- 
istent with  an  epidemic  of  yellow  fever. 

But  how  apply  such  theory  here  where  the  disease  has 
been  endemic  for  years,  and  is  also  presumably  indigenous.' 
Must  importation  also  be  had  ? 


692 


The  Philadelphia 
Medical  Journal 


] 


SANTIAGO  AS  A  YELLOW  FEVER  CENTER 


[APKIL  6,  190] 


I  have  until  now  always  believed  that  such  w'eather  was  the 
one  thing  necessarj'  to  cause  an  outbreak  of  yellow  fever  in 
a  city  wherein  the  disease  was  endemic,  if  the  other  require- 
ments were  there  and  the  nonimmunes  were  present. 

A  study  of  the  tables  given,  and  consideration  of  condi- 
tions existing  at  Havana  and  Santiago,  indicates  that  the 
theory  is  fallable 

Here  we  have  two  cities  wherein  yellow  fever  has  been 
endemic  for  many  years  :  Havana  in  1899,  from  May  to 
October,  both  months  inclusive,  had  a  mean  temperature  of 
79.75,  precipitation  17.23,  cases  of  yellow  fever  163,  deaths 
59.  For  the  same  period  in  1900  the  mean  temperature 
was  79.49,  precipitation  26.71,  cases  of  yellow  fever  916, 
deaths  215. 

For  the  year  1899  the  immigration  was  16,260,  for  the  10 
months  ending  October  31,  1900,  the  immigration  was  16,859. 

For  the  same  6  months,  Santiago  in  1899  had  a  mean 
temperature  of  81.13,  precipitation  37.03,  cases  of  yellow 
fever  235,  deaths  53 ;  and  for  the  same  period  in  1900  the 
mean  temperature  was  81.68,  precipitation  49.41,  and  no 
yellow  fever. 

In  1899,  Santiago  had  a  nonimmune  population  of  from 
1,300  to  1,500.  In  1900  the  nonimmune  population  was  over 
1,300. 

All  of  the  conditions  required  by  the  heat  and  moisture 
theory  were  present  in  both  cities.  Havana  had  a  higher 
mean  temperature  in  1899  and  less  of  a  rainfall  than  she 
had  in  1900  ;  the  difference  in  the  epidemic  can  be  seen. 

Santiago  had  a  higher  mean  temperature  and  a  greater 
rainfall  in  1899  than  Havana  had  in  either  j-ear  cited,  and 
in  1900  Santiago's  rainfall  was  much  greater  and  her  mean 
temperature  higher  than  in  1899. 

It  seems  to  me  that  in  view  of  these  facts,  the  theory  that 
heat  and  moisture  play  the  all  important  role  in  the  develop- 
ment of  yellow  fever,  must  fall,  and  the  admission  only 
granted  that  these  conditions  are  coexistent  with  an  epi- 
demic of  yellow  fever. 

The  deductions  made  from  his  observations  by  Touatre 
in  New  Orleans  cannot  apply  to  conditions  here  in  Santi- 
ago, for  the  reason,  it  is  affirmed,  that  when  yellow  fever 
appears  in  New  Orleans  it  is  due  to  importation.  Here  it 
is  endemic. 

It  would  be  egotistical  to  assert  that  our  work  here  was 
the  sole  cause  for  the  nonappearance  of  yellow  fever  in  1900, 
especially  after  the  severe  epidemic  of  1899.  Also,  to  further 
assert  that  the  sanitarj^  work  done  in  Havana  had  been  a 
failure  would  be  pessimi.stic. 

I  have  endeavored  to  obtain  data  from  Kingston,  Jamaica, 
for  comparison  with  conditions  existing  here,  but  it  is  diffi- 
cult to  obtain  official  information.  On  November  11th  I 
had  the  good  fortune  to  meet  Mr.  Goldsmith  Williams,  of 
the  Cuba  Fruit  Company,  a  gentleman  of  keen  oljservation 
who  has  lived  much  and  traveled  extensively  in  the  West 
Indies  ;  from  him  I  gathered  the  following  facts  : 

He  thinks  that  until  1897  Kingston  was  nearly  as  filthy 
as  Santiago.  He  described  the  open  sewers  in  the  streets 
and  characterized  the  odors  as  unbearable  ;  the  older  and 
business  portion  of  the  city,  he  said,  was  built  much  similar 
to  Santiago ;  climatic  conditions  were  almost  identical ;  thev 
do  not  fear  yellow  fever,  and  until  1897  they  took  no  pre- 
cautions other  than  quarantine  against  infected  ports.  The 
disease  has  never  been  considered  endemic  there.  The  in- 
habitants attribute  their  safety  to  the  trade  winds  which 
blow  steadily  over  the  city  for  from  10  to  14  hours  dailv  ;  so 
much  are  they  impressed  with  the  truth  of  this  that  the 
trade  winds  are  called  their  doctor. 

After  the  epidemic  of  1897  the  sewer  system  was  com- 
pleted, and  since  then  Kingston  has  been  in  a  much  better 
sanit<ry  condition. 

Jamacia  is  80  miles  south  of  here,  and  Kingston  is  on  its 
south  coast;  in  all,  about  140  miles  from  Santiaco,  a  little 
west  of  south  The  letter  here  given  contains  all  the  ofiicial 
information  I  have  been  able  to^obtain  ; 

British  Consulate, 

Santiago  de  Cuba,  Julv  12,  1900. 
Major  L.  C.  Carr, 

Chief  Surgeon,  U.  8.  V., 
Santiago. 
Sib  ;---I  have  the  honor  to  inform  you  that  I  have  just  received 
under  date  25th  of  June,  an  answer  from  tlie  Superintending  Medi- 
cal Officer,  Jamaica,  to  my  enquiry  of  April,  regarding  yellow  fever 
epidemic  in  Kingston,  and  which  is  as  follows : 


"  I  have  the  honor  to  acknowledge  receipt  of  your  letter  dated 
11th  April  last,  and,  in  reply,  to  Inform  you  that  the  records  at  my 
disposal  do  not  go  farther  back  than  the  year  1*79,  from  that  date 
to  the  year  IS'JS,  with  the  exception  of  1  or  2  sporadic  cases  at 
long  intervals,  there  was  no  yellow  fever  in  Kingston. 

"In  1897  we  had  an  epidemic  when  72  cases  were  recorded,  since 
then  Kingston  has  been  free  from  yellow  fever. 

"  I  regret  that  a  press  of  work  and  other  matters  have  prevented 
my  replying  to  your  letter  earlier." 

I  am,  sir. 

Your  most  obedient  servant, 
(Signed)  Roe.  Masojt, 
Consul. 

Mr.  Williams  further  informed  me,  that  in  1897  the 
authorities  claimed  to  have  located  the  first  case  of  yellow 
fever.  The  patient  was  a  man  who  had  left  an  infectai  port 
of  Central  America  a  short  time  before.  The  authorities 
agreed  that  this  case  was  responsible  for  the  epidemic,  which 
they  asserted  was  due  to  importation.  I  give  this  statement 
without  comment. 

The  question  here  raised  as  to  the  part  played  by  heat 
and  moisture  in  the  development  and  propagation  of  yellow 
fever,  is  w-orthy  of  more  study  than  has  been  given  to  it  in 
the  past.  It  appears  to  me  that  too  much  has  been  taken 
for  granted. 

Consideration  of  the  obstacles  that  were  encountered,  and 
the  steps  taken  to  overcome  them,  may  enable  the  reader  to 
arrive  at  a  conclusion  as  to  what  fact  or  factors  we  owe  our 
escape. 

1.  Meteorologically,  the  conditions  existing  in  1900  were 
more  favorable  for  an  epidemic  of  yellow  fever  than  the  con- 
ditions which  existed  in  1899. 

2.  Food  for  the  fever. 

A  careful  census  made  b.v  First  Lieutenant  Edward  F.  Ged- 
dings.  Assistant  Surgeon,  U.  S.  A.,  and  Dr.  Richard  Wilson, 
Acting  Assistant  Surgeon,  U.  8.  A.,  shows  that  during  the 
dangerous  period,  from  April  to  October,  we  had  a  resident 
and  floating  population  of  over  1,300  nonimmunes,  and  the 
greater  majoritj-  of  these  were  of  that  dangerous  class— 
migraton'  loafers.  This  condition  varies  verv  little  from 
that  of  1899. 

3.  Owing  to  the  style  of  architecture,  the  manner  of  c<m- 
struction  and  the  crowding  together  of  the  buildings,  disin- 
fection by  fumes  or  vapors  was  out  of  question. 

4.  There  were  41  distinct  foci  of  infection  in  the  city  and 
12  in  the  outskirts  and  small  towns  adjoining :  these  were 
known.    It  was  the  unknown  points  that  were  feared. 

5.  Tlie  residents,  being  immune,  have  no  fear  of  yellow 
fever,  consequently  their  carelessness,  and  in  many  instances 
their  resenting  of  American  methods  of  sanitation,  made 
our  work  very  difficult. 

6.  The  custom  of  the  people,  throwing  urine  and  other 
filth  into  the  streets  was  an  element  of  grave  danger :  this 
practice  has  not  been  overcome,  nor  will  it  be  until  a  sys- 
tem of  sewerage  shall  have  been  established. 

7.  Our  limited  water-supply  has  made  our  work  very  try- 
ing ;  at  this  writing  it  is  the  best  we  have  ever  had.  5  gallons 
per  capita.  During  the  dangerous  season  it  was  very  much 
less,  and  but  one-fourth  of  the  city  was  supplied  at  one 
time,  the  average  being  IS  hours  of  the  24  without  wat«r. 

8.  The  privy  system  liere  is  abominable ;  many  of  the  old 
vaults  had  not  been  cleaned  for  over  50  years.  Their  loca- 
tion adjoining  kitchens  and  cisterns  rendered  them  very 
offensive  and  extremely  dangerous.  Butcher  shops,  baker- 
ies, and  groceries,  were  invariably  found  to  be  in  bad  con- 
ditio. In  the  bakeries  horses  were  found  in  stalls  adjoining 
ovens,  and  seepage  of  decomposing  urine  into  the  work 
rooms  was  the  rule,  some  mixing  rooms  were  found  covered 
with  living  filth  ;  butcher  shops  and  groceries  wit  i  piles  of 
rotten  offal  in  back  rooms  and  patios;  but,  nevertheless, 
this  class  of  people  have  been  found  amenable  to  reason 
when  shown  tne  way. 

9.  Owing  to  the  fact  that  we  had  an  inadequate  water- 
supply,  the  newlv  laid  sewers  had  not  been  in  use  and  the 
manholes  along  t"lieir  course  would  fill  rapidly  and  become 
very  offensive  and  dangerous. 

10.  I  feel  constrained  to  here  call  attention  to  the  most 
serious  among  the  obstacles  that  were  encountered  : 

The  evident  and  expressed  wish  of  the  Marine-Hospital 
Officer  that  we  should  nave  yellow  fever  here. 

His  printed  circular  prior  to  April  1 ,  1900,  which  had  the 
full  force  of  an  order,  dri\ing  all  of  the  army  ladies  out  ot 
the  countrv. 


ApKIL  0,  1901) 


SANTIAGO  AS  A  YELLOW  FEVER  CENTER 


[The  Philadelphia 
Medical  Jodsnal 


693 


His  curt  refusal  to  cooperate  with  tlie  military  and  civil 
authorities. 

His  strenuous  endeavor  to  prevent  our  having  a  quaran- 
tine against  Havana. 

His  public  and  written  statement  that  we  would  have 
yellow  fever  here,  the  only  question  being  in  which  month 
it  would  develop. 

His  prophecies  and  public  utterances,  all  of  which  were  a 
grave  reflection  upon  the  service  he  represented. 

Circular  Letter  No.  3,  Headquarters  Department  of  San- 
tiago and  Puerto  Principe,  March  80,  1900,  by  order  of 
Colonel  Whitside,  contains  this  paragraph  : 

"  All  cases  of  contagious  or  infectious  diseases,  or  suspected  to  be 
such,  shall  be  reported  to  the  President  of  the  Board  (Chief  Surgeon's 
Office),  who  shall  immediately  notify  at  least  three  members  of  the 
Board  to  examine  and  decide  the  nature  of  each  case  so  reported. 
The  opinion  of  the  examining  members  shall  be  expressed  in 
writing  over  their  signatures  and  handed  to  the  President  of  the 
Board. 

"No  case  of  contagious  orinfectious  diseaseshall  be  oflScially  recog- 
nized except  when  reported  by  the  Board  of  Health." 

In  direct  opposition,  he  endeavored  on  April  23,  to  place 
in  our  yellow  fever  hospital,  over  which  hospital  he  had  no 
control,  a  case  diagnosed  by  him  as  yellow  fever ;  this  en- 
deavor on  his  part  created  great  consternation  in  the  city  ; 
a  committee  of  four  physicians  visited  the  sailor,  who  was 
then  in  the  eighth  day  of  his  sickness,  diagnosed  the  case  as 
typhoid  fever,  sent  the  patient  to  the  Civil  Hospital,  and  so 
reported  to  the  Department  Commander. 

This  act  resulted  in  his  recall ;  that  it  was  his  first  official 
experience  in  a  position  of  command,  that  he  had  only  a 
superficial  knowledge  of  yellow  fever  and  that  he  was  a 
youth,  may  be  oflfered  in  extenuation. 

The  Marine-Hospital  Service  knew  that  Santiago  was  a 
station  of  great  importance  ;  also  one  entailing  grave  re- 
sponsibility, and  it  has  too  many  well  equipped  officers  and 
gentlemen  in  its  corps  to  have  permitted,  even  for  a  day, 
such  conditions  to  exist  after  the  facts  were  brought  to  its 
knowledge. 

Dr.  M.  J.  Rosenau,  who  preceded  the  officer  referred  to, 
on  duty  here,  was  thoroughly  equipped,  did  his  work  care- 
fully, effectually  and  without  friction,  and  was  always  a 
gentleman. 

So  with  Dr.  R.  H.  von  Ezdorf,  the  present  incumbent,  who 
succeeded  him;  coming,  as  he  did,  into  an  atmosphere  of 
discontent,  distrust  and  general  misunderstanding,  he  cleared 
it  in  a  remarkably  short  space  of  time,  and  won  the  confi- 
dence and  respect  of  all  with  whom  he  came  in  contact. 
This  report  shows  what  our  success  has  been  and  much  of 
the  credit  belongs  to  Dr.  R.  H.  von  Ezdorf,  who  in  addition 
to  his  other  qualities  is  an  untiring  worker. 

To  a  station  of  such  importance  the  Marine-Hospital 
Service  should  detail  only  of  its  best  officers,  for  competent 
and  gentlemanly  medical  men  will  always  work  in  harmony 
with  other  authorities  when  the  object  is  the  greatest  good 
for  the  greatest  number. 

I  have  weighed  this  matter  long  and  carefully  before  con- 
cluding to  make  these  facts  public,  but  the  gravity  of  the 
situation,  the  possibility  of  a  similar  happening,  tlie  powers 
for  good  or  evil  that  lie  in  the  hollow  of  one  man's  hand 
when  appointed  to  such  a  post  by  the  Marine- Hospital  Ser- 
vice have  outweighed  all  other  considerations. 

Steps  Taken  For  a  Prevention  of  an  Ootbreak. 

1.  Tramps. — Recognizing  the  danger  from  this  element, 
among  whom  j'ellow  fever   usually  makes  its  first  appear- 
ance, and  fully  aware  of  the  utter  hopelessness  of  locating 
i   the  foci  when  such  people  would  be  attacked,  an  effort  was 
I   made  to  reason  with  them  to  protect  themselves  while  pro- 
1  tecting  the  city;  work  was  found  on  roads,  buildings  and  in 
[   the  iron  mines,  and  on  May  25,  some  68  of  the  most  dan- 
gerous were  arrested ;  40  were  Spaniards,  3  Americans,  8 
!  Jamaicans,  and  the  rest  of  various  lands. 

The  Spanish,  French,  and  English  Consuls,  all  in  thorough 
accord  with  this  movement,  in  company  with  tlie  Chief  Sur- 
geon, visited  them  and  matters  were  fully  explained ;  11  of 
them  were  sent  to  the  hospital  and  57  were  instructed  to 
call  at  an  office  where  a  clerk  was  kept  on  duty  all  day  dis- 
tributing them  to  places  as  seemed  suitable  ;  the  next  day  4 
of  the  57  called  for  work.  In  .June  another  effort  was  made  ; 
about  60  were  arrested  and  told  that  there  was  work  for  50, 


but  that  it  was  not  compulsory ;  only  5  of  the  number 
agreed  to  work.  The  Department  Commander  then  author- 
ized the  Alcalde  to  have  them  arrested  under  the  Spanish 
tramp  act,  as  vagrants.  This  form  of  arrest  began  July  1, 
1900,  and  arrangements  were  perfected  to  rid  the  city  of  this 
dangerous  element.  They  caused  us  more  or  less  trouble 
during  the  entire  period  until  October  31. 

2.  On  March  1,  1900,  the  general  re-disinfection  of  the  foci 
began  with  a  trained  force,  under  the  direct  control  of  an 
experienced  and  capable  chief.  The  disinfectant  used  was 
corrosive  sublimate  (strength  J  pound  to  50  gallons  of  water 
with  the  addition  of  IJ  pounds  of  salt  to  a  50-gallon  barrel). 

Force  pumps  were  used  on  wells  and  ceilings,  and  floors 
were  scrubbed  and  drenched ;  where  the  force  pump  could 
not  reach,  swabs  were  used.  This  disinfection  was  completed 
by  July  1,  1900.  All  of  these  places  were  re-disinfected; 
some  of  the  filthy  houses,  3  or  4  times,  and  cafes,  lodging 
houses,  and  resorts  frequented  by  non-immunes,  every  3  or  4 
weeks. 

3.  A  careful  watch  was  kept  over  the  town.  The  indis- 
criminate throwing  of  tilth  into  the  streets  was  in  a  measure 
prevented,  and  it  was  only  permitted  at  a  stated  hour,  while 
not  avoiding,  this  requirement  lessened  the  danger.  It  was 
Hobson's  choice. 

4.  Our  limited  water-supply  is  a  proposition  upon  which 
the  Engineer  Department  is  still  at  work. 

5.  About  500  latrines  were  found  to  be  in  a  dangerous  con- 
dition ;  the  records  of  the  Sanitary  Department  show  that 
of  this  number,  350  were  cleaned  or  contract  made  for  their 
cleaning.  On  June  22,  the  second  inspection  began  of  places 
reported  dangerous  on  the  first  inspection  ;  a  list  of  houses 
with  owners  and  tenants  who  had  failed  to  comply  with  the 
sanitary  regulation  was  submitted  to  the  Alcalde  with  re- 
quest that  these  parties  be  proceeded  against  at  once  in  ac- 
cordance with  the  regulations.  The  inspection  showed  that 
the  most  dangerous  part  of  the  city  is  the  district  bounded 
on  the  north  by  the  Paseo  de  Concha,  the  south  by  Marino, 
the  east  by  Gallo,  and  the  west  by  Cristina  .streets,  which  is 
owing  to  the  fact  that  this  section  receives  all  of  the  ground 
wash  of  the  entire  city  and  the  privy  vaults  here  are  con- 
stantly filled  to  overflowing.  The  regular  force  of  vault 
cleaners  were  not  enough  for  the  increa.sed  work  made  by 
these  inspections ;  therefore,  many  of  these  contracts  were 
sub- let  to  contractors  whose  work  has  proved  very  satisfac- 
tory. In  pursuing  this  work,  a  remarkable  condition  has 
been  presented,  which  it  is  hoped  is  only  a  local  and  not  a 
general  characteristic  of  the  people  of  Cuba;  the  poorer  and 
uneducated  classes  have  offered  no  objections  and  where 
poverty  did  not  absolutely  prohibit,  obeyed  the  instructions 
of  the  inspectors  as  best  they  could.  Per  contra,  many 
dangerous  places  were  found  belonging  to  and  inhabited  by 
the  people  of  education,  refinement  and  wealth,  a  number 
of  whom  had  traveled  extensively  abroad,  representing  the 
different  professions  and  belonging  to  the  best  families  in 
the  city ;  several  of  such  have  not  only  positively  refused  to 
clean  their  homes,  but  have  been  discourteous  and  insulting 
in  their  refusals. 

6.  The  manholes  referred  to  were  pumped  out  every  day 
and  arrangements  were  made  to  thoroughly  disinfect  them 
after  every  pumping. 

In  all  of  this  work,  tlie  Department  Commander,  Colonel 
Samuel  M.  Whitside,  took  an  active  interest  and  was  in 
hearty  sympathy  with  all  efforts  to  this  end ;  his  suggestions 
as  to  ways  and  means  were  ready  and  valuable,  and  be  al- 
ways accomplished  measures  recommended  by  his  Chief 
Surgeon  in  the  shortest  possible  time  and  with  but  little  or 
no  friction. 

For  an  officer  so  long  connected  with  purely  military 
duties  to  quickly  grasp  and  thoroughly  comprehend  the 
manifold  difficulties  solely  sanitary  and  altogether  civil  was 
an  agreeable  surprise  to  me,  and  it  is  beyond  question  that 
without  his  earnest  support  and  advice  results  here  given 
could  not  have  been  obtained. 

The  Cuban,  from  a  sanitary  standpoint,  is  of  a  class  with 
which  the  American  sanitarian  is  not  familial'.  The  man- 
ners, creeds  and  customs  of  his  forbears  are  to  him  sacred ; 
any  attempt  to  improve  his  sanitary  condition  that  conflicts 
with  his  inherited  beliefs,  is  regarded  as  bordering  on  sac- 
rilege. 

Santiago  as  a  home  of  yellow  fever  was  part  of  his  heritage ; 
that  existing  conditions  aflTected  the  future  of  the  people, 


694 


Thx  Phii^deuhia"] 
Medical  Joubsal  J 


PROPAGATION  OF  YELLOW  FEVER 


[Ap«il  6,  IMl 


crippled  the  commerce  of  the  island,  endangered  the  lives  of 
others  and  retarded  the  growth  of  bis  city,  did  not  appeal  to 
him.     He  was  immune  and  had  no  fear. 

The  following  from  the  Aew  York  Medical  Record,  page  20, 
July  7, 1900,  shows  this  feeling : 

El  Cubano,  an  Havana  newspaper,  recently  revealed  one 
of  the  reasons  for  this  opposition.  It  said,  "  the  Cubans  justly 
and  properly  object  to  the  expenditure  of  such  a  large  pro- 
portion of  the  revenues  of  the  island  in  measures  intended 
to  repress  yellow  fever,  for  the  only  result  of  such  measures 
is  to  protect  the  lives  of  the  Americans,  since  the  Cubans 
themselves  are  immune  from  yellow  fever." 

Spanish  law  is  admirably  fitted  to  interfere  with  sanitary 
procedure,  and  its  aid  was  frequently  invoked  by  people  of 
the  better  class,  when  they  thought  that  the  health  regula- 
tions being  enforced  were  interfering  with  their  personal 
comforts  or  desires. 

My  observations,  covering  a  pericd  of  28  months,  have  led 
me  to  the  conclusion,  that  for  some  time  to  come  the  people 
of  this  island  will  not  be  prepared  or  inclined  to  take  hold  of 
sanitary  measures,  and  therefore  whatever  Cuba's  future  may 
be,  theUnited  States  will  be  culpably  negligent  of  her  own 
interest,  of  the  interest  of  her  southern  States  in  particular 
and  of  the  world  in  general,  if  she  permits  health  regula- 
tions, sanitary  measures  and  quarantine  restrictions  to  pass 
from  her  control  before  she  is  convinced  that  these  matters 
are  thoroughly  understood  and  will  be  faithfully  and  intelli- 
gently prosecuted  by  the  people  of  Cuba. 

Wasdin  says  in  his  conclusions  ( Tne  Journal  of  the  American 
Medical  Assoination,  October  6,  1900) : 

"  That  the  bacillus  icteroides  is  very  susceptible  to  the  in- 
fluences iniurious  to  bacterial  life,  and  that  its  ready  con- 
trol by  the  processes  of  disinfection,  chemical  and  mechanical, 
is  assured." 

This  statement  will  not  be  questioned,  as  it  is  one  of  the 
few  points  in  connection  with  yellow  fever  that  admits  of  no 
dispute. 

Even  in  a  filthy  tropical  city,  without  proper  sewerage, 
without  any  sanitary  standard  whatever,  the  work  of  disin- 
fection can' be  pushed  to  a  successful  issue. 

This  fact  is  fairly  in  evidence ;  the  foci  of  yellow  fever  are 
in  certain  defiuiteplaces  in  a  city  where  it  is  endemic.  The 
habitat  can  be  located  and  as  fast  as  one  appears  it  should  be 
guarded  closely,  and  with  all  of  its  belongings,  disinfected 
thoroughly,  and,  as  an  added  precaution,  redisinfected  at 
intervals  during  the  danger  period ;  these  places  should  be 
kept  under  continual  surveillance  and  treatment  and  no 
pains  or  expense  should  be  spared  to  render  the  contagion  at 
such  points  inert. 

I  am  further  convinced  that  our  work  in  Santiago  did 
murh  to  ward  ofl'  an  attack,  and  yet  this  question  intrudes 
itself,  were  there  n  t  many  foci  that  escaped  us?  That  there 
were  is  undoubtedly  true ;  but  we  took  care  of  all  that  were 
of  record  and  were  prepared  for  any  new  ones  that  might 
appear. 

There  is  still  much  in  connection  with  meteorological  con- 
ditions and  nature  of  nidus  necessary  for  the  propagation  of 
this  scourge  that  we  do  not  clearly  understand. 

Nearly  all  of  the  best  men,  men  of  scientific  attainments 
who  have  had  practical  experience  in  the  care  of  yeUow 
fever,  and  in  the  sanitation  of  cities  wherein  the  fever  was 
epidemic,  are  now  engaged  in  laboratory  work,  endeavoring 
to  demonstrate  which  germ  is  responsible  for  this  scourge. 
We  all  must  admit  that  the  object  is  a  most  laudable  one 
and  our  hope  is  that  it  will  soon  be  determined  beysnd  all 
doubt. 

But  would  not  the  interests  of  humanity  be  better  con- 
served if  the  sanitary  measures  in  the  cities  wherein  yellow 
fever  is  endemic,  were  under  the  constant  watch  and  control 
of  some  such  men? 

After  an  epidemic,  this  important  work — looking  to  a  pre- 
vention of  a  recurrence — is  oft^n  left  in  the  hands  of  inex- 
perienced and  careless  persons.  Why  should  not  some  of 
these  men  devote  their  entire  time  and  attention  to  prevent- 
ive measures,  giving  intelligent  supervision  to  methods  that 
we  have,  and  know  to  be  reliable? 

Before  closing  I  wish  to  ciiU  attention  to  the  work  of  First 
Lieutenant  Ira  A.  Shinier,  Assistant  Surgeon,  U.S.A..  as 
Sanitary  Inspector.  He  enthused  the  whole  force  with  his 
energii'  and  personally  supervised  all  details.  He  satisfied 
himself  by  personal  inspection  that  all  work  outlined  was 


being  faithfully  performed.  During  his  absence  on  leave, 
this  work  was  in  charge  of  Acting  Assistant  Surgeon  Miltoo 
Vaughan,  U.  S.  A.,  who  carefully  directed  its  prosecution. 
First  Lieutenant  Edward  F.  Geddings,  Assistant  Surgeon, 
U.  S.  A.,  was  on  duty  in  connection  with  contagious  diseases, 
his  knowledge  of  yellow  fever  and  the  methods  of  its  han- 
dling, made  him  especially  valuable  at  this  time. 

I  desire  to  express  my  thanks  to  Major  Valery  Havard, 
Surgeon,  U.  S.  A.,  Chief  Surgeon  Division  of  Cuba;  Major 
William  C.  Gorgas,  Surgeoa,  U.  S.  A.,  Chief  Sanitary  Officer 
of  Havana;  Assistant  Surgeon  E.  H.  von  Ezdorf,  Marine- 
Hospital  Service ;  and  also  Mr.  A.  V.  Randall,  of  the  Weather 
Bureau,  for  data,  from  which  these  tables  hove  been  com- 
piled, and  further  to  thank  the  officers  of  the  Departmental 
Staff  for  their  unvarj-ing  courtesy  and  the  assistance  rendered 
me  whenever  it  was  required. 

November  26,  the  date  of  completion  of  this  paper,  11 
months  have  passed,  during  which  Santiago  has  been  free 
from  yellow  fever. 

Under  these  conditions  the  possibility  of  a  case  occurring 
in  December  is  very  improbable. 


A  CORRELATION  OF  SOME  FACTS  IN  THE  PROPA- 
GATION OF  YELLOW  FEVER.  WITH  THE  THEORY 
OF  ITS  CONVEYANCE  BY  THE  CDLEX  FASCL^TUS. 

bt  h.  r.  carter,  m.d. 

Surgeon  United  States  Marine-Hcxpiul  Serrioe. 

Until  the  life-history  of  the  Culex  fasciatus  is  worked 
out  it  is  not  possible  to  fuUy  compare  with  the  theory 
of  the  conveyance  of  yellow  fever  by  this  agent  as  a 
host  with  such  facts  as  are  known  of  the  propagation 
of  the  disease. 

Still  it  seems  that  a  correlation  of  some  such  facts 
weU  established  and  generally  admitted  with  the  above 
theory  may  be  of  interest. 

First. — Yellow  fever  is  not  transmitted  directly  from 
the  sick  to  the  well.  It  is  propagated  from  the  sick 
man  by  his  infecting  his  enrironment,  from  which  it  is 
contracted  by  others  exposed  thereto. 

Second. — Certain  conditions  of  environment  are  neces- 
sary for  it  to  become  infected.  Besides  temperature  and 
moisture,  there  are  others  of  which  we  are  ignorant, 
and  many  localities  habitually  have  not  received  infec- 
tion from  the  presence  of  the  sick,  although  there  are 
no  differences  in  climate,  which  we  could  appreciate, 
between  these  localities  and  others  thad  did  so  become 
infected. 

This  quality  of  a  place,  its  being  infectible  by  yeUow 
fever,  sometimes,  probably  frequently,  varies  from  year 
to  year.  Cases  of  yellow  fever  may  be  introduced  some 
summers  with  impunity  and  in  others  in  the  same 
place  spreads  on  introduction. 

From  the  first  a  necessary  deduction  is  that  the  dis- 
ease is  not  propagated  by  material  conveyed  dirediy 
from  the  sick  to  the  well;  that  some  material  after 
leaving  the  body  of  the  patient  undergoes  some  change 
outside  of  his  body,  and  after  this  change  produces 
yellow  fever  in  one  susceptible  to  that  disease. 

This  change,  which  takes  place  outside  of  thfe  body  ot 
the  sick  man,  may  be  : 

A.  A  change  in  physical  condition  of  the  excretioQ 
containing  the  microorganism  rendering  it  able  to  reach 
the  proper  atrium  for  the  infection  of  others.  Analogous 
to  the  drying  and  pulverization  of  tubercular  sputum, 
etc.,  etc. 

B.  The  infection  of  a  host,  by  which  host  (.or  its 
offspring)  the  microorganism  is  transmitted  analogous 
to  the  transmission  of  malarial  fever,  or  the  Texas  fever 
of  cattle. 


April  G,  19G11 


PROPAGATION  OF  YELLOW  FEVER 


[Thk  Phil.adei,phia 
Mkdicai.  Journal 


695 


C  A  change  in  the  microorganism  itself;  it  under- 
going development  outside  of  the  human  body  into 
some  stage  different  from  that  in  which  it  leaves  the 
body. 

This  last  has  been  the  theory  accepted  by  most  of 
the  writers  who  have  considered  this  subject,  but  there 
is  no  analogy  with  the  propagation  of  any  other  disease, 
so  far  as  is  known  to  the  writer. 

So  far  as  postulate  first  is  concerned  the  conveyance 
of  yellow  fever  by  this  mosquito  as  a  host  is  perfectly 
consistent  with  it. 

As  for  postulate  second  this  theory  would  make  an 
environment  "  infected  "  if  infected  mosquitoes  existed 
there,  and  "  infectible  "  or  its  reverse  as  the  culex  fasci- 
atuR  was  present  or  not.  If  an  investigation  shows  its 
absence  (or  general  absence)  in  noninfectible  localities 
and  the  converse  it  would  be  very  strong  corroborative 
evidence. 

I  am  informed  that  this  mosquito  was  abundant  the 
past  fall  in  Washington,  D.  C,  a  place  usually  consid- 
ered (although  for  not  sufficient  reasons)  a  noninfect- 
ible one. 

To  the  above  two  postulates  the  writer  is  inclined  to 
add  a  third  one,  viz.,  "  that  a  certain  period  of  time, 
from  the  exposure  to  the  patient,  is  necessary  for  an 
environment  to  develop  infection." 

But  while  this  is  supported  by  a  good  many  obser- 
vations, and  is  he  believes  true,  yet  it  is  not  universally 
admitted,  as  are  the  other  two.  It  will,  therefore,  not 
be  considered  on  the  basis  of  an  admitted  postulate. 

The  theory  of  the  mosquito  host  is  also  perfectly 
consistent  with  this — as  are  both  of  the  other  two 
theories  of  infection. 

Third. — lafection  may  apparently  be  retained  a  long 
time  by  an  environment  without  a  reinfection.  That  is,  a 
case  of  yellow  fever  may  be  contracted  from  an  environ- 
ment after  a  considerable  period  of  time  from  the  last 
exposure  of  that  environment  to  infection.  I  do  not 
mean  cases  like  those  aboard  the  Plymouth,  which  were 
altogether  exceptional,  or  the  occasional  hibernation  of 
the  fever  in  the  United  States.  I  mean  cases  like  the 
following — I  quote  from  only  one  season's  note  book: 

"  British  ship  Avon,  in  rock  ballast,  22  in  crew,  all 
except  4  nonimmune,  left  Rio  Janeiro  April  20,  1900. 
All  well  in  port  and  en  route  until  the  thirty-ninth  day 
out,  when  entering  Ship  Island,  a  boy  sickened  with 
yellow  fever  and  died ;  one  other  man,  a  quarantine 
employe  who  assisted  in  cleaning  up  the  room  where 
this  boy  was  treated  aboard  ship,  sickened  14  days 
after." 

"  British  ship  Curlew,  from  Rio,  in  rock  ballast,  crew 
mainly  nonimmune.  All  well  in  port,  en  route,  and  on 
arrival.  After  cleaning  ship,  one  man  sickened  with 
yellow  fever,  64  days  from  Rio." 

"  British  ship  Chippewa,  from  Rio,  rock  ballast,  21  in 
crew,  all  save  3  men  and  the  master  nonimmune  to 
yellow  fever.  All  well  in  port,  en  route,  and  on  arrival. 
After  cleaning  ship,  one  man  sickened  with  yellow 
fever,  68  days  from  Rio." 

None  of  these  vessels  made  a  port  of  call  (except 
Pensacola)  on  the  way  up,  and  the  date  of  leaving  Rio 
was  positively  the  last  possible  chance  for  any  one  of 
these  vessels  to  acquire  infection.  We  have,  then,  per- 
sistence of  infection  for  not  more  than  39,  64,  and  68 
days. 

Although  the  life  history  of  Finlays  mosquito  has 
not  been  worked  out,  the  intervals  of  time  here  given 
exceed  the  life  of  any  of  the  culicides  whose  life-history 


is  known  and  exceeds  that  given  by  Finlay  for  his. 
He  states  (verbal  communication)  that  he  has  kept  the 
female  of  his  culex  alive,  after  feeding,  only  from  8  to 
14  days ;  that  the  time  from  eggs  Inid  in  water  to  the  time 
mosquito  is  from  about  14  to  18  days.  This  agrees 
fairly  well  with  what  has  been  found  for  other 
culicides. 

To  explain  cases  like  the  above  which,  while  not 
common,  are  by  no  means  very  exceptional  on  sailing 
vessels,  in  accordance  with  the  theory  of  conveyance  by 
the  mosquito,  one  of  three  hypotheses  must  be  adopted. 

1.  This  mosquito  has  a  far  longer  life  than  the  other 
culicides,  or  than  Finlay  has  been  able  to  keep  him  in 
confinement. 

Observe,  there  is  no  question  of  hibernation  here , 
the  route  from  Rio  to  Chandeleur  in  the  spring  and 
early  summer  is  all  under  tropical  conditions. 

2.  Unrecognized  cases  of  yellow  fever  had  occurred 
abroad  en  route. 

3.  That  the  immediate  progeny  of  the  infected 
mosquito  coming  aboard  in  Rio,  are  themselves  infected 
and  capable  of  transmitting  the  infection,  as  is  the  case 
with  the  host  in  the  Texas  fever  of  cattle. 

The  first  is  hardly  reasonable ;  the  time  is  so  much 
in  excess  of  the  life  of  any  other  of  the  culicides.  It  is 
left,  however,  until  the  life  history  of  this  variety  is 
better  known. 

The  second  seems  to  me  also  improbable.  Still  these 
cases  are  not  common,  and  it  is  possible.  Something 
too,  I  think,  not  much,  must  be  allowed  for  the  chance 
of  a  non-flital  case  being  concealed  successfully  from 
the  quarantine  officers. 

The  third  hypothesis  has,  I  think,  not  been  in  terms 
advanced  by  either  Finlay  or  Reed,  but  is  naturally 
implied  (as  a  possibility  at  least)  in  the  theory,  and 
Dr.  Finlay  was  engaged  in  investigating  it  when  I  left 
Cuba.  He  had  secured  eggs  from  a  female  which  had 
been  fed  from  yellow-fever  patients,  some  laid  on  the 
surface  of  the  water,  and  some  on  the  side  of  the  vessel 
above.  These  he  intended  developing  and  experiment- 
ing with  the  resulting  moSquitoes  to  see  if  they  would 
convey  infection. 

Even  taking  this  third  hypothesis,  the  time  for  the 
Curlew  and  Chippeica  (and  there  are  other  cases)  seems 
too  long  to  be  covered  by  the  cycle  from  an  infected 
mosquito  to  the  life  of  his  immediate  progeny  from 
eggs  laid  in  water. 

The  eggs  laid  above  the  surface  of  the  water,  how- 
ever, seem  to  be  able  to  keep  a  long  time  (thirty  days 
in  Reed's  case  with  eggs  furnished  by  Finlay)  and  then 
hatched  out  when  put  in  water.  Taking  this  into  con- 
sideration, even  these  long  periods  of  time  between 
cases,  or  after  leaving  infected  ports  to  first  cases,  are 
not  absolutely  incompatible  with  the  mosquito  theory  ; 
although  they  are  certainly  not  what  we  would  expect 
therefrom. 

Mosquitoes  will  not  breed  in  bilge  water  (Finlay's 
verbal  communication),  and  for  them  to  so  frequently 
deposit  their  eggs  above  water  aboard  ship,  so  that 
they  will  be  wet,  with/rf.s/i  water,  and  come  to  maturity 
just  when  the  vessel  is  cleaned,  is  decidedly  improbable, 
less  probable  than  the  last  hypothesis. 

Fourth. — That  the  infection  of  yellow  fever  is  con- 
veyed by  fabrics,  clothing,  and  bedding  especially,  as 
fomites,  is  well  nigh  a  universal  belief. 

With  this  the  theory  of  Finlay  and  Reed  is  of  course 
absolutely  incompatible. 

I  have  said  that  the  conveyance  by  fabrics,  directly 


696 


The  Philadelphia"! 
Medical  Jocenal  J 


SUPRARENAL  CAPSULE 


[Apeil  6,  1901 


to  men  or  by  infecting  an  environment,  is  universally 
believed.     Is  it  established  ? 

There  are  many  cases  reported  which  are  ascribed  to 
this  origin,  and  the  writer  has  seen  some  which  he 
believed  thus  due ;  those  on  the  Curlew  and  Avon  for 
example;  and  with  the  best  revision  he  can  give  them, 
this  seems  for  many  the  most,  for  a  few  the  only, 
probable  explanation,  although  it  may  not  be  the  only 
explanation  possible. 

Yet  it  is  fair  to  admit  that  his  deduction  from  his 
own  reports  were  influenced  by  his  belief  that  yellow 
fever  was  habitually  thus  conveyed,  and  that  he  did 
not  consider  the  possibility  of  its  being  conveyed  by  a 
host.  He  accepted  this  because  it  was  universally 
accepted  and  because  it  was  in  accordance  with  the 
analogy  of  many  other  transmissible  diseases.  He 
used  it  as  a  proven  theory  to  explain  observations  and 
did  not  make  it  as  a  necessary  deduction  from  facts 
observed. 

There  is  an  experiment  on  a  large  scale  which  bears 
on  this  matter. 

For  a  number  of  years  (preceeding  1899),  a  large 
amount  of  baggage  (used  clothing)  of  passengers  from 
Havana  and  Vera  Cruz  has  been  going  to  New  York 
without  disinfection.  It  is  not  possible  but  that  much 
of  this  stuff  came  from  infected  houses  and  while  most 
of  it  was  clean,  yet  much  of  it  was  not.  All  of  this 
baggage  was  opened  at  the  Custom  House  at  New  York 
and  handled  in  hotels  there  and  at  Saratoga,  and  no 
yellow  fever  is  reported  among  the  Customs  Inspectors 
in  New  York. 

The  baggage  going  from  the  same  ports  to  Spain  for 
last  29  years  is  even  more  to  be  considered.  Its  amount 
has  been  enormous ;  much  of  it  (from  the  class  of 
people  to  whom  it  belongs)  must  have  been  foul.  Some, 
the  lesser  part  it  is  true,  of  this  traffic  goes  to  the 
Mediterranean  ports  of  Spain — Valencia,  Malaga  and 
Barcelona,  etc. — which  at  times,  1870  and  before,  have 
been  infectible  places,  yet  I  think  we  have  had  no  yellow 
fever  reported  in  the  Peninsula  since  the  epidemic  of 
1870. 

The  facts  cited  above  seem  to  me  to  have  great  nega- 
tive weight  and  might  be  balanced  against  the  positive 
evidence  on  this  subject.  It  seems  to  the  writer  that 
the  subject  should  be  reopened,  and  that  cases  where 
this  mode  of  conveyance  is  accused  should  be  care- 
fully scrutinized. 

Fifth. — It  is  generally  held  by  New  Orleans  physi- 
cians, that  certain  precautions  of  cleanliness  will  pre- 
vent the  infection  of  his  environment  by  a  patient  sick 
of  yellow  fever.  These  precautions  take  no  account  of 
the  mosquito,  and,  save  the  general  selection  of  an 
upper  room  for  treatment,  should  not  interfere  with 
their  access  to  the  patient. 

With  this  theory  that  of  conveyance  by  the  mosquito 
is  inconsistent.  There  is  some  good  evidence  for  this 
theory,  yet  it  may  be  questioned  if  it  is  "  proven."  It 
is  not  universally  accepted. 

Sixth. — On  the  other  hand  the  theory  of  conveyance 
by  a  mosquito  is  entirely  consistent  with  the  belief,  very 
general  but  not  universal,  that  yellow  fever  occasionally 
hibernates  in  the  States  north  of  the  Gulf;  as  well  as 
with  the  belief,  less  general,  that  it  does  not  do  so  in 
the  extreme  southern  portion  of  the  United  States, 
mosquitoes  habitually  hibernating  in  the  first  region 
and  not  doing  so  in  the  second. 

There  are  several  other  postulates  relative  to  the  prop- 
agation  of  yellow   fever  which   could    be   advanced; 


but  it  seems  advisable  to  set  out  only  those  which  are 
well-known  and  universally,  or  very  generally,  accepted. 
Indeed  the  last  three  are  outside  of  this  pale — the  last 
one  especially. 


SUPRAREhf AL  CAPSULE— ITS  USE  IN  RHINOLOGICAL 
OPERATIONS. 

Bt  CHARLE.S  C.  ROYCE,  M.D., 

of  Philadelphia,  Pa. 

Assistant  in  Rbinological  CIIdIc,  Jefferson  Medical  College  HoepitaL 

The  literature  is  seemingly  so  full  and  complete  con- 
cerning the  employment  of  suprarenal  capsule  in 
rhinology,  that  one  hesitates  to  further  add  to  it;  yet 
the  results  obtained  by  its  use  as  herein  indicated, 
while  not  altogether  original,  seem  to  justify  recording, 
because  the  writer  cannot  recall  having  seen  this 
method  described  elsewhere. 

In  all  operative  interference  within  the  nose,  it  is 
desirable  to  have  as  small  an  amount  of  primary  hemor- 
rhage as  possible,  and  certainly  no  secondary  hemor- 
rhage. The  last  result  I  have  always  obtained  when- 
ever this  method  was  employed. 

In  doing  a  turbinectomy,  the  naris  is  completely 
filled  with  a  tampon  of  cotton  soaked  in  a  5%  solution 
of  cocain.  This  is  retained  within  the  naris  some  ten 
minutes,  to  be  replaced  by  a  fresh  tampon  similarly 
filled  with  a  like  cocain  solution  and  retained  another 
ten  minutes. 

Before  placing  this  second  cocain-soaked  tampon 
within  the  naris,  it  is  rolled  in,  and  completely  covered 
with  dry  suprarenal  capsule,  (Armour's). 

When  the  second  tampon  is  removed,  a  third  is  put  in 
its  place,  soaked  only  with  a  5%  solution  of  cocain. 
This  third  tampon  remains  in  the  nose  the  same  length 
of  time  as  the  others.  In  this  way  is  complete  and 
protracted  anesthesia  obtained. 

Objections  as  to  the  amount  of  time  incurred  in  this 
method  will  be  raised,  but  the  end  surely  justifies  the 
means. 

In  hospital  practice  this  method  is  obviously  imprac- 
ticable. A  modification  is  to  saturate  a  cotton  tampon 
with  a  5%  cocain  solution,  then  roll  the  same  in  dry 
suprarenal  capsule,  and  tamponade  for  15  minutes. 
The  results  are  much  more  satisfactory  than  with  the 
simple  solution  of  cocain. 

Case  1. — Fred  R.,  25  years  of  age.  Anesthesia  was  ob- 
served for  upwards  of  90  minutes.  The  CJise  wa^s  only  diag- 
nosed as  ethmoidal  empyema.  The  anterior  half  of  the 
middle  turbinate  was  removed,  four  or  five  small  polypi, 
and  the  anterior  ethmoidal  cells  opened  up. 

Case  2. — Edward  O.,  19  years  of  age.  The  patient's  left 
naris  was  anesthetized  with  the  three  separate  tampons. 
The  inferior  turbinate  was  completely  removed.  It  was  a 
great  thick  mass,  twisted  on  itself  posteriorly,  like  a  conch 
shell,  so  that  it  was  impossihle  to  insert  a  catheter  into  the 
eustachian  orifice  by  this  route. 

In  neither  case  did  the  patient  feel  any  pain,  nor  was 
there  any  primary  or  secondary  hemorrhage. 

In  Case  2  I  wish  to  report  an  interesting  sequel. 
While  nothing  other  than  a  slight  general  hyperemia  of 
the  conjunctiva  was  observed  at  the  end  of  the  seance 
within  24  hours  the  patient  complained  of  dizziness 
The  second  day  after  the  operation  his  vision  was  si 
imperfect  that  he  was  compelled  to  abandon  his  work 
By  the  fourth  day  vision  was  normal. 


April  6,  1901] 


A  CLAVICLE  CRUTCH 


PThe  Philadelphia 
L  Medical  Jodbnal 


697 


In  this  relation  it  will  be  recalled  that  F.  R.  Packard' 
had  a  similar  result  after  a  turbinectomy,  only  his 
patient  was  temporarily  blind. 

In  closing,  it  will  not  be  amiss  to  allude  to  suprarenal 
capsule  in  the  treatment  of  hay  fever.  I  have  yet  to 
see  one  case  benefited  where  it  was  used  internally. 
The  dry  powder  used  in  insufflation  does  remove  lachry- 
mation,  coryza  and  the  characteristic  itching,  or  greatly 
modifies  the  same. 

It  is  true  that  pure  suprarenal  capsule  applied  to  the 
mucous  membrane  of  the  nose  is  likely  to  produce 
sneezing,  and  no  little  pain  at  first,  but  one  can  accus- 
tom oneself  to  these  in  view  of  the  relief  which 
supervenes. 

To  meet  such  conditions,  Formula  No.  1  is  suggested  : 

R. — Cocain  (pulv.)  2  grains. 

Suprarenal  capsule 3  drams. 

Amyli,  enough  to  make    1  ounce. 

Mix.— Sig.  Insufflate  ad.  lib. 

In  conjunction  with  Formula  No.  1  during  the  autumn 
of  1900,  I  had  most  happy  results  with  Formula  No.  2, 
which  appeared  in  Medical  Council.  Salicylate  of 
soda  was  substituted  for  salophen.  I  am  advised  that 
this  formula  is  now  on  the  market  in  tablets. 

Formula  No.  2 : 

B. — Heroin  1  grain. 

Atropini  sulph ,',  grain. 

Caffeine  cit   15  grains. 

Sodii  salicylas  75  grains. 

Mix. — Ft.  Cap.  No.  15.    Take  1  three  times  a  day. 


A  CLAVICLE  CRUTCH.  * 

By  carter  S.  COLE,  M.D., 

of  New  York. 


In  Pediatrics,  December  1,  1899,  Dr.  Henry  Ling 
Taylor  illustrates  "  a  new  clavicle  splint,"  which  had,  as 
he  himself  says,  been  invented  by  his  father  20  years 


A  clavicle  crutch. 


'"Reflex  Disturbances  o(  Nasal  Origin,"  The  Philadelphia  Medical 
Journal,  July  IG  1898. 

*  Presented  to  the  Surgical  Section  of  the  New  York  Academy  of  Medicine, 
October  8,  1900. 


before  and  used  as  a  part  of  a  spinal  apparatus.  He 
speaks  of  the  case  in  which  he  used  it  as  a  clavicle 
splint  for  Dr.  Powell,  S.D.,  at  the  latter's  request  several 
years  ago  (about  1896).  Since  that  time  the  constant 
employment  of  the  Taylor  splint  has  convinced  me  that 
one  made  distinctlj'   for  the  purpose  of    supporting  a 


A  clavicle  crutch. 

broken  clavicle  in  the  proper  position,  and  at  the  same 
time  furnishing  a  false  clavicle,  would  relieve  a  great 
deal  of  the  discomfort  to  the  patient  in  the  usual  forms 
of  dressing  for  fractures  of  that  bone,  and  with  it  give 
as  good  results  as  we  could  get  by  more  cumbersome 
methods.  For  more  than  a  year  I  have  used  with  great 
satisfaction  the  splint  presented  here  to-night.  The 
steel  bands  are  held  by  a  thumb-screw,  thus  enabling 
the  easy  change  in  distance  between  the  two  hard 
rubber  supports.  The  latter  are  made  to  fit  in  the  infra- 
clavicular space,  and  also  to  support  the  broken  frag- 
ment of  bone,  and  the  simple  adjustment  of  them  by 
a  thumb-screw  allows  us  to  change  the  angle  of  support 
as  we  may  desire.  The  two  circular  pads,  to  rest  upon 
either  scapula,  connected  by  a  steel  band  may  also  be 
put  further  apart  or  closer  together,  as  the  case  may 
demand.  The  broad  straps  passing  from  the  hard 
rubber  pads  in  front  (over  and  under  the  shoulder)  to 
the  posterior  leather  pads,  grasp  and  hold  the  shoulders 
with  sufficient  firmness  to  dispense  with  all  forms  of 
bandaging.  A  leather  pad  to  fix  the  axilla,  with  a 
loop  through  which  the  lower  strap  can  pass,  would  add 
solidity  to  the  whole,  but  is  not  a  necessary  addition  to 
the  apparatus.  The  employment  of  this  crutch  in  a 
single  case  will  satisfactorily  demonstrate  its  availa- 
bility and  superiority  over  the  ordinary  methods  now 
employed  in  fractures  of  the  clavicle. 


A  NEW  TENACULUM. 
Bv  R.  C.  COFFEY,  M.D., 


of  Portland,  Oregon. 

Below  is  described  an  instrument,  or  set  of  instru- 
ments, which  I  have  devised,  and,  I  believe,  is  useful. 
It  was  intended  to  represent  a  tenaculum  in  idea,  but 
acts  on  a  principle  different  from  any  other  I   have 


gQQ  Tbb  Phii.ai>slphia~] 

MsDicAi.  Journal  J 


A  NEW  TENACULUM 


[APBIL  6,  HOT 


Fio.  1. 


Fio.  2. 


Fia.  3. 


Fig.  6. 


Fici.  8. 


April  0,  1901) 


A  NEW  TENACULUM 


CXhs  Philadelphia 
Medical  Jocbnal 


699 


hitherto  seen  demonstrated.  Because  of  the  manner  in 
which  the  tenaculum  is  hidden  when  not  in  use,  pro- 
truded when  needed,  and  again  drawn  back  into  its  re- 
ceptacle when  it  has  served  its  purpose,  it  has  been 
called  a  "cat-claw  "  tenaculum.  The  mechanical  prin- 
ciple by  which  the  tenaculum  is  protruded  and  brought 


Cut  I. 

into  action  is  new,  I  believe,  as  applied  to  surgical  in- 
struments, and  my  instrument-maker  believes  it  is  new 
as  applied  in  any  kind  of  mechanics.  At  least  we  are 
safe  in  saying  it  is  new  as  applied  to  the  instrument 
represented.  The  accompanying  cuts,  I  hope,  will  suf- 
ficiently illustrate  its  mechanical  principles  and  uses. 
The  instrument  is  composed  of  two  principal  parts,  con- 
sisting of  a  metal  tube  represented  in  Fig.  1,  and  a  steel 
rod  which  fits  inside  the  tube,  represented  in  Fig.  2. 
The  tube  and  rod  represented  are  adajited  to  either 
single,  double,  or  quadruple  tenacula.  It  will  be  ob- 
served, aside  from  being  an  ordinary  straight  tube,  it 
has  two  rings  for  the  index  and  middle  fingers,  a  cham- 
ber on  the  bottom  side  for  the  reception  of  a 
ratchet  which  projects  from  the  lower  side 
of  the  rod,  a  spring  with  a  catch  which 
passes  into  the  chamber  and  fits  in  the 
notches  of  the  ratchet  to  prevent  the  rod 
being  forced  outward  when  traction  is  made 
on  the  tenaculum.  At  the  lower  end  of 
the  tube  will  be  noticed  openings  or  eyes 
through  which  the  fangs  are  protruded. 
Inside  the  tube,  just  at  the  lower  margin  of 
each  opening,  is  a  small  piece  of  metal, 
shown  in  the  sectional  view  represented  in 
Fig.  3,  which  serves  to  direct  the  point  of  the 
fang  out  through  the  opening  and  also  to 
support  it  and  acts  as  a  fulcrum  after  it  has 
been  protruded.  It  will  also  be  noted  that 
on  the  spring  are  two  arms  which  pass  on 
either  side  of  the  tube,  terminating  in 
buttons  by  means  of  which  the  spring  is 
thrown  out  of  the  notch  in  the  ratchet 
by  the  index  and  middle  fingers  when  the 
operator  wishes  to  withdraw  the  fangs, 
rod  has  at  its  upper  end  a  ring  for  the 
its  lower  side  is  the  ratchet  which  receives  the  catch 
of  the  spring.  Near  the  end  of  the  rod  are  two 
hooks  or  fangs  hinged  on  a  rivet.     One  inch  from  the 


end  is  a  slot  into  which  are  fitted  two  other  fangs  when 
the  quadruple  tenaculum  is  needed.  They  are  held  in 
and  hinged  on  to  a  screw  rivet  so  they  can  easily  be 
removed  when  not  needed  or  replaced  when  needed. 
These  fangs  may  be  made  any  length  necessary,  but  the 
curve  must  be  great  enough  to  comfortably  fit  the  tube 
so  the  point  will  not  pass  the  protrusion 
intended  to  direct  them  outward.  Fig.  3, 
representing  a  sectional  view  of  the  instru- 
ment, shows  the  rod  in  the  instrument 
with  fangs  just  beginning  to  project.  As 
the  rod  is  pushed  down  by  the  thumb  the 
fangs  are  forced  out.  If  it  is  pushed  still 
farther  the  points  of  the  fang  may  be  forced 
to  a  point  almost  touching  the  body  of  the 
instrument,  making  of  it  a  very  eS"ective 
hoding  agent.  The  curve  of  the  tenaculum 
thus  formed  is  maintained  by  the  ratchet 
and  spring.  Fig.  4  represents  the  instru- 
ment ready  for  use  with  the  fangs  still  hid- 
den. Fig.  5  represents  the  single  cat-claw 
tenaculum  in  half  curvature.  Fig.  6  repre- 
sents the  quadruple  cat-claw  tenaculum. 
By  removing  the  proximal  fang.  Fig.  6 
would  represent  the  double  cat- claw  ten- 
aculum as  shown  in  Fig.  2.  The  single 
and  quadruple  tenacula  in  Figs.  5  and  6 
are  shown  in  half  curvature.  By  pushing 
the  rod  down  one  notch  farther  the  points 
are  made  to  almost  touch  the  stafi'  of  the  instrument. 
Fig.  7  represents  a  cat-claw  needle  which  might  be 
used  for  passing  ligatures  in  very  inaccessible  places. 
Fig.  8  represents  a  catclaw  knife  with  its  edge  pro- 
tected by  a  second  hook.  This  appliance  may  be  used 
with  advantage  in  removing  sutures  high  up  in  the 
vagina  or  cervix.  These  two  last  appliances,  however, 
are  probably  not  important  and  may  be  fitted  to  the 
rod  used  for  the  single  tenaculum. 

Cut  I  illustrates  one  of  the  uses  of  the  double  tenac- 
ulum ;  namely,  holding  two  membranes  in  position 
for  a  continuous  suture.  The  tenaculum  is  shown  in 
this  case  holding  the  peritoneum  while  a  continuous 


Cut  II. 


The    steel 
thumb,  on 


suture  has  been  passed  around  it  and  drawn,  the  oper- 
ator still  continuing  his  suture  to  the  upper  end  of  the 
wound.  After  the  suturing  is  completed  the  fangs  of 
the  tenaculum  are  withdrawn  and  the  instrument  slips 
out,  leaving  no  opening.     The  double  tenaculum  is  use- 


^QQ       Thb  Philadelphia"! 
Medical  Journal  J 


A  NEW  TENACULUM 


'.PEIL  6,  1901 


ful  also  in  closing  rents  or  incisions  in  any  of  the  hol- 
low viscera  as  well  as  in  applying  continuous  sutures  in 
other  parts  of  the  body. 

Cut  II  represents  the  use  of  the  quadruple  tenaculum 
in  doing  an  operation  for  lacerated  cervix.  The  distal 
fangs  are  pushed  out  into  the  sides  of  the  uterine  body 
while  the  proximal  penetrate  the  anterior  and  posterior 
lips,  holding  the  uterus  down  well,  and  fixing  the  two 
lips  while  the  lacerated  surfaces  are  properly  denuded 
and  later  while  the  sutures  are  passed  and  tied.  The 
stafiF  acts  as  a  guide  so  that  the  operator  knows  exactly 
how  much  of  the  mucous  membrane  is  necessary  to 
surround  the  instrument,  thus  making  a  cervix  of  exact 
and  normal  size.  One  side  may  be  completed  and  the 
sutures  tied  before  the  other  side  is  incised  if  the  oper- 
ator sees  fit,  and  still  he  is  assured  that  his  result  will 
be  accurate.  The  sutures  are  drawn  down  tightly  over 
the  tube  and  tied  firmly,  assuring  perfect  approxima- 
tion as  well  as  an  absolutely  smooth  canal.  It  has  been 
my  observation  that  the  majority  of  operators  do  not 
get  a  smooth,  even  canal,  and  if  a  sound  is  passed  it  is 
hard  to  penetrate  the  body  of  the  uterus  because  of  the 
pockets  which  exist  along  the  course  of  the  newly 
made  canal,  due  to  some  stitches  being  placed  deeper 
than  others. 

The  quadruj)le  cat- claw  tenaculum  is  also  a  very 
valuable  aid  in  doing  a  vaginal  hysterectomy.  The  in- 
strument may  be  introduced  well  up  into  the  body  of 
the  uterus  and  the  fangs  protruded.  A  suture  is  then 
passed  around  the  cervix  and  tied  tightly  around  the 
instrument,  effectually  closing  the  cervical  canal  and 
preventing  any  of  the  secretions  from  the  uterine  cavity 
infecting  the  field  of  operation.  In  this  way  the  uterus 
is  really  forced  uj),  down,  from  side  to  side,  backward 
or  forward,  in  fact  in  any  direction  for  the  convenience 
of  the  operator  with  just  as  perfect  action  as  if  the 
uterus  were  part  of  the  instrument  itself 

The  single  cat-claw  tenaculum  is  especially  useful 
where  a  tenaculum  is  needed  in  deep  or  close  cav- 
ities which,  under  other  circumstances  make  it  diffi- 
cult to  remove  the  ordinary  tenaculum  on  account 
of  its  tendency  to  reinsert  itself  into  everything  with 
which  it  comes  in  contact.  For  instance,  it  is  well 
adapted  for  holding  the  uterus  while  stitches  are  being 
passed  in  the  operation  for  ventrosuspension  of  the 
uterus ;  for  the  sutures  may  be  even  partially  tied 
around  the  instrument;  yet  it  is  withdrawn  without 
complication.  No  amount  of  sutures,  omentum,  gauze, 
or  intestines  will  entangle  this  tenaculum  ;  for  while  it 
is  in  action  the  jjoint  may  be  turned  in  to  such  an  ex- 
tent that  it  will  not  catch  the  surrounding  parts  and  is 
still  easily  withdrawn  along  the  inside  of  the  tube.  The 
instrument  is  manufactured  by  Charles  Truax,  Greene 
and  Company,  of  Chicago. 

\\'hileone  instrument,  the  quadruple  tenaculum,  may 
be  used  as  a  double  tenaculum  by  removing  the  two 
proximal  fangs,  or  as  a  single  tenaculum  by  removing 
all  the  fangs  and  putting  in  a  single  tenaculum  with  a 
wide  base,  it  would  be  more  convenient  to  have  three 
separate  instruments,  a  single  tenaculum,  a  double 
tenaculum,  and  a  quadruple  tenaculum  ;  for  we  fre- 
quently need  at  the  same  operation  the  quadruple  tenac- 
ulum for  a  cervix  operation,  a  single  tenaculum  for  a 
ventrosuspension,  and  a  double  tenaculum  in  closing 
the  abdominal  wall. 


Gerinau  Denuatological  Cou^ress This  Congress 

Will  meet  in  Breelau  on  May  28,  i9,  and  30, 19111. 


Diphtheria  Antitoxin  as  a  Treatment  for  Pneu- 
monia.— At  a  recent  meeting  of  the  Medical  Society  of  the 
Paris  Hnspitals,  Dr.  Talamon  (J(ni.rnal  des  Praticiens,  March 
9,  1901,  No.  10)  reported  observations  made  upon  60  cases 
of  pneumonia,  ranging  in  age  from  5  to  75  years,  treated 
by  enormous  injections  of  antidiphtheritic  serum. 
Ccmplications  due  to  the  serum,  cutaneous  and  articular, 
occurred  in  but  5  cases,  one  of  whom,  an  old  woman,  72 
years  old,  died.  No  cardiac  symptoms  were  noticed,  though 
6  patients  were  between  60  and  75  years  of  age.  All  cages 
showed  albuminuria  while  the  fever  lasted.  Talamon  believes 
that  diphtheria  antitoxin  is  only  contraindicated  in  cases  with 
liver  or  kidney  disease.  Und,er  50.  he  advises  2  or  3  injec- 
tions of  20  com  ;  4  or  5,  over  50.  In  extreme  cases,  6  or  7 
injections  may  be  necessary.  This  should  be  decided  by  the 
temperature;  if  it  rises  again,  the  injections  must  be  con- 
tinued. The  sooner  this  treatment  is  begun,  the  less  will  be 
the  number  of  injections  necessary,  in  very  grave  cases, 
the  injections  should  be  given  twice  daily.  By  the  use  of 
diphtheria  antitoxin,  Talamon  thinks  the  duration  of  the 
pneumonia  is  diminished  ;  the  chance  of  complications  oc- 
curring is  less ;  and  the  mortality  Is  lowered  10%.  Though 
a  man  with  Bright's  disease  or  diabetes  often  cannot  rccDver 
from  pneumonia,  Talamon's  results,  25  caees,  treated  before 
the  fifth  day,  with  one  death  (at  72  years),  predict  a  bright 
outlook  for  this  new  treatment.  Let  us  hope  that  further 
experiments  will  be  undertaken.  Heubner  has  already 
shown  that  diphtheria-antitoxin  is  harmless,  by  the  method 
he  employs  at  the  Chari'i-  Hospital  in  Berlin,  where  every 
child  in  the  ward  receives  an  injection  of  antidiphtheritic 
serum  once  a  month,    [m  o.] 

Suppurative  Chicken  pox,  and  Secondary  Sup- 
purations in  the  Course  of  Chickenpox. — Lucien 
Di54andri?  {Gaz.  Heh.  de  Mid.  et  de  Chirur..  February  24,  1901, 
48me  Antie,  No.  16)  says  the  vesicle  of  chicken  pox  does  not 
normally  suppurate,  although  in  certain  instances  pus  is  met 
with  in  the  lesions  of  the  dieea«e.  In  the  suppnrativA 
form  the  vesicles  usually  evolve  normally,  but  at  the  end  of 
a  day  or  two  they  increase  in  volume,  become  flattened  and 
tilled  with  a  yellowish  or  greenish  pus.  Sometimes  they 
become  umbilicated  and  surrounded  by  an  inflammatory 
areola.  This  suppuration  lasts  several  dayp,  then  the  vesicle 
ruptures  or  desiccates  slowly.  In  these  conditions  the  crust 
is  much  thicker  than  that  met  with  in  ordinary  chickenpox 
and  is  also  much  more  adherent.  Furthermore,  after  it  is 
shed  a  depressed  cicatrix,  analogous  to  that  met  with  in 
smallpox,  remains.  The  duration  of  the  evolution  of  a  sup- 
purating vesicle  may  be  more  than  3  weeks,  whilst  the  nor- 
mal lesions  of  chickenpox  only  persist  for  about  15  days. 
Toe  purulent  transformation  of  "the  contents  of  the  vesicle  is 
often  accompanied  by  a  true  fever  of  suppuration,  as  in 
smallpox.  Among  the  complications  of  suppurating  chick- 
enpox, general  infection,  gangrene,  and  nephritis  are  the 
most  common.  The  bacteriology  of  simple  chickenpox  is 
little  known ;  but  in  suppurating  chickenpox  the  co)n8tant 
presence  of  the  Staphylococcus  pyogenes  has  been  shown  in 
some  instances  associated  with  the  streptococcus.  The  pus 
of  these  lesions  contains  a  number  of  polymorphonuclear 
leukocytes.  On  the  other  hand,  pus  of  smallpox  and  the 
fluid  of  simple  chickenpox  contain  mononuclear  leukocytes 
in  greatest  proportion.  The  difierential  diagnosis  between 
smallpox  and  suppurative  chickenpcx  is  based  particularly 
upon  the  induration  of  the  skin  which  accompanies  the  pus- 
tule of  the  former  disease,  and  also  on  the  fact  that  in  sup- 
purative chickenpox  the  pustules  are  more  elongated  and 
larger  than  those  of  smallpox.  The  suppuration  of  chicken- 
pox  vesicles  has  been  explained  either  by  general  causes, 
such  as  debility  or  cachectic  states  in  patients  or  by  local 
causes  depending  upon  a  former  condition  of  the  skin.  But 
suppurative  chickenpox  is  olten  epidemic  and  contagious, 
and  in  order  to  explain  such  cases  it  would  seem  as  though 
the  patient  had  been  inoculated  by  the  virus  of  chickenpox 
and  the  ordinary  organisms  of  suppuration  at  the  same  time. 
In  the  course  of  chickenpox  secondary  suppuration,  such  as 
furuncles,  abscesses,  and  general  infection  through  the  lymph 
channels  have  been  noticed.  Furthermore,  multiple  ab- 
scesses in  the  skin,  in  the  subcutaneous  tissue,  and  in  the 
joints  and  viscera  have  also  been  recorded  as  complications 
or  as  sequelae  of  chickenpox.  In  such  cases  the  infection  is 
spread  by  the  blood-paths,    [j  m.s  ] 


The  Philadelphia  Medical  Joiinial 

A  Weekly  Journal  Owned  and  Published   by  The  Philadelphia  Medical  Publishing  Company  and   Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James    Hendrie  Lloyd,    A.M,  ^\.li  ,  Editor-in-Chief 
Julius  L.  Salingkr.  M.D  ,  Associate  Editor 
Assistant  Editors 
Joseph  Sajlef,  M.D.  F.  J.  Kalteyer,  M.D, 

I).  L.  Kd*;alL,   M.D.  T.  I  .  CoLEY.   M.D.     ' 

I.  M.  ^-WAN.  M.D.  W.  A.  N.  DORL\ND,    M.D. 

'.  H.  r.iBliON,  M.     . 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the   profession 

are  solicited  for  publication.     Reprints  (2-50)  of  Original  Articles  will  be  furnished 

gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  17IG  Chestnut  St.   Address  all  correspondence  to 

The  Pl»na*lelphia  Medical  Journal,  1716  Chestnut  St.,  Philadelphia,  P». 

See  Advertising:  Page  8. 


Vol.  VII,  No.  i^ 


April  13,  1901 


$3.00  Per  Annum 


The  Cause  of  Vaccinia  and  Variola. — There  has 
been  no  lack  of  reports  concerning-  the  cause  of 
vaccinia,  but  in  spite  of  the  claims  of  a  number  of 
Investigators  that  the  cause  is  a  bacterial  one,  it 
must  be  said  that  the  protozoa  described  years  ago 
by  Guarneri,  Pfeiffer,  and  others,  have,  perhaps,  the 
greatest  number  of  points  in  their  favor  as  the 
actual  cause  of  the  affection.  The  active  interest 
awakened  by  the  earlier  reports  concerning  these 
organisms  has  quieted  down,  because  of  the  years 
that  have  passed  without  any  addition  to  our 
knowledge  concerning  them.  New  interest  has. 
however,  been  added  to  these  organisms  by  the 
recent  report  of  Funck  (Dcutsch  Med  Wocli^  Feb.  28. 
1901),  who  states  very  positively  that  they  are  the 
cause  of  vaccinia ;  indeed,  the  very  positiveness  of 
his  statements  is  likely  to  arouse  a  certain  degree 
of  skepticism.  The  results  he  has  obtained  are, 
however,  of  value,  and  a  more  complete  report  will 
be  awaited  with  interest.  The  organisms  described 
are  aparently  actually  those  written  of  nearly  fifteen 
years  ago  by  the  authors  mentioned,  though  Funck 
gives  further  details  concerning  their  morphology, 
and  contributes  some  additional  points  concerning 
the  method  of  demonstrating  and  studying  them. 
The  chief  point  upon  which  he  bases  his  statement 
that  he  has  demonstrated  their  etiological  relation 
to  vaccinia,  is  his  observation  that  while  the  indi- 
vidual organisms  are  small  and  range  from  i  to  3 
microns  in  diameter,  large  cyst-like  bodies,  which 
have  a  diameter  as  great  as  25  microns,  were  often 
to  be  seen,  and  these  were,  by  careful  examination, 
shown  to  be  filled  with  spores.  A  culture,  in  a  bac- 
teriological sense,  of  these  protozoa,  cannot  be 
made,  but  Funck  states  that  he  took  so-called  sterile 
lymph  which  contained  only  a  small  number  of  the 
protozoa,  and  was  therefore  much  more  readily  ex- 
amined than  the  contents  of  pustules,  smeared  this 
lymph  over  the  surface  of  an  ordinary  agar  plate, 
and  place  it  in  the  thermostat  for  24  hours.  Exami- 
nation at  the  end  of  this  lime  by  means  of  a  low 
Dower  of  the  microscope  enabled  him  to  pick  out 
^fiie  large  spore-containing  cysts  with  readiness,  and 
by  means  of  a  fine  platinum  needle  he  isolated  these 
Ci'Sts.  and  used  them  fur  purposes  of  injection.    The 


injections  produced  what  he  believed  was  a  typical 
vaccinia,  and  after  suffering  from  this  disease,  the 
animals  were  immune  to  inoculation  directly  from 
vaccinia  pustules.  He  states  that  the  protozoa  can, 
by  his  more  complete  and  accurate  methods  of  ex- 
amination, be  found  in  all  vaccinia  pustules  and  in 
the  immediately  surrounding  tissues,  and  he  con- 
siders that  their  constant  presence  in  the  disease, 
together  with  the  fact  that  injection  of  the  isolated 
sporoblasts,  produces  typical  vaccinia,  demonstrates 
conclusively  that  they  are  the  cause  of  vaccinia.  He 
was  also  able  to  find  protozoa  of  identical  appear- 
ance in  a  case  of  variola,  and  concludes  from  this 
that  the  two  diseases  are  due  to  the  same  cause, 
differences  in  the  virulence  of  the  protozoa  being  the 
cause  of  the  variations  in  the  results  of  infections 
produced  by  them.  It  has  been  quite  thoroughly 
established  that  cowpox  is  actually  a  modified  form 
of  smallpox,  and  one  cannot  reasonably  object  to 
Funck's  conclusion  that  variola  and  vaccinia  are 
due  to  the  same  cause.  It  may,  however,  be  prop- 
erly stated  that  the  investigations  reported  do  not 
fully  support  the  statements  made  by  Funck. 
There  are  too  many  possibilities  of  contamination 
in  the  method  used  to  exclude  the  possibility  that 
some  other  infection  was  introduced  at  the  same 
time  with  the  sporoblasts.  The  results  described, 
however,  do  approach  fairly  closely  to  a  demonstra- 
tion that  these  protozoa  are  the  cause  of  vaccinia, 
and,  with  our  present  knowledge,  it  seems  highly 
probable  that  if  they  are  the  cause  of  vaccinia, 
their  virulence  becoming  increased,  they  may  also  be 
the  causeof  variola.  This  report,  taken  in  conjunction 
with  the  older  reports  concerning  the  same  organ- 
isms, constitutes  the  most  interesting  contribution 
yet  made  to  the  nature  of  the  specific  cause  of  these 
two    affections. 

Pregnancy  Subsequent  to  Double  Salpingo- 
Oophorectomy. — The  occasional  report  of  a  gesta- 
tion occurring  in  a  woman  from  whom  both  tubes 
and  ovaries  had  been  removed  at  a  previous  opera- 
tion, attracts  a  passing  attention  and  temporarily 
awakensspeculationasto  thecauseof  such  a  remark- 
able phenomenon.  The  recent  interesting  paper  of 
^lorris   in   the   Hnxtan    )li<liiiil  and    Siirijicdl    Journal    o( 


702 


The   PuiLADF.r.pniA"! 
Medical  Journal  J 


EDITORIAL  COMMENT 


[April  13,  1901 


January  24tli,  brings  the  subject  again  to  the  front. 
Morris  reports  an  instance  of  this  peculiar  accident, 
and  culls  from  the  literature  a  'number  of  other  report- 
ed cases,  the  most  remarkable  of  which  is  that  of  a 
German  surgeon,  the  pregnancy  resulting  in  a  tube 
implanted  in  the  vaginal  vault  after  hysterectomy. 
Such  cases  sooner  or  later  find  their  places  among 
the  curiosities  of  medicine  and  surgery.  It  is  not  at 
all  improbable  that  in  some  such  manner  first  arose 
the  supposition  as  to  the  existence  of  a  third  ovary, 
it  being  at  once  admitted  that  gestation  could  not 
occur  without  the  presence  of  ovarian  tissue  from 
which  a  Graffian  follicle  had  been  developed  and  an 
ovum  discharged. 

In  a  certain  small  percentage  of  female  pelves 
that  have  been  examined  post  mortem  undoubted  in- 
stances of  a  third  ovary  have  been  noted.  A  further 
search  must  be  made,  however,  in  order  to  arrive 
at  a  definite  conclusion  as  to  the  cause  of  these  curi- 
ous.and  at  first  sight  almost  impossible, pregnancies 
occurring  in  women  in  whom  no  such  additional 
ovary  could  be  discovered.  Excluding  the  existence 
of  a  third  ovar)',  two  other  factors  must  be  taken 
into  consideration,  namely,  the  retention  of  a  portion 
of  healthy  ovarian  tissue  after  excision  of  both  oi- 
gans,  and  a  re-patency  of  the  Fallopian  tubes  after 
ligation.  The  case  of  tubal  pregnancy  already  re- 
ferred to  occurred  in  a  patient  in  whom  the  uterine 
appendages  were  retained  and  carried  down  to  the 
vaginal  vault,  where  their  function  not  being  inter- 
fered with,  gestation  was  quite  ])ossible. 

There  has  of  recent  years  occurred  a  marked  reac- 
tion in  the  technique  of  abflominal  section,  and  it  is 
now  recognized  that  whenever  possible  a  portion 
of  ovarian  tissue  should  be  retained  in  the  pelvic 
cavity.  There  thereby  results  an  arrest  of  the  un- 
pleasant phenomena  of  the  induced  menopause,  in 
consequence  of  which  the  patient  is  more  comforta- 
ble and  the  natural  phenomena  of  the  period  of  sex- 
ual activity  continue.  This  retention  of  normal  tissue 
is,  of  course,  a  sine  ijna  mm  for  the  occurrence  of  a 
subsequent  pregnancy,  granted  a  third  ovary  does 
not  exist  in  the  pelvic  cavity.  It  is  not  necessary 
that  the  ovarian  fragment  occupy  its  normal  site:  a 
piece  of  cortical  tissue  transplanted  to  the  uterine 
fundus  or  implanted  in  the  broad  ligament  can  just 
as  surely  functionate.  In  order  for  the  discharged 
ovum  to  find  access  to  the  fertilizing  element,  how- 
ever, a  second  essential  element  in  the  process  must 
be  present,  namely,  a  patent  condition  of  the  Fal- 
lopian tube.  In  fact,  according  to  Frankel,  the  dif- 
ficulty lies  not  in  securing  firm  ligation  of  the  ovi- 
duct, but  in  preventing  a  subsequent  restoration 
of  the  lumen  of  the  stump.  Not  only  has  every 
variety  of  ligature  employed  by  him  to  secure  accu- 
rate apposition  of  the  walls  of  the  tube  failed    to 


accomplish  its  purpose,  but  even  after  resection 
of  a  portion  of  a  tube  and  the  use  of  the  thermo- 
cautery the  tube  has  again  become  patent.  Only 
after  total  exsection  of  the  oviduct  from  the  uterine 
fundus  with  closure  of  the  wound  by  a  peritoneal 
flap  did  he  succeed  in  obliterating  permanently  the 
opening  into  the  pelvic  cavity. 

When  the  foregoing  fact  is  borne  in  mind,  and  it 
is  also  noted  that  in  a  very  large  number  of  abdom- 
inal sections,  as  now  performed,  a  fragment  of 
ovarian  tissue  is  intentionally  retained,  the  wonder 
is  not  that  subsequent  pregnancy  should  occur,  but 
that  it  should  occur  so  infrequently.  This  possibil- 
ity of  retained  fecundity  opens  up  a  new  question 
in  the  agitated  subject  of  conservative  gynecological 
surgery  in  those  cases  in  which  ofifsprmg  may  be 
desired. 

It  will  be  seen,  therefore,  from  the  foregoing 
resume,  that  three  elements  may  be  concerned  in  the 
development  of  the  obstetric  paradox — gestation 
subsequent  to  double  salpingo-oophorectomy — 
namely,  the  possible  presence  of  a  third  ovary,  the 
retention  of  a  fragment  of  functionating  ovarian 
tissue,  and  a  patencj'  of  one  or  both  Fallopian  tubes, 
the  latter  two  facts  being  absolutely  essential  to  the 
occurrence. 

The  Conference  on  Tuberculosis  in  Canada. — 
The  Montreal  Medical  Journal  sees  much  to  hope  fof 
in  the  fact  that  Canada  has  now  a  Tuberculosis 
Conference  of  its  own.  We  congratulate  the  Journal 
and  also  the  Dominion  in  view  of  this  progressive 
step.  Lord  Minton,  the  Governor  General,  gave  his 
full  support  in  helping  forward  the  crusade  against 
tuberculosis  by  calling  the  recent  Conference  at 
Ottawa  and  allowing  himself  to  be  termed  its  "pa- 
tron". The  Montreal  Medical  Journal  sees  in  such  a 
permanent  Association,  working  satisfactorilj'  to 
one  end,  the  promise  of  much  better  results  than 
can  be  obtained  by  sporadic  attempts  to  obtain  leg- 
islation. Its  publications,  as  the  Journal  says,  can 
reach  all  sorts  and  conditions  of  men  from  the 
school  room  upwards.  It  is  an  important  move  on 
the  part  of  the  Association  that  it  established  its 
headquarters  at  Ottawa,  where,  as  the  Journal  says, 
it  can  not  only  make  its  needs  felt  bj- the  Government, 
but  can  also  obtain  upon  its  Council  prominent 
members  of  the  Dominion  Parliament. 

The  addresses  delivered  at  the  recent  conference 
in  Ottawa  were  not  as  a  rule  strictly  scientific,  but 
the  object  of  the  articles  was  evidently  to  bring 
forward  the  general  subject  of  tuberculosis  in  a 
way  that  could  readily  be  understood  by  the  general 
public.  Papers  of  this  kind,  we  are  convinced,  are 
highly  important  in  all  such  Conferences  on  tuber- 
culosis. In  other  words,  these  national  associations, 
which  are  now  getting  to  be  the  fashion,  should  not 


ArRiL  13,  1001] 


EDITORIAL  COMMENT 


CThe  I'nii.AnELPHiA       -ni 
MEi>r  AL  JornxAL         /^J 


apply  themselves  too  strictly  to  technical  papers, 
but  should  devote  part  of  their  time  to  an  endeavor 
to  educate  the  people  on  this  subject.  We  are  to 
be  congratulated  in  this  country  that  there  has  been 
a  large  awakening  of  public  interest,  in  some  parts 
at  least,  on  the  subject  of  tuberculosis.  We  know 
that  in  some  States  an  active  campaign  has  been 
undertaken,  and  that  even  the  pulpit  and  the  lecture 
room  have  been  used  to  disseminate  knowledge. 
This  was  done  so  successfully  in  the  State  of  Maine, 
which  is  near  to  Canada,  that  the  Health  Officer  of 
the  State,  in  his  recent  annual  report,  was  able  to 
claim  that  the  lower  rate  of  mortality  from  tubercu- 
losis was  due  in  part,  if  not  wholly,  to  such  instru- 
mentalities. It  seems  probable  that  the  Twentieth 
Century  will  be  especially  identified  in  the  history 
of  medicine  with  the  great  advances  that  are  to  be 
made  in  the  field  of  public  and  preventive  medicine. 
Tuberculosis,  leprosy,  plague,  yellow  fever,  malaria, 
and  cholera  are  some  of  the  most  conspicuous  dis- 
eases that  call  for  widespread  national  treatment 
and  State  control. 

The  Antitoxic  Action  of  Bile. — The  Literary  Digest, 
quoting  from  several  French  scientific  journals, 
gives  some  curious  information  on  this  subject.  The 
natives  of  Bengal  have  believed  for  centuries,  it 
seems,  that  the  liver  is  a  reliable  antidote  for  hydro- 
phobia, and  they  .  not  "some  of  the  hair,"  but 
some  of  the  liver,  "of  the  dog  that  bit  you."  We 
have  it  on  the  authority  quoted,  that  when  a  mad 
dog  bites  a  man  in  India,  the  animal  is  killed  and 
his  "palpitating  liver"  is  removed,  cut  into  pieces 
and  fed  to  the  patient.  This  is  said  to  be  a  sure 
cure.  To  come  nearer  home,  in  the  interior  of 
France  the  peasants  have  used  bile  as  a  remedy 
for  the  viper's  bite  from  time  immemorial.  This 
empirical  knowledge  seems,  according  to  Neufeld, 
to  be  about  to  acquire  a  scientific  basis.  This  ob- 
server publishes  a  series  of  experiments  in  a  recent 
number  of  the  Zeitgdirift  fur  Hygiene,  which  show  the 
destructive  action  of  the  bile  on  certain  microbes. 
The  action  of  the  rabbit's  bile  is  very  disastrous  to 
pneumococci.  Under  its  influence  these  microbes 
diminish  rapidly,  their  contours  become  less  and 
less  clear,  and  they  finally  disappear  in  the  liquid 
These  bacteriolytic  properties  of  bile  exist  in  the 
healthy  as  well  as  in  the  sick  rabbit,  and  the  bile  can 
dissolve  three  hundred  times  its  volume  of  a  culture 
of  pneumococci.  The  bile  of  man,  as  well  as  of  the 
monkey,  the  guineapig,  the  dog  and  the  cat,  has  this 
faculty,  but  not  so  actively  as  that  of  the  rabbit. 
It  is  claimed  that  a  subcutaneous  injection  of  bile  in 
which  pneumococci  have  been  dissolved,  makes  a 
guineapig  immune  to  infection.  The  serum  of  the 
rabbit's  blood  has  none  of  the  bacteriolytic  action 
of  the  bile.     On  the  other  hand,  the    rabbit's    bile 


exerts  no  such  action  on  the  cholera  bacillus,  the 
bacillus  of  Eberth,  or  the  diphtheria  bacillus.  But 
it  seems  to  have  an  action  on  the  virus  of  hydro- 
phobia. The  active  ingredient  of  the  bile  is  proba- 
bly the  cholic  acid,  a  non-nitrogenized  substance 
formed  in  the  hepatic  cells. 

Traumatism  of  the  Pharyngeal  and  Laryngeal 
Mucous  Membranes. — Among  the  many  interesting 
features  of  the  investigations  which  have  been  car- 
ried on  by  Crile,  of  Cleveland,  for  the  past  few 
years,  are  those  observations  upon  the  inhibitory 
effect  upon  the  respiratory  and  circulatory  appa- 
ratus attending  traumatism  of  the  pharyngeal  and 
laryngeal  mucous  membrane.  In  his  studies  of  the 
pathogenesis  of  shock,  Crile  has  paid  particular  at- 
tention to  the  effect  of  trauma  in  different  regions 
and  tissues  upon  the  blood  pressure,  and  of  par- 
ticular interest  were  the  results  attending  trauma- 
tism inflicted  upon  the  mucous  membrane  of  the 
larynx  and  pharynx.  It  was  found  that  the  subjec- 
tionof  themucosaofthelar3mxor  pharynx  to  anyin- 
sult  always  had  an  inhibitory  effect  upon  the  respi- 
ratory and  sometimes  upon  the  cardiac  apparatus, 
the  upper  or  superior  portion  of  the  larynx  being  par- 
ticularly sensitive.  These  inhibitory  messages  were 
proven  to  have  been  transmitted  through  the  supe- 
rior laryngeal  nerve,  as  upon  section  of  this  nerve 
these  inhibitory  phenomena  were  not  exhibited. 
The  sudden  deaths  attending  the  introduction  of  the 
intubation  or  the  tracheotomy  tube  may,  accord- 
ing to  Crile,  be  accounted  for  in  this  way.  Many 
a  surgeon  can  recall  one  or  more  occasions  in  his 
experience  when  sudden  death  from  respiratory 
failure,  not  from  asphyxia,  immediately  followed 
the  introduction  of  the  tube.  In  some  cases  the 
anesthetic  was  held  at  fault,  in  others  it  was 
said  that  the  tube  had  become  plugged  with  a  piece 
of  membrane,  and  in  other  ways  attempts  were 
made  to  account  for  this  sudden  and  fatal  complica- 
tion. Just  at  the  time  in  which  relief  to  the  already 
partially  asphyxiated  subject  is  at  hand,  sudden 
death  robs  the  surgeon  of  a  recovery  that  seemed 
assured.  That  these  deaths  are  not  due  to  asphyxia 
will  be  admitted  if  one  but  stops  to  think  of  the 
clinical  picture,  noting  particularly  the  almost  in- 
stantaneous interruption  of  the  respiratory  act  in 
sudden  death  from  respiratory  failure,  which  con- 
trasts strongly  with  the  infreased  respiratory 
eft'orts,  lasting  several  minutes,  by  which  the  sub- 
ject with  asphyxia  attempts  to  overcome  the  effects 
of  obstruction  to  the  ingress  of  air.  If  one  could 
anesthetize  the  mucous  membrane  of  larynx  or 
pharynx  before  the  introduction  of  the  intubation 
or  tracheotomy  tube,  or  in  laryngectomies  before 
attacking  the  larynx  itself,  there  is  reason  to  believe 
that  this  complication   could  be  averted.     To  this 


«,(^«        Tnn   rnn.AnKi.rniA"] 
/    "+         Medical  Joiuxal  J 


EDITORIAL  COMMENT 


[April  13.  1901 


end  Crile  has  introduced  into  his  technique  of  this 
operation  the  complete  anesthetization,  by  the  infil- 
tration method,  of  the  tissues  of  the  larynx. 

The  results  of  investigations  upon  the  pharynx- 
would  seem  to  condemn  the  practice  of  vigorously 
swabbing  out  the  fauces  during  ether  narcosis.  This 
is  a  practice  which  no  doubt  is  justified  in  certain 
instances,  as,  for  example,  when  the  collection  of 
mucus  is  large  enough  to  embarrass  respiration. 
We  are  inclined  to  believe,  however,  from  our  ob- 
servations, that  it  is  resorted  to  much  more  fre- 
quently than  necessary,  and  in  such  instances  it 
should  be  regarded  as  a  mischievous  practice.  If,  as 
Crile  reports,  vigorous  traction  of  the  tongue  like- 
wise produces  reflex  inhibition  of  the  respiratory 
function,  some  caution  should  be  observed  in  the 
restoration  of  patients  by  the  Laborde  method — 
the  rhythmical  traction  of  the  tongue.  So,  too,  in 
those  cases  in  which,  in  its  relaxed  state,  the  tongue 
falls  back  into  the  pharynx,  the  anesthetizer  should 
be  mindful  of  this  possible  inhibitory  effect  and 
should  not  apply  the  tongue  forceps  needlessly,  nor 
make  too  vigorous  traction  upon  that  organ. 

Experimental  Hepatic  Cirrhosis. — In  few  varie- 
ties of  hepatic  cirrhosis  is  the  etilogical  relation- 
ship more  clearly  and  definitely  established  than  in 
that  form  due  to  the  action  of  bile  on  the  organ,  in 
the  course  of  obstructive  jaundice. 

Dr.  Vaughn  Harley  and  Dr.  Wakclin  Barratt  have 
recently  published  a  very  valuable  contribution  on 
"The  experimental  production  of  hepatic  cirrhosis" 
t Journal  of  Patholoyy  und  Bacterioloay,  FelJruary,  1901). 
These  observers,  after  careful  and  painstaking 
experimental  researches  made  upon  rabbits  and 
dogs  (on  the  effects  that  are  produced  by  the  liga- 
tion of  a  biliary  duct)  have  deduced  several  impor- 
tant conclusions.  They  demonstrated  that  bile 
continued  to  be  secreted  in  the  area  affected  by  the 
ligation  of  the  biliary  duct.  It  appears  that  the 
bile  escapes  from  the  fine  biliary  capillaries  b}' 
osmosis.  The  constant  presence  of  bile  outside  of 
the  biliary  passages  causes  irritation,  and  interlob- 
ular fibroid  tissue  is  produced. 

The  increase  in  the  interlobular  b>le  ducts,  which 
the  authors  observed,  they  believe  is  due  to  over- 
distentionof  these  vessels,  thereby  causing  longation 
and  tortuosity.  After  a  careful  study  of  their  sec- 
tions, they  do  not  feel  justified  in  sustaining  the 
view  that  new  bile  ducts  are  formed. 

The  atrophy  of  the  liver  cells,  occurring  in  the 
course  of  this  form  of  obstructive  biliary  cirrhosis, 
they  show,  is  most  probabh-  not  due  to  the  con- 
traction of  the  newly-formed  fibrous  tissue,  but  to 
the  toxic  action  of  the  bile.  This  atrophy  primarily, 
and  almost  exclusively,  involves  the  peripheral 
cells  of  the  liver  lobule. 


Different  animals  of  the  same  species,  experi- 
mented upon,  reacted  with  a  considerable  degree  of 
variation,  although  the  operative  procedures  were 

identical. 

The  Classification  of  Disease. — That  medicine 
is  an  art  and  not  a  science,  is  such  a  trite  saying 
that  it  seems  almost  useless  to  repeat  it.  And  yet 
to  read  a  modern  text-book  of  medicine,  particu- 
larly that  department  which  is  designated  by  the 
continentals  as  "internal  pathology,"  brings  the 
matter  to  our  attention  with  such  force,  that  it  is 
worth  while  to  inquire  why  physicians,  of  all  men, 
should  be  so  unscientific  in  the  broader  field  of  their 
work.  That  is  to  say,  in  that  department  in  which 
medicine  is  considered  as  a  whole,  and  not  as  the 
mere  practical  application  of  a  more  or  less  imper- 
fect knowledge  of  therapeutics  to  some  pathological 
symptom  or  morbid  condition.  What  we  mean  by 
speaking  of  the  manifestly  unscientific  nature  of  the 
whole  subject  is  illustrated  by  the  classification  of 
disease.  Now  we  take  it  that  the  following  defini- 
tions, taken  from  the  Standard  Dictionary,  are  fair 
representations  of  the  modern  conception  of  the  sig- 
nificance of  the  word,  (i)  "Disease  is  any  departure 
from,  failure  in,  or  perversion  of,  normal  physio- 
logical action  in  the  material  constitution  or  func- 
tional integrity  of  the  living  organism.  (2)  The 
morbid  condition  resulting  from  such  disturbance 
or  failure  of  physiological  functions."  But  medical 
men  have  emploj'ed  the  word  in  at  least  three  differ- 
ent senses,  none  of  which  are  covered  by  this  defini- 
tion. They  are:  (i)  "Disease  is  a  morbid  condition 
resulting  from   some   particular  pathogenic   agent. 

(2)  It  is  the  morbid  condition  resulting  from  the 
involvement  in  some  definite  manner,  of  a  certain 
tissue,  or  group  of  tissues,  constituting  an  organ, 

(3)  It  is  a  collection  of  symptoms  commonly  occur- 
ring together,  and  apparently  bearing  some  mutual 
relation  to  one  another."  It  will  be  seen  from  these 
three  definitions  that  the  first  involves  the  etiology; 
the  second,  the  pathology,  and  the  third  the  symp- 
tomatology. Perhaps  we  can  make  this  a  little 
clearer  by  illustration.  For  example,  epidemic  cere- 
bro-spinal  meningitis  is  a  special  form  of  disease 
due  to  the  invasion  of  the  organism  by  the  diplo- 
coccus  intracellularis  of  Weichselbaum.  This  usu- 
allv  develops  its  chief  activity  in  the  pia-arachnoid 
of  the  brain  and  spinal  cord,  and  is  therefore  a  dis- 
ease according  to  the  first  definition.  Acute  cere- 
bro-spinal  leptomeningitis  is  an  acute  inflammatory 
process  affecting  the  pia-arachnoid  of  the  brain  and 
cord,  and  may  be  produced  by  a  great  variety  of 
microorganisms,  besides  the  meningococcus.  It  is 
a  disease  according  to  the  second  definition.  Finally 
we  mav  have  a  condition  characterized  by  certain 
svniptoms,   such  as    headache,    photophobia,    and 


April  13.  inoii 


EDITORIAL   COMMENT 


["Tie  Phit-adelphia        70? 
L  Medical  Journal         /^O 


retraction  of  the  head,  from  which  the  patient  may 
recover  or  die,  and  absolutely  no  pathologic  changes 
can  be  discovered  in  the  central  nervous  system. 
This  is  sometimes  spoken  of  as  meningism,  and 
would  be  a  disease  whose  sole  characteristic,  accord- 
ing to  our  present  knowledge,  would  be  an  occur- 
rence together  of  a  certain  group  of  symptoms.  Or, 
to  take  a  more  familiar  example,  we  might  speak  of 
migraine,  which  has,  as  far  as  we  know,  no  anatomi- 
cal or  definite  etiological  basis.  Now,  unfortu- 
natel}^  in  our  text-books  on  medicine,  the  authors 
do  not  content  themselves  with  the  adoption  of  a 
single  definition  of  this  nature,  classifying  all  dis- 
ease according  to  it,  but  they  jumble  all  three  to- 
gether in  a  most  heterogeneous  and  unsatisfactory 
fashion.  The  great  majority  believe  that  thej- 
approximate  accuracy  if  they  give  an  etiological 
classification,  and  they  proceed  to  do  this  as  far  as 
possible.  Nevertheless,  they  describe  croupous 
pneumonia  in  the  "diseases  of  the  lungs" ;  they  put 
together  all  the  forms  of  acute  leptomeningitis,  ex- 
cepting the  epidemic  form,  and  place  them  in  "dis- 
eases of  the  nervous  system" ;  they  put  tlie  epidemic 
form,  very  properly,  it  is  true,  according  to  their 
adopted  system,  in  the  "infectious  diseases"  They 
do  not  discriminate  between  the  various  forms  of 
pericarditis,  appendicitis,  and  pleuritis,  although 
any  one  of  these  diseases  may  be  due  to  a  great 
variety  of  specific  germs.  They  do  not  even 
attempt  to  carry  out  their  own  principles.  A  sec- 
tion is  devoted  to  diseases  of  the  kidneys ;  one  to 
diseases  of  the  lungs ;  although  both  of  these  organs 
may  be  affected  by  tuberculosis,  and  these  two 
forms  should  properly  be  grouped  together.  The 
different  types  of  cirrhosis  of  the  liver  are  discussed 
as  patholigical  entities,  not  etiological,  and  the  func- 
tional diseases  of  various  kinds  are  grouped,  often 
without  reference  to  the  organ  affected,  or  even  to 
the  characteristic  symptoms,  as  a  rule  in  the  section 
on  nervous  diseases,  where  many  of  them  certainly 
do  not  belong.  Of  course,  it  will  be  urged  that  this 
unscientific,  and  to  a  certain  extent,  unsatisfactory 
method  of  classification  is  caused  by  the  limitation 
of  our  knowledge.  That  we  are  not  sufficiently 
acquainted  with  the  etiology  of  many  diseases :  that 
it  is  necessary  for  convenience  to  group  the  various 
affections  of  the  different  organs  together,  and  that 
the  diseases  characterized  only  by  symptom  groups, 
are  usually  instances  of  disturbed  nervous  energy, 
or  at  least  disturbance  of  certain  of  the  ductless 
glands  whose  functions  are  not  clearly  understood, 
may  be  granted,  and  yet,  if  it  is,  it  would  seem 
more  rational  either  to  discard  the  etiological  factor 
as  far  as  possible,  or  to  adopt  it  to  the  fullest  possi- 
ble extent,  and  to  gfroup  the  other  diseases  accord- 
ing to  pathological  processes,  rather  than  according 
to  origans. 


It  is  our  firm  conviction  that  the  confusion  of 
the  other  prevailing  method  is  rather  a  matter  of 
custom,  than  of  the  actual  superiority  or  necessity. 
Unfortunately,  at  the  present  day  men  take  a  broad, 
comprehensive  view  of  medicine  as  a  whole,  but 
each  is  devoting  himself  to  some  little  domain,  or 
to  the  exposition  of  some  particular  fad,  and  the 
exposition  of  the  mutual  relations  of  the  different 
parts  suffers. 

The  Social  Evil  in  Nev?  York  Tenement  Houses. 
—  The  Committee  of  Fifteen,  which  is  now  trying 
in  a  practical  way  to  bring  about  some  reforms  of 
vice  in  New  York  city,  has  taken  up  the  subject  of 
prostitution  in  the  tenement  houses  of  that  city.  In 
a  letter  recently  written  to  Governor  Odell,  it  says 
that  the  existing  condition  of  affairs  is  not  only 
deplorable,  but  intolerable.  It  seems  that  the  prac- 
tice of  prostitution  has  become  very  prevalent  in 
these  over-crowded  tenement  houses.  The  Com- 
mittee draws  attention  to  the  fact  that  the  most. 
shocking  feature  of  this  evil  is  the  prostitution  of 
young  children.  "Women  of  ill-repute  find  shelter 
in  these  houses,  where  they  are  apparently  exempt 
from  police  surveillance,  and  here  they  sow  the 
seeds  both  of  vice  and  of  the  venereal  diseases  in  a 
promiscuous  population,  both  of  young  and  old  of 
both  sexes.  The  social  evil  must  be  attacked  and 
exterminated  in  the  tenement  houses  before  any 
permanent  control  can  be  gained  over  it  in  that 
city.  The  Committee  endorsed  the  legislation  pro- 
posed by  the  Tenement  House  Commission.  We 
learn  from  the  iledknl  Recnd  that  the  penalty  for 
allowing  any  part  of  a  tenement  house  to  be  used 
for  immoral  purposes  is  a  fine  of  one  thousand  dol- 
lars, which  shall  be  a  lien  on  the  property.  This 
makes  the  owners  of  such  houses,  and  not  the 
wretched  women  who  pursue  their  avocation  in 
them,  directly  responsible  for  suppressing  this  vice. 


The  Symptoms  and  Treatment  of  Mercurial  Sore-Throat. 
— A.  I.  Liiants  (KliiiitsJieisky  Jminial.  December  1300J  be- 
lieves that  the  mercurial  affection  is  as  a  rule  circum- 
scribed and  limited  to  certain  areas.  Frequently  the  in- 
flammation is  bilateral.  In  the  majority  of  cases  only  the 
pharynx  is  affected,  the  mucous  membrane  of  the  gums, 
cheeks  and  tongue  remaining  healthy.  Mercurial  angina 
is  accompanied  by  pain  on  deglutition  which  is  at  times 
severe  and  transmitted  to  the  ear  and  temples,  and  also 
painful  enlargement  of  the  submaxillary  glands.  Acute 
onset  with  diffuse  redness  of  the  mucous  membrane  of  the 
throat,  dizziness,  headache,  nausea  and  vomiting  and 
elevation  of  the  temperature  is  rarely  observed.  The  ne- 
crosis of  the  epithelium  produces  Indentations  which  are 
covered  by  a  graj-ish-white  substance  composed  mainly 
of  epithelial  debris.  These  erosions  are  superficial  al- 
though they  have  a  tendency  to  extend  to  the  deeper 
structures.  To  prevent  mercurial  inflammations,  the  pa- 
tients takingmercury  should  wash  their  mouth  with  some 
antiseptic  both  before  and  after  each  dose.  The  mercurial 
angna  is  best  treated  with  peroxide  of  hydrogen,  while  the 
ulcerations  should  be  treated  by  applications  of  nitrate 
of  silver,  chromic  acid  and  glycerin-emulsion  of  iodoform. 
[A.  R.J 


•}Ci(\       Tbe   PhiladelphiaI 
/^^        Medical  Joubxai.  J 


CORRESPONDENCE 


[APEIL  13,  1901 


(Iorre5pon^cncc. 


THE  OXYTOXIC  ACTION  OF  SPINAL  ANESTHESIA 

BY    S.    MARX,    M.    D. 
of  New  York  City. 

To  the  Editor  of  "The  Philadelphia  Medical  Journal." 

Sir: — In  your  issue  of  last  week,  date  March  23.  I  note 
your  leader  entitled  "The  Oxytoxic  Action  of  Spinal  Anaes- 
thesia," I  read  your  comments  with  considerable  surprise, 
elnce  they  are  at  variance  with  the  views  held  by  men 
well  experienced  with  this  form  of  anaesthesia.  This 
differing  in  opinion  is  the  right  and  privilege  of  all  free 
men;  it  should  always  be  encouraged  in  order  to  fathom 
that  which  we  all  are  after;  scientific  truth.  This  is 
■well  exemplified  in  your  editorial  so  far  as  the  general 
run  of  statements  go.  So  far,  so  good,  but  when  further 
on  I  note  the  tone  of  some  of  the  sentiments  expressed 
I  certainly  wish  to  call  an  emphatic  halt.  Spinal  cocain- 
Ization  will 'never  supplant  cerebral  anaesthesia,  because 
It  will  ever  have  an  extremely  limited  field.  What  this 
limitation  is  does  not  enter  into  consideration.  I  feel  sat- 
isfied that  the  gentleman  who  wrote  this  editorial  is  a  cap- 
able and  careful  writer  and  that  the  errors  committed  in 
the  following  lines  are  not  those  of  a  deliberate  misquota- 
tion but  errors  of  inadvertence.  "The  very  decided  mor- 
tality rate  attendant  upon  cocaine  injections,  etc."  Now, 
Mr.  Editor,  in  a  spirit  of  fairness,  of  honesty,  of  equity, 
■will  you  kindly  state  in  your  next  issue  upon  what  evi- 
dence you  base  your  remarks.  More  than  likely  you  were 
Infiuenced  by  the  remarks  made  in  the  New  York  Academy 
of  Medicine  some  months  ago.  Are  you  aware  of  the  fact 
that  the  very  men  who  alarmed  the  whole  community  by 
their  wholesale  misrepresentations  of  facts  were  men 
•with  little  or  no  experience  in  this  method  at  all?  I  can 
tell  your  readers  something  which  has  never  appeared  in 
print  before;  why,  I  do  not  know,  though  it  occurred 
la  open  meeting  before  the  Greater  New  York  Medical 
Association.  The  gentleman  who  was  supposed  to  be  re- 
eponsiLle  for  the  following  damning  statement  absolutely 
denieci  having  said  so  and  had  excused  those  men  for 
having  twisted  words  in  his  own  mouth.  His  supposed 
words  were  to  the  effect  that  a  certain  French  operator 
had  reported  that  out  of  100  punctures  there  were  only 
17  successes  and  5  deaths.  These  remarks  were  made 
before  the  most  prominent  society  of  this  country.  They 
"were  writi-'n  and  copied  and  sent  broadcast,  north,  east, 
south  and  west.  When  these  same  men  were  proven 
xvrong;  that  their  quotations  were  decidedly  fakey,  when 
the  medical  journals  and  their  reporters  who  were  present 
on  the  two  occasions  knew  well  the  same,  did  any  of  them 
have  the  honesty  of  their  convictions  and  state  In  writ- 
ing In  such  large  letters  that  the  whole  world  could  read, 
that  they  wished  to  correct  a  wrong?  If  It  has  ap- 
peared, I  for  one  have  not  seen  It  In  the  many  of  the 
hundreds  of  cases  of  spinal  anaesthesia  reported,  Tuffier 
la  the  only  one  who  reports  a  fatal  case,  but  the  autopsy 
with  Its  heart  and  lung  lesions  makes  me  rather  a  doubt- 
ing Thomas  as  to  the  real  cause  of  death.  There  have 
been  rumors  of  deaths  in  various  parts  of  the  country  but 
on  Investigation  they  all  as  quickly  disappear  as  the  snow 
does  before  the  spring-time  sun.  Now,  as  to  another 
•erroneous  quotation  and  a  personal  one:  "Thus  Marx, 
of  New  York,  In  a  series  of  cases  thus  treated,  was 
compelled  to  hasten  delivery  In  16  instances  by  the  ap- 
plication of  forceps."    This  statement  I  never  made  and  I 


call  for  proofs.  Nearly  all  of  my  cases  were  operative  ones 
or  were  made  so  because  of  the  presence  of  an  ever  In- 
quiring audience.  All  my  cases  were  delivered  before  an 
audience  of  physicians,  and  while  they  were  willing  to  re- 
main for  a  short  time  to  watch  the  progress  of  labor  they 
were  most  unwilling  to  camp  out  over  night  in  a  pauper  ' 
hospital  to  watch  a  tedious  labor  case,  no  matter  what 
the  inducement  was,  short  of  a  pecuniary  one  and  that 
neither  the  commissioners  nor  I  were  willing  to  stand  fcr. 
Enough  to  my  own  satisfaction  was  the  proof  that  most 
of  the  cases  would  have  delivered  themselves  normally  even 
as  they  would  have  done  under  ordinary  conditions.  Only  in 
one  case  did  I  notice  secondary  weak  pains,  but  since  thia 
occurs  quite  often  during  the  parturient  act  I  could 
not  at  that  time  nor  can  I  to-day  hold  the  cocaine  re- 
sponsible. Neither  have  I,  on  the  other  hand,  ever  no- 
ticed an  oxytoxic  action  after  spinal  anaesthesia.  I  have 
performed  all  the  obstetric  operations  under  its  influence. 
They  are  all  readily  done  but  not  with  quite  as  much  ease 
as  under  chloroform.  There  was  never  a  greater  predis- 
position to  bleed.  Personally,  I  believe  that  the  contrac- 
tions are  not  influenced  one  way  or  the  other,  neither  made 
stronger  nor  weaker.  Now,  Mr.  Editor,  this  letter  la 
written  in  a  spirit  of  the  frankest  criticism,  and  I  hope 
you  will  receive  It  in  such  a  spirit  and  grant  me  a  little 
space  in  which  to  ventilate  my  thoughts. 

[Reference  to  the  editorial  in  question  will  show  that  the 
writer,  after  commenting  on  Prof.  Doleris'  suggestion  that 
spinal  injections  of  cocain  should  be  used  to  hasten  slug- 
gish uterine  contractions,  felt  impelled  to  take  the  con- 
servative course  and  refrain  from  speedily  adopting  what 
he  felt  was  a  method  of  treatment  not  yet  demonstrated  to 
be  free  from  danger.  The  experiments  of  Bier  and 
Seldowitsch  indicate  the  possibility  of  serious  results  fol- 
lowing the  cocain  injections.  The  conclusions  of  the 
writer  are  merely  in  accord  with  those  of  other  students  of 
surgery,  notably  Keen  and  Da  Costa,  who  In  the  last  vol- 
umne  of  the  American  Year-Book  of  Medicine  and  Sur- 
gery, remark  that  "the  real  value  of  the  method  Is  tin- 
certain,"  and  again  the  "view  that  absorption  of  cocain 
produces  the  unpleasant  after-effects  seems  to  receive 
confirmation  from  the  fact  that  the  injection  of  normal 
salt-salutlon  Into  the  subarachnoid  space  Is  not  followed 
by  giddiness,  vomiting,  or  headache.  "As  to  the  state- 
ment concerning  the  statistics  of  Prof.  Marx,  we  would 
kindly  refer  to  an  editorial  In  The  Lancet  of  March  2, 
1001.  When  ample  statistics  are  at  hand  to  prove  con- 
clusively the  desirability  and  safety  of  lumbar  puncture 
for  Inertia  or  other  conditions,  the  writer  will  prove  that 
he  is 

"Not  the  first  by  whom  the  new  Is  tried 
Nor  yet  the  last  to  lay  the  old  aside." 


Fixation  Abscesses. — About  ten  years  ago,  Professor 
Fochier  proposed  the  production  of  abscesses  by  the  sub- 
cutaneous injection  of  an  irritapt,  as  a  treatment  for  grav« 
septicemia.  Amozan  (Journal  de  Medecine  de  Bordeaux, 
March  17,  1901.  No.  II.)  reports  eight  cases  in  which  ha 
followed  this  plan.  They  were  cases  of  pneumonia,  typhoid 
fever,  phthisis,  and  bronchitis.  Four  of  them  recovered, 
two  improved  greatly,  and  two  died.  Turpentine  was  used 
as  the  Irritant,  and  those  who  died  both  had  nephritis. 
Great  car©  should  be  taken  to  avoid  secondary  infection, 
as  the  fixation  abscess  Is  perfectly  sterile^  Amozan  be- 
lieves that  the  polynuclear  leukocytes,  which  accumulate 
on  reaching  the  abscess,  there  give  up  the  microbes  which 
they  have  absorbed  from  the  blood.  Were  It  not  for  this 
means  of  exit,  the  polynuclesir  leukocytes,  on  reaching  a 
hematopoetic  organ,  might  become  the  cause  of  autointox- 
ication.    [SL  O.] 


[April  13.  inni 


AMERICAN  NEWS  AND  NOTES 


CThe   Philadelphia 
Medical  JouhnaIi 


707 


Hmcrican  IRcwo  an^  IRotcs. 


PHILADELPHIA,    PENNSYLVANIA,    ETC. 

College  of  Physicians. — At  a  meeting  of  April  3.  Dr. 
James  Tyson  read  A  IVlemorial  of  the  late  Dr.  William 
Pepper.  In  it  he  reviewed  tlie  worli  of  that  great  man  as 
a  physician,  teacher,  organizer,  founder  and  philanthrop- 
ist. 

Dr.  S.  Osmond  Goldan,  of  New  York,  read  a  paper  on 
Nitrous  Oxide  and  Oxygen  as  a  Surgical  Anesthetic;  De- 
scription of  a  new  apparatus  for  administering  these 
gases,  report  of  100  operations,  the  narcosis  lasting  half 
an  hour  upward;  rerparks  regarding  the  use  of  nitrous 
oxide  as  a  preliminary  to  ether  in  general  anesthesia. 
Nitrous  oxide  and  oxgen  was  stated  to  be  a  safe  anesthetic, 
to  which  there  is  no  contraindication.  Nitrous  oxide  is 
said  to  cause  anesthesia  by  asphyxiation  but  by  the  fact 
that  it  \vill  produce  anesthesia  when  oxygen  is  given  in 
conjunction  with  it.  When  more  than  30  per  cent,  of 
oxygen  is  used,  anesthesia  cannot  be  obtained.  In  the 
use  of  this  anesthetic  there  must  be  given  the  full  atten- 
tion of  the  administrator.  The  patient  should  be  placed 
on  the  operating  table  first.  The  nitrous  oxide  is  first 
begun,  about  6  breaths  of  it  being  given,  then  oxygen. 
Anesthesia  is  induced  in  from  60  to  120  seconds. 
The  apparatus  is  a  7-shaped  tube  with  a  cut  off  to  regu- 
late the  amount  of  oxygen  given.  The  100  cases  reported 
consisted  of  hysterectomies,  nephrectomies,  ampu- 
tlon  of  the  breast,  etc.  The  time  varied  from  one  half 
hour  to  2  hours  and  40  minutes.  The  pulse  is  raised 
very  little  above  the  normal  if  any.  and  respirations  re- 
main about  normal.  Nausea,  vomiting  and  headache  fol- 
low in  some  cases,  the  latter  not  being  severe.  Alcohol- 
ics are  difficult  to  get  under.  The  large  quantities  of 
gas  used  make  it  the  most  expensive  method  in  use. 
Nitrous  oxide  is  also  of  value  as  a  preliminary  to  the 
use  of  ether.  Dr.  Thomas  R.  Brown,  of  Baltimore,  stated 
that  he  had  used  nitrous  oxide  as  a  preliminary  to  ethei 
anesthesia  in  15  or  20  cases  and  that  his  faith  in  the  meth- 
od increased  with  the  number  of  cases  in  which  it  was 
used.  Dr.  John  G.  Clark  said  that  with  this  method  a 
specialist  was  needed  to  give  the  anesthetic.  With  the 
present  arrangement  regarding  hospitals  it  was  not  prac- 
ticable here.  In  the  London  hospitals  where  professional 
anesthetizers  are  hired,  it  would  probabyl  work  very  well. 
Dr.  Keen  stated  that  Dr.  Goldan  had  anesthetized  pa- 
tients in  his  clinic  that  day  and  that  he  was  well  pleased 
with  the  results  attained,  very  little  cyanosis  being 
caused.  Dr.  Goldan  said  that  hospital  internes  should  be 
arranged  as  junior  and  senior  so  that  one  experienced 
man  would  be  anesthetizing  and  the  new  man  simply 
watching  and  helping  him  for  the  first  months  of  his  ser- 
vice. He  believes  that  all  minor  operations  should  be 
done  under  nitrous  oxide  and  oxygen  anesthesia.  If  it 
will  not  answer  then  another  anesthetic  can  be  used. 

A  paper  by  Dr.  Orville  Horwits  entitled  Hydrocele — Its 
Treatment;  Summary  of  338  Operations;  Description  of 
a  new  method  suggested  by  Doyen  for  the  radical  cure 
ot  Hydrocele  of  the  Tunica  Vaginalis,  was  read  by  Title. 

Physician  Killed  by  an  Insane  Patient. — Dr.  R.  Erskine 
Johnston,  of  the  Medical  Staff  of  the  State  Hospital  for 
the  Insane,  at  Danville,  was  killed  by  a  patient  in  that 
Institution.  Dr.  Johnston,  who  entered  the  room  of  the 
patient  in  order  to  take  his  temperature,  was  warned 
by  the  insane  man  to  keep  away  from  the  bed.  The  doctor 
called  an  attendant  to  a.ssist  him.  the  latter  holding  one 
hand  of  the  patient,  while  the  physician  taking  the  other, 
seated  himself  at  the  side  of  the  bed.  Disengaging  his 
right  hand,  the  patient  struck  Dr.  Johnston  several  blows. 
The  doctor  staggered  out  of  the  room,  fell  over  and  ex- 
pired. Where  each  one  of  the  blows  took  effect  on  the 
doctor's  body  a  puncture  was  found  as  if  produced  by  a 
slender  instrument.  The  matter  Is  being  thoroughly  in- 
vestigated. 

Presentation  of  Dr.  Keen's  Portrait. — The  stu- 
dents of  Jefferson  Medical  College  presented  to 
that  Institution  on  Thursday  evening,  April  4,  a  portrait  of 
their  Professor  of  Surgery,  Dr.  W.  W.  Keen.  The  ex- 
ercises  were   held   in   the   amphitheatre   of  the   Jefferson 


Medical  College  Hospital,  which  was  beautifully  decor- 
ated with  palms  and  college  colors.  The  presentation 
speech  on  behalf  of  the  students  was  made  by  Prof.  J. 
Chalmers  De  Costa,  with  his  usual  eloquence.  The  ad- 
dress of  acceptance  was  made  by  William  Potter,  Presi- 
dent 01  the  Board  of  Trustees,  who  spoke  of  the  fidelity  of 
the  students  to  their  alma  mater.  The  portrait  shows  Dr. 
Keen  wearing  the  robes  of  a  Fellow  ot  the  Royal  College 
of  Surgeons. 

Vital  Statistics  of  Philadelphia  for  the  week  ending 
April  6,  1901: 

Total  mortality  490 

Cases.  Deaths. 
Infiammation  of  appendix  7,  bladder  2, 
brain  13.  bronchi  7,  kidneys  14,  lar- 
ynx 2.  lungs  73,  pericardium  1,  per- 
itoneum 6,  pleura  3,  stomach  and  bow- 
els 20   148 

Inanition   IS,   marasmus   13,   debility   6,  37 

Tuberculosis  of  the  lungs 66 

Apoplexy  23,  paralysis  3  26 

Heart-disease  of  31,   fatty  degeneration 

of  1,  neuralgia  of  .5 37 

Uremia  7,  diabetes  2.  Bright's  disease  9,  18 

Carcinoma  of  face  1,  breast  2,  stomach  3, 

uterus  2,  liver  1,  pelvis  1,  tongue  1..  11 

Convulsions  19,  convulsions,  puerperal  3  22 

Diphtheria 72  12 

Brain  abscess  of  2,  congestion  of  3,  soft- 
ening of  2  7 

Typhoid  fever  43  8 

Old  age  10 

Cyanosis    2 

Scarlet   fever    7 

Influenza  1.  aneurism  aorta  1,  alcoholism 
1,  asthma  1,  anaemia  1,  atheroma  1, 
burns  and  scalds  1,  casualties  12,  con- 
gestion of  lungs  2,  cirrhosis  of  the 
liver  2,  diarrhea  1,  drowned  1,  dropsy 
3,  dysentery  1,  eczema  1,  epilepsy  1, 
erysipelas  3,  hemorrhage  from  uterus  '• 

1.  hernia  3,  jaundice  1,  obstruction 
of  the  bowels  2.  edema  of  lungs  3, 
poisoning  2,  pyemia  1,  rheumatism  1, 
sclerosis  arterial  1,  septicemia  5, small- 
pox 1,  sarcoma,  neck  2,  stricture  of 
esophagus  1,  suffocation  4,  suicide  5, 
syphilis  2,  teething  1,  tumor  1, unknown 
coroner  cases  2,  whooping  cough  6  .  .  79 

Legislators  at  the  Jefferson  Hospital. — The  members 
of  the  Legislative  Committee  on  Appropriations  were  the 
guests  of  the  Trustees  of  the  Jefferson  Medical  College 
on  Saturday,  and  were  taken  through  the  various  depart- 
ments of  the  institution  with  the  view  of  demonstrating 
the  need  of  an  additional  appropriation  of  about  $300,000 
from  the  State,  in  order  to  make  many  necessary  en- 
largements  and   improvements. 

The  demands  upon  the  hospital  and  the  inadequate 
facilities  now  predominating  were  shown,  and  the  archi- 
tect's plans  for  a  new  fireproof  hospital  exhibited  to  the 
visitors.  The  Trustees  have  acquired  by  purchase  all  the 
properties  between  the  present  hospital  and  the  old  col- 
lege, and  have  arranged  for  the  construction  of  a  new 
building,  with  an  isolated  Maternity  Department,  of  the 
most  modern  type  of  fireproof  construction  on  the  plot 
bounded  by  Tenth,  Sansom,  Clifton  and  Moravian  streets. 

The  Founder  of  the  U.  S.  Life  Saving  Service. — Dr.  Wil- 
liam A.  Newell,  aged  S3  years,  is  still  a  practicing  phys- 
ician in  Allentown,  N.  J.  In  1839  Dr.  Newell  witnessed  the 
wreck  of  the  Austrian  brig  "Count  Perasto,"  on  Long 
Beach,  Ocean  County,  south  of  Barnegat  Inlet,  on  the 
New  Jersey  coast.  Thirteen  men  of  the  crew  were  drowned 
and  their  bodies  were  washed  up  on  the  sands  the  fol- 
lowing day.  The  force  of  the  gale  was  so  great  that  the 
vessel  was  driven  far  up  on  the  beach,  and  yet  for  want 
of  a  rope  to  the  shore  the  unfortunate  men  were  unable 
to  swim  through  the  surf  to  safety,  although  the  dis- 
tance was  but  short.  The  incident  suggested  to  Dr. 
Newell  the  idea  that  If  some  means  were  devised  for 
throwing  a  line  from  shore  across  a  wrecked  vessel,  many 
lives  might  be  saved.    He  experimented  with  various  kinds 


7o8        ^"^   Phii.adklphiaI 
/  Medical  Jolunal  J 


AMFK     A\  NEWS  AXD  NOTES 


[AlElL  13,  1801 


of  projectiles,  and  later,  when  serving  in  Congress  from 
New  Jersey,  he  secured  legislation  for  establishing  the 
Life  Saving  Service.  Dr.  Newell  was  afterwards  (in  18.57- 
69)  Governor  of  New  Jersey,  and  in  1S61  was  appointed 
by  President  Lincoln  to  be  Superintendent  of  the  New 
Jersey  coast  Llfe-Saving  Service.  From  a  small  begin- 
ning this  life-saving  service  has  grown  to  be  a  great  thing 
and  now  extends  all  along  our  coasts.  To-day  the  Govern 
ment  appropriates  more  than  $1,500,000  annually  for  its 
Bupport,  and  it  is  estimated  that  230,000  lives  have  been 
saved  by  the  methods  which  Dr.  Newell  originated,  and 
in  great  part  perfected,  half  a  century  ago. 

The  Kensington  Hospital  for  Women. — During  the 
month  of  March  thirty-three  patients  were  under  treat- 
ment. There  were  thirty-two  patients  in  the  Hospital 
March  1st,  and  thirty-five  are  under  treatment  at  the  pres- 
ent time.  There  have  been  twenty-four  abdominal  sections 
and  forty-one  plastic  and  other  operations  during  the 
month.  In  the  Dispensary  there  have  been  fifty-three  new 
patients,  who  have  paid  one  hundred  and  ninety-four 
visits. 

Fangotheraphy. — Dr.  W.  C.  Hollopeter,  Professor  of  Pe- 
driatrics  at  the  Medico-Chirurgical  College,  presented  a 
paper  on  the  abos'e  subject  ta  a  recent  meeting  of  the 
Philadelphia  County  Medical  Society.  Fango  is  a  grayish- 
Ijrown  slime  or  mud  obtained  from  certain  Italian  lakes. 
It  contains  iron,  sulphur,  magnesium,  lime,  etc.,  and  its 
properties  are  not  lost  by  transportation.  Its  use  is  indi- 
cated in  diseases  of  the  muscles,  rheumatism,  gout,  neu- 
ralgias, paralysis,  etc.  Local  application  to  the  part  af- 
fected is  made,  a  layer  3  cm.  thick,  at  a  temperature  of 
88  degrees  to  120  degrees  being  used,  the  patient  being 
placed  between  blankets  to  maintain  the  heat.  After 
one-half  to  one  hour  the  fango  is  easily  removed  by  a 
tepid  bath.  Several  cases  in  which  this  treatment  gave 
good  results  were  reported.  Among  them  were  cases  of 
rheumatism,  synovial  swelling  of  the  knee,  gastric  dis- 
turbances, etc.  Dr.  C.  W.  Burr  said  that  the  indica- 
tions for  the  employment  of  this  material  were  the  same 
as  those  for  a  hot  poultice.  He  considers  it  of  no  value  in 
diphtheritic  or  spinal-cord  palsies.  The  chemical  compo- 
sition of  the  mud  probably  plays  but  little  part  in  the 
effect  produced. 

The  Philadelphia  Polyclinic  and  College  for  Graduates 
in  Medicine. — Special  Week  in  Ophthalmology,  May  20th, 
1901.  Durius  this  week,  in  addition  to  the  regular  work  on 
the  eye  and  its  diseases,  given  in  the  Clinics,  there  will 
be  a  number  of  e.xtra  hours  of  demonstration,  clinical  con- 
ferences, and  lectures  devoted  to  the  subject  of  ophthal- 
mology. 

College  of  Physicians. — Section  on  Medicine. — The  first 
case  exhibitod  at  the  regular  meeting  of  .\pril  8  was  one 
of  sacculated  aneurism  of  the  carotid  artery  of  the  right 
Bide.  The  patient  was  an  old  colored  man  who  has  had 
the  aneurism  only  a  few  years. 

Dr.  J.  A.  Scott  exhibited  a  case  of  endocarditis  from 
typhoid  fever.  The  condition  developed  during  a  mild 
attack  of  typhoid  fever  in  which  the  temperature  became 
normal  on  the  2Sth  day.  The  heart  became  irritable  and 
nose-bleed  occurred  once.  The  diagnosis  was  based  on 
the  occurance  of  cardiac  symptoms,  a  systolic  murmur 
which  appeared  during  the  third  week  of  the  disease  and 
\rhich  still  persists  and  is  increasing,  and  on  the  leukocyto- 
els  which  was  as  high  as  15.000.  Drs.  Hare  and  Tyson 
considered  the  case  to  be  rather  one  of  relative  insuffic- 
iency. Dr.  Packard  believed  it  to  be  one  of  endocarditis. 
Dr.  Eshner  saw  no  reason  why  endocarditis,  as  well  as 
phlebitis  and  arteritis  might  not  occur  in  typhoid 
fever.  Dr.  A.  O.  J.  Kelly  reported  a  case  of  en- 
largement of  the  spleen  and  liver  which  has  no  other 
■ymptoms.  There  are  some  points  which  resemble  the 
cases  of  splenomegaly  reported  by  Brill.  Dr.  S.  M. 
liamill  exhibited  photographs  of  a  woman  who  had  a 
thoracic  aneurism  since  1888.  Recently  a  large  multl- 
locular  intraligamcntary  cyst  was  removed.  No  untoward 
result  from  the  anesthetic  occurred.  Dr.  J.  M.  Sailer 
reported  a  case  of  aortic  regurgitation  having  a  flint 
murmur.  The  theories  regarding  the  cause  of  this  mur- 
mur were  reviewed.  It  was  suggested  that  the  con- 
dlalon  was  one  of  robilivo  stenosis  caused  by  the  dilated 
condition   of   the    ventricle.     Dr.    D.   J.    Milton    Miller   ex- 


hibited specimens  showing  a  multiple  thrombosis  from  a 
case  of  aortic  and  mitral  disease.  The  thrombus  involved 
the  innominate,  e.vternal  and  internal  jugular,  and  axil- 
lary veins  as  well  as  some  smaller  ones. 

Lying-in-Charity  Hospital.— The  Lying-in-Charity  Hos- 
pital of  Philadelphia  has  been  fitted  out  with  a  Pathological 
Labratory.  This  labratory  has  been  jirovided  with  all 
the  appliances  necessary  for  the  examination  and  prepara- 
tion of  tissues.  The  laboratory  is  under  the  direction  of 
the  pathologist  of  the  Hospital,  Dr.  Fred.  J.  Kalteyer. 

Philadelphia  Hospital. — The  Bureau  of  Charities  has  elec^ 
ed  a  dental  staff  constituted  as  follows:  Dr.  R.  H.  Nones, 
Dr.  M.  H.  Cryer,  Dr.  J.  Norman  Brownell,  and  Dr.  Thomas 
C.  Steiiwagen,  Jr. 

Dr.  J.  H.  Grove. — Dr.  John  H.  Grove,  a  well-known  physi- 
cian, died  after  a  brief  illness,  aged  76  years.  Dr.  Grove 
was  born  in  Maytown,  Lancaster  county,  January  13th, 
1825.  His  father  was  Christian  Grove  and  his  mother  Eliza- 
beth Heistand  Grove.  His  ancestors  were  natives  of  Gen- 
eva, Switzerland,  from  which  place  they  removed  to  The 
Hague,  where  they  resided  for  a  short  time,  after  which 
they  emigrated  to  America  in  1865,  locating  in  Pennsyl- 
vania. 

After  receiving  his  preliminary  education  in  the  public 
schools  of  his  native  county.  Dr.  Grove  took  a  course  at  the 
Barnet  Academy,  in  Marietta.  He  then  entered  the  Medical 
Department  of  the  University  of  Pennsylvania,  graduating 
in  1849.  He  received  the  degree  of  A.  M.  from  La  Salle 
College,  this  city,  and  of  LL.  D.  from  Manhattan  College. 
New  York. 

Soon  after  graduating  he  commenced  the  practice  of  his 
profession  in  Alarieita.  where  he  continued  until  the  out- 
break of  the  Civil  War.  In  1861  he  received  the  appoint- 
ment of  Brigade  Surgeon  in  the  United  States  Volunteers, 
with  the  rank  of  Major.  He  was  later  breveted  a  Lieuten- 
ant Colonel  and  served  until  1865. 

In  1867  Dr.  Grove  commenced  the  practice  of  his  profes- 
sion in  this  citj'.  During  his  long  residence  here  he  often 
contributed  articles  to  medical  journals.  Immediately  after 
the  building  of  St.  Agnes's  Hospital  he  was  chosen  Medical 
Director,  at  the  same  time  holding  a  similar  position  at  St 
Mary's  Hospital,  which  positions  he  held  for  several 
years. 

In  1899  Dr.  Grove  presented  a  handsome  memoritl  chapel 
to  the  Presbirterian  Church  at  Marietta,  Pa.,  where  he  will 
be  buried  on  Wednesday. 

He  was  a  fellow  of  the  College  of  Physicians,  also  a  mem- 
ber of  the  Association  of  Military  Surgeons  of  the  United 
States,  the  Legion  of  Honor.  Union  League.  American  Med- 
ical Association,  Pennsylvania  Medical  Society,  Philadel- 
phia County  Medical  Society,  the  Pathological  Society  of 
Philadelphia,  the  General  .\lumnl  Society  of  the  Medical 
Department  of  the  University  of  Pennsylvania,  the  Alumni 
Society  of  Manhattan  College,  the  Medical  Club  of  Philadel 
phia,  iiOyal  Legion  and  Meade  Post.  G.  A.  R. 

NEW    YORK. 

New  York  Neurological  Society. — Stated  Meeting  March 
5,1901,  Joseph  Collins,  M.  D.,  President.  Dr.  Joseph  Coilina 
presented  for  diagnosis  and  discussion  a  boy  of  ten  years 
who  presented  a  complex  of  symptoms  which  could  not 
easily  be  placed  under  any  one  designation.  He  was  one 
of  twelve  children,  seven  of  whom  had  had  in  infancy 
marasmus  or  gastrointestinal  disorders.  The  present  ail- 
ment had  begun  about  nine  months  ago.  at  which  time 
the  boy  had  commenced  to  "hop."  He  complained  of 
pain  In  the  great  toe  of  the  left  side,  and  also  of  pain 
In  the  precordial  region.  He  had  been  taken  to  the  ML 
Sinai  Hospital  and  while  there  it  had  been  noted  that 
there  was  some  stiffness  or  weakness  in  the  lower  limbs 
on  walking.  This  impairment  of  motion  had  steadily  in- 
creased, so  that  at  the  present  time  he  was  practically 
unable  to  walk  more  than  a  few  steps.  According  to  the 
history,  there  had  been  early  in  the  disease  great  difficulty 
in  commencing  the  act  of  micturition.  At  present  there 
were  no  symptoms  referable  to  the  bowel  or  bladder.  He 
has  a  peculiar  waddling  gait,  and  when  standing,  there  Is 
a  typical  flat  fooL  There  Is  a  peculiar  knocking  together 
of  the  thighs.  The  spasticity  of  the  gait  had  been  found, 
on  closer  examination,  to  be  more  apparent  than  real. 
There  is  a  marked  ankle  clonus.     There  are  no  sensory 


Apbil  13.  1901] 


AMERICAN  NEWS  AND  NOTES 


CThe   Philadelphia       Ton 
Medical  Journal         7    9 


auturbances.  He  gets  up  from  the  lying  position  as  chil- 
dren do  In  the  early  stages  of  progressive  muscular 
dystrophy.  These  symptoms,  the  speaker  said,  seemed 
to  point  distinctly  to  a  lesion  in  the  spinal  cord  in  the 
crossed  pyramidal  tracts. 

Dr.  B.  Sachs  said  that  he  had  been  much  interested  in 
this  boy  at  the  time  he  had  been  in  the  hospital.  The 
combination  of  the  waddling  gait,  so  characteristic  of  the 
dystrophy,  with  an  increase  in  the  reflexes,  seemed  to  be 
especially  unusual.  When  the  boy  was  stripped,  it  seemed 
to  him  very  evident  that  he  had  progressive  muscular 
atrophy  of  the  Landousi  type.  In  addition  to  this  he 
thought  there  was  a  subacute  myelitis,  possibly  of  trau- 
matic origin.  There  could  be  no  question  that  the  calves 
are  hypertrophied.  This  diagnosis  had  been  arrived  at 
only  after  cacetul  observation  for  a  period  of  several 
weeks.  The  frequent  falls  which  such  children  have 
would  easily  explain  the  occurrence  of  a  subacute  myel- 
itis. The  spasticity  had  been  more  marked  nine  weeks 
ago. 

Progressive  Muscular  Dystrophies  with  a  Report  of  a 
Post-Mortem  Examination. — Drs.  B.  Sachs  and  Harlow 
Brooks  presented  this  paper.  The  authors  stated  that  it 
could  not  be  denied  that  there  was  any  sufficient  distinc- 
tion between  the  amyotrophies  and  the  dystrophies.  In 
former  years  much  stress  had  been  laid  on  the  muscular 
structure.  Hypertrophied  fibres  were  found  in  abundance 
In  dystrophies,  whereas  in  the  amyotrophies  these  fibres 
were  not  found.  But  later  it  had  been  shown  that  the 
hypertrophied  fibres  were  found  in  other  diseases  than 
dystrophies.  It  was  also  a  question  whether  the  gray 
matter  of  the  cord  was  affected  in  the  primary  dys 
trophies.  The  case  to  be  reported  was  one  of  progres- 
sive muscular  dystrophy  of  fifteen  years'  duration,  yet 
the  structural  changes,  as  demonstrated  by  the  latest 
methods  of  staining,  were  very  slight.  The  patient  had 
been  admitted  to  the  Monteliore  Home  eleven  years  ago 
at  the  age  of  twelve  years.  Early  in  life  the  parents  had 
noticed  peculiar  movements  of  the  head  and  eyes.  He 
had  been  in  good  health  up  to  about  the  age  of  ten 
years,  when  he  had  fallen  and  broken  his  leg.  At  the  age 
of  twelve  years,  after  an  attack  of  typhoid  fever,  it  had 
been  noted  that  the  calves  were  decidedly  hypertrophied. 
The  head  was  enlarged  and  exhibited  certain  move- 
ments. There  was  a  marked  atrophy  of  all  the  muscles 
of  the  shoulder  girdle,  arm  and  forearm.  The  deep  spinal 
muscles  were  intensely  atrophied.  The  thigh  muscles  were 
atrophied.  The  case  became  an  extreme  illustration  of  a 
progressive  muscular  disease  of  the  pseudohypertrophic 
type.  The  lad's  intelligence  was  fair.  Dr.  Brooks  said 
that  at  the  autopsy  the  organs  were  normal  with  the  ex- 
ception of  an  acute  pneumonia  and  a  slight  myocarditis. 
There  were  no  gross  lesions  of  the  brain  or  spinal  cord. 
No  lesion  of  the  smooth  voluntary  muscular  tissue  could 
be  found  anywhere  in  the  body.  The  psoas  muscle 
showed  extensive  fibrosis.  The  muscles  of  the  back  all 
showed  extensive  fibroid  replacement,  and  in  places,  there 
was  a  replacement  by  yellow  fat.  The  trapezii  were 
very  extensively  invaded.  The  most  extreme  changes 
were  In  the  muscles  of  the  calves,  where  normal  muscular 
tissue  was  lost.  The  autopsy  had  been  done  twenty-four 
hours  after  death,  and  at  that  time  there  had  been  no 
evidence  of  post-mortem  decomposition.  On  microscopi- 
cal examination,  the  muscles  showed  extensive  replace- 
ment with  areolar  tissue  of  the  adult  type.  In  the  calf. 
occasional  remnants  of  voluntary  muscle  were  found. 
Most  of  the  fibres  of  the  psoas  muscles  were  either 
larger  or  smaller  than  normal.  The  coarse  striae  could 
usually  be  made  out.  The  changes  in  the  other  volun- 
tary muscles  were  of  the  same  character,  though  vary- 
ing in  extent.  In  the  occipital  muscles  the  amount  of 
connective  tissue  hyperplasia  was  less,  but  nuclear  proli- 
feration was  prominent.  Examination  of  various  por- 
tions of  the  smooth  muscles  failed  to  show  degenera- 
tion or  hyperplasia  of  the  connective  tissue  forming  its 
framework.  The  heart  muscle  showed  much  less  connec- 
tive tissue  Increase  than  had  been  expected  from  the  gross 
examination.  The  cardiac  muscle  was  in  a  very  natural 
condition,  there  being  no  atrophy,  no  abnormal  pigmen- 
tation or  abnormal  nuclear  activity.  The  blood  vessels  in 
the  various  tissues  showed  uniformly  an  Increase  In  the 
connective  tissue.  No  evidences  of  new  vessel  formation 
were  found.     Numerous  peripheral  nerves  were  examined, 


but  no  appreciable  degeneration  of  fibres  was  discov- 
ered. Only  a  few  of  the  spinal  ganglia  had  been  prop- 
erly prepared  for  examination,  but  these  few  showed  a 
shrinkage  of  the  ganglion  cells  similar  to  that  produced  by 
fixing  agents.  The  irregular  perilymphatic  spaces  were, 
however,  found  filled  in  with  proliferating  capsular  cells, 
apparently  that  this  was  not  an  artefact,  but  a  distinct 
process.  Apparently  the  connective  tissue  of  the  ganglia 
had  been  increased.  The  connective  tissue  throughout 
the  entire  cord  was  found  to  be  increased.  The  blood 
vessels  of  the  cord  were  universally  congested,  but  this 
was  apparently  of  a  hypostatic  nature,  due  to  the  posi- 
tion of  the  patient  before  death.  Nothing  in  the  nature 
of  a  systemic  degeneration  of  the  fibres  was  found  at 
any  level.  In  the  cervical  region  of  the  ganglion  cells 
in  the  anterior  horn  showed  a  slight  nuclear  eccentricity. 
The  dendrites  universally  retained  their  power  to  re- 
spond to  the  stain.  Occasionally  the  achromatic  elements 
stained  to  a  slight  degree.  Eccentricity  of  the  nucleus  waa 
found  more  commonly  in  the  dorsal  cord  than  elsewhere. 
Lesions  in  the  cells  of  the  posterior  horns  were  more  lur 
frequent  than  in  the  anterior  horns.  The  most  common 
lesion  was  a  finely  granular  subdivision  of  the  plaques, 
usually  not  involving  the  entire  cytoplasm.  A  few  of  the 
lumbar  cells  showed  an  unusual  amount  of  brown  pig- 
ment collected  about  the  nucleus.  The  chief  lesions  were 
(1)  Extensive  atrophy,  which  affected  apparently  all  of 
the  voluntary  skeletal  muscles  and  was  confined  to  these 
muscles:  (2)  the  production  of  areolar  connective  tissue 
and  adipose:  (3)  slight  general  perivascular  hvperplasia; 
(4)  moderate  interstitial  myocarditis:  (5)  extensive  de- 
generative changes  in  a  few  of  the  posterior  root  ganglia. 
and  (6)  rare  changes  in  the  cytoplasm  of  the  ganglion 
cells  of  the  spinal  cord.  The  complete  absence  of  the 
changes  in  the  smooth  muscles  showed  that  the  disease 
process  was  strictly  localized  in  the  voluntary  muscular  sys- 
tem. The  authors  did  not  look  upon  the  connective  tis- 
sue increase  as  an  essential  feature  of  the  pathological 
process,  but  as  an  example  of  a  universal  function  of  this 
tissue  to  take  the  place  of  any  tissue  which  had  been 
removed.  The  perivascular  connective  tissue  hyperplasia 
was  very  slight,  and  could  not  be  considered  as  typical 
of  the  disease  or  as  produced  by  it.  Possibly  the  mod- 
erate myocarditis  was  associated  with  the  connective 
tissue  hyperplasia  of  the  blood  vessels.  It  did  not  seem 
to  be  in  any  way  connected  with  the  factors  producing 
atrophy  of  the  voluntary  muscles.  The  changes  in  the 
posterior  root  ganglia  seemed  to  be  of  great  significance, 
though  it  was  not  clear  that  they  bore  any  direct  rela- 
tion to  the  changes  in  the  voluntory  muscles.  These 
degenerations  seemed  to  be  secondary  in  their  nature, 
and  dependant  upon  death  or  disease  of  certain  portions 
of  the  neuron.     A  process  similar  to  this  occurred  after 

amputation.  There  were,  therefore,  no  evidences  of 
tract  disease.  The  cytoplasmic  degeneration  of  the 
ganglion  cells  in  the  cord  were  rare,  and  might  repre 
sent  the  early  stage  of  post-mortem  change.  Dr.  Sacha 
said  that  these  findings  did  not  indicate  that  the  cause  was 
to  be  found  in  the  gray  matter  of  the  cord.  The  disease 
represents  a  primary  affection  of  the  muscular  fibre.  The 
occurrence  of  stigmata  of  degeneration  in  so  many  cases 
of   this    dystrophy    would    lead    one   to    think    that    these 

should  be  broadly  classified  under  family  affections. 
The  question  arose  as  to  whether  these  muscular  dys- 
trophies were  essentially  progressive,  and  the  statement 
was  made  that  in  every  case  the  possibility  of  great  Im- 
provement by  systematic  exercise  should  always  be  kept 
in  mind  in  the  early  stage.  Two  Illustrative  cases  were 
briefly  reported  which  had  been  followed  for  many  years. 
Dr.  C.  L.  Dana  said  that  so  far  as  the  dystrophies  were 
concerned,  which  were  not  strictly  of  the  so-called  pseudo- 
hypertrophic type  but  rather  of  the  leg  type,  it  seemed 
to  be  a  well  known  fact  that  many  of  them  cease  to 
progress  and  live  for  many  years  in  comparative  com- 
fort. He  had  personal  knowledge  of  two  families  In 
which  there  were  six  or  seven  persons,  going  through 
three  generations,  who  were  afflicted  with  the  leg  or 
arm  type  of  dystrophy.  Some  had  lived  to  old  age  with 
only  an  inability  to  use  the  upper  arm  or  perhaps  the 
thigh  muscles.  One  of  these  cases  had  been  seen  at 
many  clinics  In  this  city  when  thirty-nine  years  of  age. 
The  atrophies  had  begun  at  the  age  of  nineteen,  and 
had   reached   their   helghth   at   about  the   age   of   twenty- 


■.jf-,       The   Philadelphia'] 
/■*  Medical  Jocrnal  J 


AMERICAN  NEWS  AND  NOTES 


[APBIL  13,   1801 


nine.  His  weight  had  been  reduced  to  eighty-eight  pounds. 
A  fairly  hopeful  prognosis  could  be  given  in  this  class 
of  cases  especially  when  the  atrophies  do  not  begin  very 
•arly  in  life.  In  his  experience  with  pseudomuscular 
hypertrophy  there  had  been  only  one  case  in  which  the 
disease  had  been  really  checked.  This  person  was  a 
lady  of  twenty-three  in  whom  the  trouble  had  begun 
»t  the  age  of  eighteen.  She  had  presented  all  of  the 
typical  symptoms  of  pseudohypertrophy  of  late  devel- 
ment.  He  had  put  her  upon  systematic  exercises,  and  as 
«  result  the  disease  had  not  only  ceased  to  progress,  but 
she  had  absolutely  improved.  In  another  case  which 
had  been  faithfully  treated  by  exercise  and  massage 
for  four  years,  there  had  been  continued  progress.  Dr. 
Dana  said  he  would  like  to  have  Dr.  Brooks  explain  why 
there  should  be  so  much  fibrosis  in  these  cases.  It  might 
be  that  4n  the  death  of  the  muscle  fibre  an  irritant  poison 
Is  formed,  and  that  this  gives  rise  to  the  increased  proli- 
feration. There  was  a  striking  difference  clinically  be- 
tween a  typical  spinal  atrophy  and  an  ordinary  dys- 
trophy, and  he  believed  these  diseases  were  very  dif- 
ferent in  their  origin  also.  The  hereditary  cases  were 
of  a  type  which  is  quite  distinct  from  that  of  the  ac- 
quired   forms. 

Anti-Spitting  Crusade. — The  medical  profession  is  in- 
debted to  Magistrate  Mott,  of  New  York  City,  for  enforc- 
ing the  ordinance  against  expectorating  in  public  vehi 
cles.  Some  communities  have  adopted  the  plan  of  having 
the  conductor  present  to  everyone  violating  the  ordinances 
a  small  card  on  which  is  printed  the  legislative  restric- 
tllns  against  promiscuous  "spitting." 

First  Aid  to  the  Injured.— The  annual  meeting  of  the 
Society  for  Instruction  in  First  Aid  to  the  Injured  was  held 
recently  in  New  York  city.  The  annual  report,  which  was 
read  by  President  Charles  H.  Marshall,  shows  that  over 
13,000  persons  had  been  instructed  by  the  society  since  its 
beginning.  President  William  H.  Baldwin,  Jr.,  of  the  Long 
Island  Railroad,  stated  that  the  instruction  given  to  the 
employes  of  the  road  last  year  was  very  beneficial. 

The  New  York  School  of  Clinical  Medicine.— Special 
lectures  at  the  school  will  be  held  as  follows:  April  5th, 
Examination  of  the  Male  Urethra  by  the  General  Practi 
tloner — Clinical  Demonstrations,  by  Ferd.  C.  Valentine. 
M.  D.;  April  12th,  Medical  Questions  of  the  Responsibility 
of  Alcoholics,  Opium  and  Other  Drug  Takers,  by  Thomas 
D.  Crothers,  M.  D.;  April  18th,  Complicated  Fractures: 
Diagnosis  and  Modern  Treatment,  by  Thomas  H.  Manley. 
M  .D.:  April  26th,  Diagnosis  and  Surgical  Treatment  of 
Prolapsed  Kidney:  With  Clinical  Demonstrations,  by  Au- 
eustin  H  Goelet,  M.  D.;  May  3rd,  Treatment  of  Strangu- 
lated Hernia,  by  Carl  E.  Pfister,  M.  D.;  May  10th.  Pelvic 
Trilogy  in  the  Diagnosis  of  Diseases  of  Women,  by  A. 
Ernest  Gallant,  M.  D.:  May  17th.  The  Technics  of  Major 
and  Minor  Amputations,  by  Robert  H.  Cowan,  M.  D.:  May 
24th,  Treatment  of  Obesity,  by  Heinrich  Stern,  Ph.  D.,  M. 
D.;  May  31st.  Diseases  of  the  Stomach— Practical  Examina- 
tions and  Treatment — Demonstrations  on  Patients,  by 
Freeman  F.  Ward,  M.  D.;  June  7th.  Psoriasis  and  Acne-- 
Effective  and  Practical  Methods  ot  Theatment— Clinical 
Demonstrations,  by  W.  R.  Inge  Dalton,  M.  D. 

Manhattan  Dermatological  Society.— A  regular  meeting 
was  held  on  Friday  evening,  April  5th  at  the  residence  of 
the  Chairman,  Dr.  Wm.  S.  Gottheil.  Dr.  Sobel  presented 
two  cases  of  pityriasis  maculata  et  circlnata  or  pityriasis 
rosea,  the  first  in  a  girl  of  twelve,  the  second  In  a  boy 
of  eight.  Both  showed  typical  patches  on  the  face.  The 
first  was  a  classical  one,  the  second  presented  in  parts 
a  close  resemblance  to  seborrheal  eczema.  The  con- 
dition was  very  itchy.  He  has  frequently  seen  the  dis- 
ease confounded  with  syphilis.  Recently  he  had  observed 
a  number  ot  these  cases  in  children  under  ten  years  of 
age.  Dr.  Weiss  remarked  that  if  one  scratch  an  erythema- 
tous patch  with  the  finger  nail  it  becomes  scaly.  This  test 
he  considers  almost  pathognomonic.  Dr.  Gottheil  said  that 
the  name  rosea  caried  little  meaning  with  it.  Dr. 
Gottheil  demonstrated  an  elaborate  apparatus  for  the 
phototherapeutic    treatment    of    dermatological    lesions. 

Dr.  Geyser  presented  a  case  of  extensive  lupus  vulgaris 
of  the  face  successfully  treated  with  the  X  ray.  The  right 
Bide  of  the  face  now  showed  a  smooth,  soft  shining  cicatrix. 
The  left  side  was  in  the  process  of  repair.     On  this  side 


a  mild  degree  of  alopecia  had  resulted.  Each  seance 
lasts  7-10  minutes  and  is  followed  by  the  static  spray.  This 
is  the  fourteenth  case  so  treated  and  all  have  been  success- 
ful. Dr.  Weiss  showed  a  case  of  mollusca  fibrosa,  show- 
ing the  development  of  the  lesions;  some  of  these  were 
more  apparent  to  the  touch  than  to  the  sight,  some  were 
sessile,  some  pedunculated,  others  again  were  soft.  Dr. 
Ochs  remarked  that  such  cases  often  do  well  with  aslatic 
pill.  Dr.  Gottheil  presented  a  case  for  diagnosis.  A  young 
boy  showed  under  the  right  arm  pit  a  large  growth  con- 
sisting of  tuberous  excrescences,  very  dark  in  color  and 
lor  the  most  part  dry.  There  were  a  few  isolated  patches 
to  the  outer  side  and  on  the  inner  side  of  the  forearm  a 
row  of  similar  lesions.  No  secondary  disturbances  were 
noted.  Dr.  Weiss  said  that  this  was  a  rare  and  interest- 
ing condition,  acanthosis  nigricans.  The  region  of  the 
axilla  is  characteristic.  Dr.  Sobel  said  that  while  various 
conditions  could  be  thought  of  the  linear  condition  or  the 
forearm  led  him  to  diagnose  nervous  linearis  verrucosus. 
Dr.  Gothheil  stated  that  the  growth  did  not  correspond  to 
acanthosis  nigricans  and  is  inclined  to  call  the  condition, 
nacvus   unis   Uteris  or  naevus   papillomatosus. 

Dr.  Sobel  presented  a  patient  with  diffuse  dermatis 
and  pigmentation  following  the  use  of  a  two  per  cent,  chrys- 
arobin  ointment  for  psoriasis.  He  prefers  to  use  coUo- 
dium  or  traumaticin. 

Dr.  Gottheil  showed  a  gummatous  deposit  in  the  stemo- 
cleido-mastia  muscle  and  in  the  clavicle.  Also  a  case  of 
undoubted  disemminated  cutaneous  sacromata,  corrobor- 
ated by  microscopic  examination  and  a  second  one  in 
which  the  diagnosis  rested  between  syphilis  and  a  begin- 
ning sarcoma  cutis. 

DELAWARE. 

Small-Pox  in  Delaware. — The  epidemic  of  small  pox  In 
the  State  is  on  the  decline.  Although  about  one  hundred 
cases  were  reported.  Of  these  53  occurred  in  Seaford,  3  In 
New  Castle,  15  in  Concord,  3  in  Bethel,  and  7  are  at  the 
pest-house  at  Farnhurst.  The  others  are  scattered  through- 
out the  lower  part  of  the  State.  Most  cases  are  varioloid 
but  there  are  a  number  of  typical  ones,  and  several  ter- 
minated fatally.  The  State  Board  of  Health  has  been 
very  active  and  efficient  in  suppressing  the  epidemic.  Dr. 
Lowber,  the  secretary  of  the  board  visited  all  the  infected 
places,  instituting  quarantine  whenever  necessary  and 
looking  after  proper  dissinfection.  It  is  noteworthy  that 
the  town  most  affected  is  Seaford.  which  is  blessed  with 
an  unusual  number  of  antivaccinationists.  Forty  families 
are  quarantined  and  supported  by  the  town.  Dr.  Dawson 
having  been  placed  in  charge  of  the  district. 

The  State  Board  of  Health. — The  three  vacancies  which 
occurred  in  the  board  were  not  filled  by  the  governor, 
owing  no  doubt  to  the  fact  that  physicians  are  not  very 
anxious  to  serve  now  when  they  would  have  to  expose 
themselves  to  small-pox.  Dr.  E.  W.  Cooper,  of  Camden, 
one  of  the  most  active  members  and  the  president  of 
the  board  was  reappointed.  Although  ot  different  faith, 
the  governor  was  forced  to  feel  that  the  doctor  could  not 
be  dispensed  with.  He  has  been  serving  on  the  board 
for  the  last  ten  years,  and  always  proved  equal  to  his 
tasks  no  matter  how  hard  they  were.  Dr.  EUegood.  of 
Concord,  will  probably  also  be  reappointed.  There  is  a 
feeling  among  prominent  men  that  the  members  of  the 
board  that  proved  efficient  in  time  of  need  are  the  ones 
whose  services  should  be  requested  regardless  of  party. 

NEW  ENGLAND. 
New  Hospital  for  Insane. — On  account  of  overcrowding 
the  State  Hospital  for  the  Insane  at  Augusta,  Me.,  the  erec- 
tion of  a  new  hospital  was  begun  six  years  ago  at  Bangor. 
Thus  far  $440,000  has  been  expended,  of  which  $35,000  has 
been  advanced  by  the  Governor  from  his  private  means,  anl 
the  new  hospital  is  still  Incomplete.  The  Lieglslature  is  to 
be  asked,  for  an  appropriation  of  $200,000. 

American  Neurological  Society. — The  twenty-seventh  an- 
nual meeting  of  the  American  Neurological  Association, 
will  be  held  at  the  Boston  Medical  Library. 

CHICAGO  AND  WESTERN  STATES. 
American   Academy  of   Medicine. — The  twenty-sixth  an- 
nual meeting  of  this  society  will  be  held  at  the  Hotel  Ab- 
erdeen, St  Paul,  Minn.,  on  Saturday,  June  1.  1901.  at  11 


April  13,  1001] 


AMERICAN  NEWS  AND  NOTES 


CTHE     PniLiDELPHIA  <7TT 

Medical  Journal         /*■'• 


A.  M.  (Executive  session) ;  the  open  session  beginning  at 
12  M.  and  continuing  througli  Monday,  June  3d.  The 
principal  features  of  the  meeting  will  be  a  symposium  on 
"Institutionalism;"  and  another  on  "Reciprocity  in  Medi- 
cal Licensure."  Series  of  valuable  papers  on  both  topics 
have  been  promised,  as  well  as  interesting  papers  on  some 
other  subjects.  The  President's  address  (Dr.  S.  D.  Risley, 
of  Philadelphia)  will  be  delivered  on  Saturday  evening, 
June  1st,  and  the  Annual  Social  Session  held  on  Monday 
evening,  June  3d. 

The  St.  Paul  "Special." — Arrangements  are  being  made 
for  a  special  train  from  New  York  to  the  St.  Paul  Meet- 
ing, to  leave  New  York  city,  Saturday,  June  1st.  Par- 
ties who  wish  to  use  this  train  in  making  the  journey  will 
communicate  with  Dr.  P.  H.  Wiggin,  55  W.  Thirty-ninth 
street.  New  York  city,  for  further  information. 

Preparations  for  the  St.  Paul  Meeting. — The  Journal 
of  the  ■iineriran  Medical  Association  states  that  those  who 
desire  to  attend  the  meeting  in  St.  Paul,  need  have  no  fear 
that  the  city  will  be  overcrowded,  or  that  there  will  not  be 
sufficient  good  accommodations  for  all.  The  people  of  St. 
Paul  are  making  extensive  preparations  to  take  care  of 
the  visitors,  all  will  be  provided  for.  A  program  of  en- 
tertainment for  the  ladies  is  being  arranged.  St.  Paul  has 
quite  a  reputation  as  a  convention  city,  and  there  is  yet  to 
be  heard  complaint  of  the  management  or  lack  of  accom- 
modation. St.  Paul  has  a  number  of  first-class  hotels,  sev 
eral  of  which  are  situated  in  the  business  district,  while 
others  are  on  the  hill  in  the  residence  portion  of  the  city, 
and  many  of  the  citizens  will  be  glad  to  open  their  houses 
to  the  city's  guests.  The  women  of  St.  Paul  have  already 
formed  committees,  made  preliminary  arrangements,  and 
are  preparing  to  help  make  this  year's  meeting  of  the 
American  Medical  Association  a  memorable  one. 

Helped  to  Populate  Two  States. — It  is  said  that  a  pas- 
senger on  a  train  between  Portland,  Ore.,  and  Spokane, 
Wash.,  went  Into  labor  and  was  delivered  of  twins.  The 
elder,  a  boy,  v/as  born  in  Oregon;  the  younger,  a  daughter, 
arrived  an  hour  later,  and  is  a  native  of  Washington. 

Restrictions  In  Indiana. — In  Indiana  a  regular  licensed 
physician,  who  removes  his  residence  to  another  county, 
must  obtain  a  license  from  the  clerk  of  that  county,  or 
he  can  not  recover  payment  for  his  professional  ser- 
vices. 

Small  Pox  Epidemic  Caused  by  a  Letter. — According  to 
the  officials  in  charge  of  the  quarantine  squad  at  Saginaw, 
Mich.,  an  epidemic  of  small  pox  affecting  in  all  34  people. 
has  been  traced  to  a  letter  received  by  a  young  lady  from  a 
soldier  of  the  United  States  Army,  stationed  in  Alaska. 


SOUTHERN    STATES. 

Farm  for  Tuberculous  Convicts. — It  is  not  generally 
known  that  the  State  of  Texas  has  isolated  her  consump- 
tive convicts,  thus  showing  a  proper  appreciation  of  the 
modern  idea  regarding  this  most  destructive  of  human 
maladies.  The  Wynne  farm,  on  which  the  diseased  prison- 
ers are  located,  is  a  large  plantation  situated  about  two 
miles  beyond  Huntsville  and  is  the  property  of  the  State. 
For  several  years  it  has  been  cultivated  by  convicts,  but 
not  until  December,  1899,  was  it  set  aside  for 
the  exclusive  occupancy  of  consumptives.  On  Oc- 
tober 31,  1900,  there  were  confined  In  the  Texas 
Penitentiary,  4,109  convicts.  Of  this  number  there  were; 
Whites,  1421;  negroes,  2,226;  Mexicans,  460;  Indians,  2. 
Many  of  the  whites  came  from  the  tramp  contingent  of 
the  population,  and  are  the  class  of  beings  who  indulge  in 
the  common  vices  of  the  age,  thus  weakening  the  power  of 
the  system  to  throw  off  disease.  Added  to  this,  many  of 
them  lie  in  crowded  and  unsanitary  jails  for 
months,  and  even  years,  before  commitment.  As 
to  the  negro  element  It  Is  well  known  that  a  large 
proportion  of  the  race  Is  particularly  susceptible  to  tuber- 
culosis. For  the  most  part  the  Mexicans  are  from  the 
salubrious  prairies  of  the  West.  Consequently,  when  they 
are  houses  In  the  buildings  of  the  prison  the  change  of  life 
seems  to  point  them  out  as  an  easy  prey  to  consumption. 
To  the  above  evils  may  be  added  as  of  prime  Importance 
the   fact   that   a   great   many   consumptives    are   sent   to 


prison— some  arriving  in  the  last  stage  of  the  disease. 
The  Wynne  Farm  is  an  ideal  "consumptive  camp."  The 
buildings  are  admirably  located  and  constructed,  and  every- 
thing about  the  place  is  kept  scrupulously  clean.  Th« 
water  is  pure,  and  every  convenience  for  bathing  is  pro- 
vided. The  food  furnished  is  of  the  most  suitable  char- 
acter, such  as  vegetables,  fresh  meats,  poultry,  cereals, 
milk,  butter,  etc.  The  men  live  and  sleep  in  a  capacious 
pavilion  or  stockade,  where  each  enjoys  as  much 
breathing  space  as  he  would  in  a  forest  camp. 
The  Wynn  Farm  convicts  are  required  to  keep  clean — 
person,  clothing  and  bedding.  The  buildings  are  frequent- 
ly whitewashed  and  constantly  fumigated.  Doctor  Fowler 
says  the  principal  medicines  used  are  cod  liver 
oil,  creosote,  the  hypophosphites  and  whiskey.  On 
this  farm  no  one  is  required  to  work  beyond  hla 
strength.  But  all  are  required  to  go  into  the  open  air  and 
sunshine  when  their  strength  admits  of  leaving  the  bed. 
Thus  far  results  have  been  most  gratifying.  Many  men 
who  went  to  farm  apparently  in  the  last  stages  of  con- 
sumption, and  who  were  scarcely  able  to  feed  themselves, 
are  now  hearty  and  stouL  A  remarkable  feature  of  th« 
arrangement  is  that  it  Is  self-supporting.  The  farm  Is  cred- 
ited with  garden,  orchard  and  other  products  furnished  the 
prison  proper,  and  for  the  overplus  sold  in  the  markets. 
At  present  there  are  fifty-nine  men  at  the  camp,  and  In 
general  appearance  seem  to  be  the  healthiest  men  among 
the  convicts.  The  crop  now  being  worked  by  this  force 
consists  of  250  acres  of  oats,  250  acres  of  corn,  thirty  acres 
of  tomatoes,  eighteen  acres  of  onions,  besides  seven 
modation.  St.  Paul  has  a  number  of  first-class  hotels,  sev- 
acres  of  melons  and  cantaloupes  and  other  feed  and  vege- 
table crops. 

Rappahannock  Valley  Medical  Association. — At  a  meet- 
ing of  the  Rappahannock  Valley  Medical  Association  held 
here  Dr.  S.  W.  Carmichael  was  elected  president  for  the 
ensuing  year  and  Dr.  J.  N.  Barney  secretary  and  treasurer. 
A  paper  on  "Epidemic  Influenza  or  Grip"  was  read  by  Dr. 
Carmichael  and  discussed  by  many  of  the  members  pres- 
ent. 

Kentucky  State  Medical  Society. — The  forty-sixth  an- 
nual session  of  the  Kentucky  State  Medical  Society  will 
be  held  in  Louisville,  May  22,  23,  24,  1901. 

Louisville. — The  sum  of  $5,000  has  been  appropriated  by 
the  Aldermen  for  three  public  baths. 

Alabama  Medical  Association. — The  Alabama  Medical  As- 
sociation will  meet  at  Selma,  Ala.,  April  16th  to  19th. 

New  Orleans  Polcylinic. — On  account  of  various  requests 
the  Sessions  of  the  Polyclinic  will  be  continued  to  May 
31st,  instead  of  May  11th,  as  announced  in  catalogue. 

Richmond,  Va. — The  section  of  Halifax  Co.,  Va.  known 
as  "South  of  the  Dan,"  is  again  visited  by  small-pox.  Here- 
tofore the  disease  was  confined  almost  entirely  to  negroes, 
but  now  the  whites  have  it  also.  There  are  20  cases  re- 
ported in  this  neighborhood  and  two  deaths  have  oc- 
curred. The  magistrates  have  ordered  several  localities 
quarantined. 

Law  Against  Employment  of  Cream  of  Tartar. — A  meas- 
ure has  been  Introduced  In  the  Legislature  of  Arkansas 
prohibiting  the  sale  of  bitartrate  of  potash  either  alone  or 
combination  with  bicarbonate  of  soda  for  the  purpose  of 
leavening  or  otherwise  preparing  food  products,  under  a 
penalty  of  a  fine  of  $500  and  six  months'  imprisonment 

Florida  Medical  Association. — The  twenty-eighth  anBual 
meeting  of  this  Asoclation  wll  be  held  in  Jacksonville,  April 
10th,  under  the  presidency  of  Dr.  William  L.  Hughlett,  of 
Cocoa.  Dr.  Jay  H.  Durkee,  Jacksonville.  Is  chairman  of  the 
Committee  of  Arrangements. 


CANADA. 

Toronto. — The  contageous  diseases  report  for  March, 
for  Toronto,  Is  as  follows:  Diphtheria,  77  cases;  scarlet 
fever,  97 ;  typhoid  fever,  6.  The  figures  for  February  wertl 
Diphtheria,  91)  scarlet  fever,  37;  typhoid  fever,  3. 


7 JO       The   PhiladelibiaT 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Apxn,  U,  1901 


MISCELLANY. 
Drug  Habits  in  the  United  States. — The  London  Lancet  of 
March  2nd,  1901,  contains  the  following  notice:  "The  New 
York  School  of  Clinical  Medicine  has  established  a  special 
department  of  neurology,  of  which  Dr.  T.  D.  Crothers,  of 
Hartford,  Conn.,  has  been  elected  professor — viz.,  the  study 
of  the  neuroses  adn  psychoses  of  alcoholism  and  of  drug 
habits.  Dr.  Crothers  is  announced  to  deliver  immediately 
a  course  of  clinical  lectures  on  inebriety  from  alcohol, 
opium,  chloral,  cocaine  and  other  narcotics.  These  lectures 
appear  to  be  timely,  for  the  disease  dependent  upon  or 
associated  with  the  abuse  of  alcohol,  opium,  chloral,  co- 
caine, and  other  narcotic  drugs  are  steadily  increasing 
In  the  United  States  of  America,  and  the  demand  for  special 
treatment  in  institutions  and  retreats  is  becoming  more 
pressing  every  year. 

Monstrosity. — M.  Dannelongue  presented  at  the  meeting 
of  the  Academie  de  Medecine  a  Hindoo  boy,  aet.  8,  well  de- 
veloped, but  who  had  attached  to  the  epigrastic  region  a 
body  without  a  head,  constituted  by  a  trunk  and  four  limbs 
Incompletely  developed.  The  palpation  of  the  parts  re- 
vealed a  certain  number  of  vertebrae,  the  iliac  bones,  and  a 
rudiment  of  a  skeleton  of  the  limbs.  No  trace  of  intestines 
could  be  found,  but  the  sexual  organs,  which  were  that  of 
the  male,  were  somewhat  developed,  and  both  subjects 
urinated  at  the  same  time. — [Exchange]. 

Obituary. — Dr.  Charles  R.  Stoddard,  in  California  on 
March,  1901,  aged  65  years.— Dr.  George  Hayward,  at  Bos- 
ton, Mass.,  on  March  30.  aged  82  years.— Dr.  George  P. 
Jones,  at  East  Newmarket,  Dorchester  county,  Md.,  on 
April  2,  aged  55  years. — Dr.  Merritt  H.  Chandler,  at  Wood- 
stock, Vt.,  on  April  6,  aged  57  years. 

RUDOLPH  VIRCHOW  FUND. — On  October  13th,  1901,  . 
Rudolf  Virchow  will  be  eighty  years  old.  When  he  com- 
pleted his  seventieth  year  a  fund  was  started  in  his  honor 
to  enable  the  great  master  to  facilitate  scientific  research 
by  establishing  soholorships.  and  by  encouraging  special 
medical  and  biological  studies.  Contributions  to  that 
"Rudolph  Virchow  Fund"  were  furnished  by  those  in  all 
countries  interested  in  progressive  medicine,  as  a  homage 
to  the  man  whose  name  is  always  certain  to  arouse 
admiration  and  enthusiasm.  In  Berlin  a  large  Committee 
containing  among  others  the  names  of  A.  Bastian.  v.  Coler, 
A  Entenburg,  B.  Fraenkel.  O.  Israel.  Fr.  Koenig,  C.  Posner 
and  W.  Waldeyer  has  been  formed  to  call  for  contributions 
which  are  to  be  added  to  the  original  "Rudolf  Virchow 
Fund"  so  as  to  increase  its  efficiency.  The  Committee 
expresses  the  opinion  that  in  no  better  way,  and  in  none 
more  agreeable  to  the  great  leader  of  modern  medicine, 
can  his  eightieth  birthday  be  celebrated,  and  ask  for 
the  sympathy  and  co-operation  of  all  those  engaged  in  the 
study  and  practice  of  scientific  medicine  all  over  the 
globe.  The  undersigned  have  formed  a  s\ib-committee  for 
the  purpose  of  making  the  American  Profession  acquainted 
with  the  intentions  of  the  Berlin  Committee,  and  urge 
their  colleagues  to  participate  in  honoring  the  very  man 
who  has  done  more,  thes  fifty  years,  than  any  other  to 
make  medicine  a  science  and  international.  Subscriptions 
should  be  sent  to  their  secretary,  who  will  receipt  therefor. 
Charles  A.  L.  Reed.  President  of  the  .\merican  Medical  As- 
sociation: Henry  P.  Bowditch.  President  of  the  Congress 
of  American  Physicians  and  Surgeons:  William  K.  Welch. 
John-Hopkins  Universty:  Rebert  F.  Weir.  President  of  the 
New  York  Academy  of  Medicine:  A.  Jacobi,  110  West  34th 
34th  Street,  Secretary. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Army,  for  the 
week   ending    April    6,    1901: 

THOM.\S   W.   BATH,   acting  assistant   surgeon,   will   pro- 
ceed   to    his    home.    La    Harpe,    III.,    for    annulment    of 
contract.    S.  O.  63,  JIarch  19,  D.  Cal. 
VERDO  B.  GREGORY,  acting  assistant  surgeon,  will  pro- 
ceed to  his  home.  Dam.  Wis.,  for  annulment  of  contract. 
S.  O.  63,  March  19.  D.  Cal. 
JAMES  W.   M.-\D.\R.\,   acting  assistant  surgeon,   will  pro 
ceed  to  his  homo.  Lexington.  Kv..  for  annulment  of  con- 
tract.   S.  O.  64,  March  20,  D.  Cal. 
M.\.IOU    HENRY    D.    TllOMASON,    surgeon,   will    proceed 
to  Beiiicia  Barracks,  Cal.,  where  he  will  report  for  tempor- 
ary dvity  at  that  post  during  the  absence  of  acting  assist- 
to  Benic;,  Barracks.  Cr.l.,  where  he  will  report  for  tern 


porary  duty  at  that  post  during  the  absence  of  acting 
assistant  surgeon  Charles  Y.  Brownlee.  Upon  the  return 
of  acting  assistant  surgeon  Brownlee  to  Benlca  Barracks, 
Major  Thomason,  surgeon,  will  stand  relieved  from  tem- 
porary duty  at  that  post  and  will  proceed  to  San  Fran- 
cisco, Cal.,  for  further  orders.  S.  O.  65,  March  21,  D. 
Cal. 
HENRY  KIERSTED,  acting  assistant  surgeon,  is  granted 

leave  for  one  month.  S.  O.  65,  March  21,  D  Cal. 
CAPT.  FREDERICK  W.  COX,  A.  S.,  is  relieved  from  tem- 
poraiT  duty  at  the  Army  general  hospital,  Presidio,  and 
will  report  to  the  commanding  ofiBcer,  squadron  6th  cav- 
alry, for  duty  with  that  command  on  the  Army  trans- 
port Hancock,  to  sail  for  the  Philippine  Islands.  Upon 
arrival  at  Manila,  Capt.  Cox  will  report  for  assignment 
to  duty.     S.  O.  66,  March  22,  D.  Cal. 

CAPT.  FRANK  P.  KENYON,  A.  S.,  is  relieved  from  tem- 
porary duty  at  the  Army  general  hospital,  Presidio,  and 
will  report  to  the  commanding  officer,  battalion  7th  in- 
fantry, for  duty  with  that  command  on  the  Army  trans- 
port Hancock,  to  sail  for  the  Philippine  Islands.  S.  O. 
66,  March  22,  D.  Cal. 

CAPT.  HENRY  A.  LITTLEFIELD,  A.  S.,  is  assigned  to 
temporary  duty  with  troops  on  the  Army  transport  Han- 
cock, to  sail  March  25.  Upon  arrival  at  Manilla,  Capt. 
Littlefield  will  report  for  assignment  to  duty.  S.  O.  67, 
March  23.  D.  Cal. 

FREDERICK  C.  JACKSON,  acting  assistant  surgeon.  Is 
granted  leave  for  one  month,  on  surgeon's  certiflcata 
with  permission  to  apply  for  an  extension  of  one  month. 

HOSP.  STEWARD  MILTON  T.  ESTERLY  is  relieved  from 
further  duty  at  the  muster  out  camp  on  the  military 
reservation  of  the  Presidio,  and  will  proceed  to  Fort  Lla- 
cum,  Alaska,  for  duty  at  that  post.  S.  O.  67,  March  23, 
D.   Cal. 

MAJ.  WILLIAM  BOWEN,  surgeon,  recently  appointed,  now 
in  San  Francisco,  Cal.,  will  report  for  transportation  tc 
Manila,  P.  I.,  where  he  will  report  for  assignment  to 
duty.     H.  Q.  A.,   March  29. 

CAPT.  EDW.\RD  F.  HORR.  A.  S.,  recently  appointed,  now 
on  duty  at  Manzanillo.  Cuba,  will  as  soon  as  his  services 
can  be  spared  by  the  commanding  general,  department 
of  Cuba,  proceed  to  San  Francisco.  Cal..  and  report  tor 
transportation  to  Manila.  P.  I.,  where  he  will  report  for 
as.signment  to  duty.    H.  Q.  A.,  March  29. 

CAPT.  W.  HOEPFNER  WINTERBERRY.  A.  S.,  recenUy 
appointed,  will  proceed  from  Fort  Mason  to  San  Fran- 
cisco., and  report  for  transportation  to  Manila,  P.  L. 
where  he  will  report  for  assignment  to  duty.  H.  Q.  A., 
March   29. 

C.-^PT.  IR.\  A.  ALLEN,  A.  S.,  recently  appointed.  Is  re- 
lieved from  duty  at  the  Army  and  Navy  General  Hospital. 
Hot  Springs,  Ark.,  to  take  effect  upon  the  expiration 
of  the  leave  granted  him  March  26,  and  will  then  pro- 
ceed to  San  Francisco.  Cal..  and  report  for  transporta- 
tion to  Manila.  P.  I.,  where  he  will  report  for  assignment 
to  duty.     H.  Q.  A.,  March  29. 

CAPT.  GEORGE  W.  D.\YWALT,  A.  S..  recently  apponlted. 
now  in  San  Francisco.  Cal.,  will  report  for  transporta- 
tion to  Manila.  P  1..  where  he  will  report  for  assignment 
to  duty.     H.  Q.  A..  .March  29. 

SURG.  H.  M.  JAMES,  acting  assistant  surgeon,  granted 
leave  March  1.  is  extended  one  month.  H.  Q.  A..  March 
29. 

CAPT.  GUY  G.  BAILEY.  .\.  S..  recently  appointed,  now  in 
San  Francisco,  Cal.,  will  report  for  transportation  to 
Manila.  J.  I.,  where  he  will  report  for  assignment  to  duty. 
H.  Q.  .-v..  March  30. 

MAJ.  GEORGE  W.  :M.\THEWS.  surgeon,  is  relieved  from 
duty  in  the  division  of  the  Philippines,  and  will  pro- 
ceed to  Fort  Warren  for  duty,  to  relieve  1st  Lieutenant 
Frederick  M.  Hartsock,  A.  S.  Lieut.  Hartsock  will  pro- 
ceed to  San  Francisco.  CaL.  and  report  for  transporta- 
tion to  Manila.  P.  I.,  where  he  will  report  for  assignment 
to  duty.     n.  Q.  A..  March  30. 

:.i.\J.  HENRY  C.  FISHER,  surgeon,  is  relieved  from  duty 
in  the  division  of  the  Philippines,  and  will  proceed  t, 
Jack.son  Barracks  for  duty,  to  relieve  Maj.  .\aron  H.  .A.i> 
pel.  surgeon.  Maj.  .\ppel  upon  being  thus  relieved  will 
proceed  to  San  Francisco,  Cal..  and  report  for  transpor- 
tation to  Manila.  P.  I.,  where  he  will  report  for  assign- 
ment to  du.y.     n.  G.  A..  M:irch  23. 


ArniL  13,  1001] 


AMERICAN  NEWS  AND  NOTES 


CTiiE   Philadelphia 
Mkdic 


I'AL  Journal 


713 


FIRST  LIEUT.  HARRY  L.  GILCHRIST.  A.  S.,  is  reliev^,a 
from  duty  in  the  division  of  ttie  Pliilippines.  and  will  pro- 
ceed to  San  Francisco,  Cal.,  and  report  by  telegram  to 
the  adjutant  general  of  the  Army  for  further  orders. 
H.  Q.  A.,  March  30. 

MAJ.  JOHN  M.  BANISTER,  surgeon,  granted  leave  March 
26,  is  extended  ten  days.     H.  Q.  A.,  April  1. 

CAPT.  JUSTUS  M.  WHYATE,  A.  S.,  recently  appointed, 
will  upon  the  expiration  of  leave  granted  him  March  12, 
proceed  to  San  Francisco,  Cal.,  and  report  for  transpor- 
tation to  Manila,  P.  I.,  where  he  will  report  for  assign- 
ment for  duty.     H.  Q.  A.,  April  1. 

CAPT.  FREDERICK  C.  JACKSON.  A.  S.,  recently  appointed 

CAPT.  FREDERICK  C.  JACKSON,  A.  S.,  recently  ap- 
pointed, now  in  San  Francisco,  Cal.,  will  report  for  trans- 
portation to  Manila.  P.  I.,  where  he  will  report  for  as- 
signment to  duty.     H.  Q.  A..  April  1. 

MAJ.  EDWARD  B.  MOSELEY,  surgeon:  orders  of  Feb- 
ruary 14,  which  assign  him  to  duty  at  Fort  Sheridan  are 
revolved.     H.  Q.  A.,  April  2. 

MAJ.  EDWARD  B.  MOSELEY,  surgeon,  will  upon  the 
expiration  of  the  sick  leave  granted  him  December  8, 
proceed  to  Denver,  Col.,  and  report  to  the  commanding 
general,  department  of  the  Colorado,  for  duty  as  chief 
surgeon  of  that  department,  to  relieve  Lieut.  Col.  Henry 
Lippincott,  D.  S.,  G.  IJeut.  Col.  Lippincott  will  proceed 
to  Governors  Island,  and  report  to  the  commanding  gen- 
eral, department  of  the  East,  for  duty  as  chief  surgeon 
of  that  department.     II.  Q.  A.,  April  2. 

MAJ.  FRANCIS  J.  IVES,  surgeon,  is  relieved  from  further 
duty  with  the  United  States  forces  in  China  and  will 
proceed  to  Fort  Sheridan  for  duty,  to  relieve  Maj.  George 
W.  Adair,  surgeon,  who  upon  being  thus  relieved  will 
comply  with  the  requirements  of  previous  orders.  H. 
Q.  A..  April  2. 

CAPT.  FREDERICK  A.  W.  CONN..  A.  S..  recently  ap- 
pointed, will  proceed  from  Philadelphia,  Pa.,  to  San 
Francisco,  Cal.,  and  report  for  transportation  to  Manila, 
P.  I.,  where  he  will  report  for  assignment  to  duty. 
H.  Q.  A.,  April  2. 

THE  following-named  officers,  recently  appointed,  now  in 
San  Francisco.  Cal.,  will  report  for  transportation  to 
Manila,  P.  I.,  where  they  will  report  for  assignment  to 
duty:  Maj.  Frederick  Hadra.  surgeon;  Capt.  Francis  J. 
Purcell,  A.  S.;  Capt.  Thomas  W.  Jackson,  A.  S.  H.  Q.  A., 
April  2. 

IIOSP.  STEWARD  CLINTON  F.  HENDERSON,  now  at 
Fort  Skaguay,  Alaska,  will  be  sent  to  San  Francisco,  Cal., 
for  assignment  to  duty.     H.  Q.  A.,  April  2. 

ACT.  ASST.  SURG.  JULIUS  C.  LeHARDY  will  proceed  to 
Fort  Wood  and  relieve  Capt.  Charles  R.  Gill,  A.  S..  and 

Act.  Asst.  Surg.  Adrian  S.  Williams.  The  latter  will  return 
at  once  to  Fort  Columbus  for  duty  with  the  1st  batallion 
11th  infantry.  S.  O.  73.     March  30,  D.  E. 

COL.  CHARLES  C.  BRYNE.  A.  S.  G.  H.  A..  April  3. 

CAPT.  EDWARD  L.  MUNSON,  A.  S.,  is  relieved  from 
further  duty  at  Washington  Barracks,  and  will  proceed 
to  Buffalo,  N.  Y.,  and  assume  charge  of  the  exhibit  of 
the  medical  department  of  the  Army  at  the  Pan-Ameri- 
can Exposition  to  be  held  in  the  latter  city.  H.  Q.  A.. 
April  3. 

Changes   in   the    U.   S.   Marine    Hospital-Service,   for  the 
week   ending  April   6,   1901: 

Official  list  of  the  changes  of  station  and  duties  of  com- 
missioned   and    non-commissioned    officers    of    the    U.    S. 
Marine   Hospital   Service   for  the   7   days   ending  April   4, 
1901: 
SURGEON    D.    A.    CARMICHAEL.    relieved    from    duty   at 

Honolulu.  II.  I.,  and  directed  to  proceed  to  San  Francis- 
co, Cal.— March  29. 
SURGEON  G.  T.   PECKHAM.  granted   20  days'  additional 

leave  of  absence  on  account  of  sickness — March  30. 
ASSISTANT  SURGEON  HILL  HASTINGS,  to  proceed  to 

Bakersfield.  Cal.,  for  special  duty — April  1. 
ASSISTANT  SURGEON  C.  H.  LAVINDER.  granted  leave 

of  absence  for  10  days  from  March  26 — March  27. 
ASSISTANT   SURGEON  M.   J.   WHITE,  to  report  to   Sur 

geon  J.  H.  White,  for  duty— March  29. 
.ASSISTANT   SURGEON  W.   C.   BILLINGS,  to  proceed  to 

■^an  Francisco,  Cal.,  for  special  temporary  duty — March 

2J. 


ASSISTANT  SURGEON  D.  H.  CURRIE,  to  proceed  to  San 
Francisco,  Cal..  for  special  temporary  duty — March  30. 

ACTING  ASSISTANT  SURGEON  R.  S.  PRIMROSE.granted 
leave  of  absence  for  5  days  from  March  30 — March  29. 

Changes  in  the  Medical  Corps  of  the  U.  S.  Navy,  for  the 
week   ending   April   6,   1901: 

DR.  A.  E.  PECK,  appointed  assistant  surgeon  from  March 

24,  1901. 
MEDICAL  DIRECTOR  W.  K.   SCHOFIELD,  placed  on  re- 
tired list,  April  28,  1901. 
SURGEON   G.   PICKRELL,   granted   sick  leave   for   three 

months,  from  April  2. 
ASST.    SURGEON    E.    M.    BLACKWELL,    detached    from 

Abarenda,    pon   reporting   of   relief,   and   home   to   wait 

orders. 
ASST.   SURGEON   R.   C.   MARCOUR,   detached    from    Ha- 
vana Naval  Station  and  ordered  to  Abarenda  after  tem- 

porory  duty,  on  Philadelphia,  May  4. 
ASST.  SURGEON  E.  DAVIS,  granted  sick  leave  for  three 

months. 
MEDICAL   DIRECTOR   G.   F.   WINSLOW,    detached    from 

Boston  Navy  Yard,  April  18,  and  ordered  home  to  wait 

orders. 
MEDICAL    DIRECTOR    E.    BOGERT,    retired     ordered    to 

the  Boston  Navy  Yard,  April  18th. 
P.  A.  SURGEON  E.  R.  STITT,  commissioned  surgeon  from 

June   7,    1900. 
PHARMACIST    J.    COWAN,    detached    from    Glacier    and 

and  ordered  to  the  Manila  and  to  additional  duty  at  the 

Naval  Hospital,  Cavite. 
SURGEON  C.  I.  STOKES,  detached  from  the  New  Orleans 

and    ordered    to    the    Solace    upon    her    arrival    on    the 

Asiatic  Station. 

Official    List   of   the    Changes   of   Station    and    Duties   of 
Commissioned  and   Non-Commissioned  Officers  of  the  U.  S. 
Marine  Hospital  Service  for  the  7  days  ended  April  4,  1901. 
D.  A. CARMICHAEL.  surgeon,  relieved  from  duty  at  Hono- 
lulu, T.   H.,   and   directed  to  proceed  to   San  Francisco, 
California.  March  29.  1901. 

C.  T.  Pl-^CKHAM.  surgeon,  granted  20  days  additional  leave 
of  absence  on  account  of  sickness,  March  30.  1901. 

HILL  H.^STINGS.  assistant  surgeon,  to  proceed  to  Bak- 
ersfield. Cal.,   for  special  temporary  duty,   .April  1,  1901. 

M.  J.  WHITE,  assistant  surgeon,  to  report  to  Surgeon 
J.  H.  White  for  duty,  March  29,  1901. 

W.  C.  BILLINGS,  assistant  surgeon,  to  proceed  to  San 
Francisco,  Cal..  for  special  temporary  duty.  March  29, 
1901. 

D.  H.  CURRIE,  assistant  surgeon,  to  proceed  to  San 
Francisco.  Cal..  for  special  temporary  dutv.  March  30. 
1901. 

R.  S.  PRIMROSE,  acting  assistant  surgeon,  granted  leave 
of  absence  for  5  days  from  March  30,  March  29,  1901. 


The  Treatment  of  Trachc:Tia  by  Bichloride  of  Mercury 
in  Glycerin. — U.  Samtshuk  (Wdeiiiio-inrdii-iiiskn  ■hiuniul,,  J^iv 
uary,  1901),  treated  186  cases  of  trachoma  in  soldiers.  The 
majority  of  them  were  far  advanced,  the  secretion  in  most 
being  mucopurulent  or  purulent.  Of  485  patients  266.  or 
54.7  per  cent.,  recovered:  the  others  were  considerably 
improved.  The  solution  employed  was  0.12  grni  of  bi- 
chloride in  30  grms  of  glycerine.  This  was  applied  to 
the  everted  lids  every  second,  third  or  fifth  day,  accord- 
ing to  the  severity  or  the  progress  of  tlie  case.  The 
applications  were  made  by  means  of  a  small  cotton  swab. 
The  burning  after  each  application  lasted  for  a  short  time 
only,  not  more  than  half-hour.  On  the  day  following  the 
the  addition  of  cocain,  was  used.  If  the  conjunctiva  was 
the  addition  of  cocain,  was  used.  In  the  conjunctiva  was 
found  much  affected  the  author  a  2-3  per  cent,  solution  of 
nitrate  of  silver  followed  by  irrigation  with  normal  salt 
solution.  The  author  believes  that  strong  solutions  of 
bichloride  of  mercury  not  only  have  an  antiseptic  but  pro- 
duce an  irritation  and  consequent  hyperemia  of  the  con- 
junctiva, facilitatiBg  the  disintegration  and  absorption  of 
the  granulations.     [A.  R.] 


714 


The   Phila 

MEnHAL 


ADELrHIA"! 
JollIlNAI,    J 


THE  LATEST  LITERATURE 


[Apsil  13.  1901 


^be  Xatcst  literature. 


6. 
7. 
8. 
9. 
10. 

11. 
12. 
13. 


BRITISH   MEDICAL  JOURNAL. 
March  ^SrU,   lUOl. 

A  Clinical  Lecture  on  the  Diagnosis  and  Treatment 
ot    intussuscepuon.     CllAKH;,i3    f.    B.    ULUliBh;. 

Auto-Reduction  of  Hernia  en  masse  as  a  Cause  of  Ab- 
dominal Obstruction.      W.  J.  WALSHAM. 

Some  Practical  Points  in  the  Diagnosis  and  Operative 
Treatment  of  Perforated  Gastric  Ulcer.  K.  C.  B. 
MAUNSELL. 

A  Case  of  Hour-glass  Stomach;  Non  malignant;  Oastro- 
enterostomy.     CHARLKS  P.  CHIUDI;;. 

Ulcer  of  Stomach;  Acute  Hematemesis:  Gastrotomy. 
H.  BRUNTON  ANGUS. 

A  Case  of  Gastric  I'^istula;  Operation;  Death.  C.  F. 
M.  ALTHORP. 

Perforated  Ulcer  of  the  Stomach.  WILLIAM  H.  HOR 
ROCKS. 

ACase  of  Subphrenic  Abscess;  Operation;  Recovery. 
H.  J.  CAMPBELL  and  T.  .JASON  WOOD. 

Four  Cases  in  which  the  Murphy  Button  was  used.     G. 
P.  NEW  BOLT. 
A  Case  of  Acute  Intestinal  Obstruction  due  to  a  Pap- 
illomatous Ovarian  Cyst  and  a  Carcinoma  of  Small 
Intestine.     H.  SAVORV  and   W.  G.   NASH. 
A  Case  of  Extreme  Stenosis  of  the  Small  Intestine  in 

an  Infant.     ERNEST  W.  HEY  GROVES. 
Notes  on   the  Anatomy   and   Surgery  of  Meckel's   Di 

verticulum.     GEORGE  A.  CLARKSON. 
The  Letlsom  an   Lectures  on   Diseases  and   Disorders 
of  the  Heart  and  Arteries  in  Middle  and  Advanced 
Life.     J.   MlTCHEI.iL  BRUCE.     Lee.   II. 


^. — Clubbe  during  the  past  7  years  has  treated  t9  cases  of 
intussusception.  Four  of  the.se  cases  were  reduced  sue- 
cesfuUy  by  injection  and  the  remaining  45  were  operated 
upon,  24  recover  ng.  The  average  duration  of  time  from 
the  onset  of  the  symptoms  till  the  operation  was  performed 
in  the  successful  cases  was  24  hours,  and  in  the  fatal  cases 
was  5G  hours.  These  figures  show  the  great  importance  of 
an  early  diagnosis  and  early  treatment  in  these  cases. 
Of  the  4'J  oases  30  were  ileo-colic.  3  colic.  1  enteric,  and  ti 
double  (ileum  into  ileum  and  both  into  cecum).  In  4  cases, 
all  fatal,  resection  of  the  bowel  was  necessary.  In  making 
a  diagnosis  the  important  symptoms  are  the  sudden  onset 
of  pain  with  pallor,  followed  l)y  vomiting.  The  pal'or 
disappears  and  the  pain  returns  at  intervals.  A  normal 
bowel  movement  accompanies  the  attack,  but  is  followed 
in  a  short  time  by  a  passage  of  blood,  and  it  is  this 
symptom  which  usually  alarms  the  mother  and  causes  her 
to  seek  medical  advice.  The  general  condit'on  of  the 
little  patient  is  apt  to  be  misleading.  It  may  be  listless  or 
it  may  be  playing  aliout  with  its  toys  in  the  intervals  be- 
tween the  pains,  the  temi)erature  may  be  normal  and  the 
pulse  but  little  accelerated.  An  examination  of  the  abdo- 
men will  usually  reveal  the  presence  of  a  "sa\isage- 
shaped"  tumor.  The  presence  of  this  mass  with  the  other 
symptoms  will  enable  one  to  make  an  absolute  diagnosis 
ot  intussusception.  If  because  of  the  pain  in  the  abdominal 
muscles  are  rigid  and  a  satisfactory  examination  cannot  be 
made,  then  the  child  should  invariably  be  anesthetised. 
Examination  per  rectum  is  usually  unsatisfactory.  It, 
however,  must  be  remembered  that  the  colon  may  be  in- 
vaginated  into  the  rectum  and  presenting  at  the  anus  be 
mistaken  for  a  prolapse  of  the  rectum.  Intussusception 
occurs  not  infrequently  during  attacks  ot  diarrhea,  and 
under  such  circumstances  an  improper  diagnosis  is  fre- 
Quently  made.  It  is  possible  to  have  an  intussusception 
with  all  the  usual  symptoms  absent.  It  the  intussuscep- 
tion is  acute  after  24  hours  there  will  always  be  symptoms 
ot  intestinal  obstruction. 

Treatment.  Clubbe  finds  in,iecfions  very  useful  in  cases 
of  intussusception.  In  fcinr  out  of  his  49  cases  reduction 
and  recovery  occurred  from  this  means  of  treatment.  In 
all  cases  dia.gnosed  early  this  treatment  should  first  be 
instituted,  and  although  it  may  not  result  in  a  cure,  it 
empties  the  lower  bowel  and  enables  the  more  perfect  ex- 
amination of  the  abdomen  and  a  more  successful  operation. 
It  this  is  found  necessary.  Before  using  the  injectiim  the 
child  should  be  prepared  for  operation  and  an  anesthetic 


g.ven.  The  tumor  may  reappear  after  apparently  being 
relieved  by  the  injection  and  then  operation  should  be 
done.  When  the  mass  is  small  and  confined  to  the  right 
side  of  the  abdomen,  incision  should  be  made  to  the  right 
of  the  rectus  muscle,  but  in  other  instances  the  incision 
should  be  median  and  extend  both  above  and  below  the 
umbilicus.  When  the  abdomen  is  opened  the  tumor  should 
be  delivered  and  reduction  accomplished  by  squeezing  the 
intussuscipiens,  traction  ot  the  intussusception  being  dan- 
gerous .  Resection  becomes  necessary  when  reduction 
cannot  be  accomplished,  or  where  the  bowel  has  been  so 
damaged  as  to  render  gangrene  probable.  Resection,  how- 
ever, should  not  be  done  unless  absolutely  necessary,  as  it 
greatly  increases  the  danger.  In  making  an  anastomosis 
catgut  is  used  in  preference  to  silk,  but  bobbins  or  buttons 
are  not  to  be  commended.  The  after-treatment  should  be 
carefully  looked  into,  and  it  must  be  remembered  that 
children  cannot  bear  post  operative  fasting  as  can  adults, 
but  must  be  fed  within  the  first  tew  hours  after  operation. 
Clubbe  thinks  it  a  mistake  to  keep  the  child  too  rigidly  on 
the  back.  Very  minute  doses  of  morphia  are  usually  re- 
quired at  varying  intervals  during  the  first  24  hours  after 
operation.  The  abdomen  is  closed  by  silk  worm  gut  sut- 
ures, which  are  not  removed  for  10  days.     [J.  H.  G.] 

2. — During  the  past  few  years  Walsham  has  seen  7 
cases  of  intastinal  obstruction  due  to  the  reduction  of  a 
hernia  en  masse.  He  thinks  the  reduction  en  masse  U 
much  more  apt  to  occur  from  the  manipulation  by  the 
patient  himself  than  by  the  attending  physician.  In  each 
of  the  7  cases  reported  the  reduction  was  accomplished 
by  the  patient.  Great  stress  is  laid  upon  the  necessity  of 
making  careful  inquiry  regarding  the  pre-existence  of  a 
hernia  in  all  cases  ot  intestinal  obstruction,  even  where  the 
abdominal  rings  show  nothing  on  examination.  In  one  of 
'he  cases  reported  the  reduction  en  masse  had  been  done 
2  months  before  the  development  ot  symptoms  ot  intestinal 
obstruction.  In  one  case  the  patient  had  ruptured  the 
bowel  in  reducing  the  hernia.     [J.  H.  G.] 

3. — Maunsell  thinks  that  in  cases  ot  perforated  gastric 
ulcer  treated  by  operation  the  per  cent,  of  recoveries  in 
the  hands  of  those  accustomed  to  operate  will  be  found  to 
be  between  45  and  50.  The  sooner  the  operation  is  done 
the  better  will  be  the  chances  of  recovry.  Ot  Mayo  Rob- 
son's  6  cases  3  were  operated  lipon  w^ithin  24  hours  and 
recovered.  3  after  24  hours  and  died.  Of  Ulster's  list  8 
cases  were  operated  upon  within  12  hours  with  64  per  cent 
ot  recoveries,  6  after  12  hours  with  33  per  cent,  ot  recov- 
eries. The  disease  is  more  common  in  men  than  is  gen- 
erally supposed.  Maunsell  reports  4  cases  of  his  own.  2  of 
which  were  operated  upon  within  13  hours  and  one  recov- 
ering. The  other  2  were  operated  upon  respectively  19 
and  31  hours  after  perforation  and  both  died.  In  making 
a  diagnosis  the  sudden  onset  of  the  symptoms  upon  sc>me 
exertion  is  of  great  importance.  Although  the  onset  may 
be  severe,  not  infrequently  the  patient  is  not  incapacitated, 
one  of  the  cases  reported  having  walked  to  the  hospital. 
Th  onset  is  frequently  preceded,  hut  not  often  followed  by 
vomit'ng.  The  pain  begins  in  the  epigastrium  and  spreads, 
but  does  not  shift  its  position.  Thirst  is  not  intense,  and 
there  is  no  restlessness,  as  is  often  present  in  sever3 
hemorrhage.  In  muscular  sublets  distension  is  rare.  The 
pulse  does  not  aid  one  in  making  an  early  diagnoss.  The 
"stomach  note"  does  not  exclude  perforation  as  a  perfora- 
tion as  perforated  and  a  collapsed  stomach  are  by  i,  > 
means  synonymous  terms.  Liver  dullness  is  diminished  f>r 
absent  in  every  case.  Treatment.  In  every  case 
in  which  a  diagnosis  of  perforation  is  made  should 
be  operated  upon,  and  in  every  case  in  which 
the  condition  is  strongly  suspected  an  exploratory 
in.'ision  should  be  made.  The  best  time  to  oper- 
ate is  as  soon  after  the  diagnosis  is  made  as  suitable 
arrangements  and  surroundings  can  be  had.  It  is  never 
too  late  to  operate  unless  the  patient  is  moribund.  In  over 
SO  per  cent,  of  cases  the  perforation  will  be  in  the  greater 
peritoneal  cavity.  The  stomach  should  be  emptied  by  a 
catheter  through  the  perforation.  After  closing  the  open- 
ing Maunsell  places  over  it  an  omental  graft.  Where  the 
soiling  of  the  peritoneum  is  general  he  thinks  that  both 
douching  and  wiping  with  gauze  are  requisite  in  order 
to  thoroughly  cleanse  the  abdominal  cavity.  He  does  not 
think  that  douching  alone  wi'l  remove  infection  from  the 
pelvis  and  from  the  upper  surface  ot  the  liver.     [.T.  H.  G.] 

4. — Child    reports    a    case   of    hour-glass    contraction    of 
the  stomach  due  to  ulceration.     All  the  symptoms  which 


Apbu.  13,  1901] 


THE  LATEST  LITERATURE 


[The   rnn-APELPHiA       71  c 
.Mi;rn<  iL  JocRNAL         10 


this  patient  complained  of  pointed  rattier  to  a  malignant 
disease  of  the  stomach,  and  the  operation  was  performed 
with  the  idea  of  doing  a  gastroenterostomy.  The  anas- 
tomosis was  done  and  the  patient  died  on  the  fourth  day 
alter  operation.  The  postmortem  examination  showed  a 
stomach  constricted  in  its  centre,  the  opening  between  the 
two  cavities  admitting  the  little  finger.  The  cardiac  por- 
tion extended  far  up  beneath  the  ribs  and  costal  cartilages 
but  at  the  time  of  operation  because  of  its  position,  was  not 
recognized.  This  case  resembles  closely  one  recently  pub- 
lished by  Dr.  Martin  and  Mr.  Pollard.  The  patient's  ribs 
extended  nearly  to  the  iliac  crest,  and  the  interspace 
between  the  costal  cartilages  was  very  narrow,  and  Childe 
doubts  whether  it  would  have  been  possible  to  make  an 
anastomosis  between  the  cardiac  portion  of  the  stomach 
and  the  bowel.  The  anastomosis  which  he  did  make  was 
between  the  pyloric  portion  and  the  small  intestine. 

[J.  H.  G.] 

5. — Angus  reports  a  case  of  ulcer  of  the  stomach  compli- 
cated by  acute  hematemesis.  The  patient  was  a  19-year- 
old  girl  who  had  suffered  some  epigrastic  pain  after  eating 
for  12  months.  Occasionally  vomiting  had  occurred,  but 
she  had  never  vomited  any  blood.  The  hematemesis 
occurred  at  11  P.  M.,  and  the  patient  was  immediately 
sent  to  the  hospital  and  the  abdomen  was  opened  at  3.30 
A.  M.  The  greater  peritoneal  cavity  was  found  in  a  nor- 
mal condition.  The  lesser  cavity  was  opened,  and  on  the 
posterior  wall  of  the  stomach  near  the  lesser  curvature  an 
Indurated  patch  was  found.  The  stomach  was  opened  and 
the  ulcer  found  opposite  the  patch  mentioned.  A  purse- 
string  catgut  suture  was  passed  around  the  ulcer,  the 
bleeding  being  controlled  in  this  way.  The  stomach 
wound  was  closed  with  three  rows  of  catgut  sutures;  no 
drainage.  Two  weeks  after  the  operation  the  patient  devel- 
oped a  phlebitis  of  the  left  leg.  and  a  week  later  the  same 
condition  occurred  on  the  right  side.  The  patient,  how- 
e  er.  made  a  good  recovery.  Angus  does  not  think  that 
the  phlebitis  was  of  a  septic  origin  because  the  constitu- 
tional disturbance  was  slight,  there  was  no  pus  formation, 
the  condition  disappeared  and  the  vascular  channels 
became  reestablished.     [J.  H.  G.] 

6. — Althorp  reports  a  case  of  gastric  fistula  in  which  he 
operated  after  the  following  method:  The  fistula  was 
dil''<ed  to  admit  the  finger,  and  through  it  was 
pat^.d  into  the  stomach  several  small  sponges  with 
silk  ligatures  attached.  The  fistulous  tract  was  then 
sterilized  with  pure  carbolic  acid  and  an  incision  made 
two  inches  away  from  the  opening  into  the  peritoneal  cav- 
ity. The  adhesion  to  the  abdominal  wall  was  ^ound  to  ex- 
tend over  an  area  of  3  by  11^  inches.  The  general  cavity 
was  protected  by  gauze  pads,  and  the  entire  fistulous  tract 
was  excised.  The  opening  into  the  stomach  was  closed 
and  an  omental  graft  placed  over  it.  The  patient  died  on 
the  sixth  day  from  pneumonia.  The  post-mortem  showed 
no  evidence  of  peritonitis  and  no  escape  of  stomach  con- 
tents.    [J.    H.    G.] 

7. — Horrocks  reports  a  case  of  perforated  ulcer  of  the 
stomach  which  was  operated  upon  8  hours  after  perfora- 
tion, the  patient  making  a  good  recovery.  There  was  no 
indication  of  gastric  ulcer  before  the  perforation  took 
place.  The  ulcer  was  near  the  cardiac  end  and  close  to  the 
lesser  curvature.  There  was  no  evidence  of  any  exciting 
cause  for  the  perforation.  There  was  marked  tension 
of  the  abdominal  wall  over  the  stomach,  but  no  distension 
and  the  hepatic  dullness  was  not  diminished.     [J.  H.  G.] 

8. — Campbell  and  Wood  report  a  case  of  subphrenic  ab- 
scess which  recovered  after  drainage  through  the  abdom- 
inal wall.  The  case  was  complicated  by  an  effusion  of 
serum  into  the  pleural  cavity,  which  was  removed  by  the 
aspirator  on  several  occasions.     [J.  H.  G.] 

9. — Newbolt  reports  4  cases  in  which  he  has  used  the 
Murphy  Button  with  satisfaction.  Two  were  cases  of 
strangulated  hernia  requiring  resection:  one  was  a  case  of 
malignant  disease  of  the  pylorus  in  which  he  did  a  gastro- 
enterostomy: and  the  fourth  case  was  one  of  intussuscep- 
tion. Recoverv  followed  in  all  cases  excepting  the  last. 
[J.  H.  G.] 

10. — Savory  and  Nash  report  an  interesting  case  of 
Intestinal  obstruction  coming  on  after  violent  exertion. 
and  In  wh^ch  subsequent  abdominal  section  revealed  the 
presence  of  a  papillomatous  ovarian  cyst  and  a  carcinoma 
of  the  small  intestine.  The  cyst  was  removed  at  the  first 
operation  and  resection  of  the  small  intestine  done  12 
days  later.    The  patient  made  a  good  recovery.     [J.  H.  G.3 


11. — Groves  reports  the  case  of  a  girl  aged  1  year  and 
S  months,  who  was  suffering  from  distended  abdomen  and 
great  emaciation.  When  the  patient  was  about  1  year  old 
she  began  to  lose  flesh  and  was  constantly  crying  as  if  in 
pain.  When  first  seen,  she  was  extremely  emaciated. 
There  were  no  signs  of  rickets,  tubercle,  or  syphilis,  and 
the  dental  development  was  good.  The  abdomen  was 
uniformly  distended:  was  tympanitic  to  percussion:  but 
there  was  no  tenderness  on  palpation  and  no  hard  masses 
or  tumor  could  be  felt.  Rectal  examination  showed  noth- 
ing abnormal.  The  bowels  were  opened  with  great  regu- 
larity two  or  three  times  a  day;  the  stools  were  soft,  but 
well  formed  and  rather  clay-colored.  The  temperature 
rose  above  100  degrees  P.,  and  the  patient  refused  her 
food.  This  continued  for  6  days,  when  the  child  died.  At 
the  post-mortem  examination  the  calibre  of  the  ileum  was 
suddenly   reduced   by   a   hard,   unyielding   stricture   three- 

inters   of   an    inch    long,   which   admitted   a   probe   with 

-acuity.  The  other  parts  of  the  intestine  were  normal, 
but  the  mesenteric  glands  wer  slightly  enlarged.  The 
condition  was  most  certainly  congenital.     [J.  M.  S]. 

12. — Clarkson  urges  the  consideration  of  Meckel's  diver- 
ticulum as  a  cause  of  internal  hernia,  and  suggests  the 
importance  of  ascertaining  whether  or  not  the  tube  is  a 
pervious  one  or  only  a  simple  fibrous  band  before  resorting 
to  its  division.     [J.  H.  G.] 

13. — In  the  second  Lettsomian  lecture.  Bruce  continues  his 
discussion  of  the  diseases  of  the  heart  and  the  arteries  in 
middle  and  advanced  life.  The  uncomplicated  effects  of 
tobacco  on  young  healthy  hearts,  as  they  present  them- 
selves clinically,  are  palpitation  in  every  instance,  a  sense 
of  irregular  action,  post-sternal  oppression  and  pain  in  half 
the  cases,  and  in  1  out  of  every  S  sufferers  either  angina  or 
uncomfortable  sensations  in  the  left  arm.  Faintness  or 
actual  faints  occurred  in  on^-third.  and  giddiness  and  a 
feeling  of  impending  death  in  a  smaller  proportion.  Physi- 
cal examination  shows  that  the  heart  is  of  ordinary  size  in 
50  per  cent,  of  the  patients:  in  a  few  it  is  very  slightly 
enlarged:  the  precordial  impulse  is  often  very  weak,  but 
occasionally  increased  in  force  and  frequency,  and  often 
irregular:  the  pulse  tension,  with  insignificant  exceptions 
is  found  low.  Out  of  twenty  such  patients  who  complained 
of  the  heart,  not  one  presented  a  cardiac  murmur  beyonJ 
a  weak  mitral  systolic  bruit,  varying  with  posture  or 
cubitus.  As  an  exemplary  case,  a  man  of  40  will  complain 
of  his  heart:  he  has  smoked  for  vears  the  strongest  and 
blackest  tobacco  he  could  buy.  His  heart  is  not  enlarged 
and  the  cardiac  sounds  may  be  described  as  ordinary  were 
they  not  peculiarly  irregular,  the  frequency  changing 
every  moment,  and  a  falter  occurring  at  short  intervals. 
There  is  not  a  trace  of  murmur  to  be  found  in  connection 
with  the  valves  and  orifices.  At  ages  over  40.  whilst  palpi- 
tation is  still  the  more  common  compla-nt,  pain,  including 
angina,  is  put  forward  more  prominently,  and  so  are  faint- 
ness. actual  faints,  a  feeling  of  impending  death,  and  a 
sense  of  cardiac  irregularity,  each  intermission  being  ac- 
companied with  a  sudden  stab  through  the  precordia.  In 
these  subjects  the  heart  is  more  frequently  found  to  be 
large  and  feeble:  the  same  weak  systo'ic  murmur  is  occa- 
sionally to  be  heard:  the  radial  pulse  is  often  irregular, 
and  the  vessel  wall  thick.  Rvery  cardiovascular  lesion 
that  may  happen  to  be  four.cl  in  tobacco  smokers  is  not  to 
be  put  to  the  credit  of  tobacco,  nor  should  precordial  pain, 
angina,  faintness.  and  irregular  pulse,  in  a  man  of  60  with 
a  full-sized  heart,  be  hastily  regarded  as  evidences  of 
grave  disease  without  further  inquiry  as  to  the  habits  of 
the  patient.  The  cardiac  enlargement  and  large  pulse  may 
be  nothing  more  than  the  result  of  a  life  of  bodily  and 
mental  activity:  the  precordial  distress  may  be  the  only 
result  of  tobacco.  The  alcoholic  heart  presents  clinical 
characters  as  a  whole  very  different  frnin  th"se  of  tn'iqcco 
heart.  The  most  striking  and  important  of  these  are  the  evi- 
dences of  actual  pathological  change  in  the  size  of  the 
heart  and  the  condition  of  the  mvocardium.  Of  2S  cases  of 
alcoholic  heart  in  only  2  were  the  hearts  of  ordinary  size, 
and  in  both  of  these  cases  the  natients  were  ii"dor  .in  vears 
of  age.  With  hardly  an  exception  the  precordial  impulse  is 
weak,  the  sounds  are  small  and  feeble,  and  may  be  almost 
Inaudible:  in  20  per  cent,  of  cases  a  weak  apex  systolic 
murmur  could  be  heard,  varvlne  with  nostnre  and  frnm  dav 
to  day.  significant,  no  doubt,  of  leakage  through  a  dilated 
mitral  opening.  The  alcoholic  heart  is  irregular  and 
accelerated  In  about  half  the  cases.  The  pulse  tension  Is 
usually  low:  in  one-third  of  the  instances  the  radial  art«r7 


7i6 


Medical  Juuhxal  J 


THE  LATEST  LITERATURE 


tAPBiL  13,  1901 


was  sclerosed:  in  one-fifth  of  them  there  was  slight  albu- 
minaria;  the  legs  may  be  edematous.  The  complaints 
with  which  the  patient  comes  to  us  are  commonly  palpi- 
tation of  the  heart,  faintness  or  actual  faints  and  pre- 
cordial pain,  but  it  is  very  interesting  to  observe  that 
angina  pectoris  is  rare  in  the  alcoholic  as  compared  with 
the  tobacco  heart  in  the  ratio  of  4  to  15  per  cent. 
Instances  of  disorder  and  disease  of  the  heart  and  arter- 
ies met  in  gouty  subjects  at  or  over  40  years  of  age.  Out 
of  29  cases,  12  had  suffered  from  ordinary  articular  gout, 
the  other  17  had  irregular  gout.  In  no  instance  was  there 
albumuria.  In  23  of  the  2!)  the  heart  proved  to  be  enlarged 
either  on  one  or  on  both  sides.  In  less  than  half  the  num- 
ber the  cardiac  action  was  feeble:  in  a  small  number  the 
impulse  was  entirely  imperceptible:  the  heart  and  pulse 
rate  was  ordinary;  the  rhythm  was  but  seldom  irregular. 
In  12  out  of  the  29  cases  of  gouty  heart  a  systolic  murmur 
was  to  be  heard  over  the  aortic  area,  the  manubrium,  and 
the  right  carotid,  significant  of  disease  either  of 
the  aortic  arch  or  of  the  aortic  valves.  In  7 
cases  a  more  or  less  well  developed  systolic  mur- 
mur was  found  in  the  mitral  area,  significant  either  of 
vulvular  atheroma  and  sclerosis  or  of  leakage  from  ver- 
micular dilation.  When  no  murmur  exists  the  cardiac 
sounds  are  commonly  somewhat  feeble  and  the  second 
sound  may  be  of  ringing  quality.  The  radial  pulse  is  more 
often  tense  in  the  subjects  of  irregular  than  of  regular 
gout,  the  great  majority  presented,  distinct  thickening  of 
the  arterial  walls.  Besides  a  distressing  feeling  of  irregu- 
larity, fluttering  or  intermittency  and  dyspnea  on  exertion, 
men  who  are  the  subjects  of  gouty  heart  complain  most 
frequently  of  precordial  pain:  women  more  often  of  palp-- 
tation  and  faintness  or  actual  faints.  In  quite  ',4  of  all 
cases  of  gouty  heart  the  pain  is  anginal,  and  such  angina 
may  be  of  'the  most  pronounced  typo.  Closely  related  to 
goutiness  is  a  clinical  type  of  disturbed  metabolism  char- 
acterized by  corpulence  and  glycosuria.  Of  patients  so 
affected  who  complained  of  cardiac  symptoms,  %  had  a 
systolic  aortic  murmur,  none  of  them  a  regurgitant  aortic 
murmur,  and  nearly  li  of  them  an  ill  developed  mitral 
systolic  murmur.  In  11  cases  of  acute  strain  of  the  heart 
the  heart  in  all  but  one  was  large,  with  feeble  precordial 
impulse;  the  sounds  wer  small  and  feeble,  the  arotic  dias- 
tolic sound  was  often  ringing:  in  but  one  case  was  there  a 
murmur.  With  few  exceptions  the  rhythm  and  the  rate 
of  the  heart  were  ordinary.  In  half  the  cases  the  radial 
artery  was  sclerosed;  in  the  majority  the  tension  was  not 
increased.  Persons  who  strain  their  heart  after  middle 
life  chiefly  complain  of  precordial  oppression,  a  sense  of 
palpitation  and  irregular  action  of  the  heart,  and  pain, 
which  may  amount  to  angina.  Of  these  11  individuals.  7 
were  gouty.  In  the  case  of  a  person  who  has  strained  his 
heart  in  youth  or  early  manhood  and  has  never  been  qu'te 
well  since,  the  heart  is  always  found  to  be  enlarged,  in 
about  %  of  the  cases  it  is  irregular.  It  may  be  weak  and 
beating  at  the  ordinary  rate,  but  in  other  instances  it  is 
increased  both  In  force  and  frequency.  In  quite  excep- 
tional cases,  endocardial  murmurs  are  heard.  High  tens'on 
and  sclerosis  of  the  radial  artery  were  respectively  found 
in  about  %  of  the  cases.  The  patients  complained  most 
commonly  of  a  distressing  sense  of  irregular  palpitation  of 
the  heart,  and  very  commonly  of  precordial  pain,  but  rarely 
of  angina.  Syphilis  appears  to  account  for  a  very  consider- 
able proportion  of  the  more  serious  cases  of  heart  disease 
that  we  meet  with  in  older  subjects,  of  course  excluding 
chronic  valvular  disease  originating  remotely  in  endocarditis 
Syphilis  as  a  cause  of  cardiovasular  lesion  is  very  often 
associated  with  other  morlnd  influences,  particularly 
strain  and  alcohol  In  case  of  cardiovascular  disordei's 
and  disease  from  nervous  strain,  the  arterial  tension  is 
\isually  high:  the  rad'al  artery  is  thick,  sometimes  marked- 
ly so;  the  heart  enlarges:  and  In  about  \~>  of  the  cases  a 
systolic  murmur  is  to  be  heard  either  in  the  aortic  or  in  the 
mitral  area.     [.I.  M.  S.] 


LANCET.     March   23d,   1901. 

1.  The   Mllroy    Lectures   on    Public   Health   and   Housing, 

Lecture  III      JOHN  F.  J.  SYKES. 

2.  Lettsomian  Lectures  on  Diseases    and  Disorders  of  the 

Heart  and  Arteries  in  Middle  and  Advanced  Life. 
Lecture  II.  3.  MITCH I^LL  BRUCE  (See  British 
Medical  Journal,  March  23,  1901. 

3.  Blackwater  Fever.     J.  W.  W.  STEPHENS. 


4.  Three   Cases    of    Diffuse    Septic    Peritonitis    Resulting 

From    Appendicitis;    Operation;    Recovery.     W.    G. 
RICHARDSON. 

5.  Resection   of   the   Superior   Cervical   Ganglion   of   the 

Sympathetic    for    Glaucoma    and    its    Results.     H. 
WORK  DODD. 

6.  The  Elimination  of  Arsenic  Through  the  Hair  and  its 

Relation      to      Arsenical      Poisoning.        EDMUND 
KNECHT  and  W.  P.  DEARDEN. 

7.  A  Short  Account  of  a  Fatal  Case  of  Laryngeal  Diph- 

theria   Complicating    Measles.     GEORGE    J.    MA- 
GUIRE. 

8.  History   of    Renal    Surgery.     DAVID    NEWMAN. 

1. — In  a  brief  summary  of  the  housing  question,  Sykes 
states  that  in  order  to  establish  healthy  housing  for  the 
people,  our  ideas  must  be  cleared  regarding  two  related 
but  distinct  factors.  The  first  is  a  pressure  of  population 
in  urban  districts,  whereby  dwellings  are  compressed 
within  the  smallest  limit.  The  remedy  for  this  will 
be  found  by  improving  transportation  between  urban 
and  suburban  centers  and  by  building  additional  houses 
m  the  suburbs.  The  second  factor  is  the  dilapidation  of 
dwelling  houses  and  the  deterioration  of  the  health  of  the 
inmates,  whereby  unsanitary  areas  are  created.  The 
remedy  for  this  v.ill  be  found  in  the  reconstruction  of  the 
worst  areas,  the  adaptation  of  the  best  streets  and 
healthy  flat-form  of  construction,  and  the  institution  of 
sanitary  laws  ha\  ing  the  dwellirg  as  ihe  basic  unit  [F.J.K.] 

3. — Stevens  discusses  blackvtrater  fever,  emphasizing  the 
methods  of  diagnosis  and  the  causation  of  this  disease. 
After  examining  the  blood  in  a  number  of  cases,  he  con- 
cludes that  his  own  observations  have  shown  him  that 
malarial  parasites  are  not  necessarily  found  in  the  peri- 
pheral circulations  in  blackwater  fever.,  but  this  does  not 
prove  that  the  case  in  question  is  not  of  malarial  origin. 
The  presence  of  pigmented  large  mononuclear  leukocytes, 
are  of  importance  from  a  diagnostic  standpoint.  The  au- 
thor believes  that  when  the  large  mononuclear  forms 
are  above  20  degrees,  there  is  abundant  proof  of  ma 
larial  infection.  The  author  therefore  attaches  great 
Importance  for  diagnostic  purpose,  by  the  presence  of 
I)igmonted  leukocytes,  and  the  leukocytic  change.  The 
following  conclusions  are  drawn:  That  blackwater  fever 
is  essentially  of  malarial  origin:  the  exacting  factor,  or 
the  determining  cause  of  this  disease  is  quinine:  black- 
water  fever  may  be  prevented  by  protecting  the  indi- 
vidual from  malaria:  the  important  points  in  the 
prophylaxis  are  attention  to  clothing  and  the  use  of  the 
mosquito   net.     [F.   J.    K.] 

4. — Richardson  reports  three  (3)  cases  of  fulminating 
appendicitis,  which  he  has  operated  upon  with  succ'ss. 
in  each  case  there  was  a  premonitory  stage  lasting  fur 
a  few  hours,  during  which  the  patient  felt  unv%-ell  and 
uneasy  in  the  abdomen,  followed  hy  a  sudden  develop- 
ment of  acute  symptoms  which  somewhat  subsided  after 
several  hours  of  severe  pain.  This  subsidence  was  fol 
lowed  in  24  hours  from  the  initial  attack  by  violent  and 
sudden  increase  of  all  symptoms,  and  a  tew  hours  later 
pus  was  found  over  the  entire  abdominal  cavity  with  a 
perforated  and  non-adherent  appendix.  Robinson's  rule 
In  the  first  treatment  is  to  apply  hot  fomentations  to  the 
abdomen,  to  administer  morphia  only  in  urgent  cases 
and  then  to  operate,  unless  there  is  an  improvement  in 
all  the  symptoms.  He  lays  great  stress  on  the  fact  that 
not  only  the  pain  should  be  less,  but  that  the  rigidity, 
anxious  expression,  etc.,  should  also  improve.  He  uses 
gauze  as  drainage,  preferring  it  to  a  tube.  The  gauze 
is  withdrawn  on  the  fifth  day.  when  it  is  accomplished 
with   little   pain.     [J.   H.  G.] 

5. — H.  W.  Dodd  believes  that  in  chronic  glaucoma  of 
central  origin  removal  of  the  cervical  ganglion  ap- 
parently does  not  interrupt  the  connection  of  the 
eye.  Either  the  connection  is  not  established  in  this 
manner,  or  some  other  means  of  communication  are  es- 
tablished soon  after  the  operation.  The  author's  first  case 
appeared  in  the  Lniuct  of  October  14.  1900.  page  71.  His 
second  case,  reported  in  the  present  paper,  is  that  of 
an  unmarried  woman  aged  44.  who  had  chronic  glaucoma 
in  both  eyes.  Iridectomy  had  given  no  relief  and  the 
tension  still  remained  plus  2  the  visual  field  markedly  and 
irregularly  cantracted.  distinct  signs  of  chronic  glaucoma 
in    the    fundus    and    considerable    pain    and    reduction    at 


Arnii,  13,  mni] 


THE  LATEST  LITERATURE 


[The  Pnir.ADELPHiA 
MlCMlAL   JoritNAL 


717 


vision.  The  ganglia  were  removed  at  dilTerent  times.  The 
operation  performed  was  that  described  by  Dr.  Jonnesco 
as  the  "premastoid"  one.  The  tension  of  the  eye  became 
immediately  lower  after  the  resection  of  the  left  gan- 
glion and  the  pain  relieved  on  that  side.  Similarly  good 
results  were  obtained  on  the  other  side.  Vision  and 
visual  fields  improved. [M.  R.  D.l 

6. — Dearden  discusses  the  elimination  of  arsenic  through 
the  hair,  and  its  relation  to  arsenical  poisoning.  The  rea- 
son for  the  non-employment  of  this  method  for  diagnosis 
is  most  likely  explained  on  account  of  the  difficulty  of 
estimating  the  arsenic  in  the  hair  by  the  ordinary  meth- 
ods. The  method  employed  by  the  author  was  Sanger's 
modification  of  the  Marsh  test:  Samples  of  hair  wer  taken 
from  six  males:  two  of  these  were  from  cases  of  arsen- 
ical poisoning;  another  was  from  a  patient  who  had 
taken  arsenic  over  an  extended  period  (one-ninth  of  a 
grain  daily),  and  three  specimens  were  taken  from 
healthy  individuals.  In  one  case  of  arsenical  beer  poison- 
ing the  arsenic  was  found  in  the  hair  to  an  extent  of  .3 
in  10,000.  In  the  individual  who  had  been  taking  arsernc 
medicinally,  the  drug  was  found  in  the  proportion  6t 
.3  in  10,000.  Arsenic  wa  sdetected  in  quantities  too 
minute  to  be  estimated  in  one  gram  (of  hair  substance)  in 
the  healthy  individuals.  From  a  medico-legal  point  of 
view  the  detection  of  arsenic  in  the  hair  may  prove  to 
be  of  immense  value,  for  hair  is  one  of  the  last  parts  ot 
the  body  that  undergoes  decomposition.     [F.  J.  K.] 

7. — Maguire  reports  a  case  of  measles  complicated  by 
laryngeal  diphtheria  which  terminated  fatally.  The  in 
tant  was  18  months  of  age  and  developed  a  typical  exan- 
them,  accompanied  by  characteristic  symptoms  of  rubeola: 
a  history  of  diphtheria  infection  could  not  be  ascer- 
tained. As  the  disease  progressed  and  it  seemed  to 
be  pursuing  an  ordinary  course,  suddenly  symptoms  ot 
dyspnea  set  in;  the  difficulty  ot  breathing  increased, 
the  child  was  cyanosed  and  appeared  to  be  in  terrible 
(".istress.  The  possibility  of  membranous  construction  was 
considered,  but  after  a  most  careful  examination  of  the 
larynx,  not  a  particle  of  membrane  could  be  found. 
Tracheotomy  was  performed,  giving  the  child  some  relief, 
but  finally  death  occurred  from  collapse.  The  autopsy 
revealed  a  thick,  tough  membrane  occu'  ving  the  larnyx 
and  producing  almost  complete  obstruction.  It  was  pro- 
ven by  a  bacteriologlc  examination  that  this  infection 
was  due  to  the  diphtheria  bacillis.     [F.  J.  K.] 

8. — Newman,  in  continuing  the  History  of  Renal  Sur- 
gery, discusses  nephrotomy  and  nephrectomy,  giving  the 
progress  ot  each  operation.  [J.  H.  G.] 


JOURNAL     OF     AMERICAN     MEDICAL     ASSOCIATION. 

April  6",  1901. 

1.  Chloralose.     JAMES  TYSON. 

2.  Postoperative  Nervous  Phenomena  or  Artificial  Meno- 

pause.    JOSEPH  PRICE. 

3.  Syphilis  as  a  Non-Venereal  Disease.     With  a  Plea  for 

the  Legal  Control  of  Syphilis.  L.  DUNCAN  BULK- 
LEY. 

4.  Recent    Clinical    Obesrvations     on    Tinea    Versicolor. 

CHARLES  WARRENNE  ALLEN. 

5.  Experiments   with   an   Epidemic   of  Rabies   in   Buffalo, 

ERNEST   WENDE. 

6.  Pure-Food  Legislation  vs.  Poor  Food-Legislation.    MUR- 

RAY GALT  MOTTER. 

7.  A  New  Leg-Splint  for  Transverse  Fracture  of  the  Tibia. 

EDWARD  A.  TRACY. 

8.  Some    Observations    in    Renal    Surgery.     W.    H.    ALL- 

PORT. 

9.  The   Relation   of   Indicanuria   and   Oxaluria  to  Gastro- 

intestinal Fermentation.     J.  A.  WESENKR. 

10.  Some  Additional   Observations   on   the   Effects   of  In- 

jury to  Peripheral  Nerves.     D.  S,  FAIRCHILD. 

11.  An  Operation  for  Cystocele.     GEORGE  H.  NOBLE. 

12.  Individual  Prophylaxis.    W.  A.  EVANS. 

13.  Statement    made    before    the    Committee    on    Public 

Health  in  New  York  Assembly  at  the  Public  Hear- 
ing on  Assembly  Bill  759.  Regulating  and  Legalizing 
the  Practice  ot  Osteopathy,  etc. 


''•  Tyson  gives  the  following  conclusion  regarding  the 
use  of  chloralose:  It  is  a  prompt  and  safe  hvpnotic,  its 
action  being  more  prompt  than  any  drug  except  morphine; 
It  IS  more  prompt  and  efficient  in  smaller  doses  than 
chloral.  The  author  believes  that  further  studies  should 
be  made  upon  this  drug.  Five  grains  is  the  maximum  dose, 
which  may  be  repeated  in  an  hour;  smaller  doses  should 
always  be  tried.     [F.  J.  K.J 

2.— Price  considers  the  subject  of  the  artificial  meno- 
pause or  post  operative  nervous  phenomenon  from  the 
standpoint  of  the  general  practitioner.  He  remarks  that  un- 
fortunately but  a  few  of  these  patients  are  kept  under 
treatment  sufficiently  long  for  permanent  results  after  the 
operation.  As  a  rule  they  are  systematically  treated  only 
for  a  period  of  three  or  four  weeks,  and  are  then  hurridly 
returned  home  where  everything  is  unfavorable  for  a  fa- 
vorable convalescence.  The  pratice  of  early  rising  and  early 
discharge  after  an  operation  favors  post-operative  sequelae 
and  a  tedious  convalscence.  The  rest-cure  would  do  very 
much  for  this  class  of  patients.  Under  such  a  course 
of  treatment  the  general  improvement  is  marked;  the 
patients  eat  and  sleep  well,  are  bright  and  cheerful,  all 
their  uncomfortable  symptoms  vanish,  and  they  recover 
flesh  and  color  rapidly.  Systematic  rubbing  and  massage 
should  be  added.     [W.  A.  N.  D.] 

3.— Bulkley  discusses  the  subject  of  syphilis  as  a  non- 
venereal  disease,  and  argues  that  so  long  as  syphilis  is 
regarded  exclusively  as  a  venereal  disease  it  will  be  ex- 
tremely difficult  to  control  its  spread.  He  urges  that 
syphilis  should  be  classified  amongst  the  contagious  dis- 
eases. He  reviews  the  subject  of  the  world  wide  distribu- 
tion of  this  disease,  and  considers  in  detail  the  methods 
by  which  the  disease  is  communicated  to  the  innocent. 
Rererence  is  made  to  three  groups:  (1)  Marital  syphilis; 
(2)  Hereditary  syphilis,  and  (3)  Extragenital  syhpilis.  He 
finally  makes  a  plea  for  legal  control  of  syphilis,  stating 
that  the  most  important  point  in  the  prevention  of  its 
spread  will  be  found  by  considering  it  contagious  and  in- 
stituting measures  to  prevent  dissemination  similar  to 
those  used  in  checking  other  contagious  diseases.  [F.  J.  K.) 
4. — Allen  discusses  the  recent  clinical  observations  on 
tinea  versicolor.  The  author  states  that  the  disease,  while 
rare  in  young  individuals,  has  been  observed  below  the 
age  of  ten  by  competent  investigators.  The  writer  cannot 
verify  the  statements  of  other  observers,  that  tinea  versi- 
color frequently  occurs  in  individuals  who  suffer  from 
phthisis  or  any  other  severe  diseases.  Patches  of  tinea 
versicolor,  as  he  pointed  out  a  year  ago,  frequently  occur 
in  the  public  region  in  both  men  and  women;  these  patches 
may  be  regarded  as  a  source  of  renewed  infection  in  some 
instances.  Recurrent  infection  in  some  instances  may  be 
ascribed  to  the  fungus  being  present  in  the  hair  follicle. 
He  believes  the  iodine  test  is  valuable  in  distinguishing 
the  pigmented  areas  of  tinea  versicolor  from  chloasmas, 
macular  syhpilides,  exanthemata,  erythemas,  etc.  How- 
ever, the  diagnosis  is  often  difficult  without  the  micro- 
scope. A  report  is  given  ot  a  case  ot  pityriasis  nigra.  In 
referring  to  the  treatment  of  tinea  versicolor,  the  author 
has  found  soap  of  itself  capable  of  ridding  the  surface  of 
fungus.  He  has  used  the  following  ointment  with  good  re- 
sults: 50  parts  of  an  ointment  made  with  calcium  bisul- 
phate  in  a  saturated  solution;  20  parts  of  lanolin  and  30 
parts  of  lard.     [F.  J.  K.] 

5. — Wende  relates  his  experience  with  an  epidemic  of  ra- 
bies, in  Buffalo.  The  first  case  was  observed  in  Novem- 
ber, 1898,  in  the  Kenmore  section  of  the  city;  following 
this  case,  there  were  a  number  ot  isolated  instances  at 
varying  intervals.  From  April  1st.,  1899,  until  April  1st., 
1900.  there  were  230  persons  bitten  by  dogs;  37  persons 
were  bitten  by  rabid  animals,  and  4  deaths  occurred  from 
hydrophobia.  From  the  beginnig  of  the  epidemic  until 
April,  1901.  4.429  dogs  were  disposed  of.  The  most  Im- 
portant and  prominent  clinical  characteristics  of  the  dis- 
ease in  the  animals  wore  the  following:  there  was  a 
changed  behavior  and  an  altered  disposition  ot  the  animals; 


7i8 


The  Philadelphia"] 
Mmiital  .TounNAL  J 


THE  LATEST  LITERATURE 


[APEn-  13,  1901 


they  were  irritable  and  restless;  they  showed  a  desire 
to  swallow  foreign  bodies,  such  as  stone,  glass,  wood  etc. 
The  animals  showed  a  tendency  to  stray  away  from  their 
homes.  The  most  constant  symptoms,  especially  from  a 
diagnostic  standpoint,  was  an  alteration  in  the  voice  due 
to  paralysis  of  the  vocal  cords.  Another  characteristic 
symptom  was  a  tendency  to  snap  and  bite  at  imaginary  ob- 
jects, and  there  was  also  peculiar  and  furious  aggression  to- 
wards anything  before  them;  the  dogs  did  not  shirk  or  re- 
tire from  impending  blows;  they  did  not  seem  to  show 
evidence  of  impending  danger.  The  author  states  that  a 
symptom  heretofore  undo  scribed  was  the  appearance  of  the 
pouching  out  of  the  neck,  due  to  spasm  of  the  muscles  of  de- 
glutition. The  author  makes  a  plea  for  municipal  restric- 
tion of  rabies.     [F.  J.  K.l 

6. — Hotter  states  that  in  order  to  solve  the  problem  of 
legislation  partaining  to  pure  food,  a  greater  interest  should 
be  shown  on  the  part  of  the  medical  profession.  More 
careful  researches  and  investigations  should  be  made  up- 
on the  physiology  of  digestion,  absorbtion  and  assimila- 
tion; and  that  the  profession  should  adopt  certain  definite 
and  more  reliable  standards,  which  would  embody  funda- 
mental principles.  Finally  in  order  to  put  into  effect  and 
carry  out  these  principles,  governmental  legislation  be- 
comes necessary.     [F.  .1.  K.] 

7. — Tracy  recommends  for  transverse  fracture  of  the 
tibia  a  splint  of  wood-plastic  material  molded  to  the  leg 
after  being  moistened  with  water.  This  splint  is  applied 
next  to  the  skin.  Tracy  holds  that  this  method  of  treat- 
ment gives  entire  satisfaction,  allowing  of  frequent  in- 
spection of  the  leg  and  of  massage.     |J.  H.  G.] 

8. — Allpovts  first  calls  attention  to  the  anamolous  posi- 
tions of  the  abdominal  viscera  and  to  the  changes  brought 
about  in  the  relations  of  the  abdominal  viscera  by  patho- 
logical conditions.  Brief  histories  are  recorded  of  14  cases 
of  Renoe  Disease  in  which  mistakes  of  diagnosis  were 
made.  Among  these  the  kidney  was  taken. for  the  spleen 
and  the  spleen  for  the  kidney;  the  liver  was  found  behind 
the  colon  in  searching  for  a  kidney,  and  the  kidney  lying 
against  the  anterior  abdominal  wall  in  front  of  the  colon; 
the  gall  bladder  was  found  in  the  loin  and  again  in  the 
iliac  fossa  and  p°rinpphritic  abscess  was  mistaken  for  cal- 
culus and  appendicitis,  and  finally  an  empyema  was  found 
to  resemble  renal  cancer.  Instances  are  recalled  where 
renal  calculus  was  treated  for  Uright's  disease  and  other 
Instances  where  the  kidney  was  opened  for  stone  and 
none  found.  After  discussing  these  cases  Allport  makes 
the  following  deductions: 

(1)  The  surgeon  should  not  attach  too  great  weight  to  the 
opinions  and  subjective  symptoms  of  the  patient  unless 
these  are  borne  out  by  the  physical  signs.  (2)  On  the  other 
hand,  due  consideration  should  be  given  to  the  state- 
ments of  intelligent  patients  especially  in  cases  where 
the  objective  symptoms  are  so  abundant  as  to  be  confusing. 
Careless  history  taking  is  shown  to  be  a  source  often- 
times of  wrong  diagnosis.  In  2  cases  of  the  14  shown  a 
history  of  traumatism  was  not  elicited  prior  to  operation 
and  the  neglect  resulted  in  a  diagnostic  error.  (3)  In  the 
presence  of  pathological  conditions  it  is  a  mistake  to  place 
too  great  reliance  on  normal  relations  of  the  viscera.  (4) 
It  is  an  error  to  make  a  diagnosis  on  the  presence  of  a 
condition  which  is  recognized  to  be  pathognomonic  with- 
out carefully  going  into  the  history  of  the  case  and  the 
other  symptoms  which  it  presents.  Stress  is  here  laid  upon 
the  great  necsesity  of  using  every  available  source  of  in- 
formation. Although  a  Skiagraph  may  fail  to  reveal  a  cal- 
culus under  certain  circumstances,  it  is  a  mistake  to  per- 
form nephrotomy  without  making  use  of  the  X-Rays.  The 
importance  of  a  record  of  temperature  and  pulse  is  urged 
as  a  diagnostic  means  in  all  cases  of  suspected  kidney 
disease.  (5)  Among  the  operative  errors  is  mentioned  the 
improper  care  of  the  ureter  after  nephrectomy.  This  organ 
hould  he  ligated  with  catgut  and  brought  separately  into 
the  wound  after  cauterization  or,  which  is  bettor,  it  may 
>  inverted  and  stitched.     Kidney  stumps  should  not  be 


ligated  with  silk.  Too  deep  incisions  in  the  kidney  sub- 
stance are  dangerous  and  jeopardize  the  subsequent  in- 
tegrity of  the  pelvis  and  ureter.  Drainage  should  always 
he  employed  at  least  for  a  few  days  after  nephrotomy. 
A  kidney  riddled  with  sinuses  should  always  be  removed. 

These  conclusions  are  well  based  on  the  llustrative  cases 
submitted  by  the  author.     [J.  H.  G.] 

9. — Wesener  discusses  the  relation  of  indicanuria  and 
oxaluria  to  gastro-intestlnal  fermentation.  The  author 
states  that  the  main  object  of  his  article  is  to  determine 
whether  or  not  there  is  a  relationship  between  excreted  in- 
dican  and  oxalic  acid,  and  what  bearing  these  substances 
have  upon  gastro-intestinal  fermentation.  He  reaches  the 
following  conclusions:  (1)  in  normal  urine  traces  of  ox- 
alates are  present.  (2)  when  oxalate  crystals  are  found 
in  the  urine  they  usually  suggest  gastro-intestinal  fermen- 
tation; however,  it  must  be  borne  in  mind  that  food  which 
is  rich  in  oxalates  must  be  excluded.  (3)  WTien  oxalate 
crystals  are  found  in  abundance  they  do  not  indicate  a 
high  acid  percentage,  for  the  reason  that  there  may  also 
be  found  oxalates  of  lime  in  solution.  (4)  Often  indican- 
uria is  associated  with  oxalate  crystals,  but  this  is  not  in- 
variably the  case.  (5)  Hyperacidity,  whether  due  to  hy- 
drochloric acids  or  acids  of  fermentation,  is  an  aid  to 
putrefaction.  (6)  In  certain  gastro-intestinal  derange- 
ments, whether  due  to  excess  of  hydrochloric  acids  or  fatty 
aci'ds,  indican  and  oxalic  acid  are  increased.  (7)  The  symp- 
toms of  oxalic  acid  diathesis  are  due  to  products  which 
are  formed  in  the  process  of  fermentation,  and  the  oxaluria 
and  indicanuria  are  diagnostic  adjuncts  in  the  determin- 
ation of  putrefaction.  The  author  finally  makes  a  plea  for 
more  careful  and  extensive  investigation  in  the  study  of 
oxaluria  and  indicanuria.     [F.  J.  K.] 

10. — Fairchild  completes  the  history  of  a  case  of  neuritis 
of  the  median  nerve  resulting  from  cicatrical  pressure  from 
a  wound  of  the  thumb.  This  case  was  reported  when  Ave 
operations  had  ben  performed,  beginning  with  excision  of 
the  cicatrix  and  ending  with  amputation  of  the  thumb. 
Each  operation  was  followed  by  a  temporary  cessation 
of  pain  but  within  a  few  weeks  the  symptom  returned  with 
all  its  former  severity.  The  pain  was  so  great  as  to  cause 
the  patient  to  beg  to  have  the  arm  amputated.  It  was 
finally  determined  to  remove  the  scar  in  the  stump,  to 
liberate  the  median  nerve  in  its  bed,  and  to  surround  it 
with  sterlized  gold  foil.  This  was  done  with  the  most 
satisfactory  result,  the  patient  returning  to  his  work  as  a 
bridge  carpenter,  at  which  he  has  continued  fo  rthe  past  18 
months.  At  first  exposure  to  cold  or  prolonged  use  of 
the  hand  would  bring  back  the  pain  temporarily,  but  these 
returns  of  pain  have  gradually  and  entirely  disappeared. 
[J.  H.  G.] 

11. — Noble  describes  on  operation  for  cystocele  which 
consists  in  making  a  diamond  shape  denudation  of  the  an- 
terior vaginal  wall  down  to  the  muscular  layer  and  in  bring- 
ing this  denuded  surface  together  by  a  number  of  layers 
of  buried  sutures,  the  principal  one  being  of  fine  silver  wire. 
The  use  of  this  material  has  never  given  an.v  bad  results  in 
his  hands  and  he  prefers  it  to  silk  or  kangaroo  tendon. 
Catgut  is  not  to  he  used  in  this  operation  except  for  the 
superficial  suture.  The  method  of  introducing  the  various 
sutures  is  explained  by  a  number  of  illustrations.  [J.  H.  G.J 

12. — Individual  prophylaxis  Is  discussed  by  Erans.  He 
confines  his  remarks  to  the  prophylaxis  of  bacterial  dis- 
ease. As  predisposing  causes  to  bacterial  diseases,  he 
mentions  mental  depression,  over-exertion,  uncleanliness 
and  exposure  to  cold.  He  considers  in  detail  the  limitations 
of  these  predisposing  influences,  and  finally  urges  that 
in  order  to  establish  personal  prophylaxis  the  resting  ca- 
pacity of  the  organism  should  be  increased.     [F.  J.  K.] 


NEW  YORK    MEDICAL  JOURNAL. 
April  h",   inoi. 

1.  The   .\ctive   Principles   of  Digitalis   Leaves.     JOSEPH 

W.    ENGLANn. 

2.  The  Compar.itive  Pathology  of  the  Jews.  (Concluded). 

MAURICE  FISHBERQ. 


Aprii,  13,  1901] 


THE  LATEST  LITERATURE 


[The  Pnii.ADEi.PBLA 
Medical  Jocknai, 


719 


3.  The    Pathology    of    Intrauterine    Death.     NEIL    Mac- 

PHRATTER. 

4.  Rectal  Feeding  in  Throat  Diseases.     A.  C.  BARDES. 

5.  The    Medical    Aspect    of    Christian    Science.     M.    M. 

POLK. 
1. — The  chemistry  of  digitalis  leaves  receives  the  at- 
tention of  Joseph  W.  England,  Ph.  G.  He  mentions  the 
fact  that  various  so-called  active  principles  which  have 
bee  isolated  from  time  to  time  have  been  found  to  be 
varying  mixtures,  such,  for  instance,  as  the  French  and 
German  digitalin.  According  to  Schmiedeberg's  investiga- 
tions, digitalin  consists  for  the  most  part  of  digitaline, 
with  small  proportion  of  digitin,  digitonin  and  Schmiede- 
berg's digitalin.  It  occurs  as  yellowish  white  amorphous 
powder  that  is  soluble  in  water  and  in  alcohol,  but  prac- 
tically insoluble  in  chloroform  and  ether.  Schmiedeberg 
decided  that  the  active  principles  of  digitalis  leaves  were 
a  digitalin  digitoxin,  digitonin  and  digitaline.  He  di3C0\- 
ered  digitoxin,  obtaining  it  from  the  leaves.  England 
gives  a  critical  survey  of  the  various  investigations  upon 
the  subject  of  the  active  principles  of  dig.talis.Digitalis 
seeds  are  largely  used  in  Germany  for  the  preparation  of 
digitalis  principles,  hence  we  do  not  know  very  much 
about  the  glucosides  of  digitalis  leaves,  the  main  work  so 
far  having  been  done  upon  preparation  of  the  seed.  Dis- 
cussing the  relative  value  of  various  principles  of  digitalis, 
England  concludes,  as  to  digitoxin,  that  its  difficulty  of 
absorption,  the  length  of  time  necessary  to  yield  cardiac 
and  renal  effiects,  its  slowness  of  elimination  and  the  rela- 
tive rapidity  of  absorption  of  digitalis  tinctures,  that  digi- 
toxin cannot  be  the  most  important  principle  of  digitalis 
leaves.  The  severe  pain  follows  the  hypodermic  injection 
of  digtoxin  injection  and  the  injected  tissues  continue 
sensitive  for  a  long  time.  The  slowness  of  the  physiologi- 
cal effects  indicate  a  great  difficulty  of  absorption  and  as- 
similation. The  cumulative  action  of  digitalis  has  been 
explained  by  the  fact  that  the  proximate  principles  of  the 
drug  were  not  excreted  by  the  drug  as  Jast  as  absorbed, 
and  that  they  therefore  accumulated  in  the  body.  But 
England  explains  this  culminative  action  to  the  slow  ab- 
sorption and  elimination  of  digitoxin.     [T.  L.  C] 

2. — Maurice  Fishberg  concludes  his  article  upon  the 
comparative  pathology  of  the  Jews  with  the  following 
summary:  The  death-rates  of  the  Jews  at  all  ages  are 
relatively  and  absolutely  lower  than  those  of  the  people 
among  whom  they  live.  2.  The  marriage-rates  and  birth- 
rates of  the  Jews  are  smaller  than  those  of  the  Christian. 
The  Jews  increase  more  rapidly  in  number  than  those  of 
the  non-Jews  because  they  lose  by  death  relatively  fewer 
children  and  bring  more  to  maturity.  3.  The  Jews  die  less 
often  than  their  neighbors  from  many  of  the  infectious 
fevers,  particularly  epidemic  cholera,  smallpox  and  tuber- 
culosis. 4.  Syphilis  and  alcoholism,  and  also  diseases  due 
in  a  great  measure  to  their  poisons,  are  comparatively  rare 
among  the  jews.  5.  Most  observers  have  recorded 
that  almost  25  per  cent,  of  all  the  cases  of  diabetes  occur 
in  Jews.  6.  All  the  functional  neuroses,  particularly 
neurasthenia  and  hysteria  occur  more  frequently  among 
the  Jews  than  others,  while  all  the  organic  nervous  dis- 
eases, such  as  tabes,  general  paralysis,  etc.,  are  less  fre- 
quent, commensurate  with  the  infrequency  of  syphilis  and 
alcoholism  among  them.  The  great  majority  of  cases  of 
amaurotic  idiocy  occur  in  Jewish  children,  and  insanity  is 
met  with  among  Jews  between  two  and  five  times  more 
often  than  among  Christians.  7.  Blindness,  color-blind- 
ness, trachoma  and  glaucoma,  and  also  varicose  veins, 
particularly  hemorrhoids  and  hernia,  are  very  frequent 
among  the  Jews.  8.  All  the  peculiarities  in  the  compara- 
tive pathology  of  the  Jews  are  not  due  to  any  ethnic 
"bio-static"  or  racial  characteristics  of  a  purely  anatomical 
or  physiological  nature  in  relation  to  non-Jews.  They  have 
their  origin  in  the  past  history  of  the  Jews  in  their  habits 
of  life  and  in  the  fact  that  syphilis  and  alcoholism  have 
but  rarely  been  seen  among  them.  9.  'UTiere  the  Jew  is 
commingling  with  his  Christian  neighbors  and  adopts 
their  customs  and  habits  of  life  sooner  or  later  loses  its 
racial  characteristics  and  its  comparative  pathology  pre- 
sents no  special  peculiarities.     [T.  L.  C] 

4. — A.  C.  Bardes  calls  attention  to  the  value  of  rectal 
feeding  In  throat  diseases.  He  cites  three  cases  in  which 
it  was  employed  to  advantage.  One  of  diphtheria,  one  of 
tuberculoscis  and  one  of  hay-fever  and  asthma.  He  sums 
i:a    the   advantages    of    rectal    feeding    as    follows:      The 


throat  being  at  rest,  is  not  irritated,  struggling  in  children 
is  obviated,  the  progress  of  the  disease  is  shortened,  there 
is  no  danger  of  food  entering  the  larynx,  the  physician  is 
able  to  give  such  food  and  stimulation  as  he  wishes  to 
give,  and  the  food  is  not  bolted  as  it  is  when  swallowing 
is  painful.  [T.  L.  C.J 
5. — Nothing. 


MEDICAL     RECORD. 


April  ti,   lUUI. 

1.  The  Relation  of  the  Public  to  the  Medical  Profession. 

D.  B.  ST.  JOHN  ROOSA. 

2.  The    Importance    of    Aseptic    Vaccination,    with    Re- 

marks on  Vaccination  in  General.    WILHELM  KARL 
KUBIN. 

3.  The  Field  for  Ethyl  Chloride  Narcosis.     MARTIN  W. 

WARE, 
i.     On  the  Diagnosis  and  Prognosis  of  Diabetes  Mellitus. 

HENRY  S.  STARK. 
2. — Wilhelm  Karl  Kubin  discusses  the  importance  of 
aseptic  vaccination,  with  remarks  on  vaccination  in  gen- 
eral. The  causes  of  the  various  untoward  results  incidental 
to  vaccination  may  be  enumerated  as  follows:  1.  Impure 
virus;  2.  Abnormal  or  paradoxical  course  of  the  cowpox 
itself;  3.  Improper  performance  of  the  act  of  vaccination; 

4.  Neglect  on  the  part  of  the  vaccinator  to  exercise  super- 
vision and  control  the  patient  until  the  time  of  complete 
healing;  5.  Coincident  diseases  such  as  scarlatena  and 
measles.  He  adds  a  number  of  cases  of  untoward  com- 
plieations  following  vaccination.  He  concludes  by  giving 
his  technique  for  the  operation,  and  recommends  that  a 
compulsory  national  law  for  vaccination  and  revaccination 
should  be  adopted  similar  to  that  of  Germany.     [T.  L.  C] 

3.— Martin  W.  Ware  studies  the  field  for  ethyl  chloride 
narcosis.  Physiologically  ethyl  chloride  seems  to  act  on 
the  sympathetic  nerves  judging  from  the  accelerated  pulse, 
flushing,  and  the  transient  dilation  of  the  pupil.  Next, 
it  seems  to  act  on  the  spinal  cord  and  lastly  on  the 
brain,  but  in  all  of  these  in  rapid  sequence.  Chemically, 
being  derived  from  the  second  series  of  hydrocarbons  it  is 
in  the  direct  line  of  relative  safety  of  alcohol  and  ether,  de- 
rivatives of  this  group,  but  since  the  drug  contains  one 
molecule  of  chlorine  and  since  an  anesthetic  is  dangerous 
in  the  proportion  to  the  chlorine  it  contains,  herein  lurks 
a  possible  danger  in  ethyl  chloride.  The  writer  advo- 
cates its  use  pre-eminently  in  minor  surgery  because  it  is 
as  safe  statistically  as  any  of  the  others:  it  induces  a 
very  rapid  narcosis  and  equally  as  quick  and  awaken- 
ing and  is  void  of  any  after  effects.  It  is  cheaper  than 
nitrous  oxide  and  does  away  with  any  especial  apparatus. 
[T.  L.  C] 

4- — Henry  S.  Starr  presents  a  paper  upon  the  diagnosis 
and  prognosis  of  diabetes  mellitus.  Of  great  prognostic 
importance  are  the  following  features:  Age.  power  of 
assimilation  of  carbohydrates:  early  recognition  of  the 
affection:  the  presence  of  intercurrent  and  complicating 
diseases:  condition  in  life:  state  of  the  urine:  and  the 
power  of  absorption  of  other  food  stuffs  than  carbohydrates. 
He  arranges  his  cases  in  one  of  three  types  from  a  prog- 
nostic standpoint.  First,  the  mild  type,  to  which  belong 
those  cases  in  which  the  glucose  disappears,  only  after 
the  complete  exclusion  of  carbohydrates,  and  the  severe 
type  in  which  may  be  classed  those  cases  in  which  the 
glycosuria  persists  despite  the  complete  exclusion  of  car- 
bohydrates and  even  of  proteids.     [T.  C.  C] 


MEDICAL    NEWS. 


April  C.  wm.      (Vol.   LXXVIII.  No.   14). 

1.  Advertising  in  the  Profession.     FRANK  LYDSTON. 

2.  Resection  of  the  Cervical  Sympathetic.     HOWARD  J. 

WILLI.\MS. 

3.  The    Question    of    Drainage    in    Appendicitis.     A.    M. 

POND. 

4.  New  Methods  in  Charity,  with  Better  Results  and  at 

Less  Cost.  WILLIAM  P.  SPRATLING. 
2. — Wiliams,  in  his  article  on  resection  of  the  cervical 
sympathetic,  says  that  it  is  indicated  in  glaucoma  simplex, 
inflammatory  glaucoma  where  iridectomy  has  failed,  hem- 
orrhagic glaucoma  early  in  the  disease;  and  should  be  tried 
in  absolute  glaucoma  with  pain,  in  preference  to  enuclea- 


720 


The  Phtladelphia"! 


THE  LATEST  LITERATURE 


[Apeh,  13.  1901 


tion.  In  unliteral  trouble  the  ganglion  of  the  eorerspond- 
ing  side  should  be  excised.  While  the  operation  may  not 
be  curative  in  every  case  of  glaucoma,  the  results  thus  far 
have  been  sufficiently  satisfactory  to  make  it  a  desirable 
procedure  in  this  serious  disease.     [T.  M.  T.] 

3.— Pond  states  the  inefficiency  of  attempts  at  drainage 
in  operations  for  appendicitis,  and  says  the  mere  presence 
of  the  drain  is  productive  of  much  "harm;  it  unquestionably 
produces  a  hyperemia  and  congestion  of  the  peritoneum 
in  closest  proximity,  thereby  lessening  the  absorption  by 
disturbing  its  normal  currents:  it  also  produces  adhesions 
about  the  drain,  which  in  turn  lessens  the  area  of  the 
peritoneum  exposed  to  the  infection,  thereby  limiting  its 
important  function  of  absorption.  It  is  known  that  the 
peritoneum  is  capable  of  disposing  of  large  quantities  of 
pus  under  favorable  conditions,  and  chief  among  these 
conditions  is  the  equal  distribution  over  the  peritoneal 
area;  in  order  to  do  this  it  becomes  necessary  to  use  some 
agent  which  will  put  pus  and  pus-forming  elements  in 
solution,  and  in  choosing  this  agent  some  very  important 
points  to  be  considered  are:  1.  Sterility.  One  species  of 
bacteria  is  often  inert  and  latent  until  another  species  is 
introduced,  thus  combining  the  efforts  of  both,  and  a  here- 
tofore  latent   sepsis   becomes   a   rapidly   active   infection. 

2.  Power  of  holding  in  a  homogeneous  solution  the  pus  as 
well  as  the  blood  and  blood-clots  incident  to  the  operation, 
in  order  to  permit  of  equal  distribution  over  the  peritoneal 
cavity.  The  presence  of  blood-clots  in  a  septic  cavity  can- 
not be  over-estimated:  no  richer  culture  medium  is  known 
for  bacteria,  and  these  must  be  protected  from  invasion. 

3.  Stimulation  of  absorption.  It  is  most  desirable  to  re- 
move all  sentic  material  as  soon  as  possible,  and  this  is 
made  possible  by  the  power  of  absorption  of  the  peri- 
toneum, which  enormous,  namely,  from  3  to  8  per  cent, 
of  the  body  weight  in  one  hour.  Hot  saline  solution  is  very 
effective  and  fulfills  all  the  requirements:  it  can  be  made 
sterile  into  the  peritoneal  cavity:  it  possesses  the  power 
of  putting  pus  and  pus-forming  elements,  such  as  blood  and 
blood-clots  into  solution,  thus  removing  the  danger  of 
fresh  invasion  of  infection,  and  being  hot-  temperature  105 
degrees  to  108  degrees  F.,  is  a  most  active  stimulant  to  the 
peritoneum  and  its  use  is  unattended  by  unpleasant  se- 
quelae. Increased  hepatic  activity  is  another  step  in  the 
right  direction.  Such  activity  produces  a  detergent  influ 
ence  in  all  cases  of  general  sepsis,  as  well  as  in  localized 
infectious  processes,  besides  removing  from  the  entire 
physical  economy  various  substances  which  in  themselves 
would  aid.  if  not  produce,  septic  conditions:  this  function 
Is  certainly  worthy  of  careful  study,  as  it  will  increase  the 
sources  of  the  surgeon  in  combating  infection,  since 
through  the  portal  circulation  we  can  increase  the  general 
resistance  against  bacteria.  Posture  does  much  in  these 
cases:  elevation  of  the  foot  of  the  bed  a  few  inches  tends 
to  gravitate  the  fluids  towards  the  diaphragmatic  lymph- 
spaces  afford  an  avenue  of  rapid  absorption  of  sepsis  held 
in  solution.     [T.  M.  T.] 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 
April  4- 

1,     Diseases  of  the  Myocardium.     HENRY  JACKSON. 

3.  The  Conditions  of  the  Myocardium   as   Affecting  Car- 

diac Murmurs.     H.  D.  ARNOLD. 

4.  A  Further  Note  on  the  Treatment  of  Epidermoid  Can- 

cer. FRANCIS  H.  WILLIAMS. 
1. — Disease  of  the  myocardium  does  not  receive  in  our 
text  books  the  important  consideration  that  It  deserves, 
this  branch  of  heart  disease  being  summarily  dispatched, 
while  many  chapters  are  written  on  the  accurate  differen- 
tial diagnosis  of  the  various  valvular  lesions,  and  this,  too, 
when  we  know  that  the  diagnosis  is  not  seldom  proved  to 
be  wrong  by  the  pathologist.  Even  in  the  consideration 
of  a  case  of  valvular  disease  the  important  points  in  the 
treatment  and  mana.gement  of  the  individual  case  are  not. 
What  is  the  lesion?  but,  what  effect  has  that  lesion  pro- 
duced upon  the  heart  itself?  Is  hypertrophy  or  dilation 
the  leading  factor  in  causing  enlargement  of  the  heart? 
is  the  action  regular,  and  what  is  the  character  of  the 
pulse  wave?  Heart  disease  does  not  necessarily  mean  val- 
rular  dispase  and  murmurs  evidently  pathognomonic  of 
regurgitation  do  not  prove  the  existence  of  organic  dis- 
ease o£  tUs  valve  curtains.    Pathologically,  diseases  of  the 


myocardium  may  be  classified  under  the  following  heads: 
(1)  Disturbance  of  the  circulation;    (2)  inflammatory  pro- 
cesses;    (3)    degeneration;     (i)    tumors:    and    (5)    hyper- 
trophy  and   dilation.     The   causes  of  enlargement  of  the 
heart  may  lie   within  the  heart  itself,   or  outside  of  the 
heart.     The  causes  outside  the  heart  may  be:    (1)    peri 
cardial   adhesions,   especially   alcohol:    (a)    overwork,   the 
so-called   soldiers   heart,    (6j    a   few   cases   in   which   the 
etiology  is  obscure;  and  (!)  by  far  the  most  important,  ar- 
teriosclerosis,  arteriocapillary   fibrosis.     In   100   autopsies 
in  cases  of  cardiac  disease,  Jackson  found  a  record  of  32 
cases  dependent  upon  arteriosclerosis,  and  in  only  4  was 
the  weight  of  the  heart  under  400  grams.     The  heart  was 
enlarged  in  16  cases.    In  6  cases  the  area  of  heart  dullness 
was  described  as  normal.     In  many  of  the  cases  the  ac- 
tion was  weak  and  the  heart  markedly  irregular  and  in- 
termittent.    The  pulse  was  usually  weak,  rapid,  intermit- 
tent and  irregular.     Murmurs  were  detected  in  10  of  the 
cases,  and  in  7  of  these  the  murmur  was  that  of  mitral 
regurgitation,  but  in  none  was  a  pathological  condition  ex- 
planatory of  the  cause  of  the  murmur  found,  postmortem. 
iU  one  case  there  was  a  systolic  murmur  in  the  aortic  area. 
In  two  cases,  a  double  murmur  was  heard  at  the  aortic 
area,    and    postmortem,    the    aortic    valves    were    demon- 
strated  to   be   relatively   insufficient.     As   murmurs   indi- 
cative of  imperfect  closure  of  the  valves  were  heard  in 
l-o  of  the  cases  of  arteriosclerosis,  it  is  evident  that  the 
presence  of  such  murmurs  cannot  be  offered  as  evidence  of 
structural   lesions   of  the  valves.     In   16   of  the   cases,   a 
trace  of  albumin  was  found  in  the  urine,  with  casts.     In 
14  cases  there  was  structural  disease  of  the  kidney  [J. M.S.] 
2. — It  has  been  demonstrated  experimentally  that  when 
fluid,  confined  in  chambers  or  tubes,  pases  through  an  op- 
ening into  a  wider  space  beyond,  the  particles  of  the  fluid 
are  thrown  into  vibration  beyond  the  opening:  and,  it  the 
force  of  the  current  is  sufficiently  strong,  these  vibrations 
attain  an  intensity  that  enables  them  to  be  transmitted  to 
the   ear,   where  they   become  audible  as   sound.     To  this 
sound  we  give  the  name  murmur.     A  narrowing  of  any 
valvular  orifice  presents  this  condition  for  the  blood  in  its 
onward   progress.     A  leakage  through   any  of  the  valves 
furnishes  the  condition  in  a  reverse  direction.    In  the  aortic 
area  a  widening  of  the  aorta  beyond  the  orifice  furnishes 
the  necessary  condition,  even  if  the  aortic  valve  is  normal. 
Arnold  believes  that  the  dilation  of  the  aorta  accompany- 
ing arteriosclerotic  changes,   rather  than  the  roughening 
of  the  lining  of  the  valve  and  the  bloodvessel,  accounts  for 
the  frequency  of  the  aortic  systolic  murmur  beyond  middle 
life,  a  murmur  which  is  so  seldom  explained  at  the  autopsy 
by  a  true  stenosis  of  the  aortic  valve.     Regurgitant  mur- 
murs may  be  caused  at  any  of  the  valve  orifices  without 
disease  of  the  valve  itself,  provided  the  orifice  is  sufficient- 
ly dilated  to  prevent  the  proper  opposition  of  the  valve 
curtains.     Variations  in  the  intensity  of  a  given  murmur 
from  time  to  time  may  give  us  information  of  the  greatest 
value  in  estimating  the  condition  of  the  heart.     They  are 
to  a  certain  extent  a  measure  of  changes  in  the  strength 
of  the  cardiac  muscle.    If  with  rest  and  treatment,  a  weak 
dilated  heart  develops  a  murmur  that  was  not  audible  be- 
fore, or  if  a  faint  murmur  becomes  louder,  it  is  a  favor- 
able sign,  for  it  means  stronger  heart  action  and  implies 
the  beginning  of  compensatory  hypertrophy.     The  diminu- 
tion or  disappearance  of  a  murmur  may.  on  the  one  hand, 
mean  improvement  through  the  removal  of  the  conditioj 
causing  the  murmur,  but  it  mp.y.  on  the  other  hand,  mean 
a  weakening  of  the   cardiac   power.     Even  organic   mur- 
murs  sometimes   disappear.     If  there   is   good   reason   to 
decide  that  a   given   murmur  indicates   an   organic  valve 
lesion,  do  not  give  too  favorable  a  prognosis  simply  be- 
cause the  murmur  disappears,  and  do  not  conclude  that 
the  diagnosis  was  necessarily  wrong.     Mitral  murmurs  ars 
much    more   liable   to   variation    and    disappearance   than 
are  aortic  murmurs.     Of  all  cardiac  murmurs,  the  presys- 
tolic murmur  of  mitral  stenosis  is  the  most  variable.     Yet 
once  definitely  heard,  it  indicates  more  surely  than  any 
other  murmur  an  incurable  lesion.     A  weakened  action  of 
the  cardiac  muscle  which  failed  to  narow  the  mitral  ori 
fice  sufficiently,  or  a  weakened  action  of  the  papillary  mus- 
cles failing  to  hold  the  valve  curtain  firmly,  may  be  a  suffic- 
ient cause  for  mitral  regurgitation.    Mitral  regurgitation,  in 
debilitated  or  in  dilated  hearts  may  he  entirely  curable  if 
the  cause  is  curable,  though  the  question  depends  also  on 
the  myocardium  and  its  capabilities.    A  toxic  state  of  the 


ApniT.  13,  lOOn 


THE  LATEST  LITERATURE 


['i 


iiK   PniLAnBi.PHii 
■Iri'icAL  Journal 


721 


blood,  fever,  and  general  prostration.  Many  of  the  systolic 
apex  murmurs  heard  in  rheumatism  are  due  to  the  muscu- 
lar weakness  and  relaxation  from  a  toxic  state  of  the  blood, 
fever,  and  general  prostration  and  not  to  endocarditis. 
Systolic  apex  in  rheumatism  are  not  necessarily  due  to 
endocarditis.  They  do  mean  mitral  regurgitation,  but  not 
necessarily  a  diseased  valve.  The  so-called  functional 
murmurs  on  the  left  of  the  heart  are  really  due  to  mitral 
regurgitation,  showing  various  areas  of  distribution  ac- 
cording to  the  means  by  which  the  vibrations  travel  from 
the  left  auricle  to  the  surface.  Whatever  their  cause,  the 
important  thing  to  understand  is  the  state  of  the  myocar- 
dium.   [J.  M.  S.] 

3._Wiliams  prints  3  photographs  of  a  patient  who  was 
treated  for  epidermoid  carcinoma  of  the  lip  by  X-rays. 
The  exposure  to  tlie  rays  lasted  5  minutes  and  was  given 
nearly  every  day  tor  some  weeks.  Experience  has  sug- 
gested that  so  long  a  period  of  treatment  is  unnecessary. 
At  the  close  of  the  treatment  of  this  patient  the  induration 
had  disappeared;  the  lip  where  the  growth  had  been  was 
without  a  scar  and  perfectly  smooth  and  soft;  and.  ex- 
cept a  little  increase  in  width  on  the  affected  side,  there 
was  nothing  abnormal  in  its  appearance.  Later,  this  in- 
crease in  width  diminished  so  that  the  cosmetic  result  was 
perfectly  satisfactory.     [J.  M.  S.] 


AMERICAN     MEDICINE. 

April    G,    1001. 
1.     Medical  Aspects  of  Carcinoma  of  the  Breast,  with  a 
Note  on  the  Spontaneous  Disapearance  of  Secondary 
Growths.     WILLIAM   OSLER. 

2  The  Mortality  of  Operation  for  Obstructive  Jaundice. 

•JOHN   B.   DEAVER. 

3  Pheips'  Operation  for  Clubfoot  with  a  Report  of  1,650 

Operations.     A.  M.  PHELPS, 

4.  An   Obscure   Case   of   Hysteria   with   Associated   right 

Mydriasis  and  Amblyopia  and  Left  Myosis.     H.   A. 
HARE. 

5.  Carcinoma  of  Pylorus,  Secondary  to  Round  Ulcer;  Per- 

foration;  Resection  of  Pylorus;   Recovery.     FRANK 
BILLINGS.     . 
C      Puerperal  Sepsis;  its  Prevention  and  Methods  of  Treat- 
ment.    E.  E.  MONTGOMERY. 
7.     On  the  Anatomy  of  the  Renal  Vessels  and  Pelvis  of  the 
Kidney   in   Relation   to   Digital   Exploration   of   that 
Organ  in  the  Operation  of  Nephrotomy.     WILLIAM 
KEILLER. 
S      A  Rare  Form  of  Extrauterine  Pregnancy.     BRUCE  W. 

GOLDSBOROUGH  and  THOMAS  S.  CULLEN. 
9.     The  Early  Diagnosis  of  Insanity.     CARLOS  F.   MAC- 
DONALD. 
10    Dust  as  a  Factor  in  Diseases  of  the  Upper  Respiratory 
Passages.     W.  SCHEPPEGRELL. 
j^o.  ^  — Will  be  abstracted  when  concluded. 
2.—     " 
3.—     " 
4.—     "       " 
5. — Frank  Billings,   of  Chicago,   reports   a   case   of  Car- 
cinoma   of   the    pylorus    which    was    secondary    to    round 
ulcer.     Perforation  occurred,  the  operation  of  resection  of 
the   pylorus  was  performed   and   recovery  followed.     The 
writer    believes    that    Zeuker   is    probably    correct    in    his 
statement  that  most  cases  of  cancer  of  the  stomach  orig- 
inate from  an  ulcer  base.     The  patient  was  a  shoe  laster 
of  28  years  and  married.    A  paternal  uncle  died  of  "tumor" 
of  the  abdomen;    otherwise  the  family  history  was  nega- 
tive.    For  three  years   he   suffered   with   attacks   of  indi- 
gestion characterized  by  epigastric  fulness, sense  of  weight, 
bloating   of  the   abdomen   eructations   of   gas   and   consti- 
pation.    The  attacks  became  more  frequent  and  epigastric 
pain  experienced  after  a  full  meal.     Gradually  the  typical 
symptoms  of  gastric  carcinoma  appeared.     A  diagnosis  of 
pyloric  stenosis  from  gastric  ulcer  was  made.     The  oper- 
ation  was   performed   by   Dr.   Bevan.     A  tumor-like   mass 
occupied  the  pylorus,  and  a  perforation  had  occurred  in  the 
anterior  aspect  of  the   pylorus.     A   mass   of  about  three 
Inches    long    was    removed.      The    duodenal    and    gastric 
stumps  were  closed  and  then  a  gastrnenterostomy  was  per- 
formed with  a  Murphy's  button.     A  microscopic  examlna 
tion  of  the  growth  revealed  histologically  a  typical  scirrhus 
carcinoma.     An  Immediate  improvement  followed  the  opera- 


tion and  this  continued  for  some  seven  months,  when  the 
patient  began  to  fail.  Nodules  can  now  be  felt  in  the 
liver  and  there  is  every  evidence  of  carcinoma  of  other 
abdominal  organs.  It  is  of  interest  to  note  in  this  case  that 
the  age  of  the  patient  is  only  28  years,  as  well  as  the  pres- 
ence of  much  HCL.  in  the  stomach  contents  two  hours 
alter  a  small  amount  of  milk  was  taken.  The  perforation 
•of  the  stomach  with  an.  opening  the  size  of  an  ortinary 
lead  pencil  caused  but  little  discomfort,  and  only  slight  con- 
stitutional disturbance  for  eight  hours.     [T.  C.  L.] 

6. — E.  E.  Montgomery  treats  of  puerperal  sepsis,  its 
prevention  and  methods  of  treatment.  Among  the  import- 
ant preventive  measures  cleanliness  stands  first.  If  pre- 
vious infectious  disease  of  the  vagina  is  suspected  the  part 
should  be  surgically  clean  and  a  pad  wet  with  sublimate 
solution  should  be  kept  over  the  vulva.  The  importance 
of  sterilization  of  the  hands  is  emphasized.  Digital  exam- 
ination during  the  course  of  labor  must  be  done  most 
cautiously,  and  the  labor  should  be  conducted  in  such  a 
manner  as  to  secure  the  least  possible  injury  to  the 
parts.  Instrumental  interference  is  permissable  when  it 
is  evident  that  the  patient  is  not  able  to  complete  the 
work  unaided.  Labor  should  be  terminated  by  the  entire 
removal  of  placenta  and  secondines.  Contraction  of  the 
uterus  must  be  secured  to  avoid  the  retention  of  clots.  The 
vagina  and  vulva  should  be  carefully  examined  for  in- 
juries and  lacerations,  which  should  be  immediately  re- 
paired with  chromicized  cat-gut  suture.  Occasionally  it 
may  be  necessary  to  insert  sutures  in  the  cervix  to  con- 
trol bleeding.  It  is  essential  to  impress  on  the  nurse  the 
importance  of  the  most  rigid  antisepsis.  The  treatment  of 
sepsis  may  be  summarized  as  follows:  1.  Prevention  by  the 
exercise  of  the  most  careful  asepsis  and  antisepsis.  2.  The 
accurate  examination  of  each  puerperal  case  to  recog 
nize  the  cause  of  high  tmperature  and  eliminate  other 
factors  than  sepsis.  3.  The  maintenance  of  the  vital 
forces  and  the  promotion  of  elimination  by  the  adminis- 
tration of  diet  aud  remedies  to  meet  indications.  4.  The 
employment  of  serum  injection  when  streptococcic  infec- 
tion can  be  recognized  or  justifiable  in  pure  sepsis.  Peri- 
tonitis or  localized  cellular  inflammation  in  the  pelvis 
should  indicate  vaginal  incision  in  drainage.  Hysterectomy 
is  indicated  whenever  the  uterus  can  be  recognized  as 
the  seat  of  localized  collections-  When  the  ovary  or  tube 
only  is  involved  it  should  be  removed.  The  recognition 
of  a  pus  collection  demands  its  evacuation  or  the  extirpa- 
tion of  the  organ  in  which  it  is  situated.  6.  The  continu- 
ance of  symptoms  of  sepsis  when  local  manifestations  are 
not  recognized  will  require  incision  to  determine  the  pres- 
ence of  secondary  sources  of  infection.     [T.  L.  C] 

7. — William  Keiller  discusses  the  anatomy  of  the  renal 
vessels  and  pelvis  of  the  kidney  In  relation  to  digital 
exploration  of  that  organ  in  the  operation  of  nephrotomy. 
The  writer  has  been  astonished  that  the  surgeon  who 
boldly  punctures  the  organ  with  the  needle  in  the  hope 
of  striking  a  stone,  or  makes  an  incision  in  the  convex 
border  and  explores  the  whole  pelvis  of  the  kidney  that 
only  venous  hemorrhage  is  encountered.  Keiller  presents 
an  accurate  account  of  the  blood-vesel  supply  of  the  kidney 
and  from  his  anatomical  study  suggests  the  following  tech- 
nique for  the  operation  of  nephrotomy:  The  kidney  is 
carefully  steadied  in  the  dorsal  wound  and  the  entire  sur- 
face of  the  organ  palpated.  Then  the  pelvis  may  be  ex- 
amined by  introducing  a  finger  along  the  pelvis  into  the 
renal  sinus,  remembering  that  a  large  artery  lies  in  the 
way.  If  the  stone  is  not  found  there  is  to  be  remem- 
bered that  the  more  expanded  infundibula  are  on  the  up- 
per and  lower  ends  of  the  organ.  These  ends  and  finally 
the  center  may  be  explored  with  a  needle.  Should  a  stone 
be  found,  an  incision  along  the  convex  border  would  be  the 
safer  route  to  it,  unless  it  is  very  near  the  surface  when 
an  incision  radiating  toward  the  hilum  may  be  prefer- 
able. Failing  to  find  a  stone  by  puncture,  a  vertical  incis- 
ion one  incli  long  and  three-quarters  of  an  inch  deep  should 
be  made  made  into  the  convex  border  of  the  kidney,  the 
finger  introduced  and  gently  pushed  on.  It  will  then  lie  in 
the  connective  tissue  of  the  renal  sinus  and  may  be 
dorsal  or  ventral  to  the  pelvis.  The  middle.  lower  and 
upper  infundibula  also  should  be  examined  in  the  order 
named,  avoiding  as  much  as  possible  splitting  the  ends 
of  the  organ,  as  at  either  end  there  is  a  good  deal  of  in- 
terlacing of  large  vessels.  The  free  venous  hemorrhage 
win  follow  the  withdrawal  of  the  exploring  finger,  but  thia 


722 


The  Philadelphia"! 
Medical  Jocrnal  J 


THE  LATEST  LITERATURE 


f  Amn,  13.  1901 


may  be  readily  controlled  by  pressure  of  the  supporting 
fingers  and  subsequently  by  deeply  buried  catgut  sutures 
through  the  parenchyma.  As  considerable  damage  will  be 
done  at  least  to  one  infundibulum  the  lumbar  wound 
should  be  packed  as  urine  may  leak  out,  and  an  enormous 
amount  of  hemorrhage  may  be  concealed  should  the 
wound  be  closed.     [T.  L.  C] 

8. — B.  W.  Goldborough  and  T.  C.  Cullen  report  a  case  of 
extrauterine  pregnancy  of  rare  form.  The  patient  was 
seen  on  February  2S,  1901.  She  had  missed  her  period  in 
April  1900  and  had  since  then  presented  the  usual  signs 
of  pregnancy,  in  August  while  lifting  some  boxes  some- 
thing suddenly  gave  way  in  her  left  side.  This  occasioned 
severe  pain  and  she  was  obliged  to  remain  in  bed  until 
November  1st.  About  the  middle  of  September  there  was 
a  bloody  uterine  discharge  and  accompanying  it  was  con- 
siderable pain  and  nausea.  Subsequently  she  had  several 
discharges  which  may  have  been  menstrual  periods.  She 
■was  able  to  be  out  of  bed  during  the  month  of  November 
but  had  to  return  in  December.  On  examining  the  patient 
under  anesthesia  the  abdomen  was  seen  to  be  very  prom- 
inent. There  was,  however,,  no  bulging  in  the  flanks.  The 
umbilicus  was  converted  into  a  tumor,  fully  5  cm.  long  by 
3  cm.  broad.  The  skin  over  this  appeared  to  be  much 
thinned  out  at  one  point  which  had  given  way.  From  this 
abraded  area  an  offensive  chocolate-colored  fluid  was  es- 
caping. Around  the  umbilicus  the  tissue  is  markedly  indur- 
ated and  pits  on  pressure.  Vaginal  examination  reveals 
the  cervix  to  be  intact,  but  it  is  impossible  to  outline  the 
uterus.  An  incision  was  made  just  below  the  sternum  and 
continued  almost  down  to  the  pubes.  The  abdominal  cav 
Ity  proper  was  not  exposed.  Filling  the  cavity  was  a  large 
quantity  of  chocolate-colored  fluid.  A  fetus  between  six  and 
seven  months  and  a  large  placenta  was  found  The  placenta 
was  attached  low  down  in  the  pelvis,  was  exceedingly  fri- 
able, but  came  away  without  producing  any  hemorrhage. 
The  walls  of  the  sac  were  about  4mm.  in  thickness  and 
exceedingly  friable.  It  is  probable  that  the  uterus  rup 
tured  and  that  the  fetus  with  its  membranes  intact  es- 
caped into  the  abdominal  cavity.  The  fetal  membranes 
were  attached  to  the  abdominal  wall  and  to  the 
rounding  structure.  The  large  sack  was  thoroughly 
washed  out  with  salt  solution  and  loosely  packed  with 
lodiform  gause.  which  was  removed  on  the  seventh  day. 
and  a  light  gauze  drain  was  inserted.  The  upper  half  of  the 
incision  was  closed,  the  lower  half  left  open  to  insure  thor- 
ough drainage.  On  histological  examination  the  placenta 
was  found  to  be  completely  necrotic,  which  accounts  for 
the  ease  with  which  it  was  peeled  off  and  also  for  the  ab- 
sence of  hemorrhage  during  its  removal.     [T.  L.  C] 

9. — C,  F.MacDonald  presents  a  paper  upon  the  early 
diagnosis  of  Insanity,  with  a  discussion  of  some  of  the 
questions  which  the  diagnosis  and  treatment  of  the  con- 
dition inspires.  He  points  out  that  the  significant  diag- 
nostic factor  to  be  sought  for  in  the  early  stage  of  the 
disease  is  evidence  of  the  change  in  the  mental  charac- 
teristics of  the  individual,  especially  if  he  is  descended 
from  insane  or  neurotic  stock.  Prominent  among  the  pre 
monitory  symptoms  of  insanity  are  disturbances  of  the 
bodily  functions,  morbid  emotional  raanifettations  and  al- 
terations in  the  mental  characteristics  of  the  individual 
Especially  to  be  observed  are  paver  nocturnus,  insomnia, 
headache,  tinnitus,  vertigo,  clammy  extremities,  and  other 
vasomotor  disturbances,  anorexia,  indigestion,  constipa- 
tion, etc. 

These  are  by  no  means  to  be  regarded  as  pathognomonic, 
nor  singly,  perhaps,  even  diagnostic,  of  mental  disease. 
If  the  tendency  is  to  mental  exaltation,  or  mania,  the  emo- 
tional changes  usually  take  the  form  of  unnatural  buoy- 
ancy, loquacity,  the  patient  frequently  appearing  to  be 
\innaturally  bright.  On  th"^  other  hand,  it  the  tendency 
is  to  depression  or  melancholia,  there  are  gloomy  fore- 
bodings, morbid  introspections,  suspicions,  etc.  Marked  al- 
terations of  character  are  seldom  wanting  in  this  stage  of 
the  disease.  In  the  diagnosis  of  insanity  it  is  important  to 
take  into  account  certain  negative  symptoms,  as  reticence, 
olistinency.  suUennr-ss  or  stupidity,  any  of  which  may  be 
significant,  especially  if  such  a  condition  is  not  natural  to 
the  individual.  Note  should  also  be  taken  of  the  fn  ^ial  ex- 
pression, the  expression  of  the  eyes,  the  hand-writing, 
condition  of  the  retlexes.  etc..  any  of  wliich  may  in  them- 
selves be  indicative  of  curtain  forms  of  mental  diseases, 
''"he   pulse   and   temperature   should   also  be  observed,  as 


persons  laboring  under  delirium  of  fever  meningitis,  et& 
have  occasionally  been  committed  to  institutions  for  the 
insane  through  inattention  to  these  points.     [T.  L.  C] 
10. —  Will  be  abstracted  when  concluded. 


DEUTSCHE  MEDICINISCHE  WOCHENSCHRIFT. 
February  21,  1901. 

1.  Treatment  of  Gangrenous  Hernia.     W.  PETERSON. 

2.  Discovery  of  the  Swine  Erysipelas  Bacilli  in  the  Stools 

of  an  Icteric  Child.     R.  LLBWSKI. 

3.  Casuistic  Communication  to  the  Knowledge  of  Acute 

Corrosive  Sublimate  Poisoning.    K.  KRAUSE. 

4.  Treatment  of  Torticollis.     JOACHIMSTHAL. 

5.  On  the  Relation  of  the  Cerebellum  to  Multiple  Sclero- 

sis.    ADLER. 

1. — Will  be  abstracted  when  completed. 

2. — The  nature  of  the  brief  report  is  practically  fully  indica- 
ted bythetitle.  It  was  impossible  to  state  what  relation  the 
bacilli  had  to  the  disease.  They  were  found  but  once,  but 
at  that  time  they  were  much  more  numerous  than  all  other 
forms  of  bacteria,  and  this  fact,  together  with  their  disap 
pearance  as  the  disease  grew  better,  and  the  fact  that  the 
intestine  is  the  usual  portal  of  entry  in  animals,  make  it 
seem  probable  that  they  had  an  etiological  relation  to  the 
disease.  Whether  there  is  any  general  importance  in  the 
observation  is  uncertain.  A  similar  case  was  investigated 
for  the  same  bacilli,  but  they  were  not  found.  The  case, 
however,  is  evidence  that  these  bacilli  may  grow  in  enor- 
mous numbers  in  the  human  intestine.  And  since  the 
bacillus  is  known  by  recent  work  to  be  able  to  cause  iotec-  I 
tion  in  man,  it  must  be  considered  highly  probable  that  the  ' 
organism  is  by  no  means  one  that  is  without  Importance 
in  human  pathology.     [D.  L.  E.] 

3. — The  remarkable  point  in  the  case  reported  was  thai 
the  patient  took  2  grm.  of  corrosive  sublimate  in  solution 
and  yet  recovered  in  spite  of  the  appearance  of  very 
grave  symptoms.  V.  Jaksch  puts  the  fatal  dose  at  0.2  grm 
The  probable  reasons  for  the  happy  issue  were  the  almost 
immediate  onset  of  vomiting,  and  the  energetic  gastric  I 
lavage  undertaken  in  the  treatment  of'the  case.  The  case 
is,  however,  an  illustration  of  the  fact  that  one  should  not 
state  an  absolutely  unfavorable  prognosis  even  when  a  verj- 
large  dose  has  been  taken.  The  patient  showed  verj-  se- 
vere sjTnptoms,  consisting  of  severe  stomatitis  with  sec- 
ondary purulent  parotitis,  violent  gastritis,  with  bloody 
tomit,  a  severe  degree  of  enteritis  and  colitis 
with  bloody  and  mucous  stools,  severe  nephritis,  and  gen- 
eral prostration.  All  these  symptoms  gradually  disap- 
peared, and  the  patient  regained  what  appered  to  be  entire 
health.  The  drug  was  taken  on  the  22nd  of  October,  and 
the  patient  was  discharged  well  on  the  16th  of  December. 
.\n  interesting  observation  was  the  fact  that  there  was  a 
marked  skin  eruption  which  appeared  first  on  the  3rd  of 
November,  and  was  of  a  bright  red  punctiform  character, 
appearing  at  first  on  the  hands,  arms  and  chest,  and  spread- 
ing from  these  points  over  the  surface  It  covered  the  face 
as  well  as  the  trunk.  There  was  no  desquamation.  The 
eruption  resembled  greatly  the  cholera  exanthem,  and  since 
cholera  in  the  Hamburg  epidemic  was  treated  with  large 
doses  of  calomel,  Krause  is  inclined  to  suspect  that  at 
least  a  portion  of  the  so-called  cholera  eruptions  observed 
in  this  epidemic  were  due  to  mercury  rather  than  to  the 
cholera  itself.  Krause  also  notes  that  the  patient  had  been 
treated  a  year  before  for  incipient  tuberculosis  which  had 
apparently  entirely  healed  in  spite  of  the  extreme  reduction 
of  his  general  health  immediately  after  the  poisoning. 
There  was  no  tendency  on  the  part  of  the  tuberculosis  to 
light  up  the  advance.     [D.  L.  E.] 

4. — Nothing. 

5. — Adler  refers  to  the  fact  that  Ferrier  noted  that  re- 
moval of  the  cerebellum  caused  movements  of  the  typical 
disseminated  sclerosis  type  on  volitional  exertion,  and  that 
in  cases  of  atrophy  of  the  cerebellum  in  man  ataxic 
movements  are  observed,  and  that  these  are  sometimes 
much  like  intention  tremor.  Nystagmus  and  scanning 
speech  have  also  been  noted  in  cases  of  atrophy  of  the 
cerebellum,  hence  most  important  symptoms  of  multiple 
sclerosis  are  seen  when  there  is  loss  of  the  cerebellar 
I'uncrion.  .\lso  the  gait  in  multiple  sclerosis  not  infre- 
quently reminds  one  of  the  typicid  cerebellar  salt     He 


April  13,  1901] 


THE  LATEST  LITERATURE 


r 


TnE  Philadelphia 
Medical  Journal, 


723 


believes  that  intention  tremor,  scanning  speech,  and  nys- 
tagmus in  multiple  sclerosis  are  all  explainable  through 
loss  of  cerebellar  control  of  volitional  movements. 

[D.  L.  B.] 


March    7th,    1901, 

1.  Further  Investigations  Concerning  the  Value  of  Arlo 

ing  and  Courmont's  Serum  Reaction  for  Tuberco- 
losis;  and  in  especial  its  Value  in  Tuberculosis  of 
Cattle.     A.  BECK  and  LYDIA  RABINOWITSCH. 

2.  A   Remarkable   Auscultatory   Phenomenon   in    a   Suck- 

ling, the  Origin  of  Which  Could  Not  be  B.xplained. 
K.  GREGOR. 

3.  The    Radical    Operation    for    Hernia    in    Children.     H. 

MASS. 

4.  A  Thread  Scoliosognost  Kurt  Tautz. 

5.  A  New  and  Certain  Method  for  the  Demonstration  of 

Diacetic  Acid  in  the  Urine.     S.  LIPLIAWSKY. 

6.  Treatment  of  Gangrenous  Hernia.     W.  PETERSEN. 

7.  Treatment    of    Pathological    Fixations    of    the    Uterus. 

STEFFECK. 

1. — The  authors  first  state  that  in  a  recent  criticism 
(abstracted  from  the  Deutsche  Mcdizin.  Woclwitliliitt),  Arloing 
and  Courmont  made  statements  concerning  the  work  of 
neck  and  Rabiuowitsch  which  were  unfair  because  they 
wore  based  upon  a  false  reading  of  their  tables;  they  state 
that  if  their  tables  are  re-examined,  it  will  be  found  that 
Ihey  are  not  subject  to  the  criticism  made.  They  then 
refer  to  the  work  of  a  number  of  other  authors  on  the 
serum  reaction  for  tuberculosis,  all  of  them  expressing 
themselves  unfavorably  toward  the  test.  Finally  they  re- 
port a  series  of  investigations  of  healthy  and  tuberculous 
cattle  with  other  affections  than  tuberculosis,  the  diag- 
noses being  confirmed  by  autopsy.  The  tables  which  they 
present  seem  to  show  that  the  reaction  was  not  more 
frequent  in  tuberculous  animals  than  in  the  non-tuber- 
culous, and  was  in  no  way  a  test  of  the  presence  of  tuber- 
culosis. They  hold  by  their  previous  conclusion  that  the 
reaction  is  by  no  means  specific  for  tuberculosis,  and  con- 
sider that  it  is  of  no  value  in  diagnosis.  They  state  that 
their  tests  were  carried  out  according  to  the  method  ad- 
vised by  Arloing  and  Courmont,  and  that  the  cultures  they 
used  were  obtained  from  Arloing  and  Courmont  and  that 
they  always  used  cultures  which  were  only  from  12  to  11 
days  old.     [D.  L.  E,] 

2.  The  phenomenon  which  aroused  Gregor's  attention 
consisted  in  the  observation  of  a  loud  systolic  murmur  of 
about  the  same  intensity  as  that  heard  with  acute  endocar- 
ditis of  the  mitral  valve,  the  murmur  being  heard  clearly 
only  over  the  lateral  portions  of  the  right  half  of  the 
thorax;  the  second  pulmonary  sound  was  not  accentuated, 
and  over  the  pulmonary  region  one  heard  a  distinct  first 
sound,  at  the  base  and  at  the  apex  pure  first  and  second 
sounds.  The  post-mortem  examination  showed  caseous 
bronchopneumonia  in  the  left  lower  lobe,  and  a  general 
miliary  tuberculosis  of  the  lungs  and  other  organs.  The 
heart  was  small,  but  there  was  no  other  acquired  or  con 
genital  abnormality  of  the  heart  or  vessels.  The  explana- 
tion of  the  murmur  was  not  apparent.  It  was  not  a  peri- 
cardial murmur  and  there  was  no  evidence  of  a  functional 
insufficiency.  A  similar  observation  by  Marfan  in  a  child 
with  splenic  anemia  is  referred  to  as  the  only  instance 
resembling  this  one  so  far  on  record.  [D.  L.  E.] 

3. — The  author  reports  33  cases  operated  on  in  the 
course  of  five  years.  One  per  cent,  of  these  were  in 
children.  He  employed  the  method  recommended  by  Kar- 
ewski,  which  consisted  of  a  simple  resection  of  the  sac 
without  any  plastic  closure.  The  result  in  all  cases  was 
favorable.  After  observations  extending  over  years,  no 
recurrences  were  observed.     [M.  R.  D.] 

4. — A  description  of  a  simply  constructed  apparatus  for 
the  diagnosis  of  beginning  scoliosis.     [M.  R.  D.] 

5. — The  test  is  carried  out  by  making  a  1  per  cent,  so- 
lution of  paramidoacetophenon,  adding  2  c  c.  of  concen- 
trated HCl  to  increace  the  solubility;  second,  a  solution 
of  1  per  cent,  potassium  nitrite;  6  c.  c.  of  the  first  and  3 
c.  c.  of  the  second  solution  are  mixed  with  an  equal  quan- 
tity of  urine,  a  drop  of  ammonia  is  added  and  the  mix- 
ture is  shaken  energetically,  when  a  red  color  appears. 
One  takes  from  10  drops  to  2  c.  c.  of  this  mixture,  adds  15 
to  20  0.  c.  ot  concentrated  HCl,  3  c.  c.  of  chloroform,  and 


2  to  4  drops  of  ferric  chloride  solution.  The  test  tube 
IS  corked,  and  is  gently  inverted  repeatedly,  and  if  dia- 
cetic acid  is  present  even  in  very  small  amounts  the 
chloroform  takes  a  characteristic  violet  color  after  a  half 
minute  to  a  minute,  while  if  diacetic  acid  is  absent  the 
color  is  yellowish  or  slightly  reddish.  The  color  as  noted 
persists,  even  in  the  light,  for  weeks.  About  400  patholo- 
gical urines  were  investigated,  and  they  reacted  only  when 
diacetic  acid  was  present;  this  test  is  extremely  deli- 
<"ile.  showing  as  little  as  one  part  of  diacetic  acid  in 
-111,000.  Drugs,  such  as  the  salicylates,  and  others  which 
iulerfere  with  the  ordinary  diacetic  acid  test,  had  no  in- 
liueuce  upon  the  test.     [D.  L|  E.] 

6- — W.  Petersen  recommends  local  anesthesia  in  these 
cases  and  advocates  an  extensive  resection  of  the  de- 
seased  portion  of  the  bowel.  He  recommends  Schleich's 
infiltration  method.  According  to  the  author  the  danger  of 
shock  and  collapse  after  the  operation  is  obviated  as  well 
as  a  risk  of  inhalation  pneumonia.  For  the  purpose  of 
anastomosis  he  employs  the  Murphy  button.  He  empha- 
sizes thorough  emptying  of  the  intestines  before  suturing. 
[M.  R.  D.] 

7. — Will  be  abstracted  when  completed. 


March  7,  1001.     [XIV  Jahrg.   No.   10.] 

t.     Infiltrated  Carcinoma  of  the  Bladder.     ENGLISCH. 

2.  Personal  Experiments  upon  the  Influence  of  Food  on  the 

Secretion    of   Acetone.     SCHUMAN-LECLEROQ. 

3.  The  Occurrence  of  Tubercle  Bacilli  in  Vienna  Butter 

and  Margarin.     MARKL. 

1- — While  very  rare,  primary  infiltrated  cancer  can  occur 
in  the  bladder  wall;  the  diffuse  form  is  especially  rare. 
fJnglisch  quotes  three  such  cases.  The  infiltrating  tumor 
takes  the  place  of  the  bladder  wall,  which  becomes  thick- 
ened. To  the  palpating  hand  the  bladder  feels  regular  and 
strikingly  hard.  It  is  difficult  to  localize,  by  bimanual 
palpation,  or  by  rectum.  Very  diffuse  infiltration  will  give 
the  balloon-like  signs  of  an  over  distended  bladder,  distinct 
upon  pressure.  The  introduction  of  a  catheter  will  not, 
however,  diminish  this.  The  first  symptom  is  frequency  of 
urination.  Pain  appears  early,  upon  micturition,  and  may 
persist  afterward.  It  may  also  radiate  in  all  directions. 
The  urine  is  normal,  though  cystitis  may  develop  later. 
The  cachexia  appears  late.  Its  course  is  slow,  with  death 
finally  from  an  affection  of  the  kidneys.  The  diagnosis  is 
made  by  the  absence  of  hypertrophy  of  the  prostate,  stric- 
ture of  the  urethra,  or  stone  in  the  bladder.  The  differen- 
tial diagnosis  from  cancer  of  the  prostate  is  difficult.  The 
treatment  will  be  extirpation  of  the  tumor  as  soon  as  it  ha.s 
tieen  diagnosed.  If  that  be  impossible,  suprapubic  cystot- 
omy will  alleviate  the  pain.  Englisch  gives  a  description 
of  his  case,  with  the  autopsy.  He  reports  a  similar  case,  in 
which  autopsy  was  not  permitted.     [M.  O.] 

2. — Schuman-Leclercq  gives  tables  showing  his  own 
experience  for  100  days,  under  many  changes  of  diet.  The 
urine  was  examined  daily,  for  acetone,  by  the  Messinger- 
Huppert  method;  for  diacetic  acid  by  Gerhardt's  chloride 
of  iron  method;  for  nitrogen  by  the  Kjeldahl  method;  for 
total  acidity  by  Lieblein's  method;  for  phosphoric  acid  by 
the  Neubauer-Malfatti  method;  and  for  the  ethereal  sul- 
phates by  Salkowski's  method.  These  experiments  show 
no  relation  between  the  amount  of  nitrogen  and  acetone  in 
the  urine.  But  albumen  or  fatty  diet  caused  an  increase 
in  the  secretion  of  the  acetone.  Last  year,  he  used  the 
Schnitzler  respiration  apparatus  to  measure  the  acetone  in 
the  breath.  This  he  added  to  that  found  in  the  urine  to 
make  the  total  acetone  excreted.  After  a  description  of  the 
experiments,  with  the  diets  used,  he  concludes  that  the 
interchange  of  fats  in  the  body  Is  probably  the  essential 
cause,  if  not  the  only  one  of  the  secretion  of  acetone, 
whather  from  the  destruction  of  the  body-fat  or  the  fat  in- 
gested, from  hunger,  fatty  diet,  pure  meat  diet,  etc.,  and 
that  the  carbohydrates,  by  their  great  infiuence  upon  the 
assimilation  of  fat,  prevent  the  production  of  acetone  by 
using  up  the  fat.     [M.  O.] 

3. — The  presence  of  virulent  tubercle  bacili  In  ordinary 
butter  and  margarin  has  been  proved  during  the  last  fiv^ 
.1.  ears.  Inoculations  and  inunctions  of  butter  have  produced 
both  true  and  pseudo-tuberculosis  in  animals.  Markl  used 
the  Obermueller  method,  inoculating  oentrifu.gated  hutt-^r 
Out  of  45  oases  Inoculated,  not  one  died  with  true  tube;- 


724 


The   Pnii.ADEi.PHiA"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


ArarL  13,  inoi] 


culosis,  and  only  one  with  pseudo-tuberculosis.  Only  ten 
animals  died  with  peritonitis.  None  of  those  injected  with 
margarin  died  v.'ith  peritonitis.  Markl  describes  the  path- 
ogenic micro-organism  in  his  pseudo-tubercular  case.  It  is 
a  relatively  acid  bacillus,  taking  Gram's  stain.  He  consid- 
ers it  a  cause  of  pseudo-tuberculosis,  beside  Petri  and  Hor 
mann-Morgcnroth  Itacilli.     [M.  O.] 


VRATCH. 

Feltruary  10.    (Vol.  22,  No.  6.) 


P.  I. 


1.  On  the  Question  of  Disease  of  the  Cerebellum 

SHATILOW. 

2.  On  the   Affection  of  the  Upper  Respiratory   Passages 

in  Rheumatism.     E.  B.  BLUMENAU. 

3.  On  the   Physiology  and   Pathology  of  the  Ventricular 

Septum.      Syphilis  of  the   Septum.      M.   lA.   BREIT- 
WAN. 

4.  Secretion  of  Watery  Fluid  from  the  Nose  (Hydrorrhea 

nasalis).  A.  PH.  EKKERT. 
1. — Will  be  abstracted  v/hen  completed 
2. — Blumenau  inclines  to  the  opinion  that  in  a  consid- 
erable number  of  cases  acute  articular  rheumatism  may 
be  preceded  by  a  sore  throat  Assuming  the  disease  to  be 
Infectious,  it  is  reasonable  to  suppose  that  the  infection 
may  gain  entrance  by  way  of  the  tonsils.  In  three  out  of 
twenty  cases  of  acute  articular  rheumatism  the  author 
could  trace  a  connection  between  the  rheumatism  and  the 
angina  preceeding  it.  In  one  case  the  rheumatic  affec- 
tion made  its  appearance  four  days  and  in  the  other  onc- 
and  one-half  to  two  weeks  after  the  sore  throat.  Three 
other  cases  are  reported  in  which  the  rheumtaism  was  pre- 
ceded by  an  acute  pharyngitis.  The  author  reports  also 
two  cases  of  rheumatism  affecting  the  crico-arytenold 
articulation.  In  one  the  disease  was  primary  and  limited 
to  that  articulation:  in  the  other  it  was  secondary  to  ty- 
phoid fever  which  was  preceded  by  grippe.  An  extensive 
bibliography  is  given.     [A.  R.] 

3. — Breitman  asks  the  pertinent  question;  How  would 
the  heart  act  if  the  septum  were  removed?  Such  an  ex 
periment  has  never  been  and  could  not  be  performed,  but 
nature  does  perform  it  in  cases  of  syphilitic  affections  of 
the  ventricular  septum.  In  these  only  the  latter  is  affected, 
the  ventricular  septum.  In  these  only  the  latter  is  affected, 
the  rest  of  the  heart  remaining  intact.  If  the  sep- 
tum is  crippled  by  gummatous  or  ulcerative  changes 
no  symptoms  make  their  appearance  during  life,  but 
the  person  may  be  carried  off  by  sudden  paralysis  of  the 
heart.  The  altered  septum  prevents  the  regularity  of  the 
contraction  of  the  ventricles,  the  right  being  principally 
affected.  However,  when  the  syphilitic  changes  involve 
the  cardiac  ganglia  the  heart  muscle  becomes  affected, 
and  a  train  of  symptoms  denoting  cardiac  insufficiency 
may  take  place  during  life.  A  number  of  observations  of 
various  authors  are  cited  by  the  author  who  claims  the 
distinction  of  being  the  first  to  call  attention  to  the  sub- 
ject from  the  physiologic  standpoint.     [A.  R.] 

4. — Ekkert  reports  an  interesting  case  of  a  woman, 
single,  39  years  old,  of  a  good  family  history,  suffering  from 
a  constant  flow  of  a  clear  watery  fluid  from  the  nose.  The 
patient  is  of  a  strong  pliysiquo,  well  nourished,  but  some- 
what hysterical  and  neurasthenic.  Since  childhood  she 
suffered  from  a  catarrhal  condition  of  the  nose.  At  pres- 
ent, she  presents  evidences  of  chronic  follicular  pharyn- 
gitis and  catarrhal  changes  in  the  lungs  accompanied  by 
cough  and  expectoration,  mucous  and  at  times  purulent  in 
character.  Repeated  examinations  of  the  sputum  failed 
to  reveal  the  presence  of  tubercle  bacilli.  At  times  she  suf- 
fers from  chills  and  elevations  of  temperature,  especially 
in  the  morning;  but  while  the  latter  are  ameliorated  by 
proper  treatment  and  change  of  climate,  the  secretion 
of  the  nose  is  but  slightly  modified.  It  goes  on  all  the 
time,  amounting  to  about  120c. o.  in  the  2-1  hours.  At 
nisht  or  when  the  patient  is  at  perfect  rest  with  the  head 
llirown  back  the  flow  is  diminished  considerably,  but  the 
least  exertion  will  bring  it  on  almost  in  a  stream.  During 
tlie  past  year  she  gained  considerably  in  weight  and  im- 
proved generally,  the  nasal  affection,  however,  remaining 
.-ibout  the  same,  despite  local  treatment  and  even  hyp- 
notic suggestion.  Repeated  and  thorough  examinations 
of  the  nasal  cavity  by  specialists  failed  to  reveal  the  cause 
(  f  the  affection.     The  author  cites  a  number  of  more  or 


less  similar  cases  recorded  in  the  medical  literature  and 
comes  to  the  conclusion  that  this  affection  is  similar  to 
hay  fever  and  is  ijrobably  of  a  nervous  origin.     [A.  R.] 


Fchruury  11,  1901  (Vol.  XXII.,  No.  7). 


1.  The  Surgical  Treatment  of  Ascites  in  Cirrhosis  of  the 

Liver.     N.  M.  BENISOVITCH. 

2.  Medical  Aid  to  the  Workingmen  of  Some  Factories  in 

the  Government  of  Vladimir  during  the  years  of  189u 
to  1898.     M.  S.  KAMNEW. 

3.  On  the  Question  of  Diseases  of  the  Cerebellum.     P.  I. 

SHATILOW. 

1. — Benisovitch  discusses  the  mechanism  of  the  compen- 
satory circulation  in  hepatic  cirrhosis  and  mentions  the 
operation  of  Talma  as  indicated  in  those  cases  in  which 
the  collateral  circulation  is  not  sufficiently  established  to 
relieve  the  rapidly  increasing  ascites.  The  cases  operated 
on  by  Talma  himself  proved  fatal.  After  that  the  operation 
was  performed  by  different  men  in  eleven  cases,  and  in 
seven  the  results  wer  satisfactory.  The  author  reports 
two  cases  in  which  he  resorted  to  Talma's  operation.In 
one.  the  patient,  twenty-two  years  old,  suffered  from  cirrhosis 
of  the  liver,  probably  brought  about  by  chronic  alcoholism. 
He  gained  admission  into  the  City  Hospital,  where  he  was 
tapped  twice  without  any  relief  from  the  ascites.  Lapora- 
tomy  was  then  performed  with  the  same  results.  He 
finally  came  to  the  author,  who  made  a  diagnosis  of  tuber- 
culosis of  the  peritoneum  and  performed  laporotomy  under 
Schleich's  anesthesia.  The  peritoneum  was  found  free 
from  disease.  The  patient  improved  after  the  operation, 
owing  to  the  evacuation  of  the  fluid,  but  soon  after  the 
ascites  returned,  together  with  the  usual  symptoms.  The 
diagnosis  having  been  changed  to  hepatic  cirrhosis  and 
medication  affording  no  relief.  Talma's  operation  was  per- 
formed. This  was  followed  by  a  marked  improvement  in 
the  general  condition  of  the  patient.  Two  months  later 
ascites  again  developed,  six  liters  of  fluid  having  been  re- 
moved by  tapping.  After  that  the  patient  felt  much  strong- 
er and  gained  in  weight.  In  the  second  case,  the  patient,  a 
man  fifty-six  years  old,  with  a  history  of  chronic  alcoholism, 
was  far  advanced  in  the  disease  when  Talma's  operation 
was  performed.  He  felt  much  better  after  it  for  about  two 
weeks,  when  he  commenced  to  decline  rapidly  and  died 
within  forty-eight  hours.  A  rapid  and  marked  accumulation 
of  fluid  took  place  before  his  death.  After  a  review  of  the 
literature  and  the  experimental  data  bearing  on  the  subject, 
the  author  comes  to  the  conclusion  that  in  Talma's  opera- 
tion we  possess  a  simple  and  harmless  method  of  treat- 
ing ascites  in  hepatic  cirrhosis.     [A.  R.] 

3. — Shallow  points  out  the  difficulty  of  diagnosing  affec 
tions  of  the  cerebellum  during  life.  Our  imperfect  know- 
ledge of  the  physiology  and  pathology  of  that  part  of  the 
central  nervous  system  is  in  a  large  measure  responsible 
for  this  difficulty.  The  various  symptoms  observed  In  the 
cases  recorded  in  literature  may  be  present  in  other 
affections,  while  the  most  characteristic  ones  are  indicative 
only  of  an  affe'ction  of  the  brain.  On  the  other  hand,  no 
symptoms  whatever  may  make  their  appearance,  this  being 
due  to  a  compensatory  physiologic  activity  of  the  healthy 
portion  of  the  cerebellum,  if  only  a  part  of  it  is  diseased, 
or  the  cerebrum,  if  the  entire  organ  is  affected.  This  fact 
had  been  verified  by  experiments  on  animals.  In  the  cas? 
reported  by  the  author,  a  boy,  15  years  old.  presented  se- 
vere gastro-intestinal  disturbance,  characterized  principally 
my  headache,  vomiting,  colic  and  obstinate  constipation. 
The  boy  was  employed  in  a  confectionery  shop  and  >a 
dulged  freely  in  sweets  which  were  usu  Uy  painted  re<J. 
The  symptoms,  together  with  the  history  of  the  case,  le-l 
to  a  diagnosis  of  lead-poisoning,  and  the  improvement,  for 
a  time,  following  the  use  of  iodide  oi  potash  and  hot  baths 
seemed  to  corroborate  the  diagnosis.  The  physical  signs 
namely,  optic  neuritis,  slow  and  tense  pulse  and  the  draw- 
ing in  of  the  abdomen  still  more  completed  the  picture 
of  chronic  plumbism.  About  two  months  after  admission 
to  the  hospital  he  began  to  feel  worse.  The  headache 
increased  in  intensity,  the  vomiting  was  frequent  and  not 
accompanied  by  nausea,  he  became  listless  and  indifferent 
was  frequently  found  laying  en  n.s  right  side  with  the  legs 
flexed,  the  knees  drawn  tightly  against  the  abdomen  and 


inn,  13,  1901] 


THE  LATEST  LITERATURE 


ETlIE     PHir.AD 
MlCIIICAL    Jl) 


ADELrniA  ^  /5  c 


the  head  thrown  well  backward.  One  mornng  he  was 
found  in  his  usual  position,  intensely  cyanotic  and  without 
the  least  signs  of  respiration.  The  heart-sounds,  however, 
could  still  be  perceived.  Artificial  respiration  so;n  removed 
the  cyanosis  and  improved  the  heart's  action,  but  respira 
tion  could  not  be  restored.  Seven-and-one-half  hours  of 
artificial  respiration,  together  with  ■■loctricity  and  diffusible 
stimuli,  proved  .utile,  and  the  heart  finally  stopped.  Dur- 
ing the  short  time  the  patient  showed  erection  c.  the  penis, 
the  priapism  disappearing  with  the  cessation  of  the  heart's 
action.  The  autopsy  showed  the  ventricles  dilated  and 
filled  with  clear,  transparent  serous  fluid.  On  the  left  cers- 
liillar  hemisphere  en  area  of  the  size  of  a  pigeon's  eg^ 
was  found  to  be  filled  with  serous  fluid.  The  walls  of  this 
cyst  were  smooth.  On  the  posterior  border  of  the  upper 
surface  of  this  hemisphere  a  round  fleshy  grovv^th  of  the 
size  of  a  walnut  was  found,  which  on  subsequent  histolog'.c 
examination  proved  to  be  a  glioma.  A  severe  entero- 
colitis was  also  demonstrated.  A  chemical  examination 
of  the  painted  cakes  showed  the  absence  of  lead.  In  analyz- 
ing the  most  prominent  symptoms,  the  author  calls  par- 
ticular attention  to  tlie  position  of  the  patient.  The  par- 
alysis of  respiratipn  he  ascribes  to  the  pressure  of  the 
medulla  exerted  by  the  accumulation  of  fluid.  The  priapism 
Is  explained  by  the  action  of  the  carbon  dioxide  on  the 
genito-spinal  center,  since  recent  investigations  have  re]e- 
gated  to  the  past  the  idea  that  the  cerebellum  is  the  seat 
of  the  sexual  center.     [A.  R.] 


REVUE    DE     MEDECINE. 
Maicli  II).  I'J'il.     (21  me,  Anaee,  No.  3.) 

1.  Hysteric  Anesthesia;   its  Psychic  Mechanism.     PERN- 

HEIIVI. 

2.  Re  education  of  the  Movements  of  the  Heart  by  Meth- 

odic  Exercises.     P.   LAGRANGE. 

3.  A  Case   of  Colothypus,   Typhoid   Fever  with   the   Les- 

ions in  the  Large  Intestines.     PH.  BOURDILLON. 

4.  On  the  Association   of  Typhoid  Fever  and   Dysentery. 

P.    REMLINGER. 

5.  The  State  of  the  Blood.     Hemoleukocytic  Formula,   in 

Zona.     SAMRAZES  and  MATHIAS. 

1. — Liernheim,  after  a  study  of  two  cases  of  hysteric 
anesthesia  reaches  the  following  conclusion:  (1)  Hysteric 
anesthesia  is  purely  psychic;  its  characters  are  those  of 
anesthesia  produced  by  suggestion.  (2)  It  is  much  more 
frequent  than  authors  have  admitted.  It  is  often  developed 
or  is  completed  artificially  by  unconscious  medical  sugges- 
tion or  imitation.  (3)  It  is  always  amenable  to  psycholher- 
cipy;  but  the  latter  is  often  difficult  on  account  of  the 
autosuggestive  resistence  of  the  subject,  (4)  It  may  have 
an  organic  origin,  peripheral  or  encephalic  vasomotor  con- 
striction or  paralysis,  but  tlie  anesthesia  being  preserved 
by  autosuggestion,  the  vascular  trouble  disappears.  (,5) 
Organic  hemianesthesia  of  cerebral  origin  by  lesion  in 
the  neighborhood  of  the  sensory  decussation  may  .sur- 
vi\e  the  lesion  and  be  preserved  by  autosuggestion,  (b) 
Sensory  impressions  in  psychic  anesthesia  are  collected 
and  impress  the  consciousness.  But  the  mind,  stimulated 
by  the  idea  of  anesthesia,  inhibits  and  effaces  the  sensation 
as  well  as  the  collection,  by  forgetting  it.     [J.  M.  S.] 

2. — Lagrange  continues  his  paper  on  re-education  of  the 
movements  of  the  heart  by  methodic  exercises.  The  elas- 
ticity and  contractility  of  the  veins  are  two  factors  that 
.act  powerfully  in  the  concert  of  the  forces  that  assure 
the  regularity  of  the  flow  of  blood.  Among  the  agents  of 
venous  constriction  centain  forms  of  vibratory  passive 
movement  occupy  the  first  place.  When  the  feet  of  a 
patient  are  placed  in  a  mechanical  vibrator  the  patient  first 
experiences  a  sensation  of  cold  at  the  same  time  that  the 
si/.e  of  his  extremities  seems  to  be  reduced.  Following 
this,  phenomena  of  vasoconstriction  with  the  inverse  sub- 
jective sensations  succeed.  At  the  end  of  a  minute  or 
two  an  impression  of  warmth  makes  itself  felt  and  the  foot 
retakes  its  normal  size.  The  contractility  of  the  veins  is 
also  brought  into  activity  by  passive  movements  of  al- 
ternate flexion  and  extension,  raising  and  lowering,  and 
abduction  and  adduction.  The  displacement  of  the  fluid 
blood  is  also  a  factor  of  importance  in  the  variations  of 
vascular  pressure.  Violent  displacements  of  the  arterial 
blood  and  the  too  sudden  passage  of  this  blood  into  the 
venous  system,  however,  are  the  principal  causes  of 
grave  accidents  that  affect  the  heart  or  the  lungs  in  the 


course  of  certain  exercises  that  are  carried  to  the  last 
degree  of  energy.  The  lung  by  thoracic  aspiration  is  an 
important  factor  in  the  education  of  the  movements  of  the 
heart  in  cases  of  tachycardiac  arythmia.     [J.  M.  S.] 

3. — Bourdilion  reports  the  case  of  a  woman  aged  60 
years  who  died  at  the  end  of  34  days  after  admission  to 
the  hospital  of  a  disease  which  had  presented  all  the 
symptoms  of  typhoid  fever,  and  which  was  said  from  the 
beginning  to  have  a  grave  prognosis  on  account  of  the 
advanced  age  of  the  patient  and  the  profound  asthenia  into 
which  she  had  fallen.  The  diagnosis  of  typhoid  fever 
was  undoubted,  both  from  the  clinical  signs  and  by  the 
presence  of  a  positive  serum  reaction.  At  the  autopsy, 
however,  the  small  intestine  was  found  to  be  intact 
throughout  its  entire  length  and  the  large  intestine  only 
presented  anatomic  evidences  of  the  disease.  It  has  been 
established  in  a  certain  manner  that  the  disease  was  due 
to  a  typhoid  infection  and  that  it  had  evolved  in  the  pa- 
tient without  attacting  the  small  intestine.  The  lesions  in 
the  large  intestines  were  those  of  an  ulcerous  and  ne- 
crotic colitis.  From  the  clinical  point  of  view  the  pre- 
dominant symptom  was  an  intense  diarrhoea  which  ac- 
counted for  the  asthenic  form  of  the  disease  and  its  grav- 
ity.     [J.   M.   S.] 

4. — Remlinger  reports  7  cases  in  which  typhoid  fever  and 
dysentery  were  associated.  In  3  of  the  cases  one  dis- 
ease followed  the  other.  In  one  case  dysentery  apeared 
in  the  course  of  typhoid  fever.  In  2  cases  the 
dysentery  followed  typhoid  fever  of  medium  intensity, 
in  one  of  which  there  had  been  a  relapse  which  was 
quite  serious  before  the  development  of  the  second  in- 
fection. In  the  seventh  case  the  2  infections  existed 
simultaneously.      [J.   M.   S.] 

5. — Sabrazes  and  Mathis  have  studied  the  condition  of 
the  blood  in  zona.  They  find  there  are  no  marked  changes 
in  the  number  of  red  corpuscles  or  in  the  percentage  of 
hemoglubin;  nor  do  the  red  blood  corpuscles  present  any 
recognizable  alteration.  The  white  corpuscles  are  above  the 
normal  on  the  first  day  of  the  eruption.  This  hyperleukocyto- 
sis  increases  until  about  the  third  day  .then  it  decreases  grad- 
u.illy  up  to  the  fifth  day.  The  increase  in  the  number 
of  white  cells  is  due  principally  to  the  polymorphonuclear 
neutrophiles  and  the  eosinophiles.  If  the  contents  of  the 
vesicles  become  purulent  the  number  of  leukocytes  dimin- 
ishes, returning  to  normal  or  slightly  below  normal.  The 
loss  being  made  up  by  the  same  varieties  of  cells  that 
constituted  the  increase.  The  period  of  dessication  and 
desquamation  is  marked  by  a  second  hyperleukocytosis. 
Sometimes  with  the  eosinophiles  in  greatest  proportion. 
At  the  end  of  about  2  weeks  the  blood  resumes  its  normal 
character.  In  the  clear  vesicles  on  the  first  day  of  the 
eruption  the  fluid  was  found  to  contains  79  per  cent,  of 
polymorphonuclear  neutrophiles,  19  per  cent,  lymphocytes, 
1  per  cent,  of  large  mononuclears,  while  the  eosinophiles 
were  very  few  in  number  or  wei'e  completely  wantiug- 
During  the  following  days  the  percentage  of  polymorphon- 
uclear neutrophiles  increases  to  9C  per  cent.:  the  micro- 
organisms being  in  pure  culture.  On  the  sixth  day  the 
contents  of  the  vesicles  presented  disintegrating  poly- 
morphonuclear neutrophilic  cells  associated  with  eosino- 
philes undergoing  disintegration.  Neutrophilic  myelocytes 
were  found  once  in  very  small  number,  0.2  per  cent,  in 
the  blood,  but  they  have  not  been  found  In  the  vesicles. 
[J.   M.   S.l 


Dionin    in   the   Treatment   of   Nervous    Excitement. — Ma- 

jewsky  (Vraifh,  Vol.  XXII,  No.  6)  presented  before  the 
Society  of  Neuropathologists  and  Psychiatrists  at  the  Uni- 
versity of  Kasan  the  results  obtained  by  him  with  dionin. 
He  employed  it  in  the  Insane,  especially  maniacs,  in  the 
stage  of  excitement.  Although  nineteen  cases  are  re- 
ported. The  conditions  in  which  this  drug  was  admin- 
istered were  mental  excitement  accompanied  by  conges- 
tion of  the  cerebral  blood-vessels;  also  in  sexual  excite 
ment.  It  appeared  that  subcutaneous  injections  of  0.04-0,05 
grms  of  dionin  constricted  the  blood-vessels  and  thus 
relieved  the  congestion.  In  some  cases  the  sexual  excite- 
ment was  allayed  and  the  erections  diminished.  The  au- 
thor considers  it  a  valuable  remedy  in  acute  masturbation 
accompanying  transient  mental  disturbances.  The  inter- 
nal use  of  the  drug  is  not  followed  by  the  same  powerful 
effects.      [A.   R.] 


-2fi       Ths  Philadelphia  1 
/^  Medical  JornxAL  J 


LIGATION  OF  THE  CAROTID 


[Apbil  13,  1901 


Qricjinal  articles. 


LIGATION  OF  THE  CAROTID  ARTERY  AS  AN  OPERA- 
TION PRELIMINARY  TO  RESECTION  OF  THE 
SUPERIOR  MAXILLA. 

8y  PKOFESSOR   CARL   SCHLATTER. 

University  of  Zurich. 

Translated,  with  Pinnission  of  the  Author,  by  Max  R.  Dinkelspiel. 

It  cannot  be  denied,  even  by  surgeons  adept  at 
operative  procedures,  that  the  modern  technique 
employed  in  resection  of  the  superior  maxilla  is 
somewhat  unsatisfactory,  both  on  account  of  the 
marked  accompanying  hemorrhages,  as  well  as  the 
great  danger  from  blood  aspiration.  Excepting  the 
proved  inexpedient  method  of  operating  with  the 
head  lowered,  two  methods  have  been  employed  for 
obviating  the  blood  aspiration.  Either  the  trachea, 
after  a  previously  performed  tracheotomy,  is  pro- 
tected by  gauze  or  a  tampon-canula,  or,  the  patient 
is  only  partially  anesthesized  and  thus  placed  in 
such  a  reactionary  condition  that  he  can  sponta- 
neously throw  out  the  blood,  that  is  flowing  into  the 
larj-nx.  The  first  method — the  performance  of  a 
prophylactic  tracheotomy  and  larj-nx-tamponade — 
is  less  frequently  employed,  because  it  is  considered 
a  too  dangerous  procedure  for  a  preliminary  opera- 
tion, and  also  because  it  impedes  the  ejection  of  dis- 
integrating masses  of  secretion  and  mucus.  Thus 
the  second  method — performing  the  operation  dur- 
ing partial  anesthesia — has  been  introduced  as  the 
sanctioned  procedure.  This  manner  of  operation, 
if  it  is  to  be  followed  by  favorable  results,  requires 
a  more  extensive  operative  technique  than  almost 
any  other  operation,  and  above  all,  rapid,  accurate 
manipulation,  which  can  only  be  acquired  with  ex- 
tensive clinical  material ;  furthermore,  a  thoroughly 
versed  corps  of  assistants  is  essential — all  these  be- 
ing requisites  that  are  not  at  the  command  of  every 
surgeon.  But  even  in  the  hands  of  accomplished 
operators,  the  prognosis,  on  account  of  the  danger 
from  aspiration  during  and  after  the  operation,  has 
remained  a  grave  one.  During  the  operation,  it  is 
the  regurgitating  non-aseptic  blood  coming  in  con- 
tact with  mucous  membrane  surfaces  that  threatens 
to  involve  the  bronchi  and  lungs.  The  fortunately 
but  brief  period  of  time,  during  which,  in  spite  of 
the  combined  efforts  of  surgeon  and  patient,  the 
respirator)'  passages  can  hardly  be  kept  free  from 
blood,  can  rarely  be  evaded.  Martens  (i)  esti- 
mated the  mortality  of  74  total  resections  of  the  su- 
perior maxilla,  performed  in  the  clinic  at  Goettingen, 
at  23  or  31  per  cent.  In  16  cases  the  cause  of  death 
was  disease  of  the  respiratory  tract.  In  the  clinic  of 
Greifswald  4  out  of  18  cases  of  total  resection  (22 
per  cent.)  resulted  fatally  in  consequence  of  the  op- 
eration. Bryant's  (2)  statistics  of  230  unilateral  re- 
sections of  the  superior  maxilla  show  a  mortality  of 
14  per  cent.  A  remarkably  small  mortality  rate, 
in  resection  of  the  superior  maxilla,  is  reported  from 
the  clinic  of  Zurich,  \Yhere  out  of  34  total  resections 
but  one  death,  referable  to  the  operation,  oc- 
curred. Referring  to  other  statistics  on  this  subject, 
of  which  I  here  report  a  few  of  the  most  recent  ones, 
we  see  that  the  exceptionally  favorable  data  just 
mentioned  do  not  correctb'  exjircss  the  universally 


accepted  grave  prognosis  of  the  operation.  Koenig 
(3)  in  the  latest  addition  of  his  text  book  still  esti- 
mates the  average  mortality  of  complete  resection 
of  the  superior  maxilla  at  30  per  cent.  The  marked 
hemorrhage  occurring  during  this  operation  and  its 
dangerous  sequels  have  recently  actuated  many 
surgeons  to  undertake,  as  a  preventative  operation, 
the  permanent  or  temporary  ligation  of  the  afferent 
vessels,  the  ligation  in  the  latter  case  being  one  in 
continuity.  The  first  report  concerning  the  ligation 
of  the  common  carotid  as  a  preliminary  operation 
in  operative  procedures  on  the  head,  is  reported 
from  the  clinic  of  Prof.  C.  Reyher  in  St.  Petersburg.- 
where  in  all  cases  a  double  ligation  of  the  artery  was 
performed  and  the  vessel  cut  between.  In  order  to 
prevent  the  apprehended  cerebral  manifestations 
which  were  liable  to  occur  in  this  operation,  pres- 
sure was  made  for  eight  days,  every'hour,  from  10 
to  15  minutes  at  a  time,  upon  the  vessel  to  be  lig- 
ated,  and  after  the  operation  strict  attention  was 
paid  to  the  fact  that  the  patient  remained  in  the  hor- 
izontal posture.  Among  27  ligations  of  the  carotid 
Reyher  had  but  one  death.  Weljaminow  (4),  in 
1882,  in  addition  to  these  cases,  reports  20  more  liga- 
tions of  the  carotid,  performed  under  antiseptic  pre- 
cautions, all  of  which  resulted  favorably ;  these  fig- 
ures— one  death  among  47  ligations — with  the  mod- 
ern treatment  of  wounds,  classifies  this  operation 
among  the  less  dangerous  ones.  In  1882  v.  Lesser 
(5)  also  performed  a  ligation  of  the  common  caro- 
tid, preliminary  to  a  resection  of  the  superior 
maxilla.  First  he  temporarily  ligated  the  vessel ; 
then,  when  after  some  time,  there  were  no  manifes- 
tations of  cerebral  disturbance,  tight  silk  ligatures 
were  placed  around  the  carotid.  From  the  clinical 
history  I  believe  for  a  reason  which  I  will  give  later 
on,  that  a  still  movable  lymph  gland,  diseased  bv 
metasasis,  was  situated  on  the  common  sheath  of  the 
vessel.  In  the  American  literature  on  this  sub- 
ject, Bryant  (2)  published  a  report  embodying  a 
recommendation  for  the  preliminary-  ligation  of  the 
external  carotid  znery,  and  on  the  other  hand  con- 
demning the  ligation  of  the  common  carotid  artery 
unless  necessitated  under  exceptional  circum- 
stances. Markedly  different,  however,  from  this 
ligation  in  continuity,  which  has  remained  in  vognie, 
is  the  preliminary  ligation  of  the  carotid  artery  in 
resections  of  the  superior  maxilla,  as  first  attempted 
by  Scnger  (6)  in  1895.  and  which  has  been  warmly 
recommended  since  that  time.  The  latter  ligation 
consists  of  a  temporary  constriction  of  the  exposed 
carotid,  a  sort  of  Esmarch's  constriction,  which,  in- 
stead of  involving  a  whole  extremity,  in  this  case 
only  effects  a  temporary  compression  of  a  single  ves- 
sel. Senger  (6)  has  shown  by  experiments  upon  ani- 
mals that  with  the  employment  of  a  small  amount  of 
precaution  a  ligature  can  be  directly  applied  to  the 
common  carotid  artery  (of  dogs  and  rabbits)  from 
one  to  three  hours  without  any  danger.  In  the 
resections  of  the  superior  maxilla  performed  on  man 
Senger  (6)  has  only  constricted  the  external  caro- 
tid. He  states,  "the  hemorrhage  was  very  slight, 
only  venous,  and  not  to  be  compared  to  the  hem- 
orrhages occurring  without  constriction."  Recovery 
followed  without  reaction  and  without  any  manifes- 
tations of  disease,  either  of  the  brain  or  the  carotid. 
Even  before  the  publication  of  Senger's  case.Schoen- 
born  had  some  cxr'rricnce  at  the  clinic  of  Koeni^sherg 


April  13,  1001] 


LIGATION  OF  THE  CAROTID 


rTnn   rnii.Ai>Ei,PHiA 
L  Mi:i>ii  AL  Joi;it.NAi, 


727 


with  tlie  temporary  ligation  of  the  larger  vessels, 
and  particularly  with  the  carotid.  On  account  of 
gangrene  of  the  anterior  flap  which  occurred  after 
a  hip  joint  amuptaion,  for  which  the  common  iliac 
artery  had  been  permanently  ligated,  Schoenborn 
was  induced  to  ha\'e  resource  there  after  to  the  tem- 
porary ligation  of  the  iliac.  He  has  also  a  few  times 
temporarily  ligated  the  common  carotid  artery  with- 
out any  bad  results  to  the  patient.  At  the  Interna- 
tional Congress  in  Rome,  Schoenborn  demonstrated 
an  artery  compressor,  consiting  of  two  parallel  steel 
rods,  movable  in  the  direction  of  their  long  axes,  and 
which  were  beak-shaped,  thus  permitting  the  tem- 
porary constrictions  to  be  accomplished  with  the 
least  possible  damage  to  the  vessel.*  Riese  (7)  re- 
ports two  other  cases  of  resections  of  the  superior 
ma.xilla  with  preliminary  temporary  ligation  of  the 
common  carotid,  performed  by  Schoenborn  at  the 
clinic  of  the  University  of  Wurzburg.  In  both 
cases  the  patients,  in  consequence  of  hemorrhages 
from  the  malignant  tumors  had  been  sinking  rap- 
idly, and  were  in  such  advanced  stages  of  the  dis- 
ease, that  in  both  operations  the  cranial  cavity  was 
opened,  and,  in  one  patient,  even  in  two  places.  The 
result  of  the  temporary  ligation,  resp.  compression, 
v>as  here  also  a  favorable  one,  the  arterial  hemor- 
rhage being  very  slight.  This  proposition  of  a  pre- 
liminary operation  seems  recently  to  have  been  ac- 
corded increased  recognition.  Kocher  (8),  in  his 
operative  teaching,  highly  recommends  the  prelim- 
inary ligation  of  the  external  carotid  artery  in  re- 
section of  the  superior  maxilla,  and  believes  that  it 
makes  the  operation  more  cleanly  and  simpler.  I 
will  consider  the  cases  of  Konig,  Jr.  (g).  and  those 
of  Gallaudet  (10)  in  another  place.  The  opinion 
of  operators  concernmg  the  favorable  influence  of 
this  preliniinary  operation  upon  hemorrhage  seems 
to  be  so  unanimous,  that  I  would  have  considered  a 
reference  to  ni}-  three  following  cases  of  preliminary 
ligation  of  the  carotid  as  entirely  superfluous,  had 
not  Pilz  (11),  in  1868,  in  his  work  on  the  ligation  of 
the  common  carotid,  asserted,  that  the  permanent 
ligation  of  the  common  carotid,  asserted  that  the 
permanent  ligation  of  the  common  carotid  in  opera- 
tions on  tumors  had  been  entirely  useless  in  13  out 
of  17  cases.  In  my  three  cases,  I,  as  well  as  the 
assistants,  were  absolutely  astounded  at  the  slight 
bleeding.  A  retrospection  of  the  above  quoted  ob- 
servation, where  in  no  case  the  efifects  of  the  pre- 
liminary operation  were  withheld,  decidedly  refutes 
Pilz's  objection.  It  is  more  justifiable  to  consider 
whether  the  danger  of  the  preliminary  operation 
is  not  of  such  a  degree  that  it  outweighs  its  useful- 
ness, and  whether  a  thrombus-formation  at  the 
point  of  ligation,  and  interruption  of  the  blood 
supply  do  not  seriously  endanger  the  brain.  Let  us 
consider  the  dangers  incident  to  the  ligation  of  the 
common  carotid  and  first  those  produced  by  a  per- 
manent ligation.  Formerly  a  ligature-thrombus,  a 
coagulation  of  blood  up  to  the  next  lateral  twig,  was 
considered  as  the  regular  consequence  of  blood  ves- 
sel ligations.  Baumgarten  has  shown  that  in  thor- 
oughh'  healthy  persons,  in  the  absence  of  suppura- 
tion, no  thrombus  results  after  the  ligation,  provided 
the  tying  of  the  ligatures  is  carefully  conducted, 
'/'though  it  is  to  be  admitted  that  at  the  present 

^  II  illustration  of  this  compressor  can  be  found  in  the  Deutsche  Med 
'  ochenschrift  1896.  pp.  88, 


time  under  aseptic  precautions  the  prognosis  of 
ligation  of  the  carotid  has  markedly  improved,  the 
fact  nevertheless  remains,  that  in  spite  of  the  excel- 
lent collateral  circulation  with  which  the  brain  is 
provided  by  means  of  the  vertebral  arteries  and  the 
Circle  of  Willis,  in  many  cases  paralysis  and  soften- 
ing of  the  brain  may  arise  after  the  interruption  of 
the  blood  supply,  be  it  due  to  a  progressive  throm- 
bosis (which,  however,  under  an  antiseptically  per- 
formed ligation  as  a  rule  does  not  take  place)  or 
to  an  embolic  occlusion.  If,  for  the  previously  men- 
tioned reasons,  we  do  not  take  Pilz's  extensive  sta- 
tistics into  account,  whose  material,  comprising  314 
ligations  of  the  carotid,  after  all  mostly  dates  from 
the  pre-antiseptic  period,  and  if  we  only  take  into 
consideration  the  figures  of  Zimmermann  (12), 
whose  cases  rather  date  from  the  time  of  antisepsis, 
we  arc  still  surprised  by  figures  showing  among  a 
mortality  of  31  per  cent.,  26  per  cent,  characterized 
by  cerebral  symptoms,  and  in  6  per  cent,  softening 
of  the  brain.  Riese  (7),  who  continued  Pilz's  statis- 
tics up  to  1885,  fovind  cerebral  involvement  17  times 
in  73  operations, — 25  per  cent.  ^More  favorable  is 
Albert's  (13)  criticism,  in  which  he  states,  that  liga- 
tion of  the  common  carotid  is  tolerably  well  endured 
by  an  entirely  healthy  person.  xA-mong  the  ligations 
performed  for  neuralgias.  lie  finds  the  mortality  3 
per  cent.  Certainly  we  will  not  consider  the  first- 
mentioned  figures  as  an  expression  of  the  most 
modern  prognosis  of  this  ligation,  if  conducted 
under  aseptic  procedures,  for  it  is  known  that  even 
the  common  carotid  has  been  ligated  on  both  sides 
simultaneously,  without  any  disturbances  follow- 
ing. But  these  figures  are,  nevertheless,  plain 
enough,  even  if  viewed  from  an  optimistic  point  of 
view,  to  dissuade  one  from  an  operation,  which, 
simply  as  an  auxiliary  procedure,  is  perhaps  fol- 
lowed by  a  greater  mortality  than  the  principal 
operation  itself.  The  temporary  constriction  of  the 
common  carotid  should  not  be  confounded  or  judged 
wtih  the  permanent  ligation  of  that  vessel.  As  far 
as  injury  to  the  brain  is  concerned,  it  is  not  imma- 
terial whether  the  blood  supply  is  cut  off  only  for 
the  short  time  during  the  operation,  or  permanently. 
When  the  blood  stream  is  cut  oft'  for  only  a  brief 
period,  the  danger  of  a  direct  atrophic  softening  of 
the  brain  is  certainly  precluded.  The  ditflculty  that 
confronts  us  in  critically  selecting  a  method,  is  the 
question,  as  to  whether  the  temporary  constriction 
predisposes  to  a  formation  of  thrombi  to  a  more  or 
less  degree  than  the  permanent  ligation  Konig,  Jr., 
(9)  cut  the  carotid  between  two  ligatures,  because 
he  believed  that  temporary  ligation  easily  causes 
thrombosis  after  the  opening  of  the  ligatures.  On 
the  other  hand,  it  appears  from  a  theoretical  point 
of  view,  that  we  can  hardly  ignore  the  fact,  that  a 
brief  ligation  performed  with  the  greatest  possible 
protection  to  the  vessel  walls,  by  means  of  broad 
rubber  bands,  or  broad  pads  placed  underneath,  pre- 
disposes considerably  less  to  the  formation  of 
thrombi.  The  vessel  wall,  especially  the  intima,  is 
certainly  more  injured  when  tightly  ligated  by  a  silk 
thread  than  by  a  broad  body  remaining  on  it  for 
only  a  short  time,  be  it  a  compressor  supplied  with 
rubber,  or  simply  a  rubber  band.  The  damage 
which  a  silk  ligature  may  cause  to  the  wall  of  an 
artery  is  found  pictured  in  a  most  instructive  man- 


728  ^"^     PnlLADKLrBIA"] 

/  MKDIC'AI.    JOLIIXAI.     J 


LIGATION  OF  THE  CAROTID 


[Afbil  13.  1901 


ner  in  the  work  of  Eberth  and  Schimmelbusch  (14) 
Dn"Thrombosis."  Here  tlie  femoral  artery  of  a  strong 
healthy  hunting  dog  was  dissected  out  and  tightly 
ligated  in  one  place  by  a  silk  thread.  The  ligature 
was  removed  in  a  quarter  of  an  hour,  and  immedi- 
ately thereon  the  artery  was  again  filled  as  in  the 
normal.  After  the  circulation  had  continued 
through  the  vessel  for  three-quarters  of  an  hour 
longer,  the  ligated  portion  of  the  vessel  was  excised 
and  placed  in  chrom-osmic  acid.  In  the  longitudi- 
nal sections  it  was  seen  that  the  intima  was  entirely 
lacerated,  the  media  crushed,  and  the  contiguous 
sheath  of  the  adventitia  somewhat  loosened.  A 
thrombus  extending  from,  the  muscular  portions 
separated  from  adventitia,  which  in  places  were 
heaped  together,  into  the  middle  of  the  lumen  of  the 
vessel.  In  Senger's  (6)  experiments  upon  animals 
no  changes  worth  mentioning  took  place  in  the  ar- 
teries after  the  carotid  had  been  ligated  from  one 
to  three  hours  by  means  of  a  rubber  ligature  and 
broad  pads;  those  animals  not  killed  immediately, 
subsequently  recovered  and  remained  permanently 
healthy.  The  results  of  two  experiments  by 
Eljerth  and  Schimmelbusch  (14)*  and  which  imi- 
tated the  process  of  temporary  constriction,  coincide 
with  the  views  of  Sengcr  (6).  Eberth  and  Schim- 
melbusch clamped  the  jugular  veins  of  two  hunting 
dogs,  in  several  places  with  a  pair  of  forceps,  so 
that  about  one-half  of  the  vessel  wall  was  squeezed 
between  the  grooves  of  the  forceps.  After 
a  few  minutes  the  blood  was  allowed  to  again  flow 
through  the  vessels  for  ten  minutes,  before  they 
were  excised.  The  clamped  areas  were  plainly  seen 
as  white  spots  which  showed  the  thin  stripes  that 
had  been  made  by  the  grooves  in  the  forceps.  In 
both  cases  microscopical  examination  of  hundreds 
\A  serial  sections  showed  neither  a  change  in  the 
vessel,  nor  a  thrombus.  Even  if  in  these  experiments 
the  duration  of  the  compression  does  not  give  data 
of  practical  value,  the  impressions  of  the  grooves 
nevertheless  showed  a  vigorous  crushing  of  the  ves- 
sel wall.  Even  in  temporary  ligatiors  of  arteries 
with  silk  thread,  Zahn,  in  spite  of  the  injury  pro- 
duced to  the  vessel  wall,  could  find  no  thrombus 
formation  at  the  point  of  laceration  .  Eberth  and 
Schimmelbusch  (14)  also  observed  thrombus  for- 
mation after  ligations  with  threads.  Where  the 
ligatures  were  allowed  to  remain  for  a  longer  period 
of  time,  they  only  found  a  simple  plate-thrombus, 
which  quickly  healed,  and  in  a  few  cases  in  addition 
to  the  conglutination  of  blood-plates,  also  fibrin ; 
.hut  a  permanent  interruption  of  the  circulation  in 
consequence  of  these  ligations  was  not  found  in  any 
case.  These  experiments  upon  animals,  in  spite  of 
the  favorable  observations  of  Zahn,  seem  rather  to 
induce  us  to  ignore  the  silk  ligature,  and  to  choose 
as  ligature  material  broad  rubber  bands  or  possibly 
grooved  clamps.  In  this  way  the  greater  injury  to 
the  intima,  as  well  as  a  deposition  of  blood-plates, 
can  probably  be  avoided.  A  simple,  uncomplicated 
retardation  of  the  blood  stream — even  when  it  gives 
rise  to  a  deposition  of  leuckocytcs  or  blood-plates 
on  the  vessel  wall — according  to  the  experiments  of 
Eberth  and  Schimmelbusch  (14),  docs  not  cause  a 
thrombus,  provided  no  other  complications,  such  as 
injuries  to  the  vessel  wall,  are  present.    In  addition 


♦Thromhosis  [888.  p.  101 


to  the  experiments  upon  animals  alluded  to,  the  re- 
sult of  two  post-mortem  examinations  that  were 
performed  upon  the  two  last  mentioned  cases  of 
Schoenborn,  who  were  operated  upon  while  in  a 
very  poor  condition,  and  who  died  shortly  after  the 
resection  of  the  superior  maxilla,  seem  to  invite 
preference  for  this  method  of  ligation.  In  the  first 
case,  the  atery  was  ligated  by  means  of  a  rubber 
band  over  a  small  rubber  block.  In  Riese's  serial  sec- 
tions of  the  carotid,  the  latter  was  seen  to  be  every- 
where patulous,  the  coats  of  the  artery  entirely 
normal,  the  endothelium  being  preserved  and 
nowhere  injured.  And  yet  in  this  case  it  is  surpris- 
ing, that,  in  spite  of  no  damage  to  the  vessel  wall, 
there  should  have  been  entirely  a  flat  mural  throm 
bus  at  the  upper  portion  of  the  area  embraced  by  the 
ligature,  consisting  principally  of  fine  fibrin  threads 
and  occupying  about  1-5  of  the  circumference  of 
the  inner  wall.  In  the  second  case,  the  carotid  was 
also  patulous  at  the  point  of  ligation ;  no  microscop- 
ical examination  was  made.  In  two  experiments 
upon  animals  performed  by  Riese  (7),  after  com- 
pression of  the  iliac  artery  for  one  hour,  obstructive 
thrombi  were  found  six  days  thereafter;  this,  how- 
ever, is  not  considered  conclusive  even  by  that  ex- 
perimenter himself,  as  the  wound  did  not  heal  in 
an  aseptic  manner.  He  also  believes  that  these  ex- 
periments cannot  be  considered  as  conclusive  evi- 
dence against  the  application  of  the  temporarj-  lig- 
ature in  man.  It  appears  to  me,  irrespective  of  the 
fact  that  asepsis  is  more  easily  carried  out  in  man 
than  in  animals,  that  the  human  carotid  is  more 
prone  to  the  formation  of  thrombi  and  obstructions 
than  the  carotid  in  animals,  not  only  on  account  of 
its  thicker  and  more  resisting  walls,  but  also  on 
account  of  its  larger  lumen.  From  all  these  obser- 
vations, it  seems  that  a  temporary  broad  compres- 
sion of  the  common  carotid  predisposes  less  to  a 
formation  of  thrombi  than  the  pern  anent  ligature, 
and  already  for  this  reason  the  lattor  is  to  be  pre- 
ferred. Moreover,  temporarj'  interruption  of  the 
blood  stream  is  to  be  preferred,  because  it  obviates 
direct  danger  of  softening  of  the  brain.  Although 
the  danger  of  thrombus-formation  in  carefully  con- 
ducted temporary  constrictions  of  the  carotid  is  a 
remote  one,  if  we  consider  the  small  amount  of 
observations  on  man  that  have  been  favorable 
throughout,  we  are  still  not  yet  justified  to  consider 
this  auxiliary  operation  as  being  entirely  without 
danger  to  the  brain.  The  most  ideal  solution  of  the 
problem  would  be,  if  we  could  entirely  ignore  the 
question  of  ligating  the  common  carotid,  and  would 
accomplish  our  purposes  by  a  ligation  of  the  exter- 
nal carotid  alone.  This  ligation  might  then  also  be  a 
permanent  one,  for  the  temporary  interruption  of 
the  blood  stream  in  this  case  would  be  an  aimless 
procedure.  Under  aseptic  procedure  a  thrombus 
extending  from  the  external  carotid  to  the  common 
carotid  could  hardly  be  expected.  Among  the  13:: 
cases  of  ligation  of  the  external  carotid,  cotppilcd  by 
Lipps(i5)  there  occurred  only  two  cases  ini&Sj  (  Du- 
brueil  and  Pozzi),  in  which  a  thrombosis  extended 
into  the  internal  carotid,  anc".  in  which  afterwards 
a  diagnosis  of  embolism  in  thr  brain  was  justifiable. 
In  Dubrueil's  patient,  aged  65.  a  hemiplegia  oc- 
curred, but  only  on  the  24th  day  after  the  ligation 
The  patient  died  throe  days  thereafter,  but  an  au- 
topsy was  not  performed.     Among  130  operations 


APRIL  13.   1001] 


LIGATION  OF  THE  CAROTID 


CTfTE     PniLADKLPHlA 
MEr.I    AL    JoLKNAl, 


729 


of  the  external  carotid  no  deleterious  results,  di- 
rectly traceable  to  the  ligation,  have  occurred,  with 
the  exception  of  these  two  cases,  which  can  still  be 
considered  as  belonging  to  the  beginning  of  the 
antiseptic  era ;  neither  were  there  any  premonitory 
symptoms  indicative  of  an  overfilling  of  the  cra- 
nium with  the  blood  supplied  by  the  internal  caro- 
tid, which  alone  took  up  the  blood  from  the  common 
carotid.  Gallaudet  (10),  who  observed  a  right- 
sided  paralj'sis  with  maniacal  conditions  followinc 
soon  after  the  ligation  of  the  external  carotid  and 
in  which,  as  the  paralysis  decreased,  melancholia 
occurred,  believed  that  on  account  of  the  mania  the 
case  was  one  of  central  narcosis-paralysis.  Does 
the  ligation  of  the  external  carotid  alone  suffice  to 
render  the  whole  field  of  operation  in  resections 
of  the  superior  maxilla  bloodless?  This  is  a  ques- 
tion which  has  been  raised  as  early  as  1840  by  Piro- 
,  goff.  In  1874  Madelung  (16)  wrote  about  the 
variance  that  existed  among  surgeons  con- 
cerning the  value  of  ligating  the  external  carotid 
and  its  relation  to  the  ligation  of  the  common  caro- 
tid. Lipps  (15),  in  a  perusal  of  the  literature  on  this 
subject,  found  that  in  1893  this  old  question  of 
Pirogoff  had  not  yet  been  unanimously  answered. 
Well-known  surgeons  had  ligated  the  common 
carotid,  and  equally  well-known  ones  had  censured 
this  procedure,  because  ligation  of  the  external 
carotid  had  sufficed.  According  to  Friedlander  (17) 
ligation  of  the  common  carotid  is  performed  in  more 
than  one-half  of  the  cases  on  account  of  disease  in 
the  region  of  the  external  carotid.  These  contradic- 
tory opinions  concerning  ligation  of  the  common 
and  external  carotids,  and  especially  as  preliminary 
operations  to  the  resection  of  the  superior  maxilla, 
have  up  to  the  present  time  not  yet  been  cleared  up. 
It  appears  from  an  anatomical  point  of  view  that  in 
resection  of  the  superior  maxilla  the  incisions  are 
made  principally  in  the  region  of  the  internal  max- 
illa artery,  which,  as  is  well  known,  arises  from  the 
external  carotid.  It  would  appear  that,  irrespective 
of  the  anastomosis,  only  those  branches  of  the  inter- 
nal carotid  in  the  orbit  should  then  be  taken  into 
consideration.  I  would  like  to  make  a  short  con- 
tribution to  this  question  by  the  report  of  the  three 
appended  cases,  in  which  it  will  be  -seen  that  my 
experiments  were  systematically  conducted.  In  the 
first  case,  I  temporarily  ligated  the  common  caro- 
tid. In  the  second  case,  separately,  first  the  exter- 
nal carotid  and  then  later  also  the  internal  carotid, 
and  in  the  third  case,  only  the  external  carotid.  In 
the  first  case,  where  I  had  to  deal  with  a  young 
patient,  there  was  a  pronounced  sarcoma  of  the 
whole  right  superior  maxilla,  together  with  the  hard 
palate,  as  well  as  a  portion  of  the  left  superior  max- 
illa. I  feared  that  during  the  resection  I  would  also 
be  obliged  to  operate  into  the  area  of  the  internal 
carotid,  and  therefore  preliminarily  ligated  the  com- 
mon carotid  with  rubber  tubing.  The  result  was 
most  satisfactory,  the  hemorrhage  being  less  than 
that  which  ordinarily  takes  place  in  these  resec- 
tions. There  was  not  the  slightest  indication  of 
cerebral  involvement.  There  was  no  recurrence, 
and  the  patient  to-day  is  still  in  the  best  of  health. 
The  second  case  presented  singular  features.  In 
this  case  I  wanted  to  avoid  ligating  the  common 
carotid,  and  placed  loose  ligatures  around  the  exter- 
and  internal  carotid.     The  rubber  ligature  around 


the  internal  carotid  was  applied  only  in  a  prophy- 
latic  sense,  so  that  in  case  an  insufficient  effect  was- 
produced  by  ligating  the  external  carotid,  the  inter-- 
nal  carotid  could  subsequently  also  be  constricted. 
As  a  matter  of  fact,  the  effect  produced  by  only  lig- 
ating the  external  carotid  is  a  very  moderate  one — 
I  believe  that  I  saw  no  greater  hemorrhage  even  in 
some  resections  of  the  superior  maxilla  performed 
without  ligating  the  carotid, — but  as  soon  as  I  like- 
wise tightened  the  ligature  around  the  internal 
carotid,  the  hemorrhage  became  perceptibly  less. 
It  appeared  to  me  that  the  hemorrhage  in  the  regiors 
of  the  pterygoid  process  was  the  one  that  was  prin- 
cipally influenced  by  this  second  ligature.  It  is. 
difficult  to  explain  this  observation,  as  the  internal: 
carotid  belongs  to  those  blood  vessels  which  rarely 
are  subject  to  anomalies.  Possibly  an  abnormalitv 
in  the  ascending  pharyngeal  artery  was  present. 
This  artery  not  rarely  arises  directly  from  the  bifur- 
cation of  the  common  carotid,  it  may  substitute  the 
ascending  palatine  artery,  or  the  latter  frequently 
arises  from  the  ascending  pharyngeal,  which,  ac- 
cording to  many  authors,  is  the  normal  condition. 
In  my  case  the  pharyngeal  and  the  internal  carotid 
arteries  must,  according  to  this,  have  been  ligated 
together,  which  is  hardly  conceivable,  as  the  phar- 
yngeal would  have  been  seen  when  the  sheath  was 
dissected  away.  It  is  more  probable  that  one  of 
those  rare  anomalies  was  present  where  the  interna? 
carotid  gives  off  supernumerary  branches.  Ouain> 
found  this  anomaly  9  times  in  144  cases.  In  my  third 
case,  b}-  the  ligation  of  the  external  carotid  alone, 
an  entirely  satisfactory  result  was  produced. 

CASE  1. — G.  J.,  male,  aged  35,  was  admitted  August  25, 
1S97  for  sacroma,  involving  the  wtiole  of  tlie  rigiit  maxilla 
and  a  portion  of  the  left.  His  father  died  from  carcinoma 
01  tt::  stomach:  family  history  otherwise  negative.  Iq 
childhood  the  patien:  had  an  attack  of  pleurisy.  Ten  years, 
ago  he  acquired  syphilis  in  America  and  was  cured  by  in- 
unction. Five  years  ago  the  patient  had  enteric  fever,  but 
after  that  was  healthy.  Six  months  before  admission  he 
noticed  a  swelling  in  the  angle  between  the  right  eye  ami 
the  nose,  which  grew  very  slowly.  Four  weeks  before  ad- 
mission the  left  cheek  became  swollen  and  the  hani 
palate  became  loosened.  The  patient  had  suffered  much 
from  toothache  during  this  half  year  and  several  teethi 
were  abstracted  because  the  attending  physician  thought 
it  was  a  case  of  abscess  of  the  gums.  But  as  there  were  no 
manifestations  of  suppuration,  it  was  concluded  that  it  was- 
a  case  of  malignant  tumor  and  the  patient  was  referred 
to  a  hospital. 

Status  praesens.  Rather  large,  well  built,  but  emaciated 
man.  Examination  of  the  internal  organs  showed  nothing 
of  note.  The  right  cheek  bulged  outward.  This  bulgin.? 
began  at  the  right  nasolabial  fold,  and  crossed  the  medlar* 
line  about  2  cm.  above  it.  extending  to  the  lid.  and  laterally 
to  the  ear.  The  r  ght  eye  was  not  as  much  opened  as  the- 
left.  Both  eyeballs  appaared  prominent.  thou:;h  the  right 
one  hardly  any  more  than  the  left.  The  movements  of  tho 
eye  ball  were  unimpeded.  Breathing  through  the  right 
nares  impossible.  Skin  on  the  right  cheek  more  taut  than 
that  on  the  left,  but  not  reddened  or  infiltrated.  There 
was  no  disturbance  of  sensibility.  A  sweetish  but  fetid 
breath  was  exhaled  from  the  mouth  and  there  was  so 
much  secretion  of  saliva  that  the  patient  frequently  was 
obliged  to  expectorate.  The  mucosa  of  the  mouth  and 
pharynx  was  discolored  a  peculiar  bluish  red.  and  ia 
places  covered  with  stringy  hyaline  mucus.  The  palate  was 
more  reddened  than  the  throat.  The  tongue  was  red  and 
covered  with  a  grayish  white  coating.  The  remaining- 
teeth  were  detective.  The  mucosa  of  the  right  upper  alve- 
olar process  seemed  to  be  hyperplastic  and  the  process 
itself  thickened  to  twice  the  size  of  the  left.  This  thicken- 
ing extended  in  front  over  the  median  line  to  the  left  can- 
ine. The  overgrown  mucosa  bled  on  the  slightest  touoh, 
as  did  also  that  on  the  right  side  of  the  hard  palate.     Tli<» 


*j-yn        The    Phtlapelphia"! 
/  o^         Medical  Journal  J 


LIGATIOX  OF  THE  CAROTID 


[APBIL  13.  1901 


right  upper  canine  and  one  incisor  were  still  in  place,  bu: 
could  be  pulled  out  by  the  fingers.  Pressure  in  the  region 
of  the  right  canine  caused  foul-smelling  pus  to  exude  from 
the  alveolus,  but  only  the  fold  of  the  mucosa  between  the 
cheek  and  the  upper  Jaw  was  sensitive  to  touch.  A  freely 
movable  lymph  gland,  the  size  of  a  cherry  pit,  could  be  felt 
on  the  right  side  under  the  angle  of  the  jaw. 

Operation  September  7th.  Total  resection  of  the  right 
and  partial  resection  of  the  left  maxilla.  Morphine  hypo- 
dermically  and  ether  anesthesia.  The  operation  was  con- 
ducted as  follows: 

Part  1.  Extirpation  of  the  submaxilliary  lymph  by  means 
of  a  5  cm.  Incision  over  the  edge  of  the  right  mandible: 
the  gland  proved  to  be  the  seat  of  carcinomitous  degenera- 
tion. 

Part  2.  Temporary  ligation  of  the  right  common  cartoid 
artery  as  follows:  A  T  shaped  incision  was  made  from  the 
opening  over  the  mandible  along  the  anterior  proter  of 
the  sterno-cleido-mastoid  muscle  as  far  as  the  upper  por- 
tion of  the  cricoid  cartilage,  and  then  continued  to  the 
sheath  of  the  cartoid.  A  thin  rubber  tube  was  then  passed 
under  the  cartoid  by  means  of  an  aneurism  needle,  and 
tied.  No  change  occurred  either  in  the  color  of  the  face  or 
In  the  radial  pulse. 

Part  3. — Resection  of  the  right  superior  maxilla.  Lang- 
enbeck  arch-shaped  incision  down  to  the  bone,  and  the 
tissues  freed  from  the  latter.  The  relatively  few  bleeding 
vessels  were  tied  with  catgut.  The  flaps  were  held  back 
upon  the  forehead  and  the  eye  ball  protected  by  a  spatula. 
After  elevating  the  periosteum  a  curved  needle  carrying 
a  Gigli-Hertel  wire  saw  was  passed  through  the  orbital 
fisure  into  the  malar  fossa  and  another  one  around  the 
lugular  process.  After  quickly  sawing  through  the  bone 
the  frontal  process  of  the  maxilla  was  cut  through,  from 
the  anterior  nasal  aperture,  and  finally  the  hard  plate  also 
sawed  through  with  the  Hertel  saw.  The  maxilla  was  now- 
twisted  out  with  bone  forceps.  The  hemorrhage  was  mod- 
erate and  chiefly  venous.  The  main  vessels  were  ligated 
and  the  rest  of  the  hemorrhage  checked  with  iodoform 
gauze  tampons.  The  carotid  was  then  released,  but  little 
hemorrhage  followed. 

Part  4.  Partial  resection  of  the  left  superior  maxilla. 
A  portion  of  the  alveolar  process  was  chiseled  away,  begin- 
ning from  the  point  corresponding  to  the  first  premolar 
tooth  and  extending  directly  upward  into  the  hard  palate. 
A  Hertel  saw  was  introduced  into  the  upper  portion  of  the 
chisel  wound,  and  by  sawing  upward  and  inward,  the 
anterior  portion  of  the  anveolar  process  and  of  the  hard 
palate  were  sawed  away.  This  caused  the  antrum  of  High- 
more  to  be  laid  open  at  its  greatest  diameter.  The  hem- 
orrhage was  now  rather  severe.  Some  of  the  vessels  were 
tied  and  the  remaining  hemorrhage  checked  with  gauze 
tampons,  the  gauze  on  both  sides  being  conducted  outward 
through  the  nares  and  fastened  together  in  front  of  the 
nasal  septum. 

Part  5.  Reunion  of  the  separated  soft  palate  by  four 
silk  stitches.  This  was  done  because  the  soft  palate  ap- 
peared to  be  only  edematous,  and  not  the  seat  of  sarcoma- 
tous infiltration.  The  mucosa  of  the  cheek  was  repaired  by 
silk  stitches  and  the  flap  restored.  The  submaxillary  In- 
cision and  that  made  for  the  ligation  of  the  carotid  were 
closed  without  drainage.  There  was  not  much  alteration 
In  the  pulse  after  the  operation  and  the  closure  of  the  lid 
on  the  right  side  was  not  interfered  with.  During  the 
operation  considerable  bloody  mucus  was  ejected  by  the 
patient.  In  the  evening  there  was  so  little  pain  that  the 
patient  did  not  want  any  morphine  Injected.  Evening 
temperature,  36.9  degrees  C:  pulse  IIS. 

September  8th.  Patient  partook  freely  of  food.  His  con- 
dition was  very  satisfactory,  the  evening  temperature  being 
37.8  degrees  C;  and  the  pulse  124. 

September  11th.  Dressings  changed.  No  secretion. 
Some  stitches  removed. 

September  13th.  A  slight  rise  of  temperature  had  been 
observed  since  the  previous  day,  reaching  38  degrees  on 
the  morning  of  the  13th.  Upon  removing  the  tampon  from 
the  left  antrum  of  Highmore  and  also  that  from  the  right, 
considerable  pus  exuded. 

September  15th.  Bandage  removed  from  the  head.  Ex- 
ternal wounds  beautifully  united.  The  evening  tempera- 
ture still  39  degrees,  but  without  great  remission.  Dullness 
was  obtained  on  the  loft  side  of  the  thorax,  posteriorly 
and  extending  downward  from  the  7th  vertebra,  as  well 
as  decreased  fremitus.    Upon  auscultation  over  this  region, 


weakened  bronchial  breathing  and  medium  sized  rales  were 
heard. 

September  17th.  The  dulness  extended  to  the  fifth 
vertebra.  Vocal  fremitus  was  now  almost  Imperceptible  on 
the  left  side.  A  puncture  was  made  for  the  purpose  of 
diagnosis,  and  foul  smelling  pus  obtained.  Resection  of  the 
eighth  rib  was  immediately  performed.  Upon  opening  the 
pleural  cavity  about  200  cc.  of  fetid  pus  was  evacuated. 
Soft  fibrinous  masses  filled  up  the  cavity,  and  in  the  pus 
there  was  what  was  thought  to  be  particles  of  food.  Drain- 
age established  by  tubes. 

September  19th.  Morning  temperature  37.4  degrees  C; 
When  swallowing  there  was  frequently  aspiration,  degluti- 
tion being  difficult.  The  right  iodoform  gauze  tampon  was 
removed. 

September  25th.  The  lower  outer  quadrant  of  the  cornea 
appeared  hazy:  there  was  pericorneal  injection  and  epiph- 
ora. A  bichloride  of  mercury  compress  (1.5000  was  applied 
to  the  eye. 

October  1st.  The  corneal  lustre  was  now  restored, 
and  the  temperature  normal.  There  was  still  discharge 
from  the  pleural  cavity,  but  without  fetor. 

October  20th.  The  patient  was  able  to  close  his  right 
eye  perfectly. 

Novembed  1st.     The  patient  was  permitted  to  get  up. 

November  14th.  The  patient  was  discharged.  There 
was  no  recurrence.  His  speech  was  scarcely  intelligible. 
There  was  no  recurrence.  There  was  epiphora,  and  on  ac- 
count of  displacement  of  the  eye  ball,  also  diplopia.  On 
November  25th  the  patient  was  placed  In  charge  of  a 
dentist,  who  prepared  a  prosthesis,  which,  on  account  of 
the  poor  condition  of  the  teeth,  had  to  be  fastened  to  gold 
crowns  attached  to  the  three  teeth  which  were  still  re- 
maining. Support  was  given  to  the  prosthesis  by  fitting 
new  crowns  over  the  crowns  already  present.  On  the  pros- 
thesis there  was  fastened  an  obdurator  according  to  Schilt- 
sky  and  Brugger. 

CASE  2.  Sch.  L.,  female,  aged  57,  was  admitted  Septem- 
ber 20th,  1899,  for  carcinoma  of  the  right  maxilla.  Family 
history  negative.  Two  years  ago  she  suffered  constant 
lancinating  pains  in  the  right  maxilla  from  the  root  of  a 
carious  tooth.  One  year  previous  she  noticed  a  tumor  In 
the  right  cheek  and  occlusion  of  the  right  nares.  The 
tumor  was  painful  to  touch,  and  was  treated  with  warm 
compresses,  but  continued  to  grow  until  it  interfered  with 
the  movement  of  the  lower  eyelid.  The  patient  was  thin 
and  pale;  musculature  thin  and  flabby:  panniculus  adiposis 
absent.  Temperature  37  C.  degrees,  pulse  84.  Thorax 
small  and  irregular:  apex  beat  in  the  5th  interspace  to  the 
left  of  the  mammillary  line,  but  strong  broad  and  irregular. 
I'pon  auscultation  a  distinct  systolic  murmur  of  a  "scratch- 
ing" character  was  heard  over  all  the  valves.  Chronic 
myocarditis.  The  right  cheek  protruded  more  than  the 
left.  Upon  palpating  the  tumor  the  latter  was  found  to 
begin  at  the  lower  edge  of  the  orbit  extending  to  the  lateral 
border  of  the  jugular  process  and  downward  to  the  nasal 
opening.  The  skin  over  the  tumor  was  still  intact,  but  thin 
and  hardly  movable  The  right  eye  was  not  opened  as 
widely  as  the  left.  Conjunctive  of  right  eye  reddened,  cor- 
nea cloudy  both  above  and  below,  tension  decreased,  and 
no  light  perception.  The  tumor  itself  was  as  hard  as  carti- 
lage and  nodulated.  The  hard  palate  protruded  and  In 
places  fluctuation  could  be  elicited.  The  finger  could  feel 
a  hard  projection  of  the  tumor  In  the  right  posterior  narea 
^2  cm.  above  the  posterior  edge  of  the  soft  palate. 

Operation  September  23rd.  Morphine  hypodermically 
and  ether  anesthesia.  Resection  of  the  right  maiilla. 
Temporary  ligation  of  external  and  Internal  carotid.  An 
Incision  was  made  along  the  anterior  border  of  the  right 
sterno-cleido-mastoid  muscle  as  far  as  the  upper  portion  of 
the  cricoid  cartilege.  The  bifurcation  of  the  carotid  under 
the  thick  jugular  vein  was  exposed.  First  a  rubber  ligature 
was  passed  around  the  external  carotid  and  temporarily 
tightened.  Another  was  passed  along  the  internal  carotid, 
but  not  tied.  A  Dieffenbach — Ferguson  Incision  was  then 
made  from  the  inner  angle  of  the  right  eye  over  the  lower 
edge  of  the  orbit  and  laterally  along  the  upper  edge  of  the 
jugular  process:  on  the  other  side  the  Incision  extended 
along  the  edge  of  the  nose  to  the  nasal  septum.  The  Up 
being  divided  in  the  median  line,  the  flap  was  drawn  aslda 
The  hemorrhage  was  not  noticeably  decreased.  The 
mucosa  of  the  hard  palate,  most  of  which  was  found  to  be 
Intact,  was  dissected  back  to  the  median  line  with  the  peri- 
osteum.    While  the   bones   were   being   sawed   a   severe 


Amn.  13.  1901] 


LIGATION  OF  THE  CAROTID 


["The   PniLADELPHiA 
L  Meiiical  Joursal 


73^ 


hemorrhage  occurred,  necessitating  the  tying  of  the  liga- 
tures around  the  internal  carotid.  This  had  the  desired 
effect.  The  tumor  was  then  easily  sawed  away  and 
removed.  The  tumor  was  found  to  be  necrotic  in  the  cen- 
tre and  had  severely  attacked  the  bones.  After  securing 
the  blood  vessels  the  ligatures  around  the  internal  and 
external  carotid  wer  removed,  but  very  little  hemorrhage 
followed.  The  flaps  of  mucosa  and  periosteum  of  the  hard 
palate  were  united  with  the  mucosa  on  the  side  of  the 
mouth,  thus  closing  the  cavity  above.  The  wound  cavity 
Itself  was  tamponed  with  iodoform  gauze,  which  was 
conducted  through  the  right  nares.  The  skin  and  muscle 
flap  was  restored  and  sewed,  and  the  wound  produced  by 
ligating  the  carotid  was  closed  with  interrupted  sutures. 
Microscopical  examination  of  the  tumor  showed  the  latter 
to  be  a  carcinoma,  with  hyalin  degeneration  of  the  reti- 
culum. Convalescence  was  interrupted  and  the  patient  was 
discharged  on  November  12th. 

CASE  3. — K.  E.,  female,  aged  59,  was  admitted  August 
22nd,   1900,   for   carcinoma  of  the  right  superior  maxilla. 
Family  history  was  negative.     On  January,   1900.  patient 
Buffered  from  an  attack  of  influenza;   since  then  the  right 
narea  have  been  occluded.     At  the  same  time  she  has  felt 
an  uncomfortable  feeling  in  the  right  eye  with  epiphora. 
On  June  15th  the  patient  experienced  severe  shooting  pains 
through  her  head  which  three  days  later  became  located  in 
the   region    of   the   right    eye.      Her    physician    prescribed 
morphine  with  quinine  and   a  salve,   but  without   results. 
One  morning  a  quantity  of  dark  coagulated  blood  gushed 
from  the  nose  and  mouth,  after  which  the  patient  felt  bet- 
ter, the  heavy  oppressive  feeling  of  the  head  being  con- 
siderably relieved.    The  symptoms,  however,  returned,  and 
the   patient   consulted    a   second    physician,   who   removed 
some  tumor  masses  in  the  right  nares,  and  then  employed 
cauterization  until  the  patient  could  again  breathe  through 
the  nares.     The  pain  decreased  under  this  treatment,  but 
a   fetid    discharge    from    the    right    nares    followed.      The 
present  tumor  began  in  May,  1900.  as  a  small,  painful  lump 
the  size  of  a  pea.     The  sight  of  the  right  eye  had  now 
become  poor.     The  third  physician  whom  the  patient  con- 
sulted  referred   her  to  the  hospital.     The  patient   was   a 
medium  sized  woman  with  somewhat  flabby  muscles  and  a 
fair  amount  of  panniculus  adiposis.     There  was  exophthal- 
mos on  the  right  side,  and  a  swelling  the  size  of  a  hazel 
nut  extending  from  the  inner  angle  of  the  right  eye  into  the 
nose  and  cheek.     The  skin  over  this  tumor  was  injected 
but  could  be  lifted  at  the  upper  portion  of  the  tumor,  while 
below,  it  had  become  adherent.     The  right  nares  were  full 
of  red  ulcerated  masses,  and  did  not  admit  a  sound:  there 
was  a  continual  discharge  of  fetid  yellow  pus.     The  nasal 
septum  showed  some  ulceration  and  was  somewhat  deviated 
to  the  left.    The  hard  and  soft  palates  on  the  right  are  red 
and   protruding.     The   right   protruding   eyeball   was   still 
freely  movable  and   not   sensitive  to  touch;    neither  was 
there  any  increased  tension.    Sclera  normal.    Lower  eyelid 
somewhat   edematous   and    slightly   reddened.     Right   ear 
appears  normal. 
No  swollen  lymph  glands  could  be  found. 
Morphine  hypodermically  and  ether  anesthesia. 
Operation  August  28,   1900.     Resection  of  the  right  su- 
perior maxilla.    Ligation  of  the  right  externa!  carotid,  and 
extirpation  of  the  right  jugular  lymphatic  gland.     A  5  cm. 
Incision  was  made  over  the  anterior  border  of  the  sterno- 
cleldo-mastoid  muscle.     The  muscle  was  pulled  aside,  the 
bulb  of  the  jugular  vein  was  pushed  outward,  and  a  hard 
bubo  excised  from  this  region.    A  Weber  incision  was  then 
made  along  the  lower  edge  of  the  orbit  down  the  side  of  the 
nose  to  the  nasal  septum  and  then  the  upper  lip  divided. 
The  tissues  from  this  flap  were  then  dissected  free  from  the 
bone   and   drawn    back.     The   jugular   process   was    sawn 
through  with  a  Gigli-Hertel  saw,  and  the  frontal  process 
of  the  maxilla  divided  by  bone  forceps.     As  the  mucosa  of 
the  hard  palate  was  also  diseased  it  was  separated  from 
the  soft  palate  and  the  entire  hard  palate  sawn  through 
In     the    median    line.       The      maxilla     wa.<!    then     easily 
removed..        There    was    exceedingly    little    hemorrhage. 
After    the     vessels     were    tied     pus  was     seen     to     flow 
from    the    frontal    and    ethmoidal    sinuses,    and    as    both 
cavities    showed    granulation    tissue,    they    were    scraned 
with  a  sharp  curet.     As  the  lower  surface  of  the  eyeball 
also  proved  to  be  Involved,  It  was  removed  with  the  dis- 
eased eyelid.    Some  suspicious  places  on  the  nasal  septum 
were  also  cut  away.     Three  strips  of  Iodoform  gauze  were 
placed  In  the  wound  cavities:  one  in  the  frontal  sinus,  the 
second   In  the  ethmoidal   sinus  and   a  third   as  a  general 


tampon.  After  extirpating  the  palpebral  conjunctiva  th& 
surface  under  the  upper  lid  was  freshened,  the  flaps 
replaced,  and  the  upper  eyelid  sewed  to  the  flap.  Aa 
attempt  to  sew  the  mucosa  of  the  cheek  to  that  of  the 
hard  palate,  on  the  left  side,  was  only  partially  successful, 
as  the  mucosa  tore  very  easily.  The  wound  in  the  neclj 
was  also  tamponed  with  iodoform  gauze  and  closed 
Pathological  examination  of  the  tumor  showed  it  to  be  a 
carcinoma.  Convalescence  was  uninterrupted  and  the- 
patient  was  discharged  as  cured  on  October  9th.  1900. 

These  three  cases,  however,  cannot  clear  up,  by 
the  establishment  of  a  precedent,  the  old   contro- 
versy,  concerning     the   feasibility  of     preliminary 
ligatmg  the   common   and   external    carotids.      On 
the  contrary,  these  cases  show    that  in    one    case 
hgating  the  external     carotid     v/ill    alone    suffice, 
and     that     in     certain     cases    it    is    necessary     to 
hgate  the  common  carotid.     The  latter  may 'have 
to  be  performed  on  account  of  various  abnormali- 
ties of  the  external  carotid.     The  external  carotid 
may  be   entirely  absent,  and  its  various  branches 
come  ofif  individually  from  the  comman  carotid,  the 
latter  then  continuing  as  such,  or  all  the  branches  of 
the  external  carotid  may  arise  in  a  fascicular  manner 
from  a  common  point  in  the  course  of  the  common 
carotid.     In  this  case    the    temporal    and    internal 
maxillary  arteries  may  arise  from  a  common  branch, 
which   m   turn   again   comes  off  fro'm   the   internal 
carotid  artery.     I  desire  to  call  attention  to  what 
appears  to  me  to  be  a  decisive  fact  in  favor  of  the 
previously   recommended   exposure   of  the   carotid. 
The  great  danger  of  recurrence,  in  resections  of  the 
upper  jaw,  is  emphasized  bv  manv  authors.     It  is 
reported  that  33  out  of  47  pat'ients  of  Konig  (3),  that 
had  withstood  the  operation,  died  from  recurrences. 
Of  6  operated  cases  of  the  clinic  in  Greifswald  that 
could  be  pursued,  5  died  from  recurrences.     23  out 
of  34  cases  of  total   resections  for  carcinoma  and 
sarcoma  reported  from  the  clinic  in  Zurich  died  from 
recurrences.  On  the  other  hand,  it  has  been  claimed 
how  remarkably  rare  it  was  in  this  disease  to  find 
enlarged  lymph  glands  in  the  submaxillary  region. 
The  explanation  of  this  is  obvious,  as  metastasis- 
occurs  through  the  lymph  channels  along  the  inter- 
nal maxillary  and  external  carotid  arteries  to  the 
bifurcation  of  the  common  carotid;  and  it  is  here 
that  the   first    lymphatic   involvement    is    noticed. 
Amog  the  few  cases  of  resection  performed  with 
a  ligation  of  the  carotid,   I   call   attention  only  to- 
those  of   Lesser    (5),   and   Schoenborn,   as   well    as 
my  third   case,  in  which  entirely  accidentally  and 
only  upon  exposing  the  carotid,  'the  first  Ivmphatic 
enlargements  were  observed.     If  in  this  jpatient  a 
prophylactic  ligation  of  the  carotid  had  not  been  in- 
stituted, the  metastastis  would  have  remained  un- 
discovered, and  the  resection  would  have  been  use- 
less from  the  very  beginning.    In  the  operation    on 
mammary  carcinoma,  modern  surgery  strictly  re- 
quires the  exposure  of  the  axillary  space,  even  "if  no- 
enlarged  lymphatic  glands  can   be  felt  externally, 
so  that  a  propagation  of  the  disease  can  be  prevented 
early.     The     execution     of     this     measure     is     re- 
sponsible   for     the     modern      favorable    prognosis- 
in  extirpation  of  mammary  carcinoma.     Have  we 
not  the  same  conditions  and  duties  to  perform  in 
carcinoma  of  the  upper  jaw?    Certainly,  the  major- 
ity of  recurrences  begin   in  the  area  of  operation, 
itself,  and  not  in  the  cervical  glands,  but  this  should 
not  be  a  cause  for  the  surgeon  to  overlook  and  un- 
derestimate the  metastasis.    Either  one  should  oper— 


732 


TllR     rUlT.Am-'lJ'HlA 

Mr.ni -AL  JoruNAi. 


] 


TREATMENT  OF  DIABETES 


LAPEIL  13,  1901 


ate  with  the  intention  and  hope  of  removing  every- 
thing that  is  diseased,  or  considering  the  futihtv 
of  a  radical  extirpation  performed  otherwise, 
had  better  not  operate  at  all  Local  recurrences  can 
only  be  successfully  combatted  by  early  diagnosi-^ 
and  extirpation  of  the  primary  focus,  in  which  case, 
if  metastasis  has  not  yet  taken  place,  my  indication 
for  exposing  the  bifurcation  may  not  be  applicable. 
If  I  am  to  briefly  summarize  the  observations  ob 
tained  from  my' resections  of  the  superior  maxilla 
and  from  a  study  of  the  literature  on  this  subject. 
they  will  comprise  the  following: 

1.  By  the  application  of  a  preliminary  ligature,  the 
hemorrhage,  as  well  as  the  danger  from  blood  aspi- 
ration, are  markedly  diminished. 

2.  This  ligation  "is  highly  recommendable  in  all 
anemic  individuals,  and  in  those  whose  vitality  ha'; 
been  lowered  from  cachexia  and  hemorrhages,  pro- 
vided they  do  not  suffer  from  diseases  of  the  bloot' 
vessels,  particularly  arteriosclerosis.  Exposing  thr 
bifurcation  of  the  carotid  in  advanced  cjises  is  in 
itself  indicated  for  the  purpose  of  extirpating  the 
lymphatic  glands,  which  in  this  region,  are  generally 
the  first  atacked  by  metastasis. 

3.  Tn  bv  far  the  most  cases,  ligation  of  the  external 
carotid  alone  will  suffice ;  the  latter  should  be  a  per 
manent  ligation.  Conducted  antiseptically,  the  pro- 
cedure is"  without  danger.  The  ligature  can  be 
applied  by  enlarging  above,  the  incision,  which  has 
been  made  for  exposing  the  bifurcation. 

4.  In  exceptional  cases  it  becomes  imperative  to 
ligate  the  common  carotid,  which,  if  done  tempora- 
rily, seems  to  be  less  dangerous  than  a  permaneni 
ligation. 

I  fear  that  without  further  comment  I  will  bi.' 
misunderstood,  that  is,  will  be  accused  of  taking  a 
too  optimistic  view  of  the  prophylactic  ligation  of 
the  carotid,  I  therefore  still  feel  that  I  will  have  to 
call  attention  to  the  fact  that  the  limitations  of  this 
operation  are  even  greater  in  actual  practice  than  at 
first  appears.  The  majority  of  resections  are  for 
carcinoma,  and  in  individuals  of  advanced  age.  in 
whom  marked  arteriosclerosis  may  contra  indicate 
a  preliminary  ligation  of  larger  vessels. 

In  conclusion,  one  other  question  concerning  pros 
thesis.  To-day,  whereby  the  astonishing  development 
of  prosthetic  technique,  defects  in  the  palate  can  be 
artificiallv  replaced  in  a  most  ideal  manner,  surgery 
still  seenis  to  strive  with  remarkable  endurance  to 
replace  by  plastic  operations  the  defects  in  the  pal- 
ate either  by  bone  or  by  muscle-flaps,  and  which, 
after  all,  can  seldom  be  satisfactorily  accomplished. 
Of  course,  the  natural  suljstitute  will  always  be 
accorded  the  superiority  over  the  artificial  one.  pro- 
vided it  can  be  accomplished  at  the  time  of  the 
operation.  But  the  inferiority  of  our  plastic 
operations  for  this  purpose,  makes  it  difficult  to 
meet  this  requirement.  Considering  the  lightness 
and  service  of  an  artificial  substitute,  it  appears  to 
methat  many  of  the  plastic  results  obtained  in  this 
direction  are  hardly  any  more  worth  the  troulile  ex- 
pended on  them.  Wliile  wc  are  in  a  position  of 
unequal  competition,  wc  will  only  welcome  it,  if  the 
dental  technicians  can  assist,  or  entirely  replace  us, 
in  such  particularly  difficult  problems. 

In  my  case  of  double  resection  of  the  upper  jaw, 
the   dciiianus  upon   tin:   dentist   were   considerable. 


The  superior  maxillary  prosthesis  had  to  replace  the 
whole  of  the  hard  palate  on  the  right  side  and  par- 
tially that  on  the  left.  In  order  to  support  the 
displaced  eyeball  and  the  retraction  of  the  soft  palate. 
the  dentist  had  to  place,  in  front,  a  Schiltsky  obtura- 
tor.* The  result  obtained  from  the  artificial  proth- 
esis,  which  has  been  worn  for  over  three  years  with- 

)Ut  difficulty  is  an  excellent  one.    The  nasal  cavity 

s  entirely  cut  off  from  the  mouth,  the  imperfect, 
unintelligible  speech  has  become  faultless  by  means 

(f  the  obturator,  and  the  annoying  diplopia  caused 
i)y  the  downward  displacement  of  the  eyeball,  has 
disappeared  under  the  employment  of  the  support- 
■ng  process,  on  the  prothesis. 

BIBLIOGRAPHY. 

1 1 )  MARTENS,  Zur  Kentniss  der  boesartigen  Oberkiefergeschwuelste 
riid  ihrer  operativen  Behandlung,  Dtsche.  Ztschft.  fuer  Chirurgie,  Bd.  46] 
\t.  18,3. 

(2)  BRYANT,  (New  York).  On  excissioa  of  the  superior  maxilla.  Astudy 
>f  two  hundred  and  fiftv  cases.  (Ann.  of  sur^erj-  Vol.  llthj  Ref  Ceo- 
tralblatt  fuer  Chirurgie  ft91,  p.  469. 

i3)  KOENIG.  Lehrbuch  der  speciallen  Chirurgie.  1  Bd.  7  shrift  1897 
).  395. 

(4)  WELJAMINOW.  21FaellevonCnterbindungenderArt.  carotiscom- 
■lumis.  Aus  der  Chirurg.  Klinik  des  Prof.  C.  Reyher.  Wratsch  1881  Noch 
li  Faelle  aus  derselben  Klinik  1882,  Ref.  Centralblatt  fuer  Chirurgie  1887 
\o.  48.  ■ 

(.5)  IvESSER.  Oberkiefereresection  Vorherige  I,igatur  der  Carotis  com- 
nuinis     Centralblatt  fuer  Chirurgie  18.83.     No.  10.  p.  1»5 

(f>)  SENGER,  EMIL.  Ueber  den  Versuch  einen  blutlosen  Oberkieferre- 
scclion  durch  temporaere  Constriction  der  isoUrten  Carotis.  Dtsche  med 
VVchshft.  189.5,  p.  lliO. 

(7)  RIESE.  rel>er  die  temporaere  Ligatur  der  grossen  Gefaessstaemme 
niit  besouderer  Bt^rueksichtigung  der  Constriction  der  Carotis  als  Voroper- 
ation  zur  Oberkieferresection.    Dtsche.  med.  Wchschrift.  1^  p  67 

(8)  KOCHER.    Chirurg.  Operationslehre.  1897,  p.  38. 

(9)  LOENIG  TUN.  Zur  Technik  ausgedchnter  Oberkieferresectionen 
-\rchiv.  fuer  Klin.  Chemrgie.  LXI.  Bd.  1900.  p.  775. 

(10)  G.ALLAUDET.  Sarcoma  of  the  upper  jaw.  New  York  surreal 
society.    Annals  of  surgen,-,  1899,  August. 

(11)  Pn^7.  Zur  L,igatur  der  Carotis  communis.  Archiv.  fuer  klin  Chi- 
rurgie. Bd.  9.  1S7S. 

(12)  ZIMMKRM.^N.  Ueber  die  Gehimerweichunff  nach  Unterbindungen 
der  Carotis  communis.    Beitraege  zur  klinischen  Chirurgie.  1981,  p.  364. 

(13)  ALBERT,  Lehrbuch  der  chinirg.    Operationslehre  Bd  1  p  436" 
(111  EBERTH  .^ND  SCHIMMEI.BISCH.    Die  Thrombose  nacii   Versu- 

chcn  und  Leichenbefunden.    Stuttgart,  1888. 

(1.5)  I.TPrs.  Ueber  die  t'nterbindung  der  Carotis  externa.  Archiv.  fuer 
klin.    Chimrgii'.  Bd.  46. 

(Hi)  M.\DEI.UNG.  Die  Unterbindung  der  Carotis  externa.  V  Lansen- 
hick's  Archiv.  1871. 

(17)  FRIEDI.AENDER.  Ueber  die  Ligatur  der  Carotis.  Inaug  — Dis- 
sert. Dorpat.  1S81. 

SCHUI.TZ.    Ueber  Oberkieferresictionen.    Diss.  Greifswald,  1900. 
SCHWALBE,    E.       Untersuchungen    zur    Blutgerinnung      Btaun- 
schweig,  1900. 

VIRCHOW— HIRSCH.    Jahresbericht  1S30,  p.  160. 

FISCHER  GEORG.     Krankheiten  des  Haises.     Dtsche.  Chimnrie 

18.-«. 


HANDBUCH  DER  PRACT    CHIRURGIE  1900.     iieferungS  und  10 

TIENI.I-;.    Gefaeslehredes  Mcnchen.    2,  .A.un. 

F.\URE.  T.  I,.    Sur  la   ligature  temporaire   des  arteres.     Congrrs 
trancais  de  chirurgie  1S9'.1.  p.  713. 


THOUGHTS  ON  THE  TREATMENT  OF  DIABETES  MEL- 
LITUS,  BEING  PART  OF  A  CLINICAL  LECTURE 
DELIVERED  AT  THE  PHILADELPHIA  HOSPITAL 
MARCH  13,  1901. 

By  JAMES  TYSON,  M.  D., 

Professor   of   Medicine,    University   of    Pennsylvania,  Physician  to   the 
Hospital. 

As  is  well  known,  diabetes  mellitus  is  a  condition 
in  which  the  carbo-hydrate  food  is  more  or  less 
unused  for  the  production  of  body  heat  or  energy, 
more,  where  all  or  nearly  all  of  the  carbohydrate 
reappears  in  the  urine  as  glucose,  less  where  part 
is  normally  oxidized.  In  the  earh*  stages  the  carbo- 
hydrates are  probably  alone  concerned.  In  more 
advanced  degrees  even  the  glucose  formed  out  of  I 
protcid  foods  is  only  partially  consumed,  while  in  ' 
the  extremest  cases  even  the  fixed  albumins  arc 
seized  upon  for  conversion  into  glucose,  which  is 
still  unoxidized  and  passed  away  with  the  urine- 
It  would  seem  that  there  is  no  inability  on  the  part 

•.\  description  and  illustration  of  this  prosthesis  can  be  found  in 
'Schwcizenschen  Viertcljalirsschrift  fuer  Zahnhcilkunde"  Vol.  10,  ISW 
No   1.  StopiKiuv,  lur  Prothesetherapie  nach  Ol)erkieferResectionenn. 


ArniL  13.  1001] 


TREATMENT  OF  DIABETES 


TTll 
L  Ml 


Philadelphia        <7,. 
edi  al  jocexal  733 


of  the  economy  to  produce  glucose  even  out  of  the 
proteid  food,  or,  if  necessary,  from  the  fixed  albu- 
mins as  well;  but  the  disability  lies  in  the  power 
to  use  up  the  sugar  in  the  blood,  and  in  this  consists 
diabetes  mellitus.  Is  it,  therefore,  surprising  that 
the  more  serious  forms  of  diabetes  are  attended  by 
emaciation  and  loss  of  strength? 

li  is  usual  to  look  upon  this  state  of  affairs  as  the 
result  either  of  excessive  glucose  formation  or  of  de- 
ficient oxidation,  the  former  being  commonly 
issigned  greater  prominence.  It  has  appeared  to 
lie  that  in  this  respect — the  prominence  assigned 
glucose  formation — there  has  been  a  certain  amount 
of  error.  \Miat  I  mean  can  perhaps  be  best  shown 
as  follows : — A  man  has  been  in  the  habit  of  in- 
gesting a  certain  amount  of  carbohvdrate  food 
daily.  His  urine  is  free  of  glucose,  and  he 
is  without  other  symptoms  of  diabetes  mellitus. 
A  little  later,  while  consuming  the  same  food  con- 
taining the  same  quantity  of  carbohydrate,  he  ac- 
quires glycosuria  and  other  symptoms  of  diabetes 
Thus  without  increasing  the  ingested  carboh3'drato 
the  glucosuria  appears.  The  natural  inference  would 
be  not  that  glucose  is  produced  in  greater  quan- 
tity, but  that  its  metabolism  is  in  some  way  dimin 
ished. 

This  brings  me  to  the,  thought  I  had  wished  to 
emphasize — should  not  our  search  for  curative 
treatment  be  directed  more  than  it  has  been  in  the 
past  to  measures  that  aid  this  oxidation  ?  Whai 
are  the  conditions  on  which  the  dietetic  treat- 
ment is  based?  Carbohydrate  food  is  with- 
drawn wholly  or  in  part,  the  latter  onlv 
when  a  part  can  still  be  oxidized  in  the 
ordinary  \va}-,  the  idea  being  that  the  increased 
amount  of  proteid  food  taken  under  these  circum- 
stances will  make  up  for  the  carbohydrate  with- 
drawn. Any  tendency  to  actual  cure  thus  brought 
about  must  be  because  a  greater  or  less  arrest  of  the 
glycogenic  and  glyco-destructive  offices  of  the 
economy  may  lead  to  restoration  of  function.  And 
this  may  happen  in  the  mildest  cases,  but  in  the 
mildest  cases  only,  because  it  is  these  only  in  which 
proteid  foods  and  the  fixed  albumins  are  untouched. 

It  appears  to  me,  therefore,  that  while  availing 
ourselves  of  the  dietetic  treatment  for  its  important 
palliati\e  effect,  we  should  also  seek  remedies  which 
will  increase  the  oxidation  of  the  glucose  thrown 
into  the  blood  from  the  liver ;  for  by  such  oxidation 
only  can  glucose  be  converted  into  energy.-  and  heat. 
Otherwise  it  must  pass  through  the  economy  unap- 
propriated and  useless. 

Now  as  to  the  remedies  which  stimulate  oxida- 
tion. Arsenic  has  long  been  regarded  as  a  remedv 
in  diabetes  mellitus,  and  with  reason,  but  the  diffi- 
culty in  the  way  of  explaining  its  good  effects  has 
always  deterred  many  from  using  it.  We  know  now 
that  it  increases  the  number  of  red  blood  discs  and 
the  (|uantity  of  haemaglobin  in  them,  and  thus 
facilitates  oxidation,  operating  in  the  way  the  above 
reasoning  suggests.  I  have  had  some  experience  in 
the  use  of  arsenic,  and  I  think  I  have  learned  the 
method  by  which  to  make  it  mc^t  effectual,  and 
that  is  by  the  administration  of  small  doses  long 
and  uninterruptedly  continued,  instead  of  largo 
doses  sufficient  to  produce  its  toxic  effect. 
It     is     true    of     arsenic    as    of   all    remedies,    that 


it  is  useful  chiefly  in  mild  cases.  The  dose  must 
not  exceed  three  drops  three  times  a  day  for  Fow- 
ler's solution,  and  one-thirtieth  grain  as  often  of 
arsenious  acid. 

Are  there  other  remedies  which  have  a  similar 
effect?  Iron  is  one  of  these,  and  although  I  am  un- 
able to  point  to  any  direct  result  in  the  use  of  iron, 
even  in  mild  cases  of  diabetes,  comparable  to  that  of 
arsenic,  I  have  never  until  recently  prescribed  it 
with  this  end  in  view,  and  I  shall  hereafter  use  it 
more  frequently  with  this  in  mind.  Certainly,  from 
it,  too,  effect  can  only  be  expected  after  long  con- 
tinued use.  A  drawback  to  the  administration  of 
iron  may,  in  certain  cases,  be  its  constipating  ef- 
fect, since  constipation  is  always  an  unfavorable 
symptom  in  diabetes,  the  cases  attended  with  it 
being  serious  cases.  This  also  may,  however,  be 
obviated  by  small  doses.  Peroxide  of  hydrogen  is  a 
remedy  which  might  be  expected  to  be  useful  for 
the  same  purpose,  but  it  is  probably  decomposed 
in  the  stomach  and  intestines,  and  does  not  reach 
the  blood  in  a  shape  capable  of  exerting  any  oxidiz- 
ing effect  in  the  blood. 

Massage  probably  operates  in  the  same  way,  and 
also  exercise.  It  is  commonly  conceded  that  glucose 
is  oxidized  in  the  muscles,  and  therefore  muscular 
activity  must  increase  such  oxidation,  and  mas- 
sage probably  does  the  same.  Over  twenty  vears 
ago.  Dr.  William  Richardson,  of  London,  published 
a  liofliuie  on  the  treatment  of  diabetes  in  the  preface 
to  which  he  said :  "Ten  years  ago  the  author  of  this 
little  book  was  attacked  with  diabetes  which  pre- 
sented symptoms  of  a  very  formidai^le  character." 
He  first  treated  himself  by  the  ordinary  dietetic  and 
medical  measures  without  any  effect,  and  goes  on  to 
saj- :  "He  has  not  only  cured  himself,  but  also  many 
others  who  have  faithfully  and  patiently  carried  out 
the  system  he  advocates."  I  do  not  think  Dr.  Rich- 
ardson's book  attracted  enough  attention,  and  many 
who  saw  it  have  forgotten  it.  His  method  includes 
bathing  of  the  body  daily  with  warm  water,  using 
plenty  of  soap  and  exposing  the  body  as  much  as 
possible  to  the  sun,  a  soda  bath  twice  a  week,  and 
flannel  clothing:  also  walking  exercise,  in  spite  of 
the  lassitude  and  weakness  which  make  this  mode 
of  treatment  particularly  irksome  He  further  says : 
"The  bath  and  walking  exercise  are  of  peculiar  im- 
portance in  the  treatment,  so  much  so,  that  if  either 
is  neglected,  but  little  good  will  result."  I  notice, 
too,  that  he  took  the  tincture  of  perchloride  of  iron 
and  chlorate  of  potash,  the  latter  also  an  oxidizing 
agent.  He  sa}s  that  after  three  months  he  was  free 
from  sugar,  and  has  been  so  ever  since.  As  is  not 
unreasonable  under  the  circumstances.  Dr.  Rich- 
ardson may  somewhat  exaggerate  the  value  of  this 
treatment,  because  it  was  so  successful  in  his  own 
case.  On  the  other  hand,  it  must  be  admitted  that 
it  rests  on  a  thoroughh^  rational  basis. 

It  is  reasonable  to  suppose,  too,  that  such  meta- 
bolism is  under  the  control  of  the  nervous  system, 
and  while  diabetes  is  not  a  disease  of  the  nerv'ous 
system,  we  have  an  abundance  of  conclusive  evi- 
dence to  show  a  very  close  association,  to  wit:  an 
influence  of  certain  nerv'ous  lesions  in  producing  the 
symptoms  of  diabetes  and  the  occasional  marked 
benefit  from  iodides  in  certain  forms  of  syphilitic 
diabetes  together  with  the  rarer  instances  in  which 


734 


The  Philadelphia"! 
Medical  Jovrxal  j 


FOOD  ADULTERATION 


CApril  13.  1901 


the  bromides  have  been  found  useful.  Nervous  dia- 
betes may  be  due  to  the  loss  of  nervous  regulation 
of  glucose  metabolism.  May  not  the  effect  of  co- 
deine and  other  derivatives  of  opium,  as  well  as  the 
less  settled  effect  of  the  petroleum  products,  an- 
tipyrin,  antifebrin,  etc.,  for  which  the  French  school 
still  claims  efficiency,  be  due  to  the  influence  upon 
the  metabolism  of  glucose  in  the  distal  capillaries  of 
the  economy? 

At  first  thought  it  may  appear  that  pancreatic 
diabetes,  a  well-recognized  form,  lends  no  support 
to  such  a  view,  or  to  put  it  differently,  forces  to  the 
conclusion  that  this  form  of  diabetes,  at  least,  is 
due  to  increased  glucose  production.  But  this  is 
not  a  necessary  conclusion.  While  it  has  been  set- 
tled that  pancreas  products  and  pancreatic  juice  are 
of  no  service  in  the  treatment  of  diabetes,  and  pre- 
sumably, therefore,  that  the  absence  of  this  secretion 
has  nothing  to  do  with  the  presence  of  this  disease, 
analogy  justifies,  at  least,  a  possibility  that  there 
may  be  some  other  internal  secretion  separated 
by  the  pancreas  during  life  and  passed  into  the 
blood,  the  presence  of  which  is  necessary  to  the 
proper  metabolism  of  glucose. 

These  are  crude  thoughts  thrown  out  at  this  time, 
with  the  hope  that  they  may  suggest  others  which 
will  lead  us  ultimately  to  more  definite  and  satisfac- 
tory results  in  the  treatment  of  this  incurable  and 
onl'v  partially  controllable  disease.  While  the  dia- 
tetic  treatment  of  diabetes  will  remain  for  some  time 
longer  our  chief  resource,  I  feel  confident  that  we 
must  look  elsewhere  for  the  complete  curative  treat- 
ment. 


THE  MEDICAL    RELATIONS  OF  THE  PREVAILING 
FORMS  OF  FOOD  ADULTERATION. 

By    HENRY    LEPFMANN,    M.    D. 
of  Philadelphia. 

The  practice  of  adulteration  is  as  old  as  the  prac- 
tice of  barter  and  trade,  that  is  as  old  as  human  ac- 
tivity, but  the  scientific  study  of  it  is,  as  with  other 
phases  of  scientific  investigations,  largelj'  a  develop- 
ment of  most  recent  times.  Within  the  last  quarter 
century  or  so,  methods  of  adulteration  have  been 
developed  by  scientific  investigation.  The  large 
manufacturing  corporations  have  been  able  to 
secure  assistance  from  chemistry,  and  hence  we  have 
industrial  enterprises,  such  as  the  manufacture  of 
oleomargarin  and  glucose  that  have  no  other  func- 
tion than  that  of  adulteration,  for  neither  of  these  is 
proper  substitute  for  an}'  of  the  food  articles  in 
which  or  for  which  they  are  used. 

The  volume  or  extent  of  food  adulterations  has 
been  a  favorite  topic  with  the  newspapers.  They 
have,  of  course,  treated  it  more  or  less  sensationally, 
generally  more,  and  have  usually  mistaken  the  sci- 
entific questions  involved,  and  confused  the  scien- 
tific nomenclature  so  that  essays  have  almost  al- 
ways a  serio-comic  character  that  renders  them  of 
no  practical  value.  As  a  rule  the  responsibility  for 
such  contributions  rests  on  some  anonymous  repor- 
ter or  sub-editor  or  some  professional  man  who 
seeks  to  secure  advertising  through  the  means  of  a 
sensational  interview.  It  is  rare  that  a  chemist 
or  physician  of  reputable  standing  will  allow  him- 


self to  be  the  means  of  promulgating  error  or  mis- 
representation. 

It  is.  therefore,  an  unpleasant  surprise  to  note  the 
appearance  recently  in  a  newspaper  of  wide  circu- 
lation and  good  standing,  of  a  sensational  article 
purporting  to  be  based  upon  information  derived 
from  a  prominent  expert  on  food-analysis.  The  ar- 
ticle is  a  sort  of  edited  interview,  that  is,  the  expert 
has  furnished  a  lot  of  detailed  information  and  the 
newspaper  reporter  has  paragraphed  it  and  sprin- 
kled it  with  quotation  marks  and  other  signs  so  as 
to  make  the  text  more  readable  to  the  average  per- 
son. There  are  so  many  points  about  this  article 
that  deserve  unfavorable  criticism  that  I  am  un- 
willing to  let  the  worst  of  them  pass  unchallenged, 
and  hence  present  some  discussion  of  the  general 
question  as  well  as  of  special  points. 

We  are  told  first  that  scores  of  millions  of  dollars' 
worth  of  adulterated  food-products  are  now  sold 
annually,  and  that  the  question  has  been  so  serious 
that  Congress  has  become  alarmed  and  has  taken 
the  matter  in  hand.  The  great  extent  of  adultera- 
tions ma}-  be  admitted,  but  it  is  doubtful  if  any 
considerable  number  of  members  of  Congress  have 
concerned  themselves  about  the  danger  to  the  pub- 
lic. One  form  of  serious  fraud,  namely,  the  sale  of 
butter  substitutes,  has  been  going  on  with  the 
knowledge  of  every  member  of  Congress  for  years 
and  but  little  relief  has  been  even  promised.  The 
adulteration  of  wheat-flour  by  corn  would  probably 
not  have  been  dealt  with  by  Congress  if  the  revenue 
necessities  of  the  Cuban  War  had  not  rendered  the 
selection  of  the  new  objects  of  taxation  necessary. 

We  are  next  told  that  a  distinction  must  be 
drawn  between  harmless  and  harmful  adulterants, 
which  statement  may  be  passed  without  dispute,  al- 
though it  is  not  at  first  clear  what  inference  is  to  be 
given  to  the  distinction,  but  this  is  indicated  by  the 
next  sentence,  in  which  it  is  said  that  "Glucose  is 
not  at  all  unwholesome."  because  it  is  prepared 
from  Indian  corn.  Who  knows  that  glucose  is  not 
unwholesome?  Thisis  a  claim  that  has  been  pass- 
ing for  years  from  book  to  book  and  pamphlet  to 
pamphlet,  and  when  we  attempt  to  discover  the 
foundation  for  it  we  get  little  satisfaction.  It  is  true, 
that  a  good  many  years  ago,  some  experts  connected 
with  the  National  Academy  of  Sciences  were  on  a 
commission,  and  after  giving  some  little  attention 
to  the  subject,  passed  a  "resolution"  that  glucose 
is  not  unwholesome,  but  it  is  now  well  known  that 
these  gentlemen  were  not  aware  of  the  composition 
of  commercial  glucose,  ow4ng  to  the  defective  meth- 
od of  analysis,  and  that  their  inferences  were  hasty. 
The  general  view  is  that  commercial  glucose  is 
merely  a  pre-digested  starch,  but  in  fact  it  is  quite 
different  in  its  nature.  It  contains  bodies  that  are 
not  found  among  the  products  of  starch  digestion. 
Ordinary  glucose,  by  which  is  meant  the  syrupy 
forms  (the  kind  that  is  almost  always  used  for  adul- 
teration), contains  about  15  per  cent,  of  unfermenta 
ble  material,  which  is  as  yet  but  little  understood 
even  chemically,  much  less  physiologically.  In  the 
face  of  these  facts,  how  can  any  one  assert  that  glu- 
cose is  a  proper  substitute  for  starch  or  sugar?  _ 

England  has  had  lately  an  interesting  object-les-  | 
son  in  this  field.     As  is     now  well     known,  many 
cases  of  arsenical  poisoning  from  the  use  of  beer 
made  from  arsenical  glucose  and  invert-sui:ar  oc- 


ArniL  i:!.  IJiOl] 


RUPTURED  ANEURISM 


[The  Philadelphia 
Medical  Jourxal 


735 


curred  in  a  particular  district.  These  cases  may  be 
traced  to  the  indifference  of  the  authorities  in  this 
very  question  of  food-substitute.  It  is  known  to  all 
who  understand  these  subjects  that  the  substitu- 
tion of  g-lucose  and  invert-sugar  for  malt  is  merely 
dictated  by  questions  of  profit.  The  indifference 
of  government  in  this  respect  (exhibited  as  much 
in  the  United  States  as  in  England)  is  due  to  the 
influence  of  the  rich  and  powerful  corporations,  i.  e.. 
tlie  political  and  financial  "pull."  Hence  the  use  of 
substitutes  goes  on  without  notice  to  the  public  or 
without  interruption.  The  introduction  of  a  poison- 
ous malt  into  been  and  ale  would  have  been  impossi- 
ble except  under  such  a  concatenation  of  circum- 
stances as  could  scarcely  occur  unnoticed.  We  must 
therefore  believe  that  if  the  English  Government 
had  insisted  that  nothing  but  malt  and  hops  should 
enter  into  the  composition  of  beer  and  ale  and  had 
required  brewers  under  heav}-  penalties  to  make 
returns  of  material  used  by  them,  the  cases  of  dis- 
ease and  death  over  which  the  people  in  certain 
parts  of  England  are  now  mourning  would  not 
have  occurred.  This  consideration  is.  of  course,  in- 
dependent of  the  question  of  the  effects  of  drinking 
malt  liquors.  That  portion  of  the  public  who  desire 
to  drink  such  liquors  is  entitled  to  them  made  in  the 
proper  form,  and  there  is  no  more  justification  for 
government  conniving  at  a  substitution  or  adul- 
teration in  the  field  than  there  was  for  ancient  mon- 
archs  debasing  coinage. 

Another  phase  of  adulteration  that  has  found 
many  apologists  in  high  places  is  the  manufacture 
of  butter  substitutes.  It  has  been  loudly  proclaimed 
that  the  process  for  making  oleomargarin  was  one 
of  the  greatest  advances  in  food-chemistry  in  the 
nineteenth  century,  and  that  the  manufacture  in- 
ures especially  to  the  benefit  of  the  poor  man.  The 
truth  is  that  oleomargarin  is  about  as  much  benefit 
to  the  poor  man  as  wild  cat  bank  notes  and  coun- 
terfeit money.  In  the  first  place,  it  is  not  butter; 
it  does  not  have  the  same  chemical  composition  as 
butter,  and  no  one  has  knowledge  enough  of  the 
matter  to  say  that  it  can  fully  take  the  place  of  but- 
ter. Secondly,  the  poor  man  never  gets  the  benefit 
of  its  economic  features.  Careful  inquiry  will  show 
that  it  reaches  the  consumer  at  practically  butter 
prices.  It  is  true  that  many  persons  buy  oleomar- 
garin knowingly,  but  they  are  restaurant  and 
boarding-house  keepers,  and  no  reduction  in  price 
of  meals  is  made  on  account  of  the  cheapness  of  the 
article  furnished.  In  the  ordinary  sales  of  oleomar- 
garin at  grocery  stores  the  buyer  asks  and  expects 
butter,  but  gets  the  substitute  at  a  price  nearly  if 
not  quite  that  which  he  would  pay  for  the  genuine 
substance. 

Another  phase  of  the  food  adulteration  question 
is  that  relating  to  baking  powders.  It  is  true  that 
an  English  judge  has  decided  that  this  is  not  a  food, 
but  this  technical  legal  opinion  may  be  here  disre- 
garded. Within  the  last  ten  years  an  active  war 
has  been  going  on  between  the  manufacturers  of 
cream  of  tartar  powders  on  the  one  hand  and  the 
manufacturers  of  the  alum-powders  on  the  other, 
and  many  experts  have  given  their  opinions.  It  is 
impossible  to  say  at  present  which  side  has  the 
worst  of  the  argument.  No  satisfactory  evidence 
has  been     brought  forward     to  show  why     alum 


should  be  more  injurious  than  cream  of  tartar.  The 
probability  is  that  both  forms  are  objectionable. 
The  leavening  of  dough  should  be  accomplished  if 
needed  by  the  injection  of  pure  carbon  dioxid  into 
the  mass  without  the  employment  of  yeast  or  any 
chemical. 

One  result  of  the  agitation  concerning  food  adul- 
terations has  been  the  adoption  of  stringent  laws 
regarding  articles  that  are  of  secondary  importance 
and  the  adulteration  of  which  is  not  serious.  For 
example,  cider-vinegar  has  been  made  the  subject 
of  stringent  enactments  in  many  states.  The  adul- 
teration consists  principally  in  the  use  of  dilute 
acetic  acid  colored  with  caramel,  this  substitute  ar- 
ticle being  closely  similar  to  cider-vinegar  and  ca- 
pable of  fulfilling  many  of  the  purposes  of  the  latter. 
The  legislation,  although  masquerading  under  the 
guise  of  interest  in  the  public  health,  has  been  really 
impelled  by  a  desire  to  protect  the  farmer,  that  is 
to  enable  him  to  secure  a  better  price  for  his  pro- 
duct. 

The  legislation  in  regard  to  butter-colors  has  ita 
surprising  features.  Practically  all  commercial 
butter  is  colored.  Preparations  of  annotto  and  tur- 
meric were  at  one  time  much  used,  but  now  coal- 
tar  colors  are  much  more  largely  employed.  At- 
tempts have  been  made  to  show' that  these  colors 
are  injurious,  but  the  doses  given  were  so  'arge  as 
to  be  of  no  value  as  guides  to  the  effect  in  small 
quantities.  To  administer  to  a  person  in  one  dose 
a  quantity  of  color  that  would  be  sufficient  to  color 
all  the  butter  eaten  by  the  person  in  six  months  is 
about  as  scientific  as  to  attempt  to  determine  the 
eft'ect  of  the  use  of  coffee,  vinegar  or  pepper  by  ad- 
ministering at  one  dose  all  the  active  principle  of 
either  of  the  agents  that  would  be  taken  in  a  long 
time.  The  theory  that  if  a  gram  of  a  substance  in 
one  dose  makes  a  person  very  sick,  one  milligram 
will  make  him  one-thousandth  that  sick,  is  at  vari- 
ance with  all  our  experience  in  therapeutics.  That 
this  is  about  what  was  done  by  some  of  the  investi- 
gators in  the  field. 

It  is  worth  noting  that  the  farmer-influence  in 
many  States  has  secured  laws  forbidding  the  color- 
ing of  oleomargarin,  while  no  restriction  has  been 
placed  on  coloring  butter. 


RUPTURED  TRAUMATIC  ANEURISM  OF  THE  FEM- 
ORAL ARTERY  DUE  TO  GUNSHOT  WOUND;  WITH 
REPORT  OF  A  CASE  • 

By  WALLACE  NEFF,  A.  M.,  M.  D. 

of  Washington,  D.  C. 

Formerly  Adjunct  Professor  of  Clinical  Iniury  and  Surgical   Pathology 
Medical  College  of  Ohio  (University  of  Cincinnattl);  late  Major  and 
Brigade  Surgeon  U.  S.  V;  Member  of  the  Southern  Surgical 
and    Gynecological     Association'     Member   of   the 
Medical  Society  of  D.  C;  Medical  and  Surgi- 
cal Society  of  D.  C,  etc. 

A  traumatic  aneurism  is  the  result  of  a  blow, 
gunshot,  or  any  form  of  injury  to  the  walls  of  an 
artery  sufficient  to  produce  dilatation,  or  a  complete 
rupture  of  its  coats.  The  injury  may  be  so  slight 
as  to  rupture  only  the  inner  coats,  producing  a 
fusiform,  or  sacculated  aneurism.  There  may  be 
a  partial  or  complete  division  of  the  continuity  of  the 

•Read  before  the  Medical  Sodetr  of  the  District  of  Columbia    March 
20th.  1801. 


pjlf.       The   PHiLAnEi.pniA"! 

/O  JlEDIIAL    JoIIlNMI,     J 


RUPTURED  ANEURISM 


[Ai'EiL  13,  1901 


vessel  causing'  a  false  aneurism.  There  may  also  be 
a  rupture  producing  the  burst  variety. 

It  is  always  a  serious  condition,  the  gravity  de- 
pending upon  the  size  of  the  artery,  the  locality, 
and  the  general  condition  of  the  patient.  The  most 
typical  false  aneurisms  are  found  in  the  extremi- 
ties, especially  in  the  femoral,  as  wounds  of  the 
artery  are  frequent. 

The  Diagnosis — The  diagnosis  is  not  diffi- 
cult owing  to  the  exposed  position  of  the  vessel. 
The  chief  symptoms  are  a  tumor,  a  bruit,  and  pain 
neuralgic  in  character,  associated  with  the  history 
of  an  injury.  The  diagnosis  is  sometimes  obscured 
by  an  abscess,  the  wound  having  been  inflicted  by 
exposure  to  air.  A  femoral  aneurism  has  been 
mistaken  and  opened  for  a  psoas  abscess.  This 
seems  inexcusable,  as  when  any  doubt  exists,  a 
positive  diagnosis  can  be  made  by  using  an  aspi- 
rating needle. 

Treff<»ien«._]\iany  of  the  forms  of  treat- 
ment which  are  applicable  to  other  aneurisms,  and 
for  which  good  results  are  claimed,  are  contra  indi- 
cated in  traumatic  aneurism  of  the  femoral.  Diet 
drugs,  acupuncture,  galvano-puncture,  needling 
(McEwan's  method),  compression,  digital  pres- 
sure, introduction  of  foreign  bodies  into  the 
aneurismal  sac,  as  fine  steel  or  silver  wire,  catgut 
or  silk.  Sub-cutaneous  injections  of  a  solution  of 
gelatine  and  salt  solution,  are  methods  best  em- 
ployed in  inoperable  aneurisms.  Compression, 
either  mechanical  or  digital,  is  difficult  to  carry  out, 
is  seldom  successful,  and  often  dangerous.  The 
best  treatment  is  ligation.  It  is  applicable  in  a 
greater  number  of  cases  than  any  other  method,  and 
offers  a  better  prospect  of  success.  The  dangers 
to  be  guarded  against  are  hemorrhage,  gangrene 
and  sepsis.  Several  difTerent  methods  have  been 
employed:  ist.  Distal  ligature;  2d,  Proximal  liga- 
ture; 3rd,  Double  ligature.  The  operations  of 
Wardrop  and  Brasdor,  illlustrate  the  distal 
method;  those  of  Hunter  and  Anel,  the  pro.ximal, 
and  that  of  Autyllus,  the  double.  The  latter  was 
introduced  during  the  4th  centr.ry,  and  consisted  in 
ligating  above  and  below  the  injured  portion.  The 
aneurism  is  then  opened  and  the  sac  emptied.  This 
operation  was  practised  for  several  hundred  years 
until  the  i8th  century,  when  it  sank  into  obscurity, 
but  has  recently  been  revived,  and  many  of  the  most 
distinguished  surgeons  of  the  present  day  are  its 
earnest  advocates.  Excision  of  the  sac  is  recom- 
mended, the  arguments  in  favor  of  it  being,  that 
harmful  pressure  of  the  sac  upon  the  adjacent 
structures  is  removed,  the  change  of  recurrence  of 
the  aneurism  is  lessened,  and  the  probability  of 
gangrene  is  diminished.  Proximal  ligation,  how- 
ever, is  considered  by  a  great  manj^  of  the  very 
highest  authorities  to  be  the  best  operation  for 
aneurism  of  the  femoral. 

The  ^tati.iticn — The  "Medical  and  Surgical 
History  of  the  War  of  the  Rebellion"  (Surgical 
Vol.  II,  Part  III,  by  Otis  and  Huntington,  Surgeons 
U.  S.  A.,  p.  8),  states  that  there  were  58,702  cases 
of  shot  wounds  of  the  soft  parts  of  the  lower  limbs. 
As  nearly  as  can  be  approximated,  26,000  were  in 
the  thigh,  about  21,000  in  the  leg,  and  about  10,000 
in  the  foot.  Of  this  number,  only  156  instances  of 
injury  of  the  large  blood  vessels  of  the  lower  ex- 


tremity, or  2.6  per  cent,  per  thousand,  were  re- 
ported. In  a  summary  of  127  cases  of  ligation  of  the 
femoral,  for  hemorrhage  unattended  by  fractures, 
there  were  91  deaths,  a  mortality  rate  of  71.7  per 
cent.  (p.  47).  There  were  74  cases  of  traumatic 
aneurism  of  different  arteries,  with  23  recoveries, 
and  51  deaths,  a  m.ortality  of  68.9  per  cent.  42  of 
the  74  cases  were  treated  by  ligation,  of  which 
number  13  recovered  and  29  died.  In  32  cases 
there  was  no  ligation,  with  10  recoveries  and  22 
deaths.  Of  the  74  cases  only  20  were  of  the  femoral, 
with  5  recoveries  and  15  deaths.  In  16  of  the  20 
ligation  was  employed,  with  5  recoveries  and  11 
deaths.  In  4  cases  there  was  no  ligation,  and  all 
died  (p.  808).  It  will  thus  be  seen  that  there  were 
only  5  cases  of  traumatic  aneurism  of  the  femoral 
during  the  Civil  War,  in  which  the  patient's  life 
was  saved.  In  the  "Medico-Surgical  Aspects  of  the 
Spanish-American  War"  (p.  130),  Senn  reports  two 
cases  of  traumatic  aneurism  on  the  "Relief",  one  an 
aneurismal  varix  (case  23),  the  other  aneurism  of 
the  femoral  (case  24).  Neither  was  operated  on, 
apparently.  One  is  now  on  the  retired  list  (case 
23).  The  subsequent  history  of  the  other  is  un- 
known. In  the  "Report  of  the  Surgeon  General  for 
igoo"  (p.  298),  two  cases  are  recorded  during  the 
year  1899  of  ligation  of  the  femoral  for  flesh  wounds, 
the  patient  recovering  in  one  case,  a  Mauser 
wound,  and  dying  in  the  other,  a  Remington  wound. 
In  the  same  report  (p.  327)  a  case  is  reported  of 
traumatic  aneurism  of  the  femoral  due  to  a  Mauser 
wound,  received  at  Tarlac,  P.  I.,  Dec.  21st.  1899. 
The  external  iliac  w'as  ligated  (Jan.  3rd,  1900),  and 
four  days  later  the  leg  was  amputated  at  the  hip- 
joint.  Patient  recovered.  The  reports  of  the 
Anglo-Boer  war  are  incomplete  as  yet.  So  far  I 
have  only  been  able  to  find  a  record  of  one  case 
reported  by  Deputy  Inspector  General  H.  T.  Cox, 
R.  N.,  in  the  Lancet,  London,  1900  (11  p.  1074),  an 
ancuri'^mal  varix  of  the  femoral  artery  and  vein, 
caused  by  a  Mauser  bullet.  This  man  was  wounded 
at  Graspan,  S.  A.,  Nov.  25th,  1899.  The  femoral 
artery  was  tied  at  the  Royal  Naval  Hospital,  Ply- 
mouth, Eng.,  April  loth.  1900.  Discharged  to  duty 
June  ist,  1900.  with  full  u«e  of  limb. 

REPORT  OF  CASE. 

The  following  case  occurred  in  my  sers-ice  at  the 
U.  S.  General  Hospital  at  Et.  McPherson,  Ga..  dur- 
ing the  Spanish-American  war:  William  H.  Buck- 
ley, private,  liattery  A,  6th  Artillery.  Sent  from 
Ft.  Clinch,  Florida.  I  first  saw  him  Aug.  30th, 
1898.  and  found  a  pulsating  tumor  on  the  left  fem- 
oral in  Hunter's  Canal,  about  the  size  of  a  duck"s 
egg,  with  a  well-defined  bruit.  He  gave  a  history 
of  having  been  shot  through  both  thighs  with  a 
38-cal.  bullet,  on  the  i8th  of  July.  The  bones  were 
uninjured.  He  had  aestivo-autumnal  malaria,, 
which,  in  addition  to  the  fatigue  of  the  journey, 
suggested  the  propriety  of  a  few  days'  rest  and 
treatment  before  operating.  When  I  saw  him  the 
following  morning  (Aug.  31st,  189S).  the  aneurism 
had  burst,  there  was  great  edema  and  extensive 
extravasation,  and  the  pulsation  in  the  two  tibials 
was  hardly  perceptible,  a  condition  rendering  an 
immediate  operation  imperative.  I  was  assisted  by 
Major  Fry,  U.  S.  V,.  and  Capt.  Flagg.  U.  S.  A.  The 
Anesthetist  was  Acting  Assl.  Surgeon  Rupert  Xor- 


ArniL  i:i,  r.'iiii 


TUMORS  OF  THE  SCIATIC 


rTHK     rHILADELPHIA 
L    MKDKAL   JoLn.NAL 


737 


I 


ton.  There  were  present  Major  Blair  D.  Taylor, 
C'apt.  Parviana  and  Lieut.  Schriner,  U.  S.  A.,  and  a 
number  of  Acting  Assistant  Surgeons.  An  Es 
march  tourniquet  was  applied,  a  four  or  five-inch 
incision  was  made,  and  a  proximal  ligation  made. 
Several  handfuls  of  blood  clots  were  removed. 
Before  operating,  I  thought  I  would  tie  above  and 
below,  and  dissect  out  the  sac.  The  rupture  was  so 
complete  that  the  walls  of  the  aneurism  came  away 
with  the  clotted  blood.  I  decided  not  to  prolong 
the  operation  by  applying  a  distal  ligation,  but  to 
depend  upon  the  proximal  ligation.  The  wound 
was  thoroughly  cleansed  and  closed,  the  limb  was 
enveloped  in  cotton,  and  slightly  elevated,  hot 
water  bottles  applied,  and  continuous  heat  kept  up, 
a  special  day  and  night  nurse  being  detailed  for  that 
purpose.  Primary  union  occurred.  Collateral  cir- 
culation was  eventually  established,  and  he  made 
a  good  recovery.  His  general  health  improved  rap- 
idly, he  gained  in  weight,  and  his  malaria  disap- 
peared under  appropriate  treatment.  He  went 
home  on  a  furlough  six  or  seven  weeks  later.  \\' hen 
I  last  saw  him  the  circulation  was  e.xcellent,  there 
was  no  atrophy  of  the  muscles,  no  impairment  of 
function  and  nothing  but  the  tell-tale  cicatrix  to 
suggest  what  had  occurred.  In  a  letter  received 
from  him  a  few  days  ago,  dated  Troy,  N.  Y.,  March 
1st,  1901,  he  says:  "iVIy  leg  is  in  fine  shape,  and 
never  gave  me  any  trouble  to  amount  to  an3-thing. 
It  feels  strong  and  does  not  bother  me.  I  have 
never  rubbed,  or  done  anything  for  it  since  I  came 
home.  I  am  a  brick-layer,  and  work  about  every 
day,  and  am  out  in  all  kinds  of  weather,  so  I  think 
the  leg  is  all  right,  with  all  thanks  to  you."  After 
a  careful  search  of  the  reports  and  records,  I  was 
surprised  to  find  that  this  was  the  only  case  of 
successful  ligation  of  the  femoral  for  traumatic 
aneurism  due  to  gunshot  during  the  Spanish- 
American  war,  or,  so  far  as  I  have  been  able  to 
ascertain,  in  the  Philippines,  or  China,  up  to  the 
present  writing,  and  it  is  also  one  of  the  very  few 
on  record  in  any  war.  In  looking  up  the  literature 
on  the  subject,  it  appears  that  while  traumatic 
aneurism  of  the  femoral  due  to  gunshot  is  not 
uncommon,  ligations  are  usually  followed  by 
gangrene,  and  subsequent  amputations,  and  that 
it  rarely  happens  that  the  limb  is  saved,  particu- 
larly when  the  aneurism  is  of  the  ruptured  variety. 
The  conclusion  seems  justifiable,  therefore,  that 
while  the  very  heavy  mortality  during  the  Civil 
War  was  due  in  a  measure  to  a  lack  of  modern 
aseptic  and  antiseptic  methods,  the  chief  diffi- 
culty was  the  non-establishment  of  collateral 
circulation,  and  even  now  with  a  technique  well 
nigh  perfect,  the  same  danger  exists. 
1730  Connecticut   Ave. 


MULTIPLE  TUMORS  OF  THE  SCIATIC  NERVE. 

JOHN  B.  ROBERTS,  M.  D. 

As  tumors  of  the  sciatic  nerve  are  comparatively  rare 
the  following  case  is  placed  on  record. 

A  man,  aged  39  years,  came  under  my  care  on  January 
22nd,  ]901,  with  the  statement  that  14  years  ago  he  had 
first  noticed  three  small  tumors  about  the  size  of  peas  on 
the  outside  of  the  left  leg  near  the  knee.  After  an  at- 
tempt had  been  made  to  remove  these  with  a  caustic  plas- 

Read  before  the  Pathological  Society  of  Philadelphia.  Febnian'  2.S.  1901. 


ter,  an  incision  was  made,  about  six  years  ago,  and  three 
small  tumors  which  were  called  fatty  tumors,  were  ex- 
cised. The  man  said  that  for  the  last  14  years  he  had  suf- 
fered with  pain  in  the  left  popliteal  region. 

About  five  years  ago  he  observed  that  there  was  a  lump 
to  be  felt  deep  in  the  left  popliteal  space.  This  tumor  has 
been  increasing  in  size  and  is  painful  on  pressure.  It  is 
for  this  condition  that  he  applies  for  treatment.  The  pain 
runs  up  and  down  the  leg  from  the  seat  of  the  tumor, 
which  is  a  spindle  shape  mass,  apparently  about  an  inch 
and  a  half  in  length.  The  tumor  lies  directly  in  the  mid- 
dle line  and  is  plainly  felt  when  the  knee  is  flexed,  so  as  to 
relax  the  tissues  of  the  ham.  The  pain  is  continuous  and 
worse  at  intervals.  It  sometimes  keeps  him  from  walking 
and  he  has  been  unable  to  work  for  about  six  vears.  He  says 
that  there  is  weakness  in  the  left  leg  and  numbness  of  the 
foot.  He  complains  of  sweating  of  the  left  foot.  It  is  al- 
ways warmer  than  the  other,  and  its  stocking  is  frequently 
saturated  with  perspiration. 

I  requested  the  Resident  Physician  of  the  Methodist 
Hospital,  Dr.  Charles  P.  Stahr.  who  had  immediate  care 
of  the  patient  for  me,  to  refer  the  case  for  examination  to 
Dr.  James  Hendrie  Lloyd,  but  unfortunately.  Dr.  Llovd  was 
not  able  to  see  the  patient  before  the  day  fixed  for' opera- 
tion. There. was  no  question  in  regard  to  the  diagnosis, 
which  was  tumor  of  the  internal  popliteal  nerve.  I  regret, 
however,  that  a  careful  study  of  the  nervous  phenomena 
was  not  made. 

On  January  2Sth  I  made  an  incision  over  the  tumor  and 
found  it  to  be  situated  within  the  internal  popliteal  nerve, 
the  fibers  of  which  were  spread  over  it.  The  cut  revealed 
many  tumors  involving  the  sciatic  nerve  and  its  internal 
and  external  popliteal  branches.  The  incision  had  to  be 
continued  upwards  to  the  lower  border  of  the  gluteal  mass 
of  muscles.  The  whole  length  of  the  sciatic  nerve  from 
the  sacro-sciatic  foramen  was  studded  with  tumors,  vary- 
ing in  size  from  an  eighth  of  an  inch  in  diameter  to  about 
an  inch  and  a  half  in  diameter.  The  external  popliteal 
and  internal  popliteal  nerves  were  also  involved.  I  re- 
moved in  all  about  thirty-six  of  these  growths.  They 
were  evidently  developed  from  the  connective  tissue  in  the 
nerve  trunk,  and  the  nerve  fibers  were  separated  by  them 
and  spread  over  their  surfaces.  The  tumors  appeared  to 
be  fibrous  in  character,  but  many  of  them  were  wholly 
or  in  part  of  a  gelatinous  consistence,  as  though  the  fibroid 
tissue  had  undergone  a  myxomatous  change.  The  fifteen 
inch  incisiou,  which  extended  from  the  buttock  to  the 
lower  extremity  of  the  popliteal  space,  was  closed  with 
twenty-six  catgut  sutures  and  an  aseptic  dressing  applied. 
The  patient  had  practically  no  pain  after  the  operation. 
The  wound  healed  by  first  intention.  Xo  marked  numb- 
ness of  the  foot  remained,  and  when  discharged  from  treat- 
ment he  had  good  motion  in  all  the  toes. 

The  microscopic  examination  showed  the  tumors  to  be 
fibromas. 

No  accurate  examination  of  the  areas  of  anesthesia,  and 
no  determination  of  the  electrical  reactions  of  the  muscles 
were  made.  Some  of  the  nerve  fibers  were  undoubtedly  In- 
jured in  excision  of  these  tumors,  though  as  far  as  pos- 
sible, the  capsule  was  split  and  the  nerve  fibers  separated 
in  a  longitudinal  direction. 

An  interesting  report  of  tumors  of  the  sciatic  nerve  will 
be  found  in  the  20th  Century  Practice  of  Medicine,  Vol- 
ume 11,  p.  333.  This  article,  written  by  Dr.  James  Hendrie 
Lloyd,  showed  me  that  the  condition  was  rarer  than  1  had 
previously  supposed.  It  is  very  much  regretted  that  cir- 
cumstances prevented  me  having  the  benefit  of  Dr.  Lloyd's 
examination  of  the  case  before  operation  was  undertaken. 
The  careful  study  of  the  neurological  features  of  the  par 
tient  would  have  been  valuable,  though  it  would  not  in  any 
way  have  influenced  the  character  of  the  operation. 


VENOUS  ANGIOMA  OF  THE   FLEXOR  MUSCLES  OF 
THE  FINGERS. 

JOHN  B.  ROBERTS,  M.  D. 
A  man  of  24  years  was  operated  upon  at  the  Polyclinic 
Hospital  on   February   11.   1901,   for  a  swelling  about  the 
middle  of  the  forearm  on  the  palmar  surface,  which  had 

Read  before  the  Philadelphia  ralhologrical  .Society.  Febnian'.  28.  1JK)1. 


nnft       The   Philadelphia  "I 
// j"        Medical  Journal  J 


DIABETES  MELLITUS 


[APEIL  13.    1901 


recently  become  the  seat  of  pain.  He  said  that  he  had  in- 
jured the  a.Tu\  when  he  was  12  years  of  age  and  that  the 
swelling  had  been  there  since  ttiat  ime.  According  to  hi& 
statement  the  growth  had  slowly  enlarged,  but  had  not 
Interfered  with  work,  and  had  given  him  no  pain  until  re- 
cently. On  grasping  the  forearm  and  having  the  patient 
move  his  fingers  there  was  a  vibratory  sensation  per 
ceived  by  the  hand  of  the  examiner  similar  to  that  observed 
In  tenosynovitis.  The  elasticity  of  the  swelling  resembled 
that  of  a  tense  thecal  cryst.  The  tumor  was  situated  in 
the  middle  of  the  palmar  surface  of  the  forearm  and  was 
about  three  inches  long  and  an  inch  and  a  half  wide.  A 
longitudinal  incision  through  the  skin,  made  under  anes- 
thesia, revealed  a  venous  angioma  involving  the  superfi- 
cial and  deep  flexors  of  the  fingers.  The  entire  thickness  of 
these  muscles  was  involved,  as  was  shown  by  carrying  the 
finger  beneath  the  muscles.  The  venous  channels  were 
developed  in  the  muscular  masses  and  were  separated 
by  abundant  fibrous  tissue.  The  fibrous  tissue  was  so  great 
In  amount  that  rolling  the  belly  of  the  muscles  between  the 
fingers  gave  the  sensation  of  hard  particles  within  their 
structure.  Examination  before  operation  made  me  think 
that  the  condition  was  possibly  a  thecal  cyst  containing 
rice-like  bodies.  This  was  evidently  due  to  the  skin  and 
superficial  fascia  slipping  over  the  rough  syrfaee  of  the 
tumor.  The  rough  surface  was  due  to  the  irregularities 
produced  by  the  hard  fibrous  tissue  and  venous  channels 
which  made  up  the  tumor.  It  was  evident  that  the  mus- 
cular tissue  was  riddled  with  fibrous  partitions  and  venous 
channels. 

The  motion  of  the  fingers  was  perfect.  Careful  examina- 
tion of  the  mass  showed  that  the  tumor  could  not  be  re- 
moved without  excising  the  entire  thickness  of  the  mus- 
cles for  a  space  of  about  three  inches.  As  this  would  have 
done  an  irreparable  injury  to  the  functions  of  the  hand, 
the  removal  of  the  tumor  was  abandoned.  One  or  two  in- 
cisions were  made  in  the  mass  to  see  whether  it  was  pos- 
sible to  enucleate  it,  and  a  small  portion  was  removed 
for  microscopical  examination.  Bleeding  was  very  free, 
but  after  the  application  of  sutures  and  a  pad  ttie  arm 
was  kept  elevated  and  no  further  hemorrhage  occurred.  It 
was  believed  that  the  pain  from  which  the  patient  had  re- 
cently suffered  would  be  relieved  by  the  incision  through 
the  deep  fascia  which  was  necessary  to  expose  the  tumor. 


The  wound  healed  promptly:  and  the  man  when  seen 
recently,  had  good  use  of  his  fingers,  though  they  were  a 
little  restricted  by  the  fear  of  pain  and  the  local  indura- 
tion at  the  seat  of  the  operation  done  sixteen  days  ago. 

The  pathological  examination  m.ide  by  Dr.  Guthrie  Mc- 
Connell,  showed  many  bundles  of  voluntary  muscle  fibres 
cut  transversely.  Between  these  fibres  in  many  placess  was 
a  large  amount  of  connective  tissue. 

In  one  portion  of  the  specimen  the  muscle,  having  com- 
pletely atrophied,  had  been  replaced  by  fibrous  tissue.  In 
this  same  part  were  many  large  blood  passages  filled  with 
blood. 

Many  of  the  muscle  fibers  were  much  smaller  than  nor- 
mal and  their  muclei  were  no  longer  visible. 

In  the  regions  of  the  blood  vessels  were  numerous  crys- 
tals, deep  brown  in  color,  apparently  derived  from  the 
blood. 

There  was  no  trace  anywhere  of  malignancy. 


DIABETES  MELLITUS  AS  A  CELLULAR  FAULT. 

THOMAS  C.  ELY,  A.  M.  M.  D.,  • 
of  Philadelphia. 

Diabetes  mellitus,  the  excretion  of  sugary  urine,  though 
known  to  the  Greeks  and  Romans,  though  observed  by  the 
Arabs  and  the  inhabitants  of  Ancient  India,  remains  to-day, 
as  then,  of  obscure  etiology,  of  Indefinite  pathology,  al- 
though of  plain  and  definite  symptoms. 

The  symptoms  are  of  well  known  nutritional  type,  re- 
sulting from  the  dally  loss  by  the  genito-uiinary  route  of 
ounces  or  pounds  of  grape  sugar  which.  Instead  of  nourish- 
ing or  affording  energy,  escapes  In  the  urine.  This  waste 
sugar  must  either  be  Imperfectly  prepared  for  cellular 
use  and  cells  cannot,  therefore,  accept  it;  or  the  cell  pro- 

•B.ead  in  the  Medical  Section  of  the  College  of  Physicians.  Nov.  12. 1900. 


toplasm  itself  is  faulty,  is  weak  or  diseased,  and  cannot 
accept  a  properly  prepared  article. 

The  fault  must  be  in  the  sugar  preparation  or  in  the 
sugar  distribution  in  cell  metabolism.  In  certain  instances 
both  may  be  true.  In  the  former  case, — in  imperfect  el- 
aboration of  sugar, — whether  due  to  alimentary  imper- 
fections, to  impaired  functions  of  the  liver,  or  pancreas 
and  its  ferment,  or  to  vasomotor  disturbance,  the  process 
is  more  simple  and  the  pathology  is  more  definite  and 
well  understood. 

It  is  with  the  latter  only, — Cellular  Diabetes, — that  this 
paper  is  concerned,  the  fault  being  neither  in  the  inter- 
nal excretions  or  external  secretions  of  the  alimentary 
tract,  the  liver  or  the  pancreas,  nor  in  the  nervous  system, 
and  hence  must  rest  in  the  protoplasm  of  the  cell. 

It  is  therefore  suggest'~d  that  even  when  the  entire  sugar 
mechanism  is  otherwis  perfect,  sugar  may  appear  in 
quantity  in  the  urine  on  u^count  of  its  non-acceptance  by 
body  cells,  due  to  a  fault  of  their  protoplasm.  If  such  may 
be  the  case,  the  etiology  of  many  cases  of  diabetes  is  made 
plainer  and  the  stigma  of  our  lack  of  knowledge  of  the 
pathology  of  diabetes  in  all  cases  becomes  more  endurable, 
because  the  whole  problem  of  cellular  metabolism  Is  still 
beyond  definite  comprehension. 

There  seem  to  be  five  general  reasons  for  considerlac 
diabetes  as  a  fault  of  cellular  protoplasm: 


A   Biologic   Reason; 
An  Hereditary  Reason; 
A  Reason  by  Exclusion; 
Associate  Diseases; 
A  Therapeutic  Reason. 


I.     A  BIOLOGIC  REASON. 

Through  the  aid  of  biologj-  we  are  just  becoming  familiar 
with  cell  life;  we,  however,  know  little,  as  yet,  of  its  in- 
herent power.  We  know  that  cells  form  fresh  cells,  form 
organs,  form  tissues — in  fact,  form  the  entire  organism; 
the  individual  parts  of  the  organism  have  been  discovered 
and  also  the  finer  components  of  these  parts,  the  organs 
and  tissues;  it  remains  for  future  pathologists  and  physi- 
ologists to  study  the  still  finer  and  elementary  constituents, 
the  living  cells,  so  far  as  they  are  discoverable.  We  may 
prophesy  a  rich  store  of  cellular  knowledge  in  the  future. 
Investigation  will  deal  less  with  organs, — particularly  in 
what  we  term  general  and  nutritional  diseases, — and  more 
with  cell  life  and  cell  activity. 

It  is  to  a  perversion  of  these  cellular  activities.partlcularly 
in  general  nutritonal  diseases,  that  we  may  with  profit  look 
for  an  explanation. 

With  reference  to  sugar  nutriment,  what  is  true  of  all 
other  substances  is  equally  true  of  sugar:  that  after  prepa- 
ration by  the  cells  of  digestion  it  is  assimilable  only  by  a 
still  more  delicate  and  more  elaborate  change, — a  change 
effected  by  the  tissue  cell, — which  change  we  call  meta- 
bolism. 

It  is  to  a  per\'ersion  of  this  intricate  cellular  change  In 
tissues  that  we  may  ascribe  some  forms  of  diabetes.  Al- 
most all  cells  may  be  nourished  by  a  form  of  sugar,  and 
sugar  foods  are  supposed  to  furnish  fuel  or  maintain  ani- 
mal heat  and  also  to  supply  energy  or  force  manifested 
through  muscular  action,  and,  therefore  sugar  may  especi- 
ally supply  tissue  cells;  but  what  cells  are  particularly  in- 
volved is  a  problem  that  must  be  solved  by  the  physiolo- 
gist. However,  no  matter  which  cells  are  involved,  this 
fact  must  be  true  of  all  cells  nourished  by  sugar,  that 
any  marked  and  extensive  cellular  fault  in  the  Inking  up 
of  the  sugar  product  must  illustrate  sugar  supply  over 
and  above  cellular  demand,  and  must  in  time  further  de- 
range cell-mechanism  and  leave  sugar  in  the  lymph,  in  the 
tissues,  In  the  blood  and  in  the  urine,  as  we  find  it  in  dia- 
betes. An  equally  decisive  cellular  fault  in  the  throiring 
off  or  elimination  of  sugar  waste  would  likewise  further 
clog  cellular  activity  and  soon  leave  sugar  in  the  lymph, 
tissues,  blood  and  urine.  Of  course  a  double  fault,  one 
of  both  taking  up  and  throwing  off  sugar  waste,  must 
speedily  bring  on  diabetes. 

Whether  the  fault  of  cell-metabolism  be  hereditary  weak- 
ness, lack  of  oxygen  which  so  hasten  disintegration,  or  lack 


April  13.  1001] 


DIABETES  MELLITUS 


fTHE    PnlLADELPHIA  'Tin 

L  MrpiCAi,  JoUKXAL         I  oy 


of  exercise  or  other  ordinary  hygienic  cause,  the  result  is 
no  less  certain.  The  fault  may  very  probably  be  a  faulty 
cell  ferment. 

Physiology  cannot  explain  metabolism. — those  intimate 
chemical  changes  in  cells  upon  which  nutrition  and  func- 
tions depend,  or  the  cellular  power  of  continually  using  up 
and  renewing  nutritional  material.  Neither  can  physiology 
explain  metabolic  equilibrium,  which  is  defined  as  the 
equality  between  absorption  and  assimilation  of  food  and 
the  excretion  of  effete  or  end  products.  Modern  physiol- 
ogy does  not  clearly  understand  either  part  of  the  process 
— anabolism.  lotistriictne  or  synthetic  metabolism,  or  kata- 
bolism,  (lestnictive  metal^olism.  In  the  metabolism  of  ni- 
trogen food  and  of  water,  as  well  as  in  that  of  sugar,  the 
same  must  be  true  and  may  help  to  explain  some  cases  of 
albuminuria  and  even  polyuria;  but  in  this  paper  we  are 
concerned  only  with  the  problem  of  sugar  assimilation, 
and  the  more  closely  we  study  biology,  animal  and  vegeta- 
ble, the  more  plausible  becomes  the  view  that  diabetes  is 
often  due  to  a  fault  of  cell  protoplasm. 

From  primitive  cells  without  a  governing  nervous  me- 
chanism to  the  highest  type  under  such  control,  cells  have 
the  power  of  appropriating  certain  food  material  and  neg- 
lecting all  else.  This  is  a  well  recognized  biological  law 
and  suggests  the  conclusion  that  cells  deranged  in  their 
power  of  imbibing  sugar  by  reason  of  an  inherited  cellu- 
lar fault,  by  weakening  or  clogging  with  waste  and  end 
products,  as  in  gout,  rheumatism,  alcoholism  and  obesity, 
cannot  take  up  their  quota  of  sugar  even  if  the  sugar  he 
proprely  prepared ;  and  such  residual  sugar,  after  filling  the 
natural  sugar  storehouses  of  the  body,  saturates  lymph 
and  blood  and  appears  in  the  urine,  in  the  disease  we  call 
diabetes. 

II.     AN   HEREDITARY   REASON. 

There  is  an  hereditary  reason  for  a  cellular  protoplastic 
fault.  According  to  Continental-  observers  (Tyson)  one- 
fourth,  and  other  authorities  (Thompson's  Diabetes,  p.  633) 
one-third,  of  the  reported  cases  of  diabetes  are  hereditary, 
which  suggests  a  cellular  hereditary  fault.  If  we  regard 
heredity  as  hinging  upon  the  fact  that  every  living  cell 
indicates  a  mother  cell,  its  matrix,  we  readily  see  how  a 
protoplasmic  fault  in  the  original  cell  in  acceptance  of 
sugar  and  disposal  of  waste  is  transmitted,  and.  in  the  ab- 
sence of  a  definite  patholog>'  in  the  organs  n  diabetes,  we 
may  with  reason  look  to  the  cell  for  a  predisposition  pre- 
sent in  the  earliest  cells  and  transmitted,  although  not  yet 
recognized.  If  we  regard  heredity  as  the  result  of  the  bio- 
logical law  that  "each  cell  or  aggregation  of  bioplasms  of 
which  the  living  body  is  composed  has  been  developed  from 
a  preceding  cell  and  inherits  the  properties  or  forces  of  the 
parent  cell  from  which  it  originated,"  it  helps  explain  here- 
ditary diabetes.  We  are  familiar  with  the  fact  that  al- 
though some  cells  are  sterile  and  some  rquire  special  pre- 
paration before  they  can  produce  a  new  brood,  yet  certain 
cells  especially  proliferate  and  all  cellx  have  their  origin 
in  a  matrix, — a  mother  cell, — just  as  the  whole  organism 
originates  from  a  single  egg-shell.  Each  tissue  cell  of 
matricial  character  may  be  liken  to  an  ovum,  and  "each 
tissue  bears,  as  a  rule,  the  stamp  of  its  matrix.  It  is  built 
on  the  maternal  plan."  and  if  this  maternal  plan  represents 
a  protoplasmic  cellular  fault  as  regards  the  metabolism  of 
sugar,  we  surely  get  such  in  the  entire  organism, — here- 
ditary diabetes.  Al  though  the  pathology  cannot  be  found 
in  the  organs,  we  may  confidently  expect  to  find  it  in  the 
cells. 

When  so  large  a  percentage  of  diabetes  cases  are  here- 
ditary, if  the  disease  were  due  to  an  jrgan  we  should  ex- 
pect some  successive  regularity  of  hef  iditary  lesion  in  said 
organ  or  organs,  but  none  such  occurs.  If,  on  the  other 
hand,  the  disease  be  due  to  a  general  cellular  weakness, 
our  disappointment  in  not  yet  finding  gross  pathological 
lesions  will  only  be  an  incentive  to  more  vigorous  work 
In  this  direction:  for  the  process  must  be  as  general  as  nu- 
trion  itself,  as  incommutable  as  the  number  of  cells  them- 
selves. Though  well  assured  of  the  fact  of  sugar  metabo- 
lism, the  physiologic  explanation  of  it  is  not  known,  and 
much  less  the  pathology. 

III.  A  REASON  BY  EXCLUSION. 
There  is  an  argument  by  exclusion  for  cellular  diabetes. 
Cells  require  so  much  sugar  in  an  assimilable  form,  and  it 
is  the  function  of  certain  organs  to  perform  the  work  of 
preparation.  It  is  likewise  the  function  of  nerve-centers  to 
control,  by  proper  conducting  paths,  the  process  of  proper 


preparation  and  assimilation.  Granted  that  the  work  Is 
all  properly  done,  so  far  as  we  know,  with  perfect  organs 
and  normal  nervous  system,  and  yet  we  have  diabetes i 
we  may  fairly  by  a  reason  of  e.xclusion  look  to  the  pur- 
pose of  nutrition — to  the  cells  themselves — and  conclude 
the  fault  may  be  in  the  cell  protoplasm. 

The  fact  that  the  disease  is  differently  classified  among  kid- 
ney diseases  (no  doubt  from  the  urinary  phenomena),  liver 
diseases,  pacreatic  diseases,  disorders  of  the  digestive  sys- 
tem, or  alimentation;  disorders  of  the  sympathetic  system; 
and  that  in  diabetes  all  of  these  organs  may  be  functionally 
and  physiologically  perfect,  forces  us  to  look  elsewhere 
for  an  explanation,  and,  very  naturally,  we  search  in  a 
most  likely  quarter,  the  very  end  of  all  food,  viz:  cell  life, 
where,  as  yet,  we  cannot  expect  to  find  a  pathologj-,  for 
we  have  no  definite  cell  physiology  as  a  working  basis. 
Saundby  affirms  that  diabetes  is  steadily  and  rapidly  in- 
creasing in  all  the  great  cities  of  Europe.  It  is  called 
a  civilization  disease;  and  when  we  consider  that  the  peo- 
ple of  modern  civilization  most  abuse  the  digestive  func- 
tions and  cerebro-spinal  axis  we  see  why  many  case  are  ex- 
plained by  disease  of  the  alimentary  tract  or  accessory 
glands,  or  disease  or  injury  of  the  nervous  system. 

We  are  familiar  with  alimentary  diabetes,  with  diabetes 
due  to  a  disturbance  of  the  glycogenic  functions  of  the 
liver,  with  pancreatic  diabetes,  due  to  interference  with  its 
ferment  from  cancer  or  from  cirrhotic  or  fatty  changes; 
with  nervous  diabetes,  from  disease  or  injury  to  the  sym- 
pathetic or  trophic  system;  and  we  find  a  pathology  for 
the  same  and  they  are  easy  to  understand,  as  all  these 
functions  are  necessary  to  prepare  a  proper  sugar  article 
for  cellular  use,  and  in  such  cases  a  healthy  cell  cannot 
accept  improperly  prepared  sugar  and  we  may,  and  often 
must,  find  excess  of  sugar  in  the  blood  and  urine — the  so- 
called  dabetes.  When  we  consider  the  modest  demand 
made  by  the  cell  for  fuel  and  energy,  and  how  lavish  its 
supply;  when  we  consider  the  large  amount  of  sugar  and 
starch  and  other  foods  consumed  by  the  human  race,  as 
compared  with  sugar  needs  (the  supply  always  exceeds 
the  demand;  when  we  consider  how  civilized  people  cook 
and  prepare  all  these  forms  of  sugar  to  coax  and  force 
them  past  the  intestinal  barriers  unchallenged  or  with 
mild  protests,  to  finally  reach  the  cell  doors  in  enormous 
and  unnecessary  amounts;  there  seems  a  good  reason  for 
damage  to  cellular  mbechanism  and  for  a  cellular  sugar 
fault  among  the  civilized.  The  active  life  of  the  savage 
might  use  up  as  energy  what  was  not  needed  for  fuel,  and 
the  raw  food  of  the  savage  if  taken  in  excess  would  early 
produce  Nature's  evidences  of  Nature's  protest  in  intestinal 
symptoms  before  appearance  of  the  urinary  symptoms  of 
more  civilized  people. 

IV.     A  REASON  OF  ASSOCIATE  DISEASES. 

In  diabetes,  concomitant,  intercurrent  and  associate  dis- 
eases point  to  metabolic  disturbances  as  the  basic  cause. 
Its  frequent  occurrence  when  metabolism  is  weakest. — after 
febrile  attacks  and  after  or  during  acute  diseases. — is 
equally  significant.  Its  frequent  association  v.-ith  diseases 
of  well-known  cellular  weakness — with  gout,  rheumatism 
and  obesity — is  still  stronger  evidence  of  faulty  metabol- 
ism. The  close  relationship  of  diabetes  with  uric  acid 
accumulation  points  to  the  cell.  According  to  Coignard 
Camillon  and  other  French  observers,  excess  of  uric  acid 
is  often  a  forerunner  of  diabetes.  In  about  one-third 
of  diabetes  cases  there  is  a  history  of  alcoholism,  which 
strongly  suggests  cell  disintegration. 

Ord  reports  a  series  of  diabetic  cases  in  which  gout  oc- 
curred in  one-third  and  rheumatoid  arthritis  in  others. 
After  the  age  of  fifty  gout  and  glycosuria  and  diabetes  in 
the  presence  of  obesity  may  interchange  without  emacia- 
tion or  particular  debility  or  seriousness,  as  if,  though  with 
cellular  weakness,  sufficient  cell  power  yet  remained  to  per- 
form sugar  and  proteid  work,  but  only  indifferently. 

That  the  esquimo  can  live  solely  upon  fat;  the  South 
Sea  Islander  upon  sugar  foods  the  hunter  and  trapper  up- 
on meat,  and  civilized  man  upon  a  conglomerate  mixture 
of  all  these  in  varied  forms,  gives  us  great  respect  for  all 
organs  which  have  to  do  with  food-preparations  and  food- 
alimentation,  and  the  highest  appreciation  of  those  body- 
cells  which  have  the  most  delicate  and  most  important 
work  to  perform, — that  of  assimilation. 

V.     A  THERAPEUTIC  REASON. 

It  is  worthy  of  mention  that  the  only  drugs  which  bene- 
fit  diabetes,   arsenic   and   codein,    may   be   called   cellular 


The   PniLADnLPniA ' 
Medical  JontNAL  . 


DIABETES  MELLITUS 


[Apeil  13,  1901 


/drugs,  as  they  have  no  particular  action  upon  the  liver  or 
pancreas,  upon  cancer  or  fatty  changes,  but  have  a  defi- 
nite and  well  recognized  action  upon  general  body  cells. 
Arsenic  as  an  alterative,  reconstructs,  builds  up  weak  cells, 
as  we  may  observe  in  gsneral  skin  diseases  other  than 
those  associated  with  diabetes.  Opium  conserves  tissue, 
retards  and  prevents  waste.  Under  the  judicious  use  of 
these  cell-drugs,  if  we  may  call  them,  many  diabetes  cases 
improve  and  some  get  well. 

The  essential  therapeusis,  however,  is  the  diet  or  with- 
drawal, paitially  or  wholly  as  the  case  demands,  of  the 
sugar  supply,  allowing  the  cells  concerned  in  the  assimila- 
tion of  sugar  to  recuperate. 

This  dietetic  treatment,  so  valuable  in  diabetes,  is  of 
little  benefit  in  cancer,  cirrhotic  change,  or  fatty  degenera- 
tion, or  even  weakness  of  the  sympathetic  nervous  system. 
In  regard  to  the  derangement  of  the  nervous  system  as  a 
full  explanation  of  diabetes,  granting  that  it  may  be  a 
sufficient  cause  in  some  instances  of  shock  or  traumatism, 
yet  the  most  unmanageable  and  serious  case  of  diabetes 
are  those  in  which  there  is  no  e.xplanatory  history  or  dem- 
onstrable lesion.  Howevr,  by  derangement  of  the  sympa- 
thetic control  of  the  vasomotor  system  we  can  explain 
almost  every  disease. 

Generally  speaking,  the  nervous  system  controls  meta- 
bolism, but,  aside  from  nervous  control,  there  is  inherent 
cell  poirer  in  gradation  from  the  lowest  form  of  cells  with 
no  nervous  control,  to  the  highest  with  most  delicate  and 
Intricate  governing  mechanism. 

Just  as  in  the  lowest  forms  of  life  cells  depend  entirely 
upon  inherent  cell-power,  so  in  the  highest  forms  in  which 
such  inherent  cell-power  remains  it  is  reasonable  to  assume 
additional  sympathetic  control. 

Again,  if  we  argue  that  organic  diseases — for  example, 
of  liver  and  pancreas — are  causes,  we  shall  still  have  to 
explain  the  fact  that  in  older  people,  where  such  organic 
changes  as  cancer  and  cirhosis  most  frequently  occur,  dia- 
betes, instead  of  being  more  deadly,  is  more  amenable  to 
treatment;  which  quite  forces  us  to  look  elsewhere  than 
the  vital  organs. 

Again,  the  fact  that  diabetes  is  most  fatal  in  the  young 
may  be  explained  by  this  cellular  theory  as  the  survival  of 
the  fittest  in  cell  life.  Very  weak  cells  fail  utterly  in  early 
life.  Older  cells  adapt  themselves,  become  more  resitant, 
and  perhaps  relegate  their  work  to  other  cells,  just  as  the 
sound  hemisphere  (  ?)  of  the  cerebrum  will  imperfectly  take 
up  the  duties  of  its  injured  fellow. 

It  is  interesting  to  note  that  the  plasma  is  usually  loaded 
with  fat  molecules  which  can  be  seen  in  fine  particles.  If 
this  fat  appeared  in  the  urine  as  it  does  in  the  serum  we 
might  call  the  disease  diabetes,  mellitus  lipogenicus.  The 
general  presence  of  this  fat  is  best  explained  by  a  theory 
of  metabolism.  The  fact  that  examination  of  the  feces  and 
urine  shows  a  striking  defect  in  assimilation  of  albuminoids 
and  fats  is  likewise  best  explained  by  a  cellular  fault. 

Some  practical  value  of  such  a  theoretical  discussion 
must  be  its  best  excuse,  and  how  little  can  be  accomplished 
by  drugs  is  herein  foreshadowed.  In  uric  acid  cases 
moderate  doses  of  Salicylates  may  assist  arsenic  and  codeia. 
The  most  successful  treatment  is  a  rest  cure  or  partial  rest 
cure  for  cell  lite,  withdrawing  sugar.  The  rest  must  be 
complete,  by  a  total  withdrawal  of  sugar,  if  by  this  means 
a  patient  tends  to  recovery;  or  a  partial  rest  cure  may  be 
Indicated  when  weak  cells  are  found  to  thrive  better  on 
some  most  assimilable  forms  of  carbohydrates. 

Even  though  some  sugar  persist  in  the  urine  and  the'pa- 
tlent  nevertheless  improves  in  weight,  strength  and  general 
health,  it  were  better  to  be  content  with  this  result  rather 
than  remove  both  sugar  and  patient  by  heroic  drug  meas- 
ures or  by  starvation,  to  which  a  too  rigid  diet  sometimes 
leads. 

In  conclusion,  when  we  consider  the  therapeutic  reason 
for  the  argument  of  cellular  fault,  and  especially  the  effect 
of  diet,  a  reason  of  associate  diseases,  the  reason  by  exclu- 
sion and  that  of  heredity,  we  seem  to  have  an  explanation 
of  the  etiology  of  this  obscure  disease  worthy  of  considera- 
tion. 

And,  finally,  the  strongest  of  all  reasons,  the  biologic 
law  that  applies  to  cells. — the  most  primitive  as  well  as  the 
most  highly  developed, — viz:  there  is  an  intrinsic  power  of 
Imbibing  and  digesting  the  netcssaru  and  refusing  all  else. 


CENTRALBLATT  FUER  INNERE  MEDIZIN. 
January  1&.  I'dDl. 
On  the  use  of  Colloids  in  the  Nourishment  of  Infants. 
K.  GREGOR. 
Gregor  reports  a  series  of  nitrogen  metabolism  experi- 
ments which  he  has  carried  out  in  animals  and  in  children, 
in  which  he  determined  that  gelatin  solutions  are  al>- 
sorbed,  and  that  the  gelatin  is  used  in  the  organism,  and  ia 
apparently  able  to  substitute  for  albumin,  fat  or  carbohy- 
drate in  the  nourishment.  Ke,  however,  ends  his  statement 
that  the  use  of  gelatin  had  evidently,  from  a  clinical  stand- 
point, an  unfavorable  effect  which  consisted  chiefly  in  a 
tendency  to  produce  inflammatory  changes  in  the  intestinal 
tract.  In  what  way  these  changes  are  produced  could  not 
be  definitely  determined.  Disease  of  other  organs  was  not 
discovered.  The  use  of  gelatin  in  small  amounts,  however, 
tended  to  cause  diarrhoea.  There  have  been,  he  states,  no 
previous  records  of  any  satisfactory  investigations  con- 
cerning the  use  of  colloidal  substances  in  the  nourishment 
of  infants,  either  in  simple  solution  or  when  used  in  dilute 
solution,  and  while  his  results  have  been  unfavorable  from 
a  clinical  standpoint,  he  believes  that  they  hare 
been  of  value  in  demonstrating  the  actual  standing  of  tbeaa 
substances.  He  directs  attention  to  the  tact  that  fruit 
gelatins,  extract  of  grapes,  and  extracts  of  veal  and  of 
calves'  bones,  are  frequently  recommended  by  writers  for 
use  in  older  children,  who  are  emaciated  or  have  poor 
appetites.  Since  these  substances  contain  a  large  amount 
of  colloids,  he  considers  that  they  should  be  investigated 
in  a  more  definite  manner  than  has  heretofore  been  don* 
before  their  use  is  recommended.     [D.  L.  E.] 


CENTRALBLATT  FUER  INNERE  MEDIZIN. 
January  2i;.  l&Ol. 
A  Contribution  to  the  Studyof  Disturbances  of  the  Lung 
Circulation. 
J.  ESSER. 
Esser  considers  that  the  width  of  the  vessels  in  the  lung 
are  to  a  considerable  extent  controlled  by  the  respiratory 
movements  by  means  of  the  elastic  fibres  which  run  from 
the  vessel  walls  to  the  walls  of  the  alveoli.  He  discusses 
disturbances  of  the  respiration  in  their  secondarj-  relation 
to  disturbances  of  pulmonary  circulation  under  the  follow- 
ing headings:  First,  a  disturbance  of  the  excursion  of  the 
lungs  through  pleural  adhesions,  persistent  exudates,  or 
deformities  of  the  thorax  Second,  a  decrease  in  the  elas- 
ticity of  the  lungs  through  widespread  indurative  pro- 
cesses, or  emphysema,  with  ultimate  disappearance  of 
the  elastic  tissue.  Third,  rigidity  of  the  pulmonary  ves- 
sels through  sclerosis  of  the  vessel  walls.  These  factors 
are  likely  to  be  combined.  The  first  heading  includes  con- 
ditions which  have  relatively  little  to  do  with  the  point 
which  he  wishes  to  make  in  this  paper:  the  elastic  traction 
between  the  alveoli  and  the  smaller  vessels  is  of  much  less 
importance  under  such  circumstances  than  the  disturb- 
ances of  suction  action  through  the  interference  with 
proper  respiration.  As  to  the  second  heading,  he  considers 
that  the  elastic  traction  may  play  an  important  role  In 
these  conditions  in  disturbing  the  lung  circulation,  and  in 
sclerosis  cf  the  vessels  of  the  lungs  there  is  of  course  mora 
or  less  complete  interference  with  dilatation  of  the  Tea- 
sels by  means  of  the  traction  of  the  elastic  tissue.  He  Is 
inclined  to  attribute  much  of  the  circulatory  disturbancea 
in  emphysema  to  this  interference  with  the  traction  of  the 
elastic  tissue,  and  the  consequent  relative  increase  of  the 
tension  in  the  lungs,  which  increase  ultimately  overtaxea 
the  right  heart.     [D.  L.  E.] 


A  New  physical  Sign  in  Cases  of  Dilatation  of  the  Stonv 
ach.^W.  D.  Sherwinsky  {Klinit^hr.^l-i  -Inurtxal.  1900.  TrateX, 
Vol.  22.  No.  5.)  found  that  in  dilatation  of  the  stomach  a 
dul  sound,  similar  to  the  one  obtained  in  pleurisy  with 
effusion,  may  be  elicited  by  percussing  the  left  subcapular 
region  on  a  level  with  the  lower  border  of  the  left  lung.  In 
the  region  of  the  ninth,  tenth  and  eleventh  ribs.  The  area 
of  dullness  is  4  to  5  cm.  wide,  and  is  separated  from  the 
vertebral  column  by  a  small  triangular  space  of  much  clear- 
er resonance.  When  the  patient  bends  forward,  the  dull 
sound  becomes  clearer,  and  on  further  stooping,  it  becomes 
tympanitic,  .\fter  thorough  lavage  the  dulness  disappears 
similarly.  The  explanation  offered  is  that  the  dilated  and 
distended  stomach  raises  the  diaphragm  and  presses  the 
lower  part  of  the  left  lung  against  the  back,  rendering  It 
1  air  tree.     fA.  R.l 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and   Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James   Hendrie  Lloyd.   A  M  ,  M.D  .  Editor-in-Chief 
JDLI0S  L,.  SA1.1NGI-R.  M.D  .  A ssociate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D,  h.  J.  Kalteyer.  M.D. 

D.  L.  Edsall,   M.D.  T.  1..  CoLEY.   M.D. 

J.  M.  Swan.  M.D.  W.  A.  N.  Dorlaxd,   M.D. 

J.  H.  GiBBO.v.  M.D.  T.  M.  'iT^ON,  M,  D. 

M     OSTHEIMER,    M.   D,  A.  KOBIN.   M.  D. 


Scientific  Articles.  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  publication.  Reprints  (250)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1710  Chestnut  St.   Address  all  correspondence  to 

The  PhlladelphiaMedical  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa.  , 

See  Advertising  Page  8. 


Vol.  VII,  No.  i6 


April  20,  1901 


$3.00  Per  Annum 


The  New  Therapeutic  Monthly. — This  new  Jour- 
nal, which  will  enter  a  most  important  field  of  med- 
ical joTirnalism,  will  appear  in  a  few  weeks,  as  we 
have  already  announced.  We  wish  to  make  the 
additional  announcement  to  our  friends  that  the 
Therapeutic  Monthly  will  be  sent  to  all  paid-up  sub- 
scribers of  the  Philadelphia  Medical  Journal  who 
make  a  request  for  it.  Professor  James  Tyson  will 
have  editorial  charge,  and  will  have  as  his  asso- 
ciates Dr.  T.  L.  Coley  and  Dr.  T.  Mellor  Tyson.  No 
eflforts  will  be  spared  to  make  the  new  Journal  a 
thorough  representative  of  therapeutical  work  and 
literature,  and  we  believe  that  the  opportunity  here 
mentioned  will  be  appreciated  by  all  our  subscri- 
bers, 

A  Voyage  in  a  Disease-Ridden  Ship. — Nothing 
can  better  show  the  need  of  rational  ideas  on  the 
subject  of  the  infectious  diseases  than  the  expe- 
rience last  summer  of  the  steamer  Chile  off  the  west 
coast  of  South  America.  Her  log  reads  like  a  page 
out  of  the  Inferno,  and  all  because  of  the  barbarity 
and  ignorance  that  prevail  in  respect  to  the  conta- 
gious diseases.  This  steamer  left  Panama  in  July, 
bound  south,  and  when  two  days  out  developed 
yellow  fever.  From  this  moment  she  was  a  doomed 
ship,  an  ocean  outcast,  a  pariah  of  the  deep.  From 
port  to  port  she  sailed,  begging  in  vain  for  succor 
and  Christian  charity,  but  was  refused  everything 
because  she  had  a  few  cases  of  yellow  fever  on 
board.  From  port  after  port  she  was  turned  adrift; 
at  one  place  she  was  even  driven  out  of  the  har- 
bor by  a  gunboat.  This  sort  of  thing  went  on  until 
the  west  coast  of  South  America  had  been  pretty 
well  skirted  and  the  Chile's  coal  bunkers  were  ex- 
hausted. Then,  of  course,  the  helpless  steamer 
could  proceed  by  her  own  power  no  farther.  Gun- 
boats could  not  drive  her  away,  and  it  is  a  wonder 
that  they  did  not  stand  oflf  and  sink  her.  The  ports 
that  had  refused  to  give  her  medicines  had  also 
refused  to  give  her  coal,  but  the  last  port  had  to 
give  her  coal  in  order  to  get  rid  of  her.  So  she  was 
towed  five  miles  out  to  sea,  and  coal  sent  to  her  in 
an  old  barge.  The  Chile^  with  her  sick  crew,  had 
to  unload  the  coal  as  best  she  could,  and  then  sink 


the  barge.  No  medicines,  disinfectants,  or  supplies 
were  granted  at  any  port — only  maledictions  and 
orders  to  get  out !  There  was  no  doctor  on  board ; 
only  an  impostor,  who  claimed  to  be  one.  All  this 
time  (about  six  weeks)  yellow  fever  was  holding 
high  carnival ;  men  were  dying,  and  a  lot  of  passen- 
gers were  terrorized,  and  their  lives  put  in  peril. 
This  sounds  like  some  tale  of  an  Ancient  Mariner, 
or  like  a  proceeding  in  the  Middle  Ages.  It  was  all 
because  there  was  no  quarant-ine  port  on  the  west 
coast  of  South  America,  and  because  of  the  dis- 
graceful panic  that  assails  some  communities  at  the 
mere  mention  of  the  name  of  yellow  fever.  How 
absurd  this  would  all  seem  if  the  disease  were  yet 
proven  to  be  only  propagated  by  the  bite  of  the 
mosquito ! 

The  report  on  International  Quarantine,  adopted 
by  the  Pan-American  Aledical  Congress,  in  the  city 
of  Mexico,  1896,  provides,  according  to  the  PuUio 
Health  Reports,  that  each  government  should  main- 
tain quarantine  stations  at  its  domestic  ports. 

Smallpox  in  the  United  States. — According  to  the 
Public  Health  Reports  there  has  been  more  smallpox 
in  the  United  States  during  this  past  Fall  and  Win- 
ter than  during  the  corresponding  period  one  year 
ago.  The  total  number  of  cases  reported  up  to 
March  29th  was  11,964,  as  against  7,279  for  approx- 
imately the  same  date  last  3-ear.  What  we  wish  to 
call  attention  to  especially  is  the  astonishingly  low 
death  rate.  As  we  pointed  out  last  year  in  these 
columns,  smallpox  has  been  prevailing  in  widely 
separated  parts  of  the  United  States,  but  almost 
everywhere  it  has  presented  itself  in  an  exceedingly 
mild  type.  Thus  there  were  but  157  deaths  among 
the  11,964  cases — little  more  than  i  per  cent.  Some 
of  the  results  are  still  more  striking  when  the  figures 
are  analyzed.  Thus,  in  Wisconsin  560  cases  were 
reported  with  only  four  deaths.  In  Virginia  there 
were  257  cases  without  a  death ;  in  Tennessee,  308 
cases  with  four  deaths,  and  in  Oklahoma  Territory 
690  cases  without  a  recorded  death.  In  Minne- 
sota there  were  not  less  than  1985  cases  reported, 
and  yet  out  of  all  these  cases  there  were  recorded 
but  three  deaths.     In  Colorado    there    were    119a 


742 


Meiucal  Journal  J 


EDITORIAL  COMMENT 


[Apeil  20,  1901 


cases  without  a  death.  In  Louisiana  the  disease 
appears  this  year,  as  last,  to  have  prevailed  in  a 
more  malignant  type  than  elsewhere,  for  out  of  157 
cases  there  were  37  deaths.  This  is  about  23  per 
cent.  This  mortality  rate  for  the  whole  United 
States  would  have  given  about  2760  deaths  instead 
of  the  157  deaths  reported.  This  serves  to  show,  as 
graphically  as  figures  can,  how  mild  a  type  of  small- 
pox has  been  prevailing  in  the  country  at  large. 
In  the  large  Eastern  States,  New  York  and  Penn- 
sylvania, there  has  been  but  little  smallpox  this 
winter;  in  the  former  416  cases;  in  the  latter  only 
102.  Pennsylvania  had  but  3  deaths  against  New 
York's  67. 

We  do  not  know  just  how  accurate  all  these  re- 
turns may  be,  for  they  are  published  in  the  Health 
Reports  without  comment ;  but  we  cannot  refrain 
from  commending  them  to  the  thoughtful  consider- 
ation of  all  persons  interested  in  preventive  medi- 
cine. These  figures  certainly  lend  support  to  the 
claim  that  smallpox  has  been  brought  under  some 
sort  of  control  by  vaccination.  They  clearly  indi- 
cate that  from  being  what  it  once  was  (the  scourge 
of  the  race),  smallpox  has  become,  in  a  large  meas- 
ure, a  comparatively  harmless  disease. 

Compulsory  Vaccination. — In  further  proof  of 
the  efficacy  of  vaccination  is  the  experience  just 
reported  from  Chicago.  The  right  of  a  school 
teacher  to  exclude  from  a  public  school  a  scholar 
who  had  not  been  vaccinated  was  under  discussion 
in  that  city,  and  an  appeal  to  the  records  of  the 
Municipal  Health  Department  was  made  in  order 
to  prove  that  vaccination  is  a  true  prophylactic.  The 
results  were  striking.  From  November,  1900,  until 
April,  1901,  the  period  of  the  recent  epidemic  in 
that  city,  171  cases  of  smallpox  had  been  reported, 
of  which  140  cases  were  in  persons  who  had  never 
been  vaccinated.  Of  the  remaining  31  cases,  29 
were  in  adults  who  had  only  imperfect  scars,  if  any 
at  all.  Hence,  of  the  171  cases,  only  2  presented 
marks  of  successful  vaccination.  One  of  these  pa- 
tients was  40  years  old,  and  had  not  been  vacci- 
nated since  childhood ;  the  other,  35  years  old,  had 
been  vaccinated  successfully  when  a  child,  and  un- 
successfully three  years  ago.  One  of  the  Chicago 
newspapers,  which  has  been  investigating  the  sub- 
ject, says  that  the  disappearance  of  smallpox  from 
the  public  schools  of  that  city  has  been  coincident 
with  the  enforcement  of  the  Compulsory  Vac- 
tination  law.  This  act  went  into  effect  in  1867, 
ftnd  from  that  date  until  1881  there  were  only 
ly  cases  of  smallpox  and  varioloid  in  the  public 
schools.  The  Public  Ledger,  of  this  city,  does  a 
public  service  in  commenting  on  these  facts  edi- 
torially, and  we  are  obliged  to  it  for  the  figures 
quoted.     These  statements  are  sufficient  answers 


to  the  critics  who  oppose,  and  the  madmen  who 
resist,  vaccination-  The  Supreme  Court  in  this 
State  sustains  the  right  of  a  school  teacher  to  ex- 
clude an  unvaccinated  scholar  from  the  public 
schools. 

A  Martyr  to  Duty. — ^The  assassination  of  Dr. 
Ralph  Erskine  Johnston  by  an  insane  Italian  pa- 
tient in  the  State  Hospital  for  the  Insane,  at  Dan- 
ville, Pa.,  was  another  instance  of  the  sacrifice  of 
a  valuable  life  on  the  altar  of  professional  duty. 
Such  a  man  deserves  public  recognition  for  his 
worth  and  martyrdom,  and  we  publish  elsewhere  a 
detailed  sketch  of  his  useful  career.  Even  in 
these  days  of  military  ardor  and  showy  pride  over 
deeds  done  on  the  field  of  battle,  this  truly  heroic 
death  will  not  lose  in  lustre  and  force  of  example  by 
comparison  with  the  fall  of  any  of  the  bravest  men 
in  the  campaigns  of  Cuba,  China  or  the  Philippines. 
The  saddest  reflection  of  all,  after  our  first  outrush 
of  sympathy  to  the  stricken  wife  and  sorrowing 
friends,  is  that  such  frightful  catastrophes  may  still 
continue  to  happen,  as  they  have  too  often  happened 
in  the  past,  in  the  arduous  and  responsible  lives  of 
the  unselfish  men  who  are  devoting  themselves  to 
the  care  of  the  insane.  Let  this  mournful  event 
remind  us  all,  in  our  fraternal  sympathy,  that  the 
men  who  are  working  in  the  asylums  for  the 
amelioration  of  the  insane,  are  often  among  the  best 
and  most  self-sacrificing  in  the  ranks  of  our  profes- 
sion. 

Notes  by  Kitasato  on  Plague  in  Japan. — Dr-  M. 
J.  Rosenau,  of  the  U.  S.  Marine  Hospital  Service, 
has  translated  the  report  by  Kitasato  and  his  asso- 
ciates on  the  epidemic  of  plague  at  Kobe  and  Osaka, 
Japan.  This  report  was  also  translated  for  the 
Philadelphia  Medical  Journal  by  Dr.  M.  Ostheimer, 
and  published  as  a  special  article  in  our  number  for 
January  19th,  1901.  A  crusade  was  carried  on  against 
rats  at  both  places,  the  government  paying  2  1-2 
cents  a  head  for  them,  dead  or  alive.  About  20,000 
were  paid  for  at  Kobe  and  15.000  at  Osaka.  These 
were  by  no  means  all  the  animals  that  were  destroyed. 
Only  about  one-tenth  of  the  rodents  killed  at  Osaka 
were  infected,  and  about  one-fifth  at  Kobe.  The 
relation  of  rats  to  the  spread  of  the  disease  is  not 
apparent,  for  the  territory  in  which  pest  rats  were 
found  was  much  more  extensive  than  that  in  which 
plague  occurred  in  the  human  population.  This 
seems  to  indicate  that  rats  do  not  spread  plague 
very  actively  among  the  people,  but  are  simply 
themselves  victims  of  it.  They  seem  to  take  the 
disease  before  the  human  subjects.  In  Japan,  it 
seems,  the  rat  is  looked  upon  as  a  sort  of  guardian 
angel  of  the  household,  and  its  destruction  is.  there- 
fore, not  easjf. 


Aprii,  'JO,  Will] 


EDITORIAL  COAIMENT 


[The     I'HII.ADKLI'HIA  747 

Meiiical  Journal         /  '+-3 


The  report  docs  not  contain  much  that  is  new. 
Carbuncles  occurred  as  primary  lesions,  and  not 
always  secondary,  as  the  Germans  have  contended- 
Buboes  of  the  cervical  and  submaxillary  glands 
were  comparatively  common,  and  the  authors  be- 
lieve that  these  were  secondary  to  infection  through 
the  tonsils.  In  fact,  they  attach  much  importance 
to  this  mode  of  infection,  and  regard  the  tonsils  as 
important  foci  from  which  to  make  cultures-  The 
most  fatal  form  of  the  disease  was  the  pneumonic, 
and  it  was  also  the  most  dangerously  contagious. 
Instances  are  given  of  deaths  in  a  few  hours.  One 
reads  with  some  astonishment  that  a  woman  nurse, 
after  having  nursed  a  malignant  case  of  pneumonic 
plague,  when  she  might  have  been  supposed  to  be 
infected,  was  given  Hafifkine's  prophylactic-  She 
promptly  developed  the  pneumonic  form  of  the 
disease  and  died.  This  practice,  we  had  supposed, 
was  always  strongly  contraindicated.  Kitasato 
claims  that  the  diagnosis  of  plague  can  only  be 
made  with  certainty  by  bacteriological  tests.  Shiga 
prepared  a  prophylactic  of  his  own.  made  somewha*^ 
after  the  method  he  used  for  obtaining  a  prophylac- 
tic against  the  Japanese  dysentery.  The  technic|ue 
is  described  in  full  in  the  report,  but  not  much  is 
said  about  the  successful  use  of  this  agent.  We  art 
much  impressed  on  reading  the  report  with  the  sci- 
entific method  and  thoroughness  of  the  Japanese 
physicians,  except  as  to  the  tise  of  HafTkine's  pro- 
phylactic. 

Removal  of  the  Superior  Cervical  Sympathetic 
Ganglion  for  Glaucoma. — In  1898  Jonnesco,  of  Duda 
Pesth  (La  I'lessc  Mcdkale,  June  6,  1898),  suggested 
and  practised  the  removal  of  the  superior  cervical 
sympathetic  ganglion  for  the  relief  of  glaucoma, 
the  object  being,  of  course,  to  permit  the  third 
nerve  to  contract  the  pupil  and  to  relieve  the  intra- 
ocular tension  by  the  paralysis  of  the  sympathetic 
fiber  that  pass  through  this  ganglion.  He  operated 
upon  7  cases  with  asserted  good  results.  The  wave 
of  eagerness  to  remove  portions  of  the  nervous  sys- 
tem that  has  recently  swept  over  the  medical  world 
and  has  had  such  disastrous  results  upon  the  integ- 
rity of  the  Gasserian  ganglion,  naturally  aided  the 
results  described  by  Jonnesco  to  secure  followers ; 
and  Dodd,  in  England  {Lnnrct_  October  19,  1900). 
and  Coover,  in  America  (Phila.  Med.  Jour.,  March 
16,  1901),  have  reported  cases.  The  former  ob- 
tained transient  improvement,  that  is,  contraction 
of  the  pupil,  soft,  normal  tension  and  cessation  of 
the  pains ;  but  there  was  prompt  relapse  to  the 
original  condition.  The  latter  did  not  succeed  even 
so  well,  tension  remaining  plus  i,  and  the  vision 
relapsing  on  the  12th  day.  In  view  of  these  results 
by  reliable  men,  it  would  seem  that  Coover's  opin- 
ion is  thoroughly  justified,  that  it  is  an  operation  of 


last  resource,  and  even  then  oii'ers  very  little  hope 
of  permanent  relief.  It  is  universally  admitted, 
however,  that  it  is  easy  and  safe,  and  it  is,  there- 
fore, perha])s,  to  be  tried.  Dodd  does  not  approve 
of  the  bilateral  operation  at  one  sitting. 

Temporary  Ligation  of  the  Common  Carotid  as 
a  Preliminary  to  Resection  of  the  Superior  Maxilla. 
— The  last  issue  of  the  Philadelphia  Medical  Jour- 
nal contained  a  most  interesting  and  scientific  dis- 
cussion by  Professor  Carl  Schlatter,  of  Zurich,  on 
the  advantages  and  dangers  of  both  temporary  and 
permanent  ligation  of  the  common  carotid  artery 
as  a  preliminary  procedure  to  the  removal  of  the 
upper  jaw-  The  question  of  the  advisability  of  first 
ligating  the  external  or  the  common  carotid  has 
long  been  one  for  discussion  and  d'sagreement 
among  surgeons.  This  able  paper  would  certainly 
tend  to  put  aside  many  objections  that  have  been 
raised  against  the  temporary  ligation  of  the  com- 
mon carotid.  x-\lthough  in  many  instances  the  liga- 
tion of  the  external  carotid  is  sufficient  to  prevent 
hemorihage  during  the  operation,  yet  there  are 
cases,  such  as  one  reported  by  Professor  Schlatter, 
where  this  ligation  does  not  prevent  the  hemor- 
rhage- •  The  cerebral  complications  which  have  so 
frequently  followed  the  permanent  ligation  of  the 
common  carotid  do  not  arise  when  a  temporary 
elastic  ligature  has  been  properly  applied  to  this 
vessel,  for  under  such  circumstances  there  is  no 
formation  of  a  clot,  and  consequently  no  danger 
from  emboli.  The  blood  control  during  the  opera- 
tion of  removal  of  the  superior  maxilla  is  alwa\'s  a 
question  which  concerns  the  surgeon,  and  Professor 
Schlatter  shows  that  the  mortality  from  the  opera- 
tion is  much  higher  and  the  chances  of  recurrence 
of  the  malignant  growth  much  greater  where  no 
means  are  employed  to  prevent  hemorrhage  before 
beginning  the  excision.  Another  advantage  which 
is  urged  for  the  exposure  of  the  carotid  is  the  im- 
portant fact  that  in  carcinoma  of  the  upper  jaw 
the  glands  about  the  bifurcation  of  the  carotid  are 
the  first  to  become  involved  in  the  malignant  pro- 
cess, and  are  ahvays  diseased  before  they  can  be 
felt  by  the  hand  of  the  surgeon.  Therefore,  the  in- 
cision necessary  for  the  ligation  also  permits  of  the 
removal  of  these  glands.  The  literature  of  this 
operation  has  been  carefully  studied  and  the  con- 
clusions arrived  at  by  the  author  must  appeal  to 
every  surgeon. 

The  Effect  of  Alcohol  on  Immunity. — In  this  age 
of  rapid  scientific  advancement,  when  old  cherished 
beliefs  are  shattered  by  newly  discovered  facts, 
our  therapeutics  are  also  subjected  to  a  thorough 
revision.  It  appears  that  just  now  alcohol  is  bear- 
ing the  brunt  of  a  searching  investigation.    So  long 


744 


The     PHILiDELPHIA"! 
ilEDICAI.   JOCKNAL   J 


EDITORIAL  COMMENT 


IApbh.  20.  1901 


as  the  question  of  the  use  or  abuse  of  alcohol  re- 
mained a  purely  sociological  problem,  the  physician 
could  have  but  little  to  do  with  it  from  a  scientific 
standpoint.  Even  if  in  sympathy  with  the  anti- 
liquor  movement,  he  still  used  alcohol  as  a  medi- 
cine, firmly  believing  that  it  was  the  remedy  par 
excellence  in  acute  infectious  diseases.  This  well-es- 
tablished belief,  expressed  ex  cathedra  by  our  text- 
book writers  and  eminent  therapeutists,  has  re- 
ceived a  crushing  blow  at  the  hands  of  Doyen, 
Abbot,  Verlaguss,  Ranelleti,  and  a  number  of  other 
scientists,  who  have  investigated  the  effects  of  alco- 
hol experimentally.  The  unanimous  verdict  is  far 
from  being  in  favor  of  this  "health-restorer."  Re- 
cently, Dr.  S.  I.  Goldberg  instituted  the  following 
experiments  in  the  Bacteriological  Laboratory  of 
Prof.  Tshistovitch  (Russia)  .  He  divided  a  number 
of  pigeons  into  three  groups.  Those  of  the  first 
group  received  an  injection  of  a  non-fatal  dose  of  a 
culture  of  the  plague  bacillus,  and  with  it,  or  dur- 
ing several  days  subsequently,  medium  and  large 
doses  of  alcohol  introduced  by  means  of  a  sound. 
The  pigeons  of  the  second  group  received  small 
doses  of  alcohol  for  a  considerable  time  prior  to 
inoculation.  Finally,  those  of  the  third  group  re- 
ceived a  fatal  dose  of  the  culture,  and  for  several 
days  afterwards  small  doses  of  alcohol  twice  daily. 
The  conclusions  reached  were  as  follows:  (i)  pig- 
eons, which  are  but  slightly  susceptible  to  the 
plague,  had  their  susceptibility  greatly  increased  by 
small  doses  (2-3C.  c.  of  40%  alcohol),  which  were 
sufficient  to  produce  intoxication.  (2)  Chronic  al- 
coholism lowered  the  natural  resistance  of  the  pig- 
eons to  the  plague.  (3)  Small  repeated  doses  of  al- 
cohol did  not  save  the  birds  after  a  fatal  dose  of 
the  plague-culture. 

These  and  other  experiments  of  a  similar  nature, 
bceorded  in  recent  medical  literature,  seem 
to  indicate  that  alcohol,  even  in  small  doses,  exerts 
a  deleterious  effect  on  the  cells  proper,  and  while 
possessing  high  caloric  value,  as  proven  by  the  ex- 
periments of  Atwater,  it  is,  nevertheless,  a  cell- 
poison.  It,  therefore,  seems  that  its  continued 
use  in  acute  infectious' diseases  should  tend  to  pro- 
duce precisely  the  effects  against  which  it  is  di- 
rected. The  results  of  mere  laboratory  ejfperiments 
on  the  lower  animals  must,  however,  be  received 
with  some  caution.  Experimenters  frequently  ar- 
rive at  opposite  conclusions,  especially  on  the  sub- 
ject of  alcohol,  and  clinical  experience  is  not  lightly 
to  be  set  aside  at  the  behest  of  every  experimenter 
in  the  laboratories. 


Specific  Biological  Reactions. — The  discovery 
that  the  injection  of  blood  of  one  species  into  ani- 
mals of  another  species  produces  substances  which 


are  destructive  to  the  blood  of  the  species  from 
which  the  injected  blood  was  derived,  has  opened 
the  way  to  investigations  which  are  of  almost  un- 
limited extent  and  variety.  A  number  of  these 
reports  have  recently  been  abstracted  in  this 
journal,  most  of  them  referring  especially  to  the 
reactions  in  blood.  Among  the  most  interesting 
was  that  of  Uhlenhuth,  who  stated  that  the  result 
of  the  injection  of  blood  from  one  species  was  to 
produce  some  substance,  which,  when  added  to  a 
solution  of  blood  from  the  original  species,  even 
when  that  blood  had  been  dried  for  a  long  time, 
caused  a  definitely  recognizable  reaction,  even  in 
extremely  dilute  solutions.  He  claims  that  the 
reaction  is  absolutely  specific,  and  can  be  used  for 
distinguishing  human  blood  stains  for  medico-legal 
purposes.  His  results  have  been  confirmed,  though 
the  absolute  specificity  of  the  reaction  has  been 
denied.  There  have  also  been  numerous  other  re- 
ports showing  most  interesting  results.  The  most 
suggestive  of  these  was  the  demonstration  that 
the  injection  of  ciliated  epithelium  produces 
a  substance  which  dissolves  the  same  variety  of 
epithelium,  but  has  no  action  upon  other  cells.  This 
must  have  shown  at  once  to  many  readers  the 
possibility  of  producing  in  this  way  an  actual  spe- 
cific cancer  serum,  though,  unhappily,  this  possi- 
bility seems  as  yet  a  very  distant  one,  and  one 
hedged  about  by  many  and  great  difficulties,  in 
spite  of  the  work  recently  referred  to  editorially. 
In  addition  to  these  reports,  Delezenne  has  recently 
stated  that  he  has  produced  anti-hepatic  and  anti- 
nervous  serums,  these  serums  having  destructive  ef- 
fects upon  the  liver  and  ner%-ous  system  respect- 
ively, and  being  produced  by  injecting  emulsions 
of  these  organs  into  creatures  of  a  different  species. 
The  most  striking  fact  recorded  by  Delezenne  was 
his  observation  that  if  these  toxic  serums  were  ad- 
ministered in  frequent  butvery  small  doses. they  had 
directly  the  contrary  effect,  the  animal  being  soon 
made  almost  absolutely  resistant  to  the  effect  of 
large  doses.  This  approaches  verj'  closely  to  the 
production  of  serums  specifically  anti-toxic  to  those 
substances  which  act  directly  upon  various  organs, 
and  suggests  most  astonishing  possibilities.  The 
most  recent  use  of  this  method  is  described  by  Mer- 
tens  (Deutsch  iled.  Woch  March  14,  1901),  who 
states  that  he  has  shown  in  a  manner  that  is  almost 
absolutely  conclusive  that  the  albumin  in  the  urine 
in  nephritis  is  directly  derived  from  the  blood,  thus 
almost  definitely  settling  a  question  which  has  given 
rise  to  much  discussion.  His  statement  is  based 
upon  the  fact  that  he  injected  rabbits  with  human 
blood  serum,  and  afterwards  found  that  the  rab- 
bits' serum  caused  a  marked  reaction  with  human 
urine  containing  albumin,  but  did  not  react  with 


Antlt.  20,  19(111 


EDITORIAL  COMMENT 


CTnE   Philadelphia 
Mkdical  JonHNAL 


745 


humaTi  urine  free  from  alhiiniin  or  with  the  tirine  of 
normal  rabbits  or  of  rabbits  which  showed  marked 
albuminuria.  Further,  the  injection  into  rabbits  of 
human  urine  containing  albumin  was  followed  by 
the  production  in  the  rabl)it's  blood  serum  of  a 
substance  which  gave  exactly  the  same  reaction  as 
that  produced  by  the  injection  of  human  blood 
serum.  This  is  almost  absolute  proof  that  the 
albumin  in  the  urine  and  the  albumin  in  the  blood 
serum  are  exactly  the  same  biologically,  and  proba- 
bly chemicall)^  A  most  interesting  observation 
was  the  fact  that  the  serum  of  a  new  born  rabbit, 
whose  mother  had  been  treated  with  albuminous 
human  urine,  reacted  in  the  same  way  as  the  serum 
of  the  mother.  Mertens  considers  that  his  results 
demonstrate  that  the  serum  of  transudates  will 
react  in  the  same  way  as  the  blood  serum,  and  that 
transudates  may  be  used  for  injection  instead  of 
blood  serum.  He  also  believes  that  it  will  be  possi- 
ble to  use  albuminous  urine  instead  of  blood  serum  ; 
since  albuminous  urine  is  so  much  more  readily  ob- 
tained than  human  blood  serum,  this  will  greatly 
widen  the  opportunities  for  this  method  of  research. 
The  constantly  increasing  number  of  reports  similar 
to  this  one  must  convince  those  who  are  abreast  of 
the  literature  that  the  possibilities  in  this  line 
are  so  great  that  most  important  discoveries  may 
be  expected  within  a  very  brief  period.  We  seem 
to  be  on  the  verge  of  a  new  era,  both  in  the  experi- 
mental study  of  abstract  biological  questions  and  in 
therapeutic  advances,  which  are  directly  connected 
with  these  biological  studies,  and  which  will  be  of 
most  grateful  portent  to  those  sufferers  who  have 
heretofore  been  beyond  anything  better  than  pallia- 
tion. 

Three  Medical  Worthies. — In  the  Popular  Sricnre 
Uontlilji  for  April,  Professor  William  A.  Locy  pays  a 
j^aceful  tribute  to  a  triumvirate  of  medical  investi- 
gators, whose  names  abide  in  medical  tradition,  but 
whose  work  is  too  likely  to  be  forgotten.  As  Pro- 
fessor Locy  well  reminds  us,  we  are  too  apt  to  think- 
that  all  the  really  good  work,  especially  in  biology, 
has  been  done  in  very  recent  times,  with  modern 
methods  and  modern  insight.  A  glance  at  the  work 
of  Malpighi,  Swammerdam,  and  Leeuwenhoek,  is  a 
good  corrective  for  some  of  this  modern  self-lamia- 
tion.  These  three  men,  not  personally  associated. 
were  contemporaries  and  represented  that  revival 
of  science  which  characterized  the  17th  Centiirv. 
The  watch-word  of  that  century  was  oitsenation. 
Knowledge  was  to  be  gained  by  direct  appeal  to 
Nature  herself,  and  the  books  and  formula  which 
had  dominated  the  dark  ages  were  discarded.  In 
this  one  vital  respect  this  was  an  age  of  pure  scien- 
tific method,  and  quite  equalled  our  own  in  the  zeal 
and  consistency  with  which  men  sought  to  wrest 


from  Nature  herself  the  secrets  of  morphology  and 
even  of  life.  The  pioneers  had  been  Vesalius,  Gali- 
leo, Harvey  and  Descartes,  and  our  three  medical 
worthies  were  of  only  one  generation  later. 

Malpighi  wasan  Italian,  born  near  Bologna  in  1628. 
In  his  discoveries,  and  in  the  position  he  occupies 
in  the  history  of  natural  science,  he  deserves  the 
title  of  an  original  and  profound  observer.  He 
studied  not  so  much  the  gross,  but  the  finer  anat- 
omy of  animals,  and  pursued  his  studies  also  in  the 
vegetable  kingdom.  He  was  one  of  the  founders 
of  modern  histology,  and  did  extraordinarily  fine 
work,  considering  his  instruments.  His  drawings 
of  the  anatomy  of  the  silk  worm  are  models  of 
accuracy.  Insect  anatomy  was  an  unknown  field, 
and  here  Malpighi  demonstrated  for  the  first  time 
the  dorsal  vessel,  the  tracheal  system,  the  stomach 
and  the  reproductive  organs.  His  work  in  embry- 
ology was  remarkable,  and  his  drawings  'jok  as 
though  they  came  out  of  some  modern  laboratory. 
He  also  observed  the  blood  corpuscles,  and  his 
name  is  identified  with  the  anatomy  of  the  kidney 
and  spleen. 

Swammerdam  was  a  native  of  Holland,  and  his 
portrait  by  Rembrandt  is  preserved.  He  was  an 
indefatigable  worker  and  an  expert  draughtsman. 
He  also,  like  Malpighi,  did  some  exquisitelv  fine 
work  in  entomology,  and  helped  to  establish  biol- 
ogy and  morphology  on  an  enduring  basis.  His 
drawings  were  even  better  than  Malpighi's.  and 
were  veritable  works  of  art.  No  one  can  look  at 
the  reproductions  of  some  of  them  and  not  be  im- 
pressed with  the  excellence  and  variety  of  such  a 
gift  in  a  scientist.  Swammerdam  opposed  the 
theory  of  spontaneous  generation,  which  in  his  day 
was  actively  debated.  He  was  a  believer,  how- 
ever, in  the  "preformation"  theory,  which  was  that 
an  animal  was  fully  formed  in  the  ovum — an  idea 
which  has  its  nearest  modern  analogue  in  the  theory 
of  pangenesis. 

Leeuwenhoek  was  an  ardent  microscopist,  and 
owned  no  less  than  247  complete  microscopes — ■ 
though  what  he  wanted  with  so  many  does  not  ap- 
pear. In  addition,  he  had  172  lenses.  Many  were 
mounted  in  silver  and  a  few  in  gold — such  was  the 
vanity  of  science  in  those  days.  His  microscopes, 
however,  were  made  without  tubes ;  the  lenses  were 
merely  held  in  place  on  pieces  of  metal,  with  screws 
to  adjust  the  object  and  secure  focus.  Leeuwen- 
hoek's  great  merit  was  to  have  demonstrated  the 
capillary  circulation.  He  sought  it  in  the  comb  of 
a  cock,  the  ear  of  a  white  rabbit,  and  the  wing  of  a 
l)at.  Rut  finally  his  search  was  rewarded  by  find- 
ing what  he  sought  in  the  tail  of  a  tad-pole.  His 
description  is  replete  with  the  enthusiasm  of  the 
simple-minded  naturalist.  Leeuwenhoek  also  made 
observations  on  the  blood  corpuscles,  although  he 


746 


The   Philadelphia"! 
SlEDirAi.  JornXAL  J 


EDITORIAL  COMMENT 


[APEIL  20.  1901 


had  been  anticipated  by  Malpighi;  but  these  two 
were  amonof  the  first  hcmatologists. 

Even  a  brief  study  of  the  lives  and  work  of  these 
famous  scientists  is  of  great  profit,  for  it  gives  to 
us,  of  the  present  day,  a  more  adequate  conception 
of  the  universality  of  science  and  of  the  great  at 
tainments  of  some  of  the  old  and  well-nigh  forgot- 
ten worthies  of  medicine. 

The  Relations  of  the  Purely  Scientific  Studies 
to  the  Physician's  Work. — In  a  paper  published  in 
the  Boston  Medical  and  Surgical  Journal,  A^rW  4,  1901, 
H.  D.  Arnold  makes  'he  following  statement:  "The 
average  practitioner  is  apt  to  rest  satisfied,  if,  by 
discovering  a  murmur,  he  is  able  to  point  out  the 
site  of  the  lesion  and  can  give  an  anatomical  name 
to  the  disease.  Fortunately,  for  both  patient  and 
physician,  the  heart  generally  has  wonderful  recu- 
perative powers,  if  given  half  a  chance.  Rest,  with 
or  without  medication — and  sometimes  in  spite  of 
bad  medication — furnishes  the  opportunitv,  and  we 
take  credit  to  ourselves  for  an  improvement  which 
was  due  to  nature,  and  neither  to  our  thorough  un- 
derstanding of  the  condition,  nor  to  an  intelligent 
application  of  remedies."  This  statement  in  rela- 
tion to  heart  disease  may,  witii  certain  modifica- 
tions, be  applied  to  diseases  of  other  organs,  and 
should,  we  think,  be  forcibly  and  fre(|uently  brought 
to  the  attention  of  the  medical  student,  ^lany  a 
student  is  prom^  to  think,  as  he  sits  on  the  benches 
during  his  first  and  second  years  of  medical  study, 
that  the  details  of  chemistry,  anatomy,  physiology, 
and  patholog}^,  which  he  is  expected  to  master,  have 
really  little  to  do  with  the  work  of  his  profession, 
and  in  this  opinion  he  is  often  confirmed  by  the  at- 
titude of  his  acquaintances,  who  have  completed 
the  prescribed  four  years  of  study  and  have  begun 
practice-  So  when  the  student  reaches  his  third 
year  and  begins  the  study  of  the  practice  of  med- 
icine, he  is  prone  to  give  scant  attention  to  the 
pathology  and  the  diflferential  diagnosis  of  the  dis- 
eases as  presented  bj-  his  instructors ;  but  so  soon 
as  a  prescription  is  put  on  the  blackboard,  he  copies 
it  with  an  energy  that  might  better  be  expended  in 
mastering  the  natural  history-  of  the  disease  in 
qustion.  The  savages  beat  upon  drums,  hoping  bv 
the  din  to  scare  away  the  evil  spirit  of  the  disease 
and  thus  renew  the  vitality  and  usefulness  of  the 
afflicted  one.  The  civilized  races  go  to  a  physician, 
expecting  to  receive  a  drug  or  a  series  of  drugs  tha' 
Avill  kill  the  same  evil  spirit  of  disease  and  render 
them  immune,  while  tjiey  hold  fast  to  their  habits 
of  unhygiene  and  of  exposure.  Drugs  have  not  this 
magic  charm,  and  those  practitioners  who  have  mis- 
applied their  energies  during  their  college  days,  as 
well  as  the  students  who  are  now  learning  of  the 
mysteries   and  the   frailties   of    the    human    bodv. 


should  bear  constantly  in  mind  that  the  normal  and 
pathological  anatomy  and  physiology  which  they 
are  expected  to  understand  will  go  farther  toward 
fitting  them  to  teach  their  patients  the  true  secret 
of  health  than  the  mere  knowledge  that  such  and 
such  a  prescription  is  good  for  this  or  that  disease. 
So,  too,  the  mere  ability  to  recognize  and  locate  a 
cardiac  murmur  or  a  bronchial  rale,  to  find  tube 
casts,  or  to  discover  albumin  or  sugar  in  the  urine, 
will  avail  little  unless  the  fundamental  principles 
of  the  cause,  course  and  lesions  of  the  disease  pro- 
ducing these  symptoms  be  thoroughly  understood- 

The  Census  of  India. — According  to  the  British 
Medical  Journal,  the  census  of  India  was  taken  verv 
quickly  and  accurately,  for  the  preliminary  figures 
were  published  fourteen  days  after  the  date  for 
counting  the  population.  There  are  some  details 
in  this  census  that  are  of  interest  to  medical  read- 
ers. The  total  population  of  India  is  hardly  as  great 
as  is  generally  supposed.  It  is  shown  by  this  cen- 
sus to  be  294,266,000,  a  gain  of  6,949.000,  or  2.42  per 
cent,  since  1891.  The  increase  revealed  by  the  cen- 
sus of  1891  was  11.2  per  cent.;  therefore,  there  ap- 
pears to  have  been  some  check  on  the  growth  of 
population  in  the  great  Hindoo  peninsula  for  the 
past  ten  years.  What  this  check  consists  of  is.  per- 
haps, not  diffictilt  to  determine.  India  has  been 
swept  with  famine  and  pestilence.  Even  allowing 
for  greater  accuracy  in  counting  the  population  (a 
factor  which  always  rather  tends  to  lessen  than  to 
increase  the  figures),  the  fact  remains  that  this 
census  is  a  mournful  object  lesson  for  mankind  in 
general. 

The  territory  directly  under  British  rule  shows 
an  increase  of  4-44  per  cent.  The  facts  all  told  are 
capable  of  but  one  interpretation.  The  native 
States  have  not,  as  a  rule,  met  the  emergencies 
caused  by  the  plague,  cholera  and  the  famine,  with 
the  same  intelligence  as  has  been  shown  by  the 
British  Government  in  the  territory  directly  under 
its  control.  The  figures,  however,  vary  for  the  sev- 
eral native  States,  and  in  some  instances  the  popu- 
lation has  increased ;  but  the  deduction  just  stated 
is  probably  in  the  main  correct.  Natural  causes 
also  explain  the  figures:  thus  those  parts  of  India 
which  are  well  watered — whether  British  or  native 
— and  which,  therefore,  escaped  the  famine  of  1897 
and  1900,  show  an  advance.  The  traces  of  the  fam- 
ine and  its  twin  progeny  (pestilence  and  impaired 
fecundity),  are  very  evident  in  these  returns.  Even 
in  famine-stricken  areas  the  loss  of  life  was  less 
under  Britsh  rule  than  under  native  government. 
This  is  a  satisfactory  proof  of  the  efficiency  of  good 
government.  Much  remains  to  be  worked  out  by 
a  study  of  these  figures,  and  this  will  be  done  by 
Mr.  H.  H.  Risley,  the  Census  Commissioner,  whose 


AriiiL  2U,  liiulj 


REVIEWS 


L  »i 


HE  Philadelphia 

EDICAL   JOCEXAL 


747 


studies  will  doubtless  bring  out  in  full  tbe  relation 
of  famine  and  pestilence  to  tbe  arrest  of  population 
in  this  teeming  region  of  the  world. 


IRcviews. 


Infant  Feeding  in   Health  and  Disease.     By  Louis  Fischer, 
M..  D.     Octavo  359.     F.  A.  Davis  Company 

The  volume  opens  with  brief  remarlis  on  the  anatomy 
of  the  infantile  stomach.  There  is  then  a  satisfactory 
short  account  of  the  chemistry  of  the  digestive  secretions. 
We  find  an  unnecessarily  full  description  of  various  forms 
of  bacteria  actions  present  in  the  gastrointestinal  tract, 
marked  details  which  only  a  specialist  in  bacteriology 
needs  or  would  understand.  The  chemical  and  physical 
properties  of  bovine  and  human  milk  are  treated  of  ex- 
tensively, as  is  the  whole  subject  of  artificial  feeding.  There 
are  given  some  useful  analyses  of  various  commercial 
foods,  and  a  serviceable  chapter  on  infant  stools.  Finally 
we  find  a  dietary  containing  many  good  formulae  at 
times  of  value.  We  have  read  Dr.  Fischer's  little  book 
with  much  interest  and  considerable  care.  We  are  sorry 
that  we  found  in  it  an  unusually  slovenly  and  often  un- 
grammatical  use  of  the  English  language.  One  wonders 
what  had  happened  to  the  publisher's  reader.  Note,  for 
instance  the  following  remarkable  sentences:  "The  in- 
vestigation of  Leo  and  von  Puteren  show  that  the  gastric 
contents  are  propelled  within  from  one  and  a  half  to  two 
hours.  With  food  that  is  more  difficult  to  digest  the 
stomach  is  emptied  much  slower  and  less  complete." 
"Another  nipple  I  have  used,  but  it  is  much  harder  to 
clean,  and,  unless  all  precautions  for  sterilization  are 
noted,  this  nipple  should  not  be  used;  yet,  in  the  hands  of 
the  intelligent,  or  where  we  have  a  trained  nurse,  it  can  be 
safely  recommended.  It  is  called,  etc."  A  much  more 
serious  and  vital  fault  is  the  author's  evident  searching 
for  evidence  in  support  of  certain  pet  views,  with  his  ig- 
noring of  what  could,  and  should,  be  said  upon  the  other 
side.  That  which  the  experience  of  many  physicians  has 
proven  useful  is  considered  utterly  without  sufficient  rea- 
son given,  and  that  which  is  unusual  and  not  generally 
accepted  is  in  terse  manner  praised,  and  its  truth  some- 
times simply  assumed.  This  makes  the  book  an  unsafe 
guide.  Yet  the  little  volume  in  this  respect  shows  a 
conscientious  study  of  recent  and  older  scientific  work 
done  in  the  domain  of  infant  feeding,  and  contains  a  large 
number  of  references  and  quotations,  which  will  be  ser- 
viceable to  those  desiring  to  make  milk  a  study  for  them- 
selves.   To  those  we  can  heartily  recommend  it.     [C.  G.] 


A  Laboratory  Guide  in  Elementary  Bacteriology.     By  Wil- 
liam Dodge  Frost,  Instructor  in  Bacteriology,  Univer- 
sity of  Michigan.     Ilustrated.     1900.     Published  by  the 
Author,  Madison,  Wis.    200  pages,  8x10%  inches. 
This  laboratory  guide  opens  with  a  list  of  texts  and  ref- 
erence books,  list  of  apparatus  and  a  few  concise  laboratory 
rules.     Following  this  the  work  is  divided  into  two  parts. 
Part    I    dealing    with    general    bacteriology    and    Part    II 
with   medical    bacteriology,   the    two   parts    embracing    10 
chapters  numbered  continuously  through  both. 

Directions  for  the  preparation  of  containers,  media,  stains 
and  directions  tor  drawing  and  special  stains  are  given  in 
Chapter  I.  Chapter  II  deals  with  the  physiology  of  the 
tacteria,  with  methods  for  determining  reaction,  influence 
of  physical  agents,  color  production,  etc.  Chapter  III,  tax- 
onomy and  subsequent  chapters  are  largely  given  to  the 
study  of  special  organisms. 

In  the  first  50  pages  and  occasionally  elsewhere,  alter- 
nate pages  are  left  blank  for  notes.  The  tables  given  for 
the  study  of  bacteria  strike  the  reviewer  as  being  of  very 
great  value  as  indicating  to  the  student  the  steps  to  be 
worked  out  and  the  data  to  be  recorded. 

Chapter  .VIII  dealing  with  animal  inoculation  and  stain- 
ing of  bacteria  in  tissue  could  be  elaborated  to  advantage. 
There  is  less  than  one  page  to  the  detection  of  pathogenic 
bacteria  in  water  and  milk  supplies  (Chapter  X).  It  might 
have   lessened   the   confusion   in   the   student's   mind   had 


synonyms  for  all  organisms  been  given  as  has  been  done 
in  the  case  of  pneumoccus. 

The  paper  is  good  and  the  typography  and  tabulation  are 
fully  acceptable.  The  copy  sent  out  for  review  has  evi- 
dently been  very  poorly  seasoned  and  cannot  be  kept  fiat. 
As  the  book  is  intended  for  the  laboratory  the  reviewer 
would  suggest  to  the  author,  who  is  also  the  publisher,  that 
it  be  bound  in  one  of  the  forms  of  rubber  cloth  now  used 
for  manuals  of  dissection. 

The  book  will  undoubtedly  be  an  acceptable  guide  for 
use  of  the  student  and  even  tor  the  investigator  as  a  con- 
venient blank  for  recording  results.     [W.  M.  L.  C] 


A   Text-Book   of  the    Medical    Treatment   of   Diseases   and 
Symptoms,   By   Nestor   Tirard_   M.   D.,   Lond.,   F.R.C.P. 
Professor  of  the  Principles  and  Practice  of  Medicine, 
King's  College,  London,  etc.     Adopted  to  the  United 
States   Pharmacopoeia   by   E.   Quin   Thornton,   M.   D., 
Dermonstrator    of    Therapeutics,    Pharmacy    and    Ma- 
teria Medica,  Jefferson  Medical  College,  Philadelphia. 
8vo,  pp.  630.     Philadelphia  and  New  York:   Lea  Broth- 
ers Co. 
This  book  is  intended  to  bridge  the  gap  between  the  in- 
struction  in   therapeutics   as   given   in   text-books   on   the 
practice  of  medicine,  and  such  treatment  of  the  patient  as 
is  needed  at  the  bedside.  The  author  very  properly  says 
that  a  student  may  know  many  diseases  and  symptoms  tor 
which  a  particular  drug  such  as  digitalis  or  belladona,  may 
be  employed,  and  yet  scarcely  be  prepared  with  the  various 
drugs  serviceable  in  the  course  of  treatment  of  any  indi- 
vidual  disease  or  treatment  of  almost  all   the  local   and 
constitutional  diseases  and  of  permanent  symptoms  such 
as    vomiting,    gastralgia,    constipation    and    night    sweats. 
The  advice  given  is  helpful,  and  even  those  having  consid- 
erable experience  in  the  treatment  of  diseases  will   find 
valuable  suggestions  in  many  places.     [H.  B.  A.] 


The     Morphology    of    the    Blood    in    Diphtheria,    Scarlet 

Fever  and  Scarlatinoform  Erythema.  Pitkianen  [I'rtrr- 
liiiriixlcdid  Disscrtatxia,  1900),  found  that  in  mild  cases  of 
diphtheria  a  moderate  hyperleukocytosis  is  present  in  the 
first  stages  of  the  disease,  gradually  disappearing  as  im- 
provement sets  in.  Polymorphonuclear  leukocytes  are  ia 
some  cases  increased,  while  in  others  remain  normal; 
as  improvement  progresses,  their  number  gradually  dimin- 
ishes. Eosinophiles  are  absent  in  the  first  stages  of  the 
disease,  but  make  their  appearance  as  the  disease  ad- 
vances toward  a  favorable  issue.  Similar  conditions  are 
observed  in  cases  of  diphtheria  of  moderate  severity.  In 
severe  cases  of  hyperleukocytosis  is  marked  from  the 
beginning  and  persists  during  the  entire  progress  of  the 
disease.  The  polymorphonuclear  leukocytes  are  increased 
at  first,  diminish  gradually  and  are  again  increased  if  the 
disease  terminates  fatally.  Eosinophiles  are  invariably 
absent  in  fatal  cases.  The  presence  of  the  eosinophiles  or 
their  increase  in  diphtheria  is  a  favorable  prognostic  sign; 
their  absence  for  three  or  four  days,  on  the  other  hand. 
points  to  a  fatal  determination.  The  morphology  of  the 
blood  in  non-diphtheritic  sore  throat  is  similar  to  that  of 
mild  cases  of  diphtheria.  A  marked  increase  of  the  latter 
is  found  in  scarlatinoform  erythema.     [A.  R.] 


Tannalbin,  Tannigen  and  Tannoform  in  Intestinal  Dis- 
eases  of  Children.  Preis  (Triidi  OliKlicattra  Riinskirh  Vintihci 
r  l/os-Ar/c.  1900).  tried  the  above  remedies  in  148  cases  of 
various  intestinal  disturbances  of  children,  the  doses  em- 
ployed being  0.03-0.03  grms.  for  a  child  one  month  old,  0.1 
for  one  2  months  old,  and  0.2  for  a  3-months-old  child.  The 
results  obtained  were  as  follows:  Tannalbin  proved  suc- 
cessful in  intestinal  indigestion,  acute  and  chronic  catarrh 
of  the  small  intestines  and  in  tubercular  diarrheas.  Tanni- 
gen failed  to  produce  any  beneficial  effect  in  every  case  it 
was  used.  Tannoform  was  successful  in  only  a  tew  cases, 
namely,  in  acute  and  chronic  intestinal  catarrh,  cholera 
infantum  and  tubercular  diarrheas,  but  even  in  these 
cases  the  effects  were  inconstant,  and  only  children  not 
younger  than  2-3  months  were  benefited.    [A.  R.] 


^jaR       Tue   Philadelphia"! 
/t"         Medical  JotJEUAL  J 


AMERICAN  NEWS  AND  NOTES 


[Apbil  20,  wn 


ainevican  mews  ant)  Tflotcs. 


PHILADELPHIA,    PENNSYLVANIA,    ETC. 

Wills'  Hospital  Ophthalmic  Society. — Meeting  held  in 
Philadelphia,  25th  March,  lyol,  Dr.  P.  N.  K.  Schwenk  in 
the  chair.  Primary  Sarcoma  of  the  Iris. — Dr.  Conrad 
Berens  presented  a  most  interesting  case  illustrating  the 
secondary  stage  of  primary  sarcoma  of  the  iris.  The  pa- 
tient, a  young  man,  who  was  free  from  any  symptoms  and 
obtainable  history  of  syphilis  or  tuberculosis,  first  noticed 
the  affection  some  three  years  previously.  Imbedded  in  a 
partially  degenerate  and  comparatively  uninflammed  iris- 
tissue  were  live  irregular  tumor-masses,  over  and  through 
which  some  fine  vessel  ramitication  could  be  plainly  seen. 
The  plane  of  the  iris  was  pushed  forward.  The  pupillary 
area  which  was  slightly  distorted,  contained  some  meshes 
of  glistening  lymph.  The  crystalline  lens  occupied  its  nor- 
mal position.  No  view  of  the  fundus  could  be  obtained. 
Intraocular  tension  was  increased  to  plus  two.  No  view  o£ 
the  fundus  could  be  obtained.  Intraocular  tension  was  in- 
creased to  plus  two.  There  was  not  any  ciliary  tenderness. 
Based  upon  these  findings  and  the  fact  that  the  therapeutic 
tests  for  syphilis  and  tuberculosis  had  been  unsuccessfully 
applied,  Dr.  Berens  felt  certain  of  the  diagnosis,  and  be- 
lieved that  it  would  be  poven  after  enucleation.  Dr.  Frani; 
Fisher  tended  to  the  opinion  that  there  might  be  an  irido- 
cyclitic  element  in  the  case.  Dr.  William  W.  McClurc 
agreed  in  the  diagnosis,  giving  a  number  of  differential 
points  between  the  one  almost  certain  and  the  other  pos- 
sible processes.  Dr.  Charles  A.  Oliver,  while  fully  agree- 
ing in  Ihe  etiology  of  the  condition  was  disposed  to  place 
the  main  bulk  of  the  growth  in  the  ciliary  body.  Embol- 
ism of  the  Central  Retinal  Artery. — Dr.  Frank  Fisher  ex- 
hibited a  series  of  water-color  sketches  of  several  stages  of 
a  case  of  embolism  of  the  central  artery  (full  details  of 
the  case  to  be  published  in  full  later).  The  patient,  a  young 
subject  with  a  mitral  murmur,  gave  the  usual  history  of 
sudden  blindness.  Besides  the  characteristic  eyeground  of 
the  affection,  all  of  the  main  retinal  blood  currents,  both 
arterial  and  venous,  were  found  to  be  interruptedly  flow- 
ing in  their  proper  directions;  the  curious  fact  being  that 
the  venous  currents  were  travelling  with  twice  the  rapid- 
ity of  the  arterial.  Dr.  McClure  stated  that  he  had  had 
the  opportunity  to  see  two  cases  in  their  very  earliest 
stages.  One  of  the  early  changes  he  had  found,  consists  iu 
a  lead-tinted  area  bounded  upon  its  superior  and  inferior 
borders  by  two  fine  vascular  twigs  that  are  not  ordinarily 
observable,  giving  the  area  of  infiltration  a  caudate  form. 
The  second  of  his  cases  which  but  partially  closed  the 
arteries,  showed  broken  blood  currents  in  the  two  prin- 
cipal veins  running  in  the  direction  of  that  which  is  pursued 
by  the  ordinary  contained  blood.  Dr.  Schwenk  had  seen 
six  clinical  cases  of  central  retinal  artery  embolism,  one 
of  which  occurring  in  Dr.  Harlan's  service  at  the  Hospital 
and  which  showed  the  vascular  bead/ngs,  he  had  made 
careful  drawings  of.  these  being  published  in  the  Trans- 
actions of  the  American  Ophthalmological  Society.  His  ex- 
perience had  been  that  vision  seldom  if  ever  returns  in 
the  pronounced  types  of  the  disorder.  Dr.  Charles  A.  Ol- 
iver was  greatly  interested  in  the  double  rapidity  of  the 
venous  current  seen  in  Dr.  Fisher's  case,  and  spoke  of 
the  difference  between  trophic  and  functional  disturbance 
found  in  these  cases,  drawing  attention  to  the  two  forms 
of  vascular  circulation  in  the  human  retina.  He  made 
mention  of  the  possibilities  of  endarteritis,  vessel-spasm 
and  thrombus  in  such  cases,  and  did  not  deem  a  differen- 
tial clinical  diagnosis  in  3uch  cases  as  entirely  certain  in 
every  instance  as  the  several  conditions  might  be  coex- 
istent. Dr.  'Walter  L.  Pyle  called  attention  to  several  cases 
In  ophthalmic  literature,  in  which  although  there  was  com- 
plete embolism  of  the  central  artery,  a  small  sector  in  the 
field  of  vision  was  preserved:  ophthalmoscopic  examina- 
tion showing  a  cilio-retinal  artery,  supplying  the  corres 
ponding  retinal  area.  Dr.  Fisher  did  not  believe  that  there 
was  any  collateral  retinal  circulation.  He  considered  the 
most  remarkable  feature  in  his  case  to  be  the  visibility 
of  both  the  arterial  and  the  venous  circulations  in  the  re 
Una  at  the  same  time.  He  deemed  prognosis  as  to  vision 
doubtful  when  an  embolism  is  situated  within  the  retina  as 
It  Is  not  likely  to  imdergo  absorption  in  such  a  position. 
Successful   Extraction  of  Manganese  Steel  from  the  Crys 


talllne  Lens. — Dr.  Schwenk  showed  a  forty-five  year  old 
man  from  whom  he  had  successfully  removed  a  piece  of 
manganese  steel  from  the  left  lens.  The  points  of  interest 
iu  his  case  consisted  in  the  facts  that  the  form  of  steel 
v.hich  was  imbedded  in  the  lens  substance  was  but  feebly- 
attracted  by  the  magnet  and  that  much  of  the  lens  matter 
which  had  appeared  transparent  at  the  time  of  the  removal 
of  the  foreign  body  afterwards  became  opaque  and  greatly 
swollen.  Dr.  McClure  gave  the  details  of  a  case  of  steel 
in  the  lens  in  which,  before  making  the  corneal  section 
with  a  von  Graefe  knife,  he  created  a  path  or  track  through 
the  lens  fibres  with  a  Hay's  needle  for  the  escape  of  the 
foreign  body.  After  this  was  done,  it  was  but  necessary 
to  bring  a  magnet  tip  to  within  two  inches  of  the  external 
wound,  the  foreign  body  fairly  leaping  out  of  the  eye 
though  its  open  pathway.  The  lens  mass  was  then  ex- 
pressed without  any  trouble.  Recovery  was  uneventful,  a 
corrected  vision  of  two-thirds  of  normal  being  later  ob- 
tained. Dr.  Oliver  stated  that  not  sufficient  attention  had 
ijceu  paid  to  the  relative  traction  qualities  of  the  different 
forms  of  steel,  all  being  classed  alike.  He  believed  that 
exlemely  hard  and  brittle  manganese  or  nickel  steel  are  so 
dense  and  contain  so  much  nonmagnetic  material  that  the 
electric  current  cannot  permeate  the  mass  sufficiently  to 
attract  eaough  of  the  ferric  elements  to  produce  expulsion 
of  the  foreign  body  unless  the  magnetic  force  be  very 
greatly  in  excess  of  that  which  is  obtained  by  the  ordin- 
ary forms  of  clinical  magnet.  He  also  called  attention  to 
the  fact  that  on  account  of  the  very  great  brittleness  of 
manganese  steel,  workmen  should  be  taught  to  be  ex- 
tremely careful  in  the  handling  of  such  material  as  it  U 
particularly  liable  to  fracture.  In  all  his  cases  where  per- 
missible, he  removed  as  much  of  the  clear  lens  material 
as  possible,  this  being  readily  accomplished  by  means  of 
a  grooved  spud.  Dr.  Berens  made  it  a  rule  to  evacuate  all 
of  the  clear  lens  matters  that  he  could  with  safety  to  the 
organ.  Removal  of  Congenital  Cataract. — Dr.  Oliver  ex- 
hibited a  nine  year  old  Hungarian  boy  from  whom  he  had 
successfully  removed  two  congenitally  opaque  lenses  by 
free  discission,  obtaining  a  corrected  vision  of  normal  in 
each  eye.  The  case  was  of  interest  as  showing  the  good 
effects  of  diametrically  opposed  forms  of  treatment  in  the 
two  eyes,  necessitated  by  an  attack  of  secondarj'  glaucoma 
from  stoppage  of  lymph  !io\v  caused  by  a  blocking  of  the 
pupillary  area.  He  did  not  consider  such  a  complication  of 
any  great  moment  in  the  young  otherwise  healthy  eye  as  it 
rapidly  subsided  under  appropriate  treatment  without  any 
damage  to  the  organ.  Dr.  Schwenk  presented  a  case  of 
congenital  cataract  in  a  white  male  of  thirty  years  of  age, 
the  interesting  point  being  that  three  brothers  were  simi- 
larly affected,  while  three  sisters  had  normal  eyes.  Ten 
days  previous,  a  free  discission  of  the  right  lens  was 
done  by  the  Senior  Resident  Surgeon  of  the  Hospital.  The 
lens  rapidly  swelled  and  several  opaque  pieces  of  matter 
fell  into  the  anterior  chamber.  One  week  later,  although 
intraocular  tension  was  normal  and  the  eye  was  quiet.much 
of  the  remaining  lens  material  was  extruded  by  means  of  a 
grooved  spud.  At  present  the  eye  is  practically  well.  The 
lmn\fdiate  Results  of  Mules'  Operation. — Dr.  Oliver  showed 
the  immediate  results  of  a  Mules'  operation  in  a  case  of 
panophthalmitis.  The  patient  was  a  twenty-three  year  old 
sailor  who  had  lost  his  eye  about  a  year  previously  from 
gonorrheal  infection.  As  a  large  area  of  the  sclerotic  coat 
at  the  upper  outer  corenal  limbus  was  softened  and  in- 
filtrated, he  took  advantage  of  excising  this  part  while 
converting  the  circular  corneal  area  into  a  lozenge  of  suf- 
ficient size  to  admit  the  placing  of  the  glass  ball  into  the 
scleral  cavity.  In  less  than  five  days'  time  without  any 
reaction,  the  conjunctival  sac  was  clean  and  the  eyeball 
was  freely  mobile.  In  accordance  with  a  suggestion  from 
the  Senior  House  Surgeon  of  the  Hospital  he  had  most 
successfully  employed  pressure  bandages  instead  of  the 
usual  feed  compresses.  He  expected,  as  is  his  rule,  to 
discharge  the  case  from  the  wards  of  the  Hospital  as  cured 
in  a  few  days'  time.  He  will  order  a  properly  adapted  arti- 
ficial eye  for  the  patient  as  soon  as  the  socket  becomes 
fixed  in  size.  He  had  learned  from  experience  that  through- 
out the  entire  procedure  it  is  always  best  to  avoid  touch- 
ing the  borders  of  tissue  intended  for  coaptation  by  any 
(ixing  instruments,  and  always  to  remove  the  ocular  con- 
tents with  a  number  of  moistened  cotton  swabs  twisted 
upon  the  end  of  clean  applicators.     He  has  broadened  the 


APRIL  'JO,    19011 


AMERICAN  NEWS  AND  NOTES 


[The  Philadelphia 
Medical  Joubkal 


749 


field  of  the  usefulness  of  the  procedure  to  cases  in  which  he 
had  previously  had  no  expectation  of  good  results,  employ- 
ing the  plan  with  immediate  cessation  of  all  inflammatory 
signs  in  cases  of  panophthalmitis  and  even  localized  ten- 
onitis in  which  even  isolated  areas  of  softening  in  the 
anterior  portion  of  the  sclera  had  become  evident. 

A  Medical  Club  Chartered. — Judge  Ralston  approved  the 
charter  of  the  Ptolemy  Society,  a  corporation  formed  for 
social  intercourse  and  to  disseminate  medical  science.  The 
officers  are:  President,  Stilroan  Henry  Conner;  vice-presi- 
dent, Bert  Edward  Goodman;  secretwy,  Atlee  David 
Mitchell;  treasurer,  Frank  Cornelius  Leytze,  and  Board  of 
Governors,  Drs.  Hiram  R.  Loux.  Hobart  A.  Hare,  Justus 
Sinexon,  Dudley  D.  Smith  and  Edwin  Russell  Kennedy. 

Epipoplexy. — Dr.  James  T.  Jelks,  of  Hot  Springs,  Arkan- 
sas, informs  us  by  letter  that  his  recent  interesting  paper 
on  this  subject  which  appeared  in  the  Malical  Keconl 
(March  23rd),  was  read  before  the  Texas  Medical  Society, 
and  consequently  before  the  appearance  of  Dr.  John  B 
Roberts'  paper  on  the  same  subject  in  the  Philadelphia 
Medical  Journal  for  January  2Gth.  This  accounts,  of 
course,  for  Dr.  Jelks'  not  having  made  reference  to  Dr. 
Roberts'  paper. 

Appointment. — Governor  Stone  has  appointed  Professor 
L.  Webster  Fox  a  member  of  the  Board  of  Managers  of  the 
Orthopaedic  Hospital  and  Infirmary  for  Nervous  Diseases. 
of  Philauelphia. 

Jewish  Maternity  Home. — The  number  of  patients  re 
celved  at  the  Jewish  Maternity  Home  in  March  was  10: 
cared  for  during  the  month.  14;  applications,  15;  births, 
8;  operations.  9;  discharged,  9;  remaining,  5.  In  the  clinic 
25  new  patients.  21  oid  patients  and  12  eye  patients  were 
treated.  In  the  Nursery  for  Motherless  Infants  there  were 
6  admissions,  added  to  7  remaining  from  February  made  13 
cared  for;  discharged,  8;  in  the  nursery  March  31,  5. 

Dr.  Henry  S.  Clemens. — Dr.  Henry  •S.  Clemens,  of  Allen- 
town,  Pa.,  died  April  Sth.  agen  63  years.  He  was  graduated 
from  the  University  of  Pennsylvania  in  1S61.  and  for  the 
last  thirty  years  practiced  his  profession  in  Allentown. 

..Berks  County  Medical  Society. — At  the  April  meting  of 
this  society  Dr.  Jno.  Bertolette  presented  the  history  of  a 
case  of  elephantiasis  that  came  under  his  care.  The 
patient  being  a  woman  of  51  years  of  age,  no  children, 
both  parents  living  to  old  age  The  foot  measured  15  inches 
in  diameter,  the  leg  12  inches.  Dr.  Bertolette  states  that 
!>he  itching  of  the  parts  was  so  intense  at  times  as  to  ne- 
cessitate the  use  of  brushes  to  allay  the  itching.  Dr.  J.  C. 
DaCosta,  of  Philadelphia,  spoke  of  the  pathological  changes 
found  in  the  case.  Dr.  Bertolette  exhibited  the  filaria  under 
the  miscroscope.  Dr.  Weidman  and  Dr.  Frankhauser  spoke 
of  a  case  that  was  in  the  Reading  Hospital  some  ten  years 
ago.  Dr.  Weidman  amputating  the  leg  at  the  lower  third 
of  the  thigh,  the  patient  is  still  living,  with  no  recurrence 
of  the  disease.  The  specimen  is  in  the  Pathological  Mu- 
seum of  the  Reading  Hospital. 

Vital  Statistics  of  Philadelphia  for  the  week  ending 
April    13.    1901 : 

Total  morality 469 

Cases.  Deaths. 
Inflammation  of  bladder  1,  brain  20.  bron- 
chi  3,   kidneys   24.   larynx    1,   lungs    68. 
peritoneum   9,   pleura   2,    stomach    and 

bowels,    11     ....'. 139 

Inanition  10.  marasmus  IS,  debility  5,....  33 

Tuberculosis  of  the  lungs    44 

Apoplexy  13,  paralysis  7   20 

Heart-disease  of  39,  fatty  degeneration  1, 

neuralgia  of  4   14 

Uremia  11,  diabetes  2,  Bright's  disease  12,  25 
Carcinoma  of  liver  1,   stomach  6,   tongue 

1,   uterus   1    9 

Convulsions  14,  puerperal  1 15 

Diphtheria 59  g 

Brain-congestion  of  2,  disease  of  2.  dropsy 
of  2.   hemorrhage  of  1,   softening  of  1, 

sarcoma  of  2    10 

Typhoid  fever  37  5 

Old  age   23 

Cyanosis    5 


Scarlet  fever  

Influenza  4,  alcoholism  1,  asthma  3,  anemia 

2,  atheroma  1,  burns  4,  blood  poisoning  1, 
casualties  7,  congestion  of  lungs  4,  cel- 
lulitis of  arm  1,  cirrhosis  of  liver  8, 
births  1,  croup,  membranous  1,  disease 
of  spine  3,  drowned  1,  dropsy  1,  dys- 
entery 3,  erysipelas  1,  fever,  puerperal 
1,  goitre  1,  gangrene,  senile  1,  hernia  2, 
indigestion  1,  jaundice  1,  obstruction  of 
bowels  1,  edema  of  lungs  2,  rheumatism 

3,  shock,  surgical  1,  septicamia  3,  suf- 
focation 1,  suicide  8,  teething  2,  un- 
known 2,  whooping  cough  6,  diarrhea  2  . 


77 


A  AIARTYR  TO  SCIENCE. 


Dr.  Ralph  Erskine  Johnston. — Dr.  Johnston  was  liurn 
January  1st,  1867,  and  was  killed  by  an  insane  patient  in 
the  Danville  Asylum  on  April  3rd,  1901.  His  name  shows 
his  Scotch  ancestry,  he  being  descended  from  Sir  Archi- 
bald Johnston,  of  Scotland,  who  was  martyred  for  adhering 
to  the'League  and  Covenant."  His  father,  both  grandfathers 
and  remoter  ancestors  were  all  Presbyterian  elders,  and 
he  himself  was  an  adherent  of  that  church.  He  was 
bright  and  precocious,  besides  having  a  practical  turn  of 
mind,  which  enabled  him  to  take  up  many  lines  of  thought 
or  action.  Even  as  a  boy,  he  showed  a  capacity  and  a 
delight  for  "doing  things,"  as  making  toys,  building  ma- 
chinery, painting,  drawing  or  taking  up  a  mechanical  pur- 
suit like  photography,  or  a  line  of  investigation,  like  hia 
family  genealogy.  He  attended  the  district  school  at  the 
home  of  his  father,  near  New  Wilmington,  Pa.  There  he 
entered  Westminster  College.  New  Wilmington,  graduating 
in  1SS9,  at  22.  He  then  spent  some  time  as  an  attendant 
at  the  Dixmont  Hospital  for  the  Insane,  where  Jie  had  beea 
previously  employed.  Here  he  acquired  a  taste  for  work 
among  the  insane,  which  never  left  him,  and  which  lea 
ultimately  to  his  death.  From  Dixmont  he  went  to  Cleve- 
land, spending  a  year  at  the  Medical  College.  He  gradu- 
ated from  the  College  of  Physicians  and  Surgeons  at  Bal- 
timore in  1894.  He  had  a  short  term  of  service  at  the  city 
hospital,  Cumberland,  Md.,  which  he  resigned  to  take  tha 


DR.  RALPH  E.  JOHNSTON. 

position  of  Assistant  Physician  at  the  State  Hospital  for 
the  Insane,  Danville,  Pa.,  September  1st.  1894.  To  a  con- 
siderable extent  Dr.  Johnson  was  "self-made,"  earning  the 
money  for  his  education  as  he  went  along.  He  was  prac- 
tical and  excelled  in  practical  pursuits;  was  a  good  ama- 
teur photographer,  and  prepared  slides  for  his  stereopticon 
lectures  at  the  hospital;  was  fond  of  electrical  engineer- 
ing; was  an  enthusiastic  botanist;  and  was  musically  in- 
clined. Though  his  life  and  character  were  many  sided, 
he  was  always  at  his  post  of  duty,  and  died  there.  A 
careless  physician  would  have  left  the  trifling  ailment 
of  the  patient  pass,  but  Dr.  Johnston  felt  it  to  be  his  duty 
to   attend   him,   and    was   murdered    by   the   man   he  was 


750 


The  Philadelphia"! 
Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


lAl'BIL  20.  lUOl 


attempting  to  benefit.  Though  his  life  was  short,  he  has 
not  lived  and  died  in  vain.  His  death  may  save  the  lives  of 
others  b.v  malving  them  more  careful  in  dealing  with  the 
insane.  His  life  may  be  an  inspiration  to  all,  for  he  was 
fearless,  yet  kind:  serious  in  business,  yet  gracious  in 
social  intercourse.  In  all  the  private  relations  of  life  he 
was  tender  and  true,  as  a  son,  a  brother  and  husband.  His 
relatives  cherish  his  memory  in  the  most  grateful  remem- 
brance, while  the  hospital  and  acquaintances  of  Danville 
feel  his  death  as  a  personal  bereavement  and  most  deplor- 
able murder.  Dr.  Johnson  was  married  to  Miss  Augusta 
Sweisfort,  daughter  of  Col.  .Jonathan  Sweisfort,  of  Dan- 
ville, Pa.,  January  Sth,  1901.  The  insane  man  responsible 
for  Dr.  Johnston's  death,  an  Italian  shoemaker,  has  been  a 
resident  of  the  institution  for  three  years,  and  was  a  case 
of  mania  with  delusions  of  persecution,  quarrelsome,  de 
nunciatory  and  threatening,  very  excitable  and  quickly 
angered.  Because  of  these  characteristics  he  had  been 
frequently  searched,  the  last  instance  being  the  day  pre- 
vious to  the  assault,  all  clothing  being  removed.  On  the 
day  in  question  the  patient  complained  of  illness  and  was 
put  to  bed.  he,  however,  requesting  that  the  physician 
should  not  disturb  him.  During  the  usual  evening  round 
Dr.  Johnston  entered  his  room  accompanied  by  a  nurse, 
despite  the  protest  of  the  patient,  sat  upon  the  edge  of  the 
bed  and  endeavored  to  take  his  pulse.  To  overcome  the 
patient's  hesistance  the  nurse  was  directed  to  hold  his 
hand,  but  before  this  could  be  secured  he  had  dealt  the 
doctor  a  blow  with  some  sharp-pointed  instrument  on  the 
left  lower  jaw  near  its  angle.  In  attempting  to  subdue  the 
patient  Dr.  Johnston  received  three  additional  wounds  in 
quick  succession,  one  in  the  right  shoulder,  one  in  the 
left  hypochondriac  region  .both  superficial,  and  a  fatal 
stab  wound  about  one  and  one-half  inches  below  the 
clavicular  notch,  penetrating  the  sternum,  pericardium  and 
arch  of  the  aorta  about  one  and  one-half  inches  from 
Its  origin,  the  puncture  being  about  one-fourth  inch  long. 
The  hemorrhage  into  the  pericardium  caused  death  in  about 
twenty  minutes.  The  weapon  with  which  the  deed  was 
done  seems  to  have  been  the  small  blade  of  a  pocket  knife 
found  secreted  in  the  crack  of  a  ward  settee  outside  the 
patient's  room.  In  justification  of  the  act  the  patient  stated 
they  were  trying  to  kill  him. 

NEW    YORK. 

New  York  Academy  of  Medicine — Section  on  Orthope- 
dic Surgery.— Meeting  of  March  15.  1901.  George  G.  Elliott. 
M.  D.,  Chairman.  Dr.  Homer  Gibney  presented  a  boy  aet. 
11  years,  who  had  infantile  spinal  paralysis.  There  was 
equino-varus  of  the  left  foot  with  slight  cavus.  According 
to  previous  history,  astragalectomy  had  been  performed 
5  years  previou.sly  without  beneficial  results.  November 
last  Dr.  Gibney  exposed  the  tarsal  bones,  curetted  the  car- 
tilages, sutured  the  wound  and  applied  a  plaster  of  Paris 
bandage.  The  result  was  that  the  foot  was  shown  at  a 
right  angle  with  slight  motion.  Acute  Hip  Disease. — A  sec- 
ond patient,  a  girl  G  years  of  age  was  shown  by  Dr.  Gibney. 
She  was  suffering  from  acute  hip  disease  when  first  seen 
In  October.  1899.  A  brace  was  applied  and  the  child  put 
to  bed.  Her  hip  became  worse:  the  hip  was  stretched  and 
a  plaster  of  Paris  spica  was  applied.  An  abscess  devel- 
oped and  was  opened  January,  1900.  Improvement  followed 
the  incision  but  owing  to  a  profuse  discharge,  fever  and 
loss  of  flesh  the  hip  was  excised  April.  1900.  The  child 
improved  rapidly  after  the  operation;  a  small  sinus  re- 
mained. Paraplegia  Complicating  Spinal  Caries. — Dr. 
Gibney  presented  a  third  patient,  a  girl  9  years  of  age. 
She  was  admitted  to  hospital  December.  1900,  with  the 
history  that  her  disease  followed  an  attack  of  diptheria  five 
years  previously.  A  plaster  of  Paris  jacket  was  worn  for 
six  weeks  at  onset  of  disease  and  then  for  eighteen  months 
she  wore  a  Taylor  brace  with  head  attachment.  In  1897 
she  had  an  attack  of  paraplegia  which  lasted  six  months. 
One  year  ago  she  had  a  second  attack  which  persisted  at 
time  of  admission  into  the  hospital.  There  was  at  that 
time  paraplegia,  incontinence  of  urine,  increased  reflexes 
with  marked  ankle  clonus.  December  last  the  child  was 
put  to  bed  wearing  a  plaster  of  Paris  jacket  with  head 
extension.  The  jacket  was  re-applied  January,  1901.  with 
head  extension  and  plaster  straps  over  the  shoulders.  A 
third  jacket  was  applied  February  21.  Improvement  was 
gradual  and  child  was  shown  with  fairly  good  voluntary  use 
of  less.     Coxa   Vara. — Dr.   W.   R.   Townsend   presented   a 


boy  15  years  old  who  came  to  the  hospital  for  R.  &.  C.  one 
month  ago.  with  the  history  that  without  any  apparent 
cause  one  year  previous  he  began  to  have  difiicuity  in  walk- 
ing and  was  easily  fatigued.  The  difficulty  in  locomotion 
had  steadily  increased.  The  limbs  were  equal  in  length 
and  the  X-ray  revealed  a  very  marked  case  of  coxa  vara. 
There  was  limitation  of  motion  and  the  great  trochanters 
were  one  inch  above  Velaton's  line.  Limitation  of  mo- 
tion, especially  in  flexion  and  extension  was  very  great. 
There  was  not  over  15  degrees  of  motion  on  the  right 
side  and  none  on  the  left.  Standing  the  knees  could  not 
be  separated  more  than  three  inches.  The  patient  sat  with 
difficulty.  A  radiograph  was  showwn.  He  asked  if  any 
member  of  the  Section  had  seen  a  case  of  coxa  vara  with 
so  much  limitation  of  motion.  Spondylose  Rhizomellque. — 
Dr.  Townsend  presented  a  man  35  years  old  who  five 
years  ago  began  to  have  stiffness  of  the  back  and  difficulty 
in  walking.  He  had  had  two  attacks  of  muscular  rheu- 
matism. He  had  had  no  pain  excepting  in  the  upper  part 
of  the  back  and  when  sitting.  These  symptoms  increased 
until  the  present  time:  he  was  obliged  to  use  crutches. 
The  thighs  were  flexed  on  the  pelvis  about  20  degrees;  ex- 
tension and  flexion  were  much  restricted.  He  regarded  the 
lesion  of  the  hip  joints  and  the  spinal  stiffness  as  typical 
of  spondylose  rhizomelioue.  He  suggested  a  plaster  ot 
Paris  jacket  as  of  some  service.  Dr.  Townsend  showed 
two  radiographs,  one  showing  union  of  a  fracture  of  the 
neck  of  the  femur  after  use  of  a  long  traction  hip  splint 
(patient  shown  before  Section  January  11,  1901):  the  other 
radiograph  was  of  a  case  of  double  dislocation  of  the  hip 
joint  which  had  been  treated  by  the  bloodless  reduction 
eight  weeks  before.  The  picture  was  taken  through  the 
plaster  of  Paris  splint. 

Congenital  Club  Foot. — Dr.  Judson  presented  a 
boy  5  years  old  first  seen  when  there  was  marked  and 
resistant  typical  double  deformity  which  had  been  re- 
duced by  the  painless  continuous  leverage  of  a  simple 
brace  applied  with  adhesive  plaster  and  often  removed  for 
manipulation  of  the' feet;  later  a  walking  brace  had  been 
used;  all  the  apparatus  used  was  of  a  common  kind  with 
a  single  invisible  upright.  The  braces  were  made  of  trac- 
table metal  allowing  change  from  the  deformity  to  the 
normal  and  later  to  overcorrection.  The  feet  followed 
these  changes  through  force  of  adhesive  plaster  and  later 
by  body  weight.  At  the  age  of  fifteen  months  the  de- 
formity had  disappeared.  Treatment  was  resumed  after 
seven  months  interval,  the  outer  border  of  the  feet  having 
become  slightly  callous:  walking  braces  were  applied  and 
worn  for  22  months,  finally  laid  aside  January  15.  1900. 
On  presentation  the  child  walked  and  ran  with  normal 
ability  and  without  defect  in  his  gait.  The  only  remaining 
defects  were  slightly  shortened  Achilles  tendons  but  this 
was  slight  as  he  could  even  walk  on  his  heels. 

In  this  affection  the  following  were  to  be  considered 
as  favorable  elements. 

1st.     The  certainty  of  rapid  growth. 

2nd.     The  plastic  or  formative  condition  of  the  parts. 

3rd.     The  absence  of  body  weight  for  IS  months. 

4th.     The  certain  affect  of  continuous  leverage. 

Sth.  The  weight  of  the  body  applied  on  the  right  side 
of  the  plane  between  varus  and  valgus  in  virute  of  which 
the  child  could  stamp  his  foot  straight. 

6th.     The   absence   of   necessity    for   haste. 

7th.  Use  of  tractable  metal.  An  unfavorable  point  was 
the  postponement  of  treatment  till  the  child  was  two 
years  old. 

Funnel  Chest. — Dr.  Judson  presented  a  man  71  years  old 
having  a  deforraality  which  although  rare,  has  been  de- 
scribed by  a  number  of  observers.  It  was  a  curious  mal- 
formation, entailing  no  great  disability,  of  uncertain  origin 
and  calling  for  no  treatment.  From  an  angular  projection 
at  the  junction  ot  the  manubrium  and  the  gladiolus  there 
was  a  continuous  depression  till  the  deepest  place  was 
reached  at  the  lower  end  of  the  xiphoid  appendix.  The 
cartilages  of  the  lower  ribs  were  prominent  as  usual  on 
each  side  and  the  front  of  the  chest,  although  somewhat 
flat,  was  normal  except  for  this  funnel  like  depression 
which  began  on  each  side  at  the  nipple  line  and  was  cup- 
shaped  at  the  bottom  with  a  depth  of  IH;  in.,  unchanged 
by  expiration  (31  ln.1  or  inspiration  (3-1  in.t  The  man  said 
he  had  always  been  so  and  had  never  known  of  another 
person  similarly  affected  in  his  family.  He  had  eighteen 
brothers  and  sisters.    He  had  been  fond  of  athletic  sports  in 


APHIL  20,  1001] 


AMERICAN  NEWS  AND  NOTES 


[The     PHrLAHELPHIA 
MEDICAi    JOURXAL 


751 


his  youth,  was  a  shoe-maker  by  occupation  and  had  en- 
listed in  the  military  service  in  1862.  There  was  no  his- 
tory or  sign  of  rickets  or  spinal  disease.  He  had  been 
free  from  notable  diseases  of  the  chest  or  otherwise,  al- 
though years  ago  he  had  been  told  that  he  had  serious 
chronic  "disease.  Dr.  H.  S.  Stokes  said  it  was  difficult  and 
fi-equently  impossible  to  make  a  correct  physical  diagnosis 
when  chest  deformity  existed.  He  cited  a  case  of  Pott's 
disease  where  the  patient  had  been  told  four  years  ago  that 
he  had  pulmonary  tuberculosis  and  a  bad  prognosis  had 
been  made.  He  had  frequently  examined  the  sputum  of 
the  patient  with  negative  results:  all  segris  of  lung  in- 
valvement  disappeared.  He  cited  two  cases  of  lateral 
spinal  curvature  which  had  lately  come  under  his  notice, 
where  errors  of  diagnosis  had  been  made.  In  one  the  di- 
agnosis of  tuberculor  consolidation  was  made.  In  one 
the  diagnosis  of  tubercular  consolidation  was  made  which 
turned  iut  to  have  been  only  a  slight  bronchitis.  Dr.  My- 
ers presented  a  case  of  polio-myelitis  in  a  boy  13  years  old; 
the  disease  dated  from  early  infancy;  the  case  was  ex- 
hibited to  show  the  muscular  changes — the  right  quad- 
riceps was  completely  paralyzed  and  the  right  ligament 
patella  was  one  inch  long:  the  left  quadriceps  was  fairly 
strong  and  the.  lig.  patella  2V4  inches  long.  Osteotomy 
had  been  performed  on  the  right  side  for  a  recurring 
genu  valgum  which  had  been  caused  by  the  greater  power 
of  the  ext.  hamstring  muscle.  The  muscle  was  split  and 
one-haU  transplanted  and  given  to  th  einternal  hamsrting 
and  the  knock  knee  did  not  recur.  He  called  attention 
to  the  marked  rotary  lateral  curvature  of  the  whole  dor- 
sal spine  with  convexity  to  the  left  the  stronger  side, 
while  concavity  was  toward  the  side  of  paralysis  of  the 
lower  extremity  and  erector  spinal  muscles.  In  club  foot 
due  to  polia-myelitis,  the  shortening  always  occurred  in 
the  stronger  or  least  paralyzed  muscles:  by  analogy  the 
erector  spinae  muscles  on  this  boy's  left  side,  those  least 
paralyzed  should  be  contracted  and  they  were.  This  drew 
the  entire  thorax  strongly  to  the  left  and  downwards.  To 
maintain  his  equilibrium  the  boy  had  thrown  his  head  and 
shoulders  to  the  right  by  voluntary  effort  inducing  the 
form  of  curvature  present.  Congenital  Dislocation  of 
Hip  with  Fracture  of  Shaft  of  Femur. — Dr.  Elliott  pre- 
sented a  five  months  old  baby  sent  to  him  three  weeks 
previously  for  diagnosis.  He  found  dislocation  of  left  hip 
and  suspected  fracture  both  of  which  were  confirmed  by 
X-ray  picture.  According  to  the  history,  birth  of  the 
child  had  been  very  difficult — the  breech  had  presented 
and  great  difficulty  had  been  experienced  and  instru- 
ments used.  No  difficulty  was  anticipated  in  reducing  the 
dislocation:  the  fracture  of  the  femur,  however,  compli- 
cated the  matter.  He  said  he  proposed  to  attempt  re- 
duction under  an  anaesthetic  and  if  any  great  difBculty 
presented  itself,  wait  till  later  and  do  it  by  the  Lorenz 
non-cutting  method.  Congenital  Dislocation  of  the  Patel- 
la. Dr.  Elliott  showed  a  patient  a  young  man  20  years  old 
with  dislocation  of  the  right  patella.  His  relatives  had 
told  him  that  it  was  first  noticed  two  days  after  his  birth: 
he  wore  apparatus  at  various  times  but  nothing  since  18S8. 
The  patella  slipped  into  place  on  extension  but  on  flexion 
slid  over  the  external  condyle  of  the  femur  even  if  force 
was  applied  to  hold  it:  there  was  two  inches  of  atrophy 
of  the  right  thigh:  a  slight  degree  of  knock  knee  existed. 
All  that  the  patient  complained  of  was  a  oinse  of  weak- 
ness and  uncertainty  of  the  leg.  The  patient  waated  to 
know  if  the  condition  could  be  remedied  without  leaving 
him  with  a  stiff  knee.  He  preferred  his  present  condition 
of  slight  disability  to  a  stiff  leg.  A  Case  of  Spondylolisthe- 
sis. Dr.  Taylor  presented  a  man  19  years  old  whose  oc- 
cupation was  loading  and  unloading  furniture.  Last  De- 
cember he  sought  treatment  for  weakness  of  his  back  and 
occasional  pains  in  the  lumbar  region  at  night,  after  hard 
■work.  About  three  years  ago  he  slipped  on  the  ice  and 
fell  heavily  on  the  buttocks.  He  worked  the  following  day. 
He  experienced  no  Inconvenience  for  sometime  but  within 
a  few  weeks  he  noticed  a  decided  projection,  lower  part 
of  spine,  which  he  still  has.  He  thinks  it  is  less  now  than 
formerly.  Examination  revealed  a  marked  projection  of 
the  fifth  lumbar  spine  and  a  deep  depression  above  it.  At 
the  bottom  of  this  depression  could  be  felt  the  fourth 
lumbar  vertebral  spine  one-half  inch  in  front  of  its  normal 
position.  The  patient  could  bend  forward  and  touch  the 
floor  -Tnd  showed  none  of  the  characteristic  attitudes  of  the 
rigidity  of  spondylitic.    He  was  strong  and  able  to  work. 


There  were  no  rectal  or  bladder  symptoms  of  lower  ex- 
tremity paralysis.  Dr.  A.  E.  Gallant  showed  a  model  of  the 
triangular  pasteboard  Van  Arsdale  splint.  He  slated  that 
this  splint  was  used  in  children  in  fractured  femur  with  ex- 
cellent results;  he  had  reported  33  cases  himself.  It  was 
light,  could  be  adjusted,  leaving  the  child  in  a  comforta- 
ble position  and  in  young  infants  it  was  out  of  the  way  of 
soiling.  T'ne  children  were  not  confined  to  bed  but  could 
sit  up  and  play  without  hindrance.  He  cut  a  model  and 
drew  a  diagram  illustrating  the  manner  of  preparing  the 
splint. 

Dr.  William  Jay  Youmans. — Dr.  Wm.  Jay  Toumans,  for 
many  years  editor  of  I'upiilnr  Science  Monthlii,  to-day 
died  at  his  home,  in  Mt.  Vernon,  N.  Y.,  a  suburb  of  this 
city,  of  typhoid  fever,  after  an  illness  of  ten  days.  ^Tien 
difficulties  a  year  ago  came  upon  the  house  of  Appleton, 
and  the  Science  Monthlij  was  transferred.  Dr.  Toumans  se 
vered  his  connection  with  it,  and  retired  permanently  from 
active  life.  He  was  deeply  attached  to  a  handsome  farm 
possessed  by  him  among  the  hills  near  Saratoga,  N.  Y., 
where  he  was  bom,  October  14,  1838,  and  near  which  he 
began  his  education  in  a  district  school.  Dr.  Youmans 
studied  chemistry  with  his  brother,  Edward  Livingston 
Youmans.  at  Columbia  College  and  at  Yale  Scientific 
School.  He  graduated  in  medicine  from  New  York  Univer- 
sity in  1865. 

NEW     ENGLAND. 

Surgical  Instruments  Taxed. — Judge  Colt,  in  the  United 
States  Circuit  Court  yesterday,  dismissed  the  petition 
brought  by  the  Massachusetts  General  Hospital  for  a  re- 
view  view  of  the  decision  of  the  Board  of  General  Apprais- 
ers, holding  that  a  case  of  imported  surgical  instruments 
was  not  entitled  to  exemption  from  duty  under  par.  638  of 
the  Dingley  Tariff  Act.  The  goods  are  dutiable  at  60  per 
cent,  under  the  act.  The  instruments  were  for  use  in  the 
hospital. 

WESTERN     STATES. 

Dr.  William  F.  McClelland  Dead.— Dr.  William  F.  McClel- 
land, tne  first  physician  to  make  a  study  of  the  climatic 
influences  of  the  mountain  region  upon  pulmonary  diseases, 
and  who  was  widely  known  in  America  and  Europe, 
through  the  performance  of  many  difficult  surgical  opera- 
tions, is  dead  at  his  home  in  Denver,  Colorado,  aged  80 
years. 

The  SL  Paul  Meeting  and  Yellowstone  Park. — Arrange- 
ments have  been  completed  for  an  excursion  of  the  mem- 
bers of  the  American  Medical  Association  to  Yellowstone 
Park.  The  Committee  of  Arrangements  has  finally  sue 
ceeded  in  persuading  the  officials  to  open  up  the  park  a 
week  earlier  than  usual  in  order  to  accommodate  the  asso- 
ciation. A  special  train  wil  be  run  from  St.  Paul  to  the 
Yellowstone  Park  and  the  railroad  officials  have  promised 
to  do  everything  in  their  power  to  make  it  satisfactory  to 
all  concerned.  The  rates  will  be  very  low.  but  how  low 
can  not  at  this  time  be  definitely  stated.  Those  who  at- 
tended the  meeting  in  1SS2  will  remember  with  much 
pleasure  a  similar  excursion  that  was  run  at  that  time,  and 
these  will  not  need  to  be  informed  that  the  one  now  pro- 
posed will  be  full  of  enjoyment.  Further  announcements 
will  be  made  later.  The  Yellowstone  National  Park  con- 
tains more  natural  wonders  than  are  to  be  found  anywhere 
else  in  the  world,  and  this  will  be  a  rare  opportunity  for 
our  Eastern  friends  to  see  what  this  portion' of  our  Great 
West  possesses. 

SOUTHERN    STATES. 

Tennessee  State  Medical  Society. — At  the  sixty-eighth 
annual  meeting  of  the  Tennessee  State  Jledical  Society 
the  following  officers  were  elected:  Deering  J.  Roberts, 
M.  D.  (Southern  Practitioner),  Nashville,  president;  J.  B. 
Murfree,  Jr..  M.  D.  Murfreesboro,  L.  A.  Yarborough,  M.  D., 
Covington.  W.  B.  St.  John,  M.  D.,  Bristol,  vice-presidents: 
.\.  B.  Cooke.  M.  D.  Nashville,  secretary!  W.  C.  Bilbro.  M. 
D.,  Murfreesboro,  treasurer.  Next  place  of  meeting,  Mem- 
phis, Tenn.,  on  the  second  Tuesday  in  April,  1902. 

Georgia  Pasteur  Institute. — The  Board  of  Governors  of 
the  Pasteur  Institute  Laboratory  met  m  Atlanta  April  12th 


,7  CO  The     I'UILAl'KLPHIA"] 

/O'*  AIEUICAL   JOUENAL    J 


AAIERICAN  NEWS  AND  NOTES 


[APEIL  20,  1901 


to  receive  the  first  semi-annual  report  of  the  physician, 
Dr.  Jas.  N.  Brawner  and  the  pathologist,  Dr.  Claude  C. 
Smith.  Since  December  1st,  eleven  cases  have  received  the 
Pasteur  treatment,  and  all  dismissed  as  cured.  Eight  were 
bitten  by  rabid  dogs  as  proved  by  inoculation  of  rabbits. 
The  pathological  department  is  doing  good  work  also,  and 
the  Board  was  highly  pleased  with  the  first  report. 

To  Investigate  the  Propagation  of  Yellow  Fever. — The 
Orleans  Parish  (La.)  Medical  Society  has  appointed  a 
special  committee  to  study  the  mosquito  as  a  means  of 
propagating  yellow  fever. 

North    Carolina    State    Board    of    Medical    Examiners. — 

The  regular  annual  session  of  the  North  Carolina  State 
Board  of  Medical  Examiners  will  be  held  at  Durham,  N.  C, 
beginning  Thursday,  May  16th,  1901. 

The  Orleans  Parish  Medical  Society. — The  Society  passed 
resolutions  urging  the  need  of  a  City  ordinance  prohibit- 
ing spitting  on  the  floors  in  public  halls  and  public  places 
of  amusement.  The  sum  of  $2.t.00  was  donated  to  the  $1000 
fund  being  raised  in  the  United  States  as  the  contribution 
to  the  amount  needed  to  erect  a  bronze  statue  of  Prof. 
Oilier,  in  the  City  of  Lyons,  France.  The  members  of  the 
Society  have  additionally  subscribed  to  the  fund  so  that 
New  Orleans  will  have  added  its  full  equivalent  to  the 
amount  to  be  raised  in  this  country. 

The  Inhalation  of  Menthol  in  Acute  Inflammations  of 
the  Throat  and  Respiratory  Tract. — Susdalsky  iWiniiiiu- 
medici ii.sk  1/  Joiiniul,  Dec,  1900),  employs  inhalations  of 
menthol  in  acute  respiratory  troubles  with  singular  suc- 
cess. The  cases  reported  by  the  author  were  all  in  sol- 
diers. Recovery  took  place  in  about  six  days.  The 
sooner  the  treatment  was  instituted  the  more  rapid  was 
the  recovery.     [A.  R.] 

Southern  Idaho  Medical  Association. — The  quarterly 
meeting  of  the  Southern  Idaho  Medical  Association  was 
held  April  4th.  The  next  meeting  wil  be  held  early  in  July 
at  Shoshone.  The  following  oflicers  were  elected:  Presi- 
dent, Dr.  McCalla,  Boise:  vice-president.  Dr.  Ed.  E.  Maxey. 
Caldwell;   secretary,  Dr.  H.  A.  Castle.  Pocatello. 

CANADA. 

{From  Our  Special  Correspondent.) 

Hospital  Work  in  Labrador  was  the  theme  of  an  address 
recently  delivered  in  Montreal  by  Dr.  W.  T.  Grenfell.  who 
for  the  past  eleven  years  has  been  superintendent  of  mis- 
sion work  among  the  fisher  folk  of  that  country.  There 
are  now  three  hospitals  in  Labrador.  One  is  situated  at 
Battle  Harbor  and  another  at  Indian  Harbor,  whilst  the 
third  is  in  course  of  construction  on  the  north  French 
shore  at  St.  Anthony.  Besides  these  there  is  the  hospital 
steamship,  Strathoona,  of  which  Dr.  Grenfell  is  captain. 
This  ship  is  provided  with  six  beds  and  all  necessary  ap 
pliances.  including  the  X-ray,  and  is  constantly  cruising 
up  and  down  the  coast.  Dr.  Grenfell  is  assisted  in  his  work 
by  two  trained  nurses,  one  a  Canadian,  and  the  other  an 
Englishwoman,  and  men  qualified  in  every  way  for  the 
work.  Last  year  the  Strathcona  attended  to  1.020  cases, 
and  there  were  sixty-two  in-patients  at  Battle  Harbor,  and 
thirty-seven  at  Indian  Harbor.  Dr.  T.  D.  Roddick,  of  Mon- 
treal, has  given  much  assistance  to  Dr.  Grenfell,  especailly 
this  season  when  he  came  to  Toronto  and  secured  six 
physicians  to  accompany  the  sealing  fleet  last  March.which 
was  the  first  time  in  the  history  of  the  colony  that  these 
vessels  had  carried  surgeons.  Dr.  Grenfell  will  return  to 
Labrador  in  May. 

Cremation  in  Quebec  has  been  legalized  by  Act 
of  Parliament.  Somo  months  back  Sir  William  Mac- 
Donald,  one  of  the  leading  of  Montreal's  philanthropic  citi- 
zens, offered  to  erect  at  his  own  expense  in  the  Mount 
Royal  Cemetery,  a  crematory,  providing  the  cemetery  auth 
ities  would  assume  the  cost  of  maintenance  once  the  struc- 
ture was  raised  and  equipped.  In  order  to  carry  out  this 
project  it  was  found  to  be  necessary  to  have  the  consent 
of  the  Quebec  Legislature,  so  a  bill  was  introduced  Into 
that  Assembly  asking  for  powers  to  construct  and  conduct 
a  crematory.  From  the  very  first  this  measure  met  with 
persistent  and  determined  opposition,  particularly  from 
the  Roman  Catholic  members  of  that  body.    With  several 


amendments  the  bill  was  finally  gotten  through  that  Hctise 
by  the  narrow  majority  of  one;  and  as  Quebec  province 
is  governed  by  two  houses  of  parliament,  it  then  came  be- 
fore the  upper  house  or  the  Legislative  Council.  As  the 
bill  stood  then  it  provided  that  the  "deceased  had  expressed 
a  desire  for  cremation  and  that  a  certificate  be  produced 
that  deceased  at  death  was  not  a  Roman  Catholic."  Before 
the  Legislative  Council  the  promoters  of  the  bill  objected 
to  this  amendment  and  stated  that  they  did  not  desire 
to  cremate  Roman  Catholics,  but  that  they  objected  to  any 
discrimination  or  exemption  of  any  creed.  In  the  Coun- 
cil, a  motion  to  strike  out  the  cremation  clause  resulted 
in  a  tie  vote  of  eleven  to  eleven,  and  according  to  the 
rules  of  this  body  was  lost,  and  as  thus  amended  the  bill 
became  law,  the  amendment  now  standing:  "That  the  de- 
ceased at  the  time  of  his  death  is  entitled  to  be  burled  in 
Mount  Royal  Cemetery  and  has  expressed  by  his  will  a 
wish  that  his  body  be  cremated."  On  the  7th  inst.  Arch- 
bishop Bruchesi  of  Montreal  issued  a  pastoral  letter  on 
the  subject  of  the  Delpit  marriage  and  cremation,  in  which 
His  Grace  condemns  the  latter  most  strongly,  stating  that 
cremation  is  prohibited  for  all  children  of  the  church.  This 
is  the  first  legal  recognition  of  the  principal  of  cremation 
in  the  Dominion  of  Canada. 

The  Annual  Report  on  Ontario  Hospitals  has  just 
been  issued.  There  are  at  present  fifty  or  sixty 
of  these  institutions,  situated  in  almost  every 
to\^n  and  city  of  any  importance.  That  these  are  recog- 
nized by  the  people  and  are  doing  good  work  is  evidenced 
in  the  largely  increased  population  over  that  of  the  pre- 
vious year.  The  hospitals  at  Sault  Ste  Marie  and  Parry 
Sound  were  added  to  the  Government  list  for  receiving  an- 
nual grants.  On  the  first  of  October,  1900  the  number  of 
patients  remaining  In  the  various  hospitals  of  the  prov- 
ince numbered  1,893,  and  the  number  of  patients  admitted 
during  the  year  was  27.061.  The  number  of  deaths  during 
the  year  was  1,451  and  the  number  of  days'  stay  in  the 
hospitals  was  739,816.  The  revenue  from  all  sources  other 
than  the  Government  grant  amounted  to  $498,579.17:  the 
provincial  grant  for  the  past  year  was  1110.000.  The  aver- 
age cost  per  day  per  patient  was  S3^■  cents.  In  addition 
to  these  institutions  there  are  100  charity  homes,  etc..  in 
Ontario,  having  an  aggregate  population  of  5,042.  It  costs 
$234,602.53  to  keep  these  up,  of  which  the  province  contri- 
butes $62,687.19. 

Raising  the  Standard  of  Medical  Matriculation  at 
McGill  will  have  become  an  accomplished  fact 
after  September  1902.  At  present  candidates  for  admis- 
sion into  this  faculty  have  to  pass  in  English,  mathematics 
and  either  French,  German.  Greek,  chemistry  or  physics. 
After  the  date  alluded  to  above  they  will  all  have  to  show 
chat  they  are  proficient  in  practical  chemistry  and  pos- 
sessing a  sound,  theoretical  acquaintance  with  physics, 
statics  and  dynamics.  The  only  optional  subjects  after 
that  date  will  be  French,  German  or  Greek,  of  which  one 
will  have  to  be  taken.  Dr.  Ruttan.  registar  of  the  faculty 
of  medicine  states  that  this  will  make  the  matriculation 
in  the  medical  department  of  the  University  the  most  ex- 
acting of  the  departments.  Some  time  ago  the  length  of 
the  regular  sessions  was  increased  from  six  to  nine 
months  for  a  four-year  course;  and  more  recently  a  com- 
bined arts  and  medical  course  was  Introduced.  The 
present  step  will  pave  the  way  for  a  still  further  increase 
in  the  matriculation  standard  which  will  provide  that  all 
students  contemplating  the  study  of  medicine  at  McGiU 
w  ill  have  to  take  a  year's  course  in  arts  before  being  per- 
mitted to  write  on  the  medical  matriculation.  The  change 
is  calculated  to  prevent  students  from  doing  outside  work 
while  supposed  to  be  working  in  the  laboratories  or  at- 
tending lectures. 

"Counter  Prescribing"  by  Druggists  In  Toronto  ap- 
pears to  be  destined  soon  to  be  a  thing  of  the  past. 
Some  little  time  ago  a  number  of  Toronto  druggists  ap- 
peared before  the  police  magistrate  charged  with  the  of- 
:"ence.  Convictions  were  registered  in  several  cases  on  the 
charge  of  practicing  medicine,  and  a  fine  of  $25  or  thirty 
days  in  jail  without  hard  labor  given.  From  this  judgment 
the  druggists  appealed  to  the  County  Court  and  had  their 
appeal  sustained  and  the  decision  of  the  magistrate's  court 
reversed,  but  purely  on  a  mere  matter  of  form.  Now  sev- 
eral more  are  before  the  police  magistrate  who  evidently 
holds  strong  viev,-s  on  this  question.  The  other  day  when 
these  cases  were  reached,  the  solicitor  for  the  druggists 
moved  that  they  be  dismissed  as  the  previous  convictions 


ArniL  20,  1901] 


AMERICAN  NES  AND  NOTES 


("TiiE  Philadelphia 
L  Medica 


CAL  Journal 


753 


had  not  been  sustained  by  the  higher  court.  This  the 
magistrate  refused  to  do  and  delivered  himself  as  fol- 
lows: "A  man  committing  an  offence  is  nothing 
to  making  a  mistake  in  a  document. — I  have  a  great  deal 
of  sympathy,  too,  with  the  poor  people  who  go  into  drug 
stores  for  medicine,  but  when  it  is  proved  that  a  man  says 
'I  am  suffering'  in  such  a  way,  and  the  druggist  replies. 
•Oh,  you  have  indigestion,'  or  some  other  complaint,  1 
will  convict  him  and  keep  on  convicting  as  many  as  are 
proved  to  have  done  this."  "The  Colonel,"  as  the  police 
magistrate  is  popularly  called  in  Toronto,  seems  to  have 
a  proper  idea  of  the  fitness  of  things. 

Society  Notices. — The  annual  meeting  of  the  Ontario 
Medical  Association  will  be  held  in  Toronto  on  the  19th 
and  20th  of  June,  under  the  presidency  of  Dr.  Angus  Mc- 
Kinnon,  of  Guelph.  Dr.  Harold  C.  Parsons,  Toronto,  is 
the  general  secretary.  The  next  annual  meeting  of  the 
Canadian  Medical  Association  will  be  held  in  Winnipeg  on 
the  28th.  29th,  30th  and  31st  August.  Dr.  H.  H.  Chown  of 
that  city  being  the  president  and  Dr.  F.  N.  G.  Starr,  of 
Toronto,  the  general  secretary. 

MISCELLANY. 

Photographing  the  Stomach. — It  is  stated  that  Drs.  Lange 
and  Melzing  have  succeeded  in  taking  photographs  of  the 
mucous  membrane  of  the  stomach  in  the  living  subject. 
A  stomach  tube,  sixty-six  centimeters  long,  with  a  diameter 
ot  eleven  millimeters  is  introduced,  having  at  the  lower  end 
au  electric  lamp  and  at  the  upper  end  a  camera.  The 
stomach  is  first  emptied  and  washed  and  then  distended 
with  air.  Then  fifty  pictures  can  be  taken  in  rapid  succes- 
sion in  from  ten  to  fifteen  minutes.  By  turning  the  appa- 
ratus on  its  axis  all  parts  of  the  mucous  membrane  can 
be  pictured.  The  photographs  are  about  the  size  of  a 
cherry  stone,  but  they  can  be  enlarged  to  any  extent. 

A  Bold  Surgical  Operation. — The  Xrw  Tnric  Trihiiiir  quotes 
the  story  ot  a  remarkable  surgical  operation  told  in  a 
Danish  medical  periodical  relative  to  the  treatment  of  a 
patient  who  had  become  asphyxiated  from  the  adminis- 
tration of  chloroform.  The  operating  surgeon  was  a  cer- 
tain Dr.  Maag,  but  the  method  which  he  had  employed 
liad  previously  been  suggested  by  Dr.  Prus  of  Lemberg. 
A  laborer,  27  years  old.  who  had  suffered  from  sciatica, 
was  to  be  operated  upon  to  relieve  that  trouble.  Chloro- 
form was  given  and  the  operation  begun.  The  patient 
struggled,  however,  and  when  the  process  of  anesthesia 
was  carried  further  he  stopped  breathing.  Several  ex- 
pedients were  resorted  to  in  order  to  restore  respiration, 
but  in  vain.  There  was  no  lon.ger  any  pulse.  In  thi.^ 
emergency  Dr.  Maag  opened  the  chest,  detached  portions 
of  the  third  and  fourth  ribs  two  and  a  half  inches  long, 
and  turned  them  back  with  a  flap  of  flesh.  Throu",h  the 
opening  thus  made,  he  thrust  his  hand.  The  heart  was 
firmly  grasped  and  compressed  rhythmically.  After  a  few 
squeezes  that  organ  began  to  beat  naturally  .  It  was  neces- 
sary to  employ  compression  again  at  times,  and  also  to 
inflate  the  lungs  artiflcially.  But  by  these  means  the  pa- 
tient was  kept  alive  for  eleven  hours  and  a  half,  and  Dr. 
Maag  Is  inclined  to  believe  that  the  man  would  have  re- 
covered were  it  not  that  one  of  the  pleura  was  accidentally 
punctured. 

Yellow  Fever  in  Jamaica. — Yellow  fever  has  made  its 
appearance  at  Port  Royal,  the  entrance  to  Kingston,  Ja. 
Two  cases  have  been  officially  reported  and  one  death  has 
resulted.  The  health  authorities  are  taking  prompt  meas- 
ures, and  with  every  prospect  of  success,  to  prevent  the 
spread  of  the  disease. 

Medical  Association  Formed  at  Bangkok. — The  noiui 
Konn  Telcgniph  states  that  the  medical  men  of  Bangkok 
have  formed  a  medical  association.  The  aims  of  the  as- 
sociation are  the  advancement  ot  medical  science  and  the 
protection  of  medical  interests. 

The  Temple  of  Aesculapius. — Two  years  ago  Dr.  Rudolf 
Herzog,  of  Tuebingen,  undertook  excavations  of  the  island 
of  Cos  with  a  view  of  finding  the  temple  of  Aesculapius.  At 
a  depth  of  eighty  centimetres  (thirty-two  inches)  he  came 
upon  a  mosaic  flooring  which  represented  Orjjheus  charm- 
ing the  wild  beasts.  At  a  depth  of  two  and  a  half  metres 
(nearly  eight  feet),  in  the  neighborhood  of  the  church  of  St. 


Anna,  he  found  two  columns,  and  not  far  from  them  the 
remains  of  an  aqueduct  and  a  small  statue  of  a  young  man. 
Great  importance  is  attached  to  Dr.  Herzog's  discovery  of 
the  supposed  temple  of  Aesculapius.  The  excavations  are 
stiil  in  progress,  and  it  is  hoped  that  many  antiquities 
will  be  found. — Medical  Age. 

Dr.  Chapot-Revost,  the  surgeon  who  operated  for  the  sep- 
aration of  the  Siamese  twins,  has  gone  to  Vienna  to  study 
a  case  of  Chinese  twins  similarly  afllicted.  The  examin- 
ation is  to  be  made  by  means  of  Roentgen  rays. 

Ten  Thousand  Plague  Victims  in  Six  Weeks.-— The  United 
States  consul  at  Canton,  China,  reports  that  10,000  deaths 
from  plague  have  occurred  there  during  the  past  six 
weeks,  and  that  there  are  thirteen  cases  of  small  pox  on 
board  the  United  States  raonotor  Monterey.  Only  one  death 
has  resulted  on  the  Monterey,  and  the  other  cases  of 
smallpox  are  progressing  favorably. 

End  of  the  Plague.— The  sanitary  report  from  Rio  de 
Janeiro  states  the  following:  On  February  20  there  existed 
in  the  isolation  hospital  3  patients,  of  whom  2  were  dis- 
charged and  1  died  on  March  1.  The  last  case  of  plague 
occurred  February  17.  Therefore,  on  March  9,  the  quar- 
antine against  Rio  de  Janeiro  has  been  raised  by  the 
Brazilian  Government  and  the  disinfection  stations  and 
isolation  hospital  closed.  The  occurrences  of  plague  since 
April  IS,  1900,  are  as  follows:  Cases  ascertained. — Patients 
received  at  the  Paulo  Candido  Isolation  Hospital:  1900— 
April,  7;  May,  50;  June,  136:  July,  112:  August,  72:  Sep- 
tember, 27;  October,  29;  November,  30;  December  22.  1901 
—January,  11;  February,  5.  Total,  491.  Cases  confirmed 
at  the  residence  of  the  patients:  1900 — April,  none:  May, 
11;  June,  IS;  July,  30;  August,  20:  September.  4;  October! 
4:  November,  6;  December,  2.  1901— January,  3:  February 
none.  Total,  98.  Therefore,  the  total  number  of  cases  was 
589.  Deaths.— Patients  who  have  died  at  the  Paulo  Candido 
Hospital:  1900— April,  2;  May,  12;  June,  55:  July.  47- 
/August,  30:  September,  15;  October,  15;  November,  15;  De- 
cember. 10.  1901 — January,  5;  February.  4:  March,  1. 
Total,  211.  All  the  cases  of  plague  confirmed  at  the  resi- 
dences of  moribunds  or  deceased  were  98,  therefore  the 
total  number  of  deaths  were  309  (52.5  per  cent).  Recov- 
eries.— Patients  who  have  removed  at  the  Paulo  Candido 
Hospital:  1900- April  and  May.  none;  June,  24;  July  70; 
i-August,  70;  September,  45;  October,  23;  November.  13; 
December,  16.  1901— January,  7:  February,  12.  Total,  28o'. 
Deaths. — The  following  Is  the  report  on  patients:  Nine  were 
dead  on  reaching  the  hospital.  62  died  within  twenty-four 
hours,  34  died  within  forty-eight  hours,  and  106  died  more 
than  forty-eight  hours  after  their  arrival  at  the  hospital. 

Obituary. — Dr.  S.  C.  Griswold,  New  Haven,  Mo.,  on  April 
7,  aged  68  years.  Dr.  James  A.  S.  Carpenter,  at  Washing- 
'ton,  D.  C,  on  April  2,  aged  74  years.  Dr.  William  Fleet 
Luckett,  at  Washington,  D.  C,  on  March  30,  aged  63  years. 
Dr.  W.  T.  Hord.  at  Washington.  D.  C,  on  April  1.  Dr. 
William  N.  Guernsy.  at  New  York  City,  on  April  9.  Dr. 
John  Ferguson,  at  Manchester,  N.  H.,  April,  1901.  Dr.  J.  P. 
Dillard,  at  Martinsville,  Va.,  on  April  10th.  Dr.  James  C. 
Larsh,  at  Washington,  D.  C,  on  April  3,  aged  80  years. 

Changes  in  the  Medica!  Corps  of  the  U.  S.  Navy,  for  the 
week   ending   April    6,    1901: 

MAJ.  CHARLES  B.  EWING,  surgeon,  now  on  duty  at  Santa 
Mesa  Hospital,  Manila,  P.  I.,  is  detailed  as  a  member  of 
the  board  of  medical  officers  appointed  Jan.  16.  1900,  for 
the  purpose  of  studying  tropical  diseases  as  they  occur 
in  the  Philippine  Islands.     H.  Q.  A..  April  5. 

FIRST  LIEUT.  CHARLES  W.  FARR,  A.  S.,  recently  ap- 
pointed, will  proceed  from  Elmira,  N.  Y.,  to  Fort  Reno, 
for  duty,  to  relieve  Capt.  Francis  M.  McCallum,  A.  S.. 
who  will  proceed  to  San  Francisco.  Cal.,  and  report  for 
transportation  to  Manila.  P.  I.,  where  he  will  report  for 
assignment  to  duty.    H.  Q.  A.,  April  5. 

CAPT.  THOMAS  C.  LONGINO,  A.  S.,  will  accompany 
troops  G  and  II.  10th  Cavalry,  to  San  Francisco.  S.  6. 
44.  April   1,  D.  T. 

ACT.  .APST.  SURG  WILLIS  S.  HORNE  will  proceed  to 
Fort  Mcintosh  and  report  to  accompany  troops  E  and  F, 
10th  Csivalry.  to  San  Francisco.     S.  O.  i4.  April  1,  D.  T. 

ACT.  ASST.  SURG.  NEVIL  M.  GARRETT  will  proceed  to 


754 


The   Philadelphia"! 
Medical  Jovunal  J 


AMERICAN  NEWS  AND  NOTES 


[APBn,  20,  1901 


the  detention  camp,  Angel  Island,  Cal.,  for  duty  with 
companies  K  and  h,  11th  Infantry.  S.  O.  75,  April  2,  D. 
Cal. 

ACT.  ASST.  SURG.  FREDERICK  H.  MOHART  having  ar- 
rived on  the  transport  Lagon.  and  now  sick  at  the  Army 
General  Hospital,  Presidio,  will  proceed  to  his  home, 
Washington,  D.  C,  when  able  to  travel,  for  annulment 
of  contract.     S.  O.  77,  April  4,  D.  Cal. 

CAPT.  GEORGE  J.  NEWGARDEN,  A.  S.,  upon  the  expira- 
tion of  leave  granted  him  Feb.  27,  will  proceed  to  Fort 
Mason,  for  duty.     H.  O.  A.,  April  8. 

LIEUT.  COL.  CALVIN  DE  WITT,  D.  S.  G.,  is  relieved  from 
further  duty  as  chief  surgeon,  department  of  Dakota,  and 
will  report  to  the  surgeon  general  of  the  Array  for  duty. 
H.  Q.  A..  April   11. 

ORDERS  of  April  5  are  so  amended  as  to  direct  Capt. 
Francis  M.  McCallum,  A.  C,  upon  his  relief  from  duty  at 
Fort  Reno,  to  proceed  via  Jefferson  Barracks  to  San  Fran 
Cisco,  Cal.,  and  report  for  transportation  to  Manila,  P.  I., 
where  he  will  report  for  assignment  to  duty.  H.  Q.  A. 
April  11. 

ORDERS  of  April  1,  relating  to  Capt.  Frederick  C.  Jack- 
son, A.  S.,  are  revoked.     H.  Q.  A.,  April  11. 

CAPT.  FREDERICK  C.  JACKSON  is  granted  leave  for  one 
month  on  surgeon's  certificate.     H.  Q.  A.,  April  11. 

CAPT.  FREDERICK  C.  JACKSON,  A.  S.,  will  upon  the 
expiration  of  the  sick  leave  granted  him  April  11,  pro- 
ceed to  Columbus  Barracks,  for  temporary  duty.  H.  Q. 
A.,  April  11. 

CAPT.  ALBERT  H.  EBER,  A.  S.,  recently  appointed,  is 
granted  leave  for  one  month.    H.  Q.  A.,  April  11. 

CAPT.  ERNEST  K.  JOHNSTONE,  A.  S.,  recently  appoint- 
ed, now  in  San  Francisco,  Cal.,  will  report  for  transpor 
tation  to  Manila,  P.  I.,  where  he  will  report  for  assign- 
ment to  duty.     H.  Q.  A.,  April  11. 

CAPT.  GEORGE  B.  LAWRASON,  A.  S.,  recently  appointed, 
will  proceed  to  San  Francisco,  Cal.,  for  transportation  to 
Manila,  P.  I.,  where  he  will  report  for  assignment  to 
duty.     H.  Q.  A.,  April  11. 

Official    List    of   the    Changes    of   Station    and    Duties    of 

Commissioned  and   Non-Commissioned  Officers  of  the  U.  S. 

Marine-Hospital  Service  for  the  7  days  ended  April  11,  1901. 

C.  E.  BANKS,  surgeon,  granted  leave  of  absence  for  6 
days  from  April  l.'i— April  11.  1901. 

J.  J.  KINYOUN,  surgeon,  relieved  from  duty  at  San 
Francisco,  Quarantine,  and  directed  to  proceed  to  De- 
troit. Michigan,  and  assume  command  of  the  service — 
April  6,  1901.  Granted  leave  of  absence  for  15  days — 
April  11,  1901. 

T.  B.  PERRY,  surgeon.  Department  letter  of  March  2, 
1901.  granting  Surgeon  Perry  leave  of  absence  for  30 
days,  amended  so  that  said  leave  shall  be  for  20  days — 
April  5,  190L 

J.  B.  GREENE,  passed  assistant  surgeon,  relieved  from 
duty  at  Berlin,  Germany,  and  directed  to  proceed  to 
Washington.  D.  C. — April  5.  1901. 

L.  E.  COFER.,  passed  assistant  scrgeon,  designated  as 
Chief  Quarantine  Officer  of  the  Territory  of  Hawaii,  re- 
lieving Surgeon  D.  A.  Carmichael— April  6,  1901. 

HILL  HASTINGS,  assistant  surgeon,  to  proceed  to  Santa 
Barbara,  Cal..  for  special  temporary  duty — April  6,  1901. 

C.  H.  LAVINDER,  assistant  surgeon.  Beaureau  telegram, 
granting  Assistant  Surgeon  Lavinder  leave  of  absence 
for  10  days,  amended  so  that  said  leave  shall  begin 
April  1st  instead  of  March  27 — April  5,  1901. 

S.  B.  GRUBBS,  assistant  surgeon,  granted  leave  of  ab- 
sence for  7  days— April  10.  1901.  Upon  expiration  of 
leave  to  proceed  to  Washington,  D.  C,  and  report  at 
Bureau  for  duty— April  10,  1901. 

L.  L.  LUMSDEN,  assistant  surgeon,  upon  departure  of 
Sergeon  J.  Kinyoun,  to  assume  temporary  command  of 
San  Francisco  quarantine  station — April  6.  1901. 

EDWARD  FRANCIS,  assistant  surgeon,  to  proceed  to  New 
York,  and  report  to  medical  officer  in  command.  Immi- 
gration Depot,  for  duty — April  S,  1901. 

G.  H.  ALTREE,  acting  assistant  surgeon,  granted  leave  of 
absence  for  4  days  from  April  10 — April  6.  1901. 

HENRY  GAHN.  hospital  steward  and  chemist,  to  assu.Tie 
temporary  charge  of  Purvc.  ing  Depot  during  absence  of 
Medical  Purvoyoi- — April  8.  1901. 


F.  L.  BROWN,  hospital  steward,  relieved  from  duty  at  Bos- 
ton, Mass.,  and  directed  to  proceed  to  Cape  Charles  Quar- 
antine station  and  report  to  medical  officer  in  command 
for  duty  and  assignment  to  quarters — April  10,  1901. 

F.  H.  PECK,  hospital  steward,  to  proceed  to  San  Francis- 
co, Cal.,  for  special  temporary  duty — April  5,  1901. 

PROMOTION. 
ASST.    SURG.    H.    S.    MATHEWSON    promoted    and    ap 
pointed  passed  assistant  surgeon  to  rank  as  such  from 
as  such  from  April  7 — April  6,  1901. 

APPOINTMENT. 

J.  A.  MONCURE  reinstated  and  ap/ointed  acting  assistant 
surgeon,  U.  S.  Marine  Hospital  jJervcie,  for  duty  at  the 
Gulf  quarantine  station — March  29,  1901. 

Changes  In  the  Medical  Corps  of  the  Navy  for  the  week 

ending   April    13. 

MEDICAL  DIRECTOR  W.  K.  SCHOFIELD.  detached  from 
duty  at  Philadelphia,  April  27,  and  ordered  here  to  wait 
orders. 

MEDICAL  DIRECTOR  W.  O.  FARWELL,  detached  from 
Navy  Yard,  League  Island,  and  to  Special  Duty  in  Phila- 
delphia. 

SURGEON  C.  BIDDLE,  ordered  to  Philadelphia  Navy  Yard, 
as  the  relief  of  Medical  Director  W.  C.  Farwell. 

SURGEON  G.  H.  GRIFFITH,  ordered  to  temporary  duty  in 
charge  of  the  exhibit  of  Bureau  of  Medicine  and  Sur- 
gery at  the  Pan-American  Exposition,  Buffalo,  April 
27th. 

ASST.  SURGEON  R.  B.  WILLIAMS,  detached  from  Navy 
Yard,  Pensacola,  and  ordered  to  Key  West  Naval  Sta- 
tion with  temporary  duty  to  Dry  Tortugas,  with  detach- 
ment of  marines. 

MEDICAL  INSPECTOR  J.  E.  WAGGENER,  detached  from 
duty  at  Naval  Hospital.  Cavite.  and  to  Naval  Hospital. 
Mare  Island,  having  been  condemned  by  Board  of  Medi 
cal  Survey. 


Health  Reports. — The  following  cases  of  smallpox,  yel- 
low fever,  cholera  and  plague,  have  been  reported  to  the 
Surgeon  General,  U.  S.  Marine  Hospital  Service,  during 
the  week  ended  April  12,  1901: 


SMALLPOX— UNITED  STATES. 


CALIFORNIA: 


DISTRICT  OF 

COLUMBIV- 
FLORIDA: 
ILLINOIS 
INDIANA 

IOWA: 

KANSAS: 

KENTUCKY: 

LOUISIANA: 

MICHIGAN: 

MINNESOTA: 
NEBRASKA: 


Los    Angeles.    Mar.23-30 

Oskland Mar.16-23 

San  Francisco  Mar.23-30 


Cases.Deaths 
1 

1 


Washington 
Jacksonville 
Chicago    . . . . 
Rvansville  . . 
Terre  Haute 


Mar.30-Apr.6 
Mar.30-Apr.6 
Mar.30-Apr.6 
Mar.23-30  .. 
Mar.18-26   .. 


NEW  HAMPSHIRE  Manchester 


Clinton    Mar.30-.-^pr.6 

Ottumwa    Mar.16-23   . . 

Wichita    Mar.30-Apr.6 

Lexington  . . .  Mar.30-Apr.6 
New  Orleans  .  Mar.30-Apr.6 
Shrowsport    .    Mar.23-Apr.6 

Detroit  Mar.30-Apr.6 

West  Bay  City  Mar.30-Apr.6 
Minneapolis  .  Mar.30-Apr.6 
Nebraska  City  Mar.2-23  . .. 
South  Omaha    Apr.1-6    


2 
19 
9 
1 
1 
1 
1 
17 
6 
8 
4 
3 
2 
20 
7 
6 
6 


NEW  YORK: 
NEW  JERSEY: 
OHIO: 

PENNSYLVANIA: 


RHODE  ISLAND: 
SOUTH  CAROLINA  Charlefton 
TENNESSEE:  M.-mphis 

"  Nashville 

T^TAH: 
VIRGINIA : 
WEST  VIROTNIA: 
WISCONSIN: 


Mar.30-Apr.6 

Newark    Mar.30-Apr.6  2 

New  York  ...   Mar.30-Apr.6  42      6 

Cincinnati   . . .  Mar.29-.\pr.6  3 

Cleveland    Mar.30-Apr.6  35       S 

McKeesport    .   Mar.30-Apr.6  1 

Philadelphia   .    Mar.30-Apr.6  1 

Pittsburg    ....    Mar.30-Apr.6  3 

Steelton   Mar.30-Apr.6  1 

Riverpoint  . . .    Mar.lO-Apr.6  5 

. .    Apr.2     A   few  cases. 

...  Mar.30-Apr.6  22       1 

..  .  Mar.30-Apr.6  14 

Salt  Lake  City  Mar.3^Apr.6  2S 

Roanoke Mar.1-31   ....  71       4 

Wheeling    Apr.l-S  2 

Green  Baj-  . . .    Mar.31-ABr.7  % 


Ai'RIL  20,  laoi] 


FOREIGN  NEWS  AND  NOTES 


rTm;    rniLADELPHiA 

L    MlCIiICAI,   JoUIiXAL 


755 


SMALLPOX— FOREIGN  AND  INSULAR. 


ARGENTINA; 
AUSTRIA: 
BELGIUM: 
CHINA: 
EGYPT; 
FRANCE; 

GREAT  BRITAIN: 


INDIA: 


MEXICO: 

NETHERLANDS: 

RUSSIA: 


SPAIN: 

SWITZERLAND: 
PHILIPPINES; 
PORTO  RICO: 


Buenos  Ayres. 

Pague  

Antwerp 

Hongkong    . .  . 

Cairo    

Paris    

St.  Etienne   .  . 
England, 

Bradrord     . 

Liverpool  . 
Southampton 
Scotland 

Glasgow    . 

Bombay    

Calcutta   

Karachi    

Madras    

Progress  

Rotterdam  . . . 

Moscow    

Odessa    

Warsaw    

Malaga    

Geneva    

Manila    

Ponce,  From  b 


37 

7 


21 


Feb.l-2li    .... 

Mar.8-23  .... 

Mar.8-16  .... 

Feb.23 -Mar.2 
.  Mar.4-11  .... 
.  Mar.16-23  ... 

Mar.1-15  .... 

Mar.8-23  .... 
Mar.lG-23  ... 
Mar.16-23  ... 

.  Mar.22-29  ... 

Mar.15-12  ... 

Mar.2-9   

Mar.3-10  .... 
.  Mar.2-8    

Mar.22-29  ..  . 

Mar.23-30  ..  . 

Mar.8-16  .... 
.  Mar.8-23  .... 

Mar.8  16  .... 
.  Mar.1-15  ....  2 

.  Mar.2-9    1 

.  Feb.16-23  ...  1 

eginning  to  epidemic  to 
Mar.,  15,132  cases 


12 


2 

4 

13 


11 
10 

85 

4 

11 


COSTA  RICA: 

CHINA; 
INDIA; 

STRAITS  SETTLE- 
MENTS: 
PLAGUE- 

:;hina: 

INDIA: 
PHILIPPINES: 


YELLOW  FEVER. 

Port  Limon    .    Apr.6   1  case 

CHOLERA. 

Hongkong    .  .  .  Feb.23-Mar.2  6 

Bombay    Mar. 5-12  ....  4 

Calcutta Mar.2-9    26 

Singapore    ...  Feb.2-23   ....  1 
-FOREIGN  AND  INSULAR. 

Hongkong    .  .  .  Fpb.23-Mar.2  7       6. 

Bombay    Mar.5-12....  1,196 

Calcutta   Mar.2-9    537 

Manila    Feb.16-23  ...  7       6 


Plague  in  the  United  States  as  reported  to  the  Surgeon 
General,  United  States  Marine-Hospital  Service,  from  Jan- 
uary 1,  1901,  to  April  12,  1901. 

PLAGUE. 


Cases.Deaths 


CALIFORNIA: 


San 


Prancisc 

Jan.  6 

It 

Jan. 15 

tt 

Feb.5 

u 

Feb.6 

" 

Feb.7 

" 

Feb  10 

" 

Feb.  11 

'■ 

Feb.l2 

" 

Mar.  2 

ti 

Apr.4 

u 

Apr.l 

GREAT    BRITAIN. 


London's  Contribution. — The  Court  of  Common  Council 
of  the  City  ot  London  have  agreed  to  contribute  the  sum 
of  100  guineas  out  ot  the  city's  cash  towards  the  purposes 
ot  the  forthcoming  Congress  on  Tuberculosis,  to  be  held 
in  London. 

Gallantry  and  Devotion  of  an  Army  Surgeon. — The  King 
has  conferred  the  Victoria  Cross  on  Lieutenant  H.  E.  M 
Douglas,  of  the  Royal  Army  Medical  Corps,  for  special 
gallantry  and  devotion  during  the  action  at  Magersfontein 
I  on  December  11th,  1899.  Under  a  very  severe  fire,  saye  the 
I  Gazette,  Lieutenant  Douglas  advanced  in  the  open  and  at- 
tended Captain  Gordon,  of  the  Gordon  Highlanders,  who 
was  wounded,  and  also  attended  to  Major  Robinson  and 
other  wounded  men  under  a  fearful  fire. 

University  of  South  Wales. — Mr.  Alfred  Thomas.  M.  P.. 
has  been  elected  President  of  the  University  College  of 
South  Wales  in  succession  to  Lord  Tredegar,  who  has  held 
the  office  during  the  last  five  years,  and  who  is  debarred 
by  statute  from  re-election. 

Memorial    Hospital    at    Cairo    to    Queen    Victoria. — Lord 


Cromer,  the  British  diplomatic  agent  in  Egypt,  and  John 
G.  Long,  United  States  Consul-General  in  Cairo,  jointy  pre- 
sided on  March  8th  at  an  Anglo-American  meeting  to  con- 
sider a  memorial  to  Queen  Victoria.  Both  delivered  ad- 
dresses advocating  the  founding  of  an  Anglo-American 
hospital,  which  suggestion  was  approved  by  the  meeting. 
Sir  Ernest  Cassel  subscribed  £1,000  to  the  memoial  fund, 
and  the  subscriptions  altogether  reached  a  total  of  £  10,000 

CONTINENTAL     EUROPE. 

Physicians  of  the  Royal  Family  of  Spain.— Dr.  Vincente 
Llorente,  one  of  the  leading  physicians  in  Madrid,  has  been 
appointed  to  fill  the  vacancy  ot  Physician  to  the  Royal 
Family  of  Spain  caused  by  the  death  ot  Dr.  Olavide. 

Dr.  Samuel  Pozi. — Dr.  Sam\iel  Pozi  has  been  appointed 
Professor  ot  Clinical  Gynecology  in  the  University  ot 
I'aris.  He  is  a  memlier  of  the  French  Senate,  and  was 
■me  of  the  most  eminent  foreigners  on  whinn  an  honorary 
lellowship  was  conferred  by  the  Royal  College  of  Surgeons 
at  its  centenary  celebration. 

St.  Bartholomew's  Hospital. — The  vacancy  for  the  post 
cf  ophthalmic  surgeon  to  St.  Bartholomew's  Hospital  causCil 
by  the  death  of  Mr.  Bowaler  John  Vernon  has  been  filled 
by  the  election  of  Mr.  Holmes  Spicer.  Mr.  W.  H.  Jessup 
I'ecomes  senior  ophthalmic'  surgeon  in  place  of  Mr.  Vernon, 
with  the  appointment  of  lecturer  in  ophthalmic  medicine 
and  surgery. 

Smallpox  Diminishing. — The  smallpox  epidemic  at  Glas- 
gow continues  to  diminish,  the  number  of  new  cases  occur- 
ring daily  being  very  much  less  and  the  officials  take  a 
more  hopeful  view  of  the  situation.  On  March  15  there 
were  405  cases  in  hospital,  while  on  March  22  there  were 
only  380  crises.  The  improvement  is  attributed  to  revac- 
cination,  which  has  been  urged  upon  the  people,  and  it  is 
asserted  that  no  case  has  occurred  among  those  who  have 
been  successfully  revaccinated.  No  further  cases  have 
been  reported  in  Edinburgh,  so  the  total  for  that  town 
remains  at  5  cases  and  1  death.  There  was  1  case  of  small- 
pox under  treatment  in  the  London  fever  hospital  for  the 
week  ended  March  16. 

Strike  of  Physicians  at  Leipsic. — At  Leipsic  one  hundred 
and  fifty-five  municipal  physiciims  have  gone  on  strike  for 
higher  pay  and  more  considerate  treatment. 

Assistant  Physicians  in  the  St.  Petersburg  Hospital 
Placed  on  a  Salary. — The  city  council  appointed  15  as- 
sistant phvsicians  to  the  various  city  hospitals  on  an  ag- 
gregate salary  ot  10.800  roubles  (about  5.400  dollars).  The 
salaries  of  the  chiefs  were  also  increased. 

An  Emergency  Medical  Society. — In  Kieft  a  medical  so- 
ciety is  being  formed  with  the  object  ot  attending  to 
emergency  cases. 

Death  of  Professor  Joseph  Von  Fodor. — With  the  death 
ot  Professor  Von  Pettenkoter  still  fresh  in  our  minds,  we 
regret  that  we  have  to  announce  the  death  ot  Prof.  Josef 
Von  Fodor.  He  was  born  at  Lakosca,  Hungary,  on  July 
16,  1843.  He  studied  medicine  at  Buda-Pesth,  Munich  and 
Vienna  and  graduated  as  Doctor  ot  Medicine  from  the  Uni 
versity  ot  Buda-Pesth  in  1865.  In  1866  he  was  appointed 
Assistant  to  the  Chair  of  State  Medicine  at  Buda-Pesth.  In 
1870  he  went  to  Munich  and  studied  under  Pettenkofer  and 
Liebig.  His  first  publication  was  a  monograph  on  Sanitary 
Administration  in  England,  which  appeared  in  1873  and 
was  crowned  by  the  Hungarian  Academy  ot  Science.  His 
greatest  work  is  his  UiiiUcnhcheii  I'litersiuliuiij/cii  iilirr  l.iifi. 
Ilodcn  1111(1  Tl'«.s-.srr,  (Hygienic  Researches  on  Air,  Soil  and 
Water),  in  two  volumes,  which  was  published  in  ISSl  and 
1882.  Among  his  other  writings  are  addresses  and  papers 
— most  ot  which  were  published  in  the  Virrtrlialirxclirift 
fitcr  oeffenlirlie  Grf:iiii(!Iicit>:i)flr(ic  and  the  .\ri-hir  (urr  llijuii'i"" 
— on  soil  and  soil  gases  (1875),  healthy  dwellings  (1S78). 
the  condition  of  longevity  (1885),  the  bactericidal  action  of 
the  blood  and  immimisation  (1890),  immunisation  by  alka- 
linisation  (1891),  water  supply,  drai|pige.  typhoid  fever,  and 
drinking  water,  etc.  Professor  von  Fodor  was  also  the 
author  ot  a  textbook  of  hygiene  for  schools  which  ap- 
peared in  1887:  a  second  edition  was  published  in  1892. 
The  liiili.^Ii  Mcflical  J<ii(nial  publishes  the  personal  remin- 
iscenses  ot  one  of  his  dearest  friends,  concerning  him. 


nrf.  The     PHILADELrniA"] 

/O  Medical  Journal  J 


THE  LATEST  LITERATURE 


[Afbil  20,  1901 


Zbe  latest  literature. 


BRITISH  MEDICAL  JOURNAL. 

March  30th,  1001. 

1.     An  Adress  on  Some  Clinical  Aspects  of  Chronic  Brigtit's 

Disease.     AL'FRED  G.  BARKS. 
3.     A  Case  of  Congenital  Hepatic  Cirrhosis  with  Obliterat- 

WARD. 

3.  A  Case  of  Congenital  Hepatic  Coirrhosis  with  Obliterat- 

ive  Cholangitis   (Congenital  Obliteration  of  the  Bile 
Ducts). H.  D.  ROLLESTON  AND  LOUIS  B.  HAYNE. 

4.  On  the  Treatment  of  Glycosuria  and  Diabetes  Mellitus 

with  Sodium   Salicylate.     R.  T.  WILLIAMSON. 
6.     An  Easy  Operation  for  Congenital  Ptosis.     FREELAND 
FERGUS. 

6.  Note  on  the  Peculiar  Nystagmus  of  Spasmus  Nutans  In 

Infants.     JOHN  THOMSON. 

7.  Case    of    Tetanus    Neonatorum    Successfully    Treated 

with  Antitetanus  Serum.     JOHN  McCAW. 
8.     A    Note    on    the    Kuee-Jerk    in    Chorea.      W.    GOR- 
DON. 
9.     Notes  of  a  Case  of  Congenital  Hypertrophy  with  Sten 
osis  of  the  Pylorus.     ANES  BLACKADDER. 

1. — Barrs  is  of  the  opinion  that  there  is  no  practical 
utility  from  a  therapeutic  or  prognostic  point  of  view  in 
distinguishing  between  a  large  white  and  a  small  red 
kidney,  even  if  it  could  be  done  with  any  certainty.  The 
one  point  in  this  connection  that  requires  determination 
is  whether  the  condition  is  chronic  or  acute.  For,  upon  its 
not  being  the  foi*mer  and  being  the  latter  depend  such 
chances  as  the  patient  has  of  recovery.  The  author  has 
rarely  seen  a  case  of  chronic  Bright's  disease  in  which 
there  is  a  history,  first,  of  acute  nephritis,  then  of  an  inter- 
val more  or  less  prolonged  in  which  the  symptoms  tall  into 
abeyance,  and  then  of  a  chronic  persistent  condition  last- 
ing for  years,  it  may  be,  and  ending  in  death.  He  ha.^ 
believed  and  taught  for  a  long  time  that  acute  nephritis 
has  much  the  same  definite  march,  though  usually  over  a 
much  longer  period  of  time,  as  acute  pneumonia,  and  ends 
in  complete  recovery  or  death  in  due  course.  We  much 
more  frequently  see  acute  nephritis  associated  with  long- 
standing latent  renal  disease  than  we  see  chronic  nephritis 
directly  traced  to  an  acute  attack.  The  etiology  of  the 
disease  according  to  the  author's  views  is  not  satisfactorily 
explained  by  the  prevailing  theories.  Lead  as  a  cause  of 
chronic  nephritis  he  can  understand;  but  he  is  of  the  opin- 
ion that  alcohol  has  little  to  do  with  its  causation.  He  is 
in  doubt  whether  the  causative  relation  of  gout  to  chronic 
renal  disease  is  so  frequent  as  is  commonly  believed.  He 
inclines  to  the  idea  of  a  bacterial  origin  of  the  chronic 
inflammatory  destructions  of  the  kidney.  A  diagnosis 
of  chronic  Bright's  disease  in  the  absence  of  albuminuria 
cannot  safely  be  made.  The  idea  of  chronic  Bright's  dis- 
ease without  albuminuria  is  based  largely,  if  not  entirely, 
upon  post-mortem  room  experience.  Those  who  have  done 
much  post-mortem  room  work  know  how  common  it  is  to 
find  kidneys  that  do  not  conform  in  every  particular  to 
normal  standards.  The  author  does  not  say  that  the  kid- 
ney condition  is  not  answerable  for  the  patient's  death,  but 
he  insists  that  such  a  condition  is  not  Bright's  disease  in 
the  strict  and  clinical  sense  of  the  term:  and  that  it  can- 
not be  recognnized  during  life.  Clinically,  the  quantitative 
estimation  of  albumin  is  of  no  importance  whatever,  nor  is 
the  estimation  of  urea  of  any  great  value.  Urines  of  per- 
sistently low  specific  gravity  without  aUuiminuria  are  said 
to  indicate  chronic  Bright's  disease,  yet  this  is  not.  in  the 
opinion  of  the  writer,  not  a  reliable  indication.  No  urine 
need  be  searched  for  the  tube  casts  which  does  not  contain 
albumin.  There  is  great  uncertainty  in  the  association  of 
renal  with  circulatory  disease.  Arteriosclerosis,  altogether 
independent  of  renal  disease,  is  a  far  more  common  causv:- 
of  cardiac  hypertrophy  than  Bright's  disease:  and  vasc\i- 
lar  disease  of  this  nature  is  probably  a  cause  as  well  as  a 
result  of  renal  disease.  Chronic  renal  disease  has  such  a 
common  association  \\^h  cerebral  hemorrhage  as  has  been 
supposed.  Speaking  of  diet  in  chronic  nephritis  the  au 
thor  advances  the  opinion  that  to  live  for  weeks  and  weeks 
on  a  purely  milk  diet  is  not.  in  many  eases,  necessary. 
and  in  some  cases  it  is  distinctly  harmf\il.  and  there  is  nn 
clear  evidence  that  it  meets  the  scientific  indication.     His 


rule  is  that  if  the  bowels  are  acting  freely,  the  patient  may 
live  on  such  ordinary  mixed  diet,  including  meat,  as  he 
has  an  appetite  for  and  can  digest.  Patients  who  are  con- 
fined to  bed  and  suffering  from  uremic  vomiting  or  diar- 
rnea  and  are,  therefore,  getting  toward  the  end  of  the  dis- 
ease cannot,  of  course,  have  any  appetite,  and  the  difficulty 
is  to  contrive  food  of  any  kind  for  them.  Of  the  many 
drugs  which  are  in  use  in  the  treatment  of  Bright's  disease, 
some  are  of  great  value.  But  the  systematic  use  of  purga- 
tives is  not  approved  of  because  he  has  no  great  faith  in  the 
so-called  vicarious  actions  of  organs.  Diuretics  such  as 
digitalis  are  frequently  of  the  greatest  use  and  almost  as 
frequtntly  fail.  Diaphoretic  drugs — and  of  these  pilocarpin 
is  the  only  really  active  one — are  sometimes  unpleasant, 
not  to  say  dangerous  in  their  effects:  and  the  hot  bath  and 
hot  air  bath  do  all  that  can  be  done,  and  are  strictly  under 
our  control.  Vasodilators  hhave  very  little,  if  any,  diu 
retic  action  in  chronic  Bright  s  disease,  but  in  dyspnea 
headache,  and  vomiting  frequently  give  great  relief.  Tht 
nervous  and  respiratory  disturbances  of  the  more  severt 
degree  of  renal  toxemia,  which  usually  portend  a  not  far 
distant  death  may  be  treated  by  bleedmg,  purging,  and 
sweating.  Morphine  can  be  given  with  perfect  safety 
sometimes.     [J.  M.  S.] 

2. — After  a  study  of  gonorrhea,  Ward  advances  the  fol- 
lowing tests  to  account  for  hte  occuneua  of  general  injec- 
tion. The  gonoccus  in  its  process  of  growth  in  the  human 
body  produces  an  irritating  toxin.  This  toxin  is  the  direct 
cause  of  all  the  symptoms  of  the  disease.  In  all  cases  ii 
is  absorbed  into  the  system,  where  its  presence  causes 
systemic  degeneration  of  varying  degrees  of  severity. 
Gonorrhea  is  thus  a  general  toxemic  affection;  but  the 
microorganisms  that  form  the  toxin  are  generally  localized 
on  or  around  a  mucous  tract.  The  microorganisms  may 
extend  to  the  organs  communicating  with  the  infected 
tract,  or  it  may  penetrate  into  the  tissues,  either  by  direct 
extension,  as  in  the  invasion  of  the  peritoneum  through 
the  uterus  and  oviducts,  or  by  a  process  of  growth  through 
the  mucous  membrane  affected.  Thence  the  infection  may 
invade  the  cellular  tissues,  the  lymphatics  and  glands,  and 
the  vascular  system.  This  invasion  is  rendered  possible  by 
the  action  of  the  absorbed  toxin  upon  the  leukocytes,  which 
is  of  a  paralyzing  nature,  and  prevents  the  encapsulation 
of  the  microorganisms  by  these  cells.  Having  reached 
the  circulation  the  gonococci  may  invade  the  heart  and 
endocardium,  or  may  be  carried  to  the  peripheral  capillar- 
ies. In  these  they  become  stranded  and  grow,  producing 
more  toxin,  which  sets  up  local  inflammations.  The  micro- 
organisms invade  the  joints,  and  are  found  in  the  synovial 
sacs,  and  also  in  the  pleura  and  pericardium.  They  are 
probably  present  in  the  analogous  inflammations  of  the 
tendons  and  periostea.  The  invasion  of  the  organism  is 
favored  by  all  too  energetic  measures  directed  to  the 
local  infection,  since  they  depress  the  local  powers  of  re- 
sistance, and  by  abrading  or  lacerating  the  mucous  surface, 
may  directly  open  the  door  to  the  invasion.  General  treat- 
ment must  vary  according  to  the  general  conditions,  and 
V.  ill  differ  when  these  are  referred  to  toxemia  alone,  or  to 
toxemia  complicated  by  metastasis.  Local  treatment  Is 
always  required,  and  should  always  be  free  from  instru- 
mental, mechanical,  or  chemical  violence.     [J.  M.  S.] 

3. — Rolleston  and  Hayne  report  the  case  of  a  male  child. 
aged  6  months,  who  had  been  jaundiced  since  birth.  A 
fortnight  before  death  the  jaundice  became  more  marked. 
The  liver  was  found  to  extend  to  the  anterior  superior 
spine  of  the  ilium.  The  spleen  was  also  enlarged  and 
projected  3  finger  breadths  below  the  costal  arch.  There 
was  no  asc'tes.  The  urine  was  bile-stained,  and  the 
motions  clay-colorod.  Just  before  death  the  temperature 
rose  to  102°.  and  an  attack  of  hemoptysis  occurred.  At 
autopsy  it  was  found  that  the  liver  was  nearly  twice  the 
normal  weight,  yellow  in  color,  and  manifestly  cirrhotic. 
The  common  bile  duct  was  small,  and  at  its  lower  half  wa? 
transformed  into  a  slender  fibrous  cord.  The  gal!  bladder 
was  small,  thickened,  collapsed,  and  buried  in  adhesions; 
the  cystic  duct  was  representeii  by  a  thin  fibrous  cord. 
There  were  enlarged  glands  in  th"  portal  fissure  suggestins 
the  condition  found  In  hypertro'.ihic  biliary  cirrhosis.  Mi- 
croscopic exaiuMirition  of  the  liver  showed  that  fibrosis 
was  cverywhevi^  iiresent.  The  case  was  one  of  coiqsnital 
hepatic  clrrhciis  with  obliter.-itive  cho'in-itis.  The  f-il- 
lowing  hypothesis  appears  to  bo  a  reasonable  explanation 
of  the  pathogeny  of  so-called  congenital  obliteration  of  the 


April  20,  1901] 


THE  LATEST  LITERATURE 


TTHE    PHILADEtPHIA 

L  Medicai.  JounxiL 


bile  djcts:  In  the  first  iustance,  poisons  pass  by  the  blood 
from  the  placenta  to  the  fetus  by  the  umbilical  vein 
some  of  this  blood  at  once  passes  through  the  liver  and, 
in  virtue  of  the  toxic  effect  of  the  contained  body  or  bodies, 
induces  ordinary  portal  or  multibular  cirhosis  of  the  liver; 
the  remainder  of  the  blood  in  the  umbilical  vein  passes 
directly  into  the  general  circulation  of  the  fetus  by  tho 
ductus  venosus,  and  subsequently,  by  means  of  the  hepatic 
artery,  will  convey  poison  to  the  liver.  By  this  means  the 
toxic  body  which  may  be  analogous  to  toluyendiamine  is 
excreted  into  the  small  intrahepatic  bile  ducts,  setting  up 
cholangitis  and  monolobblar  cirhosis.  In  this  way  a  mixed 
cirrhosis,  portal  and  biliary,  is  induced.  The  cholangitis 
descends  to  the  larger  ducts,  and  gives  rise  to  an  obliterat- 
ive  appendicitis.  The  difference  between  this  condition  of 
congenital  cirrhosis  with  obliterative  cholangitis  and  other 
forms  of  cirrhosis  in  post-natal  life  consists  in  the  further 
change  in  the  large  bile  ducts  and  gall  bladder.  An  at 
tempt  to  explain  this  additional  lesion  may  be  made  as  fol- 
lows: The  bile  ducts  are  extremely  small  at  birth,  and  any 
inflammatory  change  will,  from  the  small  size  of  the  lumen, 
produce  stenosis  much  more  readily  than  later  in  life.  J. 
M.  S.] 

4. — Williamson  reports  a  case  in  which  sodium  salicylate 
had  a  definite  influence  in  greatly  diminishing  the  sugar 
excretion  in  diabetes.  Other  conditions,  being  kept  the 
same,  when  the  drug  was  given  in  large  doses,  the  sugar 
excretion  greatly  diminished;  when  the  drug  was  discon- 
tinued the  sugar  excretion  at  once  increased  rapidly;  and 
when  the  drug  was  again  given  the  sugar  excretion  greatly 
diminished.  A  report  of  19  other  cases  of  diabetes  or 
pers. stent  glycosuria  in  which  sodium  salicylate  was  used 
is  also  published.  It  is  not  advisable  to  give  sodium  sali 
cylate  if  serious  complications  are  present,  or  if  the  patient 
appears  to  be  losing  ground  rapidly,  because  the  drug  has 
a  bad  reputation  with  many  practitioners,  and  a  fatal  ter- 
mination during  the  salicylate  treatment  is  liable  to  be 
attributed  to  the  drug.  The  author  does  not  regard  sodium 
salicylate  as  a  specific  for  diabetes.  It  does  not  usually 
produce  any  marked  diminution  of  the  sugar  excretion  in 
the  severe  forms  of  the  disease;  also  it  has  little  influence 
in  some  of  the  mild  cases. 

But  in  certain  cases  of  diabetes  or  persistent  glycosuria 
it  has  a  decided  action  in  very  markedly  diminishinm  the 
sugar  excretion.  It  requires  to  be  very  carefully  watched, 
and  fairly  large  doses  are  usually  necessary  to  produce 
j  decided  results.  It  is  best  to  commence  with  10  grs.  3  and 
I  then  4  times  a  day,  and  to  increase  slowly  up  to  15  grs. 
4  or  5  times  a  day,  watching  carefully  for  any  toxic  symp- 
toms.    [J.   M.  S.] 

5. — Freeland  Fergus  described  an  easy  operation  for 
congenital  ptosis.  A  horizontal  linear  incision  is  made  in 
the  eyebrow  so  that  the  hairs  of  tue  eyebrow  will  subse- 
quently hide  the  scar.  After  separating  the  skin  from  the 
underlying  structures  the  skin  is  separated  for  a  distance 
of  about  2  inches  above;  below,  the  skin  fascia  and  some 
of  the  muscular  structure  are  separated  from  the  tarsus, 
almost  to  the  extreme  margin  of  the  lid.  A  vertical  band  of 
the  tendon  and  fascia  of  the  occipito-frontalis  muscle  two 
inches  long  and  about  three-quarters  of  an  inch  broad, 
is  dissected  up  until  the  only  attachment  of  a  band  is  to 
that  portion  of  the  occipito-frontalis  muscle  furthest  away 
from  the  original  incision.  The  end  of  the  band  is  then 
drawn  down  into  the  upper  lid  and  its  margin  fastened 
by  catgut  sutures  as  near  the  margin  of  the  lid  as  possible. 
The  skin  wound  is  closed  and  covered  with  a  sterile  dress- 
ing.     [M.  R.  D.] 

e.John  Thompson  discusses  the  peculiar  nystagmus 
of  spasm  nutans  in  infants.  He  states  that  the  existence 
of  a  convergent  form  of  nystagmus  is  not  generally  recog- 
nized even  in  large  and  recent  works  of  ophthalmology,  nor 
in  books  on  diseases  of  children.  He  believes  it  to  be  a 
co-ordination-neurosis,  and  that  it  develops  in  the  months 
during  which  the  child  is  learning  to  co-ordinate  the  move- 
ments of  the  eye  with  those  of  the  head.  The  nystagmus 
of  spasmus  nutans  is  often  unilateral  as  well  as  verticle 
and  rotary,  and  is  invariably  recovered  from  within  a  few 
months.     [M.  R.  D.] 

7. — McCaw  reports  the  case  of  a  child  aged  13  days  who 
was  suffering  from  tetanus  neonatorum.  The  treatment 
was  begun  by  the  subcutaneous  iniection  of  5  c.c.m.  of 
tetanus  antitoxin,  and  this  was  followed.  2  days  later,  by 
214   c.  cm.   om   antitoxin.     The  progress  of  the  case  was 


entirely  satisfoctory.  Bacterial  examination  of  the  dis- 
charge from  a  sloughing  surface  at  lue  uuiumuu-  auo..  t„  .i 
plentiful  growth  of  bacilli  having  the  characters  of  the 
tetanus  bacilli.  There  were  also  some  streptococci.  [J. 
M.  S.] 

8. — Gordon  calls  attention  to  a  condition  of  the  knee-jerk 
in  chorea  which,  although  not  present  in  every  case  and  is 
not  constantly  present  in  the  same  case,  is  peculiar  to  the 
disease.  With  the  patient  recumbent,  if  one  raises  the 
knee,  allowing  the  heel  to  rest  on  the  couch,  making  sure 
that  all  the  muscles  of  the  limbs  are  relaxed  for  the  time 
being,  and  if  one  then  tests  the  knee-jerk  in  the  usual  way, 
the  foot  is  found  to  rise  more  or  less  smartly,  but,  instead 
of  falling  back  immediately,  it  remains  suspended  for  a 
variable  time — hung  up  as  it  were — and  then  slowly  sinks 
liack  to  its  initial  position.  The  author  believes  that  the 
sign  has  some  value  in  the  diagnosis  of  slight  and  doubtful 
cases.    He  has  never  once  seen  it.     [J.  M.  S.] 

9- — Blackadder  reports  the  case  of  a  boy,  aged  8  weeks, 
who  was  admitted  to  the  hospital  for  wasting  and  vomiting. 
The  first  symptom  that  attracted  the  mother's  attention 
was  extreme  constipation.  Usually  there  was  no  movement 
of  the  bowels  for  3  days  at  a  time.  When  the  child  was  a 
fortnight  old  "it  began  to  vomit  after  every  feeding.  Occa- 
sionally there  was  no  vomiting  for  1  or  2  days;  then  it 
vomited  a  large  quantity  at  once.  There  were  no  physical 
signs  of  a  dilated  stomach,  nor  was  any  tumor  palpable. 
Post-mortem  examination  showed  a  sausage-shaped  thick- 
ening of  cartilaginous  consistence  in  the  pyloric  region  % 
inches  in  length.  No  fluid  could  be  seen  to  flow  through 
the  stenosed  orifice.  The  case  was  one  of  congenital  hyper- 
trophy with  stenosis  of  the  pyloris.     [J.  M.  S.] 


LANCET. 
March  30th,  1901. 


1.  The  Hunterian  Lectures  on  the  Topographical  Anatomy 

of  the  Abdominal  Viscera  in  Man.  CHRISTOPHER 
ADDISON.     Lecture  II. 

2.  A  Lecture  on  Some  Recent  Developments  in  the  Ad- 

ministration of  Anesthetics.  FREDERICK  W.  HEW- 
ITT. 

3.  Cases   of   Injury   to   the   Epiphyseal   Mne.     RUPERT 

BUCKNALL. 

4.  Note  on  the  Treatment  of  Collapse  of  the  Ala.  Nasi. 

W.  J.  WALSHAM. 

5.  The  Treatment  of  Sciatica,  Arthritis  Deformans,  and 

Scleroderma  by  Superheated  Dry  Air.  FR.  NEU- 
MANN. 

fi.  Note  on  a  Case  of  Temporosphenoidal  Abscess  follow- 
ing Middle-Ear  Suppuration;  Operation;  Recovery. 
PERCY  JAKINS. 

7.  "Selenium  Compounds  as  Factors  in  the  Recent  Beer- 
Poisoning  Epidemic."  F.  W.  TUNNICLIFFE  and 
OTTO  ROSENHEIM. 

S.  The  Management  of  Home  Military  Hospitals.  SURG.- 
CAPTAIN  W.  PUGIN  THORNTON. 

1. — .\ddison,  in  continuing  his  lecture  on  the  topographi- 
cal anatomy  of  the  abdominal  viscera,  discusses  first  tho 
lateral  displacements  of  the  pylorus  and  next  the  move- 
ments of  the  stomach  and  its  relation  in  these  various 
positions  to  the  other  abdominal  viscera.  The  influence 
of  the  stomach  upon  the  shape  and  position  of  the  parts 
behind  it  is  then  spoken  of.  The  various  positions  and  re- 
lations of  the  duodeum  and  small  intestine  are  next  men- 
tioned. In  beginning  with  the  peritoneum  Addison  men- 
tions prolapse  of  the  mesentery.  In  these  cases  the  mesen- 
tery is  attached  much  lower  than  is  normal.     [J.  H.  G.] 

2. — Hewitt  thinks  that  the  method  of  producing  anes- 
thesia introduced  by  Cloves,  which  consists  in  administer- 
ing first  nitrous  oxide  and  then  ether,  is  far  superior  to  any 
other  method  which  we  possess  at  the  present  time.  By 
Clover's  method  of  etherization  there  are  two  factors  at 
play,  first  the  ether,  and  second  a  certain  amount  of 
asphyxia.  The  latter  is  brought  about  by  permitting  a 
very  small  ingress  of  oxygen,  the  effect  of  which  is  to 
make  the  anaesthesia  much  more  profound.  Hewitt  uses 
an  inhaler,  the  tubes  of  which  are  of  much  larger  calibre 
than  those  of  the  Clover  apparatus,  and  this  difference  he 
maintains,  eliminates  to  a  great  extent  the  stertor  and  cy- 
anosis which  accompanies  the  administration  of  nitrous 
oxide  and  ether.    He  considers  deep  and  obstructive  stertor 


758 


The  Phil.vdelphia"! 


THE  LATEST  LITERATURE 


[APEn.  2ri.  VjjI 


to  be  a  danger  signal  and  an  indication  for  the  need  of  oxy- 
gen. The  dorsal  position  with  the  face  looking  upwards  is 
an  improper  position  for  any  form  of  anaesthesia:  the  hea^l 
should  be  turned  to  one  side.  The  patient  is  allowed 
first  to  breathe  the  nitrous  oxide  until  partly  under  the 
effect  of  this  gas,  and  then  the  ether  reservoir  is  filled. 
Attention  is  then  called  to  the  successful  use  of  gas,  ether 
and  chloroform  in  producing  anaesthesia.  Gas  for  the  pa 
tient,  ether  for  the  anaesthetist,  and  chloroform  for  the 
surgeon.  Nitrous  oxide  is  pleasanter  for  the  patient  to 
take,  ether  can  be  given  with  safety  and  has  a  stimulating 
action  on  the  respiration  and  circulation,  and  chloroforn. 
is  of  advantage  because  of  the  quiet  of  the  patient  and 
the  comparative  freedom  from  venous  engorgement.  The 
danger  of  chloroform  is  during  the  second  stage  of  anaes 
thetisation,  tnat  is,  the  stage  of  excitement.  With  the  ad 
ministration  first  of  nitrous  oxide  and  then  ether,  this  dan 
ger  stage  is  avoided.  The  disagreeable  after  effects  from 
the  prolonged  use  of  ether  can  also  be  avoided  by  thi.= 
combination.  Hewitt  thinks  this  method  far  superior  to  any 
other  in  producing  anaesthesia.  The  change  from  ether  to 
chloroform  should  never  be  made  while  the  patient  is 
struggling,  nor  should  the  change  be  made  when  the  pa 
tient  is  profoundly  under  the  influence  of  ether.  It  is 
better  to  allow  the  patient  to  recover  sufficiently  from  the 
ether  to  cough  slightly,  which  frees  the  larynx  of  any 
mucus,  and  then  to  begin  the  use  of  the  chloroform.  This 
method  of  anaesthesia  is  particularly  to  be  recommended 
in  operations  about  the  mouth,  throat  and  nose,  and  in 
such  cases  the  Junker  inhaler  is  used.  Hewitt  then  do 
scribes  what  he  calls  a  chloroform-prop,  which  serves  tho 
purpose  of  keeping  the  mouth  gagged  open,  and  bavin,? 
in  addition  a  hollow  tube  attached  to  it,  which  allows 
the  inhalation  of  the  chloroform  without  interference  with 
the  work  of  the  surgeon.     [J.  H.  G.] 

3. — Buchnall  reports  six  cases  of  separation  of  the  epi- 
physes of  the  humerus  and  radius.  In  the  first  examina- 
tion of  all  the  injuries  about  elbow  joint  in  young  people 
he  strongly  urges  the  necessity  of  the  use  of  a  general 
anaesthetic  in  order  that  the  exact  condition  may  be 
known.  He  finds  that  a  molded  gutta-percha  splint  is 
more  satisfactory  in  these  cases  than  a  splint  of  wood  or 
metal.  In  most  of  the  cases  an  injury  to  the  elbow  joint 
the  arm  was  dressed  in  a  flexed  position.  Buchnall  urge.* 
the  importance  of  early  passive  motion  in  these  fractures 
in  order  to  prevent  adhesion  and  limitation  of  motion. 
This  is  usually  begun  about  the  10th  day  and  increased 
each  day,  the  separated  portion  of  the  bone  being  heid 
firmly  with  the  hand.  If  a  separated  epiphysis  has  been 
allowed  to  go  without  treatment  and  no  union  has  taken 
place,  it  is  oftentimes  better  to  remove  it.  A  separation 
of  the  internal  condyle  of  the  humerus  will  frequently 
produce  an  ulnar  palsy,  which  is  illustrated  in  one  of  the 
cases  reported.     [J.  H.  G.j 

4. — Walsham  speaks  of  the  great  difficulty  in  overcoming 
the  obstruction  of  free  inspiration  due  to  collapse  of  the 
ala  nasi.  He  urges  the  careful  observance  of  this  con- 
dition as  an  obstruction,  and  thinks  that  it  is  frequently 
overlooked.  He  has  found  drainage  tubes,  celluloid  ex 
panders,  and  the  various  rings  recommended  for  the  cond; 
tion  all  unsatisfactory  and  discomforting  to  the  patient. 
For  the  relief  of  this  condition  he  has  devised  a  plastir 
operation  which  consists  in  placing  a  flap  of  mucous  mem 
brane  rolled  upon  itself  into  the  anterior  space  between 
the  ala  and  the  septum,  and  fixing  it  here  by  means  of  a 
suture.  This  offers  sufficient  obstruction  to  prevent  the 
collapse  of  the  ala.     [J.  H.  G.] 

6. — Jakins  reports  a  case  of  a  man  who  had  suffered  from 
middle  ear  disease  for  two  years.  Five  months  before  ac 
mission  a  polypus  was  removed.  This  had  no  effect  upon 
the  discharge,  which  continued  as  before,  but  on  admission 
the  patient  complained  of  severe  pain  all  over  the  right 
side  of  the  head,  the  right  mastoid  was  tender  on  pressure 
and  there  was  marked  giddiness  and  nausea:  the  complex 
ion  was  pale,  the  breath  offensive  and  the  lips  and  teeth 
covered  with  sordes.  The  meatal  c.i^  '  was  found  full  of 
offensive  pus  and  there  was  distinct  bulging  of  the 
superior  and  posterior  meatal  walls.  On  the  next  day  th. 
mastoid  antrum  was  opened  and  found  to  contain  granulo 
tion  tissue  and  cholesteatoma,  and  a  communication  was 
found  In  the  middle  fossa,  exposing  the  dura  mater 
'The   temporal   muscle   was   then   reflected   and   a   portion 


of  bone  removed  by  the  trephine,  but  as  no  bulging  was 
found  exploration  of  the  cerebrum  was  not  made.  After 
the  operation  the  patient  was  greatly  relieved,  but  in  three 
days  he  complained  of  a  great  deal  of  pain,  became  very 
restless,  which  was  followed  by  a  comatose  condition  and  a 
palsy  of  the  left  leg  and  arm.  The  trephine  opening  was 
again  exposed,  the  dura  mater  was  found  to  bulge,  and 
when  it  was  divided  and  a  grooved  director  was  passed  into 
the  tempero-sphenoidal  lobe,  a  quantity  of  foul  smelling 
pus  escaped,  the  cavity  was  drained  and  the  patient  made  a 
good  recovery.  The  palsy  of  the  arm  and  leg  disappeared 
very  promptly.  Jakins  thinks  that  the  presence  of  a  polyp 
or  granulation  tissue  in  the  extreme  canal  indicates  trouble 
in  the  antrim  or  attic  or  both,  and  that  the  removal  of  the 
growth  through  the  external  meatus  is  of  no  advantage. 
Within  two  years  he  has  operated  upon  four  cases  of  cere- 
bral abscess  caused  by  middle  ear  disease.  [J.  H.  G.] 
.  .5. — Newman  describes  the  treatment  of  arthritis  deforrr,- 
and  and  sclerdoma  by  super-heated  dry  air  ( Tallerman 
System).  The  author  states  that  two  different  forms  o: 
the  apparatus  are  used:  il)  for  the  pelvis:  and  i2»  tr' 
the  extremities.  The  temperature  in  the  apparatus  is 
raised  to  300=  F.  The  portion  of  the  body  subjected  to  the 
heat  is  wrapped  in  a  covering  of  woven  asbestos.  On  ac- 
count of  the  profuse  perspiration  which  occurs  during  the 
course  of  treatment,  the  patient  must  be  undressed  and 
clad  in  a  loose  wrap.  A  feeling  of  moderate  warmth  is 
experienced  in  the  part  subjected  to  the  heat.  The 
intense  heat  never  produces  a  sensation  of  discomfort. 
During  the  treatmen  the  pulse  rate  increases  from  10  to 
20  beats  per  minute,  and  the  bodily  temperature  rises 
scarcely  more  than  %°  Celsius:  albuminuria  has  never 
been  produced  by  this  treatment.  The  author  believes 
that  super-heated  dry  air  will  come  into  more  general  use 
as  a  therapeutic  agent,  and  from  his  own  experience  he 
has  never  seen  any  ill  effects  either  on  the  local  seat  or 
upon  the  system.  He  has  applied  this  plan  of  treatment 
in  a  large  number  of  cases:  chiefly  rheumatic  neuritis, 
chorea,  gout,  chronic  rheumatism,  rheumatic  arthritis,  sti? 
and  swollen  joints,  sprains  and  ruptures  of  the  joints, 
fractures  and  inflamed  flat  foot.  During  the  last  year 
he  has  applied  the  treatment  of  70  cases  of  sciatica.  35 
cases  of  arthritis  deformans:  also  in  chronic  arthritic  rheu- 
matism, badly  mended  fractures  with  interruption  of  the 
circulation,  severe  sprains  of  the  pelvis  and  spine,  painful 
cicatrices  and  contraction  after  gunshot  wounds,  in  three 
cases  of  sclerodema.  one  case  of  myoxodema  and  in  cases 
of  inflamed  flat-foot.  In  three  cases  of  sciatica  no  result 
whatever  was  obtained:  doubtful  results  were  obtained 
in  two  cases  of  arthritis  deformans.  In  two  cases  of  appar- 
ently old  fracture  of  the  neck  and  of  the  femur,  with 
severe  concussions  of  the  pelvis,  there  was  no  improve- 
ment The  treatment  was  not  succesful  in  a  case  of  in- 
flamed flat  foot,  and  In  a  case  of  scleroderma,  but  all  of  the 
remaining  cases  showed  marked  improvement  and  some 
were  completely  cured.  The  author  of  a  number  of  cases 
of  sciatica  and  arthritis  deformans,  one  case  of  sclerodema 
and  one  of  myxodema.     [F.  J.  K.] 

7. — Tunnicliffe  and  Rosenheim  state  that  they  hare 
found  selenium  in  an  invert  sugar  used  in  brewing.  They 
had  previously  found  selenium  in  beer,  and  they  conclude 
"that  selenium  compounds  have  played  a  definite  role  in  the 
recent  beer  poisoning  epidemic,  their  part  being,  however, 
subsidiary  to  arsenic."  In  some  of  the  Deer  examined 
these  observers  found  selenium  dioxide  in  amounts  equal 
to  one-third  or  three-fourths  of  that  of  arsenic.     [F.  J.  K.] 

8. 


THE  NEW  YORK  MEDICAL  JOURNAL. 
April  IS.  li'Ol.     Vol.  UXXIII,  No.  15.) 

1.  German  Text-books  Half  a  Century  ago;   History  auu 

Reminiscences.    A.  JACOBI. 

2.  A   Shielded   Piston   Syringe   for  Urethral  and  Vesical 

Irrigation.     RILUS  EASTMAN. 
3      The  Correction  of  the  Deviations  of  the  Nasal  Septum. 

with  Special  Reference  to  the  Use  of  the  Author's 

Fenestrated  Comminuting  Forceps.     JOHN  O.  ROE 
4.     The    Pathologv   of   Intrauterine   Death.      NTHL    MAC- 

PHATTER. 
5      The  Preponderance  of  Male  Stammerers  over  Females. 

DAVID  GREEN'E. 


ArniL  20,  mni] 


THE  LATEST  LITERATURE 


TThk    rmi.A 

L   Mni'ICAL   J 


DELI'niA 
JOVRNAL 


759 


The     Management 
POWSKI. 


of     Gonorrhea.     BOLESLAW     LA 


2. — Eastman  advises  for  irrigating  the  most  simple  ap 
paratus,  and  uses  one  consisting  of  a  five-ounce  metallic 
syringe  with  detachable  blunt  nozzle.  A  thin-spun  metal 
shield  surrounds  the  barrel.  The  shield  is  made  movable, 
in  order  that  it  may  be  held  up  while  the  nozzle  is  intro 
duced  into  a  vessel  for  filling.  His  reasons  for  using  so 
simple  a  syringe  are:  (1.)  It  is  easily  and  entirely  ster 
ilizable;  (2)  The  solution  is  taken  from  the  top  of  a  col- 
umn of  liquid,  as,  for  example,  in  a  large  graduate,  the 
crystals  that  may  be  present  in  the  bottom  of  the  recep- 
tacle are  not  taken  up:  (3)  With  the  piston  syringe  the 
pressure  exerted  may  be  finely  gauged  by  the  resistance 
against  the  operator's  thumb  pressing  the  piston:  (4)  The 
force  of  the  current  may  be  instantaneously  lessened  or 
the  stream  entirely  cut  off;  lo)  The  use  of  the  instru- 
ment is  attended  with  no  inconvenience  or  loss  of  time: 
((i)  It  is  easily  transportable:  (7)  It  is  simple  in  con- 
struction and  application.     (T.  M.  T.) 

3. — Roe  briefly  summarizes  the  special  advantages  that 
can  be  claimed  for  the  superiority  of  the  method  which  he 
describes  over  other  methods  for  the  correction  oi  the 
various  deviations  of  the  septum:  (l)The  facility  and  ease 
with  which,  in  every  instance,  the  osseous  and  osseocartil- 
aginous portion  of  the  septum  can  be  fractured  and  all  re- 
sistance removed  without  incising  or  even  lacerating  the 
septum,  may  be  noted:  (2)  By  fracturing  the  anterior  por- 
tion of  the  osseous  septum  and  changing  its  direction  by 
putting  it  in  a  straight  line  together  with  the  cartilaginous 
port'on,  so  that,  when  this  osseous  portion  becomes  re- 
united in  its  new  position  and  firm  ossification  has  taken 
place,  the  cartilaginous  portion  is  firmly  held  in  its  new 
position.  As  osseous  tissues  does  not  readily  bend,  this 
must  necessarily  act  as  a  firm  post  or  support  to  hold  the 
cartilage  in  its  new  position,  very  much  in  the  same 
manner  as  the  direction  of  the  hang  of  adoor  is  changed 
at  its  hinges;  (3)  Moderate  deflection  of  the  cartilaginous 
portion  of  the  septum  can  also  be  fractured  with  the  for- 
ceps and  the  elasticity  overcome,  without  the  necessity  of 
incising  the  cartilage;  (4)  By  this  instrument,  wrinkles 
and  curves  can  very  readily  be  smoothed  out,  no  additional 
operative  measures  being  required,  except  for  the  removal 
of  spurs  and  ridges  or  the  breaking  up  of  adhesions  or 
attachments  that  may  have  previously  formed:  (5)  By  this 
method,  dislocations  of  the  latter  at  its  auxiliary  attach- 
ment, can  very  readily  be  reduced  and  the  parts  put  in  their 
normal  position.  By  this  method,  also,  except  in  rare  cases, 
the  extensive  incisions  proposed  by  different  operators 
are  obviated;  such  as  crucial  or  rectangular  incisions  with 
cutting  forceps;  the  horseshoe  incisions  through  which 
the  deflected  portion  is  pushed,  which  cannot  be  of  special 
service  except  in  limited  indented  deviations  of  the  trian- 
gular cortilage,  or  the  separation  and  setting  over  of  the 
base  of  the  setum  into  the  free  nostril  far  enough  to  leave 
both  nasal  passages  of  equal  calibre  which  simply  compen- 
sates for  the  bend  in  the  septum  without  straightening  it 
after  all;  (6)  In  those  cases  in  which  incision  through 
the  cartilage  is  required  to  provide  for  the  redundancy,  the 
superiority  of  the  oblique  incision,  which  promotes  co- 
aptation of  the  cut  out  surfaces,  over  the  right-angled 
incision,  wiiich  does  not  is  at  once  apparent:  (7)  The 
superiority  of  the  fenestrated  forceps  over  the  fiat-bladed 
forceps  or  the  fingers,  as  proposed  by  some  operators,  for 
breaking  up  the  base  of  tne  fragments  at  their  bony  at- 
tachments, thus  endangering  brain  complications,  and  by 
completely  removing  the  elasticity  of  the  attachments  of 
the  defl.ected  parts,  it  facilitates  the  more  ready  adjustment 
of  the  septum  to  its  normal  position  and  diminishes  the 
length  of  support  to  the  septum  is  required.     [T.  M.  T.] 


MEDICAL    RECORD. 

.4;)///   13,    I'JIII. 


1.  Remarks  on  Enteroptosis.     MAX  EINHORN. 

2.  Small  Hospitals  and  Their  Administration.    LOUIS  N. 

LANEHART. 

3.  X-Ray  Photography.     EUGENE  R.  CORSON. 

4.  Some    Facts    of    Responsibility    in     Spirit     and     Drug 

Takers.    T.  D.  CROTHERS. 


5.  An  Unusual.  Case  of  Partial  Recovery  from  Embolism 
of  the  Arteria  Centralis  Retinae.  EDGAR  S.  THOM- 
SON. 

1. — Max  Einhorn  discusses  the  condition  of  enteroptosis, 
which  he  believes  may  exist  without  giving  rise  to  any 
symptoms  whatever;  but,  on  the  other  hand,  that  enter- 
optosis may  be  accompanied  by  all  kinds  of  gastric  and 
intestinal  aections.  The  corset  seems  to  be  an  important 
factor  in  the  causation  of  these  anomalies,  but  it  certainly 
is  not  the  only  cause.  Enteroptosis  may  be  found  in  very 
young  women,  who  have  never  worn  a  corset,  and  also  in 
men.  A  weakened  condition  of  the  abdominal  walls  ap- 
pears to  be  a  primary  and  most  important  factor  in  its 
causation.  Enteroptosis  is  accompanied  in  most  instances 
by  a  movable  kidney,  and  the  latter  can  also  bo  taken  as 
an  index  for  the  occurrence  of  the  former.  McPhcdran  is 
authority  for  the  statement  that  enteroptosis  is  not  more 
frequent  in  women  than  in  men,  but  in  Einhorn's  last  45 
cases,  26  were  in  females  and  19  in  males.  Looking  over 
a  large  number  of  cases,  Einhorn  has  found  in  1912  patients 
suffering  from  visceral  ptoses,  lOSO  males  and  S32  females. 
Most  of  the  cases  of  enteroptosis,  of  which  there  were  240 
in  a  series,  were  accompanied  by  a  movable  kidney,  namely, 
212;  18  in  men  and  194  in  women.  Enteroptosis  may  exist 
without  giving  rise  to  symptoms,  but  the  patient  often  com- 
plains of  a  faint  feeling  or  a  certain  weakness  after  ris- 
ing. There  is  frequently  considerable  fatigue  after  slight 
exertion,  especially  after  walking.  In  women,  pronounced 
backache  is  often  present.  Flatulence,  constipation  and 
frequent  micturition  are  commonly  present,  and  these 
conditions  do  not  yield  readily  to  treatment.  Cases  of 
enteroptosis  lasting  a  long  period  frequently  lead  to  pro- 
nounced anemia  in  consequence  of  subnutrition.  .  The 
latter  gives  rise  to  a  host  of  manifestations  (neurasthenia). 
Patients  with  enteroptosis  are  usually  thin  and  slender, 
and  often  appear  younger  than  they  really  are.  The  ab- 
dominal walls  are  generally  fiaccid,  and  palpitation  is 
usually  easily  executed.  The  abnormal  position  of  the 
stomach  can  easily  be  demonstrated  by  the  following  pro- 
cedures: 1,  the  splashing  sound;  2,  inflation  of  the  stomach 
with  gas,  and  3,  gasto-diaphany.  Strong  pulsation  of  the 
abdominal  aorta  is  frequently  encountered,  and  is  proba- 
bly due  to  the  partial  uncovering  of  this  organ  by  the 
slipping  down  of  the  stomach.  The  transverse  colon,  the 
cecum  and  part  of  the  ascending  colon,  as  well  as  the 
sigmoid  flexure,  can  often  be  distinctly  palpated.  The 
transverse  colon  is  frequently  found  in  these  cases  as 
a  ribbon-like  body  running  horizontally  above  the  navel. 
The  diagnosis  is  easy.  Einhorn  calls  attention  to  Glenard's 
"belt-test"  as  a  valuable  auxiliary  in  diagnosis.  The  phy- 
sician stands  behind  the  patient  and  encircles  the  lower 
part  of  the  abdomen  with  both  his  hands;  at  the  same  time 
supporting  and  partly  lifting  the  patient.  If  this  proced- 
ure gives  relief  it  favors  the  presence  of  enteroptosis.  The 
prognosis  is  good  when  appropriate  treatment  is  insti- 
tuted. The  principal  treatment  consists  in  the  application 
of  a  well-fitting  supporter,  and  in  supplying  with  ample  nu- 
trition and  well-regulated  exercise.  Excellent  illustrations 
of  several  devices  accompany  the  article.  Electricity  is 
especially  adapted  when  administered  intragastrically  to 
cases  in  w-hich  there  are  manifold  disturbances  of  the 
stomach.  Iron  and  arsenic  are  frequently  indicated,  and 
the  digestive  disturbances  managed  according  to  the  gen- 
eral rule.  Too  many  laxatives,  however,  should  not  be 
given.     [T.  L.  C] 

3. — Eugene  R.  Corson  presents  a  practical  paper,  the  re- 
sults of  his  own  wide  experience  in  X-Ray  photography. 
At  first  he  uses  a  coil  giving  a  thin  10-inch  spark,  but  now 
employs  one  giving  a  very  fat  and  multiplied  spark  of  10 
inches.  This  change  has  produced  a  startling  difference 
in  his  photographic  results.  The  difference  is  due  to  the 
amount  of  current  going  through  the  tube.  The  time  of 
exposure  and  the  time  necessary  for  developing  are  both 
shortened,  and  he  secures  a  negative  which  brings  out  the 
parts  more  clearly  and  with  more  detail.  For  diagnostic 
purposes  the  fluorescent  screen   of  potassium  platino-cya 


nf,r\       The  PmLADEUHLiT 
/""        Medicai  Jocrxai.  J 


THE  LATEST  LITERATURE 


[ApkiL  20,  1901 


nide  is  a  most  valuable  addition  to  the  X-Ray  outfit,  es- 
pecially when  a  very  thick  part  is  to  be  examined.  The 
salt  gives  a  bluish  light  and  acts  with  greater  rapidity  on 
the  photographic  plate.  The  time  of  exposure  is  greatly 
shortened,  about  one-fourth  the  time  being  necessary.  With 
a  screen  made  by  Emeck's,  of  Berlin,  the  author  could 
secure  a  good  negative  of  the  hip  In  1  1-2  to  2  minutes. 
[T.  L.  C] 

4.  T.  D.  Crothers  contributes  some  facts  upon  the  re- 
sponsibility in  spirit  and  drug  takers.  The  writer  wishes 
to  make  it  prominent,  not  that  there  is  legal  irresponsibil- 
ity in  these  cases,  but  that  the  present  legal  standard  is 
wrong  and  contrary  to  all  the  teachings  of  science.  The 
superstition  that  insists  on  full  measure  of  accountability 
in  all  cases  in  which  spirits  are  used,  and  assumes  that 
the  use  of  alcohol  is  the  voluntary  act  of  the  brain,  both 
conscious  and  capable  of  control,  is  a  sad  reflection  on  the 
intelligence  of  the  present  age.  The  interpretation  of  the 
law  that  boundary  lines  of  responsibility  and  irresponsibil- 
ity can  be  marked  out  in  a  case  of  inebriety,  is  a  delusion. 
To-day  a  large  percentage  of  all  medico-legal  cases  is  asso- 
ates  is  decided  from  theories  formulated  centuries  ago. 
The  real  responsibility  and  accountability  is  very  differ- 
ent from  the  conception  of  them  formed  in  courts  of  jus- 
tice. Modem  facts  of  science  show  clearly  the  influence  of 
heredity,  of  injuries,  of  strains,  of  drains,  of  failures,  of 
diet,  of  surroundings,  of  culture,  of  ignorance,  and  all  the 
vast  range  of  influences  and  forces  which  enter  into  the 
acts  and  character  of  every  person.     [T.  L.  C] 

5.  Edgar  S.  Thomson  reports  an  unusual  case  of  partial 
recovery  from  embolism  of  the  arteria  centralis  retinae, 
occurring  in  a  man  59  years  old.  The  descending  artery 
was  almost  obliterated  and  the  ascending  one  much  re- 
duced in  size.  Under  correction  fair  vision  remained.  A 
restoration  of  the  entire  upper  half  of  the  field  was  ob- 
tained down  to  within  10  degrees  of  the  macula.  There 
was  no  light  perception  either  at  the  macula  or  in  the 
lower  half  of  the  field.  No  further  loss  of  vision  oc- 
curred, the  patient  dying  one  year  after  the  embolism 
from  heart  disease.  The  relation  of  eilioretinal  vessels  to 
the  retinal  circulation  is  discussed.     [M.  R.  D.] 


MEDICAL    NEWS. 


Murch  SO,  1901.     (Vol.  LXXVIII.,  No,  13.) 

1.  The  Immediate  and  Remote  Results  in  One  Hundred 

Conservative  Operations  on  the  Ovaries  and  Tubes: 
with  Brief  reports  of  Four  Cases.  W.  L.  BUR- 
RAGE. 

2.  Tropocaine  Hydrochlorate. — A   Substitute  for  Cocaine 

Hydrochlorate  in  Spinal  Anesthesia.  WILLV 
MEYER. 

3.  A  Study  of  Cases  Presenting  Symptoms  of  Asthenopia 

and  Anomalies  of  the  Ocular  Muscles  in  which  Abla- 
tion of  the  Middle  Turbinal  Was  Effective  Treat- 
ment.    HEBER  NELSON  HOOPLE. 

4.  Acute  Traumatic  Malignancy.     WILLIAM   B.  COLEV. 

5.  The   -Akouphone   and    Its    Limitations.     J.    A.    KENE 

PICK. 
1. — Burrage,  in  his  article  on  The  immediate  and  remote 
results  of  operations  on  the  ovaries  and  tubes,  gives  in 
his  immediate  results  the  following:  Three  patients  died 
out  of  156  operations.  In  the  early  operations  there  was 
marked  enlargement  of  a  resected  ovary  in  the  weeks  im- 
mediately following  operation:  the  enlargement  disap- 
peared in  the  course  of  time.  Some  of  the  patients  had  a 
good  deal  of  pain.  These  last  conditions — enlargement 
and  pain — were  markedly  less  in  his  recent  cases,  and  he 
thinks  were  due  to  free  puncturing  of  cysts  without  espe- 
cially careful  measures  to  produce  hemostasis.  and  that 
the  enlargements  were  caused  by  pain  as  well  as  by 
trauma.  Pelvic  inflammatory  exudate  about  ovaries  and 
tubes  has  been  noted  in  a  few  cases  following  resection 
of  a  closed  tube,  these  being  generally  in  old  gonorrheal 
cases.  His  rule  In  performing  all  multiple  opreations  is  to 
do  nothing  more  than  can  be  done  in  two  hours.  Under  the 
remote  results,  the  preservation  of  ovaries  and  tubal  tis- 
sue is  considered.  In  the  few  instances  this  has  been  done 
the  symptoms  of  the  artificially  induced  menopause  have 


seemed  to  be  lessened.  The  possibility  of  pregnancy 
occuring  in  the  Fallopian  tubes  or  in  the  abdominal  cavity 
where  the  uterus  has  been  removed  and  ovary  and  tubes 
are  left  is  to  be  considered.     iT.  M.  T.j 

4.— Will  be  abstracted  when  concluded. 

5. — Kenefick  describes  the  akouphone  as  a  telephone 
whose  electric  force  is  supplied  by  a  compact  storage  bat- 
tery of  six  volts.  The  transmitter  is  fitted  with  one  or  a 
series  of  dome  or  funnel-shaped  resonators  for  the  purpose 
of  gathering  in  and  concentrating  sound  waves  from  all 
sources  in  its  immediate  neighborhood.  This  receiver  is 
so  conducted  that  all  sounds  conducted  to  it  are  reproduced 
or  retransmitted  with  such  force  and  intensity  and  pene- 
tration which  is  magnified  still  more  on  account  of  the 
closure  of  the  external  auditory  meatus  by  the  instrument 
which  is  held  so  that  it  completely  covers  it.  The  storage 
battery  is  concealed  about  the  person.  The  intensity  of  the 
receiver  action  is  adjusted  either  by  manipulating  the 
adjustment  of  the  diaphragm  or  by  means  of  a  sliding 
switch  on  the  handle.  Persons  seeking  mechanical  aid 
generally  come  under  the  following  heading:  (1)  Those 
whose  membrane  and  ossicles  are  intact,  but  functionally 
embarrassed  by  sclerosis  or  injury  while  the  nerve  is  yet 
free.  In  these  cases  we  find  flaccidity  of  the  tympanitic 
membrane  and  hyperesthesia  of  the  acoustic  nerve.  The 
tensor  tympani  has  no  function  and  fails  to  protect  the 
hyperesthetic  nerve  terminals  in  the  labyrinth  against 
these  new  sound  waves,  therefore  resorting  to  any  mechan- 
ical aid  under  these  circumstances  would  not  be  advised 
12)  In  these  cases  whose  conducting  apparatus  is  embar- 
rassed by  the  absence  of  the  ossicles  or  the  greater  part  of 
the  tympanitic  membrane,  the  nerve  remaining  free,  it 
would  seem  theoretically  favorable  for  the  akouphone  on 
account  of  the  protection  afforded  the  nerve  terminals 
by  the  intervening  bone.  (3)  Those  in  whom  there  has 
been  disease  involving,  but  not  wholly  destroying  the 
labryinthine  nerve  terminal — deaf  mutes.  In  these  cases 
we  find  the  greatest  field  for  the  practical  use  of  the  ap- 
paratus in  teaching  these  unfortunates  articulate  speech 
(4)  Those  whose  deafness  is  caused  by  destruction  of  the 
nerve  function  somewhere  in  its  central  course  do  not  re- 
ceive any  aid  from  the  akouphine.     [T.  M.  T.] 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAU 
April  11th,  I'JOI. 

1.  A  Review  of  the  Literature  of  the  Therapeutic  Use  of 

the  X-Rays.     HAR\'EY  P.  TOWLE. 

2.  Pathologv  of  the  New-Bom  as  Illustrated  in  the  Prac- 

tice of  the  Writer.     FREDERICK  W.  TAYLOR. 

3.  Oblique  Subtrochanteric  Osteotomy,  for  the  Lengthen- 

ing of  the  Femur,  and  Correction  of  the  Deformity 
of  Flexion  Resulting  from  Hip  Joint  Disease.  R  G. 
ABBOTT. 

1.  After  a  review  of  the  literature  of  the  therapeutic  use 
of  the  X-rays,  Towle  concludes:  (1)  That  the  real  nature 
of  the  X-rays  is  not  yet  determined  definitely,  nor  whether 
the  therapeutic  result  of  their  use  is  due  to  the  action  of  the 
rays  themselves  or  of  something  of  electrical  origin  accom- 
panying them:  (2)  that  the  treatment  is  not  without  dan- 
ger, unless  the  greatest  care  is  used:  (3)  that  the  effects 
of  the  X-rays  run  a  slow  course:  (4)  that  whatever  may  be 
the  exact  origin  of  the  effects  produced,  a  definite  reaction 
is  caused  in  the  skin  by  the  use  of  the  X-rays:  (5)  that 
the  changes  induced  in  the  skin  by  the  use  of  the  X-rays: 
(5)  that  the  changes  induced  in  the  skin  are  similar  his- 
ologically  to  those  seen  in  ordinary  inflammation:  (6>  that 
the  X-rays  are  not  proved  to  have  any  bactericidal  power: 
(7)  that  their  therapeutic  effect  is  probably  due  to  the  in- 
flammation excited:  (S)  that  hair  can  be  removed  by  their 
use.  and  that  lupus  and  several  other  diseases  can  be  healed 
over:  (9i  that  in  a  few  reported  cases  we  may  fairly 
assume  that  a  permanent  cure  has  been  effected,  but  that 
in  a  majority  of  the  reported  cases  too  little  time  has 
elapsed  to  rule  out  the  possibility  of  a  return  of  the  dis- 
ease; (10)  that  the  effect  of  exposure  to  the  X-rays  is  so 
extraordinarily  slow  in  disappearing  that  months  should 
elapse  before  an  absolute  cure  is  issumed:  (11)  that  while 
while  the  permanency  of  the  cure  effected  may  perhaps  be 
doubtful  as  vet.  it  is  certainly  desirable  to  experiment  fui^ 
ther.    £J.  M.  SJ 


A^nI^,  2n,  inni] 


AMERICAN  NEWS  AND  NOTES 


[The    PHII.ADELPHIa 
Medical  Journal 


761 


2.— Out  of  654  cases  of  labor,  64,  or  nearly  I07o  of  the 
children  were  abnormal  either  at  birth  or  during  the  first 
few  days  of  life.  Of  the  23  stiUborn  infants,  9  were  deliv- 
ered by  forceps.  In  8  of  these  cases  the  forceps  were 
aplied  high.  The  number  of  children  born  alive  but  dying 
within  a  few  days  of  birth  was  22,  3  of  which  were  deliv- 
ered by  forceps,  applied  high  in  two  cases  and  low  in  one. 
On  one  case  the  child  cried  normally  immediately  after 
birth,  but  withm  2  or  3  minutes  the  breathing  became  ob- 
structed. This  was  followed  by  a  discharge  of  perhaps 
2  drachms  of  yellow,  frothy  mucus  from  the  nose  while  the 
head  was  dependent.  Respiration  then  returned  and  was 
clear  for  a  time.  An  attempt  to  feed  the  child  was  followed 
by  an  attack  of  dyspnea  and  discharge  of  liquid  through 
the  nose.  A  bougie  passed  through  the  nose  met  an  ob- 
struction 5  inches  from  the  nostril.  The  child  lived  less 
than  2  days.  At  autopsy,  a  short  distance  below  the  level 
of  the  cricoid  cartilage  the  trachea  and  esophagus  were 
firmly  joined  by  connective  tissue.  The  upper  part  of  the 
esophagus  was  a  blind  pouch.  The  lower  part  of  the  eso 
phagus  communicated  at  its  upper  end  with  the  trachea  by 
an  opening  about  a  line  in  diameter.  Above  this  opening, 
on  the  posterior  wall  of  the  trachea,  there  was  a  shallow 
groove.  In  a  case  of  meningocele,  the  temperature  rose  to 
107°  F.  on  the  second  day,  and  death  occurred  on  the 
third.  The  tumor  contained  cerebrospinal  fluid  and  brain 
tissue.  The  cerebral  hemispheres  were  small,  and  the 
corpus  callosum  absent.  In  10  cases,  there  was  delay  in 
respiration.  In  6  of  these  cases  the  children  were  delivered 
by  forceps:  in  the  other  2,  delivery  was  by  podalic  version. 
Frederick  W.  Taylor  also  records  one  case  of  hare  lip  and 
cleft  palate,  one  of  vascular  nevus,  3  of  ophthalmia,  and  2 
of  melena.  One' child  was  born  with  a  depression  in  the 
left  frontal  bone,  which,  within  4  weeks,  had  returned 
nearly  to  its  normal  contour.  Another  child  had  left  facial 
paralysis,  which  had  so  diminished  by  the  eleventh  day  as 
to  be  hardiy  perceptible.  Forceps  had  been  applied  in  the 
case  when  the  head  was  well  in  the  pelvis,  with  occiput  R. 
A.     [J.  M.  S.] 

3. — E.  G.  Abbott  reports  the  details  of  a  method  of  per- 
forming oblique  subtrochanteric  osteotomy  for  lengthening 
the  femur  and  describes  an  illustrative  case.     [J.  M.  S.] 


JOURNAL  OF  AMERICAN   MEDICAL  ASSOCIATION. 

April  13,  1901. 

1.  Reflections  Upon  the  Recent  Status  of  Clinical   Med- 
icine.    ALOYSIUS  O.  J.  KELLY. 

2.  The    Present    Status    of    Spinal    Surgery.     SAMUEL 
LLOYD. 

3.  Joint  Tuberculosis.     DePOREST  WILLARD. 

4.  Permanent  Catheterization.    J.  RILUS  EASTMAN. 

5.  Suggestions  for  the  Reconstruction  of  Syphilitic  Noses. 
JOHN  B.  ROBERTS. 

6.  The  Medical  Treatment  of  Peptic  Ulcer.    FREDERICK 
C.  SHATTUCK. 

7.  Lavage  of  the  Stomach  as  a  Therapeutic  Agent  in  the 
Treatment  of  Habitual  Constipation.    C.  D.  SPIVAK. 

8.  What  Drug  Standardization  Means  for  the  Physician. 
A.  R.  L.  DOHME. 

9.  A  Visit  to  "Jesus  Hilfe,"  or  the  Leprous  Hospital  at 
Jerusalem.     JACOB   E.   SCHADLE. 

10.  Conjugal  Tuberculosis.     A  Study  of  Case  to  Case  In- 
fection.   H.  M.  BANNISTER. 

11.  Keloid  Following  Traumatism.     W.  M.  COLE. 

12.  Immunity    Against    Zymotic  Diseases.       WILLIAM  J. 
CLASS. 

13.  Yellow     Fever     and     its    Transmission.     CHARLES 
FINLAY. 

14.  Krme    Technical    Supplements    in    Complicated    Enu- 
cleations.    M.  F.  WEYMANN. 

2. — '^ara.  Lloyd  thinks  that  certain  cases  of  Pott's  dis- 
ease with  paraplegia  may  be  benefited  by  a  laminectomy. 
Where  there  has  been  complete  degeneration  of  the  cord, 
of  course,  no  operation  could  be  of  benefit,  nor  is  it  appli- 
cable when  there  are  tubercular  lesions  elsewhere  in  the 
bod'-"  or  where  there  Is  general  and  advanced  sepsis.  The 
cases  most  benefited  by  the  operation  are  those  in  which 
the  disease  is  distinctly  In  the    posterior    portion    of   the 


spine.  The  operation  should  only  be  done  where  other 
methods  have  been  tried  and  have  failed.  Lloyd  has  per- 
formed 15  operations  since  '92.  None  of  the  patients  have 
died  from  the  operation,  and  2  have  been  successful.  Oper- 
ations in  the  cervical  region  are  much  less  satisfactory 
than  those  in  the  dorsal  and  lumbar.  A  collection  of  154 
cases  has  been  made,  and  Lloyd's  conclusions  are  drawn 
from  a  study  of  these  cases.  Two  deaths  have  followed 
hemorrhage  from  the  vertebral  artery  in  operations  on  the 
cervical  vertebrae.  He  concludes  that  the  operation  is  sel- 
dom successful  and  seldom  indicated,  but  that  undoubtedly 
certain  cases  call  for  the  operation  and  are  benefited  by  it. 
[J.  H.  G.J 

3. — DeForest  Willard  urges  upon  the  general  practi- 
tioner the  great  necessity  of  the  early  recognition  of 
tubercular  lesions  of  the  joints,  maintaining  that  many 
cases  which  go  on  to  suppuration  and  ankylosis  might  be 
aborted  if  a  diagnosis  were  made  early  and  treatment 
promptly  Instituted.  He  calls  attention  to  the  great  mis- 
take of  supposing  that  joint  pains  in  children  are  due  to 
rheumatism.  Another  prevalent  error  is  that  only  the  chil- 
dren of  tubercular  parents  are  liable  to  develop  tubercu- 
lous lesions  of  the  joints.  In  making  a  diagnosis  in  the 
early  stages,  the  most  significant  symptom,  and  the  one 
which  should  make  the  physician  suspicious  and  cause  him 
to  put  the  part  absolutely  at  rest,  is  muscular  rigidity. 
Pain  and  tenderness  may  be  entirely  absent  in  these  cases 
in  the  beginning,  and  therefore  are  not  at  all  necessary 
to  a  proper  diagnosis.  The  local  symptoms  of  inflamma- 
tion are  also  absent  in  the  early  stages  of  this  condition. 
[J.  H.  G.] 

4. — J.  RiUis  Eastman  has  in  a  number  of  cases  used  pro- 
longed permanent  catheterization  without  developing  any 
of  the  evil  effects  which  are  supposed  to  follow  this  form 
of  treatment.  He  has  found  it  particularly  useful  in  cases 
of  resection  of  the  urethra,  where  an  anastomosis  is  made. 
The  best  results  are  obtained  from  the  use  of  a  large  cath- 
eter, which  is  only  allowed  to  pass  a  short  distance  into  the 
bladder.  Occasionally  there  is  some  secretion  around  the 
catheter  from  the  mucous  membrane,  but  with  occasional 
irrigation,  with  a  solution  of  permanganate  of  potash,  this 
promptly  disappears.  In  a  number  of  cases  of  perineal  sec- 
tion, he  has  been  able  to  keep  the  catheter  in  the  bladder 
until  the  wound  is  entirely  healed.     [J.  H.  G.] 

5. — John  B.  Roberts  thinks  that  many  cases  of  syphilitic 
deformity  of  the  nose  are  advised  to  have  nothing  done, 
when  in  fact  a  plastic  operation  would  largely  do  away  ■ 
with  the  disfigurement.  He  urges  that  the  patient  should 
be  made  to  understand  that  one  operation,  or  even  two,  may 
not  result  in  complete  success,  but  that  it  is  sometimes 
necessary  to  do  a  number  of  operations,  and  that  the  time 
required  will  be  from  six  months  to  a  year.  Roberts  thinks 
that  most  surgeons  will  operate  for  deformities  involving 
the  soft  parts  of  the  nose,  but  that  when  the  bony  bridge 
Is  affected,  oftentimes  operation  is  not  undertaken.  [J.H.G.] 

6. — Shattuck  discusses  the  medical  treatment  of  peptic 
ulcer.  From  a  standpont  of  diagnosis,  he  recognizes  three 
varieties  of  gastric  ulcer:  (1)  The  latent  forms  without 
symptoms  until  the  appearance  of  hemorrhage  or  perfora- 
tion. (2)  Those  characterized  by  dyspeptic  symptoms.  (3) 
Those  with  symptoms  which  are  diagnostic.  He  recom- 
mends absolute  rest  for  two  weeks,  during  which  time  rec- 
tal feeding  should  be  enforced  rigidly.  In  some  instances 
the  period  of  rest  is  continued  longer  than  two  weeks, 
while  in  a  few  the  time  is  shortened.  Stomach  unrest  and 
vomiting  has  been  provoked  in  a  few  cases  by  the  rectal 
injection.  The  sense  of  hunger  subsides  as  soon  as  the 
stomach  ceases  to  work,  and  if  hunger  persists,  small 
doses  of  morphia  are  recommended.  The  nutrient  ene- 
mata  are  given  every  six  hours  and  a  cleansing  enema 
daily.  Small  quantities  of  water  are  allowed  by  the  mouth, 
and  in  some  cases  water  is  introduced  into  the  rectum,  or 
under  the  skin,  to  quench  the  thirst.  At  the  present  time, 
judging  from  the  statistics,  the  author  recommends  pro- 
longed rest  of  the  stomach.     [F.  J.  K.] 

7.- — Spivak,  in  an  article  on  lavage  of  the  stomach  as  a 


762 


Tf 


Pnii.APrr.rHiA" 

MKDICAI.   JOl'IlNAL    _ 


THE  LATEST  LITERATURE 


[AfBIL  20,  1001 


therapeutic  agent  in  the  treatment  of  habitual  constipa- 
tion, comes  to  the  following  conclusions:  (1)  In  some  indi- 
viduals suffering  from  habitual  constipation,  spontaneous 
bowel  movements  follov.'  the  first  lavage  of  the  stomach. 
(2)  Recovery  occurs  in  the  majority  of  patients  if  lavage 
be  continued  for  a  period  of  two  or  three  weeks.  (3)  The 
use  of  cold  water,  or  hot  and  cold  water  alternately,  gives 
promise  of  the  best  results.  (4)  One  hour  before  breakfast 
is  the  most  favorable  time  for  lavage.     [F.  J.  K.l 

8. — Dohme  emphasizes  the  value  of  drug  standardization 
to  the  physician.  By  uniformity  in  the  strength  of  the 
drug,  the  element  of  doubt  is  removed  from  the  physician's 
mind,  the  pharmacist  avoids  embarrassment,  and  the  pa- 
tient is  sure  of  getting  what  is  prescribed,  therefore  being 
advantageous  to  all  parties  concerned.     [P.  J.  K.] 

9._  Will  be  treated  editorially.     [F.  J.  K.] 

10. — Bannister  discussed  the  danger  of  contracting  tuber- 
culosis; whether  the  liability  to  contract  the  disease  de- 
pends so  much  upon  direct  infection  or  upon  constitutional 
and  hereditary  predisposition.  Short  histories  of  a  num- 
ber of  cases  are  given,  and  the  author  suggests  the  fol- 
lowing conclusion:  that  a  much  greater  personal  risk  ex- 
ists when  the  parent  is  phthisical,  than  from  having  a 
husband  or  wife  who  is  tuberculosis.     [F.  J.  K.] 

11. — \V.  M.  Cole  discusses  the  pathology  of  keloid  and 
calls  attention  to  the  fact  that  the  disease  is  not  confined 
to  the  skin  alone,  but  is  also  sometimes  met  with  in  the 
mucous  membrane.  For  instance,  on  the  conjunctiva  and 
on  the  tongue.  He  reports  a  number  of  cases  where  he 
has  had  very  satisfactory  results  from  complete  excision 
of  the  growth  with  careful  coaptation  of  the  skin  wound. 
Where  the  skin  edges  cannot  be  brought  together  skin 
grafting  wil  often  result  in  success.     [J.  H.  G.] 

12. — Class  in  an  article  on  immunity  against  zymotic 
diseases  believes  that  in  districts  where  certain  zymotic 
diseases  are  endemic,  there  is  a  wide  distribution  of  the 
germs  of  the  disease  in  question,  and  that  the  microorgan- 
isms are  present  in  an  attenuated  form.  When  the  germs 
become  virulent  they  are  apt  to  produce  an  epidemic.  The 
infection  by  attenuated  germs  renders  an  individual  im- 
mune or  insusceptible  against  a  given  zymotic  disease. 
[F.  J.  k;.] 

13.— Will  be  treated  editorially.     [F.  J.  K.] 


AMERICAN    MEDICINE. 

Aiiril  l.^S,  I'lOt. 

1.  The  Medical  Aspects  of  Carcinoma  of  the  Breast,  with 

a  Note  on  the   Spontaneous   Disappearance  of  Sec- 
ondary Growths.     WILl.IAM  OSLER. 

2.  Gastrojejunostomy  in  Gastrectasis.     A.  H.  CORDIER. 

3.  The   Morality   of  Operation   for   Obstructive  Jaundice. 

JOHN  B.  DEAVER. 

4.  Phelps'  Operation  for  Clubfoot  with  a  Report  of  16r0 

Cases.     A.  M.  PHELPS. 

5.  An   Obscure  Case  of  Hysteria  with  Associated   Right 

Mydriasis   and  Amblyopia  and  Left  Myosis.     H.  A. 
HARE. 

6.  Indications  and  Limitations  of  the  'Vaginal  Operation 

in  Pelvic  Diseases  in  Women.     J.  RIDDLE  GOFFE. 

7.  Deep  Breathing  as  a  Curative  and  Preventative  Meas- 

ure.    JOHN  H.  PRYOR. 
8     "The  Most  Useful  Citizen:"  A  Study  in  Human  Dyna- 
mics.     F.   W.   LANGDON. 
9.     Dust  as  a  Factor  in  Diseases  of  the  Upper  Respiratory 
Passages.    W,  SCHEPPEGRELL. 

1. — William  Osier  presents  a  paper  on  the  medical  as- 
pects of  carcinoma  of  the  breast,  with  a  note  on  spon- 
taneous disenppearance  of  secondary  growths.  Osier  men- 
tions that  a  large  majority  of  patients  -svith  this  condi- 
tion suffer  from  Internal  metasteses  after  operation.  In 
one  case  which  he  saw  with  Dr.  Agnew  eighteen  years 
had  elapsed  since  the  discovery  of  the  breast  tumor.  On 
the  other  hand  these  growths  may  appear  with  extraordin- 
ary rapidity.  The  cases  may  be  arranged  into  tliose  with 
cerebrospinal  thoracic  and  abdominal  manifestations.  The 
tendency  of  secondary  carcinoma  to  involve  the  bones,  es 
pecially  those  of  the  spine,  makes  the  complication  of  this 
group  very  frequent.    Secondary  cancer  of  the  bones  of  the 


skull   is   very   infrequent,    as   is   seconlary   cancer   of  the 
brain.     Osier  reports  one  case  with  symptoms  of  brain  tu- 
mor occurring  18  years  after  the  appearance  of  scirrhus 
carcinoma  of  the  breast.     Dr.  Agnew  had  seen  the  case  in 
its  incipiency  but  had  advised  against  operation,  and  the 
growth  had  gradually  become  shrunken.     The  spinal  mani- 
festations are  perhaps  the  most  important  of  all  the  groups. 
The  main  characteristics  of  this  involvment  are  pains  of 
great  intensity,  usually  about  the  sides  and  down  the  leg;. 
or  if  the  secondary  masses  are  situated  higher,  they  may  be 
in  the  arms.     Alterations  of  sensation  are  common.     The 
crisis  of  pain  are  frequently  unbearable.     Osier  recoias  7 
cases  with  this  complication  which  are  the  most  notable 
which  he  has  observed  within  the  past  8  years.     The  clin- 
ical notes  are  included  in  the  article.     The  thoracic  mani- 
festations from  the  proximity  to  the  original  disease  are 
extremelj'  common.    There  are  three  groups  of  such  cases; 
the  pleural,  glaudular  and  pulmonary.    Of  the  pleural  vari- 
ety, Osier  reports  two  cases.    In  general  there  are  pains  in 
the    chest,    sometimes   with    signs   of   an    acute   pleurisy: 
there  is  a  gradual  effusion  and  the  case  may  be  first  seen 
with  all  signs  of  a  large  exudate.     The  effusion  may  be 
the   result  of  acaneerous  pleurisy,  or  it  may  come  from 
pressure  of  enlarged  mediastinal  glands  on  the  azygos  and 
other  veins.    There  are  many  cases  of  hydrothorax  referred 
to  in  the  literature.     By  far  the  most  distressing  features 
of  breast  cancer  are  seen  in  the  cases  in  which  the  bron- 
chial and  mediastinal  glands  are  involved  and   in  which 
the  patient  dies   from   gradual  suffocation.     Osier  reports 
one  case  of  this  variety  recently  seen  and  recalls  the  death 
of  two  patients  within  a  few  years  from  this  condition. 
Secondary  scirrhus  of  the  lungs  is  not  very  common,  ex- 
cept the  presence  of  scattered  nodules  %een  postmortem. 
Encephaloid  is  more  frequent.     The  abdominal  manifesta- 
tions may  be  divided  into  two  groups,  the  peritoneal   and 
hepatic.     These  secondary  growths  may  invade  the  omen- 
tum and  peritoneum,  with  nodular  masses  in  the  mesen- 
teric glands  with,  or  without  ascites.     In  a  case  which  Os- 
ier details  the  masses  appeared  to  be  in  the  omentum  an;! 
peritoneum.    Cancer  of  the  liver  secondary  to  cancer  of  the 
breast  is  very  common.     Osier  gives  short  histories  of  2 
illustrated  cases.    In  conclusion  Osier  discusses  the  sponta- 
mous  disappearance  of  secondary  growths,  illustrating  the 
fact  that  no  condition,  however  desperate,  is  quite  hope- 
less.    In  two  of  the  cases  of  Dr.  Osier's  theories  spontan 
eous  disappearance  of  the  secondary  growths  took  place. 
The  spontaneous  involution  seen  occasionally  in  the  pri- 
mary growths  of  the  breast  affords  an  explanation  of  the 
disappearance  of  the  symptoms  in  some  cases  with  sec- 
ondary metastases.    The  treatment  is  most  unsatisfactory. 
Morphia  alone  gives  relief.     [T.  L.  C] 

2. — A.  H.  Cordicr  discusses  the  operation  of  gastrojejun- 
ostomy In  gastrectasis.  Two  illustrative  cases  are  pre- 
sented. Cordier  states  that  cancer  of  the  pylorus  ev?n 
though  removed  returns  quickly  and  always  kills.  Pylor- 
ectomy  is  attended  by  a  high  mortality  and  is  not  justiffed 
in  advanced  carcinoma  of  the  pylorus.  The  operation  aa 
advised  by  Wolfler  and  Von  Hacker  that  of  gastrojejunos- 
tomy best  meets  the  indications.  It  is  not  necessary  to 
twist  the  bowel  in  making  the  anastomosis  to  prevent  bile 
from  entering  the  stomach.  The  anastomotic  opening  in 
the  stomach  should  be  at  the  most  dependent  point  of  the 
dilated  organ.  The  operation  is  attended  with  a  low  mor- 
ality. Tables  are  appended.  The  author  believes  that  in 
all  cases  in  which  marked  dilation  of  the  stomach  exists, 
accompanied  by  emaciation,  pain  and  an  invalid  state,  this 
operation  should  be  performed.  The  patient  gains  rapidly 
in  weight,  and  if  the  disease  is  non-malignant,  good  health 
is  restored.     [T.  L.  C] 

3. — John  B.  Dcaver  presents  a  paper  upon  the  mortality 
of  operations  for  obstructive  jaundice.  A  careful  study 
of  the  causes  of  the  mortality  of  this  condition  leads  us  to 
the  consideration  of  the  best  methods  of  combating  the 
disease.  The  most  common  of  all  causes  is  obstruction 
from  gall  stone.  Parasites  are  so  rare  that  they  may  be 
passed  with  the  mention,  although  the  indication  is  dis- 
tinctly surgical  when  they  do  occur.  The  most  common 
cause  of  death  is  hemorrhage  caused  by  changes  in  the 
blood.  The  next  most  common  is  exhaustion,  or  what  we 
believe  to  be  cholemia.  The  third  most  ■common  is  shock, 
which  is  the  result  of  hemorrhage.  Deaver  believes  that 
early  operation  offers  the  best  safeguard  to  the  destructive 
possibilities  of  obstructive  jaundice  due  to  cholelithiasis. 
Strictures,  or  obliteration  of  the  duct,  tumors,  closing  the 


APKII,  20.  1001] 


THE  LATEST  LITERATURE 


[The   Pnn.AnEi.pinA       '•f.t 


orifice  of  the  duel,  or  growing  into  its  interior,  pressure 
from  without  by  tumors  of  contiguous  organs  or  by  en- 
larged glands,  in  fissure  of  the  liver,  present  unmistakable 
surgical  indications.  Marked  jaundice,  especially  of  long 
duration,  offers  serious  obstacles  to  operative  interference. 
Yet  in  some  cases  the  risk  must  be  asumed.  Deaver  classes 
these  cases  as  the  "fulminating  type"  of  the  disease.  A 
differential  diagnosis  is  often  difficult  to  establish,  but 
Deaver  points  out  that  general  peritonitis  which  is  a  usual 
accompaniment  of  fulminating  appendicitis  is  unusual  in 
disease  of  the  biliary  apparatus.  In  either  case  operation 
should  be  synchronous  with  the  establishment  of  a  diag- 
nosis. Operation  is  advisable  even  if  this  cannot  be  ab- 
lutely  determined.  Deaver  includes  the  report  of  5  cases  in 
this  paper.     [T.  L.  C] 

4. — A.  M.  Phelps  reports  16.50  operations  for  club-foot  by 
Uis  method.  In  1878  he  performed  his  first  operation  of 
open  incision,  upon  a  relapsed  club-foot.  Since  that  date 
he  has  operated  upon  1650  cases.  In  his  first  series  of  538 
cases  he  performed  17  osteotomies.  In  the  last  1100  he  has 
never  resorted  to  osteotomy,  but  has  amputated  4  times. 
Over  100  of  his  cases  occurred  in  adults  varying  in  age 
from  20  to  60  years.  The  operation  of  cuneiform  resection 
by  Davy,  of  London,  and  that  of  resection  of  the  astragalus 
by  Lund  marked  another  period  in  operative  treatment. 
There  is  no  mortality  in  Phelps'  operation.  Any  foot  at  any 
age  can  be  straightened,  and  the  results  from  the  operation 
are  equal  to  that  from  any  bone  operation,  or  mechanical 
treatment.  The  method  by  which  Phelps'  proposes  to  gov- 
ern the  management  of  club  foot  requiring  operative  work 
is  given.  The  paper  is  profusely  illustrated.  Phelps'  ob- 
servations have  led  him  to  the  following  conclusions, 
among  others  given:  All  feet  at  any  age  after  the  fourth 
month,  with  shortened  skin  and  ligaments,  should  be  oper- 
ated upon  by  open  incision.  Prolonged  medical  treatment 
is  unjustified.  Club-foot  shoes  of  every  name  and  nature 
have  been  discarded,  and  manipulation  by  the  hand  is  ad 
vised.  A  case  cannot  be  said  to  be  cured,  and  free  from 
the  dangers  of  relapse,  until  the  heel  strikes  the  ground 
first  in  walking.  A  cure  is  effected  when  new  facets  are 
formed  on  the  tarsal  bones.     [T.  L.   C] 

5. —  H.  A.  Hare  reports  an  obscure  case  of  hysteria  with 
associated  right  mydriasis  and  amblyopia  and  left  myosis. 
The  patient  was  a  woman  of  .33  years  who  suffered  from 
scarlet  fever  at  15  years,  from  which  she  did  not  recover 
for  two  months.  She  went  out  into  the  snow  with  the 
eruption  still  upon  the  body.  During  that  time  she  had 
much  pain  on  the  right  side  and  lower  axillary  region  and 
in  the  lumbar  region.  These  attacks  have  occurred  at  ir- 
regular intervals  ever  since,  usually  about  2  weeks  apart. 
After  these  paroxysms  small  white  stones  about  the  size  of 
a  grain  of  buckwheat  have  been  found  in  the  stools.  On 
one  occasion  a  stone  the  size  of  a  cherry  was  found.  For 
five  days  preceding  this  discovery  the  patient  was  un- 
able to  move  arms,  legs  or  body,  and  her  vision  and  hear- 
ing were  imperfect  although  she  was  not  in  great  pain. 
Eleven  years  ago  while  writing  she  found  her  sight  defic- 
ient and  discovered  that  one  eye  was  entirely  blind.  For 
the  past  4  years  the  left  pupil  has  been  tightly  contracted 
but  the  vision  was  good.  The  right  pupil  was  widely  di- 
lated. After  the  period  of  5  years  referred  to  she  was 
comparatively  well  for  2  years  when  she  fell  violently, 
injuring  the  waist  region.  Following  the  fall  there  was 
a  discharge  of  pus  and  blood  from  the  rectum.  Operation 
was  performed  but  no  pus  or  stone  was  found.  Dr.  de- 
Schweinitz  diagnosed  the  case  as  one  of  hysteric  ambly- 
opia. When  the  patient  was  fitted  with  proper  glasses. 
vision  markedly  improved,  and  under  proper  treatment,  in- 
cluding massage  and  Swedish  movements,  the  symptoms 
almost  entirely  disappeared.     [T.  L.  C] 

WIENER    KLINISCHE  WOCHENSCHRIFT. 

Murch   !>,,   1901.      (XIV   Jahrg..   Xo.    II.) 

1.     The  Primitive  Organs  of  Sight.     T.  BEER. 

£.     Ligation   of   the   Jugular   Vein   in   Thrombosis   of   the 

Lateral  Sinus.     F.  ALT. 
3.     Sutures  in  the  Heart.     H.  ZULEHNER. 

1. — Will  be  abstracted  when  completed. 

2. — After  a  detailed  review  of  the  literature  of  his  sub 
ject.  Alt  reports  two  cases  of  thrombosis  of  the  lateral  sinus 
following  chronic  suppurative  otitis  media.  In  both  cases 
Alt  laid  osen  the  sinus,  removing  the  clots.     In  one  case.  , 


the  jugular  vein  was  llgated.  Infection  of  the  thromDus 
contained  in  the  ligated  vein  followed:  it  was  onenea, 
cleaned  out,  and  again  ligated.  Both  cases  recovered  even- 
tually. From  the  literature  quoted,  it  seems  that  those 
cases,  in  which  it  is  not  considered  necessary  to  ligate 
the  jugular  vein,  have  a  slightly  better  prognosis  tnau 
those  in  which  ligation  must  be  done.     [M.  O.l 

3. — Zulehner  reports  the  case  of  a  man  of  35,  who  was 
stabbed  in  the  chest  and  abdomen.  The  upper  wound  pen- 
etrated the  heart.  This  was  opened  and  an  attempt  made 
to  suture  the  wound,  (only  half  a  cm.  long.)  in  the  wall 
of  the  left  ventricle.  The  fine  sutures  tore  out  at  once, 
and  the  patient  bled  to  death  on  the  opeating  table.  The 
heart  showed  marked  fatty  degeneration,  was  hvpertro- 
phied,  and  its  walls  were  very  brittle.  All  the  "viscera 
were  anemic.  The  abdominal  wound  had  suppurated,  pro- 
ducing peritonitis.  Out  of  10  cases  so  far  known  in  litera- 
ture, only  three  recovered.  Zulehner  quotes  the  first  of  the 
three,  a  man  of  22,  who  had  been  stabbed.  I  wound  over 
1  cm.  long  in  the  right  ventricle  was  sutured  with  cat- 
gut. Zulehner's  experience  shows  how  hard  a  task  it  is  to 
attempt  to  suture  the  heart  muscle.     [M.  O.] 

JOURNAL     DE     CHIRURGIE. 
FebriKiiy- March,  1901.     (Ire.  Annee,  No.   2.) 

1.  Suppurative  Arthritis  of  the  Knee.    LAUWERS. 

2.  Intestinal    Resection    for    a    Diffuse    Neoplasm    of   the 

Pelvis.      KEIFFER. 
o.     A  Rare  Case  of  Teratology.    LORTHIOIR. 

4.  Spontaneous   Rupture  of  an  Umbilical  Hernia.     DAN- 

DOIS. 

5.  A   Case    of   Pneumococcic    Peritonitis.     VANDERLIN- 

DEN. 

1- — Lauwers  reports  two  cases  of  purulent  arthritis  of  the 
knee,  in  adults,  due  to  staphyloccocci.  One  fol- 
lowed purulent  conjunctivitis,  the  other  was  puerperal.  The 
first  case  recovered  with  simple  drainage  and  fixation.  In 
the  second  case,  the  femur  was  so  diseased  that  Lauwers 
amputated  at  the  lower  third  of  the  thigh.  She  recovered 
quickly.      [M.   O.] 

2. — Keiffer  reports  an  intestinal  tumor  occurring  in  a 
woman  of  30.  Two  years  ago,  the  tumor  filled  the  entire 
pelvis.  The  urine  was  normal,  as  was  menstruation.  He 
performed  an  exploratory  laparotomy,  and  found  a  diffuse 
tumor,  covering  the  bladder,  uterus,  adnexa,  small  intes- 
tine, and  descending  colon.  While  trying  to  find  the  origin 
of  the  tumor,  part  broke  off'  in  the  hand  of  the  operator. 
This  showed  the  large  intestine  passing  through  it.  As  the 
rectal  end  of  the  broken  sigmoid  flexure  could  not  be 
found,  Keiffer  made  an  artificial  hypogastric  anus.  During 
the  two  years  since  the  operation,  the  patient  has  been  in 
good  condition,  the  abdominal  viscera  have  become  free 
•ind  are  now  palpable,  and  the  tumor  has  been  absorbed, 
following  functional  disuse  of  the  lower  end  of  the  large 
intestine.  Exploration  of  the  rectum  shows  that  this  has 
closed.  The  part  of  the  tumor  removed  shows  fatty  and 
subperitoneal  connective  tissue  in  great  quantity,  com- 
pressing the  intestinal  walls,  about  which  it  had  grown 
[M.  O.] 

3. — Lorthioir  exhibits  the  photograph  of  a  man  of  18, 
with  a  third  leg,  short  and  misshapen,  formed  by  two 
rudimentary  legs,  having  a  long  foot  with  ten  toes.  He  had 
a  penis  on  each  side  of  the  median  raphe,  with  a  distinct, 
separate  scrotum,  each  containing  one  testicle.  Urine  and 
spermatic  fluid  passed  from  each  penis  simultaneously. 
It  is  not  known  how  lon.g  this  Portuguese  specimen  of  con- 
genial  malformation  lived.     [M.  O.] 

4. — Dandois  reports  a  case  of  umbilical  hernia  in  a  woman 
5S  years  of  age,  which  had  existed  15  years.  The  hernia 
ruptured  suddenly,  and  Dandois,  four  hours  later,  performed 
a  successful  operation  for  its  radical  cure.     [M.  O.) 

5. — Vanderlinden  reports  a  case  of  peritonitis,  occurring 
In  a  woman  aged  29  years.  She  had  borne  five  children, 
the  last  one  but  a  few  months  before.  Peritonitis  came 
on  suddenly,  two  weeks  before,  with  vomiting,  diarrhea, 
and  metrorrhagia.  Laparotomy  was  performed,  the  pus 
cleaned  from  the  peritoneum,  and  drainage  instituted. 
The  pus  contained  typical  pneumococci.  Double  bron 
chopneumonia.  and  death  followed.  The  autopsy  showed 
an  intestinal  perforation,  which  probably  was  the  cause 
of  death.  A  full  review  of  the  litevaturo  of  pneumoccoccic 
peritonitis  follows.     [M.  O.] 


764 


The  Phtladelphia"! 
Mkdical  Jocrnal  J 


BRAIN  TU:\IOR 


[Apeil  20,  WOT 


©riolnal  articles. 


THE  LOCALIZATION  OF  BRAIN  TUMORS  ESPECIALLY 
WITH  REFERENCE  TO  THE  PARIETAL  AND 
PREFRONTAL  REGIONS  * 

By  CHARLES  K.  MILLS,  M.  D. 

Professor  of  Mental  Diseases  and  of  Medical  Jurisprudence  in  the  Univer- 
sity of  Pennsylvania;  Neurologist  to  the  Philadelphia  Hospital. 

During  a  little  more  than  a  year  past  I  have  ex- 
amined and  given  opinion  as  to  the  site  of  lesion 
in  five  cases  of  brain  tumor,  and  in  a  sixth  case 
which  proved  to  be  one  of  softening  and  degen- 
eration, but  in  which  the  diagnosis  of  tumor  was 
considered  probable.  Two  of  these  cases  occurred 
in  my  own  practice,  in  one  case  I  w^as  called  in 
consultation  by  Drs.  S.  Weir  Mitchell  and  J.  K. 
Alitchell,  in  two  others  by  Dr.  W.  W.  Keen,  and 
in  the  last  by  Dr.  \V.  Sinkler.  All  of  these  cases 
were  operated  upon  b}'  Dr.  Keen,  and  one  by  Dr. 
W.  J.  Taylor.  The  operation  in  each  case  re- 
vealed the  lesion  in  the  location  previously  indi- 
cated. In  four  of  the  cases  of  unequivocal  brain 
tumor  the  growth  was  removed  in  whole  or  in  part ; 
in  one  it  could  not  be  removed  owing  to  the  condi- 
tion of  the  patient ;  and  in  the  sixth  case  a  portion 
of  the  diseased  tissue  was  removed.  I  shall  confine 
my  remarks  to  a  brief  presentation  of  the  cases,  and 
to  a  few  salient  points  regarding  localization.  Four 
of  the  five  cases,  as  nearly  as  could  be  determined, 
began  in  the  parietal  region  and  were  largely  con- 
fined to  it ;  a  fifth  was  prefrontal  in  origin  and  lo- 
cation, and  a  sixth  was  mainly  in  the  motor  zone. 

CASE  I. — Tumor  of  the  Superior  parietal  Conrnlution 
(Parietal  Convolution  of  Wilder);  Localizing  Sijiiiptomii 
— Impairment  of  Cutaneous  HenMbiUty,  Loss  cf  hnscular 
Sense,. Astereo'inosis,  Ataj-ia,  Paresis  and  t'ltimately  ParaUjsi.:: 
Operation.  Recovery.  *  *  The  patient  was  a  man  .57  years  old 
who  had  suffered  from  nervous  symptoms  for  a  number 
of  years.  The  data  which  led  both  to  the  general  diagno- 
sis and  to  the  localization  of  the  growth  were  summarized 
in  the  paper  read  before  the  American  Neurological  Asso- 
ciation as  follows:  About  five  months  previous  to  the  op- 
eration the  patient  began  to  show  some  ataxia  in  the  right 
arm  and  later  in  the  right  leg,  and  when  investigation  of 
his  condition  was  tirst  made  by  the  writer  all  forms  of 
cutaneous  sensibility  were  impaired,  muscular  sense  was 
lost,  and  astereognosis  was  a  marked  symptom.  As  the 
case  progressed  paresis  and  eventually  paralysis  of  the 
arm  and  leg  supervened,  this  when  complete  of  course 
masking  the  ataxia.  The  patient  developed  a  disorder  of 
speech  chiefly  showing  Itself  as  a  verbal  amnesia  and 
fatigue  on  reading.  At  one  examination  the  patient  showed 
a  temporary  partial  right  hemianopsia.  Reversals  of  the 
color  fields  and  contractions  of  the  fields  for  form  similar 
to  those  supposed  to  be  typical  of  hysteria  were  present 
at  several  of  the  examinations.  The  reflexes  on  the 
ataxic  and  paralyzed  side  were  somewhat  exaggerated, 
ankle  clonus  being  present.  The  patient  was  emotional 
and  markedly  hysterical.  The  general  symptoms  of  brain 
tumor  were  not  prominent,  but  the  most  important  of 
them  were  absent. 

It  will  be  seen  from  this  summray  that  the  locali- 
zation of  the  lesion  in  the  parietal  region  was 
decided  upon  chiefly  by  a  study  of  the  sensory 
symptoms  present.     Almost    all  the   sensory    ele- 

♦Read  at  the  meetng  of  the  Philadelphia  Neurological  Society,  January 
28,  1901. 

♦This  case  has  aLrtadv  bten  publishc<l  in  detail  in  a  piper  which  was 
read  before  the  .\mcrican  Neurological    .\ssociat)t>n  a     its  Washincrton 

eetiii^.  May,  1900.  Journal  of  Nervous  and  Mental  Disease,  v.  27.  No.  5. 
!  or.  1900. 


ments  which  go  to  make  up  the  stereognostic 
sense  were  more  or  less  impaired  in  the  compara- 
tively early  history  of  the  localizing  phenomena 
of  the  case.  True  motor  paralysis  was  at  this  stage 
absent,  although  it  not  only  ensued,  but  became  a 
prominent  and  masking  feature  of  the  case  as  time 
progressed,  and  as  the  tumor  encroached  more  and 
more  upon  the  motor  region.  The  paresis  was  at 
first  undoubtedly  a  pressure  manifestation ;  later 
the  Rolandic  subcortex,  and,  to  some  extent,  even 
the  corte.x,  became  implicated  in  the  morbid  growth. 
I  shall  not  dwell  further  on  this  case,  which  has 
already  been  fully  reported,  except  to  recall  that 
the  operation  by  Dr.  W.  W.  Keen,  which  was  in 
the  highest  degree  successful,  was  conducted  with 
the  view  of  uncovering  the  superior  parietal  convo- 
lution as  the  central  point  of  the  procedure ;  and 
also  to  say  that  now,  after  the  lapse  of  fourteen 
months,  the  patient  remains  in  good  general  health, 
in  about  the  same  condition  as  he  was  at  the  time 
when  the  last  report  on  his  case  was  made,  except 
that  he  has  still  further  improved  as  regards  the 
use  of  his  upper  extremity.  No  signs  of  the  return 
of  the  growth  have  been  observed. 

Case  II. — Tumor  of  the  Superior  Parietal  and  Sliddlt 
Portions  of  the  Central  Convolutions;  Localizing  Symptoms — 
Impaired  Cutaneous  Sensibility,  Loss  of  Muscular  Sense.  As- 
tereognosis, Ata.ria  and  Late  Paralysis;  Operation,  Death; 
.iutopsy  Showing  the  Site  of  the  Lesion  as  Above  Indimtrd. 
*The  patient,  a  man  65  years  old,  five  weeks  before  the 
operation,  noticed  gradual  loss  of  power  in  the  right  hand, 
with  impairment  and  changes  in  sensation.  The  notes 
stated  that  he  would  drop  things  from  h:s  hand  uncon- 
sciously; that  he  could  not  tell  that  he  held  things  in  his 
hand  except  by  looking;  and  that  he  did  not  know  whether 
or  not  his  fingers  were  in  his  pocket.  It  has  seemed  to 
me  not  improbable  that  the  apparent  paresis  spoken  of 
may  at  first  have  been  a  loss  of  control  or  co-ordination 
Not  infrequently  the  awkwardness  and  ataxia  in  the  use  of 
a  member  which  come  on  as  the  result  of  impairment  of 
the  cutaneous,  muscular  and  stereognostic  sense  are  re- 
garded by  the  patient  and  others  as  a  true  loss  of  power. 
This  was  true  of  Case  I.  and  Case  rv.  of  this  series. 
Uncertainty  in  the  use  of  the  right  leg  came  on  within  a 
week  or  ten  days.  The  patient  said  that  he  felt  as  if  a  cush- 
ion was  under  his  right  foot.  Nearly  three  weeks  before 
the  operation,  that  is,  two  weeks  after  the  onset  of  the 
active  symptoms  above  noted,  examination  showed  that 
pressure  sense  was  absent  all  over  the  hand;  that  the 
pain  and  temperature  sense  were  also  absent  in  the  right 
upper  extremity,  most  markedly  in  the  ulnar  distribution  in 
the  hand  and  forearm,  on  the  ulnar  side  of  the  arm.  and 
also  in  a  small  region  just  In  front  of  the  shoulder  joint: 
that  muscle  sense  and  power  were  diminished,  although 
the  latter  was  still  considerable;  that  the  Babinski  reflex 
could  be  obtained  in  the  great  toe.  and  the  right  arm  jerks 
were  absent.  Other  reflexes  were  presumably  normal,  as 
they  wore  not  mentioned.  Ten  days  before  operation  the 
man  suffered  with  severe  cephalalgia,  chiefly  in  the  left 
temporal  region,  great  throbbing  of  the  left  temporal  artery 

on  that  side  being  visible.  November  eleventh,  six  days 
before  the  operation,  the  patient  had  a  severe  attack  of 
tonic  spasm  in  the  right  arm.  which  lasted  fifteen  minutes. 
.\bout  this  period  ophthalmoscopic  examination  showei 
marked  left  optic  neuritis  and  beginning  neuritis  in  the 
right  eye.  No  hemianopsia  was  present.  At  a  spot  near  the 
coronal  suture,  half  way  to  the  vertex,  there  was  tenderness 
to  pressure.  From  November  eleventh  the  patient's  right 
arm  and  leg  grew  steadily  weaker,  and  his  headache  stead- 
ily worse.  The  patient  was  first  seen  by  Dr.  Keen  Novem- 
ber 17th,  who  confirmed  the  observations  of  Dr.  Nichols  as 

•This  man  was  a  patient  of  Dr.  Charles  L.  Nichols.  'Worcester.  Mass. 
He  was  operated  on  by  Dr.  W.  W.  Keen  November  17,  1<^X>,  A  day  or  two 
before  the  operation  Dr,  Keen  consulted  me  in  Philadelphia  as  to' the  site 
of  the  tumor  reading  to  me  at  this  time  a  letter  of  Dr.  Nichols  in  which  the 
main  features  in  the  historj'  and  svniptomatology  of  the  case  were  clearly 
presented,  etc.    Keen  and  i  agreed  as  to  the  location  of  the  ffrowtli. 


Apeil  20,  1901] 


BRAIN  TUMOR 


[The   PHii_\DEi.rHiA        nfic 


given  in  the  preceding  notes.  In  my  consultation  witli  Dr. 
Keen  I  suggested  tliat  the  location  of  the  tumor  was  prob- 
ably about  the  same  as  that  in  case  I.,  namely:  that  it  was 
mainly  in  the  superior  parietal  convolution  with  some 
invasion  of  the  motor  region,  this  being  also  in  accord 
with  the  views  held  by  Dr.  Keen.  An  osteoplastic  operation 
vas  performed  November  17,  1900,  and  I  am  indebted  to 
Dr.  Keen  for  notes  of  the  operation,  from  which  I  have 
condensed  the  points  essential  to  my  purposes  in  this 
paper.  The  opening  was  made  10  cm.  along  the  middle  line, 
12  mm.  to  the  left  of  it,  and  was  so  placed  that  its  anterior 
border  should  uncover  the  upper  portion  of  the  central 
fissure.  The  two  vertical  incisions  were  each  7  cm.  long. 
On  opening  the  dura  the  brain  bulged  in  a  few  minutes 
up  to  above  the  level  of  the  scalp.  At  the  anterior  portion 
of  the  opening  was  seen  tne  oblique  central  fissure.  Pre- 
cisely at  the  centre  of  the  opening  in  the  sliull  was  an  area 
of  discoloration  about  15  mm.  in  diameter,  evidently  the 
result  of  a  subcortical  growth  just  bursting  through  the 
cortex.  A  large  tumor  was  as  far  as  possible  enucleated. 
Some  portions  not  reached  by  the  first  enucleation  by  the 
finger  were  curetted.  The  patient  stood  the  operation  well. 
Chloroform  was  administered  by  Dr.  Nichols,  and  Dr.  Keen 
was  assisted  by  Drs.  Homer  Gage  and  Fisher.  At  4.30  on 
the  afternoon  of  the  day  of  the  operation  the  patient  was 
perfectly  conscious,  temperature  normal,  pulse  114,  and 
neither  speech  nor  face  was  in  any  way  affected.  He 
grasped  the  hand  of  the  doctor  with  his  right  hand,  which 
he  moved  as  well  as  before  the  operation.  At  10  P.  M.  on 
the  same  day  about  the  same  conditions  obtained,  but 
he  had  a  restless  night,  developing  much  pain  in  the  head. 
The  next  morning  the  temperature  had  risen  to  101  de- 
grees, and  his  right  arm  and  leg  were  totally  paralyzed. 
Late  in  the  afternoon  of  November  ISth  his  condition 
had  not  changed  much  for  the  worse,  but  he  soon  after 
began  to  fail,  and  died  November  19th. 

An  autopsy  was  made  by  Dr.  E.  H.  Baker,  the  city  bacteri- 
ologist of  Worcester,  twenty  hours  after  death.  The  account 
of  the  autopsy  indicated  that  a  large  oval  cavity  was  left 
which  was  filled  with  blood  and  debris.  The  cavity  seemed 
to  have  included  the  superior  parietal  and  middle  portions 
of  the  central  convolutions  and  adjoining  subcortex,  a!- 
though  the  first  is  not  mentioned.  The  superior  parietal 
convolution,  from  Dr.  Keen's  description  of  the  operation, 
must  have  been  in  large  part  removed.  The  growth  was 
single,  and  not  encapsuled.  Later  a  microscopical  examina- 
tion by  Dr.  Baker  showed  it  to  be  a  gliosarcoma. 

I  shall  not  make  any  detailed  observations  on 
sensory  phenomena  in  conjunction  with  the  study 
of  this  case,  simply  saying  that  the  remarks  on  this 
subj'ect,  in  connection  with  cases  I.,  III.  and  IV. 
are  equally  applicable  here.  The  diagnosis  of  a 
lesion,  in  large  part  posteroparietal,  was  based 
chiefly  on  the  presence  of  sensory  phenomena. 

It  will  be  noted  that  six  days  before  operation 
the  patient  had  a  severe  attack  of  tonic  spasm  in  the 
right  arm,  which  lasted  fifteen  minutes.  This 
symptom  is  of  interest  as  probabh'  indicative  of 
invasion  or  irritation  of  that  portion  of  the  motor 
subcortex  which  is  related  to  the  arm  centre.  It 
was  long  shice  pointed  out  by  Scguin  and  the 
writer  that  paresis,  with  predominance  of  tonic 
spasm,  pointed  to  a  subcortical  lesion  in  the  motor 
zone.  Recently,  in  a  case  dying  in  the  Nervous 
Wards  of  the  Philadelphia  Hospital,  a  tumor 
located  in  the  motor  subcortex  and  limited  to  this 
region,  was  found.  The  patient  was  partially  hemi- 
plegic,  and  had  a  persisting  spastic  condition  in 
the  u]>per  extremity  of  the  paralyzed  side. 

CASE  in. — Tumor  of  the  Suiicrior  Parietal  ('(iiirolution; 
Lnvulr^inij  f^iimpfotiis — Iminiiniicnt  uf  Miisculur  .S'oisr.  Aster- 
rdiiiinsis;  .Itaria.  forrsix;  Oprriitidii  Recovery.  This  patient 
a  bright  boy  S  years  old,  was  brought  to  Dr.  Keen  for  opera- 
tion by  Dr.  Daniel  Z.  Dunott.  of  Baltimore.  Maryland.  I 
had  been  furnished  by  Dr.  Keen  and  Dr.  Dunott  with  notes 
of  the  history  of  the  case  before  it  was  seen  by  me.* 

•Dr.  Dunott  expects  eventually  to  publish  an  account  of  this  case  in 

detail. 


I  examined  the  patient  on  Januarw  10th  and  12th,  1901. 
The  opeiatiou  was  periormed  January  14th,  laui.  About 
one  year  previous  to  the  operation  a  great  change  in  tne 
boy's  disposition  was  noteu.  in  June,  19U0,  he  uegan  to 
have  headaches,  which  returned  at  Intervals  and  soon  were 
accompunitd  by  vomiting.  In  October,  lauu,  he  had  an 
attack  of  paresis  in  the  left  leg  and  arm,  more  marked  in 
the  former,  the  attach,  passing  ott  in  a  lew  uours.  Dr.  Du- 
nott regarded  the  case  as  prouably  one  of  brain  tumor.  1  he 
patient  was  seen  October  8th,  lauO,  and  also  December  Ibih, 
lyuu,  by  Dr.  William  Osier.  At  tuis  lime  he  showed 
markcu  paresis  of  the  left  leg,  particularly  in  the  peroneal 
group,  ui.il  also  choked  discs,  but  no  diSLurbance  oi  sensa- 
tion or  of  the  stereognostic  sense  was  determined.  Dr.  Osier 
then  conhrmed  the  earlier  diagnosis  ol  L>r.  Dunott  of  orain 
tumor,  and  advised  operation.  On  examination  Dr.  ivecii 
was  struck  with  the  fact  that  both  on  the  rigui  u,nu  the  leit 
side  from  the  forehead  back  to  the  biauricular  line,  tapping 
produced  a  distinct  cracked-pot  sound,  percepiiuie  not  oniy 
to  the  ear,  but  to  the  other  hand  placed  on  the  viorating 
bone.  He  referred  the  patient  to  the  writer  and  to  Dr. 
G.  E.  deSchweinitz  for  examination  from  the  neurological 
and  oputnalmological  points  of  view. 

As  1  made  a  written  report  of  my  examinations  and 
opinion  to  Dr.  Keen,  and  as  this  report  covers  with  sufh 
cient  fulness  my  observations  of  the  case,  I  shall  quote  it 
here: 

"The  patient  was  distinctly  paretic  in  the  left  lower  ex- 
tremity, the  loss  of  power  showing  itself  most  in  the  extens- 
ors   and    abductors    of   the   foot    tchietly    in    the    peroneal 
group  of  muscles  J.    The  other  leg  and  thigu  muscles  large- 
ly retained  their  power.     He     could  stand  and  walk,     lie- 
sides  the  paresis  some  ataxia  of  the  left  lower  extremity 
was  present,  as  shown  in  testing  him  by  liickiug  at  objects, 
blight  paresis,  chiefly   distal,   of  the- left  upper  extremity 
V.US  also  present.     The  deep  reflexes  were  all  exaggerated 
on  the  affected   (left)   side.     Ankle  clonus  was  pr..sent  at 
one  examination  and  absent  at  the  other.     The  Babnski 
reflex   was    especially   noted    at   the    second   examination. 
lOxamination  for  touch,   pain   and   temperature  showed  no 
loss,  or  so  slight  that  it  could  not  be  measured.     Careful 
und   repeated   examinations   however   showed   a   moderate 
degree   of  astereognosis   as   determined   by   manipulations 
of  objects  by  the  left  hand.     Although  he  sometimes  recog- 
nized objects  with  the  left  hand,  he  always  did  this  more 
promptly  with  the  right,  and  in  some  instances  he  failed 
entirely   with  the  left,   although   succeeding  at  once   with 
the  right.    He  could  not  promptly  locate  sensations  in  the 
distal  portion  of  the  left  upper  extremity,  and  sometimes 
failed    entirely.     When   the   little   finger   was   touched    or  ■ 
held,  for  example,  he  referred  the  sensation  to  the  thumb 
or  to  another  finger;  when  the  finger  or  palm  of  the  hand 
was  touched,  he  referred   the  sensation   to  the  wrist,     in 
exceptional  cases  the  localization  was  correct,  but  in  three- 
fourths  of  the  trials  it  was  incorrect.     He  could  properly 
designate  any  position  in  which  the  left  lower  extremity 
was  placed,  and  the  same  was  nearly  true  for  the  left  upper 
extremity,  but  sometimes  he  did  not  seem  to  be  quite  sure 
of  the  posture  in  the  latter  case.     Comparisons  were  con- 
stantly made  with  the  right  half  of  the  body  in  arriving  at 
these   determinations.      The   left   upper   extremity   showed 
some  ataxia  as  well  as  paresis  in  testing  by  having  the 
patient  bring  his  fingers  together,  touching  the  nose,  etc. 
Facial   paresis   and   speech   disorder   were   absent.     Fara- 
docontractility  in  the  affected  limbs  was  preserved.     The 
patient  could  concentrate  his  attention  readily,  was  prompt 
in  his  apperceptions,  was  keenly  alive  to  all  that  was  going 
on,   showing   unusual   intelligence   as   regarded   his   exam- 
ination, but  he  showed  irritability  and  emotionality  such 
as  might  be  expected  in  a  boy  suffering  from  brain  tumor 
or  localized  meningitis.     A  cracked-pot  sound  was  elicited 
by  percussing  the  skull  on  both  sides  of  the  median  line  in 
the  frontoparietal  regions.     As  reported  by  Dr.  George  E. 
deSchweinitz,  at  whose  examination  I  was  present,  hemian- 
opsia  and   all    disorders   of   the   ocular   muscles,   external 
and  internal,  were  absent.     Double  optic  neuritis  was  pres- 
ent.    I  have  not  thought  it  necessary  to  repeat  the  facts 
obtained  by  Inquiry,  all  of  which   were  contained   in   the 
history  submitted  to  me  before  making  the  examination. 
The   case  Is   probably   one  of   brain   tumor,   although  the 
possibility  of  localized  convexity  tubercular  meningitis  is 
worthy  of  consideration,   and   In   either  case  operation   in 
the    same    region    is    indicated.      The    lesion    Is    probablr 


766       ^'"^   Phii.adelpbia"] 
'  SIedh'al  Journal  J 


BRAIN  TUiMOR 


(ArniL  20,  1901 


parietal,    gradually    encroaching    upon    the    motor    region. 
Hydrocephalus  may  be  present." 

An  osteoplastic  operation  was  performed  by  Dr. 
Keen,  January  14,  1901.  It  is  not  necessary  to  give 
details  of  the  operation;  it  will  be  sufficient  here  to 
record  that,  strange  to  say,  a  tumor,  which  proved 
CO  be  a  sarcoma,  was  found,  with  practically  the 
iame  location  and  extensions  as  in  the  two  pre- 
ceding cases.  The  growth  was  removed  by  Dr. 
Keen,  the  patient  recovered  from  the  operation, 
and  is  almost  in  his  normal  health  at  the  time  of 
this  report   (March,   1901), 

In  this  case,  as  in  the  t\vo  preceding,  so  far  as 
could  be  determined  by  measurements  and  opera- 
tive procedure,  and  in  the  second  case  by  autopsy, 
the  growth  had  begun  in  the  subcortex  of  the  supe 
rior  parietal  convolution.  In  each  of  these  cases 
the  tumor  had  advanced  both  toward  the  surface 
of  the  brain,  and  forward  toward  or  into  the  Ro- 
landic  region.  In  the  three  cases  my  conviction 
as  to  the  situation  of  the  tumors  was  reached 
chiefly  by  a  consideration  of  the  disorders  of  sensa- 
tion and  co-ordination,  which  were  present  in  all. 
In  two  of  the  cases  cutaneous  sensibility  was  more 
or  less  impaired,  greatly  in  the  first  two  and  less 
markedly,  but  still  certainly,  in  the  last,  at  least 
at  the  time  of  my  examinations.  The  previous 
examiners  had  not  noted  any  astereognosis  or  im- 
pairment of  sensation.  In  a  cerebral  case,  when 
examination  shows  impairment  or  loss  of  cutaneous 
and  muscular  sensibility  with  astereognosis,  I  be- 
lieve that  we  can  with  certainty  look  forthelesion,or 
that  portion  of  it  which  causes  these  symptoms, 
in  that  part  of  the  brain  which  lies  between  the  post- 
central and  occipital  convolutions,  and  especially 
in  the  su])erior  parietal  convolution.  These  case's 
afford  further  confirmation  of  the  views  long  de- 
fended by  me  in  the  face  of  much  opposition, 
namely,  that  the  sensory  and  motor  areas  of  the 
cerebrum  are,  for  practical  purposes,  distinct.  Par- 
esis and  paralysis  of  a  decided  character  were  late 
symptoms. 

In  the  third  case,  even  at  the  time  of  mv  examina- 
tion, impairment  of  sensi!)ility,  astereognosis  and 
ataxia,  were  not  of  as  marked  a  character  as  might 
be  expected  from  a  lesion  of  the  dimensions  of  the 
tumor  removed  by  Dr.  Keen.  It  will  be  recollected 
that  this  tumor  was  of  the  right  cerebral  hemis- 
phere, and  one  point  to  which  I  desire  to  call 
special  attention  in  this  contribution,  is  the  proba- 
bility that  the  recognition  of  various  forms  of  sen- 
sation and  the  stereognostic  sense  may  not  be  as 
highly  developed  in  the  right  hemisphere  as  in  the 
left,  although  their  centres  of  rc]')resentation  are 
present  in  both  hemispheres  in  the  same  locations, 
just  as  the  left  half  of  the  l)rain  is  the  leading 
half  for  such  highly  evolved  and  differentiated  facul- 
ties as  speech,  writing,  right-handedness,  word  hear- 
ing and  word  seeing,  so  it  is  probable  that  the  ster- 
eognostic sense  and  the  elements  which  enter  into 
it  have  their  higher  evolution  in  the  left  hemis 
phere.  If  this  be  the  case,  a  lesion  of  the  right  hem 
isphere  might  not  give  symjitoms  referable  to  these 
senses  of  so  decided  a  character  as  lesions  of  the  lef' 
hemisphere. 

In  case  III.  it  was  a  c|uestion  before  operatior 
whether  a  tumor  originating  in  the  prefrontal  loin 
was  growing  backward  and  was  thus  invading  the 


motor  region,  or  whether  originating  in  the  superior 
parietal  convolution  it  was  advancing  forward  into 
the  motor  region.  As  indicated  in  the  report  made 
by  me  to  Dr.  Keen,  my  view  favored  a  parietal 
lesion  advancing  forward,  this  diagnosis  being  first, 
as  just  stated,  based  on  the  presence  of  sensorv 
disorders  and  ataxia.  The  mental  symptoms  which 
undoubtedly  were  and  had  been  present,  were  not 
in  my  judgment,  such  as  belong  to  destructive  le- 
sions of  the  prefrontal  regions.  It  was  stated,  and 
was  undoubtedly  true,  that  the  boy's  disposition  had 
changed.  It  appeared  to  me,  however,  that  the 
mental  symptoms  from  which  he  was  suffering  were 
chiefly  those  of  irritation  and  exhaustion,  such  as 
might  have  been  expected  from  a  tumor  of  consid- 
erable size^  situated  in  almost  any  portion  of  the 
brain.  On  studying  him  carefully,  I  could  not  dis- 
cover any  real  mental  degradation,  the  boj-  being 
even  a  da}'  or  two  before  the  operation  unusually 
intelligent,  concentrative  and  keen  in  his  mental 
processes.  Psychical  syminoms  of  a  definite  char- 
acter are  usually  present  in  lesions  and  especially 
destructive  lesions  of  the  region  anterior  to  the 
motor  zone.  "Investigators  have  found  more  or 
less  mental  degradation  to  be  the  result  of  ablation 
or  partial  abla'ion  of  these  (prefrontal)  lobes,  the 
animals  losing  the  faculty  of  close  attention  and 
intelligent  observation:  and  undoubtedly  impair- 
ment and  disturbance  of  a  peculiar  character  occur 
both  in  the  lower  animals  and  in  man  from  lesions 
of  this  portion  of  the  brain.  The  higher  and  more 
complicated  mental  processes — those  which  involve 
such  faculties  as  attention,  judgment,  and  compar- 
ison— are  alwaj's  affected.  Inhibition  is  impaired 
Destruction  of  these  lobes  causes  disintegration  of 
the  personality  and  incapacity  to  form  serially 
groups  of  images  or  representations,  more  or  less 
l^sychical  dissolution  occurring  according  to  the  ex- 
tent of  the  lesion.  Hesitation,  uncertainty,  fear, 
lack  of  force,  weakness  of  the  highest  faculties,  and 
motor,  disquietude,  due  to  loss  of  control,  may  be 
present."* 

The  mental  change  in  the  case  under  discussion 
showed  itself  rather  in  the  irritability,  emotionality 
and  lack  of  continuous  effort  which  come  from  a 
painful  and  nagging  intracranial  lesion  than  in  the 
signs  of  psychical  dissolution,  as  above  described. 

These  remarks  regarding  the  psychical  symptoms 
of  prefrontal  lesions  apply  also  to  the  fifth  case  in 
this  paper,  that  seen  by  me  with  Doctor  Mit- 
chell. The  views  expressed  regarding  the  cerebral 
representation  of  cutaneous  and  muscular  sensi- 
bility and  the  stereognostic  sense  have  further  ex- 
emplification in  the  next  case,  which  has  in  addi- 
tion some  interesting  features  as  to  visual  and 
au<litory  localization. 

CASE  IV. — Xfcrnlir  and  Dvtnnrratcd  Area.  Main  Foai.<i  of 
l.cKiiiii  ProlinliUi  almiit  the  Jtinclinn  of  the  Inferior  ParirUil 
Siiliparietalj  and  Fint  Conrohifions;  Loraliiing  Sumptoms — 
[.ttrrrnijnoDix.  Piiiiinution  in  Pain  and  Temperature  Senxrs. 
Word  Deafnexx.  Word  Hlindnrfix.  Amnexie  Apha^in.  Lateral 
lldiiiiiiij/inoH.i  lleniianoiixia  and  Late  Hrmipare^is;  Operation ; 
Uirorerii  from  Oprnition  lint  .<ri/ "'/>'""'*  remainino  ahoiit  the 
>■(/;»(•.  *  The  patient,  forty-three  years  old.  held  an  im- 
portant teaching  position,  and  was  a  man  of  unusual  intel- 
'igenco  and  scientific  attainments.  The  first  symptoms  of 
vhich  we  have  any  note  was  an  attack  in  the  early  spring 

♦Mills.  C.  K..  the  Xt-rvous  System  and  its  Diseases,  rhiladelphia.  1!W, 


[April  20,  1001 


BRAIN  TUMOR 


I   THE     i'HlLADLLI'HIA  vftn 

L  Mj;dilal  JOfllXAL  /     / 


of  1898.  When  walking  ou  the  street  oue  day  he  suddenly 
became  dizzy,  required  support,  and  was  left  numb  in  the 
arm  and  leg  of  the  right  side.  This  numbness  disappeared 
before  he  got  back  to  his  house.  The  numbness  recurred 
at  regular  intervals  after  this  time,  lasting  usually  only 
for  a  moment,  or  for  a  few  moments  at  most.  He  had  no 
other  symptoms  of  importance  until  he  began  to  have 
headaches  in  February,  I'JOO.  The  headaches  were  not  con- 
tinuous, but  occurred  at  intervals  and  were  not  always  se- 
vere. The  attaclis  of  numbness  became  more  and  more 
frequent.  For  a  year  or  two  before  the  onset  of  his 
attacks,  in  addition  to  unusual  labor,  he  had  been  subject 
to  a  variety  of  worries.  In  addition  to  the  symptoms  above 
enumerated  he  was  much  of  the  time  in  a  neurasthenic  and 
depressed  state. 

My  first  note  as  to  his  condition  were  made  June  2, 
1900.  At  this  time,  if  any  true  paresis  was  present  in  the 
extremities  of  the  right  side,  it  was  so  slight  that  it 
could  scarcely  be  made  out:  but  he  presented  in  the  right 
half  of  the  body  disorders  of  sensation,  stereognosis,  and 
co-ordination  of  a  decided  character,  but  differing  some 
what  in  the  upper  and  lower  extremities.  The  pain  and 
temperature  sense  were  diminished  in  the  face  and  upper 
extremity.  Tactile  sense  was  either  present  or  so  slightly 
diminished  that  in  the  man's  condition  the  change  could 
not  be  recognized.  In  the  lower  extremity  the  pain  sense 
was  distinctly  diminished,  but  the  temperature  sense  was 
not  affected.  Astereognosis  as  tested  in  the  hand  was 
present,  but  of  slight,  or  at  least  moderate  degree.  He 
could  make  out  objects  by  manipulation,  but  had  some 
difficulty  in  doing  this,  and  the  difference  in  facility  be- 
tween the  two  hands  was  very  noticeable.  A  study  of  the 
movements  of  the  upper  extremity  showed  some  inco- 
oi'dination,  and  in  dressing  himself  he  had  difficulty  in  fine 
movements  such  as  those  required  in  buttoning  and  unbut- 
toning the  small  buttons  of  his  shirt,  so  that,  although 
right-handed,  he  invariably  resorted  to  his  left  hand  in 
these  procedures.  Both  the  deep  and  superficial  reflexes 
were  at  this  time  nearly  normal,  the  only  change  being  a 
slight  exaggeration  of  the  knee  jerk.  The  Babinski  reac- 
tion was  not  present. 

A  study  of  the  man's  speech  mechanism  was  difficult  in 
spite  of  the  fact  that  he  was  highly  intelligent  and  evidently 
very  anxious  to  give  all  information  possible.  He  was 
partially  word  deaf,  word  bind  and  letter  blind,  although 
the  responses  which  were  obtained  in  testing  him  were 
sometimes  somewhat  contradictory.  He  would  recognize 
some  words,  usually  those  with  which  he  was  very  familiar. 
Even  when  he  recognized  letters,  he  would  generally  call 
them  all  by  the  name  of  one  letter.  He  was  not  object 
blind,  but  had  marked  verbal  amnesia,  in  almost  every  case 
failing  to  name  familiar  objects,  the  use  and  meaning  of 
which  he  evidently  understood,  a  fact  which  he  sometimes 
indicated  by  periphrase  and  at  other  times  by  pantomime; 
thus,  he  could  not  name  a  key,  but  said,  "put  it  in,"  and 
indicated  its  use:  he  made  the  movements  of  putting  off 
and  on  the  lid  of  a  box  when  a  box  was  shown  him,  etc. 
■^Vhen  examined  he  sometimes  became  excited,  confused 
and  emotional,  and  occasionally  made  use  of  brief,  but 
very  strong  words  to  express  his  disgust  with  him- 
self. 

Dr.  de  Schweinitz  reported  to  me  the  results  of  his  former 
examinations,  which  showed  a  high  myopic  astigmatism, 
and  its  usual  intraocular  and  extraocular  accompaniments; 
he  also  reported  that  the  patient  now  had  a  distinct  lateral 
homonymous  hemianopsia,  the  diagrams  of  the  fields 
accompanying  his  report.  No  positive  optic  neuritis  was 
present  at  this  time,  and  indeed  at  no  subsequent  period, 
although  fhe  conditions  present  were  such  as  to  indicate 
the  possibility  of  a  beginning  nerve  inflammation.  The 
congestion  of  the  optic  discs  present  at  previous  examina- 
tions, which  could  probably  be  attributed  to  the  disorder 
of  refraction,  was  more  marked  on  the  left  than  on  the 
right  side.  The  iritic  reflexes  were  unimpaired,  and  al- 
though the   patient   gave  a  history  of   temporary   double 


♦This  case  has  not  hitherto  been  V"l»lished.  and  I  shall  withhold  its 
complete  histon,-  and  pnhlication  until  after  developments  render  certain 
the  nature  and  extent  of  the  lesion,  or  the  opportunity  to  determine  these 
points  is  lost.  The  patient  first  consulted  nie  about  Mav  or  June,  1!)(10.  In 
the  mouth  of  .\pril  previous  hr  had  consulted  Dr.  S.  WeirMitchell,  and 
had  also  at  that  time,  at  Dr.  Mit'-hcll's  rrrniest,  been  examined  bv  Dr. 
(ieoree  K.  de  Schweinitz.  Dr.  de  Schweinitz  made  other  examinations  forui« 
previous  to  the  operation,  and  I  am  indebted  both  to  Drs.  Mitchell  and 
deSchweiuitz  for  valuable  notes. 


vision,  he  had  no  paretic  ocular  muscle.  The  examina- 
tion showed  that  the  hemianopsia  was  due  to  a  lesion  back 
of  the  primary  optic  centres,  it  not  being  accompanied 
by  the  changes  in  reflexes  which  occur  when  the  lesion 
is  in  or  anterior  to  these  centres. 

The  patient  grew  worse  as  regards  his  visual,  auditory 
and  aphasic  defects.  The  knee  jerks  became  more  exag- 
gerated and  the  Babinski  reflex  appeared  on  the  right  side. 
The  conditions  as  to  sensation  and  co-ordination  were  em- 
phasized. An  illustration  of  his  effort  to  write  made  June 
16,  1900,  is  given  below: 

Only  Sometimes   you  know  this — Oh,   it  hurts   like 

old  Harry — every  day  better  and  better.  Doesn't  give  me 
much — sick,  is  it — oh,  no,  not  that — I  forget  what  I  want  to 
say. 

About  June  23,  1900,  he  showed  decided  paresis  of  the 
right  half  of  the  body,  and  operation  was  decided  upon. 
Dr.  Keen  performed  the  operation  June  25.  1900.  In  consul- 
tation with  Dr.  William  G.  Spiller  and  Dr.  J.  W.  McConnell, 
who  had  charge  of  the  patient  during  my  temporary  ab- 
sence from  Philadelphia  I  had  indicated  as  the  proper 
place  for  operation  the  parietoocipitotemporal  junction, 
the  position  on  the  lateral  aspect  of  the  brain  where  the 
three  lobes  come  together.  My  idea  was  that  the  skull 
opening  should  cover  the  posterior  extremities  of  the  two 
parietal  and  the  first  temporal  convolutions,  and  should 
extend  backward  far  enough  to  include  the  anterior  portion 
of  the  lateral  aspect  of  the  occipital  lobe.  The  so-called 
angular  gyre  would  of  course  be  included  in  the  opening. 
In  this  way  it  would  include  the  centres  for  word  hearing, 
word  vision,  and  in  part  those  for  muscular  and  cutaneous 
sensibility.  The  position  of  the  opening  was  therefore 
more  posterior  and  inferior  than  in  the  three  previous 
cases.  The  reasons  for  this  are  evident.  In  the  first  three 
cases  disorders  of  cutaneous  or  muscular  sensibility,  or 
both,  with  late  paresis  or  paralysis  were  present,  but  no 
word  deafness,  word  blindness,  nor  hemianopsia.  Paresis 
came  on  late  in  this  case  as  In  the  others,  but  marked 
visual,  auditory  and  amnesic  disorders  coexisted  with 
the  sensory,  stereognostic  and  incoordinate  phenomena 
comparatively  early.  Operation  was  performed  by  Dr. 
Keen  June  25,  1900.* 

The  skull  was  opened  with  the  centre  of  the  flap  about  an 
inch  or  an  inch  and  a  half  above  the  external  auditory 
meatus,  and  as  soon  as  the  brain  was  exposed  a  very 
abnormal  condition  was  detected.  In  the  area  in  which  it 
had  been  expected  to  find  the  focus  of  disease  the  brain 
was  of  a  peculiar  color  as  Dr.  W.  J.  Taylor,  who  assisted  at 
the  operation,  expressed  it,  it  had  the  appearance  of  baked 
custard.  It  resembled  baked  custard  both  in  color  and 
consistence.  It  looked  like  pus.  but  was  solid.  The  open- 
ing, which  was  originally  comparatively  small,  was  ex- 
tended until  it  wa§  from  before  backward  about  three  to 
four  inches.  A  large  part  of  the  brain  was  thus  exposed, 
but  even  this  was  insufficient  to  uncover  the  whole  altered 
area.  The  diseased  portion  seemed  to  be  somewhat  pyra- 
midal in  shape,  with  the  base  of  the  pyramid  toward  the 
occipital  pole.  The  blood  vessels  supplying  the  area  were 
thrombotic.  It  was  impossible  to  remove  all  the  diseased 
tissue,  and  Dr.  Keen  decided  that  it  would  be  unwise  to 
make  the  opening  larger,  oven  though  the  whole  diseased 
area  had  not  been  exposed.  He  removed  possildy  an  inch 
or  an  inch  and  a  half  of  the  diseased  tissue  in  what  seemcii 
to  be  the  first  temporal  convolution,  but  the  convolutions 
could  not  be  accurately  determined.  The  tissue  removed 
was  semi-solid,  and  when  a  part  of  it  was  placed  In  ;v 
napkin  and  the  two  sides  of  the  napkin  laid  against  one 
another  and  then  removed,  the  slight  pressure  so  produced 
made  the  pathological  tissue  closely  resemble  pus.  Micro- 
scopical examination  failed  to  show  any  evidence  of  pus  or 
tumor.  The  vessels  were  greatly  diseased,  some  of  them 
were  completely  closed:  an  intense  round  cell  infiltration 
was  found  around  the  small  blood  vessels:  a  considerable 
amount  of  altered  blood  pigment  was  also  seen,  this  indi- 
cating the  existence  of  old  hemorrhages.  Dr.  Spiller  was 
inclined  to  believe  that  the  condition  was.  one  of  throm- 
bosis: that  the  early  symptoms  were  dependent  on  imper- 
fect nutrition  of  the  parietal  lobe:  that  the  symptoms 
wh'ch  developed  acutely  about  three  months  before  the 
operation  were  due  to  thrombosis  of  the  branch  of  the 
Sylvian  artery  supplying  the  first  temporal  convolution  and 

♦The  account  of  the  ojieratioti  and  of  the  j)atholo;iical  appearances  prc- 
.sented  bv  the  brain  when  CNposed.  and  of  tlie  microscopical  llndiugs.  has 
been  pre'pared  from  a  report  fur!ii.>hed  ;o  nie  by  Dr.  Wm.  G.  Spiller. 


768 


The   I'hiladelphia"! 

MEDICiL   JOUBNAL    J 


BRAIN  TUMOR 


[Afeil  20,  I'JOl 


parietal  lobe;  and  that  the  weakness  of  the  right  arm, 
which  also  came  on  suddenly,  was  the  result  either  o£ 
thrombosis  of  the  branch  supplying  the  arm  centre,  or  of 
hemorrhage  occurring  within  the  softened  brain  tissue, 
thereby  producing  pressure  on  the  arm  fibres  within  the 
internal  capsule. 

It  should  be  noted  here  that  numerous  examina- 
tions made  both  before  and  after  the  operation 
showed  the  presence  of  a  distinct  amount  of  albu- 
men and,  at  times,  hyaline  casts  in  the  urine.  The 
amount  of  the  albumen  varied  somewhat,  but  in 
nearly  every  instance  it  was  present,  at  least  in  the 
examinations  made  before  the  operation.  The  bear- 
ing of  these  facts  was  recognized  when  the  opera- 
tion was  determined  upon,  but  it  was  thought  that 
on  the  whole  the  chances  were  in  favor  of  a  neo- 
plasm, although  other  diseased  conditions  of  vessels 
and  brain  tissue  might  also  be  present.  Throm- 
bosis, or  obliterative  endarteritis,  such  as  not  infre- 
quently accompanies  chronic  disease  of  the  kidneys 
and  cardiac  degeneration,  may  be  the  chief  lesion, 
but  it  is  certainly  unusual  to  find  one  area  of  the 
brain  after  another  becoming  necrotic  and  degen- 
erating in  the  fashion  that  it  would  seem  occurred 
here,  if  a  tumor  was  not  present. 

For  the  purposes  of  this  paper,  it  is  not  necessary 
to  go  in  detail  into  the  history  of  this  case  subse- 
qtient  to  the  operation.  Right-sided  paralysis  was 
at  first  almost  total,  as  was  also  aphasia  and  the 
auditory,  visual,  sensory  and  other  defects  studied 
before  the  operation.  Some  necrosis  of  bone  with 
discharge  of  pus  and  debris  occurred  at  times  for 
several  weeks  after  the  operation,  but  later  the 
wound  got  into  good  condition.  The  hemiplegia 
present  after  the  operation  has  improved  to  such 
an  extent  that  on  two  occasions  the  patient  has 
come  to  m}'  office  in  the  city  from  his  residence,  a 
distance  of  eleven  miles.  He  has  made  some,  but 
not  marked,  improvement  in  his  aphasic  symptoms, 
other  conditions  remaining  much  the  same  as  be- 
fore the  operation.  It  is  not  improbable  that  the 
pathological  processes  present  for  months  before 
the  operation  are  still  going  on,  and  the  case  has 
not  a  hopeful  outlook.  The  case  is  briefly  recorded 
here  simply  with  the  view  of  teaching  its  lessons 
w^ith  regard  to  focal  diagnosis. 

A  fifth  case  was  within  a  few  months  seen  by  me  in  con- 
sultation with  Dr.  S.  Weir  Mitchell  and  Dr.  J.  K.  Mitchell. 
I  examined  the  patient  once  the  day  before  operation.  Dr. 
J.  K.  Mitchell  will  publish  a  full  report  of  this  case.  The 
general  symptoms  clearly  pointed  to  brain  tumor,  which 
was  diagnosticated  by  the  Doctors  Mitchell,  who  suggest- 
ed operation.  My  views  as  to  the  location  of  the  tumor, 
and  the  facts  on  which  these  were  founded,  were  as  fol- 
lows: 

"The  history  and  general  symptoms  indicate  clearly 
that  the  case  is  one  of  brain  tumor,  the  occurrence  of  one 
or  more  convulsions  and  the  recent  development  of  optic 
neuritis  clinching  this  diagnosis.  The  psychical  symptoms, 
under  which  head  his  lack  of  the  power  of  attention,  and  a 
certain  perverseness  with  a  tendency  to  delusion  are 
prominent,  point  to  the  perfrontal  region.  His  long  semi- 
comatose or  semisomnolent  attack  may  also  have  Its  par- 
tial explanation  in  a  lesion  well  forward  In  the  brain.  The 
paresis  of  the  right  upper  extremity  and  of  the  face,  which 
Is  slight  and  of  late  development,  is  probably  a  pressure 
symptom.  His  aphasia  and  agraphia  are  probably  partly 
pressure  and  partly  Invasion  symptoms.  The  agraphia  Is 
certainly  the  most  interesting  clinical  feature.  In  general 
terms  it  belongs  under  the  head  of  motor  agraphia,  and 
a  study  of  his  writing  gives  some  support  to  the  view  of 
:hose  who  have  said  that  the  so-called  motor  graphic  centre 
night   perhaps   be   better   called   an   orthographic   centre. 


He  tends  to  repeat  letters,  syllables  and  words  in  writing, 
misspelling  both  common  and  proper  names,  evidently  at 
times  recognizing  his  errors  and  attempting  by  erasures 
and  rewriting  to  correct  them.  On  the  negative  side  he  is 
not  word  deaf,  word  blind  nor  letter  blind;  his  speech 
aphasia  is  not  of  the  form  of  a  jargon  apuasia;  hemianop- 
sia is  not  present,  and  he  has  no  disturbance  of  common 
sensibility  or  of  the  muscular  sense. 

I  would  localize  the  growth  In  the  left  perfrontal  region, 
the  probabilities  being  that  It  is  subcortial  in  origin,  and 
that  Is  Is  extending  backwards,  so  as  to  gradually  involve 
the  second  and  third  frontal  convolutions.  If  this  is  cor- 
rect trephining  should  be  with  the  view  of  exposing  the  left 
half  of  the  brain  from  the  central  fissure  as  far  forward 
as  the  surgeon  could  safely  expose  with  one  osteoplastic 
operation." 

The  operation  by  Dr.  Keen  revealed  the 
growth  in  the  location  indicated,  although  it  did 
not  prove  to  be  subcortical  in  origin.  Several  facts 
are  notable,  (i)  the  absence  of  sensor}^  symptoms, 
astereognosis  and  ataxia ;  (2)  the  absence  of  pare- 
sis or  paralysis  until  late ;  (3)  the  presence  of  a  pecu- 
liar form  of  agraphia  or  orthographia ;  and  (4)  the 
presence  of  psychical  sj-mptoms  indicating  more 
or  less  mental  degradation  or  psjxhical  dissolution. 

Owing  to  excessive  hemorrhage,  it  was  not  possi- 
ble to  conclude  the  operation  by  removing  the 
growth.  The  patient  died  a  few  hours  after  the 
operation. 

A  few  weeks  since  (February  23,  1901)  I  had  the  privilege 
of  seeing  a  tumor  removed  in  a  sixth  case  from  the 
motor  region  of  the  right  hemisphere  by  Dr.  William  J. 
Taylor.  The  patient  had  been  under  the  charge  of  Dr. 
Wharton  Sinkler  and  Dr.  T.  C.  Potter,  and  wa.=  seen  by  me 
In  consultation  with  these  physicians  prior  to  the  operation. 
My  views  as  to  general  diagnosis  and  location  were  con- 
firmatory of  those  held  by  Drs.  Sinkler  and  Potter,  namely, 
that  the  lesion  was  a  tumor  and  was  largely,  if  not  entirely, 
confined  to  the  motor  zone.  The  patient  had  no  objective 
sensory  symptoms,  although  she  at  times  complained  of  a 
numb  feeling  in  the  left  side  of  the  face,  left  arm  and  left 
leg.  which  were  paretic,  the  loss  of  power  being  marked 
In  the  lower  extremity.  She  had  several  convulsive  seiz-  £ 
ures  chiefly  affecting  the  limbs  of  the  partially  paralyzed  I 
half  of  the  body.  All  the  deep  reflexes  on  the  left  side  were 
increased,  persistent  ankle  colonus  being  present  The 
Babinski  phenomenon  was  elicited  on  the  left  side.  Head 
ache  was  not  conspicuous,  but  vomiting  occured.  ani 
double  optic  neuritis  was  present.  A  full  account  of  this 
case  will  be  published  by  Dr.  Sinkler.  who  has  kindly  per 
mitted  me  to  make  this  brief  reference  to  It  in  order  to 
compare  the  localizing  phenomena  with  those  presented  by 
the  other  cases  included  in  this  paper.  The  most  notable 
point  Is  that  objective  symptoms  referable  to  the  areas  of 
muscular  and  cutaneous  sensibility  and  the  special  senses 
were  absent,  excepting  of  course  the  optic  neuritis  which 
has  no  localizing  value. 

The  following  are  some  conclusions  to  be  drawn 
from  a  study  of  the  foregoing  cases : 

The  diagnosis  of  the  existence  of  a  brain  tumor 
can  sometimes  be  made  even  in  the  absence  of  most 
of  the  general  symptoms,  such  as  optic  neuritis, 
headache,  vertigo,  and  vomiting,  chiefly  by  the  close 
studv  of  localizing  and  invasion  symptoms. 

Emotional  states,  even  hysterical  stigma,  are 
sometimes  present  in  cases  of  brain  tumor,  and 
must  not  be  given  too  much  weight  in  differential 
diagnosis. 

Tumors  of  the  posteroparietal  rocrion,  and  espec- 
ially of  the  superior  parietal  lobule  1  >arietal  of  Wil- 
der), give  as  their  most  important  localizing  symp- 
toms disorders  of  cutaneous  and  muscular  sensibil- 
ity, and  especially  astereognosis :  other  symptoms 
often  present  in  such  cases  are  the  result  of  com- 
pression or  invasion  of  adjoining  regions. 


[April  20,  lUOl 


FIBROID  TUMORS 


CThe   Philadelphia        vfin 
Medical  Journal         /"V 


\ 


Tumors  and  other  lesions  implicating  the  angular 
gyre  and  the  regions  adjoining  (the  subparietal,  first 
temporal  and  medioccipital  convolutions),  give  as 
their  main  localizing  symptoms  word  deafness  and 
word  blindness,  with  the  usually  accompanying 
speech  disturbances,  lateral  homonymous  hemian- 
opsias and  disorders  of  cutaneous  and  muscular  sen- 
sibility, including  astcreognosis.  Although  it  is 
possible  that  these  disorders  of  sensibility  in  the 
case  cited  may  have  been  dependent  upon  invasion 
of  the  superior  parietal  lobule. 

Just  as  the  centres  for  hearing,  vision  and  speech 
are  more  highly  differentiated  in  the  left  hemis- 
phere, so  it  is  probable  that  the  stereognostic  sense 
is  more  highly  evolved  in  this  hemisphere. 

A  tumor  strictly  confined  to  the  motor  regions 
does  not  give  objective  sensory  phenomena  of  a 
persisting  character;  the  localizing  symptoms  of  a 
growth  so  situated  are  motor,  chiefly  paralysis  and 
monospasm,  with  also  exaggerated  deep  and  super- 
ficial  reflexes. 

In  tumors  of  the  motor  subcortex  tonic  spasticity 
is  usually  a  marked  symptom.  Paresis  or  paralysis, 
and  exaggerated  reflexes,  with  monospasm  or  un- 
ilateral convulsions,  may  also  be  present. 

Tumors  of  the  prefrontal  region,  by  which  is 
meant  the  region  entirely  cephaled  of  the  motor 
zone,  chiefly  give  psychical  symptoms  of  an  especial 
character;  when  the  tumor  is  situated  on  the  left 
side,  motor  agraphia  (or  orthographia)  and  motor 
aphasia  are  usually  present  because  of  the  com- 
pression or  invasion  of  the  posterior  portion  of  the 
second  frontal  and  of  the  third  frontal  convolutions ; 
paralysis  and  other  motor  symptoms  are  often  pres- 
ent late  because  of  encroachments  tipon  the  motor 
region. 


NON-SURGICAL  TREATMENT   OF  FIBROID  TUMORS 

OF  THE  UTERUS.* 

AUGUSTIN  H.  GOELET,  M.  D., 

Professor  of  Gynecology,  New  York  School  of  Clinical  Medicine;  Consulting 

Professor  of  Gynecological  Electro-Therapeutics,  International 

Correspondence  Schools,  Scranton,  Pa.;  etc. 

The  question  often  arises — What  may  be  done  for 
uterine  fibroids  where  operation  for  their  removal 
is  not  feasible  or  is  refused,  and  in  what  class  of 
cases  will  non-surgical  treatment  be  attended  by 
results  that  would  justify  its  adoption?  These 
are  problems  that  not  infrequently  confront  the 
general  practitioner,  and  he  is.  expected  to  decide 
the  question  in  the  interest  of  his  patient,  without 
much  to  guide  him.  He  should  therefore  be  cor- 
rectly informed  upon  these  issues. 

Unfortunately  the  truth  has  been  over  shadowed 
bv  the  strenuous  efforts  to  establish  firmly,  the 
feasibility  and  comparative  safety  of  radical  meas- 
ures in  these  conditions,  and  non-surgical  treatment 
has  been  made  to  appear  incompetent.  Likewise 
the  indiscriminate  ap])lication  of  electricity  to  fi- 
broid conditions,  both  where  it  was  appropriate 
and  where  is  was  not,  led  to  failures  that  have 
opeiated  seriously  against  it.  There  is  much  to 
be  said  in  favor  of  both  methods,  and  there  are 
cases  v.'here  the  indication  for  each  is  sharply  de- 
fined.    This  then   is  the  point  at   issue — When   is 

♦Read  before  the  Section  on  Deseases  of  Women  at  the  third  Pan  Ameri- 
can Medical  Congress  at  Havana,  Cuba,  February  4th  to  7th,  1901. 


surgical  intervention  positively  indicated  and  when 
may  non-surgical  methods  be.  adopted  with  any 
promise  of  success? 

Pedunculated  fibroids  both  subperitoneal  and  sub- 
mucous never  yield  to  non-surgical  measures,  and 
they  should  be  removed  when  discovered.  The 
same  may  be  said  of  interstitial  growths  that  have 
attained  sufficient  size  to  cause  the  uterus  to  rise 
in  the  abdomen  above  the  umbilicus.  Fibro- 
cystic tumors  are  another  class  that  demand  re- 
moval since  conservative  methods  are  of  no  avail. 

It  is  true  that  much  may  be  done  to  relieve  the 
pain  of  large  interstitial  growths  when  their  re- 
moval is  not  practicable.  The  relief  thus  obtained 
may  be  only  temporary,  yet  it  adds  greatly  to  the 
comfort  of  the  patient,  and  should  be  advised  when 
extirpation  is  out  of  the  question. 

The  class  of  tumors  where  non-surgical  treat- 
ment may  be  expected  to  accomplish  satisfactory 
results  and  is  therefore  advisable,  are  both  fibrous 
and  myomatous  growths  of  the  interstitial  variety, 
that  have  not  attained  sufficient  size  to  cause  the 
uterus  to  rise  above  the  umbilicus.  The  smaller 
the  growth  the  better  the  chance  of  obtaining  suc- 
cess with  this  plan  of  treatment.  Hence  the  ques- 
tion often  arises,  should  these  growths  be  attacked 
when  they  are  first  discovered,  or  should  they  be 
disregarded  if  they  are  not  producing  inconveni- 
ence. Growths  of  this  character  are  often  dis- 
covered when  they  are  producing  no  symptoms,  and 
unfortunately  it  has  been  the  custom  to  disregard 
them. 

My  observations,  which,  have  been  by  no  means 
limited,  have  led  me  to  decide  in  favor  of  active 
measures  for  the  arrest  of  these  growths  and  their 
possible  dissipation  whenever  they  are  detected,  and 
when  they  are  small,  even  if  the}'  are  causing  no  in- 
convenience. 

First — Because  they  continue  to  grow  (though 
slowly  in  some  instances)  if  nothing  is  done,  even 
under  the  most  favorable  conditions. 

Second — Because  the  treatment, if  properly  carried 
out  by  one  competent  to  employ  it,  cannot  pos- 
sibly by  productive  of  any  harm,  but  on  the  con- 
trary, if  it  avails  nothing  more,  brings  about  a  con- 
dition that  will  facilitate  extirpation  of  the  growth 
should  it  subsequently  become  necessary. 

It  is  urged  therefore  that  the  patient  be  given  the 
benefit  of  non-surgical  treatment  in  those  cases 
of  fibroid  growths  of  the  uterus  where  unprejudiced 
observers  have  decided  that  there  is  a  reasonable 
promise  of  success. 

It  must  be  borne  in  mind  that  fibroids  are  not 
infrequently  found  where,  eitlier  because  of  some 
constitutional  defect  operation  for  their  removal 
would  not  be  safe,  or  the  patient  may  positively  re- 
fuse to  consent  to  the  operation,  yet  they  are  pro- 
ducing serious  inconvenience.  In  these  cases  it 
would  be  most  unwise  to  refuse  to  give  them  the 
benefit  of  treatment  that  would  certainly  palliate 
the  symptoms  and  possibly  relieve  them,  even 
though  such  relief  may  not  be  permanent.  In  such 
cases  therefore  non-surgical  treatment  is  to  be  re- 
garded as  a  necessary  alternative,  and  should  not  be 
witl:held. 

Foremost  among  non-surgical  measures  for  fi- 
broid tumors  of  the  uterus,  is  electricity.    Both  the 


77° 


The   rniLADELrHiA"] 
Medical  Journal  J 


FIBROID  TUMORS 


[Apeil  20,  1901 


galvanic  and  the  faradic  current  and  even  static 
electricity  may  be  employed  with  benefit. 

It  is  the  electrolytic  action  of  the  galvanic  cur- 
rent that  is  relied  upon  mainly  to  reduce  the  size 
of  the  growth,  and  cause  its  dissipation  and  when 
it  fails  to  accomplish  this  result  it  is  a  material  aid 
in  relieving  the  symptoms  .particularly  pain  pro- 
duced by  pressure  and  congestion.  It  also  stimu- 
lates absorption  of  exudates,  and  removes  many  of 
the  adhesions,  this  latter  result  being  accomplished 
by  shrinkage  of  the  mass  from  contact  with  ad- 
jacent structures  to  which  it  has  become  adherent 
and  consequent  stretching  and  giving  way  of  the 
adhesions. 

Despite  assertions  to  the  contrary,  electricity  per 
se  does  not  produce  adhesions.  Employed  incom- 
petently and  without  proper  aseptic  precautions  a 
periuterine  inflamation  may  be  excited,  resulting  in 
adhesions,  but  that  would  not  be  the  fault  of  the 
agent. 

The  method  of  application  will  depend  upon  the 
character  and  structure  of  the  growth  and  the 
symptoms  it  is  producing.  When  the  tumor  is  a 
hard  fibrous  growth,  the  negative  pole  is  to  be  em- 
ployed, an  uncovered  metallic  electrode  being  in- 
troduced into  the  uterus.  This  will  constitute  the 
active  pole,  and  the  electrode  may  be  made  of  any 
material,  because  it  is  not  acted  upon  by  this  pole. 
Copper  is  to  be  preferred  because  it  may  be  readily 
bent  to  suit  the  curve  of  the  canal.  The  ordinary 
uterine  sound,  insulated  to  within  three  or  four 
inches  of  the  point  by  slipping  a  piece  of  rubber  tub- 
ing over  it,  makes  an  excellent  electrode.  The 
external  or  indifferent  electrode,  is  to  be  placed  up- 
on the  abdomen  or  back  as  is  best  calculated  to  in- 
clude the  main  part  of  the  growth  between  the  two 
electrodes.  This  should  consist  of  a  pad  made  of 
several  layers  of  thick  felt  thoroughly  wet,  and  hav- 
ing the  surface  soaped  to  diminish  resistance.  It 
should  be  as  large  as  can  be  conviently  applied  to 
distribute  the  current  and  lessen  the  resistance. 

The  most  satisfactory  method  of  introducing  the 
electrode  into  the  uterus,  is  along  the  index  finger 
in  the  vagina  as  a  guide.  But  strict  asepsis  must  be 
observed  throughout  every  detail  of  the  procedure. 
The  hands  should  be  sterilized  by  scrubbing  them 
for  five  minutes  with  Synol  soap,  and  the  electrode 
must  be  sterilized  by  boiling  in  a  2  per  cent,  solu- 
tion of  the  same  for  three  minutes,  after  it  has  been 
scrubbed  with  a  brush  ;  or  it  should  be  passed  sever- 
al times  through  an  alcohol  flame,  or  that  of  the 
Bunsen  burner.  The  vulva  should  likewise  be 
scrubbed  with  Synol  soap,  and  the  vagina  should 
be  irrigated  with  at  least  two  quarts  of  a  three  per 
cent,  solution  of  the  same,  employing  the  distention 
method  of  irrigating.  This  consists  in  inserting  the 
vaginal  nozzle  and  compressing  the  labia,  until  the 
vagina  becomes  distended,  then  releasing  the  pres- 
sure and  permitting  the  accumulated  fluid  to  escape 
with  a  rush.  This  should  be  repeated  until  the 
resevoir  is  exhausted.  The  resevoir  should  be  placed 
high,  at  least  five  feet  above  the  table  upon  which 
the  patient   rests. 

When  zinc  or  other  oxidizable  electrodes  are 
used,  they  should  be  scrubbed  with  a  nailbrush  on  a 
cake  of  fine  Sapolio  soap,  to  clean  and  lirighten  the 
surface. 

When   there   is   hemorrhage   or   profuse   or   pro- 


longed menstruation  the  positive  pole  is  to  be  em- 
plojed  in  the  uterus  instead  of  the  negative  and  the 
electrode  should  be  of  platinum  or  zinc ;  preferably 
the  latter,  because  the  oxychloride  of  zinc  that  is 
liberated  by  the  action  upon  the  metal  is  more  ac- 
tive in  controlling  the  bleeding.  After  the  bleed- 
ing has  been  permanently  controlled  the  negative 
pole  should  be  substituted'  for  the  positive. 

Soft  myomatous  growths  should  have  the  posi- 
tive pole  applied  to  the  interior  of  the  uterus;  and 
zinc  electrolysis,  secured  by  means  of  an  electrode 
made  of  this  metal,  gives  better  results  than  simple 
posttive  electrolysis  with  the  platinum  electrode.  ' 

When  these  tumors  are  favorably  situated,  so  as 
to  permit  the  application  of  the  current  directly  to 
the  structure  by  puncture  into  it  through  the  vagina,  I 
if  judiciously  employed,  the  result  will  be  more 
prompt  and  more  pronounced.  The  puncture  is  to 
be  made  with  a  steel  needle,  of  small  diameter,  to 
a  depth  of  i-2  or  3-4  of  an  inch.  But  this  method 
of  application  should  never  be  attempted  unless 
the  puncture  can  be  accomplished  without  the  risk 
of  wounding  the  bladder,  rectum,  uterine  artery  or 
ureter;  and  never  without  observing  the  strictest 
aseptic  precautions,  both  at  the  time  and  subse- 
quently, until  the  puncture  has  healed.  There  is  no 
doubt  that  the  application  of  the  current  in  this 
manner,  directly  to  the  structure  of  the  growth  ex- 
erts a  more  decided  action  upon  it  that  when  it  is 
applied  through  the  uterus. 

The  application  of  the  galvanic  current  through 
the  vagina  by  means  of  the  cotton  covered  ball  elec- 
trode, can  only  exert  a  feeble  electrolytic  action  up- 
on the  tumor,  therefore  it  is  of  litle  value,  except  to 
relieving  congestion. 

The  strength  of  the  current  to  be  employed  will 
vary  with  the  individual  susceptibilitj'.  Usually  the 
strength  of  the  application  of  the  negative  pole  to 
tlie  interior  of  the  uterus  may  be  from  50  to  100  M. 
employed  for  ten  minutes  each  time,  and  the  appli- 
cation may  be  repeated  every  second  or  third  day 
if  the  treatment  is  to  be  continued  for  a  short  period 
(one  or  two  months).  It  is  better  to  employ  active 
treatment  of  this  character  for  a  period  of  two  or 
three  months,  then  discontinue  it  for  two  or  three 
months  and  observe  the  result,  repeating  the  appli- 
cations if  it  is  favorable. 

The  strength  of  the  application  of  the  positive 
pole  when  the  zinc  electrode  is  used  should  not  ex- 
ceed 50  or  60  M.  employed  for  ten  minutes. 

The  strength  of  the  current  used  for  puncture 
through  the  vagina  should  be  30  to  100  M.  continued 
for  ten  minutes.  The  next  puncture  is  not  to  be 
made  until  the  previous  one  has  healed.  Then  the 
puncture  should  be  made  in  a  diflferent  location. 

The  apparatus  required  for  this  treatment  is  much 
less  expensive  than  is  generally  supposed.  Sixty 
dollars  would  furnish  a  complete  outfit  for  admin- 
istering the  galvanic  current.  There  will  be  required 
40  Laclanche  cells,  a  current  controller,  a  reliable 
meter,  and  the  electrodes  with  conducting  cords. 
.\ny  dealer  will  explain  how  the  cells  should  be  set 
up  and  connected  with  the  meter  and  controller  in 
the  circuit. 

The  faradic  current  is  to  be  regarded  as  most  ef- 
fective for  relief  of  pain  and  congestion.  Though 
some  reduction  in  the  size  of  these  grrowths  has 
been  reported  from  the  use  of  this  current,  I  am  in- 


[April  :!0,  lUJl 


AKROMEGALY 


CTHE     I'illLADELPBIA 
M 


Medical  Journal 


771 


clincd  to  atribute  this  wholly  to  a  restriction  of  the 
capillary  circulation  which  can  only  be  transient 
because  it  is  powerless  to  remove  the  conditions 
that  produce  the  increase  blood  supply  to  the  tumor. 
The  method  of  application  is  with  a  metal  ball  elec- 
trode in  the  vagina  and  a  large  dispersing  electrode 
on  the  abdomen.  The  current  should  be  as  strong 
as  can  be  comfortably  borne  without  producing  pain 
or  discomfort.  The  application  should  be  con- 
tinued for  at  least  15  or  20  minutes,  and  should 
be  repeated  every  day  or  every  second  day,  as  re- 
quired to  afiford  relief. 

Static  electricity  is  useful  for  relieving  pain  but 
cannot  be  expected  to  bring  about  any  material 
change  in  the  growth  itself.  Both  the  static  spark 
and  the  static  induced  current  maj'  be  employed 
with  benefit.  The  spark  is  to  be  employed  to  the 
surface  of  the  abdomen  through  the  clothing,  but 
the  corsets  should  be  removed  because  of  the  steels. 
The  static  induced  current  may  be  emplo)'ed  with 
one  electrode  (a  metalic  ball)  in  the  vagina  well  up 
against  the  vault,  and  the  other  over  the  tumor  on 
the  abdomen.  The  external  electrode  should  be  a 
-felt  pad  as  large  as  can  be  conveniently  applied 
so  as  to  include  as  much  surface  as  possible.  Both 
electrodes  may  be  applied  to  the  external  surface — 
one  on  the  abdomen  and  the  other  on  the  back, — 
but  the  result  is  not  so  good  as  where  one  electrode 
is  applied  against  the  tumor  in  the  vagina.  By  pre- 
ference the  vaginal  electrode  should  be  connected 
with  the  postive  pole. 

Ergot  administered  internallj^  is  certainly  a 
valuable  auxilary  in  some  instances.  It  acts  by 
stimulating  contraction  of  the  muscular  structure 
of  ihe  uterus  and  by  compression  of  the  blood  ves- 
sels, diminishing  the  supply  of  blood  to  the  growth. 
It  also  has  a  controlling  influence  upon  bleeding 
from  the  endometrium  which  is  sometimes  an  an- 
noying symptom.  In  two  instances  at  least  I  have 
known  its  influence  combined  with  that  of  galvanic 
applications  to  the  interior  of  the  uterus  to  cause  a 
breaking  down  of  the  intervening  wall  with  slough- 
ing of  a  large  interstitial  fibroid  which  was  subse- 
quently delivered  successful,  through  the  cervix, 
both  patients  making  a  satisfactory  recovery.  The 
combination  of  Liquor  Sedans  with  Ergot  acts  well 
in  painful  conditions. 

I  have  found  the  iodide  and  bromide  of  potas- 
sium useful  sedatives  in  these  conditions  and  they 
are  certainly  a  material  aid  in  some  cases-  They 
are  usually  administered  five  grains  of  the  iodide 
with  ten  grains  of  the  bromide  in  water  three  or 
iour  times  a  day. 

Arsenauro  (the  bromide  of  gold  and  arsenic)  is 
a  most  valuable  internal  remedy  in  these  fibroid 
cases.  It  not  only  counteracts  the  anemia,  but  ar- 
rests the  bleedingew.o 

feet  in  diminishing  the  menstural  flow  where  it  is 
excessive  is  certainly  very  marked.  In  addition  it 
aflords  relief  by  exerting  a  distinctly  local  sedative 
action,  thus  relieving  pain  which  is  so  often  an  an- 
noying symptom.  These  patients  build  up  astonish- 
ingly under  it  when  it  is  continued  at  the  maximum 
does  for  several  months.  The  method  of  adminis- 
tration is  to  begin  with  six  drops  in  water  three 
times  a  day,  after  meals,  and  increase  the  dose  one 
drop  every  day  until  the  dose  reaches  sixteen  drops, 
then  continued  it  at  this  dose. 


Recent  observations  have  led  me  to  conclude  that 
interstitial  fibroids  of  moderate  size  do  sometimes 
disappear  under  the  influence  of  electricity,  aided 
by  the  internal  remedies  enumerated  above.  Dur- 
ing the  past  year  I  have  observed  such  tumors  dis- 
appear in  three  cases  and  many  others  have  dimin- 
ished very  much  in  size.  Prior  to  two  years  ago  I 
was  led  to  make  the  statement  that  l'  had  never 
seen  a  fibroid  removed  by  electricity,  except  where 
it  had  caused  sloughing  and  a  discharge  of  the  mass 
through  the  cervix.  But  recent  observations  have 
compelled  me  to  change  my  views.  Like  others, 
in  the  beginning  I  was  induced  to  try  the  benefit  of 
electricity  in  all  varieties  of  fibroids,  because  at  that 
time  their  extirpation  had  not  been  demonstrated  to 
be  a  safe  procedure.  Now,  however,  the  limita- 
tions of  electricity  have  come  to  be  better  under- 
stood and  by  restricting  its  use  to  those  cases  where 
it  has  been  observed  to  j-ield  results,  and  operating, 
where  permissible,  in  those  cases  where  it  could  not 
be  expected  to  accomplish  anj'thing,  there  are  now 
fewer  failures  and  consequently  more  satisfaction 
in  dealing  with  these  cases. 


AKROMEGALY,  WITH  REPORT  OF  TWO  CASES 

W.   G.   SHALLCROSS,   of   Elwyn,   Pa.. 

Assistant  Physician   Pennsylvania  Training    School    for  Feeble  AfindeA 
Children. 

Owing  to  its  obscure  etiology,  the  wide  distribution  ot 
its  lesions,  and  a  perversion  of  the  natural  laws  of  growth, 
akromegaly  has  baffled  while  inviting  curious  research. 

It  remained  for  M.  Pierre  Marie,  through  his  studies  ot 
two  singular  cases  in  the  wards  ot  Charcot  in  1886.  to  first 
point  out  the  way.  By  observing  similarities  there  pre- 
sented, he  was  enabled,  after  careful  study,  to  associate 
the  symptoms  complex  with  a  hypertrophy  of  the  pituitary 
body.  With  this  discovery  there  was  awakened  great  inter- 
est in  the  anatomy  and  physiology  of  this  body,  so  that 
today  its  structure,  nerve  and  blood  supply  and  diseased 
state  in  many  conditions  are  now  fairly  well  understood. 

Of  the  cases  since  reported,  approximating  closely  on  to 
three  hundred,  a  sufficient  number  have  been  so  amplified 
by  patho-anatomical  studies  as  to  establish  certain  facts 
more  or  less  constant. 

The  pituitary  body  is  regularly  found  to  be  diseased,  and 
generally  its  anterioi  or  glandular  portion:  changes  in  the 
secretion  of  the  thyroids,  hypertrophy  or  atrophy  rarely 
normal,  occasional  persistence  of  the  thymus  gland,  and 
changes  in  the  sympathetic  nerves  and  ganglia. 

On  the  other  hand,  the  normal  function  of  the  pituitary 
body  is  absolutely  unknown.  That  it  has  been  found  dis- 
organized, hypertrophied.  or  probably  absent  without  the 
symptoms  of  akromegaly.  Is  likewise  proven,  and  thus  an 
accidental  coincidence  of  its  disease  in  these  cases  lends 
only  to  an  hypothesis. 

The  other  ductless  glands  need  not  be  further  con- 
sidered: (c)  as  Burr  points  out,  there  is  not  a  single  one  in 
the  body  which  has  not  been  found  to  be  diseased  in  some 
of  these  cases,  and  it  is  more  than  probable  they  are  only 
of  secondary  importance  in  accounting  for  the  phenomena 
of  akromegaly. 

•These  cases  were  exhibited  by  invitation  before  the  Philadelphia 
Neurological  Society  April  Zi,  1900. 

Ic)  The  Journal  of  Nervous  and  Mental  Diseases.    Vol.  26.  No.  1. 


772 


The   Philadelphia" 
Medicai.  Joubnal  . 


AKROMEGALY 


[Ai'BiL  20,  1901 


The  theory  of  trophic  neurosis,  advanced  by  Von  Reck- 
linghausen and  Holschewnilfow,  would  seem  to  deserve  a 
more  careful  consideration  tlian  is  usually  given  in  a  study 
of  these  cases.  By  this  theory  it  is  held  that  the  nervous 
system  is  primarily  at  fault,  and  the  changes  observed  in 
the  pituitary  body  and  other  structures  are  considered  to 
be  of  a  secondary  nature.  The  reported  autopsies,  how 
ever,  so  far  as  I  have  been  able  to  trace,  add  little  or  no 
weight  to  this  theory.  In  many  there  is  no  mention  made 
as  to  the  condition  of  the  nervous  system,  excepting  the 
results  o£  pressure  through  an  enlarged  hypophysis. 

(f)  Arnold  and  Dellemagne  found,  on  several  occasions, 
an  asymmetrical  degeneration  of  the  posterior  columns  of 
the  spinal  cord.  Marie  Marinesco  and  Arnold  found  the 
spinal  ganglia  and  sympathetics  hypertrophied. 

Clinically  we  are  dependent  at  least  for  an  early  diag- 
nosis, upon  certain  trophic  changes,  such  as  paresthesias 
and  joint  pains;  numbness  and  tingling  sensations  in  the 
extremities;  hyperhidrosis,  pigmentation  and  thickening 
oftheskin;  changes  in  the  hair,  nails  and  joints,  and  further 
study  is  needed  along  these  lines  before  accurate  conclu- 
sions can  be  reached. 

The  purpose  of  this  paper  is  to  present  the  record  of 
two  cases  developing  under  daily  observation  during  a 
period  of  about  six  years. 

CASE  1. — S.  B.,  male,  aged  eighteen  years.  High-grade 
Imbecile,  admitted  in  1892  at  the  age  of  ten  to  the  Penn 
sylvania  Training  School,  made  fair  progress,  soon  learne.i 
to  read  and  write,  and  was  regularly  promoted  in  his  class 
for  four  years  when  the  limit  seemed  to  have  been  reached 


Fig,  1.    A  case  of  Akromegaly, 

and,  mental  development  ceasing,  he  was  transferred  from 
the  schools  of  the  industrial  department,  where  he  has 
ever  since  proven  a  useful  aid. 

Shortly  after  this  time  he  suffered  from  aural  catarrn. 
■which  was  merely  a  relapse  of  former  trouble  dating  from 
early  childhood.  Three  years  previous  he  had  what  was 
thought  to  be  rheumatism  of  the  right  ankle,  and  has  since 

(f)  Oppeuheim  on  Diseases  of  the  Nervous  System,  P.  873. 


had  several  recurrences.  It  is  now  presumable  that  these 
attacks  were  premonitory  symptoms  of  the  disease.  In 
August,  1896,  bursitis  of  the  right  knee  developed.  Rest 
and  treatment  soon  effected  an  apparent  cure,  and  a  month 
later  a  relapse,  the  result  of  an  injury  to  the  same  knee 
from  a  fall,  again  yielded  to  treatment,  but  after  this  muscu- 
lar atrophy  was  noted,  the  knee  began  to  enlarge  through 
bony  formation  around  the  joint,  and  osteoarthritis  became 
pronounced.  With  this  genu  valgum  slowly  progressed. 
At  present  the  trouble  is  much  exaggerated,  but  there  is 
little  or  no  pain  in  this  region.  On  bending  the  knee  a 
grating  and  creaking  sensation  can  be  distinctly  felt,  and 
what  appear  to  be  small,  loose  or  "floating  bodies"  de- 
tected.* Roswell  Park  (d)  reports  a  similar  interesting 
case.  His,  however,  was  a  cystic  tumor  without  bony  de- 
formity, which  he  evacuated,  and  removed  five 
fibrous  masses.  One  year  later,  August  ,1897,  abscess 
of  the  right  antrum  of  Highmore  developed.  After  perfor- 
ating the  cavity  at  the  root  of  the  sec-nd  bicuspid  tooth, 
irrigating  and  draining;  recovery  rapidly  ensued.  Shortly 
following  his  discharge  from  the  hospital  a  marked  change, 
both  mental  and  physical,  was  noticed,  and  within  a  year, 
at  the  age  of  fifteen,  the  symptoms  of  akromegaly  became 
apparent.  He  now  began  to  grow  rapidly,  and  a  year  later, 
when  I  first  saw  him,  he  had  attained  nearly  his  present 
size  and  stature,  presenting  all  the  symptoms  of  the  dis- 
ease. Kyphosis  undoubtedly  existed  before  the  develop- 
ment of  these  symptoms,  and  even  before  his  admission  in 
1892. 

Abnormal  development  was  first  noticed  through  the 
frequent  changes  required  in  the  size  of  his  shoes.  The 
hands  were  also  found  to  be  correspondingly  enlarged,  and 
he  became  very  sensitive  regarding  their  size. 

FAMILY  HISTORY:  Born  in  Philadelphia  May  18th, 
1882,  labor  normal.  Father  24,  mother  20  at  the  birth  of 
this,  their  first  child.  The  father  is  below  the  average  In 
intelligence,  and  deaf:  he  is  a  driver  by  .occupation,  and  is 
still  living.  The  mother  died  at  the  age  of  25  of  malaria. 
The  patient  has  one  brother  living,  fairly  strong  mentally 
and  physically.  Paternal  grandmother  died  of  consump- 
tion, maternal  grandfather  died  of  cancer  of  stomach. 

PERSONAL  HISTORY:  The  admission  blanks,  August 
1892.  describe  him  as  follows: 

Light  hair,  blue  eyes,  sight  good,  hearing  a  little 
affected.  He  is  of  the  usual  weight  and  size  for  his  age. 
Ordinary  shaped  head,  mouth  always  open,  teeth  good; 
has  long  features.  In  walking  bends  forward,  and  In 
speaking  stammers  a  little.  Is  nervous,  active,  destructive, 
and  heedless  of  danger.  Commenced  to  walk  at  sixte«i 
months;  has  had  measles,  whooping-cough  and  scarlet 
fever.  Otitis  media  developed  as  a  sequel  of  the  latter 
disease  when  four  years  old.  resulting  in  a  chronic  dis- 
charge from  his  left  ear  and  in  imiiaired  hearing: mental 
degeneration  is  supposed  to  date  from  this  period. 

A  physical  examination  was  made  March  27fh.  1S99,  with 
the  aim  af  studying  future  changes.  (See  Chart  No.  1  of 
Measurements:  also  Plate  1  showing  features  and  general 
characteristics). 

PHYSICAL  EXAMINATION:  Age.  16  years  ten  months. 
Weight,  95.2  Kg.,  approximately.  210  lbs.  Height.  190.6  cm., 
approximately  6  ft.  3  in.  Hair,  color  chestnut-brown:  on 
head  it  is  coarse  and  dry.  In  axillary  and  pubic  regions 
it  shows  no  characteristic  changes.  The  skin  is  paler  than 
normal,  and  is  appreciably  thickened  all  over  the  body: 
on  his  face  it  is  pigmented,  and  over  his  shoulders  and 
lateral  surfaces  of  chest  and  abdomen  is  thrown  in  rugae^ 

The  expression  of  his  face  is  dull:  general  muscularity 
and  fatness  diminished.  There  is  marked  cervico-dorsal 
kyphosis,  slight  scoliosis  and  right  genu  valgum.  In  June 
1900.  one  year  later,  through  the  suggestion  of  Dr.  Caspar 
W.  Miller,  X-ray  pictures  of  his  extremities  were  made. 
The  trunk  and  jaw  were  too  thick  to  obtain  any  clearness 
of  detail,  so  th's  part  of  the  investigation  we  were  forced 
to  abandon.  The  result,  however,  shows  only  a  uniform 
hypertrophy,  merely  an  exaggeration  of  the  normal  state. 
On  this  account  the  illustrations  will  be  omitted.  The 
ears  are  large  and  cartilages  thick  The  nose  is  very  large, 
measuring  6.6  Cm.  from  frontal  bone  to  tip.  and  5.2  Cm. 
across  alae.  The  nares  measure  1.5  X  2  Cm.  The  septum 
is  thickened  and  deflected  toward  the  right.    A  large  spur 


(d)  International  Medical  Maspizinc.  Vol.  4.  No  6. 


[APBIL  20,  1901 


AKROMEGALY 


LThe   Philadelphia 
Medical  Jodbnal 


773 


is  seen  on  this  31  Je  springing  from  the  lower  border  of 
septum.  Both  th  >  middle  and  inferior  turbinated  bodies 
are  deeply   congejted   and   infiltrated. 

The  lips  are  thick,  teeth  normal  in  size  and  number. 
The  alveolar  procLSst 2  are  hyperlrophied.  the  right  curved 
inward  (halt  saddle-shaped).  The  hard  palate  is  deepened. 
the  soft  palate  and  uvula  thickened.  The  post-nasal  space 
is  thereby  much  contracted.  The  tongue  is  long,  broad  and 
deeply  fissured,  measuring  at  its  broadest  part  7  Cm.  It 
resembles  closely  this  organ  seen  in  the  Cretin  and  Mon- 
golian type.  The  voice  is  thick  and  guttural.  The  face 
is  oval  and  prognatneus.  Malar  bones  massive.  Inferior 
maxilla  thick,  and  chin  projecting,  so  tliat  the  lower  incis- 
ors do  not  articulate  with  the  upper,  but  are  carried  out 
beyond  them  slightly.  His  neck  is  thick  and  short,  and 
the  right  thyroid  body  is  distinctly  enlarged  and  firm, 
(a)  (Hutchinson,  in  an  analysis  of  218  cases,  found  this 
body  enlarged  thirty  per  cent.,  and  atrophied  in  ten  per 
cent.)  The  thoracic  cage  bulges  forward,  increasing  the 
antero-posterior  diameter  materially. 

The  abdomen  is  pendulous  and  the  breasts  enlarged; 
(usually  the  latter,  in  females  especially,  are  described  as 
atrophied).  The  sternum  and  clavicles  are  very  broad  and 
thicK.  This  increase  in  size  of  the  latter  is  particularly 
marked  on  their  innncr  thirds.  The  ribs  share  equally 
In  this  bony  development,  and  at  the  sternal  junction  are 
noticeably  bead«>d.     The  genital  organs  are  hypertrophied. 


megalic,    is   never   complained   of,    and    apparently    is   ab- 
sent. 

A  full  report  of  the  examination  of  his  eyes  by  Dr.  J- 
Thorington  is  here  given;  S.  B.,  age  18  years.  Examina- 
tion OL  eyea. 

INSPECTION:  Eye  lashes,  eye-lids  and  palpebral  fis. 
sures  apparently  normal.  Eye-balls  are  not  prominent. 
Extraocular  muscles  normal  and  ocular  excursions  perfect. 
Corneas  normal.  Anterior  chambers  normal.  Pupils  ar'i 
round,  four  millimeters  in  diameter,  Irides  react  very 
sluggishly  to  light,  convergence  and  accommodation. 

VISION  AND  NEAR  POINT.  This  is  the  same  in  each 
eye,  vision  being  normal,  V|V,  and  near  point  9  Cm. 

OPTHALMOSCOPE:  Right  eye.  Media  clear.  Disc 
large,  slightly  vertically  oval.  Choroidal  ring  all  around 
the  disc.  Shallow  physiological  cup.  Arteries  smaller  than 
the  normal;  relative  jjroportion  between  arteries  and  veins 
in  health.  Veins  slightly  tortuous.  The  disc  is  decidedly 
pa'/,  in  color  and  very  few  capillary  vessels  can  be  recog 
nized.  The  direct  and  the  indirect  methods  of  examina- 
tion, and  also  the  plane  and  the  concave  mirror,  show  the 
characteristic  atrophic  nerve.  The  refraction  is  hyperopia 
about  half  a  diopter.  The  left  eye  shows  the  same  condi- 
tions as  the  right,  except  that  the  temporal  side  of  the  disc 
is  heavily  pigmented. 

COLOR    VISION:    There    is    no    color    blindness.      The 


LE  FT 


P.  K, 

1-  F'lx.ition 


RIGHT 


----Green. 
Fig.  3,    Fields  of  vision  in  a  case  of  Akromegaly 


testicles  firm.  Auto-erotism,  generally  noted  as  being 
absent,  has  apparently  in  this  case  not  diminished.  When 
younger  he  was  known  to  masturbate  and  to  practice 
sodomy.  At  present  he  tells  me  he  experiences  nocturnal 
emissions.  On  one  occasion  spermatozoa  were  found  in  the 
urine. 

The  relation  between  his  height  and  the  stretch  of  arms, 
measuring  from  the  tip  of  one  middle  finger  across  his 
chest  to  the  other,  as  might  be  inferred,  is  markedly 
altered.  Normally  the  stretch  is  approximately  5  Cm. 
greater;  in  this  case  we  find  the  difference  to  be  18.6  Cm. 
(e)  The  length  stretch  index  computed  from  this  is  1.07  -|- 
Normal  approximately  1.02.     Imbeciles  .096  to  1.068. 

The  hands  and  feet  are  steadily  increasing  in  size.  He 
now  wears  a  No.  ISVi  shoe. 

Sensation,  tactile,  thermal,  weight  and  pressure,  and  lo- 
cation are  normal. 

SIGHT:  Subjective  symptoms  are  still  absent,  excepting 
at  night  he  experiences  difficulty  in  finding  his  way 
about. 

Headache,   the   commonest   of   complaints   of  the   akro- 

(a)  Woods  Hutchinson,  New  York  Journal,  :March  12  1-S1)S, 

(e)  One  hundred  imbeciles  were  e.xaniined,  many  of  them  types  of 
atavism  for  a  comparison  of  indices,  with  the  following  results:  10  per- 
cent 1  0(B  21!  per-cent  1.043;  48  per-cent  1.018;  10  per-cent  .08.  The  hiehcst 
1.0l>8.     The  lowest  .90. 


patient    selecting    the    worsteds    accurately    and    withoul 
hesitation  in  each  instance. 

FIELDS:  The  form  field  is  contracted  to  within  ten  de- 
grees of  the  point  of  fixation.  The  color  field  is  smaller 
than  the  form  field.    This  is  the  same  in  each  eye. 

DIAGNOSIS:   Progressive  double  optic  atrophy. 

HEARING:  This  is  about  one-tnird  normal  in  his  left 
ear.  and  greatly  diminished  on  the  right  side.  He  has 
suffered  at  various  times  from  otorrhoea  in  both  ears. 

SMELL;  The  sense  is  lost  on  the  left  side,  and  appar- 
ently decreased  in  the  right.  He  still  can  recognize  the 
common  essential  oils  and  other  odoriferous  substances. 
Taste  sense  is  not  appreciably  diminished. 

MOTOR  DISTURB.4.NCES:  His  gait  is  slow  and  delib- 
erate, and  naturally  abnormal  on  account  of  the  righ> 
genu  valgum. 

Station  and  sway  are  normal. 

Cutaneous  reflexes  normal. 

TENDON  AND  MUSCLE  PHENOMENA:  The  knee 
jerks  are  diminished,  almost  lost  in  the  right'  There  is  na 
ankle  clonus.     Too,  elbow,  wrist  and  jaw  jerk  normal. 

SECRETORY  DISORDERS:  There  is  marked  general 
hyperhidrosis  which  is  particularly  increased  on  the  right 
half  of  the  body.  When  stripped,  even  in  a  comparatively- 
cool  room,  great  drops  of  sweat  are  to  be  seen  trickling 
down  the  lateral  surfaces  of  his  chest  from  the  axillary 
folds. 


774 


The   PHiLAOELriiiA"] 
Medical  Joukxal  J 


AKROMEGALY 


[APRIL  20,  1901 


TROPHIC  DISORDERS:  The  skin  Is  generally  thick- 
«ned,  and  over  the  shoulders,  sides  of  chest  and  lateral 
surfaces  of  abdomen  it  is  thrown  in  rugae.  Distinct  linea 
striata  are  to  be  seen  running  inward  and  upward  from 
crest  of  ilium.  The  nails  are  l>i-oad  and  flat,  and  finger 
tips  square.  Fleshy  pads,  so  commonly  described  in  this 
disease,  are  well  shown  in  jialms  of  hands  and  feet.  Joint 
pains  are  constant.  The  right  fingers  are  numb  and  tingle 
in  the  early  morning. 

TEMPERATURE:  The  axillary  temperatures  compared 
daily  show  a  constant  variation  of  about  two-flfths  of  a  de- 
gree higher  on  the  right  side. 

PULSE:  86-98.  The  arterial  tension  is  increased,  and 
the  coats  are  appreciably  thickened. 

Slight  varices  are  noted  in  the  legs. 

HEART:  The  heart  is  hypertrophied.  The  apex  beat  is 
forcible  in  the  sixth  interspace  and  just  outside  the  nipple 
line.  Dullness  extends  upward  to  the  third  rib  and  at  trans- 
versely two  centimeters  beyond  the  nipple  line,  and  to  the 
Tight  border  of  sternum.  The  first  sound  is  prolonged 
and  dull.  The  second  sound  at  aortic  cartilage  is  accen- 
tuated. 

RESPIRATION:  22-24,  character  abdominal.  On  percus 
sion  and  auscultation  the  chest  is  negative,  excepting  there 
is  marked  dulness  over  the  upper  sternum,  (b)  Erb,  to 
■whom  the  credit  is  due,  first  pointed  out  this  sign  in  akro- 
megaly  as  suggestive  of  an  enlarged  thymus  gland.  He, 
supported  by  Shultz  and  Verstraeter,  believed  it  to  be  char- 
acteristic. 

Appetite  is  moderate,  at  times  capricious.  He  does  not 
care  for  sweets,  and  on  diminish'ng  the  amount  of  sugar 
and  starches  in  diet  the  traces  of  sugar  found  in  the  urine 
ceased  altogether.  On  the  other  hand,  when  given  an 
«xcess,  the  amount  did  not  seem  to  material'v  increase 

LIVER:  The  liver  is  increased  in  siie.  The  lower  bor- 
der is  smooth  and  can  be  felt  about  5  Cm.  below  the  costal 
margin. 

SPLEEN:   This  is  enlarged  and  tender. 

KIDNEYS.  The  right  kidney  cannot  be  palpated.  The 
left  kidney  is  distinctly  enlarged. 

URINE:  Urine  examination  March  10th,  1900.  Average 
daily  quantity  2400  C.  c.  Reaction  acid.  Sp.  Gr.  1.02:,. 
Sugar,  albumen  and  acetone  present  in  traces.  Urea  2.6 
per  cent.  The  phosjihates.  chlorides  and  sulphates  were 
in  their  normal  relation.  No  diacetic  acid.  Microscop- 
ically casts,  granular  and  hyaline.  Crystal  calcium  ox- 
alate, 

October  15th.  Average  daily  quantity  6810  C.  c.  Reac- 
tion acid.  Sp.  Gr.  1.010.  No  sugar.  Albumen  .030  gm 
to  500  C.  c.  Acetone  traces.  No  diacetic  acid.  Phosphates, 
chlorides,  sulphates  normal. 

Microscopically— Casts  hyaline;  crystale  calcium  oxalate. 

GLANDS:    Not  enlarged. 

Blood  Examination  March  10th.  1900. 

Red  cells ,'5,265,000 

White  cells 8,000 

Hemoglobin 8.5  per  cent 

Eosinophile  cells 1.66  per  cent. 

October  13th,  1900. 

Red  cells 4,760,000 

White  cells 6,400 

Hemoglobin 85  per  cent 

Differential  Count. 

Polynuclear  neiitrophies 63  per  cent. 

Small  lymphocytes 23  per  cent. 

Large  and  transitional 9  per  cent 

Eosinophiles 5  per  cent. 

Number  of  cells  counted 1165 

CASE  NO.  2.— P.  K.,  age  20  vears.  Family  history  un- 
known. When  admitted  to  the  Pennsylvania  Training 
School  at  the  age  of  fourteen  years  he  was  classed  as  a 
middle-grade  imbecile,  unable  to  read  and  write.  He  was 
active,  noisy  and  disobedient.  His  features  were  good 
■stature  and  general  muscular  development  apparently  no- 
mal.  When  placed  in  school  it  was  quickly  found  that 
his  mental  limit  had  already  been  reached:  unable  to  con 
■centrate  attention. with  no  memory  power,  the  lessons  of  one 
■day,  even  after  constant  repetition,  would   be   forgotten   the 

4b)  Cited  by  Hin.sdale. 


next.  For  manual  artshe  was  equally  incapable,  but  develop- 
ing some  aptitude  for  ordinary  industrial  occupation,  he 
was,  offer  two  and  a  half  years'  trial,  taken  from  the 
schools  and  put  to  work  in  the  kitchen.  At  this  time, 
August,  1896,  he  was  of  the  usual  size  and  weight  of  a  lad 
of  sixteen,  and  in  vigor  and  strength  was  considered  rather 
above  the  ordinary  imbecile. 


Fig.  2.    A  case  of  Acromegaly. 

This  case  represents  a  very  early  stage  of  the  disease, 
and  it  is  only  of  late  I  have  been  enabled  to  make  a  diag- 
nosis. Among  the  imbeciles  we  have  many  abnormalities, 
so  that  one  must  consider  what  is  representative  of  this 
type  on  the  one  hand,  and  on  the  other  what  is  character- 
istic of  a  disease  like  akromegaly  in  its  erethristic  stage. 
.Adolescence  is  reached:  health  and  physical  strength 
were,  until  the  last  six  months,  exceptionally  good,  and  the 
course  of  the  disease  has  not  been  marked  by  pronounced 
clianges. 

In  December  1S99  my  attention  was  first  drawn  to  his 
malady  while  he  was  suffering  from  a  mild  attack  of  influ- 
enza. He  was  then  about  six  feet  tall,  face  slightly  prog- 
natheus,  his  hands  unusually  large,  and  he  wore  a  No.  11 
shoe.  There  was  no  kyphosis,  no  evidence  of  trophoneu- 
roses, no  apparent  enlargement  of  the  lower  jaw.  The 
urine  and  blood  examinations  wer  normal.  Later  he  began 
to  suffer  occasionally  from  indigestion,  muscular  pains, 
principally  in  the  thighs  and  legs,  and  headaches.  Plaster 
casts  of  his  hands  and  feet  were  made.  In  June  an  exam- 
ination of  his  eyes  and  fields  by  Dr.  Thorington  was  made 
and  repeated  seven  months  later  for  comparison.  The 
cuts  clearly  illustrate  the  changes.  (See  also  his  report). 
X-ray  pictures  were  also  made  about  the  same  time,  btit 
these  latter,  as  in  Case  1,  show  the  same  uniform  hyper- 
trophy, and  nothing  characteristic. 

Measurements  of  his  body  were  likewise  taken  and  com- 
pared later.  The  lower  jaw  is  elongating,  causing  the 
the  teeth  to  protrude  a  trifle.  The  eyes  and  cheek 
bones  are  becoming  more  prominent,  the  lips  thicker, 
rind  nose  larger.  The  skin  on  the  face  is  thick  and 
pigmented.  General  hyperhidrosis  is  pronounced,  although 
not  nearly  so  much  as  in  Case  No.  1.  .\  recent  study  of  the 
urine  shows  advancing  renal  changes.  .Average  daily 
quantity.  1675  C.  c.  Color,  pale  amber.  Sp.  Gr.  102°. 
Reaction  acid,  .•\lbumen.  acetone  and  indican  present  in 
traces:   no  diacetic  acid,  no  sugar. 

Microscopically — Hyaline  casts  and  calcium  oxalate 
crystals. 


[ArBiL  20.  1'JOl 


AKROMEGALY 


CThe   Philadelphia       T^r 
Medial  JnrBNAL         I/O 


p.  K. 

A/OV.  \5-'oo 


RIGHT 


Wklte. 


t  ig.  4. 


— Oreeiv. 

Fields  ol  visiou  in  a  case  ot  AKromegaly. 


r  +  Red 


Elood  is  normal.  Axillary  temperatures  equal  and  nor- 
mal. 

Respirations  24  26.  abdominal  in  type.  Chest  full  anil 
regular. 

Reflexes  normal. 

The  genital  organs  are  hypertrophied.  There  is  appar- 
ently no  diminution  in  the  auto-erotic  phenomena. 

Appetite  moderate,  stomach  and  intestinal  tract  pre- 
sumably healthy.  There  is  neither  polyphagia  or  poly- 
dipsia- His  general  disposition  is  good,  excepting  when 
suffering  from  headache  he  is  irritable  and  forgetful,  as 
might  be  expected.  Responding  to  military  training,  he 
carried  himself  well  and  was  exceedingly  erect;  but  latterly 
several  interesting  features  are  noticeable;  he  is  beginning 
to  stoop,  has  lost  the  sense  ot  time  in  music,  and  there  is 
progressive  general  weakness,  and  he  is  now  easily  fa- 
tigued. 

His  shoes  have  been  recently  changed  for  a  size  larger 
(No.  12),  and  the  two  casts  made  within  an  interval  of 
seven  months,  of  his  right  hand,  are  strikingly  dissimilar. 

Dr.  Thoringtons  Report.  June  1st,  1900.  P.  K.,  age  20 
years.  O.  D.  V. — V|V.  O.  S.  V.— V|V.  Pupils  large,  round, 
five  millimeters  in  diameter.  Irides  react  sluggishly  to 
light,  convergence  and  accomraadation. 

Opthalmoscope  shows  medium  sized  nerves.  Relative 
proportion  between  size  of  retinal  arteries  and  veins  is 
normal.  The  arteries  are  not  narrowed,  and  veins  are  not 
enlarged.  Both  nerves  appear  normal.  The  refraction  is 
hyperopic  less  than  1  D. 

Fields  show  concentric  contraction  for  form  and  colors: 
this  is  especially  marked  in  the  left  eye. 

Diagnosis:     Beginning  optic  atrophy. 

TREATMENT. 

Only  in  Case  No.  1  have  I  attempted  more  than  a  symp- 
tomatic form  of  treatment.  We  hope  later  to  be  able  to  re- 
port more  fully  on  the  value  of  the  animal  extracts. 

S.  B.  has  been  taking  an  extract  of  the  thyroid  body  for 
the  past  three  months  in  daily  doses  increasing  from  fifteen 
(o  twenty-five  grains,  with  so  far  no  apparent  benefit 

My  thanks  are  due  to  Dr.  Martin  W.  Br  Chief  Physi- 
cian of  the  Pennsylvania  Training  School,  ii-r  his  material 
assistance  in  working  up  these  cases,  and  permission  to 
uidke  this  report. 


CHART  No.  I- 


-MHASUREMENTS. 

S.  B  P. 


DATE, 

March 

March 

October 

May 

Sept. 

AGE, 

27-1899 

26-1900 

15-1900 

2-1900 

17-1900 

Weight 

9.5.3  Kg. 

90.7  Kg. 

100.4  Kg. 

70.7  Kg. 

76      Kg. 

Height 

lyo.(i  Cm. 

193      Cm. 

193.4  Cm. 

181.2  Cm. 

182.5  Cm. 

Sitting 

94.5    ■■ 

96.8    •' 

98.5    '• 

92        •• 

93.2    •■ 

Kuee 

52       •• 

53.3    •' 

57.5    " 

48 

49.2    •■ 

Pubes 

9B       ■• 

97.9    " 

9S.3    '• 

90.3     •• 

91       •• 

Xavel 

118       •' 

118.3    •• 

11S.6    " 

107.5    •■ 

108.5    " 

Sternum  .... 

\m.i  " 

l.JS.8    •■ 

169.2    •• 

149.2    " 

150       " 

GIRTH  Head 

m.a    " 

.57       •• 

.57       '• 

5u 

nki.b    ** 

Neck     .... 

3S.&    " 

40.8    ■• 

39.2    •• 

37.5    •■ 

37.5    " 

Chest,  Repose  . 

las.s  •• 

105 

99 

94       •' 

Chest,  Full    .  . 

108       •■ 

110       " 

lul.o    ■■ 

99 

Ninth  Rib  .   .   . 

106       " 

108.3    " 

91.7    •• 

96.5    " 

Inflated  .... 

an     ■■ 

110.5    " 

94 

98        " 

Waist 

8S       •• 

89     ■■ 

94 

79        " 

79        '■ 

Hips     

10.^.2    •• 

108       " 

107.5    " 

91.3     " 

91.3    " 

R.  Thigh    .  .   . 

bi.o     " 

54        " 

56.5    " 

06.0     " 

57        " 

L.        •■     .  .  .  . 

mi.o     '• 

57 

56.6    ■■ 

^5.7     '* 

.5.5.8    " 

R.  Knee  .... 

«.o    " 

44 

44       " 

38        ■• 

:«     " 

L.      •■      .... 

42.(1    •■ 

42.5    •• 

44 

38 

38       " 

R.  Calf    .... 

So.-    •• 

36.5    " 

38        " 

39,5    •• 

:*J.5    " 

I,.     •■        .... 

;«.4   •• 

34        " 

36        " 

38.7     •• 

39 

R.  .4nkle    .  .  . 

24       •• 

24       " 

24 

23.5    ■• 

i;{.5   " 

L.      ••      .   .  ;   . 

24.2    " 

24.2    ■' 

24       " 

zi     •• 

23 

"         R.  Instep   .   .   . 

297     •' 

30       ■• 

30.7    " 

'S.i   ■• 

27.2    " 

L.       ■•         ... 

2'J.4    " 

m      '• 

31       " 

■n:2   ■' 

27.2     " 

"         R.  Upper  A-Toi 

29.2    •' 

32.5    •' 

Si:2   •• 

Mi    ■• 

:«      •' 

L. 

29.3    " 

31.6    " 

33       •• 

33.3    " 

a     " 

R.  Elbow   .  .  . 

28.2    •• 

29.5    •■ 

26 

27 

L.        '•        ... 

28.2    •• 

29.7    '■ 

26       " 

27     •  " 

R.  Forearm  .   . 

26       " 

29.3    •■ 

29.5    " 

29       •' 

29        "^ 

1,.        ■■ 

26.7    ■• 

28       •■ 

29.5    " 

29       •' 

29 

R.  Wrist     .  .   . 

19.8    " 

20       ■• 

18.5    •' 

18.7     " 

L.      •■          ... 

19.4    " 

19.4    " 

18       •' 

18.5    "■ 

DEPTH,  Chest     .... 

21.5    " 

27.5    " 

19       •• 

-•.5    "• 

.\bdomen     .   . 

21       ■• 

25       " 

19       •• 

19 

BREADTH,  Head    .   .   . 

15.2    •• 

15.5    " 

15.6    •' 

14.7     •• 

14.7     " 

Neck   .   .   . 

11.4    •• 

11.5    " 

12.3    •• 

11.6    •• 

Shoulders 

40.6    •' 

41.7    ■• 

43.2    ■• 

43        " 

Waist  .   .  . 

31.2    " 

31.5    •• 

29.7     ■■ 

29        " 

Hips     .    .    . 

38       " 

39.3    •• 

31.2    •• 

31.5    •' 

Nipples  .    . 

21.9    " 

22.7    " 

22.2    •■ 

22.2    " 

I,ENGTH.  R.Should.Elb 

39.4    " 

42.4    •• 

43.2    •' 

36.3    •• 

36.5    •• 

L.      ■■ 

39.4    ■• 

42.4    •• 

43.2    " 

36.3    •• 

36.5    " 

R.  Elbow  Tip 

55.5    " 

56.2    " 

56.3    " 

50.4    ■• 

50.9    •• 

L.  Elbow  Tip 

55       •• 

56       •' 

56.8    '• 

50.2    •• 

.50.2    •• 

R.  Foot   .    .    . 

30       •• 

30.3    " 

30.5    " 

28.6    " 

:«.9   ■' 

L.  Foot   .   .   . 

31.2    •■ 

31.5    •• 

31.8    •• 

28.6    " 

28.9    " 

"          Horizontal    . 

196.2    •• 

198       " 

181.6    •• 

184.6     •• 

Stretch  of  .\rms    .... 

210       " 

212       " 

190       " 

190        '• 

Capacity  of  I.ungs  .   .   . 

4     L. 

4.4  L. 

2.5  L. 

1.8  L. 

Strength  of  Lungs  .   .    . 

170     Cm. 

130  Gm. 

150  Gm. 

135  Gm. 

"          ■■   Back     .   .   . 

150     Kg. 

140  Kg. 

200  Kg. 

150  Kg. 

•■   Legs  .... 

140       ■• 

150       • 

230     ■• 

190     '■ 

•■   Chest    .   .    . 

•   r.  .\rm    .   . 

R.     L. 

R.      L. 

R.     L. 

R.     L. 

"          "    Forearm     . 

41-35  Kg. 

34.37  Kg. 

37-»6Kg. 

45-38Kg.. 

HEAD  MEASLRE- 

iMENTS. 

Circumference 

,57     Cm. 

.57     Cm. 

56.5  Cm.. 

Naso-occipital  arc    .   . 

36.3    •■ 

38.5    ■• 

m      " 

Binauricular  arc   .... 

S7.7    " 

38       •• 

:J4.5    •■ 

.\ntero-posterior  diam. 

19.7    " 

20       '• 

20       " 

Great.  Transverse  Diam. 

1,5.5    *' 

15.6     • 

14.7    " 

Length  Breadth  index  . 

77       " 

76       •■ 

72.5    " 

Binauricular  Diam.     .   . 

I3.S    " 

13.5    •■ 

12.5    •■ 

Facial  Length 

22.3    " 

22.4    " 

19.5    •• 

Occipito-meiital  diam.  . 

22.3    •• 

27.5    '• 

24.5    •• 

Length   Body   Mandible 

11.       ■• 

9.0    ■■ 

•776       The   Philadelphia"! 
/  /  Medical  Jockxal  J 


INFANTILE  SCORBUTUS 


lAPBn.  20,  vaofi 


A  CLINICAL  NOTE  ON  INFANTILE  SCORBUTUS. 
WM.  M.  MASTIN,  M.  D. 

of  Mobile.  Ala. 

The  recent  paper  by  Dr.  Griffith  on  infantile 
scurvy  inTlie  Philadelpliia MeJicalJournal{¥^hruary  2, 
1901)  suggests  the  report  of  four  cases  of  this  dis- 
ease coming  under  my  observation  within  the  com- 
paratively short  period  of  the  past  six  months,  and 
which,  I  hope,  will  serve  to  emphasize  his  remarks 
relative  to  the  frequency  of  the  affection. 

It  is  a  matter  of  surprise  that  notwithstanding 
the  rather  numerous  publications  on  the  subject 
during  late  years,  notably  among  which  may  be 
mentioned  the  article  of  Xorthop  and  Crandall.  ap- 
pearing as  early  as  1894,  there  is  a  decided  miscon- 
ception of  the  malad\-  by  the  general  practitioner, 
and  especially  so  in  confusing  it  with  rheumatism. 
The  impression  seems  to  prevail  among  the  profes- 
sion that  scurvy  in  the  first  years  of  child  life  is 
a  very  rare  affection,  and,  on  the  other  hand,  that 
rheumatism  in  infancy  is  quite  common.  In  reality 
the  reverse  is  true,  if  I  may  judge  from  the  pub- 
lished records  and  my  own  personal  experience,  al- 
though my  work  is  largely  surgical  in  character, 
and  I  am  assured  the  observations  of  the  pediatric 
specialist  will  fully  sustain  this  opinion.  Further- 
more, there  is  scarcely  a  doubt  that  infantile 
scorbutus  is  rapidly  increasing,  due  obviously  to 
the  more  widespread  resort  to  artificial  feeding  and 
the  almost  daily  addition  to  the  already  vast  num- 
ber of  commercial  infant  foods. 

The  subjoined  cases  combine  several  features  of 
interest.  They  demonstrate  that  errors  in  the  diag- 
nosis of  infantile  scurvy  are  not  confined  alone  to 
rheumatic  affections,  but  may  extend  to  the  domain 
of  surgical  disorders — tubercular  bone  lesions, 
sprains  and  contusions ;  to  the  nervous  system — 
disease  of  the  cord ;  and  even  include  hereditary 
syphilis. 

They  show  also  that  scurvy  may  arise  during  the 
exhibition  of  several  of  the  most  popular  artificial 
or  prepared  foods,  and,  in  addition,  what  is  of  much 
consequence,  that  its  occurrence  under  the  use  of 
sterilized  milk  must  be  untjoubtedly  conceded. 

.Again,  one  of  the  cases  suggests  the  possible 
intimacy,  or,  at  least,  association,  of  infantile  scurvy 
wtih  a  form  of  pernicious  anemia,  which,  taken  in 
connection  with  the  recent  observations  in  this  di- 
rection, is  of  some  importance. 

CASE  1. — J.  M..  h  male  child.  13  months  old,  was  seen  bj 
me  in  consultation  with  the  family  physician  on  June  3rd. 
ISOO.  The  child  had  been  in  failing  health,  as  evidenced  by 
;loss  of  flesh,  disturbed  digestion,  anemic  appearance,  fretful 
itess.  etc.,  for  the  past  three  months,  during  the  last  eight 
or  nine  weeks  of  which  time  pain  in  and  swelling  of  tl;- 
'lower  extremities  was  noticed,  the  pain  being  greatly  ex- 
aggerated on  movement  and  handling  These  symptoms 
were  at  first  attnuiited  to  rheumatism,  and  the  salicylates 
and  kindred  drugs  were  freely  used. 

As  the  disease  progressed  the  swelling,  pain  and  tender- 
ness gradually  increased,  especially  Xn,  the  right  knee  an-l 
r.nkle  and  along  the  tibia,  when  the  diagnosis  was  changed 
to  that  of  periostitis  of  probabh?  syphilitic  nature.  It  was 
at  this  time  tha-L  I  requested  to  ceis  th»  case.  Examination 
now  showed  an  extremely  pale,  emaciated  and  fretful  baby. 
Voarng  the  impress  of  suffering  in  its  pinched  features, 
indisposed  to  move,  and  crying  out  with  pain  when  touched 
or  handled.  Both  lower  Tnibs  were  piinful  on  movement 
r^d  pressure,  particularly  over  the  tibial  epiphyses,  with 
rswelling.  thickening  and   somf>  redness   along  the   tibiae. 


These  symptoms  were  much  more  pronnimced  in  the  right 
leg.  Th«e  was  slight  tenderness  on  pressure  about  the 
arms  and  hands,  but  no  further  implication  was  found  in 
the  upper  extremities.  There  was  no  evidence  of  rickets. 
The  gums  were  swollen,  spongy,  and  ulcerated  along  the 
line  of  the  upper  and  lower  incisors.  The  child  had  been 
nursed  at  the  breast  for  the  first  month  and  a  half  of  life, 
but  at  this  period  the  mother's  health  became  impaired  and 
her  milk  failed.  Condensed  milk  was  now  substituted, 
upon  which  the  infant  seemed  to  thrive,  and  this,  together 
with  Mellin's  food  and  occasionally  feeding  with  farina- 
ceous articles  of  diet,  was  the  character  of  nourishment  the 
child  had  received.  On  a  diet  of  raw  cow's  milk  combined 
with  a  moderate  proportion  of  Mellin's  Food,  with  orange 
juice  daily  administered,  the  scorbutic  symptoms  rapidly 
subsided  and  were  entirely  relieved.  'The  condition  of 
anemia,  however,  progressed  unchecked,  although  recon- 
structives  wer  freely  employed.  The  child  succumbed  sev- 
eral weeks  later  to  an  attack  of  entero-colitis. 

The  noticeable  facts  in  this  case  are  that  the  dis- 
ease was  mistaken  for  both  rheumatism  and  here- 
ditary syphilitic  periostitis:  that  it  occurred  whilst 
on  a  diet  of  condensed  milk  and  Mellin's  food :  and 
thirdly,  and  of  especial  interest,  its  connection  with 
a  form  of  anemia  most  probably  of  a  pernicious 
type. 

The  affinity  between  infantile  scurvy  and  perni- 
cious anemia  was  recently  suggested  by  Dr.  J.  L. 
Duenas,  of  Havana,  who  reported  in  the  Archives  oj 
Pediatrics  January,  1901,  an  important  and  suggest- 
ive case  where  there  was  an  intimate  and  probable 
etiological  relationship  existing  between  the  two  dis- 
eases. It  is  greatly  to  be  regretted  that  careful 
blood  examinations  were  not  made  in  the  case  of  J. 
M.,  but  the  character  and  persistence  of  the  anemia, 
notwithstanding  the  prompt  and  complete  relief  of 
the  scorbutic  manifestations,  leave  scarcely  a  doubt 
as  to  its  nature  and  association,  particularly  in  the 
light  of  Dr.  Duenas'  contribution. 

"case  2. — Grace  Van  H..  a  female  child  ten  month  old. 
was  brought  to  me  from  Jackson.  Ala.,  August  10th.  1900, 
for  trouble  existing  in  the  left  hip  joint,  which  had  been 
diagnosed  as  tubercular.  The  child  was  jom  at  term,  of 
healthy  parents,  and  was  vigorous  at  birth.  For  the  first 
month  it  was  nursed  at  the  breast,  but  at  this  time  the 
mother  suffered  from  an  attack  of  fever,  with  checking 
lactation,  a  diet  of  Mellin's  food  and  condensed  milk  was 
prescribed.  This  was  the  only  food  given  and  apparently 
it  furnished  all  the  necessary  nutrition  until  about  six 
weeks  prior  to  its  visit  to  Mobile.  Then  it  was  noticed 
that  the  infant  was  growing  thin,  losing  color,  becoming 
fretful,  and  the  appetite  diminishing.  These  symptoms 
somewhat  increased  for  about  two  weeks,  when  it  was 
further  discovered  that  the  left  hip  and  thigh  were  painfrU 
and  swollen.  These  were  the  symptoms  present  when  I 
saw  the  case.  and.  in  addition,  it  was  found  that  the  thigh 
was  partially  flexed  on  the  abdomen  and  the  entire  limb 
rigid  and  almost  immovable.  There  was  moderate  swelling 
about  the  joint  including  the  thigh  down  to  the  knee,  and 
the  least  movement,  or  pressure  over  this  area  of  surface 
caused  decided  pain.  At  the  first  glance  the  symptoms 
were  certainly  those  suggestive  of  hip  disease,  but  a  closer 
examination,  together  with  finding  that  the  tenderness  also 
■existed  to  a  moderate  degree  in  the  epiphyses  of  the  bones: 

^f  both  lower  extrem-ties.  with  a  spongy  condition  of  the 
-ums   anil   the  cachectic   appearance  of  the  patient,   was 

onvincing  evidence  that  the  trouble  was  not  simply  local- 
'/ed.  but  dyscrasic  in  character.     The  food  was  changed 

0  raw  cow's  milk,  and  the  juice  of  an  orange  ordered  to  be 
•^iven  daily.  Under  these  measures  improvement  took 
nlace  rap'dly,  and  within  a  period  of  ten  days  or  two  weeks 
the  child  had  practically  recovered. 

The  diagnosis'  of  infantile  scurvy  in  the  majoritv 

■if   instances  offers   relatively  but   few   difficulties. 

and  the  present  case  is  interesting  because  of  the 

somewhat  obscure  symptoms  which  characterized 

lie  onset  of  the  attack.    With  the  presence  of  pain 

n  and  slight  swelling  about  the  joint,  flexed  thiffh 


IAphil  20,  lUill 


INFANTILE  SCORBUTUS 


[■The   P 
L  Medic 


Philadelphia 
AL  Journal 


in 


and  rigid  muscles,  and  the  general  depreciation 
of  the  child's  health,  it  can  be  readily  i-.nderstood 
iiow  one  might  be  misled.  But  with  the  appearance 
■  A  tenderness  about  the  joints  and  bones  of  both 
limbs,  with  spongy  and  ulcerated  gums,  the  diag- 
nosis  was  quite  apparent. 

CASE  3.— P.  H.  B.,  male,  one  year  old.  This  child  was 
brought  from  the  interior  of  the  State  and  seen  by  me  on 
October  18,   1900.     The  history  of  the  case  is  as  follows: 

It  was  the  first  child,  delivered  with  instruments,  bul 
healthy  and  vigorous  at  birth.  For  the  first  three  or  four 
weeks  it  received  its  mothers  niiik,  but  it  did  not  thrive 
and  improve  in  weight,  and  the  physician  in  attendance 
advised  a  change  to  sterilized  milk.  This  was  done,  and 
for  several  months  thereafter  improvement  in  nutrition 
was  marked  and  the  food  seemed  to  agree  most  admirably. 
When  the  child  was  about  seven  or  eight  months  old  it 
was  observed  to  be  losing  flesh  and  becoming  languid,  pale 
and  fretful,  but  this  was  attributed  to  the  warm  weather, 
and  the  diet  of  sterilized  milk  was  continued.  These  symp 
loms  of  depreciating  health  continued  and  increased  until 
six  weeks  prior  to  the  date  on  which  I  saw  it.  It  was  then 
noticed  also  that  the  movements  of  the  child  were  quite  fee 
ble,  especially  of  the  lower  limbs,  and.  although  it  had 
learned  to  stand  with  the  aid  of  a  support,  the  legs  now  gave 
way  under  its  weight  and  it  soon  ceased  to  make  such 
attempts. 

'  It  happened  just  at  this  time  that  the  child  slipped  from 
a  table  on  which  it  was  sitting,  and  the  nurse  in  catching 
it  was  thought  to  have  wrenched  its  back,  for  it  cried  loudly 
and  seemed  to  be  in  pain  for  some  hours.  After  this  ;t 
refused  to  make  any  effort  whatever  at  sitting  or  standing, 
and  cried  when  handled  or  moved.  An  injury  to  the  spine 
was  believed  to  have  been  sustained,  and  the  parents 
brought  it  to  Mobile.  Another  physician  was  now  consulted 
who  diagnosed  a  serious  cord  lesion  and  advised  placing 
the  child  under  the  care  of  a  neurologist,  but  before  doing 
so  I  was  asked  to  see  it.  I  found  the  infant  anemic  and 
weak,  with  the  facies  of  illness,  and  apparently  having  lost 
entire  motion  of  the  lower  extremities.  It  was  quite  thin, 
especially  the  legs,  and  the  joints  stood  out  prominently. 

The  slightest  movement  produced  intense  pain — the  child 
almost  swooning  when  turned  about  for  examination — and 
there  was  decided  tenderness  over  the  hip,  knee  and  ankle 
joints  and  along  the  tibial  crests,  but  scarcely  any  swelling 
or  thickening  in  these  localities.  The  arms  and  shoulders 
were  also  somewhat  sensitive  and  painful.  The  gums  were 
distinctly  ulcerated  about  the  upper  incisors.  The  appetite 
was  poor.  Infantile  scorbutus  was  diagnosed,  and  a  food  of 
raw  cow's  milk  combined  with  a  small  amount  of  Mellin's 
food,  and  a  liberal  quantity  of  fruit  juice,  was  suggested. 
In  addition  iron  internally  and  inunctions  of  cod  liver  oil 
was  advised.  Improvement  was  astonishingly  rapid;  within 
a  week  after  the  adoption  of  these  measures  the  child  was 
almost  free  of  pain  and  was  rolling  over  in  bed  and  using 
its  legs  vigorously;  and  each  day  added  to  these  strides 
towards  recovery  until  at  the  expiration  of  a  month  it  was 
allowed  to  return  home  perfectly  well.  The  further  pro- 
gress of  the  case  was  uneventful. 

I  wish  to  call  attention  to  the  development  of 
scurvy  in  this  case  during  the  use  of  sterilized 
milk.  I  know  quite  well  that  this  is  a  disputed 
question,  and  that  some  observers  maintain  tha' 
heating  or  sterilization  has  no  cfTcct  whatever  upor 
the  nutritive  qualities  of  cow's  milk.  But  if  we  ad 
mit,  as  the  present  status  of  our  knowledge  seems 
to  demand,  that  the  etiology  of  scurvy  is  largely 
dietetic,  then  in  this  instance  where  no  other  food  of 
any  character  except  sterilized  milk  was  employed 
and  where  the  child  promptly  recovered  after  the 
diet  was  changed  to  milk  in  the  raw  state,  we  arc 
forced  to  the  conclusion  that  the  act  of  sterilization 
was  the  prominent  or  causative  factor.  It  is  indeed 
true  that  cases  are  recorded  where  scorbtitic  child- 
ren ha\'e  been  cured  simply  by  the  exhibition  of 
fruit  juices  without  change  of  the  former  diet,  and 
it  is,  of  course,  difficult  to  determine  which  was  tli 


actual  therapeutic  agent  in  a  case  where  both  the 
use  of  orange  juice  and  a  change  of  food  had  been 
made.  But  that  the  process  of  heating  does  produce 
alterations  in  milk  which  lessen  or  seriously  impair 
its  food  value,  I  feel  convinced,  and  even  if  it  can- 
not be  proven  that  milk  thus  prepared  is  a  positive 
or  direct  cause  of  scurvy,  there  is  sufficient  evidence 
to  render  the  probability  of  such  apower  very  strong, 
which  should  be  fully  recognized  and  a  warning 
.lote  sounded  in  the  matter.  This  is  all  the  more 
essential  on  account  of  the  very  extensive  use  of 
sterilized  milk,  not  only  as  an  infant  food,  but  also 
as  a  diet  in  general  illness,  and  especially  diseases  of 
long  duration. 

This  case  also  presented  obscurities  in  the  diag- 
nosis. 

The  fact  that  probable  injury  in  the  form  of  a 
wrench  or  sprain  of  the  spine  had  been  received,  fol- 
lowed almost  immediately  by  apparent  total  loss 
of  movement  of  the  lower  limbs,  rendered  it  quite 
probable  that  traumatism  to  the  cord  had  been  re- 
ceived. With  the  continuance  of  these  symptoms 
of  paralysis,  strongly  suggestive  of  a  poliomyelitis, 
it  is  not  surprising  that  the  error  of  regarding  the 
-rouble  as  located  in  the  cord  was  made. 

CASE  4. — On  February  12,  1901,  in  consultation  with  the 
family  physician,  1  saw  I.  J.  D.,  a  female  child,  of  healthy 
parents,  13  months  of  age.  whose  history  and  condition 
were  as  follows:  This  child  was  vigorous  at  birth,  and  for 
he  first  month  was  breast  fed;  but  the  mother's  milk  now 
tailing,  prepared  or  artificial  food  was  resorted  to.  In  tho 
beginning  this  consisted  of  condensed  milk,  which  at  first 
seemed  to  agree,  but  digestive  disorders  soon  appeared  and 
it  was  changed  for  Mellin's  food.  The  gastric  and  intes- 
tinal troubles  continued,  however,  and  Horlick's  food  was 
substituted,  and  on  this  diet  the  digestion  improved  an.l 
the  intestinal  irregularities  were  corrected.  This  had  been 
the  food  employed  for  the  greater  part  of  the  child's  hie 
and  was  being  given  when  I  was  consulted.  The  present 
;iffections  began  about  eight  weeks  before,  commencing 
with  pain,  tenderness  and  swelling  in  the  right  ankle,  then 
apidly  extended  to  the  knee  and  hip  of  the  same  side,  and 
vithin  the  period  of  a  week  had  invaded  the  left  hip.  The 
pain  was  quite  severe,  and  was  greatly  exaggerated  upon 
the  least  movement  or  handling,  necessitating  carrying  the 
infant  about  on  a  pillow.  As  these  symptoms  progressed 
he  general  health  of  the  child  became  somewhat  involved, 
there  being  languor,  fretfulness,  pallow,  and  moderate 
loss  of  flesh,  but  the  nutrition  was  not  greatly  disturbed 
and  the  appetite  remained  good.  Three  weeks  later  the 
;ums  showed  aline  of  ulceration  along  the  incisors  and  were 
ipongy  and  inclined  to  bleed.  The  initial  symptoms  quite 
naturally  suggested  rheumatism,  and  anti-rheumatic  treat- 
ment was  instituted,  but  no  benefit  resulting  from  these 
measures,  and  the  local  condition  of  swelling,  thickening, 
^tc,  increasing,  the  physician  decided  that  there  must  be 
I  periosteal  or  bone  lesion  of  some  character.  My  examina- 
tion disclosed  the  condition  as  above  described,  with  the 
addition  of  finding  enlargement  of  the  joints  named,  and 
marked  thickening,  induration  of  a  brawny  type,  and  a 
rather  purplish  color  of  the  tissues  along  the  course  of 
the  tibiae. 

No  indications  of  rickets  were  present,  and  the  nutrition 
of  the  child  was  but  little  impaired.  The  entire  complexus 
)f  symptoms  was  clearly  those  of  scurvy,  and  on  a  diet 
of  raw  cow's  milk,  with  orange  juice  liberally  given,  to- 
gether with  syrup  of  iodide  of  iron,  the  symptoms  yielded 
oromptly,  and  the  child  is  now  rapidly  recovering. 

This  case  does  not  call  for  comment  other  than 
to  note  the  close  resemblance  of  the  early  or  ini- 
tial symptoms  to  acute  articular  rheumatism,  and 
then  in  the  later  stages  the  simulation,  in  its 
local  appearances,  of  osseous  and  periosteal  dis- 
ease. 

Next  to  rheumatism  it  is  very  probable  that  in- 


17^ 


The   Phil 

MEMi  AL  J 


.XDEl.l  iiia"| 
JoriiXAL  J 


COLLEGE  WOMEN 


[AI-EIL  20.  1901 


fantile  scurvy  is  more  frequently  mistaken  for  bone 
lesions.  This  belief  is  at  least  rendered  warrant- 
able by  the  histories  in  the  present  list,  since  in 
three  out  of  four  cases  this  diagnostic  error  was 
committed. 


OTSCEPTIBILITY  TO  DISEASE  AND  PHYSICAL  DE- 
VELOPMENT IN  COLLEGE  WOMEN. 
ARTHUR  MAC  DONALD, 

Washington,  D.  C. 

It  is  unnecessary  to  say  that  the  conclusions 
drawn  from  the  tables  below  are  only  fentativj.  To 
confirm  or  to  limit  such  conclusions,  a  much  larger 
number  of  facts  would  be  necessary. 

The  taoles  are  given  in  averages. ' 

The  measurements  of  weight,  lung  capacity, 
height  and  strength  were  made  wholly  independent 
of  the  medical  exmaination.  The  number  of  stu- 
dents in  all  is  i486.  When  the  numbers  for  any 
age  are  very  small,  their  averages  are  omitted  in  the 
tables. 

CONCLUSIONS. 

Comparing  those  who  report  no  diseases  (table 
i)  wjth  those  having  had  one  or  more  diseases  (table 
II)  we  find  that  those  with  no  diseases  are  less  in 
weight  but  greater  in  height  and  lung  capacity  and 
about  equal  in  strength  to  those  having  had  one  or 
more  diseases.  As  far  as  these  data  go,  they  seem 
to  indicate  that  strength  and  weight  are  not  neces- 
sarily signs  of  health,  or  rather  of  lack  of  sucepti- 
bility  to  disease. 

The  only  difference  between  those  having  any 
disease  (talile  II)  and  those  having  constitutional 
diseases  is  that  the  latter  are  shorter  in  stature  than 
the  former,  but  in  strength,  weight  and  lung  capa- 
city there  is  no  marked  difference. 

1.  The  data  from  which  the  tables  are  made,  were  kindly  furnished  bv 
the  Professor  of  physical  culture  and  the  resident  physician  in  one  of  our 
Tvoman's  colleges. 


Those  having  had  typhoid  fever  Ctable  Illjshow  a 
superiority  in  lung  capacity  and  strength,  but  are 
inferior  in  weight  and  slightly  so  in  height  to  those 
having  diseases  in  general  (table  II).  The  t3-phoi(l 
cases  compared  with  all  cases  of  specific  infectiou- 
diseases  are  inferior  in  weight,  height  and  strength. 
This  confirms  to  a  certain  extent  the  remark  of  Hil- 
debrand,  that  delicate  slender  people  are  much  more 
subject  to  typhoid  fever  than  to  consumption. 

The  cases  of  infectious  diseases  (table  IV)  are 
disinctly  superior  in  weight,  lung  capacity,  height 
and  strength  to  those  having  diseases  in  general 
(table    II). 

On  the  other  hand  those  having  hereditary  dis- 
eases (table  VII)  are  inferior  in  weight  and  slightly 
so  in  height  to  those  having  had  diseases  in  general 
(table  II).  If  we  compare  the  cases  of  hereditar\ 
diseases  directly  with  those  of  infectious  disease- 
(IV),  the  contrast  is  still  more  marked,  showing 
the  hereditarj-  cases  to  be  inferior  in  weight,  lung 
capacity,  height  and  strength  to  the  cases  of  in- 
fectious   diseases. 

Comparing  cases  of  scarlet  fever  (table  XIII) 
^vith  those  of  infectious  diseases  (table  I\')  in  gen- 
eral, the  only  noticeable  difference  is  that  the  for- 
mer are  inferior  in  height  to  the  latter. 

Diseases  of  the  digestive  system  (table  \T)  show 
cases  of  less  weight  and  lung  capacity  but  of  greater 
height  than  diseases  in  general  (table  II). 

Those  with  insufficient  respiration  (table  XI) 
have  less  weight,  but  (contrary  to  expectation  > 
greater  lung  capacity  and  height  than  those  witli 
disease  in  general   (table  II). 

Cases  of  heart  murmurs  (table  XII)  show  greater 
weight,  lung  capacity,  height  and  strength  to  cases 
of  disease  in  general  (table  II). 

Those  with  habitual  headache  (table  IX)  are  in- 
ferior in  weight,  height,  lung  capacity  and  strength 
to  those  with  diseases  in  general  (table  II). 


TABLES  OF  SUSCEPTIBILITY  TO  DISEASE  AND  PHYSICAL  DEYELOPMENT  OF  COLLEGE  NYOME.N. 


ALL 


TABLE  1. 

Those  Reporting  No  Diseases. 


TABLE  II. 
All  Having  had  One  or  More  Diseases. 


Nearest    ^  j    Lung       S    STRENGTH  OF  ; 
^°l     Age.       I    capacity     g    Ar^s  „^„^  „^„j 

I 


1 

9 
126 
462 
46S 
280 
90 
32 

ao 

12 
S 


Nearest,  ■^  j    Lung 
Capacity 


Age. 


15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
28 
28 


STRENGTH  OF 

1    R.     I    L. 
Arms 'Hand  Hand 


175 
171 
156 
161 
160 
162 
159 
165 
151 
167 
165 
127 
160 


23 
27 
27 
27 
27 
27 
27 
27 
26 
29 
22 
SI 
li> 


22 
21 
20 
20 
21 
■Jl 
20 
21 
21 
23 
20 
25 


'  Nearest     -g.  I    Lung     I  ■£    STRENGTH  OF 
No.  I  ■»  I  *     !  -jf  I  ,    _  , 

Age.  I  g  ,  Capact>-;  g  jArms  h^^^  Haid 


17 
18 
119 
20 
21 

23 


:i63 
166 

■168 
161 
165 


lie;   167 


162  zr 

162  27 

161  27 

164 1  28 

161 1  21 


159 


26 


21 

23 

21 
26 


20 
21 
20 
22 

19 


17 
18 
19 

aoj 

21 


188 
162 
161 
162 
157 
1.% 


161 

27 

2S 

30 

161 

27 

2S 

30 

160 

27 

33 

30 

161 

27 

2S 

30 

leo 

27 

22 

30 

160 

36 

24 

•>> 

CAPRIL  20,  litOl 


PROSTATIC  HYPERTROPHY 


CJ  UK     l-lULADlil^UIA  nyn 

Ml^KKAJ,   JoUUNAL  //7 


TABLE   III. 
Typhoid   Fever. 


(TABLE  CONTINUED.) 

TABLE  IV. 
Specific     Infectious    Diseases.' 


TABLE  V. 
Constitutional  Dis:ases. 


J7 

18 
19 

117 

169 

IGO 

28 

23 

20 

28 
.59 

17 

18 

119 
118 

163 
167 

1.59 
163 

27 
28 

23 
22 

20 
20 

31 

18 

119 

161 

151 

26 

24 

21 

26 

20 

117 

IM 

102 

26 

Zi 

20 

106 

19 

123 

176 

161 

28 

25 

21 

22 

19 

120 

181 

1B3 

2.5 

24 

20 

11 

117 

171 

lliO 

27 

22 

21 

49 
28 

20 
21 

120 
IH 

1G9 
169 

162 
161 

30 
29 

23 
24 

21 
21 

32 

20 

118 

160 

101 

25 

23 

20 

TABLE  Vi. 
Diseases  of  Digestive  System. 


TABLE  VII. 
Herediatary  Diseases. 


TABLE  Vill. 
Diseases  of  Nervous  System. 


1 

16 

1.58 

220 

187 

33 

28 

18 

18 

17 

117 

165 

162 

27 

23 

20 

22 

17 

118 

157 

160 

28 

22 

20 

S» 

18 

120 

IM 

102 

27 

21 

21 

.56 

18 

116 

168 

161 

25 

23 

20 

18 

18 

120 

162 

164 

28 

25 

21 

77 

19 

14.5 

151 

160 

25 

2;j 

20 

60 

19 

119 

163 

161 

26 

23 

21 

59 

19 

115 

160 

160 

28 

24 

23 

42 

20 

116 

1.5-5 

161 

26 

2:? 

20 

40 

20 

112 

163 

1.59 

2.5 

22 

20 

12 

20 

113 

162 

182 

25 

22 

20 

17 

21 

112 

167 

161 

26 

23 

20 

TABLE  IX. 
Habitual  Headache. 


TABLE  X. 
Diseases  of  Respiratory  System. 


TABLE  XL 
Insufficient  Respiration. 


IS 

17 

121 

164 

162 

26 

22 

20 

36 

17 

118 

170 

1(3 

27 

22 

21 

29 

18 

115 

162 

160 

28 

23 

21 

.57 

18 

120 

1.58 

161 

26 

24 

21 

95 

18 

116 

164 

182 

27 

23 

20 

46 

19 

113 

155 

100 

24 

22 

20 

.S4 

19 

114 

1.59 

160 

27 

23 

20 

119 

19 

116 

162 

181 

27 

22 

20 

17 

20 

113 

171 

160 

26 

20 

19 

48 

20 

119 

1R3 

161 

27 

23 

22 

.52 

20 

116 

164 

160 

27 

23 

20 

11 

21 

111 

117 

158 

24 

23 

22 

12 

21 

111 

1.54 

160 

26 

22 

19 

32 

21 

112 

162 

100 

27 

23 

21 

TABLE  XII. 
Having   Heart  Murmurs. 


TABLE  XIII. 
Scarlet   Fever. 


17 

125 

180 

164 

24 

23 

20 

11 

17 

122 

166 

I;5S 

30 

23 

20 

18 

117 

107 

162 

28 

23 

21 

19 

18 

US 

166 

164 

27 

22 

20 

19 

117 

168 

182 

28 

24 

20 

22 

19 

120 

170 

161 

26 

24 

21 

20 

122 

170 

168 

27 

24 

22 

10 

20 

120 

161 

182 

30 

26 

2.'! 

21 

112 

175 

162 

26 

23 

21 

The  weight  is  in  pounds ;  the  lung  capacity  in 
cubic  inches  ;  the  height  iu  centimeters  and  the 
strenght  in  kilograms. 


OPERATIVE  TREATMENT  FOR  PROSTATIC  HYPER- 
TROPHY. 

By  RAMON  GUITERAS,  M.  D. 

of  New  York. 

In  looking  over  the  history  of  the  last  century  we  find 
constant  references  to  prostatic  hypertrophy,  increasing 
in  number  and  value  as  the  years  roll  by  until  the  days  of 
Thomson,  Mercier  and  Socin,  when  some  definite  idea 
began  to  dawn  upon  surgeons  interested  in  prostatic  work, 
and  many  ingeniuos  devices  were  introduced. 

First  among  these  were  the  various  palliative  methods; 
then  those  of  drainage;  the  methods  causing  absorption  of 
the  gland  or  reducing  the  obstruction  by  dilatation; 
methods  of  diminishing  the  size  of  the  gland  by  the  use  of 
the  galvanic  current,  by  injections  of  various  fluids  into 
the  gland,  by  ligating  the  vessels  supplying  it,  by  castra- 
tion or  by  ligating  the  vas  deferens;  operations  tending  to 
destroy  the  obstructing  parts;  and  later  methods  of  remov- 
ing the  entire  obstructing  body. 

The  palliative  methods  I  will  not  mention,  as  they  are 
fore  fitting  for  a  paper  on  general  treatment  of  prostatic 
disease,  I  will  speak  briefly  of  operations  for  drainage  in 
this  condition.  It  is  resorted  to  in  two  ways,  1st.  by  the 
perineal  method  in  which  a  perineal  urethrotomy  is  per- 
formed, and  a  tube  inserted  into  the  bladder.  This  is 
also  more  of  a  palliative  method  to  relieve  the 
pain,     tenesmus     and     frequency     accompanying     cystitis 

♦Read  before  the  Third  Pan-American  Medical  Congress,  Havana,  Cuba 
February  6.  1901.  ' 


and  posterior  urethritis,  and  is  spoken  of  in  an  operative 
way  on  account  of  the  urethrotomy  necessary.  2nd.  Drainage 
suprapubically  by  means  of  a  cystotomy  is  resorted  to  in 
a  similar  way  for  the  relief  of  symptoms,  especially  if  there 
is  troublesome  retention,  also  when  the  obstruction  is  com- 
plete and  catheter  life  is  attended  by  distress  and  compli- 
cations, in  which  latter  case  a  permanent  drainage  may  be 
established  and  a  tube  worn  for  the  purpose  of  emptying 
the  bladder.  It  is  interesting  in  some  of  these  cases  which 
have  been  regarded  as  hopeless,  to  notice  how  much  the 
prostatic  oedema  will  subside  after  the  operation  so  that 
after  a  certain  period  spontaneous  urination  or  easier 
catheterization  may  follow. 

Dilatation  with  steel  sounds,  or  dilators,  every  four  days 
has  been  recommended  by  many  practitioners.  It  may 
be  of  some  value  at  the  start  associated  with  hot  rectals 
and  massage.  Bellfleld  says  that  he  has  been  convinced  by 
experience  of  the  value  of  this  neglected  measure  to  facili- 
tate the  exit  of  urine.  Personally  while  I  have  never  been 
much  impressed  with  this  method,  and  I  do  not  now  con- 
sider it  in  the  light  of  radical  treatment,  I  have  never- 
theless recently  tried  it  in  a  small  number  of  cases  in  which 
there  was  considerable  bladder  irritation,  accompanied  by 
a  little  residual  urine  (where  the  prostates  were  beginning 
to  enlarge)  complete  relief  to  the  symptoms  from 
which  they  were  suffering.  I  doubt,  however,  in  those 
particular  cases  if  the  prostate  was  largo  enough  to  have 
caused  sufficient  obstruction  to  warrant  any  of  the  so- 
called  radical  methods  now  in  vogue.  My  method  of  treat- 
ing them  was  first  hot  rectal-saline  irrigations  by  the 
recto-genital  tube  every  night,  accompanied  by  massage 
of  the  Brostate  twice  a  week,  and  later  by  stretching  with 


_Q-,   The  Philadelphia"! 
7°'^    Medical  Jouhnal  J 


PROSTATIC  HYPERTROPHY 


[Apbo.  20,  1901 


a  Kohlmann  dilator  after  each  massage,  the  dila- 
tion being  followed  by  urethral  irrigations  of  a  silver 
solution. 

Galvanopuncture  has  been  recommended  by  Biedert  and 
others,  but  Is  now  never  used.  A  platinum  needle  attached 
to  the  negative  pole  of  a  galvanic  battery,  and  insulated  up 
to  witnin  1%  centimeters  from  its  point  is  carried  into 
the  rectum,  inserted  to  a  depth  of  IVz  centimeters  into  the 
prostate  and  the  current  allowed  to  act  for  2  to  5  minutes 
at  a  strength  of  10  millamperes,  gradually  increased  to  2'} 
milliaraperes.  The  needle  is  then  partly  withdrawn  and  in- 
serted through  the  same  puncture  in  another  part  of  the 
gland,  and  the  current  is  again  allowed  to  work  from  2  to 
B  minutes.  The  sittings  are  repeated  at  proper  intervals 
from  10  to  20  times.  These  proved  to  be  of  very  little 
value  because  they  are  exceedingly  painful  to  the  patient, 
and  there  is  danger  of  cauterizing  the  gland  quite  severely. 

The  same  may  be  said  of  parenchymatous  injections 
which  have  also  been  tried  by  Heine.  He  used  a  hypo- 
dermic syringe  containing  a  solution  of  Iodide  of  posas- 
Bium  two  parts,  tincture  of  iodine  30,  to  60  of  water,  in- 
jecting it  into  the  gland  every  8  to  14  days.  Ergot  and 
absolute  alcohol  have  been  used.  He  states  that  there 
■were  favorable  results  in  these  cases,  but  they  are  not 
■without  danger  as  abscesses  may  follow. 

Ligation  of  the  internal  iliacs  was  recommended  by 
Bier  as  an  operation  which  would  cause  atrophy  of  the 
gland.  It  has  been  performed  by  numerous  surgeons,  bat 
the  benefit  derived  is  never  sufficient  to  counterbalance  the 
danger  of  such  an  extensive  operation. 

Castration,  an  operation  devised  by  one  of  our  most 
eminent  surgeons  with  the  object  of  causing  atrophy  of 
the  prostate  has  now  been  discarded,  as  it  was  found  that 
the  results  were  in  many  cases  not  permanent,  while  the 
mortality  was  from  16  to  18  per  cent.,  and  in  the  cases  sur- 
viving some  became  maniacal,  some  melancholic,  while 
many  others  were  neurasthenic  or  otherwise  lost  their 
mental  equilibrium. 

Vasectomy  was  then  advocated.  It  being  held  that  if 
the  ducts  were  resected  it  would  have  the  same  effect  in 
causing  the  diminution  in  size  of  the  gland  that  the  remov- 
ing of  the  testes  would.  It  was  also  argued  in  its  favor 
that  it  was  not  dangerous.  This  was  not  the  case,  how- 
ever, as  numbers  of  deaths  have  been  reported  as  resulting 
from  it.  It  has  also  been  discarded  in  this  country  as  of 
little  value,  although  it  is  still  used  by  many  English 
Burgeons. 

We  now  come  down  to  the  consideration  of  the  two  great 
operative  procedures  on  prostatotomy  and  prostatectomy, 
having  thrown  out  all  other  methods. 

During  the  last  quarter  of  the  preceding  century,  pros- 
tatotomy was  an  operation  in  which  considerable  Interest 
was  taken  and  many  procedures  were  advocated  by  men 
who  at  the  time  were  the  leaders  of  the  profession.  Rob- 
ertson performed  prostatotomy  within  the  rectum,  the  left 
forefinger  being  introduced  as  a  guide,  the  knife  was  in- 
serted along  it  and  the  prostate  divided  into  two  halves. 

Harrison  at  the  International  Congress  at  Copenhagen, 
In  1887,  advocated  perineal  urethrotomy,  then  dividing 
the  prostatic  bar  on  the  floor  of  the  gland,  and  stretch- 
ing the  prostatic  urethra  forcibly  with  his  fingers  or  a 
sound.  He  was  personally  very  much  pleased  with  this 
method,  and  the  literature  of  the  time  caused  many  to 
advocate  it. 

Mercler  then  devised  a  prostatome,  for  cutting  through 
the  median  lobe,  resembling  the  Bottini  Incisor  with  a 
sharp  male  blade  which  he  forcible  drew  through  the  im- 
pediment In  the  floor  of  the  prostatic  urethra  cutting  a  fur- 
row in  it. 

Gouley  adopted  Mercier's  procedure  through  a  perineal 
Incision.  The  instrument  resembled  somewhat  that  of 
Mercier's  and  was  used  to  cut,  or  punch  out,  segments  of 
the  overgrowth.  In  this  manner  extensive  portions  of  the 
gland  were  at  times  removed. 

Norton  modified  Gouley's  instrument  working  on  the  same 
lines. 

Maissoneuve  then  advocated  the  Secateur.  This  was  one  of 
the  most  ingenious  devices  ever  employed  in  genitourinary 
work,  although  not  as  practical  as  his  other  instrument, 
the  urethrotome.  The  shaft  of  this  instrument  had  a 
curved  beak  at  the  end  like  a  sound.  The  cutting  blade 
■was  fastened  in  the  centre  of  the  convexity  on  a  pivot  and 


lay  concealed  in  the  curve  as  far  as  the  end  of  the  in- 
strument. After  the  beak  had  been  caught  behind  the  vesi- 
cal base  of  the  prostate,  the  blade  was  made  to  move  in  an 
arc  of  a  circle,  thus  cutting  through  the  gland  in  the  floor 
of  the  prostatic  urethra,  and  landing  in  the  slot  of  the 
straight  part  of  the  shaft  where  it  was  again  concealed, 
or  else  was  again  pushed  forward  to  its  former  position 
when  the  instrument  was  withdrawn. 

Some  time  in  1877  Bottini  invented  the  galvano-caustic 
incisor,  which  was  very  similar  to  Mercier's  instrument, 
differing  from  it  principally  in  that  the  Bottini  instru- 
ment cauterized  whereas  Mercier's  simply  cut.  At  that 
time  the  incisor  was  looked  upon  with  disfavor,  and  it 
has  been  so  considered  until  recently  when  it  was  modified 
by  Freudenberg,  of  Berlin.  This  Instrument,  did,  however, 
possess  certain  features  of  advantage  which  can  now  be 
clearly  seen.  In  the  first  place  the  cauterizing  knife  is 
broader  than  a  blade  which  traverses  the  gland 
tissue.  In  the  second  place  it  is  not  accompanied  by  as 
much  hemorrhage.  Again  it  burns  the  tissues  for  some 
distance  on  the  sides,  which  when  thrown  oft  as  a  slough 
produces  a  gutter  of  some  considerable  width.  Besides 
the  cauterization  has  seared  the  vessels  of  the  prostate, 
and  thus  has  shut  off  the  blood  supply  of  the  gland  In  a 
measure  thereby  causing  it  to  atrophy. 

The  Bottini  operation  is  then  the  sole  surviving  method 
of  prostatotomy,  which  is  used  at  the  present  day,  and  la 
one  which  we  must  consider  among  the  so-called  radical 
treatments  of  the  hypertrophied  gland,  the  other  being 
prostatectomy.  Prostatotomy  is  accordingly  employed 
with  a  few  modifications  in  the  same  manner  by  all  sui^ 
geons  who  use  it,  and  that  is  by  the  Bottini  incisor. 

Prostatectomy,  on  the  other  hand,  varies  in  the  numerons 
methods  for  extirpating  the  gland,  and  also  in  the  detail  of 
the  technique.  We  ■will  consider  the  various  methods  of 
prostatectomy  later,  and  we  will  now  speak  briefly  of  the 
relative  merits  of  the  Bottini  operation  as  compared  with 
prostatectomy  In  general. 

The  advocates  of  each  of  these  methods  argue  strongly 
in  Its  favor.  Followers  of  one  procedure  are  wont  to  con- 
demn the  other  operation.  Supporters  of  prostatectomy 
contend  that  the  Bottini  operation  is  a  blind  one,  and  that 
the  surgeon  cannot  see  what  he  is  doing,  while  the  advo- 
tremely  dangerous  both  at  the  time  and  afterwards.  Both 
cates  of  the  Bottini  operation  say  that  enucleation  is  ex- 
are  right;  the  Bottini  operation  is  a  blind  one,  but  so  is 
prostatectomy,  and  in  both  cases  ■we  have  to  be  governed 
by  the  sense  of  touch.  In  the  Bottini  operation  we  can 
fairly  ■well  determine  the  size  of  the  gland  by  rectal  and 
urethral  examination,  we  then  Insert  the  instrument  into 
the  bladder,  turn  Its  beak  downward  and  pull  It  toward 
us  while  the  forefinger  of  the  other  hand  is  in  the  rectum. 
We  can  then  feel  just  where  the  beak  is.  Many  say  that  it 
sometimes  catches  in  a  diverticulum  In  the  bladder,  and 
that  the  end  is  not  felt  at  the  base  of  the  gland  by  the 
finger  in  the  rectum.  We  do  notice  at  times  that  the  end 
of  the  instrument  is  further  back  than  the  top  of  our  finger 
which  is  pressing  upon  the  border  of  the  base  of  the  gland 
through  the  rectum.  This  I  would  rather  account  for 
however,  by  the  fact  that  the  median  lobe,  or  the  intraves- 
ical tumor  as  it  is  better  called,  extends  back  into  the 
bladder  farther  than  the  base  of  the  gland  does  into  the  rec- 
tum: and  I  am  convinced  that  I  am  correct  In  this  surmise, 
for  the  suprapubic  vesical  prostatectomies  which  I 
have  done,  I  have  noticed  a  difference  in  the  rectal  and 
vesical  bases  of  the  prostate  by  bimanual  palpation,  the 
fingers  of  one  hand  being  in  the  bladder  and  those  of  the 
other  in  the  rectum. 

With  the  Instrument  in  place,  and  noting  ■where  it  is 
by  sense  of  touch  of  the  rectal  finger,  and  noting  the  dis- 
tance which  we  are  cutting,  or  cauterizing  by  the  dial  on 
the  handle  of  the  instrument,  we  can  make  an  almost  cer- 
tain and  definite  cut  for  the  number  of  centimeters  re- 
quired. Let  us  now  look  at  prostatectomy  for  an  in- 
stant. 

It  Is  a  bloody  and  dangerous  operation,  much  more  so 
than  the  Bottini.  and  in  my  opinion  It  is  as  blind,  if  not 
blinder,  for  besides  having  to  do  with  hemorrhage  in  the 
small  hole  that  we  are  working  in.  the  size  of  the  hand 
hides  the  enucleating  finger,  and  we  can  only  work  by  the 
sense  of  touch  and  feeling.  The  prostatic  gland  which  is 
so   hard   and    indurated   on   examining   It    by   the   rectum 


April  20,  1901] 


PROSTATIC  HYPERTROPHY 


Ti.T     THILADELPHIA  "Qt 

Medical  JoLK.NAL         Z*^' 


when  the  patient  is  not  under  an  anesthetic,  often  presents 
an  entirely  different  feel  when  muscular  relaxation  has 
taken  place  under  an  anesthetic,  it  then  being  softer  and 
much  more  pliahle.  The  finger  especially  in  the  perineal 
operation  cannot  be  thrust  between  the  capsule  of  the 
prostate  and  the  gland  without  considerable  digging  and 
prostrate  and  the  glandwithout  considerable  digiug  and 
forcibly  prodding  between  the  capsule  and  the  gland.  The 
enucleating  process  is  not  an  accurate  one,  for  no 
two  prostates  have  lobes  built  on  the  same  plan,  nor  are 
the  curves  and  sizes  of  these  lobes  defined  in  the  same 
way  in  all  cases.  Therefore  we  are  pushing  with  the  fore- 
finger, overcoming  obstructions,  while  working  with  its  end 
when  we  can  with  difficulty  bend  the  joint,  pulling  and  push- 
ing at  times. while  pressing  form  above  and  not  feeling,  I  may 
say  positively,  the  same  certainty  of  what  we  are  doing  as 
when  we  are  slowly  drawing  the  Bottini  blade  through 
the  hypertrophied  gland.  Taking  it  for  granted  that  these 
are  both  blind  operations  we  can  say  that  successfully 
performed,  the  Bottini.  while  not  so  dangerous,  does  not 
produce  such  good  results,  and  that  the  enucleation,  while 
more  dangerous,  produces  better  results,  if  the  patient 
survives,  but  we  must  never  endanger  our  patient's  life  for 
the  sake  of  choosing  an  operation  considered  more  scien- 
tific. Let  us  consider  what  the  indications  are  that  will 
decide  us  upon  which  operation  should  be  performed.  They 
are  as  follows:  — 

The  age  of  the  patient. 
The  size  and  shape  of  his  prostate. 
The  condition  of  his  kidneys  and  bladder. 
It  may  be  said  in  a  general  way  that  very  old  men  with 
not  very  large  prostates,  but  causing  considerable  urethral 
impediment  are  cases  for  Huttiiii  operation. 

Younger  men  with  large  prostrates  as  felt  through  the 
rectum,  with  good  kidneys  and  bladder,  for  EinicJcatiim. 

Age  Is  Important,  as  the  older  the  patient  the  lower  his 
resisting  power,  and  the  more  liable  he  is  to  death  from 
shock  and  asthenia,  therefore,  in  a  very  old  man,  if  the 
prostate  if  of  the  right  variety  a  Bottini  operation  should 
be  performed,  and  cases  of  men  over  ninety  years  of  age 
have  been  reported  as  having  been  operated  upon  by  this 
method  successfully.  Old  age.  however,  is  not  a  contra- 
indication to  prostatectomy,  as  men  over  seventy  years  old 
often  have  good  kidneys,  non-infected  urine  and  a  prostate 
which  clearly  indicates  enucleation. 

What,  then,  Is  the  variety  of  prostate  depending  upon  its 
size  and  shape  which  indicates  one  operation  or  the 
other?  We  may  say  that  the  very  large  prostates,  such 
as-  have  the  feel  of  an  apple  or  orange  on  rectal  examina 
tions.  are  favorable  for  enucleation,  while  the  smaller  ones, 
that  is  to  say,  those  in  which  there  is  not  much  enlargement 
on  rectal  touch,  but  in  which  there  is  a  distinct  impedi 
ment  in  the  prostatic  urethra  on  introducing  instruments 
together  with  a  considerable  quantity  of  residual  urine,  are 
the  best  for  the   Bottini. 

One  might  ask  if  we  can  tell  exactly  how  large  a  prostate 
is,  as  it  often  may  not  seem  to  be  particularly  large  by  the 
rectum,  whereas  the  middle  lobe  projects  to  a  marked 
degree  into  the  bladder.  In  answer  to  such  a  question  I 
would  say  that  one  can  never  say  exactly  what  the  size  of 
the  prostate  is,  or  what  its  shape  or  its  relation  to  the 
prostatic  urethra  and  neck  of  the  bladder  any  more  than 
one  can  tell  the  difference  of  the  two  sides  of  the  interior 
of  the  nose  by  feeling  of  the  bridge  and  carefully  passing 
the  fingers  over  the  cartilage  externally;  but  the  experi- 
enced rectal  touch  tells  us  a  great  deal,  and  when  added  to 
this  we  have  a  feeling  of  Impediment  in  the  posterior  ure- 
thra as  imparted  to  the  sound,  and  are  able  to  judge  of 
the  increased  length  of  the  canal  by  hooking  the  beak 
behind  the  middle  lobe,  and  also  noting  the  amount  of  res- 
idual urine  present,  we  can  form  a  fair  idea  of  the  prostate 
that  we  are  dealing  with.  Besides  this  the  cystoscope 
teaches  us  something  of  the  contour  of  the  base  of  the  gland, 
though  it  does  not,  perhaps,  show  us  as  much  of  it  as  the 
mirror  does  of  the  nose  when  placed  behind  the  soft  palate. 
(The  more  I  see  of  prostatic  tumors,  with  projections,  devi 
ations.  impediments,  curves,  etc..  the  more  I  think  of  nasal 
obstructions  in  cases  in  which  we  see  a  nose  with  a  most 
perfect  contour  on  the  outside,  and  yet  hypertrophies,  atro- 
phies, deviations  of  the  septum,  stenosis  from  obstructions, 
polyps  and  every  conceivable  condition  of  the  interior). 

Rectal  examination  is  most  important  In  telling  us  what 
to  do.  for  if  the  gland  seems  to  be  too  large  per  rectum 
there  is  a  considerable  amount  of  residual  urine  and  an  Im' 


pediment  to  instrumentation  at  7  inches  or  more  in  the 
urethra,  and  the  urethra  is  lengthened,  we  can  say  that  the 
hypertrophy  of  the  lateral  lobes  certainly  is  considerable, 
liut  if  the  gland  is  small  by  rectum  and  the  same  conditions 
exist,  we  think  that  the  impediment  is  principally  median. 
Few  practitioners  have  sufficient  experience  to  outline  the 
prostate  correctly.  This  is  brought  out  in  teaching  and 
consulting,  and  I  can  say  truthfully  that  of  the  prostatic 
cases  brought  before  me  for  a  radical  operation,  not  one- 
half  of  them  are  of  the  nature  in  which  it  is  indicated. 
Whenever  the  prostate  is  much  enlarged,  and  has  the 
characteristic  fibromyomatous  feel  enucleation  should  be 
performed,  if  the  patient  is  not  too  old  and  the  kidneys  are 
in  good   condition. 

Regarding  the  condition  of  the  bladder  and  kidneys,  it 
may  be  said  that  the  bladder  is  least  important,  because  it 
makes  no  difference  how  badly  inflamed  it  may  be.  treat- 
ment will  do  much  to  benefit  it  by  means  of  internal  urinary 
antiseptics,  and  locally  by  irrigations  through  a  cath- 
eter. An  involved  bladder  does  not  count  so  much  against 
an  operation  as  kidney  involvement  does. 

We  have  read  in  Guyon's  works,  and  those  of  everyone 
who  has  studied  Guyon.  that  one  of  the  principal  troubles 
in  prostatics  is  an  arterio-sclerosis  of  the  vessels  of  the 
wall  of  the  bladder,  and  that  the  stiffness  is  caused  by 
interstitial  changes  in  the  bladder  wall,  and  the  interfer- 
ence with  the  blood  supply,  and  that  this  prevents  the 
bladder  from  emptying  itself  more  than  the  impediment 
does.  This  may  be  true  in  a  measure,  but  we  now  do  not 
attach  so  much  importance  to  the  bladder,  as  we  find  that 
it  can  often  empty  itself  almost  entirely  after  prostatic 
operations,  even  if  it  has  been  considered  hopeless  before 
then,  and  sometimes  even  when  years  of  catheter  life  have 
been  passed. 

Bad  kidneys,  whether  medically  or  surgically  diseased, 
are  always  contraindications  to  surgical  interference  on  the 
prostate,  as  in  such  cases  any  operation  in  the  urinary  tract 
is  liable  to  be  followed  by  a  renal  congestion,  uremia  and 
death.  If.  therefore,  the  kidneys  are  damaged  in  either  a 
medical  or  surgical  way,  and  an  operation  is  demanded,  a 
Bottini  should  be  the  one  of  choice.  It  must  not  be  thought, 
however,  that  this  operation  is  wholly  without  danger,  as 
there  often  sets  in  after  the  operation  a  reaction  which  is 
most  alarming. 

The  indications,  then,  for  the  two  operations  may  be 
summed  up  briefly  as  follows:  For  a  prostatectomy,  a  pros- 
tate of  large  size  as  felt  per  rectum,  the  larger  the  better 
in  a  patient  with  healthy  kidneys  and  urine. 

A  Bottini  prostatotomy  may,  however,  be  performed  in 
almost  any  case  in  which  the  instrument  can  enter  the  blad- 
der, and  may  be  of  benefit  even  in  marked  cases  of  hyper- 
trophy when  an  enuncleation  is  clearly  indicated,  while  in 
many  cases  of  sclerosed  prostates  with  a  middle  lobe  im- 
pediment an  enucleation  could  not  possibly  be  accomp- 
lished. Cases  have  come  to  me  where  I  have  advised  an 
enucleation  to  which  the  patient  refused  to  submit,  and  a 
Bottini  was  performed.  Some  of  these  cases  had  complete 
retention,  others  partial,  but  they  were  all  improved  by  the 
operation. 

I  have  seen  other  cases  in  which  there  were  considerable 
obstruction,  large  amounts  of  residual  urine  and  all  disa- 
greeable symptoms  in  which  an  enucleation  by  the  perineal 
route  would  have  been  absolutely  impossible:  by  the  supra- 
pubic method  only  a  piece  could  with  difl5culty  be  torn 
away,  a  piece  consisting  of  dense  tissue  cerv  different  from 
large  prostatic  hypertrophy.  Bottini  operation  should  have 
been  performed. 

The  Techiiiijiw  of  the  Bottini  0/)«-ff/)0»..-— The  patient  should 
lie  on  his  back  on  the  table.  He  can  be  operated  on  either 
with  local  anesthesia  by  cocaine  or  eucaine.  or  with  gen- 
eral anesthesia,  by  ether,  chloroform,  or  nitrous  oxide. 
Personally  I  prefer  general  anesthesia  by  nitrous  oxide  gas. 
On  the  patient's  left  a  fountain  syringe  should  be  hung, 
which  contains  the  water  for  cooling  the  instrument,  and  on 
a  stool  near  the  patient's  waist  the  battery  should  he 
placed.  A  soft  rubber  catheter  lubricated  with  glycerine 
is  passed  into  the  bladder,  the  urine  is  drawn  off.  and  the 
bl.adder  is  washed  out  and  emptied,  after  which,  before  the 
catheter  is  withdrawn,  if  the  operation  is  performed  under 
a  local  anesthetic,  a  urethral  hand  syringe  of  a  4  per  cent, 
solution  of  eucaine  is  injected  into  the  posterior  urethra 
and  bladder,  and  as  the  catheter  is  being  removed  a  syr- 
ingeful  should  be  thrown  into  the  urethra.  From  this  mo- 
ment  the   work   should    be   done   quickly   and   accurately. 


782 


Thb  Philadelphia! 
Medical  Jocenal  J 


PROSTATIC  HYPERTROPHY 


tAJ-BIL  20,  laoi 


and  I  have  observed  that  the  more  quickly  the  operation 
is  performed  after  the  injection  of  the  anesthetics  into  the 
bladder,  in  cases  of  local  anesthesia,  the  less  painful  it  is 
to  the  patient. 

If  cystoscopy  is  performed,  the  time  required  for  It  will 
usually  be  sufBcient  to  allow  the  effect  of  the  anesthetic  to 
pass  off  before  the  actual  operation  is  begun,  and  for  this 
reason  I  think  it  advisable  either  to  use  the  cystoscope  at 
an  earlier  date,  or  to  again  Inject  a  local  anesthetic  after 
the  cystoscopy.  Again  cystoscopy  is  often  more  painful 
than  the  operation  itself.  It  seems  to  me  for  this  reason 
that  it  is  advisable  to  omit  the  cystoscopy  just  before  the 
operation,  as  advised  by  some,  and  consider  it  as  having 
been  performed  previously  when  the  patient  was  examined. 
Therefore,  after  the  eucain  has  been  introduced  into  a 
clean  and  empty  urethra  and  bladder,  the  catheter  should 
be  quickly  pushed  back  again  and  six  ounces  of  water 
Injected  into  the  viscus,  the  catheter  being  quickly  with- 
drawn and  the  incisor  introduced.  If  it  catches  in  the 
deep  urethra,  the  pelvis  should  be  elevated,  which  will 
allow  it  to  enter  if  the  handle  is  depressed  and  a  slight 
upward  push  is  given  to  the  instrument.  If  it  still  catches 
the  patient  must  be  anesthetized.  In  four  cases  under 
eucaine  anesthesia  I  have  failed  to  pass  the  instrument. 
I  afterwards  operated  in  three  of  these  under  nitrous  oxide 
gas  anesthesia,  and  introduced  the  instrument  without 
difficulty.  The  obstruction  is  generally  a  spasm  of  the  vesi- 
cal sphincter. 

After  the  instrument  is  in  the  bladder,  its  beak  is  turned 
downward,  and  then  drawn  forward  until  It  catches 
against  the  base  of  the  gland.  The  left  forefinger  is  then 
Introduced  into  the  rectum  to  see  if  the  instrument  is  in 
place.  If  it  is,  it  should  be  held  there,  and  the  connection 
made  with  the  battery,  when  a  current  of  4.5  amperes 
should  be  turned,  drawing  the  knife  through  the 
gland  from  this  point  and  burning  a  furrow  in  it.  The 
current  should  then  be  shut  off,  the  instrument  turned  to 
one  side  at  right  angles,  and  the  current  again  opened, 
and  an  incision  should  be  made  through  one  of  the  lateral 
lobes,  and  then  in  a  similar  way  through  the  other. 

After  the  operation  a  catheter  should  be  kept  tied  in  for 
a  few  days,  the  patient  should  be  given  some  urinary  anti- 
eeptic  and  a  milk  diet,  and  should  be  instructed  to  drink 
large  quantities  of  water  daily.  Ten  grains  of  urotropin 
given  three  times  a  day  is  the  best  urinary  antiseptic. 

After  the  Bottini  operation  if  the  posterior  urethra  is 
much  distorted  by  the  prostatic  hypertrophy  it  is  sometimes 
advisable  to  perform  a  perineal  urethrotomy  for  drainage. 
In  a  number  of  cases  after  a  Bottini  operation  there  is 
difficulty  in  introducing  the  catheter.  This  comes  from  a 
straight  cut  having  been  made  from  the  middle  of  the 
vesical  base  of  the  prostate  as  far  as  the  instrument  will 
ellow.  and  we  have  interfered  somewhat  with  the  tortuou."; 
channel  by  this  direct  cut.  In  these  cases  I  should  advo- 
cate an  immediate  perineal  urethrotomy  with  the  introduc 
tion  of  a  perineal  drainage  tube  of  large  size.  34  to  36 
French.  In  a  case  operated  upon  under  local  anasthesia  by 
a  colleague  the  patient  shrank  back  and  allowed  the  beak 
of  the  instrument  to  slip  forward  over  the  convexity  of  the 
gland,  thus  cutting  into  the  membranous  urethra  and  perin 
cum,  a  perinea!  urethrotomy  was  not  performed  at  the 
time,  necessitating  a  further  operation  for  retention,  fol- 
lowed by  death  from  uremia  and  sepsis.  This  case  would 
have  been  saved  in  all  probability  had  a  perineal  operation 
been  performed  at  the  time.  I  have  seen  other  cases 
where  I  am  sure  that  had  I  performed  a  perineal  section, 
my  patients  would  have  had  d.  better  result  than  by 
having  refrained  from  doing  so. 

Prostatertomu  is  certainly  the  operation  to  which  we 
should  look  forward  for  the  radical  treatment  of  prostatic 
hypertrophy  in  the  future.  Attempts  have  been  made  dur- 
ing a  number  of  years  to  remove  pieces  of  the  gland 
through  perineal  incisions  going  into  the  urethra,  and  also 
after  a  superapublc  cystotomy  by  tearing  away  projecting 
Impediments  by  the  fingers  and  sharp  instruments  as  the 
curette,  etc.  Within  a  few  years,  however,  much  advance 
has  been  made  In  this  most  Important  operation,  until  now 
we  have  operations  by  the  suprapubic,  the  perineal,  and  the 
combined  methods,  as  well  as  those  by  extensive  dissection 
as  Zuckerkandl's.  Von  Dlttel's.  Rydgier's  and  others. 

It  may  be  said  that  McGlU  is  the  father  of  advanced 
prostatic  surgery,  in  that  he  made  a  beginning  by 
removing  small  pieces  In  an  unscientific,  way  through 
the    bladder    after    a    suprapubic    cystotomy,    and    grad- 


ually began  to  formulate  the  operation  until  he  suc- 
ceeded in  performing  fairly  satisfactory  enucleations.  His 
method  was  briefly  as  follows:  He  used  the  rectal  bag, 
putting  from  6  to  10  ounces  in  it.  He  then  injected  the 
bladder  with  from  10  to  20  ounces  of  water,  leaving  the 
catheter  in  the  urethra  as  a  guide  until  the  bladder  is 
opened.  He  opened  the  bladder  suprapubically,  attached  it 
to  the  abdominal  wall,  and  cut  away  peduncleated  middle 
lobes  if  present  with  curved  scissors.  The  sessile  ones 
he  cut  in  the  same  manner,  helping  the  process  by  pulling 
the  tissue  with  forceps.  After  removing  these  suprapubic 
obstructions  he  cut  through  the  mucous  membrane,  ovre  the 
projecting  portion,  inserted  his  fingers  and  began  the  pro- 
cess of  enucleation,  and  at  times  aided  himself  with  the 
forceps.  After  the  gland  was  removed  the  bladder  was 
then  drained  for  a  few  days.  In  this  way  he  removed  pieces 
varying  in  size  from  a  bean  to  a  cricket  ball,  showing  in 
these  latter  cases  that  he  had  evidently  performed  a  com- 
plete  enucleation 

Bellfield  next  took  up  the  intravesical  method  of  enuc- 
leating the  gland,  also  accomplishing  good  results,  and 
advocated  the  additional  operation  of  perineal  urethrotomy 
to  facilitate  drainage.  Fuller  has  since  then  done  a  large 
number  of  prostatectomies,  following  In  the  line  of  McGUl 
and  Bellfield.  The  steps  of  his  operation  are  as  follows: 
After  suprapubic  cystotomy  he  cuts  down  (with  scissors) 
through  the  tissues  of  the  posterior  wall  of  the  neck  of  the 
bladder  covering  the  gland,  inserts  the  end  of  the  fin- 
ger into  this  incision,  and  digs  out,  or  enucleates  the 
gland  with  the  finger,  while  pressure  is  made  upward 
against  the  perineum  by  an  assistant.  In  this  way  the  bulk 
of  the  prostate  can  often  be  shelled  out  in  three  large 
pieces,  while  at  other  times  it  must  be  removed  piecemeaL 
Enucleation  cannot  always  be  performed  by  this  means, 
and  frequently  the  operator  has  to  be  content  with  the 
removal  of  a  piece  forming  the  principal  part  of  the  bar- 
rier. A  boutonniere  operation  is  then  performed  and 
suprapubic  and  perineal  drainage  Is  established. 

Personally  I  have  been  In  the  habit  of  performing  pros- 
tatectomy by  what  I  call  the  recto-vesical  method,  although 
no  part  of  the  operation  proper  is  performed  in  the  rectum, 
the  fingers  simply  being  inserted  into  It  to  exert  direct 
counter-pressure  and  guide  the  operating  finger,  which  is 
working  through  the  bladder.  The  steps  of  the  operation 
are  briefly  as  follows:  Suprapubic  cystotomy  is  per- 
formed, after  which  retention  sutures  are  passed  through 
the  bladder  wall  on  each  side  of  the  incision.  Careful  rec- 
tovesical palpation  is  then  made,  two  fingers  of  the  left 
hand  being  In  the  rectum,  while  the  right  forefinger  is  in 
the  bladder,  and  a  visual  examination  Is  made  by  means 
of  an  electric  light  Inserted  into  the  bladder.  A  pair  of 
scissors  is  Inserted  Into  the  bladder,  the  point  of  the 
closed  blades  being  pressed  against  Its  floor  over  the  pros- 
tate In  the  median  line,  until  the  blades  are  felt  depressing 
the  prostate  against  the  two  fingers  of  the  left  hand  in  the 
rectum,  which  are  in  turn  pressing  upon  the  gland  In  the 
median  line  from  below,  showing  exactly  whether  the  scis- 
sors are  in  the  right  position  or  not  The  blades  of  the 
scissors  are  opened,  tearing  through  the  bladder  tissue, 
covering  the  gland  In  a  line  corresponding  to  the  space 
between  the  two  fingers  in  the  rectum.  The  forefinger  of 
the  right  hand  Is  then  inserted  into  this  tear  through  the 
bladder,  and  gradually  works  its  way  between  the  capsule 
and  the  gland.  The  two  fingers  in  the  rectum  feel  the  one 
In  the  bladder  working  its  way  between  the  capsule  and  the 
gland,  and  they  start  counterpressure  while  the  enucleation 
is  being  performed.  The  finger  tip  under  the  capsule  first 
sweens  to  one  side  and  pulls  out  one  lateral  lobe,  then  to 
the  other  side,  and  enucleates  the  other,  and  finally  remores 
the  middle  lobe,  or  It  first  works  its  way  backward  under 
the  base  of  the  middle  lobe,  which  Is  enucleated  with  a  dis- 
secting rotary  movement,  and  then  proceeds  to  enucleate 
the  two  lateral  lobes.  The  gland  having  been  remove-i 
there  Is  always  free  hemorrhage,  and  very  hot  water  shoul : 
be  injected  for  two  or  three  minuts  into  th  bladder  sup 
rapubically.  I  then  pas  a  grooved  sound,  preferably  a 
lithotomy  guide,  through  the  urethra  Into  the  bladder.  an4 
having  brought  the  patient  Into  the  lithotomy  position  1 
rapidly  cut  through  the  membranous  urethra  and  push  a 
large  perineal  drainage  tube  Into  the  bladder,  which  I 
fasten  to  one  side  of  the  perineal  incision.  The  finishing 
steps  of  the  operation  are  to  put  two  catheters  Into  the 
bladder  sup^.publcally.  with  a  gauze  drain  packed  down 
beside  them  Into  tlie  cavity  made  by  the  removal  of  the 


April  20,  1901] 


PROSTATIC  HYPERTROPHY 


TTH 
L  Mi 


e   i'hiladelphia 
Medical  Journal 


783 


prostate,  fasten  them  into  the  skin  of  the  bladder  wall,  and 
then  sew  the  bladder  wall  up  to  the  drain.  I  then  close 
the  abdominal  wall,  including  fascia,  muscle  and  skin  as  far 
as  the  drain.  The  floor  of  the  prostatic  urethra  should  be 
cut  through  from  above  downward  before  the  perineal  tube 
is  left  permanently  in  place  to  prevent  the  formation  of  a 
pocket,  which  would  retard  the  cure. 

The  suprapubic  incision  enables  the  surgeon  to  see  and 
feel  the  tumor  distinctly  from  the  bladder,  as  well  as  by  the 
rectum.  If  a  large  middle  lobe  is  found,  called  by  some 
intra-vesical  tumor,  enucleation  should  be  performed 
by  the  suprapubic  method,  but  if  we  find  that  the  enlarge- 
ment is  principally  in  the  lateral  lobes,  it  is  better,  per- 
haps, to  remove  it  by  the  perineal  route. 

In  NicoU's  method  the  suprapubic  incision  is  the  same, 
and  the  bladder  is  then  attached  to  the  skin  by  four  stitch- 
es. The  patient  is  brought  into  the  lithotomy  position,  a 
sound  is  passed  into  the  bladder,  and  a  vertical  incision  Is 
made  down  to  the  prostate.  The  assistant  then  puts  his  fin- 
ger into  the  bladder,  and  presses  the  prostate  up  into  the  per- 
neal  wound.  A  second  incision  is  then  made  at  the  lower  ex- 
treauty  of  the  first  at  right  angles  to  it.  forming  a  T,  and 
extending  up  between  the  rectum  and  the  prostate.  Two 
fingers  of  the  left  hand  are  then  passed  into  the  bladder 


begins.  The  entire  prostate  is  shelled  out  from  within  Its 
sheath  by  a  digital  dissection.  The  mucou  membrane  of  the 
bladder  and  prostatic  urethra  is  stripped  up  from  the  parts 
to  be  removed,  but  is  not  opened.  The  lateral  lobes  are 
at  first  removed,  after  which  the  middle  enlargement  or 
tumors  can  be  pressed  down  into  the  perineal  wound  and 
enucleated  in  the  same  manner.  After  the  removal  of  tha 
prostatic  growth  a  perineal  tube  is  passed  into  the  bladder 
and  a  rubber  drainage  tube  is  inserted  suprapubically. 
The  suprapubic  wound  is  closed  above  and  below  thij 
drainage  tube.  The  after-treatment  consists  in  daily  wash- 
ing out  of  the  bladder  by  injecting  the  fluid  through  the 
suprapubic  tube.  The  upper  tube  is  removed  on  the  fourtli 
day,  and  the  lower  tube  on  the  seventh  day,  after  which 
sounds  are  passed  every  five  days  until  the  perineal  wound 
is  closed. 

In  both  these  methods  the  bladder  has  to  be  opened  in 
order  to  exert  counter-pressure  on  the  gland  during  the 
enucleation  by  the  finger  in  the  perineal  opening,  and  as  a 
suprapubic  cystotomy  is  always  a  dangerous  operation, 
more  especially  in  prostatics  where  the  system  is  below 
par,  the  bladder  often  not  dilatable  and  the  urine  septic, 
efforts  have  been  made  to  devise  some  means  of  making 
counter  pressure  without  resorting  to  this  measure.    Syms. 


Prostatic  Hypertrophy. 


suprapubically  to  press  the  prostate  into  the  perineal  incis- 
ion. The  capsule  of  the  prostate  is  then  cut  through  and 
pushed  away  on  either  side.  The  prostate  is  then  enuc- 
leated with  the  finger  of  the  right  hand,  assisted,  perhaps, 
by  a  periosteum  elevator,  or  a  Volkmann  spoon,  without 
wounding  the  urethra  or  bladder.  In  the  after-treatment 
Nicoll  recommends  passing  a  Coude  catheter  into  t'le  blad- 
der, tying  it  in  while  he  packs  the  perineum  with  gauze. 
He  then  takes  out  the  stitches  above  the  pubes  and  lets 
the  bladder  fall  back  again. 

Alexander  follows  closely  after  Nicoll,  improving  and 
simplifying  the  details  of  the  operation  somewhat.  His 
method  is  as  follows:  A  suprapubic  cystotomy  is  per- 
formed and  retraction  sutures  are  passed  through  the  blad- 
der wall.  The  patient  is  then  put  in  the  lithotomy  position 
and  a  grooved  staff  is  passed  into  the  bladder  through  the 
urethra  and  an  external  perineal  urethrotomy  is  performed 
through  the  membranous  portion  of  the  urethra  to  the 
apex  of  the  prostate  gland  and  its  capsule  incised.  The 
fingers  of  the  left  hand  are  then  passed  into  the  bladder 
through  the  suprapubic  wound,  by  means  of  which  the 
prostate  is  pressed  down  into  the  perineum.  The  forefinger 
ot  tlie  riguL  u^iiiu  is  then  luLrouiicL-u  uei,\^een  me  glana  aud 
the  fibrous  sheath  over  the  prostate  and  the  enucleation 


of  New  York,  has  endeavored  to  obviate  this  necessity  by 
a  very  ingenious  device  consisting  of  a  thick  rubber  tube 
with  a  soft  balloon  on  the  end.  This  can  be  inserted  with 
the  balloon  collapsed  through  the  perineal  opening  into 
the  bladder,  after  which  it  is  inflated  with  water.  It  is 
then  gently  pulled  down  by  an  assistant,  thus  drawing  down 
the  base  of  the  gland  and  steadying  it  while  the  operator 
enucleates  through  the  perineal  incision,  the  pressure  being 
constantly  kept  up  on  the  base  of  the  prostate  by  pulling 
down  the  balloon. 

Working  on  these  lines,  and  feeling  the  necessity  of  a 
more  complete  and  uniform  pressure  from  above  than  could 
be  obtained  by  a  balloon  in  the  bladder  I  have  devised  a 
method  which  I  consider  of  great  practical  value  in 
steadying  the  prostate  and  exerting  counter-pressure  during 
a  perineal  enucleation. 

The  steps  of  the  operation  are  as  follows: — The  bladder 
should  be  washed  out  with  boric  acid  solution  through  a 
catheter  which  is  allowed  to  remain  in  situ,  plugged  after 
the  bladder  has  been  well  distended  for  the  purpose  of 
avoiding  perineal  folds  by  pushing  it  well  up  above  the 
pubes.  The  abdominal  wall  having  been  cut  through  above 
the  symphysis  the  finders  of  the  left  hand  are  thrust  Into 
the  prevesical  space  where  the  prostate  can  be  felt  be- 


7H 


The   Philadelphia" 
Medical  Journal  _ 


PROSTATIC  HYPERTROPHY 


tAPBn.  20,  1301 


tween  the  fingers.  The  plug  Is  now  removed  from  the 
catheter,  and  the  fluid  allowed  to  escape,  thus  permitting 
the  bladder  to  collapse,  after  which  the  catheter  is  with- 
drawn. A  staff  is  now  introduced  through  the  urethra,  a 
perineal  urethrotomy  performed,  the  membranous  urethra 
being  cut  through  the  apex  of  the  prostate,  at  which 
point  the  prostatic  capsule  is  incised,  the  forefinger  of  the 
right  hand  is  inserted  between  the  capsule  and  the  gland 
and  enucleation  commences,  counter-pressure  being 
brought  to  bear  upon  the  gland  during  enucleation  by  the 
index  and  middle  fingers  of  the  left  hand  in  Retzius'  space. 
Having  enucleated  the  prostate  by  this  means,  I  may  say 
that  the  control  of  the  gland  by  the  fingers  of  the  hand  in 
Retzius'  space  is  almost  as  complete  as  if  they  were  In  ihe 
bladder.  After  the  lobes  have  been  enucleated  through  the 
perineal  opening  a  large  perineal  tube  should  be  passed 
into  the  bladder  and  drainage  should  be  kept  up  for  three 
weeks  or  more.  It  is  needless  to  say  that  the  bladder  is 
not  opened  in  this  operation. 

Of  the  different  methods  of  performing  prostatectomy, 
that  is,  of  removing  the  gland  through  the  bladder  supra 
pubicly,  or  through  the  perineum,  or  when  the  intravesical 
growths  are  present  the  bladder  method  is  easier; 
and  of  the  combined  methods  it  is  much  the  quick- 
ast,  simplest  and  safest.  Removing  it  by  the  peri- 
neal method  with  the  fingers  in  the  bladder  to  exert 
counterpressure  is  an  operation  which  is  not  so  simple,  and 
in  my  opinion  more  dangerous,  but  I  think  time  will  prove 
that  the  operation  just  outdined  will  very  much  lessen  the 
danger  connected  with  perineal  enucleation. 

The  After-Treatment: — An  enema  of  a  pint  of  hot  saline 
solution  at  a  temperature  of  120F.  to  be  retained  should 
immediately  be  given  to  the  patient,  together  with  a  thir 
tieth  of  a  grain  of  strychnine,  and  he  should  be  put  to  bed 
wiih  hot  bottles  at  his  feet.  The  shock  in  these  cases  is 
often  great,  and  should  be  guarded  against  as  much  as 
possible.  As  soon  as  he  comes  out  of  the  effects  of  the 
ether  a  little  hot  water,  or  bouillon,  should  be  given,  and 
from  this  time  on  the  water  should  be  pushed  ad  libitum. 
If  the  patient  vomits  the  water,  give  more  in  a  few  minutes, 
and  continue  to  force  it.  It  is  wonderful  how  much  water 
can  be  taken  in  thes  cases,  some  patients  taking  between 
one  and  two  gallons  in  the  first  twelve  hours.  This  has  the 
effect  of  flushing  the  kidneys  and  producing  free  diuresis. 
Any  water  is  good  for  the  purpose,  although  I  am  in  tho 
habit  of  prescribing  some  mild  diuretic  spring  water. 

The  strychnine  in  one-thirtieth  of  a  grain  doses  should  be 
given  every  four  hours  hypodermically,  and  it  is  well  to  re- 
peat the  hot  saline  enema  every  four  hours,  alternating, 
in  this  way  something  can  be  done  for  the  patient  every 
hour  if  the  enemas  and  strychnine  are  alternated  with 
the  bouillon  or  water  by  the  mouth,  remembering  that  the 
water  should  be  pushed  to  the  maximum  of  tolerance. 

It  is  well  both  before  and  after  the  operation  to  give  a 
urinary  antiseptic,  preferaiily  urotropin  in  ten-grain  doses, 
three  times  a  day.  A  diet  of  milk  from  two  to  three  quarts 
a  day  is  advisable.  The  bowels  should  be  moved  with  some 
saline  water.  Aponta  or  Hunyadi  on  the  second  day. 

In  closing  my  remarks  I  should  like  to  say  that  I 
consider  the  operation  of  prostatectomy  still  in  its  in- 
fancy, in  the  same  position  as  was  hysterectomy  some 
years  ago,  and  it  behooves  all  surgeons  interested  in  this 
line  of  work  to  try  in  every  way  to  improve  the  tech- 
nique of  the  operation  now  in  vogue,  and  further  to 
try  other  methods  which  will  make  the  operation  simpler 
than  any  yet  that  have  been  devised. 


CENTRALBLATT   FUER   INNERE   MEDIZIN 

February    2.    1901. 

Protein  Metabolism  In  the  Aged. 

G.  KOVESI. 

Kovesi  directs  attention  to  the  fact  that  there  have  been 

only  imperfect  studies  of  metabolism  In  the  aged,  and  that 

the  statement  that  has  been  repeatedly  madp  thnt  rnetahol- 

ism   in   such   subjects   Is   reduced   is   based   largely   upon 

speculation.    He  reports  a  series  of  studies  that  he  made  in 

two  subjects.  76  and  78  years  old  respectively,  particularly 

determining  the  point  to  which  the  nutriment  might  be 

reduced    with    maintenance    of   a   nirtogen    balance-     His 

general  results  were  the  discovery  that  the  food  demand 

In  old  age  is  decidedly  reduced,  and  the  daily  demand  is 

even  lower  Uian  'previous  Investigations  have  indicated. 


It  is  about  20  calories  per  kilogram.  The  absorption  of  tie 
proteids  from  the  intestine  was  about  normal.  He  was 
able  to  cause  a  nitrogen  retention  with  the  use  of  a  very 
small  amount  of  nitrogenous  substances,  because  the  de- 
mand for  nitrogenous  substances  was  so  greatly  reduced. 
The  figures  in  this  connection  are  very  striking.  With 
the  use  of  6.572  grams  of  nitrogen  per  day,  0.539  grams  of 
which  was  excreted  in  the  feces,  he  caused  an  average  re- 
tention of  0.48  grams  per  day,  the  caloric  value  of  the  food 
at  this  time  being  26  calories  per  kilo.  Finally,  he  decides 
that  there  is  decided  reduction  of  the  decomposition  of 
nitrogenous  substances  in  old  age.  All  these  disturbances 
are  of  quantative  nature.  He  believes  that  it  should  be 
recognized  that  senile  involution  occupies  a  special  place 
in  the  question  of  the  cachexias:  carcinoma,  tuberculosis, 
diabetes,  etc.,  are  associated  with  destruction  of  the  body 
protein,  and  show  qualitative  changes  of  metabolism,  while 
as  stated,  the  contrary  conditions  are  found  in  senile 
atrophy.  This,  he  considers,  indicates  that  the  cause  of 
involution  cachexia  is  to  be  found  in  disturbed  cell  fimc- 
joint.  On  the  one  hand  there  is  a  reduction  in  the  demand 
of  the  cells  for  albumin,  and  on  the  other  hand,  the  intra- 
cellular metabolism  is  of  itself  reduced  and  the  general 
cell  demand  for  energy  is  lowered.     [D.  L.  E.] 


February  9,  1901. 
Concerning  Fatty  Change  in  the  Heart  in  Mankind, 
G.  ROSEXFELB. 

Rosenfeld's  article  is  chiefly  a  discussion  of  a  recent  one 
by  Lindemann  in  which  the  latter  author  criticises  Rosen- 
feld's previous  statement  that  it  would  be  better  to  speak 
of  cell  degeneration  with  deposit  of  fat  in  the  cells,  than 
of  fatty  degeneration.  The  chief  points  which  Lindemann 
put  forward  against  this  statement  were  that  he  found  the 
iodine  continuing  power  of  the  fat  in  cases  of  degenera- 
tion much  higher  than  with  the  normal  fat  of  the  heart  or 
with  infiltration  fat.  Lindemann  decided  that  the  degen- 
eration fat  was  very  different  from  the  fat  of  fat  depots, 
and  that  it  was  verj-  different  from  the  fat  of  the  normal 
heart.  He  therefore  decides  that  Rosenfeld's  transporta- 
tion theory  plays  no  role  in  the  cases  of  actual  fatty  heart. 
Rosenfeld  criticises  Lindemann's  methods  and  figures.  He 
particularly  objects  to  his  method  of  extraction,  and  insists 
that  his  own  method  of  extraction  with  chloroform  is  much 
more  complete  and  gives  much  more  trustworthy  results. 
He  compares  results  obtained  by  the  two  methods.  He 
then  presents  the  results  which  he  has  obtained  in  exam- 
ining a  series  of  hearts  showing  conditions  varying  from 
normal  to  a  considerable  fatty  change.  The  amoimt  of  fat 
in  these  hearts  varied  from  about  15  per  cent,  in  the  normal 
cases  to  as  high  as  24  per  cent.,  and  in  some  there  was 
marked  so-called  fatty  degeneration.  He  found,  however, 
that  the  iodine  figures  varied  only  between  67. S  and  75.7. 
He  thinks  that  these  figures  are  a  strong  indication  that 
the  fat  found  in  the  hearts  in  these  cases  was  simple  infil- 
tration fat  that  had  been  deposited  from  the  fat  depots  in 
the  body.  .Another  reason  for  thinking  this  was  that  he 
compared  the  fat  on  the  right  side  of  the  heart  with  the 
fat  on  the  left  in  two  instances  in  which  there  was  much 
more  iatty  change  in  the  right  side  than  in  the  left.  The 
of  the  heart,  while  there  was  a  much  higher  percentage  of 
fat  in  the  right  side  of  the  heart.  He  also  Insists 
that  microscopically  the  main  tissue  picture  is  re- 
tained, and  that  in  the  early  stages  there  is  noth- 
ing more  than  an  apparent  deposit  of  small  por- 
tions of  fat  This  gradually  increases,  and  finally  the 
of  the  heart.  He  also  insists  that  microscopically  the  main 
tissue  picture  is  retained,  and  that  in  the  early  stages 
ther  is  nothing  more  than  an  apparent  deposit  of  small 
portions  of  fat.  This  gradually  increases,  and  finally  the 
fat  deposit  destroys  the  muscle  substance  by  pressure. 
He  insists  finally  that  these  results  give  further  proof  of  his 
statement  that  fatty  changes  of  the  heart  consists  of  a 
mere  deposit  of  fat  in  the  heart,  and  not  of  degenera- 
tion.    [D.  L.  E.] 


..Otitis  Caused  by  Bacillus  Pyocyaneus. — Gelman  {}ltd^ 
c\ina.  November,  1900),  reports  three  cases  of  fibrinous 
inflammation  of  the  ear  caused  primarily  by  the  bacillus 
pyocyaneus.  .\  pure  culture  of  the  organism  was  obtained 
In  every  case.  No  concomitant  diphtheria  wu  preeent 
[A.  R.] 


The  Philadelphia  Medical  Joiiiual 

A  Weekly  Joxrrnal  Owned  and   Published   by  The  Philadelphia  Medical  Publishing  Company  and   Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 

Scientific  Articles.  Clinical  >remoranda.  News  Items,  etc.,  of  interest  to  the   profession 
are  solicited  for  publication.     Reprints  (i50)  of  Original  Articles  will  be   furnished 


James  Hendrie  Lloyd.  AM,  \t.T>  ,  Edilor-in-Chief 
Julius  L.  s.4lingkr.  M.D  .  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kalteyer,  M.D. 

D.  L.  Edsall.   M.D.  T.  L.  COLEY.   M.Ij. 

J.  M.  Swan,  M.    .  W.  A.  N.  Dorland.    M.D. 

J.  H.  GiBBO.N,  M.D.  T.  M.  Tyson,  AI,  D. 

M.  OSTHBIUER,   M.  D.  A.  ROBIN.  .\I.   D. 


gratis  to  Authors  making  the  request. 
The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.  Address  all  correspondence  to 

The  PhlladelplilaMedlcal  Journal,  1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertisingr  Paf^e  8. 


Vol.  VII,  No.  17 


ApriL  27,  1901 


$3.00  Per  Annum 


The  Plague  Situation. — The  report  of  the  Plague 
Commission,  appointed  by  the  Secretary  of  the 
Treasury  to  investigate  the  situation  in  San  Fran- 
cisco, is  very  interesting  reading,  although  beyond 
the  one  important  and  central  fact  that  it  demon- 
strates the  existence  of  plague  in  that  city,  it  throws 
no  special  or  new  light  on  the  swbject  of  plague  in 
general.  The  energ}-  with  which  the  members  of 
the  Commission  went  to  work,  and  the  promptness 
with  which  they  discovered  what  they  were  looking 
for,  are  noteworthy  features.  It  is  very  evident 
that  the  disease  was  there  and  waiting  for  them, 
and  the  natural  queries  arise.  How  long  had  the 
plague  been  there ;  how  many  victims  had  it  al- 
ready claimed,  and  what  had  the  local  authorities 
in  San  Francisco  been  doing  all  the  while?  From  all 
that  we  can  gather  from  the  report  we  should  judge 
that  the  local  authorities  were  not  in  command  of 
the  situation.  The  Commission  had  to  undertake 
the  investigation  de  novo.  No  report  of  previous 
cases  apparently  was  given  them ;  no  evidence  of 
scientific  study  before  their  arrival  was  forthcom- 
ing. It  is  true  that  the  members  of  the  Commission 
were  well  received  and  their  work  furthered  by  the 
local  authorities ;  but  these  local  authorities  them- 
selves seem  either  to  have  had  no  exact  knowledge 
of  the  situation  or  else  had,  ostrich-like,  closed  their 
eyes  to  the  real  danger.  To  say  that  they  had  been  de- 
liberately concealing  the  truth  is  to  make  too  serious 
a  charge,  but  one  cannot  read  this  Commission's  re- 
port and  not  feel  that  it  is  at  least  a  strange  fact 
that  the  situation  depicted  in  it  had  been  allowed 
to  continue  in  San  Francisco  without  recognition, 
while  the  rest  of  the  country  was  being  assured  that 
there  was  no  plague  in  that  city. 

Drs.  Flexner,  Novy,  and  Barker,  who  constituted 
the  Commission,  had  no  difficulty  in  finding sixgenu- 
ine  cases  of  bubonic  plague.  The  diagnosis  in  each 
case  was  confirmed  by  bacteriological  tests.  Guinea 
pigs  were  used  for  inoculation.  The  investigators 
worked  under  considerable  disadvantage  because  of 
the  prejudice  of  the  Chinese  and  the  filth  of  their 
surroundings,  but  the}'  succeeded  in  demonstrating 
to  the  world  the  value  of  thorough-going,  honest 
and  scientific  methods.    Their  report  is  an  interest- 


ing and  valuable  one,  though  its  conclusions  have 
already  been  known  for  some  time. 

The  Protozoon  of  Cancer. — Dr.  H.  R.  Gaylord,  of 
the  University  of  BufTalo,  is  not  altogether  fortu- 
nate in  having  been  proclaimed  in  advance  in  the 
daily  newspapers,  as  having  demonstrated  bej-ond 
dispute  the  parasitic  origin  of  cancer.  Such  state- 
ments about  scientific  discoveries,  when  they  filter 
beforehand  through  the  newspapers,  are  more  or 
less  liable  to  be  garbled,  and  to  do  both  the  author 
and  his  discovery  some  injustice  by  causing  pre- 
judice and  prejudgment  about  his  scientific  work. 
We  are  now  able  to  state  authentically  that  Dr. 
Gaylord  will  publish  early  in  May  in  the  American 
Joiiniiil  of  the  Medical  Sciences  in  this  city,  a  paper  re- 
cording the  results  of  his  observations.  He  will  give 
a  full  description  of  an  organism,  which  belongs  to 
the  class  of  protozoa,  and  which  he  claims  that  he 
has  demonstrated  is  the  cause  of  cancer.  In  this 
paper  he  will  report  cases  of  the  production  of  can- 
cer in  lower  animals  by  inoculation  with  pure  cul- 
tures of  this  germ.  He  will  also  present  a  summary 
of  the  length  of  life  and  of  the  gross  lesions  in  72 
animals  thus  inoculated.  He  claims  that  this  trans- 
fer of  the  disease  to  animals  has  been  accomplished 
by  inoculation  with  germs  derived  originally  from 
human  patients,  and  cultivated  outside  of  the  human 
body,  and  that  the  positive  identification  of  the  dis- 
ease in  these  animals  is  scientific  proof  of  the  accu- 
racy of  his  discovery.  He  also  attempts  to  show  the 
correlation  of  the  findings  of  various  investigators 
with  the  different  phases  of  the  living  cultivated 
organism  as  he  has  observed  it.  He  even  calls  at- 
tention to  the  relation  of  the  organism  of  cancer  to 
the  protozoon  of  smallpox.  This  latter  organism 
^\•as  discussed  in  these  columns  only  recently. 
Eventually  Dr.  Gaylord,  we  are  told,  will  give  an 
analysis  of  the  histological  findings  in  the  J2  inocu- 
lated animals,  but  this  summary  will  not  be  con- 
tained in  the  article  here  referred  to.  It  is  too  soon, 
of  course,  to  attempt  to  subject  Dr.  Gaylord's  paper 
to  scientific  criticism.  We  refer  to  it  here  merely 
as  a  matter  of  promised  medical  interest.  It  has 
already  been  heralded  abroad  so  extensively  that  the 
scientific  world  will  doubtless  await  the  appearance 


.yCA        The    riiii.ADKi.rHiA"! 
/"  MiiiiUAL  Journal  J 


EDITORIAL  COMMENT 


(Apbil  27,  1901 


of  the  paper  with  interest.  It  is  needless  to  say  that 
it  IS  entirel)-  too  early  to  prophesy  what  effect  this 
discovery,  if  it  be  confirmed  by  competent  observ- 
ers, will  have  upon  the  therapeutics  of  cancer.  In 
conclusion  we  may  remind  our  readers  that  Dr.  Gay- 
lord  claims  that  cancer  is  caused  by  a  protozoon  or 
animal  parasite,  not  a  bacterial  or  vegetable  one. 

The  Epidemic  of  Enteric  Fever  at  New  Haven. — 

Enteric  fever  and  cholera  are  essentially  water-borne 
diseases,  and  are  largely  conveyed  to  the  human 
being  by  water  used  for  drinking  and  cleansing  pur- 
poses. It  has  been  repeatedly  and  positively  demon- 
strated that  the  specific  germ  of  enteric  fever,  the 
bacillus  of  Eberth,  is  destroyed  at  a  temperature  of 
IOC  degrees  centigrade  after  2  or  3  minutes.  The 
lesson  to  be  learned  then  in  the  prevention  of  the 
disease  is  to  boil  all  water  that  is  to  be  used  for 
culinary  or  drinking  purposes.  It  is  a  fact  well  es- 
tablished in  the  etiology  of  enteric  fever  that  no 
case  arises  de  novo ;  there  must  always  be  a  previous 
case.  If  this  be  true,  and  there  can  scarcely  be  a 
doubt  as  to  the  correctness  of  this  statement,  then 
whenever  a  new  case  arises,  the  ordinary  precau- 
tions regarding  the  disinfection  of  the  excreta  inafor- 
mer  case  of  enteric  fever  must  have  been  neglected, 
facts  that  are  taught  and  are  familiar  to  the  merest 
tyro  in  medicine.  Epidemics  of  enteric  fever  are 
then  due  primarily  to  neglect  by  the  medical  men 
and  perhaps  largely  also  by  the  nurse  in  charge  of 
such  a  fever  case.  It  should  be  the  duty  of  a  physi- 
cian in  charge  of  a  case  of  enteric  fever  »to  see  to  it 
that  his  patient  is  not  the  cause  of  another  case  of 
the  same  affection.  Care,  and  only  care,  can  prevent 
the  outbreak  of  this,  at  all  times  serious,  affection. 
The  authorities  of  a  city  cannot  be  held  responsible 
if  a  careless  medical  man  allows  excreta  of  an  enter- 
ic fever  patient  to  contaminate  the  water  supply  of 
a  large  citj\  What  can,  however,  be  done  by  the 
"city  fathers"  is  to  instruct  the  citizens  how  to  pre- 
vent the  affection  by  boiling  their  drinking  water, 
milk,  etc.,  and  not  to  eat  uncooked  vegetables  and 
perhaps  fruits.  We  fear  that  an  epidemic,  such  as 
is  at  present  raging  in  New  Haven  (where  there  are 
said  to  be  over  500  cases  of  enteric  fever,  according 
to  a  report  in  the  Public  Ledger)  is  due  to  careless- 
ness and  neglect  on  the  part  of  some  of  our  medical 
bretliren. 

Suppurative  Mastitis  in  the  Newborn. — The 
mamniar}'  enlargement  and  inflammation  which  are 
not  infrequently  encountered  in  newborn  children 
of  both  sexes  are  phenomena  as  j^et  not  satisfactor- 
ily explained.  Just  why  there  should  occur  such 
glandular  activity  shortly  after  birth  is  not  known, 
but  that  it  may  exist  and  even  advance  to  actual 
suppuration,  as  in  an  instance  recently  reported  bv 


Marvel  (Annals  of  Gyn.  and  Ped.,  April,  1901),  is  a 
well-recognized  fact.  As  has  been  suggested,  there 
ma}'^  be  some  obscure  relationship  between  the  oc- 
currence and  certain  metabolic  changes  taking  place 
in  the  umbilical  stump.  It  may  be  irritative  in  char- 
acter from  reflex  excitation  arising  at  this  point. 
The  theory  of  direct  traumatism  of  the  mammary 
gland  is  not  proved  and  cannot  be  accepted.  There 
is  no  substantial  evidence  in  its  support.  It  is  true, 
however,  that  the  suppurative  form  of  the  disease  is 
traumatic  in  origin,  and  is  due  to  the  mal-directed 
efforts  of  nurses  and  midwives  to  squeeze  out  the 
offending  discharge.  The  practical  point  that  is 
suggested  by  the  occurrence  of  infantile  mammitis, 
is  the  necessity  of  careful  handling  of  the  gland,  and 
the  avoidance  of  any  attempt  at  evacuation  of  the 
fluid.  The  absence  of  a  thick  pad  of  pectoral  muscle 
renders  the  spontaneous  rupture  of  the  pus  posteri- 
orly into  the  pleural  sac  by  no  means  improbable; 
hence  emollient  and  absorbent  applications  should 
constitute  the  primary  treatment  with  early  incis- 
ion, should  pus  develop.  Above  all,  should  vigorous 
manipulation  of  the  inflamed  organ  be  avoided  in  the 
primary  stage  of  the  disease. 

A  Wider  Range  for  the  Therapeutic  Employment 
of  Santonin. — Until  recently  santonin  has  been  re- 
garded as  one  of  our  most  reliable  anthelmintics,  but 
its  use  in  other  conditions  has  not  been  recommend- 
ed. However,  attention  has  been  called  of  late  to 
the  value  of  santonin  in  the  treatment  of  epilepsy 
and  the  fulgurant  pains  of  locomotor  ataxia.  The 
physiological  action  of  santonin  in  large  dose  is 
chiefly  upon  the  nervous  system.  Consciousness  is 
disturbed, a  sort  of  intoxication  seizes  the  patient, ac- 
companied by  g^eat  weakness,  tremors,  sweating, 
coldness  of  the  surface,  and  vomiting.  There  also 
follows  a  slowing  of  the  pulse  with  enfeebled  res- 
piration. Mj'driasis  occurs  with  a  frequent  onset  of 
convulsions.  Between  the  convulsions  there  is 
sometimes  paralysis  of  respiration  which  usually 
causes  death.  The  most  characteristic  action  of  the 
drug  is  upon  the  vision.  At  first  everj-thing  appears 
colored  blue,  and  afterwards  yellow  or  g:reenish-yel- 
low.  The  blue  appearance  is  very  transitory, 
lint  the  yellow  vision  (chroniatopsia)  lasts  much 
longer.  Following  this,  if  very  large  doses  have 
been  taken,  total  blindness,  sometimes  lasting  a 
week,  occurs.  It  is  said  that  this  alteration  of  the 
vision  is  due  to  stimulation  of,  and  later  paralysis  of. 
those  fibers  of  the  retina  by  which  blue  light  is  per- 
ceived. Dr.  C.  Negro,  of  Turin,  observing  particu- 
larly the  action  of  santonin  upon  the  retina  reasoned 
that  it  should  be  capable  of  influencing  general 
changes  of  nervous  sensibility.  This  supposition 
was  fully  verified  in  a  patient  with  tabes,  to  whom 
Dr.    Negro   administered   santonin   to   combat   the 


Arnii.  27.  V.nn] 


EDITORIAL  COMMENT 


TThi 
L  Me 


E  Philadelphia 

EDICAL   JOinNAL 


787 


painful  crises.  His  results  were  most  satisfactory, 
and  since  this  time  he  has  treated  a  number  of  simi- 
lar cases  always  with  favorable  results. 

He  administers  santonin  in  doses  of  15  centi- 
grammes a  day,  taken  at  intervals  of  three  or  four 
hours.  These  doses  have  generally  been  found  suffi- 
cient to  completely  abolish  the  fulgurant  pains. 
Lydston  has  used  santonin  in  the  treatment  of  a 
number  of  cases  of  epilepsy,  and  he  believes  that 
the  action  of  the  drug  is  much  more  favorable  than 
the  bromide-treatment.  Lj-dston  begins  by  admin- 
istering 2  grains  of  santonin  gradually  increased,  as 
tolerated,  until  as  much  as  15  grains,  taken  3  or  4 
times  a  da}-,  is  given.  He  has  usually  found  this 
amount  to  be  well  borne.  The  advocacy  of 
another  remedy  in  addition  to  the  host  of  thosj 
recommended  in  the  conditions  we  have  named,  will 
no  doubt  be  regarded  by  very  man}'  physicians  as 
of  doubtful  value.  But  the  results  which  have  been 
attained  from  the  employment  of  santonin  seem 
to  justify  an  extended  trial  on  the  part  of  the 
profession  so  that  its  precise  value  may  be  accurate 
ly  determined. 

The  Latest  on  Women  Doctors. — A  wise  man 
once  said  that  you  cannot  indict  a  whole  race.  He 
might  have  added  with  equal  pertinence  that  you 
cannot  indict  the  whole  female  sex.  We  do  not  sup- 
pose for  a  moment  that  Dr.  Victor  C.  Vaughan,  of 
Ann  Arbor,  Jilich.,  intended  in  his  recent  pronounce- 
ment against  women  doctors  to  indict  the  whole 
sex.  He  evidently  had  in  mind  only  that  portion  of 
•  the  sex  that  studies  medicine.  This  small  minority 
will  doubtless  bear  him  in  mind  and  feel  duly  grate- 
ful to  him.  In  a  recent  address  Dr.  Vaughan  pro- 
claimed that  women  were  often  successful  in  the 
class-room  by  reason  of  their  mental  qualities,  but 
were  not  adapted  to  practise  medicine  because  of  a 
kind  of  lack  of  resourcefulness  and  self-reliance. 
It  seems  to  us  that  we  have  somewhere  heard  this 
criticism  before,  but  still,  for  the  time  being,  we  will 
let  Dr.  Vaughan  have  entire  credit  for  it.  The  doc- 
tors in  question  will  doubtless  think  that  what  it 
1  lacks  in  originality  it  makes  up  in  erroneousness. 
The  many  women  who  are  successfully  practising 
medicine  in  the  United  States  to-day  are  perhaps  not 
all  of  the  strenuous  kind,  and  they  may  have  self- 
reserve  enough  not  to  rush  into  print  to  assail  Dr. 
Vaughan ;  but  keen  observers  of  the  facts  in  some  of 
our  large  cities  must  know  that  some  of  these  wo- 
men are  resourceful  and  masterful  enough  to  com- 
mand a  gratifying  success.  We  do  not  believe  that 
the  mental  traits  of  the  two  sexes  can  be  quite  so 
sharply  diiTerentiatcd  as  Dr.  Victor  C.  Vaughan 
imagines  they  can  be.  Scientific  training  tends  to 
eliminate  some  of  the  mere  sex  factors  in  mind — 
factors  which  after  all  are  largely  conventional  and 


the  results  of  social  evolution.  The  wide  swoop  of 
such  an  undiscriminating  pen  as  Dr.  Vaughan  rather 
rashly  flourishes  fails  to  include  too  many  minor 
problems  in  the  question.  We  are  convinced  that 
these  problems  will  not  be  settled  by  purely  mascu- 
line criticism.  ^  ^ _  ri^ 

A  School  for  Backward  Children.— The  Public 
Education  xAssociation  of  Philadelphia  has  under- 
taken a  most  praiseworthy  task  in  conducting  a 
public  school  in  this  city  for  "backward  children."' 
This  term  "backward"  covers  a  variety  of  defects, 
and  this  fact  is  fortunately  clearly  seen  by  the- 
Committee.  It  indicates  that  many  of  these  child- 
ren merely  present  need  for  special  training  by  rea- 
son of  some  one  .special  physical  or  mental  defect. 
Thus,  children  who  are  deaf  but  not  mentally  defi- 
cient, or  children  who  stammer  or  who  have  other 
speech  defects,  are  instances  of  pupils  who  require 
.special  methods  of  instruction.  One  of  the  grave 
defects  of  the  public  school  systems  in  this  country- 
is  their  hard-and-fast  mechanical  workmanship. 
The  individual  needs  of  the  scholar  receive  too- 
.little  attention.  In  the  case  of  a  child  who  is  in  any 
way  handicapped  by  physical  or  mental  defect,  this- 
rigid  and  impersonal  system  is  fatal.  Hence,  as  the 
Committee  says,  ungraded  rooms  are  needed  for 
many  kinds  of  pupils  who  are  "misfits"  in  the  regu- 
lar grades.  As  for  children  who  are  congenitally 
deficient  in  mental  faculty,  the  real  hope  of  helping 
them  lies  in  manual  training.  Such  children  are 
taught  wood-work,  card-board  work,  clay-model- 
ling, chalk-work,  basket-weaving,  painting,  and 
sewing.  We  have  just  received  the  annual  report 
of  the  Committee,  from  its  secretary.  Miss  Dora 
Keen,  and  commend  it  for  full  details  to  all  persons 
interested  in  this  benevolent  work. 

Christian  Scientists  Barred. — We  expressed  the 
opinion  some  weeks  ago  in  these  columns  that  the 
proper  way  to  do  with  the  Christian  Scientists  was 
to  require  them  to  obtain  a  license  to  pratise  medi- 
cine after  passing  an  examination,  just  as  is  demand- 
edofallothercandidates.  Noamount  of  criticism  and 
denunciation  will  exterminate  this  sect.  Anything 
that  savors  of  persecution  is  to  be  feared,  for  such 
fanatics  always  thrive  on  persecution.  They  court 
it,  and  would  even  gladly  go  to  jail  and  liken  them- 
selves to  St.  Paul  in  chains.  There  are  plenty  of 
such  people  in  the  world,  even  outside  the  ranks  of 
Christian  Scientists;  men  who  pose  as  prophets 
and  reformers.  They  are  shrewd  enough  to  know 
that  a  certain  kind  of  popular  sympathy  is  easily 
aroused  for  a  martyr  who  appears  to  suffer  for 
conscience's  sake.  When,  however,  they  are  re- 
quired to  meet  a  law  that  applies  equally  to  all, 
they  are  forced  to  show  their  hand,  and  at  the  same 


»QQ       The  PhiladelphiaI 
/""        Medical  Jocbxal  J 


EDITORIAL   COMMENT 


(  A IBIL  27.  1901 


time  are  debarred  from  playing  the  role  of  the 
persecuted.  The  recent  opinion  of  Judge  Lumpkin, 
of  the  Superior  Court  of  Georgia,  is  exactly  in  ac- 
cord both  with  law  and  with  reason.  The  Judge 
denied  the  application  for  a  charter  for  "The  At- 
lanta Institute  of  Christian  Science,"  basing  his  de- 
cision on  the  opinion  that  Christian  Science  is 
a  form  of  medical  practice,  and  that  the  practice 
of  medicine  in  Georgia,  according  to  the  law  of  the 
State,  can  only  be  pursued  by  persons  who  are 
regularly  graduated  from  medical  schools.  Judge 
Lumpkin's  decision  seems  to  debar  these  people 
from  legal  recognition  in  the  State  of  Georgia,  and 
if  they  persist  in  their  practices  they  can  be  treated 
as  any  other  law-breakers. 

The  Barbers  and  the  Surgeons. — It  must  be  diffi- 
cult for  most  readers  in  this  country  to  realize  that 
in  England  the  surgeons  still  hobnob  with  the  bar- 
bers, and  that  members  of  the  two  "professions'" 
still  regard  each  other  as  fellow-craftsmen.  This  odd 
Telationship  has  just  been  illustrated  by  the  address 
<ielivered  by  Sir  William  MacCormac  on  the  occa- 
sion of  his  receiving  the  Honorary  Freedom  and 
Livery  of  the  Barbers'  Company  in  London.  This 
fellowship  had  its  origin  in  the  remote  past,  at  a 
time  when  the  barbers  were  the  only  recognized 
surgeons,  or  "barber-chirurgeons"  of  the  country. 
A  relic  of  their  surgical  prerogatives  still  lingers  in 
their  practice  of  leeching,  bleeding  and  cupping,, 
'cven  in  tliis  country,  and  their  sign  with  its  red 
stripes  is  said  to  indicate  their  gory  occupation.  In 
England  the  tendency  is  to  adhere  to  tradition  and 
to  hold  on  to  old  ways  and  customs,  and  so  it 
came  about  recently  that  tlie  barber's  guild  had  for 
its  chief  guest  a  distinguished  surgeon  whose  career 
•and  attainments  do  not  at  all  suggest  anything  ton- 
sorial. 

But  the  modern  Company  of  Barbers,  we  sup- 
pose, must  not  be  taken  too  seriously.  It  seems 
to  be  celebrated  for  its  antiquity  and  for  its  old  sil- 
ver plate  rather  than  for  the  art  of  hairdressing 
We  doubt  whether  any  of  its  members  have  to 
make  their  living  by  cutting  hair  and  shaving.  Sir 
William  MacCormac  in  his  address  tells  us  that  the 
Guild  of  Barbers  in  London  is  of  such  ancient 
foundation  that  its  earliest  records  cannot  be 
traced.  It  dates  from  the  Thirteenth  Century.  At 
first  it  had  even  a  religious  character,  as  the  bar- 
bers used  to  assist  the  monks  to  perform  operations. 
This  must  have  been  in  still  earlier  days,  for  the 
edict  of  Tours,  in  1163,  forbade  the  priests  to 
shed  blood.  In  1462  a  charter  was  obtained,  and  in 
1540  the  surgeons  (an  insignificant  body)  became 
merged  in  the  Barber's  Company.  From  this  time, 
for  two  hundred  years,  the  surgical  practice  and 
teaching   (^f    England    were    in    the    hands    of   this 


Guild.  Its  members  were  surgeons  to  the  King  and 
they  were  content  to  bear  the  humble  title  of  "bar 
ber-chirurgeon."  In  fact,  they  rejoiced,  as  their  de 
scendants  appear  to  rejoice  to-day,  in  what  to  oui 
siders  seems  to  have  been  a  somewhat  plebeian  origin. 
The  surgeons  were  not  formally  separated  from  the 
barbers  until  1745,  when  they  formed  the  Company  of 
Surgeons,  and  this  company  became  eventually,  in 
1800,  the  College  of  Surgeons.  In  France  things 
were  much  the  same,  and  the  celebrated  Ambrose 
Pare,  who  was  surgeon  to  five  successive  kings  of 
France,  was  a  mere  barber  surgeon.  The  practice 
of  surgery  was  held  in  low  esteem  as  compared  with 
the  practice  of  physic,  and,  as  Sir  William  Mac- 
Cormac says,  it  did  not  advance  much  from  that 
time  vmtil  the  evolution  of  antiseptic  surgery  toward 
the  end  of  the  Nineteenth  Century. 

A  Medical  View  of  the  Chinese  Boxers. — It  was 
hardly  to  be  supposed  that  the  opportunity  of 
writing  about  the  psychology  of  the  Chinese  Boxers 
would  be  allowed  to  pass.  This  age  in  which  we 
live  is  the  psychological  age.  Everything  from  a 
pastime  to  a  crime  must  be  subjected  to  a  psycholo- 
gical analysis.  This  sometimes  looks  like  psychol- 
ogy gone  mad.  In  fact  we  might  almost  call  it  the 
psychiatry  of  criticism.  It  is  natural,  however,  that 
a  French  physician  should  be  among  the  first  to  call 
attention  to  the  hysterical  phases  of  the  recent  in- 
surrection in  China.  M.  Matignon  tells  us  that  he 
\\  as  impressed  long  ago  with  the  fact  that  hysteria 
is  very  common  in  China,  and  in  the  spring  of  1900 
he  undertook  to  investigate  the  subject.  He  exam- 
ined more  than  300  subjects  and  proposed  to  extend 
his  anthropological  researches  to  three  or  four  thou- 
sand cases,  when  the  catastrophe  at  Peking  put  a 
stop  to  his  studies  and  caused  him  the  loss  of  his 
notes.  He,  however,  has  recently  given  his  impres- 
sions, which  are  that  nervous  diseases,  contrary  to 
the  general  opinion,  are  extremely  common  among 
the  Celestials.  He  says  that  hysteria  especially  ex- 
ists, and  that  the  Boxer  uprising  has  thrown  new 
light  upon  this  affection  as  it  is  seen  in  China.  He 
thinks  that  the  Chinese  mind  is  very  open  to  sugges- 
tion. The  Chinaman  believes  more  as  he  under- 
stands less,  and  that  which  he  does  not  understand 
at  all  he  has  absolute  faith  in.  Last  year  this  natural 
suggestability  was  raised  to  the  paroxysmal  point. 
1  lie  whole  Middle  Kingdom  was  in  a  state  of  anxiet_\ 
which  M.  Matignon  likens  to  the  state  which  existed 
in  Europe  in  the  year  1000  at  the  prospect  of  the 
second  Advent.  The  year  1900  was  to  have  an  in- 
tercalary month,  and  this  was  a  grave  omen  which 
caused  an  exaggerated  suggestability  in  the  Chinese 
mind.  M.  Matignon  evidently  thinks  that  the  Box- 
er uprising  was  a  sort  of  pandemic  frenzy,  not  un- 


Arnii.  -JT,  l!)i>l| 


EDITORIAL  COMMENT 


[TuE   I'Hii.AnEi.rniA       ^Qr, 
Mepii-.u.  Joinx.M.         /°y 


like,  we  suppose,  some  of  the  popular  manias  which 
swept  over  Europe  durinjj  the  Middle  Ages. 

We  are  not  disposed  to  criticise  M.  Matignon's 
\  iew  adversely,  although  he  may  have  forced  his 
conclusions  rather  too  far.  We  would  remind  those 
who  are  interested  in  the  subject  that  Dr.  Nevius, 
an  American  missionary  in  China  for  forty  years, 
wrote  a  curious  book  a  few  years  ago  on  demon  pos- 
session as  he  had  observed  it  in  China.  Dr.  Nevius 
unfortunately  was  entirely  without  scientific  knowl- 
edge and  critical  acumen,  and  doubtless  misinterpre- 
ted the  many  curious  psychological  phenomena 
which  he  had  observed  in  the  Chinese  during  his 
long  sojourn  among  them.  He  was  evidently  also 
prejudiced  by  his  environment  and  took  the  ex- 
tremely superstitious  and  theological  view  of  these 
mental  traits.  He  believed  in  a  veritable  demon 
possession,  although  what  he  observed  was  evident- 
ly an  outbreak  of  wide-spread  hypnotic  manifesta- 
tions in  the  Chinese  peasantry.  If  he  had  had  the 
knowledge  and  literary  skill  of  l\I.  Malignon,  with- 
out the  superstition  which  disfigured  his  book,  he 
could  have  made  a  most  interesting  contribution  to 
the  science  of  comparative  anthropology.  He  en- 
tirely ignored  the  power  of  hypnotic  suggestion, 
especially  as  it  occurs  under  the  influence  of  re- 
ligious excitement.  In  fact,  the  good  missionary 
bad  lived  so  long  in  China  that  he  seemed  never 
to  have  heard  of  such  a  thing.  The  consequence 
was  that  instead  of  his  book  being  a  con- 
tribution to  science,  it  was  only  a  detriment  to  the 
cause  of  religion.  We  have  no  doubt  that  th'; 
Chinese  have  the  mental  characteristics  that  are 
common  to  the  whole  human  race,  and  that  in  such 
a  furious  outbreak  as  that  which  occurred  last  year 
under  the  influence  of  religious  excitement  and 
racial  animosity  they  may  have  exhibited  most  in- 
teresting symptoms  of  mental  perversion.  We  are 
indebted  to  the  Literary  Digest  for  an  interesting 
reference  to  M.  Matignon's  article. 

The  Decline  of  Population  in  France. — We  see 

a  great  deal  written  here  and  there  about  the  deca- 
dence of  France,  and  especially  about  the  decline  of 
her  population.  Some  of  the  facts  and  figures  seem 
to  us  to  be  altogether  misinterpreted.  In  the  first 
place,  the  assumption  that  every  country  on  the  face 
ol  the  earth  must  show  a  decennial  increase  of  popu- 
,  lation,  or  else  be  judged  decadent,  is  only  an  as- 
sumption. There  comes  a  time  in  the  history  of 
every  country,  (and  even  of  difl'erent  parts  of  a 
country),  when  what  is  called  the  "saturation"  point 
is  reached.  At  this  point  the  country  can  support  no 
more  people.  To  have  reached  this  point  is  not  ne- 
cessarily a  sign  of  stagnation  ;  (|uite  the  reverse,  it 
mav  be  an  evidence  of  a  verv  high  state  of  civiliza- 


tion. France  has  apparently  about  reached  this 
point.  For  that  matter,  there  are  some  localities,  or 
even  States,  in  our  own  country  which  have  almost 
if  not  quite  reached  the  same  point.  By  the  end  of 
another  half-century,  such  phenomena  will  have  be- 
come more  conmion  in  the  United  States.  At  the 
present  rate  of  increase,  in  fact,  it  would  take  but  a 
comparatively  short  time  (as  historical  time  is  meas- 
ured) for  the  whole  United  States  to  be  densely  over- 
populated.  What  will  Ijc  true  of  America,  has  been 
true  for  some  time  of  part  of  Europe  :  and  France, 
vidiich  is  the  centre  and  one  of  the  most  densely  pop- 
ulated of  the  European  States,  is  simply  in  the  posi- 
tion in  which  some  of  our  own  American  .States  will 
probably  be  long  before  all  adult  persons  now  living 
shall  have  died. 

A  recent  writer  calls  attention  to  the  fact  that  the 
more  civilized  a  nation  becomes  the  denser  popula- 
tion it  can  support.  In  the  Stone  age  France  could 
support  but  a  few  thousands ;  in  her  Golden  age  she 
supports  many  millions.  Another  writer  casts  a  re- 
proach upon  France  because  she  does  not  increase 
so  rapidly  as  Russia;  but  Russia  has  a  vast  terri- 
tory, some  of  it  almost  unpeopled.  Such  a  compari- 
son is  quite  absurd. 

It  is  well  to  remember  that  as  the  "saturation" 
point  is  attained  there  are  natural  checks  on  the  in- 
crease of  population.  Nature  looks  after  her  own 
in  this  resj)ect.  A  slight  relief  from  over-popula- 
tion, even  by  a  rechiction  in  the  birth-rate  and  an 
increase  of  emigration,  is  not  alwaj-s  a  bad  thing,  as 
history  has  shown.  It  is  like  putting  some  of  the 
persons  out  of  an  overcrowded  room,  and  letting  no 
others  come  in.  From  a  hygienic  and  medical  stand- 
point over-population  is  much  to  be  feared.  There- 
fore, instead  of  deploring  the  lot  of  France,  it  may 
be  well  to  inciuire  deeper  and  see  whether  things  are 
really  going  to  destruction  with  her. 


On  the  Agglutinating  Power  of  Some  Serums  In  Rela- 
tion to  the  Red  Blood  corpuscles  of  Man. — Jean  Camus  ami 
Pagniez.  {(Uiz.  HcO.  dc  Med.  i-t  dr.  Cliinir..  March  7,  1901,  tS 
me.  Annee,  No.  19). — At  a  meeting  of  the  Sncictc  do  BiiiUniiv 
held  March  2,  1901,  Camus  and  Pagniez  made  a  report  on 
the  agglutinating  power  of  some  human  serums  in  rela- 
tion to  the  red  corpuscles  in  man.  They  have  found  that, 
in  the  pathological  state,  human  serum  may  agglutinate  the 
red  blood  corpuscles  of  another  man.  Their  studies  have  in- 
cluded 35  specimens  of  human  serum,  both  normal  ami 
abnormal.  Normal  serums  do  not  give  agglutination  so 
far  as  the  studies  have  gone.  Among  the  pathological  ser- 
ums a  large  number  were  endowed  with  manifest  agglu- 
tinating properties.  They  agglutinated  the  red  blood  cor- 
puscles of  normal  man  but  had  no  action  upon  tliese  cells 
taken  from  other  men  suffering  from  disease.  The  active 
scrums  came  particularly  from  patients  suffering  from  ane- 
mia and  cachexia,  the  majority  of  whom  were  tuberculous. 
The  red  cells  of  a  patient  furnishing  a  very  agglutin- 
ating serum  may  be  completely  refractory  to  agglutination 
by  other  serums.  As  in  the  case  of  animal  serums,  heating 
to  58°  C.  or  60°  C.  diminishes  without  destroying  the  ag- 
!;lutinating  property.     t-J-  M.  S.l 


79° 


MKUICAL    JnlHXAL 


] 


CORRESPONDENCE 


(  Ai  niL  ar,  1901 


dorresponbencc. 


THE  TREATMENT   OF  PNEUMONIA   WITH  SALINE 
INFUSIONS. 

By   CLEMENT   A.   PENROSE,    M.    D., 
of  Baltimore,  Md. 

To  the  Editors  of  "The  Philadelphia  Medial  Journal. " 

Dear  Sirs: — As  my  paper  on  salt  infusions  in  pneumonia 
which  received  very  favorable  criticism  over  two  years  ago, 
-when  first  presented  before  a  body  of  eminent  men  (Johns 
Hopkins  Hospital  Society,  January  23d,  1899),  was  made  a 
leading  editorial  in  the  British  Medical  Journal  shortly  after, 
and  led  to  some  experiments  being  made  in  England,!  cannot 
believe  that  it  lacks  a  theoretical  basis,  and  fear  that  Dr. 
D.  E.  Keefe's  criticism  comes,  alas,  too  late  to  warn  his 
brothers  against  the  method  which  many  are  using,  and  1 
Tjelieve  will  continue  to  use. 

I  felt  that  Dr.  Keefe's  ideas  on  saline  infusions  were 
evidently  preconceived,  and  that  he  had  ignored  the  re- 
cent literature  on  the  same  when  he  states  by  way  of  a 
preface  to  his  article,  that  "he  is  opposed  to  their  use  in 
cases  of  collapse  after  surgical  operations  unless  from 
iemorrhage."  I  hope  such  a  statement  is  based  oh  ex- 
periment and  not  on  theory  alone.  Recent  work  by  some 
of  our  best  surgeons  has  demonstrated  the  great  utility  of 
saline  infusions  in  septic  cases,  after  operations  on  the  in- 
testines, appendix,  abdominal  organs,  and  so  forth,  in  which 
little  or  no  blood  is  lost,  which  now  fortunately  is  the  case 
in  most  operations. 

The  question  of  edema  of  the  lungs  is  a  very  ticklish 
problem,  both  regarding  its  physiology  and  pathology,  and 
I  take  exception  to  Dr.  Keefe's  positive  deductions.  Ac- 
cording to  the  best  authorities,  edema  of  the  lungs  is  al- 
most always  secondary  to  heart  failure,  primary  edema  be- 
ing a  rare  occurrence.  Possler  quite  recently  (\luncli. 
Med.  Wocliens..  No.  8,  February  19,  1901),  believes  he  has 
■demonstrated  by  inoculation  of  rabbits  that  the  heart 
failure  or  sudden  collapse  in  pneumonia  is  not  due  to  car- 
diac weakness  from  overwork  and  so  forth,  but  to  paraly- 
sis of  the  vasomotor  centres  in  the  medulla,  from  which  it 
might  be  concluded  that  the  small  additional  work  given 
to  the  heart  is  more  than  compensated  for  by  the  relief, 
through  the  salt  infusions,  to  the  septic  condition. 

Dr.  Keefe  says;  "Saline  infusions  fail  in  pneumonia  be- 
cause in  the  inflamed  lung  there  is  almost  complete  stasis 
by  reason  of  the  exudate  outside  and  the  clotting  within 
the  vessels."  My  own  pathological  studies  have  shown 
me  that  throughout  all  stages  of  pneumonia  in  spite  of  the 
pressure  on  the  walls  of  the  air  spaces  in  the  diseased 
portions  of  the  lungs,  the  blood  vessels  for  the  most  part 
remained  pervious  during  life,  and  clotting  or  thrombosis 
takes  place  only  in  the  very  smallest  vessels  and  capil- 
laries, and  to  little  extent  in  the  great  majority  of  cases. 
If  salt  infusion  increases  the  circulation  through  the  lungs, 
affected  areas  and  otherwise,  it  may  tend  to  prevent  stasis. 
I  am.  however,  inclined,  owing  to  the  complex  nature 
of  this  subject,  to  lay  stress  on  clinical  experience 
rather  than  any  theoretical  deductions.  Further  observa- 
tion in  my  own  practice  and  that  of  others  has  made 
me  feel  that  there  is  little  danger  of  pulmonary  edema, 
especially  if  infusions  are  given  in  parts  remote  from  the 
lungs,  i.  e.,  thighs,  abdominal  muscles,  and  so  forth.  A  few 
autopsies  on  patients  infused  under  the  breasts  after  sur- 
gical operations  have  shown  in  some  instances  blebs  on  the 
parietal  pleurae.  The  mere  weight  of  the  fluid  given  sub- 
cutaneously,  might  be  a  slight  impediment  to  respiration 
before  absorption,  which  is  usually  rapid,  has  taken  place. 

As  the  importance  of  watching  the  pulmonic  second 
sound  in  pneumonia,  and  bleeding  when  this  becomes  too 
accentuated  or  murmurish.  has  been  emphazized  by  one  of 
the  greatest  authorities  on  hearts  in  our  profession.  I  must 
regret  that  it  seems  a  useless  signal  to  Dr.  Keefe.     The 


statement  that  free  oxygen  in  the  blood  is  of  no  conse- 
quence is  a  questionable  one,  and  any  effect  from  diluting 
the  haemoglobin  may  well  be  counterbalanced  by  the  In- 
creased opportunity  given  to  the  blood  of  getting  oxygen 
through  the  stimulation  to  the  respirations  which  in  all 
my  cases  became  easier  and  deeper,  and  so  continued. 

From  Dr.  Keefe's  paper,  I  judge  he  lays  little  stress  on 
general  toxemia.  He  speaks  of  toxins  in  the  lungs,  and 
says,  "They  are  here  mostly  situated."  Are  toxins  mostly 
situated  in  the  throat  in  diptheria?  We  trust  the  Doctor 
is  not  confusing  the  bacteria  themselves  with  their  pro- 
ducts. When  a  patient  after  several  days  of  muttering  delir- 
ium becomes  conscious  a  few  hours  after  a  salme  infusion, 
I  certainly  have  every  reason  to  believe  that  great  elimina- 
tion or  dilution,  if  you  please,  of  toxins  has  taken  place. 
More  stress  is  laid  everj-  day  on  the  agency  of  the  kidney 
and  spleen  in  removing  toxins  from  the  blood  through 
the  urine  and  sweat,  and  nothing  increases  these  more  with 
less  depression  than  saline  infusions,  as  is  demonstrated 
daily  in  uremia,  eclampsia,  etc. 

In  conclusion,  it  may  be  stated  most  emphatically  that  I 
am  prepared,  in  the  light  of  further  investigation,  to  stand 
by  the  facts  laid  down  in  my  original  article.  My  cases 
were  presented  most  accurately;  in  fact,  were  well  known 
to  many  before  whom  they  were  reported.  My  results  were 
fairly  given  to  the  medical  profession,  and  endorsed  by 
prominent  physicians.  That  many  fine  physiological  points 
were  involved  was  most  apparent,  and  any  theories  ad- 
vanced to  explain  the  undoubted  facts  were  presented  with 
the  hope  of  discussion  by  the  physiologists  of  our  Society. 
1  cannot  see  that  Dr.  Keefe  has  justified  his  criticism. 

The  idea  of  employing  a  diluted  antipneumotoxin  se- 
rum, although  not  original  with  Dr.  Keefe,  is  a  good  one. 
and  some  further  work  on  this  matter  may  appear  in  the 
future. 


PAROTITIS  COMPLICATING  PNEUMONIA.  WITH  THE 
REPORT  OF  A  CASE. 

BY    GEORGE   WILLIAM    NORRIS,   A.    B..    M.    D. 
of  Philadelphia. 

To  the  Editor  of  "The  Philadelphia  Medical  JournaL" 

The  following  case  was  seen  in  the  service  of  Dr.  J.  C. 
Wilson  at  the  Pennsylvania  Hospital  during  February 
of  this  year. 

J.  S.  aet.  58,  was  admitted  suffering  from  a  croupous 
pneumonia  of  the  right  side.  He  was  desperately  ill  and 
his  life  was  almost  despaired  of.  Recovery  however  fol 
lowed,  the  disease  terminating  by  crisis  on  the  9tli  day. 
Three  days  after  this  time  the  patient  began  to  complain 
of  pain  at  the  angle  of  the  left  lower  jaw.  This  region, 
which  was  at  the  time  noticed  to  be  swollen.  increase<l 
rapidly  in  size,  and  became  intensely  swollen  and  tender- 
ihe  overlying  skin  being  tense,  red  and  angry  looking.  Six 
days  later  distinct  fluctuation  developed.  Three  days  after 
the  swelling  had  first  been  noticed  on  the  left  side,  the 
right  began  to  be  involved  and  soon  presented,  though  to 
a  less  marked  degree,  the  appearance  of  the  left.  The 
glands  were  incised  by  Dr.R.H.  Harte,  and  a  large  quantity 
of  pus  evacuated,  which  gave  a  pure  culture  of  the  staphj- 
lococcus  pyogenes  aureus.    Recovery  followed. 

Parotitis  has  been  considered  a  rare  complication  of 
pneumonia,  and  probably  is  so,  although  quite  a  number  of 
cases  have  been  reported  within  the  last  few  years.  Out 
of  a  series  of  500  cases  of  the  latter  disease  recently  tabu- 
lated by  the  author  from  the  records  of  the  Pennsylvania 
Hospital,*  the  condition  was  met  with  only  once.  From  a 
study  of  the  literature  I  have  been  able  to  collect  in  all 
eighteen   cases,    (present   case   included),   from   the   study 

1.     Am.  Jour.  Med.  Sc.  May.  liWl. 


A.rniL  27,  1001) 


CORRESPONDENCE 


L  Mi 


E     PHILAI>EM'HIA 

Medical  Journal 


791 


of  which  the  following  facts  have  been  gleaned.  The 
complication  is  met  with  in  all  ages,  more  commonly  in 
males.  It  usually  appears  with  the  defervescence 
whether  by  crisis  or  bj'  lysis.  The  side  involved 
bears  no  constant  relation  to  the  seat  of  pulmonary  lesion. 
IJoth  parotid  glands  were  involved  in  four  out  of  the  eigh- 
teen cases,  the  involvement  being  successive.  Incision  and 
evacuation  of  pus  were  necessitated  in  five  cases.  One 
evacuated  spontaneously.  The  pus  was  examined  bacteri- 
ologically  in  only  three  instances.  In  one  case  pneumo- 
cocci  were  present.  The  staphylococcus  pyogenes  aureus 
wns  found  in  this  case,  as  well  as  in  the  two  remaining 
ones.  Death  resulted  in  three  cases,  all  of  which  were 
complicated,  one  by  cystitis,  one  by  endocarditis,  one  by 
endocarditis  and  empyema.  In  none  of  these  cases  of 
parotid  bubo  was  there  apparently  any  reason  to  sus- 
pect that  the  glandular  enlargement  was  due  to  the  specific 
infection  of  mumps.  None  of  the  cases  evinced  any  ten- 
dency to  contagiousness,  there  being  no  involvement  of  the 
testes  or  mammae,  and  suppuration  occurred  frequently. 

The  channel  of  infection  was  probably  through  Stensen's 
duct: although  it  is  possible  that  a  blood  metastasis  occurred 
in  Scott's  case  in  which  pneumococci  were  found.  Paro- 
tid bubo  is  broadly  speaking  an  uncommon  condition, 
and  why  an  attack  of  croupous  pneumonia  should  pre- 
dispose to  infection  of  the  gland  through  its  duet  does 
not  seem  evident. 

The  presence  of  pus  as  indicated  by  fluctuation,  being 
in  this  region  usually  hard  to  determine  owing  to  the 
density  of  the  parotid  fascia,  incision  should  be  made  as 
soon  as  a  presumptive  diagnosis  of  suppuration  has  been 
established.  The  well  known  dangers  of  pus  in  this  re- 
gion— i.  e.  paralysis  of  the  facial  nerve,  infection  of  the 
auditory  meatus,  mandibular  articulation,  or  even  of  the 
brain  or  the  formation  of  a  retro-pharyngeal  abscess,  far 
outweighing  all  other  considerations. 

The  17  cases  are  reported  by  the  following  authors: 

Carlow,   (2  cases),  Glasgow  Medical  .Journal.  .July.  '95. 

Osier,  Univ.  Med.  Mag..  Jan.,  '94. 

Hawthorne,  Glasgow  Med.  Jour.,  July,  '95. 

Talley  &  Gittings,  "Phila.  Med.  Jour.,"  Mar.  28,  1900. 

Aldrich,  Med.  News,  Nov.  5,  '98. 

Hamilton,  Univ.  Med.  Mag.,  Vol.  8. 

Coleman,  "Phila.  Med.  Jour.,"  Apr.  29,  1900. 

Anders.  "Phila.  Med.  Jour.,"  May  26.  1900,  (2  cases.) 

Robison,  "Phila.  Med.  Jour.   May  20,   1900. 

Eshner,  "Phila.  Med.  Jour.,"  Feb.   16,  '01. 

Miller,  "Phila.  Med.  Jour.,"  Mar.  16.  '01,  (2  cases). 

Holladay,  "Phila.  Med.  Jour.,"  May  12,  1900. 

Scott,  in  process  of  publication. 

Morris,  "Phila.  Med.  Jour.,"  Mar.  16.  '01. 


THE  BRAINS  OF  TWO  MORE  CELEBRITIES. 

BY    E.   A.    SPITZKA, 

of  New  York. 
,  To  the  Editor  of  "The  Philadelphia  Medical  Journal." 

Dear  Sir: — Subsequent  to  the  completion  of  my  paper 
on  the  brains  of  the  Doctors  Seguin,  father  and  son,  I 
obtained  the  reports  of  two  recent  examinations,  those 
of  Madame  Sonya  Kovalewska,  the  celebrated  mathema- 
tician, (G.  Retzius;  liioUtijisrhe  UiitcrKiicJninijcii,  Neue  Folge, 
IX. 1900,  pp.  1-16.)  and  of  Professor  Carlo  Giacomini, 
(flionnilc  <hU(i  K.  Avnilcmia  di  Torino,  August  1900,  pp.  737- 
S08).  The  brain  of  the  latter  adds  a  noteworthy  item  to 
the  chapter  of  coincidences  since  Giacomini's  brain  ex- 
hibited a  striking  anomaly  which  he  himself  was  the  first 


to  describe,  namely:    tin,  crntral  fixmircK,  and  therefore  a 
so-called  m/riif.  h'oldiitlii  us,  upon  the  right  side. 

The  brain  of  Sonya  Kovalewska  was  not  weighed  imtil 
after  four  year's  immersion  in  alcohol,  the  weight  being 
then  1108  grams.  Retzius  calculated  the  original  weight 
to  have  been  about  1385  grams. 


A  WORD  FOR  THE  CIGARETTE. 

BY   WILLIAM   J.    ROBINSON,   Ph.  G.,    M.   D. 
of  New  York. 

To  the  Editor  of  "The  Philadelphia  Medical  Journal  '* 

A  few  words  apropos  of  your  editorial,  The  Crusade 
Against  Cigarettes,  in  a  recent  number  of  the  "Journal." 
The  writer  is  not  and  has  not  been  a  smoker.  He  smoked 
but  one  cigarette  in  his  life,  and  that  was  when  he  was 
seven  years  old;  and  that  one  made  him  so  deadly  sick 
that  he  never  after  had  any  desire  to  court  the  fragrant 
weed.  If  I  make  bold  enough  to  speak  in  favor  of  the 
cigarette,  I  cannot  well  be  charged  with  partiality  or  par- 
tisanship. That  smoking  by  minors  or  children  is  injuri- 
ous I  admit.  That  smoking  is  or  maj'  be  injurious  to  adults 
suffering  with  any  buccal,  lingual,  pharyngeal,  laryngeal, 
tracheal,  bronchial  or  pulmonary  troubles,  I  admit.  But 
that  cigarette  smoking  is  capable  of  doing  the  damage  as- 
cribed to  it  by  some  sensational  newspapers  Is  extremely 
questionable;  and  that  cigarettes  are  in  any  way  more  in- 
jurious than  cigars  is  positively  false.  That  smoked  to 
excess  both  cigarettes  and  cigars  may  cause  serious  In- 
jury, is  probably  true.  But  no  article  or  method  should 
ever  be  condemned  for  its  abuse  or  misuse.  Tobacco  is  a 
sedative  and  all  sedatives  are  dangerous  when  used  to 
excess,  but  when  used  occasionally  and  in  moderation  ci- 
garette smoking  may  prove  disiinctly  beneficial.  The 
writer  has  seen  more  than  one  case  in  which  a  cigarette 
allayed  nervousness  and  irritability  and  produced  a  dis- 
tinctly soothing  effect;  especially  so  in  women  of  a  deli- 
cate nervous  constitution.  In  one  case  I  prescribed  it  as  a 
remedial  measure,  and  it  gave  better  results  than  the 
bromides  or  valerian.  I  hope  I  shall  not  be  misinterpreted 
as  advocating  that  American  women  should  follow  in  the 
footsteps  of  European  aristocracy  and  take  up  cigarette 
smoking,  but  I  do  say  that  if  the  poor  cigarette  is  to  be 
condemned  and  ostracised  it  should  be  on  scientific 
grounds  after  a  thorough  and  sober  consideration  of  all 
the  facts  and  evidence.  To  call  smoking  immoral  and  con- 
demn it  on  that  ground — well,  it  shows  that  some  people 
have  a  very,  very  queer  notion  of  what  is  moral  and  im- 
moral. 


The  Effect  of  Carbonic  Acid  Baths  on  Healthy  and  Dis- 
eased Circulation. — Kowalsky  (Pncyhul  Ukarski,  Nov.-Dec, 
1900),  found  that  in  healthy  persons  baths  of  30-33°  C. 
diminish  the  activity  of  the  heart  and  raise  the  blood 
presure,  the  pulse  becoming  hard  and  tense.  A  tempera 
ture  of  36-39°  C.  increases  the  heart's  action,  lowers  the 
blood-pressure  and  renders  the  pulse  soft.  In  diseased 
conditions  of  the  heart  these  effects  are  greatly  intensified, 
almost  doubled.  Baths  of  a  temperature  lower  than  34  C. 
are  indicated  in  all  cases  of  cardiac  insufiiciency  dependent 
either  on  valvular  disease  or  degeneration  of  the  heart- 
muscle.  They  are  contraindicted  in  all  cases  of  circulat- 
ory disturbances  accompanied  by  increased  blood-pressure 
and  also  in  interstitial  nephritis.  In  these  conditions  the 
temperature  should  be  above  34'C.  Cold  baths  (below 
34°  C.)  also  act  on  respiration  and  the  excretion  of  urine, 
the  former  being  rendered  less  frequent  and  deeper,  the 
latter  being  increased.     [A.  R.] 


The   rHiLADF,i.rniA"| 


r-c-y        The   rHiLADF.i.rtiiA 
/V''        Medical  Jocbnal 


REVIEWS 


[A VEIL  27,  1901 


IRcvicws. 


Human  Placentation.  An  Account  of  the  Changes  in  the 
Uterine  Mucosa  and  in  the  Attached  Fetal  Structures. 
During  Pregnancy.  By  J.  CLARENCE  WEBSTER,  B. 
A.,  M.  D.  (Edin.),  F.  R.  C.  P.  E.,  F.  R.  S.  E.  Professor 
of  Obstetrics  and  Gynecology  in  Rush  Medical  College 
(affiliated  witti  the  University  of  Chicago);  Fellow  of 
the  American  and  Chicago  Gynecological  Societies 
and  of  the  Edinburgh  Obstetrical  Society;  Correspond- 
ing Member  of  the  Royal  Academy  of  Medicine,  Paler 
mo,  Italy,  and  of  the  Italian  Obstetrical  and  Gyneco- 
logical Society;  Late  Lecturer  on  Gynecology,  M'Gill 
University,  Montreal;  Formerly  First  Assistant  in  the 
Department  of  Midwifery  and  Diseases  of  Women, 
University  of  Edinburgh,  Scotland.  With  233  Illustra- 
tions.   W.  T.  Keener  &  Co.,  Chicago,  1901. 

Dr.  Webster's  book  on  the  development  of  the  human 
placenta  is  based  upon  eleven  years'  work,  during  which 
time  he  has  examined  the  uterus  in  the  second,  third, 
fourth,  fifth,  sixth,  seventh,  eighth,  and  ninth  months  of 
pregnancy,  in  the  three  stages  of  labor  and  at  various  times 
during  the  puerperium.  He  has  also  studied  a  number  of 
complete  abortions  in  the  early  weeks  of  pregnancy,  and 
has  examined  the  pregnant  uterus  in  various  stages  from 
the  mouse,  the  rat,  the  rabbit,  the  guinea  pig,  the  pig,  the 
sheep  and  the  cow. 

This  list  of  tissues  examined, is  extensive:  but  for  the 
condition  of  the  uterus  during  the  first  few  days  of  preg- 
nancy the  author  has  been  obliged  to  make  extensive  use 
of  the  monograph  of  H.  Peters  on  the  Eiiilicildiny  of  th^ 
Hiiiii'iii  Oniiii  mid  llie  EtirlUxt  Kiiiiicn  Sttnjc  of  Human  Flacci- 
tiilioii,  which  appeared  in  1899.  This  is  a  description  of 
probalily  the  youngest  human  bIa.stodermic  vesicle  known ; 
it  has  thrown  light  on  many  points  in  the  evolution  of  the 
placenta  that  were  formerly  most  hazy  and  has  caused  us 
to  make  radical  changes  in  our  ideas  concerning  this 
organ. 

The  first  chapter  is  devoted  to  a  consideration  of  the 
structure  of  the  normal  uterine  mucous  membrane  in  the 
adult  nullipara.  The  author  states  that  the  lining  epithel- 
ium consists  of  ciliated,  columnar  cells,  and  in  this  he 
agrees  with  the  statements  made  in  the  text-books.  The 
cilia  of  this  epithelum  are  extremely  difficult  to  demon- 
strate, however,  and  in  the  photomicrograph  of  the  mu- 
cosa of  the  normal  uterus  those  cilia  are  not  shown. 

The  second  chapter  treats  of  the  formation  of  the  decidua 
vera.  The  author  l)plieves  that  the  nature  of  the  change 
from  the  nonpregnant  condition  is  one  of  marked  hyper- 
trophy of  the  preexisting  cellular  elements  in  the  inter 
glandular  tissue  of  the  normal  mucosa,  and  he  has  entirely 
aliandoned.  and  for  the  best  reasons,  the  older  view  that 
the  decidual  cells  are  developed  from  leukocytes  or  from 
the  glandular  or  surface  epithelium  of  the  mucosa.  In  nor- 
mal cases,  the  author  finds  that  hemorrhage  occurs  only  to 
a  slight  extent. 

The  third  chapter  treats  of  the  formation  of  the  decidua 
reflexa;  decidua  capsularis  or  circumflexa  being  the  pre- 
ferable term  for  this  portion  of  the  decidua.  Here,  again, 
recent  researches,  including  those  of  the  author,  require 
that  we  abandon  the  old  idea  that  the  hypertrophied 
mucous  membrane  folds  around  the  blastodermic  ve.sicle, 
and  we  have  now  the  more  rational  view  that  the  ovum 
erodes  its  way  into  the  substance  of  the  mucosa  and  thu-* 
the  capsularis  is  produced.  We  have  always  been  tauglit 
and  have  in  turn  taught  that  the  capsularis  in  the  later 
months  of  gestation  blends  with  the  vera  to  form  a  single 
layer.  The  author  confirms  the  views  of  Minot  and  E. 
Fraenkel  that  the  capsularis  is  destroyed  and  that  the 
chorion  leve  lies  against  the  decidua  vera.  The  capsularis. 
according  to  this  interpretation  of  specimens,  is  removed 
by  a  process  of  coagulation  necrosis;  no  evidence  of  fatty 
degeneration  having  been  found. 

Chapter  four  is  devoted  to  a  consideration  of  the  changes 
in  the  decidua  serotina,  which  in  the  newer  nomenclature 
is  known  by  the  more  comprehensive  designation  decidua 
placentalis.  In  his  investigations.  Webster  has  reached 
the  same  conclusion  that  has  been  reached  by  Peters  and 
others,    that    the    syncytium    is    not    produced    from    the 


epithelium  of  the  uterine  mucosa,  but  from  the  fetal  ecto- 
derm which  covers  the  chorion.  These  studies  show,  fur- 
ther, that  there  is  no  evidence  in  support  of  the  view  that 
the  lumina  of  the  glands  help  to  form  the  intervillous 
spaces  of  the  placenta.  The  progressive  changes  in  the 
decidua  are  not  mechanical;  the  epithelium  on  the  surface 
and  in  the  glands  is  shed,  probably  on  account  of  the  lack 
of  nutrition  due  to  the  occlusion  of  the  lymphatics.  The 
degeneration  in  the  interglandular  tissue  is  principally  of 
the  nature  of  coagulation  necrosis,  whii  h  gives  rise  to  a 
progressive  hyaline  or  fibrinous  change. 

The  fifth  chapter  treats  of  the  early  relations  between  the 
ovum  and  the  decidua.  The  most  Important  part  of  this 
chapter  relates  to  the  method  of  establishment  of  commimi- 
cation  between  the  maternal  blood  sinuses  and  the  inter- 
villous spaces  of  the  chorion.  We  have  always  been  taught 
that  the  maternal  capillaries  rupture.  The  author,  follow- 
ing Peters,  is  of  the  opinion,  however,  that  the  trophoblast- 
ic hypertrophy  of  the  chorionic  ectoderm  absorbs  the  endo- 
thelial walls  of  the  maternal  vessels  by  phagocytic  action. 
He  points  out,  and  with  reason,  that  the  capillaries  in  the 
decidua  vera  are  dilated  as  well  as  those  in  the  decidua 
placentalis  and  asks  the  pertinent  question:  If  the  latter 
capillaries  rupture  spontaneously,  why  not  the  former? 

The  chorion  and  the  amnion  are  discussed  in  chapters  six 
and  seven,  and  in  chapter  eight  the  plane  of  separation  of 
the  ovum  is  discussed.  The  author  finds  that  in  normal 
cases  the  separation  of  the  placenta  and  the  membranes 
takes  place  through  the  compact  layer  of  the  decidua.  and 
not  through  the  spongj'  layer,  as  formerly  taught.  If  these 
observations  are  confirmed,  we  shall  again  be  obliged  to 
revolutionize  our  teaching. 

In  chapter  nine  the  author  describes  the  shed  placenta 
and  in  the  tenth  chapter  the  phylogeny  of  that  organ  Is 
discussed. 

In  all,  the  book  is  an  important  and  thorough  contri- 
bution to  the  subject  of  development  of  the  placenta,  and 
throws  light  on  many  theoretic  points  that  have  long  been 
open  to  serious  doubt,  but  that  have  been  accepted  on 
account  of  the  authority  of  those  responsible  for  the 
theories. 

An  extensive  bibliography  is  appended,  and  there  art- 
two  hundred  and  sixteen  reproductions  of  photomicro- 
graphs. The  latter,  we  think,  are  not  as  clear  as  reprodu'- 
tions  of  careful  drawings  would  have  been.     [J.  M.  S.] 


3500  Questions  on  Medical  Subjects  for  Self-Examination. 
With  the  Proper  References  to  Standard  Works  in 
which  the  Correct  Replies  Will  be  Found.  Third  Edi- 
tion. Enlarged.  With  Questions  of  the  State  Examin- 
ing Boards  of  New  York.  Pennsylvania  and  Illinois. 
Philadelphia:  P.  Blakiston's  Son  &  Co..  1901.  Price,  10 
Cents. 
Self-examination  for  medical  students  is  a  thick  book  in 
paper  cover,  published  by  the  firm  of  Blakiston  s  Sons  & 
Co.,  the  pages  of  which  measure  SVa  by  4  inches.  The 
book  purports  to  be  compiled  by  a  medical  man  ana  a 
writer  of  experience.  It  is  said  that  by  its  help  the  student 
ciin  successfully  quiz  himself  on  all  the  important  branches 
or  review  any  one  subject  in  wliich  he  feels  himselt  to  be 
particularly  deficient.  In  point  of  fact  the  book  is  an  aaver 
using  scheme  for  the  puolications  of  the  Blakiston  firm, 
since  after  each  of  the  questions,  of  which  there  are  3500 '. 
is  a  set  of  figures,  such  as  9-27.  Of  these  figures  9  refers 
to  a  quiz-conipend  on  surgery.published  by  Blakiston,  and 
27  refers  to  the  page  in  the  quiz-compend  on  wh.ch  the 
answer  will  be  found.  All  of  the  "standard  works  in  which 
the  correct  replies  to  these  questions  will  be  found  '  are 
quiz-compends,  with  the  exception  of  Gould's  Medical  Dic- 
tionary and  Morris's  Anatomy.  The  entire  book  is  founded 
on  an  erroneous  conception  of  the  value  of  the  quiz  system 
and  of  methods  of  study.  How  can  any  one  imagine  that 
by  learning  answers  to  3.500  or  35.000  questions,  a  student 
can  fit  himself  to  practise  medicine?  .\nd  yet  this  is  the 
sort  of  thing  that  a  book  of  this  kind  propagates.  .■\.  man 
learns  a  set  of  answers,  parrot  fashion,  to  a  set  of  ques^ 
tions.  and  is  sent  out  to  practise  a  profession.  The  quii 
system  at  our  colleges  is  liable  to  just  this  sort  of  abuse. 
When  a  quiz-master  conducts  his  course  for  the  purpose  of 
getting  his  men  through  an  examination  he  is  working  on 
fallacious  lines.  But  if  a  nuiz  is  conducted  on  lines  calcu- 
lated to  assist  a  student  in  understanding  his  subject,  to  en- 
able him  to  express  himself  in  good  and  intellisible  English, 


ApniL  27,  1901] 


AMERICAN  NEWS  AND  NOTES 


TTnE   P 
L  Medic 


PHII,AI>ELrIIIA  7QI 

AL  Journal         /70 


and  to  show  him  that  which  he  has  mastered  on  the  one 
hand,  and  that  in  which  he  is  deficient,  on  the  other  hand, 
the  system  is  productive  of  good.  This  applies  also  to  books. 
A  syllabus  of  a  subject  or  a  manual  is  advantageous  to  th<j 
student  because  it  points  out  the  essential  facts  of  a  sub- 
ject and  makes  a  foundation  on  which  a  more  detailed 
superstructure  can  be  reared.  But  a  quiz-compend  with  its 
question  and  its  answer  destroys  originality  and  kills  indi- 
vidual thought,  and  the  book  before  us  is  one  of  the  worst 
features  of  an  abused  system.  The  author's  name  is  prop- 
erly withheld,  and,  we  venture  to  think,  little  credit  will 
accrue  to  the  publishing  house  for  putting  the  book  on  the 
market.     [J.  M.  S.] 


Actiologis  und  Prophylaxe  der  Lungentuberculose.  Eti- 
ology and  Prophylaxis  of  Pulmonary  Tuberculosis.  By 
DR.  J.  RUHEMANN,  8  vo.,  pp.  88.  Jena:  Gustav 
Fischer,  1900.    Price,  2.50  Mark. 

While  the  doctrine  of  the  specificity  of  diseases  has  been 
more  firmly  established  in  recent  years  it  is  at  the  same 
time  recognized  that,  especially  from  the  prophylactic  point 
of  view,  attention  must  be  directed  to  the  predisposing 
and  contributory  etiologic  factors  scarcely  less  than  to  the 
exciting  causes.  In  the  monograph  before  us  evidence  and 
argument  are  adduced  to  show  the  significant  part  played, 
especially  by  influenza,  in  the  etiology  of  tuberculosis  and  as 
a  corollary,  the  importance  of  devoting  particular  care  to 
the  prophylaxis  and  treatment  of  the  former  disease  under 
two  heads  of  etiology  and  prophylaxis,  the  former  in  4 
chapters,  the  latter  in  one.  There  are  taken  up  success- 
fully "the  inadequacy  of  existing  laws  as  to  the  etiology  of 
tuberculosis,"  "the  influence  of  influenza  upon  the  develop- 
ment of  tuberculosis,"  "the  influence  of  influenza  upon  the 
progress  of  tuberculosis,"  "the  influence  of  sunlight  upon 
the  development  and  progress  of  pulmonary  tuberculosis." 
and  "the  prophylatic  measures  against  tuberculosis." 
Whether  or  not  one  agrees  with  the  argument  and  the  con- 
clusion, the  publication  will  be  found  to  contain  much  that 
is  interesting  and  well  worth  reading.    [A.  A.  E.] 


Leukocytosis  and  the  variations  of  the  Polymorphonu- 
clears in  Typhoid  Fever. — Barbaroux.  iGaz.  Hel).  ilc  Mid. 
<:/  rfc  rhiiiir.,  March  3,  1901,  48  me.,  Annee,  No.  IS.)  ( Ly 
ons  thesis,  1900-1901,  No.  137.)  After  a  study  of  the 
leukocytosis  of  typhoid  fever,  Barbaroux  concludes:  (1) 
That  during  the  fastigium  of  the  disease  there  is  usually 
a  well-marked  hypoleukocytosis.  which  effects  principally 
the  lymphocytes,  for  although  the  polymorphonuclears  may 
be  reduced  in  number  their  percentage  is  almost  always 
equal  to  or  above  the  normal.  (2)  Toward  defervescence 
an  increase  in  the  number  of  leukocytes  is  seen,  which 
does  not,  as  a  rule,  however,  reach  the  normal  figure.  In 
this  stage,  also,  there  is  a  variable  percentage  of  poly- 
morphonuclears. At  the  end  of  this  latter  period  or  in  the 
first  days  of  apyrexia,  there  is  a  considerable  and  con- 
stant diminution  of  the  total  leukocytosis,  affecting  par- 
ticularly the  polymorphonuclears  of  which  tlie  percentage 
is  very  low,  usually  less  than  50%.  (3)  At  the  end  of  sev- 
eral days  the  number  of  leukocytes  returns  to  normal  or 
above  with  a  more  rapid  increase  in  the  number  of  lympho- 
cytes than  of  the  polymorphonuclears.  (4)  In  benign  forms 
of  typhoid  fever  there  may  be  hyperleukocytosis.  as  high 
as  12.000.  or  hypoleukocytosis,  as  low  as  4.000  during  the 
entire  febrile  period.  If  pneumonia  occurs  as  a  complica- 
tion, the  number  of  leukocytes,  particularly  of  the  poly- 
morphonuclears, will  almost  certainly  increase.  If  the  com- 
plication is  due  to  the  bacillus  of  Eberth.  the  evolution  of 
the  leukocytic  curve  will  correspond  to  that  of  a  relapse. 
In  grave  forms  of  the  disease  with  relapses,  etc.,  the  leu- 
kocytic curve  is  very  variable,  showing  oscillation  above 
and  below  the  normal  or  a  constant  hyperleukocytosis.  In 
certain  forms  of  relapse  a  leukocytic  curve  similar  to  that 
of  the  first  attack  is  often  seen.  In  certain  forms  of  the 
disease  which  end  fatalb  it  is  impossible  to  demonstrate 
a  general  hyperleukocytosis  with  an  increase  of  the  per- 
centage and  of  the  absolute  numlier  of  the  polymorphonu- 
clears during  the  latter  period  of  the  disease.  In  all  irregu- 
lar forms  hypoleukocytosis  is  usual  during  the  greater  per- 
iod of  the  disease.  There  is.  as  a  rule,  no  parallel  course 
In  the  agglutinating  curve  and  the  leukocytic  curve.  On 
the  contrary,  it  is  usual  to  find  that  there  is  considerable 
lowering  of  the  number  of  leukocytes  when  the  agglutin- 
ating power  of  the  serum  is  at  the  highest.     [J.  M.  S.] 


Hnicrican  Mcvvs  all^  JHotcs. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

College  of  Physicians. — Sections  of  Gynecology. — At  the 
munihly  meeting  held  April  IS,  Dr.  R.  G.  LeConte  read  a 
paper  on  The  value  of  Hegar's  sign  in  differentiating  preg- 
nancy from  uterine  myoma.  Dr.  LeConte  spoke  of  the 
difficuUy  in  diagnosis  when  a  myoma  with  little  fibrous 
tissue  presented  a  soft,  smooth  mass  with  rounded  out- 
line. In  some  of  these  there  is  doubt  even  when  the  ab- 
domen is  opened.  Hegar's  sign  cannot  always  be  proved 
or  disproved,  especially  in  fat  subjects.  Its  value  as  a 
positive  sign  is  unequally  rated  by  eminent  authorities. 
Dr.  LeConte  has  found  it  of  value  in  3  cases  operated  upon 
for  myoma.  When  the  abdomen  was  opened  the  uterus 
appeared  so  much  like  a  pregnant  one  that  there  was 
some  doubt  as  to  the  condition  present.  A  search  for 
Hegar's  sign  showed  it  to  be  present  in  each  case  and 
hysterectomy  proved  each  to  be  a  myoma.  Dr.  C.  P  No- 
ble said  that  he  had  never  seen  Hegar's  sign  present  when 
liregnamy  was  absent.  An  eaily  sign  of  pregnancy  upon 
which  he  places  a  great  deal  of  reliance  is  the  serai- 
cystic  feel  of  the  uterus  caused  by  the  increasing  amount 
of  iiuid  within.  This  with  the  jutting  out  of  the  body 
of  the  uterus  beyond  the  cervix,  due  to  enlargement,  is 
considered  to  be  the  most  reliable  early  sign.  Dr.  E.  P. 
Davis  said  that  Hegar's  sign  should  be  present  in  all  nor- 
mal pregnant  uteri  when  no  adhesions  are  present  and  is 
a  most  positive  sign.  Dr.  Richard  C.  Norris  stated  that 
Hegar's  sign  was  not  of  any  value  to  the  man  who  makes 
casual  examinations  as  it  is  difficult  to  elicit  and  requires 
a  skilled  touch.  Sometimes  anesthesia  is  necessary.  It 
is  of  value  in  association  with  intermittent  contractions  of 
the  uterus  and  increase  in  size,  especially  unilateral  in- 
crease. Dr.  A.  Ernest  Gallant,  of  New  York,  read  a  pa- 
per on  the  corset  for  movable  kidney.  Dr.  Gallant  stated 
that  from  90  to  95%  of  symptomatic  movable  kidneys  can 
be  relieved  symtomaticaily  by  the  judicious  use  of  the 
corset.  The  symptoms  and  diagnosis  of  movable  kidney 
were  considered  at  length.  In  speaking  of  the  diagno- 
sis Dr.  Gallant  recommended  to  the  practitioner  the  con- 
stant practice  of  abdominal  palpation  in  all  cases  as  well 
as  the  examination  of  heart  and  lungs.  It  is  only  in  this 
way  that  proficiency  in  diagnosticating  pathologic  les- 
ions can  be  acquired.  He  believes  that  movable  kidney 
is  much  more  common  than  is  stated.  The  statistics  of 
1900  gynecologic  cases  wei-'e  given.  Of  1000  at  one  dis- 
pensary 21  had  movable  kidney.  Of  800  at  another  dis- 
pensary 7  had  movable  kidney.  Of  100  seen  in  office  prac- 
tice 21  had  movable  kidney.  The  various  sets  of  symp- 
toms in  different  cases  were  considered.  In  25  out  of 
Dr.  Gallant's  41  cases  both  kidneys  were  movable.  Thoso 
cases  in  which  the  kidney  is  at  the  pelvic  brim, 
as  a  rule  give  the  least  trouble.  In  speaking  of  the  treat- 
ment it  was  said  that  fixation  only  transferred  the  weight 
from  the  vascular  pedicle  lo  a  cicatrix.  This  treatment 
does  not  achieve  all  that  is  desired.  Mistakes  in  diag- 
nosis also  make  the  surgeon  hesitate  before  operating. 
Mechanical  means  are  considered  superior  to  operative 
procedure.  Belts  and  pads  have  their  advantages.  Cor- 
sets are  much  better  and  physicians  had  better  teach 
women  to  use  them  properly  than  to  give  them  up.  Tho 
prevailing  style  of  corset  is  a  good  one  for  this  purpose. 
It  should  be  as  long  in  front  as  can  be  worn.  .\  corset  2 
inches  smaller  than  the  size  usually  worn  should  be  se- 
lected. The  lacing  should  be  from  below  upward,  push- 
ing the  kidney  well  up  beneath  the  ribs  before  fastening 
tho  upper  hooks.  The  corset  should  be  fastened  on  be- 
fore the  patient  rises  in  the  morning.  Great  attention 
should  be  paid  to  the  general  health  of  the  patient.  Dr. 
John  B.  Deaver  has  had  very  little  success  with  appli- 
ances and  prefers  to  anchor  the  kidney  by  means  of  gauze. 
Jaundice  in  movable  kidney  he  believes  to  be  due  to  a  re- 
laxed condition  of  the  peritoneum  and  its  contetns  which 
allows  the  kinking  of  the  duct.  The  objection  to  the  su- 
ture is  that  it  may  cause  urinary  extravasation.  The  kid- 
ney substance  is  too  soft  for  the  stitches  to  hold  and  in- 
flammatory tissue  is  the  only  real  cause  of  holding  even 
when  sutures  are  inserted.  Dr.  Chas.  P.  Noble  examined 
all  his  patients  for  one  year  for  movable  kidney  and  found 
that  every  fifth  one  had  that  condition.     He  prefers  tha 


794 


The   Philadelphia"! 
Medical  JorBXAL  J 


AMERICAN  NEWS  AND  NOTES 


[AfBIL  27,  1901 


patient  in  the  standing  position  when  making  the  exam- 
ination. He  uses  sutures  and  has  never  had  any  untow- 
ard results  from  them.  Dr.  Shober  exhibited  a  corset  de- 
signed by  a  resident  of  Philadelphia.  He  believes  that  re- 
tention of  uriue  and  distention  of  the  bladder  is  a  cause 
of  movable  kidney  by  inducing  absorption  of  the  perirenal 
I'at.  Dr.  B.  C.  Hirst  spoke  of  the  application  of  the  corset 
to  patients  while  in  the  Trendelburg  position.  Dr.J.M.Baldy 
stated  that  movability  of  the  kidney  was  only  a  relative 
question  which  is  settled  by  the  observer's  standard  as 
to  what  constitutes  a  movable  kidney.  He  does  not  find 
any  such  proportion  of  cases  as  were  reported.  The 
symptoms  of  the  condition  are  largely  neurotic  and  he 
does  not  see  how  mechanical  appliances  are  to  ameliorate 
them.  Dr.  John  G.  Clark  said  that  the  condition  was  often 
one  of  general  enteroptosis,  especially  in  women  who  have 
some  children,  hence  relief  is  caused  by  binders.  No 
operation  should  be  done  unless  grave  symptoms  are 
present.  So  many  women  have  flat  abdomens  that  it  is 
hard  to  get  the  corset  to  fit  snugly.  Dr.  Geo.  F.  Shoe- 
maker said  that  many  women  cannot  wear  corsets.  Ap- 
pliances generally  have  little  effect  on  the  kidney.  Dr. 
B.  C.  Hirst  gave  a  very  brief  report  on  the  relative  merits 
of  the  different  methods  of  panhysterectomy  in  malignant 
disease  of  the  uterus.  Four  methods  were  named — the 
abdominal,  the  vaginal,  the  abdominal  and  vaginal,  and  the 
vaginal  and  abdominal.  The  latter  is  much  preferred.  It 
is  neater,  any  enlarged  glands  can  be  removed,  and  con- 
valescence is  shorter. 

Pediatric  Society. — The  regular  monthly  meeting  was 
April  9.  the  president.  Dr.  T.  S.  Westcott,  presiding.  The 
address  of  the  evening  was  delivered  by  Dr.  L.  Emmett 
Holt,  of  New  York,  his  subject  being  some  forms  of  indi- 
gestion in  infants  and  young  children  with  especial  refer 
ence  to  their  dietetic  treatment.  Dr.  Holt  spoke  mainly 
of  the  chronic  forms  of  indigestion.  In  regard  to  the  trans- 
mission of  this  condition  Dr.  Holt  believes  that  direct  inher- 
itance is  questionable.  The  progress  of  an  infant  during 
the  first  year  depends  upon  its  condition  during  the  first 
3  months,  and  that  upon  the  start  it  gets  in  the  first  i 
weeks.  Dr.  Holt  is  more  and  more  impressed  with  the 
sensitiveness  of  the  infant  digestive  apparatus.  Almost 
a.s  much  trouble  with  infants  is  caused  by  bad  nursing  as 
by  bad  feeding.  The  average  obstetrician  has  but  little 
knowledge  of  the  care  needed  during  the  first  few  days  or 
weeks  of  an  infant's  life.  To  be  successful  the  pediatrist 
needs  to  have  charge  of  the  infant  from  the  first,  and  not 
begin  when  it  is  1  month  old.  The  child  can  be  accustomed 
to  cow's  milk  only  by  very  careful  training.  The  milk  of 
the  Walker-Gordon  laboratory  is  considered  to  be  much 
better  than  any  other  infant  food.  The  initial  formula  is 
generally  1%  fat.  e^Ii  sugar,  and  ..5  proteids.  The  proof  of 
whether  the  child  is  doing  well  on  a  certain  formula  is  its 
degree  of  comfort.  A  healthy  infant  should  sleep  about 
22  out  of  24  hours,  should  not  vomit,  should  have  no  colic. 
Sometimes  it  will  be  constipated,  but  this  will  disappear 
when  the  food  is  made  stronger.  Is  the  child  entirely 
comfortable?  Then  bide  the  time  when  it  shall  gain  in 
weight  and  do  not  pay  too  much  attention  to  constipation. 
Feeding  should  be  begun  at  the  end  of  the  first  24  hours, 
and  with  a  strong,  lusty  child,  even  before  that  time.  Early 
feeding  helps  prevent  the  initial  loss  in  weight.  The  symp- 
toms of  indigestion  may  be  divided  into  two  groups:  those 
where  the  stomach  is  at  faiilt.  and  those  where  the  intestines 
are  the  seat  of  trouble.  Very  rarely  has  gastric  dilatation 
much  to  do  with  indigestion.  Vomiting  is  caused  more 
often  by  a  high  amount  of  fat  than  by  any  other  condition, 
the  organic  acids  formed  from  the  fat  being  the  cause  of 
trouble.  In  these  cases  avoid  milk  and  cream  and  give 
milk  and  water.  Stomach  washing  and  in  some  cases  irri- 
gation may  be  tried.  In  cases  of  vomiting  from  the  pres- 
ence of  mucus,  stomach  washing  is  the  only  remedy.  At- 
tacks of  acute  indigestion  are  dangerous  and  are  often 
caused  by  surprisingly  small  quantities  of  cow's  milk. 
These  cases  are  generally  said  to  be  due  to  infection  from 
the  milk,  but  other  causes  may  be  acting.  A  case  was  cited 
In  which  a  child  which  had  been  sick  had  had  a  normal 
temperature  for  4  days  when  one  ounce  of  milk  was  given 
and  death  followed  in  4S  hours.  This  was  due  to  a  latent 
condition  of  the  bowels  which  the  milk  had  caused  to  be 
active.     Such  cases  prove  that  good  milk  in  small  quanti- 


ties may  be  poisonous — the  fault,  however,  being  not  in  the 
milk,  but  in  the  child.  Attention  should  always  be  paid 
to  the  previous  history  of  the  child.  If  several  attacks  of 
indigestion  have  been  caused  by  cow's  milk,  do  not  begin  it 
at  once.  Dr.  Holt  stated  that  he  was  a  firm  believer  in  the 
artificial  feeding  of  infants,  but  that  it  has  its  limitations, 
and  a  wet  nurse  is  desirable  in  some  cases,  though  this 
may  be  the  worst  possible  expedient  in  others.  Every 
mother  is  to  use  her  milk  when  possible,  but  this  is  not 
always  the  best  for  the  infant,  an  immense  amount  of 
harm  being  done  by  nursing  when  it  should  not  be  done. 
The  best  test  is  the  effect  of  the  milk  upon  the  child. 
Where  there  is  persistent  indigestion  with  no  gain  in 
weight,  the  case  is  hopeless,  and  nursing  should  be 
stopped.  In  feeding  children  with  indigestion  try  less 
milk  with  higher  percentages  and  give  water  between 
meals.  Feeding  should  not  be  oftener  than  once  in  2  hours 
and  in  the  majority  of  cases  4  hours  is  better.  Some  of  the 
points  emphasized  in  conclusion  were:  (1.)  The  simplicity 
of  the  question  of  feeding  infants  when  they  possess 
healthy  organs  and  the  complexity  of  the  problem  when 
these  organs  are  deranged.  (2.)  The  comfort  of  the  infant 
is  the  guide  as  to  the  correctness  of  the  feeding.  (3.j  No 
mother  should  nurse  an  Infant  which  has  persistent 
indigestion  and  does  not  gain  in  weight.  '4.)  If  there  is  a 
gain  in  weight,  then  try  to  overcome  the  indigestion. 
1,5.)  There  is  no  more  troublesome  symptom  than  vomit- 
ing. This  is  due  in  the  majority  of  the  cases  to  too  large 
an  amount  of  fat,  hence  that  ingredient  should  not  be  in- 
creased too  rapidly.  (6.)  Too  much  attention  should  not 
be  paid  to  traditional  opinions  regarding  the  amount  of 
fat,  proteids,  etc.  In  discussing  the  paper  of  Dr.  Holt,  Dr. 
.T.  P.  Crozier  Griffith  said  that  great  care  with  the  minute 
details  of  feeding  and  nursing  infants  was  the  cause  of 
success.  Constipation  in  a  healthy  baby  is  a  sign  of  assimi- 
lation of  the  food  taken,  and  should  be  let  alone  in  very 
many  cases.  It  is  the  custom  now  to  say  that  something  is 
wron.g  with  the  food  when  indigestion  occurs.  Older 
writers  traced  many  of  these  cases  to  taking  cold,  to  wear- 
ing certain  binders,  etc.  i  hese  points  are  too  often  over-  ■ 
looked  at  lae  present  time.  There  are  undoubtedly  many  J 
instances  in  wuich  outside  conditions  are  responsible,  and  1 
the  details  of  hygiene  should  be  carefully  watched.  Dr. 
E.  E.  Graham  spoke  of  the  treatment  of  acute  indigestion,  j 
Milk  is  withdrawn,  and  sterile  water  or  albumin  water, 
with  stimulants  it  necessary,  is  given.  After  a  time  the 
use  of  expressed  meat  juice  is  begun,  this  being  followed 
by  peptonized  milk.  Dr.  .\lfred  Stengel  said  that  the  time 
had  hardly  been  reached  when  fundamental  prin- 
ciples in  infant  feeding  could  be  dealt  with.  Ef- 
forts in  that  line  are  now  mainly  attempts  to 
cause  sick  children  to  thrive  on  the  food  of  healthy 
children.  The  reduction  of  food  should  be  considered 
as  well  as  the  change  in  character.  Proteid  foods  and 
high  fat  percentages  are  badly  borne  in  proportion  to  the 
degree  of  inanition  present  in  the  infant.  Carbohydrates 
should  be  increased  and  the  others  withdrawn.  Dr.  Holt 
said  that  regarding  intestinal  lavage,  etc..  the  primary 
principle  to  follow  was  not  to  do  any  harm.  In  cases  of 
summer  diarrhea  many  infants  are  killed  by  over-treat- 
ment. A  child  fed  by  rule  can  be  managed  if  that  principle 
is  started  rightly.  Hospitals  are  the  poorest  places  to 
study  infant  feeding.  Find  out  what  food  the  child  can 
stand  and  send  it  out  to  return  for  treatment  when  neces- 
sary. 

Resignation  of  Dr.  Risley. — Dr.  Samuel  D.  Risley  has  re- 
signed from  the  service  of  the  Philadelphia  Polyclinic  after 
a  long  service  as  Professor  of  Diseases  of  the  Eye  in  that 
institution.  He  has  been  created  by  the  Board  of  Trustees, 
Emeritus  Professor  of  Diseases  of  the  Eye.  In  common 
with  several  other  members  of  the  Board  of  Trustees  of  the 
Philadelphia  Polyclinic.  Dr.  Risley  had  also  resigned  vol- 
untarily in  order  that  the  Board  might  become  entirely  a 
body  of  laymen.  Dr.  William  Campbell  Posey  was  elected 
to  the  vacancy  caused  by  Dr.  Risley's  resignation. 


Ai'UiL  27.  1901] 


AMERICAN  NEWS  AND  NOTES 


CTilR     I'HILAD 
Mkpical  Jo 


DEI.IHIA 
LRNAL 


795 


Vital  Statistics  of  Philadelphia  for  the  week  ending 
April  20,  1901: 

Cases.         Deaths. 
Inflammation  of  the  appendix  7,  bladder 
1.   brain   16,   bronchi   8,   heart   4,   kid- 
neys 19,  liver  3.  lungs  47.  peritoneum 
10,  pleura  3,  stomach  and  bowels  13, 

tonsils    1     132 

Marasmus  12,  debility  6   18 

Tuberculosis  of  the  lungs 75 

Apoplexy  17,  paralysis  9   26 

Heart-disease  of  24,   dropsy  of  2,  fatty 

degeneration  of  2.  neuralgia  of  u   .  . . .  33 

Uremia  13,  diabetes  2,  Bright's  disease  7  22 

Carcinoma  of  bladder  1.  breast  3,  stom- 
ach   4.    uterus    1.    liver    1.    penis    1, 

throat  1,  rectum  1   13 

Convulsions    17 

Diphtheria 48  10 

Brain-congestion  of  2,  disease  of  1  soft- 
ening of  4  7 

Typhoid  fever  44  8 

Old  ago   17 

Cyanosis    1 

Scarlet  fever  85  3 

Abscess  of  neck  3,  pelvic  2.  spine  1, 
alcoholism  1,  aneurism  aorta  1,  asth- 
ma 1.  anemia  1,  atheroma  2,  burns 
and  scalds  4,  casualties  9,  cerebro- 
spinal meningitis  2,  congestion  of 
lungs  G.  cirrhosis  of  liver  4,  croup, 
membranous  4,  disease  of  spine  2, 
drowned  2,  erysipelas  1.  fever,  puer- 
peral 1.  indigestion  1.  jaundice  2,  ob- 
struction of  the  bowels  1.  edema  of  the 
lungs  3,  poisoning  1.  rheumatism  1, 
sclerosis,  arterial  2.  septicemia  3, 
smallpox  1.  sarcoma  of  jaw  1.  of  uterus 
1,  suffocation  4.  suicide  1,  syphilis  1, 
tetanus  1,  unknown  coroner  case  1, 
whooping  cough  S.  wounds,  gunshot  1  81 

NEW    JERSEY. 

The  Camden  City  Dispensary. — The  Camden  City  Dispen- 
sary, the  well-known  institution  which  has  been  doing  such 
a  noble  and  charitable  service  for  the  worthy  poor  in  the 
city  of  Camden  and  vicinity,  in  need  of  medical  and  surgical 
aid,  enters  upon  the  thirty-sixth  year  of  its  history  with  a 
record  creditable  alike  to  the  city  as  well  as  the  physi- 
cians who  have  been  energetic  in  pushing  the  institution 
to  the  front.  As  early  as  1859  Dr.  Othniel  Hart  Taylor 
called  the  attention  of  the  Camden  City  Medical  Society 
to  the  propriety  of  petitioning  City  Council  for  the  estab- 
lishment of  a  dispensary.  Any  institution  like  this  one 
which  ministers  to  the  worthy  poor  is  deserving  of  the 
highest  commendation. 

NEW  YORK. 

Elected  Professor. — Dr.  Heinrich  Stern  has  been  elected 
professor  of  internal  medicine  in  the  New  York  School  of 
Clinical  Medicine. 

Dr.  Frank  Wayland  Abbott. — Dr.  Frank  Wayland  Abbot, 
regarded  as  one  of  the  foremost  oculists  in  Western  New 
York,  died  at  his  home,  No.  523  Franklin  street,  on  April  9. 
after  a  protracted  illness.  Dr.  Abbott  was  graduated  from 
the  University  of  Buffalo  in  1866.  and  was  oculist  in  chief 
at  the  General  Hospital  and  the  Eye,  Ear  and  Throat  Hos 
pital,  of  Erie  County. 

New  York  School  of  Clinical  Medicine. — The  New  York 
School  of  ClinicalMedicine  invites  the  local  profession  and 
visiting  physicians  to  the  following  course  of  lectures  to  bo 
delivered  every  Friday  evening  in  April  and  May  at  6.30. 
at  32S  West  42nd  St.  April  5th.  Examination  of  the  Male 
Urethra  by  the  General  Practitioner.  Clinical  Demonstra- 
tions; Ferd.  C.  Valentine.  M.  D.  April  12th,  Medical  Ques- 
tions of  the  Responsibility  of  Alcoholics,  Opium  and  Other 
Drug  Takers.  Thomas  D.  Crothers,  M.  D.  April  19th.  Com- 
plicated Fractures:  Diagnosis  and  Modern  Treatment. 
Thomas  H.  Manley,  M.  D.  April  26th.  Diagnosis  and  Surgi- 
cal Treatment  of  Prolapsed  Kidney:  With  Clinical  Demon- 
strations, Augustin  H.  Goelet,  M.  D.     May  3rd,  Treatment 


of  Strangulated  Hernia.  Carl  E.  Pfister,  M.  D.  May  10th. 
Pelvic  Trilogy  in  the  Diagnosis  of  Diseases  of  Women,  A. 
Ernest  Gallant.  M.  D.  May  17th.  The  Techniques  of  Major 
and  Minor  Amputations,  Robert  H.  Cowan.  M.  D.  May  24th, 
Treatment  of  Obesity.  Heinrich  Stern,  Ph.  D.  M.  D.  May 
31st,  Diseases  of  the  Stomach:  Practical  Examinations  and 
Treatment.  Demonstrations  on  Patients.  Freeman  F.  Ward. 
M.  D.  .Tune  7th,  Psoriasis  and  Acne.  Effective  and  Prac- 
tical Methods  of  Treatment:  Clinical  Demonstrations,  W. 
R.  Inge  Dalton,  M.  D.     Marcus  Kenyon,  M.  D.,  Secretary. 

New  York  Neurological  Society. — Stated  Meeting  April  2, 
1901,  Joseph  Collins,  M.  D.,  President. — Recurrent  Oculo- 
motor Palsy. — Dr.  William  M.  Leszynsky  presented  a  wom- 
an, twenty-nine  years  of  age,  whom  he  had  first  seen 
four  months  ago.  When  six  years  old  she  had  begun  to 
have  attacks  of  headache  confined  to  the  right  temporal 
and  supraorbital  regions,  and  invariably  accompanied  by 
vomiting.  The  attacks  occurred  every  five  or  six  weeks. 
At  her  twelfth  year  the  customary  paroxysm  had  been 
associated  with  ptosis  of  the  right  eye,  from  which  she  had 
recovered  m  two  weeks,  the  migraine  continuing  to  recur 
as  before.  The  second  attack  of  oculomotor  paralysis  had 
occurred  in  her  nineteenth  year,  with  some  pain  and  vomit- 
ing. There  were  partial  ptosis,  diplopia  and  inabilty  to  look 
upward  with  the  right  eye.  She  had  improved  in  three 
weeks,  but  the  eye  did  not  move  upward  as  well  as  before 
for  a  few  months  and  then  there  had  been  complete  recov- 
ery of  motility.  The  third  attack  had  occurred  in  her 
twenty-second  year,  and  had  been  characterized  by  almost 
complete  ptosis,  outward  deviation  of  the  eye  and  di- 
plopia. She  had  been  obliged  to  keep  the  eye  covered 
for  three  months,  but  had  recovered  in  about  a  year.  The 
fourth  attack  had  been  two  and  a  half  years  ago  and  the 
fifth  only  three  weeks  ago.  She  now  complained  of  the 
eye  turning  outward  and  of  her  inability  to  look  up- 
ward. The  periodical  headaches  bore  no  relation  ta 
menstruation.  Examination  showed  slight  drooping  or  the- 
right  upper  eyelid,  paralysis  of  the  superior  rectus  and 
paresis  of  the  inferior  and  internal  recti.  The  right  pupil 
is  5  mm.  in  diameter  and  rigid,  while  the  left  measures 
3  5  mm.  and  reacts  normally.  Vision  is  normal  in  both 
eyes,  and  the  fields  and  fundi  are  normal.  She  is  anemic 
and  neurasthenic.  The  family  history  was  unimportant, 
and  her  ocular  condition  had  practically  remained  un- 
changed since  the  first  examination.  The  speaker  said' 
that  the  most  interesting  features  were  the  comparative 
rarity  of  this  type  of  oculomotor  palsy  and  its  pathology. 
Only  two  authentic  cases  of  recurrent  oculomotor  palsy 
had  been  studied  post-mortem,  one  by  Richter.  in  1887,  antt 
the  other  by  Karpli.s.  in  1895.  In  the  former,  a  fibrochon- 
droma  existed  in  the  course  of  the  nerve  trunk  at  the 
base  of  the  skull,  and  separated  but  did  not  destroy  the 
nerve  fibres.  In  the  other  case,  there  was  a  neuro-fibroma 
of  the  motor  oculi  at  the  base.  In  many  of  the  reported 
cases  complete  recovery  had  taken  place,  but  in  others 
the  paralysis  had  .gradually  increased  during  the  inter- 
vals, and  had  ultimately  become  permanent.  Dr.  Leszyn- 
sky said  that  he  had  seen  four  other  cases.  In  the  first, 
there  had  been  complete  paralysis  of  the  third  nerve  with 
a  clear  history  of  accompanying  migraine.  Recovery  had 
been  spontaneous.  Dr.  B.  Socks  said  that  these  cases  were 
extremely  rare,  though  he  had  been  fortunate  enough 
to  see  two  in  the  past  six  months.  One  had  been  in  a 
boy  of  four  years  who  within  a  year  had  had  two  dis- 
tinct attacks  of  oculomotor  paralysis  of  one  eye.  He 
had  recovered  in  a  few  months  from  the  first  attack.  The 
family  history  was  entirely  negative.  He  understood  that 
improvement  had  followed  the  second  attack.  There  had 
been  apparently  no  migriane  here.  Dr.  Leonard  Weber 
said  that  he  had  presented  a  case  of  this  kind  to  the  soci- 
ety twelve  or  more  years  ago.  The  man  had  oculomotor 
palsy  on  the  right  side.  He  had  watched  the  case  for  a 
number  of  years.  After  about  two  years  there  had  only 
been  a  little  ptosis  remaining.  After  a  course  of  iodide 
the  man  had  greatly  improved,  and  had  ultimately  died  of 
pulmonary  tuberculosis.  Dr.  B.  Onuf  said  that  he  had 
presented  such  a  case  to  the  society  one  year  ago.  The 
patient  had  since  been  given  iodide  of  potassium  in  increas- 
ing doses,  and  had  moved  to  the  country.  The  attacks 
had  become  shorter  and  less  severe.  He  did  not  believe 
that  there  was  always  a  lesion  of  the  oculomotor  alone. 
His  own  case  was  undonbtt"'dly  one  of  migraine.     Dr.  Les- 


.-qA  The     I'HILADELrHIA"] 

/y  Medical  Jolrnai.  J 


AMERICAN  NE  WS  AND  NOTES 


[  A  PBII,  27,  19Ca 


zynsky  said  that  a  very  novel  theory  had  been  brought  for- 
ward regarding  this  paralysis  occurring  in  connection  with 
migraine.  It  had  been  assumed  that  there  is  an  increased 
vascularity  of  the  hemisphere  during  the  attack  of  mi- 
graine, causing  a  disturbance  of  the  function  of  the  third 
nerve.  A  Case  of  Malignant  Tumor  of  the  Shoulder  Per- 
forating the  Spinal  Canal. — Dr.  Leonard  Weber  read  this 
report,  and  presented  the  specimen.  The  subject  was 
a  man  of  thirty-one  whom  he  had  first  seen  in  1891.  He 
had  presented  the  usual  symptoms  of  a  recent  syphilis,  and 
had  been  treated  for  this  with  improvement.  In  1894  he 
had  returned  because  of  a  perichondritis  of  the  cartilagi- 
nous portion  of  the  nasal  septum.  At  this  time  a  small 
movable  tumor,  the  size  of  a  cherry,  was  noted  in  the 
right  shoulder.  This  was  supposed  to  be  gummatous.  The 
•tumor  diminished  under  mixed  treatment,  but  a  small 
nodule  remained.  In  June,  1900,  the  man  had  sought  relief 
because  of  a  hard,  solid  and  almost  immovable  tumor  of 
the  shoulder,  which  he  said  developed  shortly  after  a  blow 
on  the  shoulder  received  one  year  previously.  No  benefit 
had  resulted  from  rapidly  increasing  doses  of  iodide  or 
from  the  biniodide  of  mercury.  Three  months  later  a  por- 
tion of  the  growth  was  submitted  to  microscopical  exam- 
ination, with  the  result  that  it  was  declared  by  two  path- 
ologists to  be  a  round  cell  sarcoma.  An  effort  had  then 
been  made  to  remove  the  growth,  but  this  had  been 
found  impracticable.  Injections  of  arsenite  of  soda  and 
carbolic  acid  had  been  given  for  a  time,  but  without  bene- 
•fit.  On  December  3  he  had  been  admitted  to  St.  Mark's 
Hospital,  because  of  a  suddenly  developed  paraplegia.  Bed 
sores  soon  formed  and  he  became  septic,  and  died  on  Feb- 
ruary 11,  1901,  from  exhaustion.  The  cord  symptoms  in  this 
•case  w^ere  due  to  hemorrhage  and  degenerative  myelitis.  As 
to  whether  the  little  tumor  first  felt  in  the  shoulder  was 
•specific,  the  speaker  said  that  this  was  probable,  and  added 
that  the  case  emphasized  the  desirability  of  removing  ap- 
parently innocent  tumors  at  an  early  stage.  A  Case  of 
Cerebellar  Apoplexy  with  Autopsy.  Dr.  Weber  also  made 
this  report.  The  patient  was  a  man,  twenty-nine  years  old. 
living  amid  the  most  unsanitary  surroundings.  The  urine 
liad  a  specific  gravity  of  1024.  and  contained  a  slight 
trace  of  albumin  and  some  hyaline  and  granular  casts. 
There  was  no  history  of  syphilis.  He  had  been  sick  for 
ahout  two  months  before  coming  under  observation  on 
September  11th.  There  was  constant  headache,  but  no 
sensory  or  motor  disturbances.  The  diagnosis  seemed 
to  lie  between  tumor,  hemorrhage  and  abscess  of  the 
cerebellum.  On  account  of  the  length  of  time  that  he  had 
been  sick  abscess  seemed  to  be  more  probable  than  hem- 
orrhage. He  died  in  a  few  days,  and  ^t  the  autopsy  the 
entire  venous  system  was  found  engorged  with  blood. 
There  was  marked  hypei-trophy  of  the  left  side  of  the 
heart;  no  endarteritis  of  the  arch  of  the  aorta:  both  kid- 
neys were  slightly  enlarged,  the  cortex  showing  prolifera- 
tion of  connective  tissue  in  patches,  and  presenting  the 
gross  appearance  of  interstitial  nephritis.  No  opportunity 
was  given  for  microscopical  examination.  In  the  substance 
of  the  right  cerebellar  hemisphere  was  an  accumulation  of 
both  recent  and  old  coagula.  and  the  apoplectic  focus  had 
ruptured  into  the  fourth  ventricle.  He  had  seen  one  case 
of  cerebellar  apoplexy  in  a  girl  of  twenty-five  years,  who 
had  an  unsuspected  and  untreated  syphilis,  a"  Tumor  of 
the  Optic  Thalamus.— Dr.  Joseph  Fraenkel  presented  this 
specimen,  which  had  been  taken  from  a  person  whom  he 
had  shown  to  the  society  in  January.  1898.  At  that  time 
the  boy  had  had  the  cardinal  symptoms  of  brain  tumor, 
and  a  paralysis  of  the  face  which  was  very  marked  when 
there  was  any  emotional  disturbance.  There  had  been 
no  hemianopsia.  The  boy  had  been  discharged  from  the 
Montefiore  Home,  and  had  done  fairly  well  for  two  years 
and  a  half.  When  readmitted,  there  had  been  very  nearly 
the  same  symptoms  as  before,  and  in  addition  a  much 
more  marked  unsteadiness  of  gait  and  a  disposition  to  fall 
to  the  right  side.  Dr.  Fraenkel  said  that  it  had  been  said 
that  he  had  been  led  to  think  it  possible  that  the  tumor 
was  after  all  situated  in  the  cerebellum.  On  removing 
the  brain  at  autopsv,  a  very  old  cyst  was  found  on  the 
fourth  ventricle,  the  exact  nature  of  which  had  not  yet  been 
determined.  There  was  also  a  large  tumor  occupying  the 
right  optic  thalamus.  Spinal  Cord  Showing  Result  of 
Fracture,    Dislocation  of   the   Cervical  Spine. — Dr.  Edward 


D.  Fisher  reported  this  case  and  presented  the  specimen. 
The  patient  was  an  acrobat,  twenty  years  of  age.  While 
turning  a  somersault  from  the  shoulders  of  a  companion 
he  had  fallen  a  distance  of  about  five  feet,  and  struck  on 
his  head.  He  was  instantly  paralyzed.  When  seen  by  the 
speaker  that  evening  there  had  been  complete  anesthesia 
from  below  the  nipple  extending  down  the  arms  to  the 
armpit,  and  on  the  inner  side  of  the  arm  and  forearm,  and 
taking  in  the  ring  and  little  fingers.  There  was  complete 
loss  of  motion  and  paralysis  of  the  bladder  and  rectum. 
The  reflexes,  superficial  and  deep,  had  been  completely 
lost.  Permission  could  not  be  obtained  for  operation  until 
three  days  later,  and  inthemeantime  there  had  been  a  tem- 
perature range  of  104°  or  105°F.  The  operation  had  been 
done  by  Dr.  B.  F.  Curtis  under  cocain  anesthesia,  and  the 
laminae  of  the  fifth,  sixth  and  seventh  vertebrae  removed. 
No  evidence  of  injury  to  the  cord  could  be  discovered.  The 
man  died  three  days  later.  The  autopsy  had  revealed  a 
fracture  of  the  body  of  the  seventh  vertebra,  no  subdural 
hemorrhage,  marked  softening  of  the  cord  at  the  seventh 
cervical  segment.  There  was  very  little  gray  matter  left 
in  the  cord  at  that  level,  and  there  was  very  little  evi- 
dence of  hemorrhage  into  the  cord-proper.  A  very  promi- 
nent symptom  had  been  the  extreme  pain  experienced 
along  the  course  of  the  nerves.  The  classical  distribution 
of  the  paralysis  and  the  complete  loss  of  reflexes  were  in- 
teresting features.  Dr.  B.  Sachs  remarked  that  twenty 
years  ago  it  had  been  pointed  out  that  a  very  significant 
symptom  of  the  disease  of  the  optic  thalamus  was  this  pe 
culiar  facial  palsy  made  visible  by  emotion.  Dr.  Leszynsky 
said  that  he  had  seen  recently  a  case  of  dislocation  in  the 
dorsal  region  with  loss  of  reflexes  and  paralysis  below  the 
seat  of  injury.  An  operation  had  been  done,  but  death  had 
followed.  The  autopsy  had  revealed  a  complete  transverse 
destruction  of  the  cord.  Dr.  Fraenkel  said  that  some  time 
ago  he  had  presented  a  paper  to  the  society  on  this  mat- 
ter of  the  reflexes,  and  had  continued  to  give  a  good  deal 
of  attention  to  this  subject.  He  would  assert  that  the  skin 
reflexes  are  not  lost  in  total  destruction  of  the  cross  sec- 
tion of  the  cord,  and  the  relation  of  the  tendon  reflexes  to 
the  skin  reflexes  should  enable  one  to  decide  whether  or 
not  the  cord  has  been  completely  destroyed  in  this  man- 
ner. When  the  compression  of  cord  was  sufficiently  great 
to  interfere  functionally  with  conduction  upward  and  down- 
ward, the  tendon  reflexes  are  lost  while  the  plantar  reflexes 
are  exaggerated.  When,  however,  there  is  structural  dis- 
ease of  the  entire  cross  section  of  the  cord,  the  plantar 
reflexes  are  also  lost.  This  he  considered  a  valuable  point 
in  the  differential  diagnosis.  He  had  reported  two  casee 
with  autopsies  in  which  there  had  been  loss  of  reflexes 
without  total  abolition  of  the  conduction  in  the  cord.  Dr. 
LeszjTisky  said  that  in  the  case  he  had  just  referred  to  all 
forms  of  reflexes  had  been  abolished,  both  superficial  and 
deep  Brain  From  a  Case  of  Epilepsy  Operated  Upon. — 
Dr.  H.  U.  Winter  exhibited  this  specimen,  which  had  been 
taken  from  a  child  of  seven  years.  All  of  the  head  meas- 
urements were  small:  there  was  no  paralysis  of  any  of  the 
muscles.  The  child  was  an  imbecile  and  had  epiletoid  seiz- 
ures which  appeared  to  be  general.  Dr.  Stewart  had  oper- 
ated upon  the  child  at  Bellevue  Hospital  On  reaching  the 
brain  a  large  cyst  cavity  had  been  found  in  the  left  hemi- 
sphere. The  child  died  seven  days  later  with  a  high 
temperature.  The  hemisphere  was  found  to  have  been 
nearly  destroyed  by  the  cyst,  and  the  convolutions  were 
not  well  marked.  The  interesting  feature  was  the  al- 
most complete  destruction  of  the  hemisphere  without  any 
paralysis.  The  fibres  of  the  medulla  were  found  not  to 
decussate  as  freely  as  usual.  Abscess  of  the  Brain. — Dr. 
Joseph  Collins  presented  this  specimen.  It  had  been  im- 
possible to  make  a  localizing  diagnosis.  The  patient  was 
a  man.  twenty-seven  years  of  age.  a  tailor  by  occupation. 
Two  weeks  before  admission  he  had  been  suddenly  seized 
with  severe  and  more  or  less  paroxysmal  headache  distri- 
buted over  the  whole  head.  The  pain  was  almost  intolera- 
ble for  six  days,  and  then  he  became  dizzy  and  had  pro- 
jectile vomiting  without  nausea.  There  had  been  some 
whistling  sound  in  the  right  ear.  When  seen  by  the 
speaker,  four  days  after  coming  into  the  hospital,  there 
was  double  choked  disk,  but  no  hemianopsia.  There  was 
no  leukocytosis,  although  the  hemoglobin  percentage  was 
3G.  Apparently  there  was  no  impairment  of  hearing.  The 
knee  jerks  were  normal.     There  was  no  evidence  of  palsy 


Apeil  27.  1001] 


AMERICAN  NEWS  AND  NOTES 


CThe   Philadelphia       7Q7 
Medical  Journal        lyi 


or  of  spasm  In  any  part  of  the  body,  and  no  symptoms 
ruterable  to  the  special  senses.  The  patient  died  four  days 
later  of  exhaustion.  The  autopsy  revealed  an  abscess  situ- 
ated in  the  right  hemisphere,  and  involving  particularly 
the  posterior  end  of  the  interior  parietal  lobe  and  of  the 
superior  parietal  lobe.  The  cuneus  itself  was  partly  im- 
plicated. The  teat-lilve  e.xtremity  of  the  cuneus,  it  should  be 
noted,  was  entirely  intact  on  the  side  of  he  abscess  cavity, 
and  if  the  optic  radiations  are  not  cut  across  it  would  not 
be  diflicult  to  explain  the  absence  of  hemianop.sia.  A  di- 
agnosis had  been  made  of  abscess  of  the  right  superior 
parietal  convolution.  Dr.  Fisher  said  that  both  the  super- 
ficial and  deep  reflexes  had  been  absent  in  Lis  case,  and  it 
was  because  of  this  that  he  had  inferred  that  there  was 
complete  destruction  of  the  cord.  The  operation  had  been 
undertaken  to  relieve  intense  pain. 

WESTERN    STATES. 

Bullet  In  His  Heart. — Evidence  that  a  man  may  live  with 
a  bullet  in  his  heart  was  afforded  by  the  use  of  the  X-ray 
upon  Charles  B.  Nelson,  of  Cadillac,  Mich.,  who  in  1896  was 
the  central  figure  in  a  sensational  shooting  that  nearly  re- 
sulted in  his  death.  Under  the  fluoroscope  the  ball  in  Nel 
son's  heart  conld  be  plainly  seen  rising  and  falling  with 
each  pulsation  of  the  vital  organ.  The  bullet  has  been 
there  since  the  night  of  July  1,  1896. 

Licenses  Refused. — Seven  graduates  of  the  Pacific 
Coast  Regular  College  of  Medicine,  comprising  the  first 
graduating  class  of  that  institution,  which  began  its  work 
only  about  nine  months  ago,  have  been  refused  licenses  to 
practice  by  the  Board  of  Medical  Examiners  of  the  Medical 
Society  of  the  State  of  California,  on  the  ground  that  their 
alma  mater  does  not  meet  with  the  minimum  requirement 
for  medical  colleges,  as  adopted  by  the  Board  December  4, 
1900. 

Meeting  of  the  Chicago  Pathological  Society,  Monday. 
April  8th,  1901.  Dr.  L.  Hektoen,  President.— Dr.  Bertha  V, 
Bush  reported  a  case  of  varicose  veins  of  the  right  upper 
extremity  in  a  child.  This  report  places  upon  record  a  case 
of  developmental  varix.  in  a  young  child,  the  process  affect- 
ing the  anterior  superficial  veins  of  the  entire  right  hand, 
arm  and  shoulder.  Numerous  saccular  dilatations  occur 
just  beneath  the  skin,  those  at  the  inner  end  of  the  clavicle 
and  in  the  palm  of  the  hand  being  the  most  conspicuous. 
Skiagraphs  show  deformity  of  the  right  metacarpal  bones, 
and  generally  diminished  growth  of  the  arm  and  hand. 
There  is  no  pulsation  or  edema,  and  no  history  of  hemor- 
rhage. Noteworthy  points  in  the  case  are:  1.  The  con- 
genital origin.  2.  The  region  involved.  3.  The  obscure 
etiology.    4.  The  scarcity  of  literature. 

Dr.  H.  T.  Ricketts  presented  a  consideration  of  Blastomy- 
cetlc  (Oidiomycetic)  dermatitisand  its  organisms,  with  dem- 
onstrations. Through  courtesies  from  Professors  Hyde,  Mont- 
gomery and  Hektoen,  he  had  studied  the  pathological  and 
mycological  features  of  ten  new  cases  of  Blastomycetic  (Oi- 
diomycetic) Demratitis  observed  during  the  last  18  months, 
mostly  in  the  clinics  of  Profs.  Hyde  aud  Montgomery.  The 
work  was  done  in  the  pathological  laboratory  of  Rush 
Medical  College.  There  is  a  uniform  clinical  history  in  all 
cases;  the  process  beginning  as  a  pustule,  which  becomes 
a  large  ulcer,  the  surface  later  being  covered  with  coarse 
papillae  bathed  in  pus.  A  reddish  areola  containing  mil- 
iary abscesses  surrounds  the  verrucose  tissue:  the  centre 
of  the  lesion  cicatrizes  as  the  periphery  extends.  The  his- 
tiological  features  are  uniform;  carcinomatoid  prolifera- 
tion, and  leukocytic  infiltration  of  the  epithelium,  intra- 
epithelial abscesses,  premature  and  abnormal  corniflcation. 
peculiar  retrogressive  epithelial  changes  and  epithelial 
giant  cells,  and  in  the  corium.  dense  leukocytic  and  plasma- 
cell  infiltration,  fixed  tissue  proliferation,  subcutaneous 
abscesses,  giant  cells  and  tubercles,  resembling  those  of 
tuberculosis,  but  being  less  typical  in  the  inter-relationship 
of  cells  and  showing  less  advanced  regressive  changes. 
Plasma-cells  seek  the  periphery  of  the  process.  Apparently 
there  is  an  eosinophilous  type  of  the  disease,  which,  in  the 
case  studied,  is  associated  with  a  moiild  fungus  form  of  the 
parasite,  and  very  large  papillae.  Russell's  fuchsin  bodies 
are  found  in  plasma-cells  and  intercellular  spaces.  There 
is  a  close  relationship  between  the  plasma-cells  and  the 
formation  of  a  peripheral  protective  zone  of  fibrous  tissue. 
They  do  not  appear  to  become  fibroblasts,  but  to  undergo 
a  gradual  disintegration  as  provender  for  forming  flbrous 


tissue.  Mast-cells  exist  in  large  numbers,  and  are  classified 
as  1,  leukocytic;  2,  connective  tissue  cell  type;  3,  those 
possessing  halos;  and,  4,  the  plasma-mast-cell  type.  In  the 
tissue  the  organisms  are  found  singly,  in  budding  pairs  and 
in  groups,  in  intra-epithelial  and  subcutaneous  abscesses, 
free  between  healthy  rete  cells,  in  giant  cells,  and  in  the 
granulation  tissue  of  the  corium.  From  seven  cases  the 
organisms  have  been  cultivated.  They  fall  into  three 
groups:  1,  the  yeast-like,  resembling  those  of  Hektoen, 
Hessler,  Busse  and  Curtis;  2,  the  odium-like;  3,  the  mould- 
fungus  type,  resembling  the  organism  isolated  by  Ophuls 
aud  Moflit  from  the  protozoic  (?)  disease.  Study  shows  that 
all  these  have  common  generic  properties,  and  are  sep- 
arated only  by  specific  characteristics  which  are  more  or 
less  variable.  In  accordance  with  pre-existing  nomencla- 
ture they  all  belong  to  the  genus  oidium.  "Blastomyces" 
is  considered  not  sufficiently  inclusive.  Pure  cultures  inoc- 
ulated into  animals  produce  local  abscesses,  septicemia,  or, 
if  injected  into  veins,  mycotic  nodules  and  consolidation  in 
the  lungs.  The  various  methods  of  proliferation  in  cultures 
are,  germination,  lateral  conidia,  terminal  spore-groups, 
alijunction  of  mycelical  segments,  aerial  conidium-bearing 
hypae  (in  the  mould-fungus,  and  questionable  endogenous 
spore-formation.  Of  many  inoculations  of  tissue  from  man 
into  guinea  pigs,  none  have  resulted  in  tuberculosis.  A 
study  of  Busse's  case  of  "Sacchromycosis  hominis,"  of  the 
protozoic  (?)  disease  of  Wrenicke,  Gilchrist,  Ophuls  and 
Moflit,  and  others,  and  of  Blastomycetic  dermatitis,  together 
with  the  fungi  concerned  in  all,  alTords  convincing  evidence 
that  the  three  are  closely  related  processes,  caused  by 
similar  organisms:  the  protozoic(?)  disease  and  Saccharo- 
mycosis  hominis  (Busse)  are  examples  of  the  generalized 
infection,  while  Blastomycetic  dermatitis  (Gilchrist)  is  a 
local  manifestation  of  the  disease.  The  term  Oidiomycosis 
is  suggested  as  a  name  for  the  combined  manifestations. 
Cultures,  as  well  as  gross  and  microscopic  specimens  of  tis- 
sues were  exhibited.  Discussion  of  paper  by  Dr.  H.  T.  Rick- 
etts. Dr.  Maxmilian  Herzog:  If  so  many  varieties  of  organ- 
isms are  found  in  cases  of  clinical  blastomycetic  dermatit- 
is, they  can  not  be  a  single  disease  which  is  due  to  a  single 
cause.  Dr.  Coates  objected  to  the  term  oidiomycosis  as 
liable  to  introduce  confusion.  Dr.  Ricketts,  in  closing,  said 
he  did  not  insist  on  the  use  of  the  term  oidiomycosis.  He 
considered  the  protozoan  diseases  as  due  to  an  organism 
very  closely  related  to  the  ones  under  consideration.  Dr. 
L,.  M.  Loeb  reported  two  cases  of  infection  by  the  bacillus 
aerogenes  capsulatus.  (1)  A  compound  fracture  of  both 
bones  of  the  forearm  was  followed  by  emphysema  of  the 
whole  extremity  in  two  days.  Recovery  took  place  uninter- 
rupted after  shoulder  amputation.  (2)  An  abrasion  of  the 
outer  side  of  the  knee  was  followed  in  one  day  by  phleg- 
monous emphysema  of  the  entire  leg  and  by  constitutional 
symptoms  of  profound  intoxication.  Fifteen  to  twenty 
short  incisions  were  made  and  drainage  of  bichloride  dress- 
ings employed.  In  ten  days  gas  bacilli  and  emphysema 
were  gone  and  recovery  interrupted  only  by  a  suppuration 
of  the  knee  joint  which  took  place.  This  case  again  brings  up 
to  consideration  the  more  conservative  methods  of  treatment. 
Discussion  of  the  paper  by  L.  M.  I^oeb.  L.  F.  Barker  spoke 
on  the  circumstance  of  the  discovery  of  the  organism.  He 
urged  early  recognition  of  the  disease  and  treatment.  Dr. 
Gideon  H.  'Wells  mentioned  a  case  In  which  the  emphy- 
sema was  first  noticed  in  the  subcutaneous  tissue  of  the 
left  shoulder,  extending  some  distance  in  the  course  of  a 
few  days.  Because  of  the  finding  of  pulmonary  tuber- 
culosis, it  was  suspected  the  emphysema  was  due  to  a 
tuberculous  abscess  connected  with  the  ct^^st  wall,  which 
had  ruptured.  At  autopsy  this  was  found  to  be  not  the  case, 
but  due  to  the  bacillus  aerogenes  capsulatus. 

Missouri  State  Medical  Association. — The  programme  for 
the  Jefferson  City  meeting  is  as  follows:  Call  to  order  at 
9.30  A.  M. 

FIRST  DAY. 

MORNING  SESSION. 

Invocation — Rev.  A.  H.  Barnes. 

Reading  of  Minutes. 

Report  of  Chairman  of  Committee  of  Arrangements. 

Address  of  Welcome. — Gov.  A.  M.  Dockery. 

Report  of  Treasurer. 

Appointing  Committees:  (a)  Auditing  Committee;  (b) 
"Vacancies  on  Committee  on  Credentials;  (c)  Special  Com- 
mittees. 

Report  of  Committee  on  Scientific  Communications. 

Report  of  Committee  on  Publication;  B.  C.  Hyde,  Kansas 


798 


The   Philadelphia"! 
Medical  Jovbnai.  J 


AMERICAN  NEWS  AND  NOTES 


[Apbil  27,  1901 


City,  chairman;  F.  J.  Lutz,  St.  Louis;  H.  W.  T.oeb,.  St 
Louis. 

Report  of  Committee  on  Credentials. 

Election  of  Officers.  (Can  be  made  a  "special  order  of 
business"  for  some  other  hour  by  a  two-thirds  vote). 

Miscellaneous  business. 

AFTERNOON  SESSION. 
Report  of  Committe  on  Credentials. 

1.  Report  of  Committee  on  Progress  of  Surgery — J.  D. 
Griffith,  Kansas  City,  chairman.  Discussion  opened  by  F. 
J.  Lutz,  St.  Louis,  and  C.  H.  Wallace,  St.  Joseph,  commit- 
tee. 

2.  The  Epidemic  of  So-Called  Smallpox — J.  D.  Brummall. 
Salisbury.  Discussion  opened  by  S.  C.  James,  Kansas 
City. 

3  Treatment  of  Acute  Insanities — John  Punton,  Kansas 
City.    Discussion  opened  by  C.  H.  Hughes,  St.  Louis. 

4.  (a)  Intestinal  Obstruction — H.  Clay  Dalton,  St.  Louis, 
(b)   Intestinal   Obstruction   following   Abdominal   Sec- 
tion— Edward  Wallace  Lee.  St.  Louis.     Discussion  opened 
by  O.  Be4-erley  Campbell,  St.  Joseph. 

5.  Entropion  and  Ectropion — Flavel  B.  Tiffany,  Kansas 
City.    Discussion  opened  by  Carl  Barck  ,St.  Louis. 

6.  (a)  The  Value  of  Venesection  and  Saline  Injections 
in  the  Treatment  of  Pneumonia — and  addition  to  the  paper 
read  before  the  association  last  year — William  Porter,  St. 
Louis. 

(b)  Treatment  of  Pneumonia — H.  W.  Latham,  Lath- 
am.   Discussion  opened  by  C.  F.  Wainwright.  Kansas  City. 

7.  Peculiar  Nervous  and  Urinary  Manifestations  in  the 
Aged  Following  La  Grippe — O.  P.  Kernodle.  Sedalia.  Dis- 
cussion opened  by  Thomas  Chowning,  Hannibal. 

EVENING  SESSION. 

8.  Demonstration  of  Kidney  Lesions  with  Stereopticon — 
M.  Dwight  Jennings,  St.  Louis. 

9.  Presidents  Address — U.  S.  Wright,  Fayette. 


SOUTHERN    STATES. 

Physician  Assassinated. — Dr.  H.  S.  Scruggs.  Jr.,  who  re 
sided  at  Aulona.  a  suburb  near  Memphis.  Tenn.,  was  found 
sitting  upright  in  his  buggy  near  his  home  on  April  17th. 
with  a  bullet  hole  behind  the  left  ear.  His  horse  wandered 
along  the  roadway  for  several  hours  before  the  crime  was 
discovered. 

Cecil  County  Medical  Society. — The  Cecil  County  Medical 
Society  has  elected  Dr.  Joseph  W.  Wallace,  of  Chesapeake 
City,  president;  Dr.  John  H.  Jamar,  of  Elkton,  treasurer, 
and  Dr.  H.  P.  Hinchclifte,  of  Elkton,  secretary. 

Oral  College  Examinations. — The  faculty  of  the  Medical 
College  of  Virginia  have  recently  decided  to  examine  mem- 
bers of  the  graduating  class  by  oral,  instead  of  written  ex- 
aminations, as  has  been  the  custom  until  now. 

Relief  Bills  Contemplated. — A  meeting  of  a  joint  com- 
mittee representing  the  medical,  dental,  pharmaceutical 
and  legal  professions,  was  recently  held  at  Richmond.  Va.. 
forthe purpose  of  thoroughly  organizing  these  different  bod- 
ies for  better  protection.  The  new  State  constitutional  con- 
vention meets  early  in  June,  and  it  is  hoped  that  a  plank 
may  be  inserted  in  the  constitution  whereby  the  granting  nf 
special  privileges  and  the  passing  of  private  relief  bilKs 
allowing  certain  persons  to  practice  without  standing  the 
required  examination,  may  be  abolished. 


MISCELLANY. 

Appointment. — Dr.  .-Vristides  Agramonte.  formerly  Chief 
of  the  Bacteriological  Laboratory,  has  been  appointed  to 
the  Chair  of  Bacteriology  and  Experimental  Pathology  in 
the  Medical  Faculty  of  the  University  of  Havana,  Cuba. 

Obituary. — Dr.  J.  B.  Wait,  at  Medford.  Ore.,  on  April  .5. 
aged  59  years. — Dr.  Block,  of  San  Francisco.  Cal..  at  Berlin. 
Germany,  on  April  12. — Dr.  Charles  Kelly  Gardiner,  at 
Huntingdon.  W.  Va.,  on  April  14. — Dr.  B.  E.  LUsk.  at  Lone 
Oak.  Mo.,  on  April  15. — Dr.  George  W.  Cox.  at  Philadelphia 
on  April  l;i.  aged  CI  years. — Dr.  John  P.  Robb,  at  Freder- 
icksburg. Va..  on  April  IS,  aged  SO  years. — Dr.  L.  R.  Kirk, 
at  Elkton,  Md.,  on  April  19,  aged  69  years. 


Chances  in  the   Medical  Corps  of  Navy  for  Week  Ended 

April  20,   1901: 

P.  A.  SURGEON  N.  J.  BLACKWOOD,  detached  from  Na- 
val Hospital,  Philadelphia,  April  17,  and  ordered  to  the 
Alliance. 

P.  A.  SURGEON  L.  MORRIS,  detached  from  the  Naval 
Academy,  and  ordered  to  Naval  Hospital,  Philadelphia, 
April  17th. 

A3ST.  SURGEON  A.  E.  PECK  ordered  to  the  Pensacola. 

SURGEON  J.  F.  VniE,  detached  from  the  Dolphin,  AprU 
20,  and  ordered  to  the  Marine  Recruiting  Rendezvoas. 
Boston,  April  22. 

SURGEON  E.  P.  STONE,  detached  from  Naval  Dispensary, 
Washington,  and  ordered  to  the  Dolphin.  April  20th. 

SURGEON  F.  ANDERSON,  ordered  to  the  Naval  Dispen- 
sary, April  19th. 

SURGEON  J.  E.  GARDNER,  detached  from  Marine  Re- 
cruiting Rendezvous.  Boston,  and  ordered  to  Naval  Hos- 
pital, Cavite,  P.  I.,  May  11. 

DR.  C.  G.  SMITH,  appointed  Assistant  Surgeon  from  April 
12,  190L 

SURGEON  W.  F.  ARNOLD,  from  New  Orleans  to  Olong- 
apo,  P.  1.,  Sta. 

P.  A.  SURGEON  A.  ALFRED,  to  duty  with  Marine  Bri- 
gade, Cavite,  P.  1. 

.V3ST.  SURGEON  E.  J.  GROW,  detached  from  the  Gla- 
cier, and  to  the  Isla  de  I  uzon. 

ASST.  SURGEON  J  STEPP.  detached  from  duty  with  1st 
Regiment  of  Marines,  and  ordered  to  the  Castine. 

ASST.  SURGEON  H.  C.  CURL,  detached  from  the  Cas- 
tine and  ordered  to  the  Naval  Station,  Cavite,  P.  L 

Official    List   of   the    Changes    of    Station    and    Duties   of 

Commissioned  and  Non-Commissioned  Officers  of  the   U.  S. 

Marine    Hospital    Service   for   the   7   days    ended    April    18, 

1901: 

G.  T.  VAUGHAN,  surgeon,  reassigned  to  duty  in  the 
Marine  Hospital  Bureau.  April  13.  1901. 

H.  D.  GEDDINGS.  passed  assistant  surgeon,  directed  to 
proceed  to  Buffalo,  N.  Y..  for  special  temporary  duty 
in  connection  with  the  installation  of  the  Marine  Hos- 
pital Service  exhibit  at  the  Pan-American  Exposition, 
April  IS,  1901. 

RUPERT  BLUE,  passed  assistant  surgeon,  directed  to 
proceed  to  San  Francisco.  Cal.,  and  report  to  Surgeon 
J.  H.  White  for  special  temporary  duty.  April  16.  1901 

H.    B.    PARKER,    assistant    surgeon,    directed    to    proceed . 
to    San    Francisco.    Cal..    and    report    to    Surgeon    1.    H. 
White  for  special  temporary  duty,  .\pril  15.  1901. 

M.  H.  FOSTER,  assistant  sureon,  2  days  of  the  leave  of 
absence  granted  Assistant  Surgeon  Foster  by  Burean 
letter  of  March  11.  revoked— April  18.  1901. 

G.  H.  CORPUT.  assistant  surgeon,  directed  to  proceed  to 
San  Francisco.  Cal..  and  report  to  Surgeon  J.  H.  White 
for  special  temporary  duty — April   15.   1901. 

DUNLOP  MOORE,  assistant  surgeon,  relieved  from  duty 
at  Port  Townsend  quarantine,  and  directed  to  proceed 
to  San  Francisco.  Cal.,  and  report  to  Sureon  J.  H.  White 

for  special  temporary  duty — April  18,  1901. 

T.  D.  BERRY,  assistant  surgeon,  granted  leave  of  absence 
for  30   days   from   May  2— April   13,   1901. 

J.  C.  BALLARD,  acting  assistant  surgeon,  leave  of  ab- 
sence granted  acting  assistant  surgeon  Ballard  by  Bu- 
reau letter  of  February  4th.  amended  to  read — 6  days 
from  April  23— April  16.  1901. 

B.  W.  GOLDSBOROUGH.  acting  assistant  surgeon,  granted 
leave  of  absence  for  7  days— April  13,  1901. 

R.  H.  McGlNNIS.  acting  assistant  surgeon,  directed  to 
proceed  to  St.  Augustine,  Fla.,  for  special  temporary 
duty— -April  12.  1901. 

RICHARDSON.  S.  W..  hospital  steward,  directed  to  pro 
ceed  to  Buffalo,  N.  Y..  and  report  to  Passed  Assistant 
Surgeon  H.  D.  Geddings  for  special  temporary  duty — 
April  17,  1901. 

L.  P.  HALL,  hospital  steward,  directed  to  proceed  to 
Boston.  Mass..  and  report  to  medical  officer  in  command 
for  duty  and  assignment  to  quarters — April  13,  1901. 

APPOINTMENT. 
LOUIS  P.   HALL,   of  New   York,  appointed  Junior   Hospi- 
tal Steward  in  the  U.  S.  Marine  Service — April  12,  190L 


Al'RII. 


moil 


AMERICAN  NEWS  AND  NOTES 


CThe  Philadelphia 
Medical  Journal 


799 


Health  Reports. — The  following  cases  of  smallpox,  yellow 
fever,  cholera  and  plague  have  been  reported  to  the  Sur- 
geon General,  U.  S.  Marine  Hospital  Service,  during  the 
week  ended  April   20,   1901: 

SMALLPOX— UNITED  STATES. 

Cases.Deaths. 

CALIFORNIA:            San  Francisco  Mar.30-Apr.l3  5 
DISTRICT  OF 

COLUMBIA:   Washington..    Apr.613    1 

FLORIDA:                   Jacksonville   ..  Apr.6-13    14 

ILLINOIS:                    Chicago Apr.S-13    10 

IOWA:                            Clinton   Apr.6-13    1 

l-CRNTUCKY:              Lexington Apr.6-13    7 

Louisville....   Apr.5    1 

LOUISIANA:               New    Orleans..   Apr.6-13    12         2 

MARYLAND:              Baltimore Apr.6-13    1 

MASSACHUSETTS  Fitchburg Apr.6-13    1 

MICHIGAN:                 Detroit    Apr.6-13    3 

Smallpox    present     at  104  places     Apr.6-13. 

MINNESOTA:            Minneapolis  ..  Apr.6-13    S 

Winona Apr.6-13    1 

NEBRASKA:               Omaha    Mar.30-Apr.l3  18 

NEW  HAMPSHIRE  Manchester  .  .   Apr.6-13    3 

NEW  JERSEY:          Jersey  City  ..   Mar.31-Apr.7.  7 

Newark Apr.6-13    1 

NEW  YORK:               New  York Apr.6-13    44       U 

OHIO:                           Cincinnati  ....  Apr.5-12    1 

Youngstown  .  .  Apr.6-13    ....  1 

PENNSYLVANIA:   Lebanon    Apr.6-13    1 

Pittsburg   Apr.6-13    ....  4         1 

Steelton    Apr.6-13    4 

SOUTH  CAROLINA  Charleston    . ..  Apr.8    1 

TENNESSEE:             Memphis    Apr.6-lS    5 

g'^^  Nashville   Apr.6-13    16 

UTAH:                           Salt  Lake  City  Apr  R-13    25 

WEST  VIRGINIA:     Huntington   ..   Mar.23-Apr.l3  62 

Wheeling Apr.6-13    1 

WISCONSIN:              Milwaukee    ...   \pr.6-13    1 

SMALLPOX— FOREIGN  AND  INSULAR. 

BELGIUM:                  Antwerp    Mar.23-30 6         3 

BRAZIL:                       Rio  de  Janeiro  Mar.1-15    13 

CHINA:                        Hongkong  ....  IIar.2-9 2         1 

FRANCE:                      Paris   Mar.23-30 12 

GIBRALTAR:  Mar.23-30 1 

GREAT    BRITAIN:    Scotland 

Dundee Mar.23-30 1 

Glasgow    ...  Mar.29-Apr.5.  10 

INDIA:                           Bombay    Mar.12-19 HI 

Calcutta    Mar.S-16    151 

Karachi Mar.10-17    14       5 

Madras   Mar.9-15    11 

ITALY:                        Messina     Mar.23-30 1 

Naples    Mar.23-30 Present 

MEXICO:                     Mexico    Mar.23-30 ] 

Vera  Cruz  ....  Apr.6-13    ....  1 

RUSSIA:                      Moscow    Mar.16-23 8 

Odessa    Mar.23-30 5         1 

St.Petersburg.  Mar.16-30 30         4 

Warsaw    Mar.16-23 7 

PORTO  RICO:            Ponce    Mar.30-Apr.l.  4 

YELLOW   FEVER. 

BRAZIL:  Rio  de  Janeiro  Mar.1-15   36       28 

COLUMBIA:  Panama    Apr.1-8 7         1 

COSTARICA:  Port  Limon  ..  Apr.5    1 

CHOLERA. 

INDIA:                           Bombay    Mar.12-19 3 

CalcXitta    Mar.216   43 

Madras Mar.S-16   3 

PLAGUE— UNITED    STATES. 

CALIFORNIA:            San  Francisco   Apr.6-13    2         2 

PLAGUE— FOREIGN. 

AFRICA:  Cape  Town   ..  To  Mar.9 100      27 

BRAZIL:                       Rio  de  Janeiro  Mar.1-15   1 

CHINA:                        Hongkong  ....  Mar.2-9 15 

INDIA:                          Bombay    Mar.12-19 1,203 

Calcutta    Mar.8-16   819 

Karachi    Mar.10-17 163     126 

Madras  Mar.9-15   1 


Plague  in  the  United  States  as  reported  to  the  Surgeon- 
General,  United  Marine-Hospital,  from  Januarv  1,  1901,  to 
April  19,  1901: 

PLAGUE. 

CALIFORNIA:            San  Fancisco    Jan.  6 1  1 

Jan.15 2  2 

Feb.  5 1  1 

Feb.  6 1  1 

Feb.  7 1  1 

Feb.lO 1  1 

Feb.ll 1  1 

Feb.l2 1  1 

Mar.  2 1  1 

Apr.  1 1  1 

Apr.  4 1  1 

GREAT    BRITAIN. 

Re-election. — Sir  William  Selby  Church,  Bt.,  has  been  re- 
elected president  of  the  Royal  College  of  Physicians,  of 
London. 

Now  a  British  Subject. — Sir  Felix  Semon.  whose  appoint- 
ment as  Physician  Extraordinary  to  the  King  was  an- 
nounced, has  become  a  naturalized  British  subject. 

BRITISH   CONGRESS  ON   TUBERCULOSIS. 
PRELIMINARY     PROGRAMME.— SECTION     I. 

STATE  AND   MUNICIPAL. 
Meetings  to  be  Held  Daily  from  Tuesday.  July  23d,  to  Fri- 
day, July  26th.  from  9.30  to  2. 
In  this  section  detailed  consideration  will  be  given  to  the 
following  question,  and  resolutions  relative  thereto  will  be 
submitted  when  deemed  necessary. 

Division    I. 

STATISTICAL. 

What  conclusions  may  be  drawn  from  the  statistics 
available  as  to  connection  between  the  Mortality  from 
Phthisis  and  the  conditions  contributing  to  it? 

In  this  connection  regard  will  be  had  to  the  following 
points: 

1.  The  behaviour  of  Mortality  from  Phthisis  in  England 
and  Wales  during  the  reign  of  Her  late  Majesty  Queen 
Victoria. 

2.  The  Geographical  Distribution  of  Phthisis  in  England 
and  Wales. 

3.  The  Incidence  of  Phthisis  Mortality  in  particular  oc- 
cupations. 

4.  The  Age  and  Sex  Distribution  of  Phthisis. 

5.  The  Distribution  of  Phthisis  in  the  several  Sanitary 
Areas  of  London. 

6.  The  Statistical  Evidence  against  Heredity  of  Phthisis. 

7.  Tahcs  mrscitterira  in  relation  to  Milk  Supply. 

8.  A  Statistical  Study  of  Phthisis  in  relation  to  Soil, 
).  The  Indications  for  Future  Statistical  Research. 

Section    II. 
•MEDICAL,      INCLUDING      CLIMATOLOGY     AND      SAN- 
ATORIA. 

On  Tuesday,  the  23rd  July,  a  discussion  on  "Climatology" 
will  be  opened  by  Dr.  C.  Theodore  Williams  and  Dr.  Bur- 
ney  Yeo:  "What  Influence  has  Climate  on  the  Treatment 
of  Consumption,  and  how  far  can  cases  be  grouped  for 
Treatment  in  certain  climates?" 

On  Wednesday,  a  discussion  on  "The  Therapeutic  and 
Diagnostic  Value  of  Tuberculin  in  Human  Tuberculosis," 
uniting  with  the  Section  of  Pathology,  to  be  opened  by 
Dr.  Heron.  Professor  Koch,  of  Berlin,  has  consented  to 
take  part  in  the  discussion. 

On  Thursday,  a  discussion  on  "Sanatoria  for  Consump- 
tion" will  be  opened  by  Professor  Clifford  AUbutt. 

On  Friday,  Papers. 

Demonstrations  will  be  given  on — "Cases  of  Skin  Tuber- 
culosis and  their  Treatment."  "The  Use  of  Roentgen 
Rays  in  Diagnosis." 

If  you  are  desirous  of  joining  in  anf  particular  discus- 
sion, or  of  reading  a  paper,  please  communicate  with  the 
Secretaries  of  the  Section. 

Section  III. 
PATHOLOGY,    INCLUDING    BACTERIOLOGY. 
Tuesday.  July  23rd: 

"The  Morphological  and  Physiological  Variations  of  the 
Bacillus  tiihaculoxis.  and  its  Relations — 
(a)  To  other  'acid-tast'  bacilli. 


Qn^       The  Philadelfhia"! 
"^'-'        Mhdicai.  Journal  J 


FOREIGN  NEWS  AND  NOTES 


[APBn.  27,  1901 


(h)  To  the  ray  fungus  and  other  streptothrices." 
To  be  opened  by — 

Dr.  Alfred  Moeller,  Dirig.  Aerzt  der  Heilstaette,  Bel 

zig,  bei  Berlin. 
Dr.  William  Bulloch,  Bacteriologist  and  Lecturer  on 
Bacteriology  and  General  Pathology  to  the  London 
Hospital. 
Wednesday,  July  24th: 
"The   Tissue-changes    and    Constitutional    Effects    pro 

duced  by  the  various  constituents  of  Tuberculin." 
Joint  Discussion  in  common  with  the  Medical  Section, 
to  be  opened  by  Professor  Koch. 
Thursday,  July  25th: 

"The  Varieties  of  Tuberculosis   (Morbid  Anatomy  ami 

Histology)." 
To  be  opened  by — 

Professor  Dr.  C.  Benda,  Urbankrankenhaus,  Berlin. 
Professor  Sheridan  Delephine,   Professor  of  Pathoi 
ogy,    Victoria    University    (Owens    College,    Man 
Chester. 
Professor   D.   J.   Hamilton,   Professor   of   Pathologj. 
University  of  Aberdeen. 
Friday,  July  26th: 

"Mixed  Infections  in  Tuberculosis." 
Amongst  others  who  are  expected  to  take   part  in  (he 
work  of  this  Section  are  Dr.  Roux  and  Prof.  Metchnikoff. 
of  the  Pasteur  Institute.  Paris. 

In  addition  to  the  papers  in  the  above  subjects  the  Sec- 
retaries are  prepared  to  receive  papers  on  other  points  of 
Tuberculosis,  which  will  come  come  on  for  discussion  after 
the  official  subjects  have  been  disposed  of. 

Section  IV. 

VETERINARY   (TUBERCULOSIS  IN  ANIMALS). 
Tuesday,  July  23rd. 
ftiil)jrrt  for  diftcilisinn — 
"The  Diagnosis  of  Tubercluosis  in  Animals  during  I>ife." 
This  will  be  opened  by  Professor  Dewar,  F.  R.  C.  V.  S 
Principal  of  the  Royal   (Dick's)   Veterinary  College.  Edir 
burgh,  and  amongst  those  who  are  expected  to  take  part  in 
the  discussion  are: 

Professors  McFadyean,  Penberthy.  Edgar,  McEachrau, 
and     McLauchlan     Young;     Messrs.     Abson.    Bloyo, 
Clarke,    Dunstan,    Fraser.    Goodall.    Harding.    Hick;v 
Laithwood,  Sessions.  J.  F.  Simpson,  and  Villar. 
Wednesday,   July  24th. 
Svbjcct  for  di.iruxf:ioti — 

"Tuberculosis  .and  the  Milk-Supply."' 
This  will  be  opened  by  Mr.  Jno.  A.  W.  Dolar.  M.  R.  C.  V 
S.,  and  amongst  those  who  are  expected  to  take  part  in  tho 
discussion  are: 

Professors  McFaydean.  Stockman,  and  McLauchlan 
Young:  Dr.  McCall:  Messrs.  Laithwood,  Martin.  1' 
Simpson,  Sessions,  and  Villar. 

Thursday,  July  25th. 
Subject  for  dixrvs^iov — 

"Tuberculosis  and  the  Meat  Supply." 

This  will  be  opened  by  Mr.  James  King.  M.  R.  C.  V.  S 

Chief  Veterinary  Inspector  to  the  Corporation  of  the  Cit\ 

of  London,  and  amongst  those  who  are  expected  to  take 

part  in  the  discussion  are: 

Professors  McFadyean.  Penberthy,  Williams,  and  Stock 
man;  Messrs.  Hunting,  Malcolm.  Shaw,  and  Wolstenholmc 
Friday,   July   26th. 
Slvhjert  for  dixrux^inti — 
"The  Legislative  and  other  Measures  necessary  to  Combat 
Tuberculosis  amongst  Animals." 
This  will  be  opened  by  Professor  McEachran.  F.  R.  C.  V 
S.,  D.  V.   S.,   Chief  Veterinary   Inspector  to  the  Canadi.nn 
Government,  and  amongst  those  who  are  expected  to  tak'^ 
part  in  the  discussion  are: 

Professors    McFadyean.    Williams,    and    Edgar;    Colonel 

Nunn:  Messrs.  Abson.  Butters.  Hunting,  Shipley,  Tutt 

Villnr,  and  Wolstenholme. 

The  official  languages  of  the  Congress  will  be  En.glish 

French,  and  German,  and  authors  of  pnpers  are  requestdl 

to    supply    beforehand    abstracts    for    translation.      Each 

speaker  opening  a  discussion  will  be  Tiniited  to  thirty  min 

utes.   and   each   subsequent   speaker  to  ten   minutes.     An 

abstract  of  every  paper  and  communication  must  be  sent 

to  the  Secretary-Goneral,  20  Hanover  Square,  at  the  latest 

on  or  before  June  15th,  1901. 


MUSEUM. 
In  connection  with  the  Congress  it  has  been  decided  to 
form  a  temporary  Museum  illustrating  the  Pathology  .Treat- 
ment, or  Prevention  of  Tuberculosis. 
The  Museum  will  consist  of — 

Section    1. — Pathological   and   bacteriological   prepara- 
tions and  specimens  illustrating  Tuber- 
culosis in  man  and  animals. 
Section  II. — Plans  and  models  of  hospitals  and  sanator 
ia,  charts,  and  documents  bearing  upon 
the  historical,  geographical,  and  statis- 
tical aspects  of  the  subject. 
It  is  hoped  that  any  preparations  or  specimens  in  con- 
nection with  work  contributed  to  the  Congress  wlU  be  ex- 
hibited  in  the   Museum. 

A  fully  descriptive  Museum  Catalogue  will  be  published. 
It  is  desirable,  therefore  that  all  descriptions  should  be 
forwarded  at  the  latest  on,  or  before,  June  the  first. 

Definite  information  about  the  date  and  place  for  for- 
warding exhibits  will  be  sent  to  intending  exhibitors.  In 
the  meantime  the  Museum  Committee  are  anxious  to  ob- 
tain as  much  information  as  possible  concerning  the  ma- 
terial available  for  exhibition  and  the  amount  of  space 
required. 

RUSSIA. 
In  Favor  of  an  Occasronal  Drink. — The  petition  sent  to 
the  Military  Cabinet  by  the  Society  for  the  Protection  of 
Public  Health,  asking  that  the  customary  drink  of  rcodka 
given  to  the  soldiers  be  discontinued,  was  declined  on  the 
ground  that  the  amount  of  alcohol  given  to  each  soldier  is 
small,  and  that  he  gets  that  at  infrequent  intervals.  Such 
a  moderate  consumption  of  liquor,  the  government  thinks. 
is  harmless. 

An  Asylum  for  Prematurely-born  Babies. — The  City 
Council  of  St.  Petersburg  made  an  appropriation  of  8,000 
roubles  (|4,000)  a  year  for  the  erection  and  maintenance  of 
an  asylum  for  prematurely-born  children. 

American  Filters  are  Bad. — A  commission  of  sanitary 
specialists  in  Moscow  decided  against  the  use  of  American 
filters  which,  they  claimed,  are  ineffective. 

Foreign  Skill  Invited. — Prof.  Bergmann  was  called  out 
to  attend  to  the  wound  received  by  the  Minister  of  Public 
Instruction  at  the  recent  riots.  Several  well-known  Rus- 
sian physicians  are  also  in  attendance.  The  Vrafch  is 
quite  indignant  over  this  lack  of  confidence  in  home 
talent. 

Good  Results  Obtained  in  the  Sanitarium-Treatment  of 
Tuberculosis. — The  results  obtained  in  Chalil's  Sanitarium 
for  Consumptives  seem  to  be  very  encouraging,  indeed. 
During  a  period  of  8  years  the  number  of  cured  and  im- 
proved reached  84.4%. 

CONTINENTAL    EUROPE. 

Retirement  of  Professor  Ostroumoff. — Professor  Ostrou- 
nioff.  of  Moscow,  retires  this  year  from  his  connection  with 
the  medical  faculty  after  forty  years  of  service. 

French  Ophthalmological  Society. — The  French  Ophthal- 
omological  Society  will  hold  its  eighteenth  annual  meeting 
this  year  in  Paris,  on  May  6.  The  subject  proposed  for 
discussion  is  the  value  of  iridectomy  in  glaucoma,  to  be 
introduced  by  M.  De  Worker. 

New  Surgical  Invention. — .\ccording  to  the  Lonifoii 
Glohc,  a  sewing  machine  for  the  skin  has  been  recently 
invented  by  Dr.  Paul  Michel,  who  exhibited  it  at  the  late 
Congress  of  Medicine. 

Congenital  Cystic  Degeneration  of  the  Uterus. — Vos 
kresensky  {Kien^lin  T'nirrr.<trt.ikin  Itvrxtia.  July.  1900)  ob- 
served this  rare  condition  in  the  body  of  an  old  woman 
who  died  of  chronic  Brighfs  disease.  The  walls  of  the 
entire  uterus  were  found  composed  of  small  cysts  filled 
with  a  gelatinous  substance.  Microscopically,  the  walls 
of  the  cysts  were  found  covered  with  cylindrical  epithel- 
ium. The  structure  was  fibroid  in  character  and  only  here 
and  there  a  few  muscular  bundles  in  a  state  of  atrophy. 
The  author  attributes  this  congenital  degeneration  to  the 
accidental  presence  of  WolflRan  bodies  in  the  embryonic 
uterus  at  the  time  of  intrauterine  developement.     [X.  R.] 


Ai'RiL  27,  li»ni] 


THE  LATEST  LITERATURE 


rTllE     PHII.ADELrnIA 
L    MKt 


KDICAL   JODRNAI, 


8oi 


Zhc  TLatcst  literature. 


BRITISH     MEDICAL     JOURNAL. 

Ai)iii  ctli.  i:ii)i. 

1.  A  Plea  for  a  Pro-Maternity  Hospital. ~.T.  W.  BALI. AN 

TYNE. 

2.  On  a  Uterus  Which  Contained  One  Hiindrod  and  Tweu 

ty  Fibroids.     J.  BLAND-SUTTON. 

3.  Placenta  Previa.     R.  P.  RANKEN  LYLE. 

4.  A   Case   of   Puerperal   Infection   Treated    by   Operation 

(Pryor's  Method).     NUTTING  S.   FRASER. 

5.  A  Note  on  the  Separation  of  the  Placenta  in  the  Third 

Stage  of  Labor.     J.  D.  SLIGHT. 
C.     A    Case    of   Ectopic    Gestatioa;    Operation;    Recovery. 

H.  H.  LLOYD  PATCH. 
7.     The   Lettsomian   Lectures   on   Diseases   and   Disorders 

of  the  Heart  and  Arteries  in  Middle  and  Advanced 

Life.     See  Lancet  for  April  6,  1901.     J.  MITCHELL 

BRUCE.     (Lecture  III). 
S.     The  New  Type  of  Scarlet  Fever  from  a  Public  Health 

Point  of  View.     WM.  ROBERTSON. 

9.  A  Preliminary  Note  on  the  Use  of  Ox-Serum  in  Rec- 

tal Feeding.     OTTO  F.  F.  GRUENBAUM. 

10.  The  Value  of  Diphtheria  Antitoxin  in  the  Treatment 

of   Membranous    Non-Diphtherial   Tonsillitis.     J.    N. 
d'ESTERRB. 

L — Ballantyne  remarks  that  the  Promaternlty  Hospital 
need  not  be  a  separate  establishment;  it  may  quite  well 
be  an  annex  of  the  maternity  and  in  time  may  come  to  bo 
of  equal  size  as  the  maternity.  It  must,  however,  be  dis- 
tinct from  the  latter,  and  will  be  intended  for  the  recep- 
,  tion  of  women  who  are  pregnant  but  who  are  not  yet  in 
labor.  In  time  it  may  be  taken  advantage  of  by  more  or 
less  normal  ambulances,  as  working  women  who  ought 
to  rest  during  the  last  weeks  of  pregnancy  but  who  are 
unable  to  do  so  from  financial  reasons.  Ballantyne  re- 
marks that  practically  no  provision  is  made  in  existing 
hospitals  for  pregnant  women.  This  idea  of  the  pro-ma- 
ternity hospital  has  been  forced  upon  him  by  communica- 
tions from  medical  men  in  England  and  the  United 
States.  Such  a  hospital,  he  suggests,  would  be  an  excel- 
lent place  in  which  to  study  the  pathology  of  pregnancy, 
such  as  placenta  previa,  albuminuria,  and  the  pre-eclamp- 
tic  condition.     [W.  A.  N.  D.] 

2. — Bland-Sutton  records  a  most  interesting  case  of  a 
uterus  containing  120  fibroids  which  he  removed  by  hys 
terectomy.  Four  sessile  tumors  projected  into  the  cavity 
of  the  uterus,  and  these  had  become  so  moulded  to  each 
other  as  to  form  facets  on  their  contact-surfaces  such  as 
are  found  in  multiple  gallstones.  After  hardening  the 
uterus  in  methylated  spirit  sections  were  made  from 
which  a  careful  computation  showed  the  uterus,  which 
scarcely  exceeded  the  dimensions  of  a  fist,  to  contain  120 
fibroids.  In  all  that  were  examined  the  tumor-cells  were 
found  disposed  around  the  blood-vessels.  Each  minute  fi- 
broid was  globular,  and  one  section  quite  white,  so  that 
the  contrast  in  color  with  the  red  of  the  uterine  muscle 
fiber  made  them  conspicuous  objects  on  the  cut-  surface. 
Each  fibroid  was  sharply  differentiated  from  the  uterine 
tissue  by  a  thin  capsule,  from  which  It  could  be  readily 
enucleated.     IW.  A.  N.  D.] 

3. — Lyle  divides  placenta  previa  into  two  varieties,  the 
complete  and  the  incomplete,  and  remarks  that  the  diag 
nosis  is  not  difficult  but  depends  on  the  fact  of  being  able 
to  feel  the  placenta  attached  to  the  lower  uterine  seg- 
ment. Carcinoma  of  the  cervix  causing  hemor- 
rhage in  advanced  pregnancy  might  be  possibly  mistaken 
for  placenta  previa,  but  a  careful  examination  would 
elicit  the  true  nature  of  the  case.  The  prognosis  for  the 
mother  depends  on  the  variety,  the  complete  form  being 
more  dangerous  than  the  incomplete;  on  the  treatment 
adopted,  any  form  of  mechanical  dilatation  of  the  cervix  or 
the  rapid  extraction  of  the  child,  being  extremely  danger- 
ous to  the  mother's  life;  on  the  amount  of  interference; 
and  on  early  treatment.  The  prognosis  as  regards  the 
child,  depends  on  the  period  of  pregnancy,  the  amount  of 
hemorrhage,  and  the  rapidity  of  labor.  As  regards  treat- 
ment the  advantage  of  version  and  bringing  down  a  foot, 
are  as  follows:  1.  It  does  away  with  the  tampon,  and 
consequent  danger  of  infection.     2.  It  allows  early  opera- 


tion. 3.  It  arrests  the  hemorrhage  with  great  certainty. 
4.  It  gives  time  for  the  patient  to  rally.  5.  It  gives  time 
for  the  labor  pains  to  set  in  with  consequent  natural 
dilatation  of  the  cervix.  6.  There  is  less  danger  of  post- 
partum hemorrhage.     [W.  A.  N.  D.[ 

4. — Eraser  records  a  case  of  puerperal  infection  treated 
by  Pryor's  method.  The  infection  was  probaldy  from  a 
case  of  appendicitis  which  had  been  dross(-d'  by  the 
physician  prior  to  his  attendance  upon  the  labor  case. 
.The  operation  consisted  in  opening  of  the  posterior  cul 
de  sac  and  the  application  of  antiseptic  dressings  under 
cliioroform  anesthesia.  Follcnving  this  an  ice-bag  was 
placed  over  the  abdomen  and  from  a  pint  to  a  quart  of 
normal  saline  solution  Injected  every  eight  hour  into  the 
cellular  tissue  of  the  back.  The  patient  made  a  good 
recovery.     [\V.  A.  N.  D.l 

5. — Slight  speaks  of  Hart's  observation,  namely,  that  the 
wall  of  the  third-stage  uterus  is  thinner  at  the  placental 
site  than  it  is  elsewhere  above  the  retraction  ring.  The 
placental  site  is  about  one-quarter  of  an  inch  in  thickness 
while  the  rest  of  the  wall  is  four  times  thicker.  Slight  be- 
lieves that  in  this  fact  he  h.-js  found  the  key  to  the  mech- 
anism of  the  third  stage  of  labor.  The  hypothesis  which 
he  advances  is  that  during  the  pain  the  thin  part  of  the 
wall  is  stretched  by  the  thicker  part  and  the  placenta  and 
uterus  is  thereby  torn  through.  The  placenta  is  firmly 
grasped  by  the  encircling  uterus  and  cannot  move,  hence 
as  the  placental  site  stretches  separation  must  follow. 
[W.   A.   N.   D.] 

6. — Patch  records  a  ease  of  extrauterine  pregnancy  on 
the  left  side.  The  operation  was  performed  at  the  pa- 
tient's home  and  the  foreign  body  allowed  to  escape  in 
piecemeal.  Notwithstanding  the  unfavorable  surround 
ings,  the  patient  made  a  good  recovery.  [W.  A.  N.  D.] 

8. — While  compulsory  notification,  accompanied  by  hos- 
pital treatment,  has  lowered  the  mortality  of  scarlet  fever 
it  has  undoubtedly  altered  the  type  of  the  disease.  So 
much  so  that  now  it  is  often  difficult  to  tell  when  one 
has,  or  has  not,  to  deal  with  the  suspected  disorder.  On 
every  side  one  hears  it  repeated  that  epidemics  are  now 
characterized  by  a  want  of  symptoms  and  signs.  The 
bright  red  rash  is  seldom  seen,  and  when  there  is  a  rash 
it  often  disappears  before  the  arrival  of  the  medical  at- 
tendant. If  one  looks  for  throat  signs  they,  too,  may 
have  been  transitory.  The  symptoms  of  onset  are  so 
slight  that  even  an  anxious  parent  takes  no  notice  of  a 
passing  day's  indisposition.  In  fact,  the  only  points  that 
guide  one  are  the  existence  of  cases  in  the  same  school  or 
neighborhood,  with  perhaps  slight  pain  and  stiffness  due 
to  an  enlargement  of  the  glands  about  the  neck.  It  is 
these  mild  cases  that  kindle  into  flame  the  big  epidemics 
that  are  becoming  only  too  prevalent  in  big  towns.  In 
Paisley,  in  1900,  the  cases  of  scarlet  fever  were  of  mild 
character  and  seemed  to  William  Robertson  to  bo  a  hybrid 
between  scarlet  fever  and  epidemic  roseola.  Desquama- 
tion was  indisputable,  however.  The  infection  was  prob- 
ably propagated  through  the  summer  playgrounds.  The 
erection  of  high  tenements  In  large  towns  only  encour- 
ages the  spread  of  such  diseases  scarlet  fever,  measles 
and  whooping-cough.     [J.  M.  S.l 

9. — Otto  P.  F.  Grunbaum  uses  a  mixture  of  ox-serum, 
glucose  and  milk  with  liquor  pancreaticus  for  rectal  feed- 
ing. Ox-serum  contains  a  constant  amount  of  protoid 
which  is  easily  absorbed  by  the  mucous  membane  of  the 
large  intestine.  It  does  not  give  rise  to  offensive  stools, 
which  is  often  the  case  when  egg  albumin  is  used.  By 
injecting  90  ccm.  every  4  hours,  540  ccm.  of  serum  is  in- 
troduced in  the  24  hours,  which  contains  38  grams  of  pure 
iuoteid.  By  adding  60  ccm.  of  milk  to  each  enema  the 
total  proteid  in  the  diet  would  be  raised  to  51  grams. 
Examination  of  washings  for  the  rectum  showed  that  less 
than  a  gram  of  proteid  was  excreted  unaltered.  In  no 
case  did  a  rash  appear  nor  any  albuminuria  or  albumosur- 
ia. Carbohydrates  in  the  form  of  starch  or  glucose  are 
readily  absorbed.  The  author  has  given  30  grams,  all  of 
which  was  absorbed  without  the  production  of  glycosuria. 
Fat  is  not  easily  absorbed:  of  the  18  grams  in  the  milk, 
some  has  invaiably  been  returned  in  the  wash-out  enem- 
ata.  The  heat  value  of  th  above  diet  is  578  calories.  This 
may  bo  increased  by  another  300  calories  by  the  sub- 
cutaneous injection  of  sterilized  olive  oil:  30  or  40  ccm.  of 
which  may  be  given  daily.     [J.  M.  S.] 

10. — d'Esterre   reports   the   case   of   a   woman,   aged   35 


Q(-,2       The  Philadelphia"! 
Medical  Jocbnal  J 


THE  LATEST  LITERATURE 


[AfBIL  27,  1801 


years,  v.-ho  had  had  rheumatism,  influenza,  pneumonia, 
pleurisy,  muscular  rheumatism  and  constantly  recurring 
sore  throat.  When  first  seen  she  complained  of  sore 
throat,  and  her  temperature  was  103°.  Both  tonsils  were 
considerably  swollen  and  almost  completely  covered  with 
a  distinct  yellowish  membrane-like  deposit.  Bacteriolo 
Sical  examination  of  the  membrane  did  not  show  diph 
theria  bacilli,  but  resulted  in  an  abundant  growth  of 
streptococci.  Fifteen  hundred  units  of  antidiphtheritic 
serum  were  given  before  the  results  of  the  bacteriologi- 
cal examination  were  known,  and  the  patient  made  a 
rapid  and  complete  recovery.  Five  months  later  the 
patient  had  a  second  attack  exactly  similar  to  the  first. 
Bacteriological  examination  gave  the  same  results  and  the 
same  dose  of  antidiphtheritic  serum  was  followed  by  com 
plete  and  rapid  recovery.     [J.  M.  S.] 


LANCET. 
April  6th,  1901. 

1.  Lettsomian  Lectures  on  Diseases  and  Disorders  of  the 

Heart  and  Arteries  in  Middle  and  Advanced  life.  J. 
MITCHELL  BRUCE.     Lect  III. 

2.  Sclerotic  Hyperlasia  of  the  Pharynx  and  Xaso-Pharynx. 

A.  BROWN  KELLY. 

3.  On   the   Existence   of   Immunity   after   Enteric    Fever. 

BURTON  A.  NICOL. 

4.  The  Patholog}'  and  Treatment  of  Rheumatoid  Arthritis. 

P.  W^  LATHAM. 

5.  A  Case  in  which  a  large  Pyloric  Tumor  disappeared 

after  Gastro-enterostomy :  Post-mortem  examination 
eleven  years  after  Operation.  FRED.  BOWREMAN 
JESSETT. 

6.  The  Influence  Exerted  by  Air  upon  the  Exhibition  of 

Anesthetics.     GEORGE  FLUX. 

7.  Three    Cases   of   Acute   Ascending   Paralysis.       T.    A. 

GREEN. 

8.  History  of  Renal  Surgery.     DAVID  NEWMAN. 

2. — Kelly  concludes  that  the  pharynx  may  reveal  scler 
otic  hyperplasia  without  the  association  of  syphilis,  rhino 
scleroma,  or  other  infectious  diseases.  Similar  sclerotic  hy- 
perplasia may  show  itself  beneath  the  vocal  cords  as  sub- 
glottic hypertrophic  laryngitis.  Histologically,  the  hyper- 
plasia due  to  syphilis  closely  resembles  the  sclerotic  hyper- 
plasia of  non-syphilitic  origin.     [F.  J.  K.] 

3. — Nicols  discusses  the  existence  of  immunity  after  en- 
teric fever,  and  believes  that  at  the  present  time  proof  is 
wanting  to  show  that  such  immunity  occurs  after  an  at- 
tack of  typhoid  fever.  He  holds  that  the  teachings  of  sani- 
tary science  point  out  many  ways  by  which  the  spread 
of  the  disease  may  be  controlled.     [F.  J.  K.] 

4. — Latham  writes  upon  the  pathology  and  treatment  of 
rheumatoid  arthritis.  He  clearly  points  out  the  fact  that 
post-mortem  records  show  that  the  spinal  cord  and  the 
symphathetic  ganglia  have  never  been  examined  by  modern 
methods;  therefore,  the  question  as  to  the  existence  of 
organic  lesions  in  these  parts  is  still  unanswered  by  patholo- 
gists. The  author  believes  that  clinical  investigation  points 
strongly  to  the  presence  of  morbid  changes  in  the  nervous 
system.  Neuralgic  pains  occur  early  in  the  course  of  this 
affection,  thus  pointing  strongly  to  the  neurotic  character; 
and  not  unfrequently  migraine,  worry,  fright  or  shock  ap- 
pear to  be  exciting  factors.  Muscular  atrophy  develops  so 
rapidly  that  this  change  can  hardly  be  attributed  to  disuse; 
indeed,  in  some  instances  the  atrophy  precedes  the  arthr- 
itis. The  author  emphasizes  that  it  is  not  unreasonable  to 
assume  that  spinal  congestion  or  chronic  myelitis,  chiefly 
affecting  the  ganglion  cells  of  the  anterior  horns,  but  in 
some  instances  the  posterior  horns,  may  produce  rheuma- 
toid arthritis.  From  the  standpoint  of  treatment,  in  the 
earlier  stages  of  rheumatoid  arthritis,  the  author  thinks 
that  continuous  counter-irritaion  of  the  spine  is  a  valu- 
able therapeutic  measure.  Counter-irritaion  to  the  spine  is 
only  of  service  in  the  advance  stages  of  the  disease,  in  rc^ 
Heving  the  patient  of  pain,  during  an  exacerbation  of  the 


mischief,  thereby  preventing  further  extension  of  the  dis- 
ease.    [F.  J.  K.] 

5. — F.  B.  Jessett  reports  an  interesting  case  of  a  woman 
aged  56  years  when  he  first  saw  her  11  years  ago.  At  this 
time  she  was  suffering  with  all  the  symptoms  of  pyloric 
stenosis,  vomiting  after  meals  and  enormous  distension  of 
the  stomach  accompanied  by  emaciation.  At  that  time 
the  abdomen  was  opened  and  a  mass  was  found  as  large 
as  a  cocoanut  involving  a  large  area  of  the  stomach,  and  as 
resection  seemed  impossible,  a  gastro-enterostomy  was 
done.  The  patient  improved  at  once,  the  tumor  which  had 
before  been  readily  palpated  through  the  abdominal  wall 
gradually  disappeared,  and  the  patient  soon  regained  her 
strength  and  health.  11  years  after  the  operation  the  pa- 
tient died  of  apoplexy.  A  post-mortem  showed  a  contrac- 
tion of  the  stomach  at  the  former  seat  of  the  growth  which 
resulted  in  the  formation  of  an  hour-glass  stomach.  The 
anastomosis  has  been  made  with  the  pyloric  pouch  and 
the  opening  was  quite  free,  through  it  passing  nearly  all  of 
the  stomach  contents,  since  the  pyloric  orfice  was  very 
much  contracted.  The  opening  between  the  two  portions 
of  the  stomach  at  he  seat  of  contraction  was  o  small  as  to 
scarcely  admit  the  passage  of  one  finger,  Jessett  is  unable 
to  explain  the  disappearance  of  this  mass  which  at  the 
time  of  the  first  operation  seemed  malignant.     [J.  H.  G.) 

6. — George  Flux,  in  speaking  of  the  administration  of 
anesthetics,  urges  upon  anesthetists  the  consideration  of 
the  fact  that  it  is  the  atmospheric  air  which  acts  as  the  con- 
veying agent  for  the  anesthetic;  and  that  the  depth  of  the 
anesthesia  and  effect  of  the  anesthetic  will  depend  upon 
the  amount  of  dilution  with  atmospheric  air.  If  the  inha- 
ler is  placed  tightly  over  the  face  and  the  air  breathed  by 
the  patient  pass  through  the  inhaler,  then  of  course  much 
more  effect  of  the  anesthetic  is  obtained,  and,  on  the  con- 
trary, if  air  is  allowed  to  pas  between  the  inhaler  and  the 
patient's  face,  then  very  little  of  the  vapor  is  carried  into 
the  patient's  lungs.  Hence,  it  is  maintained,  that  the 
amount  of  anesthetic  used  is  no  index  as  to  the  extent  of 
the  anesthesia,  but  rather  the  way  in  which  it  has  been  ad- 
ministered.    [J,  H.  G.] 

7. — Green  reports  three  cases  of  acute  ascending  para- 
lysis. Two  of  the  case  terminated  fatally,  but  post-mortem 
examinations  were  not  made.     [F.  J.  K.] 

8, — David  Newman,  in  continuing  the  discussion  of  the 
history  of  renal  surgery,  speaks  first  of  the  history  of  the 
operation  of  nephrorrhaphy.  which  was  performed  by  Dow- 
lel,  of  New  Orleans,  in  1S74.  Incision  of  the  kidney  for  re- 
lief of  pain  was  recommended  first  by  Tiffany,  of  Balti- 
more, in  1S85.  Resection  of  the  kidney  was  first  done  by 
Czemy  in  1887.  and  since  then  has  become  an  established 
operation  in  renal  surgery.  The  various  methods  of  anas- 
tomosing the  ureters  is  next  described,  and  also  operations 
for  stone  in  the  ureter,  and  for  the  relief  of  stricture  and 
valvular  obstruction  of  the  ureter.     [J.  H.  G.] 


NEW   YORK    MEDICAL  JOURNAL. 
April  ill,  I'jiil. 

1.  'I'he  Earlv  Diagnosis  of  Ectopic  Gestation,     ANDREW 

F.  CURRIER. 

2.  The   Use   of   Hot-water   Vaginal    Injections.       J.\MES 

HAWLEY  BUKTEXSHAW. 
:!.     A  Case  of  Dystinuria  ending  in  Recover}-.  JOHN  REID. 

4.  Acute  Spinal  Ataxia   (Nontabetic*   and  its  Relation  to 

other  Forms  of  Acute  Ataxia.     CHARLES  L.  DANA. 

5.  The    Pathology    of    Intra-uterine  Death.      NEIL    MAC- 

PHRATTER. 

6.  Grippe,  Pneumonia  and  Insanity,     EMILE  ARONSON. 

7.  Notes  on  the  Treatment  of  Diphtheria,  Based  on  the 

Methods  of  the  New  York  City  Hospital.       WM.  L. 
SOMERSET. 

1. — Currier  remarks  that  ectopic  gestation  should  in- 
clude gestation  only  within  the  fallopian  tube  proper,  the 
interstitial  form  being,  strictly  speaking,  uterine.  The 
symptoms  which  determine  the  diagnosis  of  tubal  gestation 


April  27,  V.Wl] 


THE  LATEST  LITERATURE 


r"rnE   Pnir,At)Et.pniA       Sn'l 
L  .Mi:diial  Jotjbnal         "^O 


may  be  divided  into  the  ordinary  and  the  extraordinary. 
The  ordinary  include  the  enlargement  of  the  breasts,  with 
increased  prominence  of  the  veins  and  enlargement  of  the 
papillae  in  the  areola  that  surrounds  the  nipple,  the  bluish 
discoloration  of  the  vaginal  mucosa,  the  softness  of  the 
tissue  of  the  vagina  and  the  uterus,  non-appearance  of  the 
menses,  irritability  of  the  stomach,  possible  nausea  and 
vomiting,  increase  in  the  size  and  change  in  the  contour 
of  the  uterus,  and  increase  in  the  secretion  of  the  glandular 
structure  of  the  vagina  and  the  uterus.  The  extraordinary 
signs  should  be  regarded  as  confirmatory  of  the  ordinary. 
They  are  not  always  present,  or  always  present  at  the 
same  period,  or  always  of  equal  intensity  and  significance. 
The  most  important  is  hemorrhage.  It  is  most  likely  to 
occur,  and  occurs  most  early,  in  those  cases  in  which  the 
seat  of  of  the  gestation  is  the  fimbriated  extremity  of  the 
tube.  It  is  least  likely  to  occur  when  the  oval  sac  is  near 
the  middle  of  the  tube.  Next  in  importance  to  bleeding  is 
pain.  It  is  not  always  present,  it  is  usually  paroxysmal, 
sharp  and  darting,  and  inclines  the  patient  to  relax  the 
thigh  muscles  and  flex  the  thighs  upon  the  abdomen. 
The  third  diagnostic  point  consits  in  the  presence  of  the- 
pelvic  tumor,  which  is  usually  best  determined  by  examina- 
tion per  rectum.  The  pasing  of  decidual  membrane  by  the 
vagina,  pulsation  of  the  vaginal  arteries,  and  various 
other  signs  are  all  of  minor  importance.     [W.  A.  N.  D.] 

2. — Brutenshaw  states  that  there  is  no  therapeutic  meas- 
ure so  frequently  misapplied,  so  thoroughly  abused,  or  sn 
imperfectly  understood  as  the  hot-water  vaginal  injection. 
Employed  conscientiously  and  m  accordance  with  the  rules 
of  common  sense  it  is  one  of  the  most  valuable  remedies  at 
our  command ;  employed  as  it  usually  is  it  is  capable  ol 
doing  infinite  harm.  He  suggests  the  following  directions 
for  the  therapeutic  douche:  1.  Use  a  large  sized  fountain 
syringe  or  douche-can  attached  to  a  support  3  or  4  feet 
above  the  body.  2.  Always  lie  flat  on  the  back  when  taking 
a  douche  with  the  hips  slightly  elevated  and  the  shoulders 
depressed.  3.  Always  use  at  least  3  gallons  of  plain  water 
as  hot  as  can  be  borne  (at  a  temperature  at  from  107"  to 
120°  P.  for  each  douche.  4.  Take  the  injection  twice  daily, 
morning  and  evening,  except  on  the  2  days  preceding  and 
the  z  days  following  the  menstrual  priod,  when  it  should  be 
omitted.  5.  Rest  for  half  an  hour  or  an  hour  in  a  recum- 
bent position  after  taking  each  douche.  Large  hot-water 
vaginal  irrigations  should  never  be  employed  by  healthy 
pregnant  women  for  the  reason  that  they  reduce  the  bac- 
tericidal power  of  the  vaginal  secretion.  Reclus  asserts  that 
the  use  of  hot  water  enemeta  in  pelvic  inflamations  is  much 
to  be  preferred  to  the  vaginal  douche.  Burtenshaw  has 
made  use  of  this  method  in  but  a  few  cases,  and  not  witn 
entirely  satisfactory  results.     [W.  A.  N.  D.j 

4. — Dana  gives  the  following  summary  in  his  article  on 
acute  spinal  ataxia  (non-tabetic),  and  its  relation  to  other 
forms  of  acute  ataxia:  —  (1)  Acute  ataxia  occurs  occasion- 
ally in  tabes  dorsalis,  but  is  associated  usually  with  char 
acteristic  symptoms.  (2)  Acute  non-tabetic  spinal  ataxia 
occurs  as  a  manifestation  of  spinal  syphilis  or  senile  ar 
terial  changes,  and  shows  itself  by  a  sudden  onset  of  tem- 
porary motor  weakness  and  bladder  troubles,  great  ataxia, 
and  minor  sensory  disorders.  It  may  affect  only  one  ex 
tremity,  but  usually  affects  the  lower  limbs.  The  ten- 
dency is  to  nearly  complete  recovery.  (3)  Acute  bulbar 
or  bulbocerebellar  ataxia  occurs  as  a  sequel  of  some  acute 
infection,  and  is  usually  the  beginning  of  a  form  of  multi 
pie  sclerosis.  (4)  Acute  neuritic  ataxia  occurs  as  the  result 
of  multiple  neuritis  of  the  sensory  type.  It  is  usually  in  the 
non-alcoholic  forms  of  neuritis,  especially  those  due  to  me 
talic  poisons,  like  arsenic,  or  to  diphtheria.     [T.  M.  T.] 

5. — Macpratter  has  made  a  most  extensive  study  of  the 
pathology  of  Intra-uterine  death.  He  remarks  that  morbid 
influences  in  the  uterus,  the  embyro.  or  its  appendages,  or 
general  or  local  constitutional  perversions  may  render  it 
absolutely  impossible  for  a  viable  fetus  to  be  born.  An  in- 
vestigation into  all  the  conditions  and  various  circum- 
stances leading  up  to  and  producing  uterine  death  is  sui 
rounded  frequently  by  innumerable  difficulties.  He  empha 
sizes  the  importance  of  investigating  the  condition  of  the 
male  parent  in  those  cases  in  which  a  woman  is  unable  (o 


carry  a  fetus  to  the  full  term  of  gestation.  The  father  may 
be  too  old  or  too  young  to  impart  the  essential  potency  to 
the  fecundatal  fluid.  Certain  paternal  diseases  may  have 
a  similar  effect,  the  fetus  not  receiving  the  necessary 
amount  of  vitality  to  continue  the  development  of  the  pro- 
duct. It  has  been  demonstrated  conclusively  that  a  woman 
may  abort  consecutively  and  yet  be  parentially  fertile.  Un- 
doubtedly the  fault  here  lies  in  the  husband.  Occasionally 
this  defect  may  be  congenital,  but  more  freuently  it  is  ac 
quired.  It  is  well,  in  investigating  the  causes  of  intra- 
uterine death  to  examine  the  male  parent  for  non-descent 
of  the  testicle.  Inflammation  of  the  seminal  glands,  either 
acute  or  chronic,  may  be  the  cause  of  atrophy  of  the  testi 
cle  and  of  the  delicate  tubuli.  Syphilitic  inflammation  of 
the  testicle  has  probably  a  greater  tendency  to  be  fol- 
lowed by  deposit  of  fibrous  exudate  than  the  other  varie- 
ties. Tuberculous  disease  of  the  testicle  and  seminal 
vesicle,  and  lead-poisoning  in  the  male  are  both  responsible 
for  a  certain  percentage  of  the  intra-uterine  mortality.  The 
causes  attributable  to  the  mother  are  much  more  numerous 
and  complicated.  All  agencies  which  conduce  to  deteriora- 
tion of  the  mother's  health  converge  in  this  direction,  as 
unhealthy  surroundings,  pernicious  habits,  unsuitable  occu- 
pations, insalubrious  climate,  and  extremes  of  heat  and 
cold.  The  same  may  be  said  of  artificial  ways  of  dressing, 
tight  lacing,  irregular  or  late  hours,  lack  of  healthy  exer- 
cise in  the  open  air.  anxiety,  grief,  or  mental  depression  of 
any  kind-  Over-feeding,  and  ever-stimulation  have  a  harm 
ful  effect  upon  childbirth.  It  is  difficult  for  an  obese  woman 
to  become  pregnant,  and  if  she  does  there  is  great  liability 
to  miscarriage.  That  anemia  will  produce  the  death  of  a 
letus  is  well  recognized.  Inter-breeding  in  animals,  as 
well  as  in  plants,  has  a  tendency  to  produce  mental  and 
physicial  deformity,  and  even  premature  death  in  the  for 
mer  and  immature  leaves  and  seeds  in  the  latter.  The 
infectious  diseases  and  pneumonia  produce  death  of  the 
fetus  when  the  temperature  goes  above  104"  F.  and  before 
the  same  temperature  becomes  fatal  to  the  mother 
Kclampsia  is  particularly  fatal  to  the  fetus,  although 
whether  it  arises  from  the  accumulation  of  urea,  albumin. 
or  some  other  deleterious  substance  circulating  in  the  blood, 
is  not  known.  For  some  unexplained  reason  there  is  a  fertil- 
ity among  phthisical  pregnant  women  which  may  be  consid- 
ered abnormal.  The  tendency  to  abortion  in  these  women 
is  nevertheless  greater  than  in  healthy  women.  Heart- 
disease  is  a  much  more  serious  condition  in  pregnancy  than 
is  phthisis,  and  syphilis  in  the  mother  is  especially  inimi- 
cable  to  the  fetal  life.  The  local  pathological  conditions 
that  may  interfere  with  the  fetal  nutrition  and  cause  death 
include  diseases  of  the  fetal  appendages,  such  as  atrophy  of 
the  decidua,  apoplexy  into  the  decidua.  and  hemorrhages 
between  the  chorion  and  decidua.  the  latter  forming  one  of 
the  most  frequent  local  causes  of  death  of  the  embryo  stage 
of  gestration.  This  condition  constitutes  the  well-known 
apoplexy  of  the  ovum,  and  the  fetal  death  in  these  cases 
is  due  to  fatty  degeneration  of  the  tissues  with  consequent 
interference  with  the' fetal  nutrition.  Deciduitis  in  its  var- 
ious forms  is  likewise  responsible  in  a  certain  number  of 
cases.  Chronic  diffuse  endometritis  may  be  considered  the 
mildest  type.  Virchow  describes  a  polypoid  form:  another 
well-known  variety  is  the  catarrhal,  which  constitutes  the 
hydrorrhea  of  pregnant  women,  while  the  syphilitic  form 
is  exceedingly  grave  in  its  effect  upon  the  embryo.  Deci- 
duoma  malignum,  according  to  Macpratter,  may  occa- 
sionally be  the  offending  condition.  Diseases  of  the  chor- 
ion, such  as  the  vesicular  degeneration,  is  a  rather  infre- 
quent cause  of  embryonic  death.  In  this  condition  the 
chronic  villi  undergo  a  myoxomatous  change  with  rapid 
increase  in  size  and  total  destruction  of  the  normal  pla- 
cental and  fetal  tissue.  Morbid  conditions  of  the  amnion 
may  likewise  be  encountered,  such  as  an  excessive  amount 
of  the  amniotic  fluid  or.  the  converse,  absence  of  the 
proper  quantity,  constituting  a  so-called  "dry  labor.  "  Pla- 
cental disease  which  may  effect  the  fetal  life,  may  take 
place  as  a  hemorrhage  or  apoplexy  which  by  so  separat- 
ing the  placenta  from  the  uterine  wall  as  to  interfere  with 
its  function,  will  result  in  fetal  death.  Placenta  previa 
and  placentitis,  the  latter  syphilitic  in  origin,  must  not  be 
overlooked.  Various  forms  of  degeneration  of  the  placenta, 
such  as  fatty,  calcareous,  edematous,  myxomatous  and 
cystic  are  likewise  responsible  in  certain  cases.  There 
may  also  be  certain  diseases  attributable  to  the  umbilical 
cord,  such  as  ceilings  and  twistings  or  the  actual  forma- 


«(-, .        The   Phit.adelphta"! 
"^4        Medical  Jocknai.  J 


THE  LATEST  LITERATURE 


[Aj-Kii.  27.  laoi 


tioQ  of  knots  which  constrict  the  vessels  sufficiently  to 
arrest  the  circulation.  Among  other  causes  of  fetal  death 
not  already  enumerated  may  be  mentioned  hydrocephalous 
and  malformation  of  the  child,  rupture  of  the  uterus,  de- 
formaties  of  the  pelvis,  and  ovarian  and  fibroid  tumors. 
Macphatter  closes  his  paper  with  a  few  suggestions  as  to 
the  treatment  of  the  various  conditions  mentioned.  [W.  A. 
N.  D.] 

7. — Somerset  carries  out  the  following  special  treatment 
in  a  child  that  is  carrjing  an  intubation  tube: — (1)  Care- 
ful attention  must  be  given  to  the  drainage  of  the  air 
passages,  and  irrigation  of  the  throat  is  not  desirable;  (2) 
All  mucus  and  membrane  coughed  up,  but  not  expelled, 
should  be  removed  by  the  finger:  (3)  Nasal  irrigation  is 
permissible;  (4)  Feeding,  whenever  possible,  should  be 
done  in  the  ordinary  way,  and  if  the  child  cannot  swallow 
in  the  normal  position,  lavage  is  usually  the  remedy.  If 
lavage  is  contraindicated,  semi-solid  food  may  be  given; 
(5)  Internal  medicine  should  be  reduced  to  a  minimum. 
If  the  case  is  complicated  by  an  exudation  of  especially 
tenaceous  mucus,  the  inhalation  of  medicated  steam  should 
be  tried:  iC)  Absolute  rest  is  essential,  and  morphine 
should  be  used  if  necessary;  (7)  The  tube  should  be  used 
just  as  short  time  as  possible.  In  early  cases  it  should  be 
removed  by  the  fifth  day.  Children  under  two  years  old 
generally  carry  the  tube  two  weeks  or  longer.     [T.  M.  T.] 


MEDICAL    RECORD. 

Aiiiii  _''/,  ni'ii. 

1.  The  Toxemia  of  Pregnancy:   its  Diagnosis  and  Treat- 

ment.    S.  MARX. 

2.  Faith  Cures  and  the  Law.     JOHN  B.  HUBER. 

3.  Report  of  Three  Cases  of  Malignant  Endocarditis:  One 

following  Measles,  another  Typhoid  Fever  in  a  Child 
and  Simulating  Splenic  Lymphatic  Leukaemia,  and 
another  Terminating  in  Recovery.  ALBERT  E. 
ROUSSEL. 

4.  Strangulated    Hernia    in     Infants:     Description    of    a 

Hitherto  Unrecognized  Cause  and  Seat  of  Strangu- 
lation.    ALEXIS  V.  MOSCHCOWITZ. 

1. — S.  Marx  discusses  the  toxemia  of  pregnancy  and  its 
diagnosis  and  treatment.  He  concludes  that  the  toxemia 
is  a  complex  condition  depending  on  more  than  one  factor. 
Many  women  go  to  term  with  albuminuria,  without  symp- 
toms referable  to  toxemia.  When  such  symptoms  arise 
they  are  not  caused  by  the  albumin  present,  but  by  faulty 
urea  secretion.  In  the  most  desperate  and  malignant  cases 
there  are  found  neither  albumin  nor  casts.  Urea  is  always 
found  markedly  diminished  in  the  so-called  "true  toxemias" 
of  pregnancy,  or  urinemia.  Finally  Marx  makes  a  strong 
plea  for  a  regular  and  methodical  cause  of  urea  examina- 
tions in  all  cases  of  toxemia,  or  for  the  relagation  to  sec- 
ondary importance  of  the  time  honored  examination  for 
adbumin.  Progressive  diminution  of  urea  excretion,  with 
or  without  albuminuria,  is  the  sole  indication  of  premature 
labor,  which  is  especially  indicated  when  conscientious 
medical  treatment  fails.     [T.  L.  C] 

4. — A.  V.  Moschcowitz  reports  2  cases  of  strangulated 
hernia  in  infants  with  a  description  of  a  hitherto  unrecog- 
nized cause  and  seat  of  strangulation.  The  author  believes 
that  the  comparative  rarity  of  strangulated  hernias  in  in- 
fants of  three  and  four  months,  would  alone  be  almost 
sufficient  justification  for  the  publication  of  his  two  cases. 
His  chief  reason  is  the  heretofore  unrecognized  location  of 
the  condition  low  down  in  the  scrotum,  which  occurred  in 
both  of  his  cases.  As  a  rule  the  strangulation  occurs  in  all 
hernias  at  the  external  ring,  or  the  internal  ring,  or  the 
neck  of  sac.  The  few  exceptions  of  this  general  rule 
are  caused  by  newlj'-formed  inflammatory  bands  and  ad- 
hesions, or  more  rarely,  but  openings  in  the  prolapsed 
omentum.  He  gives  a  critical  review  of  the  reported  cases 
regarding  this  point,  and  in  order  to  explain  the  unusual 
conditions  present  in  his  cases  goes  back  to  the  develop- 
mental stage  of  the  organs  in  this  region.  In  the  course  of 
development  the  process  us  vaginalis  may  being  the 
shutting  off  of  the  normal  tunica  vaginalis,  but  the  process 


may  stop  before  it  is  entirely  completed.  The  result  will 
be  a  sac  of  the  usual  congenital  cariety  with  the  import- 
ant difference  that  it  will  be  constricted  in  its  lower  por- 
tion. In  other  words,  the  sac  may  not  improperly  be  com- 
pared to  an  hour-glass  open  at  its  top.  The  size  of  the 
two  halves  varies,  depending  upon  the  different  theories 
which  have  been  proposed  as  regards  the  exact  mode  of 
development.  He  believes  that  in  many  cases  of  strangu- 
lating by  the  neck  of  the  sac  may  be  accounted  for  by  the 
theory  of  Lockwood,  who  states  that  there  seems  to  be  a 
strong  tendency  for  the  processus  vaginalis  to  close  in  two 
places  which  are  some  distance  apart,  namely  just  above 
the  testicle  and  near  the  internal  ring.     [T.  L.  C] 


MEDICAL  NEWS. 
April  20,  1901.     (LXXVIU,  No.  16.) 

1.  An  Historical  Sketch  of  the  Department  of  Medicine 

and   Surgery  of  the  University  of  Michigan. 

2.  Some  Errors  in  the  Examination  of  Urine.       LOUIS 

HEITZMANN. 
i.     Acute  Traumatic  Aialignancy.      WILLIAM  B.  COLEY, 
4.     Epistaxis.     CHARLES  N.  COX. 

2. — Heitzmann,  In  his  article  on  Some  Errors  in  the 
Examination  of  Urine,  considers  the  heat  test  for  albumin 
the  most  reliable,  provided  that  acids  are  used  to  dif- 
ferentiate between  phosphates  and  albumin.  He  recom- 
mends the  use  of  equal  parts  of  glacial  acetic  acid  and 
water  instead  of  nitric  acid  on  account  of  the  latter's 
strength,  stating  that  in  urine  with  small  quantities  of 
albumin  it  would  not  precipitate  the  albumin,  but  dis- 
solve it  out.  The  acetic  acid  must  not  be  pure  for  the  same 
reason.  He  claims  epithelial,  blood,  granular,  fatty  and 
waxy  casts  as  true  casts,  the  first  three  being  found  in 
acute  conditions,  the  latter  three  in  subacute  and  chronic 
inflammation.  Granular  casts  are,  as  a  rule,  never  found  un- 
til the  inflmmation  has  lasted  six  weeks  or  two  months,  al- 
though exceptionally,  especially  in  cases  of  nephritis  after 
contagious  diseases,  they  can  be  seen  in  small  numbers 
in  the  2d  or  3d  week  of  the  kidney  disease.  Fatty  casts, 
when  present  in  large  numbers,  mean  chronicity  and  fatty 
degeneration  of  the  kidney.  Waxy  casts  indicate  a  waxy  or 
amyloid  degeneration  of  the  kidney  and  are  found  in  chron 
ic  constitutional  diseases.  The  sizes  of  casts  vary  greatly, 
the  most  narrow  being  those  from  narrow  or  looped 
tubules;  the  second  size,  from  the  larger  convoluted  tu- 
bules; while  the  larger  ones  come  from  the  straight  col- 
lecting tubules.  The  cylindroids  or  mucus-casts  he  de- 
scribes as  casts  made  up  of  mucus  threads  which  may  be 
derived  from  any  portion  of  the  geni to-urinary  trace  and 
are  therefore  not  diagnostic  of  nephritis.  Great  care  must 
be  taken  not  to  mistake  these  casts  for  hyaline,  as  is  not 
an  infrequent  occurrence.  He  does  not  favor  the  use  of  the 
centrifuge,  and  believes  that  allowing  the  nrine  to  stand 
six  to  twelve  hours  previous  to  microscopical  examination 
is  to  be  preferred,  except  in  case  of  tubercle  bacilli.  He 
concludes  by  saying  that  the  diagnosis  of  nephritis  does 
not  depend  necessarily  upon  the  presence  of  casts,  since 
they  are  almost  invariably  absent  in  interstitial  nephritis. 
Pus  corpuscles,  red  blood  discs  and  kidney  epitbelia  are  suf- 
ficient for  a  diagnosis.     [T.  M.  T.] 

3. — Coley  states  that  the  relationship  between  antece- 
dent trauma  and  the  development  of  sarcoma  or  carcinoma 
can  be  most  rationally  explained  on  the  theorj-  that  such 
tumors  are  infectious,  or  of  micro-parasitic  origin.  The 
similarity  between  sarcoma  and  diseases  known  to  be  of 
infectious  origin  is  very  striking.  The  clinical  evidence, 
aside  from  the  bacteriological  or  pathological,  points  more 
and  more  strongly  to  specific  infection  as  a  cause  of  sar- 
coma, and  he  especially  instances  the  close  resemblance  of 
the  histology  of     tuberculosis  sacroma.  He  suggests 

that  the  most  probable  explanation  is  that  the  microor- 
ganism exists  latent  In  certain  subjects  under  normal 
conditions.     The  local  trauma  diminished  the  vitality  of  the 


Apeil  2t,  19011 


THE  LATEST  LITERATURE 


CTna    rniLADELPHIA  0^,  r 

Medical  Joubnai.         ""O 


tissues  and  hence  their  resisting  power  and  the  germs, 
previously  inocuous,  gain  a  foothold  and  develop.  He 
concludes  as  follows:  —  (1.)  Trauma  is  a  very  Important 
factor  in  the  causation  of  malignant  tumors;  (2.)  The  rela- 
tionship between  injury  and  malignant  tumors  furnishes 
additional  and  by  no  means  unimportant  evidence  in  sup- 
port of  the  infectious  origin  of  such  tumor.     LT.  M.  T.] 

4. — Cox  holds  that  the  majority  of  nasal  hemorrhages 
are  due  to  some  intranasal  lesion  and  the  most  frequent 
injury  which  gives  rise  to  epistaxis  is  a  blow  or  tall  upon 
the  nose  resulting  in  rupture  of  some  of  the  minute  ves- 
sels of  the  mucous  membrane  lining  the  nose.  The  most 
frequent  seat  is  the  triangular  cartilage  of  the  septum 
just  within  the  vestibule.  When  bleeding  occurs  in  this 
locality  it  is  not  necessary  to  pack,  as  the  bleeding  point 
can  be  seen  and  easily  reached.  Deviation  or  spur  ol 
septum,  varicose  enlargement  of  the  veins  of  the  septum, 
minute  angiomata.  intranasal  growths  are  all  apt  to  pro- 
duce bleeding.     [T.  M.  T.] 


BOSTON   MEDICAL  AND  SURGICAL  JOURNAL. 

April  IS,  1001. 

1.  The  Opinion  Evidence  of  Medical  Experts.     JOHN  U. 

Mclaughlin. 

2.  The.Umillian  Murder.     HERBERT  B.  PERRY. 

3.  Upon   what   Sort  of   Information   shall  a   Medical   Ex- 

aminer Hold  a  View?     H.  M.  CULLS. 

4.  Leukocytosis    and    Typhoidal    Perforation.      From    the 

Medical  Clinics  of  the  Montreal  General  and  Royal 
Victoria  Hospitals.     COLIN  K.  RUSSELL. 

1. — When  testifying  to  his  opinion,  based  either  on  facts 
that  he  has  himself  observed  on  admitted  tacts,  or  upon 
some  hypothesis;  expressing  the  judgment  of  a  scientific 
man,  ready  to  submit  it  to  the  opinion  of  the  members 
of  his  own  profession,  to  the  cross-examination  of  council, 
publicly  and  to  the  world,  the  physician  evokes  an  interest 
that  rarely  surrounds  a  witness  under  any  other  circum- 
stances. Few  theories,  however  fantastic  need  go  uncham- 
pioned  at  present  in  the  condition  of  medical  expert  testi- 
mony and  it  is  the  experience  of  lawyers  that  to  testify  as 
an  expert  is  becoming  more  and  more  repugnant  to  those 
physicians  whose  evidence  would  be  of  the  most  value. 
But  who  will  say  that  the  conditions,  of  which  certain 
cases  cited  by  McLaughlin  are  but  illustrations,  are  not 
largely  owing,  rather  to  the  defective  method  of  the  law, 
than  to  the  imperfections  of  science  or  that  we  are  con- 
fronted with  a  state  of  things  that  it  is  impossible  to 
ameliorate?  Surely  the  fault  cannot  be  laid  at  the  door  or 
science.  Wherever  the  experts  in  the  cases  referred  to 
were  in  contradiction,  one  of  them  was  right  and  the  other 
wrong.  It  would  seem  that  it  is  the  duty  of  the  law  to 
establish  as  many  barriers  to  the  progress  and  triumph  of 
the  wrong  side  of  expert  testimony  as  is  humanly  possible. 
The  author  points  out  on  what  insufficient  grounds  some 
men  have  been  heard  as  expert  witnesses  in  certain  trials. 
It  is  difficult  to  perceive  how  an  expert's  position  in  relation 
to  facts  differs  from  that  of  a  judge  in  respect  to  the  law. 
In  a  law  judge,  learning  and  disinterestedness  are  the  two 
requisites  that  are  conceded  by  every  one  to  be  preeminent, 
and  the  faintest  trace  of  prejudice,  bias  or  partisanship 
disqualifies  a  person  from  becoming  a  judge.  Neither  little 
learning  nor  much  bias,  under  our  practice,  disqualifies 
the  expert.  After  describing  the  method  of  procedure  in 
Germany  the  author  says  that  he  would  not  be  thought  to 
advocate  the  German  method  but  that  he  underlying  prin- 
ciple of  the  law  relating  to  expert  testimony  is  that  the 
expert  should  not  be  a  partisan.     [J.  M.  S.J 

2. — Perry  describes  the  wounds  on  the  body  of  a  mur- 
dered man.  whose  corpse  was  found  :i  months  after  he  had 
been  killed.  The  man  accused  of  the  murder  was  sitting  in 
the  kitchen  of  a  farm-house,  handcuffed  to  an  officer.  The 
district  police  officer  came  in  suddenly  and  asked  the  the 
accused  what  he  had  done  with  the  head  of  his  victim. 
The  accused  said  the  he  "did  not  know,"  but  his  pulse, 


which  had  been  beating  at  the  rate  of  SO  per  minute  sud- 
denly increased  to  120.     [J.  M.  S.] 

4. — Russell  reports  G  cases  that  show  that  the  leukocyte 
count  may  vary  greatly  in  typhoid  fever.  Even  where 
no  complication  is  evident  the  leukocytes  may  number 
15,000.  Again,  when  certain  complications,  other  than 
perforation,  exist  the  leukocyte  count  may  be  markedly 
above  normal.  When  pain  and  tenderness  in  the  abdo- 
men come  on  suddenly  in  the  course  of  typhoid  fever  and 
there  is  absence  of  definite  complication  such  as  cholecys- 
titis the  presence  of  leukocytosis  renders  exploratory  inci- 
sion justifiable  and  advisable  in  order  to  obviate  the 
danger  of  fatal  issue  from  too  great  delay.     [J.  M.  S.J 


7. 
S. 

9. 

iO. 

li. 

12. 

13. 


JOURNAL  OF  AMERICAN  MEDICAL  ASSOCIATION. 

April  20ih,  liliJl. 
James  Lemaire.     The  First  to  Recognize  the  True  Na- 
ture of  Wound  Infection  and  Inflammation,  and  the 
First  to  Use  Carbolic  Acid  in  Medicine  and  Surgery. 
HOWARD  A.  KELLY. 
Tracheloplasty.     HENRY  PARKER  NEWMAN. 
,     The  Physiologic  Care  of  Colds.     CHARLES  H.  SHEP- 
ARD. 
Atrophy   of   the   Mucous    Membrane   of   the   Stomach. 

FREEMAN  F.  WARD. 
Some   Notes   on    Two    Cases    of   Voluntary    Laryngeal 

Whistling.    G.  HUDSON  MAKUEN. 
Some  Anomalies  of  the  Ear  Due  to  Errors  in  Develop 

ment.     GEORGE  C.  STOUT. 
Care  and  Use  of  Instruments.    ALLEN  de  VILBISS. 
Surgical    Diagnosis    of    Abdomnial    Tumors.      W.    H. 

EARLES. 
A  Contribution  to  the  Study  of   Mountain  Fever.     R. 
HARVEY  REED. 
A     Study     in     the     Hematology     of     Neurasthenia. 

CHARLES  HOWARD  LODOR. 
Intubation  of  the  Larvnx  with  Personal  Reminiscences. 

F.  E.  WAXHAM. 
Some  Points  in  the  Diagnosis  of  Gail-Stones.    JAMES 

B.  HERRICK. 
The  Present  Status  of  Spinal  Surgery.  SAMUEL 
LLOYD. 
1. — Howard  A.  Kelly  goes  very  carefully  into  the  history 
of  antisepsis,  dividing  the  honor  of  its  introduction  among 
.several  investigators,  giving  a  large  portion  of  the  credit 
to  Jules  Lemaire,  who  in  18113  published  a  very  comprehens- 
ive work  on  the  use  of  carbolic  acid.  Coal-tar  had  been 
used  tor  many  years  in  a  powder  or  paste  as  a  disinfectant 
for  hygienic  purposes,  and  was  first  put  up  in  an  emulsion 
by  Le  Beuf  in  1850  and  experimented  with  by  Lemaire, 
who  showed  that  "In  surgery  he  established  the  great  prin- 
ciple of  a  living  septic  agent  in  putrifying  and  suppurating 
wounds,  and  he  laid  the  foundation  stone  of  successful 
treatment."  Lister's  first  publication  on  the  use  of  car- 
bolic acid  was  published  in  1867.    [J.  H.  G.] 

2. — Henry  P.  Neumail  prefers  to  call  the  operation  of 
amputation  of  the  cervix  uteri  tracheloplasty.  He  thinks 
this  operation  much  to  be  preferred  over  the  curette,  the 
cautery  and  other  methods  which  are  always  more  or  less 
unsatisfactory.  The  author  then  describes  his  own  par- 
ticular method  of  amputating  the  cervix,  which  is  illus- 
trated by  a  number  of  cuts  showing  the  steps  of  the  opera- 
tion.    [J.  H.  G.] 

3. — Shepards  maintains  the  view  that  colds  are  due  to 
an  inactive  condition  of  the  excretory  organs,  resulting  in 
imperfect  elimination  through  the  normal  passages  and 
causing  a  discharge  of  some  of  the  impurities  of  the  sys- 
tem, through  the  respiratory  mucous  membrane,  particu- 
larly of  the  head.  In  the  treatment  of  a  cold,  he  re- 
commends abstainence  from  food  for  24  hours,  flushing 
of  the  bowels  with  warm  water,  exercise  in  the  open  air, 
and  a  Turkish  bath.  A  simple  "cold  in  the  head"  may 
be  treated  by  drawing  hot  water  in  the  nostrils  several 
times,  and  then  blowing  it  out.  This  measure  is  simple 
and  effective.  Cold  bathing  in  the  morning  is  recom- 
mended for  those  in  fair  health  as  a  measure  to  avoid 
colds.     [F.  J.  K. 

4. — Ward  in  an  article  on  atrophy  of  the  gastric  mucous 
membrane,  states  that  he  does  not  believe  the  condition  is 
essentially  associated  with  pernicious  anemia,  as  most 
authors  do.  He  holds  that  we  can  only  diagnose  achylia 
gastrica,  when  there  is  complete  absence  of  all  the  normal 


Q(-,5       The  Philadelphia"! 

MKIjIiAL   Jcirit.NAL   J 


THE  LATEST  LITERATURE 


AJ'BIL  27,  11)01 


constituents  of  the  gastric  juice,  and  only  after  this  condi- 
tion has  been  found,  after  repeated  examinations,  at  vari- 
ous times.  He  lays  particular  stress  upon  the  fact  that 
the  disappearance  of  free  HCI  does  not  necessarily  point  to 
gastric  carcinoma,  for  in  cancer  of  the  stomach  it  may  be 
present  in  the  gastric  juice  and  may  be  absent  in  some 
cases  of  acute  and  chronic  gastritis.  A  report  of  5  cases  of 
atrophy  of  the  gastric  mucous  membrane  is  given.  He 
emphasizes  that  diarrhea,  as  a  rule,  exists  with  achylia 
gastrica.  The  important  indication  in  the  treatment,  in  ad- 
dition to  general  hygienic  measures,  will  be  found  in  regu- 
lating the  diet:  the  patient  should  be  urged  to  take  large 
quantities  of  farinaceous  food:  a  mild  astringent,  such  as 
tannigen  or  tannalbin,  will  be  found  serviceable,  and  for 
the  anemia  iron  is  indicated.  When  there  is  much  mucous 
in  the  stomach  he  recommends  lavage.     [F.  J.  K.] 

5. — Makuen  reports  2  cases  of  voluntary  laryngeal 
whistling,  and  he  states  that  the  subject  is  of  interest  as 
showing  the  possibility  of  development  of  voluntary  laryn- 
geal muscle  action.     [F.  J.  K.] 

8. — W.  H.  Earles  urges  upon  the  surgeon  the  more 
careful  study  of  methods  of  making  accurate  diagnosis  of 
Intra-abdominal  lesions,  maintaining  that  "Surgeons  too 
often  take  things  for  granted  and  develop  conclusions  with- 
out first  having  established  the  proper  premises."  He  par- 
ticularly recommends  the  careful  consideration  of  the  his- 
tory of  the  patient  and  the  development  by  constant  prac- 
tice of  the  sense  of  touch.  He  thinks  that  although  in 
some  cases  an  anesthetic  is  of  assistance  that  in  many 
others  it  really  obscures  the  condition  by  removing  the 
evidences  of  sensitiveness  and  pain  of  the  diseased  organ. 
[J.   H.   G.] 

9. — Reed,  in  an  article  on  the  study  of  mountain  fever, 
draws  the  following  conclusions:  In  the  majority  of  cases 
of  mountain  fever,  the  Widal  test  is  negative;  the  duration 
of  mountain  fever  is  shorter  than  that  of  enteric  fever; 
the  exciting  cause  does  not  seem  to  be  Eberth's  bacillus; 
the  exacerbations  and  remissions  of  temperature  in  moun- 
tain fever  are  more  abrupt  than  in  typhoid  fever:  the 
eruption  of  mountain  fever  has  a  peculiar  "spotty  feeling:' 
it  is  raised,  does  not  disappear  upon  pressure,  and  covers 
the  entire  body.     [P.  J.  K.] 

10. — Waxbam  states  that  thcoxygen-carrying-capacity 
of  the  erythrocytes  is  lowered  in  neurasthenia,  and  that 
there  is  poor  vaso-motor  control  of  the  vascular  system, 
giving  rise  to  vari.ition  in  the  peripheral  blood.     [F.  J.  K.] 

11. —  F.  E.  Waxham  rehearses  a  number  of  interesting 
and  amusing  experiences  in  the  early  jiractice  of  intuba- 
tion, showing  the  great  popular  prejudice  against  this 
operation  when  it  was  first  introduced.  He  calls  atten 
tion  to  the  wonderful  change  in  the  mortality  of  diph- 
theria since  this  operation  has  come  into  vogue  and 
since  the  antitoxin  treatment  has  become  thoroughlv  es- 
tablished.    [.I.  H.  G.] 

12. — Herrick,  in  an  article  entitled  some  points  in  the 
diagnosis  of  gall-stones,  gives  an  analysis  of  some  of  the 
important  symptoms  of  gall-stone  colic.  The  pain  may  bo 
referred  to  the  hack,  or  it  may  be  located  to  the  left  of  the 
median  line  of  the  abdomen,  or  the  pain  may  radiate  up- 
wards or  shoot  downwards  toward  the  genitalia.  Jaundice 
follows  in  great  a  numlier  of  the  cases  of  biliary  colic,  but 
in  some  the  icterus  is  slight,  so  that  it  may  be  overlooked, 
and  ther  are  cases  in  which  no  evidence  of  jaundice  is  to 
be  discovered.  There  is  a  large  class  of  cases  in  which  in- 
flammation follows  the  passage  of  gall-stones  through  the 
duct.  Vomiting  and  nausea,  pain  and  tenderness  over  the 
gall-bladder  are  present,  and  upon  examination  the  gall 
bladder  is  found  distended.  The  author  states  that  the 
exact  nature  as  to  the  causation  of  Charcot's  hepatic  inter- 
mittent fever  has  not  been  determined.  Intermittent  he- 
patic fever,  accompanied  by  chill  and  sweating,  does  not 
only  occur  in  association  with  the  passage  of  stones  through 
the  biliary  duct,  but  has  also  been  observed  in  cases  of 
carcinoma,  which  produce  pressure  upon  the  common  bile 
duct.  The  association  of  gall-stones  with  carcinoma  can 
hardly  be  looked  upon  as  a  mere  coincidence,  as  gall-stones 
precede  the  development  of  carcinoma  in  many  cases. 
Reference  is  made  to  Riedel's  tongue-shaped  process — a 
pericystic  thickening  of  the  gall-bladder  extendin.g  from 
the  anterior  border  of  the  liver  as  indicating  a  gall-liladder 
stone  in  many  cases.  The  author  states  that  the  occurrence 
of  enteric  fever  seems  to  predispose  to  the  formation  of 
gall-stones  in  many  instances.  Reference  is  made  to  the 
differential   diagnosis   between   gall-stone   colic   when   the 


pain  Is  referred  to  the  left  side  and  angina  pectoris.  Ar- 
teriosclerosis, hypertrophy  of  the  heart,  violent,  distinct 
precordial  pain,  which  radiates  to  the  neck  and  left  arm, 
with  a  sense  of  impending  death,  points  to  angina  pectoris. 
The  differential  diagnosis  between  biliary  colic  and  senile 
pneumonia  is  often  difficult,  especially  when  the  right  lower 
lobe  is  affected  and  the  cough  is  slight  with  litlte  expec- 
toration. The  author  also  refers  to  the  difficulty  in  differ- 
entiating certain  case  of  localized  peritonitis,  appendicitis, 
intestinal  obstruction,  hemorrhagic  pancreatitis,  Dietl's 
crisis  in  floating  kidney,  hysteria,  and  malaria  with  neural- 
gic pain  and  jaundice,  from  gall-stone  colic.     [F.  J.  K.] 

13. — Samuel  Lloyd,  continuing  the  present  status  of 
spinal  surgery  discusses  the  question  of  tumors.  The 
surgical  treatment  of  tumors  of  the  spine  dates  back  to 
'S7,  and  owes  its  origin  to  Gowers  and  Horsley.  Lloyd  re- 
ports briefly  a  collection  of  51  cases.  He  reports  a  case  of 
hydatids  which  produced  compression  of  the  cord  and  in 
which  he  operated  with  complete  recovery,  the  patient 
being  able  to  return  to  his  ordinary  occupation.  Many 
of  the  deaths  following  operations  for  tumors  of  the  spinal 
cord  are  really  due  not  to  the  operation  but  to  the  nature 
of  the  growth.  Only  8  per  cent,  of  the  cases  operated 
upon  have  died  as  a  direct  result  of  the  operation  itself. 
Fractures  of  the  spine  are  next  discussed.  Recoveries 
from  operative  interference  in  the  cervical  region  of  the 
spine  have  been  very  few,  the  prognosis  in  the  lumbar 
and  dorsal  regions  is  much  better.  The  nature  of  the 
fracture  itself  will  also  influence  the  prognosis:  for  in- 
stance, where  there  is  complete  severance  of  the  cord, 
as  evidenced  by  the  rapid  appearance  of  bedsores,  paresis 
of  the  bladder  and  rectum,  and  obliteration  of  the  deep 
reflexes,  operative  interference  would  hold  out  little  hope 
of  benefit.  The  author,  however,  does  not  agree  with 
Keen  that  where  deep  reflexes  are  absent  operative  in- 
terference is  contra-indicated,  because  a  number  of  cases 
are  on  record  where  the  reflexes  have  been  absent  and 
yet  there  has  not  been  complete  severance  of  the  cord, 
and  improvement  has  followed  laminectomy.  Statistics 
show  that  most  of  the  deaths  following  facture-disloca- 
lion  of  the  spine  occur  within  a  few  days,  and  hence,  the 
number  of  deaths  which  are  attributed  to  the  operation 
would  undoubtedly  have  taken  place  even  though  no 
operation  had  been  performed.  As  to  the  best  time  at 
which  to  operate  Lloyd  thinks  that  it  is  best  to  wait 
until  the  patient  recovers  from  the  shock  and  until  It 
is  evidenced  that  there  will  be  no  spontaneous  recovery 
complete  enough  to  make  life  bearable.  If  the  patient 
shows  a  tendency  to  gradually  improve  after  the  injury, 
operation  should  not  be  done,  but  where  the  symptoms 
show  progression  or  seem  to  have  reached  the  end  of 
improvement  operation  should  be  undertaken.     [J.  H.  G.I 


AMERICAN  MEDICINE. 
Ainil  _''///,.  ;;).//. 

1.  Hos^'    to    Deal    with    the    Vermiform    Appendix:    Some 

Forms  of  Complicated   Appendicitis.     HOWARD  A 
KELLY. 

2.  The  Good  and   Bad   Effects  Obtainable  from   Digitalis 

Used  as  a  Therapeutic  Agent.     WILLIAM   HENRY 
PORTER. 

3.  Congenital  Deformity  of  Wrist;   Osteotomv  of  Radius 

De FOREST   WILLARD. 

4.  The    Logic    of    Hydrochloric    Acid    Therapy.    Restora- 

tion of  Lost  Gastric  HCI  Secretion  bv  Medical  and 
Surgical  Methods.    JOHN  C.  HEMMET ER. 
a.     Metatarsal  Fracture.     CARL  BECK. 

6.  Some  Remarks  on   Inguinal  Colostomy.     WILLIAM  J. 

MAYO. 

7.  The  Prevalence  of  Streptococci  in  Cow's  Milk.     D.  H. 

BERGEY. 

5.  Case  of  Congenital   Form  of  Hernia  of  the  Appendix 

\  erfmiformis  in  Conjunction  with  a  Cyst  of  the  Canal. 

G.  CHILDS  MacDON.\LD. 
1. — Howard  A.  Kelly  deals  with  those  cases  of  appen- 
dicitis In  which  the  appendix  is  found  to  be  densely  ad- 
herent, or  when  it  opens  into  an  abscess,  or  when  there 
exists  a  more  or  less  general  peritonitis.  In  all  such 
cases  the  operator  dreads  all  avoidable  contamination  of 
the  surrounding  tissues  with  any  part  of  the  appendicial 
abscess,  and  all  avoidable  injury  to  the  coats  of  the  ad- 
herent intestine.  Kelly  has  found  that  when  the  appendix 
is  diseased  and  densely  adherent  at  its  tip.  that  the  best 
plan  often  is  first  to  seek  out  and  expose  its  base,  which 


April  27,  19011 


THE  LATEST  LITERATURE 


[Medic'ai-  Jocksai.         8o7 
Tub     ruILAUKLlUIA  ' 


is  detached  and  divided  so  as  to  free  the  appendix  from  the 
cecum.  The  distal  portion  is  now  wrapped  for  protection 
in  gauze,  while  the  opening  into  the  bowel  is  closed.  Then 
the  severed  appendix  is  dissected  out  of  its  bed  with  much 
greater  facility  than  was  possible  with  both  ends  an 
chored,  one  to  the  cecum  and  one  to  the  adhesions.  This 
plan  of  procedure  is  especially  useful  in  the  gynecological 
field.  In  cases  in  which  the  vermiform  appendix  is  at 
tached  to  a  pyosalpinx,  or  an  ovarian,  or  fibroid  tumor, 
after  it  is  severed  from  the  bowel,  it  can  then  be  enu 
cleated  with  the  pelvic  abscess  or  with  the  tumor.  When 
the  end  of  the  appendix  enters  the  abscess  cavity  sur- 
rounded by  the  adherent  intestine,  which  cannot  be  stripped 
off  with  safety,  Kelly,  after  freeing  the  base  of  the  appen 
dix  from  cecum  traced  it  up  until  it  entered  an  abscess 
cavity  under  the  ascending  colon.  It  could  not  be  sepa- 
rated from  the  adhesions  without  injuring  the  bowel  so 
the  appendix  was  grasped  with  a  pair  of  forceps,  on  either 
side,  close  to  the  abscess  and  split  open  and  followed  to 
its  lumen,  as  a  guide,  by  using  a  groove  director  and  a 
pair  of  open  scissors,  with  one  blade  in  the  appendix.  The 
operator  was  thus  enabled  with  certainty  to  enter  the 
very  middle  of  the  abscess  cavity,  to  lay  it  open  and 
cleanse  it  out  without  doing  any  damage  to  the  colon. 
[T.  L.   C.J 

2. — (Will  be  abstracted  when  concluded). 

3. — DeForest  Willard  presents  skiagraphs  of  a  case  of 
congenital  deformity  of  the  wrist  in  which  osteotomy  of 
the  radius  was  performed.  The  patient  was  a  girl  of  14. 
whose  carpus  was  thrown  by  the  arched  condition  of  the 
radius  so  far  out  of  the  normal  line  anteriorly  that  it  en 
tirely  failed  to  articulate  with  the  ulna,  and  was  joined 
very  faultily  with  the  radius.  The  resulting  disability  was 
so  great,  and  continued  to  grow  greater  every  year,  that 
the  simplest  exertion  could  not  be  performed  with  com 
fort.  The  mother  had  the  same  deformity  in  both  wrists 
but  in  a  less  degree.  The  arch  in  the  radius  caused  its 
articulating  surface  to  looli  almost  at  right  angles  to  its 
normal  position,  while  the  semilunar  and  scaphoid  lay  with 
their  sides  against  the  joint  surface  instead  of  upon  their 
normal  faces.  An  osteotomy  of  the  radius  IS^  inches  above 
the  wrist  joint,  with  forcible  straightening:  and  fixation 
for  5  weeks  in  a  corrected  position  with  plaster  of  Paris 
gave  a  greatly  Improved  result  both  as  to  appearance  and 
strength.     [T.  L.  C] 

4. — J.  C.  Hemmeter  discusses  the  logic  of  hydrochloric 
acid  therapy,  and  restoration  of  lost  gastric  HCI  secretion 
by  medical  and  surgical  methods.  The  purposes  for  which 
HCI  are  given  are:  the  absence,  or  the  diminution  of.  nor- 
mal secretion:  to  supplement  gastric  proteolysis;  to  act 
as  an  antiseptic;  to  act  as  a  tonic  and  stomachic.  He  re- 
ports a  case  of  immense  atonic  dilatation  of  the  stomach  in 
which  the  greater  curvature  extended  into  the  pelvis 
Every  morning  before  breakfast  stagnating  food  masses 
could  be  washed  out  of  the  stomach.  Analysis  of  the 
stomach  contents  could  never  detect  free  or  combined 
HCI.  The  ferments  pepsin  and  chymosin  were  still  active 
in  their  precursory  stages.  After  6  months  of  medical 
treatment  no  lasting  improvement  was  effected.  The 
operation  of  gastroplication  was  then  advised  and  per- 
formed, and  nephrorrhapy,  which  was  indicated,  was 
also  performed  5  months  after  this  operation  free  HCI  was 
detected  after  the  test  meals.  This  was  an  evidence  that 
the  glandular  layer  had  not  been  destroyed  hy  disease  but 
that  the  peptic  cells  had  simply  been  exhausted  by  the 
presence  of  food  in  a  dilated  stomach  which  could  at  no 
time  empty  itself  entirely.     [T.  L.  C] 

5. — Carl  Beck  contributes  a  paper  on  metatarsal  fracture. 
Before  we  had  resource  to  the  X-rays,  as  a  method  of  diag 
nosis,  metatarsal  fracture  must  have  been  frequently 
overlooked.  It  only  one  or  two  metatarsal  bones  are  bro- 
ken but  little  tendency  to  displacement  is  present,  which 
explains  why  the  symptoms  are  not  pronounced.  After  dis- 
cussing the  diagnosis  of  the  condition  Beck  takes  up  the 
question  of  treatment.  If  there  Is  no  displacement  present 
in  fracture  of  any  of  the  second,  third  or  fourth  metatarsal 
bones,  a  simple  and  short  plaster  of  Paris  dressing  meets 
the  requirements.  The  patient  should  be  kept  in  bed  the 
first  week  and  during  the  next  two  w-eeks  should  be  encour 
aged  to  walk,  protected  by  the  proper  ambulatory  dress- 
ings. If  the  first,  or  fifth,  metatarsus  is  broken,  and  no 
displacement  is  noticeable,  a  small  strip  of  moss-board 
slightly  moistened  is  placed  alongside  the  outer,  or  inner 
margin,  of  the  foot  before  the  plaster  of  Paris  dressing 
is  applied.     If  there  is  displacement  of  the  second,  third 


or  fourth  metatarsal  bone  pressure  will  then  reduce  the 
fragments,  which  are  then  kept  in  place  as  indicated  in 
the  other  condition.  If  the  displacement  is  sideways  (in- 
stead of  in  the  dorsal  or  planter  direction)  reduction  is  best 
accomplished  by  grasping  the  fragments  as  firmly  as  possi- 
ble near  their  epiphyseal  end  and  alternately  turning  and 
shifting  them  until  the  reposition  is  perfect.     [T.  L..  C.J 

6. — In  this  contribution  on  inguinal  colostomy  W'illiam  J. 
-Mayo  concludes  as  follows:  Colostomy  is  not  now  a  rival 
ui  excision  of  the  rectum  for  malignant  disease,  and  should 
only  be  employed  in  hopeless  cases  presenting  obstructive 
phenomena.  For  a  permanent  colostomy  the  combination 
of  W'yeth's  and  Bailey's  methods  gives  a  satisfactory  re- 
sult. Colostomy,  preliminary  to  excision  of  the  rectum, 
should  be  located  high  on  the  colon  to  give  sufficient  length 
lo  the  sigmoid  to  permit  restoration  of  the  continuity  of 
Lhe  bowel.  For  ulceration,  and  other  conditions  in  which 
the  upper  limit  of  the  disease  is  not  definitely  known,  the 
interior  of  the  bowels  should  be  explored  through  the 
inguinal  incision  in  order  to  determine  the  proper  site  of 
the  opening.  Right-sided  colostomy  has  an  increasing 
field  of  usefulness  in  amebic  dysentery,  chronic  colitis  and 
allied  conditions.     [T.  L.  C] 

7. — D.  H.  Bergey  reports  on  the  prevalence  of  strepto- 
cocci in  cow's  milk.  During  the  past  summer  in  40  samples 
of  market  milk  examined,  90%  wer  found  to  contain  micro- 
cocci, and  in  50',r  of  the  samples,streptococci  were  found. 
Of  16  samples  of  milk  collected  from  a  well  conudcted 
dairy,  only  12.5%  cantained  micrococci,  and  only  B.25% 
contained  streptococci.  Of  28  samples  collected  from 
another  of  the  best  dairies  only  17.8%  contained  micro- 
cocci, and  no  streptococci  were  found.  In  another  first-class 
dairy  in  which  1  samples  of  mixed  milk  were  examined 
85.71%  contained  micrococci  and  28.57%  contained  strep- 
tococci. In  still  another  of  S  samples  examined  62.5%  con- 
tained micrococci,  while  none  contained  streptococci. 
These  bacteriological  examinations  illustrate  that  extreme 
cleanliness  is  necessary  in  order  to  produce  milk  containing 
less  than  ten  thousand  bacteria  per  cubic  ccm.  This  care 
will  also  tend  to  the  exclusion  of  the  extraneous  bacteria 
from  milk.     [T.  L.  C] 


VRATCH. 

Fcbniuii/  ^'-i   (Vol.  XXII,  No.  S). 

1.  On  th  Etiology  of  Large  Infants.  B.  N.  AGAPHONOW 

2.  On  the  Treatment  of  Tetanus.     M.  I.  ROSTUWTbEV. 

3.  The  Primary  Stages  of  Cardiac  Affections  in  Military 

Men.     D.  I.   VIERUSHSKY. 

I.^Agaphonow  gives  an  exhaustive  review  of  the  liter- 
ature on  the  subject,  citing  observations  of  various  au- 
thors as  to  the  normal  and  excessively  large  weights  of 
infants  at  birth.  One  of  these  infant-giants  observed  by 
Blach  weighed  12,000  grms.  The  case  reported  by  the 
author  is  that  of  a  woman,  34  years  old,  in  her  fifth  labor, 
who,  after  considerable  difficulty,  was  relieved  of  a  female 
child  weighing  5950  grms.  and  measuring  58  cm.  The 
difficulty  experienced  in  this  case  was  due  to  the  fact 
that  while  the  comparatively  small  head  was  delivered 
without  any  trouble,  the  shoulders  remained  impacted 
within  the  vagina,  the  left  shoulder  pressing  firmly  against 
the  pubis.  The  cord  was  wrapped  around  the  child's  neck, 
the  child  having  died  of  asphyxia.  After  considerable  ef- 
fort the  shoulder  was  finally  released  by  downward  trac- 
tion, and  delivery  accomplished.  The  placenta,  delivered 
by  Shultze's  method,  weighed  1190  gims.;  the  cord  was 
very  thick  and  measured  86  cm.  The  mother  of  this  child 
was  a  large  woman  with  quite  a  roomy  pelvis.  The  father 
was  also  a  large  man.  From  this  and  similar  cases,  the 
author  concludes  that  large  children  are  born  of  large 
parents,  and  that  the  difficulty  in  these  cases  is  not  in 
the  delivery  of  the  head,  as  is  usually  the  case,  but  the 
shoulders.     [A.  R.] 

2. — Rostow-tsev  points  out  that  the  frequent  disappoint- 
ments following  the  administration  of  antitetanic  serum 
are  to  be  attributed  to  the  fact  that  the  tetanus-toxins  com- 
bine chemically  with  the  nerve  cells,  and  the  antitoxin  neu- 
tralizes only  those  toxins  which  are  circulating  freely  in 
the  blood.  By  the  time  the  patient  comes  for  treatment 
a  considerable  amount  of  toxin  has  already  entered  Into 
combination  with  the  nerve-cells,  and  is  therefore  beyond 


{IqQ         The   pHiLADELPniil 
Mfjdical  Journal  J 


THE  LATEST  LITERATURE 


[  Apkh,  27,  lUOl 


reach.  Antitetanic  serum,  therefore,  Is  really  a  prophylac- 
tic, and  not  a  curative  agent.  He  reports  the  following 
two  interesting  cases:  In  one,  a  factory  woman,  38  years 
old,  received  a  severe  injury  of  the  right  thumb.  Two 
weeks  later  she  developed  tetanus,  which  at  first  was  lo- 
calized in  her  right  upper  extremity,  but  soon  became  gen- 
eralized. She  received  50  c.  c.  of  tetanus-antitoxin  on  each 
of  three  days.  She  made  a  slow  recovery,  still  showing 
some  rigidity  of  the  facial  muscles  on  the  65th  day  of  the 
disease.  The  peculiar  feature  in  this  case  is  that  the  te- 
tanus developed  at  first  locally,  which  is  rarely  the  case  in 
man.  That  the  antitoxine  as  responsible  tor  the  cure  is 
proved  by  the  fact  that  on  the  days  when  no  injections 
were  made,  the  symptoms  were  considerably  aggravated, 
while  on  the  other  hand  marked  improvement  followfed 
each  Injection.  The  second  case  was  in  a  peasant  girl,  who 
developed  what  turned  out  to  be  a  very  severe  attack  of 
tetanus,  but  gave  no  history  of  trauma.  However,  her 
body  was  found  covered  with  scratches,  some  of  which 
may  have  served  as  the  point  of  Infection.  Not  having  any 
antitoxin  on  hand,  and  hampered  by  the  expense,  the  author 
decided  to  try  normal  brain  tissue.  On  the  second  day 
after  her  admission,  10  grms.  of  pigs'  brain  rubbed  up  in 
30  c.  c.  of  normal  salt  solution  were  injected  subcuta- 
neously,  the  brain  emulsion  as  well  as  the  skin  being  In 
a  thoroughly  aseptic  condition.  Some  improvement  fol- 
lowed. The  injection  was  repeated  on  each  of  two  follow- 
ing days,  and  again  on  the  ninth  day,  calf's  brain  being 
used  on  one  occasion.  Like  In  the  first  case,  the  symp 
toms  were  aggravated  considerably  at  the  intervals  be- 
tween the  injections,  thus  proving  that  the  latter  were 
exerting  a  beneficial  effect.  The  patient  finally  recovered. 
It  is  noticeable  that  in  this  case  Kernig's  sign,  considered 
pathognomonic  of  meningitis,  was  observed.  The  author 
concludes  by  advising  urgently  the  use  of  normal  brain- 
emulsion  in  cases  In  which  the  serum  cannot  be  obtained. 
The  injections,  if  carried  out  under  strict  aseptls,  are  per- 
fectly harmless.     [A.  R.] 

3. — Vierushsky  has  observed  a  number  of  cases  of  car- 
diac diseases  in  recruits  and  soldiers,  which  could  not  be 
detected  by  the  usual  signs,  and  were,  In  many  instances, 
discovered  accidentally.  The  45  cases  studied  by  him  can 
be  divided  into  three  groups:  1.  Those  in  which  the  typi 
cal  manifestations  of  cardiac  disease  were  present  (20); 
2.  Those  which  di  not  present  a  complete  clinical  picture 
(17);  3.  Those  in  which  there  was  a  constant  murmur  at 
the  apex,  but  no  other  symptoms  (8). Owing  to  the  com- 
plicated mechanism  of  the  first  sound,  a  murmur,  imme- 
diately following,  but  not  replacing  it,  is  recognized  with 
difficutly  in  the  first  stages  of  the  disease.  The  method 
usually  employed  of  having  the  i)atlent  make  active  move- 
ments so  as  to  accentuate  both  the  normal  sound  and  the 
murmur.  Is  also  liable  to  error,  inasmuch  as  by  the  exercise 
the  two  sounds  of  the  heart  follow  each  other  in  such  rapid 
succession  that  the  murmur  may  escape  detection.  A 
much  more  satisfactory  method  is  to  examine  the  patient 
in  a  recumbent  position.  The  action  of  the  heart  Is  slower, 
but  the  sounds  are  more  distinct.  In  this  case  no  previous 
exercise  is  necessary,  inasmuch  as  in  this  position  the 
blood-pressure  is  raised.  In  some  cases  it  may  be  found 
necessary  to  slow  the  heart  and  thus  render  the  sounds 
clear  by  appropriate  medication.  Of  the  other  clinical 
signs  hypertrophy  of  the  ventricle  and  accentuation  of 
the  second  sound  in  mitral  insufficiency  was  sufficiently 
marked  to  be  recof^nized  only  in  a  few  cases.  Epigastric 
pulsation  and  displacement  of  the  apex-beat  served  as  use- 
ful indication  in  many  cases.  The  changes  in  the  pulse, 
both  in  rate  and  volume,  were  not  constantly  observed. 
These,  however,  may  be  present  in  persons  with  sound 
hearts  and  invariably  accompany  neurasthenic  conditions, 
thus  rendering  their  presence  of  little  diagnostic  value. 
Likewise,  the  changes  in  blood-pressure  are  of  slight  diag- 
nostic significance.  As  to  the  etiology,  it  was  found  that 
rheumatism  Is  by  no  means  the  only  factor.  In  many  cases 
the  cardiac  affection  followed  some  acute  Infectitlous  dis- 
ease, such  as  typhoid  fever,  smallpox,  inflammations  of 


the  lungs,  diphtheria,  etc.  In  quite  a  number  of  cases  tho 
disease  developed  apparently  without  any  cause  and  en- 
tirely unobserved  by  the  patient.  It  has  been  also  ob- 
served, as  it  might  u  piiuri  be  expected,  that  the  service 
in  the  array  tends  to  make  the  progress  of  any  cardi-oc  af- 
fection much  more  rapid.     [A.  R.] 

March  S,  JUOl   (Vol.  XXII,  No.  9.) 

1.  Five  Hundred  Operations  for  Cataract.       S.  N.  KOK- 

SHENEWSKY. 

2.  A   Case  of   Repeated   Extra-uterine  Pregnancy.     D.   D. 

SANDBERG-DEBELE. 

3.  A  Case  of  Diabetes  in  a  Nursling.     N.  A.  ORLOW. 

4.  A  Case  of  Diabetes  in  a  Boy,  3  1-2  Years  Old.     W.  I. 

NOSKOW. 

5.  Poisoning  by  Cream-tarts   in  Charkow.     P.  N.   LASH- 

ENKOW. 

1. — S.  N.  Korshenewsky  performed  500  cataract  opera- 
tions with  the  following  results:  Good  vision  was  obtained 
in  348,  or  17.27o;  medium  in  61,  or  rs.5%;  weak  in  17,  or 
3.8% ;  vision  lost  in  the  affected  eye  in  25,  or  5.5%.  The  re- 
sults in  49  cases  are  not  reported.  The  operations  were 
performed  under  various  circumstances,  in  hospitals  as  well 
as  peasents  huts.  The  condition  ot  the  eye  was  also 
variable,  almost  all  forms  of  cataract  with  their  usual 
complications  being  represented.  Iridectomy  was  employed 
in  every  case.  The  author  insists  on  thorough  asepsis  and 
antisepsis.       [A.  R.] 

2. — D.  D.  Sandberg-Debele  reports  the  case  of  a  woman 
?.4  years  old  who  was  operated  for  extrauterine  pregnancy 
in  the  right  tube.  About  14  months  later  she  presented  a 
recurrence  of  the  symptoms  accompanying  her  last  preg- 
nancy and  fluctuating  pelvic  tumor  on  the  left  side.  No  im- 
provement having  followed  the  usual  treatment,  the  tu- 
mor, was  incised  through  the  posterior  vagnial  wall  and  a 
considerable  amount  of  clotted  blood  removed.  The  pa- 
tient made  good  recovery.  In  speaking  of  the  frequency 
of  extrauterine  pregnancy,  the  author  mentions  the  fact 
that  out  ot  3873  gj'necologlc  case  in  the  Maryin  Hospital 
there  were  130  extrauterine  pregnancies  (3.4%).  As  to 
treatment,  113  of  these  cases  were  treated  without  opera- 
tion. 28  recovered  entirely,  while  85  left  the  hospital  very 
much  improved  but  with  an  encapsulated  hematoma  in  the 
pelvis.  17  patients  were  operated  on.  In  5  laporatomy 
was  resorted  to,  while  in  the  other  12  the  tumor  was  evac- 
uated through  the  posterior  vaginal  wall.  Every  one  of 
the  latter  made  an  uneventful  recovery.  The  author  pre- 
fers the  vaginal  route  as  the  most  convenient,  the  simplest 
and  safest,  especially  so  in  cases  where  hospital  facilities 
cannot  be  obtained. 

3. — N.  A.  Orlow  reports  a  case  of  diabetes  in  an  infant 
4-5  months  old,  left  at  the  Foundling  Asylum.  The  urine 
contained  large  quantities  of  sugar  as  determined  by  Trora- 
mor's,  Nylander's  and  the  indigo  tests.  The  cardinal  symp- 
toms of  diabetes,  namely,  polyuria,  polyphagia  and  auto- 
phagia  were  present.  The  child  also  had  a  number  of 
boils  on  its  body.  The  little  patient  died  on  the  lith  day. 
The  autopsy  revealed  an  acute  broncho-pneumonia  with 
Iiulmonary  edema,  acute  intestinal  catarrh,  edema  of  the 
dura  and  a  serous  effusion  in  the  third  ventricle.  The 
latter,  according  to  the  author,  was  the  etiologic  factor  in 
the  disease.  The  claim  is  made  that  this  is  the  first  case 
of  genuine  diabetes  in  an  infant  recorded.     [A.  R.] 

4. — W.  I.  Noskow  reports  the  case  of  a  boy  3  1-2  years  old 
who  after  an  attack  of  grippe  developed  an  enormous  ap- 
petite, extreme  thirst,  emaciation,  debility  and  polyuria. 
The  urine  was  found  to  contain  4.S'"<  of  sugar  and  acetone. 
The  boy  was  going  down  rapidly  and  finally  died  In  a 
state  of  coma  which  lasted  for  48  hours.  As  to  the  prol>- 
able  etiolog>-  in  this  case,  the  author  believes  that  heredi- 
tary syphilis  played  an  important  part.  The  child's 
father  suffered  for  a  number  ot  years  and  finally  died  from 
syphilitic  affection  of  the  nervous  system.  The  attack  of 
grippe  which  the  boy  had  served  as  the  exciting  cause. 
[A.  R.] 
5. — Will  be  abstracted  when  completed. 


April  27,  1901] 


THE  LATEST  LITERATURE 


CThb  Phii.ai)ei,phia       Rna 
Medical  Jocexal         <-"-'y 


ZEITSCHRIFT    FUER    HEILEKUNDE. 

February,  1901.     (Vol.  22.  No.  2.) 

1.  Experimental  Investigations  in  the  Study  of  Poisoning. 

VON  CZYHDARZ  and  DONATH. 

2.  Clinical    Observa,tions    upoq    the    "ej-ertion    interval," 

from  Retardation  of  the  Pulse,  and  its  Significance 
in  the  Diagnosis  of  Mitral  Insufficiency.  R. 
SCHMIDT. 

3.  Malignant  Tumors  of  the  Lungs.    M.  WEINBERGER. 

1. — Von  Czyhlarz  and  Donath  divide  poisons  into  bac 
terial  poisons  and  others.  Their  investigations  include  only 
the  other  poisons,  the  alkaloids,  etc.,  especially  in  relation 
to  their  effect  upon  the  liver.  From  a  review  of  the  litera- 
ture of  the  subject,  it  is  clear  that  the  liver  in  some  way 
diminishes  the  virulence  of  poisons.  Three  series  of  ex- 
periments were  performed,  72  in  number.  In  the  first  series 
an  emulsion  of  liver,  spleen,  kidney,  and  brain,  was  made, 
and  tests  made  with  each,  by  injecting  them  with  strych- 
nin in  toxic  dose,  into  animals.  These  experiments 
showed  distinctly  the  power  of  the  animal  organs,  in  emul 
sion,  to  lessen  the  effect  of  the  poison.  The  longer  the 
emulsion  and  poison  were  allowed  to  mix  before  injection, 
the  less  was  the  effect  of  the  poison.  More  experiments 
showed  plainly  that  the  richer  the  emulsion  in  cells  of  the 
organ,  the  more  active  was  the  resistance  of  the  organism 
to  the  poison.  Blood  had  the  same  effect,  while  blood 
serum  had  none  at  all.  In  the  second  series,  a  solution  of 
strychnin  was  passed  through  the  liver  cr  an  animal  before 
being  injected  into  another  animal.  Here  also  the  poison 
had  far  less  effect  after  being  conducted  through  the  liver. 
In  the  third  series  an  extremity  was  ligated.  strychnin 
injected,  and  the  ligature  only  removed  four  hours  later. 
In  spite  of  the  toxic  dose  of  strychnin  injected,  not  one  of 
the  animals  showed  bad  results.  From  all  of  this,  von 
Czyhlarz  and  Donath  conclude  that  the  power  of  decreasing 
the  activity  of  a  poison  lies  in  the  cells  of  the  animal 
organs.  And  that  all  tissue  has  some  such  power  is  shown 
by  the  last  experiments.  The  liver  undoubtedly  possesses 
this  power  to  a  very  large  de.gree.     [M.  O.] 

2. — About  40  years  ago  Marey  first  noticed  that  there  was 
an  interval  between  the  beginning  of  systole  (the  apex- 
beat)  and  the  beginning  of  the  pulse  wave  in  the  aorta  of 
about  one^tenth  of  a  second.  Martius  called  this  the 
"closed  interval"  {cerfnliliisxzcit),  while  the  "expulsive  in- 
terval" (uii/itrcibiiiKjsicit)  follows  sharply  after  it,  each 
occupying  half  of  systole.  The  "closed  interval"  was 
Inter  called  "exertion  interval"  ((iiif'l>(iiiinin;is:(  il).  Martius 
believed  that  the  length  of  the  "closed  interval"  could  be 
measured  from  the  apex-beat.  When  the  apex-beat  was 
protracted,  the  "closed  interval"  was  lengthened.  Schmidt 
reports  the  case  of  a  woman  of  60,  who  had  had  rheuma- 
tism. Cardiac  symptoms  developed  four  years  ago.  Ex- 
amination showed  orthopnea,  widespread  cyanosis,  ascites, 
and  edema.  A  diffuse  pulsation  existed  over  the  heart  and 
epigastrium;  the  apex-beat  was  heaving,  not  circumscribed. 
A  long  systolic  murmur  covered  the  first  sound,  the  second 
sound  being  dull,  ending  in  a  short  rumbling  diastolic  mur- 
mur. The  pulmonary  second  sound  was  markedly  accentu- 
ated. At  the  aortic  cartilage,  low  systolic  and  disastolic 
murmurs  were  audible.  Over  the  sternum  a  loud  blowing 
murmur  was  heard.  There  was  great  hypertrophy.  Both 
the  apex-beat  and  the  impulse  of  the  heart  were  plain.  The 
autopsy,  held  two  months  later,  showed  stenosis  and  insuf- 
ficiency of  the  mitral  valves,  with  insufficiency  of  the  aortic 
and  tricuspid  valves.  Though  the  "closed  interval"  was 
wanting,  both  the  apex-beat  and  the  impulse  of  the  heart 
were  present.  After  a  long  discussion,  with  a  complete 
review  of  the  literature  of  the  subject,  Schmidt  concludes 
that  the  apex-beat,  or  impulse  of  the  heart,  is  in  no  way  re- 
lated to  the  "closed  interval."  nor  does  it  necessarily  occur 
in  time  with  the  "closed  interval;"  that  with  regard  to  the 
retardation  of  the  pulse  after  the  apex-beat,  lengthening 
of  the  "exertion  Interval"  will  eventually  be  noted  clinical- 
ly: that  in  many  cases  of  organic  mitral  insufficiency, 
whether  well  compensated  or  following  acute  rheumatism, 
the  pulse  will  be  strikingly  retarded  after  the  apex-beat," 
and  is  caused  by  the  mitral  valves  remaining  open  during 
systole;  that  this  symptom  is  not  pathognomonic  of  mitral 
insufficiency;  but  that,  in  difficult  eases,  it  may  be  an  aid 
in  the  differential  diagnosis  between  uncomplicated  mitral 
insufficiency  and  hemic  murmurs.     [M.  O.l 

3. — Malignant  tumors  of  the  lungs  may  be  sarcoma,  en- 


dothelioma, or  carcinoma.  The  two  former  are  very  rare, 
and  generally  metastatic.  Primary  carcinoma  arises  from 
the  bronchial  mucous  membrane.  Diagnosis  during  life  is 
seldom  made  Weinberger  reports  two  cases  of  pri- 
mary bronchial  carcinoma,  one  of  which  ran  a  course 
almost  typical  of  tuberculosis,  with  symptoms  of  a 
bronchial  tumor  later;  the  other  patient  expectorated 
pieces  of  a  tumor  which  were  diagnosed  microscopically. 
A  third  case  is  added,  of  sarcoma  of  the  mediastinum  which 
had  grown  into  the  lung.  Roentgen  photographs  were  made 
of  all  three  cases,  showing  malignant  tumors  of  the  lungs, 
proved  by  autopsy.  In  the  first  case,  a  man  of  42,  who  had 
been  ill  about  one  year,  typical  signs  of  beginning  phthisis 
appeared  in  the  right  apex;  followed  later  by  a  distinct 
difference,  under  the  Roentgen  ray,  between  the  movements 
oi  both  sides  of  the  diaphragm,  the  right  side  moving  far 
less  than  the  left.  The  large  shadow  of  the  tumor  was 
upon  the  right  side.  Autopsy  showed  carcinoma  of  the 
upper  lobe  of  the  right  lung,  starting  from  a  bronchial 
twig,  embracing  the  right  bronchus,  trachea,  left  bronchus, 
esophagus,  superior  vena  cava,  pleura,  second  and  third 
ribs,  and  the  bronchial  glands,  'ihe  second  patient  was  a 
man  age  52.  Kxamiuation  under  the  Roentgen  ray  showed 
a  right  siaed  tumor  ot  me  pleura  or  lung.  At  the  autopsy 
caicmuma  ol  the  right  bronchus,  with  numerous  melaatases 
was  found,  the  tnird  case  waa  a  girl  ot  'M,  in  whom  a 
mediastinal  lymphosarcoma  had  grown  into  Uie  upper 
lobe  of  the  left  lung.  This  was  shown  both  by  the  Koenisen 
photographs  and  uy  the  autopsy.  Roentgen  photographs 
will  aid  materially  in  the  differential  diagnosis  of  thoracic 
tumors.  Adhesion  of  the  pleural  suilaces,  effusion  into  thj 
pleural  sac,  aiheroua  ot  the  aorta,  and  the  consistency  of 
a  tumor  may  sometimes  be  diagnosed  uy  the  Roentgen  rays. 
LM.  U.] 


ZEITSCHRIFT  FUER  HEILKUNDE.  ., 

February  ,iS,  I'jul.  (2S  Jahrgang,  No.  8. J 
1.  Sensation  in  Peritoneum:  Local  and  General  Anes- 
thesia in  Abdominal  operations.  K.  G.  LKNNAN- 
DKK. 
1. — In  resection  of  the  bowel  for  gangrenous  hernia,  or 
in  gastroenterostomy,  it  has  ueen  tue  custom  iu  Upsaiu, 
for  10  years,  to  stop  admiiiisteriug  aneatnetics  when  the 
operator  reacnes  lue  resection,  or  suturing  oi  tne  intestine 
itself.  Just  enough  was  tneu  given  to  prevent  the  patient 
from  coming  out  of  the  inUueuce  of  tue  anestuetic.  Leu- 
nander  has  operated  many  times,  lor  hernia,  entero-anas 
tomosis,  fecal  nstuia  cuoleycystotomy,  uepurostomy,  etc.. 
with  Schleich's  local  anestnesia.  i  lom  tuese  operations 
lie  noticed  that  tue  pariecal  peritoneum  snowed  great  excit- 
ability to  sensation  or  all  kinas,  wniie  tne  peritoneum  cov- 
ering the  abdominal  viscera  was  aosioiutciy  insensible  to 
stimuli.  Especially  was  this  marned  with  compresses; 
against  the  parietal  peritoneum  (of  the  anterior  wall  or 
siuesj,  they  caused  great  pain,  but  were  not  felt  among  the 
internal  organs  at  all.  The  subserous  tissue  of  the  parietal 
peritoneum  contains  nerve-fibres,  wliile  that  covering  the 
viscera  does  not.  In  injecting  cocain  by  Schleich  s  method, 
both  the  serous  and  subserous  tissues  of  the  parietal  peri- 
toneum are  made  insensible.  The  pain  in  colic  he  ex- 
plains as  due  to  stretching  of  the  nerves  iu  the  pai-ietal 
peritoneum  following  distension  of  a  part  of  the  intestinal 
canal.  Tenderness  on  pressure  also  will  depend  upon 
whether  the  parietal  peritoneum  is  inflamed.  From  his 
own  observations,  Lenander  concludes  that  In  all  abdom- 
inal operations  without  any  suspicion  of  Infection  the 
Schleich  method  of  anesthesia  should  be  employed.  It. 
for  any  reason,  this  should  not  be  possible,  a  general  anes- 
thetic should  be  given  until  the  main  procedure  is  reached, 
when  the  anesthetic  chould  be  stopped.  Or  enough  should 
be  given  just  to  keep  the  patient  under.  The  result  will  be 
a  painless  operation,  with  only  a  small  quantity  of  the 
anesthetic  used.  When  local  anesthesia  is  used,  one  per- 
son should  attend  solely  to  the  patient,  that  he  does  not 
see  or  hear  the  instruments.     [M.  C] 


5lO 


The   Pnti.Ai)Ei,rniA"l 
MuriUAi.  JntTRNAi,  J 


INFANTILE  SCURVY 


(  APKii.  27.  100! 


©rtolnal  articles. 


SCURVY  IN  INFANTS 

By  LOUIS  STARR,  M.  D. 

of  Philadelphia. 

Infantile  Scurvy  is  a  constitutional  disease  oc- 
curring usually  before  the  end  of  the  second  year, 
depending  upon  continued  faulty  feeding  and  pre- 
senting a  well-defined  complex  of  symptoms.  The 
characteristic  features  are:  First,  immobility,  pro- 
gressing to  pseudoparalysis,  intense  hj'peresthesia, 
and  general  swelling  situated  most  frequently  in 
the  legs,  but  not  limited  to  these  members;  the  in- 
vesting skin  is  shiny  and  tense,  but  there  is  neither 
edema  nor  local  heat,  and  subsidence  of  the  gen- 
eral swelling  reveals  deep  fusiform  tliickening  about 
the  shafts  of  the  long  bones  in  the  neighborhood  of 
the  joints.  In  extreme  cases  there  is  a  tendenc- 
to  fracture  near  the  epiphysis.  Second,  the  gums 
about  erupted  teeth  are  swollen  and  jjurple  in  color, 
and,  in  marked  cases,  become  s])ongy  and  readily 
bleed.  Third,  a  rapid  disappearance  of  all  symp- 
toms upon  the  institution  of  a  proper,  anti-scorbutic 
diet. 

Scurvy  shows  no  preference  for  sex,  occurs  at  an\ 
season,  in  any  climate  or  locality,  amidst  the  best 
or  worst  hygienic  surroimdings,  and  in  every  class, 
though  wealth  furnishes  by  far  the  larger  number 
of  cases.  In  the  majorit)'  of  instances  the  disease 
develops  between  the  age  of  six  months  and  the 
end  of  the  second  year,  though  this  limit  is  by  no 
means  a  fixed  one,  and  is  closely  confined  to  artifi- 
cially fed  infants,  there  being  but  two  recorded 
cases  in  nurslings. 

The  direct  causal  factor  is  the  continued  use  of 
food  that  lacks  some  essential  nutritive  elements 
or  presents  them  in  a  form  not  readily  assimilable. 
An  analysis  of  the  reported  cases  shows  that  the 
patients  have  received  a  great  variety  of  foods,  and 
if  the  few  instances  in  which  the  only  traceable 
cause  is  simple  poverty  in  diet  be  eliminated,  the 
sole  factor  that  is  uniformly  present  is  the  absence 
of  the  quality  of  freshness,  the  food  is  not  "live." 
To  put  the  whole  ((uestion  in  a  few  words,  tin- 
cause  of  scurvy  in  infants  is  eoiiliiiucil  deprivation  of 
fresh  food. 

The  fault)'  foods  may  be  classed  in  the  order  of 
their  potency: 

1st. — The  different  proprietary  infant's  foods  ad 
ministered  without  the     addition     of    cow's    milk. 
These  foods  are  responsible  for  the  greatest  number 
of  cases,  and   which   variety  most   readily   inducer 
the  disease,  depends  chiefly  u])on  the  extent  of  em 
ployment  or  the  fashion  at  the  time. 

2d. — Proprietary  foods  emjiloycd  with  the  addi 
tion  of  insufficient  quantities  of  cow's  milk. 

3rd. — Oat-meal  or  wheat  gruel.  Barley  and  other 
farinaceae  administered  with  water  alone  or  witl; 
water  and  insufficient  cow's  milk. 

4th. — Condensed   milk  and  water. 

5th. — Sterilized  milk.  Properly  modified  milU 
mixtures  subjected  to  a  temperature  of  212°  F.  from 
thirty  minutes  to  an  hour  or  more. 


6th. — Too  dilute  milk  and  cream  mixtures.  Lab- 
oratory mixtures  with  too  low  albuminoid  percen- 
tage. 

Consideration  of  these  groups  furnishes  an  ex- 
planation of  the  greater  frequency'  of  scurvy  in  in- 
fants reared  in  luxury  than  in  the  very  poor.  The 
proprietary  foods  being  expensive  are  little  used 
by  the  latter  class,  the  processes  of  modifying  and 
sterilizing  cow's  milk  are  troublesome  and  require 
too  much  thought  and  time,  and  the  cares  of  house 
work  and  bread-winning  prevent  regular  and  accu- 
rate artificial  feeding.  In  consequence  the  child  of 
poverty  is  fed  upon  milk,  either  diluted  or  pure, 
as  the  chance  may  be,  and  if  this  be  not  at  hand, 
upon  tea,  potatoes,  bits  of  bread  or  other  table  food ; 
a  bad  diet,  and  one  which  often  leads  to  rickets  or 
dangerous  gastro-intestinal  disorders,  but  which 
is  too  varied  and  "live"  to  produce  scurvy. 

The  variations  in  the  diet  usually  made  at  the 
end  of  the  second  year,  also  explain  the  infrequency 
of  the  development  of  the  disease  after  this  age. 

The  essential  cause  of  scurvy  is  unknown,  but 
it  is  certain  that  it  is  some  peculiar  deprivation,  and 
that  the  needed  elements  are  present  in  fresh  milk 
and  the  juice  of  fresh,  ripe  fruits. 

Very  few  post-mortem  examinations  are  on  rec- 
ord, in  fact,  since  infantile  scurvy  has  been  recog- 
nized as  a  distinct  condition  and  its  treatment  es- 
tablished a  favorable  outcome  is  to  be  expected  in 
the  vast  majority  of  instances.  Of  twenty-six 
cases  that  have  come  under  my  own  observation 
during  the  past  ten  years,  but  one  terminated  fa- 
tally. This,  my  second  diagnosed  case,  occurred 
in    1S91. 

The  patient,  a  boy  fifteen  months  old,  had  been 
ill  nearly  four  months  before  I  was  consulted,  and 
was  so  far  reduced  in  flesh  and  general  strength, 
was  so  anemic,  and  had  such  grave  intestinal  com- 
plications, that  all  efforts  at  treatment  were  un- 
successful. .\fter  death  the  body  showed  extreme 
emaciation,  the  skin  was  inelastic,  pale,  and  pre- 
sented numerous  ecchymotic  spots  of  varying  size. 
The  gums  about  the  eight  incisor  teeth  that  had 
been  cut  were  deep  purple  in  color,  very  swollen 
and  spongy  and  covered  with  blood.  Both  legs 
were  much  swollen  above  the  ankle  joints,  the  right 
to  the  greater  extent.  On  section,  the  lower  third 
of  the  right  tibia  was  found  to  be  surrounded  be- 
neath the  periosteum,  by  a  thick  mass  of  dark,  gru- 
mous  blood,  the  lower  epiphysis  was  detached,  and 
the  distal  end  of  the  shaft,  macerated  and  eroded, 
lay  free  in  the  disintegrating  blood  clot.  The  lower 
third  of  the  left  tibia  was  surrounded  by  a  similar, 
though  less  extensive,  sub-periosteal  blood  effusion  ; 
It  was  not  fractured.  The  fibulae,  femora,  and  bones 
of  the  upper  extremities  were  normal. 

The  intestines  contained  blood  and  blood-stained 
mucus,  and  the  mucous  membrane  was  thickened 
and  studded,  especially  in  the  colon,  with  follicular 
idcers. 

Microscopic  examination  of  the  bone  and  perios- 
teum showed  no  lesion  beyond  the  mechanical  on^' 
at  the  seat  of  fracture,  and  the  same  was  true  of 
sections  from  the  liver,  spleen  and  kidneys,  and  of 
the  blood. 


Aritii,  27,  moi] 


INFANTILE  SCURVY 


[The  Philadelphia 
Medical  Journal 


8ii 


These  findings  correspond  very  closely  to  those 
detailed  by  Barlow  and  Northrup,  and  the  anatomi- 
cal lesions  of  the  disease  may  be  briefly  stated  to  be 
chiefly  due  to  hemorrhage,  the  most  characteristic 
being  the  sub-periosteal  blood  effusions  about  the 
shafts  of  the  femora  and  tibiae,  sometimes  of  the 
long  bones  of  the  arms,  and  occasionally  those  of 
the  cranium  and  thorax.  Bleeding  may  also  occur 
into  the  subcutaneous  tissue  (ccchymosis),  an'.l 
from  the  nose,  stomach,  bowels  and  bladder. 

J.  J.  Thomas*  asserts  that  the  kidneys  are  fre- 
quently involved  in  infantile  scurvy,  and  attributes 
the  lesion,  catarrhal  nephritis,  to  the  presence  of  an 
irritant  in  the  blood,  which,  by  its  effects  upon  the 
walls  of  the  renal  vessels,  produces  hemorrhages. 
While  this  is  a  condition  one  would  naturally  ex- 
pect, it  was  absent  in  my  single  fatal  case,  and  in 
none  of  the  others  was  cither  albumen  or  blood 
present  in  the  urine  during  the  course  of  the  disease. 

The  scorbutic  condition  is  produced  gradually 
after  weeks  or  months  of  improper  feeding;  there 
may  be  slowly  increasing  evidences  of  impaired  nu- 
trition before  the  characteristic  symptoms  appear, 
but  usually  these  suddenly  interrupt  a  state  of  ap- 
parent health.  It  is  first  noted  that  the  infant  is 
content  only  when  perfectly  quiescent ;  that  he 
screams  when  lifted  in  the  nurse's  arms,  or  that  he 
ceases  to  creep  or  walk.  Soon  it  becomes  evident 
that  crying  is  produced  most  readily  by  movements 
involving  the  legs,  and  that  either  one  or  both  limbs 
are  held  fi.xed,  the  thigh  beilig  drawn  up  towards 
the  abdomen,  the  leg  flexed,  and  tiie  foot  drooped. 
Next  swelling  appears  above  the  knee  or  ankle 
joints,  and  immobility  and  tenderness  increase ;  the 
latter  to  such  an  extent  that  the  patient  stops  cry- 
ing only  while  lying  undisturbed  on  a  pillow.  Then 
the  gums  about  any  teeth  that  may  be  cut  become 
purple  in  color:  in  the  beginning-there  is  merely  a 
narrow  line  of  this  discoloration,  but  it  rapidly  ex- 
tends;  the  gum  swells,  grows  spongy,  and  bleeds 
at  the  lightest  touch.  With  these  special  symptoms 
there  is  moderate  general  debility  and  loss  of  flesh 
restless  leep,  impaired  appetite,  a  tendency  to  con- 
stipation, a  diminished  flow  of  high-colored,  Interi- 
tious  urine,  and  in  some  cases  moderate  elevation 
of  temperature,  though  absence  of  fever  is  the  rule. 

Without  treatment  or  when  badly  managed,  the 
disease  runs  a  chronic  course,  and  the  symptoms 
slowly  but  steadily  increase  in  gravity,  until  ema- 
ciation becomes  extreme,  petechial  spots  appear  on 
the  surface,  the  swollen  gums  overlap  the  teeth,  and 
there  is  a  constant  oozing  of  blood.  The  immobil- 
ity, hyperesthesia  and  swelling  affect  the  arms  as 
well  as  the  legs,  epij^hysial  separation  may  take 
place,  and  the  child,  irritable  and  prostrated,  lies 
passive  upon  the  bed,  dreading  the  slightest  at- 
tempt at  movement  or  even  the  approach  of  its 
nurse.  The  symptoms  deserve  a  more  detailed  con- 
sideration in  the  order  of  their  development. 

Hyperesthesia  is  almost  invariably  the  initial 
symptom,  it  appears  in,  and  may  be  limited  to  one 
leg,  but  often  involves  both.  The  infant  first  ex- 
hibits sensation  of  pain  by  changes  in  facial  expres- 
sion or  by  crying  when     the  affected     member    is 

♦Boston  M.  &  S.  Journal,  September  3rd,  ISSMi. 


moved  in  changing  the  napkin  or  in  arranging  the 
stockings  or  dress.  If  the  child  be  old  enough  to 
creep,  stand  or  walk,  it  e.xcites  the  mother's  suspi- 
cion that  something  is  wrong  by  suddenly  becom- 
ing inactive,  and  by  lamentations  when  induced  to 
attempt  previously  enjoyed  use  of  the  legs.  The 
tenderness  increases  steadily  in  degree,  and,  if  pri- 
marily seated  in  one  limb,  extends  to  its  fellow,  and, 
in  severe,  long  standing  cases,  to  one  or  both  arms; 
The  little  patient  becomes  helpless,  suffers  agony 
during  the  trifling  movements  necessary  in  making 
the  toilet,  and  even  anticipates  pain  and  screams 
on  the  approach  of  the  most  gentle  attendant.  The 
characteristic  of  the  pain  is  its  production  solely  by 
movements  of  the  parts  involved,  and  if  the  element 
of  dread  can  be  eliminated,  moderately  firm  pressure 
upon  or  friction  of  the  surface  is  readily  borne. 

Immobility  is  the  natural  sequence  of  hyperes- 
thesia, develops  almost  simultaneously,  and  with 
it  increases  in  degree  and  extent.  The  decubitus  is 
quite  typical ;  the  infant  lies  on  its  side  with  the 
trunk  thrown  a  little  forward,  the  thigh  drawn  half 
way  up  to  the  abdomen,  the  leg  semi-flexed,  and 
the  foot  drooped ;  when  long  maintained,  this  pos- 
ture produces  slight  edema  of  the  dorsum  of  the 
foot;  this  is  not  sufiicicnt  to  show  pitting  on  pres- 
sure, though  the  skin  looks  puffy  and  is  shiny. 
When  the  u})per  extremities  are  affected,  the  fore- 
arm is  semi-flexed  and  rests  on  the  trunk.  This 
posture  is  maintained  for  hours  with  no  attempt  at 
movement  and  no  complaint  while  undisturbed. 

The  immobility  is  not  paralytic  in  character,  and 
if,  despite  the  suffering  produced,  the  limbs  be  man- 
ipulated, the  joints  are  always  found  to  be  readily 
movable  and  free  from  stiffness. 

Swelling  of  the  soft  tissues  about  the  bones  is  a 
common  feature ;  it  varies  in  degree,  though  never 
very  marked,  "and  is  quite  distributed,  spreading 
over  the  area  of  the  bone  affected  ;  thus,  when  the 
femur  is  involved  the  tumefaction  extends  from  the 
knee  nearly  to  the  hip-joint,  when  the  tibia,  from 
the  ankle  nearly  to  tlie  knee;  if  the  arm  bones  are 
affected,  swelling  while  present  is  less  noticeable. 
The  swelling  is  greatest  over  the  distal  ends  of  the 
bones.     It  never  involves  the  joints. 

Any  pressure  that  does  not  move  the  limb  is  pain- 
less ;  there  is  no  pitting,  the  skin  is  normal  in  color, 
and  there  is  no  increased  local  heat. 

As  the  case  progresses  the  tumefaction  subsides 
to  a  certain  extent,  tends  to  become  limited  to  the 
lower  third  of  the  bone,  and  beneath  it,  deep  pres- 
sure reveals  a  firm  fusiform  enlargement  of  the 
shaft ;  this  is  due  to  sub-periosteal  hemorrhage  and 
varies  greatly  in  extent  in  different  cases. 

Lesions  of  the  gums  are  observed  only  in  cases 
in  which  one  or  more  teeth  have  been  cut ;  they 
appear  early,  but  often  escape  attention  until  suffi- 
cienty  far  advanced  for  hemorrhage  to  take  place. 
Primarily,  the  gum  margin  about  the  necks  of  the 
teeth  becomes  deep  red  in  color  and  slightly  swol- 
len ;  soon  the  color  changes  to  deep  purple,  the 
area  of  discoloration  extends,  the  swelling  in- 
creases, and  ultimately  the  whole  alveolar  mucous 
membrane  in  the  neighborhood  of  erupted  teeth  be- 
comes ecchymotic,  the  swelling  is  so  extreme  that 
the  thickened  gum  margin  overlaps  the  teeth,  the 


8l2 


The   Philadelphia"! 
Medical  Journal  J 


INFANTILE  SCURVY 


[  AjTtn,  27,  IflOl 


tissue  is  spongy  and  hemorrhage  is  produced  by  the 
lightest  touch  or  takes  place  spontaneously,  blood 
constantly  oozing  in  small  quantities.  Rarely 
sloughing  occurs,  and  occasionally  when  the  gum 
lesions  are  very  marked,  the  teeth  are  temporarily 
loosened  in  their  sockets;  they  should  be  main- 
tained in  position  if  possible,  however,  since  they 
become  firmly  set  again  as  the  patient  recovers. 

The  general  features  arc  very  diverse  in  degree 
of  prominence.  Often,  when  the  scurvy  is  mild  in 
grade,  the  infant  is  seemingly  so  well  nourished 
and  in  such  apparent  health,  that  the  parents  are 
surprised  at  the  sudden  development  of  local  symp- 
toms. Usually,  however,  even  in  these  cases,  ♦^hc 
trained  observer  is  able  to  detect  evidences  of  mal- 
nutrition in  the  slight  anemia  and  muscle  flabbi- 
ness. 

In  well  marked  instances  there  is  emaciation : 
dry,  pale,  or  sallow  skin ;  debility  indicated  by  an 
irritable,  weak  pulse  and  loss  of  muscle  tone ;  the 
tongue  is  lightly  coated,  the  appetite  capricious,  and 
the  bowels  tend  to  constipation,  the  evacuation^ 
being  rather  scanty  and  clay  colored,  showing  defi- 
cient biliary  secretion.  Occasionally  there  is  diar- 
rhea, with  greenish  mucoid  discharges,  and  at 
times  the  feces  contain  blood.  There  may  be 
more  active  indications  of  gastric  indigestion,  and 
very  frequently  there  is  an  antecedent  history  of 
great  difficulty  in  feeding  on  account  of  proneness 
to    gastro-intestinal    disturbance. 

Fever  is  not  a  symptom  of  scurvy,  and  when 
present  is  due  to  some  accidental  complication,  as 
intercurrent  acute  intestinal  catarrh,  and  not  to  the 
disease  itself.  Under  these  circumstances,  the  tem- 
perature is  generally  but  moderately  elevated,  the 
thermometer  ranging  from  a  little  above  normal 
to  ioo°  or  ioi°  F. 

The  urine  is  diminished  in  <|uantity,  high  colored, 
often  laden  with  urates  and  increased  in  gravity. 
The  frequent  presence  of  albumen  and  the  evi- 
dences of  nephritis  have  been  asserted,  but  is  not 
borne  out  by  my  own  experience.  In  grave  case? 
there  may  be  hematuria. 

Hemorrhage  is  a  late  feature,  appearing  after 
prostration  is  advanced  and  the  blood  crasis  has  de- 
teriorated. It  takes  place  first  in  the  sub-cutaneous 
areolar  tissue,  especially  in  dependent  parts  of  the 
body,  and  beneath  the  mucous  membrane  of  the 
mouth.  The  ecchymotic  spots  are  deep  purple  in 
color,  and  range  in  size  from  that  of  a  pin's  head 
to  patches  one-fourth  of  an  inch  or  more  in  diam- 
eter. 

Bleeding  from  the  gums  has  been  already  men- 
tioned, and  is  an  earlier  symptom  than  sub-cuta- 
neous ccchymosis.  Later,  epistaxis  and  hematuria 
may  be  observed,  and,  much  more  frequently,  hem- 
orrhage from  the  bowels,  the  leakage  either  merely 
staining  the  discharges  from  the  rectum,  or  ap- 
pearing as  pure,  though  dark  colored  and  altered 
blood.  The  loss  of  blood  directly  increases  the 
cachetic  condition  noted  in  severe  cases,  and  if  at 
all  profuse  plays  an  important  part  in  exhausting 
the  vitality  in  fatal  cases. 

Fracture  of  the  femur,  tibia,  or  humerus,  is  a  late 
symptom,  and  shows  an  extremely  grave  tj-pe  of 


affection.  Separation  at  the  lower  third  of  the 
tibia  existed  in  my  single  fatal  case,  and  I  know  of 
no  instance  of  recovery  after  its  occurrence.  In 
fact,  it  is  doubtful  if  reunion  of  the  soft  macerated 
and  eroded  lower  end  of  the  shaft  of  the  bone  with 
its  epiphysis,  could  be  accomplished,  even  grant- 
ing the  possibility  of  the  infant's  recovery  from  the 
condition  of  extreme  prostration  and  mal-nutrition 
that  is  invariably  present  before  fracture  takes 
place.  The  bone  lesion  gives  rise  to  characteristic  de- 
formity; when  the  femur  is  involved,  there  is  a 
distinct  downward  bend  in  the  thigh,  situated  a 
short  distance  above  the  knee  joint  and  due  to 
weight  traction  of  the  part  of  the  limb  below  the 
seat  of  separation  ;  with  the  tibia,  the  same  bend- 
ing is  observed  above  the  ankle  joint,  but  it  is  less 
in  degree,  because  the  fibula  acts  as  a  partial  splint, 
and  tlie  depressing  weight  is  not  so  great. 
Palpation  does  not  yield  crepitation,  and  it  is 
difficult  to  fee!  the  end  of  the  bone  through  the  sur- 
rounding soft  tissues  and  the  mass  of  extravasated 
blood. 

7\s  the  greater  number  of  scurvy  cases  are  quite 
typical,  the  diagnosis  is  usually  attended  with  little 
difficulty. 

The  distinguishing  features  are,  the  development 
in  infants  from  six  months  to  two  years  old,  after 
the  prolonged  use  of  unsuitable  food,  of  extreme 
hyperesthesia  and  immobility  of  the  limbs ;  swell- 
ing of  the  thigh  above  the  knee-joint  and  of  the  leg 
above  the  ankle-joint :  fusiform  enlargement  of  the 
lower  third  of  the  shaft  of  the  femur  and  tibia: 
deep  purple  discoloration  (ecchymosis),  swelling 
and  sponginess  of.  and  hemorrhage  from,  the  gums 
surrounding  erupted  teeth ;  general  cachexia  and 
anemia,  and  finally — the  test  feature — rapid  dis- 
appearance of  symptoms  and  complete  recovery 
following  the  adoption  of  an  antiscorbutic  diet,  and 
— the  negative  symptom — non-involvement  of  the 
joints. 

The  pain  produced  by-  movement  and  the  iin- 
mobility  of  the  limbs  are  responsible  for  most  of 
the  errors  in  diagnosis,  scurvy  being  frequently 
mistaken  for  rheumatism,  hip-joint  disease,  paraly- 
sis and  affections  of  the  spine. 

Considering  the  very  uniform  and  characteristic 
complex  of  symptoms  in  scurvy,  it  is  difficult  to 
understand  why  this  confusion  should  occur;  but 
I  have  seen  two  cases  in  which  a  reputable  surgeon 
had  applied  dressings  for  hip  disease  during  a  period 
of  four  and  six  weeks,  and  many  in  which  counsel 
was  requested,  because  a  supposed  rheumatic  at- 
tack obstinately  resisted  every  method  of  treat- 
ment. However,  since  the  disease  has  been 
more  carefully  studied,  illustrative  cases  reported, 
and  the  subject  given  a  place  in  text-books,  mis- 
takes in  diagnosis  are  becoming  more  and  more  in- 
frequent. 

The  question  of  the  relation  of  scurvy  and  rick- 
ets has  been  much  discussed.  Before  the  former 
disease  had  been  carefully  studied  rickets  was  sup- 
posed to  uniformly  precede  or  accompany  it.  and 
prior  to  the  publication  of  the  obse^^•ations  of 
Cheadle  and  Barlow,  it  was  classed  as  "acute  rick- 
ets."    Both  diseases  develop  during  infancy,  and 


AiRIL  27,  1001] 


INFANTILE  SCURVY 


[ 


The   Philadelphia       8  T  ■J 
Medical  Joubnai,        "    O 


both  arc  caused  by  food  that  is  deficient  in  certain 
essential  qualities,  but  here  the  similarity  ends.  Foi 
the  lesions  of  rickets  are  found  in  the  bone  tissue, 
those  of  scurvy  in  the  blood  vessels,  and  while  the 
effects  of  these  are  readily  and  completely  remov- 
able in  scurvy,  in  rickets  their  mark  is  left  per- 
manently in  bone  thickening  and  deformity.  Again 
alterations  in  diet  that  quickly  terminate  scurvy 
are  inoperative  in  rickets.  The  two  conditions, 
therefore,  are  not  generically  related ;  one  may  ap- 
pear without  the  other,  or  they  may  co-exist  in  the 
same  patient,  though  such  an  association  is  excep- 
tional in  my  experience. 

The  symptoms  of  rickets  show  little  similarity  to 
those  of  scurvy  and  make  the  differentiation  an  easy 
matter.     The  most  uniformly  present  and  charac 
teristic,  in  the  type  of  cases  in  which  there  is  the 
greatest  likelihood  of  confusion,  are  profuse  perspi- 
ration  about  the  head  and  chest,  anemia  and  evi 
dences  of  malnutrition,  delayed  dentition,  enlarge- 
ment of     the     joints,  bending  of     the  long     bones 
cranio-tabes,   misshapen   head   with  prominence  of 
frontal  and  parietal  bones,  rachitic  rosary,  deformity 
of  thorax  with  depressed  ribs  and  projecting,  dis 
tortcd  sternum,  and  prominent  abdomen. 

Purpura  may  be  distinsruished  from  scurvy  by  its 
etiology,  unsuitable  food  not  being  an  essential 
cause;  by  the  absence  of  hyperesthesia,  immobil- 
ity, spongv  bleedin-^  gums  and  deep  sub-periosteal 
hemorrhage.  The  leakage  of  blood  in  purpura  has 
a  tendency  to  be  general  and  more  superficial,  being 
most  marked  in  the  subcutaneous  tissue  and  from 
the  various  mucous  surfaces  and  kidneys. 

When  treatment  is  not  guided  by  a  correct  diag- 
nosis, scurvv  runs  a  protacted  course,  and  the 
patient  gradually  passes  into  a  condition  of  sucl: 
profound  cachexia  that  death  may  take  place  from 
exhaustion.  On  the  other  hand  prompt  detectioTi 
and  judicious  manacrement  almost  certainly  leads 
to  rapid  recovcrv,  improvement  beginning  after  a 
few  days  and  all  symptoms  disappearing  in  from  two 
to  three  weeks. 

Dangerous  symptoms  are  extreme  anemia  and 
prostratioti,  cpiphvsieal  separation,  the  appearance 
of  petechial  spots,  the  expulsion  of  blood  from  the 
bowels  and  hematuria.  E.xtreme  gastric  irritabil- 
ity, making  feeding  difficult,  and  the  intercurrence 
of  enteric  catarrh,  materially  add  to  the  gravity 
of  the  prognosis. 

The  subjoined  table  of  twenty-six  cases,  occurr- 
ing in  my  own  practice,  is  of  interest  as  an  illustra- 
tion  of  the  clinical  features  in  infantile  scurvy  of  the 
type  ordinarily  met  with  in  practice. 

The  management  of  scurvy  is  very  simple,  de- 
pending entirely  upon  the  substitution  of  a  fresh 
antiscorbutic  diet  for  whatever  form  of  unsuitable 
food  may  have  been  the  casual  factor.  If  a  propri- 
etary food  has  been  employed,  it  must  be  aban- 
doned, sterilization  must  be  discontinued  as  a  pro 
cess  of  preparation,  condensed  milk  or  food  too  rich 
in  farinaceous  material  must  be  changed  to  a  prop- 
erly modified,  untreated,  cow's  milk  mixture,  and 
if  the  food  has  been  simply  deficient  in  proteids,  it 


must  be  strengthened  so  far  as  the  digestive  pow- 
ers admit,  and  any  deficiency  supplemented  by  the 
use  of  some  other  form  of  albuminoid,  as  raw-beef 
juice. 

Briefly  stated,  the  essential  treatment  is  the  em- 
ployment of  a  food  composed  of  cow's  milk,  cream, 
water,  and  milk-sugar,  properly  proportioned  to 
the  age  of  the  infant,  and  given,  so  far  as  the  cream 
and  milk  are  concerned,  in  the  natural,  fresh  state, 
<.  e.,  not  passed  through  the  separator  and  not 
sterilized. 

Pasteurization  and  predigestion  at  a  temperature 
of  115°  F.,  are  admissible  in  certain  cases,  but 
should  never  be  employed  when  the  cream  and 
milk  are  carefully  handled  at  the  dairy  and  can  be 
kept  clean  and  sweet,  and  when  the  infant's  diges- 
tion is  even  moderately  active. 

The  juice  of  fresh  ripe  fruit — orange  juice  espec- 
ially— is  a  useful  addition  to  the  diet,  and  when, 
as  is  usually  the  case,  it  can  be  taken  without  pro- 
ducing diarrhoea,  is  an  efficient  aid  to  rapid  recov- 
ery. 

For  scurvy  in  an  infant  of  eight  months,  an  ap- 
propriate food  schedule  is : 

First  meal,  7  A.  M. 

Cream %  ounce 

Milk 1%  ounces 

Milk  Sugar 1  drachm 

AVater 3  ounces 

At  9  .\.  M. — One  to  two  teaspoonsful  of  fresh 
orange  juice,  according  to  effect  on  bowels. 

Second  meal,  10.30  A.  M.     Same  as  first. 

At  11.30  A.  M. — Two  teaspoonsful  of  raw-beef 
juice,  free  from  fat,  and  with  a  little  salt. 

At  I  P.  M. — One  to  two  teaspoonsful  of  fresh 
orange  juice. 

Third  meal,  2  P.  M.    Same  as  first. 

At  3  P.  M. — Two  teaspoonsful  of  raw-beef  juice 
with  salt. 

At  5  P.  M. — One  to  two  teaspoonsful  of  fresh 
orange  juice. 

Fourth  meal,  6  P.  M.    Same  as  first    . 

At  8  P.  AT. — Two  teaspoonsful  of  raw-beef  juice 
with  salt. 

Fifth  meal,  10  P.  M.     Same  as  first. 

If  orange  juice  cannot  be  obtained,  or  should  it 
disagree,  good  substitutes  are  two  to  four  table- 
spoonsful  of  scraped  ripe  apple  (raw),  two  tea- 
spoonsful of  fresh  grape  juice,  or  six  solid  grapes 
from  which  the  skins  and  seeds  have  been  removed. 

In  addition  to  the  alteration  of  the  diet  very 
little  treatment  is  necessary.  Gentle  inunction  of 
the  limbs,  with  warm  olive  oil,  may  contribute  to 
the  comfort  of  the  patient,  and  some  acceptable 
preparation  of  iron,  as  the  ferrated  elixir  of  cin- 
chona, will  assist  in  restoring  the  strength  and 
building  up  the  blood.  If  there  be  great  prostra- 
tion, strychnia  and  alcoholic  stimulants  should  be 
administered,  and  all  complications  must  be  met 
as  they  arise. 


8i4 


The  Philadelphia' 
Medical  Jd 


adelphia"! 

JciIIRNAL     J 


INFANTILE  SCURVY 


[AIBIL  27,  1901 


TABLE  OF  CASES  OF  INFANTILE  SCURVY  OCCURRING  IN  THE  AUTHOR'S  PRACTICE  FROM    1890-1900. 


Race 
Sex 

Class 


White 

F. 

Wealthy 


White 

M. 

Wealthy 


White 
F. 

Wealthy 


White 

M. 

Moderate 


White 

M. 

Moderate 


White 

M. 

Moderate 


White 

F. 
Moderate 


White 

K. 

Moderate 


White 
V. 

Wealthy 


White 

M. 

Moderate 


White 

1\1. 

Moderate 


While 

F. 

Wealthy 


White 

F. 

Wealthy 


Age 


10 

months 


10 
months 


months 


8 
months 


8 
months 


11 

months 


9 
months 


8^ 
months 


12 
months 


15 
months 


8 
months 


12 
months 


Prior 
Duration  of 

Symptoms 


SYMPTOMS 


RTIOIvOGY 


3  months 


^%  months 


1*  iiionl  lis 


2  weeks 


(i  weeks 


Condensed   milk 
from  birth. 


Grade 


Swelling  of  both  legs  above  ankle  joints.     rro])rietary  foods.     Severe 
immobility  .  hyperesthesia  ;  Gums  about  the   then        condensed 
4  erupted    teeth    purple ;     swollen,    sponpy.    milk  mixture, 
bleeding,  Ecchymosis,  slight  at  seat  of  swell- 
ing.    Impaired  digestion,    tendency    to   c<'U- 
stipation,   marked  emaciation,  anemia  and  j 
prostration;  urine  high  co  ored,  scanty.  Tern-  i 
perature  100--101  F.     No  rickets.  j 

Marked  swelling  of  right  leg  with  separa- 
tion of  ephiphysis  of  tibia ;  moderate 
swelling  at  lower  third  left  of  leg  and  al>ove 
both  wrists.  Immobility ;  hyperesthesia. 
Gums  about  the  6  erupted  teeth  extremely 
swollen,  spongy,  deep  purple,  sloughing, 
bleeding.  Distributed  petechiae,  most  nu- 
merous over  swelling.  Anorexia,  tendency 
to  vomiting  and  diarrhoea  with  blood- 
stained, mucoid  ev  icuations  ;  extreme  emac- 
iation, anemia  and  prostration  ;  urine  s<_anty 
but  normal;  temperature  ranged  from9'J-l(Xi 
F.     No  rickets. 

Marked  swelling  above  right  ankle,  less 
above  left,  considerable  ecchymosis  in  th(  se 
positions  ;  immoliility  ;  great  hyperesthesia  ; 
no  theeth  ;  gums  normal ;  anorexia  ;  irritable 
stomach  ;  diarrhoea  ;  emaciation  ;  an«_-mia  ; 
great  prostration-  Temperature  range  about 
10J°  F.    No  rickets. 

Great  enlargement  of  lower  third  of  right 
femur,  skin  over  this  region  purplish ; 
hj'peresthesia  ;  immobility.  Emaciation  and 
prostration  marked  ;  anorexia  ;  occasional 
vomiting  ;  tendency  to  diarrhoea  with  gre<  n. 
undigested  evacuations ;  urine  normal  ;  no 
fever,  no  rickets.  During  treatment  the 
lower  incisors  appeared,  and  the  gums  pre- 
viously negative  at  once  became  purple  and 
swollen. 

Slight  fusiform  swelling  at  lower  third  of       Artificially      fed|     Mild 
each     thigh,    and    less    above    each    ankle,    from  birth,  proper-l 
Hyperestiusia  ;     immobilitj' ;  gums  about  1   ly      pro|>ortioned  ; 
inci.sor  teeth    livid    purple,     very    swollen,  cream    and      mtlk| 
bleeding  readily.     Appetite   fair,  bowels  re-   mixture,  sterili7,cd 
gular,   urine     liormal,     slight     pallor     and 
muscular  flabbiness,  no  emaciation,  nofev.-r. 
no  rickets.  ^  I 

Swelling  at  lower  third  of  each  femur,  and  \     Weaned     at    6th|  Average 

to  less  extent  above  ankle  joints.  Immobili-  week,  then  fed  on 
ty ;  hyperesthesia.  G\ims  about  4  incisor  a  mixture  weak  in 
teeth  purple,  swollen  and  bleeding  at  sliLrh-  cows  milk  strong 
test  touch.  W  akness,  moderate  anemia,  in  a  proprietary 
Muscles  flabby,  no  emaciation.  Afebrile,  no  food. 
rickets.  ' 


Recoverj-  slow. 


Home  modified  milk 
mixture  (raw).  Digest- 
ants  and  tonics  (not 
sufficiently  antiscor-' 
butic,  being  my  first 
case). 


•Humanized  milk."  Death     after     five 
Beef       juice ;        Iron  ;      months  illness. 
Codliver    oil ;       stimu- 
lants. 


Artificial  food 
from  birth;  con- 
densed milk;  pro- 
prietary food.  At 
jtack  Ixrgan  while 
.taking  Stt  rilized 
icowsmilk  mixture 

I  Nursed  one  week, 
I  then  fed  upon 
strong  oat  -  mea* 
water  with  a  little 
cows  milk.  Attack 

followed      one 
months  feeding  on 
Serilized  milk. 


Severe 


TREATMENT 


RESULT 


Home  modified  milk  Scurvj'  symptoms 
mixture  (raw),  orange  disappeared  in  4 
juice,  raw  lieef  juice;  weeks.  Restora- 
Iron  tonic,  alcoholic,  tion  of  general 
stimulants.  health  slow,  about 

Z  months. 


"Humanized  milk'i  Recovery  pro- 
raw  beef  juice,  digest-  gressive  but  slow, 
ants,  stimulants,  cod  complete  in  three 
liver  oil.  (Early  case. i months. 
diet  not  sufficiently 
antiscorbutic.) 


Sterilization  discon- 
tinued. 


I 


Recovery  in  three 
weeks. 


Cream  and  milk  mix-      Improvement  af- 
ture,  fresh  and  of  pro-ter  4  days.      Reco- 
pcr    strength.      Dr.  2  very  in  3  weeks. 
raw  l»eef  juice  and  dr.: 
1  orange  juice  3  times' 
I  daily.  ! 


Considerable  swelling  above  each  knee 
joint,  less  above  the  ankles.  Hvperestlusia 
Imuiobility.  Dentition  normally  advanc  d. 
gums  purple,  swollen,  bleeding.  Anemia 
prostration,  some  emaciation,  appetite  I'oor, 
bowels  constipated.  I'rine  scanty  but  nor- 
mal.    No  fever.     No  rickets. 

Swelling  above  both  knees  and  ankKs. 
Hyperesthesia.  Immobility.  2  incisors  cut, 
gums  purple  and  swollen.  Anorexia,  im- 
paired digestion,  irregular  bowels.  Emaciat- 
oin  and  prostration.     No   fever.     No  rickets. 


Hyperesthesia  and  immobility  of  liolh  Ici^s, 
but  no  swelling.  2  incisors  cut,  gums  li\i«i 
purple,  much  swollen.  Irritable,  no  prostrat- 
ion or  emaciation,  some  pallor.  No  symp- 
toms of  rickets. 

Hyperesthesia,  immobility  of  both  le;.js, 
and  some  swelling  above  tha  knee  joints.  (> 
incisors  cut,  gums  purple  and  swollen.  Irri- 
table, emaciated,  anemic,  anorexia,  tendt  ncy 
to  vomit,  irregular  bowels.  No  symptoms 
of  rickets.  Feeble  from  long  continued  mal- 
nutrition. 

Swelliinj  above  the  knees  and  ankles.  Hy- 
peresthesia. Immobility.  Dentition  noV- 
mally  advanced,  gums  purple,  swollen, 
readily  bleeding.  Marked  anemia,  emaciat- 
ion and  prostration.  No  symptoms  of  rickets. 

Swelling  of  lower  third  of  both  legs.  Hy- 
peresthesia. Immobilitv  of  both  legs  and 
left  arm,  no  swelling  of  latter.  2  incisors 
cut,  gums  purple  and  swollen.  Anorexia. 
constipation.  .\uemia.  muscle  flabbincss 
and  emaciation.     No  fever,  no  rickets. 

Swelling  above  the  right  knee  and  ankle. 
Hyperesthesia.  in\mobility  not  complete. 
I'pper  and  lower  central  incisors  cut.  lower 
gums  show  purple  line,  \ipper  deep  purple 
and  swollen.  Anorexia,  con stiyw tion.  mode- 
rate pallor,  weakness  and  emaciation,  Vriue 
scanty.     No  fever,  no  rickets. 


Mixed  feeding  in  Average  i  Home  modified  cream 
early         months.  jand       milk      mixture 

Weak      condensed  i(rawt      Orange    juice.  '" 

milk   mixture.  At-  Raw  beef  juice. 

tack    followed    se-  ' 

vere  epidemic    ; 
fluenza. 


Improvement  in 
days.       Rtrcoven- 
weeks. 


Cream  and  milk  mix-'    Improvement  m 
ture  predigested  at  115.  ?  days.      Recovery 
Slerilir^ation    stopped.  >°  ^  weeks. 
Raw  iK-ef  juice.  Tonics. 


Artificial  feeding      Mild 

from  birth.  Steri- 
lised weak  milk 
mixture  with  pro- 

prietarj'    food. 
Attack       followed 
measles. 

Fed  at  breast  for' very  mild  Cream  and  milk  mix-  Improvement  in 
1  month,   then    on  ture    (raw).       Orange  ?  ".^ys.      Recover* 

condensed        milk  juice.    Raw  iK-ef  juice,  *"'- ^^*^*^^- 

iand  a   proprietarv 

I  food. 

Artificial  foodaf-  very  mild  Pasteurization  sutv  Immediate  im- 
ter   1st    week.    1st  stituted    for   steriliza-  provement.     R«»- 

condensetl        milk  tion.      Orange     juice.  ^'*^0' *" -^  "^^*^^ 

then     cows      milk  K.tw  I>eef  juice.  > 

and  cream  mixture  | 

STBRlLlZF.Ii. 


I  Weaned  at  4th  Severe 
month.  Cows  milk 
misttire  to  7th| 
month  then  and  at| 
time  of  onset  a  pro-j 
prietary  footl.  \ 

Mixture  of  milk|  Average 
water  and   a    pro-' 
prietar>*  foo<l  steri- 
lized    and     pretli- 
gested.  I 


Home  nodified  cream      Recover)'  in  two 
and      milk      mixture  weeks. 
(raw).     (^>range    juice. 
Raw  beef  juice. 


Sterilization  stopped.  Improvement  in 
"Hnmanired  milk".  2  days.  Recovery 
Oranpe     juice.       Raw  in  2  \recks, 

beef  Juice. 


Artificially      fed       Mild     '        Partially         predi-      Recovery  in  two 
from  birth  on  pro-  gested  cre^am  and  milk  weeks. 

prietan.-  footl.  mixtnnr.  Orange  jnice 

and    raw     beet    juice, 


Apbii.  2T,  1901] 


INFANTILE  SCURVY 


CThe   Philadelphia 
Medical  JorEXAL 


815 


TABLE  OF  CASES  OF  INFANTILE  SCURVY  OCCURRING  IN  THE  AUTHORS  PRACTICE  FROM  1890  1900. 


Race 

Sex 
Class 


While 
M. 

Wealthy 


White 

M. 

Wealthy 


White 
M. 

Wealthy 


White 

P. 

Wealthy 


White 

M. 

Wealthy 


White 

F. 

Moderate 


White 
M. 

Moderate 


White 

F. 

Moderate 


White 

M. 

Model  ate 


White 

M. 

Moderate 


15 
months 


13 
months 


15 
months 


10 
months 


months 


15 
months 


Prior 
Duration  of  J 
Symptoms  i 


SYMPTOMS 


6  weeks 


13 
months 


10 
months 


14 
months 


12 
months 


White  14 

M.  months 

Wealthy 


White 

M. 

Model  ate 


White 

F, 

Wealthy 


3  months 


6  weeks 


2  weeks 


2  weeks 


HTIOI,OGY 


Grade 


TREATMENT 


RESUI^T. 


Scurvy  followed  prolonged  illness.  Chronic  Long    continued, 

entero-colitis.    bronchitis,    mastoid    disease,  illness.      Food    on] 

Hyperesthesia  and   immobility  of  left   leg.  accont  of  impaired; 

10    Teeth    cut.    gums    deep    purple,     much  digestion,  too  low^ 

swollen,  readily  bleeding.    No  symptoms  of  in  albuminoid  per-^ 

rickets.  centage.                     I 


Added  to  dilute  milk     Recovery  rapid, 
mixture.    ma-*ihed    po- 
tatoes, dry  bread  and 
stewed      fruit.       Raw 
.beef  juice.  I 


Condensed   milk 
feeding  from  birth 


Persistant 
feeding. 


bad 


3  months 


6  weeks 


3  months 


Swelling  above  both  knee  joints.  Hyper- 
esthesia. Immobility.  Dentition  normally 
advanced,  gums  purple,  swollen,  bleeding, 
teeth  loose.  Marked  emaciation,  prostration 
and  anemia.  Temperature  ranged  from 
98.4=  to  103^  F.    No  rickets. 

Child  feeble  from  birth,  difficult  to  feed. 

and  badly  fed  and  managed.  Swelling  of 
I  both  lees  above  ankles.  Hyperesthesia. 
I  Immobility-  Dentition  normal,  giiras  purple. 
1  Extremely    swollen,     bleeding.      Anorexia, 

feeble    digestion,    obstinate  diarrhoea  with 

fetid  discharges.  Emaciation,  anemia,  pros- 
'  tration.     Fever  moderate.    No  rickets. 

Swelling  of  lower  third  of  right  femur  and  '  Artificially  fed 
'  lower  third  of  ripht  leg.  Hyperesthesia,  Im-  from  birth.  Food 
I  mobility.  Dentition  normal,  gums  purple,  too  low  in  albumi-, 
■  swollen.      Moderate    pallor,    weakness  and  'noid  percentage. 

emaciation.       Anorexia,    constipation.      No  '  ! 

fever  and  no  rickets.  1  ' 

Marked  fusiform  enlargement  of  lower  1  Artificiallv  fed 
third  of  right  femur.  Hyperesthesia.  Immo-  jfrom  birth.  Weak 
bility.  Dentition  normally  advanced,  gums  cows  milk  mixture 
purple,  very  swollen,  readily  bleeding,  with  a  proprietary* 
Anorexia,  constipation.  Emaciation,  ane-  food. 
I  mia.    Weakness.  I'rine  scanty,  high  colored.  J 

No  fever.    No  rickets.  , 

Swelling  of  both  tibiae  above  ankle  joint.  Weaned  at  2nd. 
right  most  marked  ;  slight  swelling  of  both  month,  then  fed 
arms  above  the  wrists.  Hyperesthesia.  Ira-  on  sterilized  milk 
mobility  of  legs  complete,  of  arms  partial.  7  (long process). and 
teeth  cut,  gums  purple,  swollen,  bleeding;  then  on  sterilized 
first  molars  in  upper  jaw  nearly  erupted  in-  milk  alternating 
vesting  gums,  swollen  and  purple.  Anorexia,  with  a  proprietary 
constipation ,  poor  digestion ,  prostration ,  food 
great  emaciation.  Urine  scanty,  high  color- 
ed.    No  fever.    No  rickets. 

*Hvperesthesia  and  immobility  of  legs;  no  Bottle  fed  from 
swelling,  8  teeth  cut.  gums  purple,  greatly  birth;  milk  mix-! 
swollen,  readily  bleeding.  Appitite  poor.  ture.  properly  pro- 
Irregiilar  bowels  tending  to  constipation,  portionea.  but  ste- 
Marked  anemia  and  emaciation.  No  fever,  rilized  (long  pro- 
No  rickets.  cess). 

Hyperesthesia  and  immobility  of  both  legs,  '  Bottle  fed  from 
some  swelling  above  knees.  6  teeth  cut.  gums  birth,  food  too 
purple,  slightly  swollen,  anemia,  poor  appi-  dilute.  ] 

lite,   regurgitated  a  portion  of  each  feeding.  i 

Obstinate  constipation.  No  fever,  no  rickets. 

Hyperesthesia  and  immobility  of  booth  Breast  fed  for  2 
legs',  no  swelling  about  bones,  tt  teeth  cut.  months,  then  on 
gums  purple  and  moderately  swollen  ;  poor  var\'ing  foods,  con- 
appetite,  impaired  digestion,  constipation,  denced  milk  and 
anemia,  moderate  prostration,  little  emaciat-  several  proprieta- 
ion.    No  fever.    No  rickets.  ry  foods. 

Some  swelling  above  left  ankle,  both  legs  Artificially  fed 
I  h>-peresthetic  and  immobile.      6  teeth  cut.   from    birth     to   7 

giims  purple  and  much  swollen,  anemia,  months.  No  milk 
I  muscle  fiabbiness.  anorexia,  emaciation,  diet  3  weeks,  but 
j  irregular  bowels    with   undigested  evacuat-  nursed  from  seven, 

ions.  Temperature  98.5^  to  101°,  urine  normal,   weeks  breast.  I 

I  No  rickets.  Proprietary  food. 


I 


! 


Home  modified  cows    Recoverv  in  about 
milk    mixture    ( raw  i .  3  weeks. ' 
Orange     juice.      Raw 
beef  juice. 


Severe  ,  Egg-albumin,  water  Active  scorbutic 
and  raw  beef  juice,  s^-mptoms  disap- 
child  gradually  built  peared  in  2  weeks. 
,up  to  broths  and  milk  but  restoration  to 
imixtures.  stimulants,  health  slow, 
complicating  diarr- 
hoea treated? 


Mild  Home  modified  milk    Recovery  in  about 

mixture  (raw).  4  weeks. 

Orange  juice.    Raw{ 
beef  juice. 


Hf^me  modified  milk  Improvement  no- 
mixture  (raw).  ticed  in  2  days.  Re- 

Oranpe  juice.  Raw  coven,-  complete 
beef  juice.  in  18  days. 


Very         Home  modified  milk      Improvement  at 

Severe     mixture      predigested  once.     Recovery  in 

with   peptogenic  milk  2  weeks. 

powder    at  115°  for  4 

minutes. 

;     Orange    juice,     raw 
beef  juice. 


Mild  Sterilization  discon-    Improvement  im- 

tinued.  mediate.  Recovery 

in  3  weeks. 


Very  Home  modified  milk    Improvement  im- 

Mild       mixture  (raw^.  mediate,    recovery 

Orange     juice,    raw  in  10  days. 

beef  juice,      laxative 

Suppositories. 

Ver>'         Home  modified  milk'    Recovery  rapid. 
Mild       mixture  (raw).  i 

Orange    juice,     raw' 
ibeef  juice. 


Average      Hotne  modified  milk'    Marked  improve- 
mixture  (raw).  mend  in  3  days.  re- 

Orange    juice,     raw  covery  in  3  weeks, 
beef  juice. 


9 
mouths 


10 
months 


6  weeks  Fusiform  swelling  above  both  ankle  joints.       Breast   fed  for  3  Average,    Home  modified  milk      Recovery  in  two 

Hyperesthesia.      Immobility.      No  swelling  months ;  then  pro-  mixture  (raw).  ;weeks. 

but  hyperesthesia  and  partial  immobility  of  prietary  foods.  Orange  juice. 

left  arm.    10  teeth  cut,  gums  deep  purple, 
'  ver>*    swollen,    readily    bleeding.      Appetite  | 
I  normal,  bowels  tend  to  constipation.     Urine  [ 
(  high  colored,  emaciation,  anemia,  some  pros-  { 

tration.    No  Fever.    No  rickets. 

Fusiform  swelling  above  left  ankle  joint,  [     Artificial  feeding;     Mild         Home  modified  milk 
I  with  legs  hyperesthetic    and    immobile.    6  from      birth,     too,  mixture  (raw). 

I  teeth  cut,  ^ms  deep  purple,  gfreatly  swollen   weak    milk   mixt-  i    Orange  juice 

'  and    bleeding,  anemia,    constipation,  urine  ure. 
1  scanty    but    normal,    emaciation,  weakness. 
No  fever.    No  rickets.  r 


4  weeks 


No  swelling,  but  hyperesthesia  and  immo-  Artificially  fed 
bility  of  both  legs.  One  lower  incisor  cut,  ; from  birth.  I^- 
gums  purple  and  slightly  swollen.  Constipa-  Iboratorj'  milk 

tion.  pallor  and  muscle  fiabbiness.  but  gene-       fat 4 

ral  nutrition  good.     No  fever.     No  rickets.  sugar 7 

albuminoids  .  .  1 


Recovery  rapid. 


Ver>-         Home  modified  milk      Reco\*ery  in  one 
Mild      mixture  (raw).  week. 

Orange  juice 


Ojg       The   Philadelphia"! 
Medical  JorBNAL  J 


LEUKEMIA 


[A!rail.  27.  1901 


NOTES  ON  LEUKEMIA  WITH  A  REPORT  OF  THREE 

CASES.* 

By  CHARLES  S.  JEWETT,  Ph.  B.,  M.  D. 

of  Buffalo,  N.  Y. 

Visiting  Physician  to  the  Erie  County  Hosoital.  Clinical  Path- 
ologist to  the  Buftalo  Hospital  of  the  Sisters  of  Charity. 

In  November,  1845,  Virchow  (i)  published  his 
first  description  of  a  case  in  which  the  white  cells  of 
the  blood  were  enormously  increased  both  absolute- 
ly and  relatively  to  the  red  cells.  In  1846  (2)  he  re- 
viewed his  own  and  three  other  published  cases, 
insisting  that  the  increase  of  white  cells  was  not  due 
to  pus,  and  hence  that  the  condition  was  not  a 
suppuration  of  the  blood.  In  January,  1847  (3)  he 
cited  further  cases  from  the  literature,  one  (of 
Bichat)  dating  back  to  1801,  and  discussed  the  re- 
lation of  the  spleen  to  the  white  cells.  Later  in  the 
same  year  Virchow  proposed  the  name  leukemia 
— white  blood.  In  October,  1845,  Craigie  and  Ben- 
nett (5),  of  Edinburgh,  puljlislied  a  case  of  great 
increase  of  the  white  cells  of  the  blood  which  they 
believed  to  be  due  to  the  presence  of  pus,  and  hence 
termed  suppuration  of  the  blood.  In  1851  Bennett 
(6)  published  further  cases  and  proposed  the  name 
leucocythemia  —  white-celled  blood.  Bennett's 
claim  to  priority  based  upon  his  first  paper  has  been 
generally  disallowed,  and  it  now  seems  clear  that 
\'ircliow  was  the  first  to  recognize  the  essential 
nature  of  the  disease,  the  fact  that  it  is  not  a  sup- 
puration, and  to  discover  the  relationship  between 
the  leukemic  alterations  in  the  blood  and  certain 
pathological  changes  in  the  spleen  and  lymph  nodes. 
The  first  case  diagnosed  during  life  was  tliat  of 
Vogel  (7)  in  1849.  Virchow  recognized  two  forms 
of  the  disease,  the  splenic  and  the  lymphatic,  while 
it  was  reserved  for  Neumann  (8)  in  1869  to  describe 
the  participation  of  the  bone  marrow  in  the  leuke- 
mic process,  and  to  establish  the  myelogenous  form 
of  leukemia.  During  the  past  thirty  years  leuke- 
mia has  received  much  attention  from  clinicians 
and  hematologists,  and  also  from  the  standpoint  of 
pathological  anatomy,  and  the  literature  of  the  sub- 
ject is  enormous.  It  is  not  the  object  of  this  paper 
to  review  all  the  various  theories  regarding 
the  nature  an<l  classification  of  this  disease,  but 
rather  to  summarize  our  present  views  regarding 
these  points. 

As  to  the  nature  of  leukemia,  three  chief  theories 
have  been  and  are  held,  of  which  Taylor  (9),  in 
Sajous's  Cyclopedia,  gives  the  following  suirimary ; 
"The  Virchow-Neumann  theory  considered  the  ex- 
cess of  white  corpuscles  to  be  due  to  an  abnormal 
hyperplasia  of  the  hematopoietic  tissues,  and  most 
of  the  adherents  of  this  view  have  conceived  this 
hyperplasia  as  analogous  to  that  seen  in  nialignanl 
neoplasms."  "The  Risiadecki-Loewit  theory  predi- 
cates a  retardation  of  the  evolution  and  prolonga- 
tion of  the  life  of  the  circulating  Icukocvtes,  the  col- 
lections in  the  tissues  being  interpreted  as  the  re- 
sults of  the  deposition  of  the  excess  of  the  circu- 
lating leukocytes."  This  theory  to-day  finds  few  ad- 
herents. The  modern  theory  is  "that  leukemia  is 
an  infection,  and  that  the  hyperplasia  of  the  Ivm- 
phatic  tissues  and  the  circiijatory  excess  of  white 


•Rc.id  before  the  Pathological  Section  of  the  Buffalo  Acad- 
emy  of  Medicine,   February   19,   1901. 


cells  are  the  result  of  a  specific  stimulation  and 
leukocytosis  analogous  to  those  seen  in  other  infec- 
tions." This  third  theory,  whether  accepted  for  all 
cases  or  only  for  certain  forms  of  leukemia  may  be 
regarded  as  an  elaboration  and  explanation  of'  the 
\'irchow-Neumann  theory,  agreeing  with  it  in 
regarding  the  blood  changes  as  secondarv-  to  the 
lesions  of  the  fixed  tissues  while  expanding  it  by 
attempting  to  show  the  cause  of  these  latter  lesions. 
To-day  the  infection-theory  is  the  one  most  gener- 
ally accepted  for  the  acute  leukemias,  while  it  is  by 
no  means  impossible  that  all  forms  of  leukemia 
may  be  caused  by  one  or  more  infective  agents. 
So  far  all  elTorts  to  demonstrate  the  specific  organ- 
ism have  been  disappointing.  The  various  bacterial 
forms  which  have  been  found  in  leukemic  blood 
were  probably  all  due  to  complicating  infections  or 
to  post-mortem  contamination.  Loewit  has  thus 
far  failed  to  offer  convincing  evidence  that  the  spor- 
ozoa  described  by  him  stand  in  a  causative  relation 
to  leukemia  or  even  that  they  are  anything  more 
than  the  products  of  cellular  disintegration.  Nev- 
ertheless, while  we  lack  the  demonstration  of  a 
specific  infective  agent,  the  argument  from  analog}- 
is  so  strong  that  it  is  difficult  to  doubt  the  infectious 
nature  at  least  of  the  acute  forms  of  leukemia.  The 
classification  of  the  various  forms  of  leukemia  has 
caused  much  confusion  in  the  past,  but  most  of  the 
later  writers  seem  to  be  reaching  a  substantial 
agreement  which  harmonizes  the  pathological  and 
the  morphological  classifications.  Ehrlich  and  Laz- 
arus (11),  Cabot  (12),  Osier  (13),  and  \'on  Lim- 
beck (14),  agree  in  dividing  leukemia  into  a  lym- 
phatic and  a  spleno-myelogenous  or  myelocytic 
form,  while  Engel  (15)  adds  a  splenic  leukemia  and 
Taylor  (9)  a  mi.xed  form.  Engel  says  that  in  splenic 
kukemia  the  polynuclear  neutrophiles  predominate, 
but  admits  that  these  cells  originate  in  the  bone 
marrow  and  are  adult  forms  of  the  myelocytes, 
while  he  makes  no  distinction  between  this  condi- 
tion and  neutrophilic  leukocytosis,  except  the  per- 
manence of  the  former.  Taylor's  (9)  mixed  form 
is  said  to  include  the  whole  group  of  acute  leuke- 
mias, but  in  describing  it  he  quotes  Fraenkel  as 
saying: — "The  blood  changes  are  entirely  character- 
istic. There  is  a  remarkable  increase  of  the  mon- 
onuclear elements,  which  are  of  the  most  varying 
sizes,  but  do  not  contain  neutrophilic  granules." 
Obviously,  such  a  form  would  ordinarily  be  clas- 
sified as  lymphatic  and  would  thus  be  brought  into 
harmony  with  the  more  usually  accepted  classifica- 
tion. \'on  Jaksch  (i6>  recognizes  a  splenic  form,  al- 
though he  atlmits  that,  at  the  autopsy  in  almost  any 
case,  leukemic  changes  more  or  less  marked  will  be 
found  in  spleen,  marrow  and  lymph  nodes.  His  de- 
scription of  the  splenic  form  is  "one  in  which  sim- 
ply relatively  large  leukocytes  are  found."  Judg- 
ing this  rather  vague  description  from  the  context. 
it  would  seem  to  refer  to  what  others  call  a  1^-m- 
|iheiuia,  in  which  the  larger  forms  of  lymphocytes 
predominate.  It  is  thus  not  difficult  to  bring  these 
seeming  variations  into  harmony  with  the  classifi- 
cation which  we  have  adopted  of  myelogenous  and 
lymphatic  leukemia.  While  these  two  forms  may 
usually  be  readily  distinguished,  it  is  necessary 
to  recognize  that  a  mixed  form  does  occur,  though 
rarclj".    Though  splenic  tpmor  is  a  constant  feature 


AI'RII. 


I'.'l'l/ 


LEUKEMIA 


r  The   rniUKE 
L  Mkdical  Jou 


AKELPBIA 
RXJL 


817 


of  the  myelogenous  form,  it  is  also  a  most  common 
accompaniment  of  lymphemia,  and  Neumann  (17) 
early  pointed  out  that  lymphatic  overgrowth  is  not 
necessarily  confined  to  the  lymph  nodes,  but  may 
involve  the  spleen  or  the  bone  marrow  itself.  Inas- 
much as  we  know  of  no  special  forms  of  white  blood 
cells  furnished  by  the  spleen,  and  as  we  have  no 
pathological  records  of  pure  splenic  leukemia,  there 
seems  to  be  no  reason  for  recognizing  this  as  a  sep- 
arate class,  and  when,  in  this  paper,  the  word  splenic 
is  used  in  speaking  of  anj-  case,  it  should  be  under- 
stood as  referring  to  the  splenic  tumor  and  not  to 
any  peculiarity  in  the  blood  composition.  A  further 
classification  of  leukemia  is  into  an  acute  and  a 
chronic  form.  As  the  acute  cases  are  almost  inva- 
riably, if  not  always,  of  the  lymphatic  variety,  it  is 
usual  to  sub-divide  lymphemia  into  two  forms, acute 
and  chronic.  The  diagnosis  of  leukemia  can  be  sat- 
isfactoril)'  made  only  by  means  of  a  microscopical 
examination  of  the  blood.  The  question,  however, 
whether  by  means  of  the  blood  examination  alone  it 
is  possible  to  determine  the  presence  or  absence  of 
leukemia,  and  whether  by  stpdying  stained  blood 
preparations  we  can  decide  upon  the  form  of  leuke- 
mia, which  is  present,  are  still  under  discussion : 
but  the  present  tendency  is  to  answer  both  in  the 
affirmative.  Bearing  in  mind  that  the  characteris- 
tic blood  changes  of  leukemia  are  qualitative  rather 
than  quantitative,  the  truth  seems  to  be  that,  in  any 
well  marked  case,  it  is  possible  from  the  blood 
examination  alone  to  determine  both  the  existence 
of  the  disease  and  its  variety.  In  the  earliest  stages 
this  result  may  not  be  obtainable,  and  it  must  be 
admitted  that  certain  well-developed  cases  show 
during  their  progress,  as  a  result  of  complications 
or  of  therapeutic  measures,  such  marked  remissions 
in  the  leukemic  peculiarities  of  the  blood  composi- 
tion that  an  examination  during  one  of  these  remis- 
sions would  necessarily  fail  to  show  the  true  char- 
acter of  the  disease.  In  such  cases  repeated  blood 
examinations  may  be  necessary  in  order  to  clear 
up  the  diagnosis. 

In  myelocythemia  or  splenic-myelogenous  leu- 
kemia, the  characteristics  of  the  stained  specimen 
of  blood  are,  according  to  Ehrlich  and  Lazarus  (11), 
as  follows : — 

"A.  That  aside  from  the  polynuclear  cells  the 
mononuclear  granular  leucocytes  also  appear  in  the 
circulating  blood. 

B.  That  in  the  increase  of  the  white  blood  cells 
all  three  types  of  granular  cells,  the  neutrophiles. 
the  eosinophiles  and  the  Masfscllcn  participate. 

C.  That  atypical  forms  appear,  for  example,  dwarf 
forms  of  the  various  sorts  of  white  blood  cells,  also 
mitotic  or  karyokinetic  figures. 

D.  That  the  blood  always  contains  nucleated  red 
blood  cells  in  large  numbers." 

Ehrlich  and  Lazarus  (11)  lay  special  stress  upon 
the  fact  that  no  one  variety  of  cell  is  pathognomon- 
ic of  this  disease,  and  it  is  through  a  misunderstand- 
ing of  Ehrlich's  position  in  regard  to  this  matter 
that  much  controversy  has  arisen.  The  predomi- 
nant characteristic  of  the  blood  picture  in  this  form 
leukemia,  is  the  presence  of  large  numbers  of 
myelocytes,  or  large  mononuclear  leukocytes  con- 
taining neutrophilic  granulations.  These  cells  are 
never  found  in  the  circulating  blood  in  health,  and 


although  occasionally  seen  in  other  diseases,  for 
example,  diphtheria,  pneumonia,  severe  anemias, 
lympho-sarcoma  and  various  children's  diseases, 
still  in  none  of  these  is  their  number  to  be  com- 
pared with  the  numbers  found  in  even  the  least 
marked  cases  of  myelogenous  leukemia.  Mononu- 
clear eosinophiles  are  found  in  small  numbers.  Xor- 
mally,  these  varieties  of  white  cells  are  found  only 
in  the  bone  marrow,  and  the}-  are  regarded  as  the 
direct  antecedents  of  the  corresponding  polynuclear 
cells.  The  polynuclear  eosinophiles  alwaj-s  show 
an  absolute,  and  often  a  relative  increase. 
This  point  has,  however,  lost  much  of  its 
diagnostic  value,  since  the  discovery  of  an  eosino- 
phihc  leukocytosis.  The  appearance  of  atypical 
forms  of  all  the  varieties  of  leukocytes,  and  of  cells, 
which  are  difficult  to  classify  in  any  way,  is  highly 
characteristic  of  the  disease  under  discussion,  and 
gives  to  the  blood  picture  a  most  variegated  ap- 
pearance. Nucleated  red  cells — both  normoblasts 
and  megaloblasts — are  always  found  in  large  num- 
bers, but  no  such  preponderance  of  megaloblasts 
is  seen  as  that  which  characterizes  the  blood  of  per- 
nicious anemia.  Often  in  the  early  stages  no 
anemia  is  found,  and  later  in  the  disease  the  ane- 
mia is  usually  moderate  in  degree,  so  that  the  num- 
ber of  nucleated  red  cells  is  far  greater  than  in  ane- 
mia of  like  grade,  due  to  other  causes.  We  see, 
then,  that  the  blood  in  myelogenous  leukemia  pre- 
sents a  most  characteristic  picture,  differing  in 
almost  every  point  from  normal  blood. 

In  lymphatic  leukemia  the  picture  is  quite  differ- 
ent, but  hardly  less  distinctive.  Here  the  number  of 
leukocytes  is  ordinarily  much  less  than  in  the  myelo- 
genous form,  while  the  anemia  is  usualh^  far  more 
pronounced,  especialh-  in  the  acute  and  sub-acute 
cases.  The  typical  feature  is  the  great  absolute  and 
relative  increase  in  the  number  of  lymphocytes — 
mononuclear  leukocytes  with  non-granular  proto- 
plasm. Neutrophiles.  eosinophiles  and  myelocytes 
are  comparatively  rare.  The  nucleated  red  cells 
are  far  more  numerous  than  in  myelocj-themia. 
their  number  corresponding  fairly  well  to  the  de- 
gree of  anemia  present,  except  in  children,  in  whose 
blood  the  nucleated  reds  may  be  present  in  very 
considerable  numbers.  While  leukemia  ranks  as  a 
comparatively  rare  disease  in  this  country,  it  is  not 
unlikely  that  many  cases  are  overlooked.  During 
the  past  year  it  has  been  my  fortune  to  see  and  ex- 
amine three  cases  which  I  desire  here  to  report. 
Thse  cases  occurred  in  the  practices  of  Dr.  Eugene 
Wasdin,  Marine  Hospital  Surgeon ;  Dr.  Marcel 
Hartwig,  and  Dr.  Charles  R.  Borzilleri,  and  to  the 
courtesy  of  these  gentlemen  I  am  indebted  for  the 
opportunity  of  making  this  report : 

CASE  1. — C.  S..  aged  3f,  German,  single,  a  boat  steward. 
In  1SS2  he  lived  at  Santos,  Argentina,  for  6  months,  and 
from  there  shipped  for  Liverpool.  On  this  voyage  eleven  of 
the  crew  died  of  yellow  fever,  and  six  escaped  infection. 
Ill  1.SS6  he  was  in  Brunswick.  Georgia,  for  six  months, 
where  his  general  health  became  so  poor  that  he  was  un- 
able to  do  his  work.  He  finally  left  on  the  advice  of  a 
physician.  In  189.5  he  conducted  a  bakery  beside  the 
Chicago  drainage  canal,  which  was  then  in  process  of  con- 
struction. The  water  supply  was  contaminated  with 
drainage.  Diarrhea,  dysentery  and  malaria  were  common 
in  the  camp.  Here  he  suffered  from  severe  headaches, 
diarrhea  and  great  prostation  for  five  months.  He  then 
went  to  Duluth.  where  he  speedily  recovered  from  these 


-Meuhal  Jouhn 


•ima'] 

«AI.    J 


LEUKEMIA 


[  AlBIL  27.   1901 


symptoms.  In  the  spring  of  1896  he  first  noticed  a  swelling 
in  the  left  side.  The  tumor  was  diagnosed  as  splenic,  and 
within  six  months  attained  about  its  present  size.  He  has 
talcen  Fowler's  solution  for  the  past  three  years.  On  May 
4th,  1900,  he  entered  the  Marine  Ward  of  the  Buffalo  Hos- 
pital of  the  Sisters  of  Charity,  complaining  of  diarrhea. 
Marlied  tenderness  was  found  over  the  sternum  and  tibias, 
and  a  splenic  tumor  was  found,  the  limitations  of  which 
were  as  follows:  — 

From  the  navel  toward  the  right  5  inches. 

"          "       left  11  inches 

upward      "       "  7  '  ' 

downward  6  " 

A  hlood  examination  made  by  me  two  days  later  gave  the 
following  results:  — 

Hemoglobin 50%  von  Fleischl 

Leuliocytes 272.000  per  c.m.m. 

Erythrocytes 3,630,000  per  c.m.m. 

Ratio  of  white  to  red  cells,  1:13.3. 
Differential  count  of  leukocytes:  — 

Lymphocytes  (small) 08% 

Large  raonoculear  leukocytes  and  tran- 
sitional forms 2.5% 

Polymorphonuclear  neutrophiles 39.6% 

Eosinophiles 6.4% 

MastzeUen 1.3% 

Myelocytes 49.3% 

Eosinophilic  myelocytes.  ; 0.1% 

Nucleated  red  cells: — In  counting  1000  leukocytes  there 
were  seen  30  normoblasts  and  14  megaloblasts.  The 
nuclei  of  several  of  these  cells  showed  a  ten- 
dency to  subdivide  and  one  megaloblast  was  seen  in 
v.'ihch  the  nucleus  was  completely  divided  into  two 
equal  parts.  The  red  cells  showed  poikilocytosis  with  ma- 
crocytes  and  microcytes  and  a  few  showed  polychromato- 
philic  degeneration.  Atypical  forms  of  leucocytes  which 
are  difficult  to  classify  were  seen  in  large  numbers.  The 
entire  blood  picture  was  characteristic  of  a  high  grade  of 
myelogenous  leukemia.  The  urine  showed  no  abnormality 
except  a  moderate  increase  of  indican.  The  patient  was 
discharged  from  the  hospital  May  19th.  1900,  unimproved. 

CASE  2. — P.  I?.,  male,  age  13  months:  The  elder  of 
twins  and  from  I)irth  the  smaller  and  weaker.  The  family 
history  is  negative,  father,  mother  and  twin  brother  are 
living  and  in  good  health.  The  child  was  never  robust, 
but  his  illness  dated  only  from  March,  1900.  and  was  char- 
acterized by  severe  anemia,  feebleness,  occasional  diar- 
rhea and  malnutrition.  Beginning  in  April  there  was 
slight  irregular  fever.  In  May  a  tumor  was  first  observed 
in  the  left  side  of  the  abdomen.  There  was  at  no  time  any 
visible  or  palpalUe  enlargement  of  the  superficial  lymph 
nodes,  nor  were  there  any  hemorrhages  observed. 

I  saw  this  patient  .Tune  1st,  1900,  and  found  the  child 
moderately  emaciated,  with  enlarged  abdomen  and  with  a 
profound  pallor.  The  spleen  was  easily  palpable  and  ex- 
tended downward  to  the  level  of  the  umbilicus.  Its  edge 
was  parallel  to  the  free  border  of  the  left  ribs  and  from 
IV2  to  2  inches  from  it.  The  blood  examination  gave  the 
following  results:  — 

Hemoglobin 30%  von  Fleischl 

Leukocytes.  21.000  per  c.m.m. 
Erj'throcytes,  1.912.000  per  c.m.m. 
Ratio  of  whites  to  reds.  1:91. 
Differential  count  of  leukocytes:  — 
T.,ymphocytes.  large  and  small  87.0% 
Polvmorphonuclear          neutro- 
philes  ' 10.5% 

Eosinophiles ^. .   1.5% 

Myelocytes 1.0% 

In  counting  200  leukocytes  there  were  seen  8  normo- 
blasts and  S  megaloblasts.  The  blood  picture  is  striking 
through  the  great  predominance  of  lymphocytes,  showing 
all  gradations  from  small  to  very  large,  many  of  them 
staining  poorly  both  in  nucleus  and  protoplasm.  The 
large  forms  are  very  numerous,  but  the  presence  of  all 
Intermediate  sizes  renders  the  subdivision  into  two  groups 
impracticable.  The  great  diminution  in  the  percentage  of 
neutrophiles  is  very  striking.  The  red  cells  show  a 
marked  poikilocytosis.  Microcytes  and  macrocytes  are  nu- 
merous, as  well  as  all  manner  of  irregular  forms.  Poly- 
chromatophilic   degeneration   is  well   marked.     Diagnosis: 


subacute  lymphatic  leukemia.     This  patient  died  17  days 
later.    No  autopsy  was  held. 

CASE  3. — X.,  female,  age  7  months.  Family  history;  — 
Father  and  mother,  aged  respectively  39  and  30.  both  bom 
in  Italy,  are  living  and  in  good  health.  Of  twelve  uncles 
and  aunts  nine  are  alive  and  well.  The  causes  of  death  in 
the  other  three  unknown.  No  specific  history.  Oldest 
brother,  sound  and  well  until  five  months  old,  when  he 
developed  enlargement  of  the  abdomen,  great  anemia  and 
emaciation.  These  conditions  continued  until  the  eleventh 
month,  when  he  died.  Second  brother,  died  at  three 
months  of  bronchitis.  Third  brother,  developed  gangrene 
of  both  lower  extremities  at  the  eleventh  day.  which 
gradually  extended  upward  until  his  death  on  the  twenty- 
first  day.  Sister,  well  until  four  months  old.  when  she  de- 
veloped marked  anemia,  splenic  tumor  and  emaciation, 
and  died  at  the  eighth  month.  Fourth  brother,  except  for 
some  of  the  ordinary  infectious  diseases  of  children,  has 
always  been  well,  and  is  so  now  at  the  age  of  four  years. 
Case  number  three,  the  sixth  child  in  this  family  was 
apparently  well  until  four  months  old.  He  then  developed 
anemia,  which  became  profound,  enlargement  of  the 
spleen,  emaciation,  troublesome  diarrhea,  slight  irregular 
fever  and  great  debility.  There  was  noticeable  enlarge- 
ment of  the  syperficial  lymph-nodes  in  the  cer>-ical  and 
axillary  regions.  No  history  of  hemorrhages.  At  the  age 
of  seven  months.  .Tuly  16th.  1900.  I  examined  the  blood  of 
this  patient  with  the  following  results:  — 

Hemoglobin 20%  von  Fleischl 

Leukocytes,  33,000  per  c.m.m. 
Erythrocytes,  1,150,000  per  c.m.m. 
Ratio  of  white  to  red  cells,  1:35. 

Differential  count  of  leukocytes: 

Large  and  small  lymphocytes.  .  .  78.6% 
Polymorphonuclear   neutrophiles. 18. 2% 

Eosinophiles 1.8% 

Myelocytes 1'4% 

In  counting  500  leukocytes  14  nucleated  red  cells  were 
seen,  all  normoblasts,  and  one  of  them  showing  mitotic 
division  of  the  nucleus.  The  other  characteristics  of  the 
stained  specimen  were  essentially  similar  to  those  seen  in 
Case  2,  the  most  noticeable  difference  being  the  absence 
of  megaloblasts.  Diagnosis: — Subacate  lymphatic  leuke- 
mia. The  patient  died  about  one  month  after  this  examina- 
tion.    No  autopsy  was  held. 

In  ca?cs  2  and  3  it  will  be  noticed  that  the  abso- 
lute numbers  of  leucocytes  were  not  sufficiently  high 
to  exclude  a  leucocytosis  and  a  study  of  the  mor- 
pholog'y  of  the  white  cells  was  necessary  in  order 
to  arrive  at  a  diagnosis.  Case  number  3  is  further 
interesting,  because  it  seems  highly  probable  from 
the  history  that  a  brother  and  a  sister  of  this  child 
also  died  from  leukemia. 

In  conclusion,  a  few  words  as  to  the  diag- 
nosis of  cases  2  and  3.  It  may  be  urged 
that  these  should  be  regarded  as  examples  of 
the  anemia  infantum  pseudo-leukcmica  of  von 
Jaksch.  Without  entering  into  the  controversy  as 
to  whether  or  not  we  are  justified  in  regarding  the 
group  of  rather  widely  varying  cases  which  have 
been  classified  under  this  title  as  examples  of  a  dis- 
tinct disease,  I  would  say  that  I  am  inclined  to 
agree  with  von  Limbeck  (14),  Schmaltz  (18).  Ep- 
stein (19),  Raudnitz  (19).  Fischl  (19),  and  Cabot 
(12),  in  questioning  the  existence  of  anemia  infan- 
tum pseudoleukemica  as  a  definite  entity.  ■» 

Mv  two  cases,  moreover,  differ  from  von  Jaksch's 
description  of  this  disease  in  at  least  the  following 
points : — 

a.  Neither  the  number  of  red  cells  nor  the  amount 
of  hemoglobin  is  reduced  below  the  findings  in  well 
authenticated  cases  of  leukemia. 

b.  Extraordinarily  large  neutrophiles  arc  not 
found. 


Al'IUL  27.   l:iiil| 


EXPERIENCE  W^TH  ADRENALIN 


r-i'iiK 
L  Me: 


iiii..m)kli"hia 
Medical  Journai, 


519 


c.  No  white  cells  have  been  found  which  contain 
red  cells  or  portions  of  red  cells  within  their  proto- 
plasm. 

d.  The  great  majority  of  the  leukocytes  are  lym- 
phocytes and  not  polymorphonuclear  neutrophilcs. 

While  recognizing  the  frequency  of  splenic  tumor, 
of  an  increased  percentage  of  lymphocytes  and  of 
the  appearance  of  numerous  nucleated  red  blood 
cells  in  the  severe  anemias  of  infanc}',  and  while 
regretting  the  absence  of  autopsies  in  these  two 
cases,  still,  in  view  of  the  very  great  preponderance 
of  lymphocytes,  and  of  the  absence  of  all  evidence 
of  tuberculosis,  syphilis,  rachitis,  or  other  cause  of 
secondary  anemia,  I  feel  justified  in  classifying 
both  cases  as  instances  of  true  Ij'mphatic  leukemia. 

REFERENCES. 

1.  Froriep's  Notizen,   Nov.,  1845. 

2.  MediclnLsche   Zeitung  des  Vereins   f.   Heilkunde,     Aug.     and 
Sept.,  1S46. 

3.  Medicinische  Zeitung  des  Vereins  £.  Heilkunde,  Jan.,  1S47. 

4.  \'irchow's  Arcliiv.,  Bd.  1..  1847. 
■"».   I'MiiiImrg  Medical  Joiirtial.  Oct.,  1S4.J. 

t'l.  Cited  tVoiii  Osltrr,  Tcppcr's  System  of  Medicine.   Phila..  I8t<.j. 
7.  Vircliow's  Archiv.,   Bd.   III. 

5.  Cited   from   Schmaltz.     See  No.   IS. 

9.  S-\]ous's   Annual   and    Analytical   Cyclopaedia    of     Practical 
Medicine,  Vol.   IV.,  Phila.,  1900. 
10.  Wiener  Klinische  Wochenschrift,  1S9S,   No.   20.     Centralblatt 

fUL  r  liakteriolouie.  isiis.  XXIH.  p.  2III1- 
U.  Die  Anaemie.  I  Abth.     Nothnagel's  Specielle  Pathologie  und 
Therapie.     Bd.   Vlll..  Theil  I.,   Heft  J.,   Vienna,  1.S98. 

12.  Clinical   Examination  of  the  Blood.     N.   Y.,   1S9S. 

13.  American  Text  Book  of  Medicine.     Phila.,  1S94. 

14.  Grundriss  einer  Klinischen  Pathologie  des  Blutes,  Jena,  1896. 
l.i.  Leilladcn  zur  Klinischen  I'ntersuchung  des  Bliites.     Berlin.  1898. 

16.  Klinische   Diagnostik,  Vienna  and   Leipzig,   1896. 

17.  Cited  from  Ehrlich  and  Lazarus  (11). 

18.  Die   Pathologie   des   Blutes   und   die   Blutkrankheiten,    Leip- 

zig, 1S96. 
19.  Cited  from  von  Limbeck   (14). 


CLINICAL  EXPERIENCE  WITH  ADRENALIN.* 

By  EMIL  MAYER,  M,  D. 

of  New  York  City' 

Surgeon.     New     York     Eye     and     Ear     Infirmary,     Throat    Depart- 
ment;       Fellow,       American       I,aryngolotrical       -Association, 
of  the  New  York  Academy  of  Medicine,  Etc. 

The  aqueous  extract  of  the  suprarenal  glands  is. 
perhaps,  the  best  culture  medium  known.  Its  in- 
stability, the  involved  method  of  preparation,  its 
unsightliness,  and  finally  the  inexactitude  of  its  va- 
rious strengths,  all  tend  to  make  us  welcome  a 
preparation  which  shall  be  exact,  stable,  and,  above 
all,  clean. 

Chemists  of  repute  have  been  laboring  unceas- 
ingly in  the  attempt  to  isolate  the  active  principle, 
and  in  1897  Prof.  J.  J.  Abel,  of  Johns  Hopkins  Uni- 
versity, announced  that  he  had  succeeded  in  isolat- 
ing the  blood-pressure-raising  constituent  of  the 
suprarenal  gland,  which  he  named  Epinephrin. 
Some  time  after  Dr.  Otto  von  Furth  of-Strasburg, 
declared,  in  the  Zcitschrift  fur  Physiologische  Chcmic 
(Vol.  XXIX.  p.  T06),  February.  1000),  that  Epin- 
ephrin was  merely  impurities  mixed  with  the  active 
principle,  and  claimed  that  lie  had  isolated  the  real 
active  principle,  which  he  named  Suprarenin. 

In  a  recent  communication  {American  Journal  of 
Physiology,  March,  1901),  Prof.  Abel  says  that  Su- 
prarenin is  only  a  modification  of  Epinephrin. 


•Read    before    the    Section   of   Larynology   of   the   New    York 
Academy    of    Medicine,    March  27th,    1901. 


Believing  that  neither  Prof.  Abel,  nor  Dr.  Furth 
had  obtained  the  active  principle  in  pure  isolated 
form.  Dr.  Jokichi  Takamine,  now  of  New  York  city, 
recently  undertook  the  task  of  isolating  the  active 
principle  of  the  suprarenal  gland,  and  stated  that  he 
had  been  successful  in  isolating  the  blood-pressure- 
raising  principle  of  the  gland  in  a  stable  and  pure 
crystalline  form.  His  methods  were  entirely  dififer- 
ent  from  those  of  either  Abel  or  Furth,  and  not 
wishing  to  usurp  the  credit  due  to  previous  investi- 
gators, he  named  his  product  Adrenalin. 

The  following  is  a  description  of  Adrenalin  and  its 
ph3^siological  eiTect :  "Adrenalin  is  a  light,  white, 
micro-crystalline  substance,  showing  itself  thus  far 
in  five  difTerent  forms  of  crystals,  according  to  the 
different  condition  of  solutions  from  which  they 
have  been  made.  In  fact,  a  given  quantity  can  be 
transformed  from  one  shape  of  crystal  to  another 
by  a  different  method  of  crystallization.  The  five 
different  ones  are:  (i)  wart,  or  tomato-like;  (2) 
boat,  or  leaf-shaped ;  (3)  rhombic  plates  and  their 
agglomerations;  (4)  fine  needles;  (5)  prism-shaped. 
Adrenalin  has  a  slightly  bitterish  taste,  leaving  a 
numbed  feeling  on  the  spot  of  the  tongue  where 
it  has  been  applied.  When  dry  it  is  perfectly  sta- 
ble. On  heating  it  turns  brown  at  205°  C,  and 
melts,  decomposes  and  swells  simultaneously  at 
207°  C.  Adrenalin  shows  slightly  alkaline  reaction 
on  moistened  litmus  paper.  Phenol-phthalein  also 
indicates  slight  alkalinity.  It  is  soluble  in  cold  water 
with  difficulty,  and  more  readily  in  hot  water.  The 
hot  saturated  aqueous  solution  separates  the  crys- 
tal after  cooling.  The  colorless  aqueous  solution  of 
Adrenalin  is  easily  oxidized  by  air,  changing  its 
color  from  pink  to  red  and  eventually  to  brown. 
It  is  easily  soluble  in  acids  or  alkalies,  but  not  in 
ammonia  or  alkaline  carbonates. 

"Three  kinds  of  salts,  Hydrochloride,  Sulphates, 
and  Benzoates  were  made,  by  carefully  dissolving 
Adrenalin  with  three  different  acids  and  evaporating 
in  vacuo  over  strong  sulphuric  acid.  In  course  of 
time  thev  became  abrown  brittle  amorphous  mass, 
deliquescent  in  the  air.  So  far  efforts  to  crystallize 
them  have  failed.  Experiments  were  made  and 
showed  that  the  physiological  activity  of  Adrenalin 
was  astoundingly  s'trong.  A  fraction  of  one  drop 
of  aqueous  solution  of  Adrenalin  or  its  salt,  in  the 
strength  of  i  to  10,000,  blanches  the  normal  con- 
junctiva within  30  to  60  seconds.  It  is  a  powerful 
astringent. 

"Intravenous  injection  produces  a  powerful 
action  upon  the  muscular  system  in  general,  but 
especially  upon  the  muscular  walls  of  the  blood  ves- 
sels and  of  the  heart,  resulting  in  enormous  rise  of 
blood-pressure. 

"A  comparative  test  of  the  strength  of  Adrenalin 
with  the  fresh  extract  of  suprarenal  gland,  icc.  of 
which  represents  i  gramme  of  fresh  gland,  was  car- 
ried out  on  a  dog  weighing  7  kilos.  .A-drenalin  so- 
lution corresponding  to  0.000008  gm.,  was  intra- 
venously injected,  and  the  rise  of  blood-pressure 
was  14  mm.  of  mercury.  In  order  to  have  an  equal 
amount  of  rise  in  blood-pressure,  0.005  gm.  of  the 
suprarenal  extract  was  necessary. 

"These  data     show  that  .\drenalin  is  625     times 


820 


The   I'Hii.ADEi.rHiA 
MEnicAT,  Journal 


] 


EXPERIENCE  WITH  ADRENALIN 


/.'.  BIL  27,  1901 


stronger  than  suprarenal  extract.  The  sample  of 
Adrenalin  used  for  this  experiment  contained  some 
mineral  impurities,  and  pure  Adrenalin  will  be  over 
looo  times  stronger  than  the  fresh  gland. 

"Approximately  1-200,000  gramme  of  Adrenalin 
intravenously  injected  into  an  adult  man  is  suffi- 
cient to  produce  some  distinct  effect." 

A  small  quantity  of  the  solution  of  Adrenalin 
chloride,  i  to  5,000  in  normal  salt  solution,  was 
placed  in  my  hands  in  December,  1900,  through  the 
courtesy  of  Dr.  W.  H.  Bates.  The  liquid  was  col- 
orless, odorless  and  slightly  salt  to  the  taste.  By 
an  accident  the  fluid  w^as  lost,  but  early  in  the  pres- 
ent year  several  bottles  of  varied  strengtlis  of  this 
solution,  I  to  1,000,  I  to  5,000,  and  i  to  10,000,  to- 
gether with  a  bottle  of  the  crystals  of  Adrenalin, 
were  placed  in  my  hands  for  experimentation, 
through  the  courtesy  of  Dr.  Takamine.  The  cases 
in  which  these  were  applied  were  all  rhinological, 
and  it  is  to  their  effect  in  these  conditions  only  that 
my  remarks  apply.  The  blanching  of  tissues  fol- 
lowing the  application  of  the  strongest  of  these  so- 
lutions was  accompanied  wathin  a  few  seconds  and 
was  very  thorough.  It  was  less  extensive  and  a 
trifle  slower  as  the  weaker  solution  was  applied.  In 
no  instance  was  there  any  constitutional  disturb- 
ance following  its  use.  Since  these  investigations 
began  no  suprarenal  extract  has  been  employed 
by  me  for  any  purpose  whatever.  The  solutions 
were  in  colored  glass  bottles,  with  glass  stoppers. 
and  slowly  changed  in  color,  becoming  pink,  brown 
and  finally  muddy,  and  floccules,  such  as  are  noticed 
in  cocain  and  morpliia  solutions,  appeared.  The 
effect  of  the  remedy  was  not  altered  by  these 
changes,  and  the  same  bottles  and  their  contents 
were  constantly  employed  for  six  weeks.  Subse- 
quently a  small  amount  of  chloretone  was  added  to 
the  fresh  solutions,  and  now  there  is  but  slight 
change  of  color  and  no  floccules  appear.  The  spec- 
imen of  this  latter  solution  here  presented  has  been 
in  daily  use  for  a  month  from  the  same  bottle,  and 
it  will  be  seen  to  be  clear  and  slightly  yellow  in 
color.  Tablets  of  Adrenalin  tartrate  have  been 
made  which  are  readily  soluble  in  water,;  one  dis- 
solved in  16  grammes  of  water  makes  a  solution  of 
I  to  T,ooo.  These  tablets  are  so  prepared  that  their 
solution  remains  unchanged  when  dissolved.  Still 
smaller  tablets  are  to  be  had,  and  one  of  these  lat- 
ter, when  dissolved  in  enough  water  to  fill  the  ordi- 
nary atomizer  bottle,  will  be  all  sufficient  for  the 
patient's  use.  It  is  needless  to  say  that  this  form 
of  the  tablet  will  be  most  convenient.  The  thirty- 
five  cases  in  which  this  active  principle  was  applied 
are  taken  from  my  case  book  from  among  my  pri- 
vate patients,  and  from  notes  made  at  my  clinic. 
They  are  here  briefly  tabulated:  The  tables  pre- 
sented show  at  a  glance  that  the  usual  effect  of 
the  aqueous  extract  of  the  suprarenal  gland  was 
obtained.  A  few  operative  cases  bled  freely,  a  fact 
that  occurs  occasionally  with  the  e.xtract  itself,  but 
in  every  instance  the  hemorrhage  was  promptly 
checked  by  a  second  application  of  Adrenalin.  Fol- 
lowing my  previous  experience  with  the  suprare- 


nals,in  which  subsequent  hemorrhage  occasionally 
occurred,  every  case  operated  upon,  except  two, 
were  packed  after  operation  with  iodoform  gauze 
and  the  dressing  left  in  situ  for  24  hours.  No  hem- 
orrhage occurred  in  these  cases.  In  the  two  cases 
the  patients'  noses  were  not  packed,  but  they  were 
placed  in  bed  and  kept  quiet,  for  two  days  and 
Adrenalin  i  to  10,000  was  applied  by  means  of  spray 
every  two  hours.  There  was  no  subsequent  hemor- 
rhage in  either  of  these  cases. 

It  is  worthy  of  note  that  following  the  use  of 
suprarenal  extract  and  also  of  Adrenalin,  a  slough 
occasionally  forms  just  as  occurs  in  cautery  oper- 
ations on  the  mucous  membranes.  This  has  oc- 
curred in  quite  a  number  of  cases,  both  post-opera- 
tive and  in  merely  inflammatory  states,  and  proba- 
bly tends  to  protract  the  subsequent  healing.  This 
effect  may  be  useful  to  us  in  some  of  our  operative 
work  on  the  nasal  mucosa.* 

It  will  be  seen  that  not  only  was  the  Adrenalin 
used  as  a  hemostatic,  but  for  the  relief  of  nasal  con- 
gestion, as  a  diagnostic  aid,  and  for  the  continuous 
treatment  of  acute  inflammatory'  affections  of  the 
accessory  sinuses.  It  was  of  this  latter  effect  of  the 
suprarenals  that  I  wrote  to  Bates  some  months  ago, 
that  if  that  remedy  had  no  other  uses,  its  value  in 
giving  prompt  relief  in  acute  vaso-motor  rhinitis 
was  so  enormous  as  to  place  it  in  the  front  rank 
in  nasal  therapeutics. 

The  following  conclusions  seem  justifiable  as  a 
result  of  personal  experience  with  the  active  prin- 
cipel  of  the  suprarenal  gland  in  these  cases: — 

1.  Adrenalin  solutions  supply  every  indication  in 
rhinological  practice  for  which  the  aqueous  solu- 
tions of  the  extract  have  been  hitherto  applied. 

2.  The}-  can  be  used  in  sterile  form. 

3.  They  remain  unchanged  for  a  long  time. 

4.  .\  solution  of  I  to  1,000  is  very  strong  and  is 
all  sufficient  for  operative  cases,  and  i  to  5.000 
or  I  to  10,000  for  every  purpose  of  local  medication. 

5.  They  may  be  safely  applied  to  persons  of  every 
age  and  of  either  sex. 

My  own  experience  ha\ing  been  so  highly  satis- 
factory with  Adrenalin,  makes  me  feel  justified  in 
saying  that  in  the  isolation  of  the  blood-pressure- 
raising  principle  of  the  suprarenal  glands  we  are 
confronting  an  epoch-making  discovery.  The  dis- 
covery of  the  active  principles  of  other  animal 
substances  w^ill  be  sure  to  follow  in  the  near  future 
and  organo-therapy  will  not  only  derive  a  new  im- 
petus, but  exactitude  in  the  administration  of  these 
remedies  will  be  sure  to  follow. 

A\'e  will  no  longer  be  compelled  to  use  an  animal 
extract  of  potency  to-day,  and  an  utterly  inert  one 
at  another  occasion,  but  would  always  have  the 
same  remedy  of  known  strength  and  power.  Per- 
centages of  solutions  would  be  exact  in  even,-  in- 
stance, and  in  appropriate  cases  their  administra- 
tion by  hypodermic  methods  could  safely  be  em- 
ployed with  absolutely  sterile  solutions. 


Apbil  27.  1001) 


APPENDICITIS 


The    I'HILABELPHIA 
M'DI     <l.    .7"TI1NAI. 


321 


TABULAR    CONSPECTUS   OF   THE  APPLI- 
CATION OF  ADRENALIN. 


v  .• 

Solution 

M'Sex 

CONDITION. 

RESULT. 

■^i 

1  part  in 

1 

48'  F 

5000 

Evulsion    of   nasal   polj'pi,   cold 
snare      

Bloodless 

2 

21    M 

•5000 

Breaking  nasal  synechiae.  blunt 
separator     

Bloodless 

3 

31  i  M 

5000 

Nasal  congestion  causing  constant 

Relief  prompt  and 

cough    

lasting 

4 

24 

M 

1000 

Enchondrosis     septum,     electro- 
trephine  

Bled  freely 

5 

26 

F 

10,000 

Nasal  congestion,   spray   for  pa- 

tients use 

Great  relief 

6 

311  M 

10,000 

Nasal  congestion,  spray  for  pa- 

.54:  M 

10,000 

tients  use     .  . 

7 

Nasal  congestion,  spray  for  pa. 

1 
14    F 

1000 

tients  use 

8 

Polypoid  degeneration  and  hvper- 

trophied    middle    turbinate 

uncapped  and  snared    .   .    . 

Bloodless 

9 

24 

M 

1000 

Polypoid  degeneration  and  hyper- 
trophicd    middle    turbinate 
uncapped  and  snared    .   .    . 

Bloodless 

10 

26 

F 

1000 

Enchondrosis     septum.      electro 

Complete  subsi- 
dence   of    symp- 
toms   and  even- 

tual recovery 

11 

.32    F 

10,000 

Acute  rhinitis,  acute  infection  of  Complete  subsi- 

maxillarv  antra,  spray  used 

dence    of    symp- 

by patient  every  two  hours 

toms  and    even- 
tual recovery 

12 

4.i|  M 

10,000 

Acute  rhinitis;  used  by  patient 

Relief 

13 

28 

M 

3000 

Discomfort      and    tension     after 
Asch  operation     

Immediate  Relief 

14 

.52!  M 

5000 

Epistaxis  (ulcer  septum)     .... 

Immediate  Relief 

1.3 

.50    F 

1000 

Removed     degenerated      middle 

turbinate     Bloodless 

IB 

28j   M 

10,000 

Subsequent  to  operation  enchon- 
drosis septum 

Used  at  home  with 
comfort 

17 

7     M 

10,000 

Acute  rhinitis 

Relief 

18 

10     F 

10,000 

Acute  rhinitis 

Relief 

*1<I 

.3.5    M 

Tablet 

Enchondrosis  septum,  trephine  . 

Bloodless 

*20 

IS    F 

Tablet 

Enchondrosis  septum,  trephine  . 

Bloodless 

21 

28    M 

10,000 

Nasal  polypi 

Bloodless 

22 

22!   M 

10,000 

Enchondrosis  septum,  trephine  . 

Slight  bleeding 

23 

23 

M 

10,000 

Excision  middle  turbinate,   Hol- 
mes' scissors  

1,5000  Stopped 

hemorrhage 

24 

18 

M 

.5000 

Enchodrosis  septum,    trephine  , 

Bloodless 

2.1 

22 

F 

5000 

Hemorrhage    after   packing   ex- 
cision middle  turbinate    .   . 

Slight  bleeding 
checked  bv  1-5000 

2B 

2:5    M 

10.000 

Snaring  lower  turbinate 

Slight  bleeding 
checked  by  1-5000 

27 

30    M 

10,000 

-Ifter  operation  middle  turbinate, 

spray  two  days 

No  bleeding 

2S 

35 

F 

10,000 

Excision  middle  turbinate    .   . 

Bloodless 

29 

19 

F 

10,000 

Cystic  degeneration  inferior  tur- 
binate, snare . 

Brisk  hemorrhage 
ceased  after  pack- 
ing 1-5000 

30 

18 

F 

5000 

Excision  middle  turbinate    .   .   . 

Bloodless 

31 

62 

F 

1000 

Angioma  septum,  cold  snare     ,   . 

Bled    freely,     but 
checked  at  once 
bv  MOOO 

32 

14 

F 

.5000 

Exostosis  septum  removal  .... 

Bled     freely,      but 
checked  at  once 
by  1-1000. 

3S 

24    M 

1000 

Deviated  septum.  .\sch  operation 
under  Cocain 

Bloodless 

3* 

25    F 

1000 

Excision  middle  turbinate    .   .    . 

Nearly    bloodless, 
slight       bleeding 
checked  by  1-10000 

So 

4.5 

M 

.5000 

Enchondrosis  septum 

Sli.ght 

♦Note. — No.  Ill  and  No.  20  were  treated  with  a  soUition  of  the  tablet  of 
Adrenalin  Tartrate.     1  in  ^  oz.  of  water  makes  a  solution  of  1—1000. 


OBSERVATIONS  AND  TABULATED  REPORT  OF  THE 
RESULT  OF  ONE  HUNDRED  AND  FIFTY  OPERA- 
TIONS FOR  APPENDICITIS.* 

BY  LEON  BRINKMAN,  M.  D. 

of  Philadelphi.1. 

My  object  in  presenting  a  paper  on  a  subject 
which  has  received  such  an  exhaustive  discussion, 
as  has  appendicitis,  is  to  present  the  results  ob- 

♦Read  before  the  Philadelphia  County  Medical  Society.  March  13,  liKll. 


lained  in  a  few  anomalous  cases  and  to  state  the 
conclusions  which  the  balance  have  forced  upon 
me.  I  know  of  no  other  class  of  surgical  work 
which  calls  for  as  much  acumen  to  arrive  at  a  dif- 
ferential diagnosis  as  is  required  in  obscure  cases  in 
appendiceal  surgery.  The  initial  symptoms  in  an 
acute  attack  of  appendicitis,  under  ordinary  circum- 
stances, are  so  plain,  and,  in  a  few  instances,  so  easi- 
ly recognized,  that  I  can  scarcely  conceive  how  the 
disease  is  permitted  to  advance  in  so  many  patients 
to  the  point  where  the  pus  forms,  or  wh}'  their  lives 
should  be  jeopardized  by  waiting  for  something  to 
turn  up.  The  cases  upon  which  my  observation.'* 
are  based  have  not  been  selected,  but  have  been 
taken  as  they  come,  good  and  bad,  acute  and  chron- 
ic, and  will  therefore  present  the  average  good  and 
bad  cases  in  each  variety.  The  mortality  is  lov/. 
but  I  do  not  dare  hope  ever  again  to  attain  such 
good  fortune.  The  more  cases  one  sees  of  this 
dangerous  afifection,  the  more  difficult  they  become 
from  an  operative  point  of  view,  because  we  meet 
with  more  neglected  cases  and  our  mortality  must 
therefore  of  necessity  be  greater. 

The  ordinary  symptoms  of  appendicitis  I  shall 
dismiss  with  but  mere  mention.  The  acute  onset 
of  the  disease  associated  with  nausea  or  vomiting, 
the  colicky  pain,  the  tenderness  and  rigidity  are 
characteristic  of  acute  inflammator}-  disease  of  the 
appendix.  These  symptoms  may  not  all  be  present 
in  the  early  hours  of  the  attack.  The  acute  onset 
of  any  abdominal  pain  should  always  make  the 
physician  suspicious  of  appendicitis  and  under  the 
circumstances  invites  an  examination  of  the  abdo- 
men to  ascertain  the  cause  of  the  pain.  If  this  were 
done  systematically  there  would  not  be  so  many 
neglected  cases  of  appendicitis.  Unfortunately,  only 
too  often,  a  hypodermic  injection  of  morphine 
is  administered  which  tends  to  obscure  the  symp- 
toms. Upon  inspection,  the  abdomen  of  a  patient 
suffering  from  an  acute  attack  of  appendicitis,  will 
show  voluntary  restricted  movement  and  that  they 
favor  the  aflfected  side.  Upon  palpating  the  abdo- 
men lightly,  a  distinct  sense  of  resistance  is  no- 
ticeable, which  is  lost,  however,  if  the  pressure 
exerted  is  too  great.  As  the  region  of  the  inflamed 
appendix  is  approached,  the  amount  of  tenderness, 
pain,  and  rigidity  is  found  to  increase. 

The  location  of  the  pain,  tenderness  and  rigidity 
depends  upon  the  site  which  the  appendix  occupies. 
If  the  appendix  is  retro-cecal  the  symptoms  will  be 
confined  to  the  right  iliac  fossa;  if  the  appendix 
points  toward  the  median  line,  the  maximum  focus 
of  the  SAinptoms  will  be  shown  there ;  while,  if  the 
appendix  points  into  the  pelvis,  and  the  tip  alone 
is  involved,  the  symptoms  will  be  confined  almost 
entirely  to  the  left  side  of  the  abdomen.  If  the  body 
of  the  organ  is  included  in  the  inflammatory  pro- 
cess there  may  also  be  right-sided  symptoms.  Irt 
certain  cases  of  appendicitis  the  onset  of  the  attack 
is  associated  with  pain  which  has  been  mistaken  for 
kidney  colic.  This  pain  should  not  be  mistaken  for 
a  renal  affection,  for  it  is  an  inflammatory  pain  and 
is  not  associated  with  an}'  urinary  disturbance. 

The  symptoms  of  appendicitis  after  pus  forma- 
tion arc  more  readily  reco,gnized.  The  symptoms. 
of  the  onset  of  the  disease  are  still  in  evidence,  viz.. 
pain,  tenderness,  and  rigidity.  The  pain  in  the  later 
stage  of  the  disease  is  continuous,  while  the  paiiT 


822 


The   rniLAi>Ki.rniA 
Medical  Jocrnm 


hia"] 

AI.   J 


APPENDICITIS 


[  APBU.  27.  I'.nil 


of  onset  is  paroxysmal.  The  tenderness  is  more 
marked  after  pus  is  present  and  becomes  aggra- 
vated as  the  collection  increases  in  size  and  amount. 
The  rigidity  gradually  increases  as  the  disease  ad- 
vances until  the  abdominal  wall  becomes  stiff  and 
board-like  to  the  touch.  If  the  appendix  is  located 
.n  the  pelvis  and  a  purulent  collection  is  formed, 
then  the  left-sided  .symptoms  are  more  marked  and 
the  vesical  symptoms  are  aggravated.  When  the 
bladder  is  full  or  partially  filled,  the  discomfort  is 
not  so  distressing,  but  during  micturition  and  after 
the  bladder  has  been  emptied,  the  contraction  of  the 
bladder  makes  traction  upon  the  adhesions,  thus  in- 
creasing the  pain.  The  purulent  stage  of  appendi- 
citis is  most  frequently  associated  with  a  mass. 
The  location  of  the  mass  is  variable  and  is  depend- 
ent upon  the  position  of  the  appendix ;  it  may  be 
found  behind  the  cecum,  in  front  of  the  bladder, 
on  the  left  side  of  the  abdomen  (iliac  fossa),  toward 
the  median  line  behind  the  mesentery,  and  even 
extending  down  upon  the  thigh.  Although  fecal 
impaction  has  been  considered  as  one  of  the  causes 
of  the  mass  in  appendiceal  disease,  I  have  never 
found  this  to  be  the  case. 

The  temperature  or  pulse-rate  are  valueless  as 
indications,  in  appendicitis,  of  how  far  the  disease 
has  advanced  or  what  may  be  the  condition  within 
the  abdominal  cavity.  I  have  seen  on  more  than 
one  occasion  a  patient  with  a  large  purulent  collec- 
tion, whose  temperature  and  pulse-rate  were  nor- 
mal ;  while,  in  other  instances,  there  was  every 
indication  of  the  presence  of  pus  with  high  tempera- 
ture and  rapid  pulse  and  yet  operation  revealed  only 
a  moderate  invasion,  microscopically,  involving  the 
mucus  and  submucus  coats  of  the  appendix  alone. 
In  one  instance  I  saw  a  child  which  had  an 
almost  typical  typhoid  temperature  where  operation 
revealed  numerous  small  abscesses  in  the  tip  of  the 
appendix. 

The  diagnosis  I  have  found  easy  to  make  with 
but  few  exceptions.  The  cases  in  which  there 
was  any  doubt  occurred  entirely  with  the  female 
^ex  and  were  associated  with  some  disease  of  the 
adnexa.  In  one  case  there  had  been  a  previous 
history  of  dysmenorrhea;  there  was  no  apparent 
disease  of  the  tubes  or  ovaries  on  vaginal  examina- 
tion ;  still,  a  mass  .was  noted  in  the  right  broad 
ligament,  which  was  tender  to  the  touch  and  im- 
parted to  the  patient  the  same  sort  of  pain  which 
was  elicited  on  palpating  the  abdomen  ;  she  had  the 
classic  symptoms  of  the  onset  of  an  acute  attack  of 
appendicitis.  Operation  revealed  a  purulent  col- 
lection in  the  pelvis,  a  perforated  appendix  which 
was  adherent  to  the  right  broad  ligament,  tube  and 
ovary.  There  was  some  question  as  to  the  propriety 
of  leaving  the  tube  and  ovary  on  the  affected  side 
owing  to  involvement  in  the  abscess  wall  and  to  the 
fact  that  they  had  been  included  in  the  inflamma- 
tory process.  They  were  not  removed  and  at  the 
present  time  are  in  normal  condition.  The  patient 
at  this  time  is  free  from  her  dysmcnorrhoea. 

In  another  instance  the  case  was  complicated  by  an 
extra-uterine  fetation  on  the  right  Fallopian  tube. 
The  patient  suspected  pregnancy  and  had  been  ex- 
amined by  me  some  weeks  previous  to  the  attack  of 
appendicitis,  her  pelvis  was  found  to  be  clear.  Four 
weeks  later  she  was  suddenly  attacked  with  an 
acute  abdominal  pain  with  all  the  symptoms  of  an 


acute  attack  of  appendicitis.  Owing  to  the  previous 
question  of  pregnancy,  a  vaginal  examination  was 
made,  when  a  mass  was  revealed  which  I  made  out 
to  be  an  extra-uterine  pregnancy.  Operation  re- 
vealed an  acute  appendicitis  with  the  appendix 
attached  to  the  right  broad  ligament,  and  an  unrup- 
tured extra-uterine  pregnancy  of  the  right  Fallopian 
tube.  With  all  the  symptoms  present,  the  diagnosis 
should  be  easy.  The  initial  symptoms  of  pain,  ten- 
derness and  rigidity,  Avith  nausea  or  vomiting  make 
the  diagnosis. 

A  differential  diagnosis  must  be  made  between 
appendicitis  and  intra-abdominal  lesions  other 
than  appendicitis  do  we  have  the  precise  sequence 
of  symptoms  that  are  almost  always  present  in 
acute  disease  of  the  appendix.  The  acute  intestinal 
disturbances,  such  as  enteralgia  and  indigestion, 
like  appendicitis,  have  an  acute  onset,  but  differ 
from  it  in  that  thej-  do  not  have  the  localized  ten- 
derness and  rigidity.  The  pain  in  appendicitis  is 
aggravated  by  pressure,  while  in  enteralgia  it  is 
somewhat  relieved.  In  appendicitis  the  pain  does 
not  remain  at  the  point  of  the  abdomen  in  which  it 
maks  its  appearance,  but  becomes  localized  later 
at  the  focal  point  of  the  appendiceal  inflammation, 
while  in  acute  indigestion  and  in  enteralgia  the  pain 
remains  localized  about  the  umbilicus. 

The  differential  diagnosis  between  typhoid  fever 
and  appendicitis  should  not  be  a  difficult  one  to 
make  on  account  of  the  prodromal  symptoms  on  the 
one  hand  and  the  acute  onset  on  the  other.  If  the 
patient,  the  subject  of  an  attack  of  appendicitis,  is 
seen  late  after  pus  has  formed,  and  there  is  a  hectic 
temperature,  then  it  might  present  some  features  in 
common  with  typhoid  fever.  A  careful  examination 
of  the  abdomen,  and  a  review  of  the  history  of  the 
onset  will  clearly  demonstrate  which  affection  the 
patient  is  afflicted  with.  In  appendicitis  there  is  a 
history  of  sudden  onset,  with  pain,  tenderness, 
nausea  or  vomiting  and  paroxysmal  localized  pain : 
while  in  typhoid  fever  the  history  will  show  that  the 
patient  has  suffered  from  backache,  headache,  epis- 
taxis.  lassitude,  and  the  classical  temperature  record 
with  diffused  abdominal  pain. 

From  acute  intestinal  obstruction  appendicitis 
can  be  readily  diagnosed  from  the  indiffer- 
ence of  onset.  The  symptoms  in  acute  intesti- 
nal obstruction  are  ushered  in  with  more  acute- 
ness.  the  pain  is  not  paroxysmal  as  it  is  in  appendi- 
citis, but  remittent ;  the  pain  is  always  referred 
to  the  neighborhood  of  the  obstruction,  and  this  is 
most  commonly  found  in  the  region  of  sig 
moid  flexure  of  the  colon,  unless  it  is  an  obstruc- 
tion from  a  band,  or  diverticulum,  when  it  will  be 
found  in  the  lower  part  of  the  abdomen.  There 
is  absolute  constipation  in  obstruction  while  in  ap 
pendicitis.  there  mav  be  either  diarrhea  or  consti- 
pation. There  is  usually  subnormal  temperature 
in  obstruction,  while  in  appendicitis  the  tempera- 
ture is  practically  unchanged.  In  intestinal  ob- 
struction there  is  discharged  from  the  bowel  both 
blood  and  mucus.  Shock  is  not  associated  with 
appendicitis  except  when  perforation  occurs  or  gen- 
eral peritonitis  sets  in,  while  shock  is  a  common 
symptom  of  obstruction. 

n"he  inflammatory  disease  which  is  most  diffi- 
cult at  times  to  differentiate  from  appendi- 
citis    is     acute     cholecystitis,     with     or     without 


Ariiii.  : 


APPExXDICITIS 


CT.ir     I'llIL.M'ELI'HIA  Sot 

MKI.1.  AL    .Ii.LRXAI.  "''O 


gallstones.  Both  appendicitis  and  acute  cholecys- 
titis are  inflammatory  diseases,  and  are  both 
visually  confined  to  the  right  side  of  the  abdo- 
men :  they  have  symptoms  alike,  viz.,  pain,  tender- 
ness and  rigidity.  If  the  patient  is  seen  early  it  will 
he  noticed,  if  suffering  from  acute  inflammatory 
disease  of  the  gall-bladder,  and  if  free  from  ad- 
liesions,  that  the  distended  gall-bladder  will  move 
with  respiration ;  again,  that  the  gall-bladder  occu- 
pies a  higher  position  in  the  abdomen  and  that  a 
line  drawn  from  the  tip  of  the  ninth  rib  to  the  um- 
bilicus and  divided  at  its  center  will  approximately 
indicate  the  position  of  the  normal  gall-bladder: 
it  is  at  this  point,  or  thereabouts,  that  the  maximum 
amount  of  tenderness  and  pain  will  be  found  if  the 
'.rail-bladder  is  involved.  In  appendicitis  the  maxi- 
mum focus  of  the  symptoms  will  be  noted  at  or 
about  JMcBurney's  point.  I  had  the  opportunity 
i>f  examining  a  patient,  some  time  since,  who  had 
had  several  attacks  of  hepatic  colic ;  quite  recently 
he  had  an  acute  attack  of  apendicitis.  Examination 
demonstrated  a  tender  spot  over  the  appendix  and 
another  over  the  gall  bladder.  Operation  revealed 
an  enlarged  and  cystic  appendix:  the  gall  bladder 
was  found  considerably  distended  and  contained 
twenty  stones. 

The  prognosis  in  appendicitis  is  good,  except  as 
I  have  before  stated,  when  operation  has  been  de- 
layed. In  cases  of  appendicitis  which  have  been 
permitted  to  advance  to  the  suppurating  stage,  op 
eration  is  always  attended  by  more  imcertainty,  not 
only  on  account  of  the  condition  v.'hen  seen,  but 
as  much  in  consideration  of  the  remote  effect  of  the 
disease  plus  the  effects  of  operation.  These  may  be 
summed  up  as  the  sequelae,  viz.,  liability  to  acute 
intestinal  obstruction  whether  due  to  adhesions:  to 
contraction  of  the  abscess  wall  and  kinking  of  any 
loops  of  bowel  included  in  the  abscess  wall :  or  from 
a  paretic  state  of  the  bowel  from  sepsis  or  from 
liistension:  or  a  deposit  of  lymph  which  will  inter- 
fere with  the  peristalsis  of  the  bowel. 

The  cases  operated  upon  for  chronic  diseases 
all  made  a  good  recovery.  Of  the  acute  cases  oper- 
ated upon  four  died,  giving  a  mortality  in  all  the 
cases  of  two  and  two-third  per  cent. 

The  cases  that  died  I  will  relate  in  brief: 
CASE  1. — E.  was  aged  twenty-four  years,  he  had  had  five 
attacks.  The  diagnosis  was  made  thirty-sis  hours  after  the 
onset.  The  appendix  was  gangrenous  and  greatly  distended 
with  pus.  This  patient  did  badly  from  the  time  of  operation 
until  his  death.  The  vomiting  persisted  and  the  patient 
presented  all  the  evidence  of  peritonitis.  The  bowels  were 
very  hard  to  move,  although  the  patient  passed  flatus 
occasionally.  The  abdomen  was  distended.  Autopsy  re- 
vevealed  an  ileus,  which  had  its  origin  in  the  small  bowel 
at  a  point  corresponding  to  a  small  deposit  of  lymph  which 
was  located  in  the  mesentery.  The  peritoneal  cavity  con- 
tained clear  fluid.  At  the  time  of  the  operation  a  drop  of 
pus  escaped  from  the  appendix  as  it  was  removed  and 
dropped  on  the  abdominal  wall:  this  spot  subsequently 
broke  down  and  left  a  sharply  defined  ulcer  showing  the 
intensely  infectious  nature  of  the  contents  of  this  appen- 
dix. 

CASE  2. — R.,  aged  nineteen  years,  had  three  attacks  of 
appendicitis.  The  diagnosis  was  made  forty-eight  hours 
Jitter  the  onset.  The  operation  took  place  seventy-two 
hours  after  the  onset.  A  large  abscess  was  found  extra- 
peritoneally.  a  second  abscess  existed  within  the  periton- 
>  um  and  was  not  entirely  walled  off:  the  appendix  was 
gangrenous  as  well  as  the  omentum.  The  appendix  and 
gangrenous  omentum  were  removed.  The  wound  was 
packed,  no  attempt  being  made  to  clean  the  abdomen.  The 
patient  died  twenty-four  hours  later  from  sepsis. 


CASE  3. — B.  was  aged  twenty-four  years.  This  was  her 
first  attack.  The  diagnosis  was  made  thirty-eight  hours 
after  the  onset.  The  operation  occurred  twelve  hours  later. 
.\  small  abscess  was  found,  the  appendix  was  adherent  to 
the  iliac  vessels.  The  appendix  was  removed.  Drainage  was 
employed.  Death  occurred  twelve  hours  after  operation 
and  was  due  to  heart  failure  induced  by  suddenly  arising 
from  the  recumbent  position  during  the  absence  of  the 
care-taker. 

CASE  4. — Miss  M.,  aged  twenty-two,  had  one  attack. 
She  was  sick  one  week  when  the  diagnosis  was  made.  She 
was  operated  upon  on  the  day  the  diagnosis  was  made. 
The  condition  of  the  abdomen  found  at  the  operation  was 
as  follows:  A  huge  abscess  extending  from  the  lower  bor- 
der of  the  ribs  to  the  iliac  crest,  and  bounded  Internaly 
by  the  median  line.  The  appendix  was  perforated.  The 
appendix  was  removed  and  the  abscess  cavity  drained.  Ten 
days  later  the  temperature  suddenly  shot  up  and  the  patient 
became  delirious.  The  abdomen  was  reopened  and  a  sec- 
ondary collection  evacuated.  The  patient  died  two  days 
later.  The  autopsy  revealed  a  pyelo-phlebitis  with  multiple 
absceses  of  the  liver. 

The  treatment  of  appendicitis  has  for  some  time 
past  been  considered  as  properly  within  the  pro- 
vince of  the  surgeon.  If  this  is  so  considered,  then 
it  must  be  proper  and  fit  for  the  surgeon  to  select 
such  means  or  measures  as  will  best  safeguard  the 
sufferer  and  restore  him  to  health.  It  is  incredible 
that,  at  this  time,  there  should  be  any  discussion  as 
to  the  advisability  of  removing  a  diseased  organ ; 
or  as  to  the  proper  time  for  its  removal.  The  best 
of  the  diseased  appendix  for  numerous  reasons :  to 
results  are  always  obtained  by  the  prompt  removal 
prevent  pus  formation  :  to  avoid  avoidable  compli- 
cations; to  exclude  peritonitis,  if  not  already  pres 
ent :  to  insure  a  speedy  recovery  with  the  least  like- 
lihood of  sequelae,  v.'hich  must  come  in  a  certain 
percentage  of  cases  if  the  disease  is  permitted  to 
advance  until  pus  has  formed  or  the  peritoneal 
cavity  invaded  with  pus  from  a  ruptured  appendix. 
The  treatment  of  appendicitis  should  be  confined  to 
surgical  measures  and  these  varied  to  meet  the  indi- 
vidual cases,  either  acute  or  chronic.  There  can  be 
no  fixed  or  fast  rules  laid  down  to  govern  these 
cases,  but  certain  surgical  principles  are  involved 
which,  if  observed,  will  make  our  results  all  that 
can  be  desired. 

In  two  of  the  cases  the  purulent  collection  was 
evacuated  and  the  appendix  left  undisturbed,  as  I  did 
not  not  deem  it  wise  to  remove  the  organ  at  the  time  of 
operation  on  account  of  the  desperate  condition  of 
the  patient.  After  the  immediate  effects  of  the  dis- 
ease were  i:nder  control,  the  appendix  was  re- 
moved, thus  completing  the  otherwise  unfinished 
procedure.  I  believe  it  is  bad  surger\-  to  make  this 
a  universal  practice,  but  there  are,  however,  isolated 
instances  where  conservatism,  if  it  may  be  so  called, 
can  be  properly  practiced. 

An  analysis  of  the  tabulated  statistics  is  of  inter- 
est. Of  these  cases  5  had  the  diagnosis  made  at 
once  after  the  onset  of  the  disease :  1 1  within  nine 
hours ;  9  within  fifteen  hours :  5  within  twenty- 
four  hours;  4  in  thirty-six  hours;  15  in  fort3--eight 
hours ;  9  in  three  days ;  5  in  four  days :  i  in  six  days, 
and  I  at  the  expiration  of  a  week.  In  one  case  the 
attack  was  fulminating. 

Operations  were  performed  in  the  acute  cases  as 
follows :  4  within  ten  hours  after  onset ;  1 1  after 
fifteen  hours;  11  after  twenty-four  hours;  4  after 
thirty-six  hours ;  5  after  forty-eight  hours ;  13  after 
three  days ;  3  after  four  days :  5  after  five  days ;  i  on 


824 


The   Philadeli'Iih"! 
Medical  Jourxai.  J 


APPENDICITIS 


1901 


the  sixth  day ;  2  on  the  seventh  day ;  and  one  on  the 
twelftli  day.  Of  the  chronic  cases  2  were  operated 
on  during  an  acute  exacerbation,  and  3  directly  after 
the  attack  had  subsided.  The  most  common  com- 
plications met  with  were :  perforation  in  33  in- 
stances, localized  abscesses  in  35,  abscess  in  the 
appendix  in  4,  and  abscesses  in  the  omentum  in  i 
case. 

Ten  of  the  acute  cases  were  followed  by  hernia 


and  four  by  fecal  fistula.  These  cases  all  required 
drainage,  either  tubular  or  gauze  packing.  Seven 
of  the  appendices  removed  contained  foreign  bodies, 
six  of  which  were  fecal  concretions,  the  seventh  was 
of  some  wooden  fibre  substance.  The  condition  of 
the  bowels  as  noted  was  as  follows:  Constipation 
in  73,  diarrhoea  in  29,  regular  in  7.  5  were  negative 
and  I  irrecrular. 


5  a 

>.:  :  :   a 

c  w  c  S  0 

■c3 


_??_?!„"- 


o..    . 


0 


00 


2    s     ,• 


=  i:   .k2£ 


Sg;  III  |||5=1-i 

5hv^      — .=  — r-_i;  — 


Sis 
=•---=         i;  .a  = 

-  >,c  =  - a      ji 


2    . 


?S; 


C  C  E  ES 

-" "-O 

t> 

|0>00 


Ss-1 

■°-°S.£.a-S^° 
'•ooE^- 


•c  u  c  t-3  >-^  =  S  *  3  r  S 

c.cvr..'-— .-•'■irt;-   — 

c  =  c  =  =:  =  ,T»  CJ« 
=■  — =.-  — ir-r"  c  = 


n  — 
f  E 


.A  "3 -2 

•CI        W 

D  c  •; 
o  o  o 


s^ 


n     !:=:■=     fce=         fee     3  =  S         a 

o:  .5  3    :o:   «5;  ;  :5c:  .So-S;       O:  =  :  ; 


^=    :  3  3t  u 


=  =  c=S=  =.=  eS£3 


JO  ON     I 


lfj«»-W-i«^CJ«0(DMt»NrW««»«JrfeCMi-«W<-«MC»-- 


•  :■■;  ri  I-  ^  c-i «  P5  M  ; 


E„^^„-.. 


—  C-.  rJrtwv^o- 


c^^^c^^  n^^orsi^^rjo^pi-* 


a   s 

oS     So 

oS     0. 

1 

-< 

appen. 
loc. 

loc. 
appen. 

a.  0 

no 

loc. 

bowel. 

loc. 

no 

Hart 
morph- 

been 
given. 

no 

yes 

slons  to 

yes 

no 

t  How 
soon  op. 
after 
onset. 

«  o 


tic't 


3 
>» 


3 


•°5.2 


c  c 


«  CiC    .       v:  V 

•  •^^      <* 

S     22,^0 
^     o.-  o  .3 
■?  "1 


-■9  S^oS 

S  a)  «      a 

ss-=S 

■Es-sgs-sa — ■-"^.^.S'    - 

g ^xl  5- a)  5 ^S  —  S-O c_ 

■  •C-5  -  •O'T 


•a 

1=  - 


§  '^  * 

—      o      — 


09 
-       tJ       - 

»  .g      ti 


JS 

•3 


o 
-.3 

e 

_  .     £■£«».; 

3       gS"? 


5b    ~  .•d    ?   .0  =  5=    g 

csi  dig!  %dt  !g 


-     g 
£ 

£     S     a. 

N      ^ 

M  5      o 


5" 


il  - 


I  ^1 

3 


=  •0 

?  5-    :^  ! 


«2    » 


^00  t? 


Q,  bo 

0 


O^  CO  -A.  oO  9) 


■D E'nS  — 5  = 

|ee§|15.||Re 


_  iy  i^  >.  V  a)  >.  >.  ii 


— -o  2. 9..o''o'  ii 


'<<" 


•c^a 


^  01    :  S. 
&3       ■" 


3  §*    5  S-O  S 


§  If  3.2 


,    _    Si.l    - 

h  Biz-hill 
i'-hJ^  !;«-"' i 


I!!|.">11HB 


.-  —  o>cJp..vrt- 


5.C  Mr- WN 


-_«s. 


Arini. 


liNIll 


DIABETES  MELLITUS 


r  Luu  1' 
L  Mkdic, 


I'llILADELl'HIA  Ro  ^ 

AL   JOUKNAI.  "'*0 


POINTS  CONNECTED  WITH  THE  GENERAL  ETIOLOGY 
AND  PATHOGENESIS  OF  DIABETES  MELLITUS.** 

HEXRICH  STERN,  PH.  D.,  iM.  D. 

of  New  York. 

It  may  appear  a  paradox,  but  it  is  a  fact  that,  in 
the  L'nited  States,  at  least,  the  mortality  statistics 
afford  us  the  most  reliable  method  of  obtaining  cer- 
tain general  etiological  data  of  diabetes. 

I  have  revised  and  studied  the  mortality  statistics 
of  New  York  City  for  a  period  of  ii  years  (1889-99 
inch),  pertaining  to  diabetes  mellitus,**  and  in  the 
following  are  giver  a  few  of  the  data  and  conclu- 
sions derived  therefrom : 

Sex:  Of  1867  deaths  from  diabetes  mellitus,  931, 
that  is,  almost  5070,  occurred  in  females.  This 
proportion  differs  widely  from  the  supposition  that 
the  affection  is  much  more  fatal  in  males  than  in 
females.  Former  mortality  reports  have  shown  that 
from  two  to  two  and  a  half  times  more  men  suc- 
cumbed to  this  malad}'  than  women.  It  is  but  con- 
sequential to  assume  that  the  death  rate  from  dia- 
betes mellitus  stands  in  direct  proportion  to  the 
frequency  of  the  disease  itself,  and  that  in  New  York 
City  about  equal  numbers  of  both  sexes  are  afflicted 
with  it. 

Infantile  Diabetes:  Judging  by  the  mortality  from 
diabetes  mellitus  in  childhood,  the  period  when  this 
disease  almost  always  terminates  fatally,  we  may 
adduce  that  this  malady  is  a  rare  affection  in  infancy 
and  early  adolescence.  I  found  4  cases  of  death 
from  diabetes  mellitus  in  infants  below  I  year  of 
age  during  the  11  years  from  1889-99;  "it  i  year  of 
age  I  death  ;  at  2  years  of  age,  2  deaths ;  at  3  years,  2 
deaths;  at  4  years,  4  deaths  ensued,  that  is  13  in- 
stances in  which  the  disease  terminated  fatally  be- 
low the  15th  year  of  life  .  Between  the  5th  and  9th 
year  11  cases  of  death  are  on  record  for  the  period 
in  question  ;  from  the  loth  to  14th  year  of  life  I  came 
across  17  recorded  instances;  and  from  the  15th  to 
the  close  of  the  19th  year  the  mortality  from  this 
affection  amounted  to  38.  The  total  mortality 
from  diabetes  in  infancy  and  early  adolescence 
being  79  forms  about  4.25%  of  the  total  deaths 
from  this  disease  during  this  period  of  11  years.  Of 
these  79  deaths,  55,  which  is  over  70^^,  occurred 
between  the  ages  of  10  and  19.  The  period  of  pub- 
erty seems  to  be  without  influence  upon  the  produc- 
tion of  diabetes  mellitus  or  upon  its  fatal  termina- 
tion. 

Sex  \n  Infantile  Diabetes. — Of  the  13  instances  of 
death  which  occurred  under  5  years  of  age,  3  took 
place  in  females.  Among  the  66  other  instances  of 
deaths  from  diabetes  in  early  life,  33  ensued  in 
males  and  33  in  females,  exactly  50%  in  each  sex. 
The  external  conditions  of  life  in  the  United  States 
as  a  general  rule  are  in  the  mean  the  same  for  both 
sexes  to  the  20th  year ;  a  fact  to  which  the  equal 

*DlaDetes  mellitus.  The  mortality  therefrom  in  the  city  of 
New  York  during  the  period  from  1SS9  to  1SD9;  from  the  official 
records.  Comments.— Journal  Am.  Med.  Ass'n..  Jan.  26,  1901.; 
also  the  mortality  from  diabetes  mellitus  in  the  City  of  New 
York  (Manhattan  and  the  Bronx),  in  1899.  Classified  according 
to  months,  age  and  sex;  also  an  expose  as  to  nationality, 
duration  of  residence  in  the  United  States,  occupation,  direct 
causes  of  death  and  accompanying  diseases. — Med.  Record, 
Nov.    17.   1900. 

'  ♦♦Read  at  the  meeting  of  the  New  York  Academy  of  Medi- 
cine, March  19.  1901. 


distribution  of  the  disease  in  both  sexes  may  be  well 
ascribed. 

Race. — The  death  rate  from  diabetes  in  the  colored 
race  is  exceedingly  low.  This  may  be  due  to  either 
the  infrequency  with  which  the  pathologic  condi- 
tion appears  in  the  Ethiopian  race  or  to  its  occa- 
sional non-recognition  when  it  is  present.  Of  the 
15  instances  of  death  from  diabetes  which  ensued 
among  the  colored  population  of  New  York  City, 
between  1889- '99,  9  occurred  in  males  and  6  in  fe- 
males. 

Hebrews,  no  doubt,  are  more  commonly  affected 
with  chronic  glycosuria  than  is  the  nation  among 
whom  they  dwell.  The  death  certificates  in  the 
United  States  furnish  no  direct  evidence  whether 
the  deceased  belongs  to  the  Jewish  race  or  not  nor 
in  many  instances  does  the  name  disclose  the  racial 
identity.  Those  buried  in  the  Jewish  cemeteries 
were  classed  by  me  as  Jews.  A  few  others  of  un- 
doubted Jewish  origin  (personal  name,  name  of 
[/arents,  place  of  birth)  not  interred  in  specific  Jew- 
ish burial  grounds,  were  also  counted  among  the 
Jews.  Out  of  a  total  of  202  deaths  in  1899,  54,  that 
is,  about  25%,  occurred  in  Jews;  of  these  21  were 
males  and  33  females. 

Of  those  born  in  Ireland,  37  succumbed  to  diabetes 
in  1899.  Taking  the  Irish  as  a  race — as  I  have  done 
v.'ith  the  Jews — adding  those  who  were  born  outside 
of  Ireland  of  Irish  parentage  or  who  are  of  Irish 
descent  ,we  have  a  total  mortality  of  at  least  51 — 22 
males  and  29  females.  This  figure  also  forms  over 
25%  of  the  total  mortality  from  diabetes  mel- 
litus. 

The  frequent  mortality  from  diabetes  mellitus  in 
the  Jews  and  Irish  may  be  ascribed  to  manifold 
causes ;  mental  exertion,  the  characteristic  modes  of 
living,  gluttony,  alcoholic  intoxication,  etc.,  might 
be  considered  predisposing  factors  in  the  produc- 
tion of  the  diabetic  state  but  the  cardinal  predispos- 
ing cause  in  my  opinion,  is  the  breeding  in  and  into 
which,  in  a  very  pronounced  degree,  the  Jewish,  as 
well  as  the  Irish  race,  still  adhere. 

Frequency  of  Diabetes  Among  the  Poorer  Classes. — • 
Diabetes  mellitus  is  not  a  special  visitation  upon 
the  well-to-do  as  is  commonly  supposed  ;  but  it  oc- 
curs frequently  among  the  working  people  between 
whom  gluttony  and  leisure  hours  are  the  exception. 
Among  the  102  males  who  died  from  diabetes  in 
1899.  66  at  least  were  working  for  a  livelihood  or 
were  dependent  upon  others,  and  lived  in  tenement 
houses. 

For  clinical  purposes  we  may  ascribe  the  various 
glycosurias  to  one  or  more  of  the  following  causes: 

1.  To  excessive  ingestion  .of  carbohj^drates — ali- 
mentary glycosuria. 

2.  To  diminution,  or  functional  disturbance,  or 
excessive  or  abnormal  disintegration  of  the  erythro- 
cvtes; — glycosurias  following  the  introduction  of 
poisons  and  toxines,  or  the  perverted  function  or  re- 
moval of  certain  glands  and  organs — hematogenic 
glycosuria.  (Pancreatic  diabetes — Seegen's  grave 
diabetes). 

3.  To  traumatism — neurogenic  glycosuria. 

4.  To  interference  with  the  glycogenic  function 
of  the  liver  to  the  extent  that  the  ingested  carbohy- 
drates are  not  utilized  normally — common  or  he- 
patogenic diabetes. 


Q^f.        The    PhilaukliiiiaT 
*"        Medical  Journal  J 


DIABETES  MELLITUS 


[  AL'BIL  27,  1901 


5.  To  a  general  protoplasmic  deterioration  and 
plasmolysis — diabetic  deterioration. 

It  would  be  beyond  the  scope  of  this  paper  to 
dwell  at  length  upon  the  special  and  direct  underly- 
ing factors  of  every  type  of  glycosuria.  Besides, 
the  primary  cause  of  all  hyperglycemic  conditions 
— excepting  the  alimentary  form — seems  to  be  one 
and  the  same,  and  the  true  pathogenesis  of  one 
clinical  type  of  glycosuria  or  diabetes  appears, 
therefore,  the  true  pathogenesis  of  all  the  others. 
Assuming  that  the  primary  stimulus  of  hypergly- 
caemia  acts  by  the  medium  of  the  blood,  the  clinical 
subdivision,  hematogenic  glycosuria  or  diabetes, 
although  per  se  not  comprising  the  other  before 
characterized  clinical  forms,  gains  at  once  special 
importance.  In  the  following  I  shall  consider  only 
the  hematogenic  form  and  the  most  typical  of  all 
diabetic  conditions — the  diabetic  deterioration. 
HEMATOGENIC  GLYCOSURIA  AND  DIA- 
BETES. 

Ludwig  Bremer's  method  of  diagnosticating  dia- 
betes from  a  drop  of  blood  *  while  in  all  likelihood 
will  never  supplant  in  general  favor  the  older  and 
more  approved  tests,  for  glycosuria  or  diabetes,  has 
served  on  the  other  hand,  the  admirable  purpose  of 
drawing  attention  to  a  hitherto  unknown  factor  in 
hyperglycaemia.  The  St.  Louis  physician  was  the 
first  to  observe  that  erythrocytes  of  diabetic  blood 
stained  with  an  cosin-methylene-blue  solution,  did 
not  appear  red  or  brown-red,  as  would  the  red  cor- 
puscles of  normal  blood,  but  that  they  attain  a 
yellow  or  yellowish-green  coloration.  Having 
found  that  the  specific  reaction  does  not  depend  on 
the  presence  of  dextrose,  as  it  does  not  ensue  in 
artificially  saccharated  healthy  blood  on  the  applica- 
sion  of  the  eosin-methylene  blue  solution,  he  con- 
cluded that  there  is  a  foreign  substance  in  the  dia- 
betic erythrocytes  which  calls  forth  this  unusual 
phenomenon. 

The  reducing  power  of  diabetic  blood  upon  a 
weak  solution  of  methylene  blue,  first  observed 
by  Williamson,*  confirms,  to  a  certain  degree,  Bre- 
mer's conclusions.  This  reaction,  due  in  part  to 
the  reducing  quality  of  dextrose,  cannot  be  ascribed 
to  the  latter  alone,  as  the  amount  in  which  this 
substance  usually  occurs  in  glycosuria  does  not 
suffice  to  bring  about  the  very  pronounced  methy- 
lene blue  reduction,  and  as  it  will  take  place  even 
then 
for  some  time. 

•Centralblatt,  f.  d.  nied.  Wlssenschaften,  1S94.  No.  49;  Med. 
News,  Feb.  9,  1S95;  "an  Improved  method,  etc.:"  N.  Y.  Med. 
Journal,  Mnrcli  7,  1?9G.  "Die  Diagnose  des  Diabetes  Mellitus 
aus  dem  Vei-lialteii  des  Blutes  gegen  .-inilinf.avben.  '  Central- 
blatt. t.  Innere  Med.,  1S97,  No.  23.  In  the  last  communication 
the  author  speaks  of  the  reaction  ensuing  wlien  stained  with 
Congo  red.  methylene  blue,  and  Ehrlich-Biandi's  fluid.  When 
treated  with  Congo  red  and  metliylene  blue  diabetic  blood  does 
not  appear  colored  as  the  normal  blood;  treated  with  the 
Ehrlich-Biandi  fluid,  diabetic  blood  turns  orange,  and  normal 
blood   assumes   a   violet   coloration. 

•I..epine  (Genese  des  differentes  formes  de  diabete  sucre.  Sem. 
Med..  1S97.  p.  279),  .-ind  ICichntT  and  Voelkcl  I  .\buorine  Slutfaer- 
bungen  bei  Diabetes  mellitus  und  Glycosurlen,  Wiener  Klin. 
W^ochenschrift,  1S97,  No.  4G),  foimd  a  similar  coloration  of  the 
blood  of  some  other  patliologic  conditions  (leucocythaemia. 
pselldo-Ieiikenii:!.  marasinu-^  and  Graves'  Disease).  Xardi  (Bol!, 
de  Scienze  Med.  di  Bologna,  Nov.,  1S97)  did  not  observe  the 
reaction  in  the  blood  of  other  diseases  (he  did  not  examine 
leukaeiuic  blood.)  I  have  seen  the  nou-coloratioti  of  er^'tliro- 
cvles  in  a  case  of  leukemia,  one  of  nrenun  and  three  in- 
stances of  very  low  blood  alkalinity.  The  reaction  does  not 
seem  to  be  definitely  pathognomonic  of  diabetes  or  glycosuria, 
but  it  is  possible  that  the  reaction.s  in  the  blood  of  various  dis- 
orders are  called   forth  by  different  alterations. 


when  the  diabetic  had  not  excreted  glucose 


Notwithstanding  these  facts,*  Nardi  thinks  it 
highly  probable  that  the  reaction  with  anilin  dyes 
is  the  result  of  the  presence  of  free  glucose  .in  the 
blood  of  the  diabetic.  Diminished  alkalescence  of 
the  blood  has  been  thought  the  cause  of  the  reduc- 
tion by  some  authors ;  the  blood  alkalinity  in  dia- 
betes, however,  especially  in  its  lighter  manifesta- 
tions, where  a  rigid  meat-fat  diet  is  not  observed,. 
is  hardly  ever  decreased. 

The  reaction  of  diabetic  blood  upon  certain  anilin 
color  stufis  appears  to  be  a  purely  chemical  pro- 
cess. This  inter-action  may  be  due  to  the 
presence  of  an  abnormal  element  in,  or  the  absence 
of  a  normal  substance  from  the  diabetic  blood,  or 
to  both  eventual  factors  together.  Bremer*  opines 
that  a  foreign  body  is  probably  combined  with  the 
hemoglobin ;  I.  Loewy**  concurs  with  this  view 
in  general,  and  ascribes  the  changes  in  the  blood 
as  caused  by  deviations  in  the  structure  of  the 
erythrocvtes. 

As  early  as  1896  I  approached  this  subject.  At 
that  time  I  was  inclined  to  Ebstein's  theory,  which 
supposed  that  the  general  o.xidizing  qualities  of  the 
diabetic  organism  were  more  or  less  impaired,  an 
assumption  which,  in  the  light  of  modern  research, 
appears  untenable.  (Substances  far  more  difficult 
of  oxidation  than  the  carbohydrates  are  burned  up 
in  the  body  of  the  diabetic.  Tartaric,  citric,  malic 
and  other  organic  acids  oxidize,  and,  like  in  the 
healthy  state,  are  excreted  as  salts  of  Co'  with  the 
urine  of  diabetes.  Benzol  oxidizes  to  phenol  and 
hydrocarbons,  less  o.xidable  in  the  human  system 
than  amylaceous  ingesta  are  completely  oxidized  to 
Co'  and  H'O  and  serve  as  a  most  valuable  fuel  for 
the  glycosuric  and  diabetic  organism.  Moreover, 
levulose,  invertin,  inosit  and  mannit  are  also 
burned  up  in  the  body  of  the  diabetic*  It  seems 
that  we  can  only  speak  of  diminished  oxidizing 
qualities  in  the  stages  of  acetonemia  and  acidosis.) 

Taking  the  theory  of  a  primary  sub-oxidation  for 
granted,  I  inferred  that  there  must  be  a  certain  con- 
nection between  Bremer's  phenomenon  and  the 
oxygen-carrying  property  of  the  diabetic  red  blood 
corpuscle.  Continued  examination  of  the  diabetic 
blood  with  the  inadequate  means  then  at  my  dis- 
posal apparently  confirmed  my  supposition  that  the 
oxygen  had  been  partially  replaced  from  its  he- 
moglobin combination,  and  as  carbon  monoxid  in- 
toxication is  nothing  else  but  a  deficient  oxygena- 
tion, I  considered  carbon  monoxide  of  catabolic  ori- 
gin the  replacing  factor. 

It  is  true  CO  hemoglobin  could  never  be  iden- 
tified spectroscopically,  and  those  instances  in  which 
I  detected  CO  in  hyperglycemia  by  chemical 
agents,  were,  to  the  greater  part,  not  such  of  true 
diabetes;*  in  the  latter  afTection  I  thought  to  have 
found  Co  a  few  times,  but  only  during  the  very  last 
stage.  In  ".\  contribution  to  the  patho.genesis  and 
etiology  of  diabetes  mellitus,"  which  appeared  in 
the  Mc'dical  Record  of  December  18,  iSi)7,  after  stat- 

•Loo.  cit. 

•X.   Y.   Med.  Journal.  March  7,  1S96. 

*«SaninielKrichl  «etx.r  das  Vcrhaltcn  de*  diabetischen  Blutcs  ru  den 
anilinfarlisloffeii.     Kortscli.  d,  Med..  1S!<S,  p.  171.  ; -.i,;_,  ».         t_ 

♦Knelz.KBeilracsc  ;  znr   1  alholecici  ti.l,  Thi  rapie;.  d.  ;  Diahetes'inellitiis 

Mailmrs.   l-Cl. 

•Hetnrlch  Stern.  Tobacco  as  n  factor  In  glycosuria.  Medical 
Record,  1901. 


April 


l!)(il] 


DIABETES  MELLITUS 


TTlIK     I'HlI.AllIXrHlA  807 

L    MHPl'  AL   Joi;H.NAi  / 


ing  that  the  stage  of  diabetic  auto-intoxication  is 
characterized  by  the  presence  of  dimethyl-ketone 
in  excess  of  ethyl-diacetic,  and  of  levorotatory  oxy- 
butyric  acids,  I  continued  that  I  thought  to  have 
of  late  succeeded  in  identifying  an  abnormal  chem- 
ical substance  in  the  blood  of  diabetics  who  have 
died  in  a  comatose  condition.  The  foreign  element 
in  question  detected  by  the  NaOH  and  Katayuma's 
tests  appeared  to  be  carbon  monoxid.  Fearing 
prematureness,  I  did  not  then  mention  the  details 
of  my  observation. 

The  non-detection  of  CO  in  the  blood  of  my  dia- 
betic cases  prior  to  the  establishment  of  far  ad- 
vanced toxemia,  furnishes  by  no  means  conclusive 
evidence  of  its  absence,  for  in  many  instances  of 
chronic  CO  poisoning  we  have  to  deal  with,  but 
infinitesimal   amounts   of  this   substance. 

The  negation  of  a  primary  and  general  disturb- 
ance of  the  oxidizing  qualities  of  the  diabetic,  how- 
ever, precludes  carbon-oxydemia  as  a  causative 
factor  of  true  diabetes  and  relegates  it,  together 
with  the  other  known  toxic  principles,  to  the  rank 
of  an  anomalous  metabolic  condition.  Furthermore, 
I  have  since  convinced  myself  sufficiently  that  the 
changes  in  the  cellular  substance  of  the  diabetic  red 
blood  corpuscle,  evidenced  by  the  anilin  dye  reac- 
tion, are  neither  the  direct  or  indirect  result  of  CO 
intervention. 

The  almost  characteristic  behavior  of  the  diabetic 
erythrocyte  must  be  due  to  another  factor  which 
might  be  either  the  result  or  cause  of  the  diabetic 
condition.  This  abnormal  element  in  the  cellular 
substance  of  the  er3'throcyte  is  presumably  of 
autochthonous  formation,  perhaps,  though  it  takes 
its  origin  from  exogenetic  influences.  If  the  foreign 
substance  has  arisen  from  within  the  organism,  it 
is  either  enterogenous  or  histogenetic.  It  does  not 
seem  to  be  due  to  a  retention  anomaly  as  carbon- 
aemia  and  carbonoxydemia  per  se  fail  to  reduce 
the    anilin    dye    stains. 

If  the  substance  in  question  were  derived  by 
resorption  from  the  gastro-intestinal  canal,  it  could 
not  become  an  almost  permanent  factor  in  the 
blood,  as  this  would  pre-suppose  a  long-continued, 
uninterrupted  absorption  of  the  products  of  intes- 
tinal hyperfermentation  and  putrefaction,  a  condi- 
tion hardly  ever  prevailing,  and  in  my  experience 
not  frequent  in  diabetes.  On  account  of  this  and 
some  other  less  important  reasons  we  have  to  re- 
gard the  erythrocytic  foreign  element — not  consid- 
ering at  this  moment  its  possible  ectogenesis — as  a 
product  of  abnormal  cell  and  organ  activity  or  dis- 
integration. Thus  the  foreign  substance,  whether 
it  originated  by  perverted  plasmolytic  or  nucleolytic 
processes,  or  by  anomalies  of  internal  secretions, 
may  safely  be  classified  among  the  toxic  principles. 

The  possibility  of  an  ectosystemic  origin  of  the 
substance  in  question  deserves  some  attention. 

A  considerable  number  of  authors  have  observed 
the  appearance  of  diabetes  in  formerly  healthy  per- 
sons after  they  had  come  into  more  or  less  inti- 
mate contact  with  diabetic  individuals.  The  trans- 
missibility,  therefore,  of  the  affection  seems  feasi- 
ble, although  no  convincing  proof  has  been  given 
for  it.  One  could  surmise  that  the  abnormal  blood 
constituent  represented  the  metabolic  products  of 
a  specific  bacterium,  and  that  the  potency  of  this 


toxin  gave  rise  to  the  glycosuric  phenomenon.  Some 
observers  investigated  the  subject  of  diabetic  infec- 
tivity  more  closely,  but  I  cannot  accept  their  meagre 
and  contradictory  results  as  conclusive  evidence  for 
the   same. 

I  have  dwelt  at  some  length  on  the  foreign  sub- 
stance in  the  diabetic  erythrocyte,  as  notwithstand- 
ing the  hypergh-caemia,  it  appears  to  be  the  only 
tangible  and  ever-occurring  foreign  element  in  the 
blood  of  diabetes.  Whether  it  forms  the  etilogic 
substratum,  or  if  it  is  but  another  of  the  metabolic 
products  of  the  diabetic  condition,  is  a  question 
which  the  future  has  to  answer. 

The  Diabetic  Deterioration. 

W  hile  Traube,*  Ebstein,**  Cantani,***  and  other 
observers  distinguish  between  a  mild  and  grave 
form  of  diabetes,  they  contended  that  both  are  man- 
ifestations— differing  in  degree  only — of  the  same 
directly  underlying  pathologic  condition,  and  as- 
sumed that  the  severe  form  was  but  an  advanced 
stadium  of  the  lighter  type. 

I.  Seegen,****  whose  fundamental  investigations 
on  the  production  of  sugar  in  the  animal  organism 
have  as  yet  met  with  little  appreciation,  was  the 
first  to  recognize  two  distinct,  and,  of  each  other, 
entirely  independent  clinical  types  of  the  diabetic 
affection.  He  demonstrated  that  the  one  form — the 
excretion  of  sugar  resulting  from  the  failure  of  the 
liver  cells  to  normally  convert  the  ingested  carbo- 
hydrates— bears  no  relation  to  the  other  type  which 
owes  its  origin  to  the  inability  of  the  entire  or  al- 
most the  entire  organism,  to  utilize  the  sugar  con- 
veyed to  its  structure  by  the  blood. 

The  present  writer  has  described  a  third  clinical 
form  of  diabetes,  the  diabetic  deterioration.* 

These  three  clinical  varieties  of  diabetes  emanat- 
ing respectively  from  three  distinct  direct  causes, 
seem,  however,  to  be  but  the  consequence  of  one 
and  the  same  fundamental  disturbance. 

They  may  be  thus  differentiated : 

1st  form.— The  glycosuria  disappears  after  com- 
plete or  partial  exclusion  of  carbohydrates.  The 
excreted  dextrose  is  due  to  deficient  glycolysis. 

2nd  form. — The  glycosuria  persists  after  the  com- 
plete exclusion  of  carbohydrates.  The  excreted  glu- 
cose is  due  to  proteolysis. 

3rd  form. — The  continued  excretion  of  dextrose 
concurs  with  larger  amounts  of  nitrogen  egested 
than  were  introduced  with  the  nutriment.  The  ex- 
creted dextrose  is  due  to  plasmolysis. 

Close  observations  of  a  certain  type  of  diabetics, 
conducted  by  me,*  have  demonstrated  that  diabetic 
azoturia  is  not  always  the  result  of  hyperingestion 
of  albumins,  and  that  in  this  instance  the  amount 
of  nitrogen  excreted  most  always  exceeds  that  of 
the  nitrogen  introduced  with  the  nutriment.  The 
last  fact,  not  recognized  by  an3-one  before  me,  points 
to  a  third  form  of  diabetes,  which  directly  has  little 
or  nothing  in  common  with  the  so-called  pancreatic 
type  of  the  affection.*  In  experimental  pancreatic 
diabetes  in  animals  fasting  or  under  an  exclusive 

*Virchow'?  .\rchiv  IV.  10:1.  .  . 

"Die   Zuckerharnruhr,   Ihre  Theorie   und   Praxis,  Wiesbaden. 

1S87 
***Diabetes  mellitus,  Uebersetzt  von  Hnhll,  Berlin,  ItWO. 

****Die  Zuckcrbildung  im  Tliicrkoerpcr,  ilir  unifang  und  ilire 
Beckutunq;.    Berlin.  ISIK)." 

»  V  contribution  to  the  pathogenesis  and  etiology  ot  diibetea 
mellitus.    JVIed.  Rec.,  Dec.  18,  1897. 

*I^athog..   etc..   of  diabetes   meUitns. 


MEDICiL   JOURSAI. 


] 


DIABETES  MELLITUS 


[  Aii-BIL  27,  19<jl 


meat  diet,  Minkowski**  observed  a  permanent 
ratio  between  urinary  dextrose  and  nitrogen.  The 
proportion  of  dextrose  to  nitrogen  varied  in  these 
instances  between  2.62  :i  and  3.05  :i ;  the  mean  figure 
given  by  Minkowski  being  2.8  D.  to  i  N. 

In  my  cases,  which  a  priori  are  at  variance  with 
artificial  diabetes,  the  proportion  of  D  :  N,  under 
similar  conditions,  was  most  always  a  different  one. 
For  instance,  in  case  I,  of  my  observations,  which 
I  select  at  random,  the  following  data  w^ere  ob- 
tained : 

Patient  under  an  exclusive  albuminous  diet  for 
13  daj's ;  average  daily  amount  of  albumin  ingested, 
185  grams.,  containing  28.86  gms.  N. ;  average  daily 
amount  of  urine,  3002  c.  c. ;  average  daily  amount 
of  dextrose  in  same,***  5.5%,  that  is,  165. i  gms.; 
average  daily  amount  of  carbamid  in  same,  3.2%, 
that  is,  96.1  gms.,  containing  44.9  gms.  nitrogen  ;**** 
average  amount  of  nitrogen  plus  in  urin,  16.04  gms. 

Proportion  of  dextrose  to  nitrogen,  3.67  :  i.  Pa- 
tient fasting  for  17  hours  (water  in  moderate  quan- 
tity). Amount  of  urine  for  24  hours  (including  7 
hours  after  fast),  1850  c.  c.  Amount  of  dextrose 
in  the  same,  3%,  that  is,  55.5  grams.  Amount  of 
carbamid  in  the  same,  3.8%,  that  is,  70.3  grams,  con- 
taining 32.85  grams  nitrogen.  Proportion  of  dex- 
trose to  nitrogen,  1.69  :  i. 

The  non-existence  of  a  constant  dextrose-nitro- 
gen ratio  tends  to  prove  the  discrepancy  between 
the  third  form  of  the  diabetic  alTection  and  experi- 
mental pancreatic  diabetes. 

Minkowski  is  of  the  opinion  that  his  figures 
express  quantitatively  the  production  of  sugar  from 
albuminous  substances  in  the  organism,  and  that 
after  the  removal  of  the  pancreas  the  total  quantity 
of  the  sugar  thus  produced  is  excreted  by  the 
urine. 

Admitting  that  Minkowski's  figures  are  expres- 
sive of  the  sugar  production  from  albumin  in  the 
organism,  then  the  relation  of  D  :  N  in  the  urine  of 
some  of  my  cases  must  be  exceedingly  atypical,  and 
this  the  more  so,  as  the  amount  of  nitrogen  ingested 
was  mostly  less  than  that  eliminated  by  the  kidneys 
and  faeces. 

During  the  13  days  of  albuminous  diet  the  aver- 
age daily  nitrogen  plus  in  the  urine  amounted  to 
16.04  grams. 

Utilizing  Minkowski's  figures  and  calculating 
from  the  N  ingested,  the  amount  of  urinary  glucose 
should  be  80.8  grams.  The  total  daily  average 
quantity  of  urinary  glucose  amounted,  however,  to 
165.1  grams.  Therefore,  84.3  grams  of  glucose  more 
"were  contained  in  the  urine  than  presumably  have 
been  derived  from  the  nutriment.* 

•As  stated  before,  the  same  primary  cause  seems  to  stand 
at  the  foundation  of  every  diabetic  affection.  The  pancreatic 
type  clinically  is  to  be  counted  at  once  among  the  haemato- 
genic  forms. 

••Arch.  f.  Experiment.  Pathol,  u.  Pharmakol.  Bd.  XXXI.— 
mi   r-ucluingen  iiebor  den  Di,ih<.-lfs  mclUtus   Leipzig.  ISllS. 

•••Through  a  typographical  error,  the  percentage  of  glucose 
■was  given  as  8.-1;  s.l;  S,  and  6.5,  whereas  it  should  read  5.4;  5.1: 
'5,  and  G.-'J. 

••••Urea  does  not  present  the  total  nitrogenous  excretion; 
about  7.. 5  per  cent  of  N  is  contained  in  other  urinarv  constitu- 
ents. In  my  later  investigations  I  have  determined  the  total 
N  oxitput. 

•I  have  no  reason  to  doubt  that  the  patient  adhered  con- 
sclertiously  to  the  prescribed  and  minutely  specified  albumi- 
nous regime.  He  certainly  did  not  partalse  of  larger  quantities 
of  niti-ogenous  material,  as  he  had  developed  an  aversion  to 
It.  I'l  case  he  should  reallv  have  transgressed  and  partaken 
of  carbnhvdrates.  this  would  have  only  augmented  the  intensity 
of  the  dextrose  output,  which  per  se,  is  of  little  moment  in 
our  considerations. 


We  have,  consequently,  an  unaccounted  for  plus 
of  D.  84.3  to  an  unaccounted  for  plus  of  X,  16.04. 
that  is,  a  proportion  of  5,25  :  i. 

It  would  lead  me  far  beyond  the  limits  of  the 
allotted  time  were  I  to  dwell  upon  the  points  in- 
volved in  a  more  exhaustive  manner.  For  the  pres- 
ent purpose  it  sufiices  to  know,  that  the  irregular 
and  inconstant  D  :  X  ratio  precludes  pancreative 
diabetes,  and  that  the  X  output  surpassed  during 
a  certain  period  in  almost  every  instance  the  X  in- 
troduction. 

This  third  form  of  diabetes  seems  to  be  the  man- 
ifestation of  a  specific  plasmolytic  process. 

In  the  healthy  organism  a  dextrose  resembling 
substance  may  be  normally  yielded  by  plasmolysis, 
which,  after  it  has  undergone  succeeding  changes, 
is  ultimately  disposed  of  as  carbon-dioxide.  How- 
ever, the  production  by  plasmohsis  of  dextrose  or 
of  its  precursor,  appears  to  be  an  abnormal  cata- 
bolic  process,  which  causes  permanent  disintegra- 
tion of  the  tissue-protoplasm.  This  specific  dissim- 
ilation of  the  living  protoplasm,  induced,  perhaps, 
by  the  erythrocj-tic  foreign  element,  is  a  limited 
hemi-metabolic  metamorphosis,  so  to  speak,  and 
bears  the  character  of  a  deterioration ;  that  is,  the 
protoplasm  may  retain  its  appearance  and  may 
continue  to  exist,  although  it  has  permanently  lost 
its  molecular  integrity. 

This  plasmolytic  dextrose-carbamid-yielding  pro- 
cess I  have  designated  as  diabetic  deterioration. 

In  other  words,  diabetic  deterioration  is  a  more 
or  less  limited  molecular  disintegration  of  plasmotic 
tissue  substance  into  a  carbohydrate  body  and  a 
non-colloid   nitrogenous   compound. 

-A.  logical  and  concomitant  phenomenon  of  the 
hyperexcretion  of  nitrogen  is  the  progressive  inani- 
tion of  the  patient  aflfected  with  the  disease.  The 
glycosuria  is  persistent,  but  its  intensity  does  not 
seem  to  reflect  the  progress  or  the  exact  stadium  of 
the   affection. 


CENTRALBLATT  FUER  CHIRURGIE. 
March  2,  1901.     (28  Jahrgang,  No.  9.) 

1.  Medullary  Narcosis.     KARL;  SCHWARZ. 

2.  Pseudarthrosis  of  the  Terminal  Phalanx  of  the  Finger. 

W.  MUELLER. 

1. — Schwarz,  before  using  the  Bier  method  of  medullary 
narcosis,  now  gives  his  patients  gradually  increasing  in- 
jections of  tropacocain.  In  16  cases  the  tropacocain  was 
given  in  doses  up  to  5  eg.  to  insure  total  anesthesia.  There 
were  none  of  the  unpleasant  symptoms  which  accompanied 
the  cocain  injections,  no  pallor,  sweating,  nausea,  vomit- 
ing, headache,  vertigo,  or  rise  of  tempei-ature.  The  anal- 
gesia was  perfect  10  minutes  after  the  injection.     [M.  O.] 

2. — Mueller  reports  three  cases  of  complicated  fracture 
of  the  terminal  phalanx  of  a  linger.  The  first  patient  had 
broken  the  end  phalanx  of  his  right  index  finger,  and 
three  months  later  he  found  that  his  finger  easily  tired 
when  writing.  The  tip  of  the  finger  could  be  hyperex- 
tended,  and  a  Roentgen  photograph  showed  a  groove  be- 
neath the  root  of  the  nail.  Operation  showed  marked 
pseudarthrosis.  which  was  easily  cured  by  freshening  up 
the  edges  and  then  immobilizing  the  finger.  The  second 
case  was  much  like  the  first,  in  an  older  man.  Hyper 
extension  was  also  possible.  He  would  not  permit  opera- 
tion. The  last  case  was  in  a  boy  of  16.  in  whom  operation 
affected  a  speedy  cure.  His  report  is  well  illustrated  with 
Roentgen  photographs.     [M.  O.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company  and   Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James   Hendrie  Lloyd,    A  M  .  M.D  ,  Editor-in-Chief 
Julius  L.  Salinger.  M.D  ,  AssociaU  Editor 
Assistant  Editors 
Joseph  Saileb,  M.D.  F.  J.  Kalteyer.  M.D. 

D.  L.  Edsall,  M.D.  T.  L.  Colby.  M.D. 

I.  M.  Swan,  M.     .  W.  A.  N.  Dorland,    M.D. 

I.  H.  Gibbon,  M.D.  T.  M.  Tyson,  M,  D. 

M.  OsTHBiMER,  M.  D.  A.  Robin,  M.  D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  publication.  Reprints  (iW)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.   Address  all  correspondence  to 

The  FhiladelphlaMedical  Journal,  1711)  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8. 


Vol.  VII,  No.  i8 


May  4,  1901 


$3.00  Per  Annum 


The  Pathology  and  Bacteriology  of  Diphtheria. 

— The  monograph  by  Councilman,  Mallory  and 
Pearce  ("Diphtheria,"  Boston,  1901,)  i.s  a  detailed 
study  of  the  bacteriology  and  the  pathology  of  two 
hundred  and  twenty  fatal  cases,  which  in  itself  is 
a  claim  to  distinction.  The  authors  confirm  the  ob- 
servation, already  made,  that  tuberculosis  and  diph- 
theria are  often  associated ;  sixteen  percent  of  their 
cases  presented  a  combination  of  the  two  diseases. 
They  do  not  consider  that  there  is  any  relation  be- 
tween the  two  diseases, this  percentage  representing 
merely  the  frequencyof  tuberculosis  at  an  early  age. 
The  mesenteric  lymph-nodes,  in  the  cases  observed 
in  this  series,  were  more  frequently  involved  in  the 
tuberculous  process  than  either  the  lungs  or  the 
bronchial  lymph-nodes.  Much  attention  has  been 
paid  to  the  bacteriological  condition  of  the  ac- 
cessory air  cells,  and  information  has  been  gained 
that  throws  much  valuable  light  on  the  reason  for 
the  persistence  of  the  diphtheria  bacilli  in  the  nose 
for  such  prolonged  periods  in  some  cases.  The 
maxillary  sinuses  were  examined  in  fifty-two 
cases ;  of  these,  both  sinuses  were  the  seat  of  in- 
flammatory processes  in  twenty-one  and  one  sinus 
only,  in  nine.  All  but  three  of  the  double  antral 
cases  presentad  the  diphtheria  bacillus;  but  of  the 
single  case  only  three  contained  that  organism. 
The  pneumococci  and  the  pus  cocci  were  often  as- 
sociated with  the  bacillus  of  diphtheria  in  the  patho- 
logical exudates,  which  may  be  mucoid,  serous, 
seropurulent  or  purulent,  and,  in  some  cases,  may 
consist  of  a  fibrinous  membrane.  It  is  an  im- 
portant point  for  practical  purposes  to  determine 
whether  this  infection  of  the  accessory  air  cells  oc- 
curs as  frequently  in  the  cases  that  recover  as  in 
those  that  are  fatal.  In  eighty-six  cases  out  of 
one  hundred  and  forty-four,  autopsy  showed  mid- 
dle ear  disease.  The  diphtheria  bacillus  was  found 
in  enough  cases  to  show  that  it  is  capable  of  set- 
ting up  a  suppurative  condition  and  thus  allies  itself 
with  the  pus-producing  organisms.  From  a  study  of 
the  membrane  the  authors  are  able  to  say  that  they 
have  never  found  the  diphtheria  bacillus  growing  in 
the  living  tissues  nor  in  connection  with  those  de- 
generative changes  in  the  epithelium  that  may 
be  regarded  as  the  primary  lesions  of  the  disease. 


This  observation  confirms,  if  confirmation  is 
needed,  the  toxemic  character  of  the  disease.  It 
seems,  from  this  study,  that  the  beginning  of  the 
lesion  is  due  to  the  toxic  action  of  bacilli,  probably 
growing  in  the  fluids  of  the  mouth  or  throat.  When 
necrosis  is  once  produced  the  necrotic  tissue  forms 
a  suitable  culture  medium.  The  membrane  forma- 
tion is  due  to  a  combination  of  degeneration  and  ne- 
crosis of  the  epithelium  and  an  inflammatory  exu- 
dation, rich  in  fibrin  factors,  from  the  underlying 
tissue.  The  cells  may  break  up  into  detritus  or 
they  may  form  hyaline  masses,  and  the  factors  are 
converted  into  fibrin  when  the  exudate  comes  in 
contact  with  the  necrotic  epithelium.  The  authors 
believe  that  there  is  nothing  to  be  gained  by  making 
an  anatomical  distinction  between  a  croupous  and  a 
diphtheritic  membrane;  there  is  nothing  specific 
in  the  membrane  formation  in  diphtheria.  This 
opinion  is  in  line  with  the  evidence  of  bacteriolo- 
gical examination,  that  the  clinical  distinction  be- 
tween diphtheria  and  benign  sore  throat  is  not  to  be 
depended  upon.  We  are  cordially  in  agreement 
with  this  opinion  and  would  even  go  farther  and 
say  that  all  cases  of  sore  throat  should  be  sub- 
jected to  bacteriological  examination  and  that  the 
proper  classification  of  cases  of  diphtheria  is  into 
the  bacteriological  and  the  clinical.  Degeneration 
of  the  myocardium  is  one  of  the  most  common  con- 
ditions found  in  diphtheria.  The  simplest  form  is 
fatty  degeneration,  which  may  become  very  ex- 
tensive. Acute  interstitial  lesions  of  two  kinds 
have  been  demonstrated ;  in  one  there  is  a  collec- 
tion of  plasma  and  lymphoid  cells  and  in  the  other 
there  is  a  proliferation  of  the  cells  of  the  tissue. 
The  first  variety  of  interstitial  lesion  in  not  de- 
pendent on  the  degeneration  of  the  muscle,  while 
the  second  is  due  to  that  degeneration.  The  lesions 
in  the  lungs  are  serious  and  frequent.  Broncho- 
pneumonia is  the  most  common  lesion ;  although 
atelectasis  and  inflammatory  edema  are  also  com- 
mon. True  acute  lobar  pneumonia  was.  never  found. 
The  scope  of  the  monograph  includes  a  study  of  the 
lesions  of  the  spleen,  the  alimentar}'  canal,  the  liver, 
the  kidneys,  the  lymph-nodes,  the  thymus,  the 
nervous  system,  the  skeletal  muscle,  the  bone-mar- 
row, the  pancreas,  the  adrenals,  the  thyroid  gland 


Q^n        The   PHiLAnEi.PHU"! 
"J^        Mkdical  Joubsal  J 


EDITORIAL   COMMENT 


IM(V    4.    1901 


the  salivary  glands,  the  testicles,  and  the  pituitary 
body.  Space  does  not  allow  of  more  detailed  notice 
of  these  sections  of  the  work.  The  fact  that  no 
lesions  were  found  in  the  adrenals  is  somewhat 
surprising,  because  congestion,  hemorrhage  and 
foci  of  necrosis  in  these  glands  are  the  most  common 
lesions  in  the  experimental  disease,  whether  pro- 
duced by  inoculation  with  bacilli  or  by  injection  of 
toxins.  On  the  whole,  the  work  is  an  excellent  ad- 
dition to  the  literature  of  diphtheria,  both  on  ac- 
count of  tlie  original  investigations  described  and 
because  of  the  thorough  review  of  former  writings 
on  the  subject. 

The  American  Military  Hospital  in  Peking. — It 
is  a  source  of  satisfaction,  after  reading  in  some  of 
our  home  journals  the  carping  criticisms  directed 
against  the  United  States  Government  and  its  pol- 
icy in  foreign  affairs,  to  read  the  highly  eulogistic 
account,  given  b}'  the'  correspondent  of  the  British 
Medical  Journal,  of  our  military  hospitals  in  Peking. 
This  writer  looked  upon  the  occasion  of  his  visit 
to  the  United  States  military  hospitals  as  one  of  the 
pleasantest  afternoons  he  spent  in  the  Chinese  capi- 
tal. He  learned  that  the  medical  arrangements  in 
the  American  army  possess  a  far  higher  degree  of 
importance  than  in  the  English  service.  The  hos- 
pitals are  given  the  best  sites,  and  the  amount  of 
skilled  labor  assigned  to  the  chief  medical  officer 
is  as  unstinted  as  the  funds  placed  at  his  disposal. 
Combatant  officers  good-naturedly  complained  that 
"it's  no  use  trying  to  get  a  nail  knocked  in  any- 
where else  until  the  hospital  is  finished."  The 
correspondent  was  surprised  at  the  number  of  com- 
forts allowed  the  .American  soldier.  His  diet  on  ac- 
tive service  contains  lu.xuries  unknown  in  the  Brit- 
ish commissariat.  But  it  is  not  until  the  American 
soldier  goes  to  the  hospital  that  he  is  really  in  a 
position  to  know  how  much  his  Government  loves 
him.  The  correspondent  did  not  think  it  an  exag- 
geration to  say  that  the  American  Military  Hospital 
in  Pekin  could  hold  its  own  with  most  London  hos 
pitals.  It  is  certainly  extraordinarily  high  praise 
to  compare  favorably  an  improvised  military  infirm- 
ary with  great  metropolitan  hospitals.  But  the 
correspondent  makes  good  and  plain  his  position  by 
entering  into  details  about  the  equipment  and  ser- 
vice in  these  field  hospitals.  The  diet  kitchens, 
the  skilled  cooks,  the  trained  attendants,  the 
thorough-going  antisepsis,  the  lavish  supply  of 
personal  comforts,  and,  above  all,  the  good  results 
obtained  in  both  surgical  and  medical  pratice.  are 
some  of  the  features  described  by  his  facile  pen. 

We  have  thought  it  worth  while  to  comment  on 
this  generous  praise  from  a  foreign  eye-witness, 
not  because  we  believe  it  will  surprise  the  ma- 
jority of  home  readers,  but  rather  because  it  wil'. 


be  a  partial  corrective  to  the  detractions  of  the  little 
clique  of  domestic  critics  who  never  find  anj-thing 
praise-worthy  in  the  American  Army  on  duty  in 
foreign  lands,  or  in  the  Government  behind  it. 

The  Way  They  Manage  Smallpox  in  Utah. — .\ 
correspondent  in  Utah  sends  us  some  information 
about  the  smallpox  in  that  State.  There  is  appar- 
ently a  great  deal  of  it.  In  March  there  were  112 
new  cases  in  Salt  Lake  City  alone,  and  quite  a  good 
many  new  ones  in  April,  although  the  disease  is 
slowly  decreasing.  The  authorities  tried  ver\-  hard 
to  pass  a  Compulsorj-  Vaccination  law,  but  it  was 
deteated ;  and  it  is  interesting  to  note  that  the  legis- 
lator, if  he  deserves  such  a  title,  who  introduced  the 
Anti- Vaccination  bill,  subsequently  had  smallpox 
in  his  own  family.  We  should  like  to  believe  that 
this  was  a  special  visitation  of  Providence.  It  is  as- 
tonishing how  little  attention  is  paid  to  the  disease. 
One  maj-  see  the  smallpox  flag  on  many  houses,  and 
note  that  the  windows  and  doors  are  open  and  that 
people  pass  and  repass  with  seemingly  no  fear  of  it. 
One  house  just  by  a  church  had  the  flag  out,  and  the 
inmates  of  the  house  sat  by  an  open  window  watch- 
ing the  church-goers.  Our  correspondent  was  com- 
ing down  in  the  elevator  in  one  of  the  big  business 
buildings.  A  young  man  entered  who  exclaimed; 
"Well,  I've  got  it !"  It  seems  that  the  doctor  from 
whose  office  he  had  just  come,  had  told  him  to  go 
home  and  nurse  himself.  His  face  was  full  of  pus- 
tules, but  regardless  of  this  fact,  the  young  man 
walked  to  the  corner  and  took  a  street-car.  It 
seems  that  the  Mormons  have  been  "counselled" 
against  vaccination;  hence  this  condition  of  af- 
fairs. 

\\'e  think  this  indifference  is  probably  to  be  ex- 
plained in  part  by  the  mild  type  of  smallpox  which 
is  now  prevailing  almost  everywhere  in  the  United 
States.  We  called  attention  in  these  columns  re- 
cently to  the  mildness  of  this  epidemic.  The  fact  is, 
people  have  lost  their  dread  of  the  disease  because 
the  disease  itself  seems  to  have  lost  much  of  its 
malignancy.  How  much  of  this  is  due  to  smallpox 
having  become  weakened  or  modified  by  the  pro- 
cess of  vaccination,  it  is  of  course  difficult  to  say. 
On  the  other  hand,  all  epidemics,  it  must  be  re- 
called, move  in  cycles,  and  it  may  be  that  smallpox 
in  the  United  States  at  present  is  simply  presenting 
its  mild  phase.  In  other  words,  we  cannot  assure 
ourselves  that  the  disease  may  not  at  any  time  as- 
sume a  much  more  malignant  type.  In  the  mean- 
time the  inhabitants  of  Uta.i  seem  to  be  making 
the  most  of  their  opportunities  for  getting  a  mild 
inoculation  of  the  disease  without  money  .ind  with 
small  risk. 


May   4,    liHilJ 


EDITORIAL  COMMENT 


['^ 


The   Philadelphia 

MEDH  AL   JorRNAL 


831 


The  Constitutionality  of  the  Compulsory  Vacci- 
nation Act  Upheld  in  Pennsylvania.  It  will  gen- 
erally be  found  that  the  misdirected  efforts  of  cer- 
tain well-meaning  persons  in  opposition  to  many 
progressive  movements  are  based  principally  upon 
prejudice,  misconception,  misinformation  and  want 
of  information.  This  is  peculiarly  true  with  regard 
to  such  matters  as  vaccination,  animal  experimenta- 
tion, disease-notification  and  the  like.  In  the  long 
run  a  correct  decision  will  be  rendered  by  the  sound 
common  sense  of  those  who  are  not  blinded  by  emo- 
tion, but  are  open  to  conviction  by  facts.  A  rational 
intelligence  must  ever  prevail  over  misguided  fan- 
aticism, however  well  intended.  It  is  therefore  par- 
ticularly gratifying  to  learn  that  the  Supreme  Court 
of  Pennsylvania  has  just  decided  in  an  opinion  sus- 
taining the  decision  of  the  lower  court  that  the 
Act  of  Assembly  requiring  the  vaccination  of  all 
children  desiring  to  attend  the  public  schools  is 
constitutional.  The  case  in  point  is  one  in  which 
an  anti-vaccinationist  had  applied  to  the  courts  for 
a  mandamus  compelling  the  principal  of  a  public 
school  to  receive  as  a  pupil  a  child  that  had  not 
been  vaccinated,  refusal  being  based  upon  a  rule  of 
the  Board  of  Education  and  an  Act  of  Assembly. 
The  demurrer  of  the  plaintiff  was  overruled  by  the 
Court  of  Common  Pleas,  and  it  is  the  decision  of  the 
latter  that  has  just  been  sustained.  The  Supreme 
Court  of  Pennsylvania  coincides  with  the  view  that 
■'school  directors,  in  the  exercise  of  a  sound  dis- 
cretion, may  exclude  from  the  public  schools  pupils 
who  have  not  been  vaccinated."  It  goes  on  to  say 
further:  "Whether  a  resolution  excluding  from  the 
public  schools  pupils  who  have  not  been  vaccinated 
is  a  reasonable  one  is  to  be  judged  of  in  the  first  in- 
stance by  school  directors.  In  the  present  state  of 
medical  knowledge,  and  of  convincing  opinion  of 
those  having  in  charge  the  public  health,  the  courts 
will  not  say  that  such  a  resolution  is  an  abuse  of 
official  discretion."  This  is  both  sound  law  and  com- 
mon sense.  The  utility  of  vaccination  has  been  es- 
tablished beyond  all  peradventure  and  the  preju- 
dices of  the  few  must  be  subordinated  to  the  welfare 
of  the  many. 

The  Rudolph  Virchow  Stiftung. — The  Germans 
are  practical.  In  nothing  is  this  more  evident  than 
in  their  expression  of  gratitude.  It  takes  a  form 
that  gratifies  the  object,  and  at  the  same  time  is  of 
direct  benefit  to  a  larger  or  smaller  portion  of 
humanity,  or  an  aid  to  scientific  advancemenr. 
Think  for  a  moment  of  the  great  number  of  Fest- 
schrifts that  have  been  published  in  Germany,  and 
published,  as  a  rule,  not  as  is  done  in  America,  in 
a  special  volume  with  a  limited  circulation,  but  in 
one  of  the  regular  massive  German  Archivs ;  a 
special  honorary  number  occupying  an  entire  vol- 


ume. For  example,  we  refer  to  the  most  recent, 
the  volume  of  Deutsche  Zcitschrift  fucr  Ncrvcnheil- 
kunde,  dedicated  to  Erb.  But  even  this  does 
not  seem  practical  enough  for  our  very  practical 
German  friends.  Virchow,  full  of  honors,  is  about 
completing  the  eightieth  year  of  his  age.  He  was 
born  on  the  13th  of  October,  1821,  and  for  more 
than  a  half  century  has  actively  borne  his  part  in 
the  scientific  advancement  of  the  world.  Now  his 
friends  and  admirers,  not  a  few,  have  organized  a 
committee  upon  whose  roll  appear  the  names  of 
practically  all  the  distinguished  medical  men  of 
Germany,  and  with  these  have  been  associated  a 
committee  of  foreigners,  among  whom  are  the  most 
distinguished  names  of  the  world.  And  the  object 
is  not  the  erection  of  a  monument,  or  even  the  en- 
dowment of  a  professorship,  but  the  increase  in 
the  endowment  of  the  Rudolph  Virchow  Stiftung  in 
Berlin,  by  which  the  committee  hope  to  prepare  for 
the  master  "the  greatest  pleasure  and  satisfaction 
upon  the  occasion  of  his  eightieth  birthday;"  be- 
cause "the  man  who  directs  it,  and  whose  name  it 
bears,  has  made  of  it  a  so  distinguished  use,  for  the 
purpose  of  the  advancement  of  science." 

An  Odd  Coincidence. — In  the  chapter  of  coinci- 
dences, the  case  of  Giacomini  and  his  brain  should 
take  prominent  place.  It  does  not  often  fall  to  the 
lot  of  a  man  to  describe  for  the  first  time  some 
very  striking  anomaly  of  the  brain ;  still  more  rarely 
does  it  fall  to  his  lot  to  die  and  have  some  one  else 
discover  that  he  had  the  very  anomaly  which  he 
had  himself  described.  Yet  this  seems  to  have  been 
the  happy  fate  of  Giacomini — an  illustration,  per- 
haps, of  the  truth  of  the  old  Greek  aphorism  that 
you  cannot  judge  of  a  man's  happiness  until  after 
he  is  dead.  Giacomini,  an  Italian  scientist,  was  the 
first  to  describe  a  second  central  fissure,  just  behind 
the  fissure  of  Rolando.  Afterwards  Calori  described 
a  second  case.  Since  then  the  cerebral  morpholo- 
gists  have  been  looking  eagerly  for  a  third.  Dr. 
Burt  Wilder  thought  he  had  found  it  in  an  educated 
suicide's  brain,  but  he  felt  obliged  later  to  say  that 
he  was  mistaken.  Now,  by  strange  chance,  Gia- 
comini dies,  and  his  anatomist  comes  forth  and 
says  that  in  Giacomini's  brain  is  also  a  second  cen- 
tral fissure !  We  are  indebted  to  Mr.  E.  A. 
Spitzka,  of  New  York,  for  a  drawing  of  this  brain, 
and  hope  to  present  it  in  the  near  future.  In  the 
meantime  we  should  like  to  have  a  psychological 
explanation  of  this  strange  happening. 

Bogus  American  Dental  Diplomas  in  Germany. — 
\Wt  have  received  a  communication  from  one  of  the 
American  consuls  in  Southern  Germany  to  the 
effect  that  his  Consulate  has  been  entrusted  by 
Ambassador  White  with  the  investigation  of  the 


83^ 


The   Philadelphia"] 
Mkuical  Journal  J 


EDITORIAL  COMMENT 


[May    4.    lO'il 


matter  of  the  sale  of  illegitimate  dental  diplomas 
in  that  part  of  Germany  by  certain  American  insti- 
tutions, especially  in  Chicago.     The  abuse  has  oc- 
cupied much  time  for  more  than  a  year,  and  of  late 
has   been    especially   engrossing.       The    Consulate 
has  been  collecting  evidence  against  the  scoundrels 
at  home,  and  working  with  the  Ministry  of  Justice, 
the  Attorney   General's  office   and  the   Police   De- 
partment in  Germany  to  punish  the  holders  of  such 
diplomas.     The  parties  in  America  have  been  bold 
.and  reckless  because  their  market  has  been  prin- 
cipally abroad,and  they  seem  never  to  have  dreamed 
that  their  work  could  be  brought  home  to  them, 
but   the   Consulate   has   succeded   in    a   number   of 
cases   in   securing   possession   of   the   diplomas,   li- 
censes, certificates,  etc.,  and  has  had  them  photo- 
graphed,   thoroughly  identified     under    oath,     and 
certified.     Copies  have  been  sent  to  the  Governor  of 
Illinois,  the  National  Association  of  Dental  Facul- 
ties, the  United  States  Commissioner  of  Education, 
and,  of  course,  to  the  Department  of  State.     Eight 
prosecutions    have    been    commenced    in    Germany 
against   holders   of   such   "rags,"   in   one   of   which 
conviction  was  secured  on  a  defective  indictment, 
which  was  set   aside  on    an  appeal    on    technical 
grounds,  but  the  case  will  be  retried  on  a  new  indict- 
ment which  had  just  been  found.     In  another  case 
a  conviction  is  to  be  expected.     The  .Consulate  has 
just  sent  to  the  American  State  Department  a  re- 
port covering  174  printed  pages,  giving  a  full  his- 
tory of  the  matter,  and  the  Consul  has  completed 
a   very   full   brief  of   the   law   and   facts   in   a   case 
against  one  of  the  chief  offenders,  at  the  request  of 
the    Minister   of   Justice    in    Bavaria.     So   reckless 
have  the  Chicago  people  been  that  there  is  good 
reason  to  assume  that  in  1900  about  nineteen  hund- 
red  illegitimate  licenses  have  been   issued   in   Illi- 
nois.    The   Consul    has   also   excellent   ground    for 
assuming  that  the  Imperial   German  Consulate   at 
Chicago    has    not    been    sufticiently    careful    in    the 
matter, and  diplomatic  representations  will  probably 
be  made,  and  an  explanation  asked.  Whatever  may 
be  the  ultimate  result,  the  American  Consul  is  mak- 
ing it  so  very  hot  for  the  holders  of  such  diplomas 
that     he    has     practically    closed     the     market    in 
Southern  Germany,  and  it  is  believed  that  the  evi- 
dence  furnished   to   the   American   authorities   and 
the  press  will  make  dealers  at  home  more  circum- 
spect  in   their   transactions.     We   print   the    state- 
ment of  the  Consul  largely  in  his  own  words.    This 
disgraceful  business  must  be  stopped,  and  it  rests 
largely,  we  judge,  with  the  Illinois  State  Board  of 
Dental  Examiners  to  explain  and  to  stop  it. 

The  New  Living  "Siamese"  Twins. — Dr.  Chapot- 
'Prevost,  who  successfully  operated  upon  the  only 
other  living  xiphopagus,  has  just  published  a  report 


of  his  examination  of  the  new  living  Chinese  twins, 
Liou-Tang-Sen  and  Liou-Seng-Sen.  In  a  communi- 
cation read  before  the  Paris  Academy  of  Medicine 
(Gacctte  Mcdkalc  de  Paris,  1901,  Nos.   12  and   13), 
he  says  that   this  xiphopagus  is  on  exhibition   in 
Vienna  at  the  Barnum-Bailey  circus.     After  much 
persuasion  he  was  permitted  to  make  a  thorough 
examination  of  the  twins,  who  were  born  in  1887. 
in   Nankong,  in  a  level  country,     and  were    their 
mother's  first  children.     Delivery  was  uneventful, 
the   father   alone   officiating.     Seng   came   into   the 
world  head  first,  Tang  feet  first  after  his  brother. 
At  birth   each  child  was  a  little  under  normal  in 
size.     There  was  one  umbilical  cord  with  only  one 
placenta.  The  mother  was  20  3-ears  old,  the  fathc 
18 ;  and  there  had  been  no  history  of  twins  on  either 
side.     Their    mother    had    no    children     afterward. 
The    twins    were    breast-fed    until    they    reached 
ihe  age  of  two  years  and  a  half.     The  boys  began 
to    talk    at     18    months,    plainly    only    at    three 
years.        Both    are    intelligent,   Tang   rather   more 
than  Seng.     They  can  sleep  on  either  side.     Four 
years  ago  they  had  chicken-pox.  Tang  taking  it  one 
day  after  his  brother.     Seng  shows  the  scars  yet. 
The)^  are  always  happy  and  hardly  ever  disagree. 
They  walk  and  run  together,  easily,  in  one  direction, 
but  when  they  attempt  to  go  the  other  way.  wit)' 
their  other  sides  approximated,  there  is  great  diffi- 
cult3%  one  going  from  left  to  right,  the  other  from 
right  to  left.     They  were   1 1  years  old  when  they 
left  China,  before  which  time  a  Scotch  physician  in 
Shanghai   had   examined   them.     Tang  is    1.352m. 
high,  while  Seng  measures  only   1.343m.     A  year 
ago  each  weighed  60  pounds.    One  can  urinate  at  a 
time ;  one  will  be  awake  while  the  other  sleeps:  and 
only  one  may  be  hungry.     From  the  various  meas- 
urements, radiographs,  and  photographs  taken,  but 
slight  difference  has  been  found  between  them.  The 
bridge  which  unites  them  is  4  cm.  long  above.  9  cm. 
lielow.    There  is  one  umbilicus  in  the  center  of  the 
bridge,  above.     As  they  have  grown,  this  bridge 
uniting  them  has  also  grown,  and  they  now  stand 
further  from  one  another  than  formerly.    The  two 
xiphoid  cartilages  join  inside  this  uniting  bridge, 
and  below  them  it  is  probable  that  the  liver  and 
peritoneal  cavity  of  each  joins  the  other.    Seng  has 
a  double  inguinal  hernia.  Tang  right  inguinal  her- 
nia.    Dr.  Chapot-Prevost  calls  them  the  eleventh 
reported  living  case  of  true  xiphopagus,  and  believes 
that   surgical   interference   would   undoubtedly  be 
successful. 

A  Plea  for  the  Aspirator. — Xo  error  is  more  com- 
mon, especially  in  hospital  practice,  than  mistaking 
a  pleural  effusion  for  a  pneumonic  consolidation, 
and  rice  versa.  This  is  due  largely  to  the  fact  that 
it  is  often  practically  impossible  to  obtain  an  ade- 


Mat  4.   1901] 


EDITORIAL   COMMENT 


CThe   Philadelphia       S  ?  ■j 
Medical  Jocbxal         ^oj 


quate  history,  and  that  the  physical  signs  are  so 
indefinite  that  a  final  diagnosis  cannot  be  made  im- 
mediately.    The  differential  diagnosis  is  concerned 
only    with    pneumonias  of  the  bases  and    pleurisy 
with  effusion  either  of  a  serous  or  purulent  nature. 
At  the  onset  of  the  affection  difficulties  may  arise, 
especially  if  a  chill  be  absent  and  only  "stitches  in 
the  side"  occur.     Frequently,  in  such  cases,  neither 
crepitant  rales  nor  friction  sounds  are  present.  Only 
high  fever  and  a  tj'pical  pneumonic    sputum    are 
symptoms  which  in  such  a  case  would  give  a  clue 
to  the  correct   diagnosis.     A  careful   investigation 
of  the  methods  of  physical  diagnosis  will,  however, 
sooner  or  later,  even  in  the  most  obscure  case,  show 
the  true  nature  of  the  malady.     It  is  true  that  oc- 
casionally    pleurisy      with     eft'usion,     complicates 
croupous  pneumonia,  but  a  change  in  the  symptoms 
and  physical  signs  will  readily  denote  this.    We  de- 
sire especially  to  call  attention  to  a  condition  which 
sometimes  arises,  and  is,  we  fear,  verj-  frequently 
neglected,   nameh-,   the   fact   that   a   pleuris}'   with 
effusion  (and  often  an  empyema,  especially  in  chil- 
dren  and   adolescents),  is    a    sequel    of    croupous 
pneumonia.     If,  after  the  ninth  or  eleventh  day  a 
crisis  has  occurred,  or  the  acute  affection  has  ter- 
minated by  lysis,  and  the  fever  continues,  giving 
a  subfebrile  range,  and  dyspnea  and  some  cyanosis 
be  present,  a  pleural  effusion  upon  the  affected  side 
should  be  thought  of.     The  temperature  may  even 
be  markedly  remittant  and  of  a  septic  type,    sweat- 
ing and  chills  occurring,  and  acute  phthisis  of  the 
pneumonic  type  be  thought  of,  especially  if  the  pa- 
tient  is   losing    weight    rapidly.     An    exploratory 
puncture  carefully  conducted,  in  accordance  with 
the     established     laws,     will     frequently     disclose 
the  true  nature  of  the  disease.     A    mistake    is    fre- 
quently made  in  using  a  hypodermic  needle  or  a 
Pravaz  syringe  for  the  purpose  of  puncturing.     It 
must  be  remembered  that  a  thick  serous  fluid,  and 
especially  pus.  will  not  flow  through  a  narrow  nee- 
dle,   and    even    if  its  presence  be  demonstrated    by 
these  means,  an   aspirator  will   subsequently  have 
to      be      used,      thus      inflicting      two      punctures 
upon    the    suffering    patient.         Harm      is    never 
done  in  aspiration,  if  only  the  ordinary  care,  which 
should  govern  us  in  all    operative    procedures,    is 
used.    Knowledge  of  the  position  of  the  diaphragm, 
and    the     intrathoracic    organs,  will    prevent    any 
injury  to  these.      Another  feature   in   the    differen- 
tial   diagnosis,    often    we    fear  neglected,    js    the 
displacement    of    viscera    which    is    sure    to    occur 
in  even  medium  sized  effusions.     The  recognition 
of  the  position  of  the  apex  beat  of  the  heart,  the 
position  of  the  liver,  and  the  obliteration  of  Traube's 
semilunar  space,  are  all  points  of  the  greatest  im- 
portance in  the  differentiation  of  consolidation  of 
the  lung  and  fluid  in  the  pleura. 


The  Trouble  in  the  New  York  Pathological  Insti- 
tute.— We  regret  to  learn  from  the  Medical  Rcc- 
ord  that  the  State  Lunacy  Commission  of  New 
York,  has  notified  Dr.  Ira  VanGieson  that  his  ser- 
vices will  not  be  needed  after  ^Nlay  1st.  We  have 
referred  on  several  occasions  in  these  columns  to 
the  trouble  which  has  existed  between  the  State 
Lunacy  Commission  and  the  working  staff  of  this 
institute,  ^^'e  have  always  attempted  to  be  judicial 
in  our  expression  of  opinion,  but  we  have  feared 
that  the  difference  was  a  fundamental  one  and  that 
it  might  yet  lead  to  serious  impairment  of  the  use- 
fulness of  this  institution.  Dr.  VanGieson  and  his 
associates  represent  that  we  may  call  the  ultra- 
scientific  party.  They  are  actuated  by  the  highest 
motives  and  the  most  laudable  zeal  to  advance  the 
cause  of  scientific  psychiatrj-.  Some  of  their  critics 
believe  that  they  have  taken  a  too  exclusively  la- 
boratory view  of  this  science,  and  that  their  work 
has  not  been  sufficiently  practical.  It  is  doubtless 
true  that  they  have  extended  their  field  of  work 
beyond  the  limits  that  are  usually  considered  essen- 
tial in  psychiatrical  research.  But  the  zeal  and  the 
cultivated  intelligence  which  have  led  them  to  do 
this,  are  of  the  kind  that  have  often  been  the  fore- 
runners of  important  discoveries  in  science.  They 
can  scarcely  be  blamed  because  they  have  sought 
to  throw  light  from  all  quarters  upon  one  of  the 
most  involved  and  far-reaching  of  the  medical  sci- 
ences. If  in  doing  this  they  have  somewhat  ignored 
the  immediate  practical  needs  of  the  hospitals,  the 
fact  is  not  altogether  to  be  wondered  at.  This  is 
the  indictment  which  has  been  brought  against 
them,  as  we  understand  it,  by  the  Lunacy  Commis- 
sion. They  themselves,  on  the  other  hand,  claim 
that  the  ideas  of  the  Lunacy  Commission,  and  even 
of  some  of  their  colleagues  in  the  hospitals  for  the 
insane,  are  crude  and  not  up  to  date,  and  that 
their  opponents,  indeed,  in  their  zeal  for  practical 
administration  have  shown  a  failure  to  appreciate 
the  needs  of  scientific  psychiatry. 

We  cannot  help  but  believe  that  where  such  fun- 
damental dift'erences  of  opinion  exist  on  such  an 
important  topic  there  must  be  some  mutual  funda- 
mental defects.  We  fear  there  has  been  on  both 
sides  a  lack  of  adjustability,  or  of  that  wise  spirit  of 
compromise  which  is  so  often  essential  in  the  prac- 
tical affairs  of  life.  At  this  distance  we  cannot  help 
but  feel  that  there  should  have  been  sufficient  sa- 
gacity and  forbearance  on  each  side,  as  well  as  zeal 
for  the  common  cause,  to  have  brought  harmony 
out  of  even  such  discordant  elements.  The  scien- 
tific world,  and  especially  the  world  of  psychiatry, 
may  well  deplore  the  results  of  this  unequal  con- 
test. It  may  also  well  deplore  the  fact  that  this  con- 
test has  involved  an  acute  display  of  personal  feel- 
ing which  even  extends  beyond  the  limits  of  the 


Q,  ,        The  Philadelphia"! 
o4         Medical  Jocknal   J 


EDITORIAL  COMMENT 


[Mat   4,    ^9ijl 


State  of  New  York.  This  issue  has  been  made  to 
appear  to  be  only  another  phase  of  the  so-called 
antagonism  of  the  administrative  men  to  scientific 
workers.  We  are  not  willing  to  believe  that  there 
is  as  much  of  this  antagonism  abroad  in  the  world 
as  is  made  to  appear,  but  we  would  rather  think 
that  these  unfortunate  misunderstandings  are  often 
due  as  much  to  lack  of  tact  as  to  any  inherent  or 
inevitable  want  of  agreement. 

For  Dr.  VanGieson  personally,  we  have  much 
sympathy,  and  we  trust  that  he  will  yet  find  a  con- 
genial field  in  which  to  work  out  his  plans  and 
theories.  The  members  of  the  Lunacy  Commission 
will  now  have  an  opportunity  to  show  the  world  by 
the  kind  of  appointment  they  make  what  their  real 
ideas  are  about  the  nature  of  scientific  work  in  men- 
tal science.  Their  opportunity  is  great;  their  re 
sponsibility  is  still  greater. 

The  Influence  of  Intercurrent  Disease  on  the 
Course  of  Epilepsy. — The  influence  of  intercurrent 
disease  in  a  patient  already  suffering  from  a  well- 
defined  malady  has  long  been  recognized,  but  is,  as 
yet,  not  understood.  In  general,  it  may  be  said  that 
certain  diseases  act  favorably  on  the  primary  con- 
dition; as,  for  example,  erysipelas  in  certain  forms 
of  sarcoma ;  while  others  exert  a  markedly  unfavor- 
able influence  and  aggravate  the  primary  condition. 
Such,  for  instance,  is  the  effect  of  a  broncho-  pneu- 
monia in  whooping  cough,  or  measles.  Dr.  M.  J. 
Voisin  has  recently  published  a  report  of  one  of  his 
clinics  {La  Scmaine  Medicale,  March  20th,  1901), 
in  which  one  phase  of  this  problem,  the  effect  of  in- 
tercurrent disease  on  epilepsy,  is  ably  discussed. 
He  calls  attention  to  the  fact  that  many  diseases  of 
febrile  form  exert  a  restraining  influence  upon  the 
epileptic  attacks,  while  others  show  a  decidedly 
provocative  influence.  He  has  observed  four  cases 
of  erysipelas  in  epileptics  who  averaged  two  or 
three  attacks  a  month,  with  decided  symptoms  of 
vertigo.  The  manifestations  entirely  disappeared 
during  the  acute  attack  of  erysipelas,  but  with  the 
establishment  of  convalescence  the  vertigo  reap- 
peared, soon  to  be  followed  by  the  convulsive  seiz- 
ures. The  influence  of  anthrax  was  not  less  evident 
than  in  the  cases  which  have  been  described  by  M. 
Queriand.  In  Voisin's  patient,  the  epileptic  attacks 
entirely  disappeared  with  the  suppurative  symp- 
toms which  terminated  in  the  patient's  death.  The 
effect  of  lobar  pneumonia  and  measles  is  similar  and 
more  variable.  The  attacks  usually  disappear  dur- 
ing the  acme  of  the  disease,  and  then  may  be  in- 
creased, or  diminished  in  severity,  after  convales- 
cence. The  association  of  epilepsy  with  so  preva- 
lent a  disease  as  tuberculosis  presents  a  variety  of 
results.  It  has  been  found,  however,  that  the  epilep- 
tic attacks  are  less  frequent,  or  disappear  entirely, 


when  the  tuberculous  process  is  most  acute ;  and 
that  they  reappear  when  the  pulmonary  symptoms 
are  ameliorated.  \'oisin  states  that  variola,  acute 
articular  rheumatism,  and  intermittent  fever  act 
very  similarly,  but  points  out  the  interesting  fact 
observed  by  M.  Fere,  that  when  epileptics  are  vac- 
cinated, there  is  a  decided  lessening  of  the  attacks 
in  those  patients  in  whom  the  virus  has  taken.  An 
epidemic  of  diphtheria,  occurring  in  Voisin's  ser- 
vice, afforded  him  the  opportunity  of  observing  the 
effects  of  the  disease  itself,  as  well  as  the  results  of 
antitoxin  treatment.  Of  nineteen  patients  attacked 
with  diphtheria,  four  were  epileptics.  In  these  it 
was  observed  that  the  attacks  disappeared  entirely 
during  the  course  of  the  diphtheria,  and  returned 
in  their  usual  number  after  the  disease  had  run  its 
course.  Of  a  series  of  144  children  who  received  a 
protective  dose  of  antitoxin,  63  were  epileptics.  Of 
these  63,  57  developed  an  intense  erythematous 
eruption  which  appeared  tardily.  It  was  obse^^•ed 
that  the  eruption  was  most  severe  in  the  worst  cases 
of  epilepsy,  and  in  those  children  who  were  idiots. 
X'oisin  remarks  that  it  is  not  possible  to  consider 
this  as  an  example  of  auto-intoxication,  but  be- 
lieves, rather,  that  it  is  dependent  upon  vaso-raotor 
disturbance  in  the  defective  central  nervous  systems 
of  these  cases.  The  foregoing  are  the  diseases 
which  act  more  or  less  favorably  upon  the  course 
of  epilepsy. 

Scarlatina  is  a  most  serious  disease  when  it  at- 
tacks epileptics,  and  the  prognosis  must  be  most 
guarded.  In  19  cases  of  scarlatina  which  occurred 
epidemically  in  \'oisin's  service,  4  were  in  epilep- 
tics, and  these  all  died  within  four  or  five  days, 
while  the  15  others  recovered  uneventfully.  Influ- 
enza greatly  increases  the  number  of  epileptic  at- 
tacks, and  its  pulmonary  complications  exert  a  very 
deleterious  influence  on  such  patients.  \'oisin  men- 
tions the  remarkable  increase  in  the  number  of  at- 
tacks in  certain  of  his  cases.  One  patient  had  174 
attacks  in  five  days ;  and  another  suffered  from  the 
astounding  number  of  214  in  a  single  day.  Typhoid 
fever  also  increases  the  number  of  seizures.  This 
has  been  made  the  subject  of  a  thesis  by  Dr.  Lan- 
nois,  of  Lyons.  Three  theories  have  been  adduced 
to  explain  the  effects  we  have  studied.  They  are, 
that  it  is  due  to  the  action  of  the  high  temperature 
itself ;  that  it  is  the  result  of  a  toxemia  exerting  its 
influence  on  the  nervous  centers :  and  third,  that 
the  diminution  or  the  increase  in  the  number  of  at- 
tacks is  due  to  the  fact  that  certain  toxins  exert 
an  inhibitory  action  upon  the  motor  tract,  while 
others  increase  the  motor  excitability.  The  last 
hypothesis  is  the  one  which  \"oisin  adopts  tenta- 
tively. In  conclusion,  he  points  out  that  there  is 
a  post-paroxysmal  rise  of  temperature  in  epilepsy. 


tMAY  4,   laoi 


EDITORIAL  COMMENT 


r  The   Philadelphia       q-_ 
L  MBPirAL  Journal  oj 


usually  amounting  to  five  or  six-tenths  of  a  degree 
Centigrade.  When  the  post-paroxysmal  rise 
amounts  to  one  or  two  degrees  Centigrade,  or  more, 
the  existence  of  an  intercurrent  disease  should  be 
suspected.  This  does  not  apply  to  the  status  cpilcp- 
tints,  in  which  a  greater  rise  is  common.  These  ob- 
servations are  of  wide  general  interest,  and  give 
rise  to  many  problems,  with  the  solution  of  which 
we  may  reach  a  more  comprehensive  knowledge 
of  the  pathology  of  epilepsy,  as  well  as  the  action 
of  toxins  upon  the  nervous  system. 

Uretero-Intestinal  Anastomosis. — Those  who 
have  read  the  interesting  "Historical  and  Experi- 
mental Research"  of  Dr.  Reuben  Peterson  on  anas- 
tomosis of  the  ureters  with  the  intestine,  which  was 
begun  in  the  Journal  of  the  American  Medieal  As- 
sociation, February  i6th,  and  continued  through 
six  issues  of  that  journal,  must  have  been  impressed 
with  the  author's  painstaking  efforts  to  deal  fairly 
with  the  subject  from  every  point  of  view,  and  his 
very  valuable  conclusions  regarding  the  advisabil- 
ity of  the  operation  and  the  best  method  of  per- 
forming it  must  appeal  to  every  surgeon.  The  best 
method  of  dealing  with  the  ureter  injured  during 
the  course  of  an  operation,  in  cases  of  advanced  dis- 
ease of  the  bladder,  and  in  extrophy  of  the  bladder, 
has  been  the  subject  of  unlimited  discussion.  Peter- 
son proves  conclusively  that  placing  the  ureters 
in  the  rectum  is  an  operation  not  only  accompanied 
by  a  high  mortality,  but  that  in  very  rare  cases  does 
the  patient  afterwards  escape  an  infection  of  the 
kidney  through  the  transplanted  ureters.  In  the  ex- 
periments on  dogs  this  sequel  to  the  operation  was 
nearly  universal.  He  has  shown  that  hydrone- 
phrosis is  not  an  infrequent  result  of  the  operation 
because  of  constriction  of  the  ureter  by  the  sutures, 
and  hence  the  point  is  made  that  the  sutures  should 
only  pass  through  the  peritoneum  and  fat  about 
the  ureter.  Peterson  maintains  that  the  operation 
of  introducing  either  one  or  both  ureters  into  the 
bowel  is  an  unjustifiable  operation  unless  the  tri- 
gonum  of  the  bladder  with  the  ureteral  orifices  is 
also  transplanted.  The  technique  of  the  operation 
is  excellently  illustrated  in  Peterson's  article.  Even 
with  transplantation  of  the  trigonum  infection  of 
the  kidney  from  the  bowel  may  take  place.  That  the 
rectum  tolerates  the  presence  of  urine  and  that  a 
patient  with  the  ureters  emptying  into  the  rectum 
can  remain  moderately  comfortable,  are  questions 
long  since  settled.  The  very  few  cases  on  record 
in  which  the  patient  has  escaped  infection  of  the 
kidneys  after  the  introduction  of  the  ureters  into 
the  rectum  without  their  vesical  orifices,  must  con- 
vince every  thoughtful  surgeon  of  the  wise  con- 
clusion reached  by  Peterson  regarding  the  advis- 
ability of  this  procedure. 


The  Prevention  of  Blindness. — While  the  medical 

profession  is  striving  with  remarkable  pertinacity 
for  legislation  to  prevent  the  dissemination  of  infec- 
tious diseases,  it  appears  to  be  almost  oblivious  to 
the  ravages  caused  by  ophthalmia  neonatorum. 
While  the  question  regarding  the  licensing  of  pros- 
titution is  being  argued  to  a  remarkable  degree,  the 
fact  is  lost  sight  of  that  one  of  the  gravest  sequels 
of  prostitution  is  the  blindness  caused  in  the  new- 
born by  infected  mothers.  While  the  duties  and 
privileges  of  midwives  are  being  considered,  but 
little  attention  is  paid  to  instituting  a  compulsory 
prophylaxis  which  midwives  could  carry  out  in  labor 
cases.  The  medical  profession  is  indebted  to  Dr. 
Lucien  Howe,  of  Buiifalo,  N.  Y.,  who  perhaps  has 
done  more  for  the  adoption  of  laws  governing  this 
subject  than  any  other  man  in  the  United  States. 
At  the  meeting  of  the  American  Academy  of  Medi- 
cine, held  in  Jefiferson,  N.  H.,  August  30,  1894,  he 
presented  a  paper  entitled  "The  Present  Condition 
of  Legislation  for  the  Prevention  of  Blindness." 
It  was  the  State  of  New  York  that  made  the  first 
effort  in  this  country  to  obtain  a  law  in  this  direc- 
tion, Maine,  Rhode  Island,  Minnesota,  Ohio  and 
Maryland  soon  following.  While  the  prophylaxis 
of  ophthalmia  neonatorum  should  be  a  part  of 
obstetrical  routine,  it  is  frequently  neglected  by 
some  hasty  and  careless  obstetricians.  Howe 
(Crede's  Method  for  the  Prevention  of  Purulent  Oph- 
thalmia of  Infancy  in  Public  Institutions)  states  that 
previous  to  the  introduction  of  Crede's  method,  the 
records  of  over  17,000  births  tabulated  by  thirteen 
observers,  showed  that  over  9%  of  the  the  children 
developed  ophthalmia  neonatorum,  and  that  after 
the  introduction  of  this  prophylactic  measure  the  re- 
ports of  over  24,000  births,  tabulated  by  31  observ- 
ers, showed  only  .65%.  It  is  true  that  many  women 
are  not  infected  at  the  time  of  childbirth,  but  legis- 
lation is  not  instituted  for  individuals,  but  for  the 
protection  of  the  community.  Up  to  this  time 
legislation  on  this  subject  has  been  for  the  purpose 
of  compelling  midwives,  nurses  and  persons  other 
than  legally  qualified  physicians,  to  report  a  case 
where  there  is  a  swelling,  reddening  or  discharge  of 
pus  from  the  eye. 

The  act  passed  by  the  State  of  Ohio  may  be  taken 
as  an  illustration. 

Section  1.  Should  one  or  both  eyes  of  an  infant  become 
inflamed  or  swollen,  or  show  any  unnatural  discharge  at 
any  time  within  ten  (10)  days  after  its  birth,  it  shall  bs 
the  duty  of  the  midwife,  nurse,  or  relative  having  charge  of 
such  infant  to  report  in  writing  within  six  (6)  hours  to 
the  physician  in  attendance  upon  the  family,  or,  in  the 
al)sence  of  an  attending  physician,  to  the  health  officer  of 
the  city,  village  or  township  in  which  the  infant  is  living  at 
the  time,  or,  and  case  there  is  no  such  officer,  to  some 
practitioner  of  medicine  legally  qualified  to  practice  in 
the  State  of  Ohio,  the  fact  that  such  inflammation,  swelling 
or  unnatural  discharge  exists. 

Section  2.  Any  failure  to  comply  with  the  provisions 
of  this  act  shall  be  punishable  by  a  fine  of  not  less  than 


836 


The  Philadelphia"] 
Medhal  JornXAL  J 


EDITORIAL  COAIMENT 


[Mat    4.    i;«l 


ten  dollars  ($10.00)  nor  more  than  one  hundred  dollars 
(1100.00)  or  imprisonment  for  not  less  than  thirty  (30) 
days,  nor  more  than  six  (6)  months,  or  both  fine  and  im- 
prisonment. 

There  have  been  ver}-  few  convictions,  or  even 
prosectuions,  for  violation  of  this  and  similar 
laws.  For  this  reason  alone  its  value  is-  quite  lim- 
ited. It  should  be  the  duty  of  every  State  not  only 
to  enforce  the  reporting  of  suspicious  cases,  but  to 
institute  measures  for  prophylaxis.  It  would  be 
well  for  the  profession  to  inform  the  laity  in  all 
cases  where  there  is  the  slightest  suspicion  of  con- 
tamination, that  the  instillation  of  nitrate  of  silver  is 
to  a  great  degree  a  preventive  measure  in  ophthal- 
mia neonatorum.  In  this  manner  all  persons  would 
be  invested  with  a  right  which  for  their  own  protec- 
tion they  would  attempt  to  enforce,  thereby  indirect- 
ly influencing  the  attending  physician,  the  midwife, 
or  the  nurse.  It  is  furthermore  the  duty  of  every 
State,  so  far  as  it  is  in  its  power,  to  enforce  the  em- 
ployment of  recognized  prophylactic  measures  in 
the  newborn.  Again  and  again  some  medical  man 
has  assumed  the  leadership  and  tried  to  prevent  the 
catastrophes  resulting  from  cases  of  ophthalmia 
neonatorum  by  invoking  legislation  for  its  preven- 
tion. A  great  many  not  only  become  burdens 
to  themselves,  but  burdens  and  an  expense  to  the 
State  in  which  they  live,  and  for  this  reason,  if  for 
no  other,  it  is  high  time  that  something  should  be 
done.  "There  are  none  so  blind  as  those  who  will 
not  see." 

Objectionable  Names  for  Institutions. —  The 
choice  of  a  name  for  an  institution  designed  pri- 
marily for  the  relief  of  suffering,  or  for  developing 
arrested  mentality  in  children,  is  one  upon  which, 
very  much  depends.  It  is  rather  more  than  senti- 
ment which  has  so  often  prompted  oljjections  to 
such  titles  as  Home  for  Incurables,  Home  for  Con- 
sumptives, Cancer  Hospital,  Institute  for  the  Fee- 
ble Minded,  and  even  (as  recently  established  in 
England)  a  Hospital  for  the  Dying.  There  is  some- 
thing of  pathos  in  the  thought  of  a  man  digging  the 
grave  in  which  his  bones  will  rest — there  is  a  gros.< 
violation  of  the  delicacy  that  is  born  of  the  broad 
spirit  of  humanitarianism,  in  the  thought  of  tagging 
a  man's  remaining  days  with  the  stigma  of  the  mal- 
ady from  which  he  suffers.  Every  physician  well 
knows  the  truth  of  the  lines : 

"The   wretch   condemned   with   life   to   part, 

Still,  still  on  hope  relies. 
And   every  pang  that  rends  the  heart 

Bids  expectation  rise." 

It  behooves  us  to  champion  the  changing  of  these 
objectionable  names  of  institutions.  Let  us  select 
something  which  shall  not  typify  so  ruthlessly  the 
blasted  lives,  or  undeveloped   facilities  of  the  un- 


fortunates entrusted  to  our  care.  We  recognize 
fully  the  value  of  the  element  of  suggestion  in  bet- 
tering the  ph^'sical  processes  through  the  mental, 
and  we  know  full  well  how  a  patient  deprived  of 
hope  will  quickly  wane  and  die : 

"Hope,  dead,  lives  nevermore. 
No.  not  in  Heaven." 

The  objects  and  aims  of  such  institutions  are  by 
no  means  furthered  by  this  method  of  designation. 
Rather  do  they  become  places  to  be  dreaded  and 
shunned.  It  may  be  urged  in  defense  of  these 
titles  that  after  all  a  name  stands  for  little ;  that  the 
patients  will  know  soon  enough  the  true  import  of 
their  disease  and  their  surroimdings.  But  how 
much  better  the  late  Dr.  J.  M.  DaCosta  expressed 
the  thought  in  bequeathing  a  sum  of  money  to  the 
Pennsylvania  Hospital  for  the  endowment  of  a 
ward  for  cases  "now  deemed  incurable."  The  ave- 
nue of  hope  is  still  left  open.  Every  effort  in  the  di- 
rection of  eradicating  the  significance  of  hopeless- 
ness in  these  cases  must  be  regarded  in  the  light  of 
removing  the  fetters  of  apparent  banishment  and 
ostracism. 

Cellular  Poisons  or  Cytotoxins. — The  great  \'ir- 
chow  showed  a  prophetic  instinct  when  he  formu- 
lated his  theory  of  cellular  pathology.  Each  organ 
represents  a  community  of  cells ;  each  cell  is  the  ul- 
timate unit,  possessing  in  a  large  measure  its  own 
individuality.  It  has  its  own  secretion  and  excre- 
tion ;  it  lives,  develops,  reproduces  itself  and  dies. 
When  a  large  number  of  such  cells,  constituting 
an  organ,  become  diseased,  the  entire  community 
suffers,  while  death  of  the  majority  of  cells  termi- 
nates the  life  of  the  organ,  and  if  the  latter  is  essen- 
tial to  life,  also  that  of  the  organism.  All  physiolog- 
ical functions,  as  well  as  pathological  alterations, 
therefore,  reside  primarily  in  the  cell.  In  the  course 
of  its  physiological  activity  the  cell  produces  poi- 
sons (toxins)  and  substances  which  neutralize  the 
latter  (antitoxins).  The  toxins,  on  the  other  hand, 
may  be  harmless  to  the  cell  which  secretes  them, 
but  destructive  to  the  life  of  cells  of  other  organs 
or  of  the  same  organ  in  other  species  of  animals, 
like,  for  instance,  the  insect-sting  or  snake-venom. 
These  facts,  of  such  great  importance  to  the  future 
progress  of  medicine,  are  being  elucidated  by  re- 
markable researches  along  biological  lines.  Met- 
chnikoft',  to  whom  we  owe  our  knowledge  of 
phagocytosis,  has  contributed  to  the  Russki  Archix' 
Patologii  Kliiiitshcskoy  Mcdici)iy  1  Daktcriologii  {Feb- 
)iiar\\  1901),  a  paper  of  most  absorbing  interest.  In 
it  he  reviews  the  progress  made  in  the  study  of  cell- 
toxins.  especially  with  reference  to  hemolysis,  or  the 
destruction  of  the  red  blood-corpuscles  of  one 
species  of  animals  by  the  serum  of  another.  The 
substance  which  destroys  the  blood-corpuscles,  or 


May   4,    11)01] 


EDITORIAL  COMMENT 


TThe  Philadelphia        8?T 
L  Mkdical  Journal        "O/ 


hemotoxin,  consists  of  two  distinct  bodies:  One. 
an  alexin  called  by  Metchnikoff,  cytasc,  is  unstable 
and  is  destroyed  by  a  temperature  of  55-56  C. ;  the 
other,  fixator,  withstands  a  temperature  not  higher 
than  65-68  C.  The  former  is  found  in  the  serum  of 
any  animal ;  the  latter  only  in  the  serum  of  those 
which  have  received  injections  of  blood  (active 
serum).  In  order  that  the  serum  of  an  animal  of 
one  species  may  destroy  the  red  blood-corpuscles  of 
that  of  another  a  combination  of  both  cytasc  and  fix- 
ator must  be  present.  Neither  alone  is  capable  of 
dissolving  the  red  blood-corpuscles.  To  determine 
the  source  and  distribution  of  the  hemotoxin. 
Metchnikoff  conducted  the  following  experiments : 
He  injected  defibrinated  blood  of  a  goose  into  the 
abdominal  cavity  of  a  guinea  pig.  The  red  blood 
corpuscles  were  at  once  seized  by  the  mononuclear 
leukocytes  and  digested  by  the  ferments  secreted 
by    the    latter.  The    analogy    between    this    in- 

tercellular digestion  and  hemolysis  is  so  close  that 
it  lead  to  the  conclusion  that  hemotoxin  is  the  pro- 
duct of  phagocytes  excreted  into  the  serum.  While 
the  fixator  is  circulating  freely  in  the  plasma  the 
cytasc  remains  within  the  living  phagocytes.  But 
when  the  leukocytes  are  by  some  means,  as  by  the 
injection  of  fluids,  seriously  injured,  the  cytasc  is 
released  and  also  circulates  in  the  plasma.  The 
combination  of  the  two  constitutes  the  hemotoxin. 
The  latter,  therefore,  may  be  looked  upon  as  the 
digestive  ferment  of  the  phagocytes  alone.  Any  of 
the  other  cells  produce  substances  which  are  toxic. 
The  injection  of  spermatozoa  of  one  animal  into  the 
serum  of  another  is  followed  by  the  formation  of  the 
spermatoxin,  which  is  identical  both  in  its  action 
on  the  spermatozoa  and  composition  to  hemotoxin. 
Leukotoxin,  a  substance  which  destroys  the  leuko- 
cytes, was  prepared  by  Metchnikofi',  Dellsen,  Funk 
and  others.  \^on  Dungern  obtained,  by  injecting 
into  guinea  pigs  the  mucous  membrane  of  the 
trachea  of  a  bull,  a  serum  which  destroyed  the 
motion  of  the  cilia  of  ciliated  epithelium.  Linde- 
man,  working  in  Metchnikofif's  laboratory,  injected 
intoguineapigspart  of  the  mucous  membrane  of  the 
result  that  he  obtained  a  serum  capable  of  causing 
albuminuria  and  acute  nephritis  when  injected  into 
rabbits. 

Nerve  toxins  have  also  been  produced  although 
with  less  constant  results.  So  far  experiments 
have  been  conducted  mostly  with  heterocytoxins. 
i.e.  those  produced  by  injecting  the  cells  of  one 
species  of  animals  into  those  of  another.  Further 
experiments,  however,  prove  that  the  organism  is 
also  capable  of  producing  autotoxins.  The  reason 
the  organism  is  not  poisond  under  normal  condi- 
tions is  explained  by  Metchnikoflf  by  the  following 
hypothesis:  As  long  as  the  organism  is  healthy  the 


cytasc  remains  enclosed  within  the  leukocytes,  but 
as  soon  as  the  latter  are  injured  by  some  pathological 
alteration,  the  cylase  is  released,  combines  with  the 
fixator  circulating  in  the  blood,  and  autointoxica- 
tion results.  It  has  further  been  demonstrated  that 
by  a  process  of  gradual  immunization  it  is  possible 
to  produce  specific  anticytotoxins.  In  these  Met- 
chnikoff sees  the  future  possibility  of  not  only  cur- 
ing various  degenerative  changes  produced  by  the 
toxins,  but  actually  preventing  them.  Among  the 
conditions  to  be  benefited  in  this  millenium  he  in- 
cludes senile  degenerations  and  atrophies. 


Clinical  Study  of  Deciduoma  Malignum. — G.  Jletoz,  {(faz. 
Hch.  (U:  Mid.  ct  ilc  rhinir.,  March  10,  1901,  48  me.  Annee, 
No.  20.)  (Paris  Thesis. I  A  noticable  feature  in  the  eti- 
ology of  deciduoma  malignum  is  that  the  tumor  always  fol- 
lows pregnancy,  either  after  normal  labor  or  after  abortion. 
The  tumor  may  develop,  as  a  rule,  from  4  to  8  months  af- 
ter delivery.  Women  attacked  with  the  disease  are  usually 
young,  the  usual  age  being  between  26  and  40  years. 
Hydatiform  mole  seems  to  be  an  etiological  factor  in  the 
production  of  the  tumor,  48  cases  out  of  98  show  this  condi- 
tion preceding  the  development  of  the  tumor.  In  the  case 
of  deciduoma  malignum,  as  in  epithelioma  of  the  uterus  the 
tumor  often  reaches  It  full  development  before  giving  rise 
to  symptoms.  When  the  growth  has  reached  a  certaia 
size  so  that  fungous  masses  without  consistency  are  de- 
veloped, intense  hemorrhages  appear.  This  form  of  devel- 
opment belongs  particularly  to  that  form  of  deciduoma 
which  follows  abortion,  or  normal  labor,  and  does  not  ap- 
ply to  those  cases  of  deciduoma  that  follow  extrauterine 
pregnancy.  Uterine  hemorrhage  is  the  first  symptom  of 
the  disease  and  is  due  to  the  involvement  and  the  destruc- 
tion of  the  vessels  by  the  vegetating  masses.  The  most 
important  characteristic  of  the  hemorrhages  is  their  ex- 
traordinary resistance  to  all  kinds  of  treatment.  When  the 
tumor  follows  the  molar  pregnancy  the  uterus  is  markedly 
increased  in  volume:  when  it  follows  abortion  or  normal  labor, 
the  uterusihardly  exceeds  in  size  thatof  3  months  pregnancy. 
The  tumor  is  usually  smooth  and  regular.  On  vaginal  exam- 
ination the  OS  is  sometimes  partly  open  and  sometimes 
normal.  The  uterine  cavity  presents  a  tumor  that  pro- 
jects but  little  beyond  the  surface  and  that  is  some- 
times pedunculated.  A  little  later  in  the  disease  metas- 
tases appear,  which  may  involve  all  the  organs.  Among 
the  seats  of  these  metastases,  the  vagina  seems  to  be  one 
of  the  most  common.  Pulmonary  metastases  are  common 
and  are  usually  found  at  the  base  or  at  the  apes  of  the 
lung.  Patients  thus  attacked  present  symptoms  similar  to 
those  of  patients  suffering  from  chronic  bronchitis.  Exam- 
ination of  the  sputum  reveals  nothing  characteristic. 
Cachexia  appears  early.  When  hemorrhages  appear  after 
a  patient  has  expelled  an  hydatiform  mole  the  clinician 
ought  to  think  of  deciduoma  at  once.  Hemorrhagic  metritis 
and  fibroma  produce  meuorrhagia  and  menstrual  disorders 
accompanied  by  leucorrea  but  never  such  a  profuse  flow  of 
blood  as  accompanies  deciduoma  malignum.  Vaginal  hys- 
terectomy is  the  proper  treatment  of  the  condition. 
[J.  M,   S.] 

A  Rare  Case  of  Enteroliths. — E.  M.  Schvalbe  f Medici iiskoie 
Ohoxrciiie.  ilarrh.  I'J'H)  calls  atention  to  the  rarity  of  true 
enteroliths  in  man.  In  the  Russian  literature  only  one  case 
is  reported.  He  reports  a  case  of  a  woman  68  years  old 
who  was  admitted  to  the  hospital  suffering  from  intestinal 
occlusion  and  general  peritonitis.  She  died  24  hours  later. 
An  autopsy  revealed  the  presence  of  a  white  chalky 
fluid  in  the  stomach,  while  the  intestines  were  filled  with 
large  and  small  stones  weighing  in  the  aggregate  710 
grms.  (the  largest  stone  weighed  34  grms).  A  chemical 
analysis  of  these  enteroliths  showed  them  to  consist  of 
carbonate  of  lime  with  an  admixture  of  sand.  It  was  sub- 
sequently learned  from  the  the  relatives  that  the  woman 
was  in  the  habit  for  the  past  few  years  of  her  life  of  in- 
gesting large  quantities  of  chalk  or  sand.     [A.  R.] 


Q,c        The   Philadelphia"! 
°o  Medical  JornNAL  J 


AMERICAN  NEWS  AND  NOTES 


(Mat   4,    1901 


Hmerican  mews  aiiD  Hlotes. 


PHILADELPHIA  NEWS. 

College  of  Physicians  of  Philadelphia. — Section  on  Oph- 
thalmology.—Meeting.  April  16,  1901.  Dr.  Wm.  Thomson. 
Chairman,  presiding. 

Dr.  C.  A.  Veasey  exhibited  a  male  patient,  26  years  of 
age  -with  Right  Oculomotor  Paralysis  and  Left  Trifacial 
Paralysis,  involving  both  the  sensory  and  motor  tracts,  to- 
gether with  some  impairment  of  the  right  knee-jerk.  The 
paralyses  were  complete,  and  had  been  preceded  by  con- 
siderable ciliary  pain,  described  as  being  behind  the  eye- 
balls. At  the  time  of  the  appearance  of  the  paralyses 
there  was  some  difficulty  in  passing  the  urine,  a  soreness 
and  "pulling"  behind  the  knees,  which  made  walking  pain- 
ful, considerable  vertigo,  and  some  headache,  though  the 
last  was  by  no  means  pronounced.  There  had  also  been 
Blight  staggering  at  times.  The  case  was  thought  to  be  one 
of  cerebro-spinal  syphilis  with  meningeal  involvement, 
probably  most  marked  at  the  base,  in  the  interpeduncular 
space,  and  over  the  pons. 

Dr.  Geo.  C.  Harlan  exhibited  a  case  of  Abscess  of  the 
Orbit  from  Disease  of  the  Ethmoid;  Curetting  through  the 
Orbit  and  Drainage  through  the  Nose.  The  patient  had 
had  nasal  catarrh  for  more  than  a  year,  with  caries  of  the 
turbinate  bone. 

Dr.  G.  C.  Harlan  called  attention  to  a  method  of  per- 
forming Iridectomy  in  Case  of  Obliteration  of  the  Anterior 
Chamber,  which  was  described  by  Gayet  at  the  meeting 
of  the  French  Ophthalmological  Society  in  1884.  After 
fixing  the  eye  with  the  double  fixation  forceps,  Gayet  makes 
a  minute  incision  into  the  periphery  of  the  anterior  cham- 
ber with  the  ordinary  scarificator  by  sawing  movements, 
enlarging  the  incision  with  blunt  scissors.  Dr.  Harlan 
had  found  this  method  of  operating  very  useful  recently 
in  a  case  of  chronic  iritis  with  increased  intraocular  ten- 
sion. He  had  found  a  narrow  Weber  canaliculus  knife 
admirably  adapted  to  enlarging  the  incision.  Its  probe 
point  passes  readily  between  the  iris  and  cornea. 

Dr.  S.  Lewis  Zeigler  presented  a  case  of  Hemophilic  Ex- 
travasation into  the  Conjunctiva,  Antrum,  and  Cheek,  as- 
sociated with  habital  constipation. 

Dr.  Ziegler  also  reported  Recurring  Hemorrhages  from 
the  Ciliary  Body,  in  a  woman,  aged  26  years,  who  suffered 
from  habitual  constipation. 

Dr.  John  T.  Carpenter  read  a  paper  on  Purulent  Chor- 
oiditis occurring  in  a  boy,  2  years  old,  who  had  suffered 
from  a  severe  attack  of  mumps  4  weeks  before.  There 
was  deep-seated  yellowish  reflex  behind  the  pupil,  and  the 
entire  uveal  tract  became  infiltrated  with  pus. 

Dr.  H.  F.  Hansen  made  some  remarks  on  the  Use  of  Pilo- 
carpin  in  the  Treatment  of  Inflamations  of  the  Eye.  He 
read  the  history  of  a  number  of  cases,  and  gave  in  detail 
the  method  he  employs  in  the  treatment.  The  cases  were 
those  of  interstitial  keratitis,  traumatic  purulent  iritis,  vit- 
reous opacities,  and  retinochoroditis.  In  most  of  the  pa- 
tients the  improvement  had  been  most  rapid  and  marked, 
while  in  all  the  treatment  had  proved  beneficial.  He  ex- 
pressed regret  that  the  treatment  had  not  been  more  gen 
erally  followed  in  chronic  deep-seated  ocular  inflamma- 
tions where  the  usual  routine  treatment  was  most  pro- 
longed or  unsuccessful,  and  felt  sure  from  his  Increased 
experience  that  many  forms  of  inflammation  and  of  loss  of 
vision  could,  with  few  exceptions,  be  materially  improved. 
The  recovery  in  some  of  the  cases  described  was  most 
Batisfactorj-.  The  most  striking  was  that  of  Case  No.  1.  of 
traumatic  purulent  kerato-iritis,  in  which  the  intense  in- 
jection had  decidedly  cleared  and  the  large  collection  of 
pus  in  the  anterior  chamber,  altogether  disappeared  in  24 
hours,  with  complete  recovery  In  one  week. 

DiKcnssinn — Dr.  de  Schweinitz  had  secured  gratifying 
results  with  pilocarpin  in  the  treatment  of  the  same  class 
of  cases  referred  to  bv  Dr.  Hansell.     He  stated  that  some 


nerve  specialists  placed  great  reliance  upon  the  drug  in 
toxic  insanity  after  influenza,  autointoxication,  and  similar 
processes,  the  brain  rapidly  clearing  after  two  or  three 
sweats.  Apart  from  its  action  hypodermatically,  he  had 
found  pilocarpin  or  the  fluid  extract  of  Jaborandi,  ia  small 
doses  by  the  mouth,  to  be  of  value,  especially  in  degener- 
ation of  the  vitreous.  He  had  never  had  but  twice  un- 
pleasant symptoms  following  the  pilocarpin  sweating,  one 
a  bad  attack  of  pulmonary  edema,  and  the  other  intense 
salivation.  The  persistent  nausea  that  is  so  common  after 
the  use  of  the  drug  is  usually  relieve  by  small  doses  of 
chlorodyne,  as  suggested  by  Dr.  H.  C.  Wood.  Dr.  Shumway 
had,  in  one  instance,  persistent  secondary  sweating,  for 
which  he  was  compelled  to  use  alcohol  bathing.  Dr.  Han- 
sell said  he  had  never  had  to  employ  measures  to  limit 
the  period  of  skin  action. 

Dr.  G.  E.  de  Schweinitz  reported  a  case  of  Probable 
Methyl-alcohol  Amaurosis,  the  Pathway  of  Entrance  of  the 
Posion  being  the  Lungs  and  the  Cutaneous  Surface,  and 
reviewed  the  literature  of  blindness  from  this  liquid.  The 
man,  aged  39,  was  a  vamisher  by  trade.  Two  months  prior 
to  his  amaurosis  he  had  been  constantly  employed  in  shel- 
lacing, and  was  accustomed  to  dilute  the  shellac  to  the 
desired  thinness  with  methyl-alcohol.  He  was  therefore 
almost  uninterruptedly  during  the  working  hours  of  this 
period  exposed  to  the  fumes  of  the  wood-spirit,  and  was 
also  accustomed  at  the  end  of  his  day's  work  to  wash  his 
hands,  forearms,  and  face  with  the  same  liquid  in  order 
to  remove  the  shellac  stains.  Dr.  de  Schweinitz  drew  par- 
ticular attention  to  the  dangers  which  workers  in  this 
liquid  ran,  and  thought  that  they,  as  well  as  their  em- 
ployers, should  be  properly  warned.  He  pointed  out  the 
analogy  between  these  dangers  and  those  which  were  en- 
countered by  workers  in  lead,  nitrobenzol,  and  dinitro-ben- 
zol,  and  how  in  the  last  three-named  trades  all  proper  pre- 
cautions were  taken  to  prevent  the  well-known  toxic  action 
of  these  drugs. 

Di.ictission — Dr.  Hansell  said  that  he  had  examined  the 
man  on  several  occasions.  When  he  first  came  to  the 
Jefferson  Hospital  he  had  double  optic  neuritis  of  moder- 
ate grade  and  was  totally  blind.  Under  treatment  vision 
improved  in  each  eye  so  that  he  was  able  to  go  about  the 
streets  alone.  The  improvement  was  retained  for  a  few 
weeks  and  then  vision  commenced  to  decline.  The  diag- 
nosis that  was  made  at  the  first  examination  was  hemor- 
rhage into  the  chiasm,  and  this  seemed  to  be  confirmed  at 
later  examinations  by  a  well-marked  right  hemianopsia, 
distinctly  outlined  in  the  left  eye  and  less  complete  In  the 
right.  The  optic  neuritis  gave  away  rapidly  to  atrophy. 
There  was  no  paralysis  of  any  of  the  ocular  muscles. 

Dr.  Wm.  Thomson  gave  a  demonstration  of  a  New  Lan- 
tern Test  for  Detecting  Color  Blindness,  being  aided  by  a 
young  ophthalmologist  who  suffered  from  green  blind- 
ness, the  form  of  color  defect  which  has  been  found  most 
difficult  to  detect  by  the  wool  test  of  Holmgren  and  its 
varieties. 

Neurological  Society. — At  the  meetins  of  April  22  Dr. 
Alfred  Gordon  exhibited  a  Case  of  tea-intoxication  with 
spinal  symptoms.  The  patient  ivas  a  woman  of  SI  who  had 
drank  as  high  as  SCO  ounces  of  tea  per  day.  She  presented 
the  symtoms  of  combined  sclerosis  together  with  hysteri- 
cal manifestations.  Cerebral  symptoms  were  not  marked. 
The  possibility  of  lead  poisoning  was  suggested,  this  being 
derived  from  the  coloring  of  the  tea.  Dr.  J.  Chalmers  Da 
Costa  exhibited  a  case  of  trichiniasls.  This  case,  of  which 
ony  a  preliminary  report  was  made,  was  interesting  from 
several  points  of  view.  The  affection  began  in  the  calf  of 
the  right  leg  during  January  1901.  The  gastrocnemius 
muscle  enlarged  and  was  painful  at  night.  The  condition 
has  extended  until  the  thigh  is  now  involved.  The  muscles 
are  greatly  enlarged  and  dense.  There  is  a  history  of 
traumatism  on  the  calf  of  that  leg  last  August  but  re- 
covery from  the  bruise  was  apparently  complete.  The 
patient  changed  occupation  after,  the  injury  and  began  eat- 
ing pork  4  times  a  week  but  denies  eating  any  raw  pork,  al- 
though he  has  eaten  raw  beef.    Sections  of  muscle  removed 


Mav    4.    KMIll 


AMERICAN  NEWS  AND  NOTES 


Cl'lIB     rHII.AinCI.IHIA  8  20 

Mr.ri     AT.   .IfHIlNAL  "J7 


for  study  shows  numerous  trichinae.  The  highest  per- 
centage of  eosiuophilis  in  the  blood  was  4%  the  first 
count  made.  Later  counts  show  that  the  leul^ocytes  have 
iucreased  from  12,000  to  20,000,  but  the  eosinophiles  are 
less.  The  case  is  interesting  because  of  the  absence  of 
all  the  ordinary  signs  of  trichiniasis.  Dr.  Max  Bochroch 
exhibited  a  case  ot  chronic  arthritis.  The  patient  has  a 
history  ot  3  attaclis  of  rheumatism.  There  is  now  limita- 
tion of  movement  of  the  Ijaok  and  there  is  also  some 
rigidity  of  the  shoulder  and  hip  joints.  The  supra-and  in- 
fra-spinatus  muscles  are  much  atrophied.  Drs.  William  E. 
Hughes  and  \V.  G.  Spiller  rejjorted  a  case  of  severe  anu- 
mia,  with  changes  In  the  spinal  cord.  Post  mortem  showeil 
sclerosis  of  the  spinal  cord  but  there  was  no  evidence  of 
changes  in  the  vessels  the  condition  probably  being  due 
to  a  toxic  material  in  the  blood.  Discussion  by  Drs.  Lloyd, 
Burr  and  Mills  emphasized  the  point  that  changes  in  the 
vessels  are  not  essential  points  in  the  etiology  of  this 
condition.  Dr.  Mills  stated  that  pernicious  toxemia  is  a 
better  term  than  pernicious  anemia.  Dr.  W.  W.  Keen 
reported  a  case  of  secondary  suture  of  the  posterior  in- 
terosseous nerve  w/ith  complete  re-establisment  of  function. 
The  patient  was  a  man  of  38  who  in  August  1900  received 
au  axe  wound  which  severed  the  posterior  interosseus  nerve. 
In  November  the  nerve  was  exposed,  7mm.  removed  and 
the  ends  approximated.  Slight  extension  of  the  fingers  was 
possible  in  8  days  and  the  improvement  afterward  was 
steady.  Dr.  David  Riesman  reported  a  case  of  Intermittent 
claudication.  The  patient  was  a  man  who  hart  pain,  numb- 
ness, loss  of  power  of  the  legs,  etc.  when  he  was  on  the 
street.  A  few  minutes  rest  would  enable  him  to  proceed 
again.  The  etiology  of  the  condition  seemed  to  include  only 
three  factors,  tobacco,  exposure,  and  mental  strain.  Nitro 
glycerine  and  potassium  iodide  gave  no  relief  but  the  pa- 
tient seems  better  after  the  use  of  the  bromides.  Stroph- 
anthus  will  be  added. 

Pennsylvania  Hospital. — The  Pennsylvania  Hospital, 
termed  by  its  historian.  Dr.  Thomsa  G.  Morton,  "the 
Mother  of  American  Hospitals,"  will  celebrate  on  May  11 
next  the  150th  anniversary  of  its  establishment.  It  was 
founded  by  the  Assembly  of  the  Province  of  Pennsylva- 
nia in  1751,  in  response  to  a  petition  in  the  handwriting  of 
Benjamin  Franl\lin,  which  was  drawn  up  at  the  suggestion 
of  Thomas  Bond.  Funds  were  not  plentiful,  and  it  was  only 
on  the  offer  of  Drs.  Thomas  Bond,  Lloyd  Zachary,  and 
Phineas  Bond  to  give  their  services  for  three  years  that  a 
modest  grant  of  £2,000  was  made,  to  be  supplemented  by 
a  like  amount  from  private  subscription.  Since  its  incep- 
tion, to  quote  from  the  Philadelphia  Lrdiicr,  "the  hospital 
has  either  led  or  kept  pace  with  advancements  in  surgery 
and  medicine.  It  was  the  first  to  introduce  clinical  teach- 
ing in  this  country,  the  first  bedside  instruction  in  medi- 
cine being  given  by  Dr.  Bond.  It  was  the  pioneer  in  this 
country  in  caring  for  the  insane,  and  led  the  world  in  evolv 
ing  and  perfecting  the  humane  and  rational  treatment  of 
those  suffering  from  disordered  minds."  Another  circum- 
stance that  gives  it  fame  is  that  it  is  the  one  great  hospi- 
tal in  the  country  that  has  cared  for  wounded  soldiers  of 
the  colonial  and  Revolutionary  wars,  the  War  of  1812,  the 
Mexican  war,  the  civil  war.  and  the  Spanish-American 
war. 

Philadelphia  County  Medical  Society. — A  regular  meet- 
ing of  the  Society  was  held  April  24,  the  President.  Dr. 
George  Erety  Shoemaker,  occupying  the  chair. 

Dr.  John  B.  Roberts  exhibited  2  cases:  (1)  Insertion 
of  artificial  vitreous  after  evisceration  of  the  eyeball;  (2) 
Rhinoplasty  after  loss  of  the  end  of  the  nose.  The  further 
program  of  the  evening  was  a  symposium  on  Diphtheria. 
Dr.  J.  D.  Steele  read  a  paper  on  The  present  aspect  of  the 
Antitoxin  Treatment  of  Diphtheria.  Dr.  Steele  quoted 
figures  from  various  societies  and  compilers  showing  the 
diminished  mortality  from  diphtheria  since  the  introduction 
of  the  antitoxin  treatment.  The  results  vary  according  to 
the  promptness  with  which  the  antitoxin  is  administered, 
the  mortality  being  from  3  to  5%  in  cases  where  injec- 
tions are  begun  on  the  first  day  and  increasing  each  day 
thereafter  until  the  average  of  about  1C%  is  reached. 
A  case  was  cited  to  show  the  protection  afforded  the 
myocardium  by  early  injection  of  antitoxin.  .\  girl  who 
had  a  badly  damaged  heart  as  shown  by  multiple  mur- 
murs was  taken  with  di]>htheria.  On  the  evening  of  the 
second  day  1250  cc.  of  antitoxin  in  2  doses  was  admin- 
istered.    The   girl   went   on   to   rapid   convalescence   with 


no  apparent  involvement  of  the  heart  by  the  disease. 
Paralyses  following  diphtheria  are  not  materially  reduced 
by  the  use  of  antitoxin.  As  to  the  immunizing  power  of 
antitoxin  an  occurrence  at  the  Presbyterian  Hospital  was 
cited.  Three  or  4  cases  of  diphtheria  occurred  in  the 
children's  ward.  The  remaining  children  and  the  nurses 
were  given  immunizing  doses  of  antitoxin.  Cultures  were 
soon  afterward  made  from  the  throats  of  17  patients  and 
2  nurses.  In  .5  patients  and  1  nurse  the  Klebs-Loffer  ba- 
cillus was  found.  A  later  test  from  10  patients  and  4  nurses 
showed  the  bacillus  in  3  patients  and  3  nurses.  Yet  there 
was  no  evidence  of  clinical  diphtheria  in  any  of  these 
cases.  To  prevent  the  spread  of  diphtheria  the  immun- 
izing power  of  antitoxin  should  always  be  employed  in 
addition  to  isolation  and  thf  making  of  cultures  from  the 
throat  to  determine  where  infection  exists.  A  successful 
method  of  removing  the  bacilli  from  the  throat  is  to  swab 
on  3  successive  days  with  a  solution  of  silver  nitrate,  I 
drachm  to  the  ounce.  Statistics  of  the  mortality  from 
diphtheria  in  Chicago,  New  York.  Boston,  and  Philadel- 
phia were  given.  These  showed  Philadelphia  to  have 
a  mortality  considerably  higher  than  either  of  the  other 
cities  mentioned,  the  .'general  city  ihstory  not  being  at  all 
satisfactory  in  this  respect.  The  conclusion  of  the  paper 
was  that  the  curative  and  immunizing  power  of  diphtheria 
antito.vin  bad  greatly  reduced  the  mortality  from  diph- 
theria and  that  it  should  be  promptly  used  for  the  treat- 
ment and  prevention  of  that  disease.  It  has  probably  not 
been  employed  in  Philadelphia  with  the  energy  shown  in 
the  other  cities  named,  with  the  result  of  a  higher 
death  rate  in  the  former  city. 

The  discussion  on  the  subject  of  the  evening  was  opened 
by  Dr.  A.  C.  Abbott,  who  spoke  on  The  Bacteriology  of 
Diphtheria.  Dr.  Abbott  said  that  many  physicians  had 
difficulty  in  understanding  why  some  cases  of  diphtheria 
did  not  have  severe  clinical  symptoms  and  yet  the  bacter- 
iologist would  tell  them  that  virulent  germs  were  pres- 
ent in  the  throat  ot  the  patient.  The  speaker  explained  this 
by  saying  tliat  variety  in  diphtheria  was  not  more  re- 
markable than  in  other  diseases.  This  is  probably  due  not 
so  much  to  the  bacteria  as  to  the  resistance  of  the  indi- 
vidual. Then  again  there  are  variations  in  the  virulence  of 
the  bacteria,  but  it  is  true  that  virulent  bacilli  are  as  often 
found  in  mild  cases  as  in  severe  cases  clinically.  The 
ps^eudo  diphtheria  bacillus  was  once  differentiated  by  its 
pathogenic  powers  from  the  bacillus  ot  diphtheria,  the 
guinea  pig  test  being  the  standard.  Now  the  term  is  con- 
fined to  those  which  resemble  the  true  bacillus  but  can 
bo  differentiated  by  other  methods.  Nasal  cases  with  no 
clinical  manifestations  should  be  carefully  looked  after. 
Dr.  Richard  Pearce  exhibited  lantern  slides  showingThe 
Pathology  of  Diphtheria.  The  slides  illustrated  the  changes 
taking  place  in  the  heart  and  kidneys  when  those  organs 
are  involved.  Dr.  .Toseph  McFarland  spoke  on  The  mode 
of  operation  of  antitoxins.  Two  theories  are  held  regard- 
ing this.  One  is  (hat  they  stimulate  vital  reaction  in  the 
orsanism  ag.iinst  the  toxins  present.  A  second,  held  by  the 
Germans,  is  that  there  is  a  chemical  reaction  between  the 
toxin  and  antitoxin.  It  is  impossible  at  the  present  time  to 
say  which  is  correct  but  indications  point  to  the  latter  as 
the  more  probable.  The  various  toxin  and  antitoxin  reac- 
tions are  partly  specific.  In  some  instances  where  half  a 
dozen  or  more  poisons  are  similar,  as  snake  venoms,  one 
intitoxin  does  for  all  and  is  not  specific  for  any  one. 
Diphtheria  toxin  is  the  only  one  of  its  kind,  hence  dipli- 
theria  antitoxin  is  the  only  one  that  will  counteract  it.  The 
chemical  effect  of  various  antitoxins  and  their  effects  ou 
toxins  and  tissues  was  discussed  at  length.  Dr.  M.  How- 
ard F'ussell  said  that  as  an  early  practitioner  he  had 
looked  for  the  typical  textbook  cases  of  diphtheria  but  he 
failed  to  find  them.  Neither  the  constitutional  nor  local 
symptoms  are  characteristic.  It  is  said  that  in  diphtheria 
the  exudate  is  removed  with  difficulty  and  leaves  a  bleed- 
ing surface.  But  this  is  found  in  other  infections.  Slight 
complaining  by  the  patient  is  more  characteristic  of  diph- 
theria than  of  other  infections.  The  only  positive  diag- 
nosis is  that  made  from  throat  inoculations  but  while 
waiting  for  the  result  of  the  bacteriological  investigation 
antitoxin  should  be  given.  Dr.  Fussell  rarely  uses  more 
than  1000  units  at  a  dose,  but  repeats  it  unless  improve- 
ment is  early  and  rapid.  Applications  to  the  throat  are 
made  or  not  made  according  to  the  individiml.  Deaths 
have  occurred  as  a  result  of  persistently  making  applica- 
tions to  nervous  struggling  children.  Simple  alkaline  so- 
lutions in  Dr.  Fussells  experience.     He  always  gives  mer- 


S40 


The    rmi.ADEi.rniA" 

Ml-.M'  AI,    Jllt'ltNAL    . 


AMERICAN  NEWS  AND  NOTES 


IMay    4.    1901 


cury  and  iron.  Dr.  Packard  said  tliat  he  believed  the  high 
mortality  of  Philadelphia  was  due  to  the  fact  that  many 
mild  cases  of  diphtheria  were  not  reported  as  such  because 
of  placarding   houses,   etc. 

The  Pennsylvania  Society  for  the  Prevention  of  Tuber- 
culosis.— The  annual  meeting  of  the  Pennsylvania  Society 
for  the  Prevention  of  Tuberculosis  was  held  in  Philadelphia 
on  April  11,  1901.  The  secretary  reported  that  during 
the  past  year  the  society  had  published  and  distributed 
over  30.000  of  its  tracts  and  had  used  constant  efforts  to 
induce  those  in  influential  positions  to  aid  in  preventing 
the  spread  of  the  disease.  The  Society  used  its  influence 
to  secure  the  new  rule  of  the  Bureau  of  Health  by  which 
cases  of  tuberculosis  are  to  be  registered  in  Philadelphia. 
It  has  published  a  leaflet  on  the  subject  of  Registratioi.. 
Its  publications  have  been  sent  all  over  the  United  States 
in  response  to  many  requests.  Its  officers  have  endorsed 
and  assisted  the  Free  Hospital  for  Poor  Consumptives  of 
Philadelphia  and  have  gone  to  the  New  Jersey  Legisla- 
ture to  assist  in  pleading  for  a  State  Hsopital  for  con- 
sumptives in  that  State.  The  society  has  made  strong  ef- 
forts to  show  the  need  of  a  State  hospital  tor  consump 
lives  in  Pennsylvania. 

Historical  Club  of  the  Department  of  Medicine  of  the 
University  of  Pennsylvania. — The  first  stated  meeting  ot 
this  club  was  held  at  the  office  of  Dr.  Charles  A.  Oliver, 
on  Wednesday  evening,  the  seventeenth  of  .\plrl,  1.901.  Dr. 
Oliver  presiding. 

The  club  which  was  organized  in  March.  1901,  has  for 
its  objects  "the  study  of  the  history,  with  the  collection, 
presentation  and  publication  of  dates  relating  to  the  De- 
l;artuient  of  Medicine  of  the  University  of  Pennsylvania." 
Besides  original  research  into  the  past  history  of  the  De- 
partment with  the  periodic  publication  of  a  series  of 
Proceedings,  and  the  getting  of  a  special  library,  it  is  in- 
tended that  the  club  shall  collect  historic  portraits,  pic- 
tures, engravings,  furniture,  instruments,  books,  certifi- 
cates, etc.,  to  be  placed  in  appropriate  University  quar- 
ters. After  an  informal  discussion  in  reference  to  the 
collection  and  disposition  of  some  ot  the  diplomas  of  the 
early  graduating  classes  of  the  department,  the  original 
minutes  of  the  organization  meeting  of  the  Alumni  Soci- 
ety of  the  Medical  Department  were  read  and  deposited 
among  the  archives  of  the  Club  by  the  presiding  officer  of 
the  evening.  Arrangements  were  made  to  present  a  ser- 
ies of  papers  on  the  Graduates  of  the  Medical  Depart- 
ment who  served  during  the  Revolutionary  War  at  the 
next  meeting. 

Pathological  Society  of  Philadelphia. — The  annual  Con- 
versational Meeting  of  the  Society  was  held  April  2.5.  The 
address  was  delivered  by  Dr.  Charles  Wanlell  Stiles,  of 
Vv'ashington,  his  subject  being  "Trichinella  spiralis,  Trich 
inosis,  and  Trichina  Inspection — A  Zoological  Study  in 
Public  Medicine."  Dr.  Stiles  spoke  first  of  Dr.  Leidy.  of 
Philadelphia,  who  in  1817  discovered  the  trichina  in  ham 
from  which  he  was  preparing  a  sandwich.  The  parasite 
had  been  discovered  in  man  in  183,5,  but  Dr.  Ledy's  discov- 
ery was  the  foundation  of  the  knowle<lge  of  its  life  his- 
tory. Dr.  Stiles  then  reviewed  the  trouble  between  the 
United  States  and  Germany  regarding  pork  sent  from  this 
country.  The  system  of  inspection  was  detailed.  During 
the  years  ISfiO-OS  there  were  14,S21  cases  of  trichnosis  in 
Germany  with  831  deaths.  The  German  inspection  ot  pork 
includes  the  diaphragm,  poas  muscles,  and  the  tongue.  In 
1896  there  were  in  Prussia  27,602  paid  microscopists  en- 
gaged in  meat  inspection.  This  would  mean  nearly  65,000 
for  the  United  States  were  such  a  system  inaugurated. 
Comparing  the  cost  for  the  two  countries  it  would  cost 
this  country  between  3  and  4  millions  of  dollars  annually. 
Dr.  Stiles  then  compared  the  American  curing  process  with 
German  inspection  as  a  means  of  rendering  pork  safe  to 
eat.  A  summary  of  the  cases  in  Germany  from  1881  to  1898 
shows  that  3388  cases  and  132  deaths,  or  53<~r  of  all  cases 
and  41So  of  all  deaths  were  due  to  faults  ot  German  in- 
spection methods.  Inspection  creates  a  false  security  and 
dependence  had  better  be  placed  on  curing  and  cooking. 
During  the  exclusion  of  American  pork  from  Germany  there 
■were  4093  cases  ot  trichinosis  with  274  deaths  in  that 
country.  Since  readmission  of  American  pork  there  have 
been  1093  cases  and  27  deaths.  Statistics  show  that  there 
have   actually    been   less   cases    during   the   admission    ot 


American  pork  than  during  its  exclusion.  Since  its  re- 
admission  there  has  been  greater  vigilance  by  the  au- 
thorities and  90%  of  all  cases  have  been  traced  to  their 
source.  Not  one  case  has  been  traced  to  American  pork, 
thus  fully  proving  its  sanitary  quality.  The  German  in- 
spection is  no  more  valuable  than  the  curing  methods 
here  and  the  government  should  not  accede  to  the  few 
and  establish  a  system  of  inspection  with  its  great  cost. 

In  reply  to  several  questions  Dr.  Stiles  stated  that  the 
ordinary  pickling  methods  in  use  here  would  destroy  all 
trichinae  in  3  months.  The  so-called  "embalming"  of  meat, 
made  famous  by  the  late  war,  is  one  of  the  greatest  ad- 
vances in  hygiene  ever  made  in  this  country.  It  enables 
the  process  of  curing  to  proceed  from  the  interior  of  the 
meat  outward  at  the  same  time  that  It  ie  extending  in- 
ward from  the  immersion  fluid.  The  Government  here 
takes  no  part  in  the  curing  of  meat  for  home  consumption. 
but  export  meat  must  have  been  in  the  pickle  for  a  cer- 
tain length  of  time.  The  government  takes  no  stand  in 
regard  to  the  chemicals  used  by  the  packers.  There  is 
no  inspection  here  for  local  trade  but  interstate  meat  is 
inspected  for  tuberculosis,  hog  cholera,  etc.,  but  not  for 
trichinae.  Pork  in  general  contains  trichinae  to  the 
amount  of  2%. 

Obituary. — Dr.  M'illiam  Jei^yll  Reichmann,  at  Algiers.  Af- 
rica, on  March  29. — Dr.  Joshua  Kenedy,  at  Scales  Mound, 
ill.,  on  April  20. — Dr.  Thomas  H.  Buckler,  at  Baltimore,  Md.. 
on  April  20,  aged  9C  years. — Dr.  Lewis  R.  Kirk,  at  Rising 
Sun,  Md,,  on  April  19,  aged  69  years. — Dr.  Edward  M. 
Schaeffer,  at  Baltimore  Md.,  on  April  21,  aged  45  years. — 
Ijr.  J.  H.  Woodburn,  at  Indianapolis,  Ind.,  on  April  23. — 
Or.  Joseph  S.  Carradine,  at  East  Orange.  N,  Y.,  on  April  23. 
— Dr.  Joseph  S.  Carradine.  at  East  Orange.  N.  Y.,  on  April 
23. — Dr.  Edwin  F.  Morris,  at  Birmingham,  Ala.,  on  April 
23,  aged  36  years. — Dr.  Horatio  Guzman,  at  Washington, 
D,  C,  on  April  23.  aged  50  years. 

Vital  Statistics  of  Philadelphia  for  the  week  ending 
April  27,  1901: 

Total  mortality    485 

Cases.  Deaths. 
InilammatiOD  of  appendix  2,  bladder  1, 
brain  11,  bronchi  7,  kidneys  23,  lungs 
73,  pericardium  1,  peritoneum  5.  pleura 

1,  stomach  and  bowels   16   140 

Marasmus    10,  debility    8,    inanition    11  29 

Tuberculosis  of  the  lungs    73 

Apoplexy  13,  paralysis  &   21 

Heart-disease  ot  34,  fatty   degeneration 

ot  4.  neuralgia  of  2  40 

Uremia  11,  diabetes  4,  Brights  disease 

13 28 

Carcinoma  of  bladder  1,  breast  4, 
stomach  4,  pelvic  1,  face  1,  kidney  1, 

rectum  1,  throat  1   14 

Convulsions    14 

Diphtheria    55  6 

Brain-abscess  of  2.  congestion  of  1.  soft- 
ening of  3,  tumor  of  1  7 

Typhoid  fever       44  7 

Old  age   6 

Cyanosis    4 

Scarlet    fever    114  t 

Atheroma  1.  alcoholism  2.  asthma  3. 
anemia  1,  burns  and  scalds  4,  casual- 
ties 13.  congestion  of  the  lungs  .5. 
carbuncle  1.  cirrhosis  of  the  liver  3. 
consumption  of  the  bowels  1.  croup, 
membranous  1.  dropsy,  abdominal  2, 
erysipelas  4,  fever,  gastric  1.  remittent 
1,  gall  stones  1.  gangrene  3.  hernia 
1,  influenza  6,  jaundice  2,  locomotor 
ataxia  1,  leukemia  1.  obstruction  of 
the  bowels  2.  odemia  of  lungs  2. 
rheumatism  5,  retention  urine  1.  scler- 
osis, arterial  3  septicemia  4  small- 
pox 1.  sarcoma  paroticgland  1.  sarco- 
ma liver  1.  stricture  ot  esophagus  1, 
suicide  2.  teething  1.  tetanus  1.  tumor, 
neck  1.  stomach  1,  whooping  cough 
3,  wounds,  gunshot  1,  89 


WAV  -1.  i;«iii 


AMERICAN  NEWS  AND  NOTES 


CThe   Philadelphia       Hat 
Medical  Journal         "'i'- 


NEW    ENGLAND. 

Death  of  Dr.  George  Cogswell. — Dr.  George  Cogswell,  93, 
one  of  the  oldest  residents  of  Haverhill,  died  April  11th, 
at  his  residence  in  Bradford  district.  He  was  born  in  At- 
kinson, N.  H.,  the  son  of  Dr.  William  Coswell,  who  was 
chief  surgeon  at  West  Foint  during  the  Revolution. 

Death  of  Dr.  Fred  J.  Brockway. — Dr.  Fred  .7.  Brockway 
died  at  the  Brattleboro  retreat  April  21st,  after  an  illness 
of  several  months.  Dr.  Brockway  was  born  in  South  Sut- 
ton, N.  H.,  in  1S60.  During  his  boyhood  he  attended  the 
district  schools,  and  prepared  for  college  at  the  Tilton 
seminary,  where  he  graduated.  Soon  after  he  entered 
Yale,  where  he  received  the  degree  of  A.  B.  in  1882,  after 
which  he  taught  school  in  Stamford,  Ct.,  for  two  years, 
when  he  entered  the  college  for  physicians  and  surgeons 
in  New  York,  where  he  graduated  in  1SS7,  being  class  presi- 
dent and  one  of  the  honor  men.  After  graduation  he  re- 
ceived an  appointment  in  the  surgical  department  of  Roose- 
velt hospital,  which  position  he  held  for  a  period  of  two 
years,  retiring  to  accept  the  position  of  resident  surgeon 
at  Johns  Hopkins  hospital,  Baltimore,  being  the  first  resi- 
dent surgeon.  In  the  fall  of  1890  he  returned  to  New 
York  as  lecturer  and  demonstrator  of  anatomy  at  the  college 
of  physicians  and  surgeons,  and  later  was  appointed  secre- 
tary of  the  faculty,  which  position  he  held  until  the  date 
his  last  illness.  He  was  a  member  of  Omega  society,  life 
member  of  the  New  England  society,  member  of  the  aca- 
demy of  medicine,  West  End  medical  society,  county 
medical  society,  American  association  of  anatomists,  aca- 
demy of  science,  American  museum  of  natural  history. 
New  York  athletic  club  and  the  Johns  Hopkins  resident 
association.  He  was  the  author  of  "Chemistry  and  Fhys- 
ics,"  "Compend  of  Anatomy."  He  wrote  the  chapter  on 
viscera  for  the  last  edition  of  "Gray's  Anatomy."  revised 
"Nancreed's  Anatomy,"  and  when  stricken  by  illness  was 
preparing  a  work  on  anatomy,  which  Dr.  W.  H.  Rockwell. 
Jr.,  formerly  of  Brattleboro,  will  complete.  In  addition  to 
these  he  wrote  several  monographs  on  anatomical  subjects. 
When  stricken  down  he  was  entering  upon  a  most  flatter- 
ing professional  career,  his  gentle  and  lovable  nature  hav- 
ing won  for  him  a  host  of  friends  among  his  scientific  breth- 
ren. He  seldom  took  a  vacation,  but,  on  the  contrary, 
worked  almost  incessantly,  and  the  final  breakdown  re- 
sulted largely  from  ceaseless  devotion  to  his  profession. 

A  Case  of  "Folie  Communique." — According  to  the  Jour- 
iiul  of  Mental  and  Nrnoius  Diseases,  a  family  consisting  of 
two  brothers  and  a  sister,  living  in  New  Haven.  Conn.,  re- 
cently all  became  insane  within  one  week.  The  sister 
became  ill  and  acute  mania  quickly  developed.  A  few  days 
later  the  older  brother  suddenly  lost  his  reason  and  began  to 
rave,  attacking  the  physician  who  was  called  in.  Two  days 
after  this  the  younger  brother  developed  acute  melancholia. 
Although  the  family  was  considered  well-to-do.  no  property 
lias  been  found,  and  they  will  become  charges  of  the  State 
Hospital  for  the  Insane. 

WESTERN     STATES. 

Appointment. — Dr.  Reuben  Peterson  of  Chicago  has  been 
appointed  to  the  Bates  professorship  of  the  diseases  of 
women  in  Michigan  University,  to  succeed  Dr.  J.  N.  Martin. 

Dr.  John  Bassian. — Dr.  John  Bassian  died  on  April  18th 
at  Fresno.  Cal.,  aged  70  years.  He  was  a  native  of  Turkey, 
an  eccentric  man.  one  of  profound  learning  and  one  who 
had  at  his  Hngers'  ends  all  the  languages  of  the  Mediter- 
ranean and  of  the  Levant.  He  was  the  father  of  Alexia 
Bassinm.  who  is  well  known  in  the  musical  world.  She 
once  sang  before  the  Prince  of  Wales  and  exhibits  a  soli- 
taire and  diamond  cluster  ring  as  a  gift  and  memento  of  the 
occasion.  Dr.  Bassian  served  as  a  surgeon  in  the  Turkish 
army  and  was  special  court  physician  to  the  Sultan. 

Cancer  Increasing. — Late  statistics  from  all  points  tend 
to  sustain  the  claim  of  many  American  observers  that 
cancer  is  increasing  in  frequency  to  an  alarming  extent, 
in    Mo.scow    the    number    of    rej-'^rted    cases    has    doubled 


since  ISSO,  while  in  Russia  (according  to  Heymann) 
the  rate  of  mortality  from  carcinoma  is  four  times  as 
great  as  in  1S77. 

Insane  from  Religious  Excitement. — In  the  report  of  the 
Central  Hospital  for  the  Insane,  at  Indianapolis.  Ind.,  the 
superiniendeut  classifies  the  causes  which  led  to  the  in- 
sanity of  the  persons  committed  during  the  year,  and  of 
the  five  hundred  and  seven  nearly  ten  per  cent,  were 
made  insane  by  reason  of  religious  excitement.  The  re- 
port says  that  none  of  the  latter  were  affected  bv  heredi- 
tary insanity. 

Appointment. — Dr  A,  W.  Barber,  of  Cheyenne,  Wyo.. 
was  recently  appointed  secretary  of  the  State  Board  of 
Health. 

Appointment. — Dr.  George  B.  Storey,  of  Portland,  Oregon, 
who  has  been  acting  as  assistant  surgeon  in  the  army  in 
the  Philippines  since  the  outbreak  of  the  war  with  Spain, 
has  been  appointed  assistant  surgeon  in  the  regular  army, 
with  the  rank  of  first  lieutenant 

Western  Ophthalmologic  and  Oto-Laryngologic  Associa- 
tion.— At  the  Sixth  annual  meeting  of  the  Western  Oph- 
thalmologic and  Oto-Laryngologic  Association  held  in 
Cincinnati,  Ohio.  April  11th  and  12th,  the  following  offi- 
cers were  elected:  Dr.  C.  R.  Holmes,  Cincinnati,  O.,  Presi- 
dent: Dr.  W.  L.  Dayton,  Lincoln.  Neb.,  first  vice-presi- 
dent; Dr.  J.  O.  Stillson,  Indianapolis.  Ind..  second  vice- 
president;  Dr.  H.  W.  Loeb,  St.  Louis,  Mo.,  third  vice- 
president;  Dr.  O.  J.  Stein,  100  State  street,  Chicago,  111., 
treasurer:  Dr.  William  L.  BallengeV,  100  State  street,  Chi- 
cago, secretary.  At  the  meeting  in  Cincinnati  the  scien- 
tific program  was  of  very  high  grade.  Forty  new  members 
were  elected. 

SOUTHERN    STATES. 

An  Interesting  Medico-Legal  Point. — A  case  of  a  great 
aeal  of  interest  for  medico-leg.al  experts  has  recently  oc- 
curred in  Christiansburg,  Va  It  appears  that  a  woman  was 
given  an  overdose  of  some  narcotic,  persumably  opium  in 
some  form,  by  her  husband;  he  notified  some  of  the 
neighbors  that  she  was  dead,  but  did  not  allow  them  in 
the  room;  she  was  buried  on  the  second  day.  Suspicions 
having  been  aroused,  the  body  was  disinterred  and  it  was 
found  that  she  bad  given  birth  to  an  infant,  she  being  near 
her  expected  time  of  confinement.  This  fact  at  once 
gave  rise  to  the  rumor  that  she  was  put  in  her  coffin  alive 
and  in  her  struggles  to  extricate  herself,  gave  birth  to 
(he  child. 

Blackmailers  Foiled. — Dr.  J.  H.  Hargram,  of  Petersburg, 
Va.,  has  caused  the  arrest  of  three  men  in  his  city,  who 
came  to  his  office  and  charged  him  with  wronging  the 
daughter  of  one  of  them  and  demanded  at  the  point  of  a 
pistol  that  he  should  pay  $1000.  The  doctor  finding  him- 
self at  a  disadvantage  said  he  had  no  money,  but  would  go 
out  and  fix  up  a  note.  He  was  allowed  to  go  and  went  at 
once  to  a  magistrate  and  swore  out  a  warrant  against  the 
intruders. 

In  Active  Practice  for  57  Years. — Dr.  James  McCaw.  of 
Richmond,  Va.,  on  the  occasion  of  his  retirement  from  the 
medical  profession  was  recently  presented  with  a  silver 
bowl  by  his  medical  friends. 

Decision  in  Favor  of  Vaccination. — In  a  test  case  made  in 
Austin, Texas,  the  Attorney  General  has  decided  that  school 
trustees  have  the  right  to  require  certificate  of  successful 
vaccination  of  all  children  making  application  to  be  ad- 
mitted to  schools. 

Dr.  Henry  Bryon  McKellops. — Dr.  Henry  Bryon  McKel- 
lops  died  April  2:?.  at  St.  Louis,  at  the  age  of  seventy-eight 
years.  He  had  an  international  reputation  as  an  authority 
on  all  matters  pertaining  to  dentistry  and  dental  surgery. 
He  was  born  in  Salina,  near  Syracuse,  N.  Y.  In  1855  the 
Ohio  Dental  College  conferred  on  him  the  degree  of  Doc- 
tor of  Dental  surgery;  in  1S65  he  organized  the  Missouri 
Dental  Association,  and  in  1877  was  elected  President  of  the 
St.  Louis  Dental  Association.  In  1S6S  he  was  chosen 
President  of  the  American  Dentists'  Association,  and  later 
of  the  Southern  Dental  Association,  and  the  Mississippi 
Valley  Dental  Society.  Dr.  McKellops  was  commended 
for  gallantry  during  the  Mexican  war,  commanding  Moi^ 
gans  Riflemen. 


842 


The    I'BiLAi 
Medical  J 


lIKLrHIA"! 
OURNAL    J 


American  news  and  notes 


[Mat    4,    '901 


Association  of  American  Medical  Colleges. — The  next 
regular  meeting  ot  this  association  will  be  held  at  the 
Hotel  Ryan,  St.  Paul,  Minn,,  Monday  June  3d,  1901.  It 
will  consist  of  two  sessions,  an  educational  session  and  a 
business  session.  The  educational  session  will  be  opened 
at  2  P.  M.,  by  the  President's  address,  followed  by  several 
papers  of  medical  pedagogic  interest.  To  this  session  all 
persons  interested  in  medical  education  are  respectfully 
invited.  The  representatives  and  associates  of  the  Asso- 
ciation of  Southern  Medical  Colleges  have  received  a 
special  invitation.  The  members  of  the  Confederation  of 
State  Examining  and  Licensing  Boards  are  also  invited. 
There  will  also  be  an  exhibition  of  work  done  in  medical 
colleges.  At  8  P.  M.  the  business  session  will  be  held  at 
which  the  amendments  to  the  Constitution  proposed  by 
several  colleges  will  be  considered.  The  report  of  the 
judicial  council,  the  election  of  members  and  the  election 
of  officers  for  the  succeeding  year  will  close  the  pro- 
gram. 

Retires  as  Rear  Ad.niral.— Medical  Director  Walter  K. 
Schofield,  of  this  city,  goes  on  the  United  States  Navy 
retired  list,  still  retaining  the  title  of  medical  director,  how 
ever,  but  with  the  rank  of  rear-admiral  added.  Director 
Scofield  has  been  in  the  service  for  forty  years.  He  was 
born  in  Connecticut  in  1839.  At  the  outbreak  of  the 
Civil  War  in  1S61  he  entered  the  medical  corps  as  as- 
sistant surgeon  and  was  with  Farragut's  fleet  during  many 
of  the  most  memorable  engagements  of  the  rebellion,  serv- 
ing off  Charleston  and  later  off  the  coast  of  Florida.  He 
served  a  year  in  the  hospital  in  New  Orleans;  afterward 
he  was  transferred  to  the  Norfolk  Hospital,  where  he  was 
stationed  when  peace  was  declared.  Director  Scofield  has 
a  host  of  friends  among  naval  veterans,  who  all  attest  tc 
his  skill  as  a  surgeon.  After  the  war  Director  Scofield  was 
stationed  in  China,  Japan.  South  \merica,  Africa  and 
Europe.  During  those  years  he  passed  through  all  the 
grades  of  the  medical  branch  of  the  service,  ending  with 
the  title  of  medical  director.  Six  years  ago  he  was  trans- 
ferred to  Philadelphia,  during  which  time  he  has  been 
serving  with  the  Pennsylvania  Marine  District  recruiting 
stations. 

Havana  Improving. — Major  W.  C.  Gorgas.  Chief  Sani- 
tary OfTicer  at  Havana  accompanies  a  tabulated  report  ot 
the  vital  statistics  of  Havana  for  March  with  a  letter  call- 
ing attention  to  the  fact  that  the  death  rate  (26.28)  is  lower 
Ihan  that  of  any  March  since  1889.  There  were  only  four 
cases  and  one  death  from  yellow  fever,  and  since  March 
23  the  city  has  been  free  from  the  disease  Major  Gorga? 
ascribes  this  condition  as  partly  due  to  the  systematic  and 
extensive  way  in  which  the  sanitary  officers  have  been 
killing  the  mosquitoes  during  the  month  over  a  wide  area. 
The  condition  with  regard  to  smallpox  is  equally  satisfac- 
tory, and  Havana  has  not  had  a  case  since  last  August,  al- 
though it  has  been  breaking  out  in  all  parts  of  the  United 
States. 

Leprosy  in  Canary  Islands. — The  existence  of  about  200 
lepers  on  the  Island  of  Teneriffe.  Canary  Island,  has  been 
officially  reported  at  Washington  by  the  Ignited  States 
Consul.  At  Santa  Cruz  de  Teneriffe,  the  capital,  there  are 
22  lepers,  15  of  whom  are  men.  and  there  are  also  some 
children.  There  are  in  addition  living  at  the  same  place 
about  200  people.  Officially  it  is  not  recognized  that  lep- 
rosy exists  on  these  islands. 

CANADA. 

(From  Our  Special  Correspondent.) 

Deatlis  in  Ontario  for  the  month  ot  March,  according  to 
the  bulletin  of  the  Ontario  Provincial  Board  of  Health  to- 
taled 2.111  as  compared  with  2.4S0  for  February  and  2.330 
for  the  corresponding  month  in  1900.  This  increase  repre- 
sents more  than  appears  in  the  figures  for  as  96  per  cent. 
of  the  popukition  reported  last  year  the  returns  tor  this 
year  are  from  only  87  per  cent.  The  following  are  the 
deaths  from  the  principal  contagious  diseases  in 
March:  Scarlet  fever.  M:  diphtheria,  46:  measles.  12: 
V  hooping  cough,  0:  typhoid,  21;  consumption.  188.  Diph- 
lUoria  shows  an  increase  over  1000  when  in  the  same 
month  only  34  deaths  occurred.  The  Registrar-General 
is  of  the  opinion  that  better  attention  to  registration  has 
something  to  do  with  the  increases  in  the  death  returns 
for  the   past  months.      A    Lecture   on   the    Life   of   Huxley 


was  given  before  the  Canadian  Institute  on  Saturday  eve- 
ning last,  the  20th  inst.  by  Dr.  A.  B.  MacCallum.  professor 
of  physiology  in  Toronto  University.  One  interesting  in- 
cident in  the  life  of  this  eminent  scientist  of  local  im- 
portance was  referred  to.  Huxley  was  anxious  to  marry, 
and  in  order  to  enable  him  to  carry  out  this  project,  he  ap- 
plied amongst  other  places  for  the  vacant  chair  of  natural 
history  in  Toronto  University.  This  occurred  in  the  period 
of  "stoim  and  stress"  between  1850  and  1855.  The  post 
in  the  University  of  Toronto  had  been  advertised  at  £350 
per  annum  with  a  share  of  the  fees:  and  while  he  was 
applying  for  this  position  Professor  TjTidall  was  seeking 
a  chair  in  the  same  institution,  namely  that  of  mathematics 
and  natural  philosophy.  Politics  were,  however,  then 
too  strong  in  the  affairs  of  this  university,  for  although 
Huxley  was  the  leading  scientist,  as  teacher  and  inves- 
tigator in  the  field  of  natural  history,  a  brother  of  the 
leader  of  the  then  government  of  Ontario  carried  off  the 
prize  against  his  eminent  competitor.  It  has  been  stated 
that  it  was  Huxley's  opinions  on  religious  subjects  which 
caused  his  rejection,  but  Professor  MacCallum  states  this 
could  not  be  the  truth  as  it  was  not  until  five  years  later 
that  anything  of  this  character  appeared  in  the  writings 
ot  this  great  man.  Then,  Professor  MacCallum  says  it 
was  worthy  of  note  "that  the  filling  of  the  position  was 
made  the  occasion  for  criticism  against  the  university  as  a 
Godless  institution  on  the  ground  that  the  successful  ap- 
plicant was  a  Unitarian  in  religious  belief." 

The  Executive  Committee  of  the  Canadian  Association 
for  the  Prevention  of  Tuberculosis  met  in  Ottawa  on  the 
afternoon  of  Saturday  the  30th  inst.  His  Excellency,  the 
Governor-General  presiding.  Dr.  E.  P.  Lachapelle  of  Mon- 
treal was  added  to  the  Committee.  It  was  decided  to  make 
all  the  Secretaries  of  the  provincial  boards  of  health  cor- 
responding members.  The  Rev.  Dr.  Eby.  the  general  secre- 
tary of  the  Association,  on  request  from  the  Ontario  Ex- 
ecutive and  the  Toronto  branch  was  appointed  a  special 
organizer  and  agitator  for  the  next  sis  months  in  order 
to  carry  on  a  systematic  campaign  of  education  through- 
out the  province  on  the  legislation  passed  one  year  ago 
in  the  provincial  parliament  referring  to  municipal  sanitor- 
ia:  and  towards  this  campaign,  the  central  Association 
voted  the  sum  of  $300.  Dr.  Eby  resigned  the  general  secre- 
taryship and  Dr.  H.  B.  Small,  the  treasurer  of  the  Canadian 
Medical  Association  was  invited  to  accept  the  position. 

WicGill's  Soldiers,  the  boys  who  have  returned  from  the 
South  African  battlefields  were  tendered  a  banquet  by  the 
Graduating  Society  of  the  University  on  the  evening  of 
Friday,  the  19ih  inst.  The  South  African  officers,  non- 
coms.,  and  privates  thus  honored  by  their  fellow  gradu- 
ates numbered  twenty-four  and  were  largely  from  the  medi- 
cal faculty  of  the  University  and  included  Surgeon-Majoi 
Wilson.  Surgeon-Major  Worthington  and  Surgeon-Major 
Fisct.  Two  were  undergraduates  of  McGill.  Trooper  Har- 
old Borden  and  Gunner  O'Reilly,  both  of  the  medical  facul- 
ty, were  not  forgotten  by  their  comrades  and  manv  were 
the  eulogiums  passed  upon  their  bravery  by  the  different 
speakers,  for  they  had  left  their  bodies  in  far  South 
.\frica  in  defence  of  their  country's  flag.  Both  were  sons 
of  well-known  medical  men  in  Canada,  the  former  bein.5 
the  only  sou  of  the  Hon.  Dr.  Borden.  Minister  of  Militia; 
the  latter  of  Dr.  O'Reilly,  of  Hamilton.  Ont. 

The  Sewage  Farm  in  Montreal  which  was  constructed  a 
little  over  a  year  as--o  at  a  cost  ot  S75.000  has  proven  a 
'lismal  failure.  At  that  lime  the  advice  of  the  then  city 
surveyor  that  a  double  set  of  pipes  w  as  necessary,  one 
to  carry  the  surface  water  and  the  other  the  sewage  proper 
;o  the  farm,  was  totally  disregarded;  and  now  the  filth  from 
the  sewer  outlets  empties  itself  into  the  surface  of  the 
farm  at  one  end  and  then  rushes  out  at  the  other  over  the 
intervening  country  into  the  Back  River  without  being 
tiurifled  at  all.  For  over  a  mile  there  is  a  slimy  trail  of 
filth;  and  the  stench  from  the  raw  sewage  passing  over  the 
surface  of  the  ground  is  said  to  be  awful  and  is  fast  adding 
another  source  of  disease  to  the  inhabitants  of  that  city 
v.hich  is  so  sadly  in  need  of  a  mighty  upheaval  in  sanitary 
reform.  Montreal  has  just  passed  through  a  serious  epi- 
I'emic  of  scarlet  fever;  and  the  approach  of  warm  weath-. r 
is  alre.idy  being  .".nxiously  awaited  on  account  of  the 
dreadful  filthy  condition  of  the  city  at  the  present  time. 
Ordinarily,  the  infant  mortality  in  that  city  is  enormous 
:iud  the  present  aspect  of  affairs  seems  to  give  no  indi- 
cition  that  there  will  I.e  any  abatement  in  that  respect 

The  Medical  Council  cf  Ontario  has  just  sent  out  to  a 
number  of  praitiiioners  throughout  the  province  a  circular 


May   4,   l!)(il] 


AMERICAN  NEWS  AND  NOTES 


TTnE     I'HILADELPHIA  Q  .  , 

L  Medical  Jouknal         "no 


letter  which  will  not  be  very  palatable  reading  to  many  of 
them.  It  costs  $100  to  become  a  licentiate  of  the  College 
of  Physicians  and  Surgeons  of  the  province  of  Ontario;  and 
when  licensed,  the  College  demands  that  $2.00  be  an  an- 
nual fee  for  registration.  Some  years  ago  a  rough  breeze 
blew  up  over  this  very  same  fee  and  there  was  much  feel- 
ing in  the  profession  with  regard  to  it,  many  holding  that  it 
was  an  altogether  unnecessary  tax.  that  the  College  should 
be  able  to  manage  its  affairs  out  of  the  funds  derived  from 
students  at  their  examinations.  Now  a  number  of  prac- 
titioners who  have  allowed  the  payment  of  these  $2.00  an- 
nual assessments  to  drift,  have  received  notices  from  the 
official  prosecutor  of  the  Medical  Council  that  their  names 
have  been  erased  from  the  official  prosecutor  of  the  Medi- 
cal Council  that  their  names  have  been  erased  from  the 
register  and  that  unless  all  arrears  be  paid  within  thirty 
days,  they  will  be  proceeded  against  just  the  same  and  in 
the  manner  pursued  in  regard  to  other  unregistered  practi- 
tioners, that  is,  quacks.  No  doubt,  the  affair  will  create  in- 
teresting diversion  for  the  prosecutor  in  that  he  will 
be  taking  his  pound  of  flesh  out  of  the  constituents  of  his 
employers. 

Bishop's  College,  Montreal,  held  its  annual  convocation 
for  the  Medical  and  Dental  faculties  last  week  the  chau- 
cellar.  Dr.  John  Hiimilton.  presiding.  Dean  Campbell  of 
the  Medical  Faculty  presented  the  annual  report  of  that 
department  of  the  University,  referring  in  strong  terras 
of  the  need  for  larger  endowments  for  that  faculty  if  it 
were  to  carry  on  the  work  of  teaching  as  successfully  as 
it  has  done  in  the  past.  Especially  did  the  primary  chairs 
require  assistance,  because  it  was  impossible  to  have  them 
filled  at  the  present  time  by  men  who  enjoyed  large  prac- 
tices. The  year  just  closed  shows  an  increase  in  this  fac- 
ulty, and  a  decrease  in  the  dental,  the  latter  being  no  doubt 
due  to  the  additional  year,  and  a  more  searching  prelim- 
inary examination.  During  the  past  year  there  were  84  stu- 
dents registered  out  of  which  number  nine  received  their 
M.  D.  C.  M.s  that  day.  Dr.  Hyman  Lightstone  delivered  the 
valedictory  for  the  new  M.  D.s  while  Dr.  Anglin  replied  for 
the  faculty. 

The  Sect  of  Christian  Scientists  in  Canada,  while  not 
large,  is  said  to  be  growing.  The  subject  has  been  taken 
up  repeatedly  recently  in  Toronto  pulpits  and  it  has  re- 
ceived universal  condemnation  from  all  denominations.  In 
1890  they  are  said  to  have  started  with  a  membership  of  a 
score  or  two;  while  at  the  present  time  they  have  a  mem- 
bership of  over  3,000  and  some  5,000  adherents.  Thirty- 
two  of  their  churches  exist  scattered  over  all  parts  of  the 
Dominion,  four  of  these  in  the  cities  of  Toronto,  London, 
Berlin  and  Montreal  being  owned  outright,  whilst  the  bal- 
ance SLve  merely  rented.  In  Toronto,  sometimes  spoken 
of  as  "The  Good,'  there  are  some  500  of  these  people, 
which  cannot  be  said  to  be  very  many  out  of  a  total  popu- 
lation of  230,000. 

Smallpox  has  broken  out  again  in  this  city  and  there 
are  now  some  four  or  live  cases,  one  of  them  being  a  medi- 
cal man.  Throughout  the  province  of  Ontario  the  outlook 
is  improving  generally.  Very  few  cases  have  been  re- 
ported from  old  Ontario.  The  men  employed  in  the  lum- 
ber camps  in  the  northern  part  of  the  province,  that  known 
as  new  Ontario  have  nearly  all  left  their  camps  for  their 
homes,  and  some  5,000  of  them  have  been  vaccinated.whilst 
over  2,000  pieces  of  baggage  have  been  disinfected  at  Sud- 
bury, where  is  situated  the  smallpox  camp.  At  the  pres- 
ent time  smallpox  exists  in  fifteen  centres  west  of  Sud- 
bury and  in  thirty  centres  in  old  Ontario.  At  a  number 
of  places  in  different  parts  of  Canada,  pupils  at  the  schools 
are  being  kept  away  on  account  of  not  submitting  to  the 
process  of  vaccination. 

Official    List   of  the   Changes   of   Station    and    Duties   of 
Commissioned  and  Non-Commissioned  Officers  of  the  U.  S. 
Hospital  Service  for  the  7  d.iys  ended  April  25,  1901: 
P.   W.   MEAD,   surgeon.   Department  letter  of  January   11, 
1901,   granting   Surgeon   Mead   leave   of   absence   for   60 
days,  amended  so  that  said  leave  shall  be  for  1  month 
and  24  days— April  19,  1901. 
A.  H.  GLENNAN,  surgeon,  to  proceed  to  Tallahasse.  Flor- 
ida, for  special  temporary  duty — April  22.  1901. 
W.  P.  McINTOSH.  surgeon,  to  proceed  to  Ducktown,  Tenn- 
essee, for  special  temporary  duty — April   19,   1901. 
W.  J.  PETTUS,  surgeon,  department  letter  of  January  11. 
1901.    granting   surgeon    Pettus    leave    of   absence    for    2 
months,    amended    so    that    said    leave    shall    be    for    1 
month  and  27  days— April  8.  1901. 


C.  P.  WERTENBAKER,  passed  assistant  surgeon,  to  repre- 
sent the  service  at  meeting  of  Texas  Medical  Associa- 
tion, Galveston.  Texas — April  22,  1901. 

J.  A.  NYDEGGER,  passed  assistant  surgeon,  to  proceed 
to    Cape    Charles    Venture.    Va.,    for    special    temporary 

II.  S.  MATHEWSON,  passed  assistant  surgeon,  to  proceed 
to  Ponce  and  Guayanilla,  Porto  Rico,  for  special  tem- 
porary duty — April  24,  1901. 

W.  W.  KING,  assistant  surgeon,  to  proceed  to  Guayanilla, 
Porto  Rico,  for  special  temporary  duty — April  24,  1901. 

L.  P.  GIBSON,  acting  assistant  surgeon,  granted  leave  of 
absence  for  7  days — April  25,  1901. 

J.  C.  RODMAN,  acting  assistant  surgeon,  granted  leave 
of  absence  for  7  days  from  April  24 — April  25,  1901. 

MARK  H.  WATTERS.  hospital  steward,  relieved  from 
duty  at  Chicago,  Illinois,  and  directed  to  proceed  to  St. 
Louis,  Missouri,  and  report  to  the  Medical  Officer  in 
command  for  duty  and  assignment  to  quarters — April 
19,   1901. 

Changes  in  the  Medical  Corps  of  the  Navy,  for  the  week 

ended  April  27: 

ASST.  SURGEON  J.  B.  DENNIS,  detached  from  the  Naval 
Academy,  and  ordered  to  the  Chesapeake,  May  2. 

ASST.  SURGEON  C.  G.  SMITH,  ordered  to  the  Vermont. 
April    25. 

MEDICAL  INSPECTOR  F.  ROGERS,  ordered  to  the 
Brooklyn  for  duty  as  Fleet  Surgeon  of  the  Asiatic  Sta- 
tion. 

SURGEON  W.  F.  ARNOLD,  detached  from  duty  at  Olon- 
gapo,  P.  I.,  and  ordered  to  the  New  Orleans. 

SURGEON  C.  F.  STOKES,  ordered  to  the  Cavite  Naval 
Station,  to  await  the  Solace. 

Health  Reports. — The  following  cases  of  smallpox,  yellow 
fever,  cholera  and  plague  have  been  reported  to  the  Sur- 
geon General,  U.  S.  Marine  Hospital  Service,  during  the 
week  ended  April  26,  1901: 

SMALLPOX— UNITED   STATES. 

Cases. Deaths. 

DELAWARE:  Newcastle Apr.1-15    4 

FLORIDA:  Jacksonville  ..Apr.13-20 6 

ILLINOIS:  Chicago Apr.13-20 17 

KENTUCKY;  Cynthiana Apr.17 6 


LOUISIANA: 
MINNESOTA: 


Lexington  ....  Apr.13-20  . . 
New    Oiieans.. Apr.13-20  .  . . 

Winona Apr.13-20  . . . 

ADr.13-20  . . , 


NEW  HAMPSHIRE  Manchester 

NEW  JERSEY:  Jersey  City   ..Apr.14-21 

OHIO:  Cincinnati   . 

Cleveland Apr.13-20  ... 

PENNSYLVANIA:  Pittsburg   Apr.13-20  . . . 

Steelton    Apr.13-20  ... 

Nashville   Apr.13-20  ... 

Wheeling Apr.13-20  .  . . 

Manila Mar.2-9 

San  Juan:   ....  Apr.6 


TENNESSEE: 
WEST  VIRGINIA: 
PHILIPPINES: 
PORTO  RICO: 


4 
10 
2 
7 
4 

..Apr.12-19 7 

46 
1 
3 
1 
1 
8 
13 


SMALLPOX— FOREIGN. 


AUSTRIA: 

Prague  .... 

.  .  Mar.23-Apr.6.. 

8 

BELGIUM: 

Antwerp    .  . 

..  Apr.6 

3 

1 

CHINA: 

Hongkong  . 

..  Mar.2-9 

ti 

FRANCE: 

Paris  

. .  Mar.31-Apr.6.. 

10 

GIBRALTAR: 

Apr.1-7 

2 

GREAT    BRITAIN 

;  England:    .  .  . 

SouthamptoaApr.6-13 

3 

Scotland 

Glasgow 

.  .Apr.6-13 

5 

Leith   

.  .  Mar.31-Apr.6.. 

i 

INDIA: 

Bombay    ... 

..Mar.19-26 

12 

Calcutta    ... 

..  Mar.16-23.... 

144 

Karachi    .  . . 

..Mar.9-16  

12 

8 

Madras 

..Mar.lG-22.... 

10 

MEXICO: 

Progreso  . . . 
Yucatan, 

..  Mar.31-Apr.6.. 

4 

Merida  .  . 

.  .Apr.ll  Prevalent 

NETHERLANDS: 

Rotterdam   . 

. .  Mar.31-Apr.6... 

1 

RUSSIA: 

Odessa   

. .  Mar.31-Apr.6.. 

13 

1 

SPAIN: 

Corunna    . . 

. .  Mar.31-Apr.6.. 

1 

Vigo 

..Mar.1-31    .... 

1 

C    .    ,  The     PnlLADELI'HIA  "I 


FOREIGN  NEWS  AND  NOTES 


[May   4.    lixn 


YELLOW   FEVER. 

COLOMBIA:  Panama    Apr.8-15 8 

HAITI:  Cape  Haitien  .Mar.23-30 1  i 

MEXICO:  Coatzocoalcos  .Apr.l  Prevalent 

SALVADOR:  San  Salvador  .  Mar.31 4  3 

CHOLERA. 

CHINA:                       Hongkong Mar.2-9 1 

INDIA:                          Bombay    .Mar.19-26 4 

Calcutta    Mar.  16-23 65 

Madras Mar.16-22 1 

STRAITS  SET- 
TLEMENTS :  Singapore Feb.26-Mar.2..  5 

PLAGUE— INSULAR. 

PHILIPPINES:        Manila: Mar.2-9 8 

PLAGUE— FOREIGN. 

CHINA :                       Hongkong  ....  Mar.2-9 16 

INDIA:                         Bombay    Mar.19-26 886 

Calcutta    Mar.16-23 1,040 

Karachi Mar.19-26 239       192 

STRAITS  SET- 
TLEMENTS: Singapore  Feb.26-Mar.9..  3 


CONTINENTAL    EUROPE. 

To  Investigate  Malaria. — Dr.  Koch  Intends,  in  conjunction 
with  the  German  Colonial  Office,  to  organize  various  expe- 
ditions into  German  Africa  for  the  purpose  of  carrying  on 
investigations  into  the  origin  of  malaria.  He  will  direct  the 
work  from  Berlin. 

Portuguese  Medical  Expedition. — A  Commission  had  been 
appointed  by  the  Portuguese  Government  to  study  the 
sleeping  sickness  in  the  Province  of  Angola.  This  Commis- 
sion which  will  at  the  same  time  include  amongst  its  scien- 
tiiic  researches  an  inquiry  into  the  etiology  and  the  trans- 
mission of  malaria  will  be  composed  of  the  following  mem- 
bers: Drs.  Annibal  Bettencourt,  Ayres  Jose  Kopke  Correa 
Pinto,  Jose  Gomes  Bezande,  jim.,  Joao  Braz  Gouveia,  and 
Annibal  Celestino  Correa  Mendes. 

Brains  of  300  Suicid2s  Examined. — Professor  Meller  of 
Kiel  University,  the  renowned  expert  in  mental  diseases,  as 
a  result  of  autopsies  made  during  five  years  on  300  suicides, 
states  that  he  found  that  the  brains  of  43  per  cent,  showed 
distinct  malformation;  29  per  cent,  of  the  remainder  were 
suffering  at  the  time  of  their  death  from  acute  febrile  in- 
flammation, and  li:;  of  the  whole  number  had  organs  dis- 
eased by  alcoholism. 

(From  our  Special  Correspondent.) 

German  Surgical  Society. — The  30th  session  of  the  Ger- 
man Surgical  Society,  which  meets  annually  in  its  owu 
building  in  Berlin,  began  on  Wednesday  morning,  April 
lOlh.  The  society  has  at  present  some  1050  members,  an 
unusually  large  number  of  whom  were  present.  The  con- 
gress opened  with  the  President's  address  by  Czerny  of 
Heidelberg.  Czerny  surveyed  briefly  ten  lines  of  research 
work  which  are  of  especial  interest,  and  promise  to  the 
surgeon;  the  etiology  of  the  infectious  and  contagious 
diseases,  especially  tuberculosis  and  cancer,  and  the 
question  of  immunity.  An  important  question  is  the  treat- 
ment of  hopeless  cases  of  chronic  disease.  Russia  has  set 
the  world  a  grand  example  by  founding  a  hospital  for 
hopeless  cancer  cases  in  connection  with  the  clinic  of 
Prof.  Lewschin  in  Moscow.  Czerny  urges  the  teacher  to 
provide  his  students  with  ample  opportunity  for  practical 
work,  and  not  to  fear  too  much  the  danger  of  wound  in- 
fection. He  objects  to  the  proposed  admission  of  gradu- 
ates of  the  "Real  Gymnasien"  to  the  medical  course,  as 
does  the  active  German  profession.  The  president  closed 
his  address  with  a  brief  mention  of  the  members  of  the 
society  who  died  during  the  past  year,  among  them  the 
French  surgeon  Oilier,  of  Lyons. 

The  first  paper  of  the  Congress  was  read  by  Kuester,  of 
Marburg  on  "Renal  Surgery  in  the  19th  Century:  a  Review 
and  a  Glance  into  our  Future."  Kuester  reviewed  the 
history  of  renal  surgery,  a  branch  of  surgery  which  has 
existed  for  but  one  generation.  Its  founder  was  the 
Heidelberg  surgeon  Simon;  soon  after  the  Anglo-Saxon 
surgeons  took   up   the   work,    especially   Morris;    a  little 


later  France  followed,  notably  Le  Dentu  and  Guyon.  In 
1868  an  American  performed  a  nephrectomy  as  a  result  of 
a  false  diagnosis,  and  a  little  later  Spencer  Wells  did  the 
same  operation,  yet  Simon  was  the  first  to  perform  a  well 
planned  operation  on  the  kidneys.  From  uaat  time  until 
18(5  only  8  nephrectomies  were  performed,  in  the  follow- 
ing a  years  48.  The  first  statistics  gave  a  mortality  of 
44.6%,  a  later  one  25%;  while  the  statistics  of  the  last  10 
years  show  a  mortality  of  only  16  c^.  One  can  rightly 
say  that  the  operations  on  the  kidney  have  lost  their  dan- 
ger. iuB  good  results  of  the  last  10  years  are  not  to  be 
ascribed  exclusively  to  improved  technique  and  wound 
treatment;  a  more  finely  developed  diagnostic  power  ana 
an  increased  knowledge  of  pathological  anatomy  have 
made  better  results.  The  beginning  of  disease  can  be  more 
surely  diagnosed.  The  main  symptoms  of  the  surgical 
diseases  oi  the  kidney  are  pain,  tumor,  and  path 
ological  urine.  And  yet  we  were  unable  to  determine 
whether  one  or  both  kidneys  were  diseased  until  cysto- 
scopy and  catheterization  of  the  ureters  filled  out  these 
defects  in  our  knowledge.  Even  then  our  diagnosis  was 
not  yet  complete.  The  diagnosis  of  the  kidney  function 
has  taught  us  that  a  kidney  which  excretes  apparently 
healthy  urine  may  still  be  diseased;  for  example,  when 
two  ureters  are  present,  one  of  which  leads  into  a 
healthy  part,  or  when  it  is  impossible  to  catheterize  the 
ureter.  We  cannot  always  recognize  the  more  delicate 
pathological  changes  in  the  kidney  even  after  operative 
exposure  of  the  organ.  These  defects  in  our  knowledge 
are  now  filled  by  the  diagnosis  of  the  function  of  the 
kidney,  and  by  the  phloridzin  test.  The  principal  affec- 
tions of  the  kidney  requiring  surgical  intervention  are:  (1) 
Movable  kidney.  Kuester  does  not  believe  that  the  cloth- 
ing of  the  modern  woman  explains  the  etiology  of  the 
disease,  because  floating  kidney  occurs  very  often  in  the 
women  of  Egypt,  who  wear  loose  clothing.  Nephropexy 
is  indicated  and  gives  satisfactory  results.  (2)  Wounds 
of  the  kidney  requiring  surgical  aid  to  check  hemorrhage. 
Simon  recommended  nephrotomy:  the  surgeon  of  to-day 
would  limit  nephrotomy  to  cases  of  extensive  laceration, 
ordinarily,  however,  he  would  apply  suture  and  tampon- 
ade. (3)  Pyelonephrosis.  primary  pus  formation,  which 
Kuester  would  call  cystonephrosis.  Nephrotomy  gives 
good  results  in  tuberculosis  of  the  kidney:  in  a  ureter 
diseased  in  its  entirety,  and  even  a  tuberculous  bladder  can 
heal  after  removal  of  a  diseased  kidney.  The  Roentgen 
rays  have  brought  advances  in  the  diagnosis  of  renal 
calculi.  With  a  short  exposure  one  can  succeed  in  ob- 
taining a  picture  of  even  the  phosphate  concrements.  Ne- 
phrotomy or  pyelotomy  is  indicated.  Calculus  of  the  ure- 
ter necessitates  more  extended  operation,  especially  when 
their  location  is  the  neighborhood  of  the  bladder,  kuester 
recommends  in  such  cases  osteoplastic  resection  of 
the  sacrum  according  to  the  method  of  Morris,  or  laparo- 
tomy. In  cases  of  cystonephrosis  nephrotomy  is  indicated 
in  order  that  one  be  able  to  save  all  healthy  tissue.  In 
cases  of  cystonephrosis  or  cyst  kidney  due  to  floating 
kidney,  one  often  obtains  good  results  by  nephoprexy  with 
stretching  of  the  ureter.  (4)  In  the  cases  of  tumor  of  the 
kidney,  one  often  obtains  good  results  by  nephopexy  with 
tumors  are  malignant,  as  for  example  the  struma  supra- 
renalis  accessoria  (Grawitz.)  Partial  nephrectomy  is  often 
indicated  and  has  shown  good  results.  In  regard  to  the 
methods  of  operating,  Kuester  considers  lumbar  nephrec- 
tomy the  only  rational  procedure,  except  in  some  cases 
of  tumor  where  laparotomy  is  to  be  preferred,  since  com- 
plications can  be  recognized  more  easily  and  quickly. 

The  second  paper  by  Casper,  of  Berlin,  describes  "Ad- 
vancss  in  Renal  Surgery;"  and  the  results  of  researches 
carried  on  with  Richter.  Many  failures  in  renal  surgery 
are  due  to  faulty  diagnosis:  the  question  is  not,  is  the  organ 
to  be  left  healthy,  but  is  its  function  sufficient.  The  deter- 
mination of  nitrogen,  of  the  freezing  point,  and  of  sugrar. 
enable  us  to  answer  this  question.  The  freezing  point  of 
the  blood  and  of  the  urine  is  nearer  that  of  distilled  water, 
the  nearer  normal  the  kidney.  The  excretion  of  sugar  is  deter- 
mined by  inducing  an  experimental  diabetes  by  injections 
of  phloridzin.  Casper  has  tested  the  method  in  14  cases 
and  demonstrates  the  results.  Kuemmell.  of  Hamburg. 
"Practical  Experience  in  the  Diagnosis  and  Treatment  of 
Diseases  of  the  Kidney"  has  continued  the  experiments 
in  the  determination  of  the  freezing  point  of  blood  and 
urine,  reported  by  him  at  the  congress  of  last  year.  He 
has  tested  the  method  in  100  cases  and  considers  it  me 
of  the   most    valuable  helps    in    diagnosis.     The   freeiing 


lyoi) 


FOREIGN  NEWS  AND  NOTES 


[The   rmi.ADKi.DiiA        8^r 
Medic  AL  .TotusAi.         "^J 


point  of  normal  blood  is  0.56;  0.55  or  05.57  he  considers 
comparatively  good,  with  0.58  he  would  refrain  from 
operating.  His  method  is  as  follows:  He  first  determines 
the  freezing  point  of  Ijlood;  if  this  is  normal  he  examines 
the  urine  from  each  kidney;  if  only  one  kidney  is  diseased 
operation  is  indicated.  Kuester  considers  the  determina- 
tion of  freezing  point,  of  urea  and  the  phloridzin  test  abso- 
lutely necessary  to  diagnosis,  without  them  fatal  mistakes 
will  be  made.  Kuester  demonstrates  the  method  for  deter- 
mining the  freezing  point  of  the  blood.  Braatz.  of  Koenigs- 
berg,  discusses  in  a  short  paper  the  changes  in  the  kidney 
following  median  section  of  the  organ.  He  believes  that 
contraction  of  the  organ  follows  even  when  the  sutures  are 
not  drawn  tight.  Schoenberg.  of  Hamburg.  "Demonstration 
of  Roentgen  Photographs  of  Renal  calculi,"  explains  the  fail- 
ureof theRoentgenraysinthe  diagnosis  of  gall  stones  and 
renal  calculi  by  the  fact  that  these  concretions  have  too  small 
an  atomic  weight,  for  this  reason  the  phosphates  ought 
really  to  be  most  easily  photographed,  but  their  specific 
weight  is  too  small.  The  order  is  therefore  as  follows: 
Oxalates,  phosphates  and  urates.  It  is  entirely  impossible 
to  photograph  the  xanthin  and  cystin  concretions.  The 
difficulty  in  obtaining  photographs  of  the  calculi  is,  how- 
over,  due  in  part  to  the  diffusion  of  the  rays  in  the  body. 
Schoenberg  describes  his  method  of  decreasing  this  dif 
fusion  by  means  of  bad  coverings  for  the  tubes  and  by 
using  suitable  diaphragms  and  plates,  and  demonstrated 
skiagraphs  of  very  small  renal  calculi.  Steiner,  of  Berlin, 
describes  a  rare  case  of  congenital  malformation  of  the 
kidneys,  the  left  kidney  being  absent,  the  organ  of  the 
right  side  being  double.  Symptoms  were  pain,  tumor,  urine 
containing  pus.  Steiner  removed  the  upper  kidney  of  the 
right  side,  and  although  pyonephrosis  was  present  in  the 
lower  organ  the  patient  recovered. 

The  paper  by  Goldmann.  of  Freiburg,  discusses  "The 
Treatment  of  Hypertrophy  of  the  Prostate."  Goldmann 
observed  in  a  case  where  suprapubic  puncture  had  been 
performed  and  the  catheter  had  remained  for  eight  days, 
that  the  patient  had  no  further  trouble  with  his  hyper- 
trophied  prostate.  Two  years  later  he  performed  the 
autopsy  on  this  patient  and  found  that  the  bladder  was 
fixed  to  the  abdominal  wall  in  such  a  way  as  to  exert  trac- 
tion on  the  internal  urinary  meatus.  He  then  experiment 
ed  on  the  cadaver,  and  has  operated  on  several  patients. 
He  recommends  cystopexy.  suturing  the  bladder  to  the  ab- 
dominal wall  in  suitable  cases  of  hypertrophied  prostate. 
Loewennardt.  of  Breslau.  "On  the  Treatment  of  Tumors  of 
the  Bladder,"  makes  a  plea  for  the  endovesical  operation. 
He  believes  that  the  advantages  of  the  sectic  alta,  a  better 
field  of  operation,  thorough  treatment  of  the  tumor  stump, 
are  often  more  than  compensated  by  the  less  severe  endo- 
vesical operation,  doing  away  with  general  anesthesia, 
and  with  less  loss  of  blood.  He  considers  the  difficluty  of 
manip»lating  the  instruments  of  little  moment.  Colpocy- 
stotomy  amd  Kelly's  method  are  absolute.  For  tumors  at 
the  internal  orifice  he  recommends  Gruenfeld's  method. 
Loewenhardt  demonstrates  an  instrument  for  exact  work 
with  the  cautery  on  tumors  situated  near  the  openings  of 
the   ureters. 

The  first  paper  on  wound  treatment  was  read  by  von 
Bruns.  of  Tuebingen.  which  will  be  published  later  in  the 
Philadelphia  Medical  Journal. 

Fraenkel,  of  Vienna.  "Wound  Treatment  Following  Op- 
erations for  Localized  Tuberculosis,"  believes  that  the 
small,  and  especially  the  very  small  tuberculous  foci,  can- 
not be  reacded  by  operation,  and  therefore  recommends 
the  treatment  with  iodoform  and  similar  substances,  the 
effect  of  which  he  explains  by  the  infiammation  and  con 
sequent  formation  of  connective  tissue,  thus  shutting  off 
the  pathological  from  the  healthy  tissue.  In  the  discussion 
Kuster.  of  Marburg,  recommends  the  treatment  of  infected 
wounds  with  the  cauter.v  with  which  he  has  obtained 
favorable  results.  He  expresses  his  great  mistrust  of  the 
useof  carbolicacid.  Koenig.  of  Berlin,  believes  that  the  best 
treatm  ent  of  septic  wounds  is  exposure  and  thorough  incision. 
He  uses  zinc  chloride  in  cases  where  Kuester  recommends 
the  cautery.  We  will  ol)tain  better  results  in  the  treat- 
ment of  tuberculosis  by  thorough  excision  and  formation  of 
fresh  wound  surfaces. 

The  second  session  opened  with  an  important  paper  by 
Kocher  (Hern)  "Report  on  the  Second  Thousand  Cases  of 
Extirpation  of  Goitre.  MO  On  an  Operation  for  Struma 
intra  thoracica.  (c)  On  the  Non-operative  Treatment  of 
Goitre."  Kocher  emnhasizes  first  that  he  performs  only 
excision,   rarely   enucleation.     He  has  given   up  the  latter 


operation,  and  has  not  changed  his  technique.  He  never 
severs  the  muscles.  He  has  constructed  a  forceps  for 
compressing  the  isthmus  not  to  exert  pressure  on  the 
blood  vessels,  but  to  make  the  ligatures  smaller.  Kocher  s 
mortality  is  4%.  Infection  plays  no  role.  He  introduces 
no  antiseptic  into  the  wound,  only  the  ligatures,  for  which 
he  uses  silk  exclusively,  are  prepared  with  antiseptis.  He 
has  used  the  prophylactic  treatment  with  thyroid  extract 
before  operation,  in  cases  of  diffuse  and  long  standing 
goitre.  He  seldom  or  never  uses  narcosis,  operating  under 
cocain.  and  so  avoids  the  abundant  hemorrhage  caused  by 
vomiting.  Kocher  would  give  struma  intrathoracica  an 
especial  place  in  surgery.  As  a  result  of  the  struma  pro- 
funda he  has  seen  emphysema,  bronchitis,  tachycardia, 
etc.,  and  he  claims  that  goitre  lung  as  well  as  goitre  heart 
exists.  The  main  question  in  cases  of  struma  intrathor- 
acica is  whether  it  is  movable  or  not,  the  movable  struma 
naturally  giving  more  favorable  operative  results.  Kocher 
then  demonstrated  the  diagnostic  value  of  the  Roentgen 
rays  combined  with  percussion,  and  shows  a  goitre  which 
extended  to  the  second  intercostal  space.  In  regard  to  the 
techniqueofthe  operation  for  struma  intrathoracica  Kocher 
ligates  all  blood  vessels  and  divides  the  isthmus  before 
extracting  the  goitre;  he  demonstrates  a  forceps  and  a 
spoon  which  he  has  constructed  as  aids  to  rapid  extraction. 
Tamponade  is  never  performed,  since  it  can  cause  chok- 
ing, and  is  no  guarantee  that  hemorrhage  is  checked.  In 
regard  to  the  medicinal  treatment  of  goitre,  Kocher  states 
that  he  has  given  up  the  thyroid  extract  and  has  returned 
to  the  old  treatment  with  potassium  iodide.  This  treat- 
ment may  cause  acute  and  chronic  iodism,  which,  however, 
can  also  be  caused  by  thyroidin.  Kocher  then  describes 
interesting  experiments  which  his  son,  Albert  Kocher,  has 
been  making  with  iodum  phosphate;  he  has  found  that 
the  amount  of  iodin  contained  in  the  thyroid  continually 
decreases  in  goitre,  while  the  percentage  of  phosphorus 
increases;  this  is  especially  the  case  in  pregnant  women. 
After  treatment  with  phosphorus,  he  observed  in  one  case 
an  increase  of  iodin  from  0.018  to  0.4.  in  another  case  from 
(.00862  to  1.2,  while  the  percentage  of  phosphorus  de- 
creased. Kocher  calls  attention  to  the  fact  that  in  those 
countries  where  goitre  abounds  very  little  phosphorus 
containing  foods  are  consumed,  while  in  England,  fop  ex- 
ample, where  goitre  is  practically  unknown,  eggs  and 
meat  form  the  main  food  constituent.  He  thinks  that 
this  factor  may  be  of  influence  upon  the  develop- 
ment of  goitre.  Kracke  (Freiburg)  discusses  the  treatment 
of  goitre  and  reports  on  420  operations  performed  at  the 
clinic  at  Freiburg.  One-third  of  these  cases  were  in  males, 
two-thirds  in  females.  In  220  cases  he  has  performed  ex- 
tirpation of  one-half  of  the  gland.  Some  of  the  first  cases 
were  total  extirpations,  the  rest  enucleations  or  resections. 
The  modulated  form  was  the  most  frequent,  pure  hyper- 
trophy of  the  gland  rare;  10  cases  were  of  malignant 
stroma,  in  one  of  which  he  successfully  removed  a  metas- 
tasis from  the  struma;  twice  he  removed  accessory  struma, 
once  from  the  fossa  supraclavicularis,  once  form  the  tongue. 
He  operates,  as  does  Kocher,  under  local  anesthesia,  avoid- 
ing narcosis  on  account  of  the  bad  effects  of  the  consequent 
choking,  vomiting  and  postoperative  hemorrhage.  He  has 
had  but  two  cases,  one  of  them  from  heart  trouble  probably 
due  to  excessive  use  of  thyroid  extract,  the  other  from  tet- 
any following  extirpation  of  both  lobes  of  the  gland.  He 
has  seen  dangerous  postoperative  hemorrhage  only  follow- 
ing enucleation,  never  since  he  has  abandoned  this  opera- 
tion and  the  narcosis.  He  could  explain  the  rise  of  tempera^ 
ture  following  enucleations  by  the  increased  resorption  of 
gland  substance  during  the  operation.  Kraske  points  out 
that  operations  for  goitre  are  becoming  more  frequent,  and 
therefore  that  the  treatment  with  thyroid  extract  can  be  of 
no  value.  He  has  abandoned  it  entirely.  His  opinion  is 
that  thyroid  extract  can  have  no  effect  on  the  pathological 
gland  tissue,  but  the  improvement  in  some  cases 
to  atrophy  of  normal  tissue  consequent  upon 
non-use;  The  treatment  is.  therefore,  theoretically 
wrong,  and  may  even,  by  the  production  of  con- 
nective tissue  due  to  atrophy  of  the  gland,  make 
operation  more  difficult.  He  advises  the  profession 
to  oppose  the  thyroid  extract  treatment.  In  the  discussion. 
Goldmann  (Freiburg)  reports  a  case  of  tuberculous  regen- 
eration of  a  stroma  intrathoracica.  Riedel  (Jena)  has 
operated  in  500  cases.  He  calls  attention  to  the  fact  that  the 
goitre  may  develop  on  the  left  side  with  the  thorax,  and  ap- 
pear in  the  ordinary  form  on  the  right  side.  He  thinks 
the  instruments  devised  by  Kocher  unnecessary,   provider! 


^./^         THE    I'uilaueliuia"! 

'-4'-'  MKDIi  AI.   JiiIliXAl.    J 


FOREIGN  NEWS  AND  NOTES 


[Mav   4.    i:«il 


one  makes  a  sufficiently  long  incision;  he  considers  Koch- 
er  s  incision  too  sliort  and  advises  a  curved  incision  ex- 
tending from  the  jugulum  to  the  ear.  He  operates  as  do 
Kocher  and  Kraske,  without  narcosis.  Retere  (Frankfort 
on  the  Main)  reports  a  case  so  far  advanced  that  he  would 
not  risk  operation,  but  which  was  cured  by  treatment  with 
iodids.  Koenig  (Berlin)  calls  attention  to  the  goitres  of  tli'; 
low  lying  level  districts.  He  has  seen  70-80  cases  here  in 
Berlin,  at  least  halt  of  which  were  in  natives  who  acquired 
their  goitre  here.  He  asks  Kocher  liow  much  of  the  gland 
should  be  left.  Kocher  answers  that  he  finds  %  of  the 
gland  a  sufficient  proportion  to  leave.  Krause  (Berlinl 
reports  on  "27  intracranial  Resections  of  the  Trigeminus 
(among  them  25  Extirpations  of  the  Gasserian  Ganglion) 
and  their  Results."  The  results  following  resection  of  the 
separate  branches  of  the  trigeminus  are  not  sure;  there- 
tore,  in  cases  of  true  trigeminus  neuralgia,  and  where 
such  a  severe  operation  is  indicated,  the  extiraptian  of  the 
gasserion  ganglion  and  the  trunk  of  the  trigeminus  must 
be  performed.  Krause  has  performed  resection  of  the 
branches  in  2,  extirpation  of  the  ganglion  in  25  cases  in 
patients  in  from  30  to  72  years  of  age.  He  uses  the  tem- 
poral method  of  operation  described  by  him  in  1892.  One 
patient,  a  woman  of  58  years,  in  an  extremely  weakened 
condition,  died  in  collapse;  a  man  of  72  years  died  in  con- 
sequence of  sclerosis  of  the  coronary  arteries  and  heart 
failure;  a  third  patient,  a  woman  of  60  years,  died  three 
weeks  after  operation.  The  autopsy  showed  no  inflamma- 
tion, but  an  extensive  edema  of  the  meninges.  Of  his  old- 
est cases  there  are  still  alive:  A  woman  of  76  years  and 
a  man  of  63,  operated  on.  8  and  8%  years  ago;  a 
woman  of  77  and  one  of  54,  operated  on  6%  years 
ago;  a  woman  of  43  and  one  of  51.  operated  on 
5Vi  and  5  years  ago.  None  of  these  patients 
has  had  a  return  of  their  neuralgic  pains.  Krause  finds  it 
impossilile  to  save  the  motor  branch  of  the  nerve.  Among 
the  post  operative  complications  to  be  mentioned  are,  kera- 
titis, especially  in  cases  with  an  existing  dacryocysto- 
l)lennorrhea,  or  lagophthalmus  following  attempts  at  resec- 
tion. Krause  finds  that  these  cases  yield  readily  to  suitable 
treatment;  further,  transitory  paresis  of  the  muscles  of  the 
eye,  dueto  pressure  upon  the  motor  nerves  during  operation. 
Krause  thinks  that  the  results  ofthis  operation  justify  the 
risks  of  such  a  severe  procedure.  Heidenhain  (Worms) 
presents  two  patients  from  wlioni  he  had  successfully  re 
moved  tumors  of  the  brain,  and  reports  two  further  opera- 
tions. A  man  suffered  from  paralysis  of  the  leg.  Jack- 
sonian  epilepsy,  later  paranoia  and  choked  disc.  At  opera- 
tion the  diagnoses  of  a  tumor  in  the  leg  center  was  found 
correct,  the  tumor  being  a  solitary  tiibercle  about  the  size 
of  a  walnut.  It  is  interesting  to  note  that  the  paranoia  dis 
appeared  after  the  operation.  The  patient  still  suffers 
from  epileptic  attacks  and  paresis  of  the  leg.  The  second 
patient  s\iffered  since  childhood  from  headache:  later 
paranesthenia  and  anesthesia  appeared  in  the  hand  and 
arm.  The  diagnosis  of  cystic  tumor  in  one  arm  center 
was  found  at  the  operation  to  be  correct,  the  tumor  being 
a  cystic  sarcoma  of  the  size  of  a  hen's  ogg.  The  headache 
and  the  choked  disc  disappeared  immediately,  and  the 
patient  has  only  sli.ght  sensory  and  motor  disturbances 
in  one  arm.  In  the  third  case  Heidenhain  removed  a  me- 
lanotic carcinoma  of  the  choroid  plexus,  and  with  the  tumor 
the  whole  right  temporal  lolie.  It  is  interesting  to  note 
in  this  case  that  the  musical  and  the  word  sense  sup- 
posed to  be  located  in  this  region,  were  but  slightly  affect- 
ed. In  the  foiirth  case  with  symptoms  of  tumor  of  the 
cerebellum.  Heidenhain  exposed  the  entire  cerebellum,  but 
failed  to  find  the  tumor;  the  autopsy  showed  a  softened 
sarcoma  of  the  cerebellum,  situated  exactly  in  the  median 
line. 

Barth  (Danzig)  "The  Operative  Treatment  of  Purulent 
Meningitis."  Barth  presented  a  boy  who  had  received  a 
knife  wound  in  the  region  of  the  ninth  dorsal  vertebra. 
A  week  later  the  symptoms  of  meningitis  appeared  and 
lumbar  puncture  showed  the  presence  of  pus.  Barth  per- 
formed laminectomy  and  opened  an  extra-dural-abscess: 
fever  continued  high  and  he  performed  a  second  operation, 
this  time  opening  the  dorsal  sac.  Paralysis  of  both  legs, 
tlie  bladder  and  the  rectum  followed,  but  finally  disap- 
peared, so  that  the  patient  has  recovered  except  for  some 
slight  sensory  and  motor  disturbances  and  for  a  consider- 
able gibbous  condition  which  has  developed  at  the  site  of 
operation  in  spite  of  a  plaster  east. 


THIRD    SESSION. 

The  third  session  opened  with  a  paper  by  Housell,  of 
Tuebingen  on  "The  Scientific  Foundation  of  the  Carbolic 
Acid  Therapy  of  Septic  Wounds."  Housell  has  proven 
in  his  experiments  that  pure  carbolic  acid  is  entirely 
harmless  when  used  in  wounds  or  when  injected  into  the 
tissues.  The  lethal  dose  by  the  mouth  of  the  pure  acid  is 
8  grs..  of  the  dilute  acid  2  to  3  grs.  He  has  injected  one- 
sixth  gr.  of  carbolic  acid  into  hydroceles  with  no  un- 
favorable results,  and  places  the  maximal  dose  at  6  grs.. 
for  even  the  most  extensive  wound  surfaces  have  in  no 
case  shown  symptoms  of  poisoning.  The  time  of  applica- 
tion is  one  m'nute  followed  by  a  wash  of  absolute  alcohol. 
Housell  mentions  this  fact,  long  known,  that  absolute  alco- 
hol acts  as  an  antidote  to  carbolic  acid,  probably  by  ao- 
sorbing  the  acid  more  rapidly  than  does  the  fluid  of  the 
tissues.  He  believes  that  carbolic  acid  has  a  much  more 
lasting  antiseptic  effect  than  sublimate.  He  emphasizes 
the  value  of  thorough  incision  and  would  not  recommend 
Phelp's  method  in  any  case  of  sepsis,  yet  he  believes  it 
to  be  a  decided  step  in  advance. 

Haegler,  of  Basel,  demonstrated  microscopic  sections  of 
various  kinds  of  ligatures  which  had  caused  pus  forma- 
tion. 

Reinbach.  of  Breslau  demonstrated  drawings  illustrating 
the  histology  of  granulating  wounds. 

Blumbcrg.  of  Berlin,  reported  experiments  on  the  value 
of  the  ethyldiamine  of  mercury  as  an  antiseptic. 

Kroenlein,  of  Zurich,  "Contributions  to  the  Surgery  of 
the  Brain,"  describes  the  case  of  a  patient  from  whom  he 
removed  a  tubercle  of  the  brain:  the  patient  has  been  in 
good  health  since  the  operation  six  years  ago.  In  a  second 
case  Kroenlein  diagnosed  a  tumor  of  the  right  gyrus  cen- 
tralis, but  found  no  tumor  at  the  operation  one  and  one- 
half  years  later  the  patient  died,  and  the  autopsy  showed 
a  tumor  at  the  site  of  operation.  Kroenlein  explains  the 
case  by  assuming  that  the  tumor  was  so  small  that  he  could 
not  find  it.  but  that  grew  later  to  the  size  of  a  hen's 
egg.  as  found  at  autopsy. 

Merkens,  of  Berlin,  described  cases  of  "Encephalitis  of 
the  temporal  lobe  and  other  brain  complications  following 
Otitis." 

Schjerning.  of  Berlin,  gave  a  very  complete  paper,  illus- 
tiateil  by  numerous  photographs  and  skiagraphs,  on  "The 
Shot  Wounds  Caused  by  Modern  Firearms."  He  gave  es- 
pecial attention  to  the  wounds  caused  by  the  field  artillery 
projectiles.  According  to  the  author,  it  is  impossible  as 
yet  to  definitely  answer  the  question  whether  one  should 
operate  immediately  in  cases  of  penetrating  wounds  of  the 
abdomen.  He  considers  operation  indicated  provided  no 
f\irther  transport  is  necessary.  He  prophesies  more 
serious  wounds  in  the  wars  of  the  future,  hut  believes  that 
surgerj'  is  holding  pace  with  the  improvements  in  arma- 
ment. 

Kroenlein.  of  Zurich,  showed  true  "copulated  projec- 
tiles." bullets  which  had  met  at  some  period  in  their 
flight  and  had  joined  themselves  firmly  together. 

Reger.  of  Dapzig.  discussed  the  experiments  made  by 
Kroenlein  on  the  effects  of  bullets  in  the  skull. 

Ringel.  of  Hamburg,  brings  nothing  new  while  relating 
his  experiences  with  the  Red  Cross  in  South  .-Africa. 

Ziemssen,  of  Wiesbaden,  advised  the  after-treatment  of 
wounded  soldiers  and  accident  victims  at  the  bathing  re- 
sorts. 

Bruns,  of  Tuebingen.  read  a  paper  on  "Castration  in 
Tuberculosis  of  the  Testes."  Bruns  has  collected  105  cases. 
33  of  which  were  castrat'ons  of  both  testes.  In  these 
cases  he  has  observed  that  the  epididymis  is  always  first 
attacked,  and  that  in  almost  all  cases  tuberculosis  of  the 
testes  follows  epididymectomy.  The  final  results  of  opera- 
tion were:  461-  of  cures  following  removal  of  one  testis, 
cures  lasting  up  to  34  years.  561-  of  cures  following  re 
moval  of  both  testes,  lasting  up  to  30  years.  No  observer 
has  reported  psychological  disturbances.  Bruns  arrives  at 
the  result  that  the  statistics  of  castration  is  more  favorable 
than  that  of  conservative  treatment. 

Baumgarten.  of  Tuebingen.  a  guest  of  the  society,  re- 
ported the  results  of  his  experiments  on  tuberculosis  of 
the  testes.  He  concludsd  from  his  experiments  on  rabbits 
that  the  disease  cannot  advance  against  the  excretory 
stream,  i.  e..  that  a  tuberculosis  of  the  prostate  could  never 
ascend  the  vas  deferens  to  the  testes;  the  bacilli  are  non- 
motile,  and  are  further  pure  parasites,  could  not.  tiiere 
fore,  advance  by  propagation  in  the  secretion.  In  the 
same  way  he  never  observed  tuberculosis  of  the  kidneys 


IMav    4,    lOtil 


THE  LATEST  LITERATURE 


TThe   Philadelphia 
L  Medical  Joubnal 


847 


following  tuberculosis  of  the  urethra  or  of  the  bladder. 
He  did  succeed  regularly,  however,  in  obtaining  tubercu- 
losis of  the  vasa  deferentia  and  of  the  prostate  by  causing 
tuberculosis  of  the  testis. 

Von  Buengner,  of  Hannau.  "On  the  Treatment  of  Tuber- 
culosis of  the  Male  Genital  Organs,"  defends  and  strongly 
recommends  his  method,  the  so-called  "high  castration," 
carefully  pulling  on  the  vas  deferens  until  it  tears  off. 
He  succeeds  in  this  way  in  removing  four-fifths  of  the  duct. 
He  further  describes  experiments  he  has  made  in  injecting 
the  vas  deferens  with  iodoform  glycerine.  By  inserting  the 
needle  in  the  vas  deferens  he  has  succeeded,  on  the  cadaver 
at  least,  in  completely  filling  the  canal.  He  recommends 
this  method,  believing  that  he  has  seen  favorable  results 
in  the  cu^  method  in  which  he  has  tried  It. 

Simon,  of  Heidelberg,  reported  on  107  cases  of  tuber- 
culosis of  the  testis.  Of  these  cases  he  has  followed  92 
o.nd  reports  tiii'^c  cures.  Of  29  removals  of  both  testes  ■> 
died.  21  remained  cured  up  to  20  years.  In  one  case  he 
experienced  psychical  disturbances.  He  recommends  cas- 
tration. 

Koenig,  of  Altona,  on  "The  Technic  of  Castration  for 
Tuberculosis  of  the  Epididymis  and  of  the  Testes,"  recom- 
mends opening  the  entire  inguinal  canal.  He  operates  after 
filling  the  bladder  as  in  Sectio  alta  to  avoid  injuring  the 
peritoneum.  In  the  discussion  Koenig.  of  Berlin,  refused 
to  give  up  his  belief  that  tuberculosis  can  ascend  along  the 
vas  deferens.  According  to  his  experience  in  the  last  ten 
years  he  has  the  impression  that  the  vas  deferens  and 
the  prostate  are  primarily  diseased.  He  has  tried  injecting 
iodoform-glycerin  into  the  epididymis,  and  has  seen  no 
results. 

Gussenbauer,  of  Vienna,  doubts  the  frequency  of  primary 
tuberculosis  of  some  other  organ;  it  can  appear  as  pri- 
mary tuberculosis  of  the  testis  or  epididymis.  In  most  cases 
it  is  continued  with  tuberculosis  of  some  other  organ:  it  can 
appear  from  the  first  to  the  seventieth  year  of  age,  in  one  or  in 
both  testes.  Infection  is  brought  by  the  blood  current. 
He  has  seen  cases  with  and  without  perforation,  healed 
simply  with  a  roborant  diet.  If  operation  be  indicated  we 
must  operate  as  thoroughly  as  possible,  but  one  must 
choose  his  cases. 

Kramer  (Caunnstadt)  believes  the  testis  to  be  the  seat 
of  the  primary  affection,  otherwise  the  diseased  vas  defer- 
ens and  prostate  would  not  heal  after  castration.  He 
considers  congenital  impaction  possible,  thereby  explaining 
the  frequent  cases  of  kidney  and  testis  affection  on  the 
same  side. 

Henle  (rsreslau)  reports  that  the  clinic  at  Breslau  has 
had  negative  results  with  the  iodoform  therapy. 

Bier  (Kiel)  recommends  hydrotherapeutic  treatment 
with  sea  waters.  He  has  seen  one  case  of  tuberculosis  of 
the  bladder  and  kidneys  cured  by  sea  waters!  ?) 

Heidenhain  (Worms)  reports  a  case  of  "Resection  of  th° 
Lung  for  purulent  bronchiectasis  and  presented  the  pa- 
tient." 


A  Case  of  Suprapubic  Prostatectomy. — In  the  Aiinalex 
de  la  l'ijli(}iiii(jiie  tic  liuiiUiiu-v  for  April,  1901  Dr.  E.  Lou- 
meau  reports  a  case  of  suprapubic  prostatectomy.  A  man 
of  72  had  been  forced  to  urinate  two  or  three  times  nightly 
for  some  twenty  years.  After  meals  he  had  to  evacuate 
his  bladder  at  once.  For  two  years  he  had  noticed  that 
effort  was  needed  to  begin  urination.  Suddenly  hematuria 
appeared.  He  was  pale,  but  suffered  none.  By  rectal  pal- 
pation the  prostate  was  found  as  large  as  an  orange. 
A  catheter  was  left  in  place,  yet  the  hematuria  persisted. 
Hypogastric  incision  was  made,  and  the  median  lobe  of  the 
prostate  removed.  The  bladder  was  closed,  drainage  being 
left  through  the  -wound  for  a  short  time  only.  The  hema- 
turia disappeared.  The  bladder  was  washed  out  every  few 
hours  through  the  catheter  left  in  place.  Complete  recov- 
ery followed  in  four  weeks.  The  tumor  of  the  prostate  was 
a  submucous  adenofibroma.  The  diagnosis  before  opera- 
tion rested  between  hypertrophy  of  the  prostate  with  cys- 
titis, and  a  tumor  of  the  prostate.  When  complete  extirpa- 
tion of  the  prostate  is  not  deemed  necessary,  partial  opera- 
tion, removal  of  the  median  lobe  of  the  prostate  by  supra- 
pubic incision  will  often  be  successful,     [M.  O.  ] 


Cbc  Hatcst  Uitcraturc. 


BRITISH    MEDICAL  JOURNAL. 
April    li,    1001. 

1.  A  Clinical  Lecture  on  Some  Cases,  Illustrating  the  Sur- 

gery  of  the   Large   Intestine.     CHARLES   A.   MOR- 
TON. 

2.  Cholecystectomy.     Partial    Hepatectomy   and    Pylorec- 

tomy;  Recovery.     BERTRAM  C.  STEVENS. 

3.  A  Case  of  Sarcoma  of  the  Brain  Removed  by  Operation; 

Subsequent  Operation  for  Removal  of  a  Second  Tu- 
mor; Recovery.     J.  M.  CLARKE  and  R.  G.  P.  LANS- 
DOWN. 
■4.     Case  of  Cavernous  Angioma  of  the  Orbit.  A.  L.  WHITE- 
HEAD. 

5.  The  Saline  Treatment  of     Dysentery;   Based     on     855 

Cases  with  9  Deaths.     M.\JOR  W.  J.  BUCHANAN. 

6.  The  Resistance  of  the  Larval  Mosquito  to  Cold.   M.  J. 

WRIGHT. 

7.  A  Case  of     Recurrent  Alcoholic     Peripheral     Neuritis. 

LESLIE  H.  JONES. 

8.  A  Case  of  Neuritis  Affecting  the  Optical  and  Cervical 

Nerves,  Complicated  by  Carcinoma  of  the  Breast.    J. 
R.  BENSON. 

9.  Case  of  Foreign  Body  in  the  Bronchus.  Tracheotomy; 

Recoverj".     F.  B.  JUDGE  BALDWIN. 

10.  A  Note  on  Acute     Dilatation  of    the  Heart.     H.  OLI- 

PHANT. 

11.  A  Note  on  the  Treatment  of  Genu  Valgum.    E.  MUIR- 

HEAD. 

12.  A  Polypoid  Excrescence  of  the  Tonsil.     E.  S.  YONGE. 
1- — Charles  A  Morton  reports  a  case  of  ventrofixation  of 

the  sigmoid  flexure  for  prolapse  of  the  rectum.  The  pa- 
tient was  a  married  woman,  aged  24,  who  had  suffered  from 
prolapse  for  two  years,  which  she  was  not  able  to  control 
by  means  of  a  T  bandage.  The  whole  thickness  of  the  rec- 
tal wall  protruded  for  three  inches.  An  incision  was  made 
one  inch  above  Poupart's  ligament  and  parallel  to  it.  The 
sigmoid  flexure  was  brought  up  and  the  meso-sigmoid  su- 
tured with  silk  at  the  upper  angle  of  the  wound  to  the  peri- 
toneum. The  opening  through  the  abdomen  was  made  by 
splitting  the  various  muscular  layers  so  as  to  avoid  a  subse- 
quent hernia.  The  patient  made  a  good  recovery  from  the 
operation,  and  about  a  year  later  showed  a  prolapse  equal 
in  size  to  a  medium  sized  internal  hemorrhoid.  From  a 
study  of  the  cases  reported,  particularly  those  by  Bryant. 
Morton  is  lead  to  think  that  the  mortality  of  the  operation 
is  practically  nil.  He  thinks  it  better  to  attach  the  meso- 
sigmoid  to  the  peritoneum  then  to  pass  the  sutures  into  the 
intestinal  wall  or  to  bring  any  portion  of  the  bowel  or  its 
mesentery  between  the  muscular  layers  of  the  incision. 
The  next  case  reported  is  one  of  excision  of  the  cecum  for 
carcinoma,  in  which  the  growth  was  so  movable  as  to 
closely  resemble  a  floating  kidney.  Two  years  after  the 
operation  the  patient  is  in  good  health  and  has  no  sign  of 
recurrence.  The  next  case  reported  is  one  of  obstruction 
from  malignant  growth  of  the  colon.  In  this  case  the 
growth  was  brought  outside  the  abdomen  and  fixed  by  silk 
sutures.  The  following  day  the  bowel  above  the  growth 
was  opened  and  the  obstruction  relieved.  A  fortnight  later 
the  growth  itself  was  removed,  and  two  months  later  the 
divided  bowel  was  anastomosed.  A  few  months  after  oper- 
ation the  disease  returned  at  the  seat  of  operation,  and 
in  the  liver,  requiring  the  making  of  an  artificial  anus,  and 
subsequently  the  patient  died  of  the  disease.     [J.  H.  G.] 

2. — Bertram  C.  Stevens  reports  a  case  of  gall  stones 
complicated  by  a  cancer  of  the  gall  bladder,  liver  and  pylo- 
rus, and  a  fistula  between  the  gall  bladder  and  the  pylorus, 
in  which  Jlr.  Mayo  Robson  performed  the  operation  of  re- 
moving nearly  the  entire  gall  bladder,  together  with  a 
V-shaped  portion  of  the  liver  and  the  pyloric  end  of  the 
stomach.  The  patient  made  an  uneventful  recovery,  and 
8  months  after  the  operation  showed  no  evidence  of  the  re- 


O.O  TnK     PHn-ADELPHIAT 

^  MEIIIIAL   JofBNAl,    J 


THE  LATEST  LITERATURE 


[Mat    4,    1901 


turn  of  the  disease.  The  growth  was  a  columnar-celled 
carcinoma.     [J.  H.  G.] 

3. — J.  M.  Clarke  and  R.  G.  P.  Lansdown  report  an  inter- 
esting case  of  tumor  of  the  brain,  in  which  there  was  a 
marked  absence  of  all  localizing  symptoms.  The  only  two 
points  which  would  sug.atest  the  side  of  the  brain  affected 
were  increased  dulness  over  the  left  parieto-occipital  region 
and  palsy  of  the  left  external  rectus.  Optic  neuritis  was 
also  more  marked  on  the  left  side.  The  general  symptoms 
from  which  the  patient  suffered  were  those  commonly  seen 
in  brain  tumor.  The  patient  was  trephined  over  the  dull 
area,  and  a  distinctly  encapsulated  tumor,  which  measured 
l%xl%x%  inches,  was  found  and  removed.  The  cavity 
filled  immediately  with  what  appeared  to  be  normal  brain 
tissue.  No  palsy  followed  the  operation.  After  a  few  weeks 
all  of  the  former  symptoms  returned,  and  therefore  a  sec- 
ond operation  was  deemed  advisable.  Upon  lifting  the  scalp 
a  large  tumor  was  found  protruding  through  the  opening 
in  the  skull,  and  no  healthy  brain  substance  was  visible. 
The  tumor  was  dense  and  was  easily  separated  from  the 
surrounding  brain  substance,  being  removed  in  three  or 
four  portions  in  order  to  avoid  making  the  bony  orifice 
larger.  The  growth  weighed  6%  ounces,  and  was  the  size 
of  a  large  orange.  Examination  of  this  growth  and  of  the 
former  one  showed  them  both  to  be  spindle-celled  sarco- 
mata. The  patient  was  palsied  after  this  operation,  but 
gradually  recovered  from  it.  Eight  months  after  the  oper- 
ation there  was  no  sign  of  any  recurrence  of  the  growth, 
the  patient  had  recovered  his  mental  faculties,  speech  was 
normal,  memory  good,  and  there  was  entire  absence  of 
pain.  The  vision,  however,  improved  very  little,  but  there 
was  no  oculomotor  palsy.     [J.  H.  G.] 

4. — A.  L.  Whitehead  reports  a  case  of  cavernous  angioma 
of  the  orbit  in  a  man  aged  51  years,  which  had  first  been 
noticed  about  10  years  previously.  The  eye  was  pushed  so 
far  outward  that  the  lids  could  not  be  completely  closed, 
and  ulceration  of  the  cornea  had  set  in.  The  movements 
of  the  eyeball  were  almost  lost,  and  the  pupil  was  dilated. 
The  tumor  was  bluish-black  in  color,  and  could  be  seen 
above  the  globe.  No  pulsation  was  present,  and  there  was 
no  variation  in  size  from  pressure  or  other  causes.  The 
growth  was  not  attached  to  the  walls  of  the  orbit.  The 
fundus  was  healthy  and  the  vision  6-60.  The  patient  was 
etherized,  the  external  canthus  was  divided,  the  capsule 
was  dissected  up,  and  the  external  rectus  was  divided,  the 
tumor  being  then  exposed  and  removed  en  masse  with  some 
difficulty,  but  without  injury  to  the  eyeball.  The  growth 
was  lobulated  and  nearly  encircled  the  optic  nerve.  Hem- 
orrhage was  slight,  requiring  no  ligatures.  The  recovery 
was  uneventful,  and  the  vision  improved  to  6-9,  with  al- 
most complete  range  of  movement  of  the  eyeball.  The 
growth  measured  5  4-5  cm.x3  7-10  cm.  Examination  of  the 
growth  showed  it  to  be  cavernous  angioma  of  the  fibrous 
variety.     (J.  H.  G.] 

5. — Buchanan  reports  the  result  of  300  cases  of  dysentery 
treated  with  salines  during  the  year  1900,  with  only  o 
deaths,  making  with  cases  already  reported,  a  total  of  855 
cases  with  9  deaths,  or  a  mortality  of  only  a  little  over  1 
per  cent.  There  were  51  replases  out  of  300  cases:  one 
case  relapsed  4  times,  13  cases  relapsed  twice  and  37  cases 
had  only  a  single  relapse.  Of  the  3  fatal  cases.  2  were 
extremely  acute  cases  in  which  meat-washing  stools  were 
constantly  passed,  and  a  condition  of  acute  gangrenous 
inflammation  of  the  colon  rapidly  supervened.  The  third 
fatal  case,  after  the  salines  had  failed,  made  a  wonderful 
rallyafteralargedoseof  ipecacuanha  (30grs.K  but  died  some 
7  weeks  later  with  symptoms  of  chronic  diarrhea.  At  the 
necropsy  the  small  intestine  was  found  thin  and  atrophied, 
and  the  large  intestine  was  a  mass  of  chronic  inflammation 
from  the  cecum  to  the  rectum.  The  patient  was  a  feeble, 
old  and  toothless  man.  aged  55  years.  The  author  uses  a 
mixture  of  sodium  sulphate  one  drachm  to  one  ounce  fen- 
nel water,  which  is  given  4,  6  or  8  t'mes  a  day  as  the  case 
requires.  The  saline  is  continued  until  every  trace  of 
blood  and  mucus  disappears.     In  the  majority  of  eases  the 


inflammatory  products  had  disappeared  completely  in  2  or 
3  days;  in  others  they  returned  on  the  third  or  fourth  day, 
necessitating  a  repetition  of  the  saline.  This  method  of 
treating  dysentery  is  advocated  for  acute  cases  only;  the 
author  does  not  consider  it  a  safe  method  for  chronic  or 
relapsing  cases  with  ulceration  of  the  colon.  In  cases  of 
the  chronic  or  relapsing  variety  he  only  uses  the  saline  for 
one  or  2  doses  during  an  exacerbation  of  the  chronic  state, 
and  then  continues  to  treat  the  case  with  soda  and  bismuth 
or  with  salol,  with  an  occasional  dose  of  castor  oil.  For 
stools  containing  scybala  nothing  is  so  good  as  a  dose 
of  castor  oil  guarded  by  10  minims  of  laudanum.  Unless 
the  physician  can  see  the  stools  daily  he  can  never  use  the 
method  to  its  best  advantage.  He  would  hesitate  to  ap- 
ply it  in  a  routine  fashion  in  out-patient  practice,  on  ac- 
count of  the  possibility  of  many  patients  having  had  pre- 
vious attacks,  and  having  their  bowels  in  a  state  of  un- 
healed ulceration.  The  success  which  has  this  year  at- 
tended the  treatment  of  chronic  cases  is  believed  to  be 
due  to  careful  dieting  on  rice  water,  and  boiled  milk  and 
tyre,  the  use  of  anthelmintics  and  the  careful  occasional 
use  of  the  saline,  with  Dover's  powder  and  the  intestinal 
antiseptics.  Not  a  single  case  of  liver  abscess  was  found 
among  the  885  cases  here  referred  to.     [J.  M.  S.] 

6. — From  the  observations  made  on  the  larval  stage  of  the 
anopheles  and  culex  to  withstand  low  temperatures  it  seems 
reasonable  to  infer  that  it  is  really  the  larvae  that  provide 
for  the  continuation  of  the  species  through  winter  in 
northern  countries.     [J.  M.  S.] 

7. — Jones  reports  the  case  of  a  woman  who  was  suffering 
from  absolute  paralysis  of  the  extensors  of  the  bands  and 
feet.  At  first  sight  the  case  looked  like  one  of  lead  poison- 
ing. Domestic  duties  of  a  most  exhausting  nature  re- 
duced the  patient's  strength  and  debilitated  her  constitu- 
tion, for  which  she  had  recourse  to  whiskey  in  moderate 
quantities.  The  condition  was  considered  to  be  a  typical 
case  of  alcoholic  neuritis.  After  total  abstinence  from  al- 
cohol for  4  years,  during  which  electricity  from  both  the 
continuous  and  interrupted  currents,  was  used  regularly,  the 
patient  was  cured.  Seven  years  later  she  had  a  second  attack 
of  neuritis,  following  shock  and  the  assumption  of  domestic 
duties  for  which  she  again  had  recourse  to  stimulants.  After 2 
years  total  abstinence  and  the  renewed  use  of  electricity 
she  has  once  more  regained  perfect  power  over  her  limbs 
and  her  usual  health.  The  author  concludes  that  alcohol  is 
responsible  for  much  that  has  occurred  in  the  recent  out- 
break of  neuritis,  and  that  in  a  great  measure  the  arsenic 
has  acted  on  systems  saturated  with  alcohol.     [  J.  M.  S.] 

8, — Benson  reports  the  case  of  a  woman,  aged  45  years, 
who  suffered  from  carcinoma  of  the  breast... She  experi- 
ence a  sudden,  ver>'  severe  attack  of  pain  in  both  arms, 
fhe  had  also  cramp  in  the  soles  of  the  feet  and  pain  in  the 
shoulders.  Later  she  felt  a  "shivering"  sensation  in  both 
arms  and  up  the  back  of  the  neck  and  head,  accompanied 
by  dull  aching  pain  over  the  same  area.  There  were  also 
f-ramps  in  the  calves  of  the  legs  which  came  on  especially 
at  night,  and  could  only  be  relieved  by  getting  out  of  bed 
and  walking  about,  AVhiskey  eased  her  sufferings.  She 
was  totally  blind  in  the  left  eye.  When  the  patient  seemed 
well  on  the  road  to  recovery  she  had  a  smart  relapse  or 
pain  and  the  respiratory  muscles  were  mostly  affected. 
The  carcinoma  of  the  right  breast,  which  had  become  more 
fixed  to  the  pectoral  muscle,  was  operated  on.  During  the 
night  before  the  operation  an  abundant  crop  of  herpes  ap- 
peared on  the  sternum  opposite  the  third  rib.  mainly  over 
the  musculospiral  area  of  both  arms  above  and  below  the 
elbows.  This  had  quite  cleared  up  when  the  breast  was 
dressed  a  week  later.  The  blindness  and  the  painful  symp- 
toms were  considerd  to  be  due  to  neuritis  of  the  optic  and 
the  cervical  nerves.     [J.  M.  S.] 

9. — F.  B.  Judge  Baldwin  reports  a  case  of  a  boy  aged  ,i 
years,  who  gave  the  history  of  having  swallowed  a  beech 
nut.  Upon  examination  an  hour  after  the  accident,  the  tKiy 
had  a  husky  voice  and  rather  rapid  respiration:  examina- 
tion with  thelaryngoscope  showed  bilateral  palsy  of  the  a-'l- 
ductors,  tut  no  foreign  body  coold  te  seen.   Tbere  were 


[Mav    4,    I'.idl 


THE  LATEST  LITERATURE 


r  luK  I'ui 
L  -\ii.i'i  .11. 


LAllKLI'HIA 


849 


Impaired  respiratory  sounds  on  the  left  side  in  tlie  neigh- 
borliood  of  the  third  rib.  The  respiration  on  the  opposite 
side  was  undoubtedly  exaggerated.  Two  days  after  the 
accident  the  patient  had  so  much  difficulty  in  respiration, 
that  tracheotomy  was  thought  advisable.  This  was  done, 
and  an  examination  of  the  respiratory  tract  and  explora- 
tion with  forceps  revealed  no  foreign  body.  The  patient 
made  a  satisfactory  recovery,  and  nine  days  later  two  small 
pieces  of  the  husk  of  the  nut  were  found  at  the  opening  of 
trachea.    |J.  H.  G.] 

10. — Nicholson  has  found  that  in  certain  grave  states  of 
cardiac  dilation, and  in  advanced  valvular  disease,the  actual 
blood  pressure  as  tested  by  Hill's  instrument  may  be  enor- 
mously high.  This  fact  can  only  be  accounted  for  by  admit- 
ting that  the  ventricle  is  called  upon  to  work  at  its  highest 
pressure.     [J.  M.  S.] 

11. — E.  Muirhead  Little  shows  an  illustration  of  an  ap- 
paratus used  for  genu-valgum,  where  no  operation  is  advis- 
able. The  apparatus  keeps  the  knee  perfectly  stiff  and  con- 
sists of  an  external  straight  splint  extending  from  the  hip 
to  the  shoe,  to  which  the  knee  is  drawn  by  a  series  of 
straps.     [J.  H.  G.] 

12. — Eugene  S.  Yonge  reports  a  case  of  polyp  of  the  ton- 
sil, which  was  pedunculated  and  easily  removed  with  the 
guillotine.     [J.  H.  G.] 


LANCET. 

April  13. 

4 

1.  Hunterian  Lectures  on  the  Topographical  Anatomy  of 

the  Abdominal  Viscera     in     Man.     CHRISTOPHER 
ADDISON. 

2.  On  the  Importance  of  Early  Diagnosis  and  Treatment 

in    Surgical   Diseases   of  the   Abdomen.     WILLIAM 
ROSE. 

3.  Post-Partum  Hemorrhage.     E.  STANMORE. 

4.  Remarks  on  Enlargement  of  the  Inguinal  Glands  Chiefly 

in  Connection  with  the  Diagnosis  of  Primary  Syphil- 
is.     ARTHUR   COOPER. 

5.  Remarks     on    the     Holmgren     Test.     F.  W.  EDRIDGB- 

GREEN. 

6.  The  Chemistry  of  Nerve  Degeneration.     F.  W.  MOTT. 
1. — Christopher  Addison  begins  his  third  and  last  lecture 

with  the  description  of  tlie  peritoneal  folds  and  pouches  in 
in  the  neighborhood  of  ileo-colic  junction.  Of  the  40 
cases  examined  6  presented  an  ascending  meso-colon,  and  9 
a  descending  meso-colon.  The  fact  is  emphasized  that  the 
sigmoid  flexure  of  the  colon  has  a  very  short  mesenteric 
attachment.  Seven  cases  showed  the  cecum  wholly  within 
the  pelvis  and  3  partly  within  the  pelvis.  It  is  thought  that 
when  the  cecum  is  distended  it  is  more  likely  to  become  en- 
larged into  the  pelvis  rather  than  into  the  general  abdomi- 
nal cavity.  In  22  cases  there  was  a  loop  downwards  of  the 
transverse  colon  from  the  hepatic  flexure.  This  loop  is 
often  firmly  fixed  and  difficult  to  undo,  being  frequently 
adherent  to  the  adjacent  ascending  colon.  In  9  cases  there 
was  no  such  loop,  but  the  transverse  colon  passed  directly 
across  the  abdomen.  There  were  six  cases  in  which  there 
was  a  prolapse  of  the  transverse  colon,  this  portion  of 
bowel  passing  across  the  abdomen  wholly  below  the  umbil- 
icus. The  various  positions  of  the  liver,  kidneys,  pancreas, 
and  spleen  are  next  described.     [J.  H.  G.] 

2. — William  Rose,  in  discussing  the  importance  of  early 
diagnosis  and  treatment  of  surgical  diseases  of  the  abdo- 
men, speaks  of  those  which  arise  from  inflammation  and 
those  which  may  be  classed  as  neoplasms.  The  diagnosis 
of  perforating  gastric  ulcer  is  first  taken  up,  and  the  great 
importance  of  early  recognition  of  the  condition  urged  upon 
the  general  practitioner.  The  importance  of  the  early  diag- 
nosis of  rupture  of  the  intestine  is  next  mentioned.  Most 
stress  is  laid  upon  the  fact  that  a  diagnosis  of  perfora- 
tion of  the  vermiform  appendix  is  frequently  made  so  late 
that  operative  interference  is  of  little  avail.  Even  in  cases 
of  localized  abscess  from  appendicitis,  tho  condition  is  too 
frequently  submitted  to  the  surgeon  at  a  late  day.     The 


prognosis  of  operations  for  cancer  of  the  stomach  and  can- 
cer of  the  pylorus  is  more  influenced  by  an  early  diagnosis 
and  prompt  institution  of  surgical  treatment  than  by  any 
other  factors.  When  a  patient  presents  himself  with  a  story 
of  persistent  vomiting  which  medicines  do  not  relieve,  to- 
gether with  flxed  pain  in  the  region  of  the  stomach,  and 
perhaps  a  feeling  of  resistance  in  the  epigastrium,  and  still 
more  if  there  be  some  history  of  preceding  hematemesis, 
an  exploratory  laparotomy  is  indicated.  The  wonderful 
improvement  in  the  mortality  of  pylorectomy  is  next  men- 
tioned. According  to  Barker's  statistics,  the  mortality  of 
this  operation  between  the  years  1S82  and  1890  was  76.5 
per  cent.,  but  between  the  years  1890  and  1898  the  mortal- 
ity was  only  28.6  per  cent.,  while  in  the  hands  of  certain 
individual  operators  the  moitality  is  much  lower.  The  re- 
sults of  operations  for  intestinal  cancer  are  not  as  satisfac- 
tory as  in  cancer  of  the  stomach,  the  mortality  here  being 
about  35  per  cent.  Great  stress  is  laid  upon  a  careful  in- 
vestigation of  both  history  and  symptoms  before  arriving 
at  a  diagnosis,  although  this  may  be  aparently  easy  in  cer- 
tain cases.  Every  avenue  of  information  should  be  thor- 
oughly investigated  in  every  case.     [J.  H.  G.] 

3. — Bishop,  in  speaking  of  post-partum  hemorrhage,  re- 
marks that  in  geneial  there  are  two  definite  aims:  1.  To 
obtain  contraction  of  the  uterus,  and,  second,  to  obtain  lo- 
cal coagulation  of  the  blood.  He  does  not  agree  with  most 
of  the  text-books,  but  believes  that  in  many  cases  the  uterus 
is  utterly  unable  to  contract,  no  matter  what  stimulus  may 
be  employed,  and  this  inability  increases  with  every  ounce 
of  blood  which  is  lost.  This  inability  to  contract,  he  be- 
lieves, is  due  to  the  physiological  tire  of  the  uterine  mus- 
cle. In  the  treatment  of  such  a  condition,  the  uterus  must 
be  raised  until  it  is  higher  than  the  heart,  and  that  means 
that  the  foot  of  the  bed  must  be  lifted  until  it  is  much 
higher.  The  patient  should  be  placed  as  quickly  as  possible 
in  the  Trendelenburg  position,  and  the  legs  should  be  ele- 
vated and  bandaged  from  below  upwards.  The  venous  loss 
is  thus  controlled,  and  it  now  becomes  necessary  to  stop 
the  arterial  flow.  This  may  be  accomplished  by  direct  pres- 
sure of  the  aorta,  but  as  5-6  of  the  blood  supply  to  the  uterus 
comes  through  the  uterine  arteries,  pressure  of  these  ves- 
sels will  be  preferable  to  compression  of  the  aorta.  This 
may  be  accomplished  by  placing  the  closed  fist  over  its  ulnar 
surface  resting  upon  the  aorta  as  it  lies  over  the  left  side 
of  the  vertebral  column  and  exerting  sufficient  pressure 
obliquely  backwards  and  toward  the  right,  so  as  to  enable 
it  to  compress  that  vessel  against  the  unyielding  surface 
beneath.  At  the  same  time  traction  should  be  made  upon 
the  cervix  firmly  by  means  of  a  vulsellum  forceps.  This 
traction  increases  the  angle  in  the  uterine  arteries,  and 
thereby  shuts  oft  the  flow  of  blood.  The  latter  process 
Bishop  considers  most  essential  in  the  treatment  of  these 
grave  cases  of  post  partum  hemorrhage.     IW.  A.  N.  D.J 

4. — Arthur  Cooper,  in  speaking  of  enlargement  of  the  in- 
guinal glands,  particularly  as  occurring  in  primary  syphilis, 
calls  attention  to  the  fact  that  people  vary  in  susceptibility, 
and  that  many  persons  who  are  apparently  healthy  have 
enlarged  inguinal  glands.  He  thinks  that  in  most  of  these 
cases  the  condition  is  due  to  a  mild  form  of  balano-post- 
hitis,  which  has  not  given  the  patient  any  discomfort.  The 
diagnosis  in  a  patient  who  had  not  noticed  such  enlarge- 
ment of  his  glands  might  give  rise  to  considerable  trouble 
in  the  presence  of  a  questionable  sore.  The  glands  which 
become  enlarged  from  a  chancre  usually  make  their  ap- 
pearance in  about  ten  days  after  the  appearance  of  the 
sore,  and  the  increase  is  gradual,  as  is  also  the  decline  of 
the  condition.  Not  infrequently,  however,  the  glandular 
enlargement  is  of  an  anomalous  type,  w-hich  may  result 
in  some  confusion  in  making  a  diagnosis.  The  history  of 
the  previous  condition  of  the  groins  is  of  the  utmost  im- 
portance in  making  a  diagnosis,  as  well  as  the  elimination 
of  other  causes.  In  fat  people  and  those  wearing  trusses. 
Cooper  has  found  inguinal  adenitis  frequently  absent  in  pri- 
mary syphilis.  The  application  of  irritants  to  the  eore,  he 
thinks,  frequently  results  in  suppuration  of  the  glands.  In 


Qrr,         T.ir    rmLAUELPHIA"! 

"O^         Mkdiial  Jouunal  J 


THE  LATEST  LITERATURE 


[Mav    4,    1901 


making  an  examination  of  tlie  groins  ttie  patient  should 
always  be  recumbent.     IJ.  H.  G.J 

6. — Mott  and  Halliburton  state  that  chlorine  can  be  de- 
tected In  the  blood  in  various  nervous  diseases,  such  as 
combined  sclerosis,  disseminated  sclerosis,  alcoholic  neuri- 
tis, and  beri-beri.  For  the  detection  ot  chlorine,  they  either 
employ  a  chemical  test  or  a  physiological  test.  Chlorine 
has  been  found  in  the  blood  of  animals  in  whom  the  sciatic 
rervewas  irritated.  Chlorine  was  always  found  in  greatest 
amounts  when  nerve  degeneration  was  at  its  height.  IF. 
J.  K.] 


JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 
April  2yth,  1901. 

1.  Notes    on     Adrenalin     and     Adrenalin     Chloride.       E. 

FLETCHER  INGALS. 

2.  Hypospadias.     C.  H.  MAYO. 

3.  The  Pollution  of  Streams  and  the  Purification  of  Public 

Water   Supplies.       Comparative   Efficiency   of   Slow 
Sand  and  Mechanical  Filters.     GEORGE  M.  KOBER. 

4.  Floating  Kidneys  in  Children.     I.  A.  ABT. 

5.  Advance  in  Obstetrics  During  the  Last  Half  Century. 

A.  H.  HALBERSTADT. 

6.  When  should   Patients  be  Advised  to  Eat  Everything. 

BOARDMAN  REED. 

7.  Poisoning  from  Autointoxication.     T.  D.  CROTHERS. 

8.  Proposed  National  Bureau    of  Materia    Medica.     F.  E. 

STEWART. 

9.  Hospital  Cars  for  Railway  Service.     W.  L.  ESTES. 

10.  A  Rule  for  Combining  Crossed  Cylinders.     HARRY  S. 

PEARSE. 

1. — Ingals  emphasises  the  usefulness  of  adrenalin  and 
adrenal  chloride,  the  active  principle  of  the  suprarenal 
gland  in  the  treatment  of  some  of  the  acute,  sub-acute  and 
chronic  diseases  of  the  nose  and  throat.  He  employs 
adrenalin  and  adrenalin  chloride  in  solutions,  the  strength 
of  which  varies  from  1  to  1000  to  10,000.     IF.  J.  K.] 

2. — C.  H.  Mayo  speaks  of  the  great  frequency  of  hypospa- 
dias occurring,  according  to  Rennes,  Kaufman  and  others, 
once  in  every  350  males.  The  various  operations  for  the 
relief  of  this  condition  are  classified  and  described:  many 
of  the  operations  are  illustrated.  The  operation  which  the 
author  recommends  is  one  in  which  the  deficiency  of  the 
urethrals  supplied  by  making  a  urethra  from  the  skin  of  the 
prepuse  and  dorsum,  which  is  carried  over  the  front  of  the 
glans  and  attached  to  the  distal  portion  of  the  urethra.  A 
silk-worm-gut  drain  is  used  through  the  urethra  and  the 
bladder  drained  by  a  catheter  through  the  perineum.  The 
author  reports  4  cases  the  last  two  of  which  were  operated 
upon  after  this  manner  with  good  results.     IJ.  H.  G.] 

3. — Kober  writes  that  pollution  of  streams  used  for  public 
water  supplies,  by  individuals  or  communities,  should  be 
regarded  as  a  .grave  offence.  In  order  to  prevent  river  con- 
tamination sewerage  should  be  disposed  of  properly.  Ir- 
rigation of  the  waste  products  on  the  so-called  sewerage 
farms  offers  the  most  approved  measure  in  preventing  pol- 
lution of  streams.  In  addition  to  this  measure,  water 
should  be  filtered  in  order  to  prevent  the  spread  of  the 
so-called  water-borne  diseases.  The  idea  that  rivers  purify 
themselves,  the  author  states,  is  erroneous,  and  that  biolo 
gists  have  almost  concluded  that  "no  river  is  long  enough 
to  purify  Itself."     IF.  J.  K.] 

4. — After  briefly  roviow-ing  the  literature  on  the  sub- 
ject of  floating  kidney  In  children,  Abt  states  that  from  an 
etiological  standpoint  congenital  origin  and  congenital  pre- 
disposition must  be  regarded  as  the  most  important  fac- 
tors.' Acute  and  chronic  trauma  may  be  exciting  causes. 
The  symptoms  of  floating  kidney  are  most  often  latent.  In 
some  cases  there  may  be  moderate  pain,  while  in  others 
the  pain  may  be  paroxysmal  and  colicky  in  character  and 
accompanied  by  chill,  fever,  sweating,  and  vomiting.  The 
attacks  of  acute  pain  are  due  probably  to  twisting  of  the 
kidney  pedicle.  The  kidney  is  often  tender  upon  palpation 
and  the  urinary  secretions  may  be  reduced;   in  some  in- 


stances hydro-nephrosis  may  develop.  Gastro-intestina! 
symptoms  are  common.  The  author  gives  the  report  of 
five  cases  occurring  in  children,  three  in  girls  and  two 
in  boys.  In  four  cases  the  right  kidney  was  displaced. 
[F.  J.  K.] 

5. — Halberstadt  gives  an  interesting  resume  of  the  pro- 
gress that  has  been  made  in  obstetrics  during  the  last  half 
century.  He  remarks  that  beyond  the  introduction  of  asep- 
sis, the  use  of  anesthesia,  and  symphysiotomy  in  parturi- 
tion there  has  been  but  little  else  that  is  new  in  obstetrics. 
On  the  other  hand  gj-necology  has  claimed  all  the  honor 
in  the  progress  in  this  branch  of  medicine.  Halberstadt 
in  speaking  of  the  use  of  anesthetics  remarks  that  the 
parturient  state  is  the  only  condition  of  the  system  in 
which  anesthetics  judiciously  administered  are  entirely  de- 
void of  danger.  In  puerperal  enclampsia  chloroform  is 
especially  indicated  because  of  its  direct,  rapid,  and  gen- 
eral action  controlling  nervous  physiological  irregularities, 
exciting  secretion,  relaxing  the  os  and  perineum,  and.  in 
short,  preparing  the  parts  so  as  to  aid  the  accoucheur  in  his 
manipulations.  Its  application  is  universal;  no  disease  of 
the  heart  or  lungs  should  forbid  its  use.  Owing  to  the 
fact  that  uterine  contractions  are  sometimes  lessened  by 
the  administration  it  may  be  regarded  as  important  to  pre- 
cede it  by  an  oxytocic  in  all  labors  and  at  any  stage  when 
the  pains  are  slight,  so  as  to  increase  their  force,  and  also 
to  guard  against  postpartum  hemorrhage.  In  no  instance 
has  he  seen  narcosis  of  the  child  attributable  to  the  anes 
thesia.     [W.  A.  N.  D.] 

6. — Reed  sums  up  his  conclusions  in  regard  to  some  of 
the  principles  relating  to  diatetics  as  follows:  Not  until  we 
have  cured  our  patient  of  their  diseased  digestive  organ 
should  we  advise  them  to  "eat  everything."  In  addition 
to  partaking  of  the  proper  articles  of  food — those  that  will 
nourish  and  strengthen  in  desired  amounts, — the  patient 
should  take  regular  daily  exercise.  Even  persons  in  good 
health  should  not  be  advised  to  "eat  everything."  for  idio- 
syncrasies must  always  be  carefully  considered.     [F.  J.  K.] 

7. — Crothers  concludes  that  alcohol,  taken  in  any  form 
as  a  beverage,  Is  a  poison  or  produ:es  other  poisons.  It 
acts  as  an  anesthetic  and  not  as  a  so-called  stimulant  or 
tonic.  It  decreases  elimination  and  increases  waste  pro- 
ducts of  the  body.  The  clear  indication  of  the  auto-intoxi- 
cation of  alcohol  is  seen  when  functional  and  organic  symp- 
toms disappear  by  abstinence  in  those  individuals  who  are 
accustomed  to  spirits.     (F.  J.  K.] 

8. — Stewart  advocates  the  establishment  of  a  national 
bureau  of  materia  medica,  the  chief  objects  of  which  are: 
II)  To  estal/lish  standards  of  materia  medica  prepara- 
tions; (2)  The  bureau  should  act  as  a  medium  of  com- 
munication between  manufacturers  and  those  engaged  in 
marketing  products  and  those  engaged  in  scientific  work  in 
laboratories  and  hospitals;  (3)  To  gather  knowledge  of 
materia  medica  products,  establish  a  system  of  laws  per- 
taining to  this  subject,  and  to  publish  for  the  benefit  of 
science;  (4)  Those  manufacturers  who  conform  to  the  re- 
quired standards  should  be  aided  by  the  bureau.     |F.  J.  K.] 

9. — Estes  makes  a  plea  for  the  establishment  of  hospital 
cars  for  railway  service.  He  mentions  the  advantages  that 
would  be  derived,  not  only  to  the  patient,  but  to  communi- 
ties. Individuals  suffering  from  infectious  diseases  not 
infrequently  travel  from  place  to  place  and  spread  disease. 
Careful  disinfection  could  be  practised  with  Hospital  Cars 
and  therefore  reduce  the  risk  of  communicating  diseases. 
I F.  J.  K.] 


THE  NEW  YORK  MEDICAL  JOURNAL. 
April  27,  1901.     (Vol.  LXXIII.  No.  17). 

1.  On  Tenontitis  and  Tenontothecitis  Prolifera  Calcarea. 

CARL  BECK. 

2.  A  Combined   Intranasal  and   Extranasal   Operation  for 

the  Correction  of  a  Congenital  Concave  Vertical  and 
Lateral  Deformitv  of  the  Nose,  with  the  Report  of  a 
Case.    BURTON  S.  BOOTH. 

3.  Hospital   Appointments.     Are  They  Open  to  Women? 

MISS  HELEN  MacMURCHY. 


[May    4.    11101 


THE  LATEST  LITERATURE 


TThe  Philadklphia 
L  Medical  Jouhnal 


851 


1.  A  Contribution  to  the  Explanation  of  the  Nature  of  the 
So-called  Predisposition  to  Infection  with  Staphy- 
lococci.    F.  W.  GAERTNER. 

5.  Pneumonia,  its  Proper  Management  in  Children;  Hy- 
gienic.    Drug  and  Dietetic  Details.     LOIHS  FISHEK 

C.  Peripheral  "Anesthesia-Paralysis" — Report  of  an  Un- 
usual Case  of  Bilateral  Brachial  Paralysis  occurring 
during  Narcosis  (for  Appendicitis).  WALTER  JI. 
BRICKNER. 
7.— The  Relation  of  Arterial  Changes  to  the  Heart.  BEV 
ERLY  ROBINSON. 

1. — Beck  reports  that  the  essential  nature  of  this  disease 
was  a  much  degenerated  (cheesy)  tissue  in  the  state  of  nt- 
crobiosis,  which  seemed  to  have  a  sort  of  magnetic  effect 
on  the  dissolved  calcareous  salts,  inducing  them  to  amal- 
gamate. Such  petrifications  are  found  in  tuberculous 
(cheesy)  foci  of  the  lungs,  and  not  infrequently  in  endo- 
carditis and  pericarditis,  in  old  pleuritic  bands,  in  uterine 
myomata,  and  in  renal  epithelium.  In  the  walls  of  blood- 
vessels, as  well  as  in  degenerated  thyroid  glands,  he  states 
that  he  has  had  an  opporf.mity  to  define  the  mode  of  petrifi- 
cation by  means  of  the  Roentgen  rays.  The  tendons  and 
their  sheaths  seem  to  be  but  seldom  the  seat  of  predi- 
lection for  calcareous  deposits.  Still,  with  the  increasing 
popularity  of  the  Roentgen  rays,  more  light  may  also  be 
thrown  upon  the  pathology  and  significance  of  this  hitherto 
unknown  disease.     [T.  M.  T.] 

2. — Booth  recommends,  instead  of  a  general  anesthetic, 
the  combined  use  of  cocaine  and  adrenal  capsule  in  cor- 
recting deviation  of  the  septum,  for  the  following  rea- 
sons:— (1)  There  is  less  immediate  danger  from  heart  fail- 
ure or  suspeusion  of  breathing,  accidents  not  uncommon 
in  chloroform  and  ether  anesthesia:  (2)  The  hemorrhage 
during  the  operation  is  nil,  and  he  believes  that  the  dan- 
ger of  secondary  hemorrhage  following  the  use  of  adrenal 
is  offset  by  the  danger  of  the  suspension  of  animation  fol- 
lowing the  use  of  a  general  anesthetic:  (3)  The  operator 
can  see  what  he  is  doing  at  every  step  during  the  opera- 
tion: (4)  The  patient  can  sit  upright  and  hold  his  head  in 
place  during  the  operation — an  obvious  advantage;  (5)  No 
special  instruments  are  necessary:  (6)  The  operation  can 
be  done  as  well  in  an  office  as  in  a  hospital;  (7)  The  pain 
is  insignificant,  and  certainly  less  distressing  than  the 
nausea  and  vomiting  following  the  use  of  ether.     [T.  M.  T.] 

6. — Brickner  emphasizes  the  following  important  duties 
of  the  anesthetist  for  the  prevention  of  anesthesia-paraly- 
sis:—  (1)  The  arms  should  never  be  allowed  to  hang  over 
the  edge  of  the  table.  The  position  threatens  the  musculo- 
spiral  nerves  by-  pressure,  and  the  entire  plexus  by 
stretching:  (2)  Rotation  and  superextension  of  the  head 
should  be  exercised  only  while  emergency  required  it:  (3) 
Prolonged  pressure  of  any  kind  should  be  avoided,  be  it 
(.hat  of  an  assistant's  hand  or  body,  or  that  of  a  harness: 
(4)  The  common  practice  of  drawing  the  arms  alongside 
the  head,  however  much  it  may  contribute  to  the  conveni- 
ence of  the  anesthetist  and  the  comfort  of  the  operator 
should  not  be  tolerated.  Avoid  allowing  either  to  remain 
for  more  than  a  few  minutes  in  any  one  position,  however 
innocent  that  position  may  appear  to  be  [T.  M.  T.] 


MEDICAL     RECORD. 


April  2jtli,  l'Ji)l. 

1.  Experiences  with  Tracheotomy.  JOHN  ROGERS. 

2.  Recurrent     Vomiting     of     Nervous     Origin.       LOUIS 

FISCHER. 

3.  Tobacco     as     a     Factor     in     Glycosuria.     HEINRICH 

STERN. 

4.  Pityriasis  Versicolor  of  the  Face.    WM.  S.  GOTTHEIL. 

5.  An  Extreme  Case  of  Simple  Anemia.     ROLF  FLOYD 

and  WM.  J.  GIES. 

6.  Albuminuric  Retinitis  in  Pregnancy;  Premature  Labor; 

Death  in  Utero  of  Twin  Child;  Puerperal  Convul- 
sions; Hemiplegia;  Acute  Mania:  Death.  JOSEPH 
N.  STUDY. 

1.^ — John  Rogers,  Jr..  reports  a  series  of  7  cases  in  which 
four  laryngotomies  and  ten  tracheotomies  were  performed 
without  a  death  which  could  be  ascribed  to  the  operation. 
Great  difficulty  was  found  in  administering  an  anesthetic. 
Cocaine  was  employed  in  his  third  case,  and  was  a  great 


improvement.  The  author  recommends  that  it  be  used 
when  the  patient  is  controllable,  but  in  children,  or  nervous 
patients,  chloroform  is  required.  Laryngotomy,  except  for 
tumor,  is  absolutely  useless.  The  high  opening  of  the  res- 
piratory passages,  however,  has  some  distinct  elements 
of  safety  in  its  favor.  A  low  tracheotomy  presents  some 
of  the  doubtful  advantages  of  a  less  probability  of  subse- 
quent stricture  above  a  long  retained  canula.  On  the  other 
hand,  there  is  serious  risk  of  woundisg  some  of  the  large 
veins  at  the  upper  border  of  the  sternum.  In  general,  and 
especially  for  emergencies,  and  for  chronic  stenosis,  which 
must  subsequently  be  treated  by  intubation,  the  high 
operation  is  safer  and  better  than  the  low.  The  author  has 
met  with  no  difficulty  on  account  of  granulations,  which  are 
often  heard  of  as  serious  dangers  in  cases  of  a  long  retained 
canula.  It  is  not  always  possible  to  diagnose  at  once  the 
locality  of  the  obstruction,  but  if  a  short  canule  does  not 
relieve  the  dyspnea,  a  long  one  should  be  used,  and  a  stom- 
ach tube  is  a  good  substitute.     [T.  L.  C] 

2. — Lewis  Fischer  reports  a  case  of  recurrent  vomiting 
of  nervous  origin.  The  child  came  under  observation  when 
8  years  of  age.  There  was  no  family  history  of  any  chronic 
nervous  disease,  or  "neurotic"  element.  The  child  had  suf- 
fered from  a  violent  pertussis  which  lasted  9  months.  After 
the  cough  subsided  the  vomiting  remained,  even  to  the 
present  time  (and  she  is  now  14).  She  is  a  frequent  suffer- 
er from  tonsillitis.  She  continually  complains  of  pain  in 
the  stomach,  which  is  not  distinctly  localized.  The  symp- 
toms somewhat  suggested  ulcer.  As  to  the  frequency  of 
vomiting,  sometimes  the  child  vomits  a  dozen  times  a  day. 
Occasionally  but  once,  and  rarely  a  day  passes  with  no 
vomiting  at  all.  The  urine  shows  the  presence  of  acetone 
and  indican.  The  former  indicates  a  disturbance  of  meta- 
bolism, but  it  is  well  known  that  acetonuria  does  not  of 
itself  cause  vomiting.  The  condition  persists  despite  treat- 
ment. On  several  occasions  a  distinct  hyperchlorhydria 
was   determined:    again    the    gastric    juice    was    normal. 

[T.   L.  ,C.] 

3. — Heinrich  Stern  has  observed  that  the  habitual,  or 
excessive,  use  of  tobacco  may  not  only  exaggerate  an  exist- 
ing glycosuria,  but  it  may  be  the  causative  factor  of  the 
glycosuric  condition.  He  has  found  that  tobacco  may  in- 
fluence the  pre-established  pathological  output  of  urinary 
glucose  in  the  following  ways:  First,  by  protracting  the 
duration  of  transitory  glycosuria,  and  by  imparting  to  ali- 
mentary melituria  a  certain  degree  of  chronicity.  2.  By 
increasing  the  quantity  of  dextrose  in  the  24  hours'  urine 
in  the  transitory  as  well  as  the  chronic  forms  of  glycosu- 
ria. 3.  By  transforming  the  lighter  degrees  of  chronic  gly- 
cosuria into  the  graver  forms.  Four  cases  are  cited  to  il- 
lustrate these  points.  The  following  experiment  has  been 
frequently  made  by  the  writer:  He  orders  a  patient  with  a 
tendency  to  alimentary  glycosuria  to  ingest  150  gram,  of 
dextrose  (after  the  complete  evacuation  of  the  bladder). 
The  dextrose  is  usually  given  after  his  mid-day  meal,  and 
the  patient  is  ordered  to  abstain  from  any  work  for  the 
rest  of  the  day.  The  urine  for  the  following  6.  8  or  more 
hours  is  collected  separately  and  examined  for  glucose. 
The  latter  probably  appears  in  the  urinary  secretion  until 
the  sixth,  or,  more  rarely,  the  eighth  hour  after  its  inges- 
tion. The  same  experiment  is  repeated  the  next  day.  but 
the  patient  is  ordered  to  smoke  at  least  3  or  4  strong  ci- 
gars in  the  afternoon.  On  this  day  it  will  be  found  that 
the  glycosuria  frequently  persists  for  8,  10  or  even  more 
hours.      [T.  L.   C] 

4. — William  S.  Gottheil  some  time  ago  reported  a  case  of 
pityriasis  versicolor  occurring  in  the  palm.  This  was 
unique,  since  authorities  were  agreed  that  it  never  appeared 
in  that  locality.  It  is  almost  the  same  with  the  face.  The 
parasitic  growth  occasionally  extends  from  the  chest  to 
the  neck,  and  even  to  the  jaw.  He  has  recently  met  with 
a  case  of  primary  Infection  of  the  face,  and  of  the  face 
alone.  He  has  been  able  to  find  no  record  of  a  similar  pri- 
mary involvement.     [T.  L.  C] 

5. — Floyd   and  Gier  report  an  extreme    case  of    simple 


Qj-o  THK     rHILAIiKLI'IUA"! 

"j^  Medical  Juuknai,  J 


THE   LATEST  LITERATL^RE 


IMat   4.    1901 


anemia  in  a  young  mulatto  of  19  years.  It  followed  preg- 
nancy. On  admission,  examination  of  the  blood  showed  12% 
of  hemoglobin,  750,000  blood  cells  and  33,000  white  cells. 
The  blood  was  examined  once  a  week  during  the  patient's 
stay  in  the  hospital,  2  months,  and  every  two  weeks,  then 
after  a  month  or  two  after  her  discharge.  The  hemoglobin 
was  moderately  unevenly  distributed.  "Ringing"  and  ex- 
treme pallor  of  the  cells  was  not  present,  except  in  the 
small  deformed  cells.  A  few  nucleated  reds  were  found. 
There  was  an  abnormally  large  percentage  (over  30)  of 
small  mononuclear  leukocytes.  There  was  no  excess  of 
eosinophiles  and  no  myelocytes  were  found.  A  progres- 
sive improvement  followed  under  appropriate  treatment, 
and  at  the  eighth  month  the  blood  count  showed  hemo- 
globin, 80%,  and  4,800,000  red  blood  cells.  A  number  of 
progressive  counts  are  included  in  the  article,  and  the  case 
is  classed  as  one  of  simple  anemia  because  of  the  rapidity 
and  degree  of  the  recovery.  Analysis  of  the  urine  and 
feces  were  made  daily  during  the  first  tour  weeks,  and  the 
case  was  subjected  to  a  thorough  clinical  study.  [1.  L.  C] 
6. — J.N.  Study  reports  a  case  of  albuminuric  retinitis  in 
pregnancy.  At  the  third  month  of  pregnancy  5%  of  al- 
bumin was  found  in  the  urine,  which  increased  to  10%  at 
the  fourth  month,  when  the  patient  was  passing  400  grains 
of  urea  in  24  hours.  She  suffered  from  constant  pain  be- 
hind the  eyes,  and  the  vision  was  reduced  to  40]80.  Her 
condition  did  not  Improve  at  any  time,  and  the  symptoms 
gradually  grew  worse.  Premature  labor  came  on  without 
warning  at  the  eighth  month.  Within  ten  minutes  a  pre- 
mature male  child  was  born  weighing  four  pounds,  which 
now,  at  six  months,  is  developing  into  a  strong  child. 
Within  fifteen  minutes  of  the  birth  of  the  first  child  a  sec- 
ond undeveloped  male  child  was  born  dead.  It  had  proba- 
bly been  dead  for  two  months.  A  temporary  improvement 
followed  labor,  but  very  soon  symptoms  of  partial  hemi- 
plegia appeared,  and  the  patient,  after  remaining  in  a 
maniacal  state  for  some  four  weeks,  died  about  three 
months  after  the  birth  of  the  child.     [T.  L.  C] 


MEDICAL   NEWS. 

April  27,  J'Ml.     (Vol.  LXXVIII,  No.  17). 

1.  The  Study  of  Internal  Medicine.     WILLIAM  OSLER. 

2.  The  Relation  of  the  Student  of  Medicine  and  the  Recent 

Graduate  to  the  Field  of  Surgery.  GEORGE  RYER- 
SON  FOWLER. 

3.  The  Medical  Man  in  the  Navy.    W.  K.  VAN  REYPEN. 

4.  The  Municipal  Health  Department  System,  and  More 

Especially  in  Reference  to  Its  Advantages  and  Dis- 
Advantagcs  as  an  Opening  for  the  Young  Medical 
Graduate.     ARTHUR  H.  GUERARD. 

5.  The    Advantages    of    Examining    for    Life    Insurance. 

BRANDRETH  SYMONDS. 

6.  The  Outlook  for  the  Young  Physician  in  State  Hospital 

and  Sanitarium  Work.     CARLOS  F.  MAC  DONALD. 

7.  The  Medical  Man  in  the  United  States  Marine-Hospital 

Service. 

3. — Van  Reypen,  in  his  article  on  the  medical  man  in 
the  navy,  gives  the  following  order  of  examinations: — 1st. 
Physical;  2d.  Written;  3d.  Oral;  4th.  Clinical;  5th.  Practi- 
cal. 1.  The  physical  examination  is  necessarily  thorough, 
as  the  question  involved  is  not  simply  one  relating  to  prob- 
able length  of  life,  but  more  especially  to  continued  physi- 
cal ability  to  perform  duty,  for  the  officer  is  paid  when  sick 
and,  when  permanently  incapacitated  for  active  naval  ser- 
vice on  account  of  physical  disability,  has  the  privileges 
of  the  Retired  List,  where,  if  his  disability  has  been  an 
incident  of  service  ,or  his  retirement  is  on  account  of 
age,  he  receives  as  much  as  seventy-five  per  cent,  of  the 
pay  at  sea.  2.  In  the  written  examination  the  candidate  is 
required  to  address  a  letter  to  the  Board  of  Examiners,  stat- 
ing the  date  and  place  of  his  birth,  the  school  or  college  at 
which  he  receivd  his  gneral  education,  the  medical  school 


or  schools  in  which  he  received  instruction,  and  if  he  is  an 
alumnus,  the  date  of  his  graduation,  the  time  when  he  com- 
menced the  study  of  Medicine,  also  the  titles  of  text-books 
studied;  the  opportunities  he  has  had  in  engaging  in  the 
practice  of  his  profession  and  whether  he  has  or  has  not 
been  a  resident  physician  or  interne  in  a  hospital  His 
name  in  full  and  post-office  address  should  be  appended. 
He  next  prepares  a  thesis  upon  some  professional  subject 
indicated  by  the  Board,  and  then  makes  written  answers  to 
questions  on  the  usual  professional  subjects,  including  hy- 
giene and  quarantine.  3.  The  oral  examination  is  upon 
general  educational  subjects  and  the  usual  professional 
branches,  including  hygiene  and  microscopy.  4.  The  clini- 
cal examination  of  the  patients  is  made  at  a  naval  hos- 
pital, and  includes  the  use  of  microscope,  thermometer,  lar- 
yngoscope and  ophthalmoscope.  5.  The  practical  examina- 
tion comprises  surgical  operations  on  the  cadaver,  the  appli- 
cation of  splints,  bandages  and  surgical  dressings,  the 
use  of  the  microscope  and  chemical  and  pharmaceutical 
manipulations.  He  must  have  a  good  general  education, 
but  need  not  necessarily  be  a  college  graduate.     [T.  M.  T.] 

4. — Guerard  gives  the  following  duties  of  the  sanitary  au- 
thorities in  connection  with  health  department  work: 
-  hey  must  insure  to  the  community  and  to  each  individual 
an  abundant  supply  of  pure  air,  light  and  water,  and 
wholesome  food.  The  preservation  of  the  purity  of  the  air 
and  the  furnishing  of  an  abundance  of  light  and  ventilation, 
involves  comprehensive  measures  relating  to  the  character 
of  the  habitations,  their  construction,  their  cleanliness  and 
the  cleanliness  of  their  surroundings;  the  provision  of  ef- 
ficient plumbing;  good  sewerage;  sufficient  air-space,  and 
the  prevention  of  overcrowding:  protection  against  nox- 
ious vapors  or  odors  arising  from  oBensive  trades, 
slaughter-house,  gas-works,  decomposing  animal  and  vege- 
table matter,  and  the  purity  of  the  atmosphere  from  sus- 
pended solid  particles.  It  is  also  incumbent  upon  the  sani- 
tary authorities  to  prevent  adulteration  and  to  guarantee 
the  wholesomeness  of  food — meat,  milk,  fish,  fruit  and  gen- 
eral articles  of  consumption.  The  purity  and  quality  of  var- 
ious drinks  must  be  inquired  into,  and  the  relative  food 
values  of  different  products  determined.  Besides  special 
inspection  relating  to  plumbing,  ventilation,  overcrowding, 
inspections  of  food,  etc..  there  are  also  general  inspections 
relating  to  street  excavations,  wells,  privies,  stables,  the 
conditions  surrounding  the  removal  of  garbage  and  dead 
animals,  the  conditions  of  public  places  and  places  of  as- 
sembly, the  manner  and  place  of  burial,  etc.  Another 
special  feature  of  the  work  relates  to  the  restriction  and 
prevention  of  infectious  diseases,  the  inspection  of  re- 
ported cases,  and  the  quarantine  of  patients  affected  with 
contagious  affections  and  their  removal  to  hospital  when 
required;  the  disinfection  of  infected  premises,  clothing, 
etc.     [T.  M.  T.] 

7. — General  information  regarding  the  medical  man  in 
the  United  States  Marine-Hospital  Service  may  be  summed 
up  as  follows:  Examinations  are  usually  held  once  a 
year,  in  the  spring,  sometimes  more  frequently.  The  boards 
meet  either  in  Washington  or  in  New  York.  All  applicants 
must  be  graduates  of  reputable  medical  colleges.  They  are 
given,  first,  a  physical  examination,  including  a  test  of 
color  vision.  Absolute  health  is  a  prerequisite  to  apoint- 
ment  Each  applicant  then  writes  a  personal  history  of 
himself,  giving  his  educational  advantages,  etc.  A  written 
examination  is  then  conducted  in  the  chief  branches  of 
medicine,  including  anatomy,  physiology-,  chemistry,  ma- 
teria medica  and  therapeutics,  practice  of  medicine,  prac- 
tice of  surgery,  obstetrics  and  diseases  of  women,  hygiene, 
pathology  and  bacteriology.  This  is  followed  by  a  brief 
clinical  examination  in  a  hospital.  Added  to  this  is  an  oral 
examination  in  common  school  branches,  also  the  col- 
lateral sciences  and  literature,  sufficient  to  demonstrate  the 
scope  of  each  applicant's  preliminary  education.  Each  ap- 
plicant reaching  the  grade  of  80  is  eligible  for  one  year 
and  appointments  are  made  to  vacancies  as  they  occur  in 
the  relative  order  of  merit.     IT.  M.  T.] 


May  4,   11X11] 


THE  LATEST  LITERATURE 


CThE    PniLADELPHLi  R  r -J 

Medical  Joubnal         ^JO 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

April  25,  I'JOl.    (Vol.  CXLIV,  No.  17.) 

1.  Remarks    on   Anesthesia — General,    Local    and    Spinal. 

MAURICE    H.    RICHARDSON. 

2.  Experience  in  Search  of  a  Cure  for  Asthma  in  the  Far 

Southwest,  with  Observations  on  the  Comparative 
Value  of  Different  Sections  in  Respiratory  Diseases. 
ROBERT  BELL. 

3.  Cholera  During  Pregnancy.    F.  S.  NEWELL. 

4.  The  Economics  of  the  X-Light  Tube.— An  X-Light  Plate- 

holder. — Removing  the  Irritating  Gases  Produced  by 
X-Light  Generators.     WILLIAM  ROLLINS. 

1. — Richardson  believes  that  the  dangers  of  etherization 
are  trivial  and  that  the  subcutaneous  use  of  cocain,  espec- 
ially in  extensive  dissections  will  be  found  to  be  much 
more  hazardous.  The  only  justification  for  the  use  of  e.x- 
tensive  local  and  of  spinal  anesthesia  lies  in  diminished  risk 
to  the  patient.  One  of  the  dangers  from  general  anesthesia 
is  that  real  one  of  regurgitation  into  the  throat  from  a 
distended  stomach  or  intestine  when  the  patient  is  unable 
to  swallow.  Another  danger  arises  when  the  patient  has 
extensive  disease  of  the  heart,  lungs  or  kidneys.  In  such 
cases,  it  may  be  advisable  to  substitute  local  or  spinal 
anesthesia  for  general  anesthesia  by  ether.  Local  anes- 
thesia is  to  be  preferred  for  all  trivial  operations  in  re- 
gions where  it  can  be  thoroughly  applied,  but  for  opera- 
tions like  appendectomy,  the  radical  cure  of  hernia,  ex- 
cision of  the  elbows  and  amputations  of  arm  or  leg,  seem  to 
the  author  to  be  very  far  from  advantageous  as  compared 
with  ether. 

In  some  very  feeble  patients  the  effect  of  ether  is  bene- 
ficial: but  the  dangers,  definite  though  they  may  be,  are 
unlikely  to  be  lessened  by  methods  whose  dangers  are  as 
yet  unknown.  In  acute  febrile  diseases,  it  seems  a  ques- 
tion whether  the  dangers  of  general  anesthesia  will  be 
avoided  by  local  or  by  spinal  cocainization.  The  use  of 
these  doubtful  methods  in  operations  of  emergency  seems 
ultraradical,  if  not,  with  our  present  knowledge,  unjusti- 
fiable. Another  class  of  diseases  inviting  disaster  under 
general  anesthesia  comprise  operations  upon  deep  cervi- 
cal phlegmons,  tumors  close  to  and  adherent  to  the  trachea, 
inflammations  and  growths  involving  or  pressing  upon  the 
recurrent  laryngeal  nerves  and  imperative  operations  upon 
the  trachea  and  larynx.  In  these  cases  the  value  of  local 
anesthesia  is  great,  and  it  is  the  author's  custom  to  use 
cocain  when  possible.  When  ether  is  carefully  given  there 
is  no  distressing  anxiety  as  to  the  outcome,  and  the  au- 
thor feels  confident  of  the  patient's  safety  and  has  that 
confidence  shaken  only  when  the  anesthetic  is  in  the  hands 
of  the  careless  and  overconfident  or  when  the  patient's 
condition  is  desperate.  He  cannot  believe  that  either 
spinal  or  local  cocanization,  after  50  years  of  use  as  ex- 
tensive and  varied  as  that  of  ether,  or  even  of  chloro- 
form has  been,  will  show  a  safety  to  be  compared  with 
them.     [J.  M.  S.] 

2. — Arizona,  in  Bell's  judgment,  stands  first  as  a  climate  ot 
value  for  all  respiratory  diseases.  He  places  Tucson  at 
the  head  of  the  list  of  cities  in  Arizona  to  which  to  send 
such  patients.  Tucson  has  an  elevation  of  about  4,000 
feet;  there  is  .very  little  irrigation  carried  on  near  it;  its 
annual  rain-fall  is  from  S  to  10  inches;  its  mean  average 
annual  humidity  is  36%.  It  is  singularly  free  from  wind, 
dust  and  sudden  changes  of  temperature  because  it  is  near- 
ly surrounded  by  high  mountains.  It  has  a  maximum  of 
sunshine  and  is  a  desirable  place  to  live  in.  South  Cali- 
fornia is  frequently  resorted  to  by  tuberculous  patients, 
but  in  the  author's  opinion  there  are  many  places  that  are 
much  better  for  this  class  of  invalids.  Although  the  an- 
nual rain-fall  is  but  15  inches  the  dense  fogs  which  pre- 
vail all  over  Southern  California,  except  in  the  moun- 
tains, render  the  climate  too  moist  for  many  tuberculous 
patients  and  for  others  suffering  from  such  respiratory 
diseases  as  asthma  and  chronic  bronchitis. 

Physicians  in  sending  patients  to  the  far  South-west 
should  be  careful  to  send  them  in  the  first  stage  of  their 
disease.  Second  and  third  stage  patients  may  have  lite 
prolonged  but  rarely  recover.  On  arriving  at  his  destina- 
tion the  patient  should  spend  the  early  months  of  his  so- 
journ in  resting  and  living  as  much  as  possible  in  the 
open  air.  Nervous  patients  and  patients  who  are  liable  to 
hemorrhage  should   be  sent  to   a  moderate  altitude.     Pa- 


tients who  are  too  week  to  endure  the  fatigue  of  a  jour- 
ney and  those  who  are  likely  to  become  a  tax  on  the 
people  of  the  "West  should  remain  at  home.  Every  patient 
should  distinctly  understand  that  he  is  to  remain  in  the 
West  after  his  cough  has  ceased  until  he  has  regained  and 
held  his  weight,  and  under  no  consideration  should  he 
return  East  until  he  has -received  the  sanction  of  a  com- 
petent and  experienced  physician.     [J.   M.  S.] 

3. — Symptomatically  the  chorea  that  occurs  in  pregnant 
women  is  identical  with  infantile  chorea.  The  special  con- 
ditions under  which  it  develops  and  the  grave  form  it 
tends  to  assume  in  the  large  proportion  of  cases  give  it 
a  special  significance,  so  that  it  deserves  to  be  considered 
by  Itself  as  a  definite  complication  of  pregnancy,  rather 
than  as  a  modification  of  the  more  common  chorea  of 
adolescence.  An  important  factor  in  the  etiology  of  this 
affection  is  the  existence  of  a  previous  chorea  during 
childhood.  Heredity  and  nervous  impressionability  are 
also  important  etiological  factors.  Previous  infectious  dis- 
eases, probably,  also  have  an  etiological  importance  in 
relation  with  the  disease,  in  that  they  prepare  the  ground 
for  its  development.  Pregnancy  alone  is  no  more  to  be 
considered  the  direct  cause  of  chorea  than  is  active  growth 
in  children  the  cause  of  infantile  chorea.  The  movements 
come  on  gradually  in  the  majority  of  cases  and  become 
more  violent  as  the  time  of  delivery  approaches.  In  mild 
cases,  the  fetus  may  live  and  be  born  at  term;  in  severe 
cases  it  usually  dies  and  causes  abortion  or  premature 
labor.  The  chorea  usually  lasts  the  whole  time  of  gesta- 
tion and  sometimes  days  or  weeks  after  delivery.  As  a 
general  rule  the  spasms  become  less  violent  after  delivery, 
a  fact  which  indicates  the  appropriate  treatment  in  severe 
cases.  The  mortality  in  the  published  tables  varies  from 
one  in  every  17  to  one  in  3%  cases.  Newell  considers  rest 
in  bed  and  freedom  from  worry  valuable  adjuncts  to  the 
treatment  by  sedative  drugs.  The  history  of  an  illustra- 
tive cases  is  given.     [J.  M.  S.] 

4. — Rollins  believes  that  the  most  important  discovery  to 
be  made  in  X-light  tubes  is  to  find  how  to  keep  the  char- 
acter of  the  light  constant.  Meanwhile,  the  best  way  to 
excite  an  X-light  tube  is  to  use  surges  of  millions  of  volts 
and  many  horse-power,  each  surge  lasting  for  not 
more  than  a  millionth  of  a  second.  No  X-Ught  should 
reach  a  plate  except  after  it  has  passed  through  the  patient 
being  photographed.  The  author  states  several  requisites 
for  a  satisfactory  plate-holder  for  X-light  photographs. 
Since  a  powerful  X-light  generator  produces  ozone  and 
combinations  of  nitrogen  and  oxygen  which  are  irritating 
to  the  I'espiratory  mucous  membranes,  a  fan  should  be 
placed  within  the  case  of  a  static  machine  to  drive  the 
gases  into  the  nearest  chimney.    [J.  M.  S.] 


AMERICAN  MEDICINE. 
April  ^7,   moi. 

1.  An  Analysis  of  my  Vaginal  Ablations  in  181  Cases  of 

Pelvic  Inflammation  and  Uterine  Fibroid  Degenera- 
tion.    W.  R.  Pryor. 

2.  The  Good  and   Bad   Effects   Obtainable   from   Digitalis 

used  as  a  Therapeutic  Agent.     WM.   HENRY  POR- 
TER. 

3.  The  Logic  of  Hydrochloric  Acid  Therapy,  Restoration 

of  Lost  Gastric  HCl  Secretion  by  Medical  and  Sur- 
gical Methods.     JOHN  C.  HEMMETER. 
1.     Hyperplastic  Colitis:   Extirpation  of  the  Entire  Colon, 
the  Upper  Portion  of  the  Sigmoid  and  Four  Inches 
of  the  Ileum.     HOWARD  LILIENTHAL. 

5.  The  Value  of  Intestinal  Antiseptics  with  Simple  Aseptic 

Pads   in   Obstetric   Practice.      HARRIET   E.   GARRI- 
SON. 

6.  Gastroptosis.     ALEXANDER  McPHEDRAN. 

7.  Pneumonia.     A    Historical    Review   of   its    Treatment 

WM.  CRAWFORD  JOHNSON. 

2. — William  Henry  Porter  concludes  his  paper  on  the 
good  and  bad  effects  obtainable  of  digitalis  used  as  a  thera- 
peutic agent,  with  the  following  summary:  The  compo- 
sition of  digitalis  is  chemically  speaking,  very  complex, 
and  some  of  its  active  principles  antagonize  others.  The 
different  preparations  differ  widely  in  their  composition 
and  action.  Its  cunuilaiive  action  is  due  to  it  contracting 
the  arterioles  thus  shutting  off  nutrition.  It  is  a  useful  but 
dangerous  remedy  and  has  but  a  limited  range  of  use  in 
lesions  of  the  mitral  valve  and  even  then  only  for  a  short 


854 


The   Philadelphia"! 
Medical  Jocrsal  J 


THE  LATEST  LITERATURE 


[May   4.    i:*01 


time.  It  should  only  be  employed  when  there  is  low  ar- 
teriai  tension  and  marked  venous  engorgements,  and  as 
soon  as  these  conditions  are  overcome  its  action  should 
be  suspended.  As  a  diuretic  it  is  only  useful  when  there 
is  low  arterial  tension,  venous  engorgement,  and  obstruc- 
tion to  the  exit  of  blood  from  the  kidney.  Acting  upon  the 
normal,  and  in  all  diseased  conditions,  in  which  there  is 
obstruction  to  blood  from  the  exit  of  the  kidney.  It  decreases 
the  excretory  activity  of  the  renal  glands  and  impairs  a 
nutritive  activity.  Finally,  if  pushed  to  the  fullest  extent 
it  may  completely  arrest  the  functional  activity  of  the 
renal  glands.     [T.  L.  C] 

3. — Hemmeter  concludes  his  article  (partially  abstracted 
in  our  last  issue),  upon  the  logic  of  hydrochloric  acid  ther- 
apy by  recommending  HCl  for  its  efficacy  in  supplementing 
the  digestive  work  of  the  stomach  in  bringing  about  the 
normal  condition  for  duodenal  digestion.    He  prescribes  20 
drops  of  diluted  HCl  in  2  ounces  of  water  every  15  or  20 
minutes,  beginning  15  minutes  before  the  meal:    then  20 
drops  are  taken  during  the  eating,  and  20  drops  half  an  hour 
after  the  meal.     He  recommends  that  the  medicine  should 
be  taken  through  a  glass  tube  and  the  mouth  rinsed  after- 
wards with  a  weak  solution  of  sodium  carbonate.    [T.  L.  C] 
4. — Howard  Lilienthal  reports  an  extremely  bad  case  of 
hyperplastic  colitis  accompanied  by  papillomatous  growths 
throughout   the   entire  colon   and   a   small   portion   of  the 
ileum,   which  was  not  improved  by  any  form  of  medical 
treatment.     In  order  to  give  the  lower  bowel  a  rest  a  left 
inguinal  colostomy  was  done  with  marked  relief  of  symp- 
toms, the  hemorrhages  entirely  ceasing.     The  patient  im- 
proved   so   much    after   this   operation   that   the    artificial 
anus  was  closed.    The  symptoms  all  returned,  however,  and 
the  patient  came  under  Dr.  Lilienthahl's  care  very  anemic 
and  weak  and  having  about  12  stools  a  day.    On  December 
30,  1899  he  established  an  artificial  anus  in  the  right  in 
guinal  region  in  order  to  give  the  entire  colon  a  rest.     At 
this  time  he  used  irrigations  of  silver  solution,  etc..  without 
apparently  improving  the  condition  of  the  mucous   mem- 
brane.    The  patient's  general  condition,  however,  greatly 
improved  and  the  hemorrhages  again  nearly  entirely  ceased. 
On  March   6th  an   end-to-end   ileo-sigmoidostomy   was  per- 
formed the  colic  end  of  the  ileum  and  the  proximal  end  of 
the    sigmoid    being   invaginated.      A    Murphy    button    was 
used  in  making  the  anastomosis,  and  was  passed  13  days 
after  the  operation.     The  general  condition  of  the  patient 
improved  but  the  stools  were  very  frequent;   these,  how- 
ever, were  reduced  to  about  9  a  day  in  a  few  weeks.     Ir- 
rigation through  the  colostomy  wound  made  appearance  in 
the  rectum  which  could  only  be  explained  by  a  fistulous 
opening  at  the  divided  portion  of  the  sigmoid  which  was 
confined  by  subsequent  operation.     The  patient  was  great- 
ly inconvenienced  by  the  fistula  of  the  colon  and  insisted 
that  something  be  done  to  relieve  it.    On  June  15,  1900.  the 
entire  colon  was  removed  beginning  at  the  rectum.     The 
patient  developed  pneumonia  after  this  operation  but  re- 
covered from  it.     On  the  fourth  day  there  was  a  fecal  dis- 
charge  from   the   right   iliac  -  wound    which    could    be    ex- 
plained.    On  June  27th  an  abscess  ruptured  at  the  site  o* 
the   old   left  colostomy   and   there   was   discharged   a   por- 
tion of  gangrenous  meso-colon.     On  October  6th  the  right 
wound  was  explored  to  ascertain  the  cause  of  the   fecal 
discharge  and  here  was  found  a  "single  piece  of  intestine. 
not  a  loop,  passing  directly  into  the  fistula."    This  was  in- 
vaginated and  the  wound  closed.    The  patient  made  a  good 
recovery  from   this   last  operation   and   finally  all   of  the 
■wounds  closed  and  the  patient  was  exhibited  on  January 
14,  1901  in  excellent  general  health  and  was  having  only 
2  stools  a  day.     [J.  H.  G.] 

5. — Garrison  has  made  a  study  of  intestinal  antisepsis  in 
its  relation  to  the  puerperium,  ^\itll  special  reference  to  the 
use  of  simple  aseptic  pads  in  obstetric  practice.  When 
called  to  a  case  of  obstetrics  she  sees  that  the  intestinal 
tract  is  rendered  aseptic  as  soon  as  possible.  If  this  is  not 
possible  before  delivery  she  begins  to  cleanse  the  bowels 
as  soon  as  possible  after.  For  this  purpose  the  saline  lax- 
atives are  preferable  on  account  of  their  antiseptic  action, 
and  the  best  of  these  is  the  tartrate  of  potassium  and  so- 
dium. She  begins  with  dram  doses  within  four  hours  of 
delivery  and  gives  a  dose  every  four  hours.  The  laxative 
may  be  aided  by  enemata  if  the  bowels  do  not  act  in  twen- 
ty-four hours.  If  the  bowels  have  moved  during  labor,  she 
allows  twelve  hours  to  elapse  before  giving  a  saline,  and  it 
the  bowels  have  not  been  acted  upon  freely  or  the  tongue 


is  foul  she  gives  a  compound  cathartic  pill  within  twenty- 
four  hours  of  the  delivery.  In  addition  to  these  precau- 
tions the  gastro-intestinal  tract  is  further  rendered  free 
from  danger  by  giving  other  antiseptics  as  salol  and  qui- 
nine. A  flow  of  pure  blood  is  Nature's  way  of  freeing  the 
parturient  canal  of  toxins.  This  is  favored  by  means  of  a 
binder  which  holds  the  uterus  up  in  the  proper  position 
and  prevents  obstruction  at  the  cervix.  Aseptic  pads  should 
then  be  applied  to  present  the  entrance  of  the  germs 
of  putrefaction.     [W.  A.  N.  D.] 

6. — Alexander  McPhedran  reports  3  cases  of  gastroptosis. 
He  offers  the  following  conclusions:  Gastroptosis  frequent- 
ly exists  without  symptoms  as  long  as  the  functions  of  the 
stomach  are  performed  efficiently.  The  symptoms  of  the 
condition  arise  from  the  retention  and  decomposition  of 
food  in  the  stomach  with  the  local  irritation  and  constitu- 
tional poisoning  resulting  therefrom.  In  the  condition 
known  as  Glenard's  disease  the  gastroptosis.  or  splanch- 
noptosis, plays  often  a  minor  part  in  the  production  of  the 
symptoms.  In  not  a  few  instances  the  splanchnoptosis  is 
rather  the  result  than  the  cause  of  the  condition.     [T.  L.  C.J 


UNIV.  OF  PENNA.  MEDICAL  BULLETIN. 
Aiiiii.   I'Ml. 

1.  A  Series  of  Twelve  Articles  on  Medical  Men  Prominent 

in  the  Civil  and   Military  Affairs   of  Revolutionary 
Times.     FRANCES  R.  PACKARD. 

2.  Notes  on   Fiftv  Operations  for  Otitic  Extra-dural  Ab- 

scess.    B.  ALEX.  RANDALU 
?..     Primary  Sarcoma  of  the  Spine.    JAMES  K.  YOUNG. 

4.  A    Critique   of    Certain   Methods   of   Gastric   Analysis. 

DAVID  L.  EDSALL. 

5.  Adrenalin,  the  Active  Principle  of  Adrenal  Extract,  a 

Proposed  Agent  in  Morphin  and  Opium  Poisoning, 
etc.     EDWARD   T.   REICHERT. 

1. — Dr.  Francis  R.  Packard  continues  his  interesting 
series  of  articles  on  medical  men  prominent  in  civil  and 
military  affairs  of  the  Revolutionary  Times.  In  this  paper 
he  presents  sketches  of  Dr.  John  Brooks  and  Dr.  William 
Eustis,  both  Governors  of  Massachusette.  and  both  physi- 
cians of  prominence,  and  Dr.  Nathaniel  Freeman,  soldier 
and  Judge.     [T.  L.  C] 

2. — B.  Alexander  Randall  contributes  a  paper  in  the  na- 
ture of  a  critique  on  50  operations  for  otitic  extradural 
abscess.  Post-mortem  teachings  have  more  and  more  em- 
phasized the  frequency  of  the  aural  causation  of  extra- 
dural abscess.  Very  frequently  extradural  collections  of 
pus  present  only  aural  symptoms.  The  efficacy  of  the 
Wilde  incision  formerly  practiced,  a  mere  periosteal  sec- 
tion over  the  inflamed  mastoid  is  no  longer  believed  in. 
External  mastoid  periostitis  may  primarily  occur,  but  the 
belief  is  gaining  that  the  reported  cases  have  been  largely 
errors  of  diagnosis.  Randall  believes  that  those  cases 
which  have  apparently  been  much  benefited  by  heat  or 
cold  to  the  aural  region,  hot  douching  in  the  canal,  leeching 
or  antiphlogistic  measures,  would  have  done  equally  well 
without  such  treatment.  When  pus  is  present  on,  or  in 
the  mastoid,  delay  is  of  very  great  danger.  Pus  upon  the 
surface  of  the  mastoid  is  rarely  formed  there.  It  may  have 
burrowed  out  sub-periosteally  along  the  canal  or  may  have 
oozed  through  the  apparently  healthy  cortex.  Its  exit 
through  a  large  bone  sinus  may  be  so  frank  as  to  tempt 
us  to  believe  that  drainage  is  already  adequate  without  op- 
erative attack  on  the  bone.  Experience  shows  this  is  fal- 
lacious. The  healthiest  looking  bone  may  wall  in  a  pus- 
collection  which  is  not  merely  menacing  local  structures, 
and  tending  to  general  pyemic  infection,  but  is  burrowing 
between  the  dura  and  the  skull  and  locally  infecting  the 
intracranial  contents.  In  50  cases  of  extradural  abscess 
operated  upon  by  the  author  he  has  been  struck  by  the 
usual  absence  of  symptoms  suggesting  intracranial  mischief 
in  even  ..le  worst  cases.  The  subnormal  temperature  or 
slowed  pulse  was  lacking  wholly,  although  the  bulk  of  the 
intracranial  collection  was  often  enough  to  pre-suppose 
decided  pressure.  The  extent  of  the  dura  covered  with 
villus  granulations  was  at  times  markedly  at  variance 
with  the  normal  temperature  and  apparent  well-being. 
The  eye  grounds  were  almost  invariably  studied  and  in  only 
one  or  two  cases  suggested  involvement.  The  hearing  was 
good,  except  as  explained  by  peripheral  conditions,  and  pa- 
retic or  incoordinate  sj-mptoms  were  absent.  Operation  was 
invariably   successful.     The   author   includes   notes   of   5 


Mav    4,    IIMIIJ 


THE   LATEST   LITERATURE 


r  rilK     I'UILAriELI'HlA  Qrc 

L    MEDHAI,   JfllllXAI,  °0>> 


very  interesting  cases.  He  believes  that  the  antrum  should 
be  freely  opened  in  acute  cases,  all  of  the  tympanic  cavities 
in  the  chronic,  not  only  for  drainage  but  for  full  inspection 
of  the  walls,  and  every  portion  of  the  decidedly  sus- 
picious bone  should  be  curetted  away.  The  operator 
need  not  fear  reaching  the  inner  table  of  the  dura  for  the 
inspection  of  this  part  will  frequently  reveal  further  dis- 
eased conditions,  and  make  the  primary  operation  a  suc- 
cess.    [T.  L.  C] 

3. — James  K.  Young  reports  a  case  of  primary  sarcoma  of 
the  spine,  in  a  Russian  Hebrew  child  of  5  years  who  was 
first  seen  April  13,  18'J9,  when  a  diagnosis  of  incipient  Pott's 
disease  was  made.  Under  treatment  great  improvement 
followed  in  a  fortnight.  The  patient  was  finally  readmitted 
in  February,  1900,  and  died  in  June  of  that  year,  of  as 
thenia.  No  necropsy  was  permitted.  From  this  case 
Young  concludes  that  the  characteristic  symptoms  are: 
pain,  paraplegia,  grave  constitutional  involvement,  rapid 
course  and  metastasis.  Metastatic  growths  occurred  in  the 
postorbital  region  of  this  child,  but  there  were  probably 
also  growths  in  the  liver  and  in  all  the  abdominal  organs. 
According  to  Edes  the  pain  in  sarcoma  of  the  spine  is  not 
nearly  so  severe  as  in  carcinoma,  whether  it  be  primary  or 
secondary.  It  is  increased  on  pressure,  on  standing  or 
sitting  up  quickly  or  upon  turning  over  in  bed.  The 
diagnosis  may  be  made  from  a  severe  localized  pain,  tho 
tenderness  over  the  spine,  a»d  the  rapid  progress  of  tho 
disease.  An  exhaustive  study  of  the  differential  diagnosis 
of  primary  sarcoma  of  the  spine  from  a  host  of  other  con- 
ditions is  given.     [T.  L.  C] 

4. — D.  L.  Esdall  presents  a  critique  of  certain  methods  of 
gastric  analysis,  especially  4  of  which  may  be  used  by  clin- 
icians for  determining  the  total  HCI  of  the  gastric  contents. 
These  4  which  are  worthy  of  consideration  are  Leo's.  Toep 
fer's,  Hewes',  and  the  one  recently  described  by  Colnheira 
and  Krieger.  Leo's  method  is  perfectly  satisfactory  in 
cases  in  which  organic  acids  are  absent,  and  if  simply 
qualitative  tests  for  lactic  acids  and  for  volatile  organic 
acids  are  negative,  it  may  be  used  clinically  with  entire 
confidence,  remembering  always  that  calcium  chloride 
must  be  added  to  the  stomach  contents  before  the  primary 
titration  for  total  acidity  is  carried  out.  Edsall  believes 
that  Toepfer's  method  is  of  little  value  even  for  clinical 
purposes,  because  the  color  changes  in  the  titrations  are 
so  difficult  to  recognize.  One  of  the  most  serious  errors 
in  the  employment  of  Hewes'  test  is  the  use  of  3  indicators, 
thus  multiplying  the  errors  due  to  indicators.  Cohnheim 
and  Krieger's  method  depends  upon  the  fact  that  phospho- 
tungstic  acid,  and  the  salts  of  this  acid,  precipitate  native 
albumins  and  the  products  of  their  digestion  in  combination 
with  the  phosphotungstic  acid.  This  method  in  brief  con- 
sists in  the  determination  of  the  total  acidity  of  the  gas- 
tric contents,  then  adding  to  another  portion  of  gastric 
contents  a  solution  of  phosphotungstate  of  calcium,  which 
precipates  the  albumin  and  albumoses  and  sets  free 
the  HCI  in  combination  with  them.  The  HCI  combines 
with  the  calcium  of  the  phosphotungstate  and  forms  neut- 
ral calcium  chloride.  There  occurs,  therefore,  a  reduction 
of  acidity  corresponding  to  the  amount  of  combined  HCI 
present,  and  the  combined  HCI  is  at  once  indicated  by  ti- 
trating a  second  time  after  the  precipitation  and  by  deter- 
mining the  difference  between  the  second  and  first  titra- 
tion. These  authors  report  a  series  of  results  which  they 
obtained  with  stomach  contents  controlling  these  results 
by  Sioeqvist's  method,  and  also  results  obtained  when 
working  with  known  quantities  of  HCI  in  solutions  contain- 
ing Witte's  peptone.  Their  results  were  strikingly  accur- 
ate. Edsall  believes  that  this  method  is  more  accurate 
than  those  which  have  l.ieen  suggested  with  the  possible 
exception  of  Sjoeqvist's  method.     [T.  L.  C] 

5. — Edward  T.  Reichert  presents  the  results  of  experi- 
mental work  upon  adrenalin,  the  active  principle  of  adren- 
al extract  as  a  proposed  agent  in  morphine  and  opium 
poisoning,  in  circulatory  failure  in  the  prevention  of  pro- 
lapse in  anesthesia  and  in  allied  conditions.  Reichert 
found  while  in  normal  dogs  a  dose  of  0.00025  grams  per 
kilo  is  without  any  decided  effect  upon  general  metabolism 
and  body  temperature,  in  morphinized  dogs  it  is  sufficient 
to  prevent  the  profound  decrease  of  general  metabolism, 
and  the  marked  fall  of  liody  temperature,  caused  by  mor- 
phine. This  marked  difference  is  most  interesting  and 
adds  evidence  in  favor  of  the  view  advanced  as  to  the  prob 
able  involvement  in  morphine  poisoning  of  the  processes 
contained  in  internal  secretion,  and  the  consequent  import- 


ant bearing  of  the  action  upon  toxic  phenomena.  It  sug- 
gests also  that  morphine  acts  as  a  direct  depressant  to  tho 
secretory  processes  of  the  adrenal  glands,  thus  depriving 
the  vital  centers  of  the  secretion  with  the  resultant  marked 
depression  of  both  general  and  special  forms  of  metabolism. 
In  normal  dogs  very  small  doses  are  without  effect,  pre- 
sumedly because  the  quantity  of  adrenalin  introduced  is  so 
minute  as  to  be  rapidly  destroyed.  The  normal  supply 
of  adrenalin  being  sufficient,  any  quantity  beyond  this  in- 
troduced into  the  blood  and  lymph  being  immediatelv  de- 
stroyed, or  compensated  for,  by  an  inhibition  of  the  secre- 
tory activity  of  the  glands;  but  in  morphinized  dogs, 
because  of  the  blood  lacking  this  proper  constituent,  adren- 
alin is  not  destroyed  until  it  has  lieen  utilized  in  its  nor- 
mal work.  The  positive  and  prompt  action  of  adrenalin 
upon  the  respiratory  movement  of  the  heart,  arterial 
pressure,  general  metabolism  and  body  temperature  justify 
the  belief  that  this  substance  will  be  found  of  value  in 
opium  and  m.orphine  poison  and  the  conditions  named  in 
the  title.  It  is  probably  owing  to  its  powerful  local  action 
as  a  vasoconstrictor  that  abscess  will  be  caused  by  subcu- 
taneous injections.  When  administered  by  the  stomach, 
in  morphinized  individuals,  it  should  be  given  with  alcohol 
in  some  form  so  as  to  increase  the  rapidity  of  absorption. 
[T.  L.  C] 


AMERICAN    JOURNAL    OF    THE    MEDICAL    SCIENCES. 

April,  I'.inl. 

1.  Primary  Splenomegaly.     BRILL. 

2.  Enteoptosis.     ARNEILL. 

:;.  The  Estimation  of  the  Urinary  Sulphates  and  of  the 
Fecal  Fat  in  the  Diagnosis  of  Pancreatic  Disease. 
EDSALL. 

4.  Premature  Infants.     ADRIANCE. 

5.  Contribution  to  the  Study  of  Fatty  Infiltration  of  the 

Heart    Secondary    to     "Supercardial     Over-Fatness. 
ANDERS. 
G.     Multiple  Neuritis  and  Hematoporphyrinuria  Following 
the   prolonged   Ingestion  of  Trional.     HART. 

I- — The  extraordinary  interest  of  Brill's  communication 
lies  in  the  fact  that  3  cases  of  an  exceedingly  rare  disease 
occurred  in  the  same  family.  The  family  history  was  ab- 
solutely negative:  none  of  the  parents,  grandparents,  or 
great-grandparents  apparently  had  any  similar  condition. 
Six  children  were  born  in  the  family.  The  1st  and  4th 
are  now  in  perfect  health.  The  2d  died  at  the  age  of  3 
years  of  chronic  diarrhea:  the  3d,  5th  and  6th,  all  suffered 
from  enlargement  of  the  spleen.  The  youngest  of  these 
died  at  the  age  of  9  years:  he  had  been  sickly  from  his 
3d  year,  and  before  death  an  enormous  enlargement  of  the 
spleen  was  recognized.  The  oldest  of  these  3,  now  34 
years  of  age  and  married,  at  about  the  age  of  22  noticed  an 
enlargement  of  the  abdomen  under  the  ribs  on  the  left 
side,  which  proved  to  be  an  enormous  enlargement  of  the 
spleen.  About  seven  years  later  she  developed  a  tendency 
to  sweating  with  development  of  sudamina.  This,  a  year 
later  became  hemorrhagic,  and  the  patient  had  numerous 
'blood  boils,'  She  also  had  2  attacks  of  pleural  effusion. 
The  blood  was  always  normal,  in  all  respects.  During  an 
attack  of  typhoid  fever  the  spleen  became  soft,  but  sub- 
sequently enlarged  again.  Later  there  apeared  on  the 
sclerae  on  the  inner  side  of  the  corneae.  a  yellowish  wedge- 
shaped  patch.  The  organs  of  the  thorax  and  the  lower 
part  of  the  abdomen  are  displaced  by  the  enormous  spleen, 
but  the  patient  is  otherwise  comfortable  and  fairly  ener- 
getic. There  is  also  progressive  emaciation.  There  have 
Geen  no  atacks  of  fever,  no  symptoms  of  renal  disease, 
and  tho  liver  is  apparently  normal  in  size  and  consisten- 
cy. The  3d  patient,  the  5th  child,  a  man,  discovered  the 
existence  of  a  slightly  enlarged  spleen  at  the  age  of  19. 
He  was  then  suffering  from  sudamina :  there  were  fre- 
quent ;itacks  of  epistaxis  and  an  erythematous  eruption 
about  the  nose.  The  blood  was  always  normal.  Drugs  had 
no  effect:  the  spleen  enlarged  progressively,  and  there  have 
been  hemorrhagic  boils  and  some  pigment  patches  on  the 
skin.  In  neither  patient  has  there  been  any  enlargement 
of  the  Ivmphatlc  glands.  There  is  moderate  enlargement 
of  the  liver.  The  distinctive  features  of  these  two  cases, 
both  of  which  have  been  carefully  stu4ied  by  Brill  are  the 
enormous  enlargement  of  the  spleen,  the  moderate  enlarge- 
ment of  the  liver,  the  profuse  perspiration,  the  sudamina. 
the  hemorrhagic  tendency,  the  peculiar  brownish  yellow 
coloration  of  the  skin,  and  the  absence  of  blood  changes 


8.s6 


The    I'Hii.Ai>ELPHiA"| 


THE   LATEST  LITERATURE 


[Mat    4.    J 901 


for  aperiod  of  more  than  10  years.  Both  patients  have 
the  yellowish  wedge-shaped  patches  to  the  inner  side  of 
the  cornea  on  the  sclera.  The  disease  is  evidently  not 
due  to  malaria,  syphilis,  rachitis,  nor  tuberculosis.  It  is 
not  a  form  of  amyloid  disease,  leukemia.  Hodgkln's  dis- 
ease, or  splenic  anemia.  Neither  can  it  be  due  to  abscess. 
The  course  has  been  too  slow  for  malignant  tumor:  the 
absence  of  any  condition  that  would  give  rise  to  possible 
congestion  excludes  this  process,  and  the  fact  that  the 
liver  is  not  cirrhotic  shows  that  the  condition  is  not 
Banti"s  disease.  It  is  therefore  impossible  to  classify  these 
cases  at  present.     [J.  S.] 

2. — Arneill.  dicussing  enteroptosis,  states  that  Virchow 
nrst  called  attention  to  displacement  of  the  intestines  in 
1853  [Morgagui  preceded  him  by  nearly  a  century. — J.  S.] 
Glenard  first  suggested  the  relation  existing  between  this 
displacement  and  certain  complexes  of  clinical  symptoms. 
In  the  examination  of  these  patients  the  important  points 
are:  to  determine  the  position  of  the  stomach,  the  abnormal 
mobility  of  the  10th  rib.  and  to  palpate  carefully  the  other 
organs.  He  prefers  inflation  for  the  determination  of  the 
stomach  area,  and  usually  employs  tartaric  acid  and  bi- 
carbonate ot  soda  taken  separately.  In  2004  cases  of 
which  he  has  records  since  1892,  he  has  found  enterop- 
tosis in  11  men  and  69  women.  In  24  cases  both  kidneys 
Tvere  dislocated;  in  33  the  right  kidney  alone:  and  in  4. 
the  left  kidney  alone.  Stiller's  phenomenon  was  present 
completely  in  S.  and  partially  in  T  cases  that  were  exam- 
ined. The  condition  in  the  other  cases  was  not  recorded. 
Tn  69  of  these  cases  the  stomach  was  distended,  and  was 
more  or  less  enlarged.  The  total  acidity  was  apparently 
Slightly  decreased  in  some  of  the  cases.  In  a  few  of  them 
there  was  moderate  chlorosis,  and  in  several  slight  anemia. 
The  majority  of  cases  occurred  between  20  and  50  years. 
The  sjTnptoms  were  chiefly  those  of  neurasthenia,  and  in 
adition.  poor  appetite,  coated  tongue,  nausea  and  vomit- 
ing, and  chronic  constipation.  He  reports  a  few  cases., 
and  in  discussing  treatment  expresses  his  skepticism  of  the 
use  of  operation,  but  believes  that  nux  vomica,  hydrochloric 
acid  and  over-feeding  are  of  great  value.    [J.  S.] 

3. — Edsall  in  a  valuable  paper  upon  pancreatic  disease, 
reports  2  cases.  The  first,  a  man  of  36,  had  pain  above 
and  to  the  right  of  the  umbilicus,  and  subsequently  rapid 
emaciation.  There  was  absence  of  free  HCl  in  the  stomach 
contents,  but  none  of  the  other  chemical  symptoms  usually 
supposed  to  indicate  carcinoma  were  present.  There  was 
slight  tenderness  on  pressure  in  the  epigastrium.  Later 
he  developed  jaundice  and  very  rapid  emaciation.  Esti- 
mation of  the  sulphates  showed  that  the  ethereal  sulphates 
bore  a  relation  of  1  to  20  or  30  to  the  preformed  sulphates, 
showing  that  they  were  markedly  diminished.  An  opera- 
tion was  performed  and  shortly  afterward  the  man  died. 
At  the  autopsy  a  carcinoma  of  the  head  of  the  pancreas 
was  found  completely  occluding  the  biliary  and  pancreatic 
ducts.  The  author  also  reports  another  case  of  jaundice 
in  which  the  etheral  sulphates  bore  a  relation  of  1  to  8  to 
the  proformed  sulphates,  and  pancreatic  disease  was  there 
fore  excluded.  After  discussing  the  literature,  however,  he 
reaches  the  conclusion  that  this  sign  is  not  of  great  value. 
It  must  be  carefully  considered  in  each  individual  case,  and 
is  only  of  importance  when  positive.  In  addition  the  fats 
were  carefully  estimated  in  the  second  case,  and  it  was 
foimd  that  they  constituted  over  SO'^c  of  the  entire  amount 
of  the  feces,  and  that  a  very  small  proportion  of  the  amount 
of  fats  ingested,  that  is  about  (i(^'~'c.  has  been  absorbed.  How- 
ever,these  fats  have  been  split.that  is  to  say.TSf^  was  formed 
of  fatty  acid.  It  seems  to  show  that  mere  absence  of  bile 
does  not  prevent  the  action  of  the  fat-splitting  ferments. 
Excessi.e  amount  of  fat  in  the  stools,  however  does  not  of 
itself  indicate  pancreatic  disease.     [J.  S.] 

4. — Adriance  discusses  the  symptomatology  and  treat- 
ment of  premature  infants.  There  is  usually  considerable 
disturbance  of  temperature,  most  commonly  it  is  sub-nor- 
mal, but  occasionally  irregular,  or  febrile.  The  children  are 
very  liable  to  attacks  of  cyanosis  on  account  of  the  in- 
efficiency of  the  respiratory  centre  and  the  p-^rtial  atelec- 
tasis of  the  lungs.  The  kidneys  sometimes  do  ^ot  act  well, 
and  there  is  often  an  excessive  secretion  of  unc  acid. 
There  is  a  very  marked  tendency  to  the  levelopment  of 
anemia  Weight  is  gained  very  slowly.  The  author  has 
observed  40  cases  -in  which  the  children  were  bom  any 
where  from  the  2Sth  to  the  3Sth  week.  Of  these  24  died 
and  16  lived.  All  born  before  the  30th  week  died,  although 
one  of  these  lived  to  be  9  months  of  age.  In  fact  11  of  the 
24  deaths  were  due  to  complications  and  not  to  premature 


birth,  all  of  the  11  children  surviving  the  period  of  full 
term.  Of  course  the  prognosis  for  life  is  graver  the  earlier 
the  children  are  born.  With  regard  to  treatment  the  most 
important  points  are  the  temperature  and  the 
feeding  period.  The  children  should  be  placed  in  an  in- 
cubator whose  temperature  is  regulated  according  to  their 
condition:  lower  if  they  have  fever,  and  higher  if  their  tem- 
perature is  subnormal.  The  children  should  be  left  abso- 
lutely at  rest  and  not  even  bathed,  and  the  clothing  should 
be  readily  removable.  The  feeding  is  a  very  important 
process.  The  milk  obtained  from  a  woman  whose  child  is 
about  a  month  old  is  most  suitable  for  administration.  It 
should  be  given  with  a  dropper,  remembering  that  the 
stomach  capacity  is  not  more  than  a  dram  or  two.  Attacks 
of  cyanosis  should  be  met  by  the  administration  of  oxygen 
and  whiskey.  Constipation  should  be  avoided  by  small 
doses  of  caster  oil.     [J.  S.] 

5. — Anders  discusses  fatty  infiltration  of  the  heart,  and 
reports  the  following  cases.  A  woman  of  40.  weighing  220 
pounds,  who  had  been  in  ill  health  for  some  time,  and  asth- 
matic, had  delirium  cordis.  She  was  extremely  nervous  and 
from  time  to  time  had  anginoid  attacks  that  could  only  be 
relieved  by  morphia.  She  was  evidently  suffering  from  fatty 
infilitration  of  the  heart.  The  second  case,  a  woman  of 
50,  weighing  310  pounds,  suffered  from  extreme  dypsnea, 
cyanosis  and  exhaustion  on  exertion.  Appropriate  treat- 
ment reduced  the  weight  125  pounds,  and  the  patient  re- 
covered. It  is  possible  that  this  was  merely  a  case  of 
fatty  infiltration  of  the  pericardium.  He  also  reports  sever- 
al other  cases  in  which  reduction  of  weight  caused  very 
marked  improvement  in  the  cardiac  symptoms.  He  has 
collected  7  cases  from  the  literature  in  addition  to  his 
own.  It  is  interesting  that  in  many  of  these  cases  the 
fatal  termination  was  due  to  rupture  of  the  heart.    [J.  S.] 

6. — A  woman  of  50  had  suffered  for  20  years  from  in- 
somnia for  which  she  took  large  quantities  of  trional.  This 
treatment  was  interrupted,  but  subsequently  she  again 
commenced  it.  After  a  considerable  interval  during  which 
she  used  the  drug  constantly,  she  developed  pain  in  the 
abdomen,  nausea,  and  vomiting.  Later  she  passed  red  urine 
which  gave  the  characteristic  spectrum  of  haematoporphy- 
ria.  Tbere  was  then  tingling  in  both  arms,  loss  of  botli 
knee-jerks,  hyperesthesia  and  reactions  of  degeneration  in 
the  extensor  muscles  of  the  arms.  She  had  delirium  with 
somehallucination.and  subsequently  extreme  hyperesthesia 
of  the  skin  of  the  body.  The  trional  was  stopped  and  she 
gradually  improved,  and  subsequently  recovered  complete- 
ly. It  is  important  therefore  to  remember  that  trional 
can  produce  acute  poisoning  just  as  sulphonal  does,  that 
it  has  a  cumulative  action,  and  that  while  it  is  being  given 
the  kidneys  and  bowels  should  be  kept  active.     [J.  S.] 


A  Case  of  Ascites  and  Prolonged  Fever  as  a  Result  of 
Syphilis. — A  Kasem-Bek  i  l/K/ciHsii.,-'  i)lH,xiriii,  Jiiiiiinry. 
lU'il,  reports  the  case  of  a  man  34  years  old  who  suffered 
from  neurasthenia,  ascites  accompanied  by  marked  en- 
largement of  the  abdominal  veins,  edema  of  the  lower  ex- 
tremities, and  an  irregular  fever  characterized  by  chills, 
elevation  of  temperature  and  night-sweats.  The  parox- 
ysms would  last  for  two  or  more  months,  followed  by  an 
intermission.  On  examination  both  the  liver  and  spleen 
were  found  enlarged.  Altogether,  this  state  of  affairs  ex- 
isted for  4  years.  Antimalarial  as  well  as  general  treat- 
ment did  not  have  the  slightest  effect,  the  patient  get- 
ling  progressively  worse.  Ha\-ing  obtained  a  history  of 
syphilitic  infection  dating  10  years  back,  the  author  placed 
the  patient  on  specific  treatment.  After  the  ninth  in- 
jection ot  salicylate  of  mercury,  the  ascites  the  other 
symptoms  promptly  disappeared,  except  an  obstinate  per- 
iostitis of  several  bones.  The  author  explaines  the  ascites 
by  the  suppositica  that  the  enlarged  Ij-mphatics  of  the 
hepato-duodenal  ligament  compressed  the  port!il  vein. 
[A.  R.] 


A  Case  of  Malignant  Syphilis. — Mironowitch  (ilediciniioir 

Oiiixiiiii.  ■litHiiinii.  ami  I  had  under  his  care  a  young  man 
of  30  of  good  physique  and  family  history  who  contracted 
syphilis,  and  despite  vigorous  and  persistent  specific  treat- 
ment passed  through  practically  the  three  stages  of  syphilis 
within  seven  months,  his  central  nervous  system  becoming 
finally  involved.  The  patient  comined  suicide  while  in 
a  stale  of  despondency.     [.-V.  R.] 


Mat  4,   19011 


PUERPERAL  POLYNEURITIS 


CThe  Philadelphia 
Medical  Jocesal 


857 


Orioinal  Hrtidcc^ 


PUERPERAL  POLYNEURITIS  AND  POLIO-MYELITIS 

By  JAMES   STEWART,   M.   D. 

of  Montreal. 

Professor  of  Medicine  and  Clinical  Medicine.  McGill  University;  Physician 
to  the  Royal  Victoria  Hospital. 

Neuriti.s,  either  localized  or  multiple,  is  a  well 
recogfnized  condition,  occurring  either  during  preg- 
nacy  or  within  a  short  period  after  labor.  The  fol- 
lowing case  is  an  interesting  example  of  polyneuri- 
tis coming  on  during  pregnancy,  and  in  which  also  a 
poliomyelitis  existed,  as  well  as  changes  in  the  pos- 
terior and  lateral  columns  of  the  cord.  The  patient 
first  came  under  observation  on  the  23d  of  August, 
1900,  complaining  of  tremor  and  numbness  below 
the  knees  and  elbows.  She  was  a  farmer's  wife,  33 
years  of  age,  and  the  mother  of  five  children.  She 
was  uncertain  as  to  the  exact  time  when  she  first 
experienced  the  numb  feelings  in  her  limbs,  but  is 
almost  certain  that  they  were  present  about  two 
months  before  her  labor,  which  was  on  the  first  of 
July.  On  the  23d  of  August,  in  addition  to  the  numb 
feeling,  she  had  a  fine  tremor  of  both  hands, 
which  eventually  disappeared.  At  this  time  no  dis- 
tinct paralysis  was  evident,  but  the  movements 
were  slow.  The  tremor  was  increased  on  move- 
ment. On  the  nth  of  September  she  was  admitted 
into  the  Royal  Victoria  Hospital.  In  her  past  the 
most  noteworthy  medical  events  were:  (i)  Severe 
vomiting  after  the  first  and  last  pregnancies ;  this 
necessitated  her  remaining  in  bed  6  weeks  on  each 
occasion.  (2)  During  the  2nd,  3rd  and  4th  pregnan- 
cies, vomiting,  although  severe  and  long  continued, 
did  not  prostrate  her  to  that  degree  that  she  was 
compelled  to  keep  her  bed.  (3)  During  her  child- 
hood she  had  measles,  chicken  pox  and  scarlet 
fever.  She  lived  alwa3'S  on  the  farm,  and  since  her 
marriage,  about  nine  years  ago.  her  work  has  been 
heavy  and  prolonged.  She  also  had  much  anxiety  as 
to  whether  her  husband  and  herself  would  be  able  to 
retain  the  farm.  Her  father  and  mother  are  living 
and  in  good  health.  Four  sisters  living,  and  all 
said  to  be  in  good  health.  One  is  hysterical.  A 
brother  died  of  pneumonia,  and  a  maternal  aunt  of 
cancer.  There  is  no  history  of  tuberculosis  in  the 
family. 

State  on  Admission,  Sept.  uth.  1000. — She  was  a 
well  nourished  woman,  of  a  neurotic  temperament. 
Her  weight  was  114  pounds.  She  assumed  the  dor- 
sal decubitus,  but  was  able  with  considerable 
effort,  to  turn  to  either  side.  There  was  no  gastro- 
intestinal disturbance,  except  a  slight  tendency  to 
constipation. 

A^crvoiis  System.  Seitsorimn. — Althousrh  emotional, 
the  mental  state  was  normal,  and  remained  so  up  to 
the  end.  At  no  time  v.as  there  complaint  of  head- 
ache. 

Motion. — There  was  considerable  loss  of  power  in 
the  muscles  of  both  lower  limbs,  but  in  no  single 
muscle,  or  group  of  muscles,  did  it  reach  an  abso- 
lute degree.  It  was  distinctly  more  marked  in  the 
most  peripherally  situated  muscles,  but  not  suffi- 
cient to  produce  a  foot  drop.  The  patient  was  able 
to  walk  the  lens;th  of  the  ward,  but  with  considera- 
ble cflFort.     In  both  upper  limbs  a  similar  but  less 


marked  paralysis  was  present,  being,  as  in  the  case 
of  the  lower  limbs,  more  marked  in  the  distal  parts. 
The  extensors,  although  weaker  than  the  flexors, 
were  not  paralyzed  to  the  extent  of  causing  a  wrist 
drop.  There  was,  however,  no  single  muscle  or 
muscular  group  in  a  normal  state  as  far  as  voluntary 
power  is  concerned. 

Sensation. — She  complained  of  a  constant  and  dis- 
agreeable sensation  of  numbness  in  the  lower  limbs 
and  lower  part  of  the  abdomen  up  to  about  the  re- 
gion of  the  eleventh  thoracic  segment.  There  was 
no  girdle  sensation.  The  same  abnormal  sensations 
were  complained  of  in  the  upper  limbs  to  about 
midway  between  the  elbow  and  shoulder  joints. 
Sensation  to  touch  was  slightly  lessened  over  both 
lower  limbs,  and  on  the  trunk  to  nearly  the  level 
of  the  umbilicus.  There  was  only  a  slight  diminu- 
tion over  the  upper  extremities.  The  reaction  to 
painful  and  thermic  stimuli  appeared  to  be  unim- 
paired- The  calf  muscles  were  very  tender  on  pres- 
sure, while  the  remaining  muscles  were  only  slightly 
so.  There  was  no  disturbance  of  the  muscular 
sense  in  any  of  its  varieties.  Both  knee  jerks  were 
normal.  The  plantar  and  pharyngeal  reflexes  were 
lessened.  The  abdominal  reflex  was  normal.  The 
organic  reflexes  of  swallowing,  micturition  and  def- 
ecation were  not  interfered  with.  The  electrical 
reactions  were  not  disturbed. 

Sight. — The  vision  was  normal,  and  no  change 
was  found  in  the  fundi.  The  pupils  were  equal  and 
active  to  both  light  and  accommodation.  The  move- 
ments of  the  eyeballs  in  all  directions  were  not  in- 
terfered with.  There  was  neither  nystagmus  or 
jerking  on  voluntary  movements  of  the  eyeballs. 
The  other  special  sense  organs  did  not  present  any 
sign   or  S3"mptom  of  disease. 

The  pulse  was  persistently  rapid  throughout  the 
course  of  her  illness,  ranging  from  90  to  120.  The 
respirations  were  also  increased,  ranging  between 
24  and  30.  till  within  a  few  days  of  death,  when,  in 
consequence  of  the  terminal  pneumonia,  they  be- 
came still  more  rapid  (45  to  50).  The  temperature 
throughout  the  course  of  the  disease  remained  sub- 
normal till  the  advent  of  the  pneumonia,  when  it 
reached  from  lOO.  to  102°.  The  urine  at  all  times 
was  free  from  abnormal  ingredients. 

J  Sumjnary  of  the  Course  of  the  Disease,  from  her 
.Idmission,  on  Sef!.  nth,  till  Death,  on  the  21st  of  No- 
vember.— When  admitted,  she  was  able  to  both  stand 
antl  walk,  but  with  some  difficulty.  There  was  a  slow 
but  irregular,  increase  in  the  depth  of  the  muscular 
weakness  during  the  first  month  of  her  stay  in  the 
hospital.  About  the  15th  of  October,  the  paralysis 
in  the  lower  limbs  was  absolute  and  general.  In  the 
upper  limbs  it  was  absolute  in  the  distal  parts,  and 
approaching  so  in  the  more  proximal  areas-  There 
was  complete  wrist  and  foot  drop.  Ten  days  after 
admission,  both  knee  jerks  had  entirely  disappeared. 
The  great  nerve  trunks  of  both  the  upper  and  lower 
extremities  were  at  this  period  very  tender  on  pres- 
sure, as  were  also  the  muscles.  The  tenderness  in 
the  calf  muscles  was  especially  marked-  She  did 
not  complain  of  spontaneous  pain  when  quiet.  About 
the  first  of  October  there  were  signs  of  intercostal 
weakness,  but  it  was  not  till  later  that  the  dia- 
phragm showed  signs  of  beginning  failure.  About 
the  middle  of  October,  wasting  of  the  muscles  of  the 


grC        The  Philaiieli  hia"| 
O*-'  Medical  Jouhnal  J 


PUERPERAL  POLYNEURITIS 


[May   4,    1901 


extremities  was  observed,  being  particularly  dis- 
tinct in  the  calf  muscles.  Towards  the  end  of 
October,  for  a  few  days  there  was  apparent  im- 
provement, not  only  in  the  motor,  but  also  in  the 
sensory  disturbances.  On  several  occasions  through- 
out the  course  of  the  disease,  a  similar  but  less 
marked  amelioration  in  the  symptoms  led  to  a  hope 
of  a  favorable  termination.  Such  hope,  however, 
proved  to  be  false.  There  was  on  the  whole  soon 
after  such  changes,  a  deeper  degree  of  disability, 
both  motor  and  sensory,  and  nearly  always  evidence 
of  extension  upwards  of  the  paralysis.  On  the  17th 
of  November  the  diaphragm  showed  signs  of  fail- 
ing, and  the  following  day  a  pneumonia  was  de- 
tected, which  proved  fatal  on  the  21st.  The  onset, 
course  and  termination  of  this  interesting  case  will 
be  made  clearer  by  a  short  epitome  of  the  leading 
events. 

A  woman,  aged  33,  after  suffering  severely  from 
vomiting,  began  to  complain  about  the  seventh  or 
eighth  month  of  her  pregnancy  of  a  sensation  of 
numbness  in  the  lower  limbs,  and  shortly  afterwards 
in  the  upper  limbs.  This  was  followed  after  a  period 
of  two  months  by  a  slowly  increasing  motor  paraly- 
sis of  all  four  extremities,  which  progressed  to 
practical  total  disability.  The  paralysis  was  of  the 
ascending  type,  and  finally  involved  the  respiratory 
muscles.  The  sensation  to  touch  was  diminished, 
but  not  lost,  while  the  reaction  to  painful  and  ther- 
mic stimuli  was  retained.  The  knee  jerks  were  lost, 
as  well  as  the  plantar  reaction.  The  abdominal 
reflex  was  retained.  There  was  considerable  mus- 
cular atrophy,  but  no  disturbance  of  the  organic 
reflexes.  At  first  the  electrical  reactions  were  nor- 
mal, but  afterwards  there  was  lessening  of  the 
Faradic  reaction,  showing  the  middle  form  of  the 
reaction  of  degeneration.  (A  full  examination  of 
the  electric  irritability  was  not  carried  out,  owing 
to  the  pain  induced)  A  pneumonia,  chiefly  owing 
to  the  previous  paretic  state  of  the  respiratory  mus- 
cles, ended  the  scene  two  and  one-half  days  after  its 
onset. 

Autopsy  One  Hour  and  a  Half  after  Death:  by  Dr. 
Adami. — Fiody  of  a  middle  aged  female,  fa'r 
size,  rigidity  just  beginning,  livldity  moderate  in 
dependent  parts ;  body  still  warm,  nutrition  fair,  pu- 
pils equal  and  moderate  in  size ;  orifices  of  body  nor- 
mal;  breasts  normal;  some  roughening  of  the  skin 
over  the  front  of  abdomen.  There  was  a  slight, 
smooth  scar  on  the  anterior  and  inner  surface  of  the 
left  thigh-  Feet  in  position  of  complete  ankle  drop, 
skin  over  the  dorsum  of  feet  puffy  in  appearance 
and  slightly  desquamating,  probably  an  atrophic 
change.  '  Muscles  everywhere  extremely  flabby,  es- 
pec'ally  those  of  the  arms  and  legs. 

Thorax. — Both  lun<rs  free  from  adhesions;  left 
lung  290  grms.,  only  slightly  pigmented;  apex 
showed  some  compensatory  emphysema,  lowest 
lobe  completely  collapsed,  pleural  surface  near  grea' 
fissure  in  both  lobes  somewhat  raised  and  granular 
looking  a"d  covered  w'th  a  thin  layer  of  fibrinous 
lymph-  The  anterior  edge  of  the  lowest  lobe,  near 
fissure,  was  consolidated  and  somewhat  friable.  The 
upper  lobe,  a  long. narrow  strip  extending  almost 
the  whole  length  of  the  great  fissure,  was  consoli- 
dated, airless  and  friable,  on  section  of  a  greyish 
granular  appearance.    Condition  of  diffuse  pneumo- 


nia in  grey  hepatization  stage ;  condition  found  to 
be  somewhat  patchy ;  possibly  it  started  as  a 
bronchopneumonia.  Bronchi  somewhat  reddened, 
contained  somewhat  sticky  mucus;  pulmonary  ves- 
sels free. 

Right  lung,  340  grms. ;  slight  compensatory  em- 
physema of  the  upper  and  middle  lobes;  pleural 
surface  of  the  lowest  lobe,  somewhat  granular,  cov- 
ered with  flaky  lymph  ;  upper  third  of  lowest  lobe 
swollen  and  firm,  on  section  rather  dry,  consoli- 
dated, in  a  state  of  grey  hepatization,  condition  more 
uniform  than  in  other  lung.  Lowest  third  of  lowest 
lobe  completely  collapsed ;  bronchi  and  pulmonary 
arteries  as  before. 

Smears  from  consolidated  area  showed  numerous 
bacilli  of  unknown  form  and  an  occasional  micro- 
cocctis  lanceolatus. 

The  other  organs  of  the  body  showed  nothing 
markedly  abnonnal,  but  showed  a  marked  tendency 
to  congestion. 

The  Micros. o^ical  Appearai.ec  of  the  Lungs. — The 
parts  which  are  not  so  much  consolidated  are  much 
congested,  the  bronchi  show  marked  acute  bron- 
chitis, the  lumen  being  filled  with  exudate,  the 
alveoli  of  the  lung  are  for  the  most  part  filled  with 
an  inflammatory  exudate,  consisting  of  leukocytes 
with  occasional  red  cells  and  fibrin.  The  inflamma- 
tory exudate  is  irregular  in  intensity  and  somewhat 
patchy ;  certam  other  of  the  alveoli  contain  rela- 
tively few  leukocytes,  but  a  great  deal  of  fibrin  and 
some  again  filled  for  the  most  part  with  red  cells ; 
one  or  two  small  hemorrhages  were  noticed. 

Examination  of  the  Nervous  Structures. 
r-y  Dr.  Shirres. 
The  brain,  spinal  cord  and  ganglia  were  removed 
for  examination,  also  both  sciatics.  musculo-spirals, 
anterior  crurals.  peroneals,  anterior  tibials  and  their 
end  ramifications,  pneumogastrics  and  phrenics.  The 
peripheral  nerves,  certain  parts  of  the  brain  and 
of  the  cord  at  different  levels,  were  placed  in  Mul- 

Fiirur*-  I. 


Transverse  section  of  the  .\nterior  Tibial  Xer\-e,  showing  the  distetisiont 
and  separation  of  the  connective  tissue  by  the  fluid  exudate. 


May   4,   liiol] 


PUERPERAL  POLYNEURITIS 


L  Med  1 1 


"^'HE  Philadelphia        Rcq 
AL  Jorit.NAL        "a? 


ler's  fluid,  while  the  remaining  sections  were  at  once 
placed  in  alcohol  for  Nissl's  stain. 

Fcrif'hcnil  Nerves,  Cord,  etc. — Naked  eye  changes. 
— All  the  peripheral  nerves  were  found  markedly 
swollen  and  of  a  reddish  yellow  color,  especially  so 
the  sciatics  and  anterior  tibials,  which  were  at  least 
twice  their  normal  size  and  seemed  to  be  very  ede- 
matous. The  internal  plantar  was  about  the  ordi- 
nary size  of  a  normal  sciatic  nerve.  Cord  and 
spinal  gaglion  cells  appeared  normal.  After  thor- 
ough fi.xation  and  hardening  of  the  different  parts, 
sections  of  the  cord  and  peripheral  nerves  and 
spinal  ganglia  were  imbedded  in  celloidin  or  par- 
affin- 

The  methods  employed  were  (i)  Weigert-Pals' 
hematoxylon,  (2)  Van  Gieson's  hematoxylon  and 
eosin.  (4)  ATarchi's  osmic  acid,  (5)  NissTs  methy- 
lene blue  method. 

Peripheral  Nerves. — Longitudinal  and  transverse 
sections  were  made,  the  latter  being  by  far  the  most 
instructive.  The  changes  found  may  be  summarized 
as  follows:  Marchi's  method  of  investigation 
showed  the  distinctive  signs  of  a  true  parenchyma- 
tous degeneration.  Under  a  low  magnifying  power 
the  nerves  are  seen  to  be  studded  with  black  gran- 
ular spots,  with  the  higher  power  the  dark  spots 
are  seen  to  be  sections  of  degenerated  nerve  fibres, 
in  some  places  two  or  more  being  blended  into  large 
masses.  Scattered  irregularly  among  those  degen- 
erated fibres,  in  e\'cry  bundle  more  or  less,  are  to 
be  found  normal  healthy  fibres. 

Hematoxylon  and  Van  Gieson's  method  re- 
vealed that  along  with  the  parenchymatous  degen- 
eration there  was  also  marked  interstitial  inflamma- 
tion, the  blood  vessels  being  distinctly  distended, 
thickened,  and  with  numerous  small  hemorrhages 
in  the  epineurium  and  endoneurium  ;  also  a  distinct 
sero-fibrinous  exudate  and  leukocyte-like  corpuscles 
and  spherical  cells  surrounding  the  vessels  and  infil- 
trating the  sheaths  and  interstitial  tissue  between 
the  fasciculi  and  a  few  in  the  substance  of  the 
fasciculi  between  the  nerve  fibres.  The  lymph 
spaces  between  the  laminae  of  the  perineurium  were 
markedly  distended.  The  nuclei  of  the  cells  of  the 
endoneurium  were  very  evident  on  longitudinal  sec- 
tion and  were  in  greatly  abnormal  numbers.  All 
the  nerves  examined  showed  the  changes  above  de- 
scribed, more  or  less ;  it  was  noticed  that  the  fur- 
ther away  from  the  cord,  the  condition  of  a  simple 
parenchymatous  degeneration  was  more  marked. 
The  pneumogastrics  and  phrenics,  like  the  above, 
did  not  suffer  so  much  from  interstitial  changes, 
but  showed  more  of  the  parenchymatous  condition, 
the  degenerated  fibres  being  clearly  demonstrated 
by  Marchi's  method. 

Cord  Changes. — ^^'hite  .Matter  :Sectionsof  the  cord 
that  were  hardened  in  Muller's  fluid  and  treated  by 
Marchi's  method  showed  a  scattered  degeneration  in 
the  position  of  the  posterior  columns,  involving  both 
Goll  and  Burdach's  tracts  in  the  lumbar  region.  In 
the  cervical  region  the  degeneration  was  confined 
to  Burdach's  column.  Degenerated  fibres  could 
also  be  seen  in  the  lateral  region  of  the  cord  (direct 
cerebellar  tract)  in  the  up])er  dorsal  and  cervical 
regions-  Upon  examination  of  the  posterior  roots, 
along  the  whole  length  of  the  cord,  degenerated 
fibres  could  be  seen— Lissauer's  column  being  dis- 


tinctly affected.  No  changes  could  be  detected  in  the 
anterior  roots- 

\'an  Gieson's  or  the  hematoxylon  method  did  not 
reveal  anything  like  a  condition  of  lepto-men- 
ingitis  or  myelitis  of  the  cord  or  membranes. 
Sections  of  the  cord  that  were  fixed  and 
hardened  in  alcohol  and  stained  by  Nissl's 
methylene  blue  method,  revealed  marked  and 
advanced  chromolytic  changes  of  the  peripheral 
central  and  perinuclear  varieties,  in  the  gan- 
glionic cells  of  the  grey  matter,  more  especially  in 
the  anterior  horns  and  Clark's  columns.  The  most 
advanced  changes,  even  on  to  complete  atrophy  and 
disappearance  of  cells,  were  to  be  noted  in  the  cer- 
vical  cord  in  the  region   of  the  5th,  6th,   and   "th 

Fiffurc  II. 


Ganglionic  Cells  of  the  .\nterior  Horns  in  the  I^urabar  Cord,  showing  dis- 
placement, etc..  of  the  Xeucleus  and  Chromatolysis. 

cervical  segments.  Here,  as  above  stated,  there  was 
a  marked  numerical  lessening  in  the  number  of  cells 
compared  to  the  normal  condition  in  those  situa- 
tions; also,  there  was  a  marked  difference  between 
the  right  and  left  anterior  horns,  the  right  contain- 
ing hardly  any  ganglionic  cells  at  all,  the  few  that 
were  present  were  simply  atrophied  shreds-  The 
other  ganglionic  cells  of  the  grey  matter  did  not 
present  such  a  picture  of  atrophy,  but  all  more  or 
less  showed  marked  chromolytic  changes.  The 
lumbar  and  lower  dorsal  regions  were  aft'ected  in  a 
minor  degree  compared  with  the  cervical.  The 
changes  were  essentially  polymorphous,  every 
grade  of  chromatolysis  was  seen  from  where  the 
cells  were  swollen  or  spherical  with  the  protoplasm 
undergoing  alterations,  and  showing  chromatic 
bodies  normal  in  amount  and  situation,  to  stages  in 
which  these  were  distinctly  granular  or  gave  a  con- 
dition of  a  diffuse  stain,  and  finally  to  a  condition 
in  which  the  cell  body  was  very  pale  and  did  not 
present  any  chromatic  particles,  or  protoplasmic 
processes  and  the  nucleus  was  absent  or  eccentric. 
Spinal  Ganglion  Cc//.f— Nissl's  Method.— The  spi- 
nal ganglion  cells  did  not  show  any  marked  altera- 
tion, but  there  was  present  a  marked  increase  and 


QAr\       The  Philadelphia  "I 
"'-'^        Medical  Jol'hsal   J 


PUERPERAL  POLYXEURITIS 


IMat    4.    KXn 


proliferation  of  the  cells  (which  looked  like  an  in- 
flammatory reaction)  of  the  capsule  surrounding 
the  individual  ganglionic  cells. 

The  clinical  course  makes  it  highly  probable  that 
we  had  to  deal,  first,  with  a  neuritis,  and  later  with 
a  localized  myelitis  (poliomyelitis).  The  symptoms 
were,  for  several  months,  those  of  a  neuritis,  rather 
than  a  poliomyelitis.  In  fact,  at  no  time  were  there 
sufficiently  distinctive  symptoms  present  to  enable 
one  to  say  definitely  that  the  spinal  cord  was  in- 
volved. It  was  onl}'  the  gradual  ascending  charac- 
ter of  the  paralysis  (Landry  type)  that  some  three 
or  four  weeks  before  death  gave  a  clue  as  to  a  prob- 
able spinal  involvement.  The  development  of  the 
symptoms  and  the  appearances  met  with  in  the 
ner^-es  makes  it  clear  that  we  had  to  do  in  the  first 
place  with  a  parenchymatous  neuritis.  The  pro- 
longed primary  stage  of  numbness  in  all  the  four 
extremities,  together  with  a  prolonged  period  of 
simple  weakness  of  the  peripheral  muscles  pointing 
to  a  distal  parenchymatous  multiple  neuritis  as  the 
primary  lesion.  Dr.  Shirres  refers  to  the  fact  that 
with  the  Pal-Weigert  stain  he  was  able  to  obtain  a 
much  clearer  view  of  the  degenerated  fibers.  The 
axis  cj-linders  seem  to  have  in  many  places  disap- 
peared when  this  stain  was  used,  while  with  the 
Marchi  stain  a  much  less  degree  of  degeneration  was 
noticeable.  He  explains  this  by  referring  to  the  es- 
tablished fact  that  the  Marchi  stain  gives  more  clear 
results  if  the  degeneration  is  recent  (6  to  lO  weeks), 
while  the  Pal-Weigert  shows  more  definite  changes 
in  older  cases.  The  disease  was  probably  upwards 
of  6  months'  standing,  and  therefore  the  changes 
showed  more  clearly  with  the  Pal-Weigert  stain- 
The  ultimate  cause  of  the  neuritis  is  not  clear-  The 
bacteriological  examination  of  the  nervous  struc- 
tures was,  unfortunately,  neglected,  although  cul- 
tures were  taken  at  the  time  of  the  post-mortem 
examination.  All  the  common  causes  of  neuritis 
were  absent,  as  lead,  alcohol,  acute  and  chronic  in- 
fectious diseases,  septicemia,  etc..  etc.  What,  if 
any,  relation  existed  between  the  severe  vomiting 
(pregnancy)  and  the  neuritis,  I  have  no  evidence 
to  show.  A  number  of  cases  of  puerperal  neuritis 
have  been  reported,  in  which  vomiting  had  been 
verv  severe,  and  the  only  marked  feature  present. 
Dr.  Whitfield,  in  the  Lancet  (March  30.  i88q),  gives 
an  account  of  such  a  case.  Dr.  E.  S.  Reynolds 
(British  Medical  Jcunial.  vol.  2.  1897.  p.  1080).  nar- 
rates a  case  of  paraplegia  after  labor,  which  he  at- 
tributes to  a  peripheral  neuritis,  and  in  which  abor- 
tion was  performed  on  account  of  vomiting. 
He  refers  to  a  view  held  by  Cliflford  Allbut, 
who  looks  upon  the  vomiting  of  pregnacy  as 
due  to  a  toxin,  and  that  the  same  toxin  may 
induce  a  neuritis.  In  the  considerable  num- 
ber of  cases  of  multiple  netiritis  of  puerperal 
origin,  very  few  have  been  reported  in  which 
the  onset  occurred  during  pregnancy,  nearly  all  be- 
ing instances  of  post  partum  neuritis,  which  usually 
is  attributed  to  sepsis.  It  is  worthy  of  note  that  the 
changes  in  the  spinal  cord  are  not  limited  to  the 
cells  of  the  ventral  horns,  but  that  we  have  also  a 
similar  breaking  down  in  the  cells  of  Clarke's  col- 
umns, and,  as  a  result,  a  degeneration  in  the  cerebel- 
lar tracts  in  the  lateral  cord.  Although  no  degen- 
erative changes  were  found  in  the  proper  structure 


of  the  spinal  ganglion  cells,  the  posterior  columns 
show  considerable  areas  of  degeneration  fsee 
Fig.  III).  In  using  the  term  "ascending  paral- 
ysis," it  should  be  understood  that  it  is  meant 
purely  in  a  clinical  sense,  and  not  as  signifying  that 
the  degeneration  spread  gradually  up  the  cord  from 
the  peripheral  ner\-es-  It  is  much  more  probable 
that  the  poison  affected  the  cord  and  peripheral 
ner\-es  separately,  and  not  that  the  peripheral 
changes    caused   the   spinal    changes   by   extension 

Figure  III. 


Outline  Drawing  of  a  Transverse  Section  of  the  upper  portion  of  the 
Dorsal  Cord,  showing  the  location  ol  the  degenerated  areas  in  the 
posterior  and   lateoal  columns. 

from  the  periphery  to  the  center.  Further,  it  is  still 
less  likely  that  the  central  changes  were  the  direct 
cause  of  the  peripheral  degeneration.  The  fact  that 
the  anterior-intra-medullar\-  ner\-e  roots  did  not 
show  any  signs  of  degeneration  is  evidence  in  favor 
of  there  being  no  direct  causative  relation  between 
the  central  and  peripheral  changes. 

I  am  indebted  to  Dr.  Adami  and  Dr.  A.  G.  Nich- 
olls  for  the  report  on  the  general  post-mortem  ex- 
amination, and  to  Dr.  D.  A.  Shirres  for  the  care  and 
time  he  has  taken  in  making  a  full  and  thorough 
examination  of  the  spinal  cord  and  peripheral 
nerves ;  and  also  to  Dr.  Hugh  Patrick  for  the  care 
he  has  taken  in  developing  the  photographs. 

Literature  on  Puerperal  Polyneuritis. — To  anyone 
especially  interested  in  this  subject,  the  following 
articles  will  prove  to  be  very  valuable:  ist,  J-  Hen- 
drie  Lloyd,  in  the  T'venticth  Century  Practice  of  Med- 
icine (\"ol.  XI.).  has  a  very  exhaustive  article  on  the 
whole  subject  of  neuritis,  and  much  attention  is  di- 
rected to  both  the  local  and  generalized  neuritides 
connected  with  the  pueperal  state.  2d,  Professor 
Eulenburg  (Deutsche  Med.  il'och..  1895.  Xos.  8  and 
9),  has  a  valuable  paper  on  38  collected  cases  of  pu- 
erperal neuritis,  being  chiefly  instances  of  the  local 
(traumatic)  form  of  the  disease.  A  sj-nopsis  of  the 
chief  symptoms  in  all  the  cases  is  given.  3rd.  Mo- 
bins  (Neurologischc  Beitrage.  Heft.  4.  p.  24).  who  was 
the  first  to  give  a  description  of  puerperal  neuritis, 
gives  details  of  his  ow-n  cases  (chiefly  local  form) 
and  others.  4th.  C.  K.  Mills  (Univ.  Sledical  Maga- 
cine.  Vol.  s.  p.  308").  A  valuable  article.  5th,  E.  S. 
Re}-nolds  ^(British  Medical  .fc-.imal.  Oct.  i6th.  1897), 
rep<~>rts  two  cases,  both  paraplegic  in  disir-bution. 
He  was  able  to  collect  17  cases,  not  incVuding  any 
reported  on  by  Eulenburg.  6th.  H.  M.  Thomas 
(.7ohns  HopkinsHospita!  Bulictin.  Nov..  iqoo').  Chiefly 
dealing  with  the  localized  forms  of  puerperal  neu- 
ritis. 


May  4,   1901] 


LOCALIZATION  OF  SOUND 


rTuE  Philadelphia        q^t 
Medh'al  Journal 


LOCALIZATION  OF  SOUND  AND  ITS  BEARING  ON 
HEARING— ESPECIALLY  IN  UNILATERAL  DEAF- 
NESS. 

By  B.  ALEX.  RANDALL,  M.  A.,  M.  D. 

of  Philadelphia. 
Clinical  Professor  of  Otolog>'  in  the  University  of  Pennsylvania,  etc. 

The  attempt  has  been  made  to  map  the  field  of 
hearing  in  a  manner  analogous  to  that  of  vision ; 
but  the  essential  difference  must  not  be  lost  sight 
of,  that  sound-waves  are  not  like  light-waves  prop- 
agated only  in  straight  lines.  The  eye  can  take 
cognizance  only  of  that  which  lies  in  front  of  the 
plane  of  the  iris,  and  is  further  restricted  by  the 
prominence  of  the  nose  and  the  orbital  margins. 
Its  field,  therefore,  is  sharply  defined.  The  relative 
field  of  good  hearing  has  some  comparable  limita- 
tions, as  has  been  worked  out  by  Ogston  (Med. 
Press  and  Circ,  June  i8,  1890)  ;  but  it  is  probable 
that  great  individual  variations  exist,  and  that  for 
different  sounds  the  fields  may  vary  even  more 
markedly  than  the  color  fields  of  the  eye.  The 
absolute  field  of  hearing  is  hardly  definable,  however, 
for  not  only  can  both  ears  hear  sounds  in  the  sagit- 
tal plane  of  the  head,  but,  to  a  considerable  extent, 
in  each  other's  fields.  Hence  the  great  difficulty  of 
excluding  one  ear  from  cognizance  of  tests  directed 
to  the  other,  and  the  need  for  such  differential 
tests  as  have  from  time  to  time  been  brought  for- 
ward. With  all  of  this  otologists  are  familiar,  and 
they  generally  take  these  matters  into  practical  ac- 
count ;  but  the  effect  upon  the  good  ear  of  deafness 
of  the  other  is  not  fully,  if  at  all,  considered.  To  have 
a  deaf  side  is  generally  recognized  as  awkward,  even 
when  the  other  ear  is  perfect  and  suggests  no  likeli- 
hood of  sharing  the  same  fate.  We  meet  many  re- 
ports also  of  cases  in  which  successful  treatment  of 
the  worse  ear  has  given  notable  gain  of  the  other, 
which  had  no  share  in  the  intervention ;  but  the 
rationale  of  this  has  rarely  been  explained  with  any 
plausibility  or  fulness.  A  brief  note  upon  the  mat- 
ter seems  in  place,  therefore,  if  only  as  a  means  of 
directing  attention  to  a  neglected  but  important 
series  of  phenomena. 

In  hearing,  with  both  ears  good,  there  should  be 
little  difficulty  in  localizing  many,  at  least,  of  the 
sounds  that  come  to  us.  Not  only  are  they  lateral- 
ized,  but  the  other  factors  as  to  their  direction  can 
generally  be  sub-consciously  determined.  This  is 
a  matter  of  differential  impression  and  analysis, 
for  which  an  appreciable  timiC  is  requisite:  and  very 
brief  sounds  may  greatly  puzzle  us  both  as  to  their 
localization  and  interpretation.  Ordinarily,  we 
ha-^-e  sufficient  continuity  of  impression  to  be  able 
to  follow  intelligently  one  or  more  series  of  sound.s. 
ignoring  those  interruptions  which  often  intrude, 
since  we  can  so  readily  recognize  them  as  irrele- 
vant. We  form  our  mental  concept  of  them  from 
their  quality,  loudness  and  direction,  aided  generally 
in  large  measure  by  our  concomitant  visual  impres- 
sions, but  also  in  no  slight  degree  by  some  subtle 
appreciation  of  their  reflection  from  adjacent  sur- 
faces. This  is  much  as  we  can  locate  a  distant 
conflagration  by  a  sort  of  triangulation  in  noting 
the  direction  and  distance  of  buildings  from  which 
its  light  is  reflected.  Our  drumheads  can  respond 
to  and  convev  a  vast  number  of  coincident  sound- 


waves to  a  deeper  acoustic  apparatus,  which  then 
takes  cognizance  of  their  pitch  and  volume,  the  lat- 
ter having  probably  some  slight  dependence  upon 
the  form  and  position  of  the  external  ear.  The  rest 
of  the  analysis  and  appreciation  is  solely  a  function 
of  the  sensorium.  Cognizant  of  such  differences 
in  the  sounds  assailing  us,  we  may  be  able  to  hold 
the  attention  concentrated  upon  those  which  we 
wish  to  hear  amid  a  babel  of  irrelevant  noises,  un- 
disturbed unless  we  permit  our  thoughts  to  wander. 
One  ear  is  often  given  to  the  sounds  engrossing  us 
while  the  other  merely  keeps  guard-hearing,  yet 
giving  no  heed  to  the  sounds  upon  that  side  and 
even  almost  automatically  side-tracking  those  on 
the  busy  side,  which  might  confuse  its  task. 

The  condition  is  very  different  when  one  ear  must 
act  alone,  unaided  by  its  fellow.  The  physical 
problem  is  little  changed,  and  the  auditory  appa- 
ratus receives  and  transmits  to  the  percipient  cen- 
ters the  same  range  of  sounds  coming  from  prac- 
tically all  directions ;  but  the  psychic  task  is  far 
more  complex.  One  side  of  the  brain  to  a  much 
greater  extent  than  usual,  has  to  receive  and  an- 
alyze all  the  impressions,  and  these  lack  that  ele- 
ment of  double  yet  diverse  character  which  in 
vision  we  call  stereoscopic.  Yet  all  acknowledge 
the  huge  importance  for  many  purposes  of  this  fac- 
tor in  the  everyday  use  of  our  sight,  in  which,  as 
we  have  seen,  the  problem  is  far  simpler.  With  the 
eyes  we  recognize  the  apparent  increase  of  illumi- 
nation afforded  by  the  superposed  images  of  binoc- 
ular vision  and  work  with  far  less  fatigue  when 
the  eyes  thus  suppliment  each  other  and  distance, 
direction  and  object  are  practically  unchangingly 
simple.  With  the  ears  we  have  no  strain  of  ac- 
commodation or  convergence  (which  should  be  no 
burden  to  healthy  eyes),  but  the  absence  of  these 
functions  leaves  us  devoid  of  any  such  ready  means 
of  determining  the  distance,  and  hence  many  other 
characteristics  of  the  objects  of  our  attention,  and 
throws  the  more  work  upon  the  interpreting  facul- 
ties. Few  persons  make  any  success  of  fixing  by 
a  brief  glance,  any  considerable  number  of  articles, 
so  that  they  can  later  enumerate  or  describe  them ; 
yet  this,  with  a  presumed  "sense  of  the  context" 
as  our  only  aid,  is  what  is  continuously  demanded 
of  the  hearing.  Rotation  and  other  movements  of 
the  head  can,  as  in  binocular  vision,  furnish  some 
localizing  factors;  yet  the  problem  remains  too 
largely  a  mental  one,  and  the  "fatigue  of  the  deaf," 
of  which  Dr.  Blake  so  well  speaks  in  the  Introduc- 
tion to  Gorham  Bacon's  IManual,  is  by  no  means 
absent  in  those  who,  with  one  perfectly  good  ear, 
are  often  unrecognized  by  their  companions  as 
having  any  lack.  Some  of  them  are  themselves  as 
surprisingh'  unconscious  of  the  defect,  as  are  some 
who  have  grown  up  in  ignorance  that  one  eye  is  vir- 
tually sightless;  but  this  is  usually  rather  a  matter 
of  unilateral  deafness  for  certain  sounds  only,  such 
as  the  tick  of  a  watch,  which  are  often  very  une- 
qually heard  by  ears  supposedly  normal.  Yet  it  is 
full  time  that  the  value  and  importance  of  "binau- 
ral hearing"  should  be  more  fully  recognized,  and 
that  due  care  be  exercised  to  retain  or  secure  it  in 
those  who  are  really,  if  unconsciously,  suffering 
for  the  lack  of  it. 


0^2  TUK    PHILADELI'HIA 

""^         Medical  Journal 


] 


GERMAN  CLINICS 


[MaV    4.    1!«1 


THE  GERMAN  CLINICS  OF  TO-DAY. 
By  JOHN  C.  HEMMETER,  Phil.  D.,  M.  D.,  Etc. 

of  Baltimore,  Md. 

Professor  in  the  Medical  Department  of  the  University  of   Maryland,   and 
Director  of  the  Clinical  Laboratory. 

About  thirty  years  ago  the  methods  of  scientific 
diagnostic  investigation  which  had  been  inaugu- 
rated in  Vienna  by  Rokitansky  and  Skoda,  had 
taken  root  firmly  in  Berlin,  and  had  been  further 
developed  by  Virchow  and  Traube.  Pathological 
anatomy  not  only  led  the  advance  and  assigned  the 
guiding  line  for  clinical  diagnosis,  but  the  deduc- 
tions for  therapeutics  were  also  based  upon  the  evi- 
dences furnished  by  this  science.  Experimental 
physiology  and  experimental  pathology  were  also 
sciences  influencing  the  tendencies  of  clinical  med- 
icine. This  was  a  glorious  and  epoch-making  pe- 
riod in  the  history  of  clinical  diagnosis.  Unfortu- 
nately, however,  some  of  the  skepticism  and  nihi- 
lism of  the  Vienna  school  had  gone  along  with  the 
advancement,  the  diagnosis  was  held  up  as  the 
main  object  of  the  clinician;  but  the  actual  thera- 
peutics, what  could  be  done  to  control,  check  and 
remove  the  disease,  was  passed  over  and  neglected. 
Expectant  therapeutics,  to  observe,  not  to  injure, 
those  were  the  motives. 

The  treatment  of  disease  was  not  entirely  neg- 
lected, but  the  therapeutists  placed  their  hope  in 
the  future,  and  had  no  confidence  in  the  methods 
of  the  present.  There  were  many  ironical  allusions 
to  the  helplessness  of  internal  medicine  when  it 
was  put  to  the  test  of  relieving  suffering  or  healing 
a  disease.  Among  the  practitioners  there  pre- 
vailed a  spirit  of  pessimism.  .Such  must  inevitably 
be  the  case  when  the  practical  therapeutic  duties  of 
clinicians  are  subjected  to  too  rigid  a  scientific  crit- 
icism, based  upon  the  ideals  of  pathological  anat- 
omy. The  objects  of  therapeutics  could  not  be  ac- 
complished ;  our  methods  to  help  and  to  heal  could 
not  be  improved,  if  we  were  to  be  guided  exclusively 
from  the  lessons  of  autopsies.  Therapeutics  must 
reckon  with  the  result  of  approved  experience,  also, 
and  must  help  and  heal  according  to  the  measures 
which  are  at  their  disposal  at  any  one  time.  We 
cannot  console  the  suffering  patient  with  promises 
of  remedial  discoveries  of  the  future.  This  truth, 
once  recognized,  therapeutics  was  freed  from  the 
spell  under  which  too  rigid  a  scientific  criticism  had 
placed  it  to  the  disadvantage  of  practical  results 
for  the  patient.  Up  to  that  time  the  motto  was  "to 
cure  diseases."  This  was  transformed  to  the  devise, 
■"To  make  the  diseased  well,"  or  "To  heal  the  pa- 
tient." These  two  mottoes  do  not  represent  a  "dis- 
tinction without  a  difference.'"  ft)r  by  saying  "To 
cure  diseases"  we  refer  by  the  name  "Disease"  to 
whatever  abstract  conception  of  a  morbid  condition 
may  prevail  in  the  medical  mintl  at  any  given  time. 
Such  conceptions  have  differed  greatly  concerning 
the  same  disease  at  various  times ;  and  accord- 
ingly the  treatment  necessarily  dift'ered  also.  It  was 
greatly  to  the  merit  of  Von  Leyden  to  emphasize 
the  difference  between  attempting  to  cure  a  disease 
and  attempting  to  heal  a  patient.  By  healing  a  pa- 
tient we  mean  relieving  him  of  his  suffering,  heal- 
ing his   morbid   condition,   independently   of   what 

'Address  liefore  the  Medical  and  Chirurgical  Kaculty  of  Maryland. 


our  conception  of  the  d.sease  maj-  be.  In  the  one 
case  we  are  dealing  with  the  abstract  formulation 
of  symptoms  known  as  a  "disease,"  and  based  upon 
the  alterations  pointed  out  by  pathological  anato- 
mists, too  apt  to  be  manipulated  categorical'y  and 
dogmatically.  In  the  other  case  we  are  dealing  with 
the  many  varieties  of  human  individuality  as  they 
are  influenced  by  abnormal  states.  Modern  thera- 
peutists are  not  satisfied  to  stud}-  the  disease  pro- 
cess and  its  course ;  the  physician  must  also  famil- 
iarize himself  with  the  special  manner  in  which 
disease  manifests  itself  in.  and  influences  the  indi- 
viduality of  each  and  every  patient.  The  person- 
ality of  the  patient  is  put  in  the  foreground  of 
treatment,  not  the  conception  of  the  disease.  This 
is  one  of  the  predominant  features  of  the  thera- 
peutics in  the  German  clinics  of  to-day.  It  proba- 
bly had  its  origin  in  the  great  discovery  of  Lister, 
and  the  impulse  it  has  given  to  modern  surgery. 
Then  came  the  suggestion  to  the  internal  clinicians: 
"You  must  become  surgical  also,"  and  as  much  as 
possible  internal  therapeutics  has  attempted  to  fol- 
low out  this  suggestion.  Under  the  direction  of 
that  scholarly  medical  philosopher,  Naunyn,  a  jour- 
nal is  published  on  the  border  districts  of  disease 
lying  between  internal  medicine  and  surgery,  much 
to  the  advantage  of  both  these  branches. 

Another  feature  of  the  German  clinics  is  the  ten- 
dency to  make  use  of  a  large  variety  and  many 
methods  for  the  relief  of  suffering  and  to  cure  dis- 
ease. Pharmacy,  i.  e.,  medicines  and  the  improve- 
tient."  These  two  mottos  do  not  represent  a  "dis- 
First  came  the  evolution  of  so-called  specific  rem- 
edies, based  and  inspired  by  the  cure  of  hydropho- 
bia by  Pasteur ;  Koch  brought  out  his  tuberculin ; 
Behriiig  the  diphtheria  anti-toxic  serum.  Then  fol- 
lowed similar  serums  for  the  treatment  of  tetanus, 
the  plague,  cholera,  and  the  pneumonia  antistrep- 
tococcic serum.  But  even  where  there  are  no  spe- 
cific remedies,  the  efforts  are  persistently  made  to 
restore  health  to  the  patients.  The  therapeutics 
of  the  disease,  of  the  localized  pathological  pro- 
cess, may,  in  some  cases,  have  to  continue  to  be 
expectant,  but  the  treatment  of  the  diseased  indi- 
vidual must,  nevertheless,  be  active  and  system- 
atic. Frequently  a  sick  individtial  may  be  aided  in 
overcoming  the  disease  by  the  thoughtful  and  logi- 
cal application  of  a  number  of  aparently  insignifi- 
cant means  and  methods.  The  patient  is  helped 
through  the  danger  of  the  disease.  As  Thos.  Clif- 
ford AUbutt  puts  it,  "The  physician  learns  to  play 
a  winning  game  against  the  disease."  Next  to  the 
actual  treatment  by  drugs,  medicines,  etc..  the  Ger- 
man clinic  has  wonderfully  evolved  the  method  of 
treatment  by  diet.  In  no  other  civilized  nation  in 
the  world  are  diet  treatment  or  nutritional  thera- 
petitics  made  the  objects  of  thorough  scientific  in- 
vestigation as  in  German}-.  There  are  two  journals 
which  make  the  dietetic  treatment  one  of  the  chief 
reasons  for  their  publication.  Boas'  ".Arcliiv  fur  J\r- 
danungs"  kratiklh-itcii  (.\rchives  for  Digestive  Dis- 
eases), and  Leyden's  Zcitschrift  fur  Diatctischc  und 
Physikalisclic  Thcrapic."  and  a  third  journal  exclu- 
sively devoted  to  methods  and  means  that  add  to 
the  comfort  of  the  sick  {Die  Thcra['ic  dcr  Gcgci:- 
7varf").  Right  here  I  desire  to  emphasise  the  ne- 
ces'^ity  of  such  a  journal  in  our  cotintry.     \\  e  need 


Mat   4,    1901] 


VOL\'ULUS  AND  INTUSSUSCEPTION 


[The  Philadelphia        of. , 
Medical  Joirxal        ""J 


a  journal  of  high  scientific  standard,  which  will 
be  the  depository  for  all  investigations  and  obser- 
vations, clinical,  experimental  and  pathological, 
concerning  the  treatment  of  disease  by  diet 
and  physical  methods.  It  will  be  a  poor  con- 
solation to  suggest  to  us  to  utilize  the  al- 
ready existing  German  journals  for  tliat  purpose. 
In  the  first  place,  very  few  of  our  American  practi- 
tioners understand  German  sufficiently  to  derive 
any  benefit  from  these  journals,  and  in  the  second 
place,  our  American  digestive  organs  are  sufficiently 
different  from  the  German,  our  diet  a  more  manifold 
and  peculiar  one,  our  habits  greatly  at  variance 
with  those  of  the  Teuton,  to  make  such  a  journal 
edited  from  the  American  standpoint  a  great  desid- 
eratum. Moreover,  many  of  our  foods  are  un- 
known in  German}-.  Our  beverages  have  an  entire- 
ly different  chemical  composition.  Even  the 
amount  of  proteid,  carbohydrate  and  fats  in  the 
more  commoijly  used  solid  foods  differ  from  those 
used  in  Germany. 

Among  other  newer  tendencies  issuing  from  the 
German  clinics  is  the  participation  of  internal  med- 
icine in  the  humanitarian  and  social  duties  of  our 
present  age.  This  is  the  sphere  where  phophylaxis 
becomes  active.  This  tendency  found  its  expres- 
sion in  the  International  Congress  for  combating 
tuberculosis,  as  a  collective  disease.  I  would  urge 
upon  the  profession  the  expediency  of  a  Congress 
to  design  methods  and  means  for  the  study  and 
relief  of  malignant  diseases  in  this  countr\ ,  which 
are  alarmingly  on  the  increase.  Large  expositions 
have  been  held  in  Berlin  exhibiting  every- 
thing that  is  employed  for  the  cure  of  disease, 
but  more  particularly  for  the  care  and  comfort  of 
the  sick.  I  could  not  mention  all  the  practical  lit- 
tle devices  seeking  to  improve  the  condition  of 
patients,  improved  bed  clothes,  practical  devices 
in  dishes,  cups,  feeding  tumblers  and  tables  to  be 
extended  over  the  sick  bed,  both  for  feeding  and 
entertainment,  improvements  in  the  construction 
of  the  bed  itself,  in  bandages,  urinals,  thermome- 
ters, expectoration  cups,  gastric,  rectal,  colon  and 
vesical  irrigation,  etc. 

Great  interest  is  manifested  in  hydro-therapeu- 
tics, also  in  aero-therapeutics,  the  treatment  by  hot 
and  cold  air,  by  gymnastics  and  massage.  The 
representative  German  internal  clinic  of  to-day  is 
no  longer  under  the  ban  of  pathological  anatomy, 
but  its  highest  aim  is  the  perfection  of  treatment, 
to  help  and  to  heal.  Naturally,  an  exact  diagnosis 
is  essential  to  correct  treatment :  it  is  not  now 
ecjually  harmless  and  insignificant,  whether  we  are 
right  or  wrong :  since  we  are  no  longer  supinely 
and  helplessly  carried  down  the  stream  of  patho- 
logical events,  but  feel  ourselves  capable  of  buffet- 
ing at  least  with  its  waves,  or  perhaps  of  riding  tri- 
umphantly over  them  :  for  why  should  we  despair 
that  the  reason  which  has  enabled  us  to  subdue  all 
nature  to  our  purpose,  should  (if  permitted  and 
assisted  by  providence),  achieve  a  more  difficult 
conquest,  and  ultimately  find  some  means  of  en- 
abling the  collective  wisdom  of  medicine  to  bear 
down  those  obstacles  which  individual  shortsight- 
edness, selfishness  and  passion,  oppose  to  all  sani- 
tary and  prophylactic  improvements,  and  by  which 


the  highest  hopes  are  continually  blighted,  and  the 
fairest  prospects  marred? 

After  all  that  can  be  said  of  the  benefits  the  hu- 
man race  derives  from  other  sciences,  medicine  re- 
mains the  most  blessed  of  them  all.  Its  theories 
and  lessons  may,  it  is  true,  occasionally  baffle  the 
medical  mind  in  the  sphere  of  conduct,  as  part  of 
an  order  of  things,  too  vast  to  be  more  than  partly 
understood.  .Medicine,  indeed,  presents  some  diffi- 
culties which  perplex  the  intellect,  and  a  few,  also, 
it  cannot  be  denied,  w^hich  wring  the  heart.  But  on 
the  whole,  the  progress  in  medical  science  is  in  har- 
monious relation  with  the  human  spirit,  and  it 
shows  at  the  present  day  a  more  enduring  progress 
than  any  other  science.  Different  from  these,  med- 
icine has  not  passed  its  zenith;  it  does  not  point 
centuries  back  to  the  life  and  work  of  its  great  men ; 
they  are  here,  living  with  us  at  the  present  day, 
our  contemporaries,  and  the  prospects  are  that  the 
future  will  produce  medical  men  equally  as  great 
who  will  solve  for  us  the  riddles  of  the  nature  of 
syphilis,  the  cause  and  cure  of  cancer,  the  biology 
of  the  bacteria,  and  why  it  is  that  they  cause  cer- 
tain diseases.  From  out  the  dim  future  these  prob- 
lems to  be  solved  and  our  suffering  fellow-men  ca'l 
to  us.    "Work  and  despair  not." 

1734  Linden  Ave. 


VOLVULUS  AND   INTUSSUSCEPTION  OF  MECKEL'S 
DIVERTICULUM. 

By  JOSEPH  McFARDAND,  M.  D. 

of  Philadelphia. 

Professor  of  Patholog>-  in  the  Medico-Chirurgical  College,  Pathologist   to 
the  Philadelphia  and  Medico-Chirurgical  Hospital,  etc. 

The  patient  in  whom  the  following  case  oc- 
curred, died  in  the  wards  of  Blockley  Hospital,  with 
symptoms  partly  attributable  to  intestinal  obstruc- 
tion, partly  to  uremia,  and  became  of  interest  only 
at  the  subsequent  pathological  examination : 

Necropsy. — Body  of  a  somewhat  emaciated  mid- 
dle-sized man  of  about  60-65  years  of  age.  Nothing 
of  interest  upon  the  exterior  of  the  body  except  a 
lipoma  the  size  of  a  pea  upon  the  inner  aspect  of  the 
left  foot  just  below  the  inner  malleolus.  From  the 
mouth  a  discharge  of  froth}-,  bloody  fluid  has  oc- 
curred. Death  12  hours  ago,  rigor  mortis  well 
marked.  Body  cold.  Usual  incisions  made  to  reach 
the  organs.  Costal  cartilages  not  calcified.  As  the 
parietes  were  turned  back,  the  abdominal  cavity 
was  found  to  contain  about  a  liter  of  purulent  fluid. 
The  surface  of  the  intestines  w-as  dulled,  and  there 
were  numerous  deposits  of  fibrinous  lymph  by 
which  the  different  links  of  intestine  were  glued 
together  in  places,  and  on  the  left  side  to  the  ab- 
dominal wall.  The  great  omentum,  w-hich  was  con- 
gested, was  drawn  up  like  a  fringe  along  the  trans- 
verse colon.  There  was  an  incomplete  external  in- 
guinal hernia  on  each  side,  that  on  the  right  being 
larger  than  that  on  the  left.  Both  contained  a  sin- 
gle knuckle  of  small  intestine,  which  drew  out  with 
ease.  The  vermiform  appendi.x  was  small  in  size 
and  short.  It  was  normal  except  that  it  had  a  pe- 
culiar acute  angle  at  about  its  middle.  It  contained 
no  enterolith,  and  was  not  adherent  to  the  neigh- 
boring parts.  As  the  bowel  was  examined,  it  was 
found  that  an  obstruction  occurred  in  the  ileum 
about  two  feet  above  the  cecum,  where  a  peculiar 


Qf. .        The  Philadelphia  "1 

*-      +  MEDHAL   JOfBSAl.    J 


ANESTHETICS 


[Mat    4.    1901 


knotty  twist  was  observed.     This  will  be  consid- 
ered under  the  head  of  "intestines." 

Thorax. — The  left  side  of  the  chest  contained 
about  500  cc.  of  blood-stained  fluid.  There 
were  no  pleuritic  adhesions.  The  pericardium  was 
normal,  and  contained  a  normal  amount  of  normal 
fluid. 

Heart — The  heart  was  of  normal  size.  The  right 
side  and  its  valves  were  normal,  the  auricle  proba- 
bly somewhat  dilated.  The  left  chambers  were 
probably  slightly  dilated.  The  endocardium  of  the 
left  ventricle  was  thickened  and  opaque  and  ob- 
scured the  muscular  substance  below.  The  mitral 
valve  showed  thickening  of  both  leaflets  and  the 
chorda  tendinae  were  thickened.  The  valve  con- 
tained a  few  j^ellowish  atheromatous  patches  and 
was  dotted  with  red  areas  as  if  blood  had  irregu- 
larly infiltrated  into  the  tissue.  The  aortic  valves 
were  slightly  thickened.  The  coronary  arteries 
were  not  sclerotic.  In  the  aorta  a  small  amount  of 
atheroma  was  present,  but  the  ascending  aorta  was 
widely  dilated  and  seemed  thinner  than  normal. 
Lungs. — Both  lungs  showed  inflation  of  the  upper 
lobes  and  congestive  edema  of  the  lower  lobes. 
Abdomen. — The  spleen  was  of  normal  size.  Its  sub- 
stance was  very  soft  and  flabby,  and  the  organ  was 
so  lacerated  as  to  be  torn  in  removal.  The  capsule 
was  thickened,  and  there  were  several  deep  scars 
upon  the  surface  resembling  those  left  by  old  inju- 
ries. Section  showed  the  substance  of  the  organ 
transformed  to  a  reddish  pulp.  Adrenals. — Normal. 
Kidneys. — Right — Considerably  larger  than  normal, 
pale  yellowish  in  color,  flabbj-  in  consistance.  The 
capsule  strips  readily.  Upon  the  surface  there  are 
several  deep  depressions  suggesting  the  loss  of  tis- 
sue seen  in  anemic  infants,  but  not  accompanied 
by  fibroid  changes.  The  pelvis  and  ureter  are  di- 
lated. There  were  a  few  superficial  cysts.  Left. — 
This  kidney  is  much  larger  than  the  right,  and  is 
also  in  the  advanced  stages  of  chronic  parenchyma- 
tous nephritis,  with  fatty  change.  The  pelvis  and 
ureter  are  both  dilated.  Bladder. — The  organ  is 
contracted.  Its  shape  is  pyriform,  the  fundus  form- 
ing the  narrow  part  of  the  pear.  The  walls  feel  so 
thick,  and  the  organ  so  filled  with  solid  matter  that 
a  neoplasm  was  suspected.  When  opened,  how- 
ever, it  was  found  that  there  was  an  enlargement 
of  the  middle  lobe  of  the  prostate,  and  chron- 
ic cystitis.  The  obstruction  of  the  urethra 
by  the  prostate  probably  explains  the  hydron- 
ephrosis that  existed.  Duodenum  and  Gall-Ducts. — 
Normal ;  the  ducts  patulous.  Gall-Bladdcr. — Con- 
tained three  ordinary  calculi  the  size  of  small  cher- 
ries. There  was  no  cholecystitis.  Lircr. — Normal. 
Pancreas. — Normal.  Stomach. — Normal.  Large  In- 
testine.— Normal  except  for  the  inflammation  of  the 
serous  surface.  Small  hitestine. — This  organ  was 
the  seat  of  the  interesting  observation  already  men- 
tioned. When  this  was  torn  loose  from  the  numer- 
ous plastic  adhesions  found  about  it,  it  was  found 
that  a  Meckel's  diverticulum  about  4  centimeters 
in  length  was  rotated  upon  its  long  axis  about  one 
quarter  of  a  circle,  and  then  invaginated  for 
about  two  centimeters  into  the  ileum,  producing  an 
obstruction  that  reduced  the  lumen  of  the  intestine 
to  about  one-third  or  less.  The  intestine  was  quite 
empty,  so  that  it  is  probable  that  the  obstruction 


has  at  no  time  been  complete.  By  what  force  the 
Meckel's  diverticulum  ever  became  so  twisted  and 
invaginated,  is  difficult  to  conceive.  The  intesti- 
nal obstruction  observed  before  death  and  the  per- 
itonitis with  purulent  exudate  to  which  death  was 
in  part  due,  depended  upon  the  intussusception. 
The  deeply  congested  and  swollen  state  of  the  in- 
vaginated tissue  indicate  that  had  death  occurred 
a  little  later,  gangrene  of  the  bowel  would  have  oc- 
curred. This  case  adds  one  more  to  the  already 
long  list  in  which  Meckel's  diverticulum  has 
been  responsible  for  intestinal  obstruction.  In 
addition  to  the  obstruction,  the  intestine  pre- 
sented at  about  the  junction  of  ileum  and 
jejunum  a  lipoma  the  size  of  a  peach  stone  at- 
tached by  a  short  peduncle.  There  was  also  a  sin- 
gle small  body  the  size  of  a  pea,  loosely  attached 
to  the  peritoneal  surface  of  the  small  intestine.  It 
was  dark  in  color,  matted  in  appearance,  and  more 
closely  resembled  one  of  the  scattered  peritoneal 
nodules  seen  in  abdominal  neoplasms  than  anything 
else.  It  was.  imfortunately,  lost  before  microscopic 
study  could  be  made.  As  there  was  no  primary 
neoplasm  elsewhere,  it  may  have  been  a  primary 
neoplasm  of  the  peritoneum,  possibly  an  endothe- 
lioma. Unless  the  condition  of  the  kidneys  pre- 
cluded the  possibilit}'  of  operation  and  spinal  anes- 
thesia was  out  of  the  question  for  some  reason,  the 
case  could  easily  have  been  relieved  by  surgical 
operation.  Probably,  however,  the  symptoms  pre- 
sented were  so  vague  that  a  correct  diagnosis  was 
impossible,  and  had  the  symptoms  of  intestinal  ob- 
struction been  complete,  the  existence  of  two  her- 
nias might  have  further  confused  the  surgical  diag- 
nosis. 


DEATHS  FROM  ANESTHETICS. 

B.v  D.  H.  GALLOWAY.  M.  D. 

of  Chicago. 

Three  deaths  from  anesthetics  have  occurred  re- 
cently in  Chicago,  all  within  a  period  of  ten  days. 
This  statement  is  both  startling  and  disquieting  to 
any  one  who  makes  much  use  of  anesthetics,  either 
as  an  operator  or  as  an  anesthetizer.  The  daily 
press  has  noticed  two  of  these  cases,  but  I  have  seen 
no  mention  of  them  in  any  medical  journal.  The 
profession  regards  them  with  an  apathy  which 
seems  borne  of  a  belief  that  they  are  inevitable,  and 
that  there  are  no  means  at  hand  for  lessening  the 
numbers  of  such  deaths.  A  prominent  surgeon 
said  to  me  the  other  day:  "A  few  years  ago  the 
dread  of  the  surgeon  was  sepsis,  and  that  caused 
most  of  the  deaths;  but  now  the  anesthetic  has 
taken  the  place  once  occupied  by  sepsis."  I  hardly 
think  the  majority  of  physicians  or  surgeons  will 
entirely  agree  with  him.  yet  there  is  some  founda- 
tion for  the  opinion.  Sepsis  can  now  be  almost  ab- 
solutely avoided,  but  the  danger  from  anesthetics 
does  not  seem  to  be  in  the  least  diminished.  It 
seems  that  in  our  present  state  of  knowledge  no 
human  foresight  or  skill  can  prevent  occasional  fatal 
results  from  anesthetics.  It  may  be  that  these  three 
cases  were  all  of  the  unpreventable  kind :  but  most 
of  us  know  that  of  all  surgical  procedures  the  ad- 
ministration of  anesthetics  receives  the  least  amount 
of  attention  and  skill.     Thousands  of  patients  are 


Mat   4,    I'JOl] 


ANESTHETICS 


CThe  Philadelphia        Sfic 
Medical  Journal  ""-"O 


anesthetized  every  year  in  Chicago  by  persons 
wholly  devoid  of  skill  in  the  use  of  these  agents, 
who  are  unable  or  unwilling  to  give  to  the  work 
the  amount  of  attention  that  is  given  to  every  other 
surgical  procedure  by  every  one  making  any  pre- 
tensions to  surgical  skill. 

A  few  weeks  ago  I  was  in  an  operating  room,  as 
a  spectator,  and  saw  chloroform  given  in  a  careless, 
ofT-hand  manner;  I  turned  to  the  surgeon,  who  was 
waiting  in  another  part  of  the  room,  and  said  to 
him  that  if  I  should  administer  chloroform  as  it  is 
being  administered  there,  I  was  sure  I  should  kill 
ever}-  patient  I  tried  it  on.  \\'hile  we  were  talking, 
the  patient  stopped  breathing,  and  we  were  obliged 
to  spend  several  anxious  minutes  in  bringing  him 
back  to  life.  On  another  occasion  I  was  present  to 
assist  at  an  operation,  and  advised  two  or  three 
times  that  the  chloroform  be  stopped  to  prevent 
what  I  believed  was  going  to  be  a  collapse  of  the 
patient  from  the  anesthetic.  The  anesthetizer  after- 
wards made  some  very  caustic  remarks  about  what 
he  considered  officious  interference.  .\  few  days 
later,  while  assisting  at  another  operation  at  which 
everybody  but  the  operator  was  wholly  unknown 
to  me,  I  saw  the  anesthetizer  giving  chloroform  and 
talking  to  nurses  and  others  standing  about,  ap- 
parently only  looking  at  the  patient  occasionally. 
We  had  scarcely  begun  the  operation  when  I  no- 
ticed the  patient's  condition  was  bad.  I  hesitated 
to  interfere,  but  I  could  not  refrain  from  calling  the 
anesthetizer's  attention  to  the  patient's  condition, 
and  advising  the  removal  of  the  chloroform  ;  he  re- 
moved the  mask,  and  after  watching  the  child  for 
a  few  moments,  said :  "Why,  he's  all  right,"  which 
was  true.  .A.fter  a  few  inspirations  of  fresh 
air.  he  revived,  and  the  mask,  chloroform,  in- 
attention, and  conversation  were  resumed.  In 
less  than  five  minutes  I  saw  that  the  child 
was  again  being  overwhelmed  by  the  chlo- 
roform. I  again  suggested  to  the  anesthetizer 
that  he  stop  the  chloroform  for  a  little  while.  He  did 
so,  and  after  watching  the  patient  while  he  took 
half  a  dozen  more  inspirations,  he  said  with  a  scowl 
and  in  an  impatient  tone :  "The  child  is  all  right." 
The  chloroform  was  reapplied,  and  in  two  or  three 
minutes  more  the  child  stopped  breathing.  I  no- 
ticed this,  though  the  anesthetizer  did  not.  I  called 
the  surgeon's  attention  to  the  patient's  condition, 
and  he  asked  the  anesthetizer  whether  the  child 
was  breathing.  The  anesthetizer  slowly  removed 
the  mask,  and  after  watching  the  patient  for  a  time 
which  seemed  to  me  interminable,  slowly  said : 
"Why — I — don't — believe — he — is."  After  another 
apparently  long  time,  and  without  moving,  he  said, 
with  great  deliberation :  "Ought  we  to  do  some- 
thing?" ^^'ith  this  I  took  the  child  from  the  table, 
and  standing  on  one  foot,  with  the  patient  hanging 
head  down  on  the  other  leg,  did  artificial  respiration 
for  six  or  eight  minutes  before  there  were  any  signs 
of  life.  Then  putting  the  patient  back  on  the  table 
we  prepared  to  resume  the  operation.  The  anes- 
thetizer, who  had  not  moved  from  his  stool,  put  the 
mask  over  the  patient's  face  and  resumed  the  chlo- 
roform. I  told  him  to  take  the  mask  off  and  give 
no  more  chloroform  until  he  had  to.  We  finished 
the  operation,  which  required  twenty  or  twenty-five 
minutes,  without  another  drop  of  chloroform  being 
given,   and   during  that   whole   time   the   child   was 


as  limp  as  a  rag.  That  anesthetizer  afterwards  told 
me  that  he  had  not  given  more  than  a  dozen  anes- 
thetics, that  he  had  never  received  any  instruction 
at  all,  but  had  never  had  any  trouble  before.  A  sur- 
geon once  told  me  that  he  did  not  care  who  gave 
his  anesthetics,  that  he  believed  they  were  just  as 
safe  in  the  hands  of  one  person  as  another.  He  ac- 
knowledged having  had  a  number  of  deaths  from 
anesthetics.  If  his  opinion  is  correct,  this  is  the 
only  instance  on  earth  where  knowledge  and  skill 
are  of  no  advantage  in  carrying  on  a  complicated 
process.  I  believe  few  surgeons  would  have  the 
hardihood  to  make  public  such  an  opinion  if  they 
held  it;  yet  the  majority  of  them  in  practice  act  as 
if  this  were  their  opinion.  They  are  perfectly  wil- 
ling that  medical  students  or  recent  graduates 
without  any  skill  or  instruction ;  or,  even  persons 
making  no  pretense  to  medical  knowledge,  should 
administer  anesthetics  to  their  patients.  In  remote 
districts,  where  doctors  are  few.  and  emergencies 
are  urgent,  this  is  justifiable.  In  a  city  like  Chicago 
such  emergencies  almost  never  arise.  There  is 
another  opinion  among  the  profession  at  large  which 
might  be  called  a  superstition ;  it  is  that  if  a  patient 
is  taken  off  the  table  alive  the  anesthesia  has  been 
entirely  successful,  even  though  the  patient  lies  in 
a  stupor  for  hours  afterward.  There  can  scarcely 
be  a  greater  mistake  than  this.  The  patient  should 
have  enough  anesthetic  to  allow  the  operation  to 
proceed  without  consciousness  on  his  part  or  inter- 
ference with  the  work  of  the  surgeon.  The  ideal 
anesthesia  would  be  one  in  which  this  was  attained 
with  the  use  of  the  smallest  possible  amount  of  the 
anesthetic  and  not  one  drop  more.  It  is,  of  course, 
impossible  to  attain  this  condition  exactly,  but  it 
may  be  approximated  by  skillful  administration 
and  by  continuous,  and  the  closest,  attention  to  the 
condition  of  the  patient  every  moment  of  the  time. 
While  in  most  cases,  unless  the  patient  is  very  fee- 
ble, or  there  has  been  great  shock  from  the  opera- 
tion, he  should  revive  and  become  conscious  within 
a  very  few  minutes  after  the  anesthetic  is  discon- 
tinued ;  but  if  he  has  been  drowned  in  the  vapor  of 
the  anesthetic,  he  may  lie  relaxed  for  an  hour  or 
two  afterwards ;  such  a  condition  certainly  adds 
greatly  to  the  gravity  of  the  operation.  Many  oper- 
ations arc  practically  devoid  of  danger,  but  no  anesthetic 
is  ei.'er  administered  zvithout  jeopardizing  the  life  of  the 
patient.  If  a  surgeon  takes  a  hundred  dollar  watch 
into  a  jewelry  store  and  asks  to  have  it  repaired  or 
cleaned,  and  the  jeweler  hands  it  over  to  a  wholly 
inexperienced  apprentice  who  ruins  it,  the  surgeon 
would  consider  the  act  of  the  jeweler  unjustifiable. 
If  this  same  jeweler  comes  to  the  surgeon  for  an 
operation,  he  is  sent  to  a  hospital,  and  very  likely 
an  inexperienced  interne  is  called  upon  to  adminis- 
ter the  anesthetic.  Every  surgeon  realizes  that  this 
is  the  state  of  affairs  which  exists ;  but  very  few 
make  the  slightest  effort  to  remedy  it.  The  respon- 
sibility for  this  condition  of  things  lies  not  wholly 
with  the  surgeons,  but  partly  with  those  who  are  in 
authority  in  the  medical  colleges.  The  subject  i.s 
scarcely  ever  mentioned  to  the  students :  no  effort  is 
made  to  interest  them  in  the  subject  of  anesthetics, 
and  the  facilities  at  hand  are  not  used,  or  are  inade- 
quatelv  used  for  purposes  of  instruction.  A  few  of 
the     students     appreciate      their      responsibilities 


866 


TiK  rniLADEi.ru 


Medical  J 


OUKXAL     J 


ESOPHORIA 


(Mat    4.    V.Kll 


when  called  upon  to  administer  an  anesthetic 
and  are  anxious  for  instruction.  A  few  days 
ago  in  one  of  the  college  clinics,  a  student 
was  assigned  by  the  man  in  charge  of  the 
clinic  to  administer  an  anesthetic  to  a  little  girl.  I 
was  attending  this  clinic  for  the  purpose  of  instruct- 
ing students  in  the  use  of  anesthetics,  and  told  this 
one  that  I  would  put  the  little  girl  to  sleep ;  that  he 
should  watch  carefully  how  it  was  done ;  I  would 
then  turn  the  case  over  to  him,  and  give  him  what 
instruction  I  could.  When  I  had  the  child  anesthet- 
ized, I  looked  around  for  the  student,  and  he  was 
gone.  I  saw  him  in  the  next  room  talking  and 
laughing  with  other  students ;  he  was  keeping  one 
eye  on  me,  and  when  he  saw  me  look  he  hastened 
in  and  asked  whether  I  was  read}'  for  him.  I  said 
to  him :  "I  thought  you  were  going  to  stay  and 
learn  how  to  give  chloroform?"  He  replied,  airily: 
"Oh,  I  am  not  afraid  of  chloroform  ;  I  never  have 
any  trouble  with  it ;  I  have  given  it  twice."  I  turned 
the  patient  over  to  his  care,  or  carelessness,  and  left 
the  room,  believing  that  any  effort  toward  instruct- 
ing him  would  be  wasted.  One  in  every  two  or 
three  thousand  anesthetics  result  fatally.  How 
many  of  these  might  be  prevented  if  all  anestheti- 
zers  were  careful  and  skillful,  it  is,  of  course,  impos- 
sible to  say ;  but  surely  many  of  them.  Do  you 
suppose  a  surgeon  would  be  looking  about  him  and 
laughing  and  talking  while  opening  the  abdominal 
cavity, if  one  in  two  or  three  thousand,  or  one  in 
ten  thousand,  were  accidentally  killed  by  him  at  the 
very  beginning  of  that  operation?  I  rather  think 
he  would  be  very  seriously  intent  on  his  work,  and 
acutely  alert  to  every  indication  which  might  enable 
him  to  minimize  the  chances  of  a  fatal  result;  yet  I 
have  often  seen  an  anesthetizer  holding  an  ether 
cone  over  the  face  of  a  patient,  while  he  was  en- 
gaged in  flippant  conversation  with  some  one,  and 
not  looking  at  the  patient  at  all. 

The  number  of  times  a  man  has  administered  an- 
esthetics is  no  criterion  of  his  skill,  though  he  may 
acquire  skill  b}'  practice  and  without  instruction,  he 
will  do  so  at  an  wholly  unknown  expense  to  the 
unfortunate  patients  who  come  under  his  care.  T 
liave  resuscitated,  or  helped  to  resuscitate,  when 
artificial  respiration  was  necessary,  seventeen  pa- 
tients from  an  overdose  of  an  anesthetic.  I  have  not 
had  a  case  of  my  own  for  nearly  six  years  imtil 
within  a  few  weeks.  This  one  case  illustrates  so 
well  the  power  of  chloroform,  as  well  as  the 
dreadful  suddenness  of  its  action,  that  I  shall  de- 
scribe it.  The  patient  was  a  woman,  and  the  opera- 
tion was  for  the  removal  of  a  calculus  from  the 
common  duct.  The  patient  was  in  a  very  weakened 
condition,  and  the  surgeon  warned  me  that  he 
feared  trouble  from  the  anesthetic.  Chloroform  was 
the  anesthetic  selected.  The  patient  was  anesthet- 
izd,  placed  upon  the  table,  and  the  operation  begun. 
She  had  taken  the  anesthetic  without  the  slightest 
untoward  symptom  ;  all  reflexes  were  abolished  :  the 
pupils  contracted;  ears,  cheeks  and  lip?  pink;  cir- 
culation and  respiration  perfect ;  but  the  abdominal 
muscles  were  rigid.  .\  little  more  chloroform  was 
given,  and  although  the  patient's  condition  re- 
mained as  before,  T  felt  that  the  anesthesia  was  as 
deep  as  was  safe.  The  surgeon  again  remarked  that 
the  abdominal  muscles  were  unrelaxed ;  the  other 
conditions  remained  perfect.     I  picked  up  the  chlo- 


roform bottle  with  some  misgivings.  I  was  using 
a  small  piece  of  gauze  bunched  over  the  patient's 
mouth  and  nose  as  an  inhaler;  I  put  on  three  drops 
of  chloroform,  and  before  I  could  set  the  bottle  down 
the  pupils  dilated  widely  and  respiration  ceased. 
I  instantly  removed  the  inhaler,  raised  the  pa- 
tient's jaw,  inserted  my  finger  in  her  mouth,  and 
raised  the  epiglottis.  The  change  was  so  sudden 
that  T  believed  respiration  would  be  resumed  spon- 
taneously. The  color  of  the  patient's  face,  and  the 
appearance  of  the  eyes  soon  dispelled  that  illusion. 
The  operation  was  suspended,  artificial  respiration 
resorted  to  aijd  continued  for  about  one  minute  be- 
fore natural  breathing  was  re-established.  The 
operation  was  resumed,  and,  strange  enough,  though 
the  patient  was  never  again  so  completely  anesthet- 
ized (the  surgeon  insisted  on  changing  to  ether), 
the  abdominal  muscles  were  completely  relaxed. 
The  anesthesia  had  been  produced  so  quickly,  and 
the  surgeon  had  worked  so  rapidly,  that  a  very 
short  time  had  elapsed  from  the  beginning  of  the 
anesthesia  to  the  time  of  the  accident,  so  that  I  be- 
lieve that  had  the  anesthesia  been  maintained  at  the 
same  safe  degree  a  little  longer  time,  the  abdominal 
muscles  would  have  relaxed.  If  unnecessary  deaths 
occur  from  anesthetics,  the  responsibility  e.\tends 
beyond  the  anesthetizer  and  includes  the  managers 
of  medical  colleges  who  ignore  its  importance ;  who 
make  no  efifort  to  teach  it  properly,  if  at  all,  and  who 
confer  diplomas  which  the  people  accept  as  evi- 
dence of  a  training  which  the  student  has  not  re- 
ceived. 


ESOPHORIA,  OR  LATENT  SQUINT.* 

By  FR.\N'CIS  V.A.UC.  M.  D. 

of  New  York. 

Professor  of  the  Diseases  of  the  Eve.  New  York  PosKlraduate  School  and 
Hospital,  etc..  etc. 

Opthalmology,  as  well  as  other  branches  of  our 
profession,  has  been  advancing  during  the  past  de- 
cade, and  to-day  the  methods  of  diagnosis  and  the 
treatment  of  the  conditions  of  errors  of  re- 
fraction and  the  motility  of  the  eye,  are  al- 
most complete,  so  much  so.  that  we  may  and 
can  complete  our  diagnosis  of  these  condi- 
tions simply  by  the  objective  examinations. 
It  is  to  this  advance  that  I  would  suggest  to 
you  the  consideration  of  latent  squint.  I  remember, 
not  so  many  years  ago,  at  the  time  I  read  my  first 
paper  on  refraction,  before  this  Society,  that  nearly 
all  my  cases  were  reported  as  simply  hypermetropic 
and  we  gave  little  thought  to  the  muscular  equilib- 
rium or  balance  of  the  eyes.  Hence,  many  of  ourcases 
failed  to  find  the  relief  from  the  use  of  their  glasses, 
as  might  have  been  expected.  This  was  no  doubt 
due  to  the  imperfect  methods  of  examinations  in 
use  at  that  time,  as  now  the  results  would  be  far 
different.  But  all  ophthalmologists  have  not  agreed 
upon  the  exact  methods  of  examinations  that  we 
should  pursue,  nor  are  the  results  of  our  final  work 
the  same  in  all  cases,  even  though  we  may  be  so 
much  more  exact  in  the  estimation  of  the  refractive 
condition  of  the  dioptric  apparatus,  particularly  so 
in  the  methods  of  testing  the  motility  of  the  eyes, 
in  other  words,  the  power  of  the  eyes  to  move  in 

•Read  upon  the   Medical  Society  of  the  State  of  New  York,   .\lhany' 
Januarj-.  liKll, 


May   4,    lIKil] 


ESOPHORIA 


TThe  Philadelphia         RA7 
L  Medical  Joiunal  °^/ 


the  field  of  fixation  and  in  that  of  fusion.  May  I  not 
also  suggest  that  there  is  the  same  difference  of 
opinion  in  the  other  branches  of  our  profession,  of 
which  you  are  more  interested  than  this  one,  as  I 
believe  it  is  not  fully  settled  yet  whether  antitoxin 
is  a  true  and  positive  specific  for  that  dreaded  dis- 
ease, diphtheria,  and  as  to  the  right  and  proper  time 
to  operate  in  all  cases  of  appendicitis?  Some  will 
advance  one  method,  and  yet  we  will  find  others  who 
will  take  the  opposite  side  just  as  strongly.  Medi- 
cine has  not  yet  reached  that  stage — nor  do  I  think 
it  ever  will — when  we  can  make  the  conditions  of 
all  our  cases  an  exact  science,  by  which  we  can  tell 
just  what  will  be  the  final  result,  as  in  all  we  must 
deal  with  the  personal  equation  of  our  patients,  an 
extremely  varying  quantity.  If  others  may  have 
diverse  opinions,  so  do  the  ophthalmologists  hold 
the  same  in  reference  to  the  subject  I  propose  to 
present  to  you,  and  while  some  may  tell  you  that 
latent  squint  does  not  exist,  or  simply  requires  the 
use  of  glasses :  others  will  tell  you  that  nearly  all 
cases  of  asthenopia  present  this  condition,  and  that 
the  majority  will  require  one  or  more  operations. 
For  mv  own  views,  I  must  say  that  I  am  inclined 
to  take  a  conservative  course,  simply  endeavoring 
to  correct  the  refractive  error,  whatever  that  may 
be,  and  then  to  place  the  muscular  apparatus,  if 
necessary,  in  that  condition  of  equilibrium  that  Na- 
ture obviously  intended  it  should  have.  Having 
done  this,  and  the  patient  finding  no  relief,  I  can 
justh^  feel  that  the  eyes  are  not  at  fault.  My  meth- 
ods of  examination  may  not  be  correct — as  they 
are  not  approved  of  by  all — but  they  have  at  least 
the  advantage  of  having  been  used  for  many  years, 
and  so,  as  to  their  reliability,  and  to  the  advisability 
of  operations,  I  must  leave  to  your  own  conclusions. 
If  not  correct,  they  will  not  stand  the  test  of  time 
and  will  soon  pass  into  innocuous  desuetude.  There 
is  much  diversity  of  opinion  in  reference  to  the  con- 
dition of  the  muscular  equilibrium  of  the  eyes. 
When  there  is  an  absence  of  this  condition,  the 
writers  state  that  the  fundamental  cause  is  hyper- 
metropia,  and  then  proceed  to  explain  the  relation 
between  cause  and  effect,  or,  we  may  say.  the  physi- 
ological connection  between  accommodation  and 
convergence,  to  account  for  it.  But  they  fail  to 
point  out  why  this  condition  may  and  does  exist 
when  the  refraction  of  the  eye  is  found  to  be 
myopic.  So  we  find  this  latent  tendency,  with 
myopia,  described  in  "vague  terms"  as  ciliary 
spasm — a  rare  condition  in  myopia — or  we  find  no 
explanation  at  all ;  or,  again,  it  is  so  described  that 
the  reader  cannot  decide  what  is  the  chief  or  primal 
cause  of  the  symptoms,  and  is  completely  at  sea  as 
to  what  procedure  he  shall  adopt  when  he  fails  to 
correct  his  cases  by  the  use  of  glasses  or  by  the 
method  of  exercising  the  muscles,  so  frequently 
suggested.  It  is  for  these  reasons  that  I  shall  at- 
tempt to  give  some  suggestions,  based  on  the  treat- 
me-n  of  mv  own  cases,  which  has  invar-a'iU- 
given  relief.  At  one  time  I  also  held  the  opinion 
that  hyperopia  was  the  cause  of  this  condition,  but 
I  noticed  the  vast  number  of  hyperopes  that  had  no 
tendency  to  latent  or  fixed  squint,  and  that  the 
greater  the  hypermetropia,  the  less  did  I  find  this 
inabilitv  to  keep  the  visual  lines  fixed,  then  I  beg-an 
to  doubt  my  former  opinions.     \Mien  I  also  found 


this  condition  associated  with  myopia,  and  even 
emmetropia.  I  felt  compelled  to  discard  the  theory 
of  the  connection  between  accommodation  and  con- 
vergence as  the  true  cause  of  the  squint,  and  natur- 
ally to  look  for  other  reasons  that  would  meet  all 
the  indications.  This,  I  think,  can  be  found  in  the 
field  of  fusion  or  the  desire  for  single  vision  existing 
in  the  human  eye.  This  desire  for  single  vision,  or 
fusion,  must  be  controlled  by  a  different  center  of 
the  brain  than  that  which  controls  the  movements 
of  the  eyes  in  the  field  of  fixation. 

The  power  of  an  eye  muscle  to  act  according  to 
its  physiological  function  is  shown,  first,  by  the 
ability  of  the  individual  to  do  certain  acts  by  the 
process  of  muscular  contraction,  stimulated  bv  the 
innervation  and  controlled  by  the  will  power,  and 
secondly,  the  power  to  turn  the  eyes,  one  independ- 
ent of  the  other,  under  the  stimulation  of  the  desire 
for  single  or  binocular  vision.  This  latter  power 
is  the  fusion  force,  and  is  not  under  the  control  of 
the  will  power  of  the  individual.  Under  these  con- 
ditions, we  find  that  the  eyes  can  turn  to  all  parts 
of  the  field  of  fixation  in  nearly  the  same  degrees 
of  the  arc  of  a  circle,  while  on  the  other  hand  the 
eye  will  also  move  to  a  certain  extent  and  within  a 
certain  field  (fusion),  not  by  the  will  power,  but  by 
that  of  the  muscular  apparatus,  under  the  stimula- 
tion of  the  center  for  fusion,  from  the  desire  for  sin- 
gle images,  or  that  the  images  may  be  on  corre- 
sponding parts  of  the  retina.  This  power  of  the 
muscular  apparatus  seems  to  be  limited  within  a 
certain  field,' and  we  find  this  fusion  force  acting  in 
the  same  way  when  the  eyes  are  directed  to  the  dif- 
ferent parts  of  the  field  of  fixation.  Hence  the  ability 
to  fuse  these  images  must  be  controlled  by  a  special 
center,  and  the  extent  to  which  the  eyes  can  be 
turned  to  produce  this  fusion  must  represent  the 
power  of  the  muscles  to  turn  the  eyes.  I  can  see 
no  other  wav  to  consider  the  action  of  the  ocular 
muscles  than  as  their  individual  power  to  turn  the 
eyes  under  certain  conditions ;  moreover,  I  cannot 
consider  this  force  as  innervation,  nor  that  there 
should  be  more  stimulation  to  one  muscle  tiian  to 
the  other,  since  the  size  and  the  insertion  of  all  the 
straight  muscles  seem  to  point  to  the  fact  that  one 
muscle  must  have  more  power  than  the  other,  or,  in 
other  words,  exert  a  greater  power  to  turn  the  eye 
under  the  stimulation  of  the  fusion  force. 

The  physiological  act  of  turning  the  eyes  in  all 
directions  w-ithin  certain  limits  requires  very  little 
force,  as  is  well  shown  by  the  action  of  the  interni 
and  the  superior  recti  muscles,  for  the  eyes  w  11 
turn  upward  as  well  as  inward :  and  yet  the  size  and 
the  insertion  of  the  interni  clearly  indicate  that  these 
muscles  must  have  been  intended  to  exert  a  greater 
power  in  some  way.  May  we  not  also  accept  the 
supposition  that  Nature  arranged  this  muscular 
force,  not  only  to  perform  the  simple  act  of  turn-"T 
the  eyes,  but  that  they  might  also  conform  to  all 
the  requirements  of  the  more  important  functions, 
namelv.  that  of  binocular  vision  and  corivergence,  as 
controlled  by  the  fusion  force  of  the  eyes?  Do  not 
the  dailv  needs  of  vision  confirm  all  this?  It  is  in 
the  act  of  single  vision,  both  for  the  distant  and  near 
points,  that  we  find  the  eyes  constantly  called  upon 
to  keep  the  visual  lines  fixed  on  an  object,  while  at 
the  same  time  the  eves  are  moved  to  different  parts 


fififi       The  I'hiladei.i'Hia"] 


ESOPHORIA 


[Mav    4.    1901 


of  the  field  of  fixation.  Upon  this  supposition  I 
cannot  see  what  influence  innervation,  the  position 
of  rest,  or  the  natural  elasticity  of  the  externi,  have 
to  do  with  the  fusion  of  the  images  on  the  retina. 
If  we  accept  this  reasoning,  and  believe  that  certain 
muscles  have  a  greater  power  to  turn  the  eyes  under 
certain  stimulation,  then  we  should  have  some  test, 
sufficiently  reliable  and  exact,  which  will  meet  the 
requirements,  and  indicate  to  us  what  is  the  actual 
power  of  these  muscles  to  turn  the  eyes  under  cer- 
tain conditions.  I  have  used  and  tried  faithfully  all 
the  various  tests  as  suggested  for  this  purpose,  such 
as  the  phorometer,  Maddox  rods,  etc.,  but  I  can  find 
no  one  so  reliable  and  so  clearly  indicative  of  the 
power  of  these  muscles  as  the  old  and  simple  prism 
test.  We  turn  the  eyes  in  the  field  of  fixation  under 
the  stimulation  of  the  will,  simply  because  we  wish 
to  see  in  certain  directions.  This  is  the  conscious 
part  of  the  action  of  the  eye-muscle ;  but  having 
performed  this  act,  we  now  call  into  action  the  un- 
conscious part,  in  which  the  eyes  must  adjust  the 
visual  line  according  to  the  direction  of  the  rays  of 
light  as  they  pass  through  the  dioptric  media.  If 
these  rays  of  light  are  deviated  from  their  natural 
path,  the  eyes  will  turn  on  the  center  of  rotation 
to  meet  the  deviated  rays  until  the  visual  line  will 
be  parallel  with  them  and  the  principal  axial  ray 
falls  upon  the  macula.  If  I  deviate  the  rays  passing 
into  one  eye  20°  from  a  direct  line,  then  to  have  sin- 
gle vision  there  must  be  sufficient  muscular  power 
to  turn  the  eye  in  the  direction  of  the  deviated  ray. 
nameh'  20°  of  the  arc,  and  if  we  cannot  fuse  the 
images  then,  we  do  not  have  sufficient  muscular 
power  in  the  muscle  so  tested.  Therefore,  the 
strongest  prism  that  will  deviate  the  rays  and  yet 
have  single  vision  remain  must  indicate  the  power 
of  that  muscle  to  turn  the  eye.  Now  if  the  deviation 
by  a  prism  represents  the  power  of  the  eyes  to  turn 
on  the  center  of  rotation  under  the  stimulation  of 
the  fusion  force  (duction),  what  do  we  find  is  the 
relative  force  or  power  of  these  straight  muscles? 
Evidently  we  may  have  some  standard  comparison, 
in  the  same  way  and  for  the  same  reason,  that  we 
have  the  standard  for  the  acuity  of  the  vision.  First, 
the  power  of  the  externi  to  turn  the  eyeball  outward 
must  be  considered.  Let  me  state  at  once  that  I 
do  not  consider  this  power  as  acting  from  the  posi- 
tion of  extreme  convergence  or  any  point  midway 
between  that  of  extreme  convergence  and  diver 
gence.  as  has  been  suggested  by  some  writers,  bui 
as  starting  from  the  usual  first  position  of  the  eyes, 
in  which  they  are  directed  toward  a  point  about 
twent}'  feet  distant  and  about  15°  below  the  horizon. 
Secondly,  the  power  of  the  eyes  to  move  under  the 
stimulation  of  that  unconscious  force,  or  duction.  as 
shown  by  the  prism  test  must  be  measured.  We 
should  find  the  outward  movement  or  abduction 
about  6°  ;  any  docido*!  variation  from  this  may  indi- 
cate some  latent  squint.  The  inward  movement  or 
adduction  is  about  24°  :  the  upward  movement  or 
sursumduction,  about  2°,  and  the  downward  move- 
ment, or  dorsumduction.  about  3°.  or  somewhat 
greater  than  the  upward  power.  These  movements 
are  indicated  by  the  relative  size  and  insertion  of  the 
straight  muscles,  and  very  beautifully  represent 
the  power  of  the  muscles  to  turn  the  eyes  under  the 
desire  for  single  vision,  while  the  slightest  failure 


of  this  muscular  power  may  result  in  diplopia.  Now, 
in  the  above  standard  we  shall  find  a  certain  rela- 
tion in  the  power  of  these  muscles,  one  to  the  other, 
as  the  interni  are  the  most  powerful,  next,  the  ex- 
terni ;  then  the  inferior,  and  lastly  the  superior,  each 
one  having  a  certain  ratio  to  the  other.  When  this 
is  constant — no  matter  \vhat  the  actual  power  may 
be — we  will  not,  as  a  rule,  find  much,  if  any,  mus- 
cular asthenopia  or  tendency  to  latent  squint.  Hav- 
ing then  this  standard  by  which  to  compare  the  re- 
sults of  our  tests  of  the  muscular  balance  as  found 
in  our  patients,  what  will  be  the  indications  of  the 
condition  that  is  the  title  of  this  paper?  At  once 
we  note  that  the  power  of  the  interni  is  far  greater 
than  that  indicated  by  our  standard ;  or  vice  versa, 
that  the  power  of  the  externi  is  too  low.  so  that 
under  the  stimulation  of  the  fusion  force  the  power 
of  abduction  is  not  great  enough  to  control  the  posi- 
tion of  the  eyes  except  by  the  excessive  stimulation 
of  the  externi  to  keep  the  visual  lines  fixed.  These 
patients  present  the  usual  train  of  symptoms,  chietiy 
pain  in  the  head,  radiating  backward  toward  the 
neck,  and  a  pulling  sensation  about  the  eyes.  Latent 
squint  of  the  convergent  class  is  sometimes  de- 
scribed as  spasmodic  action  of  the  interni.  and  in 
some  cases  our  tests  show  this  condition ;  but  even 
if  it  is  spasmodic  action  of  that  muscle,  it  still  indi- 
cates too  much  power  and  should  and  can  be  con- 
trolled by  proper  and  suitable  means.  Some  of  my 
best  cases  have  shown  this  condition,  as  I  have 
noticed  a  peculiar  change  in  the  response  of  the 
externi  to  the  prism  test,  in  which  there  seems  to  be 
a  decided  loss  of  power  after  we  have  tested  the 
adduction.  This  is  shown  by  our  test  as  well  a^ 
by  the  phorometer  or  the  Maddox  rod.  If  we  tesi 
the  power  of  abduction  we  find  a  certain  ability  to 
turn  the  eye  outward  under  the  stimulation  of  the 
fusion  force,  that,  as  measured  by  the  prisms,  may 
be  as  high  as  8°.  Now  testing  the  adduction  in  the 
same  way,  we  have  20°  or  more,  showing  a  fairly 
good  balance  between  adduction  and  abduction  :  but 
if  we  go  back  and  again  test  the  power  of  abduc- 
tion, we  will  find  that  it  has  become  reduced  to  1° 
or  2°,  or  possibly  we  will  have  homonymous  diplo 
pia — particularly  if  we  place  a  red  glass  before  one 
eye.  which  may  persist  for  some  time  before  the 
balance  again  adjusts  itself,  and  we  have  single 
vision.  I  have  considered  this  a  ver\-  valuable  tes: 
to  develop  the  tendency  of  the  eyes  to  turn  inward 
and  while  it  may  be  due  to  some  spasmodic  action 
of  the  interni,  yet  I  consider  it  one  of  the  best  indi- 
cations for  the  operation  I  shall  propose.  H<iv"ing 
found  the  conditions  of  latent  convergent  squint, 
our  methods  of  treatment  for  its  correction  are, 
first,  the  use  of  suitable  glasses  to  correct  any  exist- 
ing refractive  errors :  these  failing,  the  combination 
of  prisms  with  the  glasses  may  be  tried ;  then,  pos- 
siblv.  tenotomy  of  the  interni :  but  best  of  all.  in  my 
opinion,  is  the  operation  for  shortening  the  extemu> 
with  the  catgut  suture,  thereby  increasing  its  power 
to  turn  the  visual  line  outward  and  at  the  same  time 
avoiding  all  danger  of  an  over-correction.  It  is  to 
show  the  results  of  this  operation  of  shortening  the 
ocular  muscles  for  the  correction  of  this  condition 
that  I  present  these  cases  from  my  private  case- 
book, and  also  to  demonstrate  the  utility  of  this 
standard  test : 


May   4,    1901] 


STRANGULATED  HERNIA 


TThe  Philadelphia        RAo 
L  ilEDii  AL  Journal        ""-"y 


Case,  1484,  Hy.  with  Ah.  glasses  for  four  years,  ¥.-20,20 
Ad.20°,  Ab.2',  (Ratio  1  to  10).  Operation  shortening  Ext. 
Rect.     Result,  Ad.  15'  Ab.4°,  (Ratio  1  to  4). 

Case,  1755,  Hy,  with  Ah.  glasses  several  years,  no  relief. 
V.-20;15,  Ad.25°,  Ab.2';  after  testing  interni.  Ab.0°.  Was 
told  by  another  oculist  that  operation  would  do  no  good. 
Operation  was  shortening  left  externus,  result.  Ad. 15',  Ab. 
5\  Two  years  later  reports:  Can  use  the  eyes  all  that  is 
needed  with  comfort. 

Case,  1829,  Ah  glasses.  V.-20  15,  Ad.30°,  Ab.4''.  Opera- 
tion, shortening  left  Est.  Rect.  One  year  after,  is  so  much 
improved  that  she  returns  and  asks  for  an  operation  on  tho 
ether  eye  and  I  shortening  the  R.  Ext.  Rect.  in  the  same 
vay  with  this  final  result.  Ad.  20°,  Ab.  5°.  Can  now  use 
the  eyes  with  comfort. 

Case.  1839.  Hy.  with  Ah.  using  glasses,  no  improvement. 
V.  20 15.  Ad.  15°.  Ab.  0°.  Operation  shortening  L.  Ext. 
Rect.  result.  Ad.  16°,  Ab.  3°. 

Case,  1909.  My.  with  Am.  using  glasses.  V.-20  15.  Ad.  20°. 
Ab.  4°.  after  testing  Interni,  Ab.  0°,  operation  shortening 
left  Ext.  Rect.  Final  result.  Ad. 15°,  Ab.  6°.  Two  years 
later  reports  no  pain  or  asthenopia. 

Case.  1492.  Hy.  with  Ah.  using  glasses,  V.-20'20,  Ad.  10°. 
Ab.  1°.  Operation  shortening  left  Ext.  Rect.  One  year 
Efter  has  Ad.  12°,  Ah.  4°. 

Case  1977.  Hy.  using  glasses,  V.-20|15.  Ad.  25°,  Ab.C. 
Operation,  left  Ext  Rect.  Final  result.  Ad.  20°,  Ab.  6°. 

Case,  2051.  Ah.  using  glasses,  V.-20;i5,  Ad.  30°,  Ab.6°. 
After  testing  interni,  Ab.  falls  to  0°.  Operation  on  Ext. 
Rect.  Final  result.  Ad.  20°.  Ab.  6°.  six  months  after  opera- 
tion. 

Case,  2065.  My.  using  glasses.  V.-20!1d.  Ad.  30°,  Ab.  3°. 
Operation  Ext  Rect.    Final  result.  Ad.  24,  Ab.  6°. 

Case.  2292.  Hy.  with  Ah.  using  glasses.  D.-20I20, 
OS.-20  40.  Ad.  30".  Ab.  3.  Operation,  Final  result.  Ad.  20°, 
Ab.  6°. 

Case,  2371.  Hy.  with  Ah.  using  glasses.  V.-20  20.  Ad.  25°, 
Ab.  G°.  after  testing  interni,  Ab.0°.  Operation  shortening 
Rt.  Ext  Rect.    One  year  after.  Ad.  25°.  Ab.6°.  permanent 

Case,  23S5.  Ah.  ax.  180°.  using  glasses.  V.-20;15.  Ad.  20°, 
Ab.  4°.  after  testing  interni,  Ab.  0°.  Operation  shortening. 
Four  months  after.  Ad.  15°,  Ab.  4°. 

Case  2088.  Ah  using  glasses.  V.-20  15.  better  with  glass- 
es, but  not  relieved.  Ad.  20'.  Ab.  1°.  and  homonymous 
diplopia  after  testing  interni.  Operation  shortening.  Ab 
4 ".  much  better. 

Case.  2459.  Ah.  using  glasses.  V.-20  15.  Ad.  25°.  Ah.  2°. 
tails  to  0',  with  homonymous  diplopia  after  testing  interni. 
Operation  shortening.    Six  months  after,  Ad.l5°,  Ab.  5°. 

Cace.  2621.  Ah.  V.-20|15.  Glasses  do  not  stop  asthenopia. 
Ad.  20',  Ab.  1°.  Operation  shortening.  Result  Ad.  15°, 
Ab.  4°. 

Case.  2571.  Ah.  ax.  180°,  V.-20  15.  Glasses  relieve  at  first, 
then  fail.  Ad.  15°,  Ab.  homonymous  diplopia  with  re<l 
plass.  Operation  shortening,  result.  Ad.  15°.  Ab.  5°,  com- 
plete relief. 

These  cases  usuall}-  present  the  historj-  that  the 
patients  cannot  read ;  the  eyes  are  painful ;  head- 
aches, frontal  and  usually  extending  backward,  are 
experienced ;  and  there  are  car  sickness,  nausea, 
etc.,  etc.  I  have  presented  the  histories  of  these 
cases  of  esophoria,  or  latent  convergent  squint,  in 
the  simplest  condensed  form  possible,  noting  the 
refraction;  glasses  worn  without  relief;  acuity  of 
vision;  the  muscle  imbalance;  the  muscle  operated 
upon,  and  the  final  result.  They  all  seem  to  show 
a  want  of  power  in  the  externi  recti  muscles,  a  ten- 
dency for  the  eyes  to  turn  inward,  and  finally  show 
an  improvement  in  that  power,  by  the  muscle  bal- 
ance after  the  operation.  Now,  I  would  state  that 
the  same  operation  was  performed  in  each  case, 
namely,  that  of  shortening  the  muscle  by  the  inser- 
tion of  the  catgut  suture  with  a  single  needle  so  as 
to  form  a  "'auk"  at  the  insertion  of  the  tendon  into 


the  sclera,  and  allowing  the  suture  to  be  absorbed. 
The  operation  was  described  in  the  PostGraduate 
Jmirnal  for  May,  1896,  and  it  seems  to  me  to  more 
fully  meet  the  indications  than  any  other  proced- 
ure, such  as  graduated  or  partial  tenotomy  of  the 
interni,  since  we  have  a  want  of  power  in  the  ex- 
ternal recti  muscles.  To  counteract  this  imbalance, 
I  have  found  the  operation  for  shortening  the 
straight  muscles  the  best  in  my  experience.  Some 
of  you  must  be  familiar  with  this  simple  method  of 
mine,  by  which  I  shorten  the  ocular  muscles  in  their 
long  axis,  thereby  increasing  its  natural  power  to 
turn  the  eyeball  under  the  stimulation  of  single 
binocular  vision,  but  in  a  few  words  I  would  state' 
that  I  use  a  single,  sterilized  catgut  suture,  and 
after  the  muscle  has  been  exposed,  dissected  from  its 
sheath  in  Tenon's  capsule  and  held  away  from  the 
eyeball  by  these  little  twin  strabismus  hooks,  the 
needle  is  passed  through  the  tendon  very  close  to 
the  sclerotic,  then  under  the  muscle  and  as  far  back- 
ward as  we  propose  to  make  the  "tuck,"  and  then 
through  the  belly  of  the  muscle.  Now  crossing 
the  muscle  with  the  sutttre,  the  needle  is  again 
passed  through  and  under  the  tendon,  at  a  point 
above  or  below  the  place  at  which  we  started.  You 
can  now  see  that  as  we  tie  the  suture  over  the  in- 
sertion of  the  tendon,  we  must  bring  the  middle  part 
of  the  muscle  forward,  so  taking  the  "tuck,"  and 
shortening  the  muscle  very  materially  in  its  long 
axis.  There  is  very  little  if  any  reaction  after  the 
insertion  of  this  suture ;  it  does  not  require  a  second 
operation  for  its  removal,  and  the  prominence  re- 
maining gradually  flattens  out  and  disappears  in 
from  six  to  eight  weeks.  The  operation  has  never 
failed  in  my  hands,  and  I  am  glad  to  say  that  in  the 
hands  of  my  friends  it  has  shown  the  same  measure 
of  success  and  may  be  used  in  cases  of  true  squint, 
of  both  the  convergent  and  other  varieties,  as  in 
that  of  the  subject  of  this  paper.  In  closing,  let  me 
sav  I  am  trying  to  follow  Nature  in  the  movements 
of' the  eye,  and  to  quote  from  Prof.  Tyndale,  'Tn 
dealing  with  Nature,  the  mind  must  be  on  the  alert 
to  seize  all  her  conditions ;  otherwise  we  soon  learn 
that  our  thoughis  are  not  in  accord  with  her  facts." 


STRANGULATED  HERNIA. 

By  WALTER  LATHROP,  M.  D. 
of  Hazleton,  Pa. 
Superintendent  and  Surgeon,  State  Hospital,  Hazleton,  Pa. 

The  great  importance  of  this  subject,  and  the 
comparatively  frequent  occurrence  of  the  trouble, 
are  my  chief  reasons  for  bringing  it  before  you  this 
evening. 

These  cases,  as  a  rule,  first  come  under  the  care 
of  the  general  practitioner,  and  on  his  judgment  and 
skill  much  of  the  result  of  the  case  depends,  for  very 
often  the  preliminary  treatment,  or  handling,  of  the 
hernia,  determines  the  result,  as  regards  reduction, 
and  certainly  the  life  of  the  gut,  to  say  nothing  of 
the  mortality. 

I  shall  say  nothing  about  the  anatomy  of  hernia, 
but  will  speak  of  the  subject  in  a  general  way.  The 
clinical  varieties  leading  up  to  strangulation  are  the 
irreducable,  incarcerated,  inflamed,  and,  lastly, 
strangulated.  In  the  irreducable  form,  we  have  the 
circulation  and  function  of  the  bowel  or  omentun, 


Q-jr\       The  Thiladem  iiia"] 
/  Medical  Juuunai.  J 


STRANGULATED  HERNIA 


[Mat   4,    liKJl 


unimpaired,  hut  the  contents  of  the  sac  cannot  be 
returned  or  reduced. 

This  condition  occurs  often  in  umbilical  hernia, 
but  may  be  present  in  any  variety.  The  contents  of 
the  sac  are  usually  omentun,  though  a  coil  of  intes- 
tine may  also  be  present. 

The  symptoms  are  few  in  these  cases,  being 
usually  shown  by  colicky  pains  and  constipation. 
Often  rest  alone  will  cause  the  symptoms  to  disap- 
pear, and  the  hernia  may  be  returned  easily. 

Local  inflammation  calls  for  antiphlogistic  treat- 
ment, cold  applications,  and  absolute  rest. 

An  incarcerated  hernia  is  an  irreducible  one,  in 
which  the  contents  of  the  bowel  are  held  back,  or 
obstructed,  and  yet  the  circulation  is  unimpaired. 
The  symptoms  develop  slowly,  owing  to  the  slow 
accumulation  of  feces  in  the  loop  of  gut,  and  the 
gradual  filling  up  of  same;  constipation  is  present, 
and  usually  a  sense  of  weight,  and  dragging  is  ex- 
perienced. There  may  be  nausea,  and  even  vom- 
iting, but  it  is  not  the  rule,  except  in  late  stages  of 
the  trouble.  There  is  pain,  often  radiating  about 
the  abdomen.  Examination  reveals  a  tumor  quite 
tense  and  painful.  There  is  impulse  on  coughing, 
but  not  marked.  The  symptoms  may  subside  grad- 
ually, or  increase,  and  go  on  to  strangulation. 

Failure  to  obtain  relief  after  giving  enemas  and 
using  all  medical  means,  would  lead  one  to  sus- 
pect strangulation.  In  these  cases  it  is  positivelv 
injurious  to  resort  to  force  in  attempting  reduction, 
and  by  this  I  mean  the  us^  of  taxis,  of  which  I  will 
speak  later  on.  High  enemas  may  be  given,  and  if 
any  result  follows,  should  be  repeated,  and  purga- 
tives given  also ;  rest  is  imperative ;  applications  to 
the  hernia  are  essential  and  useful.  These  may  be 
hot  or  cold,  but  better  hot.  The  salines  in  small  and 
repeated  doses  may  be  used,  after  the  enemas  have 
partially  reduced  the  swelling. 

If  these  means  fail,  then  operation  is  indicated. 
Inflamed  hernia  would  most  naturally  occur  in  an 
irreducible  hernia,  where  there  has  been  any  pro- 
longed irritation,  such  as  taxis  (rejieated  and  se- 
vere), a  blow  or  fall,  an  ill-fitting  truss,  etc.  We 
have  in  these  cases  a  serous  exudation,  and  a  peri- 
tonitis, in  which  the  sac  and  its  contents  are  in- 
volved. These  cases  may  be  quite  severe  when  the 
tumor  is  an  entero-epiplocele,  but  otherwise  they 
tend  to  recovery.  Ice  may  be  used  in  these  cases, 
and  opium  may  be  given  if  pain  is  severe ;  enemas 
should  be  used  also.  No  cathartic,  or  laxatives 
should  be  given  until  pains  and  tenderness  have  sub- 
sided. 

\\'e  now  conic  to  the  most  important  condition 
of  all,  namely,  strangulated  hernia,  which  to  m\ 
mind  is  one  of  the  most  satisfactory  of  all  surgical 
affections,  if  attended  to  at  the  proper  time,  and  a 
most  unsatisfactory  and  dangerous  one  if  neglected, 
or  its  seriousness  overlooked. 

Strangulation  in  a  hernia  is  present  when,  in  ad- 
dition to  1)cing  incarcerated,  the  blood  supply  is  cut 
off.  It  is  apt  to  occur  in  middle  and  old  age.  and 
usually  in  an  old  hernia,  for  which  a  truss  has  been 
worn,  often  for  years;  but  I  have  had  one  case  in 
which  the  strangulation  was  apparently  spontaneous 
with  the  ru]iture:  The  man  was  working  in  the 
mines,  and  on  attempting  to  life  a  large  piece  of  coal 
felt  something  "give  wa},"  as  he  expressed  it,  and 


from  a  short  time  after  that  till  his  admission  to 
the  hospital  (24  hours  later),  he  presented  the  typi- 
cal symptoms  of  strangulation,  and  the  operation 
proved  it  to  be  so. 

The  chief  causes  of  this  trouble  are :  straining, 
lifting,  vomiting,  sometimes  coughing,  absence  of 
truss,  after  wearing  for  a  time,  or  any  severe  muscu- 
lar action.  It  may  also  follow  in  irreducible  or  in- 
carcerated hernia,  after  manipulation  has  been  pro- 
longed. It  is  said  to  occur  oftener  in  femoral  than  in 
inguinal  hernia,  though  I  have  not  yet  seen  one  ot 
the  femoral  variety. 

As  to  the  mechanism  of  strangulation,  many  the- 
ories have  been  advanced,  and  it  is  probable  that 
there  is  some  truth  in  all  of  them  :  suffice  to  say, 
that  venous  congestion,  and  interference  with  the 
blood  supply  is  a  chief  factor. 

We  have  the  compression  of  the  ring  itself;  we 
have  frequently  fecal  impaction,  and  paralysis  of 
the  muscular  coat  of  the  gut.  Congestion  is  in- 
creased, serous  exudate  thrown  out,  and  thus  the 
volume  beyond  the  neck  is  increased,  and  reduction 
rendered  impossible.  The  pathology  of  this  condi- 
tion is  well  described  by  Coley.  The  seat  of  most 
marked  pathological  changes  is.  in  most  cases,  at 
the  neck  of  the  sac,  not  because  the  neck  is  an  ac- 
tive agent  of  constriction,  but  on  account  of  its  be- 
ing the  narrowest  portion  of  the  sac,  and  the  tissues 
being  densest,  and  most  resisting  immediately  about 
it.  In  some  instances  the  les:ors  may  be  most 
marked  in  the  sac,  owing  to  its  own  constricting  ef- 
fect. The  first  abnormal  phenomena  are  those  of 
venous  obstruction.  The  color  of  the  intestine  be- 
comes dark  red,  blue,  or  mahogany.  The  wall  is 
thickened  from  edema,  and  its  surface  becomes 
dull,  instead  of  glistening.  This  is  followed  by  ex- 
udation into  the  sac,  the  fluid  being  first  clear,  then 
bloody  or  turbid.  This  is  followed  by  coldness  of 
the  bowel,  a  deep  furrow  at  the  neck,  becoming 
later  on  gray  or  yellowish  in  color,  but  first  hemor- 
rhagic. The  whole  loop  may  become  gan.grenous. 
and  separation  of  the  slough  may  occur  at  the  neck. 
the  sac  being  converted  into  an  abscess  cavity. 
There  may  be  lesions  of  general  suppurative  peri- 
tonitis before  this  occurs,  or  local  peritonitis  and 
adhesions  about  the  neck,  may  prevent  infection  of 
the  general  peritoneal  cavity. 

Syiii('foms. — These  are.  as  a  rule,  well  marked, 
and  should  not  be  overlooked  in  making  a  diagnosis, 
between  strangulation  and  simple  irreducible  her- 
nia, though  the  latter  may  become  strangulated  if 
not  relieved.  The  general  symptoms  are  those  of 
intestinal  obstruction.  The  local  are  usually  pain, 
tenderness  on  pressure,  irreducibility.  and  loss  of 
impulse. 

Where  the  hernia  has  been  reducible,  the  symp- 
toms are  shown  after  straining  at  stool,  or  a  sudden 
cftort,  such  as  a  heavy  lift,  vomiting,  or  violent 
coughing  will  sometimes  produce  it. 

The  pain  is  often  referred  to  the  umbilicus,  or  to 
neck  of  the  tumor.  There  is  no  impulse  on  cough- 
ing, and  a  dull  sound  on  percussion.  The  general 
symptoms  are  usually  well  defined :  there  is  nausea. 
vomiting  and  severe  pain.  The  vomit  changes  in 
character  from  the  contents  of  stomach  to  watery 
substances,  bile,  and  later  on  to  fecal  matter.  Con- 
stipation is  absolute,  the  only  movement  of  bowels 


Mav  -1,  lyni]  ■ 


STRANGULATED  HERNIA 


CTHE    PBrLADELPHIA 
Mi.l.l    Al,   JulUXAL 


871 


being  below  the  seat  of  trouble,  which  might  follow 
the  use  of  enemas.  The  temperature  is  not  ele- 
vated, as  a  rule,  but  the  pulse  is  increased,  slightly 
at  first,  and  soon  becomes  rapid,  as  the  trouble  pro' 
gresses.  Nourishment  is  refused,  from  the  fact  of 
persistent  vomiting.  The  prostration  becomes 
greater  and  the  countenance  assumes  an  anxious 
look.  The  abdomen  may  be  swollen,  and  tympan- 
itic. The  extremities  grow  cold,  cyanosis  is  present : 
and  then  hiccough  occurs,  and  dissolution  is  the 
outcome,  after  a  period  of  from  four  to  eight  days. 
Tliis  is  a  case  in  which  operation  is  not  performed.  The 
diagnosis  would  be  shown  by  the  symptoms  of  in- 
testinal obstruction,  vomiting,  constipation,  and 
pain  with  a  tumor  at  the  site  of  the  hernia. 

The  prognosis  depends  on  the  length  of  time  the 
strangulation  has  progressed.  The  mortality  is 
greater,  the  longer  the  time  of  operation  is  delayed 

The  complications  may  be  several,  such  as  peri- 
tonitis from  sloughing  of  returned  gut,  and  conse- 
cjtient  infection.  Local  peritonitis  may  be  present 
for  a  time,  but  is  not  serious;  shock  may  cause 
death  in  old  patients,  and  in  late  operations. 

It  is  said  that  the  mortality  is  from  10%  to  12% 
in  cases  operated  upon  within  36  hours,  or  less,  while 
50%  die  after  delaying  three  days.  It  is  said  to  be 
greater  in  umbilical  hernias,  than  in  femoral,  or 
inguinal. 

Treatment. — We  have  two  things  before  us  in 
these  cases :  first,  to  return  the  contents  of  the  sac 
to  the  abdomen  by  what  is  known  as  taxis,  and 
second,  to  do  the  operation  of  herniotomy.  It  is 
wise  before  doing  either  of  these  things  to  try  the 
effect  of  rest,  opiates  (hypodermically),  and  cold 
applications  to  the  tumor.  In  very  large  hernias, 
or  in  old  persons,  hot  applications  are  best;  always' 
keep  the  thighs  flexed,  and  pelvis  elevated. 

These  procedures  being  unavailing,  the  next  thing 
is  to  try  reduction  by  taxis ;  and  right  here  let  me 
state  that  after  a  fair  experience  with  these  cases 
(40),  I  believe  taxis  is  decidedly  harmful,  and  per- 
sonally, I  am  opposed  to  trying  it.  If  used  at  all, 
it  should  not  be  longer  than  three  to  iivc  minutes.  It 
is  all  right  to  try  in  entcrgcncies,  or  when  operation 
is  refused,  or  some  time  must  elapse  before  surgical 
aid  can  be  procured.  Again,  some  diseases  may  con- 
traindicate  operation,  such  as  serious  kidney  lesions, 
but  even  in  these  cases  local  anesthesia  can  be  usi^.d, 
and  the  strangulation  relieved,  thtis  rendering  pro- 
longed manipulation  or  taxis  entirely  unnecessary. 
Some  of  the  dangers  of  taxis  are,  if  too  severe,  or 
prolonged,  rupture  of  bowel  or  production  of  subse- 
quent peritonitis.  There  may  result  an  apparent 
reduction,  yet  the  symptoms  reappear  after  a  few 
hours,  owing  to  the  sac  being  reduced,  and  yet  the 
constriction  at  its  neck  not  being  relieved.  Aspi- 
ration of  the  fluid  in  the  sac  has  been  recommended. 
but  is  of  little  value. 

If  reduction  should  follow  taxis,  the  after  treat- 
ment should  be  rest  in  bed,  until  the  bowels  move, 
replacement  of  truss  if  opening  be  small,  and  best 
of  all,  the  radical  treatment  of  the  case.  It  is  not 
necessary  to  remind  you  of  the  contra-indications 
to  performing  taxis,  but  in  general  it  should  never 
be  attempted  after  twenty-four  {24)  hours. 

The  next  consideration  is  relief  by  operation.  I 
believe  the  mortality  recorded  against  operations 
for  strangulated  hernia  is  due  largely  to  injudicious 


and  prolonged  taxis,  and  postponement  of  operation 
till  late  stages  of  strangulation. 

If  performed  early,  .1  believe  the  operation  of  her- 
niotomy to  be  practically  safe,  and  the  result  almost 
certain. 

Under  anesthesia,  a  free  incision  should  be  made 
down  to  the  sac,  then  proceeding  carefully,  the  sac 
is  opened,  and  the  constriction  sought  for  and  then 
divided,  'i  he  bowel  should  now  be  inspected,  and 
will  be  found  in  nearly  every  case  to  be  dark  and 
hemorrhagic,  and  frequentlj-  will  require  some 
thinking  to  determine  its  vitality;  hot  saline  solu- 
tion should  be  used  freely  and  warm  gauze  sponges 
applied  to  the  intestine.  Returning  circulation  will 
be  shown  after  a  few  minutes,  by  the  change  of 
color,  from  dark  brown  to  reddish,  and  then"  to  a 
fairly  healthy  look,  though  congested. 

It  may  now  be  replaced,  and  a  radical  cure  be  per- 
formed if  the  patient's  condition  warrants  it,  and 
I  have  not  yet  failed  to  do  the  complete  operation. 
Gushing,  of  Johns  Hopkins,  advocates  the  use  of 
local  anesthesia  in  these  cases,  and  has  reported  a 
number  of  operations.  He  uses  infiltration  anes- 
thesia, and  has  had  good  success.  It  is  certainly 
adapted  to  aged  patients,  and  those  in  whom  serious 
kidney  complications  are  to  be  feared.  Several  New 
York  surgeons  also  use  eucaine  B.  in  some  of  their 
cases ;  I  have  had  no  experience  with  eucaine,  but 
mean  to  try  it  as  soon  as  I  have  the  opportunity' ;  but 
believe  I  shall  prefer  general  anesthesia.  I  had  re- 
cently an  interesting  case  of  strangulated  inguinal 
hernia  in  a  woman,  five  months  pregnant.  The  tu- 
mor was  large  and  hard.  The  operation  was  per- 
formed one  hour  after  her  admission,  and  showed 
a  large  enterocele,  the  ring  of  constriction  being  ex- 
ceedingly tight,  and  the  mass  of  intestine  large,  and 
very  suspicious  in  appearance.  The  constriction 
was  relieved,  the  intestine  covered  with  gauze  wet 
■with  saline  solution,  and  after  a  few  minutes  the 
color  improved,  and  I  returned  it  to  the  abdomen, 
ligated  the  sac,  and  did  a  radical  operation.  Her 
recover}'  was  rapid  and  uneventful. 

In  February  I  had  another  case  of  interest,  this, 
also,  in  a  woman  pregnant,  and  presenting  a  large 
strangulated  umbilical  hernia.  She  had  been  ill  four 
days,  was  vomiting  continuously,  and  had  absolute 
obstruction  of  bowels.  Taxis  had  been  practised 
until  the  surface  of  the  tumor  looked  like  a  large 
inflamed  area  over  an  abscess.  Her  condition  was 
anything  but  favorable,  but  I  determined  to  operate 
at  once,  and  had  her  prepared  rapidly,  and  ether- 
ized. A  free  incision  showed  a  mass  of  omentum, 
in  the  centre  of  which  was  a  large  knuckle  of  gut, 
verj'  dark  and  forbidding  in  appearance.  I  found  a 
very  tight  ring  of  constriction,  which  was  divided, 
and  the  usual  treatment  of  the  bowel  begun.  After 
probably  eight  or  ten  minutes  the  color  began  to 
improve,  though  very  slowly,  several  large  hemor- 
rhagic spots  persisting,  leading  me  to  fear  perfora- 
tion ;  but  I  determined  to  replace  the  bowel,  and 
trust  to  nature,  as  the  woman  was  in  a  ver}'  critical 
condition.  I  closed  the  opening  completely,  with 
three  rows  of  chromicizcd  gut,  and  to  be  brief,  her 
recovery  was  uneventful,  and  she  went  home  in 
twentv'(20)  days,  none  the  worse  for  her  very  nar- 
row escape. 

I  have  little  to  add  to  this  article,  but  I  would  like 


8/2 


The  Phtladeuhi  i  "1 

ilEDICAI.   JOCBSiL  J 


AMMONIUM  PERSULPHATE 


[Mat   4,    1901 


to  impress  the  importance  of  early  interference  in 
these  cases,  and  mj-  belief  in  the  safety  of  operation 
when  taken  in  time,  and  even  when  gotten  late,  we 
should  not  despair,  but  resect  the  gut  if  gangrenous, 
though  careful  applications  of  hot  saline  should  be 
thoroughly  tried  beforehand.  I  believe  a  radical 
cure  should  be  done  in  ever\'  case  where  possible, 
and  there  is  practically  no  added  danger  in  doing  it. 
To  sum  up  then,  I  would  say: 

I. — The  mortality  in  these  cases  is  due  to  delay 
in  operation,  and  to  unnecessary-  taxis. 

2. — Taxis  is  never  free  from  danger,  and  its  use 
should  be  discouraged,  save  in  emergencies 

3. — Strangulated  hernia  is  invariably  fatal,  unless 
relieved,  and  early  operation  will  nearly  always 
succeed,  and  life  will  be  saved. 


AMMONIUM  PERSULPHATE  SOLUTION.  A  NEW  DE- 
COLORIZING FLUID  FOR  STAINING  SPORES  AND 
SPUTUM. 

By  ROBT.  L.  PITFIELD,  M.  D. 

of  Philadelphia. 

Assistant  Bacteriologist.  Pennsylvania  Board  of  Health. 

The  following  method  of  staining  spores  is  in- 
troduced as  new  because  of  the  original  formula  for 
a  new  decoloring  agent  which  is  used  in  the  process. 
The  decolorizing  of  anything  by  acids  means  oxi- 
dization. This  method  of  decolorization  depends  al- 
so upon  oxidization.  The  active  ingredient  of  the 
reagent  is  the  persulphate  of  ammonium.  This  salt 
of  ammonium  decomposes  in  the  presence  of  water 
and  oxygen  is  evolved.  To  demonstrate  spores, 
prepare  a  cover  slip  as  usual,  spreading  it  verj' 
lightly,  fix  in  flame  and  then  stain  with  boiling  car- 
bol-fuchsin  or  Ehrlich's  aniline  water,  gentian  violet 
or  fuchsin.  The  cover  slip  should  be  in  boiling  stain 
for  at  least  a  minute.  Wash  and  run  on  the  follow- 
ing: 

Ammonium  Persulphate 5  grams 

Alcohol,  95  per  cent oO.c.c. 

Water lO.c.c. 

At  the  end  of  a  half  minute  wash  in  water  and  coun- 
ter stain.  The  preparation  will  show  red  or  violet 
spores  and  bacilli. stained  with  contrast  stain.  In 
case  the  spores  are  not  stained  repeat  the  staining 
and  decolorize  for  a  shorter  period  and  then  counter 
stain. 

The  decolorizing  solution  will  keep  for  several 
months.  After  making  it,  it  will  be  observed  that 
some  of  the  ammonium  persulphate isnot  dissolved. 
This  is  unimportant  and  keeps  the  solution  charged 
with  oxygen  for  several  days  as  it  slowly  decom- 
poses. 

This  solution  is  slightly  acid,  but  its  properties  do 
not  depend  upon  the  reaction.  The  addition  of  soda, 
potash,  or  ammonia  to  neutralization  does  not  de- 
tract from  its  decolorizing  powers. 

This  stain  will  decolorize  all  of  the  basic  dyes  in 
solution.  It  apparently  does  not  affect  eosin. 
methyl-green  or  their  tinctorial  properties.  Glycer- 
ine causes  an  amorphous  precipitate  and  de- 
stroys the  action  of  the  reagent.  Sputum  may  be 
stained  in  this  way,  but  there  are  disadvantages.  The 
stain  can  decolorize  the  tubercle  bacillus  if  pushed 
too  far. 


The  tubercle  bacillus  resists  the  decolorizing  ac- 
tion of  this  reagent,  and  the  preparation  is  clean  and 
free  from  all  precipitates.  But  the  reagent  must  be 
kept  a  day  before  using,  since  a  fine  crystalline  de- 
posit forms  on  the  preparation  after  using  a  fresh 
solution. 


Histological  Study  of  the  Cerebrospinal  Fluid  in  the 
Course  of  Herpes  Zoster.— BRISSAUD  and  SICARD.  iGaz. 
Hcij.  de  Sled,  et  de  Cliirur..  March  21.  li»01.  48  me.  Annee. 
No.  23).  At  a  meeting  of  the  Societe  Medicate  des  Hos- 
pitaux,  held  March  15,  l&Ol,  Brissaud  and  Sicard  reported 
the  results  of  the  histological  study  of  the  cerebrospinal 
fluid  from  2  patients  suffering  from  herpes  zoster.  The 
eruption  had  a  longitudtnal  disposition.  Lymphocites 
were  present  in  large  niunbers.  The  cells  took  the  stain  In 
a  variable  way,  and  were  associated  in  pairs  and  in  chains: 
more  rarely  they  -nere  actually  attached  to  each  other. 
These  cases  show  that  leukocytes  may  appear  in  the  cere- 
brospinal fluid,  even  in  such  a  benign  disease  as  herpes 
zoster,  in  which  the  meninges  axe  only  slightly  affected. 
It  is  probable  that  lumbar  puncture  will  in  the  future 
permit  a  study,  in  this  disease  which  is  so  rapidly  curable. 

01  the  final  disposition  of  the  leukocytes  in  the  cerebro- 
spinal fluid.  In  the  discussion  that  followed  the  reading 
of  the  paper  Widal  said  that  the  interesting  studiea 
showed  the  importance  of  histological  study  of  the  cere- 
brospinal fluid  in  the  course  of  nervous  diseases.  In 
chronic  meningeal  processes,  such  as  follow  general  par- 
alysis, tabes  or  meningo-myelitis,  large  monoculear  leu- 
kocytes are  found  as  well  as  lymphocytes.  It  is  diflScult 
in  such  a  case  to  say  whether  these  large  mononuclear 
cells  are  leukoc>'tes  or  endothelial  cells.  Ch.  Achard  and 
M.   Loeper  said  that  they  had  made  lumbar  puncture  in 

2  cases  of  herpes  zoster  of  the  lumbocrural  region.  Cul- 
tures from  the  cerebrospinal  fluid  in  these  2  cases  resulted 
in  the  growth  of  micro-organism  that  presented  the  char- 
acteristics of  certain  varieties  of  the  bacillus  coli  com- 
munis, with  this  peculiarity  that  inoculated  milk  was  net 
coagulated  at  the  temperature  of  the  incubator,  but  be- 
came coagulated  by  boiling.  The  result  seems  to  add 
evidence  to  the  opinion  that  herpes  zoster  is  of  an  infec- 
tious origin.  It  also  confirms  the  theory  that  accounts 
for  the  cutaneous  eruption  in  a  large  number  of  cases  by 
making  it  dependent  upon  a  spinal  or  meningeal  change 
that  involves  either  the  nerve  roots  or  the  nerve 
centers  themselves.  Finally,  the  question  arises  whether 
herpes  zoster  may  not  be  produced  by  different  micro-oi^ 
ganisms  and  whether  cerebrospinal  meningitis  may  not 
be  set  up  by  different  infections?     [J.  M.  S.] 


Recurrent  Gastric  Ulcer. — Professor  Hayem.  in  L'  Inde- 
pendanre  Hedimle  (April  3.  1901.  No.  14).  reports  the  case 
of  a  man  of  41.  in  whom  gastric  troubles  had  existed  for 
five  years.  At  first  there  were  symptoms  of  dyspepsia,  then 
suddenly  hematemesis  occurred.  With  treatment  he  Im- 
proved. Then  the  symptoms  recurred,  again  improving 
with  treatment.  This  was  repeated  once  more.  Now  he 
has  his  fourth  attack.  There  is  pain  under  the  xiphoid  car- 
tilage, with  fecal  masses  palpable  in  the  intestines,  to  ac- 
count for  the  constipation.  He  is  thin,  very  pale,  and 
functional  murmurs  are  audible.  Hematemesis  persists. 
Hayem  diagnosed  recurring  gastric  ulcer.  The  cause 
of  recurrent  gastric  ulcer  with  hemorrhage  is  ■wor 
known.  In  a  case  of  this  sort,  it  is  always  possible  for 
cancer  to  develop,  and  hemorrhage  or  perforation  may 
cause  death  at  any  time.  The  stomach  must  be  kept  at  rest 
long  enough  to  allow  the  ulcer  to  heal  well,  only  small 
amounts  of  water  being  given  by  mouth,  and  alimentation 
per  rectum.  Should  abundant  hematemesis  occur,  gastro- 
enterostomy may  be  necessary.     [M.  O.] 


A  Rare  Idiosyncrasy  Toward  Quinine. — Gorbatsheff  re- 
ported before  the  Moscow  Therapeutic  Society  1  Mrdicinfkoie 
ntioitrciiie.  Marth.  j(ni] .  a  case  of  a  man  in  whom  even 
small  doses  of  quinine  produced  chills,  considerable  ele- 
vation of  temperature,  delirium,  dryness  In  the  throat, 
thirst,  vomiting  and  a  severe  dematitis  accompanied  by  a 
scarlatiniform  eruption.    [A.  R.] 


SUPPLE  me:  NT    TO 

The  Philadelphia  Medical  Journal 


The  Latest  Literature 


ANNALS    OF    SURGERY. 

Fcbruury,  imi. 

1.  Gunshot  Wounds  in  the  Philippine-American  War.     E. 

F.  ROBINSON,  M.  D. 

2.  Sarcoma  of  the  Uterus.     VAN  BUREN  KNOTT,  M.  D. 

3.  Contribution  to  the  Surgery  of  Multilocular  Renal  Cyst. 

CARL  BECK,  M.  D. 

4.  Cicatricial  Stricture  of  Pharynx  Cured  by  Plastic  Oper- 

ation.    B.  FARQUHAR  CURTIS,  M.  D. 

5.  The  Improved  Technique  in  the  Operative  Surgery  of 

Carcinoma  of  the  Stomach.  WILLIS  G.  MACDON- 
ALD,  M.  D. 

6.  Cases  of  Compound  or  Complicated  Fracture  Illustrat- 

ing the  Value  of  Operative  Interference  in  the 
Treatment  of  these  Injuries.  HENRY  R.  WHAR- 
TON, M.D. 

7.  A  Method  of  Performing  Anastomosis  of  Hollow  Viscera 

by  a  New  Instrument.    M.  O  HARA,  Jr..  M.  D. 

8.  1.  An  Improved  Brace  for  Head  Extension.    2.  A  Hard 

Rubber  Spring  Brace  for  Lateral  Curvature.  JOS- 
EPH M.  SPELLISSY,  M.  D. 

1. — Out  of  22,181  patients  received  at  the  First  Reserve 
Hospital  in  Manila,  from  August  1st,  1S9S,  to  May  1st,  1900. 
only  7  per  cent,  had  gunshot  wounds.  There  were  59  cases 
of  intentional  self-inflicted  gunshot  wounds,  a  number  of 
these  being  wounds  of  the  forefinger.  At  one  time  there 
seemed  to  threaten  an  epidemic  of  these  wounds.  Of  the 
total  number  of  gunshot  injuries  received  223  were  brought 
in  dead,  or  died  within  24  hours,  leaving  the  total  number 
treated  as  1373.  The  mortality  of  this  latter  number  was 
4.2  per  cent.  Robinson  found  the  "explosive  effect"  to  be 
rare,  occurring  in  only  24  cases  out  of  462.  When  it  did 
occur  it  was  usually  in  gunshot  wounds  of  the  long  bones 
or  of  the  calvarium.  In  no  instance  was  it  noted  in  muscles 
alone,  and  in  but  2  ri^stances  was  it  observed  in  wounds 
of  solid  organs.  The  old  Remington  bullet  produces  a 
wound  which  is  nearly  always  infected,  and  the  same  is 
true  of  the  "soft-nosed,"  or  Dumdum  Mauser  bullet.  The 
modern  high-velocity  projectile  produces  a  wound  which  is 
seldom  infected.  This  is  due  to  its  hardness  and  smooth- 
ness, which  produces  little  bruising  of  the  tissues,  and  to  the 
fact  that  probably  its  high  velocity  produces  sterility.  Also 
the  early  application  of  antiseptic  dressing  on  the  field 
must  be  considered  one  of  the  greatest  means  of  preventing 
infection  from  gunshot  injuries  in  modern  warfare.  Many 
of  the  gunhsot  wounds  of  bone,  even  where  comminution 
takes  place,  if  produced  by  the  modern  bullet,  will  heal 
without  suppuration  or  necrosis.  In  a  number  of  cases 
where  the  bullet  has  not  been  extracted  it  has  produced 
little  trouble.  It  is  thought  advisable,  however,  always  to 
remove  the  bullet  of  a  Remington  or  a  revolver.  In  63 
cases  of  high-velocity  gunshot  wounds  of  long  bones  there 
were  but  12  infected,  while  out  of  27  Remington  wounds 
of  the  bones  23  were  infected.  Almost  50  per  cent  of  the 
low-velocity  gunshot  wounds  of  the  chest  became  infected, 
while  only  12  per  cent,  of  those  due  to  the  new  modern  pro- 
jectile gave  serious  trouble.  Primary  hemorrhage  from  gun- 
shot wounds  produced  by  the  modern  bullet  was  very 
uncommon.  Three  cases  of  aneurism  are  recorded  as  a  re- 
sult of  gunshot  wounds.  Gunshot  wounds  of  the  knee 
joint  are  usually  aseptic,  but  if  infected.  Robinson  thinks 
demand  immediate  amputation  to  save  life.  As  the  direct 
result  of  gunshot  wounds  there  were  only  12  major  ampu- 
tations performed,  and  only  3  of  these  were  primary.  A 
number  of  interesting  cases  are  recorded  of  injuries  to 
bones  requiring  resection:  also  several  cases  of  interesting 
gunshot  wounds  of  the  face.  Three  cases  are  recorded 
of  severe  penetrating  gunshot  wounds  of  the  brain  which 
recovered.  Every  case  but  one  of  gunshot  wounds  of  the 
spinal  cord  died  of  cerebrospinal  meningitis  in  from  3  to 


5  days.  Robinson  is  strongly  of  the  opinion  that  gunshot 
wounds  of  the  abdomen,  when  produced  with  a  modern 
high-velocity  projectile,  should  not  be  operated  upon.  Of 
30  cases  treated  without  operation  20  recovered.  Of  4 
cases  operated  upon  3  died  and  only  1  recovered.  Death 
from  hemorrhage  usually  followed  gunshot  wounds  of  the 
spleen.  Among  these  patients  there  were  2  factors  which 
Robinson  thinks  militated  against  aseptic  surgery,  the 
greater  tendency  here  to  infection  and  the  general  poor 
health  of  the  patient.     [J.  H.  G.] 

2. — Knott  gives  his  conclusions  from  a  study  of  118  cases 
of  sarcoma  of  the  uterus,  which  he  has  collected  from  the 
literature  of  the  past  ten  years.  Of  the  118  cases,  33  were 
reported  as  affecting  the  mucosa  of  the  fundus  uteri. 
Forty-six  cases  of  sarcoma  of  the  parenchyma. were  found. 
Circumscribed  sarcoma  of  the  muscular  wall  of  the  uterus 
microcsopically  closely  resembles  a  fibro-myoma.  Knott 
reports  an  interesting  case  of  diffuse  sarcoma  of  the  uter- 
ine wall  which  he  considers  an  extremely  rare  condition. 
Sarcoma  of  ihe  grape-like  variety  was  found  In  29  of  the 
US  cases.  These  growths  usually  arise  from  the  mucous 
membrane  of  the  cervical  canal.  Sarcoma  beginning  in  the 
chorionic  villi  is  the  most  malignant  type  of  uterine 
sarcoma,  and  pulmonary  metastasis  is  frequent.  Out  of  the 
lis  cases  there  were  10  of  sarcoma  deciduo-cellulare.  The 
ages  of  the  patients  ranged  all  the  way  from  7  months  to 
67  years.  As  sarcoma  of  the  mucous  membrane  so  closely 
resembles  a  simple  polypus,  microscopic  examination  of  all 
such  growths  becomes  of  very  great  importance.  The  most 
frequent  form  of  metastasis  in  the  cases  collected  was 
pulmonary.  The  only  thing  which  promises  anj'thing  in  the 
way  of  treatment  in  uterine  sarcoma  is  an  early  and  com- 
plete hysterectomy.     [J.  H.  G.J 

3. — Cystic  degeneration  of  the  kidney  in  adults  is  rare, 
occuring  more  frequentl.v  in  the  male.  In  most  instances 
both  kidneys  are  involved,  one  usually  being  much  in  ad- 
vance of  the  other.  The  disease  may  last  for  a  long  time 
without  producing  any  trouble  and  not  become  known 
until  the  tumor  is  large  enough  to  be  palpated.  Albumin 
is  not  found  in  the  urine  until  late  in  the  disease.  The 
condition  may  be  suspected  in  the  presence  of  a  renal 
tumor  with  a  sudden  uremia  or  anuria  in  a  pauent  who  has 
heretofore  shown  no  signs  of  renal  disease.  The  presence 
of  tumor  on  both  sides  renders  the  diagnosis  much  more 
likely.  The  difficulty  in  treatment  arises  from  the  inade- 
quate knowledge  of  the  exact  condition  of  the  less  diseased 
kidney,  and  this  can  only  be  told  by  exploratory  incision 
and  inspection.  Beck  reports  a  case  of  a  woman  55  years 
of  age  who  gave  an  Interesting  family  history,  two  sisters 
having  died  of  cystic  degeneration  of  both  kidneys.  The 
patient  had  a  tumor  in  the  left  abdomen  which  reached 
from  the  iliac  crest  to  the  costal  arch,  and  which  was 
nodular  and  movable.  A  diagnosis  of  cystic  kidney  was 
made.  In  operating,  the  trans-peritoneal  route  was  chosen 
in  order  to  give  an  opportunity  for  examining  the  right 
kidney.  This  kidney  was  found  slightly  enlarged  and  gave 
evidence  of  the  presence  of  cysts  at  its  lower  pole  only. 
The  left  kidney  was  removed  in  its  entirety:  it  weighed 
three  (3)  pounds  and  was  made  up  of  a  number  of  cysts 
varying  in  size,  the  largest  being  three  inches  in  diameter. 
The  patient  reacted  well  from  the  operation,  and  in  the 
first  24  hours  passed  17  ounces  of  urine.  Eight  days  after 
the  operation  the  urine  became  scant  and  renal  cells  were 
increased.  Uremia  set  in  and  the  patient  died  on  the  11th 
day  from  interstitial  nephritis.  Beck  doubts  the  advisa- 
bility of  removing  a  cystic  kidney  even  when  the  other 
organ  appears  to  be  normal.  He  thinks  that  probably  a 
better  treatment  would  be  puncture  followed  by  an  injec- 
tion of  a  drop  of  a  saturated  solution  of  iodoform  in  ether, 
for  the  smaller  cysts,  and  in  the  larger  ones  he  advised 
their  excision.     [J.  H.  G.] 

4. — Curtis  reports  a  case  of  a  girl  20  years  of  age  suffer- 


874 


The    PHlLADELrHIA  "I 


THE  LATEST  LITERATURE 


[MaV    4,    VMl 


ing  from  cicatrical  contraction  of  the  pharynx  and  pos- 
terior naris  following  ulceration  due  to  inherited  syphilis 
The  opening  from  the  mouth  to  the  nose  was  less  than  1% 
inch  in  diameter.  The  opening  downwards  into  the  eso- 
phagus and  larynx  was  only  ',4  inch  in  diameter.  Her 
diet  was  restricted  to_  fluids  and  semi-solids.  Breathing 
■was  noisy  and  difficult,  and  dyspnea  came  on  with  slight 
exertion.  Chloroform  was  administered,  tracheotomy 
performed  and  the  anesthesia  kept  up  through  the  trache- 
otomy tube.  The  patient's  head  was  drawn  over  the  end 
cf  the  table  and  allowed  to  hang  down.  A  transverse 
Incision  was  made  above  the  hyoid  Lone  on  the  le.t  s.de  and 
deepened  until  the  pharynx  was  opened  between  the  epi- 
glottis and  the  tongue.  The  lower  pharynx  was  found  shut, 
off  from  the  upper  by  a  membranous  septum  extending  from 
the  posterior  pillar  of  the  fauces  and  left  side  of  the  phar- 
ynx across  to  the  base  of  the  tongue.  The  right  side  was 
nearly  free  from  cicatricial  tissue  and  the  opening  was  on 
that  side.  The  septum  was  divided  with  the  knife  while 
the  finger  made  pressure  from  the  wound  below.  The 
division  was  continued  until  three  fingers  could  be  passed 
through  into  the  mouth.  A  flap  of  skin  was  then  cut  from 
the  left  side  of  the  neck  near  the  angle  of  the  jaw  and 
was  carried  in  and  sutured  over  the  raw  surface  in  the 
pharynx,  its  base  being  still  attached.  The  upper  pharynx 
was  then  packed  with  gauze  so  as  to  firmly  press  the  flap 
into  position.  Rectal  feeding  was  kept  up  for  7  days.  No 
infection  occurred.  The  flap  healed  nicely  in  its  new 
position.  After  the  first  week  she  was  fed  through  a 
stomach  tube.  On  the  10th  day.  under  local  anesthesia, 
the  skin  flap  was  divided  transversely  where  it  joined  the 
mucous  membrane  of  the  pharynx.  On  the  14th  day  the 
patient  was  out  of  bed.  Twenty-four  days  after  the  first 
operation  chloroform  was  again  administered  and  thi? 
opening  in  the  pharynx  closed  by  suture.  The  wound 
healed  rapidly.  The  tracheotomy  tube  was  removed  sev- 
eral days  after  this  operation.  The  patient  was  given  a 
soft  rubber  rectal  bougie.  No.  1.  about  %  inch  in  diameter, 
and  instructed  to  pass  it  at  frequent  intervals.  In  spite  of 
the  fact  that  the  patient  did  not  do  this  there  has  been  very 
little  contraction,  and  the  instrument  passed  with  but  little 
difiiculty.  The  transplanted  skin  in  the  pharynx  has  as- 
sumed the  appearance  of  mucous  membrane.     [J.  H.  G.  [ 

5. — Macdonald  thinks  that  lymphatic  Involvement  in 
carcinoma  of  the  stomach  comes  on  later  than  in  other 
organs,  and  that  when  the  disease  is  situated  at  the  py- 
lorus the  patient  is  apt  to  die  from  stenosis  before  any  very 
extensive  lymphatic  involvement  occurs.  These  facts 
would  tend  to  make  a  prognosis  of  pylorectomy  more  favor- 
able than  is  generally  supposed.  Of  course  the  earlier  the 
operation  is  done  the  more  favorable  will  be  the  prognosis, 
and  Macdonald  thinks  that  many  cases  may  be  operate*! 
upon  earlier  than  is  now  the  custom.  He  thinks  a  combi 
nation  of  the  following  symptoms  may  be  taken  as  an  indi- 
cation for  an  exploratory  operation :  First,  a  chronic  gastrit- 
isprogressiveinspiteof  proper  dietetic  medicinal  and  phys- 
icEil treatment:  second, a  loss  of  gastric  motility:  third,  pro 
gressive  diminution  of  gastric  peristalsis:  fourth  a  diminu- 
tion of  free  hydrochloric  acid,  progressive  in  character: 
fifth,  emaciation  of  patient  under  forced  diet:  sixth,  reduc- 
tion of  the  hemoglobin  in  the  blood  progressive  to  65  per 
cent,  or  under,  and  a  moderate  leukocytosis.  Hemad- 
temesis,  lactic  acid,  the  Oppler-TBoas  bacillus,  and  epigastric 
tumor  are  symptoms  which  occur  too  late  to  permit  of 
radical  surgical  intervention.  When  the  cardia  is  involveil 
the  esophagus  is  much  more  apt  to  become  infected  than  is 
the  duodenum  when  the  pylorus  is  the  seat  of  the  cancer. 
In  a  complete  pylorectomy  it  is  very  desirable  to  remove 
the  lymphatics  along  both  curvatures  of  the  stomach  as 
well  as  those  lying  behind  the  pylorus.  The  line  of  excision 
should  be  at  least  three  centimetres  from  the  line  of  palp- 
able infiltration.  JIacdonald  thinks  Kocher's  recent  clamps 
to  be  the  best  adapted  for  this  work.  It  is  his  custom  to 
close  the  stomach  and  duodenum  after  doing  the  resection 
then  to  anastomose  the  jejunum  with  the  posterior  gastric 
wall  and  then  to  unite  the  duodenum  and  jejunum  below 
During  the  past  year  he  has  employed  this  method  8  times 
with  7  recoveries.  In  making  the  anastomosis  between  the 
stomach  and  bowel  he  uses  the  suture,  but  in  making  the 
anastomosis  between  the  jejunum  and  duodenum  a  Murphy 
button  is  employed.  When  a  case  of  carcinoma  of  the 
stomach  is  too  far  advanced  to  permit  of  a  radical  opera- 
tion Macdonald  has  found  an  amelioration  of  symptoms 
to  follow  a  gastroenterostomy.    [J.  H.  G.] 


6. — Wharton  reports  first  a  case  of  compound  dislocation 
and  fracture  of  the  lower  end  of  the  tibia  with  fracture 
of  the  fibula  in  which  a  good  result  was  obtained  after  tho 
iinmediateresectionof  a  portion  of  the  tibia  and  astragalus. 
The  next  case  is  one  of  a  compound  comminuted  fracture 
of  the  tibia  and  fibula  in  which  a  loose  fragment  of  tn«; 
tibia  was  wired  between  the  distal  and  the  proximal  por- 
tions of  the  bone.  The  patient  made  a  good  recovery.  His 
next  case  was  one  of  fracture  of  the  fibula  with  marked 
displacement  due  to  a  portion  of  muscle  lying  between  the 
fragments.  His  fourth  case  was  one  of  Pott's  fracture 
where  reduction  was  only  accomplished  after  a  division  oi 
the  tendo-Achilles.  His  fifth  case  was  one  of  comminuted 
fracture  cf  the  upper  extremity  of  the  humerus  in  which 
an  excellent  result  was  obtained  from  an  excision  of  the 
shoulder  joint.  His  last  case  was  one  of  extensive  gunshot 
injury  of  the  shoulder  joint  in  which  excision  was  done 
with  a  good  result.     IJ.  H.  G.] 

7. — O'Hara  describes  an  original  forceps  for  making 
Intestinal  and  visceral  anastomoses  and  illustrates  his  arti- 
cle by  a  number  of  photographs  showing  the  use  of  the 
forceps.  The  instrument  is  a  small  one  and  possesses 
the  advantage  of  requiring  no  additional  instrument  or 
even  the  hands  of  an  assistant  to  prevent  contamination 
of  the  wound  surfaces  with  fecal  matter  during  the  anas- 
tomosis.    [J.  H.  G.] 

8, — Spellissy  describes  an  improved  brace  for  head  exten- 
sion which  is  applicable  to  all  cases  of  Pott's  disease  in  the 
cer\ical  and  upper  dorsal  regions.  He  also  presents  photo- 
graph.s  and  describes  a  hard  rubber  spring  brace  for  lateral 
curvature.     [J.  H.  G.] 


THE  JOURNAL  OF  EXPERIMENTAL   MEDICINE. 
J/«/<7i   .>J.   niijl.      (Vol.  v..  No.  5.) 

1.  Malarial  Parasitologj-.    JAMES  EWING. 

2.  The  Nerves  of  the  Capillaries  with  Remarks  on  Nerve 

Endings  in  Muscle.    A  New  Theory  of  Lymph-Forma 
tion  and  of  Glandular  Secretion.    CHR.  SIHLER. 

3.  The   Influence  of   Bile  on   Metabolism.     ELLIOTT   P. 

JOSLIN. 

4.  The  Relation   of  Diabetes   Mellitus  to   Lesions  of  the 

Pancreas.     Hyaline  Degenerations  of  the  Islands  of 
Langerhans.    EUGENE  L.  OPIE. 

1. — Ewing  begins  his  study  of  the  malarial  microorgan- 
ism by  a  consideration  of  the  staining  methods  employeil 
to  demonstrate  it.  He  then  considers  the  general  morphol- 
ogy of  the  parasites.  He  believes  that  the  rings  form  of 
the  tertian  parasite  does  not  represent  a  vesicular  nucleus. 
The  study  of  this  form  by  Nocht's  method  indicates  that 
the  nucleus  of  this  protozoon  is  one  of  the  distributed  type 
which  does  not  exhibit  a  vesicular  nor  possess  a  nuclear 
membrane.  The  ring  form  of  the  tertian  parasite  may  be 
fully  distinguished  from  the  ring  form  of  the  estivo-autum- 
nal  parasite  even  in  early  stages  by  the  following  charac- 
teristics: (1)  The  nuclear  body  and  the  chromatin  mass 
of  the  young  tertian  parasite  is  achromatic  to  methylene 
blue,  ■which  densely  stains  the  nucleus  of  the  estivo-au- 
tumnal  organism.  (2)  The  tertian  ring  is  usually  coarse 
and  irregular,  but  the  estivo-autumnal  ring  is  geometrically 
circular  and  more  delicate.  (3)  One  or  two  grains  of  pig 
ment  are  nearly  always  invariably  found  in  the  early  ter- 
tian ring  but  are  absent  from  the  estivo-autumnal  ring. 
I  4)  The  tertian  ring  is  usually  pigmented  before  the  chro- 
matin becomes  subdivided,  while  the  chromatin  of  the 
estivo-autumnal  ring  is  always  subdivided  before  the  ap- 
pearance of  pigment,  i.i^  The  infected  cell  is  usually 
swollen  from  the  moment  of  infection  by  the  tertian  spore 
and  commonly  shrunken  when  harboring  the  estivo-autum- 
nal ring.  The  author  interprets  the  larger  forms  of  the 
tertian  ring  which  are  devoid  of  chromatin  as  sterile  forms, 
and  cannot  accept  the  view  that  the  chromatin  entirely  dis- 
appears at  any  stage  of  the  fertile  parasite.  In  specimens 
stained  by  methylene  blue,  the  first  demonstrable  indica- 
tions of  the  division  of  the  parasite  are  seen  in  deeper 
staining  capacity  and  tendency  toward  reticulation.  After 
considering  the  arguments  for  and  against  pleurality  of 
species  in  the  estivo-autumnal  group  of  parasites,  the 
author  concludes  that  the  evidence  secured  fails  to  esta!>- 
lish  any  clinical  or  morphologic  grounds  on  which  to  sep- 
arate the  parasites  of  pernicious  malarial  fever  into  2 
or  more  groups,  and  he  further  considers  that  the  gr>-'i;:'  :> 
are  insufficient  to  warrant  the  classification  of  Wnndjii-j; 


WAV     4,     l!»il| 


THE  LATEST  LITERATURE 


The  Philadelphia       87  r 
.  Medical  Jouuxal         "/O 


iiiimaciihitu  as  a  separate  species  of  parasite.  Further- 
more, the  arguments  so  far  advanced  seem,  at  best,  merely 
to  justify  the  opinion  of  other  observers  that  pigment — free 
rosettes,  as  seen  in  the  human  subject,  are  an  occasional 
form  of  the  estivo-autumnal  parasite.  He  finds  that  the 
nucleus  of  the  malarial  parasite  belongs  to  the  "distributed 
type"  of  protozoan  nucleus,  consisting  of  granules  of  chro- 
matin, and,  certainly  in  the  older  and  possibly  in  all 
stages,  of  an  achromatic  substance  in  which  the  granules 
are  imbedded.  While  the  claim  of  Bastianelli  and  Bignami 
that  the  parasite  possesses  no  "true  nucleus,"  in  the  meta- 
zoan  sense  must  be  admitted,  it  exhibits,  nevertheless, 
all  the  nuclear  structures  required  in  some  protozoa.  In 
specimens  derived  from  fresh  malarial  blood,  chromatin 
was  never  seen  in  the  form  of  a  filament,  all  elongated 
masses  being  invariably  of  granular  structure.  On  the 
other  hand,  when  exflagellation  occurs  with  the  human 
parasite,  the  chromatin  becomes  filamentous,  figures  rep- 
resenting monaster  are  produced  and  the  chromasomes  are 
extruded  as  active  flagella.  It  appears,  therefore,  that  in 
the  further  cycle  of  the  malarial  parasite,  division  occurs 
by  a  very  simple  process  which  may  be  likened  to  amitosis, 
the  only  visible  changes  in  the  chromatin  being  subdivision 
and  fusion.  In  another  cycle  of  development,  adapted  for 
the  extracorporeal  growth  of  the  parasite,  division  occurs 
by  a  modified  form  of  karyokinesis,  the  chromosomes  leav- 
ing the  parent  cell  to  fertilize  other  individuals..  The 
full  significance  of  crescentic  bodies,  even  in  the  coccidia. 
has  not  yet  been  demonstrated,  although  the  position  of 
these  bodies  in  the  development  cycle  has  been  determined. 
There  is  evidence  in  the  coccidia  that  some  of  the  cres- 
eentio  bodies  represent  the  female  element  and  require 
fecundation  by  the  flagellum  or  male  element  in  order  to 
become  fertile.  Of  the  mode  of  origin  of  the  crescents  in 
man  there  is  still  nothing  definitely  known.  With  Nocht'i 
method,  however,  the  author  has  been  able  to  demonstrate 
chromatin  granules  in  the  vast  majority  of  crescents  in  all 
stages.  That  the  young  parasite  during  its  passage  from 
the  parent  rossete  to  the  new  red  cell  is  sometimes  caught 
in  the  plasma  in  both  fresh  and  dry  specimens  is  evident 
from  the  reports  of  various  observers.  The  possibility  of 
identifying  such  young  forms  in  the  fresh  condition  may, 
however,  be  doubted.  The  young  parasites  probably  swim 
In  the  plasma  for  a  very  short  time,  and  soon  become 
attached  to  red  cells.  They  remain  attached  to  the  cell  for 
a  while,  but  soon  penetrate  within,  where  their  further 
development  is  completed,  as  has  already  been  explained 
by  Mannaberg.  In  4  cases  of  tertian  infection  the  author 
has  encountered  appearances  in  the  blood  that  seem  to 
admit  of  no  other  explanation  than  that  of  conjugation  of 
malarial  parasites  has  been  accepted  probably  by  a  ma- 
jority of  clinical  observers  residing  in  temperate  climates; 
hut  seems  never  to  have  gained  uniform  support  from  those 
who  have  studied  largely  in  tropical  climates,  nor  from 
comparative  biologists.  The  strongest  evidence  in  favor 
of  plurality  of  species  is  found  in  the  results  of  experiments 
on  the  inoculation  of  malaria,  which,  when  properly  con- 
trolled, have  invariably  produced  the  type  of  organism 
found  in  the  specimen  of  blood  used  in  the  inoculation. 
Whatever  may  be  the  final  outcome  of  the  discussion  it 
cannot  be  doubted  that  the  3  groups  of  parasites,  quartan, 
tertian  and  estivo-autumnal,  exhibited  morphologic  charac- 
ters that  are  to  a  large  extent  immutible.  Yet  the  2  widely 
different  forms — the  estivo-autumnal  rings  and  the  cres- 
cents— are  regarded  as  belonging  to  the  same  species,  and 
the  whole  ground-work  of  a  morphologic  classification  is 
found  to  be  insecure  on  account  of  an  extreme  poly- 
morphism observed  throughout  the  entire  group  of  proto- 
zoa.     [J.    M.    S.] 

2. — After  tracing  the  fibers  of  the  chorda  tympani  nerve 
in  the  submaxillary  gland.  Sihler  came  to  the  conclu- 
sion that  the  gland  cells  themselves  are  not  supplied  with 
nerve  fibers,  but  that  the  terminal  fibers  are  found  on  the 
capillary  vessels  just  as  in  the  case  of  the  capillaries  of 
muscular  tissue,  and  that,  therefore,  those  nerves  of  muscle 
tuat  are  analogous  to  the  glanijular  nerves  are  not  the 
motor  nerves  proper,  but  are  those  going  to  the  capillaries. 
The  author's  histologic  studies  lead  him  to  the  conclusion 
that  there  is  a  vast  peripheral  network  of  fine  nerves,  co- 
extensive with  the  capillaries  of  the  muscles  and  glands, 
which  has  connection  with  sensory  nerves  and  into  which 
motor  nerve  trunks  also  enter,  and  which  he  therefore 
looks  upon  as  being  both  sensory  and  motor.    These  nerves, 


so  intimately  connected  with  the  capillaries,  influence  the 
protoplasm  of  their  walls  in  such  a  way,  that,  according  to 
the  activity  of  the  nerves,  the  transudation  of  lymph  is 
increased  or  diminished.  Further,  they  take  cognizance 
of  disturbances  of  a  local  or  mechanical  nature,  and,  in 
response  to  local  causes  of  irritation,  influence  the  capil 
laries  of  a  part  to  pour  out  more  fluid  and  act  in  the 
interest  of  the  organ  in  question.  As  increase  of  lymph 
formation  and  vasodilation  must,  in  the  long  run,  go  hand 
in  hand,  it  would  seem  reasonable  to  suppose  that  the 
nerve  fibers  going  from  the  capillaries  to  the  arteries  and 
veins  may  exert  an  inhibitory  influence  on  the  vaso- 
constrictors, or  a  stimulating  one  on  the  vasodilators, 
thereby  a  larger  supply  of  blood  is  furnished  to  the  irritated 
part.  The  author's  investigations  have  led  him  to  conclude 
that  the  motor  nerve-endings  of  the  muscles  remain  on  the 
outside  of  the  sarcolemma,  and  except  that  the  surfaces 
where  muscle  and  nerve  come  into  contact  are  covered 
with  a  strong  sheath  of  Schwann  which  has  its  own 
nuclei.  What  may  be  the  exact  condition  of  things  at  the 
points  where  muscle  and  nerve  fibers  are  in  actual  contact 
whether  the  sarcolemma  and  neurolemma  are  wanting 
there,  or  perforations  exist,  or  whether  electrical  phenom- 
ena observed  in  nervous  activity  can  be  used  to  explain  the 
processes  going  on  there — cannot  at  present  be  stated. 
The  precise  relation  of  muscle  to  nerve  here  is  an  unsolved 
and  difficult  histologic  problem.     [J.  M.  S.J 

3. — In  the  case  of  a  married  woman,  aged  54  years,  who 
for  the  past  3  years  had  suffered  from  attacks  of  gall 
stone,  operation  was  undertaken  for  the  relief  of  the 
condition.  The  patient's  condition  became  so  criti- 
cal while  on  the  operating  table  that  the  gall  blad- 
der alone  was  emptied  of  stones  and  a  billiary  fis- 
tula made,  the  duct  being  left  untouched.  After  the 
operation  the  discharge  of  bile  from  the  wound  was  con- 
stant, the  stools  remained  colorless  and  repeated  tests 
failed  to  show  bile  acids  in  them.  Joslin  then  instituted  a 
series  of  experiments  to  determine  the  influence  of  bile  on 
metabolism.  The  experiments  were  divided  into  3  periods 
which  were  similar  in  all  respects  except  that  in  the 
middle  period  the  patient  received  30  grams  of  dried  ox 
bile  daily.  As  a  result  of  his  experiments  the  author  con- 
cludes: (1)  That  bile  increases  the  digestion  of  fat  when 
given  by  the  mouth  in  pill  form.  The  percentage  of  tat 
lost  in  the  stools  of  the  patient  with  complete  biliary  fistula 
was  63%  in  the  first  period  and  57%  in  the  third.  Under 
bile  medication  the  stools  contained  23%  less  fat  than  in 
the  first  period  and  17%  less  than  in  the  third.  In  other 
words,  bile  increased  the  digestion  of  fat  relatively  by  50%. 
(2)  That  the  digestion  of  nitrogenous  food  is  improved 
by  bile  pills,  when  the  amount  of  fat  in  the  stools  is  larga 
Instead  of  an  average  of  15%  being  lost  in  the  feces,  but 
7%  escaped  digestion  during  the  4  days  the  patient  took 
bile.  (3)  That  ox  bile  is  a  cholagogue.  t4)  That  the 
effect  of  the  bile  on  the  bowels  in  this  case  was  not  re- 
markable, although  they  moved  more  satisfactorily  during 
the  bile  period.  (5)  That  urea  and  nitrogen  were  excreted 
in  greater  amount  in  the  bile  period  than  in  either  of  the 
other  periods.  No  definite  conclusion  as  to  the  general 
effect  of  bile  on  body  metabolism  can  be  drawn  from  this 
fact  that  because  more  nitrogen  was  Ingested  during  the 
bile  period.  (6)  That  the  amount  of  urine  was  increased 
more  than  50%  during  the  bile  period.  Although  the  bile 
pills  were  coated  with  salol,  the  amount  of  that  drug  ad- 
ministered was  not  enough  to  produce  this  effect.  On  the 
other  hand,  in  taking  30  pills  daily  the  patient  drank  sev- 
eral extra  glasses  of  water,  and  in  the  second  experiment 
her  general  condition  was  naturally  better  than  at  any 
other  time.     [J.  M.  S.] 

4. — Opie  reports  the  case  of  a  negress.  aged  54  years, 
who  died  from  diabetes  mellitus.  At  the  autopsy  It  was 
found  that  the  pancreas  weighed  SO  grams,  was  soft  in 
consistence  and  on  section  was  of  a  gray-yellow  color. 
Microscopically,  it  was  found  that  the  islands  of  Langer- 
hans  were  the  seat  of  a  very  remarkable  change.  In  vary- 
ing amount  within  almost  every  island  there  was  a  homo- 
genous material  that  stained,  with  eosin.  This  hyalin  sub- 
stance at  times  lay  in  the  midst  of  groups  of  cells,  but  was 
usually  in  contact  with  the  walls  of  the  capillaries  pene- 
trating the  island,  or  next  the  peripheral  fibrous  tissue, 
and  was  therefore  usually  between  the  remaining  cells  and 
the  capillary  walls.  The  cells  of  tlie  island  were  in  lai-ge 
part  replaced,  so  that  between  the  hyaline  particles  only 
an   occasional   compressed   fusiform   or   irregular   nucleus 


8/6 


Thk  I'hiladelphia" 
Medkal  Jouknal  . 


THE  LATEST  LITERATURE 


[MaV    4,    1(*01 


could  be  seen.  The  hyaline  metamorphosis  was  strictly 
limited  to  the  islands  of  I.angerhans,  the  glandular  acini 
remaining  intact.  In  this  pancreas,  therefore,  a  lesion  of 
obscure  etiology  has  destroyed  the  cells  of  the  islands  of 
Langerhans.  while  those  of  the  secreting  acini,  as  well  as 
those  of  other  organs,  are  uneffected.  The  association  of 
diabetes  mellitus.  the  author  believes,  affords  convincing 
proof  that  the  islands  of  Langerhans  are  intimately  con- 
nected with  the  glycogenic  metabolism. —  [J.  M.  S.] 


THE   PRACTITIONER. 

March,    1901. 

1.  Etiology,     Prophylaxis     and     Treatment     of     Malaria. 

PATRICK  MANSON. 

2.  Malaria — Its  Parasitology:  with  a  Description  of  Meth- 

ods  for   Demonstrating   the   Organism   in   Man   and 
Mosquito.     D.  C.  Ri;ES. 

3.  The  Intermittant  Fevers  and  Blackwater  Fever.    LOU- 

IS \V.  SAMBON. 

4.  The  Genus  Anopheles.     ERNEST  E.  AUSTIN. 

1. — Palrick  Manson  discusses  the  etiology,  prophylaxis 
and  treatment  of  malaria  from  two  points  of  view.  First, 
the  circumsLances  bearing  on  the  Introduction  of  the  para- 
site into  man;  dnd  seconil,  t!ie  circumstances  affecting  the 
development  of  the  clinical  manifestations  of  malarial  in- 
fection. Under  the  first  head,  he  remarks  that  the  knowl- 
edge that  certain  species  of  mosquito  are  the  necessary 
media  for  malarial  infection,  has  enabled  us  to  completely 
and  satisfactorily  e.<plain  many  facts  which  hitherto  eluded 
us,  such,  for  instance,  as  the  long  recognized  association 
of  malaria  with  high  atmospheric  temperature  and  palu- 
dal conditions.  The  danger  of  being  out  of  doors  at  night 
in  malarial  countries  is  explained  by  the  habits  of  mos- 
quitos.  which  are  mainly  noctural.  The  value  of  the  mos- 
quito net  and  similar  contrivances,  of  smoke,  and  of  fire, 
as  protections  from  malaria  are  explained  by  the  circum- 
stances that  these  things  keep  the  blood-sucking  insect  at 
a  distance.  The  etiology  of  malaria  therefore,  resolves  it- 
self in  a  great  measure  into  the  study  of  the  natural  his- 
tory of  certain  species  or  mosquito.  Especially  the  genus 
anopheles,  which  so  far  has  been  the  only  variety  definitely 
proven  to  serve  for  the  transmission  for  the  parasite.  The 
leading  facts  in  the  life  of  a  mosquito  are  as  follows:  The 
egg  deposited  on  still  water  floats  on  the  surface  or  be- 
comes attached  to  vegetation  at  the  margin  of  the  pool.  In 
about  two  days  a  minute  larva  is  hatched  out  and  at 
once  proceeds  to  feed  greedily  upon  the  organic  materials 
suspended  in  the  water.  It  grows  rapidly  and  finally  as- 
sumes the  pupa  form  from  v.-hich  the  perfect  insect  pres- 
ently emerges.  The  duration  of  acquatic  life  varies  with 
different  species  and  is  affected  by  the  temperature  of  the 
water.  In  cold  weather  the  development  is  entirely  sus- 
pended. This  hibernation  of  the  larva  is  one  of  the  ways 
by  which  the  cold  season  is  bridged  across  and  the  species 
carried  over  from  summer  to  summer.  The  insect  remains 
quiet  during  the  day,  feeding  at  night.  The  male  is  In 
most  instances  purely  phytophagous.  The  female  ano- 
pheles even  in  confinement  will  accept  a  meal  of  blood 
every  2  or  3  days.  About  20  days  after  birth  she  deposits 
some  150  or  200  eggs,  an  operation  repeated  every  few 
days  so  long  as  conditions  are  favorable.  The  entire  cycle 
from  egg  to  egg  occupies  about  50  days.  It  is  calculated 
that  a  single  female  will  give  rise  in  four  generations  to  a 
progeny  of  two  hundred  million.  In  confinement  the  mos- 
quito has  been  kept  alive  for  2  months.  Man  is  the  great 
source  from  which  the  mosquito  obtains  the  parasite.  Un- 
der his  second  head,  dealing  with  the  circumstances  af 
fecting  the  development  of  the  clinical  manifestations  of 
malarial  infection,  Manson  mentions  the  important  con- 
sideration of  age,  the  young  being  especially  susceptible, 
individual  susceptibility  innate  or  acquired,  and  such  ac- 
cidental occurrences  as  make  for  physiological  depressions. 
Very  few  individuals  are  absolutely  immune  to  the  dis- 
ease. Discussing  the  prophylaxis  of  malaria,  Manson  takes 
up  the  question  of:  first,  suppression  of  mosquitos;  second 
prevention  of  infection  by  mosquitos:  and  third,  pre- 
vention of  infection  of  mosqiJitos.  XTnder  the  first  head 
he  discusses  the  abolition  or.  the  prevention  of.  the  forma- 
tion of  the  special  type  of  pool  in  which  these  insects  breed. 
Subsoil  drainage  should  he  practiced  wherever  possible. 
The  painting  of  stagnant  water  with  petroleum  is  also  men- 
tioned. The  prevention  of  infection  of  mosquitos  should 
be  secured  by  insisting  that  all  malarial  patients  should 


use  mosquito  net,  at  the  same  time  endeavoring  by  the 
vigorous  and  persistent  use  of  quinine,  to  remove  the  ma- 
larial gametes  from  the  blood.  Lastly,  he  discusses  the 
value  of  preventing  mosquito  bites,  and  details  the  vari- 
ous experiments  of  Sambon  and  Low,  Celli,  Grassi  and 
the  Red  Cross  of  Italy.  These  show  very  much  can  be 
done  to  prevent  malaria  in  individuals  living  in  notoriously 
malarious  counties.  He  does  not  believe  that  Koch's  meth- 
od by  drugging  an  entire  community  with  quinine  Is 
feasible.  As  to  treatment,  quinine  is  the  only  reliab'.'? 
drug.  He  seems  favorably  impressed  with  the  value  of 
euquinine.     [T.  L.  C] 

2. — D  C.  Rees  has  made  a  careful  study  of  the  parasitol- 
ogy of  malaria,  and  presents  an  historical  account  of  the 
development  of  our  knowledge.  The  malarial  parasite  is 
now  regarded  as  belonging  to  the  class  sporozoa,  and 
closely  connected  with  the  coccidldae.  English  observ- 
ers have  grouped  the  malarial  parasites  of  man  with  those 
of  birds  into  a  separate  sub-order,  the  hemamebidae.  He 
presents  a  clever  schematic  ilustration  of  the  phases  of 
development  of  the  endogenous  and  exogenous  life  cycles 
of  the  malaria  parasite.  A  convenient  table  is  included  in 
'he  article,  showing  the  nomenclature  employed  by  vari- 
ous writers  for  describing  the  stages  of  development  of 
the  malaria  parasite.  The  technique  of  the  demonstra- 
tion of  the  malaria  parasite  in  the  blood  is  also  given  in 
great  detail,  and  the  author  describes  his  method  of 
breeding,  transporting  and  infecting  mosquitos.     [T.  L.  C.) 

3. — Lewis  \V.  Sambon  contributes  a  paper  upon  the  in- 
termittant fevers,  and  black-water  fever.  Under  the  phen- 
omena of  the  paroxysm  he  describes  the  three  distinct 
stages,  the  cold,  hot  and  sweating  stage,  and  presents  a 
detailed  account  of  the  correlation  of  the  parasites  and  the 
course  of  intermittant  fevers.  Especially  interesting  in 
that  part  of  his  paper  devoted  to  multiple  and  mixed  in- 
fections, in  which  he  considers:  1.  infection  with  several 
groups  of  the  same  species  of  parasites:  2.  mixed  infec- 
tion, with  a  parasite  of  two  or  more  types  of  intermittant 
fever;  3,  complications  with  other  diseases.  Under  this 
latter  head  he  states  that  we  now  know  positively  that 
there  is  no  such  thing  as  a  true  "malarial  pneumonia," 
hut  a  pneumoccocus  pneumonia  may  occur  in  the  course 
of  a  mild  tertian  or  quartan  infection.  Siriasis  may  be 
come  a  very  grave  complication  of  intermittant  fever,  ani 
multiple  neuritis  may  develop  after  an  attack  of  intermit- 
tant fever.  Black-water  fever  is  described  by  Sambon  as 
an  acute  infectious  disease  characterized  by  a  sudden 
and  intense  hemolysis  and  clinically  marked  by  irregular 
paroxysmal  fever  accompanied  by  rigors,  bilious  vomiting, 
jaundice  and  hemoglobinuria.  In  considering  the  etiology 
of  black  water  fever  Sambon  concludes  that  the  symp-  ! 
toms.  the  postmortem  findings  and  the  epidemiologrical  fea- 
tures of  animal  fevers  (referring  to  a  hemoelobinuric  fever 
found  in  sheep  and  other  animals,  in  which  an  exceeding- 
ly minute  parasite  is  present)  are  exactly  like  those  of  the 
hemoglobinuric  fever  of  man.  It  is  therefore  quite  reason- 
able to  infer  that  black-water  fever  may  be  due  to  a 
protozoal  organism  akin  to  that  of  cattle  red-water  fever. 
We  have  as  yet  no  remedy  known  to  be  of  the  slightest 
value  in  black-water  fever.  Sambon  recommends  a  mod- 
erate dose  of  calomel  followed  by  irrigations  of  the  colon. 
He  places  more  dependence  upon  the  irrigations.  Plenty 
of  water  may  be  allowed.  In  general  the  treatment  is  sym- 
tomatic.    [T.  L.  C] 


ARCHIVES  OF   PEDIATRICS. 

.•I;)ri7.   1901.     (18th   Year.   No.   ^^  i 

1.  The  Blood  in  Infancv  and  Childhood.    ALFRED  STEN- 

GEL and  C.  Y.  WHITE. 

2.  Enteric  Fever  in  Childhood.    Wm.  L.  STOWELL. 

3.  An  Unusual  Case  of  Erythema  Multiforme.    FLOYD  M. 

CR.\NDALL. 

4.  Duodenal   Ulcer  in   an   Infant  of  Ten   Months.     VAN 

DERPOEL  ADRIANCE. 

5.  Apparent   Cure   of   a    Case   of   Frequent    Convulsions. 

Probably  Epileps.v.     ANNA  R.  LAPHAM.  , 

6.  A   Case  of  Head-Nodding   .Associated  with   Spasmodic      I 

Torticollis.    JOHN  H.  JOPSON. 

2. — William  L.  Stow  ell  reports  24  cases  ocurring  in  lO 
fjimily  groups.  Sixty-one  cases  of  typhoid  fever  in  children, 
of  which  the  author  believes  that  in  many  c,^ses  careJces 
ness  in  the  home  caused  the  spread  of  the  disease  rather 
than  an  identity  of  origin.     The  youngest  patient  was  d 


May   4,    IWil] 


THE  LATEST  LITERATURE 


TThe 
L  Mee 


"The    PniLADELrHIA  fi-Tr 


years  old.  The  convulsions  were  not  frequent,  nor  was 
delirium  a  constant  symptom.  Apathy  and  mental  dullness 
are  common  in  children,  even  the  very  young.  Headache 
was  often  present,  perhaps  more  in  those  with  high  tem- 
perature than  in  those  without.  Epistaxis  is  very  common, 
usually  during  the  first  week.  It  is  sometimes  one  of  the 
very  first  symptoms  and  relieves  the  early  headache.  In 
2  cases  there  was  an  almost  universal  eruption,  which 
appeared  about  the  time  the  temperature  had  reached 
its  height.  Beside  the  rose  spots  there  may  be  other  erup 
tions,  such  as  erythema,  herpes  or  sudamina.  The  com 
pressibility  and  non-resistant  qualities  of  the  pulses  are 
diagnostic.  Both  leukocytes  and  erythrocytes  are  dimin 
ished  in  number.  If  pneumonia  sets  in  as  a  complication 
there  is  usually  a  great  increase  in  leukocytes.  The  hemo- 
globin is  greatly  reduced,  ranging  from  25%  to  60%.  In 
95%  of  cases  the  serum  reaction  is  positive.  Tympanites 
is  less  common  in  children  than  in  adults.  Gurgling  at 
the  iliocecal  valve  cannot  be  counted  a  diagnostic  point. 
Excessive  tympany  is  usually  a  precursor  of  death.  If  it 
develops  very  suddenly  the  possibility  of  perforatiou 
should  be  borne  in  mind.  The  author  has  not  had  u 
case  of  perforation  in  a  young  child,  and  from  his  experi- 
ence he  would  infer  that  the  hemorrhages  are  more  com- 
mon and  more  likely  to  be  fatal  in  adults.  Children  are 
prone  to  be  constipated  during  the  first  week,  and  usually 
have  from  1  to  3  loose  stools  daily  during  the  second  week. 
Diarrhea  was  noted  in  32.6%  of  the  cases.  A  majority  of 
these  cases  presented  tender  and  enlarged  spleens.  Albu- 
min was  absent  as  a  rule,  but  the  diazo-reaction  was  found 
to  be  a  helpful  diagnostic  test.  Complications  of  typhoid 
fever  in  children  include  varicella,  parotitis,  pneumonia, 
intestinal  hemorrhage  and  perforation  of  the  bowel.  Three 
of  77  cases,  16  of  which  were  adults,  had  relapses.  The  aver- 
age duration  of  the  disease  was  23%  days.  The  mortality  in 
61  children  was  nil.  Milk  diluted  with  ^nchy,  seltzer  or  lime 
water  and,  if  the  fever  is  high,  partly  peptonized,  is  the 
best  diet.  licmonade,  iced  coffee  and  iced  cocoa  may  be 
used  freely;  ice  cream  is  also  allowed.  Intestinal  anti- 
septis  is  of  prime  importance.  Salol  is  the  author's  favorite 
drug:  but  he  has  also  had  good  results  from  the  use  of  the 
well-known  tablets  of  podophyllin,  calomel,  guaiacol,  men- 
thol, etc.  He  has  never  aborted  a  case  thereby.  During 
the  third  week,  the  soft  compressible  pulse  of  a  flagging 
heart  needs  help;  stiTchnine,  digitalis,  camphor  and 
ammonia  may  be  used  for  this  purpose.  He  does  not  give 
alcohol  to  children;  although  he  uses  liquid  peptonoids 
freely.  Occasional  doses  of  antipyretics  may  be  given  in 
certain  cases  and  be  very  helpful;  but  their  effect  on  the 
circulation  should  be  watched.  Children  do  not  show  the 
same  benefit  or  even  tolerance  of  tubbing  that  adults  do. 
and  the  author  relies  on  sponging.     [J.  M.  S.] 

3. — Floyd  M.  Crandall  reports  the  case  of  a  boy,  aged  Sy^ 
years,  who  had  been  healthy,  but  who  became  ill  with 
fever  and  sore  throat.  On  the  fourth  day  of  the  disease  a 
multiform  erythematous  rash  had  developed  that  involved 
the  entire  body.  A  culture  made  from  the  throat  was  con- 
taminated but  contained  no  diphtheria  bacilli.  Recovery 
was  complete  and  there  has  been  no  recurrence.    [J.  M.  S.] 

4. — Vanderpoel  Adriance  reports  a  case  of  duodenal 
ulcer  in  an  infant,  10  months  of  age.  The  diagnosis  was 
confirmed  at  autopsy.     [J.  II.  S.] 

5. — Anna  R.  Lapham  reports  the  case  of  a  girl,  aged  '! 
years  and  4  months,  who  had  frequent  convulsions.  During 
a  3  weeks'  residence  in  hospital  387  attacks  are  recorded. 
The  child's  father  was  nervous  and  her  mother  was  a 
neurasthenic.  The  mother,  in  addition,  had  convulsions 
when  a  child  of  3,  which  were  followed  by  paralysis.  Treat> 
ment  by  bromides,  tincture  of  pd^s^i/tani  itu-arnuta.  trionaJ 
and  codeine  had  reduced  the  number  of  the  convulsions, 
when  the  mother  too.k  the  child  away.  The  convulsions 
immediately  returned  and  a  paresis  developed.  Dater, 
the  child  was  sent  to  the  country  and  all  medication  was 
abandoned,  and  under  the  care  of  a  trained  nurse  who 
regulated  the  patient's  diet  the  convulsions  and  the  paresis 
disappeared  and  the  child  has  been  well  for  months.  The 
author  believes  that  the  etiology  of  the  condition  is 
traceable  to  a  toxemia  due  to  intestinal  ptomaines,  although 
there  was  a  history  of  a  fall.  Of  course,  heredity  must 
have  played  some  part  in  the  development  of  the  con 
dition.     [J.  M.  S.] 

6. — John  H.  Jo])son  reports  the  case  of  a  female  infant, 
aged  11  months,  who  presented  spasmodic  torticollis  due  to 
right-sided    contraction   of   the   sternomastoid   muscle,   ac- 


companied by  head-nodding.  One  month  before  the  patient 
was  seen,  she  had  fallen  down  stairs  and  the  following 
day  developed  a  bronchitis.  The  torticollis  and  head- 
nodding  were  noted  after  recovery  from  the  attack  of  bron- 
chitis. The  condition  improved  under  treatment  by  small 
doses  of  tincture  of  belladonna.     [J.  M.  S.] 


JOURNAL  OF   NERVOUS  AND   MENTAL   DISEASE. 
.l/</;c7i,   I'JOI.      [No.  3.] 

No.  1.  The  Amelioration  of  Paralysis  Agitans  and  Other 
Forms  of  Tremor  by  Systematic  Exercise. —  JOHN 
MADISON  TAYLOR. 

No.  2.  A  Case  with  Symptoms  of  Cerebro-spinai  Menin- 
gitis, with  Intense  and  General  Alteration  of  the 
Nerve-Cell  Bodies,  but  \vith  Little  Evidence  of  In- 
flammation.    WILLIAM  J.  SPILLER. 

No.  3.  A  case  of  Muscular  Dystrophy.  CHAS.  GILBERT 
CHADDOCK. 

1. — Taylor  has  studied  the  effects  of  systematic  exer- 
cises and  massage  in  various  cases  of  paralysis  agitans. 
He  reports  in  detail  one  case.  A  man  of  52  had  been, 
afflicted  with  the  disease  for  about  7  years.  The  rigidity 
gradually  became  so  extreme  that  the  only  voluntary  mo- 
tion preserved  was  the  festinating  gait.  There  were  pro- 
nounced contractures  in  the  tissues  of  the  trunk  and  neck, 
and  exaggerated  cervical  and  dorsal  curvatures  of  tho 
spine;  even  the  power  of  articulate  speech  was  lost.  The 
evercises  were  continued  for  six  months,  and  consisted  of 
massage  of  the  thickened  rigid  skin,  passive  extension  of 
the  contracted  muscles,  and  gradually  increased  volun- 
tary movements.  There  was  at  first  considerable  pain, 
then  tingling,  and  finally  a  pleasurable  sensation  after  the 
exercises.  The  patient  was  able  to  write  and  to  speak,  and 
was  also  capable  of  performing  light  tasks.  Taylor  be 
lieves  that  the  points  to  be  observed  in  this  form  of  treat- 
ment are  the  re-establishment  of  the  largest  degree  of 
elasticity  in  the  tissues  which  have  suffered  contractures, 
which  should  be  obtained  by  passive  extensions  and  flexions 
followed  by  active  movements.  As  far  as  possible  the  nor- 
mal attitude  and  carriage  should  be  restored.     [J.  S.] 

2. — The  patient,  a  boy  of  8,  an  idiot  with  spastic  gait, 
was  suddenly  attacked  with  fever,  pain  and  diarrhea.  Ho- 
developed  photophobia,  hyperesthesia  of  the  skin,  sluggish 
reaction  of  the  pupils,  which  gradually  gave  way  to  imme 
bility  of  the  pupils  and  retraction  of  the  head.  He  devel- 
oped coma  and  died,  6  days  after  the  appearance  of  the 
first  symptoms.  At  the  autopsy  a  petechial  eruption  was 
observed  on  the  thighs;  there  was  edema  of  the  brain,  no 
distinct  evidences  of  inflammation  of  the  membranes,  an-i 
miliary  tubercles.  The  internal  organs  were  apparently 
normal.  Microscopically  no  evidence  of  inflammation  of 
the  nerve  tissue  was  discovered,  but  extensive  degeneration- 
of  the  nerve  cells  in  the  entire  central  nervous  system. 
There  was  a  slight  round  celled  infiltration  of  the  pia  mater 
of  the  spinal  cord.  This  condition  has  been  reported  in  two- 
other  cases;  one  published  by  Spiller  and  McCarthy,  was  a 
case  of  internal  hemorrhagic  pachymeningitis  in  an  idiotie 
child,  and  the  other  by  Hirsch  and  Sachs,  a  case  of  amau- 
rotic family  idiocy.  Numerous  bacteria  were  found  in  the 
nervous  tissue,  which  were  probably  present  before  death. 
It  is  not  certain  that  this  is  a  case  of  intoxication    [J.  S.] 

3. — The  patient,  a  man  of  39,  without  a  significant 
family  history,  had  never  been  able  to  whistle.  At  the  age- 
of  15  he  first  noticed  that  he  was  not  able  to  close  his 
eyelids  completely.  At  the  age  of  24  there  was  distinct 
weakness  of  the  right  arm,  which  gradually  extended  to  the 
left  arm.  Nevertheless,  he  was  able  to  continue  his  occu- 
pation of  machinist.  Finally,  however,  increasing  feeble 
ness  compelled  him  to  give  up  that  occupation.  His  pres- 
ent condition  is  one  of  muscular  wasting,  involving  the 
muscles  of  the  face,  with  the  exception  of  the  muscles  of 
mastication,  the  shoulder,  the  arms  and  the  thighs.  The 
forearms,  legs  and  abdomen  are  fairly  well  preserved. 
The  weakness  on  the  right  side  is  greater  than  that  on  the 
left  side.  There  is  very  marked  emaciation,  and  the  mus- 
cles that  are  still  normal  in  size  have  a  curious  wooden-like 
consistency.  The  patient  has  evidences  of  senility,  that  is- 
to  say,  there  is  an  arcus  senilis,  and  he  has  suffered  from; 
presbyopia  for  several  years.     [J.  S.] 


878 


The  Tbiladblpbia"! 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[May   4.    lU"Jl 


EDINBURG   MEDICAL  JOURNAL. 

March,   I'Ml.     [Vol.     LI.,   No.   549.] 

1.  Psj-choses  following  Pelvic-Abdominal  Operations.     J 

HALLIDAY  CROOM. 

2.  On  the  Formation   of  Crystals.   Dendrites,   and   Spiral 

Structures,  in  relation  to  Growth  and  Movement,  es- 
pecially Rhvthmic  Movements.  J.  PETTIGREW 
BELL. 

3.  On   the  Prognosis  of  Acute  Disease.     R.   KINGSTON 

FOX. 

4.  Some  Recent  Researches  on  Alcohol;  their  Bearing  on 

Treatment.     .T.  MACKIE  WHYTE. 

5.  Pernicious  Anemia — With  an  Analysis  of  Eighty-seven 

published  Cases,  and  an  Inquiry  into  the  After-His 
tory  of  Twenti'-two  reported  Cures.  HORACE  C. 
COLMAN. 

1- — Croom  reports  several  cases  in  which  mental  dis- 
turbancesoccurredaftergynecologicoperations,  which  were 
uncomplicated  and  simple,  and  in  which  the  operation  pc,' 
■se  was  entirely  successful.  In  another  group  of  casets 
anajor  operations  were  performed.  The  cases  developed  in 
women  who,  so  far  as  could  be  traced,  had  no  hereditary 
tendency  ta  insanity.  Undoubtedly  the  first  factor  in  thy 
jjroduction  of  post  operative  insanity  is  heredity;  the  sec- 
ond, is  sepsis;  and  the  third  group  of  causes,  such  as  loss 
of  blood  and  defective  action  of  the  kidneys.  It  seems 
probable  that  the  essential  prerequisite  for  the  develop- 
ment of  postoperative  insanity  must  be  a  neurotic  organi- 
zation predisposed,  either  from  hereditary  taint  or  acquired 
nexvous  weakness  and  instability,  to  take  on  diseased  or 
perverted  action  in  consequence  of  any  disturbing  influ- 
ence. Under  no  circumstances  ought  any  insane  woman  to 
be  operated  upon  unless  for  some  distinct  condition  that 
.  is  compromising  life.     [.J.  M.  S.] 

3. — ^A  benign  acute  disease  is  one  in  which  the  natural  ten- 
dency is  towards  recovery  and  in  which  our  efforts  are 
directed  to  keep  the  patient  alive  until  the  disease  ha.s 
subsided.  In  such  cases  the  nutritive  condition  and  the 
state  of  the  blood  and  the  tissues  are  the  really  dominant 
factors  in  the  maintenance  of  life.  On  the  other  hand, 
there  are  cases  of  acute  disease  that  do  badly  from  the 
outset  and  progress  steadily  until  lite  is  destroyed.  Arf 
simple  examples  of  this  class,  we  may  take  acute  tubercu- 
losis and  the  acute  form  of  ulcerative  endocarditis.  Such 
acute  diseases  are  malignant  by  their  very  nature.  There 
are  other  disorders  which,  although  benign  in  some  sub- 
jects, are  malignant  in  others,  such  as  erysipelas  in  the 
old  and  feeble  and  acute  catarrhal  pneumonia  in  debilitated 
persons.  The  diagnosis  between  the  benign  and  the  ma- 
lignant forms  of  the  same  acute  disease  is  then  of  great 
importance.  The  malignancy  may  depend  in  some  caeee 
upon  the  varying  virulence  of  an  infective  disorder  in  dif- 
ferent outbreaks,  such  a  disease  as  scarlatina,  or  even 
measles  appearing  sometimes  in  a  severe  form,  and  proving 
fatal  to  the  healthy.  But  more  commonly  in  the  case  of  an 
ordinarily  benign  disorder,  the  malignancy  is  due  to  bad 
reaction  on  the  part  of  the  subject.  .-V  true  diagnosis  is 
the  first  condition  of  prognosis.  Inheritance  has  much  bear- 
ing on  prognosis.  Some  families  show  a  poor  vitality,  and 
■when  an  epidemic  disease  attacks  the  children,  they  die 
off  rapidly.  In  other  stocks  the  physique  may  be  far  from 
robust,  and  yet  the  members  are  tough  and  pull  through 
illness  successfully.  The  history  of  the  patient  has  an 
obvious  bearing,  for  example,  alcoholism  hinders  recovery 
from  every  kind  of  acute  disorder.  Other  factors  that 
Fox  considers  as  having  a  bearing  on  prognosis  are.  gen- 
eral physique  and  habits,  temperament,  the  condition  of 
the  circulatory  organs,  the  respirator^'  organs,  the  digeet- 
ive  organs,  the  skin  and  the  kidneys.     [J.  M.  S.] 

4. — Whyte  believes  that  recent  researches  show  that  the 
stimulant  effect  of  alcohol  on  the  brain,  the  heart,  and  the 
KnoBCles.  if  existing  at  all,  is  very  brief,  lasting  probably 
only  a  few  minutes.  The  apparent  effect  of  the  drug  in 
stimulating  respiration  needs  further  investigation  as  to 
its  mode  of  causation.  On  the  tissues,  alcohol  acts  as  a 
protoplasmic  poison,  and  this  must  be  borne  in  mind  if  we 
are  to  use  alcohol  for  Its  nutritive  value.  Clinical  observa- 
tion has  been,  on  the  whole,  moving  along  parallel  lines 
with  the  researches  in  the  laboratory,  and  there  has  been  a 
marked  tendency  in  recent  years  to  restrict  the  administra- 
tion of  alcohol  as  a  medicine.  As  regards  the  whole  class 
of  diseases  of  the  nervous  system,  there  are  few  who  would 


expect  any  benefit  from  alcohol  except  of  a  sedative  or  nar- 
cotic character.  The  great  mixed  maes  of  mental  diseases, 
as  found  in  asylums,  are  best  treated  without  alcohol,  what- 
ever the  cause  or  nature  of  the  case,  in  some  cases  of 
simple  dyspepsia  a  little  alcohol  with  a  meal,  well  dUuted, 
is  found  to  give  relief  often,  no  doubt,  through  its  sesdative 
action  on  the  nerves  or  it  may  be  by  increasing  the 
secretion  of  gastric  juice  and  thus  aiding  digestion.  Other 
gastric  conditions,  such  as  catarrh  and  ulcers,  as  well  ae 
all  intestinal  disorders,  are  better  treated  without  alcohoL 
Liver  disorders  are  probably  in  all  cases  prejudicially  in- 
fluenced by  alcoholic  beverages.  In  kidney  diseases  of  al! 
kinds  alcohol  should  be  rigidly  withheld.  In  no  class  of  dis- 
eases is  alcohol  more  generally  considered  indispensible 
that  in  septic  cases,  puerperal  fever  particularly  its  value 
is  questioned.  Alcohol  is  recommended  in  croupous  pneumon- 
ia as  a  food  and  as  a  stimulant  The  brief  stimulating  effect 
of  alcohol,  such  as  it  is.  is  to  to  be  measured  by  about  15  min- 
utes, after  which  comes  a  prolonged  period  of  depression. 
The  food  value  of  alcoholfin  pneumonia  need  hardly  be  taken 
into  account  These  facts  should  give  pause  to  the  employ- 
ment of  alcohol  in  this  disease.  The  complication  of  pneu- 
monia with  inebriety  is  very  grave,  and  it  has  been  a 
widely  accepted  dictum  that  alcohol  must  be  given  in  such 
cases;  but  it  has  been  proved  best  in  cases  of  delirium 
tremens  or  habitual  alcoholism  to  stop  the  alcohol  at  once 
and  completely,  therefore  why  should  it  be  contiued  where 
an  infectious  disease  is  engrafted  on  an  intoxication. 
[J.  M.  S.] 
5. — Will  be  abstracted  when  concluded. 


BRITISH  GYNECOLOGICAL  JOURNAL 

Fehfuary,  1901. 

Inflammation    of   the    Fallopian    Tubes. 

E.  STANMORE  BISHOP. 

1. — Bishop  gives  a  comprehensive  paper  on  inflamma- 
tion of  the  Fatlopion  tubes  with  illustrative  cases.  He  re 
marks  that  ever  since  it  became  possible  to  diagnose  sal- 
pingitis as  distinct  from  inflammations  of  the  pelvic  con- 
nective tissue  it  has  been  recognized  that  in  certain  cases 
suppuration  occurs;  that  the  pus  thus  formed  distended 
the  closed  tube;  and  that  the  tube  thus  became  converted 
into  an  abscess-sac  of  which  the  ovary  might  or  might  not 
be  a  part,  the  presence  of  which  was  a  continuous  menace 
to  the  life  of  the  patient.  For  the  removal  of  this  pus- 
cavity  operators  have  been  divided  as  to  which  operation  is 
the  best,  the  vaginal  or  the  abdominal.  Those  in  favor  of 
the  vaginal  route  claim  that  the  tube  tends  to  sag  downward 
from  its  own  weight  into  Douglas'  pouch,  and  can  most 
easily  be  reached  by  a  posterior  kolpotomy.  An  open'ng 
thus  made  gives  vent  to  the  purulent  accumulation  and  per- 
mits of  its  free  escape  without  interfering  with  the  contents 
of  the  abdominal  cavity.  Bishop,  however,  claims  that 
various  improvements  in  the  abdominal  operation  have  ren- 
dered that  the  operation  of  choice.  Especially  is  this  true  of 
the  Trendelenberg  position.  The  increased  view  of  th'.- 
field  enables  the  operator  to  proceed  more  cautiously  and 
more  correctly.  Also,  the  doing  away  with  the  drainage- 
tube  has_removed  the  mostpotent  cause  of  subsequent  voitral 
hernia.  His  illustrative  cases  are  of  the  severe  type,  and 
show  the  conditions  for  which  the  surgeons  should  be  pre- 
pared who  propose  to  attack  a  case  of  pyosalpin  by  the 
abdominal  route.     [W.  A.  N.  D.] 


ARCHIV.  FUER  EXPER.  PATH.  UNO  PHARM. 
[Band   XLV.,   Heft  3  und  4.] 

1.  Investigations    concerning    Nuclein    Metabolism.      By 

LOEWI. 

2.  Concerning  Compensation  in  Mitral  Lesions.    By  GEIR- 

HARDT. 

3.  Concerning  Diuresis.     Third  Communication  Concern- 

ing the  Relations  Between   Plethora  and  Diuresis. 
By  MAGNUS. 

4.  Concerning    Diuresis.      Fourth    Communication — Con- 

cerning the  Relations  Between  the  Renal  Circulation 
and  Diuresis.    By  GOTTLIEB  and  MAGNUS. 

5.  Concerning  Diuresis.     Fifth  Communication.     The  Re- 

lation Between  the  Ureteral  Pressure  and  Diuresis. 
By  GOTTLIEB  and  MAGNUS. 

6.  The  Behavior  of  Theobromin  in  the  Organism  of  Man. 

By  KRUGER  and  SCHMIDT. 


I'.llll  1 


THE  LATEST  LITERATURE 


CTlIK    I'llU,/ 


ADKI.I  IDA 

lurilNAI. 


879 


7.  A    Case    of    Protozoan    (Coccidian?)      Disease   of   the 

liues.ine.     By  GRITNNO. 

8.  Investigations  Concerning  the  Depressing  Effects  upon 

tlie  Temperature  of  some  Convulsive  Poisons.  By 
HARNAUK.  assisted  by  H.  DANNER  and  J. 
STARKE. 

1. — Tjoewi  presents  a  series  of  investigations  concerning 
nuclein  metabolism.  His  eonclasions  are  that  tlie  nuoleins 
of  the  food  are  partly  broken  up  in  the  intestine,  the  plios 
phone  acid  of  the  separated  portion  being  excreted  in  the 
feces  while  the  nitrogenous  portion  is  absorbed.  The  major 
portion  of  the  nuclein  is,  however,  absorbed  in  toto,  the 
jihosphoric  acid  remaining  in  organic  combination.  It  is 
possible  by  feeding  nucleins  to  cause  a  nitrogen  and  phos 
phoric  acid  retention  in  the  same  ratio  in  which  these  sub- 
stances are  contained  in  the  ingested  nucleins.  The  addi- 
tion of  nucleins  to  the  food,  under  some  circumstances, 
increased  the  retention  of  nitrogenous  substances  and  also 
of  phosphoric  acid.  With  the  exception  of  uric  acid  no 
specific  nitrogenous  or  phosphorous-containing  end  pro- 
ducts of  nuclein  destruction  appear  in  the  human  urine  in 
recognizable  amounts.  The  ingestion  of  guanin.  combined 
with  nuclein.  results  in  marked  increase  of  the  uric  acid 
excretion.  The  uric  acid  excretion  is  normally  purely  de- 
pendent upon  the  food  taken.  The  observation  concerning 
the  influence  of  nucleins  in  causing  a  nitrogen  and  phos- 
phoric acid  retention  is  a  very  notable  one,  and  one  that 
is  very  difficult  to  explain.  It  is  an  observation  that  is 
supported,  however,  Ijy  the  work  of  other  observers  re- 
ferred to,  the  only  contrary  results  being  found  in  the 
■work  by  Milroy  and  Malcolm,  who  found  a  loss  of  nitrogen 
and  of  PO.  The  preparation  they  used  was,  however, 
probably  toxic  in  its  effect,  and  the  condition  was  there- 
fore not  caused  by  the  nuclein  itself.  The  statement  that 
uric  acid  is  the  only  end  product  of  nuclein  disintegration 
found  in  the  urine  is  based  upon  coincident  observations 
of  the  nitrogen,  uric  acid,  and  P  O.  excredon.  There  were 
no  determinations  of  the  amount  of  xanthin  bases,  and  It 
is  quite  possible  that  these  bases  may  have  been  present 
in  considerably  larger  amounts  than  normal.  The  final 
conclusion  that  the  uric  acid  excretion  is  normally  depend- 
ent purely  upon  the  food  is  in  direct  opposition  to  the 
recent  statement  of  Burian  and  Schur,  who  insist  that  there 
are  in  normal  persons  decided  differences  in  the  amount  of 
uric  acid  excreted:  that  there  is,  in  other  words,  an  indi- 
vidual disposition  observable  in  relation  to  the  uric  acid 
e.Ncretion.  Loewi  criticises  the  statements  made  by  Burian 
and  Schur,  which  are  certainly  contradictory  in  many  par 
ticulars,  and  are  rather  strongly  fenced  about  with  con- 
ditions. Loewi's  own  statement  is  based  upon  his  obser- 
vation of  three  persons  who  were  excreting  practically  the 
same  amount  of  nitrogen  and  the  same  amount  of  PO. 
The  uric  acid  in  these  persons  was  directly  proportionate 
to  the  nitrogen  ingestion.  He  insists,  therefore,  that  if 
normal  persons  are  put  imder  exactly  the  same  conditions 
of  metabolism,  the  excretion  of  uric  acid  will  be  practically 
exactly  the  same  in  all  normal  individuals.     [D.  L.  E.] 

2. — Gerhardt's  article  refers  to  the  question  whether  in 
cases  of  mitral  lesion  the  enlargement  of  the  right  heart  is 
really  a  compensatory  change,  or  whether  it  is  purely  a 
result  of  the  extra  work  thrown  upon  the  right  heart. 
Basch  and  his  students  claim  that  the  right  heart  does  not 
compensate  for  the  mitral  lesion,  but  that  it  merely  hyper- 
trophies in  order  to  carry  out  properly  the  extra  work 
which  has  been  thrown  upon  it  and  to  keep  from  failing  in 
its  own  work.  The  three  questions  which  Gerhardt  at 
tempts  to  answer  in  this  connection  are:  First,  Whether, 
as  Basch  states,  swelling  and  rigidity  of  the  lungs  consti- 
tute the  chief  unfavorable  results  of  the  mitral  lesion  or 
whether  the  most  important  unfavorable  influence  is  really 
imperfect  flow  of  blood  into  the  left  ventricle:  second.  What 
monns  are  theire  for  increasing  the  flow  of  blood  into  the  left 
ventricle:  third,  can  increased  labor  on  the  part  of  the  right 
ventricle  actually  increase  to  the  normal  point  the  blood 
pressure  in  the  larger  circulation,  which  in  mitral  cases  is 
below  the  normal,  Gerhardt  has  carried  out  experiments 
which  he  details  at  length,  and  which  convince  him  that 
whi'e  there  is  some  actual  reduction  of  the  amount  of  air 
Inspired  when  the  pulmonary  vessels  are  over-full,  this  Is 
so  slight  that  it  is  by  no  means  sufflcient  to  explain  the 
severe  respiratorv  disturbance  which  is  seen  In  casfw  of 
mitral  disease.  The  real  cause  of  the  disturbance  of  ros- 
piratlon,  and  of  the  other  main  symptoms  In  mitral  lesions, 
he  thinks  must  be  considered   to  be  imperfect  supply  of 


blood  to  the  various  organs.  Compensation  of  the  mitral 
lesions  would  therefore  be  furnished  if  the  disturbance  of 
ihe  l;loo(i  flow  through  the  mitral  orifice  were  in  any  way 
improved.  The  only  way  in  which  the  blood  flow  could  be 
improved  would  bo  through  increasing  the  pressure  in 
the  auricle  as  compared  with  that  in  the  ventricle.  Ger- 
hardt thought  that  it  was  possible  that  the  suction  action 
in  the  left  ventricle  was  sufficiently  increased  in  cases  of 
mitral  stenosis  to  succeed  in  some  degree  in  compensating 
for  the  lesion.  Were  this  tne  case,  one  would  expect  some 
degree  of  hypertrophy  of  the  left  ventricle,  even  in  pure 
mitral  stenosis.  This  he  was  unable  to  show.  It  is  \vell 
known,  however,  that  the  auricle  itself  does  hypertrophy, 
and  this  furnishes  some  compensation;  it  is  only  an 
Imperfect  compensation,  however,  particularly  in  stenosis 
with  regurgitation,  and  the  auricle  soon  fails  in  carrying 

out  the  work  put  upon  it.  He  reports  another  series  of 
experiments  in  which  he  largely  increased  the  pressure 
on  the  right  side  of  the  heart,  and  consequently  in  the 
pulmonary  vessels,  and  determined  the  pressure  in  the 
larger  circulation  (in  the  carotid).  He  found  that  the 
carotid  pressure  could  be  distinctly  increased  by  increasing 
tlie  work  of  the  right  ventricle,  though  the  increase  in  the 
carotid  pressure  was  much  less  than  the  increase  in  the 
pressure  of  the  pulmonary  arteries;  he  decides  that  in- 
creased work  on  the  part  of  the  right  ventricle  can  to  some 
extent  compensate  for  a  mitral  stenosis,  and  he  believes 
that  the  hypertrophy  of  the  riglit  ventricle  seen  In  the.se 
cases  is  a  real  phenomenon  of  compensation.  Another  way, 
and  this  is  evidently  purposeful,  in  which  the  flo'A" 
of  blood  through  the  mitral  orifice  is  made  more  com- 
plete, is  by  slowing  the  heart  beats.  One  may 
frequently  observe  in  mitral  stenosis  that  the  pulse  is 
unusually  slow.  As  a  general  conclusion,  he  states 
in  which  the  flow  of  blood  througli  the  mitral  orifice  is 
made  more  complete,  is  by  slowing  the  heart  beats.  One 
may  frequently  observe  in  mitral  stenosis  that  the  pulse  is 
evidently  purposeful.  As  a  general  conclusion,  he  states 
that  one  may  consider  the  changes  seen  in  the  right  ven- 
tricle to  be  actual  compensatory  changes,  and  although 
there  are  certain  unfortunate  collateral  results  connected 
with  these  compensatory  changes,  he  does  not  believe  that 
the  most  important  alterations  seen  in  mitral  lesions  are 
swelling  and  rigidity  of  the  lungs,  and  the  consequent  in- 
terference with  respiration.  The  changes  in  the  lungs  are 
rather  due  to  changes  in  the  vessel  walls  resulting  from  the 
constant  high  pressure  in  these  vessels.     ID.  L.  E.] 

3. — Magnus  refers  to  the  work  that  has  already  been 
done,  particularly  by  Starling.  The  latter  author  attributes 
the  diuresis  seen  after  mjection  of  salt  solutions  to  the 
plethora  supposed  to  be  produced  by  these  injections. 
Magnus  believes,  on  the  contrary,  that  his  experiments 
do  not  justify  this  conclusion,  and  that  the  diuresis  is  rather 
due  to  a  change  in  the  constitution  of  blood  after  the  injec- 
tion: that  the  diuresis  is  due,  in  other  words,  not  really  to  the 
injection  of  fluid,  but  to  the  amount  of  salts  introduced  into 
the  blood.  In  order  to  study  this  question  further  he  made 
transfusions  of  blood  itself,  of  the  same  species,  without 
defibrinating.  He  found  that  transfusing  from  33  per  cent, 
to  70  per  cent,  of  the  entire  quantity  of  blood  contained  in 
one  dog  into  another,  resulted  in  no  serious  symptoms. 
Urine  was  excreted  in  just  about  the  same  amount  after 
the  transfusion  as  before;  in  only  one  instance  was  there 
any  notable  increase  in  the  urine.  Hence  he  decides 
that  transfusion  causes  either  no  increase  in  the  urine  or 
an  extremely  slight  increase  that  is  not  w'orthy  of  any  atten- 
tion. He  then  raises  the  question  as  to  whether  there 
was  really  an  increase  in  the  total  quantity  of  blood  after 
the  transfusion,  or  whether  a  good  deal  of  the  fluid  passed 
into  the  tissues.  He  answers  this  question  by  reporting 
hemoglobin  estimations  which  he  made  before  and  after 
transfusion.  The  total  amount  of  blood  in  the  animal 
was  taken  to  be  7  per  cent,  of  the  body  weight,  and  reckon- 
ing the  total  amount  of  blood  before  and  after  the  trans- 
fusion, and  taking  the  hemoglobin  contained  in  the  blood 
before  and  after,  he  decided  that  there  was  a  decided  In- 
crease in  the  amount  of  blood,  though  this  was  not  fully 
equal  to  the  quantity  injected.  The  increase  in  the  amount 
of     blood      varied;      the     smallest     increase      was     from 

100  up  to  117.  the  largest  from  100  up  to  195. 
He  believes,  however,  that  the  tables  presented 
show  that  there  was  an  actual  increase  in  the 
amount  of  blood,  in  other  words,  a  plethora,  and 
that  this  did  not  increase  the  excretion  from  the  kidneys. 
He  believes  that  the  explanation  of  the  apparent  passage 


QCn       The  Pbu-adelpbia  " 
""^         MEDiciL  Journal  . 


THE  LATEST  LITERATURE 


[Mat    4.    1901 


of  a  portion  of  the  fluid  into  the  tissues  must  be  found  in 
filtration.  The  blood  was  the  same  as  that  of  the  animal 
injected,  and  diffusion  or  osmosis  can  therefore  not  be 
made  answerable  for  the  phenomenon.  There  is  no  reason 
for  considering  that  there  is  any  such  thing  as  an  increased 
secretory  power  of  the  capillary  cells,  consequently  filtra- 
tion is  the  only  explanation.  It  was  remarkable  how 
rapidly  this  filtration  took  place.  The  effect  of  the  trans- 
fusion" was  to  raise  the  blood  pressure  greatly,  the  arterial 
pressure  going  from  100  to  1-50.  and  the  venous  pressure 
showing  as  marked  a  change  as  from  60  to  160  within  10 
minutes.  The  question  as  to  whether  the  capillary  pressure 
in  the  kidneys  was  raised  in  this  general  increase  of 
pressure  was  Investigated  by  means  of  the  onkometer. 
There  was  a  distinct  increase  in  the  volume  of  the  kidneys 
which  gradually  increased  to  the  normal.  This  does  not 
demonstrate  definitely,  however,  that  there  was  an  increase 
in  the  capillary  pressure,  but  it  does  demonstrate  a  general 
increase  of  pressure,  and  shows  that  there  is  no  vaso-con- 
striction  of  the  kidneys  in  transfusion.  To  demonstrate 
that  change  in  the  composition  of  the  blood  will  cause 
increased  diuresis  after  injections  of  salt  solutions,  animals 
were  given  first  an  injection,  a  solution  of  Glauber's  salts, 
and  directly  afterward  a  transfusion  of  blood.  In  these  cases 
there  was  a  marked  increase  in  the  urine  excretion.  The  gen- 
eralconclusions  reached  werethat  transfusion.without  char;;; 
Ing  the  constitution  of  the  blood,  causes  a  marked  plethora 
with  increase  of  the  arterial,  venous  and  capillary  pres 
sure,  and  in  the  general  volume  of  the  kidneys.  This  is  as- 
sociated with  the  passage  of  fluid  into  the  tissues,  but  not 
■nith  diuresis:  while  with  a  change  in  the  character  of  the 
blood  diuresis  follows.  Plethora  cannot  be  consid- 
ered to  be  the  cause  of  the  diuresis  after  injection  of  salt 
solution:  the  diuresis  is  rather  due  to  change  in  the  con- 
stitution of  the  blood.     [D.  L.  E.] 

4. — Gottlieb  andMagnusconeludethat  in  some  cases  there 
is  no  very  marked  parallelism  between  diuresis  and 
changes  in  the  kidney  circulation.  This  is  chiefly  seen 
when  the  diuretic  acts  rapidly  and  temporarily,  while  if  the 
action  be  prolonged  or  frequently  repeated,  this  relation 
between  circulatory  changes  and  diuresis  is  not  observed. 
Diuresis  may  occur  without  any  increase  in  the  blood  flow. 
In  some  animals  after  a  single  dose  of  the  diuretic  the 
excretion  of  urine  and  the  amount  of  blood  flowing  through 
the  kidney  were  not  parallel.  This  was  chiefly  the  caso 
in  chloralizt!d  animals,  and  was  perhaps  due  to  the  influ 
ence  of  the  chloral.  They  observed,  on  the  contrary,  that 
increased  readings  of  the  onkometer  were  seen  without 
a  coincident  diuresis.  They  therefore  conclude  that  there 
are  very  complicated  relations  between  the  activity  of  the 
kidneys  and  the  circulation  through  these  organs,  and  that 
their  espeiiments  do  not  allow  them  to  conclude  that 
there  is  any  casual  relation  of  increased  circulation  to 
increased  diuresis,  and  the  changes  in  the  circulation  can- 
not be  considered  to  be  primum  movens  for  the  dii;- 
resis.  The  conclusion,  which  they  believe  is  justified,  is 
that  rapid  circulation  through  the  kidneys  is  as  a  rule 
an  accompaniment  of  active  functionation  of  these  organs, 
and  a  free  circulation  is  usually  associated  with  free 
diuresis,  but  a  large  amount  of  blood  in  the  kidneys  does 
not  always  mean  a  very  marked  actirity  of  these  organs. 
They  conclude  that  the  diuretic  effect  of  caSein  is  due  to 
the  influence  of  this  dru.g  upon  the  secreting  apparatus  of 
the  kidney,  and  not  due  to  its  influence  upon  the  circulation 
and  the  kidney.  Finally,  they  state  that  the  cause  of  diuresis 
is  really  in  the  first  place  in  the  increase  of  one  or  more  of 
the  blood  components  above  a  certain  point.  This  occur- 
rence results  in  the  active  secretion  by  the  kidneys  of  the 
excess,  and  this  is  accompanied  by  the  excretion  of  con- 
siderable portion  of  water  carrying  these  portions  in  solu- 
tion. They  think  that  it  is  possible  that  the  diuresis  in  such 
instances  occurs  merely  passively  without  any  special  cell 
action,  and  that  the  kidneys  really  act  as  a  filter  which 
works  only  when  the  concentration  of  the  blood  goes  above 
a  certain  point.  This  is.  however,  very  improbable.  It  is 
much  more  probable  that  there  is  a  marked  selective 
activity  of  the  kidney  cells,  which  is  greatly  increased  in 
normal  subjects  by  any  increase  in  the  blood  concentra- 
tion,   D.  L.  E.] 

5.  After  detailing  their  experiments,  the  authors  discuss 
their  results,  and  state  that  during  diuresis  there  is  very 
frequently  to  be  observed  a  decided  increase  in  the  ure- 
teral pressure  and  this  is  certainly  due  to  the  diuresis 
when  it  occurs,  but  exactly  in  what  way  it  is  caused  is  not 


clear.  The  fact  that  increase  of  the  ureteral  pressure  does 
not  occur  regularly  with  diuresis  indicates  that  there  are 
complicated  relations  between  the  two.  It  is  certainly  not 
due  directly  to  changes  in  the  blood  pressure.  It  Is  more 
probably  dependent  upon  the  excretory  activity  of  the  kid- 
upys  and  the  suction  filtering  action  of  the  organ,  and 
therefore  dependent  upon  two  variable  factors.  They 
think  it  is  very  probable  that  there  is  a  relation  betweoD 
pressure  in  the  ureters  and  the  activity  of  the  secretory 
elements  of  the  kidneys.     [D.  L.  E.] 

6, — The  authors  refer  to  the  fact  that  3-methylxanthin 
has  not  previously  been  found  in  human  urine  .even  when 
Krueger  and  Salomon  determined  the  lanthin  bases  prea- 
rnt  in  10.000  liters  of  urine.  Hence  they  decided  that 
theobromin  did  not  produce  3-methylxanthin  in  man  as  it 
does  in  animals,  or  that  in  the  hospitals  from  wliich  the 
10.000  liters  of  urine  were  obtained  the  patients  were  receiv 
ing  food  that  either  contained  no  theobromin,  or  contained 
so  little  that  it  had  no  influence  upon  the  constitution  of 
the  xanthln  bases  found.  The  investigations  reported  here 
showed,  however,  that  after  taking  9.3  grams  of  theobromin. 
1.313  grams  of  heteroxanthinwereobtained.and  0.796  grams 
of  3-methylxanthin:  in  other  words,  that  theobromin  in 
man  furnishes  for  each  100  parts  about  S.56  grams » of 
3-methylxanthin,  and  probably  even  more:  hence  the  human 
organism  behaves  in  the  same  way  toward  theobromin  as 
do  the  organisms  of  lower  animals.     [D.  L.  E.] 

7. — The  case  reported  was  that  of  a  man  of  61  who  had 
emphysema,  bnmchilis,  arteriosclerosis,  with  diarrheal 
attacks  and  associated  with  marked  distension  of  the  ab- 
domen, but  unassociated  with  either  tenesmus  or  the  pas- 
sage of  mucus  and  blood.  Microscopic  examination  showed 
great  numbers  of  coccidia-like  bodies.  The  patient's  condi- 
tion was  somewhat  improved  by  giving  him  yeast,  but  he 
was  made  worse  by  calomel  Xo  further  special  medication 
was  undertaken  in  connection  with  his  intestinal  trouble,  as 
his  general  condition  would  not  allow  of  active  intervention. 
Death  soon  occurred.  The  post  mortem  showed  some  in- 
jection of  the  mucous  membrane  of  the  intestine  with 
occasional  ecchymoses,  and  slight  swelling  of  some  of  th€ 
follicles.  The  patient  died  of  edema  of  the  brain  and 
encephalomalacia.  The  bodies  described  are  very  attract 
ively  picttired  in  an  accompanying  illustration.  They  were 
usually  from  fi  to  8  micrometers  in  diameter,  the  largest  be- 
ing 12  or  13  micrometers  in  diameter.  There  was  a  slightly 
greenish  shining  homogeneous  body  with  a  delicatecapsule: 
the  body  was  round,  and  occasionally  seemed  vacuolated. 
Some  of  the  bodies  showed  nuclei  and  some  did  not.  Oc- 
casionally two  nuclei  could  be  seen.  .-Vt  times  there  were 
two  bright  points  seen  on  the  periphery  diametrically  oppo- 
site to  each  other.  These  strongly  resembled  the  polar 
bodies  seen  in  kairokinesis.  Lugol's  solution  had  no 
effect  and  the  bodies  took  stains  in  general,  badly.  Methy- 
ene  blue  gave  a  poor  stain,  but  a  much  better  stain  was 
obtained  with  carholfucsin.  Hematoxylin  gave  imperfect 
results.  Sections  from  the  intestine  showed  the  bodies 
to  be  present  in  the  lumen  and  in  the  mucosa,  but  only  near 
the  surface  of  the  latter.  The  bodies  seemed  to  be 
coccidia.  but  this  could  not  be  definitely  determined.  They 
were  thought  to  be  most  probably,  however,  coccidia  bl- 
gemina  because  of  their  general  appearance  and  the 
position  in  which  they  were  found.  Their  pathogenicity 
was  doubtful,  but  it  was  thought  that  they  were  pathogenic 
because  of  the  fact  that  some  histolo.gical  changes  were 
nearly  always  found  in  the  areas  where  they  were  present 
in  considerable  numbers.  This  chiefly  consisted  in  loss 
of  epithelium,  hyperemia,  hemorrhages,  jnd  frequently 
riarked  infiltration  with  leukoc>-tes.     fP-  L-  E.l 

8. — Hamack  contributes  an  extensive  report  that  is  of 
general  interest  only  in  its  conclusions.  He  decides  that 
santonin  reduces  the  rectal  temperature  throutih  increasing 
the  heat  loss,  and  that  the  l.itter  is  due  to  dilatation  of  the 
peripheral  vessels.  The  alteration  of  the  vessels  is  con- 
stant, and  coincides  with  the  depression  of  temperature. 
The  fall  of  temnerature  does  not  occur  if  increase  of  the 
heat  loss  is  mide  impossible  in  the  themtostat.  It  also  does 
not  occur  if  the  vasodilating  effect  of  santonin  is  antidotM 
Vy  coincident  use  of  cocain.  The  influence  of  santonin 
is  more  complicated  when  doses  are  given  of  such  a  size 
that  they  produce  convulsions,  as  in  such  cases  much  more 
heat  is  produced.  The  result  then  depends  upon  individual 
factors,  such  as  age,  size,  and  the  species  of  animal.  In 
youni;  or  small  animals,  in  spite  of  nrotracted  convulsions 
subnormal  temperature,  is  found  to  be  persistent  The  ef- 
fect of  santonin  is  much  more  dangerous  when  increased 


May   4,    I'.iOll 


THE  LATEST  LITERATURE 


CTHE    I'HILADEI.rillA  SSt 

Mt.1.1    AI,    JOIKNAL  ""'^ 


loss  of  heat  is  rendered  impossible  by  keeping  the  animal  in 
a  high  temperature.  It  therefore  seems  probable  that  the 
increased  heat  loss  is  a  method  of  protecting  the  organism 
against  the  effect  of  the  convulsive  poison.     [D.  L.  E.J 


DEUTCHES   ARCHIV.    FUER    KLINISCHE    MEDICIN. 

IhAcmhrr  ,.'/,  lOmi.     (\o\.  G9,  Heft  2). 

1.  Intermttent  Biliary  Fever.    PICK. 

2.  Gas-formation  in  the   Liver.     KiiRSCHENSTEINER. 

3.  The  Examination  of  Methylen  Blue.     ELSNER. 

4.  Clinical  Investigations  Upon  the  Circulatory  Organs  in 

The  Early  Stages  of  Syphilis.     GRASSMANN. 

5.  A  Case  of  Progressive  Muscular  Dystrophy  Complicated 

by  a  Neuritic  Affection  of  the  Serratus  Together  with 
a  Contribution  to  the  Analysis  of  the  Paralyses  of 
the  Shoulder,  according  to  the  Method  of  Mollier. 
KAUFMANN. 

6.  A  Case  of  Acne  Telangiectodes  (Kaposi).    JESIONEK. 

7.  Experimental    Studies   upon   Contusion   of  the  Breast. 

REIXEBOTH. 

8.  Experimental  Investigations  upon  the  Origin  of  Goutv 

Tophi.     STRUPPLER. 

1. — Pick  reports  the  following  cases.  The  first,  a  woman 
of  29,  who  had  been  sick  for  a  year  with  slight  jaundice,  had 
chills  followed  by  fever,  sometimes  with,  sometimes  with 
out  pains  in  the  abdomen,  and  appearing  at  regular  inter- 
vals. In  a  period  of  6  months  46  of  these  attacks  occurred. 
Subsequently  there  was  apparently  complete  obstruction 
of  the  bileducts,  ascites  and  death.  A  gallstone  was  found 
that  had  been  impacted  in  the  common  duct,  and  had 
broken  through  into  the  duodenum.  There  was  biliary 
cirrhosis  of  the  liver.  The  second  patient,  a  woman  of  53, 
had  an  attack  of  typhoid  fever  in  1892.  then  had  severe 
pains  in  the  abdomen  followed  by  the  passage  of  numer- 
ous facetted  gallstones.  The  liver  was  slightly  enlarged. 
and  at  intervals  of  2  or  3  days  she  had  attacks  of  chills  fol- 
lowed by  fever,  and  usually  accompanied  by  abdominal 
pain.  The  liver  was  enlarged,  and  there  was  slight  jaun- 
dice. SuiiseQuently  she  improved,  and  became  entirely  well. 
Careful  investigations  of  the  urea  in  this  case  showed  that 
during  these  attacks  it  was  diminished,  apparently  as  a  re- 
sult of  diminished  formation,  although  according  to  the 
present  status  of  the  ammonia  theory  this  could  not  be 
positively  proved,  because  neither  the  ammonia  nor  the 
total  nitrogen  was  diminished.  It  seems  therefore  reason- 
able to  conclude  that  the  products  of  the  albuminous  meta- 
bolism are  not  convoyed  to  the  liver  in  the  form  of  am- 
monia salts  but  in  some  other  form  which  cannot  be  ex- 
creted by  the  urine.  In  regard  to  the  diagnosis  of  inter- 
mittent biliary  fever  Pick  gives  the  following  points.  The 
regular  intermittent  fever:  the  prolonged  course:  the  ab- 
sence of  any  signs  of  acute  inflammation:  particularly  the 
absence  of  leukocytosis  during  the  attacks,  and  the  very 
marked  reduction  in  the  elimination  of  urea  in  the  urine, 
which  is  contrary  to  the  usual  marked  increase  during  feb- 
rile conditions.  The  prognosis  is  rendered  very  grave  by 
the  occurrence  of  this  form  of  fever,  but  not  hopeless.  The 
most  unfavorable  complication  is  the  development  of  biliary 
cirrhosis.     [J.  S.] 

2. — The  patient,  a  woman  of  74,  had  suffered  for  15 
years  with  pain  in  the  right  hypochondrium.  Neverthe- 
less she  had  remained  in  good  health.  One  morning  she 
awoke  with  nausea,  and  vomiting  of  blood.  This  was  re- 
peated; the  patient  rapidly  became  weak,  and  died  in  the 
course  of  the  day.  The  autopsy  was  made  32  hours  later, 
and  there  was  found  bilateral  lobular  pneumonia,  paren- 
chymatous nephritis,  hemorrhagic  and  biliary  cirrhosis  of 
the  liver,  and  marked  cystitis.  In  addition  the  liver  was 
spongy,  crepitated,  contained  numerous  fine  bubbles  of  gas 
and  showed  the  characteristic  changes  of  cirrhosis:  micro- 
scopical examinations  revealed  numerous  short  rod-shaped 
bacteria  that  upon  cultivation  proved  to  be  the  bacteria  coli 
communis,  proving  that  gas-formation  can  be  produced  by 
various  microorganisms,     [J.  S.] 

3. — Eisner  has  performed  a  very  elaborate  series  of  ex- 
periments in  order  to  determine  the  amount  of  methylen 
blue  that  is  excreted  from  the  body.  The  blue  was  ad- 
ministered and  then  the  amount  excreted  in  the  urine  and 
intestines  determined  by  coloro-metric  methods.  These 
are  necessarily  somewhat  inexact,  but  control  showed  that 
they  were  accurate  enough  to  determine  within  a  few  per 
cent.  In  4  cases  it  was  found  that  the  total  quantity  ex- 
creted averaged  about  68%  of  the  quantity  ingested.     The 


remaining  methylen  blue  is  probably  either  decomposed  by 
bacteria  or  retained  in  the  body.  This  is  particularly  likely 
to  be  the  case  if  there  is  any  dead  tissue  near,  as  for  ex- 
ample, in  a  case  of  general  amyloid  disease,  in  a  case  with 
gangrenous  ulcers,  and  a  very  low  per  cent,  of  excretion 
was  found  in  a  case  of  severe  gastrointestinal  atony  which 
improved  as  the  latter  was  benefited.     [,I.  S.] 

4. — Grassmann  in  continuation  of  his  article,  reports  2 
cases  in  which  pericardial  murmurs  appeared  in  the 
course  of  syphilis,  in  one,  heard  best  over  the  apex  and 
disappearing  when  the  patient  lay  down,  and  in  the  other, 
best  heard  over  the  pulmonic  area.  He  also  reports  96 
cases  in  which  there  was  alteration  in  the  outline  of  the 
heart.  In  79  of  these  there  was  dilation  of  the  right  ven- 
tricle: in  S.  dilation  of  the  left  ventricle:  and  in  9  cases, 
of  both  ventricles.  He  gives  the  histories  of  a  number  of 
these  cases.  In  many  of  them  symptoms  of  relative  mi- 
tral insufficiency  developed  in  the  course  of  the  disease.  In 
some  cases  these  are  possibly  due  to  the  alteration  that 
takes  place  in  the  blood  in  the  secondary  stage  of  syphilis. 
N'evertheless,  this  cannot  be  always  true,  because  in  some 
cases  in  which  relative  insufficiency  exists,  the  hemoglobin 
may  be  present  in  great  quantities,  or  only  slightly  re- 
duced. It  is  interesting  to  note  that  from  time  to  time 
the  outline  of  the  heart  may  change  considerably.  (The 
paper  is  still  unfinished.)     [J.  S.] 

5. — Kaufmann  reports  the  case  of  a  man  30  years  of  age, 
who  had  convulsions  at  the  age  of  3  years,  and  subse- 
quently suffered  from  a  slowly  progressive  paralj'sis.  There 
were  no  disturbances  of  sensation,  or  of  the  functions  of 
the  sphincters.  The  reflexes  persisted,  and  there  was  no 
degeneration  in  the  muscles,  but  greatly  diminished  re- 
sponse to  electric  stimulation,  and  indications  of  fibrillary 
contractions.  There  was  a  luetic  infection,  after  whicii 
the  right  arm  became  paralyzed:  there  was  tenderness 
along  the  surface,  and  slight  fever.  This  was  impi-oved  by 
anti-leuetic  treatment  but  not  completely  cured.  The  case 
therefore  presents  a  progressive  muscular  dystrophy  asso- 
ciated with  paralysis  of  the  serratus  muscle  as  a  result  of 
syphilitic  neuritis.  Kauffmann  has  undertaken  a 
series  of  exact  measurements  upon  this,  and  upon 
3  other  cases  according  to  the  method  of  Mol- 
lier, in  order  to  determine  the  various  combina- 
tions of  paralysis  that  occur  in  the  muscles  of  the 
shoulder  girdle.  It  is  impossible  to  go  into  the  details  of 
these,  but  the  results  show  paralysis  in  the  right  shoul- 
der, of  the  pectoralis,  of  the  rhomboidei  of  the  serratus, 
and  of  the  serratus  in  the  left  shoulder.  The  elevators  of 
the  clavicle  and  the  scapula,  and  the  upper  trapezius  were 
approximately  implicated  on  both  sides.  In  conclusion  he 
mentions  a  fifth  case  in  which  the  right  shoulder  was  very 
much  higher  than  the  left,  and  the  scapulae  occupied  a  cur- 
ious oblique  position.  Measurements  showed  that  this  was 
probably  due  to  paralysis  of  the  rhomboidei     [J.  S.] 

6. — Jesionek  reports  the  case  of  a  woman  56  years  of  age, 
who  developed  an  eruption  of  reddish  spots  upon  the  body 
associated  with  swelling  of  the  knees  and  ankles.  The 
joint  symptoms  rapidly  disappeared  but  the  eruption  re- 
mained in  the  form  of  pea-sized  spots  of  brownish  color 
slightly  depressed,  that  gradually  disappeared  to  be  re- 
placed by  a  new  group  in  the  course  of  5  or  6  weeks.  The 
spots  were  not  painful  nor  irritating  in  any  way.  The  fact 
that  they  appeared  on  the  face  caused  such  discomfort  of 
mind  that  she  could  not  sleep  and  rapidly  emaciated.  When 
examined  it  was  found  that  the  head,  neck  and  mucous 
membranes  of  the  throat  were  all  involved,  whilst  only 
some  old  spots,  indicating  a  previous  eruption,  could  be 
distinguished  below  the  waist.  Three  types  of  eruption 
were  detected,  the  first,  pea-  or  cherry-sized,  sharply  cir- 
cumscribed and  projecting  from  the  surface.  These  had 
a  brownish-red  color:  the  surface  was  glistening,  their 
consistency  was  somewhat  like  that  of  putty,  and  they  were 
slightly  translucent.  Another  type  were  flat  papular  brown- 
ish-red bodies,  round  or  oval:  these  were  somewhat  softer 
than  the  others,  and  also  .glistening.  Finally  there  was  a 
group  of  small  irregular  nodules  about  the  size  of  a  pin- 
head,  pink'  in  color,  slightly  projecting,  and  closely  resem- 
blin.g  the  eruption  of  acne.  Numerous  intermediary  forms 
were  also  observed.  Microscopically  these  bodies  showed 
a  tumor-like  infiltration  starting  from  the  middle  of  the 
corium  and  extending  into  the  center  of  the  bodes.  Most 
of  the  cells  apparently  resembled  lymphoid  cells,  other.s 
however,  were  large  and  oval  and  resembled  epithelioid 
cells.      Numerous    giant    cells    were    also    present.      How- 


882 


The  Philadelphia" 
SlEDiCAJL  Journal  . 


THE  LATEST  LITERATURE 


[Mat   4,    1901 


«ver,  nothing  resembling  tuberculous  growth  was  found. 
Treatment  consisted  in  the  careful  curettment  of  all  the 
■diseased  bodies,  and  then  touching  the  raw  surface  lightly 
with  the  actual  cautery.  Perfect  recovery  ensued  with 
very  small  scars.  The  case  evidently  resembled  acne 
telangiectodes  as  described  by  Kaposi,  and  apparently  rep 
resented  a  degenerative  process  of  the  epithelium  of  the 
hair-follicles.     [J-  S.] 

7. — Reineboth  has  performed  a  number  of  experiments  in 
order  to  determine  the  macroscopic  results  of  contusion  of 
the  lungs  and  pleura.  When  the  pleura  was  exposed  and 
bullets  of  various  weights  dropped  through  glass  tubes  5U 
ccm.  long,  it  was  found  that  even  if  weights  of  2  grams 
•were  employed  no  microscopic  effect  occurred  in  either 
the  lung  or  the  pleura,  proving  that  the  pulmonary  tissue 
is  not  very  vulnerable.  Similarly  it  was  impossible  by  strik- 
ing upon  the  pleximeter  laid  upon  the  exposed  ribs,  to 
produce  a  suggillation  of  the  pleura.  Weights  of  20  gram.- 
or  more  were  also  dropped  upon  the  exposed  thoracic  wall 
from  a  height  of  60  ccm..  It  was  found  that  suggillation 
rarely  occurred  if  the  first,  second,  or  third  ribs  were 
struck:  never  when  the  3rd  to  5th  ribs  were  struck,  and 
not  infrequently  when  the  5th  to  the  8th  rib  was  struck, 
proving  that  the  thin  edge  of  the  lung  was  more  vulnerable. 
When  a  hammer  was  used  it  was  found  that  suggillations 
could  be  produced  in  any  part  of  the  lung.  They  were  dif- 
fuse and  particularly  severe  in  the  lower  portions.  When 
the  movable  ribs  were  struck  it  required  considerable  force 
to  produce  the  suggillations.  When  the  blows  were  made 
upon  the  back  either  upon  or  near  the  spinal  column  sug- 
gillations were  sometimes  but  not  frequently  produced. 
These  occupied  the  apex  of  the  lung  and  sometimes  ex- 
tended along  the  course  of  the  ribs.  Contusion  of  the  lung 
could  not  be  produced  by  blows,  however  severe,  upon  the 
epigastrium,  and  the  effect  of  the  period  of  the  respiration 
rhythm  was  not  observed.  Reinel)oth  considers  that  the 
results  cannot  be  applied  directly  to  human  pathology,  but 
liopes  that  they  will  stimulate  more  careful  observations 
of  the  results  of  contusion  in  man.     [J.  S.] 

8. — Freudweiler  has  performed  an  elaborate  series  of  ex 
periments  in  continuation  of  those  abstracted  for  the 
Phila.  Medical  Journal  from  the  previous  number  of  the 
Archives.  In  that  paper  he  studied  particularly  the  histol- 
ogy of  artificial  tophi  produced  by  the  injection  of  blurate 
of  sodium  into  the  tissue.  A  number  of  questions  were, 
liowever.  raised  regarding  the  cause  of  spontaneous  tophi. 
Among  these  he  mentions  particularly  the  idea  that  they 
are  produced  by  some  local  alteration  in  the  tissue  that  is 
associated  with  general  defect  in  the  chemistry  of  the  bodv. 
This  local  effect  upon  the  tissue  may  be  produced  by  the 
trophic  influence  of  the  nervous  system,  and  this  influence 
upon  the  tissue  may  be  produced  by  an  action  upon  the 
central  nervous  system  of  the  defective  blood  (the  so-called 
neurogenic  theory),  or  the  local  alteration  may  be  produced 
t>y  local  congestions.  The  predisposing  causes  are  of 
course  the  familiar  ones  of  alteration  in  the  alkalinity  of 
the  body  juices.  Finally  the  local  alteration  may  be  pro- 
duced by  some  injury  or  disease  of  the  part,  or  gout  may  be 
an  infectious  process.  In  order  to  elucidate  these  points 
Freudweiler  has  performed  a  number  of  experiments  in 
which  he  has  attempted  to  saturate  the  body  juices  with 
uric  acid,  chiefly  by  the  ligation  of  both  ureters,  and  then 
to  promote  the  deposit  of  urates  by  local  injury,  or  by  al- 
terations of  the  chemical  reaction  of  the  tissues.  In  n. 
series  of  preliminary  experiments  he  found  that  the  tissues 
of  the  hen  do  not  react  as  vigorously  to  uric  acid  as  do 
those  of  the  rabbit.  He  also  experimented  with  the  xan 
thin  and  hypoanthin  bodies  and  found  that  they  were 
both  more  poisonous  than  uric  acid.  Various  of  the  pre- 
liminary bodies  formed  in  the  synthetic  production  in  uric 
acid,  particularly  ammonium  lactate  and  glycocol.  also  pro- 
duced considerable  local  irritation,  and  the  same  was  true 
of  hipuric  acid,  kreatine  and  kreatinine,  and  uric  acid. 
All  these  experiments  seem  to  prove  that  the  formation  of 
uric  acid  from  various  other  substances  was  not  possible, 
but  that  the  tophi  were  composed  of  uric  acid  deposited  as 
such.  Neither  uric  acid  nor  any  of  these  other  bodies  ap 
parently  were  capable  of  producing  an  additional  deposit, 
even  if  the  uric  acid  contents  of  the  blood  was  increased, 
and  the  same  was  true  of  increased  alkalinity,  or  local  ne- 
crosis caused  by  the  actual  cautery.  When,  however,  there 
is  a  great  excess  of  uric  acid  in  the  juice  it  was  found  that 
it  was  deposited  in  the  following  organs  named  in  the  order 
of  frequency:      The  pericardium,   the  pleura,   the   periton- 


eum, the  kidneys,  the  liver,  the  stomach,  the  heart,,  the 
fatty  tissue  of  the  abdomen,  and  the  muscles.  It  is  rarely 
deposited  in  the  joints  or  tendon  sheaths.  The  serous 
membranes  are  much  more  frequently  affected  than  the 
ethers,  and  usually  there  is  some  inflammatory  change  in 
the  neighborhood  of  this  infiltration.  It  seems  likely,  how- 
ever, that  acute  inflammatory  processes  have  a  tendency 
to  promote  a  deposit  of  uric  acid  crystals,  and  the  fact  that 
the  synovial  membrane  of  the  great  toe  is  commonly  in- 
jured in  these  days,  may  explain  the  greater  frequency 
with  which  this  place  is  affected  in  gouty  attacks.  Freud- 
weiler, however,  particularly  avoids  suggesting  any  new 
theories,  but  he  believes  as  a  result  of  his  experiments 
that  we  may  reasonably  assume  that  gout  is  a  constitu- 
ti(mal  disease  characterized  by  an  increase  in  the  uric  acid 
in  the  body  juices.  This  has  a  tendency  to  promote  the 
occurrence  of  local  infections,  and  when  these  occur  coin- 
cidently  with  the  maximum  proportion  of  uric  acid  in  the 
blood  there  is  a  local  deposit  of  crystals.  These  deposits 
relieve  the  tissues  for  awhile,  until  there  is  again  a  local 
infection  with  maximum  proportion  of  uric  acid.     [J.  S.] 

9. — Strupler  calls  attention  to  the  great  difficulty  of 
diagnosis  in  disease  of  the  pancreas  associated  with  septic 
processes.  He  reports  two  cases,  one  a  man  of  44,  who  waa 
brought  to  the  hospital  unconscious  with  the  history  that 
he  had  suffered  for  some  months  with  a  feeling  of  discom- 
fort in  the  abdomen  and  thorax  and  had  suddenly  fallen  un- 
conscious on  that  day.  There  was  bilateral  tuberculosis,  en- 
docarditis and  embolism  in  the  left  cerebral  hemi- 
sphere, there  was  some  distension  in  the  abdomen,  and  a 
trace  of  albumen  in  the  urine,  but  neither  blood  nor  sugar. 
He  died  6  days  after  admission.  In  addition  to  the  condi- 
tions recognized  clinically,  there  was  fat-necrosis  of  the 
pancreas.  In  another  case  the  patient,  a  very  obese  wo- 
man, had  suffered  for  25  years  with  pain  in  the  abdomen 
just  beneath  the  ribs.  She  was  slightly  edematous,  had 
extreme  tenderness  in  the  epigastric  region:  the  urine 
contained  a  trace  of  albumen  and  of  sugar.  She  gradually 
developed  a  sense  of  resistance  in  the  abdomen,  had  a 
septic  temperature  and  died.  The  feces  did  not  contain 
an  exces  of  fat.  At  the  autopsy  there  was  necrosis  of  the 
pancreas  going  on  to  gangrene  and  internal  pachymenin- 
gitis.    Broncho-pneumonic  areas  were  found  In  the  lungs. 


ARCHIV  FUER  KLINISCHE  CHIRURGIE. 
1900.     (Volume  62,  No.  3.) 

XXIII.  The  Occurrence  of  Ganglions  in  the  Triceps  Ten- 
don.    M.  BORCHARDT. 

XXIV.  A  New  Procedure  for  Extirpating  the  Seminal  and 
Vasa  Deferentia.     H.  H.  YOUNG. 

XXV.  Pyonephrosis  Occurring  in  Kidneys  with  Double 
i-elvis  and  Two  Ureters.     K.  G.  LENNANDER. 

XXVI.  Clinical  Observations  upon  Osteomyelitis  of  the 
Long  Bones.     E.  REISS. 

XXVII.  Conservative  Operations  for  Renal  Retention  Pol- 
lowing  Stricture  or  Valve  formation  of  the  Uretar. 
CHRISTIAN  FENGER. 

XXVIII.  A  Study  of  •Joint-Bodies."    V.  SCHMIEDEN. 

XXIX.  A  Method  of  Ascertaining  the  Virulence  of  Bao- 
teria.     H.  MARX  and  F.  WOITHE. 

XXX.  The  Lance,  a  Historical  Study  in  Military  Surgery. 
F.  SCHAEFER. 

XXIII. — Until  a  few  years  ago.  ganglions  were  com- 
monly believed  to  be  due  to  synovial  fluid  from  a  nearby 
joint,  which  had  escaped  along  a  tendon.  After  re- 
viewing the  literature  of  the  subject,  Borchardt  reports 
the  case  of  a  Russian  dentist,  with  a  firm,  spindle-shaped 
tumor,  6  cm.  long,  on  the  inner  side  of  her  arm.  The  skin 
was  not  adherent  over  it.  As  it  was  increasing  in  siie, 
she  had  it  excised.  On  incision,  a  bluish  cyst  was  found 
in  the  tendon  of  the  long  head  of  the  triceps,  containing 
a  mass  of  jelly.  It  was  a  typical  ganglion,  both  ma- 
croscopically  and  microscopically,  characterized  by  a  specif- 
ic, widespread  degeneration  of  the  connective  tissue,  lead- 
ing to  the  cyst  formation.  Its  etiology  was  unknown.  Only 
two  analogous  cases  have  been  found  in  literature^  They 
are  quoted.  From  the  minute  study  of  these  cases.  Borch- 
art  concludes  that  a  ganglion  can  be  compared  with  other 
softening  cysts.  He  believes  that  most  ganglions  are  para- 
articular, a  true  arthrogenous  ganglion  being  very  rare. 
The  case  above  described  is  an  example  of  a  tendogenou» 
ganglion,  due  to  degeneration  of  the  tendon:   while  those 


May   4,    1901] 


THE  LATEST  LITERATURE 


TTiTF.  r 

L  Miiuit 


HILADELIHIA 

AL  Journal 


883 


ganglions  which  follow  softening  in  the  periosteum  should 
111!  called  periosteal  ganglions.     LM.  O.] 

XXIV. — Young  reports  the  case  of  a  man  of  iS.  who  had 
haa  his  right  testicle  removed  nine  months  ago  for  tuber- 
culosis. Since  then  he  has  had  great  pain  at  the  end  of 
urination,  with  an  evening  elevation  of  temperature.  The 
urine  contained  tubercle  bacilli.  From  a  cystoscopic  exam- 
ination, under  chloroform,  the  posterior  wall  at  the  upper 
end  of  the  bladder  seemed  diseased.  There  were  hard 
nodular  masses  about  the  right  seminal  vesicle  and  vas  do 
ferens.  Suprapubic  cystotomy  was  performed,  and  another 
cystoscopic  examination  was  then  made.  The  vertex  and 
posterior  wall  of  the  bladder  were  found  affected.  Th'> 
peritoneum  was  stripped  from  the  bladder  and  rectum,  and 
the  seminal  vesicles  and  vasa  deferentla  excised.  Then 
the  upper,  posterior  part  of  the  bladder  was  excised,  and 
the  bladder  closed,  a  catheter  being  left  in  the  urethra, 
with  drainage  through  the  suprapubic  wound.  He  recov- 
ered very  slowly.  The  second  case  was  in  a  man  of  62,  iu 
whom  the  same  operation  was  performed,  with  the  excision. 
also,  of  the  upper  part  of  the  prostate,  and  of  both  testicles. 
A  tubercular  ulcer  in  the  bladder  was  also  removed.  He  is 
now  recovering  nicely.  Young  describes  the  technique  of 
the  operations  in  full.     [M.  O.] 

XXV. — Lennander  reports  the  case  of  a  woman,  aged  29. 
from  whose  right  kidney  a  swelling  had  been  growing  for  i 
years.  Six  years  ago  she  had  an  attack  of  pain  and  tender- 
ness over  the  tumor,  with  fever,  all  of  which  symptoms 
disappeared  suddenly,  with  the  appearance  of  pus  and  blood 
in  the  urine.  The  tumor  did  not  diminish  appreciably  in 
size.  Percussion  over  the  large  tumor  now  elicited  absolute 
flatness,  and  causes  the  patient  much  pain.  On  opening 
the  abdomen,  it  was  seen  that  the  tumor  had  pushed  up  the 
peritoneum  before  it,  and  on  incision,  at  first  a  clear  fluid 
escaped,  which  later  became  thick  and  purulent.  As  the 
patient's  genera!  condition  was  very  poor,  the  pyonephrotio 
sac  was  stitched  to  the  abdominal  wall,  and  packed.  The 
tumor  was  no  longer  palpable,  region  of  the  kidney  was 
tender,  yet  the  patient's  genera!  condition  was  very  poor. 
From  the  pus,  a  pure  culture  of  the  bacterium 
coll  commune  was  obtained.  Ten  days  later,  acute  apendi 
citis  occurred,  lasting  about  5  days.  Two  months  later,  as  the 
fistula  had  not  healed,  Lennander  operated  again,  removing 
the  appendix,  and  the  pyonephrotic  sac,  after  which  he  per 
formed  nephropexy  upon  the  rest  of  the  right  kidney  in 
which  one  pelvis  was  still  sound.  The  kidney  had  a  double 
pelvis  and  two  ureters,  and  had  probably  been  movable  for 
at  least  8  years.  This  might  have  caused  pyonephrosis. 
In  two  months  the  patient  was  well.  Lennander  quotes 
three  similar  cases  already  reported,  and  then  adds  a  de- 
scription of  a  preparation,  from  a  boy  of  6.  in  whom  tho 
left  kidney  had  a  double  pelvis  and  two  ureters.  In  thi.s 
case  pyonephrosis  had  followed  cystitis  from  phimosis, 
[M.  O.] 

XXVI. — While  osteomyelitis  is  primarily  a  disease  of 
childhood  and  youth,  it  sometimes  occurs  also  after  the  age 
of  25  years.  The  oldest  patient  among  the  cases  Reiss  re- 
ports was  aged  54.  Occasionally  a  healed  osteomyelitis  will 
break  out  again  years  later.  Following  the  infectious  di.^- 
eases,  osteomyelitis  may  occur  at  the  site  of  a  former  frac 
ture,  rheumatism,  or  bone  disease.  Osteomyelitis  generally 
occurs  in  the  diaphysis  of  the  long  bones,  near  the  epiphy- 
seal junction.  Suppuration  leads  down  to  marrow,  anci 
necrosis  follows.  Lengthening  often  follows  necrosis. 
Fracture  may  occur  spontaneously.  The  result  of  these 
processes  depends  upon  the  cartilage  groove:  when  this  re- 
mains intact,  growth  continues;  if  this  he  destroyed,  even 
partially,  shortening  will  result,  and  no  epiphyseal  line  will 
be  seen  in  Roentgen  photographs.  Reiss  reports,  in  all. 
16  case  of  osteomyelitis,  with  discussion  of  their  course 
and  main  complication,  disease  of  the  neighboring  joint. 
He  concludes  that  when  the  cartillage  groove  is  partially 
destroyed,  recovery,  with  normal  growth  following,  is  pos 
sible;  but  that  in  most  cases,  even  when  a  part  of  the  carti! 
age  groove  is  macroscopially  normal,  bony  callus  will  tak.-^ 
its  place;  that  after  separation  of  the  epiphysis,  in  osteomy 
elitis  of  the  epiphysis,  no  regeneration  of  the  epiphyseal 
cartilage  can  occur,  since  bony  calbis  holds  them  together; 
that  when  osteomyelitis  occurs  primarily  in  the  epiphysis, 
it  in  no  way  affects  normal  growth;  and  that  shoiild  this 
process  extend  from  the  epiphysis  to  the  diaphysis.  thus 
destroying  the  cartilage  groove,  further  growth  will  stop 
The  article  is  well  illustrated  with  Roentgen  photographs. 
[M.  0.] 


A/\vil. — Fenger  reviews  the  literature  of  the  renal  re- 
tenuon,  dividing  the  cases  into  those  in  which  the  sito  of 
obstruction  is  iu  the  kidney  itself,  in  the  pelvis  of  the  kid- 
ney or  outlet  of  the  ureter,  and  in  the  ureter  itself.  A  table- 
of  30  cases  collected  follows,  10  of  which  Fenger  had  hini- 
seU'.  The  extra-pelvic  operation  gives  the  best  results, 
liut  v/hen  a  large  cystonephrotic  sac  exists,  the  trans-pelvic 
method  must  be  followed.  There  is  little  danger  to  life  in 
these  operations.  In  J  cases  the  result  was  negative,  nephrec- 
tomy -uUowing  in  four  of  them.  Good  functional  results 
were  obtained  in  22  of  the  cases.  In  a  tew  of  these,  fistulae 
remained.  Only  two  of  the  cases  have  recurred,  in  both  of 
vthich  nephrectomy  was  necessary.     [M.  O.] 

XXvlll. — Schmieden  studied  49  cases  in  which  "joint- 
liodies"  occurred,  and  removed  all  but  5  of  them  by  opera- 
tion. He  considers  only  cartilaginous  or  bony  bodies  true 
joint-bodies,  excludin.g  foreign  bodies,  blood-clots,  tumors, 
etc.  They  frequently  follow  traumatism,  especially  in 
tubercvilar  subjects.  A  few  showed  connection  with  the 
interarticula.r  cartilage.  One  was  found  outside  of  the 
joint-capsule.  These  true  joint-bodies  are  composed  of  con- 
nective tissue,  cartillage,  and  bone,  being  broken  off  bits  of 
the  bones  which  enter  into  the  formation  of  the  joint.  They 
may  in  fict  increase  in  size,  being  set  free  in  the  joint, 
fc'climiedcn  divides  them  into  those  caused  by  arthritis 
deformans,  which  are  not  microscopically  part  of  the 
normal  joint  surfaces,  and  tnose  not  due  to  arthritis  defor- 
mans, which  contain  parts  of  normal  joints.  Nine  cases. 
were  due  to  arthritis  deformans.  Those  not  caused  by 
arthritis  deformans  may  be  traumatic.  Fourteen  cases- 
were  due  to  direct  traumatism.  6  cases  to  indirect  trauma- 
tism. In  three  cases  the  joint-bodies  certainly  contained 
part  of  the  joint  surfaces,  yet  no  traumatism  or  inflamma 
tion  had  ever  effected  the  joint.  Perhaps  a  slight,  hardly 
noticeable  traumatism,  in  childhooa,  might  have  caused 
these  join  bodies.  In  simple  cases,  the  joint-bodies  can 
be  removed.  In  severe  cases,  resection  of  the  joint  will  be 
necessary.     [M.  O.] 

XXIX. — Marx  and  Woithe  believe  that  all  methods  in  use 
for  ascertaining  the  virulence  of  bacteria  are  faulty.  Nei- 
tlier  animal  inoculation  nor  serum  reactions  have  overcome 
these  faults.  They  estimate  the  functional  worth,  i.  e..  the- 
virulence,  of  a  pathogenic  micro-organism,  not  from  it'^ 
effect  upon  any  animal,  under  unknown  conditions  (immun- 
ity, or  disposition),  but  from  certain  morphologic  peculiar- 
ities of  the  bacterial  csUs,  which  stand  in  the  closest  rela- 
tion to  the  creation  of  specific  functions  (chemical,  biolog- 
ical, etc.). easily  and  surely  recognizable  microscopically, 
with  judicious  handling  of  material.  Their  process,  whicli 
depends  upon  the  formation  of  "Babes-Ernst"  metachro- 
matic bodies  when  the  bacteria  have  reached  the  point  of 
greatest  virulence,  passes  through  four  stages  of  morpho- 
logic differentiation.  To  do  this  successfully,  the  following 
technical  points  must  be  carefully  carried  out.  No  water 
must  be  allowed  on  the  cover-glass;  the  culture  materi.al 
must  be  thickly  spread;  it  must  be  well  dried  and  fixed: 
it  must  be  cooled  before  adding  the  methylen-blue:  and  it 
must  be  examined  microscopically  at  once.  Their  method 
is  for  bacteria  without  spores,  which  do  not  belong  to  the 
tuberculosis  group.  To  ascertain  the  grade  of  virulence  of 
pathogenic  bacteria  found  in  a  body,  the  bacteria  must  be 
examined  directly  with  the  body  juices  in  which  they  were 
found.  For  cultures  will  not  show  how  virulent  the  fresh 
micro-organism  was.  They  have  experimented  mainly  with 
staphylococci.  After  the  virulence  has  been  discovered, 
inoculation  in  animals  will  show  its  pathogenicity.     [M.  O.7 

XXX. — Schaefer  gives  a  detailed  history  of  the  lance 
as  an  implement  of  war.  with  an  account  of  the  character 
of  the  wounds  caused  by  it  in  the  different  parts  of  the 
human  body.  He  concludes  that  from  statistics  of  militarv 
surgery,  lance  wounds,  in  the  overwhelming  majority  of 
cases,  have  been  slight.  The  literature  shows  a  series  of 
severe  lance  wounds  which  have  nm  a  surprisingly  favor- 
Pble  course.  This  is  due  to  the  shape  of  the  lance,  as  its 
blunt,  swollen  point  pushes  the  organs  out  of  the  wav. 
Therefore  it  is  a  humane  implement.  Finally,  by  makinsc 
its  point  sharper,  it  would  become  a  very  dangerous  wea- 
pon.    [M.  0.] 

1001.     (Volume  62,  No,  4.) 

31.  Retrograde  Sounding  in   Cicatricial   Stricture   of   thc 

Esophagus.     H.  AIJAPY. 

32.  The      Treatment      of      Complicated      Fractures.     P 

FRANKE. 

33.  Corcinoraa  Occurring  in  a  Dermoid  Cyst.     H.  WOLF. 


8»^        The  ruiLADELrniA"! 
T'         Medical  Journal  J 


THE  -LATEST  LITERATURE 


(May   4.    1901 


34.  Mechanical   Appliances   in   Gastro-entero-anastomosis 

G.  KELLING. 

35.  Ileo-cecal  Resection  In  Tuberculosis  of  the  Intestines. 

K.   HUGEL. 

36.  Congenital  Bone  Defects.    U.  GROSSE. 

37.  Upon  Grafting  the  Facial  Nerve  upon  the  Accessories. 

P.  MANASSE. 

31. — In  those  cases  of  narrow  stricture,  situated  low  down 
in  the  esophagus,  in  which  gastronomy  must  be  performed, 
much  depends  upon  whether  even  a  small  instrument  will 
then  pass  through  the  stricture.  If  this  first  effort  meet 
with  success,  all  will  probably  go  well.  Alapy  reports  the 
case  of  a  boy  of  7,  with  two  strictures  of  the  esophagus 
following  the  ingestion  of  lye.  The  upper  stricture  couM 
be  passed,  but  the  lower,  just  above  the  cardia,  would  not 
let  even  a  filiform  bougie  by.  Gastrostomy  was  performed. 
A  week  later,  an  elastic  bougie  was  introduced  through  the 
stomach  up  to  the  site  of  the  stricture,  and  a  silk  catheter 
was  passed  over  it.  Then  the  bougie  was  withdrawn,  and 
a  filiform  inserted,  which  easily  passed  through  the  stric- 
ture and  out  to  the  mouth.  After  that,  dilatation  was 
accomplished  quickly,  and  the  child  recovered.  Alapy  de- 
vised this  method  to  overcome  two  difficulties:  Finding 
the  cardia,  and  pasing  the  stricture.  As  ordinary  filiform 
bougies  are  not  long  enough,  he  advises  the  use  of  the 
rhillips  bougies.     [M.  O.] 

32. — Franke  divides  his  researches  in  the  treatment  of 
complicated  fractures  into  two  parts,  those  of  the  extremi- 
ties, and  those  of  the  skull.  Modern  aseptic  treatment  has 
made  these  wounds  much  less  dangerous  than  they  for 
merly  were.  In  every  case  he  tried  to  keep  the  wound 
aseptic,  to  put  the  fragments  in  good  position,  to  keep  up 
absolute  rest,  followed,  after  healing,  by  regulated  move- 
ments. The  region  of  the  wound  was  disinfected,  and  if 
the  wound  was  small,  and  contained  a  foreign  body,  it  was 
removed,  the  wound  dried  out  with  sterile  gauze,  and  a 
sterile  dressing  applied.  In  large  wounds,  counterincisions, 
drainage,  removal  of  splinters  of  bone,  etc.,  followed,  but 
washing  out  with  antiseptics  was  never  done.  Large  pieces 
of  bone  were  saved,  sharp  edges  being  sawed  off  first,  to 
prevent  pressure  on  the  blood  vessels,  and  gangrene. 
When  dislocation  seemed  imminent,  bones  were  sutured 
together  with  silver  wire.  Attempts  were  made  to  cover 
the  bone  with  soft  parts.  The  injection  of  a  little  iodoform 
ether,  and  drying  with  sterile  gauze,  completed  the  treat- 
ment. With  this  many  limbs  escaped  amputation.  Even 
when  gangrene  was  feared,  conservative  treatment  was 
carried  out.  Yet  some  cases  had  to  be  amputated.  Immo- 
bilization was  secured  by  plaster  bandages,  extension,  or 
splints.  Roentgen  photographs  were  taken  regularly.  The 
fractures  of  the  skull  were  treated  in  the  same  way. 
Wounds  were  generally  enlarged,  to  see  the  amount  of 
damage  done.  Even  a  greater  attempt  was  made  here, 
to  make  the  surface  smooth.  Many  blood  vessels  of  the 
dura  and  pia  were  ligated.  Where  parts  of  the  brain  were 
badly  injured,  they  wore  removed,  as  were  foreign  bodies, 
splinters,  etc.  If  possible,  clefts  in  the  dura  were  sutured. 
Great  care  was  taken  to  prevent  bone  defects.  The  bone 
was  replaced,  after  being  washed  in  a  boric  acid  solution, 
and  the  skin  closed  over  it.  Osteoplastic  resection  was 
necessary  in  some  cases.  The  histories  of  73  complicated 
fractures  of  the  extremities,  and  of  24  complicated  frac- 
tures of  the  skull  are  given  in  detail.     [M.  (I.  | 

33. — Wolff  reports  the  rare  case  of  a  carcinoma  occur- 
ring in  the  wall  of  a  closed  dermoid  cyst.  He  could  find 
no  similar  casein  literature.  A  Russian,  aged  21,  had 
always  had  a  small  tumor  over  the  inner  canthus  of  his  left 
eye.  This  had  increased  in  size  during  the  past  two  years, 
but  never  caused  any  symptoms.  It  was  elastic,  but  did 
not  decrease  on  pressure.  A  typical  dermoid  cyst  was  re- 
moved with  difficulty,  on  account  of  its  attachment  to  the 
periosteum.  Some  of  the  surrounding  connective  tissue 
was  removed  with  it.  Microscopical  examination  showed 
carcinomatous  degeneration  of  the  cyst  wall.  He  reports 
a  similar  case  following  the  removal  of  a  dermoid  cyst  of 
the  sacrum.  In  both  cases  carcinomatous  changes  occurred 
in  dermoid  cysts,  in  one.  closed  and  intact,  in  the  other, 
upon  the  remaining  wall  loft  after  excision  of  the  cyst 
[M.  O.] 

34. — Kelling  speaks  of  the  prejudices  against  the  use 
of  the  Murphy  button  in  gastro-entero-anastomosis.  Yet 
he  considers  that  a  good  anastomosis  button  will  resemble 
the  Murphy  button,  for  it  must  remain  unchanged  until  the 


necrotic  intestinal  wall  has  been  thrown  off,  and  then  be 
wholly  digested  in  the  stomach  or  intestines.  Kelling  has 
constructed  a  button  from  ivory  that  has  been  deprived  of 
Ity  calcium.  It  is  in  one  piece,  a  cylinder  with  funnel- 
i-haped  ends,  covered  with  rubber  as  a  protection  against 
the  digestive  juices.  This  covering  is  absent  in  the  deep 
outside  groove  where  the  stitches  will  be  placed.  It  is  fixed 
in  place  by  two  sutures.  Its  application  is  fully  described, 
with  attention  to  every  detail.  A  number  of  experiments 
upon  animals  follow  to  show  its  usefulness.  For  operations 
on  the  colon.  Kelling  has  devised  a  wooden  button,  which 
he  has  used  in  dogs.  Kelling  has  also  employed  absorbable 
plates  of  bone  or  ivory  from  which  the  calcium  has  been 
removed.     [M.  O.] 

35. — Hugel  reports  three  cases  of  colon  tuberculosis  in 
which  operation  was  necessary.  In  the  first  the  mass  was 
in  the  ileocecal  region:  in  the  second,  in  the  ileoceal  r& 
gion,  ascending  and  transverse  colon:  and  in  the  third,  in 
the  right  colic  flexure.  Resection  of  the  affected  part  of  the 
intestine,  with  anastomosis,  was  performed.  Two  of  the 
patients  reaovered  while  the  other  died.  Microscopic  ex- 
amination confirmed  the  diagnosis  of  all  three  cases.  Huge) 
believes  that  the  whole  part  affected  should  be  removed. 
Should  phthisis  also  exist,  he  thinks  that  the  intestine 
should  be  stripped  for  its  entire  length,  and  the  exposed 
ends  of  the  intestine  opened.  With  an  iodoform  gauze 
compress  the  stripped  intestine  can  be  cut  off  from  the 
peritoneum,  and  resection  can  be  formed  later,  when  the 
strength  of  the  patient  permits,  without  a  second  laparot- 
omy. But  he  believes  that  by  lighting  off  the  mesenteric 
vessels  leading  to  the  exposed  section  of  the  intestine,  cer- 
tain involution  of  the  tubercular  process  will  follow,  and 
perhaps  save  later  resection.     [M.  O.] 

36. — Grosse  reports  the  case  of  a  girl  of  5.  whose  right 
leg,  especially  below  the  knee,  was  markedly  smaller  than 
the  left,  even  at  birth.  Nor  did  the  right  leg  grow  below 
the  knee.  Various  different  supports  had  been  used  with- 
out effect.  Roentgen  photographs  showed  the  absence  of 
the  tibia,  the  fibula  being  alone.  Professor  von  Bramann 
operated,  bringing  the  fibula  into  the  knee  joint,  taking 
great  care  that  the  epipyseal  cartilage  was  not  injured. 
Foot  and  leg  were  then  put  in  plaster.  With  a  support 
down  the  leg,  about  the  waist,  and  a  block  under  the  foot, 
she  soon  could  run.  In  six  weeks  femur  and  fibula  had 
grown  together,  and  her  leg  has  developed  well  in  the 
two  and  a  half  years  since.  The  former  shortening  of  5'< 
cm.  has  been  decreased  2  cm.  She  can  now  support  her- 
self without  any  splint,  walking  with  a  slight  limp.  Grosse 
reports  another  cose  of  von  Bramann's.  with  similar  re- 
sults, no  splint  now  being  needed.       M.  O. 

37.  Manasse  reviews  the  experimental  operations  upon 
nerves,  before  telling  of  his  work  in  grafting  one  nerve 
upon  the  other.  For  a  successful  result,  in  investigations 
of  this  kind,  he  believes  that  function  must  be  restored 
throughout  the  region  supplied  by  the  paralyzed  nerve, 
the  peripheral  end  of  which  has  been  grafted  upon  a  neigh- 
boring nerve:  that  electric  excitability  must  return:  that 
the  two  nerves  must  grow  together  anatomically,  which 
will  be  seen,  histologically,  by  the  continuity  of  the  nerve- 
fibres.  On  account  of  its  simplicity.  Maaasse  decided  to 
graft  the  facial  nerve  upon  the  accessories,  as  treatment 
for  traumatic  paralysis  of  the  facial  nerve.  He  performed 
experiments  upon  11  dogs.  5  of  which  were  carried  to  a 
conclusion.  Their  histories  follow  in  detail.  A  description 
of  the  different  methods  of  operating  is  given. Manasse's 
results  wer  not  at  all  satisfactory,  nor  does  he  consider  the 
operation   an  easy  one.     [M.   O.] 


24. 


L'o. 
2G. 


28. 
29. 

30. 


DEUTSCHE  ZEITSCHRIFT    FUER  CHIRURGIE. 

I'd  riKinj.  19111.    (Volume  oS.  Xos.  5  and  e.t 

Injuries  Following  Intubation.     VOX  POK.\Y. 
Spontaneous    Gangrene    in    Young    Individuals.      P. 

WULFF. 
Fractures  of  the  Heel.    HELBING. 
The  History  of  Esophagoscopy  and  Gastroscopy.   KIL- 

LIAN. 
Protracted  Appendicitis  and  its  Results.    E.  ROSE. 
Ostomyelites  of  the  Vertebrae.     M.  SCMMIDT. 
Leontiasis  with  Generalized  Fibroma  Molluscum.     O. 

LANZ. 
Sarcoma  of  the  Penis.    PUPOVAC. 


May    4.    r.Hill 


THE  LATEST  LrfERATURE 


CThe  Philadelphia        88^ 
Medical  Jovbxal         *-'"0 


31.  Isolated   Fracture   of   the   Smaller   Tuberosity   of   the 

Humerus.  H.  LORENZ. 

32.  Hemorrhagic  Proctitis.     R.  STIERLIN. 

23. — During  10  years'  experience,  von  Bokay  has  intu- 
bated 1203  times.  He  divides  the  injuries  from  intubation 
into  those  occurring  during  intubation;  those  occurring 
while  the  tube  remains  in  the  larynx;  those  occurring 
during  extubation;  and  those  occurring  later,  cicatrical 
stricture,  stenosis,  etc.  During  intubation  the  mucous 
membrane  is  apt  to  be  scraped  off.  or  false  passages  may 
be  made.  Both  occur  as  a  rule  above  the  vocal  cleft,  and 
it  may  be  possible  to  fracture  the  cricoid  cartilage.  The 
slight  abrasions  of  the  mucous  membrane  occur  often, 
and  heal  rapidly.  The  histories  of  .5  cases  of  false  passages 
are  given,  with  photographs  from  the  autopsies.  The  diag- 
nosis is  easily  made,  for  the  symptoms  do  not  ameliorate, 
and  hemorrhage  may  occur  following  intubation.  The 
prognosis  is  unfavorable.  Von  Bokay  thinks  that  these 
accidents  are  due  mainly  to  unskilled  intubation.  Tracheo- 
tomy will  often  be  necessary,  yet  life  may  not  even  then 
be  saved.  While  the  tube  Is  in  place,  ulcers  can  easily 
form.  The  mucous  membrane  becomes  irritated  by  the 
pressure  of  the  tube,  inflammation  follows,  and  the  carti- 
lage is  laid  bare  72  hours  after  intubation.  Such  ulceration 
was  found  in  13%  of  von  Bokay's  cases  at  autopsy.  In  o% 
only  were  deep  ulcers  seen.  In  his  experience,  the  ulcers 
were  seen  on  the  anterior  wall  of  the  larynx,  trachea,  thy- 
roid and  cricoid  cartilages.  Experiments  show  that  ulcera- 
tion is  not  due  to  frequent  intubation,  but  to  tubes  that  have 
been  left  in  place  some  time.  Sixteen  cases  of  ulceration, 
out  of  1203  cases,  healed  after  tracheotomy.  Most  ulcers 
occurred  in  the  first  and  second  year;  a  tube  was  perhaps 
used  that  did  not  suit  the  child;  or  the  diphtheritic  process 
may  itself  have  caused  ulceration.  The  histories  of  18  such 
cases  follow.  Expectoration  will  be  blood-streaked,  the 
ulcer  is  sensitive  to  pressure,  a  dark  spot  will  be  noted  upon 
the  tube,  or  laryngeal  examination  may  locate  the  ulcer. 
When  the  ulcers  are  slight  and  superficial,  they  will  heal 
easily.  The  use  of  well-modeled  and  well-graduated  tubes 
<  orrectly  put  in  place,  left  there  as  short  a  time  as  possible, 
with  serum  given,  will  prevent,  as  far  as  possible,  the  oc- 
lurrenee  of  deep  ulceration  in  cases  intubated.  Trache- 
tomy  is  only  Indicated  when  the  presence  of  a  deep  ulcer 
is  positively  known.  The  danger  of  injury  during  extuba- 
tion is  least  when  the  tube  is  extracted  by  the  thread  or  by 
hand;  while  it  is  most  possible  when  instruments  are  used 
for  e.Ktraction.  Slight  abrasions  heal  easily,  but  hemorr- 
hage may  occur.  Some  degree  of  hoarseness  results.  If 
this  persists  over  a  week  after  the  removal  of  the  tube, 
post-diphtheritic  paralysis  has  occurred.  It  is  but  seldom 
that  cicartricial  stricture,  stenosis,  or  atresia  of  the  larynx 
follows  intubation,  and  then,  only  in  cases  of  laryngeal 
diphtheria.  It  has  always  occurred  in  children  under  six 
years  of  age.  The  histories  of  two  cases  of  stricture  with 
stenosis,  and  three  cases  of  atresia  follow.  Renewed 
dyspnea,  a  hindrance  to,  or  the  impossibility  of  withdraw- 
ing or  introducing  the  tube,  with  laryngoscopic  examina- 
tion, will  show  a  stricture.  The  prognosis  is  favorable 
for  permeable  strictures,  but  not  for  complete  atresia. 
Slow  healing  about  a  properly  fitting  tube  Is  the  best 
method  of  treatment  for  these  cases.  The  treatment  will 
ije  incision  of  the  cicatrix,  followed  by  methodic  intubation; 
widening  by  bougies;  transplantation  of  epithelium;  or 
resection  of  the  scar  completely,  followed  by  suturing  the 
ends  of  the  respiratory  passages  together.  Methodic  intu- 
bation has  been  most  successfully  performed,  in  four  out  of 
six  cases;  neither  the  use  of  the  bougies  nor  the  transplanta- 
tion of  epithelium  has  been  a  success.  The  one  operated  case, 
complete  resection  of  the  cicatrix  with  the  ends  of  the 
larynx  and  trachea  sutured  afterward,  has  been  wholly 
cured.  Thus  methodic  intubation  should  always  be  at 
tempted,  the  more  severe  operations  being  left  as  the  last 
resort.     [M.  O.] 

24. — Wulff  reports  two  cases  of  spontaneous  gangrene. 
The  first  patient,  a  Pole,  aged  3S.  had  noted  pain,  with 
feelings  of  cold  and  "pins  and  needles"  in  his  left  leg  for 
three  years.  Two  years  ago,  an  ulcer  appeared  on  the 
inner  side  of  the  leg.  Though  syphilis  was  denied,  anti- 
syphilitic  treatment  somewhat  improved  the  condition,  but 
not  the  ulcer.  The  pulse  was  still  felt  under  Poupart's 
ligament,  but  not  in  the  popliteal  space.  The  next  year  his 
( ondition  grew  worse,  and  the  ulcer  increased  in  size,  with 
widespread  necrosis  of  the  tibia.  The  entire  bone  grew  cold, 
and  the  pain  excruciating.    There  was  uo  longer  any  pulsa- 


tion palpable  at  Poupart's  ligament.  The  leg  was  disartic 
ulaied  at  the  knee,  since  which  operation  some  necrosis 
of  the  skin  of  the  inner  flap  has  persisted.  The  arteries 
in  the  leg  were  found  with  a  very  narrow  lumen  and  thick 
walls,  easily  distinguished  from  the  veins  macroscopically. 
Thrombi  existed  in  the  veins,  but  not  in  the  arteries.  The 
nerves  were  normal.  The  other  patient  was  also  a  Pole,  aged 
2S.  He  had  never  contracted  syphilis.  Pain  first  appeared 
in  the  left  leg  four  years  ago.  upon  walking  for  a  long 
time.  He  was  treated  for  rheumatism  until  gangrene  of  tne 
little  toe  developed,  a  year  later.  First  the  foot,  then  the 
thigh,  was  amputated,  with  quick  recovery  following.  Two 
years  later  tne  same  condition  began  in  the  right  foot. 
As  in  the  former  case,  the  heart  and  kidneys  were  normal. ' 
The  toes  were  black,  the  rest  of  the  foot  cold  and  pale. 
A  Pirogoff  amputation  was  dope,  but  the  flaps  became 
necrotic.  Resection  of  the  tibia  was  necessary,  followed 
later  by  disarticulation  at  the  knee,  since  which  proceedin.g, 
he  has  kept  well.  Here,  also,  the  nerves  were  found  nor- 
mal and  the  arteries  and  veins  very  small.  After  a  full  re- 
view of  the  literature,  Wulff.  who  observed  five  cases,  con- 
siders it  a  general  dyscrasia,  often  found  in  the  people  of 
Poland,  generally  in  men  free  from  lues,  diabetes,  or  n<>- 
phritis,  but  who  smoke  30  cigarettes  or  more  daily.  He 
concludes  that  the  process  is  probably  a  primary  endarter- 
itis with  secondary  thrombosis,  due  to  an  abnormal  vaso 
motor  contraction,  analogous  to  Raynaud's  disease.    [M.  O.] 

25. — Helbing  divides  the  fracture  of  the  calcaneum  into 
those  which  are  broken  apart,  leaving  a  cleft  between  the 
fragments,  and  those  which  are  crushed  into  pieces.  He 
discusses  the  former  variety  only,  and  reports  the  case  of  a 
woman  of  57.  who,  on  putting  her  foot  backward  while 
standing  upon  a  chair,  came  down  heavily,  her  foot  striking 
the  floor.  There  was  great  pain,  yet  she  has  been  able  to 
walk  since.  There  was  slight  foot-drop,  with  a  large  tumor 
above  the  insertion  of  the  tendo-Achilles.  Below  this  a 
straight  furrow  was  noticeable.  A  Roentgen  photograph 
showed  that  the  calcaneum  had  been  fractured,  the  uppe-- 
fragment  being  pulled  up  by  the  tendo-Achilles, 
whic'n,  with  some  exudate,  caused  the  tumor  The 
furrow  below  it  showed  the  cleft  of  the  fracture.  She 
was  well  in  four  weeks.  But  on  being  examined  six  months 
later,  the  upper  fragment  had  again  risen,  from  the  tension 
of  the  tendo-Achilles.  without  causing  any  pain.  Helbing 
concludes  that  this  fracture  is  not  like  the  ordinary  frac- 
tures of  the  calcaneum  in  which  the  cleft  is  vertical:  that 
the  prognosis  of  this  sort  of  fracture  is  very  unfavorable; 
and  that  while  the  ordinary  vertical  fracture  is  due  to  a 
fall  from  a  height  of  two  meters  or  more,  this  results  from 
a  fall  of  one  meter  or  less.  The  cause  of  the  fracture,  the 
power  of  the  tendo-Achilles,  is  also  the  cause  of  the  un- 
favorable result.    [M.  O.] 

26. — In  1807  Bozzini  first  attempted  esophagoscopy.  But 
not  until  Kuessmaul,  in  1S6S  was  any  practical  method  of 
esophagoscopy  or  gastroscopy  discovered.  In  this.  Kuss- 
maul  followed  the  "sword-swallower"  idea.  Then  came  the 
Desormeaux  endoscope,  in  1S53.  Killian  describes  the 
many  methods  invented,  many  of  them  practically  useless, 
with  a  detailed  review  of  the  subject.     [M.  O.] 

27. — When  appendicitis  is  protracted,  a  fecal  fistula  often 
results.  Rose  reports  three  fatal  cases  of  perforation  of  the 
cecum  following  appendicitis.  In  the  first  case  fecal  matter 
escaped  and  formed  a  circumscribed  peritoneal  abscess, 
between  the  folds  of  the  small  intestine.  In  the  other  two 
cases,  perforation  occurred  in  the  cecum,  circumscribed 
abscesses  being  also  found.  The  autopsy  reports  are 
given.  Rose  advances  four  theories  to  account  for  the  oc- 
currence of  the  rectal  fistulae  in  appendicitis,  (1)  from  in- 
juries during  operation;  (2)  softening  of  the  intestinal 
walls  from  long  standing  disease,  old  age,  etc.;  (3)  a 
stitch  abscess  following  operation;  and  (4)  secondary  in- 
flammation of  the  cecum.  A  fistula  generally  arises  in  the 
small  intestine,  from  perforation  of  the  cecum  with  or 
without  operation,  following  atrophy  or  ulceration  of  the 
intestinal  walls  from  the  pressure  of  a  quantity  of  pus. 
Secondary  inflammation  of  the  cecum  with  fistulae,  ad- 
hesions, and  much  lymph  formation  needs  speedy  opera- 
tion. Should  fecal  matter  appear  in  the  wound  after  opera- 
tion, it  will  be  due  to  perforation  probably  from  the  long 
pressure  of  an  abscess.  A  case  of  true  appendicular  fistula 
is  described,  which  was  cured  by  removing  the  appendix. 
The  histories  of  10  other  cases  follow,  with  recal  fistula, 
artificial  anus,  peritonitis,  empyema,  urinary  fistula  is  dtr 
scribed,  which  was  cured  by  removing  the  appendix.  The 
histories  of  10  other  cases  follow,  with  fecal  fistula,  arti- 


886 


Thk 


•nil-AHKLl'IUA   r 
.  AL   JuUUNAL     L 


THE  LATEST  LITERATURE 


(May    4.    13(11 


flcial  anus,  peritonitis,  empyema,  urinary  fistula,  etc.  When 
appendicitis  is  protracted,  tiie  mesenteric  glands  will  swell, 
and  periconitis  may  follow.  But  the  main  danger  in  this 
form  of  appendicitis  is  that  fecal  matter  may  enter  the 
peritoneum,  to  prevent  which,  an  early  laparotomy  will  be 
necessary.  If  the  appendicitis  has  lasted  over  two  weeks, 
laparotomy  should  be  done  at  once.  If  an  abscess,  or  free 
pus  is  found,  it  will  be  better  to  leave  in  drainage  than  lo 
close  the  wound  again.     [M.  O.J 

28. — Schmidt  reports  the  case  of  a  girl  of  13,  who  knocked 
her  right  internal  malleolus.  An  abscess  followed,  which 
was  incised.  She  then  complained  of  stiff  neck,  with  ten- 
derness along  the  cervical  vertebrae.  Paralysis  of  thi.- 
right  arm  occurred  suddenly,  followed  by  paralysis  of  the 
three  remaining  extremities.  Then  pain  appeared  in  both 
legs.  Next  involuntary  evacuation  of  bladder  and  rectum 
was  noted.  On  operating,  an  abscess  was  found  in  the 
cervical  vertebrae,  from  which  a  large  quantity  of  pus 
flowed.  The  left  arm  and  leg  improved  at  once,  and  the 
pain  disappeared  Next  the  left  hip  became  affected,  bui 
recovered  without  forming  another  abscess.  Both  malleo- 
lar and  cervical  wounds  healed.  Her  neck  can  now  be 
moved  well.  The  left  arm  recovered  rapidly,  the  right 
very  slowly.  Schmidt  calls  it  an  undoubted  case  of  out 
spoken  mu-ltiple  osteomyelitis,  affecting  the  right  ankle, 
cervical  vertebrae,  and  the  left  hip  in  turn.  He  discusses 
in  full  the  nervous  symptoms  from  the  pressure  of  the 
pus  contained  in  the  cervical  abscess,  and  quotes  16  more 
cases  of  osteomyelitis  of  the  vertebrae.     [M.  O.] 

29. — Lanz  reports  a  rare  case  of  leontiasis  with  general 
ized  fibroma  molluscum,  in  a  man  of  55.  His  left  eye 
was  always  larger  than  the  right.  At  the  age  of  9,  his  left 
upper  eyelid  began  to  swell,  increasing  in  size  gradually. 
At  20,  it  so  deformed  his  face  as  to  prevent  all  idea  of  mill 
tary  service.  He  believes  that  the  left  eye  was  already 
blind  at  9  years,  when  the  skin  eruption  first  appeared. 
There  has  never  been  any  pain.  Over  the  left  side  of  the 
face  hangs  a  huge  sac  of  skin,  rising  from  the  nose  ami 
forehead,  extending  to  the  left  angle  of  the  mouth.  It 
hangs  in  five  folds,  and  is  well  shown  in  the  photograph.^ 
accompanying  the  article.  There  is  very  little  hair  on  the 
mass,  in  which  an  empty  cavity  is  seen  for  the  left  eye. 
the  lids  swollen  and  edematous,  the  eyeball  invisible.  The 
left  eyebrow  and  lashes  are  absent.  When  he  closes  his 
eye  forcibly,  the  mass  rises  2  cm.  Over  the  entire  body  is 
a  widespread  fibroma  molluscum.  He  will  not  permit  any 
surgical  interference,  unfortunately.     [M.  O.] 

30. — Pupovac  reports  a  rare  case  of  sarcoma  of  the  p^.iis, 
occurring  in  a  man  aged  47  years.  A  swelling  on  the  rignt 
side  of  the  penis  was  first  noticed  6  months  before  adiuis- 
sion  to  the  hospital.  This  gradually  increased  in  size 
in  spite  of  potassium  iodide  administered  internally 
and  externally.  Otherwise  he  was  perfectly  healthy.  Thy 
inguinal  glands  swelled  gradually.  Sarcoma  was  diagnosed, 
and  the  penis  amputated.  The  inguinal  iliac,  and  abdominal 
lymph  glands,  along  the  descending  aorta,  were  found 
affected  and  were  extirpated.  Two  days  later  he  died  with 
diffuse  peritonitis.  The  tumor  was  a  round  celled  sarcoma 
of  the  corpora  cavernosa,  with  metastasis  of  the  lymph 
glands.  The  urethra  and  the  blood  vessels  were  not  af 
fected.     [M.  O.] 

31. — The  great  rarity  of  isolated  fractures  of  the  lesser 
tuberosity  of  the  humerus  caused  Lorenz  to  report  lhi.= 
case.  A  man  aged  45.  was  struck  by  a  falling  marble  pil 
lar,  which,  striking  his  hand,  rolled  his  right  arm  outward 
forcibly,  causing  great  pain  in  the  shoulder.  After  the 
swelling  disappeared,  he  was  able  to  use  the  arm.  It 
could  be  rotated  outward  to  an  abnormal  extent.  On 
palpation  a  jagged  surface  was  felt  in  the  place  of  the  lesser 
tuberosity.  This  is  tender,  and  crepitus  is  audible  on  rotat- 
ing the  arm.  The  arm  cannot  be  rotated  inwardly  at  all. 
A  review  of  the  literature  follows,  with  the  quotation  of  a 
few  cases.  It  is  probably  caused  by  forcible  contraction  of 
the  subscapularis  muscle.  The  treatment  should  consist  in 
incision  with  suturing  or  nailing  the  fragment  into  place. 
His  patient  would  not  permit  operation.     [M.  O.] 

32. — While  the  diagnosis  of  malignant  tumors  of  the 
rectum  is  not  as  a  rule  difficult,  it  is  impossible  to  find 
the  cause  of  some  cases  of  hemorrhagic  proctitis.  SUerlin 
reports  such  a  case  in  a  man  of  40.  For  four  years  he  has 
lost  blood,  off  and  on.  when  his  bowels  moved.  This  often 
was  lost  in  quantities,  with  attacks  of  diarrhea.  He  was 
treated  for  hemorrhoids  for  three  years.  On  admission 
to  the  hospital,  he  was  having  5  to  6  bowel  movements 


daily,  mixed  with  bright  red  blood.  He  was  very  thirsty 
and  weak.  The  mucous  membrane  was  easily  injured,  fol- 
lowed by  bleeding.  Otherwise  the  rectum  was  normal 
The  sphincter  was  dilated,  the  entire  mucous  membrane 
being  found  a  mass  of  soft  folds,  like  a  bloody  sponge. 
There  were  no  hemorrhoids,  ulcers,  or  tumors.  After  thref: 
weeks'  treatment  with  bismuth,  tannic  acid,  etc.,  he  began 
to  improve,  and  recovered,  ocner  cases  are  quoted  from 
the  literature.  The  cause  of  the  hemorrhage  is  unknown. 
The  diagnosis  of  hemorrhagic  proctitis  is  made  only  uy 
inspection.     [M.  O.] 


CENTRALSLATT  FUER  GYNECOLOGIE. 

.Intiuiirij  ],i,  1001.     No.  2. 

1.  Discussion  on  Gersuny's  Method  of  Paraffine-Injection. 

in  Incontinence  of  Urine.     JOHANNES  PFANNEN- 
STIEL. 

2.  On  Subcutaneous  Division  of  the  Sphincter  in  Restora 

tion  of  the  Peritoneum.     HEINRICH  FRITSCH. 

3.  A   Case  of   Uterine  Myoma  Complicated   by  Diabetes. 

DR.  JAHREISS. 
1. — Pfannenstiel,  in  writing  on  the  question  of  Ger- 
suny's method  of  injections  of  paraffine  In  inconti- 
nence of  urine,  reports  the  following  case;  K 
woman,  39  years  old,  with  a  strong  constitution 
and  free  from  organic  disease,  suffered  from  incon- 
inence  following  extirpation  of  the  urethra  for  car 
rinoma  of  the  uterus  which  had  involved  the  vaginal  walls. 
The  entire  urethral  canal  had  to  be  extirpated  together  with 
the  connective  tissue  up  to  the  pubic  arch.  A  fistulous 
tract  admitting  of  the  index  finger  resulted,  and  in  order 
to  cure  this  it  was  resolved  to  practice  injections  of  par- 
affine ointment  as  recommended  by  Gersuny.  By  means  of 
a  sharp  pointed  canula  an  injection  into  the  connective  tis- 
sue of  the  vaginal  submucosa  was  made.  The  patient  stood 
the  operation  well,  but  shortly  after  the  injection  suffered 
from  nausea,  chills,  severe  headache,  shortness  of  breath 
and  dyspnea.  The  respirations  reached  36  per  minute.  Ex- 
amination of  the  lungs  showed  no  pathologic  condition,  but 
on  the  following  day  the  patient  complained  of  pain  in  the 
left  side.  The  respirations  had  increased  to  40  per  minute, 
and  there  was  a  slight  cyanosis  of  the  face.  The  tempera- 
ture was  39  degrees  C.  and  the  pulse  104.  Still  there  were 
iio  objective  signs  to  be  found  on  examination  of  the  lungs. 
On  the  following  day  examination  showed  some  consolida- 
tion of  the  lung  on  the  left  side,  and  a  diagnosis  was  made 
(jf  a  paraffine  embolus  into  the  lung.  After  a  slightly  pro- 
longed convalescence  the  patient  made  a  good  recovery. 
Pfannenstiel  speaks  of  the  possibility  of  lung-embolism  and 
also  of  embolism  of  the  brain  as  sequelae  of  this  method 
of  treatment.     [W.  A.  N.  D.] 

2. — Fritsch  remarks  that  in  performing  perineorrhaphy 
there  are  two  important  principles  to  observe:  1.  To  cut 
nothing  away,  to  sacrifice  no  t'ssue.  and  not  in  the  old 
sense  to  freshen  the  edges,  but  merely  to  split  the  tissues, 
restore  the  old  relations,  and  then  to  suture  together  the 
perineum:  and  secondly,  to  recognize  the  value  of  the 
fimction  of  the  sphincter.  After  the  operation  has  been 
performed,  however,  in  this  manner  in  certain  cases  the 
sphincter  is  so  tight  that  the  introduction  of  the  finger  into 
the  anus  is  alm.ost  impossible.  The  tension  is  so  strong 
that  flatus  can  hardly  escape,  and  as  a  result  there  not 
infrequently  follows  a  distension  of  the  ampulla  of  the  rec- 
tum in  which  there  accumulates  both  gas  and  fecal  matter. 
To  overcome  this  condition  Simon  suggested  subcutaneous 
division  of  the  sphincter.  This  can  be  accomplished,  the 
finger  in  the  rectum,  by  means  of  a  sharp  tenotome,  the  action 
of  the  knife  being  controlled  by  the  finger  in  the  rectum.  Tt 
is  best  to  make  two  incisions,  one  to  the  right,  the  other  to 
the  left  about  one-and-one-half  cm  apart  The  small  incis- 
ions mav  then  be  closed  by  means  of  iodoform-gauze. 
Fritsch  has  also  employed  a  sagittal  incision,  whereby  the 
homorrha.ge  is  not  so  severe  and  healing  is  just  as  sure, 
although  the  pain  is  more  severe  than  by  the  subcutaneous 
division.  The  after-results  of  the  subcutaneous  division  of 
the  sphincter  are  so  good  that  he  is  inclined  hereafter  to 
employ  this  method  as  a  regular  procedure.  [W.  A.  N.  D  t 
3. — .Jahreiss.  of  .\ugsbure.  renor's  an  interesting  case  of 
uterine  myoma,  complicated  by  diabetes,  the  patient  being 
a  woman  4.S  years  of  age  who  hid  for  four  years  suffered 
from  severe  menorrhagia.  and  for  one  month  had  com 
nlained  of  a  severe  thirst,  together  with  palnitst'on  of  th-* 
heart  and  slight  swelling  of  the  feet.  Examination  showe-l 
her  to  be  somewhat  anemic,  and  there  was  a  certain  amount 


May   4,    1901] 


THE  LATEST  LITERATURE 


rTHK  p 

L  Mi;dI( 


Philadelphia        R87 
AL  Journal        <jo / 


of  lividity  of  the  mucous  membranes.  The  pulse  was  fre- 
quent, small  and  irregular,  and  both  feet  up  to  the  aitkles 
were  edematous.  The  uterus  presented  a  myomatous  tumor 
which  reached  up  to  the  umbilicus.  The  urine  was  quite 
sugary.  On  account  of  the  marked  anemia  and  the  irregu- 
larity of  the  heart,  operative  interference  for  the  relief  of 
the  myoma  seemed  contraindicated.  Instead  the  patient 
was  placed  in  absolute  rest  in  bed  and  administered  iron 
and  tonics.  After  four  weeks  the  general  condition  was 
better  and  the  pulse  was  less  frequent.  There  was  but 
slight  change,  however,  in  the  amount  of  sugar  in  the  urina 
The  patient  ultimately  suffered  from  neuralgic  attacks,  es- 
pecially in  the  right  iliac  fossa.  The  constituents  of  the 
urine  remained  the  same  until  the  death  of  the  woman. 
The  etiology  of  the  diabetes  is  not  plain;  there  was  no 
hereditary  history,  nor  was  there  the  history  of  syphilis; 
the  nervous  system  was  also  intact.  The  cause  might  have 
been  found  in  the  excessive  hemorrhage.     [W.  A.  N.  D.] 

Januurij  19,  I'Jdl. 

1.  Gynecological  Massage.    R.  OLSHAUSEN. 

2.  A  Case  of  Extensive  Radical  Operation  for  Pregnancy 

Complicated    by    Uterine    Cancer.      TH.    MICHOI>- 
ITSCH. 

1. — In  discussing  the  question  of  gynecological  massage 
Olshausen  concludes  as  follows:  Pelvic  massage  is  of 
value  in  cellular-tissue  exudates  which  show  a  tendency  to 
become  torpid  and  in  all  inflammatory  conditions  which 
persist  for  a  long  time.  Also  in  all  cases  of  exudate  which 
can  be  grasped  by  the  external  hand  and  compressed  be- 
tween the  fingers  of  this  hand  and  that  introduced  through 
the  pelvis.  Only  such  tubal  tumors  as  are  high  up  in  the 
pelvis  are  open  to  this  method  of  treatment,  as  hydrosal- 
pinx in  which  the  fluid  accumulations  can  be  caused  to 
escape  through  the  uterine  canal.  In  tubes  with  thickened 
wall,  but  without  fluid  contents,  massage  may  be  employed 
to  favor  removal  of  the  infiltration.  Peritoneal  adhesions, 
hematoceles,  and  anomolies  of  position  of  the  vagina  and 
uterus  are  not  suitable  for  massage  unless  accompanied 
by  exudates  which  are  the  direct  cause  of  the  displacement: 
the  massage  then,  by  removing  the  exudate,  will  Improve 
the  local  condition.     [W.  A.  N.  D.] 

2. — Micholitsch  states  that  the  question  arises  as  to 
what  is  the  proper  treatment  for  carcinoma  of  the  uterus 
in  pregnancy,  whether  by  vaginal  or  abdominal  opera- 
tion. He  reports  a  case  of  radical  operation  performed 
upon  a  woman  in  the  eighth  month  of  her  pregnancy.  The 
history  of  the  case  is  as  follows:  The  patient,  a  woman  41 
years  of  age,  was  in  her  tenth  pregnancy,  and  advanced  to 
the  eighth  month.  For  three  months  she  had  suffered 
from  irregular  hemorrhages.  Examination  showed  her 
tobesomewhatcachetic  with  wasting  of  the  panniculus  adi- 
posus.  She  was  in  a  generally  run  down  condition,  and 
over  both  lungs  there  were  marked  bronchitis  rales.  The 
fundus  of  the  uterus  reached  to  the  xiphoid  cartilage.  The 
fetal  heart-sounds  could  be  plainly  detected.  On  the  anter- 
ior cervical  lip  was  found  a  small  circumscribed  cancerous 
ulcer  of  the  size  of  a  walnut.  The  vaginal  mucous  mem- 
brane was  intact:  the  parametrium  was  free,  and  it  was 
impossible  to  find  any  large  lymph-glands.  The  operation 
on  the  following  day  consisted  in  a  median  Ceesarean  sec- 
tion, removal  of  the  child,  the  introduction  of  a  gauze-tam- 
pon into  the  uterine  cavity  and  closure  of  the  uterine 
wound  by  deep  sutures.  The  ureters  were  difficult  to  locate 
on  account  of  the  enlargement  of  the  parts,  but  they  were 
finally  freed  from  their  relations  to  the  uterus,  as  was  also 
the  bladder.  The  round  ligaments,  the  infundibulo-pelvic 
ligaments,  and  the  sacro-uterine  ligaments  were  ligated 
and  divided.  An  examination  was  then  made  for  infiltrated 
glands  with  the  object  of  their  removal,  should  they  be 
found.  The  vaginal  wall  was  divided  4cra.  below  the  portio 
vaginalis,  and  iodoform  gauze  drainage  was  established 
through  the  vagina.  The  peritoneum  was  sutured  above 
the  gauze  drainage  and  the  abdominal  wound  closed  in 
two  layers.  The  duration  of  the  operation  was  one  hour. 
The  child  was  a  male.  44  cm.  long  and  weighing  2250  dram?. 
The  patient  made  an  uninterrupted  recovery.  fW.  A.  N. 
D.] 

■/fiiiiinrii    ??,    mot. 

1.  Information    Concerning  the   Traces   of  the  Volsellum 

Forceps  in  the  Cervix  Uteri.    R.  CHROBAK. 

2.  On  the   Suprasmyphyseal   Cross-section  after  Kuester. 

F.  KUEHNE. 


?..     Puerperal    Gangrene    of    the    Lower    Extremities.      E. 
WORMSER. 

1 .  Chrobak  has  made  an  interesting  study  as  to  the  amount 
of  injury  caused   by  volsellum  forceps   in  the  cervix  uteri 

and  also  the  length  of  time  that  the  traces  of  these  forceps 
remain  in  the  uterine  tissue.  His  attention  was  first  called 
to  this  subject  by  a  case  of  uterine  rupture,  the  tear  lying 
near  the  fundus,  the  question  arising  as  to  whether  there 
was  any  relationship  between  the  uterine  tear  and  the 
use  of  the  instruments.  He  has  been  assisted  in  his  labors 
by  Peham,  who  gathered  statistics  for  him.  He  has  been 
able  to  find  20  cases  of  abortion  in  which  the  cervix  was 
grasped  by  the  forceps, in  all  of  which  slight  cervical  lacera- 
tions existed,  the  result  of  traction  by  the  forceps.  He 
found  that  in  most  of  the  cases  within  five  days  no  sign 
of  the  teeth  of  the  forceps  could  be  detected.  This  rapid 
disappearance  was  due  to  the  quick  regeneration  of  the 
ephithelial  tissue  which  is  peculiar  to  the  puerperal  uterus 
[W.  A.  N.  D.] 

2. — Kuehne  saw  the  first  case  of  cross  abdominal  incision 
performed  by  his  chief.  Kuester,  in  1896.  Ahfeld  also  short- 
ly afterwards  performed  the  operation  in  suitable  cases,  and 
Frantzen  in  1S97  slightly  modified  Kuesters  operation  and 
employed  it  for  ventral  fixation  of  the  uterus  for  the  cure 
of  the  prolapse.  Kahn  and  others  followed  in  their  footsteps. 
Mikucki  has  employed  the  Kuester  incision  twice,  once 
in  a  case  of  ovariotomy  and  once  in  ventral  fixation  for 
complete  prolapse,  with  falling  of  the  anterior  vaginal  wall. 
Pfannenstlel  more  recently  has  modified  the  method  so 
that  he  not  only  incises  the  skin  transversely,  but  also  the 
fascia,  and  then  opens  the  peritoneum  through  an  incision 
lengthwise  between  the  recti  muscles.  He  has  done  this 
in  order  to  avoid  the  subsequent  development  of  hernia.  He 
employed  this  incision  in  51  cases.  Kuehne  reports  12 
cases  in  his  clinic  operated  upon  by  thjs  method  for 
retroflexion  and  slight  vaginal  prolapse.  In  five  of  the  cases 
the  operation  was  performed  for  movable  retroflexion,  in  one 
of  which  there  was  also  a  prolapse  of  the  anterior  wall. 
The  other  cases  include  the  following:  One  case  of  pro 
lapse  with  hypertrophy  of  the  anterior  cervical  lip,  one  of 
complete  prolapse  with  falling  of  the  anterior  vaginal  wall, 
the  uterus  lying  in  the  middle  position,  and  five  cases  of 
complete  procidentia.  In  the  first  case  there  was  also 
performed  for  the  correction  of  the  uterine  prolapse  an 
anterior  kolporrhaphy;  twice  was  a  one-sided  salpingo- 
oophorectomy  performed.  The  ligament  was  also  fastened 
to  the  abdominal  wall.  The  indications  for  the  operation 
are  certain  conditions  of  the  uterine  displacement,  tubal 
pregnancy,  small  sized  uterine  myomata,  and  for  the  per- 
formance of  ventral  fixation.  The  contraindications  of  the 
transverse  incision  are  large  solid  ovarian  tumors,  or  those 
which  require  total  extirpation  of  the  uterine  appendage. 
IW.  A.  N.  D.] 

3. — Wormser  refers  to  the  article  by  Burckhard  in  No. 
51,  1900,  of  this  journal,  in  which  he  reported  two  cases  of 
gangrene  of  the  lower  extremities  occurring  during  the 
puerperium.  Miller  also  quotes  a  case  of  this  complication 
occuring  in  the  practice  of  Duflocq,  the  patient  being  a 
woman  3S  years  old.  in  her  flfth  pregnancy,  who  at  the  end 
of  the  pregnancy  suddenly  experienced  severe  pains  in 
the  right  foot  with  anesthesia  of  the  part.  In  spite  of  this 
condition  a  normal  birth  followed.  Four  weeks  after  the 
labor  the  foot  presented  the  appearance  of  marked  gan- 
grene with  a  well-defined  line  of  demarcation.  Glycosuria 
ensued  and  the  patient  died  on  the  29th  day  after  the 
disease  manifested  itself.  Autopsy  showed  a  slight  thick- 
ening of  the  mitral  valve  with  a  thrombosis  of  the  right 
femoral  artery.  Another  case,  according  to  Wormser.  is 
reported  by  J.  B.  Swayne  of  a  woman  34  years  of  age  in  her 
first  pregnancy.  She  likewise  suffered  from  pain  in  the  right 
leg  followed  by  the  development  of  a  gangrenous  spot  in  the 
foot  and  ankle,  which  also  necessitated  operation.  Section 
showed  a  slight  thrombosis  in  the  muscular  veins,  but  no 
thrombosis  In  the  larger  veins.     [W.  A.  N.  D.] 


CENTRALBLATT    FUER   CHIRURGIE. 

Janiiunj  .j_  1001.  (28  Jahrgang.  No.  1.) 

1.  The    Treatment    of    the    Shortening    in    Fractures    of 

Both  Bones  of  the  Leg.     N.  KAEFER. 

2.  The  Treatment  of  the  Fractures  of  the  Patella.   ALEX. 

WIENER. 
1. — When  both  bones  of  the  leg  are  broken,  some  short- 
ening follows.    The  fractured  bones  should  be  reduced,  un- 


CQC  The    I'lIILADELl-HIA  1 

"'-"-'  Medical  Juvhnal  J 


THE  LATEST  LITERATURE 


[Mav    4.    I'JOI 


der  anesthesia,  placed  in  a  plaster  of  Paris  bandage,  and 
left  8  to  10  days.  Weight  extension  seems  of  doubtful  bene- 
fit in  treating  these  fractures.  Von  Eiselsberg  used  elastic 
traction  in  the  plaster  bandage.  Kaefer  has  made  an 
apparatus,  with  screws,  which  is  fitted  into  the  plaster 
bandages  at  some  little  distance  from  the  site  of  the 
fracture.  Some  space  is  left  between  the  upper  and  lower 
bandages,  only  bridged  over  by  the  screws  of  the  appa- 
ratus. By  taking  in  a  half  screw  daily,  this  distance  is 
increased,  and  shortening  is  thus  prevented.  Kaefer  re- 
ports a  case  treated  in  this  manner  with  excellent  re- 
sult.    [M.  O.] 

2. — Fractures  of  the  patella  only  heal  with  difficulty. 
The  ideal  treatment,  cutting  down  upon  the  fragments, 
suturing  them  together,  and  then  closing  the  incision,  is 
attended  with  great  danger  of  infection,  and  a  few  patients 
will  submit  to  it.  Wiener  treats  them  by  wrapping  the 
knee  in  elastic  bandages,  over  much  wadding,  and  the  pa- 
tient walks  home.  This  is  left  on  4  or  5  days.  All  exu- 
date Is  then  absorbed,  and  the  fragments  of  the  patella  are 
in  opposition.  The  elastic  bandages  are  then  replaced, 
tighter  this  time.  Wiener  reports  two  cases  treated  thus. 
Pain  is  spared  the  patient  and  time  saved  for  the  sur- 
geon. Wiener  believes  that  fracture  of  the  patella  is  a  new 
indication  for  this  old  treatment.     [M.   O.] 

Januarii  li,  VJOl.     (28  Jahregang,  No.  2.) 

1.  The  Treatment  of  Luxation  of  the  Peroneus  Tendons. 

H.    REERINK. 

2.  A  Simple  Method  of  Plastic  Achillotomy.     C.  BAYEP 

3.  A  New  Hand   Operating-Table.     RATHMANN. 

1.^ — Reerink  reports  a  case  of  luxation  of  the  peroneus 
tendons  of  the  left  foot,  upon  the  external  malleolus,  with 
great  pain  and  swelling.  There  was  foot-drop,  with  adduc- 
tion Of  the  toes.«  The  foot  was  placed  in  a  splint,  and  ice 
applied.  Six  days  later  the  tendons  were  replaced  in  po- 
sition, and  kept  there  by  strips  of  zinc  oxide  adhesive 
plaster.  Four  days  later  a  plaster  of  Paris  bandage  was 
applied.  Two  weeks  afterward,  this  was  removed,  and 
another  put  on  for  three  weeks  longer.  Then  massage 
was  given  daily  for  a  few  weeks.  Since  then  the  foot  has 
been  in  excellent  condition.  A  Roentgen  photograph 
showed  the  malleolus  intact.  Reerink  cites  the  literature 
of  the  subject.     [M.   O.] 

2. — Bayer  reports  a  case  in  which  he  performed  tenotomy 
upon  the  tendo  Achillis,  dividing  the  operation  into  halves. 
One  half  of  the  tendon  he  slit  subcutaneously,  in  the 
muscle  itself;  the  other,  down  near  the  calcaneum.  in  the 
tendo  Achillis  proper.  Thus  no  scar  resulted,  and  the 
foot-drop  was  easily  corrected.  A  week  later,  on  removing 
the  splint,  the  tenotomy  openings  had  completely  healed, 
and  the  foot  was  in  normal  position.  There  was  no  visible 
difference  between  the  two  sides  of  the  divided  tendo  Ach- 
illis.    After  another  week,  the  patient  walked  well.     [M.O.] 

3. — Rathmann  describes  a  stand  which  can  be  clamped 
upon  any  table,  to  be  used  for  operations  upon  the  hand. 
It  is  made  of  glass,  held  in  metal,  and  can  be  raised  to 
any  height  desired.  Rathmann  advises  its  use  for  all 
operations   upon   the   hand.      [M.   C] 

Jaiiiiarii  1!).  Ifliil.     (28  Jahregang,  No.  3.) 

1.  How   is   Regular,   Deep,   Quiet  Breathing  Obtained,   in 

Administering  Anesthetics?   C.  HOFMANN. 

2.  A  New   Plastic  Operation   on  the  Cheek,   with  Double 

Flaps.     F.   NEUGEBAUER. 

3.  The  Sterilization  of  Silk  Catheters.     M.  W.  HERMAN. 
1. — It  is  now  generally  understood  that  the  best  method 

of  administering  anesthetics  is  to  allow  plenty  of  air. 
Ilolmann  believes  that  quiet  talking,  and  counting  aloud 
will  keep  some  individuals  still  while  taking  an  anes- 
thetic. But  to  make  them  begin  counting  at  200,  and  count 
backward  will  cause  them  to  breathe  quietly  and  regu- 
larly. Patients  take  more  easily  to  this  than  to  ordinary 
counting.  He  lets  the  counting  begin  a  minute  before  a 
drop  of  the  anesthetic  is  used,  and  then  this  is  added  drop 
by  drop,  gradually,  so  that  enough  air  enters  the  lungs 
to  prevent  coughing,  etc.  Hypodermic  injections  of  V4  to  ^i. 
of  a  grain  of  morphi,ne,  before  the  anesthetic  is  given,  will 
also  help  to  cause  regular,  deep,  quiet  breathing  through- 
out the  entire  operation.     [M.  O.] 

2. — Neugebauer  operated  upon  a  child,  5  j'ears  old,  part 
of  whose  cheek,  near  the  angle  of  the  mouth,  had   been 


destroyed  by  noma.  He  employed  Krause's  method,  ma- 
king two  skin  flaps,  without  pedicles,  from  the  neck.  In 
two  weeks  the  double  flaps  had  grown  together,  and  cicatri- 
cial contration  was  not  noticeable.  The  results  of  the 
Krause  double  flap  method,  without  pedicles,  cannot  be 
distinguished  functionally  from  the  operations  with  pedi- 
cled    flaps.      [M.    O.] 

3. — While  metal  catheters  are  easily  sterilized  by  boil- 
ing, the  sterilization  of  silk  catheters  has  always  been 
difficult.  Hermann  has  experimented  with  an  ammonio- 
sulphurlc  solution,  concluding  that  silk  catheters  become 
more  elastic,  and  are  in  no  wise  harmed  by  being  boiled  5 
hours,  frequently,  in  this  solution;  that  very  dirty  cathe- 
ters will  be  sterilized  after  boiling  from  3  to  0  minutes  in 
this  solution;  that  they  can  be  used  straight  from  the 
solution,  without  injury  to  the  urethra:  and  that  metal 
and  elastic  catheters,  sounds,  and  bougies  can  be  steril- 
ized in  this  solution  also.  Herman  believes  that  this  is  the 
simplest  and  best  method  for  sterilizing  silk  catheters. 
[M.    O.] 

January  Hd,  I'JDl.     (28  Jahregang,  No.  4.) 

1.  Chirol.— R.  SCHAEFFER. 

2.  Two  Technical  Prooositions  in  Gastro-enteric  Surgerv. 

M.   SCHMIDT. 

1. — In  reply  to  Kossmann's  last  article  defending  the 
use  of  chirol  upon  the  hands  in  vaginal  examinations,  (of 
midwives  especially),  Schaeffer  repeats  his  objections  to 
chirol,  and  details  six  experiments  with  the  bacillus  pyo- 
caneus  and  the  bacillus  prodigiosus,  in  all  of  which  the 
chirol  showed  its  inefficiency.  Schaeffer  strongly  de- 
precates its  use.     [M.  O.] 

2. — Schmidt  suggests  gastro-duodenostomy,  after  separa- 
tion of  the  duodenum  from  the  pylorus,  and  occlusion  of 
the  pylorus.  This  can  take  the  place  of  resection  of  the 
pylorus,  or  of  gastro-enterostomy,  especially  when  the 
pylorus  is  badly  affected,  and  the  duodenum  is  healthy. 
He  also  suggests  a  plan  to  avoid  the  purse-string  suture 
when  using  the  Murphy  button.  For  this,  he  advises  push- 
ing and  rolling  the  half  of  the  button  into  place  in  the 
intestine,  until  it  reaches  the  spot  where  it  is  wanted. 
Schmidt  would  be  glad  to  hear  of  results  of  either  of 
these  propositions  in  practice.     [M.  0.] 

Fihruary  i.  J'JOl.     (28  Jahregang,  No.  5.) 

1.  A  Divided  Ureter  Treated  by  Direct  Suturing.     VON 

GUBAROFF. 

2.  The  Treatment  of  Oblique  Fractures  of  Both  Bones  of 

the   Leg   by    Bardenheuer's   Weight    Extension.      O. 
WOLFF. 

1. — Vt'hcn  it  is  impossible  to  stitch  the  torn  end  of  a 
divided  ureter  into  the  bladder,  the  two  ends  can  be  sutured 
together.  Von  Gubaroft  reports  an  operation  for  the  re- 
moval of  an  enormous  fibrosarcoma,  during  which  a  bit  of 
the  right  ureter  was  carried  away.  As  Van  Hook's  typical 
method  of  joining  the  ends  would  have  taken  too  much 
time,  von  Eubaroff  divided  the  lower  end  lengthwise,  and 
invaginated  the  upper  into  the  lower  end,  putting  in  sutures 
running  lengthwise.  A  sound  was  first  introduced.  The 
technique  is  shown  in  several  drawings.  The  operation 
was  quite  successful.  Laying  the  ureter  free,  as  was  done 
in  this  case  over  4  cm.,  seems  to  have  had  no  bad  effect 
upon  recovery.  As  the  patient  died  a  month  later,  the 
autopsy  showed  the  excellent  result  of  operation.    [M.  O.] 

2. — Wolff,  in  reply  to  Kaefer's  recent  criticism  of  Barden- 
heuer's weight  extension  believes  that  it  is  only  when  the 
technique  is  faulty  th;U  this  method  of  treating  oblique 
fractures  of  both  bones  of  the  leg  is  unsuccessful.  He 
mentions  the  details  of  the  technique  as  it  should  be.  the 
large  weight  required,  (30  to  35  lbs.)  and  that  extension 
must  be  constant,  day  and  night.  In  his  experience  this 
treatment  has  not  been  followed  by  shortening.     [M.  O.] 

Fehruarii  S,  1901.     (2S  Jahregang,  No,   6.) 

1.  A  Consideration  of  the  Injuries  of  the  Soft  Parts  and 

the  Origin  of  the  Hemorrhage  in  Hemarthrosis  Genu. 
C.  LAUENSTEIN. 

2.  A  New  Procedure  in  Treating  Fractures  of  the  Patella. 

POPPER. 

3.  The   Treatment    and   the   Prevention   of   Arthrogenous 

Contractures  in  the  Knee-joint.     C.  BURNS. 
1. — .\   bloody   effusion    into   the   knee-joint  is  treated   in 


May   4,    I'.ioll 


THE  LATEST  LITERATURE 


TThe  Philadelphia        RSq 
L  Medical  JouHSAL  ""-"y 


three  different  ways:  (1)  by  compression,  massage,  move- 
ments, etc.:  (2)  absolute  rest,  with  ice.  elevation,  etc.:  and 
(.T)  puncture,  with  rest  following  the  withdrawal  o£  the 
effusion.  The  last  method  has  been  commonly  employed 
in  Hamburg,  where  Lauenstein  operated  mainly  upon  sail- 
ors. It  removes  the  effusion  more  quickly  than  any  other 
way.  Besides,  it  will  permit  observation  upon  the  origin 
of  the  hemorrhage,  especially  when  the  soft  parts  have 
been  injured.  For  this,  Lauenstein  used  a  long  probe,  passed 
through  the  canula,  with  which  he  found  injuries  of  the 
capsula  and  ligaments.  After  cleaning  out  the  joint,  it  Is 
put  at  rest  with  a  tight  bandage.     [M.  O.] 

2. — Popper  has  described  his  method  of  treating  fractures 
of  the  patella.  He  places  pieces  of  adhesive  plaster  above 
the  upper  fragment  and  below  the  lower  fragment,  then 
pulls  them  together,  passing  one  through  the  other.  An- 
other strip  of  adhesive  plaster  passes  over  them.  Plaster 
of  Paris  bandages  are  applied  below  and  above  the  knee, 
over  the  ends  of  the  adhesive  strips.  The  next  day  mas- 
sage is  begun,  even  while  the  plaster  casts  are  on.  After  2 
or  3  weeks,  the  plaster  bandages  are  removed  and  mas- 
sage continued.     [  M.  O.] 

3. —  Burns  reports  the  case  of  a  girl  of  8.  with  a  con- 
tracture of  her  right  tcnee  following  septic  arthritis  in  in- 
fancy. Resection  of  the  knee-joint  was  performed,  but  the 
contracture  again  appeared.  The  flexor  muscles  had  con- 
tracted, especially  the  biceps.  In  another  case,  a  boy  with 
the  same  contracture  following  fungus  of  the  knee,  the 
biceps  tendons  were  transplanted  into  the  quadriceps 
tendons,  and  left  bandaged  for  three  weeks.  Since  then  he 
walks  perfectly.  The  parents  of  the  little  girl  would  not 
permit  operation.  Two  more  cases  were  operated  upon 
with  excellent  results.  Resection  may  become  necessary 
later  in  some  of  these  cases.  But  transplantation  of  the 
tendons  gives  good  functional  results.     [M.  O.] 

Fehruury  16,  I'Ml.     (28  Jahregang,  Xo    7.) 

1.     An    Original    Mechanical   Treatment   for   Inguinal   and 
Femoral  Hernia.     W.  WOLFERMANX. 

1. — Wolfermann  believes  that  a  number  of  the  opera- 
tions for  the  radical  cure  of  hernia  are  performed  because 
of  the  trouble  caused  by  uncomfortable,  incorrectly  applied 
trusses.  The  pressure  of  the  spring  used  must  not  be  too 
great.  Constant  correctly  applied  pressure  will  cause  in- 
flammation in  the  inguinal  canal  with  some  adhesion  of  the 
opposing  walls,  and  eventual  cure  of  the  hernia.  Yet  the 
truss  should  be  worn  for  some  months  longer.  His  truss 
has  a  long,  oval  cushion,  with  its  convex  surface  so  ap- 
plied to  the  abdominal  wall  that  its  highest  point  covers 
the  abdominal  opening  of  the  inguinal  canal.  Details  of  the 
manufacture  of  his  patented  truss,  of  its  usefulness,  and  of 
how  it  should  be  applied,  are  given,  with  some  of  its  good 
results.     [M.  O.] 

Mnrch  16,  1001.     (28  Jahrgang,  Xo.  11.) 

1.  An  Aid  in  the  Demonstration  and  Study  of  Roentgen 

Negatives.     K.   LUDLOFF. 

2.  An  Additional  Hint  in  Ether  Narcosis.    W.  REINHARD. 

3.  Benzin  in  Surgery.     F.  FRANKS. 

1. — The  Roentgen  negative  has  been  used  for  demonstra- 
tion in  Koenigsburg.  with  the  Hirschmann  apparatus,  a 
closed  box  containing  an  electric  light,  with  the  negative 
fixed  before  it.  in  a  darkened  room.  Ludkoff  has  found  that 
by  using  an  ordinary  opera-glass,  the  details  of  the  nega- 
tive will  come  out  wonderfully  clear.  A  window  may  be 
substituted,  though  the  light  will  not  be  as  strong.     [M.  O.] 

2.  On  account  of  the  accumulation  of  mucus  in  the 
throat,  so  common  when  ether  is  employed  as  an  anes- 
thetic, Reinhard  uses  atropin,  with  morphin  or  codein, 
hypodermically,  before  operation.  Beside  drying  up  the 
secretion,  atropin  acts  as  a  stimulant.     [M.  O.] 

3. — As  a  substitute  for  ether  in  removing  fat.  dirt,  adhesive 
plaster,  etc..  from  the  skin  before  operation.  Franke  uses 
benzin.  It  is  cheaper  than  ether,  does  not  have  such  a 
frigid  effect,  nor  does  it  burn,  like  ether,  upon  open 
wounds.  Franke  has  used  benzin  for  ether  for  years,  since 
many  consider  the  odor  less  objectionable  than  the  ether. 
[M.  O.] 

Mnrch  ,?.?.  I'jdl.     (28  Jahrgang.  Xo.  12.) 
1.     The  Application  of  Bandages  in  Fractures.F.  BAEHR. 
1. — The  main   cause  of  failure   to   secure   union   of  the 


bones  after  a  fracture  is  the  poor  or  loose  application  of 
bandages.  Baehr  applies  pressure  by  loops  about  either 
end.  in  oblique  fractures  especially,  pulling  the  two  ends 
into  place  while  the  plaster  bandages  are  applied.  This  se- 
cures excellent  apposition.  Baehr  reports  two  ca^e  treated 
thus.  The  loops  pull  in  opposite  directions.  Both  caseB 
healed  in  three  weeks.  This  simple  method  is  especially 
serviceable  in  fractures  of  both  bones  of  the  forearm  or 
leg.     [M.  O.] 

March  30,  1901.     (28  Jahrgang,  No.   13.) 

1.     The  Technique  for  Radical  Cure  of  Large  Ventral  Her- 
nia.    SALISTSCHEFF. 

1. — Saltstscheff  reports  two  cases  of  large  ventral  hernia 
in  which  he  operated.  The  first  patient  was  a  man  of  30, 
who,  three  months  before,  had  cut  across  his  left  rectus 
muscle  in  the  upper  abdomen,  in  an  attempt  at  suicide. 
This  had  not  been  stitched,  and  a  hernia  had  formed.  The 
sac  was  replaced  in  the  abdominal  cavity,  the  peritoneum 
closed,  and  two  flaps  cut  from  the  rectus,  8  cm.  above  and 
below  the  cut.  These  were  then  turned  back  and  united. 
Fascia  and  skin  were  closed  afterward,  and  he  recovered. 
The  second  patient  was  a  man  of  39,  with  a  hernia  through 
the  external  oblique  muscle.  After  closing  the  peritoneum, 
he  cut  a  long  flap  from  the  rectus,  and  drew  it  over  the 
opening.  This  also  healed  well.  No  degeneration  of  the 
muscle  has  occurred,  and  the  radical  cure  in  both  cases 
was  accomplished.     [M.  O.] 


CENTRALBLATT     FUER     INNERE     MEDIZIN. 

February  16,  1901. 

Concerning  the  Demonstration  of  the  Presence  of  Bilirubin 

in  the  Urine  by  Means  of  the  Ehrlich-Diazo  Reaction. 

F.  PROESCHER. 
Proescher  has  previously  reported  that  he  has  isolated 
azobilirtibin  in  chemically  pure  form.  He  considerB  that 
the  diazo  reaction  is  specific  for  bilirubin,  and  is  extrermeiy 
delicate.  Biliverdin  and  bilihumin  either  do  not  give  the 
reaction  or  give  it  in  only  the  slightest  degree,  and  this  is 
even  more  markedly  true  of  bilifucsin  and  bilifrasin.  The 
reaction,  he  states,  is  an  extremely  striking  color  change, 
and  is  carried  out  by  saturating  10  c.  c.  of  urine  ■with 
ammonium  sulphate,  separating  the  pigmented  precipitate 
on  a  small  filter,  and  extracting  the  pigment  with  9-5  per 
cent  alcohol.  The  alcoholic  extract  is  acidulated  strongly 
with  HCI,  and  the  diazo  test,  using  the  ordinary  solutions, 
is  carried  out.  If  bilirubin  is  present  the  fluid  takes 
a  striking  blue  color.  If  caustic  potash  solution  is  added 
it  becomes  red  at  the  neutral  point,  and  when  the  mixtures 
becomes  alkaline  it  takes  a  marked  green  color.  It  is  beet 
to  precipitate  with  ammonium  sulphate  and  then  extract, 
rather  than  test  the  urine  directly,  as  other  substances  in 
the  urine  interfere  with  the  reaction.  He  states  that  one 
can  in  this  way  determine  the  presence  of  one  part  of  bili- 
rubin in  60,000  parts  of  fluid.     [D.  V.  E.] 

March    16,    1!)01. 
On  Reflex  Excitation  of  the  Pulse. 

M.  HEITLER. 
Heitler  refers  to  some  observations  previously  reported 
(which  were  abstracted  in  the  Philadelphia  Medical  Journal 
from  the  Wini.  Klin.  Wlicli..  1S99,  No.  52).  These  consisted 
of  a  note  of  increase  in  the  volume  of  the  pulse  in  a  neur- 
asthenic man  after  percussing  the  region  over  the  liver  and 
a  similar  observation  when  the  precordia  was  percussed. 
As  the  pulse  grew  larger  in  size  the  cardiac  dulness  grew 
smaller.  He  has  investigated  this  phenomenon  further  In 
a  series  of  persons,  chiefly  convalescent  from  slight  illness- 
es, and  finds  that  the  phenomenon  occurs  in  the  minority 
of  cases  only  after  irritation  of  the  region  of  the  heart  and 
liver:  in  most  cases  it  occurs  after  irritation  of  the  heart  and 
liver  region,  but  also  after  irritation  of  the  skin,  the  bones, 
the  muscles,  the  mucous  mebranes,  and  the  arteries,  and 
after  flexing  and  extending  the  extremities.  Those  per- 
sons who  show  the  phenomenon  after  irritation  of  various 
regions  exhibit  a  marked  variety  in  the  manner  in  which 
the  phenomenon  is  produced.  With  some  the  reflex  is  pro- 
duced only  by  irritation  of  the  skin  in  definite  regions:  in 
others  irritation  of  the  whole  skin  surface,  and  in  still 
others  by  irritation  of  other  tissues,  or  by  irritation  of  any 


Snn        ''"E  Pmi.ADKr.PniA  "I 
"y*-"  Medical  Jovhnal  J 


THE  LATEST  LITERATURE 


IMav  4.   i;<oi 


of  the  body  tissues.  The  phenomenon  is  much  more  pro- 
nounced as  a  rule  after  irritation  of  the  sternum  than  after 
irritation  of  the  surrounding  regions,  though  the  surface 
over  tiie  ribs  near  the  sternum  and  over  the  inner  end  of 
the  clavicles  apparently  reacts  readily,  and  a  particularly 
irritable  region  is  tliat  over  the  5th  rib  between  the  para^ 
sternal  and  mammary  lines.  The  reflex  after  percussion  of 
the  liver  region  is  produced  only  when  this  percussion  is 
undertaken  directly  over  the  liver,  not  as  a  result  of  per- 
cussion of  surrounding  regions.  The  phenomenon  varies 
In  the  same  individual  on  the  same  day  or  different  days, 
sometimes  being  produced  by  irritation  of  the  same  regions, 
and  at  other  times  not  by  the  methods  first  used,  but  by 
Irritation  of  other  areas  or  tissues.  Irritation  of  one  region 
of  the  body  produces  a  reflex  which  gradually  decreases 
in  intensity.  It  is  notable,  however,  that  if  the  pulse  is 
excited  by  irritating  one  region  .  although  irritation  of  this 
region  will  soon  lose  its  effect,  irritation  of  another  region 
will  then  cause  a  much  more  active  reflex  than  if  there  had 
been  no  previous  excitation  of  the  pulse.  Also,  if  irritation 
of  the  sltin  causes  no  reflex,  percussion  of  the  liver  and 
subsequent  irritation  of  the  skin  will  frequently  pro 
<luce  a  reflex.  The  appearance  of  the  reflex  is  some- 
times very  rapid  and  sometimes  slow;  it  sometimes 
persists  for  a  considerable  period  and  sometimes  rapidly 
vanishes.  The  reflex  from  irritation  of  the  skin  is  much 
more  marked  than  that  from  irritation  of  the  muscles  or 
flora  irritation  of  the  bones.  A  change  in  the  pulse  after 
stroking  a  large  area  of  the  skin  is  not  greater  than  that 
after  stroking  a  small  area;  it  is  sometimes  even  less. 
[D.  L.  E.] 


NEUROLOGISCHES    CENTRALBLATT. 

M(inh  Jst,   [No.   5.] 

No.  1.     A  Little-Known  Tract  of  Fibres  in  the  Periphery 
of  the  Anterolateral  Portion  of  the  Cervical  Cord. 
By   V.    BECHTEREW. 
No.  2.     Intermittant  Claudication.     By  GOLDFLAM. 
No.  3.     Amyotactic  Dysphagia.     By  ROSSOLIMO. 
No.  4.     The   Histology   of   the   Changes   Produced    by   the 
Compression   of  the   Spinal   Cord   by  Vertebral   Tu- 
mors.—By    BIELSCHOWSKI. 

No.  1. — Von  Bechterew  refers  to  the  band  of  fibres  that 
he  described  in  1S94  under  the  name  of  the  "Olivary 
Tract."  In  regard  to  the  direction  in  which  these  fibres 
pass,  he  believes  that  they  invariably  convey  impulses 
downward,  and  of  course,  degenerate  in  the  same  direc- 
tion, although  Pick  is  of  a  contrary  opinion.  They  prob- 
ably have  some  relation  to  the  lower  olive,  although  there 
is  not  at  present  sufficient  evidence  to  prove  this  point.  It 
is  not  certain  that  they  are  similar  to  other  tracts  in  this 
region.  They  have  been  described  by  various  writers. 
J.  S. 

No.  2. — Goldflam  has  observed  a!to2;othor  the  consider- 
able number  of  24  cases  of  intermittant  claudication.  The 
symptoms  of  this  condition  are  the  development  of  pain 
or  paraesthesia  in  the  legs  after  more  or  less  prolonged  ef- 
fort at  walking,  which  disappears  after  a  brief  period  of 
rest,  and  reappears  upon  renewed  exertion.  During 
these  attacks  it  has  been  observed  that  the  pulse  in  the 
artery  of  the  foot  has  disappeared,  and  the  pathology 
therefore  consists  in  more  or  loss  complete  occlusion  of 
the  arteries  of  the  lower  extremity.  The  feet  as  a  result 
are  cold,  cyanosed  and  slihtly  swollen  and  the  muscles  of- 
ten slightly  wasted.  In  the  24  cases  observed  by  Gold- 
flam  pulsation  in  the  dorsalis  pedis  artery  was  absent  in 
13  cases  on  both  sides;  in  10  cases  on  one  side;  and  in 
1  case  it  was  very  weak  but  palpable  on  both  sides.  The 
posterior  tibial  artery  could  not  be  felt  on  either  side  in 
7  cases,  and  on  only  one  side  in  8  cases.  In  the  remain- 
ing 9  cases  the  pulse  was  present.  The  symptoms  of  this 
disease  may  last  for  many  years,  but  as  the  vascular  con- 
dition is  progressive  they  usually  increase  in  severity, 
and  from  time  to  time  there  will  be  spontaneous  attacks 
of  pain.  In  addition  there  are  often  vasomotor  dis- 
turbances that  contribute  to  the  symptoms.  In  some 
cases  the  paresthesia  exceeds  the  pains,  as  in  the  case 
of  a  man  30  years  of  age,  exposed  to  severe  weather 
in  his  occupation  of  forester.  He  suffered  from  a  feel- 
ing of  cold  in  the  toes,  particularly  in  the  great  toe, 
and  the  4th  toe.  In  this  case  pulsation  was  absent  from 
the    artery    of    the    foot    and    there    were    evidences    of 


occlusion  of  the  veins.  He  also  reports  the  case  of  a 
man  40  years  of  age  in  whom  the  symptoms  appeared  on 
only  one  side,  whilst  on  the  other  the  artery  pulsated 
freely  and  there  were  no  pains.  Another  case  in  which 
the  artery  could  not  be  felt  in  either  foot,  but  the  vaso- 
motor symptoms  were  present  in  only  one  foot,  and  in 
that  the  pains  occurred.  The  author  also  reports  a 
case  occurring  in  a  man  of  23,  and  involving  only  the 
left  leg.  In  regard  to  the  etiology  of  this  condition  it 
occurs  naturally  among  older  men.  Twenty-one  cases 
were  over  30  years  of  age.  In  only  one  case  was  diabetes 
present,  and  in  this  the  sugar  appeared  long  after  the 
claudication.  Many  of  the  patients  were  smokers,  but 
some  had  never  used  tobacco,  and  the  withdrawal  of  the 
weed  had  no  beneficial  effect.  As  2  cases  have  occa- 
sionally been  observed  in  the  same  family,  it  is  possible 
that  there  is  a  family  predisposition,  and  neuropathic  dis- 
position is  also  of  influence.  Svphilis  and  alcohol  appear  to 
be  without  any  influence.  Some  of  the  cases  closely  re- 
semble Raynaud's  disease,  as  for  example  the  following, 
occurring  in  a  woman  of  30  who  had  had  a  severe  per- 
sistent pain  in  the  ring  finger  of  the  right  hand,  that 
had  failed  to  yield  to  any  treatment,  even  operative  inter- 
ference. She  also  suffered  from  migraine,  the  attacks 
occurring  from  one  to  several  times  a  month.  Her  pa- 
rents were  first  cousins.  Two  sisters  had  distinct  neu- 
rotic manifestations.  The  ring  finger  of  the  right  hand 
was  bluish  at  the  extremity,  and  the  whole  hand  was 
colder  than  the  left.  There  were  evidences  of  nephritis 
and  weakness  of  the  heart.  The  finger  was  finally  ampu- 
tated, but  the  patient  died  of  heart  disease  a  few  months 
later.  There  was  some  thickening  in  the  artery  of  the 
amputated  finger.  Goldflam  believes  that  the  purely 
functional  Raynaud's  disease  may.  in  time,  produce  vas- 
cular changes  in  the  peripheral  arteries.  In  regard 
to  the  treatment  of  intermittant  claudication,  it  should  be 
directed  partly  to  the  prevention  of  the  most  serious  com- 
plication, gangrene,  and  partly  to  the  relief  of  the  symp- 
toms. The  patient  should  be  directed  not  to  make  any 
tours  on  toot.  The  feet  should  be  kept  warm,  and  should 
be  protected  against  the  wet.  Alcohol  and  tobacco  should 
be  forbidden,  and  only  milder  forms  of  food  consumed. 
No  drugs  are  of  value,  not  even  the  iodides,  or  nitrites.  In 
a  few  cases  a  transient  Improvement  may  be  obtained  from 
electrical  treatment.     [J.  S.] 

No.  3. — Rossolimo  reports  3  additional  cases  of  difficulty 
in  swallowing.  The  first,  a  woman  of  38,  with  a  bad 
hereditary  history,  who  had  suffered  a  great  variety  of 
forms  of  anxiety,  developed  fear  of  swallowing  at  the  age 
of  SO.  This  lasted  about  3  months,  and  disappeared  after 
the  administration  of  sodium  bromide  and  static  electric- 
ity. The  next  patient,  also  a  degenerate,  a  woman  of  31, 
as  a  result  of  emotional  disturbances  had  difficulty  in 
swallowing,  at  first  solids  and  later  liquid  foods.  She 
was  not  improved  by  treatment.  The  third  patient,  a  man 
of  26,  without  neuropathic  heredity,  had  had  a  variety  of 
infectious  diseases.  .A.s  a  result  of  a  severe  cold  he  employed 
large  quantities  of  snuff,  causing  dryness  of  the  throat  and 
difficulty  in  swallowing.  This  was  relieved  by  local  treat- 
ment. Renewed  indulgence  in  snuS  caused  complete 
inability  to  swallow.  These  symptoms  continued  for  11 
years.     [J.  S.] 

No.  4. — Bielschowski  reports  the  case  of  a  woman  who 
had  had  a  tumor  of  the  breast  followed  by  metastasis  to  the 
spinal  column,  involving  the  bodies  of  the  vertebrae  from 
the  6th  to  the  8th  dorsal,  and  causing  pressure  upon  the 
spinal  cord,  without  invasion  of  the  membranes.  Sec- 
tions of  the  spinal  cord  from  this  region  showed  by  Van 
Giesen's  stain  a  peculiar  sieve-like  condition  of  the  white 
substance,  as  a  result  of  the  degeneration  of  the  nerve 
fibres.  There  were  also  numerous  compound  granular 
cells,  some  normal  fibres,  and  various  colloid  bodies.  The 
neuroglia  was  not  markedly  changed  except  in  the  pos- 
terior columns,  where  it  was  somewhat  hyperplastic. 
The  cells  showed  extreme  degeneration,  both  by  this  and 
Nissl's  method;  the  pia  mater  was  normal.  Microscopically 
a  few  black  bodies  were  found,  and  a  considerable  num- 
ber of  fat  granules  in  the  small  vessels.  There  was  sec- 
ondary degeneration  in  the  pyramidal  columns  below  the 
lesion  and  in  the  posterior  column  above  the  lesion. 
Schultze's  comma  degeneration  was  present  in  the  pos- 
terior column  below  the  lesion.  Flechsig"s  oval  area  was 
not.  however,  involved.     [J.  S.] 


Mat   4,   IWl] 


THE  LATEST  LITERATURE 


LTnE  Philadelphia        Rqt 
Medical  Jouuxal         fyj- 


ZEITSCHRIFT    FUER    ORTHOPAEDISCHE    CHIRURGIE. 
1901.     [Volume  8,  Nos.  3  and  4.] 

16.  The  Etiology  of  Deviations   of  the  Trunk.     P.   LOR 

ZEN. 

17.  The   Origin   and   Treatment   of   Club-Toes.     C.    HOP- 

MAN. 
18     Hysteric  Scoliosis  of  the  Wertheim-Salomonson  Type. 
J.   SHOEMAKER. 

19.  Inexpensive  Bandages.     W.  SENDER. 

20.  The  Funnel  Breast.     CHLUMSKY. 

21.  The   Orthopedic   Work   of  the   late   Professor   Albert. 

A.  LORENZ. 

16. — An  uncomplicate<l  lateral  curvature  of  the  spine  is 
rare,  as  there  is  generally  some  asymmetrj'  of  the  body. 
The  physician  must  first  decide  whether  a  true  deforn^- 
itH  (scoliosis,  kyphosis,  etc.)  is  present,  or  whether  there  Is 
merely  an  anomaly  of  position.  From  long  study,  Lorenz 
believes  that  every  deviation  in  the  shape  of  the  trunk  is 
the  result  of  habitual  position,  assumed  for  rest  or  comfort. 
That  this  habit  becomes  a  true  deformity  depends  upon  a 
diseased  condition,  either  general,  or  localized  to  the  ver- 
tebral column.  Rarely  a  position  which  has  been  a  habit 
for  years  may  of  itself  become  a  deformity.  Or  an  attitude, 
formerly  assumed  only  on  walking  or  standing,  may,  during 
illness,  became  permanent.  This  occurs  more  often  among 
girls  than  boys.  In  early  life,  rachitis  predisposes  to  de- 
formity later.  Deformity  may  occur  from  long  standing, 
depressing  disease  or  during  convalescence  from  any  ill 
ness.  Chronic  rheumatism  may  predispose  to  deformity, 
especially  in  those  who  habitually  return  to  a  position 
of  rest  .  Pleurisy  and  sciatica  act  in  the  same  way. 
The  deformity  following  rheumatic  myositis  generally  ap- 
pears in  the  upper  half  of  the  trunk,  with  torticollis.  Lum- 
bago may  cause  a  similar  anomalous  condition  of  the  lum- 
bar vertebrae.  In  such  cases  an  infiltration  appears  in  the 
affected  muscle-fibres,  which  then  remain  distended,  pro- 
ducing the  deformity.  In  some  of  these  cases,  the  spinal 
column  is  undoubtedly  affected.  In  treating  these  cases, 
any  existing  local  affection  must  first  be  cured.  Apparatus 
v.ill  do  harm  in  children  in  whom  faulty  position  causes 
apparent  deformity.  Exercise  is  then  needed.  If  true  de- 
formity exist  immobilization,  with  general  and  local  treat- 
ment, is  necessary.  In  all  cases,  the  cause  of  the  deformity 
must  be  sought  and  removed.  Finally,  in  cases  which  at 
first  seem  hopeless,  bandages  and  systematic  movements 
may  be  the  means  of  discovering  a  local  curable  condition. 
[M.  O.]. 

17. — Club-toes  fhammer-toesi  is  the  name  given  by  Hof- 
man  to  that  deformity  in  which  the  toes  are  held  in  a  posi- 
tion of  plantar  flexion  and  median  adduction.  With  this 
exists  some  grade  of  fiat-foot.  Hofman  describes  two  such 
feet,  found  accidentally  in  a  cadaver.  As  in  hallux  valgus, 
there  can  be  no  suspicion  of  arthritic  process.  Hofman 
reports  the  case  of  a  man  who  hurt  his  knee  a  year  ago, 
since  when  he  has  voluntarily  assumed  the  position  in 
which  the  knee  hurts  least  This  is  the  club-toe  position, 
described  above.  The  deformity  is  not  fixed,  and  he  can 
walk  normally,  but  with  pain  in  the  knee.  Hofmann  con- 
cludes that  club-toes,  when  not  congenital,  may  exist  when- 
ever the  toes  assume  an  acquired  position,  due  to  some 
painful  condition,  and  that  this  position  may  in  time  become 
a  true  deformity.  Therefore  the  cause  of  the  condition 
must  be  sought  and  treated  if  jjossible.  Tenotomy  may  be 
necessary,  after  immobilization.  Finally  resection  of  the 
first  phalanx,  or  of  the  head  of  the  metatarsal  bone  of  the 
great  toe  may  be  performed.     [M.  O.] 

18. — Shoemaker  gives  thedetails  of  two  cases  of  hysterical 
scoliosis  already  reported  by  Wertheim-Salomonson.  and 
reports  another  case.  All  three  were  easily  cured.  The 
position  assumed  is  the  following:  the  patient  stands  on 
one  leg,  which  is  straight,  extended,  and  somewhat  ad- 
ducted,  the  pelvis  and  shoulders  are  oblique,  the  pelvis 
higher  and  the  shoulder  lower  upon  that  side  on  which  the 
leg  is  extended,  and  there  is  a  compensatory  scoliosis. 
Shoemaker  believes  that  the  scoliosis  is  purely  secondary, 
andthatthe  condition  should  be  termed  the  "hysterical  hip 
position."  The  patients  describe  a  feeling  as  if  something 
had  broken  in  the  hip.  upon  flexing  the  extended  leg. 
Salomonson  believed  this  to  be  a  physiological  subluxation 
of  the  femur.  But  Schoemaker  shows  that  anyone  can 
produce  it  upon  himself,  and  that  it  is  due  simply  to  the 
extended  fascia  lata  slipping  over  the  femur.  The  differ- 
ence in  the  length  of  the  legs  is  due  to  the  different  func- 


tional activity  of  the  two  legs.    Nothing  abnormal  can  be 
found  in  either.    Hysteria  is  undoubtedly  the  cause  of  this 

position.     [M.  O.] 

19. — Sender  describes  Professor  Turner's  inexpensive  sub- 
stitute for  plaster  of  Paris  dressings,  consisting  of  cellulose- 
wadding  (liguin),  ordinary  glue,  and  gauze  bandages.  He 
describes  its  aplication.  It  is  as  good  as  Plaster  of  Paris, 
and  much  cheaper.  When  good  glue  is  employed,  the  odor 
only  remains  a  day.     [M.  O.] 

20. — In  1860  an  unknown  Frenchman  described  that  de- 
formity of  the  anterior  chest  wall  known  as  "funnel 
breast  The  deepest  point  of  the  funnel  lies  in  the  stern- 
um near  the  xyphoid  process.  The  cartilages  of  the  ribs 
rise  convexly  to  either  side  of  this  median  cavity.  The 
depression  is  either  oval  or  round:  its  depth  varies,  the 
deepest  point  lying  below  the  intermammillary  line.  The 
sternum  shows  backward  kyphosis,  either  throughout  its 
entire  length,  or  at  the  lower  end.  The  sternum  may  also 
show  slight  lateral  curvature.  The  outward  convexity  of 
the  ribs  may  be  equal  on  both  sides,  or  one  side  may  pro- 
ject less  than  the  other.  Different  grades  of  scoliosis  or 
kyphosis  are  generally  found  with  the  deformitory.  It  does 
not  affect  the  rest  of  the  thorax  in  any  way.  li  is  generally 
congenital,  and  may  be  hereditary.  It  is  probably  due 
to  a  defect  of  development,  in  individuals  with  a  tainted 
family  history.  Rarely  it  is  acquired,  following  rachitis, 
niediastinaj  tumors,  etc.  In  its  treatment,  respiratory  gym- 
nastics should  be  used  with  trumpet  blowing  and  local  ap- 
plications tending  to  decrease  the  atmospheric  pressure, 
that  the  internal  pressure  may  help  to  push  out  the  deform- 
ity. Chlumsky  reports  in  full  five  cases  of  funnel  breast  in 
children,  with  histories,  and  excellent  photographs.     [M.O.] 

21. — Lorenz  describes  the  varied  and  valuable  work  of 
the  late  Professor  Edward  Albert  in  the  field  of  orthopedic 
surgery.  The  article  is  practically  a  review  of  the  subjects 
and  operations  of  interest  to  orthopedists  during  the  past 
50  years,  with  a  detailed  account  of  Professor  Albert's 
opinions  and  operative  procedures.     [M.  O.J 


DEUTSCHE   MED.  WOCHENSCHRIFT. 

iliifch  :>A. 

1.  The  Epidemic  of  Typhoid  Fever  in  Goettingen  in  the 

Summer  of  1900.     P.  FRAEXCKL. 

2.  The  Surgical  Treatment  of  Gastric  Ulcer  and  Its   Se- 

quelae.    W.  KOERTE. 

3.  Experimental  Investigations  Concerning  Compensation 

in  Sensory  Ataxia.     A.  BICKEL. 

4.  Indifferent  Dyes  as  Stains  for  Fat.    L.  MICHAELIS. 

5.  Concerning  the  Reputed  Immunity  of  the  Hedge  Hog 

to  Cantharadin.  L.  LEWIN. 
ti.  On  Trigeminus  Symptoms  as  Initial  Signs  of  Tabes.  V. 
FRAGSTEIN. 
1. — Goettingen  is  usually  completely  or  almost  complete- 
ly free  from  typhoid  since  the  water  supply  has  been  a 
satisfactory  one.  Suddenly  an  epidemic,  wh'.ch  altogether 
produced  .51  cases,  broke  out  during  the  early  part  of  the 
summer  of  1900.  The  cases  were  divided  into  three  groups. 
Twenty-six  were  evidently  from  the  same  source:  these 
occurred  first.  Seventeen  others  were  from  various  parts 
of  the  city,  and  8  cases  were  from  the  surrounding  re- 
gions. All  the  first  26  cases  occurred  in  persons  who  fre- 
quent one  special  inn:  the  source  of  the  disease  in  this 
group  of  cases  seemed  to  be  definitely  determined  to  be 
a  well  from  which  they  had  all  frequently  drunk,  and  which 
might  readily  have  been  contaminated  with  urine.  The 
water  of  the  well,  however,  apparently  did  not  contain 
typhoid  bacilli,  and  chemical  analysis  showed  but  slight 
increase  of  the  organic  matter.  The  second  group  of 
cases  began  to  appear  three  or  four  weeks  after  the  first 
group,  and  this  second  outbreak  was  probably  started  by 
the  case  of  a  servant  who  had  washed  for  one  of  those 
first  taken  ill.  The  source  of  the  third  group  could  not  be 
determined  definitely.  The  cases  occurred  chiefly  in  young 
persons.  The  clinical  picture  was  that  of  a  severe  infec- 
tion, particularly  in  the  first  group.  Seven  of  the  2i)  cases 
in  this  group  resulted  in  death,  while  the  general  mortality 
in  the  Goettingen  Clinic  has  for  some  years  been  about  S"~p. 
Of  the  remaining  cases,  those  of  the  second  and  third 
group,  but  2  were  fatal.  An  interesting  observation  was 
the  fact  that  bronchitis  was  unusually  rare,  only  11.5% 
of  the  cases  showing  it.  The  disease  in  the  cases  which 
were  not  fatal  was  usually  prolonged,  the  average  dura- 
tion of  treatment  in  the  first  series  being  57  days,  and 
there  were  6  in  this  group  who  were  treated  for  from  70  to 


Qq2       The  Philadelphia  "I 
V''        Medical  Joibxal  J 


THE  LATEST  LITER^VTURE 


[Mav    4.    irml 


109  days.  Six  of  the  fatalities  were  due  to  severe  general 
Infection,  3  to  complications.  In  1  case  there  was  a  violent 
delirium  shortly  before  death,  the  latter  occurred  from 
heart  weakness.  One  case  is  noted  in  which  there  was  an 
anomaly  of  some  interest:  the  left  coronary  artery  was 
absent.  This  anomaly  has  frequnetly  been  noticed,  and 
is  one  which  Fraenckel  is  inclined  to  believe  is  of  some 
importance.  The  patient,  a  student,  had  shown  no  signs  of 
heart  weakness  under  ordinary  circumstances  of  living,  but 
there  was  a  history  that  if  he  indulged  in  any  very  active 
exercise  he  had  attacks  of  heart  weakness.  This  Fraenckel 
believes  was  due  to  the  fact  that  the  single  coronary  ar- 
tery was  just  about  sufficient  to  maintain  proper  nutrition  of 
the  heart  muscle  under  ordinary  circumstances  but  did  not 
suffice  when  special  strain  occurred.  This  patient  showed 
marked  degenerative  changes  in  the  heart,  and  Fraenkel 
believes  that  it  is  quite  possible  that  the  anomaly  made 
the  heart  less  resistent  to  the  influence  of  the  typhoid  toxin. 
One  case  showed  a  wide-spread  petechial  eruption  shortly 
before  death,  evidently  a  septic  eruption.  Bacteriological 
study  of  this  case  is  not  given.  (To  be  concluded).  [D. 
L.  E.J 

3. — Bickel  discusses  the  source  of  the  compensation 
which  occurs  in  many  cases  of  ataxia,  particularly  under 
treatment,  and  which  may  be  observed  in  animals  after 
cutting  through  the  posterior  nerve  roots.  He  has  made 
a  series  of  investigations,  in  association  with  Jacob,  and 
states  that  after  compensation  for  the  ataxia  has  been 
reached  in  animals,  subsequent  to  cutting  the  posterior 
nerve  roots,  extirpation  of  the  labyrinths  causes  a  new  on- 
set of  ataxic  phenomena  which  are  not  followed  by  such 
marked  compensation  as  was  present  previously.  He  also 
found  that  cutting  off  the  sense-motor  zones  of  the  cere- 
bral cortex  in  animals  who  had  gained  some  compensa- 
tion for  ataxia,  in  the  manner  previously  mentioned,  would 
cause  a  new  onset  of  marked  atactic  phenomena  which  were 
not  compensated  to  nearly  the  same  degree  as  had  been 
the  case  after  the  preliminary  lesion  of  the  nerve  roots. 
He  also  observed  in  one  animal  that  diWsion  of  the  nerve 
roots  was  followed  by  the  usual  ataxia  which  was  com- 
pensated largely.  The  subsequent  removal  of  a  small 
piece  from  each  of  the  four  cortical  zones  was  followed  by 
ataxia  which  again  was  largely  compensated,  but  the  re- 
moval of  the  remainder  of  the  senso-motor  zones  was  fol- 
lowed by  a  third  onset  of  outspoken  ataxia.  Bickel  decides 
that  there  is  no  doubt  that  the  labyrinth  has  some  relation 
to  the  production  of  compensation  in  ataxia.  This  is  also 
certainly  due  in  part  to  the  motor-zones  in  the  cortex,  and 
probably  other  regions  will  be  found  to  be  important  in  this 
connection,  particularly  the  optic  thalmus,  the  corpora- 
quadrigemina.  and.  in  especial  the  cerebellum.     [D.  L.  E.] 

4. — Michaelis  first  gives  a  technical  definition  of  indiffer- 
ent stains.  Acid  stains  are  produced  b.v  the  entrance  into 
the  molecule  of  an  electro  negative  group,  the  basic  stains 
by  the  entrance  into  the  molecule  of  an  electro  positive 
group,  while  those  which  Michaelis  terms  indifferent  stains 
are  produced  by  the  entrance  into  an  azobenzol  molecule 
of  an  indifferent  group.  He  has  found  that  these  stains 
have  a  peculiar  affinity  for  fats.  A  stain  which  is  to  bo 
considered  a  stain  for  fats  must  have  such  affinity  for  fats 
as  to  diffuse  spontaneously  into  fat  from  a  70'~f  alcoholic 
solution  of  the  stain.  Michaelis  particularly  recommends 
scarlet  R.  He  considers  this  even  better  than  Sudan  III. 
It  does  not  stain  cholesterin  crystals  but  it  always  stains 
fats  of  any  kinds  and  stains  nothing  but  fats.  The  staining 
is  best  carried  out  by  using  a  saturated  solution  of  the 
dye  In  TO^c  alcohol.     [D.  L.  E.] 

6. — While  trigeminus  symptoms  are  not  uncommon  in  the 
later  stages  of  tabes  they  are  extremely  rare  as  initial 
signs,  and  very  few  cases  have  been  reported.  In  the 
case  described,  a  man  of  3S.  who  had  had  syphilis  13  years 
previously,  complained  of  a  trigemius  neuralgia  involving 
all  the  branches  of  the  nerve,  the  pain  being  of  a  peculiarly 
sudden,  lightning-like  character  which  suggested  a  possi- 
ble tabetic  process.  There  was.  however,  an  entire  absence 
of  other  signs  of  tabes.  Antisyphilitic  treatment  caused 
no  improvement.  A  year  and  a  half  afterward  the  man 
was  found  to  have  a  complete  sensory  paralysis  of  the 
trigeminus,  with  the  exception  of  taste  sense.  He  presented 
at  that  time  very  distinct  signs  of  tabes.  The  seat  of  the 
lesion  of  the  trigeminus  must  have  been  between  the  nu- 
cleus and  the  ascending  root,  or  in  both  regions,  because  of 
the  absence  of  disturbance  of  taste  ana  ol  any  trophic  or 
vaso-motor  symptoms.     [D.  L.  E.] 


MUENCHENER    MEDICINISCHE    WOCHENSCHRIFT. 
March  12,  1901.     (Yahrg.  48,  No.  11  ) 

1.  Subcutaneous  Injections  of  Paraffine.    By  Meyer. 

2.  A  Case  of  Cerebral  Pressure  Produced  by  a  Rupture 

of  the  Sinus.  Cured  by  Operation.     By  Bertelsmann. 

3.  Chronic   Inflammation  of  the  Spinal  Cord  with  Anky- 

losis.    By  Bender. 

4.  A  Case  of  Polyneuritis.    By  Zahn. 

5.  The  Arsenic  Question.     By  Stich. 

6.  A  Case  of  Paralysis  of  the  Point  of  Insertion  of  the 

Placenta.     By  Gerlach. 

7.  The  Treatment  of  Panarthritis     By  Schulze. 
9.     Spring  Mydriasis.    By  Gessner. 

1. — Meyer,  in  view  of  Gersuny's  suggestion  that  hypoder- 
mic injections  of  paraffin  could  be  used  with  advantage  for 
cosmetic  or  mechanical  effects,  because  they  remain  indefi- 
nitely in  the  tissue  without  causing  any  reaction  or  being 
absorbed,  has  injected  animals  with  various  quantities  of 
this  substance,  and  has  found  that  as  a  matter  of  fact,  a 
considerable  portion  was  gradually  removed  from  the  orig- 
ina'  mass  and  could  be  found  in  the  lymph  glands.  Other 
animals  had  definite  quantities  injected  into  their  bodies, 
and  a  very  careful  analysis  was  made  to  dttermine  how 
much  remained.  It  was  found  that  one  rabbit  in  4  weeks 
lost  20%  of  the  injected  mass,  and  another  in  8  weeks  more 
than  50%.     [T.  S.[ 

2. — The  patient,  a  woman  of  40.  had  been  violently  thrown 
upon  the  pavement,  and  received  a  severe  blow  upon  the 
back  of  the  head.  She  immediately  became  unconscious, 
then  partially  regained  consciousness  for  a  short  time,  af- 
ter which  she  had  general  convulsions,  vomiting,  and 
slight  paralysis  of  the  face.  As  the  patient's  condition 
grew  worse,  and  she  was  apparently  moribund,  an  opera- 
tion was  performed.  At  the  seat  of  injury  the  brain 
showed  all  the  symptoms  of  compression,  and  as  the  dura 
was  lightly  dissected  away  from  the  skull,  a  considerable 
quantity  of  dark  blood  gushed  forth.  There  was  also  blood 
beneath  the  dura,  and  this  was  accordingly  opened  and 
pressure  relieved.  The  bleeding  apparently  came  from 
the  torn  sinuses  at  the  torcula.  It  was  arrested  by  tampons, 
and  the  patient  subsequently  had  an  uninterrupted  but  slow 
recovery.  It  is  possible  that  in  this  case  the  injury  had 
not  completely  torn  the  sinuses,  but  that  the  subsequent 
vomiting  had  so  increased  the  cerebral  pressure  that  It  had 
ruptured.  Subsequently  further  temorrhage  was  caused 
by  the  convulsions.     [J.  S.] 

3. — Bender  reports  the  case  of  a  girl  24  years  of  age  who 
had  been  obliged  to  work  9  or  10  hours  a  day  in  one  posi- 
tion for  9  years.  Four  years  ago  she  began  to  have  pain 
in  the  back,  especially  in  the  morning.  This  extended  to 
the  neck,  and  gradually  she  perceived  stiffness  of  the 
spinal  column.  Her  present  condition  is  as  follows:  She 
has  total  ankylosis  of  the  spinal  column,  with  slight  kyph- 
osis of  the  cer\ncal  region,  and  extension  of  the  thoracic 
region.  Slight  tenderness  of  the  first  dorsal  and  first  lum- 
bar vertebrae,  fixation  of  the  thorax,  so  that  the  respiration 
is  purely  abdominal;  some  atrophy  of  the  muscles  of  the 
back  and  shoulders,  but  absolutely  no  involvement  of  any 
of  the  other  joints.  Otherwise  the  patient  is  apparently 
healthy.  The  case  corresponds  to  the  rhizomelic  spon- 
dylosis of  the  type  of  Von  Bechterew.  with  the  exception 
that  there  is  no  hereditary  factor.  Bender  believes  that 
this  case  is  best  explained  by  assuming  an  ossification  of 
the  intervertebral  disks.     [J.  S.] 

4. — Zahn  reports  a  case  of  polyneuritis  occurring  in  a 
woman  32  years  of  age.  who  had  had  no  infectious  dis- 
ease, who  was  not  exposed  to  any  intoxication,  and  had 
not  received  any  injury.  .  The  first  symptoms  were  rapid 
fatigue  in  the  legs  after  walking,  then  difficulty  in  mov- 
ing the  arms,  and  finally  severe  pains  in  the  limbs.  There 
was  marked  impairment  of  memory.  She  became  Irrita- 
ble and  moody,  and  was  brought  to  the  hospital,  where  it 
was  found  that  the  symptoms  of  chronic  multiple  neuritis 
were  present,  with  slight  contracture  of  the  left  knee.  The 
paralyzed  muscles  showed  the  reactions  of  degeneration. 


May   4,    V.M] 


THE  LATEST  LITERATURE 


CThz  Philadelphia       Qq., 
Medical  Joubnal         ^yo 


The  patient  was  treated  with  electricity,  rest  and  mas- 
sage, and  rapidly  improved.  She  died,  however,  of  an- 
other disease.  Microscopical  examination  of  the  crural  nerve 
in  the  spinal  cord  was  entirely  negative.  The  interesting 
features  of  the  case  are  the  distribution  of  the  lesions,  that 
is  to  say,  chiefly  the  extensors  of  the  legs,  and  the  absolute 
impossibility  of  discovering  any  cause.     [J.  S.] 

5. — Stich  reports  some  interesting  cases;  one  in  which 
arsenic  was  obtained  from  the  stomach  contents  of  a 
woihan  who  had  been  poisoned  by  placing  a  large  quantity 
of  arsenic  in  the  vagina.  This  was  evidently  a  form  of 
excretion  with  the  gastric  juice.  In  another  case,  a  girl 
of  21  showed  the  presence  of  arsenic  in  the  stomach  con- 
tents and  feces,  and  arsenic  was  also  discovered  in  the 
organs  of  her  3  months"  fetus.  In  a  third  case,  a  man  who 
had  taken  enormous  quantities  of  arsenic  for  the  cure  of 
a  skin  disease,  showed  the  presence  of  a  perceptible  quan- 
tity in  the  urine.  Snails  were  then  poisoned  with  arsenic, 
and  it  was  found  that  there  was  a  general  dilation  of  the 
lymph  vessels,  increase  in  the  quantity  of  pigment,  fatty 
degeneration  of  the  protoplasm  of  the  parenchymatous 
cells  without  any  symptoms  of  inflammation.  Plants  were 
also  poisoned,  and  it  was  found  upon  analysis  that  they 
absorbed  very  little  of  the  poison.     [J.  S.] 

6. — Gerlach  reports  a  case  of  persistent  hemorrhage  re- 
sulting from  paralysis  at  the  insertion  of  the  placer.ta. 
After  all  other  methods  of  stanching  had  failed,  he  packed 
the  uterus  with  gauze  soaked  in  a  solution  of  ferric  chlo- 
ride.    The  patient  recovered.     [J.  S.] 

7, — Schulze  having  had  occasion  to  treat  a  case  of  pan- 
arthritis of  the  thumb  in  which  operation  was  refused,  ob- 
served that  after  the  expulsion  of  the  necrotic  distal  pha- 
lanx, the  callus  that  had  formed  about  it  took  its  place  and 
was  capable  of  performing  all  its  functions,  the  only  de- 
fect being  that  it  was  slightly  wider.  He  subsequeniiy 
treated  other  cases  expectantly  with  like  results.     [J.  b.] 


DEUTSCHE    MEDICINISCHE    WOCHENSCHRIFT.    .. 
iluixh  l.'i,  I'jiJl.     (Vol.  27,  No.  11. 

1.  A  Biological  Proof  that  the  Albumin  in  the  Urine  of 

Nephritis  is  Derived  from  the  Blood.     V.  E.  MER- 
TEXS. 

2.  Concerning  the  Question  of  the  Destruction  of  Tuber- 

cle Bacilli  in  Fatty  Foods.  A.  GOTTSTEIN  and  H. 
MICHAELS. 

3.  Concerning    Lipochrome    of    the    Ganglion    Cells.      M. 

ROTHMAXX. 

4.  Erji;hema  Exsudativum   Multiforme  Following  Chemi- 

cal Irritation  of  the  Urethra.    J.  HELLER. 

1. — Treated  editorially. 

2. — The  authors  have  further  investigated  the  question 
of  the  degree  of  heat  to  kill  tubercle  bacilli  in  fats,  and  the 
time  of  exposure  needed  for  this  purpose.  They  took  a  mix- 
ture of  fats  which  became  fluid  between  40°and  50°  C, 
and  afterwards  solidified  at  about  25'  C.  They  then  grad- 
ually brought  the  oily  mass  to  a  temperature  of  S7^  C.  and 
Injected  animals  at  once  after  it  had  reached  this  tempera- 
ture, as  well  as  after  five,  fifteen,  thirty,  forty-five  and 
sixty  minutes.  The  13  animals  which  were  injected  with 
the  mass  after  it  reached  87°  C.  escaped  tuberculosis  with- 
out exception.  They  decide,  therefore,  that  heating  for 
five  minutes  or  longer  to  a  temperature  of  87^  C.  is  quite 
sufiScient  to  sterilize  oil  infected  with  virulent  tubercle 
bacilli.  This  is  contrary  to  the  statement  of  Rabino- 
witsch.     [D.  L.  E.] 

3. — Rothmann  directs  attention  to  the  fact  that  the  pig- 
ment found  in  the  ganglion  cells  is  of  fatty  nature.  He  then 
reports  his  results  from  the  study  of  a  number  of  animals 
which  had  advanced  to  what  was  for  their  species  an  old 
age.  Horses  over  fifteen  years  of  age  contained  large 
numbers  of  these  granules  in  the  ganglion  cells,  as  did  the 
cells  of  an  old  dog.  and  he  decides  that  the  presence  of 
this  pigment  in  the  ganglion  cells  is  proportionate  to  the 
age  of  the  nervous  organs  examined,  and  he  thinks  that  It 
may  be  possible  by  this  means  to  tell  fairly  closely  the 
age  of  the  animal.     [D.  L.  E.] 

4. — The  case  reported  was  that  of  a  man  of  33  who  had 
had  chronic  gonorrhea  in  "92.  who  had  had  an  acute  exacer- 


bation in  '93,  and  a  similar  occurrence  in  '97.  He  had 
married  two  years  later  and  infected  his  wife,  but  under 
treatment  seemed  to  become  entirely  well.  In  October, 
1899,  after  bathing  the  penis  in  20%  creolin  he  had  marked 
swelling  of  the  organ,  afterward  followed  by  swelling  of 
the  right  wrist  and  fingers  and  back  of  the  hand,  with  a 
free  secretion  of  sero-purulent  fiuid  from  the  urethra, 
which  contained  no  gonococci  and  very  little  diplococci, 
but  a  large  number  of  other  cocci,  together  with  a  number 
of  pus  cells.  Soon  after  he  had  a  general  eruption  of  eru- 
thema  multiforme  which  persisted  for  over  a  month  with 
occasional  exacerbations.  Soon  after  this,  however,  he 
recovered  entirely.  This  is  said  to  be  the  first  case  in 
which  chemical  irritation  of  the  urethra  caused  such  an 
outbreak.  The  skin  affection  has  been  observed  with 
gonorrheal  or  other  inflammation  of  the  urethra,  but  not 
as  a  result  of  the  irritation  may  be  considered  an  auto 
intoxication,  and  in  this  case  he  things  that  it  was  an  auto- 
intoxication from  the  serum  secreted  m  the  urethra  and 
into  the  skin  followins  the  irritation  of  the  creolin.  [D 
L  .E.] 


JOURNAL   DES   PRATICIENS. 

Uanh  23.  lO'.'l.     (XVme.  Annee.  Xo.  12.) 

1.  Electrical    Treatment   in    Spasmodic    Stricture    of    the 

Esophagus.     H.  BORDIER. 

2.  Pyramidon.     M.  DEGUY. 

3.  Worms  in  Appendicitis.    L.  METCHNIKOFF. 

4.  Antidiphtheritic  Serumtherapy  at  Present.    H.  GILLET. 

1. — Spasmodic  stricture  of  the  esophagus  is  a  neurosis 
which  may  be  idiopathic,  with  emotion:  symptomatic,  with 
irritants,  poisons,  etc.:  or  sympathetic,  with  pregnancy.  Its 
main  symptom  is  dysphagia,  either  complete  or  incomplete 
It  may  occur  during  a  meal,  in  a  healthy  Individual,  with 
pain,  some  dyspnea,  and  anxiety.  Its  duration  varies  from 
a  few  moments  to  days,  or  even  weeks.  It  is  often  inter- 
mittent, and  then  persists  for  years.  The  point  of  the 
stricture  can  be  found  by  passing  an  esophageal  bougie, 
which,  when  left  in  place,  will  often  cause  a  gradual  re- 
laxation of  the  muscle-fibres  in  spasm.  Many  methods  of 
dilation  have  also  been  tried.  But  electricity  acts  in  a  far 
superior  manner.  It  may  be  applied  directly  or  indirectly. 
In  the  indirect  method,  both  sides  of  the  neck  are  treated 
daily  with  galvanism,  to  affect  the  vagus  and  pneumogas- 
tric  nerves.  Directly,  electricity  is  given  in  three  ways 
In  all,  an  esophageal  bougie  with  electrical  attachment  is 
introduced  to  the  point  of  the  stricture.  Static  electricity, 
the  faradic,  and  the  galvanic  current  are  employed.  Bor- 
dier  advises  the  indirect  method  first.  If  this  fail,  fara- 
dization, and  finallv  galvanization  should  be  employed. 
[M.  O.] 

2. — After  reviewing  the  literature  of  pyramidon,  Deguy 
believes  that  it  can  be  used  in  headaches,  neuralgia,  sci- 
atica, and  febrile  tuberculosis:  that  it  does  not  nauseate: 
and  that  it  acts  quicker,  in  smaller  doses,  than  antipyrin. 
Its  use  is  especially  indicated  in  influenza,  where  it  will 
reduce  a  rapid  pulse,  decrease  a  high  temperature,  and 
cause  profuse  sweating  with  the  disappearance  of  all 
pain.  In  influenza  one  grain  can  be  given  every  two  hours: 
in  migraine,  etc,  5  to  7  grains  should  be  given  immedi- 
ately.    [M.  O.] 

3. — Four  years  ago,  Metchnikoff,  believing  that  intestinal 
worms  could  cause  appendicitis,  found  ova  of  the  ascaris 
lumbricoides  and  trichocephalus  dispar  in  fecal  matter 
from  a  young  girl,  aged  19.  who  had  already  had  six  attacks 
of  appendicitis.  Santonin  was  given,  and  repeated  several 
times.  She  has  been  well  since,  over  four  years.  Lemoine 
reported  two  similar  cases,  in  a  child  of  12,  and  a  man  of 
23.  Both  have  been  well  ever  since.  He  also  quotes  an- 
other case,  a  boy  of  10.  who  recovered  after  passing  two 
ascarides.  It  is  impossible  to  state  the  exact  condition  of 
the  appendix,  as  the  four  cases  recovered  without  opera- 
tion. But  the  clinical  symptoms  were  typical  of  appen- 
dicitis. Other  cases  have  been  discovered  in  the  literature, 
of  worms  found  in  the  appendix,  or  in  the  peritoneal  cavity 
after  perforative  appendicitis.  The  action  of  intestinal 
worms  is  both  direct  and  indirect.  The  former  is  either 
mechanical  or  chemical,  from  their  presence  alone:  the 
latter  is  the  opening  of  a  lesion  which  is  an  excellent 
field  for  the  action  of  bacteria.  After  reporting  some 
other  cases.   Metchnikoff  concludes  that  in  all  cases  of 


gq.        rT?^  Philadelphia 


L  Medical  Jocbnal 


THE  LATEST  LITERATURE 


May  4,   I'jfJlJ 


appendicitis,  the  stools  should  be  examined  for  worms  or 
their  ova:  that  when  possible,  santonin  and  thymol  should 
be  given,  for  the  expulsion  of  the  ascaris  lumbricoides  or 
the  trichocephalus  dispar  respectively;  that  raw  vegetables, 
such  as  salads,  strawberries,  etc.,  and  unboiled  or  unfiltered 
water  should  be  prohibited  those  with  appendicitis,  or  sub- 
ject to  it;  and  that  the  stools  of  such  people,  especially  of 
children,  should  be  examined  from  time  to  time,  or  vermi- 
fuge given.     [M.  O.] 

4. — Gillet  advises  small  doses  of  diphtheria  antitoxin  for 
the  initial  injection.  At  5  weeks  he  gives  5  c.c. ;  up  to  2 
years,  10  c.c;  after  2  years,  20  to  30  c.c,  in  simple  cases. 
When  more  injections  seem  necessary,  10  c.c  are  given. 
Only  rarely  does  a  child  receive  as  much  as  90  or  100  c.c. 
But  when  the  attack  is  grave,  1500  to  2000  units  may  be 
given  at  once,  repeated  when  necessary.  Serum  that  has 
been  heated  to  58  degrees  before  being  injected  will  be 
followed  by  fever  eruptions,  etc.  ■  In  hospitals  every 
suspected  case  should  have  an  injection  of  20  c.c.  of  serum 
at  once,  before  the  result  of  bacteriologic  examination  is 
known.  In  private  practice,  while  not  necessary,  such  an 
injection  will  always  be  safer.  Should  dyspnea  be  noted, 
the  injection  is  needed.  Should  the  bacteriologic  exam- 
ination be  negative,  yet  the  clinical  signs  typical,  give  the 
serum.  For  if  the  serum  does  no  good,  it  at  least  does  no 
harm.  If  the  general  condition  remain  low,  it  the  mem- 
brane increase,  or  the  temperature  remain  elevated,  repeat 
the  injection.  Albuminuria  is  not  a  contraindication  to 
the  use  of  serum.  Nor  is  the  presence  of  other  bacteria, 
associated  with  the  diphtheria  bacilli,  a  contraindication. 
The  causes  which  prevent  the  success  of  the  antidiphthe- 
ritic  serum  are  the  rapid  toxicity  of  the  bacilli,  secondary 
infection.  asph>-xia  from  obstruction  of  the  smaller  bronchi, 
and  failure  of  the  organism  to  react.  This  lack  of  re- 
action decreases  as  the  age  advances.  The  serum  should 
be  used  prophylactically  whenever  diphtheria  bacilli  are 
found  in  healthy  throats,  and  when  an  epidemic  exists.  It 
seems  impossible  to  obtain  immunity  to  diphtheria.  It  re- 
curs frequently.     [M.  O.] 


ANNALES  DE  MEDICINE  ET  CHIRURGIE  INFANTILES. 
Fehruary   1st,   lU'Ji. 

1.  Instruction  and  Hygiene.     E.  PERIER. 

2.  Vegetati\e  Rheumatic  Endocarditis  with  Multiple  Em- 

boli; the  Presence  of  a  Bacillus  analogous  to  the 
"Bacillus  of  Rheumatism,"  without  Associated  Mlcro- 
bic  Infection.     H.  BARRIER  and  L.  TOLLEMER. 

3.  Physical  Education  in  Japan.     M.  YAMANE. 

1. — E.  Perler  mentions  the  fact  so  often  noted  that  school 
instruction  for  children  is  carried  on  quite  regardless  of 
the  mental  capacity  of  the  growing  child.  In  spite  of 
the  cry  of  alarm  so  often  raised  by  medical  men  as  to  the 
dangers  arising  from  faulty  methods  in  the  subsequent  de- 
velopment of  the  child,  those  in  authority  have  done  noth- 
ing, in  France,  to  make  the  school  course  more  rational 
and  the  school  hours  less  arduous.  The  course  of  study 
is  quite  out  of  all  proportion  to  the  ages  of  the  pupils  and 
the  strain  upon  the  nervous  system  of  the  children  kept 
in  enforced  silence  and  in  repressed  nervous  strain  for 
long  periods  of  time  has  been  too  little  taken  into  ac- 
count.   The  cry  of  reform  should  be  heeded.     [  T.  L.  C] 

2. — Barbier  and  Tollemer  discuss  the  gravity  of  the  se- 
quelae of  acute  veyetative  endocarditis  in  childhood  occur- 
ing  at  the  mitral  and  arotic  orifices,  sometimes  effecting 
the  aorta  itself  and  even  the  cardiac  plexus.  Very  fre- 
quently pericarditis  occurs  with  a  formation  of  pericardial 
adhesions,  and  to  this  fact  is  due  the  greater  part  of  the 
gravity  of  the  pathological  conditions  which  arise  sub- 
sequent to  the  acute  attack.  One  of  the  authors  has  pre- 
viously published  an  account  of  the  breaking  up  of  vege- 
tations from  the  mitral  valve  and  the  subsequent  pro- 
duction of  multiple  emboli  which  seemed  in  particular  to 
have  obliterated  almost  totally  the  arteries  of  the  left 
hemisphere.  The  history  of  the  case  is  given.  It  began  as 
a  benign  one.  On  the  fourth  day,  however,  without  any 
apoplectic  seizure,  motor  aphasia  appeared  suddenly,  and 
later  a  progressive  right  hemiplegia,  particularly  affecting 
the  face.  Toward  the  end  of  the  disease  there  were  seen 
to  develop  the  phenomena  of  meningo-encephalitis,  and  at 
the  same  time  a  bedsore  appeared  over  the  right  side  of 
the  sacrum  and  purpura  developed.     The  authors  call  es- 


pecial attention  in  this  case  to  the  number  of  emboli 
which  penetrated  the  brain  and  produced  areas  of  necrosis 
of  varying  intensity.  The  trunk  of  the  sylvian  artery 
was  totally  obliterated  and  the  arteries  of  the  Internal 
striate  and  lenticule-optic  bodies  were  also  obliterated.  The 
anterior  cerebral  arteries  of  the  left  side  were  not  spared 
nor  were  certain  arteries  of  the  right  hemisphere.  These 
authors  now  present  an  interesting  case  of  subacute  ar- 
ticular rheumatism  in  a  girl  of  eleven  years,  in  which  vegi- 
tative  endocarditis  occurred  followed  by  multiple  em- 
boli, aphsia,  extensive  cerebral  softening  and  death.  Two 
thorough  bacteriological  examinations  of  the  spinal  fluid 
were  made  but  were  all  negative  save  in  one  on  milk  iu 
which  evidently  there  had  been  accidental  contamination. 
Careful  notes  of  the  autopsy  are  given,  and  thorough  ex- 
aminations were  made  of  the  vegetations  on  the  mitral 
valve.  A  great  number  of  bacilli  were  discovered  which 
were  extremely  difficult  to  determine.  They  stained  by 
Gram's  method.  The  bacillus  is  slightly  larger  than  the 
b.  typhosus  and  a  little  longer.  This  bacillus  was  found 
only  in  the  mitral  vegetations,  and  they  believe  that  it 
is  identical  with  that  described  by  Achalme  and  Thiroloi. 
LT.    L.   C] 

3. — Yamane  of  Tokio  contributes  a  very  interesting  pa 
per  upon  the  wide-spread  interest  which  has  been  aroused 
in  physical  culture  throughout  Japan.  In  all  parts  of  the 
Empire  large  organizations  with  well  equipped  gymna- 
siums are  flourishing  and  the  course  of  instruction  is  fully 
systematized  and  carefully  carried  out.  The  writer  be 
lieves  that  the  health  of  both  sexes  will  be  greatly  bene- 
fited under  this  system.  Already  a  decided  betterment  of 
the  moral  tone  has  been  observed. — [T.  L.  C] 


Irreducible  Dislocations  of  the  Shoulder. — Legueu,  in 
L'  Indfprndiini:e  MiiliinJe  (April  10,  l&ol.  No.  15),  reports  a 
case  operated  for  old,  irreducible  luxation  of  the  shoulder. 
In  such  cases  two  things  must  be  considered,  the  lesions 
which  prevent  reduction,  and  the  lesions  which  prevent  re- 
duction, and  the  lesions  caused  by  the  failure  of  reduction. 
The  cause  of  the  inability  to  reduce  the  dislocation  may 
be  a  fragment  of  the  tuberosity  which  has  been  broken  off. 
with  muscles  attached;  part  of  the  joint  capsule,  or  the 
tendon  of  the  biceps,  has  interposed,  or  the  head  of  the 
humerus  is  caught  between  muscles  and  tendons.  None  of 
these  may  be  present,  yet  an  unreduced  or  poorly  reduced 
dislocation  will  become  irreducible  in  time,  generally  after 
two  months.  Retraction  of  the  fibrous  tissue  of  the  cap- 
sule occurs  with  sclerosis;  bone  will  probably  fill  up  the 
joint  cavity;  and  the  muscles  near  the  point  are  altered. 
To  overcome  these  three  elements,  three  methods  of  treat- 
ment exist,  gentle  reduction,  forcible  reduction,  and  opera- 
tion. The  first  are  applied  after  an  anesthetic,  the  former 
by  Kocher's  method,  the  latter  with  apparatus.  Even  when 
the  dislocation  is  reduced  by  the  gentle  method,  the  joint 
cavity  may  be  obliterated,  and  good  functional  use  cannot 
result.  The  forcible  method  rarely  achieves  results.  Opera- 
tion then  alone  remains.  Legueu  prefers  an  antero-extemal 
incision,  in  the  line  of  the  deltoid  fibers.  This  was  done 
in  the  case  reported,  the  head  of  the  humerus  being  found 
under  the  coracoid  process  which  it  was  necessary  to  cut. 
A  partial  fracture  was  found  in  the  anatomic  head,  which 
had  worked  into  the  glenoid,  and  so  prevented  reduction. 
The  glenoid  cavity  was  deformed,  the  muscles  and  fibrous 
tissue  altered.  Resection  was  then  performed  at  the  level 
of  the  anatomic  neck,  the  bone  left  being  well  rounded  ofT 
to  fit  the  glenoid  cavity.  With  massage  later.  Legueu  ex- 
pects a  good  result     [M.  C] 


Success  Following  Talma's  Operation. — Scherwincky  re- 
ported before  the  Moscow  Therapeutic  Society  (  i  Ucdicin- 
skoie  Ofiosrciiie.  Marrh.  lom )  the  further  progress  of  his 
case  of  hepatic  cirrhosis  in  which  he  performed  Talma's 
operation  about  a  year  ago.  The  liver  and  spleen  re- 
mained in  the  same  condition;  the  circulation  improve'1 
markedly;  the  collateral  circulation  was  well  established: 
digestion  was  also  satisfactory.and  the  ascites  did  not  recur. 
The  patient,  a  woman,  gained  14  pounds  and  became  preg- 
nant.    [A.  R.] 


May   4.    inol  1 


THE  LATEST  LITERATURE 


TTiiK  Philadelphia        Qr\c 
L  MKnuAL  Journal         ^yJ 


ARCHIVES    DE    MEDECINE    DES    ENFANTS. 
Murcli,   I'jOl.   (Volume  4,  No.  3). 

1.  Congenital  Cerebral   Hemiplegia.     WEILL  and  GALA- 

VARDIN. 

2.  Diabetes  Mellitus  in  an  Infant  Six  Months  Old.     BAU- 

MEL. 

3.  Subacute  Diabetes  at  22  Months.     LE  GENDRE. 

4.  Diabetes  due  to  Hereditary  Syphilis.     LEMONNIER. 

1. — The  patient,  a  girl  of  13,  entered  the  hospital  a  month 
before  death.  Rightsidod  hemiplegia  was  first  noted  at 
the  age  of  two  months.  She  learned  to  walk  later.  Her 
light  arm  and  leg  are  weaker  than  the  left,  and  there  is 
marked  atrophy  and  shortening,  with  pes  oquinus.  The 
heart  is  greatly  hypertrophied,  with  a  mitral  systolic  mur- 
mur. The  liver  is  enlarged.  Edema  appeared,  and  rap- 
idly increased.  There  was  albumin  in  the  urine,  and  the 
dyspnea  became  intense.  A  few  rales  were  heard.  She 
died  suddenly.  The  autopsy  showed  a  very  large  heart, 
with  the  mitral  valve  but  little  affected.  Liver  and 
kidney  were  congested  and  sclerotic.  The  left  hemi- 
sphere, when  the  dura  was  removed,  was  but  a  cavity, 
filled  with  clear  fluid.  The  upper  anterior  convolutions 
had  disappeared,  so  that  the  left  hemisphere  weighed  about 
half  the  right.  The  left  crus,  and  the  left  side  of  tht 
pons  and  medulla  showed  some  atrophy.  The  walls  of 
the  cavity  contained  no  nervous  cells;  the  cord  showed 
the  left  side  smaller  than  the  right:  with  marked  neurog- 
liar  sclerosis,  and  a  few  motor  cells,  on  the  right  side 
below  the  point  of  decussation.  A  diffuse  interstitial  myo- 
carditis was  found  There  was  no  doubt  that  the  hemi- 
plegia was  congenital.  After  a  discussion  upon  the  dif- 
ference between  true  and  false  porencephalia,  Weill  and 
Galavardin  conclude  that  this  is  a  case  of  pseudo- 
porencephalia,  because  there  was  no  idiocy,  or  other  trou- 
ble of  the  intellect.  Nor  was  there  any  cranial  asymmetry 
[M.   0.1 

2. — Baumel,  who  believes  that  the  pancreas  is  alwayB 
the  cause  of  glycosuria,  reports  a  case  of  diabetes  mellitus 
in  an  infant  of  six  months.  A  general  skin  eruption  ap- 
peared upon  fourth  day  after  birth.  Two  weeks  before 
coming  to  the  hospital,  her  lips,  hands,  and  legs  became 
swollen.  She  nursed  constantly,  and  urinated  frequently. 
The  edema  increased,  there  was  meteorism,  and  the 
urine  contained  1.5  grams  of  glucose  to  the  liter.  This 
gradually  decreased,  upon  using  calcium  lactophosphate.and 
disappeared  a  month  later.  After  a  long  discussion, 
Baumel  concludes  that  the  diabetes  was  caused  by  the 
nervous  effect  of  teething  upon  the  pancreas.  Thus  the 
calcium  given,  by  helping  the  evolution  of  the  teeth,  cured 
the  glycosuria.     [M.  O  ] 

3. — Le  Gendre  reports  a  case  of  diabetes  occurring  in  a 
Jewish  boy,  aged  22  months,  whose  .grandfather,  who  had 
diabetes,  died  of  cirrhosis  of  the  liver.  Both  his  pa- 
rents were  extremely  nervous  before  he  was  born.  He 
was  a  precocious  infant,  ceasing  to  urinate  in  bed  when 
18  months  old.  He  never  had  convulsions  or  night-terrors. 
It  was  first  noted  that  he  was  growing  thin  about  six 
weeks  before  his  death.  Next  thirst  was  noticed.  There 
were  no  signs  of  rachitis  or  tuberculosis.  He  urinated 
frequently,  and  again  wet  the  bed.  Sugar  was  found  in 
urine  in  large  quantity.  Diet  was  instituted,  and  sodium 
arseniate  and  phosphate  given.  The  liver  was  some- 
what enlarged.  The  sugar  in  the  urine  increased  in 
amount,  and  acetone  was  found.  Extract  of  liver  was 
given  by  rectal  injection.  Edema  appeared,  followed  by 
coma  and  death.     [M.  O.l 

4.  A  girl  of  seven  and  a  half  years  had  grown  very 
thin  during  the  past  3  months,  drank  4  to  5  liters  daily, 
and  passed  great  quantities  of  urine.  Lemonnier  found 
her  very  thin,  sallow  in  color,  her  skin  dry.  There  was 
constipation  with  vomiting.  The  liver  was  enlarged,  and 
sugar  was  found  in  the  urine.  Her  father  had  acquired 
syphilis  three  years  before  marriage.  This  had  never 
been  treated.  Her  mother  had  had  two  miscarriages, 
with  one  premature  still-born  child.  At  birth  the  patient 
had  coryza,  a  widespread  papular  eruption,  and  ulcers 
at  the  commissures  of  the  lips.  Mercurial  inunctions  were 
employed  for  a  long  time.  A  year  later  another  syphilitic 
child  was  born.  When  Lemonnier  had  diagnosed  diabetes, 
he  ordered  25  grains  of  potassium  iodide,  and  30  grain.^ 
of  mercurial  ointment  daily.     Two  months  later,  the  llTer 


had  decreased  in  size,  but  the  urine,  though  reduced  to 
ibout  half  as  much  in  amount,  still  contained  sugar.  The 
inunctions  and  iodide  were  given  for  three  weeks  at  a 
time,  alternately,  over  four  months,  after  which  polyuria 
and  glucosuria  had  disappeared.  Since  that  time  she  has 
uad  20  inunctions  every  three  months,  and  has  not  had 
a  recurrence  for  over  a  year.  She  now  eats  everything. 
Lemonnier  concludes  that  diabetes  may  be  due  to  nervous 
lesions  of  the  liver  or  pancreas,  syphilitic  in  origin,  cured 
by  specific  treatment:  that  diabetes  may  appear  as  a 
manifestation  of  syphilitic  diathesis,  without  the  occur- 
rence of  the  above  mentioned  lesions:  and  that,  finally, 
syphilis  may  create  in  children  of  syphilitics,  a  tendency 
to  diabetes,  in  which  specific  treatment  will  do  no 
good.     [M.  O.] 


JOURNAL  DE   MEDECINE   DE  BORDEAUX. 
Mtm-h  iiJ,,  Will.     (31me.  Annee,  No.  12.) 

1.  A  Case  of  Cerebral  Tumor  Treated  by  Lumbar  Punc- 

ture.    ABADIE. 

2.  A  Foreign  Body  in  the  Trachea.     BRINDEL. 

3.  Influenza  in  a  Child  of  Three  Years  and  a  Half.     CORl- 

VEAUD. 

1. — Abadie  reports  a  case  shown  by  Professor  Pitres,  .a 
woman  of  42,  who  had  constant  violent  headache.  Since 
the  age  of  15,  she  always  had  severe  headaches  during 
menstruation.  At  25,  she  had  a  slight  sunstroke.  The 
headaches  then  disappeared  for  a  few  years,  but  returned 
again.  For  the  past  few  weeks  they  have  been  more  vio- 
lent, extended  over  the  entire  head,  and  continued  night 
and  day.  The  right  eye  seemed  somewhat  larger  than  the 
left,  and  the  left  pupil  was  dilated.  Both  pupils  failed  to 
react,  and  the  visual  field  was  retracted.  Diplopia  existed, 
also  left  optic  neuritis.  There  was  no  vertigo  or  ataxia, 
and  reflexes  were  normal.  She  vomited  frequently  and  had 
no  appetite.  Mercurial  treatment  had  no  effect,  nor  had 
any  other  drug.  Lumbar  puncture  was  performed,  25  c.c 
being  withdrawn,  followed  by  disappearance  of  the  head- 
ache, with  no  recurrence  since.  Four  days  later  she  began 
to  pick  up,  her  eye-sight  was  again  excellent,  and  she 
recovered.  Yet  she  continued  thin.  The  diagnosis  of 
cerebral  tumor  seems  certain.  The  headache  and  the  optic 
neuritis  were  evidently  due  to  increased  intracranial  press- 
ure, after  the  removal  of  which,  by  lumbar  puncture,  they 
disappeared.    [M.  O.] 

2. — Will  be  abstracted  when  completed. 

3. — Coriveaud  reports  the  case  of  a  boy  of  three  and  a 
half  years  of  age.  who  had  Just  had  whooping  cough.  He 
had  been  out  of  doors  all  day,  though  it  was  damp  and 
cold,  had  no  appetite,  and  had  not  slept  well.  Physical 
examination  revealed  nothing  abnormal.  The  next  day  he 
coughed,  complained  of  headache,  and  had  a  few  moist 
rales  in  the  bronchi.  The  cough  becomes  incessant,  he 
vomited,  and  broncho-pneumonia  developed.  Counter- 
irritants  were  applied,  and  he  was  placed  upon  milk  diet 
The  fever  continued  with  changes  in  the  resonance  and 
rales.  Baths  were  given  to  control  the  fever,  which 
reached  106°  F.  Beside  the  baths,  a  little  quinine  was 
given.  The  cough  resembled  that  of  pertussis.  He  recov- 
ered quickly.  Coriveaud  believes  that  this  was  a  case  of 
influenza.     [M.  O.] 


RUSSKI    ARCHIV    PATOLOGII.    KLINITSHESKOI    MEDI- 
CINI  I  BAKTERIOLOGII. 

JuiiiKinj  HI.  1901.     (Vol.  XI,  No.  1.) 

1.  Absorption   by   the    Blood    of   Minimum    Quantities   of 

Carbonic   Oxide.     S.    L    KOSTIN. 

2.  Miliary   Tuberculosis   of  the   Mammary   Gland.     N.   N. 

MICHAILOW. 

3.  On  the  Decomposition   of  Iodide  of  Potash  in  the   Di- 

gestive Tract.     A.  STEPANOW. 

4.  Bacteriolysis  of  the  Plague  Bacillus.     SH.  MALIFITA- 

NO. 

5.  On  the  Study  of  Diffuse  Congenital  Hyperkeratosis.    M. 

SNIESAREW. 


PiOft       T^^  Philadelphia"! 
"y^        Medical  Journal   J 


THE  LATEST  LITERATURE 


[Mat   4,    1901 


1. — S.  I.  Kostin  finds  that  the  present  methods  of  detect- 
ing small  quantities  of  carbonic  oxide  in  the  air  are  either 
inaccurate  or  so  complicated  as  to  be  inapplicable  for  or- 
dinary sanitary  analysis.  By  a  series  of  elaborate  experi- 
ments he  found  that  blood  serves  as  the  best  agent  for  ab- 
sorbing small  quantities  of  CO,  providing  the  oxygen  from 
the  air  is  previously  removed.  He  devised  a  simple  and  in- 
genious apparatus  by  which  the  air  is  first  passed  through 
a  solution  of  cupric  sulphate  in  ammonia  which  absorbs 
the  oxygen.  The  blood  saturated  with  the  CO  is  then  tested 
by  Kunkel's  tannin-test.  The  author  believes  with  Robert 
that  small  quantities  of  CO  produced  a  slow  form  of 
poisoning  which  is  responsible  for  many  an  obscure  ail- 
ment.    [A.  R.] 

2. — N.  N.  Michailow  reports  a  very  interesting  case  of 
primary  tuberculosis  of  the  breast.  A  woman,  33  years  old, 
married  and  a  mother  of  4  children.  During  her  last 
period  of  nursing  the  left  breast  became  very  painful,  ne- 
cessitating the  removal  of  the  child.  On  examination  the 
right  breast  was  found  atrophied  with  practically  no  sub- 
cutaneous fat.  On  the  skin  a  few  small  ulcers  (tuber- 
cular) were  scattered.  The  left  breast  was  greatly  en- 
larged, firm  and  heavy;  the  skin  was  edematous;  the  lym- 
phatic glands  along  the  lower  border  of  the  pectoralis 
major  were  considerably  enlarged  and  some  of  them  ad- 
herent to  the  skin  and  ulcerated.  All  the  other  organs 
were  found  normal,  and  the  general  condition  good.  For 
cosmetic  reasons  it  was  determined  to  remove  only  the 
mammary  gland,  leaving  the  skin  intact.  Under  chloro- 
form the  gland  as  well  as  the  lymphatics,  including  those  of 
the  axilla  which  were  found  diseased,  were  removed.  On 
examination,  both  macro-and  microscopical,  the  diseased 
tissue  presented  a  characteristic  picture  of  miliary  tuber- 
culosis. The  author  notes  the  strange  fact  that  the  af- 
fected glands  showed  coagulation  necrosis  but  In  none  was 
cheesy  degeneration  found.  The  patient  made  an  unevent- 
ful recovery.  In  connection  with  this  case  the  author  re- 
calls another  which  came  under  his  observation  several 
years  back.  That  was  one  of  chronic  mastitis  developing 
in  a  woman  of  30  at  the  end  of  lactation.  The  breast  was 
enormously  enlarged  and  infiltrated.  During  a  seance  of 
massage  at  one  time  there  was  a  sudden  discharge  from 
the  nipple  of  a  large  quantity  of  a  gray  fluid  which  re- 
sembled tubercular  pus.  Lack  of  experience  at  that  time 
prevented  a  correct  diagnosis,  but  now,  recollecting  the 
symptoms  of  the  case,  the  author  is  positive  that  he  had  to 
deal  with  a  primary  tubercular  abscess.     [A.  R.] 

3. — A.  Stepanow  believes  on  the  ground  of  his  own  ob- 
servations as  well  as  those  of  others  that  iodide  of  potash 
may  become  decomposed  in  the  stomach  under  the  in- 
fluence of  the  acid  contents  of  the  latter  and  the  nitrites  of 
the  saliva.  This  explains  the  gastric  disturbances  fre- 
quently observed  after  the  administration  of  iodide  of  pot- 
ash. This,  however,  is  not  constant.  Usually  decomposition 
takes  place  in  the  small  intestine,  the  nitrites  in  this  case 
being  derived  from  the  pancreas.     [A.  R.] 

4. — Sh.  Malfitano  advances  a  number  of  arguments  based 
on  experiments  which  prove  that  bacteria  posses  proteo- 
lltic  ferments  which  digest  the  bacteria, — a  process  of  auto- 
digestion  called  by  him  "autobacteriolysis."  These  diastat- 
ic  ferments  are  released  from  the  bodies  of  the  bacteria 
when  the  latter  are  placed  in  an  environment  unfavorable 
to  their  growth.  Such  an  environment  may  be  produced 
by  adding  various  antiseptics,  especially  chloroform,  xylol 
and  thymol,  to  the  culture-media,  or  by  adding  the  dias- 
tetic  ferments  produced  by  other  bacteria.  The  observa- 
tions of  Emmerich  and  Low  would  then  be  explained  not 
by  attributing  specific  bacteriolytic  properties  to  the  bacil- 
lus pyocyaneus,  but  the  fact  that  the  ferments  of  the  latter, 
when  added  to  a  culture  of  the  plague  bacillus,  act  in  the 
same  manner  as  antiseptics  do,  namely,  causing  autobac- 
teriolysis.    [A.  R.] 

5. — M.  Sniesarew  describes  a  museum  specimen  of  dif- 
fuse congenital  hyperkeratosis  in  a  fetus  miscarried  at  the 


seventh  month.  The  pathological  characteristics  which  dis- 
tinguish it  from  Wassmuth's  case  are  as  follows:  1.  The 
stratum  comeum  is  greatly  increased;  2.  the  stratum  luci- 
dum  and  stratum  granulosum  are  still  present;  3,  the  Mal- 
pighian  layer  is  diminished;  4.  the  papillae  are  Increased 
both  in  size  and  number;  5.  the  blood  vessels  are  dilated; 
6.  the  sweat  glands  are  well  developed;  7.  hyaline  degene- 
ration of  the  connective  tissue  is  present;  8.  the  reticular 
layer  is  diminished.     [A.   R.] 


RUSSKI    ARCHIV    PATOLOGIl,    KLINITSHESKOJ    MEDI- 

CINY    I    BAKTERIOLOGII. 

February,  1901.     (Vol.  II,  No.  2). 

1.  Cellular  Posions  (cytotoxins).  I.  I.  METCHNIKOFF. 

2.  On  the  So-called  Lipoma  Arborescens.     N.  N.  MICHAIL- 

OFF. 

3.  On  Glycosolvol.     S.  W.  LEVACHEFP. 

4.  A  Method  of  Quantitative  Determination  of  Urea  in  the 

Urine.     A.  P.  BRAUNSTEIN. 

1. — Considered  editorially. 

2. — Michailoff  defines  lipoma  aborescens  as  a  rare  and 
extremely  peculiar  disease  of  the  synovial  membranes  of 
the  large  joints  and  the  sheaths  of  tendons  characterized 
by  the  development  on  the  surface  of  masses  of  newly- 
formed  tissue.  On  account  of  the  latter  entering  into  the 
formation  of  these  growths,  the  author  does  not  agree  with 
the  nomenclature.  He  considers  them  as  chronic  Inflam- 
matory hyperplasia  and  believes  that  they  are  of  tuber- 
cular origin,  being  produced  by  the  toxins  of  the  tubercle 
bacilli.  He  has  seen  several  cases  and  describes  one  In 
which  the  growth  appeared  on  the  sheath  of  the  extensor 
carpi  radialis  longior  et  brevior  of  the  right  hand.  The 
tumor  was  removed  and  the  patient  recovered.     [A.  R.] 

3. — Levacheft  quotes  the  observation  of  Daehne,  Martin 
Wiessenthal  and  Schedler  on  the  remarkable  curative  ef- 
fects of  glycosolvol  in  diabetes  mellitus.  This  substance 
was  invented  by  a  Dresden  druggist  Otto  Lindner.  It  Is 
made  by  the  action  of  oxypropionic  acid  (C'H'C)  on 
chemically  pure  pepsin  and  sodium  theobrominate  on  tryp- 
sin. The  product  is  claimed  to  possess  the  power  of  dis- 
solving carbohydrates  and  is  therefore  indicated  in  diabetes. 
To  facilitate  the  absorption  of  the  drug  the  originator  com- 
bines it  either  with  powdered  jambol  seeds  and  aromatics 
or  compound  fluid  extract  of  myrtle.  The  most  extrava- 
gant claims  made  by  Lindner  incited  the  author  to  try  his 
preparation  in  two  typical  cases  of  diabetes.  The  results 
obtained  were  greatly  at  variance  with  the  statements  of 
those  who  have  used  he  drug  before  him.  The  liquid 
preparation  exerted  no  beneficial  effect  whatever;  the  pow- 
der did  reduce  the  amount  of  sugar  in  the  urine  but  only 
when  very  large  doses,  far  in  excess  of  those  recommended, 
were  employed.  The  conclusion,  therefore,  is  reached  that 
the  virtues  of  this  preparation  reside  not  in  the  glycosolvol 
but  in  the  jambol  which  is  a  well  known  and  apparently 
quite  a  potent  remedy.     [A.  R.] 

4. — Braunstein  points  out  the  inaccuracies  in  the  various 
methods  employed  for  quantitative  determination  of  urea. 
For  accurate  work  he  suggests  the  following:  5  c.  c.  of  urine 
are  precipitated  by  5c.c.  of  a  mixture  of  barium  chloride 
and  barium  hydrate  (250  grms.  of  barium  chloride  and  50 
grms.  of  barium  hydrate  to  the  liter  of  water)  and  100  c.c. 
of  alcohol  and  ether  (2:1)  added.  On  the  following  day 
the  mixture  is  filtered  and  the  filter  washed  6-7  times 
with  ether  and  alcohol.  The  filterate  is  evaporated  at  a 
temprature  not  higher  than  55  C.  until  10  c.c.  remain.  Just 
before  this  point  is  reached  a  little  distilled  water  with  a 
small  amount  of  MgO  is  added.  The  10  c.c.  of  the  filtrate 
are  then  put  into  a  small  Erlenmeyer  flask  containing  10 
grms.  of  crystalline  phosphoric  acid  and  7  c.c.  of  liquid 
phosphoric  acid.  The  whole  is  heated  in  an  airbath  at  140- 
145  C.  for  4  1-2  hours.  When  cool,  the  nitrogen  is  deter- 
mined by  Kjeldahl's  method.     [A.  R.] 


The  Philadelphia  Medical  Journal 

A   Weekly  Journal  Owned  and  Published   by  The  Philadelphia  Medical  Publishing  Company  and   Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James   Hendrie  Lloyd.    AM  ,  M.D  .  Editnr-in- Chief 
JOLltJS  L.  Salingkr,  M.D  .  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.D.  F.  J.  Kaltf.ver.  M.D. 

D.  L.  Edsall,   M.D.  T.  L.  COLEY.    M.U. 

J.  M.  Swan,  M.D.  W.  A.  N.  DoRLAVn,    M.D. 

J.  H.  Gibbon,  M.D.  T.  M.  Tyson,  M.  D. 

M    OSTHEIMER,  M.  D.  A.  KOBIN.   .M.  D. 


Scientific  Articles,  Clinical  Memoianda,  News  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  publication.  Reprints  (250)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.   Address  all  correspondence  to 

The  PhiladelphiaMecUcal  Journal,  171fi  Chestnut  St.,  Philadelphia,  Pa. 
See  AdTertising  Page  .s. 


Vol.  VII,  No.  19 


May 


I  go  I 


$3.00  Per  Annum 


The  Therapeutic  Monthly. — The  Philadelphia 
Medical  Journal  wishes  to  call  the  attention  of  its 
subscribers  to  the  fact  that  each  full  paid  subscrip- 
tion entitles  its  holder  to  a  free  copy  of  The  Thera- 
peutic Monthly  until  its  expiration.  It  is  only  neces- 
sary for  the  subscriber  to  send  a  postal  card  to  The 
Philadelphia  Medical  Journal,  expressing  his  wish 
to  receive  the  Monthly.  We  repeat  this  notice, 
which  will  not  add  one  cent  to  the  income,  but,  on 
the  contrary,  a  considerable  amount  to  the  expense 
of  this  journal, — because  we  want  all  our  subscri- 
bers who  care  for  a  first-class  Therapeutic  paper,  to 
make  the  fullest  use  of  their  opportunities.  The 
Philadelphia  Medical  Journal  has  secured  a  large 
number  of  copies  of  The  Therapeutic  Monthly,  but  a 
a  great  many  have  been  ordered  already,  and  after 
the  number  secured  has  been  exhausted,  this  offer 
will  be  withdrawn. 

Dr.  Gaylord's  Paper  on  the  Cause  of  Cancer. — In 

another  column  of  the  present  issue  we  give  a  full 
abstract  of  the  eagerly  awaited  article  on  the  para- 
site of  cancer,  by  Gaylord.  The  author's  claim  to 
have  determined  the  true  parasite  of  cancer  rests 
apparently  upon  the  following  facts :  First,  the  dis- 
covery of  a  peculiar  organism  in  the  peritoneal  fluid 
of  a  patient  suffering  with  adenocarcinoma  of  the 
peritoneal  cavity.  Second,  the  discovery  of  similar 
bodies  in  a  large  number  of  tumors  (carcinomas  and 
sarcomas  and  even  syphilitic  gummas)  which  he 
has  examined.  Third,  the  identification  of  these 
bodies  with  Plimmer's  bodies,  and  the  determina- 
tion of  their  relationship  to  Russell's  fuchsin  bodies. 
Fourth,  a  certain  peculiar  series  of  changes  that 
take  place  in  the  bodies  when  the  fluid  in  which  they 
are  contained  is  kept  in  a  thermostat.  (These  are 
analogous  to  sporulation.)  Fifth,  the  production  of 
small  white  nodules  in  the  lungs  of  animals  injected 
with  this  fluid,  that  resemble  adenocarcinoma  and 
originate  in  the  columnar  epithelium  of  the  l:)ron- 
chi.  Sixth,  the  discovery  of  the  parasites  in  the 
epithelial  cells  of  these  growths. 

We  must  confess  that  we  feel  greatly  disappoint- 
ed in  this  paper,  and  this  is  not  altogether  justified, 
because  Dr.  Gaylord  does  not  publish  it  as  a  fin- 
ished presentation  of  his  views,  but  promises  in  the 


near  future  a  second  article  in  which  he  expects 
to  deal  with  the  really  serious  part  of  the  subject, 
the  cultivation  and  innoculation  of  this  organism. 
For  the  present  he  is  content  with  a  description  of 
the  various  observations  and  experiments,  the  re- 
sults of  which  we  have  given  above.  One  of  the 
most  interesting  features,  and  one  that  will  require 
a  very  careful  explanation,  is  the  analogy  of  this  or- 
ganism to  the  vaccine  bodies  of  Gorini  and  Funk, 
and  the  statement  that  they  belong  to  the  protozoa 
and  not  to  the  blastomycetes.  Gaylord  admits 
that  the  cultures  made  by  Plimmer,  which 
the  latter  regards  as  cultures  of  his  own  or- 
ganism, are  true  blastomycetes,  and  the  only 
inference  that  we  can  draw  is  that  Plimmer 
has  been  guilty  of  gross  inaccuracy  in  his  work, 
and  has  mistaken  a  contamination  for  a  growth 
of  his  bodies.  It  is  interesting  in  this  connection 
to  recall  the  statement  of  Schaudinn,  a  zoologist, 
working  especially  with  the  protozoa,  that  the  so- 
called  cancer  bodies — and  he  was  familiar  with 
preparations  stained  by  Plimmer's  method — have 
no  resemblance  whatever  to  the  protozoa  or  cocci- 
dia.  It  is  very  curious  also,  that  such  a  vast  number 
of  experiments  (Fischel,  Duplay  and  Cazin,  Plim- 
mer, Senn,  etc.)  made  under  conditions  very  simi- 
lar to  those  of  Gaylord — that  is  to  say,  intraperito- 
neally  and  intravenously — have  been  fruitless.  It 
is  unfortunate,  perhaps,  when  we  read  of  the  forms 
of  peritonitis  produced  by  intraperitoneal  injections, 
which  are  apparently  inflammatory  in  nature,  that 
we  are  irresistibly  reminded  of  the  work  of  Adam- 
kiewicz,  who  obtained  such  remarkable  results  by 
the  intra-cerebral  implantation  of  fragments  of 
carcinoma,  results  that  could  not  be  confirmed  by 
other  observers. 

r.ut  when  all  is  said  and  done,  we  must  take  per- 
sonal prejudice  into  account.  Gaylord  admits  that 
his  feeling  toward  Sanfelice's  results  was  somewhat 
modified  by  his  acquaintance  with  that  gentleman, 
and  by  the  recognition  of  his  honesty  and  earnest- 
ness ;  and  our  acquaintance  with  Dr.  Gaylord  has 
made  exactly  the  same  impression  upon  us.  If 
his  paper  is  at  present  incomplete  and  unsatisfac- 
tory, it  is  because  his  results,  although  clear  enough 
to  himself,  are  not  capable  of  the  accurate  scientific 


CqO       The  Philadelphia  "] 
y         Medical  Journal    J 


EDITORIAL   COMMENT 


[Mat  n,  lyji 


demonstration  that  is  insisted  upon  before  the  sci- 
entific world  is  ready  to  accept  them.  How  often 
has  it  occurred  that  important  discoveries  have  been 
placed  before  the  world  in  such  form  as  to  create 
considerable  skepticism  regarding  their  truth,  and 
if  Dr.  Gaylord  refuses  to  publish  a  series  of  ex- 
periments that  have  not  yet  been  conducted  to  com- 
pletion, he  deserves  rather  to  be  congratulated  than 
condemned,  and  we  should  endeavor  to  curb  our 
natural  impatience. 

It  is  interesting  in  this  connection  to  note  that 
Musser  and  Sailer  have  recently  reported  a  case  of 
infectious  pseudo-leukemia,  in  which  they  were  able 
to  produce  tumors  resembling  lymphoma  in  the  lung 
of  a  rabbit,  into  which  they  had  injected  intrave- 
nously some  of  the  patient's  blood.  Although  Len- 
gemann  has  been  unsuccessful  with  his  experiments 
undertaken  by  this  method,  there  is  much  reason 
to  believe  that  by  it  the  question  of  malignant  tu- 
mors, and  perhaps  other  diseases,  is  on  the  verge 
of  solution.  It  would  be  curious,  and  yet  perhaps 
not  altogether  to  be  regarded  as  a  cause  for 
surprise,  if  the  suggestion  of  Smith  and  Wash- 
burn, that  there  are  many  forms  of  infectious  gran- 
ulomas hitherto  not  recognized  as  such,  should  turn 
out  to  be  true,  and  if  some  of  these  forms  proved 
to  be  the  types  of  malignant  tumor  that  can  be  con- 
veyed to  certain  of  the  lower  animals. 

A  Noteworthy  Meeting.^It  is  seldom  that  a  more 
important  or  more  instructive  meeting  of  a  medical 
society  is  held  than  was  that  of  the  Association  of 
American  Physicians, at  Washington  last  week,under 
the  presidency  of  Professor  Welch,  a  report  of  the 
proceedings  of  which  is  published  in  another  part 
of  the  current  issue  of  the  Philadelphia  Medical 
Journal.  In  addition  to  important  clinical  papers 
on  the  first  day  a  very  interesting  and  sug- 
gestive one  was  read  by  Dr.  Herter,  of  New 
York  City,  on  "The  Acid  Intoxication  of  Diabetes 
and  its  Relation  to  Prognosis,"  with  valuable 
additions  by  Drs.  Pfaflf  and  Jocelyn,  of  Boston. 
The  recent  work  of  these  men  and  others  seems 
to  indicate  that  the  day  is  not  distant  when  a 
new  light  is  to  be  thrown  on  this  obscure  sub- 
ject. In  the  evening  most  instructive  micrographic 
demonstrations  were  given  by  Dr.  Bond  and 
Dr.  Ernst,  of  bacteriological  subjects,  and  by  Dr. 
Cotmcilman,  of  the  lesions  of  interstitial  nephritis 
in  diphtheria.  Rare  morbid  specimens  were  exhib- 
ited by  Dr.  Welch.  On  the  second  day  two  contri- 
butions of  great  importance  were  made,  that  by  Drs. 
Flexner,  Barker,  and  Novy,  reporting  their  studies 
of  the  plague  in  San  Francisco.  It  will  be  remem- 
bered these  physicians  constituted  a  commission  ap- 
pointed by  the  United  States  Government  to  investi 


gate  the  cases  of  plague  in  San  Francisco.  Even  of 
greater  importance  to  us  in  America  was  the  re- 
port of  Drs.  Reed  and  Carroll,  of  the  U.  S.  Army. 
of  their  researches,  which  have  gone  so  far  to  prove 
the  mosquito  theorj*  of  the  origin  of  yellow  fever. 
.\n  account  of  their  work  was  reported  at  the  Pan- 
American  Congress  at  Havana  in  February,  and  has 
been  made  known  to  us  through  the  columns  of  the 
Journal  of  the  American  Medical  Association,  and  com- 
mented upon  editorially  in  a  previous  number  of 
The  Philadelphia  Medical  Journal;  but  it  was  a 
great  privilege  to  hear  these  facts  presented  so 
clearly  and  impressively  by  Dr.  Reed.  In  the  re- 
mainder of  the  day  many  valuable  papers  were  read, 
notably  one  by  Dr.  Osier,  on  the  Spinal  Form  of 
Arthritis  Deformans,  and  another  by  Drs.  John  K. 
Mitchell.  Flexner  and  Edsall,  on  the  Chemical  and 
Zvlicroscopical  Results  of  the  Examination  of  three 
cases  of  Family  Periodic  Paralysis.  On  both  the 
first  and  third  days  other  papers  of  clinical  inter- 
est were  presented,  conspicuous  among  which  was 
that  of  Dr.  Thayer,  on  "The  Presystolic  Murmur." 
and  that  of  Dr.  Biggs,  of  New  York,  on  "The  Rel- 
ative Prevalence  of  Bright's  Disease  in  New  York, 
London  and  Berlin." 

Puerperal  Septicemia  Among  Italians  in  This 
City. — W't  have  seen  certificates  proving  that  four 
women  have  recently  died  of  puerperal  fever  in  the 
section  of  this  city  known  as  "Little  Italy,"  and  we 
are  credibly  informed  by  a  reputable  Italian  phy- 
sician tb.at  these  four  cases  all  occurred  in  the  prac- 
tice of  one  particular  Italian  midwife.  This  physi- 
cian has  taken  pains  to  trace  these  cases,  and  also 
to  make  himself  familiar  with  the  methods  of  this 
woman.  He  informs  us  that  her  "practice"  is  care- 
less and  dirty  to  the  last  degree,  and  that  these  four 
cases  are  entirely  due  to  her  negligence.  It  can 
readil)-  be  imagined  that  the  environment  of  her  pa- 
tients is  not  conducive  to  the  most  scrupulous 
asepsis,  but  it  certainly  does  seem  that  there  should 
be  some  waj-  to  stop  the  career  of  a  slovenly  mid- 
wife, who  is  thus  strewing  death  in  her  path.  It  is 
not  to  the  credit  of  any  large  American  city  at  the 
present  date  that  such  a  thing  should  be  allowed  to 
proceed  without  some  official  notice  and  some 
prompt  corrective.  In  this  period  of  preventive 
medicine  and  antiseptic  midwifer}-,  such  a  har\-est 
of  death  in  the  practice  of  one  midwife  is  scandal- 
ous. We  imagine  it  would  be  within  the  province 
of  the  coroner  to  investigate  this  slaughter  and 
bring  the  perpetrator  to  a  speedy  reckoning  with 
the  law.  Any  physician  or  midwife  who  has  one 
case  of  puerperal  fever  faces  a  grave  responsibility, 
but  by  the  time  he  or  she  has  four  cases  in  rapid 
succession,  that  practitioner  owes  it  to  the  public 
to  purify  and  e.xplain. 


Mat  11,  1901] 


EDITORIAL  COMMENT 


["The  Philadelphia        Rrtn 
L Medical  Journal  "77 


The  Sesquicentennial  of  the  Pennsylvania  Hos- 
pital.— When  in  1750  Dr.  Thomas  Bond  (who  seems 
to  have  been  the  real  founder)  solicited  the  aid  of 
his  friend,  Benjamin  Franklin,  to  further  his  scheme 
for  founding  a  hospital  in  Philadelphia,  he  builded 
better  than  he  probably  knew  or  imagined.  When 
the  Provincial  Assembly  approved  the  act  establish- 
ing the  Pennsylvania  Hospital  (7th  February, 
1751),  it  met  with  some  opposition  from  the  coun- 
try members,  who  said  that  the  cost  of  medical  at- 
tendance would  alone  be  enough  to  consume  all 
the  money  that  could  be  raised— an  objection  which 
nowadays  would  not  have  much  weight,  and  which 
at  that  time  was  met  by  Drs.  Thomas  and  Phineas 
Bond  and  Dr.  Llo3'd  Zachary,  who  offered  to  give 
gratuitous  services  for  three  years.  This  was  prob- 
ably the  first  occasion  when  the  now  familiar  cry 
of  "hospital  abuse"  was  or  could  have  been  raised 
in  Philadelphia.  Dr.  Zachary  and  the  brothers 
Bond  may  possibly  have  had  to  face  some  such  pre- 
judice when  they  quieted  the  fears  of  the  country 
members  by  promising  that  the  Pennsylvania  Hos- 
pital should  be  free.  And  free  it  has  been,  and 
widely  benevolent,  for  one  hundred  and  fifty  years. 
It  is  a  pioneer  hospital,  not  only  of  a  city  and  n 
province,  but  of  a  nation  and  a  continent.  The 
country  members  who  demand,  when  they  vote  an 
appropriation,  that  the  hospital  which  gets  it  shall 
be  free  (especially  to  the  country  members  and 
their  friends)  are  still  with  us,  and  we  need  not  cel- 
ebrate their  sesquicentennial — but  the  old  hospital 
with  its  traditions,  its  architecture,  its  noble  record, 
is  with  us,  too,  and  the  opportunity  is  here  for  the 
celebration  of  its  foundation  in  accord  with  its  dig- 
nity and  its  usefulness.  The  managers  have  decided 
upon  the  nth  and  18th  of  this  month  as  special  fete 
days. 

Electricity  and  Nerve  Force. — The  statement  is 
not  infrequently  made  that  nerve  force  is  identical 
with  electricity,  but  there  is  little  scientific 
ground  for  such  a  claim.  The  two  forces  are  distin- 
guished in  a  variety  of  ways.  Thus,  the  speed  at 
which  they  travel  is  very  unequal ;  the  nerve  im- 
pulse travels  at  the  rate  of  only  about  one  hundred 
to  one  hundred  and  twenty  feet  per  second,  while 
the  rate  of  electricity  is  vastly  greater.  But  while 
the  two  forces  are  apparently  not  identical,  it  is  true 
that  the  generation  of  nerve  force  seems  to  be  ac- 
companied by  electrical  phenomena.  This  may  be 
merely  in  accord  with  the  fact  that  all  chemical 
changes  are  thus  accompanied ;  as,  for  instance,  the 
reactions  between  the  elements  in  a  Leclanche'  jar. 
Vito-chemical  reactions  in  a  neuron-body  probably 
in  the  same  way  generate  electrical  force,  but  this  is 
not  necessarily  the  same  thing  as  the  nerve  force 
itself.    Another,  and  still  more  potent,  argument  is 


based  on  the  fact  that  nerve  force  is  variously  differ- 
entiated until  in  its  psychic  manifestations  it  reach- 
es its  highest  display.  This  would  be  quite  incon- 
ceivable of  such  a  force  as  electricity,  for  certainly 
no  one  would  say  that  thought  and  consciousness 
are  merely  electrical   phenomena. 

M.  August  Charpentiere  has  recently  made  ob- 
servations which  tend  still  further  to  prove  that  the 
two  forces  are  distinct.  He  found  that  an  electric 
stimulation  of  the  nerve  trunk  causes  a  double 
transmission,  (i)  An  almost  instantaneous  trans- 
mission just  as  in  an  ordinary  conductor.  This  is 
evidently  the  electric  current.  (2)  A  current,  also 
with  electrical  phenomena,  transmitted  at  the  very 
moderate  speed  of  the  nerve-impulse  (65  to  100 
feet).  That  this  true  nerve-impulse  is  accompanied, 
however,  by  electrical  energy  is  proved  by  the  fact 
that  it  can  send  a  stimulus  over  a  wire  to  a  nerve  in 
another  animal  and  thus  cause  a  response.  But 
Charpentiere  found  that  a  second,  third,  and  even 
fourth  impulse  or  wave  is  carried  over  this  wire, 
the  inference  being  that  the  nerve-impulses  are 
"oscillatory."  This  latter  display  is  probably  sim- 
ply in  accord  with  the  idea  of  Schaefer  and  Hors- 
ley,  that  neurons  have  a  rhythmical  discharge.  M. 
Charpentiere's  observations  are  discussed  in  the 
Revue  Sciciitifiquc. 

The  Death  Rate  from  Influenza. — In  the  ^^lonthly 
Bulletin  of  the  Chicago  Health  Department  for 
March,  1901,  the  leading  article  is  devoted  to  the 
discussion  of  the  effect  of  influenza  upon  the  mor- 
bidity of  the  city.  After  calling  attention  to  the 
rapid  increase  in  the  death  rate  from  pneumonia,  and 
to  a  less  extent  from  other  pulmonary  conditions, 
they  discuss  the  clinical  manifestations  of  this  dis- 
ease, and  the  great  importance  of  its  recognition  at 
the  very  incipiency  of  the  epidemic.  This  can  only 
be  accomplished  by  careful  bacteriological  exami- 
nations which  the  Chicago  Board  of  Health  is  now 
prepared  to  undertake,  systematically.  W^ith  the 
"culture  tube  and  microscope,"  they  believe  that 
the  epidemic  can  be,  to  a  certain  extent,  controlled. 
However,  they  admit  that  the  disease  spreads  with 
extreme  rapidity,  and  affects  the  clean  (hygienic- 
ally)  as  severely  as  the  unclean. 

The  great  difficulty  in  all  these  epidemic  diseases 
is  to  educate  the  public.  It  is  astonishing  how  hope- 
lessly ignorant  the  medically  uneducated  are ;  how 
ready  they  are  to  grasp  at  cure-all  straws ;  to  be- 
lieve blindly  the  alleged  efficiency  of  drugs;  to  ex- 
pect their  physicians  to  keep  them  well,  just  as  Tor- 
quata  Tasso  expected  of  his  physician,  without  dis- 
turbing the  reckless  tenor  of  his  life,  or  obliging 
him  to  do  anything  that  was  essentially  disagreea- 
ble. Persons  intelligent  enough  in  their  own  line 
are  often  entirely  unwilling  to  put  themselves  to 


onn      """^  Philadelphia  "I 
y'-"-'       Medical  Journal    J 


EDITORIAL  COMMENT 


[Mat  U,  1901 


any  serious  inconvenience  in  order  to  prevent  the 
ravagfes  of  an  epidemic  of  which  they  are  not  as  yet 
personally  the  victims.  We  have  frequently  been 
impressed  by  the  curious  indifference  on  the  part 
of  the  people  to  these  things.  By  this  we  do  not 
mean  that  they  foolishl)'  expose  themselves  to  the 
presence  of  patients  suffering  with  well-known  con- 
tagious disease;  indeed,  in  some  cases,  such  as  lep- 
rosy, they  are  panic-stricken  if  a  single  case  of  this 
nature  appears  in  the  community ;  but  we  allude 
to  their  unwillingness  to  adopt  even  mild  measures 
to  prevent  the  spread  of  fatal  epidemics. 

Therefore,  articles  such  as  this  of  the  Chicago 
Health  Board,  in  which  stress  is  laid  upon  the  ter- 
rifying aspects  of  the  disease,  are  to  be  strongly 
commended,  for  the}^  should  serve  to  some  extent 
to  arouse  the  public,  not  so  much  from  its  sense  of 
false  security,  as  from  its  indolence  and  indifference. 

Hydrophobia. — Dr.  D.  E.  Salmon,  Chief  of  the 
Bureau  of  Animal  Industry,  Washington,  D.  C,  has 
just  issued  in  pamphlet  form  his  study  of  rabies. 
Dr.  Salmon  relates  the  circumstances  which  led  a 
few  years  ago  to  the  discovery  of  the  fact  that  hy- 
drophobia was  much  more  prevalent  in  the  District 
of  Columbia  than  any  one  had  supposed.  The  dis- 
ease, in  fact,  was  not  believed  at  the  time  to  have 
occurred  there  with  any  frequency,  but  as  a  re- 
sult of  investigation  quite  a  large  number  of  cases 
were  discovered  in  animals  of  various  kinds.  Thus 
in  1893  it  was  found  that  11  dogs  and  i  horse  had 
the  disease.  In  1895,  4  dogs  and  2  foxes ;  in  1896, 
5  dogs ;  in  1897,  2  dogs,  i  cow ;  1898,  7  dogs ;  1899, 
19  dogs,  I  cow  and  i  cat,  and  in  1S90,  up  to  August, 
32  dogs,  3  cows,  I  horse  and  i  cat.  Therefore,  the 
total  number  of  animals,  nearly  all  of  which  were 
domestic  animals,  which  had  been  found  to  be  suf- 
fering from  rabies,  was  91.  Twenty-eight  persons 
were  reported  to  have  been  bitten  by  these  rabid 
animals.  Dr.  Salmon  says  that  these  developments 
.were  quite  unexpected.  It  was  not  supposed  at  that 
time  that  rabies  existed  to  this  extent  anywhere  in 
the  United  States,  and  this  discovery  in  the  Dis- 
trict of  Columbia  led  to  quite  extensive  inquiries  as 
to  the  prevalence  of  the  disease  in  the  country  at 
large.  It  was  found  that  hydrophobia  is  more 
prevalent  than  is  generally  supposed,  as  the  fol- 
lowing figures  for  some  of  our  larger  cities  clearly 
prove.  In  the  decade  from  1890  to  1899  there  were 
230  deaths  from  this  disease  in  ■jt,  cities.  In  Greater 
New  York  there  were  27  deaths ;  in  Chicago,  68 ;  in 
Philadelphia  only  8;  but  we  desire  to  say  here  dis- 
tinctly, with  reference  to  these  reports  in  Philadel- 
phia, that  we  do  not  consider  them  reliable.  It  is  a 
well-known  fact  in  this  city  that  the  officials  in  the 
coroner's  office  have  declared  openly  their  unbelief 
in  the  existence  of  such  a  disease  as  hydrophobia. 


and  that  they  have  deliberately  returned  such 
deaths,  in  which  all  the  scientific  evidence  was 
clear,  as  due  to  other  causes.  One  coroner  of  this 
town  is  even  reported  to  have  refused  to  accept 
certificates  of  death  from  hydrophobia,  and  required 
that  certificates  be  made  ascribing  death  to  other 
diseases.  This  high-handed  proceeding,  both 
against  the  public  weal  and  the  teachings  of  sci- 
ence, goes  far,  perhaps,  to  justify  the  opinion,  given 
by  Judge  Yerkes,  of  Bucks  Countj',  that  the  coro- 
ner's office  should  be  abolished. 

\^'e  have  not  space,  of  course,  to  review  the  whole 
of  Dr.  Salmon's  interesting  pamphlet.  The  author 
gives  both  historical  and  scientific  data  of  great 
interest  and  value.  The  disease  is  probably  of  great 
antiquity,  for  Homer  is  supposed  to  have  referred 
to  it  when  he  mentions  Sirius,  the  dog-star,  or 
Orion's  dog,  as  exerting  a  malignant  influence  upon 
the  health  of  mankind.  One  great  value  of  such 
publications  as  this  of  Dr.  Salmon's,  especially  when 
they  issue  under  the  auspices  of  the  Government 
of  the  United  States,  is  that  they  tend  to  enlighten 
public  intelligence,  for  this  is  needed  in  two  direc- 
tions. First,  to  disabuse  the  minds  of  the  public  of 
the  almost  superstitious  fear  with  which  hydropho- 
bia is  regarded.  While  it  is  undoubtedly  one  of  the 
most  serious  aflfections,  it  is  well  that  people  should 
know  that  it  is  amenable  to  both  prophylactic  and 
curative  treatment.  This  is  one  of  the  triumphs  of 
modern  science,  which  should  never  be  allowed  to 
be  forgotten.  Secondly,  such  a  publication  is 
much  needed  to  counteract  the  influence  of  a  cer- 
tain skepticism,  now  somewhat  prevalent,  to  the 
effect  that  there  is  no  such  disease  as  hydrophobia. 
These  two  extreme  views  of  the  disease  are  erro- 
neous and,  therefore,  mischievous,  and  the  only 
safe  course  is  the  medium  course,  to  regard  the  dis- 
ease not  only  as  a  reality  and  at  the  same  time  a 
grave  affection,  but  one  fortunately  which  is  now 
often  cured. 

The  Physiology  and  Chemistry  of  the  Internal 
Secretions. — With  the  revival  of  organo-therap}-  in 
medicine,  tliis  time  upon  a  truly  scientific  basis, 
physiologists  and  chemists  have  given  increased  at- 
tention to  the  stud}'  of  the  ductless  glands.  The 
April  number  of  The  Practitioner  is  devoted  to  the 
subject  of  organo-therapy  and  contains,  among 
others,  an  excellent  article  by  Dr.  John  Rose  Brad- 
ford upon  the  physiolog}"  of  these  glands.  Their 
activity  depends  upon  what  Brown-Sequard  has 
called  their  "internal  secretions,"  the  term,  exter- 
nal excretion,  being  reserved  for  the  products  of  the 
glandular  activity  which  are  subsequently  carried 
to  the  surface  by  means  of  a  duct.  Glands 
besides  secreting,  may  excrete,  and  the  distinction 
between  these  two  terms  lies  in  the  fact  that  the 


Mat  11.  1901] 


EDITORIAL  COMMENT 


CThb  Philadelphia        ^^j 
Medk-al  Journal  y^'- 


products  of  secretion  are  not  elaborated  by  the  ac- 
tivity of  the  gland  protoplasm,  but  are  withdrawn 
by  it  from  the  circulating  blood.  Glands,  besides 
possessing  an  internal  and  external  secretion, 
may  elaborate  an  excretion.  Some  glands  are 
restricted  in  function  to  the  production  of  an  exter- 
nal secretion,  as,  for  instance,  the  salivary  glands. 
The  thyroid  and  suprarenal  glands  probably  pro- 
duce only  an  internal  secretion,  as  far  as  our  knowl- 
edge goes  at  present.  The  pancreas  and  the  liver 
have  the  double  function,  and  in  the  kidney  we  have 
an  example  of  a  gland  in  which  the  excretory  func- 
tion is  well  developed,  although  it  is  by  no  means 
settled  that  the  kidney  does  not  possess  also  an  in- 
ternal secretion.  It  is  interesting  to  observe  the 
ability  of  interchange  of  these  functions  in  certain 
glands.  For  instance,  the  salivary  glands,  normally 
secretory,  will  excrete  iodide  of  potassiiun  when  this 
is  present  in  the  circulatory  stream  ;  and  the  liver 
will  excrete  a  large  number  of  toxic  substances 
from  the  alimentary  tract,  and  we  must  not  lose 
sight  of  the  fact  that  in  uremia  the  stomach  will  ex- 
crete urea  in  appreciable  amounts.  It  would  seem 
that  the  internal  secretions  are  elaborated  in  re- 
sponse to  the  physiological  needs  of  certain  tissues 
of  the  bod}-.  The  thyroidin  of  the  thyroid  gland  may 
be  necessary  for  the  performance  of  the  normal  ac- 
tivities of  the  central  nervous  system,  and  the  in- 
ternal secretion  of  the  suprarenals  seems  to  have 
an  important  function  in  maintaining  the  activity' 
of  the  muscular  coats  of  the  blood  vessels.  The  es- 
sential nature  of  the  external  secretions  is  that  of 
a  ferment  with  exceptions,  as,  for  instance,  the  se- 
cretion of  bile  salts  by  the  liver.  This  material  is 
used  over  and  over  again,  being  poured  into  the  in- 
testine, then  reabsorbed  and  carried  back  to  the 
liver.  We  are  ignorant  whether  this  is  true  in  case 
of  the  internal  secretions,  but  we  know  that  they  are 
used  in  the  metabolism  of  the  various  tissues  of  the 
body,  and  in  the  case  of  the  pancreas,  there  is  evi- 
dence of  the  formation  of  a  body  allied  to  a  ferment. 
This  seems  to  be  exceptional.  A  verj'  great  deal 
remains  to  be  explained  in  this  field,  as,  for  in- 
stance, the  fact  that  the  reyioval  of  all  parathyroi- 
dal  tissue,  although  its  actual  bulk  is  small,  is  fol- 
lowed by  the  same  effects  as  is  the  complete  remov- 
al of  all  thyroidal  tissue.  This  is  in  spite  of  the  fact 
that  the  parathyroidal  tissue  seems  to  contain  no 
colloid  material,  which  is  the  essential  product  of 
thyroid  activity.  In  1895  Baumann  discovered  the 
presence  of  iodine  in  the  thyroid  gland,  and  this 
served  to  arouse  renewed  interest  in  the  study  of 
its  chemistry.  The  thyroid  seems  to  possess  a  pe- 
culiar affinity  for  iodine,  but  it  has  been  proven  that 
iodine  is  not  invariably  present  in  the  thyroids  of 
young  infants.  It  is  generally  accepted  that  iodo- 
thyrin  is  the  only  physiological  active  constituent 


of  the  gland,  but  Robert  Hutchison  states  that  if 
the  presence  of  iodine  in  iodothyrin  is  essential  to 
the  activity  of  this  subsance,  it  is  not  so  in  virtue 
of  its  being  iodine,  but  owing  to  the  form  of  organ- 
ic combination  in  which  it  occurs.  Gley  has  recent- 
ly declared,  as  the  result  of  his  research  work,  that 
the  normal  thyroid  gland  contains  approximately 
ten  times  as  much  iodine  as  the  hypertrophied 
glands  of  patients  suffering  from  exophthalmic  goi- 
ter. Regarding  the  function  of  the  parathyroids,  it 
is  probable  that  they  are  concerned  in  removing 
something  from  the  blood  rather  than  adding  any- 
thing to  it.  We  know  that  the  administration  of  the 
gland  by  the  mouth  will  not  ameliorate  the  symp- 
toms which  result  from  their  removal. 

The  Value  of  Adrenalin  as  an  Antidote  in  Mor- 
phin  and  Opium  Poisoning. — Dr.  Edward  T.  Reich- 
ert,  in  an  article  in  this  journal  in  the  issue  of  March 
9th,  showed  that  morphin  administered  in  minute 
doses  to  dogs  profoundly  depressed  general  meta- 
bolism, and  stated  that  this  depression  is  so  wide 
spread  as  to  probably  involve  the  processes  which 
are  concerned  in  internal  secretion.  As  a  conse- 
quence of  this  fact,  the  intensification  of  the  toxic 
effects  of  the  drug  is  in  part  explained.  Reichert 
has  experimented  recently  with  adrenalin,  the  ac- 
tive principle  of  adrenal  extract,  for  the  purpose  of 
observing  its  action  upon  the  internal  secretions 
both  in  health}'  and  morphinized  dogs.  Dr. 
Reichert  has  reported  the  results  of  his  investiga- 
tions in  the  April  number  of  the  Uinzrrsity  of  Penn- 
sylvania Medical  Bulletin.  When  given  by  the  stom- 
ach or  administered  in  any  form,  adrenalin 
is  a  decided  circulatory  and  respiratory  stim- 
ulant, and  increases  metabolic  activity.  Pos- 
sessing these  properties,  Reichert  claims  thai 
it  should  be  pre-eminently  useful  in  antagoniz- 
ing the  lethal  influences  of  opium  and  its  deriva- 
tives. He  has  found  that  a  dose  of  0.00025  gram 
per  kilo  exerts  no  distinct  influence  in  a  normal  dog, 
but  in  the  morphinized  dog  it  is  sufficient  to  pre- 
vent the  profound  decrease  of  general  metabolism, 
and  the  fall  of  temperature  caused  by  the  morphin. 
This  fact  indicates  that  in  morphin  poisoning 
there  is  an  involvement  of  the  processes  concerned 
in  internal  secretion.  The  drug  seems  to  act  as  a 
depressant  to  the  secretory  processes  of  the  adrenal 
gland,  thus  depriving  the  vital  centers  of  their  se- 
cretions. In  making  these  observations,  Reichert 
mentions  the  fact  that  very  small  doses  of  adrenalin 
seem  to  exert  no  effect  in  the  healthy  animal,  for 
the  reason  that  the  quantity  introduced  is  minute, 
and  the  normal  supply  being  sufficient,  the  excess 
is  destroyed,  or  there  is  a  temporary  inhibition  of 
the  secretory  processes  of  the  glands,  but  in  the 
morphinized  animal  it  is  probable    that    the    blood 


902 


The  Philadelphia 
Medical  Journal 


] 


REVIEWS 


fMAT  11.  1301 


lacks  this  normal  constituent,  and  that  the  adrena- 
lin introduced  is  not  destroyed  until  its  function 
has  been  performed.  This  theory  seems  to  be  borne 
out  experimentally,  in  that  when  larger  doses  are 
given  to  normal  dogs,  effects  are  noted  comparable 
to  those  in  morphinized  animals  after  much  smaller 
doses.  Reichert  explains  this  by  stating  that  the 
quantity  being  in  excess  of  what  can  be  immedi- 
ately destroyed,  or  compensated  for,  the  effects  are 
comparable  to  a  hypernormal  state  of  the  activity 
of  the  adrenal  glands.  From  his  studies  of  the  ac- 
tion of  adrenalin  upon  the  respiratory  movements, 
the  heart,  arterial  pressure,  general  metabolism 
and  body  temperature,  Reichert  believes  that  this 
drug  will  be  found  of  great  value  in  opium  and 
morphin  poisoning,  in  failure  of  the  circulation,  and 
in  the  prevention  of  collapse  in  anesthesia.  Mink- 
owsky, among  others,  has  also  recommended 
adrenalin  in  the  latter  condition.  The  careful  work 
of  Dr.  Reichert  in  this  field  makes  the  preliminary 
report,  and  his  conclusions  of  great  interest.  Very 
minute  doses  of  the  drug  only  are  required.  Thus 
it  is  stated  that  1-200,000  of  a  gram  injected  intra- 
venously produces  distinctive  effects  in  man.  Reich- 
ert observes  that  owing  to  the  powerful  vasocon- 
strictor local  action  of  adrenalin,  abscesses  will 
likely  follow  its  subcutaneous  injection,  and  he  rec- 
ommends that  if  given  by  the  stomach,  it  should  be 
administered  with  alcohol  in  some  form  so  as  to  in- 
crease the  rapidity  of  absorption. 


IRcvlcws. 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmo- 
scopic Diagnosis.  By  Prof.  Dr.  O.  Haab,  Director  of  the 
Eye  Clinic  in  Zurich.  From  the  Third  Revised  and 
Enlarged  German  Edition.  Edited  by  Geo.  E.  De 
Schweinitz,  Professor  of  Ophthalmology,  Jefferson 
Medical  College,  Philadelphia;  Consulting  Ophthalmolo- 
gist to  the  Philadelphia  Polyclinic;  Ophthalmic  Sur- 
geon to  the  Philadelphia  Hospital  and  to  the  Ortho- 
pedic Hospital  and  Infirmary  for  Nervous  Diseases. 
With  162  colored  lithographic  Illustrations  and  85 
pages  of  text.  Philadelphia  and  London:  W.  B.  Saun- 
ders &  Co.,  1901.     Price,  f3.00  net 

The  names  on  the  title  page  are  suflBcient  guarantee  for 
the  excellence  of  this  work.  Closer  examination,  however, 
will  at  once  reveal  features  which  could  only  be  brought 
to  the  perfection  they  possess  by  careful  selections  and 
extensive  clinical  material.  The  beautifully  executed 
lithographic  illustrations  show  some  of  the  hidden  changes 
of  the  eyeball  that  are  unlocked  by  the  ophthalmo- 
scope. Of  no  little  value  to  the  student  of  ophthaJmoscopy 
are  the  illustrations  representing  the  non-pathological 
changes  in  the  normal  eye-ground  which  so  often  mislead 
and  contuse  him.  The  plates  showing  the  microscopical 
changes  are  characterized  tinctorially  by  wealth  of  color 
and  correctness  of  demarcation.  To  those  general  practi- 
tioners who  value  ophthalmoscopy  as  a  means  of  accessory 
diagnosis  this  book  will  be  of  material  assistance.  Even 
the  specialist  will  find  careful  reproductions  of  such  con 
ditions  as  "Retinitis  Circinata,"  "Glioma  of  the  Retina" 
and  microscopical  sections  of  "Hyaline  Bodies  (Drusen) 
In  the  Vitreous  Layer  of  the  Choroid."     The  text  is  con 


else,  free  from  typographical  errors  and  admirably  trans- 
lated. Especially  free  is  it  from  the  "Germanicisms"  so 
frequently  observed  in  English  translations,  and  so  diffi- 
cult to  overcome.  The  publishers  have  placed  the  book 
on  the  market  in  such  a  manner,  that  it  forms  a  valuable 
adjunct  to  the  other  atlases.     [M.  R.  D.] 

The  Technique  of  Surgical  Gynecology. — By  Augustin  H. 
Goelet,  M.  D.,  Professor  of  Gynecology  in  the  New 
York  School  of  Clinical  Medicine;  Consulting  Profes 
sor  of  Gynecological  Electro-Therapeutics,  Interna- 
tional Correspondence  Schools,  Scranton,  Pa.;  Fellow 
of  the  New  York  Academy  of  Medicine,  and  of  the  New 
York  Obstetrical  Society;  Member  of  the  American 
Medical  Association;  New  York  County  Medical  Asso- 
ciation; Fellow  of  the  Societe  Francais  d'Electrother- 
apie,  etc.  International  Journal  of  Surgery  Co.  New 
York,  1900.     Pp.  331. 

This  work  is  devoted  entirely  to  operative  technique,  as 
its  title  implies,  and  no  space  is  given  to  diagnosis,  pathoU> 
gy  or  forms  of  treatment  other  than  operative.  In  this 
respect  it  supplements  many  works  on  gynecology,  which 
give  only  general  directions.  There  is  no  hesitation,  there- 
fore, in  devoting  abundant  attention  to  minor  points  which 
are  of  great  importance  to  those  unfamiliar  with  a  given 
operation.  The  writer  has  the  power,  not  possessed  by 
all,  of  making  clear  that  which  he  is  trying  to  describe. 
In  general  he  gives  but  one  method  of  operating,  the  one 
which  he  considers  best.  This  detracts  somewhat  from 
the  value  of  the  work,  as  the  reader  might  care  less  to 
know  what  method  was  used  by  this  author,  than  to  find 
in  a  work  on  technique  clear  descriptions  of  those  meth 
ods  which  have  wide  acceptance  among  the  best  operators. 
For  example,  the  only  method  of  shortening  the  round  liga- 
ments given  is  that  of  cutting  down  on  the  ligament  within 
the  inguinal  canal,  as  practiced  by  Dr.  Kellogg.  Thi> 
method  is  a  good  one,  but  many  operators  of  very  large 
experience  prefer  to  reach  the  ligaments  at  the  external 
ring,  or  to  lay  open  the  canal,  and  these  methods  merit 
description  in  a  work  on  technique.  So  with  lacerations 
of  the  perineum.  To  be  sure,  it  might  be  said  that  the 
operations  are  too  numerous  to  describe;  but  to  confine 
the  description  to  a  simple  triangular  method  with  the 
apex  in  the  centre  above,  layer  sutures  of  catgut,  or  two  purse 
string  silver  sutures  for  hurried  work,  is  not  doing  justice 
to  the  subject.  One  might  infer  that  the  writer  seldom 
does  combined  plastic  operations  at  a  single  sitting,  for  if 
the  peritoneum  and  anterior  vaginal  wall  be  properly  sut 
ured,  the  removal  of  silver  sutures  from  the  cervix  is  diffi- 
cult, and  such  treatment  of  the  canal  as  daily  subsequent 
packing  with  iodoform  gauze  is  out  of  the  question.  Sel- 
dom indeed  will  the  operation  of  cervical  repair  be  the 
only  one  done  at  a  sitting  in  most  hands.  He  uses  stick 
sponges  rather  than  continuous  irrigation.  He  does  not 
advocate  the  self-retaining  vaginal  speculum.  He  would 
carry  conservatism  In  tubal  surgery  so  far  as  in  some 
cases  to  wash  out  and  leave  a  tube  In  which  ectopic  preg- 
nancy had  occurred.  How  this  can  be  reconciled  with  the 
very  common  history  of  repeated  hemorrhage  attacks  after 
rupture,  is  not  stated.  He  advocates  the  mass  ligature 
only  for  tumor  pedicles,  and  in  vaginal  ovariotomy  sews  in 
the  ligature  to  prevent  slipping.  He  believes  that  the  li- 
gation per  vaginam  of  uterine  arteries  has  a  field  in  the 
case  of  tumors  low  down,  but  advises  cutting  the  artery. 
The  chapter  on  curettage  and  after-treatment  as  modifie<l 
by  conditions  Is  very  good.  Many  practical  and  suggestive 
points  are  to  be  found  in  the  work,  which  will  find  appre- 
ciative readers.     [G.  E.  S.] 


A  Case  of  a  7  months  Extrauterine  Pregnancy  Operated 
on  through  the  Vagina.  .A.  Ph.  Kablukoff  (Mcdi'in-ikoie  Ofni- 
urtnif.  Fchruari/.  lOnl.)  reports  a  case  of  extrauterine  preg- 
nancy in  a  nullipara  30  years  old.  .\  well  formed  dead  fetus 
of  7  months  was  removed  through  the  posterior  vaginal 
wall.  Owing  to  adhesion,  the  placenta  was  left  in  situ. 
The  post-operative  period  progressed  without  any  compli- 
cations, except  for  an  elevation  of  temparature  accompany- 
ing the  gradual  discharge  of  the  placental  tissue.     [.\.  R.] 


Mat  11,  19011 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia       _^, 
Lmedical  Journal         y^o 


american  IRcws  an&  Hlotcs. 


PHILADELPHIA  NEWS. 

Jefferson  Medical  College. — The  annual  commencement 
exercises  of  the  Jefferson  Medical  College  will  be  held  at 
the  Academy  of  Music  on  May  15th  at  noon.  142 
graduates  will  receive  their  diplomas.  Professor  W.  W. 
Keen  will  hold  the  commencement  address.  The  alumni 
meeting  will  be  held  on  Muy  llth,  7  P.  M.,  at  the  Stratford 
Hotel,  and  the  alumni  dinner  at  8  P.  M.  of  the  same 
evening. 

Philadelphia  School  for  Backvirard  Children. — The  Phila- 
delphia School  for  Backward  Children  is  asking  the  Board 
of  Education  to  undertake  the  supervision  of  the  school 
and  to  locate  it  in  the  Hollingsworth  public  school  build- 
ing, Locust  above  Fifteenth  street.  Medical  School  In- 
spectors and  Hospital  Physicians  would  do  well  to  refer 
to  this  School  all  such  children  coming  to  their  notice  that 
are  in  need  of  individual  instruction.  The  Board  of  Edu- 
cation and  Councils  no  doubt  will  readily  see  the  efticicacy 
of  this  movement  and  they  cannot  give  too  much  sup- 
port to  it. 

For  an  Obstetrical  Amphitheatre. — The  University  of 
Pennsylvania  has  received  a  gift  of  $25,000  from  Mrs.  C.  B. 
Newbold,  of  Philadelphia,  for  the  erection  of  an  obstetrical 
amphitheatre  as  an  addition  to  the  maternity  department 
of  the  university  hospital.  The  gift  was  made  in  honor 
of  her  mother,  Mrs.  Thomas  A.  Scott. 

Whooping  Cough  Among  Contagious  Diseases. — The  Hy- 

gienie  Committee  of  the  Board  of  Education  decided  to  add 
whooping  cough  to  the  list  of  contagious,  and  considers  it 
a  cause  for  exclusion  from  the  public  schools. 

Removal  of  Alms  House  and  Insane  Hospital. — Efforts 
are  being  made  for  urging  the  speedy  removal  of  the 
Almshouse  and  Insane  Department  of  the  Philadelphia 
Hospital,  (Blockley),  to  a  more  suitable  location.  The  sum 
of  $200,000  has  been  made  available  for  the  erection  of 
new  buildings,  through  the  action  of  Congress, 
ad  Continental  Europe — 

Obituary. — Dr.  Samuel  Kuypers  Lyon,  at  New  York,  on 
May  4,  aged  60  years. — Dr.  Harold  Snowden.  at  Alexandria, 
Va.,  on  May  5,  aged  65  years. — Dr.  Abraham  Deyo,  at 
Gardiner,  N.  Y.,  on  May  5,  aged  71  years. 

Obituary. — Dr.  Roy  Ingliss,  at  Denver,  Col.,  on  April  23. — 
Dr.  Henry  Byron  McKellops,  at  St.  Louis,  Mo.,  on  April  24, 
aged  78  years. — Dr.  Charles  A.  Eisenhart,  at  York,  Pa.,  on 
April  23,  aged  56  years. — Dr.  George  Dale,  at  Chicago,  111., 
on  April  25. — Dr.  William  H.  Draper,  at  New  York  City, 
on  April  26,  aged  71  years. — Dr.  J.  A.  Someville,  at  Marin- 
ette, Wis.,  on  April  27,  aged  59  years. — Dr.  Joseph  W.  Ben- 
ton, at  Indianapolis,  Ind.,  on  April  28,  aged  77  years.— Dr. 
James  H.  Woodburn,  at  Indianapolis,  Ind.,  on  April  28. — 
Dr.  Jacob  A.  Sherman,  at  Plainfield,  N.  J.,  on  April  29,  aged 
81  years. — Dr.  M.  B.  Baldwin,  at  Wardencliffe,  Mass.,  on 
April  30. — Dr.  F.  G.  Brown,  at  Hutchinson,  Kan.,  on 
April  29,  aged  57  years. — Dr.  Richard  C.  Baker,  at  Otego, 
N.  Y.,  on  April  24,  aged  47  years. — Dr.  William  F.  Creighton. 
at  Alexandria,  Va.,  on  May  2. — Dr.  Irving  C.  Rosse.  at 
Washington,  D.  C,  on  May  3,  aged  54  years. — Dr.  David  H. 
Bartine,  at  Merchantville,  N.  J.,  on  May  3,  aged  60  years. — 
Dr.  M.  Albert  Rhoads,  at  Reading,  Pa.,  on  May  4,  aged  53 
years. — Dr.  Orlando  Mitchell,  at  Marshall,  Mo.,  on  May  3. 

Vital  Statistics  of  Philadelphia  for  the  week  ending 
May  4,  1901: 

Total    mortality    494 


Cases     Deaths 


Inflammation  of  the  appendix  1,  blad- 
der 1,  brain  21.  bronchi  8,  heart  1, 
kidneys  28,  larynx  1.  liver  5,  lungs  55, 
pericardium  3,  peritoneum  4,  pleura 
3,  stomach  and  bowels  19,  spine  3   . . 

Marasmus  15,  debility  4,  inanition  11   . . 


153 
30 


Cases.     Deaths. 

Tuberculosis  of  the  lungs    72 

Apoplexy  14,  paralysis  6   20 

Heart-disease  of  32,   fatty  degeneration 

of  5,  neuralgis  of  3  40 

Uremia  9,  diabetes  1,  Bright's  disease  12  22 
Carcinoma  of  the  breast  1,  stomach  8, 
uterus   5,   jaw  2,   leg   1,   liver   1,   pan- 
creas 1  19 

Convulsions  14,  convulsions,  puerperal  1,  15 

Diphtheria 66  10 

Brain-disease  of  3,  softening  of  1 4 

Typhoid  fever   71  5 

Old  age   11 

Cyanosis    3 

Scarlet   fever    113  6 

Influenze  2,  abscess  of  breast  1,  ab- 
dominal 1,  alcoholism  1,  asthma  1, 
anemia  1,  atheroma  2,  burns  and  scalds 
4,  casualties  11,  cerebro-spinal  menin- 
gitis 1,  congestion  of  lungs  3,  cirrhosis 
of  the  liver  1,  diarrhea  2,  drowned  1, 
dropsy,  kidneys  1,  dysentery  1,  ex- 
tra uterine  pregnancy  2,  epilep- 
sy 2,  erysipelas  2,  fever,  ma- 
larial 1,  puerperal  1,  gangrene  2,  hem- 
orrhage from  uterus  2,  indigestion  1, 
locomotor  ataxis  1.  measles  2,  edema 
of  lungs  3.  rheumatism  1,  sclerosis  ar- 
terial 4,  shock,  surgical  1,  septicemia 
6.  smallpox  1.  suffocation  1,  suicide  1, 
tabes  mesenterica  1,  teething  3,  un- 
known 1,  unknown  coroner  cases  3, 
w  hooping  cough  8   84 

NEW    JERSEY. 

The  Salem  County  Medical  Society  has  elected  officers 
for  the  year,  as  follows:  President,  Dr.  E.  E.  De  Groft;  Vice- 
President,  Dr.  B.  A.  Waddington;  Secretary  and  Treasurer, 
Dr.  H.  Chavanne;  Reporter,  Dr.  W.  H.  Carpenter;  Censor, 
Dr.  N.  S.  Hires. 

Cape  May  County  Medical  Society.— The  annual  meeting 
of  the  Cape  May  County  Medical  Society  was  held  May  7. 
Several  interesting  papers  were  read,  and  at  the  close  of 
the  business  session  a  banquet  was  served.  The  following 
officers  were  elected:  President,  John  S.  Douglass,  of  Tucka- 
hoe;  Vice  President,  Joseph  Marshall,  of  Tuckahoe;  Secre- 
tary, Nathan  Cohen,  of  Wildwood;  Treasurer,  Randolph 
Marshall,  of  Tuckahoe. 

NEW    YORK. 

New  York  State  Hospital  for  the  care  of  Crippled  and  De- 
formed Children.  The  opening  of  the  Hospital  will  take 
place  on  Friday,  May  17th,  1901  from  3-5.  The  Right  Rev- 
erend Henry  C.  Potter,  D.  D.,  President  of  the  Hospital, 
will  preside.  Short  addresses  will  be  made  by  Professor 
Robert  F.  Weir,  M.  D.,  of  Columbia  University;  Professor 
A.  Alexander  Smith,  M.  D.,  of  the  University  of  the  City  of 
New  York,  and  Professor  William  Polk,  M.  D.,  of  Cornell 
University.  A  special  train  will  leave  the  Grand  Central 
Station  at  2.06  P.  M.  returning  will  leave  Tarrytown  at 
5.55  P.  M.  reaching  New  York  at  6.35  P.  M.  Anyone  in- 
terested may  obtain  tickets  for  the  special  train  upon  appli- 
cation to  Dr.  Newton  M.  Shaffer,  28  E.  38th  street.  New 
Yory  City. 

The  American  Congress  of  Tuberculosis  will  be  held  at 
the  Grand  Central  Palace,  in  the  City  of  New  York,  May 
15th  and  16th.  and  perhaps  May  17th,  1901,  in  joint  session 
with  the  Medico-Legal  Society  of  New  York.  The  medical 
profession  of  all  countries  have  been  invited  to  contribute 
papers  to  be  read  before  this  congress,  in  their  behalf,  by  a 
committee  selected  for  that  purpose,  in  case  of  the  inabili- 
ty of  the  author  to  attend,  and  to  enable  those  who  could 
not  hope  or  expect  to  be  present  to  participate  in  the 


nri/i  r^THE  Philadelphia  "I 
yu4  L^  Medical  Journal    J 


AMERICAN  NEWS  AND  NOTES 


[Mat  U.  1901 


•work  and  usefulness  of  the  body.  As  the  questions  to  be 
discussed  involve  medical  legislation,  legislators,  lawyers, 
judges  and  all  publicists  who  take  an  interest  in  the  sub- 
ject are  also  invited,  both  to  enroll  and  contribute  papers. 

The  governors  of  the  American  states  and  territories  and 
of  the  Provinces  of  the  Dominion  of  Canada  have  been 
invited  to  send  at  least  three  or  more  delegates. 

The  governor  of  Colorado  has  appointed  the  following 
delegates  to  represent  the  state  of  Colorado  at  the  Ameri- 
can Congress  of  Tuberculosis,  to  be  held  at  the  Grand  Cen- 
tral Palace,  in  the  City  of  New  York,  May  15-17,  1901:  Dr. 
J.  N.  Hall,  of  Denver;  Dr.  Will  B.  Davis,  of  Pueblo;  Dr. 
B.  P.  Anderson,  of  Colorado  Springs;  Dr.  J.  Tracey  Mellvin, 
of  Sagauche;  Dr.  R.  F.  Graham,  of  Greeley,  and  Mrs.  W.  S. 
Decker,  of  Denver. 

The  governor  of  Kentucky  has  appointed  the  following 
delegates  to  the  same  Congress:  Dr.  J.  N.  McCormick,  of 
Bowling  Green;  Dr.  M.  K.  Allen,  of  Louisville,  and  Dr.  Ches- 
ter Mayer,  of  Louisville. 

The  governor  of  Vermont  has  appointed  the  following 
delegates  to  that  Congress:  Dr.  Charles  S.  Caverly,  of  Rut- 
land; Dr.  Henry  D.  Holton,  of  Battleboro,  and  Dr.  Truman, 
R.  Stiles,  of  St.  Johnsbury. 

The  governor  of  Washington  has  appointed  the  following 
delegates  to  this  Congress:  Hon.  Watson  C.  Squire,  ex-U. 
S.  Senator  from  Washington,  D.  C;  Edward  H.  Thomas, 
Esq.,  of  Whatcome,  Washington,  and  Ralcy  Husted  Bell, 
M.  D. 

The  Nicaraguan  Minister  has  appointed  the  following 
physicians  to  represent  Nicaragua  at  theCongress:  Dr.Louis 
H.  Debayle.  21  Irving  Place,  New  York  City,  and  Dr.  Juan 
B.  Sacasa,  Columbus  Hospital,  New  York  City. 

The  governor  of  Alabama  has  appointed  the  following 
delegates  from  that  state:  Dr.  W.  H.  Blake  of  Wetumpka; 
Dr.  C.  H.  Jeringan,  of  Birmingham,  and  Dr.  W.  J.  Kerna- 
han.  of  Florence. 

The  governor  of  Missouri  has  appointed  twenty-five  del- 
egates; the  governor  of  Georgia  has  named  twelve  dele- 
gates, Iowa  eigth,  Virginia  thre,  and  nearly  every  state  and 
territory  will  be  represented. 

Similar  invitations  have  been  sent  to  the  presidents 
of  the  Central  and  South  American  countries.  Arrange- 
ments have  been  concluded  for  reduced  railway  rates 
throughout  the  United  States  and  Canada.  A  letter  has 
been  sent  to  the  delegates  and  officials  by  the  President  of 
the  Medico-Legal  Society  embracing  the  following  ques- 
tions: 

1st — What  importance  do  you  attach  to  preventive  legis- 
lation as  a  factor  in  diminishing  the  spread  of  Tubercu- 
losis? 

2nd — Assuming  the  importance,  necessity  and  utility  of 
preventive  legislation,  how  can  the  public  be  best  educated 
and  its  sentiment  aroused  sufficiently,  to  secure  the  pass- 
age of  preventive  laws,  and  their  enforcement  after  they  are 
passed? 

3rd — Which  would  you  regard  as  for  the  best  interest  of 
the  people?  . 

(1)  Legislation  authorizing  the  employment  of  drastic 
measures  for  the  enforcement  of  the  necessary  regula- 
tions, or, 

(2)  A  broad  policy  of  education  of  the  masses,  as  to 
the  cause,  the  danger  and  the  remedy  for  a  factor  in  dimin- 
ishing the  spread  of  Tuberculosis? 

Kindly  reply  to  this  letter  at  once,  because  the  time  is  so 
short;  and  if  you  will  contribute  a  paper  and  enroll  in  the 
congress,  do  so. 

Please  send  your  reply  to  the  questions  as  early  as  pos- 
sible, so  that  I  can  publish  your  answer  as  a  part  of  my 
contribution  to  the  Congress,  to  be  sent  at  least  a  month 
before  its  session  to  delegates,  and  in  time,  to  awaken  in- 
terest, and  arouse  discussion  upon  the  subject  at  the  Con- 
gress itself. 

NEW     ENGLAND. 
Sterilizing   Money. — Scarlet  fever,  which  is  epidemic  in 
Keene.  N.  H.,  has  caused     the  Cheshire  National  Bank  of 
that  town  to  sterilize  all  the  money  which  passes  through 


the  bank  by  means  of  a  sterilizing  oven  which  they  have 
put  there  for  that  purpose. 

Hartford  County  Medical  Society. — The  annual  meeting 
of  the  Hartford  County  Medical  Society  was  held  April  17. 
Papers  read  were:  "Etiology  and  Treatment  of  Sub-Acute 
Rheumatism,"  by  Dr.  Thomas  S.  O'Connell:  "The  Surgical 
Treatment  of  the  Peritoneum,"  by  Dr.  Arthur  J.  Wolff; 
obituaries.  Dr.  Abner  S.  Warner,  by  Dr.  Gordon  W.  Russell, 
Dr.  Julian  N.  Parker,  by  Dr.  William  R.  Tinker;  "Gun- 
shot Wounds  of  the  Brain,"  by  Dr.  Harmon  G.  Howe; 
"Typho-Malarial  Fever,"  by  Dr.  Edward  K.  Root;  "Ectopic 
Gestation,"  by  Dr.  Phineas  H.  Ingalis. 

American  Laryngological  Association.  The  programme 
of  the  23rd  annual  congress  of  the  American  Laryngologi- 
cal Association  to  be  held  at  Yale  University,  New  Haven, 
Conn,  on  May  27-28-29,  is  as  follows:  Monday,  May  27th, 
morning  session  at  10.15  a.  m.  Roll  call.  Reception  of 
Guests.  Address  of  Welcome,  by  the  President  of  Yale 
University.  President's  address,  by  Henry  L.  Swain,  M. 
D..  New  Haven,  Conn.  Papers.  1  A  leaf  from  the  ancient 
history  of  the  anatomy  of  nasal  catarrh.  Jonathan  Wright, 
M.  D.  2.  Asymmetry  of  the  nasal  cavities.  A.  Coolidge.  Jr., 
M.  D.  3.  Reflex  epilepsy  from  nasal  disease  successfully 
treated  by  the  removal  of  the  intra-nasal  cause,  John  O. 
Roe,  M.  D.  4.  The  supra-labial  operation  (Dr.  Harrison 
Allen's)  for  deflection  of  the  nasal  septum.  Arthur  Ames 
Bliss.  M.  D.  5.  Edema  of  the  pharjnx.  palate  and  uvula 
following  application  of  supra-renal  extract.  S.  Solis-Cohen, 
M.  D.  6.  (o)  Can  we  prevent  secondary  hemorrhages 
following  nasal  operations?  (6)  Epipharyngeal  sarcoma  In 
a  boy  (with  radiographic  study),  Henry  L.  Wagner.  M.  D. 

7.  Chancre  of  the  tonsils,  J.  Edwin  Rhodes.  M.  D. 
Afternoon  session  at  3  p.  m.  Papers:  8.  Mouth  breath- 
ing and  its  relation  to  disease  of  the  nose,  throat,  ears  and 
accessory  cavities.  Mayo  Collier,  M.  D.  9.  Diagnosis  of 
adenoids  in  infancy,  W.  F.  Chappell.  M.  D.  10.  Serous  dis- 
ease of  the  maxillary  antrum  with  a  report  of  two  cases.  W. 
E.  Casselberry,  M.  D.  11.  Empyema  of  the  antrum  of  High- 
more  in  infants.  Emil  Mayer.  M.  D.  12.  Abscess  of  the 
frontal,  ethmoidal  and  sphenoidal  sinuses  complicated  by 
adenoma  of  the  posterior  ethmoidal  and  sphenoidal  re- 
gions, J.  H.  Bryan.  M.  D.  At  4.15  adjournment  to  the  Psy- 
chological Laboratory.  Evening.  Reception  in  Alumni 
Hall  by  the  President  of  Yale  University  and  the  President 
of  the  Association.  Tuesday.  May  28th.  Session  at  lf>  a. 
m.  Business  meeting.  Open  only  to  fellows  of  the  Associa- 
tion. Papers.  1.  Discussion  on  general  anesthesia  in  oper- 
ations upon  the  nose  and  throat:  (<;)  On  the  use  of  the  A. 
C.  E.  mixture  and  ethyl  bromide  for  adenoid  operations.  J. 
W.  Gleitmann,  M.  D.  (h)  Nitrous  oxide,  chloroform  and 
ether,  T.  R.  French.  M.  D.  2.  The  tonsils  from  a  purely 
clinical  point  of  view,  F.  H.  Bosworth.  M.  D.  3.  The  his- 
tology of  the  retrograde  changes  in  the  faucial  tonsils  of  the 
adult.  J.  H.  Goodale.  M.  D.  4.  Vocal  nodules.  C.  H.  Knight. 
M.  D.  5.  The  effects  of  cinchonism  upon  vocalization  and 
articulation,  Carl  Seller.  M.  D.  6.  A  study  of  the  proper  ap- 
plication of  intubation  in  chronic  stenosis  of  the  larynx.  W. 
K.  Simpson.  M.  D.  7.  A  case  of  stenosis  of  the  larynx  fol- 
lowing fracture;  operation;  recovery.  A.  W.  Watson.  M.  D. 

8.  Some  cases  of  paralysis  of  the  right  vocal  chord.  J.  W. 
Farlow,  M.  D.  9.  A  note  on  tonsillotomy  rash.  Wyatt  Win- 
grave,  M.  D.  Evening.  Annual  dinner  of  the  Asosciation 
at  the  New  Haven  Lawn  Club.  Wednesday.  May  29th. 
Closing  Session  at  10  a.  m.  Papers.  1.  A  report  of  a 
method  of  local  treatment  employed  to  eradicate  the  sus- 
ceptibility of  the  nasal  mucous  membrane  to  hay  fever.  C. 

C.  Rice.  M.  D.     2.  '1  he  surgery  of  naso-pharyngeal  tumors. 

D.  Bryson  Delevan.  M.  D.  3.  Lymphangiectasis  of  the 
nose  ( illustrated  >.  D.  Braden  Kj-le.  M.  D.  4.  Note  on  the 
use  of  the  electro-magnet  for  the  extraction  of  foreign 
bodies  from  the  air-passages.  A.  W.  de  Roaldes.  M.  D.  5. 
The  cleft  palate  and  its  relation  to  speech.  G.  Hudson  Ma- 
kuen.  M.  D.  6.  The  laryngeal  syringe  in  the  treatment  of 
laryngitis  and  bronchitis.  Thomas  Hubbard.  M.  D.  7. 
Aqueous  sprays  in  diseases  of  the  upper  air-passages.  G. 
V.  Wollen.  M.  D.  8.  (f?)  A  case  of  sarcoma  of  the  nose 
and    naso-pharynx.      (fi)    A   case   of  thyrotomy   for   papiK 


Mat  U,  ISOl] 


AMERICAN  NEWS  AND  NOTES 


[The  Philadelphia 
Medical  Journal 


905 


loma;  a  supplementary  report.     T.  Melville  Hardle,  M.  D. 

9.  Osteophytes  of  the  nasal  chambers,  A.  W.  MacCoy,  M.  D. 

10.  Pedunculated  fibroma  of  the  esophagus  obstructing  the 
larynx,  F.  C.  Cobb,  il.  D.  11.  Report  on  three  cases  of  tu- 
mors, (a)  Osteo-sarcoma  of  inferior  turbinate,  (b)  True 
papilloma  of  the  nasal  septum,  (c)  Sarcoma  of  branchial 
cleft,  J.  E.  Newcomb,  M.  D. 

WESTERN  STATES. 
Central  Illinois  Medical  Association. — The  twenty-seventh 
annual  meeting  of  the  Central  Illinois  Medical  Association 
convened  in  Pana,  111.,  April  30,  for  a  two  days'  session.  The 
attendance  was  the  largest  in  the  history  of  the  associa- 
tion. The  following  program  was  rendered:  "Puerperal 
Fever,"  W.  K.  Wright.  M.  D.,  Taylorville;  "Diagnosis  of  Per- 
icarditis with  Effusion,"  S.  E.  Munson,  M.  D.,  Springfield; 
"Pulmonary  Tuberculosis,"  Amos  Sawyer,  M.  D.,  Hillsboro; 
"Suggestion  as  an  Element  in  Treatment,"  W.  T.  Moffett, 
M.  D.,  Blue  Mound;  "The  Practical  Value  of  the  Cystoscope 
in  Diagnosis,"  Joseph  Milligan,  M.  D.,  Jacksonville;  "Gas- 
tric and  Duodenal  Ulcers,"  with  report  of  cases,  Everett  J. 
Brown,  M.  D..  Decatur;  "Report  of  a  Case,"  Pierce  Collins, 
M.  D.,  Decatur;  "Rheumatoid  Arthritis,"  Frank  P.  Nor- 
bury,  M.  D.,  Jacksonville;  "Some  Notes  on  Course  and 
Treatment  of  Pneumonia,"  W.  A.  Melton,  Jr.,  M.  D.,  War- 
rensburg. 

The  Oklahoma  anti-cigarette  law  which  takes  May  1, 
1901  is  as  follows:  Section  1.  That  it  shall  be  a  misde- 
meanor for  any  person,  firm  or  corporation  to  sell,  offer  to 
sell,  or  to  bring  into  the  territory  for  the  purpose  of  sell- 
ing, giving  away  or  otherwise  disposing  of,  any  cigarettes, 
cigarette  paper  or  any  substiute  for  the  same.  Section  2. 
Be  it  further  enacted  that  it  shall  be  a  misdemeanor  for  any 
person,  except  parents  or  guardians,  either  for  himself  or 
another,  to  give  away  cigars,  chewing  tobacco,  or  tobacco 
in  any  form,  to  a  minor  under  the  age  of  15  years.  Section 
3.  Any  person  convicted  of  the  above  misdemeanor,  or  for 
selling  or  giving  away  cigarettes  or  tobacco,  or  paper  for 
the  purpose  of  making  such  cigarettes,  shall  be  fined  for 
each  offense  in  any  sum  not  less  than  (?50)  nor  more 
than  two  hundred  ($200),  and  any  person,  except  parents  or 
guardians,  convicted  of  selling  or  giving  away  cigars, 
chewing  tobacco,  or  tobacco  in  any  form,  to  any  minor  un- 
der the  age  of  fifteen  years,  shall  be  fined  in  any  sum  not 
less  than  ten  dollars  ($10).  nor  more  than  fifty  dollars  ($50) 
for  each  offense.  Section  4.  Be  it  further  enacted  that  the 
grand  juries  shall  have  power  to  inquire  into  the  alleged 
offenses  committed  under  this  act.  Section  5.  Be  it  further 
enacted  that  this  act  shall  take  effect  from  and  after  the 
1st  day  of  May,  1901,  the  public  welfare  requiring  it. 

The  Detroit  Medical  Journal. — The  initial  edition  of  the 
Xeic  Detroit  MediraJ  Joiirnnl,  under  the  editorial  manage- 
ment of  Dr.  G.  H.  Stockwell.  will  be  issued  about  April  15. 
It  is  announced  that  this  publication  will  be  devoted  solely 
to  the  interests  of  the  medical  profession. 

American  Proctological  Society. — The  third  annual  meet- 
ing will  be  held  at  Hotel  Aberdeen,  St.  Paul,  Minn.,  June 
4  and  5.  1901.  The  programme  is  as  follows:  First  Day — 
Meeting  of  the  Council.  1.30  P.  M.:  Executive  meeting: 
President's  Address,  Dr.  James  P.  Tuttle.  M.  D.,  New  York: 
Primary  Tuberculosis  of  the  Rectum  and  Anus,  with 
Report  of  Cases,  Dr.  Leon  Strauss.  St.  Louis:  Disease  of 
the  Sigmoid,  Dr.  George  B.  Evans,  of  Dayton.  O.:  Report 
of  two  Cases  of  Valvotomy,  Dr.  Samuel  T.  Earle,  Balti- 
more; Treatment  of  Prolapse  of  the  Rectum,  Dr.  J.  Raw- 
son  Pennington.  Chicago:  Foreign  Bodies  in  the  Rectum, 
with  Report  of  a  Case.  Dr.  Lewis  H.  Adler,  Jr..  of  Phila- 
delphia: A  Study  of  Simple  LHceration  of  the  Rectum  from 
a  Clinical  Standpoint.  Dr.  .\.  Bennett  Cooke,  Nashville;  A. 
New  Method  for  the  Painless  Removal  of  Hemorrhoids,  Dr. 
Thomas  Charles  Martin.  Cleveland:  Anal  Pockets,  Dr. 
Louis  J.  Krouse,  Cincinnati:  The  Treatment  of  Recto-Coli- 
tis, Dr.  William  M.  Beach.  Pittsburg:  Paper,  Dr.  George  J. 
Cook,  Indianapolis. 

SOUTHERN   STATES. 
Richmond,  Va. — The  annual  final  exercises  of  the  IJnl- 
versity    College    of    Medicine,    Richmond.    Va.,    were    held 


May  2d.  The  graduates  and  the  public  were  addressed  by 
Dr.  Charles  D.  Mclver,  of  Greensboro,  N.  C.  In  the  Medi- 
cal Department  there  were  72  graduates;  In  the  dental,  4, 
and  in  the  pharniical  6. 

The  Hunter  McGuire  Memorial  Annex  to  the  Virginia 
Hospital,  erected  at  a  cost  of  515,000  was  dedicated  with 
appropriate  exercises  on  May  1st. 

Dr.  S.  V.  Sherrill  who  was  recently  relieved  from  duty  as 
first  assistant  physician  01  the  Southwestern  State  Hospi- 
tal for  the  Insane  at  Marion,  Va.,  has  preferred  charges 
against  Dr.  R.  J.  Preston,  Superintendent  of  the  same  in- 
stitution, on  the  grounds  of  "mismanagement,  neglect  and 
incompotency." 

A  New  Medical  Society,  known  as  the  Church  Hill  Medi- 
cal Society  has  been  organized  in  the  eastern  part  of  Rich- 
mond, Va.,  with  20  m.embers.  Dr.  R.  D.  Garcin  is  president 
and  Dr.  B.  A.  Hord,  secretary. 

Association  of  American  Physicians. — At  the  closing 
session  of  the  sixteenth  annual  meeting  of  the  Association 
of  American  Physicians,  held  May  2,  the  following  officers 
were  elected:  President,,  Dr.  James  C.  Wilson,  Philadel- 
phia; vice-president.  Dr.  James  Stewart,  Montreal;  record- 
er. Dr.  S.  Soils  Cohen,  Philadelphia;  secretary.  Dr.  Henry 
Hun,  Albany,  N.  Y. :  treasurer.  Dr.  J.  Crozier  Griffiths,  Phil- 
adelphia; councilors,  Drs.  Frank  Billings,  Chicago,  and 
Francis  P.  Kinnicutt,  New  York;  representative  on  execu- 
tive committee  of  congress.  Dr.  William  Osier,  Baltimore; 
alternative  representative,  Dr.  Francis  H.  Williams,  Bos- 
ton. 

The  Louisiana  State  Board  of  Health  has  appointed  the 
following  resident  medical  inspectors  at  Central  American 
fruit  ports:  Dr.  J.  S.  Allison,.  Belize,  British  Honduras; 
Dr.  D.  P.  Albers,  Livingston,  Guatemala;  Dr.  P.  R.  Outlaw, 
Port  Barrios,  Guatemala;  Dr.  Percy  Ahrons,  La  Ceiba, 
Spanish  Honduras;  Dr.  King  Holt,  Bluefields,  Nicaragua; 
Dr.  Ed.  B.  Preis,  Port  Cortez,  Spanish  Honduras;  Dr.  Allen 
Jumel,  Port  Limon,  Costa  Rica;  Dr.  D.  A.  Wailes,  Bocas  del 
Tore,  United  States  of  Columbia. 


Changes  in  the  Medical  Corps  of  the  Navy  for  Week  End- 
ing May  4,  1901: 

ASSISTANT  SURGEON  B.  L.  'WRIGHT,  ordered  to  the  Massa- 
chusetts, May  1st. 

ASSISTANT  SURGEON  S.  S.  RODMAN,  detached  from  the 
Adams,  and  ordered  to  the  Alert,   May  11th. 

SURGEON  H.  L.  LAW,  retired,  detached  from  the  Recruiting 
Rendezvous,   Buffalo,   N.   T..   and  ordered  home. 

Official    List   of   the    Changes   of   Station    and    Duties   of 

Commissioned  and  Non-Commissioned  Officers  of  the  U.  S. 

I    Marine  Hospital  Service  for  the  7  days  ended  May  2,  1901: 

D.  A.  CARMICHAEL,  surgeon,  to  assume  temporarj-  command 

of  the  San  Francisco  quarantine  station— April  27,  ISul. 
C.   P.   WERTENBAKER,  passed  assistant  surgeon,   to   proceed 

to  Prescott,  Arkansas,  for  special  temporarj-  duty— April  27, 
1901. 
J.  B.  GREENE,  passed  assistant  surgeon,  detailed  lor  tempo- 

rarj-  duty  in  the  Bureau— April  29,   1901. 
V.  G.  HEISER.  assistant  surgeon,  to  proceed  to  Norfolk,  Va., 

for  special  temporan,'  duty — April  27,   1901. 

To  proceed  to  Quebec,  Canada,  and  report    to    the    United 

States  Commissioner  of  Immigration  for  duty — May  1,  1901. 
W.   F.  Schlaar,  hospital  steward,   granted  leave  of  absence  for 

26  days— March  29,  1901. 

Preliminary   Program   of  the   International   Association   of 
Railway  Surgeons. 

Mr.  Hutton  Crater,  Kansas  City,  Mo..  "The  Relation  of  tha 
Surgeon  to  the  Claim  Department.  " 

Dr.  J.  L.  Salmon,  Ashland.  Ky.,  "Physical  Examination  of 
Railway  Employes.  "  Synopsis:  I.  Physical  Requirements  of 
Railroad  Labor."  II.  Railway  Accidents:  How  Caused.  III.  Ad- 
vantages of  Phvsical  Examination  (a)  to  the  public.  Cb)  to  rail- 
war  companies,  (c)  to  railway  employes.  TV.  Alleged  Disad- 
vantages.   V.  Mode  of  Conducting  Examinations. 

Dr.  H.  A.  Leipziger.  Burlington.  Iowa,  "Description  of  a 
Passenger  'U'reck  and  its  Management." 

Synopsis:  The  accident:  course  pursued  by  the  operating  de- 
partment: first  aids;  temporary  management  by  surgeons; 
methods  of  conveying  injured:  secondary  care  of  injured:  sum- 
marv  of  Injuries;  results;  subsequent  histories;  psychoses;  ad- 
vantages of  hospital  facilities:  remote  consequences,  alleged 
and  real.  „  .  „. 

Dr.  N.  J.  Pettijohn,  Kansas  City.  Mo.,  "Fractures  of  Pha- 
Lin^es." 

Dr.  J.  B.  Jfiirphv.  Chicago.  Til..  "Non-union  of  Fracturea. 
Cau'^e  pnd  Treatment."  „  ,    ,. 

Dr.  Ben.  Thompson.  Tama.  Iowa.  "Transverse  Myelitis. 

D"-.  TV.  N.  Middleton.  Davenport.  Iowa,  ".\bdomlnal  Contt»- 
sions." 

Dr  Geo.  F.  Beaslev  T.afavette.  In<1..  "Should  Chemical  An- 
tiseptics be  Used  in  Recent  Wounds;  'When.  'What.  How?" 


r«-ifi       Teie  Philadelphia  "1 
V*-'"       Medical  Journal    J 


AMERICAN  NEWS  AND  NOTES 


[Mat  U,  1901 


Dr.  G.  G.  Cottam,  Rock  Rapids.  Iowa,  "The  Immediate 
Treatment  of  Open  Fractures  of  the  Skull." 

Dr.  Arthur  D.  Bevan.  Chicago,  lU.,  "The  Use  of  X-Rays  In 
Fractures."  ,    ,       „  ,  „ 

Dr.  A.  F.  Jonas,  Omaha,  Neb.,  "Under  Symposium  on  Frac- 
tures." 

Dr.  D.  Maclean.  Detroit,  Mich.,  "Fractures— Simple,  Com- 
pound. Comminuted  and  Ununited;  Diagnosis,  Pathology,  Prog- 
nosis and  Treatment." 

Dr.  G.  W.  Cale,  Jr.,  Springfield,  Mo.,  "A  New  and  Rapid 
Method  of  Making  Finished  Radiographs." 

Dr.  O.  Johnson,  "Rare  Fractures  of  Upper  Extremity  with 
Unusual  Complications,  and  Synopsis  of  a  Few  Special  Cases." 

Dr.  W.  B.  Outtcn,  St.  Louis,  Mo..  "The  Most  Frequent  Frac 
tures  Met  with  in  Railway  Accidents.  Based  on  a  Series  of  50,- 
000  Personal  Cases." 

American  Pediatric  Society. — Papers  to  be  read  at  the 
Thirteenth  Annual  Meeting  of  the  American  Pediatric  So- 
ciety, to  be  held  at  Niagara  Falls,  New  York,  May  27,  28 
and  29,  j901: 

1.    President's  Address— William  D.  Booker,  M.   D.,  Baltimore. 
2.    "The  Visceral  Lesion  of  the  Erythema  Group  of  Skin  Dis- 
eases In  Young  Children." 
"Congenital    Absence    of   the   Abdominal    Muscles   with   Dis- 
tended and  Hypertrophled   Urinary   Bladder  in  a  Child  of 
Six   Tears."   by   Wm.   Osier,    M.    D.,    Baltimore. 
3.     "The  Feeding  of  an  Incubator  Baby,"   by  Chas.  W.   Town- 
send,  M.  D..  Boston. 
4.    "Glass   Sun   ftooms   on   City   Roofs,   or  'Winter   Playhouses" 
(illustrations),    by   W.    P.    Northrup,   M.    D..   New   York. 

5.  "An   Account   of  an   Epidemic  of  Malaria  In  Children,"   by 

Rowland  G.  Freeman,  M.  D.,  New  York. 

6.  "An  Analysis  of  32  Cases  of  Congenital  Heart  Disease,"  by 

John  Lovett  Morse,  M.  D.,   Boston. 
7.     "A  Study  of  £71  Cases  of  Summer  Diarrhea,"    by    Chas.    Gil- 
more  Kerley.  M.  D..  New  York. 

"A  Note  on  the  Little  Finger  of  the  Mongolian  Imbecile  and 
of  Normal  Children."  by  J.  Park  West,  M.  D..  Bellaire.  O. 

"A  Case  of  Pulmonary  Gangrene  In  a  Baby,"  by  Walter 
I, ester  Carr,  M.  D..  New  York. 

'Bulbar  Symptoms  In  the  Newly  Born,"  by  Irving  M.  Snow. 
M.  D.,  Buffalo. 

"A  Case  of  Acute  Hemorrhagic  Nephritis  complicating  In- 
fluenza In  a  thirteen-months-old  Baby,"  by  D.  J.  Milton 
Miller.  M.  D..  Philadelphia. 

(a)  "Amaurotic  Famllv  Idiocy",  (b)  "Monster,"  by  A.  C. 
Cotton.  M.  D..  Chicago. 

"Cyclical  Albumenuria."  with  report  of  a  case,  by  Frank 
Spooner  Churchill.   M.   D..    Chirngn. 

(a)  "Heart  Leap."  fb)  "Maternal  Impressions"  (report  of 
ca.'!e).  by  B.  K.  Rachford.  M.  D..  Cincinnati. 

"Measles  Complicated  by  Appendicitis,"  by  Harold  Wil- 
liams. M.  D.,  Boston. 

"The  Treatment  of  Tuberculosis,"  by  B.  IC.  Rachford,  M. 
D..  Cincinnati. 

17.  Title  to  be  announced.  F.  Hiiber.  M.  D..  New  York. 

18.  Title  to  be  announced,   A.   Seibert.  M.   D.,   New  York. 
Papers  are  promised  by  Doctors  Rotch,    Acker,    Adams    and 

others. 


8. 


le. 


11 


12. 
13. 


14. 

15. 


16. 


Health  Reports. — The  following  eases  of  smallpox,  yellow 
fever,  cholera  and  pleague  have  been  reported  to  the  Sur- 
geon General,  U.  S.  Marine  Hospital  Service,  during  the 
■week  ending  May  3.  1901: 

SMALLPOX— UNITED  STATES  AND  INSULAR. 


CALIFORNIA: 
ILLINOIS: 

INDIANA: 

KANSAS: 
KENTUCKY: 
MASSACHUSETTS : 

MICHIGAN: 


MINNESOTA: 
NEBRASKA: 
NEW  HAMPSHIRE 
NEW    YORK: 
OHIO: 
PENNSYLVANIA : 


TENNESSEE: 


UTAH: 
PHILIPPINES: 


PORTO  RICO: 


d 
U 

San  Francisco Apr.  13-20 2 

Chicago Apr.  20-27....  9 

Freeport  Apr.  20-27 1 

Evansvllle    Apr.  20-27....  1 

Wichita    Apr.  13-20....  30 

Lexington    Apr.  20-27 2 

Fitchburg    Apr.  13-20 2 

Holyoke   Apr.  20-27 1 

Bay  City   Apr.  13-20....  5 

Detroit     Apr.  20-27. .. .  1 

At  94   places    Present 

Minneapolis     Apr.  16-22 8 

Omaha     Apr.  13-20 11 

Manchester     Apr.  20-27 5 

New    York    Apr.  13-27 94 

Cincinnati Apr.  19-26....  4 

Allegheny  Cltv  Apr.  12-19 8 

Johnstown    Apr.  13-20 1 

Philadelphia     Apr.  13-27....  12 

Steelton    Apr.  20-27 1 

Williamsport    Apr.  20-27...  3 

Ducktown    Apr.  20,    Present 

Memphis    Apr.  13-20 24 

Nashville    Apr.  20-27 14 

Salt   Lake  City   Apr.  13-20....  17 

Cebu    Mar.  12    5 

Manila    Mar.    8- IS 8 

Aguas    Buenas    To    Apr.    10..  4 

Clales    To    Apr.    10..  1 

Isabela    To    Apr.    10..  4 

Manati    To    Apr.    10..  1 

Ponce    To    Apr.    10..  34 

San  Juan   To    Apr.    10..  6 


IS 


SMALLPOX— FOREIGN. 

CHINA:  Hongkong Mar.    8-23....    23 

COLOMBIA:  Panama   Apr.  15-22 5 

ECUADOR:  Guayaquil    Mar.    2-23 

EGYPT:  Cairo Mar.  2S-Apr.  1 

FRANCE:  Paris    Apr.    6-13.... 

GREAT  BRITAIN:-    England- 
Liverpool    Apr.    6-13.... 

Wales — Cardiff    Mar.    8-30 6 

_                                      Scotland- 
Dundee  Apr.    6-13 2 

Glasgow    Apr.  12-19 

MEXICO:  Mexico    Apr.    7-14.... 

RUSSIA:  St.  Petersburg Mar.  30- Apr.  614 

Warsaw    Mar.  23-30 

STRAITS 

SETTLEMENTS:     Singapore Mar.    2-16.... 

YELLOW    FEVER. 

MEXICO:  Vera  Cruz Apr.    8-16.... 

PLAGUE— FOREIGN  AND  INSULAR. 

AUSTRALIA:  Adelaide    Feb.  28 1 

CHINA:  Canton    Feb.  28,   Epidemic 

Chan  Tsln  Feb.  28 

Fatahan Feb.  28 

Hongkong Mar.    8-23 22 

STRAITS 

SRTTLEMENTS:     Singapore Mar.    7-16.... 

H.VW.AII:  Honolulu  Mar.  29 

PHILIPPINES:  Manila  Mar.    8-16....    10 


10 


MISCELLANY. 


The  Association  of  American  Physicians.^ — Washington, 
D.  C,  April  30,  May  1  and  2,  1901— First  Day.  morning. — 
The  meeting  was  called  to  order  at  11  A.  M..  the  President, 
William  H.  Welch,  of  Baltimore,  in  the  chair. 

In  the  President's  address,  Dr.  Welch  compared  the  op- 
portunities enjoyed  in  this  country  by  the  men  who  desire 
to  study  the  branches  of  scientific  medicine  and  the  oppor- 
tunities open  to  those  who  desire  to  become  proficient  in 
clinical  medicine  and  surgery.  There  are  laboratories  In 
this  country  that  are  equal  to  any  in  the  world  that  are 
open  to  young  men  who  have  graduated  and  who  wish  to 
become  teachers  of  anatomy,  physiology  or  pathology.  In 
these  laboratories  a  young  man  must  serve  his  apprentice- 
ship, but  his  promotion  is  sure.  In  clinical  medicine  and 
in  surgery,  on  the  other  hand,  the  only  way  open  to  men 
who  desire  to  become  teachers  of  these  branches  is 
through  dispensary  work  and  private  practice.  The  facili- 
ties at  the  disposal  of  those  who  desire  to  work  in  the  prac- 
tical branches,  then,  are  not  so  good  as  the  facilities  at 
the  disposal  of  those  who  desire  to  devote  their  life-work 
to  the  branches  of  scientific  medicine.  In  other  words, 
the  training  of  physicians  has  not  kept  pace  with  the  train- 
ing of  scientists.  Dr.  Welch  referred  in  a  feeling  manner 
to  the  unusually  large  number  of  deaths  that  had  occurred 
among  the  mebers  of  the  association  during  the  past  year 
Of  the  4  members  who  had  died,  all  were  founders  and  3 
were  ex-presidents.  He  read  brief  biographical  sketches 
of  Dr.  James  T.  Whittaker,  Dr.  Jacob  M.  DaCosta.  Dr.  Sam- 
uel C.  Busey  and  Dr.  William  H.  Draper.  All  of  these  men 
belonged  to  the  group  of  humanists  who  were  known  by 
the  members  of  the  association,  as  well  as  to  the  public,  by 
their  Interest  in  the  advancement  of  the  human  race. 

Hobart  A.  Hare,  of  Philadelphia,  read  a  paner  entitled 
an  undescribed  cardiac  sound.  The  sound  referred  to  by 
the  reader  is  a  peculiar  vibrating,  systolic  sound  that  la 
often  heard  by  him  on  the  level  of  the  nipple  in  an  area 
extending  from  one  inch  to  the  right  to  one  inch  to  the  left 
of  the  sternum.  The  sound  is  dry  and  is  like  a  pericardia] 
friction  sound,  but  it  is  not  a  friction  and  is  believed  hv  the 
author  to  be  due  to  a  vibration  of  the  chordae  tendineae 
dependent  upon  deficient  contraction,  of  the  papillary  mus- 
cles. The  sound  has  been  heard  in  patients  who  were  suf- 
fering from  debilitating  diseases.  For  example,  it  is  heard 
in  the  early  stages  of  pulmonary  tuberculosis  and  in  the 
patients  who  suffer  from  the  anemia  of  infiuenza.  It  is  not 
a  hemic  murmur,  and,  in  fact,  is  not  .a  murmur  in  the  or- 
dinary acceptation  of  the  term,  but  is  a  vibration.  It  Is 
accentuated  by  nervousness,  but  not  by  exercise.  It  re- 
sembles the  word  "ching"  as  nearly  as  anv  word.  Patients 
who  have  a  shallow  chest,  and  in  whom  the  heart  is  acting 
rapidly,  present  the  sound.  There  are  no  sublective  cardiac 
svmptoms.  William  Osier,  of  Baltimore,  said  that  in  cases 
of  weak  heart  he  had  heard  a  sound  at  the  apex  like  the 
sound  of  pericardial  friction,  but  having  a  more  grating 
character.  He  had  also  heard  a  sound  which  as  ausculta- 
tion In  the  neighborhood  of  the  sternum  was  done  because 
of  a  crunching  character.  One  of  these  sounds  may  be 
the  one  referred  to  by  Dr.  Hare. 


Mat  n.  1901] 


AMERICAN  NEWS  AND  NOTES 


[The  Philadelphia. 
Medical  Journal 


907 


William  S.  Thayer,  of  Baltimore,  read  a  paper  entitled 
the  frequency  and  the  diagnosis  of  the  Flint  murmur  in 
aortic  insufficiency.  During  the  last  11  years  the  author 
has  studied  the  cases  occurring  in  the  Johns  Hopkins  Hos- 
pital that  presented  the  Flint  murmur.  During  that  pe- 
riod 74  cases  of  aortic  insufficiency  were  treated,  in  45  of 
which  the  Flint  murmur  was  heard.  In  12  of  these  45  cases 
mitral  stenosis  was  also  present  at  autopsy,  in  17  cases 
the  mitral  valve  was  normal,  and  in  other  cases  various 
changes  in  the  mitral  leaflets  were  found.  The  writer 
is  of  the  opinion  that  disease  of  the  mitral  valve,  other 
than  stenosis,  can  play  no  part  in  the  production  of  a  pres- 
ystolic murmur.  The  Flint  murmur  is  not  so  harsh  nor  so 
intense  as  the  murmur  of  mitral  stenosis.  The  thrill  is 
botli  less  frequent  and  less  Intense  with  the  Flint  murmur. 
In  cases  of  aortic  insufficiency,  accompanied  by  Flint  mur- 
mur, the  systolic  impulse  is  not  of  the  tapping  charater 
noted  In  cases  of  mitral  obstruction:  and  the  snapping, 
valvular  character  of  the  first  sound  is  rare.  In  cases  that 
present  the  Flint  murmur,  signs  that  point  to  the  existence 
of  endocarditis  are  rare,  and  evidence  of  arterio  sclerosis 
is  common.  The  anatomical  change  in  the  aortic  valves 
in  cases  that  presented  the  Flint  murmur  during  life  are 
those  of  arteriosclerosis  and  present  nothing  character- 
istic. The  characteristics  of  the  pulse  in  cases  of  Flint 
murmur  are  those  of  aortic  insufficiency.  A  positive  diag- 
nosis of  functional  presystolic  murmur  is  difficult  to  make. 
The  diagnosis  is  made  with  a  fair  degree  of  accuracy,  In  a 
patient  who  is  without  rheumatic  history,  who  has  a  full, 
sudden  pulse,  and  in  whom  the  other  signs  of  aortic  in- 
sufficiency are  present.  The  murmur  is  common,  since  it 
occurred  in  %  the  cases,  and  it  may  be  associated  with 
the  features  of  true  mitral  obstruction.  Cabot,  of  Boston, 
said  that  he  had  made  autopsies  on  10  cases  in  which  the 
Flint  murmur  was  present  during  life  and  in  which  the 
mitral  valve  was  normal.  In  these  cases  the  diagnosis  of 
mitral  stenosis  had  been  made  during  life.  This  series  of 
cases  would  tend  to  confirm  Thayer's  observation.  James 
Tyson,  of  Philadelphia,  referred  to  a  case  of  aortic  regurgi- 
tation in  which  the  Flint  murmur  was  present,  and  in  which 
a  loud,  aortic,  diastolic  murmur  was  absent.  The  case  pre- 
sented all  the  signs  of  aortic  regurgitation. 

Alfred  Stengel,  of  Philadelphia,  read  a  paper  entitled, 
the  causes  and  clinical  features  of  right-sided  cardiac  hy. 
drothorax.  It  is  difficult  to  distinguish  between  unilateral 
cardiac  hydrothorax  and  inflammatory  effusions  of  the 
pleura.  The  author  has  analyzed  100  cases  of  cardiac 
disease,  in  17  of  which  hydrothorax  was  present.  In  5  of 
these  the  effusion  was  on  the  right  side  only;  in  3  it  was 
left-sided;  in  9  it  was  bilateral,  and  in  7  of  these  the 
effusion  was  greater  in  amount  on  the  right  side.  In  2 
of  the  cases  of  bilateral  effusion  the  fluid  made  its  appear- 
ance first  on  the  right  side.  The  greater  frequency  of  right- 
sided  effusion  cannot  be  accidental.  The  condition  may  be 
explained  by  the  pressure  of  a  dilated  superior  vena  cava 
on  the  right  lymphatic  duct;  but  this  is  unlikely.  A  more 
probable  explanation  is  that  the  effusion  is  due  to  obstruc- 
tion of  the  great  azygos  vein  as  it  empties  into  the  superior 
vena  cava  by  the  dilation  of  the  latter  vessel.  Right- 
sided  cardiac  hydrothorax  was  always  seen  in  cases  with 
considerable  enlargement  of  the  right  heart,  and  this  fact 
tends  to  confirm  the  opinion  that  the  effusion  is  due  to 
pressure.  The  anatomical  relations  of  the  azygos  veins 
explain  how  dilation  of  the  right  heart  may  compress  the 
larger  vessel,  while  the  2  smaller  azygos  veins  of  the  left 
side  are  not  involved  by  the  process.  The  secondary  de 
velopment  of  left-sided  effusion  is  to  be  explained  by  back 
flow  into  the  vena  azygos  minor.  William  Osier,  of  Balti- 
more, said  that  the  history  of  cases  of  right-sided  hydro- 
thorax indicates  a  local  cause.  The  condition  almost 
always  develops  in  cases  of  mitral  disease.  J.  C.  Wilson, 
of  Philadelphia,  said  that  in  general  edema,  such  as  from 
renal  disease,  the  volume  of  pleural  effusion  is  usually 
greater  on  the  right  side.  In  such  cases  the  heart  is  almost 
always  enlarged,  and  conseuently  the  space  in  the  left  side 
of  the  chest  occupied  liy  the  enlarged  heart  would  tend  to 
prevent  fluid  from  accumulating  in  the  left  pleural  cavity. 
K.  G.  Janeway.  of  New  York,  said  that  right-sided  hydro- 
thorax is  an  accompaniment  of  weaTc  heart  as  well  as  of 
valvular  disease.  Ho  cited  a  case  in  which,  at  autopsy, 
there  was  no  valvulitis,  but  in  which  there  wes  extensive 
fibrorayocarditis  and  thrombosis.  H.  A.  Hare,  of  Philadel- 
phia, said  that  it  would  be  well  to  take  into  consideration 
the  movements  of  the  heart,  which  might  serve  to  urge 


on  the  fluids  of  the  left  side,  without  affecting  the  fluids  of 
the  right  side.  He  described  as  illustrative  case.  A. 
Jacobi,  of  New  York,  said  that  in  his  opinion  the  likelihood 
of  myocarditis  was  too  frequently  neglected  in  the  consid- 
eration of  the  possibilities  of  a  case  of  heart  disease.  Many 
cases  that  present  symptoms  of  valvular  disease  are.  In 
reality,  muscular.  Muscular  lesions,  as  is  well  known,  re- 
sult early  in  the  production  of  edema.  The  myocarditis 
may  be  local,  and  then  the  lesion  is  very  likely  to  be 
overlooked.  Alfred  Stengel,  of  Philadelphia,  referred  to  a 
case  in  his  series  that  shows  that  weak  heart  may  be  the 
exciting  cause  of  the  effusion.  In  this  case  the  hydrothorax 
was  the  beginning,  clinically,  of  the  condition.  Evidences 
of  valvular  disease  developed,  but  disappeared  under  treat- 
ment. 

Beverly  Robinson,  of  New  Y'ork,  read  a  paper  entitled, 
myocarditis  and  fatty  degeneration  of  the  heart.  The 
author  finds  that  in  cases  of  anemia,  gouty  heart  and 
obesity,  fatty  degeneration  is  a  common  and  a  serious 
occurrence.  In  obese  women,  particularly,  this  tendency 
toward  fatty  change  in  the  heart  should  make  the  physician 
cautious  in  advising  operation,  and  if  operation  is  deemed 
Justifiable,  the  anesthetic  should  be  administered  with 
great  care. 

Dr.  A.  Jacobi,  of  New  York,  read  a  paper  entitled,  hem- 
orrhage into  the  pleura,  from  a  pyothorax.  The  patient 
was  a  boy,  aged  9  years,  who  had  suffered  for  a  month 
with  languor,  fever,  emaciation,  cough  and  pain  in  the  right 
chest.  The  temperature  was  102°;  the  respiration  was  40 
per  minute  and  the  pulse,  140.  There  was  dullness  over  the 
apper  and  flatness  over  the  lower  portion  of  the  right 
lung.  Puncture  of  the  right  pleura  showed  the  presence 
of  pus.  and  the  sixth  rib  was  resected  for  its  relief.  Irri- 
gation of  the  cavity  brought,  first,  pus,  then,  blood-stained 
pus,  and  then,  pure  blood.  The  bleeding  came  from  tufts 
of  granulation  tissue  seen  on  the  pulmonary  pleura,  which 
varied  in  size  and  which  were  quite  numerous.  The  pleura 
was  packed  with  gauze  and  in  a  few  days  the  bleeding  had 
ceased.  There  was  no  malignant  tumor,  tuberculosis  was 
not  present  and  there  were  no  adhesions.  The  recovery, 
which  was  complete,  was  retarded  by  the  slowness  of  the 
expansion  of  the  lung. 

Dr.  Jacobi  also  read  the  report  of  a  case  of  cyst  of  the 
omentum.  The  patient  was  an  Italian  girl,  aged  7  years, 
who  had  suffered  for  4  years  with  swelling  of  the  abdomen 
and  emaciation.  The  abdomen  was  tapped  and  2  quarts 
of  blood-stained  serum  were  withdrawn  and  the  condition 
was  apparently  cured.  Two  years  later  the  swelling  again 
appeared  and  the  patient  was  again  tapped  and  again  cure 
was  apparently  obtained.  The  swelling  returned  a  second 
time,  however,  and  tapping  was  unsuccessful  because  the 
trocar  was  obstructed.  At  operation,  after  the  swelling 
had  returned  to  its  usual  size,  a  thin-walled,  multilocular 
cyst  was  found  attached  to  the  great  omentum.  The  cyst 
was  removed  and  2  days  later  the  temperature  rose  and 
cough  developed.  This  accident,  however,  did  not  retard 
the  recovery,  which  was  complete.  The  specimen,  which 
was  exhibited,  was  a  multilocular  cyst  cavity.  The  walls 
were  lined  by  endothelial  cells  and  it  originally  contained 
a  gelatinous  substance.  The  author  is  of  the  opinion  that 
cyst  is  composed  of  dilated  lymph-vessels.  He  is  of  the 
opinion  that  serous  cysts,  which  are  sometimes  found,  are 
probably  chylous  cysts  of  long  standing,  the  contents  of 
which  have  become  converted  into  serous  fluid.  Kinnicut, 
of  New  York,  referred  to  a  case  of  acute  lobar  pneumo- 
nia which  was  followed  by  effusion.  Aspiration  of  the 
effusion  withdrew  almost  pure  blood.  Later  aspiration 
withdrew  a  sero-sanguinolent  fluid,  and  still  later  the 
fluid  became  serous.  The  pneumococcus  was  obtained  in 
the  fluid  from  the  second  tapping  and  the  subsequent  his- 
tory of  the  case  was  not  tuberculous.  It  is  possible  that 
the  patient  had  a  tuberculous  affection  of  the  pleura  that 
produced  the  bloody  effusion.  F.  P.  Henry,  of  Philadel- 
phia, said  that  he  doubted  whether  tuberculosis  had  a 
causative  relation  to  hemorrhagic  pleurisy,  since  the  ma- 
jority of  pleural  effusions  are  tuberculous  and  since  hem- 
orrhagic pleurisy  is  rare.  The  only  cases  of  hemorrhagic 
pleuritis  that  he  had  seen  were  due  to  scorbutus.  Pea- 
body,  of  New  York,  said  that  many  cases  of  hemorrhagic 
peluritis  get  well  and  no  tuberculous  symptoms  subse- 
quently develop.  He  aleo  Is  skeptical  as  to  the  tuberculous 
origin  of  hemorrhagic  pleuritis.  F.  H.  Shattuck.  of  Bos- 
ton, said  that  cases  of  hemorrhagic  pleurisy  undoubtedly 
recover  but  he  would  not  agree  that  recovery  from  such  a 


Q(-c       The  Philadelph 
y  Medical  Journal 


lA-l 

L     J 


AMERICAN  NEWS  AND  NOTES 


[Mat  U,  1901 


condition  excluded  tuberculosis.  P.  P.  Henry,  of  Phila- 
delphia, said  that  tuberculosis  of  the  serous  membranes  is 
more  benign  than  in  other  situations.  He  holds  that 
hemorrhagic  pleuritis  is  not  common.  William  Osier,  of 
Baltimore,  said  that  only  one  variety  of  tuberculous  pleu- 
ritis was  liable  to  be  hemorrhagic  and  that  is  the  variety 
accompanied  by  fresh  tubercles  and  by  fresh  exudate.  Such 
cases  are  seen  in  the  terminal  forms  of  acute  miliary 
tuberculosis.  A.  Jacobi  said  that  the  case  was  reported 
as  one  of  hemorrhage  into  the  pleural  sac.  He  brings  it 
forward  as  additional  cause  of  hemorrhage  into  the  pleu- 
ral cavity  to  those  already  so  well  known. 

Charles  Gary,  of  Buffalo,  read  a  paper  entitled  a  case 
of  pneumonia  complicated  by  pseudomembranous  exudate 
on  the  mucous  memijranes  of  the  mouth,  tongue,  pharynx, 
nares,  conjunctivae,  glans  penis,  anus,  etc.,  caused  by 
the  diplococcus  pneumoniae.  The  patient  was  a  boy,  aged 
11  years,  in  whom  there  was  a  membranous  exudate  on 
nearly  all  the  exposed  mucous  membranes  of  the  bodj'. 
The  symptoms  suggested  that  the  membrane-formation  in- 
volved the  entire  length  of  the  digestive  tract  as  well  as 
the  pleurae.  The  diplococcus  pneumoniae  was  present  in 
the  sputum  and  in  the  membrane.  The  bacillus  diphtheriae 
and  the  streptococcus  was  absent.  After  the  exudate  was 
peeled  off  the  underlying  surface  was  granular  and  bled 
freely.  There  was  a  leukocytosis.  The  patient  recovered 
after  an  illness  of  3  months.     |J.  M.  S.] 

First  Day,  Afternoon. — F.  P.  Henry,  of  Philadelphia,  read 
a  paper  entitled  further  notes  of  a  case  of  pernicious  ane- 
mia reported  at  the  meeting  of  1900.  The  author  referred 
to  a  ca.se  reported  by  liim  at  the  meeting  last  year.  The 
patient  had  been  suffering  from  pernicious  anemia  for  d 
years.  During  that  time  he  had  had  several  slight  and  2 
severe  relapses.  There  were  gastrointestinal  symptoms, 
low  red  corpuscle  count,  relatively  high  hemoglobin  per- 
centage, hypoleukocytosis  and  poikylocytosis.  At  the  time 
the  report  was  made-  the  patient  considered  himself  well. 
This  year  the  patient  is  profoundly  anemic:  his  red  cells 
number  1,240,000;  the  hemoglobin  precentage  is  32;  the 
leukocytes  number  3,000.  There  is  poikylocytosis  and  the 
presence  of  megaloblasts  and  normoblasts.  The  patient 
had  an  attack  of  erysipelas  during  the  year,  but  he  is  im 
proving  again  under  iron  and  arsenic.  The  author  believes 
that  the  presence  of  magaloblasts  is  not  the  sole  criterion 
of  the  existence  of  progressive  pernicious  anemia  and  that 
there  are  symptoms  that  distinguish  this  from  other  dis- 
eases whether  the  cells  mentioned  are  present  or  not. 
Megaloblasts  are  found  in  leukemia,  in  Bothriocephalus 
anemia,  in  carcinoma  ventriculi  and  in  syphilis.  The  diag- 
nosis of  the  disease  is  best  made  by  the  aggregate  of  the 
symptoms  and  the  appearance  of  the  patient. 

Frank  Billings,  of  Chicago,  read  a  paper  entitled  report  of 
progress  of  cases  of  pernicious  anemia  presented  to  the 
association  in  1900  and  a  report  of  a  case  of  pernicious 
anemia  with  diffuse  spinal  cord  lesions  with  post-mortem 
findings.  Of  the  20  cases  of  pernicious  anemia  reported 
last  year  10  were  living  when  the  report  was  made.  Of 
these  10,  4  died  during  the  year.  4  are  still  living,  and  2  have 
passed  from  observation.  One  of  the  patients  who  died 
in  February,  1901,  presented  a  sudden  accession  of  nu- 
cleated red  cells  just  before  death,  and  a  diminution  of 
leukocytes  instead  of  the  usual  increase.  Of  the  4  pa- 
tients who  are  still  living  one  is  still  improving.  The 
color  index  remains  high,  however,  during  the  period  of 
improvement.  One  patient  had  an  improvement  wave  of 
nearly  a  year's  duration.  The  author  has  seen  9  new 
cases  during  the  year,  of  which  7  are  males  and  2  are 
females.  He  has  adopted  a  method  of  estimating  the  vol- 
ume index  of  the  blood.  He  estimates  the  percentage  of 
red  cells  with  the  hematnkrit  and  counts  them  with  the 
hemocytometer.  He  then  makes  a  fraction  the  numerator 
of  which  is  the  percentage  by  the  hematokrit  estimation 
and  the  denominator  of  which  is  the  percentage  by  the  hem- 
ocytometer. The  result  of  the  division  gives  the  volume- 
index.  One  of  the  patients  who  died  was  a  woman,  aged 
36  years.  She  had  had  gastrointestinal  symptoms,  men- 
struation had  ceased,  she  was  anemic,  with  lemon-yellow 
color  of  the  skin  and  loss  of  control  of  bladder  and  bowels. 
There  were  no  carious  teeth,  the  lungs  were  negative,  there 
was  a  soft  systolic  murmur  at  the  base  of  the  heart  and 
visceral  ptosis.  The  patient  died  on  an  improvement  wave, 
with  terminal  leukocytosis,  paraplegia  and  sensory  phen- 
omea.  The  immediate  cause  of  death  was  an  ascending  in- 
fection of  the  genito-urinary  tract  from  infection 
of    the     bladder,     over    w-hich     control     had     been     lost. 


At  autopsy,  important  changes  were  found  in  the  spinal 
cord.  In  the  lumbar  region,  the  posterior  columns  were 
sclerosed  and  the  lateral  pyramidal  tract  was  also  degener- 
ated. In  the  cervical  region,  these  columns  were  degener- 
ated as  well  as  the  anterior  pyramidal  tract  and  Gower's 
tract.  James  J.  Putnam,  of  Boston,  said  that  it  is  an  open 
question  whether  the  spinal  cord  lesions  were  pathogno- 
monic or  whether  they  are  similar  to  those  seen  in  other 
diseases.  They  are  certainly  not  due  to  the  anemia  as 
such.  They  are  similar  to  the  lesions  seen  in  diseases 
characterized  by  changes  in  nutrition.  William  Osier,  of 
Baltimore,  said  that  there  is  a  group  of  cases  of  pernicious 
anemia  in  which  the  anemia  occurs  after  the  onset  of  the 
spinal  symptoms  which  needs  full  clinico-pathological  study 
in  this  country.  McPhedran,  of  Toronto,  said  that  he  had 
seen  such  a  case  as  referred  to  by  Osier  in  which  the 
blood  did  not  show  the  changes  of  pernicious  anemia. 
F.  H.  Shattuck,  of  Boston,  referred  to  a  case  of  pernicious 
anemia  following  mental  shock.  John  H.  Musser,  of  Phila- 
delphia, said  that  he  had  had  a  patient  under  observation 
since  1896  who  presented  the  clinical  picture  of  locomotor 
ataxia  and  w-hose  blood  was  a  typical  picture  of  that  of 
pernicious  anemia.  In  this  patient  the  nervous  symptoms 
developed  first.  Blood  examination  showed  hemoglobin, 
50%;  red  corpuscles,  1,500,000;  white  corpuscles.  45,000; 
myelocytes,  poikylocytes.  megaloblasts  and  microcytes. 
There  were  no  normoblasts,  however,  and  the  color  index 
was  high.  He  said  that  many  patients  with  pernicious  ane- 
mia were  sent  to  hospital  with  diagnosis  carcinoma  of  the 
stomach,  gastric  catarrh,  carcinoma  of  the  liver,  heart 
disease  and  tuberculosis.  Frank  Billings,  of  Chicago, 
called  attention  to  the  fact  that  the  degenerated  tracts  in 
his  case  of  spinal  cord  lesion  were  not  shrunken. 

David  D.  Stewart,  of  Philadelphia,  read  a  paper  entitled 
acute  miliary  tuberculosis,  primarily  splenic.  The  patient 
was  a  nurse,  aged  29  years,  in  whom  there  was  no  tuber- 
culous history.  Four  weeks  before  she  was  admitted  to 
hospital  she  had  had  an  attack  of  influenza  and  before  she 
had  recovered  from  that  attack  she  took  charge  of  a  case 
of  tuberculosis.  On  admission,  she  was  suffering  from 
chills  and  fever,  debility,  and  pain  in  the  dorsal  region.  She 
died  on  the  sixty-eighth  day  of  her  illness.  During  life  the 
spleen  was  enlarged  and  extended  from  the  sixth  interspace 
to  below  the  costal  margin.  Two  weeks  before  death,  en- 
larged glands  developed  in  the  supraclavicular  fossa.  At 
autopsy,  tuberculosis  of  the  lungs,  the  liver,  the  kidneys 
and  the  membranes  of  the  brain  was  found,  the  existence  of 
which  was  not  indicated  by  clinical  signs  during  life.  The 
spleen  was  full  of  tubercles,  some  of  which  had  advanced 
to  complete  caseation.  The  infection  was  apparently  from 
the  tuberculous  patient  whom  she  had  nursed. 

John  H.  Musser.  of  Philad'='lphia,  read  a  paper  entitled 
notes  on  relapsing  fever  in  Hodgkin's  disease.  The  pa- 
tient was  a  man  who  had  been  ill  5  months  before  admis- 
sion to  hospital  and  who  presented  hemorrhage  from  the 
nose,  enlarged  spleen  and  general  lymph-node  enlarge- 
ment. He  had  recurrent  attacks  of  fever  accompanied  hy 
acute  enlargement  of  the  IjTnph-nodes  and  jaundice.  The 
patient  died  1  month  after  admission  and  during  that  time 
treatment  had  no  effect  on  the  course  of  the  febrile  attacks. 
There  was  a  febrile  period  of  6  days,  then  a  period  of  apy- 
rexia  of  9  days,  febrile  period  9  days,  apyrexia  11 
days,  fever  8  days,  apyrexia  11  days,  fever  10 
days  and  death  from  exhaustion.  In  a  second 
patient,  a  man.  aged  58  years,  who  was  under 
observation  for  3  years  there  was  a  family  history  of  tuber- 
culosis. The  patient,  however,  was  a  man  of  correct  hab- 
its. Ho  had  moderate  anemia  which  became  more  marked 
and  progressive  and  there  was  the  appearance  and  the 
disappearance  of  enlarged  glands  with  the  attacks  and  re- 
missions in  the  fever.  Enlarged  spleen  was  also  present. 
There  was  a  febrile  period  of  12  days,  then  a  period  of 
apyrexia  of  10  days,  fever  for  9  days,  apyrexia  6  days,  fever 
S  days,  apyrexia  I.t  days,  fever  8  das.  apyrexia  S  days,  fever 
S  days  and  then  the  fever  l>ecarae  continuous  on  account 
of  the  development  of  pleuritis  with  effusion.  During  the 
course  of  the  disease  the  patient  began  to  cough  but  once 
only  was  the  sputum  found  to  contain  the  tubercle  bacil- 
lus. Before  the  occurrence  of  a  febrile  attack  the  patient 
became  irritable  and  had  pain  in  the  inguinal  lymph-nodes 
and  loss  of  appetite.  During  the  febrile  paroxysms  insom- 
nia was  a  very  annoying  symptom.  The  pleural  effusion 
was  sterile  by  cultural  and  inoculation  tests.  Blood  from 
the  patient  was  injected  into  a  rabbit  and  the  animal  died 
from  the  development  of  lymphomata  on  the  lungs.     Wil- 


May  U.  1901] 


FOREIGN  NEWS  AND  NOTES 


TThe  Philadelpria 
LMedical  Journal 


909 


Ham  H.  Welch,  of  Baltimore,  said  that  in  many  cases  the 
fever  of  Hodgkin's  disease  had  been  shown  to  be  due  to 
tuberculosis.  John  H.  Musser,  of  Philadelphia,  said  that  he 
believed  that  in  the  cases  reported  the  fever  was  proba- 
bly due  to  the  development  of  tuberculosis. 

Alfred  Stengel,  of  Philadelphia,  read  a  paper  for  C.  Y. 
White  and  William  Pepper,  of  Philadelphia,  entitled  a 
study  of  granular  degeneration  of  the  red  blood  corpuscles. 
The  reader  referred  to  cases  of  chronic  lead  poisoning 
in  which  a  granular  degeneration  of  the  red  cells  was 
noted.  The  granules  were  sioall  and  were  evenly  distrib- 
utetl  throughout  the  cell  in  some  cases,  or  had  a  tendency 
to  clumping  in  others  The  granules  show  a  different  affin- 
ity for  certain  basic  stains.  They  may  be  found  in  normal 
cells,  in  poikylocytes  or  in  nucleated  cells.  The  granules 
are  not  detected  in  fresh  or  dried  specimens.  The  condi- 
tion is  not  due  to  karyorrhexis,  but  is  probably  due  to  some 
chronic  blood  poisoning.  They  were  experimentally  pro 
duced  by  Grawitz  in  early  lead  poisoning  in  mice.  The 
authors  have  studied  the  condition  in  lead  workers,  in 
patients  suffering  from  chronic  lead  poisoning,  in  cases 
of  patients  exposed  to  high  temperatures,  and  experiment 
ally  in  poisoning  animals  with  lead.  In  4  cases  of  lead 
poisoning  the  granules  were  present  in  all;  in  21  lead  work- 
ers, with  no  symptoms  of  lead  poisoning,  the  granules 
were  present  in  all.  In  4  individuals  who  worked  in  front 
of  furnaces  and  in  4  patients  treated  by  the  local  applica 
tion  of  superheated  air  only  one  presented  the  change. 
The  granules  appeared  in  dogs,  in  which  small  doses  of 
acetate  of  lead  wer  administered,  in  24  hours.  The 
splenic  vein  contained  the  greatest  number  of  corpuscles  af- 
fected by  this  degeneration.  This  granular  degeneration,  then, 
is  a  constant  finding  in  lead  poisoning;  they  disappear 
from  the  blood  as  convalescence  progresses;  there  is  no 
immunity.  The  granules  are  a  true  degenerative  product. 
A.  Jacobi,  of  New  York,  asked  of  what  significance  the 
granules  were?  He  is  in  the  habit  of  giving  large  doses  of 
acetate  of  lead  at  times.  David  H.  Stewart,  of  Philadel- 
phia, said  that  it  appeared  to  him  that  the  granules 
might  be  an  important  diagnostic  sign  of  lead  poisoning, 
and  that  they  might  be  called  a  symptom  of  lead 
poisoning.  .\lfred  Stengel,  of  Philadelphia,  said  that 
the  patients  in  whom  these  granules  were  found  had  also 
nucleated  red  cells  and  poikylocytes.  In  other  words,  they 
were  actually  uoisoned  by  lead,  but  without  symptoms, 
diagnostic  sign  of  lead  poisoning.  Alfred  Stengel,  of  Phila- 
delphia, said  that  the  patients  in  whom  these  granules 
were  found  had  also  nucleated  red  cells  and  poikilocytes. 
In  other  words,  they  were  actually  poisoned  Ijy  lead,  but 
without  symptoms. 

(To  be  Continued.) 


30TH    CONGRESS    OF    THE    GERMAN    SURGICAL    SO- 
CIETY. 

(From  our  Special  Correspondent.) 
(Continued.) 

5th  Session. — On  Wednesday  evening  a  number  of  dem- 
onstrations of  photographs,  skiagraphs,  etc.,  were  given. 

Gobel  of  Ruhrsort  reported  a  case  of  resection  of  the 
lung  similar  to  Heidenhain's  case.  Sarfert  of  Berlin  treats 
of  "The  operative  treatment  of  tuberculosis  of  the  lung." 
Kuster  of  Marburg  demonstrates  photographs  showing  his 
method  of  rhinoplasty.  Paper  of  Graz  "Conservative  oper- 
ations on  the  testis  and  the  epididymis."  Paper  reports 
the  case  of  a  patient  with  acute  orchitis  following  gonor- 
rhea. Paper  incised  and  opened  an  abscess,  but  gangrene 
followed,  and  he  was  compelled  to  castrate.  Two  years 
later  an  acute  orchitis  of  the  remaining  testis  appeared, 
and  Paper  again  performed  a  conservative  operation  in- 
cising the  albuginia  and  opening  an  abscess;  this  time  he 
succeeded  in  saving  the  testis,  and  has  demonstrated 
living  spermatozoa  in  the  patients  semen.  Bessel-Hagen 
of  Charlottenburg  described  a  plastic  operation  for  com- 
plete loss  of  the  skin  of  the  penis  and  scrotum.  He  first 
healed  the  penis  under  the  skin  of  the  abdomen,  then 
formed  two  skin  flaps  at  the  side  of  the  penis,  and  closed 
them  over  the  dorsum  of  the  penis,  in  much  the  same  way 
as  Senn  operated  some  years  ago,  an  operation  apparently 
unknown  to  Bessel-Hagen.  v.  Mikulicz  of  Breslau  "The 
different  methods  of  anesthesia  and  their  indication."  He 
has  been  collecting  information  bearing  on  the  question, 


which  of  all  the  narcotics  is  the  least  dangerous,  and  has 
arrived  at  the  conclusion  that  it  is  not  a  question  whether 
one  should  narcotize  with  chloroform  or  with  ether,  but 
when  one  should  use  chloroform  and  when  ether.  The 
question  whether  one  should  use  inhalation  anesthesia  at 
all  has  been  actively  discussed  of  late  years  scince  the 
introduction  of  local  anesthesia,  v.  Mikulicz  then  gives  a 
chronological  review  of  the  methods  of  local  anesthesia; 
the  freezing  method,  cocain  injection,  Schleich,  Oberst's 
and  Bier's  methods.  He  has  used  lumbar  anesthesia  in  40 
cases  with  startling  results,  and  considers  it  the  method 
of  the  future,  although  not  yet  sufficiently  perfected  to  be 
introduced  into  general  practice.  He  has  lost  no  case,  but 
has  experienced  some  very  unpleasant  after  effects.  The 
statistics  of  narcosis  and  of  local  anesthesia  show  that 
the  former  is  still  in  much  greater  use.  Local  anesthesia 
in  spite  of  having  now  such  large  fields  of  surgery  is  never- 
theless of  no  value  in  many  laparotomies,  in  nephrec- 
tomies, amputations  of  the  breast,  etc.  There  is  room  for 
question  in  operations  on  the  stomach  and  bowels,  hernio- 
tomies, and  in  operations  for  goitre.  Deaths  have  occurred 
with  local  anesthesia.  A  great  drawback  is  that  the  topo- 
graphic relation  of  the  parts  is  changed  by  the  infiltration. 
One  would  naturally  prefer  local  anesthesia  in  cases  of 
heart  and  lung  affections,  yet  the  mortality  of  post-opera- 
tive pneumonias  following  Schleich  is  still  large.  Much 
depends  upon  the  kind  of  operation  and  upon  the  re- 
action of  the  individual  to  pain.  Shock  can  be  caused  by 
pain  alone  without  narcosis,  v.  Mikulicz  formerly  used 
chloroform  exclusively,  now  he  uses  ether  oftener  since 
he  has  learned  to  avoid  the  dangers  of  the  ether  narcosis 
by  using  the  graduated  method  of  Hoffman  of  Bonn.  Bier 
of  Greifswald;  "Anesthesia  of  the  Cord."  Up  to  the  pres- 
ent time  1200  operations  have  been  performed  with  his 
method.  After  injecting  one-third  gr.  of  cocain  the  sense  of 
pain  is  first  paralysed,  then  the  sense  of  heat  and  cold, 
then  the  sphincters;  finally  the  anesthesia  extends  so  high 
that  amputations  of  the  mamma  and  and  resections  of  the 
ribs  can  be  performed.  Toxic  effects  are  met  with; 
headache,  dizziness,  vomting,  loss  of  appetite  and  sleep, 
chills,  feved,  sweats,  disturbances  of  the  circulation,  pare- 
sis, collapse  and  death.  Bier  has  consequently  arrived  at  the 
conclusion  that  the  method  in  its  present  form  is  useless  for 
the  practitioner.  He  has  been  trying  by  experiments  upon 
animals  to  find  a  way  to  counteract  the  harmful  effects  of 
cacain.  He  has  succeded  in  obtaining  anesthesia  by  in- 
jecting normal  salt  solution  into  the  cord  of  cats,  and 
thinks  it  was  caused  by  pressure  upon,  and  swelling  of,  the 
cord.  He  has  tried  further  all  the  cocain  derivatives,  and 
diluted  solutions  of  cocain,  but  succeded  in  obtaining  either 
no  anesthesia  at  all,  or  only  one  of  short  duration.  Tro- 
pacocain  never  gave  good  results;  the  diluted  solutions  of 
cocain  gave  an  analgesia  which  extended  over  a  large  terri- 
tory, but  he  never  abtained  anesthesia,  the  sense  of  touch 
and  of  warmth  remained  perfectly  normal.  Bier  thinks 
it  would  be  possible  by  compressing  the  neck  with  a  hand- 
age  until  marked  cyanosis  of  the  face  appears  to  shut  off 
the  toxic  effects  from  the  brain.  His  opinion  is  that  the 
method  is  still  in  the  stage  of  development,  and  still  far 
removed  from  general  use. 

Braun  of  Leipzig  demonstrates  a  new  aparatus  for  nar- 
cotizing with  a  mixture  of  chloroform  and  ether. 

Wohlgemuth  of  Berlin;  "A  new  Oxygen-chloroform  Nar- 
cosis." Wohlgemuth  demonstrated  an  apparatus  consist- 
ing of  a  cylinder  containing  oxygen  under  a  pressure  which 
can  he  regulated,  and  so  arranged  that  escaping  oxygen 
passes  through  an  automatic  attachment  which  permits 
chloroform  to  fall  in  drops  into  the  stream  of  gas;  then  the 
mixture  is  conducted  into  a  tight-fitting  mask.  Wohlge- 
muth has  tested  the  apparatus  in  181  cases  and  expresses 
his  complete  satisfaction  with  the  method,  especially  with 
its  effect  on  the  pulse.  In  almost  all  cases  the  pulse  re- 
gistered 60  beats  per  minute.  The  amount  of  chloroform 
used  is  small,  for  the  longest  operations  not  more  than 
F.-18  grains. 

eth    Session. — The    6th    session    opened    with    a    paper 


•910 


The  Philadelphia" 
Medical  Journal    _ 


FOREIGN  NEWS  AND  NOTES 


[Mat  11.  1901 


by  Tilmanns  of  Greifswald  on  "Intracranial  Pressure."  The 
speaker  observed  two  cases  in  which  the  change  from  the 
vertical  to  the  horizontal  position  was  immediately  fol- 
lowed by  coma;  these  cases  led  him  to  subject  the  brains  of 
dogs  to  the  pressure  of  fluids  of  different  specific  weigths. 
Tilmanns  concludes  that  an  intracranial  hemmorrhage  does 
not  cause  pressure  by  decreasing  the  volume  of  the  intra- 
cranial cavity  alone,  but  also  according  to  the  laws  of 
igravitation. 

Brann  of  Goettingen  read  an  interesting  paper  on  "The 
Resection  of  the  Sympathetic  in  Epilepsy."  Brann  first  de- 
scribes the  operations  performed  by  Jonnesco,  and  ex- 
presses his  surprise  that  Jonnesco  could  succed  in  remov- 
ing the  three  upper  ganglia  of  the  sympathetic,  on  account 
>of  the  anatomical  difliculties.  Brann  has  operated  in  9 
cases,  incising  behind  the  sternocleido  mastoid,  but  has 
found  it  impossible  to  resect  the  inferior  ganglion.  He  has 
observed  no  influence  on  the  respiration  or  the  heart  ac- 
tion, but  has  seen  in  each  case  ptosis  contraction  of  the 
pupil  and  dilatation  of  the  blood  vessels.  He  has  seen  no 
■change  in  the  pulse  tension;  increased  excretion  of  the 
sweat  glands  did  not  occur  in  every  case.  The  contrac- 
tion of  the  pupil  gradually  disappeared,  the  dilatation  of  the 
blood  vessels,  by  which  Jonnesco  endeavors  to  explain  the 
value  of  the  operation  in  epilepsy,  disappeared  in  the  course 
•of  24  hours.  Nor  does  Brann  believe  that  the  dilatation  of 
the  vessels  of  the  brain  continues  for  any  length  of  time. 
Brann  lost  2  of  his  9  cases,  one  of  them  in  an  epileptic  at- 
tack following  the  extirpation  of  both  nerves.  The  opera- 
tion itself  is  not  dangerous,  but  although  he  thought  some 
cases  improved,  in  no  case  could  he  report  a  cure. 

Jordan  of  Heidelberg  opened  a  large  field  for  discussion 
with  a  paper  on  "The  Operative  Treatment  of  Carcinoma 
Uteri."  Of  the  four  methods  for  extirpating  the  uterus  2 
Tiave  been  completely  deserted;  the  perineal  and  the  sacral. 
Most  operators  now  prefer  the  abdominal  route,  especially 
80  in  France.  Jordan  believes  that  the  vaginal  route 
should  be  followed  except  when  extraordinary  features  indi- 
cate the  abdominal  route;  he  also  considers  it  questionable 
whether  one  should  extend  the  operation  to  the  whole  lym- 
phatic system  of  the  pelvis  as  advised  by  Freund.  Jordan 
then  discussed  the  question  in  relation  to  mortality  and  re- 
currence, using  the  statistics  of  the  Heidelberg  clinic;  he 
concludes  that  the  dissatisfaction  with  the  vaginal  route 
Is  entirely  unjustified.  To  be  sure  the  field  of  operation  is 
"better  with  the  abdominal  route;  it  is  easire  to  clean  out 
the  pelvic  tissues,  but  the  same  can  be  accomplished  with 
the  vaginal  operation  even  If  not  quite  so  extensively.  The 
removal  of  the  lymphatic  glands  can  be  accomplished  only 
by  the  abdominal  route,  against  which  fact  Jordan  places 
the  great  variability  in  the  Infection  of  the  lymphatic  glands 
In  all  classes  of  carinoma  uteri.  It  is  Impossible  to  re- 
move the  whole  lymphatic  system  of  the  pelvis;  his  ob- 
servations have  thaught  him  that  the  glands  become  first 
affected  at  a  late  stage,  and  that  only  in  rare  cases.  His 
conclusion  is,  since  it  is  impossible  to  remove  the  glands 
completely,  and  the  partial  removal  has  no  object;  since 
the  danger  of  the  extended  abdominal  operation  is  consider- 
able; and  since,  finally,  the  percentage  of  lasting  cures 
Is  no  larger  with  the  abdominal  than  with  the  vaginal 
route;  therefore,  the  normal  method  is  the  vaginal.  The 
tact  of  the  cancer  having  attacked  the  bladder  and  the 
rectum  is  no  contraindication  of  the  vaginal  route.  He 
recommends  Schuhardt's  paravaginal  incision  and  sews  the 
anterior  and  posterior  walls  of  the  vagina  over  the  portio 
to  avoid  infection. 

Schuchardt  of  Stettin;  "The  Paravaginal  Method  for  Ex- 
tirpation of  the  Uterus  and  the  final  Results  of  the  Method 
in  Carcinoma  uteri."  Schuchardt  believes  that  with  his 
method  the  indications  for  extirpation  of  the  uterus  can  be 
made  much  broader,  and  demonstrated  preparations  which 
are  intended  to  show  that  one  can  remove  the  entire  para- 
metria with  the  aid  of  his  Incision.  His  mortality  In  all 
cases,  both  the  simple  and  the  severe  cases,  was  12'^^.  The 
incision  is  of  itself  perfectly  harmless  and  always  heals 
by  first  intention.     He  has  performed  60  operations  in  58 


cases.  Of  the  noncomplicated  cases  he  has  obtained  88%, 
of  the  complicated  cases  37%,  of  the  severe  cases  14% 
complete  cures.  If  he  counts  only  the  cases  operated  more 
than  5  years  since,  he  can  show  40%  lasting  cures.  His 
aboslute  percentage  of  cures  Is,  therefore,  as  large  again 
as  that  of  other  gjnecologists. 

Duhrssen  of  Berlin;  "Vaginal  Laparotomy  as  a  Rival  of 
Ventral  Laparotomy,  based  on  874  Cases."  Duhrssen's 
operation,  colpoceliotomy  anterior,  has  led  him  to  abandon 
the  abdominal  route  almost  entirely.  Even  the  largest  tu- 
mors of  the  ovary  can  be  removed  with  this  method  and 
their  pedicles  can  be  securely  ligated.  The  advantages  of 
the  operation  consist  in  the  low  mortality;  in  his  last  series 
of  374  operations,  in  spite  of  numerous  difficult  cases, 
Duhrssen  has  had  but  2%  mortality;  further,  in  the  more 
rapid  recovery,  and  in  the  avoidance  of  the  inconveniences 
and  dangers  following  the  abdominal  wound.  Duhrssen  has 
operated  700  times  in  cases  of  retroflexion  and  retrover- 
sion; in  the  majority  of  these  cases  the  abdominal  position 
of  the  uterus  was  combined  with  various  diseases  of  the 
adnexae  or  with  chronic  pelvic-peritonitis.  The  adhesions 
of  the  uterus  and  the  adnexae  can  be  separated  under  con- 
trol of  the  eye  by  means  of  Duhrssen's  method.  Any  un- 
favorable influence  of  vaginofixation  on  subsequent  par- 
turition can  be  avoided  by  careful  suturing  of  the  wound 
of  the  peritoneum.  He  has  seen  normal  childbirths  followed 
in  37  of  his  cases.  In  300  cases  of  various  inflammations 
and  pathological  growths  he  has  removed  the  ovary  and 
the  tubes  ,leaving  in  each  case  the  uterus,  and  at  least  a 
part  of  one  ovary.  Duhrssen  has  performed  200  conserva- 
tive operations  on  the  adnexae,  removal  of  both  ovaries  to 
prevent  conception  in  severe  chronic  disease,  salpingos- 
tomy to  make  conception  possible,  and  especially  often  ig- 
nipuncture  or  resection  In  cases  of  small  cystic  degenera- 
tions of  the  ovary,  after  which  operations  he  has  showed 
normal  pregnancies.  In  74  cases  he  has  performed  con- 
servative operations  on  the  uterus,  for  the  most  part  enu- 
cleations of  myoma,  and  in  6  cases  of  uncontrollable  hem- 
orrhage, excision  of  the  mucous  membrane  of  the  uterus  in- 
stead of  total  extirpation.  In  spite  of  this  simpler  technic 
the  mortality  of  these  operations  was  larger  than  in  oper- 
ations on  the  adnexae.  Duhrssen  claims  that  it  is  possible 
by  dividing  one  of  the  broad  ligaments  in  addtion  to  his  in- 
cision, the  operation  which  he  calls  colpoceliotomy  anterio- 
lateralis,  to  remove  with  safety  the  pus  containing  tumors 
of  the  adnexae. 

DoderleinofTueblngen;"A  New  Method  of  Performing  the 
Total  Extirpation  of  the  Uterus  through  the  Vagina."  The 
new  method  consists  in  the  complete  division  of  the  uterus 
into  two  halves  by  an  incision  beginning  at  the  posterior 
wall  of  the  cervix,  thence  into  and  through  the  uterus  ca- 
vity, following  the  pasterior  wall  up  to  the  apex  of  the  cor- 
pus and  down  the  anterior  wall;  continuing  the  incision 
through  the  anterior  wall,  the  operator  reaches  the  vesico- 
cervical space  without  danger  of  injuring  the  bladder, 
which  has  ben  removed  from  the  cervix  by  the  strong  down- 
ward traction  on  the  uterus.  The  incision  which  began  ' 
at  the  posterior  lip  of  the  cervix  is  completed  by  incising 
the  anterior  lip,  and  the  operation  is  finished  by  extirpat- 
ing each  half  of  the  uterus  by  itself. 

Olshausen  of  Berlin  followed  with  a  paper  on  the  same 
subject  as  the  preceding  papers.  His  experience  has  been 
the  same  as  Jordan's.  It  has  always  been  his  opinion  that 
one  can  expect  a  cure  only  when  the  cancer  has  not  gone 
beyond  the  boundaries  of  the  uterus,  and  he  considers  only 
such  cases  operable.  He  has  never  thought,  and  especial- 
ly of  late, that  one  should  remove  the  lymphatic  glands. even 
though  he  has  extended  his  operation.  Cancer  can  recur  af- 
ter 4  to  5  years:  he  has  been  recurrences  in  SS.S'r  after 
5  years.  He  believes  further  that  the  abdominal  opera- 
tion is  only  admissible  where  the  vaginal  method  is  tech- 
nically impossible.  Schuchardt's  icision  is  necessary  in 
only  %%  of  all  cases:  he  has  seen  abundant  hemorrhage 
and  canced  infection  of  the  wound  after  using  Schuchardt  s 
method.  Olshausen  points  out  that  the  pus  of  a  pyome- 
tra  is  especially  septic  and  for  that  reason  he  would  con- 


,  Mat  11,  1901] 


FOREIGN  NEWS  AND  NOTES 


rTHE  Philadelphia 
Medical  Journal 


9H 


aider  Doderlein's  method  aplicable  only  to  cases  of  begin- 
ning carcinoma,  l)ut  not  to  cases  complicated  by  pyometra. 
He  dpes  not  believe  in  the  great  danger  in  separating  ad- 
hesions of  the  bladder,  except  possibly  in  unusual  cases, 
and  then  he  doubt's  that  Dorderlein's  method  would  give 
any   better   results. 

In  the  discussion  following  these  papers,  Martin  of  Greifs- 
wald  says  he  agrees  perfectly  with  Jordan.  He  has  experi- 
enced one  very  unpleasant  hemorrhage  following  Schu- 
chardt's  incisin,  yet  thinks  he  can  recommend  the  method. 
He  expresses  some  doubts  in  regard  to  Doderlein's  me- 
thod, but  thinks  it  should  be  tried. 

Werthheim  of  Vienna  took  the  opposite  view.  It  is  his 
iprinciple  to  operate  in  all  cases  by  the  abdominal  route  and 
[to  remove  the  connective  tissue  surrounding  the  uterus, 
land  the  lymphatic  glands,  having  found  in  18  out  of  50 
cases  that  the  glands  were  affected,  all  of  these  being  cases 
.which  were  not  far  advanced.  Werthheim  considers  it  more 
important,  however,  to  clean  out  this  parametrium  than  to 
remove  the  glands,  and  he  thinks  this  is  only  possible  by 
the  abdominal  route.  His  results  were  at  first  unfavorable, 
losing  11  out  of  33  cases.  He  thinks  now  that  he  then 
went  too  far.  Of  his  last  20  cases  he  has  lost  but  3,  2  from 
necrosis  of  the  ureters,  and  one  from  metastasis  in  the 
liver.  The  future  will  show  the  superiority  of  the  abdom- 
inal method. 

Kummell  of  Hamburg  mentioned  those  hopeless  cases 
in  which  one  must  operate  to  relieve  complications.  In 
three  cases  of  closure  of  the  ureters  he  has  resected  the 
mreters  and  sewed  them  into  the  bladder. 

Frundof  Strassburg  emphasizes  that  statistics  can  only  be 
of  value  when  one  and  the  same  operator  uses  one  and  the 
same  operation  in  all  his  cases.  He  consider?  the  vaginal 
operation  merely  palliative.  The  abdominal  mtthod  is  in- 
dicated in  all  earlier  cases  where  there  is  any  hope  of 
success. 

Petersen  of  Heidelberg;  "The  Structure,  Growth  and  His- 
togenesis of  Carcinoma  of  the  Skin.  Petersen  has  made 
use  of  the  ebryological  method  (after  Born  and  Strasser) 
of  plate  models  in  wax  in  the  study  of  cancer.  He  believes 
that  the  study  of  such  magnified  serial  sections,  besides 
being  of  great  value  to  the  teacher,  proves  that  skin  cancer 
propogates  itself  in  two  ways,  unicentric.  starting  from 
one  single  center  and  spreading  into  the  neighboring  tis- 
sues, and  multicentric,  beginning  at  several  points  inde- 
pendently. The  masses  of  epithelial  cells  which  grow  from 
each  independant  focus,  spread  by  sending  branches  into 
the  tissue;  the  so-called  cancer  alveoil  are  in  the  majority 
of  cases  merely  cross  sections  of  such  branches  of  the 
main  growth.  Petersen  believes  this  study  of  such  serial 
reconstructions  teaches  that  the  growth  of  the  epithelium 
1b  the  primary  factor  in  the  histogenesis  of  carcinoma,  as 
opposed  to  Ribber's  theory  of  the  primary  growth  of  the 
connective  tissue. 

Kossmann  of  Berlin;  "The  Orgin  of  Carcinoma,  especial- 
ly In  the  Ovary."  Kossmann  showed  micro-photographs  of 
a  "cancer"  of  the  ovary  which  contained  both  clyindrical 
and  pavement  epithelium,  and  consideres  it  an  impossibili- 
ty to  assume  that  a  parasite  could  cause  the  growths  of 
such  widely  different  kinds  of  epithelium.  He  would  there- 
fore hold  to  the  theory  of  Connheim  that  the  cells  had  be- 
come dislocated  from  their  normal  position  at  some  period. 

Ehrhardt  of  Koenigsberg  advised  the  use  of  boiling  water 
Instead  of  the  paquelin  to  destroy  any  remains  of  a  tumor  in 
the  wound,  to  guard  against  transplantation.  In  the 
general  discussion  Gussenbauer  of  Vienna  considers  Peter- 
sens'  method  too  schematic,  v.  Hausemann  points  out  that 
we  cannot  call  such  models  diagrams  and  that  they  are  of 
great  value  in  the  study  of  the  histo-morphology  of  cancer. 
Israel,  v.  Kahlden,  Heidenhain  and  Petersen  took  part  in 
the  discussion.  Hollander  of  Berlin  presented  a  case  of 
carcinoma  of  the  nose;  the  patient  has  now  multiplie  can- 
croids on  her  whole  body. 

Kronlein  of  Zuerich;  "Is  Narcosis  advisable  in  Resection 
of  the   Upper  Jaw  or  not?"     Kronlein  demonstrated  in  a 


table  that  the  earliest  recorded  cases  of  this  operation 
showed  a  better  mortality  than  the  operations  performed 
since  antiseptic  and  aseptic  times.  He  concludes,  there- 
fore, that  some  further  factor  must  enter  into  the  question. 
This  factor  is  the  narcosis,  a  belief  supported  by  the  re- 
sult of  Koenig  and  Kuster.  Both  of  these  authors  owe  the 
half  of  their  lost  cases  to  bronchopneumonia  following  aspi- 
ration of  the  blood.  This  danger  cannot  be  avoided  by 
partial  narcisis,  and  so  Kronlein  operates  with  almost  no 
narcosis.  He  has  lost  but  one  of  his  35  patients,  and  this 
one  died  of  meningitis. 

Wohlhardt  of  Halle;  "The  Disappearance  of  the  Toxicity 
of  Cocain  in  the  Animal  Body."  1  he  author  has  found 
that  a  lethal  dose  of  cocain  injected  into  a  rabbit's  leg  and 
prevented  from  entering  the  general  circulation  by  a  rubber 
bandage,  produced  no,  or  only  slight  toxic  symptoms  after 
removal  of  the  banadge  %  to  1  hour  after  the  injection;  he 
concludes  that  the  cocain  must  have  lost  its  toxic  proper- 
ties. Discussion:  Schwarz  of  Agram;  "Lumbar  Anesthe- 
sia,"claims  that  tropacocain  is  superior  to  cocain  in  its  after 
effects;  in 44 cases  he  has  seen  headache  in  but 4 cases,  in  no 
case  nausea  or  rise  of  temperature.  Blau  of  Tuebingen  dem- 
onstrated blood  pressure  curves  and  showed  that  the  blood 
pressure  rises  uder  ether  and  sinks  under  chloroform. 
Riedel  of  Jena  fears  the  aspiration  of  blood,  and  operates 
in  all  cases  on  the  mouth  easily,  etc.,  with  the  lead  hang- 
ing below  the  horizontal.  Kader  of  Breslau  reported  fa- 
vorable results  in  56  cases  of  lumbar  anesthesia.  He  gives 
digitalis  for  one  or  two  days  before  operation,  and  uses 
camphor  if  any  heart  symptoms  appear.  Gussenbauer  of 
Vienna  uses  complete  narcosis  in  resections  of  the  jaw, 
and  operates  with  the  head  held  forward.  He  has  had 
to  perform  treacheotomy  in  consequence  of  aspiration  of 
blood  In  2  cases,  both  of  which  recovered. 


19TH  GERMAN  CONGRESS  FOR  INTERNAL  MEDICINE. 
Held  at  Berlin,  April  16th-19th,  1901. 

The  annual  German  Congress  for  Internal  Medicine  which 
meets  alternately  at  Berlin  and  Wiesbaden,  assembled  for 
its  19th  session  in  the  Architecten-Haus,  Wilhelmstrasse, 
Berlin,  on  April  i  Jth,  1901.  The  usual  exposition  accom- 
panying the  congress  was  devoted  this  year  especially  to 
instruments,  etc.,  designed  as  aids  in  diagnosis;  an  ex- 
traordinary feature  was  the  large  and  richly  illustrated 
volumpe  prepared  under  the  direction  of  Mendelsohn  of 
Berlin  "The  Development  of  Apparatus  for  Clinical  Diag- 
nosis," which  was  presented  to  each  member  of  the  con- 
gress. This  volume  gives  a  short  description  by  men  of 
note  in  their  various  lines  of  work,  of  the  numerous  me- 
chanical, optical  and  electrical  aids  in  clinical  diagnosis. 

The  President,  Senator  of  Berlin,  paid  especial  atten- 
tion to  his  address  opening  the  congress,  to  the  progress 
made  in  the  diagnosis  of  internal  disease  during  the  past 
century.  Senator  described  in  a  brief  historical  sketch 
the  gradual  development  from  pure  empiricism,  through 
the  reactionary, — the  nihilistic  period  when  the  physician 
doubted  his  ability  to  influence  disease — to  the  present 
period  when  internal  medicine,  firmly  footed  on  the  foun- 
dation built  by  the  pathologists;  notably  Brichat.  Rokit- 
ansky  and  Virchow,  began  its  scientific  career,  a  period  to 
be  best  judged  byt  its  results.  The  chief  results  have  been 
in  diagnosis.  Here  is  to  be  especially  noted  the  modern 
treatment  of  tuberculosis,  and  serum  therapy.  Truer  to- 
day than  ever  before  is  the  old  saying,  "qui  lene  diagnoncit, 
i-ciic  oirat." 

The  congress  was  then  greeted  by  the  representatives  of 
the  Austrian  Ministry  for  Education,  von  Jakseh  of  Vienna, 
and  of  the  Prussian  Ministry,  Pistor  of  Berlin,  and  by  the 
representatives  of  the  city  of  Berlin,  etc. 

The  work  of  the  congress  then  began  with  the  first  main 
topic  of  the  program,  "Heart  Sitmulants  and  Vasomotor 
Stimulants?"  Gottlieb  of  Heidelberg  treated  the  subject 
from  the  experimental  standpoint.  He  described  first,  the 
conditions   in  which   vasomotor   stimulants   are   indicated. 


912 


The  Philadelphia"] 
Medical  Journal   J 


FOREIGN  NEWS  AND  NOTES 


[Mat  11.  1> 


In  the  case  of  paralysis  of  the  vasomotor  nerves  due  to 
some   influence   upon  the  vasomotor  center,   such   as  the 
narcotic  poisons,  or  in  the  course  of  acute  infectious  disease, 
blood  vessels  of  the  abdomen  become  congested  and  ane- 
mia of  the  vessels  of  the  periphery  and  of  the  brain  results; 
the  pulse  becomes  small,  the  heart  chambers  are  poorly 
filled;  but  this  not  because  the  heart  lacks  the  power  to  do 
the  work,  but  because  it  lacks  material  with  whicn  to  work; 
the  blood  is  retained  in  the  congested  vessels  of  the  ab- 
domen.    In  these  conditions  the  vasomotor  stimulants  by 
causing  contraction  of  the  blood  vessels  controlled  by  the 
splanchnicus,  bring  the  distribution  of  the  blood  back  to 
the  normal,  relieve  the  anemia,  and  enable  the  heart  to  ful- 
fil its  function.     The  oldest  of  these  vasomotor  stimulants  is 
strychnin;  caffein  is  preferably  because  of  the  tendency  of 
strychnin  to  produce  convulsions.     Camphor  also  acts  in 
the  same  was  as  strychnin  and  caffein;  another  vasomotor 
stimulant  is  the  local  application  of  cold.    It  is  to  be  noted 
that  only  the  blood  vessels  which  are  controlled  by  the 
splanchnicus  are  affected  by  these  drugs.    They  also  affect 
the  respiration.    Ether  and  alcohol  have  no  tonic  effect,  but 
on   the   contrary   a   dilating   effect   upon   the   vasomotors. 
Heart   stimulants   increase  the   functional   activity   of  the 
heart  by  increasing  the  volume  of  the  heart  stroke,  thus 
relieving  the  pathological  distribution  of  the  blood  which 
follows  heart  lesions  as  well  as  abnormal  innervation  of  the 
blood  vessels.     The  theraputic  value  of  digitalis  is  to  be 
sought   in   this   increase   of  the   functional   power   of  the 
heart;  its  effect  is  always  on  the  action  of  the  heart,  never 
on  the  organic  lesion.     The  constriction  of  the  blood  ves- 
sels caused  by  digitalis  is  of  but  secondary  therapeutic  im- 
portance.    Gottlieb  described  experiments  on  the  heart  of 
the  higher  vertebrates,  using  a  modification  of  the  method 
of  Hering  and  Bock  on  the  heart  of  the  living  animal,  and 
the  method  of  Langerdorff  on  the  isolated  heart.     Gottlieb 
and  Magnus  have  further  studied  the  heart  action  by  in- 
troducing a  rubber  balloon   into  the  heart  chambers,   in- 
flating the  same,  and  registering  the  degree  of  systolic  com- 
pression of  the  baloon.     They  have  found  that  the  work 
done  by  the  auricle  is  increased  three  or  four  fold  after 
giving  digitoxin.     The  increase  is  due  to  a  stronger  sys- 
tolic contraction  of  the  heart  muscle.    This  increase  of  the 
functional  power  of  the  organ  is  of  especial  significance 
in  valve  lesions.     This  lessening  of  the  frequency  of  the 
heart  beat  which  follows  the  use  of  digitalis,  caused   by 
stimulation  of  the  vagus  is  also  of  no  little  therapeutic 
value.  The  complete  therapeutic  action  of  digitalis  is  there- 
fore  attained   in   this   stage   when   the   lessened   frequncy 
of  the  beat  permits  complete  diastolic  expansion  and  filling, 
and   the  strengthened    systole    brings    a    more    complete 
emptying  of  the   organ.        All   drugs   containing  digitalis 
cause  contraction  of  the  blood  vessels;  this  effect  is.  how- 
ever, of  but  secondary  therapeutic  value,  for  example  in 
aiding  to  overcome  the  congestion  of  the  vessels  of  the 
abdomen.     If  this  contraction  becomes  too  pronounced  it 
can  be  of  detriment  to  a  disease  heart  by  mcreasing  the 
vork  to  be  done.  Gottlieb's  paper  finished  by  merelv  touch- 
ing upon  the  other  important  heart  stimulants.     Camphor 
influences   the   heart   indirectly   by   its   stimulative   action 
on  the  vasomotors,  but  also  directly  by  making  the  heart 
itself  more  susceptible  to  stimulation.    Caffein  has  a  direct 
effect  on  the  heart  by  increasing  the  power  of  the  organ 
to  ovrcome  pathological  difficulties.     Caffein  does  not  af- 
fect a  healthy  heart  if  the  pulse  tension  remains  normal. 
Gottlieb  notes  the  elective  action  of  theobromin  upon  the 
coronary  vessels  and  the  consequent  value  of  the  drug  in 
angina   pectoris.     Alcohol   influences   the   heart   indirectly 
by  causing  dilatation  of  the  blood  vessels,  thus  decreasing 
the  diflSculties  to  be  overcome,  in  cases  for  example  where 
the  pulse  tension  is  too  high.     Gottlieb  expresses  the  hope 
that  pharmacology  and  clinical  experience  together  will  in 
the  future  solve  the  problem  of  the  right  choice  of  the  stim- 
ulant or  combination  of  stimulants,  in  spite  of  the  compli- 
cated mechanism  which  governs  the  heart  and  the  vaso- 
motor supply.     Sahli  of  Bern  treated  the  clinical  side  of 


the  problem  of  heart  stimulants  and  vasomotor  stimulant 
He  emphasized  first  that  the  future  of  internal  medicine 
to  be  sought  in  the  advancement  of  functional  diagnosii 
the  search  after  a  specific  treatment  leads  us  too  far  ini 
the  future.     His  paper  began  with  a  discussion  of  the  p 
thologj'  of  the  circulatory  disturbances.     Sahli  divided  tl 
congestions  into  three  groups  whose  common  charactei 
istic  is  in  the  slowing  of  the  aortic  blood  stream  and  tl 
pathological  distribution  of  the  blood:  (1)  The  cardiac  co 
gestions    due   to   insufficiency   of   the   systole,    or   to    m 
chanical  prevention  of  the  diastole.     (2)   Respiratory  co 
gestions  in  diseases  of  the  respiratory  organs,  or  due 
intrathoracic  exduations;  Sahli  considers  the  congestions  ■ 
this  group  due  indirectly  to  cardiac  congestion.     (3)  Vas 
motor,  better,  vasodilatator  congestions,  caused  by  paral 
sis  of  the  small  vessels  of  the  body.  Sahli  divides  the  ca 
diac  congestions  into  high  tension  and  low  tension  conge 
tions.      A  further  group  form  the  congestions  in  the  ve 
sels  controlled  by  the  splanchnicus,  congestions  caused  hv 
by   heart    lesions   and    by   primary   vasodilatation.      Sal 
then  emphasized   the   necessity   of  diagnosing  these  co 
gestions  in  their  early  stages,  and  advised  the  practitioa 
to  begin  treatment  much  earlier  than  is  usually  the  cas 
He  believes  that  digitalis  is  useful  in  all  these  forms 
congestion;  but  the  physician  must  avoid  schematic  tree 
ment.  and  must  know  when  further  therapeutic  meason 
should   be   added   to  the   digitalis   treatment.     In   conge 
tion  with  high  tension  pulse  Sahli  has  found  that  digital 
is  by  no  means  contraindicated,  but  that  it  may  even  less* 
the  pulse  tension.     The  success  of  the  digitalis  treatmer 
the   explanation   of  the   fact   that   digitalis   may   effect 
cure  which  may  last  for  years  after  one  has  stopped  tret 
ment.  is  the  interruption  of  the  circulus  vitiosus  by  tl 
drug;    the  heart  itself  suffering  from  the  congestion, 
gains  normal  circulation  in  the  coronary  vessels,  and  a 
hold  its  own  again.     Sahli  then  discusses  those  cases 
which   digitalis   gives   no   results,   cases   which   he   wou 
call  essential  congestion.    By  this  term  he  designates  tho 
cases  where  the  valve  lesion  has  become  so  pronouno 
that    is   is   mechanically    impossible   to   avoid   congestlo 
even  with  normal  heart  power  and  normal  systole.    In  su< 
cases  digitalis  treatment  is  either  of  no  value,  or  else 
merely  transitory  value.     Sahli's  opinion  is  that  there 
no  difference  in  the  action  of  digitalis  on  any  of  the  valv 
lesions.     The  claim  that  the  drug  has  no  effect  in  insu; 
ciency  of  the  aorta  he  expleins  by  the  fact  that  these  cas 
first  come  under  treatment  after  the   lesion   has   exist» 
for  years  and  the  congestion  has  become  '"essential." 
regard  to  the  dose  Sahli  pointed  out  the  difference  in  t' 
principle  of  large  doses  and  of  small  doses;   large  dos 
affect  both  systole  and  diastole,  small  doses  the   systr 
alone.  In  regard  to  the  long  continued  use  of  the  drug,  to  i 
cumulative   action,   and   to   the   patients   becoming   acci 
tomed  to  digitalis,  Sahli  agreed  with  Grodel  and  Kussma> 
Caffein  and  camphor  act  in  an  entirely  different  mann 
from   digitalis.     Their  stimulative   effect  on  the   heart 
confined  to  the  systole.    Their  chief  value  is  in  their  acti' 
on  the  vasomotors.     The  action   of  caffein  and  camph 
on  the  respiration  and  the  diuretic  action  of  caffein  are  t 
vantages  not  to  be  overlooked.    There  is  no  direct  proof 
a  direct  action  of  alcohol  on  the  heart.    In  cases  of  high  U 
sion  it  can  be  of  value  by  diminishing  the  tension  and  til 
aiding  to  cardiotonic  drugs.     Its  effect  is  too  transitory 
make  alcohol  of  value  when  used  exclusively  in  cases 
high  tension.     Sahli  considers  alcohol  contraindicated 
the  actue  infectious  diseases  because  it  acts  in  the  sai 
way  as  the  toxins  themselves.        Alcohol  is  useful   as 
transitory  stimulant   in  chills,  etc.       Neither  alcohol  n 
ether  are  indicated  in  all  case  of  collapse.    In  closing  Sal 
emphasized  the  importance  of  the  right  choice  of  the  dm 
or  combinations  of  drugs,  and  noted   further  the  comi    s- 
cated  mechanism  of  the  human  body.     Oftentimes  dr«| 
etc.,  which  have  absolutely  no  direct  action  on  the  bet 
may  be  of  the  greatest  therapeutic  value. 

(To  be  Continued.) 


[AT  n,  1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia        qj  ^ 
LMedical  Journal         y   O 


Cbe  ILatcst  Xitcvaturc. 


BRITISH  MEDICAL  JOURNAL. 

Ai)ril  20,  1901. 

Medical  Notes  from  the  Imperial  Yeomanry  Hospital  at 

Pretoria.     J.  W.  WASHBOURN. 
Reminiscences  of  the  Welsh  Hospital  in  South  Africa 

(Springfontein  and  Pretoria).    J.  LYNN  THOMAS. 
No.  6.     General  Hospital,  Johannesburg.    ARCHIBALD 

WATSON. 
Clinical    Notes    on    the    Wounded    in    South    Africa. 

J.    W.    SMITH. 
The    Princess    Christian    Hospital    in    South    Africa.. 

GEORGE  V.  WORTHINGTON. 
Veld  Sores.     ALEXANDER  OGSTON. 
Some    Observations    on    Veld    Sores.      W.    H.    HAR- 

LAND. 
Report  on  295   Cases  of  Enteric  Fever,   General   Hos- 
pital, Tin  Town,  Ladysmith.     DAVID  MELVILLE. 
Enteric  Fever  in  South  Africa;   Effective  Sterilization  of 

Excreta.     MAJOR  H.  A.  CUMMINS. 
).     Venesection  in  the  Treatment  of  Gunshot  Wounds  of 

the  Chest.    CAPTAIN  F.  J.  W.  PORTER. 

1. — In  the  Imperial  Yeomanry  Hospital  at  Pretoria, 
''ashbourn  has  met  with  a  very  large  number  of  cases  oE 
lundlce.  As  recovery  always  occurred,  the  pathology  of 
lis  affection  can  only  be  surmised  at.  The  nausea,  vomit- 
'-^''  ig  and  abdominal  pain  which  accompany  the  disease, 
iggest  an  inflammation  of  the  duodenum  which  leads  to 
blocking  of  the  orifice  of  the  bile  duct,  and  thus  causes 
16  jaundice.  The  occurrence  of  jaundice  in  epidemic  form 
Dints  to  some  infective  agency.  In  the  cases  of  enteric 
iver  which  the  author  has  observed,  constipation  is  the 
lie  and  diarrhea  and  hemorrhage  are  uncommon.  Phlebitis 
of  very  frequent  occurrence,  and  is  very  much  more 
^  jmmon  than  in  England.  Patients  who  have  been  ex- 
'•^1  3sed  to  excessive  fatigue,  and  those  who  have  been  con- 
"iayed  long  distances  in  an  ambulance  during  the  early 
ages  of  the  disease  frequently  succumb  ultimately  to  car- 
nJlac  failure,  although  the  attack  has  otherwise  not  been 
vere.  From  clinical  observation  the  author  is  satisfied 
7  lat  inoculation  does  not  modify  this  disease.  Phlebitis 
IS  followed  other  conditions  than  typhoid  fever,  or  has 
risen  without  any  definite  cause  in  a  number  of  cases, 
is  probable  that  there  are  several  specific  fevers  in  South 
iliffrica  that  have  not  been  recognized;  although  they 
;present  Malta  fever  more  frequently  than  any  other 
isease.     [J.   M.   S.] 

2. — Thomas  describes  the  method  of  pitching  hospital 
!nts.  He  has  also  found  that  wounds  inflicted  by  rico- 
let  bullets  are  severe  and  that  lesions  of  an  expanding 
jllet  are  most  disastrous  after  penetrating  bone;  and 
lose  of  the  Lee  Metford  and  Mauser  are  of  a  comparative- 
trivial  character.  The  author  uses  a  forceps-tourniquet 
'■''ii  all  cases  of  amputation,  and  regards  it  as  the  most  re- 
1 -liable  and  convenient  instrument  when  the  surgeon  cannot 
^i-,di!ly  upon  the  help  of  any  skilled  assistants  to  control  hem- 
-ilThage.  The  application  of  the  forceps-tourniquet  causes 
,-)iie  simultaneous  closure  of  both  the  arteries  and  the 
/.Mns.  In  the  use  of  the  telephone  probe  the  author  be- 
eves that  it  is  more  desirable  to  put  the  silver  plate  on  the 
itient's  tongue  than  to  apply  it  as  directed  to  the  skin. 
"  '  ver  40%  of  the  cases  in  the  Welsh  Hospital  were  surgical 
id  there  was  extraordinary  uniformity  of  healing  in  al- 
tlAost  all  of  the  cases.     [J.  M.  S.l 

.,;iji3. — Watson  describes  the  conditions  pertaining  at  No.  6 
ospital,  Johannesburg.     [J.  M.  S.] 

4. — J.  W.  Smith  reports  a  number  of  interesting  cases  of 

jn-shot  wounds   occurring   in   the  war   in    South    Africa. 

e    reports    briefly    a    number    of    cases    of    penetrating 

*  ound  of  the  chest,  in  which  it  would  seem  most  probable 

lat  the  heart  itself  had  been  injured  by  the  ball,  and  yet. 

)oil  tter   a   few    days    of   hemoptysis    the    patient    recovered. 

Sa  ^e  also  refers  to  cases  of  penetrating  wounds  of  the  abdo- 

j.'l  len    which    recovered    without    operation.      The    prompt 

j,j,  ealing  of  wounds   in   other  parts   of  the   body   was   also 

"^irprising.     Aneurysms  as  the  result  of  injury  to  arteries 

as   not   infrequent.     Injuries   to   nerves   were   more   nu- 

erous  than  would  be  expected,  and  a  number  of  instan- 

98  are  reported  where  operation  was  necessary  for  this 

andition.     It   is   thought   that    where   bullets   lie    deeply, 

specially   in   the   trunk,    and    are   causing   no    symptoms, 


«l 


it  is  probably  better  not  to  disturb  them.  Smith  found 
that  the  fractures  of  the  long  bones  were  generally  oblique 
in  direction,  irregular  and  accompanied  by  a  great  deal  o£ 
splintering.  The  wounds  of  the  knee  joint  made  the  most 
surprising  recoveries.  What  is  said  of  the  modern  bullet 
wound  cannot  be  said  of  the  expanding  bullet  or  of  the 
shell;  most  of  the  wounds  caused  by  the  latter  become 
infected.     [J.  H.  G.] 

6. — Alexander  Ogston  describes  the  Veld  sore  as  a  super- 
ficial infected  blister  closely  resembling  the  well-known 
onychia  occurring  in  mill  workers.  The  epidermis  is  ele- 
vated into  a  semi-translucent  swelling  with  an  area  of 
inflammation  around  it.  Lymphatic  involvement  is  seldom 
seen.  This  peculiar  sore  is  only  seen  in  South  Africa: 
it  occurs  mostly  on  the  hands  and  forearms  and  on  the 
feet  and  legs.  Suppuration  is  not  a  characteristic  of  the 
Veld  sore,  but  crusts  of  serum  are  apt  to  form  over  the 
sore.  The  sore  is  due  to  a  micrococcus  closely  resembling 
the  gonococcus,  and  Ogston  thinks  that  this  organism  is 
an  inhabitant  of  the  vegetation  and   soil   of  the  Veld. 

[J.  H.  G.] 

7. — W.  H.Harland  describes  the  Veld  sore  very  much 
as  is  done  in  the  foregoing  article,  but  seems  to  have 
observed  lymphatic  Involvement  and  fever  more  often  than 
did  Ogsten.  He  has  found  the  disease  very  amenable  to 
treatment  by  mild  antiseptics.  He  thinks  it  due  to  the 
sting  of  an  insect.  [  J.  H.  G.[ 

10. — F.  J.  W.  Porter  reports  an  interesting  case  of  an 
officer  in  South  Africa  who  was  shot  through  the  chest,  and 
who,  as  a  result,  suffered  great  inconvenience  in  respira- 
tion from  a  large  accumulation  of  blood  in  the  right  pleural 
cavity.  It  was  necessary  to  carry  the  patient  over  a  num- 
ber of  miles  of  rough  country.  24  hours  after  this  injury 
his  pulse  was  small  and  the  heart's  impulse  diffuse. 
Lividity  was  very  marked  and  the  patient  was  quite  delir- 
ious. At  this  time  10  ounces  of  very  dark  blood  was  drawn 
from  the  median  basilic  vein  with  the  most  gratifying 
result,  the  patient  turning  on  his  side  and  going  to  sleep 
immediately  afterward.  The  patient  was  enabled  to  con- 
tinue his  journey  with  much  less  suffering,  and  ultimately 
made  a  good  recovery.     [J.  H.  G.] 

5. — Worthington  describes  the  conditions  pertaining  in 
the  Princess  Christian  Hospital,  South  Africa.     [J.  M.  S.] 

8. — During  April,  May  and  June,  1900,  there  were  295 
cases  of  enteric  fever  in  the  General  Hospital  in  Tin  Town, 
Ladysmith.  The  disease  was.  as  a  rule,  of  malignant 
type.  In  about  40%  of  cases  no  rash  was  found,  and  in 
about  20%  the  rose  spots  were  thickly  scattered  over  the 
trunk  and  extremities,  whilst  the  remaining  40%  followed 
the  usual  course.  In  only  5  cases  out  of  the  entire  number 
was  any  diarrhea  noted.  As  a  genera.l  rule,  the  delirium 
was  of  the  rambling  or  muttering  type,  giving  rise  to  no 
anxiety  and  calling  for  no  treatment.  Thirty  of  the  295 
cases  had  been  inoculated.  The  complications  were  more 
numerous,  the  duration  of  the  fever  longer  and  the  death 
rate  higher  in  the  inoculated.     [J.  M.  S.] 

9. — Cummins  makes  a  second  report  on  his  method  of 
sterilizing  the  excreta  of  patients  suffering  from  typhoid 
fever.  In  2  minutes  all  forms  of  life  have  become  ex- 
tinct, and  even  spores  have  lost  their  vitality.  The  caul- 
dron used  in  his  hospital  has  a  capacity  of  40  gallons. 
It  is  emptied  every  evening  for  cleansing  purposes;  20 
gallons  of  a  solution  of  izal  or  crude  carbolic  acid  in  water 
is  poured  into  it,  and  when  this  has  been  heated  to  near 
the  boiling  point  the  apparatus  is  again  fit  for  use.  Smell 
from  the  boiling  cauldron  is  practically  absent,  and  fllea 
do  not  approach  it.     [J.  M.  S.] 


LANCET. 


April  20,  1!)01. 

1.  A  Clinical  Lecture  on  Carcinomatous  Stricture  of  the 

Duodenum.     H.   D.  ROLLESTON. 

2.  Autopsychorhythmia     or     Repetition     Psycho-neurosis. 

Morbid  Rhvthmic  Forms  of  Automaticity  and  Rhyth- 
mic Forms  of  Mental  Alienation.    C.  H.  HUGHES. 

.S.  Correspondence  between  Cholera  and  the  Prevalence 
of  Comma  Bacteria  in  Well  Waters  of  Gujerat  dur- 
ing the  Famine  of  1900.    GEORGE  LAMB. 

4.  When  to  Operate  In  Perforative  Peritonitis.  ARTHUR 
C.  ROPER. 

.I.  Recurring  Attacks  of  Catalepsy  alternating  with  Vio- 
lent Mental  Excitement.     W.  G.  STONE. 

fi.  On  the  Causation  and  Treatment  of  Profuse  Eplstaxls 
in  People  beyond  Middle  Age.    GEORGE  COATES. 


914 


The  Philadelphia"! 
Medical  Journal   J 


THE  LATEST  LITERATURE 


[Mat  U,  IMI 


7.  Case  o(  Recovery  after  Operation  for  Diffuse  Peritoni- 

tis from  Perforation  of  tlie  Appendix.    CHARLES  A. 
MORTON. 

8.  The  Open-air  Treatment  of  Phthisis  at  Home;  A  Short 

History  of  a  Case.    F.  WHINFIELD  BARTLETT. 

1. — Rolleston  delivered  a  lecture  on  carcinomatous  stric- 
ture of  the  doudenum,  at  St.  George's  Hospital  on  March 
11.  1901.  The  following  history  of  the  case  is  given: 
On  November  29,  1901,  a  plumber,  50  years  of  age,  was 
admitted  to  the  St.  George's  Hospital  complaining  of  weak- 
ness, vomiting,  and  abdominal  pains.  He  had  suffered 
from  pain  in  the  epigastrium,  immediately  after  taking 
food,  for  the  past  two  years.  The  patient  had  two  attacks 
of  vomiting,  one  in  July  and  August,  1900,  and  the  other 
In  November.  The  following  report  was  made  while  the 
patient  was  in  the  Hospital:  He  complains  of  great  weak- 
ness, he  has  lost  weight,  and  suffers  from  constipation. 
The  heart  and  lungs  appear  normal  and  nothing  abnormal 
can  be  palpated  In  the  abdomen.  The  blood  revealed  a 
slight  leukocytosis:  the  urine  varied  in  specific  gravity  from 
1010  to  1030,  and  at  times  contained  a  trace  of  albumen,  and 
indican  in  varying  quantities.  The  vomiting  material  was 
bile  stain  and  did  not  contain  free  acid.  After  persistent 
and  copious  vomiting  the  amount  of  urine  decreased.  On 
December  6th  the  patient  vomited  11\i  pints  in  15  hours. 
The  diagnosis  of  stricture  of  the  duodenum  below  the  bil- 
iary papilla  suggested  itself.  During  the  course  of  the  ill- 
ness the  patient  developed  pyemia.  The  probable  source 
of  the  infection  was  a  transfusion  wound.  Death  occurred 
from  exhaustion  on  February  6,  1901.  The  post-mortem 
examination  revealed  a  tight-stricture  of  the  third  part 
of  the  duodenum,  due  to  a  new  growth  which  almost 
completely  encircled  the  lumen  of  the  bowel.  Microscop- 
ically this  tumor  proved  to  be  a  columnar-celled  cari- 
noma.  The  author  believes  that  gastro-enterostomy  would 
no  doubt  have  relieved  the  patient  temporarily,  but  the 
diagnosis  was  never  sufficiently  clear  to  justify  laparotomy. 
The  article  is  concluded  with  some  general  remarks  on 
malignant  disease  of  the  duodeum.  Mention  is  made  of 
the  frequency  of  carcinoma  in  this  part  of  the  intestine. 
The  most  frequent  situation  of  primary  cancer  of  the 
duodeum  is  in  the  second  part,  less  frequently  in  the  first 
part,  and  the  most  uncommon  position  is  the  third  part. 
[F.   J.   K.] 

2. — Hughes  calls  attention  to  a  morbid  rhythmic  activity 
of  the  brain  which  he  has  termed  "autopsychorythmia." 
or  repetition  psycho-neurosis.  He  gives  a  brief  account 
of  a  number  of  such  cases  and  maintains  that  this  form 
of  mental  derangement  is  a  forerunner  of  grave  insanity. 
However  slight  and  remote  the  symptoms  may  be.  thorough 
investigation  and  prompt  endeavor  is  imperative.    [F.  J.  K.] 

3. — Lamb  writes  upon  the  correspondence  between  chol- 
era and  the  prevalence  of  comma-becteria  in  well  water 
of  Gujerat  during  the  famine  of  1900.  The  results  of  his 
researches  show  that  none  of  the  comma-shaped  bacteria 
Isolated  from  Gujerat  waters  could  be  termed  true  cholera 
vibrio.  There  was.  however,  a  marked  resemblance  mor- 
phologically, biologically,  and  tinctorially  with  the  true 
cholera-producing  microbe.  So  marked  was  this  similarity 
that  the  author  believes  that  the  bacteria  found  belonged 
to  the  tribe  of  curved  bacteria,  which  includes  the  true 
cholera-producing  microbes.  In  many  of  the  localities 
where  these  comma-bacteria  were  found,  cases  of  true 
cholera  were  present,  which  shows  an  inhanced  signifi- 
cance between  the  incidence  of  cholera  in  a  locality  and 
the  presence  of  curved  comma-shaped  micro-organisms. 
[F.  J.  K.] 

4. — A.  C.  Roper  discusses  the  diagnosis  of  the  various 
abdomir.ll  conditions  which  may  give  rise  to  perforative 
peritonitis,  and  the  best  time  to  operate  in  such  cases.  In 
perforation  of  gastric  ulcer  the  four  principle  signs  are  rig- 
idity, tenderness,  the  presence  of  fluid  in  the 
flanks,  and  free  gas  in  the  peritoneum,  to  which 
of  course  are  added  pain  and  the  signs  of 
collapse.  These  symptoms  are  very  apt  to  be 
followed  by  amelioration  which  is  oftentimes  misleading. 
It  is  during  this  period  of  improvement,  when  rigidity  is 
being  followed  by  distension,  when  tenderness  is  less,  when 
there  is  no  passage  of  flatus,  that  operation  should  be  done. 
Roper  thinks  that  it  is  better  not  to  operate  immediately 
during  the  shock  which  follows  perforation  of  a  gastric 
ulcer,  but  to  relieve  the  pain  and  treat  the  shock,  all  of 
which  can  be  done  while  preparation  is  being  made  for 
operation.     In   any  form   of  perforative  peritonitis  opium 


must  be  given  at  first  to  relieve  the  suffering,  but  a  diag- 
nosis should,  if  possible,  be  made  before  the  drug  is  ad- 
ministered.    [J.  H.  G.] 

6. — Coates  discusses  the  cause  and  treatment  of  profuae 
epistaxis  in  people  beyond  middle  age.  He  gives  a  briet 
report  of  5  cases  and  states  that  the  sequence  of  eventt 
leading  up  to  the  epistaxis  was  similar  in  all  cases,  namely 
(1)  High  arterial  tension;  (2)  sudden  cardiac  failure 
either  due  to  loss  of  power  of  the  cardiac  muscle,  or  froH 
the  giving  way  of  valve:  (3)  overdistension  of  the  whoU 
venous  system:  d)  leakage  following  from  an  over  dis 
tended  vein.  The  author  states  that  a  question  whicl 
naturally  presents  itself  is.  Why  should  only  some  indi 
viduals,  suffering  from  circulatory  diseases  develop  epis 
taxis.  The  most  plausible  explanation  for  this  is  that  th« 
relatively  weakest  point  in  those  indivduals,  complaininj 
of  epistaxis,  is  probably  in  the  venous  sinuses  of  the  nose 
From  the  standpoint  of  treatment,  (of  these  cases  of  epis 
taxis),  the  most  satisfactory  measures  will  be  those  whicl 
tend  to  relieve  the  passive  venous  distension  by  keepini 
down  the  high  blood  pressure  and  by  strengthening  th< 
weakened  heart  muscle.  In  most  cases  plugging  of  tli< 
nostrils  is  unnecessary,  as  the  hemorrhage  can  be  con 
trolled  without  resorting  to  this  procedure,  which  is  alwayi 
uncomfortable  to  the  patient  and  may  even  prove  danger 
ous.  The  drugs  which  prove  to  be  quite  effective  are  niiro 
glycerine,  amyl-nitrite,  strychnia,  and  strophantus.  [F..J.K. 

5. — Stone  reports  a  case  of  catalepsy  alternating  witt 
violent  mental  excitement,  occurring  in  a  married  woman 
27  years  of  age.  The  condition  had  existed  for  some  timi 
before  the  author  observed  the  case,  which  was  on  No 
vember  15.  1900.  The  attacks  seemed  to  occur  at  or  aboir 
the  menstrual  period.  During  one  of  the  menstrual  periodi 
she  passed  a  membranous  cast  of  the  uterine  cavity  an( 
said  that  this  had  occurred  some  months  previously.  Th< 
patient  also  complained  of  dysmenorrhea  and  menorrhagia 
Recovery  seemed  to  follow  dilatation  of  the  cervix  ant 
curetteir.ent  of  the  uterus.     [F.  J.  K.] 

7. — Charles  A.  Morton  reports  a  case  of  diffuse  periton 
itis,  the  result  of  a  perforated  appendix,  which  recovere< 
after  operation  and  thorough  drainage.  The  case  is  in 
teresting  because  it  shows  the  danger  of  delaying  opera 
tion  in  patients  who  have  suffered  from  previous  attacks  o 
appendicitis.  In  this  instance  the  patient  har  three  pr« 
vious  attacks.  On  the  first  day  it  was  thought  that  tli' 
patient  might  recover  from  his  attack  and  no  operation  wa 
advised.  48  hours  after  the  commencement  of  the  attach 
there  was  distension,  more  general  tenderness  and  abdoir 
inal  breathing  had  disappeared.  All  of  the  lower  ponioi 
of  the  peritoneal  cavity  was  found  to  be  involved  and 
large  quantity  of  pus  was  evacuted  from  the  pelvis.  [JH.G. 

8. — Bartlett  gives  a  detailed  report  of  a  case  of  phthisi 
and  discusses  the  value  of  open  air  treatment  at  hom« 
The  patient,  age  38.  the  wife  of  a  baker,  residing  in  th 
country  two  miles  from  a  small  town,  complained  f 
cough  and  expectoration,  shortness  of  breath,  severe  nigb 
sweats,  weakness  anorexia,  and  had  lost  weight.  Fevf 
was  present:  well  marked  physical  signs  of  consolidation  1 
the  upper  lobe  of  the  left  lung  and  cavity  formation  wer 
elicited.  Tubercle  bacilli  were  found  in  the  sputum.  Th 
author  advised  open  air  treatment  Improvement  graduall 
followed:  the  patient  gained  weight  fever  subsided  an 
tubercle  bacilli  disappeared  from  the  sputum.    [T.  J.  K.] 


MEDICAL     RECORD. 
ilau  ith.  19'il. 

1.  The   Operation   for  Radical   Cure  of   Inguinal   Hemli 

CAMPBELL  FORD. 

2.  Varicella  in  Adults.     ALVAH  H.  DOTY. 

3.  A  Plea  for  the  Conservation  of  Breast  Milk  in  'Whole  o 

in  Part.     THOMAS  S.  SOUTHWORTH. 

4.  On    Bandages   for   Nephroptosis.     GEORGE    M.    EDI 

BOHLS. 

5.  'Version.  Indication.  Technique.  Limitation.     S.  MAR> 

6.  Axis-Traction  Forceps.     EGBERT  H.  GRANDIN. 

7.  Caesarean  Section.    ED'WIN  B.  CRAGIX. 

1. — Campbell  Ford  has  had  the  opportunity  of  belB 
j  present  at  operations  performed  for  the  radical  cure  of  ii 
guinal  hernia  by  Bassini.  Lucas-Championniere.  De  Garrm 
Coley  and  Broca  which  he  describes.  He  approves  of  O 
Garmo's  method  of  using  kangaroo  tendon  as  suture  iw 
terlal  or,  in  lieu  of  It  silk,  and  also  endorses  this  surgeom' 


Mat  11,  1901j 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
L  Medical  Journal 


915. 


metliod  of  suturing  the  external  oblique  and  the  pillars  of 
the  ring  by  taking  a  wide  stitch.  He  advocates  the  use  of 
a  Reverdin  needle  and  the  square-knot  stitch  for  the  deepest 
layer  and  also  uses  the  lap  insertion.     [T.  L.  C] 

2. — Alvah  H.  Doty  states  that  the  prevalent  belief  that 
chickenpox  does  not  affect  adults  is  erreoneus.  He  be- 
lieves that  it  occurs  in  typical  form  in  adults  and  discusses 
the  character  of  the  eruption,  the  manner  in  which  it  ap- 
pears and  its  distribution  or  location.  Even  in  mild  cases 
of  smallpox  the  hands  and  feet  are  to  some  extent  in- 
volved, but  in  chickenpox,  even  with  a  profuse  eruption 
this  is  uncommon.  The  back  presents  the  best  surface  to 
study  the  eruption  of  varicella.     [T.  L.  C] 

3. — T.  S.  Southworth  makes  a  plea  for  the  conservation 
of  breast  milk  in  whole,  or  in  part.  The  cases  in  which 
the  breast  milk  is  thought  to  be  at  fault  may  be  of  two  va- 
rieties. In  the  first  are  those  children  who  appear  to  be 
gaining  satisfactorily  in  weight  but  are  suffering  from  colic, 
vomiting,  crying  or  disturbed  stools.  It  is  necessary  to  de- 
termine whether  the  child  is  still  gaining  weight,  and  if 
this  is  the  case  the  other  ills  may  usually  be  remedied.  The 
diet  of  the  mother  must  be  investigated  and  regular  period 
of  nursing  insisted  upon.  In  the  second  class  are  included 
those  children  who  do  not  appear  to  thrive  on  breast  milk, 
and  who  in  addition  to  their  small  weight  may  present 
symptoms  of  irritability  and  indigestion.  In  these  cases 
accurate  weighing  of  the  child  every  second  day  is  im- 
portant. It  is  necessary  to  examine  the  mother's  breasts, 
correct  her  diet,  insist  upon  regular  periods  of  nursing  and 
these  simple  methods  will  frequently  be  followed  by  im- 
provement in  the  child's  condition.  Should  they  fail  sup- 
plementary feeding  may  be  resorted  to.     [T.  L.  C] 

4. — G.  M.  Edebohls  describes  the  various  bandages  for 
nephroptosis.  The  bandages  for  this  condition  may  be  divid- 
ed into  two  general  classes.  Simple  bandages  and  apparatus 
embodying  the  feature  of  a  special  kidney  pad.  The  simple 
bandages  act  by  supporting  the  entire  contents  of  the  abdo- 
men and  more  or  less  immobilizing  the  moveable  kid- 
ney on  the  intestinal  mass.  All  of  the  relief 
derived  from  bandages  encircling  and  sustaining 
the  lower  two-thirds  of  the  abdomen,  or  from  a  long 
and  low  reaching  corset  have  the  same  object  The 
relief  obtained  will  depend  upon  the  presence  and  the  de- 
gree of  anv  associated  enteroptosis.  The  greater  the  de- 
gree of  this  condition  the  better  are  the  prospects  of  re- 
lief from  bandage  or  corset.  When  movable  kidney  exists 
without  general  enteroptosis  no  form  of  apparatus  will 
prove  satisfactory.  The  writer  believes  that  all  appliances 
with  special  kidney  pads  or  trusses  are  useless  and  inju- 
rious, and  that  the  operation  of  nephropexy  is  indicated 
when  relief  of  symptoms  cannot  be  obtained  from  a  simple 
bandage  or  corset.     [T.  L.  C] 

..5. — The  indications  for  version,  according  to  Marx,  are: 
1.  Malpositions  and  malpresentations;  2.  contracted  pelvis, 
either  relatively  or  absolutely  so;  3.  Prolapsus  funis  or  al- 
lied conditions;  4.  For  all  other  unclassified  conditions, 
such  as  placenta  previa:  5.  Except  under  very  rare  condi- 
tions in  all  cases  in  which  the  head  remains  above  the 
brim;  the  exception  being  in  those  cases  in  which  there  is 
present  a  uterine  rupture  or  a  very  much  thinned-out  lower 
uterine  zone  showing  plainly  the  contraction-ring  of  Bandl. 
Finally,  it  may  be  stated  in  general  terms  that  version  is 
indicated  in  all  cases  in  which  the  life  of  the  mother  is 
threatened,  as  by  uremic  convulsion  or  an  embolus  of  the 
lung.  Under  these  conditions  a  dilatable  or  one  that  is 
fully  dilated  must  be  presupposed.  When  the  latter  con- 
ditions do  not  obtain  the  version  must  be  immediately  an- 
ticipated by  a  rapid  manual  dilatation  or  a  deep  Duehrssen's 
incision  of  the  os.  The  lowest  limit  for  a  deliberate  elec- 
tive version  would  be  in  the  case  of  a  pelvis  whose  true  con- 
jugate is  at  or  above  3%  inches  in  the  presence  of  an  aver- 
age size  or  small  child.  The  extreme  lowest  limit  in  the 
Walcher  position  is  3  inches.  Marx  believes  that  the  opera- 
tion of  symphysiotomy  finds  no  indication  in  pelvic  contrac- 
tion.    [W.   A.   N.   D.] 

6. — Gardin  remarks  that  forceps  applications  is  conveni- 


ently divided  into  high,  median  and  low.  For  the  purpose 
of  low  application  any  type  of  forceps  should  answer,  and 
similarly  in  the  case  of  median  application  in  instances  in 
which  deficiency  in  the  expelling  force  is  at  the  bottom  of 
the  retardation  in  labor.  High  application  in  his  hands  is 
limited  to  instances  in  which  the  membranes  have  ruptured 
and  the  presenting  part  has  just  engaged.  The  axis-trac- 
tion instrument  should  fulfil  the  following  indications:  1. 
Traction  in  the  correct  axis;  2.  traction  with  expenditure 
of  the  least  effort  on  the  part  of  the  operator;  3.  Traction 
with  the  least  compression  of  the  fetal  head;  4.  Traction 
with  the  least  interference  with  normal  mechanism  (e.  g., 
rotation) ;  5.  Traction  with  the  least  consequent  damage 
to  the  maternal  parts.  The  rules  governing  the  application 
of  the  axis-traction  forceps  are  similar  to  those  associated 
with  other  types.  In  high  application  the  blades  are  ap- 
plied to  the  sides  of  the  pelvis;  in  median  application  to 
the  sides  of  the  fetal  head.     [W.  A.  N.  D.] 

7. — Cragin  records  a  series  of  9  cases  of  Caesarean  section 
which  illustrate  the  various  indications  for  the  operation. 
He  remarks  that  a  deliberate  craniotomy,  or  endryotomy 
upon  a  living  child,  with  the  mother  in  good  condition.  Is 
justifiable  only  in  conditions  of  emergency  and  extreme 
infrequence.  He  admits  that  in  private  practice  the  ob- 
stetric surgeon  must  be  governed  largely  by  the  wishes 
of  the  family  and  friends  of  the  patient  who  may  prefer  a 
craniotomy  to  a  Cesarean  section.  There  are  two  periods 
when  the  question  of  delivery  by  a  cutting  operation  pre- 
sents itself  for  acceptance  or  rejection:  1.  Early  in  preg- 
nancy when  a  prognosis  of  a  difficult  or  obstructed  labor  is 
made;  2.  in  labor,  difficult  or  obstructed.  At  the  time  of  la- 
bor several  questions  present  themselves:  1.  Can  the 
woman  be  delivered  of  a  living  child  by  forceps  or  version? 
2.  Is  the  woman  in  good  condition?  3.  Is  the  child  in  good 
condition?  If  the  first  question  is  answered  in  the  af- 
firmative the  cutting  operation  should  not  be  considered. 
If  the  woman  is  in  a  poor  condition  Cesarean  section 
should  yield  to  a  craniotomy  be  the  child  living  or  dead. 
If  the  child  is  in  poor  condition  all  cutting  operations  upon 
the  mother  should  yield  to  craniotomy,  unless  the  parturient 
canal  is  so  obstructed  that  delivery  by  craniotomy  would 
expose  the  woman  to  greater  danger  than  Cesarean  section. 
The  latter  operation,  viewed  from  the  standpoint  of  mor- 
tality, ease  and  rapidity  of  convalescence  and  ease  of  the 
surgeon,  deserves  the  preference  over  symphysiotomy.  [W. 
A.  N.  D.] 


NEW  YORK   MEDICAL  JOURNAL. 

Mai/  },th,    tool.      (Vol.   L'XXIII,   No.   IS.) 

1.  Abdominal      Pain      in      Tvphoid      Fever.        THOMAS 

McCRAE. 

2.  Spinal  Anesthesia   by  Cataphoresis.     J.   J.   LEONARD 

CORNING. 

3.  The  Pathology  and  Bacteriology  of  the  Uretero-intes- 

tinal  Anastomosis.    F.  ROBERT  ZEIT. 

4.  The    use    of    the    Suprarenal    Capsule    in    Diseases    of 

the  Heart.     SAMUEL  PLOERSHEIM. 

5.  The   Law    and    the   Inebriate:    with   Remarks    on   the 

Treatment  of  Inebriety.    JOSEPH  COLLINS. 

1. — McCrae  sums  up  the  cases  in  which  there  was  ab- 
dominal pain  in  typhoid  fever  as  follows:  (1)  About  two- 
fifths  of  patients  were  without  pain,  one-fifth  had  tender- 
ness, two-fifths  had  pain  sometime  during  the  disease,  and 
one-third  had  pain  through  the  entire  course:  (2)  Pain 
due  to  some  condition  other  than  the  specific  bowel  lesions 
was  present  in  about  14  per  cent,  of  all  cases  and  in  about 
two-fifths  of  the  patients  having  pain  during  the  course; 
(3)  Pain  occurred  with  hemorrhage  or  perforation  in 
about  .5''r  of  all  cases  and  in  about  15%  of  the  cases  in 
which  there  was  pain  during  the  course:  (4)  Pain  was  most 
constantly  present  with  perforation,  when  it  was  sudden  in 
onset,  severe  in  character  and  paroxysmal  in  occurrence.  The 
painof  perforation  was  most  closely  simulated  by  that  occur- 
ing  in  somecasos  of  hemorrhage,  tliat  from  phlebitis. and  that 
of  unknown  origin:  (5)  In  about  two-fifths  of  all  cases 
with  pain  during  the  course  no  cause  could  be  found. 
Should  this  occur  with  other  abdominal  symptoms  the 
condition  may  much  resemble  perforation.     [T.  M.  T.] 


Cjf,       The  Philadelphia'] 
y    "       Medical.  Jouknal   J 


AMERICAN  NEWS  AND  NOTES 


[siat  11,  iscn. 


2. — Dr.  Corning  proposes  to  produce  spinal  anesthesia 
by  cataphoresis  in  ilie  following  manner:  The  apparatus 
consists  of  a  tube  four  inches  long,  terminating  at  one  end 
in  a  small  metal  bulb,  pierced  to  give  passage  to  a  tube  of 
smaller  calibre,  upon  passing  the  latter  down  through  the 
larger  tube.  At  the  other  ( upper j  end  of  the  larger  tube 
is  a  binding-post  for  securing  the  conducting  cord  (posi- 
tive pole)  of  a  galvanic  batterj-.  The  smaller  tube,  which 
projects  an  inch  and  a  quarter  beyond  the  upper  end  of  the 
larger  tube,  is  provided  with  the  socket  requisite  to  attach 
it  to  a  hypodermic  syringe  (glass).  A  diminutive  metal 
collar,  sliding  along  the  smaller  tube  between  the  socket 
and  the  upper  end  of  the  larger  tube,  may  be  kept  in  place 
at  any  point  by  the  aid  of  a  small  set-screw.  By  this  device 
it  is  possible  to  regulate  accurately  the  distance  to  which 
the  small  tube  shall  be  thrust  beyond  the  bulbous  end  of 
the  larger  tube  fabout  half  a  centimetre).  The  lower  end 
of  the  smaller  tube  has  no  bevel  whatever,  and  is  slightly 
rounded  at  the  edges.  The  larger  (outer)  tube  is  insulated 
throughout  its  entire  length,  save  at  the  bulb,  which  is 
bare.  He  proposed  to  introduce  the  larger  (insulated) 
tube  between  the  spinous  processes  of  the  third  and  fourth 
lumbar  vertebra  till  the  metal  bulb  was  stopped  by  the 
ligamentum  subflavum,  then  to  thrust  forward  the  inner 
tube  sufficiently  to  pierce  the  ligament,  yet  leave  the 
dura  and  arachnoid  unscathed,  a  thing  very  easily  done: 
as  these  membranes,  bolstered  only  by  the  yielding  cere- 
brospinal fluid,  would  inevitably  give  before  the  rounded 
end  of  the  small  tube,  which  could  at  most  indent,  but 
never  pierce  them.  Once  having  pierced  the  ligamentum 
subflavum,  attach  the  syringe  to  the  small  tube,  and 
inject  the  anesthetic  upon  the  dura.  This  done,  unscrew 
the  syringe,  withdraw  the  smaller  tube,  secure  the  positive 
conducting  cord  of  a  galvanic  battery  to  the  binding-post 
of  the  larger  tube — the  negative  sponge  of  the  battery  be- 
ing already  over  the  abdomen — cause  the  current  to  pass. 
The  cataphoretic  action  thus  resulting  would,  he  hoped, 
materially  aid  the  passage  of  the  anesthetic  through  the 
membranes.     [T.  M.  T.] 

4. — Floersheim.  in  his  article  on  the  use  of  the  suprarenal 
capsule  in  diseases  of  the  heart,  advises  the  use  of  the 
dried  and  powdered  gland,  which  can  be  kept  indefinitely. 
He  places  it  in  a  gelatine  capsule,  as  the  tablet  form  is 
useless.  The  dose  is  three  grains,  but  larger  doses,  one 
drachm  or  more,  are  not  injurious.  In  administering,  the 
capsule  must  be  thoroughly  chewed,  dissolved  in  the  mouth 
and  swollowed  without  water.  For  children  he  advises  an 
emulsion  by  the  mouth,  three  grains  of  the  powder  mixed 
in  a  little  water  in  a  teaspoon.  The  action  of  the  extract 
became  apparent  in  less  than  five  minutes.  The  effect 
continues  from  five  minutes  to  three  hours  or  longer.  It  is 
not  poisonous  and  has  no  accumulation  effect  like  digitalis, 
and  does  not  act  upon  the  nervous  system.     [T.  M.  T.] 


MEDICAL    NEWS. 
May  :,.  1901.     (Vol.  LXXVIII.  No.  18.) 

1.  Medical  Department  of  the  University  of  Pennsylvania. 

CHARLES  W.  DULLES. 

2.  A  Report  of  Twenty-four  Operations  Performed  during 

Spinal     Analgesia.        WILLIAM      SEAMAN      BAIN- 
BRIDGE. 

3.  Some  Sources  of  Error  in  Labratory  Clinical  Diagno- 

sis.   THEODORE  C.  JANEWAY. 

2. — Bainbridge,  in  his  article  on  spinal  analgesia,  prefers 
cocain  to  eucain  for  the  following  reasons:  (1)  The  latter 
is  less  potent,  more  evanescent,  the  areas  of  analgesia  are 
frequently  "patchy."  Cocain  produces  no  more  unpleasant 
after  effects  and  it  decidedly  more  reliable:  (2)  Analgesia 
to  the  level  of  the  diaphragm  can  be  depended  upon  in  all 
cases  in  which  it  is  introduced  by  lumbar  puncture.  In 
some  instances  the  analgesia  is  sufficient  for  operations  on 
the  upper  extremities:  (3)  Complete  analgesia,  including 
eyes,  nose  and  throat  has  occurred:  (4)  Preparation  of 
the  patient  as  for  a  general  anesthetic  diminishes  all  the 
unpleasant  effects  and  often  prevents  them:  (5)  By  moder- 
ate doses  of  bromide  before  injection  the  initial  vomiting  is 
frequently  avoided  and  liability  to  headache  lessened:  (6) 
Hysterical  symptoms  occur,  but  as  a  rule,  a  few  moments  af- 
ter the  injection  the  patient  becomes  quiet:  (7)  Initial  nausea 
and  vomiting  often  occur  soon  after  injection,  but  only  last 
for  a  moment  and  usually  do  not  happen  during  opera- 
tion: (S)  Analgesia  lasts  from  thirty  minutes  to  four  hours: 
(9)    Depression   after  puncture  is   inconsiderable.     Ethyl 


chloride  largely   prevents  pain  when  the  needle  is  intro- 
duced;  (10)  Using  nitroglycerine  by  hypodermic  injection, 
or  one  of  the  coal-tar  products  with  caffeine,  controls  the 
headache;    (11)  There  may  be  motor  paralysis  or  vertigo, 
but  both  are  temporary;   (12)  Spinal  puncture  has  no  effect 
on  normal  or  diseased  kidneys;    (13)    Usually  the  tactile 
power,  muscular  sense,  and  the  abiUiy  to  detect  heat  and 
cold  are  retained;    (14)   The  patient  generally  sleeps  the 
I   first  night;    (15)   Often  slight  temperature  within  eight  or 
■  ten  hours  after  operation.    The  circulation  and  respiration 
'   are  not  seriously  embarrassed.     [T.  M.  T.] 

3. — Janeway  considers  that  the  sources  of  possible  error 
(  in  the  application  of  laboratory  methods  to  diagnosis  are 
I  those  due  to  the  methods  themselves  or  faulty  technique 
I  in  their  use  and  those  due  to  inaccurate  reasoning  from 
accurate  results.  He  also  gives  a  few  of  the  commoner 
sources  of  error.  (1)  In  testing  for  albumin,  one  of  the 
most  frequent  is  not  filtering  the  urine,  as  it  is  absolutely 
impossible  to  make  a  delicate  test  without  it;  also  in 
Heller's  test  where  there  is  a  small  quantity  of  albumin, 
the  test  should  not  be  discarded  until  at  least  fifteen  min- 
utes have  elapsed.  In  the  heat  and  acid  test  the  upper 
part  of  the  urine  should  be  boiled  and  acid  added  so  that 
a  comparison  can  be  made  with  the  clear  urine.  Tests 
made  by  dropping  the  solution  into  the  urine  should  al- 
ways be  judged  by  the  side  of  a  tube  of  filtered  urine. 
The  acetic-acid  and  ferrocyanide  test  needs  a  special  check, 
not  with  clear  urine  but  with  urine  to  which  acetic  acid 
has  been  added.  In  diagnosis  of  diseases  of  the  urinary 
apparatus  the  detection  of  serum  albumin  and  globulin, 
and  possibly  abnormally  large  amounts  of  neuclio-albumin 
is  important,  and  the  most  reliable  tests  for  these  sub- 
stances are  Heller's,  the  acetic  acid  and  potassium  ferro- 
cyanide tests:  (2)  In  testing  for  sugar,  he  does  not  con- 
sider the  Fehling's  test  as  reliable  as  the  polariscope,  fer- 
mentation and  phenyl-hydrazin  reaction,  and  only  uses  it 
for  excluding  the  presence  of  the  sugar,  as  various 
drugs,  rhubarb,  salicylates,  camphor,  etc. .will  give  some  sort 
of  reduction.  Another  common  error  is  in  connection  with 
specific  gravity,  concluding  that  urine  does  not  contain 
sugar  when  it  is  10.20  or  below.  Still  another  error  is 
overlooking  the  significance  of  urine  of  constant  low  sj)€ci- 
fic  gravity.  This  he  states,  strongly  points  to  the  exis- 
tance  of  contracting  kidney.  He  advises  urine  to  be  ex- 
amined to  be  procured  at  three  different  times — morning, 
late  afternoon  and  on  retiring,  instead  of  taking  the  whole 
twenty-four  hours'  urine.  (3)  In  examination  for  urea  the 
greatest  difficulty  is  the  inaccuracy  due  to  decomposition 
of  the  urine,  especially  in  summer,  causing  considerable 
loss.  (4)  In  the  examination  of  the  sputum  the  physician 
always  looks  for  tubercle  bacilli,  when  in  the  unstaine<1 
expectoration  Charcot-Leyden's  crystals  and  Curschmann's 
spirals  can  be  found,  fo)  In  the  blood  examination  not 
enough  attention  is  paid  to  the  marked  leucocytosis  present 
In  continued  fevers,  which  points  to  the  existence  of  sepsis, 
and  in  the  diagnosis  of  appendicitis  their  increase  should 
give  more  weight  to  the  diagnosis.     [T.  M.  T.] 


BOSTON    MEDICAL  AND  SURGICAL  JOURNAL. 


May 


19'Jl. 


1.  Contusions    of    the    Abdomen.      CHARLES    L.    SCtTD- 

DER. 

2.  Observations  on  the  Use  of  Antistreptococcus  Serum  in 

the  Treatment  of  Puerperal  Sepsis  with  a  Report  of 
Five  Cases.     FRANK  A.  HIGGINS. 

3.  A  Case  of  Caesarean  Section.  Complicated  by  Uterine 

Fibroid.     EMMA  S.  CALL. 

1. — Scudder  discusses  the  treatment  of  contusions  of  the 
abdomen,  and  especially  a  group  of  acute  abdominal  emer- 
gencies due  to  traumatism.  Injuries  to  the  ureter  in  addi 
tion  to  the  general  symptoms  of  shock,  which  may  subside 
within  a  few  hours,  are  characterized  by  little  blood  ap 
pearing  in  the  urine  and  perhaps  only  an  occasional  clot. 
If  no  lesion  of  an  abdominal  organ  accompanies  rupture  of 
the  ureter,  no  very  great  symptoms  will  be  manifested. 
Transient  hematuria  should  not  be  overlooked,  especially 
with  persistent  pain  in  the  side.  Treatment  is  briefly 
described.  Rupture  of  the  urinary  bladder,  of  the  liver, 
contusions  of  the  kidney.  Injury  to  the  stomach,  rupture 
of  the  intestines,  lacerations  of  the  spleen,  injuries  to  the 
pancreas,  shock,  hemorrhage  and  peritonitis  are  described. 
He  calls  attention  to  the  shook  which  is  present  in  almost 
every  abdominal  contusion  of  consequence.     Shock  T&rlee 


May  11,  I0,)1] 


THE  LATEST  LITERATURE 


U 


The  Philadelphia 
MEDICAL  Journal 


917 


in  individuals  affected  by  tlie  same  lesion  according  to  tlie 
temperament  and  nationality  of  the  patient.  An  absence 
of  shock  does  not  signify  the  absence  of  a  serious  lesion. 
The  conditions  of  the  pulse,  and  temperature  are  dis- 
cussed as  diagnostic  factors.  When  the  pain  depends 
upon  the  hemorrhage  other  signs  of  hemorrhage  will  ac- 
company the  pain.  Tenderness,  vomiting,  distension  and 
rigidity  of  the  abdominal  muscles  are  carefully  consid- 
erd.     [M.  R.  D.] 

2. — Higgins  reports  his  observations  on  the  use  of 
antlstreptococcus  serum  in  the  treatment  of  puerperal 
sepsis  with  a  report  of  five  cases.  His  observations  are 
confined  to  the  use  of  the  serum  in  five  cases  occurring  dur- 
ing the  past  year.  He  thinks  that  we  cannot  fail  to  be 
disappointed  in  the  result  of  the  serum  treatment  and 
are  obliged  to  conclude  that  as  a  curative  agent  its 
power  is  limited.  The  author  believes  that  the  serum 
has  a  marked  depressing  effect  upon  the  patient  and  is 
not  to  be  indiscriminately  administered  to  a  very  sick 
patient  repeatedly  and  in  large  quantities,  as  is  sometimes 
done  in  following  the  directions  that  come  with  the 
serum.  He  further  believes  that  the  serum  treatment 
has  no  position  in  the  routine  treatment  of  puerperal  sepsis 
that  it  should  only  be  employed  in  such  desperate  cases 
after  one  has  failed  to  obtain  improvement  by  other  effi- 
cient remedies,  and  that  if  then  no  improvement  is  mani- 
fested within  two,  or  at  the  most  three  days  after  40-60 
ccm.  have  been  used,  it  should  be  discontinued.     [M.  R.  D.] 

3. — E.  S.  Call  reports  a  case  of  Caesarean  section  in  a 
case  of  face  presentation  complicated  by  uterine  fibroid. 
The  patient,  aged  20,  in  her  second  labor  was  an  apparent- 
ly healthy  woman,  whose  first  labor  15  months  before 
had  been  apparently  normal  and  not  unusually  protracted. 
Upon  e.xammation  the  os  was  found  dilated  about  the  size 
of  a  silver  dollar,  the  membranes  still  unruptured  but 
relaxed,  and  the  face  of  the  child  presenting  in  the  right 
mento-posterior  position,  but  still  above  the  brim  of  the 
pelvis.  Ordinary  manipulations  having  failed  and  the 
life  of  the  child  being  in  jeopardy.  Caesarean  section  was 
performed  by  Dr.  Alexander.  After  the  incision  an  inter- 
stitial fibroid  was  discovered.  The  results  were  entirely 
satisfactory.     [M.  R.  D.) 


JOURNAL  OF  AMERICAN  MEDICAL  ASSOCIATION. 

May  >,fh,  IDOL 

■  1.     The  Gvromele  in  the  Diagnosis  of  Stomach  and  Ihtes- 
tinai  Diseases.     KENTON  B.  TURCK. 

2.  A  New  Operative  Method  to  Expose  the  Seminal  Vesi- 

cles and  Prostate  Gland  for  Purposes  of  Extirpation 
and  Drainage.  A  Preliminary  Report.  EUGENE 
FULLER. 

3.  Myasthenia  Gravis  Pseudoparalytica  (Asthenic  Bulbar 

Paralysis).    J.  T.  BUIST  and  E.  G.  WOOD. 

4.  Limitations  of  the  Laryngologist  in  the  General  Treat- 

ment of  Nose  and  Throat  Diseases.     H.  W.  LOEB. 

5.  Absolute  Increase  of  Measurement  from   the  Anterior 

Superior  Spine  to  the  Malleolus  as  a  Sign  of  Hysteric 
Hip  Disease.     JAMES  JACKSON  PUTNAM. 

6.  A  Case  of  Transient  Motor  Asphasia,  Complete  Anomia, 

Nearly  Complete  Agraphia  and  Word-blindness  Oc- 
curring in  a  Left-Handed  Man;  with  Special  Ref- 
erence to  the  Existence  of  a  Naming  Center, 
CHARLOSS  S.  POTTS. 

7.  The  Pharmacology  of  the  Nitro-Sugars.     C.   R.   MAR- 

SHALL. 

8.  The     Classical     Cesarean     versus      Porro       Cesarean. 

GEORGE  M.  BOYD. 

9.  Ocean  Climates;  Their  Effects  and  the  Cases  they  Ben- 

efit. JOHN  A.  ROBINSON. 

10.  Adhesive  Rubber  Dam  for  the  Prevention  of  Possible 

Infection  at  the  Site  of  Operation.  J.  B.  MUR- 
PHY. 

11.  The    Present    Status    of    Spinal    Surgery.      SAMUEL 

LLOYD 
1. — Turck  mentions  the  usefulness  of  the  gyromele  in 
the  diagnosis  of  stomach  and  intestinal  diseases.  The 
gyromele,  or  revolving  sound,  is  made  of  a  flexible  steel 
cable,  the  end  of  a  more  flexible  steel  spiral,  and  the  tip 
of  the  spiral  steel  is  provided  with  a  metallic  pellet  covered 
hy  a  sponge,  cotton,  or  lamb's  wool.  A  revolving  apparatus 
is  fastened  to  the  sound.  The  scope  of  usefulness  of  the 
gyromele  is  not  restricted  to  the  investigations  of  the 
stomach  alone;    the  nose  and  throat,  the  esophagus,  the 


pylorus  and  the  small  intestine,  the  colon,  the  bladder, 
the  uterus,  the  thoracic  cavity,  and  false  cavities  of  various 
kinds  have  all  been  successfully  explored.     [E-  J-  K.J 

2. — Eugene  Fuller  describes  an  original  operation  for 
gaining  access  to  the  seminal  vesicles  and  prostate  gland. 
The  patient  is  placed  upon  the  table  with  his  face  and 
abdomen  down  and  his  thighs  flexed  upon  the  abdomen 
astride  of  the  table.  The  portion  of  the  table  which  sup- 
ports the  pelvis  is  then  elevated  as  in  the  Trendelenburg 
position.  The  incision  extends  on  either  side  of  the  anus 
along  the  inner  side  of  the  tuber  ischl,  and  is  connected 
by  a  transverse  cut  across  the  perineum  about  %-inch 
anterior  to  the  anus.  The  rectum  is  then  carefully  lifted 
up  and  separated  from  the  urethra  and  bladder  by  careful 
dissection.  The  finger  in  the  rectum  enables  the  operator 
to  avoid  wounding  this  organ.  Fuller  has  used  this  method 
on  five  occasions  for  operations  of  various  kinds  upon  the 
seminal  vesicles,  and  has  found  it  most  satisfactory.  His 
article  is  illustrated  by  three  cuts  which  show  the  position 
on  the  table  and  the  line  of  incision.     [J.  H.  G.] 

3. — Buist  and  Wood,  in  an  article  on  myasthenia  gravis 
pseudoparalytica,  state  that  little  is  known  of  the  etiology 
and  pathology  of  this  disease.  It  is  characterized  by  mus- 
cular weakness,  rapidly  coming  on  exhaustion,  and  the 
presence  of  the  myasthenic  reaction.  The  bulbar  muscles 
are  not  only  affected,  but  also  those  of  the  eye  and  ex- 
tremities. Exacerbation  and  remissions,  varying  in  inten- 
sity from  day  to  day.  are  of  common  occurrence.  The  in- 
tellectual and  sensual  powers  are  not  impaired,  and  the 
reflexes  are  undisturbed.  Muscular  atrophy,  fibrillar 
twitching,  sensory  disturbances,  reaction  of  degenera- 
tion, and  bladder  and  rectal  troubles  are  not  features  of  this 
disease.  The  cranial  nerve  muscles  are,  as  a  rule,  the 
first  involved;  ptosis  or  diplopia  being  early  manifesta- 
tions. In  some  cases  permanent  paralysis  develops,  which 
may  affect  any  of  the  voluntary  muscles.  It  is  a  remark- 
able fact  that  with  such  pronounced  motor  defects  often 
terminating  fatally,  there  is  complete  absence  of  so  many 
of  the  signs  of  organic  disease  of  the  nervous  and  muscular 
systems.  Out  of  63  cases  there  were  23  fatal  ones.  There 
are  no  known  remedies  which  seem  to  influence  the  course 
of  this  disease.  The  article  is  concluded  with  a  report  of 
a  case.     [F.  J.  K.] 

4. — Loeb  concludes  that  the  limitations  of  the  laryngolo- 
gist in  the  general  treatment  of  the  nose  and  tliroat  are 
the  following:  (1)  Nose  and  throat  conditions  of  an  acute 
character  influenced  by  measures  which  have  an  important 
local  effect;  (2)  nose  and  throat  diseases  of  a  rheumatic 
character  which,  under  appropriate  treatment,  are  relieved 
early;  (31  syphilitic  nose  and  throat  diseases,  the  general 
treatment  of  which  being  best  observed  by  watching  the 
effect  upon  the  local  lesion.  Even  under  the  conditions 
named  the  assistance  of  one  who  is  less  directed  to  local- 
ism may  be  advantageous  to  the  patient.     [F.  J.  K.] 

5. — Putnam  gives  an  account  of  a  case  of  hysteria  in 
which  there  was  an  absolute  increase  of  measurement 
from  the  anterior  superior  spine  to  the  internal  malleolus. 
After  a  prolonged  and  careful  study  the  diagnosis  of 
hysteric  hip  disease  was  made.  Marked  thickening  in  the 
region  of  the  affected  trochanter  was  noticed  after  the 
patient  had  been  under  observation  for  fifteen  months. 
This  swelling  was  believed  to  be  due  to  hysteria  edema. 
Upon  pressure  tenderness  was  present.  The  patient  im- 
proved greatly  under  treatment,  but  did  not  recover  entire- 
ly. The  author  mentions  that  the  last  account  received  of 
her  was  that  she  was  still  lame.     [P.  J.  K.] 

6. — Potts  gives  a  report  of  a  case  of  transient  motor 
aphasia,  complete  anomia,  nearly  complete  agraphia,  and 
word  blindness,  occurring  in  a  left-handed  man.  aged  42 
years,  a  coal  miner  by  occupation.  In  summing  up  the 
symptoms  the  author  states  that  there  was  loss  of  the 
power  of  naming  objects  seen,  felt  or  herd,  smelled  or  tast- 
ed. The  patient  could  not  repeat  the  name  of  an  object. 
There  was  almost  complete  word  blindness,  however,  the 
power  of  recognizing  and  reading  the  numerals  was  pre- 
served. There  was  inability  to  write  spontaneously,  except 
his  name  and  address,  and  the  power  of  writing  from 
dictation  was  veiy  imperfect,  and  to  read  from  a  copy  was 
impossible.  The  muscles  of  the  tongue  and  lower  part  of 
the  face  on  the  left  side  were  paralyzed.  From  the  sudden- 
ness of  onset  th'^  condition  was  probably  due  to  an  embo- 
lus or  hemorrhage.     [F.  J.  K.] 

8. — Boyd  remarks  that  the  life  of  the  infant  alone  under 
certain  conditions  justifies  the  Cesarean  section.  The 
classical   Cesarean  section  has  as  low  a  mortality  as  an 


qtQ       The  Philadelphia  "I 
7  Medical  Journal    J 


THE  LATEST  LITERATURE 


[May  11,  ISiOl 


easy  ovariotomy.  The  life  of  the  child  should  then  be  as 
good  a  reason  for  performing  a  simple  abdominal  section  as 
are  the  vague  symptoms  for  which  operations  are  daily 
done.  The  classical  Cesarean  section  is  less  mutilating 
than  the  Porro  Cesarean  section,  and  with  the  patient  in 
good  condition,  is  therefore  the  operation  of  choice.  The 
Porro  Cesarean  section  has  about  the  same  mortality  as 
has  hysterectomy  for  fibroids.  It  should  be  performed 
when  the  patient  demands  it  or  when  infection  or  a  neo- 
plasm of  the  uterus  makes  it  necessary.  It  is  the  duty  of 
the  practitioner  in  attendance  on  a  multipera  with  the 
history  of  one  or  more  dead  children  to  be  prepared  to 
perform  the  Cesarean  section.     [W.  A.  N.  D.] 

9. — Robison  discusses  the  beneficial  effects  of  a  sea  voy- 
age. Ocean  climates  are  more  equable  and  the  desires  of 
the  traveler  to  spend  most  of  the  time  in  the  open  air,  en- 
forces rest,  revives  the  exhausted  body,  and  creates  an 
appetite.  The  sea  air  increases  metabolism,  weight,  in- 
clination to  sleep,  and  it  also  acts  as  a  sedative  on  the 
nervous  system.     [F.  J.  K.] 

10. — J.  B.  Murphy  recommends  the  use  of  an  adhesive  rub- 
ber dam  over  the  field  of  operation  in  order  to  prevent 
possible  infection  from  the  patient's  skin.  The  dam  is 
prepared  by  Johnson  &  .lohnson,  and  is  made  to  adhere 
closely  to  the  skin  and  is  not  affected  by  any  of  the  wound 
fluids  or  by  antiseptic  solutions.  As  the  dam  adheres  close- 
ly to  the  skin  the  incision  is  made  through  it  as  if  it  were 
a  layer  of  skin  itself.  It  is  retained  in  position  until  the 
stitches  are  introduced,  and  then  it  is  removed.  A  small 
amount  of  ether  on  the  skin  of  the  patient  increases  the 
adhesive  quality.  The  author  has  found  it  useful  where 
wound  fluids  are  continually  flowing  over  the  adjacent 
skin,  as  it  here  prevents  irritation  of  the  skin.     [J.  H.  G.] 

11. — Samuel  I.loyd  concludes  his  discussion  of  the  pres- 
ent status  of  spinal  surgery  with  statistical  proof  of  his  as- 
sertion that  it  is  better  not  to  operate  immediately  after 
the  receipt  of  injuries  to  the  spine,  and  he  urges  that  when 
the  operation  is  undertaken  that  it  should  be  thorough,  all 
possible  pressure  from  the  cord  being  removed.  Shock  Is 
probably  the  greatest  danger  of  the  operation:  hemorrhage 
he  has  not  found  difficult  to  control  where  packing  has 
been  used  for  a  short  time,  the  use  of  hemostats.  however, 
only  delays  the  operation.  The  loss  of  cerebro-spinal  fluid 
possesses  no  particular  danger.  In  one  of  his  own  cases  a 
fistula  discharging  cerebro-spinal  fluid  continued  for  12 
weeks  without  inconvenience  to  the  patient.  Four  cases 
operated  upon  for  fracture  dislocation  of  the  spine  are 
added  to  the  author's  former  report  of  his  personal  experi- 
ence.    [J.  H.  G.] 


AMERICAN  MEDICINE. 
Mail  -'ith,  1901. 

1.  An  Analysis  of  my  Vaginal  Ablations  in  181  Cases  of 

Pelvic   Inflammation   and   Utrine  Fibroid   Degenera- 
tion.    W.  R.  PRYOR. 

2.  Inguinal  Hernia.     MERRILL  RICKETTS. 

3.  Vaginal  False  Membrane  due  to  Bacterium  Coll.     J.  N. 

HALL. 

4.  A  New  Series  of  Anaerobic  Bacteria.     LOUIS  LEROY. 

5.  Conclusions  from  Personal  Observations  of  Compound 

Fractures.     DOUGLAS  C.  MORIARTA. 

6.  The  Food  Value  of  Alcohol,  and   Professor  Atwater's 

Experiments  and  Teaching.     JOHN  MADDEN. 

7.  Some  Remarks  on  the  Cumulative  Action  of  Digitalis. 

with  an  Illustrative  Case.     EDWIN  ZUGSMITH. 

8.  Prolonged  Intubation.     EDWIN  ROSENTHAL. 

1. — Pryor  remarks  that  the  first  surgeons  who  brought 
the  vaginal  radical  operation  to  this  country  seemed  to 
have  abandoned  it  almost  entirely.  His  own  experience 
with  the  application  of  the  vaginal  method  of  operating, 
not  only  in  those  cases  which  require  the  radical  procedure, 
but  also  in  those  in  which  conservatism  may  be  applied  has 
been  such  as  to  convince  him  that  the  greater  proportion 
of  operations  now  performed  through  the  abdomen  could 
more  easily  and  with  better  results  be  made  through  the 
vagina.  In  the  last  six  years  he  has  been  enabled  to  cure 
by  the  vaginal  operation  S:!'';  of  all  those  who  have  applied 
to  him  and  without  mortality.  As  to  the  indications  for  the 
radical  operation  ho  does  not  consider  the  presence  of  pus 


an  Invariable  indication  for  the  removal  of  a  pus-sac.  Pus- 
foci  of  gonorrheal  origin  in  young  women  may  very  safely 
be  broadly  incised  and  allowed  to  heal  up.  This  process 
prevents  the  disagreeable  effects  of  a  percipitate  meno- 
pause. In  those  who  have  suffered  from  repeated  attacks 
the  radical  operation  is  preferable.  Ectopic  gestation  of 
one  side  associated  with  inflamed  adnexa  of  the  other  In- 
dicates ablation.  Hydrosalpinx  of  both  sides  associated 
with  many  adhesions  may  be  treated  conservatively  or  radi- 
cally according  to  the  surgeon's  judgment.  Cases  of  geni- 
tal sclerosis  indicate  a  radical  treatment.  Pryor  protests 
against  the  removal  of  one  pyosalpinx  and  leaving  the 
other  tube  although  it  be  apparently  normal.  He  opposes 
myomectomy  except  in  rare  instances.  He  remarks  that 
the  firmness  of  structure  and  charactet  of  the  vaginal 
canal  have  much  to  do  with  the  facility  of  operating  through 
the  vagina  in  fibroid  cases.  The  vaginal  method  is  parti- 
cularly applicable  in  intraligamentous  and  retroperitoneal 
fibroids  and  in  fibroids  associated  with  pus.  After  the 
operation  the  average  time  in  bed  is  about  three  weeks 
and  most  patients  return  home  within  four  weeks.  He  has 
found  no  shortening  of  the  vagina  after  vaginal  ablation 
nor  has  he  heard  any  complaint  of  dyspareunia.  [W.  A. 
N.  D.] 

2. — B.  M.  Ricketts  gives  an  anatomical  description  of  In- 
guinal Hernia  and  details  differences  of  opinions  existing 
among  surgeons  on  certain  points.  From  a  consideration 
of  the-  anatomy  of  the  structures  involved  in  inguinal  her- 
nias it  will  be  seen  that  they  lack  vascularity  and  nerve 
supply.  The  ventral  hernia  following  laparotomy  is  as- 
scribed  to  the  division  of  the  motor  nerves.  The  abdom- 
inal muscles  lose  their  innervation  and  undergo  paralysis 
and  atrophy;  hence  atrophic  and  weakened  abdominal 
walls  are  easily  protruded  in  response  to  intra-abdominal 
pressure.  In  at  least  10%  of  cases  operated  upon  the  ad- 
hesions resulting  from  the  closure  of  the  inguinal  ring 
are  inefficient.  This  is  true  with  all  kinds  of  sutures.  The 
ideal  material  for  this  purpose  is  one  of  sufficient  life  to 
permit  a  deposit  of  new  fissures  upon  the  peritoneum  ex- 
ternally. The  author  believes  after  discussing  the  merits 
and  demerits  of  the  various  sutures  commonly  employed 
that  the  use  of  a  wire  mattress  meets  all  objections  that 
can  be  urged  against  the  other  means  of  uniting  the  severed 
tissues.  He  denies  the  influence  of  infection  in  causing 
recurrence  of  hernia  and  attributes  such  an  event  to  Im- 
perfect methods.  The  views  of  Coley,  Fenger,  Marcy, 
Phelps  and  Warren  are  given,  as  to  the  cause  of  failure 
and_  the  percentage  of  recurrences  after  operations  for 
hernia.     [T.  L.  C] 

3. — Hall  records  a  case  of  vaginal  false  membrane  due 
to  the  liartrriuiii  coli  in  a  young  girl  of  14  years.  This  was 
removed  after  the  application  of  the  1:5000  bichloride  solu- 
tion, after  which  the  symptoms  disappeared.  He  remarks 
that  the  diseases  caused  by  this  bacillus  are  rather  within 
the  body  than  on  the  external  surfaces.  Thus  it  may  cause 
cystitis,  nephritis,  pyelonephritis,  perinephritis,  peritonitis, 
endocarditis,  icterus,  disease  of  the  gall-bladder,  meningitis, 
lymphangitis,  urethritis,  abscess,  sepsis,  pyemia  and  sep- 
ticemia. It  is  possible,  he  concludes,  that  other  membranes 
ordinarly  considered  diphtheric  maybefoundtobedue  to  the 
liiirtciiiim  coli.     [W.  A.  N.  D.] 

4. — Louis  Leroy  mentions  the  fact  that  the  importance  of 
Anerobic  Bacteria  has  been  overlooked  in  the  past  Fol- 
lowing a  systematic  series  of  researches  he  has  been  able 
to  isolate  14  species  of  strictly  anerobic  organisms.  These 
are  the  principal  agents  of  a  whole  series  of  affections  of 
a  gangrenous  or  putrid  nature.  They  have  been  isolated 
in  otitis,  pulmonary  gangrene,  appendicitis,  puerperal  infec- 
tion and  a  host  of  other  conditions.  These  bacteria  have 
the  property  of  causing  necrosis  in  living  tissue  and  to  pro- 
duce a  process  of  disintegration  in  them  analogous  to  pu- 
trefaction. They  not  only  act  locally  but  by  the  toxins 
which  they  secret  provoke  general  poisoning.  The  writer 
hopes  in  the  near  future  to  have  a  serotherapeutic  treat- 
ment which  will  be  rational  and  efficacious.     [T.  L.  C] 


Mat  11.  1901] 


THE  LATEST  LITERATURE 


[The  Philadelphia        qtq 
Medical  Jocksal  7-^7 


5. — D.  C.  Moriarta  presents  his  conclusions  from  personal 
observation  of  compound  fractures  with  clinical  notes  of 
5  cases.  He  urges  that  in  compound  fractures,  when  the 
pathological  condition  is  not  positively  determined,  that  the 
puncture  or  laceration  be  enlarged  and  the  bone  fully  ex- 
posed, approximated  and  held  in  position.     [T.  L.  C] 

7. — Edwin  Zugsmith  reports  a  case  illustrating  the  cum- 
ulative action  of  digitalis  in  a  female  child  of  23  months.  It 
seemed  reasonable  to  the  author  that  since  fever  is  an  ad- 
mitted hinderance  to  the  action  of  the  digitalis  if  the  child's 
temperature  could  be  raised  by  harmless  means,  the  digi- 
talis which  had  been  administered  might  be  rendered  in- 
active for  a  long  enough  time  to  prevent  its  cumulative  ac- 
tion. Hot  air  was  employed  in  the  effort  to  raise  the  child's 
temperature  but  did  not  subserve  its  purpose,  the  ther- 
mometer registering  but  99  degrees  in  the  rectum  Imme- 
diately after  the  hot  air  bath.  The  child,  however,  re- 
covered.    [T.  L.  C] 

8. — E.  Rosenthal  illustrates  a  short  article  on  prolonged 
intubation  with  the  report  of  a  case.  He  states  that  it 
should  be  a  rule  of  practice  to  remove  the  tube  within 
five  days  after  the  operation  unless  it  be  removed  by  ex- 
pectoration before,  and  then  be  no  longer  required.  All 
cases  requiring  a  tube  for  a  longer  period  than  five  days 
should  receive  large  doses  of  strychnia  and  constant  re- 
intubation  and  extubation  daily  or  every  second  day  and 
progressively  smaller  tubes  should  be  used  until  the  case 
no  longer  requires  it.     [T.  L  .C] 


BERLINER   KLINISCHE  WOCHENSCHRIFT. 

Fehrmiry    IS.    IWil. 

1.  The  Removal  of  the  Waste  'ft'ater  of  Cities.  GAERTNER. 

2.  Concerning  a  new  Method  for  Differentiating  between 

Human    and    Animal    Blood    for    Medico-Legal    Pur- 
poses.    A.  WASSERMANN  and  A.  SCHUETZE. 

3.  The  Feeding  of  Infants  with  Whole  Milk.    E.  SCHLES- 

INGER. 

4.  Abortion  with  Poisons.     G.  SCHWARZWAELT  ER. 

2. — The  authors  describe  the  results  which  they  have 
obtained  by  the  method  recently  reported  by  TJhlenhuth. 
They  injected  human  blood  serum  into  rabbits,  and  found 
that  the  blood  serum  of  the  rabbits  afterward  had  a  speci- 
fic action  upon  a  solution  of  human  blood  but  upon  no  other 
blood  excepting  that  of  apes.  The  reaction  occurred  with- 
in twenty  minutes,  or  even  earlier.  It  acted  even  with 
blood  that  had  been  dried  for  three  months,  and  under 
these  circumstances  also  was  entirely  specific.  They 
decide  that  If  a  reaction  occurs  within  a  half  hour  to  one 
hour  that  the  suspicious  blood  may  be  considered  to  be 
human  blood  if  it  had  been  tested  by  the  serum  of  a  rabbit 
that  had  been  treated  with  human  blood.  A  test  should 
always  be  carried  out  with  controls,  using  in  the  latter 
other  varieties  of  blood.  If  the  reaction  occurs,  and  there 
is  no  possibility  that  the  blood  could  be  that  of  a  monkey, 
one  may  decide  positively  that  it  is  human  blood.     [D.L.E.] 

3. — Schlesinger  first  states  that  we  do  not  know  that  the 
mere  dilution  of  cow's  milk  makes  the  milk  any  more  di- 
gestible, indeed  the  result  of  mere  dilution  is  to  introduce 
a  smaller  quantity  of  actual  nourishment  with  the  same 
bulk  of  food,  and  if  the  child  is  given  the  proper  quantity 
of  food  with  a  much  diluted  cow's  milk,  it  means  that  the 
infant  must  take  large  amounts  of  water,  and  it  is  alto 
gether  probable  that  these  large  amounts  of  water  are 
not  wholly  without  damaging  results.  The  child  must  use 
a  great  deal  of  energy  in  an  abnormal  way  in  absorbing 
and  again  excreting  the  mere  water.  Wassermann  do- 
scribes  results  which  he  has  had  from  the  use  of  whole 
milk  after  the  children  had  been  put  upon  diluted  cow's 
milk,  and  presents  tables  to  show  the  remarkable  im- 
provement which  occurred  after  such  a  change  in  diet. 
The  cheapness  of  cow's  milk,  and  the  readiness  with  which 
whole  milk  is  used,  makes  cows'  milk  the  most  satisfac- 
tory of  all  foods  that  cfin  be  used,  and  he  believes  that  the 
use  of  whole  milk  will  come  to  occupy  a  much  more  im- 
portant place  than  it  now  does.     [D.  L.  E.] 

4. — Schwarzwaeller  directs  attention  to  the  fact  that  it  Is 
known  that  criminal  abortion  is  sometimes  brought  on  by 


using  lead.  He  himself  reports  4  cases  in  which  it  was 
definitely  determined  that  lead  was  taken  for  this  purpose, 
and  in  which  a  diagnosis  was  made  by  discovering  a  blue 
line  on  the  gums.  He  states  that  he  knows  14  similar  in- 
stances, seme  of  which  he  has  himself  seen,  the  others  hav- 
ing occurred  in  the  practices  of  colleagues.  As  a  rule  the 
diagnosis  in  these  cases  was  at  first  acute  gastritis,  renal 
colic,  tubal  iuQammation,  and  similar  conditions.  In  many 
cases  the  patients  misrepresented  matters  absolutely,  and 
there  was  not  the  least  suggestion  in  their  story  of  the 
actual  cause  of  their  condition.  Lead  can  be  obtained  by 
any  one,  and  its  sale  cannot  well  be  forbidden:  its  use, 
therefore,  may  be  easily  carried  out  by  any  one,  and  it 
is  wise  in  all  suspicious  instances  to  examine  the  gums, 
and  to  consider  the  possibility  of  lead  polsomng,  volun- 
tarily undergone  for  this  purpose. 


JOURNAL   DES   PRATICIENS. 
ilairh  16,  1901.     (15  me.  Annee,  No.  11.) 

1.  Chylous  Ascites.     M.  RENDU. 

2.  Wells,  their  Impurities  and  Disinfection.     P.  REILLK. 

3.  Lavage  of  the  Stomach  in  Gastrorrhagla.     G.  LINOS- 

SIER. 

4.  The   Diagnosis   and   Treatment   of   Foreign   Bodies   in 

the  Nasal  Fossae.    A.  COTJRTADE. 

1. — Rendu  reports  the  case  of  a  woman.  42  years  old,, 
who,  a  year  ago.  noticed  edema  of  both  feet  and  legs  below 
the  knees.  There  were  no  varicose  veins.  Ascites  devel- 
oped. Sis  months  later  the  edema  of  the  legs  reached  the 
hips,  and  spread  into  the  lumbar  region.  Nausea  occurred, 
N\ithout  vomiting,  but  with  diarrhea.  She  grew  thinner, 
and  passed  but  little  urine.  There  was  so  much  anasarca 
that  fluctuation  was  hardly  obtainable,  though  ascites  was. 
evident.  Varicose  lymphatic  vessels  appeared  in  the  sup- 
rapubic region.  The  edema  made  the  skin  hard  as  in 
elephantiasis.  There  was  bilateral  pleural  effusion.  The 
absence  of  any  albumin  in  the  urine  at  any  time  elimin- 
ated nephritis.  The  history  excluded  cirrhosis  of  the  liver. 
Nor  were  there  any  typical  signs  of  peritonitis.  Tap- 
ping the  swollen  abdomen  revealed  chylous  ascites.  The 
liquid  looked  like  diluted  milk.  It  contained  irregular 
fat  droplets,  which,  on  being  estimated  quantitatively, 
showed  from  6  to  S  grams  of  fat  to  the  liter.  Rendu 
considers  this  a  true  case  of  chylous  ascites,  probably 
due  to  compression  or  rupture  of  the  thoracic  duct  by  a 
cancerous  or  tuberculous  growth.  There  were,  however, 
no  other  signs  of  tuberculosis  or  cancer.  The  prognosis 
is  grave.  Exploratory  laparotomy  may  cause  some  im- 
provement.    LM.  O.] 

2. — Reille  disclosses  the  impurities  in  surface  well 
water  in  France,  and  suggests  the  addition  of  potassium 
permanganate  as  a  means  of  disinfection.  [U.  O.] 

3. — Linossier  believed  until  recently  that  it  was  dan- 
gerous to  introduce  the  stomach  tube  In  cases  of  hemv 
temesis.  But  in  the  past  two  months,  he  has  treated 
two  cases  which  have  disproved  this.  The  first  case,  a 
v.oman  aged  46,  had  been  treated  for  hepatic  colic.  XJpork 
examination,  Linossier  found  sjTnptoms  of  a  gastric  neo- 
plasm, though  no  tumor  was  palpable.  She  had  great 
pain  and  vomited  blood  constantly.  As  nothing  did  any 
good.  Linossier  washed  out  a  great  quantity  of  dark 
blood  and  food,  with  the  stomach  tube.  The  immediate 
result  was  excellent.  He  repeated  it  daily,  and  found 
no  more  blood  the  third  day.  She  improved  markedly. 
The  other  case,  a  woman  71  years  old.  had  cancer  of  the 
pylorus.  She  also  vomited  blood,  and  had  great  pain. 
Her  stomach  was  much  dilated.  Lavage  relieved  the 
condition  at  once,  and  was  repeated.  She  improved  also. 
Lavage  seemed  to  Linossier  the  only  way  to  put  the 
stomach  at  absolute  rest,  beside  tending  to  clot  forma- 
tion.    [M.  O.] 

4. — The  diagnosis  of  a  foreign  body  In  the  nasal  fossa, 
depends  upon  its  presence  there,  its  nature,  its  size,  and 
it  shape.  Sometimes  these  are  known,  oftener  they  are 
not.  Before  any  attempts  are  made  to  extract  the  for- 
eign body,  it  must  be  seen.  Then  its  consistency  caa 
be  tried,  and  some  method  followed  for  its  extraction. 
Courtade  reports  finding  a  cork  (1  cm.  by  1.5  cm.)  in  the 
uostril  of  a  child  of  7.  It  was  incrusted  with  lime  salts, 
of  a  consistency  of  stone.  Any  method  of  extraction  appli- 
cable to  the  individual  case  should  be  employed,  only- 
care  must  first  be  taken  to  see  the  object  to  be  extracted. 
[M.  O.] 


920 


The  Phii.apelphia 
Medical  Journal 


] 


THE  DOCTOR'S  FEE 


[Mat  U.  1901 


©ricjinal  Hrticlcs. 


THE    DOCTOR'S    FEE.— A   PLEA   FOR  HONORABLE 
DEALING.* 

By  JOHN  B.  ROBERTS,  M.  D., 

Of    Philadelphia. 

Ex-President  of  the   Society   and   ex-President   of  the  Medical 
Society  of  the  State  of  Pennsylvania. 

"Trust  not  to  the  omnipotency  of  gold,  and  sav 
not  unto  it  thou  art  my  confidence."  ******* 
"Persons  lightly  dipped,  not  grained  in  generous 
honesty,  are  but  pale  in  goodness,  and  faint-hearted 
in  integrity." 

These  reflections  of  the  17th  century  physician  of 
Norwich  seem  a  fitting  introduction  to  this  paper, 
prepared  for  the  consideration  of  the  20th  century 
physicians  of  Philadelphia. 

Three  hundred  and  fifty  years  have  greatly 
changed,  and  for  the  better,  the  methods  of  treating 
disease,  and  have  much  increased  the  physician's 
knowledge  of  nature's  processes;  but  the  fundamen- 
tal principles  of  medical  conduct  and  of  the  doctor's 
relation  to  his  patient  are  still  unaltered  and  unal- 
terable. 

"That  he  be  as  free  from  crafte  and  deceyte  in  all 
his  workyngs,  as  the  East  is  from  the  Weast.  *  *  * 
that  he  taketh  no  cure  in  the  hande  for  lucre  or 
gaynes  sake  only,  but  rather  for  an  honest  and  com- 
petent rewarde  with  a  Godl}'  affection  to  doe  his 
diligence."  Such  should  be  the  true  surgeon,  said 
Thomas  Gale,  in  1563,  in  the  first  surgery  written 
in  the  English  tongue.  His  words  may  well  be 
associated  with  William  Bulleinc's  contempora- 
neous advice  to  the  apothecary,  "To  remember  his 
ende,  and  the  iudgement  of  God ;  and  thus  I  doe 
commende  him  to  God,  if  he  be  not  coueitous  or 
craftie  sekyng  his  owne  lucre,  before  other  mennes' 
health  succour  and  comfort." 

These  quotations  from  our  medical  fathers  sound 
a  little  old-fashioned,  and  look  a  trifle  unfamiliar 
in  their  spelling.  \\'ouId  they  not  sound  discordant 
if  read  in  parallel  columns  with  the  following 
statements  recently  published  in  the  official  organ 
of  the  American  medical  profession.  "It  is  openly 
charged  that  certain  men  are  to-day  giving  com- 
missions to  physicians  sending  them  cases."  "A 
prominent  physician  not  long  ago  read  a  paper  be- 
fore a  medical  society,  in  which  he  advocated  a  di- 
vision of  the  fee"  (between  the  family  phj^sician 
and  the  consultant  surgeon). 

It  is  not  the  wish  of  the  author  of  this  paper  to 
pose  as  the  Doctor  Purissimus  of  some  half  jesting 
or  half  sneering  friend ;  nor  does  he  desire  to  offend 
his  hearers,  as  did  the  clerirynian,  who  was  described 
by  a  prominent,  but  dissatisfied,  member  of  his  con- 
gregation as  "too  damned  pious."  It  is  but  the 
truth,  however,  to  state  that  some  recent  personal 
experiences  and  observations  have  been  the  excit- 
ing cause  of  the  preparation  of  this  communication 
to  the  Philadelphia  County  Medical  Society. 

To  one  who  believes  that  the  medical  man  be- 
longs to  a  liberal  profession  and  not  to  that  portion 
of  the  body  economic,  whose  sole  object  is  the  accu- 
mulation of  money,  certain  tendencies  now  seen  in 

•Read  before  the  Philadelphia  County  Medical  Society,  .\pril  10,  ISIOI. 


the  ranks  of  medicine  cause  distress.  The  apparent 
drifting  away  from  the  ideals,  which  formerly  held 
possession  of  the  minds  of  physicians,  forces  the 
conclusion  that  a  spirit  of  commercialism  is  replac- 
ing the  spirit  of  professionalism. 

No  slur  is  meant  to  be  cast  on  the  merchant, 
tradesman  or  promoter,  who  endeavors  to  increase 
his  capital  or  his  earnings  in  honest  business  enter- 
prises ;  no  intention  exists  to  deprive  the  doctor  of 
his  right  to  earn  his  living  by  collecting  proper 
compensation  for  his  professional  services.  The 
point  insisted  upon,  however,  is  this :  that  the 
province  of  the  doctor  is  to  relieve  the  sick  and  suf- 
fering, and  to  subordinate  to  that  first  object  of  his 
calling,  the  obtaining  of  a  financial  reward  for  his 
labor.  "Do  your  duty  and  then  collect  your 
money,"  is  the  physician's  motto.  "Be  sure  of  your 
money  before  you  deliver  the  goods,"  is  the  per- 
fectly proper  motto  of  the  business  man. 

My  critics  sa}'  that  it  is  difficult  to  determine  what 
is  a  proper  and  just  enterprise  and  thrift  in  one's 
professional  work,  and  what  is  an  improper  com- 
mercial spirit.  The  decision  should  not  be  difficult 
for  the  honorable  physician,  who  believes  in  the  lib- 
eral spirit  of  his  profession,  and  who  is  inspired  by 
the  ideals  of  Gale,  Bulleine  and  Browne.  In  a  re 
cent  discussion  on  the  possible  immoral  tendency 
in  art,  a  well-known  teacher  stated  his  opinion  in 
some  such  words  as  these:  "If  the  moral  quality  is 
so  w-eak  that  j'ou  cannot  taste  it,  and  the  sensuous 
so  strong  that  you  cannot  miss  it.  then  the  work  of 
art  is  dangerous,  no  matter  how  well  it  is  done."  A 
similar  test  is  all  that  is  needed  when  a  conscien- 
tious physician  wishes  to  know  w^hat  is  allowable 
in  his  relations  with  his  patient.  If  the  sincerity, 
humanity,  generosity  and  truthfulness  of  an  action 
cannot  be  readily  seen ;  while  its  selfishness,  cupid- 
ity and  necessary  secrecy  are  recognizable,  he  may 
be  quite  sure  that  it  does  not  meet  the  requirments 
of  professional  standards. 

Let  me  illustrate  by  a  few  examples: 

A  well-known  optician  recently  called  upon  me 
and  showed  me  a  hollow  gold  ball  to  be  used  in 
Mules's  operation  on  the  eye.  His  argument  was 
that  the  use  of  this  gold  ball,  instead  of  the  usually 
employed  glass  sphere,  would  make  the  patient  wil- 
ling to  pay  me  a  larger  fee  for  my  operation ;  since 
the  operation  would  seem  more  important  and  ex- 
pensive. In  other  words,  my  fee  was  not  to  be 
based  on  the  skill  and  time  required,  but  on  the 
amount  that  the  patient  could  be  induced  to  give  up 
without  protest.  I  was  to  use  a  gold  sphere,  cost- 
ing me  three  dollars,  instead  of  a  glass  one  costing 
thirty  cents ;  not  because  it  was  better  for  the  pa- 
tient, which  it  wasn't,  but  because  it  would  be  a 
good  bait  by  which  to  play  on  his  ignorance  for  a 
double  or  triple  fee.  Such  a  trick  may  be  "good 
business."  but  it  doesn't  appeal  to  a  physician  I 

In  my  mail  a  few  mornings  ago  I  found  the  ad- 
vertisement of  a  dealer  in  trusses,  bandages,  and 
other  surgical  appliances.  Snugly  wrapped  in  the 
circular  was  a  neatly  printed  slip,  telling  me  that 
23%  commission  would  be  given  to  me  on  sales 
made  to  my  patients. 

Not  many  years  since,  a  half  page  advertisement 
of  a  sanitarium  appeared  in  a  well-known  medical 
journal,  offering  stock  of  the  sanitarium  company 


Mat  11,  19011 


THE  DOCTOR'S  FEE 


TThe 

Lmed 


Philadelphia 

icAL  Journal 


921 


on  very  advantageous  terms  to  doctors  sending 
patients  to  that  institution.  It  did  not  lessen 
the  insult  of  this  intimation  to  learn  that  the  lead- 
ing spirit  of  the  Sanitarium  Company  was  a  Fel- 
low of  a  learned  medical  organization  of  this  State. 

A  certain  mineral  springs  company  has  recently, 
it  is  said,  offered  its  stock  to  physicians,  so  as  to 
induce  them  to  advocate  the  use  of  its  water  by  their 
patients. 

Who  does  not  know  that  in  this  city  some  opti- 
cians give,  and  some  oculists  shamefully  accept, 
commissions  on  sales  made  to  patients?  The  pub- 
lic should  realize  that  an  oculist,  who  insists  on  his 
patients  buying  their  glasses  at  one  or  two  special 
stores,  lays  himself  open  to  the  suspicion  of  being 
bribed  to  do  so  by  a  commission  from  tlie  dealer. 
The  same  suspicion  attaches  to  the  doctor,  who  un- 
duly urges  patients  to  buy  medicines  from  one 
apothecary.  It  is  true  that  spectacles  and  medi- 
cines should  be  accurately  made  and  compounded  ; 
but  tliere  are  usually  too  many  reliable  dealers,  es- 
pecially in  large  cities,  to  necessitate  so  restrictive 
a  choice  for  the  mere  benefit  of  the  patient. 

Another  scheme,  to  impose  on  the  patient  and  ex- 
tract from  him  what  is  practically  two  fees,  consists 
in  giving  him  a  prescription  for  medicine  under  a 
special  name,  agreed  upon  by  the  doctor  and  the 
druggist  with  whom  he  is  in  collusion.  The  pa- 
tient is  then  obliged  to  go  to  the  apothecary  men- 
tioned by  the  doctor,  even  if  it  be  several  miles  out 
of  his  way,  under  the  impression  forsooth  that  no 
other  apothecary  prepares  the  remedy  so  carefully ! 

This  business  enterprise  is  not  unlike  that  prac- 
tised by  some  hospitals,  which,  to  obtain  a  large 
and  interesting  accident  service,  keep  beer  and 
whiskey  ready  for  the  men  running  the  patrol 
wagon.  Little  wonder  is  it  that  the  injured  are  at 
times  driven  many  unnecessary  squares,  and  that 
certain  institutions  can  show  an  unusally  long  list 
of  accident  cases.  Whether  these  institutions  sim- 
ilarly profit  by  using  their  private  wards  and  rooms 
as  boarding  houses  for  members  of  State  Legisla- 
tures and  their  friends,  who  visit  the  centres  of  gay- 
ety  for  pleasure  or  business,  need  not  be  discussed 
in  this  paper. 

Life  insurance  companies  seem  to  me  to  have  a 
code  quite  unlike  that  which  the  true  medical  pro- 
fession believes  to  be  honorable.  A  couple  of  years 
ago  I  received  a  letter  from  a  well-known  life  in- 
surance company  of  this  city,  saying  that  a  Mr. 
So  and  So,  who  had  applied  for  insurance,  had  once 
been  under  my  professional  care,  and  would  I  kindly 
give  the  company  information  as  to  my  diagnosis 
of  the  obscure  abdominal  condition,  to  aid  its  medi- 
cal examiners  in  arriving  at  a  conclusion  as  to  the 
character  of  the  risk.  This  unwarranted  inquiry, 
apparently  made  without  the  knowledge  of  the  man, 
who  had  entrusted  his  health  to  a  supposedly  hon- 
orable physician,  elicited  no  reply.  Soon  I  re- 
ceived a  personal  letter  from  the  Medical  Director 
of  the  Company,  who  is  an  old  and  valued  friend, 
making  the  same  request.  A  firm  refusal  to  dis- 
close professional  confidences,  without  the  consent 
of  the  patient,   closed  the   incident. 

It  is  supposa1:)le  that  many  insurance  companies 
are  doing  this  thing  constantly.  It  is  not  likely  that 
my  experience  was  an  isolated  one.    Are  doctors  to 


be  tempted  by  fees  or  claims  of  friendship  to  dis- 
close professional  confidences,  because  life  insur- 
ance companies  doubt  the  skill  of  their  medical  ex- 
aminers? 

Take  another  side  of  the  fee  question.  A  New 
England  Insurance  Company  sent  me  several  weeks 
ago  the  blank  forni  of  affidavit  usually  filled  up  by 
the  attending  physician,  when  an  insured  person 
dies.  I  was  told  that  if  I  would  answer  the  ques- 
tions and  make  afifidavit  as  to  the  truthfulness  of 
my  replies,  I  would  be  paid  a  certain  fee.  When 
I  replied  that  Dr.  So  and  So  was  the  attending  phy- 
sician, and  that  I  was  merely  the  consultant,  an- 
other letter  was  sent  me,  saying  that  my  affidavit 
would  probably  do,  and  that  if  I  would  indicate  in 
pencil  my  replies,  I  would  be  paid  a  certain  fee.  The 
fee  spoken  of  in  the  second  letter  was  twice  that 
previously  mentioned.  Here  again  appeared  to  be 
an  attempt  on  the  part  of  a  life  insurance  company 
to  get  a  doctor  to  disclose  confidential  information 
about  his  patient ;  for  neither  letter  showed  that  the 
relatives  of  the  deceased  desired  my  affidavit ;  and 
the  unwillingness  to  apply  to  the  attending  physi- 
cian, whose  address  I  had  given,  awakened  my  sus- 
picion. This  suspicion  was  increased,  possibly  un- 
justly, by  the  doubling  of  the  fee  for  the  testimony; 
and  how  easily  lead  pencil  replies  could  have  been 
changed  after  I  had  sworn  to  the  certificate ! 

Some  doctors,  it  is  believed,  make  a  fee  by  ac- 
cepting money  from  manufacturing  drug  companies 
for  statements,  certifying  to  the  excellence  of  their 
secret  nostrums.  These  certificates  are  then  pub- 
lished and  distributed  as  advertisements.  It  is 
probable  that  in  some  cases  the  doctor  has  had  lit- 
tle experience  with  the  vaunted  remedy ;  in  others 
he  may  use  the  preparation  in  his  practice  for  a  time 
and  then  write  a  hurriedly  prepared  clinical  report 
detailing  the  wonderful  results  obtained.  The  latter 
method  will  undoubtedly  bring  a  higher  financial 
reward  from  the  drug  firm,  for  the  report  has  the 
appearance  of  being  a  scientific  investigation. 

The  editors  of  reputable  medical  journals  have, 
I  believe,  been  deceived  at  times  by  such  literary 
outputs,  and  have  printed  these  clinical  experience' 
as  original  articles  of  real  worth.  The  instigator  of 
the  supposed  scientific  test  and  the  doctor,  who  has 
pocketed  the  fee,  or  bribe,  from  the  exploiters  of 
the  synthetic  compound  or  recently  discovered  al- 
kaloid, probably  smile  at  such  innocence.  The  de- 
ceived editor  and  his  thoughtful  readers  suspect 
the  truth,  however,  when  the  writer  orders  many 
thousands  of  reprints  of  his  clinical  report,  and  the 
drug  house  fills  the  mails  with  "literature"  testify- 
ing to  the  successful  use  of  its  products  by  Dr. 
Blank,  whose  hospital  and  professorial  titles  are 
conspicuously  mentioned. 

These  bribes  for  suborned  testimony  need  not 
always  take  the  shape  of  cash.  Liberal  donations 
of  drugs  for  the  doctor's  private  sanitarium  or  hos- 
pital or  a  few  cases  of  carbonated  water  for  his 
private  use,  are  perhaps  offered  and  accepted  as 
less  likely  to  offend  the  sensibility  of  the  profes- 
sional conscience.  Great,  indeed,  are  the  tempta- 
tions of  doctors  who  unite  the  running  of  a  board- 
ing house  for  the  sick  with  the  practice  of  medicine 
or  surgery.  Business  methods  are  so  different  from 
truly  professional  methods  that  the  necessary  com 


922 


The  Philadelphia"! 
Medical  Journal    J 


THE  DOCTOR'S  FEE 


[May  U,  1901 


bination  in  the  conduct  of  a  private  hospital  or  san- 
itarium is  liable  to  result  in  damage  to  the  integrity 
of  the  latter.  It  is  so  easy  to  charge  unnecessarily 
high  rate  of  board  and  to  advise  patients,  that  a 
month's  longer  stay  will  be  undoubtedly  beneficial. 
Five  or  ten  dollars  a  week  added  to  the  rate  of 
board  make  it  even  possible  to  be  liberal  enough 
to  charge  no  fee  whatever  for  operative  treatment. 
How  generous  this  seems  to  the  unsuspecting  pa- 
tient ! 

It  is  a  question  whether  the  testimony  given  in 
suits  for  damages  against  railroads  and  other  cor- 
porations is  not  at  times  biased  by  the  knowledge 
that  the  doctor  will  get  no  fee  for  his  attendance,  if 
the  patient  fails  to  "recover"  for  his  injury.  I  was 
once  asked  to  give  a  note  saying  that  I  was  too  busy 
to  come  to  court  to  testify,  because  it  was  known 
that  my  opinion  would  be  unfavorable  to  the  cause 
of  the  plaintiff.  Does  any  one  doubt  that,  acceding 
to  the  request,  would  have  rendered  the  payment 
of  mj-  bill  more  certain? 

What  is  more  despicable  than  the  action  of  that 
operator  who  gets  his  patient  ready  for  operation, 
perhaps  even  upon  the  operating  table,  and  then 
declines  to  go  a  step  further  until  the  family  or 
friends  pay  at  once  a  fee  for  professional  services. 
Patients'  trickiness  and  unwillingness  to  settle  just 
claims  may  almost  seem  to  require  this  sort  of 
shrewdness;  but  professional  standards  do  not  en- 
dorse it.  Better  is  it  to  be  defrauded  than  to  resort 
to  the  methods  of  the  road-agent  and  the  black- 
mailer. One  modern  surgeon  at  least  has  suffered 
from  reports,  let  us  hope  untrue  reports,  that  he 
has  used  this  method  to  collect  his  fees. 

There  has  been  developed  of  late  a  system  of 
paying  commissions  to  the  family  physician,  who 
brings  medical  or  surgical  cases,  to  the  consultant. 
Sometimes  this  takes  the  shape  of  agreeing  to  give 
the  doctor,  who  succeeds  in  sending  or  bringing  the 
patient  to  the  operator  or  medical  consultant,  a  per- 
centage of  the  fee  obtained  for  the  operation  or 
advice.  At  other  times  the  iniquity  of  this  arrange- 
ment is  understood  by  both  medical  conspira- 
tors, and  the  family  doctor  is  made  a  quasi  assistant 
and  is  paid  by  the  surgeon  or  gynecologist  a  part 
of  the  fee. 

A  recent  investigator  of  this  evil  declares  that 
he  wrote  letters  to  a  number  of  well-known 
operators  in  a  single  city,  asking  whether  they 
would  give  him  a  commission  on  patients  sent  to 
them.  The  number  of  affirmative  replies  was  as- 
tonishing evidence  of  the  extent  of  this  criminal 
traffic   in   human   suffering. 

That  his  statement  is  not  unworthy  of  confidence 
is  shown  by  this  extract  from  the  columns  of  the 
Journal  of  the  American  Medical  Association  of 
February  2,   1901 : 

"Resolutions  on  Division  of  Fees. — The  commit- 
tee to  whom  was  referred  the  resolutions  of  the 
Chicago  Medical  Society,  January  23rd,  met  and 
adopted  the  following  resolutions,  which  were  rec- 
ommended to  the  Society  for  adoption:  'Resolved, 
That  the  offering,  or  the  giving  of  a  commission, 
or  percentage  of  a  fee,  by  a  consulting  physician  or 
operating  surgeon,  or  the  asking  or  receiving  such 
a  fee  or  commission  in  any  guise  whatsoever,  by  the 
physician  referring  the  case,  is  dishonest,  disrepu- 
table  and   unethical,   unless   such   arrangement    be 


made  with  the  full  knowledge  of  the  patient;  Re- 
solved, That  a  violation  of  this  resolution  shall 
subject  the  offender  to  expulsion  from  the  Society.' 
The  resolutions  were  adopted  unanimously  by 
a  rising  vote.  The  Physicians'  Club  has  passed  a 
resolution  to  the  same  effect:  'Resolved,  That  the 
Physicians'  Club  of  Chicago  most  severely  con- 
demns the  seeking  for  or  the  receiving  of  a  com- 
mission or  part  of  a  consultation  or  operation  fee. 
as  well  as  the  offering  or  giving  of  a  commission,  or 
a  part  of  a  fee,  as  practices  highly  dishonorable  and 
detrimental  to  the  best  interests  of  the  medical  pro- 
fession.' 

It  is  not  the  province  of  this  address  to  elabo- 
rately argue  against  the  propriety  of  such  an  ar- 
rangement, which  tempts  the  family  physician  to 
look  first,  not  to  the  welfare  of  the  confiding  pa- 
tient, but  to  how  the  most  profit  may  be  made  out 
of  his  ill  health  or  accident;  and  which  tempts  the 
consultant  to  raise  his  fee  to  an  extortionate  figure, 
in  order  to  divide  with  his  "pal."  The  fact  that  such 
a  commission  arrangement  is  always  concealed  from 
the  patient  is  a  sufficient  proof  of  its  professional 
impropriety.  The  excuse  given  by  the  family  doc- 
tor that  the  patient  will  pay  a  large  fee  to  a  con- 
sultant and  leave  his  bill  unpaid,  is  no  adequate 
apology.  It  is  the  family  doctor's  duty  to  collect 
his  bill  by  fair,  not  foul,  means ;  and  it  is  the  duty 
of  the  consultant,  it  must  be  remembered,  not  to 
charge  such  an  exorbitant  fee  that  the  patient's 
means  are  so  exhausted  that  he  cannot  pay  the  doc- 
tor who  has  attended,  and  who  is  to  attend,  him. 

Few  consulting  surgeons,  I  imagine,  have  not  met 
this  evil  in  some  form  or  other.  It  may  be  a  quiet 
request  to  add,  to  the  consultant's  fee.  a  certain 
sum  "for  me."  It  may  be  put  in  this  wise:  "Don't 
mention  your  fee,  as  being  so  much,  before  the  pa- 
tient ;  for  I  have  told  him  it  was  so  much,  because 
I  wanted  thus  much  for  myself."  The  latter  ad- 
monition, after  an  operation  done  for  a  medical  ac- 
quaintance, was  my  first  intimation  of  a  possibility 
of  such  dishonor  in  the  profession.  The  doctor  who 
called  me  in  consultation  subsequently  became  the 
president  of  his  county  medical  society.  I  evidently 
had  seen  a  side  of  his  character  which  his  col- 
leagues had  not  had  disclosed  to  them. 

The  family  physician  should,  undoubtedly,  charge 
more  than  his  usual  fee,  when  he  meets  another 
physician  in  consultation  over  his  patient's  case. 
The  visit  is  longer  than  usual,  more  important  than 
usual,  and  makes  more  demand  upon  the  family 
doctor.  He,  therefore,  should  receive  additional 
compensation.  If  he  does  not  charge  a  proper  fee 
under  these  circumstances  and  collect  it.  he  is  un- 
just to  himself.  It  happens,  however,  not  infre- 
quently, that  the  general  practitioner  fears  that  the 
consultant  wil  charge  so  much  that  he  cheats  him- 
self, in  order  to  be  sure  that  the  patient  may  have 
the  advantage  of  the  best  consultant  skill.  It  is  to 
be  regretted  that  the  extravagant  estimate,  put  by 
some  consultants  upon  the  value  of  their  operative 
and  diaonostic  skill,  justifies  the  fear  that  either 
the  family  doctor  must  go  without  proper  compen- 
sation, or  the  patient  lack  the  benefit  of  additional 
professional  service. 

Have  we  not  all  known  of  honorable  and  faith- 
ful physicians  treating  men  and  women  in  moderate 


Mat  11,  1901] 


THE  DOCTOR'S  FEE 


CThe  Philadelphia       q2  i 
Medical  Journal  y^o 


circumstances  for  practically  nothing,  and  who, 
having  called  a  surgeon  or  physician  in  consulta- 
tion, have  been  shocked  and  astonished  at  the  large 
fee  demanded  and  even  insisted  upon?  If  the  gen- 
eral practitioner  grades  his  fee  down  to  the  finan- 
cial condition  of  the  sick  or  injured  man,  should  not 
the  consultant  have  a  similar  reasonable  apprecia- 
tion of  professional  humanity? 

Put  the  case  in  another  way.  If  doctors  treat 
fellow  members  of  the  profession  without  fee ;  if 
they  treat  doctors'  wives  and  children  without 
charge,  should  they  not  be  willing  to  operate  upon, 
or  see  in  consultation,  without  charge,  a  doctor's 
patient,  when  that  patient  is  unabl?  to  pay?  The 
logic  seems  irresistible.  If  the  physician  is  worried 
and  anxious  about  his  case  and  desires  advice  from 
a  man  who  has  had  more  experience  in  that  particu- 
lar disease,  it  seems  only  proper  that  his  brother 
practitioner  should  come  to  his  aid  as  a  consultant, 
for  a  small  fee ;  or  no  fee,  if  none  is  obtainable  from 
the  patient.  It  is  the  bond  of  professional  brother- 
hood that  seeks  to  lessen  the  mental  stress  in  both 
instances.  Yet  consultants  have  been  known,  I  un- 
derstand, to  refuse  to  thus  relieve  the  anxiety  of  a 
doctor,  because  the  payment  by  the  patient  of  a  cer- 
tain fee  was  not  possible.  There  is  little  doubt  that 
the  family  physician  at  times  pays  consultation 
fees  out  of  his  own  pocket,  in  order  to  do  his  best 
for  patients  with  whose  straightened  circumstances 
he  is  familiar. 

Doesn't  all  Scotland  know  of  Weelum  MacClure's 
ofifer,  when  Sir  George  came  to  the  Highlands  to 
save  the  life  of  Tammas  Mitchell's  wife?  and  didn't 
Sir  George  do  more  honor  to  Medicine  by  his  refu- 
sal to  take  the  check  of  MacClure's  partner  in  hu- 
manity than  by  his  brilliant  operation? 

Some  doctors  of  the  20th  Century  need  to  read 
that  story  again,  before  sending  out  their  bills. 

The  consultant  sometimes,  in  his  anxiety  for  his 
fee,  unjustly  assumes  that  the  family  physician 
should  play  the  role  of  collector,  because  the  pa- 
tient lags  in  the  payment  of  the  debt.  I  well  re- 
member the  righteous  indignation  of  a  certain  coun- 
try physician,  when,  some  years  ago.  he  was  almost 
dunned  by  a  metropolitan  surgeon,  who  found  dif- 
ficulty in  collecting  a  consultation  fee. 

A  trust,  or  at  least  a  belief,  in  the  "omnipotency 
of  gold"  seems  to  have  debauched  the  professional 
spirit  of  these  days.  Perhaps,  however,  the  doctors 
only  breathe  the  same  air  and  react  to  the  same  en- 
vironment, as  their  business  associates.  The  pro- 
fessional result,  however,  seems  to  the  doctors  of 
the  school  of  ethics  of  Browne  and  Gale  to  be  more 
deplorable  than  that  exhibited  in  the  ranks  of  trade. 
The  chief  end  of  business  is  financial  gain ;  but  the 
doctor  should  take  "no  cure  in  the  hande  for  lucre 
or  gaynes  sake  only."  It  is  this  different  view- 
point that  makes  the  "pursuit  of  avarice"  in  a  doc- 
tor's work   so   objectionable. 

Is  it  not  true  that  doctors'  bills  against  the  estates 
of  deceased  patients  are  at  times  larger  than  they 
would  have  been  for  the  same  amount  of  medical  at- 
tendance, had  the  sick  man  lived?  Do  not  sur- 
rogates and  orphans  courts  act  justh'  in  viewing 
with  suspicion  the  large  bills  sometimes  presented 
for  adjudication?  Is  there  no  reason  for  thinking 
that  some  medical  men  are  willing  to  charge  a 
larger  fee  than  their  custom,  when  they  know  that 


dead  men  can  neither  complain,  nor  confer  future 
benefit  by  contracting  bills  for  medical  service? 

I  recently  heard  of  a  doctor  replying  to  a  criticism 
that  his  bill  against  the  patient's  estate  was  too 
large,  by  saying  that  he  always  charged  more  when 
the  patient  died,  because  the  death  hurt  his  repu- 
tation !  Such  reasoning  must  be  very  soothing  to 
the  surgeon  who  has  a  fatal  result  to  bewail.  If 
carried  to  its  legitimate  conclusion,  the  argument 
would  indicate  that  the  justifiability  of  an  operative 
procedure  should  be  decided  by  the  ailing  patient, 
and  the  work  done  by  a  surgical  engine  without  soul, 
conscience  or  heart.  Then  would  Petrarch's  in- 
nuendo that  physicians  trifled  with  human  sickness 
for  game  and  mercenary  gain  be  justified  (Medi- 
cal Economy  during  the  Middle  Ages.  Fort,  p 
428)  ;  and  the  boy's  objection  to  becoming  a  doctor 
because  "he  couldn't  kill  a  cat,"  seem  a  valid  reason 
for  adopting  another  means  of  livlihood. 

It  is  scarcely  to  be  doubted  that  the  triumphs  of 
modern  medicine  and  surgery  have  turned  the  heads 
of  some  practitioners,  and  that  charges  have  be- 
come so  large  in  certain  instances  as  to  be  properly 
dubbed  extortionate.  The  chronicles  of  the  Middle 
Ages  show,  according  to  Fort  (p.  461),  that  re- 
course to  saintly  remedies  was  induced  by  the  ex- 
cessive demands  of  the  doctors,  by  which  entire 
patrimonies  were  frequently  swallowed  up  before  re- 
course was  had  to  these  ecclesiastical  curative  agen- 
cies. Uncommon  pharmaceutical  compounds  or 
double  doses  were  prescribed  as  necessary  medi- 
caments, when  the  patient  was  wealthy,  while  for 
the  poor  the  smallest  dose  was  considered  sufficient 
to  cure.  Do  not  these  records  aflford  food  for 
thought  on  the  relation  of  professional  fees  in  this 
decade  to  the  Christian  Science  Healer,  to  Hos- 
pital Abuse,  and  to  the  Gold  Cure  for  Inebriety? 

The  medical  professors  of  the  Middle  Ages  are 
said  to  have  been  able  to  dictate  terms,  because  "af- 
fluent invalids  readily  believeditimpossibletoescape 
death"  unless  attendance  by  these  eminent  doctors 
was  secured.  Do  we  not  see  evidences  of  this  mor- 
bid belief,  at  the  present  day;  and  is  not  its  abuse 
advancing  "practitioners  rapidly  to  enormous 
wealth  and  pomposity?"     (Fort  op.  cit.  p.  428). 

Does  any  member  of  this  Society  really  believe 
that  eight  thousand  dollars  or  ten  thousand  dollars 
is  a  just  fee  for  the  performance  of  any  possible 
gynecological  operation,  done  on  a  private  citizen, 
even  if  he  be  a  multimillionaire?  By  a  fee  for  the 
performance  of  an  operation,  I  mean  the  charge  for 
the  operation  alone,  not  including  the  preparatory 
treatment,  the  after-treatment,  the  nursing,  or  the 
hospital  private  room.  I  admit  the  possibility  that 
the  national  importance  of  the  patient,  a  ruler  for 
example,  might  increase  the  surgeon's  responsibili- 
ty so  much  that  this  enormous  fee  might  be  justi- 
fiable. Under  other  circumstances  its  propriety  is 
scarceh'  conceivable. 

Would  any  one  present  to-night  justify  the  ac- 
tion of  a  surgeon,  who  when  asked  for  his  bill, 
said  "I  send  nobill.butlget  for  such  professional  ser- 
vice from  five  hundred  to  ten  thousand  dollars?" 
This  is  the  attiudc  of  the  negro  porter  on  the  sleep- 
ing car,  who,  with  a  scrape  of  his  foot,  says  to  the 
man  whose  hat  he  has  brushed,  "Gib  me  what  you 
please,  sah ;"  because  he  hopes  to  get  a  half  dollar 
for  ten  cents'  worth  of  service.     This  attitude  may 


924 


The  Philadelphia 
Medical  Journal 


] 


THE  DOCTOR'S  FEE 


[Mat  U.  1901 


not  demean  an  ex-slave,  but  it  does  not  seem  worthy 
of  a  medical  gentleman,  does  it? 

If  such  fees  are  to  be  asked  by  the  medical  gentle- 
men of  to-da}',  the  patient  certainly  ought  to  be 
frankly  apprised  of  the  fact,  before  he  is  allowed  to 
incur  the  debt.  I  know  of  an  instance  where  a 
physican  of  eminence  was  requested  to  come  to  a 
distant  town  to  see  a  patient  in  consultation ;  a  tele- 
graphic reply  was  promptly  sent,  "My  fee  is  three 
hundred  dollars,  shall  I  come?"  I  have  but  little 
criticism  to  offer  to  this  frank  mode  of  action.  It  is 
a  different  thing  when  a  patient  with  trusting  con- 
fidence submits  to  the  professional  offices  of  a  doc- 
tor, and  receives  a  bill  of  such  proportions  that  it 
takes  years  of  self  sacrificing  economy  to  discharge 
the  debt. 

There  is,  it  seems  to  me,  one  just  plan  by  which 
fees  should  be  regulated.  It  is  that  the  doctor 
should  have  an  estimate  of  the  value  of  his  ser- 
vices, operative  or  otherwise,  fixed  in  his  mind. 
The  amount  should  be  based  on  his  experience  and 
skill.  It  should  not  be  so  low  as  to  coax  away  un- 
justly the  patients  of  the  younger  and  less  ex- 
perienced men  of  the  profession.  This  fee  should 
be  lessened  when  the  financial  position  of  the  pa- 
tient would  make  its  payment  a  serious  burden.  It 
is  not  professional  or  humane  to  take  a  man's  in- 
come for  a  whole  year,  to  pay  for  the  doctor's  bill 
of  a  month. 

A  well-to-do  patient  should  pay  the  full  fee,  which 
should  be  generous  in  order  to  recompense  the  doc- 
tor for  his  expensive  education  and  hazardous 
life.  This  fee,  however,  should  not  be  increased 
because  the  services  of  the  doctor  are  utilized  by  a 
very  wealthy  person,  unless  an  unusual  time  is 
given  to  the  service  or  additional  responsibility  is 
placed  upon  the  physician  by  reason  of  the  man's 
position. 

"Make  it  up  on  a  rich  patient,"  or  "Charge  him 
a  big  fee,  because  he  is  a  millionaire,"  are  admoni- 
tions not  to  be  heeded  by  the  true  physician  ;  but 
only  by  that  healer  of  men's  ills  who  is  but  "lightly 
dipped  in  generous  honesty  and  faint  hearted  in  in- 
tegrity." Such  words  may  do  for  the  motto  of  the 
man  who  is  "coucitous  or  craftie  sekyng  his  owne 
lucre,  before  other  mennes  health  succour  and  com- 
fort," but  not  for  the  doctor  who  taketh  "the  cure 
in  the  hande"  for  "an  honest  and  competent  rewarde 
with  a  Godly  affection  to  doe  his  diligence." 


THE  ETIOLOGY  OF  ARRESTED  MENTAL  DEVELOP- 
MENT. 

BY    PEARCE   BAILEY,    M.    D. 

of  New  Voi*k. 

.Mteiiding  Physici,iTi  to  the  .■Mms  House  Hospital,  New  York. 

Idiocy,  imbecility,  and  feeble-mindedness  are 
varying  degrees  of  the  same  condition.  So  gradu- 
ally do  they  merge  into  one  another  that  it  is  impos- 
sible to  say  where  the  one  begins  and  the  other 
ends.  They  all  are  the  psychological  expressions  of 
infantile  cerebral  pathology.  Their  causes,  there- 
fore, which  include  all  factors  that  interfere  with 
the  development  of  the  brain  of  the  child,  must 
be  considered  together.  For  the  purpose  of  brief 
reference,  they  are  best  divided  into, 

I.  Those  occurring  before  birth. 


2.  Those  occurring  at  birth. 

3.  Those  occurring  during  infancy  and  child- 
hood. 

I.  Prenatal  Cause. — More  than  fifty  per  cent,  of  all 
cases  of  idiocy  and  feeble-mindedness  are  congenital, 
and  in  a  large  proportion  of  this  number,  defective 
nervous  systems  on  the  part  of  parents  or  near 
relatives,  is  demonstrable.  Statistics  as  to  exact 
proportions  vary  greatly,  and  it  seems  to  me  fruit- 
less to  attempt  to  harmonize  them.  All  agree  that 
bad  nervous  heredity  is  the  most  conspicuous  in- 
hibiting factor  to  the  growth  of  the  infantile  brain, 
and  daily  observation  shows  that  idiotic  and  feeble- 
minded children  are  the  products  which  are  to  be 
expected  from  marriages  in  which  one  or  both  pa- 
rents carry  in  their  blood  the  taint  of  degenerative 
nervous  conditions.  In  comparison  with  this  cause. 
all  others  sink  into  insignificance.  So  that  in  study- 
ing the  etiology  of  idiocy,  we  must  begin  with  the 
causes  of  degeneration. 

Degeneration,  which  endangers  the  capacity  of 
the  individual  to  beget  normal  descendants,  may  be 
a  result  of  ancestral  defects,  or  may  be  acquired. 
When  inherited,  it  is  the  insane,  the  hysterical,  the 
alcoholic,  the  epileptic,  the  exhausted,  and  the  de- 
fective generally  who  transmit  it.  Of  all  degenera- 
tive conditions,  mental  enfeeblement  is  the  one  in 
which  direct  inheritance  is  the  most  frequently  de- 
monstrable. Profound  idiots  are  sterile.  But  in  the 
lesser  degrees  of  idiocy,  and  in  imbecility  and  fee- 
ble-mindedness, either  parent  may,  unfortunately, 
he  capable  of  procreation. 

In  a  large  proportion  of  cases  in  which  one  pa- 
rent is  idiotic,  the  child  bears  the  identical  stigma. 
Direct  inheritance  in  idiocy  is  more  frequent  than  in 
other  degenerative  conditions.  The  child  of  an  in- 
sane mother  may  become  alcoholic  and  be  sane,  or 
the  child  of  alcoholic  inheritance  develop  any 
degenerative  ner\ous  disorder:  in  such  cases  the 
neuropathic  constitution  is  inherited,  but  the  partic- 
ular tj-pe  of  its  manifestation  is  decided  by  environ- 
ment or  other  conditions.  But  with  idiotic  parents 
the  rule  is  that  the  type  itself  is  perpetuated. 

It  may  seem  that  child-bearing  idiots  and  imbe- 
ciles are  not  numerous  enough  to  demand  close  at- 
tention. Such,  however,  is  not  the  case.  The  com- 
missioners appointed  to  inquire  into  the  state  of 
lunatics  in  Scotland  ascertained  that  the  number  of 
idiotic  women  who  had  borne  illegitimate  childrei; 
was  126 — one  mother  having  born  five  children. 

Feeble-minded  women  are  easy  prey  to  the  lust 
of  men.  \\'hen  lacking  natural  or  State  protection, 
therefore,  they  are  extremely  liable  to  increase  th-.- 
State's  dependents.  They  are  also  particularly  sub- 
ject to  infection  from  venereal  diseases.  They  thercbv 
doubly  disseminate  the  factors  of  degeneration.  To 
protect  this  class  and  the  consequences  of  it.  there 
was  established  at  Newark  several  years  ago.  the 
New  York  State  Custodial  Asylum  for  Feeble- 
minded Women.  This  institution  shelters,  during 
tile  child-bearing  period,  over  four  hundred  feeble- 
mintled  women  who  lack  natural  protectors.  By 
thus  forcing  sterility  on  these  unfortunates,  the 
State  serves  them,  and  at  the  same  time  serves  3 
very  vital  economic  purpose  of  its  own. 

In  acquired  degeneracy,  it  is  assumed  that  the  in- 
dividual is  born  normal,  but  that  through  disease 


May  11. 


ARRESTED  MENTAL  DEVELOPMENT 


ri'FE  Philadelphia 
Lmedical  Journal 


925 


or  abuse  he  has  lost  the  power  of  procreating  nor- 
mal children.  Trominent  among  the  causes  ot 
acquired  degeneracy  are  tuberculosis,  alcoholism 
and  syphilis. 

Tuberculosis  in  the  parents  as  a  cause  of  degen- 
eration is  well  recognized.  As  a  cause  of  idiocy, 
it  does  not  seem  to  receive  the  attention  it  meril.s. 
Yet  it  is  a  most  important  one.  Piper  found  tuber- 
culosis in  the  parents  and  near  relatives  in  23%  of 
his  cases  of  congenital  idiocy,  and  a  large  proportion 
of  the  deaths  among  idiots  is  from  phthisis. 

Alcohol  is  the  most  important  factor  in  acquired 
degeneration.  The  disastrous  effect  of  alcohol  upon 
the  developing  egg  has  been  proved  experimentally. 
Fe're'found  that  the  injection  of  a  few  drops  of  an 
alcoholic  solution  beneath  the  sheU'was  followed  by 
a  great  variety  of  developmental  defects.  It  is 
rather  difficult,  however,  to  determine  the  relation- 
ship in  which  idiocy  and  alcoholism  stand  to  each 
other.  Drunkenness  of  a  parent  at  the  time  of  con- 
ception has  long  been  regarded  as  a  fertile  cause  of 
imbecility.  "Young  man,"  said  Diogenes  to  a  stupid 
boy,  "thy  father  must  have  been  very  drunk  when 
thy  mother  conceived  thee."  My  experience  teaches 
me  that  the  drunkard  is  per  se  a  degenerate ;  that 
the  acquisition  of  an  uncontrollable  alcoholic  habit 
is  in  itself  a  sufficient  indication  of  an  enfeebled  or 
perverted   nervous   system. 

When,  therefore,  the  child  of  a  drunkard  turns  out 
feeble-minded,  it  seems  as  though  there  may  well 
have  been  a  cause  antedating  the  alcoholism.  Cer- 
tain it  is  that  alcoholic  persons  are  frequent  among 
the  forbears  of  idiots.  Ireland,  in  his  "Mental  Af- 
fections of  Children,"  expresses  himself  as  believing 
that  "idiocy  is  not  the  ordinary  legacy  which  drunk- 
ards leave  to  their  children."  I  think  this  view  is 
correct.  In  my  experience  the  child  of  the  drunk- 
ard is  apt  to  have  a  nervous  system  of  poor  resist- 
ance and  great  excitability.  Epilepsy,  chronic 
chorea,  morbid  impulses,  and  bad  habits  frequently 
overtake  him.  These  aftections,  rather  than  pri- 
mary idiocy,  seem  the  contmon  legacies  of  alcohol- 
ism. They  may  well  bring  all  varieties  of  mental 
defects  in  their  train. 

Active  syphilis  in  one  or  both  parents  is  reflected 
in  the  offspring.  It  is  a  fertile  cause  of  miscarriage. 
Most  children  born  actively  syphilitic  die  soon  after 
birth.  Hereditary  syphilis  also  causes  organic  brain 
disease  in  infants  and  young  children — and  organic 
disease  of  a  developing  organ,  even  w^ithout  sucli 
gross  lesions  as  hemorrhage,  etc.,  precludes  perfect 
development. 

The  question  is  more  difficult  when  it  concerns 
the  responsibility  of  a  parent  who  has  had  syphilis, 
but  who  has  been  free  from  all  active  manifestations 
of  it  for  several  years  before  the  conception  of  the 
child.  The  existence  of  a  parasyphilitic  toxin  is  as 
well  established  as  a  non-demonstrated  theory  can 
be.  But,  so  far  as  we  know,  this  toxin  acts  solely 
on  the  nervous  system  of  the  patient  himself,  as,  for 
example,  in  locomotor  ataxia.  Proof  that  it  can  act 
directly  upon  the  tgi^  is  wanting.  We  all  know 
fathers  and  mothers  who  have  had  healthy  children, 
yet  I  doubt  if  any  of  us  know  an  idiotic  or  feeble- 


minded child  of  who.-:)e  imperfect  mental  state  para- 
syphilitic poison  is  the  only  possible  explanation. 

The  causes  which  have  been  mentioned  are  the 
chief  ones  which  impair  the  power  of  parents  to 
bring  forth  healthy  and  resistant  children.  They 
occupy  first  rank  by  reason  of  the  frequency  with 
which  they  can  be  demonstrated  throughout  the 
neuropathic  class.  The  more  massed  the  parental 
degenerative  factors,  the  more  certain  it  becomes 
that  the  child  will  not  escape  his  birthright.  With 
both  parents  tainted,  the  hopes  of  normal  issue  are 
slight.  By  the  continuous  intermarriage  of  degen- 
erates, degeneration  progresses  till  it  results  in  ex- 
tinction of  race.  It  is  through  the  propagation  of 
stigmata  that  consanguineous  marriages  have  ob- 
tained their  bad  name. 

The  most  far-sighted  optimist  cannot  make  out 
the  dawn  of  the  day  when  inherited  degeneracy 
shall  cease.  But  it  does  not  require  a  very  wide 
excursion  of  the  imagination  to  discern  conditions 
under  which  it  might  be  materially  curtailed.  For 
one  thing,  society  may  well  be  expected  to  some  day 
place  importance  upon  the  eligibility  of  persons 
who  wish  to  marry.  As  it  is  to-day,  it  puts  few  ob- 
stacles in  the  way  of  the  most  improper  alliances. 
I  know  many  excellent  families  which  have  sanc- 
tioned marriages  of  their  daughters  with  confirmed 
alcoholics.  It  was  said  that  matrimony  would  work 
reform.  The  clergy  take  little  or  no  care  to  ascer- 
tain the  parental  fitness  of  the  couples  they  join  in 
wedlock.  The  opinions  of  physicians  are  only  oc- 
casionally sought  by  prospective  brides  and  bride- 
grooms. And  physicians'  warnings  are  generall}' 
disregarded.  Physicians  themselves  are  not  alto- 
gether free  from  blame  in  these  matters.  It  is  as 
much  their  duty  to  investigate  the  marital  fitness 
of  their  patients  as  it  is  to  discover  the  nature  of  a 
disease.  And  their  warnings  to  the  matrimonially 
inclined  degenerate  should  be  given  with  the  same 
emphasis  and  the  same  conviction  as  they  would  be, 
were  the  object  the  deterring  of  the  syphilitic  patient 
from  sexual  indulgence,  or  the  epileptic  from  alco- 
hol. Two  cases  have  come  to  my  notice  in  which 
physicians  with  full  cognizance  of  the  facts,  so  far 
outraged  their  scientific  knowledge  as  to  contract 
marriage  with  epileptics. 

The  eradication  of  degeneracy  has  its  brightest 
hope  in  increased  education  and  better  State  care. 
Teach  boys  and  girls  physiology,  and  young  men 
and  women  the  pathology  of  generation.  This  is  a 
step  not  difficult  to  accomplish,  and  would  provide  a 
certain  protection  to  the  normal.  For  the  abnormal 
and  degenerate,  sequestration  is  the  only  solution.  For 
advanced  cases,  institutions  are  the  legitimate 
homes.  But  for  borderland  cases,  for  the  feeble- 
minded, the  half  insane,  the  drunkards,  the  tuber- 
culous, the  epileptic,  colonization  is  the  surest 
means  of  caring  for  the  future. 

As  is  well  known,  tliis  idea  is  receiving  more  and 
more  approval.  It  should  be  developed,  enlarged 
and  propagated.  The  Craig  Colonv  for  epileptics 
and  the  institution  at  Newark.  N.  Y..  have  demon- 
strated their  usefulness.  The  colony  system  for  the 
insane  is  being  gradually  extended.  The  State 
Hospital  for  Consumptives  is  an  established  fact. 
As  vet  there  is  no  colony  for  alcoholics.  To  protect 
itself  against  them  the  state  is  still  powerless. 
However   dangerous   a   drunkard    may   be   to   the 


Q26       The  Philadelphia  T 
y^"       Medical  Journal    J 


ARRESTED  MENTAL  DEVELOPMENT 


[Mat  U,  1901 


actual  community,  or  to  communities  yet  unborn, 
the  moment  his  liberty  is  threatened  he  raises  thn; 
cry  of  "inalienable  right"  and  is  free.  Yet  the  time 
must  come  when  chronic  alcoholism  shall  be  placed 
within  the  pale  of  State  control,  and  when  alcohol- 
ics shall  be  sequestrated  on  farms  on  which  there 
is  a  rigorous  quarantine  against  alcohol. 

Brief  mention  will  suffice  for  the  other  prenatal 
causes  of  feeble-mindedness.  They  are  chiefly  ma- 
ternal. Diseases  of  the  mother  occupy  a  place  of 
importance.  Of  them,  diabetes  is  one  which  should 
be  regarded  as  a  moral  disqualification  for  con- 
ception. Popular  tradition  attaches  much  signifi- 
cance to  a  variety  of  other  factors.  Fright,  grief, 
and  similar  violent  emotions,  traumatisms,  unhygi- 
enic surroundings,  are  all  from  time  to  time  invoked 
as  explanations  of  feeblemindedness  in  a  child.  Of 
prenatal  causes  referable  to  the  fetus  may  be 
mentioned  the  various  fetal  diseases  and  twin  preg- 
nancy. 

II.  Causes  Acting  at  Birth. — The  various  factors 
which  complicate  delivery  stand  in  prominent  rela- 
tionship to  idiocy  and  imbecility.  Cerebral  injuries 
incurred  at  this  time  may  cause  gross  lesions,  which 
naturally  imperil  the  development  of  the  intellect. 
The  commonest  clinical  manifestations  of  such  in- 
juries are  diplegia  and  paraplegia.  Even  when 
clinical  evidences  of  such  gross  lesions  are 
absent,  difficult  labor  with  the  attendant  com- 
pression and  asphyxiation,  is  sometimes  the 
only  discoverable  cause  for  feeble-mindedness. 
In  support  of  this  is  the  fact  that  first  chil- 
dren are  much  more  apt  to  be  feeble-minded 
than  later  ones,  and  that  boys  are  affected  with 
nearly  twice  the  frequency  of  girls. 

The  proper  use  of  the  forceps  in  delivery  should 
be  regarded  as  a  means  of  avoiding  brain  injury, 
rather  than  a  cause  of  it,  as  the  dangers  of  skillful 
extraction  are  less  than  long  continued  pressure  on 
the  head.  Nevertheless,  the  use  of  forceps,  by  a 
reliable  practitioner,  is  in  itself  an  indication  that 
delivery  was  difficult,  and  consequentlv  not  without 
danger  to  the  head  of  the  child. 

III.  Causes  acting  after  Birtli.— The  study  of  the 
post-natal  causes  of  idiocy  is  the  study  of  pediatrics. 
All  causes,  whether  they  be  traumatic,  toxic,  or  nu- 
tritional, which  act  on  the  developing  infant  brain, 
fall  into  the  rubric.  But  unless  they  be  definite^ 
quickly  acting,  and  with  evident  and  immediate 
results,  they  are  extremely  difficult  to  define  and  to 
evaluate. 

If  a  child's  development  is  arrested  consecutively 
to  a  serious  head  injury,  or  to  an  attack  of  convul- 
sions, or  unconsciousness  followed  by  hemiplegia,  or 
to  an  attack  of  scarlet  fever,  the  immediate  cause  is 
easily  understandable.  But  when  the  evidences  of 
retardation  follow  no  such  crisis  diagnosis  is  much 
more  elusive. 

In  the  child  at  birth  consciousness  is  not  yet  wak- 
ened, and  all  nervous  phenomena  are  es'sentiallv 
reflex  in  character.  In  the  absence  of  pljysical  de- 
formities if  the  child  sleeps  and  nurses  well,  as 
feeble-minded  children  often  do,  it  is  impossible  to 
decide  as  to  mentality  during  the  first  two  or  three 
weeks  of  life.  The  child  is  usually  several  months 
old  before  it  is  brought  to  the  physician  bv  the 
mother,  who  is  becoming  alarmed.     She  has  at  last 


observed  that  the  baby's  attention  is  not  attracted 
by  moving  objects,  by  lights  or  sounds,  that  it  does 
not  follow  with  its  eyes,  that  is  is  heavy  and  inact- 
ive, and  unlike  other  children.  It  is  practicall)-  im- 
possible to  determine  whether  such  slow  developing 
symptoms  are  post-natal  in  their  causation,  or 
whether  they  had  their  origin  before  birth.  As  an 
example  may  be  cited  cretinism,  developing  in  early 
infancy.  No  one  can  say  whether  such  cases  are 
congenital  or  acquired. 

Whenever  the  causes  first  begin  their  action,  it 
must  not  be  forgotten  that  they  exert  their  influence 
on  an  organ  with  its  future  all  before  it. 

At  birth  the  fibers  of  the  infantile  brain  are  only 
partially  medullated.  Its  cells  are  comparatively 
few  in  number  and  of  imperfect  development,  as  is 
shown  by  their  great  irritability.  It  resembles  in  its 
function  a  primitive  nervous  ganglion  more  than 
it  does  the  adult  encephalon.  From  the  simplicity 
of  its  structure  and  from  its  hyper-excitability, 
causes  which  leave  the  adult  brain  undisturbed,  ex- 
ert intense  impressions  upon  the  brain  of  the  child. 
.Anyone,  for  example,  who  has  witnessed  the  pro- 
found cerebral  symptoms  in  very  young  children  I 
which  may  result  from  intestinal  disturbance,  will 
not  question  the  extreme  susceptibility  to  poisons 
of  the  child's  ganglion  cells.  As  in  all  low  forrns 
of  life,  also,  the  infantile  brain  is  extremely  suscep- 
tible to  reflex  stimuli.  Severe  nervous  storms  result 
in  infants  from  slight  peripheral  irritations.  But 
the  period  which  is  that  of  the  brain's  greatest  sus- 
ceptibility, is  also  the  period  of  its  greatest  growth. 
At  the  end  of  the  second  year  of  life  the  brain 
weighs  three  times  as  much  as  it  did  at  birth.  With 
such  rapid  workmanship  on  the  structure  which  is 
to  be  the  permanent  home  of  the  intellect,  every 
moment  is  precious.  Interruptions  to  progress, 
even  though  brief,  may  have  far  reaching  results. 

Still  another  factor  in  infantile  pathology,  which 
gives  an  added  importance  to  cerebral  disorders,  is 
the  tendency  for  focal  lesions  to  aflfect  the  whole 
brain.  In  the  adult  brain,  focal  lesions  may  come, 
and  remain,  or  go  away,  exerting  only  a  temporary 
effect  on  intelligence.  I  have  reported  the  case  of  a 
man  who  had  suffered  total  destruction  of  the 
frontal  lobes  of  one  side,  with  atrophy  of  the  rest 
of  the  hemisphere,  without  the  slightest  disturbance 
of  intelligence.  During  infancy  and  early  child- 
hood, however,  no  lesion  is  too  small  or  too  circum- 
scribed to  affect  the  whole  encephalic  mass  or  to 
inhibit  its  growth.  This  fact  creates  the  greatest 
difficulty  in  the  diagnosis  of  cerebral  diseases  in 
infancy.  These  disorders  are  characterized  by  the 
general  symptoms  of  cerebral  trouble,  such  as  con- 
vulsions, or  coma,  or  irritation,  or  vomitinsr:  only 
occasionally  is  the  most  painstaking  examination 
rewarded  by  a  definite  focal  sign.  Thus  clinical 
behavior  and  ontogenesis  go  hand  in  hand.  The 
brain  of  the  infant  is  too  undeveloped  to  permit  of 
true  focal  disease. 

With  so  delicate,  easily  influenced  and  rudimen- 
tary an  organ  as  the  infantile  brain,  therefore, 
causes  which  seem  trivial,  may  be  none  the  less  act- 
ive in  arresting  development.  Only  some  of  the 
most  important  ones  can  be  touched  upon  here. 

A  foremost  place  among  them  is  occupied  by  dis- 
eases of  the   brain   and   its  membranes.     Cerebral 


Mat  U,  1901] 


ARRESTED  MENTAL  DEVELOPMENT 


["The  Philadelphia 

Lmedical  Journal 


927 


or  meningeal  hemorrhage  is  not  rare  in  infancy  and 
tarly  childhood.  It  becomes  less  frequent  after 
three  years  of  age.  In  the  early  cases,  that  is,  be- 
fore two  years  of  age,  the  resulting  idiocy  is  pro- 
found. Older  children  sometimes  escape  with  little 
or  no  intellectual  impairment,  and  in  older  children, 
if  mental  defect  occurs,  it  is  usually  manifested  as 
feeble-mindedness  merely.  All  varieties  of  menin- 
gitis also  are  fertile  causes.  It  is  to  be  remembered 
that  sporadic  and  epidemic  cerebro-spinal  menin- 
gitis are  not  rare  in  infants  and  young  children. 

Of  the  infectious  diseases,  scarlet  fever  and  ty- 
phoid fever  are  the  ones  most  frequently  mentioned 
as  entailing  mental  deficiencies  in  children.  To 
these  must  be  added  the  intestinal  disturbances 
which  form  so  important  a  chapter  in  infantile  path- 
ology. The  cerebral  manifestations  of  these  intes- 
tinal intoxications  are  extremely  diverse  and  seri- 
ous. Convulsions,  coma,  all  forms  of  jerking  move- 
ments, rigidity  of  the  muscles  of  the  neck,  strabis- 
mus and  similar  symptoms  result  from  them  without 
any  gross  lesion  in  the  brain.  If  temporary,  the  re- 
sults may  not  be  serious.  But  if  continued  as  they 
sometimes  are,  over  days  and  weeks,  it  is  difficult 
to  believe  that  they  do  not  interfere  with  the  normal 
development  of  the  brain. 

The  subject  of  infantile  convulsions  is  too  ex- 
tensive to  receive  more  than  the  most  cursory  men- 
tion in  a  paper  of  this  character.  It  is,  however, 
too  important  to  be  passed  over  without  a  word. 
Many  children  pass  through  all  the  trials  of  infancy 
and  childhood  without  convulsions.  Alany  of  those 
who  have  them,  grow  up  into  normal  people.  But 
in  some  children,  convulsions  ensue  upon  the  slight- 
est provocation.  Of  these  children  a  certain  pro- 
portion become  confirmed  epileptics.  And  as  epi- 
lepsy developing  in  infancy  and  childhood  is  almost 
invariably  associated  with  intellectual  defects,  this 
question  has  important  bearings  on  our  subject. 
Now,  when  epilepsy  develops  in  adults,  it  is  only 
very  rarely  that  the  trained  and  wide-minded  ob- 
server can  be  convinced  that  it  is  of  reflex  origin. 
But  in  infants  and  young  children  the  case  is  differ- 
ent. They  are  essentially  reflex  organisms  and 
respond  vehemently  to  peripheral  stimulation. 
There  is  no  doubt  whatever,  that  convulsions  in 
children  may  be  the  direct  consequences  of  such 
peripheral  irritations  as  worms,  phimosis,  constipa- 
tion, dentition,  adenoids  and  the  like.  It  may  well 
be  that  the  nervous  organization  of  such  children  is 
more  excitable  than  normal.  It  is  none  the  less 
true  that  the  convulsions  often  cease  when  the  irri- 
tation is  removed.  If  convulsions  recur  with  suf- 
ficient frequency,  the  reflex  arc  becomes  so  well 
travelled  that  the  child  forms  the  epileptic  habit 
until  finally  the  fits  take  place  without  discoverable 
cause.  The  disease,  though  originating  peripheral- 
ly, would  eventually  be  called  idiopathic  epilepsy. 
Now  idiopathic  epilepsy  is  a  disease  which  is  con- 
sidered par  excellence  as  a  child  of  the  neuropathic 
family.  All  statistics  place  it  high  in  the  list  of  ner- 
vous diseases  in  which  degenerative  stigmata  have 
occurred  in  near  relatives.  Yet  in  a  certain  number 
of  cases  the  family  record  is  clean.  Now  I  am  of 
the  opinion  that  in  many  such  cases  the  disease 
had  a  peripheral  origin  in  infancy.  If  this  opinion  is 
correct,  it  carries  with  it  an  important  moral  in  the 


matter  of  the  treatment  of  infants  and  young  child- 
ren of  excessive  reflex  excitability. 

Sensorial  idiocy  is  the  variety  of  mental  defect 
brought  about  by  the  loss  during  infancy  or  early 
childhood,  of  one  or  more  of  the  special  senses.  It 
is  limited  almost  exclusively  to  sight  and  hear- 
ing. 

The  deprivation  of  these  means  of  education 
necessarily  implies  that  fundamental  conceptions 
supplied  by  them  can  never  be  acquired.  Without 
special  instruction,  the  menial  horizon  of  children 
so  afflicted  is  necessarily  limited.  Sucn  women  as 
Laura  Eridgman  and  Helen  Keller  are  brilliant  ex- 
amples of  what  skillful  and  painstaking  instruction 
can  do.  It  cannot  be  said  that  such  persons  are 
feeble-minded,  but  it  cannot  be  gainsaid  that  they 
are  defective.  Loss  of  hearing  affects  the  minds  of 
children  more  than  loss  of  sight.  The  cranial  ca- 
pacity of  deaf  mutes  is  below  that  of  hearing  chil- 
dren. Also  mental  culture  in  the  average  deaf  mute 
cannot  reach  such  a  high  point  as  in  the  hearing 
child.  In  disposition,  also,  deaf  mutes  are  less  pleas- 
ant and  less  trustworthy. 

With  slight  degrees  of  sensorial  defect,  children 
can  usually  be  well  educated  and  be  normally  de- 
veloped. But  even  in  them  one  can  hardly  expect 
the  full  mental  unfolding  that  might  have  been 
looked  for  had  the  child  not  been  hampered  in  the 
acquisition  of  its  ideas. 

In  addition  to  the  mental  defects  caused  by  total 
blindness  or  total  deafness,  imperfections  in  the 
special  sense  organs  of  sight  and  hearing  may  so 
much  interfere  with  the  education  of  a  child  that  it 
gets  the  name  of  being  a  backward  child.  This  is 
especially  true  of  hearing.  Even  slight  imperfec- 
tions in  hearing  may  seriously  interfere  with  the 
child's  education.  It  is  needless  to  say  that  in 
very  young  children,  partial  deafness  is  a  very  dif- 
ficult thing  to  discover.  Errors  of  refraction  and 
muscular  insufficiencies  always  put  obstacles  in  the 
way  of  the  development  of  the  intelligence.  It  so 
frequently  happens  that  children  with  these  trou- 
bles do  not  learn  to  spell  well,  that  some  authorities 
maintain  that  in  nearly  all  children  who  are  con- 
spicuously bad  spellers  some  ocular  imperfection 
mcLY  be  demonstrated. 

Traumatisms  play  so  small  a  part  in  the  causation 
of  feeble-mindedness  and  idiocy  that  I  shall  pass 
them  over.  But  I  cannot  bring  this  paper  to  a  close 
without  some  mention  of  the  nutritional  disturb- 
ances by  which  the  brain  of  the  child  is  interfered 
with  in  its  development. 

A  large  number  of  feeble-minded  children  are 
rachitic.  From  the  frequency  with  which  rickets 
attacks  the  cranial  bones,  there  was  long  thought 
to  be  an  intimate  connection  between  the  local  bone 
disease  and  the  defective  intelligence.  There  may 
be,  but  to  my  mind  the  relation  between  rickets  and 
faulty  brain  development  is  better  to  be  explained 
by  disturbances  of  nutrition  in  the  developing  gan- 
glion cells,  than  by  any  local  process  of  pressure, 
irritation  or  anemia.  A  rachitical  pelvis  is  due  to 
the  bones  not  being  properly  supplied  with  essen- 
tials at  the  time  they  need  it  most.  And  idiocy  or 
feeble-mindedness  in  a  rachitic  child  finds  its  best 
explanation  in  under-feeding  of  the  ganglion  cells 
at  the  time  of  their  greatest  growth. 

In  malnutrition,  both  when  arising  from  improper 


928 


The  Philadelphia  "] 


Medical  Jt_ 


CATARACT  EXTRACTION 


[Mat  U,  1901 


food  and  poor  hygienic  surroundings,  and  when 
arising  from  poisons  circulating  in  the  blood,  are  to 
be  found  the  origin  of  many  cases  of  defective  braiii 
development. 

Some  of  the  acute  nutritional  and  toxic  influences 
have  been  mentioned  under  infectious  diseases. 
Here  must  be  added  some  which  act  more  slowly. 

In  amaurotic  family  idiocy,  which  usually  makes 
its  appearance  between  the  second  and  eighth  month 
of  extra  uterine  life,  there  is  a  visible  degeneration 
throughout  the  whole  nervous  system.  No  satis 
factory  explanation  of  the  pathogenesis  of  this  dis- 
ease has  yet  been  offered.  But  it  must  result  from 
toxic  or  nutritional  causes.  We  have  learned  some- 
thing abotit  the  pathogenesis  of  cretinism,  but  we 
are  far  from  knowing  why  the  thyroid  secretion  dis- 
appears. It  is  interesting  to  note  in  this  connection 
the  case  of  Shield's  (New  York  Medical  Journal,  1898, 
No.  13),  in  which  a  child  ten  years  old,  had  an  at- 
tack of  acute  thj'roiditis  with  fever.  Subsequently 
the  thyroid  atrophied  and  cretinism  developed. 

As  to  external  poisons,  alcohol  is  the  only  one  I 
shall  mention.  Difficult  as  it  is  to  believe,  chronic 
alcoholism  and  its  effects  in  infants  and  very  young 
children,  are  more  and  more  frequently  heard  of. 
It  comes  about  from  the  parents  giving  beer  and 
wines  to  their  little  ones,  and  from  medicines  given 
in    alcoholic   solutions. 

In,  closing,  I  wish  to  express  my  appreciation  of 
the  inequality  in  point  of  frequency  and  importance, 
of  the  causes  which  have  been  mentioned.  Some  of 
them  are  very  rare  and  are  significant  in  gross  totals. 
Others  merit  much  more  detailed  description  than 
the  limits  of  this  paper  would  justify.  But  all  have 
this  in  common,  that  the  study  of  any  one  of  them, 
whether  frequent  or  infrequent,  teaches  important 
lessons  to  those  who  wish  to  have  children,  and  to 
those  whose  dutv  it  is  to  care  for  them. 


CATARACT  EXTRACTION. 

By  EDWARD  J.\CKSON,  A.  M.,  M.  D., 


of  Denver. 


» 


Ophthalmologfist  to  ihe  .'Vrap.-^hOL-  County  Hospit.il,  consultant  in  Ophthal- 
mology to  St.  Anthony's  Ho.ipital.  Denver;  Emeritus  Professor ; 

of  Diseases  of  theKye  in  the  I'hiladelphia  Polyclinic. 

The  following  series  of  recent  cases,  although  -x 
small  one,  illustrates  as  well  as  could  large  num- 
bers,  the  more  important  points  regarding  cataract 
extraction,  as  it  is  now  resorted  to  and  executed. 

Case  1. — L.  G.,  a  colored  woman  aged  70,  has  been  slow- 
ly losing  her  sight  for  some  years.  The  right  eye  still 
counts  fingers  at  four  feet.  The  left  can  just  perceive 
movements  of  the  hand  in  front  of  the  eye.  In  the  right, 
there  is  a  nuclear  cataract  so  far  advanced  that  no  fundus 
reflex  is  visible.  The  left  presents  a  hyper-mature,  white, 
slightly  shrunken  cataract.  The  anterior  chamber  is  of 
moderate  depth;  the  tension  of  the  eye  normal.  The  pupils 
are  normal  in  reaction  and  of  moderate  size.  Fields  of 
vision  apparently  normal,  with  good  quantitative  perception 
of  light. 

March  6,  1900,  extraction  was  done  on  the  left  eye  with 
a  small  iridectomy,  because  the  prominence  of  her  eye 
andthethick  powerful  lids  of  a  colored  person  increased  the 
risk  of  iris  prolapse  after  simple  extraction.  The  incision 
was  made  just  within  the  corneal  margin.  The  capsule 
was  opaque,  opposite  the  lower  portion  of  the  pupil;  but 
Jmmediately  after  the  operation  the  patient  could  count 
fingers.  Four  days  later,  the  anterior  chamber  had  begun 
to  reform,  showing  that  the  wound  had  closed;  and  next 
day  it  was  of  full  depth.     The  patient  was  allowed  to  sit 


up  on  the  fourth  day  and  the  dressing  omitted  from  her 
right  eye. 

Recovery  was  somewhat  slow,  but  uninterrupted.  At 
the  end  of  six  weeks  she  had  vision  of  4-20  mostly.  I  then 
(lidaneedle  operation,  incising  the  capsule  in  the  form  of  an 
inverted  T.  A  week  later  the  eye  was  entirely  quiet,  and 
with  -|-12.5  -|-3.cv.  ax.  145'  vision  equal  to  4.6  mostly.  Three 
months  later  vision  had  risen  to  4-5  full. 

CASE  2. — B.  W.,  a  man  aged  SI;  has  been  unable  to  read 
for  5  or  six  years,  his  sight  having  begun  to  fail  some  years 
before  that.  The  right  eye  was  first  affected.  Vision  is 
noticeably  worse  now  than  a  year  ago.  There  is  good 
quantitative  perception  of  light  in  the  left  eye  and  fair  in 
the  right;  with  good  fields.  The  pupils  react  slightly  to 
light,  the  right  being  3.5  mm.  and  the  left  2.5  mm.  in  diam- 
eter. They  are  very  dark  gray,  the  color  of  the  pupil  in 
many  old  people  who  retain  good  vision;  but  no  fundus 
reflex  can  be  obtained  with  the  ophthalmoscope.  Tension 
of  the  eyeballs  normal;  anterior  chamber  deep.  He  has  a 
habit  of  squeezing  the  lids  tightly  together,  and  does  so 
whenever  they  are  touched.  He  had  a  slight  chronic  catar- 
rhal conjunctivitis,  for  which  he  was  treated  a  few  days 
with  applications  of  silver  nitrate  solution. 

June  20,  1900,  simple  extraction  was  done  on  the  left  eye, 
at  St.  Anthony's  Hospital.  The  incision  in  the  corneal 
margin  was  of  full  size,  including  almost  half  of  the  cornea 
The  lens  proved  to  consist  of  a  large,  hard,  dark  brown 
nucleus,  with  only  a  trace  of  cortex.  The  pupil  was  left 
clear  and  central,  but  distorted  by  the  stretching  of  the 
large  nucleus.  Pilocarpin,  1  to  20,  was  used  to  contract  the 
pupil.  The  dressing  was  omitted  from  the  right  eye  on 
tiie  sixth  day,  and  from  the  operated  eye,  during  the  day- 
time, on  the  eighth  day.  No  sign  of  the  anterior  chamber 
having  reformed  was  noted  until  the  tenth  day.  It  was 
again  quite  empty  on  the  eleventh  day,  and  a  small  pro- 
lapse of  the  iris  occurred  at  this  time.  The  wound  had 
.  closed  and  the  anterior  chamber  was  fully  reestablished 
on  the  fifteenth  day.  On  the  seventeenth  day  the  patient 
went  home  to  Julesburg. 

October  5,  he  retruned,  the  eye  being  entirely  quiet.  The 
ophthalomometer  showed  an  astigmatism  of  10.  D.  With 
-  -  8  equal  to  -|-  7.  cy.  ax.  170°. vision  equal  to  4.8  partly.  The 
only  trace  remaining  of  the  prolapse  was  a  moderate  length- 
ening of  the  pupil  upward,  and  a  small  pigment  spot  near 
the  centre  of  the  firm  corneal  scar. 

CASE  3. — C.  S..  a  man  aged  28,  two  years  ago  was  struck 
in  the  right  eye  by  a  small  flying  fragment  of  rock,  which 
caused  no  bleeding  or  subsequent  inflammation.  A  year 
ago  he  noticed  that  "something  was  growing  over  the 
sight  of  the  eye."  Vision  is  now  reduced  to  counting  fin- 
gers at  ten  inches,  while  in  the  left  eye  vision  equals  4-5. 
There  is  no  scar,  no  adhesion  of  the  iris.  Tension  of  eye- 
ball normal.  The  right  pupil  is  occupied  by  white  lens 
opacity,  but  not  of  a  uniform  milky  appearance.  Under 
cocain  the  pupil  dilates  to  8.  mm.,  but  its  periphery  is  occu- 
pied by  hazy  lens.  There  was  slight  conjunctival  dis- 
charge, which  disappeared  under  the  protargol  solution- 
August  28,  1900.^1  removed  the  lens  from  the  right  eye 
by  simple  extraction.  The  nucleus  proved  to  be  as  largo 
and  firm  as  the  average  at  50  years  of  age,  and  was  deliv- 
ered with  some  difliculty  through  what  was  practically  a 
"mm.  flap  incision  in  the  upper  corneal  margin.  The  iris 
prolapsed  and  had  to  be  returned  with  the  spatula,  but  after 
that  the  pupil  remained  central  and  round.  Eserin  was  in- 
stilled and  both  eyes  closed  with  a  simple  dressing.  At 
the  end  of  32  hours,  the  anterior  chamber  was  fully  re- 
established. 

Au.gust  30. — Eserin  was  used  for  the  last  time  and  the 
dressing  was  omitted  from  the  left  eye. 

September  1.- — Hysocyamin  was  instilled,  and  next  day 
the  pupil  was  well  dilated,  showing  numerous  gray  masses 
in  the  capsule,  with  a  cle.-u-  space  above  them. 

September  3. — .\11  dressings  omitted. 

September  7. — Patient  came  to  the  office,  and  the  oph- 
thalmometer showed  5.  D.  of  astigmatism,  axis  of  convex 
cyl.  at  30°. 

.\pril  9th.  1901.— With  -|-  13.5  equal  to  -;-  0.50  cyl.  ai.  35° 
vision  equal  to  4.9. 

C.\SE  4, — J.  C.  P..  a  man  aged  75.  began  to  wear  glasses 
at  45.  and  between  50.  and  60.  he  got  his  "second  sight,"  so 
that  he  could  read  without  glasses.  But  for  three  years 
vision  has  been  failing.  He  can  still  see  pretty  well  in  the 
periphery  of  the  field,  but  In  each  eye  central  vision  Is 
reduced  to  counting  fingers  at  one  foot.  He  has  flashes  of 
light  before  the  left  eye  and  sometimes  dark  specks  floating 


Mat  11,  1901] 


CATARACT  EXTRACTION 


TThe  Philadelphia 
Lmedical  Journal 


929 


in  front  of  it.  The  tension  of  the  eye-ball  is  normal.  The 
fields  of  vision  are  apparently  perfect,  and  there  is  good 
quantitative  perception  of  light. 

September  15. — I  did  simple  extraction  on  the  right  eye. 
The  globe  was  rather  collapsed  and  soft  from  cocain.  The 
lens  proved  to  be  chiefly  a  yellowish  brown,  hard  nucleus. 
After  its  removal  the  patient  said  that  everything  looked 
blue,  except  at  the  centre  of  the  field.  The  pupil  contracted 
well  under  eserin,  and  remained  central  and  circular.  Both 
eyes  were  closed  with  a  simple  dressing.  At  56  hours  the 
anterior  chamber  was  of  full  depth.  The  pupil  was  occu 
pied  by  gray  cortex;  and  ue  saw  no  better  than  before  th( 
operation. 

September  19. — The  dressing  was  omitted  from  the  left 
eye,  and  after  this  no  eserin  was  employed  in  the  right. 

September  22. — Instilled  a  mydriatic. 

Sptember  24. — All  dressings  omitted.  Complains  of  ach- 
ing and  pain  in  the  eye,  probably  from  rubbing  of  scar 
against  the  lid.  Eye  free  from  hyperemia,  except  in  the 
region  of  the  scar.. 

October  2. — Came  to  office;  eye  quiet  and  free  from 
pain.     The  ophthalmometer  shows  9.  D.  of  asitgmatism. 

October  11. — Some  reflex  is  visible  in  the  right  pupil, 
and  ho  thinks  his  vision  has  improved  in  the  last  few  days; 
but  it  is  still  limited  to  counting  fingers  within  two  feet. 
I  did  a  needle  operation,  incising  the  capsule  on  the  lines 
of  an  inverted  V.  A  simple  dressing  was  used,  until  the 
next  day.  Four  days  later,  the  eye  was  free  from  hyper- 
emia, and  with  -|-  8  equal  to  -]-  4.  cy.  ax.  5°  vision  equal  to 
4.12  partly. 

November  23. — He  was  given  right  -|-  9.  equal  to  -|-  2.5 
cy.  ax.  11)°,  which  gave  vision  4-6  partly,  and  -I-  3.5  sperical 
was  added  for  reading. 

March  6,  1901. — His  vision  with  the  same  glass  is  4-5 
mostly. 

CASE  5. — E.  K.  B.,  a  woman  aged  68,  always  near- 
sighted, had  noticed  her  vision  failing  for  several  years. 
She  had  suffered  from  apoplexy  four  months  previously, 
a  right  hemiplegia  but  no  aphasia,  followed  by  complete 
recovery.  The  fields  were  good  and  central  vision;  right, 
4-SO,  left  4-20  mostly,  .with  correcting  lenses.  There  was 
general  haziness  of  the  right  lens  with  streaks  of  cortical 
onacity.  In  the  left  there  was  a  dense  posterior  polar  opacity 
A  few  days  after  I  first  saw  her,  she  suffered  a  severe  at- 
tack of  angina  pectoris,  with  very  great  disturbance  of  the 
circulation,  after  which  her  general  condition  slowly  im- 
proved. At  the  end  of  three  months  her  vision  was  reduced 
to:     Right,  counting  fingers  at  1  metre;  Left.  4-30. 

October  22. — I  did  simple  extraction.  The  incision  wos 
placed  slightly  beneath  the  conjunctiva.  The  nucleus  was 
large,  and  considerable  clear  cortex  was  scraped  away  in 
expelling  it.  The  iris  settled  back  without  stroking.  Eserin 
was  instilled  and  a  simple  dressing  applied  to  both  eyes. 
The  opreation  was  done  in  the  morning,  with  the  patient 
sitting  in  an  easy  chair:  and  she  was  kept  in  this  chair 
until  evening,  and  then  put  to  bed  with  the  head  consider- 
ably elevated,  to  diminish  the  risk  of  hemorrhage.  At  the 
end  of  33  hours,  the  anterior  chamber  had  reformed,  but 
was  still  shallow.  It  did  not,  however,  re-open,  and  two 
days  later  was  full  of  depth. 

October  24. — Eserin  was  omitted:  and  the  next  day  a 
mydriatic  was  used.  On  the  seventh  day  she  complained 
much  of  the  feeling  of  a  foreign  body  under  the  under  lid, 
probably  from  bulging  of  the  scar.  Up  to  this  time  there 
had  been  a  good  deal  of  swelling  of  the  conjunctiva;  but  it 
was  now  diminishing. 

November  10. — She  came  to  the  office.  The  corneal  as- 
tigmatism amounted  to  7.  D. 

November  28. — She  was  given  distance  glasses:  Right 
-|-  7.5  equal  to  -[-  4.  cy.  ax.  17°.     Vision  equal  to  4-5. 

January  17,  1901. — The  strength  of  the  cylinder  was  di- 
minished to  3.5  D.,  giving  vision  of  4-4  mostly. 

CASE  6. — L.  M.  L.,'a  woman  aged  60,  who  four  years  ago 
suffered  from  a  very  severe  iritis  in  the  left  eye,  with  a  his 
tory  of  preceding  slight  traumatism,  but  no  perforating 
wound.  At  this  time  she  was  seen  by  five  oculists,  and  was 
nnder  treatment  for  9  months.  She  was  advised  by  three 
of  them  to  have  the  eye  enucleated.  But  this  eye  finally 
became  quiet  and  has  shown  no  relapse  since.  Last  July, 
the  right  eye  became  inflamed  and  was  sore  for  two 
months.  The  inflammation  followed  exposure  to  cold  and 
wet.  She  has  always  been  near  sighted.  Could  read  some 
with  the  right  eye  after  the  left  was  first  affected.  But 
vision  has  gradually  failed  ever  since.  Now  the  right 
counts    fingers    at    three    feet,    the    left    counts    fingers 


held  within  three  inches  of  the  eye.  Right  pupil  is  oval, 
long  axis  vertical,  and  reacts  fairly  to  light.  The  iris  is 
normal  in  appearance,  but  shows  three  broad  posterior 
synechiae,  when  the  pupil  is  dilated.  There  is  general 
haziness  of  the  lens,  but  the  fundus  reflex  can  be  detected 
throughout  the  pupil.  Tension  of  the  both  eyes  about 
normal  December  10. — The  right  was  extracted,  without 
iridectomy.  It  was  almost  entirely  nucleus,  brown,  hard, 
4.  mm.  thick,  and  8  mm.,  in  diameter. 

December  15. — A  small  incarceration  of  the  iris  occurred; 
the  anterior  chamber  was  re-established,  and  there  was 
mild  iritis.  From  this  time  on  there  was  a  slow  iritis,  at- 
tended with  moderate  hyperemia,  very  little  pain  and  no 
tenderness  of  the  eyeball;  but  with  considerable  exudate 
into  the  pupil.  Not  until  the  last  of  January  did  the  eye 
become  free  from  hyperemia,  and  then  vision  was  no  bet- 
ter than  before  the  operation. 

February  10 — A  needle  operation  v,'as  done,  giving  a  very 
small,  clear  pupil,  but  permitting  considerable  retraction 
of  the  iris.  At  first  there  was  very  little  reaction,  then  aa 
iritis  occurred,  slowly  increasing  for  two  weeks,  after 
which  it  slowly  yielded.  But  the  eye  was  not  free  from 
hyperemia,  March  9,  when  the  patient  had  to  leave  the 
city  for  her  home  in  Wyoming. 

When  first  tested  with  the  ophthalmometer,  January  13, 
her  astigmatism  was  3  D.,  when  last  sen  it  had  diminished 
to  2  D..  with  the  axis  at  30°  and  with  -j-  12  sp.  vision  equal 
to  10-200. 

CASE  7.— T.  B.,  a  man  aged  48.  Sight  in  the  left  eye 
has  been  failing  for  3  years.  He  is  a  miner  and  his  eyes 
have  frequently  been  struck  by  pieces  of  flying  rock;  but 
have  not  been  severely  injured,  and  no  scar  can  be  de- 
tected. The  vision  of  the  right  eye  is  normal.  The  left 
has  good  light  perception,  and  good  field.  Tension  normal 
in  both.  The  left  pupil  is  occupied  by  grayish  white  opa- 
city; which  is  almost  uniform,  but  on  examination  proves 
to  be  entirely  so.  The  pupil  reacts  normally  and  the  an- 
terior chamber  is  very  deep.  He  has  a  pterygium  5.  mm. 
wide,  extending  3.  mm.  on  the  cornea  at  the  nasal  margin. 

March  2,  1901.  I  did  simple  extraction  on  the  left  eye 
at  St.  Anthony's  Hospital.  The  incision  included  the  up- 
per third  of  the  corneal  margin.  The  nucleus  was  found  as 
large  laterally,  but  not  so  thick  as  the  average  senile  nu- 
cleus. It  was  thinly  covered  by  soft  cortex.  The  incision 
having  been  planned  for  a  smaller  nucleus,  there  was 
some  difficulty  in  expelling  the  lens.  It  was  immediately 
followed  by  fluid  vitreous,  1-6  to  1-4  of  the  vitreous  being 
lost.  Eserin  was  instilled  and  the  simple  dressing  applied 
to  both  eyes.  At  the  end  of  30  hours  the  anterior  chamber 
was  of  full  depth;  the  eye  was  free  from  pain,  and  tho 
sound  eye  showed  as  much  hyperemia  from  bandaging  as 
did  the  eye  operated  on.  The  wound  did  not  reopen.  Eser- 
in was  omitted  on  the  third  day,  and  atropin  instilled 
on  the  fiifth.  All  dressings  were  removed  on  the  seventh 
day;  and  on  the  ninth  day,  the  patient  left  the  hospital, 
[lis  astigmatism,  as  shown  by  the  ophthalmometer,  was 
7.3  D. 

March  18. — The  eye  was  quiet  and  with  -|-  8.  equal  to 
-|-  4.5  cy.  ax.  155°.  vision  equal  to  4}10. 

Senile  Cataracts  at  the  Age  of  Fifty. — The  above- 
histories  indicate  sufficiently  the  common  details  of 
such  cases.  In  a  general  way  they  may  be  classed 
as  cases  of  senile  cataract,  although  two  of  the  pa- 
tients were  under  50.  In  these  two  the  cataract 
was  probably  of  traumatic  origin.  But  the  regular 
operation  for  senile  cataract  was  required ;  and  even 
with  this,  the  attempt  to  reduce  slightly  the  size  of 
the  corneal  incision  added  to  the  difficulty  of  the 
operation.  In  these  cases  the  pupil  presented  a 
white  and  almost  uniform  appearance,  so  that  my 
first  impression  was,  that  I  had  to  deal  with  fluid 
cataracts.  Closer  examination,  however,  showed 
that  the  opacity  was  not  perfectly  uniform  in  color. 
The  operation,  therefore,  was  planned  as  for  ordi- 
nary senile  cataract  and  the  conditions  developed' 
by  it  fully  confirmed  its  necessity. 

In  extracting  non-traumatic  cataract  in  young- 
persons,  I  have  a  few  times  found  the  lens  so  soft 
that  it  could  have  been  expelled  through  a  much> 


930 


The  Philadelphia  "I 
Medical  Journal    J 


CATARACT  EXTRACTION 


[Mat  U,  19«1 


smaller  incision.  But  more  frequently,  as  in  these 
two  cases,  any  decided  reduction  in  the  size  of  the 
corneal  incision  increased  considerably  the  difficulty 
of  expelling  the  lens,  and  I  have  known  operators 
of  large  experience  to  be  completely  balked  by  the 
large  size  of  the  nucleus  encountered  in  compara- 
tively young  persons.  When  a  cataract  in  a  young 
person  is  directly  traceable  to  a  wound  penetrating 
the  lens,  we  may  hope  to  find  the  lens  largely  com- 
posed of  soft  cortex.  But  when,  as  in  these  two 
cases,  the  cataract  follows  obscure  disturbance  of 
the  lens  nutrition,  the  condition  seems  to  be  more 
one  of  premature  senile  change,  including  the  en- 
largement and  rigidity  of  the  nucleus,  that  com- 
monly occur  in  later  life. 

Mature  Cataracts. — Cases  i,  3  and  7  were  of  ma- 
ture cataract.  The  first  and  last  even  somewhat 
hyper-mature.  Case  2  was  one  of  the  slow  cases. 
It  had  been  progressing  10  or  12  years  and  was 
still  advancing.  Although  the  power  to  read  had 
been  lost  for  5  or  6  years,  the  appearances  presented 
by  the  lens  were  not  those  of  mature  cataract.  The 
patient  had,  however,  reached  an  age  when  the 
lens  is  wholly  converted  into  firm  nucleus.  It  came 
away  in  a  single  mass,  giving  immediate  restora- 
tion of  vision,  so  that  fingers  could  be  counted  at 
once,  and  vision  of  4-8  partly  was  obtained  without 
any  secondary  operation. 

Extraction  of  Immature  Cataracts. — In  cases  4, 
5  and  6,  immature  cataracts  were  operated  upon. 
In  4,  although  the  central  vision  was  reduced  to 
counting  fingers  at  i  foot,  the  cortex  was  clear 
enough  to  permit  a  fair  fundus  reflex,  and  peri- 
pheral vision  good  enough  for  the  patient  to  get 
about  some  alone.  In  cases  5  and  6  fingers  could 
be  counted  at  3  feet.  So  immature  were  4  and  6, 
that  the  extraction  operation  alone  gave  no  im- 
provement in  vision.  So  much  clear  cortex  was  left 
behind,  to  become  opaciue  in  a  few  days  after  the 
operation,  that  it  interfered  with  vision  as  much  as 
did  the  original  cataract. 

These  cases  illustrate  fully  the  the  disadvantages 
of  operating  on  unripe  cataracts,  and  they  give  an 
opportunity  for  comparing  these  disadvantages 
with  the  gain  which  justifies  such  operations.  The 
patient  gained  no  material  advantage  until  after 
the  second  operation.  In  case  6  it  is  possible  that 
the  irits  was  more  severe  and  more  prolonged  than 
it  would  have  been  had  the  cataract  been  mature, 
although  this  is  not  certain.  In  case  2  and  in  case 
4,  the  healing  was  as  prompt  and  the  restoration 
of  vision  as  complete  as  could  be  expected  after  the 
removal  of  mature  cataracts,  and  no  secondary 
operation  was  required. 

But,  on  the  other  hand,  if  operation  had  not  been 
done  on  the  immature  cataract,  these  patients  were 
doomed  to  years  of  di.sability  from  loss  of  all  useful 
vision.  In  cases  2  and  4,  it  is  altogether  probable 
that  waiting  for  the  maturity  of  the  cataract  would 
simply  have  meant  leaving  the  patients  to  end  their 
days  in  blindness.  If  the  good  accomplished  bj"^  it 
ever  justifies  a  cataract  operation,  it  justifies  the 
operation  in  such  cases. 

Ripening  Operations. — This  one  question  can 
be  raised  about  immature  cataracts.  Is  it  better 
to  extract  the  unripe  cataract,  or  to  do  some  pre- 
liminary ripening  operation?  My  experience  with 
ripening  operations    has.    without    exception,    been 


favorable.  (Transaction  American  Ophthalmolog- 
ical  Society,  1893 j.  But  even  if  this  were  the  uni- 
versal experience,  which  it  is  not,  I  think  it  very 
doubtful  if  the  ripening  operation  would  be  worth 
doing  in  any  considerable  class  of  cases. 

The  chances  of  a  subsequent  secondary 
operation  being  necessary,  or  at  least  bene- 
ficial, are  not  materially  diminished  by  the  prelim- 
inary ripening;  and  the  slight  gain  in  ease  of  extrac- 
tion and  brillianc-y  of  immediate  result,  scarcely 
compensates  for  the  additional  period  of  waiting 
after  the  preliminary  operation,  before  the  chief 
operation  can  be  done.  This  view  with  regard  to 
operations  for  ripening  is  substantially  the  one  held 
by  Knapp,  Weeks,  de  Schweinitz  and  others,  who 
have  expressed  themselves  on  this  point  in  recent 
years.  The  latest  writer  on  the  subject,  W.  S. 
Dennett,  dismisses  the  question  of  ripening  opera- 
tions by  merely  remarking:  "They  are  not  worth 
while."  (New  York  Eye  and  Ear  Infirmary  Reports, 
1901.)  That  ripening  operations  are  better  than 
waiting  for  spontaneous  maturity  of  cataract  in 
many  cases,  there  can  be  no  question.  But  now  that 
we  have  learned  that  immature  cataracts  can  b  ■ 
extracted  with  safety,  their  field  of  usefulness  ha- 
largely  disappeared. 

Cataract  Confined  to  One  Eye. — Of  course,  what 
has  been  said  about  the  advantages  of  extraction  oi 
immature  cataracts  applies  only  w-hen  vision  has 
been  greatly  impaired  or  lost  in  the  other  eye.  If 
in  the  other  eye,  vision  is  normal  or  as  good  as  the 
cataract  extraction  is  likely  to  give,  there  is  little 
reason  for  doing  extraction  before  the  cataract 
reaches  maturity. 

When  one  eye  presents  a  mature  cataract,  should 
it  be  extracted  even  if  the  other  has  normal  vision? 
This  question  was  raised  in  cases  3  and  7.  Under 
some  circumstances  it  may  be  proper  not  to  advise 
any  operation.  Patients  who  are  old  and  feeble, 
and  who  do  not  lead  an  active  life,  will  experience 
but  little  benefit  from  the  removal  of  the  cataract. 
But  those  who  are  younger  and  who  lead  an  active 
life  should  always  be  advised  to  have  a  ripe  cataract 
removed. 

As  a  rule,  the  removal  of  monocular  senile  catar- 
act will  not  restore  true  binocular  vision.  The 
strong  lens  required  by  the  aphakic  eye  prevents  it 
from  working  satisfactorily  with  the  eye  which  re- 
tains its  crystalline  lens.  The  chief  positive  gain 
from  the  extraction  in  these  cases  is  from  the  in- 
creased field  of  vision.  Even  without  any  cataract 
glass,  the  patient  will  gain  by  the  operation  the  full 
binocular  field  for  all  practical  purposes.  In  this 
way  he  will  be  saved  from  the  dangers  of  accident 
that  attend  one  who  is  blind  of  one  eye.  The  ex- 
tent of  this  advantage  will  of  course  depend  upon 
the  patient's  activity  and  liability  of  exposure  to 
such  accidents. 

The  other  gains  through  the  removal  of  the  cat- 
aract in  such  cases  are  the  avoidance  of  the  risks  of 
hypermature  cataract,  and  of  temporary  blindness 
should  the  other  eye  become  involved.  The  danger 
of  a  cataract  becoming  hypermature  is  much  less 
in  an  old  person,  while  in  one  imder  50  there  i* 
every  probability  of  such  an  event.  The  risks  from 
hypermature  cataract  are  quite  serious.  I  have 
recently  seen  an  eye  very  badly  damaged  bv  glau- 
coma, apparently  due  to  this  cause.    H.  GiflFord.  in 


May  11,  1901] 


CATARACT  EXTRACTION 


TTHE    PHILADELPHIi 

Lmedical  Journal 


931 


discussing  the  dangers  of  the  spontaneous  cure  of 
senile  cataract,  reports  four  cases  of  the  kind. 
(American  Journal  of  Ophthalmology,  October, 
1900J,  and  H.  D.  Bruns  (American  Journal  of  Oph- 
thalmology, February,  1901),  reports  an  additional 
case. 

I  have  seen  the  good  eye  largely  disabled  from  the 
irritation  caused  by  the  movements  of  the  iris  over 
the  hard  rough  anterior  surface  of  a  partly  calcar- 
eous lens  in  the  other  eye,  the  removal  of  which 
gave  immediate  complete  relief.  The  extraction 
of  a  hypermature  cataract  is  attended  with  decided- 
1_."  greater  danger  than  is  the  removal  of  one  that 
IS  simply  mature,  or  even  immature.  I  should 
always  regard  an  overripe  cataract  as  one  that  was 
seriously  complicated.  As  a  rule,  the  capsule  be- 
comes thickened,  increasing  the  difficulty  of  extrac- 
tion, and  rendering  a  secondary  operation  neces- 
sary and  more  difficult.  Then  a  hypermature  cat- 
aract in  a  relatively  young  person  is  generally  quite 
white,  making  a  very  noticeable  deformity.  Sev- 
eral times  I  have  extracted  such  cataracts  from 
completely  blind  eyes,  simply  because  of  this  cos- 
metic indication. 

One  cannot  urge  operation  for  monocular  cataract 
just  as  he  would  urge  iridectomy  for  acute  glau- 
coma; or  enucleation  of  a  blind  eye  that  threatened 
sympathetic  opthalmia.  But  he  can  lay  these  im- 
portant considerations  before  the  patient,  and  posi- 
tively advise  extraction  in  most  cases  before  the 
age  of  60,  and  in  some  at  a  still  later  age. 

Simple  Extraction. — In  the  above  cases  simple 
extraction  was  done  except  in  case  i.  But  it  may  be 
questioned  if  case  6  was  not  also  better  suited  to 
•extraction  with  iridectomy.  I  will  not  here 
discuss  the  advantages  of  simple  extraction 
in  cases  suited  for  it.  They  are  well  il- 
lustrated by  the  patient  shown.  In  the  after- 
treatment,  the  especial  danger  of  this  operation  is 
prolapse  of  the  iris.  This  danger  is  lessened  by  the 
use  of  eserin.  In  the  one  case  in  which  prolapse 
occurred  eserin  was  not  used,  and  the  long  time  the 
wound  remained  open  with  the  habit  of  nipping  the 
lids  together  invited  such  an  accident. 

The  Dressing. — The  simple  dressing  employed  in 
all  the  cases  is  one  that  I  have  used  for  15  years 
after  cataract  extraction.  Besides  its  simplicity, 
it  seems  to  me  to  better  meet  the  indications  than 
any  other.  It  consists  of  a  small  loose  mass  of  ab- 
sorbent cotton  held  in  place  by  one  or  more  strips  of 
adhesive  plaster,  extending  from  the  brow  of  the 
cheek.  It  is  applicable  to  many  other  conditions 
requiring  some  sort  of  ocular  dressing.  I  have 
never  seen  any  bandage  that  would  retain  a  dress- 
ing with  the  accuracy,  with  as  little  chance  of 
displacement  or  disturbance  by  turning  the  head  on 
the  pillow. 

When  used  after  cataract  extraction,  the  dressing 
must  be  removed  with  especial  care,  not  to  provoke 
a  squeezing  together  of  the  lids  by  the  pull  of  the 
plaster.  During  the  first  few  days  I  usually  cut  the 
plaster,  leaving  the  part  in  contact  with  the  skin 
undisturbed.  After  the  first  dressing,  the  new 
strip  is  attached  to  the  piece  left  fast  to  the  skin. 

I  have  never  used  any  form  of  protective  mask 
after  cataract  extraction,  to  prevent  the  patient 
from    striking    the    dressings    and    reopening    the 


wound.  But,  in  over  200  cases,  I  have  never  had 
any  serious  interference  with  healing  from  this 
cause.  Those  who  use  such  masks  have  occasion- 
ally reported  that  the  accident  which  it  was  sought 
to  guard  against  occurred  when  the  mask  had  been 
removed.  It  seems  rather  an- insufficient  precau- 
tion, and  yet,  impressing  the  patient  strongly  at  the 
time  of  eperation,  with  the  idea  that  the  hands  must 
be  kept  away  from  the  operated  eye — establishing 
the  habit  of  inhil)iting  movements  in  that  direction 
— seems  to  have  proved  quite  as  reliable  and  efTect- 
ive  in  preventing  such  accidents  as  any  mechanical 
device.  When  the  mask  is  relied  upon  this  habit  of 
keeping  the  hands  from  the  eyes  is  not  acquired, 
and  then  when  the  mask  is  left  ofT,  the  accident 
C)cciirs. 

Delayed  Union. — These  cases  illustrate  the  va- 
riety in  the  length  of  time  required  for  closure  of 
the  corneal  incision.  In  case  7,  the  anterior  cham- 
ber was  found  of  full  depth  at  the  end  of  30  hours. 
In  case  2  it  was  not  so  completely  re-established 
until  after  15  days.  Yet  in  both  cases  the  result 
was  favorable,  although  in  case  2  the  prolapse  was 
probably  due  to  this  long  delay  in  closure  of  the 
wound.  I  have  once  had  the  incision  remain  open 
for  21  days.  This  case  also  did  well  in  every  other 
respect.  These  cases  of  slow  healing  have  usually 
been  marked  by  rather  deficient  hyperemia  of  the 
eyeball  for  several  days  after  operation.  Case  2 
of  this  series  was  no  exception.  The  closure  of  the 
wound  has  several  times  appeared  to  be  hastened, 
as  in  this  case,  by  removing  all  dressings  and  allow- 
ing greater  freedom  of  movement. 

Risk  of  Expulsive  Hemorrhage. — Case  5  was  one 
that  was  undertaken  with  especial  anxiety.  Expuls- 
ive intraocular  hemorrhage,  following  lens  extrac- 
tion, is  a  rare  but  utterly  disastrous  accident.  I 
have  twice  encountered  such  hemorrhage,  once  fol- 
lowing removal  of  the  lens  in  absolute  glaucoma, 
hoping  to  escape  the  necessity  for  enucleation,  and 
once  after  removal  of  a  dislocated  lens.  In  this 
latter  case  I  had  not  left  the  hospital  when  the  hem- 
orrhage occurred.  Placing  the  patient  in  the  up- 
right position,  the  free  flow  of  blood  from  the  eye 
was  immediately  stopped.  Since  then,  I  have  op- 
erated three  times  for  cataract  extraction,  in  pa- 
tients that  seemed  to  be  in  especial  danger  of  such 
hemorrhage,  with  the  patient  sitting  up;  and  have 
kept  her  sitting  up  for  several  hours  afterward.  In 
none  of  these  cases  did  hemorrhage  occur.  In  this 
patient,  therefore,  in  whom  the  previous  cerebral 
hemorrhage,  the  marked  vascular  disease,  and  her 
stout,  heavy  build,  all  indicated  especial  danger  of 
intraocular  hemorrhage,  the  operation  was  done 
with  the  patient  sitting  in  her  chair ;  and  she  was 
kept  with  her  head  high  until  after  the  corneal 
wound  had  closed. 

Secondary  Operations.  —  Secondary  operations 
were  done  in  but  three  of  the  seven  cases.  This  un- 
usually small  proportion  was  due  to  special  causes. 
In  case  3,  the  patient  has  perfect  vision  in  his  other 
eye,  and  does  not  need  to  wear  correcting  lenses. 
He  sees  just  as  well  with  the  eye  as  it  is,  as  he  would 
after  a  secondary  operation,  even  though  that 
should  give  him  perfect  vision  with  a  correcting 
lens.  He  probably  has  many  years  of  life  before 
him.     It  is  not  certain  that  after  opening  the  pos- 


f,-jo       The  Philadelphia  "I 
Vo^       Medical  Journal    J 


ABSCESS  OF  THE  ORBIT 


[Mat  U,  1901 


terior  capsule  and  hyaloid  membrane,  the  nutrition 
and  health  of  the  eye  would  be  as  well  preserved 
for  a  period  of  many  years.  If  a  secondary  opera- 
tion should  ever  be  of  advantage  to  him,  it  can 
then  be  done.  Until  that  time  the  eye  is  better  as 
it  is. 

In  case  7,  the  escape  of  vitreous  occurred  through 
a  large  central  opening  in  the  capsule,  so  that  we 
had  the  effect  sought  by  a  secondary  operation  with- 
out having  to  do  one.  In  cases  2  and  5,  sufficiently 
good  vision  was  obtained  from  the  primary  opera- 
tion. In  case  2,  it  might  be  improved  by  making 
an  opening  in  the  capsule,  but  the  patient  was  satis- 
fied with  the  vision  he  had  (4-8) ;  and  extremely 
anxious  not  to  be  detained  away  from  home.  It  is 
possible  that  in  these  two  cases,  a  thickening  and 
wrinkling  of  the  capsule  may  occur  in  the  next  year 
or  two,,  that  will  make  its  division  desirable.  This 
very  often  happens,  and  in  any  large  series  of  ex- 
tractions fully  three-fourths  of  the  cases  will  ulti- 
mately be  the  better  for  a  secondary  operation. 

Results. — According  to  the  usual  standards,  in 
six  of  these  cases,  the  result  is  to  be  counted  a 
perfect  success,  (vision  ranged  from  4-4  to  4-10.  In 
the  seventh  it  was  a  partial  success,  10-200.  It  has 
been  customary  to  count  as  perfect  successes  al! 
cases  obtaining  vision  of  20-200  or  i-io.  But  this 
standard  is  too  low.  Even  Schweigger's  proposi- 
tion to  raise  the  standard  for  perfect  success  to  1-6 
is  scarcely  sufficient.  Probably  to  make  20-100  the 
requirement  for  perfect  success  would  be  better. 
With  most  patients  1-5  vision  allows  of  reading 
ordinary  fype,  writing,  sewing  and  all  ordinary  oc- 
cupations that  do  not  require  especially  acute 
vision.  If  the  vision  falls  much  below  this,  the 
patient  is  prevented  from  freely  doing  these  things. 

But  these  standards  of  success,  perfect  or  partial, 
are  of  little  practical  importance  as  regards  the  in- 
dividual case.  The  general  rule  must  be,  to  aim 
at  the  best  vision  possible.  If  a  patient  with  vision 
of  20-40  can  be  brought  up  to  20-30,  or  even  20-20 
by  a  secondary  operation,  it  is  worth  doing.  Then 
the  vision  obtained  furnishes  but  a  poor  criterion 
of  the  perfection  of  the  operation.  In  the  great 
majority  of  cases,  that  fail  to  reach  perfect  vision, 
the  impairment  is  due  to  defects  of  the  eye  apart 
from  cataract,  that  existed  before  the  cataract  was 
removed.  Perfect  vision  is  not  the  rule  in  senile 
eyes  that  are  free  from  cataract ;  and  when  the 
nutrition  of  the  lens  suffers,  the  nutrition  of  other 
parts  of  the  eye  is  commonly  impaired  also. 

Cataract  extraction  has  been  less  aflfected  by  the 
evolution  of  antisepsis  than  any  other  important 
surgical  operation.  We  must  disclaim  the  possibil- 
ity of  making  the  operation  absolutely  aseptic.  It 
is  done  with  recouse  to  few  of  the  more  pretentious 
methods  and  procedures  by  which  asepsis  is  sup- 
posed to  be  secured  in  other  capital  operations ;  and 
yet,  is  there  any  other  surgical  operation  that  can 
show  a  better  record,  as  regards  infection.  Our 
experience  with  it  seems  to  teach  the  lesson,  that 
the  line  is  yet  to  be  drawn  between  essentials  and 
non-essentials  in  the  technique  of  aseptic  surgery. 


ABSCESS  OF  THE  ORBIT  FROM  DISEASE  OF  THE 
ETHMOID;  CURETTING  THROUGH  THE  ORBIT 
AND  DRAINING  THROUGH  THE  NOSE. 

BY   GEORGE   C.   HAKLANT,    M.   D. 

of  Philadelphia. 

A  rather  delicate  looking  lad.  sixteen  years  of  age.  was 
referred  from  the  Nose  and  Throat  Dispensary  of  the 
Pennsylvania  Hospital  to  the  Eye  Department.  He  had 
been  suffering  with  nasal  catarrh  for  a  year  or  more,  and 
Dr.  MacCoy  found  an  extensive  oedematous  swelling  of  the 
mucous  membrane  of  the  nose  and  caries  of  the  middle 
turbinated  bone.  The  lids  were  swollen,  and  there  was  a 
high  degree  of  exophthalmos  of  the  right  eye,  the  ball 
being  projected  downwards,  forwards  and  outwards  and  its 
motions  limited.  The  vision  was  not  much  impaired.  In- 
distinct fluctuation  could  be  detected,  and  the  patient  was 
admitted  to  the  Hospital  on  March  14,  and  a  deep  Incision 
just  below  the  upper  margin  of  orbit  gave  exit  to  a  quan- 
tity of  pus.  Careful  probing  of  the  cavity  failed  to  reveal 
dead  bone  or  any  connection  with  the  accessory  cavities, 
and  it  seemed  that  the  abscess  was  the  result  of  a  second- 
ary focus  of  inflan  mation.  Twelve  days  later,  however, 
while  introducing  a  gauze  tent,  dead  bone  was  felt  and  a 
probe  was  then  passed  through  an  opening  in  the  wall  of 
the  orbit.  It  was  therefore  decided  to  operate  at  once.  An 
incision  was  made  along  the  upper  margin  of  the  orbit, 
commencing  at  the  junction  of  its  middle  and  outer  thirds 
and  curving  down  the  side  of  the  nose  to  the  level  of  the 
lendooculi.  The  periosteum  was  then  stripped  from  the 
median  wall  and  half  of  the  roof  of  the  orbit,  and  the 
soft  parts,  including  the  eyeball,  were  drawn  outwards 
with  a  retractor.  -\  patch  of  necrosis  in  the  os  planum  and 
an  opening  into  the  posterior  ethmoidal  cells  were  founJ. 
When  the  dead  bone  was  removed  with  the  cutting  for- 
ceps the  opening  admitted  the  end  of  the  index  finger. 
The  frontal  sinus  and  anterior  ethmoidal  cells  did  not 
appear  to  be  involved.  The  ethmoid  cells  were  curetted 
with  a  sharp  spoon.  A  rubber  drainage  tube  was  then 
introduced  into  the  orbit  through  the  nose,  by  means  of  a 
lenestrated  silver  probe  very  sharply  curved,  and  held  in 
position  by  a  silver  wire  passed  through  sound  skin  at  the 
root  of  the  nose  and  fastened  to  the  forehead  by  rubber 
plaster.  The  upper  end  of  the  tube  was  thus  just  behind 
the  skin,  while  the  lower  projected  from  the  nostril.  The 
wound  was  closely  sutured,  and  the  abscess  cavity  was 
syringed  twice  a  day  through  the  tube,  at  first  with  boric 
acid  solution  and  after  a  few  days  with  peroxide  of  hydro- 
gen, one  part  to  two  of  warm  water.  There  was  very 
little  reaction  and  the  wound  healed  promptly,  except 
vhere  the  abscess  had  been  opened  where  there  is  still  a 
fistula  which  is  dailv  diminishing  in  size.  The  exopthal- 
nios  is  rapidly  subsiding  and  the  eye  now  moves  freely 
in  all  directions. 

This  is  practically  the  Jansen  operation  for  empye- 
maof  the  frontal  and  ethmoidal  sinuses,  except  that 
instead  of  packing  the  cavity  with  gauze,  as  Jansen 
does,  drainage  through  the  nostril  is  used  and  the 
wound  is  sutured,  .^t  the  last  meeting  of  the  Amer- 
ican Ophthalniological  Society  I  reported  two  cases 
— one  of  the  empyema  of  the  anterior  ethmoid  cells 
and  one  of  empyema  of  the  frontal  sinus  and  of  al! 
of  the  ethmoid  cells  operated  upon  with  this  same 
incision.  A  permanent  cure  resulted  in  each  case 
with  a  scarcely  visible  scar ;  the  cicatrix  being  prac- 
tically concealed  by  the  eyebrow.  I  hope  for  a 
quicker  result  in  this  case,  as  in  the  others  I  allowe<I 
the  tube  to  project  from  the  wound,  as  well  as  from 
the  nose,  for  a  month  and  so  retarded  the  healing. 
This  does  not  seem  necessary,  as  the  wire  holds 
the  upper  end  of  the  tube  just  behind  the  incision  of 
the  skin,  making  thorougfh  cleansing  easy,  while 
passing  as  it  does  through  the  sound  skin,  it  doe-- 
not  interfere  with  the  healing  of  the  external 
wound.  The  healing  would  probably  have  been 
more  prompt  if  I  had  performed  the  radical  opera- 
tion  at   once   instead   of   establishins:   a   fistula   bv 


Mat  11,  1901] 


PURULENT  CHOROIDITIS 


FTke  Philadelphia        q  t  t 
Lmedical  Journal  yoo 


lancing  the  abscess  and  allowing  it  to  drain  through 
the  puncture  for  twelve  days.  It,  however,  seems 
likely  to  close  in  a  short  time.  A  primary  abscess 
of  the  orbit,  except  from  traumatism,  is  very  rare. 
These  abscesses  are  nearly  always  connected  with 
diseased  bone,  generally  with  empyema  of  the  ac- 
cessory cavities,  and  when  the  nose  is  known  to  be 
diseased,  simple  evacuation  of  the  pus  is  much  the 
same  kind  of  surgery  as  is  making  a  Wilde  incision, 
instead  of  performing  the  radical  operation,  in  case 
of  abscess  of  the  mastoid. 


PURULENT  CHOROIDITIS.  FOLLOWING  AN  ATTACK 
OF  MUMPS:  DIAGNOSIS,  METASTATIC  CHOROIDI- 
TIS, REVISED  BY  STUDY  OF  THE  ENUCLEATED 
EYE-BALL. 

BY  JOHN  T.  CARPENTER,  M.  D., 

of  Philadelphia. 

Deep-seated,  purulent  inflammation  of  the  eye 
having  its  origin  in  the  choroid  or  retina,  may  be  the 
result  of  infection  from  without ;  as,  for  example, 
from  penetrating  wounds  by  foreign  bodies,  from 
operations  or  from  ulcers  of  the  cornea.  On  the 
other  hand,  the  infection  may  originate  within  the 
body  and  cause  choroiditis  or  retinitis  by  metasta- 
sis. 

Mestatatic  choroiditis  following  the  infectious 
fevers  of  childhood  is  not  of  very  frequent  occur- 
rence, but  we  find  cases  in  literature  which  have  fol- 
lowed pneumonia,  typhus,  variola,  measles,  scarlet 
fever  and  other  infectious  diseases  in  which  the  de- 
velopment of  the  purulent  choroiditis  is  explained 
in  a  rather  vague  way  as  due  to  changes  in  the  vas- 
cular or  lymphatic  system. 

The  explanation  of  foci  of  suppuration  in  the 
choroid  associated  with  ulcerative  endocarditis,  sup- 
purative diseases  of  the  sinuses  adjacent  to  the  orbit 
thrombosis  of  the  orbital  veins  or  w'ith  general 
septicemia  is  much  less  difficult.  That  most  of 
these  cases  are  due  to  the  lodgement  of  infected 
emboli  is  no  doubt  true.  Germann,  St.  Petersburg 
Med.  Woch.,  Dec.  15th,  1900.  found  during  conva- 
lescence from  pneumonia  a  purulent  metastatic  iri- 
do-choroiditis  with  symptoms  of  meningitis  and 
death  in  six  days.  Another  fatal  case  is  described 
in  which  croupous  pneumonia  was  followed  by  endo- 
carditis, embolic  retinitis  and  panophthalmitis. 
Pure  cultures  of  the  diplococcus  were  derived  from 
the  anterior  chamber. 

In  1892  Herrnheiser  observed  metastatic  panoph- 
thalmitis with  diplococci  in  the  choroid,  consecutive 
to  croupous  pneumonia.  Blessig,  Everbusch  and 
Natanson  have  each  reported  metastatic  irido-cho- 
roiditis  after  influenza. 

Cases  studied  from  bacteriologic  standpoint  have 
not  yet  been  very  numerous,  but  as  our  knowledge 
of  the  specific  germ  of  the  infectious  fevers  in- 
creases, no  doubt  these  will  be  more  frequently 
found. 

Schiess  (quoted  by  Kniess — "Eye  in  General  Dis- 
eases") observed  metastatic  irido-choroiditis  which 
necessitated  enucleation  following  an  attack  of 
mumps. 

The  following  notes  of  a  case  of  deep  suppurative 
inflammation  of  the  left  eye  in  a  young  child  just 


recovering  from  mumps,  in  which  the  diagnosis 
of  metastatic  choroiditis  was  made,  contain  some 
points  of  interest  which  seemed  to  me  sufficiently 
striking  to  merit  the  report  of  the  clinical  history. 

Harold,  aet  2,  of  Carlisle,  Penna.,  was  brought  to  me 
on  July  ISth.  1S96,  by  Dr.  S.  S.  Bishop. 

Previous  history:  Four  weeks  ago  he  had  a  severe  at- 
tack of  mumps  which  was  worse  on  the  left  side.  About 
two  weeks  after  recovery  his  parents  noticed  the  left  eye 
was  inflamed,  and  that  the  child  was  restless  and  evidently 
suffered  pain  in  that  eye.  One  week  later  Dr.  Bishop 
found  the  following  conditions  present:  lids  were  swollen; 
conjunctiva  chemotic.  with  engorgement  of  both  super- 
ficial and  deep  vessels;  the  cornea  steamy;  the  iris  bound 
down  by  unyielding  synechiae;  and  a  deep-seated  yel- 
lowish reflex  behind  the  pupil.  The  entire  uveal  tract  be- 
came involved  and  a  large  hypopyon  developed;  no  evi- 
dence of  light  perception  in  the  eye. 

Conditio  praesens:  There  is  deep  ciliary  injection;  the 
cornea  opaque  and  steamy,  and  quite  insensitive;  anterior 
chamber  obliterated;  pus  is  seen  lilocking  the  iris,  which 
is  degenerated  and  atrophic.  As  its  upper  periphery  there 
is  localized  bulging  of  the  iris,  which  is  completely  atro- 
phied and  looks  as  if  upward  iridectomy  had  been  made. 
Commencing  staphyloma  w.as  noted  in  upper  ciliary  re- 
gion: eyeball  stony  hard.  No  evidence  of  penetrating 
wound   was  found. 

In  view  of  the  history  of  the  case  and  the  early  exis- 
tence of  purulent  infiltration  of  the  vitreous  without  any 
evidence  of  external  injury,  the  diagnosis  made  was,  metas- 
tatic choroiditis  following  mumps.  Because  of  the  severe 
pain  from  which  the  child  was  suffering,  together  with  the 
increased  tension  of  the  eyeball,  and  the  probability  of 
early  rupture  of  the  sclera  as  shown  by  its  staphyloma- 
tous  condition,  enucleation  was  advised  and  performed  and 
the  eye  placed  in  Dr.  Edward  A.  Shumway's  hands  for 
study. 

After  hardening  in  alcohol,  the  eyeball  was  frozen  and 
cut  in  half  in  a  horizontal  plane  passing  through  the 
cornea  and  optic  nerve.  It  was  found  to  be  filled  with  a 
brittle  white  mass,  in  which  the  lens  was  embedded.  The 
upper  half  was  mounted  in  glycerine-jelly,  and  the  lower 
half  embedded  in  celloidin  for  microscopic  sections.  On 
cutting  the  lower  part  of  the  celloidin  block,  in  order  to 
mount  it  squarely  on  the  object  holder  of  the  microtome, 
the  knife  struck  a  small  particle  of  rusted  metal,  lying  in 
the  retina,  which  measured  (1x1. omm.)  This  was  dissolved 
in  strong  hydrochloric  acid,  and  on  the  addition  of  potassi- 
um ferrocyanide,  a  dark  blue  color  was  produced  (Prus- 
sian blue),  indicating  the  presence  of  iron. 

Microscopic  examination  of  the  sections,  stained  with 
haematoxylin-eosin,  showed  the  condition  to  be  beginning 
panophthalmitis. 

The  cornea  is  intact,  except  for  a  moderate  infiltration 
with  round  cells,  and  distension  of  the  blood  vessels,  at 
the  limbus.  In  the  center,  Descemet's  membrane  is  torn, 
but  this  is  probably  an  artefact.  On  the  nasal  side,  in 
the  ciliary  region  there  is  a  depression  in  the  globe,  the 
the  iris  is  here  adherent  to  the  corneal  surface  which  is 
especially  Infiltrated  with  round  cells  at  this  point.  The 
anterior  chamber  is  filled  with  a  granular  material  which 
contains  a  few  leucocytes.  Tlic  iris  is  swollen  to  several 
times  its  normal  size,  and  densely  infiltrated  with  poly- 
morphonuclear leucocytes,  which  have  separated  widely  its 
stroma-cells. 

Its  anterior  surface  is  covered  with  a  layer  of  fibrinous 
exudate,  with  a  few  entangled  leukocytes,  which  extend 
from  its  posterior  surface,  in  a  thin  layer,  over  the  en- 
tire surface  of  the  retina,  and  in  two  line:*  converge 
from  the  equator  of  the  lens  on  either  side,  toward  the  op- 
tic nerve  entrance. 

The  remainder  of  the  vitreous  cavity  is  filled  with  a  gran- 
ular exudate,  which  contains  scattered  pus  cells 
The  anterior  capsule  of  the  lens  is  ruptured  on  the  tem- 
poral side,  and  a  line  of  pus  cells  runs  directly  backward 
through  the  broken  and  cataractous  lens  fibres,  to  com- 
municate through  a  similar  rupture  in  the  posterior  cap- 
sule, with  the  masses  of  cells  In  the  vitreous,  showing 
the  apparent  track  of  the,  foreinn  hody.  Lines  of  pus  cells 
also  follow  the  lines  of  cleavage  of  the  lens  fibres,  and  on 
the  nasal  side,  at  the  equator,  a  large  collection  of  them 
separates  the  capsule  from  the  cortex.  The  ciliary  pro- 
cesses are  drawn  forward,  and  the  ciliary  bodies  are  mod- 


934 


The  Philadelphia  "| 
Medical  Journal    J 


RUPTURE>OF  THE  SPLEEN 


[Mat  U,  1901 


erately  infiltrated.  The  layer  of  pus  cells  on  the  inner 
surface  of  the  retina,  is  much  thicker  on  the  temporal  than 
on  the  nasal  side,  and  at  a  point  just  posterior  to  the 
equator  shows  a  break  in  the  mass.  The  sections  are 
stained  a  brownish  red,  in  this  position  and  on  treatment 
by  the  Perl  iron  reaction  (Hydrochloric  acid  and  Potas- 
ferrocyanide)  take  a  deep  blue  color,  which  gradually  fades 
in  intensity,  as  the  distance  from  this  point  increases. 

The  underlying  retina  shows  a  dense  infiltration  with 
round  cells,  especially  surrounding  and  filling  the  blood 
vessels,  but  the  process  has  not  lasted  long  enough  to 
completely  disorganize  this  membrane,  as  its  various  lay- 
ers may  be  readily  distinguished.       ' 

The  pigment  cells  are  proliferated,  and  are  commencing 
to  infiltrate  the  retina.  The  distant  parts  of  the  latter 
show  edema  and  infiltration  with  cells  around  and  in  the 
blood  vessels. 

The  choroid  is  hyperemic  and  at  the  point  above  de- 
scribed corresponding  probably  to  the  former  position  of 
the  foreign  body  before  it  fell  to  the  bottom  of  the  vitre- 
ous cavity,  it  is  thickened  to  three  times  its  normal  size, 
and  is  densely  infiltrated  Kith  round  cells. 

The  optic  nei  re  is  moderately  infiltrated.  A  careful 
search  for  micro-organisms  v/as  made,  but  none  was 
found. 

DiiKjnoxis.  Beginning  panophthalmitis;  traumatic  catar- 
act, foreign  body  (iron  particle)  in  the  vitreous. 

In  order  to  explain  if  possible  the  presence  of  the 
foreign  body  in  the  eye,  careful  inquiries  were  made 
with  the  following  result.  A  blacksmith's  shop  was 
situated  just  back  of  the  house  in  which  the  child 
lived,  and  during  his  convalescence  from  mumps 
he  had  been  allowed  to  play  most  of  the  day  in  the 
shop.  No  doubt  the  small  chip  of  iron  from  the 
anvil  penetrated  his  eye,  although  no  one's  attention 
had  been  called  to  such  an  accident.  The  develop- 
ment of  purulent  choroiditis  from  this  foreign  par- 
ticle led  to  acute  inflammatory  symptoms  which 
the  child's  mother  detected,  and  for  which  he  was 
brought  for  treatment. 

It  is  impossible  to  say  how  soon  after  the  entrance 
of  the  chip  of  iron  into  the  eye  the  examination  was 
made,  but  no  trace  of  the  wound  was  discovered  by 
Dr.  Bishop,  and  one  week  later  when  the  eye-ball 
had  become  generally  infiltrated  with  leukocytes 
there  was  certainly  no  trace  of  the  track  taken  by 
the  foreign  body. 

In  the  absence  of  any  history  of  traumatism,  an  at- 
tack of  purulent  choriditis  in  a  young  child  who  was 
convalescing  from  mumps  was  naturally  interpreted 
as  metastatic  choroiditis.  The  accidental  discovery 
of  the  foreign  body,  in  making  repeated  sections 
with  the  microtome,  alone  enabled  us  to  correctly 
interpret  the  nature  of  the  attack.  It  was  most  for- 
tunate, in  the  light  of  this  discovery,  that  enucle- 
ation was  promptly  done  and  sympathetic  ophthal- 
mitis in  the  sound  eye  was  prevented. 


SPONTANEOUS    (?)    RUPTURE    OF    THE    SPLEEN. 

LAPAROTOMY— DEATH— REPORT  OF  CASE. 

By  D.  C.  HOWARD,  M.  D.,  Captain,  Med.  Dept.,  U.  S.  A. 

G.  C,  22  years  of  age,  a  private  of  Battery  "O,"  4th  U.  S. 
Artillery,  single,  birthplace,  U.  S.,  2^^  years  in  service. 
Served  at  this  post  for  past  eight  months.  Used  alcoholics 
immoderately  at  times.  He  was  brought  to  hospital  10  A. 
M.,  February  19th,  in  a  state  of  practical  collapse.  Com- 
plained of  agonizing  pain  in  abdomen,  especially  in  left 
hypochondrium  and  stilted  that  he  had  not  felt  well  for  sev- 
eral days  previously.  Denied  any  injury  to  abdomen.  Had 
not  been  drinking  for  two  weeks.  Had  eaten  but  little  food 
for  several  days,  bowels  constipated.  A  comrade  occupying 
an  adjacent  bed  in  barracks  stated  that  the  patient  had 
complained  of  a  cramp-like  pain  in  left  side  for  a  week 
past,  that  in  walking  his  body  was  bent  forward  to  relieve 


the  pain.  At  night  he  was  restless  and  coughed  consider- 
ably. On  the  morning  of  February  17  he  was  seen  to  be  very 
pale  and  advised  to  go  to  the  hospital.  However,  he  did  full 
duty  with  his  battery  until  the  morning  of  admission,  when 
at  about  9  A.  M.  pain  became  very  intense,  vomiting  set  in 
and  he  suddenly  became  very  weak. 

On  admission  he  was  exsanguinous  in  appearance;  pulse 
small,  rapid  and  weak,  respirations  frequent  and  shallow, 
temperature  99.4,  extremities  cold.  He  called  constantly 
for  water  and  drank  eagerly  the  large  quantity  brought  him 
from  time  to  time  without  allaying  the  intense  thirst.  He 
was  in  paroxysms  of  pain  located  chiefly  in  left  hypochon- 
drium. External  warmth  applied  and  morph.  sulph.  .030 
gm.  with  atropine  given  at  once.  In  a  short  time  he  be- 
came more  comfortable,  and  a  careful  abdominal  examina- 
tion was  made.  Abdomen  was  rather  prominent  and  tense 
and  extreme  tenderness  noted,  but  more  marked  in  left 
hypochondriac  and  left  half  of  epigrastic  regions.  Complete 
dullness  in  left  hypochondriac  and  left  lumbar  regions,  ex- 
tending to  the  right  as  far  as  the  left  border  of  rectus  in 
epigastric  and  umbilical  regions.  Upper  limit  of  dullness 
was  at  a  point  l\'z  inches  below  nipple  line.  Below,  it 
extended  to  crest  of  ilium.  No  thoracic  abnormality  noted. 
Urine,  lOOCc.  removed  by  catheter,  examined  with  negative 
result.  The  apearance  of  the  patient  was  so  suggestive 
that  a  dangerous  intraperitoneal  hemorrhage  was  recog- 
nized, though  its  source  was  undetermined.  With  no  his- 
tory of  previous  disease  nor  abdominal  injury  to  suggest 
splenic  rupture  the  condition  was  considered  more  likely  to 
be  pancreatic  hemorrhage.  Though  his  condition  remained 
critical,  his  pulse  and  respiration  had  improved  somewhat, 
and,  after  consultation  with  Acting  Assistant  Surgeon  E. 
H.  Porter,  U.  S.  Army,  as  to  the  advisability  of  immediate 
operation,  it  was  decided  to  await  further  developments. 
He  dropped  into  a  quiet  sleep  about  1  P.  M.  An  hour  later 
he  awoke,  and  during  a  momentary  absence  of  the  nurse 
from  his  bedside  arose  and  went  to  the  water  closet,  where 
the  nurse  found  him  a  moment  later  on  the  closet  seat  in 
collapse.  He  was  carried  to  his  bed  and  I  saw  him  at 
once. 

He  was  pulseless,  respiration  50  per  minute,  shallow 
and  frequently  sighing.  Extremities  cold  and  covered  with 
clammy  perspiration.  Abdomen  showed  marked  increase 
in  limits  of  dulness.  Hypodermics  of  ether  and  brandy 
given  at  once  and  frequently  repeated.  Hot  saline  solution, 
one  liter  given  per  rectum.  External  warmth  and  friction 
to  limbs  employed.  After  a  few  minutes  a  pulse  could  be 
felt,  rapid  and  weak  <140  per  minute).  Violent  paroxysmal 
pain  now  complained  of.  Acting  Assistant  Surgeon  E.  H. 
Porter  now  saw-  the  man  with  me  and  coincided  in  my 
opinion  that  an  immediate  operation  gave  him  his  only 
chance,  though  it  was  hardly  believed  that  he  could  sur- 
vive it.  Preparations  for  operation  were  at  once  begun, 
though  one  and  one-half  hours  elapsed  before  they  were 
completed.  Meanwhile,  under  free  stimulation  and  subcu- 
taneous injection  of  oOOCc.  normal  saline  solution  his 
pulse  had  improved  (120  per  minute),  his  extremities  had 
become  warm,  and  g!eneral  improvement  noted.  Tempera- 
ture. 99.4. 

Exploratory  Laporatomy,  3.30  P.  M. 

Eucaine  solution  (4Tc)  used  for  infiltrating  tissues  in 
line  of  incision.  A  few  whiffs  of  ether  w-ere  given  from 
time  to  time,  but  never  to  point  of  anesthesia.  Assisted  by 
Acting  Assistant  Surgeon  E.  H.  Porter  and  hospital  corps 
attendants,  an  incision  four  inches  in  length  was 
made  in  left  semi-lunar  line  about  one  inch  be- 
low free  border  of  ribs,  which  was  rapidly  car- 
ried down  through  the  muscular  planes  to  peritoneum. 
Great  tension  within  peritoneal  cavity  was  indicated  by 
marked  bulging  through  incision  when  the  peritoneum 
was  reached.  The  peritoneum  was  cai'efuUy  nicked  when 
a  column  of  blood  serum  mixed  with  blood  spurted  upward 
with  great  force  to  a  height  of  several  feet-  The  opening 
was  enlarged  the  length  of  incision,  and  an  enormous 
amount  of  fluid  poured  out.  which  it  is  impossible  to  cor- 
rectly estimate,  but  it  is  believed  the  amount  was  at  least 
two  liters.  Strychnine  and  brandy  hypodermically  had 
been  freely  given  during  operation,  but  the  sudden  escape 
of  so  much  fluid  from  the  peritoneal  cavity  nearly  col- 
lapsed patient,  and  heroic  stimulation  was  again  demanded. 
Hypodermoclysis  again  employed.  Rapid  exploration  was 
now  made,  and  spleen  was  found  adherent  to  diaphragm, 
greatly  distended  with  blood  clot,  and  firmly  attached  to 
its  concavity  was  a  mass  of  blood  clot  filling  the  lesser 
peritoneal   cavity,   its  surface  as  smooth  and  firm  as  the 


Mat  U,  1901) 


EPHEMERAL  IXSAXITY 


TThe  Philadelphia 
L  Medical  Journal 


935 


splenic  capsule  itself  and  as  large  as  an  Infant's  head.  In 
the  patient's  critical  condition  further  operative  interfer- 
ence would  certainly  have  ended  his  life  on  the  table.  It 
was  seen  that  nothing  short  of  total  extipation  of  spleen 
and  removal  of  haematoma  would  be  of  lasting  benefit,  and 
that  the  patient's  condition  would  not  allow.  The  periton- 
eal cavity  was  therefore  filled  with  hot  saline  solution, 
gauze  strips  packed  deeply  in  concavity  of  spleen,  upper 
angle  of  wound  hastily  closed  by  suture  and  a  thick  gauze 
dressing  applied.  He  was  removed  to  warm  bed,  freely 
stimulated,  salt  solution  given  and  very  slowly  reaction 
set  in.  The  operation,  by  relieving  tension,  had  relieved 
all  pain.  Temperature  98,  pulse  130,  extremely  weak. 
Throughout  the  evening  and  night  he  was  in  a  calm  sleep 
most  of  the  time,  but  would  rouse  when  spoken  to.  Took 
water  and  stimulants  by  stomach,  though  hypodermic 
stimulation  was  continued.  Pulse  ranging  from  120  to  160. 
Temperature,  2  A.  M.,  99.6.  Death  occurred  at  6.45  A.  M. 
February  20,  over  fourteen  hours  following  operation. 

Autopsy,  4  hours  after  death. 

Body  of  muscular  man,  5  feet  10  inches  in  height,  weigh- 
ing about  165  pounds.  No  rigor  mortis.  Gauze  dress- 
ings of  operative  wound  saturated  with  bloody  ser- 
um. Abdomen  opened  from  ensiform  cartilage  to 
pubes.  Overlying  stomach,  intestines  and  liver  there  was 
a  thin  layer  of  clotted  blood,  soft  and  friable.  Nearly 
BOOCc.  bloody  serum  in  greater  cavity  of  peritoneum.  The 
spleen  was  firmly  adherent  to  diaphragm.  Capsule  dis 
tended  with  blood  clot,  with  a  rupture  12  cm.  in  length 
leading  from  hilum  downward  along  its  inferior  surface, 
then  upward  to  centre  of  convexity.  The  margins  of  rup- 
tured capsule  were  separated  8  cm.  midway  from  angles. 
From  this  point  protruded  a  globular  mass  of  clot  into  the 
lesser  peritoneum  continuous  with  that  distending  the  rup- 
tured spleen.  From  examination  by  touch  it  was  almost 
impossible  to  define  the  limits  of  the  spleen  and  that  of  the 
attached  clot,  as  both  were  of  equally  firm  consistency. 
In  removing  the  organ  the  blood  clot  was  accidentally  de- 
tached just  beyond  the  splenic  border.  It  was  practically 
encapsulated  by  the  lesser  peritoneum.  'Weight  of  detached 
clot  .960  kilogram.  A  portion  of  omentum  about  10  cmxlO 
cm.  was  removed  with  spleen  as  it  served  as  a  portion 
of  haematoma  capsule  and  was  densely  infiltrated. 
\Veight  of  spleen  and  contained  clot  with  omentum  as 
above,  1.1  kilograms.  Left  lung  collapsed,  500Cc.  bloody 
serum  in  left  pleural  cavity.  Small  perforation  in  dia- 
phragm, posterior  segment  well  to  the  left.  Pericardium 
ccontained  16Cc.  straw  colored  serum. 

In  the  photograph,  "A"  can  be  seen  the  widely  separated 
margins  of  splenic  capsule  and  the  centra!  blood  clot  with 
infiltrated  omentum.  Exposure  on  day  of  removal.  The 
specimen  has  been  preserved  and  sent  to  the  Army  Medical 
Museum,  Washington,  D.  C. 

Remarks. — Splenic  rupture  with  fatal  intraperi- 
toneal hemorrhage  most  often  follows  traumatisms, 
but  it  also  is  said  to  occur  spantaneously  in  acute 
enlargements  of  the  organ  during  typhoid  and  ma- 
larial fevers  in  certain  localities.  According 
to  Osier  the  condition  is  very  rare  in  this 
country.  In  the  case  reported  an  element  of 
doubt  must  remain  as  to  its  cause.  It  is  assumed, 
however,  that  the  rupture  occurred  spontaneously 
in  the  absence  of  history  to  the  contrary.  As  to 
traumatism,  it  is  possible  that  while  intoxicated  at 
some  time  he  may  have  sustained  an  injury  to 
splenic  region,  of  which  he  subsequently  remem- 
bered nothing.  No  marks  of  injury  to  body,  either 
recent  or  remote,  were  found. 

Acute  enlargement  from  malarial  infection  cannot 
be  positively  excluded  as  a  predisposing  cause  of 
rupture,  malarial  diseases  being  prevalent  here  at  all 
seasons.  It  is  not  probable,  however,  as  a  malarial 
infection  of  sufficient  intensity  to  cause  such  en- 
largement would  most  likely  have  come  to  the  no- 
tice of  the  Medical  Officer.  This  man  had  been 
under  treatment  for  slight  injuries  only  during  his 
service  here.  As  to  typhoid,  there  has  been  but  one 
case  in  this  cominand  for  i8  months  past,  that  case 


being  imported.    It  is  considered  a  more  improbable 
cause  than  others  mentioned. 

Undoubtedly  some  splenic  disorder  existed  sev- 
eral days  before  rupture.  Whether  it  was  simple 
congestion  or  an  acute  splenitis,  both  from  causes 
unknown,  must  remain  unansv^'ered. 


EPHEMERAL 


INSANITY   WITH   REPORT    OF 
CASES. 


TWO 


By  CHARLES  J.  ALDRICH,  M.  D., 

of  Cleveland.  Ohio. 

Lecturer  on  Clinical   Neurology  and  Anatomy    of  the   Nervous  System, 

Cleveland  College  of  physicians  and   Surgeons;    visiting  Physician 

and   Neurologist  to' the   Cleveland    General   Hospital  and 

Dispensary-;  Neurologist  to  the  Cleveland  City  Hospital. 

The  occurrence  of  insanity  which  has  a  duration 
of  a  few  hours  or  a  few  days  in  an  otherwise  appar- 
ently healthy  and  normal  individual  possesses  not 
only  great  medical  interest,  but  involves  questions 
of  forensic  medicine  that  are  tremendous  in  signifi- 
cance and  scope.  Clouston  has  described  this  form 
of  insanity  as  "mania  traiisitoria,"  but  since  the 
word  transient  means  passing,  without  any  par- 
ticular reference  to  time,  it  has  occurred  to  the 
writer  that  the  other  term  used  by  Clouston — eph- 
emeral insanity — is  the  better  one. 

Clouston  believes  that  most  of  these  cases  are 
epileptiform — the  mental  epilepsy  of  Hughlings- Jack- 
son, or  the  masked  epilepsy,  the  "epilepsie  larvee" 
of  JNIorel ;  that  a  few  cases  are  seen  in  young  person.^ 
of  unstable  nervous  and  mental  organization,  and 
usually  possessing  an  intense  neurotic  heredity. 
None  of  these  causes  or  predispositions  will  explain 
the  advent  of  insanity  in  my  cases. 

It  seems  very  strange  that  any  person  who  has 
never  suffered  an  attack  of  mental  aberration  or 
epilepsy  should  suddenly  become  insane  and  remain 
so  but  a  few  hours  or  a  few  days  and  then  recover 
without  one  bit  of  demonstrable  mental  peculiarity 
remaining. 

The  following  cases  serve  to  illustrate  this  phase 
of  insanity,  and  are  very  suggestive  as  to  the  legal 
complications  which  might  arise. 

CASE  I.  L.  G.,  age  IS.  "female,  white,  German,  domes- 
tic, with  good  family  history:  has  been  uniformly  healthy 
and  never  suffered  from  any  sickness  but  those  incident 
to  childhood:  no  history  whatever  of  any  unconscious 
spells,  spasms  or  evidence  of  mental  aberration.  She  was 
employed  in  the  family  of  Mrs.  R.,  who  looked  upon  her  as 
a  very  trustworthy,  honest  and  religious  woman.  She  has 
never  indulged  in  narcotics  or  stimulants  of  any  kind.  She 
retired  at  an  early  hour  on  the  night  preceding  the  Fourth 
of  July,  1898,  intending  to  arise  in  the  morning  and  view 
a  street  pageant.  In  the  morning  about  four  o'clock  her 
mistress  was  aroused  by  her  pounding  upon  the  door  and 
loudly  calling  for  her  to  come  out.  Mrs.  R.,  opened  the 
door  and  found  the  young  woman  standing  in  her  night 
clothes  with  a  Bible  under  her  arm.  'When  the  door  was 
opened  she  threw  her  arms  around  her  mistress  and 
begged  her  to  come  with  her.  Her  mistress, 
thinking  that  perhaps  the  house  was  on  fire,  urged 
her  to  tell  what  was  the  matter.  She  answered  that 
the  world  was  about  to  end  and  Christ  had  sent  her 
to  save  her  mistress.  This  insane  talk  apprized  Mrs.  R. 
that  the  girl  was  in  delirium,  and  she  immediately  began 
to  soothe  her,  telling  her  to  go  and  dress.  The  girl  retired 
to  her  room,  put  on  her  best  clothing  and  came  downstairs, 
ate  a  hearty  breakfast  which  her  mistress  had  prepared 
for  her,  talking  in  the  meantime  incoherently  on  religion 
and  the  threatened  destruction  of  the  world.  Soon  after 
this  a  young  woman  friend  appeared  who  was  to  accom- 
pany her  to  witness  the  street  pageant  and  persuaded  her 
to    go    and    view    the    procession.      Carefully    and    neatly 


936 


The  PEnLAiiELPHiA ' 
Medical  Journal    . 


EPHEMERAL  INSANITY 


[Mat  U.  1501 


dressing  herself,  and  taking  her  Bible  under  her  arm  she 
■walked  half  a  mile  and  stood  nearly  one  hour  watching  the 
procession  most  of  the  time  in  perfect  silence.  Then  she 
declared  herself  to  be  very  tired  and  wished  to  return  to 
her  place  of  employment.  Upon  arriving  at  this  place 
she  immediately  undressed  herself,  put  on  her  night- 
clothing,  folded  up  the  garments  that  she  had  worn,  and 
put  them  away  in  her  usual  manner.  She  then  retired  and 
immediately  fell  asleep.  She  slept  for  a  period  of  about 
Jive  hours  and  awoke  with  a  dim  recollection  only  of  the 
street  pageant.  She  has  since  been  under  observation  for 
a  period  of  two  years  and  has  never  manifested  the  slightest 
degree  of  mental  aberration.  She  has  no  sonnambulistic 
tendencies  or  symptoms  that  would  lead  to  the  idea  that 
she  is  mentally  unbalanced  or  suffering  from  masked 
epilepsy. 

The  following  case  I  had  the  pleasure  of  seeing 
with  Dr.  Friedman  at  the  Cleveland  General  Hos- 
pital :  ; 

CASE  II.  R.  L.,  Hungarian,  age  40,  married,  paver. 
He  gave  a  good  family  history:  had  previously  enjoyed 
good  health  and  no  mental  aberration  had  ever  manifested 
itself. 

One  day  while  at  work  and  without  having  complained 
of  any  ailment,  he  went  to  his  foreman  and  told  him  that 
two  of  his  fellow-workmen  were  plotting  to  kill  him  and 
that  one  of  them  had  a  knife  concealed  in  his  clothing 
with  which  he  intended  to  assault  him.  He  declared  that 
he  had  heard  them  talking  and  planning  his  destruction, 
and  begged  the  foreman  to  prevent  its  accomplishment 
The  man  seemed  so  sincere  and  had  always  been  such  a 
sober,  industrious,  peaceful  workman  that  the  foreman 
believed  his  story  and  called  the  other  men  to  account, 
who,  it  is  needless  to  state,  were  perfectly  astounded 
There  had  never  been  one  word  said  in  reference  to  the 
complainant  and  on  search,  neither  of  the  men  was  found 
to  have  anything  that  might  have  been  mistaken  for  a 
weapon.  He  insisted,  however,  with  added  vehemence  that 
he  had  heard  them  plotting  and  planning  to  kill  him  and 
had  seen  the  knife.  He  was  taken  to  his  home  and  thence 
to  the  Cleveland  General  Hospital.  He  had  no  fever  nor 
bodily  ailments  whatever,  neither  could  the  slightest  history 
of  any  spasmodic  seizures  or  mental  aberration  previous  to 
this  time  be  obtained  from  his  family  or  friends.  He  was 
kept  in  bed  for  a  few  days  and  treated  symptomatically. 
Shortly  he  discovered  that  he  had  been  a  victim  of  de- 
lusions and  seemed  surprised  that  they  had  occurred  but 
was  unable  to  assign  any  cause.  He  was  discharged  from 
the  hospital  in  a  few  days,  since  which  time  I  have  heard 
that  he  has  been  in  perfect  health  and  has  never  had  a 
recurrence  of  his  delusions  or  other  evidence  of  insanity 
or   epilepsy. 


Fatty  Degeneration  of  the  myocardium  considered  as  a 
Fatty  Infiltration  on  the  Cardiac  Fibers.  LOUIS  GALLA- 
VARDIN.  (da:.  Heh.  dc  Mai.  ct  <!e  Cliinir..  March  24,  1901. 
48  me.  Annee  Xo.  24.     Lyons  Thesis,  1899-1900,  No.  155). 

Fatty  degeneration  of  the  myocardium  may  present  2 
different  anatomical  varieties:  (1)  That  in  which  the 
fatty  change  in  the  cardiac  fibers  occurs  in  the  form  of 
islands,  principally  beneath  the  endocardium,  and  (2)  That 
in  which  the  fatty  change  in  the  cardiac  fiber  in  dif- 
fuse. When  the  fatty  degeneration  exists  in  islands  the 
grouping  of  these  islands  beneath  the  endocardium  and 
their  whitish  appearance  produces  a  characteristic  mark- 
ing known  as  subendocardial  mottling.  This  sign  is  path- 
ognomic of  this  form  of  fatty  degeneration  of  the  myocar- 
dium. By  the  use  of  injections  of  coloring  matter  the 
general  disposition  of  these  islands  of  fatty  degeneration 
is  seen  to  be  controlled  by  the  vascular  distribution,  and 
in  the  majority  of  cases  they  seem  tb  be  situated  in  the 
portions  of  the  myocardium  that  are  injected  with  great- 
est difHculty.  The  cells  that  compose  these  islands  are 
cardiac  fibers  regularly  infiltrated  by  fine  fatty  granula- 
tions, but  presenting  neither  the  characteristics  of  necro- 
biosis nor  of  cellular  degeneration.  The  diffuse  form  of 
fatty  change  in  the  myocardium  is  only  to  be  diagnosed 
after  microscopic  examination.  Fatty  degeneration  of 
the  myocardium  is  rarely  found  in  the  course  of  the 
acute  infections.  It  follows  frequently,  on  the  other  hand. 
In  the  course  of  cardiac  affections  or  of  chronic  pulmonary 
diseases  accompanied  by  insufficient  oxidation  of  the  blood, 
and  in  the  course  of  cachexias  and  anemias.     The  sympto- 


matic expression  of  this  lesion  appears  to  be  restricted. 
It  has  little  influence  upon  the  course  of  the  affection 
which  it  complicates.  Gallavardin  admits,  however,  the 
possibility  of  sudden  death  and  attacks  of  cardiac  failure 
in  obese  patients.  The  author  attributes  to  this  lesion 
a  signification  analogous  to  that  of  fatty  liver.  This 
lesion  is.  then,  according  to  the  views  of  the  author, 
neither  a  myocarditis  nor  a  fatty  degeneration,  but  a  fatty 
infiltration  of  the  cardiac  muscle  fibers.  And  he  proposes 
to  employ  the  term  fatty  myocardium  or  fatty  infiltration 
of  the  cardiac  fibers  for  it.     [J.  M.  S.] 


Prostatic  Abscess  Which  Opened  into  Both  Urethra  and 
Rectum. — In  the  Aiiiialfs  de  la  PolirlinUjue  de  Bordeaux  for 
March,  1901,  Dr.  E.  Loumeau  reports  the  case  of  a  man 
of  35,  in  whom  gonorrhea  or  gleet  was  constant  For  two 
weeks  before  consulting  his  physician,  his  symptoms  had 
become  aggravated.  Though  examination  showed  no  sign 
of  recent  gonorrhea,  permanganate  injections  were  given. 
At  the  moment  the  liquid  reached  the  bladder,  the  patient 
experienced  sudden  severe  pain  in  the  perineum,  followed 
by  a  chill  and  a  temperature  of  104°  F.  This  perineal  pain 
persisted  with  frequent  urination,  a  few  drops  of  blood  ap- 
pearing at  the  end  of  micturition.  Pus  was  found  in  the 
urine  in  large  quantity.  The  diagnosis  of  acute  prostatitis 
with  cystitis  was  made.  Complete  retention  of  urine  oc- 
curred, to  relieve  which  catheterization  was  employed, 
though  so  painful  that  chloroform  was  necessary.  Rectal 
palpation  at  this  time  revealed  an  abscess  in  the  right  lobe 
of  the  prostate,  which  was  evacuated  through  the  ure- 
thra by  pressure  with  the  finger.  As  this  treatment  yielded 
no  good  result,  the  abscess,  which  had  pointed  in  the  rec- 
tum, was  opened  there.  The  cavity  was  cleaned  out.  dried 
with  gauze,  and  drained  per  rectum.  The  fever  and  pain 
disappeared.  Pneumaturia  was  noticed  for  a  few  weeks, 
but  no  fecal  matter  was  seen  in  the  urine,  or  urine  in  the 
bowel  movements.  Two  weeks  after  operation,  right  epi- 
didymitis occurred,  going  on  to  suppuration.  This  abscess 
was  also  opened  and  drained.  The  patient,  who  had 
wholly  recovered,  left  for  Brazil,  where  he  died  of  yellow 
fever  six  months  later.  This  phlegmonous  prostatitis 
opened  into  the  urethra,  causing  a  cystitis  and  urethritis; 
by  its  pressure  into  the  rectum,  it  caused  great  pain,  and 
after  evacuation  it  was  still  the  cause  of  epididymitis. 
Loumeau  believes  that  when  such  an  abscess  points  into 
the  rectum,  rectal  incision  is  to  be  preferred  to  perineal 
section.     [M.  O.] 


Soda  Compresses  in  Suppuration.  G.  E.  MadimiroS  (1/e- 
ilii  inxkoie  Olinsrtnii'.  Fehrunni.  19'il.)  fully  corroborates  the 
splendid  results  obtained  by  a  number  of  Russian  physici- 
ans from  the  use  of  compresses  of  soda  in  diverse  suppura- 
tive processes.  The  use  of  this  drug  in  such  cases  was 
first  suggested  by  Georgiewski  who  claimed  for  it  the  fol- 
lowing advantages:  1.  It  is  cheap  and  readily  obtainable; 
2.  no  drainage  is  required;  3.  the  patient  is  much  more 
comfortable;  4.  the  pain,  at  imes  severe,  accompanying  the 
change  of  tampons  is  altogether  avoided;  5.  the  bad  odor 
and  the  unsightly  appearance  of  the  dressings  are  absent; 
C.  recovery  is  much  more  rapid.  The  author  employed  this 
treatment  in  30  cases.  In  6  there  were  bums  of  the  second 
and  third  degree;  in  2  a  pustular  eruption:  in  1  a  suppurating 
fistula;  in  10  contused  and  incised  wounds;  in  6  suppurat- 
ing lymphatic  galnds;  in  5  ingrown  toe-nails.  He  employed 
the  compresses  in  the  following  forms:  1.  a  layer  of  gauze 
saturated  with  a  2T^  solution  of  soda  was  applied.  This  was 
covered  with  a  piece  of  oil-cloth,  cotton  and  a  bandage. 
The  compress  was  changed  3-4  times  in  24  hours.  2.  The 
gauze  next  to  the  body  was  not  removed  but  kept  saturated 
by  pouring  on  it  2-3  times  during  the  24  hours  a.  2'~c  solution 
of  soda.  3.  Several  layers  of  gauze  saturated  in  the  soda 
solution  were  placed  over  the  suppurating  surface,  these 
were  covered  by  a  thick  layer  of  boric  acid  and  camphor 
salve,  then  a  piece  of  oil  silk,  cotton  and  bandage.  Such  a 
compress  remained  moist  for  1-2  days.  The  results  ob- 
tained were  exceptionally  good.     [A.  R.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company   and  Conducted 

Exclusively  in  the  Interests  of  the  Medi;al  Profession 


James  Hendrie  I^loyd,  A.  M.,  M.  D.,  Editorin-Chiej 
jDLios  1,.  Salinger,  M.  D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.  D.  F.  J.  Kalteyer,  M.  D. 

D.  L.  Edsall,  M.  D.  T.  l.  Colev,  M.  D. 

J.  M.  Swan,  M.  D.  W.  a.  N.  Dorland,  M.  D. 

J.  H.  Gibbon,  M.  D.  T.  M.  Tyson,  M.  D. 

M.  OSTHBIMER,  M.  D.  A.  Robin,  M.  D. 


Scientific  Articles.  Clinical  Memoranda.  News  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  publication.  Reprints  (250)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,    1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8. 


The  Pennsylvania  Hospital. — ^The  story  of  colo- 
nial Philadelphia  will  always  be  an  important  part 
of  the  wider  history  of  the  nation.  The  provincial 
history  of  this  city  has  special  signiiicance,  because 
it  was  associated  not  only  with  the  birth  of  the  re- 
public, but  also  with  the  inception  of  more  than  one 
movement,  and  the  origin  of  more  than  one  institu- 
tion, which  were  not  merely  political,  but  were 
widely  educational  and  humanitarian.  Among 
these  institutions  stands  pre-eminent  the  Pennsyl- 
vania Hospital.  The  steady  hand  of  Benjamin 
Franklin  was  felt  in  its  early  administration,  and 
its  history  derives  an  added  colonial  flavor  from  as- 
sociation with  the  name  of  "Poor  Richard."  As  Mr. 
John  B.  Garrett  said  in  his  commemoration  address 
last  Saturday  at  the  sesquiccntennial  anniversary 
of  the  hospital,  the  conservatism  of  the  founders  has 
been  preserved  in  their  successors  ;  nothing  has  been 
ruthlessly  destroyed,  and  the  ways  of  to-day  are  in 
accord  with  the  best  traditions  of  every  period  of 
its  histor}'.  With  all  this  the  hospital  has  kept  pace 
with  every  advance  in  medical  and  surgical  science ; 
its  name  is  forever  associated  with  one  at  least  of 
the  greatest  reforms  in  psychiatry ;  its  staff  has  been 
for  a  century  and  a  half  recruited  from  the  most 
distinguished  teachers  and  practitioners  of  medicine 
and  surgery  in  the  oldest  medical  center  in  America; 
anditsbenefactionshave  involved  the  expenditure  of 
millions  of  dollars.  As  Mr.  Garrett  reminded  his  hear- 
ers,thepromotersofthe  Pennsylvania  Hospital  were 
far-seeing  men.  There  was  nothing  provincial  about 
them  or  about  the  scheme  which  aimed  to  estab- 
lish in  a  colonial  city  a  hospital  which  was  as  metro- 
politan at  the  beginning  as  it  remains  to-day.  If 
aught  were  needed  to  emphasize  this  statement,  it 
can  be  found  in  the  provision  made  for  the  reception 
and  treatment  of  the  insane.  This  department  was 
destined  to  become,  under  Rush,  a  clinic  in  psychi- 
atry, which  is  hardly  surpassed  anywhere  in  this 
country  at  the  present  time  (and  hardly  equalled, 
if  literary  and  scientific  results  are  to  be  the  stand- 
ard). In  the  original  petition  drawn  up  by  Frank- 
lin, the  insane  are  mentioned  first  as  the  objects  of 
wise  hospital  treatment. 

As  it  stands  to-day  in  its  old  colonial  building. 
backed  by  its  modern  but  less  imposing  structures. 


and  supplemented  by  its  great  estate  in  West  Phil- 
adelphia, the  Pennsylvania  Hospital  is  one  of  the 
most  significant  institutions  on  the  continent.  It 
represents  a  colonial  movement  of  wide  scope  and 
foresight,  which  bears  fruit  in  these  modern  times 
quite  in  accord  with  our  most  advanced  ideals. 

Dividing  the  Responsibility. — Our  friends  in  San 
Francisco  should  understand  by  this  time  that  it  is 
not  easy  for  medical  observers  here  in  the  East  to 
solve  all  the  mysteries  of  the  plague  situation  in 
that  city.  Now  that  the  Pla,gue  Commission  has 
published  its  report,  the  local  physicians  seem  in- 
clined to  come  forth  and  blame  the  State  authori- 
ties for  all  the  trouble.  We  have  received  several 
letters — explanatory  and  expostulatory — on  the  sub- 
ject. One  of  our  correspondents  finds  fault  with  us 
for  reflecting  on  the  authorities  out  there,  and  in  the 
next  paragraph  lays  the  blame  for  the  concealment 
of  the  plague  on  their  "wrong-headed  Governor, 
knavishly  advised."  He  tells  us  that  at  our  distance 
"it  is  simply  impossible  to  realize  the  forces  of  evil 
which  have  been  brought  into  plaj'  to  try  to  smother 
and  suppress  the  truth  as  to  the  plague  situation 
here.  The  selfish  and  provincial  point  of  view  as- 
sumed by  the  business  portion  of  the  community,' 
ably  seconded  by  the  San  Francisco  press,  has  been 
responsible  for  this  condition."  The  power  of  the 
State  Legislature,  he  tells  us,  "has  been  used  to 
make  it  a  crime  to  even  publish  mention  of  the  ex- 
istence of  a  plague  case." 

This  is  worse  than  anything  we  have  ever  said  in 
these  columns  about  the  authorities  in  San  Fran- 
cisco, and  coming  from  a  correspondent  whose  ob- 
ject is  to  chide  us  for  being  unjust  to  them,  it  sounds 
at  least  rather  odd.  If  the  local  authorities  in  San 
Francisco,  such  as  the  Mayor,  City  Councils,  and 
Board  of  Health,  allowed  themselves  to  be  con- 
trolled by  a  "wrong-headed  Governor,  knavishly  ad- 
vised," they  cannot  well  evade  their  responsibility. 
If  they  bowed  before  an  ignorant  public  sentiment 
and  a  mendacious  press,  they  did  not  do  their  duty. 
It  is  not  for  us  to  attempt  to  distribute  the  respon- 
sibility in  due  proportion  among  the  State  and  local 
authorities.  In  common  with  the  rest  of  the  world 
we  know  merely  that  the  whole  truth  did  not  come 


QjQ       The  Philadelphia 
yo"       Medical   Journal 


] 


EDITORIAL  COMMENT 


[May  is,    1901. 


out  until  it  was  brought  out  by  a  United  States  Gov- 
ernment commission.  The  importance  of  the  sub- 
ject is  not  confined  to  the  cit}'  of  San  Francisco.  It 
is  not  a  local,  but  a  national  affair. 

Another  correspondent  tells  us  that  "The  local 
health  authorities  had  the  situation  scientifically 
well  in  hand,  and  the  rest  of  the  country  was  never 
assured  by  or  upon  the  authority  of  the  Board  of 
Health  that  there  was  no  plague  in  the  city."  To 
which  we  can  only  say  that  it  would  have  been  a 
source  of  satisfaction  to  the  "rest  of  the  country" 
to  have  known  this  sooner.  We  are  glad  to  chron- 
icle the  fact  that  "the  cases  which  had  occurred 
prior  to  the  coming  of  the  Commission  had  been 
studied  by  the  local  pathologists  and  bacteriologists 
in  the  same  manner  and  with  the  same  thorough- 
going, honest  and  scientific  methods  which  the  mem- 
bers of  the  Commission  employed."  This  is  greatly 
to  the  credit  of  the  local  health  authorities,  and  they 
should  have  full  credit  for  it.  The  statement,  how- 
ever, only  increases  our  wonderment  how,  in  spite 
of  this  fact,  it  was  constantly  proclaimed  that  there 
was  no  plague  in  San  Francisco,  or,  if  any,  that  it 
was  of  a  "non-contagious"  character.  We  are  sat- 
isfied that  the  local  pathologists  and  bacteriologists 
could  not  have  been  responsible  for  these  false 
statements. 

Febrile  Albuminuria. — Gerhardt  (Deutsches  Arch- 
iv.  f.  Klin.  Med.,  V.  i868,  page  212)  described  a  con- 
dition of  the  urine  occurring  in  the  acute  infectious 
fevers,  in  which  albumin,  usually  in  small  amounts, 
appeared.  To  this  condition  he  gave  the  name 
"febrile  albuminuria."  The  urine  in  this  condition 
also  occasionally  contains  hyaline  tube  casts  and 
propepton.  It  was  supposed  that  this  albuminuria 
was  due  to  the  febrile  process,  and  albumin  occur- 
ring as  a  result  of  renal  disease,  was  termed  "true 
albuminuria."  Within  recent  years,  v.  Kahlden  (Die 
Aetiologie  u.  Gcnesc  dcr  Acutcn  Nephritis,  vol.  II,  page 
441)  has  had  an  opportunity  of  examining  these  so- 
called  cases  of  "febrile  albuminuria"  pathologically. 
He  found  that  in  some  of  these  cases  almost  exclu- 
sively the  epithelium  of  the  convoluted  urinary  tub- 
ules and  Henle's  loops  was  pathologically  altered, 
and  in  those  cases  in  which  the  glomerular  epithe- 
lium was  affected,  these  changes  were  ahvays  sec- 
ondary. A  histological  examination  of  the  renal  tis- 
sue showed  that  blood  was  rarely  present  in  the  in- 
terstitial structure,  but  almost  invariably  in  the 
glomerular  capsules,  and  in  the  urinary  tubules. 
Besides,  these  hemorrhages  were  very  frequently 
missed  by  v.  Kahlden  in  his  examinations.  He  is  of 
the  opinion  that  in  the  case  of  "febrile  albuminuria" 
there  is  actual  change  in  the  renal  structure,  which 
is  identical  with  the  preliminary  stages  of  an  acute 
nephritis,  and  that  the  same  etiology  was  respon- 


sible for  the  condition.  This  etiology  depends 
largely  upon  toxic  substances  w^hich  circulate  in  the 
blood  stream.  Nevertheless,  it  will  remain  justifia- 
ble to  differentiate  between  a  beginning  nephritis 
and  a  well  developed  nephritis,  as  well  in  a  diagnos- 
tic as  a  prognostic  sense.  It  would  be  preferable 
to  give  to  the  condition  known  as  "febrile  albumi- 
nuria," which  is,  as  a  rule,  transitory,  simply  the 
designation  "albuminuria,"  and  to  leave  off  the  ad- 
jective "febrile."  The  differential  points  between 
nephritis  and  albuminuria  would  then  not  be  diffi- 
cult to  determine.  In  the  latter  condition  the  albu- 
min is  noted  during  the  infectious  process.  There 
is,  as  a  rule,  but  a  small  quantity  of  albumin,  and 
hyaline  tube  casts  are  occasionally  present.  In 
nephritis  complicating  the  infectious  diseases,  the 
condition,  as  a  rule,  is  acute,  and  albumin  and  tube 
casts  are  present  in  comparatively  large  amounts. 
The  term  "toxic  albuminuria"  is  not  well  chosen, 
as,  according  to  our  knowledge,  both  conditions  are 
due  to  toxic  causes. 

The  Editorship  of  "Brain." — We  regret  to 
learn  that  Dr.  A.  de  Watteville  has  retired 
from  the  editorship  of  this  important  jour- 
nal. The  announcement  is  made  in  the 
last  number  of  the  Journal  of  Mental  Scienct 
that  at  the  annual  meeting  of  the  London  Neuro- 
logical Society,  held  on  February  14th,  the  resigna- 
tion of  Dr.  de  Watteville  was  accepted.  The  Coun- 
cil of  the  Society  put  on  record  a  statement  of  its 
appreciation  of  the  way  he  had  conducted  the  jour- 
nal for  the  past  twenty  years.  Dr.  de  Watteville  ha? 
brought  Brain  to  a  high  standard  of  perfection  and 
secured  for  it  a  great  European  reputation.  He  is 
even  credited  with  having  saved  the  very  life  of 
the  journal  at  a  critical  period  of  its  existence.  The 
success  of  his  editorial  charge,  extending  over 
twenty  years,  deserves  wide  recognition.  Brain  has 
come  to  be  an  important  exponent,  not  only  of 
English  neurology,  but  to  a  limited  extent  of  Amer- 
ican neurology  as  well.  It  has  been  through  its 
pages  that  not  a  few  important  papers  by  American 
neurologists  in  recent  j^ears  have  been  introduced 
to  the  still  wider  field  of  European  specialists.  It  is 
to  be  hoped  sincerely  that  under  its  new  editor.  Dr. 
Percy  Smith,  it  will  continue  to  have  a  successful 
career. 

The  Priority  in  the  Discovery  of  the  Pest  Bacillus. 
— It  has  been  generally  believed  that  the  specific  mi- 
crobe of  the  pest  was  discovered  simultaneously  by 
Kitasato  and  Yersin,  during  the  Honk-Kong  epi- 
demic of  1894.  Kitasato"s  paper  appeared  July  7, 
1894,  while  that  by  Yersin  was  only  published  July 
30.  But  Dr.  Tatsusaburo  Yabe.  a  physician  in  the 
Japanese  Marine,  has  shown  in  the  Archives  de  Mede- 


Mat   18,    1901) 


EDITORIAL  COMMENT 


TThe  Philadelphia.        qjq 
L  Medical   Journal         70  7 


€iiie  Navale,  quoted  by  Le  Dantec,  in  the  Journal  de 
Mcdccinc  de  Bordeaux  (1901,  No.  16),  that  the  two 
bacilli  described  were  not  identical.  For,  while  Kit- 
asato  made  his  culture  from  the  blood,  Yersin  took 
his  from  the  bubo  directly.  La  Dantec  compares  the 
pest  to  diphtheria;  while  the  Klebs-Loffler  bacillus 
is  always  found  in  the  membrane,  streptococci  may 
appear  in  the  blood.  So  it  seems  probable  that  Kita- 
sato's  bacillus  was  but  a  microbe  of  secondary  in- 
fection. It  stained  by  Gram's  method,  coagulated 
milk,  made  bouillon  turbid,  and  was  motile.  But 
Ycrsin's  bacillus,  which  has  been  proved  the  true 
cause  of  the  past,  docs  none  of  these  things.  Aoyoma 
has  shown  that  both  microbes  exist  in  cases  of 
pest,  that  of  Yersin  in  the  buboes,  that  of  Kitasato 
in  the  blood.  La  Dantec  recently  received  some  pest 
preparations  from  the  Island  of  Reunion,  in  all  of 
which  Yersin's  bacillus  existed  in  pure  culture.  The 
bacillus  of  Kitasato  was  not  found  in  a  single  pre- 
paration. No  doubt,  therefore,  remains  that  the  bac- 
illus of  Yersin  can  exist  alone  in  cases  of  pest.  This 
is  now  generally  recognized  by  bacteriologists  all 
over  the  world. 

Self-Performed  Caesarean  Section. — Probably 
nothing  better  shows  the  remarkable  immunity  en- 
joyed by  the  peritoneum  than  the  interesting  cases 
of  self-performed  CjEsarean  section,  that  from  time 
to  time  are  reported  in  the  current  literature.  Be- 
sides manifesting  an  astounding  degree  of  stoicism, 
these  patients  seem  to  have  the  happy  faculty  of 
evading  the  disastrous  consequences  of  their  temer- 
ity, and  that  notwithstanding  the  most  inauspicious 
circumstances  under  which  the  act  is  consummated. 
Filth  to  them  is  apparently  innocuous,  and  bacilli 
have  no  terrors. 

A  remarkable  fact  associated  with  these  blood- 
curdling reports  is  that  most,  if  not  all,  of  the  cases 
have  occurred  among  the  degraded  classes  of  South- 
ern and  Eastern  Europe,  as  in  the  last  instance  re- 
corded by  Loffler  (in  the  Wiener  Med.  IVoch.,  No. 
TO,  igoi),  the  victim  being  a  Turkish  peasant  woman. 
Suffering  from  some  obscure  chronic  affection,  and 
fearing  she  would  perish  before  the  termination  of 
her  pregnancy,  this  stoical  creature,  at  the  eighth 
month  of  gestation,  deliberately  opened  her  abdo- 
men and  uterus  with  an  ordinary  pen-knife.  As  the 
child  emerged,  the  woman  fainted  from  shock  and 
loss  of  blood.  On  regaining  consciousness  some 
time  afterwards  the  wound  was  sewed  up,  at  her  re- 
quest, by  her  thirteen-year-old  daughter,  an  ordi- 
nary needle  and  waxed-hemp  thread  being  employed 
for  the  purpose.  Notwithstanding  these  primitive 
measures,  and  the  fact  that  a  simple  Ca?sarean  sec- 
tion was  performed,  that  is,  without  the  insertion 
of  uterine  ligatures,  the  woman  made  an  uninter- 
rupted recovery.     There  were  no  manifestations  of 


sepsis  or  peritonitis,  and  union  of  the  abdominal  in- 
cision was  unattended  with  suppuration.  The  ab- 
dominal dressing  employed  was  a  layer  of  moss 
held  in  place  by  a  filthy  linen  cloth.  The  child, 
which  also  survived,  was  nursed  by  its  convalescent 
mother. 

Such  cases  seem  to  indicate  the  uselessness  of  the 
modern  methods  of  antisepsis.  If  patients  placed 
in  the  most  unfavorable  of  circumstances  can  re- 
cover from  the  gravest  of  injuries  without  the  de- 
velopment of  any  untoward  symptoms,  it  would 
seem  that  the  extreme  care  practised  by  the  modern 
surgeon  is  altogether  unnecessary  and  a  waste  of 
valuable  time  and  material.  Such  cases  naturally 
fall  in  line  with  those  remarkable  instances  recorded 
of  unbroken  recovery  following  most  extensive 
traumatism — accidental,  military  and  surgical. 

Many  feet  of  bowel  may  be  resected  from  one 
individual  without  ill-result,  while  a  simple  enter- 
rhaphy  in  another  will  be  rapidly  followed  by  a  fa- 
tal termination ;  gravel,  filth,  and  curious  foreign 
bodies  gain  entrance  into  the  peritoneal  cavity  and 
apparently  excite  not  the  slightest  irritation,  while 
a  simple  exploratory  incision  will  be  followed  by 
grave  or  even  fatal  sepsis.  The  explanation  of  this 
curious  phenomenon  must  be  found  in  some  refine- 
ment and  extreme  developmental  sensitiveness  of 
the  tissues,  whereby  in  one  case  there  will  be  an 
apathy  of  the  parts  to  external  influence  and  in  an- 
other a  high  degree  of  reaction.  It  is  well  known 
that  individuals  of  higher  mental  and  social  devel- 
opment will  react  more  promptly  to  these  delete- 
rious influences  than  will  individuals  much  lower  in 
the  mental  and  social  scale.  The  leader  in  the  com- 
munit}^  will  succumb  to  a  moderately  severe  peri- 
toneal operation,  while  the  hod-carrier  will  recover 
from  some  grave  lesion  without  any  untoward  symp- 
tom to  interrupt  the  progress  of  th6  recovery.  In 
the  auto-Ciesarean  section,  above  recorded,  and  in 
the  others  that  have  filled  the  curiosity-pages  of  sur- 
gery, this  low  position  in  the  social  scale  was  one  of 
the  attendant  features  in  the  cases.  It  was  not  be- 
cause of  the  lack  of  surgical  care  that  recovery  fol- 
lowed, but  in  spite  of  the  dangerous  concomitants 
of  the  operation. 

Fallacies  in  the  Chemistry  of  the  Blood. — Al- 
though the  examination  and  estimation  of  the  cor- 
puscular constituents  of  the  blood  are  approaching 
a  stage  of  perfection,  and  although  the  hemo- 
globin can  be  estimated  to  a  nicety,  much  of  the 
chemistry  of  the  blood  is  still  to  be  discovered. 
This  expansive  field  of  research  is  fraught  with 
many  difficulties.  The  mineral  constituents  of  the 
blood  have  been  estimated  almost  without  excep- 
tion from  blood-ash.  Unless  scrupulous  precau- 
tions are  observed,  a  portion  of  the  chlorine  and  the 


940 


The  Phiuldelphia  ~\ 

ilEDICAI,    JOUBXAL    J 


EDITORIAL  COMMENT 


[Mat  18,   1901. 


phosphoric  acid  is  lost.  The  distribution  of  acids 
and  bases  in  the  blood  taken  from  the  body  is  dif- 
ferent than  in  the  ash ;  acid  salts  become  neutral  or 
basic,  carbon  dioxide  is  produced  while  the  ash  is 
being  formed,  and  may  be  left  behind  combined 
with  the  bases;  furthermore,  the  carbon  dioxide 
originally  present  in  the  form  of  carbonates,  may  es- 
cape, while  the  acid  phosphates  become  transformed 
into  neutral  ones.  Even  the  iron  shows  an  errone- 
ous picture,  because  the  iron  that  previously  had 
been  combined  with  albumin  may  also  go  over  to 
the  phosphoric  acid,  leaving  no  clew  regarding  the 
distribution  of  the  iron  in  either  organic  or  inorganic 
combinations.  Another  fallacy  is  that  the  greater 
part  of  the  sulphuric  acid  found  is  derived  from  the 
sulphur  in  the  albumin  combinations.  Liebig  has 
shown  that  the  amount  of  sulphur  in  meat  juice  is 
so  small  that  it  is  almost  indeterminable  in  a  whole 
animal,  but,  as  later  investigators  have  shown,  an 
enormous  quantity  of  sulphuric  acid  is  found  in  the 
blood-ash.  This  is  due  to  the  fact  that  during  the 
formation  of  the  ash  some  of  the  organic  acids  are 
broken  up  and  the  sulphuric  acid  from  the  albumin 
combinations  is  liberated.  The  sulphuric  acid  lib- 
erated in  this  case,  although  it  certainly  has  nothing 
to  do  with  the  mineral  constituents  originally  pres- 
ent, may,  nevertheless,  be  a  marked  source  of  error. 
Similar  fallacies  are  present  in  the  case  of  phospho- 
rus, for  only  a  portion  of  this  substance  which  is 
found  in  the  ash  as  phosphoric  acid  has  been  origi- 
nally present  as  such.  The  amount  of  nitrogen  is 
generally  somewhat  parallel  with  the  amount  of  al- 
bumin, and  consequently  changes  according 
to  the  degree  of  decomposition  of  the  latter.  In 
determining  the  amount  of  sulphates  and  phos- 
phates, it  will  be  found  that  the  organic  albumin 
combinations  containing  sulphur  and  phosphorus  all 
enter  into  solution,  and  that  finally  the  sulphur 
and  the  phosphorus  are  again  found  as  sulphuric  and 
phosphoric  acid  .  The  next  century  will  undoubt- 
edly reveal  many  of  the  long-looked-for  facts  in  the 
chemistry  of  the  blood. 

The  Maniaco-Melancholic  Insanity  of  Kraepelin. 
— Dissatisfaction  with  the  existing  schemes  of  clas- 
sification of  mental  diseases  is  constantly  cropping 
out.  This  is  inevitable.  When  scientists  attempt  to 
classify  what  they  do  not  fully  understand,  the  re- 
sults are  not  altogether  educational.  As  yet  we  do 
not  fully  understand  the  various  forms  of  insanity — 
their  etiologj'  and  pathology.  Our  knowledge  is 
largely  clinical,  for  it  is  based  on  a  study  of  symp- 
toms ;  it  is  not  sufficiently  profound  to  allow  us  to 
erect  a  classification  on  data  which  are  truly  funda- 
mental. Thus  it  happens  that  some  good  alienists 
have  almost  ignored  classification,  as  Sankey.  for 
instance ;  while  at  the  other  extreme  some  of  the 


Germans  have  elaborated  deeply  involved  schemes. 
A  marked  tendency  toward  simplicity  in  this  matter 
has,  however,  been  perceptible  for  some  years.  San- 
key  led  this  movement  (or  was  in  the  van  of  it) 
when,  in  his  text-book,  he  described  "ordinary  in- 
sanity," and  included  under  this  colorless  term  al- 
most all  the  symptoms  of  mental  disease.  This  was 
too  iconoclastic,  but  it  suited  those  simple-minded 
souls  who  have  always  maintained  that  Esquirol 
fathomed  the  whole  subject  when  he  divided  insan- 
ity into  Mania,  Melancholia,  Monomania  and  De- 
mentia. 

It  is  interesting  now  to  note  that  these  simpler 
methods  are  gaining  credit  even  in  Germany.  Re- 
cently the  eminent  Jena  alienist,  Kraepelin,  in  his 
"Psychiatrie,"  has  expressed  some  rather  original 
views  on  the  nosological  position  of  mania  and  mel- 
ancholia. By  almost  universal  consent  these  two 
psychoses  have  been  considered  distinct.  They  are 
primitive  and  typical  forms  with  almost  every  sys- 
tematist.  Each  stands  out  separate  and  alone — one 
the  antithesis  of  the  other.  This  fact  was  the  A,  B, 
C,  of  psychiatry.  But  now  Kraepelin  (who  will  be 
listened  to  with  respect)  classifies  the  psychoses  into 
acute,  demential,  and  chronic ;  and  in  the  first  of 
these  he  includes  the  maniaco-melancholic  insanity. 
In  other  words,  he  unites  or  fuses  melancholia  and 
mania  into  one  clinical  form,  regarding  these  two 
states  simply  as  phases  of  one  identical  disease.  The 
essential  character  of  this  disease  is  the  occurrence 
of  symptoms  of  mental  exaltation  on  the  one  hand, 
and  of  mental  depression  on  the  other,  these  symp- 
toms appearing  separately,  or  in  irregular  alterna- 
tion, or  simultaneously  in  a  confused  form.  This 
disease  arises  on  a  basis  of  degeneracy — and  here 
again  Kraepelin  departs  from  some  of  his  confreres 
who  have  not  considered  the  psychoses  as  forms  of 
degeneracy. 

The  interesting  point,  and  the  one  to  which  we 
call  special  attention,  is  the  tendency  here  shown  to 
cut  loose  from  some  of  the  old  moorings.  Many 
acute  observers  will  agree  that  the  affective  moods, 
as  marked  by  exaltation  or  depression,  are  not  con- 
stant in  numerous  cases,  and  that  after  all  they  are 
not  the  disease  itself.  They  are  but  phases  of  the 
troubled  surface — the  true  pathological  deeps  are 
not  yet  e.xplored.  Still  the  fact  remains  that  for  all 
clinical  purposes  the  old  division  into  mania  and 
melancholia  will  not  be  lightly  ignored.  The  view 
of  Kraepelin  will,  however,  invite  discussion,  excite 
speculation,  and  incite  to  investigation,  and  out  of 
these  may  come  an  increase  of  knowledge.  Galdi, 
an  Italian  alienist,  has  recently  subjected  Kraepe- 
lin's  views  to  a  criticism,  and  this  is  abstracted  in 
the  Journal  of  Mental  Science  for  April. 


Mat    is,    19U11 


REVIEWS 


["The  Philadelphia 
L  Medical   Journal 


941 


•Reviews. 


Points  of  Practical  Interest  in  Gynecology,  by  H.  Mac- 
naughtonJones,  M.  D.,  M.  Ch.,  Q.  U.  I.;  Master  of  Ob- 
stetrics (Honoris  causa),  Royal  University  of  Ireland, 
etc.;  Reprinted  from  the  Edinbxirgh  Medical  Joiiniul. 
1900,  with  twelve  plates.  New  York.  William  Wood 
&  Company,  1901. 

In  this  little  volume  of  124  pages  are  reprinted  a  series 
of  communications  from  the  pen  of  the  distinguished  au- 
thor, which  primarily  appeared  in  the  Edinhur(jh  Medical 
Journal.  They  are  six  in  number  and  include  the  follow- 
ing subjects:  Some  points  in  gynecological  asepsis;  some 
pitfalls  in  gynecological  diagnosis;  the  therapeutics  of  dis- 
orders of  menstruation:  conservatism  and  its  influence  on 
operative  technique:  affections  of  the  female  genitalia  as 
causal  factors  in  the  etiology  of  neuroses  in  insanity,  and 
their  special  bearing  on  the  operative  treatment  of  the 
insane;  and  the  indications  for  the  operations  of  hyster- 
ectomy and  myohysterectomy  in  myoma..  Like  all  that 
emanates  from  the  pen  of  Dr.  Macnaughton-Jones,  the 
material  is  absolutely  up-to-date  and  full  of  instructive 
suggestions.  Especially  do  we  commend  his  attitude  to- 
ward the  so-called  "brilliant"  operating,  in  which  he  says 
that  "deliberation  and  completeness  are  to  be  aimed  at;" 
Too  many  men  sacrifice  these  essentials  in  successful  op- 
erating in  their  eager  desire  to  appeal  to  the  eye.  In  the 
performance  of  hysterectomy  for  fibroid  tumor  of  the 
uterus  the  author  is  guided  in  his  technique  by  the  nature 
of  the  complications  encountered,  a  list  of  which  he  ap- 
pends to  his  article  on  that  subject.  Twelve  handsome 
plates  add  to  the  value  of  the  book,  as  well  as  an  extensive 
bibliography  bearing  on  the  subject  of  sexual  neuroses 
and  insanity.     [W.  A.  N.  D.] 


Hmerican  IRevvs  ant)  Ulotes. 


Essentials  of  the  Diseases  of  Children. — By  William  M. 
Powell,  M.  D.  Third  Edition.  Thoroughly  Revised  by 
Alfred  Hand.  .Jr.,  M.  D.,  Dispensary  Physician  and 
Pathologist  to  the  Children's  Hospital,  Philadelphia. 
12mo.,  259  pages.     Philadelphia  and  London:    W.     B. 

Saunders  &  Company.  Price  $1.00.  net. 
The  Third  edition  of  Powell's  Essentials  of  the  Diseases 
of  Children,  prepared  by  Dr.  Hand,  is  thoroughly  modern. 
The  section  upon  the  Infectious  Diseases,  which  has  been 
rewritten,  contains  many  important  details.  The  manage- 
ment of  a  case  of  contageous  disease,  to  which  a  few 
pages  are  devoted,  cannot  fail  to  prove  of  great  assistance 
to  the  young  practitioner.  The  chapters  upon  the  Diseases 
of  the  Stomach,  Intestines,  and  Peritoneum  are  also  well 
compiled.  A  new  chapter  upon  Infant  Feeding  has  been 
added,  which  embraces  the  essentials  of  that  subject  only, 
in  a  mo.'it  concise  manner.  It  is  natural,  in  a  compact  book 
of  this  kind,  that  all  subjects  treated  should  be  brief. 
One  is  therefore  somewhat  surprised  to  find  the  rarer 
diseases,  such  as  perleche,  Bednar's  aphthae. Riga's  disease, 
cyclic  vomiting,glandular  fever. and  head-nodding  mentioned. 
The  three  pages  given  to  epidemic  cerebrospinal  menin- 
gitis are  well  filled.  In  pathology  and  treatment,  the  book 
is  quite  up  to  date.  The  treatment  of  acute  bronchitis  is 
most  concisely  disposed  of,  in  two  short  paragraphs.  And 
it  is  Interesting  to  note  that  mercury,  as  a  laxative,  in  any 
of  its  preparations,  is  contra-indicated  in  all  forms  of 
stomatitis.  Salol  is  not  mentioned  in  the  treatment  of  in 
fluenza,  while  phosphorus  still  holds  a  front  place  in  the 
treatment  of  rachitis.  The  occurrence  of  functional  heart 
murmurs,  and  of  a  venous  hum  over  the  jugular  veins,  is 
not  given  among  the  symptoms  of  chronic  gastrointestinal 
catarrh,  though  both  are  found  under  chlorosis.  Nor  is 
the  appearance  of  craniotabes,  given  as  a  symptom  of 
rickets,  spoken  of  under  syphilis  or  marasmus.  The  print- 
ing is  singularly  free  from  typographical  errors,  and  the 
book  is  well  made.  It  will,  without  doubt,  be  of  use  to  the 
young  physician,  and  to  the  medical  student  preparing 
for  examination.     [M.  O.] 


PHILADELPHIA,    PENNSYLVANIA,    ETC. 

Appointment. — Dr.  S.  Lewis  Ziegler  has  been  appointed  a 
surgeon  to  the  Wills  Eye  Hospital,  in  place  of  Dr.  George 
C.  Harlan,  resigned. 

Diphtheria  is  not  "Quarantinable."— The  Steamer  Rhyn- 
land,  from  Liverpool  and  Queenstown,  with  three  cases  of 
diphtheria  on  board,  was  passed  May  13th,  by  both  the 
Federal  and  State  quarantines  and  allowed  to  proceed  di- 
rectly to  the  city  of  Philadelphia.  Although  both  the 
Federal  and  State  authorities  consider  diphtheria  con- 
tagious, they  do  not  classify  it  as  a  "quarantinable"  dls- 

Philadelphia  Lying-ln  Charity. — At  the  annual  meeting  of 
the  contributors  to  the  Philadelphia  Lying-ln  Charity,  Elev- 
enth and  Cherry  streets,  held  May  8,  one-third  of  the  Board 
of  Managers  was  elected  to  serve  for  three  years.  Stephen 
Green,  Charles  W,  Warrington,  Mrs.  Gulielma.  M.  S.  P. 
Jones.  Hood  Gilpin,  Colonel  Charles  H.  Howell  and  Mrs. 
Mary  Warrington  Stokes  were  re-elected.  The  Treasurer's 
report  showed  receipts  for  the  year  amounting  to  $14,555.45, 
with  $14,698.70  disbursements,  leaving  a  floating  indebted- 
ness  of   $2170.10. 

Sesquicentennial  of  the  Pennsylvania  Hospital. — Hundreds 
of  friends  and  contributors  to  the  Pennsylvania  Hospital 
were  present  on  Saturday,  the  11th  inst.,  to  celebrate  the 
150  years  of  the  Hospital's  existence.  Programmes  were 
furnished  narrating  the  simple  exercises  and  containing 
a  chronological  list  of  the  principal  events  in  the  history 
of  the  Hospital  from  May  11,  1751  to  the  present  time. 
On  the  ISth  inst.  the  invited  guests  will  visit  and  inspect 
the  well-equipped  Department  for  the  Insane,  at  44th  and 
Market  streets.  The  separation  of  this  department  from 
the  hospital  proper  took  place  in  1841.  The  exercises  on 
Saturday  last  were  held  in  the  new  Assembly  building.  T. 
Wistar  Brown  read  St.  Luke's  version  of  the  parable  of 
the  Good  Samaritan.  Benjamin  H.  Shoemaker,  President 
of  the  Board  of  Managers  extended  a  welcome  to  the  "little 
provincial  hospital"  for  which  Franklin  petitioned  in  1751. 
Mr.  John  B.  Garrett  delivered  the  formal  address.  He  paid 
a  special  tribute  to  the  memory  of  those  men  prominent 
in  the  early  history  of  the  country  who  assisted  in  the 
establishing  of  the  hospital  and  gave  to  it  their  substantial 
aid.  Among  those  to  whom  he  referred  were  John  Morton 
and  Benjamin  Franklin,  and  in  the  later  history  of  the 
institution,  Wistar  Morris  and  Dr.  Kirkbride. 

Pathological  Society. — The  first  paper  at  the  meeting  of 
May  9  was  the  report  by  Dr.  W.  S.  Wadsworth  of  a  case  of 
ball-clot  in  the  auricle.  Death  by  occlusion.  The  clot 
was  spherical,  and  at  least  2  inches  in  diameter,  being  per- 
fectly free  in  the  cavity.  Death  was  sudden.  The  patient 
was  an  alcoholic  who  had  been  drinking  heavily  for  2 
weeks,  this  being  the  apparent  cause  of  the  clot  forma- 
tion. 

Dr.  F.  S.  Pearce  exhibited  2  specimens  of  hemorrhagic 
pachymeningitis  and  a  tumor  of  the  spinal  cord.  ..The 
lesion  in  the  first  2  cases  was  unilateral  and  had  not  been  di- 
agnosticated. The  tumor  of  the  dura  which  pressed  upon 
the  spinal  cord  in  the  lower  thoracic  region  had  also  been 
undiagnosticated.  spastic  paralysis  of  the  lower  extremi- 
ties being  the  only  symptom. 

Dr.  J.  Walsh  read  a  paper  on  Diphtheria  bacilli  in  noma. 
The  paper  was  a  report  of  8  cases  of  noma  observed  by 
Dr.  Walsh  at  St.  Vincents'  Home  during  the  past  2%  years. 
In  every  case  the  diphtheria  bacillus  was  found.  Four  of 
these  cases  began  as  an  ulcerative  stomatitis.  Other  ca- 
ses of  stomatitis  in  which  gangrene  was  not  present  were- 
not  found  to  contain  the  diphtheria  bacillus.  This  would 
indicate  that  the  important  agent  in  these  cases  is  not 
originally  a  saprophyte  but  the  diphtheria  bacillus.  Dr. 
Joseph  McFarland  stated  that  he  had  experimentally  pro- 
duced a  condition  resembling  gangrene  by  injecting  cul- 
tures of  the  diphtheria  bacillus.  Dr.  D.  Riesmann  said  that 
the  diphtheria  bacillus  was  not  the  only  cause  of  gan- 
grene, as  in  a  case  of  gangrene  of  the  vulva  no  diphtheria 
bacilli  were  found. 


942 


Thb  Philadelphia" 

Medical   Journal  . 


AMERICAN  NEWS  AND  NOTES 


IMat   18,    UOL 


Dr.  W.  W.  Babcock  exhibited  new  apparatus.  These 
■were  1.  for  rapidly  filling  tubes  with  cultures  media,  and  2. 
for  washing  gross  specimens. 

Dr.  W.  B.  Hughes  and  Joseph  McFarland  exhibited  a 
specimen  of  Rupture  of  the  aorta.  The  rupture  had  oc- 
curred just  above  the  heart. 

Philadelphia  Academy  of  Surgery. — At  the  regular  meet- 
ing of  May  6  Dr.  R.  H.  Harte  exhibited  three  cases  of  em- 
pyema. The  importance  of  surgical  interference  in  these 
cases  was  emphasized  and  the  operative  technlc  discussed. 
Dr.  Harte  advises  the  resection  of  at  least  2  ribs  and  some- 
times 3  for  the  purpose  of  securing  ample  drainage.  A 
very  large  drainage  tube  should  be  employed.  The  open- 
ing should  be  made  in  the  mid-axillary  line.  After  operation 
a  rise  in  temperature  means  that  the  tube  is  not  draining 
properly  or  that  a  secondary  pocket  of  pus  is  present. 
Even  though  the  tube  appears  to  be  draining  properly  it 
should  be  removed  and  reinserted.  If  this  is  not  effective 
remove  the  tube  and  insert  a  urethral  sound,  22  or  23 
French,  and  break  up  any  pocket  formations  which  may 
be  present.  Dr.  R.  G.  Le  Conte  said  that  in  cases  where  the 
chest  was  very  much  distended,  the  patients  did  not  bear 
the  operation  well  and  a  preliminary  puncture  should  be 
made.  Afterward  a  resection  may  be  done.  This  view  was 
also  endorsed  by  Drs.  Taylor,  Wharton,  Davis  and  Jop- 
son. 

Dr.  W.  J.  Taylor  read  for  Dr.  W.  W.  Keen  the  report  of 
two  cases  of  ligation  of  the  external  carotid.  The  ligation 
in  one  case  was  for  the  control  of  obstinate  hemorrhage  fol- 
lowing tonsillotomy.  The  second  case  was  one  of  hemor- 
rhage after  an  intranasal  operation. 

Dr.  Lewis  S.  Mutschler  read  by  invitation  the  report  of 
two  cases  of  facial  anthrax  treated  by  carbolic  acid  in- 
jections. The  cases  were  undoubted  anthrax  as  proven 
clinically  and  bacteriologically.  The  treatment  consisted 
in  the  injection  of  25  minims  of  pure  carbolic  acid  in  the 
tissues  surrounding  the  lesion,  the  drug  being  introduced 
at  8  or  9  points.  This  was  repeated  the  second  day  after, 
two  injections  sufficing.  Bichloride  dressings  were  applied. 
No  internal  treatment  was  instituted.  Recovery  followed  in 
both  instances.  Dr.  Jopson  stated  that  these  cases  made 
in  all  10  cases  reported  in  Philadelphia.  Dr.  J.  Chalmers 
Da  Costa  said  that  studies  at  the  Jefferson  Dispensary 
some  few  years  ago  demonstrated  that  tanners,  etc.,  were 
subject  to  three  lesions  which  must  be  differentiated.  These 
are  tuberculosis,  sores  due  to  the  acids  used,  and  anthrax. 
Dr.  R.  H.  Harte  said  he  saw  no  reason  why  cases  of  an- 
thrax should  be  refused  admission  to  the  wards  of  general 
hospitals. 

Dr.  R.  G.  Le  Conte  reported  the  ultimate  result  in  a  case 
of  interscapulo-thoraclc  amputaion  for  sarcoma.  Autopsy 
revealed  the  fact  that  the  only  metastasis  was  a  growth 
the  seize  of  an  orange  in  the  lung  of  the  opposite  side. 

Jefferson  Medical  College  Commencement. — At  the  Pub- 
lic Commencement  of  the  Jefferson  Medical  College  held 
at  the  American  Academy  of  Music  on  May  15,  1901.  the 
Degree  of  Doctor  of  Medicine  was  conferred  on  one  hun- 
dred and  forty-two  graduates  by  the  President.  Hon.  Wil- 
liam Potter,  the  exercises  closing  with  a  Valedictory  bv 
Prof.  W.  W.  Keen,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.)  The 
following  prizes  were  awarded: 

The  Henry  M.  Phillips  Prize  of  Seventy-five  Dollars. 
Awarded  upon  the  recommendation  of  the  Professor  of 
Medicine  to  the  graduate  in  his  opinion  most  worthy,  to 
James  Edwin  Weller,  of  Indiana. 

The  Henry  M.  Phillips  Prize  of  Seventy-five  Dollars. 
Awarded  upon  the  recommendation  of  the  Professors  of 
Surgery  to  the  graduate  in  their  opinion  most  worthy,  to 
Albert  B,  Craig,  of  Washington. 

Physiology  Prize.  Awarded  by  bequest  of  Dr.  Francis 
W.  Shain,  for  the  best  Essay  or  the  best  Examination  on 
a  subject  pertaining  to  Physiology  (open  to  undergraduates 
of  the  second  year),  to  Undergraduate  Thomas  Cook  Stell- 
wagen,  Jr.,  of  Pennsylvania. 

Chemistry  Prize.     A  Gold  Medal,  for  the  best  Original 


Work  in  the  Chemical  Laboratory  (open  for  undergrad- 
uates), to  Undergraduate  Max  R.  Dinkelspiel,  of  New 
York. 

Therapeutics  Prize.  A  Gold  Medal,  for  the  best  Exam- 
inations in  Therapeutics,  to  Acheson  Stewart,  of  Ireland. 

Obstetrical  Prize.  A  Gold  Medal,  for  General  Excellence 
in  Obstetrics,  to  George  A.  Ulrich.  of  Pennsylvania. 

Anatomy  Prize.  A  Gold  Medal,  tor  the  best  Anatomical 
Preparation  (open  to  undergraduates),  to  Undergraduate 
Thomas  Cook  Stellwagen,  Jr.,   of  Pennsylvania. 

Ophthalmology  Prize.  By  Professor  De  Schweinitz,  a 
Gold  Medal,  for  the  best  Examination  on  Ophthalmology, 
to  Pascal  Brooke  Bland,  of  Pennsylvania,  with  honorable 
mention  of  William  Carey  Vail,  of  Indiana,  and  Theodore 
T.   Girould,   of   Illinois. 

Gynecology  Prize.  By  Professor  Montgomery,  a  Gold 
Medal,  for  the  best  Examination  in  Gynecology,  to  Collin 
Foulkrod,  of  Pennsylvania,  with  honorable  mention  of 
George  A.  LaMotte,  of  Missouri. 

The  W.  S.  Forbes  Anatomical  League  Prize  of  One 
Hundred  and  Fifty  Dollars  given  by  Professor  Forbes  to 
the  member  of  the  Anatomical  League  having  the  highest 
standing  in  a  competitive  Examination  in  Anatomy,  to 
Louis  C.  Williams,  of  New  Jersey,  with  honorable  mention 
of   Douglas   Symmers,   of    South    Carolina. 

Clinical  Orthopedics  Prize.  By  Professor  H.  Augustus 
Wilson,  Twenty-five  Dollars  for  the  best  Examination  in 
Orthopedic  Surgery,  to  Albert  B.  Craig,  of  Washing- 
ton. 

Clinical  Pediatrics  Prize.  By  Professor  Graham,  Twenty- 
five  Dollars  for  the  best  Report  on  his  Clinics,  to  Louis 
C.  Williams,  of  New  Jersey,  with  honorable  mention  of  J. 
B.   Horinstein  and  Joseph  Weller. 

Clinical  Neurology  Prize.  By  Professor  Dercum.  Twen- 
ty-five Dollars,  for  the  best  Examination  in  Neurology, 
to  William  C.  Vail,  of  Indiana,  with  honorable  mention 
of   George   A.    LaMotte,   of   Missouri. 

Clinical  Genitourinary  Prize.  By  Professor  Horwitz, 
Twenty-five  Dollars,  for  the  best  Examination  in  Genito- 
urinary Surgery,  to  George  A.  LaMotte,  with  honorable 
mention  of  Robert  G.  Davis. 

Clinical  Obstetrics  Prize.  By  Professor  Davis,  Twenty- 
five  Dollars,  for  the  best  Report  of  his  Clinics,  to  George 
Althouse  LaMotte.  of  Missouri,  with  honorable  mention 
of  Collin  Foulkrod.  of  Pennsylvania,  and  Francis  Wayland 
Goddard.  of  Pennslyvania. 

Clinical  Ophthalmology  Prize.  By  Professor  Hansell, 
Twenty-five  Dollars,  for  the  best  Report  of  his  Clinics,  to 
J.  Leslie  Davis,  of  Kentucky. 

Clinical  Otology  Prize.  By  Professor  S.  MacCuen  Smith. 
Twenty-five  Dollars,  for  the  best  Examination  in  Otology, 
to  J.  Leslie  Davis,  of  Kentucky,  with  honorable  mention 
of  William  C.  Vail,  of  Indiana,  and  Collin  Foulkrod,  of 
Pennsylvania. 

Clinical  Dermatology  Prize.  By  Professor  Stelwagon, 
Twenty-five  Dollars,  for  the  best  Examination  in  Derma- 
tology, to  W.  C.  Vail,  of  Indiana,  with  honorable  mention 
of  George  A.  LaMotte,  of  Missouri. 

Clinical  Laryngology  Prize.  By  Professor  D.  Braden 
Kyle,  Twenty-five  Dollars,  for  the  best  report  of  his 
Clinical  Lectures,  to  Collin  Foulkrod.  of  Pennsylvania. 

Clinical  Laryngology  Prize.  By  Professor  Jones.  Twen- 
ty-five Dollars  for  the  best  Report  of  his  Clinics,  to  J. 
Leslie  Davis,  of  Kentucky,  with  honorable  mention  of 
Louis  C.  Williams,  of  New  Jersey. 

Alumni  Prize.  By  the  Alumni  Association,  a  Medal  for 
the  best  General  average  gained  in  the  Examinations  for 
the  entire  curriculum,  to  George  Althouse  LaMotte,  of 
Missouri. 

W.  B.  Saunders  Prize.  Ten  Volumes  of  Saunders'  Med- 
ical Hand  Atlases,  to  the  student  who  passes  the  best 
General  Examination  at  the  close  of  the  College  term,  to 
Collin  Foulkrod.  of  Pennsylvania. 

Out-Patient  Department  Obstetric  Prize.  By  Dr.  W.  H. 
Wells,  Demonstrator  of  Clinical  Obstetrics,  a  Case  of  In- 
struments, for  the  best  Report  of  work  in  out-patient  ma- 
ternity service,  to  George  Burton  Angle,  of  Texas. 

The  S.  McCuen  Smith  Prize  of  Two  Hundred  Dollars. 
Awarded  by  Professor  Smith,  upon  the  recommendation 
of  a  Committee,  for  the  best  Essay  embodying  original 
research  "On  the  Discharge  from  the  Ear.  with  Special 
Reference  to  Intra-Cranial  Lesions."  to  John  Funke.  Penn- 
sylvania. 


May  is,  19u1] 


AMERICAN  NEWS  AND  NOTES 


TThe   Phil^peiphia        ni7 
I  Medical  Joubnai,        y4o 


Ptolemy  Prize.  A  Gold  Medal,  by  the  Ptolemy  Society: 
to  the  student  of  the  Graduating  Class  who  passes  the 
Examinations  of  the  Senior  year  with  the  highest  general 
average,  to  Collin  Foulkrod.  of  Pennsylvania. 

Philadelphia  County  Medical  Society. — At  the  meeting 
of  May  8,  Dr.  Simon  Baruch  of  New  Vork  read  a  paper 
on  Lessons  of  a  Decade  in  Hydrotherapy.  Dr.  Baruch  stated 
that  of  the  remedies  in  use  during  the  tim?  of  Hippocrates 
two  now  remained — venesection  and  water.  Water  is  used 
for  the  purpose  of  conveying  temperature  and  thus  to  pro- 
duce the  effects  of  temperature  changes.  The  medical 
profession  has  been  backward  in  the  employment  of  cold 
water  because  of  the  erroneous  idea  that  it  produces  shock. 
On  the  contrary  it  produces  the  opposite  effect  when  judici- 
ously used.  In  deciding  upon  the  dosage  3  elements  are  to 
be  considered — duration,  temperature,  and  pressure.  The 
circulation  is  under  the  control  of  water  at  a  proper  tem- 
perature as  proven  by  experiments  upon  animals  when  por- 
tions of  the  brain  were  exposed.  The  desired  effect  of 
cold  water  is  the  enhancement  of  the  resisting  powers  of 
the  individual.  In  typhoid  fever  the  peripheral  resistance 
and  the  circulation  in  general  is  increased  by  the  stimula- 
tion of  the  peripheral  nerve  filaments.  When  the  teeth  of  a 
typhoid  patient  in  the  cold  bath  begin  to  chatter  the  bath 
should  be  stopped.  If  the  patient  shivers  but  the  teeth 
do  not  chatter  the  bath  need  not  be  stopped  but  friction 
should  be  increased.  Under  no  circumstances  should  the 
ice  coil  be  applied  to  the  abdomen.  In  chronic  diseases 
cold  baths  deepen  inspiration  and  increase  the  heart's  ac- 
tion thus  sending  an  increased  amount  of  hemoglobin 
and  blood  cells  to  the  periphery  of  the  body  and  also  to 
the  lungs.  This  increases  the  oxj-genating  power  of  the 
individual.  In  the  treatment  of  tuberculosis  hydrotherapy 
should  supplement  dieting  and  open  air  life.  The  good  re- 
sults of  hydrotherapy  in  this  disease  are  traceable  to  the 
stimulating  effect  of  cold  on  the  nervous  system.  In  neu- 
rasthenia a  large  proportion  of  cases  are  benefited  and  not 
a  few  cured  by  hdyrotherapy  where  there  is  no  organic 
lesion  associated.  Dr.  Baruch  gave  in  detail  the  method  of 
treatment.  Hydrotherapy  is  of  value  in  diabetes,  especial- 
ly in  obese  patients.  The  glycogenic  function  of  the  liver 
can  be  influenced  but  little,  but  the  glycogen  in  the  volun- 
tary muscles  plays  a  large  part  in  the  disease.  The  amount 
cf  sugar  can  be  decreased  by  paying  attention  to  the  mus- 
cles in  the  way  of  exercise  and  the  improvement  of  the  cir- 
culation by  the  use  of  cold  water. 

Dr.  Wharton  Sinkler  read  a  paper  on  The  effect  of  the 
douche  in  neurasthenia  and  other  Nervous  Troubles.  Dr. 
Sinkler  spoke  of  the  good  results  from  the  use  of  hydro- 
therapy in  nervous  affections.  His  method  of  employing 
it  is  practically  the  same  as  that  of  Dr.  Baruch.  It  Is 
particularly  valuable  in  combatting  the  insomnia  of  neu- 
rasthenia. Exercise  after  the  bath  is  a  very  important 
matter.  Dr.  S.  Solis  Cohen  spoke  in  confirmation  of  Dr. 
Baruch's  advocacy  of  hydrotherapy.  He  believes  that 
every  medical  center  should  support  an  institution  for  the 
application  of  hydrotherapy,  pneumotherapy.  massage,  and 
electrotherapy.  Dr.  J.  H.  Musser  statel  that  the  term 
"cold  friction  bath"  as  used  by  Dr.  Baruch  was  a  most 
happy  one  and  much  more  impressive  than  the  term  "cold 
bath."  The  belief  in  the  efficacy  of  hydrotheraphy  in  the 
treatment  of  typhoid  fever  is  becoming  stronger  every  day. 
He  hopes  to  see  the  hydriatic  treatment  of  tuberculosis  In- 
crease in  use  and  value.  Dr.  Pearce  read  for  Dr.  J.  M. 
Anders  his  discussion  on  the  subject  in  question.  Dr.  An- 
ders spoke  of  its  value  in  neurasthenia  and  typhoid  fever. 
He  also  said  that  in  actue  conditions  where  there  was  an 
overwhelming  toxemia  large  draughts  of  water  acted  as  a 
diuretic  and  were  thus  useful  in  ridding  the  body  of  the 
toxins  present. 

In  closing  the  discussion  Dr.  Baruch  said  that  in  treating 
insomnia  by  the  use  of  water  certain  precautions  must  be 
taken.  Warm  water  dilates  the  capillaries.  If  the  patient 
then   comes   in  contact   with   cooler   air  this   dilatation   is 


counteracted  and  the  patient  is  weakened.  Hence  Instead 
of  allowing  this  chilling  of  the  surface  the  patient  should 
be  wrapped  in  warm  sheets  and  blankets  and  then  placed 
between  warm  sheets  and  hot  water  bottles  applied.  A  still 
better  way  is  to  give  a  cold  wet  pack.  Dr.  Baruch  said  that 
the  diuretic  effect  of  water  was  not  due  to  simple  flushing 
of  the  kidneys.  It  acts  in  the  stomach  as  it  does  on  the 
skin,  causing  a  contraction  and  then  a  dilatation  of  the  ves- 
sels. This,  through  action  on  the  nerves,  stimulates  respi- 
ration and  the  systole  of  the  heart.  In  this  way  diuresis 
is  brought  about.  Because  of  this  fact  the  giving  of  1  or  3 
ounces  of  water  at  40°  every  2  hours  will  produce  more 
diuresis  than  will  the  giving  of  one-half  a  pint. 

Dr.  R.  G.  Le  Conte  read  a  paper  on  The  value  of  com- 
bined medical  and  surgical  clinics  to  the  student.  Dr.  Le 
Conte  claims  that  a  purely  medical  or  surgical  clinic  gives 
only  a  one-sided  view  of  many  cases  and  the  student  does 
not  get  a  connected  idea  of  the  case.  Several  combined 
clinics  were  given  at  the  Pennsylvania  Hospital  during  the 
past  winter,  with  a  great  degree  of  satisfaction  to  clini- 
cians and  students. 

College  of  Physicians  of  Philadelphia. — The  meeting 
held  May  1  was  de\oted  to  the  discussion  of  The  relation 
of  diseases  of  the  heart  to  surgical  operations,  and  espec- 
ially to  the  use  of  general  anesthetics.  The  first  paper  was 
read  by  Dr.  W.  J.  Mayo,  of  Rochester,  Minn.,  on  Pra-ex- 
istent  heart  disease,  in  reference  to  surgical  operations. 
Dr.  Mayo  said  that  the  condition  of  the  heart  muscle  was 
of  prirne  importance  to  the  surgeon  and  the  reserve  power 
of  the  heart  so  far  as  is  possible,  must  be  estimated  and 
taken  into  consideration.  Will  it  stand  the  anesthetic, 
the  blood  loss,  the  nerve  shock,  of  the  operation''  The 
reserve  power  of  the  heart  is  commonly  thought  to  be 
less  in  infancy  and  in  old  age.  Dr.  Mayo  finds  this  to  be 
more  true  in  regard  to  the  former  period  than  in  the  lat- 
ter. His  experience  does  not  enable  him  to  substantiate 
the  statement  that  people  above  the  average  height  bear 
anesthetics  badly.  Many  people  in  the  Northwest  are  above 
the  average  in  height  and  they  take  anesthetics  excel- 
lently. Valvular  lesions  of  the  heart  are  usually  viell 
compenaeted  in  persons  between  the  ages  of  10  and  40 
years  and  there  is  generally  little  risk  in  giving  them  an 
anesthetic.  If  failing  compensation  is  present,  only  the 
most  urgent  operations  should  be  done  before  treatment 
has  been  instituted.  After  40  valve  lesions  are  usually  as- 
sociated with  myocarditis.  The  most  dangerous  lesion  is 
fatty  degeneration.  Dr.  Mayo  believes  that  many  of  the 
unexpected  and  sudden  deaths  which  occur  soon  after 
operation  are  due  to  myocardial  change.  Cases  were  cited 
in  illustration  of  this  point.  Some  of  the  cases  of  death 
following  operation  for  exophthalmic  goiter  are  undoubted- 
ly due  to  myocarditis  incident  to  that  disease.  The  one 
death  in  7  thyroidectomies  done  by  Dr.  Mayo  was  due  to 
that  cause.  A  knowledge  of  cardiac  insufficiency  by  the 
surgeon  and  anesthetizer  is  a  great  safeguard  against 
danger  during  an  operation.  Dr.  H.  A.  Hare  spoke  on  The 
safest  anesthetic  to  use  in  organic  disease  of  the  heart 
and  vessels.  Dr.  Hare  said  that  comparatively  few  people 
having  heart  disease  died  from  the  effect  of  an  anesthetic 
as  compared  with  the  deaths  from  straining  at  stool,  go- 
ing rapidly  up  stairs,  etc.  The  majority  of  the  accidents 
in  surgery  are  due,  not  to  the  anesthetics,  but  to  the 
shock  of  the  operation.  He  has  seen  the  condition  of  the 
patient  improve  under  the  influence  of  the  anesthetic.  The 
question  of  poisoning  by  these  drugs  must  be  taken  into 
consideration.  Probably  not  more  than  1  surgeon  in  100 
knows  how  much  anesthetfc  his  patient  really  receives. 
The  quantity  poured  on  the  inhaler  is  not  the  true  amount 
and  for  this  reason  the  dosage  is  unknown.  In  choosing 
an  anesthetic  the  idiosyncrasy  of  the  patient  is  often  not 
taken  ir.to  account.  The  statement  of  Dr.  Mayo  in  regard 
to  persons  of  overheight  may  apply  to  the  hardy  races  of 
the  Northwest,  but  it  does  not  to  people  in  this  locality. 
Dr.  Hare  laid  great  stress  on  the  condition  of  the  vessels 
In  regard  to  the  use  of  anesthetics.  Ordinarily  the  clin- 
ician or  surgeon  examines  the  heart  but  does  not  inves- 
tigate the  cardio-vascular  tone,  blood  pressure,  etc.  In 
many  cases  of  high  arterial  tension,  ether  is  contraindi- 
cated.  although  generally  it  is  the  safest  anesthetic  we 
have.  American  surgeons  do  not  often  enough  use  strop- 
ine  for  its  effect  in  checking  secretion  caused  by  the  anes- 


Q  .  ,       The  Philadelphia  "| 
V't4        Medical   Jclrnal  J 


AMERICAN  NEWS  AND  NOTl-.S 


[Mat   18,   190L 


thetic.  The  choice  ot  method  of  giving  an  anesthetic  is 
as  important  as  the  choice  of  the  anesthetic  itself.  The 
inhaler  to  which  a  rubber  bag  is  attached  and  which 
causes  the  patient  to  breathe  his  own  respired  air  should 
never  be  used.  The  giving  of  an  anesthetic  by  means  of 
oxygen  bubbling  through  it  is  a  disadvantage.  If  chloro- 
form be  used  a  chemical  change  may  take  place  and 
ether  is  rendered  more  combustible.  If  it  is  desirable  to 
increase  the  oxygen  the  anesthetic  is  increased  at  the  same 
lime  while  a  decrease  in  oxygen  means  a  decrease  in  anes- 
thetic. Too  much  oxygon  will  produce  apnea.  The  oxygen 
should  be  given  alone  and  the  anesthetic  alone  as  it  is  only  by 
this  means  that  a  proper  amount  of  each  is  used.  Ether 
is  the  safest  anesthetic  except  in  cases  of  vascular  dis- 
ease. It  is  not  strongly  contraindicated  in  Bright's  dis- 
ease. Chloroform  in  cases  of  myocardial  change  is  often 
dangerous.  Nitrous  oxide  is  contraindicated  when  vas- 
cular changes  are  present.  In  regard  to  the  use  of  a  gen- 
eral anesthetic  in  cases  having  valvular  and  myocardial 
disease,  Dr.  Hare  said  that  the  patient  often  improves  un- 
der the  use  of  the  anesthetic.  General  anesthesia  is  better 
than  local  or  spinal  anesthesia.  Shock  to  the  nervous  and 
circulatory  systems  is  greater  in  the  latter  method  and 
patients  have  been  seen  to  improve  when  it  was  aban- 
doned and  general  anesthesia  used.  In  Dr.  Hare's  opinion 
intraspinal  injection  will  soon  be  a  medical  curiosity.  Dr. 
Finney  exhibited  charts  which  he  has  the  anesthetizer 
keep  for  each  case.  These  show  the  pulse  frequency  at 
each  5  minutes  during  the  operation.  Dr.  Alfred  Stengel 
spoke  of  The  cardiac  complications  which  may  arise  after 
operation.  There  is  very  little  to  warrant  the  belief  that 
anesthetics  will  produce  a  heart  lesion  except  of  the  myo- 
cardium. For  the  immediate  effect  inferences  should  be 
drawn  from  examinations  with  no  blood  loss,  and  from 
trivial  operations.  In  pre-existing  myocardial  change 
ether  is  well  borne.  Some  cases  show  an  improved  cardiac 
condition  immediately  after  operation.  After  some  days 
a  weakness  may  develop.  Pneumonia  is  often  said  to  be 
due  to  aspiration,  irritation,  etc.,  when  it  is  due  to  a  failing 
circulation  and  anesthesia  has  been  the  exciting  cause. 
Pneumonia  embolism  is  more  frequent  in  gynecological 
cases.  The  heart  is  the  predisposing  cause.  Myocardial 
disease  is  common  in  women  who  have  myomata  of  the 
uterus.  Dr.  Stengel  emphasized  the  necessity  of  recogniz- 
ing that  pneumonia,  late  vomiting,  embolism,  etc.,  are  in 
some  cases  really  due  to  the  failure  of  the  operator,  caus- 
ing sepsis,  etc.  Dr.  Ochsner.  of  Chicago,  stated  that  he 
had  never  had  an  alarming  condition  from  anesthesia  in 
patients  suffering  from  a  demonstrable  heart  lesion.  A 
paper  by  Dr.  R.  G.  LeConte  entitled  Hydatid  disease  of  the 
breast  was  read  by  title. 

Philadelphia  Obstetrical  Society. — At  the  stated  meeting 
held  May  2,  Dr.  Frank  W.  Talley  reported  A  case  of  puer- 
peral septicemia  treated  with  Unguentum  Crede.  In  addi- 
tion to  treatment  by  whiskey,  strychnine,  etc.  in  an  un- 
doubted case  of  septicemia,  Crede's  ointment  was  used  by 
inunction.  Improvement  was  noticed  the  morning  after  its 
use  was  begun.  On  the  fifteenth  day  the  temperature  was 
normal  and  the  inunctions  were  discontinued.  The  tempera- 
ture rose  again. in  5  days  reaching  102°.  Inunctions  were  again 
used  and  the  temperature  was  normal  by  the  second  day.  In 
all  3  ounces  of  the  ointment  were  used.  Dr.  ,T.  M.  Baldy 
said  that  cases  of  septicemia  were  deceptive,  sudden 
changes  often  taking  place.  He  does  not  see  that  the 
silver  ointment  can  do  any  good  in  such  cases.  Dr  Chas. 
P.  Noble  stated  that  a  large  percentage  of  the  cases  of 
puerperal  septicemia  recover.  He  has  never  used  silver 
ointrtient  but  it  is  worthy  of  note  that  Dr.  Tallev  used  other 
approved  methods  ot  treatment  in  his  case.  Dr.  Strieker 
Coles  uses  whiskey,  strychnine,  sponging,  etc.  and  has  had 
no  fatalities  in  8  cases.  ■  Dr.  ,1.  M.  Baldy  reported  three 
cases  and  exhibited  specimens.  Case  1  was  an  apparent 
caloarecus  degeneration  of  both  ovaries  but  histological 
examination  showed  it  to  be  a  tibrous  change,  the  tissue 
being  remarkably  dense.  Case  2  was  an  adeno-carcinoma 
of  the  fundus  of  the  uterus.    Case  3  was  an  ovarian  cyst. 

OBITUARY. 

Dr.  Andrew  K.  Minnich. — Dr.  Andrew  K.  Minnich  died 
May  11,  at  his  residence,  145  Susquehanna  avenue,  in  his 
54th  year,  after  an  illness  of  six  months.  Dr.  Minnich 
was  born  in  Mount  .loy.  Pa,  He  was  graduated  with  hon- 
ors from  L'afayette  College,  and  then  entered  the  Jefferson 
Medical   College,   from   which   he  was   graduated    in   1870 


The  Franco-German  War  was  in  progress  at  that  time,  and 
he  enlisted  as  surgeon  in  the  German  army.  At  the  close 
of  the  conflict  he  was  induced  to  return  to  this  city  as  a 
teacher  and  lecturer  in  the  Wagner  Institute  of  Science. 
For  more  than  twenty  years  Dr.  Minnich  was  a  visiting 
ijhysician  to  the  Episcopal  Hospital,  and  for  many  years 
was  quiz-master  and  lecturer  in  the  Jefferson  College.  He 
contributed  many  valuable  treatises  on  blood  disease.  He 
was  a  member  of  the  Medical  Club,  Philadelphia  County 
Medical  Society  and  Metropolitan  Club. 

Dr.  Julius  Boushey.  at  San  Francisco,  Cal.,  on  April  29. — 
Dr..  George  Cyprian  Jarvis,  at  Hartford,  Conn.,  on  May  7. 
aged  67  years. — Dr.  E.  L.  Priest,  at  Nevada,  Mo.,  on  May 
S. — Dr.  M.  E.  Downes,  at  Wilmington,  Del.,  on  May  10. — 
Dr.  H.  D.  Peters,  at  Henry  County,  Md.,  on  May  10,  aged 
8^4  years. — Dr.  Daniel  Humphrey,  at  Lawrence,  Mass.,  on 
May  0,  aged  79  years. — Dr.  E.  Stanley  Perkins,  at  Philadel- 
phia, Pa.,  on  May  6.  aged  59  years. — Dr.  Robert  Boiling. 
at  Chestnut  Hill.  Philadelphia,  Pa.,  on  May  12.  aged  6*5 
years. — Dr.  Charles  Rice,  at  New  York  City,  on  May  13. 
aged  60  years. — Dr.  Norman  Armett  Smith,  at  Greenwich. 
Conn.,  on  May  12.  aged  78  years. — Dr.  George  W.  Pem- 
brooke,  at  Friendship,  Md.,  on  May  12,  aged  58  years. — Dr. 
James  Hayes,  Plainfield,  N.  J.,  on  May  13. 

Vital  Statistics  of  Philadelphia  for  the  week  endinc. 
May  11,  1901: 

Total  mortality   475 

Cases.     Deaths 

Inflammation  of  the  appendix  3, 
bladder  2,  brain  9,  bronchi  6,  heart 
2,  kidneys  16,  larynx  2,  lungs  71, 
peritoneum  9,  pleura  3.  stomach 
and  bowels  21,  uterus  1,  spine  1  , .  146 

Marasmus  13,  debility  8,  inanition 
16 37 

Tuberculosis  of  the  lungs 62 

Apoplexy  15,  paralysis  5   20 

Heart-disease  of  36,  fatty  degener- 
ation of  1,  neuralgia  of  3 40 

Uremia  14,  diabetes  1,  Bright's  dis- 
ease 3 18 

Carcinoma  ot  the  breast  1,  stomach 

4,  uterus  5,  larynx  1   11 

Convulsions    15 

Diphtheria     56  16 

Brain-abscess  of  1,  congestion  of  2. 

disease  of  2,  tumor  of  1 6 

Typhoid  fever  98  12 

Old  age   10 

Cyanosis    2 

Scarlet  fever   101  6 

Influenza  1,  abscess  ot  lungs  1.  al- 
coholism 6,  asthma  3,  anemia  2, 
burns  and  scalds  2,  carbuncle  1. 
casualties  5.  congestion  of  lungs 
4,   child   birth   1,   cholera   morbus 

1,  cirrhosis  of  the  liver  3.  croup  1, 
croup,  membranous  1.  diarrhea  1. 
drowned   4,  dysentery  1.   epilepsy 

2.  fever,  malarial  1,  puerperal  1. 
hemorrhage  from  uterus  2.  gan- 
grene 2,  jaundice  1.  locomotor 
ataxia  2.  lymphadenoma  1,  meas- 
les 4,  obstruction  of  the  bowels 
2,  edema  of  lungs  2,  poisoning 
1,  rheumatism  2.  shock  2,  septice- 
mia 2,  sarcoma,  multiple  1,  suffoca- 
tion 1,  suicidel,  tetanus  1,  ulcer- 
ation of  the  stomach  1,  unknown 

coroner  case  1,  whooping  cough  3  74 

NEW  JERSEY. 
Smallpox  Epidemic  at  Gloucester  City. — Considerable 
excitement  prevails  in  Gloucester  City  on  account  of  the 
epidemic  of  smallpox  which  exists  there.  All  cases  have 
been  isolated  and  rigid  sanitary  measures  have  been  in- 
stituted. There  is  no  positive  knowledge  as  to  how  the 
disease  was  introduced  in  Gloucester  City,  but  the  first 
victim,  who  is  a  paper-hanger  by  trade,  is  said  to  have 
repapered  the  house  in  Woodbury  in  which  the  only  ta'al 
case  of  that  town  occurred.  The  superintendents  ot  mills 
and  factories  have  insisted  upon  general  vaccination  of  the 
employees. 


May  is,  19111] 


AMERICAN  NEWS  AND  NOTES 


LThe  Philadelphia       „  , ;. 
Medical   Journal         ynO 


NEW   YORK. 

New  Lunacy  Commissioner. — Governor  Odell  has  ap- 
pointed Dr.  Frederic  Peterson,  of  New  Yorli  City,  the  Medi- 
cal member  of  the  State  Lunacy  Commission,  to  succeed 
Dr.  Wise.  Dr.  Peterson  was  largely  instrumental  in  the 
organization  of  the  Craig  Colony  for  Epileptics,  and  is 
president  of  the  Board  of  Managers  of  that  institution. 

Dr.  Charles  Rice,  Chairman  of  the  Revision  Committee  of 
the  United  States  Pharmacopeia,  died  May  13th„  at  Belle- 
vue  Hospital,  N.Y.  Dr.Rice  was  l)orn  in  Munich  in  1841.  He 
received  an  education  in  Vienna,  Munich  and  Passau,  ac- 
quiring a  thorough  mastery  of  several  Oriental  languages, 
the  classics  and  the  modern  tongues.  He  was  a  most  thor- 
ough and  accomplished  linguist  and  recognized  as  an  au- 
thority on  questions  of  philology  and  etymology.  Dr.  Rice 
came  to  America  in  1862,  and  during  the  war  served  in  the 
navy  as  surgeon's  steward.  After  his  discharge  from  ser- 
vice he  entered  the  Department  of  Public  Charities  and 
Corrections  of  New  York  City,  and  has  been  the  chemist 
to  that  department  and  superintendent  of  its  drug  depart- 
ment for  many  years. 

Appointment. — Dr.  L.  Emmett  Holt  has  been  appointed 
Clinical  Professor  of  Diseases  of  Children  at  the  College 
of  Physicians  and  Surgeons,  New  York. 

Home  for  Chronic  Invalids. — The  Montefiore  Home  for 
Chronic  Invalids,  of  New  York,  has  maintained  a  sani- 
tarium for  consumptives  at  Bedford  Station,  Westchester 
County,  for  several  years.  It  has  now  widened  its  scope 
by  adding  a  new  building  capaljle  of  accommodating  up- 
ward of  150  patients.  This  building  is  nearing  completion, 
and  will  be  formally  opened  on  Memorial  Dav,  Thursdav, 
May  30. 

Appointment. — Dr.  Louis  Fischer  has  been  appointed  a 
Visiting  Physician  to  the  Willard  Parker  and  Reception 
rlospitals  of  New  York  City. 

Dr.  Samuel  K.  Lyon. — Dr.  Samuel  K.  Lyon,  who  has  been 
a  police  surgeon  for  thirty  years,  died  suddenly  May  4th. 
in  New  York  City.  He  was  a  graduate  of  the  College  of 
Physicians  and  Surgeons,  and  a  member  of  the  County 
Medical  Assrciation,  the  Academy  of  Medicine,  and  the 
County  Medical  Society. 

Edward  N.  Gibbs  Memorial  Prize  Fund. — The  Trustees 
of  the  Nev/  York  Academy  of  Medicine  have  the  pleasure 
of  announcing  the  receipt  of  Ten  Thousand  Dollars  from 
Mrs.  Sarah  Barker  Gibbs  and  Miss  George  Barker  Gibbs, 
for  the  establishment  of  The  Edward  N.  Gibbs  Memorial 
Prize  Fimd.  the  income  to  be  awarded  triennially  to  the 
physician  of  regular  standing  in  the  medical  profession  of 
the  United  States  of  America,  who  shall  present  the  best 
original  essay  upon  the  etiology,  pathology  and  treatment 
of  the  diseases  of  the  kidney, 

Manhattan  Dermatological  Society. — The  regular  monthly 
meeting  was  held  on  Friday  evening.  May  3d,  at  the  resi- 
dence of  Dr.  A.  Bleiman,  No.  206  E.  4Sth  St.  Dr.  Wm.  S. 
Gottheil  presided.  Dr.  R.  Abrahams  presented  a  patient 
with  tinea,  versicolor  limited  to  the  palms.  The  lesion 
had  existed  for  a  year  and  a  half  and  when  first  seen  con- 
sisted of  light  and  dark  yellow  patches  of  various  shapes 
and  sizes.  Sweating  was  noticed  during  the  summer  months 
and  but  little  during  the  winter.  The  lesions  were  more 
perceptible  with  daylight.  At  present,  owing  to  the  con- 
stant washing,  the  palms  simply  showed  a  superficial  scali- 
ness.  Microscopical  examination  by  Dr.  Gottheil  demon- 
strated typical  mycelia  and  spores  of  the  microsporon. 
.^part  from  the  case  of  Dr.  Gottheil.  this  is  the  only  one 
recorded.  Dr.  Gottheil  remarked  that  although  from  a  clin- 
ical standpoint  this  case  was  not  as  characteristic  as  his 
own,  the  microscopical  picture  was  classical.  Dr.  Bleiman 
said  that  at  present  the  case  looked  like  tellositas,  and  Dr. 
L.  Weiss  that  it  resembled  a  chronic  eczema.  Dr.  J.  Sobel 
recommends  the  application  of  Leyol's  solution  for  bringing 
into  view  pale  and  imperceptible  lesions  of  the  disease 
(.\llen's  Test.)  Dr.  E.  L.  Cocks  presented  two  cases  of 
prurigo  in  a  native  born  boy  and  girl  of  eight  and  nine 
years  respectively.  These  cases  would  refute  the  state- 
ment of  Hyde  and  White  that  this  disease  occurred  only  in 
foreign  born  individuals.  Both  presented  papules  on  the 
exterior  surfaces  of  the  extremities,  the  feeling  of  a  nut- 


meg grater  and  enlarged  glands.  Both  gave  a  preurticarial 
history.  Dr.  Kinch  agreed  with  the  diagnosis.  Dr.  R. 
Abrahams  would  call  both  chronic  urticaria  and  advise 
pilocarpine.  Dr.  S.  Sobel  remarked  that  neither  case  cor- 
responded to  his  conception  of  prurigo  nor  to  the  cases  as 
he  had  seen  them  abroad.  The  papules  lacked  a  certain 
firmness,  he  could  not  detect  the  nutmeg  grater  feeling, 
the  prurigo  buboes  were  wanting.  He  would  call  both 
chronic  papular  urticaria.  Dr.  L.  Weiss  said  the  preurticar- 
ial state  might  speak  for  prurigo.  Against  it  were  the 
absence  of  haggard  look  and  anemia,  and  the  prurigo 
buboes.  He  would  call  them  lichen  urticatus  or  chronic 
lichen  simple.x.  Dr.  Oberndorfer  stated  that  neither  case 
looked  like  prurigo.  He  missed  the  great  infiltration  of  the 
skin,  the  hardness  of  the  individual  lesions  and  the  char- 
acteristic glandular  enlargement.  He  calls  it  chronic  pop- 
ular eczema. 

Dr.  Gottheil  said  the  picture  was  not  quite  that  of  prur- 
igo or  popular  urticaria.  He  inclined  however  toward  a 
diagnosis  of  prurigo. 

Dr.  Weiss  presented  a  case  of  eczema  neuroticum  vege- 
tans. The  patient  showed  symmetrical  lesions  of  the  lower 
oxtremeties;  there  were  patches  with  healed  centres,  the 
individual  lesions  being  small,  elevated  popules  resembling 
lichen.  Dr.  E.  L.  Cocks  considers  it  lichen  planus'  on  an 
eczematous  base.  Dr.  Oberndorfer  fails  to  see  lichen  plan- 
us. Ezema  is  his  diagnosis.  Dr.  Bleiman  believes  the 
primary  condition  to  be  pruritus  senilis.  Dr.  J.  Sober  would 
call  this  condition  a  mycotic  eczema.  For  this  speak  the 
more  or  less  circular  form,  the  somewhat  sharply  defined 
edges,  the  healed  centre,  the  persistency  of  the  lesions. 
Chrysarobin  and  formalin  act  well.  Dr.  R.  Abrahams  ex- 
cludes lichen  planus.  pruritus,  and  neurotic  ec- 
zema, and  diagnoses  a  parasitic  eczema.  Car- 
bolic acid  and  strong  silver  colution  (.50%)  are  advised. 
Drs.  Gottheil  and  Kinch  consider  it  eczema. 

Dr.  L.  Weiss  presented  a  rosacea  of  the  cheeks:  upon 
stretching  the  skin  the  cjpullary  dilation  and  circluation 
became  apparent.  Dr.  Geyser  advised  the  use  of  a  fine 
steel  needle  attached  to  the  negative  galvanic  pole  and  in- 
serted at  right  angles  into  the  vessels.  Dr.  A.  Bleiman 
presented  a  girl  of  twenty-three  with  favus  of  the  nails 
of  the  left  hand.  There  were  lesions  of  favus  on  the 
scalp.  Dr.  Kinch  did  not  find  much  evidence  of  favus  on 
the  scalp.  Drs.  Oberndorfer,  Gottheil  and  Cocks  would 
expect  more  destruction  of  hair  in  a  favus  of  such  dura- 
tion. 

Dr.  Oberndorfer  showed  a  patient  with  a  probable  acne 
varioliformis  of  the  scalp  and  neck,  together  with  a 
number  of  bald  spots  of  the  head.  Many  lesions  were  not 
characteristic.  Dr.  R.  Abrahams  would  call  the  condition 
acne   vulgaris   with   folliculitis. 

Dr.  J.  Sobel  calls  it  acne  pustulosa  and  folliculitis  absce- 
dens.  Dr.  L.  Weiss  said  that  the  bald  spots  speak  for 
folliculitis  decalvans.  Dr.  E.  S.  Cocks  does  not  consider 
it  acne  varioliformis.  Dr.  Ochs  presented  a  patient  with 
resolving  syphilis.  Dr.  A.  Bleiman  showed  a  pityriasis 
rosea,  rfsembling  seborrheal  eczema  and  a  case  of  scabies, 
showing  the  continuous  treatment  of  the  disease  with 
Wilkinson's  ointment. 

WESTERN     STATES. 

National  Confederation  of  State  Medical  Examining  and 
Licensing  Boards. — At  the  next  meeting  of  the  National 
Confederation  of  State  Medical  Examining  and  Licensing 
Boards  to  be  held  at  St.  Paul,  Minn.,  June  3rd,  1901,  there 
will  be  a  discussion  of  the  question:  "What  should  be  the 
legal  definition  of  the  practice  of  medicine?"  following  a 
paper  on  that  subject  by  Dr.  Henry  Beates,  .Jr.,  of  Phila- 
delphia. Also  a  discussion  following  the  report  of  the 
Committee  on  Interstate  Reciprocity  and  Uniform  Medical 
Legislation. 

Meeting  of  the  American  Medical  Editors'  Association. — 
The  annual  business  meeting  of  the  American  Medical  Edi- 
tors' Association  will  convene  in  the  library  rooms  of 
the  Ramsey  County  Medical  Society.  Lowry  Arcade  build- 
ing, St.  Paul,  at  2.30  P.  M.,  Monday,  .Tune  3d.  The  Lowry 
.Arcado  building  is  situated  in  St.  Peter  street,  between 
Fourth  and  Fifth.  The  session  will  open  promptly  at  the 
above  hour,  and  all  members  are  urged  to  be  present  at 
that  time. 

This  association,  as  implied  in  the  name,  consists  of 
medical  editors  of  the  United  States.     Meetings  are  held 


f,-A         The  Philadelphia"! 
Vt^^         Medical   Journal  J 


AMERICAN  XE\\S  AXD  XOTES 


[Mat  18.   ISOU 


annually,  coincident  with  the  American  Medical  Associa- 
tion. The  aims  of  the  association  are  the  advancement  of 
medical  iournalism.  the  foundation  of  an  ethical  press  in 
medicine"  and  the  improvement  of  the  medical  profes- 
sion in  general.  The  membership  includes  the  leading 
-medical  writers  and  editors  of  the  country. 

The  meeting  this  year  will  be  a  most  successful  one, 
both  from  the  point  of  presentation  of  valuable  papers  and 
the  energetic  work  of  the  members  of  the  association  which 
will  be  made  manifest  at  the  meeting.  The  preliminary 
program  is  calculated  to  interest  and  benefit  every  medical 
editor.    A  partial  list  of  papers  includes: 

President's  Address.  Dr.  Alex.   j.   Stone,   of  St.   Paul. 

Relative  Value  of  Medical  Advertising,  by  Dr.  John  Pun- 
ton,  of  Kansas  City,  Missouri. 

Paper,  subject  unannounced,  by  Dr.  John  V.  Shoemaker, 
of    Philadelphia. 

Improvements  in  Medical  Education,  by  Dudley  S.  Rey- 
nolds, of  Louisville. 

Some  Thoughts  on  the  Ethics  of  Medical  Journalism,  by 
Burnside  Foster,  of  St.  Paul. 

Editorial  Corps  and  Medical  Journalism,  by  Dr.  George 
F.  Butler,  of  Alma,  Michigan. 

Relation  of  the  Medical  Editor  to  Original  Articles,  by 
Harold  Moyer.  of  Chicago;   and 

Paper,  subject  unannounced,  by  Dr.  George  H.  Sim- 
mons,' of  Chicago. 

The  annual  dinner  of  the  association  will  be  held  at  9 
P.  M.,  June  3d,  reservation  of  plates  should  be  made  at 
once.  Membership  applications  and  titles  of  additional  pa- 
pers can  be  sent  to  Alexander  J.  Stone.  Lowry  Arcade,  St. 
Paul,  president,  or  O.  F.  Ball,  Century  building,  St.  Louis, 
secretary. 

Not  Obliged  to  Attend  Patients. — The  supreme  court 
of  Indiana  has  recently  decided  that  a  licensed  physician 
is  not  legally  obliged  to  attend  a  patient  when  called,  al- 
though he  has  been  the  family  physician  of  the  patient  in 
times  past.  Dr.  Weddingfield  refused  to  attend  a  patient, 
although  he  had  been  called  three  times.  The  patient  died, 
and  It  was  charged  that  her  death  was  caused  by  the 
doctor's  refusal  to  respond  to  the  call.  He  was  sued  for 
?10,000    damages. — Western    Medical    Review. 

Mississippi  Valley  Medical  Association. — It  is  announced 
that  the  dates  of  the  next  meeting  of  the  Slississippi  Valley 
Medical  Association  have  been  changed  from  the  10th.  11th, 
and  12th  of  September  to  the  12th,  13th.  and  14th  of  Sep- 
tember. This  change  has  been  necessary  because  the 
dates  first  selected  conflicted  with  another  large  Associa- 
tion meeting  at  the  same  place. 

The  meeting  is  to  be  held  at  the  Hotel  Victory,  Put-in- 
Bay  Island,  Lake  Erie,  O.,  and  the  low  rate  of  one 
cent  a  mile  for  the  round  trip  will  be  in  effect  for  the 
meeting.  Tickets  will  be  on  sale  as  late  as  September  12th. 
good  returning  without  extension  until  September  15th. 
By  depositing  tickets  with  the  Joint  Agent  at  Cleveland 
and  paying  50  cents  the  date  can  be  extended  until  October 
8th.  "This  gives  members  an  opportunity  of  visiting  the 
Pan-American  Exposition  at  Buffalo,  to  which  very  low 
rates  by  rail  and  water  will  be  in  effect  from  Cleveland. 

Full  information  as  to  rates  can  be  obtained  by  address- 
ing the  Secretary.  Dr.  Henry  E.  Tuley,  No.  Ill  'West  Ken- 
tucky street.  Louisville.  Ky.  Members  of  the  Profession 
are  cordially  invited  to  attend  this  meeting. 

Those  desiring  to  read  papers  should  notify  the  Secre- 
tary at  an  early  date. 

A  Bill  introduced  by  Mr.  Stubblefield  for  an  act  requiring 
reports  of  births  and  deaths,  and  the  recording  of  same: 
legulating  the  interment  or  other  disposal  of  dead  bodies, 
and  prescribing  a  penalty  for  non-compliance  with  the  pro- 
visions hereof  has  passed  both  Houses  in  the  State  of 
Illinois  and  will  go  into  effect  January  1,  1902. 

Pleads  Guilty. — Stephen  .\.  Weltmer  and  Joseph  H.  Kel- 
ly, formei-  president  and  secretary  of  the  'Weltmer  Insti- 
tute of  Magnetic  Healing,  at  Nevada.  Mo.,  who  recently 
pleaded  guilty  to  indictments  charging  them  with  using 
the  mails  to  defraud,  were  each  fined  $1,500  by  Judge  Phil- 
lips, in  the  United  States  District  Court.  The  men  gave 
"absent  treatment."  and  their  mail,  which  reached  a  tre- 
mendous volume,  was  stopped  by  the  Postoffice  Depart- 
ment at  Washington  on  a  fraud  order. 

Smallpox  in  California. — Eighteen  cases  of  smallpox  have 
broken  out  at  the  State  institution  for  the  deaf,  dumb  and 
blind,  at  Berkeley,  Cal. 


SOUTHERN   STATES. 

Women  Doctors  in  South  Carolina. — Two  young  women 
have  recently  been  graduated  from  the  Medical  College 
of  South  California.  They  are  the  first  women  graduates 
of  the  institution  and  also  of  the  State. 

Dr.  Stanford  E.  Challle,  dean  of  the  medical  department 
of  Tulane  University,  in  New  Orleans,  has  been  given  the 
degree  of  LL.D.  by  the  university  on  his  completion  of 
fifty  years  in  its  service. 

Medical  Springs. — The  Secretary  of  the  Interior  has  ad- 
dressed letters  to  the  Governor  of  each  State  in  the  Union 
asking  for  detailed  reports  as  to  the  safeguards  thrown 
about  thermal  and  medical  waters  within  the  borders  of 
the  states.  He  seeks  the  information  for  the  International 
Commission  of  Medical  Hydrology  which  will  meet  in  Ber- 
lin shortly. 

Meeting  of  the  American  Therapeutic  Society.  (Reported 
by  Dr.  T.  L.  Colev). — The  second  annual  meeting  of  the 
society  was  held  in  Washington,  on  Tuesday  morning.  May 
7th,  at  10  o'clock  In  the  absence  of  Dr.  H.  C.  Wood,  who 
v»as  prevented  from  attending  on  account  of  illness,  the 
meeting  was  called  to  order  by  the  vice-president,  R.  W. 
Wilcox,  of  New  York.  Dr.  Robert  Reybum.  chairman  of  the 
Judicial  Council,  delivered  the  address  of  welcome.  Dr. 
1.  E.  Satterthwaite,  of  New  York,  responded  on  behalf  of 
the  visiting  members.  The  reports  of  the  secretary  and 
treasurer  followed.  Dr.  George  C.  Ober.  of  Washington, 
delivered  a  memorial  address  upon  the  late  Dr.  Samuel  C. 
Busey.  of  Washington.  The  morning  session  was  then 
adjourned.  The  Judicial  Council  met  at  12  o'clock.  The 
afternoon  session  convened  at  2  o'clock  and  the  presi- 
dent's address,  "Reviewing  the  Progress  of  Therapeutics 
for  the  Preceding  Twelve  Months."  was  delivered  by  Dr. 
R.  W.  Wilcox.  -\  business  meeting  behind  closed  doors 
followed.  In  the  evening  the  District  Therapeutic  Society 
gave  a  reception  at  the  Cochran.  At  the  morning  session 
of  May  8th.  Francis  G.  Morgan.  M.  D..  of  Washington,  read 
a  paper  on  "Sug.gesticns  Concerning  the  Use  of  the  Metric 
System  in  Prescription  Writing."  and  an  interesting  dis- 
cussion followed.  Dr.  F.  E.  Stewart,  of  New  York,  read  a 
paper  on  "The  Relation  of  the  Pharmacist  to  the  Physi- 
cian, and  the  Relation  of  Pharmacy  to  Materia  Medica  and 
Drug  Therapeutics."  This  paper  was  of  especial  interest 
on  account  of  Dr.  Stewart's  well-known  advocacy  of  the 
idea  for  the  establishment  of  a  National  Bureau  of  Materia 
Medica.  Dr.  Stewart  called  attention  to  the  necessity  of 
regulating  the  papers  to  be  read  before  the  society  in  such 
a  manner  that  it  would  be  impossible  to  permit  commer- 
cial interests  to  assume  control  or  allow  the  society  to  be 
used  for  advertising  purposes.  On  the  other  hand,  it 
should  be  permissible  for  the  results  of  all  truly  scientific 
investigations  upon  pharmacology  to  be  submitted  to  the  so 
ciety.  but  care  must  be  taken  that  no  drugs  are  d'scussed 
under  their  copyright  names  but  under  their  chemical  des- 
ignations. He  made  an  urgent  plea  for  the  establishment 
of  a  National  Bureau  of  the  Materia  Medica.  and  desired 
that  the  American  Therapeutic  Society  should  be  known 
as  strongly  advocating  this  measure.  The  matter  was  re- 
ferred for  favorable  consideration  to  the  Jud'ci?l  Council. 
D'v  Robert  Reybum.  of  Washington,  read  a  paper  upon 
"The  Inertness  of  Petroleum  Compounds  'When  Giveri 
Medicinally."  The  good  effects  of  petroleum  when  obtaine*?. 
the  writer  believed  to  be  due  to  its  emulcent  and  lubricat- 
ing qualities.  It  also  aids  general  absorption  by  increasinir 
peristalsis,  but  the  drug  is  not  absorbed.  Dr.  .\lbert  C. 
Barnes,  of  Philadelphia,  stated  that  it  is  well  knov  u 
that  petroleum  is  not  absorbed  in  the  gastro-intestinal 
tract,  but  a  remedy  may  nave  the  most  pronounced  physio- 
logical effects  purely  upon  account  of  its  mechanical 
uronerties.  He  quoted  Dr.  Robinson,  of  Philadelphia,  wh.) 
had  treated  over  50  selected  cases  in  which  nutrition,  di- 
gest'on  and  body  weicht  were  impaired  and  the  purest  oil 
administered  for  periods  of  several  months.  There  was 
in  every  instance  increase  in  weight  and  improvement  in 
health.  The  fact  that  petroleum  passes  through  the  In- 
testine in  the  original  form  and  that  it  has  been  proven 
to  be  a  solvent  of  many  remedies  administered  for  their 
antiseptic  and  astringent  influence  indicate  a  useful  field 
for  petroleum  as  a  vehicle.  In  closing  Dr.  Reybum  ex- 
pressed his  conviction  that  the  petroleum  was  in  no 
sense  a  substitute  for  cod  liver  oil.  At  the  afternoon 
session  Dr.  T.  E.   Satterthwaite.  of  New  York,  discussed 


May  is,  1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia 
L  Medical   Journal 


947 


"The  Therapeutics  of  Chronic  Heart  Diseases  and  their 
ComiJlications."  He  placed  especial  stress  upon  the  faci, 
that  the  condition  of  the  cardiac  muscle  and  the  cardio- 
vascular system  generally  was  far  more  Important  than 
the  precise  valvular  lesion,  and  he  placed  more  dependence 
upon  exercise  alternating  with  periods  of  rest  and 
upon  the  bath  treatment,  with  strychnia  and  heart 
tonics  given  only  as  indicated,  than  upon  the 
total  rest  in  the  treatment  of  these  condition;;. 
Eli  H.  Long,  M.  D.,  of  Buffalo,  contributed  a  paper  upon  the 
"Principles  of  Cardiac  Therapeutics  in  Recent  Valvu- 
lar Disease."  On  account  of  the  absence  of  Dr.  Long,  the 
paper  was  read  by  the  Secretary.  J.  N.  Hall,  M.  D.,  of  Den- 
ver, read  "A  Report  of  Two  Cases  of  Aneurysm  Treated 
by  Wiring  and  Electrolysis."  These  cases  illustrated  the 
great  benefits  to  be  derived  from  this  method  when  gelatin 
and  other  treatment  have  proven  unavailing,  and  the  loca- 
tion of  the  aneurysm  is  suitable  for  the  operation.  In  the 
evening  a  banquet  was  served  at  the  Cochran.  At  the 
morning  session  of  May  9th,  Francis  H.  Miner.  M.  D.,  of 
Washington,  discussed  "Hypnotism:  a  Practical  Demon- 
stration of  its  Therapeutic  Value."  Dr.  Miner  exhibited  a 
patient  whom  he  could  hypnotize  very  readily,  and  who 
was  extremely  susceptible  to  post-hypnotic  suggestion. 
He  had  been  an  inveterate  smoker,  and  had  been  cured 
by  post-hypnotic  suggestion.  At  this  point  in  the  pro- 
ceedings a  discussion  arose  as  to  the  advisability  of  per- 
mitting the  next  paper  on  the  program,  "The  Therapeutic 
Use  of  Chlorotone,"  to  be  read  under  that  title.  Dr. 
Stewart  remarked  that  the  drug  is  covered  by  a  patent, 
and  the  right  to  the  use  of  the  name  chlorotone  is  limited 
to  one  firm  of  manufacturers.  Dr.  Barnes,  of  Philadel- 
phia, believes  that  the  attitude  of  the  physician  toward 
remedies  covered  by  patent,  copyright  or  fanciful  name 
should  be  unequivocally  decided  at  this  meeting.  If  the 
society  is  to  be  made  a  place  of  discussion  for  patented 
remedies  it  will  soon  lose  its  usefulness  as  a  scientific 
body.  Dr.  Barnes  stated  that  this  drug  is  not  a  new  pro- 
duct. It  was  first  produced  in  Germany  by  Willgerodt  in 
1S8S  and  scientifically  investigated  by  Kossak  and  Rudolf, 
and,  as  Eichengriin  states,  is  shown  to  be  dangerous  as  an 
internal  remedy  because  of  its  strong  depressing  influence 
upon  blood  pressure.  The  product  has  been  sold  for 
years  in  Germany  under  the  name  of  Aneson.  Dr. 
Barnes  therefore  moved:  "that  any  therapeutic  agent  of 
fered  for  discussion  before  the  society  should  be  discussed 
under  its  chemical  name,  and  not  under  its  fanciful  patent- 
ed or  copyrighted  commercial  name."  This  motion  was 
unanimously  passed  by  the  Society.  Dr.  Wilcox  therefore 
Instructed  Dr.  Houghton  to  discuss  the  preparation  under 
the  name  Acetone-Chloroform,  which  is  its  chemical 
name.  Dr.  E.  M.  Houghton,  of  Detroit,  then  read  a  paper 
on  "The  Therapeutic  Use  of  Acetone-Chloroform.  This 
drug,  he  declared,  was  of  value  as  a  local  anesthetic,  a 
hypnotic  and  an  antiseptic,  and  from  his  studies  he  believed 
that  it  wa^  perfectly  safe  and  adapted  to  general  employment. 
At  the  atfternoon  session  the  following  officers  were  elected: 
President,  Reynold  W.  Wilcox,  M.  D.,  New  York,  N.  Y.: 
first  vice-president,  Howard  H.  Barker,  M.  D.,  Washington, 

D,  C:  second  vice-president,  Eli  H.  Long.  M.  D.,  Buffalo, 
N.  Y.:  third  vice-president,  Leon  L.  Solomon,  Louisville, 
Ky. ;  secretary.  Noble  P.  Barnes,  M.  D.,  Washington,  D.  C; 
recorder,  William  M.  Spriggs,  M.  D.,  Washington,  D.  C; 
Treasurer,  John  S.  McClain,  M.  D.,  Washington,  D.  C: 
Curator,  Dr.  George  C.  Ober,  of  Washington,  Dr. 
Leon  L.  Solomon,  of  Buffalo,  read  the  final  paper  of  the 
meeting,  "The  Therapeutics  of  Alcohol." 

A  committee  was  appointed  to  investigate  the  plan  of 
establishing  a  Bureau  of  the  Meteria  Medica.  with  Dr.  P. 

E.  Stewart  as  chairman.  A  committee  was  also  appointed 
to  investigate  the  plan  of  establishing  a  Psycho-Physical 
Laboratory  under  the  control  of  the  Department  of  the  In- 
terior. The  Society  adjourned  to  meet  in  New  York,  the 
second  Tuesday  of  May,  1902. 

Correspondence  from  Dr.  George  Elliott,  129  John  St., 
Toronto. 

CANADA. 

Sir  William  Hlngston,  on  the  occasion  of  the  fortieth  an- 
niversary of  his  entering  Hotel  Dieu  Hospital. Montreal, was 
the  object  of  a  very  pleasing  demonstration  on  the  Gth  inst 
Sir  William  has  now  reached  his  seventy-third  year,  but 
still  continues  in  the  active  practice  of  his  profession,  and 
even  on  that  very  day  had  performed  two  critical  opera- 


tions at  the  Hotel  Dieu.  The  ceremonies  opened  with  a 
religious  ceremony.  Mass  in  the  chapel  of  the  hospital 
being  celebrated  by  Archbishop  Bruchesi,  after  which  the 
surgeons  of  tho  Hotel  Dieu  presented  Sir  William  with  an 
address  accompanied  by  an  urn  of  great  value.  Then  the 
students  of  Laval  University  gathered  in  the  operating 
room,  where  they  presented  their  esteemed  professor  with 
an  address  and  handed  Lady  Hingston  a  magnificent  bou- 
quet. The  sisters  of  the  institution  also  paid  their  re- 
spects to  the  distinguished  surgeon,  and  presented  him 
with  some  relics  brought  over  from  France  by  Mille. 
Mance  over  two  hundred  years  ago  and  since  preserved 
by  her  successors.  The  patients  of  the  hospital,  too,  gath- 
ered into  one  of  the  wards  where  Dr.  St.  Jacques  in  their 
name  thanked  Sir  William  for  the  many  services  he  had 
rendered  during  the  forty  years  of  his  service  at  the 
Hotel  Dieu.  Sir  William  overwhelmed  by  such  praise  and 
thanks  expressed  some  surprise  at  the  latter  testimonial 
when,  as  he  facetiously  remarked,  he  had  always  been 
busily  engaged  taking  off  their  arms  and  legs  or  taking 
out  their  eyes.  However,  he  thought  he  had  never  per- 
formed an  operation  which  he  did  not  deem  justifiable 
in  the  interests  of  his  patients. 

The  value  of  a  Smallpox  Waiver  in  the  case  of  life  as- 
surance has  been  aptly  illustrated  in  the  recent  unfortu- 
nate death  of  one  of  Toronto's  physicians.  Dr.  Thomas 
Henry  Little  died  on  the  morning  of  the  25th  of  April,  at  th.j 
smallpox  hospital,  of  hemorrhagic  smallpox,  he  having 
contracted  the  disease  from  a  very  mild  case,  and  at  the 
same  time  thinking  that  he  was  not  attending  on  a  case 
of  smallpox  at  all,  but  for  another  ailment,  having  the 
patient  calling  at  his  office  for  treatment.  Dr.  Little  was  a 
graduate  of  Toronto  School  of  Medicine  and  had  been 
practising  in  this  city  for  twelve  years.  He  was  thirty- 
nine  years  of  age.  He  had  never  been  vaccinated,  although 
this  was  subsequently  denied  by  his  friends.  It  transpires 
also  that  he  had  signed  smallpox  waivers  to  the  extent  of 
$11,000  insurance.  His  sad  death  also  emphasizes  the  im- 
portance of  vaccination,  viz.,  in  contracting  a  malignant 
form  from  an  unsuspected  mild  form  of  the  disease. 

A  Slander  by  one  Medical  Man  Against  Another  has  re- 
cently been  tried  at  the  non-jury  sittings  of  the  High 
Court  on  the  Gth  inst.  at  the  town  of  Barrie,  Ont.  Dr. 
L.  H.  Campbell,  of  Bradford,  Ont.,  sued  Dr.  L.  Clement, 
of  the  same  place,  for  libel.  It  appears  that  the  defend- 
ant wrote  a  letter,  accusing  the  plaintiff  of  want  of  skill 
in  his  profession.  The  letter  was  addressed  to  a  friend 
of  Dr.  Campbell,  in  which  Dr.  Clement  offered  to  put 
up  $50  to  $100  that  if  a  post  mortem  were  held  on  a  certain 
case,  his  charges  would  be  substantiated.  At  the  trial  the 
defendant  conducted  his  own  case.  He  admitted  writing 
the  letter  and  said  there  was  no  malice,  that  his  action 
was  in  the  public  interest.  He  further  admitted  that  his 
practice  had  been  reduced  two-thirds  since  Dr.  Campbell 
had  come  to  practice  in  Bradford.  Judgement  was  given 
for  the  plaintiff  for  $200  with  costs,  although  the  Judge 
remarked  he  felt  tempted  to  allow  the  full  amount  asked 
for,   viz.,   $1,000. 

The  Canadian  Nurse,  if  a  report  which  comes  to  the 
Toronto  daily  press  from  New  York  can  be  relied  upon, 
is  evidently  holding  her  own  in  the  United  States — and 
presumably  even  more  than  doing  so  with  her  American 
cousin.  It  is  said  that  Canadian  girls  constitute  one-half 
of  the  graduating  classes  of  the  leading  training  schools 
of  New  York  and  all  the  big  cities  from  the  Atlantic 
Ocean  to  the  Rocky  Mountains.  The  Canadian  girl  is  now 
said  to  be  prominent  in  all  the  professions  in  the  United 
States,  but  it  is  in  trained  nursing  that  she  has  achieved 
her  greatest  distinction.  The  report  goes  on  to  say  that 
they  are  even  popular  as  wives  of  Amreican  doctors. 
Amongst  some  of  the  best  known  are  Miss  Russell,  a 
daughter  of  the  medical  superintendent  of  the  Hamilton 
Insane  Asylum,  who  went  to  Cuba  to  nurse  American  sol- 
diers, and  who  has  also  been  in  South  Africa :  Jliss  Bur- 
dette,  superintendent  of  the  lying-in  hospital  built  by  Mr. 
J.  Pierpont  Morgan:  Miss  Rykert,  who  is  superintendent  of 
the  training  school  of  the  Post  Graduate  Hospital:  and 
Miss  Richmond,  assistant  head  nurse  at  the  Kemp  Mem- 
orial Hospital.  Other  cities  mentioned  where  these  Cana- 
dian nurses  hold  prominent  positions  are  Pittsburg,  Chi- 
cago, Cleveland,  Cincinnati  and  Buffalo. 

The  Toronto  Branch  of  the  Anti-Consumption  League 
hold  its  annual  meeting  in  this  city  on  the  evening  of  the 
Sth  inst..  Dr.  E.  J.  Barrick,  the  president,  in  the  chair. 
It  was  decided  that  the  time  was  opportune  for  the  sub- 


„,Q       The  Philadelphia"! 
y4"       Medical   Journal  J 


AMERICAN  NEWS  AND  NOTES 


tMAT    1«.    1901. 


mission  of  a  by-law  to  the  ratepayers  for  $50,000  for  the 
purpose  of  a  municipal  sanitarium.  Last  fall  the  local 
board  of  health,  acting  under  the  advice  of  Dr.  Sheard. 
the  medical  health  officer,  recommended  the  submission  of 
such  a  by-law,  and  it  was  at  that  time  that  the  National 
Sanitarium  Association  made  an  offer  to  provide  accom- 
modation for  Toronto's  consumptive  poor.  The  report  of 
the  secretary,  the  Rev.  Dr.  Eby,  showed  that  there  were 
now  600  members  of  this  branch  of  the  league.  The  treas- 
urer's report  showed  the  receipts  to  have  been  $1,362  and 
the  expenditure  $1,250.  A  suggestion  was  made  that  the 
city  establish  a  canvass  hospital  beyond  the  city  limits 
for  the  reception  this  summer  of  at  least  a  percentage 
of  its  hundreds  of  consumptives.  The  local  branch  de- 
cided to  accept  the  offer  of  the  Central  Association  at  Ot- 
tawa to  provide  $700  to  send  Dr.  Eby  through  Ontario  as 
a  special  organizer  and  educator  for  the  next  six 
months. 

The  Victorian  Order  of  Nurses,  Toronto  branch,  held 
their  annual  meeting  in  this  city  on  the  afternoon  of  April 
the  27th.  Dr.  James  Thorburn,  the  president,  in  the  chair. 
Lady  Minto  was  present  from  Ottawa,  and  delivered  an 
address  on  the  work  of  the  Order  throughout  Canada. 
She  told  of  the  encouragement  she  was  receiving  for 
her  cottage  hospital  scheme  for  the  Northwest  Territories. 
The  Dominion  Government  has  given  $6,000  for  this  work: 
Sir  William  MacDouald.  Montreal,  has  donated  $3,000, 
and  contributions  to  the  amount  of  $4,000  have  been  re- 
ceived from  other  sources.  The  report  of  the  local  super- 
intendent showed  that  during  the  past  year  the  Order  had 
cared  for  249  cases  in  Toronto,  with  4,323  visits  and  sixteen 
deaths.  There  had  been  added  to  the  list  thirty-eight  To- 
ronto physicians,  who  now  employ  these  nurses.  During 
the  year  ?472  had  been  collected  in  fees. 

Samaritan  Hospital,  Montreal,  held  its  annual  meeting 
last  week,  when  the  report  of  the  surgeon-in-chlef  and 
superintendent.  Dr.  A.  Lapthorn  Smith,  was  presented  by 
himself.  During  the  past  year  this  institution  has  cared  for 
110  in-patients  with  a  total  number  of  2,125  days  in  the 
institution.  Many  were  very  serious  cases  and  142  opera- 
tions had  to  be  performed.  Only  five  deaths  occurred, 
three  of  which  followed  operations,  which  gives  a  death  rate 
of  a  trifle  over  two  per  cent.  There  were  also  250  out-door 
patients;  and  at  the  present  moment  all  the  beds  in  the 
hospital  are  occupied.  Dr.  Smith  stated  that  this  institu- 
tion only  admitted  women  of  irreproachable  character,  who 
required  medical  treatment  peculiar  to  their  sex.  At  the 
present  time  there  are  a  large  number  of  suitable  young 
ladies  waiting  to  be  trained  as  nurses,  but  until  such  time  as 
a  larger  building  can  be  provided  no  increase  will  be 
made  to  the   present   staff. 

The  Toronto  Clinical  Society  held  its  final  meeting  for 
the  season  of  1900-1!)01  on  the  evening  of  May  1st.  The 
year  has  been  a  very  successful  one.  Dr.  H.  A.  Bruce  pre- 
sented a  patient,a  young  man  of  24  years,  upon  whom  he  had 
operated  about  seven  weeks  ago  for  mastoid  disease  and  in 
addition  to  finding  pus  there  also  found  a  large  quantity  in 
the  teraporo-sphenoidal  lobe,  some  three  or  four  ounces. 
When  five  years  of  age  this  young  man  had  otitis  media 
of  the  right  ear  and  after  treatment  for  two  years  wa5 
cured.  Whenever  he  contracted  a  cold,  however,  a  few 
drops  of  discharge  appeared,  but  only  for  a  day  or  so. 
When  taken  again  two  weeks  prior  to  operation,  he  had 
slow  pulse,  depressed  temperature,  exaggerated  knee 
jerks,  ankle  clonus,  slight  vomiting:  no  unconsciousness. 
Patient  made  a  good  recovery  after  operation,  some  slight 
exaggeration  in  the  knee  rellexes  and  ankle  clonus  being 
still  present.  Dr.  F.  LeM.  Graeett  showed  a  large  lipoma 
removed  from  the  thigh  of  a  woman  just  above  the  popli- 
teal space.  Considerable  difficulty  was  experienced  in 
separating  the  great  sciatic  nerve  from  the  tumor,  it  being 
spread  out  over  the  posterior  aspect  of  the  tumor.  Dr. 
George  A.  Bingham  related  the  history  of  an  enterprising 
lad  of  14  years,  a  cripple,  who.  having  heard  of  the  good 
work  being  performed  for  crippled  children  at  the  Vic- 
toria Hospital  for  Sick  Children.  Toronto,  and  not  being 
possessed  of  sufficient  means  to  come  by  train,  harnessed 
his  dog  to  his  sleigh  and  drove  all  the  way  to  the  city, 
a  distance  of  twenty  miles,  in  the  dead  of  winter.  He  was 
very  much  deformed  from  his  knees  down.  The  lad 
reaped  the  reward  of  ambition.  The  election  of  officers 
took  place  and  resulted  as  follows:  President.  Dr.  J.  F.  W. 
Ross:  Vice-President,  Dr.  E.  E.  King:  Treasurer.  Dr.  W. 
H.   Pepler;    Recording  Secretary.  Dr.  George  Elliott:    Cor- 


responding Secretary.  Dr.  A.  A.  Small:  Executive  Com- 
mittee, Drs.  H.  J.  Hamilton,  H.  B.  Anderson,  W.  B. 
Thistle,  H.  A.  Bruce  and  George  A.  Bingham. 

The  Victoria  Asylum  for  Women,  Coburg,  Ont.,  is  rapidly 
Hearing  completion  and  the  Government  expects  to  open 
it  for  the  reception  of  patients  by  the  1st  of  September. 
Dr.  McNichol  has  been  appointed  medical  superintendent 
and  will  have  associated  with  him  as  assistant  physician, 
Dr.  Harriet  Cockburn,  of  Toronto,  this  being  the  first  in- 
stance of  official  recognition  of  the  claims  of  the  lady 
medicos.  Dr.  Cockburn  has  had  considerable  experience 
in  hospital  work. having  been  connectend  for  some  time  with 
the  Dakota  State  Asylum  for  the  Insane.  Dr.  McNichol 
has  retired  from  private  practice  in  Coburg  and  is  at 
present  devoting  his  attention  to  asylum  work  in  the  vari- 
ous institutions  of  the  province. 

UNIFORM    MEDICAL  LEGISLATION. 

By   EMIL  AMBERG,    M.   D.. 

Secretarj'  of  the  Committee  on  Interstate  Reciprocity  and  Uni- 
form JMedical   jL.egislation  of   the  .Natiouai  v.ouxeueralion 
of  State   .dieuical   KXiiminiiig  and    L^iceosing    iioaros. 

Conditions  which  exist  in  regard  to  the  license  to  practice 
medicine  in  the  various  political  divisions  of  our  country  iiave 
thus  far  escaped  the  necessary  attentio.n  on  the  pan  of  ih- 
public.  It  must  he  taken  for  granted  that  very  few  peopl,-.  out- 
side of  the  medical  profession,  liave  an  idea  of  tlie  serious  prob- 
lem which  must  confront  them  in  tlie  near  future.  '1  he  fact 
that  a  physician  wiio  is  allowed  to  practice  medicine  and  sur- 
gery in  one  state  or  territory  is  regarded  as  unfit  to  treat  peo- 
ple in  another  political  division  necessarily  invites  eveir  Intel- 
iigent  citizen  to  investigate  the  reasons  for  such  a  state  of 
affair.s. 

In  any  country  the  lives  of  all  citizens  should  be  valued 
equally  high.  1  his  is  not  the  case  in  the  I'nited  States.  Any- 
one who  Is  familiar  with  the  different  medical  laws  in  the  vari- 
ous states  and  territories  cannot  conceal  his  grievance  and  in- 
dignation that  conditions  are  allowed  to  exist  which  reflect 
upon  the  intelligence  of  manj',  and  on  the  good  will  of  some, 
in  a  way  so  strange  to  the  American  mind  and  so  little  in 
Hccord   with    the   general   interest   in    other   public   matters. 

Many  states  absolutely  refuse,  within  their  jurisfii  'i.  •  .  'he 
license   to   practice   to   the  same   physicians   whom    ■  f 

other    states    legally    authorize    to    exerci.se    their    ;  1 

duties,  and   to  whom   they  intrust  their  own  lives  a: I' 

their   families.     This   fact   can   be  explained   only   in   two   wiys. 
Either  the  standing  of  those  physicians  is  not  sufficiently  high 
for   the    former   states   or   the    former   states    intend    to    protect 
their    ■home  ind.istrj'."     Although  it  must  be  admttte<l— and  we 
cannot    help    being    ashamed    of   this    f.-^ct — that    the    last    men- 
tioned  rea.son   seems    to   prevail     in   a     few    Instances,    ir     '>■" 
greater   majority    of   cases   the   responsible     jjanies     in 
states  do  not   recognize  the  standard   of  the  n^edical   me- 
;'.rr  .'if^repted  in  others  as  sufficiently  high.  Special  »''■-■»■'- 
ated  in  most  of  the  divisions,  have  th^  dmy  to  exer 
trolling   power   over   the   phvsicians     who     Intend      i 

within    their   boundaries.     B<- "  '•■'  '  s   th.it   th-    -• 

physician    depen-is    upon    IV  ani     m' 

which  he  received,  it  is  n-;  r  those  w 

ble   to   the  community   for    iii--,     .lu-.rn    they    a,,-  ..     ^  ■    i 

to  extend  their  control  to  the  preliminar>-  education  of  th 

f^ent   who    intends   to   become   a    physician    and    to   the   it 

education    proper. 

If  all  physicians  would  be  equally  well  trained,  no  political 
division  would  be  justilied  in  refvsi-r  re'v>trrftion  to  the  phy- 
sicians of  another  division.  Tl  ""  •  ■  ■  ■  -  -  -  .^ 
rqually  well  tr.iined,  so  far  as  it 

In  order  to  educate  properly  a    -  i 

good  physician,  we  mvist  have  m'-i:cal  «,_•!■•..•. .is  ••:  ;i  hisn  <iar.l- 
ard.    and    only    those. 

It  Is  admitted  that  we  have  too  many  medic.il  s-h  ■!<  .and 
that   we  are   in    need   of  a    greater     number  of  t 

would  be  a  wise  step  to  close  about  three- four- 
cal    schools    now    existing,    and    to    place    the    J  -    I 

stale    control;    or.    what    would    be    still    better,    to    :  i 

state  institutions,  as.  for  example,  the  University  ■ 
Medical  School,  even  admitting  that  some  of  t! 
schools   are   satisfactor>-. 

Manv  of  the  medical  schools  now  existing  are  the  prop- 
ert\-  of  corporations  for  the  benefit  of  a  few.  Special  privi- 
leges have  been  granted  to  these  combinations.  This  should 
never   ba\-e   been    done. 

That   the  existing  conditions  reflect  upon  the  whole  medic.-il 
profession    is   easily    understood,   and   it   cannot   be  denied    th   • 
the  public  in  general  should   have  more  interest  in  a  quest!' 
which    concerns    everj-    citizen. 

■  So  f.^r  as  the  physician  is  concerned,  the  overcrowding  of 
the  medical  profession,  especially  with  so  many  inefficient 
men.  who  have  the  same  rights  as  others,  is  one  .^f  ''■•  nvist 
serious    ■^uesti'ins.      It    is   reported    that    there    is   or.  -i 

to  less  than  6on  inhabitants  in  the  Unitetl  States:  w 
ratio       In     Oreat     F.ritain    is   one  to  l.PXi.   and    in   Ri;>--.  .  ..i 

S.i^i'O.  There  arc  In  the  Urited  States,  proportionately,  six  limes 
as  manv  practitioners  as  in  Italy,  about  four  times  as  manv  as 
in  France  and  in  Germany,  and  there  are  about  15*;  mdical 
schools  in  our  country  to  twenty  medical  schools  in  Germany. 
In  ainiin.g  at  "interstate  reciprocitv  for  the  license  to  practic* 
medicine  and  at  uniform  me-lical  legislation  "  all  points  men- 
tioned,  besides   others,   must   be  considered. 

The  importance  of  the  movement  is  recognlred  more  and 
more  evc-v  dav  by  the  me-iical  profession,  and  the  public  wUl 
undoubtedly  take  a  hanfl  as  soon  as  It  understands  the  subject 
more  thoroughly.     The  question  is  a   comp-iratively  simple  one. 


J[AY    IS.    IWl] 


AMERICAN  NEWS  AXD  NOTES 


TThe  Philadelphia       o/IO 
L-Medical   Journal         V'+V 


and  it  can  be  dealt  with  more  satisfactorily    it    the    puDlic    at 
large  interests  itself  in  the  same  to  a      gieater   extent. 

A  great  problem   is  before  the  people  of  the   United   States. 
Its    solution    should    not    be    delayed. 


Changes  in  the   Medical   Corps  of  the  Navy,  weel<  ending 
May  11,  1901. 

S.    TAYLOR,    detached     from     the 
the   Naval     Hospital,     Yokohama, 


ASSISTANT  SURGEON  J 
-Manila  and  ordered  to 
Japan. 

ASSlfeT.A.NT    SURGEON    F. 


L.    BENTON,    detached    from   the 

Naval   Hospital,    Y'okohama,   and    ordered     to   duty   on     the 

.\siatic   Station. 
MEDICAL  DIRECTOR  E    Z.   DERR,  detached  from  the  Naval 

Academy,    and    ordered    home    to    wait   orders. 
surgeon"  F.    W.    F.    \VIEBER,    detached    from   the   San   Juan 

Naval  Station,  and  ordered  to  the  Naval  Academy.  May  lith. 
SURGEON  C.   H.  T.   LOWNUES.  detached  from  the  Lancaster. 

May  11.  and  ordered  to  the  San  Juan  Naval  Station  via  the 

Majflower. 
P.    A.    SURGEON    E.    S.    BOGERT,   ordered   to   the   Lancaster. 

May  llth. 
SURGEON   L.  ^V.   CURTIS,   detached  from   the  Vermont.   May 

llth.   and  ordered  home  to  be  in   readiness  for  sea  duty. 
SURGEON  G.   PICKRELL,  ordered  to  the  Vermont,   May  llth. 
SURGEON  C.   F.   STOKES,  detached   from  the  Asiatic  Station. 

and    ordered    home,    via    mail    steamer. 

Health  Reports. — The  following  cases  of  smallpox 
yellow  Sever,  cholera  and  plague,  have  been  reported  to  the 
Surgeon  General.  U.  S.  Alarine  Hospital  Service, 
during  the  week  ending  May  11.  19U1. 


SMALLPOX- 
ALASKA: 

CALIFORNIA; 


FLORIDA: 
ILLINOIS: 


INDIANA: 
IOWA: 


KANS.A.S: 
LOUISIANA: 


-UNITED  STATES  AXD  INSULAR. 

Cases.      Deaths. 

Sitka Apr.  9,    prevalent 

among    Indians. 

Los  Angeles Apr.20-27 5 

Oakland Apr.  6-27 2 


San  Francisco. 
Jacksonville  .  . 

Chicago 

Freeport 

ivansvilie.  .  .  . 
Michigan  City. 

Clinton 

Ottumwa.  .   .    . 

Wichita 

Bossier. 


..  Apr.20-27 

. .  Apr.20-27 

..  Apr.27-May  5. 
..  Apr.27-May  4  . 
..  Apr.27-Mav  4  . 
..  Apr.22-May  6  . 
..  Apr.27-Mav  4  . 
..  Mar.30-Apr.27  . 
..  Apr.20-May  4  . 
. .  Apr.  1-30 


21 


MARYLAND: 

MASS-\CHUSETTS: 

MICHIGAN: 
MINNESOTA- 
NEBRASKA: 
NEW  HAMPSHIRE 
NEW  JERSEY: 

NEW   YORK: 
NORTH  CAROLINA 
OHIO: 

PENNSYLVANIA: 


TENNESSEE: 

UTAH: 
VIRGINIA: 
WEST  VIRGINIA: 
WISCONSIN: 

PORTO   RICO: 


Caddo Apr.l-.'iO 

New  Orleans Apr.20-May  4  .  23 

Sabine Apr.1-30    1 


Cambridge Apr.1-30 5 

Fitchburg Apr.20-27    2 

Holvoke Apr.27-May  4  .    1 

Bay  City Apr.20-27    7 

Detroit Apr.27-May  4  .    1 

Minneapolis Apr.20-May  5  .  44 

Winona Apr.20-27 3- 

Omaha Apr.20-aiay  4  .  32 

Manchester Apr.27-May  4  ..  4 

Jersev  Citv Apr.21-May  5  .  23 

Newark Apr.30-May  4  .  11 

New  York Apr.27-May  4  ..86      10 

Charlotte Apr.  1-30 18       1 

Cincinnati Apr.26-May  3  .    1 

Cleveland Apr.27-May  4  .  61       2 

Lebanon Apr.27-May  4  .    3 

McKeesport •..Apr.20-27 1 

Philadelphia    Apr.27-May  4.2       1 

Pittsburg   Apr.20-May  4   .   5 

Steelton Apr.27-May  4   .   1 

Williamsport Apr.  T-May  4   .   1 

Memphis Apr.20-May  4  .  40       2 

Nashville    Apr.27-May  4  .   6 

Salt    Lake   City   .    ..Apr.20-27 18 

Roanoke Apr.  l-3ti 42       1 

Wheeling Apr.20-May  4.8       1 

Green  Bay Apr.2S-May  5  .   1 

Milwaukee  Apr.20-May  4  .  2 

Ponce   Apr.13-20 9 


ARGENTINA: 

AUSTRIA: 
BELGIUM: 
BRAZIL: 

CEYLON: 

CHINA; 

COLOMBIA: 

EGYPT: 

FRANCE; 

GREAT  BRITAIN: 


GIBRALTAR: 
INDIA: 


ITALY: 
MALT.\: 


SMALLPOX— FOREIGN. 

Buenos  Aires eb. 

Prague Apr. 

Antwerp Apr. 

Pernambuco Mar, 

Rio  de  Janeiro Mar, 

Colombo Mar, 

Hongkong Mar 

Panama  Apr. 

Cairo .\pr. 

Marseilles Mar, 

Paris Apr. 

England — 

Leeds Apr. 

Liverpool  Apr. 

Scotland- 
Dundee  Apr. 

Glasgow  Apr. 

Apr. 

Bombay  -ar 

Karachi   Mar, 

Madras    Mar 

Sicily Apr- 
Apr, 


...  1 
...13 

...  5 


1-2S, . 

6-20    . 

6-20.  . 

16-31    , 
.16-31. 
,2i-30   . 
23-30  . 
22-29  . 

S-15  . 

1-31. 
13-20   . 

13-20    . 
13-20    . 


13-27  .  .. 
19-26   .    . 

7-21    .    . 

26-Apr.9 

l-Apr." 
.16-29  

6-13,  prevalent 

7-13    6 


32 


36 


MEXICO: 


NETHERLANDS: 
RUSSIA: 


STR.\ITS 

SETTLEMENTS: 
SPAIN: 

TURKEY; 


BRAZIL: 

CUBA; 

MEXICO: 


INDIA: 


AFRICA: 

CHINA; 

IxNDiA: 

JAPAN: 


Case.s.  Deaths. 

Mexico Apr.21-2S 2 

Nuevo  Laredo Apr.13-20 1 

Yucatan,  Mcrida 'i  hree  or  four  deaths 

aaily. 

Rotterdam Apr.13-29 1 

Moscow    Mar.30-Apr.l3  .  15  4 

oaessa  Apr.  6-10   13  3 

St.   Petersburg Apr.  6-13 9  2 

Warsaw  ajiui-.3l-Apr.l3  .  14 

Singapore  Mar.16-23 2 

Corunna Apr.20-27    1 

Malaga Mar.16-31    S 

Smyrna   Mar.l7-Apr.l4  .  1 

YELLOW  FEVER. 

Rio  de  Janeiro  Mar.16-31 42 

Havana   Apr.20-27 1 

Vera  Cruz Apr.20-27 1 

resident  for  ten 

>ears. 

CHOLERA. 

Bombay  .   Mar.26-Apr.2  .  10 

Madras  Mar.l6-i9 3 

PLAGUE. 

Cape  Town  Apr.  6-13 43  22 

Hongkong Mar.L3-3« 14  10 

Bombay  .<Aa..io-Apr.9  .         1407 

Karachi    Mar..4-Apr.7  .429  358 

Wakayana  Kon  Apr.l:; 1  1 


Appointed  Assistant  Surgeons. — Acting  upon  the  recom- 
mendation of  Surgeon-Geneial  Wyman  of  the  Marine  Hos- 
pital Service,  the  Secretary  of  the  Treasury  has  appointed, 
the  following  persons  as  assistant  surgeons,  to  serve  dur- 
ing the  quarantine  season  at  the  various  fruit  ports  of 
Central  America,  their  principal  duty  being  that  of  inspect- 
ing fruit  to  be  exported  to  the  United  States:  Bocos  del 
Toro,  Colombia,  Paul  Osterhout;  Port  Limon.  Costa  Rica, 
D.  W.  Goodman;  Livingston,  Guatemala,  W.  K.  Fort; 
Puerto  Cortez.  Honduras,  S.  H.  Backus;  Ceiba,  Honduras, 
R.H.Peters;  Belize. British  Honduras,  J. Grey  Thomas;  Blue- 
fields,  Nicaragua,  W.  H.  Carson. 

MISCELLANY. 

Fourth  Annual  Meeting  of  the  American  Gastro-Entero- 
logical  Association. — The  Shoreham.  Washington,  D.  C, 
May  1st,  1901. — The  meeting  was  called  to  order  by  Presi- 
dent Einhorn  at  10,24  A.  M.  Paper  by  Dr.  Max  Einhorn, 
"Syphilis  of  the  Liver."  The  doctor  gave  a  very  compre- 
hensive resume  of  the  subject,  and  said  that  from  the  mid- 
dle ages  to  the  beginning  of  the  seventeenth  century  great 
importance  was  attached  to  the  liver  in  syphilitic  diseases. 
It  was  generally  believed  that  syphilitic  ulcers  were  the 
result  of  bad  humors  of  the  body,  the  origin  of  which  was 
to  be  looked  for  in  the  liver.  The  pathological  anatomy 
and  clinical  studies  were  reviewed  and  a  report  made  of 
thirty  cases.  29  of  whom  died.  He  di^^ded 
syphilis  of  the  liver  into  three  classes — gummata, 
syphilitic  cirrhosis,  and  syphilitic  disease  belong- 
ing to  either  of  the  above-mentioned  groups  and  ac- 
companied with  icterus.  The  first  case  was  that  of  a  pa- 
tient who  had  chancre  six  years  previously.  He  suffered 
with  disturbances  of  digestion,  poor  appetite,  much  belch- 
ing, loss  of  weight,  etc.  With  treatment  by  iodide  of 
sodium  and  innunctions  of  mercury  the  patient  finally  was 
cured.  Diagnosis  of  hepatic  syphilis  can  be  most  posi- 
tively made  in  cases  in  which  there  exist  gummata  of  the 
liver,  in  conjunction  with  other  signs  of  a  present  or  re- 
cent attack  of  syphilis.  Gummata  of  the  liver  are  easily 
confounded  with  malignant  neoplasms.  The  majority  of 
cases  have  pain  in  the  right  hypochondrium.  sometimes 
constantly  and  sometimes  in  attacks,  occasionally  gall- 
stone colic;  this  is  accompanied  by  disturbances  of  diges- 
tion, and  a  feeling  of  tension  in  the  upper  half  of  the  ab- 
domen, with  loss  of  weight.  In  the  more  advanced  stages 
there  is  amyloid  degeneration.  The  doctor  did  not  al- 
ways find  enlargement  of  the  spleen.  The  treatment  should 
consist  of  anti-luetic  measures,  iodide  of  potassium  or  ido- 
dide  of  sodium  and  similar  preparations  of  iodine.  The 
hygienic  and  dietetic  elements  in  a  patient's  lite  should  not 
be  overlooked. 

In  discussion.  Dr.  J.  C.  Hemmeter  said  that  he  was  im- 
pressed with  the  very  scholarly  paper  and  that  its  value 
chiefly  consisted  in  the  collated  literature  brought  before 
the  society  in  one  article. 


ccn      The  Philadelphia"! 
yo^       Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Mat  18,   190L 


Dr.  Edward  Quintard  mentioned  a  case  of  a  tumor  as 
large  as  a  small  fist,  in  which  the  polymorphonuclear  neu- 
trophiles  were  absent  and  asked  the  essayist  whether  any 
note  was  made  of  that  particular  count.  He  concurred  in 
the  combination  treatment  of  iodide  of  potassium  and  the 
ointments  mentioned. 

Dr.  John  A.  Lichty  commended  the  essayist  on  the  use 
of  iodides  and  anti-syphilitic  treatment,  especially  in  cases 
■where  there  is  a  marked  condition,  and  believed  that  after 
all  one  would  be  obliged  to  fall  back  upon  the  therapeutic 
test. 

Dr.  J.  C.  Hemmeter,  speaking  again,  said  that  he  recol- 
lected three  cases  of  syphilis  of  the  liver  that  occurred  in 
his  experience.  One  was  that  of  a  man  who  was  supposed 
to  have  tuberculosis  of  the  lung,  but  the  autopsy  proved 
it  to  be  a  gumma  of  the  lung  which  had  pulled  apart  the 
bronchial  tube. 

Paper  by  Dr.  J.  C.  Hemmeter,  "The  German  Clinics 
of  To-Day,"  The  doctor  said  that  "modern  therapeutists  are 
not  satisfied  to  study  the  diseased  process  and  its  course, 
the  physician  must  also  familiarize  himself  with  the  spec- 
ial manner  in  which  disease  manifests  itself  in  and  in- 
fluences the  individuality  of  each  and  every  patient.  The 
personality  of  every  patient  is  put  in  the  foreground  of 
treatment,  not  the  conception  of  the  disease.  This  is  one 
of  the  predominant  features  of  the  therapeutists  in  German 
clinics  of  to-day."  After  reviev.-ing  the  different  contribu- 
tions of  Continental  experimentors.  he  made  a  plea  for  the 
establishment  of  a  journal  on  diet  and  physical  medical 
treatment,  which  should  be  the  offspring  of  the  Society, 
in  which  could  appear  the  investigations  and  clinical,  ex- 
perimental and  pathological  observations  concerning  the 
treatment  of  disease  by  dietetic  means,  that  such  a  journal 
is  a  necessity. 

Dr.  Quintard  said,  in  speaking  of  the  new  journal:  "It 
is  necessary  for  the  majority  of  American  physicians  and  I 
think  the  suggestion  is  really  particularly  timely." 

Dr.  Einhorn  said  that  one  must  appreciate  not  only  the 
necessity  for  studying  scientific  methods,  but  of  practically 
helping  the  patient,  and  the  giving  of  proper  sunshine,  cor- 
rect diet  and  good  nursing. 

Dr.  Aaron  expressed  himself  in  favor  of  the  establish- 
ment of  the  proposed  journal  of  dietetics  and  hygiene. 

The  following  papers  were  read  by  title  in  the  absence 
of  their  authors:  "Etiology  of  Hepatic  Sclerosis."  Dr.  A.  L. 
Benedict:  "Treatment  of  Gastric  Ulcer,"  Dr.  D.  D.  Stew 
art:  "The  State  of  the  Gastric  Secretion  in  Chroinc  Rheu- 
matism and  Rheumatoid  Arthritis,"  Dr.  Frank  H  Murdoch. 
Paper  by  Dr.  Edward  Quintard  on  "Spastic  Ileus."  The 
author  believed  that  spastic  ileus  is  of  much  more  common 
occurrence  than  is  generally  recognized  and  he  reported  a 
number  of  cases  in  which  he  gave  not  only  the  similarity 
which  existed  between  spastic  ileus  and  mechanical  ileus, 
but  also  gave  the  methods  of  differential  diagnosis.  As  to 
the  theory  of  the  causes  of  fecal  vomiting  there  was  a 
sketch  given  from  the  time  of  Galen  to  that  of  the  Hague- 
not  theory  and  the  theories  of  the  present  day. 

In  discussion  Dr.  Quintard  reported  two  of  his  own  cases, 
in  neither  of  which  had  there  been  the  fecal  vomiting 
which  had  been  observed  in  many  other  cases.  He  held 
that  there  was  such  a  thing  as  pathological  antiperistalsis. 
The  author  cited  several  cases  which  proved  almost  con- 
clusively that  such  was  the  case,  and  although  he  believed 
that  the  Haguenot  theory  explained  many  of  the  cases  of 
fecal  vomiting  in  mechanical  ileus,  he  also  held  that  in 
spastic  ileus  the  theory  of  antiperistalsis  came  very  nearly 
covering  the  point. 

Dr.  Rose  spoke  of  the  desirability  of  the  pathological 
condition  of  the  splanchnic  nerves  being  better  understood. 
He  proposed  the  treatment  of  warm  water  and  opiates,  also 
the  application  of  carbonic  acid  gas — the  inflation  of  the 
rectum  with  this  gas.  With  him  this  last  named  treat- 
ment had  been  effective  in  cases  of  dysentery  and  per- 
tussis in  children. 

Paper  by  Dr.  Wm.  Gerry  Morgan,  "Some  Cases  of  Tet- 
any." He  defined  tetany  as  an  affection  characterized  by 
the  occurrence  of.  for  the  most  part,  tonic,  but  occasionally 
clonic,  spasms  in  the  hands,  forearms,  feet,  legs,  and.  in 
severe  cases,  the  neck,  face,  larynx  and  trunk.  The  doctor 
thoroughly  explained  the  etiological  factors  and  spoke  of 
the  dehydration  theory  of  Kaussmal.  The  opportunities  for 
pathological  study  have  been  very  few.  Prognosis  in  tet- 
any depends  upon  the  pirtioular  disp"^-^  wit>i  which  the 
condition  is  associated  and  upon  the  nature  of  the  attack. 


The  doctor  made  a  fine  distinction  between  epilepsy  and 
gastric  tetany  and  related  many  interesting  cases. 

In  discussion,  Dr.  Rose  said  that  in  English  literature  one 
would  find  a  great  many  cases  of  tetany  in  connection  with 
acute  dilatation  of  the  stomach.  He  spoke  of  the  compen- 
sating element  as  analagous  to  that  in  heart  disease. 
Further  discussion  was  prevented  by  the  usual  midday 
adjournment. 

Afternoon  Session. — Paper  by  Dr.  Julius  FYiedenwald, 
"The  Report  of  Two  Cases  of  Acute  Dilatation  of  the  Stom- 
ach." The  doctor  believed  that  the  symptoms  of  the  dis- 
ease are  so  clearly  established  that  diagnosis  can  usually 
be  made  without  difficulty.  Much  attention  has  been  paid 
to  chronic  dilatation,  while  little  has  been  said  concerning 
the  acute  form,  which  is  probably  due  to  the  fact  that  it  oc- 
curs with  much  less  frequency.  Dilatation  may  be  caused 
by  serious  infectious  diseases  and  sudden  overloading  of 
the  stomach  or  improper  diet.  Many  cases  of  acute  dila- 
tation were  reported  with  fatal  results,  the  necropsy  afford- 
ing an  opportimity  to  note  the  pathological  conditions.  In 
one  case  lavage  and  the  use  of  the  stomach-pump  proved 
of  great  value.  The  etiology  of  the  acute  form  is  some 
what  obscure,  except  as  previously  mentioned,  through 
gross  errors  in  diet  and  overloading.  Pepper  and  Stengel 
were  quoted  as  suggesting  the  immediate  cause,  being 
spasm  of  the  pylorus.  It  is  well  to  remember  the  possi- 
bility of  the  occurrence  of  acute  dilatation  in  all  cases  of 
acute  dyspepsia  and  quickly  to  empty  the  stomach  either 
by  means  of  some  brisk  emetic  or  by  means  of  the 
stomach  tube. 

Dr.  Hemmeter  referred  to  the  great  obscurity  of  the 
pathogenesis  of  these  acute  dilatations.  He  related  a  case 
in  consultation  in  which  a  patient  was  operated  for  gall- 
stone and  the  surgeon  had  an  opportunity  of  seeing  the 
stomach  and  said  that  it  was  normal  and  in  its  proper 
position,  but  looked  rather  small.  Test  meals  had  been 
taken  and  everything  seemed  to  be  normal.  The  day  af- 
ter the  operation  the  patient  died  from  symptoms  of  ileus 
and  at  the  autopsy  an  enormously  distended  stomach  was 
found. 

Dr.  Einhorn  said  that  these  cases  should  be  termed  acute 
dilatation,  and  that  in  order  to  make  that  positive,  it  would 
be  necessarj-  to  observe  such  patients  for  quite  a  while  af- 
ter and  see  if  they  had  any  return.  He  mentioned  certain 
cases  of  beginning  obstruction  of  the  pylorus,  with  no 
noticeable  symptoms  until  suddenly  an  abrupt  awakening. 

Dr.  Quintard  referred  to  Dr.  H who  took  the  $100 

pri/.e  in  the  Philadelphia  Medical  Journal  on  the  "Size  and 
Location  of  the  Stomach." 

Dr.  Julius  Friodenwald  closed  the  discussion  by  saying 
that  there  were  but  few  authentic  cases  of  dilatation  of  the 
stomach,  a  great  many  being  spoken  of  as  gastric  atony. 

In  the  absence  of  their  authors  the  following  papers  were 
read  by  title:  "Experiments  in  Peristalsis."  Dr.  Fenton 
B.  Turck:  "Some  Clinical  Studies  in  Gastric  Secretion." 
Dr.  G.  W.  McCaskey:  "Report  of  a  Case  of  Cancer  of  the 
Cardiac  End  of  the  Esophagus  at  a  Distance  of  Twenty- 
one  Inches  from  the  Incisor  Teeth  in  a  Man  Five  Feet  and 
Three  Inches  Tall,"  Dr.  C.  D.  Spivak. 

Paper  by  Dr.  A.  Rose.  "Treatment  of  Atonia  Gastrica 
and  Splanchnoptosia  by  means  of  Abdominal  Strapping." 
Dr.  Rose  cut  from  a  newspaper  the  size  and  kind  of  bandage 
that  he  specially  recommends.  His  paper  proved  to  be  a  very 
exhaustive  treatise  on  the  subject.  He  believed  that  a 
number  of  pathological  conditions  of  the  stomach  are  caused 
by  insufficient  activity  of  its  muscular  fibres,  diminisheu 
activity  of  its  walls,  elongation  of  the  suspending  ligament 
of  the  lesser  curvature,  the  lesser  omentum  and  gastrop- 
tosia.  The  doctor  said  he  uses  the  term  "gastroptosia"  in- 
stead of  "gastroptosis."  as  formerly.  He  was  of  the  opin- 
ion that  gastroptosia  is  very  frequently  present  in  phthis- 
ical patients  and  rare  in  strong  and  robust  people,  except 
when  caused  by  trauma  or  by  peritonitic  adhesion.  It  may 
be  caused  by  hernia:  .ilso  tumors  of  the  spleen  and  liver 
and  enlargement  of  the  abdominal  space.  Tight  lacing  and 
the  tight  attachment  of  skirt  strings  aggravate  an  existing 
gastroptosia.  He  spoke  of  an  interesting  examination  of 
one  hundred  patients  in  order  to  establish  the  significance 
of  the  phenomenon  of  the  splashing  sound  of  the  stomach. 
Men  afflicted  with  the  condition  present  symptoms  of  gen- 
eral nervous  irritability  less  often  than  women.  Discus- 
sion was  spirited  on  the  subject  of  supporting  the  abdo- 
men by  strap  or  bandage.  Dr.  T.ichty  said  he  was  dis- 
.appointed  in  the  bondage.  Dr.  Hemmeter  said  that  the 
bandage   as   described    by    Dr.    Rose   seems    to   hare   the 


Mat  18,  1901] 


AMERICAN  NEWS  AND  NOTES 


["The  Philadelphia 
Lmedical,  Journal, 


951 


advantage  of  grasping  the  whole  abdomen.  Dr.  Aaron 
asked  whether  the  secretions  would  not  soften  the  bandage 
and  thus  shorten  its  life.  Dr.  Lincoln  reported  that  by  his 
method  of  application  he  secured  support  for  five  weeks. 

Dr.  Einhorn  said  that  strapping  would  not  do  as  much 
for  the  patient  as  the  bandage. 

Paper  by  Dr.  John  A.  Lichty,  "Hyperchlorhydria."  The 
doctor  said  that  about  one-third  to  one-half  of  the  patients 
suffering  from  digestive  disturbances  have  hyperacidity. 
Among  225  consecutive  cases  whose  stomach  contents 
were  analyzed  84  or  about  one-third  had  more  than  the 
normal  amount  of  acid.  The  patient  suffering  from  hyp- 
erchlorhydria proper  usually  gives  no  history  of  indiscre- 
tion of  diet.  He  believed  that  the  splanchnoptosis  is  the 
result  of  the  starvation  diet  to  which  the  patients  are 
driven.  Electricity  should  be  applied  percutaneously.  The 
doctor  had  not  found  any  advantage  in  the  intragastric 
electrode  in  these  cases. 

Dr.  Hemmeter  reviewed  some  Interesting  experiments,  on 
two  fox  terriers,  one  of  which  was  fed  on  the  proteids  and 
the  other  was  fed  on  soup  meat,  etc.  Dr.  Friedenwald 
favored  internal  electricity. 

ELECTION    OF   OFFICERS. 

President.  Dr.  John  C.  Hemmeter.  Baltimore:  First  Vice 
President.  Dr.  W.  D-  Booker.  Baltimore:  Second  Vice  Presi 
dent.  Dr.  S.  J.  Meltzer  New  York:  Secretary  and  Treas- 
urer, Dr.  Charles  D.  Aaron. 

Dr.  Max  Einhorn  was  elected  as  a  member  of  Council  to 
serve  for  three  years. 

(Adjourned.) 

The  American  Association  of  Genito-Urinary  Surgeons. — 
Held  at  the  Hotel  Chamberlin.  Old  Point  Comfort,  Va., 
April  30.  May  1  and  2,  1901.  The  President,  Samuel  Alex- 
ander, M.  D..  of  New  York,  in  the  chair. 

Address  by  the  President,  Dr.  Samuel  Alexander.  M.  D.. 
of  New  York,  called  the  attention  of  the  Association  to  the 
death  of  one  of  its  former  Presidents.  Dr.  Fessenden  F. 
Otis.  He  then  considered  the  subject  "The  Treatment  of 
Intraperitoneal  Traumatic  Rupture  of  the  Bladder  by  Lap- 
arotomy and  Suture."  He  reported  45  cases  with  23  d^ths 
and  22  recoveries,  and  considered  the  following  questions: 
How  can  we  prevent  delay  in  operating  upon  these  cases? 
How  shall  we  treat  the  abdominal  cavity  to  obtain  the 
most  thorough  asepsis?  How  shall  we  most  effectually 
close  the  bladder  wound? 

Report  of  a  Case  of  Nephrectomy  for  Adeno-Carcinoma 
with  Remarks  on  Combined  Cystoscopy  and  Segregation 
as  a  guide  to  the  Earlier  Surgical  Intervention. — Dr.  John 
P.  Bryson,  of  St.  Louis,  read  a  paper  with  this  title.  He 
said  that  the  matter  of  the  relative  excretion  of  the  urea 
may  have  been  too  much  overlooked  but  we  cannot  tell  how 
well  a  kidney  may  be  doing  until  we  know  what  the 
blood  brings  to  it  and  the  antecedents  or  urea  in  the  blood 
are,  so  far  as  we  know,  influenced  by  so  many  condi- 
tions that  it  is  difficult  to  bring  it  within  a  working  formu- 
la. Cystoscopy  may  be  of  service  in  this  matter,  but  the 
phloridzine  test  appeared  to  have  the  greater  value.  He 
thought  it  would  be  but  a  one-sided  pathology  and  too 
narrow  specialism  which  would  fail  to  take  into  account 
the  relationship  of  the  condition  and  functional  activity 
of  other  important  organs  as  their  changes  affect  the 
kidney  and  its  work. 

The  value  of  the  X-Ray  in  the  Diagnosis  of  Renal  Stone: 
Report  of  Four  Cases. — Dr.  Paul  Thorndike,  of  Boston, 
briefly  reported  these  cases  not  in  order  to  show  beautiful 
X-ray  plates  of  kidneys  containing  calculi,  l)ut  because 
the  cases  were  studied  by  the  same  people  under  the  same 
conditions  and  show  results,  partly  negative  in  character, 
which  the  writer  deemed  of  enough  interest  to  justify  pre- 
sentation. It  seemed  to  be  true  that  stones  which  contain 
mineral  salts  are  much  more  readily  photographed  than 
others,  and  yet.  in  two  of  the  cases  presented,  where  the 
stones  were  made  up  of  layers  of  uric  acid  and  in  both  dis- 
tinct shadows  were  evident,  while  in  one  of  them  the  stones 
were  shown  with  considerable  clearness,  probably  due  to 
the  admixture  of  urates  in  the  former  and  of  calcic  phos- 
phate in  the  latter  case. 

Rupture  of  the  Urethra:  A  Report  of  Cases. — Dr.  James 
R.  Hayden,  of  New  York,  read  a  report  of  three  cases,  giv- 
ing the  detailed  histories  of  them,  describing  the  opera- 
tion and  giving  the  results  of  treatment. 

Inversion  of  the  Tunica  Vaginalis  for  Hydrocele. — Dr. 
Robert  H.  Greene,  of  New  York,  read  a  paper  with  this 
title,  in  which  he  made  the  following  conclusions:   (1)  That 


this  is  an  easy  operation  to  perform,  and  that  it  results 
in  the  cure  of  the  hydrocele  seems  undoubtedly  true.  (2) 
The  fact  of  so  many  operations  having  been  recorded  with 
the  history  of  no  unfavorable  result  as  regards  suppuration 
or  neuralgia  of  the  testicle  offers  pretty  conclusive  evi- 
dence as  to  the  safety  of  this  operation  from  the  above 
complications.  (3)  The  effect  it  may  have  in  causing  atro 
phy  of  the  testicle  or  changes  in  the  function  of  that  op- 
gan  is  a  subject  concerning  which  clinical  data,  extending 
over  a  long  period  of  time,  are  necessary  before  final  con- 
clusions can  be  drawn. 

A  Case  of  Unusual  Bacillus  of  Abnormally  Behaving. 
Gonococcus. — Dr.  J.  P.  Tuttle,  of  New  Y'ork,  described  such 
a  case,  in  which  the  behavior  of  the  coccus  found  was  en- 
tirely different  from  that  of  the  gonococcus  in  that  it 
was  rapidly  destroyed  in  all  acid  media,  but  in  an  alkaline 
media  it  rapidly  thrived.  The  case  finally  resolved  itself 
into  a  very  obscure  form  of  syphilis,  and,  under  the  in- 
fluence of  mercury,  the  urinary  symptoms  gradually  cleared 
up. 

Partial  excision  of  the  Bladder  and  Urethra  for  Carci- 
noma.— Dr.  Tuttle  reported  this  case  of  cancer  of  the  rec- 
tum which  involved  the  urethra,  the  prostate  and  possibly 
the  wall  of  the  bladder. 

SECOND   DAY,   MAY   1,   1901. 

Some  Unusual  Manifestations  of  Syphilis  (Clinical  and 
Pathological  Illustrations). — Dr.  John  A.  Fordyce,  of  New 
York,  considered  gangrene  of  the  initial  lesion,  lichen 
planus  and  syphilis,  syphilis  and  pemphigus,  syphilis  and 
psoriasis,  syphilis  and  lepra  and  syphilis  and  lupus.  These 
were  accompanied  by  illustrations. 

A  Case  of  Prostatectomy. — Dr.  James  Bell,  of  Montreal, 
read  a  report  of  such  a  case  showing  the  peculiar  enlarge- 
ment of  the  prostate,  and  the  fact  that  the  Bottini  incisions 
could   not  have   effected   this  enlargement. 

What  I  Have  Learned  From  One  Hundred  and  Sixty- 
one  Operation  for  the  Relief  of  Senile  Hypertrophy  of  the 
Prostate  Gland. — Dr.  Orville  Horwitz.  of  Philadelphia,  read 
a  very  long  and  complete  paper  on  this  subject,  considering 
the  subject  under  the  sub-headings  of  vasectomy,  castra- 
tion, supra-pubic  cystotomy,  prostatectomy  and  the  Bot- 
tini operation.  His  conclusions  in  brief  were  as  fol- 
lows: 1.  Success  follov.'ing  the  Bottini  operation  depends 
on  having  perfect  instruments,  a  good  battery,  the  neces- 
sary skill,  and  the  employment  of  a  perfect  technique.  2. 
In  suitable  cases  the  Bottini  operation  is  the  safest  and  best 
for  the  radical  cure  thus  tar  devised  for  the  relief  of  pros- 
tatic hypertrophy.  3.  It  is  often  very  efficacious  in  ad- 
vanced cases  of  obstruction  as  a  palliative  measure,  ren- 
dering catheterism  easy  and  painless,  relieving  spasm, 
lessening  the  tendency  to  constipation,  and  improving 
the  general  health.  4.  It  is  of  special  service  in  the 
beginning  of  obstructive  symptoms  due  to  hypertrophy  of 
the  prostate  gland,  and  may  be  regarded  as  a  means  of 
preventing  catheter  life.  5.  It  is  indicated  in  all  forms  of 
hypertrophy  except  where  there  is  a  valve  formation,  or 
where  there  is  an  enormous  growth  of  the  three  lobes, 
associated  with  tumor  formation  giving  rise  to  a  pouch, 
both  above  and  below  the  prostate  gland.  6.  Where  the 
bladder  is  hopelessly  damaged,  together  with  a  general  ath- 
eromatous condition  of  the  blood-vessels,  associated  with 
polyuria,  results  are  negative.  7.  Pyelitis  is  not  a  contra- 
indication. 8.  The  character  of  the  prostatic  growth  has 
no  bearing  on  the  results  of  operation. 

Some  of  the  Conditions  Following  the  Bottini  Operation 
for  Prostatic  Obstruction. — Dr.  L.  Bolton  Bangs,  of  New 
York,  brought  out  the  following  points,  which  he  considered 
of  importance:  1.  The  muscular  impediment  which  almost 
immediately  follows  the  removal  of  the  instrument.  2. 
The  process  of  repair,  as  witnessed  by  the  cystoscope, 
which  begins  and  proceeds  as  in  ordinary  aseptic  wounds. 
3.  The  decided  necessity  for  after-treatment  because 
patients  that  come  to  us  usually  suffer  from  a  chronic 
catarrhal  condition  of  the  prostate,  seminal  vesicles,  blad- 
der   and    urethra. 

Contracture  of  the  Neck  of  the  Bladder. — Dr.  Charles  H. 
Chetwood,  of  New  York,  after  considering  the  causes  and 
symptoms,  referred  to  the  treatment,  as  advocated  by  him, 
and  which  was  a  modified  Bottini  operation.  He  used  a 
specially  constructed  Instrument  which  performed  the  same 
function  as  the  galvano-cautery  knife  of  Bottini  which 
operates  through  a  perineal  opening.  He  then  described 
the  instrument  and  the  technique  of  operating.  16  cases 
were  reported.  The  ages  were  between  30  and  73  years.  6 
being   under   45    and   the   remainder   between    45    and    73. 


952 


The  Philadelphia"] 
Medical   Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Mat  is,   laOL 


Out  Of  this  number  there  was  one  death,  which  occurred 
five  weeks  after  the  operation  from  a  pyelonephritis.  He 
stated  that  if  a  perineal  opening  was  made  many  cases  of 
the  contracture  type  of  prostatic  hypertrophy  would  be 
recognized,  and  many  would  be  found  suitable  cases  for 
the  use  of  the  perineal  prostotomy  with  the  galvano- 
cautery.  The  perineal  incision  permits  of  exploration, 
which  is  better  and  more  rapid  than  the  cystoscope. 

Officers  Elected  for  the  Ensuing  Year:— President,  Dr.  W. 
T.  Belfleld,  of  Chicago;  vice-president.  Dr.  Paul  Thorndike, 
of  Boston:  secretary,  Dr.  James  R.  Hayden,  of  New  York. 
Member  of  Council.Dr. William  K.  Otis,  of  New  York.  Place 
of  meeting,  Atlantic  City,  N.  J. 


THE  ASSOCIATION  OF  AMERICAN  PHYSICIANS. 


(Continued.) 

M.  Allen  Starr,  of  New  York,  read  a  paper  entitled  the 
toxic  origin  of  neurasthenia  and  melancholia.  Cases  of 
toxic  neurasthenia  are  found  in  poorly  nourished  women 
and  in  men,  about  45  years  of  age,  who  are  negligent  of 
diet  and  exercise  and  who  are  free  livers.  These  patients 
■complain  of  pain  in  the  head  and  back,  irritability,  dis- 
■ordersofcirculationiand  digestion.  The  urine  was  irregular 
-in  quantity  and  always  contained  a  large  amount  of  indican. 
The  symptoms  of  depression  are  at  their  height  at  about 
4  o'clock  A.  M.,  they  gradually  disappear  until  noon, 
when  the  patient  feels  at  his  best,  and  they  gradually  re- 
turn during  the  afternoon  and  night.  This  train  of  symp- 
toms, worse  in  the  morning,  is  not  due  to  the  wear  and 
tear  of  exhausion,  but  is  more  probably  due  to  the  action  of 
some  intoxicant,  which  accumulates  during  sleep,  and  by 
its  irritation  wakens  the  patient.  Although  indican  is 
found  in  the  urine,  it  is  probably  not  the  cause  of  the 
symptoms.  In  the  treatment  of  the  condition  the  diet 
should  be  nourishing,  ami  of  the  best  form  that  the  patient 
can  assimilate.  Fluids  should  be  given  in  great  excess. 
Digestion  should  be  aided  by  drugs  which  stimulate  the 
liver,  such  as  calomel,  podophylin  and  Carlsbad  salt  and 
by  the  intestinal  antiseptics  which  may  act  in  counteract- 
ing the  toxic  agent.  The  author  uses  3  forms  of  intestinal 
antiseptic  medication:  (X)  a  capsule  of  5  grains  of  sulpho- 
carbolate  of  sodium,  with  one  grain  of  potassium  perman- 
ganate; (2)  a  capsule  of  5  grains  of  salol  and  one  minim 
of  castor  oil;  (3)  a  capsule  of  2  grains  of  benzoate  of 
sodium,  and  one  grain  each  of  sulphocarbolate  of  zinc  and 
naphthol.  These  capsules  are  coated  with  shellac  to  pre- 
vent them  from  becoming  dissolved  before  they  reach  the 
intestine.  Baths,  exercise  and  rest  form  an  important  part 
of  the  treatment. 

W.  W.  Johnston,  of  Washington,  showed  the  patient 
suffering  from  Addison's  disease  that  he  exhibited  to  the 
association  last  year.  'l"bo  improvement  continues  under 
treatment  with  suprarenal  extract,  the  patient  lives  on  a 
farm  and  does  heavy  farm  work.  He  has  gained  2  pounds 
in  weight. 

Johnston  read  a  paper  entitled,  the  evils  arising  from 
failure  to  recognize  the  true  nature  of  neurasthenia  and 
some  of  the  causes  of  this  failure.  The  reader  referred 
Ho  the  case  of  Charles  Darwin,  who.  from  the  affects  of 
fatigue,  hardship  and  strain,  was  a  neurasthenic  when  he 
returned  to  England  from  his  voyage  in  the  Beagle.  Dar- 
win found  that  his  sufferings  were  much  relieved  by  rest, 
and  if  he  had  abandoned  all  work  as  soon  as  he  returned 
to  England,  he  might  have  recovered  from  his  neuras- 
thenia and  saved  himself  much  later  suffering  and  misery. 
When  a  diagnosis  of  neurasthenia  is  made  the  patient 
should  be  required  to  take  a  complete  rest.  Many  cases  of 
this  affection  are  curable,  but  others,  of  course,  are  incur- 
able. Devoting  attention  to  gastrointestinal  symptoms. 
or  to  the  symptoms  of  any  one  system  in  the 
body  is  a  hindrance  to  final  recovery,  for  as 
the  neurasthenic  symptoms  disappear  from  one  sys- 
tem they  appear  in  another.  The  reader  was  of  the 
opinion  that  there  should  be  more  sanatoria  in  this  country 
devoted  to  the  treatment  of  this  disease.  Cabot,  of  Boston, 
said  that  calomel  and  podophyllin  are  not  hepatic  stimu- 
lants, and  that  ox-bile  was  the  only  true  cholagogue.  He 
thinks  that  the  term  hepatic  stimulant  should  be 
divorced  from  such  drugs  as  mentioned.  James  J. 
Putmam.  of  Boston,  thought  that  Starr  had  not 
proved    his   case   concerning   the   toxic   origin   of   neuras- 


thenia. The  daily  fluctuation  ot  symptoms  is  seen  in  other 
forms  of  the  disease  than  the  so-called  toxic  form.  Be- 
cause one  has  found  a  remedy  it  does  not  follow  that  the 
cause  of  a  disease  has  been  found.  He  is  in  thorough  ac- 
cord with  the  suggestion  to  provide  sanatoria  for  the 
treatment  of  the  condition.  C.  A.  Herter,  of  New  York, 
said  that  there  was  a  relation  between  intestinal  putrefac- 
tion and  melancholia.  In  melancholia  the  etherial  sul- 
phates, which  are  the  best  indicators  of  intestinal  putre- 
faction, are  increased.  Indol  produces  irritability  of  the 
nervous  system  and,  later,  depression.  Calomel  probably 
acts  in  such  cases  by  reducing  the  absorption  of  etherial 
sulphates.  Baumgarten  said  that  it  is  difficult  to  assign 
mental  fatigue  to  its  proper  cause.  The  mental  worker 
does  not  always  feel  the  effect  of  his  overwork  immedi- 
ately. Daily  habitual  overwork  may  indeed  stimulate  the 
patient  until  neurasthenia  finally  develops. 

C.  A.  Herter,,  of  New  York,  read  a  paper  entitled  the 
acid  intoxication  of  diabetes  and  its  relation  to  prognosis. 
In  normal  urine,  the  total  of  acid  and  base  almost  coin- 
cide, with  slight  excess  of  acid.  In  diabetes  there  is  an 
apparent  excess  of  base,  the  acid  excreted  not  being  suffi- 
cient to  neutralize  the  bases  excreted.  When  the  method 
of  estimating  the  total  amounts  of  acids  and  bases  cannot 
be  carried  out  in  detail  an  approximate  result  can  be  ob- 
tained by  estimating  the  nitrogen  of  ammonia.  In  cases 
of  diabetes  with  impending  coma  the  nitrogen  of  am- 
monia will  be  increased.  In  cases  of  diabetes,  the 
urines  of  which  were  examined,  there  was  increase 
in  the  excretion  of  organic  acids,  estimated  in 
terms  of  oxybutyric  acid,  and  also  of  the  nitrogen  of  am- 
monia during  coma  and  in  impending  coma.  In  the  case 
of  a  patient  who  was  on  a  moderately  restricted  diet  the 
amount  of  organic  acid  excreted  was  high  and  the  excretion 
of  potassium  was  almost  as  much  as  that  of  sodium. 
Under  strict  exclusion  of  carbohydrates  for  4  days,  the 
amount  of  acid  excreted  decreased  and  the  pot- 
assium excreted  decreased  and  returned  to  its  normal 
relation  to  the  sodium  excreted,  about  1  to  2. 
In  cases  of  diabetes  in  which  urine  does  not  contain 
an  ejccess  of  organic  acids  the  progress  of  the  case  is  usu- 
ally satisfactory.  The  relation  between  the  sugar  excreted 
and  the  amount  of  organic  acid  in  the  urine  is  not  con- 
siant:  the  sugar  may  drop  and  the  acid  continue  high  or  rice 
n-isa.  As  a  rule,  when  large  quantities  of  sugar  are  present 
in  the  urine  the  organic  acids  are  also  present  in  large 
amount.  The  estimation  of  the  nitrogen  of  ammonia  is 
useful  for  clinical  purposes,  because,  as  a  rule,  consider- 
able oxybutyric  acid  is  attended  by  an  increase  of  the 
nitrogen  of  ammonia.  'I  ae  latter  factor,  however,  cannot 
be  relied  upon  in  the  estimation  of  the  output  of  small 
amounts  of  oxybutyric  acid.  There  is  danger  of  coma 
whenever  the  amount  of  oxybutyric  acid  is  high:  but  the 
nitrogen  of  ammonia  may  be  increased  to  17%  and  coma 
be  delayed.  A  patient  may  feel  well  and  be  able  to  do  a  con- 
siderable amount  of  muscular  work  even  when  he  is  excret- 
ing 30  mg.  of  oxybutyric  acid  daily.  A  patient  whose  urine 
contains  no  organic  acid  is  in  no  immediate  danger  of 
coma,  but  he  is  liable  to  the  other  accidents  of  diabetes. 

E.  P.  Joslin  read  a  paper  entitled  metabolism  in  diabetic 
coma  with  special  reference  to  acid  intoxication.  The  au- 
thor referred  to  a  case  of  diabetes  which  was  under  treat 
nient  for  2  years  and  2  months.  During  this  time  the 
jjalient  gained  in  weight.  Diacetic  acid  was  absent  from 
the  urine  when  the  patient  was  first  seen:  it  then  made  its 
ajipearance  and  remained  for  2  years:  it  then  disappeared 
and  remained  absent  until  death  occurred.  The  relation 
of  organic  acid  to  nitrogen  was  high.  Victor  C.  Vaughan. 
of  Ann  Arbor,  said  that  the  substance  producing  acid  in- 
toxication is  not  known,  or  else  the  admiration  of  alkalies 
would  result  in  cure.  He  believes  that  death  is  hastened 
by  excessive  nitrogen  metabolism,  because  acid  substances 
arise  from  nitrogenous  food  and  coma  may  be  prevented 
by  reducing  the  amount  of  that  kind  of  food  administered 
He  is  inclined  to  believe  that  the  elimination  of  potassium 
indicates  a  disintegration  of  the  body  cells.  C.  .\.  Herter. 
of  New  York,  said  that  the  amount  of  acid  produced  in 
cases  of  diabetes  is  so  large  that  the  alkali  administered 
can  neutralize  only  a  portion  of  it.  He  believes  that  acid 
is  the  cause  of  the  condition,  although  the  nature  of  the 
acid  is  not  known.  His  studies,  however,  point  to  oxybuty- 
ric acid  as  the  offending  substance.  He  agrees  that  the 
acid  is  derived  from  the  nitrogenous  food,  and  he  thinks 
that  the  ammonia  also  comes  from  meat  diet.    Franz  Pfaff. 


May    18,    1901] 


AMERICAN  NEWS  AND  NOTES 


CThe  Philadelphia         q  c  7 
Medical  Journal  Voo 


of  Boston,  said  that  the  administration  of  fat  increases  the 
amount  of  aceton  in  the  urine. 

J.  George  Adami,  of  Montreal,  read  a  paper  entitled 
classification  of  the  intoxications  from  a  pathological  point 
of  view.  The  author  divides  the  intoxications  into  (1) 
exogenous,  due  to  poisons  introduced  from  without  and 
(2)  endogenous,  due  to  poisons  elaborated  within  the 
body.  The  exogenous  intoxications  may  be  (1)  exotic.  If 
introduced  through  the  skin  or  through  the  mucous  mem- 
brane of  the  respiratory  or  digestive  tracts,  and  (2)  indi- 
genous or  excretory,  due  to  reabsorption  of  secretions,  in- 
direct autointoxication,  or  disintegration  processes.  The 
endogenous  intoxications  may  be  (1)  direct  autointoxica- 
tions due  to  internal  secretions  discharged  from  the  cells 
or  to  disintegrative  processes  of  the  cells  and  (2)  parasitic, 
■nhich  mav  in  turn  be  microparasitic  or  macroparasitic. 

[J.  M.  S.] 

p'Irst  Day,  Evening. — The  evening  session  was  occupied 
by  demonstrations  of  photographs  with  the  stereopticon, 
gross  morbid  anatomy  specimens  and  microscopic  speci- 
mens of  various  pathological  conditions.  Charles  Bond,  of 
Richmond.  Indiana,  showed  with  the  stereopticon.  speci- 
mens of  photomicrography,  some  of  which  represented  work 
at  a  magnification  of  3.000  diameters. 

William  F.  Councilman,  of  Boston,  ■showed  a  series  of 
photomicrographs  with  the  stereopticon  representing  the 
lesions  of  the   kidney  in  cases  of  diphtheria. 

H.  C.  Ernst,  of  Boston,  showed  a  series  of  photomi- 
crographs with  the  stereopticon  showing  various  patholo- 
gical conditions. 

Simon  Flexner.  and  R.  M.  Pearce,  of  Philadelphia,  ex- 
hibited a  collection  of  gross  specimens  illustrative  of  the 
lesions  of  experimental  acute  pancreatitis  in  the  dog. 

vVilliam  H.  Welch  and  Eugene  L.  Opie.  of  Baltimore,  ex- 
hibited specimens  that  illu.strated  hemorrhagic  pancreatitis, 
both  human  and  experimental  and  a  specimen  of  filarial 
lymph-varix. 

William   H.   Welch.   W.   G.   MacCallum   and   Buckley,  of 
Baltimore,  exhibited  specimens  of  multiple  myelomata  and 
of  epizootic  hemorrhagic  encephalitis. 
(To  be  Continued.) 


NINETEENTH  GERMAN  CONGRESS  FOR  INTERNAL 
MEDICINE. 
(Continued.) 
2D  SESSION. — V.  Struempell  of  Erlangen  in  the  chair. 
The  second  session  was  devoted  principally  to  a  discussion 
of  the  papers  read  at  the  first  session.  Schott  of  Manheim 
considered  the  strengthening  of  the  heart  itself  of  prime 
importance,  the  effect  on  the  vasomotors  secondary;  a  more 
powerful  systole  acts  at  the  same  time  as  a  stimulant  to 
the  vasomotor  nerves.  The  effect  of  the  heart  stimulants 
is  largely  dependent  upon  the  concentration  and  mode  of  ap- 
plication, especially  in  the  case  of  camphor.  Jacob  of  Cudo- 
wa  confirmed  the  statement  that  digitalis  has  no  effect  in 
lesions  of  the  aortic  valves,  and  explained  this  failure  of 
the  drug  by  the  fact  that  the  heart  is  already  performing 
the  utmost  possible  amount  of  work;  a  stimulant  cannot, 
therefore,  increase  the  heart  action.  Lang  of  Marienbad 
called  attention  to  the  poor  and  varying  preparations  of  di- 
gitalis as  the  cause  of  varying  action  of  the  drug.  This 
is  especially  the  case  with  the  infusions.  The  action  of  the 
drug  can  often  be  increased  by  combining  it  with  other 
stimulants,  especially  alcohol.  Heintz  of  Erlangen  remarked 
that  the  finely  powdered  drug  often  gives  much  better  re- 
sults than  a  coarsely  powdered  preparation.  Goldscheider 
of  Berlin  warmly  recommended  the  use  of  0.1-0.2  gr.  digi- 
talis pro  die  for  months  at  a  time,  in  cases  with  a  tendency 
to  frequent  recidivation.  Goldscheider  recommended  the 
gradual  discontinuing  of  the  drug,  gradually  decreasing  the 
dose  for  weeks.  He  believes  that  one  can  obtain  more  exact 
results  with  digitoxin.  Hirsch  of  Leipzig  described  the  ex- 
periments made  by  himself  and  Beck  on  the  determina- 
tion of  the  viscosity  of  the  blood.  The  viscosity  of  the 
blood  is  not  due  to  the  corpuscles  alone,  but  also  due  to 
the  composition  of  the  blood  serum.  He  has  found  that 
it  is  to  some  degree  dependent  upon  the  nutrition  of  the 
animal.        He   found  that  no   proportion   existed   between 


the  specific  weight  and  the  viscosity  of  the  blood.  Ewald 
of  Berlin  emphasized  the  necessity  of  removing  the  pres- 
sure of  exudations  and  transudations  upon  the  walls  of  the 
blood  vessels,  and  demonstrated  an  apparatus  devised  by 
Dehio  of  Dorpat  to  aid  in  the  sacrification  of  edema.  Ewald 
pointed  out  further  that  digitalis  can  cause  digestive  dis- 
turbances, even  when  given  in  the  form  of  a  clysma,  or 
in  a  suppository,  and  considered  the  anorexia  due  to  the  in- 
fluence of  the  drug  upon  the  nervous  centre.  Friedel  Pick 
of  Prague  mentioned  the  action  of  digitalis  In  lessening 
edema  by  the  contractile  effect  of  the  drug  on  the  blood 
vessels.  Hydrastin  acts  advantageously  in  the  same  way. 
ITnverricht  of  Madgeburg  noted  the  poor  quality  of  many 
digitalis  preparations.  He  judges  the  effect  of  a  given 
preparation  from  the  amount  of  digitoxin  it  contains.  Un- 
verricht  recommended  the  dialysaies  prepared  by  Golaz, 
which  contain  constant  quantities  of  the  glucoside.  He 
considers  digitoxin  better  than  any  of  the  other  digitalis 
preparations.  The  speaker  considered  the  continued  use 
of  the  drug  to  be  disadvantageous,  on  account  of  the  cumu- 
lative action  of  the  drug  and  the  further  results — digital- 
ism  and  anorexia — which  latter  he  has  also  been  following 
the  use  of  the  drug  per  rectum,  and  which  he  also  considers 
of  central  origin.  Rosenstein  of  Leiden  praised  strophan- 
tus, which  he  uses  almost  exclusively  in  his  clinic,  and 
which  he  prefers  because  strophantus  causes  no  stomach 
disturbances.  The  French  clinicians  use  the  drug  exten- 
sively. Camphor,  because  of  its  transitory  action,  should 
be  confined  to  cases  of  immediate  danger,  but  in  such 
cases  should  be  used  more  frequently  than  it  is.  In  regard 
to  the  viscosity  of  the  blood  Rosenstein  mentions  the  view 
long  held  by  English  authors  that  anemic  murmurs  are 
caused  by  a  changed  composition  of  the  blood.  He  does 
not  believe  in  the  idea  suggested  by  Hirsch  that  a  change 
in  the  viscosity  of  the  blood  can  cause  hypertrophy  of  the 
ventricles.  Xaunyn  of  Strassburg  considers  the  old  in- 
fusum  digitalis  the  most  valuable  preparation.  His  experi- 
ments with  digitoxin  were  negative.  He  does  not  believe  In 
the  cumullative  action  of  digitalis  nor  In  the  bad  effects 
on  the  stomach.  He  uses  the  drug  in  long  continued  small 
doses.  Grodel  of  Bad  Nauheim  has  never  seen  digitalism, 
either  in  a  form  similar  to  morphinism,  or  that  his  patients 
ceased  to  react  to  the  drug.  He  does  not  believe  that  the 
drug  lengthens  the  patient's  life,  but  that  it  does  make  their 
last  years  more  comfortable.  Of  course  one  must  some- 
time change  the  drugs,  or  cease  giving  it,  according  to  the 
conditions.  Rosenfeld  of  Stuttgart  has  returned  to  the  in- 
fusion, having  obtained  no  results  with  digitoxin.  He 
thinks  this  due  to  the  fact  that  the  latter  is  prepared  from 
the  stems  as  well  as  the  leaves,  and  the  stems  contain  vary- 
ing amounts  of  the  active  principle.  In  order  to  retain  the 
good  effects  of  digitalis  Rosenfeld  recommends  the  use  of 
adonis  vernalis  as  a  tea,  a  tablespoonful  to  a  cup  of  water, 
1-2  daily.  Schreiber  of  Goettingen  discussed  the  value  of 
the  determination  of  the  viscosity  of  the  blood.  Baeltz  of 
Tokio,  Japan,  recommended  the  use  of  digitalis  infusum. 
Xext  to  digitalis  ranks  strophanthus.  which  is  of  especial 
value  if  one  wishes  to  attain  results  in  a  short  time.  Baeltz 
also  recommends  adonis  vernalis  in  the  form  of  tea  as  a 
substitute  for  digitalis.  He  does  not  consider  digitalism 
rare.  Pranke  of  Munich  suggested  that  investigators  di- 
rect their  attention  more  to  the  action  of  drugs  on  the 
normal  organism  before  directing  taking  up  pathological 
conditions.  Ott  of  Prague  called  attention  to  the  difference 
in  digitalis  gathered  in  different  parts  of  the  same  country, 
and  to  the  action  of  carbonic  acid  on  the  heart.  Gottleib 
confirmed  Ott's  statement  in  regard  to  the  different  toxic  ef- 
fects of  preparations  of  different  origin.  The  physician 
should  know  not  only  how  much  he  prescribes,  but  also  the 
toxic  equivalent  of  the  prescription.  Sahli  repeated  that 
there  is  no  difference  in  principle  between  any  of  the  digi- 
talis preparations.  He  uses  strophanthus  often,  but  the  pre- 
parations vary  considerably.  The  best  preparation  is  the 
French  strophanthin  in  the  form  of  pills.  Sahli  has  ex- 
perienced disturbances  In  the  digestive  tract  following 
the  use  of  strophanthus.  especially  diarrhea.    He  has  seen 


-  .       The  Philadelphia"! 
yo'f      Medical  Journal  J 


FOREIGN  NEWS  AND  NOTES 


IMat   U.    1901. 


good  results  with  digitoxin,  but  it  often  has  little  effect, 
possibly  because  it  acts  too  strongly  on  the  blood  vessels. 
He  warns  against  proclaiming  it  as  a  complete  substitute 
for  digitalis.  Smith  of  Schloss  Marbach;  "The  Examina- 
tion of  the  Function  of  the  Heart  and  some  Facts  Derived 
Therefrom,"  claims  to  have  found  dilatation  of  the  heart 
to  be  an  etiological  factor  in  certain  forms  of  neurasthenia, 
melancholy,  hypochondria,  etc.,  etc.,  after  curing  the 
heart  trouble  Smith's  patients  recovered,  or  at  least  were 
improved. 

Hoffman  of  Schloss  Marbach;  "The  Objective  Effect  of 
Modern  Internal  Heart  Stimulants  on  the  Heart  Func- 
tion." 

Schott  of  Manheim;  "The  Pulse  Tension  in  the  Treatment 
of  Chronic  Heart  Disease."  Schott  finds  by  means  of  Gart- 
ner's tonometer  that  his  balneological-gymnastic  treatment 
is  followed  in  certain  cases  by  an  increased  pulse  tension; 
In  these  cases  his  method  is  indicated.  In  certain  other 
cases,  as  in  the  advanced  stages  of  aterio-sclerosis  or 
myocarditis,  and  in  aneurism  of  the  heart  or  the  aorta, 
the  pulse  tension  is  lessened  and  the  treatment  is  contrain- 
dicated. 

GREAT  BRITAIN. 

Divers'  Diseases  and  Perils. — The  London  Globe  quotes: 
The  latest  report  on  the  health  of  the  navy  contains  some 
important  remarks  on  the  accidents  and  diseases  caused 
iiy  diving  operations,  contributed  by  Surgeon  Henry  N. 
Stephens.  Royal  Navy.  The  diving  operations  in  his  Ma- 
jesty s  navy  are  carried  out  by  men  who  received  a  special 
training  in  this  branch  at  one  of  the  three  gunnery  estab- 
lishments. The  principal  causes  of  rejection  are  (1)  to- 
bacco heart:  (2)  alcoholic  subjects  are  rejected  on  the 
slightest  suspicion;  (3)  degeneration  of  the  blood  vessels. 
Bull-necked  men  are  rejected  if  over  thirty-five  years  of 
age  on  account  of  their  tendency  to  apoplexy,  and  men  are 
rejected  who  suffer  from  nervousness.  In  the  novice  the 
effects  of  diving  may  be  classed  under  two  headings,  name- 
ly. (1)  hunger,  (2)  sleepiness.  In  the  first  place,  the  di- 
gestive fimctions  are  stimulated  by  one  or  a  combination 
of  the  following  causes:  (a)  Owing  to  the  increased 
pressure  of  air  while  diving,  there  is  probably  an  increased 
metabolism  in  the  body,  nature  calling  attention  to  this  by 
an  increased  appetite.  It  is  proved  by  the  following  case 
that  the  blood  becomes  hyperoxygenated  by  inhaling 
compressed  air  while  diving;  (bi  the  lightness  of  the  man's 
breakfast  may  also  partially  account  for  his  hunger.  Sec- 
ondly, sleepiness,  which  is  induced  after  diving  may  be 
(1)  produced  by  reaction  after  excitement;  or  (2)  may 
be  an  effort  of  nature  to  make  up  for  increased  metabolism; 
or  (3)  the  after  effects  of  congestion  of  the  blood  vessels 
of  the  brain.  Suffocation  may  be  caused  by  defective  ap- 
paratus, injury  to  the  air  pipe,  or  insufficient  knowledge  of 
the  diving  apparatus.  Fainting  or  loss  of  consciousness 
is  of  freo.uent  occurrence,  and.  when  the  diver  is  a  begin- 
ner, is  attributed  to  nervousness.  This  is  often  entirely 
unknown  to  the  diver  (the  loss  of  consciousness).  The 
officer  instructing  divers  in  this  establishment  describes 
it  thus:  The  man  is  signaled  to  and  asked  if  he  is  all  right, 
and  he  does  not  reply  He  is  then  signaled  to  come  up  and 
still  there  is  no  reply:  then  he  is  pulled  up  to  the  surface, 
when  he  often  regains  consciousness  and  strikes  out  to 
get  hold  of  the  ladder.  The  man  when  questioned  about  it 
says  he  did  not  notice  the  signals,  or  that  he  does  not 
remember  anything  about  it.  The  signals  are  good 
heavy  pulls  on  the  breast  rope.  When  a  man 
goes  under  the  surface  of  the  water  his  body  is  sub- 
jected to  considerable  pressure  in  proportion  to  depth, 
varying  from  eight  and  a  quarter  pounds  to  the  square  inch 
at  twenty  feet  depth  to  sixty-five  and  a  half  pounds  to  the 
square  inch  at  150  feet  depth.  In  conclusion.  Surgeon 
Stephens  recommends  that  no  man  should  go  down  after  a 
heavy  meal,  probably  two  hours  after  a  light  breakfast 
being  the  best  time.  No  man  should  ascend  or  descend 
more  quickly  than  one  foot  per  second  in  shallow  water, 
that  is.  under  five  fathoms,  and  in  deeper  water  one  foot 
in  five  seconds,  with  frequent  stoppages  to  allow  the  ears 
to  be  eased  and  the  body  to  accommodate  itself  to  the 
altered  pressure.  He  should  take  about  fifteen  minutes 
to  descend  twelve  fathoms,  including  stonpages.  No  man 
should  be  allowed  to  stay  at  a  depth  of  fifteen  fathoms  for 


longer  than  one  hour  at  a  time  without  coming  to  the  sur- 
face. 

The  Registration  of  Plumbers. — The  British  Medical 
Juuniiil  slates  that  at  a  meeting  of  representatives  of  dis- 
trict councils  for  the  National  Registration  of  Plumbers, 
held  at  London,  on  April  24th,  it  was  reported  that  since 
the  conference  of  Health  and  Water  Authorities  and  Plum- 
bers, held  in  Birmingham  in  October  last,  2,082  operative 
plumbers  and  494  master  plumbers  have  been  registered, 
and  that  numerous  applications  for  registration  remained 
to  be  dealt  with.  On  the  motion  of  Dr.  Alfred  Hill, 
Medical  Officer  of  Health,  Birmingham,  it  was  resolved  that 
apprenticeship  should  be  encouraged  in  connection  with 
the  National  Registration  of  Plumbers. 

King  Edward  has  made  Sir  William  Henry  Broadbent, 
M.  D.,  a  Knight  Commander  of  the  Royal  Victorian  Order, 
and  Dr.  A.  R.  Manley,  who  has  been  for  many  years 
surgeon  apothecary  to  the  Prince  of  Wales,  a  member  of 
the  fourth  class  of  the  same  order. 

CONTINENTAL  EUROPE. 

Valuable  Discovery. — The  well-known  Austrian  scien- 
tists. Professor  Loeffler  and  Dr.  Uhlenhuth,  announce  that 
they  have  discovered  serum  which  will  protect  animals 
against  the  foot  and  mouth  disease.  This  serum  affords 
to  animals  inoculated  with  it  immunity  for  from  four  to 
eight  weeks  against  infection  from  the  disease.  As  soon 
as  Urs.  Loeffler  and  Uhlenhuth  receive  the  authorization  of  J 
their  Government  the  new  remedy  will  be  placed  at  the  dis-  * 
posal  of  the  public. 

The  Military  Step. — Dr.  Colin,  of  the  French  Army,  has 
published  (La  Salud,  January.  1901 )  the  results  of  his  investi- 
gations regarding  the  effects  which  the  regulation  military 
step  of  the  disciplined  soldier  produces  on  his  health  and  on 
his  constitution.  The  regularity  of  the  military  step  causes 
an  indefinite  repetition  of  the  shock  affecting  the  bones 
and  the  brain  which  is  much  more  prejudicial  than  that 
produced  by  an  irregular  walk.  Dr.  Colin  attributes  to  the 
regular  and  uniform  repetition  of  this  shock  on  the  same 
parts  of  the  body  much  of  the  pains  and  diseases  peculiar 
to  the  soldier.  During  the  march  of  a  single  day  this 
shock  is  repeated  40.000  times,  and  the  strongest  men. 
who  can  walk  a  long  distance  without  fatigue  when  usin:? 
the  ordinary  step,  yield  to  the  tension  caused  by  the  mili- 
tary step  after  two  or  three  days.  Dr.  Colin  proposes  that 
the  heel  of  the  military  shoe  be  made  of  rubber.  The 
French  infantry  have  begun  to  adopt  this  kind  of  heel,  and 
it  seems  to  afford  some  relief  to  the  soldier.  The  Govern- 
ment still  continues  to  experiment  with  the  rubber  heels.  • 

Prof.  A.  von  Eiselberg,  a  pupil  and  assistant  of  Billroth 
and  now  professor  at  Koenigsberg.  has  been  appointed  to 
the  chair  of  surgery  at  Vienna  made  vacant  by  the  death 
of  Professor  Albert. 

Hypnotism  In  Hungary. — On  account  of  the  number  of 
crimes  committed  of  late  in  Hungary,  which  have  been 
attributed  to  hypnotic  influence,  the  Hungarian  govern- 
ment has  prohilbited  the  practice  of  hypnotism  except  by 
medical  men  and  under  special  permission. 

Death  of  Bizzozero. — The  illustrious  Italian  Pathologist. 
Giulio  Bizzozero.  died  on  April  S.  aged  56.  His  illustrious 
achievements  in  histology  and  biology  are  well  known.  He 
was  an  untiring  and  conscientious  worker  and  has  con- 
tributed many  valuable  articles  embracing  original  re- 
search,  to  medical   literature. 

Professor  Brouardel,  the  Dean  of  the  Paris  Faculty  of 
Medicine,  will  not  permit  his  name  to  be  considered  for 
re-election  when  his  term  expires  in  1902.  He  has  been 
Dean  of  the  Medical  Faculty  for  15  years  now. 

Dr.  Lannelongue,  Professor  of  Surgery  in  Paris.  Surgeon 
to  the  Hospital  des  Enfants  Malades.  has  received  a  me- 
dallion, his  portrait  engraved  by  Chaplain,  from  his  former 
students,  for  his  services  during  the  last  International 
.Medical    Congress. 

Professor  Rudolph  Virchow  will  attain  his  SOth  year  on 
October  13th.  and  preparations  are  being  made  to  cel<v 
brate  the  occasion  in  a  manner  commensurate  to  his  po- 
sition in  the  scientific  world. 

Women  Physicians  of  Switerland  have  succeeded  in  hav- 
ing a  new  hospital  exclusively  for  women,  opened  in  Zurich. 
The  plant  costs  about  500.000  francs.     The  physicians  ar«^ 


May  18,  1901J 


THE  LATEST  LITERATURE 


TThe   Philadelphia 
Lmedical   Journal 


955 


exclusively  women,  and  a  training  school  for  nurses  is 
ooiinecterl  with  the  institution. 

Correction. — We  lieg  leave  to  call  attention  to  an  omis- 
sion which  occurred  in  the  Philadelphia  Medical  Journal 
of  April  13,  1901.  in  the  article  entitled  "Ligation  of  the 
Carotid  as  a  Preliminary  Operation  to  Resection  of  the 
Superior  Maxilla,"  namely  that  the  article  constituted  the 
advanced  sheets  of  the  Beitraege  zur  Klinischen  Chirurgie 
which  were  sent  by  the  courtesy  of  Prof.  Bruns,  the 
editor. 

Lepers  in  Russia. — According  to  statistics  there  are  862 
lepers  near  the  Baltic  Sea. 

A  New  Veterinary  Bacteriological  Laboratory. — An  insti- 
tute is  being  established  in  Moscow  for  the  purpose  of 
studying  infections  diseases  in  animals. 

A  Kind-hearted  Physician  Dies  a  Pauper. — A  well-known 
physician  died  recently  in  Kharkow  who  devoted  his  life 
to  the  poor.  He  gave  them  not  only  free  medical  advice, 
but  the  greater  part  of  his  earnings.  He  was  buried  by  the 
police. 

An  Over-supply  of  Medical  Journals. — The  epidemic  of 
medical  journalism  is  invading  even  Russia.  A  number  of 
medical  journals  general,  as  well  as  special,  made  their 
appearance  within  the  last  year.  Referring  to  one  of 
them,  the  Mr.dinnskoii;  Ohodroiii'  remarks  that  such  a  rapid 
growth,  which  is  out  of  all  proportion  to  the  demand,  not 
only  endangers  the  life  of  the  journals  already  existing, 
but  tends  to  lower  the  standard. 

A  New  Laboratory  for  the  Study  of  the  Plague. — An  ex- 
tensive and  costly  laboratory  is  being  established  in 
Kronstadt  for  the  purpose  of  studying  the  plague,  as  well 
as  for  preparing  serum. 

American  Treatment  of  Appendicitis. — Prof.  Eichhorst 
calls  the  operative  treatment  of  appendicitis  the  "Ameri- 
can" treatment.  That  the  Americans  may  not  be  so  far 
from  right  in  their  treatment  has  just  been  evidenced  in 
Prof.  Eichhorst's  own  clinic,  where  a  case  of  pulmonary 
gangrene  has  developed  from  an  appendicitis  treated 
by  "passive  therapy."  The  case  is:  A  boy  of 
13  years  was  brought  into  the  hospital  on  March 
23.  suffering  with  appendicitis.  Treated  with  opium 
and  cataplasms,  the  attack  passed  off.  But  on 
April  17.  the  boy  began  to  cough  up  the  typical  spu- 
tum of  pulmonary  gangrene,  and  now  the  lower  lobe  of 
the  right  lung,  with  a  suspicion  of  participation  on  the 
part  of  the  left  lung  is  involved.  There  is  considerable 
exudative  pleurisy.  The  prognosis  is  not  very  favorable. 
Some  bacteria  have  been  found  in  the  boy's  blood  but  they 
have  not  as  yet  been  identified. 

Russia. — It  is  proposed  to  increase  the  salary  of  the  pro- 
fessors of  the  Military  Medical  Academy  in  St.  Peters- 
livrj:.  The  professors  in  charge  of  clinics  are  to  receive 
6000  roubles  (3000  dollars)  a  year,  while  those  who  are 
fre«  from  such  duties  will  get  -tOOO  roubles  (2000  dollars). 

Thfi  Minister  of  Public  instruction,  who  received  a  gun- 
shot wound  during  the  recent  riots,  died  as  a  result  of 
suppuration.  The  number  of  male  medical  students  is  grad- 
ually decreasing,  while  the  female  students  are  on  the  in- 
crease. 

In  1898  the  Russian  Government  established  a  monop- 
oly of  the  liquor  trafhc,  with  a  view  of  limiting  the  sale 
and  abuse  of  intoxicants.  It  appears  now  that  within  the 
tai'.t  two  years  drunkeness  and  crime  Increased  consider- 
ably. 


Sexual  Impotence  Following  Gonorrhea. — Professor  Fll- 
aretopoulo,  of  Athens,  has  written  in  //  Independance  Medi- 
calc  (1901,  No.  16),  upon  sexual  impotence  following  gon- 
orrhea and  its  complications.  Gonorrhea  affects  the  human 
generative  function  in  two  ways,  causing  inability  to  copu- 
late, or  total  absence  of  spermatozoa.  The  latter  follows 
orchitis  or  prostatitis.  While  theoi-etically  double  epididy- 
mitis or  orchitis  ought  to  prevent  the  occurrence  of  sper- 
matozoa, they  are.  nevertheless,  sometimes  found.  Fila- 
retopoulo  has  seen  four  such  cases.  Following  premature 
erection,  which  is  common  with  gonorrhea,  absolute  im- 
possibility of  erection  eventually  results.  Gonorrhea  may 
cause  latent  or  apparent  spermatorrhea;  or  it  may  pro- 
duce urethral  stricture.  In  some  of  these  cases  urethrot- 
omy may  effect  a  cure,  virility  possibly  returning  after  op- 
eration.    [M.  O.] 


XLbc  ILatest  Xiteraturc. 


BRITISH    MEDICAL  JOURNAL. 

April  21  Ih.   1901. 

1.  Presidential  Address  on  Traps  and  Pitfalls  in  Special 

and  General  Practice.     J.  DUNDAS  GRANT. 

2.  Remarks  on  the  Training  of  Ophthalmic  Surgeons.     A. 

FREELAND  FERGUS. 

3.  On  the  Advisability  of  the  Inclusion  of  the  Study  of 

Anesthetics  as  a  Compulsory  Subject  In  the  Medical 
Curriculum.     DUDLEY  W.  BUXTON. 

4.  On   Certain   Practical   Applications   of   Extract   of   Su- 

prarenal Medulla.     E.  A.  SCHAFER. 

5.  Suprarenal   Gland  Extract  in  the  Epistaxis  of   Hemo- 

philia.    DAN   McKENZlE. 

6.  The    Dietetic    Value    of    Sugar.        H.    WILLOUGHBY 

GARDNER. 

7.  A  Preliminary  Note  on  the  Hibernation  of  Mosquitos. 

H.  E.  ANNETT,  and  J.  E.  DUTTON. 

3. — Buxton  advises  that  the  sluay  or  anesthetics  be  intro- 
duced into  the  medical  curriculum  as  a  compulsory  subject. 
He  advises  a  course  which  shall  include  lectures  dealing 
with  the  theory  of  anesthesia,  its  physiology,  pharmacology 
and  practice.  The  student  should  have  acutally  admin- 
istered nitrous  oxide  gas,  ether  and  chloroform.  As  a 
minimum.  50  cases  might  be  accepted  at  which  the  stu- 
dent has  been  present  and  of  these  at  least  12  should  have 
been  conducted   by   him  from   start  to   finish.     [J.   M.   S.] 

4. — As  the  result  of  numerous  experiments  which  have 
been  conducted  in  Schater's  laboratory  by  Slight,  Malcolm, 
and  Frost,  which  are  not  yet  published  nor  entirely  finished, 
he  feels  justified  in  suggesting  that  a  trial  should  be 
made  of  the  extract  of  superarenal  medulla  in  all  cases 
in  which  it  is  desired  to  strengthen  or  to  induce  uterine 
contraction.  The  observations  which  have  hitherto  been 
made  show  that  his  extract  has  a  far  greater  power  in 
causing  contraction  of  the  muscular  tissue  of  the  uterus, 
whether  pregnant  or  nonpregnant,  than  any  other  drug 
having  the  same  reputed  action,  and  this  whether  the  ex- 
tract be  applied  directly  to  the  muscular  tissue  or  be  in- 
troduced into  the  circulation.  Since  the  active  principle 
is  unaffected  by  the  gastric  juice,  it  can  be  given  by  the 
mouth,  but  in  postpartum  cases  it  would  doubtless  be  more 
advantageous  to  inject  it  directly  into  the  uterine  cavity, 
where  it  would  only  tend  to  produce  immediate  contraction 
of  the  uterine  musculature,  but  also  of  the  uterine  arteri- 
oles, and  thus  more  effectually  control  accompanying  hem- 
orrhage. The  solution  which  I  would  recommend  to  be 
used  is  an  infusion  of  dry  medullary  substance,  30  grs. 
to  the  pint  of  water.  This  should  be  sterilized  by  boiling 
and  inject  whilst  still  fairly  hot.  Such  a  solution  is  a 
powerful  styptic,  and  its  value  in  this  respect  may  be 
still  further  increased  by  the  addition  of  60 
grs.  of  calcium  chloride.  Another  class  of  cases 
in  which  the  extract  in  question  may  prove  of 
great  clinical  value  are  those  of  sudden  cardiac  failure. 
In  these  cases  the  sterilized  decoction,  which  may  be  of  the 
strength  of  5  grs.  to  a  fluid  ounce  and  must  be  filtered, 
should  be  injected  with  a  hypodermic  syringe  very  slowly 
into  a  superficial  vein,  or  even,  in  extreme  and  apparently- 
hopeless  cases,  into  the  heart  itself  through  the  thoracic 
wall.     [J.  M.  S.] 

5. — McKenzie  reports  case  of  a  boy,  aged  13  years,  who 
had  been  suffering  from  bleeding  at  the  nose  for  10  days. 
A  solution  of  suprarenal  gland  was  applied  locally  with 
immediate  success.  The  patient  presented  a  clear  history, 
hereditary  and  personal,  of  the  hemorrhagic  diathesis. 
[J.  M.  S.] 

6. — The  Anglo-Saxon  may  be  distinguished  as  the  sugar- 
eating  race.  The  characteristics  of  that  race  are  Its 
energy,  robustness  and  vigor,  its  pluck,  and  its  power  of 
endurance.  The  great  feature  in  the  metabolism  of  all 
carbohydrates  is  that  they  are  completely  oxidized  in  the 


c^rf,       The  Philadelphia-] 
yo"       Medical   Joukkal  J 


THE  LATEST  LITERATURE 


[Mat  is,   ISOl. 


body  into  water  and  carbonic  acid,  without  waste,  and  with- 
out residue.  Sugar  it  is  not  acted  upon  by  the  saliva,  ex- 
cept in  so  far  as  it  may  be  dissolved  or  further  diluted.  In 
the  stomach  it  is  partly  changed  into  dextrose  by  the 
gastric  juice  and,  to  a  small  extent,  absorbed.  The  greater 
part,  however,  passes  into  the  small  intestine,  where  it  is 
rapidly  changed  into  grape  sugar-dextrose.  It  is  then 
quickly  absorbed  into  the  portal  blood  and  is  carried  by  it 
to  the  liver,  where  it  is  stored  as  glycogen  in  the  hepatic 
cells.  This  glycogen  is  again  turned  into  grape  sugar  when 
it  is  required  for  use  and  in  this  form  undergoes  oxidation 
in  the  tissues,  splitting  up  into  CO=  and  H=0,  liberating 
kinetic  energy  in  the  process.  This  kinetic  energy  may  be 
utilized  either  for  the  production  of  heat  or  for  mechanical 
work.  Sugar  is  easily  digested  and  absorbed.  It  is  readily 
stored  up  as  glycogen,  forming  a  reserve  of  force-producing 
material.  It  is,  in  this  form,  readily  available  when  re- 
quired. It  becomes  completely  oxidized  without  waste  and 
without  residue.  It  can,  under  certain  circumstances,  be 
converted  into  fat,  in  which  form,  also,  it  can  be  stored 
up  in  the  body  and  so  be  capable  of  producing  heat  and 
force  in  the  future.  It  is  also  what  is  called  a  proteid- 
sparing  food,  that  is,  it  will  save  the  wear  and  tear  of  the 
proteids  of  the  body,  being  used  up  instead  of  these  sub- 
stances. Then,  again,  it  is  pleasant  to  take,  and  thus  acts 
as  a  relish,  stimulating  the  activity  of  the  digestive  pro- 
cesses. So,  it  would  seem  that  the  theoretical  considera- 
tions derived  from  a  study  of  the  chemical  and  physiologi- 
cal properties  of  sugar,  the  experiments  upon  animals  and 
upon  men  in  the  laboratories,  the  general  instinct  of  man- 
kind leading  it  to  increase  its  consumption  of  sugar  where- 
ever  it  can.  the  experience  of  different  races  in  widely 
different  climates,  the  energy  and  vitality  of  the  great 
sugar-eating  races,  the  experience  of  athletes,  and  lastly, 
the  experiments  conducted  upon  a  large  scale  in  the  Ger- 
man army  all  point  to  the  same  conclusion — all  tend  to 
show  the  great  value  of  sugar  as  an  article  of  diet.  If 
sugar  is  such  a  valuable  food  it  is  likely  to  be  of  value  in 
the  numerous  cases  in  which  nutrition  is  at  fault,  such  as 
simple  marasmus,  phthisis,  and  in  the  condition  of  malnu- 
trition in  those  who  inherit  a  predisposition  to  phthisis. 
For  growing  boys  and  girls  it  is  also  needed,  and  we  often 
find  their  nutrition  suffering  owing  to  a  popular  prejudice 
against  sugar.  For  the  aged  and  for  convalescents  it  is 
probably  one  of  the  best  of  foods.  Those  who  are  gouty  and 
fat  must  avoid  sugar,  but  those  who  are  gouty  and  thin, 
while  their  nitrogenous  food,  especially  red  meat,  soups, 
etc.,  must  be  strictly  limited,  may  use  the  sugars  and 
starches  without  much  fear.     [J.  M.  S.] 

7.- — Annett  and  Dutton  have  found  that  mosquitoes  of 
both  genera,  culex  and  anopheles,  hibernate  during  the 
winter  months  in  England.  It  seems  certain  that  not  only 
the  adults  but  also  the  larval  forms  provide  for  the  con- 
tinuation of  the  species  during  the  cold  weather.    [J.  M.  S.] 


6. 


LANCET. 

April   :nth.   1<>01. 

A  Clinical  Lecture  on  the  Sometimes  Successful  Treat- 
ment of  Cases  of  Apparently  Incurable  Blindness. 
CHARLES   BELL  TAYLOR. 

On  Two  Cases  Bearing  Upon  the  Question  of  Limita- 
tions of  Enterectoniy.     ARTHUR  E.  BARKER. 

On  Hour-Glass  Stomach:  with  List  of  Six  Cases  Operat- 
ed upon  by  the  Writer,  etc.  B.  G.  A.  MOYNI- 
HAN. 

Reversed  Pulsus  Paradoxus  due  to  Aneurysm  of  the 
Aortic  Arch.     JOHN  HAY. 

Case  of  a  Parasite — "Argas  (or  Ornithodorusl  MSgnlnl" 
Dug^s— in  Each  Ear.  J.  CHRISTIAN  SIMPSON  and 
E.    G.    WHEELER. 

A  Case  of  Belladonna  Poisoning:  Morphia  Used  as  an 
Antidote.PETER  D.  STRACHAN. 

Dermatitis  from  Arsenic  in  Stockings.  F.  W.  TUNNI- 
CLIFFE. 

Tetanus  Puerperalis.     KEDARXATH  DAS. 

Mercury  and  Iodide  of  Potassium  Internally  Given 
with  Pilocarpine  Hvpodermicallv  in  Disease  of  the 
Eyes.     G.  HERBERT  BURXHAM. 


1. — Charles  BhU  Taylor,  in  a  Clinical  lecture  on  the 
sometimes  successful  treatment  of  cases  of  apparently 
incurable  blindness,  calls  the  attention  of  the  profession 
to  electricity  as  a  therapeutic  measure  which  is  of  especial 
use  on  account  of  the  electrical  conductiWty  of  the  eye- 
ball. The  facility  with  which  a  current  can  be  passed 
through  the  eyeball  along  the  optic  nerve  to  the  brain 
makes  it  all  the  more  remarkable  why  electricity  is  not 
employed  more  frequently.  He  not  only  considers  elec- 
tricity of  value  in  cases  of  ocular  and  facial  palsies,  but 
even  considers  it  a  means  for  restoring  power  in  neuritis 
and  degenerative  changes  such  as  accompany  and  follow 
attacks  of  influenza,  diphtheria,  diabetes,  typhus,  typhoid, 
rheumatic,  and  other  fevers.  He  reports  a  case  of  blindness 
caused  by  optic  neuritis  in  which  sight  was  restored  under 
the  employment  of  a  powerful  galvanic  current.  He 
recommends  elaterin  in  detachment  of  the  retina.  He 
makes  a  strong  plea  for  vivisection.     [M.  R.  D.] 

2. — Arthur  E.  Barker  reports  first  the  case  of  a  woman 
5S  years  of  age  who  suffered  from  a  carcinoma  of  the 
transverse  colon  complicated  by  a  long-standing  diabetes. 
At  the  time  of  operation  the  urine  contained  B-G*^  of 
sugar.  At  the  operation  4%  inches  of  the  colon  were 
removed  and  an  end-to-end  anastomosis  made  by  means 
of  a  silk  suture.  The  patient  made  a  good  recovery  from 
the  operation,  and  after  the  use  of  codeine,  the  per  cent.  1 
of  sugar  decreased  rapidly.  The  abdominal  wall  suppurat-  f 
ed  and  there  was  discharged  from  it  a  slough  of  omentum 
which  had  been  found  adherent  to  the  growth  and  sep- 
arated at  the  time  of  operation.  There  was  for  a  while  a 
discharge  of  fecal  matter  from  the  wound,  but  this  subse- 
quently ceased,  and  the  wound  healed  satisfactorily. 
Barker  thinks  that  where  gentleness  is  used  in  the 
manipulation  of  the  tissues  and  careful  asepsis  observed 
that  many  operations  which  are  now  declined  might  be 
performed  in  the  presence  of  glycosuria.  The  second  case 
reported  is  that  of  a  feeble  woman  aged  76  years,  who 
suffered  from  strangulated  ventral  hernia.  In  this  case 
it  was  found  necessary  to  excise  5^2  feet  of  small  intestine, 
after  which  an  end-to-end  anastomosis  was  made.  The  pa- 
tient made  a  satisfactory  recovery,  the  wound  healing 
without  trouble.  Subsequent  to  the  operation  there  was 
some  slight  diarrhea,  which  was  easily  controlled.  Bar- 
ker thinks  that  it  is  oftentimes  better  to  remove  a  stran- 
gulated portion  of  bowel,  the  vitality  of  which  is  question- 
able, rather  than  to  return  it  with  the  possibility  of  sub- 
sequent palsy,  perforation  or  adhesion.     [J.  H.  G.] 

3. — B.  G.  A.  Moynihan  discusses  first  a  case  of  hour-glass 
constriction  of  the  stomach,  and  expresses  very  strongly 
the  opinion  that  this  condition  is  rarely,  if  ever,  congenital. 
Acquired  hour-glass  stomach  is  attributed  to  four  causes: 
first,  perigrastic  adhesions:  second,  ulcer  with  local  per- 
foration and  anchoring  to  the  anterior  abdominal  wall: 
third,  circular  ulcer  with  cicatrical  constriction:  and  indura- 
tion and  fourth. cancer.  The  usual  s>Tnptoms  of  this  condition 
are  those  of  a  dilated  stomach  supervening  upon  chronic  ul- 
cer of  the  stomach.  Two  signs  which  are  of  assistance  here 
are.  first,  the  fact  that  upon  introducing  fluid  into  the 
stomach  it  seems  to  disappear  altogether  and  does  not 
return  through  the  tube.  This,  of  course,  is  explained  by 
the  passage  of  the  fluid  into  the  second  compartment. 
Second,  that  upon  washing  out  the  stomach  until  the 
fluid  returns  clear,  a  sudden  unlooked-for  gush  of  foul  fluid 
occurs:  or  if.  after  apparently  thoroughly  cleansing  the 
stomach,  the  tube  is  again  introduced,  then  through  it  may 
pass  an  amount  of  foul  fluid  due  to  reflux  of  the  contents 
of  the  pyloric  cavity  through  the  stricture..  The  author 
has  also  observed  that  upon  distending  the  stomach  with 
CO',  the  bubbling  and  gushing  of  fluid  through  a  narrow 
chink  could  be  heard  with  the  stethoscope.  The  symp- 
toms, of  course,  are  influenced  by  the  situation  of  the  con- 
striction. The  operation  for  the  relief  of  this  condition 
will  depend  upon  the  condition  found  at  the  time  of  op- 
eration, and  will  consist  in  gastroplasty,  gastro-gastros- 
tomy.  gastro-enterostomy  and  partial  gastrectomy.  While 
the  process  of  ulceration  is  still  active  it  is  unwise  to  per- 
form gastroplasty,  but  if  the  ulcer  has  healed  entirely  and 
there  are  no  adhesions,  the  operation  can  be  done  with  the 
expectation  of  recurrence.  When  the  condition  is  due 
to  cancer  of  course  a  partial  gastrectomy  must  he  per- 
formed.    [J.  H.  G.l 

4. — Hay  reports  a  case  of  aneurysm  of  the  aortic  a^t^b 
in  which  the  pulse  of  the  carotids  and  right  radial  arter- 
ies had  the   reversed  character  of  the   pulsus   paradoxus. 


Mat  18,  1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia       01-7 
L Medical   Journal         yoi 


There  was  a  very  marked  diminution  in  the  volume  of  the 
pulse  during  expiration,  and  with  the  respiratory  varia- 
tions there  was  present  a  definite  anacrotic  wave.  Upon 
post-mortem  examination  an  aneurism  was  found  which 
involved  chiefly  the  posterior  portion  of  the  aorta  in  the 
region  of  the  transverse  arch.  The  left  carotid  and  in- 
nominate arteries  sprang  from  the  anterior  surface  of  the 
arch  instead  of  from  the  convexity,  on  occount  of  the 
distention  of  the  aorta.  With  each  expiratory  excurses 
these  blood  vessels  were  compressed  against  the  bony 
thorax.     [F.  J.  K.] 

5. — Simpson  reports  a  case,  in  which  a  live  animal  para- 
site, a  species  of  tick  (argas  mggninl).  existed  in  each 
ear  for  fully  two  months  without  producing  local  or  gen- 
eral sj-mptoms  sufficiently  severe  or  annoying  to  necessi- 
tate surgical  examination  during  this  time.     [F.  J.  K.] 

6. — Stracham  reports  a  case  of  belladonna  poisoning  in 
which  morphia  was  used  as  the  antidote.  The  case  was 
that  of  a  boy,  five  years  of  age.  who  had  been  given  a 
large  tablespoonful  of  glycerine  of  belladonna.  The  sym- 
ptoms of  belladonna  poisoning  developed  rapidly.  The 
sulphate  of  morphia  was  given  hypodermatically  on  sev- 
eral occasions  and  recovery  followed.  The  case  is  of 
particular  interest  in  view  of  the  fact  that  the  child  showed 
a  remarkable  tolerance  for  belladonna  and  that  morphia 
was  an  effective  antidote.     [F.  J.  K.] 

7. — Tunnicliffe  and  Rosenhein  give  an  account  of  two 
cases  of  dermitis  from  arsenic  in  stockings.     [F.  J.  K.] 

8. — Das  discusses  tetanus  puerperal  is  and  states  that  on 
account  of  the  rarity  of  this  almost  fatal  complication  of 
the  puerperal  state,  he  feels  that  a  report  of  a  case,  suc- 
cessfully treated,  warrants  publication.  The  case  was 
that  of  a  Hindoo  female.  2S  years  of  age,  who  was  deliv- 
ered on  July  20,  1900.  of  a  full-term  child.  The  child  died 
on  the  10th  day  of  trismus  neonatorum.  On  July  30th  the 
mother  developed  stiffness  of  the  muscles  of  the  neck  and 
jaw.  On  August  3  symptoms  of  tetanus  were  well  de- 
fined. There  was  opisthotonos,  the  jaw  was  locked,  the 
temperature  was  100.2'F..  and  the  pulse  rate  120  per  min- 
ute. An  enema  of  soap  and  water  was  immediately  given 
and  followed  by  a  rectal  injection  of  40  grains  of  chloral 
hydrate.  Five  grains  of  calomel  were  administered  by 
mouth  and  a  uterine  douche  of  bichloride  of  mercury  was  giv 
en  at  once.  During  the  course  of  her  illness  she  was  kept 
under  the  influence  of  chloral,  and  apomorphin  was  ad- 
ministered hypodermatically.  On  several  occasions  intra- 
cellular injections  of  normal  salt  solution  were  employed 
so  as  to  aid  in  the  elimination  of  the  toxin.  The  spasms 
subsided  in  about  six  weeks.     [F.  J.  K.] 

9. — Bernhan  highly  recommends  the  use  of  mercury  and 
iodide  of  potassium  internally,  given  with  pilocarpin  hypo- 
dermatically in  disease  of  the  eyes.  This  treatment  was 
used  successfully  in  a  case  of  sclero-keratitis  and  in  a  case 
of  acute  sympathetic  ophthalmia.     [F.  J.  K.] 


MEDICAL   RECORD. 
Hay   11.    1901. 

1.  The   Toxic    Oriain    of   Neurasthenia   and    Melancholia. 

M.  ALLEN  STARR. 

2.  Potain's  Simple  and  Accurate  Method  of  the  Percussion 

of    the     Heart     (with     Post-mortem     Verifications). 
GEORGE  M.  CON\'ERSE. 

3.  The  Treatment  of  Pneumonia.  Including  the  Hypoder- 

mic Injection  of  Saline  Solution.     F.  NEUHOFF. 

4.  Syphilis  in  the  Well-to-do.     J.  A.  McDOXALD. 

5.  Subarachnoid  Spinal  Cocainization  as  a  Means  of  In- 

ducing Surgical  Anesthesia.    E.  N.  LIELL. 

1. — M.  Allen  Starr  describes  a  type  of  neurasthenia  and 
melancholia  of  toxic  origin,  the  chief  symptoms  of  which 
are  headache,  dull  pressure  in  the  head  and  back  of  the 
neck,  sensations  of  fulness  in  the  head,  with  inability  to 
concentrate  the  attention,  of  temper,  manifest  irregularities 
of  the  circulation,  shown  by  cold  extremities,  and  by 
frequent  flushings  and  burnings.  There  are  general  dis- 
orders of  digestion,  frequently  with  eructations  of  gas,  and 
irregular  and  offensive  stools.  The  urine  at  times  con- 
tains a  large  quantity  of  indican  or  indoxyl.  It  is  usually 
irregular  in  quantity,  of  high  color  and  high  specific  grav- 
ity, but  may  be  the  reverse.  A  mild  state  of  melancholia  is 
usually  associated  with  the  neurasthenia.  Patients  in  this 
condition  present  cvcles  of  depression  and  well  being. 
Starr  believes  that  the  cause  resides  in  some  toxic  agent 


which  accumulates  in  the  blood  during  the  period  of  sleep 
which  reaches  the  point  of  irritation  early  in  the  morning, 
which  is  counteracted  by  the  activity  of  the  day,  and  hence 
is  less  intense  in  its  action  towards  the  afternoon.  He 
theorizes  that  this  toxic  agent  is  manufactured  either  in 
the  intestines  or  the  stomach.  As  to  treatment  the  diet 
should  be  carefully  directed,  and  the  alimentary  tract 
treated  as  indicated.     Baths  and  exercises  are  of  value. 

[T.  L.  C] 
2. — George  M.  Converse  advocates  Potain's  simple  and 
accurate  method  of  the  percussion  of  the  heart  and  pre- 
sents postmortem  verifications.  The  percussion  stroke 
must  be  moderate  in  force,  precise  and  single.  The  per- 
cussion must  be  concentric,  that  is,  must  proceed  from 
points  situated  at  a  little  distance  from  the  heart,  some 
3  or  4  cm.  toward  its  periphery.  On  reaching  the  border 
of  the  heart  there  occurs  a  slight  difference  in  the  intensity 
of  the  sound,  and  what  is  most  important,  a  sudden  rise 
in  pitch.  Here  the  percussion  stops.  Potain  makes  a 
tracing  of  the  projection  of  the  heart  on  the  chest  wall 
which  is  mapped  out  by  three  lines  and  three  angles.  The 
first  corresponds  to  the  curved  border  of  the  left  ventri- 
cle, and  forms  the  left  boundary  of  the  dulness.  The  sec- 
ond line  forms  the  right  line  of  the  dulness  and  corres- 
ponds to  the  right  border  of  the  right  auricle,  and  to  part 
of  the  ascending  aorta.  The  third  line  should  correspond 
to  the  curved  border  of  the  right  ventricle,  but  as  this  can- 
not be  distinguished,  usually  by  digital  percussion,  a 
straight  line  is  drawn  from  the  upper  border  of  the  liver 
at  its  point  of  junction  with  the  right  border  to  the  apex. 
Of  the  three  angles,  the  right  inferior  has  already  been 
determined,  since  it  is  formed  by  the  junction  of  the  right 
border  with  the  lines  of  the  liver.  The  left  inferior  angle 
is  rounded  and  corresponds  to  the  apex.  The  superior  an- 
gle, also  rounded,  corresponds  to  the  point  at  which  the 
aorta  leaves  the  immediate  vicinity  of  the  sternum  to  take 
its  course  backward.  With  these  attentions  it  will  be 
found  that  these  tracings  may  be  verified  exactly  by  the 
post  mortem  findings.     [T.  L.  C] 

3. — F.  Xeuhoff  discusses  the  treatment  of  pneumonia 
including  the  hypodermic  injection  of  saline  solution.  As 
to  the  latter  in  acute  croupous  pneumonia,  he  believes  it  la 
a  useful  adjunct  in  selected  cases.  It  acts  as  a  powerful 
heart  stimulant  when  other  remedies  can  no  longer  sus- 
tain the  flagging  circulation.  It  increases  the  secretions, 
moistens  the  tongue  and  throat  as  well  as  the  skin,  and 
lessens  delirium.  It  is  contraindicated  in  pulmonary  ede- 
ma.    [T.  L.  C] 

4. — J.  A.  McDonald  contributes  a  paper  on  syphilis  in 
the  well-to-do.  In  145  adults  with  acquired  syphilis  he  di- 
vided the  cases  in  the  following  manner.  1st.  (and  to 
which  65'^c  belong),  were  those  having  mild  transitory- 
lesions  which  left  no  trace  when  they  had  disappeared. 
The  2d  class  included  26%  of  the  cases,  were  those  show- 
ing destructive  lesions  of  any  sort  whatever,  from  the 
pustular  eruptions  which  left  scars,  to  the  necrosis  of 
bones.  In  the  3d  class,  numbering  6'~r  of  the  cases,  were 
included  those  which  exhibited  considerable  severity  for 
a  time,  but  which  finally  cleared  up  completely,  leaving 
no  trace.  He  concludes  that  the  prognosis  of  syphilis 
should  not  alarm  us,  especially  in  the  well-to-do,  in  whom 
it  seems  particularly  amenable  to  treatment.  '  [T.  L.  C] 

5. — E.  X.  Liell  presents  a  contribution  to  the  study 
of  subarachnoid  spina!  cocainization  as  a  means  to  inducing 
surgical  anesthesia.  He  mentions  the  usual  causes  of 
failure  which  may  be  due  to  inert  cocain  solutions,  idio- 
cyncrasv  to  the  drug,  faulty  technique,  or  too  small  a 
quantitv  of  the  drug  employed.  The  ill  effects  of  the  treat- 
ment are  nausea  and  vomiting,  headache,  increased  tem- 
perature, increased  pulse  rate,  and  sometimes  vertigo, 
pallor  and  prostration.  He  believes  that  this  method  has 
passed  the  experimental  stage,  and  that  we  are  justified 
in  entertaining  the  hope  that  it  will  have  its  field  for 
practical  usefulness  along  with  ether,  chloroform  and  ni- 
trous oxide.     [T.  L,  C] 


NEW  YORK  MEDICAL  JOURNAL. 
Hay  11,  1901.    (Vol.  LXXIII,  No.  19.) 

1.  Atonia  Gastrica  and  a  New  Method  of  Treatment.    A. 

ROSE. 

2.  What    Constitutes    Sexual    Intemperance.     W.    J.    S. 

STEWART. 

3.  The    Patholog>-.    Diagnosis,    Special    Prophylaxis    and 


fjrH       The  Philadelphia"! 
Vo  Medical   Journal  J 


THE  LATEST  LITERATURE 


[Mat  18,   1901. 


Treatment   of  Tuberculosis   of  the   Skin.    JOHN  A. 
FORDYCE. 

4.  Primary    Chancre    of   the    Septum    of   the    Nose.      W. 

FREUDENTHAL. 

5.  Syphilis  of  the  Nervous  System.    B.  ONUF  (ONUFRO- 

WICZ). 

6.  Acute  Strangulated  Femoral  Hernia  on  a  Puerto  Rican 

Hillside.     P.  R.  EGAN. 

3. — Fordyce's  treatment  for  tuberculosis  of  the  skin 
is  as  follows:  (I)  Depends  upon  the  form:  (2)  The  ex- 
tent of  tissue  involved:  (3)  lx)cality  implicated.  In  tuber- 
culous ulcerations  about  the  orifices,  usually  preceded 
by  grave  pulmonary  or  intestinal  tuberculosis,  in  most 
cases  local  remedies  which  alleviate  without  holding  out 
any  prospect  of  permanent  cure  must  be  used.  Iodoform 
is  the  best,  as  it  relieves  pain  and  promotes  healing.  A 
more  radical  remedy  is  the  Paquelin  cautery  under  local 
anesthesia.  Anatomical  tubercle  and  other  forms  of  pa 
pillary  tuberculosis  of  the  extremities  are  best  removed 
by  the  curette  after  local  anesthesia.  Total  excision  of 
the  patch  with  skin  grafting  is  also  recommended,  es- 
pecially in  lupus  of  the  face.     [T.  M.  T.] 

4. — Freudenthal  states  in  his  article  on  primary  chancre 
of  septum  of  the  nose  that  it  is  not  always  essential  that 
a  lesion  of  the  epithelial  layer  be  necessarily  present  be 
fore  a  syphilitic  infection  can  take  place.  Most  of  the 
cases  of  extragenital  chancres  occur  in  and  around  the 
mouth  and  in  many  instances  a  lesion  has  not  been  found. 
It  is  well  known  that  the  virus  of  syphilis  is  one  of  the 
most  energetic  and  certain  of  animal  contagions,  and 
exerts  its  power  whenever  and  wherever  it  can  find  a  suit- 
able opportunity  differing  from  tuberculosis.  The  condi- 
tion is  mostly  transmitted  by  kissing  and  through  drink- 
ing cups,  and  at  the  present  day  is  not  very  frequent. 

[T.  M.  T.] 

5. — Onuf  gives  the  special  characteristics  of  cerebro- 
spinal syphilis  to  be  paralysis  of  single  cranial  nerves, 
especially  that  of  the  ocular  nerve.  Recently  Sachs  has 
pointed  out  the  irregular  manner  of  contraction  of  the 
pupil,  in  cases  of  cerebrospinal  syphilis,  and  believes  it  to 
be  characteristic.  The  author  says  that  there  is  no  doubt 
that  it  is  frequently  met  with  in  this  disease,  but  is 
also  observed  quite  commonly  in  general  progressive 
paralysis  and  sometimes  locomotor  ataxia.  He  does  not 
entirely  agree  with  Sachs,  and  thinks  the  irregular  shape 
of  pupil  is  not  so  typical  as  the  very  contracted  or  pin 
head  pupil  which  is  more  characteristic  of  syphilis,  than 
the  irregularly  shaped  pupil.  Vertigo  is  another  symptom 
■which  should  put  one  on  one's  guard  for  cerebral  syphilis, 
although  it  occurs  In  other  diseases.     [T.  M.  T.] 


MEDICAL    NEWS. 


Mail  11,  ]'-WI.     (Vol.   LXXVIII,  No.  19.) 

1.  Practical  Food  Prescribing.     FLOYD,  M.  CRANDALI.. 

2.  Studies   in   the   Bacteriology   of   Typhoid    Fever,   with 

Special  Reference  to  its  Pathology,  Diagnosis  and 
Hygiene.      PHILIP   HANSON   HISS,   JR. 

3.  Restoration  of  Useful  Vision  in  a  Complicated  Case  of 

Acute  Inflammatory  Glaucoma  of  Ten  Days'  Duration 
with  Visual  Acuity  Reduced  to  the  Perception  of 
Light.     C.   A.   VEASEY. 

4.  Rupture   of  the   Right   Kidney;    Nephrectomv;    Recov- 

ery. G.  R.  TROWBRIDGE. 
1. — Crandall  classifies  the  knowledge  required  by  prac- 
titioners to  become  good  infant-feeders  as  follows:  (1)  A 
knowledge  of  breast  milk:  (2)  Aritificial  foods,  their  chem- 
istry and  physical  composition:  (3)  Good  cow's  milk  an-1 
bow  it  is  to  be  secured:  (4)  The  differences  between  cow's 
milk  and  breast  milk:  (.5)  The  modifying  or 
adapting  of  cow's  milk  to  each  individual  infant:  (6)  The 
character  of  the  food  required  in  health  and  disease.  Ho 
also  gives  two  tables,  one  explaining  the  proportion  of  fats 
and  proteids  in  the  upper  nine  or  fifteen  ounces  of  milk 
;and  cream: 

7  ounces  top  milk  contain  16  per  cent.fat,  4  per  cent.proteld 

8  ' "  14  "  "  "  4  "  "  " 

9  «  <«        "  *'  ]^2  *'  "  **  4  *'  *•  " 

11       ' "  10  "  "  "  4  "  "  " 

15  "         "        "  "  08  "  "  "  4  "  "  " 

20       ' "  06  "  "  "  4  "  "  " 


and  a  table'  when  the  requisite  per  cent,  of  fats  and  pro- 
teids are  established  for  the  amount  of  sugar  required— 
1  part  sugar  to  20  parts  food  adds  5  per  cent. 

"  "  *'     "-  •'  '■  n         A       it         a 


25 
33 
50 


3 

2 


— [T.M.T.] 


2. — Hiss  gives  the  following  conclusions  in  his  article  on 
typhoid   fever,   dividing   them   into   general   and   hygienic. 
Under    general    conclusions,    he    gives:     (1)    During    the 
course  of  typhoid  fever,  usually  after  the  first  week,  ty- 
phoid  bacilli  can   frequently  be  obtained  from  the  blood, 
spleen,  rose-spots,  urine,  and  feces,  and  in  rarer  instances. 
it   is   claimed,    from   the   secretions   or   exudations   of  the 
mouth,   throat   and   lungs.     After   death   the   bacilli   have 
been  demonstrated  in  these  and  other  locations  and  lesions, 
such  as  the  lymphatic  tissues  of  the  intestine,  the  mesen- 
teric glands,  bone-marrow,  lungs,  liver,  kidneys,  gall-blad- 
der, etc.;   (2)  The  bacilli,  as  far  as  can  be  determined  from 
various  observations,  do  not  thrive  or  even  survive  long 
in    the    circulating    blood.      They    are,    however,    able    to 
live  and  multiply  at  some,  at  least,  of  the  points  at  which 
they  are  deposited  by  the  blood  and  lymph,  thus  forming 
bacterial  foci  within  the  tissues:    (3)   Morphological  exam- 
inations of  tissue  sections  to  determine  the  relation  of  the 
bacilli  to  the   lesions   of  typhoid   fever  have   in   most   in- 
stances proved  unsatisfactory  and  have  given  inconstant 
results.      Some    of   the    lesions,    without    aoubt.    occur    at 
points  remote  from  the  bacilli.     On  the  other  hand,  it  is 
probable   that  the   bacilli   are   intimately   associated   with 
many  of  the  lesions,  since  wherever  the  bacilli,  after  gain- 
ing access  to  the  tissues  and  fluids  of  the  body,  find  lodg- 
ment and  establish  foci,  the  various  products  of  bacterial 
metabolism   and   degeneration  are  thus   concentrated   and 
doubtless  give  rise  to  lesions  at  these  points.     Moreover, 
it  is  not  unlikely  that  certain  lesions  occur  only  at  points 
of  localization  of  the  bacilli:   (4)  Typhoid  fever,  therefore, 
is  an  infectious  disease,  in  which  a  wide  dissemination  and 
multiple  localizations  of  the  bacilli  are  frequently  demon- 
strable both  during  life  and  after  death.    During  the  course 
of   the   disease   various   tissue   changes   take   place,   some 
necrotic,  others  hyperplastic.     Some  of  these  lesions  are 
at    points    remote    from    the    inciting    organisms:    certain 
facts,  however,  point  strongly  to  a  close  association  of  the 
bacilli   with   some  of  the  more  characteristic  lesions,   es- 
pecially  those  of  the   lymphatic  tissues:    (5)    There  is   a 
close   connection,   in   time   at   least,    between   the   appear- 
ance in,  and   disappearance  from  the  intestinal   contents, 
of  the  typhoid  bacilli  and  the  appearance  and  repair  of  the 
intestinal    ulcers.      The    organisms    are   only    very    rarely 
demonstrable   in   the   stools   before  the   first   days   of   the 
second    week   and    disappear   with   the   fall   of   the   fever. 
During  the  period  at  which  intestinal  tissue  destruction  is 
most   active   they   can   be   isolated   with   great   regularity. 
When  continuously  absent  in  typical   cases,  this   may   be 
looked  upon  as  indicating  a  probable  scarcity  or  absence 
of  intestinal  lesions:   (6)  The  urine  in  a  certain  percentage 
of  cases  contains  the  bacilli,  though  not  often  before  the 
end    of   the   second   week.      The    organisms    may    not   ap- 
pear  until   very   late   in   the   disease   or   during   convales- 
cence.    They  may  persist  for  days,  weeks,  and  it  has  been 
claimed,  for  months,  and  are  generally  associated  with  al- 
buminuria. '  Under    hygienic:     (1)    The   urine    of   typhoid 
fever  patients  should  always  be  disinfected.     From  a  hy- 
gienic standpoint  bacteriological  examination  of  the  urine 
of  patients  convalescing  from  typhoid  fever  is  important 
and  should  never  be  omitted  before  patients  are  allowed  to 
go  at  large,  so  that  proper  precautions  may  be  taken  to 
guard  against  the  dissemination  of  typhoid  bacilli  by  the 
urine.     This  is  an  often  neglected  source  of  infection  that 
should  be  seriously  considered  in  the  hygiene  of  typhoid 
fever:    (2)   Feces,  of  course,  should   be  disinfected   at  all 
stages   of   the   disease,   but   the   organisms   being   present 
generally  only  from  the  beginning  of  the  second  week  to 
the  fall  of  the  fever  and   the  patient  during  this  period 
usually  being  confined   to  bed.  the  feces  are  not   such  a 
source  of  infection  to  the  community  at  large  as  the  urine: 
(31    The  bacilli  may.  on   account  of  the  lung  and  throat 
lesions,  be  present  in  the  mouth  of  those  suffering  from 
typhoid   fever,   hence,   the  expectoration   should   be  disin- 
fected,  as   well   as   all   eating  utensils,   etc..   used   by   the 
patients.     [T.  M.  T.] 

4. — Trowbridge  gives  in  rupture  of  the  kidney  the  signs 
And  symptoms  as  follows:  A  history  of  violence  over  the 
organ:   hemorrhage  per  urethra:   a  sense  of  fulness  about 


May  18,  1901] 


THE  LATEST  LITERATURE 


TTHE     rniLADEI-PHIA  n  CQ 

L Medical   Journal         Joy 


the  kidney,  often  discoverable  by  palpation:  pain  extending 
into  tlie  groin  and  testicle  of  the  same  side;  weal^  pulse: 
pallor  of  mucous  surfaces  and  skin,  and  signs  of  collapse. 
All  these  signs  vary  with  the  extent  of  the  injury,  al- 
thoiigh  he  does  not  think  signs  and  symptoms  should 
always  be  taken  as  an  Indication  of  the  extent  of  the  rup- 
ture. The  hemorrhage  may  be  severe,  the  blood  clotting 
in  the  bladder  and  blocking  the  urethra,  or  it  may  be  so 
slow,  that  in  the  absence  of  an  exploratory  operation  the 
surgeon  is  misled,  and  sepsis  and  peritonitis  result  from 
too  long  delayed  operation.     [T.  M.  T.] 


.2. 
3. 


A. 


BOSTON    MEDICAL  AND  SURGICAL   JOURNAL. 
Mail  9.  I'JOl.     (Vol.  CXLIV,  No.  19.) 

Some  Reported  Cases  of  Typhoid  Fever  Attributed  to 
Contaminated  Oysters,  with  Certain  Pacts  Con- 
cerning this  Means  of  Infection.  CHARLES  HAR- 
RINGTON. 

Experience  with  the  Widal  Reaction  in  Typhoid  Fever. 
CHARLES  P.  WITHINGTON. 

The  Widal  Reaction  in  Typhoid  Fever.  GEORGE  B. 
SHATTUCK. 

Means  of  Infection  in  Typhoid  Fever.  E.  N.  WHIT- 
TIER. 
5.  Early  Diagnosis  of  Typhoid  Fever  by  Isolation  of  Ba- 
cillus Typhosus  from  Stools:  Conclusions  of  Dr.  L. 
Remy  Based  on  the  Use  of  his  Asparagin-Lactose- 
Carbol  Gelatine.  CALVIN  G.  PAGE. 
«.     The  Fevers  of  the  Philippines.     JOSEPH  J.  CURRY. 

1. — Harrington's  article  is  a  review  of  the  literature  con- 
cerning the  transmission  of  typhoid  fever  by  eating  raw 
oysters. —  [J.     M.     S.] 

2. — The  general  experience  of  the  past  4  or  5  years 
tends  to  confirm  the  favorable  impression  of  the  value  of 
the  Widal  reaction  as  a  diagnostic  sign  in  typhoid  fever. 
The  usual  95%  of  successful  results  indicates,  certainly, 
a  valuable  diagnostic  aid.  The  limitations  of  the  test, 
however,  as  to  the  time  of  its  first  appearance,  which  is 
rarely  before  the  sixth  day  and  often  not  before  the  ninth 
•or  tenth,  are  such  as  to  deprive  it  of  the  value  that  one 
■would  like  to  attach  to  it  for  early  diagnosis.  Withington 
gives  the  results  of  the  application  of  this  test  to  the 
cases  of  typhoid  fever  in  the  Boston  City  Hospital  for  •; 
months.  During  this  period  there  were  253  cases  of  typhoid 
fever  in  the  institution  and  of  these  there  were  4%  of 
failures.  The  author  excludes  6  cases  in  which  the  evi- 
dence of  typhoid  fever  is  not  conclusive,  but  in  which 
the  diagnosis  of  typhoid  fever  was  made.  If  these  cases 
are  included  there  will  be  259  cases  with  failures  in  a  little 
over  6%.     [.I.  M.  S.] 

3. — Shattuck  refers  to  the  paper  of  Withington,  No.  2, 
as  confirmatory  of  conclusions  reached  by  him,  in  1S97,  in 
a  paper  read  before  the  Association  of  American  Physi- 
cians. In  his  recent  service  at  the  Boston  City  Hospital 
there  were  62  cases  of  typhoid  fever,  clinically,  of  which 
3  failed  to  respond  to  the  Widal  test.     [J.  M.  S.] 

4. — The  typhoid  of  city  origin  may  be  atypical  and  puz- 
zling; care  and  restrictions  may  be  as  prolonged,  but  it 
is  without  the  terror,  the  destructiveness,  the  lethal  drift 
characteristic  of  country  typhoids.  Whittier  refers,  in  his 
paper,  to  an  epidemic  of  typhoid  fever  at  Martion,  Mass., 
due  to  eating  raw  oysters.     [J.  M.  S.] 

5. — Page  refers  to  the  method  of  Remy,  which  was  pub- 
lished in  At\n(tldi  de  rinstitiit  PnstPiir.  Vol.  XIV,  1900,  and 
Vol.  XV,  1901,  for  the  separation  of  the  bacillus  typhosus 
from  the  stools  and  quotes  his  results.     [J.  M.  S.] 

6. — Some  of  the  typhoid  fever  seen  in  the  American 
troops  in  the  Philippines  may  have  been  imported  to 
Manila  from  San  Francisco.  But  the  great  source  of 
sickness  among  our  soldiers  was  the  old  Spanish  camp- 
grounds that  our  troops  were  obliged  to  occupy  for  mili- 
tary reasons.  Malarial  fever  and  dysentery  were  promi- 
nent features  among  the  soldiers  that  were  encamped  on 
these  old  Spanish  camp-grounds.  At  the  First  Reserve 
Hospital  there  were  fi53  cases  of  typhoid  fever  and  of 
this  number  15%  died,  a  remarkable  result  for  a  tropical 
country  and  a  high  recommendation  for  the  Medical  De- 
partment of  the  Army.  The  immediate  cause  of  death  in 
over  1-3  of  these  cases  was  intestinal  hemorrhage  or  per- 
foration. The  death  rate  was  higher  after  the  Philippine 
insurrection  than  before  the  outbreak,  this  is  to  be  ex- 
plained by  the  fact  that  the  soldiers  infected  during  the 


existence  of  hostilities  were  more  fatigued  and  had  less 
resisting  power.  Curry  has  seen  16  cases  of  Malta  fever 
among  the  soldiers  in  the  Philippines.  Compared  with  other 
tropical  countries  the  malarial  fevers  of  the  Philippines  are 
not  severe.  However,  out  of  20,000  cases  admitted  to  the 
First  Reserve  Hospital,  23%  were  cases  of  malarial  fever. 
The  types  met  with  are  the  same  as  those  seen  in  other 
tropical  countries.  In  the  Philippines,  however,  the  ter- 
tian type  was  much  more  common  than  the  estivoautum- 
nal  variety.  Out  of  1,187  blood  examinations  malarial  par- 
asites were  found  in  but  223.  This  is  accounted  for  by  the 
fact  that  as  soon  as  an  American  soldier  begins  to  have 
fever  he  begins  to  take  quinine.  The  Anopheles  are  very 
common  in  the  Philippines  where  malaria  is  common.' 
There  are  many  fevers  of  obscure  origin  met  with  in  the 
Philippines  which  are  being  studied  by  the  Army  sur- 
geons. It  is  possible  that  many  of  these  will  prove  to  be 
cases  of  Malta  fever.  There  is  a  class  of  cases  charac- 
terized by  jaundice  and  enlargement  of  the  liver  that  are 
known  as  hepatic  fever.  In  a  fatal  case  of  this  type  there 
were  multiple  abscesses  of  the  liver  without  previous  dys- 
entery. There  was  an  acute  duodenitis  and  the  liver  in- 
fection may  have  come  through  the  bile  ducts.  [J.  M.  S.] 


JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION. 

May  11. 

1.  The  Diagnosis  and  Treatment  of  Injuries  of  the  Head. 

JAMBS  H.  DUNN. 

2.  The  Relation  and  Position  of  Pelvic  Organs;  Examina- 

tion of  Patients.     FRANKLIN  H.  MARTIN. 

3.  Four  Cases  of  Calculi  Impacted  in  the  Ureter.    Nephro- 

Ureterectomy.  Abdominal  Uretero-Lithotomy,  Va- 
ginal Uretero-Lithotomy.     B.  R.  SCHENCK. 

4.  The  Differential  Diagnosis  of  Ectopic  Pregnancy,  with 

Especial  Reference  Between  it  and  that  of  Early 
Uterine   Abortion.     HIRAM   N.   VINEBERG. 

5.  I.  Union  Following  Pathological  Fracture  of  the  Femur 

Due  to  Secondary  Carcinoma.  II.  Spontaneous  Dis- 
appearance of  Carcinoma  of  the  Lip.  LEONARD 
FREEMAN. 
G.  The  Rational  Use  and  Limitations  of  Therapeutic  Meas- 
ures Intended  to  Promote  the  Absorption  of  Ex- 
udates within  the  Eyeball.  Medical  Measures.  RAN- 
DOLPH BRUNSON. 

7.  Suppurating  Mastoditis  with  the  Report  of  Cases.    Sup- 

purating Ostitis  Media,  Both  Ears;  Suppurating  Mas- 
toditis on  the  Right  Side,  Abscess  Extending  into  the 
Deeper  Tissues  of  the  Neck,  Extradural  abscess.  J. 
H.  BRYAN. 

8.  Remarks   on   the   After-Effects   of   Operations   for   the 

Removal  of  Adenoid  Tissue  at  the  Vault  of  the 
Pharynx.     E.  L.  SHURLY. 

9.  Medical  Treatment  of  Actinomycosis.  J.  L.  SAW\EKS. 

10.  Tropical  Abscess  of  the  Liver.     B.  F.  ROBINSON. 

11.  The  Prevention  of  Insanity.     DANIEL  R.   BROWER. 

12.  When    Should    we    Operate    in    Appendicitis.     DOUG- 

LAS C.  MARIARTA. 

13.  Operating  under  X-Rays.     J.  P.  BALDWIN. 

1. — James  H.  Dunn  goes  very  carefully  into  the  diagnosis 
and  treatment  of  injuries  of  the  head.  He  first  of  all  lays 
great  stress  on  the  careful  examination  of  the  head  after 
the  hair  has  been  removed.  Shaving  of  the  head  not  only 
enables  the  surgeon  to  observe  the  injury  to  the  part,  but 
also  to  observe  and  note  the  natural  irregularities  of  the 
skull  which  otherwise  might  later  be  made  the  basis  of  a 
claim  for  damages.  A  hematoma  with  a  hard  rim  about  it 
is  not  infrequently  mistaken  for  a  fracture,  but  if  steady 
pressure  is  made  with  the  finger  over  this  rim  it  will  be 
found  that  an  impression  can  be  made  in  it,  which  would 
not  be  true  if  it  were  bone.  He  urges  upon  the  general  prac- 
titioner the  great  necessity  of  cleansing  the  nasal,  oral,  and 
aural  cavities  in  all  cases  where  a  fracture  of  the  base  of 
the  skull  is  diagnosed  or  suspected.  Tne  careful  keeping 
of  notes,  both  as  to  history  and  as  to  progress  Is  advised 
and  the  giving  of  a  most  guarded  prognosis.  Excepting 
where  symptoms  of  compression  are  marked   or  there  is 


nfir,       The  Philadelphia"! 
y  Medical   Journal  J 


THE  LATEST  LITERATURE 


[Mat   1«.   190L 


hemorrhage  which  demands  immediate  operation,  it  is 
better  not  to  operate  at  once  in  fractures  of  the  vault  but 
to  wait  until  a  thorough  preparation  of  patient,  instru- 
ments, etc.,  can  be  made,  as  asepsis  is  most  important  in 
these  cases.  Where  depression  is  suspected  it  is  better  to 
make  an  exploratory  incision  rather  than  to  remain  in 
doubt.  Dunn  is  of  the  opinion  that  it  is  better  where 
symptoms  would  indicate  a  lesion  of  the  brain  on  the  side 
opposite  that  of  injury,  to  trephine  first  at  the  point  in- 
dicated by  focal  symptoms  and  then  at  the  site  of  injury 
only  in  case  of  clear  indication.  The  symptoms  and  treat- 
ment of  rupture  of  the  middle  meningeal  artery  are  next 
detailed.  The  author  expresses  the  opinion  strongly  that 
many  more  cases  of  fracture  of  the  base  of  the  skull  re- 
cover than  is  generally  supposed.  The  deaths  occurring 
late  from  this  condition  are  usually  due  to  infection  and 
hence  the  greatest  care  should  be  observed  in  keeping  the 
connecting  cavities  as  clean  as  possible,  by  means  of  fre- 
quent spraying  with  antiseptic  solutions.  Brain  abscess 
occurring  from  farcture  of  the  base  is  usually  so  deep- 
seated  and  diffuse  as  to  be  beyond  treatment  and  not  in- 
frequently there  are  multiple  foci  of  suppuration.  The 
prevention  of  cortical  irritation  from  adhesion  of  tissues 
is  next  spoken  of,  and  the  author  thinks  that  all  the 
methods  heretofore  suggested  of  placing  gold  foil,  gutta- 
percha tissue,  egg-membrane,  etc.,  between  the  scalp  and 
the  dura  are  impracticable  and  in  most  instances  pro- 
ductive of  cyst  formation.  The  replacing  of  bone  but- 
tons or  chips  of  bone  is  not  recommended  because  of  the 
tendency  to  necrosis;  the  later  also  excite  connected  tissue 
proliferation  and  produce  even  more  pressure  by  cicatri- 
cial formation  than  would  otherwise  be  the  case.  The  author 
does  not  advise  the  use  in  traumatic  cases  of  the  plates  of 
gold,  silver,  platinum,  or  even  celluloid.  He  thinks  that 
the  best  results  are  obtained  by  the  careful  preservation 
of  the  structures  as  they  are  divided  and  their  careful  and 
separate  suturing  after  the  operation  is  completed.  The 
use  of  the  osteoplastic  flap  is  highly  commended  where  it 
is  practicable.  The  tecnique  of  opening  the  skull  is  finally 
described.     [J.  H.  G.] 

2. Martin,  in  speaking  of  the  pelvic  relations,  remarks 
that  under  normal  circumstances  the  free  upper  wall  of 
the  bladder  does  not  lie  in  contact  with  the  anterior  wall 
of  the  uterus.  That  space,  when  not  occupied  with  the  blad- 
der, normally  distended,  is  filled  with  light,  constantly  mov- 
ing, small  intestines.  If  the  uterus  rested  on  the  free  su- 
perior wall  of  the  bladder,  as  usually  represented,  it  would 
never  have  a  minute  of  equilibrium,  but  would  constantly  be 
moving  about  as  the  bladder  filled  and  emptied,  and  as  the 
cervix  would  remain  comparatively  stationary,  the  intra- 
abdominal pressure  would  impinge  on  a  different  portion  of 
the  uterus  almost  every  minute  of  the  day.  His  reasons 
for  believing  that  the  uterus  occupies  this  position  are  the 
following:  1.  Because  it  is  the  only  position  that  the  uterus 
can  occupy  in  which  it  would  not  be  subject  to  constant 
important  changes  in  position  with  the  normal  changes  in 
the  bladder  and  rectum.  2.  In  this  position  the  intra-ab- 
dominal pressure  impinges  on,  or  just  posterior  to,  the  nar- 
row crest  of  the  uterus  in  the  direction  of  its  line  of  axis, 
and  in  such  a  way  as  to  equally  distribute  the  force  to  all 
of  its  supports;  and  the  organ  in  this  position  does  not  re- 
ceive the  whole  impulse  of  the  intra-abdominal  pressure 
at  one  point,  but  it  is  equally  distributed  to  all  parts  of  its 
surfaces  and  is  divided  by  its  lateral,  posterior  and  anterior 
support.  3.  On  opening  the  abdomen  the  uterus,  when  not 
pathologic,  almost  invariably  lies  in  the  position  as  de- 
scribed above  with  the  space  between  it  and  the  bladder 
filled  with  light  coils  of  small  intestines.  Three  things  are 
important  to  bear  in  mind  in  the  blood  supply  of  the  pelvis: 
1.  The  arterial  supply  to  the  pelvic  organs  is  derived  from 
widely  separated  points  and  is  provided  with  the  freest 
anastomoses.  2.  The  veins  of  the  uterus  contain  no  valves. 
3.  The  left  spermatic  or  ovarian  vein  enters  the  general  cir- 
culation at  a  disadvantage,  as  it  enters  the  left  renal  vein 
at  right  angles,  while  the  right  spermatic  vein  enters  di- 


rectly the  vena  cava  at  an  advantageous  angle.       [W.  A- 
N.  D.] 

3. — B.  R.  Schenck  reports  4  cases  of  calculi  impacted 
in  the  ureter  which  were  operated  upon  by  Professors  Kelly 
and  Halsted.  The  first  case  is  that  of  a  woman  aged  29 
years.  Dr.  Kelly  here  made  a  diagnosis  of  calculus  im- 
pacted in  the  ureter  by  catheterizing  the  ureter  with  a 
wax-tipped  catheter.  The  catheterization  of  the  opposite 
ureter  showed  the  kidney  on  that  side  to  be  healthy.  The 
operation  was  performed  by  the  peritoneal  and  extraperi- 
toneal incisions.  The  left  ureter  was  nodular  and  enor- 
mously enlarged,  being  the  size  of  the  colon  and  very  ad- 
herent. A  rough  calculus  1  2-5"  x  3-5"  completely  oc- 
cluded the  ureter.  Gauze  drainage  was  employed  after  the 
removal  of  the  kidney  and  ureter.  The  patient  made  a  good 
recovery.  Case  No.  2,  a  woman  aged  37  years.  This  pa- 
tient gave  a  history  of  repeated  attacks  of  hydronephrosis, 
but  for  the  last  six  weeks  the  condition  had  been  per- 
manent. Upon  opening  the  abdomen  the  kidney  was  found 
enormously  dilated,  its  cortex  being  about  %"  thick.  370 
c.c.  of  pale  urine  was  evacuated  together  with  a  small  stone. 
Two  other  stones  were  removed  from  a  point  1  1-5"  below 
the  renal  orifice.  This  was  accomplished  with  difficulty  and 
required  an  incision  in  the  ureter  1  2-5"  long.  The  incisions 
in  the  pelvis  and  in  the  ureter  were  closed  with  Interrupted 
silk  sutures.  A  gauze  drain  was  employed  and  the  patient 
made  a  satisfactory  recovery.  Case  No.  3,  a  woman  aged 
32  years.  This  patient  had  suffered  for  a  long  time  with 
pyuria.  Hydronephrosis  was  present  on  admission.  Cathe- 
terization of  the  ureters  showed  the  left  to  be  patulous 
but  scratch  marks  were  visible  on  the  wax  tip:  the  right 
ureter  was  partially  obstructed  about  2  3-5"  from  the  blad- 
der and  several  deep  scratches  were  visible  upon  the 
catheter.  A  radiograph  showed  a  shadow  in  the  region  of 
the  left  kidney  and  another  on  the  right  side  lower  down. 
A  lumbar  operation  was  done  on  the  left  side  and  a  large 
amount  of  purulent  urine  was  withdrawn,  together  with  a 
large  calculus.  There  was  considerable  hemorrhage  at  this 
time  and  operation  on  the  right  side  was  postponed  until 
about  a  month  later,  when  an  exploratory  laparotomy  re- 
vealed a  calculus  located  about  2  3-5  inches  from  the  vesicle 
opening.  This  was  removed  through  the  vaginal  vault  and 
the  abdominal  wound  closed.  Previous  to  this  operation 
a  ureteral  catheter  had  been  introduced  and  was  used  as  a 
guide  during  the  operation.  It  remained  in  place  for  16 
hours  after  the  operation  and  during  this  time  drained 
660  c.c  of  urine.  The  vaginal  wound  closed  after  draining 
urine  for  a  short  time  and  the  patient  made  a  good  re- 
covery. Case  No.  4  was  a  woman  aged  56  years.  This  pa- 
tient suffered  from  hydronephrosis  and  examination  of  the 
ureter  with  a  wax-tipped  catheter  showed  a  calculus  to  be 
situated  high  up  near  the  kidney.  At  the  time  of  the  opera- 
tion by  Dr.  Halsted  it  was  found  that  this  calculus  had 
descended  considerably  lower  in  the  ureter  and  it  was  re- 
moved through  the  vaginal  vault.  Urine  drained  throueh 
the  vagina  for  some  time  and  ceased  entirely  on  the  16lli 
day.  The  patient  made  a  good  recovery.  The  author  then 
classifies  84  cases  operated  upon  for  stone  in  the  ureter. 
In  19  of  these  the  calculus  was  located  within  6  cm.  of  the 
kidney;  in  8,  at  or  near  the  pelvic  brim  and  in  41  within 
5  cm.  of  the  vescile  opening.     [J.  H.  G.] 

4. — Vineberg  gives  the  following  conclusions  from  his 
study  of  the  differential  diagnosis  of  ectopic  pregnancy 
with  especial  reference  to  the  symptoms  of  earl.v  uterine 
abortion:  1.  Ectopic  gestation  is  diagnosed  very  frequently 
as  early  uterine  abortion.  2.  It  is  advisable  to  look  with 
suspicion  upon  every  case  presenting  apparently  the  symp- 
toms of  earl.v  uterine  abortion,  and  if  the  case  is  not  run- 
ning a  simple  and  natural  course  to  fully  anesthetize  the 
patient  for  a  rigid  examination  and  for  the  proper  perform- 
ance of  curettage  in  the  event  of  uterine  abortion  being 
present.  3.  If  after  carrying  out  this  plan  there  still  be 
some  doubt,  the  advisability  of  making  a  posterior  vaginal 
exploratory  incision  should  be  considered  in  order  to  de- 
termine the  presence  or  absence  of  blood  in  the  peritoneal 


May    is,    1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia       nf^r 
L  Medical   Journal        v>-"- 


cavity.  The  so-called  pathognomonic  signs  of  ectopic  ges- 
tation are  unreliable.     [W.  A.  N.  D.] 

5. — Leonard  Freeman  reports  a  case  ot  union  following 
pathological  fracture  of  the  femur  due  to  secondary  car- 
cinoma. This  patient  was  a  woman  aged  35  years  on  whom 
the  author  had  twice  operated  for  carcinoma  of  the  breast. 
After  the  second  operation  there  was  no  return  of  the 
growth.  The  patient,  however,  complained  of  pain  in  the 
dorso-lumbar  region  and  on  the  external  surface  of  the  left 
side  of  the  pelvis.  In  turning  over  in  bed  the  patient  broke 
her  left  femur  at  the  level  of  the  lesser  trochanter.  There 
had  been  no  pain  or  tenderness  at  this  point  and  nothing  to 
call  attention  to  the  process  going  on  within  the  bone.  Ex- 
tension was  applied  and  four  weeks  later  firm  union  had 
resulted.  The  patient  died  shortly  after  this  and  post- 
mortem examination  showed  a  secondary  growth  at  the 
seat  of  fracture,  and  firm  union  had  taken  place  at  this 
point.  The  second  case  reported  is  that  of  a  man  38  years 
of  age  who  gave  a  history  of  having  had  an  ulcerated 
sore  upon  the  lip  which  disappeared  without  treatment  and 
did  not  return.  About  a  year  after  the  disappearance  of  the 
ulceration  glandular  enlargement  occurred  below  the  jaw 
and  was  twice  operated  upon.  At  the  time  of  the  author's 
examination  there  was  a  large  inoperable,  deeply  ulcerated, 
indurated  mass  over  the  right  inferior  maxilla,  the  neck 
and  side  of  the  face,  microscopic  sections  of  which  showed 
it  to  be  a  typical  epithelioma.  The  author  believes  the 
original  sore  upon  the  lip  to  have  been  of  the  same  character 
and  this  growth  to  have  been  secondary  to  it.  The  pa- 
tient gave  no  history  or  evidence  of  syphilis.     [J.  H.  G.] 

6. — Randolph  Brunston  discusses  the  rational  use  and 
limitations  of  therapeutic  measures  Intended  to  promote 
absorption  of  exudates  within  the  eye-ball.  Medicinal 
measures.  He  believes  that  this  is  a  branch  of  ophthal- 
mology which  has  been  neglected,  and  that  in  the  eager- 
ness to  use  the  knife  and  the  needle,  therapeutic  measures 
are  forgotten.  Rest,  hygienic  surroundings  and  the  pre- 
vention of  all  excitement  should  not  be  neglected.  The  io- 
dides are  the  most  reliable  of  the  so-called  alteratives. 
Iodide  of  sodium  is  to  be  preferred  to  iodide  of  potassium 
because  it  is  better  tolerated  by  the  stomach.  The  io- 
dides are  frequently  given  in  too  small  doses,  and  in  con- 
junction with  hot  baths  much  larger  doses  can  be  tolerated. 
Although  mercury  and  the  iodides  form  the  sheet-anchor 
in  the  removal  of  exudates  caused  by  syphilis,  profuse  dia- 
phoresis can  be  advantageously  produced  by  pilocarpine. 
Salicylate  of  sodium  has  marked  value  in  the  absorption 
of  exudates  especially  in  rheumatic  subjects  or  those  that 
have  a  uric-acid  diathesis.  Hydrotherapy  is  a  valuable  ad- 
junct to  the  internal  remedies.  He  questions  whether 
the  benefit  sometimes  derived  by  the  administration  of 
mineral  waters  depends  upon  any  mineral  properties  they 
may  contain,  or  whether  it  is  rather  the  great  quantity  of 
water  taken  into  the  system  which  naturally  stimulates  the 
elimination.     [M.  R.  D.] 

7. — J.  H.  Bryan  reports  5  case  of  suppurative  mastoditis, 
the  first  of  which  occurred  in  a  six  year  old  boy,  and  is  of 
interest  as  it  seems  to  have  had  its  origin  In  an  attack  of 
influenza.  In  this  case  there  was  e.xtensive  necrosis  of  the 
mastoid  process  requiring  in  its  treatment  the  exposure  of 
the  lateral  sinus  for  some  distance  and  an  extensive  wound 
in  the  neck.  The  patient  ultimately  made  a  good  recovery. 
[J.  H.  G.] 

8. — E.  L.  Shurley  speaks  of  the  after  effects  of  operations 
for  the  removal  of  adenoid  tissue  at  the  vault  of  the 
pharynx.  The  immediate  effects  of  this  operation  are  clas- 
sified as  hemorrhage,  injury  to  the  pharynx,  reactionary 
acute  inflammation  of  thepharynx  and  accessory  cavities 
and  sepsis.  The  remote  effects  are  subacute  inflammatory 
conditions  of  the  pharynx,  the  ear,  accessory  sinuses  and 
tuberculosis.     [J.  H.  G] 

9. — Sawyers  considers  the  treatment  of  actinomycosis 
from  a  medical  stand-point.  He  gives  a  report  of  a  number 
of  cases,  his  chief  object  being  to  call  attention  to  the  fre- 
quency of  the  disease,  especially  in  argicultural  communi- 


ties, and  to  direct  attention  to  the  most  satisfactory  plan 
of  treatment  of  the  cases  coming  under  his  own  observa- 
tion. The  author  concludes  that  the  disease  it  not  an 
uncommon  one,  and  that  when  uncomplicated  it  is  a  non- 
suppurative, slow-progressing,  afebrile,  and  a  comparitively 
painless  disease.  Often  the  signs  and  symptoms  of  the 
disease  are  pathognomonic.  Referring  to  the  character- 
istics of  the  micro-organisms  he  states  that  the  coccus- 
like bodies  are  most  constantly  found,  the  threads  less  fre- 
quently, and  the  globe-shaped  bodies  are  often  absent. 
The  most  favorable  results  have  been  obtained  by  combin- 
ing surgical  measures  and  the  administration  of  potas- 
sium iodide.  A  large  percentage  of  the  cases  being  cured 
by  the  internal  use  of  the  iodide  potassium.  Hypodermic 
injection  of  iodide  of  potassium  into  the  diseased  areas  pro- 
duces a  marked  curative  influence.     [F.  J.  K.] 

10. — Robinson  states  that  the  subject  of  tropical  dis- 
eases has  assumed  new  importance  to  the  medical  profes- 
sion, and  in  this  connection  abscess  of  the  liver  has  especi- 
ally attracted  attention.  The  author  gives  a  detailed  report 
of  a  number  of  case  of  tropical  a'bscess  of  the  liver,  stating 
that  they  are  usually  multiple  and  that  the  right  lobe  of 
the  liver  has  been  found  most  commonly  affected.  Atten- 
tion is  called  to  the  fact,  that  the  symptoms  of  liver  abscess 
afford  little  aid  in  the  establishment  of  the  diagnosis.  The 
detection  of  pus  by  aspiration  is  the  means  by  which  the  di- 
agnosis can  be  absolutely  made.  In  his  cases  a  general 
anesthetic  was  given  while  making  the  exploratory  puncture. 
The  needle  was  introduced  to  its  full  extent  in  five  or  six 
different  directions  in  the  eighth  intercostal  space  in  the 
midaxillary  line.  If  pus  was  not  found  the  needle  was  in 
troduced  in  other  places  before  abscess  of  the  liver 
could  be  excluded  in  the  diagnosis.  The  finding  of  pus 
should  at  once  establish  an  indication  for  operation.  Rob- 
inson states  that  unless  there  Is  evidence  of  pointing  ex- 
cision of  a  portion  of  a  rib  and  drainage  from  the  side  is 
a  most  favorable  method  of  treatment.     [F.  J.  K.] 

11. — Brower  points  out  that  as  heredity  is  a  most  potent 
factor  in  the  causation  of  insanity,  measures  should  be  di- 
rected to  regulate  marriages  and  to  asexualize  degener- 
ates. Before  either  one  of  these  methods  is  carried  into 
effect,  a  great  deal  of  educational  work  must  be  done  by 
the  medical  profession.  The  medical  profession  can  only 
direct  the  proper  measures  of  prevention,  while  it  is  a 
duty  of  the  state  to  enact  laws  and  enforce  them.    [F.  J.  K.] 

12. — Douglas  C.  Moriarta  urges  upon  the  general  prac- 
titioner the  great  importance  of  early  operation  in  cases  of 
appendicitis.      [J.  H.  G.] 

13. — J.  F.  Baldwin  reports  a  case  of  a  boy  9  years  of  age 
in  whom  he  used  the  X-rays  for  locating  and  during  the 
extraction  of  a  bullet  from  the  knee-joint.  The  manipula- 
tions of  the  instrument  and  the  location  of  the  bullet  In  the 
cavity  was  easily  observed  during  the  operation  by  means 
of  the  fluoroscope.     [J.  H.  G.] 


AMERICAN    MEDICINE. 
May  11. 

1.  The   Necessity   for   Greater   Conservatism   in  the   Use 

of  Vasodilators  in  Certain  Cases  of  Cardiovascular 
Disease.     LOUIS  FAUGERES  BISHOP. 

2.  Aneurism   of   Ascending  Aorta   of   Great   Size;    Treat- 

ment by  Gelatin  Injections  and  Electrolysis,  with 
Effect  of  Coagulating  Most  of  the  Contained  Blood. 
W.   W.   JOHNSTON. 

3.  Postpartum  Metastatic  Panophthalmitis,  with  a  Clini- 

cal and  Pathological  Study  of  the  Case.  WALTER 
L.  PYLE. 

4.  Preliminary  Note  upon  Hydrocyanic  Acid  Gas  as  a  Dis- 

infecting Agent.     JOHN  S.  FULTON. 

5.  The  Food  Value  of  Alcohol,  and  Professor  Atwater's 

Experiments  and  Teaching.     JOHN  MADDEN. 

6.  A   Case  of  Double  Bladder;    Each   with     a     Separate 

Ureter.  A  Study  of  the  Urine  from  Each  Kidney. 
E.  P.  HERSHEY. 


^Ao        The  Philadelphia-] 
V"''        .\rEDiCAL   Journal  J 


THE  LATEST  LITERATURE 


[Mat   W,    ISOU 


7.  Transfusion,    Infusion,    Autotransfusion.     G.    W.    WA- 

GONER. 

8.  Litholapaxy  in  a  Child  Four  Years  Oild  with   an  Im- 

provised Evacuator.     GWILYM  G.  DAVIS. 

2. — W.  W.  Johnston,  of  Washington,  reports  the  case  of 
aneurysm  of  the  ascending  aorta  of  great  size  which  was 
treated  by  gelatin  and  electrolysis  with  the  effect  of  coa- 
gulating most  of  the  contained  blood.  The  question  of 
electrolysis  of  the  aneurysm  was  discussed  for  some  time 
and  was  finally  performed  by  Dr.  Finney  of  Johns  Hopkins 
Hospital.  Three  unsuccessful  attempts  were  made  to  reach 
fluid  blood  with  a  canular  needle,  four  inches  long  passed 
directly  into  the  tumor.  The  fourth  insertion  at  a  point 
near  the  shoulder  was  successful.  Ten  feet  of  silver  wire 
was  passed  through  the  tube  of  the  needle.  A  current  of 
ten  milliamperes  from  a  dry  cell  battery  was  then  turned 
on  and  continued  for  one  hour.  The  operation  was  com- 
paratively painless  except  at  the  beginning.  A  few  weeks 
after  this  operation  the  patient  suffered  from  an  attack 
of  intermittent  fever.  Several  large  blebs  formed  near  the 
sternal  margin  of  the  aneurysm,  some  of  these  finally  ul- 
cerated through  revealing  necrosed  fragments  of  the  ribs 
and  discharged  continually  a  thin,  bloody  serum.  Small 
hemorrhages  occurred  on  several  occasions  from  these 
blebs,  but  they  were  controlled  by  pressure.  The  pa- 
tient died  suddenly  from  a  sudden  loss  of  about  one  pint 
or  more  of  blood  from  the  point  of  successful  puncture. 
The  autopsy  showed  that  cure  had  been  progressing  and 
there  were  evidences  of  recent  coagulation  about  the  silver 
wire.  Death  was  due  to  the  blood  current,  making  chan- 
nels between  the  clot  and  the  sac,  and  finally  making  an 
exit  through  eroded  spots  on  the  outer  wall.     [T.  L.  CI 

3. — Walter  L.  Pyle  reports  a  clinical  and  pathological 
study  of  a  case  of  postpartum  metastatic  panophthalmitis. 
The  patient  was  a  well  nourished  primipara,  agfd  27  years, 
who  after  having  been  in  labor  for  56  hours  was  delivered 
by  forceps.  Ten  days  after  delivery  the  right  eye  became 
inflamed  and  although  somewhat  relieved  by  atropine,  hot 
and  cold  compresses,  etc.,  inflammation  continued  in  viol- 
ence and  persisted  for  five  or  six  weeks.  When  the  author 
first  saw  the  case  the  right  eye-ball  was  congested  and 
atrophic,  although  the  cornea  was  clear,  the  iris  quite 
•distinct  but  adherent  to  an  opacity  in  the  pupillary  area  re- 
sembling a  calcareous  lens.  On  the  following  day  the  eye 
was  enucleated.  Microscopical  examination  showed  that 
the  eye  ball  was  phthisical,  and  had  undergone  disorgani- 
zation. The  sclera  had  been  ruptured  resulting  in  the  evacu- 
ation of  some  of  its  contents.  The  rupture  had  occurred  at 
the  posterior  portion  of  the  eye  ball,  to  which  the  author 
calls  attention,  as  such  ruptures  usually  occur  at  or  near 
the  corneoscleral  junction.  The  literature  on  the  subject 
is  carefully  reviewed.  Diagnosis,  etiology  and  pathology, 
prognosis,  treatment,  as  well  as  the  microscopical  ap 
pearances  of  each  portion  of  the  eye-ball  are  described. 
CM.  R.  D.] 

4. — John  S.  Fulton  has  made  a  number  of  experiments 
which  seem  to  indicate  that  hydrocyanic  acid  may  be  found 
a  reliable  agent  for  house  disinfection  by  Boards  of  Health; 
that  it  is  especially  servicable  in  maritime  disinfection 
and  alone  or  in  combination  with  other  gaseous  germicides 
very  effective  against  certain  infectious  diseases.  [T.  L.  C] 

6. — E.  P.  Hershey  reports  a  case  of  double  bladder  each 
with  a  separate  ureter,  and  presents  a  report  of  the  study 
of  the  urine  from  each  kidney.  The  patient  was  2S  years 
of  age  before  her  condition  was  discovered  and  had  been 
treated  for  many  diverse  conditions.  Hershey  believes 
that  the  condition  of  surgical  left  kidney  is  present  with 
a  dilated  ureter  and  collapsed  bladder.  The  left  kidney  is 
so  far  diseased  that  it  secretes  urine  only  at  times  and  when 
this  secretion  occurs  the  posterior  bladder  fills  and  the 
urine  is  voided  by  virtue  of  its  own  pressure.  By  means  of 
filling  the  anterior  bladder  with  methylene-blue.and  the  pos 
terior  with  a  deci-normal  salt  solution  and  subsequently 
examining  the  contents  of  both  bladders,  it  was  proven 
that  there  was  no  connection  between  the  two.  The  pos- 
terior  bladder  was  first  treated  daily   with   a  solution  of 


creolin   gradually  reduced  to  one   washing  a  week.     She 
has  gained  15  pounds  in  weight.       [T.  L.  C.] 

8. — G.  G.  Davis  reports  a  case  of  litholapaxy  in  a  child  4 
years  old,  with  an  improvised  evacuator.  The  case  is  in- 
teresting on  account  of  the  rarity  of  the  condition  in  so 
young  a  child.  The  instrument  devised  was  a  No.  18  French 
Civiale  instrument.  The  stone  having  been  found  and 
crushed  an  ordinary  silver  catheter  17  French  was  intro- 
duced. This  was  attached  by  means  of  a  rubber  tube  a  few 
inches  long  to  an  ordinary  one  ounce  glass  syringe  filled 
with  boric  acid  solution.  The  fragments  were  readily 
withdrawn.     [T.  L.  C] 


VRATCH. 
llarth  10,  J'jOI.     (Vol.  XXII,  Xo.  10. 

1.  On    the    Casuistic    of    Sudden    Irresistible    Sleepiness 

(Narcolepsy).     S.  la.  SELTZER. 

2.  A   Case   of   False    .\rterio-venou3   Aneurism.     Ligation 

of  the  Vein.     W.  I.  LISIANSKL 

3.  On   the   Casuistic   of   Extrauterine   Pregnancy.     B.   A. 

FRATKIN. 

4.  Poisoning  by  Cream-Tarts  in  Charkow.     P.  N.  LASH- 

ENKOW. 

1. — Seltzer  reports  4  cases  of  narcolepsy.  All  occurred 
in  peasants.  One  in  a  young  man  of  18.  the  other  in  a 
woman  of  30.  the  third  and  fourth  in  women  of  35  and 
40.  respectively.  In  three  of  the  cases  the  affection  oc- 
curred independently,  following  mental  depression:  in  the 
fourth  it  v.-as  associated  with  cephalalgia.  On  the  ground 
of  his  own  observations  and  those  collected  frcm  the 
literature  on  the  s'lbject  the  author  draws  the  following 
conclusions:  (1)  Narcolepsy  may  occur  as  an  independent 
disease.  (2)  As  such  it  develops  under  the  influence  of 
pleasurable  or — more  frequently — ,?rievous  mental  pertur- 
bations. (3)  Independent  narcolepsy  occurs  more  fre- 
quently in  persons  or"  limited  intellectual  development.  (4i 
.-Sudden  sleepiness  in  general  is  met  with  more  frequently 
in  persons  debilitated  by  disease:  possibly  as  a  result 
of  depressed  spirits  caused  by  the  patients  being  aware 
of  the  gravity  of  the  malady  from  which  he  suffers.  (5> 
Change  of  environment  and  mode  of  life  should  have  a 
beneficial  effect  on  the  course  of  the  disease.     fA   R.) 

3. — Fratkin  reports  5  cases  of  extrauterine  pregnancy  and 
devotes  considerable  space  to  a  critical  review  of  the 
recent  literature  on  the  subject  He  does  not  believe  that 
our  knowledge  of  the  causes  of  ectopic  gestation  is 
greater  now  chan  it  was  in  years  ago  nor  are  we  in 
possession  of  more  diagnostic  signs.  Up  to  the  fifth  month 
the  diagnosis  is  at  best  uncertain.  The  reason  a  positive 
diagnosis  is  established  with  greater  frequency  is  to  be 
sought  in  the  fact  that,  owing  to  our  accumulated  experi- 
ence, the  condition  is  readily  suspected.  Indications  for  and 
various  methods  of  operating  are  discussed.  An  expectant 
plan  of  treatment  is  recommended  in  cases  in  which  at- 
tacks of  prostration  are  not  repeated.     [A  .R.) 

4. — Lashenkow  in  discussing  the  various  forms  of  poison- 
ing by  decomposed  food  points  out  that  in  many  obscure 
cases  wi-iich  cannot  be  elucidated  by  a  chemical  examina- 
tion the  poisoning  is  due  to  bacterial  toxins.  In  the  case 
studied  by  him  about  2iK*  persons  were  poisoned  by  cream- 
tarts  obtained  at  a  well  known  confectionary.  The  symp- 
toms were  those  of  gastro-intestinal  irritation  and  varied 
considerably  in  intensity,  resembling  in  some  arsenical 
pfiisoning.  They  all  recovered.  A  bacteriologic  examina- 
tion of  the  cream  mixture  which  is  usually  composed  of 
milk.  eggs,  sugar,  flour  an<i  pastry  showed  the  presence  of 
streptococcus  pyogenes  aureus  of  unusual  virulence.  A 
series  of  experiments  established  the  fact  that  when  the 
crc-am  mixture  becomes  sour  and  is  kept  in  a  ver>-  warm 
room  the  pyogenic  cocci  with  which  such  mixture  is  liable 
to  become  contaminated  develope  very  rapidly.  The  sug- 
gestion is  made  that  the  cream-mixture  be  heated  to 
SO;)0  =  C.  and  the  tarts  kept  in  a  cool  place  after  they  are 
finished.  Moreover,  the  manufacture  of  cream-tarts  in  very 
hot  weather  should  be  prohibited.     [A.  R.] 

ifan-h  n.  1901.     (Vol.  XXII,  Xo.  11.) 

1.  On  the  Action  of  the  Alkaloid  Johimbin  on  the  Animal 

Organism  and  its  Utilitv  in  the  Treatment  of  Impo- 
tence.   X.  P.  KRAWKOFF. 

2.  On  the  Question  of  the  Alkalinitv  of  the  Blood.    W   F. 

ORLOWSKI. 


May    is,    1901J 


THE  LATEST  LITERATURE 


LThe  Philadelphia       qA? 
Medical   Journal        V^O 


a      On  Some  Difficulties  in  the  Restriction  of  Diphtheria. 

G,  N.  GABRITSCHEWSKI. 
■1      A  Contribution  to  the  Study  of  Metrophlebitis  following 
Labor.     B.  A.  LIBOFF. 
1. — Will  be  abstracted  when  completed 
2. — Orlowski    presents    a    preliminary    report    of   his    ex- 
periments   undertaken    with    a    view    of    establishing    the 
causes  of  the  variations  in  the  alkalinity  of  the  blood  ob- 
served   not    only    in    pathological    conditions    but    also    in 
health.     He   found  that  the  method  *f  Landois-Jaksch  is 

i  uncertain  and  inaccurate,  the  alkalinity  of  the  blood  de- 
pending to  a  great  extent  on  the  number  of  blood  corpus- 
cles. He  has  made  observations  on  45  patients  suffering 
from    diverse   diseases,    having    determined    in    each    case 

!  not  only  the  alkalinity  of  the  blood  but  the  hemoglobin,  as 
well   as   the   number   of   red   and   white   blood    corpuscles. 

[     The    results    obtained    were    very    satisfactory.      The    fol- 

'  lowing  conclusions  were  reached.  (1)  Eugels  alkalimeter 
gives  results  exceeding  the  normal  to  the  extent  of  lOfi 
mlgrm.  when  litmus  is  used  as  an  indicator;  with  lacmoid 
the  error  amounts  to  119  mlgrms.  (2)  The  alkalinity  of  the 
bloori  in  health  equals  240-267  mlgrms.  of  NaOH  to  lOOc.c.  of 
blood,    when    litmus    is    used,    and    269-299    mlgrms.    with 

'     lacmoid.     (3)  In  various  forms  of  disease  the  alkalinity  of 

1  the  blood  is  in  proportion  to  the  number  or  red  blood  cor 
puscles.  diminishing  with  the  diminution  of  the  latter  and 
remaining  normal  as  long  as  these  are  in  normal  propor- 
tions. (4)  In  view  of  this  fact  the  determination  in  dis- 
ease of  the  alkalinity  alone  is  not  sufficient  to  form  an  idea 
of  its  deviation  from  the  normal.  (5)  Of  the  accumula- 
tion in  the  blood  of  acid-salts  and  consequent  autointoxica- 
tion one  can  judge  only  when,  with  a  normal  proportion 
of  red  blood  corpuscles,  the  alkalinity  is  diminished,  or, 
should  oligocythemia  be  present,  the  lessened  alkalinity  is 
out  of  all  proportion  to  it.  (6)  Such  a  disproportion,  sug- 
gesting the  possibility  of  acid  intoxication,  the  author  ob- 
served in  grave  cases  of  diabetes  and  cancerous  cach- 
exia. (7)  Small  (250  grms.),  warm  alkaline  enemas  raise 
the  alkalinity  of  the  blood  more  than  the  ingestion  of  soda, 
both  in  health  and  disease.  (8)  The  increase  of  the  alka- 
linity of  the  blood  by  the  administration  of  alkalies  and 
alkaline  enemas  is  transient.  A  more  extensive  report  of 
these  observations  is  promised.     [A.  R.] 

3. — Gabritshewski,  referring  to  the  paper  of  Dr.  Wolfson 
on  the  same  subject,  (abstracted  in  the  Philadelphia  Med- 
ical Journal,  April  6,  1901),  remarks  that  in  his  experience 
the  prolonged  residence  of  diphtheria  bacilli  in  the  throats 
of  convalescents  from  the  disease  is  due  to  some  patholo- 
gic alterations  in  the  throat  or  nasal  cavity  of  such  per- 
sons (adenoids,  hypertrophy  of  the  tonsils,  rhinitis, 
syphilitic  infections,  etc.)  In  anemic  or  de- 
bilitated children  the  diphtheria  bacilli  persist 
for  p.  much  longer  period  than  they  do  in  the  robust, 
it  is.  therefore,  necessary  to  pay  special  attention  to  the 
soil  which  favors  the  harboring  of  the  bacilli.  He  be- 
lieves that  in  cases  in  wiiich  complete  isolation  is  im- 
possible, at  least  partial  isolaton  should   be  practiced,  in 

I     the  same  manner  in  which  it  is  employed  in  cases  of  tuber- 

'     culosis.     [A.  R.] 

4. — Liboff  discusses  at  length  a  form  of  metrophlebitis 
which  receives  but  little  attention  in  text-books  and  is  often 
overlooked.  This  form  is  usually  local,  is  characterized  by 
chills,  sudden  elevation  of  temperature,  tailing  place  late 
in  the  puerperium.  and  extremely  rapid  pulse,  but  without 
any  subjective  symptoms  or  visible  jiathological  altera- 
tions in  the  genitalia.  In  the  graver  forms  phlegmasia  alba 
dolens  develnpes,  which  serves  as  a  useful  diagnostic  sign. 
Occasionally  this  local  affection  may  lead  to  a  general  in- 
vasion with  a  fatal  issue.  The  diagnostic  signs  are  the 
ngular  fever,  the  rapidity  of  the  pulse,  which  is  out  of 
all  proportions  to  the  temperature,  and  the  tendency  to  be- 
rome  localized.  As  a  rule,  chronic  gonorrhea  is  the  predis- 
I  losing  or  exciting  factor.  Five  cases  are  described  by  the 
author  to  illustrate  these  points.     [A.  R.] 


BERLINER     KLINISCHE    WOCHENSCHRIFT, 

FeliriKirii  11.  V.lOI.     (38  Jahrgang.  No.  6.) 

1.  The    Hereditary    Predisposition    to    Poisons.      E.    von 

BSHKING  and  KITASHIMA. 

2.  Work  as  Treatment  for  Nervous  Patients  in  Sanatoria. 

ALBRECHT  ERLENMRYER 

3.  The  Tallerman  Apparatus.     FR.  NEUMANN. 

4.  Experiences   with  the  Tallerman  Apparatus.     O.   ZIM- 

MERMANN. 


5.  Observations  upon  the  Treatment  of  Puerperal  Fever 
with  Marmorek's  Antistreptococcic  Serum.  M. 
BLUMBERG. 

^. — E;>.periments  hive  been  made  in  Marburg  for  years 
to  test  the  predisposition  to  poisons,  of  the  different  spe- 
cies of  animals,  and  of  the  different  individuals  of  the 
same  species,  in  normal  and  al)norraal  conditions.  Horses 
ot  al!  races  and  at  any  age  can  be  made  immune  to  the 
poison  of  diphtheria  by  antitoxin  in  increasing  doses.  Even 
in  those  horses  which  died  with  diphtheria,  the  antitoxin 
was  found  in  the  blood.  Experiments  upon  apes  had  simi- 
lar results.  Guinea-pigs  on  the  other  hand,  always  died 
of  diphtheria,  even  when  very  small  doses  of  the  antitoxin 
were  injected  consecutively.  Guinea-pigs,  however,  will  live 
longer  when  attacked  by  diphtheria  bacilli,  if  they  have  had 
diphtheria  antitoxin  beforehand.  Yet  they  die  eventually, 
anyway.  Mice  are  almost  immune  to  diphtheria  antitoxin, 
yet  are  well  able  to  withstand  diphtheria  bacilli.  For  there 
is  no  increase  in  the  predisposition  to  the  poison  of  diph- 
theria following  bacillary  infection.  Animals  are  pre- 
disposed to  the'  poison  of  tuberculosis  in  this  order:  sheep, 
horses,  goats,  dogs,  cattle,  and  guinea-pigs.  To  bacillary  in- 
fection the  order  is  reversed.  White  mice  are  even  more 
rapidly  affected  by  tubercle  bacilli  than  guinea-pigs.   [M.  O.] 

2. — Open  air  sanatoria  for  nervous  patients  were  begun 
by  Otto  Mueller,  who  realized  that  some  patients  would  be 
much  better  oft'  with  physical  work  and  exercise.  This  has 
always  been  advised  for  melancholia,  etc.  But  for  neuras- 
thenia, work  is  not  to  be  thought  of.  Such  patients  need 
rest  and  rest  and  rest.  Should,  however,  psychopathic 
complications  appear,  some  regular  work  will  be  necessary 
to  distract  the  patient's  attention  from  himself.  But  the 
nervous  patient  must  be  distinguished  from  the  neurasthe- 
nic, for  while  the  latter  is  really  tired  out  physically,  the 
former  only  feels  tired,  and  can  do  more  than  enough 
work,  should  opportunity  present.  For  him,  too,  at  first, 
rest  will  be  necessary.  Later  exercise  and  work  will  do 
immense  good.  Work  will  also  benefit  the  hysteric  and 
epileptic  physically,  but  his  illness  not  at  all.  For  chorea, 
exophthalmic  goiter,  tetany,  paralysis  agitans,  spinal  and 
cerebral  diseases,  rest  will  be  necessary.  But  this  treat- 
ment is  not  new,  as  it  was  instituted  about  30  years  ago. 
[M.  O.] 

3. — Tallerman's  hot  air  apparatus,  invented  in  1893,  is 
now  well  known  all  over  the  world.  Two  sorts  of  appa- 
ratuses are  in  use,  a  larger  for  the  trunk,  and  a  smaller  for 
the  extremities.  The  temperature  can  be  raised  to  230°  F. 
The  only  unpleasant  cardiac  symptoms  occurred  in  fright- 
ened, excitable  individuals.  In  arteriosclerosis,  myocardi- 
tis, or  valvular  disease,  no  bad  effects  resulted.  Neumann 
noted  not  only  temporary  improvement,  but  permanent 
effect  in  many  cases.  He  treated  gout,  sciatica,  arthritis 
deformans,  etc.,  the  most  severe  cases  only  being  baked. 
In  the  past  year  the  Tallerman  apparatus  was  used  in  70 
cases  of  sciatica  and  lumbago,  in  four  of  which  there  was 
no  effect:  35  cases  of  arthritis  deformans,  two  of  which 
remained  unchanged:  chronic  rheumatism,  fractures,  anky- 
losis, scleroderma,  etc.  Some  of  the  cures  were  marked 
and  imn'ediate.  The  histories  of  23  cases  follow.  A  case 
of  scleroderma  which  had  existed  for  six  years  in  a  woman 
of  4G,  was  much  improved  by  the  hot  air  treatment.  In  the 
most  severe  cases  of  arthritis  deformans,  the  effect  is  al- 
vvays  marked.  No  treatment  has  hitherto  been  found  so 
effective  in  its  results.      [M.   O.] 

4. — Zimmermann  reports  the  effect  of  the  use  of  the 
Tallerman  hot  air  apparatus  in  40  cases.  8  wer»  pro- 
tracted acute  articular  rheumatism,  10  chronic  articular 
rheumatism,  12  arthritis  deformans,  7  sciatica,  and  3  in- 
flammatory flat-foot.  In  all  but  seven  cases  the  improve- 
ment was  great  and  lasting.  In  the  grave  cases  the  ame- 
lioration was  most  noticeable.    [M.  O.] 


The  Reductive  Action  of  the  Blood  After  Chloroformiza- 
tion.— At  the  recent  meeting,  at  Nancy,  of  the  Congres  des 
Societes  Savantes,  (Krnw  Mrdinilr  di'  I'E.ft.  1901,  No.  8), 
Professor  Garnier  reported  the  result  of  a  number  of  ex- 
periments made  by  Dr.  Lambert  and  himself.  After  the 
inhalation  of  chloroform,  the  glycogen  in  the  liver  decreas- 
es, while  the  reductive  power  of  the  blood  increases.  The 
action  of  chloroform  upon  the  blood  in  ritro  confirmed  the 
results  obtained  in  riro.  Garnier  believes  that  under 
these  conditions  hydrolysis  of  the  glucose  occurs,  with 
the  formation  of  a  fermentible  sugar  belonging  to  the 
hexose  group.     [M.  O.] 


q6z1       '''^^^  Philadelphia ~| 
y    "t        Medical    Journal  J 


DISINFECTION  OF  WOUNDS 


[Mat  18.    190L 


©ritjinal  articles. 


THE    DISINFECTION    OF    WOUNDS     WITH     PURE 
CARBOLIC  ACID. 

By    PROFESSOR    DR.    VON    BRUNS, 

of  Tuebingen,   Germany. 

Tran-ilated.  with  perini«sion  of  the  author,  hy  Max  R.  Diiikelspiel, 

Although  our  mclhods  for  rendering  operative 
wounds  aseptic  have  been  productive  of  a  certain 
definite  result,  there  is,  nevertheless,  still  more  to  be 
desired  in  the  treatment  of  infected  wounds.  The 
times  during  which  all  good  results  were  expected 
from  antiseptic  irrigations,  are  passed  Anti- 
septics came  into  discredit  because  the  danger  of 
poisoning  accompanied  their  employment,  as  car- 
bolic acid  and  sublimate,  and  also  because,  when 
coming  in  contact  with  the  albuminous  secretions 
and  tissues  of  the  body,  they  lost  their  efficiency, 
like  corrosive  sublimate,  etc.  We  were  soon  con- 
vinced that  no  disinfection  could  render  a  septic 
wound  aseptic,  and  even  ascertained,  by  comparing 
the  efficiency  of  the  aseptic  and  antiseptic  treatment 
of  infected  wounds,  that  neither  was  superior  to  the 
other. 

The  principal  value,  therefore,  has  been  ascribed 
to  the  ph}-sical  action  of  the  means  at  our  disposal : 
free  incision  exposes  the  focus  of  suppuration,  the 
infectious  wound  secretion  is  washed  oft',  moist  dres- 
sings are  applied  for  the  purpose  of  absorbing  the 
secretion,  and  we  attempt  to  obviate  the  inspissa- 
tion  and  retention  of  the  secretion  by  frequently 
changing  the  dressings.  In  many  instances  antisep- 
sis is  entirely  desisted  from  and  only  sterile  salt  so- 
lution employed  for  irrigation  and  moistening  the 
dressings. 

But  I  believe  we  should  not  desist  from  chemical 
disinfection,  but  look  for  a  procedure  which  is  ger- 
micidal, without  causing  injury.  I  have  recently 
again  conducted  experiments  in  this  direction, 
which  promise  favorable  results,  although  the  lat- 
ter are  not  yet  conclusive.  This  consists  in  disinfec- 
tion with  pure  carbolic  acid. 

This  may  cause  considerable  hesitation,  es- 
pecially when  the  times  of  Lister's  carbolic  acid  an- 
tisepsis are  thought  of,  and  also  the  innumerable 
cases  of  eczema,  intoxication,  marasmus,  and  gan- 
grene, caused  by  carbolic  acid.  All  this  was  attrib- 
uted to  the  employment  of  dilute  solutions,  and 
consequently  one  should  suppose  that  the  con- 
centrated solution,  96%  carbolic  acid,  would  act 
even  worse.  This  apprehension  is  at  first 
disproved  by  Lewis's  method  of  treating 
h3'drocele  with  injections  of  pure  carbolic  acid  into 
the  sac  of  the  delicate  tunica  of  the  testicle.  The 
procedure  never  causes  intoxication,  and  is  charac- 
terized by  the  slight  reaction  and  the  absolute  pain- 
lessness after  its  employment.  Recentlj-  Phelps  has 
treated  wounds  with  pure  carbolic  acid,  after  open- 
ing tuberculous  abscesses  and  joints,  especially  the 
hip  joint,  and  has  recommended  this  method  on 
account  of  the  brilliant  results  which  he  has  ob- 
tained. The  joint  is  opened  freelv.  scraped  out  or 
resected,  and  then  filled  with  pure  carbolic  acid, 
which  after  one  minute  is  washed  out  with  absolute 
alcohol.     Phelps  here  considers  the  alcohol  as  an 


antidote  against  the  corrosive  action  of  the  carbolic 
acid. 

By  these  procedures  the  applicability  of  pure  car- 
bolic acid  to  wounds  is  demonstrated ;  but  before 
we  proceeded  with  the  practical  application  of  the 
method,  certain  questions  had  to  be  answered  in  an 
experimental  manner.  The  experiments  were  con- 
ducted by  Dr.  Hoij^all,  who  will  report  the  results. 
I  will  but  state,  that  carbolic  acid  in  concentrated 
solution  is  relatively  less  toxic  than  when  diluted, 
that  its  penetrabilitj'  during  its  brief  influence  is 
but  slight,  and  that  the  bactericidal  action  of  pure 
carbolic  acid  surpasses  that  of  sublimate  in  albu- 
minous compounds. 

In  view  of  these  asumptions  the  precedure  of 
Phelps  seems  to  me  to  be  of  considerable  value  in 
septic  wounds.  We  have  employed  it  in  more  than 
80  cases  of  infected  wounds,  plegmons,  suppuration 
of  joints,  etc.  After  incision,  and  subsequent  curet- 
ting or  excision  of  the  wound,  the  surrounding  skin  |j 
is  protected  against  the  excess  of  carbolic  acid,  by  |! 
wetting  it  with  absolute  alcohol;  the  wound  is  then 
thoroughly  swabbed  with  a  gauze  sponge  previously 
immersed  in  pure  carbolic  acid.  The  amount  of  car- 
bolic acid  employed  depends  upon  the  size  of  the 
wound,  but  more  than  2-6  gr.  was  not  even  used  in 
the  largest  wound,  therefore,  not  more  than  is  in- 
jected in  a  hydrocele  sac  and  left  there  with  im- 
punity. 

Not  only  is  this  cauterization  with  carbolic  acid 
not  particularly  painful,  so  that  it  may  be  performed 
without  anesthesia,  but  the  subsequent  pain  after 
fresh  incisions  is  also  remarkably  slight.  Particu- 
larly remarkable  is  the  small  amount  of  secretion 
after  the  first  dressing,  so  that  the  latter  may  remain 
from  2-4  days  in  cases  where  otherwise  the  dress- 
ings would  have  had  to  be  regularly  changed  after 
12-24  hours.  I'or  example,  in  a  case  of  resection 
of  the  hipjoint, performed  on  account  of  grave,  acute 
puerperal  suppuration,  the  first  dressing  was  al- 
lowed to  remain  four  days,  during  which  the  tem- 
perature was  nearly  normal. 

From  this  alone  it  follows  that  carbolic  acid  ap- 
plied but  once  markedly  influences  the  condition  of 
septic  wounds.  The  course,  as  a  rule,  is  simpler  and 
less  interrupted  than  is  ordinarily  observed.  Local 
injury  was  never  noticed,  neither  a  trace  of  toxic 
symptoms,  and  not  in  a  single  instance,  carboluria. 

The  result  obtained  obviously  depends  upon  the 
fact  that  carbolic  acid  belongs  to  the  few  antiseptics, 
whose  germicidal  power  is  not  weakened  by  the 
secretions  and  tissues  of  the  body.  Pure  carbolic 
acid  destroys  with  certainty  the  bacteria  on  the  sur- 
face, and  also  those  in  the  most  superficial  layers  of 
the  wound.  In  addition,  the  superficial  sloughing 
brings  about  a  reaction  in  the  deeper  layers,  which 
assists  in  the  demarcation  and  desquamation  of  the 
septically  infiltrated  areas,  thus  assisting,  as  it  were. 
in  the  cleansing  process  of  the  wound. 

I  do  not  hesitate  to  recommend  the  application 
of  pure  carbolic  acid  in  spiall  quantities  and  for  one 
minute,  followed  by  immediate  irrigation  with  ab- 
solute alcohol,  as  a  remedy  that  forms  a  valuable 
adjunct  to  our  mechanical  procedures  in  infected 
wounds.  It  would  be  a  special  providence  if 
that  remedy  which  was  the  foundation  of  the 
whole  antiseptic  era.  and    which    since    then    has 


May  18,  1901] 


PRESYSTOLIC  MURMUR 


PThe  Philadelphia        -t- 
Lmedical   Joukxal         y^v. 


again  been  generally  discarded,  would  be  called 
upon  to  serve  us  anew  in  the  battle  against  wound- 
infection. 


A  FURTHER  REPORT  ON  A  CASE  OF  PRESYSTOLIC 
MURMUR  ASSOCIATED  WITH  PREGNANCY,  ETC., 
ORIGINALLY  REPORTED  AT  THE  MEETING  OF 
THE  ASSOCIATION  IN  MAY,  1899.* 

By  JAMES  TYSON,   M.  D., 

of  Philadelphia. 
Professor  of  Medicine.  University  of  Pennsylvania.  Etc. 

It  may  be  remembered  that  I  read  before  the  As- 
sociation at  its  meeting  in  -May,  1899,  a  short  ac- 
count of  a  case  of  presystolic  murmur  associated 
with  systolic  tricuspid  murmur  complicating  preg- 
nancy in  a  woman  who  was  admitted  to  the  hospital 
of  the  University  of  Pennsylvania  with  these  symp- 
toms and  condition.  In  addition  she  had  a  striking 
jugular  pulse  simultaneous  with  systole  of  the  ven- 
tricles, a  marked  presystolic  thrill  at  the  apex,  and 
increased  area  of  cardiac  dulness.  There  was  a 
thumping  first  sound  characteristic  of  a  case  of  mit- 
ral stenosis,  with  sharp  accentuation  of  the  pul- 
monic second.  There  were  associated  aggravated 
dyspnea  and  distressing  cough,  emaciation  and  ex- 
liaustion,  but  no  dropsy  except  the  amniotic  drops}'. 
The  phv'sical  signs  are  illustrated  by  Fig.  i.  With 
the  birth  of  her  child  came,  as  was  to  be  expected 
marked  improvement  of  all  symptoms,  including 
disappearance  of  the  jugular  pulse,  replacement  of 
the  apex,  and  probably  slight  change  in  the  situation 

Fig.  I. 


Heart 

dulness. 


Presystolic  mur- 
mur and  thnmp- 
iuor  first  sound. 


of  the  right  border.  An  enlarged  liver  could  now  be 
recognized.  At  the  date  of  my  first  report  to  the 
Association  her  breathing  rate  was  20,  her  pulse  60 
and  the  temperature  97.2°,  these  being  approximate- 
1)'  the  temperature,  pulse,  and  rate  for  three  days 

'  *Read  before  the  .\ssociation  of  .-Vmerican  Physicians,  Washington 
D.  C,  Mav,  1901. 


previous.  She  was  discharged  thus  improved  June 
2 1  St,  and  a  month  later  went  to  work  in  a  shoe  fac- 
tory, and  continued  to  work  a  part  of  each  day  until 
Christmas,  1899.  She  could  not,  however,  do  a 
full  day's  work  because  of  shortness  of  breath  easily 
induced,  an  irrepressible  drowsiness  at  times,  faint- 
ness,  and  sometimes  syncopal  attacks.  Soon  after 
the  new  year  1900  she  grew  worse,  and  was  read- 
mitted to  the  hospital  January  16,  1900. 

Fig.  2. 


Tricuspid 
murmur. 


Heart 
dulness. 


Presystolic  mur- 
mur iind  thump- 
ing first  souna. 


Physical  Examination  on  Rcadniission. — Negative  as 
to  all  organs  excepting  the  heart.  There  is  visible 
pulsation  over  the  left  praecordium  and  the  apex 
beat  is  visible  and  palpable,  somewhat  irregular,  in 
fifth  interspace  slightly  outside  the  nipple  line.  A  pre- 
systolic thrill  can  be  felt.  Absolute  cardiac  dulness  be- 
gins at  the  lower  edge  of  the  third  rib,  to  the  left  of 
the  sternum,  that  of  the  right  border,  between  mid- 
sternum  and  left  edge  of  sternum,  .\uscultation 
recognizes  a  short,  rough  presystolic  murmur  at  the 
apex,  terminating  in  a  sharply  accentuated,  thump- 
ing first  sound,  the  first  part  of  diastole  being  also 
occupied  by  a  murmur.  x\t  the  tricuspid  area  a  dis- 
tinct systolic  murmur  is  heard,  conducted  a  short 
distance  to  the  left  of  the  sternum  toward  the  apex 
growing  fainter  as  the  latter  is  approached.  There 
is  also  heard  at  the  base  a  markedly  accentuated 
pulmonic  second  sound.     (See  Fig.  2.) 

On  April  9,  1900.  the  following  note  was  made : 
■Mrs.  -McC.  has  been  quite  comfortable  for  some 
time,  being  up  and  about  the  ward.  For  purposes 
of  examination  she  is  again  put  to  bed.  Her  tem- 
perature and  pulse  rate  have  been  normal  for  some 
weeks ;  her  breathing  rate  has  varied  between  20 
and  27.  On  inspection  we  find  chest  symmetrical 
V\-ell  nourished,  and  a  scarcely  appreciable  promi- 
nence of  the  left  praecordium.  -A.pex  beat  is  not 
visible,  but  can  be  felt  in  fifth  interspace  in  nipple 
line.  At  this  time  there  is  no  thrill  palpable,  but 
sometimes  under  agitation  there  has  been  a  thrill 
since  her  return  to  hospital.     Relative  cardiac  dul- 


nftf.       The  Philadelphia"! 
y  Medical   Journal  J 


IMPERFORATE  ANUS 


[Mat  is,    1301 


ness  is  recognized  at  lower  edge  of  tliird  rib  to  the 
left  of  sternum,  and  at  the  right  in  the  mid-sternal 
line.  Absolute  cardiac  dulness  at  the  upper  edge  of 
the  fourth  rib  and  at  the  left  edge  of  sternum.  Aus- 
cultation recognizes  only  a  very  short  presystolic 
murmur,  ending  in  an  exaggerated  thumping  first 
sound;  this  is  much  less  marked  than  originally. 
At  this  time  no  diastolic  murmur  except  the  pre- 
systolic is  heard,  nor  a  systolic  at  apex,  nor  a  sys- 
tolic at  ensiform,  although  there  was  at  time  of  re- 
admission  and  at  times  since.  Pulmonic  second 
sound  is  sharply  accentuated  in  strong  contrast  with 
aortic  sound.  She  menstruates  regularly  and  has 
gained  seven  pounds  since  her  admission. 

She  was  again  readmitted  February  i,  1901,  hav- 
ing had  a  cold  all  winter  and  grippe  early  in  Janu- 
ary, when  she  went  to  bed  and  remained  there  until 
admission  to  hospital.  Befo'^e  the  grippe  she  had 
at  times  a  smothering  sensation,  especially  when 
she  went  up  stairs  rapidly.  During  the  grippe  her 
lungs  filled  up  and  there  was  copious  expectora- 
tion, sometimes  bloody,  especially  recenth'.  She 
could  not  sleep  lying  down,  and  had  a  few  fainting 
spells.    Her  feet  were  swollen  once. 

On  readmission  her  pulse  was  80,  breathing  26, 
and  temperature  98.6°.  She  was  somewhat  dysp- 
neic,  but  soon  improved  after  resting,  and  in  a  few 
days  seemed  quite  well.  Evidently  her  condition 
•w  as  vastly  improved  as  compared  with  the  first  and 
even  second  admission.  The  physical  examination 
the  next  day  revealed  trifling  prominence  of  the 
left  precordium,  breathing  20,  pulse  78,  tempera- 
ture 97.4°.  There  was  no  thrill  appreciable  in  mitral 
area;  the  apex  beat  was  in  fifth  interspace,  mid- 
clavicular line.  There  was  no  presystolic  mitral 
murmur,  no  systolic  mitral  murmur,  or  tricuspid 
murmur.  There  remained,  however,  a  thumping 
first  sound  at  apex,  though  less  marked  than  at 
previous  admissions,  growing  rapidly  fainter  as  the 
sternum  was  approached  and  disappearing  at  the 

Fig.  3- 


third  rib,  where  the  pulmonic  element  of  the  second 
sound  was  well  heard.  Percussion  found  relative 
dulness  to  the  left  of  the  sternum,  at  lower  border 
of  the  third  rib,  absolute  dulness  on  the  fourth  rib ; 
for  the  right  border  relative  dulness  at  right  border 
of  sternum,  absolute  at  about  mid-sternal  line. 

Fig.  3  indicates  the  area  of  dulness  at  the 
third  admission,  and  the  shading  at  the  apex  the  seat 
of  the  thumping  first  sound.  There  was,  as  men- 
tioned, no  mitral  murmur  and  no  presystolic  mur- 
mur, although  at  times  the  latter  seemed  to  come 
out  culminating  in  the  thumping  first  sound. 

There  were  in  addition,  on  admission,  some  physi- 
can  signs  of  the  pulmonary  engorgement,  which  was 
responsible  for  her  more  serious  symptoms  at  this 
time,  but  these  rapidly  passed  away,  and  she  was 
discharged  March  20,  1901,  much  improved,  the 
last  weeks  of  her  stay  being  rather  protracted  be- 
cause I  desired  her  to  remain  in  the  wards  longer 
than  any  real  necessity  for  her  so  doing. 

It  is  not  very  usual  to  have  an  opportunity  to  ex- 
amine a  cardiac  case  at  such  long  intervals  and  ex- 
hibiting so  strikingly  different  stages  in  returninsr 
compensation  as  this,  which  furthermore  illustrates 
t}"pically  the  changing  physical  signs  of  mitral 
stenosis. 


Presystolic  innr- 
iimr  and  thump- 
ing first  sound. 


Heart 
dulness. 


AN  EXCEEDINGLY  RARE  CASE  OF  IMPERFORATE 

ANUS. 

By   CHARLES   B.   KELSEY,   M.   D. 

of  New  York. 

Through  the  kindness  of  Dr.  Nichols,  of  Barton. 
Vermont,  I  am  enabled  to  place  upon  record  the  fol- 
lowing exceedingly  interesting  and  possibly  unique 
case : 

The  patient,  a  man  of  twenty-four,  fairly  well  nourished, 
though  weighing  only  one  hundred  and  seven  pounds  at 
time  of  operation,  was  born  with  an  imperforate  anus.  The 
history  beyond  this  is  exceedingly  meagre  from  the  fact 
that  both  his  parents  died  in  his  childhood:  but  he  knows 
that  the  opening  was  made  in  the  perineum  during  the 
first  few  days  of  life,  and  that  there  has  always  been  a. 
freo  communication  between  the  bladder  and  the  rectum  by 
which  urine  escaped  per  rectum  and  feces  per  urethram.  He 
states  that  he  has  frequently  gone  for  three  months  with- 
out any  fecal  evacuation  of  any  sort:  and  that  after  such 
a  period  it  is  not  unusual  for  him  to  fill  two  chamber-uten- 
sils full  of  solid  matter.  On  examination  there  is  found  a 
deep  anal  depression  ending  in  a  narrow,  firm  undilatable 
slii.  running  antero-posteriorly.  which  admits  the  index 
finger  with  pain.  The  slit  is  surrounded  by  and  located 
in  firm  fibrous  tissue.  Through  this  slit  the  finger  impinges 
upon  an  immense  fecal  impaction  extending  above  the 
umbilicus  and  filling  the  entire  lower  abdomen.  Any  at- 
tempt to  break  up  or  loosen  the  impaction  or  to  pass  the 
finger  around  it  causes  intense  pain  and  free  bleeding: 
and  the  mass  is  so  stony  that  hardly  any  impression  can 
be  made  upon  it  with  the  finger.  There  is  no  sphincteric 
power  (no  sphincterl.  and  the  usual  fluid  discharge  exist- 
ing with  impaction  is  caught  in  a  large  sponge  which  the 
patient  has  been  always  in  the  habit  of  wearing  against 
the  anus.  Under  ether  it  required  the  united  efforts  of  two 
men  and  two  nurses  forty-five  minutes  to  break  up  and 
wash  out  the  fecal  mass.  No  attempt  was  made  to  esti- 
mate its  weight,  its  size  being  sufficient  indication  of  the 
amount,  and  its  stony  hardness  of  the  time  it  must  have 
been  present.  A  sound  passed  into  the  urethra  revealed 
an  entire  absence  of  corpus  spongiosum  for  about  an  inch 
and  a  half  in  front  of  the  triangular  ligament,  its  place 
being  taken  by  a  thin  membrane  which  separated  the  ure- 
thra from  the  rectum.  This  membrane  was  absent  at  one 
point  for  a  space  about  one  third  of  an  inch  in  diameter, 
through  which  communication  with  the  rectum  existed. 
The  malformation  was  of  the  general  type  shown  In  the 


Mat  is,  IWl] 


PUBLIC  AND  PROFESSION 


TThe  Philadelphia       qA^ 
Lmedical   Journal         ?    / 


cut  except  that  the  communication  was  uretheral  instead 
of  vesical. 

The  usual  incision  for  colostomy  was  made  on 
the  left  side,  and,  as  had  been  predicted  before 
opening  the  abdomen,  no  descending  colon  was  to  be 
found  at  the  usual  site.  Instead  of  this  an  immense 
muscular  pouch  was  found  spreading  like  an  apron 
over  the  entire  small  intestine  in  contact  with  the 
abdominal  muscles,  and  reaching  from  the  anus  to 
the  diaphragm.  I  cannot  describe  this  better  than 
by  saying  that  at  first  it  felt  like  a  greatly  dilated 
stomach,  but  as  part  of  it  was  pulled  through  the 
incision,  it  was  seen  to  be  at  least  three  times  as 
thick  as  any  human  stomach,  and  that  the  mesen- 
teric veins  spreading  over  it  at  regular  intervals  of 
a  little  more  than  an  inch,  were  two-thirds  the  size 
of  an  ordinary  lead  pencil.  The  muscular  layer  Avas 
hypertrophied  to  such  an  extent  that  each  fasicu- 


A  case  of  imperforate  anus. 

lus  could  be  plainly  distinguished  with  the  ej-e.  This 
pouch  was  replaced  and  a  long  rectal  bougie  passed 
per  anum  for  a  guide.  The  end  of  this  being 
brought  out  of  the  incision,  was  found  to  be  enclosed 
in  this  same  muscular  pouch,  proving  that  this  was 
the  only  descending  colon  we  were  to  find.  It  was 
therefore  followed  up  several  inches,  when  at  about 
the  point  which  I  should  judge  would  ordinarily 
mark  the  end  of  the  transverse  and  beginning  of 
the  descending  colon,  it  rather  suddenly  narrowed 
into  something  more  like  a  greatly  hypertrophied 
large  bowel,  and  here  an  artificial  anus  was  estab- 
lished with  the  usual  spur,  under  the  gut  through 
the  mesentery.  The  wall  of  the  gut  when  cut  away 
still  showed  a  muscularis  at  least  three  times  the 
ordinary  thickness.  Other  congenital  defects  cas- 
ually noted  during  the  operation  were  absence  of 
development  of  the  muscles  of  the  left  thumb,  and 
almost  complete  absence  of  both  radial  arteries. 

It  is  well  known  that  attempts  to  establish  an  anus 
in  the  perineum  by  mere  incision  in  cases  of  imperfo- 
ration  do  not  usually  result  favorably  either  for 
length  of  life  or  function  ;  but  I  have  never  seen  a  de- 
scription of  the  result,  twenty-four  years  later,  of 
nature's  efforts  to  utilize  such  an  opening  as  was 
here  very  successfully  made  by  the  surgeon.  Cases 
are  recorded,  however,  of  children  who  have  lived 
to  adttlt  life  with  this  deformity  entirely  unrelieved 
thirty  years  (Gross). 


THE  RELATIONS  OF  THE  PUBLIC  TO  THE  MEDICAL 
PROFESSION." 

By  WM.  H.  THOMSON,  M.  D.,  L.  L.  D. 

of  New  York. 

Visiting  Physician  to  the  Roosevelt  Hospital,  and  President  of  the  New 
York  Academy  oi   Me<liciue. 

To  a  physician  who  is  conscious  of  the  aims  of 
his  profession,  it  seems  but  natural  to  expect  the 
fullest  sympathy  and  co-operation  on  the  part  of 
the  public  in  whatever  involves  the  relations  of  the 
public  to  his  profession.  One  has  but  to  enumerate 
the  long  list  of  deadly  diseases  which  a  solitary 
dweller  on  an  island  would  never  have,  to  perceive 
how  community  of  disease  is  involved  in  the  very 
word  communit)'.  In  all  communities  men  must 
constantly  give  and  take  in  everything,  disease  in- 
cluded. With  children,  every  school,  and  with 
adults,  every  passenger  vehicle  aiTords  many 
chances  for  illustrating  what  is  involved  in  the 
term  public  health.  All  this  seems  plain  enough. 
Therefore,  why  should  not  physicians  expect  to  be 
a  generally  popular  body  whenever  they  appear  as 
a  class  of  professionals,  men  specially  trained  to 
guard  the  public  health? 

There  are  causes,  rather  than  reasons,  which  ac- 
cotmt  for  the  comparative  failure  of  the  public  to 
appreciate  the  services  of  the  medical  profession 
to  the  community  as  such,  and  it  behooves  tis  med- 
ical men  clearly  to  recognize  just  what  those  causes 
arc. 

We  would  rank  as  first  the  conception  of  the 
medical  profession  as  a  trade.  That  it  is  anything 
else  than  a  means  for  getting  a  livelihood  by  its 
members  is  seldom  thought  of.  W'hy,  therefore, 
should  the  public  take  a  special  interest  in  the  medi- 
cal profession  more  than  in  any  other  bod}'  of  per- 
sons who  make  a  living  by  their  btisiness?  But  with 
many  there  exists,  besides,  the  impression  that  the 
medical  profession  is  a  particidarly  close  corpora- 
tion, strongly  dominated  by  class  feeling,  and 
which  aims  to  monopolize  to  its  exclusive  profit  the 
whole  field  of  the  treatment  of  disease  wherein  it 
is  very  jealous  of  all  competitors.  Also  the  com- 
mon term  used  to  designate  members  of  the  regfu- 
lar  profession,  "doctors  of  the  old  school,"  is  cou- 
pled in  many  minds  with  hostility  to  all  innovation 
and  to  modern  progress. 

Thus  it  is  that  one  of  the  most  creditable  feat- 
ures of  our  profession  in  its  acknowledgment  of  a 
code  of  professional  ethics,  which,  as  the  term  itself 
implies,  relates  to  questions  of  honor  in  profes- 
sional life  and  conduct,  is  interpreted  by  many  as 
a  pnrc^ly  trades  union  code  of  the  most  despotic 
nature.  That  consideration  which  one  gentleman 
should  show  to  another  with  whom  he  is  brought  in 
professional  relations  is  also  regarded  as  formu- 
lated among  physicians  into  a  rigid  and  artificial 
systems  of  etiquette,  which  no  outsider  can  pretend 
to  comprehend.  This  widely  spread  delusion  tends 
to  hamper  the  relations  of  our  profession  to  the 
public  in  many  wa^-s.  It  constitutes  the  first  re- 
source of  the  charlatan  to  appeal  for  sympathy  to 
the  generous  public  against  the  persecution  of  the 
great  Union  of  the  Doctors,  and  that  sympathy  is 
vcrv  readily  granted.    Costly  experience  in  the  past 


♦Paper  read  before  N.  V.  .\cadeniy  of  Medicine.  April  4,  1901, 


qAO        The  Philadelphia"! 
y  Medical   Journal  J 


PUBLIC  AND  PROFESSION 


fMAY    18.    !901 


has  shown  us  that  nothing  so  often  defeats  itself  as 
an  official  condemnation  by  representative  medical 
organizations  of  any  form  of  quackery,  be  it  ever 
so  absurd  or  ridiculous.  So  soon  as  our  profession 
publicly  arrays  itself  against  anything  of  the  kind, 
it  multiplies  its  adherents  indefinitely.  Instead  of 
extinguishing  the  fire,  it  simplj-  scatters  it. 

Another  fact  which  we  should  bear  in  m'.nd  is 
that  in  the  present  state  of  public  intelligence  on 
medical  matters,  ph)-sicians  by  no  means  are  re- 
garded as  having  a  monopoly  of  the  knowledge  of 
disease,  and  least  of  all  of  curing  it.  On  the  one 
hand  there  exists  a  great  world  of  minds  "which 
craves  for  the  marvelous  and  the  occult,  and  no- 
where as  in  medicine  can  this  tendency  find  such 
free  play.  Such  people  are  ever  ready  to  welcome 
any  prophet  or  prophetess  who  hails  from  the 
realms  of  the  vast  unknown.  From  Hahnemann 
down  to  Mrs.  Edd)-,  and  to  the  apostles  of  osteo- 
pathy, the  procession  of  wondermongers  has  no 
end,  for  the  reason  that  such  multitudes  of  our  fel- 
lows find  it  so  easy  to  part  with  their  common 
sense  whenever  the  subject  is  raised  of  our  life  in 
tlie  flesh  and  its  ills.  .\s  life  is  a  mysterj',  so  is  dis- 
ease a  myster}',  and  therefore  the  more  mysterious 
and  incomprehensible  the  personage  is  who  talks 
about  them,  the  higher  he  or  she  rises  in  their  esti- 
mation. But  apart  from  this  indifinitely  large  class 
of  credulous  weaklings,  there  will  be  found  a  very 
general  belief  that  alter  all  doctors  do  not  know 
so  much  more  than  other  people  about  their  own 
business.  The  average  man  privately  considers 
himself  as  good  as  an}-  doctor  about  most  diseases, 
and  resents  the  assumption  of  superior  knowledge 
by  a  simply  formalh-  qualified  fellow-mortal.  \\'e 
physicians  are  constantly  made  aware  that  we  live 
in  a  world  of  male  and  female  critics,  who  feel 
abundantl)'  able  to  pass  judgment  upon  us,  and  they 
often  do  so  unreservedly.  There  can  be  no  greater 
mistake  than  for  a  medical  man  to  take  it  for  grant- 
ed that  because  he  has  spent  years  in  the  investiga- 
tion and  study  of  the  human  body  and  its  diseases, 
therefore,  that  he  will  be  considered  as  knowing 
a  good  deal  on  the  subject.  The  truth  is  that  while 
in  most  things  else  special  training  and  experience 
are  accorded  proper  consideration,  the  doctor  must 
not  be  surprised  at  any  time  to  find  the  judgment 
of  some  female  friend  of  the  patient  rule  him  right 
out  of  court. 

In  view  of  these  and  many  like  facts  which  bear 
upon  the  actual  relation  of  the  medical  profession 
to  the  public,  we  come  to  the  question,  how  can 
these  serious  evils  be  counteracted?  What  is  it 
which  makes  quackery  in  any  form  possible  or 
flourishing?  Why  is  rational  medicine  so  com- 
monly unappreciated?  The  sufficient  answer  is. 
becatise  of  ignorance,  and  of  nothing  but  ignor- 
ance. W't  may  truthfully  say  that  it  is  impossible 
to  over-estimate  the  ignorance  of  the  public  in 
medicine — there  is  nothing  with  which  it  can  be 
compared  for  its  completeness  and  universality. 
The  most  intelligent  man  in  town  is  likely  to  come 
into  the  physician's  office  with  his  diagnosis  al- 
ready made.  "Doctor,  my  liver  is  out  of  order,  and 
I  want  j'ou  to  give  me  something  to  set  it  right," 
when,  ten  to  one,  he  does  not  know  on  which  side 
of  his  bodv  his  liver  is.     Men  would  be  ashamed 


to  confess  that  they  did  not  know  a  good  deal  about 
geography  or  of  history,  or  that  Jupiter  was  a 
planet  and  Sirius  a  fixed  star,  while  they  cannot  tell 
what  is  the  diflference  between  an  artery  and  a  vein, 
or  the  difference  between  a  bronchial  tube  and  a 
pleura,  or  that  the  meninges  do  not  cover  the  stom- 
ach. \'ery  few,  even  among  the  intelligent  classes, 
have  anj'thing  but  the  vaguest  conception  that  med- 
icine is  a  great  science,  and  nothing  less.  That  like 
every  other  great  science,  it  cannot  be  known  by 
ignoramuses,  but  that,  on  the  contrary,  it  demands 
the  severest  mental  training  and  the  most  patient 
and  exclusive  study  to  become  at  all  proficient  in 
it. 

That  there  is  no  marvel  like  life  and  like  the  liv- 
ing body,  nor  anj-  investigation  which  can  surpass 
its  investigation  for  the  problems  which  it  presents. 
That  the  astronomer's  task  is  simplicity  itself  com- 
pared with  the  world  which  we  turn  to  with  the 
microscope  for  its  revelations  of  living  structure. 
Xo  chemistry  which  compares  for  intricacy  with 
the  chemical  facts  of  life,  or  any  branch  of  that  ma- 
jestic science  which  is  practically  so  important.  That 
there  is  no  skill  in  observation  which  can  surpass 
what  is  needed  for  watching  the  manifestations  of 
life  before  per\-ersion,  and  after  perversion  by  dis- 
ease. Xo  such  courage  or  readiness  of  resource  de- 
manded in  anj'  emergency,  as  in  the  exigencies  of 
surgical  or  of  medical  practice,  and  that  adequately 
to  meet  such  crises  calls  for  years  of  preparation  be- 
forehand. 

In  this  connection  one  may  say  that  nothing 
would  so  impress  intelligent  laymen  as  some  ade- 
quate information  about  not  only  the  wonderful 
progress  of  the  science  of  medicine  in  our  time,  but 
also  how  it  is  achieved.  Medicine  now  makes  no 
haphazard  or  accidental  discoveries,  but  only  by 
means  of  research  after  the  most  exacting  scientific 
methods.  In  this  w^ork  is  illustrated  the  world- 
wide and  international  brotherhood  of  medical  sci- 
ence unparalleled  in  any  other  of  the  sciences  All 
.America,  all  Europe,  and  far-oflf  Japan  contribute  to 
tlie  great  company  of  investigators,  working  in  the 
most  elaborately  equipped  laboratories,  where  every 
alleged  discovery  in  any  department  of  medical 
knowledge  is  subjected  to  the  severest  tests  known, 
either  to  confirm  or  to  disprove  it,  so  that  nothing 
of  the  truth  can  escape  such  general  and  independ- 
ent scrutiny.  Due  to  this  great  modern  system  of 
experimental  medicine,  the  discoveries  made  in 
medicine  in  our  age  are  really  greater  than  any  of 
the  boasted  scientific  achievements  of  the  past  cen- 
tury for  their  far-reaching  effect  upon  human  wel- 
fare. What  is  the  gain  to  humanity  by  steam, 
telegraph  or  telephone  compared  with  the  benefits 
of  antiseptic  surgery  or  of  the  demonstration  of  what 
tuberculosis  really  is:  what,  also,  is  the  secret 
enemy  which  works  in  every  pestilence,  and.  lastly, 
why  whole  regions  of  the  globe  are  afflicted  with 
the  deadly  agent  now  proved  to  be  miscalled  mala- 
ria or  bad  air?  These  and  many  more  inestimable 
gains  to  humanity  have  been  won  by  the  most  skil- 
ful and  masterly  processes  of  investigation  which 
the  history  of  pure  science  can  afford.  And  yet  ra- 
tional medicine  demands  that  by  no  other  way  shall 
its  progress  be  attempted.  Theories  and  specula- 
tions are  now  quickly  brushed  aside  with  con- 
tempt, and  only  pairstak'ng  observations  checked 


May  18.  1901] 


PUBLIC  AND  PROFESSION 


TThe  Philadelphia        qAq 
Lmedical   Journal         V^y 


by  exact  experimental  tests  are  allowed  any  hear- 
ing. The  result  has  been  that  as  medical  knowledge 
has  become  more  and  more  based  upon  facts,  the 
growth  of  its  vast  store  of  information  has  exceeded 
all  possibility  of  acquisition  by  any  one  mind,  how 
ever  great.  There  is  r.o  man  living  who  himself 
knows  one-fourth  of  what  is  now  known  about  the 
human  body  and  its  diseases.  The  profession  has 
therefore  been  obliged  to  apportion  its  great  field 
to  different  bands  of  workers.  But  what  does  this 
fact  indicate  as  to  the  impossibility  of  an  ignoramus 
being  ever  fit  to  treat  anything,  when  the  most 
highly  trained  ph3'sician  constantly  acknowledges 
that  he  is  not  himself  qualified  to  treat  everything? 
Were  these  truths  generally  known  as  they  should 
be,  the  status  of  the  medical  profession  in  the  esti- 
mation of  the  people,  would  be  proportionately 
raised.  People  would  as  soon  think  of  committing 
themselves  or  their  families  when  sick  to  unin- 
structed  hands  as  they  would  commit  the  locomo- 
tive of  an  express  train  to  a  man  who  knew  noth- 
ing about  locomotives,  or  to  let  a  common  day 
laborer  have  charge  of  a  powerful  dynamo.  How. 
therefore,  the  deplorable  nescience  of  the  great  mass 
of  the  public  with  the  most  elementary  facts  about 
medicine  is  to  be  remedied,  is  a  question  of  the 
most  practical  concern  to  our  profession  as  a  body. 
Every  day  furnishes  some  new  illustration  of  the 
mischievous  effects  of  this  public  ignorance  on  the 
community  itself  rather  than  on  ourselves,  and  it 
has  become,  in  my  opinion,  a  duty  on  the  part  of 
the  profession  to  take  some  concerted  action  to  de- 
vise measures  against  this  great  evil.  One  of  the 
readier  means  for  this  purpose,  it  seems  to  me, 
would  be  a  demand  that  some  suitable  plan  should 
be  devised  for  the  teaching  of  anatomy  and  physi- 
ology in  the  curriculum  of  every  high  school,  acad- 
emy and  college  in  the  land,  and  equally  for  both 
sexes.  It  is  high  time  that  some  acquaintance  with 
the  mechanism  of  life  should  be  recognized  as  an 
indispensable  requisite  in  all  systems  of  education 
fit  for  the  name.  Thereby  to  know  something  of 
oneself  in  the  structure  and  functions  of  the  bodies 
we  have,  is  equal  in  importance  to  the  study  of 
grammar,  of  belles  letters,  or  of  the  dead  lan- 
guages. To  remain  four  years  at  college  and  then 
leave  without  knowing  virtually  anything  about 
how  the  lungs  breathe  or  the  heart  beats,  or  the 
nerves  act,  is  a  satire  upon  the  modern  systems  of 
education.  Of  course,  we  do  not  advocate  any 
teaching  of  medicine  as  such  in  this  suggestion. 
What  we  do  maintain  is,  that  as  the  average  man 
and  woman  in  society  has  heard  at  school  enough 
about  astronomy  to  render  astrology  to  them  ridic- 
ulous, so  would  a  corresponding  degree  of  informa- 
tion given  at  school  about  the  great  facts  of  bodily 
life  tend  to  render  the  quack  and  the  charlatan 
equally  ridiculous  and  impotent. 

But  we  cannot  wait  at  present  for  such 
an  educational  reform,  on  account  of  a  pub- 
lic exigency,  which  though  orders  like  it  have 
happened  before,  yet  in  this  instance  is  more 
than  usually  acute.  A  sect  has  arisen  which 
calls  itself  both  Christian  and  scientific,  whose 
members  prefer  to  heal  disease,  first  l)y  total 
banishment  of  all  physicians,  and  by  exclusion  of 
all  medical  measures,  suljstituting  instead  ideas  and 


ideas  alone.  1  he  first  of  these  all-healing  ideas  is 
that  there  is  no  pain,  and  there  is  no  disease,  but 
only  mind.  The  rest  of  their  propositions  we  have 
no  time  to  state,  nor  are  we  sure  that  we  could 
state  them  if  we  did  have  the  time.  We  need  not 
be  surprised  at  the  numerous  following  which  ihis 
sect  has  received,  for  by  tjiis  time  physicians  ought 
not  to  be  surprised  at  anything  in  connection  with 
medicine  in  this  remarkable  country.  But  it  can- 
not be  too  publicly  announced  that  the  medical  pro- 
fession would  not  attempt  to  interfere  with  any 
human  being  believing  what  he  pleases  about  dis- 
ease and  about  doctors.  As  far,  also,  as  doctors  are 
concerned,  they  may  act  as  they  please  and  never 
run  up  a  doctor's  bill  on  any  acount.  But  how  about 
the  public?  It  is  the  public's  turn  to  speak  now. 
Suppose  a  man  finds  his  next  door  neighbor  regard- 
ing a  case  of  smallpox,  or  of  scarlatina,  or  of  diph- 
theria, in  his  house  as  only  ideas,  and  for  getting 
rid  of  these  ideas  calls  in  a  Christian  Scientist  to 
deal  with  them  by  his  or  her  ideas,  what  then?  It 
may  be  that  his  Christian  Science  neighbor  does 
not  even  do  that,  but  pays  a  fee  to  some  'scientist"  to 
operate  through  "absent  treatment"?  The  fact  is 
practice  based  upon  this  childish  delusion  is  more 
dangerous  than  allowing  children  to  play  with  fire. 
Allowed  to  act  itself  out,  cases  of  the  most  virulent 
infectiousness  will  occur  beyond  the  reach  of  any 
timely  recognition  by  those  who  often  alone  would 
recognize  them,  until  hundreds  of  innocent  persons 
are  fatally  stricken  down  by  sul)sequent  dissemina- 
tion of  the  infection.  In  that  aspect  this  whole  sys- 
tem of  doctrine,  so  soon  as  consistently  carried  out, 
becomes  simply  criminal.  If  a  separate  earth  could 
be  provided  to  which  Christian  Scientists  might  be 
consigned,  it  would  not  so  much  matter,  but  in  this 
crowded  miscellaneous  world,  we  must  have  quali- 
fied guardians  who  do  not  believe  in  smallpox  be- 
ing an  idea,  but  a  hideous  sickness,  and  whose  only 
form  of  absent  treatment  is  to  absent  the  patient 
himself  from  everybody  as  soon  as  possible.  A  most 
stringent  law  ought  to  be  passed,  and  most  effec- 
tively enforced,  enacting  that  every  case  of  dis- 
ease in  the  community  should  be  visited  at  least 
once  by  a  properly  qualified  medical  man.  If  a 
properly  qualified  medical  man  has  not  been  called 
in,  then  one  such  man  should  be  provided  by  the 
public  as  its  official  public  authority,  whose  sole 
duty  then  should  be  to  determine  whether  the  pa- 
tient is  sick  or  not  with  an  infectious  disease.  Other 
than  that  dutj'  he  should  have  nothing  more  to  do. 
All  that  he  is  there  for  is  not  for  either  patient  or 
the  patient's  friends,  certainly  not  as  a  repre- 
sentative of  the  medical  profession  as  such.  He 
should  be  a  public  officer  only  to  see  to  it  that  the 
sick  one  does  not  become  a  public  danger.  But  for 
reasons  which  we  have  already  adverted  to,  such 
a  law  should  not  be  proposed  either  by  medical  men 
or  by  medical  organizations.  It  is  the  public's  busi- 
ness to  see  to  such  an  enactment,  and  public 
bodies,  other  than  medical,  should  take  it  up.  In- 
itiated and  advocated  by  the  medical  profession, 
any  attempt  of  the  kind  will  raise  multitudes  to  pro- 
test that  the  doctors  are  frightened  about  their 
business  being  ruined  by  the  success  of  these  apos- 
tles of  the  new  faith,  and  the  old  story  of  futile  ap- 
peal h\  our  profession  to  the  world  will  simply  be 
repeated. 


970 


The  Philadelphia" 
Medical   Journal  . 


GASTRIC  TETANY 


[May   18,    1901 


GASTRIC  TETANY,  WITH  REPORT  OF  CASES* 

By  WM.   GERRY  MORGAN,  M.  D. 

of  Washington,  D.  C, 

Assistant  to  the  Chair  of  Theory  and   Practice  and  Diseases  of  Children, 
Georgetown  University. 

Definition. — Tetany  is  an  affection  characterized 
by  the  occurrence  of,  for  the  most  part  tonic,  but 
occasional!}',  also,  clonic  spasms  in  the  hands,  fore- 
arms, arms,  feet,  legs,  and  in  severe  cases,  the  neck, 
face,  larynx  and  trunk.  Consciousness  is  usually 
undisturbed,  but  may  be  partially  or  wholly  lost : 
it  may  be  entirely  lost  at  one  time  and  undisturbed 
at  another  time  in  the  same  individual.  The  con- 
tractures are,  for  the  most  part,  bilateral,  and  pain- 
ful ;  either  paroxysmal  or  continuous. 

Etiology. — Up  to  the  present  time  there  have 
been  several  theories  advanced  to  explain  the  symp- 
tom-complex of  tetany,  i.  The  dehydration  theory 
of  Kussmal  was  the  first  of  these,  which  has  al- 
ready been  proven  untenable,  and  abandoned  by 
him.  2.  When  the  dehydration  theory  failed  to 
explain  the  spasms'seen  in  tetany,  Germain  See  de- 
cided that  tetany  was  of  reflex  origin,  and  certainly 
there  is  much  in  these  cases  to  support  this  theory. 
He  argues  that  the  spasms  are  due  to  irritation  of 
the  hypersensitive  terminal  nerves  of  the  mucous 
membrane  of  the  stomach,  which  in  turn  excite  the 
cells  in  the  brain.  If  this  theory  be  the  true  one, 
it  is  difficult  to  explain  why  tetany  is  not  more  fre- 
quently met  with  than  it  is,  in  view  of  the  many  se- 
vere conditions  of  the  stomach  with  which  it  is 
never  associated.  And,  too,  the  fact  that  the  early 
weeks  of  pregnac}'  are  very  nearly  quite  immune 
to  tetany  speaks  against  the  reflex  theory,  because 
at  this  time  there  is  an  increase  in  all  the  reflex 
phenomena.  One  case  was  reported  in  which  a 
young  woman  who  had  been  subject  to  attacks  of 
tetany  prior  to  becoming  pregnant,  was  entirely 
free  from  seizures  for  a  period  of  several  months,  al- 
though she  vom.ited  nearly  every  morning  during ' 
this  period.  3.  The  third  theory  is  based  upon  the 
belief  that  there  are  certain  toxic  substances  elabo- 
rated and  reabsorl:)ed  by  the  stomach  which  produce 
the  manifestations  seen  in  tetany.  This  auto-intoxi- 
cation theory  is  the  one  most  supported  by  experi- 
mental and  clinical  research.  An  increasing  num- 
ber of  the  foremost  observers  in  this  line  of  re- 
search have  accepted  this  theory.  Kulneff,  as  well 
as  Bouveret  and  Devic,  have  done  much  by  their 
admirable  experimental  work  to  establish  and 
strengthen  the  theory  of  auto-intoxication  in  tetany. 

Pathology. — The  opportunities  for  the  study  of 
the  pathological  changes  which  occur  in  gastric 
tetany  have  been  surprisingly  few.  and  compara- 
tively little  has  been  learned  concerning  the  mor- 
bid changes  which  take  place  in  this  affection. 

Quite  recently  an  article  appeared  in  the  Central- 
blatt  fucr  Iiincre  Mcdicin,  from  the  pen  of  Ferranini, 
giving  the  results  of  his  study  upon  the  histological 
changes  in  a  case  of  tetany  following  Reichman's 
disease,  which  terminated  fatally.  In  this  article  he 
gives  a  very  clear  picture  of  all  the  pathological 
changes  which  were  found  by  him. 

On  post-mortem  examination,  the  stomach  was 
found   enormously  dilated.     The  pylorus  and    the 


•Rend  before  the  .\n>^ri':an  Gastro-E"terologici 


ssociatio".  Ma.-   Isf, 


upper  portion  of  the  duodenum  were  also  dilated, 
and  entirely  without  hypertrophic  alteration,  a  fact 
of  especial  interest,  as  it  shows  that  stenosis  of  the 
pylorus  is  not  a  necessary  accompaniment  of  Reich- 
man's  disease. 

His  studies  seem  to  indicate  that  gastritis  does 
not  precede  Reichman's  disease.  He  claims  to  have 
been  able  to  trace  out  the  different  stages  in  the  his- 
tological changes  pari-passu. 

In  the  first  stage,  the  glandular  ducts  and  fundi 
are  dilated,  and  the  parietal  cells  are  slightly  swol- 
len and  clouded.  In  the  second  stage  the  dilatation 
increases,  the  parietal  cells  become  much  clouded 
and  swollen  and  project  into  the  lumen  of  the 
glands,  and  are  increased  in  number.  The  principal 
cells  are  shrunken  and  decreased  in  number.  The 
interstital  tissue  was  not  in  this  stage  increased, 
but  later  there  was  a  small  celled  infiltration,  slight 
fibrous  thickening,  and  hyperemia.  These  inflam- 
matory changes  were  very  superficial  and  most 
marked  at  the  outlets  of  the  glands,  where  in  spots 
small  erosions  and  ulcerations  were  seen. 

In  the  third  stage,  all  the  previously  described 
changes  reached  their  highest  degree.  The  princi- 
pal cells  were  almost  entireh'  destroyed.  The 
parietal  cells  were  enormously  enlarged,  and  the 
number  decreased,  and  in  all  stages  of  granular  de- 
generation. In  the  neighborhood  of  the  most  de- 
generated glands  the  connective  tissue  had  the  ap- 
pearance of  cicatricial  tissue.  At  these  points  the 
inflammatory  changes  could  be  traced  to  the  sub- 
mucosa. 

He  observed  in  the  first  stage  evidences  of  hyper- 
secretion only,  which  is  soon  followed  by  hyper- 
plasia of  those  elements  which  are  called  upon  to 
produce  the  increased  secretion.  As  a  further  re- 
sult of  hypcrsection  there  is  hyperemia  followed 
by  inflammator}-  processes.  From  this  Ferranini 
argues  that  the  gastritis  is  the  effect  and  not  the 
cause  of  hypersecretion.  As  a  further  result  of  this 
hypersecretion  and  hyperacidity,  the  terminal  nerve 
filaments  become  irritated,  and  nutritive  changes 
follow,  with,  as  a  final  result,  dilatation  of  the  stom- 
ach. 

Numerous  attempts  to  demonstrate  the  terminal 
nerve  fibrils  in  the  gastric  mucosa  by  the  gold- 
chloride  and  Golgi's  osmo-chromic  acid  methods, 
were  unsuccessful.  Ferranini  attributes  his  failure 
in  this  respect  to  alterations  in  the  nerve  terminals. 
However,  I  do  not  think  it  proves  disease  in  the 
nerve  terminals,  because  these  methods  in  the  hands 
of  the  most  skilled  are  uncertain  when  applied  to 
the  nerves  of  the  mucosa. 

The  kidneys  showed  very  little  pathological 
change.  There  was  only  very  insignificant  increase 
in  the  connective  tissue  development  in  the  liver, 
which  increase  was  most  marked  about  the  bile 
ducts  and  blood  vessels. 

The  most  important  changes  were  obser\-cd  in 
the  nerve  centers,  especially  in  the  motor  cells  of 
the  medulla  oblongata  and  in  the  dorsal  portion  of 
the  cervical  cord,  where  nearly  all  the  nerve  cells 
showed  pathological  alterations.  The  perivascular 
spaces  were  dilated.  The  cells  were  much  and  va- 
riously deformed  in  shape,  mostly  longish-oval.  bis- 
cuit shaped,  shrunken  at  the  margins,  and  especially 
in  the  i-'lnniii<  <xi  Clarke  much  swollen.     The  cell 


May  LS.  ISOIJ 


GASTRIC  TETANY 


TThe  Philadelphia 
Lmedical   Journal 


971 


walls  were  much  thickened.  The  cell  protoplasm 
showed  various  degenerative  alterations,  from  slight 
alterations  of  form  of  the  chromophile  granules  to 
complete  granular  disintegration  of  them,  and  in- 
volving either  parts  of  or  the  entire  cell.  Many  of 
the  cells  were  infiltrated  with  yellow  pigment,  some- 
times to  an  extreme  degree.  Other  of  the  nerve 
cells  showed  changes  of  the  achromatic  substance, 
which  in  many  places  was  completely  destroyed, 
leaving  vacuoles.  The  nucleus  was  usually  distort- 
ed, often  so  enlarged  as  to  occupj^  nearly  the  entire 
cell,  and  usually  periplierally  situated  or  protrud- 
ing from  the  margin  of  the  cell.  The  nerve  pro- 
cesses were  often  thin  and  knobbed. 

These  observations  of  Ferrranini  in  regard  to  the 
changes  in  the  central  nervous  sj'stem  are  in  accord 
with  those  previously  made  by  Weiss,  Bonome  and 
Cervisato  and  others.  All  clinical  and  experimental 
researches  go  to  prove  that  these  lesions  are  caused 
by  the  absorption  of  poisons  elaborated  in  the  stom- 
ach. The  exact  nature  of  these  toxins  has  not  yet 
been  determined,  so  far  as  I  am  aware,  although 
severa'.  experimentors  have  been  able  to  separate 
certain  toxic  substances  which  are  capable  of  pro- 
ducing tetanic  convulsions. 

Symptoms. — The  attacks  are  usually  preceded  by 
premonitory  symptoms,  as,  a  feeling  of  nausea  with 
or  without  vomiting,  or  there  may  be  a  pain  or  burn- 
ing in  the  stomach,  or  a  tingling  in  the  finger  tips, 
or  a  sense  of  unutterable  fatigue  in  the  group  of 
muscles  about  to  be  affected,  as  occurred  in  my  sec- 
ond case.  At  times  there  may  be  no  warning  of  the 
impending  attack.  The  spasms  are  almost  invaria- 
bly symmetrical,  and  usually  begin  in  the  hands  and 
extend  upward  to  the  arms.  In  a  few  cases  the 
spasms  have  begun  in  the  toes  and  extended  up- 
ward, involving  legs,  thighs  and  trunk.  In  rare  in- 
stances the  attack  began  in  the  hands  and  extended 
upward  until  the  muscles  of  the  neck  and  jaws  were 
affected.  These  spasms  are  tonic  in  character,  and 
either  paroxysmal  or  continuous,  or,  as  Allbutt  puts 
it,  either  intermittent,  remittent,  or  continuous.  The 
hands  assume  a  position  which  is  designated  as  the 
obstetrical  hand,  so  called  for  obvious  reasons.  The 
flexor  group  of  muscles  are  the  ones  especially  af- 
fected. The  contractures  are  painful,  and  any  at- 
tempt to  overcome  the  rigidity  greatly  increases 
the  pain.  The  duration  of  the  spasm  varies  from  a 
minute  to  several  hours  or  even  days.  Conscious- 
ness in  most  cases  remains  undisturbed,  but  may  be 
partially  or  wholly  lost,  and  further,  may  vary  in 
different  attacks  in  the  same  individual.  Reflexes 
are  usually  normal.  Both  the  electrical  and  the 
mechanical  irritability  of  the  nerves  and  muscles 
of  the  parts  affected  are  increased  for  some  time 
after  the  attack,  and  are  looked  upon  as  character- 
istic symptoms  of  the  disease. 

Prognosis. — The  prognosis  in  tetany  depends 
upon  the  particular  disease  with  which  it  is  asso- 
ciated, and  upon  the  nature  of  the  attack.  In  a  gen- 
eral way,  in  mild  attacks  of  short  duration,  not  as- 
sociated with  lesions  of  the  stomach,  which  are  of 
themselves  serious,  a  favorable  prognosis  may  be 
made.  On  the  other  hand,  a  prolonged,  severe  at- 
tack accompanying  well  marked  ischochymia  is  a 
very  grave  complication,  and  in  such  cases  the  rate 


of  mortality  is  very  high,  being  placed  by  Bouveret 
and  Devic  as  high  as  70%. 

Treatment. — The  treatment  of  tetany  should  be 
that  for  the  particular  gastric  disorder  with  which 
it  is  associated.  In  addition  the  bromides,  especially 
the  bromide  of  strontium,  should  be  given  with  a 
maximum  dose  in  the  beginning  and  alter  a  greater 
or  lesser  length  of  time  be  gradually  reduced. 

CASE   I. — Mr.    I ,   merchant,    age    forty    years;    well 

nourished  and  muscular:  o£  nervous  temperature,  but  o£ 
cheerful  disposition.  His  family  history  was  negative  ia 
so  far  as  it  had  any  bearing  upon  his  present  illness.  He 
had  never  had  an  illness  severe  enough  to  confine  him  to 
liis  bed  tvvo  days  in  succession.  Has  led  a  temperate  life. 
Has  been  troubled  with  mild  attacks  of  dyspepsia  for 
more  than  ten  years.  These  periodic  attacks  have  been 
increasing  in  frequency  and  severity  until  at  present  they 
are  well  nigh  continuous.  At  times  during  the  first  three 
years  of  this  period  he  was  was  annoyed  with  spells  of 
dizziness  whenever  worried  or  hurried  after  eating  a  hearty 
meal.  Seven  years  ago.  after  enduring  the  paroxysms  of 
vertigo  for  three  years,  he  was  attacked  suddenly  witli 
what  he  calls  "a  fit."  He  was  then  travelling  and  one  af- 
ternoon immediately  aften  an  unusually  heavy  dinner  he 
received  a  telegram  to  return  home  to  meet  a  crisis,  and 
while  hurrying  to  pack  his  belongings  and  at  the  same 
time  worrying  as  to  the  outcome  of  the  impending  affair 
he  became  unconscious  and  had  what  was  then  diagoosed 
an  epileptic  fit.  When  he  regained  consciousness  his  arms, 
felt  so  very  sore  and  stiff  that  he  could  not  use  them  for 
some  hours;  he  was  nauseated.  For  eleven  months  there 
was  no  recurrence,  at  which  time  he  passed  through  a 
second  convulsion,  which  was  preceded  by  a  severe  at- 
tack of  nausea  and  vomiting.  .Again  he  noted  the  ex- 
cessive soreness  and  stiffness  of  the  muscles  of  his  arms- 
These  attacks  have  been  increasing  in  frequency  until  at 
the  time  when  he  came  to  me  in  December  1900  he  was 
having  from  two  to  three  a  week.  During  the  past  tw& 
years  he  has  retained  consciousness  throughout  some  of  the 
attacks,  although  he  invariably  falls  to  the  floor  with 
vertigo,  unless  there  be  a  chair  or  bench  near  at  hand 
During  these  attacks  he  noticed  that  the  muscles  of  the 
arms  and  chest  alone  seem  to  be  knotted  beyond  his  con- 
trol, and  excessively  painful;  and  further,  that  the  attack 
is  invariably  ushered  in  with  vomiting  of  an  extremely 
acid  liquid  with  or  without  admixture  of  food.  The  at- 
tacks in  which  consciousness  is  lost  are  not  preceeded  by 
vomiting,  but  are  usually  followed  by  both  nausea  and 
vomiting  upon  return  of  consciousness.  He  says  that  for 
some  hours  before  the  occurrence  of  a  spasm  he  has  an 
insufferable  feeling  of  weariness  and  lassitude.  He  says- 
he  has  warded  off  attacks  by  drinking  a  pint  of  hot  water 
in  which  he  dissolved  a  table  spoonful  of  baking  soda,  which 
caused  him  to  vomit.  His  friends  tell  me  that  during  the 
attacks  in  which  consciousness  is  lost  his  hands  and  fore- 
arms are  flexed  and  rotated  inward:  the  fingers  and  thumbs 
are  flexed  and  claw-like:  and  that  in  the  beginning  of 
the  attack  there  are  muscular  twitchings  which  gradually 
become  quiet,  although  the  contractures  continue.  The 
head  is  rotated  more  or  less  to  the  right  side.  The  tongue 
is  not  protruded,  nor  has  he  ever  bitten  it.  His  spasms  last 
for  three  to  ten  or  twelve  minutes.  For  the  past  ten 
years  he  has  suffered  from  severe  burning  sensations  in 
the  stomach  and  along  the  esophagus,  which  are  relieved 
for  an  hour  after  partaking  of  food.  He  belches  very  con- 
stantly an  odorless  gas.  His  appetite  is  excellent,  but  he 
has  sense  of  hunger  a  couple  of  hours  after  meals.  Thirst 
is  abnormally  increased.  If  his  stomach  is  empty  beyond 
the  usual  time  for  meals  he  is  hungry  and  nauseated  at 
tue  same  time.  His  bowels  are  obstinately  constipated, 
not  having  enjoyed  an  unaided  movement  in  fifteen  years. 
Has  no  pain  in  stomach  or  bowels.  Has  lost  only  ten 
or  fifteen  pounds  in  weight  in  the  past  three  years. 

Present  condition.  Heart  and  lungs  normal.  Tongue 
clean  and  moist,  showing  no  scars  or  indentations.  Breath 
not  offensive.  Epigastrium  not  sensitive  to  pressure. 
Splashing  sound  is  produced  over  the  stomach  from  ensi- 
form  process  to  navel.  Moderate  tenderness  in  right  iliae 
region,  where  there  is  some  increased  resistance  noted. 

On  examining  the  stomach  in  a  fasting  condition  it  was 
found  to  be  empty.  One  hour  after  the  test  breakfast: 
acidity  104,  free  HCl  SS;    dextrin  very  much,  erythrodex- 


972 


The  Philadelphia  " 
Medical  Journal   . 


FL'X'CTIOXAL  TESTS  OF  HEARIXf, 


[May   1&,    iWl. 


trin  present.  The  urine  was  normal,  excepting  for  large 
numbers  of  uric  acid  crystals  present.  Feces  showed 
nothing  of  interest  excepting,  as  has  been  often  noted  by 
me  in  cases  of  hyperchlohydria,  large  numbers  of  triple 
phosphate  crystals  were  observed. 

The  treatment  in  this  case  consisted  of  a  suitable  diet, 
with  small  fretjuent  meals;  teaspoonful  doses  of  sodium 
bicarbonate  an  hour  after  mealS:  to  be  repeated  in  an 
hour  if  the  pyrosis  was  not  relieved.  Bromid  of  strontium 
In  five  grain  doses  before  meals.  For  five  weeks  after  be- 
ginning this  treatment  he  had  no  recurrence  of  the  spasms 
but  thiniiing  himself  cured,  one  evening  after  a  hard  days 
work  he  ate  a  hearty  dinner  of  most  ill-favored  combina- 
tion of  foods  one  could  well  imagine  and  went  to  bed 
shortly  thereafter.  On  awaking  in  the  morning  he  felt  the 
soreness  and  stiffness  in  the  muscles  of  his  chest  and 
arms  and  was  told  by  his  wife  that  he  had  had  anothei' 
"fit"  as  a  result  of  his  folly.  He  has  had  only  one  other  recur- 
rence up  to  the  present  time,  and  that  again  was  the  re- 
sult of  over-eating. 

CASE    II. — Mrs.    E ,   nearly    60    years   of   age.      Had 

typhoid  fever  about  20  years  ago,  from  which  she  made  a 
perfect  recovery,  and  remained  in  good  health  up  to  three 
years  ago,  when  her  digestive  troubles  began,  since  which 
time  she  has  been  gradually  getting  worse. 

Present  condition:  Appetite  is  good.  Is  very  thirsty  and 
her  mouth  is  often  dry.  Tongue  clean  and  moist.  About 
two  hours  after  meals  has  a  feeling  of  weight  and  oppres- 
sion in  pit  of  her  stomach,  accompanied  with  "a  misery," 
which  lasts  until  food  or  magnesia  are  taken.  Often 
has  water-brash.  Belches  an  odorless  gas  so  constantly 
that  it  is  a  source  of  much  annoyance  to  her.  Has  no 
nausea  or  vomiting.  Bowels  are  regular.  Feces  and  urine 
are  normal.  During  the  past  eight  or  ten  months  she  has 
been  suffering  at  times  from,  attacks  during  which  she  was 
unable  to  use  her  arms,  and  which  last  from  a  few  minutes 
to  an  hour.  These  attacks  be!?in  with  a  distress  in  her 
stomach  which  is  soon  followed  by  a  feeling  of  weariness 
and  actual  pain  down  the  flexor  surfaces  of  her  arms, 
forearms  and  hands.  After  a  few  minutes  she  uses  the 
power  of  movement  in  these  limbs:  the  elbows  are  drawn 
close  to  the  sides  of  her  body,  the  arms,  forearms  and 
hands  rotated  inward:  the  hands  are  flexed  at  the  wrists 
and  assume  the  Trousseau  position.  During  this  time  the 
feeling  of  weariness  has  passed  off,  but  the  pain  con- 
tinues, aud  any  attempt  to  change  the  position  of  either 
of  these  members  caused  greatly  increased  pain.  Twice 
only  have  the  muscles  of  the  neck  become  involved.  The 
second  time  it  occurred  in  my  ofBce  immediately  after  I 
had  withdrawn  the  gastric  contents  through  a  tube.  While 
the  tube  was  still  in  her  stomach  she  began  to  experience 
much  weariness  and  pain  in  her  arms.  Upon  withdraw- 
ing the  tube  a  spasm  in  the  upper  extremities  followed, 
typical  of  tetany.  After  lasting  for  about  two  minutes,  the 
head  was  rotated  slightly  to  the  right  and  backward  and 
appeared  fixed.  The  muscles  of  the  face,  jaws  and  tongue 
were  not  effected.  In  two  or  three  minutes  the  spasm 
passed  off,  leaving  her  weak  and  nervous,  with  stiffness 
of  the  muscles  of  her  arms,  but  none  in  those  of  the 
neck.  The  following  morning  I  was  called  to  her  home  to 
relieve  the  pain  and  stiffness  in  the  muscles  at  the  back 
of  her  neck.  I  found  these  muscles  much  swollen  and  pain- 
ful, which  rendered  her  unable  to  rotate  her  head.  This 
condition  subsided  in  about  four  days. 

Examining  the  gastric  contents  one  hour  after  the  test 
breakfast:  acidity  59,  free  HCI  53;  dextrin  present,  ery- 
throdextrin  very  much. 

The  treatment  In  tli:s  case  was  s:m::ar  to  that  persued  in 
Case  I.  except  that  in  the  place  of  the  bromid  salt  I  or- 
dered Phospho-glycerite  of  I-ime  in  capsules. 

In  my  first  case  there  is  much  to  suggest  a  com- 
plication of  tetany  with  epilepsy,  and  certain  it  is 
that  he  has  two  very  different  kinds  of  attacks,  but 
having  the  same  after  effects,  viz. :  the  marked  sore- 
ness and  stiffness  of  the  muscles,  which  are  at  the 
time  affected.  That  this  case  is  one  of  epilepsy  only 
I  do  not  believe,  both  on  acount  of  the  nature  of 
the  attacks,  the  after  effects,  and  because  ot  the 
marked  relief  which  has  followed  the  simple  treat- 
ment which  he  has  carried  out,  the  20  grains  of 
bromid  salt  in  divided  doses  daily  not  being  suffi- 


ciently powerful  to  control  the  convulsiona  of  a 
well-established  epilepsy  of  seven  years'  standing. 
I'hat  my  second  case  is  gastric  tetany  may  be  ac- 
cepted, 1  think,  without  further  comment. 

THE  FUNCTIONAL  TESTS  OF  HEARING. 

By   WILLIAM   LINCOLN   BALLENGER,   M.   D., 

of    Chicaso. 

.\.s.tii.stant  Professor  of  Otologj;     knmo.u^y  and  laryngology,    college  of 

I'hysician.-,  and  .Mirgcons. 

The  value  of  the  functional  tests  of  the  organ 
of  hearing  as  aids  in  the  diagnosis  and  prognosis  in 
diseases  of  the  ear  has  for  more  than  three  genera- 
tions been  a  controversial  subject.  In  spite  of  thi.-> 
fact  they  are  still  used  and  recommended  by  most 
of  the  great  authorities  on  otology,  .\iuch  dis- 
cussion lias  arisen  because  of  certain  exceptions  to 
the  general  rules  laid  down  b}^  various  writ- 
ers, or  on  account  of  an  imperfect  understanding^ 
of  the  principles  underlying  the  physiological  ex- 
periments. Ihe  fact  that  three  generations  of  otol- 
ogists have  used  them  and  are  using  them  more 
L^enerally  now  than  ever  before  is  a  fair  indication 
I  1  their  utility,  and  of  their  fixed  place  in  otologic 
practice. 

1  can  do  no  better  than  quote  Prof.  A.  Politzcr 
in  this  connection:  "The  tests  for  hearing  are  of 
the  greatest  importance  in  the  diagnosis  of  diseases 
of  the  ear ;  for  thej-  serve  not  only  to  determine  the 
extent  of  the  disturbance  of  hearing,  but  not  infre- 
quently also  to  localize  the  affection,  inasmuch  a-^ 
i'l  cases  in  which  the  other  objective  methods  o» 
examination  give  a  negative  result,  we  are  enabled 
*.o  judge  whether  the  anatomical  cause  of  the  func- 
tional disturbance  has  its  seat  in  the  apparatus  for 
the  conduction  of  sound  or  in  the  nerve  apparatus. 
Hut  thej-  are  also  of  special  value  because  by  mean> 
of  them,  while  the  patient  is  under  observation,  wc 
can  note  the  course  of  the  disease,  and  also  the  re- 
sult of  the  treatment.'" 

Some  Physiological  Facts. —  (a)  The  normal  range  of 
hearing,  in  man.  for  musical  tones  is  from  16  tc> 
about  48,000  \ibrations  per  second.  After  the  fifti- 
eth year  the  upper  limit  of  hearing  is  somewhat 
lowered.  Persons  seventy  or  more  years  old  do  not 
usually  hear  tones  of  more  than  37.000  vibrations. 

(b.)  Soimd  waves  reach  the  labyrinth  chiefly 
through  the  tympanic  membrane,  the  ossicles,  and 
the  oval  window  into  which  the  foot-plate  of  the 
stirrup  is  inserted.  As  you  all  knc)w,  the  foot-plate 
does  not  form  a  bony  union  with  the  oval  window, 
but  is  attached  to  it  by  means  of  a  fibrous  mem- 
brane or  ring.  This  allows  it  to  vibrate  freely  ii< 
the  window.  Politzer  first  demonstrated  that  the 
malleus  performed  the  greatest  excursions,  the  in- 
cus less,  and  the  stapedius  least  of  all.  Helmholtz 
found  the  greatest  excursions  of  the  stapes  to  be 
iii8-i'i4mm.  It  can  readily  be  seen  that  slight  in- 
terference with  the  movements  of  the  foot  plate 
I'V  either  adhesive  bands  or  anchylosis  at  the  win- 
dow will  very  materially  interfere  with  the  func- 
tion of  hearing, 

(c.'l  It  is  more  than  probable  that  sound  waves 
also  reach  the  labyrinth  through  the  round  window. 

lituwjs thr    fnnctinn    nf    the    rnr    i'    nnt — alliiyillR'i 

hence  the  function  of  the  ear  is  not  altogether 
destroyed  when  tlie  foot  plate  is  fixed. 

•Read   before   the   Chicago   Laryngological   and   CUmatololog- 
Ical  Society.  Feb.  2S.  1901. 


May   IJi.   Will  J 


FUNCTIONAL  TESTS  OF  HEARIXG 


CTHE    PHII.ADELPHIA 
MEDICAL   Journal 


973 


(d.)  Sound  Waves  are  also  carried  to  the  laby- 
rinth to  a  considerable  extent  through  the  bones  of 
the  skull.  This  explains  the  somewhat  startling 
fact  that  certain  deaf  persons  hear  tolerably  well 
if  the  speaker  places  the  tips  of  his  fingers  against 
the  forehead  of  the  listener.  It  is  well-known  that 
if  whenatuning  fork  of  512  vibrations  is  placed  upon 
the  skull  and  the  external  meatus  is  artificially 
closed  with  the  finger,  the  vibrating  fork  is  heard 
much  better  on  that  side.  In  other  words,  bone  con- 
tluction  is  thercbj-  increased. 

(e.j  In  the  normal  ear  bone  conduction  for  tun- 
ing forks  is  a  little  more  than  one-half  the  time  of 
hearing  by  air  conduction.  Most  text  books  state 
that  it  is  about  one-half.  In  my  text  book  which 
appeared  last  year,  I  make  this  statement.  This, 
should  be  somewhat  qualified  as  the  relative  dura- 
tion of  hearing  by  bone  and  air  conduction  varies 
greatly  with  dift'ertnt  forks  of  the  same  number  of 
vibrations.  It  will  also  vary  with  the  point  of  con- 
tact made  with  the  fork.  For  instance  it  is  heard  a 
little  longer  when  placed  over  the  mastoid  antrum 
than  when  placed  on  the  tip  of  the  mastoid.  It  is 
customary  with  most  otologists  to  place  it  between 
these  two  extremes  be  just  posterior  to  the  external 
meatus.  At  this  point  m}-  fork  will  register  in  the 
normal  ear  about  12  seconds  by  bone  conduction, 
while  it  is  heard  28  seconds  by  air  conduction, 
Politzer  has  wisely  called  attention  to  the  varying 
results  obtained  by  forks  of  the  same  number  of 
vibrations.  Each  set  of  forks  should  be  carefully 
and  repeatedly  tested  upon  normal  cases  so  as  to 
establish  its  its  normal  register.  Gradinego  at  the 
last  International  Congress  of  Otologists,  of  which 
1  had  the  honor  of  being  a  member,  gave  a  scheme 
for  the  uniform  record  of  the  functional  tests,  in 
which  he  gives  the  register  of  his  fork.  This  should 
be  done  by  all  observers.  In  this  way  our  reports 
will  be  of  much  greater  value  to  otologists  in  gen- 
eral. 

(f.)  The  tensor  tympani  and  stapedius  muscles 
have  long  beeb  regarded  as  the  tension  regulatorsof 
the  drum-head,  the  stapedius  counter-balancing  the 
tensor  tympani.  A  few  years  ago  Dr.  T.  F.  Rum- 
bold  wrote  an  article  to  the  effect  that  they  were  the 
tone-selecting  muscles  of  the  ear  as  the  ciliary 
muscles  are  the  view-point  selectors  of  the  eye. 
In  other  words,  that  they  are  the  focusing  muscles 
of  the  ear.  He  says  that  through  their  action  one 
selects  the  voice  from  a  multitude  of  voices  he  wish- 
es to  hear;  and  that  they  attune  the  drum-head  to 
catch  and  transmit  to  the  labyrinth  the  sound  waves 
desired  by  the  listener. 

(g.)  The  normal  ears  of  a  given  subject  perceive 
sound  in  its  actual  pitch.  Both  ears  perceive  it  ex- 
a.:tly  alike.  They  co-ordinate  in  pitch  timbre  and 
intensity.  In  certain  pathologic  states  one  or  both 
ears  may  get  "out  of  tune." 

In  order  that  we  may  have  a  simple  basis  for  the 
study  of  the  physiologic  tests  of  hearing,  I  will 
here  quote  from  my  text  book  *  the  principles  un- 
derlying them.  I  ha^•e  thus  formulated  them  for  use 
in  my  clinical  teaching  and  have  found  them  of 
great  value   in   making  the  subject  attractive   and 


•Eye,  Ear,  Nose  and  Throat,  Ballanger  and  Wippern,  pp.  182- 
183. 


lucid  to  Students  of  otology.  They  are  herewith 
given  with  slight  ainendmeiU  and  explanatory  re- 
marks. 

l-'nuciplcs  Underlying  the  Tests  of  Hearing. —  (i; 
i  he  normal  range  ot  hearing  is  from  16  to  48,000 
vibrations  per  second,  i  he  upper  limit  of  hearing 
IS  lowered  after  the  50ih  year  Irom  senile  changes, 
independent  of  other  pathologic  process. 

(2.)  When  the  conduction  apparatus  is  diseased 
or  obstructed  the  power  to  hear  low  tones  is  im- 
paired or  lost. 

(.3. J  \V  hen  the  perception  apparatus  is  diseased, 
I  he  power  to  hear  hign  tones  is  generally  unpaired 
or  lost,  'ihere  are  cases  in  whicu  ihe  ruie  wul  not 
uold  good,  high  tones  being  heard  when  there  is  un- 
(.loubLcU  labyrinthine  disease.  1  he  exceptions  are 
bO  rare,  however,  that  the  rule  is  of  greac  vaiue  in 
uiffereniiatihg  between  middle  ear  and  labyrinthine 
disease.  r\s  age  diminishes  bone  conduction  the 
rule  IS  not  of  so  great  vaiue  m  testing  the  aged. 

{4.)  'ihe  normal  ear  hears  about  twice  as  long  as 
by  bone  conduction,  .^s  already  stated,  this  rul.; 
snould  be  somewhat  modified,  as  bone  conduction 
for  some  forks  is  more  than  hall  as  long  as  air 
conduction,  while  in  others  it  is  shorter,  'i  his  is  not 
a  matter  of  great  importance,  however,  as  the  rule 
applies  more  particularly  to  the  use  of  the  Rinne 
experiment,  in  which  the  most  important  question 
IS,  as  to  whether  it  is  positive  or  negative  Rinne. 
The  rule  also  applies  to  the  Schwaback  test,  and. 
therefore,  a  more  accurate  statement  is  desired.  In 
recording  the  results  of  the  Schwaback  test  the 
number  of  seconds  the  vibrating  fork  is  heard  by- 
bone  conduction  and  by  air  conduction  is  noted. 
For  instance,  if  the  normal  time  of  the  fork  is  12 
seconds  by  bone  and  28  seconds  by  air,  and  it  heard 
only  15  seconds  by  air  conduction,  the  rule  as 
above  stated  would  show  that  either  air  conduction 
IS  shortened.  Each  fork  used  for  this  test  should 
be  tested  on  a  number  of  normal  ears  and  its  register 
determined.  In  reporting  cases  the  register  and 
number  of  vibrations  should  be  stated  so  as  to  avoid 
further  confusion  in  this  regard. 

(5.)  When  the  conduction  apparatus  is  diseased 
or  obstructed,  bone  conduction  is  increased  and  the 
time  left  in  which  the  fork  should  be  heard  by  air 
conduction  is  diminished ;  or  bone  conduction  is 
often  lengthened  so  as  to  exceed  air  conduction  in 
duration. 

(5.)  When  the  perception  apparatus  is  diseased, 
bone  conduction  is  shortened  or  is  entirely  absent, 
so  that  the  relative  time  of  hearing  by  air  conduction 
is  increased. 

(7.)  In  addition  to  the  above  principles  I  might 
add  the  following:  When  the  normal  ear  once 
clearly  hears  the  tick  of  a  watch  upon  approaching 
the  patient,  it  will  be  heard  as  i^  is  gradually  with- 
drawn to  a  greater  distance.  The  distance  to  which 
it  may  be  withdrawn  and  still  be  heard  varies  from 
6  to  t8  inches.  In  some  cases  of  impaired  hearing 
there  is  inability  to  hear  the  watch  as  it  is  with- 
drawn beyond  the  point  at  which  it  is  distinctlv 
heard  upon  the  approach.  Rumbold  thinks  this  is 
due  to  weakness  of  the  tensor  tympani  muscle.  I 
have  observed  the  sign  in  a  number  of  poorly  nour- 
ished and  neurasthenic  cases,  in  which  it  might  well 
be  true  that  there  was  muscle  weakness,  although 


974 


The  Philade:,phia"| 
Med:cai.  jolknal    J 


FUX'CTIOXAL  TESTS  OF  HEARING 


[Mat  1*,    ISO! 


1  am  not  certain  as  to  the  significance  of  this 
sign. 

The  AppLcatiOii  uf  the  Functional  Tests. — We  are 
now  ready  to  discuss  the  apphcation  of  some  oi 
the  most  approved  physiologic  expermienis  per- 
taining to  the  ear  with  the  hope  of  arrivmg  at  some 
conckision  as  to  their  value  as  aids  m  diagnosis  and 
prognosis.  It  is  not  assumed  by  the  writer  that  a 
correct  diagnosis  cannot  usually  be  made,  or  at 
least  pretty  accurately  guessed  at,  without  the  use 
of  the  functional  tests.  We  grant  as  much.  The 
only  question  herein  discussed  is  as  to  the  reliability 
of  the  tests  in  cases  in  which  there  is  some  doubt 
as  to  the  diagnosis.  I  may  be  pardoned  for  remark- 
ing just  here  that  one  should  make  constant  use  of 
the  tests  in  order  that  he  may  become  skillful  in 
their  application  and  in  his  deductions  therefrom. 
It  may  be  necessary,  therefore,  for  some  to  make  it 
a  routine  practice  to  apply  them  to  all,  or  nearly 
all,  cases  coming  under  their  observation.  The 
writer  has  for  several  years  made  this  his  practice  in 
both  clinical  and  private  practice.  He  feels  that 
he  has  been  well  rewarded  for  his  trouble,  and  the 
convictions  herein  expressed  are  based  upon  this 
experience.  The}'  are  offered  for  your  thoughtful 
consideration  with  the  hope  that  you  will  add  to 
his  knowledge,  rather  than  he  will  add  to  yours. 

The  Watch  Test. — This  instrument  has  long  been 
used  to  test  the  acuteness  of  hearing  and  is  of  more 
or  less  value.  The  patient  may  be  able  to  hear  the 
watch  distinctly  at  about  the  normal  distance  and 
j'et  not  understand  conversation,  or  vice  versa. 
While  it  may  not  ailord  an  accurate  means  of  diag- 
nosis, it  is  often  a  means  bj-  which  comparisons  may 
be  readily  made  from  time  to  time  during  the  pro- 
gress of  treatment.  In  catarrhal  inflammation  of 
the  middle  ear,  and  especially  of  the  Eustachian 
tube  the  watch  may  be  heard  distinctly  one  day 
and  indistinctly  or  not  at  all  another  day.  This 
variation  is  rather  diagnostic  of  this  type  of  ear 
disease,  and  is  accounted  for  by  the  intermittalit. 
through  irregular  stoppage  of  the  lumen  of  the  tube 
and  the  subsequent  absorption  of  the  oxygen  from 
the  middle  ear.  When  the  tube  becomes  clear  again 
air  is  restored  to  the  tympanic  cavity  and  the  nor- 
mal tension  of  the  drumhead  and  ossicular  chain 
is  restored.  We  use  two  watches,  one  a  high- 
pitched  ticker,  the  other  a  low  one.  The  low-pitched 
ticker  is  one  of  the  dollar  Ingersoll  watches,  and 
can  be  heard  at  a  distance  of  ten  feet,  while  the 
high-pitched  ticker  (a  Paillard's  non-magnetic 
Swiss)  can  be  heard  at  five  feet.  Prout's  method  of 
recording  the  result  of  the  test  is  used,  i.  e.,  the 
number  of  inches  the  watch  is  heard  by  the  normal 
car  is  used  as  the  denominator  and  the  distance 
at  which  it  is  actually  heard  as  the  numerator. 
Thus,  if  the  Pailldrd,  or  high-ticker,  is  used  and  it 
is  heard  at  lo  inches  the  fraction  ten-sixtieths  ex- 
presses the  result.  If  the  loud-ticker  is  used  and 
is  heard  at  30  inches  the  fraction  thirty-one  hun- 
dred and  twentieths  expresses  the  result.  There 
are  four  ways  of  using  the  watch,  namely,  (a)  find- 
ing the  distance  at  which  it  is  heard  upon  approach- 
ing the  ear;  (b)  placing  it  in  firm  contact  with  the 
auricle ;  (c)  placing  it  against  the  mastoid  process : 
(d)  placing  it  between  the  teeth  and  noting  in 
which  ear  if  is  heard  the  plainest,  as  in  the  Weber 


experiment;  and  finally  (ej  after  first  finding  the 
distance  at  which  tlie  watch  is  heard  upon  approach, 
and  then  noting  how  much  farther  it  can  be  hearc 
upon  withdrav.'ing  it  from  the  ear.  As  before  stated, 
Ivumbold  uses  this  test  to  ascertain  the  tonicity  of 
the  Stapedius  muscle.  'Ihe  writer  has  also  used  it 
for  the  same  purpose  for  the  last  three  years  and 
imds  improvement  in  such  cases  follows  the  admin- 
istration of  strychnia,  iron,  rest,  and  out-door  exer- 
cise. 

The  Voice  Test. — In  1S71  Oscar  Wolf  published 
his  conclusions  as  to  the  voice  as  a  means  of  testing 
the  organ  of  hearing.  He  found  the  letter  R  to  be 
the  lowest  in  the  scale,  having  128  vibrations  per 
second,  while  the  highest  number  of  vibrations  was 
given  by  S  wTiich  gave  form  5400-10840  vibrations 
per  second.  Hence,  by  the  use  of  these  two  con- 
sonants we  may  test  the  hearing  for  the  lower  and 
within  two  octaves  of  the  highest  musical  tones. 
With  marked  limitations  this  experiment  may  be 
used  to  differentiate  between  disease  of  the  middle 
car  and  of  the  labyrinth.  He  found  speech  in  other 
words  to  be  confined  within  about  6%  octaves.  The 
greatest  strength  and  timbre  belongs  to  the  vowel 
A,  which  can  be  heard  252  m.,  and  the  smallest  to 
the  consonant  H,  which  can  be  heard  at  8.4  m. 
distance.  And  so  he  goes  on  to  classify  the  various 
sounds  and  letters  so  that  they  may  be  used  for 
testing  purposes.  There  are  several  objections  to 
this  method  of  testing  in  spite  of  the  great  amount 
of  scientific  investigation  bestowed  upon  it  by 
Wolf,  Clarence  Blake  and  others.  If  words  are  used 
the  patient  often  hears  only  the  vowel  sounds  dis- 
tinctl)^  and  if  numerals  are  used  he  experiences  the 
same  difficulty  with  the  additional  one  of  attempting 
to  infer  the  number  by  sequence.  Then,  too,  there  is 
the  difference  in  the  quality,  timbre,  pitch  and  car- 
rying quality  of  the  voices  of  different  observer?. 
This  difi'erence  is  less  pronounced  in  the  whispered 
voice,  especially  if  it  is  given  c)ut  with  the  residua; 
air.  In  fact,  when  the  whispered  voice  is  used  it 
should  be  given  only  with  the  residual  air.  thus 
rendering  all  voices  more  nearly  alike.  As  a  careful 
analysis  of  Wolf's  method  would  require  many 
pages,  it  will  not  be  considered  further  here.  Suffice 
it  to  say  that  a  thoughtful  application  of  his  methoil 
will  aid  the  diagnotition.  and  will  be  useful  in  not- 
ing the  progress  made  under  treatment. 

The  Politzcr  Acowncfcr. — This  instrument  was  d;:- 
signcd  to  take  the  place  of  the  watch,  or  at  least  to 
supplement  it,  and  can  be  heard  at  about  40  feet. 
All  of  the  instruments  are  supposed  to  be  of  the 
same  pitch  and  timbre,  but  in  the  mad  rush  of 
-American  dealers  I  fear  little  attention  has  been 
given  to  their  exact  construction.  It  is,  however, 
a  valuable  adjunct  to  the  watch  tests,  and  may 
be  applied  in  the  same  way,  40  feet  being  taken  fc-r 
the  denominator,  and  the  actual  number  of  feet  at 
which  it  is  heard  as  the  numerator.  Politzer  and 
Lucac  claim  it  more  nearly  corresponds  with  th-- 
^•oice  test  than  either  the  watch  or  distance  tests 
with  the  tuning  forks. 

^lany  ingenious  physiologic  tests  of  more  or  les^ 
value  have  been  devised,  but  after  all  the  most  valu- 
able are  those  made  with  the  tuning  forks  and  whis 
ties.    We  will  now  proceed  to  discuss  some  of  the 
more  valuable  ones. 


May  18,  1901] 


FUNCTIONAL  TESTS  OF  HEARING 


TTHE    PHII.*DEI.PHIA  „,r 

LMEDICAL  JOUKNAL  V/0 


The  Range  of  Hearing. — As  already  stated,  the  nor- 
mal range  of  hearing  for  adults  under  50  years  of 
iige  is  from  16  vibrations  to  48,000  per  second.  Af- 
ter the  fiftieth  year  this  may  be  reduced  to  37,000  pet 
second.  In  other  words,  the  upper  register  is  low- 
ered by  the  changes  incident  to  senility.  By  refer- 
ing  to  the  third  principle  we  find  that  high  tofies 
are  diminished  or  lost  in  disease  of  the  perception 
or  nerve  apparatus,  hence  in  applying  this  principle 
the  age  of  the  patient  should  be  taken  into  account. 
The  upper  limit  of  hearing  is  also  lost  in  certain 
conditions  of  the  middle  ear,  notably  in  marked  re- 
traction of  the  drumhead  whereby  the  footplate  of 
the  stapes  is  forced  inwards  against  the  labyrinthine 
fluid.  This  increased  pressure  so  afTects  the  ter- 
minal endings  of  the  auditory  nerve  as  to  interfere 
with  the  perception  of  high  tones.  This  condition 
can  usually  be  readily  differentiated  from  true 
labyrinthine  or  nerve  deafness  by  inflation  of  the 
middle  ear.  This  procedure  usually  restores  the 
normal  tension  to  the  drum-head  and  ossicles,  and 
thereby  relieves  the  increased  intratympanic  ten- 
sion. The  upper  limit  of  hearing  being  restored, 
the  diagnosis  can  easily  be  made. 

The  best  outfit  for  making  a  complete  test  of  the 
range   of   hearing   is   the    Bezold-Edlemann   set   of 
forks  and  whistles.     With  these  every  musical  tone 
from   16  to  48,000  vibrations  can  be  tested.     This 
is  very  important  in  a  certain  number  of  cases,  more 
especially  in  deaf  mutes.     It  is  a  well-known  fact 
that  a  large  percentage  of  so-called  deaf-mutes  are 
not  totally  deaf,  but  only  to  such  an  extent  that 
they    do    not    hear    well    enough    to    learn    speech. 
Then,  too,  some  of  them  can  only  hear  certain  tones 
in  the  entire  range  of  hearing.     In  these  cases  these 
j       tones   should   be   ascertained,   and   they   should   be 
;       trained  to  distinguish   sounds,   musical  tones,   and 
j       speech  at  these  pitches.  The  information  gained  by 
this  simple  test  may  be  made  the  avenue  through 
'       which  some  of  these  poor  unfortunates  are  brought 
within  the  range  and  influence  of  the  greatest  pleas- 
ure  in   life,   namely,   social    conversation   with   his 
fellows. 

By  referring  to  the  second  principle  we  find  that 
in  disease  of  the  conduction  apparatus  the  power 
to  hear  low  tones  is  impaired  or  lost.  Loss  of  hear- 
ing for  low  tones  is,  therefore,  usually  a  sign  of  mid- 
dle ear  disease  or  obstruction  to  the  external 
meatus.  It  must  not  be  forgotten,  however,  that 
i  the  portion  of  the  nerve  apparatus  concerned  in  the 
perception  of  low  tones  may  be  diseased  while  the 
other  parts  are  not  afifected.  In  this  case  the  loss 
of  low  tones  would  not  signifiy  middle  ear  disease. 
These  cases  are  exceedingly  rare,  and  would  not, 
therefore,  often  confuse  the  observer. 

The  Weber  Experiment. — This  is  one  of  the  best 
known  and  most  reliable  tests  made  with  the  forks. 
Weber's  experiment  consisted  in  placing  the  tuning 
fork  02,  512  v.,  on  the  median  line  of  the  skull,  and 
then  closing  the  external  meatus  of  one  ear  with 
the  finger,  under  which  conditions  he  found  the 
sound  lateralized  toward  that  ear.  Clinically  it  has 
been  shown  that  when  the  middle  ear  is  diseased,  or 
the  external  meatus  is  obstructed  by  cerumen  or 
other  morbid  conditions,  the  sound  for  the  vibrating 
tuning  fork  (when  on  the  median  line  of  the  skull), 
is  lateralized  to  the  affected  side;  and  that  when 


the  labyrinth  is  afifected  the  sound  is  lateralized 
toward  the  good  ear.  This  rule,  like  all  rules,  has 
exceptions.  If  the  labyrinth  and  middle  ear 
are  both  diseased  there  are  manifestly  two 
opposing  conditions,  one  increasing,  the  other 
decreasing  bone  conduction.  In  such  cases 
dependence  must  be  placed  upon  a  much 
more  extended  examination  of  the  case.  Indeed 
dependence  should  rarely,  if  ever,  be  placed  upon  a 
single  test.  Where  both  the  middle  ear  and  laby- 
rinth are  afifected  the  Schwaback  test  will  often 
help  to  clear  the  diagnosis.  By  this  test  both  the 
bone  and  air  conduction  are  measured  and  the  vari- 
ation from  the  normal  may  aiiford  evidence  of  the 
true  condition. 

Another  exception  to  the  rule  which  has  been 
noted  by  several  observers,  is  often  found  in  cases 
in  which  both  middle  ears  are  affected,  but  un- 
equally. Ordinarily  the  fork  is  lateralized  toward 
the  side  most  affected,  but  the  opposite  is  often  true. 
Hence  in  bilateral  deafness  the  Weber  experiment 
is  not  so  reliable  as  in  unilateral  deafness. 

In  simple,  or  uncomplicated  labyrinthine  disease, 
however,  the  fork  is  almost  universally  lateralized 
toward  the  good  ear.  Jacobson  and  Politzer  have 
never  seen  an  exception  to  this  in  undoubted  cases. 
The  test  seems,  therefore,  to  be  a  reliable  one  in  this 
class  of  cases. 

The  accuracy  of  the  Weber  test  will  depend  very 
much  upon  the  fork  used.  In  nearly  all  cases  the 
best  results  are  obtained  with  fork  c2  512  v.  Occa- 
sionally better  results  are  gotten  with  lower  ones. 
Higher  forks  should  not  be  used,  as  they 
often  give  exactly  the  opposite  result.  They  are 
almost  useless  for  making  this  test.  In  excep- 
tional cases  a  c2  512  v.  fork  may  not  be  at  all 
adapted  for  this  test.  W'hen  we  remember  that  a 
fork  of  a  higher  pitch  should  never  be  used  we  can 
readily  understand  why  a  C2  fork  with  marked  over- 
tones should  not  be  used.  The  high  over-tones 
might  so  counterbalance  the  true  tone  of  the  fork 
that  it  would  be  a  question  as  to  which  was  referred 
to  by  the  patient  in  response  to  the  test. 

According  to  Politzer,  when  the  result  is  question- 
able the  sound  will  be  lateralized  if  ear  specula  are 
inserted  in  both  external  meatuses.  He  also  calls 
attention  to  the  fact  that  in  double  chronic  middle 
ear  disease  the  sound  of  the  fork  may  be  lateralized 
to  one  side  when  placed  on  the  vertex  and  to  the 
other  when  placed  on  the  maxilla  or  base  of  the 
nose.  The  writer's  experience  leads  him  to  depend, 
chiefly,  upon  the  median  line  of  the  upper  teeth  and 
the  base  of  the  ear. 

The  Weber  test  is,  therefore,  found  to  be  more  re- 
liable in  unilateral  middle  ear  disease  and  somewhat 
less  reliable  in  labyrinthine  disease,  and  still  more 
unreliable  in  double  chronic  middle  ear  affections. 

The  Schzvaback  Test. — This  consists  in  ascertain- 
ingthenumberofsecondsthe  fork  is  heard  by  bone 
and  by  air  conduction.  The  result  is  to  be  compared 
with  the  normal  register  of  the  fork.  Thus,  if  the  nor- 
mal register  is  bone  conduction  10  seconds,  and  air 
conduction  20  seconds,  and  the  result  in  the  given 
case  is  bone  conduction  20  seconds  and  air  conduc- 
tion 18  seconds,  it  is  a  natural  conclusion  to  say  that 
there  is  an  increase  in  bone  conduction,  and  there- 
fore the  deafness  is  due  to  disease  of  the  conduction 


9 -A       The  Philadelphia  T 
/  Medical  Jovrmal    J 


FUNCTIONAL  TESTS  OF  HEARING 


[Mat  is.  aai. 


apparatus.  If  there  is  both  middle  ear  and 
labyrinthine  disease  the  result  is  very  dif- 
itrent.  It  would  be  something  like  this:  bone 
duction  o  seconds;  air  conduction  5  seconds.  Per- 
ception by  both  bone  and  air  being  reduced  below 
the  normal.  In  making  this  test  the  fork  should 
be  placed  over  the  mastoid  just  posterior  to  the  ex- 
ternal meatus.  It  will  make  some  difference  in  the 
result  if  it  is  placed  over  the  mastoid  antrum  rather 
tlian  the  tip  of  the  mastoid.  In  the  former  position 
bone  conduction  will  be  a  little  longer  than  in  the 
latter.  It  might  afford  useful  information  to  make 
tests  in  all  three  of  these  positions.  For  instance, 
if  there  is  a  small  antrum  from  sclerosis,  bone  con- 
duction should  be  diminished  as  compared  with  the 
normal  register.  The  writer  has  not  extensively 
experimented  in  this  direction,  but  only  throws  out 
the  suggestion  for  what  it  may  be  worth.  Dr.  A. 
H.  Andrews  has  done  considerable  work  along  this 
line  and  speaks  of  greater  differences  in  bone  con- 
duction from  the  3  points  on  the  mastoid  than  have 
been  observed  by  the  writer. 

The  Riniic  Test. — This  is  only  a  modification  of  the 
Schwaback,  or  rather  a  modification  in  the  method 
of  recording  and  drawing  deductions  therefrom. 
In  this  test  only  the  difference  between  bone  and  air 
conduction  is  recorded.  For  instance,  if  bone  con- 
duction is  25  seconds  and  air  conduction  is  15  sec- 
onds, it  is  recorded  negative  Rinn6  or  Rinn^  -10.  If 
air  conduction  is  10  seconds  longer  than 
bone  conduction  it  is  recorded  positive  Rinn<^ 
-|-  10.  By  this  test  if  air  conduction  exceeds 
that  by  bone  when  applied  to  the  deaf  ear 
there  is  nerve  deafness,  and  when  bone  con- 
duction exceeds  that  by  air  when  the  fork 
is  applied  to  the  deaf  ear  there  is  middle  ear 
deafness.  This  test  is  not  so  reliable  as  the  Weber. 
but  is  nevertheless  one  that  should  always  be  used 
in  conjunction  with  the  others. 

According  to  Lucae  the  Rinn^  is  only  reliable 
when  hearing  for  whispered  conversation  is  reduced 
to  I  m. 

If  there  is  increase  of  bone  conduction  to  such 
an  extent  that  a  negative  Rinn^  is  obtained  the  test 
is  pretty  reliable.  If,  however,  bone  conduction  is 
only  increased  to  a  moderate  extent  and  a  plus 
Rinn^  obtained,  it  does  not  afford  much  information. 
The  more  profound  the  deafness  from  middle  ear 
disease  the  more  reliable  is  the  test. 

If.  in  examinations,  there  is  a  correspondence 
between  the  results  of  the  Weber,  Schwaback  and 
Rinn4  tests,  the  latter  is  additional  proof  of  the  path- 
ologic condition  present.  Thus,  if  a  patient  com- 
plains of  deafness  in  the  right  ear  and  the  Weber 
test  lateralizes  to  the  right  side,  the  Schwaback 
shows  bone  conduction  25"  and  air  conduction  15". 
andtheRinnL^-TO.  the  Rinn^  corroborates  the  other 
tests  and  confirms  the  other  signs  pointing  to  middle 
ear  disease.  Ther  are  many  cases  in  which  the  diag- 
nosis is  in  doubt  when  the  information  afforded  by 
the  various  physiological  tests  render  the  diagnosis 
clear.  When,  however,  we  get  a  -Rinne  with  dura 
tion  of  bone  conduction  also  shortened,  there  mav  be 
some  doubt  as  to  the  significance  of  the  negati^-e 
Rinn^  ( — Rinni^).  In  such  oases  there  may  be  present 
both  middle  and  labyrinthine  diseases.  This  ap- 
parently anamolous  result  is  often  very  significant. 


and  should  lead  to  most  careful  investigation  and  to 
a  very  guarded  prognosis.  So,  it  is  often  the  case, 
that,  through  the  very  contradictions  arising  be- 
tween the  tests  that  we  are  enabled  to  arrive  at  a 
pretty  correct  idea  as  to  the  location  and  extent  of 
the  pathologic  process. 

In  middle  ear  disease  of  very  moderate  degree 
the  Weber  test  is  the  more  reliable  of  the  two. 

In  the  aged  the  Rinn^  test  is  not  so  reliable  on  ac- 
count of  the  diminished  bone  conduction  incident  to 
senility. 

In  severe  deafness  when  the  Rinn6  gives  the  posi- 
tive result  (plus  Rinn^)  it  is  a  prettj-  reliable  sign  of 
nerve  involvement. 

The  tuning  fork  best  suited  for  m.aking  this  exper- 
iment is  C",  512,  although  it  may  be  made  with  forks 
two  octavis  higher.  With  higher  forks  than  c- 
it  is,  however,  difficult  to  eliminate  hearing  by  air 
conduction.  Unlike  the  Weber,  the  lower  forks  are 
not  suited  to  this  test  as  upon  the  mastoid,  the 
patient  cannot  so  easily  distinguish  between  the 
mechanical  vibrations  and  the  tone  of  the  fork. 

The  fork  used  should  have  its  register  established 
by  numerous  experiments  upon  normal  ears,  and  in 
publishing  reports  of  cases  this  register  should  be 
named. 

The  Gelle  Test. — This  test  is  based  upon  the  physic>- 
logic  experiments  of  compressing  the  air  in  the  ex- 
ternal auditory  meatus,  while  the  vibrating  fork  is 
upon  the  vertex.  At  the  time  of  compression  the  per- 
ception for  the  tone  of  the  fork  is  greatly  diminished 
in  a  normal  ear.  This  is  due  to  the  increased  pressure 
within  the  labyrinth.  If  there  is  ankylosis  of  the 
foot-plate  (according  to  Gelle),  there  will  be  no 
change  in  the  tone,  he,  therfore,  claims  it  is  of 
value  in  diagnosing  this  condition.  If,  on  the  other 
hand,  there  is  marked  deafness  and  the  tone  is  great- 
W  diminished  with  each  compression  it  signifies  that 
the  foot-plate  is  freely  movable,  and,  that  deafness  is 
due  to  labyrinthine  disease.  My  own  personal  ex- 
perience with  this  test  does  not  warrant  me  in  ex- 
pressing an  opinion  as  to  its  value.  According  to  Pol- 
itzer,  it  is  only  of  value  in  cases  of  severe  deafness 
and  even  in  these  cases  often  fails  to  afford  inforftia- 
tion. 

Biiig  Test.  Xo.  I. — This  test  is  also  used  to  differ- 
entiate between  middle  ear  and  labyrinthine  affec- 
tions. This  experiment  is  based  upon  the  fact  that 
when  the  turning  fork  upon  the  mastoid  ceases  to 
be  heard,  it  is  heard  anew  when  the  external  meatus 
is  closed  with  the  finger.  In  cases  with  pronounced 
deafnesss  if  closing  the  meatus  does  not  develop  the 
tone  anew  it  is.  according  to  Bing.  a  sign  of  middle 
ear  disease,  whereas  if  it  is  heard  again  (in  cases  of 
pronounced  deafness)  it  is  a  sign  of  labyrinthine 
disease.  This  test  seems  to  be  of  value  only  in  very 
severe  deafness. 

B'mg  Test.  No.  2. — This  test  is  thus  referred  to  for 
the  sake  of  convenience  of  reference,  and  refers  to 
whatBingcalls  the"entotic"use  of  thespeakingtube. 
The  purpose  of  the  test  is  to  differentiate  between 
ankylosis  of  the  foot-plate  of  the  stapes,  and  adhes- 
ive bands  or  other  pathologic  condition  which  hin- 
ders the  malleus  and  incus  in  transmitting  sound 
waves.  The  test  is  made  by  comparing  the  hearing 
of  a  patient  through  a  speaking  tube  applied  to  the 
external  meatus  and  one  applied  to  the  Eustachian 


Mat  18.  1901] 


RUPTURE   OF   THE   EYE-BALL 


CThe  Philadelphia 
Medical  Journal 


977 


tube  by  means  of  a  suitable  fitting  to  the  Eustach- 
ian catheter.  If  the  patient  hears  better  through 
the  speaking  tube  by  way  of  the  catheter, 
than  he  does  through  the  external  meatus,  the 
inference  is  that  the  foot-plate  is  freely  mov- 
able while  the  malleus  and  incus  are  fixed 
or  hindered  in  their  vibrations.  If  such  is 
the  case,  a  rational  sort  of  treatment  is  at 
(■nee  suggested,  i.  e.,  either  the  freeing  of  the  mal- 
leus and  incus  from  the  adhesions  or  other  hin- 
drances or  removing  one  or  both,  perhaps,  prefer- 
ably only  the  incus.  The  sound  waves  might  then 
reach  the  foot  plate  through  the  vibrations  of  the 
i'ir  in  the  tynpanic  cavity  and  hearing  be  materially 
improved. 

A  condition  which  has  been  but  recently 
much  spoken  of  in  this  country  is  known 
under  various  names,  as  "'Spongifying  of  the 
Bony  Capsule  of  the  Labyrinth,"  "Multiple 
Sclerosis  of  the  petrous  portion  of  the  tem- 
poral bone,"  "Rarefying  osteitis  of  the  pet- 
rous portion  of  the  temporal  bone,  especially  that 
part  near  the  oval  window."  This  condition  was, 
I  believe,  first  described  by  Bezold  more  than  twelve 
years  ago,  but  is  best  known  by  the  writings  of 
Siebenmann.  Briefly,  it  is  a  rarefying  osteitis  of  the 
petrous  portion  of  the  temporal  bone,  especially 
that  part  around  the  oval  window.  It  begins  chiefly 
between  the  ages  of  eighteen  and  thirty,  with  grad- 
ually increasing  deafness,  although  it  may  progress 
in  rare  cases  by  leaps  and  bounds.  It  developes  in- 
dependently of  middle  ear  disease,  although  both 
may  be  present  in  the  same  case.  When  spongify- 
ing IS  present  alone,  the  case  may  be  readily  diag- 
nosed by  the  absence  of  any  objective  signs  of  mid- 
dle ear  desease,  and  by  the  three  signs  as  described 
by  Siebenmann,  namely,  (a)  increased  bone  conduc- 
tion for  fork  A ;  (b)  the  loss  of  hearing  for  low 
tones,  and  (c)  the  negative  Rinn^. 

In  closing  the  writer  wishes  to  say  that  he  has 
found  many  of  the  foregoing  tests  of  great  value  in 
making  a  differential  diagnosis,  and  in  estimating 
the  probable  course  and  termination  of  certain  cases. 
Of  course,  in  many  cases  all  this  can  very  well  be 
done  without  such  aids,  but  this  fact  does  not  minify 
their  importance,  but  rather  sets  them  apart  as  of 
especial  value  in  selected  cases. 

\\'hat  seem  to  be  numerous  exceptions  to  the 
rule  are,  after  all,  neither  numerous  nor  difl[icult  to 
understand.  This  is  true  if  they  are  studied  in  the 
light  of  well-known  physiologic  experiments,  rather 
than  as  arbitrary  exceptions  to  be  remembered  and 
used  empirically. 


A  Severe  Case  of  Anthrax  Cured  by  Injections  of  5% 
Carbolic  Acid.  W.  A.  Niemtchenkoff  O'of nno-medicinski 
Journal,  19(i0;  Mediciii-iloie  Ohogrenie,  February.  1901.)  reports 
the  case  of  a  man  who  developed  a  malignant  pustule  on 
the  right  cheek  near  the  eye.  The  infiltration  was  great 
and  the  systemic  manifestations  severe.  Injections  of  10 
%  springeful  of  a  o'^'c  solution  of  carbolic  acid  into  the 
affected  region  brought  about  a  prompt  subsidence  of  the 
alarming  symptoms,  resulting  finally  in  complete  recovery. 
The  author  states  that  while  weak  solutions  of  carbolic  acid 
may  cause  poisoning  from  the  absorption  of  the  drug  strong 
Bolutions   have  no   such  effect.     [A.   R.] 


REPORT  OF  A  CASE  OF  RUPTURE  OF  THE  EYE-BALL 
FROM  CONTUSION— LUXATION  OF  THE  LENS. 
HERNIA  OF  THE  IRIS  AND  CILIARY  BODY.* 

By  J.  W.   SHERER,   M.   D. 
of  Kansas  city.  Mo. 

On  February  25th,  1901,  D.  N.,  married,  art  47,  was  re- 
ferred to  me  by  the  courtesy  of  Dr.  Coons.  Patient  was 
seen  at  midnight  about  an  hour  after  having  received  a 
light  blow  on  the  outer  side  of  the  right  eye  with  the  tips 
of  the  fingers  of  the  open  hand  of  an  acquaintance  wiiU 
whom  he  was  liaving  a  friendly  sparring  match.  When 
seen  by  me  the  tension  of  the  eyeball  was  nil:  the  anter- 
ior chamber  was  completely  evacuated;  the  pupil  was 
distorted  and  displaced  upward  and  inward;  the  pupillary 
space  was  narrow,  elongated  and  extended  to  the  limbus 
opposite  a  point  where  a  rent  in  the  sclera  and  conjunctiva 
showed  the  black  mass  of  the  iris  and  ciliary  body  pro- 
truding. 

There  was  evidence  of  extensive  hemorrhage  into 
the  interior  of  the  eye-ball.  The  rupture  was  situated  about 
three  m.  m.  from  the  sclero-corneal  junction  and  extended 
about  5  mm.  in  a  line  parallel  with  the  same  from  50°  to 
about  80°  from  the  horizontal  in  the  upper  internal  quad- 
rant of  the  globe.  The  rupture  was  slightly  irregular  and 
Its  edges  somewhat  serrated.  The  location  corresponded 
accurately  to  what  is  described  by  T.  Collins  to  be  the 
typical  place  for  scleral  rupture  to  occur.  According  to 
Fuchs  the  rupture  is  most  likely  to  occur  90°  from  the 
point  where  the  disrupting  force  impinges  upon  the  eye- 
ball. He  bases  his  opinion  upon  the  hypothesis  of  Arlt, 
which  is  as  follows:  When  a  non-penetrating  force  is  ap- 
plied to  an  elastic  globe,  flattening  of  the  globe  occurs  with 
the  point  of  sharpest  curvature  at  a  right  angle  to  the 
axis  of  the  thrustiug  force.  Thus  if  a  blow  fall  directly 
upon  the  center  of  the  cornea,  the  place  of  sharpest  curva- 
ture, the  place  of  greatest  strain,  and  the  most  probable 
place  of  rupture,  will  be  at  the  equator.  Other  theories 
have  been  advanced.  One  is  that  of  rupture  by  contre 
coup  at  a  point  opposite  to  the  point  where 
the  thrust  is  received.  I  do  not  think  it 
possible  that  the  eye  ball  can  afford  perfect  exem- 
plification of  the  physical  forces  and  principles  involved, 
but  that,  as  in  the  present  instance,  the  place  of  rupture 
is  determined  by  the  compound  of  all  the  opposing  forces 
present.  In  other  words  the  rupture  will  occur  at  the 
weakest  place  assailed  by  a  sufficient  strain.  The  eye  is 
most  liable  to  violence  from  in  front  and  from  the  outer 
side. 

I  consider  that  it  is  peculiarly  the  very  prominent, 
protruding  eye  which  most  frequently  ruptures.  This  i'i 
vividly  shown  in  this  case.  You  will  observe  that  the 
patient  has  very  prominent  eyes  which  have  almost  no 
bony  protection  whatever  externally.  This  being  the  case 
the  rupture  will  tend  to  occur  in  the  upper  and  ftiner 
quadrant  of  the  globe.  The  sclera  varies  in  thickness.  Its 
diameter  of  one  mm.  posteriorly  gradually  diminishes  an- 
teriorly to  the  equator.  In  the  zone  just  behind  the  insertion 
of  the  recti  muscles  which,  as  you  know.is  five  to  eight  m.m. 
from  the  cornea,  the  diameter  is  .35  m.m.  More  anteriorly 
it  is  reinforced  by  the  tendinous  insertions  of  the  recti 
muscles,  these  becoming  interlaced  with  and  felted  into 
the  fibers  of  the  sclera.  Thus  we  would  expect  to  find  the 
weaker  spots  between  the  tendons.  In  fact  it  is  here  that 
nearly  all  ruptures  occur. 

Approaching  the  cornea  the  bundles  of  fibers  become  ar- 
ranged so  that  there  is  a  preponderance  of  those  fibers 
which  run  in  a  circular  direction  parallel  with  the  cornea. 
This  explains  the  invariable  extension  of  these  ruptures 
in  this  direction. 

On  account  of  the  late  hour  at  which  this  patient  was  first 
seen,  and  because  he  did  not  wish  to  enter  a  hospital,  it  was 
deemed  inexpedient  to  attempt  more  at  the  time  thaatoasep- 
licise  the  eye  and  apply  a  suitable  bandage.  Thus  protected 
the  patient  was  carefully  conveyed  to  his  home  and  placed 
quietly  in  the  recumbent  position.  Next  morning  under 
the  strictest  aseptic  precaution,  after  excising  so  much  of 
the  prolapsed  viscera  as  could  not  be  reposed,  with  a  very 
fine  sharp  needle  and  very  fine  black  silk  the  ruptured 
conjunctiva  and   episclera   were  sutured   conjointly.     The 

*Read  before  the  Kansas  City  Academy  of  Medicine  April  20tb,  I90r 


Q78       The  Philadelphia"! 
V/  Medical  Journal    J 


ANISOMETROPIA 


[Mat  1«,    UOL 


importance  of  great  care  in  securing  asepsis  will  be  better 
realized  when  it  is  remembered  that  the  vitreous  has  very 
little  power  or  resisting  infection.  In  fact  it  possesses 
a  number  of  qualities  necessary  to  a  good  culture  media 
for  bacteria,  including  alkaline  reaction  which  nearly  all 
bacteria  require. 

The  wound  being  closed,  atropine  was  instilled, 
both  eyes  bandaged,  a  calomel  and  soda  laxative 
given,  the  patient  admonished  to  lie  very  quietly  on  his 
back,  and  to  partake  of  no  food  except  such  as  was  light 
easily  digested  and  required  very  little  mastication.  The 
patient  was  very  obedient  and  contributed  all  in  his  power 
to  gaining  a  good  result.  For  several  days  the  eye  was 
asepticised  twice  daily;  then  when  it  was  seen  that  there 
was  no  inflammatory  reaction  worth  mentioning,  once 
daily.  On  March  4th,  the  seventh  day,  the  surgical  dres- 
sings were  removed.  March  6th  all  blood  had  disappeared 
from  the  anterior  chamber  which  was  again  established. 
The  pupil  was  still  occluded  with  blood  clot. 

The  left  eye  was  now  left  uncovered  one  hour  in  the  morn- 
ing and  afternoon,  and  the  patient  permitted  to  use  gentle 
exercise  during  these  periods.  March  14th  the  bandage  was 
removed  entirely.  The  tension  of  the  eye  was  again  normal. 
Smoked  coquilles  were  advised  to  be  worn  with  cotton  be- 
hind the  right  lens,  thus  closing  and  protecting  the  injured 
eye.  An  uneventful  recovery  was  thus  secured.  When  the 
blood  in  the  vitereous  was  absorbed  a  clear  fundus  was 
found.  The  lens  was  dislocated  and  a  -j  -  10. D.  lens  in  the 
ophthalmoscope  gave  the  best  view  of  the  retina.  On  the 
nasal  side  there  was  an  area  of  retinal  detachment  (ablatio 
retinaej.  The  ophthalmometer  showed  2.7.5  D.  astigmatism 
with  the  rule  and  the  best  vision,  6-12,  was  secured  with 
+  10.00  3.         -t-  2.00  c.  ax.  60\ 

I  wish  to  point  out  that  incised  wounds  of  the 
sclera  frequently  recover  and  that  ruptures  very 
rarely  do.  I  have  been  able  to  find  record  of  but 
three  cases  of  bona  fide  ruptures,  but  feel  assured 
that  they  occasionally  occur.  I  have  been  unable  to 
ascertainthepercentageof  recoveries,  but  systematic 
writers  uniformly  agree  that  these  cases  are  uni- 
formly lost.  The  violence  done  the  organ  of  vision 
is  best  indicated  by  calling  attention  to  the  great 
fragility   and   delicacy   of   its   internal    mechanism. 

The  scleral  capsule  is  tough  and  inextensible.  Its 
contents  are  soft  and  easily  di.sorganized.  The  at- 
tachment of  the  retina  in  its  most  vital  part  is  so 
slight  as  to  be  almost  elusive.  The  mesh-work 
which  contains  the  vitreous  fluid  and  makes 
it  a  body  instead  of  a  fluid  is  so  exquis- 
itely delicate  that  the  finest  gossamer  fila- 
ments of  silk  that  can  float  on  a  summer 
zephyr  is  as  a  ship's  hawser  compared  to  it.  Imagine 
the  pulpifying  effect  of  a  contusing  blow  sufficient 
to  burst  the  eyeball  by  compressing  its  contents,  as 
is  always  the  case  in  a  rupture. 

In  the  present  case  not  only  the  sclera,  but 
the  extremely  elastic  conjunctiva  also  was  rup- 
tured. The  degree  of  vision  saved  in  this 
case  is  three-sixths,  or  one-half  of  normal,  which  is 
considered  successful  for  a  cataract  operation.  Buc 
€ven  after  recovery  is  accomplished  there  are  still 
elements  of  hazard  in  the  sequel.  The  scleral 
cicatrix  may  become  cctatic  and  a  scleral  staphy 
loma  result.  Cases  are  known  where,  by  some  oc- 
cult means,  infection  lias  developed  after  many 
montlis  and  panophthalmitis  has  resulted. 

Retinal  detachment  may  occur  from  differen*^ 
causes,  such  as  the  violence  of  the  blow, 
sub-retinal  hemorrhage,  loss  of  vitreous,  and 
as  a  late  sequel  tension  upon  that  part  of 
the  uvea  connected  with  the  cicatrix  produced  bj^ 
cicatricial  contraction.  The  danger  of  irido-cyclitis 
ard  glaucoma  is  not  altogether  phantasmal.     That 


bug-bear,  or,  as  the  Germans  say,  das  Schreckens- 
gespenst,  sympathetic  ophthalmia,  is  always  within 
the  horizon  of  the  conservative  surgeon  when  a  dis- 
located lens  is  retained  within  the  globe,  as  in  this 
case.  However,  the  danger  is  very  remote,  and  the 
eye  is  likely  to  remain  quiescent  for  years. 


ANISOMETROPIA. 


By   NORBURNE   B.   JENKINS,   M.   D., 
of  Chicago. 

About  half  of  the  civilized  have  unlike  eyes;  one 
eyeball  is  different  in  shape  from  the  other,  and 
spectacles  are  required  with  the  two  glasses  ground 
differently.  This  trouble  is  called  anisometropia, 
and  a  study  of  it  may  show  the  general  practitioner 
why  many  are  unable  to  read  five  or  six  hours  a 
day ;  why  many  needing  proper  glasses  are  wrongly 
supposed  to  have  weakness  of  eyeball  muscles ;  why 
some  are  fitted  with  glasses  in  a  few  minutes  and 
others  are  never  fitted ;  why  the  importance  of  fit-  I 
ting  glasses  is  underestimated ;  why  nervousness  ' 
and  headaches  are  so  often  unrelieved. 

Farsightedness  is  the  most  common  of  all  eye 
imperfections.  Many  with  plain  farsightedness 
have  one  eyeball  flatter,  smaller  or  shorter  than  the 
other ;  again,  the  two  eyeballs  may  be  alike  and  one 
focusing  muscle  stronger  than  the  other.  Such,  at 
best,  are  often  difficult  to  fit ;  at  worst,  when  both 
focusing  muscles  and  eyeballs  are  unlike,  the  diffi- 
culty is  greatly  increased.  About  one-third  of  the 
people  have  the  same  degree  of  farsightedness  in 
each  eye,  and  also  have  one  focusing  muscle  just  as 
strong  as  the  other.  These,  sooner  or  later,  need 
spectacles  with  two  magnifiers  exactly  alike,  and, 
as  a  rule,  are  easy  to  fit,  often  fit  themselves  in  the 
stores.  Sometimes  one  eye  is  more  farsighted  and 
has  a  proportionately  stronger  focusing  muscle  than 
the  other,  consequently,  the  eyes  balance  and  un- 
like glasses  may  not  be  needed  until  late  in  life. 

In  most  plain  near-sightedness  one  eyeball  is 
longer  or  larger  than  the  other.  Such  are  wrongly 
supposed  to  be  more  easily  fitted  than  unlike  far- 
sighted  eyes.  Nearsightedness  is  the  least  common 
of  eye  imperfections,  and  is  rare  in  some  parts  of 
the  world  and  in  savage  and  semi-civilized  peo- 
ples. 

A  few  have  a  nearsighted  and  a  farsighted  eye, 
and  some  of  these  read  with  one  eye  and  see  at 
a  distance  with  the  other. 

In  astigmatism  the  eyes  are  usually  unlike,  for,  as 
a  rule,  one  eyeball  is  imperfectly  rounded  either  in 
a  different  location  or  to  a  greater  extent  than  the 
other;  often  both  the  location  and  amount  of  the 
astigmatism  are  different  in  each  eye.  Astigma- 
tisni  is  almost  as  common  as  farsightedness. 

.\bout  half  of  the  people  have  farsightedness 
united  with  astigmatism  in  one  or  both  eyes,  and 
worse  still,  one  or  both  imperfections  is  usually 
different  in  each  eyeball,  so  most  with  both  far- 
sightedness and  astigmatism  have  unlike  eyes. 
While  the  shape  of  the  two  eyeballs  is  usually  dif- 
ferent in  these  cases,  the  size  is  frequently  the  same, 
consequently,  if  magnifiers  are  used,  the  average 
power  of  each  glass  is  the  same,  an  important  guide 
in  balancing  such  eyes.* 

"N.  V.  Medical  Journal,  July.  1900.  page  ISS. 


Mat  is,  1901] 


ANISOMETROPIA 


TThe  Philadelphia       n70 
LMedical  Journal  V/V 


More  than  half  of  the  nearsighted  have  astigma- 
tism, and  it  is  common  for  the  amount  of  both  im- 
perfections and  for  the  location  of  the  astigmatism 
to  be  different  in  each  eyeball.  In  nearsightedness 
united  with  astigmatism,  one  eye  practically  al- 
ways requires  a  glass  ground  differently  from  the 
other,  and,  further,  the  average  concavity  of  each 
glass  is  usuall)'  different. 

Some  have  one  eye  about  perfect,  while  the  other 
is  somewhat  imperfect,  or  even  deformed  and  prac- 
tically useless. 

There  may  be  both  farsightedness  and  nearsight- 
edness in  the  same  eye.  This  is  mixed  astigmatism. 
Such  an  eye  may  be  perfect  in  size,  but  imperfect  in 
shape,  for  an  eyeball  may  be  as  much  too  broad 
across  as  too  short  up  and  down.  Mixed  astigma- 
tism is  somewhat  common,  and  is  easily  mistaken 
for  nearsightedness.  The  eyes  are  usually  unlike 
in   mixed   astigmatism. 

There  are  thirty-five  combinations  of  unlike 
eyes.  The  two  eyeballs  tend  to  be  the  same  size 
and  shape,  and  even  unlike  eyes  have  this  ten- 
dency. Eyes  with  less  farsightedness,  nearsighted- 
ness or  astigmatism  than  O.  25  D,  and  not  more  un- 
like than  O.  12  D,  may  be  considered  perfect.  Only 
about  one  person  in  a  hundred  has  such  eyes. 

In  unlike  eyes  one  focusing  muscle  gets  weak 
prematurely.  The  difference  in  the  strength  of  the 
two  muscles  is  usually  noticeable  at  the  age  of 
forty,  while  at  the  fiftieth  or  fifty-fifth  year  one  of 
the  muscles  is  often  powerless.  Sometimes  one  of 
the  focusing  muscles  never  develops  whether  the 
eyeball  is  perfect  or  not. 

In  unlike  eyes,  in  time,  the  sight  of  one  will  be 
better  than  the  other,  still,  with  right  glasses,  the 
sight  of  each  is  alike.  The  slightest  difference  in 
the  shape  or  size  of  the  two  ej'eballs  is  easily  dis- 
covered in  the  aged,  for,  if  tried  by  holding  a  mag- 
nifier before  one  eye  and  then  the  other,  fine  print, 
held  at  reading  distance,  is  more  distinct  to  one  of 
the  eyes.'  When  indicated,  a  concave  or  a  cylin- 
dric  glass  may  be  used  instead  of  a  magnifier.  The 
focusing  mechanism  in  children  is  so  powerful  that 
slight  degrees  of  unlike  eyes  are  often  impossible 
to  detect.  Belladonna  may  be  used  in  the  young, 
and  the  fine  print  test  tried  as  above. 

The  worst  results  of  unlike  eyes  are  crosseye  or 
squint,  and  its  blindness  and  another  blindness 
in  which  the  eyes  look  all  right  even  to  the  expert. 
Strange  to  say,  a  slight  difference  in  the  shape  of 
the  two  eyes  may  cause  these  troubles,  and  worse 
still,  it  is  usually  the  better  shaped  eye  that  suffers. 
In  crosseye  and  cockeye  the  eyes  are  usually  unlike 
in  shape  or  size,  and  the  strength  of  the  two  focus- 
ing muscles  is  always  different. 

About  half  of  aged  readers  with  unlike  eyes  have 
the  full  use  of  only  one  eye ;  the  other  has  become 
more  or  less  blind  from  suppression  of  retinal  im- 
ages and  non-use.-  This  blindness  comes  from  un- 
like eyes  and  lack  of  proper  glasses.  Every  pair  of 
peddlers'  and  store  spectacles  has  the  two  glasses 
exactly  alike,  and  cannot  suit  any  unlike  eyes,  and 
so  may  cause  this  blindness  which  may  come  in  un- 
like eyes  unless  glasses  make  fine  print  as  distinct  to 
one  eye  as  to  the  other.     If  the  aged  use  but  one 


1  Philadelphia 

2  Ophthalin 


nia  Medical  Journal.  December,  1899,  page  V2.'A. 
lie  Record,  February,  1900,  page  S3. 


eye,  they  are  not  particular  about  their  glasses,  just 
so  they  magnify  too  much.^ 

Three  or  four  years  ago  refractionists  thought 
all  was  known  about  correcting  eye  imperfections. 
Recent  investigations  show  that  more  than  half  of 
the  people  have  astigmatism,  unlike  eyes  or  both, 
and  sooner  or  later  have  trouble  in  reading  and  in 
getting  proper  glasses.  Astigmatism  is  easily  over- 
looked in  the  most  delicate  tests,  and  is  often  con- 
fused with  beginning  amblyopia.  It  is  often  diffi- 
cult to  discover  astigmatism,  much  less  to  deter- 
mine its  location  and  amount.  Uncorrected  or  im- 
properly corrected  astigmatism  causes  more  trou- 
ble to  readers  than  all  other  eye  troubles  put  to- 
gether. Some  read  all  day  and  others  have  pain 
and  blurring  after  reading  a  few  minutes.  This  dif- 
ference comes  from  misshapen  eyeballs  and  not 
often  from  weakness,  as  most  believe.  With  the 
right  spectacles,  most  with  illrshaped  eyeballs  can 
read  about  as  much  as  those  with  perfect  eyes. 
There  is  not  enough  known  about  fitting  simple 
farsightedness  and  nearsightedness,  and  in  compli- 
cated astigmatism  and  unlike  eyes  proper  glasses 
are  seldom  or  almost  never  obtained,  for  astigma- 
tism is  commonly  overlooked  or  about  half  correct- 
ed. Correction  of  astigmatism  is  by  far  the  most 
difficult  problem  and  work  in  ophthalmology. 

The  standard  text  books  contain  remarkable 
statements  about  anisometropia.  Different  treat- 
ments are  advised  and  theories  given  to  support 
them.     Some  authorities  say  : 

"With  different  glasses  the  two  retinal  images  of 
the  same  object  are  different,  and  so  cannot  match 
one  another,  cannot  perfectly  superimpose,  conse- 
quently, in  unlike  eyes,  either  give  the  same  glass 
for  both  eyes,  or  correct  only  one  eye  and  place  a 
plane  glass  over  the  other."     Others  follow  this: 

"If  the  eyes  are  much  unlike  only  the  better  one 
is  used  for  vision ;  the  other  has  not  been  used  to 
clear  images,  consequently  a  glass  which  makes  the 
siglit  normal  will  not  be  tolerated.  In  such  cases 
the  better  eye  should  be  fully  corrected,  and  the 
worse  eye  should  be  partially  corrected,  fitted  with 
a  plane  glass  or  given  the  same  glass  as  that  on  the 
better  eye." 

People  with  eye  imperfections  amounting  to  de- 
formity have  never  had  good  vision,  yet  these  "tol- 
erate" the  clearest  images  if  the  right  glasses  are 
given.  Those  blind  for  3'ears  with  cataract  wear 
best  glasses  that  give  best  sight.  ATany  with  eyes 
farsighted  exactly  alike,  but  with  unlike  focusing 
muscles,  wear  a  different  magnifying  glass  on  each 
eye  with  perfect  comfort.  In  an  imperfect  eye  with 
a  proper  glass,  and  in  a  perfect  eye,  images  are  the 
right  size.  If  "superimposing"  amounts  to  any- 
thing, images  of  imperfect  and  unlike  eyes  ought  to 
"superimpose"  if  glasses  make  them  like  the  images 
of  perfect  eyes  and  make  them  both  the  same  size. 

If  there  is  no  disease  and  no  deformity  ametro- 
pia (astigmatism  of  more  than  3.5  D,  or  farsighted- 
ness or  nearsightedness  of  more  than  7.D),  there 
is  nothing  to  prevent  use  of  both  eyes  at  the  same 
time  for  reading  or  far  vision,  provided  proper 
glasses  are  prescribed,  each  eye  fitted  right.*    The 

3  Journal,  A,  M.  A.,  May,  1H99,  page  lUiJ. 
4journal,  A.  M.  .\.. 'February,  1SJI9,  page  ;i.'>l. 


afin       'Fhe  Phii.apei.phia  1 
V""       Medical  Journal    J 


ANISOMETROPIA 


[May    18.    l*tt 


reasons  given  in  the  standard  text  books  for  these 
different  treatments  are  wrong.  If  the  sight  of  an 
eye  can  be  helped,  the  sight  should  be  made  as  near 
normal  as  a  glass  can  make  it,  otherwise  the  retina 
and  the  focusing  mechanism  may  suffer  from  non- 
use.  In  unlike  eyes  there  is  but  one  treatment,  dif- 
ficult though  it  be,  and  that  is  to  fit  each  eye  on  its 
own  merits.  If  this  is  properly  done,  the  eyes  bal- 
ance, see  alike  and  act  in  harmony. 

One  diopter  of  farsighted  astigmatism  affects 
the  size  of  the  eyeball  the  same  as  one-half  diopter 
of  farsightedness.  The  eyes  tend  to  be  the  same 
size,  and,  if  one  eye,  the  right  eye,  has  one  diopter 
of  farsightedness  and  one  diopter  of  farsighted  as- 
tigmatism, while  the  left  eye  has  half  a  diopter  far- 
sighted  astigmatism,  then,  it  is  usual  for  farsight- 
edness of  a  diopter  and  a  quarter  to  be  in  the  left 
eye,  when  spectacles  with  the  two  glasses,  each  of 
the  same  average  convexity,  will  be  required.  Typ- 
ical eves  may  further  sim.plify:  If  the  right  eye  re- 
quires':  +  O.  75  S.  =  +  O.  50  C. ;  +  O.  50  S.  =  +  i. 

C. :  +  O.  25  S.  =  +  I  50  C. ;  or  +  2.  C.  then,  as  a 
rule,  the  left  eye  will  require  one  of  these  four 
glasses,  or  even  a  +  i  S.  All  these  glasses  make 
dift'erent  images  and  yet  the  average  convexity  of 
each  is  the  same. 

Size,  shape  and  position  of  the  crystalline  lens  are 
not  considered  in  this  paper. 


JOURNAL  DES  PRACTICIENS. 
Majch  30,  1901.     (15me.    Annee,  No.  13.) 

1.  The  Evolution  and  Treatment  of  Strabismus  in  Young 

Children.      ROCHON-DUVIGNEAUD. 

2.  The  Choice  of  Catheters  and  the  Difflculties  of  Cath- 

eterization in  Hypertrophy  of  the  Prostate.     S.  BAN- 
ZET. 

3.  Surgical    Analgesia    by    Sub-arachnoidal    Injection    ot 

Cocain  through  the  Lumbar  Spine.     H.  MILHIET. 

1. — Convergent  strabismus  in  children  may  be  congeni- 
tal, it  may  occur  suddenly  with  convulsions,  or  it  may 
develop  gradually,  as  is  most  common,  between  2  and  3 
years  ot  age.  The  majority  of  cases  of  congenital  strabis- 
mus disappear  spontaneously.  The  absence  of  diplopia 
will  distinguish  strabisnms  from  oculomotor  paralysis 
Vision  cannot  be  determined  until  the  age  of  4  or  5  years 
and  it  is  then  found  uneiiual  in  the  two  eyes,  the  fixins; 
eye  having  far  superior  sight.  Most  such  children  show 
hypermetropic  astigm.atism.  The  squinting  eye  early  de 
velops  amblyopia  from  disuse.  While  these  cases  gener 
ally  recover  about  puberty,  the  amblyopia  persists.  In 
some  cases  diver.gent  strabismus  may  result  later.  Atrop 
ine  should  be  used  in  the  fixing  eye.  so  that  the  other  eye 
must  act  functionally,  for  the  good  eye  will  have  its 
accommodation  paralyzed.  This  should  be  dropped  into 
the  eye  for  tue  first  three  days  of  each  week,  or  tor  two 
weeks,  alternating  with  two  weeks  of  rest.  But  after  the 
age  of  4.  correcting  glasses  should  be  used.  Refraction 
is  done  under  atropine,  and  the  glasses  ordered  for  con- 
stant wear.  To  continue  the  use  of  the  squinting  eye.  the 
fixing  eye  should  be  bandaged  at  noon  for  the  rest  of  the 
day.  This  will  prevent  amblyopia  from  disuse,  and  neither 
the  one  eye  nor  the  other  will  become  the  permanent  fixing 
eye.  When  the  child  grows  older,  stereoscopic  exercises, 
tenotomv,  or  advancement  mav  effect  a  permanent  cure. 

[M.  0.1 

2. — In  hypertrophy  of  the  prostate,  regular  evacuation 
of  the  bladder  by  repeated  catheterization  is  the  ordinary 
palliative  method  of  treatment.  For  this  a  Nelaton  rubber 
catheter  or  a  Mercier  elbowed  catheter  can  be  used.  The 
former  is  preferable  for  the  patient's  own  use.  and  can  be 
easily  sterilized.  When  the  former  can  not  be  employed. 
the  latter  may.    But  this  is  hard  to  sterilize.    Many  sounds 


will  be  tried  before  the  correct  curve  is  found.  Besides. 
the  fact  that  the  prostatic  urethra  may  change  its  form 
must  not  be  forgotten.  A  catheter  that  has  passed  easily 
will  not  then  pass,  or  rice  lersa.  More  attempts  will  then 
be  necessary  with  different  catheters.     LM.  O.] 

3. — For  this  new  method  of  producing  analgesia,  a  1  or 
2%  solution  of  cocain  is  employed,  in  injections  of  %  to  4 
eg.  Large  doses  cause  distinct  after-effects.  The  solution^ 
the  needle,  and  the  patient's  back,  must  all  be  well  steril- 
ized. The  puncture  should  always  be  made  below  the  second 
lumbar  vertebra,  preferably  in  the  third  interspace.  The 
patient  should  be  sitting  up,  and  the  needle  should  be  9  or 
10  cm.  long.  A  few  drops  of  cerebro-spinal  fluid  is  allowed 
to  escape,  and  then  a  full  minute  is  given  to  slowly  inject- 
ing the  cocain.  A  collodion  dressing  is  applied.  Analgesia 
begins  in  the  feet,  and  gradually  rises  higher.  It  is  general 
in  10  minutes.  It  lasts  from  20  to  50  minutes,  depending 
on  the  dose  of  cocain  injected.  Nausea,  vomiting,  thirst, 
headache,  tremulousness,  and  anxiety  are  the  common 
after-effects.  Headache,  insomnia,  and  mental  troubles 
may  persist  for  some  time  afterward,  with  fever.  As  small 
a  dose  of  cocain  should  be  used  as  possible,  and  an  injec- 
tion ot  caffeine  and  morphine  given  before  operation.  Men 
bear  it  better  than  women.  It  should  never  be  employed 
in  children  under  16  years,  in  nervous  or  alcoholic  sub- 
jects, nor  when  a  long  operation  is  necessary,  in  which 
case  chloroform  is  to  be  preferred.  But  this  method  is 
especially  useful  in  the  debilitated  and  the  depressed,  those 
affected  with  pulmonary  or  cardiac  lesions,  nephritis  or 
arteriosclerosis,  and  in  those  who  object  to  general  anes- 
thesia.    LM.  O.j 

April  6,  1901.     (lome.    Annee,  No.  14.) 

1.  The  Psychic  Equivalent  of  Epilepsy.    P.  RAYMOND. 

2.  Enteroptosis.     FRANTZ  GLENARD. 

1. — In  epilepsy,  in  place  of  the  usual  convulsive  attack, 
motor,  sensory,  or  psychic  equivalents  may  occur.  Or 
psychic  manifestations  may  appear  with  or  after  an  ordi- 
nary fit.  In  a  girl  of  19,  the  attack  would  come  on  as 
usual,  but  convulsions  were  limited  to  the  pharynx.  She 
made  the  motion  of  swallowing  a  few  times,  then  was  her- 
self again,  ignorant  of  the  attack.  Another  had  hiccough, 
with  vertigo,  and  also  loss  of  consciousness  for  a  few 
seconds.  Another  whose  aura  was  always  great  hunger, 
would  lose  consciousness  after  feeling  hungry.  Another 
had  erotic  sensations,  became  unconscious,  rubbed  her 
abdomen  vigorously,  and  again  became  conscious.  One 
felt  very  happy  during  her  attacks;  another  showed 
sudden  sadness:  and  another  became  very  much  fright- 
ened. One  suddenly  observed  that  her  surroundings  were 
strange,  unknown  to  her.  though  she  had  seen  them  for 
months:  another  told  a  friend  that  he  was  pale,  then  fell 
unconscious  himself.  A  certain  word  pronounced,  an  in- 
comprehensible idea,  a  souvenir,  will  all  cause  these 
psychic  attacks,  with  or  without  convulsions.  More  inter- 
esting cases  are  reported      [M.  O.] 

2. — Enteroptosis,  descent  of  the  intestines,  hais  been 
considered  a  morbid  entity  since  1885.  Glenard  says  that 
it  may  occur  in  four  separate  conditions,  nervous  ailments, 
dyspepsia,  disease  of  the  liver,  or  general  constitutional 
illness.  It  is  very  common,  four-fifths  of  the  cases  being  in 
women.  The  symptoms  will  be  many,  pallor,  a  sad  expres 
sion.  complaints  of  feeling  badly  all  over,  loss  of  memory. 
of  the  power  of  concentrating  attention,  irritability,  etc. 
Symptoms  of  all  kinds  exist,  of  indigestion,  weakness, 
emaciation,  etc..  and  no  treatment  will  prove  beneficial. 
Examination  of  the  urine,  blood,  gastric  juice,  etc..  shows 
everything  normal.  Physical  examination  will  reveal  ten- 
derness in  the  epigastrium,  with  a  marked  epigastric  pul- 
sation, great  diminution  in  the  tension  of  the  abdominal 
wall,  and  the  transverse  colon  will  be  felt  crossing  the 
aorta,  about  the  size  of  a  cord,  freely  movable  under  pal- 
pation. The  rest  of  the  colon  will  also  be  palpable,  the 
cecum  alone  being  found  of  normal  size.  The  right  kidney 
may  be  movable,  and  the  right  lobe  of  the  liver  elongated, 
thin,  and  low  down.  These  are  the  three  main  symptoms, 
a  stenosis  of  the  colon  which  lies  low  in  the  abdomen,  mov- 
able kidney,  and  deformed  liver.  The  sustaining  ligaments 
of  the  viscera  are  relaxed,  and  gastroptosis.  enteroptosis. 
nephroptosis,  hepatoptosis.  splanchnoptosis,  finally,  fol- 
low. An  abdominal  binder,  correctly  applied,  will  aid  in  the 
treatment.     [M.  O.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company   and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hendrie  Lloyd.  A.  M.,  M.  D..  Editorin-Chiej 
JCLics  L.  Salinger,  M.  D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.  D.  F.  J.  K.alteyer,  M.  d. 

D.  L.  Edsall,  M.  D.  T.  L.  Coley,  M.  D. 

J.  M.  Swan,  M.  D.  W.  a.  N.  Dorland.  M  D. 

J.  H.  Gibbon,  M.  D.  T.  M.  Tyson,  M.  D. 

M.  Ostheimer,  M.  D.  a.  Robin,  M.  D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc..  of  interest  to  the  profession 
are  soliciled  for  publication.  Reprints  (250)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,    1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8. 


Vol.  VII,  No.  21 


May  2^,  1901 


53.00  Per  Annum 


The  Therapeutic  Monthly. — We  are  happy  to  an- 
nounce the  appearance  of  the  first  number  of  tliis 
new  journal  under  the  editorial  charge  of  Professor 
Tyson,  Dr.  Coley  and  Dr.  T.  'M.  Tyson.  In  appear- 
ance it  is  not  unlike  the  Philadelphia  Medical 
Journal,  and  will  constitute  an  important  month- 
ly companion  to  this  journal  for  those  of  our 
subscribers  who  have  availed  themselves  of 
the  opportunity  of  obtaining  it.  There  is  not, 
of  course,  a  more  important  field  in  scientific 
medicine  than  therapeutics,  and  the  new  journal  will 
cover  this  field  to  the  satisfaction  of  the  active  prac- 
tioner  who  wishes  to  keep  himself  and  his  practice 
fully  abreast  of  the  progress  of  the  times. 

The  Proposed  National  Bureau  of  the  Materia 
Medica. — The  necessity  of  definite  and  concerted 
action  on  the  part  of  the  profession  in  order  to  reg- 
ulate the  introduction  of  new  remedies  of  whatever 
class,  may  be  regarded  as  one  of  the  vital  questions 
for  discussion  at  the  St.  Paul  meeting  of  the  Amer- 
ican ^ledical  Association.  Our  Materia  Medica 
stands  in  need  of  careful  revision  and  cautious  ex- 
pansion. In  the  development  of  synthetic  chemis- 
try, with  its  tremendous  possibilities  in  the  field  of 
treatment,  we  witness  hundreds  of  products  placed 
daily  on  the  market,  and  to  this  class  may  be  added 
the  various  "special  formulae"  of  well-known  agents. 
The  scientific  work  done  in  the  well-equipped 
chemical  laboratories  of  these  firms  is  frequently 
of  the  highest  order,  and  there  can  be  little  doubt 
that,  as  such,  it  is  entitled  to  respectful  hearing  and 
full  investigation.  Along  with  the  meritorious  pre- 
parations are  hosts  of  worthless  ones  duly  pro- 
claimed as  of  great  value.  The  good  and  the  bad 
alike  are  seeking  endorsement.  The  question  of  the 
employment  of  proprietory  products  in  general  is  a 
broad  one.  It  is  too  vast  in  extent  and  impor- 
tance to  be  ignored  utterly.  In  this  connection,  we 
believe  that  the  plan  suggested  by  Dr.  F.  E.  Stew- 
art for  the  establishment  of  a  National  Bureau  of 
the  Materia  Medica  is  a  most  excellent  one  in  its 
general  scope.  It  is  Dr.  Stewart's  idea  that  such  a 
Bureau  should  be  empowered  to  examine  carefully, 
and  at  length,  the  pharmacology  of  such  new  reme- 
dies as  may  be  presented  for  its  official  sanction,  as 


w-ell  as  to  investigate  the  method  of  preparation, 
and  by  extended  clinical  trial  determine  the  value 
of  these  new  remedies.  The  duties  of  the  Bureau 
would  include  the  determination  of  a  suitable  meth- 
od of  standardization  of  all  of  the  remedies  of  the 
Materia  Medica.  Its  establishment  would  insure  a 
greater  amount  of  uniformity  in  our  drugs,  as  well 
as  supplying  us  with  reliable  information  as  to 
newly  discovered  products.  This  question  was 
brought  up  at  the  recent  meeting  of  the  American 
Therapeutic  Society  in  Washington,  and  a  Commit- 
tee was  appointed  to  investigate  the  matter.  This 
Society  also  took  the  initiative  in  the  important  mat- 
ter of  regulating  the  subjects  to  be  discussed  before 
it  by  passing  unanimously  the  resolution  declaring 
that :  "Any  therapeutic  agent  offered  for  discussion 
before  the  Society  should  be  discussed  under  its 
chemical  name,  and  not  under  its  fanciful,  patented, 
or  copyrighted  commercial  name."  It  is  our  opin- 
ion that  in  this  action  the  American  Therapeutic 
Society  has  done  a  wise  thing,  and  its  example 
should  be  followed  by  medical  bodies  generally. 

The  Treatment  of  Sarcoma  with  Toxins. — Every 
practitioner  of  every  branch  of  the  medical  profes- 
sion must  entertain  an  active  interest  in  anything 
that  pertains  to  the  cure  of  that  dread  malady, 
sarcoma,  and,  therefore,  w-e  can  commend  to  our 
readers  the  interesting  account  by  Dr.  William  B. 
C'oley,  of  the  "Late  Results  of  Treatment  of  In- 
operable Sarcoma  with  the  Mixed  Toxins  of  Ery- 
sipelas and  Bacillus  Prodigiosus,"  to  be  found  on 
another  page  of  this  issue  of  the  Journal.  This 
method  of  treatment,  introduced  a  number  of  years 
ago  by  Bull  and  Coley,  has  suffered,  as  have  so 
many  other  new  methods,  in  having  too  much  ex- 
pected of  it  by  the  profession  at  large,  even  more 
than  was  claimed  by  its  originators.  Hence  there 
has  been  considerable  criticism  of  the  treatment 
because  it  did  not  relieve  all  cases  of  sarcoma  in 
which  it  was  employed,  and  oftentimes  not  thor- 
oughlv  employed.  Coley,  however,  has  not  been 
discouraged,  but  has  continued  his  interesting  work 
and  now  gives  us  his  results  after  a  number  of  years 
have  elapsed  since  the  treatment  was  instituted,  and 
thev  are  such  as  to  impress  upon  any    but    a  con- 


f^Qo       The  Philadelphia"] 
V"''       Medical   Journal  J 


EDITORIAL  COMMENT 


[Mat  25.  19(0 


firmed  pessimist,  not  only  the  advisability,  but  the 
necessity  of  using  this  treatment  in  certain  forms 
of  inoperable  sarcoma.  He  shows  the  danger  of  the 
treatment  to  be  practically  nil,  and  only  recom- 
mends it  in  inoperable  cases.  If  he  and  other  sur- 
geons can  produce  an  occasional  cure  by  the  use 
of  the  mixed  toxins,  as  has  certainly  been  done,  then 
it  becomes  our  duty  to  a  patient  suffering  from  an 
inoperable  sarcoma  to  give  this  method  a  thorough 
and  conscientious  trial.  The  profession  certainly 
owes  to  Coley  a  debt  of  gratitude  for  his  careful 
and  painstaking  work  in  the  treatment  of  inoperable 
sarcomata,  where  all  our  former  methods  have 
proved  so  absolutely  hopeless. 

Auto-Inoculation  of  Cancer. — As  a  contribution  to 
the  subject  of  the  causation  of  cancer,  Dr.  A.  T.  Ca- 
bot reports  {Boston  Medical  and  Surgical  Journal, 
May  i6,  1901)  an  interesting  case  of  what  appears 
to  have  been  an  accidental  inoculation  of  cancer  in 
a  fresh  wound.  The  patient  was  a  man  who  was 
suiifering  from  cancer  high  up  in  the  anterior  wall 
of  the  rectum.  A  Kraske  incision  was  made  and  the 
cancer  dragged  down  into  this  opening  and  removed 
through  it.  During  this  manipulation  the  fluid  from 
the  cancerous  growth  was  rubbed  over  the  wound 
made  by  the  Kraske  operation.  At  the  end  of  four 
years  the  cancer  had  not  recurred  at  its  original 
site,  but  two  years  after  the  operation  a  hardening 
of  the  tissues  was  noticed  behind  the  rectum,  at 
some  distance,  of  course,  from  the  site  of  the  origin- 
al growth.  Cabot  operated  for  this  second  growth, 
which  was  about  as  large  as  a  hen's  egg.  On  micro- 
scopical examination  it  was  found  to  be  an  adeno- 
carcinoma with  colloid  degeneration  identical  with 
the  original  growth.  The  scar  in  which  the  second- 
ary growth  took  place  was  separated  by  an  inter- 
val of  five  or  six  inches  from  the  seat  of  the  original 
growth.  As  Cabot  points  out,  this  is  not  a  case 
of  direct  extension  of  the  disease.  The  lymphatic 
vessels  from  the  seat  of  the  original  disease  run 
upward  of  the  lumbar  glands,  and  not  downward 
toward  the  point  of  recurrence.  This  anatomical 
relation,  together  with  the  absence  of  any  lymphat- 
ic structure  in  the  recurring  nodule,  removes  any 
suspicion  of  this  having  been  a  secondary  growth 
in  a  lymphatic  gland.  It  seems,  therefore,  that  this 
was  a  transplanation  of  cancer;  in  other  words, 
a  true  autogenous  inoculation.  The  conditions  were 
certainly  favorable  for  such  an  event,  as  the  cancer 
ous  growth,  torn  and  squeezed  by  the  forceps, 
was  incidentally  rubbed  for  several  minutes  on  the 
fresh  wound. 

Dr.  Cabot  points  out  the  practical  importance  of 
taking  great  care  in  the  removal  of  cancer  to  avoid 
such  a  contingency.  From  a  pathological,  or  we 
may  saj'  theoretical  standpoint,  the  case  is  certainly 


an  interesting  and  apparently  conclusive  one.  It 
was  an  accidental  experiment,  such,  of  course,  as 
would  not  be  justifiable  intentionally  in  any  patient, 
and  therefore  of  unique  importance. 

The  Presidency  of  the  New  York  Lunacy  Com- 
mission.— The  State  of  Xew  York  is  fortunate  in 
obtaining  the  services  of  Dr.  Frederick  Peterson 
as  President  of  the  State  Lunacy  Commission,  and 
Governor  Odell  is  to  be  congratulated  on  such  a 
wise  and  discriminating  use  of  the  appointing  pow- 
er. The  Lunacy  Commission  of  that  State  in  re- 
cent years  has  not  altogether  succeeded  in  holding 
public  and  professional  confidence.  Its  wrangle 
with  the  Pathological  Institute  was  an  instance  that 
proved  that  it  hac|  not  the  wisdom  at  least  to  extri- 
cate itself  and  one  of  its  charges  from  an  embarrass- 
ing situation.  Whatever  the  merits  of  that  contro- 
versy may  have  been,  the  one  fact  that  remains 
most  apparent  is  that  the  trouble  should  never  have 
been  allowed  to  reach  the  acute  and  aggravated 
stage  in  which  the  public  came  to  know  it. 

Dr.  Frederick  Peterson  is  admirably  equipped 
to  step  in  at  this  juncture  and  bring  harmony  to 
both  the  administrative  and  scientific  work  which  is 
to  be  done  under  the  general  supervision  of  the 
Commission.  He  is  well  known  as  a  scientist,  and 
he  is  almost  equally  well  known  by  reason  of  his 
work  for  the  Craig  Colony  of  Epileptics  as  a  prac- 
tical man  of  affairs.  He  will  have  great  opportuni- 
ties now  to  do  good  work,  for  the  field  in  New  York 
is  a  great  one,  and  by  reason  of  its  importance  and 
prominence  is  always  looked  to  for  initiative  and 
good  example.  We  think  the  occasion  is  also  oppor- 
time  to  express  confidence  in  a  Governor  who  has 
already  given  many  proofs  that  he  believes  it  to 
be  his  business  to  govern. 

A  Psycho-Physical  Laboratory. — Efforts  are  be- 
ing made  to  induce  the  United  States  Government 
to  establish  a  laboratory  of  this  kind  in  the  Depart- 
ment of  the  Interior.  If  properly  equipped  and 
conducted  by  competent  students  of  psychology, 
such  a  laboratory  would  be  of  distinct  ser\'ice.  The 
present  cry  of  "degeneracy"  for  every  aberrent  and 
vicious  display  of  human  nature  does  not  have  our 
sympathy,  and  we  could  only  endorse  the  founding 
of  such  a  laboratory  if  we  felt  sure  that  it  would 
be  conducted  on  strictly  scientific  and  critical  lines, 
and  not  merely  to  exploit  the  theories  and  fads  of  in- 
expert and  visionary  compilers.  A  vast  field  re- 
mains to  be  explored  in  psycho-physics,  but  it  is  » 
most  difficult  and  involved  one.  To  conduct  the  in- 
vestigations which  are  to  be  the  object  of  such  a 
laboratory,  will  require  the  skill  of  men  who  have 
high  natural  and  acquired  attainments.  Such  talent 
can  be  commanded  in  most  fields  by  the  L'nited 


Mat  25,  1901] 


EDITORIAL  COMMENT 


CThb  Philadelphia       qRi 
Medical   Journal         -'"j 


States  Government  much  more  easily  than  it  can  be 
found  in  psycho-physics,  and  it  will  behoove  the  au- 
thorities at  Washington,  if  they  consent  to  under- 
take this  scheme,  to  recall  constantly  the  fact  that 
not  only  money,  but  also  men,  are  recjuired  to  equip 
a  laboratory. 

The  Treatment  and  Prophylaxis  of  Rabies. — The 

department  for  the  treatment  of  rabies,  of  the  in- 
stitute for  infectious  diseases  in  Berlin,  was  opened 
in  1898,  on  the  recommendation  of  Dr.  Robert 
Koch.  In  1896  there  was  a  marked  increase  in  the 
number  of  cases  of  rabies  in  Berlin,  from  66,  the  in- 
cidence in  1895,  to  128,  the  incidence  in  1896.  In 
1896  the  mortality  was  3.13%.  In  1897,  there  were 
161  cases,  with  a  mortality  of  ^.iifo;  in  1898,  263 
cases  with  a  mortality  of  3.42% ;  in  1899,  287  cases 
with  a  mortality  of  1.05%  ;  and  in  1900,  384  cases 
with  a  mortality  of  0.27%.  These  figures  demon- 
strate that  although  the  number  of  cases  of  rabies 
has  steadily  increased  since  1896,  the  mortality  since 
the  opening  of  this  department  of  the  institute  has 
fallen  until  it  has  reached  the  remarkably  low  per- 
centage quoted.  In  Germany,  the  majority  of  cases 
of  rabies  occur  near  the  Austrian  and  Russian  boun- 
daries (Public  Health  Reports).  The  infected  ani- 
mals wander  over  into  Prussia  and  there  spread  the 
disease.  In  Germany,  an  animal  is  killed  as  soon 
as  it  shows  the  first  signs  of  rabies;  but  it  will  be 
impossible  to  banish  that  disease  from  Germany  un- 
til the  neighboring  countries  take  the  same  precau- 
tionary measures  against  its  spread  as  Germany 
has  taken.  In  Berlin  proper,  no  case  of  rabies  has 
developed  since  the  passage  of  a  law,  in  1873,  requir- 
ing the  muzzling  of  all  dogs  during  the  entire  year. 
The  experience  of  the  medical  authorities  in  Berlin 
is  that  the  decrease  of  danger  during  the  winter 
months  is  not  sufficient  to  cause  the  law  to  be 
relaxed  during  that  time.  In  the  institute  for  infec- 
tious diseases  rabies  is  treated  according  to  Pas- 
teur's plan  with,  as  figures  show,  most  excellent  re- 
sults. This  showing  should  completely  set  aside  all 
captious  criticism  concerning  rabies  as  a  morbid 
entity  and  the  efficiency  of  the  Pasteur  treatment 
ab  a  therapeutic  measure.  The  compulsory  muz- 
zling of  dogs  while  on  the  public  streets  seems 
to  us,  on  the  whole,  to  be  a  wise  measure.  Fortu- 
nately, rabies  is  a  rare  disease  in  the  United  States, 
but  there  are  many  persons  who  would  feel  much 
easier  if,  when  they  met  some  of  our  huge  canine 
friends,  they  could  feel  sure  that  the  animals  were 
incapable  of  doing  harm. 

A  Review  of  the  History  of  Cardiac  Pathology. — 
Dr.  Alfred  Stengel  delivered  an  address  before  the 
Wisconsin  State  Medical  Society  on  June  21,  1900. 
which  was  published  synchronously  in  the  Univer- 


sity Medical  Magacinc  and  in  the  Philadelphia  Med- 
ical Journal,  on  "A  Review  of  the  History  of  Cardiac 
I'athology  with  Especial  Reference  to  Modern  Con- 
ceptions of  Myocardial  Disease."  In  this  valuable 
contribution  to  medical  literature  an  excellent  re- 
view of  the  history  of  this  subject  is  given  from 
the  time  of  Galen,  whose  doctrines  on  pathology 
were  taught  for  many  centuries,  and  to  whom  is 
credited  the  first  suggestion  of  the  possibility  of 
cardiac  disease,  up  to  the  early  part  of  the  nine- 
teenth century.  Stengel  outlines  the  many  import- 
ant events  leading  up  to  the  knowledge  upon  which 
are  based  our  modern  conceptions  of  this  subject, 
especially  emphasizing  Harvey's  brilliant  achieve- 
ment, the  demonstration  of  the  circulation,  the 
learned  classifications  established  by  the  distin- 
guished French  physician,  Corvisart,  the  important 
observations  of  Bouillaud  on  valvular  disease,  the 
valuable  methods  of  physical  diagnosis  contributed 
to  medical  science  by  Auenbrugger  and  Laennec, 
and  the  later  writings  on  cardiac  diagnosis  by  Hope, 
Testa,  Burns,  and  Kreysig.  Accurate  knowledge 
of  myocardial  disease  had  its  origin  about  the  mid- 
dle of  the  nineteenth  century,  and  was  largely  the 
outcome  of  careful  and  painstaking  study  by  Gaird- 
ner,  Weigert,  Bamberger,  Hasse,  Rokitansky, 
Bochdalek,  Dittrich  and  Virchow.  The  names  of 
Allbutt,  Myers,  Seitz,  and  DaCosta  stand  foremost 
amongst  those  who  have  added  to  our  store  of  clin- 
ical knowledge. 

The  author  states  that  experience  and  statistics 
indicate  that  circulatory  diseases  are  on  the 
increase.  At  the  present  day  our  efforts  must  be 
directed  to  determine  the  causes  of  one  of  these 
problems,  namely,  myocardial  weakness  and  de- 
generation. Of  great  interest  is  the  statement  that 
troubled  times  and  general  unrest  of  mankind  prob- 
ably play  a  most  important  causative  role.  During 
the  revolution  of  1830  in  France,  and  during  the 
revolt  in  Italy  in  1848,  and  in  Sicily  in  i860,  there 
was  an  increase  in  the  number  of  cases  of  heart  dis-- 
ease. 

In  an  account  of  the  clinical  considerations  of  my- 
ocardial disease  Stengel  alludes  to  some  of  the 
early  symptoms  which  should  attract  attention,  par- 
ticularly loss  of  physical  activity,  a  disposition  to  be 
less  interested  in  affairs,  and  a  peculiar  yellowish 
pallor  of  the  face  with  slight  prominence  of  the 
venules.  Often  after  sudden  fright  there  occurs  a 
distinct  change  of  color  which  may  persist  for  an 
unusually  long  time.  Somewhat  later  manifestar 
tions  are  weakness  and  irregularity  of  the  pulse, 
and  a  relaxed  condition  of  the  skin  accompanied  by 
sweating.  The  author  is  convinced,  from  his  own 
clinical  observations,  that  a  changeable  character 
of  the  specific  gravity  of  the  urine  is  a  sign  which 
exists  in  many  ca.ses  of  myocarditis  combined  with 


r\fiA        The  Philadelphia 
y^'f       Medical  Journal 


] 


EDITORIAL  COMMENT 


[Mat  25.  ISOl 


arteriosclerosis.  Gastric  plienomena,  especially 
gastralgic  attacks,  the  probable  explanation  being  a 
deranged  nervous  association,  he  regards  as  early 
signs. 

Dr.  Stengel  believes  that  if  myocardial  disease  can 
be  recognized  earh-  the  progress  of  many  of  these 
cases  may  be  arrested.  A  positive  diagnosis,  how- 
ever, is  usually  impossible  until  the  disease  has 
become  incurable,  and  for  that  reason  he  has  direct- 
ed attention  to  the  earlier  signs. 

Protection  from  the  Malarial  Mosquito  in  Italy. 
— Assistant  Surgeon  J.  M.  Eager  writes  from  Na- 
ples, Itah-,  to  the  Surgeon  General  of  the  Marine 
Hospital  Service,  that  prophylactic  measures  are  be- 
ing taken  on  the  railroads  of  that  country  for  the 
protection  of  employes  from  the  attacks  of  mos- 
quitoes. Extensive  areas  of  fertile  land  in  Italy- 
are  almost  wholly  deserted  in  the  malarial  season. 
The  shepherds  who  feed  their  flocks  on  these  lands 
in  winter  go  to  the  higher  countn,-  in  summer.  The 
few  peasants  who  are  forced  to  remain  behind  go 
to  the  higher  lands  every  night  to  sleep.  But  rail- 
road employ(?s  must  remain  at  their  posts,  and  they 
form  a  class  of  sallow,  fever-smitten  men  who  have 
for  a  long  time  been  a  sorry  sight  to  railroad  trav- 
elers in  Italy.  The  railroad  companies  now  pro- 
pose to  furnish  them  protection  as  far  as  possible. 
Wire  gauze  is  supplied,  and  the  windows  and  doors 
of  station  houses  are  screened.  Switch  houses  are 
made  of  wire  gauze,  and  v.hole  verandas  of  like  ma- 
terial are  built.  Head-covering,  similar  to  that  used 
in  America  by  men  handling  honej'-bees,  is  pro- 
vided for  employes  who  are  obliged  to  expose  them- 
selves. Special  material,  supposed  to  be  impenetra- 
ble to  mosquito  bites,  is  supplied  for  clothing.  Sur- 
geon Eager  does  not  express  any  skepticism  about 
the  efficacy  of  these  measures,  but  we  should  sup- 
pose it  would  be  difficult  to  have  the  average  Ital- 
ian workingman  adopt  such  precautions.  We  know 
from  personal  inquiry  that  it  is  not  easy  to  induce 
the  American  workingman  to  observe  common- 
sense  precautions,  as,  for  instance,  in  lead  factories, 
grinding  establishments,  etc.  If  the  Italian  work- 
ingman at  home  is  more  reasonable  than  the  Ameri- 
can in  such  matters,  it  is  more  than  can  be  said  of 
him  when  he  comes  to  this  country. 

Dr.  Eager  says  that  not  much  is  to  be  expected 
from  drainage  and  the  use  of  petroleum  in  ridding 
the  Roman  campania  of  the  mosquito  pest. 

The  Control  of  the  Venereal  Diseases. — There 
is  now  being  undertaken  in  Greater  New  York 
the  first  systematic  attempt  that  has  been 
made  to  collect  statistics  of  venereal  diseases. — a 
large  but  neglected  class  of  affections  which  have 
a  most  important  relation  to  the  public  health.    We 


wish  to  call  editorial  attention  to  this  work  and  to 
urge  a  general  response  upon  the  part  of  the  medi- 
cal profession  in  the  metropolis.  The  work  is  under 
the  supervision  of  the  Committee  of  Seven,  of 
which  Dr.  Prince  A.  ^lorrow  is  chairman,  which  has 
recently  been  appointed  by  the  Society  of  the 
County  of  New  York.  A  resolution  empowered 
the  President  of  the  Societj'  to  appoint  this  Commit- 
tee for  the  study  of  the  most  practical  kind  of  Mu- 
nicipal and  State  legislation  to  repress  or  control 
prostitution  with  a  view  of  reducing  the  morbidity 
snd  mortality  of  venereal  diseases.  The  Committee 
seeks  for  information  from  everj'  practitioner  and 
every  dispensar)'  as  to  the  number  of  cases  of  gon- 
orrhea and  syphilis  treated.  It  is  especially 
desirous  of  gaining  the  fullest  possible  infor- 
mation relative  to  the  prevalence  of  syphilis  in- 
sontinm,  of  gonococcic  infection  in  marriage,  and  of 
venereal  diseases  occurring  in  children.  This  is  a 
most  important  subject,  and  we  trust  this  investi- 
gation will  result  in  the  institution  of  some  practi- 
cal method  of  controlling  the  terrible  ravages  of 
the  venereal  diseases.  We  published  recently,  as 
will  be  remembered,  a  most  instructive  paper  on 
this  subject  by  Dr.  Morrow. 


Corrc5pon^cncc. 


ERYSIPELAS  IN  ASIA 
By   CL.AJIENCE   D.   USSHER,   M.   D.. 
of  Van,  Turkey,  Asia. 
Editor  Philadelphia  Medical  Journal, 

Dear  Sir;  — 

The  Philadelphia  Medical  Journal  has  been  a  helpful 
and  welcome  friend  since  its  second  volume.  This  help  1 
have  received  has  led  me  to  pass  on  a  few  items  which 
have  been  helpful  to  me  during  the  past  two  years. 

First,  a  treatment  for  erysipelas.  I  have  been  through 
three  fairly  sharp  epidemics  besides  the  ordinary  run  of 
a  medical  missionary's  practice.  I  cannot  say  how  many 
cases  I  have  treated,  but  probably  more  than  150.  First 
I  used  equal  parts  of  jaborandi  and  iron  internally  and 
externally,  an  idea  learned  from  Dr.  A.  M.  Wilson,  of 
Kansas  City,  Mo.  Then  I  tried  bathing  with  hot  water  and 
riainting  with  ergot.  Then  a  combination  of  the  two 
treatments  with  moderate  success.  Finally,  knowing  that 
the  streptococcus  of  erysipelae  was  quickly  destroyed  by 
even  weak  solutions  of  bichloride  of  mercury  I  began  to 
figure  on  getting  it  into  the  tissues.  With  Dr.  C.  S.  Merri- 
man"s  suggestion  of  hot  bathing  as  a  starter,  I  ordered 
bathing  for  an  hour  with  water  kept  as  near  the  boiling 
point  as  could  be  borne,  followed  by  an  application  of  1-500 
bichloride  solution  for  20  minutes,  to  be  repeated  four 
times.  The  erysipelas  had  disappeared  by  next  morning. 
I  have  since  modified  it  to  1-1000  solution,  used  after  H  an 
hour  bathing.  Two  applications  generally  sufficing,  though 
in  severe  cases  I  ordered  four,  the  last  one  followed  by 
yellow  oxide  of  mercury  salve.  S  grs.  in  one  ounce  of  vase- 
line. The  only  fatal  case  was  one  in  which  the  disease  had 


Mat 


19011 


REVIEWS 


TThe  Philadelphia       qQ; 
LMedicai,  Journal  y^Z 


reached  the  brain  before  I  was  called  on  the  8th  day  ot  the 
disease. 

Among  your  therapeutic  notes  last  year  was  a  mention 
of  creosote  and  olive  oil  rubbed  into  sides  and  chest  as  ideal 
treatment  for  malaria  in  children.  My  experience  confirms 
it  with  this  important  point  to  note  that  "beech-wood"  cre- 
osote acts  perfectly,  but  synthetic  creosote  (Merk's  and 
others)  has  gi\'en  me  absolutely  negative  results. 

Antisyphilitic  "mixed  treatment"  combined  with  iodide 
of  potassium  in  progressive  doses  up  to  point  of  toleration 
works  well  in  both  tubercular  and  anesthetic  forms  of 
leprosy.  One  patient  required  25%  drams  of  a  saturated 
solution  daily  to  produce  effect.  27  drams  (1620  grains) 
produced  marked  coryza  and  pain  in  the  limbs,  but  no 
eruption  or  ptyalism.  2oV^  drams  caused  no  unpleasant 
effects.  Is  there  any  record  of  a  larger  dose  being  toler- 
ated? 


TRcvicws. 


International    Clinics. — A    Quarterly    of    Clinical    Lectures 
and      Especially     Prepared     Articles     on     Medicine. 
Neurology.     Surgery,   Therapeutics,     Obstetrics,    Pedi- 
atrics,  Pathology,  Dermatology,  Diseases  of  the  Eye, 
Ear.  Nose,  and  Throat,  and  Other  Topics  of  Interest  to 
Students  and  Practitioners.     Edited  by  Henry  W.  Cat- 
tell,    A.    M..    M.    D.,    Philadelphia,   U.    S.    A.,    with   the 
Collaboration  of  John  B.  Murphy,  M.  D.,  of  Chicago; 
Alexander   D.    Blackader,    M.    D.,   of   Montreal;    H.    C. 
Wood,  M.  D.,  of  Philadelphia;   T.  M.  Rotch,  M.  D.,  of 
Boston;    E.  Landolt,  M.  D..  of  Paris;    Thomas  G.  Mor- 
ton. M.  D.,  and  Charles  H.  Reed.  M.  D.,  of  Philadelphia. 
Volume  I.     Eleventh  series,  1901.     Philadelphia.     J.  B. 
Lippincott  Company,  1901;   price  in  cloth,  $2.00;   half- 
leather,  12.25. 
This  volume  of  the  International  Clinics  is  most  excellent 
from  cover  to  cover.     Its  contributors  are  widely  known, 
and  the  subjects  treated  are  of  great  general  interest.    We 
might    mention    especially    the    chapter    upon:     "Nervous 
Diseases  and  Psychoses  following  the  Grippe."  by  Williau' 
Broaddus  Pritchard;   and  that  upon:   "Sacculated  Pleurisy. 
Bronchial    Pneumonia,    .Anemia,    Pernicious    Anemia."    by 
Francis  Delafield.  and  the  "Report  of  100  Cases  of  Aortic 
Aneurysm  with  Details  of  Three  Cases  of  Aneurysm  of  the 
Basilar  Artery."   by   H.   Batty   Shaw,   M.   D.     The   chapter 
upon  "Laboratory   Methods,"  dealing  with  some  practical 
methods  in  photomicrography,  by  W.  H.  Walmsley,  is  re- 
plete   with    excellent    suggestions    and    accompanied    by 
beautiful  lithographs  of  his  work.    Edward  Jackson  contri- 
butes a  chapter  on  "Points  in  the  Diagnosis  of  Iritis  and 
Glaucoma."     This   article  will   command   the   respect  and 
attention    of   those   interested   in   ophthalmology.     Dr.    A. 
Doleris    treats    of    "Obstetrical    Analgesia.    Obtained    by 
Cocain  In.iections  into  the  Lumbar  Arachnoid."    On  account 
of  the  present  prominence  of  this  subject  this  conservative 
article  will  be  read  with  interest.     Dr.  A.  A.  Stevens  has 
written  a  chapter  on  "Notes  on  New  Remedies,"  which  is 
comprehensive,    progressive,    and    yet    conservative.      The 
work   closes   with   a   review   of  the   progress   of  medicine 
during  the  year  1900  by  Dr.  N.  J.  Blackwood,  U.  S.  N.     In 
the  department  of  therapeutics,  this  somewhat  overlaps  Dr. 
Steven's  more  thorough  contribution,  but  this  was  scarcely 
to  be  avoided.     We  cannot  do  better  in  closing  this  brief 
review  than  to  mention  the  chapter  by  Professor  H.  Hal- 
lopeau  on  "The  Treatment  of  Eczema."     It  is  pleasure  to 
be  able  to  commend  this  volume,  both  on  account  of  the 
excellence  of  its  subject  matter,  and  as  a  good  example  of 
high-class  book  making.     [T.  L.  C] 

Saunders'  Medical  Hand-Atlases.  Atlas  and  Epitome  of 
the  Nervous  System  and  its  Diseases. — By  Profes- 
sor Dr.  Chr.  Jakob,  of  Erlangen.  Frum  thr  t^rcond  AV- 
riix-d  Crrmnii  Editinn.  Edited  by  Edward  D.  Fisher, 
M.  D.,  Professor  of  Diseases  of  the  Nervous  System, 


University  and  Bellevue  Medical  College,  New  York. 
With  83  plates  and  copious  text.  Philadelphia  and 
London:  W.  B.  Saunders  &  Co.,  1901.  Cloth,  $3.50 
net. 

This  authorized  translation  from  the  second  revised 
German  Edition  is  a  useful  work  in  the  field  which  it 
covers.  The  plates  are  beautifully  executed,  and  are  copi- 
ous enough  to  be  of  great  value  to  the  student.  The  dia- 
gramatic  interpretation  of  each  plate  is  given  upon  the 
page  facing  it  so  that  even  those  unfamiliar  with  the  his- 
tology and  pathology  of  the  nervous  system  can  readily 
observe  the  features  to  be  pointed  out.  We  find  in  this, 
volume  of  218  pages,  84  plates,  and  their  excellence  leaves 
but  little  to  be  desired.  The  work  is  considered  under  the 
following  heads:  First,  Morphology  of  the  nervous  Sys- 
tem, and  in  this  chapter  14  plates  are  included;  second. 
The  Development  and  Structure  of  the  Nervous  System, 
Ontogenesis  and  Histology  of  the  Nervous  System,  which. 
is  illustrated  with  38  plates;  third,  the  Anatomy  and  Physi- 
ology of  the  more  important  Nervous  Pathways;  the  three 
plates  accompanying  this  part  are  excellent  diagramatic 
explanations  of  the  nervous  pathways,  done  in  color,  and. 
will  greatly  aid  the  student  in  mastering  the  intricacies  of 
the  subject.  The  General  Pathology  and  Treatment  of 
Diseases  of  the  Nervous  System  follows.  This  is  an  im- 
portant chapter,  and  in  it  are  given  the  etiology  of  nervous 
diseases  with  plates  of  many  of  the  pathologic  alterations 
observed,  as  well  as  symptomatology  and  topical  diagnosis  of 
nervous  diseases.  Special  pathology  and  treatment  is 
handled  with  rare  conciseness  and  yet  admirable  clearness. 
While  of  course  in  a  work  of  this  limited  size  the  text  is  in 
no  sense  complete,  yet  it  is  wonderfully  comprehensive, 
and  is  enlightened  by  the  beautiful  and  artistic  illustra- 
tions. The  book  closes  with  some  general  remarks  on 
autopsy  technique  and  the  microscopic  examination  of  the 
nervous  tissues.  We  know  of  no  one  work  of  anything 
like  equal  size,  which  covers  this  important  and  compli- 
cated field  with  the  clearness  and  scientific  fidelity  of  this 
hand-atlas.     [T.  L.  C] 

The  International  Medical  Annual,  A  Year  Book  of  Treat- 
ment and  Practitioner's  Index.  E.  B.  Treat  &  Co.  New 
York  and  Chicago.    Price  in  cloth  $3.00. 

This  is  the  19th  edition  of  Treat's  well-known  Medical 
Annual.  It  has  some  especial  features  which  deserve  men- 
tion. The  chapter  on  Toxins  and  Antitoxins  is  the  work  of 
Joseph  McFarland  and  William  Murrel,  and  the  latter  has 
also  contributed  a  special  article  on  the  Light  Treatment. 
X-Ray  Work  in  Medicine  and  Surgery,  is  from  the  pen  of 
Dr.  Maciutyre,  of  Glasgow.  Dr.  Eldridge-Green  has  written 
the  chapter  on  Color  Blindness;  and  Mr.  Turner,  F.  R.  C. 
S.,  is  the  author  of  that  upon  Dental  and  Oral  Surgery. 
Professor  Ruata,  of  the  University  of  Perugia,  Italy,  has 
contributed  the  article  on  Tuberculosis.  The  dictionary 
of  new  treatment  covering  the  whole  range  of  medicine 
and  surgery  makes  the  work  one  of  great  value  and  con- 
venience as  a  book  of  reference.  That  part  of  the  work 
dealing  with  pharmacology  in  general  should  be  found  of 
interest  considering  the  multiplicity  of  new  drugs  and  the 
difficulty  which  at  present  confronts  physicians  in  the 
effort  to  find  out  precisely  what  chemical  combinations 
many  of  these  preparations,  sold  under  tradenames,  really 
contain.  We  believe  that  the  subject  of  organo-therapy 
has  received  less  than  its  share  of  consideration.  The 
work  as  a  whole  is  of  unquestioned  value,  and  this  19th 
consecutive  volume  bears  witness  to  the  fact  that  its 
merits  have  been  appreciated.     [T.  L.  C] 


An  Early  Diagnostic  Sign  of  Phthisis. — At  the  recent 
meeting  of  the  Congres  des  Societes  Savantes,  {Revue 
Mcdiralc  de  VEst,  1901,  No.  8.).  at  Nancy.  Dr.  Finck.  of  the 
French  Army,  reported  the  fact  that  20  c.c.  of  normal  salt 
solution,  injected  Into  an  individual  in  whom  pulmonary 
tuberculosis  is  suspected,  will  cause  marked  febrile  re- 
action in  the  nine  hours  succeeding  the  Injection,  This 
will  occur  in  tubercular  patients  without  fever,  at  the  be 
ginning  of  invasion,  or  after  the  process  lias  developed. 
On  the  contrary,  non-tubercular  individuals  will  show  no 
fever  at  all  after  injection.  SBould  the  reaction  occur, 
the  diagnosis  of  tuberculosis  may  be  made  with  almost 
absolute  certainty;  if  no  fever  occur,  tuberculosis  may 
nevertheless  exist,     [M,  O.] 


^Q(C       The  Philadelphia-] 
V-""       Medioal   Journal  J 


AMERICAN  NEWS  AND  NOTES 


[May  23.   1501 


Hntcrican  IWevos  an&  IRotcs. 


PHILADELPHIA,    PENNSYLVANIA,    ETC. 

College  of  Physicians. — Abstract  of  the  monthly  report 
of  the  Honorary  Lil)rarian,  Library  of  the  College  of 
Physicians  of  Philadelphia,  April,  1901: 

Books,  pamphlets  and  journals  received: 
General  Library:   447  volumes.  806  pamphlets.  3415  journals 
Lewis  Library:         11         "  0  •'  0       " 

S.D.Gross  Library:    1        '•  0  "  0      " 


459 


806  3415 

Duplicates,  81  volumes 


Accessions.  378  volumes. 
Donors.  General  Library,  67. 

The  College  has  acquired,  by  purchase,  the  valuable  and 
perhaps  unique  collection  of  books  and  pamphlets  known 
as  the  "J.  Stockton  Hough  Library."  About  three  thous- 
and voldmes,  valued  at  eight  thousand  dollars. 

Dr.  Aloysius  O.  J.  Kelly,  instructor  in  clinical  medicine 
in  the  University  of  Pennsylvania,  recently  was  elected 
professor  of  the  theory  and  practice  of  medicine  in  the 
L^niversity  of  Vermont.  He  leaves  Philadelphia  shortly 
for  Burlington  to  begin  his  professorial  duties,  but  he  will 
return  to  Philadelphia  in  the  early  fall. 

The  Kensington  Hospital  for  Women. — During  the  month 
of  April  seventy-four  patients  were  under  treatment.  There 
were  thirty-five  patients  in  the  Hospital  April  1st,  and 
thirty-five  are  under  treatment  at  the  present  time.  Nine- 
teen sections  and  fifty-two  other  operations  have  been 
performed.  In  the  Dispensary  there  have  been  thirty-nine 
new  patients,  who  have  paid  one  hundred  and  forty-nine 
visits. 

Medical  Society  of  the  State  of  Pennsylvania. — The 
meeting  of  the  Medical  Society  of  the  State  of  Pennsylva- 
nia in  Philadelphia  will  be  changed  from  September  1718-19 
to   September  24-25-26. 

Philadelphia  Polyclinic. — Dr.  Ralph  Zeiss,  who  has  been 
Professor  of  Diseases  of  the  Ear  for  17  years  at  the  Phila- 
delphia Polyclinic,  has  resigned  his  position  and  has  been 
succeeded  by  Dr.  Francis  R.  Packard,  the  present  Dean  of 
the  Institution.  Dr.  Packard's  place  will  be  occupied  in 
the  fall  by  Dr.  Randolph,  of  Richmond.  Va..  who  is  at 
present  abroad  studying  Pathology.  Dr.  Randolph  on  his 
return  will  also  take  charge  of  the  Pathological  Labora- 
tories. 

Nathan  Lewis  Hatfield  Prize. — The  Committee  on  the 
Nathan  Lewis  Hatfield  Prize,  for  original  research  in 
Medicine  of  the  College  of  Physicians  of  Philadelphia  has 
awarded  to  Prof.  H.  F.  Harris,  M.  D.,  of  -Atlanta,  Georgia, 
the  sum  of  Five  Hundred  Dollars  for  an  original  research, 
conducted  at  the  instance  of  the  Committee,  entitled:  "A 
Study  of  the  Alterations  produced  in  the  Large  Intestines 
of  Dogs  by  the  Amoeba  Coli,  by  Heat,  and  by  Various 
Chemic  Substances,  with  Notes  on  the  Anatomy  and  His- 
tology of  the  Viscus." 

College  of  Physicians  of  Philadelphia:  Section  on  Gyne- 
cology.— At  the  meeting  of  May  IG.  Dr.  Charles  P.  Noble 
reported  3  cases.  (Ij  A  case  of  appendicitis  complicated 
by  diabetes  and  nephritis.  The  patient  was  26  years  of 
age.  The  sugar  averaged  about  .75'c  but  reached  at  one 
time  1.66%.  The  operation  was  performed  under  ether 
and  recovery  was  good.  This  is  the  fourth  case  operated 
upon  by  Dr.  Noble,  when  glycosuria  was  present.  Three 
made  good  recoveries  and  1  died  of  diabetic  coma.  Dr. 
Noble  concludes  that  a  moderate  degree  of  glycosuria  is 
not  a  positive  contraindication  to  operation:  (2)  Hem- 
orrhage following  abdominal  section.  Hemorrhage  oc- 
curred in  this  case  because  of  the  retraction  of  the  uterine 
pedicle.  This  is  the  only  case  of  secondary  hemorrhage  for 
11  years,  during  which  time  1275  abdominal  sections  have 
been  made.  Dr.  Noble  ligates  the  ovarian  artery  and  the 
anastomosing  branch  between  ovarian  and  uterine,  when 
removing  tube  and  ovary.  Silk  and  catgut  ligatures  have 
given  equally  good  results:  (3)  A  cyst  of  inflammatory 
oi'igin  anterior  to  the  uterus — a  sequel  of  hysterorraphy. 
Dr.  C.  H.  .ludd  reported  conclusions  based  on  850  cases  of 
etherization.  He  finds  that  ether  is  safe  in  any  compensat- 
ed  heart  lesion.     He  employs  oxygen   in   every   case  and 


uses  a  gauze  inhaler.  The  time  for  inducing  anesthesia 
varies  between  10  and  15  minutes  and  the  amount  of  ether 
from  1  to  2  ounces.  Dr.  Baldy  said  that  every  institution 
should  have  a  pad  anesthetizer  and  internes  not  allowed 
to  give  anesthetics.  To  become  a  good  etherizer  requires 
skill  and  training  as  well  as  to  become  a  good  operator. 
He  prefers  the  Allis  inhaler,  gauze  being  bad  in  the 
hands  of  the  ordinary  anesthetizer.  The  finger  should 
never  be  put  in  the  patient's  eye  to  determine  the  re- 
flexes. Tongue  forceps  are  very  seldom  needed,  their  use 
in  the  majority  of  cases  being  caused  by  faulty  etheriza- 
tion. The  majority  of  cases  of  pneumonia  following  opera- 
tion are  due  to  the  ether  and  most  such  patients  have  been 
black  in  ihe  face  or  giving  trouble  during  the  anesthesia. 
Dr.  J.  C.  DaCosta  said  it  was  desirable  to  have  a  regular 
etherizer,  but  he  had  seen  some  unfortunate  results  under 
an  expert  anesthetist.  He  generally  had  better  results 
from  trained  hospital  residents,  as  his  experience  is  that 
they  are  generally  good  etherizers.  He  always  used  oxy- 
gen after  etherization. 

Dr.  H.  D.  Beyer  read  a  paper  on  Conservation  of  the 
ovary  and  functionating  uterine  tissue  in  the  operation 
for  hysteromyomectomy.  This  refers  to  cases  of  myoma 
where  the  uterus  is  involved  and  the  ovaries  are  normal. 
In  siich  cases  he  leaves  one  or  both  ovaries  and  amputates 
the  uterus  as  high  up  as  possible.  This  prevents  the  ar- 
tificial menopause  Cases  were  cited  to  show  the  good 
results  of  this   procedure. 

Vital  Statistics  of  Philadelphia  for  the  week  ending 
May   18,   1901: 

Total  mortality    446 

Cases.  Deaths. 

Inflammation  of  the  appendix  2. 
bladder  3.  brain  14.  bronchi  9,heart 

2.  kidneys   21,   larynx   1,   liver   1, 
lungs  36.  pericardium  1.  periton- 
eum   5.    pleura    3,    stomach    and 

bowels  16   114 

Marasmus  9,  debility  9.  inanition  12  30 

Tuberculosis  of  the  lungs    69 

Apoplexy  21.  paralysis  9   30 

Heart    disease    29.    dropsy    1,    fatty 

degeneration  of  4.  neuralgia  of  1. .  35 
Uremia  11,  diabetes  1,  Bright's  dis- 
ease 4 16 

Carcinoma  of  the  bowels  1,  breast 
4.  stomach  5.  face  1,  leg  1,  liver 

1.  throat  1  14 

Convulsions  9,  convulsions,  puer- 
peral 2 11 

Diphtheria    59  12 

Brain,    congestion    of    4,    dropsy   of 

1.  softening  of  1   6 

Tvphoid  fever   102  12 

Old  age   9 

Cyanosis    4 

Scarlet  fever 124  8 

Influenza  3,  abscess  of  ear  1.  ab- 
scess of  pelvis  1.  aneurysm  aorta  1, 
alcoholism  I.  asthma  1.  anemia  1. 
atheroma  1.  burns  and  scalds  3. 
casualties  4.  cerebro-spinal  men- 
ingitis 1.  congestion  of  the  lungs 
4.  cirrhosis  of  the  liver  6.  con- 
sumption of  the  bowels  1.  croup, 
membranous  1. diarrhea  1. drowned 

3.  epilepsy  1.  gall  stones  1.  hem- 
orrhage from  circumcision  1.  hem- 
orrhage from  stomach  1.  indiges- 
tion 1.  leukemia  1.  locomotor 
ataxia  1.  obstruction  of  the  bow- 
els 5.  edema  of  lungs  3.  poisoning 
1.  rheumatism  1.  sclerosis,  spine  1. 
shock,  surgical  1.  septicemia  5, 
smallpox  1.  sarcoma,  rectum  1. 
suffocation  2.  suicide  2.  tabes 
mesenterica  1.  teething  l.unknown 

coroner  case  1.  whooping  cough  9  76 

NEW  YORK. 

Medical  Society  of  the  State  of  New  York. — At  the  95th 

Annual  Session  of  the  Medical  Society  of  the  State  of  New 

York,  held  at  Albany.  N.  Y..  January  2!Hh.  30th  and  31st, 

1301.  it  was  moved  and  unanimously  adopted  that  in  order 


Mat   25,    1901] 


AMERICAN  NEWS  AND  NOTES 


["The  Philadelphia       nS"? 
L  Medical  Journal        y-"/ 


to  increase  the  faoilities  for  becoming  permanent  members 
of  the  State  Society,  each  County  Society  should  be  al- 
lowed to  send  five  times  the  number  of  delegates  it  had 
formerly  sent.  These  delegates  are  elected  for  a  term  of 
three  years,  and  are  eligible  for  permanent  membership 
when  they  have  registered  at  two  Annual  Meetings. 
This  will  make  the  number  of  delegates  sent  by  county  so- 
cieties 750  in  all,  or  one  delegate  for  every  eight  or  nine 
members  of  county  societies,  without  increase  in  expense 
to  the  county  societies. 

It  was  further  agreed,  in  response  to  a  widely  expressed 
desire,  that  the  Society  hold  a  semi-annual  meeting  in  the 
city  of  New  York  in  the  early  autumn,  to  be  devoted  entirely 
to  scientific  work  and  to  social  intercourse.  The  officers  of 
the  State  Society  announce  that  they  have  engaged  the 
New  York  Academy  of  Medicine  for  this  meeting,  which 
will  be  held  October  loth  and  16th.  1901.  Members  wishing 
to  read  papers  are  requested  to  communicate  with  Dr. 
Nathan  Jacobson,  Chairman,  Business  Committee,  430 
South  Salina  St.,  Syracuse,  N.  Y.,  and  information  of  any 
other  nature  can  be  obtained  of  Dr.  Frederick  C.  Curtis, 
17  Washington  Ave.,  Albany,  N.  Y.,  or  of  Dr.  Frank  Van 
Fleet,  Associate  Secretary,  63  East  79th  St..  New  York 
City.  It  is  further  announced  that  the  Society  will  tender 
a  reception  to  its  members,  delegates  and  guests,  at  Del- 
monico's,  on  the  evening  of  October  15th.  Tickets  to  this 
reception  will  be  furnished  without  cost  to  all  who  regis- 
ter at  this  meeting,  a.nd  to  the  society's  guests. 

Smallpox  has  broken  out  about  four  miles  from  Pough- 
keepsie,  N.  Y.  The  victims  are  colored  people,  one  of  whom 
is  thought  to  have  brought  the  disease  from  New  York 
City  two  weeks  ago. 

The  New  Mount  Sinai  Hospital. — The  corner  stone  of  this 
magnificent  structure  was  laid  on  May  22  in  the  presence 
of  the  Governor  and  representatives  of  the  Municipal 
Administration,  with  the  most  imposing  ceremonies.  The 
estimated  cost  is  $1,335,000.  A  more  detailed  acount  of 
the  ceremonies  will  be  published  in  the  next  issue  of  this 
Journal. 

Insurance  Against  Malpractice  Suits. — A  New  York  in- 
surance company  proposes  to  insure  medical  practitioners 
against  losses  by  malpractice  suits.  It  bases  its  action 
upon  the  assumption  that  when  it  becomes  generally 
known  that  physicians,  surgeons  and  dentists  are  thus  pro- 
tected, there  will  be  less  inclination  than  there  is  at  present 
on  the  part  of  speculative  lawyers  to  bring  such  actions 
against  members  of  the  profession. 

(From  our  Special  Correspondent.) 

American  Congress  of  Tuberculosis  in  joint  session  with 
the  Medico-Legal  Society.  May  15th  and  16th.  1901.— The 
initial  session  of  the  Congress  was  held  on  the  morning 
of  May  15th,  Dr.  A.  N.  Bell,  of  Brooklyn,  in  the  chair  on 
behalf  of  the  American  Congress  of  Tuberculosis:  Clark 
Bell,  of  New  York,  presiding  on  behalf  of  the  Medico- 
Legal  Society. 

The  introductory  paper  on  "Legislation  and  Tubercu- 
losis" was  read  by  Clark  Bell,  who  referred  to  tuberculosis 
as  being  rightly  considered  the  most  prominent  sanitary 
question  of  the  day.  The  presence  of  delegates  from  far 
and  wide — from  our  various  States,  from  the  Canadas. 
from  the  South  and  Central  Americas — attested  the  fact. 
The  questions  which  the  Congress  were  to  consider  were 
summarized  as  follows:  Is  tuberculosis  an  infectious  or 
communicable  disease?  How  far  can  legislation  avert  it, 
framed  with  a  view  of  arresting  the  spread  of  the  disease, 
by  regulations,  the  enforcement  of  which  would  result  in 
diminishing  the  facilities  for  its  communication  from  one 
person    to    another? 

In  discussing  the  paper.  Dr.  E.  P.  Lachapelle,  of  Toronto, 
said  that  he  advocated  certain  legislative  measures,  to  wit: 
Compulsory  notification,  compulsory  disinfection  of  dwell- 
ings after  the  death  of  a  consumptive,  the  proper  regula- 
tion of  the  cubic  space  in  buildings,  the  exclusion  of  all 
cows  presenting  tuberculosis  of  the  udder,  fixing  a  mini- 
mum air  space  for  cow-sheds.  In  addition,  co-operation 
of  the  public  by  education  in  the  schools,  by  conference.? 
and  by  the  distribution  of  suitable  literature  and  the 
multiplication  of  sanatoria  would  be  desirable  measures. 

Dr.  G.  B.  Johnson,  ot  Richmond.  Va..  said  the  keynote  of 
the  question  was  education:  that  the  best  way  of  educating 
the  masses  was  through  the  formation  of  associations  in 
each  community  for  the  purpose  ot  discussion  of  the  sub- 
ject  and   the  dissemination   of  the  correct   ideas   through 


the  medium  of  the  press.  In  this  way,  the  knowledge  of 
what  constituted  preventive  measures  would  be  spread. 
Dr.  V.  Havard  (U.  S.  Army)  recommended  that  the 
States  found  sanatoria  where  the  afflicted  might  be  induced 
to  go.  and  where  they  might  be  treated,  either  gratuitious- 
ly  or  according  to  their  means.  Patients  wishing  to 
remain  at  home  should  observe  prescribed  regulations  and 
be  subjected  to  official  inspection. 

Dr.  J.  H.  Pyror,  of  Buffalo,  dealt  with  the  question  of  the 
care  of  the  consumytives  in  the  State  of  New  York.  He 
deplored  the  fact  that  the  State  did  not  offer  to  take  care 
of  them  until  the  suflerers  were  in  the  last  stages — when  it 
was  too  late.  In  the  State  there  were  14,000  deaths  an- 
nually from  tuberculosis,  aside  from  the  question  of  hu- 
manitj%  and  viewed  entirely  as  an  economical  one,  the 
State  could  much  better  afford  to  take  care  of  the  60,000 
afllicted  with  tuberculosis — as  soon  as  the  diagnosis  was 
made — than  to  harbor  the  14,000  dying  ones.  Legislation, 
Dr.  Pyror  said,  must  move  with  education.  It  would  not 
do  to  wait  until  the  last  man  was  educated  before  insisting 
upon  the  passage  of  certain  measures  beneficial  to  the 
public  health.  In  other  words,  it  is  absolutely  necessary  to 
compel  certain  things.  We  do  know  a  few  facts  about  tuber- 
culosis: It  is  communicable,  it  is  preventable,  it  is  curable  i£ 
taken  in  hand  early  enough.  Under  these  conditions,  it  is  the 
duty  of  the  State  to  help  the  sufferer,  not  as  is  done  to- 
day, when  it  is  too  late,  but  in  the  early  stages  when  the 
afflicted  can  be  made  well.  The  mission  of  the  State  Sana- 
toria is  three-fold:  To  treat  the  individual,  to  protect  the 
community,  to  educate  the  people. 

Dr.  A.  N.  Bell  read  a  paper  entitled  "The  Prevention 
of  Tuberculosis,"  dwelling  at  length  on  the  part  the  vet- 
erinarian plays  in  this  respect,  and  emphasizing  the  im- 
portance of  the  public  inspection  of  the  milk  supply  in  all 
its  details.  In  the  discussion  of  this  paper.  Dr.  W.  B. 
Huested  severely  criticised  the  U.  S.  Government  tuber- 
culosis test  for  cattle  as  being  quite  inadequate  in  not  fur- 
nishing the  proper  cnntral  tests. 

Dr.  C.  F.  Ulrich.  of  Wheeling.  W.  Va.,  in  a  paper  enti- 
tled "Suggestions  for  the  Prevention  of  Tuberculosis"  rath- 
er startled  the  delegates  by  his  reference  to  the  treatment 
of  confirmed  consumptives.  "In  regard  to  confirmed  con- 
sumptives, who  have  passed  the  years  of  childhood  and 
for  whom  there  is  no  hope  for  recovery,  with  nothing  be- 
fore them  but  a  life  of  misery.  I  am  going  to  say  some- 
thing that  may  be  stigmatized  as  unfeeling  and  cruel.  But 
on  the  principle  of  the  greatest  good  to  the  greatest  num- 
ber, I  regard  the  idea  as  humane.  I  do  not  refer  to  what 
was  at  one  time  advocated  by  many  physicians  under  the 
title  of  "Euthanasia."  because  in  this  age  of  exaggerated 
humanity,  it  would  not  be  permitted  even  if  its  general 
benefits  to  mankind  were  proved  beyond  a  shadow  of  a 
doubt.  What  I  wish  to  suggest  is  this:  In  every  case  of 
confirmed  and  hopeless  tuberculosis,  desist  from  all  ef- 
forts to  prolong  life,  devoting  your  entire  energy  to  mak- 
ing your  patient  as  comfortable  as  possible  even  if  the 
means  employed  should  have  a  tendency  to  shorten  life. 
For  if  you  lengthen  out  the  span  of  a  miserable  existence, 
permitting  the  unhappy  being  to  marry  and  send  out  into 
the  world  an  infected  progeny,  to  increase  the  aggregate 
of  suffering  in  geometric  progression  until  the  earth  is 
filled  with  pale,  emaciated,  unhappy,  useless,  life-marring 
men  and  v/omen,  do  you  feel  3'ou  have  accomplished  a  hu- 
manitarian work?" 

A  paper  "On  the  Curing  of  Tuberculosis  in  Sanatoria." 
by  Prof.  Schrotter.  of  Vienna,  was  read  by  proxy.  In  the 
paper,  the  writer  urges  greater  care  in  the  compilation  of 
statistics.  Only  cases  which  can  positively  be  considered 
such,  ought  to  be  enumerated  as  cured  and  all  cases  where 
treatment  in  the  sanatorium  failed  should  be  made  the 
object  of  special  study  and  special  analysis.  In  the  medi- 
cal reports  of  the  sanatorium  at  -Alland,  near  Vienna,  great 
care  is  made  of  the  use  of  the  term  "cured;"  most  cases 
are  discharged  as  improved  or  relatively  healed.  If  possi- 
ble, cases  are  kept  under  observation  for  years,  so  that 
the  real  outcome  of  the  case  mav  be  watched  and  record- 
ed. Patients  are  required  to  present  themselves  for  ex- 
amination regularly  at  either  the  sanitarium  or  at  the 
central  bureau  in  Vienna:  there  subsequent  examinations 
are  made  by  the  same  physicians  who  admit  the  patients. 
Comparisons  with  the  written  histories  are  thus  possible 
and  reliable  statistics  of  positive  cures  can  thus  be  ob- 
tained. 

Papers   by   title  were   read   as   follows:    "Prevention    of 


qCjc       The  Philadelphia  "I 
y"-  ^       Medical   Joubsal  J 


AMERICAN  NEWS  AND  NOTES 


[Mat  25,  ISM 


Tuberculosis,"  by  Dr.  E.  Liceagua.  of  City  of  Mexico: 
"Treatment  of  Tuberculosis,"  by  Dr.  G.  W.  Brown,  of  At- 
lanta. Ga.:  "A  Contribution  to  the  Surgical  Treatment  of 
Tuberculosis,"  by  Dr.  J.  B.  Socasa.  of  Nicaragua;  "The 
Bacillus  of  Tuberculosis,"  by  Dr.  H.  W.  Mitcliell,  New  Torli; 
"Transportation  of  Tuberculous  Passengers,"  by  Dr.  G. 
Chaffee.    Brooklyn. 

Dr.  Henry  D.  Holton.  of  Brattleboro,  Vt..  was  elected 
President:  Dr.  A.  N.  Bell,  of  Brookljii,  the  retiring  Presi- 
dent, was  elected  Honorary  President.  The  following  were 
elected  Vice-presidents:  T.  D.  Crothers,  M.  D..  Hartford, 
Conn.:  C.  K.  Cole,  M.  D.,  Helena,  Mont.:  Col.  E.  Chancel- 
lor. M.  D.,  St.  Louis,  Mo.:  A.  P.  Grinnell,  M.  D..  Burlington, 
Vt.:  A.  E.  Osborne.  M.  D.,  Glen  Ellen.  Cal.:  V.  O.  B. 
Wingate.  M.  D..  Milwaukee.  Wis.:  Wm.  Bayard,  M.  D.,  St. 
John.  N.  B.:   W.  L.  Bullard,  M.  D..  Columbus,  Ga.:   Henry 

B.  Baker,  M.  D..  Lansing.  Mich.:  Raley  Huested  Bell.  St. 
Louis.  Mo.:  J.  Mount  Bleyer  M.  D.,  New  York  City:  Prof. 
Thos.  Bassett  Keyes.  M.  D..  Chicago,  111.:  Dwight  S.  Moore, 
M.  D.,  Jamestown,  S.  Dak. 

The  session  of  the  Congress  was  brought  to  a  close 
with  a  dinner  held  on  the  evening  of  May  16,  at  the  Hotel 
Majestia 

WESTERN     STATES, 

Emergency  Outfits  in  Mills. — Factory  Inspector  Moersch, 
ot  the  State  Labor  Department  of  Minnesota,  is  endeavor- 
ing to  place  surgical  emergency  outfits  in  all  mills,  fac- 
tories and  shops  of  the  State  where  there  are  many  em- 
ployees. 

The  yorthirestern  Lancet  states  that  the  Iowa  State  Board 
of  Medical  Examiners  has  refused  to  recognize  diplomas 
from  Barnes  Medical  College  of  St.  Louis  as  entitling  their 
holders  to  enter  the  examinations  of  Iowa. 

The  Fiftieth  Anniversary  of  the  invention  of  the  ophthal- 
moscope will  be  commemorated  at  the  meeting  of  the 
American  Medical  Association  at  St.  Paul  next  month. 

Arkansas  Medical  Society. — The  Arkansas  Medical  So- 
ciety, at  its  last  session,  beginning  May  14,  and  lasting 
three  days,  elected  the  following  officers:  President.  F. 
Vinsonhaler,  Little  Rock;  first  vice-president,  C.  R.  Che- 
nault.  Helena:  second  vice-president,  W.  N.  Yates,  Bates- 
ville:    secretary.  J.  B.  Runyan,  Little  Rock;   treasurer,  R. 

C.  Thompson,  Pine  Bluff. 

SOUTHERN  STATES. 

A  Bill  has  passed  the  legislature  of  Florida,  making  four 
successive  years  of  insanity  on  the  part  of  husband  or 
wife  a  ground  for  divorce.  The  party  obtaining  the  di- 
vorce must  provide  for  the  maintenance  of  the  divorced 
party. 

Clinical  Society  of  the  District  of  Columbia. — On  Tues- 
day evening.  May  2S.  1901,  the  Clinical  Society  of  the  Dis- 
trict of  Columbia  will  give  its  annual  banquet.  An  elabor- 
ate programme  has  been  prepared  by  the  Committee,  of 
which  Dr.  W.  M.  Barton  is  Chairman,  and  Drs.  Wells. 
James.  Ramburgh  and  De  Vries  the  other  members. 

The  Baltimore  County  Medical  Association  has  elected 
the  following  officers:  President.  Dr.  J.  F.  H.  Gorsuch: 
vice-president,  Dr.  R.  Percy  Smith:  recording  secretary. 
Dr.  W.  P.  E.  Wyse:  corresponding  secretary,  Dr.  R.  C. 
Massenburg:  treasurer.  Dr.  H.  S.  Jarrett:  executive  com- 
mittee. Drs.  H.  B.  Stevenson,  J.  E.  Bensen,  Charles  I.  Hill: 
committee  of  honor,  Drs.  William  J.  Todd.  L.  Gibbons 
Smart.  B.  F.  Bussey:  historical  committee.  Drs.  Jackson 
Piper,  H.  L.  Naylor,  William  J.  Todd;  medical  jurispru- 
dence. Dr.  Charles  G.  Hill,  Dr.  P.  F.  Sappington  and  Judge 
N.  Charles  Burke. 

The  Washington  Star  states  that  the  Commissioners  of 
the  District  of  Columbia  have  received  from  the  con- 
troller of  the  treasury  an  opinion  on  the  question  raised  by 
the  auditor  of  the  District  as  to  the  compensation  which 
should  be  allowed  to  the  visiting  physicians  of  the  Wash- 
ington Asylum  and  the  police  surgeons  for  examining 
suspected  lunatics.  Both  the  visiting  physicians  and  the 
police  surgeons  are  salaried  officers.  The  Act  of  Con- 
cress  regulating  admissions  to  the  Government  Hospital 
for  the  Insane  provides  that  two  physicians  shall  certify 
as  to  the  lunacy  of  the  patient,  and   that  each  shall  be 


compensated  at  the  rate  of  flO  per  diem  for  his  services. 
It  often  happens  that  the  examining  physicians  in  lunacy 
cases  are  the  visiting  physicians  and  police  surgeons,  and 
the  question  raised  was  as  to  whether  they  were  entitled 
to  double  pay  in  the  premises.  The  controller  decides  that 
the  physicians  are  entitled  to  pay  in  both  instances,  say- 
ing that  their  duties  in  connection  with  the  two  services  are 
entirely  separate  and  distinct. 

The  National  Association  for  the  Study  of  Epilepsy  and 
Care  of  Epileptics,  was  held  in  conjunction  with  the  Con- 
ference of  Charities  and  Correction  at  Washington,  D.  C, 
on   May   14th. 

Changes  in  the  Medical  Corps  of  the  Navy  for  Week  End- 
ing May  18,  1901: 

MEDICAL  DIRECTOR  J.  C.  WISE,  appoinied  a  member  of 
a  Board  for  the  physical  examination  of  candidates  for 
appointment  to  the  Xaval  Academy. 

P.  A.  SURGEON  W.  B.  GRO^'E,  orders  appointing  him  mem- 
ber of  the  Examining  Board  at  Annapolis,   revoked. 

SURGEON  O.  DIEHL.  detached  from  the  Indiana,  and  or- 
dered to  the  Philadelphia  Xa\-}-  Yard. 

SURGEON  C.  BIDDLE.  detached  from  the  Philadelphia  Navy 
Yard,    and   ordered   to   the   Indiana. 

Official  List  of  the  Changes  of  Station  and  Duties  of 
Commissioned  and  Non-Commissioned  Officers  of  the  U.  S. 
Marine  Hospital  Service  for  the  7  days  ended  May  9,  1901; 

H.  W.  AUSTIN,  surgeon,  to  proceed  to  Washington.  D.  C.  for 
special   temporary  duty — May  9,   1901. 

R.  M.  WOOD^\"ARD.  surgeon,  granted  leave  of  absence  for  18 
davs   from   May  7— May  6.   i»>l. 

W.  G.  STlill'SON.  passed  asisstant  surgeon,  to  proceed  to  Coal- 
gate.    I.    T..    for  special   temporarj-   duty— May  9.  1901. 

TALIAFERRO  CLARK.,  assistant  surgeon,  granted  30  days'  ex- 
tension of  leave  of  absence,  on  account  of  sickness,  from 
April    21— Mav  6,   19(']. 

D.  E.  ROBINSON,  assitant  surgeon,  to  proceed  to  Port  Town- 
send  (Washington)  quarantine  station,  and  report  to  the 
medical  officer  in  command  for  speci.tl  temporary  duty — 
Mav  6.  1901. 

DUNI.OP  MOORE,  assitant  surgeon,  that  portion  of  Bureau 
order  of  April  IS.  1901.  directing  Assistant  Surgeon  Moore  to 
proceed  to  San  Francisco.  Cal.,  revoked— May  6,  1901. 

I-.  W.  RYDER,  hospital  steward,  granted  leave  of  absence  for 
15  days  from  May  6— May  7,  1901. 

Official  list  of  the  Changes  of  Station  and  Duties  of 
Commissioned  and  Non-Commissioned  Officers  of  the  U.  S. 
Marine  Hospital  Service  for  the  7  days  ended  May  16,  1901; 

JOHN  GODFREY,  surgeon,  upon  being  relieved  by  Surgeon  J. 
J.  Kinyoun.  to  proceed  to  Wilmington.  N.  C  and  assume 
command  of  the  service,  relieving  Surgeon  T.  B.  Perry— 
Mav  U,  1901. 

EUGENE  \VASDIN.  surgeon,  to  proceed  to  Gardner,  lU.,  for 
special   temporary  duty— May  14.   19'31. 

Bureau  order  ot  Mav  14.  directing  Surgeon  AlYasdin  to  pro- 
ceed  to  Gardner,    111.,   revoked— May   14.    190L 

T.  B.  PERRY,  surgeon,  upon  being  relieved  from  duty  to  Wil- 
mington, N.  C  to  proceed  to  Baltimore.  Md..  and  report  to 
medical  officer  in  command  for  duty  and  assignment  to  quar- 
ters—Mav  11.   19iil. 

R.  M.  WOODW.VRD.  surgeon,  granted  10  days'  extension  of 
leave  of  absence— May  13.  1901. 

G.  B.  YOUNG,  passed  assitant  surgeon,  granted  leave  of  ab- 
sence for  2  months  and  22  days  from  May  30— May  9.  1901. 

W.  G.  STIMPSON.  passed  assitant  surgeon,  to  proceed  to  Guth- 
rie. Oklahoma,  for  special  temporarj-  duty— May  14.  1901. 

J.  A.  NYDEGGER.  passed  assitant  surgeon,  granted  leave  of 
absence  for  one  day — May  15,  IKil. 

J.  B.  GREENE,  passed  assitant  surseon.  granted  leave  of  ab- 
sence for  10  days  from  May  13— May  14.  1901. 

CARROLL  FOX.  assistant  surgeon,  to  proceed  to  Sitka  and 
Juneau.   Alaska,   for  special  temporary  duty— May  10.   1901. 

F.  J.  THORNBURY.  assistant  surgeon,  relieved  from  duty  at 
Chicago.  111.,  and  directed  to  proc<»ed  to  Dutch  Harbor. 
Alaska,   and   assume   ctimmand  of  the  service — May  16.   1*31. 

FRANCIS  DUFFY,  acting  .nssitant  surgeon,  granted  leave  of 
absence  for  2  davs  from  May  21— May  16.  1901. 

C.  F.  UXRICH.  acting  asisstant  surgeon,  granted  leave  of  ab- 
sence for  1'?  davs  from  May  14 — May  It.  1901. 

M.  R.  M.\SON.  hbspit.ll  steward,  relieved  from  duty  at  San 
Francisco.  Cal..  and  directed  to  nroceed  to  Dutch  Harbor. 
Alaska,  and  report  to  medical  officer  in  command  for  duty 
—May   16.    1901. 

Psycho-Physical  Laboratory. — Efforts  are  being  made 
to  pass  the  following  resolution:  Resolved.  That  we  are 
in  favor  of  the  establishment  of  a  Psycho-Physical  Labora- 
tory in  the  Department  of  the  Interior  at  Washington  for 
practical  application  of  physiological  psychology  to  socio- 
logical and  abnormal  or  pathological  data,  especially  as 
found  in  institutions  for  the  criminal  pauper  and  defective 
classes  and  in  hospitals,  and  also  as  may  be  observed  in 
schools  and  other  institutions. 


Mat   2S,   1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia       „Qq 
Lmedical   Journal         y-"? 


Health  Reports:  The  following  cases  of  smallpox,  yellow 
fever,  cholera  and  plague  have  been  reported  to  the  Sur- 
geon General,  U.  S.  Marine  Hospital  Service,  during  the 
week  ending  May  17,  1901: 

SMALLPOX— UNITED  STATES  AND   INSULAR. 

«  ft* 

.    ■.*■-    o      r? 

ARKANSAS:  Prescott May  8  .    ........5      " 

CALIFORNIA:  San  Francisco May  4-11 3 

COLORADO:  40  Counties  Apr.1-30 430 

ILLINOIS:  Chicago   May  4-11 9 

Freeport    May  4-11 2 

IOWA:  Clinton    May  4-11 1 

KE.N'TUCKY:  Lexington    May  4-11 S 

LOUISIANA:  New  Orleans May  4-U 10 

MASSACHUSETTS:  Boston May  9    1 

New   Bedford   May  14 1 

MICHIGAN:  Detroit    May  4-11 1 

Grand   Rapids Apr.29-May  11.    6 

NEBRASKA:  Omaha    May  4-11 IS 

NEW  HAMPSHIRE  Manchester May  4-11 S 

NEW  JERSEY:  Camden    May  4-11 1 

Newark    May  4-11 3 

NEW  YORK:  New    York    May  4-11 107      19 

OHIO:  Cincinnati May  3-10 8 

Cleveland   May  4-11 32 

Dayton    May  4-U 1 

PENNSYLVANIA:      Philadelphia:       Ma v  4-11 3 

Pittsburg   May  4-U 7 

TENNESSEE:  Memphis    May  4-U 27       ? 

Nashville Mav  4-11 S 

WASHINGTON:  Tacoma  Apr.27-May  4  .    2 

WEST  VIRGINIA:      Huntington Apr.l3-May  11.  27 

WISCONSIN:  Milwaukee    May  4-U 1 

PORTO  RICO:  Ponce    Apr.22-29 3 

SMALLPOX— FOREIGN. 

CHINA:                            Hongkong Mar.23-Apr.6  .  22  17 

COLOMBIA:                   Panama  Apr.29-May  6   .    4  1 

FRANCE:                        Paris  Apr.22-27  20 

GERMANY:  Bremen   Apr.13-20 1 

GREAT    BRITAIN:    England- 
Sheffield  Apr.13-20 1 

Scotland- 
Glasgow Apr.26-May  3  .   ..  3 

INDIA:                             Bombay  Apr.8-16 6 

Calcutta  Mar.23-Apr.l3    .  339 

Karachi  Apr.7-14 3  3 

Madras    Mar.30-Apr.5  .  5 

ITALY:                             Naples Apr.22-29 149  30 

MEXICO:  Mexico    Apr.2S-May  5    .    1 

RUSSIA;                          St.   Petersburg Apr.13-20 13  1 

SPAIN:                             Corunna Apr.1-30 2 

YELLOW  FEVER. 

CUBA:  Havana  Apr.2S-May  4   .   1 

CHOLERA. 

INDIA:  Bombay  Apr.8-16 3 

Calcutta Mar.23-Apr.l3  .       194 

PLAGUE. 

CHINA:  Lam  Ko  District  .. .    Feb.14-Mar.26        10000 

INDIA:  Bombay  Apr.S-16    681 

Calcutta    Mar.23-30 20-57 

Karachi  Apr.7-14 229    214 

JAPAN:  Nagasaki   Apr.l9—        1   case,   1 

death  on  Japanese 
steamship  Taichu 
Maru. 


Physical  Fitness  for  Philippines. — The  Civil  Service  Com- 
mission has  received  from  the  Philippine  civil  service 
board  a  communication  regarding  the  question  of  physi- 
cal fitness  for  service  in  the  Philippine  Islands,  based  on 
a  report  from  Col.  Charles  R.  Greenleaf,  assistant  surgeon 
general.  United  States  army.  In  addition  to  the  age  limi- 
tations, minimum  eighteen  and  maximum  forty  years,  it 
reports  that  the  following  disabilities  constitute  debar- 
ments of  Americans  who  seek  civil  service  appointments 
in  the  islands: 

Chronic  skin  disorders — Diseases  of  the  eyes  and  er- 
rors of  refraction,  not  susceptible  of  correction  by  glasses: 
also  chronic  diseases  of  the  mucous  surface  of  the  eye- 
lids. Catarrhal  and  purulent  forms  of  ear  diseases.  Or- 
ganic diseases  of  the  heart  or  large  blood  vessels;  all 
forms  of  tuberculosis  or  other  pulmonary  diseases.  Chron- 
ic diseases  of  the  gastro-intestinal  tract,  including  diarrhea 
and  dysentery.  Diseases  of  any  of  the  organs  included  in 
the  abdomen.  Venereal  diseases.  Chronic  rheumatism: 
dropsy  of  joints:  chronic  diseases  of  the  bones:  varicose 
veins,  if  excessive.  Habitual  intemperance  as  to  alcohol 
or  drugs  of  any  kind.  Obesity  or  marked  disproportion  of 
height  over  weight. 


THE  ASSOCIATION  OF  AMERICAN   PHYSICIANS. 


(Continued  from  page  953.) 
Second  Day,  Morning. — The  morning  session  opened  with 
a  study  of  bubonic  plague  based  upon  the  outbreak  in  San 
Francisco.  L.  F.  Barker,  of  Chicago,  discussed  the  clinical 
aspects  of  the  subject.  Plague  belongs  to  the  group  of 
septicemic  infections.  The  epidemic  in  San  Francisco  was 
not  peculiar,  but  showed  the  same  features  as  have  been 
seen  in  nearly  all  places  in  the  early  stages  of  the  out- 
break. The  epidemic  was  a  sneaking  one,  with  long  inter- 
vals between  the  cases.  It  is  not  necessary  that  a  severe 
epidemic  follow  this  local  manifestation  of  the  disease.  So 
far,  in  San  Francisco,  there  has  been  no  outbreak  of  plague 
among  the  rats:  in  all  great  epidemics  a  rat  epidemic  has 
preceded  the  .general  outbreak.  The  majority  of  cases  in 
San  Francisco  occurred  among  the  Chinese  population, 
only  3  cases  having  been  met  with  among  the  Caucasians. 
The  majority  of  cases  occurred  between  the  ages  of  31  and 
40  years.  This  is  explained  by  the  fact  that  there  are  very 
few  Chinese  children  in  San  Francisco.  The  majority  of 
cases  were  in  the  male  sex.  This  feature  is  explained  by 
the  small  number  of  Chinese  women  in  San  Francisco.  The 
bubonic  type  of  the  disease  was  the  one  generally  met 
with:  although  one  case  of  plague  septicemia  and  one  of 
plague  pneumonia  occurred.  The  cases  usually  begin  sud- 
denly with  a  chill,  which  is  followed  by  intermittent  and 
irregular  fever,  nausea,  vomiting,  nervous  symptoms,  in- 
cluding delirium  and  coma.  The  bubo  usually  develops 
in  24  hours.  The  disease  progresses  steadily  to  death  in 
from  4  to  6  days.  Chronic  cases  are  accompanied  by  sup- 
puration. The  bubo  develops  rapidly,  it  is  usually  large 
and  involves  a  group  of  glands  together  with  the  surround- 
ing tissue,  which  presents  hemorrhage  and  edema.  The 
edema  is  characterized  by  a  sense  of  elastic  resistance  on 
palpation.  Pain  is  usually  present  in  the  neighborhood 
of  the  bubo:  it  is  sometimes  spontaneous  and  is  always 
elicited  by  pressure.  The  buboes  are  found  in  the  follow- 
ing situations  in  order  of  frequency:  groin,  axilla,  neck, 
popliteal  space  and  bend  of  elbow.  Cervical  bubo  is  often 
complicated  by  enlargement  of  the  tonsils  and  by  ulcera- 
tion of  the  tonsils.  The  pathologists  distinguish  a  pri- 
mary bubo  of  the  first  order,  which  is  the  one  in  which  the 
bacteria  first  multiply:  primary  bubo  of  the  second  order, 
which  is  due  to  direct  extension  of  the  primary  bubo  of  the 
first  order:  and  secondary  buboes,  which  are  due  to  em- 
bolic processes.  Clinically,  the  only  classification  that  can 
be  made  of  buboes  is  into  primary  and  secondary.  The 
latter  class  includes  buboes  of  the  second  order  and  sec- 
ondary buboes.  In  the  pneumonic  form  the  ba- 
cillus develops  primarily  in  the  respiratory  tract. 
This  form  presents  the  symptoms  of  pneumo- 
nia but  the  sputum  contains  great  numbers  of  the  plague 
bacillus  and  large  amounts  of  blood.  There  is  a  secon- 
dary form  of  pneumonic  plague  due  to  the  development  of 
pneumonia  in  a  bubonic  case.  In  some  cases  the  plague 
bacilli  multiply  in  the  skin,  poducing  abscesses  and,  in 
some  cases,  true  carbuncles.  Cases  of  septicemic  plague 
may  be  primary  or  secondary.  Cases  of  pestis  minor  in 
which  the  patients  recover  without  having  been  ill  enough 
to  have  been  in  bed.  are  found  at  the  beginning  and  at  the 
end  of  epidemics  Such  cases  are  often  unrecognized  and  . 
are  a  distinct  danger  to  the  community  in  which  they  oc- 
cur, because  the  urine  and  the  feces  contain  the  bacilli. 
The  safest  plan  is  to  call  all  cases  of  glandular  swelling 
cases  of  plague  until  they  are  positively  proved  not  to  be 
such.  The  diagnosis  is  to  be  made  positively  by  bacteriologi- 
cal examination  and  it  is  not  necessary  to  have  a  living  case 
in  order  to  arrive  at  a  definite  conclusion  that  the  condition 
existing  is  one  of  plague.  The  diagnosis  can  be  positively 
made  from  the  cadaver.  The  disease  has  been  confounded 
with  severe  malaria,  typhoid  fever,,  relapsing  fever,venereal 
bubo,  anthrax  of  the  skin,  septic  conditions  without  bubo, 
croupous  pneumonia  and  dengue.  Bacteriological  exam- 
ination of  the  following  pathological  products  should  be 
made:  bubo  juice,  blood,  spleen  juice,  sputum,  urine  and 
feces.  The  serum  reaction  is  not  to  be  depended  upon  for 
diagnostic  purposes  because  it  occurs  late  in  the  disease. 
When  plague  is  present  in  a  community,  every  case  of 
fever  and  every  cadaver  should  be  considered  to  be  of 
plague  origin  until  positively  proved  by  bacteriological 
examination  not  to  be  such.  Roux's  serum  is  the  only  hope 
in  the  treatment  of  the  condition.  F.  G.  Novy,  of  Ann  Ar- 
bor, discussed  the  bacteriology  of  plague.  The  greatest 
importance  is  to  be  attached  to  the  demonstration  of  the 


QQci       The  Philadelphia"] 
"-'         Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Mat  25,  ISOl 


bacillus  pestis  in  cases  of  suspected  plague.  The  bacillus 
can  be  detected  during  life,  but  it  is  often  a  difficult  mat- 
ter. Detection  of  the  bacillus  in  the  blood  is  not  always 
successful.  The  American  Commission  recommended  that 
every  case  of  fever  in  an  Asiatic  in  San  Francisco  and 
every  dead  body  of  an  Asiatic  should  be  considered  a  case 
of  plague  until  proved  not  to  be  so  by  bacteriological  exam- 
ination. The  bacillus  can  usually  be  easily  demonstrated 
in  a  fresh  cadaver,  although  inoculation  experiments  are 
often  necessary  before  a  positive  conclusion  can  be 
reached.  The  inoculation  should  be  made  into  rats  if 
possible.  Guinea  pigs  are  not  good  animals  for  inoculation 
experiments  on  account  of  their  resisting  power  to  the  ba- 
cillus. Involution  forms  of  the  bacillus  are  common.  For 
ordinary  purposes  of  diagnosis  the  direct  microscopic  ex- 
amination of  cover  slips  is  usually  sufBcient.  The  San 
Francisco  cases  were  cases  of  true  plague  as  bacteriologi- 
cal examination  showed,  and  the  infection  of  a  laboratory 
worker  with  acute  pneumonic  plague  is  a  further  confirm- 
atory fact.  Simon  Flexer,  of  Philadelphia,  discussed  the 
pathology  of  plague.  The  bacilli  of  plague  may  pass 
through  the  skin  without  leaving  an  indication  of  their 
entrance  and  thence  they  extend  through  the  lymphatics. 
The  appearance  of  the  lymphnodes  in  plague  is  pathog- 
nomic on  account  of  the  hemorrhage,  the  character  of  the 
edema  and  the  foci  of  necrosis  in  the  gland  and  the  sur- 
rounding tissues.  In  the  secondary  buboes  the  hemorr- 
hage and  edema  are  less  in  amount  and  the  foci  of  necro- 
sis in  the  gland  are  less  numerous.  There  is  no  lymphan- 
gitis except  in  the  immediate  neighborhood  of  the  infected 
glands,  so  that  no  connection  can  be  traced  between  the 
primary  and  the  secondary  buboes.  On  account  of  the  ir- 
regular metastasis  of  the  bacilli  the  glands  on  the  opposite 
side  become  involved  as  well  as  the  glands  on  the 
same  side  as  the  primary  bubo,  but  to  a  less 
extent.  The  smaller  glands  show  cellular  prolifera- 
tion, but  the  increase  in  size  of  the  larger  glands  is  due  to 
the  hemorrhage,  the  edema  and  the  enormous  number  of 
bacteria  that  are  found  in  the  lymph-sinuses.  The  latter 
condition  results  in  an  obstruction  of  the  flow  of  lymph 
within  the  glands.  The  necroses  in  the  lymph-nodes  are 
probably  due  to  the  presence  of  the  bacteria  occluding  the 
bloodvessels.  The  obstruction  of  the  lymphvessels  with 
bacteria,  however,  may  act  by  preventing  the  passage  of 
lymph  from  the  smaller  bloodvessels.  In  the  secondary 
buboes  the  enlargement  is  due  chiefly  to  the  proliferation 
of  the  cells.  Plague  pneumonia  is  usually  lobular,  although 
the  numoer  of  affected  lobules  may  be  so  great  that  their 
coalescence  produces  a  condition  similar  to  that  of  lobar 
pneumonia.  The  exudate  contains  few  cells  except  red 
bloodcorpuscles:  fibrin  is  absent,  but  the  number  of  bacilli 
is  so  great  that  they  produce  the  consolidation  by  filling 
the  alveoli.  The  changes  in  the  spleen  are  those  of  acute 
splenic  tumor.  There  is  in  addition  acute  splenitis  which 
Is  characterized  by  the  presence  of  a  large  number  of  poly- 
morphonuclear leukocytes  which  wander  all  through  the 
trabeculae  and  reticulum  of  the  spleen.  The  enlargement 
of  the  oi-gan  is  chiefly  due  to  the  amount  of  blood  which  it 
contains.  There  are  a  large  number  of  phagocytes  con- 
taining red  bloodcorpuscles.  Metastases  are  occasionally 
found  in  the  liver  and  kidneys  producing  lesions  that  re- 
semble abscesses  in  appearance.  The  bacilli  are  thrown 
off  from  the  glands,  if  these  break  through  the  skin:  they 
are  thrown  off  in  the  sputum  in  pneumonic  cases:  they 
are  often  passed  in  the  urine,  particularly  when  the  kidney 
lesion  is  of  a  hemorrhagic  nature:  they  are  f.ound  in  the 
feces  when  there  are  hemorrhagic  lesions  in  the  mucous 
membrane  of  the  intestine.  In  animals,  the  lesions  cor- 
respond pretty  closely  with  those  found  in  human  beings. 
The  author  believes  that  the  system  of  control  in  San 
Francisco  is  so  much  improved  that  when  the  statement 
comes  that  plague  had  disappeared  we  can  believe  it. 
George  M.  Sternberg,  of  the  U.  S.  Army,  said  that  if  this 
small  epidemic  in  San  Francisco  had  occurred  30  years 
ago  we  might  be  reading  in  the  daily  papers  to-day  of  500 
or  more  cases  in  San  Francisco  and  of  the  extension  of 
the  epidemic  throughout  other  parts  of  the  country.  The 
good  results  in  this  epidemic  are  entirely  due  to  the 
presence  of  laboratories  and  of  trained  bacteriologists. 
William  A.  Park,  of  New  York,  said  that  he  had  met  with 
2  cases  of  plague  on  a  Brazilian  ship  in  New  York  harbor. 
Bacteriological  examination  of  the  pus  from  the  buboes 
showed  the  presence  of  the  bacillus  pestis.  Both  patients, 
•who  had  attended  a  fatal  case  of  plague  while  at  sea.  re- 


covered.    F.  H.  Shattuck,  of  Boston,  asked  how  soon  the 
bacilli  appeared  in  the  urine  in  cases  of  plague.    Victor  C. 
Vaughan,   of  Ann  Arbor,   described   the  condition   of  the 
laboratory  worker  at  Ann  Arbor  who   contracted   plague 
pneumonia.     The  initial  symptoms  in  the  case  were  head- 
ache, pain  in  the  back  like  that  of  renal  calculus,  tempera- 
ture 102°  and  later  104°,  and  vomiting.     The  patient  and  2 
fellow  students  who  were  caring  for  him  v.'ere  isolated,  the 
door  of  the  laboratory  in  which  he  had  worked  was  locked, 
and  his  bedroom  was  thoroughly  disinfected.    The  sputum 
was  very  carefully  sterilized  as  soon  as  brought  up.    George 
Dock,  of  Ann  Arbor,  showed  the  temperature  chart  of  the 
patient  in  question.     The  patient  presented  a  pleural  fric- 
tion on  the  affected  side  and  dulness  similar  to  that  elicited 
in  the  pneumonia  of  the  aged.     The  patient  had  the  ap- 
pearance  of  a  very  sick  man,  which  was  entirely  out  of 
proportion  to  his  physical  signs.     The  spleen  became  en- 
larged and  painful  on  the  fourth  day  of  the  disease.    After 
the  last  injection  of  Roux's  serum,  of  which  120  ccm.  were 
administered  in  the  first  24  hours,  the  temperature  fell  but 
not  as  decidedly  as  it  does  in  cases  of  croupous  pneumonia. 
The  patient's   heart  was  weak  and   slow  and  he  suffered        ! 
from  marked  dyspnea  at  one  period  of  the  attack.    He  had        '• 
urticaria    and    joint    pains    and    a    rise    of    temperature       ' 
after  the  injection  of  the  serum.    Each  of  those  exposed  to       j 
the  disease  received   10   ccm.  of  Roux's  serum.     In  2  of       j 
these   cases    urticaria,    asthma    and   joint    pains    followed        ' 
the  injection.    L.  F.  Baker,  of  Chicago,  said  that  he  did  not        ; 
know  how  early  bacilli  might  appear  in  the  urine  in  cases        [ 
of  plague.     'RTiile  all   cases  are  probably  contagious  the       i 
pneumonic  cases  are  the  most  virulent.    It  is  dangerous  to        ' 
make   autopsies   in   plague   cases.     The   whole  country   is 
indebted  to  Kellogg  and  Kinyoun  for  their  admirable  work 
in  San  Francisco.     He  congratulated  the  Ann  Arbor  men 
on  their  speedy  recognition  of  the  case  of  plague  and  on 
their  successful  treatment  of  it.     Simon  Flexner.  of  Phila- 
delphia, said  that  bacilli  have  been  found  in  the  urine  in 
plague  cases  as  early  as  the  third  day. 

Walter  .Reed  and  James  Carroll,  of  the  V.  S.  Army,  read 
a  paper  entitled  experimental  yellow  fever.  The  authors 
tried  to  produce  yellow  fever  in  human  beings  (II  by  the 
bites  of  culex  fasciata  which  had  previously  bitten  a  yel- 
low fever  patient.  (2)  By  injecting  the  blood  from  a 
yellow  fever  patient  into  a  nonimmune  subject.  (3)  And 
by  the  exposure  of  individuals  to  fomites.  The  authors 
succeeded  in  infecting  4  out  of  5  patients  by  injections  of 
human  blood.  These  cases  confirm  the  presence  of  the 
parasite  in  the  blood  of  the  general  circulation  of  patients 
suffering  from  the  disease  and  confirms  the  possibility  of 
its  transference  by  the  bite  of  the  mosquito.  Inoculation 
of  blood  from  a  case  of  yellow  fever  into  suitable  culture 
media  produced  no  growth,  thus  depriving  the  bacillus 
icteroides  of  its  position  as  the  cause  of  yellow  fever. 
The  paper  contains  an  account  of  4  additional  cases  of 
inoculation  of  yellow  fever  by  mosquito  bites.  One  of  the 
patients  was  bitten  57  days  after  the  insects  had  been  fed 
on  a  yellow  fever  patient.  This  patient  contracted  severe 
yellow  fever.  The  parasite  is  present  in  the  general  cir- 
culation of  the  infected  individual  both  before  and  after  the 
intermission  of  the  fever.  All  mosquitoes  do  not  acquire 
the  parasite  on  biting  a  yellow  fever  patient  because  the 
organism  may  not  be  present  in  the  capillary  circulation. 
The  average  period  of  incubation  of  yellow  fever  in  1«  cases 
was  S7  1-3  hours,  or  3  days  and  a  few  hours.  The  period 
of  incubation  in  one  case  was  7  days.  The  cases  may  be 
severe,  mild  or  very  mild.  Mild  cases  are  difficult  to  diag- 
nose in  the  absence  of  complete  data,  but  such  cases  may 
serve  as  a  focus  of  infection  through  the  bites  of  mos- 
nuitoes.  All  the  cases  in  the  series  presented  albuminuria 
with  one  exception.  George  M.  Sternberg,  of  the  U.  S. 
Army,  said  that  this  demonstration  of  the  infection  of  non- 
immune patients  by  the  bite  of  the  mosquito  makes  clear 
many  apparently  contradictory  facts  concerning  the  eti- 
ologj-  of  the  disease.  It  explains  the  occurrence  of  yellow 
fever  in  stevedores  when  a  ship  appeared  to  have  no  yellow 
fever  on  board.  It  explains  why  sulphur  fumigation  dis- 
infected these  ships.  It  explains  how  the  infection  traveled 
from  a  ship  anchored  in  the  harbor  to  the  neighboring 
land  without  communication  with  the  shore.  He  consid- 
ers the  demonstration  that  the  infectious  agent  is  in  the 
blood,  and  that  it  may  be  conveyed  to  a  susceptible  indi- 
vidual by  the  bite  of  a  mosquito.  William  H.  Welch,  of 
Baltimore,  said  that  it  is  fortunate  that  the  authors  had 
no  deaths  in  their  work.     They  were  cognizant  of  the  ex- 


May   :::.,   1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia       qqj 
Lmedical   Journal         77 


treme  responsibility  resting  upon  them,  and  the  young 
American  soldiers  who  volunteered,  without  pay,  for  the 
work,  were  heroes. 

James  Ewing.  of  New  York,  read  a  paper  entitled  a  case 
of  malarial  nephritis  with  the  massing  of  the  parasites 
in  the  kidney.  Albuminuria  is  nearly  always  present  in 
pernicious  estivoautumnal  malaria,  and  in  some  cases  of 
severe  tertian  infection.  The  acute  nephritis  of  malaria  Is 
seldom  fatal.  When  a  fatal  case  does  occur,  however,  the 
lesions  found  have  been,  in  the  majority  of  cases,  degen- 
erations of  the  epithelium  of  the  convoluted  tubules  with 
an  exudate  of  albumin  into  the  tubules  and  into  the  glomeruli, 
with  few  parasites  in  the  vessels.  The  case  repoi'ted  by 
the  author  shows  that  the  kidney  lesion  may  be  due  to 
excessive  accumulation  of  parasites  in  the  renal  capillaries. 
These  parasites  were  demonstrated  by  staining  the  tissues 
by  Nocht's  method.  The  cells  lining  the  tubules  were  de 
generated  and  their  detritus  filled  the  lumen  of  the  tub- 
ules. Many  of  the  capillaries  were  ruptured,  producing 
miliary  hemorrhages.  There  was  partial  or  complete  sup 
pression  of  the  urine,  which  contained  a  large  number  of 
red  cells,  a  large  amount  of  albumin,  coarse  granular, 
epithelial  and  blood  casts,  with  infected  red  cells  and  pig 
mental  leukocytes  adhering  to  the  casts.  The  diagnosis 
was  made  during  life. 

Walter  B.  Jones,  of  New  York,  read  a  paper  entitled 
septic  i/ifection  through  the  stomach  and  the  duodenum. 
The  stomach  and  the  duodenum  contain  at  all  times  large 
numbers  of  micro-organisms  that  are  capable  of  setting 
up  a  septicemia  if  a  solution  of  continuity  of  the  mucous 
membrane  occurs.  The  case  of  a  man,  aged  .56  years, 
was  cited  The  patient  had  lost  weight,  had  had  nausea 
and  vomiting  and  anemia,  from  which  he  had  apparently 
recovered.  Then  he  was  taken  with  a  chill  and  intermit- 
tent fever  that  suggested  septic  thrombosis.  At  autopsy,  an 
adenoma  was  found  on  the  mucous  membrane  surface  of 
the  greater  curvature.  The  surface  of  this  tumor  was 
eroded  and  inflamed.  This  was  thought  to  be  the  original 
seat  of  the  infection.  The  author  advanced  the  opinion 
that  such  a  complication  might  be  seen  in  cases  of  gastric 
ulcer  and  gastric  carcinoma,  in  both  of  which  there  is  a 
solution  of  continuity  of  the  lining  of  the  stomach.  Prob- 
ably septic  poisoning  through  breaks  in  the  lining  of  the 
stomach  and  duodenum  are  more  frequent  than  is  at 
present  believed.  S.  J.  Meltzer,  of  New  York,  said  that 
such  cases  might  come  under  the  head  of  terminal  infec- 
tions. Francis  P.  Kinnicutt.  of  New  York,  said  that  the 
cases  of  fever  of  septic  type  in  which  the  patient  recovered 
could  hardly  be  called  cases  of  terminal  infection.  The 
observations  of  cases  in  his  own  wards  tend  to  make  him 
agree  with  the  opinion  of  James.  Walter  B.  James,  of 
New  York,  said,  in  answer  to  a  question  by  Cabot,  that 
leukocytosis  had  been  found  in  some  cases.  Lowered 
resistance  would  undoubtedly  render  a  patient  more  sus- 
ceptible to  such  an  infection. 

John  H.  Musser,  of  Philadelphia,  read  a  paper  for  himself 
and  Norman  B.  Gwyn.  of  Philadelphia,  entitled  two  cases 
of  streptothrlcal  infection,  one  of  bronchopneumonia,  the 
second  abscess  of  the  brain.  The  patient,  who  had  an 
abscess  of  the  brain,  was  a  man,  aged  22  years,  who  was 
poorly  nourished  and  who  had  a  family  history  of  tubercu- 
losis. He  began  to  have  convulsions  with  no  other  symp- 
toms except  hypesthesia  of  the  right  side.  The  convul- 
sions recurred  and  coma  appeared.  Lumbar  puncture  was 
negative.  At  autopsy  an  abscess  was  found  in  the  white 
matter  of  the  brain  behind  the  lissure  of  Rolando,  some- 
what involving  the  cortex.  The  abscess  contained  foul 
smelling  pus  in  which  a  streptothrix  was  found  in  a  cover 
glass  preparation.  Cultures  were  negative  and  animal 
inoculations  were  not  conclusive.  The  other  case  presented 
a  bronchitis  with  increased  frequency  of  pulse  and  res- 
piration. The  condition  went  on  to  the  production  of  a 
bronchopneumonia.  The  sputum  showed  a  streptothrix. 
The  patient  died,  but  an  autopsy  was  not  permitted.  These 
organisms  may,  of  course,  be  one  of  the  branching  forms 
of  tubercle  bacilli.  Simon  Flexner,  of  Philadelphia,  re- 
ferred to  a  case  simulating  tuberculosis  which  he  reported 
to  the  society  several  years  ago.  A.  C.  Abbott,  of  Philadel- 
phia, said  that  he  had  seen  a  condition  in  one  of  the 
lower  animals  that  resembled  tuberculosis.  From  this 
animal  he  had  obtained  a  streptothrix  in  pure  culture,  but 
v.'as  not  able  to  inoculate  it  into  animals. 

McPhedran,  of  Toronto,  showed  a  specimen  of  blue  urine 


that  had  been  passed  in  his  office  by  a  neurasthenic  pa- 
tient.   The  coloring  matter  was  pure  indigo  blue. 

Kdward  L.  Trudeau,  of  Saranac  Lake,  N.  Y.,  exhibitied 
some  specimens  of  chemical  substances  obtained  from  the 
tubercle  bacillus.  These  consisted  of  (1)  a  reddish  color- 
in.i5  matter.  (2)  A  wax,  which  constituted  307o  of  the 
tubercle  bacillus.  This  wax  is  the  ingredient  that  causes 
the  bacillus  to  resist  the  action  of  nitric  acid  after  it  has 
lM:en  stained.  It  is  possible  that  this  wax  is  the  cause  of 
the  resistance  of  the  bacillus  to  the  disintegrating  action  of 
the  tuberculous  processes.  (3)  The  outside  coating  of  the 
bacillus  is  composed  of  cellulose,  {i)  Three  nucleopro- 
teids,  having  different  coagulating  points  and  from  which 
pure  nucleic  acid  was  obtained  which  had  a  high  percent- 
age of  phosphorus.  This  nucleoproteid  is  probably  the  act- 
ive ingredient  of  the  tuberculin.  (5)  The  tubercle  bacillus 
contains    glycogen. 

A.  C.  Abbott,  of  Philadelphia,  reported  a  product  of  the 
bacillus  pyocyaneus  that  presented  some  of  the  reactions 
of  cellulose  and  some  of  the  reactions  of  mucin.  This  body 
was  found  in  old  cultures  only  and  seems  to  be  a  degener- 
ative product. 

Victor  C.  Vaughan,  of  Ann  Arbor,  read  a  paper  entitled 
the  toxin  of  the  colon  bacillus.  He  has  studied  the  toxin 
of  the  colon  bacillus  chemically,  and  is  of  the  opinion  that 
it  is  an  intracellular  product.  He  uses  for  his  studies  a 
large  moist  chamber  for  growing  the  organisms  in  which 
he  can  develop  20  square  feet  of  culture.     [J.  M.  S.] 

Third  Day,  Morning.— Franz  Pfatf,  of  Boston,  read  a 
paper  entitled  some  observations  made  in  a  case  of  diverti- 
culum of  the  esophagus.  The  patient  suffered  from  loss  of 
weight  and  regurgitation  of  food.  The  gastric  digestion 
was  shown  to  be  normal  and  the  motility  of  the  organ  was 
satisfactory.  A  tube  was  passed  into  the  stomach  with  no 
difficulty,  but  it  was  possible  to  remove  from  the  esophagus 
food  that  had  been  swallowed  as  much  as  20  hours  before. 
The  patient  was  fed  through  a  tube  for  3  years  and  then, 
when  he  tried  to  pass  the  tube,  it  was  arrested  about  37cm. 
from  the  mouth.  On  one  occasion  90ccm.  of  undigested 
food  were  evacuated  from  the  esophagus,  which  contained 
lactic  acid,  but  no  pepsin  and  no  hydrochloric  acid.  After 
this  material  was  evacuated  the  tube  could  be  passed  on 
into  the  stomach  with  ease,  and  a  fluid  containing  hydro- 
chloric acid  was  obtained.  The  absence  of  saliva  from  the 
stomach,  in  this  case,  had  no  influence  on  gastric  secretion 
nor  on  the  motility  of  the  organ.  During  the  last  year  and 
15  months  the  size  of  the  diverticulum  has  not  changed. 
The  patient  has  to  empty  the  diverticulum  before  he  can 
introduce  the  tube  into  the  stomach.  Experiments  have 
shown  that  carbohydrates  are  digested  to  considerable 
extent  in  the  esophagus.  Lactic  acid  is  always  present 
in  the  esophagus,  but  the  amount  is  decreased  by  keeping 
the  esophagus  clean.  There  is  practically  no  absorption 
from  the  esophagus  of  even  readily  diffusible  substances 
like  sodium  chloride.  Feeding  by  means  of  the  stomach 
tube  has  resulted  in  a  gain  of  43  pounds  in  the  weight  of 
the  patient.  In  a  second  case  of  diverticulum  of  the  eso- 
phagus, tube-feeding  resulted  in  a  gain  of  23  pounds  iu 
weight  in  a  short  time.  In  the  first  patient  spoken  of  in 
the  paper  an  X-ray  pliotograph  showed  the  diverticulum 
low  down  near  the  cardiac  end  of  the  stomach.  S.  J. 
Meltzer,  of  New  York,  said  that  the  mucous  membrane  of 
the  esophagus  absorbs  slowly.  In  cases  of  diverticulum  the 
mucous  membrane  is  altered  in.  appearance  so  that 
absorption  does  not  take  place.  In  a  patient  suspected  of 
having  a  diverticulum  of  the  esophagus,  vomiting  from  the 
stomach  would  be  an  indication  that  a  diverticulum  was 
present.  If  the  condition  was  one  of  organic  stricture 
fluids  could  pass  neither  from  the  esophagus  into  the 
stomach  nor  from  the  stomach  into  the  esophagus.  But 
in  the  case  of  a  diverticulum,  while  fluid  would  not  pass 
from  the  esophagus  into  the  stomach,  vomiting  from  the 
stomach  would  be  possible. 

(To  be  Continued.) 


Abstract  of  Papers  and  Discussions  at  the  Annual  Meet- 
ing of  the  American  Surgical  Association,  held  in  Balti- 
more on  May  7th,  8th  and  9th,  1901,  the  President,  Dr. 
Roswell    Park,  of   Buffalo,   In  the  Chair. 

MAY  7.  1901,  MORNING  SESSION. 

Immediately  after  calling  the  meeting  to  order,  a  short 
executive  session  was  held  and  then  the  scientific  business 
was  commenced. 

The  President  read  his  Annual  Address,  entitled  "Some 
Phases  of  the  Cancer  Question,"  and  stated  that  patholo- 


992 


The  Philadelphia  "I 
Medical   Journal  J 


AMERICAN  NEWS  AND  NOTES 


[Mat  25,   1901 


:^ists.  who  Study  the  condition  purely  from  the  dead-house 
point  of  view,  have  confronted  some  of  the  greatest  prob- 
lems which  it  has  to  offer,  but  have  also  missed  some  of 
its  most  important  aspects.  The  parasites  of  cancer,  be 
their  nature  what  it  may,  are  in  all  probability  polymor- 
phic in  extreme  degree  and  masquerade  under  many  forms, 
■changing  with  their  different  stages  of  reproduction.  There 
is  no  other  disease  which  is  characterized  by  metastasis  iu 
■which  the  pathologists  decline  to  see  evidence  of  parasit- 
ism. Every  metastasis  of  cancer  has  the  form  and  sig- 
nificance of  an  inoculation  experiment  only  performed  un- 
der the  most  favorable,  because  natural,  conditions.  The 
primary  question  after  all.  is  the  general  one  of  parasit- 
ism but  it  has  not  yet  been  reduced  to  a  question  of  just 
T\'hat  parasites.  In  the  author's  opinion  it  may  and  prob- 
ably will  be  found  that  cancer  is  not  a  question  of  any 
single  organism,  and  possibly  not  even  of  a  single  class. 
The  latest  work  of  Roger  Williams  was  then  quoted  at 
some  length  and  reference  was  made  to  Demarquay,  who 
collected  one  hundred  and  thirty-four  cases  of  cancer  of 
the  penis,  whereas  in  only  one  instance  was  the  wife  af- 
fected with  uterine  cancer.  Numerous  cases  are  now  on 
record  of  cancer  along  the  track  of  the  trocar  used  in 
tapping  for  ascites  due  to  cancerous  disease,  and  surgeons 
now  generally  admit  this  traumatic  dissemination  of  the 
disease  by  inoculation  of  wourds  during  operations.  From 
studies  already  made  in  the  New  York  State  Laboratory  it 
seems  to  be  clear  that  death  in  cases  of  cancer  comes  about, 
as  in  so  many  other  diseases,  by  a  sort  of  terminal  infec- 
tion, which  is  a  conspicuous  feature  of  the  disease  and 
has  not  hitherto  attracted  sufficient  attention.  The  exact 
nature  of  these  terminal  changes  has  not  yet  been  made 
out  beyond  what  is  implied  in  the  term  "Hematogenous."' 
The  predictions  of  the  Italians  have  failed  in  many  re- 
spects, and  it  is  by  no  means  so  easy  to  successfully  inocu- 
late animals  with  the  yeast  as  has  been  generally  sup- 
posed. By  comparing  tumors  removed  by  operation  with 
those  removed  post  mortem,  it  became  evident  that  the  or- 
ganisms either  increased  rapidly  during  the  period  jusi 
before  death,  or  that  they  proliferate  in  the  tissue  imme- 
diately after  death.  In  practically  all  scrapings  from  can- 
cer could  be  seen  either  small  hyaline  refractive  forms 
which  in  suspension  possess  a  characteristic  oscillating 
TOotion  or  larger  forms  with  projecting  pseudopodia  or 
sacular  forms  containing  very  refractive  spherical  bodies. 

The  work  of  Dr.  Gaylord,  in  association  with  the  author 
■was  then  referred  to  at  considerable  length,  and  reference 
"Was  made  to  a  number  of  publications  by  these  gentlemen 
•on  this  subject.  It  was  mentioned  that  considerable  diffl 
<"ulty  is  added  to  the  work  of  investigation  by  the  extra- 
ordinary polymorphism  of  many  of  the  minute  organisms 
found  in  cnncer.  Plimmer's  work  was  referred  to  to  a  con- 
siderable extent  and  deductions  drawn  therefrom.  It  ap- 
pears that  the  protozoa  are  capable  of  producing  in  man 
lesions  of  widely  different  nature  from  mere  infection  of 
•epithelium,  and  Pfeiffer  has  shown  that  they  might  pro- 
■duce  both  in  man  and  in  animals.  A  full  report  was  prom- 
ised in  a  short  time  of  the  results  of  inoculating  seventy- 
two  animals  with  the  technique  employed. 

Pfeiffer's  work  was  quoted  from  at  some  length  and  vari- 
ous deductions  were  drawn  therefrom. 

That  cancer  begins  as  a  purely  local  infection  has  been 
verified  by  the  recent  paper  by  the  author  in  the 
laboratory  at  Buffalo,  and  also  that  it  kills  by  becoming 
generalized,  which  is  equally  true  of  tuberculosis,  and  these 
•constitute  apparent  exceptions  to  the  above  rule,  but  even 
they  do  not  prove  that  the  disease  did  not  have  a  local 
beginning. 

The  author  concluded  his  paper  by  stating.  "I  want  to 
make  it  as  evident  as  possible  that  carcinoma  is  an  epi- 
thelial infection." 

Dr.  Thomas  S.  Cullen.  of  Baltimore,  gave  a  lantern  slide 
exhibition  of  The  Early  Signs  of  Carcinoma  of  the  Uterus, 

Dr.  W.  S.  Halstead,  of  Baltimore,  made  a  few  remarks 
«n  a  Brief  Consideration  of  the  Cases  of  Cancer  of  the 
Breast  treated  at  the  ,Iohns  Hopkins  Hospital  since  18S0, 
He  spoke  of  the  difficulties  of  getting  a  good  picture  of 
the  cancer,  and  stated  that  drawings  are  made  in  every 
case  to  file  away  with  the  records.  He  reported  havin,g 
operated  on  320  cases  of  carcinoma  of  the  breast  and  450 
cases  of  the  breast  tumor,  as  well  as  three  cases  of  pri- 
mary sarcoma  of  the  breast.  Intra-canalicular  myxomata 
-and  fibromata  are  often  spoken  of  as  sarcoma,  but  in  Dr. 
llalsted's  opinion,  they  are  not.    He  referred  at  great  length 


to  the  difficulty  of  compiling  statistics  and  demonstrated 
the  method  of  grouping  the  cases  at  the  Johns  Hopkins  in 
order  to  arrive  at  the  proximate  results.  His  experience 
is  that  the  percentage  of  recurrences  is  very  veriable,  and 
he  reported  that  out  of  129  cases  operated  upon,  51  had 
been  cured. 

Dr.  W.  B.  Coley  of  New  York  read  a  paper  entitled: 
"Late  Results  of  the  Treatment  of  Inoperable  Sarcoma 
with  the  Mixed  Toxins  of  Erysipelas  and  Bacillus  Prodig- 
iosus,  with  a  Reijort  of  Cases." 

The  writer  referred  to  his  paper  published  in  August. 
iS98,  (1)  in  which  he  gave  the  results  of  140  cases  of 
inoperable  sarcoma  treated  with  the  mixed  toxins  of  ery- 
sipelas and  bacillus  prodigiosus.  In  24  of  these  the  tumor 
completely  or  partially  disappeared  as  a  result  of  the  treat- 
ment. In  84  cases  of  this  series  the  sarcoma  was  round- 
celled:  in  21  spindle-celled:  in  9  melanotic:  2  chondro- 
sarcoma: in  12  the  type  of  cell  was  not  stated,  though  the 
diagnosis  was  confirmed  by  the  microscope:  ti  were  in- 
operative carcoma,  the  diagnosis  resting  uopn  clinical 
symptoms,  combined  in  most  cases  with  a  history  of  re- 
peated recurrence. 

In  40  cases  of  the  round-celled,  or  slightly  less  than 
half,  more  or  less  improvement  was  shown  by  decrease  in 
size  or  cessation  of  growth.  In  only  4  of  these  was  the 
treatment  permanently  successful. 

Of  21  cases  of  spindle  celled  sarcoma  10  disappeared  en 
lirely;  all  the  remainder  showed  marked  improvement. 

In  no  case  of  melanotic  growth  more  than  temporarj 
improvement  was  noted. 

At  the  time  of  this  report  8  cases  had  remained  well 
from  3  to  6  years;  9  from  1},^  to  3  years. 

In  addition  to  these  personal  results,  the  paper  con- 
tained a  summary  of  results  in  35  cases  successfully 
treated  by  other  surgeons  employing  the  same  method. 
Of  these  35  cases  10  were  round-celled:  10  spindle-celled: 
in  5  the  diagnosis  was  clinical  only:  in  5  there  was,  in  ad- 
dition to  the  clinical  signs  of  sarcoma,  a  history  of  recur- 
rence after  operation:  in  4  the  diagnosis  of  sarcoma  was 
confirmed  by  microscopical  examination,  but  the  type  not 
stated:  1  was  an  endothelio-carcoma. 

Of  these  35  cases  26  disappeared  completely:  2  others 
decreased  so  much  that  only  a  small  node  was  left,  which 
was  easily  excised.  One  of  the  latter  cases  was  well  three 
years  and  the  other  1  year  at  the  time  of  the  report. 

Of  the  35  cases  referred  to,  14  were  w^ell  over  two  years, 
and  6  cases  over  3  years. 

The  object  of  the  present  paper,  the  author  said,  was  to 
determine,  if  possible,  from  a  careful  tracing  of  the  suc- 
cessful cases,  whether  the  action  of  the  toxins  upon  sar- 
coma is  to  be  regarded  as  of  temporary  or  permanent  value- 
in  other  words,  whether  or  not  it  is  entitled  to  be  called 
curative. 

\\'hile  at  the  time  of  his  report  in  1898.  8  of  his  personal 
cases  had  remained  well  from  3  to  6  years,  he  stated  that 
this  number  had  now  increased  to  15  that  had  remained 
well  from  3  to  8  years.  Of  these  2  recurred  after  3  and  6 
years,  respectively:  the  second,  after  having  remained 
well  for  6  years,  is  now  again  under  treatment.  This 
being  an  exceedingly  interesting  case,  the  writer  stated 
that  it  would  shortly  be  published  in  detail.  All  the  cases 
comprising  the  foregoing  series  were  hopeless,  inoperable 
cases  and  the  diagnosis  was  confirmed  by  the  microscope 
with  two  exceptions,  and  in  these  the  history  of  the  cases 
together  with  the  clinical  appearances,  made  the  diagnosis 
of  sarcoma  unquestionable.  The  type  of  tumor  in  the  fif- 
teen eases  that  passed  the  three  year  limit,  was  as  fot 
lows : 

Spindle-celled  sarcoma  S 

Round-celled  sarcoma  2 

Mixed-celled  sarcoma   2 

Epithelioma    1 

Sarcoma   ( clinical  diagnosis  only)    2 

It  is  worthy  of  special  note  that  two  of  the  successful 
cases  now  well  3?i  and  4\j  years,  respectively,  are  sar- 
coma of  the  parotid  gland.  Butlin.  in  his  last  edition  of 
"Operative  Treatment  of  the  Parotid  Gland"  states  that 
"up  to  the  present  time  there  are  very  few  instances  of 
cure  by  operation  of  undoubtedly  malignant  disease  of  the 
parotid."  In  the  author's  two  cases  treated  by  the  toxins 
the  diagnosis  was  not  only  confirmed  by  a  competent  path- 
ologist, but  further,  by  a  history  of  repeated  recurrence  af- 
ter operation.  Another  case  still  is  also  worthy  of  special 
mention,  inasmuch  as  it  shows  that  the  toxins  may  be  taken 


May   25,   1901] 


FOREIGN  NEWS  AND  NOTES 


TThe  Philadelphia       qoj 
L Medical   Journal         yyo 


for  long  periods  of  time  without  harm.  The  patient,  a  well- 
known  physician,  with  eight  times  recurrent  spindle-celled 
sarcoma  of  the  soft  parts  of  the  chest  (anteriorly)  was 
treated  with  small  doses  of  the  mixed  toxins  with  vary- 
ing intervals  of  rest,  for  nearly  three  years.  The  patient 
regained  his  usual  health,  and  has  now  been  perfectly  well 
over  six  years  from  the  beginning  and  four  years  since 
the  cessation  of  the  treatment.  The  tumors,  while  orig- 
inally pure  spindle-celled,  were  becoming  more  mixeil 
with  round  cells  and  more  vascular  with  each  recurrence. 
In  other  words,  the  disease,  as  so  often  happens,  was 
increasing  in  malignancy  until  the  toxins  were  begun. 
(To  be  Continued.) 


NINETEENTH    GERMAN    CONGRESS    FOR     INTERNAL 
MEDICINE. 


(Continued  from  page  954.) 

Meyer,  of  Berlin,  took  the  field  to  defend  his  diplostrep- 
tococcus  as  a  specific  organism.  He  described  his  experi- 
ments and  emphasized  the  connection  between  the  affec- 
tion of  the  tonsils  and  rheumatism.  He  has  found  his  or- 
ganisms in  12  cases  of  angina  which  led  to,  or  accompa- 
nied, articular  rheumatism.  Injection  of  the  organism 
produced  typical  joint  affections,  and  he  obtained  the 
coccus  from  the  infected  animals.  Menzer  of  Berlin  also 
opposed  Singer,  and  claimed  that  he  and  Meyer  have  for 
the  first  time'  experimentally  caused  multiple  arthritic 
rheumatism  with  the  subsequent  endocarditic  affection. 
Glaser  of  Berlin  also  opposed  Singer's  views.  Michaelis 
of  Berlin  defended  Meyer  and  declared  his  belief  that  the 
organism  found  by  Meyer  is  the  specific  cause  of  the  dis- 
ease. The  discussion  assumed  a  personal  character  and 
therewith  lost  scientific   interest. 

Gliick,  of  Berlin:  "The  Development  of  the  Surgery  of 
the  Lungs."  Gliick  described  his  experiments,  which 
prove  that  one  can  resect  lobes  of  the  lung,  or  even  a  whole 
organ,  and  reports  14  cases  which  he  has  successfully  op- 
erated  on. 

Von  Schrotter.  of  Vienna,  reported  "A  Rare  Cause  of  Out- 
side Paralysis  of  the  Recurrent — an  addition  to  the  Symp- 
tomatology and  Diagnosis  of  open  Ductus  Arteriosis."  In 
this  case — congenital  heart  lesion — the  autopsy  showed 
that  the  recurrent  was  injured  by  being  wedged  in  be 
tween  the  dilated  ductus  arteriosis  and  the  aorta.  Roent- 
gen photographs  showed  clearly  the  pathognomic  sign 
of  persistence  of  the  ductus,  first  described  by  Zinn;  a 
shadow  in  the  second  left  intercostal  space.  He  considers 
the  case  of  significance  in  the  question  of  differential  di 
agnosis. 

Kraus  and  Graz  reported  a  case  of  Recurrent  Paralysis 
in  Stenosis  of  the  Mitral  Valve,  due  to  strangulation  of 
the  nerve  following  the  topographical  changes  due  to  the 
dilatation  of  the  right  ventricle. 

Vogt.  of  Berlin,  described  the  advantages  which  could 
be  gained  if  the  work  on  the  anatomy  of  the  brain  could 
be  done  at  some  central  station,  instead  of  being  scattered 
as  at  present. 

Hampaln  of  Riga;  "The  Hospital  Mortality  in  Pneumo- 
nia" claimed  that  the  means  of  transporting  the  sick  is  to 
blame  for  a  large  proportion  of  the  hospital  mortality: 
he  failed,  however,  to  suggest  any  improvement. 

Rosenfeld.  of  Breslau,  on  "The  Fatty  Degeneration  of  the 
Organs,"  claimed  that  no  such  thing  as  fatty  degeneration 
exists,  but  that  fat  wanders  from  other  tissues  into  the 
organs — as  from  subcutaneous  tissue  into  the  liver  in 
cases  of  phosphorus  poisoning,  etc. — in  order  to  take  the 
place  of  some  substance  which  is  lacking.  In  all  cases  of 
poisoning  there  is  a  lack  of  glycogen  in  the  liver,  and 
Rosenfeld  thinks  the  fat  destined  to  take  the  place  of  the 
lost  glycogen.  He  denies  in  short  that  there  is  such  a 
thing  as  tatty  degeneration. 

The  Congress  closed  with  a  discussion  following  a  paper 
by  Moritz,  of  Munich,  on  "The  Results  of  the  Orthodia- 
graphic  Determination  of  the  Heart  Boundaries  and  their 
Bearing  on  Percussion."  Moritz  concluded  that  percus- 
sion does  not  exactly  determine  the  heart  boundaries — in 
68%  of  89  cases  he  found  the  results  of  percussion  cor- 
rect when  controlled  by  his  Roentgen  ray  machine. 

Third    Session. 
Rosenstein,  of  Leiden,  in  the  chair. 

The  third  session  opened  with  a  paper  by  Mendelsohn, 
of  Berlin,  on  "The  Recuperative  Power  of  the  Heart  as  a 


Means  of  Judging  the  Heart  Function."  Mendelsohn  de- 
scribed first  the  different  methods  which  have  been  sug- 
gested to  conclude  from  the  amount  of  work  necessary  in 
a  given  case  before  the  patient  feels  tired,  whether  the 
heart  performs  its  normal  function  or  not.  It  is,  however, 
not  always  advisable  to  carry  the  test  so  far,  and  so 
Mendelsohn  has  endeavored  to  fix  a  new  criterion.  While  a 
person  is  performing  some  work  the  normal  heart  changes 
the  rapidity  of  its  stroke,  to  return  sooner  or  later  to  the 
normal  rate,  according  to  the  amount  of  work  done.  It 
the  heart  is  diseased,  if  it  is  not  sufficiently  nourished  dur- 
ing the  diastole,  the  pulse  rate  will  remain  high  for  a  much 
longer  time  than  the  rate  of  the  normal  heart  after  per- 
forming the  same  amount  of  work.  From  this  change  in 
the  pulse  rate,  and  from  the  time  required  for  the  rate  to 
become  normal,  Mendelsohn  draws  his  conclusions  as  to 
the  functional  power  of  the  organ.  He  advises  the  study 
of  the  heart  function  in  this  way,  and  to  regulate  the 
patient's  mode  of  life  accordingly. 

Baeltz.  of  Tokio,  Japan,  thinks  one  cannot  always  judge 
from  the  pulse  rate.  He  himself  has  a  weak  heart — oftea 
in  mountain  climbing  a  pulse  rate  of  120 — yet  he  feels  no 
bad  effects.  He  mentioned  the  wonderful  recuperative 
power  of  the  Japanese  couriers,  who  can  day  after  day, 
cover  100  to  150  kilometers. 

Kier.  of  Greifswald  read,  by  special  request,  a  paper  on 
"The  Place  of  Artificially  Caused  Hyperemia  in  Therapy." 
Brier  has  found  his  method — the  causing  of  venous  con- 
gestion by  placing  a  rubber  bandage  around  the  limb — a 
method  which  he  originally  proposed  for  the  treatment  of 
tuberculous  arthritis,  of  no  value  in  cases  of  carcinoma, 
sarcoma  or  lues:  he  has  been  successful,  however,  in  cases 
of  arthritis  following  gonorrhea.  He  finds  that  it  shortens 
the  course  of  erysipelas,  and  that  it  aids  in  bringing  a  be- 
ginning phlegmon  to  resorption.  He  emphasized  that  one 
must  use  only  the  "hot  congestion;"  "cold  congestion." 
when  the  bandage  is  drawn  too  tight,  or  "white,"  or  "lymph 
congestion"  is  directly  injurious.  The  advantages  of  the 
method  are:  If  used  rightly  it  quiets  pain — otherwise  it  is 
contraindicated — and  aids  in  the  resorption  of  pathological 
growths  and  exudates..  This  latter  can  best  be  obtained 
by  combining  hyperemia  with  massage.  Bier  reported  a 
series  of  experiments  made  by  Noetzl  to  ascertain  whether 
the  hyperemia  has  any  direct  effect  on  bacteria;  51  of  ilT 
animals  lived  after  injection,  into  the  congested  limbs,  of 
doses  of  anthrax  which  are  ordinarily  certainly  fatal.  Bier 
described  further  the  use  of  hot  air  and  showed  a  simple 
apparatus  long  used  by  himself  for  applying  the  heated  air. 
In  spite  of  the  discussion  as  to  the  value  of  hot  air.  Bier 
believes  that  It  exerts  an  influence  upon  the  deep-lyini; 
blood  vessels.  He  recommends  the  method  to  the  prac- 
titioner, especially  in  the  treatment  of  rheumatism.  Mul- 
ler.  of  Wiirzburg,  described  the  changes  in  the  blood  fol- 
lowing artificial  hyperemia.  He  claims  that  the  red  blood 
corpuscles  increase  in  number. 

Hoffman,  of  Diisseldorf,  discussed  "Paroxysmal  Arrhy- 
themia.  Heintz,  of  Erlangen,  has  experimented  on  the  ef- 
fect of  external  irritation  (chemical  and  thermal)  on  tho 
deep-lying  blood  vessels.  He  concludes  that  temperatura 
variations  of  several  degrees  can  be  produced  by  external 
changes. 

Guniprecht,  of  Weimar:  "The  Importance  of  Iodine  as  a 
Vasomotor  Stimulant."  Guniprecht  has  found  no  other  ef- 
fect of  iodine  on  the  blood  vessels  than  the  toxic  effect  of 
large  doses.  Clinically  he  has  found  no  influence  of  iodine 
on  the  p\]lse  tension.  He  considers  it  false  therapy  to  use 
iodine  in  cases  of  hemorrhage  from  the  lung.  Asher,  of 
Bern,  noticed  the  necessity  of  studying  the  effect  of  iodine 
on  the  heart  nerves— -not  alone  on  the  pulse  tension.  Lewy. 
of  Berlin,  emphasized  the  value  of  iodine  in  irregular  pulse 
rate. 

Strassburger,  of  Bonn,  read  a  paper  on  "The  Fermenta- 
tion-dyspepsia of  Adults," 

Courniont,  of  Lyron,  read  in  French  two  papers,  the 
first  on  "The  Hyperleukocytosis  in  clinical  and  experi- 
mental Rabies."  He  has  found  that  an  enormous  increase 
in  the  number  of  the  polynucleate  neutrophile  cells — up  to 
95% — takes  place  in  all  cases  of  rabies.  He  points  out  the 
great  value  of  this  symptom  in  diagnosing  the  disease,  al- 
though hyperleukocytosis  with  increase  of  the  polynuclo- 
ated  cells  may  occur  in  other  diseases,  a  disease  without 
this  increase  can  never  be  rabies.  rhis  condition  con- 
tinues several  hours  after  death:  the  fluid  from  the  lungs 
of  a  normal  dog  contained  50%  of  polynucleated  cells,  while 
that  rrom  the  rabied  animal  contains  over  80%. 


^rtA       The  Philadelphia"] 
yy^f       Medical   Jocrnal  J 


FOREIGN  NEWS  AND  NOTES 


[Mat  25,  1901 


Courrcont's  second  paper  was  on  "Serum  Diagnosis  in 
Tuberculosis."  Arlonig  and  Courmont  have  shown  that  the 
tubercle  bacilli  in  serum  from  tuberculous  patients  be 
some  agglutinated.  Courmont  described  the  difficulties  in 
the  wav  of  the  method,  and  emphasized  especially  the  need 
of  carefully  examining  the  cultures,  and  of  ascertaining 
their  toxic  equivalent.  He  then  gives  the  results  of  a 
series  of  experiments  carried  out  at  the  abattoir  at  Lyon; 
a  large  number  of  animals  were  tested  with  the  agglutin- 
ation test,  and  the  results  compared  with  the  results  of 
the  examination  mads  by  a  veterinary  surgeon  after  the 
animals  were  slaughtered,  the  surgeon  having  no  knowl 
edge  of  the  results  of  the  serum  test.  In  all  but  one  case 
the    serum    diagnosis    proved    correct. 

V'olhard,  of  Giessen,  communicated  a  valuable  paper  on 
••The  Fat-splitting  Ferment  of  the  Gastric  Juice."  Vol- 
hard  has  found  a  ferment  which  rapidly  splits  fats  when 
they  are  in  the  form  of  an  emulsion. 

The  session  concluded  with  papers  by  Reissuer,  of  Bad 
Nauheim,  on  "Whv  is  Free  Acid  Lacking  in  Cancer  of  the 
Stomach:"  and  one  by  Muller,  of  Wiirzburg.  on  "The  Ex- 
tent of  Starch  Digestion  in  the  Human  Mouth  and  Stom- 
ach." 

The  fourth  session  under  the  presidency  of  von  Jaksch, 
of  Prague,  opened  with  a  demonstration  of  a  case  of  so- 
celled  iuionathic  dilatation  of  the  esophagus,  by  Strauss,  of 
Berlin.  Strauss  also  demonstrated  a  number  of  instru- 
ments which  he  has  found  useful  in  the  diagnosis  of  the 
condition.  Von  Jaksch.  of  Prague,  demonstrated  prepara- 
tions from,  and  described,  a  case  of  multiple  periostitis 
with  peculiar  changes  in  the  blood.  A  young  girl  suffered 
from  a  multiple  inflammatory  affection  of  the  periosteum 
with  fever  and  a  continual  increase  in  the  number  of  tht 
monoculeated  neutrophil  leukocj-tes,  while  the  polynucleat- 
ed  cells  continuallv  decreased  in  numbers.  Later  large  nuc- 
leated red  blood  corpuscles  and  cells  showing  polychromatic 
degeneration  appeared.  Shortly  before  death  the  number 
of  the  eosinophiie  cells  increased.  Patient  died  with  well 
marked  anemic  symptoms.  The  autopsy  showed  a  tumor 
of  the  spleen:  the  bone  marrow  in  some  of  the  bones  had 
more  or  less  disappeared.  Although  leukemia  can  be  the 
cause  of  changes  in  the  bones  themselves,  von  Jaksch  is 
inclined  to  consider  the  case  peculiar  to  itself — a  case  of 
disease,  the  chief  characteristic  of  which  was  the  multiple 
inflammatory  affection  of  the  periosteum,  the  secondary 
characteristic  being  the  changes  in  the  blood. 

Strufller,  of  Munich,  and  Hirsch,  of  Leipzig,  presented  pa- 
tients  with   hernia   diaphragmatica. 

Franke.  of  JIunich.  demonstrated  a  new  instrument  for 
measuring  pulse  tension. 

Von  Hausemann.  of  Berlin,  discussed  and  showed  a  large 
number  of  alcohol  preparations  of  syphilis  of  the  lung. 
He  believes  the  cases  were  undoubtedly  syphilis,  since  the 
patient  gave  a  history  of  lues,  and  since  he  was  unable 
to  find  tubercle  bacilli  in  the  nodules,  and  finally  since  the 
infection  of  animals  with  the  material  gave  negative  re- 
sults. 

Levy-Dorn,  of  Berlin,  demonstrated  an  apparatus  con- 
structed on  the  same  principle  as  the  apparatus  demon- 
strated by  Moritz.  of  Munich,  at  last  year's  congress,  for 
more  exact  work  with  the  Roentgen  rays.  The  principle 
is  to  cut  off  all  rays  from  the  tube  except  those  which  fall 
vertically  upon  the  object  to  be  examined,  thus  avoiding 
the  magnification  following  the  use  of  the  whole  cone  of 
rays.  Moritz  defends  his  machine,  (which  by  the  way  is 
of  course  patented),  and  claims  that  it  does  absolutely 
exact  work. 

Michaelis,  of  Berlin,  described  a  case  of  Giant  Cell  Of- 
generation  of  the  Blood-generating  Organs,  with  Peculiar 
Changes  in  the  Blood.  A  woman  of  50  years  had  an 
attack  of  influenza  10  weeks  previous  to  hospital  treat- 
ment. When  first  seen  she  was  very  cachectic,  and  had 
En  enormous  tumor  of  the  spleen,  lymph  glands  were  not 
swollen.  The  white  blood  corpuscles  rapidly  increased 
(1.220)  with  a  large  number  of  lymphocytes  (75<^)  and  7% 
neutropl-ile  myelocytes.  The  autopsy  showed  enormous 
tumor  of  the  spleen,  lymph  glands  not  swollen.  Bone 
marrow  red.  but  not  very  soft,  no  changes  in  the  bones 
The  microscope  showed  a  great  increase  of  the  giant  cells 
of  the  bone  marrow,  and  giant  cells  in  the  lymph  glands, 
liver  and  spleen:  and  in  spleen  and  liver  some  small  celled 
infiltration.  Michaelis  considers  his  case  analgous  to  leuke- 
mia. 

Jager.  of  Konigsberg  i.  P.,  gave  a  statistical  paper  on 
"The  Spread  of  Epidemic  Cerebrospinal  Meningitis."  Aside 


from  the  great  value  of  the  bacteriological  examination 
now  often  carried  out,  with  the  aid  of  lumbar  puncture. 
Jager  considers  a  study  of  statistics  of  great  value.  He 
demonstrated  a  large  number  of  maps,  tables,  etc.,  and 
comes  to  the  interesting  conclusion  that  the  disease  '.-. 
Europe  is  imported  from  Africa,  from  the  Eastern  Stat-r- 
especially  New  York  and  Massachusetts.  Jager  concludes 
from  his  study  that  an  endemic  disease  focus  must  exist 
in  these  states,  notably  in  New  York.  According  to  his 
maps  the  disease  in  New  York  and  Massachusetts  is  sharp- 
ly defined  by  the  very  unnatural  physical  boundaries  of 
said  States — a  fact  which  might  lead  to  the  probable  con- 
clusion that  said  States  kept  better  statistics  than  their 
neighbors.  Jager  also  states  that  the  disease  is  a  dis- 
ease of  filth  and  unhygienic  conditions.  The  cause  of  the 
disease  is  undoubtedly  the  Jager-Weichselbaum  diplo- 
streptoeoccus. 

'   ■      Fifth  Session. 
Dehio,  of  Dorpat,  in  the  chair. 

Munzer.  of  Prague,  discussed  "Febris  hepatica  inter- 
mittens v,-ith  remarks  on  the  formation  of  urea."  He  de- 
cides that  Febric  hepatica  intermittens  is  an  independent 
disease,  and  from  his  study  of  one  case  that  the  liver  is 
not  to  be  considered  the  special  organ  for  the  formation 
of  urea. 

Rosenstein,  of  Leiden,  points  out  that  experiments  on 
pathological  livers  are  no  proof  of  the  normal  function  of 
said  organ.  Intermittent  fever  occurs  in  a  number  of 
different  affections  of  the  liver,  so  in  hypertrophic  cirr- 
hosis. He  does  not  believe  that  Fabris  intermittens  hepa- 
tica exists  as  an  independent  disease. 

Hirsberg.  of  Frankfurt  a.  M..  "The  Operative  Treatment 
of  Hypertrophic  Cirrhosis  of  the  Liver."  Hirsberg  described 
at  length  a  case  in  which  he  could  arrive  at  no  other  di- 
agnosis than  hypertrophic  cirrhosis:  he  decided  to  operaf 
and  drain  the  bile  ducts:  he  performed  laperotomy.  four 
the  larger  bile  ducts  free,  so  opened  the  smaller  bile  due  - 
through  the  liver  substance.  A  fistula  was  formed  whica 
discharged  quantities  of  bile  at  first,  later  less  and  les>. 
until  it  closed  on  the  thirtieth  day.  Patient  recovered  ami 
has  remained  well  since  operation,  about  one  year.  Maun- 
yen,  of  Strassburg,  considered  the  prognosis  in  cases  of 
atrophic  or  hypertrophic  cirrhosis  by  no  means  passima: 
both  affections  maj-  heal  spontaneously.  He  expressed  his 
doubts  that  Hirsberg's  case  was  really  an  hypertrophic 
cirrhosis,  especially  'necause  the  liver  tissues  had  not  b-»- 
come  hardened.  He  thinks  it  was  an  infectious  cholangi- 
tis. Rosenstein.  of  Leiden,  questions  the  diagnosis  h-?- 
cause  there  were  no  gastric  symptoms  at  first,  etc.  He 
considers  Hirsberg's  case  of  no  value  as  proving  the  ad- 
visability of  operation  in  genuine  hypertrophic  cirrhosis: 
operation  might  be  of  value  in  cases  where  the  distention 
of  the  bile  ducts  threatened  to  cause  cirrhosis.  Hirsberg 
answered  Ewald,  of  Berlin,  and  states  that  the  bactena 
coli  communis  was  found  in  the  bile:  he  holds  to  his  diag- 
nosis until  some  one  suggests  a  more  probable  one. 

The  second  main  topic  of  the  congress.  "Acute  Myelitis."' 
was  treated  from  the  clinical  standpoint  by  von  Seyden.  of 
Berlin.  Von  Seyden  first  gave  a  brief  history  of  the  de- 
velopment of  our  knowledge  of  the  disease:  the  same  dates 
from  the  middle  of  the  last  century.  The  complex  of  symp- 
touis  was  known  long  before  the  anatomical  lesion  was 
recognised.  Myelomacia  was  the  name  first  applied  to  all 
transverse  lesions.  Gradually  the  inflammatory  process  was 
separated  from  the  whole  sum  of  the  diseases  of  the 
cord  and  placed  aside  as  an  independent  disease.  We 
now  distinguish  the  following  different  forms  of  the  acute 
process:  (1)  inflammatDry  softening,  a  severe  form  and 
also  a  result  of  inflammation  not  to  be  separated  from  the 
inflammatory  process  as  was  formerly  done.  (2)  Hem- 
orrhage (Hematorayelia)  likewise  not  markedly  differenti- 
ated from  the  inflammations,  neither  clinically  nor  anat'> 
mically.  Myelitis  occurs  in  four  forms:  (1st)  transverse 
myelitis:  (2)  disseminated  myelitis:  (3)  poliomyelitis. 
Degeneration  following  cachexia,  anemia,  diabetes,  etc..  is 
to  be  excluded.  (4)  Compression  myelitis,  especially  thit 
due  to  caries  of  the  vertebra,  which  is  clinically  related 
to  the  acute  myelitis,  although  there  are  certain  differ- 
ences. The  inflammatory  changes  accompanyinc  tumors 
of  the  cord  are  so  clearly  marked,  yet  these  have  resera- 
blriuces  to  the  acute  forms.  Pathogenic  infection  plaj-s 
the  chief  part  in  the  etiology  of  myelitis.  These  cases  were 
formerly  considered  spontaneous.  The  bacterial  cause  is 
to  be  sure,  only  certain  in  poliomyelitis;  to  be  considered 
as  casual  factors  are  the  diplostreptococcus  of  Jager- Welch- 


Mat  ^,  1901] 


FOREIGN  NEWS  AND  NOTES 


TThe  Philadelphia       qqc 
Lmedical   Journal         WO 


selbaum  and  the  streptococci.  Myelitis  occurs  principally 
after  infectious  diseases;  influenza,  typhoid,  even  simpler 
diseases,  as  angina,  also  in  pregnancy  and  during  con- 
finement. Part  of  these  cases  following  infectious  dis- 
eases have  been  cured.  Trauma  must  further  be  consid- 
ered as  an  etiological  factor,  not  only  local  trauma  but 
also  general  shock.  Alcohol,  lead,  arsenic,  carbonic  oxide 
can  also  act  as  etilogical  factors.  Fright  has  been  the 
cause  in  one  case.  The  causes  of  chronic  myelitis  are 
tuberculosis,  syphilic  and  gonorrhea.  The  symptoms  de- 
pend upon  the  location  of  the  disease  in  the  different  seg- 
ments of  the  cord-bulbar.  cervical  or  dorsal  segments.  Tlio 
initial  symptoms  are  of  importance.  The  disease  appears 
sometimes  so  rapidly  that  we  have  the  clinical  picture  of  a 
myelitis  acutissima  or  apoplectica,  though  even  here  there 
are  otien  slight  prodromal  symptoms.  Again  the  disease 
appears  more  gradually  reaching  its  height  after  several 
days.  We  are  unfortunately  often  unable  to  prevent  the 
progress  of  the  disease:  it  goes  on  either  (1)  ascending, 
with  the  dangerous  result  of  acute  bulbar  paralyses, 
which  is  not  always  fatal,  or  (2),  the  disease  progresses 
transverse  directions;  or  (3),  neuroparalytic  symptoms  ap- 
pear— cystitis, decubitus  and  trophic  disturbances  which  may 
lead  to  gangrene.  Sometimes  these  complications  re- 
cede, and  then  the  prognosis  becomes  better  as  regards 
life,  but  not  as  regards  complete  recovery.  Both  the 
transverse  and  the  disseminated  myelitis  are  to-day  con- 
sidered curable,  since  exudates  and  hemorrhages  can  be 
resorbed.  The  treatment  can  only  be  symtomatic;  von 
Seyden  lays  the  greatest  stress  upon  careful  nursing. 
The  pathological  anatomical  side  of  the  question  was 
treated  by  Redlich,  of  Vienna,  who  distinguishes  with  Ley- 
den  and  Goldscheider  transverse,  disseminated,  diffuse, 
and  poliomyelitis  These  forms  fuse  into  one  another, 
poliomyelitis  into  the  disseminated  form,  and  this 
into  the  transverse  and  the  diffuse  forms.  Larger 
disease  foci  show  always  a  change  in  the  consist- 
ency of  the  cord,  even  to  genuine  softening,  which  is  due 
in  part  to  edema  and  hyperemia,  in  part  to  true  necrosis 
of  the  tissues.  Acute  poliomyelitis  shows  in  its  fresh  stages 
all  the  characteristics  of  an  inflammatory  process,  with 
the  principal  pathological  changes  in  the  blood  vessels. 
These  changes  follow  mostly,  though  not  exclusively,  the 
arteria  spinalis  anterior  and  the  arteria  centralis.  It  is, 
however,  entirely  possible  that  a  poliomelitis  may  be  limit- 
ed to  the  acute  degenerations  of  the  ganglion  cells.  Red- 
lich believes  it  impossible  to  give  an  exact  anatomical 
definition  of  acute  myelitis,  from  the  fact,  if  from  no  other, 
that  we  have  no  valid  definition  of  inflammation  in  general. 
The  question  whether  bacteria  are  the  direct  cause  of  acute 
myelitis  is  of  great  importance;  bacteria  have  been  found 
in  a  small  number  of  cases,  but  in  the  majority  of  cases 
the  disease  is  probably  not  due  to  the  direct  action  of  the 
bacteria,  but  to  the  prognosis  and  the  therapy,  it  is  to  be 
kept  in  mind  that  the  symptoms  are  not  always  due  to  a 
destruction  of  tissue,  but  to  the  pressure  of  edema,  hem- 
orrhage, etc. 

Von  Strumpell,  of  Erlangen.  followed  with  a  paper  on  the 
same  subject.  He  would  call  only  those  affections  myelitis 
which  are  caused  by  an  external  factor  acting  locally  on  the 
tissue,  and  where  the  primary  change  in  the  tissues  is 
followed  by  the  reactive,  reparative,  processes  in  the  tissue, 
especially  the  processes  in  the  blood  vessels.  It  is  es- 
pecially difficult  to  find  the  cause  of  myelitis  because  we 
can  neither  observe  the  diseased  focus  itself,  nor  exam- 
ine the  pathological  products  of  the  same.  The  examina- 
tion of  the  cerebrospinal  fluid  obtained  by  lumbar  puncture 
can  be  of  help.  v.  Strumpell  has  found  lumbar  puncture  of 
value  in  the  two  cases  in  which  he  had  occasion  to  try  it. 
In  the  first  case  myelitis  followed  a  panaris.  Lumbar 
puncture  gave  a  liquid  turbid  with  leukocytes,  which  con- 
tained staphylococci  in  large  quantities.  The  second  case 
was  one  of  disseminated  myelitis,  which  began  with  a 
neuritis  optica.  The  cerebrospinal  liquid  was  perfectly 
clear  and  sterile.  The  first  case  was  therefore  bacterio- 
genic  inflammation,  the  second  hematogenotoxic.  These 
latter  cases  are  often  recognizable  from  the  elective  char- 
acter of  the  affection,  v.  Striimpell  observed  such  a  case 
following  erysipelas,  limited  almost  entirely  to  the  pos- 
terior columns.  The  more  chronic  the  action  of  the  toxin, 
so  much  more  the  picture  of  the  inflammation  recedes,  and 
we  find  degeneration  of  the  nervous  tissue  with  conse- 
quent hyperplasia  of  the  connective  tissue.  In  this  sense 
one  can  speak  of  chronic  myelitis,  provided  the  disease 
is  of  cxorganic  origin.    The  hereditary  endogenic  affections 


of  the  cord  cannot  be  counted  with  the  forms  of  myelitis; 
as  also  multiple  sclerosis  which  v.  Striimpell  considers 
an  endogenic  affection.  Schiiltze,  of  Bonn,  emphasized 
the  affection  of  the  meninges  which  often  accompanies 
myelitis,  especially  poliomyelitis.  He  considers  lumbar 
punciure  of  great  value  in  diagnosis.  Von  Kahlden,  of 
Freiburg,  emphasized  his  standpoint  in  pathology — that 
the  primary  changes  in  inflammation  are  not  in  the  blood 
vessels,  but  in  the  parenchyma.  Rothmann,  of  Berlin, 
recommended  the  method  of  Lanie  for  the  study  of  the 
pathogenesis  of  myelitis — injection  of  bacteria,  etc.,  into 
the  cord  from  the  lumbar  artery.  Goldsheider,  rf)f  Berlin, 
upheld,  in  opposition  to  v.  Kahlden.  the  old  theory  that  the 
process  first  begins  in  the  blood  vessels.  This  explains 
easily  the  fact  that  the  ganglion  cells  are  affected  in 
groups.  Richter.  of  Berlin,  reported  6  cases  of  myelitis  in 
children,  following  scarlatina,  diphtheria  and  lues. 

Sixth  Session. 
Ewald.  of  Berlin,  presiding.  The  first  paper  of  the  after- 
noon was  read  by  Wiener,  of  Prague,  on  "The  Synthetic 
Formation  of  Uric  Acid  in  the  Animal  Body."  Wiener 
fed  hens  with  different  substances  which  contained  no 
nitrogen,  at  the  same  time  injecting  urea,  and  found  an 
increase  in  the  excretion  of  uric  acid  after  feeding  glycer- 
ine and  those  oxy-acids,  ketone  acids  and  dibasic  acids 
which  contain  a  chain  of  three  carbon  atoms.  He  found 
the  largest  increase  in  the  excretion  of  uric  acid  after  feed- 
ing the  dibasic  acids,  which  leads  him  to  the  supposition 
that  all  the  other  active  substances  are  first  changed  to 
dibasic  acids.  He  obtained  similar,  although  quantitatively 
smaller,  results  in  the  human  body.  All  of  the  compounds 
which  he  examined  produced  no  increase  of  uric  acid  when 
added  to  the  isolated  liver  of  vertebrates  except  the  tartaric 
acid  and  its  ureid.  the  dialuric  acid.  From  his  experiments 
Wiener  concludes,  (li  That  not  only  in  birds,  but  also  to 
a  less  extent  in  animals,  a  synthetic  formation  of  uric  acid 
occurs:  (2)  That  the  process  consists  in  a  changing  of  the 
active  substances  to  dibasic  acids  with  a  chain  of  3  carbon 
atoms,  which  acids  then  change  to  tartaric  acid:  a  part  of 
the  radical  of  urea  .ioins  this  latter  acid,  forming  the  ureid, 
and  this  passes  by  the  addition  of  a  second  part  of  the 
urea  radical  into  uric  acid.  In  the  human  body  this  syn- 
thesis plays  a  small  role,  but  it  is  possible  it  attains  a 
higher  significance  in  pathological  conditions,  especially 
in  gout. 

IVIayer.  of  Karlsbad,  "Experimental  Researches  on  the 
Katabolism  of  Sugar  in  the  Body."  a  paper  which  had  al- 
ready been  read  before  the  Medical  Society  of  Berlin. 
Rosin,  of  Berlin,  reported  his  researches  on  the  quantitative 
relations  of  the  carbohydrates  in  the  urine  and  blood,  es- 
pecially of  diabetics,  which  had  also  been  treated  before 
the  Medical  Society. 

Wohlgemuth  and  Nerberg.  of  Berlin,  "The  Physiological 
Action  of  the  Three  Arabinoses."  The  authors  have  en- 
deavored to  find  whether  substances  which  differ  only  in 
the  arrangement  of  their  atoms,  have  a  different  influence 
on  the  mechanism  of  biological  processes,  and  come  to 
the  conclusion  that  such  is  the  case. 

Bial,  of  Kissingen,  "Observations  and  Experiments  on 
Chronic  Pentosuria."  Authors  are  not  yet  agreed  as  to  the 
pathological  significance  of  the  disease;  some  consider  it 
a  disturbance  of  the  metabolic  processes,  others  consider  it 
dependent  upon  the  nourishment.  Bial  considers  that  Blu- 
menthal's  experiments  have  excluded  the  latter  suppo- 
sition. Bial,  working  with  Blumenthal.  has  found  that 
grape  sugar  is  completely  oxidized  in  the  bodies  of  patients 
suffering  from  pentosuria,  likewise  levulose  and  galactose. 
The  injection  of  phloridzin  causes  a  normal  glycosuria. 
The  normal  amount  of  grape  sugar  in  the  blood  proves  also 
that  the  glycogen  of  the  liver  is  changed  to  dextrose  as 
usual.  Therefore,  there  is  no  relation  between  pentosuria 
and  diabetes:  pentosuria  is  an  affectios  in  generis.  As  re- 
gards the  origin  of  pentose,  it  is  produced  neither  from  the 
albumen  nor  from  the  carbohydrates,  since  500  gr.  of 
thymus,  rich  in  nuclein.  did  not  increase  the  pentosuria-  It 
must  be  produced  in  the  body  itself,  and  since  it  is  to  be 
found  in  the  blood,  it  must  be  produced  beyond  the  kid- 
neys. Even  for  the  pentoses  themselves  the  patient  pos- 
sesses a  normal  oxidizing  power. 

Elllnger  and  Seelig.  of  Konigsberg  i.  P..  "The  Influence 
of  Lesions  of  the  Kidney  on  the  Course  of  Pancreas  Dia- 
betes in  the  Dog."  If  one  cause  an  acute  nephritis  in  a  pan- 
creas-diabetic dog  by  injecting  cantharidin.  one  finds  that 
the  amount  of  sugar  in  the  urine  becomes  less.     Not  only 


ctaft       The  Philadelphia") 
yy"       Medical  Journal   J 


FOREIGN  NEWS  AND  NOTES 


[Mat  25,  19(tt 


the  procental  and  the  absolute  amount  of  sugar  becomes 
less,  but  the  relation  between  the  excreted  sugar  and  nitro- 
gen becomes  much  smaller.  This  influence  of  cantharidin 
on  the  excretion  of  sugar  disappears  much  more  quickly 
than  the  albumen  disappears.  If  an  acute  nephritis  de- 
velops spontaneously  in  a  dog  suffering  from  pancreas- 
diabetes,  the  same  thing  occurs;  the  sugar  can  completely 
disappear  from  the  urine.  This  disappearance  of  sugar 
by  a  faulty  excretion  of  sugar  from  the  kidneys;  the 
amount  of  sugar  in  the  blood  is  found  in  such  cases  to  be 
considerably  increased.  The  main  factor  in  the  diabetic 
disturbance  of  the  metabolism  of  the  body,  the  hypergly- 
cemia, persists,  while  the  glycosuria  ceases.  Maunyn,  of 
Strassburg,  doubts  the  advisability  of  drawing  conclusions 
from  experimental  studies,  in  regard  to  the  human  patholo- 
gy. He  has  seen  in  cachectic  conditions,  for  example  fol- 
lowing pulmonary  tuberculosis,  that  the  glycosuria  disap- 
peared, while  no  trace  of  a  kidney  lesion  could  be  found. 

Sommer.  of  Giessen,  "The  Analysis  of  the  Motor  Disturb- 
ances in  those  suffering  from  Nervous  Disease,  and  in  the 
Insane."  He  has  constructed  a  series  of  very  Ingenious 
instruments  for  graphically  recording  and  analyzing  the  mo- 
tions characteristic  of  mental  disease.  The  motion  is  an- 
alysed Into  its  three  dimensions.  The  value  of  the  ap- 
paratus can  best  be  seen  by  a  study  of  the  curves  of  knee 
jerks  from  patients  suffering  from  tabes,  and  from  hyster- 
ical patients.  Sommer  demonstrated  curves,  showing  that 
the  curves  of  hysteria  show  fixed  characteristics  which  can- 
not appear  when  the  motion  is  a  pure  reflex,  as  in  tabes. 
The  Congress  listened  to  Sommer's  description  of  the 
complicated  instrument  with  marked  interest,  and  it  seems 
indeed  that  the  apparatus  will  be  of  great  aid  in  the  diag- 
nosis of  obscure  nervous  diseases. 

Seventh    Session. 

Kraus,  of  Graz,  in  the  chair. 

Rothmann,  of  Berlin:  ■Experimental  Lesions  of  the 
Medulla  Oblongata."  Rothmann  has  found  that  a  lesion  of 
the  pyriad  in  the  dog  or  ape  produces  merely  transitory 
symptoms,  etc.,  whereas  a  double  sided  lesion  In  the  dog 
produced  spastic,  from  which  the  animal  did  not  recover. 
The  symptoms  produced  by  a  lesion  in  one  pyramid  had  dis- 
appeared after  a  few  weeks. 

v.  Kahlden,  ,of  Prague,  on  "Parencephalia,"  considered 
trauma  an  etiological  factor  in  this  disease.  He  does  not 
believe  that  the  usual  explanation  for  acquired  parence- 
phalia— thrombosis  or  embolism — is  sufficient  to  explain  all 
cases:  nor  have  we  suflicient  reason  to  consider  lues  con- 
genita a  casual  factor,  v.  Kahlden  then  described  a  case 
where  he  thinks  trauma  was  the  etiological  factor;  a  child 
fell  from  a  table  and  died  14  days  later.  The  autopsy 
showed  no  lesion  of  the  skull,  but  a  double-sided  parence- 
phalic  defect,  which  communicated  on  the  left  side  with 
the  ventricle.  Benda.  of  Berlin,  considers  that  trauma  will 
also  fail  to  explain  all  cases. 

The  following  papers  gave  rise  to  an  active  discussion 
between  the  Vienna  and  Berlin  schools,  as  to  whether 
acute  inflammatory  rheumatism  is  caused  by  staphylococci 
and  streptococci  in  general  or  by  a  specific  organism. 
Singer,  of  Vienna,  representing  the  one  school,  reported 
five  cases  of  acute  arthritic  rheumatism  and  two  cases  of 
chorea  rheumatica.  In  all  cases  of  polyarthritis  and 
in  one  of  the  cases  of  chorea  he  obtained  from  the  joint 
fluids  as  well  as  from  the  different  organs,  pure  cultures 
of  the  streptococcus  pyogenes,  which  could  also  be  found 
microscopically  in  the  tissues.  In  the  second  case  of 
chorea  with  purulent  inflammation  of  the  joints,  following 
an  angina  follicularis,  bo  found  pure  cultures  of  the 
staphylococcus  pyogenes  aureus.  Singer  then  criticised  the 
publications  from  the  Berlin  school,  of  Westphal.  Wasser- 
man,Malkoff  and  Meyer,  who  claim  to  have  found  organisms 
with  specific  characteristics.  Singer  claims  that  it  is 
impossible  from  the  standpoint  of  bacteriology  to  conclude 
that  a  microorganism  which  shows  but  small  variations  of 
growth,  etc.,  variations  which  are  common  to  the  whole 
class  of  the  streptococci — is  a  specific  organism.  Nor 
can  the  experiment  be  considered  positive  proof,  since  It 
is  a  well-known  fact  that  inflammations  of  the  joints  can 
be  caused  by  the  most  different  streptococci. 


Tuberculosis  in  St.  Petersburg. — Dr.  A.  N.  Rubel  recent- 
ly stated  at  a  meeting  of  the  Society  of  Hospital  Physicians 
that  37,000  persons  or  25%  die  yearly  of  tuberculosis  in 
St   Petersburg. 


THIRTIETH    CONGRESS   OF  THE   GERMAN    SURGICAL 
SOCIETY. 

Sixth  Session,  Friday  Afternoon. 
(Continued  from  Page  'Jll.j 

The  session  opened  with  a  paper  by  Werckmeister,  of 
Zittau  on  "The  Extirpation  of  the  Larynx."  Werckmeister 
has  collected  297  cases,  36  of  which  were  fatal.  Gluck 
records  26  total  extirpations  with  a  successful  result  in  23 
cases.  Werckmeister  presented  a  patient  successfully  op- 
erated on  two  years  ago.  von  Hacker,  of  Innsbruck,  re- 
ported a  case  of  mediastinal  phlegmon  following  an  esoph- 
atomy,  successfully  operated  on  by  opening  the  9  cm.  long 
abscess  early  from  the  neck.  Gottstein,  of  Breslau,  de- 
scrided  his  experience  with  the  esophagoscope  In  100  cases, 
a.nd  warmly  recommends  the  excision  with  the  aid  of  this 
instrument  of  small  pieces  of  a  tumor  as  an  aid  in  diag- 
nosis. Kuster,  of  Marburg,  demonstrated  a  case  of  osteo- 
plastic resection  of  the  foot  and  described  his  method,  for 
which  he  claimed  the  advantage  of  but  %-l  cm.  shortening 
a&  compared  with  Le  Fort's  method  with  3  cm.  shortening. 

Schuchardt,  of  Stettin :  "Operative  Reposition  of  the  Frac- 
tured Epiphysis  of  the  lower  end  of  the  Femur."  Schuch- 
ardt fastened  the  epiphysis  with  a  pin  and  demonstrated 
Roentgen   photographs   and   his   patient. 

Henle,  of  Breslau:  "Pneumonia  and  Laparotomy," 
claimed  that  pneumonia  is  especially  frequent  after  lapar- 
otomy, and  that  the  lowering  of  the  patient's  temperature 
during  the  operation  is  the  cause.  He  gives  the  results 
at  the  clinic  at  Breslau  as  a  proof  of  his  claim,  showing 
that  although  the  number  of  laparotomies  has  increased 
since  1899,  pneumonia  has  decreased,  due,  he  believes,  to 
the  methods  introduced  at  Breslau  during  that  year — op- 
erating on  heated  tables  and  treating  the  exposed  bowe! 
with  hot  douches.  His  experiments  with  animals  have 
shown  that  animals  which  were  cooled  off  during  the  opera- 
tion recovered  much  more  slowly  from  the  narcosis  than 
the  animals  which  were  kept  warm,  and  further  that  the 
former  always  had  an  affection  of  the  lungs.  Henle  re 
ported  the  case  of  one  patient  who  developed  pneumonia 
on  the  day  following  an  operation,  in  which  a  large  cavity 
was  washed  out  with  a  cold  solution.  He  grants  that  aspira- 
tion and  infection  can  of  course  also  be  the  cause  of  pneumo- 
nia, but  believes  that  thelowered  temperature  of  the  patient  is 
the  cause  in  the  majority  of  cases.  In  the  discussion  fol- 
lowing the  paper.  Czerny,  of  Heidelberg,  asked  whether 
the  injection  of  Schleich's  solution  in  Henle's  case  could 
possibly  have  been  the  cause  of  the  pneumonia.  Henle  re- 
plied that  he  thought  it  might  be  possible,  although  only  a 
small  quantity  of  the  solution  was  used.  Kronlein,  of  Zu 
rich.  laid  the  blame  upon  the  narcosis,  especially  on  ether, 
and  the  quality  of  the  ether.  In  his  clinic  no  special  pre- 
cautions are  taken  against  cooling  off  of  the  patients,  anj 
yet  he  has  lost  but  one  case  from  pneumonia,  a  man  of  77 
years.  Kummell.  of  Hamburg,  reported  that  he  has  had  40 
cases  of  pneumonia  in  1070  laparotomies,  of  which  40  cases 
he  has  lost  11:  of  these  11  cases  4  were  ether  pneumonias. 
The  patients  who  developed  pneumonia  were  very  sick 
individuals,  for  the  most  part  sufferers  from  cancer,  and 
with  marked  cachexia.  He  consequently  has  all  his  pa- 
tients who  have  a  tendency  to  bronchitis  get  up  very  soon 
after  the  operation,  or  at  least  change  their  position.  Stol- 
per,  of  Breslau.  mentioned  fat  embolism  in  the  lungs,  which 
can  follow  extended  operations  as  well  as  fractures,  as  x 
cause  of  postoperative  pneumonia. 

Stamter,  of  Konigsberg:  "The  use  of  v.  Mikulicz  Peri- 
toneal Tamponade  recommended  the  method  as  a  support 
for  the  sutures  and  as  a  means  of  checking  hemorrhage, 
especially  in  operations  on  the  stomach  and  gail 
ducts.  Kelling,  of  Dresden,  described  at  considerable  length 
his  experiments  on  the  cadaver  to  determine  the  mechan- 
ism of  acute  dilatation  of  the  stomach.  He  finds  that  in 
many  individuals  a  passive  valvular  closure  of  the  cardia 
and  the  duodenum  exists.  In  consequence  of  these  valves 
the  stomach  can  be  dilated  to  its  maximum  and  lose  the 
power  of  spontaneously  emptying  itself.  Narcosis  acts 
in  the  latter  way  by  lessening  the  motile  power  of  tb-» 
stomach:  operations  for  gall  stones  by  causing  local  peri- 
tonitis of  the  upper  duodenum,  and  finally  tight  bandages 
can  hinder  the  motility  of  the  stomach.  Gastroptosis  is  an 
accessory  factor.  Acute  dilatation  can  be  caused  in  cases 
of  hindrances  in  the  lower  duodenum  or  in  the  upper  je- 
junum by  this  valvular  closure  of  the  cardia.  Kelline 
criticises  the  general  use  of  gastroenterostomy  in  cases  of 


Mat   25.   1901] 


FOREIGN  NEWS  AND  NOTES 


TThe  Philadelphia       0Q7 
Lmedical  Journal        77/ 


acute  dilatation.  One  must  find  and  remove  the  hind- 
rance. 

Schmidt,  of  Cuxhaven,  on  "Hyperemesis  Lactantium 
and  its  Relation  to  Congenital  Hypertrophic  Stenosis  of  the 
Pylorus.  Respectively  Pylorospasmus,  and  its  Treatment 
by  stretching  the  Pylorus."  Schmidt  treated  and  healed 
three  cases  by  introducing  forceps  and  forcibly  widening 
the  stenosis. 

Lobker.  of  Bochum.  Steinthal.  of  Stuttgart,  and  Borch- 
ard,  of  Posen,  discussed  Schmidt's  paper. 

Seventh    Session. 

The  7th  session  opened  with  a  paper  by  von  Eiselsberg, 
of  Vienna,  on  "The  Technic  of  Uranoplasty."  He  discussed 
the  different  methods  and  their  results.  The  operation 
often  fails  because  a  large  fissure  remains  and  a  compli- 
cated method  must  be  resorted  to  to  close  the  same. 
Von  Eiselsberg  has  finally  resorted  to  a  method  with  the 
aid  of  the  forearm.  He  cuts  a  pediculated  skin  flap  from 
the  arm.  as  in  the  Italian  method  of  rhinoplasty,  using  the 
Italian  method  of  bandaging. 

Wolff,  of  Berlin,  thinks  that  the  method  proposed  by  v. 
Eiselsberg  would  be  of  value  in  cases  of  extremely  large 
defects,  but  that  one  can  do  without  it,  as  his  series  of 
over  200  cases  shows.  One  must  operate  at  two  sittings, 
first  forming  the  flaps  and  letting  them  hang  in  order  to 
favor  circulation,  and  then  after  a  few  days  sewing  them 
together.  He  believes  that  we  can  do  away  with 
Billroth's  method.  Von  Eiselsberg  believes  that 
in  spite  of  the  operation  at  two  sittings  a  large 
number  will  be  unsuccessful.  Czerny.  of  Heidelberg, 
operates  extensively  at  one  sitting,  with  the  patient's 
head  hanging  below  the  horizontal:  sutures  with 
wire  or  silkworm.  He  has  often  used  Billroth's  method. 
Fistulae  remain  in  about  %  of  the  cases. 

Wolff,  of  Berlin:  "Arthrolysis  and  the  Resection  of  the 
Elbow  joint."  Wolff  demonstrated  a  patient.  Von  Eisels- 
berg. of  Vienna,  reported  a  case  of  ankylosis  of  the  elbow 
following  scarlet  fever.  He  operated  on  one  arm  with 
success,  using  two  lateral  incisions.  The  operation  on 
the  otner  arm  failed,  due  to  an  overproduction  of  bone, 
caused,  he  thinks,  by  the  fact  that  he  did  not  exactly  strike 
the  joint  line.  Cramer,  of  Wiesbaden,  reported  a  case 
where  he  succeeded  in  freeing  an  adherent  patella  by  using 
Halfarich's  method. 

Wolff,  of  Berlin:  "The  Treatment  of  Fractures  of  the 
Patella."  presented  a  patient  whom  he  had  cured  by  fasten- 
ing a  miniature  Malgaigne's  screw  into  the  fragments  and 
drawing  them  together,  after  having  removed  the  tuberosi- 
ties of  the  tibia:  he  added  an  osteoplastic  operation  on  the 
patella.  Rontgen  photographs  taken  later  showed  that  the 
fragments  had  separated  after  all.  and  were  only  held  by 
the  bridge  of  bone  formed  by  the  osteoplastic  operation. 
The  fragments  showed  a  separation  of  some  2  cm.  and  the 
patient  had  considerable  difliculty  in  ascending  the  stairs. 
The  congress  indulged  in  unbounded  merriment  when  one 
of  the  members  who  had  sustained  a  fracture  of  the  patella 
some  15  years  ago,  which  had  united  with  a  separation  of 
some  6  cm.,  showed  how  he  could  run  up  and  down  the 
stairs   with   ease. 

Bunge,  of  Konigsberg:  "Further  Additions  to  the  Ques- 
tion of  the  Carrying  Power  of  Amputation  Stumps  of  the 
Diaphysis."  Bunge  would  leave  the  question  open  whether 
the  Ijone  marrow  itself  is  sensitive  or  not,  but  thinks  be- 
yond doubt  that  the  callus  formed  from  the  marrow  for  2  to 
3  cm.  high  in  amputation  of  the  fibula,  and  careful  removal 
of  the  periosteum. 

Bier,  of  Greifswald,  expressed  his  opinion  that  careful 
removal  of  the  periosteum  is  necessary,  yet  he  would  not 
give  up  the  osteoplastic  method  which  gives  the  stump 
natural  boundaries.  Czerny,  of  Heidelberg,  expressed  his 
surprise  that  the  author  of  the  osteoplastic  method  now 
favors  operation  with  the  removal  of  the  periosteum.  Bier 
answered  that  he  would  still  operate  all  aseptic  cases  ac- 
cording to  the  osteoplastic  method,  but  that  the  method 
is  not  suited  to  infected  cases. 

(To  be  Continued.) 


Medical  Society  at  Mexico. — At  a  meeting  of  the  Mexico 
and  Audrian  Medical  Society  in  Mexico.  May  7th,  the  fol 
lowing  delegates  were  elected:  To  the  American  Asso- 
ciation in  ,Iune  at  St.  Paul.  Drs.  J.  Rule  Fritts  and  G.  P. 
Toalson.  of  Mexico.  To  the  State  Association  at  Jefferson 
City  in  May.  Drs.  J.  Rule  Fritts,  E.  Bridgetord  and 
Eugene  Hultz,  all  of  Mexico. 


GREAT    BRITAIN. 

Appointed  Health  Officer  for  the  Transvaal. — Dr.  George 
Turner  has  been  appointed  by  Sir  Alfred  Milner  Medical 
Officer  of  Health  for  the  Transvaal.  Dr.  Turner,  who  prior 
to  the  outbreak  of  the  war  filled  a  similar  position  in  Cap* 
Colony,  has  been  provisionally  acting  as  Medical  Officer 
for  the  Transvaal,  and  his  services  have  been  recognized 
by  Lord  Roberts. 

Dr.  Christisn  Fenger,  of  Chicago,  has  received  the  Cross 
of  the  Dannebrog  from  King  Christian  IX,  of  Denmark,  in 
recognition  of  his  contribution  to  surgical  knowledge. 

A  Grave  Epidemic  of  scarlet  fever,  prevailing  in  Shore- 
ditch  and  Bethnal  Green,  has  been  ascribed  to  infected 
milk. 

CONTINENTAL     EUROPE. 

Dr.  Pozzi,  in  a  recent  lecture  in  Paris,  paid  a  glowing 
tribute  to  American  surgeons,  whom  he  characterized  as 
"scientifically  audacious  and  brilliantly  cool." 

A  Society  for  the  Investigation  of  Malignant  Tumors. — 
A  new  society  is  being  organized  in  Moscow  for  the  pur- 
pose of  investigating  the  question  of  cancer  and  other 
malignant  growths. 

The  Governor  of  California  Noted  in  Russia. — The  Vratch 
is  making  merry  over  the  actions  and  decisions  of  the 
wise  governor  of  Calfornia.  The  assertion  is  made  that  he 
is  possessed  of  a  purely  Russian  spirit.  Well  may  this  of- 
ficial be  proud  of  his  fame. 

A  New  Sanitarium  for  Tuberculous  Patients. — The  city 
council  of  St.  Petersburg  decided  to  open  a  sanitarium  ex- 
clusively for  the  poor  of  the  city. 

A  commission  has  been  appointed  by  the  Por- 
tuguese government  to  study  the  sleeping  sickness 
in  the  Province  of  Angola.  The  commission,  which 
will  at  the  same  time  include  amongst  its  scientific 
researches  an  inquiry  into  the  etiology  and  the  transmis- 
sion of  malaria,  will  be  composed  of  the  following  mem- 
bers: Drs.  Annibal  Bettencourt.  Ayres  Jose  Correa  Pinto, 
Jose  Gomes  Rezande.  Jr..  Joao  Braz  Gouveia,  and  Annibal 
Celestino  Correa  Mendes. 

Dr.  J.  G.  Adami,  Professor  of  Pathology  at  the  McGill 
University,  Montrael,  has  been  appointed  vice-president 
of  the  section  of  pathology  and  bacteriology  of  the  Interna- 
tional Congress  on  Tuberculosis,  to  be  held  in  London  In 
July,  under  the  patronage  of  King  Edward. 

"Stomatite  Erucique." — The  Medical  Aye  states  that  at 
a  recent  meeting  of  the  Parisian  Society  of  Biology,  M. 
Artault  gave  an  account  of  a  curious  form  of  stomatitis 
which  he  proposes  to  call  "stomatite  erucique,"  the  origin 
of  which  had  been  hitherto  unknown.  It  is,  however,  now 
known  to  be  caused  by  eating  fruits  which  have  been  In 
contact  with  the  nest  of  certain  caterpillars  possessing  an 
urticating  property.  The  inflammation  attacks  the  mucous 
membrane  of  the  mouth,  the  lips,  the  gums,  the  cheeks,  and 
the  palate.  The  cause  is  the  irritating  hairs  and  secre- 
tions which  the  caterpillars  leave  in  their  nests.  The  dis- 
ease, as  a  rule,  attacks  children  who  eat  fruits  which  are 
taken  into  the  mouth  whole,  such  as  cherries  and  goose- 
berries, and  it  is  hardly  ever  seen  except  during  the  months 
of  May  and  June,  especially  in  dry  years.  A  mouth-wash 
composed  of  tincture  of  "myrrh"  generally  cures  the  com- 
plaint very  easily. 


Anesthetic  for  an  Elephant. — An  elephant  in  the  zoo- 
logical gardens  at  Hanover,  Germany,  was  recently  found 
to  be  suffering  from  a  growth  upon  the  lower  part  of  one 
of  its  hind  feet,  and  it  was  decided  to  remove  it. 
In  order  to  make  the  animal  insensible  a  dose  of 
six  hundred  grains  of  morphia  in  six  bottles  of  rum  was 
administered.  About  an  hour  after  the  elephant  had  con- 
sumed this  combination  narcosis  was  complete,  and  the 
operation  was  performed  without  any  trouble. — Interstate 
Midical  Joiintal. 

Foreign  Body  in  the  Maxillary  Sinus  Discovered  by  Radl- 
oscopic  Examination. — Dr.  Mignon.  of  Nice,  reported  in  the 
[iitcniat.  Archil,  dr  LiinjngoJ.  an  interesting  case  in  which 
the  patient,  a  young  man  twenty-one  years  of  age,  with 
suicidal  intent  discharged  a  revolver  against  his  temple.  A 
few  days  after  the  incident,  as  no  symptoms  of  reaction 
occurred,  an  examination  by  the  radioscope  was  attempted, 
rtid  it  was  found  that  the  bullet  was  lying  loose  within 
the  left  maxillary  sinus. 


nnR       The  Philadelphia  "I 
77°        Medical  Jockxal    J 


THE  LATEST  LITERATURE 


[Mat  25,  ISOl 


^be  Xatcst  literature. 


BRITISH  MEDICAL  JOURNAL. 
May  4th,  1901. 

1.  A    Clinical    Lecture    on    Functional    Nerve    Diseases. 

GEORGE  E.  RENNIE. 

2.  On  the  Centralization  of  Medical  Education  by  the  Uni- 

versity  of  London.     A.  D.  WALLER. 

3.  Some  Remarks  on  the  Inheritance  of  Acquired  Immun- 

ity.    GEORGE  OGILVIE. 

4.  Note  on  the  Results  Obtained  by  Antityphoid  Inocula- 

tions  in   Egypt   and   Cyprus   during   the   year   1900. 
A.  E.  WRIGHT. 

5.  Case  of  Secondary  Anemia  Becoming  Pernicious;  with 

Detailed    Examination    of    the    Blood.      WILFRID 
EDGECOMBE. 

6.  The  Treatment  of  Two  Cases  of  Nerve  Leprosy  in  which 

Recovery  Took  Place.    GEORGE  THIN. 

7.  On  Operating  on  the  Subjects  of  Exophthalmic  Goitre. 

J.  DELPRATT  HARRIS. 

8.  A  Case  of  Descending  Landry's  Paralysis  in  a  Child. 

LEONARD   A.   ROWDEX. 

9.  Two  Cases  of  Severe  Frontal  Herpes.    C.  HIGGENS. 

10.  An  Unusual  Svmptom  in  Secondary  Syphilis.     A.  A. 

SCIT  SKIRVING. 

11.  Whooping-Cough    Cured   by   Irrigation   of   the   Nares. 

ED.  MARTIN  PAYNE. 
1. — In  an  attempt  to  understand  the  conditions  accom- 
panying functional  nerve  diseases  the  physician  should  al- 
ways remember  the  immense  influence  exerted  by  the  mind 
on  the  body.  It  is  also  important  to  recognize  the  influence 
of  suggestion  either  from  without  or  from  within.  The 
moral  and  emotional  side  of  human  nature  and  the  strong 
desire  for  sympathy  that  exists  in  some  individuals,  partic- 
ularly in  young  women,  also  has  a  bearing  upon  the 
causation  of  these  diseases.  The  influence  of  heredity  is 
a  further  important  factor.  Clinically,  there  are  4  types  of 
functional  nerve  disease;  (1)  feigned  disease,  (2)  hysteria. 
(3)  neurasthenia,  and  (4)  functional  disease  concommitant 
with  or  dependent  upon  organic  disease.  There  may  be  a 
variety  of  motives  to  induce  patients  to  feign  or  simulate 
disease,  and  in  the  investigation  of  any  supposed  case  of 
this  nature  the  motive  should  be  sought  for.  In  examining 
a  patient  supposed  to  be  feigning  disease  the  fact  that 
pressure  upon  or  manipulation  of  a  tender  or  painful  area 
leads  to  slight  increase  in  the  pulse-rate,  to  slight  variation 
in  the  pulse-curve,  to  dilation  of  the  pupils,  and  variation 
In  the  vasomotor  reaction  these  may  serve  as  diagnostic  fac- 
tors. If  hemianesthesia  be  feigned.there  will  be  no  difference 
In  the  skin  reflexes  or  in  the  reaction  of  the  pulse,  pupils  or 
respiratory  movements  on  the.  two  sides.  If  epilepsy  be 
feigned  an  important  sign  that  would  indicate  the  absence 
of  true  epilepsy  is  the  condition  of  the  toxicity  of  the 
urine.  It  is  well  known  that  the  urine  of  epileptics  is  hypo- 
toxic.  Hysterical  nerve  disease  should  be  regarded  as 
partly  mental  and  partly  physical,  the  underlying  psychical 
state  being  allied  to  the  hypnotic  state..  Important  assist- 
ance in  the  diagnosis  of  hysteria  may  be  obtained  from  a 
study  of  the  plantar  reflex:  in  conditions  of  health  and  in 
purely  functional  nerve  disease  the  flexor  response  is  the 
rule:  whereas,  in  cases  of  organic  disease  involving  the 
pyramidal  tracts,  an  extensor  response  is  almost  invariable. 
The  symptoms  of  neurasthenia  are  more  subjective  than 
objective,  though  none  the  less  real  to  the  patient,  and,  in 
certain  cases,  neurasthenia  approaches  very  closely  to  in- 
sanity. 

Neurasthenics  frequently  complain  of  headache.  One 
of  the  most  frequent  forms  for  this  symptom  to  assume 
is  the  "helmet  headache"  of  Charcot  The  head  feels  as 
it  a  helmet  were  pressed  down  upon  it,  producing  a  feelins: 
of  tightness  all  around  it.  Prolonged  mental  or  physical 
exertion  probably  by  entailing  formation  of  an  excessive 
amount  of  waste  nerve  products  with  deficient  excretion 
of  the  same  and  their  injurious  effects  upon  the  nerve 
cells  p.nd  fibers  frequently  determines,  according  to  Rennie. 
the  onset  of  neurasthenia.     [J-  M.  S.] 

3. — Ogilvie  is  of  the  opinion  that  a  more  thorough  study 
of  the"  tropical  diseases  in  the  colonies  has  somewhat 
shaken  the  unconditional  belief  in  many  statements  re- 
garding the  Inheritance  of  acquired  immunity.  The  im- 
munity enjoyed  by  colored  races  seems  by  no  means  so 
absolute  as  has  been  generally  taught.  In  not  a  few 
cases,  on  close  inquiry,  the  immunity  of  the  adult  natives 


to  a  certain  disease  seems  to  have  been  the  result  of  an 
attack  of  that  disease  early  in  life.  Furthermore,  no  grad- 
ual immunization  has  ever  been  observed  in  the  white 
races  with  regard  to  any  of  the  infectious  diseases  from 
which  they  suffer.  Until  we  have  at  least  some  clinical  or 
experimental  proof  that  infectious  diseases  lead  by  them- 
selves to  a  gradually  increasing  immunity  in  the  offspring 
the  accumulation  theory  as  an  explanation  of  racial  im- 
munity will  remain  an  unsubstantial  hjT)othesis.    [J.  M.  S.] 

4. — During  the  year  1900  a  record  was  kept  of  the  inci- 
dence of  typhoid  fever  among  the  inoculated  British  troops 
in  Egypt  and  Cyprus.  During  this  period  there  were,  on  an 
average,  2669  uninoculated  troops  and  720  inoculated 
troops.  Among  the  uninoculated  troops  there  were  2.5%  of 
cases  of  typhoid  fever.  Among  the  inoculated  troops  0.14. 
The  death  rate  among  the  uninoculated  cases  was  0.4"Ji, 
among  the  Inoculated  0.14%.     [J.  M.  S.] 

5. — Edgecombe  reports  the  case  of  a  single  woman,  aged 
38  years,  who  was  highly  neurotic  and  who  had  suffered 
almost  continuously  from  anemia  for  12  years.  During 
the  whole  of  this  time  she  suffered  from  trouble  in  the 
nasal  cavity  attended  by  repeated  discharge  of  blood  and 
pus  in  small  quantities.  Examination  of  the  blood  showed 
23%  of  hemoglobin,  475,000  red  bloodcorpuscles,  1.400  white 
corpuscles,  color  index  of  2.40  and  the  presence  of 
nucleated  red  cells,  both  normoblasts  and  megoloblasts. 
Under  treatment  with  HommeVs  hematogen  and  inhalations 
of  oxygen  a  great  improvement  resulted.  Later,  a  recur- 
rence of  the  blood  condition  was  noted  and  death  finally 
resulted.  The  author  believes  that  this  case  is  one  of 
chronic  secondary  anemia  which  passed  into  the  pernicious 
form.      [J.    M.    S.] 

6. — Thin  reports  the  case  of  a  boy.  aged  11  years,  a  native 
of  the  West  Indies,  who  was  suffering  from  a  fully  devel- 
oped and  severe  nerve  leprosy.  Three  months  after  the  in- 
stitution of  treatment  with  chaulmoogra  oil  considerable 
improvement  had  occurred  and  the  patient  was  taking  21 
drops  daily  without  discomfort.  Five  months  later  there 
was  apparently  a  slight  setback. 

Thirteen  years  later  the  patient  reported  that  he  had 
been  in  perfect  health  for  a  nimiber  of  years  and  that  he 
had  been  cured  by  chaulmoogra  oil.  which  he  had  taken 
for  nearly  3  years.  The  only  evidence  of  his  having  had 
leprosy  was  found  in  the  mutilation  of  the  hands  and  feet 
and  in  the  incomplete  restoration  of  sensation  on  some 
parts  of  the  limbs.  The  author  also  reports  the  second 
case  in  which  nerve  leprosy  was  detected  at  a  very  early 
stage  in  a  youth  that  had  been  some  years  abroad.  Com- 
plete recovery  followed  treatment  with  the  local  applica- 
tion of  pyrogallic  acid  ointment  and  the  internal  use  of 
gurjun  oil  and  arsenic.     [J.  M.  S.] 

7. — Harris  reports  the  case  of  a  married  woman,  aeed 
46  years,  who  was  the  subject  of  exopththalmic  goiter. 
The  patient  was  operated  on  for  the  removal  of  a  tumor 
in  the  left  breast.  In  operations  upon  patients  suffering 
from  exophthalmic  goiter  the  condition  of  the  heart  is  from 
the  first  the  great  difficulty.  The  heart,  which  beats  ir- 
regularly and  at  great  speed  probably  has  thin  and  dilated 
ventricles.  The  anesthetic  at  once  produces  acute  em- 
barrassment, while  the  unavoidable  loss  of  blood  causes 
temporary  quickening  of  the  already  too  quick  pulsations 
producing  general  weakness  and  exhaustion,  which,  owing 
to  the  anesthetic  sickness,  cannot  at  first  be  remedied  by 
food.  Thus,  before  compensation  can  be  restored  the  pa- 
tient sinks,  as  did  the  patient  whose  case  is  reported. 
Therefore,  in  advanced  cases  of  exophthalmic  eoiter.  the 
author  believes  that  every  effort  should  be  made  to  avert 
a  serious  operation.  If.  however,  such  an  operation  is  ab- 
solutely imperative  a  course  of  treatment  with  remedies 
of  the  digitalis  class  should  precede.  If  the  heart  does  not 
respond  to  this  treatment  the  operation  should  be  recon- 
sidered, for  undoubtedly  the  risk  in  such  cases  is  of  the 
gravest  possible  character.     [J.  M.  S.] 

8. — Robin  reports  the  case  of  a  boy.  aged  10  years,  in 
whom  a  diagnosis  of  Landry's  paralysis  of  the  descending 
type  was  made  on  account  of  fl^  progressive,  symmetrical, 
motor  paralysis,  which  effected  the  muscles  of  the  neck 
and  then  extended  to  the  arms,  forearms,  chest  and  legs; 
i'2^  nondisturbance  of  sensation  until  a  few  hours  before 
death:  fSI  absence  of  rigidity,  pain,  twitching  or  spnsm: 
and  (4>  the  unimpairment  of  the  mental  functions  and  the 
persistence  of  control  over  the  bowels  and  bladder.  Al- 
though the  patient  had  a  fall  of  10  or  11  feet  into  a  nit.  the 
traumatism  seemed   not  to  have  any  relation  to  the  dis- 


Mat  K,  laoi] 


THE  LATEST  LITERATURE 


TThe  Philadelphia       qqq 
LAlEDiCAL  Journal  yyv 


ease  which  caused  death,  as  there  was  no  sign  whatever 
of  damage  to  the  vertebral  column.  The  author  does  not 
consider  the  case  to  be  one  of  infantile  paralysis.  The 
case  was  an  extremely  rapid  one  and  ended  fatally.   [J. M.S.] 

9. — Higgins  reports  the  case  of  a  married  woman,  aged 
45  years,  who  had  a  severe  attack  of  left  frontal  herpes. 
Also  the  case  of  a  married  woman,  aged  49  years,  who  had 
had  frontal  herpes  10  weeks  before.  In  the  first  patient 
there  was  extensive  ulceration  of  the  cornea  and  severe 
iritis,  which  resulted  in  corneal  and  vitreous  opacity.  In 
the  second  patient  there  was  much  scarring  and  ulcera- 
tive keratitis  with  complete  paralysis  of  the  third,  fourth, 
ophthalmic  division  of  the  fiith  and  sixth  nerves.     [J.  M.  S.] 

10. — During  the  last  few  years  Skirving  has  seen  several 
cases  of  secondary  syphilis  of  the  throat  in  which  itching 
of  the  fauces  was  a  prominent  symptom.     [J.  M.  S.] 

11. — Payne  reports  the  case  of  a  boy,  aged  9  years,  who 
was  suffering  from  a  severe  attack  of  whooping-cough.  The 
a\ithor  irrigated  the  nose  of  his  patient  with  1  to  40  solu- 
tion of  carbolic  acid.  Ten  or  20  ounces  of  this  solution  were 
passed  through  the  nose  three  times  a  day.  At  first,  the 
irrigation  caused  a  good  deal  of  sneezing  and  coughing 
and  the  ejection  of  a  considerable  amount  of  gelatinous 
mucus,  some  of  which  was  greenish  in  color.  After  the 
operation  had  been  performed  a  few  times  there  was  less 
discomfort  and  the  patient  looked  forward  to  the  injection 
as  bringing  relief  from  his  suffering.  The  cure  was  com- 
plete in  about  a  week,  but  the  treatment  was  continued  a 
few  days  longer  in  order  to  prevent  the  recurrence.  [J.  M. 
S.] 


LANCET. 

May  !,th.  I'JOl. 

1.  A   Clinical  Lecture  on    Eczema  in    Relation    to    Age. 

MALCOLM  MORRIS. 

2.  The  Action  of  Arsenic  as  Observed  During  the  Recent 

Epidemic    of   Arsenic    Poisoning.     Sir    T.    LAUDER 
BRUNTON. 

3.  Some   Further   Investigations   upon   Rheumatic   Fever. 

F.  J.  POYNTON  and  ALEXANDER  PAINE. 

4.  A  Case  of  Perforating  Gastric  Ulcer  with  Rigors.    AN- 

THONY A.  BOWLBY  and  J.  F.  STEEDMAN. 

5.  On  Serous  Vaccinia  in  Connection  with  Cretinism  and 

Rickets.     ROBERT  KIRK. 

6.  Three  Cases  of  Sarcoma  of  the  Uterus.     E.  OCTAVIUS 

CROFT. 

7.  A  Case  of  Recovery  after  Operation  for  Diffuse  Peri- 

tonitis from   Perforation   of  the   Appendix.        RUS- 
SEL  COOMBE. 

8.  On  the  Uses  of  Diphtheria  Antitoxin.     T.  B.  BROAD- 

WAY. 

9.  The  Respiratory  Movements  of  the  Precordial  Area  in 

Health  and  in  Disease.     J.  AIKMAN. 

1. — Morris  delivered  a  clinical  lecture  at  the  Medical 
Graduates'  College  and  Polyclinic  on  January  9,  1901,  On 
eczema  In  relation  to  age.  He  classiffies  the  subject  as  fol- 
lows: Eczema  in  the  infant;  eczema  in  the  young  child; 
eczema  in  puberty;  eczema  in  the  adult;  eczema  in  the 
adult  woman  at  menopause;  and  eczema  in  the  aged. 
[F.  J.  K.] 

2. — T.  Lauder  Brunton  writes  on  the  action  of  arsenic  as 
observed  during  the  recent  epidemic  of  arsenic  poisoning. 
He  gives  a  short  classification  of  the  symptoms  and  states 
the  manner  in  which  the  general  action  of  arsenic  upon  the 
body  is  brought  about.  It  appears  that  arsenic  inter- 
feres with  the  normal  metabolism,  but  the  exact  nature  of 
the  chemical  changes  which  occur  is  not  understood.  Arse- 
nic, while  beneficial  in  very  minute  doses,  in  sufflicently 
large  quantities  is  able  to  produce  inflammation  in  any 
part  of  the  body,  either  applied  directly  or  through  the  cir- 
culation. The  stomach  may  be  irritated  by  direct  action, 
or  after  the  arsenic  is  absorbed  the  stomach  may  become 
the  seat  of  inflammation  from  the  arsenic  in  the  circula- 
tion. The  arsenic  in  the  circulation  reaches  all  tissues. 
Almost  all  of  the  symptoms  arc  produced  by  the  action  ot 
the  irritant  in  this  manner.  The  author  states  that  there 
can  be  little  or  no  doubt  that  the  cause  of  the  recent  Man- 
chester epidemic  was  due  to  arsenic,  because  there  was 


an  absence  of  any  other  sufficient  cause;  sufficient  arsenic 
was  discovered  to  produce  the  symptoms  of  poisoning; 
and  that  the  symptoms  were  identical  with  those  produced 
by  chronic  arsenic  taken  in  other  ways.  Reference  is  al- 
so made  to  the  discovery  of  selenium  in  beer,  by  Dr. 
Tuunicliffe,  as  being  the  factor  which  is  partly  responsible 
for  some  of  the  symptoms,  but  before  definite  conclusions 
can  be  arrived  at  further  investigation  is  required.  [F.  J.  K.} 

3. — Will  be  treated  editorially. 

4. — Bowlby  and  Steedman  report  a  case  of  a  woman  27 
years  of  age  who  was  operated  upon  for  perforating  gas- 
tric ulcer.  In  addition  to  the  other  symptoms  the  patient 
had  2  rigors  before  operation.  The  perforation  was  in  the 
anterior  wall  near  the  cardiac  end.  The  peritoneal  cavity 
was  wiped  out  with  gauze  and  contained  very  little 
foreign  material.  The  patient  did  well  for  three  weeks 
when  she  developed  tenderness,  distension,  restlessness 
and  some  temperature.  The  abdomen  was  again  opened  and 
a  volvulus  of  the  small  Intestine  was  found  in  the  pelvic 
cavity.  This  was  relieved  and  the  patient  made  a  satisfac- 
tory recovery.  The  volvulus  occurred  as  a  result  of  ad- 
hesions which  had  taken  place  within  the  pelvic  cavity. 
Attention  is  called  to  the  unusual  symptom  of  rigors  after 
perforation.  The  temperature  here  too  was  unusual  reach- 
ing at  one  time  106  while  the  pulse  never  was  very  rapid. 
[.J.   H.   G.] 

5. — Kirk  discusses  serous  vaccinia  in  connection  with 
cretinism  and  rickets.  The  author  states  that  the  serous 
character,  occasionally  manifested  by  vaccine  lymph,  has 
received  very  slight  consideration  in  connection  with 
cachectic  states,  and  for  that  reason  he  makes  mention 
of  this  condition  which  he  has  observed  in  4  cases. [F.  J.  K.] 

6. — Croft  remarks  that  primary  sarcoma  of  the  uterus  is 
undoubtedly  a  very  common  disease  but  that  in  all  prob- 
ability its  rarity  is  considerably  overestimated.  Such  a 
large  number  of  cases  of  malignant  disease  of  the  uterus- 
come  under  observation  only  when  the  disease  is  so  far 
advanced  that  anything  more  than  palliative  treatment  is 
impossible  and  therefore  a  careful  pathological  examina- 
tion of  the  nature  of  the  growth  is  not  made  and  it  is  pos- 
sible that  many  of  these  cases  may  have  been  of  sarco- 
motous  rather  than  of  carcinomatous  malignancy.  Williams 
in  his  recent  book  states  that  his  analysis  of  2649  con- 
secutive cases  of  primary  uterine  neoplasms  comprises  only 
two  examples  of  sarcoma  to  1571  cancers.  He  does  not 
state  whether  these  were  all  confirmed  pathologically. 
Croft  records  three  new  cases  of  this  neoplasm,  two  of 
which  were  fatal.     [W.  A.  N.  D.] 

7. — Russell  Coombe  reports  a  case  of  a  boy  aged  14  years 
upon  whom  he  operated  for  diffuse  peritonitis  following  per- 
foration of  the  appendix.  The  abscess  here  was  completely 
walled  off  from  the  upper  portion  of  the  abdominal  cavity 
but  there  was  no  attempt  at  walling  off  below,  the  pel- 
vis containing  a  large  quantity  of  dirty  brown  fluid.  The  ab- 
scess cavity  and  the  pelvis  were  carefully  sponged  out  and 
drainage  instituted.  The  appendix  was  not  seen.  The  pa- 
tient made  a  good  convalescence  except  that  about  two 
weeks  after  the  operation  there  developed  an  abscess  of 
the  right  tunica  vaginalis  which  was  due  to  a  patulous 
condition  of  this  sac  at  the  time  of  operation.     [J.  H.  G.J 

8. — Broadway,  in  an  article  on  the  uses  of  diphtheria  an- 
titoxin, states  that  the  serum  treatment  of  diphtheria, 
when  used  early,  practically  saves  life  and  has  generally 
placed  the  prognosis  of  this  disease  in  a  more  favorable 
light.  Abscesses  may  be  avoided  at  the  seat  of  inocula- 
tion by  using  proper  antiseptic  precautions.  Its  use  should 
alone  be  justified  by  the  almost  instantaneous  relief  which 
follows  the  injection.  The  administration  of  saline  solu- 
tion with  the  antitoxin  probably  adds  its  efficiency.  In 
children  the  author  selects  the  gluteal  or  interscapular 
region  for  the  seat  of  the  Injection,  and  in  other  individuals 
he  prefers  the  loose  tissues  of  the  breast,  unless  the  child 
dreads  the  operation,  when  he  selects  the  gluteal  region  in- 
stead. In  order  to  secure  good  results  the  serum  should 
be  used  early,  freely,  and  In  all  doubtful  cases.     [F.  J.  K.J 


looo 


The   Philadelphia 
Medical   Journal  _ 


THE  LATEST  LITERATURE 


[Mat  z;,  19(0. 


9.— ^ikman  discusses  the  significance  of  the  respiratory 
movements  of  the  precordial  area  in  health  and  in  disease. 

In  health  the  left  intercostal  space  rises  and  falls  at  its 
sternal  and,  during  the  respiratory  act,  to  a  lesser 
degree  than  the  right.  The  respiratory  movement  does 
not  extend  beyond  the  Junction  of  the  cartilage  of  the  rib. 
In  children  the  restricted  respiratory  movement  extends  as 
high  as  the  second  intercostal  space,  and  in  adults  down- 
wards to  the  fourth  intercostal  space.  In  order  to  observe 
this  sign  the  patient  should  lie  flat  on  his  back  with  his 
arms  along  his  sides.  Deformity  of  the  chest  obscures 
this  sign.  In  acute  pericarditis  this  area  of  stillness  is  in- 
creased in  extent,  and  the  decrease  in  the  respiratory 
movement  is  pronounced.  This  sign  preceeds  the  stetho- 
scopic  manifestations  of  pericarditis  by  a  period  varying 
from  one  to  four  days.  In  endocarditis  with  compensatory 
hypertrophy  of  dilatation,  the  precordial  stillness  is  wider 
than  normal.     [P.  J.  K.] 


MEDICAL   RECORD. 


May    ISth.    1001. 

1.  The  Recent   Buffalo   Investigation   Regarding  the  Na- 

ture of  Cancer.     ROSWELL  PARK. 

2.  Contracture  of  the  Neck  of  the  Bladder.     CHARLES  H. 

CHETWOOD. 

1. — In  and  address  before  the  American  Surgical  Associa- 
tion at  its  Baltimore  meeting.  Dr. Roswell  Park  discussfd  the 
recent  Buffalo  investigations  regarding  the  nature  of  cancer. 
His  address  covers  pratically  the  ground  gone  over  by  Dr. 
Gaylor,  (See  Philadelphia  Medical  Journal,  May  4  and 
May  11,  1901),  as  to  the  nature  of  the  cause  of  the  condition 
and  as  to  the  results  of  the  inoculation  experiments  which 
were  performed  on  72  animals.  14  guinea  pigs  inoculated 
in  the  peritoneum  with  peritoneal  fluid  containing  the  or- 
ganism had  an  average  life  of  58  days;  4  inoculated  in  the 
peritoneum  with  cancer  mush, an  average  length  of  58 days; 
11  inoculated  into  the  peritoneum  with  dry  cancer  lymph 
nodes.  45  days,  while  6  guinea  pigs  inoculated  with  material 
from  these  animals  already  infected  gave  an  average  life  of 
29  days.  This  clearly  shows  the  increased  virulence  ob- 
tained by  passing  the  organisms  through  even  one  animal. 
By  other  experiments  organisms  grown  in  a  collodion  sac 
within  the  peritoneal  cavity  of  rabbits  were  so  enhanced  in 
virulence  that  a  healthy  rabbit  inoculated  in  the  ear  vein 
died  within  15  days  of  general  hematogenous  infection. 
The  material  used  for  the  inoculation  was  in  every  case 
bacteriologically  sterile,  and  consisted  essentially  of  pure 
culture  of  the  cancer  parasite.  All  these  animals  rapidly 
emaciated,  and  presented  on  opening  the  abominal  cavity 
enlarged  peritoneal  lymph  nodes,  and  increase  in  fluid,  and 
enlargement  of  the  spleen.  Several  also  presented  minute 
nodules  in  the  lungs  which  were  considered  beginning 
adeno-carcinoma.  Similar  nodules  were  noticed  in  other 
instances  in  the  liver  and  spleen.  In  all  of  the  organs  thus 
far  examined  by  Plimnier's  method  large  numbers  of  para- 
sites were  found  in  various  stages  of  development.  The 
lungs  in  all  instances  show  that  the  parasites  had  pene- 
trated the  bronchial  epithelium,  causing  a  typical  prolifera- 
tion and  epithelial  nests  beneath  the  basement  membrane. 
Cancer  begins  as  a  purely  local  infection,  and  kills  by  be- 
coming generalized.  Operation,  if  done  before  general 
infection  has  occurred,  is  extremely  promising  if  done 
thoroughly.  Carcinoma  as  a  type  of  disease,  is  in  every  in- 
stance an  example  of  epithelial  infection.  Sarcoma  on  the 
other  hand  is  an  infection  of  connective  tissue,  probably  by 
the  same  organisms,  the  tissue  cells  reacting  somewhat 
differently.  It  would  seem,  as  far  as  the  investigations 
have  gone,  that  different  forms  of  parasites  have  specific 
tendencies  in  one  direction  or  the  other.     [T.  L.  C] 

2. — Charles  H.  Chetwood  presents  a  paper  on  contrac- 
tion of  the  neck  of  the  bladder,  a  subject  which 
encroaches  upon  that  of  prostatic  hypertrophy.  Contrac- 
tion of  the  neck  of  the  bladder  is  a  fibroid  stenosis  of  the 
vesicle  sphincter,  or  fibrous  infiltration  of  the  glandular 
and  muscular  tissue  encircling  the  bladder  neck,  simulat- 


ing symtomatically  stone  in  the  bladder  and  resembling 
senile  prostatic  hypertrophy,  by  producing  mechanical  hin- 
drance to  the  urinary  outlet.  It  is  commonly,  but  not  neces- 
sairly,  of  gonorrheal  origin.  The  only  satisfactory  means  of 
treatment,  which  has  been  tried,  and  which  has  accomp- 
lished the  end  in  view,  is  free  incision  of  the  obstructing 
area  through  a  perineal  wound.  The  author  employs  an 
improved  instrument  in  the  operation  which  he  describes. 
16  cases  (the  author's  own)  in  which  operation  was  per- 
formed, are  given.     [T.  L.  C] 


NEW  YORK  MEDICAL  JOURNAL. 
May  IS,   1901      .(Vol.   LXXIII,    Xo.   20). 

1.  The   Pathology  and  Bacteriology  of  Uretero-intestinal 

Anastomosis.     ROBERT   ZEIT. 

2.  Air,  a  Factor  in  Digestion.     EDWIN  V\'.   MOORE. 

■i.     The    Proper   Administration   of   the   Schott   Exercises. 
VICTOR   NEESEN. 

4.  The  Use  of  the  Suprarenal  Capsule  in  Diseases  of  the 

Heart.    Second  Paper,  with  a  Report  of  Cases.    SAM- 
UEL  FLOERSHEIM. 

5.  Relations  of  Vascular  Disease  to  Heart  Disease.    WIL- 

LIAM  H.   THOMSON. 

1. — Zeit  concludes  in  his  article  on  uretero-intestinal 
anostomosis  as  follows:  (1)  Ureteral  implantation  into 
the  rectum  is  always  followed  by  ascending  infection. 
The  resulting  pyelonephritis  is  caused  by  the  Bacillus  coli 
communis;  (2)  The  primary  mortality  is  very  large,  84 
per  cent.,  no  matter  whif:h  operation  is  done:  (2)  Of  120 
(logs  operated  upon,  90  per  cent,  died  of  peritonitis  due  to 
leakage  of  urine  or  general  sepsis  and  pyelonephritis 
during  the  first  ten  days:  (4)  Dogs  living  a  longer  time 
(lied  of  pyelonephritis,  pyelonephrosis,  and  pyemia:  (5) 
Dogs  which  had  fully  recovered  from  the  operation  and 
the  resulting  pyelonephritis,  and  were,  to  all  appearances, 
in  perfect  health  and  vigor  again,  all  had  granular  contract- 
ed kidneys,  due  to  induration  and  cicatrization  of  diseased 
areas.  The  rectum  acts  as  a  fair  substitute  for  the  bladder 
in  such  cases:  (6)  Dogs  which  had  fully  recovered  after 
unilateral  implantation  were  living  by  the  other  kidney. 
The  kidney  of  the  side  operated  on  was  atrophic  and  gran- 
ular, the  result  of  an  early  pyelonephritis.  The  function- 
ally active  kidney  was  of  two  to  eight  times  the  size  of  the 
atrophic  one;  (7)  A  review  of  the  literature  on  uretero- 
intestinal  anastomosis  in  man  shows  that  no  better  results 
can  be  expected  in  man  than  in  animal  experiments:  (St 
The  ureters  are  frequently  dilated,  but  show  very 
little  or  no  disease,  no  matter  how  extensive  a 
pyelitis  or  pyelonephritis  is  present:  (9)  The  bladder 
is  always  infected  by  way  of  the  urethra,  whether  it  is  emp- 
tied at  the  time  of  operaton  or  not  A  purulent  cystitis 
was  found  in  every  case,  caused  by  Staph !ilotvn-u.i  alhu^ 
;ind  lUiciUus  coli  rommiini.^:  (10)  Artificial  immunity  to 
infection  by  the  so-called  colon  group  of  bacteria  is  the 
only  hope  of  making  uretero-intestinal  anastomosis  a 
feasible  operation.     [T.  M.  T.] 

3. — Neesen  states  that  the  primary  object  of  the  exercises 
is  not  to  develop  the  muscles,  but  to  relieve  the  over- 
!>urdened  heart  by  (1)  drawing  blood  away  from  it  into 
the  extremities  and  muscular  structures:  (2)  accelerating 
the  circulation  (contraction  of  the  muscles  upon  the 
blood-vessels):  (3)  Soothing  the  nervous  mechanism  of 
the  heart  by  acting  upon  the  motor  nerves  through  the 
slow  movements  of  the  muscles.  The  rules  laid  down  are 
as  follows:  (1)  Each  movement  is  to  be  performed  slowly 
and  evenly,  without  jerking  or  trembling:  (2)  Each  move- 
ment is  to  be  followed  by  an  interval  of  rest  (sitting): 
i:')  .\rm  movements  should  alternate  with  leg  or  body 
p-iovements:  (4)  Xo  part  of  the  body  is  to  be  held  so  as  to 
compress  the  blood-vessels  or  interfere  with  the  breathing: 
(5)The  patient  should  be  instructed  to  breathe  naturally 
:ind  regularly:  (6)  The  patient  should  be  watched  closely 
lor.  (a)  irregular  breathing:  (h)  straining;  (c>  trembling: 
id)  flushing  or  pallor  of  face  and  lips:  (e)  dilatation  of 
nostrils:  (f)  vawning:  and.  (g)  drawing  down  of  corners 
(if  the  mouth.     [T.  M.  T.] 

4. — Floersheim  observed  in  using  suprarenal  powder 
(1)  .-V  weak  and  irregular-acting  heart  became  stronger 
and  more  regular:  (2'>  a  dilated  heart  was  contracted:  (3) 
a  diifused  apex  beat  became  localized:  i4)  a  diffused, 
loud,  and  rough  mitral  regurgitant  murmur  became  local- 


May   S,   19i)1J 


THE  LATEST  LITERATURE 


TThe  Ph: 

L  iJEDlCAI 


"The  Philadelphia 
Journal 


lOOI 


ized.  smoother  and  lessened  in  intensity,  while  in  some 
cases  the  murmur  disappeared:  (5)  a  murmur,  which 
owing  to  the  extreme  weakness  of  the  heart,  could  scarcely 
he  heard,  became  more  distinct,  thus  aiding  in  the  diag- 
nosis: (6)  the  normal  cardiac  sounds,  when  indistinct, 
became  clearer  and  more  easily  distinguished:  (7)  in 
some  cases  a  rapid  pulse  became  less  rapid:  in  other 
cases  a  slow  pulse  became  faster:  (8)  patients  who  were 
very  weak,  with  organic  heart  disease,  were  improved: 
(9)  no  effect  was  observed  in  organic  heart  disease  when 
the  pulse  was  strong  and  regular.     [T.  M.  T.] 


MEDICAL    NEWS. 


Man  IS,  19i)J.      (Vol.  LXXVIII,  No.  20). 

1.  On     the     Modern     Treatment     of     Acute     Gonorrhea. 

GEORGE  KNOWLES  SWINBURNE. 

2.  Chronic  Gonorrhea.     JOHN  VANDER  POBL. 

3.  On  Gonorrheal  Conjunctivitis.    WARD  A.  HOLDEN. 

4.  Treatment    of    Gonorrheal    Stricture    of    the    Urethra. 

—JAMBS  R.  HAYDEN. 

5.  The  Treatment  of  the  Complications  of  Acute  Gonor- 

rheal Posterior  Urethritis.    JAMES  PEDERSEN. 

2. — Van  der  Poel  describes  chronic  gonorrhea  as  one  in 
which  as  a  consequence  of  previous  gonorrheal  infection, 
there  exists  a  secretion  containing  gonococci,  composed  of 
mucus  and  epithelial  cells,  manifesting  itself  (1)  either 
by  a  drop  of  muco-purulent  fluid  at  the  meatus  some  hours 
after  urination,  or  upon  pressure,  the  so-called  "morning 
drop."  which  may  be  increased  in  amount  and  be  present 
at  any  and  all  times;  (2)  by  gluing  the  lips  of  the  meatus 
in  case  there  is  not  sufficient  discharge  to  form  a  drop; 
(3)  simply  by  the  presence  of  shreds  in  the  urine,  the  so- 
calle<l  "clap-threads."  He  also  states  that  the  pathological 
changes  consist  of  an  inflammatory  connective  tissue  for- 
mation or  hyperplasia  characterized  (1)  by  round  small- 
cell  infiltration,  usually  localized  about  the  glands  and 
lacunae,  representing,  when  advanced,  the  granulations 
seen  in  the  endoscope:  and  (2)  by  an  atrophy  and  shrink- 
ing of  the  new  connective  tissue  with  the  formation  of  in- 
durations. The  process  can  be  either  superficial,  a  non- 
stricture  forming  scar;  or  deep,  involving  the  cavernous 
tissues,  a  true  cirrhotic  formation  or  stricture.  Anter- 
iorly, this  is  generally  the  case,  while  posteriorly,  the 
same  process  extends  into  the  submucous  tissues,  causing 
swelling  of  the  caput  gallinaginis  and  chronic  prostatitis 
In  addition  proliferation  of  the  epithelium  and  transfor- 
mation of  the  cylindrical  into  flat,  both  upon  the  surface 
and  the  glands  with  eventual  obliteration  and  destruction 
of  the  latter.     [T.  M.  T.] 

3. — The  symptoms  of  gonorrheal  conjunctivitis,  given  by 
Holden,  are  as  follows:  From  one  to  four  days  after  in- 
fection, the  first  signs  manifest  themselves. in  a  swelling 
of  the  lids  and  in  adults  a  discharge,  thin  and  watery.  The 
lids  continue  to  swell  until  they  become  brawny, 
when  eversion  is  impossible.  The  conjuntiva  of 
the  eyeball  becomes  edematous  and  flakes  of 
mucus  appear  in  the  discharge,  with  considerable  dis- 
comfort. A  day  or  two  later  a  thick,  creamy,  purulent 
discharge  fills  the  conjunctival  sac,  floods  the  cornea  and 
pours  out  through  the  aperature  of  the  lids.  At  this  time 
the  nutrition  of  the  cornea  Is  interfered  with  and  it  some 
times  sloughs  and  breaks  down.  After  the  purulent  dis- 
charge is  established,  the  swelling  and  tension  of  the 
lids  diminish,  but  the  conjunctiva  remains  swollen  and 
velvety  from  a  hypertrophy  of  its  papillae.  The  paren- 
chyma of  the  cornea  may  now  become  diffusely  hazy  or 
superficial  ulcers  may  appear  which  rapidly  extend  deep 
and  often  lead  to  perforation  of  the  cornea.  The  purulent 
discharge  gradually  decreases,  and  in  the  course  of  several 
weeks  may  cease,  but  a  chronic  papillary  hypertrophy  of 
the  conjunctiva  still  persists.     [T.  M.  T.] 

4. — Hayden  considers  fll  stricture  of  the  meatus:  (2) 
stricture  of  the  pendulous  urethra:  (3)  the  stricture  of  the 
bulbous  portion,  statina;  that  the  best  routine  treatment  for 
lecent  and  even  fairly  recent  cases  of  gonorrheal  stricture, 
is  careful  and  gradual  dilatation,  combined  with  instilla- 
tions or  irrigations,  and  appropriate  diet  and  internal 
medication  to  render  the  urine  bland  and  non-irritating:  It 
gradual  dilatation  fails,  or  for  any  reason  cannot  be  em- 
ployed, he  then  resorts  to  one  of  the  cutting  operations 
which  he  describes,  being  guided  in  his  choice  of  procedure 
by  the  location  and  extent  of  the  contraction,  which  is 
readily  ascertained  by  the  hitnijir  a  houlr.     [T.  M.  T.l 


BOSTON     MEDICAL    AND    SURGICAL    JOURNAL. 
May  10th,  1901. 

1.  The  Treatment  of  Psoas  Abscess  by  Incision.  ROBERT 

W.  LOVETT. 

2.  Infantile    Scorbutus.     JOHN    LOVETT    MORSE. 

3.  Neuritis  recurring  after  Atrophy  of  Both  Optic  Nerves 

in    a    Case    of    Brain    Tumor.     EDWARD    R.    WIL- 
LIAMS. 

1. — Lovett  concludes  that  fever  is  not  necessarily  an  ac- 
companiment of  psoas  abscess  formation.  When  fever 
does  occur  the  prognosis  is  not  so  good  as  in  cases  in 
which  it  is  absent.  The  best  method  of  operation  is  by  an 
iliac  incision;  the  next  most  desirable  method  is  by  a 
lumbar  incision.  On  general  principles  it  seems  desirable 
to  put  on  a  plaster  jacket  almost  immediately  after  the 
operation  so  as  to  enable  the  patient  to  sit  erect  and  to 
enable  the  abscess  to  drain  almost  from  the  first.  [J.  M.  S.] 

3. — Edward  R.  Williams  reports  a  case  of  neuritis  recur 
ring  after  atrophy  of  both  optic  nerves  in  a  case  of  brain 
tumor,  in  a  woman  22  years  old.  There  had  been  attacks 
of  headache  and  vomiting  followed  shortly  by  failing  of 
vision  which  was  unimproved  by  glasses.  One  year  there- 
after there  was  marked  atrophy  of  each  optic  nerve  with 
signs  of  old  hemorrhages  about  the  maculae.  Two  days 
before  death,  which  occurred  three  months  later  after  pro- 
gressive coma,  ophthalmoscopic  examination  showed  typi- 
cal double  optic  neuritis  worse  in  the  left  eye.  The  litera- 
ture on  the  subject  is  freely  referred  to.     [M.  R.  D.] 


JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 

Muu  Id,  1901. 

1.  Amputation  Through  the  Hip-Joint,  with  a  Synopsis  of 

267  Cases  in  Which  the  Author's  Method  was  Em- 
ployed.    JOHN  A.  WYETH 

2.  The  Ocular  Expression  of  Intranasal  Lesions.    ROBERT 

SATTLER. 

'.J.  A  Brief  Note  on  the  Pathology,  Diagnosis  and  Treat- 
ment of  Nasal  Accessory  Sinus  Affections.  R. 
LARUE  VANSANT. 

'i.  The  Reduction  of  Temperature  in  Fevers  by  Evapora- 
tion Baths;  Warm  Water  Being  Used  for  Baths. 
FRANCIS   H.   WILLIAMS. 

5.  The  Streptococcus   Pyogenes  in  Gynecologic  Diseases. 

G.  BROWN  MILLER. 

6.  Meniere's  Disease  with  Report  of  a  Case.    R.  A.  BACH- 

MANN. 

7.  The  Financial  Relations  of  the  Medical  Profession  to 

the  People  and  Public.    J.  J.  CONNER. 
S.     A  Study  of  the  Etiology  and  Pathology  of  Rheumatism 
with   Special    Reference   to   "Rheumatic   Diathesis." 
A.   P.   STONER. 

9.  A  Case  of  Acute  Dermatitis  Caused  by  the  Use  of  Hair- 

Dye  Having  for  its  Base  the  Hydrochlorate  of  Para- 
phenylene  Diamin.     A.  D.  MEWBORN. 

10.  Difficulties  and  Dangers  of  Anesthetics.     DANIEL  N. 

EISENDRATH. 

11.  The  Vesicular  Murmur  and  its  Relation  to  Pulmonary 

Health  and  Disease.     THOMAS  NEIL  McLEAN. 

1 2.  On  the  Relation  Between  the  Variety  of  Micro-organ- 

isms and  the  Composition  of  Stone  in  Calculous  Pye- 
lonephritis.    THOMAS  B.  BROWN. 

13.  Complete  Inguinal  Extraperitoneal  Hernia  of  the  Blad- 

der: Recovery.  J.  P.  BALDWIN. 
1. — John  A.  Wyeth  gives  the  history  of  hip-joint  ampu- 
tation and  the  various  methods  of  controlling  hemorrhage 
during  its  performance.  His  own  method  of  using  the 
lai-ge  mattress  needles  was  first  employed  in  February, 
1S90.  After  the  disarticulation  is  completed.  In  order  to 
avoid  subsequent  oozing  from  the  wound  surfaces,  it  is  the 
author's  custom,  before  removing  the  pins  and  tourniquet 
to  thoroughly  dry  the  wound  surfaces,  to  introduce  the  su- 
tures and  to  apply  a  light  dressing  with,  a  firm  gauze 
bandage.  The  pins  and  tube  are  then  removed  and  the 
dressing  completed.  Wyets  finds  that  this  procedure  with 
the  elevation  of  the  foot  of  the  bed  prevents  the  extensive 
oozing  which  is  apt  to  take  place  after  the  operation.  He 
thinks  his  method  of  controlling  hemorrhage  is  simpler  and 
safer  than  the  intraperitoneal   compression  of  either  the 


I002 


The  Philadelphia" 
Medical   Journal  . 


THE  LATEST  LITERATURE 


[Mat  S,  1901 


aorta  or  common  iliac.  The  article  is  illustrated  by  several 
excellent  cuts  representing  the  steps  of  the  operation  and 
there  is  appended  a  table  of  267  cases  of  amputation  at 
the  hip-joint,  where  the  Wyeth  method  was  used.  These 
are  divided  into  three  classes;  first,  neoplasms,  of  which 
there  were  137  cases  with  a  mortality  of  10.2%  second,  sep- 
tic infections,  of  which  there  were  94  cases  with  a  mortal- 
ity of  17%;  third,  traumatisms,  with  or  without  septic  in- 
fection, of  which  there  were  3G  cases  with  a  mortality  of 
63.9%.  [J.  H.  G.] 

2. — Robert  Sattler  in  discussing  the  ocular  expressions  of 
intranasal  lesions  considers  two  classes.  Among  the  first 
class  are  included  certain  chronic  processes  which  affect 
the  anterior  portion  of  the  middle  meatus  of  the  nose. 
Lesions  in  this  region  often  perplex  and  disappoint  the 
oculist.  Persistent  ocular  phenomena  may  exist  with 
symptoms  on  the  part  of  the  nose  entirely  out  of  propor- 
tion or  even  negative.  Persistent  injection  of  the  vessels 
of  the  bulbar  conjunctivae,  distinction  of  the  muscular 
branches  and  frequent  accompaniment  of  retrotarsal  pas- 
sive edema  are  some  of  the  clinical  expressions  of  these 
lesions.  The  palpebral  conjunctiva  is  generally  exempt 
from  this  vascular  injection.  Persistant  neuralgic  pain  is 
present,  and  becomes  manifest  at  any  continued  effort  at 
close  woiiv.  Pain  on  pressure  can  be  elicited  by  passing 
and  pressing  the  finger  against  the  inner  wall  of  the  orbit. 
Congenital  causes  or  those  affecting  early  life,  such  as 
syphilis,  rhachitis,  scrofula,  etc.,  frequently  act  as  pre- 
disposing causes  for  the  obscure  intranasal  processes  and 
the  ocular  participations.  The  second  class  constitutes 
those  cases  where  invariably  a  focal  suppuration  of  the 
nose  is  present.  The  author  describes  the  surgical  pro- 
cedures required  in. these  cases.     [  M.  R.  D.] 

3. — Vansant  gives  a  brief  outline  of  the  pathology,  diag- 
nosis, and  treatment  of  the  nasal  accessory-sinus  affec- 
tions. The  most  important  etiological  factors  are  nasal 
polyps,  deviation  of  the  nasal  septum,  swelling  and  thiclc- 
ening  of  the  mucous  membrane  of  the  nasal  openings  of 
the  sinuses,  obstruction  due  to  masses  of  granulation  tissue 
or  inspiss.ated  mucus.  When  nasal  obstruction  occurs  path- 
ological changes  develop — inflammation  or  chronic  conges- 
tion— in  the  mucous  membrane  lining  the  obstructed  sin- 
uses. The  most  prominent  symptom,  pain  in  the  head, 
greatly  aids  in  the  diagnosis  of  this  condition.  The  head- 
ache varies  greatly  in  intensity,  duration,  and  position;  it 
is  usually  localized  to  a  definite  area.  The  diagnosis  is 
frequently  confirmed  by  inspection,  and  transillumination, 
while  at  times  a  valuable  aid  in  the  diagnosis,  is  not  always 
a  reliable  one.  The  treatment  should  be  directed  so  as 
to  provide  proper  drainage  for  the  affected  sinus;  the  dis- 
eased membrane  should  also  be  treated.  The  author  highly 
recommends  forcible  syringing  of  the  sinuses  with  dry 
hot  air  under  pressure.     [F.  J.  K.] 

4. — Williams  states  that  a  valuable  method  of  reducing 
the  temperature  in  fevers  is  the  evaporation  bath,  warm 
v.'ater  being  used  for  the  bath.  Of  15  patients  treated  by 
this  method  there  was  an  average  fall  of  temperature  per 
bath  of  1.94°P.  The  following  directions  are  given:  The 
bath  should  be  given  whenever  the  temperature  reaches 
102  or  102. 5°F.;  the  patient  should  lie  on  a  blanket  and  be 
covered  witli  one  thickness  of  surgeon's  gauze;  the  gauze 
should  be  sprinkled  with  water  having  a  temperature  of 
115' F.;  the  duration  of  the  bath  should  be  guided  by  the 
amount  of  water  evaporated.  During  the  interval  between 
the  baths  the  patient  should  have  as  little  clothing  on  as 
possible.     [F.  J.  K.] 

5. — Miller  reports  11  cases  of  pelvic  inflammation  oper- 
ated upon  at  Johns  Hopkins  Hospital,  in  which  the  strep- 
tococcus pyogenes  was  found  to  be  the  infecting  agent. 
Nine  of  the  11  cases  presented  certain  features  which 
were  indicative  of  the  etiology  of  the  infection.  In  6  of 
the  cases  the  peritoneal  cavity  was  invaded  at  the  opera- 
tion, and  2  of  the  patients  died.  In  the  other  5  the  peri- 
toneum was  not  disturbed  and  all  recovered.  The  high 
mortality  in  these  cases  in  which  the  peritoneal  cavity  was 
invaded,  in  contradistinction  to  the  almost  uniformly  fa- 
forable  results  in  celiotomy  in  which  the  gonococcus  is  the 
Infecting  agent,  should  make  the  operator  careful  to  dis 
tinguish  between  these  two  classes  of  pelvic  infection.  The 
history  is  of  the  utmost  importance  in  making  a  diagnosis. 
In  the  large  majority  of  cases  of  streptococcic  pelvic  in- 
flammation the  lesion  is  a  parametritis.  Of  almost  equal 
value  with  the  history  is  the  pelvic  examination.  The  pel 
vie   structures   present   certain    characteristics   which   are 


almost  unmistakable.  These  are  the  situation  of  the  mass, 
its  consistency,  and  the  intimate  connection  of  the  uterus 
lo  the  walls  of  the  pelvis.  In  nearly  all  the  cases  the 
.sireptococcus  invades  the  surrounding  tissues  through  the 
lymphatics.  The  parametric  exudate  lies  in  a  connective 
Lissue  surrounding  the  uterus  and  vagina  and  beneath  the 
pelvic  peritoneum.  It  is  deep  seated,  may  be  situated  in 
either  broad  ligament,  but  is  usually  unilateral.  It  may  lie 
posterior  to  the  uterus,  in  the  septum  between  the  peri- 
coneal  cavity  and  the  vagina,  may  surround  the  rectum, 
or  may  be  ante-uterine,  lying  between  the  uterus  and  blad- 
der. The  mass  is  nearly  always  asymmetrical.  Its  con- 
sistency is  of  bone-like  hardness.  The  immobility  of  the 
uterus  is  marked  and  the  exudate  can  be  felt  directly  from 
this  organ  to  the  pelvic  wall.    [W.  A.  N.  D.] 

5. — Bachmann  discusses  Meniere's  disease  and  gives  a 
report  of  a  case.  The  author  states  that  the  disease  oc- 
curs more  frequently  in  the  male  sex  at  about  the  age  of 
CO,  and  that  syphilis  and  the  rheumatic  diathesis  seem  to 
Ije  the  most  frequent  direct  causes.  Other  important  eti- 
ological factors  are  senile  changes,  leukemia,  simple  ane- 
mia, hemorrhages,  serous  effusions,  cerebral  disturbances, 
parotitis,  and  influenza.  While  much  of  the  pathology  is 
siill  obscure,  inflammation  with  or  without  hemorrhages 
is  the  chief  lesion.  The  cardinal  symptoms  are  vertigo, 
tinnitus  aurium,  progressive  deafness,  and  gastric  disturb- 
ances. Other  symptoms  are  nystagmus,  volitional  tre- 
mor, loss  of  memory,  and  weakness  of  the  extremities.  The 
author  gives  the  report  of  a  case  of  Meniere's  disease 
which  occurred  in  a  man,  aged  67.  The  symptoms  began 
.1  years  before  the  patient  came  under  the  observation  of 
the  author.  The  patient  improved,  but  not  wholly  recov- 
ered under  the  treatment,  which  consisted  of  the  admin- 
istration of  potassium  bromide.  7  grains,  and  hyoscin  hy- 
drobromate,  1-200  of  a  grain,  given  three  times  daily  for 
over  a  month.  He  was  then  placed  on  salicylic  acid.  10 
grains,  and  potassium  acetate,  5  grains,  given  three  times 
daily.  Pilocarpine  injections  were  used  weekly  in  addition 
to  the  salicylate  treatment.     [F.  J.  K.] 

7. — Conner  discusses  the  financial  relations  of  the  medi- 
cal profession  to  the  people  and  the  public.  The  author 
urges  that  medical  men  should  consider  themselves  friends, 
not  rivals,  and  that  there  should  be  a  better  fraternal  spirit 
in  our  dealings  and  associations  with  one  another.  He  ad- 
vises the  establishment  of  a  uniform  fee-bill  which  should 
be  rigidly  enforced.  Services  rendered  employes  of 
companies  and  corporations  should  be  compensated  by 
these  companies  and  corporations.  Recognition  and  com- 
pensation for  services  should  be  demanded  ol  public  author- 
ities.    [F.  J.  K.] 

8. — Stoner  writes  on  the  etiology  and  pathology  of  rheu- 
matism, with  special  reference  to  rheumatic  diathesis. 
He  concludes  that  rheumatism  is  an  infectious  disease. 
The  variations  in  the  symptoms  depend  upon  the  position 
and  the  attenuation  of  the  germs.  Other  diseases,  for  ex 
ample,  scarlet  fever,  may  at  times  be  complicated  by  in- 
fection of  these  micro-organisms,  thereby  causing  rheumatic 
symptoms:  he  believes  that  the  germs  may  be  situated  in 
the  joints,  in  the  heart,  and  in  the  muscles.  Uric  acid  and 
lactic  acid  are  products  of  the  disease.  Heredity  is  an  im- 
portant etiological  factor  in  a  large  majority  of  the  cases. 
He  maintains  that  gout  and  rheumatism,  while  dissimilar 
diseases,  possess  many  similar  traits,  which  justifies  their 
lieing  classed  in  the  same  group,  of  diatheses.  The  author 
concludes  the  artcle  with  the  report  of  a  case  of  rheumatic 
fever  in  a  girl.  4  years  of  age.     [F.  J.  K.] 

9. — Mewborn  reports  a  case  of  acute  dermatitis  caused 
by  the  use  of  hair-dye.  The  base  of  this  dye  was  found 
to  be  hydrochlorate  of  paraphenylene  diamin.  This  der- 
matitis occurred  in  a  married  woman.  44  years  of  age. 
'I'he  eruption,  occurring  soon  after  the  use  of  the  hair-dye. 
covered  the  forehead,  which  was  red  and  shiny,  with  a  few 
vesicles  near  the  margin  of  the  hair,  the  eye-lids,  the  ears, 
the  nose,  and  cheek,  and  the  flexor  and  extensor  sur- 
faces of  the  forearms.  The  anterior  and  inner  sides  of  the 
thighs  were  covered  with  numerous  small  slightly  elevated 
papules  and  a  few  vesicles.  The  patient  complained  of  a 
prickling  sensation  and  an  uncomfortable  tension  of  the 
face.      [F.  J.   K.] 

10. — D.  N.  Eisendrath  discusses  the  difficulties  and  dan- 
gers of  anesthetics.  H(  urges  upon  the  anesthetist  the 
necessity  of  observing  the  pulse  rate  ard  tension  and  the 
condition  of  the  pupils  before  beginning  the  anesthetic.  A 
dilated  pupil  which  does  not  react  to  lisrht   's  one  of  the 


Mat   25,  1901 ; 


THE  LATEST  LTfERATURE 


[1/ 


HE  Philadelphia 
EDiCAL   Journal 


1003 


earliest  symptoms  of  syncope.  In  case  of  heart  failure 
during  anesthetization  the  author  has  found  Konig's  method 
of  massaging  the  heart  to  give  most  satisfactory  results. 
It  is  accomplished  by  making  regular  pressure 
with  the  semi-closed  hand  over  the  heart  with  the 
object  of  stimulating  a  ventricular  contraction. 
It  is  useless  to  give  cardiac  stimulants  before 
the  circulation  has  been  re-established.  The  author 
has  found  that  chloroform,  as  well  as  ether,  will  produce 
albumin  and  casts  in  the  urine,  although  in  cases  of  renal 
disease  its  effect  is  much  less  deleterious  than  the  effect 
of  ether.     [J.  H.  G.] 

11. — McLean  believes  that  the  vesicular  murmur  is  de- 
pendant upon  the  tidal  air  imposed  ujioii  the  residual  air. 
the  sound  being  produced  by  contraction  and  distinction 
of  the  vesicular  walls.  The  rush  of  air  into  the  lungs  with 
inspirration  stimulates  the  alveolar  walls  to  contraction 
and  thereby  aids  in  the  propulsion  of  the  blood  through  the 
pulmonary  capillaries.  In  order  to  liring  about  perfect 
contraction,  the  proper  amount  of  air  must  be  inspired. 
Incomplete  pulmonaiw  action  leads  to  stasis  and  transuda- 
tion of  serum  into  the  vesicular  and  bronchial  structures 
and  into  the  interstitial  tissues.  Impared  pulmonary  func- 
tion aids  in  the  formation  of  the  proper  soil  for  the  devel 
opment  01  tuberculous  infection.  Any  imperfect  pulmon- 
ary function  interferes  with  the  production  of  the  vesicular 
murmur.  In  the  treatment  of  imperfect  function,  measures 
should  be  adopted  that  tend  to  strengthen  the  respiratory 
movements.  The  author  holds  that  too  much  stress  has 
been  laid  upon  diagnosis  by  the  aid  of  the  microscope, 
and  that  of  more  importance  is  the  absence  of  muffling  of 
the  vesicular  murmur.  He  believes  that  the  principle,  gov- 
erning the  action  of  the  imeumatic  cabinet,  is  correct, 
and  that  this  measure  is  indispensable  in  the  treatment  of 
many  cases,     [F.  J.  K.] 

12. — Thomas  R.  Brown  disposes  of  the  former  theories 
regarding  the  formation  of  renal  calculi  as  unsatisfactory 
and  submits  a  number  of  cases  which  go  rather  to  prove 
the  more  recently  advanced  theory  of  the  bacterial  origin 
of  calculi.  In  e.ich  case  which  he  reports  there  was  pre- 
vious to  operation  a  careful  analysis  made  of  the  urine 
from  each  kidney  obtained  by  ureteral  catheterization. 
F'rom  the  urine  thus  obtained  cultures  were  made  and  in  all 
cases  excepting  one  the  urine  from  tlie  supposed  healthy 
kidney  was  found  absolutely  normal,  while  from  the  dis- 
eased side  were  obtained  various  cultures.  The  reaction  of 
the  urine  from  the  infected  side  depended  entirely  upon  the 
variety  of  micro-organisms  met  with,  being  acid  in  one 
case,  due  to  the  colon  bacillus,  and  alkaline  in  5  cases  in 
which  there  were  found  various  microorganisms  possess- 
ing an  ability  to  decompose  urea  In  5  instances,  where 
the  urine  was  alkaline,  nephrectomy  was  performed  and  the 
stone  examined  in  each  case.  In  3  cases  bacteria  were 
found  in  the  center  of  the  calculus;  in  3  other  cases  the 
stones  were  not  examind.  In  only  one  case  was  the  urine 
acid  and  here  the  micro-organism  found  was  the  B.  coli 
communis.     [J.  H.  G.] 

13. — J.  F.  Baldwin  reports  an  interesting  case  of  hernia 
of  the  bladder.  The  patient  was  a  man  aged  51  years, 
weighing  215  pounds,  wlio  had  suffered  from  an  inguinal 
hernia  for  8  years  which  he  was  unable  to  retain  with  a 
truss.  It  was  difficult  at  times  to  completely  empty  the 
bladder  unless  the  hernia  were  elevated.  When  seen  by 
Baldwin  the  hernia  had  been  irreducible  for  about  48  hours. 
There  were  no  symptoms  of  intestinal  obstruction,  but  there 
was  considerable  pain  and  tenderness.  A  diagnosis  of 
omental  hernia  with  probably  some  involvement  of  the 
bladder  was  diagnosed.  When  operated  upon  it  was  found 
that  the  hernia  consisted  entirely  of  the  bladder  without 
any  peritoneal  covering.  Because  of  the  patient's  obesity 
reduction  was  dillicult,  but  ultimately  the  patient  made  a 
good  recovery.  Baldwin's  case  is  the  11th  to  be  recorded 
of  hernia  of  the  bladder  only.     [J.  H.  G.] 


LA  SEMAINE    MEDICALE. 

Fchi-uanj  ;'.~lth.  V.)(ll. 

1,  Operative  Treatment  of  Balanitic  Hypospadias.     F.  dp 

QUERVAIN, 

2,  A    Practical    Means    of    Differentiating    Human    Bloo,' 

from  that  of  Animals.     L,   CHEINISSE. 
1. — De  Quervin  describes  the  operation  first  employed  by 
Beck  of  New  York  and  independently  by  von  Hacker,     A 
Y-shaped  incision,  almost  approaching  a  T-shape  is  made 


upon  the  under  surface  of  the  glans.  The  straight  portion 
of  the  incision  being  parallel  to  the  urethra  which  is  care- 
fully dissected  out.  Then  the  operator  has  the  choice  of  two 
procedures;  either  to  make  an  incision  in  the  line  of  the 
urethra  in  the  head  of  the  penis,  practically  grooving  the 
head  for  the  purpose  of  placing  the  urethra  in  this  groove 
and  then  covering  it  in  with  the  two  flaps  of  the  head, made  by 
the  surgeon  in  forming  this  groove,  and  fastening  it 
there.  The  parts  thus  fashioned  approximate  the  normal 
penis:  or  the  operator  may  pass  a  straight  bistoury  from 
the  position  of  the  proposed  meatus,  tunnelling  through 
the  head.  If  this  course  is  chosen  a  pair  of  forceps  inserted 
through  this  canal  may  be  used  to  bring  the  urethra,  pre- 
viously dissected  out.  into  its  proper  position.  The  article 
Ih  well  illustrated  and  the  author  closes  with  a  brief  outline 
of  post-operative  treatment.     [T.  L.  C] 

Marcli  6th,  1901. 

1.  Severe     'Vomiting     Complicating      Pregnancy.         CH. 

ACHARD. 

2.  The  Value  of  the  Presence  of  the  Bacillus  Filiformis 

in  the  Stomach  in  the  Early  Diagnosis  of  Cancer  of 
that  Organ.     H.  EHRET. 

1. — Pregnant  women  frequently  suffer  from  vomiting 
which  can  neither  be  classed  as  simple  nor  yet  pernicious 
in  form.  In  this  variety  of  cases  the  spells  are  frequent 
and  occasion  great  distress,  but  they  are  by  no  means  in- 
controllable.  Achard  classifies  the  condition  according  to 
its  amenability  to  treatment.  In  his  first  case  cited  the 
patient  was  a  young  woman  of  26  years,  pregnant  3  months 
and  had  vomited  from  the  sixth  week.  She  was  of  hysteri- 
cal temperment.  The  patient  improved  rapidly  upon  a  mix- 
lure  of  e^ual  parts  of  bicarbonate  of  soda  and  magnesia, 
taken  in  teaspoonful  doses  whenever  the  pains  appeared. 
She  was  also  placed  upon  an  absolute  milk  diet.  This 
patient  was  a  sufferer  from  hyperchlorhydria.  His  two  other 
cases  mentioned  were  also  of  nervous  taint  but  hyper- 
chlorhydria was  not  present.  In  the  second  case  the  alkaline 
treatment  was  of  no  avail:  nor  did  other  remedial  measures 
employed  prove  beneficial.  Lavage  was  finally  resorted  to, 
and  while  at  first  the  spasms  of  vomiting  increased,  after 
14  washings  the  stomach  symptoms  quite  disappeared,  and 
the  patient  rapidly  gained  in  weight.  His  third  case  was 
similar  to  the  one  just  mentioned  and  was  also 
cured  by  lavage.  There  was  a  decidedly  neurotic 
factor     in     this     case     also.  Achard      believes     that 

hysteria  may  play  an  important  part  in  the  development 
of  this  condition.  There  may  be  in  these  cases  a  hyperexci- 
tability  of  the  vomiting  center,  easily  disturbed  by  reflex 
influences  from  the  stomach  itself  as  well  as  the  sexual 
organs.     [T.  L.  C] 

March  13th.  1901. 
1.     The  Pathology  Treatment  of  Obesity.     DEBOVE. 

1. — Debove  considers  obesity  as  a  disease  of  the  nervous 
system,  either  primary  or  secondary.  It  may  be  called  pri- 
mary when  the  cause  is  not  discoverable,  and  secondary 
when  it  develops  under  the  influence  of  an  easily  estab- 
lished cause  such  as  gout,  diabetes,  chlorosis,  the  meno- 
pause, myxedema,  arrest  of  development  of  the  testicles, 
etc.  The  quantity  of  food  ingested  is  not  by  any  means 
proportionately  adapted  to  the  needs  of  the  organism.  We 
know  that  the  needed  quantity  is  utilized  and  the  excess  de- 
stroj'ed  by  processes  of  oxidation.  If  there  was  a  total 
absorption  by  the  economy  of  the  ingested  food  there  would 
be  a  steady  increase  in  size.  There  must  be  a  regulating 
force  in  the  nervous  system  which  moderates  combustion 
and  maintains  bodily  equilibrium  durin,g  periods  of  fasting. 
Obesity  is  caused  by  the  derangement  of  this  nervous  cen- 
ter. Its  treatment  comprises  2  periods.  The  first  of  which 
Debove  calls  the  period  of  insuflicient  alimentation:  and 
the  second  the  period  of  voluntary  regulation.  No  cure  can 
be  brought  about  unless  the  patient  is  willing  to  assist  by 
carrying  out  the  dietetic  measures  conscientiously.  De- 
bove determines  the  amount  of  food  necessary  to  the  body 
weight  by  the  establishment  of  the  thermic  value  of  food. 
For  instance,  if  we  wish  ta  determine  this  quantity  In  a 
man  who  weighs  70  kilos.,  we  know  that  43  calories  per 


I004 


The  Philadelphia"] 
Medical   Journal  J 


THE  LATEST  LITERATURE 


[Mat  25,  1901 


kilo,  are  required  in  a  state  of  rest,  and  the  simple  multi- 
plication will  give  us  the  number  of  calories  necessary  for 
the  sustenance  of  this  man.  Physiology  furnishes  us  with 
the  thermic  value  of  various  foods,  and  we  can  so  arrange 
the  patient's  alimentation  that  he  receives  whatever  pro- 
portion of  the  3010  necessary  calories  which  we  desire  to 
give  him.  A  sample  diet  upon  which  a  patient  lost  53  kilos 
in  less  than  5  months,  is  as  follows:  For  breakfast,  a  cup 
of  tea  or  milk;  mid-day  meal,  one  or  two  slices  of  meat,  a 
few  vegetables  or  a  little  salad,  a  hundred  to  a  hundred 
and  fifty  grams  of  bread,  a  little  cheese,  fruits  as  desired, 
and  a  cup  of  black  coffee  without  sugar.  For  supper,  a 
glass  of  hot  milk,  sweetened,  30  to  50  grams  of  bread  and 
fruits  as  desired.  He  believes  that  this  treatment  is  best 
carried  out  in  a  sanatarium  and  that  above  all  the  patient 
should  not  eat  at  table  with  the  family.  Exercise  is  not  of 
any  special  value  in  the  treatment  of  obesity  for  the  rea- 
son that  it  causes  an  increased  appetite,  which  will  more 
than  compensate  in  weight  increase  for  the  amount  lost. 
He  believes  that  mineral  waters  are  apt  to  produce  serious 
digestive  disturbances.  Thyroid  feeding  is  of  value  only 
In  those  cases  in  which  myxedema  can  be  regarded  as  a 
cause.  He  has  observed  serious  dangers  arising  from 
thyroid  treatment,  and  in  one  case  sudden  death  of  the 
patient.  The  principle  upon  which  Debove's  treatment  de- 
pends is  that  we  shall  supply  the  deranged  automatic  con- 
trol of  the  nervous  center  by  voluntary  control,  and  so 
induce  the  proper  regulation  of  body  weight.     [T.  L.  C] 


VRATCH. 

March  2.'fth.  ISnl.     (Vol.  XXII,  No.  12.) 

1.  Balantidium  Coli  the  Cause  of  Chronic  Diarrhea.    N.  S 

SOLOWJEFF. 

2.  On  the  Action  of  the  Alkaloid  Johimbin  on  the  Animal 

Organism   and   its   Utility  in  the  Treatment  of  Im- 
potence.    N.  P.  KRAWKOFF. 

3.  A  Case  of  Intestinal  Invagination.     A.  P.  KRIMOFF. 

4.  Fibromyoma  and  Pregnancy.     I.  S.  KALABIN. 

6.     On  the  Excision  of  the  Retrotarsal  Fold.     N.  A.  KAN. 
6.     A  few  Words  on  the  Question  of  Heredity  of  Tubercu- 
losis.    E.  E.  MILLER. 
1. — Will  be  abstracted  when  completed. 

2. — Krawkoft  has  made  an  exhaustive  Investigatoion  of 
the  physiological  effect  of  johimbin,  an  alkaloid  first  iso- 
lated by  Spiegel  from  the  bark  of  the  tree  jambehou  which 
grows  in  South  Africa.  An  infusion  of  the  bark  is  very 
popular  among  the  natives  as  an  aphrodisiac,  and  the  alka- 
loid has  been  claimed  to  possess  marked  aphrodisiac  prop- 
erties, almost  approaching  a  specific  action,  .-^mong  the 
observers  who  classed  this  new  drug  with  the  very  best 
and  safest  of  the  aphrodisiacs  were  Oberwarth.  Loewy 
and  Mendel.  The  experiments  performed  by  the  author 
show  that  on  frogs  johimbin  exerts  a  paralysing  effect. 
At  first  the  cerebrum,  then  the  respiratory  center  and  final- 
ly the  spinal  cord  are  affected.  The  heart's  action  stops 
owing  to  the  paralysis  of  the  cardiac  ganglia:  this  being 
followed  by  paralysis  of  the  cardiac  muscle.  The  general 
paralysis  is  preceded  by  a  brief  period  of  excitement.  On 
rabbits,  the  same  effects  are  produced.  After  a  brief  period 
of  stimulation  characterised  by  excitability  and  increased 
respiration  there  dovelopes  general  paralysis  of  the  central 
nervous  system.  The  temperature  is  markedly  lowered 
owing  to  the  paralysis  of  the  vasomotor  and  consequent 
increased  radiation.  The  pronounced  antipyretic  action 
of  johimbin  was  demonstrated  on  rabbits  as  well  as  birds, 
the  fall  of  temperature  amounting  to  1-2  degrees.  Owing 
to  the  vasomotor  paralysis,  the  penis  becomes  greatly 
overfilled  with  blood.  This  engorgement  of  the  blood 
vessels  may  lead  to  occasional  erections,  but  the  latter 
are  not  brought  about  by  a  stimulation  of  the  sexual 
centers.  In  dogs  the  same  effects  were  observed.  Six 
physicians  having  offered  themselves  for  experiment,  the 
drug  was  also  tried  on  them.  Some  of  them  suffered  from 
partial  impotence  as  a  result  of  neurasthenia.  In  one  10 
drops  of  johimbin  taken  on  an  empty  stomach  produced 
dizziness,    disturbance    of    locomotion,    nausea,    sweating. 


sensation  of  heat,  engorgement  of  the  conjunctiva  and 
migratory  pains.  A  general  mental  depression,  inability  to 
concentrate  the  mind,  aversion  to  work  and  weakness 
added  to  the  disagreeable  effects  of  the  alkaloid.  There 
was  not  the  least  indication  of  any  specific  affect  on  the 
sexual  centers.  In  the  second  case  10  drops  after  a  light 
breakfast  produced  heaviness  in  the  head,  irritability, 
nausea,  salivation,  fainting  sensations,  a  feeling  of  heat 
in  the  abdomen,  engorgement  of  the  conjunctiva  and  slight 
flow  of  tears.  Such  a  wretched  state  of  the  mind  was 
produced  that  the  doctor  did  not  care  to  continue  the  ex- 
periment. No  effect  on  the  sexual  center  was  observed  in 
this  case;  on  the  contrary,  the  last  sparks  of  sexual  desires 
were  completely  extinguished.  Similar  effects  were  ob- 
served in  the  third  case,  while  in  the  rest  the  manifesta- 
tions were  much  milder.  In  neither  was  any  aphrodisiac 
action  noticed.  On  the  ground  of  his  experiments  on 
animals  and  observations  on  man  the  author  comes  to  the 
conclusion  that  johimbin  possesses  no  aphrodisiac  proper- 
ties whatever,  and,  moreover,  it  is  not  an  altogether  harm- 
less drug.     [A.  R.] 

3. — Krimoff  reports  a  case  of  invagination  in  a  soldier 
24  years  old.  The  diagnosis  was  established  only  7  days 
after  the  onset,  and  an  operation  performed  about  5  weeks 
later.  In  the  meantime  the  patient  suffered  from  repeated 
attacks  of  severe  abdominal  pains  and  obstipation  which 
could  be  relieved  with  difficulty  by  calomel  and  high  ene- 
mas. The  suffering  becoming  unbearible,  the  patient 
agreed  to  an  operation.  A  laparotomy  disclosed  an  in- 
vagination of  the  cecum  and  ascending  colon  into  the 
transverse  colon,  bringing  the  end  of  the  illeum  close  to 
the  latter.  Owing  to  the  numerous  adhesions  formed,  the 
removal  of  the  invaginated  gut  could  not  be  accomplished 
and  intestinal  anastomosis  between  the  illeum  and  the 
descending  colon  was  performed.  Convalescence  was  com- 
plicated by  bronchitis  and  suppuration,  but  the  patient 
finally  made  a  complete  recovery.  Indican  was  present 
in  the  urine  in  excess  before  the  operation,  disappearing 
entirely  after  it     [A.  R.] 

4. — Kalabin  reports  a  case  of  a  primipara,  36  years  old, 
in  whom  pregnancy  was  complicated  by  two  uterine 
fibroids.  Gestation  was  frequently  interrupted  by  threat- 
ened abortion  which  was  prevented  by  the  use  of  rest, 
opium,  viburnum  prunifolium,  hot  compresses  and  bro- 
mides. The  woman  was  finally  delivered  of  a  healthy  child, 
the  labor  having  lasted  for  34  hours.  When  examined  a 
year  later,  the  uterus  was  found  somewhat  enlarged,  one  of 
the  fibroids  much  smaller  in  size,  while  the  other  disap- 
peared entirely.     [A.  R.] 

5. — Kan  points  out  the  excision  of  the  retrotarsal  fold 
as  thei  best  method  of  treating  trachoma.  The  operation 
has  always  proved  successful  in  his  hands  and  can  be 
performed  without  difficulty.  Some  points  in  the  technic 
of  the  operation  are  discussed.     [A.  R.] 

6. — Miller  asks  whether  the  facts  in  every-day  life  sul>- 
stantiate  the  universal  claim  that  tuberculous  parents 
transmit  a  predisposition  to  the  disease.  He  answers 
this  question  by  presenting  in  a  tabulated  form  data  ob- 
tained from  71  cases  of  tuberculosis.  The  table  shows 
that  in  only  11  was  there  tuberculosis  in  one  or  both 
parents.  In  the  other  60  the  disease  was  evidently  ac- 
quired. All  these  cases  occurred  in  well  to  do  families, 
and  there  can.  therefore,  be  no  suspicion  of  even  an  ac- 
quired predisposition.  In  other  words,  these  were  cases 
of  primary  infection.  Admitting  that  tuberculous  parents 
may  transmit  to  their  offsprings  a  special  vulnerabilitv  of 
the  cells,  there  is  no  reason  to  apply  this  transmission 
specifically  to  tuberculosis.  Such  persons  are  susceptible 
to  any  other  infectious  disease.  Again,  tuberculosis  is 
more  apt  to  run  in  families  not  so  much  on  account  of  the 
so-called  heredity  but  owing  to  the  direct  or  indirect  ex- 
posure to  infection  which  the  various  members  of  the 
family  suffer.  The  author  makes  a  plea  for  restrictive 
measures  on  the  part  of  the  individual,  society  and  the 
state.  He  emphasizes  especially  the  necessity  of  cleanli- 
ness, as  a  preventive  measure.     [A.  R.] 


Mat 


IdOl] 


CHRONIC  ULCER  OF  THE  STOMACH 


CThe  Philadelphia 
Medical   Journal 


1005 


©licjinal  articles. 


THE  SURGICAL  TREATMENT  OF  CHRONIC  ULCER  OF 
THE  STOMACH. 

By  A.  W.  MAYO  ROBSON,  F.  R.  C.  S., 

of  Leeds,   England. 

Senior  Surgeon  to   the  General   Inlirmary  at   Leeds;     Emeritus 

Professor  of  Surgery  in  the   Yorkshire  College 

of  the  Victoria   University. 

Mr.  President: — 

I  must  first  thank  you,  sir,  most  sincerely  for  the 
kind  invitation  which  you,  personally,  and  the  Coun- 
cil of  the  American  Surgical  Association  have  ex- 
tended to  me  in  asking-  me  to  take  part  in  your  pro- 
ceedings, an  honor  which  I  very  highly  appreciate. 
The  subject  of  the  "Surgical  Treatment  of  Ulcer  of 
the  Stomach"  is  one  that  has  for  some  time,  and  is 
now,  attracting  the  attention  of  surgeons  all  over 
the  world,  so  that  I  hope  I  shall  need  to  inake  no 
apology  for  ventilating  my  views  on  its  treatment 
before  this  important  Surgical  Association. 

The  treatment  of  gastric  ulcer  is  at  first  essen- 
tially medical,  and  when  properly  carried  out  and 
for  a  suiticient  length  of  time  it  is  usually  completely 
successful.  Leube  says  that  one-half  or  three- 
fourths  of  all  cases  will  be  cured  by  4  or  5  weeks  of 
treatment,  but  that  if  not  cured  in  that  time  they 
will  not  be  cured  by  medical  treatment  alone,  a 
view  in  which  I  thoroughly  concur.  Unfortunately, 
however,  in  many  cases,  treatment  is  stopped  as 
soon  as  relief  to  pain  is  obtained  and  long  before  the 
ulcer  is  healed.  In  some  cases  this  may  be  due  to 
the  uncertaint)^  of  diagnosis  or  from  the  impatience 
of  the  patient ;  perhaps  in  others,  to  ignorance  as  to 
how  long  it  takes  to  secure  the  healing  of  a  gastric 
ulcer.  The  earlier  in  the  course  of  the  disease,  that 
radical  treatment,  in  the  shape  of  dieting  and  rest, 
is  adopted,  the  less  prolonged  will  the  treatment 
need  to  be  and  the  more  likely  is  it  to  be  effectvial : 
but  probably  the  very  earliest  time  that  a  patient 
should  be  allowed  to  be  out  of  bed  is  from  a  fort- 
night to  a  month  after  all  pain  and  tenderness  have 
disappeared. 

Failing  this  thorough  treatment,  relapses  will  be 
certain  to  occur,  and  in  the  long  run  complications 
will  supervene  or  the  ulcer  will  become  chronic, 
when,  though  medical  treatment  may  relieve  in 
some  cases,  cure  can  only  be  looked  for,  in  the 
greater  number,  by  surgical  inethods. 

In  considering  the  treatment  of  ulcer  of  the  stom- 
ach, it  is  useful  to  hold  in  view  the  course  of  an 
ulcer  of  the  leg,  which,  directly  the  healing  stage  has 
arrived,  becomes  free  from  pain  ;  but  this  neither  in- 
dicates that  healing  is  completed  nor  that  care  may 
cease,  and  should  treatment  be  abandoned  and  the 
ulcer  become  chronic,  though  it  may  even  then  be 
painless,  it  is  at  any  time  liable  to  become  inflamed 
or  to  extend  :  moreover,  the  surrounding  tissues  be- 
come infiltrated  with  lymph  which  tends  to  organ- 
ize, and  this  in  a  hollow  viscus  soon  ends  in  strict- 
ure, as  in  the  leg  it  tends  to  drag  on  the  surround- 
ing skin  and  produce  constriction  of  the  limb. 

The  surgical  treatment  of  intractable  or  relapsing 
gastric  ulcer  is  in  the  greater  number  of  cases  the 
only  satisfactory  method  of  dealing  with  these  re- 

•Read  before  the  American  Surgical  Associatioo.  at  Ballimore.  May,  1901. 


fractory  cases,  and  operation  should  be  resorted  to 
at  a  much  earlier  period  than  has  hitherto  been  the 
custom  ;  and  always  before  the  patient  is  so  far  re- 
duced by  pain  and  starvation  or  the  supervention 
of  serious  complications  that  weakness  and  anemia 
render  any  operative  procedure  hazardous. 

Ulcer  of  the  stomach  is  a  much  more  serious  mat- 
ter than  is  generally  recognized,  for,  according  to 
various  authors  it  has  a  mortality,  when  treated  by 
general  ami  medical  means  only,  of  from  20  to  50 
per  cent. 

Dr.  Einhorn,  in  his  well  known  work  on  Diseases 
of  the  Stomach  (p.  223),  says:  "At  first  glance  it 
would  appear  that  the  prognosis  of  gastric  ulcer  is 
cjuite  good,  especially  nowadays,  when  the  diagno- 
sis of  the  affection  is  usually  made  at  an  early  date. 
However,  if  we  take  into  consideration  the  tabu- 
lated statistics  given  by  Debove  and  R^mond  (p. 
276),  in  reference  to  the  outcome  of  all  cases  of  ul- 
cer, we  become  more  careful  in  our  favorable  pre- 
dictions. This  table  gives  in  a  hundred  cases  of 
ulcer : 

Perfect   cure 50 

Perforations  and  peritonitis 13 

Foudroyant   hematemesis 5 

Pulmonary  tuberculosis 20 

Inanition 5 

Dififerent  complications 7 

The  excuses  of  a  few  years  ago  that  there  is  a 
great  responsibility  in  recommending  surgical 
treatment  either  froin  the  uncertainties  of  diagnosis 
or  from  the  risk  of  operation,  can  no  longer  avail, 
since  the  diagnosis  of  gastric  ulcer,  thanks  to  the 
researches  of  Ewald,  Hemmeter,  Einhorn  and  oth- 
ers, has  been  brought  to  a  greater  state  of  perfec- 
tion than  exists  in  many  other  obscure  diseases, 
where  radical  treatment  has  to  be  adopted  on  much 
more  slender  foundations ;  and,  fortunately,  now 
that  the  mortality  in  operations  for  simple  diseases 
of  the  stomach,  including  perforation  and  hemor- 
rhage, has  been  reduced  in  the  hands  of  experienced 
surgeons  to  about  5  per  cent,  the  great  risks  of  sur- 
gical treatment  cannot  be  advanced  even  by  its  most 
ardent  opponents. 

We  have  to  consider,  not  only  the  treatment  of 
gastric  ulcer  itself,  but  also  that  of  all  its  compli- 
cations, which  are  no  less  numerous  than  serious,, 
and  before  describing  each  separately,  it  may  be 
well  to  name  them  collectively.  They  are  as  fol- 
lows : 

1.  Local  peritonitis  or  perigastritis,  ending  in  ad- 

hesions. 

2.  Local  peritonitis  ending  in  suppuration  and  a 

localized  absctss. 

3.  Subphrenic  abscess. 

4.  Abscess  of  liver,  pancreas,  or  spleen. 

5.  Fistula  between  the  stomach  or  pylorus  and 

adjoining  organs,  or  with  the  surface  of  the 
body. 

6.  Acute  perforation  of  the  stomach  wall. 

7.  General  peritonitis. 

8.  Hematemesis  and  melena. 

9.  Dilatation  of  the  stomach. 

10.  Tumor  of  the  stomach  or  pylorus. 

11.  Cicatricial  stenosis  of  the  pylorus. 

12.  Hour-glass  stomach. 

13.  Spasm  of  the  pylorus  producing  intermittent 

narrowing  (Reichmann's  Disease). 


T<~ir>^       The  Philadelphia"! 
•'■'-''-'"       Medical   Jolrxal  J 


CHRONIC  ULCER  OF  THE  STOMACH. 


[Mat  25.  ISOl 


14.  Atonic  motor  deficiency. 

15.  Severe   gastralgia. 

16.  Persistent  vomiting. 

17.  Tetany. 

18.  Acute  or  chronic  pancreatitis. 

19.  Profound    anemia    resembling    the    pernicious 

form. 

20.  Pressure  on  or  stricture  of  the  bile  ducts  with 

jaundice. 

21.  Catarrh  of  the    gall-bladder    from    adhesions 

producing  attacks  like  those  of  cholelithiasis. 

22.  Great    loss  of    flesh  and    strength,  ending    in 

phthisis. 

23.  Cancer   secondary   to   ulcer.     "Ulcus   carcino- 

matosum." 

We  are  not  prepared  to  subscribe  fully  to  the 
views  of  Tricomi  {Riforma  Mcdica,  1899),  who  draws 
a  parallel  between  the  treatment  of  hernia  and  that 
of  ordinary  gastric  ulcer,  and  proposes  that  as  her- 
nia is  treated  radically  with  success,  so  gastric  ulcer 
should  be  treated  radically  by  the  performance  of 
gastro-enterostomy.  Heydenreich  {Scm.  Med.,  Feb. 
2nd,  1898)  argues:  "The  death  rate  from  all  cases  of 
gastric  ulcer  is  from  25  to  30  per  cent.,  but  from 
gastro-enterostomy,  only  16.2  per  cent. ;  therefore, 
the  operation  has  less  danger  than  the  disease." 

The  question  of  medical  versus  surgical  treat- 
ment in  this  class  of  cases  is,  however,  one  that  can 
be  much  simplified  by  a  careful  study  of  statistics. 

At  the  time  I  delivered  the  Hunterian  Lectures, 
in  March,  1900,  1  had  been  able  to  collect  from  va- 
rious sources  iSS  operations  on  the  stomach  for 
gastric  ulcer  (excluding  those  for  perforation  and 
hemorrhage),  of  which  157  recovered  and  31  died, 
thus  giving  a  mortality  of  16.4  per  cent.  These  in- 
cluded 34  personal  cases. 

Now,  although  the  deaths  from  gastric  ulcer  med- 
ically treated,  averaged  25  per  cent.,  taking  a  low 
estimate,  and  those  from  even  the  worst  and  most 
inveterate  cases  of  ulcer  when  treated  surgically, 
only  16  per  cent,  at  the  time  of  those  lectures,  yet, 
the  difference  did  not  then  appear  so  great  as  to 
make  it  desirable  or  prudent  very  strongly  to  advo- 
cate surgical  treatment  until  the  disease  had  be- 
come chronic,  or  until  serious  complications  had 
ensued. 

To-day,  however,  the  facts  are  very  materially 
altered  b}-  the  all-round  improvement  in  operations 
on  the  stomach,  and  the  contrast  of  25  per  cent,  of 
deaths  in  cases  treated  medically  and  5  per  cent,  as 
shown  in  our  latest  statistics  in  those  treated  surgi- 
cally, in  the  worst  and  most  complicated  cases,  is 
so  striking,  that  we  feel  it  incumbent  to  urge  most 
strongly,  that  although  cases  of  gastric  ulcer  should 
first  be  submitted  to  medical  treatment,  yet,  if  such 
treatment  fails  to  cure  in  a  reasonable  time,  or  if  re- 
lapses occur  on  the  resumption  of  solid  food,  then 
medical  should  give  place  to  surgical  treatment :  for 
it  is  unfair  to  the  surgeon  to  hand  over  to  him  al- 
most moribund  cases,  and  it  is  unjust  to  the  patients 
to  persist  in  dosing  them  with  medicine,  or  other- 
wise treating  palliatively,  cases  that  can  only  be 
benefited  or  cured  by  surgical  means. 

Operative  Treatment. — Before  the  abdomen  is 
opened,  it  is  quite  impossible  to  say  what  opera- 
tion or  operations  will  be  required,  and  the  surgeon 
must  be  prepared  to  adapt  himself  to  circum- 
stances on  discovering  the  position  of  the  ulcer  and 


the  conditions  associated  with  it,  especially  as  to 
the  presence  or  absence  of  adhesions  and  other  com- 
plications. 

Any  one  of  the  following  operations,  or  a  combi- 
nation of  one  or  more,  may  be  called  for  in  each 
individual  case :  Exploratory  Gastrotomy;  Gastro-enter- 
ostomy to  secure  physiological  rest  to  the  stomach 
and  relieve  the  hyperchlorhydria,  or,  in  other  cases, 
to  short  circuit  a  stenosis  ;  Excision  of  tlie  ulcer;  Pylo- 
rectomy;  Pyloroplasty;  Gastro-plasty;  Gastro-Gastros- 
iomy;  Gastrolysis;  Pylorodiosis;  Gastro plication. 

The  Preparation  of  the  Patiait. — It  has  been  the 
custom  with  many  surgeons  to  put  stomach  patients 
through  a  long  course  of  preliminary  treatment, 
such  as  frequent  lavage  of  the  stomach  and  absten- 
tion from  food  before  operation ;  this,  as  a  rule,  is 
quite  unnecessarA'  and  certainly  inadvisable  in  the 
greater  number  of  cases,  first,  because  the  treatment 
is  depressing  and  debilitating  in  the  case  of  pa- 
tients already  exhausted  by  a  long  illness ;  secondly, 
as  proved  by  Dr.  Harvey  Cushing's  bacteriological 
investigations,  the  stomach  contents  speedily  be- 
come aseptic  if  the  mouth  be  cleansed  and  aseptic 
foods  administered,  and  thirdly,  as  proved  by  ample 
clinical  experience,  elaborate  preliminary  treatment 
is  unnecessary  to  success. 

If  the  stomach  is  greatly  dilated  and  the  contents 
are  foul,  then  lavage  with  simple  boiled  water  night 
and  morning  is  adopted  for  two  days  before  opera- 
tion. The  careful  cleansing  of  the  mouth  and  teeth 
and  the  administration  of  foods  sterilized  by  boiling 
is  advisable.  The  last  meal  is  given  the  night  be- 
fore, about  12  hours,  the  stomach  is  washed  ov.c 
about  two  hours,  and  a  nutrient  enema  given  about 
an  hour  before  operation. 

In  other  cases  no  lavage  is  adopted,  but  the  same 
care  is  exercised  in  cleansing  the  mouth,  giving 
sterilized  food  and  administering  a  nutrient  enema 
consisting  of  i  oz.  of  brandy,  i  oz.  of  liquid  pepto- 
noids,  and  10  oz.  of  normal  saline  solution.  Ever>- 
patient  is  enveloped  in  a  suit  of  cotton  wool  made 
by  the  nurse  out  of  Gamgee  tissue,  and  each  has  an 
injection  of  10  minims  of  Liquid  strychnia  B.  P.,  ad- 
ministered subacutaneously  before  the  operation  is 
begun.  The  preparation  ot  the  skin  and  other  asep- 
tic details  of  the  operation  differ  in  no  respect  from 
those  observed  in  operations  generally. 

Exploratory  Gastrotomy,  or  opening  the  stomach  by 
a  free  incision  of  its  anterior  wall,  is  an  operation 
occasionally  called  for  in  the  surgical  treatment  of 
ulcers. 

(a)  In  order  to  verify  the  diagnosis  of  ulcer  when 
there  is  so  much  thickening  of  the  stomach  walls  as 
to  suggest  the  presence  of  cancer. 

'b)  \\'hen,  although  the  symptoms  have  pointed 
to  ulcer  as  the  cause  of  the  gastric  trouble,  the 
stomach,  on  exposure,  betrays  no  evidence  of  puck- 
ering or  other  characteristic  signs,  and  when  in  or- 
der to  verify  the  diagnosis  and  ascertain  what  is 
best  to  be  done,  it  is  felt  desirable  to  examine  the 
interior  of  the  organ. 

(c)  In  certain  cases  of  gastrorrhagia,  it  is  desira- 
ble to  perform  exploratory  gastrotomy  in  order  to 
find  and  ligature  the  bleeding  vessels  or  to  other- 
wise arrest  the  hemorrhage. 

(d)  It  necesarily  forms  part  of  any  operation  for 
the  excision  of  ulcer  of  the  stomach. 

It  is  not  neccsarv  for  me  here  to  enter  into  anv 


Mat  S,  1901] 


CHRONIC  ULCER  OF  THE  STOMACH. 


CThe  Philadelphia 
Medical  Journal 


1007 


detailed  description  of  the  operation,  which  must 
be  so  familiar  to  all  1113-  hearers,  and  which  requires 
to  be  varied  according  to  the  object  in  view.  The 
following  arc  examples  of  exploratory  gastrotomy 

for  ulcer: 

Man  aged  38.  Symptoms  of  chronic  ulcer  extending  over 
several  years;  on  exposure  of  stomach  no  evidence  on 
surface  to  indicate  accuracy  of  diagnosis:  exploratory 
gastrotomy;  discovery  of  large  ulcer  IV2  inches  by  3  inches 
on  posterior  wall  of  stomach:  posterior  gastro-enterostomy; 
recovery. 

Acute  gastrorrhagia:  no  evidence  on  exposing  stomach: 
exploratory  gastrotomy:  numerous  bleeding  ulcers  seen, 
two  of  which  were  bleeding  freely  and  were  ligatured 
'en  masse";  gastro-enterostomy:  recovery. 

Excision  of  the  Ulcer  is,  as  a  rule,  unnecessary,  but 
not  always  to  be  avoided,  as  in  some  cases  of  bleed- 
ing ulcer,  and  in  others  -where  the  thickening  and 
induration  render  it  difficult  to  decide  on  the  ab- 
sence of  malignant  disease ;  this  was  the  case  in  a 
man  of  54  on  whom  I  operated  in  1891,  when,  find- 
ing the  pylorus  the  seat  of  diffuse  induration,  excis- 
ion of  the  whole  indurated  area  was  performed  suc- 
cessfully. A  careful  examination  of  the  removed 
mass  showed  that  the  growth  was  inflammatory 
around  a  chronic  ulcer. 

In  another  middle-aged  man  in  whom  the  diffuse 
induration  was  suggestive  of  cancer,  the  pylorus 
was  opened  and  a  deep  ulcer  on  the  posterior  wall 
successfully  excised,  the  edges  of  the  original  in- 
cision as  well  as  the  margins  of  the  posterior  wound 
being  brought  together  in  a  direction  transverse  to 
the  a.xis  of  the  pylorus  over  a  bone  bobbin,  as  in 
the  modified  operation  of  gastro-enterostomy. 

Rydygier  prefers  excision  of  the  ulcer  to  gastro- 
enterostomy, because  he  believes  that  carcinoma  not 
infrequently  develops  in  the  scar  of  an  old  ulcer. 

It  is  impracticable  to  give  any  specific  description 
of  the  operation  of  e.xcision  of  an  ulcer,  seeing  that 
the  procedure  will  vary  according  to  its  size  and 
position. 

After  excision  of  an  ulcer,  the  bleeding  from  large 
vessels  must  be  controlled  by  ligature,  but  the  ooz- 
ing from  the  smaller  vessels  will  be  stopped  readily 
by  the  continuous  suture  employed  to  bring  to- 
gether the  edges  of  the  wound.  If  the  excision  in- 
volve the  serous  coat,  a  Lembert's  continuous  stitch 
with  a  silk  or  celluloid  suture  will  be  necessary. 
Should  the  excision  have  been  near  the  pylorus,  the 
line  of  suture  must  be  placed  transversely  to  the 
ax's  of  the  canal  so  as  to  avoid  stricture. 

The  following  cases  are  examples  of  gastric  ulcer 
treated  by  excision : 

Ulcer  of  Pylorus,  Stenosis.  Dilatation  of  Stomach,  Excis- 
ion of  Ulcer  and  Pyloroplasty. 

John  W.  R.,  aged  3S,  admitted  to  the  Leeds  Infirmary 
with  the  history  of  stomach  trouble  for  thirteen  years. 
Pain  after  food  and  vomiting  were  the  initial  symptoms. 
Severe  hematemesis  occurred  6  years  after  the  commence- 
ment of  symptoms.  Great  loss  of  flesh  and  weakness  were 
followed  by  inability  to  work,  although  he  had  stomach 
lavage  and  other  appropriate  treatment.  On  admission 
the  patient  was  very  thin  and  profoundly  weak.  He 
weighed  8  stones.  A  swelling  could  be  felt  below  the  right 
costal  margin.  The  stomach  reached  three  inches  below 
the  umbilicus  and  there  was  visible  peristalsis.  Free 
HCl  present.  Operation  November  15,  1900.  The  pylorus 
was  found  much  thickened,  forming  a  nodular  swelling  ad- 
herent to  the  gallbladder  and  liver  and  to  the  abdominal 
wall  by  omental  adhesions.  After  separating  the  adhe- 
sions a  small  perforation  was  discovered  in  front  of  the 
pylorus  evidently  the  site  of  a  perforation  which  his  medi- 
cal man  who  was  present  said  he  remembered  occurring 


some  months  previously  and  which  was  then  treated  suc- 
cessfully by  rest  and   rectal   feeding. 

The  pylorus  was  freely  laid  open  and  found  to  be  the 
site  of  a  round  perforating  ulcer  in  front  and  another  on 
the  posterior  wall:  the  latter  had  perforated  into  the  sub- 
stance of  the  pancreas:  both  were  excised  thus  practi- 
cally constituting  a  pylorectomy.  The  edges  of  the  posterior 
wound  were  brought  together  transversely  to  the  axis 
of  the  stomach.  The  anterior  wound  was  prolonged  into 
the  duodenum  and  stomach  and  its  edges  were  brought  to- 
gether transversely  to  the  axis  of  the  stomach  over  a 
bone  bobbin,  thus  leaving  a  capacious  channel  between 
the  stomach  and  duodenum  surrounded  by  healthy  mu- 
cous membrane. 

Recovery  was  uninterrupted  and  he  was  discharged  on 
December  12th,  weighing  8  stone,  5  pounds. 

On  January  9th,  1901,  he  returned  to  report  himself 
well  and  then  weighed  9  stone    11  pounds. 

Pyloric  Ulcer  Treated  by  Excision  of  Ulcer  and  Pyloro- 
plasty.— Mrs.  M.  K.,  aged  44.  well  till  two  years  ago,  when 
she  had  colic  and  loss  of  flesh.  Under  treatment  recov- 
ered and  regained  some  of  lost  weight.  September  15,  '97. 
recurrence  of  attacks  similar  to  that  of  a  year  before,  but 
with  pain  at  the  right  side  over  the  pylorus.  Loss  of  weight 
and  strength.  The  patient  had  for  some  time  been  an 
invalid  and  had  been  continuously  under  medical  treatment 
for  months.  Her  weight  was  fi  stone,  11  pounds.  There 
was  visible  peristalsis  towards  the  pylorus,  which  was 
fixed  to  the  gallbladder:  no  pain  or  tenderness.  Liver  2 
inches  below  costal  margin  but  no  nodular,  and  no  jaun- 
dice   present. 

Operation  23.7.98.  An  ulcer  at  the  pylorus  was  found 
adherent  to  the  liver,  which  formed  its  base.  Stenosis  of 
pylorus.  Pyloroplasty  performed  after  excision  of  ulcer, 
the  opening  being  sutured  transversely  over  a  bone  bob- 
bin. 

3. 12. 98.  Had  gained  1st,  8  pounds  in  weight.  No  trou- 
ble in  digesting  anything. 

23.12.99.    Reported  as  "very  well"  and  of  normal  weight. 

The  operation  of  Pylorectomy  for  ulceration  of  the 
pylorus  may  be  conveniently  mentioned  under  the 
heading  of  excision  of  ulcer.  Dr.  Rodman  (  Phila- 
delphia Medical  Journal,  June  9,  igoo)  has  collected 
from  literature  and  personal  correspondence,  de- 
tailed reports  of  40  pylorectomies,  partial  gastrecto- 
mies and  excisions  for  ulcer,  with  6  deaths.  This 
includes  cases  since  1881,  but  later  operations  under 
improved  technique  contrast  favorably  with  the 
earlier  ones.  I  have  myself  performed  the  opera- 
tion of  excision  of  gastric  ulcer  6  times,  all  the  pa- 
tients recovering. 

Nevertheless,  the  mortality  after  excision  will 
probably  always  be  higher  than  the  more  simple 
operation  of  gastro-enterostomy.  The  more  severe 
and  radical  operation  should,  therefore,  be  reserved 
for  cases  that  are  not  suitable  for  the  less  severe  op- 
eration, or  in  which  the  suspicion  of  cancerous  de- 
generation is  entertained  and  cannot  be  disproved 
on  naked  eye  inspection.  The  following  case  is  an 
example: 

Tumor  of  Pylorus  and  Chronic  Hematemesis  due 
to  ulcer.  In  1891  I  was  asked  by  a  medical  friend 
to  see  a  man  of  54,  who  for  6  months  had  suffered 
from  pain  coming  on  an  hour  after  food,  and  more 
recently  from  vomiting  blood  of  coffee-ground  char- 
acter in  considerable  quantities,  so  that  he  was  not 
onlv  reduced  in  flesh  and  strength,  but  had  also 
been  rendered  profoundly  anemic  by  the  loss  of 
blood. 

A  tumor  of  the  pylorus  could  be  easih'  felt,  and 
the  stomach  was  markedly  dilated. 

As  he  was  rapidly  losing  ground  an  operation  was 
performed,  and  the  .pylorus  was  found  thickened 
and  nodular,  with  adhesions  to  the  liver  and  omen- 
tum. 


TnnS       The  Philadelphia"! 
luuo       jiEDiCAL  Journal    J 


CHRONIC  ULCER  OF  THE  STOMACH 


[Mat  25,   1301 


After  separating  the  adhesions,  the  pylorus  was 
excised  and  the  open  end  of  the  duodenum  was 
fixed  to  the  opening  in  the  stomacli  by  means  of 
two  lines  of  sutures  without  the  use  of  a  bobbin, 
the  rest  of  the  stomach  aperture  being  closed  by  a 
double  layer  of  sutures.  The  tumor  proved  to  be 
inflammator}'  around  an  open  ulcer,  which  had  been 
the  source  of  the  hemorrhage.  The  bleeding  was 
not  repeated,  and  the  patient  rapidly  gained  flesh 
and  returned  home  within  the  month. 

The  subsequent  history  of  this  case  is  interesting 
on  account  of  cicatrical  contraction  of  the  new  py- 
loric aperture  which  led  to  the  invention  and  em- 
ployment of  a  decalcified  bone  bobbin  to  act  as  a 
temporary  splint  over  which  to  apply  the  sutures 
and  thus  to  secure  a  large  aperture  which  has  little 
tendency  to  contract. 

Gastro-ciifc7-osloiny,  in  the  absence  of  special  com- 
plications, is  the  operation  to  be  relied  on  in  the 
treatment  of  ulcer  of  the  stomach ;  it  acts  by  secur- 
ing physiological  rest  by  means  of  drainage,  thus 
allowing  the  ulcer  to  heal  without  being  subjected 
to  the  irritation  of  acid  secretion,  accumulation  of 
food,  or  frequent  stomach  movement.  It  also, 
while  remedying  the  hyperchlorhydria,  relieves  py- 
loric spasm,  and  while  preventing  stagnation  of 
fermenting  fluids,  materially  diminishes  gastric  dila- 
tation. The  posterior  operation  is  the  one  I  person- 
ally prefer,  the  junction  of  the  posterior  wall  of  the 
stomach  with  the  first  part  of  the  jejenum  being  ef- 
fected by  two  continuous  sutures  with  or  without 
a  decalcified  bone  bobbin.  The  use  of  a  bone  bob 
bin  not  only  secures  an  ample  and  immediately 
patent  opening  between  the  two  viscera  for  the  pas- 
sage of  the  stomach  contents,  but  protects  the  line 
of  union  from  the  irritation  of  the  stomach  contents. 

The  whole  operation  can  be  easily  completed  in 
half  an  hour,  and  it  may  even  be  done  in  half  the 
time.  Along  with  my  colleague,  iVlr.  Moynihan.  I 
have  given  my  full  experience  of  the  operation  and 
of  stomach  surgery  in  general  in  book  form,  now 
in  the  hands  of  the  publishers,  Messrs.  Bailli^re. 
Tindall  &  Cox. 

Our  experience  with  the  posterior  operation  has 
been  very  favorable,  not  only  in  the  rate  of  recov- 
ery of  the  patients,  but  in  the  smoothness  of  the  re- 
covery, many  of  the  patients  recovering  without 
even  once  vomiting,  and  only  on  two  occasions  have 
we  seen  regurgitant  vomiting  of  bile,  which  in  the 
anterior  operation  is  much  more  frequently  seen 
and  at  times  l)ccomes  seriotis  or  even  leads  to  a  fatal 
issue. 

We  have  performed  the  posterior  operation  on  40 
patients  with  two  deaths,  or  an  average  mortality 
of  5%,  but  as  the  deaths  were  from  more  or  less  ac- 
cidental causes  which  should  be  avoided  in  the  fu- 
ture, and  occurred  respectively  on  the  loih  and  iith 
days  after  operation,  during  the  whole  of  which  time 
the  patients  had  been  able  to  take  and  assimulate 
food,  the  gastro-enterostomy  "per  se"  cannot  l)e 
blamed  for  the  result,  which  might  under  similar 
circumstances  have  occurred  after  any  operation. 

Dr.  Fantino  (Archi7'.  fiicr  Kliiiischc  Cliirurgic. 
xlxi,  I  and  2)  examined  Professor  Carle's  cases  of 
gastro-enterostomy  as  regards  the  following  points : 

(i)  Changes  in  the  peristalsis  of  the  stomach. 

(2)  The  ability  or  non-ability  of  the  new  sphinc- 
ters to  close  the  outlet. 


(3)  The  capacity  of  the  stomach. 

(4)  The  secretion  of  hydrochloric  acid. 

In  the  cases  examined,  the  operation  immediately 
improved  the  paristaltic  power  of  the  stomach, 
though  it  did  not  render  it  normal.  The  stomach 
could  generally  empty  itself,  but  did  so  gradually. 
Systematic  examinations  of  the  stomach  contents 
were  made  tifter  test-meals,  etc.,  and  showed  that 
after  an  irregular  period  the  stomach  regained  com- 
pletely its  power  of  emptying  itself;  in  fact,  as  a 
rule,  after  gastro-enterostomy  the  stomach  would 
be  found  practically  empty  in  three  to  five  hours 
after  a  meal. 

Generally  it  was  found  that  the  stomach  de- 
creased in  size  soon  after  gastro-enterostomy,  so 
that  the  formerly  distended  organ  became  normal  in 
size.  Examinations  of  the  stomach  by  means  of 
distension  with  carbonic  acid  and  by  other  methods 
showed  that  a  sphincter  was  developed  at  the  new 
opening,  and  that  its  power  increased  with  time. 
The  secretion  of  hydrochloric  acid  after  operation 
was  studied :  In  cases  where  there  was  formerlv  hy- 
peracidity, this  condition  was  lost,  and  though  the 
degree  of  acidity  in  any  individual  case  varied  from 
time  to  time,  yet  these  variations  did  not  depart 
from  physiological  limits.  In  the  same  examina- 
tions it  was  found  that  regurgitation  of  bile  into  the 
stomach  took  place,  but  it  was  of  no  importance  so 
long  as  the  outlet  from  the  organ  was  sufficient. 
Cases  of  hypo-and  anacidity  showed  no  change  in 
their  gastric  juice  after  operation,  showing  clearly 
that  this  condition  is  not  dependent  on  obstruction, 
but  on  previous  changes  in  the  mucous  membranes, 
these  changes  being  probably  in  the  nature  of  an 
atrophy  of  the  peptogastric  glands. 

The  following  cases  are  given  as  examples  of  the 
.treatment  of  gastric  ulcer  by  gastro-enterostomy : 

CASE  1. — Mrs.  W.  aged  32,  pyloric  ulcer  treated  by 
pyloroplasty,  with  subsequent  contraction.  Gastro-enter- 
ostomy (anterior).  Pyloroplasty  during  active  ulcera- 
tion of  pylorus  in  December.  'S5.  Great  relief  for  a  time. 
but  later  recurrence  of  dilatation,  vomiting,  pain,  and  otUf  r 
symptoms.  Very  considerable  loss  of  flesh.  Patient  thin 
and  anemic:  pulse  feeble  and  rapid,  marked  dilatation,  the 
stomach  reaching  well  below  the  umbilicus. 

4.10.98.  Operation.  Gastro-enterostomy.  (bone  bobbin 
employed).  In  October.  lSt'9.  patient  well  and  active. 
February,  1900.  had  gained  1  stone.  10  pounds. 

CASE  2.— Mr.  M.  A.,  aged  28.  Pyloric  ulcer,  tumor  of 
pylorus,  gastro-enterostomy.  ( Anterior  1.  Two  years  ago 
woighed  12  stone.  12  pounds,  now  9  stone.  6  pounds.  Pain 
2  hours  after  food.  For  last  two  months  vomiting  on  an 
average  .S  times  a  week,  twice  coffee-ground  vomit  Enor- 
mous dilatation  of  stomaT;h.  Pyloric  tumor  movable,  visible 
peristalsis. 

4.8.99.  Operation.  Large  mass  at  pylorus  evidently  thick- 
ening due  to  active  ulceration,  glands  large  but  not  mat- 
ted.   Gastro-enterostomy.     (Bone  bobbin  used). 

27.8.99.  Good  recovery.     Weighs  9  stone.  "  pounds. 
20.9.99.     Weighs  10  stone,  13  pounds.     Can  eat  anythiu;?. 

Well.   1901. 

CASE  3. — Mr.  D.  B..  aged  31.  Extensive  ulceration  of 
stomach  with  large  tumor.  Gastro-enterostomy  (anter- 
ior). Dyspepsia  IT  years.  More  severe  last  20  months. 
li>  months  ago  vomiting  recurred  and  from  the  outset 
large  quantities  ejected  but  never  containing  blood.  Re- 
currence occasionally  of  similar  attacks  always  relieved 
by  treatment.  December,  1S97.  stomach  reached  pubes  and 
visible  peristalsis  seen.  Relief  followed  dieting  and  lavage 
till  March  1S9S.  since  which  time  pain  almost  constant. 
Pain  not  materially  worse  after  food,  nor  relieved  by  vomit- 
ing. I^oss  of  weight  from  10  stone  to  8  stone,  6M  pounds. 
Great  feebleness. 

6.5. 9S.  Operation.  Large  irregular  tumor  at  pylorus 
and  along  lesser  curvature,  but  glands  though  large,  dis- 


May   25.    1901] 


CHROXIC  ULCER  OF  THE  STOMACH 


CThe   Philadelphia 
Medical   Journal 


1009 


Crete.    Gastroenterostom.v,  bone  bobbin  employed.    8  stone 
in  weight  when  he  left  the  Home,  7.6.98. 

17.S.i)8.  weighs  !)  stone.  3  pounds.  Letter  dated  12.2.1900, 
to  say:  "My  health  continues  perfect.  I  have  not  lost  a 
(lay's  woi-k  through  illness  since  I  recovered." 

CASE  4. — Miss  H..  aged  32,  sent  to  me  with  a  history  of 
stomach  symptoms  extending  over  several  years.  She  had 
had  hcmatemesis  in  92  and  90,  since  which  time  she  had 
suffered  from  flatulency  and  pain  after  food.  For  two 
years  epigastric  pain  constant  but  increased  by  food.  A 
year  ago  vomited  daily,  then  relief  for  a  time,  but  for  some 
months  only  milk  could  be  retained.  Epigastric  tenderness 
was  well  marked  and  on  distending  the  stomach  with 
CO-  it  reached  half  an  inch  below  the  umbilicus  and  far 
over  to  the  right  of  the  middle  line. 

5.10.00.  Posterior  gastro-enterostomy  performed,  a  bone 
bobbin  being  employed. 

Recovery  uninterrupted.  Returned  home  w-ithin  the 
month,  taking  solid  food  without  any  discomfort  and  gain- 
ing flesh. 

On  November  8th  Dr.  A  wrote:  "I  have  seen  Miss  H. 
since  her  return  and  there  is  every  reason  to  be  pleased 
\\'ith  her  condition.  She  has  lost  all  her  pain  and  is 
taking  food  well.  Allow  me  to  thank  you  for  her  restora- 
tion to  comparative  health." 

Report  of  weight  February.  1901,  8  stone,  6  pounds,  at 
time  of  operation  6  stone.  12  pounds. 

CASE  5. — Mr.  H.,  aged  52,  began  to  suffer  in  1897,  from 
symptoms  of  ulcer  of  stomach  which  were  relieved  by  re- 
stricted diet  and  general  treatment,  but  in  July  1899  the 
symptoms  returned  with  great  loss  of  flesh  and  strength. 
Well  marked  dilatation  of  the  stomach  was  discovered  and 
operative  treatment  advised. 

Lavage  and  other  treatment  were  carried  out  in  London 
and  in  Scotland,  but  without  material  improvement. 

When  first  seen  by  me  there  was  visible  peristalsis  with 
well  marked  stomach  splash  and  a  tender  spot  under  the 
right  costal  margin.  Although  tall,  the  patient  only  weighed 
8  stone.  10  pounds,  and  he  was  extremely  weak  and  palid. 

11'. 10  00.  Operation.  Hour-glass  stomach  found,  but  the 
stricture  was  not  extreme.  Puckering  on  anterior  wall 
of  the  stomach  with  well  marked  thickening.  Free  HCl 
discovered  in  the  stomach  contents.  Posterior  gastro- 
enterostomy performed.     Good  recovery. 

March  4,  1901,  patient  wrote  from  Bournemouth,  say 
ing:  "I  am  pleased  to  be  able  to  tell  you  that  I  have  had 
no  return  of  my  former  complaint  and  that  I  eat,  drink 
and  sleep  well.    Have  got  back  to  my  former  weight. 

CASE  6. — History.  J.  S.,  aged  45,  residing  at  Batley, 
gave  the  history  of  two  years'  pain  about  an  hour  after 
food,  with  great  loss  of  flesh.  For  nine  months  he  had 
vomited  every  day  or  every  second  day,  a  large  quantity  of 
yeasty  material,  but  no  blood,  though  he  was  very  ane- 
mic. 

There  were  well-marked  signs  of  dilatation,  with  tender- 
ness over  the  pylorus.  Operation  12.6.00.  On  opening 
the  abdomen  the  pylorus  was  much  thickened  and  adher- 
ent, forming  a  tumor,  and  through  the  centre  of  the  mass 
a  No.  10  catheter  onlv  could  be  passed,  over  a  roughened, 
ulcerated  surface.  A  posterior  gastro-enterostomy  was 
perfoi-med. 

After  History. — An  uninterrupted  recovery  followed. 
Food  was  begun  the  second  day,  and  solids  could  be  taken 
in  the  second  week  without  pain.  He  rapidly  gained 
flesh  and  strength,  and  is  now  well.  The  following  case 
illustrates  the  value  of  gasti'o-enterostomy  in  acute  hem- 
atemesis. 

Chronic   Ulcers:    Kcmatemesis:    Gastro-enterostomy. 

Mr.  F..  a  farmer  residing  in  Essex,  was  sent  to  me  by 
Dr.  A.  J.  T.  White,  on  the  26th  of  March,  and  he  kindly 
furnished  the  following  history. 

"I  first  saw  Mr.  F.  ,".  years  ago.  He  had  then  occasional 
pain  in  the  epigastrium,  with  much  flatulence  and  at  times 
vomiting.  This  kept  on  at  intervals  more  or  less  for  three 
years.  IS  months  ago  Dr.  G.  saw  him  with  me.  At  that 
time  instead  of  his  former  weight  of  16  stones,  he  only 
turned  the  scale  at  12  stones.  He  then  improved  grad- 
lUillv  for  about  three  months  and  gained  about  a  stone 
in  weight.  Six  months  later  or  about  a  year  ago.  he.  while 
out  driving,  had  some  abdominal  pain  and  vomited  consid- 
erable Quantities  of  blood.  He  continued  being  sick  and 
suffering  for  some  time  with  slight  hematemesis  and 
molena,  but  again  improved.  About  3  or  4  months  ago. 
he  got  worse,  and  has  been  vomiting  and  suffering  con- 
siderable pain  on   and   off  ever  since.     I  have  very  little 


doubt  but  that  this  original  trouble  was  gastric  ulcer,  but 
my  fear  now  is  lest  malignant  ulceration  should  have 
supervened  and  some  time  ago  I  asked  him  to  see  you. 
He  could  not  go  then  as  he  had  various  business  matters 
to  set  right,  but  now  is  willing.  He  is  a  man  of  iron  will 
and  constitution  though  terribly  pulled  down."  On  Mr. 
K's  arrival  in  Leeds  he  went  direct  to  a  surgical  home, 
his  weight  then  being  10  stone.  He  was  then  suffering 
severe  pain  but  was  able  to  take  a  little  milk,  which  was 
in  fact  the  only  form  of  food  he  had  been  able  to  digest 
for  a  lon;j  time.  Within  a  few  hours  he  was  seized  with 
violent  heiuuteniesis  and  vomited  5  pints  of  clots  and  dark 
fluid  mixed  with  mucus.  Rectal  feeding  was  at  once 
adopted  and  an  ice-bag  applied  to  the  epigastrium.  The 
next  day  much  coffee-ground  material  was  vomited  and  on 
the  third  day  the  bleeding  ceased.  An  operaton,  which 
was  clearly  demanded,  was  arranged  for  March  22nd,  but  on 
the  night  of  the  21st  he  again  vomited  two  pewters  full 
of  pure  dark  blood  which  clotted  soon  after  being  vom- 
ited. The  stomach  was  quite  empty  of  food,  as  after  the 
night  of  his  admission  feeding  had  been  entirely  rectal. 
He  was  now  extremely  weak,  but  as  the  vomiting  and 
bleeding  were  continuing  Dr.  White  agreed  with  me  that 
it  would  be  better  not  to  postpone  operation,  for  he  was 
rapidly  losing  ground  and  clearly  could  not  stand  a  great- 
er loss.  An  hour  before  operation  he  vomited  blood  freely 
again.  On  the  morning  of  March  22d.  on  opening  the  ab- 
domen, the  lesser  curvature  of  the  stomach  was  found  to 
be  much  indurated,  forming  a  tumor.  There  was  also  much 
puckering  of  the  surface  of  the  stomach  and  the  glands  in 
the  greater  and  lesser  omentum  were  enlarged  but  discrete. 
A  posterior  gastro-enterostomy  was  performed,  a  bone  bob- 
bin being  used.  In  order  to  guard  against  shock  he  was 
enveloped  in  cotton  wool,  had  10  minims  of  liquid  strych- 
uiae  (B.  I'.),  given  subcutaneously  before  operation  and 
had  a  pint  of  saline  fluid  with  an  ounce  of  brandy  given  into 
the  bowel.  Immediately  after  operation,  which  was  finished 
within  the  half  hour.nearly  a  pint  of  saline  fluid  was  injected 
into  the  subcutaneous  tissues  of  the  axilla  and  another  pint 
together  with  an  ounce  of  brandy  administered  per  rec- 
tum. During  the  day  three  injections  of  5  minims  of  liquid 
strychniae  were  given  and  the  rectal  enemata  were  re- 
peated. 

Very  little  shock  was  felt  and  the  after  progress  was 
uninterrupted.  The  bowels  were  moved  on  the  third  day 
and  the  wound  was  dressed  and  found  healed  on  the  10th. 
No  more  blood  was  parted  with  and  stomach  feeding  was 
begun  four  days  after  operation.  By  the  end  of  the  week 
he  was  taking  as  much  as  5  pints  of  fluid  nourishment  in 
i"ne  24  hours.  He  said  he  had  never  had  any  pain  since 
the  operation  and  was  feeling  better  than  he  had 
done  for  a  long  time.  He  had  lost  all  the  acid  eructations, 
the  constant  burning  at  the  epigastrium  and  the  flatulency. 
He  returned  home  within  the  month  very  well  and  as  show- 
ing the  state  of  his  digestion  he  had  gained  4  pounds  in  the 
week  before  he  left  the  surgical  home. 

Pyloroplasty  as  a  curative  measure  in  this  class  of 
cases  has  certain  very  definite  limitations,  but 
where  it  is  feasible  it  is  a  method  of  great  utility 
which  can  be  performed  rapidly  and  with  very  little 
exposure  of  viscera.  P3ioroplasty,  if  the  pylorus  be 
stcnosed,  free  from  extensive  adhesions,  easily 
drawn  forward  and  not  actively  ulcerating,  is  a  sim- 
ple and  short  operation,  and  in  quite  a  number  of 
cases  of  both  gastric  and  pyloric  ulcer  I  have  found 
it  to  answer  well.  It  must  not  be  relied  on.  how- 
ever, where  active  tilceration  of  the  pylorus  itself  is 
found,  unless  at  the  same  time  the  ulcer  be  com- 
pletely excised;  otherwise  cicatricial  contraction 
will  follow.  It  acts  in  the  same  way  as  does  gastro- 
enterostomy, by  affording  a  free  exit  to  the  stom- 
ach contents  and  thus  securing  physiological  rest  to 
the  stomach. 

The  histories  to  be  related  exemplify. the  complete 
success  which  attended  the  operation  in  appropriate 
cases  and  also  the  disapi^ointment  which  followed  its 
employment  in  one  of  the  earlier  examples,  which, 
owing  to  experience,  was  not  properly  selected. 

Profs.  Carle  and  Fantino   (he.  cit.)   compare  the 


lOIO 


The  Philadelphia 
Medical   Journal 


]        CIIROXIC  L"LCER  OF  THE  STOMACH 


[May  25,  1901 


operation  of  gastro-enterostomy  and  pyloroplasty. 
Out  of  fourteen  cases  in  which  the  latter  operation 
was  performed  only  one  died. 

The  results  of  pyloroplasty,  as  regards  function, 
have  been  little  noticed  in  literature.  To  the  au- 
thor's fourteen  cases,  three  may  be  added  where 
the  operation  Avas  by  tearing,  btit  the  results  were 
the  same.  In  all  the  seventeen  cases  the  results 
were  excellent,  in  thirteen  of  them  perfect  and  per- 
manent, as  it  is  now  from  three  to  seven  years  since 
operation.  In  these  the  condition  of  the  secretions 
and  of  the  peristaltic  power  of  the  stomach  was  the 
same  as  after  gastro-enterostomy  for  non-malignant 
stenosis.  Diminution  in  size  of  the  stomach  was  not 
so  marked  as  would  be  expected  in  the  presence  of 
such  remarkable  recovery  of  the  general  health  and 
of  the  stomach's  power  to  empty  itself.  In  all  cases, 
with  one  exception,  the  gastric  capacity  was  more 
or  less  diminished,  but  in  no  case  did  it  become  nor- 
mal in  size. 

A  few  cases  must  be  excepted  where  operation 
was  performed  for  hyperacidity  with  gastric  atony. 
In  these,  four  or  five  months  after  operation,  there 
was  delayed  evacuation  of  the  stomach  and  a  feel- 
ing of  weight.  Although  the  general  improvement 
was  considerable,  yet  the  authors  were  persuaded 
that  a  posterior  gastro-enterostomy  would  have 
given  better  results.  In  one  of  the  cases  a  subse- 
quent gastro-enterostomy  gave  a  perfect  recovery. 

In  cases  in  which  therewashyperaciditybeforethc 
operation,  there  was  a  rapid  return  to  the  normal, 
but  not  to  bcloui  normal,  as  was  found  after  gastro- 
enterostomy. The  authors  believe  that  the  rapid  and 
great  diminution  in  hydrochloric  acid  after  the  lat- 
ter operation  is  due  to  the  very  rapid  evacuation  of 
the  stomach  after  a  meal,  and  do  not  deny  the  pos- 
sible influence  of  a  regurgitation  of  bile  into  the 
stomach.  Both  these  conditions  are  absent  after 
pyloroplasty,  hence  the  difference  in  secretion. 

In  cases  of  hypo-  and  anacidity,  operation  pro- 
dticed  no  change  in  this  particular,  and  yet  health 
was  restored.  The  results  of  pyloroplasty  may  be 
summarized : 

(i)  Regurgitation  of  bile  into  the  stomach  is  pre- 
vented. 

(2)  Secretion  of  hydrochloric  acid,  when  it  has 
been  excessive,  becomes  normal. 

(3)  If  the  secretion  of  hydrochloric  acid  has  been 
diminished  or  absent  before  operation,  it  remain,'; 
"in  statu  cjtio"  after  operation. 

(4)  If  there  has  been  primary  gastric  aton}',  peri- 
stalsis is  but  little  improved. 

(5)  This  function  improves  rapidly  or  reaches 
perfection  if  the  muscular  contractility  has  been 
normal  or  increased,  and  when  the  obstruction  was 
due  to  fibrous  stenosis  or  pyloric  spasm. 

(6)  In  all  such  cases  evacuation  of  the  stomach 
is  accomplished  in  its  physiological  period.  Only  in 
rare  cases,  and  these  only  in  the  first  months,  after 
operation,  may  it  be  delayed. 

(7)  The  capacity  of  the  stomach  always  de- 
creases, but  rarely  becomes  as  small  as  normal, 

(8)  The  pylorus  recovers  tone. 

Points  of  difference  between  the  results  of  pyloro- 
plasty and  gastro-enterostomy  are : 

(i)  The  absence  of  regurgitation  of  bile,  and 
hence  the  absence  of  any  possible  biliarv  influence 
on  the  gastric  secretions. 


(2)  The  evacuation  of  the  stomach  is  not  accel- 
erated, hence  the  difficulty  the  stomach  has  in  reach- 
ing its  normal  size. 

(3)  The  slight  or  negative  result  obtained  by  py- 
loroplasty in  obstruction  from  primary  gastric 
atony  compared  with  the  positive  results  from 
posterior  gastro-enterostomy. 

Pyloroplasty  is  too  dangerous  in  cases  where 
there  is  extensive  induration  of  the  tissues,  much 
peripyloritis  and  adhesions  to  liver,  gall-bladder, 
colon,  etc.,  and  in  cases  of  duodenal  stenosis.  It  is 
indicated  in  cases  of  spasmodic  stenosis,  and  in 
slight  annular  stenosis  from  ulceration  accompa- 
nied by  muscular  hypertrophy. 

Statistics.  In  the  Hunterian  Lectures  I  collected 
318  cases  of  pyloroplasty  from  all  sources,  of  which 
269  recovered,  which  equals  a  mortality  of  15.4%  ; 
this  included  I4cases  of  the  lecturers, of  which  12  re- 
covered a  mortality  of  14.2%.  As  in  the  earlier 
operations,  many  were  performed  on  cases  that 
would  be  now  treated  by  gastro-enterostomy,  the 
mortality  in  properly  selected  cases  should  not  ex- 
ceed 5%  at  the  outside  estimate,  and  of  the  12  cases 

1  have  operated  on  since  1897,  there  is  no  fatality  to 
record. 

CASE  1.-9.3.95.  Mrs.  W.,  aged  29.  "Spasms"  for  10 
years,  but  pain  more  on  left  side.  Attacks  two  or  three 
times  a  week,  start  without  apparent  reason,  last  an  hour 
or  two,  but  may  persist  24  hours,  relieved  by  vomiting. 
Severe  cramps  in  legs.  loss  of  2  stones  in  weight:  no  jaun- 
dice, marked  constipation.  Rigid  right  rectus,  no  rigidity 
but  tenderness  to  left.  Dilatation  of  stomach  well  marked, 
22.11.95.  Relief  under  treatment  followed  by  relapse,  now 
vomiting  daily.  Weight,  9Et.  Operation.  Adhesions  of  pylorus 
separated.  .Active  ulceration  at  pylorus  and  tight  stric- 
ture. Pyloroplasty  (Bone  Bobbin).  24.7.96.  Weight  9st. 
5  ))ounds.  very  much  better.  Relapse  in  '98.  possibly  from  re- 
currence of  ulceration.  I  then  performed  gastro-entei^ 
ostomy.  Quite  well  in  1900,  and  former  weight  fully  re- 
gained. 

CASE  2.— 13.1.97.  Mr.  M.  B.,  aged  52.  Ulcer  of  pylorus 
with  stricture.  Pyloroplasty.  Bad  health  for  20  years 
with  dyspepsia  worse  since  enteric  fever  9  years  ago.    Last 

2  years  much  worse,  pain,  sickness  and  vomiting  2  to  3 
hours  after  meals  relieved  by  vomiting  of  large  amounts. 
Never  vomited  blood.  Loss  of  flesh.  Weight  9st.  3  lbs. 
Emaciation,  dilatation  .of  stomach.  No  tumor.  Operation. 
Stricture  of  Pylorus.  Pyloroplasty  (Bone  bobbin  used). 
19. 9. 98.  Dr.  W.  writes:  "For  some  time  little  improve- 
ment, stomach  now  works  well.  Looks  better  than  I 
have  ever  seen  him."  Well  February.  1901.  Had  gained 
normal  weight. 

CASE  3. — Mrs.  W..  aged  46.  Stricture  with  active  ulcer- 
ation at  pylorus.  Pyloroplasty.  Gastralgia  for  several  years, 
relieved  by  food.  In  November,  1894,  vomited  dark  fluid, 
since  them  frequent  vomiting,  longest  interval  2  or  3 
weeks.  Pain  in  stomach  accompanied  by  hard  lump  and 
often  followed  by  vomiting.  Great  loss  of  flesh  and 
strength.  Operation.  Pyloroplasty  for  contraction  and  thick- 
enin.s;  of  pylorus,  passage  only  admitted  No.  2  catheter. 
Good  recovery.  Well  1SP9.  Considerable  gain  in 
weight. 

CASE  4.— 24.5.97.— Mr.  H..  aged  39.  Letter  dated  May 
13,  1S97,  to  say:  "Puring  the  last  IS  months  I  have  suf- 
fered much  pain,  which  has  caused  me  to  be  bedfast  for 
two,  three  or  four  weeks  at  a  time,  and  it  has  required 
another  month  or  more  for  m,?  to  gain  strength  enough  to 
move  about."  Eighteen  months  ago  epigastric  pain  sev- 
eral hours  after  food,  relieved  by  vomiting.  Since  then 
health  never  good.  3'A  months  ago  similar  attack,  very  se- 
vere with  collapse.  Vomit  contained  blood.  Fourteen  days 
ago  another  severe  attack  normal  weight  10  stones  10 
pounds,  now  9  stone  3^  pounds.  Stomach  "weak"  since 
oiMklhood.  Marked  dilatation.  No  tumor.  Operation.  Deep 
ulcer  at  pylorus.  Extreme  stricture  barely  admitting 
ordinary  viirector.  Pyloroplasty.  (Bone  bobbin  usedK 
ComV'lete  recovery  from  operation  and  rapidly  regained 
norma!  weight.     Letter  dated  16.2."9S  to  say:     "I  thought 


Mat   25,   1901] 


CHRONIC  ULCER  OF  THE  STOMACH 


Lm 


HE  Philadelphia 
Medical  .icup.nal 


lOII 


you  would  like  to  know  that  I  am  able  to  attend  business 
as  usual  and  have  done  so  without  interruption  since  July 
ISJlh,    1897." 

CASE  5. — 12.7.'J7.  Mrs.  W.,  aged  46.  Said  to  have  had 
ulcer  of  stomach  20  years  ago.  Since  then  subject  to  at- 
tacks ot  pain  1,2  to  2  hours  after  food,  sometimes  continuous 
pain.  For  3  or  4  months  vomiting  3  times  a  day,  lost  a 
stone  weight  in  that  time.  Leading  life  of  an  invalid 
and  tor  a  long  period  under  medical  treatment  without  ben- 
efit. Dilatation  of  stomach,  visible  peristalsis,  tendernes.4 
over  stomach,  especially  at  the  pylorus.  No  tumor 
could  be  felt.  Operation.  Stomach  much  dilated,  thickening 
at  pylorus.  Pyloroplasty.  (Bone  bobbin  used).  Good  re 
covery. 

8.1  9S.    Weighed  11  stone,  a  gain  of  over  two  stones. 

CASE  6. — 27.7.97.  Mr.  C,  aged  23.  Vomiting  and  loss, 
of  flesh  for  2  years.  Once  vvas  10  stone,  now  is  7  stone  in 
weight.  Dieting  and  lavage  give  only  temporary  relief 
Emaciation,  pallor,  dilatation  of  stomach.  No  tumor. 
Operation.  Much  contracted  pylorus,  great  hypertrophy,  the 
walls  more  than  one-third  of  an  inch  thick.  Pyloroplasty 
with  bone  bobbin.  Good  recovery.  23.12.97,  weight  9  stone 
13   pounds.     Well. 

CASE  7. — W.  F.,  aged  52,  had  suffered  from  indigestion 
for  two  years.  This,  however,  had  not  interfered  much 
with  bis  general  health  till  the  previous  Christmas,  when 
the  indigestion  was  accompanied  every  second  day  by 
acute  pain  and  vomiting,  coming  on  about  two  hours  after 
food.  The  vomited  matter  was  in  large  quantity,  oflensive 
and  sour,  and  at  times  cofceeground  in  character.  From 
this  time  the  patient  became  extremely  weak  and  pale, 
and  rapidly  lost  flesh  to  the  extent  of  1%  stone  in  five 
weeks.  He  had  pain  on  pressure  over  the  pylorus,  but  nn 
distinct  tumor  was  felt.  There  was  marked  dilatation  of 
the  stomach,  and  during  the  attacks  of  pain  it  could  be 
felt  to  harden  under  the  hand. 

On  April  Sth.  1S95,  the  abdomen  was  opened  by  an  in- 
cision in  the  middle  line  above  the  umbilicus,  exposing  the 
pylorus,  which  formed  a  distinct  tumour  adherent  to  and 
under  cover  of  the  liver,  and  which,  after  being  freed 
from  adhesions  to  surrounding  structures,  was  found  to  be 
tightly  strictured.  so  as  only  to  admit  the  passage  of  a  No. 
12  catheter:  the  mucous  membrane  being  extensively 
ulcerated,  and  the  walls  thick  and  almost  cartilaginous. 
The  stricture  was  incised  longitudinally  and  sutured  trans- 
versely over  a  bone  bobbin  by  a  double  row  of  sutures. 
The  stomach  was  much  dilated  and  atonic.  Though  the 
pyloric  timior  gave  rise  at  the  moment  to  a  suspicion  of 
cancer,  there  was  no  evidence  of  growth,  and  the  glands 
were  not  affected. 

October  30.  1896.  he  called  to  report  himself,  looking 
robust  and  well.  He  had  gained  3  stones  in  weight  since 
his    operation. 

Gasfro-plasty  is  an  operation  that  I  have  success- 
fully employed  in  a  number  of  case  of  chronic  ulcer 
leadingr  to  hour-s^lass  stomach.  It  consists  in  mak- 
ing a  longitudinal  incision  through  the  strictured 
part  of  the  stomach  and  bringing  the  edges  of  the 
wound  together  transversely,  thus  obliterating  the 
stricture. 

A  convenient  method  of  performing  the  opera- 
tion is  by  the  use  of  a  large  decalcified  bone  bob- 
bin, as  described  in  the  cases  appended.  If  the 
strictured  part  of  the  stomach  be  actively  ulcerating. 
the  ulcer  must  be  excised  at  the  same  time,  other- 
wise subsequent  contraction  may  occur  ;  or  possibl}- 
the  ulcer,  alreadv  chronic,  may  persist  and  lead  to 
a  continuance  of  the  symptoms ;  in  such  a  case, 
if  excision  be  impracticable,  gastro-enterostomy 
must  be  performed,  or  if  the  pylorus  be  free  from 
disease  the  operation  of  gastro-gastrosfomy  may  be 
done  in  order  to  short  circuit  the  constriction. 

I  have  operated  on  13  cases  of  hour-glass  stomach 
due  to  chronic  ulcer,  with  12  recoveries. 

The  following  are  good  examples : 

CASE  1, — M.  B.,  aged  29,  gave  a  four  years'  history  of 
ulceration  of  the  stomach,  with  vomiting  of  blood  on  one 


occasion,  and  the  presence  of  a  melena  several  times.  As 
the  pain  was  always  easier  when  the  patient  was  lying  on 
the  back,  an  ulcer  on  the  anterior  surface  of  the  stomach 
was   diagnosed. 

This  was  confirmed  at  the  operation,  as  the  anterior 
wall  of  the  stomach  was  so  puckered  that  the  cavity  was 
divided  into  two,  which  were  connected  by  a  narrow 
channel,  which  was  laid  open  by  a  free  longitudinal  in- 
cision, in  which  was  laid  a  large  bone  bobbin,  the  wound 
1/eing  then  brought  together  transversely  over  it,  thus 
leaving  a  channel  of  nearly  two  inches  between  the  two 
cavities. 

The  patient  went  home  within  the  month,  and  has  com- 
,  '.etely   recovered   her  health   and    strength. 

CASE  2. — Mr.  D.  H..  aged  44,  admitted  with  well-marked 
;'.  latation  of  the  stomach,  and  a  history  of  twenty  years' 
,,.  stric  trouble. 

rhe  constriction  in  this  case  was  two  and  a  half  inches 
r/-;m  the  pylorus,  the  cavity  between  the  stricture  and 
t).e  pylorus  being  very  much  smaller  than  the  proximal 
one.  The  treatment  was  by  gastroplasty  over  a  large  bone 
bobbin. 

Recoveiy  was  delayed  b^  an  attack  of  pleurisy,  hut  the 
patient  is  now  quite  well,  and  has  gained  rapidly  in 
V.  eight. 

CASE  3. — Double  hour-glass  contraction  of  stomach. 
Gastroplasty  and  Gastrolysis. 

Miss  M.  P..  aged  30.  There  had  been  attacks  of  pain 
and  vomiting  for  I.t  years.  The  pain  began  at  the  left  side 
Knd  passed  to  the  epigastrium  and  through  to  the  left 
subscapular  region.  There  had  been  severe  hematemesis 
10  years  before.  Occasionally,  both  before  and  since  the 
vomit  had  been  streaked  with  blood,  which  was  sometimes 
coiTeeground,'  but  it  had  contained  no  large  quantity 
of  blood  for  eight  years.  The  patient  vomited  large  quan- 
tities at  limes  and  had  lost  flesh  steadily  for  the  last  five 
years.  There  were  dilatation  of  the  stomach,  and  peris- 
talsis. No  tumor  could  be  felt  but  the  pylorus  was  fslt 
to  harden  from  time  to  time. 

Operation.  6, 6. '99,  at  a  surgical  home  in  Leeds.  Double 
hour-glass  contraction  discovered.  One-third  of  the  dis- 
tance from  t'ne  cardiac  extremity  adhesions  caused  a 
marked  diminution  cf  calibre,  and  two  inches  from  the 
pylorus  a  contraction  only  admitting  the  tip  of  the  little 
finger  was  found.  The  adhesions  were  divided  and  gastro- 
plasty was  performed,  the  wound  being  sutured  over  a 
large  bone  bobbin. 

After  history.  The  patient  made  an  uninterrupted 
recovery,  and  in  two  months  she  had  gained  2  stone  in 
weight. 

CASE  4. — Extreme  hour-glass  contraction.    Gastro-plasty. 

Miss  H.  D..  aged  48.  The  patient  had  had  con- 
stant indigestion  and  flatulence  for  20  years  with  a  feel- 
ing of  pulsation  and  tenderness  at  the  epigastrium. 
There  had  been  free  hematemsis  two  years  before  and 
vomiting  occasionally  since,  but  lately  the  patient  had 
ceased  to  take  much  solid  food.  She  had  noticed  slime 
and  blood  in  the  motions,  possibly  due  to  constipation, 
which  was  extreme.  There  had  been  great  loss  of  flesh. 
No  tumor  was  present,  but  there  was  tenderness  in  the 
epigastrium  and  a  well-marked  splash  on  succussion. 

Operation.  2S.7.'99.  Extreme  contraction  one-third  way 
from  pylorus,  just  admitted  tip  of  little  finger.  Gastro- 
plasty was  performed,  a  large  bone  bobbin  being 
used. 

After  history.  The  patient  made  a  good  recovery  from 
the  operation  and  the  digestion  was  relieved.  There  was 
an  increase  in  weight  of  about  a  stone  and  improvement 
in  the  general  health,  but  the  stomach  remained  dilated 
and  she  continued  anemic  and  v,'eak.  This  was  at 
first  thought  to  be  due  to  bleeding  from  piles,  but  after 
they  had  been  ligatured  the  weakness  still  continued,  and 
although  there  was  no  vomiting,  flatulency  and  discomfort 
after  meals  with  loss  of  appetite  led  to  a  suspicion  of  re- 
currence of  disease  in  the  stomach,  which  on  being  dis- 
tended with  CO-  reached  3  inches  below  the  umbilicus 
and  en  being  washed  out  after  a  test  meal,  showed  im- 
paired  motility. 

January  24.  1901.  The  abdomen  was  opened  again 
through  a  median  incision  above  the  umbilicus,  when 
marked  dilatation  of  the  stomach  was  seen  with  contrac- 
tion and  some  thickening  over  the  pylorus,  but  where  the 
hour-glass  contraction  had  been  operated  on  IS  months 
previously,  it  was  interesting  to  note  that  neither  scarring 
nor   contraction   were   seen,   and    it    would    have   been    ira- 


IOI2 


The  Philadelphia 
iiEDiCAL   Journal 


]         CHRONIC  ULCER  OF  THE  STOMACH 


[Mat  2S.  1361 


possible  to  tell  by  the  naked  eye  appearances  that  anything 
had  been  done. 

A  posterior  gastroenterostomy  was  performed,  a  bone 
bobbin  being  employed.  Recovery  was  uninterrupted,  and 
before  the  patient  left  the  home  at  the  end  of  the  month 
she  was  taking  ordinary  food  with  relish  and  without  any 
discomfort.  She  had  then  gained  several  pounds  in 
weight. 

Adhesions  of  the  stomach  to  adjoining  organs  are 
so  common  in  chronic  stomach  ulceration  that 
gasfrolysis,  or  tlie  detaching  or  otherwise  treating 
bands  and  sliort  adhesions  to  adjoining  viscera  or 
to  the  abdominal  wall,  is  performed  in  by  far  the 
greater  number  of  cases.  Such  adhesions  are  fre- 
quently only  the  remnants  of  ulcers  that  have 
healed ;  at  other  times  they  have  been  left  by  per- 
foration of  the  stomach  wall  by  an  ulcer,  from  the 
direful  consequences  of  which  they  have  saved  the 
patient.  In  many  cases  they  give  rise  to  symptoms 
resembling  ulcer,  though  th'e  adhesions  may  be  due 
to  causes,  such  as  gall-stones,  outside  the  stomach 
itself;  in  such  cases  the  operation  of  gastrolysis  may 
be  entirely  curative.  I  iiave  performed  gastrolysis 
in  56  cases,  all  of  which  have  recovered. 

The  following  case  is  given  as  an  example : 

Gastrolysis  for  adhesions  caused  by  chronic  gastric 
ulcer. 

Miss  M.  B.,  aged  42.  Twenty-two  years  ago  had  symp- 
toms of  ulcer  in  the  stomach,  since  then  has  suffered  from 
vomiting  attacks  every  week  or  two,  and  from  pain  after 
food.  During  the  last  3  years  symptoms  were  more 
marked.  Under  medical  treatment,  with  rest  in  bed.  no 
improvement.  Vomit  large  in  quantity  and  fermenting, 
sometimes  containing  blood.  Loss  of  weight  to  the  ex- 
tent of  three  stones.  Great  tenderness  over  stomach,  es- 
pecially to  the  left.  Stomach  dilated,  reaching  below 
umbilicus  and  well  over  to  the  right. 

Operation.  On  anterior  surface  of  stomach  scar  of  an 
old  ulcer  is  visible.  Lesser  curvature  of  stomach  closely 
adherent  to  the  liver.  Pyloric  extremity  and  first  part  of 
duodenum  attached  to  gall-bladder  and  cystic  duct  Ad- 
hesions separated  and  omentum  interposed  between  py- 
lorus and  gall-bladder. 

After-history.  Perfect  recovery.  March  7,  1900,  can 
eat  anything  without  discomfort  and  is  rapidly  putting  on 
flesh.  Has  gained  20  pounds  since  her  operation.  March, 
.1901,  quite  well:  had  gained  over  two  stones  in  weight. 
Many  other  examples  of  gastrolysis  might  be  given  where 
the  benefits  derived  from  operation  have  been  quite  as 
great. 

Pylorodiosis,  by  which  name  is  understood  the 
operation  of  stretching  the  pyloric  sphincter,  either 
by  means  of  the  fingers  invaginating  the  stomach 
wall,  when  it  is  known  as  "Halm's  operation."  or  by 
digital  or  instrumental  stretching  after  having  made 
an  opening  into  the  stomach,  when  it  is  known  as 
"Loreta's  operation,"  is  a  method  of  little  practical 
value  in  the  treatment  of  ulcer,  and  in  some  of  the 
eases  where  I  performed  the  operation,  though  the 
immediate  results  were  good,  relapses  subsequently 
occtirred.  If  performed  by  invagination  without 
opening  the  stomach  cavity,  it  is  an  operation  un- 
attended by  risk.  It  may  possibly  be  of  service  in 
simple  spasm  of  the  pylorus,  but  I  have  not  much 
faith  in  its  eflfects  being  lasting. 

Did  the  time  permit  of  it,  it  would  be  easy  to 
givefrom  my  own  experience  cxamplesof  operations 
for  all  the  complications  of  gastric  ulcer  that  I  have 
mentioned,  and  as  many  of  the  cases  are  of  great 
individual  interest,  I  think  they  would  have  proved 
interesting  to  my  audience,  but  it  is  quite  impossible 
to  do  more  than  refer  to  them  unless  I  am  to  occupy 


the  whole  of  the  afternoon,  and  this  I  have  neither 
the  desire  nor  the  intention  of  doing. 

I  will,  however,  mention  the  results  of  my  expe- 
rience in  operations  for  simple  diseases  of  the  stom- 
ach out  of  over  200  operations  that  I  have  per- 
formed. 

In  56  cases  I  have  performed  gastrolysis  for 
the  separation  of  adhesions  which  were  producing 
disabling  conditions,  all  the  patients  recovering.  In 
13  cases  I  have  operated  for  hour-glass  stomach  due 
to  ulcer,  12  of  the  patients  recovering  and  being 
now  well. 

In  6  cases  I  have  operated  for  hematemesis,  with 
five  recoveries ;  in  4  cases  for  fistula,  due  to  chronic 
ulcer,    all    the    patients    recovering. 

Of  the  18  cases  in  which  I  have  performed  pyloro- 
plasty, 16  have  recovered,  the  two  deaths  being  in 
the  earlier  cases,  one  being  due  to  perforation  in 
the  second  week  after  operation. 

Of  the  posterior  gastro-enterostomies,  previously 
referred  to  for  simple  diseases  of  the  stomach,  in  40 
cases  there  were  two  deaths,  both  due  to  accidental 
causes,  one  being  pneumonia  in  a  phthisical  patient. 

Of  the  anterior  gastro-enterostomies,  including 
cases  operated  on  lo  \'ears  ago,  in  19  cases  there 
were  4  deaths,  one  from  an  accident  at  the  time  of 
separation  of  a  Murphy's  button,  one  from  shock 
in  a  patient  very  exhausted  at  the  time  of  op- 
eration (Senn's  plates  being  used),  one  from  perfo- 
ration of  an  ulcer  on  the  12th  day,  when  apparently 
convalescent,  and  one  from  peritonitis  extending 
from  the  abdominal  wound. 

Of  the  2  gastroplications,  both  recovered. 

Of  the  three  cases  of  pylorodiosis,  all  recovered. 

In  8  operations  for  perforating  gastric  ulcer  there 
were  two  deaths  directly  following  on  operation  in 
cases  treated  when  peritonitis  was  general. 

Of  the  6  cases  in  which  I  directly  excised  a  gas- 
tric ulcer  or  ulcers  after  opening  the  stomach  by 
gastrotomy,   all   recovered. 

Of  one  case  of  gastrotomy  for  the  removal  of 
foreign  bodies  and  one  for  perforating  wound  of  ab- 
domen with  hematemesis.  both  patients  recovered. 

It  will  be  seen  that  out  of  177  operations  for  sim- 
ple diseases  of  the  stomach,  including  perforation 
and  hemorrhage,  165  patients  recovered,  or  93.2 
per  cent. 

Description  of  the  method  of  employing  the  de- 
calcified bone  button. — In  the  course  of  my  paper 
reference  has  been  made  to  a  method  I  have  been 
systematically  pursuing  since  1S91,  not  only  in 
stomach  operations,  but  in  nearly  all  the  operations 
which  involved  the  making  of  an  anastomotic  open- 
ing between  the  hollow  viscera.  I  mean  the  method 
of  suture  over  a  decalcified  bone  bobbin. 

I  have  adopted  it  in  a  very  large  number  of  cases 
and  in  a  great  variety  of  operations,  and  as  a  result 
of  this  extensive  experience  I  am  more  than  ever 
convinced  that  it  is  a  reliable  procedure  which  I  can 
thoroughly  recommend  to  others.  It  is  more  easily 
demonstrated  than  described,  and  at  the  end  of  this 
discussion  or  at  such  other  time  as  you,  sir,  may 
think  it  desirable,  I  shall  be  pleased  to  show  the 
method  either  on  the  cadaver  or  on  a  model..  It  is 
really  very  simple,  and  only  involves  two  continu- 
ous sutures,  one  of  chromicised  catsrut  to  unite  the 


Mat   25. 


19011 


TREATMENT  OF  INOPERABLE  SARCOMA 


TThe  Philadelphia 
L  Medical   Journal 


IOI3 


mucous  margins  of  the  two  openings  and  one  of 
celluloid  thread  to  unite  the  serous  surfaces  about 
a  quarter  of  an  inch  away  from  the  new  opening. 
Pagenstecker's  thread  or  spun  celluloid  has  replaced 
silk  in  my  practice,  it  being  stronger,  easily  steril- 
ized by  boiling,  and  less  absorbent. 

The  bobbin,  which  is  made  for  me  by  Messrs. 
Down  Bros.,  of  London,  in  various  sizes,  from  the 
small  one  required  for  cholocystenterostomy  or  for 
the  union  of  the  small  viscera  of  children,  to  the 
large  one  employed  for  gastroplasty  or  for  the  end 
to  end  union  of  large  intestine  in  the  adult,  is  noth- 
ing more  than  a  cylinder  of  decalcified  bone  with 
raised  ends,  which  is  placed  in  the  new  anastomotic 
opening,  around  which  the  sutures  are  applied. 

The  advantages  claimed  for  the  method  are : 

1.  That  it  secures  the  opening,  being  of  the  ex- 
act size  intended,  and  that  there  is  no  possibility 
of  the  passage  being  made  too  small  by  the  drawing 
up  of  the  sutures  before  the  knots  are  tightened. 

2.  That  it  secures  an  immediately  patent  chan- 
nel between  the  two  anastomosed  viscera. 

3.  That  the  bobbin  protects  for  from  24  to  48 
hours  the  new  line  of  union  from  pressure  and  from 
the  irritation  of  the  visceral  contents. 

4.  That  it  facilitates  the  application  of  the  su- 
tures and  so  adds  to  the  expedition  of  union  by  su- 
tures. 

5.  That  no  foreign  material  is  left  in  the  alimen- 
tary canal,  which  may  irritate  or  cause  subsequent 
trouble,  for  the  bobbin  rapidly  dissolves  in  the  ali- 
mentary juices. 

6.  That  the  method  has  now  been  proved  by 
ample  experience  to  be  rapid,  easy,  efficient  and 
safe. 

For  stomach  operations  it  is  used  in  gastro-en- 
terostomy,  in  pyloroplasty,  in  gastroplasty,  and  in 
pylorectomy  or  partial  gastrectomy,  and  in  the  lat- 
ter operation  it  is  unnecessary  to  use  more  than  two 
continuous  sutures  for  the  whole  operation. 

In  adopting  the  method,  it  is  convenient  to  begin 
with  the  serous  suture,  which  is  applied  around 
the  posterior  half  of  the  circle.  The  needle  still 
threaded  is  then  laid  aside  till  the  final  stage;  the 
openings  into  the  viscera  are  then  made,  and  any 
redundant  mucous  membrane  cut  away ;  the  mu- 
cous suture  is  now  applied  uniting  the  posterior  half 
of  the  circle ;  the  boiie  bobbin  is  now  inserted  and 
the  mucous  suture  continued  around  the  anterior 
half  circle  until  it  reaches  the  point  where  the  mu- 
cous stitch  was  begun  and  where  the  loose  end  will 
be  found;  these  two  ends  are  then  tied  firmly:  the 
serous  suture  previously  laid  aside  is  now  picked 
up  and  continued  around  the  anterior  half  circle  un- 
til the  loose  end  of  the  celluloid  thread  is  reached, 
when  the  two  ends  are  tied  firmly. 

The  two  hollow  viscera  are  now  united  by  a  hol- 
low cylinder  of  decalcified  bone  surrounded  by  two 
continuous  threads,  one  uniting  the  mucous  margins 
and  one  the  serous  surfaces,  about  1-4  or  1-3  of  an 
inch  away  from  the  anastomotic  opening. 


LATE  RESULTS  OF  THE  TREATMENT  OF  INOPER- 
ABLE SARCOMA  WITH  THE  MIXED  TOXINS  OF 
ERYSIPELAS  AND  BACILLUS  PRODIGIOSUS. 
By  WILLIAM  B.  COLEY,  M.  D., 

of  New  York. 

Attending  Surgeon  to  the   (jeneral  Memorial  Hospital,  Assistant  Surgeon 
to  the  Hospital  for  Ruptured  and  Crippiea. 

In  May,  1894,  I  was  highly  honored  by  an  invita- 
tion of  the  American  Surgical  Association  to  read 
my  first  paper  upon  the  treatment  of  inoperable 
malignant  growths  with  the  mixed  toxins  of  ery- 
sipelas and  bacillus  prodigiosus.  The  results  up  to 
that  time,  though  remarkable,  covered  a  compara- 
tively small  number  of  cases,  and  had  not  stood  the 
test  of  time.  Yet,  the  words  of  kindly  encourage- 
ment then  received  from  the  members  of  the  Amer- 
ican Surgical  Association  did  much  to  stimulate  my 
enthusiasm  and  helped  me  to  persevere  during  the 
period  of  doubt  and  discouragement  that  necessar- 
ily attend  the  introduction  of  any  new  method  of 
treatment  of  malignant  tumors,  and  especially  the 
treatment  of  malignant  tumors  already  pronounced 
inoperable  and  hopeless  by  competent  authorities. 

Seven  years  have  passed  since  the  reading  of  the 
paper  referred  to,  and  just  a  decade  since  the  begin- 
ning of  the  experiments  of  Dr.  Bull  and  myself 
with  the  living  cultures  of  erysipelas  in  inoperable 
sarcoma,  and  the  practical  question  may  well  be 
asked  by  the  profession :  ''Has  the  toxin  method  ful- 
filled any  of  the  early  hopes  and  claims?  In  other 
words,  just  what — in  brief — is  its  proper  place  in 
the  therapeutics  of  malignant  tumors?" 

This  question  is  certainly  a  fair  one,  and  I  shall 
attempt  to  answer  it  in  the  briefest  possible  way 
and  do  so  after  the  manner  of  the  judge  rather  than 
the  advocate.  The  results  of  this  method  during  the 
last  three  years  have  given  me  no  reason  to  change 
the  conclusions  expressed  in  my  earlier  papers,  and 
I  have  nothing  new  to  add  in  the  way  of  improve- 
ment in  technique  or  in  preparing  the  toxins.  While 
the  results  are  far  better  in  spindle-celled  sarcoma 
than  in  any  other  form,  there  has  been  a  sufficient 
number  of  round-celled  sarcomas  successfully  treat- 
ed to  make  it  advisable  to  give  every  patient  with 
inoperable  sarcoma  the  benefit  of  a  brief  trial.  If 
no  improvement  has  occurred  at  the  end  of  3  or  4 
weeks  of  daily  injections,  the  treatment  is  not  likely 
to  be  successful.  If  improvement  does  occur,  the 
treatment  should  be  kept  up,  either  until  the  tumor 
has  entirely  disappeared  or  until  it  has  become 
evident  that  the  injections  have  lost  their  inhibitory 
influence.  The  toxins  may  be  given  for  long  peri- 
ods in  moderate  doses  without  harm  to  the  patient. 
The  risks  of  the  treatment  are  practically  nil,  if  pro- 
per precautions  are  observed.  In  upward  of  twa 
hundred  cases  I  have  had  but  two  deaths,  both  of 
which  occurred  more  than  five  years  ago.  It  should 
be  remembered  that  the  method  is  advised  only  in  in- 
operable tumors,  and  practically  only  in  sarcoma;  in 
other  words,  in  the  entirely  hopeless  cases.  As 
above  indicated,  the  percentage  of  probable  cures 
depends  largely  upon  the  type  of  cell,  varying  fron-; 
perhaps  four  or  five  per  cent,  in  the  round-celled, 
to  nearly  fifty  in  the  spindle-celled  variety.    Up  to 

*Read  before  the  .\inerican  Surgical  .\ssocia'ion.  Baltimore.  May,  1901. 


IOI4 


The  Philadelphia"! 
Medical   Journal  J 


TREATMENT  OF  INOPERABLE  SARCOMA 


[Mat  25,  1901 


the  present  time  I  have  had  no  success  with  the 
toxins  in  the  treatment  of  melanotic  sarcoma,  al- 
though I  have  tried  them  in  about  a  dozen  cases. 
In  some  of  these  cases  the  disease  was  held  in 
check  for  some  time,  but  after  a  longer  or  shorter 
period  the  inhibitory  action  of  the  toxins  was  in 
some  way  lost.  Lynipho-sarcomas  of  the  neck  form 
another  class  that,  up  to  the  present  time,  justifies 
a  prognosis  almost  as  bad  as  that  in  melanotic 
growths.  Although  I  have  treated  a  large  number 
of  such  cases  most  carefully  and  for  long  periods  of 
time,  I  have  not  as  yet  had  a  single  permanent 
success.  These  cases  are  nearly  all  of  very  rapid 
growth,  and  very  highly  malignant.  It  should  be 
borne  in  mind  that  these  lympho-sarcomas  of  the 
neck  are  also  practically  hopeless  from  the  start, 
from  an  operative  point  of  view.  Butlin  states  that 
he  has  been  unable  to  find  a  record  of  a  single  case 
in  which  a  cure  has  resulted  from  operation.  In 
spite  of  these  discouraging  results  in  melanotic 
sarcomas  and  lympho-sarcomas  of  the  neck,  the 
remarkable  inhibitory  action  of  the  toxins  that  I 
have  observed  in  certain  tumors  of  these  varieties, 
justifies  us  in  advising  a  thorough  trial  of  the  treat- 
ment in  all  such  cases,  unless  the  disease  is  very 
far  advanced  or  has  already  become  generalized. 
After  generalization  has  occurred — whatever  be  the 
variety  of  sarcoma — I  doubt  that  any  permanent 
result  can  ever  be  obtained  by  the  toxins. 

In  August,  1898  {Journal  of  the  Am.  Med.  Ass'n), 
I  published  my  results  in  140  cases  of  inoperable 
sarcoma  treated  with  the  mixed  toxins.  In  24  of 
these  the  tumor  completely  or  partly  disappeared. 
Eighty-four  of  this  series  were  round-celled  sar- 
coma; 21  spindle-celled;  9  melanotic  sarcoma;  2 
chondrosarcoma;  12  were  sarcoma  (diagnosis  con- 
firmed by  the  microscope,  but  type  of  cell  not 
stated)  ;  6  were  inoperable  sarcoma  resting  on  clin- 
ical diagnosis  combined  with  a  history  of  repeated 
recurrence  in  most  cases. 

In  40,  or  slightly  less  than  half  of  the  round-celled 
cases,  there  was  more  or  less  improvement,  as 
shown  by  decrease  in  size  and  cessation  of  growth. 
In  onlv  three  of  these  was  the  treatment  success- 
ful. 

Of  the  21  cases  of  spindle-celled  sarcoma,  ten  dis- 
appeared entirely,  and  all  the  remainder  showed 
marked  improvement. 

In  melanotic  sarcoma,  as  I  have  stated,  I  have 
had  no  successes.  It  should  be  noted,  however,  that 
Dr.  George  R  .l-"owlcr,  of  Brooklyn,  has  reported 
one  case  of  melant)tic  sarcoma  of  the  tonsil  and 
fauces,  which  entirely  disappeared  under  the  use 
of  the  mixed  toxins.  The  patient  remained  well  for 
two  years,  when  a  local  recurrence  followed  and 
proved  fatal. 

In  addition  to  these  personal  results,  the  paper 
contained  a  summary  of  results  in  35  cases  success- 
fully treated  by  other  surgeons  employing  the  same 
method.  Of  these  35  cases,  10  were  round-celled: 
10  spindle-ccllcd ;  in  5  the  diagnosis  was  clinical 
only;  in  5  there  was,  in  addition  to  the  clinical  signs 
of  sarcoma,  a  history  of  recurrence  after  operation ; 
in  4  the  diagnosis  of  sarcoma  was  confirmed  by  mi- 
croscopical examination,  but  the  type  not  stated; 
I  was  an  endothelio-sarcoma. 

Of  these  35  cases,  26  disappeared  completely:  J 


others  decreased  so  much  that  only  a  small  node  was 
left,  which  was  easily  excised.  One  of  the  latter 
cases  was  well  three  years,  and  the  other  one  year 
at  the  time  of  the  report. 

Of  the  35  cases  referred  to,  14  were  well  over  two 
years,  and  6  cases  over  three  years. 

At  the  time  of  my  report  (Aug.,  1898),  8  of  my 
cases  had  remained  well  from  3  to  6  years.  I  have 
made  a  very  great  effort  to  trace  the  after-histories 
of  these  patients,  with  the  following  results : 

CASE  1. — Recurrent,  inoperable  spindle-celled  sarcoma 
of  the  neck  and  tonsil,  treated  with  the  injections  of  the 
living  cultures  of  erysipelas,  in  May,  1891,  for  four  months, 
during  which  time  a  severe  attack  of  erysipelas  occurred. 
The  tumors  nearly  disappeared  and  the  patient  recovered 
perfect  general  health.  He  remained  well  for  eight  years, 
at  which  time  the  malignancy  reappeared  and  proved  fatal 
during  the  following  year. 

CASE  2. — Recurrent  mixed-celled  sarcoma  (round, 
oval  and  spindle)  of  the  back  and  groin.  The  patient  was 
first  treated  in  April,  1S92,  with  the  living  bouillon  cul- 
tures of  erysipelas.  The  tumor  entirely  disappeared.  It 
recurred  two  months  later  and  finally  disappeared  under 
the  mixed  toxins.  During  the  treatment  the  patient  had 
four  attacks  of  erysipelas,  artificially  produced.  He  re- 
mained well  for  3',4  years,  then  had  an  intra-abdominal 
recurrence,  of  which  he  died  in  about  six  months. 

CASE  3. — Inoperable  spindle-celled  sarcoma  of  the 
abdominal  wall  and  pelvis,  7x5  inches  in  diameter.  The 
tumor  entirely  disappeared  under  four  months'  treatment 
with  the  mixed  filtered  toxins.  The  boy  was  in  perfect 
health  when  last  seen,  between  7^  to  8  years  after  treat- 
ment. The  diagnosis  was  confirmed  by  Dr.  H.  T.  Brooks, 
pathologist  at  the  Post-Graduate  Hospital. 

CASE  4. — Darge,  inoperable  sarcoma  of  the  abdominal 
wall.  The  patient,  female,  aged  28  years,  had  an  explora- 
tory laparotomy  performed  in  August,  1893,  at  the  Massa- 
chusetts General  Hospital,  by  Dr.  Maurice  H.  Richardson. 
Such  a  large  portion  of  the  abdominal  wall  was  found 
involved,  that  removal  was  considered  impossible.  A 
portion  of  the  growth  was  excised  for  microscopical  exam- 
ination, and  pronounced  spindle-celled  sarcoma  by  Dr.  W. 
F.  Whitney,  pathologist  of  the  hospital.  The  treatment 
with  the  mixed  toxins  was  begun  in  October,  1893.  and 
was  continued  for  about  four  months,  with  the  result  that 
the  tumor  entirely  disappeared.  The  patient  remains  in 
perfect  health  at  the  present  time,  nearly  eight  years  after 
treatment. 

CASE  5. — Spindle-celled  sarcoma  of  the  leg  and  popli- 
teal space,  three  times  recurrent.  The  tumor  disappeared 
under  the  toxins,  but  recurred  1%  years  later.  Amputation 
below  the  trochanter  was  performed,  but  a  growth  soon 
appeared  in  the  gluteal  region.  This  grew  in  size  very 
rapidly  and  was  quite  inoperable.  The  toxins  were  admin- 
istered for  a  number  of  weeks;  the  greater  portion  of  it 
was  removed  under  ether.  The  toxins  were  continued  after 
the  operation,  with  intervals  of  rest,  for  nearly  a  year. 
The  remaining  portion  of  the  tumor  disappeared  and  the 
patient  is  at  present — more  than  four  years  afterwards — 
in  perfect  health,  without  any  sign  of  return. 

CASE  6 — Spindle-celled  sarcoma  of  the  scapular  region 
involving  the  soft  parts  of  the  left  half  of  the  thoracic 
v.a]\.  The  patient,  a  girl  of  16,  was  admitted  to  the  N. 
Y.  Cancer  Hospital.  June  20.  1S94.  The  tumor  had 
started  in  the  left  scapular  region  four  months  before,  and 
had  grown  very  rapidly,  until  it  measured  13  inches  ver- 
tically behind,  7  inches  in  front.  The  growth  seemed  ad- 
herent to  the  scapula  and  the  ribs:  it  was  about  two 
inches  in  thickness  in  its  most  protuberant  part.  A  por- 
tion from  this  region  was  removed,  under  cocaine,  for 
microscopical  examination,  and  the  diagnosis  of  spindle- 
celled  sarcoma  was  made  by  Dr.  H.  T.  Brooks,  pathologist 
of  the  Past-Graduate  Hospital.  The  tumor  entirely  disap- 
peared by  absorption,  without  breaking  down,  under  about 
three  months'  treatment.  The  after-history  of  this  pa- 
tient is  of  great  interest,  and  will  very  shortly  be  published 
in  detail  by  Dr.  Buxton  and  myself.  She  remained  well 
tor  six  years  and  then  developed  a  peculiar  growth  in  the 
region  of  the  right  scapular  and  right  pectoral  muscles. 
.\  portion  of  the  tumor,  removed  from  the  pectoral  region 
in  October.  1900.  seemed  microscopically  to  be  dense, 
fibrous  tissue,  infiltrating  the  pectoral  muscle.     The  diag- 


May   -Ja,   1901] 


TREATMENT  OF  IXOPERABLE  SARCO^LV 


TThe  Philadelphia 
Lmedical   Journal 


IOI5 


nosis  of  progressive,  muscular  fibrosis  was  made  by  Dr. 
Buxton.  Sliortly  afterward,  a  piece  of  new  bone,  about  2 
iuclies  long  and  %  inche  in  diameter,  was  removed  from 
the  pectoral  muscle.  A  little  later,  a  new  bony  formation 
occurred  in  the  region  of  the  sterno-mastoid  muscle  and  was 
removed  under  ether.  A  portion  of  soft  tissue  was  also 
removed  from  the  scapular  region,  and  microscopical  ex- 
amination showed  the  characteristic  changes  of  myositis 
ossificans. 

CASE  7. — -Round-celled  sarcoma  involving  omentum, 
colon  and  lobe  of  small  intestine.  The  diagnosis  was  made 
by  Dr.  Willy  Meyer,  confirmed  by  exploratory  laparotomy 
and  microscopical  examination  of  a  portion  removed,  by 
Dr.  F.  Schwyzer,  pathologist  to  the  German  Hospital.  The 
toxins  were  begun  in  September,  1S94.  and  continued 
for  about  four  months.  The  tumor  slowly  disappeared  in 
size  and  finally  disappeared.  A  year  later,  several 
calculi  were  removed  from  the  gall-bladder,  with  no  evi- 
dence of  a  tumor  to  be  found.  The  patient  was  in  perfect 
health  four  years  after  treatment. 

CASE  8. — Inoperable  angiosarcoma  of  the  breast,  treat- 
ed in  spring,  1895,  at  the  New  York  Cancer 
Hospital.  The  growth  became  sufficiently  reduced 
in  size  to  be  easily  remo\ed.  The  patient  was  well 
when  last  seen,  about  six  months  later. 

CASE  9. — Recurrent,  spindle-celled  sarcoma  of  the  palm 
of  the  hand.  The  growth  entirely  disappeared  under 
two  months'  treatment.  The  patient  remained  well  for 
about  21A  years,  when  there  was  a  local  recurrence.  This 
at  first  responded  to  the  toxins,  but  later  they  evidently 
lost  their  control.  Amputation  of  the  arm  was  advised. 
The  patient  refused  operation  and  chose  the  Christian 
Science  treatment  for  a  period  of  eight  months,  during 
which  time  the  tumor  increased  from  the  size  of  a  small 
vvalnut  to  that  of  a  cocoanut.  and  extended  nearly  to  the 
elbow.  Amputation  just  below  the  shoulder  joint  was 
performed,  but  with  no  hope  of  doing  more  than  removing 
the  foul  and  sloughing  mass,  as  evidence  of  generalization 
had  already  appeared.     Sne  died  in  3  months. 

CASE  10. — Recurrent,  spindle-celled  sarcoma  of  the 
thigh  and  groin,  in  a  female,  aged  48  years.  The  tumor 
was  partially  removed  in  March,  1896,  at  the  New  York 
Hospital,  by  Dr.  Bull.  A  large  mass  remained  in  the 
inguinal  region,  and  there  was  marked  edema  of  the 
whole  leg  The  toxins  were  begun  on  May  30,  1896.  and 
rontinued  for  about  three  months,  at  the  end  of  which  time 
the  tumor  had  entirely  disappeared  and  the  left  leg  had  be- 
come normal  in  size.  The  patient  remained  well  for  about 
:i  year,  when  she  had  a  local  recurrence.  The  toxins 
were  again  administered  with  temporary  improvement,  but 
later  the  disease  returned  and  proved  fatal  in  less  than  a 
year. 

Case  11. — Spindle-celled  sarcoma  of  the  iliac  fossa, 
probably  starting  in  the  Ilium.  The  patient,  Mrs.  D..  aged 
40  years,  first  noticed  a  growth  in  the  right  iliac  region  in 
the  early  part  of  1895.  This  increased  steadily  in  size, 
until  October,  1895.  exploratory  laparotomy  was  performed 
hy  Dr.  Johnston,  of  Boston.  The  tumor  was  about  the  size 
of  a  cocoanut,  attached  to  the  ilium  as  well  as  abdominal 
wall  and  was  totally  inoperable.  It  seemed  to  start  from 
the  crest  of  the  ilium.  The  diagnosis  of  spindle-celled  sar- 
coma was  made  by  Dr.  W.  F.  Whitney,  of  the  Massachu- 
setts General  Hospital.  The  treatment  with  the  mixed 
toxins  was  begun  by  Dr.  Farrar  Cobb,  of  Boston,  in  No- 
vember, 1895.  In  a  letter  the  doctor  stated  that,  at  the 
end  of  six  weeks'  treatment,  the  growth  had  entirely  disap- 
peared. In  May,  1896.  six  months  later,  the  patient  came 
to  me  with  a  well-marked  recurrence,  extending  from 
the  crest  of  the  ilium  nearly  to  the  level  of  the  umbilicus 
and  as  far  to  the  left  as  the  median  line.  The  toxins  were 
again  begun  and  continued  with  intervals  of  rest,  for  three 
months,  when  the  patient  was  discharged  from  the  hos- 
pital for  a  few  months'  rest.  When  she  left,  the  tumor 
was  less  than  one  fifth  of  its  original  size.  She  was  re- 
admitted to  the  hospital  in  November.  The  tumor  had  in- 
creased considerably  in  size  during  the  interval  of  rest, 
but  under  the  treatment  began  to  diminish  rapidly.  She 
left  the  hospital  in  June,  1897,  after  six  months,  when  the 
tumor  had  markedly  decreased  in  size  and  her  general 
health  was  good.  Owing  to  a  change  of  address.  I  was  un- 
able to  trace  her  and  believed  that  she  had  probably  died, 
until  1  received  a  letter  in  December.  1900.  SVi  years  after 
the  cessation  of  the  treatment,  more  than  tour  years 
from  the  beginning,  in  which  she  stated  that  she  had  been 


in  good  health  and  been  supporting  the  family 
during  the  entire  time.  She  has  noticed  no  evi- 
dence of  a  return  of  the  growth. 

CASE  12. — Inoperable  sarcoma  of  the  sacrum.  The 
patient,  male,  38  years,  had  a  rapidly  growing  tumor  in 
the  upper  portion  of  the  sacrum,  which  could  be  easily  felt 
on  rectal  examination.  His  weight  had  fallen  from  175 
pounds  to  134  pounds  within  three  months.  He  had  lan- 
cinating pains  in  the  legs  with  marked  lameness.  The 
clinical  diagnosis  of  sarcoma  was  made  by  Dr.  Francis  P. 
Kinnicutt  and  confirmed  by  physicians  and  surgeons  who 
examined  him  at  St.  Luke's  Hospital.  No  microscopical 
examination  was  made.  The  toxins  were  begun  in  May, 
1895.  The  injections  in  this  case  were  all  made  in  the 
gluteal  region,  remote  from  the  tumor.  The  prognosis 
given  was  extremely  bad.  However,  the  patient  began 
improving  immediately  after  the  beginning  of  the  treat- 
ment and  the  patient  had  gained  28  pounds  in  weight  two 
months  later:  his  lameness  had  entirely  disappeared  and 
six  months  later  no  trace  of  the  tumor  could  be  detected 
on  rectal  examination.  The  patient  was  in  perfect  health, 
weighing  175  pounds,  when  last  seen,  nearly  four  years 
after  the  treatment, 

CASE  13. — Inoperable  sarcoma  of  the  iliac  fossa.  E.  S., 
male,  aged  14  years.  A  year  and  a  half  previously  he  had 
been  dragged  under  a  trolley  car,  causing  contusions  about 
the  pelvis.  In  January,  1895,  he  began  to  feel  pain  in  the 
right  groin  and  a  tumor  soon  developed  in  the  right  iliac 
fossa.  Exploratory  laparotomy  by"  Dr.  George  R.  Fow-ler. 
of  Brooklyn,  on  March  7,  1897,  showed  a  vascular  tumor, 
filling  up  the  whole  right  iliac  fossa,  extending  upward 
three  inches  above  the  crest  of  the  ilium  and  Poupart's  lig- 
ament. The  tumor  was  so  vascular  that  Dr.  Fowler  did 
not  think  it  wise  to  remove  a  portion  for  examination. 
He  closed  the  wound  and  regarded  the  case  as  entirely 
hopeless.  The  condition  continued  to  grow  rapidly  worse 
after  the  operation  and  on  .\pril  10,  1897,  the  mixed  toxins 
were  given  as  a  last  resort.  The  treatment  was  carried 
out  under  my  direction  by  Dr.  G.  H.  Davis,  of  Brooklyn,  and 
continued  for  several  months.  The  improvement  was  im- 
mediate and  rapid.  At  the  time  it  was  begun,  the  pa- 
tient was  extremely  emaciated,  with  marked  cachexia  and 
could  not  have  weighed  more  than  sixty  pounds.  Within 
the  next  three  weeks  he  was  walking  about  and  had  gained 
at  least  ten  pounds  in  weight.  Examination  of  the  abdo- 
men showed  that  the  tumor  had  almost  entirely  disap- 
peared. The  injections  were  not  made  into  the  tumor, 
but  into  the  gluteal  region  and  upper  thigh.  A  few 
months  later  he  developed  a  fiuctuating  swelling  over  the 
ilium  behind.  The  skin  became  broken,  and  a  slight 
infection  occurred,  causing  some  temperature.  I  in- 
cised the  swelling,  evacuating  several  ounces  of  degener- 
ated, broken  down  tissue.  No  bare  bone  was  detected  at 
any  time.  The  curettings  of  the  walls  of  the  cavity  were 
carefully  examined  and  not  the  slightest  evidence  of  tu- 
berculous disease  could  be  found,  practically  verifying  the 
original  diagnosis  of  sarcoma.  Another,  similar  opera- 
tion was  performed  on  April  10,  1898.  The  boy  has  re- 
mained in  good  health  up  to  the  present  time,  four  years 
later. 

CASE  14. — Spindle-celled  sarcoma  of  the  abdominal 
wall.  The  patient,  a  girl  of  18  years,  was  admitted  to  the 
New  York  Cancer  Hospital,  December  29,  1S96,  with  a 
tumor  in  the  lower  part  of  the  abdomen  of  several  months' 
duration.  Exploratory  operation  performed  by  Dr.  Joseph 
Brettauer  and  Dr.  George  W.  Jarmon.  A  large  mass  was 
found  in  the  abdomen,  both  intra-  and  extra-peritoneal.  Tt 
was  regarded  as  entirely  inoperable.  A  portion  was  re- 
moved and  the  diagnosis  of  spindle-celled  sarcoma  con- 
firmed by  Dr.  Buxton,  pathologist  of  the  hospital.  After 
thirty  injections — the  largest  dose  being  6  minims — of  the 
filtered  toxins,  the  tumor  had  entirely  disappeared.  Very 
little  pain  and  discomfort  resulted  from  the  treatment,  and 
but  four  chills  occurred  durin.g  the  entire  time.  The  pa- 
tient was  in  perfect  health,  without  recurrence,  1%  years 
later,  when  she  returned  to  Germany. 

Case  15. — Spindle-celled  sarcoma  of  the  parotid  gland. 
The  patient,  a  man  of  40,  was  carpenter  by  occupation. 
The  timtor  was  first  noticed  early  in  1897.  It  grew  rapidly 
and  in  March,  1897  was  removed  by  Dr.  J.  W.  Wright,  of 
Bridgeport.  Conn.  A  second  and  a  third  operation  were 
performed  in  April,  but  the  growth  was  found  too  exten- 
sive for  removal.  The  submaxillary  glands  of  the  same 
side  were  involved.  In  July.  1897,  the  patient  was  treated 
with  the  mixed  toxins  at  the  Bridgeport  Hospital,  for  three 


ioi6 


The  Philadelphia 
Medical   Journal 


]   TREATMENT  OF  INOPERABLE  SARCOMA 


[Mat  25,  1301 


weeks,  with  little  improvement.  He  was  sent  to  me  by 
Dr.  Wright.  August  10,  1897,  for  advice  and  treatment. 
Believing  that  perhaps  the  toxins  had  not  been  pushed  to 
their  full  limit,  1  began  with  daily  doses,  increasing  to 
the  point  of  producing  a  chill  and  temperature  of  103-104° 
nearly  every  day.  The  patient's  excellent  condition  ena- 
bled him  to  withstand  this  severe  treatment  without  loss 
of  weight.  He  was  up  and  about  the  ward  the  entire  time. 
Some  improvement  was  evident  at  the  end  of  two  weeks 
and  although  this  was  not  great,  it  continued  constant  un 
til  the  middle  of  October,  when  the  disease  had  entirely 
disappeared.  The  patient  was  shown  before  the  N.  Y. 
Surgical  Society  in  March,  1898.  in  perfect  health.  I  re- 
ceived a  letter  from  him.  dated  April  29,  1901.  stating  that 
he  was  still  in  good  health,  without  recurrence,  nearly  four 
years  after  treatment. 

CASE  16. — Three  times  recurrent  mixed-celled  (round 
and  spiadle  celled)  sarcoma  of  the  parotid.  Fe 
male,  aged  34  years.  The  tumor  had  been  re 
moved  three  times  by  Dr.  William  T.  Bull,  and  fur 
ther  operation  was  deemed  in  advisable.  Dr.  Bull  kindly 
referred  the  case  to  me  for  treatment  with  the  toxins.  The 
injections  were  begun  in  January,  1897,  and  continued  for 
seven  months  in  very  small  doses.  The  patient  was  ex- 
tremely nervous.  The  tumor  became  much  reduced  in  size 
and  very  movable,  so  that  most  of  the  tumor  could  be 
easily  removed  under  ether  anaesthesia.  It  would  havt> 
been  impossible  to  remove  all  of  it  without  sacrificing  thr 
facial  nerve.  The  toxins  were  continued  after  the  opera 
tion  for  a  considerable  time,  in  very  small  doses,  nearly 
sufficient  to  produce  a  chill.  The  patient  is  still  well  and 
free  from  recurrence,  more  than  four  years  later. 

CASE  17. — Twice  recurrent  round-celled  sarcoma  of  the 
lower  lip.  The  patient,  a  little  girl,  5  years  of  age,  daughter 
of  a  physician  in  Tacoma,  was  referred  to  me  in  February, 
1897.  The  diagnosis  of  round-celled  sarcoma  was  con- 
firmed by  the  pathologists  of  the  Cancer  Hospital,  Drs 
Dunham  and  Buxton.  In  this  case  the  mixed  toxins  were 
used  for  about  6  weeks,  with  the  result  that  the  growth 
entirely  disappeared.  The  patient  has  remained  well  up 
to  the  present  time,  more  than  four  years  after  the  treat- 
ment. 

CASE  18. — Eight  times  recurrent  spindle-celled  sarcoma 
of  the  chest  wall,  soft  parts.  The  patient,  male,  himself  a 
surgeon  of  prominence,  had  been  operated  upon  eight 
times,  for  rapidly  recurring  spindle-celled  sarcoma  of  the 
chest  wall,  soft  parts.  The  intervals  between  operation 
and  recurrence  were  becoming  shorter  and  shorter,  and  the 
character  of  the  growth  more  vascular  and  more  malign- 
ant. The  toxins  were  begun  in  November,  1S94,  and  used  in 
small  doses  for  3%  years  with  intervals  of  rest.  The  pa- 
tient gained  in  weight  under  the  treatment  and  continued 
to  perform  his  daily  duties.  Two  to  three  small  nodules 
were  removed  during  the  treatment.  He  has  had  no  in- 
jections now  for  nearly  four  years,  and  there  has  been  no 
evidence  of  return. 

CASE  19. — Inoperable  sarcoma  of  the  tibia.  Male,  aged 
25.  The  patient  was  admitted  to  the  General  Memorial 
Hospital  in  February,  1899,  with  a  recurrent  tumor 
of  the  tibia,  for  which  amputation  had  been  advised.  A 
portion  of  the  growth  removed  had  been  examined  by  Dr. 
John  Caven,  Professor  of  Pathology  at  the  University 
of  Toronto,  and  pronounced  spindle-celled  sarcoma.  In 
view  of  this  report  I  believed  it  to  be  wise  to  give  him 
the  benefit  of  a  short  period  of  toxin  treatment,  before 
amputating.  After  about  two  months,  the  tumor  had 
apparenly  disappeared  and  the  injections  were  discontin- 
ued. The  tumor  disappeared  partly  by  sloughing  and 
the  granulating  area  left  behind  became  infected  with  ery- 
sipelas, there  having  been  a  case  in  the  ward  some  months 
before.  The  patient  had  a  very  severe  attack  of  erysipelas, 
extending  over  the  whole  leg  and  portion  of  the  body, 
and  after  recovering  from  this  he  returned  home.  He  re- 
mains in  perfect  health  at  the  present  time,  and  has  con- 
tinued his  occupation  as  farmer. 

CASE  20. — Very  large  recurrent  sarcoma  of  gluted  re 
gion.  Inoperable.  The  toxin  were  administered  for  two 
months  in  1893.  The  tumor  slowly  decreased  in  size  and 
after  several  months  becime  very  small  and  all  evidence 
of  malignancy  disappeared.  Five  years  later  she  was  in 
good  health.  I  then  removed  two  hard,  fibrous  nodules 
from  site  of  growth,  and  they  proved  to  be  pure  fibrous 
tissue. 

CASE   21. — Large   chondrosarcoma   of   the    ilium,   which 


disappeared  under  the  treatment.  The  patient  remained 
well  for  seven  months,  when  a  recurrence  took  place,  which 
proved  fatal  in  about  a  year's  time. 

CASE  22. — Fibro-angioma  of  the  lip.  Recurrent  in 
operable  was  well  when  last  heard  of,  over  two  years  after 
treatment. 

CASE  23. — Inoperable  epithelioma  of  the  chin,  lower 
jaw  and  floor  of  mouth.  The  growth  disappeared  entirely 
under  four  months'  treatment  with  the  mixed  toxins.  The 
patient  was  well,  without  recurrence,  when  last  seen, 
four  years  after  treatment.  The  case  was  referred  to  me 
by  Dr.  Geo.  R.  Fowler,  of  Brooklyn,  who  regarded  it  as 
entirely  inoperable. 

CASE  24. — Spindle-celled  sarcoma  of  the  palm  of  the 
hand — three  times  recurrent — the  toxins  as  a  prophylactic 
measure  immediately  after  the  last  operation.  The  patient 
is  in  good  health  1\^  years  after  operation.  The 
patient,  a  boy  aged  six  years,  was  operated  upon  by  Dr.  J. 
D.  Bryant,  in  1898,  for  acute  traumatic  sarcoma  of  the  palm 
of  the  hand.  A  small  operation  was  first  performed,  and 
later  a  more  radical  one,  with  removal  of  the  ring  and 
little  fingers  and  their  metacarpal  bones.  Recurrence 
quickly  followed  after  each  operation,  and  finally,  in  the 
fall  of  1899,  a  sarcomatous  tumor  appeared  in  the  axillary 
region.  This  was  removed  also  by  Dr.  Bryant,  and  as 
soon  as  the  wound  had  closed,  the  patient  was  referred  to 
me  for  the  toxin  treatment.  The  injections  were  given  in 
small  doses,  two  or  three  times  a  week  for  about  three 
months.  The  boy  has  remained  in  good  health  up  to  the 
present  time,  without  recurrence. 

The  following  cases  of  carcinoma  are  of  special 
interest: 

CASE  1. — Extensive  recurrent  carcinoma  of  the  breast 
following  amputation  of  both  breasts  for  carcinoma.  The 
toxins  were  used  continuously  for  nearly  four  years. 
The  patient  is  still  alive,  4%  years  after  treatment. 

This  case  is  of  great  interest,  as  it  shows  that  in  certain 
f  onditions  the  toxins  may  be  used  to  advantage  even  in 
carcinoma,  especially  as  an  aid  to  partial  operation.  The 
patient,  Mrs.  W.  H.,  56  years,  was  operated  upon  by  Dr. 
Maurice  H.  Richardson,  of  Boston,  for  carcinoma  of  both 
breasts.  October  8,  lS9.i.  Recurrence  was  first  noticed  in 
.'une.  1896.  nine  months  after  the  primary  operation.  Dr. 
Richardson  advised  against  further  operation  and  referre<l 
the  patient  to  me  for  opinion  as  to  the  propriety  of  using 
the  toxins.  I  stated  that  I  believed  the  treatment  would 
prove  of  only  temporary  value,  and  might  have  no  effect. 
I  urged  the  removal  of  the  carcinomatous  area  which,  at 
this  time  was  about  3  to  4  inches  in  size,  infiltrating  the 
skin,  and  as  soon  as  the  wound  was  healed  to  begin  the 
toxins  in  the  hope  of  delaying  recurrence.  Dr.  Richardson 
removed  the  diseased  area  November  27.  1896.  On  Janu- 
ary 1,  before  the  wound  had  entirely  healed,  new  nodules 
appeared  in  the  outlying  skin  near  the  anterior  axillary 
line.  The  toxins  were  begun  on  January  10.  1897.  and  con- 
tinued in  small  daily  doses  for  one  month.  The  small 
nodules  in  the  skin  disappeared.  After  a  short  interval 
of  rest  her  general  health  was  much  improved  compared 
to  what  it  was  prior  to  the  beginning  of  the  treatment. 
She  returned  to  her  home  in  Massachusetts,  and  with 
occasional  intervals  of  rest,  the  treatment  was  continued 
in  moderate  doses  upwards  of  three  years.  On  three  or 
four  occasions  some  minute  localized  skin  infiltrations, 
not  more  than  M  inch  in  diameter,  were  removed  under 
cocaine.  .-Vhout  a  year  ago.  she  developed  ascites,  and  has 
been  tapped  by  Dr.  Richardson  a  number  of  times.  No 
tumor  has  been  felt  in  the  abdomen,  although  it  is  quite 
possible  that  generalization  of  the  disease  has  taken 
place.  The  fact  remains  that  life  has  been  unquestionably 
greatly  prolonged  by  the  continued  use  of  small  doses  of 
the  toxins  in  a  most  unpromising  case  of  double  recurrent 
carcinoma  of  the  breast. 

C.\SE.  2. — .\nother  case  of  rapidly  growing  recurrent 
carcinoma  of  the  breast  in  a  comparatively  young  woman, 
aged  40  years,  with  involvement  of  the  axillary  glands, 
was  kept  in  good  health  with  complete  control  of  the  dis- 
ease from  2M:  years  by  the  administration  of  small  doses 
of  mixed  toxins,  two  or  three  times  a  week. 

\Miile  at  the  time  of  my  report,  i:i  iSoS.  eight  of      ' 
my  own  cases  had  remained  well  from  .^  to  6  years, 
T  am  now  able  to  report  sixteen  cases  that  have  re 
mained  well  from  3  to  8J  years.    Of  these  two  re- 
curred after  3  and  8  years  respectively,  one  dying  of 


Mat   25,   1901J 


PARALYSIS  AGITAXS 


CThe  Philadelphia 
Medical   Journal 


IOI7 


metastases  in  the  abdomen ;  the  second,  after  re- 
maining well  for  8  years,  died  of  local  recurrence. 
The  cases  were  all  hopeless,  inoperable  cases,  and 
the  d.agnosis  was  confirmed  by  the  microscope  with 
two  exceptions.  In  these  instances  the  history  of 
the  cases,  with  the  clinical  appearances,  made  the 
diagnosis  of  sarcoma  unquestionable.  The  type  of 
tumor  in  the  fifteen  cases  that  passed  the  three-year 
limit  was  as  follows : 

Spindie-celled   sarcoma    9 

Round-celled   sarcoma    2 

Mixed-celled   sarcoma    2 

Epithelioma  i 

Sarcoma  (clinical  diagnosis  only)  .  .2 
It  is  worthy  of  special  note  that  two  of  the  suc- 
cessful cases,  now  well  34  and  45  years,  respectively, 
were  sarcoma  of  the  parotid  gland.  Buthn,  in  his 
last  edition  of  "Operative  Treatment  of  Malignant 
Tumors,"  states  that:  "Up  to  the  present  time  there 
are  very  few  instances  of  cure  by  operation  of  un- 
doubtedly malignant  disease  of  the  parotid."  In 
my  two  cases  treated  by  the  toxins,  the  diagnosis 
was  not  onl}-  confirmed  by  a  competent  pathologist, 
but,  further,  by  a  history  of  repeated  recurrences 
after  operation.  Another  case  still  is  also  worthy 
of  special  mention,  inasmucn  as  it  shows  that  the 
toxins  may  be  taken  for  long  periods  of  time  without 
harm.  The  patient,  a  well-known  physician,  with 
eight  times  recurrent  spindle-celled  sarcoma  of  the 
soft  parts  of  the  chest  (anteriorly)  was  treated  with 
small  doses  of  the  mi.xed  toxins  with  varying  inter- 
vals of  rest,  for  upwards  of  two  years.  The  patient 
regained  his  usual  health,  and  has  now  been  per- 
fectly well  over  six  years  from  the  beginning  and 
four  years  since  the  cessation  of  the  treatment.  The 
tumors,  while  originally  pure  spindle-celled,  were 
becoming  more  mixed  with  round  cells  and  more 
vascular  with  each  recurrence;  in  other  words,  the 
disease,  as  so  often  happens,  was  increasing  in 
malignancy  until  the  toxins  were  begun. 

In  addition  to  these  sixteen  cases  that  have  passed 
the  three-year  limit,  in  eight  others  the  tumors  dis- 
appeared. One,  a  spindle-celled  sarcoma  of  the  ab- 
dominal wall,  was  well  i|  jears,  when  the  patient 
returned  to  her  home  in  Europe  and  was  lost  sight 
of.  Another,  an  extensive  round-celled  sarcoma  of 
the  iliac  fossa,  was  well  one  year  and  then  lost  sight 
of.  A  third,  a  spindle-celled,  recurrent  sarcoma  of 
the  leg,  is  now  in  perfect  health,  without  recurrence, 
two  and  one-quarter  years  after  treatment.  A 
fourth,  a  twice  recurrent,  spindle-celled  sar- 
coma of  the  palm  of  the  hand,  disappeared, 
and  the  patient  remained  well  two  and  a 
half  years,  when  the  tumor  recurred.  Refus- 
ing amputation  of  the  arm,  she  was  under  the 
care  of  a  Christian  scientist  for  eight  months,  during 
which  time  the  tumor  in  the  hand  reached  the  size 
of  a  cocoanut  and  extended  above  the  elbow.  I  then 
amputated  the  arm  just  below  the  shoulder  joint, 
but  she  died  of  metastases  three  and  a  half  months 
later.  Though  the  patient  was  an  especially  intel- 
ligent girl,  22  years  of  age.  while  under  the  Christian 
science  treatment,  she  watched  a  small  tumor,  the 
size  of  an  English  walnut,  grow  to  the  size  of  a  co- 
coanut, and  yet  was  made  to  believe  it  was  actually 
getting  smaller  and  improving.  She  also  stated 
that  she  felt  no  pain.  This  is  a  good  illustration  of 
the  utter  impossibility  of  placing  any  value  upon 


personal  statements  of  patients  in  regard  to  im- 
provement or  cure  of  malignant  tumors  by  Christian 
science. 

A  fifth  case,  a  chondro-sarcoma  of  the  ilium,  of 
large  size,  disappeared,  and  the  patient,  after  re- 
maining well  for  seven  months,  had  a  recurrence, 
which  proved  fatal  in  about  a  j-ear's  time.  A  sixth, 
a  round-celled  angio-sarcoma  of  the  breast,  was 
well  six  months  later,  when  the  patient  was  lost 
sight  of.  A  seventh,  a  recurrent  fibro-angioma  of 
the  lip,  was  well  when  last  heard  of,  over  two  years 
after  operation ;  and  an  eighth,  a  recurrent,  spindle- 
celled  sarcoma  of  the  thigh,  disappeared,  but  the 
patient,  after  remaining  well  for  a  year,  had  a  re- 
currence locally  and  in  the  groin,  which  no  longer 
yielded  to  the  treatment. 

In  addition  to  these  24  personal  cases,  I  would 
mention  two  other  cases  in  which  I  directed  the 
treatment,  although  it  was  carried  out  by  another 
surgeon.  One  case  (Johnson's),  a  large,  spindle- 
celled  sarcoma  of  the  pharynx,  entirely  disappeared, 
and  the  patient  was  well  more  than  six  years  later. 
The  second  (Storr"s  and  Griswold's)  inoperable  sar- 
coma of  the  breast  and  axilla,  disappeared  under  78 
injections  of  the  mixed  toxins,  and  is  now  well  more 
than  four  years  after  treatment.  The  diagnosis  in 
both  of  these  cases  was  confirmed  by  microscopical 
examination,  in  the  latter  case  b}'  the  highest  au- 
thority in  this  country,  Prof,  ^^'illiam  H.  Welch,  of 
Johns  Hopkins  University. 

The  results  thus  far,  he  stated,  seem  sufficient  to 
warrant  advising  the  treatment  as  a  routine  measure 
after  all  operations  for  primary  sarcoma.  \\'hile  the 
treatment  is  not  recommended  in  carcinomatous 
growths,  it  has  been  the  experience  of  the  writer 
that  in  many  cases  the  toxins  exert  a  marked  inhib- 
itory influence  in  carcinoma,  although  it  is  rarely 
curative.  The  only  cases  of  carcinoma  in  which  the 
toxins  are  likely  to  prove  of  much  value,  I  think,  are 
those  in  which  they  are  used  after  primary  or  sec- 
ondary operation,  as  a  prophylaxis  against  recur- 
rence. Up  to  the  present  time  sufficient  experience 
is  lacking  to  justify  one  in  making  any  definite 
statements  as  to  how  much  may  thus  be  accom- 
plished. 

The  writer  still  believes  that  the  action  of  the 
toxins  upon  malignant  tumors  can  be  explained  only 
upon  the  theory  that  such  tumors  are  the  result  of 
some  infectious  micro-organism,  and  this  view  is 
strongly  supported  by  the  recently  expressed  opin- 
ion of  Czernv. 


TRAUMA   AS  AN  EXCITING  CAUSE  OF  PARALYSIS 
AGITANS.* 

By  F.  SAVARY  PEARCE,  M.  D., 

of  Philadelphia. 

Clinical   Profes'or  of  Nervous  Diseases  in  the  Medico-Chirurgical  Col- 
lege, and  Neurologist  to  tHe  Philadelphia  Hospital. 

The  subject  of  commotio  cerebri  as  an  exciting 
cause  of  definite  organic  lesion  of  the  neuron,  was 
fore  bly  l-mught  to  the  writer's  attention  v.  a  c?5. 
of  Friedreich's  disease  terminating  fatally,  which 
was  reported  by  Dr.  John  M  Swan  and  myself  in  the 
Philadelphia  Medical  Journal  for  May  26,  1900.  In 
this  case,  definite  exacerbation  of  the  disease  fol- 
lowed a  "fall."    Repeatedly  following  such  injuries, 

•Read  by  title  before  The  Pan  American  Medical  Congress.   Havana. 

Cuba,  Februan.'  4.  I'jo:. 


ioi8 


The  Philadelphia"] 
Medicai.  Journal    J 


PARALYSIS  AGITANS 


[Mat   25,   ISOl 


conditions  of  tremor  have  been  observed  by  the 
writer  in  cases  not  otherwise  hysterical.  The  latter 
have  recovered  after  the  adoption  of  rest  and  nutri- 
tional measures.  The  subject,  therefore,  in  the 
writer's  experience,  has  lead  him  to  suspect  that  dis- 
organization of  the  glia  and  the  neurons  may  have 
its  starting  point  from  undue  concussion  of  the 
central  nervous  system.  In  this  contribution,  it  is 
meant  to  bring  more  forcibly  before  the  profession 
the  fact  that  some  of  the  degenerations  of  the  ner- 
vous system  are  at  least  e.xcited  by  concussion ;  and 
that  trauma  should  be  given  place  in  etiology  along 
with  infectious  diseases  and  other  well-known 
causes.  The  above  statement  is  re-enforced,  too, 
by  the  knowledge  of  wide  difiference  of  opin- 
ion as  to  pathology  in  the  so-called  Trau- 
matic Neuroses,  as  shown  by  the  various  pa- 
pers read  at  the  Symposium  on  this  subject 
before  the  Section  of  Nervous  and  Mental  Dis- 
eases of  the  American  Medical  Association,  June 
6,  1900.  In  this  one  gentleman  took  the  ground  that 
most  of  the  tremors,  rigidity  of  the  back,  and  gen- 
eral nervous  symptoms  were  largely  of  malingering, 
in  some  cases  hysterical,  and  that  there  was  no 
ground  for  suspecting  the  border  line  of  organic 
spinal  disease  in  any  instance  of  this  afifection.  The 
other  speakers  were  more  conservative  in  their 
statements,  admitting  a  widespread  functional  dis- 
turbance to  be  excited  by  the  injury,  and  Lloyd  re- 
ported a  case  with  an  undoubted  organic  basis.  Of 
course,  we  are  barring  all  cases  of  actual  fracture 
or  displacement  of  the  vertebra.  The  writer  feels 
from  the  clinical  evidence  at  hand,  that  many  cases 
of  traumatic  neuroses  are  functional :  and  not  a  few, 
expressions  of  malnutrition  with  incipient  secondary 
degeneration  of  the  spinal  axis,  which,  with  rest  and 
hyper-nutrition  after  months  and  even  years,  may 
ultimately  recover,  leaving  the  individual  in  good 
health.  Other  cases  may  go  on  to  development  of 
a  system  sclerosis. 

But,  as  to  our  subject .  Paralysis  agitans  is  a 
disease  found  more  frec|uently  about  mid-life,  and 
whose  pathology  is  indefinite ;  yet  it  is  known  that 
interstitial  plaques  of  sclerosis,  and  hardening  of 
the  blood  vessels  do  occur.  Therefore,  in  the  etiol- 
ogy of  paralysis  agitans,  it  could  be  that  sudden  con- 
cussion might  excite  connective  tissue  proliferation 
and  an  irritability  of  the  motor  neurons  already  in  a 
condition  of  malnutrition  ;  and  I  have  no  doubt  that 
not  a  few  cases  of  this  disease  date  their  onset 
of  actual  tremor  from  the  time  of  a  fall  01; other  sud- 
den concussion.  I  should  say  the  older  the  case, 
the  more  likely  is  trauma  to  be  a  cause  of  the  onset 
of  paralysis  agitans  :  and  that  even  the  senile  tremor, 
so-called  and  so  much  simulating  that  of  paralysis 
agitans,  is  often  precipitated  by  some  sudden  cere- 
bro-spinal  concussion.  Thus  excitation  of  the  affer- 
ent axons  may  cause  an  increase  of  irritation  of 
motor  neurons,  the  reflex  message  being  carried 
back  accentuated,  producing  tremor  of  the  muscles 
and  therefore  of  the  extremity  involved.  The  fol- 
lowing case  is  ilustrative  of  this  source  of  tremor 
which  obeys  all  rules  of  paralysis  agitans.  though 
aberrant  in  type,  inasmuch  as  no  other  part  of  the 
body  is  involved  excepting  the  -woman's  left  arm. 

CASE  1. — M.  R.,  white,  aged  65,  fell  from  her  porch,  a  dis- 
tance o'  eiprht  feet,  producing  quite  a  severe  "shaking  up." 
Init  with  no  marked   concussion  of  the  spine.       She  also 


sustained  by  the  accident,  a  fracture  of  the  neck  of  the  right 
humerus.  This  was  on  May  first,  18&8.  The  bone  healed 
kindly  after  being  set  by  her  physician,  but  was  followed 
by  subacute  arthro-neuritis  involving  the  shoulder  joint 
and  brachial  ple.xus.  This  I  treated  by  galvanism,  and 
later  massage  was  administered.  From  this  time  on,  the 
right  shoulder  troubled  her,  the  range  of  motion  remaining 
quite  up  to  the  normal,  although  there  was  slight  stiffness 
in  the  movements  of  the  arm.  The  patient  remained  in 
good  health  for  a  year,  but  about  June  1st,  1900,  she  noted 
a  fine  tremor  taking  place  in  the  left  thumb  and  index 
finger  when  the  arm  was  at  rest.  This  would  be  made 
worse  by  over  exertion  or  excitement  of  any  sort,  finally 
becoming  at  the  end  of  a  few  months,  a  well  marked  and 
quite  continuous  dynamic  tremor,  always  under  control 
by  intention.  The  hand  is  now  distinctly  held  in  the  pill- 
rolling  attitude  but  does  not  interfere  with  needle  work. 
There  is  no  nerve  trunk  tenderness  or  apparent  weakness 
in  this  extremity.  There  is  absolutely  no  tremor  any- 
where else  in  the  body.  There  is  a  certain  mask-like  ex- 
pression, however,  but  no  festination  is  present. 

I  take  it,  the  tremor  in  this  case  is  due  to  the  reflex 
transference  of  irritation  from  the  right  to  the  left  motor 
neuron  in  the  cervical  region  of  the  spinal  cord,  not  an 
unknown  but  an  unusual  condition  and  is  likened  to  the 
transference  of  trophic  disturbance  from  one  extremity  to 
the  opposite  one  by  a  severe  burn  as  of  the  fingers.  The 
tremor  mentioned  has  been  almost  continuous  since  No- 
vember, 1900.  The  facies  of  the  patient  as  stated  is  some- 
what expressionless,  with  head  drooped  slightly  forward. 
These  are  the  only  other  evidences  of  Parkinson's  disease. 
On  December  28,  1900,  this  patient  was  seen  with  me  by 
Dr.  S.  Weir  Mitchell  who  suggested  the  diagnosis  given. 
There  has  been  very  little  improvement  with  the  prolonged 
use  of  galvanism  and  massage,  and  she  is  now  taking  in- 
creasing doses  of  Tr.  Hyoscyamus.  I  cannot  feel  any 
doubt  of  this  unusual  origin  of  the  tremor  which  is  not 
due  to  a  primary  commotio-cerebri.  per  se,  but  to  the 
secondary  irritation  of  the  spinal  neurons  from  an  affarent 
irritative  impulse  as  indicated  and  transmitted  to  the  op- 
posite extremity  as  tremor. 

The  conclusions  which  seem  to  be  the  more  defi- 
nite as  regards  trauma  as  an  exciting  cause  of  paral- 
ysis agitans,  are  that  the  later  the  origin  of  the 
disease,  is  trauma  more  apt  to  have  been  the  excit- 
ing cause :  in  any  event,  it  is  more  apt  to  produce 
an  aberrant  type  of  the  malady,  especially  when 
the  insult  to  the  nervous  system  has  been  primarily 
in  the  periphery  of  the  body  rather  than  of  the  cen 
tral  neurons. 

Treatment  would  differ  essentially  in  one  particu- 
is  first  of  less  widespread  extent  of  the  tremor,  and 
therefore  of  less  disturbance  to  the  individual,  al- 
though later  the  affection  may  become  general.  The 
downward  course  is,  perhaps,  less  rapid  than  in  so- 
called  idiopathic  cases. 

Treatment  would  differ  esentially  in  one  particu- 
lar to  obtain  better  results  of  therapeutics.  Nerve 
stretching  seems  to  be  a  rational  procedure  in  cases 
as  here  reported,  where  the  tremor  is  localized,  and 
especially  where  the  reflex  origin  below  the  cere- 
brum seems  to  be  pretty  definitely  the  cause  of  the 
irritation  of  the  motor  neurons.  I  have  advised  this 
operation  in  the  case  in  question,  but  as  yet  have 
not  received  the  consent  of  the  patient. 

CASE  II. — Pseudoparalysis  agitans  following  scoliosis  of 
the  cervical  spine.  M.  S..  aged  58.  white  woman  in  my 
wards  at  the  Philadelphia  Hospital,  suffering  from  periods 
of  mental  excitation  and  fine  tremor  involving  th«»  right 
upper  extremity:  obeying  the  laws  of  a  tremor  of  para- 
lysis agitans.  There  is  no  other  evidence  of  Parkinson's 
disease.  The  peculiarity  of  the  case,  therefore,  is  that  at 
some  remote  period  following  this  posterior  cervical  cur- 
vature of  the  spine,  with  more  or  less  fixation,  probably  of 
rheumatic  origin,  we  here  have  an  instance  most  likely 
of  irritation  of  the  sensory  motor  roots  of  the  nerves 
leading  to  the  brachial  plexus:  and  in  this  way.  the  local- 
ized tremor  has  perhaps  been  brought  about.    The  rheumat 


Mat   25,   1901] 


TWO  CASES  OF  LOBAR  PNEUMONIA 


CThe  Philadelphia 
Medical  Journal 


IOI9 


ic  element  in  the  case,  too,  is  also  shown  by  a  slight 
arthritis  recently  occurring  in  the  right  knee  joint.  I  am 
interested  in  the  possible  result  upon  the  tremor,  of  treat- 
ment which  we  have  directed  to  the  rheumatic  poisoning  in 
this  case  and  also,  too,  of  probable  relief  of  tremor  we  may 
get  through  prolonged  head  extension  to  the  possible 
straightening  of  the  curvature  mentioned. 

CASE  III. — A  third  case  of  paralysis  agitans  in  a  man, 
due  to  trauma,  is  given  me  by  my  friend.  Dr.  Guy  Hins- 
dale. A  brief  history  is  as  follows:  Male,  white,  age  45. 
fell  upon  his  thumb  some  years  ago,  the  digit  bending  un- 
der in  extreme  flexion.  This  was  followed  immediately 
by  secondary  ascending  neuritis  of  the  same  arm  that  de- 
fled  all  treatment  including  nerve  stretching  which  was 
done  by  Dr.  H.  A.  Wharton.  The  case  has  gone  on  to  a 
general  symptomatology  in  all  typical  aspects  of  shaking 
palsy,  and  the  man  is  now  in  the  Home  for  Incurables, 
practically   bed-ridden. 

This  latter  case  pretty  positively  proves  the  trati- 
matic  origin  of  a  case  that  ultimately  became  gen- 
eral and  typical  of  the  disorder  under  discussion. 

The  two  preceding  cases,  result  of  trauma  or  local 
irritation,  I  feel  will  progress  in  the  same  fashion 
unless  some  happy  treatment  as  yet  not  resorted  to 
as  indicated  in  the  foregoing  notes,  may  possibly 
stay  the  advance  of  so  serious  a  disorder  of  the  mo- 
tor neurons. 


TWO  CASES  OF   LOBAR  PNEUMONIA  FOLLOWING 

ETHER  ANESTHESIA,  WITH  UNUSUAL  COURSE. 

By  W.  S.  SCHLEY. 

of  New  York. 

Assistant  Surgeon,  Trinity  Hospital,   Assistant  Surgeon,  St.  Luke's  Hospi 
tal.  Out-Patient  Service. 

The  following  cases  of  lobar  pneumonia  occurred 
after  the  administration  of  ether  for  surgical  opera- 
tion, ventral  suspension  of  the  uterus  and  hernio- 
tomy. There  was  nothing  unusual  of  note  in  anes- 
thesia, operation  or  condition  of  patient  preceding 
operation.  The  post  operative  course  of  each  seems 
worthy  of  record  ;  both  cases  developed  typical  lobar 
pneumonia  upon  the  1st  and  3rd  days  respectively 
following  operation.  In  each  case  the  right  lower 
lobe  was  the  portion  of  lung  involved.  There  were 
in  both  cases  stibsidence  of  temperattire  within  i6 


hours  and  beginning  resolution  within  2  days  after 
the  administration  of  a  single  large  dose  of  calomel 
(20-25  grs.)  The  mercury  was  given  within  16 
hours  of  the  initial  rise  of  temperature  and  dry  on 
the  tongue.  The  cases  occurred  upon  the  surgical 
division  of  St.  Luke's  Hospital,  one  each  in  the  ser- 
vices of  Dr.  Robert  Abbe  and  Dr.  F.  H.  Markoe,  to 
whom  I  am  indebted  for  permission  to  report  the 
same.  They  were  the  only  cases  of  pneumonia  oc- 
curring upon  the  division  after  several  thousand 
anesthesias  extending  over  a  period  of  about  two 
and  one-half  years.  A  resume  of  the  bedside  notes 
and  temperature  charts  is  appended. 

A.  B.  Hospital  No.  48,066.  Quite  well  nourished  but 
neurotic  female,  aged  26,  married,  the  mother  of  one  living 
child  with  one  still  birth  at  term.  Admitted  to  St.  Luke's 
liospital  November  21,  1898.  Her  history  was  entirely 
negative  except  tor  the  trouble  for  which  she  entered; 
retro-displaced  and  retro-flexed  uterus  with  chronic  endome- 
tritis. Physical  examination  of  the  chest  entirely  nega- 
tive, urine  negative,  operation  two  days  later,  nitrous  oxide 
followed  immediately  by  ether,  curettage  and  celiotomy 
with  anterior  fixation  of  the  uterus.  Duration  of  anesthe- 
sia about  three  quarters  of  an  hour.  The  anesthetic  was 
very  well  taken — pulse  90,  respirations  24,  at  the  close  of 
operation.  During  the  two  succeeding  days  the  patient 
complained  of  slight  pain  in  the  right  chest  anteriorly  and 
there  was  an  occasional  cough  with  some  white  mucus 
expectoration.  She  appeared  nervous  and  anxious  about 
her  condition.  One  the  third  day  "chilly  sensations"  in  the 
early  morning,  more  followed  by  a  temperature  of  104  4-5° 
and  a  respiration  of  52  by  8  A.  M.  A  yellowish  purulent 
expectoration  with  frequent  suppressed  cough  had  replaced 
the  mucus.  By  the  afternoon  a  perfectly  typical  picture 
of  a  pneumonia,  with  an  involvement  of  the  right  lower 
lobe,  was  present.  There  was  a  general  bronchitis  of  the 
larger  and  smaller  bronchi,  moderate  dusky  color  of  skin. 
At  12  midnight  she  was  given  20  grs.  of  calomel  dry  on  the 
tongue  (see  chart).  At  4  P.  M.  the  succeeding  day  she 
was  sweating  profusely,  the  signs  in  the  chest  were  un- 
changed and  the  temperature  still  elevated.  From  this 
time  the  pulse  and  temperature  elevation  began  to  fall. 
The  leukocyte  count  showed  15,000  the  following  day  when 
resolution  began.  Two  days  later  the  count  showed  11.000. 
Resolution  progressed  slowly — twelve  days  later  the  lung 
had  not  cleared  up.  The  patient  (finally)  made  a  perfect 
recovery   with    primary    union    in    the   abdominal    wound. 


NameJX.S. 


ST.  LUKE'S  HOSPITAL 


_Ward 


_Ward 


Name.    E.    C. 


-Wabd- 


FlBure 


I020 


The  Philadelphia 
Medical   Journal 


]       TWO  CASES  OF  LOBAR  PNEUMONIA 


[Mat  2S,   1901 


There  was  no  purgation  from  the  calomel.  The  expectora- 
tion was  purulent  throughout  and  contained  no  blood. 
Three  days  following  defervescence  it  had  largely  ceased. 
The  bronchitis  cleared  up  long  before  the  signs  of  the 
exudate  into  the  lung.  Labial  herpes  present.  Chlor- 
ides in  the  urine  were  diminished  during  the  attack.  Al- 
bumen varied  from  a  trace  to  1%. 

E.  C.  Hospital  No.  48,727,  male  aged  31.  Admitted 
March  4,  1899.  History  negative  except  for  right  inguinal 
hernia  of  several  years  duration.  Physically  he  was  an 
unusually  well  developed  and  muscular  man  and  in  good 
condition.  Operation  two  days  later — gas  followed  by  ether 
anesthesia  of  three  quarters  of  an  hour  duration — pulse 
72 — respiration  18  on  return  to  the  ward.  Between  8  and  12 
midnight  the  temperature  rise  began,  there  was  no  chill — 
by  12  midday  the  signs  of  a  right  lower  lobe  pneumonia 
were  present.  There  was  a  general  bronchitis  with  mod- 
erately frequent  cough — expertoration  thick  and  purulent — 
skin  very  dusky — respiration  apparently  not  however  pro- 
proDortionately  accelerated.  At  bSiO  P,  M.  he  was  given  cal- 
omel grs.  XXV.  By  8  A.  M.  the  next  day  he  was  per- 
spiring profusely,  the  temperattire  had  fallen  to  100  3-3 '. 
the  signs  in  the  chest  were  unchanged.  Expectoration  the 
same — resolution  began  the  following  day  but  progressed 
slowly — expectoration  ceased  in  aljout  5  days.  In  both  of 
these  cases  there  was  a  perfectly  normal  condition  of  the 
chest  preceding  the  anesthetic  as  far  as  could  be  deter- 
mined by  the  physical  examination.  There  was  no  undue 
exposure  before,  during  or  following  the  operation.  The 
anesthesia  was  uneventful,  the  open  Allis  inhaler  was  used 


March  1899. 


The  fall  in  the  count  in  the  case  examined  was 
slow,  corresponding  to  the  delayed  resolution.  The 
above  cases  are  reported  because  they  seem  suffi- 
ciently interesting.  The  marked  and  persistent  phy- 
sical signs,  characteristic  temperature,  behavior 
ot  the  patient  and  leukocyte  count  make,  I 
think,  the  diagnosis  very  certain.  The  use  of 
mercury  in  this  connection  is  very  old,  com- 
paratively little  literature  has  appeared  upon  the 
subject  in  the  last  50  years.  There  is  reason 
to  believe  that  a  certain  number  of  patients  have 
been  benefited  by  such  treatment.  A  large  class 
undoubtedly  will  not  be.  \\'hether  the  measure  is 
one  that  should  be  tried  in  the  majority  of  cases,  or 
whether  the  subsidence  of  the  disease  in  these 
cases  was  due  to  the  drug  or  spontaneous  abortion 
are  matters  with  which  this  article  does  not  attempt 
to  deal. 


Discipline  in  Tuberculosis. — In  the  Jniinwl  de  ilederine 
(Ic  lliirilini.r  (1901.  No.  ]»)i.  Dr.  Portes,  Director  of  the 
Sanatorium  of  Gelos.  Pau,  describes  the  discipline  neces- 
sary in  tuberculosis.  Every  individual  with  phthisis  must 
be  taught  what  is  best  for  him.  This  can  be  best  accom- 
plished in  a  sanatorium,  which  Professor  Landouzy  calls 


Figure  ■; 


after  narcosis  was  induced.  The  clinical  picture  was  typi- 
cal of  lobar  pneumonia.  The  physical  signs  showed  an  in- 
volvement of  the  right  lower  lobe  in  each  instance  and 
sharply  defined.  The  calomel  was  given  early  in  the  dis- 
ease. There  was  no  purging  or  salivation  following  the 
mercury.  One  case  required  a  saline  and  enema  addition- 
ally. Resolution  began  about  2  days  after  defervescence  in 
each  case  and  was  somewhat  prolonged,  changes  in  breathing 
and  especially  dullness  on  percussion  persisted  for  some 
days  over  the  lobe.  The  l)ronchitis  cleared  up  5-6  days 
following  defervescence.  1  he  pulse,  characteristically  full 
at  the  beginning,  remained  of  good  force — there  was  no  ir- 
regularity of  rhythm  or  intermittent  character  precedint; 
defervescence. 

The  apparent  early  cessation  in  the  progress  of 
the  disease  so  soon  after  the  administration  of  a 
comparatively  large  dose  of  calomel  seems  signifi- 
cant and  worthy  of  consideration.  The  disease  de- 
veloping in  cases  already  under  observation  inade  it 
possible  to  administer  the  mercury  at  an  early  date. 
It  is  to  be  regretted  that  no  leukocj'te  count  was 
recorded  in  the  second  case  until  the  temperature 
was  ncarlv  normal,  and  that  more  were  not  made. 


the  school  for  the  tub^culous.  This  is  especially  neces- 
sary for  those  who  have  never  taken  care  of  ihemselvee. 
those  who  are  treating  themselves,  with  the  advice  of 
friends,  and  those  who  have  acquired  the  bad  habit  of  living 
Isolated,  absolutely  alone.  They  will  be  encouraged  In  a 
sanatorium,  will  rest,  receive  good  advice  only,  find  good 
air,  amusement  and  atmosphere  of  gaiety  and  companion- 
ship new  to  them.  Naturally,  some  patients  cannot  long 
live  happily  in  a  sanatorium.  But  they  will  have  learned 
how  to  live  when  they  leave:  hygiene,  diet.  rest,  exercisa, 
etc.,   having  been  regulated  to  suit  each  individual   case. 

[M.  0.] 


A  Case  of  Natural  Small-pox  in  an  Infant  of  3  Days  Old. — 
B.  P.  Voitsechowski  reported  to  the  Pediatric  Society  ot 
Kieff,  \  riitrh.  Vo/.  WII.  .Y«<.  im,  the  case  of  an  infant  who 
developed  on  the  third  day  of  its  birth  an  elevation  of  tem 
perature  and  an  eruption  which  became  pustular  on  the 
sixth  day.  A  diagnosis  of  small-pox  was  established.  The 
mother  had  been  vaccinated  and  was  at  the  time  perfectly 
heilthy.  The  period  of  incubation  being  10  to  14  days, 
the  author  believes  that  intrauterine  infection  took  place 
in  this  ease.  He  is  also  of  the  opinion  that  vaccination  of 
the  mother  does  not  protect  the  fetus  in  utero  against 
tmallpox.     [A.  R.] 


The  Philadelphia  Medical  Jouiml 

A  Weekly  Journal  OwneJ  and  Published  by  The  Philadelphia  Medical  Publishing  Company    and  Conducted 

Exclusively  in  ihe  Interests  of  the  Medical  Profession 

JAMES  HENDRiE  LLOYD,  A.  M.,  M.  D..  Editorin-Chiej        Scientific  Articles,  Clinic:il  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession 
TOLius  I,.  SALINGER,  M.  D.,  Aisoctate  Editor  are  solicited  for  publication.    Reprints  (250)  of  Original  Articles  will  be  furnished 

----■ '   F-j_^-_.  gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  rhiladelpliia  Medical  Journal.    1716  Chestnut  St.,  Philadelphia,  Pa. 

See  AdvertisiuB  Page  8. 


Assistant  Editors 
Jo.SEPH  Sailer,  M.  D.  F.  J.  Kaltever,  %'.  D. 

D.  I,.  Edsall,  M.  D.  T.  L.  Colev,  M.  D. 

J.  M.  Swan,  M.  D.  W.  A.  K.  DoRLAND,  M.  D 

J.  H.  Gibbon,  M.  D.  T.  M.  Tyson,  M.  D. 

>  M.  OsTHEiMER,  M.  D.  A,  Robin,  M.  D. 


Vol.  VII,  No.  22 


June  i,  '901 


$3.00  Per  Annum 


The  Reorganization  of  the  American  Medical  As- 
sociation.— \\'c  had  no  adequate  idea,  until  we  read 
the  report  of  the  Committee  on  Organization,  that 
the  American  Medical  Association  is  such  a  loosely 
organized  body  that  it  is  hardly  capable  of  attend- 
i  ing  to  its  business.     It  is,  in  fact,  so  unwieldj'  and 
I  so  uncertain  in  its  membership  and  has  such  a  lim- 
'  ited  time  at  its  disposal,  that  it  is  in  part  deprived 
ji  of  its  true  usefulness  and  influence  as  a  great  na- 
I  tional  representative  of  the  medical  profession.  Ac- 
I  cording  to  the  Committee,  it  has  less  than  seven 

(hours  a  year  in  which  to  transact  its  business.     Its 
potential  membership  depends  largely  upon  the  lo- 
cality in  which  it  happens  to  meet,  for  this  is  one 
,|  thing  in  Atlantic  City,  another  in  St.  Paul,  and  still 
i  another  in  San  Francisco.     Finally,  the  Association 
;  is  so  hurried  that  it  has  not  had  time  in  the  last  ten 
j  or  twelve  years  even  to  reform  itself;  this  is  shown 
I  by  the   Committee   in   its   narrative   of  the   former 
abortive  efforts  at  reorganization.    The  trouble  with 
I  the  Association  is  that  it  is  too  large  and  too  unsta- 
j  ble.     It  urgently  needs  reorganization,  and  its  best 
friends  demand  it. 

^^'e  can  approve  without  hesitation  the  scheme 
of  reorganization  now  proposed.    Minor  details  may 
!'c  criticised,  but  the  main  plan  is  broad  and  states- 
manlike.   This    plan    proposes    a    House  of  Dele- 
j  gates,  which  shall  be  the  Legislature  of  the  Associa- 
jl  tion.    In  effect,  this  body  will  be  a  Section  on  Busi- 
■  ness  and  will  have  nothing  to  do  but  to  attend  to 
business,  and  will  have  sufficient  time  in  which  to  do 

fit.  If  the  American  Medical  Association  has  wis- 
,  dom  (and  time),  it  will  surely  consider  this  propo- 

'  sition  or  some  simple  modification  of  it,  favorably. 
Such  a  legislative  body  being  elected  by  the  State 
Societies  on  a  basis  strictly  of  numerical  strength, 

'"  would  be  purely  representative  and  responsible, 
am!  would  not  be  a  fluctuating  and  indeterminate 

1  body,  such  as  the  main  Association  is  too  apt  to  be. 

'    Such  a  plan  is  closely  in     accord     with     the    ideas 

"  which  have  created  the  best  representative  bodies 
in  the  world — as,  for  instance,  in  the  .State  and  in 
the  church.  For  a  body  which  may  soon  number 
20,000  members  to  proceed  on  the  old  plan,  some- 
what like  an  old-fashioned  town   meeting,   with   a 


referendum,  is     simply    absurd.     The    Association 
needs  a  Legislature  and  should  have  it. 

Concerning  minor  details,  we  should  perhaps 
doubt  the  expediency,  or  at  least  the  popularity,  of 
conferring  upon  this  House  of  Delegates  the  whole 
elective  power  of  the  Association.  We  believe  that, 
in  the  main,  it  is  the  best  for  a  society  (medical  or 
political)  to  elect  its  own  officers  and  not  have  them 
elected  for  it.  But  this  is  a  detail  for  the  American 
Medical  Association  to  settle  for  itself.  The  cen- 
tral, pivotal  idea  is  that  the  Association  must  be  bet- 
ter organized  than  it  is  at  present. 

Pancreatitis. — .Mr.  Mayo  Robson,  in  his  valuable 
article  upon  pancreatitis,  published  in  another  col- 
umn of  this  week's  issue,  calls  attention  to  the  ig- 
norance of  this  subject  that  exists  in  the  profession 
as  a  whole,  an  ignorance  fostered,  we  fear,  by  the 
studious  neglect  of  this  organ  in  the  current  text- 
books of  medicine  and  surgery.  Although  we  un- 
doubtedly know  more  of  the  physiology  of  the  pan- 
creas than  of  the  thyroid,  for  example,  yet  the 
symptomatolo,gy  of  its  diseases  is  so  indefinite  and 
confused  that  it  has  hitherto  been  a  very  unsatisfac- 
torv  field  of  research.  If  Mr.  Robson  will  accom- 
plish for  it  what  Kocher  has  accomplished  for  the 
thyroid  gland,  he  will  deserve  the  lasting  gratitude 
of  the  medical  world. 

]\]r.  Robson  calls  attention  to  the  importance  of 
injury  as  an  etiological  factor.  We  have  long  sus- 
pected that  the  sickening  sensation  following  a 
blow  on  the  epigastrium  was  the  result  of  bruising 
the  pancreas  rather  than  the  solar  plexus,  as  it  is 
the  fashion  to  believe.  But  our  author  believes 
that  gall-stones  are  even  more  important  in  this 
connection.  A  priori,  this  seems  not  unlikely,  for 
anything  setting  up  an  inflammatory  condition  of 
the  common  bile  duct  would  naturally  involve  sec- 
ondarily the  duct  of  \\'irsung. 

The  data  upon  which  Robson  relies  for  the  diag- 
nosis of  pancreatitic  disease  are  very  scanty.  An 
abnormal  amount  of  fat  in  the  stools  (a  small 
amount  is,  of  course,  normal)  is  only  a  contribu- 
tory svmptom.  Pain  in  the  epigastrium  and  rapid 
emaciation  are  common  to  many  conditions ;  for 
example,  gastric  carcinoma.    Jaundice  is  merely  the 


I022 


The  Philadelphia"! 
Medical  Journal   J 


EDITORIAL  COMMENT 


[June  t  uoi 


symptom  of  a  common  complication.  He  appar- 
enth-  is  unfamiliar  with  or  does  not  value  the  dis- 
appearance of  the  ethereal  sulphates  from  the  urine. 
We  should  be  inclined  to  place  considerable  value 
upon  this  sign.  His  remarks  upon  hemorrhage  are 
of  great  interest.  Admitting  a  pronounced  hemor- 
rhagic tendency,  he  does  what  few  have  hitherto 
attempted,  and  suggests  an  explanation.  It  is  that 
the  glycerin  liberated  in  the  process  of  fat  necrosis 
is  absorbed  by  the  blood  and  interferes  with  coagu- 
lation. To  our  mind  it  would  be  more  reasonable 
to  suppose  that  the  pancreatic  juice  that  escapes 
into  the  tissues  gives  rise  to  the  formation  of  pep- 
tones or  albumoses,  whose  anticoagulant  action  is 
well  known.  In  the  treatment  of  the  hemorrhagic 
tendency  he  employs  chloride  of  calcium  before  and 
after  operation,  and  for  periods  and  in  doses  quite 
contrary  to  the  prevalent  teaching;  that  is,  there 
is  no  stopping  at  the  end  of  three  days.  He  does 
not  seem  to  be  aware  of  the  very  excellent  results 
obtained  by  Kehr  in  the  treatment  of  cholemic  hem- 
orrhage by  gelatin  injections  nor  of  the  advantages 
claimed  for  the  prophylactic  injections  of  the  same 
substance  by  Jaboulay. 

Finally,  we  wish  to  express  our  heartiest  admira- 
tion for  the  courage  Mr.  Robson  has  shown  in  break- 
ing away  from  the  old  tradition,  and  classifying 
pancreatitis  under  the  acute,  sub-acute  and  chronic 
forms.  Whj'  the  inflammation  of  this  organ  should 
differ  so  greatly  from  that  of  other  glands  has  al- 
ways been  a  mystery,  and,  like  most  other  myster- 
ies, apparenth'  solely  of  human  making. 

Trichinosis  as  an  Economic  Problem. — At  a  re- 
cent meeting  of  the  Philadelphia  Pathological  So- 
ciety an  important  paper  on  this  subject  was  read 
by  Dr.  Charles  Wardell  Stiles,  of  the  Bureau  of 
Animal  Industry  at  Washington.  Dr.  Stiles'  evident 
object  was  to  demonstrate  the  futility  of  the  Ger- 
man method  of  microscopic  inspection  of  pork,  and 
to  prove  that  the  presence  of  trichinosis  in  Germany 
is  due  to  the  German  habit  of  eating  raw  meat.  If 
the  Germans  would  cook  their  pork  they  would  not 
have  trichinosis,  and  if  they  do  not  cook  it  tTiey  will 
continue  to  have  the  disease  whether  they  eat 
American  pork  or  some  other  pork  and  whether  thev 
inspect  it  or  not.  In  other  words,  trkhinella  spiralis 
is  not  confined  to  American  hogs,  and  it  cannot  be 
eliminated  by  microscopic  inspection.  In  the  first 
place,  the  disease  is  much  less  prevalent  in  America 
than  in  Germany.  Dr.  Stiles  collected  only  about 
900  cases  in  this  country  from  i860  to  1895,  although 
he  thinks  the  disease  is  rather  more  common  than 
these  figures  indicate.  The  significant  fact  is  that 
of  274  American  cases  in  which  the  nationality 
could  be  determined,  only  four  were  in  American- 
born  persons,  while  208  were  in  German  emigrants. 


This  tells  the  whole  story.  Again,  during  the  years 
1883-1891,  when  American  pork  was  prohibited  in 
Germany,  there  were  4093  cases  of  trichinosis  re- 
ported in  the  Empire  with  274  deaths.  The  mortal- 
ity for  eighteen  years  was  about  5%. 

Dr.  Stiles  presents  elaborate  tables  to  prove  .that 
the  system  of  meat  inspection  in  vogue  in  Germany 
is  not  a  success.  He  denies  that  the  systematic 
attacks  on  American  pork  in  the  German  agrarian 
press  find  any  support  in  the  accessible  German 
health  statistics.  He  points  out  that  Virchow  has 
not  admitted  some  of  the  evidence  against  Ameri- 
can pork  as  valid.  Many  cases  occur  due  to  faults 
in  the  inspection  methods,  and  this  fact  leads  Dr. 
Stiles  to  condemn  the  method  by  microscopic  in- 
spection as  unreliable  and  extremely  expensive. 
Prussia  alone  employed  in  1896  an  army  of  27,602 
inspectors  at  a  great  expense,  and  an  adequate  corps 
of  inspectors  for  the  United  States  would  probably 
mean  a  tax  upon  the  people  of  $3,000,000  or  S4.000,- 
000  per  annum.  The  inspection  method  tends  to 
foster  a  false  sense  of  security,  and  hence  encour- 
ages the  people  in  their  habit  of  eating  raw  pork. 
The  only  safety  is  in  cooking  the  meat,  and  to  thi4 
custom  he  attributes  the  comparative  immunity  ol 
the  American  people.  The  trichiiiclla  spiralis,  it  will 
be  remembered,  was  accidentally  discovered  in  a 
ham-sandwich  by  Professor  Leidy,  of  PhiladelphiOi 
in  1847 ;  and  Dr.  Stiles  does  full  justice  to  the  fame 
of  this  eminent  man  and  the  momentous  importance 
of  his  disco\ery. 

A  Trolley  Ambulance  Service. — The  thought  has 
probably  occurred  to  not  a  few  persons  that  a  trol- 
ley car  might  be  made  into  an  ideal  ambulance.  The 
smoothness  with  which  it  can  be  run,  and,  above  all, 
the  quick  time  that  can  be  made  with  it.  are  feat- 
ures which  make  it  far  superior  to  the  horse-ambu- 
lance. Then  it  is  much  more  roomy — a  matter  of 
importance  in  some  emergency  cases.  Instances 
have  occurred  in  this  city  in  which  the  trolley  has 
been  used  for  ambulance  service  with  most  gratify- 
ing success.  A  few  months  ago  a  physician  had  oc- 
casion to  bring  a  bed-ridden  patient  to  her  home  in 
West  Philadelphia  from  a  location  far  out  on  the 
York  Road.  The  distance  was  more  than  ten  miles, 
and  by  horse-ambulance  the  journey  would  have 
been  a  long,  painful  and  somewhat  risky  one.  The 
happy  thought  occurred  to  the  doctor  to  have  a 
trolley  car ;  and  this  was  secured,  and  the  patient 
moved  with  speed,  comfort  and  safety.  It  is  due 
to  the  Traction  Company  to  say  that  in  this  case 
a  very  moderate  charge  was  made — less,  in  fact, 
than  was  asked  for  the  service  of  a  hospital  ambu- 
lance, although  two  men,  a  motorman  and  a  con- 
ductor, were  required.  Probably  not  one-half  the 
time  was  taken  that  would  have  been  needed  iat 


June  1,  1901] 


EDITORIAL  COMMENT 


TThe  Philadelphia 
L  Medical  Journal 


1023 


the  ordinary  ambulance,  while  the  comfort  (both 
physical  and  mental)  to  the  patient  was  far  greater. 
We  think  it  would  be  a  good  idea  for  the  Traction 
Company  to  have  a  completely  equipped  trolley 
ambulance.  We  have  no  doubt  it  would  be  patron- 
ized, were  it  once  known. 

Cryoscopy. — Cryoscopy   may   be    defined    as   the 
determination  of  the  osmotic  pressure  of  liquids  at 
the?r  freezing-points.  The  lowering  of  the  freezing- 
point  is  directly  proportionable  to  the  osmotic  pres- 
sure of  the  liquid.     Cryoscopy  is  a  method  intro- 
duced by  Raoult,  of  Grenoble,  for  the  purpose  of 
measuring  the  urinary  toxicity  as  well  as  furnishing 
enlightenment  upon  the  metabolic  changes  in  the 
blood,  cerebrospinal  fluid  and  pleural  fluid.     It  has 
been  found  that  the  determination  of  the  freezing- 
points  of  these   fluids  of  the   body  present    certain 
appreciable    differences    in    certain    diseases.      The 
method  has  a  wide  field  of  usefulness  both  in  experi- 
mental research  and  in  the  diagnosis  and  prognosis 
of  disease.     At  present  it  is  in  its  infancy,  but  the 
increasing  reports  of  work  done  in  cryoscopy  bear 
out  the  originator's  claims  of  its  value.     According 
to  Cushny,  osmotic  pressure  may  be  defined  as  the 
resistance  oflfered  by  a  non-permeating  salt  to  the 
passage  through  the  membrane  of  the  fluid  in  which 
it  is  dissolved.    When  both  salts  in  solution  on  the 
opposite  sides  of  the  membrane  are  unable  to  pass 
through  it,  the  movement  of  the  fluid  is  determined 
by  the  relative  osmotic  pressure  on  the  two  sides, 
water  tending  to  pass  from  the  solution  of  the  lower 
osmotic    pressure     (hypotonic  solution)     to    that     of 
the  higher  (hypertonic  solution).  WHien  an  equilibrium 
is  established  between  the  two  solutions  they  are 
said  to  be  isotonic.     In  the  animal  body  there  is  an 
analogue  to  the  membrane  and  the  salt  solutions 
in  the  fact  that  the  body-cells  consist  of  colloid  sub- 
stances containing  fluid  and  diffusable  bodies,  and 
are  surrounded  by  liquids  which  are  practically  salt 
solutions,   isotonic  with  the  contents  of  the   cells. 
Any  changes  in  the  cells    or    surrounding    lymph 
give  rise  to  certain  movements  of  the  fluids  in  the 
same  manner  as  if  each  cell  were  surrounded  by  a 
memln-ane.     The   red   blood   corpuscles   have   been 
studied  carefully  in  their  action    to    certain    salts. 
They  are  found  to  be  permeable  to  ammonium  chlo- 
ride and  impermeable  to  sodium  chloride  and  other 
salts  of  the  fixed  alkalies.  The  study  of  metabolism 
involves  a  consideration  of  renal  secretion,  and  it  is 
in  this  work  that  cryoscopy  has  a  physiological  sci- 
entific value  as  well   as   a  practical  application   to 
the  physician.     By  its  means  we  are  enabled  to  de- 
termine the  question  of  renal  sufiiciency  or  insuf- 
fiency.     And  it  is  found  that  in  cases  of  nephritis 
there  is  a  lowering  of  the  cryoscopic  point,  and  an 
elevation  of  that  of  the  blood.    Normal  urine  freezes 


at  about  1.35  C,  indicating  a  mean  molecular  weight 
of  62-63  (Bouchard).  Extremes  in  health  vary  from 
60  to  68.  In  pathological  conditions  the  mean  mole- 
cular weight  may  vary  from  68  to  112,  sometimes 
the  higher  value  indicates  the  presence  of  disease,, 
such  as  syphilis,  which  otherwise  might  often  be 
overlooked.  The  freezing-point  of  the  blood  varies 
littlefrom — .s6C.  It  is  elevated  in  grave  anemias  and 
the  cachexias,  but  lowered  by  accumulation  of  car- 
bon dioxide  in  the  blood  and  by  the  retention  of  ex- 
crementitious  products.  In  the  latter  case  oxygen 
does  not  cause  the  freezing-point  to  return  to  nor- 
mal, while  in  the  case  of  the  accumulation  of  carbon 
dioxide,  oxygen  makes  the  freezing-point  again 
— .56C.  Acetone  is  found  to  lower  it  markedly,  and 
the  diet  must  be  uniform  in  performing  this 
method. 

From  the  results  of  his  experiments  in  cryoscopy, 
Ldon  Bernard  believes  that  the  renal  permeability- 
is  normal,  or  even  increased,  in  the  early  stages  of 
parenchymatous  nephritis,  but  the  kidney  has  prob- 
ably other  functions,  as  yet  unknown,  which  when 
disturbed  cause  the  production  of  uremia.  Wald- 
vogel,  examining  the  blood  in  typhoid  fever,  con- 
cludes that  the  higher  freezing-point  of  the  blood 
is  not  necessarily  indicative  of  uremia.  It  is  evi- 
dently not  so  much  the  quantity  as  the  quality  of 
the  toxic  substances  retained  in  the  blood  that 
causes  the  disturbance  in  uremia.  The  freezing- 
point  is  higher  in  certain  cases  of  typhoid  fever, 
and  Waldvogel  makes  the  interesting  observation 
that  this  is  probably  a  phenomenon  connected  di- 
rectly with  the  formation  of  antitoxin.  In  the  cases 
in  which  the  freezing-point  is  only  slightly  above 
normal — below  — ./C. — the  prognosis  of  the  disease 
is  generally  unfavorable.  Repeated  cryoscopy  of  the 
fluid  of  a  pleural  effusion,  it  is  claimed,  will  reveal 
the  indication  for  intervention. 

A  Remedy  for  Sleeplessness. — Irreverent  read- 
ers may  smile  when  they  learn  that  a  college  presi- 
dent has  written  a  discourse  on  insomnia.  Every 
clergyman  is  supposed  to  carry  a  simple  remedy  for 
this  dread  malady  in  his  sermons,  but  the  Rev.  Wil- 
liam DeWitt  Hyde,  of  Bowdoin  College,  bravely 
ignores  the  possibility  of  jokes  at  his  expense  and 
writes  very  entertainingly  in  the  Outlook  about  how, 
to  go  to  sleep.  His  method  is  somewhat  compli- 
cated, and  we  will  not  spoil  the  description  of  it  by 
paraphrasing  it  here.  Sufficient  to  say,  it  consists 
in  a  sort  of  rhythmical  breathing,  with  alternate 
closing  and  opening  of  the  eyes.  Dr.  Hyde  pleasantly 
says  that  he  has  not  patented  the  process  and  in- 
tends to  collect  no  fees  for  it,  but  he  vvould  like  to 
hear  by  mail  from  all  persons  who  find  it  efficacious. 
It  is  based  upon  a  rather  well-known  fact  that  the 
quality  of  rhythm,  or  the  monotonous  repetition  of 


I024 


The  Philadelphia"! 
Medical   Journal  J 


EDITORIAL  COMMENT 


[Jlke   1.   1901 


an  act,  has  a  soporific  effect.  Counting  in  imagina- 
tion a  flock  of  sheep,  one  after  the  other,  jump  over 
a  fence,  is  based  on  the  same  principle. 

A  Philadelphia  Specialty. — The  New  York  Sun 
has  recently  been  having  a  little  fun  with  this  city 
on  the  subject  of  appendicitis.  After  quoting  from  a 
prominent  Philadelphia  surgeon,  it  comes  to  the 
conclusion  that  the  Quaker  City  is  the  center  and 
capital  of  that  disease.  This  is  a  distinction  which 
we  will  try  to  support  with  becoming  modesty.  We 
do  not  doubt  for  a  moment  that  by  reason  of  the 
brilliant  work  of  her  surgeons,  Philadelphia  is  the 
capital  not  only  of  appendicitis,  but  of  all  kinds  of 
surgery  as  well.  This  has  ever  been  so  and  doubt- 
less will  continue  to  be  so.  The  fact  that  a  metro- 
politan newspaper  has  discovered  this  truth  is 
greatly  to  its  credit.  The  Swi  says  that  rich  Phila- 
delphians  can  afford  to  have  appendicitis,  and  they 
do  have  it ;  but  they  seldom  die  of  it.  This,  we  af- 
firm, is  evidentl)'  because  they  have  Philadelphia 
surgeons  to  attend  them.  The  causes  assigned 
for  the  prevalence  of  appendicitis  here  and  here- 
abouts are  the  low-lying  land  (home  of  "miasma, 
hay-fever  and  grip"),  and  the  athletic  pursuits  of 
the  inhabitants.  Golf,  cricket,  and  bicycling  in  ex- 
cess, disturb  the  equilibrium  of  the  appendix.  But 
the  Sun  affirms  that  a  little  appendicitis  is  not  too 
high  a  price  to  pay  for  out-door  sport,  and  it  evi- 
dently believes  that  the  proper  thing  for  the  vic- 
tims everywhere  to  do  is  to  resort  to  the  "capital" 
of  the  disease  for  care  and  treatment. 

The  New  Medical  Laboratories  of  the  University 
of  Pennsylvania. — The  problem  of  the  combination 
of  undergraduate  instruction  with  post-graduate  re- 
search work  is  always  a  difficult  one  for  any  insti- 
tution to  solve  satisfactorily.  A  school  that  is  con- 
cerned in  giving  elementary  instruction  to  under- 
graduates places  a  great  strain  upon  instructors 
and  professors  and  makes  a  great  demand  upon  its 
financial  and  material  resources.  With  the  system 
of  concentration  of  the  curriculum  recently  intro- 
duced by  the  faculty  of  medicine  of  the  University 
of  Pennsylvania,  a  step  toward  the  practical  solu- 
tion of  this  problem  has  been  taken.  Bj-^  condens- 
ing the  time  during  which  the  undergraduates 
claim  the  energies  of  the  teaching  staff,  that  staff 
is  freed  for  a  portion  of  the  year  to  devote  its  ener- 
gies to  research  and  to  the  direction  of  original  work 
b}^  advanced  or  graduate  students.  This  step  is  now 
to  be  followed  by  another  step  of  great  importance. 
The  trustees  of  the  University  have  decided  to  pro- 
vide the  necessary  laboratories  in  which  this  ad- 
vanced work  can  be  carried  on,  as  well  as  modern 
and  commodious  laboratories  in  which  the  under- 
graduates may  work,  together  with  lecture  halls 


and  demonstration  rooms  under  the  same  roof.  The 
new  building,  according  to  the  plans  submitted,  is 
a  two-story,  oblong  structure,  with  a  central  court- 
yard, the  long  sides  of  which  face  north  and  south, 
thus  securing  a  maximum  amount  of  the  best  light. 
The  first  floor  will  be  devoted  to  laboratories  of 
physiology,  pharmacy  and  pharmacodynamics.  The 
arrangement  of  the  building  is  so  carried  out  that 
the  rooms  for  advanced  work  are  entirely  separate 
from  those  used  by  the  undergraduates.  There 'are 
separate  rooms  for  professors  and  demonstrators, 
as  well  as  the  necessary  store-rooms,  etc.  The  en- 
tire second  floor  is  to  be  devoted  to  pathological  lab- 
oratories. In  the  front  of  the  building,  along  the 
entire  north  side,  there  are  small  private  rooms  for 
research,  as  well  as  a  room  for  the  professor.  In 
the  back  of  the  building  there  is  a  large  laboratory 
for  the  study  of  pathological  histology,  as  well  as 
smaller  rooms  devoted  to  neuropathology,  compar- 
ative pathology  and  surgical  pathology.'.  The  west 
end  contains  the  laboratory  for  advanced  bacteri- 
ology, a  pathological  museum,  a  room  for  demon- 
strations in  morbid  anatomy,  a  room  for  micro- 
photography,  and  store-rooms  for  supplies  and  mi- 
croscopes. In  the  east  end  there  is  a  large  labora- 
tory for  experimental  pathology  and  a  laboratory  for 
advanced  pathology.  The  lecture  rooms  occupy  a 
separate  extension  from  the  south  side  of  the  build- 
ing and  the  demonstration  rooms  are  in  the  center 
of  the  court-yard  between  the  north  and  south  sides 
of  the  oblong.  It  is  the  purpose  of  the  trustees  of 
the  University  of  Pennsylvania  to  equip  these  labo- 
ratories with  all  the  apparatus  that  modern  knowl- 
edge has  shown  to  be  necessary  to  the  successful 
pursuit  of  these  branches  of  medical  education.  This 
plan  will  put  the  University  of  Pennsylvania  in  pos- 
session of  a  plant  that  will  be  without  a  rival  in  this 
or  other  countries,  so  that  the  undertaking  is  one 
not  only  of  local,  but  also  of  national  importance. 
\A'e  look  forward  with  much  pleasure  to  the  com- 
pletion of  this  elaborate  scheme  and  extend  our 
best  wishes  for  complete  success  to  the  Univer- 
sity of  Pennsylvania  in  its  undertaking. 

The  Fate  of  the  Uterus  in  Abdominal  Section. — 
.\.  matter  which,  like  Banquo"s  ghost,  constantly  re- 
curs to  haunt  the  pelvic  surgeon,  is  the  question 
of  the  disposal  of  the  uterus  after  the  operation  of 
double  salpingo-oophorectomy.  Again  and  again 
do  we  see  the  disconsolate  victims  of  pelvic  disease 
returning  to  the  office  or  clinic  room  with  the  re- 
currence of  all  their  distressing  symptoms — minus 
the  formation  of  pus-sacs — after  the  removal  of  their 
uterine  appendages.  In  a  small,  and  a  very  small, 
proportion  of  these  cases  will  recovery  ensue  after 
a  tedious  course  of  intrauterine  treatment  covering 
a  period  of  months  or  years.    Many  of  these  unfor- 


i 


June  1,  1901] 


EDITORIAL  COMMENT 


[ 


The  Philadelphia 
Medical.  Journal 


I025 


tunate  women  wander  from  hospital  to  hospital  and 
from  surgeon  to  surgeon,  in  the  vain  quest  for 
health,  and  become  the  deplorable  subjects  of 
chronic  hospitalism,  an  eye-sore  to  the  doctors  and 
an  incumbrance  to  themselves,  their  families  and 
the  community.  Discouraged  by  the  failure  of  the 
first  operation,  they  often  refuse,  even  when  urged, 
to  submit  to  another  abdominal  section.  Pelvic  sur- 
gery suffers  in  repute  from  these  failures  to  cure, 
and  the  individual  surgeon  loses  thereby  a  portion 
of  his  prestige.  Naturally,  we  ask,  what  is  the  rem 
edy  for  this  matter?  Should  the  uterus  be  removed 
whenever  the  appendages — tubes  or  ovaries — are 
removed?  Or  are  there  certain  cases  only  in  which 
the  more  extensive  extirpation  may  be  performed? 
It  would  be  as  dogmatic  to  lay  down  a  positive 
statement  in  one  direction  as  in  the  other.  The  sur- 
geon who  states  that  the  uterus  after  extirpation  of 
the  appendages  is  a  useless  organ,  a  menace  to  the 
woman,  and  therefore  should  be  removed  when  its 
adnexa  are  lost,  is  making  just  as  sweeping  a  state- 
ment as  is  his  colleague,  who  claims  that  in  the  ab- 
sence of  marked  apparent  uterine  disease  the  organ 
should  always  be  retained.  In  other  words,  there 
is  a  radicalism  that  is  too  radical  as  there  may  be  a 
conservatism  that  is  dangerous  and  therefore  repre- 
hensible. A  close  investigation  into  the  uterine  con- 
dition in  the  unfortunate  class  of  women  referred  to 
almost  invariably  shows  a  chronic  form  of  endome- 
tritis and  metritis  very  often  associated  with  an  ex- 
tensive parametritis,  that  can  be  remedied  only  by 
removal  of  the  offending  organ.  Often  it  will  be 
found  to  be  of  gonorrheal  or  tuberculous  origin. 
Now  it  stands  to  reason  that  a  local  tuberculosis 
wherever  found  is  a  menace  to  health,  and  should 
be  removed  as  quickly  as  detected.  A  tuberculous 
endometritis  is  as  dangerous  as  a  cheesy  lymph- 
gland  or  a  tuberculous  testicle.  The  local  disease 
may  at  any  time  light  up  a  general  conflagration 
that  will  quickly  destroy  the  patient.  Again,  the 
curious  anatomical  relationship  of  the  utricular 
glands  makes  the  eradication  of  gonorrheal  infection 
practically  impossible,  while  a  streptococcic  inva- 
sion of  the  parametrium,  resulting  in  the  develop- 
ment of  tubal  or  ovarian  abscess,  may  so  deterior- 
ate the  vitality  of  the  tissues  around  the  uterus  that 
a  cure  is  possible  only  after  extirpation  of  that  or- 
gan, whereby  thorough  evacuation  and  drainage  of 
the  infected  region  will  be  secured.  Unfortunately, 
the  pelvic  conditions  are  so  obscure  that  it  is  beyond 
the  power  of  the  operator  in  every  given  case  to 
state  positively  what  is  the  degree  of  infection  and 
what  the  probable  outcome  of  a  simple  removal  of 
the  apendages  will  be.  A  careful  study  of  the  scrap- 
ings of  the  uterine  cavity  will  solve  the  question  in 
a  certain  portion  of  the  cases.    The  condition  of  the 


parts  at  the  time  of  operation  will  be  the  guide  in 
another  proportion.  The  operator  must  in  other 
cases  be  influenced  by  the  ability  of  his  patients  to 
stand  the  graver  operation  of  hystero-oiiphoro-sal- 
pingectomy.  The  following  rules  may,  however,  be 
laid  down  as  safe  to  follow:  i.  The  uterus  should 
be  removed  in  every  case  in  which  the  tubercle  bac- 
illus is  discovered  in  the  uterine  scrapings.  2.  In 
every  grave  double  tubal  affection  of  gonorrheal 
origin,  extirpation  of  the  uterus  would  seem  to  be 
indicated,  since  the  simple  excision  of  the  append- 
ages removes  but  a  portion  of  the  diseased  tissue 
and  leaves  the  balance  to  become  a  source  of  trouble 
and  suffering  to  the  patient.  3.  In  extensive  in- 
volvement of  the  broad  ligament  by  the  streptococ- 
cus subsequent  to  parturition  at  term  or  premature 
expulsion  of  the  ovum,  the  uterus  should  be  removed 
in  order  to  afford  free  pelvic  drainage. 

The  Trouble  at  Gallipolis. — It  is  much  to  be  re- 
gretted that  pathological  laboratories,  established 
and  supported  by  the  State,  cannot  be  conducted' 
without  disastrous  factional  fights.  Following  hard 
upon  the  trouble  in  the  New  York  Pathological  In- 
stitute, there  now  comes  word  of  a  violent  quarrel 
over  the  pathological  laboratory  in  the  Ohio  Hos- 
pital for  Epileptics  at  Gallipolis.  Each  faction  is 
led  by  a  medical  man,  and  each  of  these  at  our  re- 
quest has  sent  us  his  own  version  of  the  affair.  Dr. 
A.  P.  Ohlmacher,  who  is  favorably  known  for  his 
scientific  work  at  Gallipolis,  states  that  he  was  sum- 
marily discharged  by  Dr.  H.  C.  Rutter,  the  manag'er 
of  the  Hospital,  for  the  alleged  but  false  reasons 
that  he  had  failed  to  publish  anything  for  a  year 
past,  and  that  the  expense  of  his  salary  was  too 
great.  He  claims  that  he  has  made  seven  contribu- 
tions to  science  within  the  year,  but  he  does  not 
give  their  titles.  Dr.  Rutter  charges  broadly  that 
Dr.  Ohlmacher  has  neglected  his  work,  and  that  he 
does  not  contribute  enough  to  science  to  justify  the 
expense  of  his  salary.  Each  man  charges  that  his 
opponent  is  identified  with  a  political  faction  in  an 
effort  to  keep  control — and  this  is  the  one  point  upon 
which  they  both  entirely  agree.  Dr.  Rutter  asserts 
that  he  himself  has  been  the  virtual  founder  and 
supporter  of  the  laboratory,  securing  appropriations 
for  its  maintenance  and  meeting  the  criticisms  of 
the  politicians — a  thankless  but  indispensable  office, 
and  one  which  is  too  little  appreciated  by  imprac- 
tical editorial  critics. 

Governor  Nash,  of  Ohio,  has  very  abruptly  set- 
tled the  trouble  by  refusing  to  allow  Dr.  Ohlmacher 
to  be  discharged,  and  by  discharging  Dn  Rutter  in- 
stead. It  thus  appears  that  Dr.  Ohlmacher  is  tri- 
umphant, and  he  claims  that  the  result  is  a  victory 
for  science,  while  Dr.  Rutter  says  that  it  is  a  victory 
for  politics.    The  duty  now  seems  incumbent  upon 


1026 


The  Philadelphia"! 
Medicai,   Journal  J 


EDITORIAL  COMMENT 


tJUNE    1,    1901 


Dr.  Ohlmacher  of  meeting  the  charge  that  he  has 
been  neglecting  his  work — a  task  which  we  should 
suppose  not  to  be  difficult.  His  reputation  is  ex- 
cellent, and  he  owes  it  to  himself  and  his  specialty 
to  keep  it  so.  We  do  not  presume  to  sit  in  supreme 
judgment  on  the  case.  The  exact  merits  of  the 
quarrel,  we  confess,  are  not  entirely  clear  to  us, 
but  we  wish  sincerely  that  it  had  not  happened. 
It  weakens  the  cause  of  science. 

The  Cause  of  Rheumatic  Fever.— The  older  the 
ories,  that  rheumatic  fever  is  due  to  lactic  acid,  ad- 
vanced by  Prout,  and  its  nervous  origin  advocated 
by  John  K.  Mitchell,  in  1831,  have  given  place  to  the 
more  generally  accepted  view,  that  the  disease  is  of 
an  infectious  character.  The  frequency  with  which 
the  disease  occurs  in  the  same  house  and  its  preva- 
lence in  large  communities  have  been  emphasized 
by  many  writers  to  support  the  latter  theory.  News- 
holme,  in  1805  (Milroy  Lectures),  advanced  im- 
portant statistical  evidence  to  prove  its  infectious 
jiature  and  showed  that  the  mortality  and  frequency 
of  rheumatic  fever  fluctuate  in  a  manner  similar 
to  those  of  erysipelas  and  scarlet  fever. 

In  1891  Bouchard  and  Charrin  claimed  to  have 
often  found  the  staphylococcus  pyogenes  albus  in 
the  aflfected  joint-fluid  of  subacute  and  chronic 
cases.  In  1893  Saint  Germain  succeeded  in  produc- 
ing ioint  inflammation  with  cultures  of  staphylo- 
cocci by  intravascular  inoculation.  The  following 
year  Saca7e  suggested  that  the  tonsils  were  the 
channels  through  which  infecti(Mi  occurred.  Singer, 
in  1895,  reported  a  numl)er  of  cases,  in  which  staphy- 
lococci were  found  in  tlie  urine  in  ten  cases  and 
twice  in  the  blood  ;  streptococci  in  the  urine  in  three 
instances  and  the  streptococcus  pyogenes  with  the 
staphylococcus  pyogenes  albus  in  the  urine  in  two 
cases;  while  in  one  instance  he  found  the  staphy- 
lococcus pyogenes  aureus.  Chbostek  did  not  suc- 
ceed in  finding  micro-organisms  in  the  urine  in  nine 
out  of  twelve  cases.  Sahli  isolated  the  staphy- 
lococcus pyogenes  citrus  from  the  blood,  synovial 
membranes  of  the  joints  and  the  pericardial  and  en- 
docardial exudates  of  a  fatal  case  of  rheumatic  fe- 
ver. Sternberg  sustained  the  view  that  pus  cocci 
are  responsible  for  the  disease,  the  infection  occur- 
ring when  the  natural  immunity  of  an  individual 
is  lost. 

We  especially  wish  to  direct  attention  to  the 
important  investigations  of  Poynton  and  Paine 
(Lancet,  May  4th,  1901).  These  observers  have 
isolated  a  diplococcus  from  sixteen  cases  of  rheu- 
matic fever.  In  a  brief  summary  of  their  work  they 
statei  that  in  three  rheumatic  nodules,  taken  from 
two  cases,  they  have  demonstrated  this  diplococ- 
cus; in  one  instance  they  succeeded  in  isolating  the 
micro-organism  from  the  nodule  in  pure  culture,  and 


that  intravenous  inoculation  of  this  culture  in  a 
rabbit  produced  polyarthritis,  pericarditis,  and  val- 
vulitis. The  diplococcus  .was  again  isolated  from 
the  joint-exudate  of  this  animal.  They  maintain 
that  the  rheumatic  nodule  should  be  regarded  as  a 
highly  characteristic  manifestation  of  the  disease. 
They  also  suggest  the  association  of  this  infection 
with  the  commencement  of  rheumatic  chorea.  In 
October,  1900,  these  investigators  reported  a  case 
which  they  believed  to  be  chorea  in  a  rabbit,  due  to 
the  intravenous  injection  of  this  diplococcus.  The 
animal  presented  definite,  sudden,  involuntary 
movements,  which  are  so  characteristic  of  rheumatic 
chorea,  and  also  developed  polyarthritis  and  valvu- 
litis. In  the  brain  of  the  animal  were  found  diplo- 
cocci, — in  the  endothelial  cells  of  the  blood  capil- 
laries of  the  motor  cortex  and  in  the  pia  mater.  In 
the  last  named  structure  there  was  also  slight  cellu- 
lar proliferation  and  cellular  swelling.  From  these 
observations  Poynton  and  Paine  conclude  that  the 
presence  of  this  diplococcus  lends  strong  support  to 
the  view  that  it  is  the  specific  cause  of  rheumatic 
fever. 

Hospital  Contagion  in  Typhoid  Fever. — The  pos- 
sibility of  direct  contagion  in  typhoid  fever  has  again 
been  discussed  at  a  recent  meeting  of  the  Medical 
Society  of  the  Paris  Hospitals  (Bulletins  et  Memoircs 
dc  la  Soeictc  Mcdicale  des  Hopitaux  dc  Paris,  1901,  No. 
4).  Troisier  reported  the  case  of  a  patient  with 
dilatation  of  the  stomach,  in  whom  lavage  with  un- 
boiled, filtered  water,  was  performed  daily.  37 
days  after  admission,  typhoid  fever  developed.  As 
there  were  9  cases  of  typhoid  in  the  ward,  it  is  pos- 
sible that  direct  contagion  occurred,  though  the 
water  used  for  washing  out  the  stomach  might  have 
been  contaminated.  Le  Gendre,  in  his  thesis,  in  1886, 
noted  that  dilatation  of  the  stomach  was  favorable 
to  the  invasion  of  infectious  diseases,  especially  ty- 
phoid. In  a  surgical  ward,  in  the  same  hospital, 
three  cases  of  typhoid  also  developed.  Troisier 
could  ffhd  no  possibility  of  contagion  here,  and  be- 
lieves that  these  cases  were  due.  probablv,  to  drink- 
ing contaminated  water.  Ballet  reported  the  case 
of  a  patient  in  his  charge,  who,  with  her  nurse,  fre- 
quented a  public  bath.  During  the  struggling  in  the 
water,  not  only  the  patient,  but  the  nurse  also  fre- 
quently swallowed  water.  Both  developed  typhoid 
at  the  same  time.  Lctulle  reported  7  cases  occur- 
ring in  persons  who  had  been  a  long  time  in  the  hos- 
pital, three  maternity  patients,  and  four  nurses.  Two 
of  the  nurses  were  on  duty  in  the  tj'phoid  ward.  In 
none  of  the  other  cases  was  any  mode  of  contagion 
found.  Catrin  (Mcdccinc  Modcrue,  1901.  No.  16.)  has 
reported  two  cases  in  which  direct  contagion  seems 
probable.  A  nurse  in  attendance  upon  a  typhc>id 
fever  patient  was  accustomed  to  sleep  with  her  head 


June  1,  1901J 


AMERICAN  NEWS  AND  NOTES 


["The  Philadelphia 


aiCAL  Journal 


1027 


resting  upon  the  patient's  bed.  She  was  taken  ill 
three  weeks  after  she  had  begun  nursing  the  case. 
A  friend  of  hers,  who  often  came  in  to  speak  to  her 
and  shook  hands,  developed  typhoid  a  month  after- 
ward. None  of  the  patients  in  the  neighboring  ward 
were  affected.  There  is  no  doubt  that  sporadic 
cases  of  typhoid  fever  may  appear  in  hospitals  just 
as  they  do  elsewhere,  for  direct  contagion  can 
be  proved  in  but  a  small  number  of  cases.  Yet,  as 
contagion  is  possible,  Catrin  pleads  that  every  case 
of  typhoid  be  isolated.  He  believes,  as  in  mumps, 
that  all  that  is  necessarv  is  a  closed  door. 


On  the  Influence  of  the  Cervical  Sympathetic  on  the 
Frequency  of  the  Movements  of  the  Heart  in  Man.  F. 
Wertheinier  and  H.  Gaudier,  (L'  Echo  ilaliral  dii  Xoid, 
Feb.  .1',,  imi,  oOme.  Aniiee.  A'o.  <S;. 

In  the  case  of  a  woman,  aged  24  years,  who  was  suffer- 
ing from  exopthalmic  goiter,  Gaudier  resected  both  cervi- 
cal sympathetics  at  an  interval  of  7  days.  The  authors 
found  in  this  patient  that  the  cervical  sympathetic  had  no 
action  upon  the  heart.  It  may  be  objected  that  the  fre- 
quency of  the  heart's  action  was  already  augmented  and 
that  the  excitation  of  the  accelerator  nerves  could  add  noth- 
ing to  it.  But  the  tachycardia  in  the  patient  was  not 
exaggerated.     [J.  RI.  S.] 

Three  Cases  of  Poisoning  by  Cannabis  Indica. — Kosso- 
budski,  (Mahjcmu.  Feb.  ^J.  ]y01 ;  Yratch.  Vol.  XMl,  No.  11). 
reports  the  following  cases:  (1)  A  woman  of  36,  suffering 
from  chronic  metritis  and  salpingitis,  received  an  infusion 
and  subsequently  fluid  extract  of  cannabis  indica  in  doses 
of  10  drops  twice  daily.  After  taking  the  infusion  the 
woman  felt  gastric  pain  which  became  unbearable  after 
a  repeated  dose  of  the  fluid  extract.  She  became  greatly 
excited  and  uncontrolable,  prayed  loud  and  called  for 
help.  Washing  out  the  stomach  and  internal  administra- 
tion of  bromides  relieved  her.  (2)  A  woman  of  20,  suffer- 
ing from  a  flexed  uterus  and  perimetritis,  received  5  drops 
of  cannabis  indica  3  times  daily.  In  a  few  days  she  devel- 
oped extreme  irritability  and  a  maniacal  state,  accompanied 
by  trembling  of  the  extremities  and  burning  in  the  stomach. 
She  was  relieved  by  lavage  and  bromides.  (3)  A  woman 
of  20  with  an  endometritis  was  treated  by  cannabis 
indica  in  doses  of  8  drops  of  the  fluid  extract  3  times  daily. 
Symptoms  of  poisoning  developed  after  the  first  dose.  In 
view  of  the  above  cases  the  author  advises  that  the  dose  of 
the  infusion  of  this  drug  should  not  exceed  5  to  7  drops. 

[A.    R.] 


Spinal  anesthesia.  1.  W.  M.  Mintz  reported  before  the 
Society  of  Russian  Surgeons  which  had  its  first  meeting 
In  Moscow  (Mediciitskoie  Obosrenie,  February,  100],)  4  suc- 
cessful cases  of  medullary  anesthesia.  1%  solution  of  co- 
cain  was  used.  Anesthesia  appeared  within  6-8  minutes  and 
lasted  for  one  hour.  In  one  case,  however,  the  internal  ab- 
dominal viscera  failed  to  become  anesthetized  and  chloro- 
form had  to  be  resorted  to.  No  complications  or  untoward 
effects  were  noticed.  2.  At  the  same  meeting  I.  la.  Meero- 
vitch  reported  78  cases.  The  strength  of  the  solution  used 
was  from  one-fifth  to  4%.  In  17  the  operation  was  per- 
formed on  the  extremities,  while  the  other  35  were  gyne- 
cological and  included  several  laparotomies.  In  50%  of 
the  cases  the  anesthesia  was  followed  by  headache  last- 
ing for  2-3  days.  Vomiting  was  less  frequent  than  with 
chloroform.  Retching  was  quite  frequent  and  interfered 
considerably  with  the  operation.  An  elevation  of  temper- 
ature lasting  for  6-8  hours  was  observed  in  a  number  of 
cases.  Herpes  labialis  was  another  complication,  and  in  a 
few  instances  involuntary  discharge  of  urine  took  place. 
In  a  few  cases  clonic  and  tonic  spasms  of  the  lower  extre- 
mities occured  6-7  hours  after  the  injection  and  lasted  tor 
18  hours.  By  using  strong  solutions  of  cocain  together 
with  sodium  bromide  better  anesthesia  was  obtained  and  the 
untoward  effects  were  slight.     [A.  R.] 


Hmcrican  IHews  an^  Hlotcs. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

New/  Quarters  for  a  Children's  Hospital. — The  Children's 

Hospital,  which  has  been  located  on  East  Price  street, 
Germantown.  for  nearly  two  years,  will  remore  shortly  to 
No.  47  West  Penn  street. 

The  University  of  Pennsylvania  is  about  to  erect,  at  a 
cost  of  more  than  $500,000,  exclusive  of  grounds  and  equip- 
ment, a  medical  laboratory  building  which  will  be  unex- 
celled in  every  respect.  The  sul)ject  is  treated  edi- 
torially in  the  Philadelphia  Medical  Journal. 

Location  of  Hospital  Causes  Protest. — At  a  special  meet- 
ing of  the  Pay  Hospital  for  Contagious  Diseases  held  at 
Philadelphia  May  24,  a  protest  from  prominent  property 
holders  at  Narberth  against  the  locating  of  the  institu- 
tion in  the  borough  was  considered.  The  gi'ound  on  which 
the  protest  is  made  is  that  the  institution  would  injure 
property  values.  It  is  urged  on  the  other  hand  that  all 
possible  precautions  to  prevent  danger  to  outside  persons 
would  be  taken,  that  there  could  not  be  any  danger,  and 
that  the  arrangements  would  be  passed  on  by  the  State 
Board  of  Health. 

Colleges  will  Nominate  Candidates. — At  the  meeting  of 
the  Department  of  Charities  and  Corrections.  May  24,  a  res- 
olution was  adopted  which  provides  that  hereafter  the  elig- 
ible lists  of  applicants  for  positions  of  resident  physicians 
in  the  Philadelphia  Hospital  shall  be  submitted  to  the  vari- 
ous medical  colleges  of  the  city,  and  that  the  University  of 
Pennsylvania,  the  .Jefferson  College  and  the  Medico-Chir- 
urgical  College  be  requested  each  to  nominate  seven  candi- 
dates, and  the  Woman's  Medical  College  three  candidates, 
for  election  by  the  Board.  John  M.  Scott  took  his  seat  in 
the  Board  as  successor  to  Mr.  Dingee,  resigned. 

Jewish  Hospital  Association. — At  the  thirty-sixth  annual 
meeting  of  the  Jewish  Hospital  Association,  held  on  May 
26th,  the  following  officers  were  elected  to  serve  during 
the  ensuing  year:  President,  William  B.  Hackenburg:  Vice- 
President,  Hon.  Mayer  Sulzberger;  Treasurer,  August  B. 
Loeb;  Secretary,  Ephraim  Lederer;  Corresponding  Secre- 
tary, Herman  Jonas:  Directors,  Dr.  L.  W.  Steinbach,  Mau- 
rice Bamberger.  Joseph  L.  Greenwald  and  Hyman  H.  Gins- 
burg.  Jacob  Wiener,  having  completed  ten  years  of  con- 
tinuous service  as  a  member  of  the  Board,  became  an  hon- 
orary Director. 

Philadelphia  County  Medical  Society. — The  meeting  of 
May  22  was  devoted  to  the  address  of  the  retiring  Presi- 
dent. Dr.  John  H.  Musser.  his  subject  being  Streptothrix 
infections.  Dr.  Musser  said  that  actinomycosis  and  madura 
foot  were  no  longer  ihe  only  infections  of  that  class  which 
were  recognized.  He  reviewed  the  literature  and  gave  the 
results  of  investigations  of  various  observers.  The  lungs, 
brain,  and  skin  are  the  organs  most  often  the  seat  of  these 
infections.  In  the  lung  they  give  rise  to  broncho-pneumo- 
nia, bronchiectasis,  abscess,  empyema,  etc.  In  the  nervous 
system  they  are  chiefly  the  result  of  metastasis  and  in  the 
brain  they  give  rise  to  abscess,  meningitis,  softening,  etc. 
Prom  the  clinical  standpoint  there  is  but  little  that  is  new 
in  these  cases.  The  pulmonary  cases  are  often  hidden  un- 
der tubercular  symptoms  or  those  due  to  other  infections. 
The  flnding  of  the  streptothrix  settles  the  diagnosis.  Bac- 
teriologically  the  streptothrix  is  etween  the  moulds  and 
bacteria.  Of  the  most  importance  to  the  clinician  is  the 
finding  of  mycelial  tufts  or  granules  in  the  lesions  or  the 
sputum.  Many  instances  are  probably  unrecognized.  Dr. 
Musser  reported  2  cases  of  streptothrix  infection. 
Case  1  was  a  nervous  case  in  whom  there  was  at 
first  an  unaccountable  rise  of  temperature.  The 
pulse  was  quickened,  but  the  only  lesion  found  was  that 
of  a  moderate  bronchitis.  There  was  a  moderate  degree 
of  anemia  with  no  leukocytosis.  Sputum  was  obtained  with 
difficulty.  The  physical  signs  of  broncho-pneumonia  devel- 
oped, the  temperature  rose  to  105°  and  death  followed.  The 
sputum  w.is  found  to  contain  a  tew  thin  tubercle  bacilli  and 
in  addition  branching  filaments  and  rod-like  bodies  which 
showed  some  tendency  to  branching.  These  were  undoubt- 
edly the  streptothrix  but  were  very  few  in  number  and 
were  found  only  when  stained  by  Gram's  and  the  Ziehl- 
Neelson  methods.  Case  II  was  important,  as  showing  how 
large  areas  of  the  brain  may  be  affected  without  producing 


Tr>oR        The  Phjladelphia  "1 
■"-'■'°       Medical   Journal  J 


AMERICAN  NEWS  AND  NOTES 


UuiTE  :,  1901 


localizing  symptoms.  The  patient  was  seized  -with  head-  . 
ache  and  soon  afterward  fell  unconscious  for  a  time,  a  sec- 
ond attack,  both  resembling  epilepsy,  ensued.  Other  than 
a  slight  hypesthesia  of  the  right  side  there  was  no  evidence 
of  brain  Involvement  as  shown  by  localizing  signs.  The 
patient  finally  went  into  collapse.  Lumbar  puncture  gave  , 
relief,  no  bacteria  being  found  in  the  fluid.  A  repetition  of 
the  puncture  produced  no  change  and  the  patient  died  one 
week  from  the  date  of  the  first  convulsion.  Autopsy  re- 
vealed an  abscess  cavity  in  the  brain  Z^i  cm.  in  diameter 
and  contained  a  chocolate-colored,  foul-smelling  fluid.  Ex- 
amination showed  no  tubercle  bacilli  in  the  fluid,  but  one 
bunch  of  long  thin  filaments  with  suggestion  of  branching 
■yas  detected.  A  careful  study  of  the  abscess  wall  was 
made.  100  sections  being  made  before  a  mass  of  the  same 
streptothrLx  filaments  was  found.  At  least  150  more  were 
made  before  a  second  bunch  was  seen.  Otherwise  the  pus 
and  cavity  wall  were  sterile.  This  shows  how  the  strepto- 
thrix  may  be  overlooked.as  it  probably  is  in  many  cases.  Two 
thoughts'  suggested  by  these  cases  were  given  by  Dr.  Mus 
ser  in  conclusion:  (1)  Many  of  the  so-called  sterile  ab- 
scesses may  be  due  to  a  streptothrix  infection.  (2)  Ab- 
scesses of  various  forms,  especially  in  the  brain,  occur 
without  fever.  These  also  may  be  due  to  the  strepto- 
thrix. 

Philadelphia  Pathological  Society. — At  the  regular  meet- 
ing held  May  23.  Dr.  M.  P.  Ravenel  exhibited:  (1)  scabies 
in  rats.  Scales  containing  the  characteristic  parasites  were 
found  on  the  tip  of  the  nose,  the  ears,  and  the  tail  of  the 
animals.  The  several  varieties  of  the  disease  are  all  prob- 
ably due  to  one  organism  but  differ  in  the  manifestation  ac- 
cording to  the  mammal  infected  and  the  thickness  of  the 
skin.  (2)  Unusual  types  of  tubercle  bacilli.  Two  cultures 
on  dog's  blood  serum  and  glycerin  were  shown.  The  first 
contained  a  great  amount  of  fat.  To  get  a  spread  from 
this  culture  it  was  necessary  to  first  melt  the  growth.  It 
however,  stained  but  slightly  with  sudan  III  and  not  at 
all  with  osmic  acid.  The  second  culture  showed  a  jet  black 
and  also  a  greenish  growth  from  absorbed  pigment  from 
the  media. 

Drs.  W.  M.  Welsh  and  J.  F.  Schramberg  exhibited  spec- 
imens from  a  case  of  variola.  The  first  was  an  area  of 
skin  taken  from  a  patient  who  died  on  the  twelfth  day.  The 
pustules  were  discreet  and  all  umbillcated.  It  was  stated 
that  the  old  view  of  the  umbilication  being  caused  by  the 
resistance  of  the  hair  follicles  and  sweat  ducts  was  now 
being  discarded  for  the  view  that  it  is  caused  by  a  differ- 
ence in  the  rapidity  of  necrosis.  The  stomach  and  eso- 
phagus were  also  shown.  These  were  interesting  from  the 
fact  that  the  former  was  deeply  injected,  almost  hem- 
orrhagic, while  the  esophagus  was  extremely  pale.  The 
line  oi  junction  of  the  two  conditions  was  very  distinct  at 
the  cardiac  orifice.  The  esophagus  also  contained  small 
ulcers  which  were  probably  vesicles. 

Dr.  R.  M.  Pearce  spoke  of  the  increase  of  connective  tis- 
sue in  the  lung  in  chronic  passive  congestion.  Dr.  Pearce 
said  that  the  increase  in  the  lung  in  cases  of  chronic  con- 
gestion is  an  increase  in  the  elastic  tissue.  The  studies 
demonstrating  this  fact  are  made  possible  by  Weigert's 
stain.  The  increase  in  elastic  tissue  is  most  marked  at 
the  points  w-here  it  normally  exists.  The  function  of  the 
new  tissue  is  to  support  the  blood  vessels  (thus  aiding  cir- 
culation) and  the  air  vesicles.  Dr.  Flexner  said  that  the 
increased  rigidity  of  the  lungs  in  cases  of  chronic  heart 
disease  was  due  to  an  increase  in  elastic  tissue.  Dr.  Pearce 
said  that  this  increase  of  elastic  tissue  could  be  found  in 
all  viscera  which  were  the  seat  of  chronic  passive  con- 
gestion. 

Drs.  F.  A.  Packard  and  Simon  Flexner  exhibited  a  speci- 
men of  probable  primary  intestinal  tuberculosis  in  an  adult 
with  multiple  metastases.  The  appendix  was  greatly  en- 
larged and  metastases  were  found  in  every  viscus  of  the 
body.  Some  doubt  as  to  the  lesion  being  primarily  intes- 
tinal was  occasioned  by  the  fact  that  at  the  apex  of  the 
left  pleura  there  was  a  marked  thickening,  although  ao 
caseation  was  found  in  the  adjacent  lung. 

In  the  meninges  very  young  tubercles,  macroscopically 
invisible,  were  found.  There  was  also  a  tuberculous  area 
in  the  left  optic  thalamus. 

Dr.  TV.  F.  Hendrickson  exhibited  a  Teratoma  of  the  tes 
tide. 

Drs.  W.  S.  Wadsworth  and  W.  F.  Hendrickson  exhibited 
a  specimen  of  Tuberculosis  of  the  Heart. 


Vital    Statistics    of    Philadelphia    for    the    week    ending 
May  25,  1901: 

Total  mortality  421 

Cases.  Deaths. 
Inflammation  of  the  appendix  2, 
bladder  1,  brain  15,  bronchi  7, 
heart  2,  kidneys  22,  liver  1,  limgs 
49,  peritoneum  o,  pleura  1,  stom- 
ach   and     bowels     19,    uterus     1, 

spine  2  127 

Marasmus  5,  debility  9,  inanition  15  2& 

Tuberculosis  of  the  lungs 55 

Apoplexy  13,  paralysis  6   19 

Heart-disease  of  25,  fatty  degenera- 
tion of  1 2S 

Uremia  8,  diabetes  3,  Brighfs  dis- 
ease 12   23 

Carcinoma  of  the  breast  4,  colon  1, 
stomach  3.  uterus  1,  liver  2,  larynx 

1,  mouth  2,  rectum  1 15 

Convulsions  16,  puerperal  1 17 

Diphtheria 66  8 

Brain — dropsy  of  1,  softening  of  2, 

tumor  of  3 6 

Typhoid  fever   142  9 

Old  age  12 

Cvanosis    4 

Scarlet  fever 108  5 

Influenza  1,  abscess,  psoas  1.  aneu- 
rysm aorta  1,  alcoholism  1.  asthma 
3.  anemia  1.  atheroma  1.  bums 
and  scalds  3,  casualties  6.  cerebro- 
spinal meningitis  2.  congestion  of 
the  lungs  3,  cirrhosis  of  the  liver  3, 
consumption  of  the  bowels  1.  di- 
arrhea 1,  drowned  1,  dropsy,  ab- 
dominal 1,  epilepsy  2,  erysipelas 
1.  gangrene  4.  homicide  2.  intusses- 
ception  of  bowels  1.  measles  1.  ob- 
struction of  the  bowels  2.  sclerosis, 
arterial  1.  spine  1.  shock,  sur- 
gical 2.  septicemia  2.  sarcoma, 
stomach  1.  suffocation  1.  suicide  2. 
teething  1.  tumor,  addominal  1.  ul- 
ceration of  the  stomach  1.  whoop- 
ing cough  9  65 

NEW  YORK. 

The  New  Mount  Sinai  Hospital. — The  comer  stone  of 
the  new  Mount  Sinai  Hospital  buildings.  Fifth  avenue  and 
One  Hundredth  street.  New  York  City,  was  laid  on  May  22 
with  beautiful  ceremonies.  After  the  presentation  of  a  sil- 
ver trowel.  Mr.  I.  Wallach.  president  of  the  Mount  Sinai 
Hospital,  pronounced  the  comer  stone  of  what  promises  to 
become  one  of  the  finest  hospital  structures  in  New  York 
City,  "well  and  truly  laid."  Governor  Odell.  of  New  York, 
who  was  to  have  been  present  and  deliver  an  address,  was 
prevented  from  so  doing  on  account  of  illness  in  his  fam- 
ily. .-Addresses  were  held  by  Hon.  Seth  Low,  of  Columbia 
University.  Hon.  Randolph  Guggenhetmer.  president  of  the 
Council  of  the  City  of  New  York,  and  Hon.  Edward  Lauter- 
bach.    No  distinction  of  race  or  creed  will  be  made. 

The  American  Orthopedic  Association  will  meet  at  Ni- 
agara Falls,  N.  Y.,  on  June  ISth.  19lh  and  20th. 

Appointment. — At  a  recent  meeting  of  the  German  Hos- 
pital of  Buffalo.  N.  Y..  Drs.  Lucien  Howe  and  Julius  Pohi- 
mann  were  appointed  oculists. 

The  Library  of  the  Medical  Society  of  the  County  of 
Kings,  of  Brooklyn.  N.  Y..  which  was  founded  A.  D.  1S43, 
reports  that  on  May  19.  1900.  the  Library  contained  over 
30,000  volumes.  15.000  pamphlets  and  some  500  current' 
medical  periodicals,  all  of  which  were  free  to  the  public. 
In  addition  to  the  very  best  publications,  the  collection  i3 
especially  rich  in  classics.  The  earliest  printed  volume  ifl 
a  folio  published  A.  D.  1474.  The  first  donation  to  the  per- 
manent invested  endowment  was  the  "Dr.  John  Lloyd  Z» 
briskie  Memorial  Library  Fund."  presented  in  1S99  by  Mrs. 
Zabriskie  as  a  memorial  of  her  husband,  the  late  Dr.  Joba 
Lloyd  Zabriskie. 

New  York  Neurolcgical  Society. — Stated  Meeting  May  7, 
1901. — John  Collins.  M.  D..  President. — A  Case  of  Succes* 
ful    Moral    Treatment    of   a    Form    of    Hysteria. — Dr.    Mary 


June  1,  1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia 
Lmedical  Journal 


1029 


Putnam  Jacobi  reported  this  case.  The  patient  was  a  woman 
of  twenty-four,  belonging  to  a  neurotic  family.  Her  symp- 
toms had  begun  four  years  before  coming  under  observation 
by  an  endometritis  and  uterine  retroflexion.  She  had  been 
subjected  to  a  good  deal  of  local  treatment,  including  curet- 
tage and  an  Alexander's  operation.  The  latter  procedure 
had  relieved  the  dysmenorrhea,  but  had  been  followed  by 
a  fixed  pain  in  the  abdomen  not  increased  by  pressure. 
She  claimed  to  be  unable  to  walk  or  stand  because  of  se- 
vere pain  in  the  back  and  abdomen  which  it  induced.  Ex- 
amination showed  no  motor  inability,  and  when  started  to 
walk  she  could  walk  very  readily  and  energetically.  The 
uterine  disease  had  entirely  disappeared.  She  was  mod- 
erately anemic  and  quite  constipated.  The  speaker  said 
that  at  some  portion  of  the  cerebrospinal  tract  an  area  of 
nerve  tissue  must  be  so  nearly  on  the  border  of  exhaustion 
that  an  attempt  at  function  carries  it  beyond  this  line.  It 
was  conceivable  that  with  the  exhaustion  of  the  cerebral 
centre  the  very  thought  of  the  movement  would  be  followed 
by  pain.  According  to  Sanier  such  hysterical  pains  point 
to  a  partial  anesthesia  in  the  brain.  Apart  from  the  inter- 
mittent pains  excited  by  the  sense  of  walking  there  seemed 
to  be  a  permanent  and  distressful  sense  in  the  back,  re- 
quiring support.  In  a  previous  experience  with  a  bed-rid- 
den patient  she  had  succeeded  in  making  her  walk  within 
a  week  by  the  the  application  of  a  Taylor  spinal  brace. 
This  simple  device  had  given  great  relief.  The  necessary 
nerve  stimulus  has  been  secured  by  the  application  of 
static  electricity.  This  remedy  seemed  to  be  almost  a 
specific  for  hysterical  pains.  The  subject  of  the  present 
report  had  been  persuaded  to  leave  her  home  and  take  a 
room  near  Dr.  Jacobis  office.  At  first,  it  was  not  difficult 
to  get  her  to  walk  a  portion  of  a  block,  but  when  finally 
asked  to  walk  a  whole  block  she  obstinately  refused.  All 
sorts  of  changes  in  the  treatment  and  methods  of  man- 
agement were  necessary  in  order  to  conquer  the  patient's 
wilfulness,  yet  this  was  essential  to  further  progress.  Her 
mode  of  life  for  each  day  was  mapped  out  most  minutely. 
By  the  most  persistent  and  painstaking  efforts  exerted  for 
a  period  of  four  months  the  patient  was  finally  conquered. 
During  the  last  eighteen  months  she  had  been  living  a  fair- 
ly normal  life.  Dr.  .Jacobi  said  that  in  hysterics  the  habit- 
ual dependence  upon  fellow  minds  is  immensely  intensi- 
fied. To  get  rid  of  a  false  idea  it  must  be  starved  out  and 
atrophied  by  an  entire  lack  of  support  from  the  minds  of 
those  around  the  patient.  The  essential  element  of  the 
treatment  of  this  case  was  the  bringing  of  the  personality 
of  the  patient  under  the  control  of  another  mind. 

Dr.  B.  Sachs  commended  the  general  plan  of  treatment 
described  in  this  paper,  though  admitting  that  it  required 
far  too  much  expenditure  of  time  and  attention  to  detail  to 
make  it  generally  available. 

The  Morbid  Anatomy  of  a  Case  of  Progressive  Muscular 
Atrophy  which  was  Clinically  one  of  Amyothropic  Lateral 
Sclerosis. — Dr.  Carlin  Philips  read  this  paper.  He  said  that 
the  patient  was  a  woman  of  thirty-six.  who  had  come  under 
Dr.Collin's  observation  for  the  first  time  on  June  17,1897.  She 
had  then  complained  of  severe  frontal  headache,  inability  to 
lift  the  head  from  the  pillow  without  the  help  of  the  hands, 
treniulousness  of  the  hands,  and  easily  induced  fatigue. 
She  had  lost  thirty  pounds.  Examination  showed  atrophy 
of  the  supraspinatus  and  of  the  right  shoulder  girdle,  and 
these  muscles  showed  fibrillary  twitchings.  The  knee 
jerks  were  increased;  there  was  ankle  clonus  on  both  sides; 
there  was  no  affection  of  the  special  senses.  Six  months 
later  she  had  complained  of  dyspnea  and  had  shown  loss 
of  will  power  and  suicidal  impulses,  together  with  some 
difficulty  in  swallowing.  The  atrophy  of  the  muscles  was 
more  marked,  and  extended  to  the  trapezius  muscle.  She 
began  about  this  time  to  have  attacks  of  major  hysteria, 
and  the  atrophy  increased  rapidly.  The  gait  became  spas- 
tic and  the  body  rigid.  She  had  the  use  of  her  limbs  up 
to  about  six  weeks  before  death  on  May  25.  1899.  An  autop- 
sy was  allowed  only  upon  the  brain  and  spinal  cord.  The 
weight  of  the  bodj'  was  forty-eight  pounds.  The  meninges 
of  the  brain  were  anemic.  The  brain  was  normal  in  gross 
appearance,  as  was  also  the  spinal  cord.  The  latter  was 
carefully  segmented  and  prepared  in  various  ways  for  ex- 
amination. In  the  second  cervical  segment  was  a  concen- 
tric zone  encircling  each  anterior  horn  and  involving  the 
anterior  mesial  and  anterior  lateral  portions  of  the  funda- 
mental columns,  while  the  tracts  of  Gowers  and  the  pyra- 
midal tracts  were  left  intact.  Corresponding  to  the  de- 
generated areas  in  this  segment  the  neurogliar  prolifera- 
I       tion  was  very  slight.    The  fourth  cervical  segment  showed 


a  sinking  in  of  the  periphery  just  at  the  margins  of  the  an- 
terior roots,  and  this  change  of  contour  extended  down  sev- 
eral segments.  The  gray  matter  extended  laterally,  giving 
a  sickle-shape  to  the  degenerated  area.  While  there  was 
no  evidence  of  the  destruction  of  the  cells,  the  most  strik- 
ing feature  was  the  extensive  destruction  of  these  cells. 
The  fifth  cervical  segment  was  practically  the  same  as  the 
fourth.  The  sixth  segment  show-ed  a  tongue-shaped  area 
of  degeneration  extending  almost  to  the  posterior  horn.  In 
the  seventh  segment  the  anterior  roots  showed  more 
marked  degeneration.  From  the  first  to  the  fourth  dorsal 
segments  inclusive  there  was  a  zone  of  degeneration  en- 
circling the  anterior  horns,  and  becoming  less  intense  until 
almost  invisible  in  the  fourth  segment.  The  disappearance 
of  the  motor  cells  throughout  these  four  segments  was  more 
difficult  to  determine  than  in  the  caseof  thecervicalsegments 
but  apparently  there  was  about  the  same  amount  of  atrophy 
of  these  cells.  From  the  fifth  to  the  eighth  segments  there 
appeared  to  be  an  increase  in  the  neurogliar  tissue.  From 
the  twelfth  dorsal  down  to  the  end  of  the  cord  the  area  oc- 
cupied the  peripheral  laimna  of  the  ventral  half  of  the 
cord,  and  extended  around  to  a  point  opposite  the  apex  of 
the  lateral  horn,  where  it  expanded  into  a  lateral  mass. 
The  lumbar  and  sacral  regions  were  found  to  be  as 
severely  involved  as  the  cervical.  Throughout  the  cord  the 
blood  vessels  were  apparently  normal.  Nissl  preparations 
of  the  medulla  showed  small  areas  of  periarteritis  with 
small  cell  infiltration  of  the  adjacent  gray  matter.  The  an- 
terior roots  were  found  to  be  atrophic.  The  crossed  pjTa- 
midal  tracts  were  apparently  unchanged. 

NEW   ENGLAND. 
The  National  Association  of  Life  Insurance  Medical  Direc- 
tors will  hold  their  annual  meeting  at  Hartford,  Conn.,  May 
28-29. 

New  Hospital.— By  the  will  of  George  Griffin,  of  Shelton, 
Conn.,  two-thirds  of  the  residue  of  his  estate,  amounting 
to  about  $25,000,  is  left  to  establish  a  hospital  for  the  bene- 
fit of  Shelton  and  the  towns  of  Seymour,  Ansonia  and 
Derby, 

WESTERN   STATES. 

The  International  Association  of  Railway  Surgeons  will 
meet  at  Milwaukee.  Wis.,  on  June  10th,  11th  and  12th. 

The  American  Dermatological  Association  will  hold  Its 
twenty-fifth  annual  meeting  at  the  Beach  Hotel,  Chicago, 
111..  May  30  and  31  and  June  1,  1901.  Twenty-five  papers 
and  reports  are  on  the  program  of  the  first  two  days.  The 
morning  session  of  the  third  day  will  be  devoted  to  the  ex- 
hibition of  patients. 

Dr.  Winslow  Appointed. — Gov.  Yates  has  appointed  Dr. 
Frederick  C.  Winslow,  of  Jacksonville,  to  be  superintendent 
of  the  hospital  for  incurable  insane,  now  nearing  com- 
pletion at  South  Bartonville,  a  suburb  of  Peoria,  the  ap- 
pointment to  take  effect  as  soon  as  the  hospital  is  opened  to 
patients,  which  will  be  about  October  1.  Dr.  Winslow  is 
at  present  superintendent  of  the  Jacksonville  asylum,  and 
is  an  insanity  expert. 

The  California  Eye  and  Ear  Hospital,  San  Francisco, 
established  four  years  ago,  has  outgrown  its  present  quar- 
ters, and  w-ill  erect  a  new  $20,000  building.  Dr.  Tension 
Deane  is  President,  and  Dr.  Redmond  W.  Payne,  Secre- 
tary. 

Appointment. — Henry  Sheridan  Keys,  M.  D.,  has  been 
appointed  Surgeon-in-Chief  to  the  Emergency  Hospital,  now 
building  at  Los  Angeles,  California. 

A  "Healer"  in  the  Meshes  of  the  Law. — The  Coroner's 
Jury  in  Chicago  which  for  two  days  had  been  listening  to 
the  testimony  of  witnesses  in  the  case  of  Mrs.  Emma 
Lucy  Judd.  who  was  associated  with  John  Alexander 
Dowie's  Zion.  returned  a  verdict  holding  Dowie,  H.  W. 
Judd.  husband  of  the  woman,  Mrs.  Sprecher  and  Mrs. 
Bratsch  to  await  the  action  of  the  Grand  Jury.  The  two 
women  named  in  the  verdict  w-ere  in  attendance  upon  Mrs. 
Judd  prior  to  her  death.  The  charge  against  them  la 
"criminal  responsibility"  for  the  death  of  Mrs.  Judd.  The 
evidence  given  at  the  inquest  by  some  of  the  leading  phy- 
sicians of  the  city  who  had  examined  Mrs.  Judd's  body 
after  it  had  been  exhumed,  was  to  the  effect  that  the  most 
simple  surgical  care  would  have  prevented  the  woman's 
death.  They  testified  that  she  was  allowed  to  die  when  the 
slightest  attempt  to  save  her  life  would  have  been  success- 
ful. Papers  were  at  once  made  out  and  officers  sent  to  ar- 
rest Dowie,  Judd  and  the  two  women. 


The  Philax>elphia  "I 


■'^"-'o^       Medical   Journal 


AMERICAN  XEWS  AND  NOTES 


tJfSE    1,    l*/l 


SOUTHERN  STATES. 
The  Chicago  Inter  Orcaii  slates  the  following:  Dr.  Dud- 
lev  S.  Reynolds,  one  of  the  founders  of  the  Louisville  Hos- 
pital College  of  Medicine,  and  a  member  of  its  faculty  from 
its  inception,  has  been  dismissed  from  the  institution  be-  j 
cause  of  his  antagonism  to  cigarette  smoking.  He  is  now 
suing  Central  University,  of  which  the  medical  school 
is  a  part,  for  $15,000  damages.  Dr.  Reynolds,  in  his  lec- 
tures to  his  classes,  denounced  cigarette  smoking  and 
smokers  in  unqualified  terms.  The  students  took  offense 
and  refused  to  attend  his  lectures  unless  an  apology  was 
made.  This  he  declined  to  do.  At  this  juncture  the  faculty 
joined  with  the  students  and  requested  his  resignation. 
Again  he  declinerl,  and  his  dismissal  followed. 

Richmond.— Among  the  recent  changes  which  have  taken 
place  at  the  close  of  the  session  of  the  University  College 
of  Medicine.  Richmond,  Va.,  are  the  election  of  Dr.  H.  I. 
j.IcLean  to  the  Chair  of  Histology  and  Pathology,  vice  Dr. 
M.  D.  Hoge.  Jr..  re.signed,  and  that  of  Dr.  A.  L.  Gray  to 
the  Chair  of  Physiologj'. 

The  Savannah  Academy  of  Medicine  has  recently  been 
permanently  organized  in  Savannah,  Ga.,  with  the  following 
officers:  President,  Dr.  A.  A.  Morrison:  vice-president.  Dr. 
Frederick  Wahl;  secretary.  Dr  J.  Oliver  Cook;  treasurer, 
Dr.  G.  L.  Harman. 

CANADA. 

(From    Our    Special    Correspondent). 

The  Ontario  Medical  Council  has  extended  the  time  limit 
to  another  month  to  those  physicians  who  have  been  negli- 
gent in  the  past  in  paying  their  annual  assessments.  As  a 
consequence  of  their  first  circular  to  the  profession  so  in 
arrears  there  are  now  only  some  three  or  four  hundred 
physicians  in  this  province  w,ho  have  not  met  the  demands 
of  the  Medical  Coimcil.  The  law  against  unregistered 
practitioners  will  most  assuredly  then  be  put  in  operation 
if  compliance  with  this  second  mandate  be  not  executed 
at  once.  The  action  of  the  Council  has  called  forth  in- 
numerable letters  to  the  lay  press,  and  hot  shot  has  been 
poured  out  ad  libitum  at  the  offending  heads  of  this  body. 
We  may  look  for  squalls  after  the  19th  of  June. 

The  Grave  Robbing  Case  in  which  Mr.  William  Patter- 
son, a  third  year  student  in  medicine  at  Queen's  University, 
was  concerned  last  February,  was  disposed  of  on  the  22nd 
day  of  May  by  his  Honor,  Judge  Waller,  of  the  Petersboro 
County  Court.  On  the  charge  of  opening  the  grave  Patter- 
son was  adjudged  "not  guilty,"  the  prosecution  failing  to 
prove  that  he  had  any  connection  with  that  part  of  the 
affair.  On  the  charge  of  indecently  interfering  with  a 
dead  body,  however,  he  was  found  guilty  and  fined  $200,  or, 
in  event  of  his  failing  to  pay  the  fine,  he  was  to  be  gaoled 
for  the  term  of  one  year.  The  Ontario  law  provides  for 
such  misdemeanor  a  sentence  of  five  years  in  the  peniten- 
tiary or  a  fine  at  the  discretion  of  the  judge.  Paterson's  pre- 
vious good  character  saved  him  from  the  heavier  judgment. 
This  is  the  first  case  of  its  kind  ever  before  the  Ontario 
courts. 

A  Suit  for  Malpractice. — It  is  very  gratifying  to  notice  the 
magnanimous  manner  in  which  the-  profession  throughout 
Canada  are  coming  to  the  assistance  of  Dr.  J.  M.  Conerty. 
of  Smith's  Falls.  Ontario,  who  has  had  to  bear  a  prolonged 
defence  in  a  suit  for  malpractice  brought  against  him 
by  the  father  of  the  boy,  who  had  neglected  following  the 
doctor's  instructions  in  the  treatment  of  a  case  of  Colles" 
fracture.  That  Dr.  Conerty  is  wholly  innocent  of  any  mal- 
practice has  been  abundantly  proven  to  the  satisfaction  of 
the  profession,  and  their  financial  sympathy  bears  full 
testimony  of  the  fact.  The  statement  has  recently  been 
circulated  that  Dr.  Conerty.  who  has  been  financially  crip- 
pled in  defending  this  suit,  had  compromised  for  $600.  This 
is  incorrect.  He  purposes  continuing  the  fight  to  the  bitter 
end.  The  Montreal  Medico-Chirurgical  Society,  the  To- 
ronto Clinical  Siciety,  Dr.  R.  W.  Powell,  of  Ottawa,  and 
others,  have  come  to  his  aid.  and  thus  fortified.  Dr.  Conerty 
can  continue  the  fight  with  vim,  confident  that  his  action  is 
upheld  by  his  professional  brethren.  This  case  particu- 
larly emphasizes  the  importance  of  immediate  action  being 
taken  in  establishing  the  long-talked-of  Medical  Defence 
■Union  in  the  Dominion  of  Canada. 

The  Monthly  Report  of  the  Provincial  Board  of  Health  of 
Ontario   shows    2.247   deaths   in   April,   as   compared    with 


2.525  in  March  and  2.311  in  April  of  last  year.  The  deaths 
from  contagious  diseases  were  as  follows:  Consumption, 
236:  diphtheria.  39:  scarlatina,  IT:  whooping  cough,  14; 
typhoid  fever.  12.  The  deaths  from  consumption  and  diph- 
theria show  increases,  the  figures  in  April,  1900.  being  203 
and  24  respectively.  Six  deaths  have  occurred  from  small- 
pox so  far  during  the  present  outbreak  in  a  total  of  600  or 
more  cases.  This  means  only  one  per  cent,  of  those  afflict- 
ed during  the  present  epidemic.  The  per  capita  percentage 
is  infinitesimal.  Brides  seem  to  think  they  have  special 
immunity  from  smallpox.  A  wedding  at  Sault  Ste.  Marie 
was  the  cause  of  seven  or  eight  cases:  while  a  young  girl 
recently  escaped  from  quarantine  at  Havelock,  Ont.,  fled 
to  Auburn.  N.  Y.,  and  was  there  married,  but  subsequently 
quarantined. 

Bishop's  Medical  College,  Montreal. — A  number  of  chang- 
es have  recently  been  made  in  the  teaching  staff  of  this 
institution  and  several  new  appointments  made.  Dr.  F. 
W.  Campbell,  the  dean,  will  in  future  give  a  special  course 
of  lectures  in  insurance  law  in  addition  to  his  regular 
lectures  in  medicine  and  neurologj-.  As  professor  of  medi- 
cine he  will  have  associated  with  him  Dr.  J.  B.  McConnell, 
vice-dean,  the  chair  being  further  assisetd  by  Dr.  W.  E. 
Deeks,  lecturer  on  internal  medicine:  Dr.  A.  G.  Richer, 
specialist  in  pulmonary  diseases,  and  Dr.  W.  Grant  Stewart. 
Dr.  Deeks  is  a  new  member  of  the  staff.  Dr.  James  Perrigo 
will  continue  to  have  charge  of  gynecology,  and  will  have 
associated  with  him  Dr.  A.  Dapthorn  Smith,  who  remains 
also  professor  of  clinical  gynecology:  Dr.  H.  L.  Reddy  and 
William  Burnett  retain  their  professorships.  Dr.  George 
T.  Ross,  professor  of  laryngology  -and  rhinology.  who  up 
to  the  present  time  has  been  registrar  of  the  faculty,  has 
been  replaced  as  such  by  Dr.  James  M.  Jack,  a  new  member 
of  the  staff  who  will  also  lecture  on  dermatology.  The 
chair  of  surgery  is  to  be  occupied  by  Dr.  F.  R.  England, 
with  whom  will  be  associated  as  lecturers.  Dr.  F.  J.  Hack- 
ett  and  Dr.  RoUo  Campbell,  and  as  instructors  Dr.  George 
Fisk  and  Dr.  Herbert  Tatley.  Dr.  Louis  Laberge.  Mon- 
treal's health  oflScer  has  been  appointed  lecturer  in  hygiene 
to  replace  Dr.  Richer.  Dr.  W.  G.  Reilly  has  been  appointed 
to  the  chair  of  anatomy. 

Winnipeg  General  Hospital. — The  regular  monthly  meet- 
ing of  the  Board  of  Governors  of  the  Winnipeg  General 
Hospital  was  held  in  the  hospital  on  the  afternoon  of  the 
20th  of  May.  The  report  of  the  Committee  appointed  to 
arrange  for  a  pathologist  and  bacteriologist  was  received 
and  adopted.  Arrangements  were  made  whereby  Dr. 
Gordon  Bell,  the  provincial  bacteriologist  of  Manitoba, 
should  undertake  all  of  this  work  connected  with  the  hospi- 
tal at  the  yearly  salary  of  $500.  Dr.  Bell  to  furnish  at  his  own 
expense  an  assistant  who  must  be  present  at  the  hospital 
daily  for  such  hours  as  may  be  found  necessary  for  carry- 
ing on  this  work.  Dr.  Bell  will  assume  his  duties  on  the 
first  of  June.  Dr.  Chestnut,  the  medical  superintendent 
asked  to  be  allowed  to  resign.  This  was  permitted  and 
Dr.  Jasper  Halpenny.  who  has  been  acting  as  assistant 
medical  superintendent  since  February  last,  was  appointed 
to  the  position  of  medical  superintendent  for  one  year  from 
the  1st  of  June.  Dr.  Popham.  secretary  of  the  Board  of 
Examiners,  reported  that  nine  nurses  had  passed  the  final 
examination  in  the  training  school.  Nurse  Macdonald  re- 
ceived the  Ogilvie  prize  for  the  highest  general  profi- 
ciency. 

Public  Works  Health  Regulations  have  just  been  adopted 
by  the  Dominion  Government.  They  will  provide  for  the 
preservation  of  health  and  the  mitigation  of  diseases  among 
persons  employed  in  the  construction  of  public  works. 
Some  few  months  ago  an  inspector  was  appointed  to  en- 
force the  Act.  and  these  new  regulations  define  his  duties. 
He  is  to  act  as  chairman  when  present,  of  meetings  of 
health  boards,  notify  the  Minister  of  Agriculture  and  sec- 
retary of  the  provincial  board  of  health  wherin  public 
works  are  being  carried  on  of  all  cases  of  infectious  dis- 
eases in  such  works.  Contracting  persons  or  companiefi 
must  engage  a  medical  officer,  who  will  attend  the  em- 
ployes where  the  number  is  over  100,  and  does  not  exceed 
500.  An  additional  medical  man  is  to  be  appointed  where 
the  number  exceeds  500.  the  idea  being  to  have  a  medic^ 
officer  for  every  500  men.  each  properly  supplied  with 
medicine  and  means  of  conveyance.  The  health  board  on 
such  works  will  consist  of  the  inspector,  the  medical  officer 
or  officers  and  the  engineer.  The  regulations  further  pro- 
vide for  the  establishment  of  hospitals  in  connection  with 
such  works  to  accommodate  at  least  six  patients.     Isola- 


June  1,  1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia 
LMedical   Journal 


IO31 


tion   hospitals   for   infectious   diseases   must   also   be   pro- 
vided. 

Montreal  General  Hospital. — The  annual  meeting  of  the 
Governors  was  held  last  week.  The  Committee  of  Manage- 
ment recommended  that  on  and  after  June  1st,  1901,  a 
charge  of  ten  cents  should  be  made  for  the  first  bottle  of 
medicine  and  five  cents  for  each  subsequent  bottle  in  the 
out-door  department.  Dr.  John  McCrae  was  appointed  res- 
ident assistant  pathologist,  and  the  engagement  of  Dr.  Von 
Eberts  as  medical  superintendent  was  extended  to  the  1st 
of  May,  1902,  his  staff  to  consist  of  ten  resident  house  doc- 
tors and  a  lady  superintendent  with  seventy  nurses.  A 
complete  new  sterilizing  apparatus  with  all  the  latest  im- 
provements has  been  put  in  at  a  cost  of  $500.  Dr.  Fin- 
ley,  the  secretary,  reported  that  at  the  end  of  the  year  the 
expenditure  had  amounted  to  $S4,2S0:  the  income,  $75,994: 
indicating  an  excess  of  expenditure  of  $8,286  for  the  year. 
This  with  last  year's  deficiency  af  $14,149  makes  a  total 
deficit  of  over  $22,000  against  the  hospital.  During  the  past 
year  there  have  been  in  the  hospital  3,178  in-door  patients, 
of  whom  2.823  were  treated  to  a  conclusion.  The  out-door 
patients  numbered  41,606  against  33,373  the  year  previous. 
Two  hundred  and  fifty  died  in  the  hospital  during  the  year. 
105  deaths  occurring  within  three  days  of  admission.  The 
average  number  of  patients  per  day  was  17S.  and  the  aver- 
age cost  per  patient  per  day  was  $1.37. 

The  Ontario  Medical  Assiciation  will  meet  in  Toronto 
on  the?  19th  and  20th  of  June. 

The  Canadian  Medical  Association  will  meet  in  Winni- 
peg on  the  2Sth,  29th,  30th  and  31st  of  August. 

Appointment. — Dr.  Harriet  Cockburn.  Toronto,  has 
been  appointed  physician  to  the  new  Victoria  Asylum  for 
Women  at  Cobourg,  Ont.,  the  first  instance  of  a  lady 
physician  being  appointed  to  a  similar  position  in  Can- 
ada. 

Dr.  T.  H.  Little  died  at  Toronto.  Canada,  on  April  25t.h, 
from  hemorrhagic  smallpox,  contracted  while  attending  one 
of  his  patients.  He  was  a  graduate  of  the  Toronto  School 
of  Medecine,  and  had  been  in  active  practice  in  Toronto  for 

twelve  years. 

Dr.  Thomas  Ritchie  Almon,  one  of  the  foremost  physi- 
cians of  Nova  Scotia,  died  in  the  city  of  Halifax,  on  April 
25th.  He  was  a  graduate  of  King's  College  and  also  of  the 
College  of  Physicians  and  Surgeons,  New  York. 


Medico-Chirurgical  College  Commencement. — At  the  com- 
mencement exercises  of  the  Medico-Chirurgical  College, 
held  at  the  Academy  of  Music  on  May  25th  there  were  69 
graduates  in  medicine.  The  following  medals  were  award- 
ed: 

Faculty  gold  medal,  for  highest  general  average,  Senior 
Class,   to  Dr.   Evan  W.   Meredith. 

Faculty  gold  medal  for  best  thesis,  to  Dr.  Morris  C.  Thrush. 

Faculty  gold  medal  for  highest  general  average.  Junior 
Class,   to    Hardie   I^ynch. 

Faculty  gold  medal  for  highest  general  average  in  Sopho- 
more  Class,    to   Donald   G.    McCaa. 

Faculty  gold  medal  for  highest  general  average  in  Fresh- 
man Class,  Robert  J.   Hunter. 

Gold  medal  given  by  Professor  James  M.  Anders  for  the 
best  report  of  his  medical    clinics,    to   Dr.   Harry   Lowenberg. 

Gold  medal  by  Professor  Ernest  Laplace  for  best  report 
of  his  surgical   clinics,   to  Dr.   Ignatius   L.   J.    Fitzpatrick. 

Gold  medal  by  Professor  L.  Webster  Fox  for  best  report  of 
his  opthamological   clinics,   to  Dr.    Morris  C.   Thrush. 

Gold  medal  by  Professor  W.  Frank  Haehnlen  for  best  re- 
port   of   his    obstetrical    clinics,    to   r>r.    t.ouis    H.    Jacob. 

Prize  given  by  Professor  Elwood  R.  Kirby  for  best  exam- 
ination in  genito-iirinary  surgery,   to  Dr.   Clarence  E.   Gardner. 

Prize  for  best  examination  in  hygiene  by  a  member  of  the 
Sophomore   Class,    to   Warren   C.    Batroff. 

The  graduates  honored  by  medals  in  the  Department  of 
Dentistry  were: 

Facility  medal  to  Arthur  R.  Dray  for  the  highest  senior 
average. 

Faculty  medal  to  Peter  McAneny  for  the  highest  junior 
average. 

Faculty  medal  to  Frank  'U'.  Miller  for  highest  freshman 
average. 

Robert  H.  Nones  medal  to  Arthur  R.  Dray  for  highest  se- 
nior  average    in    prosthetic   dentistry. 

Robert  H.  Nones  medal  to  AVarren  H.  Stover  for  highest 
junior   average    in    prosthetic    dentistry. 

Robert  H.  Nones  medal  to  Richard  Souder  for  highest 
freshman   average   in   prosthetic   dentistry. 

Walter  H.  Neall  medal  to  Arthur  R.  Dray  for  highest  se- 
nior average  in   operative  dentistry. 

George  W.  Cupit  medal  to  Joseph  Scott  for  highest  senior 
average    in   dent.al    palhologr;,'    and    therapeutics. 

The  award  of  medals  in  the  Department  of  Pharmacy  was 
as  follows: 


Faculty  gold  medal  for  highest  general  average  in  final  ex- 
aminations  for   graduation,   to   William   F.   Hennings. 

Faculty  gold  medal  for  highest  general  average  in  Junior 
Class,  to  Lloyd   W.  Conrad. 


Official  List  of  the  Changes  of  Station  and  Duties  of 
Commissioned  and  Non-Commissioned  Officers  of  the  U.  S. 
Marine  Hospital  Service  for  the  Seven  Days  ending 
May   23,   1901. 

C.   T.   PECKHAM,   surgeon,   grranted  leave   of  absenoce   for  30 
days  from  April  19,  on  account  of  sickness— May  16,  1901. 
Granted  30  days'  extension  of  leave  of  absence,  on  account 
of  sickness  from  May  20— May  21,  1901. 

A.  H.  GLENNAN,  surgeon,  to  rejoin  station  at  Habana — May 
21,   1901. 

C.  P.  WERTENBAKER,  passed  assistant  surgeon,  to  proceed 
to  Meridian,  Miss.,  for  special  temporary  duty— May  18,  1901. 

J.  B.  GREENE,  passed  assistant  surgeon,  granted  5  days'  ex- 
tension of  leave  of  absence— May  19,  1901. 

C.  B.  DECKER,  assistant  surgeon,  granted  leave  of  absence 
for  10  days  from  May  11,  on  account  of  sickness— May  20, 
1901. 

TALIAFERRO  CLARK,  assistant  surgeon,  granted  leave  of 
absence  for  30  days  from  May  22— May  22,  1901. 

G.  M.  CORPUT,  assistant  surgeon,  to  proceed  to  South  Atlan- 
tic  quarantine— May   16,   1901. 
Granted   leave  of  absence   for  1  month— May  16,   1901. 

J.  C.  RODMAN,  acting  assistant  surgeon,  granted  leave  of 
absence   for  4  days— May  18,   1901. 

A.  W.  SLAUGHTER,  acting  assistant  surgeon,  granted  leave 
of  absence   for  4  days  from  June  4 — May  22,   1901. 

Board   Convened. 

Board  convened  to  meet  at  Washington,  D.  C,  May  20, 
1901,  for  the  purpose  of  making  physical  examination  of  appli- 
cants for  cadetship  in  the  Revenue  Cutter  Service.  Detail  for 
the  Board;  Surgeon  L.  L.  Williams,  chairman:  Assistant  Sur- 
geon  B.   S.   Warren,   recorder. 

Changes  in  the  Medical  Corps  of  the  Navy,  w/eek  ending 
ending    May  25,   1901. 
P.   A.    SURGEO.N-    R.   M.    KENNEDY,  ordered   home   via   public 

conveyance. 
ASSISTANT  SURGEON  M.  V.  STONE,  detached  from  Buffalo, 

and   ordered  home  to  wait  orders. 
ASSISTANT  SURGEON  C.  N.  DeLANCY,  detached  from  Ban- 
croft and  ordered   to   the   Buffalo. 
ASSISTANT   SURGEON   F.   M.    FURLONG,   ordered   home  by 

public   conveyance. 
ASSISTANT  SURGEON  D.  B.  KERR,  ordered  home  by  public 

conveyance. 
ASSISTANT    SURGEON     E.     J.     CROW,     ordered     home     by 

public   conveyance. 
ASSISTANT  SURGEON   A.   C.   CRUNWELI,  ordered  home  by 

public   conveyance. 
ASSISTANT     SURGEON     D.    C.    BEEBE,    ordered     home     via 

public   conveyance. 
ASSISTANT  SURGEON  C.  D.  I.ANGHORNE,  ordered  home  by 

public   conveyance. 
ASSISTANT  SURGEON  J.  STEPP,  detached  from  the  Castine 

and    ordered   to   the   Isia  de    Ijuzon. 
ASSISTANT  SURGEON   F.   J.   CROW,  detached  from  the  Isla 

de   Luzon,    and   ordered   to  the   Cnstine. 
ASSISTANT    SURGEON    E.    THOMPSON,    detached    from    the 

Solace  and   to   the  Petrel. 
ASSISTANT    SURGEON    R.    W.    PLUMMBR,    detached    from 

the    Petrel    and    ordered    to    the    X.ishville. 
ASSISTANT    SURGEON    F.    N.    FURLONG,    order    detaching 

from  the  Brutus,  and  ordering  him  forward  to  Guam,  L.  I. 


Abstracts  of  Papers  and  Discussions  at  the  Annual  Meet- 
ing of  the  American  Surgical  Association,  held  in  Balti- 
more on  May  7th,  8th  and  9th,  1901,  the  President,  Dr. 
RoEwell  Park,  of  Buffalo,  in  the  Chair. 


(Continued  from  Page  993.) 

In  addition  to  these  fifteen  cases  that  have  passed  the 
three-year-limit,  8  were  mentioned  in  which  the  tumors  dis- 
appeared entirely.  One.  a  spindle-celled  sarcoma  of  the 
abdominal  wall,  was  well  1%  years,  when  the  patient  re- 
turned to  her  home  in  Europe  and  was  lost  sight  of.  An- 
other, an  extensive  round-celled  sarcoma  of  the  iliac  fossa, 
was  well  one  year  and  then  lost  sight  of.  A  third,  a 
spindle-celled,  recurrent  sarcoma  of  the  leg.  is  now  in  per- 
fect health,  without  recurrence,  nearly  two  years  after 
treatment.  A  fourth,  a  twice  recurrent,  spindle-celled  sar- 
coma of  the  palm  of  the  hand,  disappeared  under  the  toxin 
treatment  and  the  patient  remained  well  2'^  years,  when 
the  tumor  recurred.  Refusing  amputation  of  the  arm.  she 
was  under  the  care  of  a  Christian  scientist  for  eight 
months,  during  which  time  the  tumor  in  the  hand  reached 
the  size  of  a  cocoanut  and  extended  above  the  elbow.  Am- 
putation of  the  arm  just  below  the  shoulder  joint  was  then 
performed,  but  the  patient  died  of  metastasis  3%  months 
later. 

A  fifth  case,  a  chondro-sarcoma  of  the  ileum,  of  large 
size,    disappeared    and   the    patient,    after   remaining   well 


I032 


The  Philadelphia" 
Medical  Journal  . 


AMERICAN  NEWS  AND  NOTES 


[Jlne   1.   1301 


for  seven  months,  had  a  recurrence  which  proved  fatal  in 
about  a  year's  time.  A  sixth,  a  round-celled  angiosarcoma 
of  the  breast,  was  well  six  months  later,  when  the  patient 
was  lost  sight  of.  A  seventh,  a  recurrent  fibro-angioma 
of  the  lip,  was  well  when  last  heard  of,  over  two  years 
after  operation;  and  an  eighth  case,  a  spindle-celled  sar- 
coma of  the  thigh,  disappeared,  but  after  a  year's  time 
recurrence  took  place  locally  and  in  the  groin,  which  no 
longer  yielded  to  the  treatment. 

In  addition  to  the  24  personal  cases,  the  writer  mentioned 
2  other  cases  in  which  he  directed  the  treatment,  although 
it  was  carried  out  by  another  surgeon.  One  case  (John- 
son's) a  large,  spindle-celled  sarcoma  of  the  pharynx,  en- 
tirely disappeared,  and  the  patient  was  well  more  than 
six  years  later.  The  second  (Storr's  and  Griswold's),  an 
inoperable  sarcoma  of  the  breast  and  axilla,  disappeared 
under  76  injections  of  the  mixed  toxins,  and  is  now  well 
more  than  four  years  after  treatment.  The  diagnosis  in 
both  of  these  cases  was  confirmed  by  microscopical  exam 
ination,  in  the  latter  case  by  the  highest  authority  in  this 
country,  Prof.  William  H.  Welch,  of  Johns  Hopkins  Univer- 
sity. 

The  writer  stated  that  the  results  of  this  method  during 
the  last  tw-o  years  had  given  him  no  reason  to  change  thg 
conclusions  expressed  in  earlier  papers.  His  further  ex- 
perience has  confirmed  the  opinion  that  spindle-celled 
sarcoma  yields  far  better  results  than  any  other  variety, 
although  there  have  been  a  sufficient  number  of  round- 
celled  cases  successfully  treated,  to  make  it  advisable  to 
give  every  inoperable  case  the  benefit  of  a  brief  trial.  If 
no  improvement  has  occurred  at  the  end  of  3  to  4  weeks, 
w'ith  daily  injections,  the  writer  does  not  believe  the  treat- 
ment is  likely  to  prove  successful.  If  improvement  does 
occur,  the  injections  should  be  continued  either  until  the 
tumor  has  entirely  disapeared,  or  it  has  become  evident 
that  the  toxins  have  lost  their  inhibitory  influence.  The 
toxins  may  be  given  for  long  periods  in  moderate  doses, 
without  harm  to  the  patient.  The  risks  of  the  treatment 
are  practically  nil.  provided  proper  precautions  are  ob- 
served. In  upwards  of  200  personal  cases  there  were  but 
2  deaths,  both  of  which  occurred  more  than  5  years  ago. 
The  percentage  of  probable  cures  depends  largely  upon 
the  type  of  the  cell,  varying  from  perhaps  3  to  4  per  cent. 
in  the  round,  to  nearly  15  per  cent,  in  the  spindle-celled. 

Thus  far,  no  permanent  successes  have  been  obtained 
In  melanotic  growths,  nor  in  lymphosarcomas  of  the  neck. 
The  writer  stated  his  belief  that  the  toxins  administered  in 
small  doses  immediately  after  primary  operations  for  sar- 
coma, offer  a  most  valuable  prophylactic  measure  against 
future  recurrence.  The  results  thus  far,  he  stated,  were 
sufficient  to  warrant  advising  the  treatment  as  a  routine 
measure  after  all  operations  for  primary  sarcoma.  While 
the  treatment  is  not  recommended  in  carcinomatous 
growths,  it  has  been  the  experience  of  the  writer  that  in 
many  cases  the  toxins  exert  a  marked  inhibitory  influence 
in  carcinoma,  although  it  is  rarely  curative.  The  only 
cases  of  carcinoma  in  which  the  toxins  are  likely  to  prove 
of  much  value,  he  believes,  are  those  in  which  they  are 
used  after  primary  or  secondary  operation,  as  a  prophy- 
laxis against  recurrence.  Up  to  the  present  time  sufficient 
experience  is  lacking  to  justify  one  in  making  any  definite 
statements  as  to  how  much  may  thus  be  accomplished. 

The  writer  still  believes  that  the  action  of  the  toxins 
upon  malignant  tumors  can  be  explained  only  upon  the 
theory  that  such  tumors  are  the  result  of  some  infec- 
tious micro-organism,  and  this  view  is  strongly  supported 
by  the  recently  expressed  opinion  of  Czerny. 

Dr.  Joseph  D.  Bryant,  of  New  York,  read  a  paper  en- 
titled "The  Influence  of  Mental  Depression  on  the  Devel- 
opment of  Malignant  Diseases,"  in  which  he  dwelt  at  length 
on  the  history  of  cancer  as  affected  by  mental  depression. 
Pare,  in  1510,  was  the  first  man  to  refer  to  mental  pertur- 
bation, anger  and  the  like,  as  making  a  cancer  "more 
lierce  and  raging,"  w'hile  the  same  authority  under  the 
head  of  treatment,  insists  that  the  patient  must  eschew 
fasting,  watching,  sorrow's,  cares  and  mourning.  Sir  Astley 
Cooper  was  of  the  same  opinion,  while  Velpeau  thought 
otherwise.  Grant  and  Napoleon  have  been  referred  to  as 
examples  of  cancer  following  reverses,  and  Paget  and  'Vir- 
chow  gave  a  qualified  allegiance  to  the  passive  side  of  the 
question. 

The  foundations  of  the  different  phases  of  the  contention 
rest  on  the  beliefs  (1)  that  cancer  may  result  from  the 
direct  influence  of  mental  depression  (2)  that  cancer  may 


arise  indirectly  from  mental  depression  because  of  the 
defective  nutrition  attendant  upon  it,  and  (3>  that  mental 
depression  exercises  in  no  respect  influences  that  admit  of 
sufficient  proof  to  warrant  serious  discussion. 

The  author  referred  to  the  infrequency  of  cancer  in  in- 
sane patients,  and  stated  that  females  suffered  twice  as 
often  as  males.  Statistics  were  given  from  a  number  of  in- 
stitutions which  showed  that  the  death  rate  in  the  female 
was  nearly  double  that  of  the  male,  although  there  were 
more  male  melancholies,  but  melancholia  in  the  male  does 
not  seem  to  exercise  any  distinctive  effect  on  the  death 
rate.  Neither  is  melancholia  in  the  male  more  often  as 
tociated  with  cancer  than  with  other  forms  of  malignant 
growths. 

Many  authors  were  quoted  and  the  following  division  of 
the  cases  was  suggested:  (Ij  Cases  in  which  mental  de- 
pression is  not  associated  with  the  idea  of  cancer:  (2) 
Cases  in  which  mental  depression  is  associated  with  the 
idea  of  impending  cancer  of  primary  or  secondary  occur- 
rences, and  (3 J  Cases  in  w-hich  the  depression  is  the  out- 
come of  common  causes. 

Afternoon    Session. 

Dr.  J.  Collins  Warren,  of  Boston,  in  discussing  the  fore- 
going papers,  stated  that  there  were  several  different  ways 
of  approaching  the  ouestion  as  exemplified  by  different 
writers,  and  referred  to  the  geographical,  statistical,  his- 
tological, experimental,  blastomycetic.  The  experimental 
was  divided  into  chronic  irritation  and  inoculation,  and 
reference  was  made  to  the  fact  that  two  papers  had  ap- 
Iieared  during  the  year  in  favor  of  the  protozoan  theory  of 
the   disease. 

Reference  was  made  to  the  experiment  of  Lack  in  pro- 
ducing peritoneal  cancer  in  a  rabbit  by  scraping  the  ovar- 
ies, which  observation,  so  far  as  known  has  not  been  con- 
firmed  by  any   other  observer. 

Dr.  Cullen  closed  the  discussion  on  the  foregoing  pa- 
pers and  stated  that  in  order  to  prove  conclusively  that 
a  given  organism  is  the  cause  of  cancer  it  is  necessary  (1) 
to  find  or  isolate  the  organism  (2)  to  produce  cancer  by  in- 
oculating the  organism  into  another  body  and  (3)  to  recover 
the  organism  from  the  cancer  thus  produced. 

He  commented  at  considerable  length  on  the  work  of 
Dr.  Gaylord  and  hoped  that  he  and  his  associates  would 
not  be  discouraged  in  their  work. 

In  closing  the  discussion  Dr.  Park  stated  that  he  had 
not  said  one-half  of  what  he  would  like  to  say  but  he 
promised  to  give  more  details  of  the  work  in  the  future 
in  a  paper  to  be  prepared  by  Dr.  Gaylord  and  himself,  deal- 
ing particularly  with  the  methods  and  results  of  inocula- 
tion. 

Dr.  J.  C.  Bloodgood.  of  Baltimore  read  a  paper  on  "Blood 
Examination  as  an  Aid  to  Surgical  Diagnosis."  and  illus- 
trated the  subject  with  a  large  number  of  statistics  and 
tables. 

The  Clinical  Value  of  Blood  Examinations  in  Appendi- 
citis: A  Study  Based  on  the  Examination  of  One  Hundred 
and  Eighteen  Cases  in  the  German  Hospital.  Philadelphia, 
was  the  title  of  a  paper  read  by  Dr.  J.  C.  DaCosta.  Jr.  The 
author  discussed  the  subject  under  the  heading  of  (1) 
Methods  and  Technique.  (21  Classification  and  (3i  the 
.\nemia  of  Appendicitis.  The  details  under  each  one  of 
these  headings  were  discussed  at  great  length  and  a  large 
number  of  blood  counts  were  given  both  actual  and  com- 
parative. 

Drs.  J.  B.  Blake.  J.  C.  Hubbard,  and  R.  C.  Cabot  read  a 
paper  entitled  Blood  Examination  in  Relation  to  Surgical 
Diagnosis,  and  divided  the  subject  into  six  headings.  (11 
the  leukocTi-te  count  in  fractures.  (2)  Post  operative  leu- 
kocytosis. (3)  Etherleukocytosis.  (41  the  effect  of  fear  on 
the  leukocytes,  (.i)  Regeneration  of  the  blood  after  opera- 
tions on  malignant  tumors  and  I61  Blood  examinations  in 
relations  to  intestinal  perforation  in  typhoid  fever. 

Dr.  J.  Chalmers  Da  Costa  and  J.  U.  Kalteyer.  of  Phila- 
delphia read  a  paper  entitled  "The  Effect  on  the  Blood  of 
Ether  as  an  Anaesthetic."  The  paper  reviews  the  rather 
meagre  literature  of  the  subject,  dwelling  particularly  upon 
the  writings  of  Mickuliz.  J.  Chalmers  Da  Costa.  Oliver. 
Hamilton   Fish   and   Bloodgood. 

They  dwell  on  the  great  difference  which  exists  as  to 
whether  or  not  ether  causes  blood  destruction.  They  hold 
that  it  does  cause  blood  destruction  and  that  those  who 
affirm  the  contrary  have  been  misled  by  the  blood  concen- 
tration which  results  from  the  preliminary  treatment  and 
which  is  often  added  to  by  sweating  during  the  anesthetic 


Juke  1,  1901] 


AMERICAN  NEWS  AND  NOTES 


CThe  Philadelphia 
Medical   Journal 


1033 


state.  This  blood  concentration  may  marlc  the  fall  of 
hemoglobin;  in  fact  in  some  cases  will  cause  an  apparent 
rise.  The  important  facts  to  note  are  that  the  color  in- 
dex practically  always  falls  and  that  the  number  of  cor- 
puscles increases  These  facts  prove  marked  blood  de- 
struction and  increased  production  of  corpuscles  deficient 
in  hemoglobin,  resulting  from  ether  anesthetic.  The  au- 
thors report  upon  50  cases  in  which  blood  examinations 
were  made  and  subdivide  these  cases  into  numerous  tables 
for  purposes  of  examination  and  comparison.  In  49  of  the 
cases  the  color  index  was  lowered.  The  writers  also 
showed  sections  of  the  marrow  of  a  rabbit's  femur,  the 
animal  having  been  etherized  to  death.  These  sections 
show  mocked  erythroblastic  proliferation. 

The  authors  conclude  that  the  hemoglobin  is  absolutely 
reduced  after  the  administration  of  ether,  this  reduction 
being  manifest  in  the  individual  corpuscular  hemoglobin 
value.  The  increased  hemolysis  which  occurs  in  nature's 
effort  to  rapidly  replace  the  destrojed  corpuscles  and  the 
regenerated  cells  are  imperfectly  supplied  with  hemo- 
globin. The  authors  urge  that  whenever  possible  one  or 
two  blood  examinations  should  be  made  before  ether  is 
administered  and  these  examinations  should  be  made  be- 
fore preparatory  treatment  has  been  instituted.  If  less 
than  fifty  per  cent,  of  hemoglobin  is  present  an  anesthe- 
tic is  dangerous  and  should  only  be  given  in  a  surgical 
emergency,  which  threatens  life.  In  malignant  disease  a 
percentage  of  under  fifty  per  cent,  contraindicates  opera- 
tion. Mickuliz  says  no  general  anesthetic  should  be  given 
under  any  circumstances  if  the  hemoglobin  is  under  thir- 
ty, but  the  authors  believe  that  forty  per  cent.  Is  probably 
the  lowest  justifiable  limit.  If  operation  must  be  per- 
formed when  the  hemoglobin  is  under  forty  per  cent,  a 
local  anesthetic  should  be  given.  It  is  true  cases  with  under 
forty  per  cent,  of  hemoglobin  are  occasionally  etherized 
successfully,  (for  instance,  one  case  was  recalled  with  only 
twenty-four  per  cent.),  but  such  instances  are  rare,  are  not 
sufficiently  numerous  to  set  aside  the  rule  and  are  only 
justified  by  the  imperative  necessities  of  a  vital  emergency. 
Whenever  the  percentage  of  hemoglobin  is  low  the  ad- 
ministration of  the  anesthetic  should  be  entrusted  only  to 
an  experienced  man,  as  little  ether  as  possible  should  be 
given,  the  surgeon  should  operate  quickly  and  proper  meas- 
ures should  be  adopted  to  bring  about  reaction  promptly 
and  to  remove  the  ether  from  the  lungs  and  blood  as 
quicklj'   as   possible. 

Dr.  John  B.  Deaver,  of  Philadelphia,  read  a  paper  enti- 
tled "Examination  of  the  Blood  in  Relation  to  Surgery  of 
Scientific  Value,  but  Too  Often  of  no  Practical  Value  and 
May  Misguide  the  Surgeon." 

The  subject  of  appendicitis  was  discussed  in  detail  and 
the  value  of  the  microscope  in  bedside  diagnosis  was  re- 
ferred to,  but  the  author  felt  that  too  much  importance 
should  not  be  attached  to  this  as  compared  with  the  weight 
given  to  other  signs  of  the  disease,  some  of  the  latter  pos- 
sessing in  his  opinion  greater  merit  as  aids  to  the  sur- 
geon. 

In  his  discussion  on  the  foregoing  papers  Dr.  B.  Farqu- 
bar  Curtis,  of  New  York,  remarked  the  frequency  of  leuko- 
cytosis following  either  anesthesia  and  stated  that  it  oc- 
curred quite  as  often  after  intraspinal  anesthesia.  He 
did  not  believe  that  leukocytosis  should  be  considered  as 
demonstrating  the  existence  of  infection,  but  rather  that 
it  should  be  looked  upon  as  a  fixed  factor  following  anes- 
thesia, illustrating  this  point  by  reference  to  a  case.  While 
he  considered  this  point  of  great  value,  he  felt  that  the 
temperature  and  pulse  record  were  equally  so. 

Second    Day,    Morning    Session. 

This  session  was  held  at  the  Johns  Hopkins  Hospital  and 
addresses  were  made  by  Drs.  Osier  and  Welch.  Demon- 
strations were  also  given  by  Dr.  Kelly  in  the  employment 
of  the  newer  methods  of  diagnosis  in  rectal  and  urinary 
disease  and  by  Dr.  Young  in  catheterization  of  the  male  ure- 
thra. Dr.  Osier's  remarks  referred  to  the  clinical  and  Dr. 
Welch's  to  the  laboratory  methods  of  teaching  employed  at 
the  Johns  Hopkins. 

Dr.  Oscar  H.  Allis  gave  a  demonstration  of  fractures  of 
the  pelvis.  He  demonstrated  upon  the  cadaver  the  effects 
of  violence  directed  against  the  pelvis  through  the  medium 
of  the  femur,  being  a  comparative  study  of  the  relative 
strengths  of  the  neck  of  the  femur  and  that  of  the  pelvis. 
The  application  of  force  was  by  means  of  a  lever  driving 
the  head  of  the  femur  against   the   acetabulum,   directed 


(a)   at  right  angles  to  the  long  axis  of  the  trunk  and  (b) 
parallel  to  the  long  axis  of  the  trunk. 

Afternoon   Session. 

Dr.  A.  W.  Mayo  Robson,  of  Leeds,  England,  read  a  paper 
entitled  "Pancreatitis  with  Especial  Reference  to  Chronic 
Pancreatitis."  The  author  commented  on  the  fact  that  he 
thought  it  strange  it  had  not  until  recently  dawned  on  the 
minds  of  clinical  observers  that  whatever  obstructs  the 
common  bile  duct  at  its  lower  end  must  also  of  necessity 
lead  to  obstruction  in  the  pancreatic  duct.  When  the  com- 
mon bile  duct  is  obstructed  the  o'ojective  signs  of  jaundice 
at  once  demonstrate  the  fact  but  hitherto  no  pathognom- 
onic sign  has  been  discovered  which  will  show  conclusive- 
ly that  the  pancreatic  ducts  are  occluded,  unless  it  be 
the  extremely  rapid  loss  of  weight.  When  it  is  borne  in 
mind  that  the  pancreatic  duct  opens  along  with  the  com- 
mon bile  duct  into  the  second  part  of  the  duodenum  it  is 
not  a  matter  for  surprise  that  pancreatitis  should  be  met 
with.  The  essential  and  immediate  cause  of  the  various 
forms  of  pancreatitis  is  bacterial  infection,  which  has  been 
positively  proved  both  clinically  in  the  human  subject  and 
experimentally  in  the  lower  animals.  The  association  of 
gall-stones  with  chronic  pancreatitis  was  absolutely  forced 
on  my  mind  by  the  frequency  with  which  I  found  inflam- 
matory enlargements  of  the  head  of  the  pancreas  when  op- 
erating for  gall-stones  in  the  common  duct. 

Taking  up  the  subject  of  fat  necrosis  it  was  stated  that 
this  condition  is  commonly  found  in  association  with  pan- 
creatitis and  the  relationship  between  the  two  conditions 
has  given  rise  to  much  speculation. 

Hemorrhage  in  pancreatic  diseases  was  dwelt  upon  and 
it  was  mentioned  that  death  from  collapse  may  occur  either 
immediately  or  some  hours  after  spontaeous  hemorrhage. 
Several  illustrative  cases  were  cited,  together  with  the 
symptoms  and  results,  the  following  conclusions  being 
reached:  (1)  that  in  certain  diseases  of  the  pancreas  there 
is  a  general  hemorrhagic  tendency,  which  is  much  inten- 
sified by  the  presence  of  jaundice:  (2)  that  hemorrhage 
may  apparently  occur  in  the  pancreas  unassociated  with 
inflammation  or  with  jaundice  or  with  a  general  hemorrhag- 
ic tendency:  (3)  that  both  acute  and  chronic  pancreatitis 
can  and  do  frequently  occur  without  hemorrhages,  and  (4) 
that  some  cases  of  pancreatitis  are  associated  with  local 
hemorrhage. 

It  was  suggested  that  pancreatitis  should  be  divided  into  the 
acute,  sub-acute  and  chronic  and  that  the  hemorrhagic 
be  considered  a  variety  of  the  acute.  The  glycerine  set 
free  in  the  tissues  by  the  fat  necrosis  was  looked  upon  as  a 
possible  cause  for  the  local  hemorrhage  and  some  details 
en  this  point  were  gone  into.  In  addition,  the  results  of 
blood  examinations  with  a  view  of  discovering,  if  possible, 
the  cause  of  the  hemorrhagic  tendency  were  given. 

The  treatment  of  the  three  stages  of  the  disease  was 
then  discussed  fully  and  examples  given  of  each,  together 
with  the  results  of  treatment,  as  well  as  of  post-mortems. 

Dr.  George  E.  Brewer,  of  New  York,  in  discussing  Dr. 
Robson's  paper  on  Pancreatitis,  stated  that  he  believed 
the  disease  to  be  of  far  more  frequent  occurrence  than  is 
generally  supposed  and  in  support  of  this  assertion  he  cited 
the  records  obtained  from  the  autopsy  table,  as  showing  its 
serious  nature,  frightful  mortality  and  obscure  symptomat- 
ology, as  well  as  the  fact  that  certain  surgeons,  as  the 
author  of  the  foregoing  paper,  have  had  a  large  personal 
experience  with  the  disease  and,  where  it  has  been  exten- 
sively discussed,  a  fairly  large  number  of  cases  have  annu- 
ally been  reported.  The  fact  of  its  non-recognition  by  the 
profession  at  large  is  established  by  the  fact  that,  in  other 
localities,  no  cases  are  reported.  He  stated  that  in  going 
over  the  recent  annual  reports  of  fifteen  or  twenty  of  New 
York's  largest  hospitals  he  found  but  one  which  recorded 
surgical  treatment  of  the  disease,  and  in  this  one  institu- 
tion four  cases  are  reported  as  having  been  operated  uopn 
during  a  single  year. 

He  believed  the  profession  failed  to  recognize  this  dis- 
ease more  readily  for  two  reasons:  (1)  their  attention  has 
not  been  directed  to  it  by  reports  of  cases  and  monographs 
on  the  subject  and  (2)  sufficient  data  have  not  been  collected 
on  the  subject  and  (2)  sufficient  data  has  not  been  collected 
accurate  and  complete  catalogue  of  the  characteristic  sym- 
toms.  He  dwelt  upon  the  importance  of  constant  vigilance  be- 
ing maintained  for  this  disease  and  the  value  of  recording  and 
publishing  the  clinical  histories  and  results  of  operations, 
together  with  the  autopsy  findings  of  all  cases  of  this  dl*- 


1034 


Tee  Philadelphia' 
Medical  Journal    . 


AMERICAN  NEWS  AND  NOTES 


[Juke  1,  isoi 


order  coming  under  the  surgeon's  observation.  This,  he 
ffelt.  would  be  of  great  value  to  the  profession  at  large,  en- 
abling them  to  diagnose  the  condition  much  more  readily. 
The  anatomy  of  this  region  could  be  renewed  with  great 
interest  not  only  in  regard  to  the  clinical  history  and  path- 
ology of  the  disease,  but  might  furnish  some  very  valuable 
suggestions  in  reference  to  treatment.  At  a  very  early  per- 
iod in  the  development  of  the  embryo  pancreas  is  formed  by 
two  offshoots  from  the  intestinal  tube  just  below  the 
gastric  dilatation  between  the  two  layers  of  the  posterior 
mesenterj'.  These  tv/o  branches  rapidly  develop  and  again 
divide  and  subdivide,  forming  an  innumerable  number  of 
fine  twigs,  each  one  ending  in  a  small  epithelial-lined  sac, 
These  are  surrounded  by  minute  plexuses  of  blood  vessels, 
nerves  and  lymphatics  and  held  together  by  areolar  tis 
sue  which  divide  the  gland  into  a  large  number  of  seg- 
ments or  lobules.  The  further  development  of  the  pan- 
creas was  then  discussed  at  some  length  and  the 
the  development  of  another  outgrowth  which  after- 
wards forms  the  liver  was  noted.  The  different 
stages  in  the  development  of  the  bile  duct  and  the  two  pan- 
creatic ducts  were  recognized  and  the  fusion  of  the  lower 
pancreatic  duct  with  the  bile  duct  forming  the  ampulla  of 
Vater,  which  opens  into  the  duodenum  in  the  adult  sub- 
ject was  remarked.  He  referred  to  the  fact  that  the  older 
anatomists  taught  that  the  upper  pancreatic  duct  gradually 
atrophied  and  only  remained  patent  in  a  few  instances,  but 
jater  investigation  resulted  in  the  discovery  that  it  could  ije 
injected  from  the  main  pancreatic  duct  in  about  fifty-isx  per 
cent,  cf  the  cases  and  still  later  investigation  by  improved 
methods  demonstrated  the  fact  that  the  duct  of  Santorini  is 
practically  always  present  in  the  human  subject.  He  then 
presented  five  or  six  photographs  furnished  him  by  Dr. 
Carlton  Flint  of  the  anatomical  department  of  Columbia 
University,  showing  the  arrangement  and  accessory  in  some 
of  the  lower  animals  as  compared  with  those  of  the  human 
body.  He  then  called  the  attention  of  the  society  to  the  fact 
that  in  the  early  stage  of  its  development  the  pancreas  is 
completely  invested  by  the  peritoneum  and  only  becomes  a 
retroperitoneal  organ  by  the  absorption  and  conversion  into 
areolar  tissue  and  fat  of  the  several  layers  of  the  posterior 
mesentery.  The  attention  of  the  society  was  directed  to 
the  four  different  routes  by  which  the  pancreas  may  be 
reached,  namely:  by  dividing  the  gastro-hepatic  omentum 
just  abo\e  the  lesser  curvature  of  the  stomach,  (2)  by  divid 
ing  the  gastrocolic  omentum  just  below  the  greater  curva- 
ture of  the  stomach,  (3)  by  dividing  the  transverse  meso- 
colon, and  (4)  by  reflecting  the  parietal  peritoneum  through 
a  lumbar  incision  until  the  peri-renal  fat  is  reached,  which 
is  continuous  with  the  areolar  tissue  surrounding  the  pan- 
creas. He  then  mentioned  the  fact  that  in  his  opinion  a 
probable  causative  relationship  existed  between  an  en- 
larged and  relaxed  duodenal  orifice  of  the  ampulla  of  Vatc-r 
due  to  the  frequent  passage  of  biliary  calculi  and  inflamma 
lory  diseases  of  both  the  bile  duct  and  the  pancreatic  duct, 
stating  that  he  based  his  opinion  upon  observations  regard- 
ing the  existence  of  like  conditions  in  other  portions  of  the 
body  of  ducts  emptying  into  septic  cavities  in  other  por- 
tions of  the  body.  In  concluding  he  mentioned  the  probable 
digestive  action  of  the  pancreatic  juice  when  allowed  to 
percolate  into  the  connective  surrounding  the  gland  as  a 
cause  of  erosion  of  the  blood  vessels  and  extensive  necrosis 
in  addition  to  the  well  known  power  it  has  of  producing  fat 
necrosis. 

(To  be  Continued.) 


THE    ASSOCIATION    OF    AMERICAN    PHYSICIANS. 


Obituary. — Dr.  Frank  C.  Hoyt,  at  Kansas  City,  Mo.,  on 
May  21. — Dr.  Marie  J.  Mergler.  at  Los  Angeles.  Cal..  on 
May  IS,  aged  50  years. — Dr.  Hugh  Stockdcll.  at  Petersburg. 
Va..  on  May  23.  aged  66  years.^Dr.  R.  \.  Gottsleben.  at 
Mayville,  Wis.,  on  May  23.  aged  50  years. — Dr.  Conrad 
Weinges.  at  Jersey  City,  N.  J.,  on  May  23.  aged  53  years.— 
Dr.  John  T.  Hagan.  at  Baltimore.  Md.,  on  May  23.  "aged  51 
years. — Dr.  Jane  Kendrick  Culver,  at  Boston.  Mass.,  on 
May  23. — Dr.  Thomas  F.  Rumbold,  at  St.  Louis.  Mc,  on 
May  23,  aged  71  years. — Dr.  George  Washington  Whitney, 
at  Chicago.  111.,  on  May  23. 


Smallpcx  Delays  Troops. — Further  cases  of  smallpox  have 
been  discovered  on  the  United  States  transport  Indiana,  and 
the  Ninth  Infantry  Regiment,  which  left  Pekin  May  22,  on 
its  way  to  Manilla,  has  gone  into  camp  at  Taku. 


(Continued  from  Page  &&1.) 

Edward  L.  Trudeau,  of  Saranac  Lake,  N.  Y.,  read  a  paper 
entitled  the  importance  of  a  recognition  of  the  significance 
of  early  tuberculosis  in  Its  relation  to  treatment.  The 
search  for  the  tubercle  bacilUus  should  be  begun  early  and 
continue  as  long  as  the  symptoms  remain  obscure.  The  | 
absence  of  the  tubercle  bacillus  from  the  sputum  is  not 
conclusive  evidence  of  the  absence  of  the  disease,  particu- 
larly in  its  early  stages,  and  too  much  stress  should  not 
be  laid  upon  the  negative  finding.  The  tuberculin  test  is 
of  value  in  reaching  a  conclusion  when  the  bacilli  are  not  ■ 
found.  The  results  of  the  tuberculin  test  are  most  reliable  ll 
when  the  patient  has  no  fever.  Early  diagnosis  is  of  the  I 
first  importance  in  the  treatment  of  the  disease,  because 
it  is  in  the  incipient  stage  that  the  greatest  amount  of  good 
can  be  done.  Although  the  open-air  treatment  of  tuber- 
culosis gives  renewed  hope  to  physician  and  to  patient, 
disappointment  will  result  unless  the  importance  of  early 
diagnosis  is  realized.  In  answer  to  a  question  by  Mc- 
Phedran.  of  Toronto,  the  author  said  that  a  regular  rise  of 
temperature  to  ;i9.5'  at  a  definite  time  of  day  is  of  sig- 
nificance in  a  case  of  suspected  tuberculosis.  A.  Jacobi. 
of  New  York,  said  that  mouth  temperature  in  cases  where 
accuracy  is  a  desideratum  is  unreliable.  Rectal  tempera- 
ture is  the  only  one  that  can  be  absolutely  relied  upon. 
Even  in  the  rectum  there  is  a  difference  of  %°  between  the 
lower  and  the  higher  portions  of  the  rectum.  Rectal  tem- 
peratures of  99.5'  are  normal.  Some  cases  with  prolonged 
expiration  and  impairment  of  resonance  are  due  to  inter- 
stitial pneumonia  of  long  duration.  Edward  L.  Trudeau  said 
that  in  a  case  such  as  cited  by  Jacobi  the  tuberculin  test 
w-ould  give  conclusive  demonstration  as  to  the  nature  of 
the  disease.  He  begins  to  inject  one  mg.  of  tuberculin  for 
diagnostic  purposes,  then  gives  S  mg..:  and  finally,  6  mg. 
In  surgical  cases  it  is  often  necessary  to  use  between  5  and 
15  mg. 

J.  George  Adami  read  for  J.  McCrae.  of  Montreal,  a  pa- 
per entitled  a  study  of  a  series  of  cases  of  burns.  The  pa- 
per is  based  upon  the  study  of  13  cases  of  bums.  4  of 
which  came  to  autopsy.  In  burns  it  is  possible  that  a 
toxemia  is  produced  which  is  similar  to  the  toxemias  of 
bacterial  origin. 

Focal  necroses  are  not  a  constant  accompaniment  of 
burns.  The  lymph-nodes  sometimes  present  a  clear  central 
portion  with  a  cortex  closely  packed  with  cells:  and.  in 
other  instances,  there  is  degeneration  throughout.  The 
proliferated  endothelial  cells  in  the  lymph-nodes  are  phago- 
cytic and  the  author  interprets  the  clear  center  that  he 
has  seen  as  a  later  stage  than  the  necrotic  center  described 
by  Bardeen.  The  l>Tnphocytes  in  such  a  lymph-node  have 
disappeared  by  a  combination  of  toxic  and  phagocytic  ac- 
tion. In  cases  of  severe  burns  the  kidneys  were  the  seat 
of  degenerative  changes.  The  liver,  also,  showed  various 
changes  that  were  similar  to  the  condition  seen  in  other 
toxic  states.  The  pathological  processes  present  a  similar- 
ity to  the  diseases  characterized  by  the  presence  of  toxins 
in  the  blood.  The  damage  to  lymphatics  in  bums  is  con- 
stant but  not  necessarily  focal.  The  focal  lesions  are  not  true 
necroses  but  are  due  to  the  proliferation  of  the  endothelium 
of  the  capillaries.  Simon  Flexner.  of  Philadelphia,  said  that 
Bardeen's  investigations  were  suggested  by  the  similarity 
of  the  lesions  found  after  burns  and  those  accompanying 
diphtheria.  The  changes  in  burns  are  more  prolifer- 
ative th:in  degenerative.  The  appearances  of  degenera- 
tion may  indeed  be  due  to  phagocytosis  but  in  the  toxemias 
the  degenerative  changes  are  complete.  A.  Jacobi.  of  New 
York,  asked  whether  there  was  any  relation  between  the 
changes  described  and  the  physical  changes  such  as  the 
con  version  of  hemoglobin  into  raethemoglobin.  The  kid- 
neys are  usually  the  seat  of  a  hemorrhagic  nephritis  when 
inethemoglobin  is  present  in  the  blood.  William  H.  Welch. 
of  Baltimore,  said  that  probably  the  toxin  elaborated  in  a 
burn  is  due  to  the  action  of  heat  on  the  blond  in  the  super- 
ficial capillaries.  He  could  accept  the  granules  found  in 
the  lesions  of  the  lymph-nodes  as  the  result  of  the  digestion 
of  lymph-cells  by  endothelial  cells.  The  process  then 
would  be  that  the  manufactured  toxin  stimulates  the  fixed 
endothelial  cells  to  proliferation  and  they  take  up  the 
lymphoid  cells  by  phagocytic  action.  It  would  seem  more 
reasonable  to  suppose,  however,  that  these  phagocytic  cells 
were  utilized  to  remove  lymph-cells  already  damaged  bj" 
toxin. 


June  1,  1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadei-phia 
LMedical  Journai. 


1035 


S.  J.  Meltzer,  of  New  York,  read  a  paper  entitled  hemo- 
lysis. The  author  has  found  that  immunized  serum  con- 
sists ot  2  substances:  one  of  which  is  stable,  the  other  of 
which  is  destroyed  by  heating  to  55^C.  The  latter  sub- 
stance is  a  ferment-like  l)ody,  which  causes  a  precipitate  in 
fresh  serum.  Hemolytic  serum,  during  its  stay  in  the 
peritoneal  cavity,  loses  its  enzyme-like  compliment. 

The  following  papers  were  read  by  title:  Slow  pulse 
with  special  reference  to  Stokes-Adams'  disease.  By  Rob- 
ert T.  Edes,  of  Boston. 

Exhibition  of  a  cardiograph  and  a  kymographion  for  bed- 
side use.    By  Alfred  Stengel,  of  Philadelphia. 

A  case  of  acute  leukemia  presenting  some  interesting 
features.     By  D.  D.  Stewart,  of  Philadelphia. 

Masked  malarial  infection.  By  Morris  J.  Lewis,  of  Phila- 
delphia. 

Sarcosporidia  of  the  mouse  (sarcocystis  muris)  trans- 
mitted directly  by  feeding  muscular  tissue.  By  Theobald 
Smith,  of  Boston. 

A  further  report  on  a  case  of  presystolic  mitral  murmur 
associated  with  systolic  tricuspid  murmur  complicating 
pregnancy  reported  to  the  association  in  May,  1899.  By 
James  Tyson,  of  Philadelphia. 

The  extension  of  aortic  aneurysms  into  and  between  the 
walls  of  the  heart  and  dissecting  aneurysm  of  the  heart. 
By  Ludvig  Hektoen,  of  Chicago. 

A  study  of  bacteria  isolated  from  cases  of  dysentery. 
By  F.  F.  Wesbrook.  of  Minneapolis. 

The  relative  prevalence  of  Bright's  disease  in  New 
York,  London  and  Berlin.  By  Hermann  N.  Biggs,  of  New 
York. 

Lithemic  or  recurrent  coryza.  By  B.  K.  Rachford,  of  Cin- 
cinnati. 

Report  of  a  case  of  spondylosis  rhizomelia  with  autopsy. 
By  Charles  L.  Dana,  of  New  York. 

The  relation  of  the  tracheal  tug  to  fixation  and  elastic- 
ity of  the  left  lung.     By  Henry  Sewell,  Denver. 

The  following  officers  were  elected  for  the  ensuing  year: 
President,  James  C.  Wilson,  of  Philadelphia;  vice-presi- 
dent, J.  Stewart,  of  Montreal:  recorder,  S.  Solis-Cohen,  of 
Philadelphia:  secretary.  Henry  Hun,  of  Albany:  treasurer. 
J.  P.  Crozer  Griffith,  of  Philadelphia:  councillors,  Frank 
Billings,  of  Chicago,  and  Francis  P.  Kinnicutt,  of  New 
York:  member  ot  the  executive  committee  of  the  Ameri- 
can Congress,  William  Osier,  of  Baltimore:  alternate, 
Francis  H.  Williams,  of  Boston.     [J.  M.  S.] 

Second  Day.  Afternoon. — William  A.  Park,  of  New  York, 
read  a  paper  entitled  To  what  extent  is  urine  a  suitable 
soil  for  bacterial  growth?  The  paper  is  based  on  the  study 
ot  50  urines  to  determine  their  fitness  to  be  used  as  a 
culture  medium  for  microorganisms.  The  author  found 
that  in  highly  acid  urines  the  majority  of  microorganisms 
would  grow  with  difficulty  and  that  some  would  not  grow 
at  all.  He  suggested  that  if  a  urine  was  rendered  highly 
acid  by  suitable  medicinal  substances  it  might  help  to 
prevent  infection  and  be  ot  assistance  in  the  therapeutics 
of  cystitis. 

Francis  P.  Kinnicutt,  ot  New  York,  read  a  paper  en- 
titled orchitis  complicating  typhoid  fever.  He  reported  2 
cases  that  he  had  seen  in  his  wards  in  the  Presbyterian 
Hospital  in  New  York.  One  of  the  patients  was  a  man, 
aged  24  years.  The  orchitis  developed  after  convalescence 
was  established  and  was  accompanied  by  phlebitis  of  the 
long  saphenous  vein  of  the  same  side.  The  spermatic  cord 
was  involved.  The  second  patient  was  34  years  old.  The 
disease  was  apparently  cured  and  then  recurred.  During 
the  recurrence  an  abscess  developed,  the  pus  of  which 
contained  the  bacillus  of  Eberth.  It  is  possible  that  the 
bacilli  reached  the  testicle  through  the  blood  current  as 
well  as  through  the  vas  deferens  from  the  bladder.  The 
condition  is  a  rare  complication  of  typhoid  fever;  the  testi- 
cle seldom  contains  microorganisms;  it  usually  occurs  late 
in  the  course  of  the  typhoid  fever  and  is  usually  unilater- 
al. William  Osier,  of  Baltimore,  spoke  of  a  case  of  orchi- 
tis complicating  typhoid  fever  that  illustrated  its  late  oc- 
currence, F.  H.  Shattuck.  of  Boston,  ^lad  seen  one  case  in 
his  hospital  service  recently  and  at  the  same  time  there 
were  3  cases  in  the  service  of  his  colleague.  John  H.  Mus- 
ser,  of  Philadelphia,  had  seen  a  case  of  orchitis  in  a  boy 
who  had  not  been  sick  in  bed.  The  presence  of  the  serum 
reaction  explained  the  nature  of  the  condition.  While  the 
patient  was  under  treatment  for  the  orchitis  he  had  a 
relapse  of  his  typhoid  fever.  Francis  H.  Williams,  of 
Boston,  said  that  he  had  seen  a  similar  case  to  the  ones 


reported  by  Kinnicutt.  Baumgarten  said  that  he  had  seen 
one  case  accompanied  by  phlebitis  of  the  internal  saphen- 
ous veins  during  a  relapse  in  typhoid  fever.  The  vein 
was  involved  before  the  testicle. 

Francis  H.  Williams,  of  Boston,  read  a  paper  entitled 
notes  on  the  treatment  of  some  forms  of  cancer  by  the 
X-rays.  In  employing  X-rays  for  the  treatment  of  carci- 
noma of  the  skin,  great  care  should  be  taken  not  to  pro- 
duce burns.  The  cases  treated  by  the  author  include 
epithelioma  of  the  lip,  of  the  hand  and  of  the  eyelid.  The 
advantages  of  the  treatment  are  (1)  that  there  is  no 
pain,  (2)  that  there  is  no  delay  on  account  of  dread  of  the 
knife,  (3)  that  healing  can  occur  without  caustic  effect,  (4) 
that  the  results  from  a  cosmetic  standpoint  are  excel- 
lent and  (5)  that  the  treatment  is  ambulatory.  The  dis- 
advantages of  the  method  are  (1)  that  great  care  is  re- 
quired, (2)  that  it  is  expensive  and  (3)  that  the  treat- 
ment must  be  continued  for  some  time. 

In  reply  to  a  question  from  Charles  S.  Bond,  ot  Rich- 
mond, Indiana,  the  author  said  that  the  X-rays  are  the 
active  agent  in  the  treatment  and  not  the  cathode  rays. 
There  is  no  disadvantage  in  placing  a  cloth  between  the 
growth  and  the  Cooke's  tube.  In  answer  to  a  question  by 
Peabody,  of  New  York,  he  said  that  all  cases  except  one 
had  been  submitted  to  microscopic  examination.  The 
cases  were  consecutive. 

Frederick  A.  Packard  and  J.  Dutton  Steele,  of  Philadel- 
phia, read  a  paper  entitled  osteitis  deformans.  The  pa- 
tient was  a  German,  aged  62  years,  who  had  a  large  box- 
shaped  head  with  a  projection  in  the  frontal  region  and 
a  tumor  at  the  junction  of  the  frontal,  parietal  and  tem- 
poral regions.  The  circumference  of  the  skull  was  in- 
creased. The  clavicles  were  thickened  and  projected 
backward.  The  attitude  of  the  patient  was  like  that  of  an 
Ourang  Outang.  At  autopsy  the  calvarium  was  much 
thickened,  the  diploe  were  absent  except  in  the  frontal  and 
occipital  regions.  The  pituitary  body  and  suprarenal  bodies 
were  unaltered.  The  clavicle  cut  and  decalcified  easily 
The  processes  of  bone  absorption  were  taking  place  in 
localized  areas  in  both  the  calvarium  and  the  clavicle.  The 
tumor  was  a  giant-celled  sarcoma  and  nodules  from  the 
pia  mater  of  the  brain  and  the  pleura  presented  the  same 
lesion. 

William  Osier,  of  Baltimore,  read  a  paper  entitled  the 
spinai  form  of  arthritis  deformans.  There  are  2  varieties 
of  spinal  involvement  in  arthritis  deformans:  one  described 
by  Bechterew,  is  characterized  by  rigidity  of  the  vertebral 
column,  kyphosis  in  the  thoracic  region  and  nerve-root 
symptoms.  The  other  form  was  described  by  Marie  and 
is  characterized  by  involvement  of  the  large  joints  at  the 
proximal  extremities  of  the  limbs  and  the  absence  of  nerve 
root  symptoms.  The  author  has  seen  recently  2  cases  of 
the  former  and  3  of  the  latter  type.  In  the  2  cases  of 
Bechterew's  type,  the  nerve-root  symptoms  were  agonizing. 
In  the  3  cases  of  Marie's  type,  complete  thoracic  immo- 
bility was  present.  The  ligaments  in  the  vertebral  col- 
umn may  be  completely  ossified.  The  cases,  in  the  opin- 
ion of  the  author  are  a  variety  of  arthritis  deformans  and 
are  not  examples  of  separate  diseases.  Charles  G,  Stock- 
ton, of  Buffalo,  showed  the  skeleton  of  an  intemperate  man 
who  had  suffered  from  .gonorrheal  rheumatism  which  ren- 
dered him  so  diseased  that  he  was  unable  to  move.  The 
skeleton  is  an  excellent  example  of  the  changes  found  in 
the  second  type  of  ease  described  in  Osier's  paper.  The 
thorax  is  absolutely  immobile,  the  right  temporomaxillary 
joint  is  ankylosed,  the  se.gments  ot  the  vertebral  column 
the  ribs  and  the  hip  joints  are  firmly  ankylosed.  Lamb, 
of  Washington,  showed  a  prehistoric  skeleton  from  Alaska, 
obtained  from  the  communal  house,  in  which  the  spinal 
column  was  completely  ankylosed,  and  in  which  there  were 
kyphosis  and  complete  bony  union  between  the  spinous 
processes  in  the  lower  thoracic  and  lumbar  regions.  The 
ribs  were  not  ankylosed.  He  also  showed  specimens  of  bones 
from  a  skeleton  in  which  all  the  bones  were  involved 
in  the  process  except  those  of  the  vertebral  column.  B. 
Sachs,  of  New  Y'ork  said  that  he  considered  these  cases 
to  be  a  varieties  of  arthritis  deformans.  He  referred  to 
a  ease  illustrating  the -early  stages  of  the  Bechterew 
type.  J.  P.  Crozer  Griffith,  of  Philadelphia,  referred  to 
tiie  case  of  a  woman,  aged  71  years  who  had  had  enlarge- 
ment of  the  head  since  the  age  of  64.  He  showed  the  cal- 
varium. which  was  very  much  thickened.  The  bones  of  the 
pelvis  were  thick  and  friable  and  the  bones  of  the  upper 
and  lower  extremities  were  thickened.  He  also  referred 
to  the  case  of  a  child,  aged  8  years,  who  had  a  b.rge  head 


To->ft       The  Phii,ax)Elphia"| 
^'-'6^       Medical   Journal  J 


AMERICAN  NEWS  AND  NOTES 


IJCKE   1,   190! 


and  in  whom  the  limbs  were  involved.  The  case  was  di- 
agnosed syphilitic  osteitis,  but  that  diagnosis  is  not  satis- 
factory. Cabot,  of  Boston,  thinks  that  the  productive  and 
the  destructive  lesions  are  2  distinct  diseases.  He  spoke 
of  the  great  advantage  to  be  had  by  supporting  the  spinal 
column  for  the  relief  of  the  spinal  symptoms.  James  J. 
Putnam,  of  Boston,  spoke  of  a  case  that  seemed  to  have 
had  its  origin  in  gonorrheal  rheumatism.  He  also  thinks 
that  mechanical  support  of  the  vertebral  column  is  of 
great  value  in  the  treatment  of  the  condition. 

B.  Sachs,  of  New  York,  read  a  paper  entitled  certain 
trophoneuroses  and  their  relation  to  vascular  disease  of  the 
extremities.  Erythromelalgia.  scleroderma  and  Raynaud's 
disease  often  merge  into  each  other.  The  author  cited  the 
case  of  a  man,  aged  27  years,  who  was  suffering  from  Ray 
naud's  disease,  involving  the  feet  and  when  he  changed 
his  occupation  to  one  in  which  he  had  to  use  his  hands, 
Ra>-nauds  disease  developed  in  his  upper  extremities.  In 
this  case  there  was  an  obliterating  phlebitis  in  both  the 
upper  and  the  lower  extremeties.  In  a  second  case,  a  man 
aged  31  years,  erythromelalgia  was  present.  Following 
an  operation  for  ingrowing  toe  nail  an  infectious  process 
developed  and  amputation  was  necessary  for  gangrene.  In 
this  case  there  were  arterio-  and  phleboscle-sclerosis.  There 
were  slight  changes  of  neuritis  in  the  anterior  and  the 
posterior  tibial  nerves.  The  relation  of  vascular  disease 
to  trophoneuroses  seems,  from  these  instances  to  be  ap- 
parent. Whether  the  vascular  changes  are  primary  or 
secondary  is  open  to  discussion.  E.  G.  Janeway.  of  New 
York,  referred  to  a  case  in  which  the  patient  who  had  pain 
in  the  hands  with  loss  of  the  nails  was  advised  to  ride  a 
bicycle.  As  soon  as  he  began  to  ride  systematically  the 
same  symptoms  appeared  in  the  feet.  In  this  case  the 
urine  contained  a  trace  of  albumin  and  a  few  casts,  but  no 
sugar.  The  vessels  were  diseased.  He  is  of  the  opinion 
that  the  vessels  play  an  important  part  in  the  course  of 
such  affections.  Wiiliam  Osier,  of  Baltimore,  said  that  an 
important  point  in  the  study  of  these  cases  is  to  determine 
the  relation  of  the  pains  in  the  extremities  to  the  arterial 
disease.  He  had  seen  such  combinations  followed  by 
gangrene,  particularly  in  cases  of  paresthesia  of  the  ex- 
tremeties in  elderly  women  and  in  numbness  in  old  men 
with  vascular  change.  James  J.  Putnam,  of  Boston,  said 
that  although  the  diseases  under  discussion  seem  to 
merge,  still  they  are  faily  distinct.  B.  Sachs,  of  New 
York,  said  that  he  would  admit  that  all  cases  of  this 
class  of  diseases  were  not  due  to  disease  of  the  blood- 
vessels, but  some  of  them  are  undoubtedly  due  to  such 
changes,  and  some  are  due  to  disease  of  the  nervous  sys- 
tem. Examination  of  the  dorsalis  pedis  artery  in  addi- 
tion to  the  examination  of  the  radial  and  the  ulnar  arter- 
ies often  give  valuable  information  concerning  a  case. 

J.  Stewart,  of  Montreal,  read  a  paper  entitled  a  subcor- 
tical glioma  of  the  lower  part  of  the  ascending  frontal  con- 
volution; a  conribution  to  the  nature  of  the 
speech  disturbance  arising  from  the  lesions  in 
this  situation.  The  patient  was  a  man.  aged  37 
years,  who  became  mute  for  '^  hour  or  so  every 
day  or  every  other  day  for  several  weeks.  He  had  head- 
ache, twitching  of  the  muscles  of  the  lower  half  of  the 
right  side  of  the  face,  dysarthria  and  later  anarthrya.  He 
understood  what  was  said  to  him  and  he  could  read  print- 
ing and  writing.  There  was  bilateral  optic  neuritis  and 
weakness  and  paralysis  of  the  muscles  of  the  right  upper 
extremity.  There  was  tenderness  on  percussion  over  the 
left  side  of  the  skull.  Later,  dysgraphia  appeared.  A 
diagnosis  of  intracranial  new-growth  situated  at  the  lower 
part  of  the  ascending  frontal  convolution  was  made  from 
these  symptoms.  The  tumor  was  removed  and  recovery 
followed. 

James  J.  Putman.  of  Boston,  read  a  paper  entitled  per- 
sonal experiences  in  cases  of  Jacksonian  epilepsy  with 
special  reference  to  the  questio.i  of  treatment  by  opera- 
tion. The  therapeutic  value  of  operation  is  undoubted. 
Cortical  excision  is  of  somewhat  more  value  than  other 
varieties  of  operation.  There  are,  however,  some  cases  in 
which  this  form  of  operation  has  been  followed  by  fail- 
ure. Simple  exposure  of  the  cortex  has.  in  some  cases, 
been  followed  by  satisfactory  results.  The  objects  of  corti- 
cal excision  are  (11  to  remove  gross  lesions:  (2)  to  re- 
move sources  of  irritation  in  the  cortex  not  visible  to  the 
naked  eye  and  (3)  to  remove  epileptic  discharge  centers. 
The  author  thinks  that  in  some  instances  excision  serves 
to  check  the  discharge  of  the  epileptic  impulse  for  awhile 
and,  before  the  patient  can  recover  his  former  habit,  new 


habitual  impulses  can  be  created  or  medication  may  have 
a  chanco  to  effect  a  cure.  A.  Jacob!,  of  New  York,  said  that 
of  all  the  forms  of  epilepsy,  the  Jacksonian  variety  is  less 
likely  to  be  influenced  than  any  other.  It  seems  that 
operations  are  less  frequent  in  epilepsy  than  they  were 
formerly.  In  many  cases  no  lesion  can  be  found  when 
operation  is  undertaken  and  he  thinks  that  operation  is 
not  now  so  promising  as  it  was.  B.  Sachs,  of  New  York,  said 
that  neurologists  were  becoming  more  consen-ative  in  ad- 
vising operation  in  cases  of  epilepsy  and  that  the  Jack 
sonian  type  was  the  only  form  in  which  operative  inter- 
ference was  justifiable.  If  operative  treatment  is  to  be 
instituted  in  a  case  of  Jacksonian  epilepsy  it  should  be 
applied  in  the  early  stage  of  the  disease.  If  the  portion 
of  the  cortex  excised  presents  no  gross  lesion  microscopic 
examination  should  be  made  of  the  excised  portion:  then 
evidence  of  focal  lesion  may  be  found.  He  quoted  a  case 
in  which  operation  had  been  followed  by  cessation  of 
symptoms  for  SM  years.  Even  with  this  feature  known, 
the  operation  was  justifiable  because  it  has  allowed  the 
patient  to  earn  his  own  living  during  a  period  of  8^4 
years  and  his  life  has  been  more  pleasant  to  him.  It  is 
possible  that  ordinary  medication  will  be  able  to  stop  his 
convulsive  seizures  now. 

John  K.  Mitchell  read  for  himself  and  Simon  Flexner 
and  David  L.  Edsall.  of  Philadelphia,  a  paper  entitled  the 
chemical,  clinical  and  physiological  results  of  the  exam- 
ination of  3  cases  of  family  periodic  paralysis.  During  the 
attacks  the  urine  of  2  of  the  patients  had  a  high  degree  of 
acidity.  The  authors  had  already  determined  the  absence 
of  toxicity  of  the  urine.  The  ammonia  output  was  low  in 
the  intervals  of  the  attack  as  well  as  during  the  attack. 
The  stomach  contents  of  one  patient  showed  anacidity  and 
there  was  entire  suspension  of  the  digestive  functions 
during  the  attacks.  The  excretion  of  creatinin  was  studied 
for  3  weeks  in  one  of  the  patients.  This  substance  was 
found  to  be  much  increased  just  before  the  attack  while 
just  after  the  attack  its  excretion  returned  to  normal.  The 
attacks  are  probably  due  to  a  metabolic  disturbance  pos- 
sibly seated  entirely  in  the  muscles.  In  one  of  the  pa- 
tients potassium  citrate  prevented  and  relieved  the  attacks, 
but  considerable  daily  use  of  this  substance  did  not  post- 
pone them.  Two  of  the  patients  were  able  to  ward  off  au 
attack  when  they  felt  it  coming  on.  James  J.  Putnam,  of 
Boston,  referred  to  a  case  in  which  the  use  of  potassium 
citrate  had  no  effect.  The  cases  are  much  alike.  S.  J. 
Meltzer,  of  New  York,  said  that  it  appeared  that  the  in- 
voluntary muscles  such  as  the  diaphragm  and  those  sup- 
plied by  the  cranial  nerves  were  not  involved.  He  ques- 
tioned why.  if  the  disease  was  due  to  a  poison  affecting  the 
muscles,  the  poison  should  be  thus  selective.  John  K. 
Mitchell,  of  Philadelphia,  said  that  the  involuntary  mus- 
cles are  Involved  in  the  paralysis.  A.  Jacobi,  of  New 
York,  said  that  the  cases  appeared  to  him  like  cases  of 
hysteria. 

F.  Forchheimer.  of  Cincinnati,  read  a  paper  entitled  the 
heredity  of  appendicitis.  He  described  the  genealogy  of 
one  family  in  which,  out  of  25  members,  3  had  appendicitis 
In  a  second  family  of  52  members.  9  had  appendicitis. 
In  a  third  family,  of  20  members,  6  had  appendicitis.  A.  D 
Blackadder,  of  Montreal  referred  to  a  neurotic  family  in 
which  many  of  the  members  suffered  from  appendicitis. 


THIRTIETH   CONGRESS   OF  THE   GERMAN   SURGICAL 
SOCIETY. 


(Concluded  from  Page  997.) 
Nils  Sjobring,  of  Lund,  a  guest  of  the  society,  read  hy 
special  invitation  of  the  society,  a  paper  on  "The  Parasites 
of  Cancer."  The  paper  was  very  long  and  it  was  next  to 
impossible  to  understand  Sjobring.  President  Czemy  sug- 
gested that  some  of  the  members  who  had  examined  Sjo- 
bring"s  preparation  express  their  opinion  of  the  same. 
Israel,  of  Berlin,  declared  that  he  could  see  nothing  more 
than  one  can  find  in  any  tissue  which  is  kept  in  unsuitable 
culture  fluids,  and  nothing  which  one  could  consider  ameba. 
Gussenbauer.  of  Vienna,  has  known  the  bodies  demon- 
strated by  Sjobring  for  years  and  years,  but  has  never 
been  able  to  cultivate  them.  Jurgens,  of  Berlin,  says  th?t 
Sjobring  demonstrated  the  same  preparations  in  Aach-n 
calling  them  the  cause  of  sarcoma.  He  does  not  th::.'-; 
that  they  deserve  any  notice  whatever.  Czemy  defen  i  : 
Sjobring  from  the  reproach  of  having  imposed  upon  ih-  > 
ciety.  reminding  that  Sjobring  has  been  at  work  for 
vears  on  the  question      Hofmeister   iTubingent   descr:     ? 


June  1,  1901] 


FOREIGN  NEWS  AND  NOTES 


TThe  Philadelphia 
LMedical  Journal 


1037 


"A  New  Method  for  the  Reposition  of  a  Dislocated  Humer- 
us," a  modification  of  the  well  known  methods  of  gradually 
Increasing  traction  on  the  arm  by  means  of  weights  and 
pulleys,  until  the  muscles  relax,  etc.  Hildebrand  (Basel) 
described  several  cases  of  "The  Operative  Treatment  of 
Habitual  and  of  Old  Dislocations."  Payr  (Graz)  discussed 
"The  Technic  of  Operative  Reposition  of  Dislocations  of 
the  Hip  in  Adults."  He  considers  Mikulicz's  proposal  to 
remove  the  trochanters  a  very  severe  operation,  and  only 
suited  to  cases  where  there  is  very  little  shortening.  In 
the  discussion  Schede  (Bonn)  described  a  case  of  double 
luxation.  Drehmann  (Breslau)  praised  the  method  of 
Mikulicz  because  the  removal  of  the  trochanter  with  the 
muscle  attachments  gives  a  much  better  view  of  the  field 
of  operation.  Rotter  (Berlin)  presented  an  interesting 
case  ot  Resection  of  the  Entire  Upper  Arm.  The  pa- 
tient had  a  tumor  of  the  humerus;  R.  resected  the  mus- 
cles of  the  upper  arm  and  the  entire  humerus,  and  at- 
tached the  remains  of  the  capsule  of  the  elbow  to  the 
shoulder  capsule.  After  %  of  a  year  the  radialis  was  able 
to  perform  its  function,  and  the  patient  could  use  the  hand 
for  many  purposes.  Katzenstein  (Berlin)  demonstrated 
two  cases  of  Spina  bifida  occulta.  In  one  of  the  patients 
symptoms  appeared  at  the  period  of  most  rapid  growth, 
and  Katzenstein  believed  them  caused  by  the  traction  of 
the  cord  of  tissue  which  is  regularly  found  connecting  the 
skin  and  the  dura  mater  of  the  cord.  K.  removed  this 
cord,  dissecting  it  from  the  dura  mater,  and  the  symptoms, 
incontinence  of  urine  and  feces  disappeared.  Heusner 
(Barmen)  discussed  "The  Treatment  of  Contraction  fol- 
lowing Inflammation  of  the  Knee  Joint."  In  two  cases  he 
has  obtained  good  results  by  changing  the  insertions  of 
different  muscles.  Steiner  (Berlin)  presented  a  patient 
who  had  Multiple  Sarcoid  Angioma  of  the  Sole  of  the 
Foot  with  Numerous  Phleboliths.  S.  removed  the  entire 
sole  of  the  foot,  forming  a  new  sole  by  taking  large  flaps 
from  the  back  of  the  foot  covering  the  defect  with 
Thiersch's  transplantation.  Joachimsthal  (Berlin)  demon- 
strated a  number  of  preparations  showing  the  conditions 
in  congenital  dislocation  of  the  hip:  also  a  large  number  of 
skiagraphs  of  the  several  patients  whom  he  also  presented. 

Franke  (Braunschweig)  reports  several  cases  of  Extir- 
pation of  the  Pancreas  for  Carcinoma.  The  first  case 
showed  a  tumor  of  the  head  of  the  pancreas:  he  extirpated 
the  entire  organ.  For  18  days  the  patient  had  diabetes,  up 
to  3%  sugar,  but  no  stools  and  no  other  disturbances.  The 
patient  lived  6  months.  Autopsy  showed  only  metastases 
in  the  lymphglands,  so  that  it  was  probably  a  case  of 
primary  carcinoma  of  the  pancreas.  F.  mentions  two 
further  cases  where  he  removed  but  a  part  of  the  pan- 
creas, since  metastases  were  already  present.  He  arrived 
at  the  result  that  diagnosis  of  tumor  of  the  pancreas  has 
made  advances.  The  first  symptoms  are  extreme  pain  in 
the  abdomen  and  rapid  cachexia.  He  recommends  an  early 
exploratory  laparotomy.  Korte  (Berlin)  referred  to  two 
cases  of  extirpation  of  pancreas  tumors.  One  patient  died 
from  extensive  hemorrhage,  the  other  in  coma:  the  latter 
case  showed  diabetes,  yet  the  autopsy  showed  only  a  part 
of  the  pancreas  affected.  Hildebrandt  (Basel)  questioned 
whether  in  Franke's  case  the  entire  pancreas  was  re- 
moved. Franke,  although  he  did  not  perform  the  autopsy 
himself,  answered  in  the  affirmative.  Ahrens  (Bonn) 
described  a  case  of  Fetal  Inclusion  in  the  Mesocolon  As- 
cendens.  A  girl  of  16  came  under  observation  with  a  his- 
tory of  having  had  a  swelling  of  the  abdomen  while  a 
child:  she  showed  the  symptoms  of  hydronephrosis,  but  the 
operation  disclosed  a  tumor  in  the  mesocolon  ascendens. 
Function  gave  4  liters  of  a  dark  brown  fluid  found  to  be 
blood.  The  preparation  which  Ahrens  demonstrated  has 
the  form  of  a  stomach,  with  pj-lorus  and  cardia,  and  shows 
a  microscopical  structure  of  the  stomach,  except  that  all 
the  different  forms  of  epithelium  were  to  be  found.  Pepsin 
was  found  in  the  contents.  Further  this  extra  stomach 
had  a  true  peptic  ulcer.  Ahrens  explains  the  curiosity  by 
assuming  that  the  cells,  or  part  of  the  cells,  destined  to 
form  the  digestive  tract  and  its  outgrowths  become  dislo- 
cated at  an  early  period  of  fetal  life. 

Goldmann,  of  Freiburg:  The  Pathogenesis  and  Treatment 
of  the  Keloid." 

Goldmann  believes  he  has  found  the  cause  of  the  keloid 
in  the  disappearance  of  the  elastic  fibers  of  the  cutis,  and 
compares  the  origin  of  the  tumor  to  an  aneurysm,  due  to 
the  loss  of  the  elastic  tissue.  Contrary  to  what  others 
claim,  he  has  found  medullated  nerve  fibers  in  these  tu- 


mors.    He  recommends  excision  and  closure  of  the  defect 
by  transplantation. 

Lauenstein,  of  Hamburg,  reported  a  case  in  which  incis- 
ions which  went  through  the  cutis  were  followed  by  keloid 
degeneration. 

Eighth  Session. 

The  Sth  session  of  the  congress  was  devoted  principally 
to  the  discussion  of  the  surgical  treatment  of  acute  appen- 
dicitis. An  impartial  observer  was  forced  to  the  conclu- 
sion that  the  German  surgeons  had  reached,  at  the  end 
of  their  discussion,  the  point  where  American  surgery  stood 
some  ten  years  ago.  Rehn,  of  Frankfurt  a.  M.,  believes  that 
his  results  show  him  the  only  proper  method  to  be  early 
operation,  as  soon  as  the  diagnosis  is  fixed.  Sprengel,  ot 
Braunschweig,  agrees  with  Rehn.  Roller,  of  Berlin,  recom- 
mended highly  the  recto-vaginal  route  for  opening  Douglas 
abscess.  He  claims  extraordinary  results.  Hirschberg,  of 
Fraukfurt  a.  M.,  believes  believes  that  Rehns  method  ot 
opening  the  abdomen  as  soon  as  possible  can  only  be 
carried  out  in  hospitals  ot  large  cities.  Kummell.  of  Ham- 
burg, enters  the  lists  for  conservative  treatment.  Of  the 
1042  cases  in  the  HamburgEppendorfer  hospital  only  1.6% 
ended  fatally.  To  be  sure  he  believes  in  the  old  principle 
"Ubi  pus  ibi  evacua."  with  the  exception  of  the  peritoneum. 

The  vote  for  the  President  of  the  next  Congress  resulted 
in  a  tie  between  Kuster,  of  Marburg,  and  Kocher,  of  Bern. 
A  second  vote  elected  Professor  Kocher. 


GREAT  BRITAIN. 


The  British  Medical  Association  will  meet  at  Chelten- 
ham, England.  July  :;Oth  to  August  2nd,  inclusive. 

Appointment. — Dr.  Samuel  West  has  been  appointed 
Joint  Lecturer  on  the  Principles  and  Practice  of  Medicine 
in  St.  Bartholomew's  Hospital  Medical  College. 

Monument  to  Professor  Huxley. — It  is  proposed  to  erect, 
at  the  place  of  his  birth,  a  memorial  to  Professor  Huxley. 
The  form  it  will  take  is  not  at  present  decided  upon.  Sub- 
scriptions to  the  fund  may  be  forwarded  to  Mr.  T.  Simpson, 
Fennymere.  Castle  Bar.  Ealing. 

Gift  to  the  Royal  Hospital. — Alfred  Harmsworth.  of  the 
Dailn  Mail,  is  credited  with  having  donated  £10,000  to  the 
Royal  Hospital  for  the  purpose  of  installing  a  plant  for 
the  electric  light  cure  of  lupus. 

Mr.  Frederick  Treves,  C.  B,,  F,  R.  C.  S.,  was  Knighted  by 
his  Majesty  the  King,  on  May  4th,  and  invested  with  the 
Insignia  of  a  Knight  Commander  of  the  Royal  Victorian 
Order. 

Dr.  Lillie  Saville  is  the  first  woman  doctor  who  has  re- 
ceived the  decoration  of  the  Red  Cross  during  the  present 
reign.  The  distinction  was  conferred  on  her  on  account 
of  her  services  while  under  fire  in  Pekin. 

CONTINENTAL     EUROPE. 

French  Gynecological  Congress. — The  third  meeting  of 
the  French  National  Periodical  Congress  of  Gynecology. 
Obstetrics  and  Pediatrics  will  be  held  this  year  at  Nantes 
under  the  general  presidency  of  Dr.  Sevestre,  of  Paris,  who 
will  also  preside  over  the  Section  of  Pediatrics.  Dr.  Se- 
gond.  of  Paris,  will  be  President  of  the  Section  of  Gyne- 
cology, and  Professor  Queirel,  of  Marseilles,  ot  that  of 
Obstetrics. 

A  French  philanthropist. — Mile,  de  Noualhier  has  a  hobby 
for  caring  for  consumptives  in  the  last  stages,  found  in 
Paris,  from  which  city  she  has  them  taken  to  a  villa  in 
Limoges,  not  far  away,  to  be  eased  in  their  last  moments. 
She  works  only  among  destitute  consumptives,  taking 
them  to  her  chateau,  where  they  are  cared  for  and  buried 
at  her  expense.  She  began  her  work  some  five  years  ago. — 
Exchange. 

New  Children's  Hospital. — St.  Petersburg  has  decided  to 
erect  a  new  children's  hospital  in  that  city  in  commemora- 
tion of  the  coronation  of  the  Czar.  The  hospital  is  to  con- 
sist of  eight  pavillions.  containing  in  all  402  beds.  The 
estimated  cost  is  1,700,000  roubles. 


Physicians  for  the  Newfoundland  Sealing-Fleet. — For 
the  first  time  in  the  history  of  the  Newfoundland  sealing- 
fleet.  says  the  Canadian  correspondent  of  The  Lancet,  phy- 
sicians accompanied  it.  The  fleet  numbers  about  sis 
thousand  sailors,  and  left  St.  John  on  March  9th. 


1038 


The  Philadei-phiaI 
Medical  Journal   J 


THE  LATEST  LITERATURE 


[June  1.  ISOl 


Ebe  Xatest  ^Literature. 


BRITISH    MEDICAL    JOURNAL. 

Muv  11,  1901. 

1.  An  Address  on  Pancreatitis.     A.  W.  MAYO  ROBSON. 

2.  Notes  on  a  Mild  Tvpe  of  Small-Pox  (Variola  Ambulans?) 

P.  MONTIZAMBERT. 

3.  Note  on  the  Probable  Relationship  of  Vaccinia  to  the 

Inoculated   Form   of  Small-Pox  in   Man.     S.   MONK- 
TON   COPEMAN. 

4.  Note  on  a  Case  of  Enormous  Dilatation  of  the  First  Part 

of  the  Duodenum.     GILBERT   BARLING. 

5.  A  Case  of  Gastrojejunostomy  for  Complete  Rupture  of 

the  Intestine  at  the  Duodeno- Jejunal  Flexure.     B.  G. 
A.  MOYNIHAN. 

6.  A   Case   of   Sarcoma   of  the   Stomach.     A.     CHRISTY 

WILSON. 

7.  Perforated     Gastric     Ulcer:     Operation     Twenty-eight 

Hours   after   Perforation;    Recovery.     H.   WYNTF.R 
SHETTLE. 

8.  A.    Case    ol    Tuberculous    Disease   of   the    Cecum.      .!. 

MAITLAND. 

9.  The    Spontaneous    Cure    of    Hydatid    Cysts.      W.    M. 

STEVENS. 

10.  Experiments   upon  the  New   Specific  Test   for  Blood. 

G.  H.  F.  NUTTALL  and  E.  M.  DINKELSPIEL. 

11.  Responsibility   and    Crime.      ALEXANDER    ROBERT- 

SON. 

1- — See  this  issue  of  the  Philadelphia  Medical  Journal. 

2. — Montizambert  describes  the  epidemic  of  small-pox 
that  is  at  present  affecting  the  inhabitants  of  Canada,  which 
he  believes  was  imported  into  that  country  from  the  Unite'! 
States.  The  patient,  as  a  rule,  has  but  little  initial 
fever,  a  very  sparse  and  discrete  eruption  and  no  sec- 
ondary fever.  He  is  usually  not  confined  to  bed  and,  in 
many  cases,  not  even  to  the  house,  so  that  no  physician 
sees  the  disease.  In  the  country  the  disease  is  called 
chicken-pox  or  German  measles;  while  in  many  of  the 
lumber  camps  it  is  tpoken  of  as  "cedar  itch."  Those  af- 
fected travel  in  public  conveyances  from  one  part  of  the 
country  to  anotlfr  during  the  period  of  incubation  and 
with  the  eruption  in  its  early  stages  visible  on  their  faces 
and  thus  spread  the  disease.     [J.  M.  S.] 

3. — In  3  series  of  experiments  Copeman  inoculated  small- 
pox lymph  or  pulp  directly  into  calves  with  negative  results 
in  every  instance.  When  the  same  substances  were  inoculat- 
ed into  monkeys  success  was  invariably  obtained  and  when. 
after  one  or  more  passages  through  fhis  animal.the  contents 
of  the  local  inoculation  vesicles  were  employed  tor  inocula- 
tion into  the  calf,  a  result  was  produced  which,  after  one  or 
more  removes  in  that  animal. was  indistinguisable  from  typi- 
cal vaccinia.  Moreover. from  the  contents  of  vesicles  produced 
in  this  manner  on  the  calf  a  considerable  number  of  children 
have,  in  turn,  been  vaccinated  and  afterward  kept  under 
observation  for  about  2  months.  Every  such  vaccination 
took  normally  and  in  no  case  was  any  bad  result  observed. 
It  would  thus  seem  as  though  there  was  some  relation  be- 
tween vaccinia  and  the  inoculated  form  of  small-pox  in 
man.      [J.   M.   S.] 

4. — Barling  reports  the  case  of  a  man.  aged  31  years,  who 
for  4  years  complained  of  pain  and  sickness  after  eating. 
Three  and  one-half  years  before  his  admission  to  the 
hospital,  when  his  symptoms  were  of  the  same  character, 
an  exploratory  operation  with  gastrojejunostomy  was  ad- 
vised. The  operation  of  an  exploratory  nature  was  done 
but  was  followed  by  no  appreciable  benefit.  The  pain  fol- 
lowing this  operation  was  greatly  increased  and  the  pa- 
tient, in  consequence,  took  so  much  morphin  that  he  de- 
veloped the  morphin  habit.  The  patient  was  now  ad- 
mitted to  the  hospital  and  was  operated  on  a  second  time. 
There  was  marked  dilatation  of  the  stomach  but  no  definite 
obstacle  to  explain  the  condition.  Dense  adhesions  were 
found,  however,  uniting  the  pylorus  of  the  stomach  to  the 
surrounding  structures.  Gastrojejunostomy  was  done  and 
progress  for  the  first  4  days  was  satisfactory.  On  the  fifth 
day  the  patient  became  suddenly  worse  and  died  of  general 
peritonitis.  At  the  autopsy  it  was  found  that  fluid  was  es- 
caping into  the  peritoneal  cavity  from  a  tear  in  the  ex- 
tremely dilated  duodenum.  The  first  portion  of  the  duode- 
num was  so  dilated  that  it  would  hold  about  a  half  pint.  The 
communication  between  this  cavity  and  the  stomach  was 
free, but  the  opening  into  the  second  portion  of  the  duodenum 


was  guarded  by  3  flap-like  projections  of  mucous  mem- 
brane. The  walls  of  the  dilated  duodenum  were  extremely 
thin  and  consisted  almost  entirely  of  thin,  almost  transpa- 
rent, fibrous  tissue.  The  increased  difficulty  of  emptying 
this  dilated  portion  of  the  duodenum,  due  to  the  establish- 
ment of  communication  between  the  stomach  and  the  je- 
junum was  undoubtedly  the  cause  of  the  rupture.  [J.  M.  S.J 
5. — B.  G.  Moynihan  reports  an  interesting  case  of  rupture 
of  the  small  intestine  at  the  duodeno-jejunal  juncture  ia 
which  it  was  necessary  to  excise  4%  inches  of  the  jejunum 
and  in  which  it  was  impossible  after  this  resection  to  do 
an  end-to-end  anastomosis  because  the  duodenal  end 
was  inaccessible.  This  end  was  then  inverted  and  the  jeju- 
num united  to  the  anterior  wall  of  the  stomach  by  a  Mur- 
phy button.  The  condition  of  the  child  was  such  that  no 
lateral  anastomosis  could  be  made  between  the  duodenum 
and  jejunum  below.  The  patient  made  a  good  recovery. 
On  the  104th  day  after  the  operation  the  child  suddenly 
became  seized  with  an  acute  abdominal  pain  and  died  with- 
in a  few  hours.  The  postmortem  showed  death  to  be  due 
to  perforation  of  the  duodenal  stump  from  pressure  exerte-l 
by  the  Murphy  button  which  had  become  lodged  here.  The 
case  is  an  interesting  one  because  it  shows  that  for  104 
days  this  child  was  in  perfect  health  although  the  bile  and 
pancreatic  juice  flowed  into  the  stomach.     [J.  H.  G.] 

6. — A.  C.  Wilson  reports  an  Interesting  case  of  sarcoma 
of  the  stomach  which  involved  the  greater  curvature  and  a 
considerable  part  of  the  duodenum.  The  growth  was  iso- 
lated with  some  difficulty  and  was  then  excised  with  % 
considerable  portion  of  the  stomach  and  duodenum.  An 
anastomosis  was  then  made  between  the  remaining  por- 
tion of  the  stomach  and  bowel  by  means  of  AUingham's 
bobbin  of  decalcified  bone.  The  patient  made  a  good  re- 
covery and  had  returned  to  his  work  two  weeks  before  this 
report  was  made.  The  growth  was  found  to  be  a  sarcoma 
of  the  mixed  cell  type.     [J.  H.  G.] 

7. — H.  Wynter  Shettle  reports  a  case  or  a  young  girl 
upon  whom  he  operated  2S  hours  after  perforation  of  a 
gastric  ulcer.  At  the  time  of  the  operation  there  wa.s 
general  abdominal  pain  and  pain  in  the  back:  the  abdo- 
men was  rigid  and  tender.  The  distension  was  moderate 
and  liver  dulness  was  present.  Upon  opening  the  abdomen 
the  perforation  was  found  to  be  in  the  anterior  wall  of  the 
stomach  near  the  lesser  curvature  just  below  the  esopha- 
geal opening.  The  toilet  of  the  peritoneum  consisted  in 
careful  wiping  with  dry  sponges.  The  patient  made  a  sat- 
isfactory recovery.     [J.  H.  G.] 

8. — Maitland  reports  the  case  of  a  Hindu,  aged  44  years, 
who  complained  of  abdominal  pain  and  constipation.  Eight 
years  previously,  the  patient  began  to  suffer  from  attac!?^  of 
severe  pain  which  occurred  at  irregular  intervals  in  the 
right  side  of  the  abdomen.  The  patient  thought  he  could 
feel  a  lump  at  the  seat  of  pain  and  stated  that  the  con- 
dition WIS  accompanied  by  constipation.  When  he  was 
admitted  to  hospital  a  tumor  could  be  felt  in  the  right  iliac 
region,  and  a  diagnosis  of  chronic  disease  of  the  cecum  cr 
ascending  colon  causing  thickening  of  the  intestine  and 
possibly  stenosis  was  made.  At  operation  the  bowel  was 
found  to  be  much  thickened  and  embedded  in  a  mass  of 
considerable  thickness.  The  diseased  area  was  excised,  the 
end  of  the  divided  large  intestine  was  closed  and  the  cut 
end  of  the  small  intestine  was  united  to  the  large  intestiae 
by  a  lateral  anastomosis  with  a  SInrphy's  button.  The  ex 
cised  portion  of  the  bowel  consisted  of  ileum,  cecum  and 
ascending  colon.  The  wall  of  the  intestine  was  thickened 
and  hypertrophied.  the  mucous  membrane  of  the  cecum 
presented  an  ulcerated  surface  and  there  were  5  small  ul- 
cers in  the  ileum.  Recovery  was  uninterrupted.  The  ulcer- 
ations in  the  intestine  were  tuberculous  in  nature.     [J.M.S.7 

9. — Stevens  describes  a  liver  in  which  there  were  2 
hydatid  cysts  in  different  stages  of  degeneration.  Both 
cysts  were  situated  in  the  peripheral  parts  of  the  liver  and 
projected  considerably  beyond  its  surface.  There  was  no 
evidence  of  pus  in  the  contents  of  either  cyst.  The  cap- 
sules of  both  cysts  were  globular  and  tense  with  no  sign? 
of  puckering  or  contraction.  Neither  cyst  contained  bile. 
There  was  a  general  fibrotic  condition  of  the  liver.  Tha 
author  beliexes  that  in  the  majority  of  cases  the  death'of 
the  parasite  in  an  hydatid  cyst  is  due  to  changes  in  and 
around  its  capsule,  and  that  these  changes  are  most  Ukely 
to  occur  in  organs  in  which  fibrous  overgrowths  are  com 
mon.  The  author  believes  that  early  removal  of  the  entire 
cvst  contents  is  the  onlv  rational  treatment  of  the  disease. 

[J.  M.  S.] 


June  1,  1901] 


THE  LATEST  LITERATURE 


"The  Phit.adkj.phia 
_Mfi>icai^  Journal, 


1039 


10. — Nuttall  and  Dinkelspiel  have  injected  rabbits  by  tlie 
peritoneal  route  with  horse,  dog,  ox,  sheep  and  human  ser- 
um and  have  been  able  to  observe  the  formation  of  speci- 
fic precipitins  in  their  blood.  The  antiserums  have  been 
tried  on  24  different  bloods  with,  with  tew  exceptions,  uni- 
formly negative  results.  Bloods  which  have  been  dried 
for  2  months  gave  a  positive  reaction  when  tested  with 
their  particular  antiserum.  The  authors  conclude  that  these 
precipitins  are  specific  although  they  may  produce  a  slight 
reaction  with  the  serums  of  allied  animals.  The  substances 
in  the  serum  which  brings  about  the  formation  of  a  preci- 
pitin, as  also  the  precipitin  itself,  are  remarkably  resistant. 
This  test  can  be  applied  to  a  blood  which  has  been  mixed 
■with  that  of  another  animal.  The  authors  believe  that  this 
is  the  most  delicate  test  for  detecting  and  differentiating 
bloods  and  hope  that  is  will  be  put  to  forensic  use.     [J.M.S  ] 

11. — Robertson  describes  3  cases  which  seem  to  shov/ 
that  epileptics  often  commit  criminal  acts  of  which  they 
are  entirely  unconscious  and  for  which  they  are  of  course 
not  responsible.     [.J.  M.  S.J 


LANCET. 

Mav  11th.  1901. 

1.  The  Erasmus  Wilson   Lectures  on  the  Pathology  and 

Diseases  of  the  Thyroid  Gland.  WALTER  ED- 
MUNDS. 

2.  An  Address  on  the  Importance  of  the  Teaching  of  In- 

sanity to  the  Medical  Student  and  Practitioner  in 
Relation  to  the  Prevention  of  Insanity.  ROBERT 
JONES. 

3.  Local  v.  General  Anesthesia  in  Certain   Cases  of  Ab- 

dominal Surgery.     THOMAS  H.  MORSE. 

4.  The    Etiology    and    Treatment   of   Convergent    Squint. 

CLAUD  WORTH. 

5.  Diseases   of   the    Maxillary   Antrum,    their    Symptoms, 

Causes  and  Treatment.     ADOLPH  BKONNER. 
€.     Mental  Fatigue  in  School  Children.    JOSEPH  BELLEI. 

7.  Three  Cases  of  Myxedema  of  Varied  Type.     WILLIAM 

WYLLYS. 

8.  Medical  Notes  on  the  Life  of  Edward  Gibbon,  the  His- 

torian.    WILLIAM  H.  HORROCKS. 

1. — Abstract  will  appear  when  the  lectures  are  concluded. 

2. — Jones  delivered  an  address  before  the  South  Eastern 
Division  of  the  Medico-Psychological  Association  on  April 
24th.  1901,  on  the  importance  of  the  teaching  of  insanity 
to  the  medical  student  and  practitioner.  In  Great  Britain 
and  Ireland  there  is  on  an  average  one  insane  person  to 
everj'  two  hundred  and  sixty-six  persons  of  the  population. 
The  law  pertaining  to  insanity  imposes  a  great  responsibili- 
ty upon  the  medical  men  in  certification.  On  an  average 
each  member  of  the  medical  profession  in  England  has  is- 
sued five  certificates.  The  author  states  that  this  duty 
of  the  physician  is  of  far  less  importance  when  compared 
with  the  duty  of  prevention  and  treatment  of  insanity.  He 
suggests  that  the  teaching  of  mental  disorders  should  be  a 
part  of  the  curriculum  of  every  medical  school.  One  of  the 
chief  reasons  why  ^.he  student  should  be  familiar  with  the 
study  of  insanity,  is  that  the  disease  can  be  most  success- 
fully treated  in  its  early  stages,  and  therefore  its  recogni- 
tion at  this  time  becomes  most  important.  He  also  sug- 
gests that  every  public  asylum  should  become  a  school 
for  post-graduate  teaching.     [F.  J.  K.] 

3. — Thomas  H.  Morse  advises  the  use  of  local  anesthesia 
in  those  cases  of  acute  peritonitis,  internal  hemorrhage 
and  intestinal  obstruction  where  tne  patient's  condition  is 
so  bad  that  the  effect  of  a  general  anesthetic  is  to  be 
feared.  He  reports  5  cases  in  which  he  has  used  local  anes- 
thesia in  making  an  abdominal  section  and  in  three  in- 
stances the  patient  recovered.  Two  of  the  cases  which  re- 
covered were  ruptured  tubal  pregnancies.  Very  little  pain 
was  complained  of  during  the  operations  excepting  in  the 
cases  just  referred  to,  where  dragging  upon  the  tube  pro- 
duced some  pain  although  the  ligation  caused  none.  The 
author  thinks  that  pain  is  less  acutely  felt  when  the  pa- 
tient is  ill  extremis.  He  refers  to  a  case  of  strangulated 
umbilical  hernia  which  died  after  operation  under  general 
anesthesia,  due  to  the  fact  that  some  of  the  fecal  vomit 
found  its  way  into  the  air  passages.     [J.  H.  G.] 


5. — Adolpli  Bronner  discusses  the  diseases  of  the  maxil- 
lary antrum.  Up  to  the  6th  or  7th  year  the  antrum  should 
always  be  opened  through  the  miodle  nasal  meatus  and  not 
through  the  alveolus.  Cases  of  acute  empyema  of  the  an- 
trum were  rare  prior  to  the  recent  epidemics  of  influenza. 
The  pain  in  these  cases  is  intermittent  and  depends  greatly 
upon  the  amount  of  fluid  in  the  antrum.  The  teeth  are 
painful  and  will  frequently  cause  the  attendant  to  suspect 
that  they  are  diseased  and  the  cause  of  the  empyema. 
These  cases  usually  recover  spontaneously.  Chronic  em- 
pyema is  very  common  and  the  idea  that  this  condition 
gives  rise  to  distressing  symptoms,  such  as  distension  of 
the  cheek,  severe  pain,  etc.,  is  a  mistake,  the  subjective 
symptoms  being  in  truth  very  slight.  Intra-orbital  neu- 
ralgia, and  more  frequently  pain  over  the  nose  and  orbit, 
are  very  common.  The  condition  is  frequently  mistaken 
for  disease  of  the  frontal  sinus.  A  blocking  of  one  nos- 
tril and  nasal  discharge  and  a  bad  smell  are  frequent  symp- 
toms, particularly  the  latter.  The  discharge  and  the  smell 
are  more  marked  when  the  patient  bends  the  head  for- 
ward or  to  one  side.  The  irritation  of  the  pus  gives  rise 
to  polypi,  hypertrophy  of  the  middle  turbinated,  and  dry- 
ness of  the  throat.  The  so-called  incurable  cases  of  ozena 
are  usually  those  m  which  the  antrum  is  involved.  Where 
the  cheek  is  distended  the  cause  is  usually  a  cyst  and 
not  an  empyema.  In  these  cases  an  opening  should  be 
made  into  the  lower  meatus  with  a  trocar  and  the  cavity 
washed  out.  The  author  does  not  think  transillumination 
of  great  benefit.  He  denies  the  existence  of  "hydrops" 
of  the  antrum,  these  cases  always  being  cysts.  Cysts  of 
the  antrutn  are  nearly  always  of  dental  origin  caused  by 
the  retention  of  unerupted  teeth  or  due  to  inflammatory 
changes  in  the  root  membrane  of  an  aU'eady  erupted  tooth. 
Carcinoma  is  the  most  common  form  of  neoplasm  found  in 
the  antrum  and  its  first  symptoms  are  severe  pain  in  the 
cheek  and  nasal  discharge.  Nasal  polypi  are  frequently 
present  and  bleed  freely.  Removal  of  the  entire  upper 
jaw  should  be  the  treatment  and  the  prognosis  is  fairly 
good.  Morse  says  that  inflammatory  conditions  of  the 
antrum  are  rarely  due  to  the  teeth  and  nearly  always  have 
their  origin  in  the  nasal  cavity.  The  treatment  of 
empyema  consists  in  opening  the  antrum  at  lowest  point 
and  keeping  up  the  drainage.  Morse  prefers  to  open 
through  the  alveolus  excepting  in  cases  of  polypi,  large 
cvsts,  and  when  the  teeth  are  all  sound,  when  the  canine 
fossa  is  preferred.  The  drainage  should  be  kept  up  for  at 
least  4  to  6  weeks  after  all  discharge  has  ceased.     [J.  H.  G.] 

6 — Bellei  writes  upon  mental  fatigue  in  school  children 
and  draws  conclusions  upon  this  subject  from  2760  dicta- 
tions, which  observations  he  collected  in  2  months.  He 
found  that  at  the  end  of  the  afternoon  lessons  the  worst 
results  were  obtained  and  that  at  12.30  P.  M.,  that  is, 
just  after  the  mid-day  rest,  the  best  results  were  obtained. 
He  believes  that  the  morning  lessons  do  not  produce  great 
mental  fatigue  and  that  the  rest  at  mid-day  is  of  great 
benefit  to  the  children,  the  mind,  just  after  this  period,  be- 
ing in  the  best  condition.  The  application,  to  study,  for 
an  hour  or  so  in  the  afternoon  produces  marked  mental 
fatigue.     [F.  J.  K.] 

7. — Willis  reports  three  cases  of  myxedema  of  varied 
type.  The  first  case  was  that  of  a  woman,  60  years  of  age, 
who  presented  many  of  the  typical  symptoms  of  myxedema, 
developed  delusions  and  hallucinations  after  thyroid  treat- 
ment had  been  instituted  for  a  short  while.  The  treatment 
was  then  discontinued  but  the  mental  excitement  did  not 
subside,  and  finally  the  patient  developed  acute  mania.  She 
was  removed  to  an  infirmary  and  died  within  a  few  weeks. 
The  second  case  was  that  of  a  woman,  45  years  of  age,  the 
case  bein.n  of  special  interest  on  account  of  its  very  insidi- 
ous onset,  making  the  diagnosis  very  difficult  for  a  time. 
The  third  case  occurred  in  a  married  woman,  52  years  of 
age,  and  was  instructive  from  a  diagnostic  standpoint,  be- 
cause of  its  marked  resemblance  to  Bright's  disease  and 
of  its  similarity  to  brain  disease.  The  last  two  cases  Im- 
proved under  treatment  with  tabloids  of  thyroidin.  [F.  J. 
K.l 


1040 


The  Philadelphia"] 
.L   J 


Medical  Journal 


THE  LATEST  LITERATURE 


[June  1,  1901 


MEDICAL  RECORD. 

May  ;^o,  1901. 

1.  Orchitis  and  Epididymitis  in  Typhoid  Fever.    FRANCIS 

P.  KINNICUTT. 

2.  The  Operative  Treatment  of  Umbilical  Hernia  in  Adults, 

JOSEPH  A.  BLAKE. 

3.  The  Borderland  of  Insanity;    Where  and  What  is   It? 

HENRY  WALDO  COB. 

4.  Recurrent  Oculomotor  Paralysis;  Report  of  a  Case  with 

Remarks.      WILLIAM    M.    LESZYNSKY. 

1. — Francis  P.  Kinnicutt  gives  a  history  of  two  cases  of 
orchitis  and  epididymitis  occurring  in  typhoid  fever.  He 
believes  that  epididymitis  or  orchitis  occurring  in  the 
course  of  the  typhoid  fever  is  a  rare  lesion,  is  of  typhoid 
origin,  and  is  only  exceptionally  due  to  secondary  micro- 
bic  infection.  It  develops  at  a  late  period  of  the  disease. 
The  lesion  is  as  a  rule  unilaterial.  Effusion  into  the  tunica 
vaginalis  is  rare  and  the  termination  is  most  often  by  reso- 
lution. Suppuration  occurs  in  25%  of  all  cases.  Local- 
ized necrosis  and  extrusion  of  testicular  tissue  is  not  un- 
common, exceptionally  there  is  obstruction  of  the  entire 
organ,  and  atrophy  of  the  testicle  may  occur.  The  lesion 
gives  rise  to  very  little  constitutional  disturbance  and  death 
from  the  lesion  has  not  been  noted.     [T.  L.  C] 

2. — Joseph  A.  Blake  discusses  the  operative  treatment  of 
umbilical  hernia  in  adults,  after  first  reviewing  the  pathol 
ogy  of  umbilical  hernia,  and  its  palliative  treatment.  Um- 
bilical herniae  are  divided  into  two  classes. — those  in  which 
there  is  no  separation  of  the  recti  muscles  and  those  in 
which  these  muscles  are  separated.  Lack  of  muscular  tone 
and  fat,  by  diminishing  the  contractile  power  of  the  recti 
muscles,  tend  to  the  production  of  this  form  of  hernia  in 
adults.  The  stretching  is  not  confined  to  the  linea  alba 
but  the  sheaths  of  the  muscles  also  participate  in  the  pro- 
cess. Blake  thinks  that  strangulation  in  umbilical  hernia 
is  more  frequent  than  is  generally  supposed  and  that  when 
it  does  occur  the  prognosis  is  more  grave  than  in  either 
inguinal  or  femoral  hernia.  The  results  from  operation, 
particularly  in  large  herniae,  have  not  been  very  satisfac- 
tory. The  smaller  the  hernia  the  better  the  chance  of  a 
radical  cure.  The  condition  of  the  contents  will  greatly 
influence  the  diagnosis.  The  various  methods  of  radical 
cure  are  discussed  and  the  one  of  lapping  the  abdominal 
wall  is  preferred  by  the  author;  he  reports  three  cases 
operated  upon  in  this  way.  This  method  is  particularly  ap- 
plicable to  the  cases  in  which  there  is  a  separation  of  the 
recti  muscles.  It  consists  in  the  overlapping  of  the  entire 
abdominal  wall  on  one  side  by  that  on  the  other.     [J.G.H.] 

3. — Henry  W.  Coe  discusses  the  borderland  of  insanity. 
His  paper  in  the  main  is  taken  up  with  the  sexual  phase  of 
the  subject.  He  deplores  the  erroneous  belief  that  sexual 
expenditures  is  necessary  for  the  maintenance  of  good 
health,  and  believes  that  this  fallacy  has  had  much  to  in 
with  the  encouragement  of  sexual  excesses  and  the  conse- 
quent prevalence  of  the  class  of  cases  discussed.     [T.  L.  C] 

4. — William  M.  Lesxynsky  reports  a  case  of  recurrent 
oculomotor  paralysis  occurring  in  a  woman  29  years  of  ago 
and  a  type-setter  by  occupation.  When  12  years  of  age  the 
usual  paroxysms  and  ptosis  of  the  ri.ght  eye  occurred,  ro 
covery  taking  place  in  two  weeks.  The  second  attack  of 
oculomotor  paralysis  occurred  in  her  19th  year,  and  the 
third  attack  in  her  22nd  year.  A  fourth  attack  occurred 
when  she  was  27  years  of  age  and  the  fifth  attack  three 
weeks  before  the  patient  was  seen  by  the  author.  Exam- 
ination at  this  time  showed  slight  drooping  of  the  right 
upper  eyelid,  paralysis  of  the  superior  rectus  muscle  and 
paresis  of  tiie  inferior  and  internal  recti  muscles.  There 
was  no  diplopia,  as  the  image  of  the  right  eye  was  sup 
pressed.  The  excursions  of  the  external  ocular  muscles  of 
the  left  eye  were  normal.  The  author  calls  attention  to 
the  comparative  rarity  of  this  variety  of  oculomotor  palsy 
and  its  pathology.  He  refers  to  the  two  authentic  cases 
that  have  been  studied  postmortem.  Electrical  treatment 
in  this  case  caused  recovery  in  throe  weeks.     [M.  R.  D.] 


NEW    YORK    MEDICAL    JOURNAL. 
Man  ~'5,  IHOI.       (Vol.  LXXVIII,  No.  21.) 

1.  Hyperacidity    (Superacidity.    Hyperchlorhydria.    Super- 

aciditas  Chlorhydrica) ;   a  Clinical  Study.     H.  ILLO- 
WAY. 

2.  Nasal    Condition    observed    in    the    Aged.        BEAMAN 

DOUGLASS. 


3.  What   Route   shall   we   Adopt   in   Examining   the   Eye 

Muscles?     ALEXANDER  DUANE. 

4.  Ossiculectomy  for  Chronic  Suppurative  Otitis  Media.    J. 

A.  STUCKY. 

5.  The  Importance  of  the  Early  Recognition  of  Abdominal 

Infections.     W.  D.  HAMILTON. 

6.  Antistreptococcus  Serum  in  two  cases  of  Puerperal  Sep- 

tic Infection.     A.  J.  PRIMROSE. 

2. — Douglass  tries  to  explain  why  fewer  old  people  com- 
plain of  nasal  catarrh  than  do  younger  or  middle-aged  peo- 
ple, in  the  following  manner:  (1)  The  physiological  activity 
of  the  nose  has  been  increased  so  as  to  overcome  the  dam- 
age from  the  lesions;  (2)  That  the  lesion,  with  its  resulting 
discharge  and  reflex  pain,  is  in  some  way  less  active,  and 
allows  the  nose  to  resume  its  physiological  functions.  It  is 
possible  that  as  the  system  grows  older  elmination  is  de- 
creased and  there  is  less  demmand  on  the  part  of  the  in- 
spired air  for  heat  and  moisture  to  satisfy  the  physiological 
function  of  the  respiratory  tract.  The  symptoms  of  pain, 
together  with  those  of  reflex  phenomena,  he  thinks,  de- 
pends not  so  much  on  the  quantity  of  inflammation  or  up- 
on the  degree  of  circulatory  disturbance  and  lymphatic  ob- 
struction as  upon  a  certain  condition  of  the  nervous  struc- 
tures that  are  distributed  through  the  nares.     [T.  M.  T.] 

3. — Duane  gives  the  diagnosis  between  habitual  binocu- 
lar fixation,  an  alternating  fixation  and  a  uniocular  squint 
as  follows:  (1)  If  in  binocular  uncovering  hut  one  eye  mine*, 
we  have  heterophoria  and  not  squint;  (2)  If  either  both  eyes 
mine  or.  in  spite  of  there  being  an  evident  deviation,  hoth 
rye.s  remain  steady,  there  is  a  squint;  (3)  In  the  latter  case, 
if,  when  the  left  eye  is  uncovered,  the  eyes  behave  in  the 
same  way  as  they  do  when  the  right  eye  is  uncovered 
(both  alike  moving  or  both  alike  remaining  steady,  no  mat- 
ter which  eye  is  uncovered,  the  squint  is  alternating;  (4) 
If.  when  one  eye  (for  instance,  the  right)  is  uncovered, 
both  eyes  move,  and  when  the  other  eye  (in  this  case  the 
left)  is  uncovered,  both  eyes  remain  steady,  the  squint  is 
uniocnlar  (confined  in  this  case  to  the  left  eye).  [T.  M.  T.) 

4. — Stucky  recommends  in  cases  of  chronic  suppurative 
otitis  media  which  have  existed  for  a  long  time,  the  removal 
of  the  necrotic  ossicles  and  part  or  all  of  the  tympanitic 
membrane  and  the  cavity  thoroughly  curetted  He  also 
removes  the  anterior  attic  wall  which  will  give  free  drain- 
age and  open  the  way  for  remedial  applications.  He  gives 
the  advantages  of  this  method  as  follows:  (1)  It  gives 
free  drainage:  (2)  It  affords  an  opportunity  to  successfully 
combat  the  suppurative  process;  (3)  It  is  free  from  danger 
to  life  and  health;  (4)  In  a  large  percentage  of  cases  the 
disease  is  arrested,  the  hearing  improved,  only  rarely 
made  worse;  (5)  There  is  no  deformity  or  scar.  He  does 
not  believe  in  dry  treatment  of  this  disease,  as  it  is  inade- 
quate because  of  the  debris  collecting  around  the  ossicles 
and  thinks  conservative  surgery  is  justified  because  this 
hindrance  is  removed.     [T.  M.  T.] 


MEDICAL  NEWS. 


May  io,  IVOl.     (Vol.  LXXVIII,  No.  21.) 

1.  Some    Notes    on    Medical    Diagnosis.     WILLLA.M   N. 

BERKELEY. 

2.  The    Mineral    Waters    of    ML    Clemens,    Michigan,    as 

Viewed    and    Compared    with    those    of    European 
Watering  Places.     RICHARD  LEUSCHXER. 

3.  The  Treatment  of     Chronic   Purulent     Otitis     Media. 

JAMES  F.  McKERNON. 

4.  Tuberculosis  of  the  Iris.     WILLIAM  F.  .«.-.  .  r-.x.'ORF. 

4. — Mittendorf  states  that  tuberculosis  iritis  may  start 
in  the  iris  itself  or  in  the  ciliary  body  and  the  choroid.  It 
spreads  very  soon  from  one  to  the  other  involving  the 
entire  eyeball,  or  at  least  its  inner  parts.  It  is  usually  A 
secondarry  affection,  but  sometimes  primary.  The  auth<^ 
divides  it  into  (1)  The  solitary  form,  and  (21  Multiple 
form.  The  multiple  he  also  divides  into  acute  and  chronic 
It  is  generally  a  disease  of  the  young  or  early 
middle  life  and  only  affects  one  eye,  differing  from  tuber- 


JuxE  1,  l9;il] 


THE  LATEST  LITERATURE 


[The  Philadelphia 
Medical  Jcurxal 


1041 


culous  affections  of  the  choroid,  which  attacks  both  eyes 
at  the  same  time.  In  the  solitary  form  the  disease  as- 
sumes a  more  or  less  acute  stage  at  once,  characterized 
by  the  formation  of  one  or  more  grayish  nodules  develop- 
ing on  the  iris  tissue.  It  consists  of  inflammatory  pro- 
ducts with  a  small  number  of  bacilli  and  is  marked  by 
the  early  appearance  of  ciliary  infection  and  is  accom- 
panied by  intense  pain  in  the  eye  and  forehead.  The  pain 
is  sometimes  so  great  that  enucleation  of  the  eye  becomes 
necessary.  In  this  form  there  is  impairment  of  vision  or 
destruction  of  the  entire  eyeball  and  not  infrequently  death, 
which  is  brought  about  by  similar  simultaneous  attacks 
of  the  meninges  or  lungs,  or  by  direct  extension  of  the 
disease  to  the  brain.  The  multiple  form  is  not  so  violent 
in  its  onset  and  there  are  not  so  many  bacilli  present  in 
the  deposits.  This  occurs  generally  in  the  earlier  stages 
of  pulmonary  tuberculosis.  We  find  in  the  iris  this  form 
more  than  one  or  two  tubercular  deposits.  There  are  also 
pain  and  photophobia  and  more  or  less  Invasion  of  the  pu- 
pillary border  of  the  iris,  which  in  turn  leads  to  the  forma- 
tion of  the  posterior  synechiae.  This  form  runs  a  much 
slower  course  and  iritis  may  be  relieved  entirely  If  the 
general  condition  of  the  patient  improves,  or  it  may  result 
in  occlusion  of  the  pupil  with  eventual  shrinking  of  the 
eyeball.     [T.  M.  T.] 


BOSTON  MEDICAL  AND  SURGICAL  JOURNAL. 

May  23,  1901. 

1.     Municipal  Care  of  the  Consumptive  Poor.  S.  A.  KNOPF. 

1. — In  an  address  before  the  clinical  section  of  the  Suf- 
folk District  Medical  Society,  Knopf  emphasized  the  fact 
that  pulmonary  tuberculosis  is  a  curable  disease  as  well 
as  a  preventable  one,  provided  it  is  diagnosed  early.  The 
mortality  from  tuberculosis  is  most  frequent  between  the 
ages  of  17  and  35,  just  at  a  period  when  the  individual 
should  be  a  most  useful  member  of  society,  a  breadwinner 
and,  if  possible,  a  supporter  of  a  family.  This  is  a  great 
economic  loss  to  the  community  as  well  as  a  calamity  to  the 
family  of  which  the  afflicted  person  is  a  member.  The  most 
essential  requirements  for  the  treatment  of  a  consumptive 
are  good  pure  air  and  plenty  of  it,  sunshine  and  plenty  of 
it,  medical  supervision  and  plenty  of  it.  A  city  tenement 
house  is  not  a  place  in  which  these  conditions  prevail.  San- 
atorium treatment,  besides  including  the  administration  of 
drugs,  teaches  the  patient  to  control  his  cough,  except 
when  he  has  to  expectorate;  to  be  rigorously  clean  and 
careful  with  his  expectoration  and  other  secretions;  how 
not  to  take  cold;  what  to  do  in  case  of  accident;  what  to 
avoid  and  what  to  do  in  order  to  continue  on  the  road  to 
recovery.  The  regular  life  that  he  leads  and  the  hygienic 
training  that  he  receives  are  of  inestimable  value  to  the 
patient  as  well  as  to  his  family.  One  objection  to  the 
establishment  of  a  sanatorium  for  consumptives  comes 
from  property  holders  in  the  neighborhood,  who  believe 
that  the  disease  will  spread  and  that  the  value  of  their 
property  will  decrease.  It  can  be  proved  by  official  statis- 
tics that  the  mortality  from  tuberculosis  in  2  German  vil- 
lages where  consumptive  sanatoria  now  exist  has  been 
reduced  one-third  since  the  establishment  of  these  insti- 
tutions. An  instance  was  also  cited  in  which  the  estab- 
lishment of  a  sanatorium  for  the  treatment  of  tuberculosis 
resulted  in  an  increase  in  the  value  of  the  adjoining  prop- 
erty. Each  city  should  have  an  especially  constructed 
building  that  should  serve  as  a  recption  hospital  for  tuber- 
culous patients  whence  cases  for  the  city  hospital  or  state 
sanatorium  should  be  selected.  A  sanatorium  should  be 
established  near  the  seashore  for  the  treatment  of  tuber- 
culous and  scrofulous  children.  The  managers  of  mater- 
nity hospitals  should  set  apart  the  best-lighted  and  best- 
ventilated  wards  and  rooms  for  the  exclusive  treatment  of 
tuberculous  pregnant  women.  A  tuberculosis  commission 
should  be  formed  composed  of  physicians  and  laymen. 
The  duties  of  this  commission  should  be  (1)  to  determine 
the   applicant's   condition  by   a   medical   examination   and 


to  assign  him  to  the  proper  hospital  or  dispensary  for  treat- 
ment; (2)  to  visit  the  home  of  the  patient  and  to  institute 
such  hygienic  measures  as  seem  necessary  to  prevent  fur- 
ther contamination;  (3)  to  examine  the  other  members  of 
th  family  fn  order  to  determine  whether  any  of  them  have 
contracted  the  disease  and  to  counsel  proper  treatment;  (4) 
to  make  full  report  to  the  sanitarj-  authorities  as  to  the  con- 
dition of  the  patient's  dwelling;  (.5)  to  distribute  litera- 
ture and  to  give  advice  concerning  the  prevention  of  tuber- 
culosis and  hygiene  in  general;  (6)  to  determine  the  fin- 
ancial condition  of  the  applicant  for  treatment  and  the 
condition  of  other  members  of  the  family  if  it  is  the  father 
who  is  removed.     [J.  M.  S.] 


JOURNAL  OF  THE  AMERICAN  MEDICAL  ASSOCIATION 
May  25,  1901. 

1.  The  Pathology  of  Active  Tuberculosis  of  the  Pericar- 

dium.    H.  GIDEON  WELLS. 

2.  Tuberculosis  of  Fascia.    J.  CLARK  STEWART. 

3.  Sarcoma  of  the  Pancreas.     GEORGE  A.  BOYD. 

i.  A  Case  of  Epithelioma  Developed  on  the  Basis  of  a 
Hesled  Lupus  Vulgaris  Treated  by  X-Rays.  DAVID 
LIEBERTHAL. 

5.  LTrethral  Implantation  into  the  Bowel  for  Diversion  of 

the    L^rine.      An    Experimental    Research.    JACOB 
FRANK. 

6.  An      Overlooked      Nasal      Factor     in      Ear     DiseasG. 

CHEVALIER  JACKSON. 

7.  Compound  Fracture  of  Olecranon  with  Dislocation  of 

Both  Bones  of  Forearm.    E.  N.  TORREY. 

8.  Tubercular  Disease  of  the  Knee-Joint  and  Hip- Joint  in 

Children.     Biagnosis  and  Treatment.     EDWARD  A. 
TRACY. 

9.  Cough  Due  to  Reflex  Irritation  in  the  Upper  Air-Pas- 

sages.    FRANK  S.  MILBURY. 

1. — Wells  gives  an  account  of  the  pathology  of  active  tu- 
berculosis of  the  pericardium  and  reports  ten  cases.  Three 
of  these  cases  were  of  the  chronic  miliary  variety  accom- 
panied by  fibrous  adhesions.  In  three  there  was  an  acute 
miliary  eruption  accompanied  by  a  serous  or  bloody  fluid, 
mixed  with  fibrin,  in  the  pericardial  sac.  In  three  cases 
caseous  masses  and  fibrous  synechia  were  found,  and  in 
one  case  acute  inflammation  of  the  pericardium  was  pres- 
ent, without  tuberculous  lesions,  due  to  tuberculous  toxin. 
A  general  tuberculosis,  of  the  lungs  and  of  the  abdominal 
viscera,  was  found  in  this  case.  Wells  states  that  the  ba- 
cilli may  be  carried  to  the  pericardium  with  the  lymph 
stream,  this  being  the  most  common  manner  in  which  in- 
fection takes  place; or  the  bacilli  may  gain  entrance  through 
the  blood  stream  or  by  extension — from  the  mediastinal 
glands,  the  pleura,  the  myocardium,  and  the  vertebrae.  As 
a  rule,  tuberculous  pericarditis  terminates  in  death,  but 
it  is  possible  for  healing  to  occur.  Commonly  death,  in 
cases  of  tuberculosis  of  the  pericardium,  is  not  due  to 
causes  relating  to  the  heart,  but  results  from  tuberculosis 
of  some  other  part  of  the  body.  Rarely  is  tuberculosis  peri- 
carditis recognized  during  life  as  the  condition  is  generally 
unaccompanied  by  symptoms  referable  to  the  heart.  [F.J.K.l 

2. — Stewart  discusses  tuberculosis  of  fascia  and  con- 
cludes that  this  condition  occurs  with  sufficient  frequency 
to  entitle  it  to  more  general  attention.  He  recognizes  two 
varieties.  (1)  primary  acute  cases,  the  most  important  fea- 
ture of  these  being  an  extensive  cheesy  degeneration;  (2) 
chronic  cases,  which  are.  as  a  rule,  secondary,  accompa- 
nied by  hyperplasia  of  connective  tissue  with  disseminated 
areas  of  caseation.  He  maintains  that  it  is  essential  to  dis- 
tinguish these  forms  in  order  to  properly  institute  surgi- 
cal treatment.  Inoculation  experiments  may  be  necessary 
to  demonstrate  the  tuberculous  character  of  the  fibrous 
tissue,  and  he  believes  that  the  fibrous  tissue  resulting  from 
tuberculous  infections  should  be  regarded  as  tuberculous 
tissue,  and  therefore  should  be  treated  accordingly.  [F.J.K.] 

3. — Boyd  reports  a  case  of  sarcoma  of  the  pancreas  which 
occurred  in  a  male.  47  years  of  age.  The  patient  was  ad- 
mitted to  the  Policlinic  Hospital,  Chicago,  on  November 
16,  1S9S.  His  family  and  previous  personal  history  did 
not  throw  any  light  upon  his  condition.  The  patient  no- 
ticed a  lump  in  his  abdomen  and  complained  of  a  pain  in 
that  region  in  June  1S9S.  An  exploratory  laparotomy  w,is 
made  on  November  23d  by  Dr.  Harris.  It  was  found  that 
the  case  was  inoperable,  so  further  procedure  was  aban- 


1042 


The  Philadelphia"! 
Medical   Journal  J 


THE  LATEST  LITERATURE 


[Jlxe  1,   ISOl 


^oned.  The  patient  died  a  short  time  after  the  operation. 
A  complete  autopsy  was  not  performed,  however,  the  ab- 
domen was  opened  and  the  tumor  removed,  which,  upon 
microscopical  examination,  proved  to  be  a  sarcoma.  [F.J.K  i 

4. — Lieberthal  gives  an  account  of  a  case  of  epithelioma, 
developed  on  the  basis  of  a  healed  lupus  vulgaris.  Tlie 
patient  developed  lupus  when  two  years  of  age  and  suf 
fared  from  this  condition  until  he  was  12,  then  for  a  period 
of  38  years  he  enjoyed  comparatively  good  health.  About 
8  months  ago  a  painful  nodule  appeared  on  the  left  side 
of  the  lower  jaw.  This  mass  increased  in  size  very  rapidly; 
the  diagnosis  of  epithelioma  of  the  face  was  confirmed  by 
microscopic  examination  of  the  tumor.  The  application  of 
the  X-Ray  was  suggested,  and  it  appears  that  the  growtli 
of  the  neoplasm  was  not  checked.  The  mass  had  flattened 
somewhat  but  it  spread  towards  the  chin  about  an  inch. 

[F.  J.  K.] 

5. — Jacob  Frank  discusses  ureteral  implantation  into  the 
bowel  which  he  thinks  should  never  be  an  operation  of 
choice  but  only  one  of  necessity.  It  Is  preferable  to  neph- 
rectomy, and  Is  justifiable  in  certain  cases  of  cancer  of  the 
bladder  in  which  ihe  outlets  of  the  ureters  are  encroached 
upon.  Unilateral  implantation  is  Indicated  where  the  ure- 
ter is  wounded  high  up  in  case  an  anastomosis  or  repair 
cannot  be  made.  The  author  reports  10  experiments  which 
he  has  performed  on  dogs.  The  technic  of  the  operation 
is  minutely  described  and  illustrated.  An  incision  is  made 
longitudinally  through  the  peritoneal  coat  which  is  then 
loosened  and  retracted.  The  muscular  and  mucous  coats 
are  then  divided  longitudinally,  the  ureters  Inserted  and 
fixed  to  the  mucous  membrane  below  this  incision,  which 
is  then  closed  transversely.  The  transverse  closing  of  this 
longitudinal  incision  tends  to  lessen  any  compression  of 
the  ureter.  The  peritoneal  coat  Is  then  sutured.  This 
method  prevents  any  possible  infection  of  the  peritoneal 
coat  by  means  of  the  sutures,  as  those  entering  the  bowel 
are  entirely  enclosed  below  the  peritoneal  coat.  In  a  large 
majority  of  dogs  operated  upon  inflammatory  changes  in 
the  kidneys  took  place.     [J.  H.  G.] 

6. — Chevalier  .lackson  thinks  that  a  much  overlooked 
nasal  factor  in  ear  diseases  consists  in  the  hj'pertrophic 
thickening  which  takes  place  at  the  posterior  margin  (!f 
the  vomer  and  which  results  in  a  deflection  of  the  inspired 
air  against  the  Eustachian  eminences.  The  author  has 
found  this  hypertrophy  of  the  vomer  to  be  present  in  2a% 
of  his  private  ear  cases  and  in  11%  of  his  nose  and  throat 
dispensary  patients.  Operations  are  frequently  done  upon 
the  inferior  turbinals  when  the  real  cause  of  the  trouble 
lies  in  the  vomer.  It  is  urged  that  where  this  hypertrophy 
exists  wi:h  ear  disease  that  it  should  be  completely  re- 
moved and  that  wherever  it  is  found  alone  it  should  be 
removed  in  order  to  prevent  subsequent  ear  disease.  In 
relievmg  stenosis  it  is  a  mistake  in  removing  the  posterior 
turbinal  hypertrophy  to  take  away  so  much  as  to  expose 
the  Eustachian  eminence  to  the  direct  blast  of  the  inspira- 
tory current.     [J.  H.  G.] 

8. — Edward  A.  Tracy  urges  upon  the  general  practitioner 
the  great  necessity  of  being  aljle  to  diagnose  early  tuber- 
cular lesions  of  the  joints,  since  the  early  institution  of 
treatment  has  so  great  an  influence  upon  the  prognosis. 
Since  slight  injuries  of  the  knee-joint  in  individuals  with  a 
tubercular  tendency  are  so  apt  to  give  rise  to  serious 
trouble,  the  family  history  and  predisposition  of  the  pa- 
tient should  always  be  carefully  inquired  into  in  case  of 
injury  to  joints.  The  chief  diagnostic  signs  of  tubercular 
knee-joint  diseases  are  limitation  of  motion,  enlargement 
of  joint  measurements,  tenderness  on  pressure  and  muscu- 
lar spasm  elicited  by  attempting  passive  motion.  In  acute 
cases  heat  is  often  present.  The  treatment  of  this  con- 
dition consists  in  immediate  fixation  of  the  joint  and  rest, 
together  with  the  proper  hygienic  and  constitutional  treat- 
ment. The  author  thinks  that  plaster-of-paris  is  an  ineffec- 
tual method  of  producing  fixation  and  recommends  instead 
the  wood-plastic  material.  This  should  be  moistened  and 
applied  next  to  the  skin.  .■Vs  improvement  takes  place  the 
patient  should  be  gotten  out  of  bed  and.  if  over  six  years  of 
age.  should  be  made  to  use  crutches,  but  if  younger  than 
this  a  Thomas  splint  should  be  applied.  The  early  symp- 
tom of  tubercular  hip-joint  disease  is  limitation  of  the  nor- 
mal motions  of  the  joint  together  with  the  usual  well-known 
symptoms,  such  as  pain  and  limp.  The  principle  of  the 
treatment  here  is  the  same  as  in  diseases  of  the  knee-joint, 
fixation  and  rest,  and  here  ag-ain  the  wood-plastic  material 


is  recommended  after  any  flexion  of  the  thigh  which  may 
be  present,  has  been  overcome.     [J.  H.  G.] 

9. — Milbury  maintains  that  when  cough  is  spasmotic  or 
when  cough  is  unaccompanied  by  physical  signs  of  pul- 
monary disease,  or  when  cough  persistently  resists  all 
medication  for  permanent  relief,  it  is  of  reflex  origin.  He 
further  states  that  when  there  is  comparatively  little  dis- 
turbance of  the  general  health,  and  when  upon  removal 
of  the  cause  the  cough  ceases,  it  should  also  be  regarded-' 
reflex  in  origin.     [F.  J.  K.] 


AMERICAN    MEDICINE. 

May    18th,    1901. 

1.  Diseases  and  Deformity  of  the  Knee:    Etiology,   Diag- 

nosis and  Treatment.     D.^NIEL  W.  M.\RSTON. 

2.  The  Cause  of  Cancer.     THOMAS  S.  CULLEN. 

3.  Slow   Pulse,  with   Special  Reference  to  Stokes-Adams 

Disease.     ROBERT  T.   EDES. 

4.  The     Toxin     of     the     Colon     Bacillus.       VICTOR     C. 

VAUGHAN. 
T:     A  Plea  for  Uniformity  of  Technic  in  Widal's  Reaction. 
RANDLE   C.   ROSENBERGER. 

6.  The  Effect  on  the  Blood   of  Ether  Used   as  an  Anes- 

thetic.    J.   CHALMERS   DaCOSTA  and   F    J.   KAL- 
TEYER. 

7.  Blood   Examinations  as  an  Aid  to  Surgical  Diagnosis. 

JOSEPH  C.   BLOODGOOD. 

5.  Fractures  and  Dislocations  of  the  Spine.     STEPHEN 

H.  WEEKS. 

1. — Will  be  abstracted  when  concluded. 

4. — Victor  C.  Vaughan  has  found  in  his  work  on  the 
bacteriology  of  cheese  that  the  colon  bacillus  is  present  in 
practically  all  samples  of  American  green  cheese,  and  h  •- 
determined  that  cultures  of  this  germ  may  be  boiled  wi;l: 
out  destroying  its  toxicity.  The  facts  that  he  has  learn^  ; 
may  be  summed  up  as  follows:  The  toxin  is  not  contain- 
within  the  germ-cell  from  which  it  does  not.  at  least  unc'  : 
ordinary  conditions,  diffuse  into  the  culture  media.  Ti.- 
toxin  is  not  extracted  from  the  cell  by  either  alcohol  or 
ether.  Very  dilute  alkali  do  not  extract  the  toxins  from  the 
cells.  The  germ  substance  may  be  heated  to  a  high  tem- 
perature with  water  without  destruction  of  the  toxin. 
Boiling  with  a  2%  solution  of  hydrochloric  acid,  has  but 
little  if  any  effect  upon  the  germ  cell  or  its  contained  toxin. 
The  toxin  as  separated  from  the  cell  wall  by  digestion  of 
the  latter  with  HCl  and  pepsin  is  markedlv  active. 

[T.  L.  C] 

5. — R.  C.  Rosenberger  makes  a  plea  for  uniformity  of 
technic  in  the  Widal  reaction.  He  emphasizes  the  fol- 
lowing points:  fll  The  use  of  a  uniform  dilution.  (2) 
.\.  definite  time  limit  (3)  An  agreement  as  to  what  consti- 
tutes a  positive  reaction.  (41  The  use  of  a  culture  of 
definite  aid  and  a  clear  statement  as  to  incubation  or  non- 
incubation.  (5)  .\  decision  as  to  whether  dry  blood,  fresh 
blood  or  serum  is  to  used.  rS)  A  stated  number  of  tests 
to  be  made  in  a  given  case.  (71  To  drop  the  terms  "doubt- 
ful" and  "pseudo-reaction."  and  (81  To  use  the  terms 
"positive"  and  "negative"  only.     [T.  L.  C] 

7. — Joseph  C.  Bloodgood  presents  the  abstract  of  his  pa- 
per on  blood  examinations  as  an  aid  to  surgical  diagnosis. 
Observations  have  shown  that  there  is  a  leukocytosis  of 
15.000  to  24.000  following  hemorrhage.  There  is  also  a  di- 
minution of  the  red  blood  cells  and  the  hemoglobin.  In 
severe  hemorrhage  the  blood  count  will  indicate  to  a  cer- 
tain extent  the  amount  of  blood  lost,  but  not  usually  until 
<;  to  10  hours  after  the  hemorrhage.  Less  than  30%  of 
hemoglobin  is  regarded  by  most  surgeons  as  a  contra 
indication  to  operation.  He  mentions  the  importance  of 
the  study  of  postoperative  leukocytosis,  and  mentions  the 
value  as  a  means  of  differential  diagnosis  of  cour.'' 
white  blood  cells  in  the  first  24  to  48  hours  after 
otomy  between  benign  abdominal  distension  and  i^.,  ...  . 
I  tion  or  peritonitis.  In  appendicitis  there  are  usually  %  .1 
liable  indications  to  be  derived  from  the  study  of  whi:.- 
blood  cells.  Cases  of  the  recurrent  variety  there  is  rarely 
an  increase,  In  a  few  instances  when  the  case  is  first  ob- 
served within  48  hours  after  the  beginning  of  the  attack 
when  the  symptoms  have  subsided,  there  have  been  a  few 
Ieukoc>T:e  counts  of  Li.OOO.  which  have  rapidly  fallen  to 
10,000  and  7.000.     The  rapid  rise  of  the  leukocyte  count  is 


JUN-E    1,    1301] 


THE  LATEST  LITERATURE 


rfHE   Philadelphia 
Lmedical   Journal 


1043 


an  important  indication  for  the  necessity  of  operation.  The 
record  of  leukocyte  counts  in  gangrenous  appendicitis  and 
the  differentiation  between  abscess  and  peritonitis  is  dis- 
cussed as  well  as  leukocytosis  occurring  in  intestinal  ob- 
struction.    [T.  L.  C] 

8. — Stephen  H.  Weeks  reports  a  case  of  a  patient  aged 
70  who  sustained  a  fall  from  a  ladder  and  who  presented  on 
examination  a  deformity  of  the  cervical  spine  at  about 
the  fourth  or  fifth  vertebra.  A  laminectomy  was  per 
formed.  The  laminas  of  the  fourth  and  fifth  cervical  verte- 
bra were  found  broken  and  depressed.  The  patient  made 
a  good  recovery  and  in  5  weeks  was  able  to  sit  up  in  a 
chair.  The  author  believes  that  the  surgeon  should  per- 
form an  experimental  laminectomy  in  every  case  if  the 
condition  of  the  patient  is  such  as  to  justify  operation. 
Drainage  is  usually  required  for  two  or  three  days.  The 
spine  is  best  supported  during  the  healing  process  by 
plaster  of  Paris  dressing  or  by  sand  bags  placed  on  each 
side  of  the  patient.     [T.  L.  C] 


.yai/ 


isni. 


1.  Apoplexy  and  Hemiplegia.     HAROLD  N.  MOVER. 

2.  A    Case   of   Intermittent   Claudication.     DAVID   RIES- 

MAN. 

3.  Disease  and  Deformity  of  the  Knee;  Etiology,  Diagnosis 

and  Treatment.     DANIEL  W.  MARSTON. 
-i.     Chronic   Heart   Disease   in   Children   Relieved   by   Svs- 

tematic  Movements.     JOHN  MADISON  TAYLOR. 
5.     Peripheral  Venous  Thrombosis  in  Cardiac  Disease,  with 

Report  of  a  Case.    J.  A.  MacGRBGOR. 
().     A  Hitherto  Undescribed  Reaction  Following  the  Inocu- 
lation   of    Vaccine    Virus.      A    Preliminary     Report. 

HEINRICH   STERN. 
7.     Pregnancy  Complicated  by  Fibroid  Tumors.     Cesarean 

Hysterectomy   at   Eighth   Month.     MARY   ALMIRA 

SMITH. 
S.     On  the  Use  of  Alcohol  in  Treatment  of  Carbolic  Acid 

Bums  and  Poisoning.    P.  PIRKNER. 
9.     The  Mission  of  a  Medical  College.    W.  W.  KEEN. 

2. — Riesman  reports  a  case  of  intermittent  claudication, 
a  condition  first  described  by  Charcot  in  185S.  The  symp 
toms  of  the  condition  In  general  are  a  sensation  of  pain 
and  numbness  in  the  legs  shortly  after  the  patient  starts  to 
walk,  the  walking  becomes  impossible.  After  a  short  rest 
locomotion  can  be  resumed  only  to  be  again  interrupted  as 
at  first.  The  patient  thus  becomes  intermittently  limping. 
Sensation  is  usually  normal,  objectively;  subjectively  the 
patient  often  experiences  various  paresthesias.  Gangrene 
is  of  common  occurrence  (in  seven  out  of  twentj'-four  cases 
reported  by  Goldflam).  The  majority  of  patients  are  men. 
The  etiology  of  the  disease  coincides  with  that  of  arteri- 
osclerosis. Syphilis,  alcohol,  exposure  and  tobacco,  and 
perhaps  diabetes,  play  a  role.  In  Riesman's  case  examin- 
ation of  the  arteries  of  the  feet  show'ed  that  pulsation  was 
entirely  absent  in  both  dorsales  pedes.  There  was  short- 
ness of  breath  on  exertion,  transient  aphasia  and  gastric 
symptoms.  As  to  treatment.  Riesman's  case  was  benefited 
by  the  iodides  and  nitroglycerin.  The  alkaline  mineral  wa- 
ters are  helpful.  The  patient  should  avoid  fatigue  and  pro- 
tect himself  carefully  from  cold  and  dampness.     [T.  L.  C.] 

5. — .1.  A.  BlacGregor  reports  a  case  of  peripheral  venous 
thrombosis  occurring  in  cardiac  disease.  Six  weeks  before 
death  there  appeared  the  evidences  of  thrombosis  of  the 
left  axillary,  subclavian  and  internal  jugular  veins.  The 
onset  was  marked  by  pain  and  swelling  and  there  was  ten- 
derness over  the  vessels.  Edema  of  the  lungs  caused  death. 
An  autopsy  was  not  performed.  The  patient  was  a  sufferer 
from  mitral  stenosis  and  the  thrombosis  appeared  during 
broken  compensation.  The  length  of  life  of  the  patient  in 
this  condition  must  have  been  attributable  to  the  estab- 
lishment of  a  sufficient  collateral  circulation.  Twitching  of 
the  arm  and  leg  was  noticed  several  hours  before  death, 
and  may  have  been  caused  bv  the  jugular  thrombosis. 

[T.  L.  C] 

6. — Heinrich  Stern  has  investigated  the  question  as  to 
whether  the  gouty  and  kindred  phenomena  may  disappear 
after  vaccination.  He  reports  two  experimental  inocula- 
tions. The  gouty  pains  disappeared  in  both  instances.  And 
he  mentions  that  the  same  may  stand  as  the  foundation  of 
many  affections  which  are  clinically  regarded  as  gout, 
rheumatism  and  neuralgia.  Since  vaccine  lymph  hardly 
possesses  solvent  or  specific  eliminating  properties  he  re- 
gards the  reaction  as  secondary  or  indirect.     [T.  L.  C] 

7. — Smith   records  a  case  of  pregnancy  complicated   by 


fibroid  tumor  in  which  a  Cesarean  section  was  performed 
at  the  eighth  month  followed  by  hysterectomy  by  Baer's 
method.  The  patient  died  from  heart  failure,  the  result  of 
an  old  endocarditis.     [W.  A.  N.  D.] 


THE  JOURNAL  OF  NERVOUS  AND  MENTAL  DISEASE. 
May,  1901.     [Vol.   28.     No.   5.) 

1.  A   Study  of  the  Cases  of  Tabes  Dorsalis   in  Prof.   M. 

Allen  Starr's  Clinic,  Columbia  University,  from  Jan- 
uary, 1888,  to  January,  1901.     A.  B.  BONAR. 

2.  The     Scapulo-Humeral     Reflex     of     von     Bechterew. 

WILLIAM  PICKETT. 

Z.  Psychical  Form  of  Epileptic  Equivalent.  CHARLES 
CARY  and  J.   ULLMAN. 

4.  Cases  Illustrating  the  Differential  Diagnosis  of  Cere- 
bral and  Hysterical  Hemianesthesia.  CHARLES  K. 
MILLS  and  THEO.  H.  WEISENBERG. 

1- — Bonar  in  his  study  of  a  large  number  of  cases  of 
tabes  dorsalis  gives  the  following  symptoms  with  the  per- 
centage of  each:  Loss  of  knee-jerks,  92.5;  Changes  in 
knee-jerks,  3.69;  Romberg  symptom,  79.02;  Change  in 
pupillary  reaction,  78.67;  Pains  in  the  legs,  78.67;  Ataxia 
in  legs,  70.62:  Vesical  disturbance.  62.23:  Paresthesia  and 
numbness,  54.54;  Girdle  sensation,  48.6;  Loss  of  muscular 
sense,  28.32;  Crises,  16.78;  Pains  in  trunk,  12.93;  Optic 
nerve  atrophy,  8.74;  Ataxia  in  arms,  7.69;  Pains  in  arms, 
6.99;  Loss  or  diminution  of  sexual  instinct,  6;  Pains  in 
thighs.  4.89;  Ocular  paralyses  (strabismus,  diplopia,  etc.), 
3.21;  Nystagmus.  2.44;  Arthropathies,  2.09;  Constriction 
around  legs  or  tighs.  1.74;  Tremors,  1.74;  Perforating  ul- 
cers of  foot,  1.39:  Muscular  atrophy,  1.39;  Anosmia.  1.04; 
Deafness.  0.69:  Vertigo.  0.34;  Loss  of  taste,  0.34.    [T.  M.  T.] 

2. — Prickett  describes  the  scapulo-humeral  reflex  of  von 
Bechterew  as  one  elicited  by  the  percussion  hammer  along 
the  entire  inner  edge  of  the  shoulder  blade  beneath  its  in- 
ner angle — most  markedly  at  the  inner  edge  of  the  in- 
ferior angle.  It  consists  in  adduction  of  the  corresponding 
humerus  toward  the  trunk,  often  also  in  slight  outward  ro- 
tation, mainly  produced  by  contraction  of  the  infraspinatus 
muscle,  and  apparently  of  the  teres  minor.  According  to 
von  Bechterew  it  is  influenced  in  the  following  conditions: 
It  is  absent  in  poliomyelitis,  in  the  spinal  form  of  pro- 
gressive muscular  atrophy,  in  neuritis  when  the  shoulder 
girdle  muscles  are  affected:  diminished  or  absent  in 
muscular  dystrophy  and  in  "rigidity  of  the  spinal  column." 
It  is  exaggerated  in  cerebral  hemiparesis  or  hemiplegia, 
especially  when  there  is  marked  atrophy  of  the  shoulder 
girdle  muscles.  Thus  in  determining  whether  such  atrophy 
be  of  spinal,  neuritic,  or  cerebral  origin  in  a  given  case, 
the  state  of  the  scapulo-humeral  reflex  is  significant.  [T. 
M.  T.] 


UNIVERSITY      OF      PENNSYLVANIA      MEDICAL      BUL- 
LETIN. 

-l/»//.    I'MI. 

1.  A  Trimanual  Method  of  Percussion  for  the  Detection  of 

Cystic  of  Locculated  Fluids  in  the  Abdomen.     JOHN 
G.  CLARK. 

2.  Recent  Statistics  on  the  Primary  and  Ultimate  Results 

of  Hysterectomy  for  Cancer  of  the  Uterus.     JOHN 

G.  CLARK. 
;'.     Diagnostic   Curettage  of  the   Uterus.   Associated   with 

Fibroma  of  the  Inguinal  Canal.     JOHN  G.  CLARK. 
■!      Unique  Pathological  Changes  in  Two  Cases  of  Uterus 

Bicornis  Unicollis,  etc.     JOHN  G.  CLARK. 

5.  ,\  Practical  Application  in  Abdominal  Surgery  of  Scien- 

tific Investigations   on   the   Function,   Anatomy  and 
Pathology  of  the  Peritoneum.     JOHN  G.  CLARK. 

6.  A  Series  of  Twelve  Articles  on  Medical  Men  Prominent 

in  Civil  and  Military  Affairs  of  Revolutionary  Times. 

FRANCIS  R.  BACKARD. 
1. — Clarke  describes  a  new  method  of  percussion  for 
the  detection  of  cystic  or  locculated  fluids  in  the  abdomen. 
It  is  a  trimanual  method  consisting  in  the  usual  bimanual 
examination  of  the  pelvic  mass  while  the  percussion  is  per- 
formed by  an  assistant.     In  this  way  the  intestines  inter- 


I044 


The   Philadelphia"] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[J  USE  1.  lyn 


vening  between  the  anterior  abdominal  wall  and  the  tumor 
are  excluded.  He  describes  an  illustrative  case.  [W.  A.  N. 
D.] 

2. — Clark  has  made  a  study  of  the  recent  statistics  on  the 
primary  and  ultimate  results  of  hysterectomy  for  cancer 
of  the  uterus.  He  remarks  that  he  is  forced  to  confess 
that  these  statistic  show  that  the  operative  treatment  has 
not  yielded  as  satisfactory  results  as  has  been  anticipated. 
The  great  majority  of  cases  operated  upon  have  died  witl]- 
in  six  years  from  the  recurrence  of  the  disease.  The  aden- 
ocarcinoma of  the  body  of  the  uterus  gives  the  best  results 
if  the  operation  be  performed  at  a  very  early  stage.  In 
cancer  of  the  fundus  there. is  no  recurrence  in  these  cases. 
Winter's  statistics  show  that  the  immediate  mortality  fol- 
lowing operations  for  cancer  of  the  uterus  varies  between 
5.7%  and  lO.S^c.  From  his  review  of  308  cases  he  reaches 
the  conclusion  that  vaginal  hysterectomy  cannot  be  con- 
sidered a  radical  means  of  cure,  and  also  that  the  indica- 
tions for  operation,  cannot  be  further  extended.  Schu- 
chardt's  operation,  according  to  Clark,  has  not  and  will 
not  have  an  extensive  acceptance  among  surgeons  for 
obvious  reasons.  If  vaginal  hysterectomy  is  the  operation 
of  election,  the  clamp  method  is  to  be  preferred  to  the 
ligature  method,  first,  when  it  is  necessary  to  rapidly  com- 
plete the  operation,  and,  secondly,  when  it  is  difficult  or 
impossible  to  place  ligatures  on  account  of  the  dense  fixa- 
tion of  the  uterus.  Winter's  final  conclusion  with  regard 
to  inoculation-growths  are  as  follows:  1,  the  inoculation 
and  growth  of  cancerous  tissues  into  fresh  wounds  may 
be  accepted  as  an  established  fact;  2,  this  factor  unques- 
tionably plays  a  role  in  the  local  recurrences  after  can- 
cer operation;  3,  on  account  of  the  lack  of  statistics  it  is 
impossible  to  state  the  frequency  of  these  recurrences, 
but  unquestionably  a  simple  continuance  of  the  local 
growth  is  much  more  frequent  than  inoculation-growths. 
Clark  remarks  that  the  ordinary  clinical  diagnosis  of  these 
cases  is  extremely  difficult  and  in  many  instances  impos- 
sible, and  only  through  a  careful  microscopical  examina- 
tion of  currettings  can  be  definite  decision  be  reached. 
[W.  A.  N.  D.] 

3. — Anspach  reports  two  cases  of  endometritis  closely 
simulating  cancer  of  the  fundus  in  order  to  emphasize 
the  fact  that  the  microscope  as  a  means  of  exclusion  is 
quite  as  valuable  as  in  the  positive  diagnosis  of  cancer. 
He  claims  that  the  microscopic  examinations  of  uterine 
scrapings  in  cases  of  suspected  carcinoma  may  be  of 
value  in  differential  diagnosis  either  as  a  positive  or  nega- 
tive factor.  It  is  positive  when  the  examination  shows 
without  question  the  presence  of  cancer;  it  is  of  just  as 
great  value  when  it  as  certainly  reveals  the  benign  nature 
of  a  pathological  process  which  has  given  rise  to  symptoms 
characteristic  of  cancer.     [W.  A.  N.  D.] 

4. — Clark  remarks  that  of  the  malignant  tumors  of  the 
uterus  cancer  is  by  far  more  frequent  than  sarcoma.  Can- 
cer of  the  uterus  most  frequently  arises  from  the  cervix, 
and  seldom  in  the  fundus.  Sarcoma  on  the  other  hand 
rarely  arises  in  the  cervix  but  almost  always  from  the 
fundus.  This  peculiarity  in  relationship  of  the  two 
growths,  as  to  the  part  of  the  uterus  from  which  they 
spring,  has  been  offered  in  support  of  the  hypothesis  that 
sarcomata  of  this  organ  most  frequently  are  malignant 
transformations  of  myofibromata.  The  fact  that  a  tumor 
had  appeared  in  the  inguinal  region  subsequent  to  the  uter- 
ine growth  in  the  case  that  Clark  reports  of  sarcoma  of  the 
uterus  confused  very  decidedly  the  diagnosis,  for  sarcoma 
seldom,  if  ever,  gives  metastasis  to  the  inguinal  glands, 
whereas  this  is  not  infrequent  in  cancer  of  the  fundus. 
Sarcomas  arise  either  from  the  endometrum  or  from  the 
uterine  wall.  The  endometrial  variety  is  much  more  fr«^ 
quent.  Gessner  has  formulated  the  following  law  con- 
cerning the  origin  of  these  new  gi'owths:  round-cell,  and 
a  majority  of  the  spindle-cell  sarcomata,  spring  from 
connective  tissue.  A  small  proportion  of  the  latter,  how- 
ever, may  be  transformed  from  muscle-cell.  The  points 
of  interest  in  a  case  reported  by  Clark  are:  1.  a  history  sig- 
nificant of  myoma  uteri:    2,  the  consistence  and  appear- 


ance of  the  tumor  that  of  sarcoma,  although  the  later  oc- 
curance  of  the  tumor  of  the  inguinal  canal  was  significant 
cf  cancer  of  the  uterus;  3,  confirmation  of  the  clinical 
diagnosis  as  to  sarcoma  of  the  uterus,  and  correction 
of  the  diagnosis  as  to  malignant  tumor  of  the  inguinal 
glands  by  microscopic  examination:  4,  the  coincidence  of 
two  rare  pathological  conditions,  sarcoma  of  the  fundus 
and  fibroma  of  the  inguinal  canal,  most  probably  of  the 
round  ligament.     [W.  A.  X.  D.] 

5. — Clark  reports  unique  pathological  changes  in  two 
cases  of  uterus  bicornis  unlcollis — (1)  unilateral  pyo- 
metra  and  pyosalpinx;  (2)  myoma.  He  remarks  that  in 
view  of  the  peculiar  development  of  the  uterus  thro'.z'- 
fusion  of  the  lower  segments  of  the  two  Miillerian  ducts  to 
form  one  common  uterine  cavity,  it  is  surprising  that  mal- 
formations are  so  infrequent,  especially  when  animals  in 
the  higher  evolutionary  scale,  such  as  the  cat,  dog,  pig, 
cow,  etc..  all  have  bicomate  uteri.     [W.  A.  X.  D.] 

6. — Clark  makes  the  study  of  the  investigations  during 
the  last  six  years  of  various  scientists  upon  the  functions 
and  anatomy  of  the  peritoneum.  In  1S96  as  a  result 
of  the  combined  study  of  1700  abdominal  section  cases, 
and  the  review  of  the  literature  bearing  upon  the  structure 
and  function  of  the  peritoneum,  he  took  radical  ground 
against  abdominal  drainage  as  then  generally  employed 
and  advocated  certain  measures  which  were  in  direct  op- 
position to  principals  then  generally  in  vogue.  He  favored 
the  thorough  irrigation  of  the  peritoneal  cavity,  at  the  com- 
pletion of  an  abdominal  operation  to  remove  as  far  as  pos- 
sible all  debris,  blood  and  infectious  matter,  and  then  the 
leaving  of  a  considerable  quantity  of  salt  solution  lO-.S"^) 
in  the  peritoneal  cavity  to  disseminate  and  promote  rapid 
absorption.  He  reviews  the  experiments  of  Wallgren  and 
gives  the  latter's  conclusions.  Based  upon  practical  experi- 
ence in  a  large  series  of  abdominal  sections,  and  sustained 
by  his  own  and  the  scientific  investigations  of  others,  he 
believes  that  the  thorough  irrigation  with  normal  solution 
of  the  peritoneal  cavity  after  abdominal  operation  for  the 
purpose  of  removing  all  possible  debris  or  infectious  matter 
and  then  leaving  large  quantities  of  salt  solution  is  the 
most  effective  preventive  measure  we  have  against  post- 
operative peritonitis.     [W.  A.  X.  D.] 


MUENCHENER  MEDICINISCHE  WOCHENSCHRIFT. 
Uarch  19th,  19(11. 

1.  Experimental  Investigations  upon  Disinfection  of  the 

Hands.     PAUL  and  SARWEY. 

2.  Clinical  Experiments  upon  the  Treatment  of  Pulmonary 

Tuberculosis  with  Intravenous  Injections  of  Cinna- 
niate  of  Soda.     KCHX. 

3.  Further  Communications  upon  the  Therapeutic  Value 

of  Heroin  and  Aspirin.     XVSCH. 

4.  The  Treatment  of  Gonorrhoea  with  Protargol.     XIES- 

SEN. 

5.  Contribution  to  the  Technique  of  the  Re-Position  of 

congenital    Dislocation    of    the    Hip.    according    to 
Lorentz.     SCHLESIXGER. 

6.  The  Treatment  of  Ileus  with  Atropine.    SIMON. 

7.  Another     Case     of     Ileus     Treated     with     Atropine, 

HOCHTLEX. 

8.  The  Treatment  of  the  Leg  Vlcers.     SCHTJLZE. 

9.  Max  von  Pettenkofer.     LEHMAN^X. 

1. — In  a  careful  review  of  the  literature.  Paul  and  Sar- 
wey  call  attention  to  the  various  modifications  of  the 
solutions  of  corrosive  sublimate  that  have  been  designed 
to  render  it  more  efficient,  that  is  to  say.  to  increase  the 
quantity  of  mercury  in  the  solution,  which  is  of  course 
the  only  effective  agent.  The  more  complex  the  molecule 
of  which  the  mercury  forms  a  part,  the  less  is  its  bacteri- 
cidal power,  and  the  same  is  true  of  the  various  prepara- 
tions containing  silver.  Much  depends  upon  the  solvent,  for 
instance  nitrate  of  silver  in  50""^  alcohol  manifests  its  maxi- 
mum effect.  In  the  discussion  of  the  methods  employed 
to  render  the  mercjry  harmless,  they  have  experimented 
with  Gepperfs  solution  of  hydrogen  sulphide  in  liquor 
ammoniae.  It  was  found  that  if  the  sublimate  solution  was 
allowed  to  act  for  six  minutes  that  the  number  of  spores 
capable  of  developing  depended  directly  upon  the  per' 
ceutage  of  ammonium  sulphide  employed.     This  method. 


June  1,  1901] 


FOREIGN  NEWS  AND  NOTES 


r  I  HE     HHll-ArELPHlA 

L-\Ie;>ical   Jolrnal 


1045 


therefore,  diniinishes  the  bactericidal  effect  of  the  anti- 
septic. The  authors  do  not  approve  of  artificial  disinfection 
of  the  hands  before  performing  the  experiments.  They 
do  not  agree  with  Kroenig  that  sterilization  of  the  hands 
is  complete  when  they  are  no  longer  capable  of  infecting 
the  body,  but  insists  that  we  should  discover  some  method 
which  renders  the  site  of  operation,  provided  it  is  not 
previously  infected,  absolutely  free  of  germs,  in  order 
that  when  it  heals  it  will  act  just  as  a  subcutaneous  in- 
jury.    [.I.  S.] 

2. — Kuhn  has  experimented  upon  11  cases  of  various 
forms  of  pulmonary  tuberculosis  with  hypodermic  injec- 
tions of  Haetol,  that  is.  sodium  cinnamate.  It  does  no; 
seem  clear  just  how  this  acts,  for  it  appears  unlikely  that 
it  is  due  to  the  leukocytosis  produced  by  the  injection.  At 
any  rate,  it  is  entirely  harmless,  and  in  a  small  number 
of  cases  a  certain  amount  of  improvement  could  be  ob 
served.  As.  however,  the  usual  forms  of  hygienic  treat 
ment  were  employed,  this  improvement  can  be  ascribed 
as  well  to  them  as  to  the  injections.  In  one  of  the  4  cases 
that  died  an  autopsy  was  performed,  and  considerable 
induration  of  the  pulmonary  tissue  discovered.  This 
however,  is  not  an  uncommon  phenomenon.     [J.  S.] 

3. — Nusch  reports  his  experience  gained  in  Neukirch's 
clinic  with  heroin  and  aspirin.  Heroin,  or  triacetate  of 
morphia,  is  considerably  less  poisonous  than  morphia  or 
cocaine.  It  may  be  given  with  considerable  safety  in  doses 
of  one-twelfth  to  one-sixth  gr.  (.005  to  .01 ).  It  quiets  cough, 
increases  the  depth  of  respiration,  and  in  large  doses  often 
causes  the  patients  to  sleep,  although  it  has  no  direct  hyp- 
notic action.  .Apparently  it  does  not  quiet  pain.  It  is  par- 
ticularly useful  in  tuberculosis  of  the  larynx.  Aspirin  does 
not  appear  to  have  the  objectionable  effects  of  salicylic 
acid,  and  rarely  produces  tinnitus  or  headache.  It  is  partic- 
ularly effective  in  cases  of  acute  and  chronic  rheumatism, 
and  seems  to  have  a  considerable  antipyretic  action,  even 
in  such  severe  cases  as  pulmonary  tuberculosis.  The 
dose  is  15  grs.  (1.0)  from  5  to  2  times  daily  in  acute  cases, 
or  4  times  daily  in  the  more  chronic  cases.  It  is  also 
useful  in  neuralgias.     [J.  S.] 

4. — Niessen.  as  regimental  surgeon,  has  had  opportunities 
of  treating  236  cases  of  gonorrhea  in  the  course  of  one  year. 
He  used  solutions  of  protargol.  %%  in  strength  for  the  first 
2  weeks,  increasing  gradually  if  the  secretion  persisted. 
Ninety-nine  of  these  cases  had  their  first  attack,  and  from 
these  he  deduces  his  statistics.  The  time  required  to 
obtain  a  cure  ranged  from  5  to  43  days.  In  34  of  these 
cases  there  were  complications.  Comparing  his  series  of 
ijTO  cases  treated  during  1S96.  he  found  that  the  average 
duration  of  the  attack  was  no  better  with  protargol  than 
with  other  methods  of  treatment.  Its  advantage  is 
that  it  is  rather  less  painful.     [J.  S.] 

5. — Schlesinger  describes  a  modification  of  Lorentz'  meth- 
od of  reducing  congenital  dislocation  of  the  hip.  If  the  first 
attempt  fails  the  limb  is  placed  in  the  position  for  re- 
position, and  fixed  by  means  of  a  plaster  bandage  for  3 
or  4  days.  In  the  first  day  there  is  usually  considerable 
pain.  Reduction  is  then  again  attempted,  and  in  the 
great  majority  of  cases  is  accomplished  with  extraordinary 
ease.  In  one  case  it  occurred  whilst  the  bandage  was  in 
position.  If.  however,  it  cannot  be  accomplished,  the 
plaster  cast  is  applied,  and  in  all  cases  hitherto  treated, 
the  third  attempt  has  been  successful.  He  reports  5  cases 
ranging  in  age  from  G  to  13  years.     [J.  S.] 

6. — Simon  reports  the  case  of  a  woman  29  years  of  age. 
who,  S  days  after  delivery  had  diarrhea  and  vomiting  fol 
lowed  by  chills  and  severe  pain  in  the  abdomen.  This  was 
followed  by  all  the  symptoms  of  intestinal  obstruction. 
Accordingly  an  injection  of  one-sixtieth  grain  of  atropine 
was  given,  followed  by  three  others  the  next  day.  The 
pulse  became  slower  and  the  general  condition  of  th>.^ 
patient  improved,  but  there  was  no  movement  of  the  bow- 
els. Accordingly,  on  the  third  day  one-thirtieth  grain  of 
atropin  was  injected,  repeated  in  6  hours,  and  the  fol- 
lowing morning  there  was  a  liquid  movement  of  the 
bowels,  followed  by  diarrhe.a  and  complete  recovery. 
The  patient  was  slightly  delirious  after  the  large  injections. 

[J.  S.] 

7. — Hochtlen  reports  the  case  of  a  woman  71  years  of 
age,  who  had  had  attacks  of  appendicitis  and  peritoniti?;. 
She  had  severe  constipation,  followed  in  4  days  by  vom''- 
ing  and  distension  of  the  abdom?n.    As  the  symptoms  were 


not  relieved  by  a  large  enemata  one-twentieth  grain  ot 
sulphate  of  acropin  was  administered  on  the  7th  day. 
There  was  some  delirium,  and  the  patient  complained 
of  dryness  in  the  throat.  A  subsequent  injection  was 
therefore  not  made,  but  the  patient  was  from  time  to  time 
given  an  enema  and  morphin.  She  finally  died  in  collapse. 
At  the  autopsy  it  was  found  that  the  transverse  colon  was 
occluded  by  firm  peritoneal  adhesions,  and  the  case  was 
one  that  raanifestlv  could  be  helped  only  by  an  operation. 

[J.  S.] 

8. — Schulze  recommends  a  salve  containing  camphor, 
composed  according  to  the  fallowing  formula,  for  leg 
ulcers: 

Camphor 2  parts 

Oxide  of  zinc 15  to  20  parts 

Lard q.  s.  ad  100  parts 

In  some  cases  where  this  is  too  stimulating  he  employs 
the   following   formula: 

Camphor 2  parts 

Olive  Oil 50  parts 

Zinc  oxide 40  to  50  parts 

Cloths  are  soaked  in  this  and  laid  over  the  ulcer.  .Appli- 
cation is  to  be  made  2  or  3  times  every  day.  The  pa- 
tients necessarily  must  keep  still.     [J.  S.] 


3. 


SCOTTISH    MEDICAL   AND   SURGICAL   JOURNAL. 
yarvli,  1001.     (Vol.  VIII,  Xo.  3.) 

The  Edinburgh  Hospital  in  South  Africa  and  its  Work. 
FR.A.XCIS  D.  BOYD  and  GEORGE  L.  CHIENE. 

Gastric   Hemorrhage  and  Its  Surgical  Treatment,     A. 
W.  MAYO  ROBSON. 

A  Case  of  Acute  Cellulitis  Treated  by  Antistreptococcic 
serum.     FRANCIS  KELLY. 
4.     A  Plea  for  tlie  More  General  Use  of  Ether  as  an  Anes- 
thetic in  General  Surgery.    THOMAS  D.  LUKE. 

2. — Robson  in  his  article  urges  the  following  treatment 
in  gastric  ulcer:  (1)  All  cases  of  acute  uncomplicated 
gastric  ulcer  should  be  submitted  to  thorough  medical 
treatment  in  the  shape  of  long-continued  rest  and  attention 
to  diet,  the  cases  not  being  allowed  to  get  up  or  to  resume 
solid  food  until  at  least  a  fortnight  after  all  disappearance 
of  pain;  (2)  Where  the  ulceration  persists  and  proves 
intractable  to  medical  treatment,  or  where  relapses  occur, 
gastro-enterotomy  should  be  performed,  so  as  to  secure 
physiological  rest  and  relieve  the  hyperacidity  of  the 
gastric  juice  nearly  always  found  in  such  cases:  (3)  Per- 
foration demands  immediate  surgical  treatment:  (4)  The 
complications  of  disabling  adhesions  around  the  stomach 
and  pylorus,  pyloric  contraction  and  hour-glass  contraction 
due  to  chronic  ulcers  leading  to  pain,  dilatation,  loss  of 
flesh  and  general  impairment  of  health,  and  now  often 
treated  as  chronic  indigestion,  should  always  be  treated 
surgically:  (5)  In  recurring,  or  so-called  cnronic  hema- 
temesis  from  gastric  ulcer,  surgical  treatment  is  decidedly 
called  for:  (6)  In  acute  hematemesis,  further  accuracy 
in  diagnosis  as  to  the  size  of  the  bleeding  vessels  is  urg- 
ently needed:  and  the  co-operation  of  the  physician  and 
surgeon  is  advisable  in  all  cases  of  hematemesis,  so  that 
if  relief  be  not  obtained  by  medical  and  general  treatment, 
surgical  means  may  be  adopted  if  the  bleeding  is  believed 
to  occur  from  a  large  vessel:  but  seeing  that  capillary  henv 
orrhage  is  capable  of  relief  by  medical  means  alone,  medi- 
cal should  always  precede  surgical  treatment.     [T.  M.  T.] 

4.Luke  concludes  by  referring  to  the  Hyderabad  Commis- 
sion's Report  as  follows:  II)  That  the  mortality  from 
anesthetics  had  been  unduly  high  and  by  improved  methods 
i'.nd  greater  care  the  death  rate  can  be  lowered:  (2)  That 
ether,  when  properly  administered  from  an  inhaler  per- 
mitting graduafcn  of  the  strength  of  the  vapor,  is  the 
safest  anesthetic  for  general  surgery  in  temperate  cli- 
mates: (3)  That  nitrous  oxide  gas  for  minor  surgery  and 
dental  operations  should  replace  chloroform,  (4> 
That  chloroform,  when  given  by  a  carefully 
trained  person,  is  a  comparatively  safe  body,  but 
in  no  case  devoid  of  risk:  (5t  That  no  age  or  nation- 
nl  ty  removes  the  danger  under  anesthetics:  (6)  That 
the  perils  of  anesthetics,  however  slight,  demand  that  the 
undivided  attention  of  a  d>\"y  qualified  and  trained  medical 
man  fhnuld  he  f'iven  to  the  administration  of  the  anee- 
thetic.    [T.  M.T.I 


1046 


The  Philadelphia"! 
Medical   Journal  J 


SECOXDARY  SUTURE  OF  XER\'ES 


l.'VKE    I.    1901 


©rwinal  Hrticlcs. 


TWO  SUCCESSFUL  CASES  OF  SECONDARY  SUTURE. 
ONE  OF  THE  POSTERIOR  INTEROSSEOUS  NERVE 
AND  ONE  OF  THE  MEDIAN  AND  ULNAR  NERVES. 

W.  W.  KEEX.  M.  D.,  LL.D.,  F.R.C.S.   (Hon.). 

of   Philadelphia. 

Professor  of  the  Princdpies  of  Surgery  and  of  Clinical   Surgerj-,  Jeffcr.-oa 

Medical  College,  Philadelphia. 

CASE  1. — Dirixhin  of  the  posterior  interosseous  nerte  anil 
common  extensor  muscle  of  the  fingers,  followed  by  total  loss  of 
extension  of  the  fingers;  suture  after  three  months;  entire  re- 
storation of  function* 

W.  B.  H..  of  Pine  Bluff.  Avk.,  aet.SS,  6  ft.  4%  in.  tall, 
weight  260  lbs.,  flrst  consulted  me  November  6tli,  1900,  at 
the  instance  of  Dr.  J.  L.  Goree,  of  Pine  Bluff. 

On  August  1st,  1900.  while  camping  out  and  standing  in 
front  of  a  guide,  who  was  chopping  down  a  tree,  the  ax- 
head  flew  oif  the  handle  and  struck  him  on  the  back  of 
the  left  forearm.  17  cm.  below  the  olecranon  and  12  cm. 
above  the  styloid  process  of  the  ulna,  inflicting  a  wound 
5.3  cm.  long,  and  almost  precisely  transverse  to  the  long 
axis  of  the  forearm.  The  wo'ind  extended  down  to  the 
bones,  but  did  not  fracture  them.  A  surgeon,  who  also  war 
camping  out  in  his  neighborhood,  but  with  no  surgical  in 
struments  or  dressings  with  him.  closed  the  wound  witli 
out  suturing  the  muscles  or  nerves.  The  wound  healed 
by   first  intention. 

On  examination  I  found  that  he  could  extend  the  hand 
at  the  wrist  by  the  radial  and  ulnar  extensors,  but  exten- 
sion of  the  fingers  was  impossible.     (Fig.  1.) 

Dr.  Wharton  Sinkler  kindly  examined  the  electrical  con- 
dition of  the  muscles  and  reported  as  follows:  "The  ex- 
tensors of  the  left  forearm  above  the  incision  all  respond 
to  the  faradic  current:  below  the  wound  they  do  not.  aw'. 
galvanically  there  is  reaction  of  degeneration  in  the  lower 
portion  of  the  extensor  communis  digitorum.  I  would  in 
fer  from  this  that  the  nerve  had  been  severed  at  the  same 
time  with  the  muscles,  and  that  it  would  be  desirable,  if 
possible,  to  find  the  ends  of  the  nerve  and  suture 
them." 

Dr.  Spiller  made  an  examination  of  the  sensation  and 
fcund'th.^.t  there  was  no  loss,  except  over  a  small  area  just 
below   the  scar. 

On  comparing  his  two  hands  I  found  that  he  had  a  pecu- 
liarity of  the  two  thumbs.  Abduction  of  the  meta 
carpal  bone  of  the  thumb  was  very  poor  on  both  sides,  and 
was  scarcely  greater  on  the  uninjured  than  it  was  on  the 
injured   side. 

Operation,  November  9th.  1900.  I  made  a  vertical  in- 
cision 13cm.  long  in  the  long  axis  of  the  forearm.  After 
reaching  the  muscle  I  was  agreeably  surprised  to  find  tha' 
there  was  no  visible  evidence  of  any  grent  gap  filled  with 
connective  tissue  at  the  point  where  it  had  been  divided 
but  that  there  was  only  a  recognizable  linear  cicatrix.     1 

♦Read  before  the  Philadelphia  N;:nrological  Society.  .A.pril.  IflOi. 


Before  operation,  showmir  the  scar  ot  the  accident,  extension  of  the  wrist 
but  inability  to  extend  the  fingers. 

made  a  blunt  dissection  down  to  the  interosseous  mem- 
brane and  endeavored  to  find  the  prolongation  of  the 
posterior  interosseous  nerve  toward  the  wrist  joint,  but 
failed  to  find  it.  1  did  find,  however,  the  posterior  branch 
going  to  the  common  extensor  of  the  fingers.  This  I  veri- 
fied by  the  battery.  At  the  point  of  injury  the  nerve  was  very 
much  attenuated  below  the  wound  and  immediately  above 
the  wound  it  v%as  considerably  thickened.  1  first  passed  a  su- 
ture both  above  and  below  the  wound,  next  removed  7  mm. 
of  the  nerve,  and  then  approximated  the  freshened  ends  to 
each  other  and  closed  the  wound. 

His  recovery  was  uneventful,  the  highest  temperature 
once  being  99.S''.  He  left  the  hospital  November  17th, 
S  days  after  the  operation.  At  that  time  slight  extension 
of  the  fingers  was  already  beginning  to  be  possible. 

I  tlirected  that,  after  his  return  home,  he  should 
use  the  hot  aiiflcold  ilouchein  alternation, active  and 
pa.-?ive  exercise  and  massage,  and  especially  elec- 
iricity.  beginning  with  the  galvanic  current  and 
later  the  faradic.  .-Ml  this  treatment  he  carefully 
carried  out  with  the  exception  of  the  electricity,  for 
which  there  was  no  apparatus  available.  His  wife 
wrdte  under  the  date  of  January  3rd.  1901 :  "Mr. 
H.'*  arm  has  improved  most  wnnderfuUv.  and  the 


FiRure    'i, 
.\ppearance  of  the  arm  six  months  after  the  operation,  showing  the  gain  in  extension  of  the  fingers. 


June  1,  19J1] 


SECOXDARV  SUTURE  OF  XER\"RS 


r  The  Philadelphia 


1047 


loss  of  muscular  force  is  hardly  noticeable."  A 
letter  received  .May  ist.  lyoi.  transmits  two 
photographs  showing  that  the  lingers  and  wrist  can 
be  extended  in  a  straight  line,  but  he  states  that 
when  the  wrist  is  in  extension  he  is  not  quite  able 
to  extend  the  fingers  completely.  (Fig.  2  shows  the 
same  arm  with  the  wound  and  mv  incision  making 
a  X). 

CASE  2. — Uiviaion  of  iiicdiun  and  iiluiir  iiencx;  sccoinliti'i) 
suture  after  six  months;  entire  reeoiery. 

Chas.  D.,  aet  10.  first  consulted  me  about  the  middle  of 
April,  1892.  In  October,  1891,  he  lost  his  balance,  and,  to  pre- 
vent his  falling,  thrust  his  left  hand  through  a  pane  of 
glass.  The  forearm  was  cut  transversely,  2  cm.  above  the 
pisiform  bone,  and  when  I  .saw  him  showed  a  scar  extend- 
ing from  a  point  2  cm.  from  the  radial  border  of  the  fore- 
arm to  the  internal  edge  of  the  ulna.  IFigs  1  and  5).  Dr.Hor 
ton,of  Peekshill.New  York, where  the  boy  was  at  school, states 
that  the  cut  extended  completely  down  to  the  bone,  se- 
vering all  the  tendons,  and  divided  the  median  and 
ulnar  nerves  and  the  ulnar  artery.  Dr.  Horton  ligated  the 
artery  and  desired  to  suture  the  tendons  and  nerves  at  the 
time  of  the  accident,  but  was  overruled  by  an  older  prac- 
titioner. 

On  examination  I  found  that  he  had  control  over  the 
thumb  and  forefinger  in  flexion  and  extension,  but  they 
were  weak.  The  thumb  could  not  be  apposed  to  the 
other  fingers.  The  three  ulnar  fingers  were  all  in  a  state  cf 
flexion  and  could  not  be  extended  except  partially 
upon  strong  flexion  of  the  wrist.  The  thenar  and  hypothenar 
eminences  were  entirely  wasted.  His  grasp  was  good  if  any- 
thing was  placed  in  the  flexed  fingers.  Sensation  was  witli 
difficulty  ascertained,  but  it  was  evident  that  there  was  no 
absolute  anesthesia  at  any  point.  The  radial  surface  of  the 
little  finger  was  the  dullest,  and  even  there  a  light  touch 
was  perceived,  though  not  sharply.  The  whole  hand  was 
purplish  and  very  cold. 

Operation,  .\pril  21st,  1892.  A  longitudinal  incision  was 
made  over  the  ulnar  nerve,  the  incision  being  extended  fi- 
nally downward  over  the  hypothenar  eminence  about  4 
cm.  below  the  wrist  and  9  cm.  above  the  wrist  The  upper 
bulbous  extremity  of  the  ulnar  nerve  was  easily  found, 
but  was  fused  in  a  mass  of  connective  tissue.  In  order 
to  find  the  distal  end,  the  cut  was  prolonged,  as  stated, 
over  the  hypothenar  eminence.  The  ulnar  nerve  was 
found  there,  not  wasted,  but  above  the  normal  size,  the 
upper  end  being  directly  continuous  w'ith  one  of  the 
superficial  flexor  tendons.  Both  ends  of  this  nerve  were 
loosened,  resected  and  both  stretched,  the  upper  end  es- 
pecially yielding.  With  some  little  tension  the  two  ends 
could  then  be  brought  together  and  were  sutured  with  one 
fine  silk  thread.  Through  the  same  incision  the  median 
nerve  was  then  found  with  some  difficulty.  At  the  level 
of  the  cicatrix,  the  two  ends  had  united,  and  at  the  same 
point  another  flexor  tendon  joined  them  in  a  bulbous 
mass.  I  debated  for  some  time  whether  to  excise  this 
mass  and  attach  the  two  ends  of  the  nerve  together  after 
stretching,  but  finally  decided  to  sever  the  connection  of 
the  tendon  with  the  mass  and  let  the  nerve  alone.  If  the 
nerve  did  not  improve  a  later  resection  could  be  done. 
The  tendons  I  found  in  one  general  cicatricial  mass. 
As  it  was  impossible  to  differentiate  the  individual  ten- 
dons. I  contented  myself  with  elongating  the  deep  flexors 
by  the  method  of  tenotomy  which  I  devised.  (Trans. 
College  of  Physicians,  March  4th,  1891).  The  superficial 
flexors  I  severed  obliquely  and  attached  them  at  a  distance 
by  several  strands  of  catgut  suture.  The  gap  between 
the  two  ends  was  2  cm.  The  hand  was  then  placed  on  a 
splint. 

April  2.'ith.  (fourth  day).  No  opportunity  was  offered  for 
testing  sensation  through  the  dressing, excepting  by  touching 
the  last  two  joints  of  the  fingers  that  were  exposed.  This 
showed  that  the  ring  and  little  fingers  were  devoid  of 
sensation,  the  ring  finger  not  only  on  the  ulnar,  but  on  the 
radial  side.  The  sides  of  the  other  two  fingers  and  the 
thumb  showed  sensation.  To-day  he  perceived  a  prick 
over  the  ulnar  fingers  for  the  first  time.  He  returned  the 
next  day  to  Peekskill. 

.Tune  2nd  (six  weeks  later).  Dr.  Horton  reports  the  cir- 
culation in  the  forearm  good,  motion  of  the  wrist,  thumb 
and  forefinger  normal,  with  the  exception  of  extreme  ex- 
tension of  the  wi-ist.     Sensation  of  the  three  ulnar  fingers 


is  not  very  acute,  but  is  improving.  The  blueness  of  the 
nails  which  was  first  nouced  is  rapidly  passing  away. 

November  25th,  1892,  (seven  montns).  I  examined  him 
to-day.  The  general  condition  of  the  hand  is  good,  the 
ring  and  little  fingers  are  a  little  purplish  and  also  a  little 
cold,  but  not  at  all  to  the  same  degree  as  before  the  opera- 
tion. Sensation  exists  in  all  parts  of  the  hand.  He  can  move 
any  part  of  the  hand,  except  the  ring  and  little  fingers,  and 
even  over  these  two  fingers  he  can  feel  and  localize  a  pen- 
cil point.  Motion  in  the  thumb,  middle  and  index  fingers 
is  excellent,  and  he  can  grasp  objects,  though  not  with 
great  strength.  Flexion  in  the  two  ulnar  fingers  is  lim- 
ited to  the  last  phalanges,  there  being  as  yet  no  flexion  at 
the  knuckles   of  these  fingers. 

Ever  since  the  operation  he  has  been  using  continuously 
massage,  electricity,  hot  and  cold  douche,  active  and  pas- 
sive exercise. 

April  aih,  1893,  (one  year  later.)  His  hand  has  improved 
immensely.  He  can  touch  the  tip  and  the  base  of  each 
finger  with  the  end  of  his  thumb,  can  make  a  fist,  the  fin- 
gers being  in  almost  complete  flexion  and  his  grip  is  good. 
little,  if  any  difference  being  perceptible  in  the  grasp  of  the 
two  hands.  Each  finger  can  be  moved  independently  of  the 
others,  the  motion  of  the  little  and  ring  fingers  now  being 
nearly  normal  and  the  others  quite  so.  Sensation  is  also 
perfect 

December  22nd,  1899.  (seven  years).  I  re-examined  the 
hand  to-day.  His  grip  is  wonderfully  strong,  his  fist  is  as 
last  described.    Practically  the  hand  is  as  useful  as  ever. 

May  15th,  1901  (nine  years).  He  sends  me  the 
accompanying  photographs  (figs.  3  and  4)  just  taken 


Figure  3. 

Nine  years  after  tht.-  operation  -showing  gooi!  fle.vion  of  the  fingers 


1048 


The  P 
Medical 


Hir.ArE?  PHIA"! 

AL   Journal  J 


PANCREATITIS 


[June  1,  1901 


Figure  4, 

Nine  years  after  the  accident,  showing  goofi  extension  ot  the  fingers. 

'to  show  liis  power  of  flexion  and  extension  of  the 
fingers.  Though  he  cannot  quite  close  his  fingers, 
yet  practically  his  hand  is  as  useful  as  a  normal 
hand. 

The  photographs  presented  are  the  best  evi- 
■dence  of  the  excellent  results  of  the  two  operations 
here  recorded,  lioth  hands  were  useless,  practi- 
cally, for  the  same  reason — the  want  of  the  power 
of  extension — but  from  wounds  of  two  entirely  dif- 
ferent nerves.  The  wound  of  the  posterior  inter 
osseous  prevented  extension  at  the  knuckles  by  the 
■common  extensor  of  the  fingers,  while  the  wound 
of  the  ulnar  and  median,  in  the  second  case,  pre 
vented  extension  of  the  last  two  phalanges  by  the 
interosseous  and  lumbrical  muscles.  I  would  call 
attention  to  the  late  periods  (three  and  six  months) 
at  which  the  secondary  suture  was  done.  In  the  first 
case,  also,  the  very  speedy  return  of  motion  was 
surprising.  It  began  within  a  week  after  the  oper- 
ation and  was  practically  complete  within  two 
months.  This  is  the  more  gratifying,  as  the  pos- 
terior interosseous  is  so  small  a  nerve  that  I  doubted 
whether  I  could  find  it  in  so  muscular  a  patient,  or 
if  I  did  whether  it  v.'ould  hold  a  thread.  Suturing  it 
before  excising  the  point  at  which  it  had  been 
•Avound:d  was  cxcclUnl.    Had  I  first  exc-sed,  the  cut 


ends  would  have  been  considerably,  and  possibly, 
irreparably  injured  by  forceps  or  other  means  used 
toseize  them  and  steady themwhile  passingthe  nee- 
dle. So  far  as  Dr.  J.  C.  Merrill,  of  the  Surgeon  Gen- 
eral's Library,  in  Washington,  who  kindly  had  his 
records  looked  over,  or  my  own  references,  show, 
this  is  the  only  case  as  yet  recorded  of  operation 
on  this  nerve. 

The  second  case  shows  how  a  younger 
man,  well  up  in  the  latest  surgical  procedures,  may 
be  hampered  by  an  older  practitioner,  who  has 
not  kept  up  with  the  progress  of  surgery.  Had  Dr. 
Horton's  advice  been  followed  and  tendon  been 
sutured  to  its  appropriate  tendon  and  nerve  to  nerve 
when  the  accident  occurred,  in  all  probabilit)'  no 
later  operation  would  have  been  necessary.  That 
the  operation  has  resulted  so  happily  is  remarkable, 
especially  as  the  tendons  had  to  be  united  hap-haz- 
ard,  one  above  to  one  below,  with  no  possibility  of 
ascertaining  which  belonged  to  which. 


PANCREATITIS.* 

By  A.  W.  MAYO  ROBSON    F.  R. 
of  Leeds,   England. 


C.  S., 


Senior   Surgeon   to   the  General   Infirmary   at   Leeds;   Emeritu.'j 

Professor  of  Surgery  in   the  Yorkshire  College 

of  the  Victoria  University. 

}ilr.  President : — 

I  must  first  thank  you,  sir,  and  the  Council,  for 
the  great  honor  done  me  in  inviting  me  to  come  to 
Baltimore  and  take  part  in  the  proceedings  of  the 
American  Surgical  Association,  which  I  consider 
also  a  privilege  and  a  pleasure. 

Having  expressed  my  views  on  Chronic  Pancre- 
atitis and  its  relation  to  Cholelithiasis  at  the  London 
Polyclinic  in  June,  1900,  and  having  been  invited  tc 
open  the  discussion  on  Diseases  of  the  Pancreas  al 
the  International  Medical  Congress,  in  Paris,  in  Au- 
gust last,  I  almost  regretted  having  promised  to  give 
this  paper  before  the  American  Surgical  Associa- 
tion, lest  it  might  appear  as  if  I  were  simply  giving 
a  rechauffe  of  mj'  views,  but  it  is  astonishing  how 
much  has  recently  been  written  on  the  subject.  Not 
only  have  my  observations  been  confirmed  by  nu- 
merous workers  who  have  expressed  their  views  in 
writing,  but  from  conversations  that  I  have  had 
with  surgeons  who  frequently  operate  in  the  abdo- 
men, I  learn  that  nearly  all  have  had  one  or  more 
cases  which  they  have  diagnosed  as  gall-stones  in 
the  common  duct  for  which  they  had  operated,  but 
finding  a  tumor  of  the  head  of  the  pancreas,  the>- 
had  simply  drained  the  gall-bladder  and  given  a  bad 
prognosis,  thinking  the  disease  to  be  cancer :  and 
only  on  the  complete  recovery  of  the  patients  had 
wonder  been  e.xcited  and  some  other  explanation 
sought.  Moreover,  my  own  experience  has  been  in- 
creased, and  as  the  result  of  further  observations  I 
have  views  to  advance  which  will.  I  hope,  produce 
a  useful  discussion. 

I  do  not  propose  to  weary  the  Association  with 
a  recital  of  many  cases,  a  number  of  which  have 
been  reported  and  can  easily  be  referred  to  if  want- 
ed ;  but  I  should  like  to  give  what  time  I  have  to 
a  brief  consideration  of  the  relation  between  fat  ne- 

*Rea»l  before  the  meeting  M  tlie  American  Snrgic;il  .Association  in  Bait: 
move,  Ma>-,  looi.     Published  from  mauuscripl  furnished  by  the  author. 


June  1,  19J1] 


PANCREATITIS 


TThe  Philadelphia 
L  Medical   Journal 


1049 


crosis  and  hemorrhage — to  the  relation  of  gall-stones 
and  pancreatic  disease  and  in  the  treatment  of 
pancreatitis  generally. 

It  is  a  curious  fact  that,  although  surgeons  have 
been  removing  gall-stones  from  the  common  duct 
for  a  little  over  100  years,  i.  e.,  since  Courvoisier's 
first  successful  choledochotomy,  in  1790,  and  that, 
although  the  subject  of  jaundice  dependent  on  ob- 
structed common  duct  received  great  attention  from 
physicians  many  years  ago,  yet  until  comparatively 
recently,  it  never  seemed  to  dawn  on  the  minds  of 
clinical  observers,  that  whatever  obstructs  the  com- 
mon bile  duct  at  its  lower  end,  must  also,  of  neces- 
sity, lead  to  an  obstruction  in  the  pancreatic  duct ; 
and  although,  since  the  description  of  the  disease 
by  Charcot  as  Intermittent  Hepatic  Fever,  infective 
and  suppurative  cholangeitis  have  been  well  recog- 
nized by  pathologists,  yet  infective  and  suppurative 
catarrh  of  the  pancreatic  ducts  even  now  has  re- 
ceived no  place  in  the  medical  text-books;  which 
means,  in  reality,  that  all  diseases  of  the  pancreas 
except  those  producing  gross  organic  changes,  such 
as  cancer,  acute  pancreatitis,  cysts  and  calculi,  have 
been  practically  ignored  :  yet  we  know,  both  by  post- 
mortem observation  and  by  surgical  experience,  that 
under  similar  conditions  the  pancreatic  ducts  par- 
ticipate in  the  same  inflammatory  processes  as  the 
bile  ducts. 

When  the  common  bile  duct  is  obstructed,  the 
objective  sign  of  jaundice  at  once  demonstrates  the 
fact ;  hitherto,  however,  no  pathognomonic  sign  has 
been  discovered,  which  will  show  conclusively  that 
the  pancreatic  ducts  are  occluded,  unless  it  be  the 
extremely  rapid  loss  of  weight.  As  is  now  well 
known,  the  presence  of  fat  necrosis  does  afford  some 
olue,  and  a  very  important  one,  hitherto  only  dis- 
covered, however,  when  the  abdomen  is  opened  ;  but 
even  for  fat  necrosis  to  take  place,  there  must  prob- 
ably have  been  some  escape  of  the  fat  splitting  fer- 
ment from  the  gland,  and  therefore  the  affection  of 
the  pancreas  must  be  somewhat  advanced  before 
the  sign  is  evident.  Glycosuria,  lipuria,  and  fat  in 
the  stools  occur  too  seldom  to  be  of  much  use  in  the 
diagnosis  of  pancreatic  disease,  though  when  pres- 
ent they  are  of  great  diagnostic  importance.  I  think 
that  physiological  chemistry  may,  perhaps,  help  us 
in  the  diagnosis,  and  though  our  observations  are 
not  by  any  means  yet  complete.  I  hope  that  some 
researches,  at  present  being  conducted  on  cases  un- 
der my  care,  by  my  friend,  Mr.  P.  J.  Cammidge. 
Pathologist  to  the  West  Riding  County  Council, 
may  prove  of  practical  use,  and  I  have  some  grounds 
for  hope  that  by  an  examination  of  the  urine  alone 
or  of  the  urine,  the  blood  and  the  ffeces,  we  may 
have  some  assistance  in  the  diagnosis  of  these  dif- 
ficult cases. 

The  pancreas  is  a  racemose  gland,  well  supplied 
with  blood,  and,  unlike  the  parotid,  the  lobules  of 
which  are  well  supported  by  fibrous  partitions,  its 
tissues  are  comparatively  soft  in  consistence  and 
easily  bruised ;  so  that  although  it  is  placed  in  the 
most  favorable  position  for  protection  from  direct 
injurv,  yet  a  slight  injury  takes  more  effect  on  it 
than  on  many  other  firmer  organs,  and  we  have 
knowledge  of  pancreatitis  resulting  from  blows  in 
the  epigastrium  apparently  trifling  in  character.  In  a 
case    that     I     saw     several     vears    ago,    a    butler 


slipped  and  fell  forward  against  a  knife  board  pro- 
jecting from  the  end  of  the  table  at  which  he  was 
working;  the  blow  was  comparatively  slight,  and 
the  man  did  not  even  fall  to  the  ground ;  but  acute, 
so-called  hemorrhagic  pancreatitis  followed,  and  the 
patient  died ;  an  exploration  for  peritonitis  followed 
by  an  autopsy  revealing  the  true  cause  of  death. 

Probably  slight  injury  to  the  pancreas  often  oc- 
curs in  abdominal  operations  for  gall-stones  in  the 
common  duct,  when  it  is  sometimes  necessary  to 
manipulate  and  rather  forcibly  draw  the  parts  in 
the  neighborhood  of  the  pancreas  forward  in  order 
to  view  the  common  duct  when  sutures  are  applied. 
Such    a  case    has,  indeed,    been    related    recently. 

When  it  is  borne  in  mind  that  the  pancreatic  duct 
opens  along  with  the  common  bile  duct  into  the  sec- 
ond part  of  the  duodenum,  a  channel  usually  con- 
taining septic  organisms,  especially  when  it  is  the 
seat  of  catarrh,  to  which  it  is  especially  liable,  it  is 
not  a  matter  for  surprise  that  pancreatitis  should  be 
met  with,  but  rather  that  it  should  not  occur  more 
frequently. 

As  in  the  liver,  we  may  have  simple,  infective,  and 
suppurative  catarrh  of  the  excretory  ducts,  as  well 
as  inflammation  of  the  interlobular  tissues,  so  in 
the  pancreas,  we  undoubtedly  have  similar  diseases, 
which  are  only  awaiting  our  recognition  during  life 
by  greater  diagnostic  skill.  As  bearing  on  this,  the 
pathologist  of  a  large  hospital  has  told  me  that  in 
cases  of  obstruction  of  the  common  duct  by  gall- 
stones, he  has  noticed  that  pus  can  usually  be  ex- 
pressed from  Wirsung's  duct,  and  this  has  been  con- 
firmed by  others.  I  feel  sure  that,  as  our  means  of 
diagnosis  become  more  perfected,  diseases  of  the 
pancreas,  both  functional  and  r;rganic,  will  be  more 
frequently  recognized  and  awarded  their  deserved 
positions  in  medicine. 

Since  my  countryman,  Mr.  Walker,  of  Peterbor- 
ough, showed  that  the  absence  of  the  pancreatic  se- 
cretion from  the  intestine,  even  though  bile  was 
present  in  the  intestinal  canal,  led  to  pale  colored 
motions,  very  little  attention  has  been  paid  to  this 
sign,  although  much  has  been  written  about  the 
presence  of  sugar  in  the  urine  in  pancreatic  disease ; 
yet,  glycosuria  is,  in  my  experience,  a  very  rare  phe- 
nomenon in  this  relationship,  and  in  fact  it  only  oc- 
curs when  there  is  great  destruction  of  pancreatic 
tissues,  as  in  extensive  cirrhosis  or  in  extensive  ma- 
lignant disease. 

Fat  in  the  stools  is  more  common,  but  not  by  any 
means  universal,  and  lipuria  is  very  uncommon. 

I  have  seen  cases  of  discomfort,  with  some  swell- 
ing at  the  epigastrium,  associated  with  dyspepsia 
and  ague-like  attacks,  but  without  jaundice,  or  with 
onlv  very  slight  jaundice,  which  I  thought  might  be 
explained  on  the  hypothesis  of  infective  inflamma- 
tion of  the  pancreatic  duct,  the  cases  having  cleared 
up  under  general  treatment.  I  have  also  seen  the 
same  symptoms  associated  with  more  pain,  irregu- 
lar fever,  more  marked  swelling  and  tenderness  over 
the  pancreas  and  discharge  of  pus  by  the  bowel  from 
time  to  time,  but  without  any  collection  sufficiently 
large  to  form  a  distinct  abscess.  I  related  a  case  like 
this  in  the  lecture  previously  referred  to,  but  the 
recoverv  of  the  patient  made  the  absolute  certainty 
of  the  diagnosis  doubtful,  though  an  examination 
under  an  anesthetic  enabled  a  swelling  of  the  pan- 


men       The  Philadelphia"! 
■"-'o*-'       Medical  Joubxal    J 


PANCREATITIS 


(June  l.  ma 


creas  to  be  felt,  and  this  was  confirmed  by  palpita- 
tion of  the  abdomen  at  a  later  stage,  when  tender- 
ness was  less  marked. 

I  thought  this  case  was  probably  a  subacute  pan- 
creatitis, associated  with  suppurative  catarrh  of  xh  ■ 
pancreatic  ducts  analogous  to  suppurative  cholan 
gitis. 

The  essentia!  and  immediate  cause  of  the  variou? 
forms  of  pancreatitis  is  bacterial  infection,  this  hav- 
ing been  positively  proved,  both  clinically  in  the  hu 
man  subject,  and  experimentally  in  the  lower  ani- 
mals :  but.  as  in  inflammatory  affections  of  the  live- 
and  bile-ducts,  we  look  for  extrinsic  causes,  so  ir 
pancreatic  diseases  we  find  biliary  and  pancreati  ■ 
lithiasis,  injury,  gastro-duodenal  catarrh,  ulcer  aTn'. 
cancer  of  the  stomach,  pylorus,  or  duodenum,  aiu! 
zymotic  diseases,  such  as  typhoid  fever  and  influ- 
enza, to  be  determining  factors;  though  in  somj 
cases  pancreatitis  has  come  on  suddenly  in  person^ 
in  robust  health,  and  the  determining  cause  has  beer 
beyond  recognition. 

Though  the  infection  may  arise  from  the  blood 
as  in  pya?mia,  or  by  direct  extension  from  the  neigli 
boring  tissues,  as  in  ulcer  of  the  stomach,  yet  tht- 
most  usual  channel  is  through  the  duct,  as  in  the 
cases  arising  from  gall-stones  in  the  common  duct 
and  from  gastro-duodenal  catarrh,  that  I  related  in 
my  lecture. 

The  association  of  gall-stones  with  chronic  pan- 
creatitis, was  absolutely  forced  on  my  mind  by  the 
frequency  with  which  I  found  inflammatorj-  en- 
largement of  the  head  of  the  pancreas  when  operat- 
ing for  gall-stones  in  the  common  duct:  the  first  in- 
stance of  the  kind  having  been  observed  by  me  in 
1892  in  a  case  on  which  I  operated  for  deep  jaun- 
dice, supposed  to  be  due  to  common  bile  duct  ob- 
struction, but  in  which  I  found  cirrhosis  of  the  head 
of  the  pancreas.  Since  that  time  I  have  operated  on 
a  considerable  number  of  cases  (over  20).  and 
though  only  one  patient  has  died  directly  from  the 
operation,  in  the  other  two,  one  a  cholecystenteros- 
tomy.  and  the  other  a  cholecystotomy,  death  oc- 
curred within  a  few  months,  and  the  correctness  of 
the  diagnosis  was  verified  both  by  autopsy  and  by 
a  microscopic  section  of  the  diseased  pancreas.  I 
am  able  to  show  the  pancreas  from  the  last  case, 
and  also  a  microscopic  section  of  the  specimen.  I' 
is  a  simple  matter  to  infer,  that  if  common  duct 
cholelithiasis  can.  give  rise  to  chronic  pancreatitis, 
it  will  also  be  likely  to  induce  the  subacute  and  acute 
forms  of  the  disease,  and  this  is,  I  think,  now  clearlv 
proved.  In  the  Brit.  Med.  .Tour,  for  Nov.  14,  1896,  Dr. 
Kennan  described  a  case  of  acute  pancreatitis,  end- 
ing fatally  on  the  second  day,  in  a  woman  of  38. 
and  at  the  post-mortem  examination  a  large  number 
of  gall-stones  were  found  in  the  common  duct,  one 
being  partly  extruded  into  the  duodenum. 

Korte  (Deutsche  Chir..  Stuttgart,  1898)  notes  tha' 
lesions  of  the  pancreas  are  frequently  associated 
with  diseases  of  the  bile  ducts.  Lancereaux  (Traitc 
dcs  Maladies  de  la  Foic  et  du  Pancreas.  1898)  mentions 
the  possibility  that  a  gall-stone  impacted  in  the  di- 
verticulum of  \"ater  may  occlude  the  pancreatic  duct 
and  produce  conditions  favoring  the  entrance  of  or- 
ganisms into  that  duct.  Dr.  Opie.  in  a  very  instruct- 
ive and  interesting  paper  in  the  American  Journal  of 
the    Medical  Sciences    for    Jan.,  190!.    p.  27.  relate^ 


cases,  one  of  Dr.  Osiers  and  several  from  various 
sources,  showing  the  relationship  between  pancre- 
.itic  and  gall-stone  troubles.  Mr.  Gilbert  Barling 
{B.  M.  J.,  Dec.  22,  1900)  has  given  several  interest- 
ing cases  bearing  out  very  full}-  the  views  expressed 
above.  In  some  of  my  cases,  gall-stones  were  not 
found,  but  only  old  and  firm  adhesions,  with  an  ante- 
cedent history  of  paroxysmal  attacks,  followed  by 
jaundice,  which  afforded  strong  presumptive  evi- 
dence that  cholelithiasis  had  been  present  at  some 
time ;  and  it  seems  quite  possible  that  temporary 
occlusion  of  the  common  duct,  with  the  damming 
back  of  infected  secretions  or  with  injurj-  to  the 
ducts,  may  set  up  a  pancreatitis,  which  may  itself 
then  cause  compression  of  the  common  bile  duct 
and  so  lead  to  a  perpetuation  of  the  obstructive 
jaundice  and  other  troubles,  started  in  the  first  in- 
stance by  impacted  gall-stone. 

Fat  Necrosis. — By  fat  necrosis  is  understood 
splitting  up  of  the  fat  into  fatty  acids  and  glycerin, 
the  latter  is  absorbed,  but  the  acids  being  insoluble 
remain  in  the  cells  and  unite  with  calcium  salts, 
forming  yellowish  white  patches  of  various  sizes  in 
the  sub-peritoneal  fat  and  in  the  omentum,  mesen- 
tery, etc.  It  was  first  described  by  Balser,  in  1882 
but  has  been  since  investigated  by  Langerhans.  Hil- 
debrand,  Dettiner,  Milisch,  \\"illiams.  Flexner.  Opit. 
and  others.  Experiments  by  Opie.  who  ligated 
the  pancreatic  ducts  in  the  cat,  go  to  show  that  wide- 
spread fat  necrosis  maj-  be  expected  to  follow  verA- 
rapidly. 

Fat  necrosis  is  commonly  found  in  association 
with  pancreatitis  and  other  diseases  of  the  pancreas, 
and  the  relationship  between  the  two  conditions  has 
given  rise  to  much  speculation :  but  the  facts  that 
fat  necrosis  is  not  found  in  all  acute  pancreatic  dis- 
eases, and  that  it  has  been  noted  during  abdominal 
operations  for  other  ailments,  and  in  autopsies  whert 
there  was  no  suspicion  of  pancreatitis,  appear  to 
show  that  the  condition  giving  rise  to  it  is  not  e&- 
sentialh-  a  pancreatitis,  as  suggested  by  certain  au- 
thors ;  though  these  facts  do  not  disprove  that  tm 
necrosis  is  essentially  due  to  interference  with  the 
discharge  of  pancreatic  secretion,  and  so  to  an  es- 
cape of  pancreatic  fluid  into  the  tissues,  whence  it 
may  be  taken  up  by  the  lymphatics  or  blood  vessels. 
Flexner  (Contribution  to  the  Science  of  Medicine, 
Johns  Hopkins  Press.  Baltimore.  1900)  and  others,  re- 
gard the  fat  necrosis  as  the  effect  of  the  fat  splittinjf 
ferment  of  the  pancreatic  fluid,  which  has  in  some 
way  escaped  from  the  duct  into  the  surrounding  tis- 
sues. It  is  difficult  at  first  sight  to  explain  the 
patches  of  fat  necrosis  occurring  at  a  distance  from 
the  pancreas,  for  instance,  in  the  pericardium,  un- 
less it  be  by  absorption  of  the  ferment  and  its  diffu- 
sion by  means  of  the  lymphatics  ;  though  this  is  easy 
to  understand,  and  undoubtedly  does  explain  the 
disintegration  of  the  fatly  tissues  immediately  sur- 
rounding the  pancreas  and  extending  by  continuity 
first  to  adjoining,  and  then  even  to  distant  parts  in 
the  abdomen  and  thorax. 

Hemorrhage  in  Pancreatic  Diseases. — It  is  well 
known  that  local  hemorrhages  into  the  pancreas  may 
occur  apart  from  injury  and  apart  from  any  general 
hemorrhagic  tendency,  and  that  although  they  may 
be  recovered  from,  as  shown  by  the  remains  of  ex- 
travasated  blood  in  the  gland  in  persons  dying  from 
other  diseases ;  yet  such  spontaneous  hemorrrhages 


June  1,  1901] 


PANCREATITIS 


TThe  Philadelphia 
L  Medical   Journal 


IO5I 


may  lead  to  death  from  collapse  either  immediately 
or  after  some  hours.  Curiously,  this  may  occur  in 
persons  apparently  in  good  health  and  without  any 
premonitory'  signs  on  which  a  diagnosis  can  be 
based,  the  only  symptoms  at  the  time  being  those  of 
collapse  with  dyspnea  and  feeblepulse.  It  is  alsowell 
recognized  that  a  hemorrhagic  condition  may  co- 
exist with  cancer  of  the  head  of  the  pancreas.  Some 
years  ago  I  thought  this  to  be  altogether  dependent 
on  the  cholemia,  until  increased  experience  in  oper- 
ations on  deeply  jaundiced  subjects  has  taught  me 
that  there  is  much  less  danger  of  serious  hemor- 
rhage in  patients  jaundiced  from  gall-stones  than  in 
those  where  the  jaundice  depends  on  pancreatic  dis- 
ease. In  several  cases  of  cancer  of  the  pancreas  on 
which  I  have  operated,  the  bleeding  has  been  the 
immediate  cause  of  death  ;  in  one  aged  subejct  es- 
pecially this  was  well  marked,  after  a  cholecystot- 
omy  for  the  relief  of  jaundice.  Death  occurred  on 
the  third  day  from  collapse,  and  at  the  autopsy  there 
was  found  extensive  effusion  of  blood  away  from 
the  site  of  operation  and  behind  the  peritoneum, 
extending  into  the  loins  around  the  kidneys,  and 
into  the  cellular  tissue  beneath  the  diaphragm,  the 
blood  being  in  sufficient  quantity  to  account  for 
death  ;  and  though  the  bleeding  had  evidently  arisen 
from  the  pancreas,  there  was  no  manifest  vascular 
lesion  to  account  for  the  hemorrhage.  In  another 
case,  sent  to  me  in  i8S8  by  Professor  Clifford  All- 
butt,  a  cholecj^stotomy  was  followed  by  persistent 
oozing  of  blood  from  the  interior  of  the  gall-blad- 
der and  from  the  stitch  punctures,  which  resisted  all 
then  known  remedial  measures  in  the  way  of  styp- 
tics, pressure,  transfusion,  etc.,  and  proved  fatal  on 
the  9th  day.  In  neither  of  these  cases  was  there  anv 
peritonitis  or  cause  other  than  the  hemorrhage  to 
account  for  death.  Now,  in  another  patient  equally 
deeply  jaundiced,  that  I  saw  with  my  colleague.  Dr. 
Churton,in'89,  but  in  which  the  disease  was  depend- 
ent on  cancer  of  the  common  bile  duct  above  the 
entrance  of  the  pancreatic  duct,  there  was  no  hem- 
orrhage, although  the  patient  survived  several 
weeks  and  died  from  exhaustion  due  to  the  disease 
and  to  the  suppurative  cholangeitis  accompanying  it. 
I  could  give  many  similar  comparisons  showing  the 
difference  between  the  behaviors  of  the  blood  in  the 
two  classes  of  cases.  Before  operating  on  these 
cases,  I  now  always  administer  chloride  of  calcium 
in  30  to  60  grain  doses  thrice  daily  for  from  24  to  48 
hours  previous  to  operation,  and  by  enema  in  60 
grain  doses  thrice  daily  for  48  hours  afterwards  :  this 
is  nearly  always  successful  in  correcting  the  hemor- 
rhagic tendency.  The  following  case  illustrates  as 
well  as  any  case  could,  how  the  failure  to  give  it 
after  operation  led  to  hemorrhage,  and  how  its  ad- 
ministration in  heroic  doses  apparently  saved  the 
patient : 

Cholelithiasis:  deep  jaundice:  chronic  pancreatitis:  Duo- 
denocholedochotomy:  hemorrhage;  recovery.  Reported 
by  Mr.  Gough..  House  Surgeon.  Mrs.  M.  E.  G..  aged  3S.  was 
admitted  to  the  Leeds  General  Infirmary  on  January  23.  '01, 
■with  the  history  that  she  had  had  typhoid  fever  in  Sep- 
tember. Is99,  and  that  she  had  never  been  quite  well 
since.  Shortly  afterwards  she  began  to  suffer  from  biliary 
colic,  though  she  had  never  been  jaundiced  till  six  months 
before  admission,  from  which  time  jaundice  had  never  left 
her.  On  December  24th.  1900.  she  became  much  worse, 
and  had  very  severe  paroxysmal  pain  accompanied  by  shiv- 
ering and  profuse  sweats.  From  that  time  she  lost  weight 
very  rapidly  and  the  jaundice  deepened.  On  admission 
the  liver  could  be  felt  below  the  ribs  and  there  was  a  dis- 


tinct fulness  on  deep  palpation  in  the  region  of  the  pan- 
creas. From  January  21st  to  the  31st  she  took  chloride  of 
calcium  in  20  gr.  doses  thrice  daily. 

January  31st  duodeno-choledochotomy  was  performed. 
There  was  very  little  bleeding.  A  stone  nearly  as  large 
as  a  pigeons'  egg  was  removed  from  the  ampulla  of  'Vater, 
which  was  laid  open  over  a  director  introduced  through  the 
papilla  at  its  opening  into  the  duodenum.  The  head  of 
the  pancreas  was  felt  to  be  much  enlarged  and  hard.  The 
incision  into  the  ampulla  was  not  sutured,  but  through  it 
the  common  bile  duct  very  much  dilated  was  explored  by 
the  finger.  The  anterior  wound  in  the  duodenum  was  then 
sutured  and  the  abdominal  wound  closed.  A  drainage 
tube  was  inserted  through  a  stab  wound  in  the  right  loin. 
The  patient  inadvertently  did  not  have  chloride  of  cal- 
cium given  in  the  nutrient  enemata  as  is  usual  in  these 
cases.  She  did  well  till  the  morning  of  the  2nd  of 
February,  when  the  nurse  noticed  at  3  A.  M.  that  the 
dressings  were  soaked  with  bright  blood. 

The  drainage  wound  was  exposed  but  no  hemorrhage 
was  occurring  there.  On  examining  the  abdominal  incision 
blood  was  seen  to  be  slowly  oozing  from  it  and  the  stitch 
punctures.  One  drachm  of  chloride  of  calcium  was  at  once 
administered  by  the  mouth  and  three  stitches  were  removed, 
the  surface  of  the  wound  was  then  seen  to  be  oozing  all 
over.  It  was  packed  with  gauze  soaked  in  tincture  of 
hammamelis  and  a  firm  dressing  applied.  1  drachm  of 
chloride  of  calcium  was  given  again  in  two  hours  and  af- 
terwards repeated  in  30  gr.  doses  every  two  hours 
six  limes,  it  being  then  given  thrice  daily.  There  was 
no  recurrence  of  hemorrhage  and  the  patient  made  an  un- 
interrupted recovery.  The  drainage  tube  was  removed  on 
February  4th  and  she  returned  home  within  the  month. 

In  this  case  Mr.  Camraidge  found  the  characteristic  crys- 
tals in  the  urine  and  an  examination  of  the  blood  showed 
a  very  marked  diminution  in  the  blood  plates. 

These  arguments  are  brought  forward  to  show 
that  there  is  some,  as  yet  ill  understood,  relation  be- 
tween pancreatic  disease  and  serious  hemorrhage, 
but  I  cannot  help  thinking  that  it  is  a  mistake  to 
allow  this  fact  to  influence  our  views  on  the  path- 
ology of  inflammation  by  adopting  permanently 
the  name  hemorrhagic  pancreatitis  in  cases  where 
there  has  been  no  bleeding  or  no  more  than  occurs 
frequently  in  inflammatoin  of  other  parenchyma- 
tous organs,  though  it  may  be  useful  to  retain  the 
name  for  those  cases  of  pancreatitis  associated  with 
well  marked  interstitial  hemorrhage,  in  which 
the  disruption  of  the  gland  by  the  bleeding  may  be 
the   direct  cause  of  the  inflainmation. 

I  have  recently  read  a  very  interesting  paper  in 
the  Boston  City  Hospital  Report,  for  December, 
1900.  by  Dr.  F.  B.  Lund,  entitled :  "Acute  Hemor- 
rhagic Pancreatitis  and  its  Surgical  Treatment : 
with  a  Report  of  Six  Cases,"  yet  in  remarking  on  the 
second  case,  the  author  says:  "This  case  is  notable 
for  the  absence  of  pancreatic  hemorrhage."  In  the 
fifth  case  there  was  the  evacuation  and  drainage  of 
a  small  abscess  of  the  pancreas  and  no  evidence  of 
hemorrhage,  and  in  the  sixth  case,  also,  there  was 
apparently  no  evidence  whatever  of  hemorrhage. 
The  title  of  the  paper  is  surely  a  misnomer  ;  yet 
other  authors  adopt  the  same  nomenclature  in  the 
same  indefinite  manner.  Dr.  Flexner  produced  an 
inflammation  of  the  pancreas  associated  with  hem- 
orrhage within  48  hours,  by  injecting  the  Bacillus 
pyocyaneus  and  the  B.  diphtheria'  into  the  pancre- 
atic duct  in  animals  {Contribiilions  to  the  Science 
of  Medicine,  Baltimore,  1900,  p.  743).  Hlava  also 
produced  hemorrhagic  pancreatitis  by  injecting  the 
B.  diphtheriie  into  the  pancreas.  Hildebrand  (Cen- 
tralblntt  fuer  Chinirgic,  1894,  band  22,  p.  297)  sug- 
gested that  the  hemorrhage  in  acute  pancreatitis 
was  due  to  trypsin. 

The  facts  concerning  hemorrhage  in  diseases  of 


3  052 


The  Philadelphia"] 
Medical    Journal  J 


PANCREATITIS 


[June   1,   1901 


the  pancreas  and  the  conclusions  we  have  come  to, 
after  carefulh-  considering  the  whole  subject,  are: 
(i)  That  in  certain  diseases  of  the  pancreas  there 
is  a  general  hemorrhagic  tendency  which  is  much  in- 
tensified by  the  presence  of  jaundice.  (2)  That 
hemorrhage  may  apparently  occur  in  the  pancreas 
unassociated  with  inflammation,  or  with  jaundice, 
or  with  a  general  hemorrhagic  tendency.  (3)  That 
both  acute  and  chronic  pancreatitis  can  and  do  fre- 
quently occur  without  hemorrhage.  (4)  That  some 
cases  of  pancreatitis  are  associated  with  local  hem- 
orrhage. 

From  these  conclusions,  I  think,  therefore,  that 
inflammations  of  the  pancreas  may  be  more  conve- 
niently and  scientifically  classified  like  inflamma- 
tion of  other  organs,  as  acute,  subacute,  and  chron- 
»c,  and  that  there  is  no  reason  to  use  the  term 
hemorrhagic  pancreatitis,  except  as  a  variety  of 
acute  pancreatitis,  the  hemorrhage  being  merely  an 
accident  in  the  course  of  the  disease. 

It  seems  to  me  worth  while  considering  if  the  gly- 
cerine set  free  in  the  tis.sues  by  the  fat  necrosis  mav 
possibly  be  the  real  cause  of  the  local  hemorrhagic 
tendency  in  pancreatic  affections,  though  our  ob- 
servations are  not  yet  sufficiently  far  advanced  to 
say  that  this  is  an  adequate  explanation  of  all  the 
cases.  While  inquiring  into  the  subject,  I  have  be- 
come acquainted  with  certain  very  important  facts 
bearing  on  the  question.  If  glycerine  in  very  small 
amount  be  injected  into  mice,  it  rapidly  produces 
hematuria  (Cammidge)  or  hemoglobinuria,  due  to 
destruction  of  the  blood  corpuscles ;  and  in  certain 
cases  in  which  glycerine  has  been  used  by  gynecol- 
ogists for  the  purpose  of  inducing  abortion  and  in 
others  where  it  has  been  injected  along  with  iodo- 
form for  the  treatment  of  tubercular  disease  in  the 
human  subject,  blood  has  also  been  noticed  in  the 
urine,  sometimes  in  large  quantity. 

The  blood  conditions,  about  to  be  mentioned,  may 
possibly  serve  to  explain  the  general  hemorrhagic 
tendency  in  cases  of  chronic  pancreatitis  associated 
with  jaundice,  but  behind  this  there  must  be  some 
other  cause  not  yet  discovered.  Can  it  be  due  to 
something  absorbed  from  the  pancreas  into  the 
blood,  which  only  acts  when  the  absorption  has 
been  active  over  a  prolonged  period  of  time.  This 
matter  seems  to  me  to  be  worth  attention,  and  it 
should  be  possible  to  prove  or  disprove  it  by  experi- 
mental work. 

In  discussing  these  matters  with  Mr.  Cammidge. 
he  suggested  that  only  a  small  amount  of  glycerine 
could  obtain  access  to  the  blood  as  the  result  of  fat 
necrosis.  When  the  glycerine  is  set  free  and  the 
fatty  acids  are  saponified,  it  would  become  oxidized 
just  like  any  other  alcohol,  and  the  oxidation  pro- 
ducts for  which  one  would  look  would  be  an  alde- 
hyde, but  the  tests  emploved  failed  to  demonstrate 
this. 

In  the  course  of  these  investigations,  however,  it 
was  found  that  if  the  urine  was  boiled  for  a  short 
time  with  an  oxidizing  agent  and  then  the  phenyl 
hydrazine  test  performed,  an  abundant  crop  of  deli- 
cate yellow  needles  arranged  in  sheaves  and  ro- 
settes was  produced.     (Specimen  shown.) 

The  untreated  urine  gave  no  such  result ;  norma! 
urine,  morbid  urines  from  gout,  etc.,  and,  most  im- 
portant, bilious  urine  from  patients  suffering  froin 
simple   catarrhal   jaundice,   also  gave   negative   re- 


sults. I  mav  say  also  that  some  experiments  per- 
formed on  bile  and  bile  salts  yielded  none  of  the 
crystals. 

The  number  of  cases  is  too  few  to  allow  one  to 
more  than  suggest  that  it  may  prove  useful  as  a 
diagnostic  test  in  this  class  of  cases,  but  it  is  also 
interesting  to  note  that  on  one  day  I  operated  on 
two  patients  deeply  jaundiced,  in  one  of  which  there 
was  chronic  pancreatitis,  whereas  in  the  other,  al- 
though there  was  a  small  gall-stone  in  the  common 
duct,  there  was  no  manifest  enlargement  or  disturb- 
ance of  the  pancreas.  Both  urines  were  submitted 
to  Mr.  Cammidge,  and  without  his  knowing  the  his- 
tory of  either  case  he  sent  me  word  that  the  urine 
in  the  latter  case  (where  there  was  no  pancreatitis) 
gave  negative  results  so  far  as  the  crystals  were 
concerned,  and  that  in  the  former  case,  just  de- 
scribed at  length,  he  was  able  to  obtain  abundant 
crystals. 

An  examination  of  the  blood  has  also  been  made 
in  a  number  of  cases,  with  a  view  to  ascertain  if  any 
information  can  be  found  to  explain  the  hemor- 
rhagic tendency.  Although  glycerine  may  be  pres- 
ent, Mr.  Cammidge  knew  of  no  test  sufficiently  deli- 
cate to  demonstrate  its  presence  in  the  blood. 

A  histological  examination  of  the  blood  showed 
in  two  of  the  cases  a  very  striking  diminution  in  the 
number  of  blood  plates  as  compared  with  the  nor- 
mal blood.  This  diminution  of  the  blood  plates, 
whatever  may  be  its  cause,  may  possibly  explain 
the  general  hemorrhagic  tendency  in  these  cases. 

Treatment  of  Aeute  Panercatitis. — In  acute  infective 
pancreatitis,  treatment  practically  resolves  itself 
into  that  of  peritonitis,  commencing  in  the  superior 
abdominal  region.  The  pain  at  the  onset  is  so  acute 
as  to  necessitate  the  administration  of  morphia,  and 
the  collapse  will  probably  demand  stimulants, 
which,  on  account  of  the  associated  vomiting,  may 
have  to  be  given  by  enema.  In  the  early  stages  the 
symptoms  are  usually  so  indefinite  that  the  indica- 
tions for  surgical  treatment  are  not  clear  enough  to 
warrant  operation,  and  until  the  collapse  has  passed 
ofif  no  surgical  procedure  would  generally  be  justi- 
fiable. The  stimulation  of  intestinal  obstruction 
will  probabl}'  lead  to  efforts  to  secure  an  evacuation 
of  the  bowels  and  relief  of  the  distension. 

Just  as  in  a  perforative  or  gangrenous  appendici- 
tis, an  early  evacuation  of  the  septic  matter  is  nec- 
essary to  recovery,  so  in  this  equally  lethal  afltec- 
tion,  an  carh'  exploration  from  the  front  through 
the  middle  line  above  the  umbilicus,  or  from  be- 
liind  through  the  left  costo-vertebral  angle  is  de- 
manded, in  order  to  evacuate  the  septic  material 
and  adopt  free  drainage. 

The  after  treatment  should  be  chiefly  directed  to 
combating  shock  and  keeping  up  the  strength  until 
the  inateries  morbi,  both  local  and  general,  can  be 
thrown   off. 

Even  if  no  pus  be  found,  no  harm  should  accrue 
by  such  an  exploration,  which  can  be  made  in  a  few 
minutes  through  a  very  small  incision  in  the  middle 
line  above  the  umbilicus,  if  necessary  with  the  aid 
of  cocaine  anesthesia.  After  establishing  the  diag- 
nosis by  the  anterior  small  incision  and  the 
introduction  of  a  finger,  the  posterior  incision,  which 
must  be  a  free  vertical  one  in  the  left  costo-vertebral 
angle,  so  as  to  permit  the  insertion  of  the  whole 
hand  if  thought  desirable,  will  enable  the  diseased 


June  1,  19  Jl] 


PANCREATITIS 


TThe  Philadelphia 
L  MEDICAL  Journal 


1053 


organ  to  be  very  freely  examined  and,  if  necessary, 
drained  for  the  evacuation  of  pus  and,  gangrenous 
material,  thus  involving  no  risl-;  to  the  general  peri- 
toneal cavity  and  little  danger  of  retained  septic 
matter,  as  the  drainage  will  be  a  dependent  one. 

Treatment  of  Subacute  Pancreatitis. — The  subacute 
form  of  pancreatitis  is  more  amenable  to  treatment, 
as  the  indications  are  so  much  more  definite  and 
there  is  more  time  for  careful  consideration ;  and 
though  it  has  usually  only  been  attacked  when  an 
abscess  has  formed  and  is  manifestly  making  its 
way  to  the  surface,  }'et  there  is  no  reason  why  in 
some  cases  surgical  treatment  should  not  be  adopted 
at  an  earlier  stage.  As  in  the  acute  condition,  mor- 
phia may  be  required  to  relieve  the  collapse  and 
support  the  strength. 

iJiitension,  if  present,  may  also  demand  atten- 
tion, and  may  ha\'e  to  be  relieved  by  lavage  of  the 
stomach  and  turpentine  enemata  or  by  the  admin- 
istration of  calomel  by  the  mouth.  Calomel  is  also 
of  benefit  by  acting  as  an  intestinal  antiseptic ;  for 
which  purpose  it  may  be  given  in  small  repeated 
doses  or  in  doses  of  five  grains,,  followed  by  a  saline 
aperient.  As  soon  as  the  constipation  is  relieved, 
diarrhea  is  apt  to  supervene,  when  salol  and  bismuth 
with  small  doses  of  opium  may  be  given.  If  surgi- 
cal treatment  is  decided  on,  a  median  incision 
above  the  umbilicus  will  enable  the  operator  to  pal- 
pate the  pancreas  and  locate  any  incipient  collection 
of  pus,  which,  if  practicable,  should  then  be  evac- 
uated by  a  posterior  incision  in  the  left  or  right 
costo-vertebral  angle ;  or,  if  the  posterior  incision 
be  thought  impracticable,  the  collection  of  pus  may 
be  aspirated  and  the  cavity  opened  and  packed  with 
gauze,  which  may  be  brought  forward  through  a 
large  rubber  drainage-tube,  that  will  in  the  course 
of  from  24  to  48  hours  establish  a  track  isolated  from 
the  general  peritoneal  cavity.  In  one  case  I  was 
able  to  do  this,  but  the  operation  was  undertaken  at 
too  late  a  stage  to  be  successful,  and  though  the  pa- 
tient lived  two  or  three  days  afterwards,  the  evac- 
uation of  the  pus  seemed  to  make  very  little  differ- 
ence in  the  general  septic  condition  previously  ex- 
isting, and  death  occurred  on  the  4th  day  from  in- 
creasing debilit)'.  The  method  adopted  had,  how- 
ever, been  successful  from  the  point  of  vieW  of 
drainage,  and  the  track  of  the  gauze  and  tube  had 
been  isolated  from  the  general  peritoneal  cavity.  If  a 
definite  abscess  forms  and  approaches  the  surface  in 
front  or  in  either  loin,  the  treatment  will  be  that  of 
incision  and  drainage,  as  in  the  case  of  any  other 
abdominal  abscess.  Of  five  cases  on  which  I  have 
operated,  three  recovered  completely,  one  recovered 
from  the  operation,  but  died  a  few  weeks  later  from 
chest  complications  and  debility,  and  the  fifth  case 
is  the  one  just  referred  to.  The  strength  must  be 
maintained  by  careful  feeding  and  the  administra- 
tion'of  stimulants,  and  it  will  be  necessary  to  keep 
a  sharp  lookout  for  further  collections  of  pus  and 
for  subphrenic  abscess  or  empyema,  which,  on  re- 
cognition, will  need  treatment. 

The  following  case  of  pancreatitis  is  so  excep- 
tional, both  with  regard  to  course  and  treatment, 
that  I  think  it  is  worth  relating: 

Clironic  (jnntric  ulcer  erodiitfj  patirrcas;  pancreulitis;  abscess 
of  puiurens  hnrsliiiy  into  stoiiiiirh.  Vomiting.  Impending  dealJi. 
Posterior  gaslro-enterostomy.    J'eeoierii. 

On  November  12,  1900,  I  was  asked  by  Dr.  Mercer,  of 


Bradford,  to  see  Mr.  R.,  who  was  extremely  ill  and  uUp- 
posed  to  be  suffering  from  pancreatic  disease. 

On  arrival  I  found  the  patient,  aged  35,  extremely  ema- 
ciated, lying  in  a  typhoid  condition,  vomiting  extremely 
offensive  dark. colored  pus  and  mucus  mixed  with  blood. 
He  was  extremely  feeble  and  had  a  rapid  weak  pulse  and 
a  slight  icteric  tinge  in  the  conjunctivae,  a  tumor  could 
be  fell  above  the  umbilicus  which  was  tender  to  pressure. 
On  distending  the  stomach  with  CO-  great  pain  was  pro- 
duced and  vomiting  followed.  The  stomach  was  dilated, 
reaching  on  the  left  side  to  the  level  of  the  umbilicus. 

There  had  been  an  elevated  temperature  for  a  few  weeks, 
but  this  had  become  subnormal  after  the  vomiting  of 
pus.  Pain  after  food  a.nd  indigestion  had  existed  for  some 
months,  during  which  time  there  had  been  steady  loss  of 
flesh:  but  recently,  especially  during  the  last  months,  the 
wasting  had  been  very  considerable.  There  was  a  little 
sugar  in  the  urine  with  a  trace  of  albumen  and  the  feces 
contained  free  f=it. 

No  medicine  had  done  any  good  either  for  the  relief 
of  the  vomiting  or  in  controlling  the  horrible  odor,  which 
permeated  the  whole  house.  A  diagnosis  of  chronic  gastric 
ulcer  of  the  posterior  wall  of  the  stomach  with  secondary 
ulcerative  pancreatitis  and  abscess  of  the  pancreas  was 
made,  and  gastroenterostomy  proposed  as  the  only  means 
likely  to  produce  any  chance  of  relief,  but  even  that  seemed 
almost  hopeless. 

He  was  removed  to  a  surgical  home  by  ambulance  and 
the  stomach  washed  out  carefully  by  Dr.  Stevens.  As 
showing  the  nature  of  the  stomach  contents,  both  the  at- 
tendant nurses  were  made  sick  .by  the  odor  of  the  mater- 
ial evacuated  by  the  tube. 

On  November  18th  after  enveloping  the  patient  in  cotton 
woo!  and  subcutaneously  administering  strychnine,  poster- 
ior gastro-enterostomy  was  performed,  a  bone  bobbin  be- 
ing used.  The  operation  was  done  as  quickly  as  possible 
in  order  to  save  shock.  The  tumor  felt  before  operation 
was  found  to  be  formed  by  stomach  and  pancreas  firmly 
fixed  together  towards  the  pyloric  end.  but  leaving  the 
dilated  portion  free  at  the  cardiac  end  of  the  stomach,  so 
that  no  difficulty  was  found  in  doing  a  satisfactory  opera- 
tion, which  was  completed  in  20  minutes.  Saline  subcu- 
taneous injections  and  rectal  injections  were  given  and 
strychnine  was  freely  administered,  but  for  two  days  we 
had  a  great  fight  with  death  apparently  due  to  poisoning 
with  the  foul  stomach  contents.  Hot  water  was  freely  giv- 
en to  induce  vomiting  on  the  second  day.  as  the  patient 
could  not  bear  the  stomach  tube  being  used.  This  gave 
relief,  and  afterwards  progress  to  recovery  was  uninter- 
rupted. He  rapidly  gained  strength  and  put  on  iiesh.  re- 
turning home  five  weeks  after  operation.  His  friends,  who 
had  despaired  of  his  recovery,  were  astonished  to  find  him 
so  well.  In  April  he  was  in  such  good  health  that  he  mar- 
ried. 

The  treatment  of  Chronic  Pancreatitis  is  also  by  ab- 
dominal section  and  drainage,  but  in  this  case  the 
drainage  is  indirect  and  obtained  by  draining  the 
gall-bladder  by  cholecystotomy,  cholecystenterost- 
omy,  or  duodeno-choledochotomy.  The  exact  line 
of  treatment  cannot  be  determined  until  the  abdo- 
men is  opened,  and  for  this  purpose  I  prefer,  as  in 
all  my  gall-bladder  operations,  a  vertical  incision 
through  the  upper  part  of  the  right  rectus,  splitting 
that  muscle  to  whatever  extent  is  necessary  in  or- 
der to  obtain  a  good  view  of  the  diseased  region, 
and  to  afford  plenty  of  room  for  manipulation.  If 
a  mere  cholecystotomy  on  a  distended  gall-bladder 
is  necessarv,  an  incision  of  one  or  two  inches  will 
usually  suffice  :  but  if  the  gall-bladder  is  contract- 
ed, or  if  the  ducts  have  to  be  attacked,  an  incision 
of  4  to  6  inches  will  be  required,  and  if  the  several 
layers  of  the  abdominal  wall  are  sutured  separately, 
there  is  no  fear  of  subsequent  hernia;  this  I  can  af- 
firm by  ample  experience.  It  saves  much  time  and 
much  unnecessar}'  dragging  on  the  parts  when  op- 
erating on  the  common  duct  or  duodenum,  to  have 
a  free  incision,  and  there  is  no  retractor  equal  to  the 
hand  of  a  skilful  assistant,  who.  with  a  flat  sponge, 
interposed   between   the    spread-out   fingers   of   his 


I054 


The  Philadelphia"! 
Medical   Journal  J 


PANCREATITIS 


[JPNE    1,    ISOl 


left  hand  and  the  viscera,  will  at  the  same  time  af- 
ford the  operator  a  good  view  of  the  field  of  opera- 
tion, and  with  his  right  hand  help  in  the  further 
steps  of  the  operation. 

If  the  right  costal  margin  or  the  edge  of  the 
liver  obstructs  the  view,  another  assistant  may 
with  advantage,  retract  it  either  by  digital  manipu- 
lation or  by  means  of  a  wide  retractor  with  a  long 
handle,  so  that  he  can  stand  back  a  little  and  avoid 
embarrassing  the  operator.  As  a  matter  of  expe- 
rience, I  seldom  find  a  second  assistant  necessary. 
A  sponge  in  the  pouch  to  the  right  of  the  common 
duct  and  one  pushed  down  over  the  right  kidney, 
helps  to  catch  all  escaping  fluids  and  to  keep  the 
peritoneum  clear.  When  the  ducts  or  the  duode- 
num are  opened,  sterilized  gauze  pads  are  employed 
to  mop  up  the  fluid  as  it  escapes,  but  none  of  these 
are  allowed  to  remain  even  temporarily  in  the  ab- 
domen. When  there  are  gallstones  present,  they 
should  be  removed,  unless  the  patient  is  too  ill  to 
permit  of  the  complete  operation :  but  in  every  case 
drainage  must  be  secured,  if  possible  by  cholecys- 
totoni}-,  as  in  nearly  all  my  successful  cases ;  more- 
over, the  drainage  must  not  be  stopped  before  the 
bile  has  become  healthy  and  not  before  the  greater 
amount  of  bile  is  being  passed  by  the  bowel,  which 
will  be  certain  to  occur  as  soon  as  the  swollen  pan- 
creas has  subsided,  if  the  duct  be  otherwise  clear  of 
obstruction. 

It  might  be  thought  that  cholecyst  enterostomy 
w^ould  be  an  ideal  operation  in  the  treatment  of 
these  cases,  but  experience  says  it  is  not.  For  in- 
stance, in  one  of  my  cases  the  operation  brought 
about  so  much  relief  that  a  cure  was  being  antici- 
pated, yet  in  the  third  month  relapse  occurred  and 
death  ensued,  apparently  simply  owing  to  closure 
of  the  new  opening  between  the  gall-bladder  and 
duodenum.  In  one  of  ]\Ir.  Barling's  cases  {B.  M.  J.. 
Dec.  22,  1900),  where  the  gall-bladder  was  joined 
to  the  duodenum,  he  states  that  although  the  symp- 
toms were  relieved,  enlargement  of  the  pancreas 
persisted.  The  course  and  treatment  of  chronic  in- 
terstitial pancreatitis  is  exemplified  in  the  cases  re- 
lated in  my  lecture  before  the  Polyclinic  in  June  of 
last  year.  Possibly,  in  some  of  these,  the  manipula- 
tion of  the  indurated  tumor  may  have  detached  cal- 
culi impacted  in  the  pancreatic  duct,  though  I  was 
unconscious  of  it ;  but  in  others,  the  relief  of  tension, 
as  the  result  of  draining  the  bile  ducts  by  cholecy- 
stotomy  or  cholecyst  enterostoni}-,  indirectly 
drained  the  pancreatic  duct  and  thus  led  to  a  subsi- 
dence of  the  pancreatitis,  then  to  an  opening  of  the 
common  duct  by  the  relief  of  the  tension,  and  so  to 
a  cure  of  the  patient.  The  simulation  of  malignant 
disease  of  the  head  of  the  pancreas  by  chronic  inter- 
stitial pancreatitis  would  make  me  hesitate  to  de- 
cline operation  in  any  case  of  distended  gall-blad- 
der where  the  patient  is  in  a  condition  to  bear  it. 
or  even  in  any  case  of  chronic  jaundice  without  dis- 
tention of  the  gall-bladder  where  the  general  health 
is  deteriorating;  as,  though  it  should  be  recognized 
that  if  the  disease  be  really  malignant,  very  little 
good  will  be  done  and  life  may  even  be  shortened  or 
only  prolonged  for  a  short  time :  yet,  if  the  disease 
prove  to  be  chronic  pancreatitis,  a  real  and  perma- 
nent cure  may  be  brought  about.  If  a  calculus  be 
felt  imbedded  in  the  head  of  the  pancreas  or  impact- 
ed in  the  pancreatic  duct,  it  may  be  reached  through 


the  second  part  of  the  duodenum  by  laying  open  the 
papilla  and  exploring  the  duct,  or  by  dividing  the 
peritoneum,  passing  between  the  duodenum  and 
hepatic  flexure  of  the  colon,  and  then  cutting 
through  the  overlying  pancreas  on  to  the  concre 
tion.  If  the  papilla  common  to  the  bile  and  pancre- 
atic ducts  be  incised  in  the  duodenum  it  does  not  re- 
quire suture,  and  in  the  cases  in  which  I  have  ex- 
plored the  ducts  by  the  duodenal  route,  there  has 
been  no  serious  hemorrhage ;  the  anterior  duodenal 
opening  only  requires  closing  by  a  mucous  and  a 
serous  suture.  Drainage  of  the  right  kidney  pouch 
for  from  24  to  48  hours  is  advisable,  though  not  al- 
ways necessary,  and  this  is  best  done  by  a  stab 
wound  at  a  most  dependent  part. 

The  results  of  treatment  in  this  class  of  cases 
have  been  most  encouraging,  as  out  of  22  cases  op- 
erated on,  only  one  died  directly  from  operation, 
and  in  that  case  the  patient's  life  was  only  very 
slightly  shortened,  since  he  was  reduced  to  the  last 
stage  of  exhaustion  before  a  surgical  opinion  was 
sought.  Of  those  recovering  from  operation,  with 
the  exception  of  two  that  died  a  few  months  later, 
complete  and  perfect  recovery  ensued.  These  re- 
sults contrast  very  markedly  with  the  surgical  treat- 
ment of  cancer  of  the  pancrea.=.  where  nearly  half 
the  cases  operated  on  have  died  directly  as  the  re- 
sult of  operation,  and  in  those  who  have  survived, 
life  has  only  been  prolonged  for  a  comparatively 
short  time. 

Of  the  three  following  cases,  two  have  not  beea 
previously  reported. 

CHRONIC  PANCREATITIS:  CHOLECYSTOTOMY;CUR£. 
Mr.  D.,  aged  4.".  years,  was  brought  to  see  me  19.3.9S, 
the  history  bein?  that  he  had  been  well  up  to  12  months 
before,  when  he  began  to  have  painful  attacks  at  the  pit 
of  the  stomach,  ending  in  vomiting,  but  not  followed  by 
jaundice  until  an  attack  on  January  1st,  1S9S.  since  which 
time  he  had  been  deeply  and  continuously  jaundiced.  He 
had  also  from  that  time  onward  had  ague-like  attacks,  and 
two  da}  s  before  seeing  me  he  bad  had  within  24  hours  three 
of  these  seizures,  each  accompanied  by  pain.  Within  a 
twelvemonth  he  had  losf  2  stone.  8  pounds  in  weight.  Oa 
examining  him  there  was  some  swelling  in  the  gall-bladder 
region  but  no  tenderness.  The  liver  was  a  little  enlargetl 
but  the  margins  felt  smooth.  There  was  decided  tender- 
ness in  the  middle  line  just  above  the  umbilicus  and  on 
deep  pressure  the  pain  was  considerable  and  an  indefinite 
fulness  could  be  felt.  The  diagnosis  of  gall-stone  in  the 
common  duct  was  made,  and  an  operation  was  adrised. 
The  patient  was  operated  on  at  a  surgical  home  on  March 
30th.  when  the  gall-bladder  was  found  to  be  slightly  dis- 
tended and  surrounded  by  adhesions  to  the  pylorus,  duo- 
denum, colon,  and  omentum.  No  gall-stones  could  be  dis- 
covered, but  there  was  a  well-marked  swelling  of  ths 
head  and  the  first  two  inches  of  the  pancreas  which  though 
nodular  was  not  very  hard.  This  extended  further  to  the 
right  than  normal  so  as  to  cover  in  the  lower  end  of  the 
bile-duct.  Cholecystotomy  was  performed.  Within  24 
hours  of  the  operation  nearly  fovj  pints  of  very  offensive 
bile  was  discharged  through  the  tube.  A  specimen  was 
examined  by  the  Clinical  Research  Association  and  their 
report  was  as  follows:  "The  bile  contains  both  staphy- 
loccocci  and  streptococci,  but  no  bacillus  coli  communis 
could  be  found  either  under  the  microscope  or  in  the 
culture."  Fearing  that  the  disease  might  be  malignanl 
and  the  patient  being  so  extremely  weak  and  ill  I  gave  a 
poor  prognosis,  but  in  a  few  days  I  was  able  to  write: 
"The  patient  is  progressing  very  satisfactorily,  although  he 
is  still  profoundly  weak.  Bile  has  appeared  in  the  mo- 
tions so  that  the  obstruction  is  evidently  overcome.  The 
bowels  have  been  moved  naturally  and  the  patient  is  less 
deeply  jaundiced  and  looking  better  generally."  On  April 
5th  I  was  able  to  report  that  he  was  taking  food  well 
and  that  bile  was  passing  freely  in  the  motions.  He  had 
had  no  recurrence  of  the  shivering  attacks.    The  drainag* 


JCXE    1,   13J1] 


EXAMIXATIOX  OF  THE  BLOOD 


[The  Philadelphia 
Medical   Journal 


1055 


was  continued  for  14  days.  On  the  20th  he  returned 
home.  The  urine  was  then  free  from  bile  and  the  mo- 
tions were  assuming  a  natural  color:  he  was  taking  food 
■well,  gaining  flesh,  and  looking  better  generally.  I  still. 
however,  gave  a  guarded  prognosis,  though  I  said  that  I 
hoped  that  the  tumor  would  prove  to  be  inflammatory  and 
not  malignant.  From  that  time  onward  his  progress  to 
recovery  was  extremely  rapid.  A  report  I  had  of  his  con- 
dition a  few  months  later  said  that  he  was  perfectly  well  in 
every  respect  and  that  he  had  fully  regained  his  lost 
weight. 

On  March  2Sth  of  this  year  I  had  a  letter  from  Mr.  D., 
on  the  third  anniversary  of  his  operation  expressing  his 
gratitude  and  saying  that  he  was  in  perfect  health. 
CHRONIC  PANCREATITIS  WITH  ABSCESS  ASSOCIAT- 
ED   WITH     GALLSTONES.     CHOLECYSTOTOMY,  RE 
LIEF.      DEATH    FOUR    MONTHS    LATER   FROM    EX- 
H.\USTION.    AUTOPSY. 

Mr.  H..  aged  40,  seen  by  me  with  Dr.  Woods,  of  Batley. 
on  the  11th  of  October,  1900.  The  patient  was  then  deeply 
jaundiced  and  extremely  ill.  suffering  from  continuous 
fever  with  exacerbations,  great  debility  and  extreme  ema- 
<;iation.  A  large  tumour  in  the  region  of  the  pancreas 
could  then  be  felt  as  well  as  a  distended  gall-bladder.  He 
gave  the  history  of  failing  health  for  9  months  and  a  his- 
tory of  gallstone  atacks  and  painful  indigestion  for  some 
time  before  that,  but  although  he  had  frequent  attacks  of 
abdomnial  pain  for  3  or  4  months,  the  jaundice  had  onlj 
supervened  a  fortnight  before  ray  seeing  him.  At  the 
operation  he  was  too  ill  to  bear  a  prolonged  search  and 
there  were  numerous  adhesions  around  the  tumor,  which 
was  made  out  to  be  a  swelling  of  the  pancreas:  the  gall- 
bladder was  simply  opened  and  drained  of  a  quantity  of 
muco-pus.  A  quantity  of  pus  was  discharged  from  the 
drainage  tube  several  days  after  operation  and  this  was 
repeated  on  two  or  three  occasions,  as  if  it  came  from  a 
deeply  seated  abscess.  A  large  drainage  tube  having  been 
used,  there  was  a  free  discharge-  of  bile  and  a  considerable 
number  of  gallstones  were  evacuated  through  it.  33  in  all. 
Previous  to  the  operation  the  patient  was  suffering  from 
shivering  attacks  and  a  persistently  elevated  temperature, 
which  subsided  immediately  after  drainage  was  effected 
and  the  temperature  kept  nearly  normal  throughout  the 
remainder  of  his  illness,  it  being  normal  in  the  morning, 
though  there  was  usually  a  hectic  rise  each  evening.  He 
made  a  slow  though  apparently  steady  recovery  from  the 
operation,  and  the  pancreatic  tumor  diminished  so  rapidly 
that  it  was  confidently  believed  to  be  entirely  disappear- 
ing, it  being  only  one  third  as  large  as  at  the  time  of 
the  operation.  He  returned  home  December  14th,  but  he 
never  really  picked  up  strength,  and  though  there  was  no 
further  elevation  of  temperature,  he  gradually  got  weaker 
and  died  in  February. 

At  the  post-mortem  examination  made  by  Dr.  Woods,  a 
tumor  of  the  pancreas  was  discovered  which  was  carefully 
examined  by  Mr.  Cammidge  and  pronounced  to  be  a  chronic 
inflammatory  tumor  and  not  new  growth,  the  center  being 
occupied  by  pulpy  material  where  the  abscess  had  orig- 
inally been.  Nothing  else  was  discovered  and  there  were 
no  gallstones  left,  either  in  the  gall-bladder  or  ducts.  I 
am  able  to  show  you  the  specimen  and  also  a  microscopic 
section  of  the  preparation  for  both  of  which  I  have  to 
thank  Mr.  Cammidge. 

CHRONIC    PANCREATITIS,    CHOLECYSTOTOMY. 

On  the  2Sth  of  January,  1901,  Mr.  E.  R.  H.,  aged  2C. 
was  sent  to  me  from  Malvern.  He  was  deeply  jaundiced 
and  told  me  that  he  had  had  jaundice  since  the  age  of 
17,  it  having  supervened  upon  a  severe  attack  of  what  ap- 
peared to  be  biliary  colic,  of  which  he  had  had  several  seiz- 
ures since  the  age  of  14.  For  two  or  three  years  he  had  had 
several  ague-like  attacks  and  during  that  time  lost  very 
seriously  in  weight  and  strength,  but  during  the  past  two 
years  there  had  been  no  shivers  and  he  had  also  been  free 
from  the  severe  paroxysms  of  pain,  though  he  had  had 
slighter  seizures,  after  all  of  which  the  jaundice  becamo 
more  intense.  The  patient  was  then  only  weighing  9 
stone  and  all  the  bile  was  apparently  passing  in  the  urine 
and  none  in  the  motions.  There  was  also  some  swelling 
in  the  region  of  the  pancreas,  slight  enlargement  of  the 
liver,  and  a  very  decided  enlargement  of  the  spleen. 

Four  days  later,  the  abdomen  was  opened  by  a  vertical 
incision  through  the  right  rectus.  The  gallbladder  was 
found  contracted  and  surrounded  by  numerous  adhesions. 
After  the  separation  of  these,  the  ducts  were  carefully  e.K- 


plored  but  without  discovering  any  gallstones.  The  head 
of  the  pancreas  was  found  to  be  enlarged  and  very  hard. 
As  the  obstruction  appeared  to  be  entirely  due  to  the 
pressure  exercised  by  the  pancreas  on  the  common  duct, 
the  gallbladder  was  drained.  For  a  few  days  the  jaun- 
dice was  deeper.  It  then  became  gradually  less  until  it 
almost  disappeared.  In  10  days  the  stools  became  bile  stained 
and  have  since  retained  their  colour,  though  there  has 
never  been  complete  freedom  from  a  tinge  of  jaundice  in 
the  skin.  He  returned  home  on  the  16th  of  April,  having 
gained  nearly  half  a  stone  in  weight.  He  looked  and  felt 
much  better  and  as  a  small  quantity  of  bile  was  still  com- 
ing from  the  tube  it  was  felt  desirable  to  retain  it  until 
the  last  tinge  of  jaundice  had  disappeared.  From  the 
first  week  of  operation  up  to  the  present  he  has  had  no 
further  pain  and  has  been  able  to  take  ordinary  food  and 
to  digest  it  well. 


THE  EXAMINATION  OF  THE  BLOOD  IN  RELATION  TO 
SURGERY  OF  SCIENTIFIC  BUT  OFTEN  OF  NO 
PRACTICAL  VALUE.  AND  MAY  MISGUIDE  THE 
SURGEON. 

By  JOHN  B.   DEAVER,  M.   D., 

of  Philadelphia. 

Surgeon  to  the  German  Hospital,   Philadelphia. 

The  object  of  this  paper  is  not  to  decry  the  value, 
to  the  surgeon,  of  examinations  of  the  blood  ;  for 
we  undoubtedly  can,  by  this  means,  often  obtain 
valuable  information  as  to  the  nature  and  progress 
of  pathological  conditions  that  can  be  obtained  in 
no  other  way.  Yet  valuable  as  this  sign  is,  its  use- 
fulness is  confined  to  quite  narrow  limits,  and  even 
in  its  proper  field  its  significance  is  frequently  very 
difficult,   and   sometimes  impossible,  to  determine. 

The  blood  count  is  a  valuable  physical  sign,  but 
it  is  only  one  sign,  and  should  be  kept  in 
its  proper  perspective.  One  spot  is  not  sufficient 
evidence  upon  which  to  base  a  diagnosis  of  typhoid 
fever,  nor  can  the  presence  of  pus  be  asserted  or 
denied  from  an  estimation  of  the  number  of  leuko- 
cytes alone. 
'  In  the  last  few  years  there  has  crept  into  the 
profession  a  tendency  to  replace  the  bedside  by  the 
laboratory  as  the  point  from  which  to  make  the 
diagnosis';  to  substitute  the  highly  magnified  but 
extremely  limited  field  of  the  microscope  for  the 
broader  view  of  the  eye  of  the  physician.  This  we 
regret,  for  in  the  majority  of  instances  che  diagno- 
sis must  be  made  at  the  bedside  without  the  aid  of 
the  microscopist,  and  any  man  who  has  no  confi- 
dence in  diagnosis  made  without  the  aid  of  the  lab- 
oratory limits  his  usefulness. 

The  blood  count  theoretically  promises  the  sur- 
geon more,  perhaps,  than  any  other  of  the  lines  of 
laboratary  investigation,  and  is  certainly  of  great 
practical  value,  yet  the  information  thus  obtained 
is  open  to  many  fallacies,  and  the  surgeon  who  de- 
pends on  this  means  alone  to  decide  for  or  against 
operation  in  any  condition,  is  often  acting  to  the 
detriment  of  his  patient. 

The  technique  of  a  blood  count  is  one  in  which 
there  are  opportunities  for  inaccuracies  without 
number,  and  the  dilution  with  which  it  must  be 
made  multiplies  each  error  a  hundred  fold.  There- 
fore, except  in  the  hands  of  an  expert,  its  evidence 
is  always  open  to  a  reasonable  doubt,  and  even  with 
an  expert  it  is  only  on  repeated  examinations  that 
absolute  dependence  can  be  placed. 

•Read    before   the   American    Surgical    Association,    in    BslI- 
timore.    May,    1901. 


1056 


The  Philadelphia"! 
Medical   Journal  J 


EXAMINATION  OF  THE  BLOOD 


[June  1,  1901 


ilie  secret  of  life-saving  surgery  is  promptness 
in  diagnosis  and  operation,  and  often  the  time  lost 
in  awaiting  the  confirmation  of  our  opinions  by 
the  laborator}-  can  be  ill-afforded  by  the  patient. 

An  effort  has  been  made  lately  to  determine  the 
exact  degree  of  anemia  below  which  it  is  unwise 
to  attempt  a  surgical  operation.  In  this  we  are 
asking  more  of  a  blood  count  than  it  will  ever  be 
able  to  give.  In  medicine  we  are  dealing  with  liv- 
ing organisms,  with  widely  varjing  powers  of  re- 
sistance, and  therefore  the  degree  of  anemia  com- 
patible with  successful  surgery  will  vary  with  each 
patient.  Then,  too,  what  the  operation  promises 
is  another  important  factor;  for  we  are  certainly 
justified  in  attempting  an  operation,  which,  if  suc- 
cessful, W'ill  restore  our  patient  to  health  under 
conditions  that  would  positively  forbid  a  merely 
palliative   operation. 

To  illustrate  this,  let  me  briefly  cite  two  cases 
that  have  recently  occurred  in  my  practice : 

CASE  1. — Mrs.  L.  B.,  55  years  old,  was  admitted  to  the 
German  Hospital  12y  20/1900,  and  the  following  history 
obtained:  Family  and  previous  history  negative.  Men- 
struation physiological  until  three  years  ago,  when  she 
apparently  reached  the  menopause  in  a  perfectly  normal 
manner.  After  an  interval  of  eight  months  an  excessive 
metrorrhagia  appeared,  accompanied  by  a  profuse  offensive 
leukorrhea.  One  year  after  a  fibro-myoma  was  expelled 
from  the  uterus;  this  was  followed  by  a  temporary  im- 
provement, but  six  months  later  the  symptoms  were  as 
bad  as  ever,  and  she  has  steadily  and  rapidly  lost  strength 
and  weight  ever  since. 

On  admission  the  patient  was  extremely  emaciated  with 
that  bronzing  of  the  skin  very  suggestive  of  malignant 
disease,  and  so  weak  that  she  was  hardly  able  to  raise  her- 
self in  bed.  She  had  a  very  offensive  leukorrhea  and  an 
almost  constant  metrorrhagia.  A  large,  hard  mass  could  be 
easily  made  out  connected  with  the  uterus  and  rising  above 
the  symphysis  pubis. 

The  cervix  was  patulous  and  presenting  at  the  internal  os 
can  be  felt  a  large  fibroid. 

On  the  day  after  admission  her  blood  count  was:  Hemo- 
globin 27%,  erythrocytes  4,070,000,  leukocytes  5,200.  She 
was  put  under  appropriate  treatment,  but  showed  only  the 
slightest  improvement.  On  12/31/1900,  the  blood  count 
was:  Hemoglobin  307c,,  red  blood  cells  3,980,000,  whites 
5,400.  Despairing  of  much  improvement  by  delay,  she  was 
then  operated  upon.  A  large  multinodular  uterine  fibroid 
was  removed  by  an  abdominal  panhysterectomy  and  the 
wound  closed  without  drainage.  Convalescence  was  un- 
eventful and  the  patient  left  the  hospital  2/11,  ISOl  in  good 
health.  She  has  been  seen  within  the  last  two  weeks 
and  reports  herself  to  be  perfectly  well. 

CASE  2. — Mrs.  M.  C,  48  years  old,  was  admitted  to  the 
wards  of  the  German  Hospital  with  the  following  history: 
A  brother  died  of  cancer  of  the  stomach,  but  the  family 
history  was  otherwise  negative.  Previous  personal  his- 
tory negative,  menstruation  always  physiological.  No 
metrorrhagia  or  excessive  menorhagia.  For  the  last  six 
years  has  been  conscious  of  a  mass  in  the  lower  abdomen, 
and  during  this  time  has  lost  about  forty  pounds  in  weight 
For  the  last  two  years  has  been  extremely  weak  and  short 
of  breath. 

Examination  on  admission  shows  the  patient  to  be  a  tall 
thin  woman  with  all  the  inspection  symptoms  of  carci- 
noma. A  soft  blowing  murmur  was  heard  at  the  base  of  the 
heart.  The  blood  count  on  the  day  of  admission  was: 
Hemoglobin  22%,  erythrocytes  2,980.000,  leukocytes  5.200. 
A  large  mass  could  be  felt  in  the  lower  abdomen,  both  by 
vaginal  and  supervaginal  palpation. 

She  was  operated  on  the  next  day  and  a  large  fibro- 
myoma  removed  by  an  abdominal  pan-hysterectomy,  wound 
closed  without  drainage.  Convalescence  was  uneventful 
and  the  patient  left  the  hospital  2  11,  1900  in  very  good 
condition. 

Grave  anemias  are,  of  course,  a  general  contra- 
indication to   an    anesthetic    and    operation    in    the 


same  way  that  organic  heart  lesions  and  nephritis 
are,  yet  we  all  know  how  often  the  severest  opera- 
tions are  successfully  performed  in  the  presence  of 
these   complications. 

Sometimes  in  a  patient  suffering  from  prolonged 
suppuration,  frequent  hemorrhages  or  other  condi- 
tions that  would  lead  us  to  expect  a  profound  ane- 
mia, we  find  either  a  normal  or  abnormally  high 
percentage  of  hemoglobin  and  erythrocytes.  Such 
results  are  often  very  misleading,  as  they  by  no  , 
means  express  the  blood  condition  of  the  patient. 
The  chief  cause  leading  to  this  artifact  is  a  tran- 
sient concentration  of  the  blood  due  to  a  lessening 
of  its  fluid  constituents  from  purgation,  excessive 
vomiting  or  free  sweating.  In  addition  to  this  a 
stasis  in  the  peripheral  circulation  from  either  or- 
ganic heart  disease  or  functional  depression  from 
profound  toxemia,  will  raise  the  blood  count  above 
the  true  measure  of  the  patient's  anemia. 

The  significance  of  the  presence  or  absence  of  a 
leukocytosis  is,  perhaps,  the  part  of  this  subject 
that  we,  as  surgeons,  are  most  often  concerned 
about. 

\N  ithotit  going  into  the  discussions  that  have  re- 
cently arisen  on  this  ubject,  we  can  consider  the 
phenomena  of  leukocytosis  as  primarily  one  of 
phagocytosis,  it  making  no  difference  whether  the 
toxic  materials  are  directly  taken  up  by  the  leuko- 
cytes or  neutralized  by  a  substance  formed  in  part 
by  their  activity. 

If  poisons  of  certain  kinds  are  in  the  general  cir- 
culation, there  is  ordinarily  a  general  leukocytosis, 
its  grade  depending  largely  on  the  resisting  powers 
of  the  individual  and  the  amount  and  kind  of  poi- 
son. 

Sometimes  a  sudden  and  overwhelming  dose  of 
septic  poison  will  so  depress  the  patient  that  there 
is  no  phagocytic  reaction  and  a  leukocjtosis  does 
not  appear. 

Then,  too,  in  prolonged  suppurative  processes, 
with  free  absorption  of  the  septic  poison,  at  first 
there  is  an  active  phagocytosis  with  a  large  leuko- 
cytosis, but  as  the  powers  of  resistance  of  the  pa- 
tient sink  the  leukocj'tosis  becomes  very  insignifi- 
cant, or  as  time  goes  on  the  focus  of  suppuration 
may  be  shut  off  by  nature  from  the  general  circu- 
lation, and  again  the  number  of  leukocytes  falls. 

In  a  general  way,  high  grades  of  leukocytosis  are 
most  commonly  satisfactory  signs ;  while  they  are 
due  to  severe  infection,  they  usually  mean  good  re- 
action. 

Moderate  grades  of  leukocytosis,  if  the  other 
signs  of  infection  are  severe,  are,  in  themselves, 
suggestive  of  a  bad  result ;  if  the  other  signs  of  in- 
fection are  slight,  a  mild  leukocytosis  means  noth- 
ing of  itself. 

If  the  origin  of  the  infection  is  in  a  part  of  the 
body  rich  in  lymphatics  and  rapid  in  absorption, 
other  things  being  equal,  the  leukocytosis  will  be 
more  marked.  Thus  it  is  that  a  peritonitis  gives 
a  greater  leukocytosis  than  a  pleurisy,  and  why 
the  upper  part  of  the  peritoneal  cavity,  if  infected, 
gives  a  quicker  and  more  profound  systemic  infec- 
tion than  the  lower. 

Of  course,  in  a  streptococcus  infection,  per  se, 
wc  should  get  a  higher  grade  of  leukocytosis  than  in 
a  staphylococcus :  yet,  as  we  have  shown,  the  de- 
gree of  leukocytosis  is  so  dependant  on  the  amount 


JrxE  1,  1901] 


COMPLICATED  FRACTURES 


CThe  Philadelphia 
Medical   Journal 


1057 


of  poison  absorbed  and  the  resistance  of  the  patient, 
that  we  can  form  no  judgment  as  to  the  character 
of  the  infection  from  the  blood  count. 

For  years  the  text-books  have  nearly  all  con- 
tained the  statement  that  there  is  commonly  a  leu- 
kocytosis in  cancer.  On  what  this  is  founded  we 
do  not  know,  for  any  one  with  any  practical  expe- 
rience in  this  matter  must  know  that  such  is  not 
the  case,  a  leukocytosis  in  this  condition  being  very 
uncommon  and  does  not  seem  to  be  influenced  by 
metastasis.  Only  nineteen  out  of  forty-nine  pa- 
tients, at  the  German  Hospital,  suffering  from  car- 
cinoma, gave  a  leukocytic  count  of  over  10,000,  and 
only  two  of  these  were  above  20,000,  these  two  be- 
ing respectively  an  ulcerating  carcinoma  of  the 
breast,  which  gave  a  blood  count  of  31,500  leuko- 
cytes, and  a  carcinoma  of  the  liver  with  40,800  leu- 
kocytes. 

In  cases  of  appendicitis,  we  cannot  depend  on 
the  blood  count  for  our  indication  for  operation,  for 
the  favorable  time  for  this  operation  is  in  the  first 
hours  of  the  attack,  when  the  chief  symptoms  are 
those  of  appendiceal  colic  and  before  severe  sys- 
temic infection  has  taken  place.  In  these  cases  we 
often  have  rupture  of  the  appendix,  or  transmigra- 
tion of  organisms  so  suddenly  infecting,  in  an  over- 
whelming manner,  the  entire  peritoneal  cavity,  that 
a  leukocytosis  is  not  established,  or  is  very  evanes- 
cent, owing  to  the  rapid  paralysis  of  the  resisting 
powers  of  the  individual.  Or,  as  the  symptoms  im- 
prove and  the  leukocytosis  falls,  we  might  think 
that  the  appendix  was  becoming  normal  again,  when 
the  truth  was  that  an  abscess  had  only  become  lo- 
calized, and  no  more  septic  material  was  being  ab- 
sorbed. If  acting  on  this  supposition,  we  should 
decline  to  operate,  we  should  leave  our  patient  ex- 
posed to  the  greatest  risk  of  a  secondary  outbreak 
that  would  be  verj-  likely  to  cost  him  his  life. 

We  shall  be  doing  much  better  surgery  if  we 
promptly  operate  on  our  appendicitis  cases,  than  if 
we  waste  time  over  a  blood  count  that,  as  is  shown 
by  Dr.  Da  Costa's  paper,  read  before  you,  is  of  very 
little  value.  In  the  experience  of  the  author,  in 
cases  of  salpingitis,  even  quite  moderate  grades 
of  leukocytosis  (14,000  to  17,000),  are  indicative  of 
the  presence  of  pus.  Yet  this  is  by  no  means  con- 
stant, for  nature  is  so  well  able  to  care  for  these 
cases,  that  often  large  collections  of  pus  are  pres 
ent  without  a  leukocytosis,  much  to  the  embarrass- 
ment of  the  surgeon  who  depends  upon  the  blood 
count  alone  to  show  the  presence  of  suppuration. 

In  cases  of  obstructive  jaundice  a  leukocytosis  is 
usually,  but  not  always,  present,  and  in  our  expe- 
rience seems  to  be  most  often  due  to  a  local  peri- 
tonitis around  the  gall-bladder.  In  eight  out  of 
fourten  cases  of  obstructive  jaundice,  due  to  gall- 
stones, a  leukocytosis  was  present. 

Although  I  have  not  the  data  at  hand  to  verify 
this  statement,  I  will  venture  the  opinion  that  the 
most  virulent  of  micro-organisms  may  inhabit  the 
altered  bile  of  an  occluded  gall-bladder  without  giv- 
ing systemic  signs,  thus  explaining  many  cases  of 
peritonitis  after  gall-stone  operations,  in  which  the 
operator,  thinking  the  bile  sterile,  has  allowed  it  to 
soil  the  general  abdominal  cavity. 

Pohl  (i),  Wilkinson  (2)  and  Boland  (3)  have 
done  some  very  interesting  work  in  regard  to  drug 
leukocvtosis.    These  investigators  have  found  that 


many  drugs  have  the  power  of  producing  a  quite 
marked  leukocytosis;  among  these,  quinine,  the 
silicylates,  antipyrine,  phenecetine,  pilocarpine,  Do- 
ver's powder  and  morphine ;  all  drugs  that  our  pa- 
tients may  have  been  taking  at  the  time  we  are 
called  upon  to  make  a  diagnosis. 

We  might  go  on  showing  many  other  instances  of 
surgical  conditions  in  which  the  blood  count  is  of 
doubtful  value,  or,  at  any  rate,  disappointing,  but 
we  have,  we  think,  said  enough  to  define  our  posi- 
tion. 

We  believe  that  if  we  have  a  decided  leukocytosis 
(20,000  or  over),  after  excluding  pneumonia,  leuke- 
mia, etc.,  we  can  safely  infer  the  presence  of  pus. 
Yet  without  a  leukocytosis  we  cannot  be  sure  that 
pus  does  not  exist.  We  also  consider  exquisite  ten- 
derness, temperature,  pulse,  and  the  general  ap- 
pearance of  the  patient  as  much  more  reliable  guides 
than  blood  count. 

Therefore,  gentlemen,  I  wish  to  say  in  conclu- 
sion :  let  us  have  blood  counts  made  on  our  patients ; 
we  have  already  learned  valuable  lessons  from  them 
and  undoubtedly  will  learn  more  in  the  future ;  but 
let  us  not  be  drawn  aside  by  their  still  uncertain 
evidence  from  the  lessons  learned  by  practical  ex- 
perience at  the  bedside. 

(i).  Arch,  fucr  cxpcr.  Path,  unci  Pharmak.,  vol.  15, 
1889. 

(2).  British  Medical  Journal,  9-26-1896. 

(3).  Ceniralhlalt  fucr  iiiuere  Mcdiziu,  4-S-1900. 

In  the  preparation  of  this  communication  I  wish 
to  credit  Dr.  Edward  K.  Moore,  my  ex-house  sur- 
geon, with  the  greater  part  of  the  work  thereon. 


COMPLICATED  FRACTURES.  THEIR  DIAGNOSIS  AND 

TREATMENT.* 

By  THOMAS  H.  MANLEY,  Ph.  D.,  M.  D. 
of  Xew  York. 

Gentlemen :  When  requested  by  my  colleagues  to 
participate  in  this  series  of  evening  lectures,  I  cast 
about  for  something  on  which,  from  an  ample  ex- 
perience, I  might  be  permitted  to  speak  with  some 
emphasis.  Therefore,  now  after  nearly  twenty 
years  as  an  interne  and  assistant  surgeon  and  sur- 
geon to  a  hispital  service  in  which  grave  trauma- 
tisms predominate,  and  wherein  I  had  seen  several 
eral  thousand  mechanical  disorganizations  of  the 
osseous  parts,  and  every  conceivable  type  of  frac- 
ture, I  decided  to  select  for  this  evening's  discourse 
the  consideration  of  a  theme  always  of  doininating 
interest  and  importance  to  practitioners,  for  of  all 
the  serious  traumatisms,  there  are  none  so  com- 
mon as  fractures,  broken  bones.  It  has  been  well 
said  that  there  is  no  class  of  injuries  which  are  ap- 
proached with  greater  misgivings,  hesitation  and 
doubt,  and  no  one  which  calls  forth  a  greater  de- 
gree of  knowledge,  skill,  discernment  and  judgment, 
than  the  diagnosis  and  correct  management  of  ob- 
scure or  serious  fractures.  Time  will  not  permit  of 
a  brief  survey  of  the  traumatisms  of  the  irregular 
bones,  of  the  carpus  and  tarsus,  the  vertebrae  and 
bones  of  the  face,  or  the  flat  bones  of  the  cranium 
and  pelvis ;  and  hence  only  fractures  involving  the 
extremities  can  be  touched  on  this  evening.  As  a 
preliminary  step,  let  us  glance  cursorily  at  the  osse- 
ous abode  of  man,  the  skeleton,  that  we  may  ap- 

»Read  beford  the  N.  V.  School  of  ClinicalfMedicine — April  19,  looi. 


1 058 


The  Philadelpbia"! 
Medical  Journal    J 


COMPLICATED  FRACTURES 


[June  1,  1901 


preciate  its  mechanism  and  purposes,  and  the  spec- 
ial functions  of  its  members.  \Ve  will  observe  as  a 
preliminary  step  the  position  and  functions  of  the 
extremities.  We  see  that  the  lower  consist  of 
doubly  jointed  levers,  that  they  stand  as  double  pil- 
lars or  columns  to  support  the  whole  body  in  the 
standing  attitude,  and  when  in  action,  raise,  lower, 
move  or  project  it.  Though  these  members  sub- 
serve a  high!}-  important  purpose,  this  is  insignifi- 
cant as  contrasted  with  the  hands  and  arms,  the 
mechanism  of  w'hich,  their  strength,  action,  and 
marvelous  execution,  stamp  man  as  the  monarch  of 
all  animal  creation.  These  administer  to  our  every 
want,  provide  us  with  the  necessaries  of  life,  and 
enable  us  to  maintain  ourselves  and  others.  We 
need  not  wonder,  then,  why  a  comprehensive  and 
practical  knowledge  of  the  traumatic  lesions  of 
these  appendages  of  the  body  is  expected  of  all  who 
exercise  the  healing  art. 

Diagnosis. — Now,  let  us,  in  this  brief  study,  first 
consider  the  symptoms  and  signs  of  fracture,  in  this 
instance  the  art  of  detecting  fracture.  But  I  am 
sure  that  some  may  submit,  that  in  a  post-graduate 
course,  like  this,  it  will  be  largely  labor  lost,  as  any 
tyro  can  have  no  difficulty  in  this  direction,  if  he 
observe  a  few  rules  of  the  text-books,  if  he  note  that 
in  every  fracture  there  is  loss  of  function  in  the 
limb,  that  there  is  visible  deformity  and  a  false  point 
of  motion  w-hen  a  shaft  is  involved.  The  practi- 
tioner called  upon  to  deal  with  this  class  of  inju- 
ries, will  soon  learn  that  in  a  considerable  number 
it  is  a  delusion,  and  occasionally  we  will  encounter 
instances  in  which,  by  no  means  short  of  an  opera- 
tive incision,  by  no  way  known  to  art,  can  some 
fractures  be  detected  with  certainty.  It  is  fortunate 
that,  as  a  rule,  in  these  obscure  cases,  accurate, 
definite  diagnosis  is  not  imperative  in  order  to  in- 
stitute appropriate  treatment ;  however,  that  we  may 
safeguard  our  reputation,  and,  besides,  for  medico- 
legal reasons,  in  cases  liable  to  be  followed  by  a 
civil  action,  we  must  exhaust  every  resource  to  at- 
tain definite  information  here,  which  will  not  inflict 
injury  or  be  to  the  detriment  of  our  patient.  We 
proceed  to  diagnosticate  the  case  of  suspected  frac- 
ture by  availing  ourselves  of  the  following : 

1st.  A  history  of  the  case. 

2nd.  Inspection  of  our  patient. 

3rd.  Posture,  attitude.or  position. 

4th.  Manipulation,  palpation,  pressure,  torsion. 
and  traction. 

5th,  Narcotic  relaxation  of  the  muscular  system. 

6th.  The  Roentgen  Rays,  transillumination. 

7th.  The  exploratory  incision. 

8th.  A    consultation. 

Now,  let  us  hastily  recapitulate,  and  first,  we  will 
begin  with  an  inquiry,  A  searching  history  of  a 
case  is  a  most  helpful  aid ;  for  example,  if  an  elderly 
person,  more  particularly  a  female,  has  suffered  a 
fall  on  the  hand  with  resulting  loss  of  power  and 
great  pain,  we  are  quite  certain  of  a  Colles'  fracture, 
and  if,  again,  one.  as  the  former  in  age,  has  suf- 
fered a  fall  on  the  hip,  with  loss  of  power  following, 
we  suspect  a  fracture  through  the  neck  of  the  femur. 
But  we  must  be  cautious  here,  that  the  patient,  in 
detailing  his  case,  has  not  deceived  himself,  or  is 
striving  to  deceive  us  for  fraudulent  purposes.  Not 
long  since  a  man  came  to  me  with  a  bandage  on  his 


wrist,  stating  that  in  the  morning  he  was  injured 
through  the  neglect  of  a  car  conductor  in  dismount- 
ing a  street  car.  The  silver-spoon  deformity  of 
Colles'  was  well-marked,  but  on  a  verj-  superficial 
examination,  it  was  evident  that  the  deformity  was 
an  old  one.  The  fellow  was  shown  the  door.  Again, 
many  suffer  so  little  that  they  suspect  nothing 
more  than  a  sprain,  but  they  have,  besides  a  sprain, 
fracture,  something  not  uncommon  at  the  wrist  and 
ankle  joints. 

Inspection. — A  critical  examination  of  the  limb 
or  body  should  never  be  overlooked  in  any  dubious 
case ;  by  it  alone  we  may  frequently  differentiate 
a  fracture  from  a  dislocation  in  thin  subjects ;  before 
swelling  sets  in  the  deformity  in  displaced  fractures 
is  something  plainly  discernible,  though  of  itself  in- 
spection weighs  for  little. 

Posture. — The  attitude  of  the  limb  or  body  when 
injured,  with  a  view  of  relieving  tension,  is  a  great 
help.  In  fractures  of  the  non-displaced  character, 
its  value  is  the  greatest,  notably  so  when  these  in- 
volve the  shoulder-girdle,  the  neck  of  the  scapula 
or  its  apophyses,  the  outer  third  of  the  clavicle,  or 
are  in  close  proximity  to,  or  pass  through  the  ana- 
tomical neck  of  the  humerus.  In  order  to  be  ef- 
fective, our  patient  must  always  be  placed  on  a 
hard,  flat  surface,  a  table  if  possible.  For  suspected 
fractures  about  the  shoulder  joint,  the  head  and 
shoulders  are  raised,  and  the  arm  carried  well  up- 
ward. When  the  hip  joint  is  the  site  near  which 
fracture  is  suspected,  we  flex  the  knee  on  the  thigh 
and  the  thigh  on  the  trunk.  Many  times  we  will 
succeed  in  bringing  out  well-defined  crepitus  and 
movement  of  the  fragments  by  change  of  posture, 
something  always  available,  and  all  the  more  de- 
sirable, as  it  rarely  provokes  suffering. 

Manipulation,  with  all  that  this  term  implies,  gent- 
ly, skillfully  and  perseveringly  applied  in  closed 
fractures,  is  the  most  valuable  of  all  aids  in  their 
elucidation.  It  will  rarely  fail  us,  if  judiciously  em- 
ployed. In  some  cases,  however,  its  results  are  not 
definite  at  the  first  examination,  but  if  we  flex  the 
limb  and  let  it  rest  for  24  hours  or  more,  when  mus- 
cular spasm  has  passed  off,  it  may  often  then  clearly 
expose  the  character  of  the  injury.  In  all  instances, 
giving  a  history  of  a  severe  sprain,  let  us  search 
for  a  fracture,  and  critically  manipulate  the  nude 
parts,  lest  we  commit  an  oversight  and  damage  our 
reputation  by  incomplete,  superficial  work.  Five 
years  ago  a  malpractice  suit  arose  in  this  city,  in 
which  the  first  physician  called  was  the  defendant. 
The  patient,  a  young  actress,  summoned  the  doctor 
for  what  she  said  was  a  bruise  of  the  knee,  from  a 
fall  on  the  floor.  The  doctor  hesitated  to  expose 
and  critically  examine  the  parts  injured.  After  a 
week  she  dismissed  him  and  called  another  physi- 
cian, who  at  once  stripped  the  parts  and  discovered 
a  fractured  patella  with  three  inches  of  separation. 
-Vgain  it  would  seem  that  manipulation  will  mislead 
in  inexperienced  hands.  Several  instances  have 
come  under  my  notice  in  which  limbs  had  been  braced 
or  splinted  for  fractures  which  did  not  exist:  one 
case  being  a  woman,  who  was  being  treated  for  an 
intracapsular  fracture  of  the  femur.  On  examina- 
tion I  could  find  no  trace  of  fracture,  but  a  disloca- 
tion onto  the  dorsum  of  the  ileum.  This  was  easily 
reduced,  and  the  poor  woman  spared  from  oeing 
left  a    helpless    cripple.    One    case  in  a    man.  Dr. 


JUNE    1,    1301] 


COMPLICATED  FRACTURES 


TTuE  Philadelphia 
L  Medical  Journal 


1059 


Sayre's  harness  for  fracture  of  the  clavicle,  the  bone 
being  found  perfectly  normal ;  and  another,  the 
case  of  a  boy,  whose  foot  and  leg  were  bound  up  in 
a  plaster  of  Paris  dressing  for  a  fracture  of  both 
bones;  but  not  the  slightest  trace  of  osseous  lesion 
could  be  found.  These  were  illustrated  instances  of 
inexcusable  carelessness  at  the  time  of  examination. 
Narcotic  relaxation  of  the  muscles  we  must  some- 
times resort  to,  in  hyperesthesic  conditions  of  the 
limb,  in  children  or  hysterical  women,  or  in  many 
obscure  or  doubtful  cases,  when  a  diagnosis  is  ur- 
gently called  for.  When  other  measures  fail,  and 
muscular  spasm  is  extreme,  pulmonary  anesthesia 
carried  just  far  enough  to  obliterate  the  pain  sense 
will  slacken  the  grip  of  the  muscles  quite  enough  to 
allow  motion  of  the  locked  up  fragments.  In  some 
cases  a  critical  precise  examination  of  a  doubtful 
case  is  impossible,  without  this  precious  resource. 
A  little  over  a  year  ago  a  case  came  under  my  care 
which  proved  its  great  value.  A  gentleman  of  40 
years  sustained  a  severe  injury  to  his  hip  joint  from 
a  fall.  The  family  practitioner  being  in  doubt  as  to 
the  character  of  the  injury,  called  in  one  of  our  best- 
known  surgeons  for  a  consultation.  It  was  then 
decided  that  the  injury  was  a  severe  contusion  with 
a  resulting  arthritis.  But  the  man  continued  from 
bad  to  worse,  suffering  the  greatest  torture  on  any 
movement  of  the  limb  or  body.  A  week  after  the 
first  consultation,  the  case  was  seen  by  me  w-ith  the 
doctor.  Now,  on  a  strong  table  he  w-as  placed,  and 
under  an  anesthetic,  creptitus  with  displacement  was 
clearlv  obvious.  The  Roentgen  ray,  all  must  con- 
cede as  one  of  the  most  useful  diagnostic  agents  of 
modern  times.  Yet  in  osseous  traumatisms  this 
mode  of  photography  is  by  no  means  free  from  er- 
rors and  uncertainties.  Except  in  the  hands  of  an 
expert,  it  is  quite  useless,  and  even  then,  the  shad- 
owgraph is  not  infallible.  No  two  of  them  are  quite 
alike;  one  may  exhibit  a  sound  limb  as  sundered, 
and  in  another,  perfect  continuity,  where  the  evi- 
dence of  fracture  is  unequivocal.  \\^ith  a  method 
so  full  of  vagaries,  errors  and  ambiguities,  we  must 
necessarily  accept  with  reserve  its  revelations,  a 
diagnosis  on  which  alone,  in  very  obscure  cases,  is 
certainly  not  indefensible.  The  open  incision  in- 
volves a  surgical  operation  and  has  been  recently 
advocated  as  a  means  of  diagnosis.  It  is  certain  that 
the  scalpel  will  remove  all  possible  doubt,  but  in  the 
greater  number  of  cases  of  closed  fracture,  their 
recognition  is  possible  by  simple  methods.  More- 
over, should  infection  with  suppuration  follow,  un- 
less special  conditions  justified  it,  this  sequence 
might  involve  us  in  serious  troubles.  From  my  own 
very  limited  experience  with  it,  however,  under 
proper  precautions,  it  seems  to  be  a  perfectly  harm- 
less procedure.  Here  before  you  are  two  patients, 
who  came  into  my  service  within  the  past  month, 
on  whom  it  was  employed.  You  will  observe  that 
one  is  a  young  man  and  the  other  a  man 
advanced  in  years.  The  former,  ten  days  be- 
fore he  entered,  sustained  an  injury  at  the 
ankle  in  a  brawl.  He  was  first  treated  for  a 
sprain ;  having  no  improvement,  he  consulted  an- 
other physician,  who  was  in  doubt,  and  who  sent 
him  to  mv  clinic  for  a  diagnosis.  At  that  time  the 
ankle  and  foot  were  swollen  and  edematous,  the 
ioint  stiflf    and  parts  highly  sensitive.     An  incision 


three  inches  long,  four  inches  above  the  head  of  the 
fibula,  readily  exposed    an    oblique    non-displaced 
fracture.     There  was  a  free    discharge    of    venous 
blood.     The   incision   was  immediately   completely 
closet!,  and  a  plaster  dressing  applied.     In  the  other, 
though  only  treated  three  weeks  ago,  you  will  ob- 
serve  that  the  incision   is  completely  healed.     He 
sustained  an  injury  to  the  forearm  six  weeks  since. 
Went   to  a  dispensary   and   was  given  a  liniment, 
the   arm  was  bathed   and   massaged.     He  was  ad- 
vised to  keep  up  free  motion  in  the  wrist  and  elbow 
to  overcome  the  rigidity,  but  this  he  found  was  im- 
possible because  of  the  great  pain  it  provoked.    On 
a   very   thorough    examination,   we    believed    that 
there     was    a    probable     fracture    near  the    round 
head  of  the  radius.    Here,  again,  a  free  incision  was 
made,  when  another  non-displaced  fracture  of  the 
radial  shaft  was  discovered.     The  wound  was  her- 
metically sealed  and  a  support  applied.     In  both  of 
these  cases  the  results  have  been  very  gratifying, 
and  it  would  certainly  seem  that  the  division  of  the 
tense  indurated  soft-parts  exercised  a  most  salutary 
influence  by  relieving  pressure,  by  local  depiction 
and   favoring   reparative   processes   in   the  osseous 
parts,  as  you  will  find  on  examination  perfect  con- 
solidation of  the  fragments.     We  now  turn  to  the 
last,  or,  perhaps,  what  should  be  the  first  step,  a 
consultation  with  a  practitioner  whose  knowledge  is 
greater  than  our  own  in  this  type  of  traumatism. 
In  all  severe  or  doubtful  fractures,  one  should  not 
neglect  this;  both  for  the  patient's  advantage,   to 
divide  the  responsibility  and  protect  ourselves.     If 
circumstances  prevent  it,  one  may  send  the  case  to 
a  hospital  where  his  responsibility  ends.     Having 
decided  on  diagnosis,  we  proceed  to  the  considera- 
tion, in  outline  of  the    treatment    of    complicated 
fractures.    And  let  us,  at  the  outset,  distinctly  bear 
in  mind  that  in  all  fractures,  the  result  of  direct  vio- 
lence, the  lesion  of  the  bone  is  but  one,  and  some- 
times the  least  one,  sustained  by  the  crippled  limb, 
the  main  blood-vessels,  which  sustain  the  vitality, 
maintain  its  nutrition  and  provide  the  regenerative 
elements,  may  have  been  mortalh'  crushed,  or  have 
sustained  various  degrees  of    damage ;    the    nerve 
cords  which  animate  the  limb  may  have  been  contused 
or  torn  ;  the  muscles  never  entirely  escape,  nor  the 
ligaments,    in    breaks    contiguous  to  the  articula- 
tions, and  hence  we  may  say.  in  a  measure,  all  severe 
fractures  are  more  or  less  complicated.  We  broadly 
dividetheinjuriestobonesintotwoclasses,  the  closed 
and  the  open.     This  nomenclature   is  much   more 
accurate  than  the  older,  of  "simple  and  compound 
fracture,"  because,  as  has  been  noted,  everv  fracture 
is  compounded,  i.  e.,  the  so-called  simple  with  the 
skin  unbroken,  sometimes  is  a  more  serious  trau- 
matism  than   the   one   attended   with   exposure   by 
laceration  of  the  skin  and  displacement  of  the  frag- 
ments.    Reduced  to  a  brief  summary  of-basic  rules, 
the  principles  of  all  fractures  involve:  1st,  the  plac- 
ing of  the  limb  in  a  comfortable  position.     2nd,  we 
must  look  well  to  an  unhampered  circulation.     3rd, 
we  will  reduce  the  fragments  and  support  the  limb. 
These  directions  are  certainly  simple  enough,  but 
I  am  sure  you  will  regard  them  as  inadequate,  in- 
asmuch, as  I  have  not  emphasized  the  importance 
of  enforcing  the  time-honored  maxim,  to.  in  all  frac- 
tures immediately,   reduce  the   fragments   and   im- 
mobilize them.     Now,  in  closed  fractures  we  have 


io6o 


The  Philadelphia"! 
Medical   Journal  J 


COMPLICATED  FRACTURES 


fJUNE    1,    1901 


essentially  three  types:  ist,  the  displaced;  2nd,  the 
non-displaced ;  and  3rd,  the  impacted.  This  being 
the  fact,  it  should  give  us  the  raison  d'  etrc,  or 
explain  why  we  should  observe  this  antiquated 
vicious  dictum,  in  the  two  latter,  or,  how  can  we  re- 
duce fragments  which  are  not  displaced?  And  again 
explain  how,  in  those  fractures,  followed  by  impac- 
tion, in  brittle,  articular  heads  of  bones  of  old  peo- 
ple, we  can  improve  on  Nature's  mode,  of  at  once 
reducing  and  firmly  impacting  the  fragments?  In  the 
displaced  variety  there  is  rarely  any  urgency  for  the 
application  of  great  force,  or  even  immediate  reduc- 
tion. We  will  note  that  in  some  cases  of  fractures 
of  the  leg,  the  tibial  fragment  so  far  resists  traction 
immediately  after  injury,  that  Achilles-tendon  must 
be  divided  to  overcome  it,  and  the  limb  thereby  left 
weak  for  the  remainder  of  life ;  but  if  we  simply 
flex  the  knee  to  a  right  angle,  and  let  the  limb  rest 
on  a  pillow,  in  24  hours  the  spasm  will  have  passed 
off,  the  gastrocnemius  will  have  relaxed,  and  with 
the  greatest  ease  the  end  of  the  fragments  will  fall 
into  place  by  slight  pressure  and  there  remain.  If 
rest  and  relaxation  are  helpful  aids  in  diagnosis, 
they  are  especially  so  in  treatment.  Can  we,  or 
should  we,  attempt  early  firm  fixation  in  all  frac- 
tures? Yes,  if  we  would  expose  the  limb  to  the 
peril  of  gangrene,  if  we  would  retard  the  circula- 
tion, delay  or  arrest  repair.  Mechanically,  we  can 
fix  or  immobilize  anything,  but  here  we  are  dealing 
with  living  parts;  moreover,  prompt  ni  efifective 
repair  is  only  possible  when  the  circulation  is  un- 
hampered. Supports  we  must  utilize  not  so  much 
always  to  steady  the  fragments  as  to  prevent  joint 
action  when  the  fragments  tend  to  displacement. 
Splints  are  mechanical  adjustments;  when  shall  we 
apply  them,  and  which  are  the  best?  In  order  to 
answer  this  question,  we  may  recall,  that  the  osse- 
ous frame  is  made  up  of  connective  tissue,  and  that 
when  traumatized  or  disorganized,  its  mode  of  re- 
pair is  precisely  the  same  as  we  witness  in  connec- 
tive tissue  elsewhere ;  on  division  it  unites  by  pri- 
mary tinion.  For  what  possible  reason  then  should 
we  employ  any  descrijition  of  restraining  agent  in 
a  non-displaced  fracture,  when  the  best  splint  is 
none  at  all,  when  there  is  no  need  of  a  splint  at  anv 
time?  Several  years  ago  the  late  Sampson  Gamgee 
demonstrated  that  when  a  fracture  was  non-dis- 
placed, or  a  displaced  one  was  unhampered  in  ap- 
proximation, union  often  occurred  in  from  one  to 
two  weeks,  and  in  all  these  cases  there  was  no  cal- 
lus formation  of  any  description.  More  recentlv. 
Lucas  Championniere,  of  Paris,  has  entirely  dis- 
pensed with  splints  in  fractures  not  attended  with 
marked  displacement.  This  had  been  his  rule  in 
the  treatment  of  a  very  large  number.  By  this 
mode,  pain  is  reduced  and  speedy  solid  union  fol- 
lows. I  may  say  that  this  has  been  my  line  of 
practice  for  several  years,  the  general  results  being 
most  satisfactiry.  Prejudice  and  custom  die  hard, 
imitation  becomes  a  habit  slow  to  outgrow.  So 
habituated  to  mechanical  adjustment  has  the  prac- 
titioner become,  that  almost  instinctively,  as  soon 
as  a  fracture  is  detected,  he  reaches  out  for  a  splint, 
and  the  people  not  being  educated  up  to  modern 
advances,  will  certainly  regard  him  as  careless  or 
^ncompctont,  if  the  limb  is  not  immediately  set  and 
bound  up   with    braces.     Last    autumn    a   devoted 


mother  came  to  me  and  begged  that  the  house  staf? 
would  splint  her  boy's  broken  leg,  as  he  had  been 
in  the  hospital  ten  days,  and  this  was  not  yet  done. 
She  was  assured  that  he  would  not  be  neglected. 
Two  weeks  later,  when  he  walked  out  without  a 
limp,  the  poor  woman  was  amazed,  and  declared 
that  the  lad  could  not  have  done  so  if  the  limb 
had  been  broken,  and  that  we  must  have  imposed 
on  her.  Many  times  after  grave  injuries  to  a  limb 
multiple  fractures  occur,  and  the  parts  are  so 
crushed  that  we  are  not  so  much  concerned  about 
reduction  and  complete  fixation,  as  we  are  as  to  how 
we  shall  preserve  the  limb  at  all.  We  bolster  up 
the  fractured  limb,  relax  the  flexor  muscles,  leach, 
bathe  and  swathe  the  parts,  we  wait  the  subsidence 
of  inflamiTiation,  of  plastic  union  of  the  fragments, 
and  then  splint,  not  so  much  to  splice  the  fragments 
as  to  hold  the  joints  and  support  the  enfeebled 
parts.  The  open  incision,  the  operative  treatment  of 
closed  fractures,  has  been  recommended  of  late 
years.  Mr.  Arbuthnot  Lane,  of  London,  has  been 
a  warm  advocate  of  it,  but  the  English  surgeons  do 
not  share  his  enthusiasm.  Recently,  Rothschild,  of 
Germany,  and  Hatch,  of  Massachusetts,  have  pub- 
lished brochures  on  this  means  of  treating  fractures, 
and  appear  to  have  had  satisfactorj'  results.  How- 
ever, view  it  in  any  way  we  may,  the  primary  incis- 
ion in  closed  fracture  is  full  of  peril.  The  trauma- 
tized parts  possess  an  enfeebled  circulation,  their 
vitality  is  diminished,  and  hence  are  susceptible  to 
septic  infection.  This  radical  measure  is  highly 
praised  by  Dr.  Hatch,  who  claims  for  it  that  it  les- 
sens pain  and  shortens  convalescence.  The  fracture 
is  first  made  compound,  the  fragments  adjusted, 
then  closed  by  suture,  and  rendered  simple  aga'n. 
It  would  seem  an  ideal  means  in  femoral  fracture, 
which  so  generally  unite  with  over-riding  of  the 
fragments  and  shortening  of  the  limb.  In  two  ca^^es 
of  this  fracture  so  treated  by  myself  seven  j^ears 
ago,  both  patients  narrowly  escaped  death ;  in  one 
union  failed  absolutely ;  ankylosis  of  the  knee  with 
great  muscular  wasting  followed  in  both.  While 
the  greater  number  of  closed  fractures  yield  to  safe 
and  simple  measures,  the  cases  must,  indeed,  be  few 
which  warrant  this  sanguineous  and  dangerous  re- 
sort. As  a  conservative  measure,  after  all  inflam- 
matory changes  have  abated,  to  correct  a  deflection 
or  deformity,  the  open  incision  combined  with  os- 
tetomy  and  osteoclasis  is  utilized  with  great  advan- 
tage. This  young  man's  limb  illustrates  the  happv 
results  succeeding,  when  we  divide  the  non-inflam- 
mable parts.  Six  months  ago,  it  appears,  he  suf- 
fered a  very  bad  fracture  of  the  lower  third  of  the 
tibia  and  fibula,  the  fragments  united  with  so  much 
distortion  that  the  inverted  foot  presented  the  sole 
up  and  the  dorsum  resting  on  the  ground,  left  a 
hopeless,  helpless  cripple,  with  great  atrophy  of  the 
muscles  of  the  leg.  an  ankylosed  ankle  joint,  and  a 
swollen  sensitive  foot.  By  the  free  open  incision,  a 
complete  refracture  and  osteosection,  after  two 
months'  treatment,  you  will  observe  that  he  readilv 
walks  up  and  down  the  aisle  without  anv  support, 
and  call  stand  on  one  foot  quite  as  well  as  on  the 
other.  But  here  let  it  be  noted  that  we  operated  in 
healthy  tissues,  we  employed  no  drain,  and  secured 
practically  primary  union.  We  hear  much  about  the 
ainbiihuif  freatniciit  of  frjclurcs.  which  means  moving 
about  daily,  to  take  advantage  of  exercise,  fresh  air 


June  1,  1901] 


PITYRIASIS  VERSICOLOR 


r  The  Philadelphia 
L Medical  Journal 


I061 


and  change  of  surroundings.  No  one  will  dispute 
the  advantages  of  early  locomotion,  but  in  practi- 
cally all  fractures  of  the  lower  limb,  at  the  time  of 
injury,  the  body  has  simultaneously  sustained  great 
shock.  Here  composure  and  rest  in  bed  are  indis- 
pensible.  In  the  earh'  stages  of  fracture  of  the 
lower  extremities,  the  horizontal  position  of  the 
body  is  essential,  but  after  the  first  or  second  week 
the  osseous  repair  is  much  facilitated  and  hastened 
in  the  vertical  position ;  the  venous  turgescence 
and  marked  swelling  seem  rather  to  accelerate  con- 
solidation, and  in  these  fractures  we  will  often  ob- 
serve how  union  is  generally  hastened  when  we  re- 
move all  splinting,  and  place  the  patient  on  crutches. 
Of  compound  or  closed  fractures,  time  will  only  per- 
mit of  a  very  brief  reference.  These,  with  few  ex- 
ceptions, are  formidable  injuries,  often  endangering 
life,  or  leading  up  to  an  amputation.  In  form»?r 
times  they  filled  the  practitioner  with  the  greatest 
apprehension,  infection  frequently  occurred,  intense 
inHammation  set  in,  erysipelas  developed,  or  gan- 
grene seized  on  the  parts,  destroyed  the  limb,  and 
often  life  with  it.  But  of  late,  it  has  become  quite 
the  established  rule  to  save  all  these  cases  in  which 
the  circulatory  current  has  not  suffered  mortal  dam- 
age at  the  time  of  injury.  By  the  aid  of  antiseptics, 
anesthetics,  and  aseptic  precaution,  we  first  endeav- 
or to  preserve  the  limb  in  the  best  shape  we  can. 
By  resorting  to  modern  osteoplastic  methods,  as 
taught  by  tlie  late,  great  Oilier,  we  now  restore  to 
usefulness  thousands  of  limbs  which  formerly  went 
to  the  amputating  table.  Our  next  lecture  will  be 
devoted  to  a  consideration  of  this  class  of  fractures. 
In  conclusion,  gentlemen,  permit  me  to  make  a 
plea  for  practitioners  treating  more  fractures  at 
home  :  keep  them  at  home.  They  constitute  an  in- 
teresting class,  and  are  amply  remunerative.  Stop 
this  demoralization  of  the  people,  of  forcing  on 
them  your  service  for  nothing.  If  ^-ou  feel  you  are 
incompetent,  then  take  a  post-graduate  course  or 
several  of  them  in  some  institution  where  this  im- 
portant branch  of  surgery  provides  ample  opportu- 
nities and  facilities  for  instruction. 


PITYRIASIS   VERSICOLOR,  WITH  SPECIAL  REFER- 
ENCE TO  ALLEN'S  IODINE  TEST. 

By  JACOB  SOBEL.   M.   D., 

of  New  York. 

Dermatological   Assistant   at   the  Good   Samaritan   Dispensarj'; 
Member    of   the    Manhattan    Dermatological    So- 
ciety, etc.,   New  York. 

Among  the  cutaneous  parasitic  diseases  of  the 
adult,  none  is  more  frequent  and  yet  none  more 
overlooked  than  that  of  pityriasis  versicolor  or 
chromophytosis.  Owing  its  existence  to  the  lodg- 
ment and  proliferation  in  the  superficial  cutaneous 
layers  of  the  microsporon  furfur,  it  appears  mainly 
on  the  surfaces  hidden  by  the  clothing — chest,  back 
and  abdomen— in  the  form  of  yellowish,  brownish, 
reddish,  or  chamois-colored  furfuraceous  patches  of 
various  shapes  and  sizes,  which  produce  but  slight 
subjective  disturbance,  and  which  give  a  very  char- 
acteristic reaction  when  painted  with  various  iodine 
solutions,  particularly  Lugol's  solutnon.  It  is 
mainly  because  these  patches  are  so  small  and  so 
light  in  color  in  the  very  early  stages,  that  they  es- 


cape the  notice  of  both  patient  and  physician.  Apart 
from  a  mild  degree  of  itching,  the  constitutional  dis- 
turbance is  ).'(/  or  in  inverse  proportion  to  the 
amount  of  fungus  present.  These  patients  seek 
treatment  mainly  for  esthetic  reasons  or  because 
they  fear  that  the  spots  are  indicative  of  liver  dis- 
ease, and,  indeed,  they  are  frequently  referred  to  as 
"liver  spots."  From  one  text-book  to  the  other  va- 
rious premises  have  been  handed  down  with  regard 
to  the  parts  of  the  bodj'  involved  and  the  predispo- 
sition of  certain  patients.  The  most  common  state- 
ment met  with  is  that  the  disease  spares  the  parts 
exposed  to  light — that  is,  the  face,  hands  and  neck. 
On  this  fact  all  authors  practically  agree.  Closer 
observation,  however,  and  the  aid  of  Lugol's  solu- 
tion have  served  to  disprove  these  time-honored 
"axioms."  Time  and  again  have  I  been  able  to 
demonstrate  the  existence  of  the  eruption  upon  the 
front  and  back  of  the  neck,  at  the  angle  of  the  jaw 
and  even  upon  the  side  of  the  face  as  high  as  the 
forehead.  It  is  quite  true  that  in  many  cases  only 
a  preliminary  staining  with  Lugol's  solution  served 
to  bring  into  relief  the  seemingly  hidden  lesions. 
These  areas  when  painted  with  the  solution  appear 
of  a  deep  mahogany  or  verj-  dark  brown  color, 
which  Shows  itself  in  marked  contrast  to  the  sur- 
rounding tissue.  We  may  note  from  this  test  not 
only  the  existence  of  the  disease,  but  also  its  se- 
verity and  retrogression,  for  the  more  active  the 
disease  the  darker  will  be  the  stain  ;  in  the  declining 
stages  the  lesions  take  up  the  stain  but  faintly.  This 
test  is  of  such  marked  value  for  class-room  demon- 
stration, that  it  is  surprising  it  has  not  been  more 
generally  adopted  by  teachers.  I  cannot  say  that 
the  test  would  be  of  especial  value  in  dififerentiating 
this  disease  from  others  of  a  truly  or  presumably 
parasitic  nature,  viz.:  disseminated  ringworm,  pity- 
riasis rosea,  mycotic  eczema,  because  they  all  react 
to  the  iodine  applications,  but  it  certainly  excites  a 
marked  suspicion  of  the  parasitic  nature  of  the  dis- 
ease under  diagnosis;  for  if  the  test  be  applied  to 
other  conditions  of  a  desquamative  character,  such 
as  seborrheal  eczema,  dermatitis,  scaly  syphilide, 
exanthemata,  etc.,  it  will  invariably  fail,  in  that 
while  the  cast-off  epithelium  will  take  up  the  stain 
to  a  mild  degree,  tlict'e  is  no  markedly  positive  reaction. 
Though  Gottheil.  in  his  "Illustrated  Skin  Diseases." 
joined  the  majority  in  saying  that  the  "face,  palms 
and  soles  are  always  free,"  he  at  the  same  time  gave 
the  death  blow  to  the  statement  that  the  palms  are 
nex'er  affected,  in  the  publication  of  a  very  typical 
and  unique  case  (Medical  Record,  July,  1899).  fo'' 
a  long  time  it  was  supposed  that  the  disease  bore 
some  relation  to  phthisis  on  account  of  the  great 
numl^er  of  cases  found  in  subjects  of  this  disease. 
That  they  are  frequently  attacked  is  quite  true,  but 
that  pityriasis  versicolor  occurs  chiefl}-  in  such  pa- 
tients is  very  questionable.  Its  more  frequent  dis- 
co\-er\-  in  phthisical  subjects  is  due  to  the  fact  that 
this  class  expose  their  chest  for  examination  more 
frequently  than  others,  and  the  chromophytosis  is 
discovered  incidentally.  No  class  or  age  is  exempt, 
thotigh  children  and  very  old  people  are  rarely  at- 
tacked. I  have  never  seen  an  instance' in  those  over 
55  and  children  under  15  years.  Such  cases  have 
been  recorded,  however.  Any  disease  or  condition 
which  produces  hyperidrosis  offers  by  reason  of  this 
symptom  a  predisposition  to  the  growth  of  the  fun- 


Tnfio       The  Philadelphia"! 
•^'-'"^       Medical   Jocknal  J 


THE  BICEPS  TENDON  JERK 


[JUKB   1,   1901 


gus.  Though  parasitic  in  its  nature,  it  is  generally 
conceded  that  the  disease  is  not  hetero-inoculable, 
no  positive  case  to  my  knowledge  having  thus  far 
been  recorded.  !Max  Joseph  reports  an  instance  in 
which  it  appears  that  the  husband  using  the  same 
bath-tub,  towel  and  soap,  infected  his  wife.  Only 
recently  I  obser\-ed  six  cases  in  one  family,  a 
condition  strongly  suggestive  of  contagion.  The 
treatment  of  the  disease  is  apparently  simple,  any 
desquamating  and  penetrating  agent,  such  as  hypo- 
sulphite of  sodium,  B  naphthol,  sulphur,  resorcin. 
salicylic  acid,  etc.,  effecting  a  cure.  Treatment  must 
be  thorough  and  persistent ;  to  limit  one's  self  to  the 
use  of  exfoliating  measures,  which  simply  remove 
the  uppermost  layers,  will  result  in  dismal  failures. 
As  the  origin  "of  each  patch  is  peri-  and  perhaps  in- 
trafollicular,"  the  penetrating  agents  must  be  added 
if  we  will  prevent  recurrences.  To  prevent  renewed 
outbreaks  is  not  always  an  easy  matter.  As  long  as 
anv  vestige  of  the  disease  remains  another  attack  is 
assured.  There  can  be  no  question  that  one  impor- 
tant cause  of  recurrence  will  be  found  in  the  failure 
to  treat  a  region  hitherto  overlooked — the  supra- 
public  region.  Here,  as  Dr.  Allen  has  pointed  out. 
numerous  patches  may  exist  in  their  efflorescence, 
and  yet  owing  to  the  covering  of  hair  entirely  es- 
cape recognition  and  treatment.  These  patches 
stTxe  as  sources  of  renewed  contagion  and  the  dis- 
ease breaks  out  afresh.  In  men  as  well  as  women, 
these  patches  are  often  so  small  as  to  be  brought 
into  view-  only  by  the  application  of  the  iodine  test. 
It  has  seemed  to  me  that  pityriasis  versicolor  in  the 
suprapubic  region  is  at  times  attended  with  more 
itching  than  that  of  the  rest  of  the  body.  This  cir- 
cumstance gives  rise  to  scratching  and  the  carrying 
of  the  causative  agent  to  other  parts  of  the  body — 
autoinoculation,  as  it  were.  As  a  result  of  expe- 
rience my  conclusions  are:  (i)  The  old  theory  that 
only  hidden  parts  are  affected  is  no  longer  tenable. 
(2)  Allen's  iodine  test  is  of  marked  value  not  only 
for  class-room  demonstration  and  for  bringing  into 
relief  pale  and  hidden  lesions  of  pityriasis  versicolor, 
but  also  for  differentiating  parasitic  or  presumably 
parasitic  skin  affections  from  those  of  a  non-para- 
sitic nature.  (3)  Recurrences  are  in  the  main  due 
to  the  overlooking  and  non-treatment  of  the  supra- 
pubic region  and  to  the  use  of  desquamative  agents 
to  the  exclusion  of  penetrating  ones.  Both  must  be 
combined  if  a  cure  is  desired.  (4)  Phthisical  sub- 
jects, while  affected  in  great  measure  on  account 
of  the  hypersecretion  of  sweat,  do  not  form  the 
greater  part  of  these  patients.  It  occurs  in  all  de- 
grees of  health  and  disease,  a  marked  hyperidrosis. 
however,  predisposing  towards  it.  (5)  Children  and 
the  very  old  are  occasionally,  though  rarely,  at- 
tacked. (6)  It  may  occur  in  all  shades  from  a  very 
light  pink  to  almost  coal  black  (pityriasis  nigra),  the 
color  being  influenced  by  the  condition  of  cleanli- 
ness, the  circulation  of  the  skin,  the  occupation  of 
the  patient,  and  the  color  of  the  underclothing. 


THE  BICEPS  TENDON  JERK  IN  LOCOMOTOR  ATAXIA 

By   MOSES  BEHREND,  M.  D., 

of  I'hiHt'.clphia. 

At  the  suggestion  of  Dr.  Burr  and  under  his  guid- 
ance, I  have  studied  the  biceps  tendon  jerk  in  29 
cases  of  tabes.     Frenkel,  in  the  July,  1900,  number 


of  the  "Deutsche  Zeitschrift  fuer  Nervenheilkunde" 
states  that  he  has  come  to  the  important  conclusion 
that  the  absence  of  the  tendon  reflexes  in  the  upper 
extremities  is  a  constant  symptom  of  tabes ;  and 
that  this  is  even  more  constant  than  the  absence 
of  the  patellar  reflex.  He  says  that  it  is  not  only 
constant  in  the  medium  and  severer  cases  of  the 
disease,  but  also  forms  one  of  the  earliest  signs  of 
tabes  in  the  severest,  less  severe  and  medium  cases, 
where  the  ataxia  shows  itself  in  its  various  grades; 
not  one  case  has  been  observed  in  which  the  re- 
flexes were  present  in  the  upper  extremities.  The 
above  conclusions  were  reached  by  him  from  an 
examination  of  several  hundred  cases. 

A  table  of  23  cases  is  given  by  him  in  which  the 
triceps  reflex  was  present  in  5  cases  and  3  in  w^hichit 
was  present  in  one  arm  and  absent  in  the  other. 
This  appears  to  be  a  contradiction  to  the  paragraph 
above  quoted  in  full.  It  is  hard  to  realize  that  such 
statements  should  be  made,  and  especially  since  he 
repeats  the  statement  in  various  parts  of  his  paper 
that  the  reflexes  are  constantly  absent  in  the  upper 
extremities. 

Out  of  29  cases  of  undoubted  tabes  which  I  ex- 
amined, the  biceps  tendon  jerk  was  present  in  nine 
and  the  triceps  tendon  jerk  w^as  present  on  both 
sides  in  two  patients  and  present  on  one  side  only 
in  two  others.  In  the  two  cases  in  which  the  tri- 
ceps tendon  jerks  were  present  on  both  sides,  the 
biceps  tendon  jerks  w^ere  absent  on  both  sides  in 
one  and  preserved  on  both  sides  in  the  other.  In 
one  case  the  biceps  tendon  jerk  was  present  on  both 
sides  with  the  triceps  tendon  jerk  present  on  one 
side  only:  in  another  the  triceps  tendon  jerk  was 
present  and  the  biceps  tendon  jerk  was  absent  on 
the  same  side ;  the  reverse  was  true  in  the  other 
arm. 

The  muscle  jerks  of  the  arms  were  present  in  all 
the  cases  and  in  various  degrees  of  excitability.  The 
muscle  "hump"  always  appeared  upon  percussing 
the  muscle.  The  duration  of  the  cases  ranged  from 
one  to  25  years. 

Some  interesting  results  were  obtained  in  examin- 
ing these  cases  for  sensibility  to  all  forms 
of  stimuli ;  the  relation  of  the  reflexes  to 
the  degree  of  ataxia  and  the  severity  of  the 
shooting  pains.  Generally,  it  may  be  said  that 
in  those  cases  in  which  the  biceps  tendon  jerk 
was  absent  ataxia  was  more  marked  in  the  arms, 
but  there  were  a  few  exceptions.  Of  17  cases  in 
which  the  biceps  tendon  jerk  was  absent,  marked 
ataxia  existed  in  the  arms  of  11,  while  in  the  re- 
maining six  ataxia  of  the  arms  was  only  slight.  Of 
the  latter  two  were  of  the  ocular  form  of  tabes.  In 
this  variety  we  have  as  a  rule  the  ataxia  lessened, 
therefore  I  believe  they  should  be  considered  as  a 
separate  class.  One  case  of  ocular  tabes  is  in  a  col- 
ored man  :  he  is  not.  however,  a  full-blooded  negro. 
One  of  the  six  above  referred  to  has  had  locomotor 
ataxia  for  the  past  2^  years  and  the  ataxia  of  the 
legs  is  very  marked,  the  patient  being  unable  to 
walk. 

For  the  sake  of  comparison  let^us  consider  the 
relation  of  the  arm  to  the  leg  ataxia.  In  three 
of  the  six  eases  in  which  there  was  slight  ataxia 
in  the  arms,  ataxia  of  the  legs  was  marked,  while  in 
the  II  cases  referred  to    ataxia    of    th.e    legs    was 


June  1,  1301] 


THE  BICEPS  TENDON  JERK 


TThb  Philadelphia 
Lmedicai.  Journal 


1063 


marked  in  10  and  slight  in  one.  The  latter  illus- 
trates the  occurrence  of  hemiplegia  in  tabes.  The 
history  of  the  case  is  as  follows : 

Patient  is  Frederick  P.  Age  62.  Denies  syphilis.  In 
1892  patient  had  shooting  pains,  some  disturbance  when 
walliing  in  the  dark,  followed  by  a  sensation  of  velvet  on 
the  soles  of  his  feet  while  walking.  A  couple  of  years  later 
he  complained  of  girdle  pains  which  were  not  constant 
In  1897  after  his  symptoms  had  slowly  progressed  he  was 
suddenly  unable  to  open  his  left  eye.  The  patient  did  not 
have  any  other  paralyses.  At  the  present  time  the  right 
foot  is  dragged  a  little  in  walking  and  the  gait  is  some- 
what staggering.  The  patient  is  a  well-nourished  male, 
average  height,  iron  gray  hair  and  beard.  Sensation  for 
all  forms  entirely  normal.  The  knee  jerks  are  present  on 
both  sides,  more  marked  on  the  right  leg.  The  biceps 
tendon  jerks  are  absent  in  both  arms.  The  triceps  tendon 
jerks  are  present  in  both  arms.  Achilles  tendon 
jerks  are  marked  on  both  sides.  The  Babinski  reflex  is 
present  as  is  shown  by  stroking  the  sole  of  the  right  foot, 
the  great  toe  extends,  the  others  flex  with  separation.  On 
the  left  foot  there  is  marked  flexion  of  the  small  toes  with 
no  movement  of  the  great  toe.  The  patient  sways  some 
with  eyes  shut.  Pupils  do  not  react  to  either  light,  con- 
vergence or  accommodation. 

The  Babinski  reflex  was  present  on  both  sides  in 
another  case  in  which  the  knee  jerks  were  lost  in 
the  absence  of  the  hemiplegic  state.  The  history  of 
the  case  is  as  follows : 

Patient  is  Ludwig.  Age  61.  He  is  so  dull  and  stupid  that  we 
are  compelled  to  rely  solely  on  the  physical  examination.  He 
is  somewhat  emaciated,  skin  is  bronzed;  gait  is  ataxic: 
sways  considerably  with  eyes  closed.  Argyl-Robertson 
pupil  is  present.  Knee  jerks  are  absent.  Biceps  tendon 
jerks  are  present  on  both  sides  as  are  also  the  triceps  ten- 
don jerks.  Achilles  jerks  are  absent.  Ataxia  of  the 
arms  and  legs  is  marked.  Upon  stroking  the  soles  of  the 
feet  marked  extension  of  all  the  toes  occurs. 

In  nine  cases  the  biceps  tendon  jerk  was  present. 
Ataxia  of  the  arms  was  vtry  marked  in  two.  In  one 
of  the  latter  atrophy  of  the  muscles  of  the  hand  was 
seen,  with  changes  in  the  joints  similar  to  those 
found  in  rheumatoid  arthritis.  The  right  knee  jerk 
was  absent,  the  left  was  lightly  present.  In  the  re- 
maining seven  ataxia  of  the  arms  was  very  slight. 
One  has  had  tabes  for  22  years.  He  has  marked 
ataxia  of  the  legs,  relaxation  of  the  ligaments 
around  the  knee  joints,  causing  retroflexion.  Of  the 
nine  cases  in  which  the  biceps  tendon  was  present, 
ataxia  of  the  legs  was  marked  in  five. 

Absent  biceps  tendon  and  knee  jerks  were  con- 
stant in  those  cases  having  arthropathies.  The 
trophic  changes  comprised  three  dislocated  hips, 
one  dislocated  shoulder,  two  retrofle.xcd  knee  joints 
and  a  tabetic  foot.  The  patient  having  the  latter 
has  never  been  reported.  Her  history  is  as  follows : 
Alice  B.  Aged  59.  Syphilis  denied.  Her  family  and  past  med- 
ical history  are  unimportant.  The  patient  says  she  was  per- 
fectly well  until  five  years  ago, when  after  exposure  she  had  a 
chill.  Since  then  she  has  been  subject  to  pain  in  the  joints. 
She  was  afraid  to  walk;  she  would  stagger  and  fall  if  un- 
supported. Two  years  ago  her  right  shoulder  and  left 
hip  were  dislocated  without  the  history  of  an  accident. 
The  patient  is  a  very  well-nourished  female,  very  nerv- 
ous disposition,  very  irritable,  becomes  easily  flusterej 
upon  slight  provocation.  The  left  pupil  is  greatly  dilated, 
eyes  are  prominent  and  convergent.  Irides  do  not  react 
to  light,  accommodation  or  convergence.  A  condition  of 
double  ophthalmoplegia  is  present.  She  sees  very  little 
and  cannot  distinguish  objects.  The  right  shoulder  is  very 
prominent,  not  painful  and  can  be  proti-uded  at  will  in 
various  directions.  Marked  lordosis  of  the  spine  is  also 
present.  The  reflexes  are  all  absent,  ataxia  of  arms  and 
legs  is  well  marked.  Sensation  is  impaired:  pain,  tactile 
and  thermal  losses  being  found  only  in  areas  on  the  legK 
After-sensations  are  found  in  the  legs.  A  feeling  of  prick- 
ing and  sticking  is  felt  from  three  to  five  minutes  after  the 
aesthesiomeler  is  used:  the  discomfort  being  greater  than 


when  the  stimulus  is  applied.  The  left  foot  is  swollen  and 
edematous,  the  toes  are  turned  slightly  downward  and  there 
is  complete  foot  drop. 

Sensation  was  normal  in  six  of  the  nine  cases  in 
which  the  biceps  tendon  jerk  was  present  on  both 
sides,  and  in  eight  of  the  seventeen  cases  with  the 
biceps  tendon  jerk  absent. 

Two  of  the  eight  cases  above  mentioned  were  of 
the  ocular  type.  .Sensation  was  also  normal  in 
two  of  the  three  cases  in  which  the  biceps  tendon 
jerk  was  present  on  one  side  and  absent  on  the 
other;  while  in  the  remaining  one  pain  and  thermic 
sense  were  diminished  on  the  side  in  which  the 
biceps  tendon  jerk  was  lost.  As  is  usual  in  loco- 
motor ata.xia,  deranged  pain  sense  was  almost  con- 
stant. In  one  case  hyperaesthesia  existed  in  the 
arms  with  a  large  biceps  tendon  jerk. 

Astereognosis  was  complete  in  four  cases  and  par- 
tial in  three  others.  The  biceps  tendon  jerk  was 
absent  and  all  were  markedly  ata.xia  in  the  arms. 

The  sense  of  position  is  lost  only  in  those 
cases  showing  marked  ataxia.  One  exception 
is  found  in  an  advanced  case.  He  is  a  blind 
colored  man,  in  whom  the  left  hip  is  dislo- 
cated, together  with  such  relaxation  of  the 
ligaments  of  both  hips  as  to  enable  him  to  throw 
his  feet  far  above  his  head  and  with  the  knees  touch 
his  chest.  The  loss  of  the  sense  of  position  occurred 
in  II  cases  in  only  one  of  these  is  it  lost  in  both 
arms  and  legs. 

The  shooting  pains  of  locomotor  ataxia  do  not 
seem  to  have  any  relation  to  the  degree  of  ataxia. 
Nine  cases  in  which  the  biceps  tendon  jerk  was  ab- 
sent, were  devoid  of  shooting  pains  in  the  arms ; 
of  these  five  showed  marked  ataxia,  while  the  pains 
were  present  in  nine  others,  with  the  biceps  tendon 
jerk  lost.  Marked  ataxia  was  found  in  eight  of 
these.  In  the  nine  cases  in  which  the  biceps  tendon 
jerk  was  present  on  both  sides  the  characteristic 
pains  were  found  in  two,  while  one  had  slight  shoot- 
ing pains  in  the  arm  in  which  the  biceps  tendon 
jerk  was  present  and  severe  pains  on  the  side  in 
which  the  jerk  was  absent. 

The  loss  of  weight  sense  was  present  in  the  most 
advanced  cases  and  occurred  in  only  two  cases. 
.\taxia  was  very  marked  in  both  of  these.  One  of  the 
patients  was  unable  to  recognize  a  weight  below 
eight  ounces  in  either  band.  The  most  advanced,  and 
naturally  the  most  ataxic  case  in  the  hospital  was 
unable  to  recognize  a  weight  below  one  pound  in 
the  left  hand  and  two  pounds  in  the  right  hand. 
This  patient  has  had  the  symptoms  of  tabes  for  ten 
years.  He  is  unable  to  walk  and  he  has  also  lost 
nearly  all  of  his  teeth  since  the  onset  of  the  dis- 
ease. The  conclusions  to  be  drawn  from  these  ob- 
servations are : 

1.  That  the  ataxia  in  the  arms  is,  as  a  rule,  more 
marked  when  the  biceps  tendon  jerk  is  absent. 

2.  That  the  ataxia  of  the  arms  is  usually  marked 
when  the  same  is  found  in  the  legs.  In  these  the 
biceps  tendon  jerk  is  absent. 

3.  That  in  the  presence  of  the  biceps  tendon  jerk 
with  slight  ataxia  in  the  arms,  ataxia  in  the  legs  is 
invariably  well-marked. 

4.  That  sensation  is  usually  normal  in  those 
cases  with  normal  biceps  tendon  jerk. 

5.  That  the  sensory  losses  are  usually  found 
when  the  biceps  tendon  jerk  is  absent. 


1064 


The  Philadelphia 


] 


THE  BICEPS  TEXDOX  JERK 


[JU.VE    1,    13<tt 


6.  That  arthropathies  are  only  found  in  the  ad- 
vanced cases. 

7.  That    astereognosis    is    only    present    in    the 
markedlv  ataxic. 

8.  That  the  loss  of  the  sense  of  position  is  almost 
constant  in  the  advanced  cases  of  tabes. 

9.  That  the  shooting  pains  in  the  arms  do  not  bear 
anv  relation  to  the  degree  of  ataxia. 

10.  That  the  marked  ata.xics  seldom  show  the  loss 
of  weight  sense. 

1 1.  That  the  intensity  of  the  symptoms  are  not  de- 
pendent on  the  duration  of  the  case,  but  rather  upon 
the  extent  of  the  sclerotic  process.  For  example,  I 
saw  one  of  my  patients  who  has  had  tabes  for  the 
past  22  years  sitting  on  a  railing  with  the  feet  rest- 
ing on  a'bench  and  balancing  himself  well.  Another 
striking  point  is  the  selective  power  of  the  patho- 
logical" lesions.  We  find  that  the  biceps  tendon 
jerks  are  present  in  three  patients  on  one  side  and 
absent  in  the  other.  We  can  explain  this  by  assum- 
ing that  the  degeneration  has  limited  itself  to  one 
side  of  the  cord.  In  those  cases  in  which  the  biceps 
tendon  jerks  are  absent,  the  sclerosis  probably  ex- 
tended to  the  cervical  region,  but  it  is  not  to  be 
forgotten  that  this  reflex  may  be  absent  in  normal 
individuals. 


BERLINER    KLINISCHE   WOCHENSCHRIFT. 
Fehruiirii   2-J.    l'.)'il. 

1.  A  Hitherto  Unknown  Form  of  Atresia  of  the  Uterus. 

LANDAU.  » 

2.  Demonstration    of    an    Aortic    Aneurism    Which    Gave 

Rise    10    the    Svmptoms    of    a    Mediastinal    Tumor. 
EWALD. 

3.  The  Application  of  the  Phonograph  in  the  Pathology 

and  Treatment  of  the  Voice.    FL.A-T.XU. 
■1.     The  Disposal  of  City  Sewage.     GAERTXER. 

1. — Landau  reports  several  interesting  cases.  -A. 
woman  of  40  had  had  menstrual  disturbances  every  four 
weeks  from  her  12th  year,  without,  however,  any  loss  of 
blood.  Operations  performed  in  the  ISth  and  23rd  years 
were  without  result.  She  had  suffered  from  frequent  at- 
tacks of  inflammation  in  the  abdomen,  that  had  rendered 
her  incapable  of  working.  A  vaginal  examination  showed 
a  huge  fornix  and  cervix  with  the  evidences  of  a  tumor. 
At  the  operation  this  was  found  to  be  an  enlarged  uterus 
filled  with  blood,  and  there  were  also  hematosalpinx  of 
both  sides,  and  alterations  in  the  ovaries.  The  cervix  of 
the  uterus  was  found  to  be  replaced  and  the  canal  occluded 
by  a  large  tumor,  that,  upon  histological  examination, 
proved  to  be  a  mesonephron  form  of  obstruction  of  the 
cervix  that  has  not  hitherto  been  described.  The  second 
case,  a  woman  30  years  of  age.  had  had  similar  symptoms 
and  at  the  operation  both  tubes  were  discovered  distend- 
ed with  blood,  and  there  were  changes  in  the  ovaries.  As 
the  pains  were  not  relieved  by  a  bilateral  oophorectomy 
the  uterus  was  opened  and  some  blood  evacuated.  In  dis- 
cussion of  the  pathogenesis  of  this  condition.  Landau  be- 
lieves that  it  is  due  to  an  embryonal  hyperplasia  of  the 
lower  portion  of  the  Wolffian  duct:  although  he  admits 
that  it  is  possible  that  there  was  a  bacteriological  element 
in  the  production  of  the  hematosalpinx.     [J.  S.] 

2. — Ewald  reports  the  case  of  a  woman  43  years  of  age. 
who  shortly  before  examination  noticed  shortness  of 
breath,  swelling  of  the  face,  and  of  the  right  shoulder. 
At  the  same  time  there  was  distension  of  the  veins  on 
the  whole  right  side  of  the  upper  part  of  the  body,  some 
difficulty  in  swallowing  solid  food,  and  as  a  result  almosr 
complete  anorexia  and  loss  of  flesh.  When  examined  it 
was  found  that  the  face,  neck  and  hands  were  dark  biue  in 
color,  the  head  was  held  to  one  side,  and  unon  the  thorax 
and  abdomen  the  veins  were  prominent.  Upon  examina- 
tion with  the  Roentgen  ray  a  tumor  was  discovered  lying 
above  and  to  one  side  of  the  heart.  It  did  not  appear  to 
pulsate,  nor  have  any  of  the  other  characteristic  signs  of 
aortic  aneurism.  The  heart  was  not  enlarged.  There  was 
no  murmur  over  it,  nor  over  any  of  the  large  vessels.    The 


pulse  was  apparently  normaL  Dullness  was  found  over  the 
sternum,  and  from  the  rig-it  clavicle  to  the  3rd  rib.  Other- 
wise the  lungs  were  normal.  The  patient  died  about  3 
weeks  later  in  an  attack  of  severe  dyspnea.  At  the  autop- 
sy a  saccular  aneurism,  about  the  size  of  a  fist,  arising 
aom  the  ascending  portion  of  the  aortic  arch  and  filled  with 
clots,  occupied  the  position  of  dullness.  This  had  almost 
occluded  the  superior  vena  cava.  It  had  also  compressed 
the  trachea,  causing  partial  erosion  of  its  wall,  and 
slightly  compressed  the  esophagus.  The  inferior  cava  was 
not  involved.  In  regard  to  the  distension  of  the  superficial 
reins  of  the  thorax  and  abdomen,  Ewald  believes  that  a 
collateral  circulation  with  the  current  downward  is  neces- 
sarily established  whenever  the  superior  cava  is  occluded. 
He  does  not  believe  that  it  is  clinically  possible  to  distin- 
guish the  direction  of  the  blood  current.     [J.  S.] 

3. — Flatau  believes  that  the  phonograph  is  valuable  for 
The  study  of  the  pathology  of  the  disturbances  of  speech, 
for  the  demonstration  and  control  of  the  results  of  ther- 
ixpy.  and  for  the  purpose  of  clinical  and  physiological  In- 
.struction.  He  demonstrated  in  the  lecture  different  phono- 
'  grams  from  the  voice  of  the  same  person  taken  before  and 
I  after  the  removal  of  various  swellings  in  the  naso-laryn- 
I  geal  tract.  He  calls  attention  to  the  fidelity  with  which 
ihe  curious  forcing  tone  due  to  slight  stenosis  of  the  larynx, 
is  reproduced.  The  ordinary  apparatus  requires  few  modi- 
fications. The  cylinder  may  be  driven  by  clock-work  or 
by  an  electric  motor.  The  best  cylinders  are  probably  de- 
rived from  America  and  those  that  have  been  used  several 
times  give  the  clearest  records.  On  account  of  the  fragility 
of  these  records  it  is  desirable  to  take  as  many  as  possi- 
ble of  each  interesting  case.  The  maximum  number  is 
probablv  six.  Copving  is  unfortunately  at  present  impos- 
sible.    [J.  S.] 


REVUE  MEDICALE  DE  LEST. 

il'ii'h  lo.  i:<')l.  (Volume  33,  No.  6.) 
1.  The  Treatment  of  Congenital  Dislocation  of  the  Hip. 
R.  FROELICK. 
1. — In  the  past  fi\e  years.  Froelich  has  treated  31  cases 
of  congenital  dislocation  of  the  hip.  Successful  treatment 
depends  upon  radiography.  Dislocation  of  both  hips  oc- 
curred in  15  of  his  cases:  on  the  right  side  alone  in  10:  and 
on  the  left  side  alone,  in  6.  26  cases  were  found  in  girls. 
Congenital  dislocation  of  the  hip  had  already  appeared  in 
the  family  in  S  cases:  and  S  of  these  children  were  tuber- 
cular. Hernia  existed  only  in  two  cases,  for  one  of  which 
the  operation  for  radical  cure  was  done  four  times,  with 
success  at  last.  In  all  but  four  cases  the  congenital  dis 
location  was  due  to  a  congenital  malformation.  In  4 
cases  Froelich  believes  that  it  followed  infantile  paralysis. 
This  was  confirmed  by  radiographs  in  13  cases,  whose 
measurements  have  been  tabulated.  As  a  rule  they  grew 
less  lame  during  10  years,  bat  the  limping  became  aggra- 
vated after  15  years,  and  was  always  worse  after  an  ill- 
ness. In  boys  it  grows  rapidly  worse,  much  worse  than  in 
girls.  The  treatment  will  depend  upon  the  condition  seen 
In  the  radiograph.  Operation  will  be  indicated  in  most 
cases,  however.  Exceptionally,  a  new  joint  will  form  by 
Itself,  and  should  not  be  disturbed.  Operation  is  most  suc- 
cessful between  the  second  and  fourth  years.  Over  nin«> 
years  the  bloodless  operation  ■will  not  be  possible.  Froe- 
lich employs  the  bloodless  Paci-Lorenz  operation,  with  the 
Lorenz  after-treatment  The  result  in  S  cases,  out  of  2^ 
cases  operated,  was  perfect-  Fracture  of  the  upper  third 
of  the  femur  occun'ed  once.  Froelich  advises  operation, 
but  the  good  results  from  operation  will  only  become 
apparent  from  two  to  three  years  afterward.     [M.  O.] 


Orthostatic  Albuminuria. — Xiviere.  before  the  Medical 
Society  of  the  Paris  Hospitals,  c  BuUetinx  rt  Memoirr^  de  la 
societe  ileflicali-  ilrx  Hnpitnvj-  de  ParU.  1901.  No.  6).  reported 
a  case  of  albuminuria  which  lasted  six  months,  in  a  young 
man  of  20.  For  5  years  he  had  been  troubled  with  dyspep- 
.■^ia.  He  had  scarlet  ffver  when  7  years  old.  Examination 
showed  a  movable  right  kidney.  There  was  one  gram  of 
albumin  to  the  liter  of  urine.  A  flannel  binder  was  ap- 
plied at  once,  after  which  neither  morning  nor  evening  urine 
contained  albumin.  When,  however,  the  binder  was  forgot- 
ten or  not  tightly  applied,  albumin  reappeared.  He  has 
wholly  recovered,  and  is  in  better  health  than  ever.  Nivi^re 
Relieves  that  the  albuminuria  was  due  to  mechanical  causes, 
which  disappeared  when  the  abdominal  viscera  were  kept 
in  place.     [M.  C] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical   Publishing  Company    and  Conducted 

Exclusively  in  the  hiterests  of  the  Medical  Profession 


James  Hendrie  Lloyd,  A.M.,  M.  X>.,  Editor -in-Ckiej 
Julius  L.  Salinger,  M.  D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.  D.  F.  J.  Kalteyer,  m.  D. 

D.  I*.  Edsall,  M.  D.  T.  L.  Coley.  M.  D. 

J.  M.  Swan.  M.  D.  \V.  A.  N.  Dorland.  M.  D. 

J.  H.  Gibbon,  M.  D.  T.  M.  Tvson.  :^I.  D. 

M.  Ostheimer,  M.  D.  a.  Robin,  M.  I>. 


Scientific  Articles,  Clinical  Memoranda.  News  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  publication.  Reprints  (250)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philailelplila  Medical  Journal,    1716  Chestnut  St..  Philadelphia.  Pa. 
See  Advertising  Page  8. 


Vol.  VII,  No.  23 


June  8,  1901 


$j.oo  Per  Annum 


Mr.  Rockefeller's  Gift. — We  learn  that  Mr.  John 
D.  Rockefeller  is  about  to  establish  in  New  York 
City  an  institute  for  the  promotion  of  original  medi- 
cal research.  It  is  reported  that  he  has  placed  at 
its  disposal  the  sum  of  $200,000.  This  is  not  an  en- 
dowment, but  rather  for  immediate  expenditure. 
It  is  announced  that  the  institute  is  to  furnish  fa- 
cilities for  original  investigation,  particularly  in 
such  problems  in  medicine  as  hygiene  and  the  treat- 
ment of  disease.  While  it  is  to  be  estab- 
lished in  New  York  City,  it  is  apparently  not  to  be 
a  purely  local  affair.  The  Board  of  Directors  in- 
cludes the  names  of  well-known  pathologists  and 
medical  scientists  not. only  of  New  York,  but  of 
Philadelphia,  Boston  and  Baltimore.  It  seems  that 
this  institute  is  to  be  without  any  organic  affiliation 
with  existing  medical  schools.  At  least  we  judge 
this  from  statements  which  we  have  read  in  the 
newspapers.  Thus,  the  names  of  specialists  con- 
nected with  the  University  of  Pennsylvania.  Johns 
Hopkins  University,  Columbia  University,  Harvard 
University  and  the  Bellevue  Hospital  Medical 
School  are  mentioned.  This  feature  of  the  plan 
strikes  us  as  being  not  without  its  advantage.  There 
is  no  reason  why  an  institute  for  original  research 
in  medicine  should  not  be  entirely  independent  of 
any  existing  medical  school.  The  idea  is,  of  course, 
somewhat  of  a  novelty,  but  with  money  to  back  it, 
it  can  no  doubt  be  embodied  in  a  successful  way. 
It  seems  that  the  new  institute  is  to  be  somewhat 
on  the  model  of  such  establishments  as  the  Koch 
Institute  in  Berlin  and  the  Pasteur  Institute  in 
Paris.  If  it  is  well  endowed  and  its  scientific  work 
conducted  by  learned  experts  and  scientists  drawn 
from  various  parts  of  this  country,  it  doubtless  will 
have  a  great  future,  and  the  fact  that  it  can  draw 
upon  the  best  workers  and  teachers  without  regard 
to  the  schools  in  which  they  teach  will,  perhaps,  be 
an  advantage.  The  difficulty,  we  should  think, 
would  be  to  secure  active  work  in  New  York  City 
from  men  who  are  located  in  other  places.  This, 
perhaps,  may  not  be  entirely  within  the  design,  as 
the  names  announced  are  simply  of  those  who  will 
constitute  the  Board  of  Directors.  It  is  doubtless 
true  that  in  an  ordinary  college  routine  too  much 
valuable  time  is  taken  up  in  teaching  that  might  be 


spent,  and  must  be  spent,  upon  original  work.  In 
other  words,  the  two  interests,  teaching  and  origi- 
nal work,  do  not  by  any  means  necessarily  go  to- 
gether, as  seems  too  often  to  be  the  idea  in  this 
country. 

The  Study  of  Tropical  Diseases  in  the  Philippine 
Islands. — \\'e  have  received  a  copy  of  the  medical 
circular  on  tropical  diseases  issued  from  the  office 
of  the  Chief  Surgeon  of  the  Division  of  the  Philip- 
pines. Under  the  authority  of  the  Surgeon  General 
of  the  Army,  this  circular  was  ordered  to  be  pre- 
pared by  First  Lieutenant  R.  P.  Strong,  Assistant 
Surgeon,  U.  S.  A.,  with  a  view  of  presenting  to  the 
medical  officers  on  duty  in  those  islands  a  concise 
report  of  the  diseases  with  which  they  have  to  deal. 
This  is  a  most  satisfactory  evidence  of  the  care  now 
being  taken  by  the  United  States  Government  to  ad- 
vance not  only  the  cause  of  medical  science,  but  also 
the  welfare  of  the  troops  in  those  distant  posses- 
sions. Dr.  Strong  has  prepared  a  series  of  interest- 
ing reports,  or  tracts,  on  some  of  the  infections 
which  cause  intestinal  disorders  especially.  These 
disorders,  we  judge,  are  particularly  rife  in  all  trop- 
ical countries. 

The  ameba  dysenterite  is  described  minutely. 
It  was  encountered  in  the  stools  of  nearly  500  cases 
of  dysentery.  The  lesions  were  such  as  are  usually 
described  in  amebic  dysentery.  The  parasite  was 
found  in  the  mucosa,  sub-mucosa,  and  intermuscu- 
lar septa.  These  amebip  were  also  found  in  18  ab- 
scesses of  the  liver ;  on  two  occasions  these  abscesses 
had  penetrated  the  lung  cavity,  and  the  parasites 
were  found  there.  They  are  pathogenic  for  cats, 
which  can  readily  be  inoculated  with  them  through 
the  rectum.  Great  stress  is  laid  upon  the  importance 
of  amebic  dysentery  as  a  tropical  disease.  It  may 
be  overlooked  until  it  has  established  a  firm  hold 
upon  the  victim.  Repeated  attacks  of  diarrhea  and 
intestinal  catarrh  should  excite  suspicion,  and  the 
case  should  be  treated  radically.  Dr.  Strong  ap- 
pears to  rely  upon  the  local  treatment  with  high 
quinine  enemata.  He  also  distinguishes  between 
this  ameba  and  the  ameba  coli,  the  latter  of  which, 
he  thinks,  is  apparently  harmless. 

We  cannot  dwell  in  detail  on  all  the  parasitic  dis- 


Medical   Journal 


] 


EDITORIAL  COMMENT 


[June  8,  VM. 


eases  mentioned  by  Surgeon  Strong.  In  an  inter- 
esting paper  on  the  infusoria,  he  describes  the  halan- 
tidium  coli,  ■which  is  also  a  cause  of  intestinal  dis- 
ease. The  flagellates  are  also  described.  These  pa- 
pers show  clearly  how  important  it  is  nowadays  for 
the  physician  to  be  also  a  naturalist.  The  cestodes, 
or  worms,  are  about  the  same  in  the  Philippine  Is- 
lands as  here  at  home.  The  common  forms  are  the 
tfenia  saginata  and  the  taenia  solium.  The  echi- 
nocctis  is  not  common.  The  troops  have  been 
much  infested  with  the  common  lumbricoid 
worm.  One  of  the  most  interesting  of  Dr. 
Strong's  papers  is  the  one  on  filaria.  He  shows 
the  relation  of  this  infection  to  the  mosquito,  which 
may  act  as  intermediate  host.  Not  the  least  of  the 
soldiers'  troubles  in  the  Philippines  is  caused  by  a 
small  leech,  which  works  its  way  into  the  skin  even 
through  the  shoe  laces.  As  we  have  already  said, 
this  paper  is  an  interesting  evidence  of  the  good 
medical  work  being  done  in  the  Philippine  Islands 
under  the  auspices  of  the  United  States  Govern- 
ment. 

The  Relation  of  the  Art  and  Science  of  Surgery. — 
An  interesting  paper  has  been  written  by  Dr.  John 
A.  Wyeth,  of  New  York,  on  "The  Value  of  Clinical 
Microscopy,  Bacteriology,  and  Chemistry  in  Surgi- 
cal Practice,"  being  his  oration  on  surgery  before 
the  American  Medical  Association  at  St.  Paul.  In 
this  address,  Dr.  Wyeth  shows  the  great  advantage, 
in  fact,  the  absolute  necessity,  for  every  one  who 
does  surgical  work  to  understand  thoroughly  the 
science  as  well  as  the  art  of  his  branch,  and  he  re- 
views very  carefully  what  bacteriology,  chemistry 
and  the  microscope  have  done  to  make  surgery  an 
exact  science.  He  points  out  very  clearly  how  im- 
possible it  is  for  one  to  be  a  thorough  surgeon  who 
does  not  understand  and  appreciate  the  work  done 
in  the  laboratory,  and  tells  us  that  this  knowledge 
is  as  necessary  as  the  practice  of  a  perfect  aseptic 
technique.  The  author  shows  a  wonderful  famil- 
iarity with  the  various  methods  of  examining  the 
blood,  urine,  sputum,  etc.,  when  it  is  remembered 
that  his  life  as  a  surgeon  and  teacher  is  a  very  busy 
one,  and  what  he  has  also  done  to  advance  the  prac- 
tical side  of  surgery.  Although  all  good  surgeons  are 
not  agreed  on  these  subjects,  one  has  but  to  refer  to 
what  the  blood  count  alone  has  done  to  aid  in  surgical 
diagnosis  and  to  direct  surgical  treatment,  to  concur 
with  Wyeth  that  it  is  the  duty  of  every  surgeon, 
it  matters  not  how  busy  he  may  be  in  the  operating 
room,  to  familiarize  himself  with  the  science  of  sur- 
gery and  to  keep  himself  informed  of  the  great  ad- 
vances made  in  laboratory  methods.  These  ad- 
vances all  have  a  very  practical  bearing  on  his  suc- 
cess as  a  life  saver.  Too  often  are  operations 
recommended  and  performed  when,  if  we  had  been 


more  careful  in  our  examination  of  the  supposed 
health}'  organs  as  well  as  those  diseased,  the  opera- 
tion might  have  been  avoided  and  perchance  an  op- 
erative death  prevented.  Not  infrequently  do  we 
discover  after  operation  that  our  patient  is  suffering 
from  some  lesion  of  the  kidney  or  condition  of  the 
blood,  which,  if  known  previously,  might  have 
greatly  altered  our  treatment.  The  wise  and 
thoughtful  advice  of  Wyeth  cannot  be  too  heartily 
commended  to  those  doing  surgical  work. 

The  Treatment  of  Chronic  Ulcer  of  the  Stomach. 
— Those  of  our  readers  who  are  interested  in  either 
general  medicine  or  surgery  must  have  read  with 
pleasure  and  profit  the  excellent  paper  by  Mayo 
Robson,  in  a  recent  issue  of  the  Journal,  on  the  sur- 
gical treatment  of  chronic  gastric  ulcer.  One  who 
is  familiar  with  the  work  done  by  Mr.  Robson,  feels 
that  what  he  writes  on  this  subject  must  be  author- 
itative, for  few  individual  surgeons  have  had  the 
extensive  experience  in  operations  upon  the  stom- 
ach and  neighboring  viscera  which  he  has  enjoyed. 
Although  one  cannot  always  agree  with  some  of  his 
statements,  and  occasionally  may  feel  that  the  au- 
thor is  too  radical,  jet  on  the  whole  his  article  on 
this  interesting  condition  impresses  the  reader  as 
being  from  the  pen  of  one  who  thoroughly  under- 
stands the  subject  and  who  has  given  it  the  most 
careful  thought  and  consideration.  He  urges  upon 
the  practitioner  the  great  necessity  of  instituting 
early  the  most  rigid  medical  treatment  for  acute  gas- 
tric ulcer  and  of  keeping  this  treatment  up  for  a 
number  of  weeks  after  pain  and  other  symptoms 
have  subsided.  He  shows  us  very  plainly  that  sub- 
sidence of  s)-mptoms  does  not  mean  that  the  ulcer 
has  entirely  healed,  but  only  that  the  healing  pro- 
cess has  become  established.  Chronic  ulcer  usually 
follows  a  number  of  relapses  after  lax  and  ineffec-  , 
tual  medical  treatment.  Robson  shows,  too.  the 
greatly  lessening  mortality  brought  about  in  all 
surgical  work  upon  the  stomach  during  the  past  few 
years,  and  proves  that  in  the  treatment  of  gastric 
ulcer  this  mortality  is  much  less  than  in  cases  in 
which  medical  treatment  alone  is  depended  upon. 
The  paper  is  a  long  one,  but  every  general  practi- 
tioner, as  well  as  every  surgeon,  can  derive  benefit 
from  its  perusal. 

The  Proposed  Removal  of  the  Almshouse. — The 
city  of  Philadelphia  erected  the  present  buildings 
occupied  as  Almshouse,  Hospital,  and  Asylum  for 
the  Insane,  in  the  early  thirties,  and  five  wards  only 
have  been  added  to  the  structure  in  all  these  years. 
The  city  in  the  meantime  has  grown  from  a  pro- 
vincial town  to  be  one  of  the  great  cities  of  the 
world,  and  the  original  plan  of  grouping  the  sick,  the 
paupers,  and  the  insane  beneath  the  same  roof  and 


June  S,  1901] 


EDITORIAL  COMMENT 


TThe  Philadelphia 
Lmedical  Journal 


1067 


jurisdiction,  has  proven  sadly  inadequate.  Despite 
the  best  energies  of  a  judicious  management  and 
an  able  medical  staff,  the  death-rate  in  the  institu- 
tion is  admittedly  unnecessarily  high,  owing  to  the 
unfavorable  conditions,  such  as  the  overcrowding 
and  the  old  infected  buildings  which  were  built  be- 
fore the  day  when  sanitary  construction  became  so 
important  a  factor.  There  is  no  division  of  opinion 
among  the  profession  or  among  those  interested  in 
public  charities  as  to  what  should  be  done.  There 
must  be  a  speedy  separation  of  these  three  great  de- 
partments of  city  charities,  ilodern  treatment  of 
the  insane  exacts  the  proper  conditions  under  which 
these  unfortunates  shall  be  treated.  In  the  light  of 
present-day  knowledge,  an  almshouse  mus't  be 
built  with  due  regard  to  light  and  air,  and  there  must 
surround  it  a  number  of  acres  of  land,  the  tilling  of 
which  ma}'  occupy  the  minds  and  bodies  of  these 
unfortunates.  The  Philadelphia  Hospital  should  be 
a  representative  institution  of  its  kind,  built  with 
properly  constructed  buildings,  and  of  sufficient  size 
to  prevent  the  lamentable  overcrowding  which  at 
present  exists,  and  to  enable  its  patients  to  secure 
the  most  improved  hygienic  surroundings,  as  well 
as  the  best  medical  treatment.  There  is  also  great 
need  that  the  Philadelphia  Hospital  be  separated  en- 
tirely from  the  Almshouse,  so  that  the  stigma  of 
pauperism  may  not  fall  upon  its  patients.  On  last 
Monday  evening  the  Council  Committee  on  Chari- 
ties and  Correction  held  a  public  meeting  to  discuss 
this  subject,  which  was  attended  by  a  large  and  re- 
presentative gathering.  There  was  a  concensus  of 
opinion  as  to  the  necessity  of  making  the  changes 
mentioned  above,  and  a  resolution  was  offered  and 
passed  unanimously  directing  the  Board  of  Charities 
and  Correction  to  decide  upon  suitable  sites  and  to 
present  their  report  to  the  City  Council.  We  trust 
that  every  medical  man  will  interest  himself  person- 
ally in  emphasizing  the  great  necessity  for  these 
proposed    changes. 

Hygiene  and  Sanitary  Science. — Dr.  George  M. 
Kober.  Professor  of  Hygiene  in  the  Georgetown 
University,  delivered  before  the  52d  annual  meeting 
of  the  American  Medical  Association  at  St.  Paul  this 
week,  the  annual  oration  in  State  Medicine  on 
"The  Problem  and  Tendency  of  Hygiene  and 
Sanitary  Science  in  the  Nineteenth  Century." 
In  view  of  the  fact,  as  Dr.  Kober  has 
pointed  out,  that  hygiene  is  not  an  inde- 
pendent science,  but  a  correlation  of  the  teach- 
ings of  physiology,  chemistrj',  physics,  meteorology, 
^  patholog}-,  sociology,  epidemiology,  and  bacteriol- 
ogy-, it  is  not  surprising  that  the  progress  of  this 
branch  has  been  phenomenal.  To  emphasize  that 
this  science  is  not  of  modern  origin,  he  alludes  to 
the  hygiene  of  the  Greeks  and  Romans — the  care 


they  paid  to  their  water-supplies  and  bathing  facili- 
ties, and  the  special  attention  paid  to  the  physical 
culture  of  their  youth. 

The  greater  portion  of  his  address  is  confined  to 
the  discussion  of  the  progress  of  sanitation  in  the 
United  States,  referring  to  the  duties  of  health 
boards,  quarantine  regulations,  the  results  derived 
from  improved  water-supplies,  the  value  of  pure 
food  and  drug  legislation,  industrial,  rural,  and 
school  hygiene,  and  the  management  and  control  of 
infectious  diseases.  The  enactment  of  proper  san- 
itary legislation  and  the  education  of  the  public  in 
regard  to  the  nature  and  causation  of  infectious  dis- 
eases, will  be  important  advances  in  the  solution 
of  the  problem  of  prevention.  In  this  connection 
of  special  interest  is  the  statement  that  enteric  fe- 
ver, a  so-called  preventable  disease,  causes  an  an- 
nual total  loss  in  the  United  States  of  $185,000,000. 
Dr.  Evans  has  estimated  that  the  annual  loss  sus- 
tained from  tuberculosis  in  the  United  States  is 
$574,000,000.  However,  the  mortality  statistics  of 
1890  and  1900  show  a  marked  decrease  in  the  death- 
rate  from  typhoid  fever  and  consumption,  and  the 
American  medical  profession  has  much  to  be  proud 
of  in  the  century's  progress  in  preventive  medicine. 

In  this  important  contribution  to  medical  litera- 
ture w'e  cannot  fail  to  be  struck  with  the  develop- 
ment of  modern  hygiene,  especially  when  we 
reflect  upon  the  ignorance  and  superstition  that 
prevailed  in  former  times.  With  the  ever-increas- 
ing means  of  observation  and  the  more  intimate  cc>- 
operation  of  the  profession  throughout  the  civilized 
world,  further  progress  and  perfection  in  hygiene 
are  to  be  expected  with  confidence. 

The  Cause  of  Cancer. — In  view  of  the  great  inter- 
est that  has  recently  been  e.-<fcited  by  Gaylord's  ar- 
ticle regarding  the  parasite  of  cancer,  som.e  recent 
work  performed  in  the  laboratory  of  Professor  Wys- 
sokowitsch  may  be  of  interest.  De  ^leser,  having 
observed  some  lycopodium  spores  in  the  interior  of 
a  cancer  of  the  skin,  which  had  evidently  been  de- 
rived from  the  powder  that  had  been  used  in  dress- 
ing it,  called  attention  to  the  extreme  difficulty  of 
distinguishing  between  parasitic  bodies  and  pani- 
cles of  foreign  material  absorbed  from  the  surface. 
Konstantinowitsch  having  become  interested  in 
these  cases,  endeavored  to  determine  just  what  ef- 
fects different  bodies,  such  as  the  spores  of  lyco- 
podium, would  produce  when  injected  into  the  skin. 
He  found  that,  as  a  matter  of  fact,  they  produced 
gfrowths  not  dissimilar  from  ordinary  granuloma, 
containing  epithelioid  and  giant  cells.  This  is  only 
an  additional  illustration  of  the  very  important  part 
that  mechanical  conditions  play  in  the  development 
of  tumors,  an  element  that  was  recognized  nearly 
half  a  century  ago  by  Virchow,  and  which,  in  the 


io68 


The  Philadelphia  "I 
Medical  Journal    J 


EDITORIAL  COMMENT 


[June  8,  1901 


eagerness  to  discover  a  parasite  or  to  explain  their 
origin  as  a  result  of  some  disturbance  of  the  embry- 
ological  mechanism,  has  been  again  and  again  for- 
gotten. The  experimental  work  to  be  done  with  re- 
gard to  tumor  formation  is  very  considerable,  and 
it  is  strange  that  pathologists  have  neglected  it  so 
much. 

A  Judge's  Opinion  on  Osteopathy. — We  fail  to  see 
of  what  use  it  is  to  pass  a  law  for  the  regulation  of 
the  practice  of  medicine  and  surgery  when  any 
country  judge  can  deliberately  misinterpret  the  act 
so  as  to  render  it  inoperative.  Recently,  in  Venango 
County,  Pennsylvania,  the  judge  in  the  Common 
Pleas  Court  rendered  an  extraordinary  decision  in 
a  case  involving  the  legal  status  of  osteopathy ;  and 
the  grounds  upon  which  his  decision  was  based 
were  as  fair  a  sample  of  judicial  sophistry  or  word- 
splitting  as  it  has  been  our  lot  to  see.  Judge  Cris- 
well  declared  that  the  "practice  of  medicine,"  as  de- 
fined by  the  act  of  Legislature,  means  the  treatment 
of  disease  by  the  use  merely  of  drugs,  and  that  any 
other  kind  of  treatment  is  not  the  "practice  of  med- 
icine." Therefore,  as  osteopathy  does  not  treat  dis- 
ease by  the  use  of  drugs,  it  is  not  a  practice  of  medi- 
cine within  the  meaning  of  the  law,  and  its  practi- 
tioners can  have  full  swing  in  the  State  of  Pennsyl- 
vania without  a  license  and  without  let  or  hindrance. 

It  is  difficult  to  characterize  such  judicial  wisdom 
as  this.  The  respect  which  we  owe  the  bench  is  se- 
verely tested  by  the  utterance  of  such  Dogberry 
opinions.  According  to  Judge  Criswell,  a  physician 
is  simply  a  drug  dispenser.  What  a  surgeon  is,  in 
his  opinion,  we  do  not  pretend  to  know.  To  keep 
within  the  meaning  of  the  law,  the  doctor  must  pre- 
scribe pellets.  If  he  attempts  to  practice  in  the 
broad  field'  of  preventive  medicine,  of  hygiene,  of 
dietetics,  of  hydrotherapy,  of  climatology,  of  sug- 
gestive therapeutics,  of  psychiatry,  of  obstetrics,  of 
ophthalmology,  and  of  three-fourths  of  the  whole  field 
of  surgery  (i.  e.,  so  far  as  he  practises  in  these  fields 
without  drugs)  he  is  no  doctor.  Ergo,  any  ignorant 
charlatan  can  enter  these  fields,  and,  so  long  as  he 
gives  no  drugs,  he  is  not  required  to  have  a  license 
under  the  laws  of  Pennsylvania!  Fortunately,  it  is 
sufficient  merely  to  present  Judge  Criswell's  opinion 
in  order  to  show  its  foolishness.  We  trust  the  Su- 
preme Court  will  reverse  his  decision  and  save  the 
Commonwealth  from  such  stultification. 

A  Mayor's  Objection  to  Vaccination. — The  Hon- 
orable Tom  Johnson,  of  Cleveland,  Ohio,  announces 
to  the  world  that  he  does  not  believe  in  "contami- 
nating a  man's  blood  with  poison,"  and  he  declares 
that  "no  doctor  shall  pump  any  virus"  into  him. 
These  bellicose  utterances  of  the  Honorable  Tom 
Johnson,  Mayor  of  Cleveland,  were  called  forth,  ac- 


cording to  the  Plain  Dealer,  by  the  prevailing  epi- 
demic of  small-pox  in  that  city.  We  do  not  know 
what  power  the  Mayor  of  Cleveland  has  to  control 
the  vaccination  problem  in  the  State  of  Ohio,  but  we 
call  attention  to  the  figfures  supplied  by  the  Public 
Health  Reports.  From  January  ist  to  May  nth  there 
had  been  899  cases  of  smallpox  in  Cleveland  and  its 
neighborhood.  According  to  these  figures  an  ad- 
verse fate  has  been  "pumping  the  virus"  of  smallpox 
into  the  citizens  of  Cleveland  at  a  high  rate  of 
speed.  If  the  Honorable  Tom  Johnson  is  to  have 
his  way  in  that  town,  it  is  highly  probable  that  a 
great  many  more  Clevelanders  will  have  their  blood 
contaminated  with  the  poison  of  smallpox  before 
the  epidemic  is  ended.  It  is  deplorable  that  in  this 
country  a  street  car  magnate  who  happens  to  get 
himself  elected  Mayor,  should  thus  assume  to  speak 
upon  a  subject  which  docs  not  properly  fall  within 
his  jurisdiction.  The  Buffalo  Medical  Journal  accuses 
Mayor  Johnson  of  neglecting  to  enforce  the  methods 
of  sanitary  science,  and  holds  him  responsible  in 
part  for  the  situation.  \\'e  are  apt  in  this  country 
to  commiserate  other  countries  in  which  an  ignorant 
populace,  as  in  India,  resists  the  progress  of  sani- 
tary science — but  we  should  reflect  that  we,  too, 
have  our  troubles  of  this  kind,  and  they  are  not  con- 
fined to  Cleveland.  That  city  is  a  very  progressive 
and  enlightened  one,  and  we  do  not  believe  for  a 
moment  that  it  will  follow  the  lead  of  its  Mayor 
in  this  matter.  Its  many  able  physicians  can  doubt- 
less lead  public  opinion  even  against  the  influence 
of  the  Honorable  Tom  Johnson. 

Continuous  Sneezing  for  Seven  Months. — We 
strongly  suspect  that  the  interesting  case  of  sternu- 
tation reported  by  Mass^  {Reznie  Hcb.  de  Laryngol- 
ogie.  d'  Otologic  et  de  Rhinologie,  Feb.  2,  1901)  was  of 
hysterical  origin.  This  seems  all  the  more  probable 
from  the  fact  that  the  affection  was  promptly  cured 
by  the  use  of  an  orthopedic  apparatus  on  the  spine, 
for  which  there  seems  to  have  been  but  little  indi- 
cation. The  case  occurred  in  a  neurotic  girl,  aged 
16.  She  had  had  dyspeptic  symptoms,  with  fre- 
quent headaches  and  facial  neuralgia.  After  a  se- 
vere attack  of  influenza  she  had  a  dry  cough,  which 
ceased  rather  suddenlj-  and  was  replaced  by  parox- 
ysms of  sneezing.  These  paroxysms  began  on  the 
patient's  awakening  and  continued  seven  or  eight 
times  a  minute  until  she  went  to  sleep.  There  was 
a  sense  of  irritation  in  the  nose,  and  the  paroxysms 
were  worse  after  eating.  All  treatment  was  inef- 
fectual until  Mass6  noticed  that  the  spinal  column 
was  bent  slightly  forward.  This  suggested  the  use 
of  a  corset  or  supporting  apparatus,  and  the  adjust- 
ment of  this  was  promptly  followed  by  a  cure.  .\I1 
this,  we  say,  looks  suspiciously  hysterical.  There 
is,  in  fact,  no  end  to  the  symptoms  of  hysteria,  and 


JUNE   8.    l&Ol] 


REMEWS 


[The  Philadelphia 
Medical.   Journal 


1x369 


some  of  the  most  interesting  and  obscure  of  these 
stigmata  are  associated  with  the  respiratory  tract. 
Sneezing  has  not  been  frequently  observed,  but 
bouts  of  yawning,  and  various  forms  of  rapid  res- 
piration and  other  affections  of  respiration  have  not 
infrequently  been  noted.  The  use  of  a  simple  ap- 
paratus or  spinal  brace  would  be  just  the  kind  of 
a  thing  to  favorably  influence  the  mind  of  an  hj's- 
terical  patient  and  effect  a  cure.  In  other  words, 
the  use  of  such  an  apparatus  would  be  simply  a  re- 
sort   to    suggestive    therapeutics. 


IRcvievvs. 


"A  Handbook  of  Genito-Urinary  Surgery  and  Venereal 
Diseases,"  by  Dr.  G.  M.  Phillips,  Professor  of  Genito- 
urinary Surgery  and  Venereal  Diseases,  Barnes  Medi- 
cal College.  Illustrated  with  half-tone  cuts  and  special 
drawings  by  Dr.  L.  Crusius.  St.  Louis.  Lewis  S. 
Matthews  &  Co.,  1900. 

Although  a  "handbook"  it  would  seem  to  a  reader  of  this 
volume  that  the  author  might  have  treated  certain  import- 
ant subjects  with  more  consideration  thaji  he  has  done. 
The  portion  devoted  to  venereal  diseases  is  thoroughly 
practical  and  relates  the  authors  experience.  The  portion 
devoted  to  genito-urinary  surgery,  particularly  the  chapters 
on  the  Prostate  Gland  and  on  the  Surgical  Diseases  of  the 
Kidney,  is  markedly  deficient.  Seven  pages  are  devoted 
to  the  diseases  of  the  kidney,  and,  although  some  of  the 
diseases  of  this  organ  are  described,  yet  others,  such  as 
tuberculosis  and  cystic  degeneration,  are  passed  over  with- 
out a  word  as  to  their  diagnosis  and  little  more  as  to 
their  treatment.  The  only  symptoms  ascribed  to  floating 
kidney  'are  pain  and  nervousness,  either,  or  both  of 
which  may  be  paroxysmal  or  constant."  To  these  in- 
definite symptoms  are  added  the  statement  that  a  twist  of 
the  ureter  may  occur  and  hydronephrosis  may  result.  But 
one  method  of  operative  treatment  is  described  for  the 
relief  of  this  condition,  and  this  description  is  hardly 
sufficient  to  guide  one  in  the  performance  of  the  operation. 
In  describing  the  operation  for  varicocele  the  author  makes 
no  mention  of  the  more  recent  "high"  operation  for  this 
condition.  One  can  hardly  speak  of  the  author's  style  with- 
out criticising  it,  many  of  his  sentences  being  entirely 
unintelligible.  The  following  quotation  will  give  some  idea 
of  the  difficulty  one  has  in  understanding  exactly  what 
the  author  means  to  convey:  "No  doubt  much  of  the 
trouble  associated  with  varicocele  is  psychic,  and  largely 
due  to  the  literature  of  the  advertising  quack:  for  the 
majority  of  my  patients  have  shown  unmistakable  evi- 
dence of  having  seriously  studied  this  free  literature,  and 
many  times  fallen  victims  to  their  proposals  and  become 
hypochondriacs,  either  on  account  of  the  disease  or  the 
treatment:  it  would  be  difficult  to  decide." 

Some  of  the  illustrations,  particularly  the  photographs, 
in  this  book,  are  very  good.     [.J.  H.  G.] 

An  Index  of  Symptoms  as  a  Clew  to  Diagnosis,    By  Ralph 
Winnington  Leftwitch,  M.  D..  Late  Assistant-Physician 
to  the  East  London  Children's  Hospital.     Second  Edi- 
tion.    New  York:     William  Wood  &  Co.,  1901. 
"An  Index  of  Symptoms"  is  a  small  book  in  which  the 
various  symptoms  of  disease  are  enumerated  and  beneath 
each  symptom  there  is  a  list  of  all  the  diseases  in  which 
that  symptom  may  occur     As  examples,  taken  at  random, 
delirium  is  a  symptom  of  43  diseases,  and  pale  urine,  is 
a  symptom  of  16.     It  is  to  be  supposed  that  if  a  physi- 
cian   has   a   patient    who    passes    pale    urine,    he   turns 
to   the   list   of   diseases   of   which    pale   urine   is   a   symp- 
tom and  determines  from  what  diseases  his  patient  ma>- 
be  suffering  and  then  by  exclusion  arrives  at  his  diagnosis. 
The  book  is  one  of  those  short-cuts  to  successful  diagnosis 
which  are  often  so  popular  with  the  busy  practitioner. 

[J.  M.  S] 


Syphilis  of  Children.— George  Carpenter,  M.  D.,  honA.  Wil- 
liam Wood  &  Co.    New  York.     1901. 

It  is  rare  that  a  busy  practitioner  has  either  the  time  or 
inclination  to  give  to  the  profession  the  minutely  ob- 
served results  of  his  own  large  experience  in  a  particular 
class  of  patients.  This  has  been  done  by  George  Carpenter,. 
who  has  had  exceptional  facilities  for  the  study  of  syphilis 
in  children  in  several  hundred  cases  in  his  private  prac- 
tice and  in  work  at  the  Evelina  Hospital  for  Sick  Children. 

The  book  is  illustrated  by  sketches  made  on  the  spot  to- 
illustrate  the  clinical  memoranda  from  which  the  mono- 
graph has  been  compiled.  The  cutaneous  manifestations, 
the  lymphatic  glands,  mucous  membranes,  larynx,  anal 
orifice,  lungs,  spleen,  liver,  kidneys,  heart,  pancreas,  thy- 
mus, thyroid,  testicles,  and  the  blood  are  considered  under 
separate  headings.  There  is  a  chapter  devoted  to  clinical 
history  and  a  brief  summary.  There  is  a  short  section  on 
prognosis,  and  one  on  treatment.  Mercury  and  chalk  is 
preferred,  of  which  one  grain  is  given  three  times  daily 
to  an  infant.  Intolerance  of  the  drug  is  not  shown  in 
infants  by  salivation,  because  the  function  is  not  properly 
established,  but  by  diarrhea.  Intramuscular  injections  are- 
also   advised. 

This  brochure  of  110  pages  can  be  read  in  an  hour,  and 
should  prove  profitable  and  helpful  to  those  whose  experi- 
ence has  been  limited  in  this  class  of  affections.     [E.  M.] 

A  Text-Book  of  Gynecology — Edited  by  Charles  A.  L.  Reed. 
A.  M  .  M.  D.,  President  of  the  A.merican  Medical  Asso- 
ciation (1900-1901):  G>Tiecologist  in  the  Cincinnati 
Hospital,  etc.  New  York.  D.  Appleton  &  Co.  1901. 
Pages  900,  cloth,  $5.00. 

To  the  preparation  of  this  work  the  editor  has  brought, 
the  experience  of  many  years  of  active  labor  in  his  choseu 
field  of  surgery.  He  has  been  ably  seconded  by  some  of  the 
best  writers  in  their  lines  of  work,  including  such  well- 
known  names  as  Hobart  Amory  Hare,  Dercum,  Ballantyne, 
McMurtry,  Newman,  Sinclair,  Mann  and  Coe.  While  open, 
to  some  of  the  objectionable  features  of  composite  works. 
of  this  kind,  such  as  overlapping  of  subjects  and  multi- 
plicity of  views,  this  has  largely  been  overcome  by  the 
judicious  and  tjuly  excellent  editorial  efforts  of  Dr.  Reed. 
If  composite  work  should  be  written  at  all  we  heartily 
endorse  the  practice  that  has  been  adopted  in  this  case  ot 
securing  the  cooperation  of  men  in  the  various  departments, 
of  medical  science  in  their  synthetic  relation  to  gynecol- 
ogy, whereby  the  best  and  most  recent  views  of  the  various 
subjects  may  be  obtained  in  the  most  succinct  form.  The 
confining  of  the  contributors  to  those  who  had  already  ac- 
quired considerable  reputation  as  writers  and  authorities 
!n  their  various  lines  has  tended  also  to  the  same  desirable 
end^  A  gratifying  feature  of  the  book  is  the  retaining  of 
the  names  of  the  contributors  in  the  table  of  contents, 
whereby,  if  it  be  desired,  the  reader  may  know  whose- 
views  he  is  noting  and  to  whom  tribute  may  te  paid.  The 
system  adopted  throughout  the  work  is  a  rational  one 
beginning  with  a  thorough  review  of  the  history  of  gyne 
cology  and  of  the  general  topics  bearing  on  pelvis 
surgery,  such  as  its  nomenclature  and  radical- 
ism and  conservatism  in  gynecology.  A  chapter 
on  the  general  etiology  of  diseases  of  womeii 
is  of  special  interest,  and  is  from  the  pen  of  the 
editor.  The  general  pathology  of  the  female  generative 
organs  includes  a  study  of  the  pelvic  functions  of  menstru- 
ation, ovulation,  and  pregnancy,  and  the  bacterial  origin 
of  inflammatory  diseases  of  the  female  genitalia,  as  well 
as  trophic  and  neoplastic  changes.  The  general  thera- 
peutics of  g.vnecology,  instruments,  and  methods  of  diag- 
nosis are  ably  discussed  by  Reed,  Herzog,  Robb  and  Potter, 
while  the  editor  gives  a  rctunre  of  the  modern  methods  of 
antisepsis  and  of  the  management  of  sepsis,  shock  and 
hemorrhage.  In  the  presentation  of  the  pathologic  condi- 
tions of  the  pelvis  an  anatomatical  basis  is  adopted,  pro- 
ceeding from  the  external  genitalia  through  the  vagina, 
perineum,  uterus,  tubes,  ovaries,  and  broad  ligaments. 
Interesting  features  are  the  chapters  on  Cesarean  Sectiott 
and  ectopic  gestation.  We  regret  that  the  more  recent  sug~ 
.eestion  of  Fritsch  fails  to  find  mention  in  the  section  on 
the  performance  of  Caesarean  Section:  in  a  certain  class 
cf  cases  it  may  claim  a  limited  use.  The  rarer  forms  of 
ectopic  pregnancy  do  not  find  a  place  in  the  book,  nor  do 


lOTO 


The  Philadelphia  "I 
Medical  Jolka.^.    J 


CORRESPONDEX'CE 


[June  8,  WJl 


the  cui-ious  accidents  to  which  that  complication  is  subject 
receive  extensive  mention.  The  chapter  on  infections  o£ 
the  Fallopian  tubes  is  well  written  and  shows  careful  in- 
vestigation; the  illustrations  are  somewhat  idealized,  but 
no  doubt  will  be  of  value  from  the  standpoint  of  the  stu- 
dent. The  literature  of  malignant  deciduoma  is  by  no 
means  complete,  nor  do  we  altogether  accord  with  the 
statement  that  this  condition  is  a  "degenerative  malignant 
disease  of  the  sarcomatous  type;"  there  are  undoubted 
cases  of  this  growth  of  fetal  origin  which  show  true  carci- 
nomatous degeneration.  The  section  treating  of  the  path- 
ology of  the  female  urinary  apparatus  deserves  special 
mention.  It  comprises  a  most  admirable  series  of  chapters 
from  the  pen  of  Harris,  of  Chicago,  and  enters  exhaustively 
into  the  subject:  we  fail  to  find  any  omission  even  of  the 
newer  phases  of  this  comparatively  recently  developed 
branch  of  surgery.  The  section  on  neoplasms  of  the  uterus, 
tubes,  and  ovaries  is  complete.  We  note  with  interest  that 
the  ovulogenous  theory  of  Wilms  in  the  production  of  pelvic 
dermoids  is  endorsed  by  the  author  (Rothrock).  Unfortu- 
nately the  important  subject  of  degenerative  changes  in 
uterine  fibromyoraata  is  disposed  of  within  the  space  of 
less  than  one  page,  while  the  valuable  operation  of  ventral 
suspension,  valuable  in  the  proper  cases,  is  placed  very 
materially  in  the  background  to  favor  the  Alexander  opera- 
tion, which  it  is  claimed  "unquestionably  fulfils  the  indica- 
tions in  a  large  majority  of  simple  cases."  We  do  not  en- 
dorse the  suggestion  in  fixed  cases  of  freeing  adhesions 
through  an  incision  in  the  vaginal  vault  with  a  subsequent 
Alexander  operation  to  hold  the  uterus  forward.  On  the 
■whole,  however,  the  book  that  Dr.  Reed  has  presented 
the  profession  is  a  most  admirable  expose  of  modern  gyne- 
cology, from  which,  here  and  there,  the  individual  gyne- 
cologist will  differ  as  to  certain  methods  of  treatment  and 
technic  according  as  he  has  been  taught  by  his  experience. 
The  entire  subject  has  been  excellently  grouped  and  ably 
treated.  The  mechanical  work  is  of  the  best  and  the  illus- 
trations are  instructive  and  not  merely  introduced  for  the 
purpose  of  padding.     [W.  A.  N.  D.] 


(ToiTcijpon^cncc. 

ANTHRAX  IN  PHILADELPHIA. 
By  John  H.  .Topson,  M.  D.,  of  Philadelphia. 
To  the  Editor  of  the  Philadelphia  Medical  Journal. 

Dear  Sir: 

The  report  of  two  eases  of  anthrax  by  Dr.  L.  H.  Mutch- 
ler  before  the  Philadelphia  Academy  of  Surgery  on  May 
■Sth,  again  brings  to  the  attention  of  the  medical  profession 
■of  this  city,  the  presence,  and  apparently  increasing  num 
bers  of  cases  of  this  malignant  infection  in  the  community. 
In  December,  1S99,  Dr.  A.  A.  Ghriskey  and  myself  reported 
a  fatal  case  before  the  Philadelphia  Pathological  Society, 
and  referred  to  four  cases  that  had  been  reported  or  related 
to  us  verbally  as  having  previously  occurred  in  Philadelphia, 
and  also  remarked  on  the  possible  occurrence  of  other  cases 
■which  had  passed  unrecognized  or  unrecorded.  Our  case 
•was  observed  in  the  Surgical  Dispensary  service  of  the 
Episcopal  Hospital.  In  the  eighteen  months  which  have 
•elapsed  since  that  time  three  other  cases  have  been  encoun- 
tered in  the  same  hospital,  two  studied  by  Dr  Mutchler, 
and  one  by  Dr.  E.  E.  W.  Ziven,  and  Dr.  Mutchler  was  able 
to  refer  to  ten  cases  in  all  as  having  been  observed  in  Phil- 
adelphia in  a  period  of  about  ten  years.  It  seems  highly 
probable  that  many  more  have  occurred  in  that  time  which 
have  not  been  reported  or  recognized.  The  disease  is  often 
so  obscure  in  its  symptomatology  especially  in  the  pulmonic 
lorm,  that  it  might  easily  be  mistaken  for  something  else 
Avheu  occurring  sporadically,  and  the  external  form  might 
also  be  confounded  with  cellulitis,  carbuncle  or  erysipelas, 
when  not  seen  in  its  earlier  stages.  At  least  fifty  percent, 
of  these  ten  cases  were  first  seen  at  the  Episcopal  Hospi- 
tal, which  being  situated  in  the  center  of  an  enormous  man- 
tifacturing  district,  would  naturally  attract  the  cases  from 
the  tanneries  and  morocco  factories  where  most  of  the  pa 
tieuts  were  employed.  Dr.  Mutchler  proposes  to  notify  the 
Agricultural  Department  of  his  cases,  and  it  would  certainly 
seem  lo  be  the  duty  of  everv  physician  who  encounter.^ 
Other  cases  to  do  the  same.  Ravenel  has  pointed  out  the 
.fact  that  the  present  methods  of  curing  hides  are  notoriously 
unsafe,  and  that  many  of  those  imported  are  liable  to  be 
Infected  is  well  known.     Until  those  trustworthy  methods 


shall  come  into  general  use  the  employers  of  those  ex- 
posed should  be  urged  to  guard  the  health  of  their  work- 
men as  far  as  possible.  Many,  if  not  all  of  these  men,  seem 
ignorant  of  their  danger.  Scratches  or  abrasions  of  the 
exposed  epidermus  are  the  usual  avenues  of  infection  in 
tanners,  and  the  men  should  be  warned  of  this  source  of 
danger.  Other  measures  for  protection  would  suggest  them- 
selves. The  problem  has  been  skilfully  dealt  with  in  the 
Bradford  Woolen  Mills  in  England,  as  Bell  describes  in 
his  article  in  AUbutt's  System,  and  it  would  seem  to  be  a 
good  time  to  suggest  an  attempt  to  solve  it  here. 


INSTANTANEOUS  DRY  HEAT  FOR  EXTERNAL  APPLI- 
CATION;   ELECTRIC  SUBSTITUTE   FOR 
HOT     WATER     SAG. 

By  De  B'orrest  Willard,  M.  D.,  of  Philadelphia. 
To  the  Editor  of  the  Philadelphia  Medical  Journal. 

Electricity  being  now  in  use  in  nearly  all  of  our  hospi- 
tals and  in  many  private  homes,  I  have  found  the  following 
use  of  the  current  very  helpful.  It  has  the  advantage  of 
being  instantly  a.pplicable,  and  especially  at  night  it  saves 
much  trouble  and  time  in  the  securing  of  a  hot  water  bag. 

The  ordinary  electric  bulb  attached  to  a  long  wire,  which 
is  in  common  use,  can  be  wrapped  in  one  or  two  layers  ot 
cloth  and  applied  directly  to  the  part  affected,  the  heat  being 
readily  regulated  by  the  thickness  of  the  folds.  At  the  first 
symptoms  of  a  chill,  during  the  premonitory  creeps  down 
the  spine,  such  a  bulb  applied  directly  between  the  scapulae 
is  of  the  greatest  comfort,  and  will  often  prevent  a  rigor. 
It  has  the  advantage,  too,  that  the  patient  lying  in  bed  can 
quickly  seize  it  himself  as  it  hangs  by  his  side,  and  make 
himself  comfortable  even  before  the  nurse  reaches  him. 

To  the  physician  also  who  returns  to  his  office  cold  and 
wet,  this  bulb  dropped  in  beneath  his  coat  between  the 
shoulders,  while  be  sits  at  his  desk  will  be  the  speediest 
means  of  making  him  comfortable.  Once  tried,  it  is  certain 
to  be  repeated. 

For  local  pains  in  abdomen  or  chest,  and  neuralgic  pains 
in  the  head,  it  has  all  the  advantages  of  the  hot  water  bag 
and  never  grows  cold. 

The  bare  bulb  used  as  a  flat  iron  is  also  very  helpful  in 
rheumatic  pains  of  muscles,  in  sciatica,  etc.    Try  it! 

As  a  heat  producer  after  operation:  as  an  application  for 
cold  feel,  etc.,  it  has  the  special  advantage  of  quick  and 
continuous  service. 


A    QUESTION    OF    PRIORITY. 

By  James  F.  E.  Colgan.  M.  D..  of  Philadelphia. 

To  the  Editor  of  the  Philadelphia  Medical  Journal. 

Professor  Schlatter  in  his  article  published  in  the  Phila- 
delphia Medical  Journal,  April  13tb.  on  "Ligation  of  the 
Carotid  Artery  as  a  Preliminary  Operation  to  Resection  o£ 
the  Superior  Maxilla."  states  that  the  first  report  concern- 
ing the  ligation  of  the  common  carotid  as  a  preliminary 
operation  in  operative  procedure  on  the  head  is  from  the 
clinic  of  Professor  C.  Reyher.  of  St.  Petersburg.  Is  not  this 
an  error?  In  the  American  Medical  Recorder  for  April, 
1821.  is  the  report  of  an  operation  by  Horatio  G.  Jaimeson, 
of  Baltimore,  Md.,  in  which  previous  to  remoNnng  a  large 
tumor  of  the  superior  maxilla  he  ligated  the  common  caro- 
tid with  an  animal  ligature.  As  the  patient  was  alive 
several  years  after  and  in  enjoyment  of  perfect  health,  the 
credit  of  the  first  successful  operation  in  my  opinion  be- 
longs to  America,  and  not.  as  stated  in  the  article,  to 
Russia. 


A  Case  of  Poisoning  from  Hair  Dye. — Dr.  George  Petit 
(L'Imhpttidunvc  ilitlinih:  1901,  No.  IS)  reports  the  case 
of  a  woman  of  33  who.  while  confined  to  her  bed  after 
having  injured  her  foot  had  her  hair  cut  short.  Later, 
in  Budapest,  she  bought  a  hair  dye,  which  she  used  for 
three  years.  She  grew  thin  and  weak,  and  showed  all  the 
signs  of  dyspepsia.  During  the  three  years  she  had  16 
successive  attacks  of  erysipelas,  for  which  no  cause  could 
be  found.  Petit  finally  came  to  the  conclusion  that  the 
hair  dye  must  be  the  cause  of  all  these  symptoms  of  sys- 
temic intoxication.  Examination  showed  that  it  contained 
resorcin.  Since  she  has  stopped  using  the  dye.  she  has 
grown  gradually  well.  Oddly  enough  she  had  herself  come 
to  the  conclusion  that  the  hair  dye  was  the  cause  of  all 
her  trouble,  but  tried  to  hide  the  fact  from  her  physician. 

[M.  O.) 


JUN-E    8,    1901] 


SOCIETY  REPORTS 


TThe  Philadelphia 
L. Medical  Journal 


IO7I 


Socict\?  IRcports. 


Meeting  of  the  American  Pediatric  Society. — The  twen- 
tieth annual  meeting  was  held  at  Niagara  Falls.  Greater 
Buffalo,  May  27-29.  1901.  at  the  International  Hotel,  Mon- 
day. May  27.  President's  address.  Dr.  Wm.  D.  Booker,  Bal- 
timore. After  alluding  to  the  death  of  Dr.  J.  H.  Fruitnight. 
the  president  proceeded  to  a  thorough  discussion  of  the 
history  of  summer  diarrhea  of  infants.  Its  first  appear- 
ance in  this  country  was  in  the  middle  of  the  eighteenth 
century,  when  the  colonists  had  liecome  collected  in  towns 
and  villages.  It  had  been  unknown  among  the  aborigines 
and  was  supposed  by  the  American  physicians  not  to  have 
occurred  in  Europe.  The  first  noteworthy  description  was 
by  Dr.  Benjamin  Rush.  1777.  under  the  term  cholera  infan^ 
tum.  Auretius.  however,  in  the  second  century,  mentioned 
an  epidemic  diarrhea  of  children,  occurring  in  the  summer 
months.  Harris,  1650.  described  it  as  occurring  in  England 
and  Claghorn,  1744.  as  in  Minorca.  Rosenstein.  of  Stock- 
holm, 17.30.  devoted  40  pages  to  this  disease.  There  fol 
lowed  an  exhaustive  review,  especially  of  the  early  Ameri- 
can literature,  up  to  about  1S30.  Dr.  Allen  Baines  of  To- 
ronto, reported  a  case  of  general  arteriosclerosis  in  a  boy 
aged  ten  years,  with  specimen  and  microscopic  mounts. 
The  case  had  been  observed  for  about  a  year  before  death, 
but  no  cause  was  discovered.  Drs.  T.  SI.  Rotch  and  May- 
nard  Ladd,  of  Boston,  reported  a  case  of  pernicious  Ane- 
mia in  infancy,  emphasizing  the  value  of  inhalations  of 
oxygen.  As  the  case  was  reported  as  apparently  recover- 
ing, considerable  doubt  was  expressed  in  the  discussion, 
as  to  the  diagnosis. 

Dr.  Frank  Spooner  Churchill,  of  Chicago,  made  a  pre- 
liminary report  of  a  case  of  so-called  "cyclic  albuminuria." 
He  considered  the  term  objectionable  as  the  condition  was 
merely  a  symptom.  A  review  of  the  literature  had  im- 
pressed him  with  two  facts,  the  superiicial  examinations  of 
the  urine  made  the  short  length  of  time  that  the  cases 
were  under  observation.  No  one  knows  whether  these 
cases  would  develoo  into  recognizable  organic  disease 
or  not.  The  women  might  develop  puerperal  eclampsia,  the 
men  an  interstitial  process.  His  case,  that  of  a  boy  aged 
II,  was  distinctly  one  of  chronic  parenchymatous  nephritis, 
as  shown  by  casts,  blood,  renal  epithelium,  and  pus  in 
the  sediment.  Eighty  examinations  of  single  specimens  had 
been  made,  with  absence  of  albumin  night  and  morning  and 
presence  in  the  middle  of  the  day.  albumin  being  increased 
after  exercise  in  the  gymnasium,  diminished  after  rest  in 
bed.  The  urea  percentage  was  uniformly  high  but  not  ex- 
cessive, considering  the  age.  Phosphates  were  increased, 
chlorids  low.  No  generalizations  could  be  drawn  from  these 
observations  but  the  case  would  be  reported  later  and  it 
was  worth  inquiring  whether  the  conditions  leading  to  these 
chemic  states  were  immediately  or  remotely  causes  of 
nephritis. 

Dr.  Rowland  G.  Freeman,  of  New  York,  reported  a  ciiri- 
ous  epide'nic  occurring  in  the  Foundling  Hospital.  In  June. 
1S99,  82  cases  developed  either  simultaneously  or  within 
a  few  days.  These  included  all  of  77  children  who  spent 
the  day  in  a  certain  play  room  and  five  of  thirty  children 
in  an  adjoining  play  room,  isolated  on  account  of  ring- 
worm. No  other  cases  occurred  in  the  total  of  700  in- 
mates. Drowsiness,  loss  of  appetite  and  fever  from  101  ' 
to  105°, were  symptom;!  common  to  all.  A  digestive  disorder 
was  at  first  suspected  but  no  symptoms  developed  to  justify 
this  diagnosis.  One  case  had  marked  malarial  signs  and  the 
Plasmodium  was  found.  In  seven  mild  cases,  no  parasite 
was  demonstrable.  The  other  cases  were  treated  with 
quinine  so  successfully  that  a  cure  resulted  before  the 
order  to  examine  the  blood  was  carried  out  In  many  cases, 
two  grains  daily  were  insufficient  but  six  grains  produccil 
a  cure.  Celli  and  Koch  and  the  English  Expedition  to 
Sierra  Leone,  were  quoted  to  establish  the  susceptibility  of 
young  children  to  malaria.  .\s  to  etiology  some  structural 
changes  in  the  hospital  had  allowed  some  pools  of  stag- 
nant water  to  form  near  the  play  room  windows.  There 
had  not  been  time  for  musquito  larvae  to  develop  sinoe 
cold  weather  and  there  were  no  indications  of  bites  on  the 
children,  so  that,  it  the  fever  were  malarial,  inoculation 
must  have  occurred  in  some  other  manner.  In  the  dis- 
cussion, influenza  was  suggested  as  an  explanation.  Amau- 
rotic Family  Idocy.  A.  C.  Cotton.  Chicago.  36  cases  had 
been  collected  from  the  literature  and  the  author  added  one 
more.    The  spastic  symptoms  resembled  infantile  birth  pal- 


sy ma  the  diagnosis  was  established  by  the  Tay-Kingdon 
spot  in  the  retina.  The  author  expressed  the  belief,  on  ac- 
count of  the  liability  of  error  in  diagnosis,  that  many  cases 
were  overlooked  and  urged  the  routine  examination  of  the 
fundus  in  all  suspicious  cases.  Note  on  the  Little  Finger 
of  the  Mongolian  Imbecile  and  of  Normal  Children.  Dr.  J. 
Park  West,  Beilaire,  Ohio.  Eight  cases  were  reported,  and 
radiographs  exhibited  which  showed  a  characteristic  c\irve 
of  the  phalanges  toward  the  ring  finger.  Dr.  B.  K.  Rach- 
ford.  of  Cincinnati,  reported  a  Case  of  Maternal  Impression, 
The  mother  was  operated  on  for  appendicitis  in  the  third 
month  of  pregnancy.  The  child,  v.'hen  six  months  old. 
showed  a  corresponding  line  with  stitch  marks,  in  the  right 
inguinal  region,  but  no  scar  tissue  was  apparent.  Drs. 
Frederick  A.  Packard  and  Alfred  Hand.  Jr..  of  Philadelphia, 
made  a  report  on  the  "Pathologic  Anatomy  of  Cretinism, 
Showing  Specimens  of  the  Atrophied  Thyroid  and  Large 
Thymus."  The  discussion  branched  off  into  a  considera- 
tion of  the  thyroid  extract.  While  the  general  opinion  was 
favorable  to  its  place  in  therapy,  it  was  held  that  its  suc- 
cess in  cretinism  had  not  been  marked  and  that  the  im- 
provement had  been  in  all  instances  thus  far  known,  mere- 
ly temporary.  Drs.  Henry  Koplick  and  I.  Lichtenstein,  of 
New  YorK,  contributed  to  the  "Symptomatology  of  Cretin- 
ism, an  Observation.  Illustrated  by  Casts."  that  the  hypo- 
thenar  Eminence  of  Cretins  rises  abruptly  from  the  line 
of  the  wrist  instead  of  gradually,  as  in  normal  individuals. 

Dr.  J.  P.  Crozer  Grifliths,  of  Philadelphia,  reported  the 
case  of  a  child  (colored)  aged  three  months,  which  was 
first  seen  in  a  moribund  condition.  On  autopsy,  it  was  found 
that  the  appendix  was  gangrenous.  He  appended  an  ex- 
haustive review  of  the  literature  of  appendicitis  in  infancy. 
Among  97  cases,  the  appendix  was  perforated  in  15.  In  4, 
it  had  descended  into  the  scrotum.  Nine  cases  had  been 
subjected  to  operation  with  seven  recoveries.  In  two  of 
the  nine  cases,  operation  was  undertaken  with  the  diagno- 
sis of  intussusception.  He  also  reported  a  case  of  Long 
Gontinued  Laryngeal  Stenosis  in  a  child  of  20  months.  The 
child  began  to  suffer  with  dyspnea  on  February  15  and  con- 
tinued, with  some  remissions,  to  grow  worse  till  April  0, 
when  intubation  was  practiced.  The  tube  was  coughed  up 
several  times  and  was  left  -out  for  a  couple  of  hours  on  one 
occasion,  otherwise  it  was  retained  till  April  27.  On  May 
4.  the  child  was  doing  well  but  still  had  stridor  or  cough- 
ing or  swallowing.  May  5,  pneumonia  developed.  By  May 
20.  the  child  was  well  except  for  a  husky  voice.  The  mother 
insisted  that  the  child  had  had  a  similar  attack  in  August 
and  September  previous,  lasting  four  weeks  and  that  five 
of  the  childs'  brothers  and  sisters  had  suffered  similarly 
while  teething  or  undergoing  analogous  disturbances,  the 
attack  lasting  a  couple  of  weeks  in  each  instance.  The  con- 
dition difiered  from  ordinary  croup  in  being  persistent, 
night  and  day.  Diphtheria  was  excluded  by  bacteriologic 
examinations,  pressure  by  enlarged  lymphatics,  the  thymus, 
etc.  on  the  trachea  was  excluded  by  the  relief  afforded  by 
intubation  which  located  the  trouble  in  the  larynx.  Pres- 
sure of  a  lymph  node  on  a  branch  of  the  pneumogastric  has 
been  assigned  as  a  cause  of  laryngeal  spasm,  but  as  Mar- 
fan points  out.  unilaterial  pressure  should  not  cause  bili- 
teral  spasm.  Edema  and  papilloma  were  excluded  by  ex- 
amination. The  symptoms  did  not  accord  at  all  with  laryn- 
gismus stridulus  Rhachitis  was  present  and  was  proba- 
bly a  predisposing  cause.  Evidently,  some  family  tendency 
to  laryngeal  spasm  existed.  In  the  discussion,  the  opinion 
was  expressed  that  the  case  was  really  diphtheritic,  the 
bacilli  having  been  absent  at  the  time  of  the  examination, 
but  the  previoiis  attack  having  been  of  this  nature.  Dr. 
Griffith  did  not  agree  with  this  theory. 

Dr.  Wm.  F.  Northrup.  of  New  York,  read  a  paper,  with 
illustrations,  on  Glass  Sun  Rooms  on  City  Roofs,  or  Winter 
Playhouses. 

Tuesday.  May  28.  Dr.  Charles  Gilmore  Kerley.  of  the 
Davis  Hospital.  O.  P.  D..  New  York,  read  a  paper  entitled: 
"A  Study  of  551  Cases  of  Summer  Diarrhea."  Only  6%  of 
his  cases  were  nursed.  472  were  fed  on  cow's  milk,  in  whole 
or  in  part.  He  considered  the  expense  of  proprietary  in- 
fants' foods  a  fortunate  circumstance.  When  first  seen, 
his  cases  had  lasted  from  one  to  ten  days  or  more.  80  cases 
recovered  in  three  days.  168  in  4-7  days,  the  remainder  in 
longer  times,  for  instance,  11  recovered  during  the  third 
week,  58  in  the  fourth  and  fifth  weeks,  11  during  the  sixth 
and  seventh,  6  in  the  eighth  to  tenth  week.  499  patients 
were  treated  to  the  conclusion  of  the  sickness,  10  resulting 
fatallv.    One  Invariable  rule  was  to  stop  the  milk,  on  the 


1072 


The  Philadelphia"! 
Medical   Journal  J 


SOCIETY  REPORTS 


[Juke  8,  1991 


ground  that  it  favored  the  growth  of  the  various  bacteria 
involved.  Clinically,  it  was  impossible  to  differentiate  the 
tacteria  causing  the  disease,  nor  could  the  extent  of  lesions 
"be  determined  by  the  apparent  severity  of  the  case,  in 
218  autopsies,  in  which  gross  lesions  were  expected,  slight 
troubles  were  found  and.  on  the  other  hand,  extensive  ul- 
cerations had  been  found  in  cases  from  which  little  mucus 
-and  no  blood  had  been  passed.  In  patients  dying  within  a 
tew  hours,  a  pale,  washed-out  gut,  with  enlarged  lymph 
follicles,  was  found,  but  no  ulcers.  Most  cases  begin  grad- 
ually, as  an  intestinal  dyspepsia,  neither  the  colon  bacillus 
nor  the  streptoccocci  being  of  much  importance  at  first. 
Milk  is  recommended  only,  when  the  stools  become  ap- 
proximately normal.  In  one  instance.  5  months  elapsed 
before  it  was  given  and  in  fifty  per  cent,  of  the  cases,  re- 
lapses occurred  after  beginning  milk  diet.  For  the  most 
part,  cereal  waters  were  administered,  4  or  5  ounecs  of  bar- 
ley water  being  combined  with  one  or  two  ounces  of  vari- 
ous broths,  or  two  tablespoonfuls  of  beef  juice,  changing 
Irom  one  preparation  to  another  to  avoid  flagging  of  the  ap- 
petite. Brandy  should  not  be  given.  White  of  egg  mixture 
has  been  discarded  as  not  being  digested,  and  as  favoring 
.putrefaction  as  much  as  milk.  It  is  impossible  to  give  for 
a.ny  length  of  time  a  stronger  barley  water  than  that  con- 
taining two  tablespoonfuls  to  the  pint.  By  dextrinizing  the 
fcarley,  the  strength  may  be  doubled.  Dextrinization  muwt 
not  be  carried  out  at  a  higher  temperature  than  100  F.  or 
a  disagreeable  malty  taste  will  develop.  After  trying  the 
newer  tannin  compounds,  eudoxin,  etc..  he  had  limited  the 
drugs  used  to  four — calomel,  castor  oil,  bismuth  subnitrate 
and  opium.  The  production  of  bismuth  sulphid  was  nec- 
essary, hence  if  the  stools  did  not  become  colored,  sul- 
phur was  added,  one  grain  to  ten  of  bismuth,  every  hour  or 
two  while  the  patient  was  awake.  Four  or  five  passages  a 
day  should  be  considered  normal  as  maintaining  drainage. 
Irrigation  of  the  colon  has  been  much  overdone,  it  should 
never  be  practiced  oftener  than  once  in  eight  hours  and  not 
at  all  without  a  positive  indication.  Dr.  J.  P.  Crozer 
Griffitli  abided  to  experiments  showing  the  lack  of  valuo 
of  tannin,  opiates,  antiseptics,  etc.  Dr.  Henry  Koplik  ad- 
\ocated  albumin  water  for  the  acute  period  and  regarded 
irrigation  with  salt  solution  as  positively  nutrient,  on  ac 
count  of  the  absorption  of  the  salt.  The  stimulant  action 
of  heat  should  also  be  considered.  Dr.  Buckingham  ob 
jected  to  the  wholesale  condemnation  of  brandy  Dr.  L. 
Emmett  Holt  said  that  babies  were  too  often  fatigued  )>}■ 
■having  too  much  done  for  them.  He  cited  a  case  in  which 
irrigation  had  been  maintained  for  seven  months,  twi,e 
daily,  to  cure  a  discharge  of  mucus  that  ceased,  as  soon 
as  the  irrigations  were  stopped.  However,  he  believed  thor- 
•ougly  in  irrigation  at  the  beginning  of  an  attack.  He  would 
add  one  drug  to  the  list  of  Dr.  Kerley.  magnesium  sulphate. 
ten  to  fifteen  grains  every  hour  or  two  until  the  stools  are 
practically  pure  water,  usually  120  grains  being  necessary. 
Dr.  Chapin  alluded  to  the  danger  of  irrigation  by  kinking 
of  a  long  tube  and  thought  that,  for  most  cases,  it  was  bet- 
ter to  rely  on  the  ordinary  rectal  tip.  elevating  the  hips.  He 
did  not  believe  in  continuing  cereals  long,  quoting  a  Boston 
■writer:  "If  cereals  are  not  good  for  well  babies,  how  can 
they  be  good  for  sick  babies?"  Otherwise,  he  agreed  with 
T)T.  Kerley.  Dr.  Adams  did  not  take  so  favorable  view  as 
tlie  author  of  the  possibilit>  of  controlling  dispensary  cases 
He  cited  a  case  in  which  irrigation  had  been  carried  on  from 
summer  into  the  winter,  to  relieve  a  discharge  of  mucus 
from  the  bowel,  which  was  due  to  adenoids  in  the  pharynx. 
l)r.  Cotton  emph.isized  that  a  sharp  distinction  must  lie 
drawn  between  cleansing  irrigations,  the  use  of  hot  water 
In  the  bowel  for  stimulation  and  the  cool  sedative  flushing 
in  fever.  He  could  not  see  that  there  was  anything  objec- 
tionable in  the  use  of  egg  albumin  except  the  bad  odor  of 
sulphuretted  hydrogen  produced.  A  long  discussion  followed, 
in  which  many  points  were  reiterated  and  combatted.  Dr. 
Hotch  objected  to  the  term  "summer  diarrhea."  but  Dr. 
Kerley  insisted  that  it  was  impossible  to  follow  out  a  proper 
classification  clinically  or  even  to  distinguish  sharply  be 
Itween  functional  and  organic  troubles. 

"The  Feeding  of  an  Incubator  Baby,"  was  the  title  of  a 
paper  read  by  Dr.  Charles  W.  Townsend.  of  Boston.  The 
•child  which  was  apparently  only  two  weeks  premature 
■weighing  2  pounds.  12  ounces.  The  placenta  contained 
numerous  areas  of  necrosis  and,  as  is  usually  the  case,  the 
infarcts  were  associated  with  maternal  albuminuria.  The 
heat  of  the  incubator  was  maintained  by  a  pan  of  water  at 
S5  F.  The  birth  weight  was  doubled  in  two  weeks,  more 
than  quadrupled  in  six  months  and  at  one  year,  the  child 


weighed  17  pounds.  He  detailed  his  method  of  modifying 
milk,  which  he  preferred  to  use  raw,  whenever  possible. 
Bach  ounce  of  10%  cream,  obtained  by  skimming  oft  the  up- 
per quarter  of  a  bottle  of  milk  after  standing  five  hours,  ad- 
ded to  a  twenty  ounce  mixture  represents  5-10%  of  fat, 
2-10%  sugar,  2-10%  proteids.  Each  even  tablespoonful  of 
sugar  of  milk  raises  the  percentage  of  sugar  2%.  The  white 
of  one  or  two  eggs  may  be  added,  the  egg  albumin  resem- 
bling lactalbumin.  The  infant's  progress  was  uninterrupted 
and  the  first  tooth  was  cut  at  the  age  of  six  months  and  one 
week.  When  three  months  old,  the  baby  was  taken  into 
the  country  and  Jersey  milk  was  used.  This  produced  more 
frequent  stools  and  some  gas  and  Holstein  milk  was  sub- 
stituted with  good  results.  After  the  eighth  month,  a  cer- 
eal in  the  form  of  oatmeal  or' barley  water  was  added.  Us- 
ually, he  believes  in  employing  the  cereal  at  or  before  this 
time,  especially  if  pallor  develops.  He  alluded  to  a  similar 
case  occurring  in  an  infant  born  at  the  seventh  month. 

"The  Place  of  Cereals  in  Infant  Feeding,"  Dr.  Henry  D. 
Chapin.  of  New  York.  Believing  that  their  use  is  well  es- 
tablished clinically,  he  attacked  the  problem  from  the  sci- 
entific standpoint.  Our  methods  of  analyzing  milk  are  not 
sufficiently  perfect  to  warrant  too  strong  insistance  on  per- 
centage modification  of  cow's  milk,  to  imitate  mother's 
milk.  Ordinarily,  we  do  not  distinguish  clearly  enough  be- 
tween soluble  albumin  and  globulin  on  the  one  hand  and 
nucleo-albumin,  mainly  caseinogen.  which  contains  phos- 
phorus, on  the  other.  Neither  is  it  correct  to  call  every- 
thing fat  that  is  extracted  by  ether.  Albumin,  globulin,  al- 
bumose,  sugar,  etc.,  could  be  absorbed  after  little  digestive 
effort  while  nucleo-albumin  represented  in  the  curds,  re- 
quired a  tedious  process  of  digestion.  Mammals  may  be 
divided  into  carnivorae,  and  non-ruminants,  for  conveni- 
ence. The  milk  of  each  division  is  similar,  a  high  per- 
centage of  proteids  being  found  in  carnivorae  with  short  in- 
testines, a  high  percentage  of  nucleo-albumin — and  hence 
relative  coarseness  of  curds — in  ruminants.  Carnivorae 
double  in  weight  in  about  ten  days  after  birth,  ruminants 
only  after  sixty  days.  During  the  first  days  of  life,  all 
mammals  are  nourished  by  colostrum,  which  is  rich  in 
soluble  albumins  and  sugar  and  hardly  coagulates  at  all 
on  the  addition  of  rennet.  In  practice,  it  is  found  necessary 
to  begin  with  1-8  to  1-4  of  the  proteid  found  in  human  milk 
and  by  furnishing  additional  amounts  of  carbohydrates, 
proteid  metabolism  is  diminished,  more  readily  than  by  in- 
creasing the  fats.  Hence,  a  modified  milk  which  contains 
only  the  percentage  of  sugar  found  in  mother's  milk,  is  in- 
adequate. Maltose  saccharose  and  lactose  all  have  the 
same  formula  CloH22011.  and  all  rotate  light  to  the  right. 
Saccharose  is  eliminated  if  introduced  into  the  blood,  the 
other  two  are  assimilated,  oxidation  depending  on  enzymes 
of  the  blood.  Cow's  milk  contains  two  sugars,  one  of  which, 
at  least,  is  different  from  that  of  mother's  milk  and  it  is  im- 
possible to  modify  cow's  milk  so  as  to  imitate  human  mirn, 
physiologically,  even  if  the  percentage  composition  seems 
to  agree  perfectly.  Both  by  diminishing  the  size  of  curds 
and  by  furnishing  readily  oxidizable  nutriment,  he  believed 
that  the  use  of  cereals  was  useful  and  he  thought  it  better 
to  use  a  simple  cereal  gruel  as  a  basis  rather  than  let  the 
baby  be  turned  over  to  a  mercenary  manufacturer. 

In  the  discussion  of  these  two  papers,  considerable  op- 
position was  manifested  toward  Dr.  Chanin's  theory  and 
the  general  feeling  seemed  to  be  that  his  advocacy  of  cer- 
eal gruels  would  tend  to  the  use  of  proprietary  prepara- 
tions. Dr.  Rotch  criticized  his  tables  of  milk  analysis  as 
incorrect  and  alluded  to  the  popular  belief,  in  which  he 
shared,  that  it  would  be  difficult  to  get  a  sample  of  mules 
milk.  He  acknowledged  that  barley  would  favor  curdling 
in  smaller  particles  than  plain  water  as  a  diluent,  but  he 
did  not  recognize  the  necessity  of  securing  this  end  and 
he  preferred  to  use  whey,  as  containing  the  more  digestible 
albumin  and  globulin  and  sugar  of  milk.  Dr.  Koplik  favored 
the  general  use  of  modified  milk  but  thought  that  dextrin- 
ized  foods  were  of  value  in  certain  cases,  especially  chronic 
ones  in  which  the  child  was  poisoned  from  within  its  own 
alimentai'v  tract.  Melitose  or  malt  would  render  the  case- 
in more  digestible.  Dr.  Griffith  believed  that  a  perfect  imi- 
tation of  human  milk  was  impossible  and  that  good  results 
might  be  obtained  from  diverse  methods.  Dr.  Rotch  ob- 
jected to  any  attempt  to  harmonize  the  conflicting  theories. 
Dr.  Holt  believed  thit  in  healthy  children,  there  was  no 
advantage  in  adding  cereals  but  he  favored  an  occasional 
change  of  diet.  Dr.  Winters  had  tried  cereals  and  had 
abandoned  them.    Dr.  Saunders  had  had  good  results  from 


JDNE    8,    1901] 


SOCIETY  REPORTS 


TThe  Philadelphia 
L  Medical  Journal 


1073 


whey  and  had  used  cereals  to  advantage  in  sick  children 
but  did  not  dvocate  them  in  health.  The  afternoon  ses- 
sion was  shortened  in  order  to  visit  the  Pan-American  Ex- 
position, where  the  members  were  entertained  by  Dr.  Ir- 
ving M.  Snow,  of  Buffalo.  Wednesday  morning.  May  29.  Dr. 
A.  C.  Cotton,  of  Chicago,  showed  a  monster  born  at  the 
seventh  month,  although  not  much  larger  than  a  normal 
fetus  of  five  months,  which  was  passed  around  with  it,  for 
comparison.  The  principal  abnormalities  were:  webbing 
and  clubbing  of  the  fingers,  deficiency  of  some  of  the  limb 
bones,  as  shown  by  radiographs,  ophthalmocele,  deficiency 
of  the  cranial  bones  superiorly,  hernia  containing  intestine 
and  left  lobe  of  liver.  The  celosomia  would  locate  the  dis- 
turbance early  in  the  second  month  or  earlier.  Hydroceph- 
alus existed  but  must  have  developed  later  or  the  monster 
would  have  been  anancephalic. 

Dr.  Saunders,  of  Cincinnati,  showed  a  specimen  of  con- 
genital hypertrophic  stenosis  of  the  pylorus,  with  thicken- 
ing of  the  stomach  wall  but  without  dilatation.     The  child 
was  born  of  healthy  parents,  without  lesion  at  birth.    Vom- 
iting had  been  frequent  and,  often,  of  two  nursings  at  once, 
so  tiiat  the  diagnosis  was  made  before  death  and  operation 
advised  but  refused.     The  child  had  died  when  five  weeks 
old.     The  stomach,  prepared  with  formalin,  was  exhibited 
in  contrast  with  a  normal  child's  stomach   similarly  pre- 
pared.   Dr.  Holt  disputed  the  diagnosis,  calling  attention  to 
the  suspiciously  large  number  of  cases  reported  lately.    He 
considered  the  absence  of  dilatation  as  against  the  diagno- 
sis.    Various  contractions  and  even  hour-glass  contraction 
of  the  stomach  are  often  diagnosed  when  the  appearance 
is  due  to  muscular  rigidity.    Dr.  A.  L.  Benedict,  of  Buffalo, 
a   guest,   while   agreeing   with   the   diagnosis,   spoke   of   a 
fact  that  he  had  recently  observed,  namely  that  embalming 
with  formalin  sometimes  caused  hardening  and  fixation  of 
muscularly  contracted  hollow  viscera,  to  such  a  degree  that 
mistakes  of  diagnosis  might  occur.  Dr.Freeman  spoke  of  the 
differences  occurring  in  normal  cases. according  to  dilatation 
with    gas    or    contraction.      The    author    referred    to    the 
history  as  establishing  the  diagnosis  and  also  pointed  out 
the  characteristic  appearance  of  the  pylorus  as  seen  from 
the    duodenum,    resembling    the    portio    vaginalis    cervicis 
uteri.     Dr.  John  Lovett  Morse,  of  Boston,  reported  a  case 
of  a  premature  infant  that  was  put  into  a  basket  lined  with 
blue  silk,  in  order  to  maintain  warmth.    A  regular  incubator 
was  considered  unnecessary  on  account  of  the  warm  weath- 
er.    The  child  was  slightly  blue  at  birth  and,  after  a  few 
weeks,  a  systolic  cardiac  murmur  was  heard  intermittently. 
At  six  months,  slight  albuminuria  and  hematuria  and  in- 
crease of  blueness  led  to  a  more  thorough  examination  and 
finally,  arsenic  was  detected  in  the  urine.     The  blue  silk 
lining   of  the   basket   was   the   only   object  that   could   be 
found  containing  arsenic.     Except  for  an  exacerbation  due 
to  an  epidemic  coryza,  the  case  progressed  favorably.     Dr. 
Samuel  S.  Adams,  of  Washington,  showed  eight  tempera- 
ture charts  of  children  from  two  to  eleven  years  old  with 
pulmonary  tuberculosis  in  the  third  stage,   most  of  them 
having   cavities.     The   temperature   fluctuated    widely   be- 
tween 95  and  105.6  with  no  correspondence  in  other  symp- 
toms, the  children  having  neither  chill,  sweat,  loss  of  ap- 
petite, nervousness,  malaise,  etc.,  at  the  time  of  the  fluc- 
tuation.    Dr.  Holt  thought  that  there  must  be  some  other 
cause  than  tuberculosis,  for  example  a  streptococcic  process 
in  the  lungs,  to  account  for  the  fluctuation.    Dr.  L.  Emmett 
Holt,  of  New   York,  reported  a  case  of  diphtheria  of  the 
conjunctiva,  yielding  promptly  to  antitoxin.    General  symp- 
toms were  slight,  the  local  lesion  conspicuous.    He  also  re- 
ported a  case  of  gastric  hemorrhage  without  obvious  escape 
of  blood  by  the  stools,  occurring  on  the  second  day  after 
birth  and  promptly  relieved  by  suprarenal  extract,  one  grain 
every  hour  for   twelve   doses.     The   last   few   doses   were 
taken  with  difficulty  on  account  of  the  puckering  of  the 
esophagus.     The  child   subsequently  did  well,  there  being 
no  hemorrhage  when  the  cord  came  away.     A  child  of  the 
same  parents  had  previously  died  of  similar  hemorrhage. 
A  friend  of  his  had  used  the  same  method  successfully,  so 
far  as  the  gastrointestinal  hemorrhage  was  concerned,  but 
the  child  died  later,  apparently  from  internal  hemorrhage. 
He  also  reported   a  case  of  protracted  high  temperature, 
from  January  10  to  May  5,  when  death  ensued.    For  several 
days,   the   temperature  was   very   high,   reaching   106   and 
pneumonia  was   diagnosed  from  the  physical  signs.     For 
the  most  part,  however,  only  a  few  rales,  feeble  breathing 
and  slight  dullness,  bilaterally,  were  noted.     Examination 
tor  the  Plasmodium,   five  Widal  tests,  attempted  cultures 


from  the  blood,   examination  of  sputum,  etc.,  were  nega- 
tive.    There  were  gastro-enteric  symptoms  with  discharge 
of  mucus.     At  the  autopsy,  broncho-pneumonia,  universal 
adhesions  of  the  lungs,  a  pocket  of  15  c.c.  of  pus  in  the 
right   lower   lobe    and    a   sacculated    empyema   containing 
60  c.c.  on  the  diaphragmatic  surface  of  the  left  lung  were 
found.     In   the   middle   of  the   sickness,     the     leucocytes 
amounted  to  22,000,  falling  to  14,000  and  11,000.    Dr.  Uorae 
reported  a  case  of  oozing  from  forceps  wounds,  in  which 
suprarenal  powder  applied  locally  had  no  effect.     Finally 
Monsel's   solution   and   digital   pressure   for   twelve   hours 
were  resorted  to.  successfully.     Drs.  Rotch  and  Bucking- 
ham reported  a  case  of  prolonged  fever  in  which  the  path- 
ologic diagnosis  was  Ij'mphogenous  pneumonia,  the  pneu- 
mococcus  being  present.     Dr.   Chapin  reported  a  case  of 
elevation  of  temperature,   recurring  regularly   every   fifth 
day,  unexplainable  and  not  yielding  to  antimalarial  treat- 
ment, but  gradually  recovering.     He  had  seen  four  or  five 
cases  of  ocular  diphtheria  in  which  antitoxin  was  used  but 
he  believed  the  cure  had  been  due  rather  to  local  treatment. 
Dr.  Carr,  in  regard  to  suprarenal  extract,  quoted  Bates's 
experiments  which   show   that   an   aqueous   solution   must 
be  used.     Dr.  J.  P.  Wilson,  of  Philadelphia,  spoke  of  the 
usefulness  of  suprarenal  extract  in  adult  cases,  mention- 
ing one  of  purpura  hemorrhagica,  with  filling  of  the  blad- 
der with  blood,  occurring  in  the  course  of  gonorrhea.     He 
urged   examination  of  the  heart  in   all   protracted  fevers, 
without  obvious  explanation,  for  some  form  of  endocarditis, 
not  necessarily  ulcerative,  might  be  the  cause.     Dr.  Rotch 
mentioned   the  case  of   an  oculist's   child,   suffering   from 
conjunctival  diphtheria,  in  which  local  measures  had  been 
unavailing  but  which  yielded  promptly  to  antitoxin.     Dr. 
Holt   emphasized   the   difference  between  hemorrhages  in 
the  new  born  and  hemophilia,  in  that  infants  either  die  or 
recover  without  further  hemorrhagic  tendency.    Dr.  Chapin 
disagreed  with  this,  alluding  to  Dr.  Holt's  case  and  to  one 
of  his  own  in  which  two  children  of  the  same  family  had 
hemorrhages  within  a  day  or  two  after  birth  and  the  mother 
herself  suffered  from   hemophilia.     Dr.  Holt  mentioned  a 
method  of  obtaining  sputum  in  young  children,  by  the  pas- 
sage of  the  tube  into  the  esophagus,  while  the  stomach  was 
empty.    Dr.  Harold  Williams,  of  Boston,  reported  a  case  of 
Appendicitis  occurring  with  Measles.     The  signs  pointing 
to  the  appendix  were  obscure  though  there  was  a  history 
of    gostro-enteric    disturbances.      Measles    had    previously 
occurred  so  that  the  case  was  considered  from  the  side  of 
the  bowel  till  the  eruption  made  the  one  diagnosis  positive. 
The  next  day  after  the  appearance  of  the  eruption,  however, 
it  became  evident  that  measles  was  not  the  only  condition 
present  and  operation  was  performed,  resulting  in  finding 
a  slightly  gangrenous  appendix.     Temperature  fell  to  nor- 
mal the  next  day  and  convalescence  was  rapid.     Dr.  W.  S. 
Christopher,  of  Chicago,  read  a  paper  on  Physical  Measure- 
ments at  Puberty,  their  Significance,  Variation  and  Appli- 
cations, based  on  studies  made  for  the  Educational  Depart- 
ment  of   Chicago.     Tables   of   weight,   height,   rapidity   of 
growth,  vital  capacity  and  hand  grip  were  shown,  giving 
both  averages  and  a  "belt"  of  normal  variations  from  the 
average.    Immediately  before  puberty,  there  is  a  decline  of 
the  life  processes,  followed  by  an  exaltation  for  a  couple  of 
years  or  thereabouts,  of  all  the  life  processes  enumerated. 
This  wave  begins  earlier  and  lasts  a  shorter  time  in  girls. 
As   compared   with   boys,  this  exaltation   in  girls  is  more 
marked  in  weight  and  height,  less  so  in  the  other  aspects. 
At  puberty  mortality  is  low  and  morbidity  high,  neuroses, 
psychoses,    neurasthenia,    deformities    and    anemias   being 
the  chief  diseases  noted.    There  is  a  wider  "belt"  of  norma! 
deviation  from  the  average  at  puberty,  and  a  corresponding 
accentuation  of  individualism,  as  compased  with  other  per- 
iods    of     childhood.        He      had      noted      that      the      in- 
mates   of     a     school     to     which     boys     are     committed 
by     the     criminal      courts,      fell      below      the      averages 
of  boys  of  corresponding  ages  at  other  schools,  the  differ- 
ence being  more  and  more   marked   with   advancing  age. 
The  following  officers  were  elected:    President.  Dr.  W.  S. 
Christopher,   Chicago:    first  vice-president.   Dr.   John   Dor- 
nung.   New   York:    second   vice-president.   Dr.   Charles   W. 
Townsend.  Boston:  secretary.  Dr.  Samuel  S.  Adams.  Wash- 
ington; treasurer.  Dr.  J.  Park  West,  Bellaire,  O.:  editor  and 
recorder.  Dr.  Walter  Lester  Carr,  New  York:   council.  Dr. 
A.  D.  Blackader,  Wm.  Osier.  C.  P.  Putnum.  F.  Forchheimer, 
J.  C.  Wilson,  F.  M.  Crandall.  T.  M.  Rotch. 
The  next  meeting  will  be  held  in  Boston. 


I074 


The  Philadelphia" 
.Medical  Journal    . 


SOCIETY  REPOR'i  S 


[June  S,   1901 


American    Laryngological    Association. 


The  twenty-third  annual  Congress  of  the  American 
Laryngological  Asociation  opened  in  Dwight  Hall,  Yale  Col- 
lege. Monday  morning.  .May  27th.  President  Henry  L.. 
Swain  in  the  chair.  After  the  roll  call  and  reception  of 
guests,  President  Hadley.  of  Yale  College,  welcomed  the 
members  in  the  name  of  the  college  in  a  few  well-chosen 
and  felicitious  remarks. 

President  Swain  then  delivered  his  address,  in  which  he 
took  for  his  text  the  education  of  the  medical  man  of  the 
future.  The  first  paper  that  was  read  after  the  meeting 
was  formally  opened  was  by  .Jonathan  Wright,  M.  D.,  of 
Broolvlyn,  N.  Y..  entitled.  A  Leaf  From  the  Ancient  His- 
tory of  the  Anatomy  of  Nasal  Catarrh." 

Then  Dr.  A.  Coolidge,  Jr.,  Boston,  Mass.,  discussed  Asym- 
metry of  the  Nasal  Cavities. 

In  this  community  at  least,  asymmetry  of  the  nasal 
passages,  to  a  greater  or  less  degree,  is  so  com- 
mon that  it  might  almost  be  considered  the  rule  and 
not  the  exception.  It  is  commonly  observed  that  in  cases 
of  deflection  of  the  septum  the  turbinate  body  opposite  a 
concavity  is  enlarged,  and  the  one  opposite  the  convexity 
is  small.  The  causes  assigned  for  this  condition  come  un- 
der three  heads:  First,  that  the  deviation  of  the  septum 
is  primary,  and  that  the  accompanying  changes  in  the 
turbinates  are  due  either  to  changes  brought  about  by  the 
inspired  air  current,  or  to  pressure  on  the  turbinate.  Sec- 
ond, that  deviations  of  the  septum  are  secondarily  caused 
by  a  primary  change  in  the  shape  of  the  turbinates,  and 
third,  that  both  the  deflected  septum  and  the  asymmetrical 
turbinates  and  outer  wall  are  due  to  a  common  asymmet- 
rical development. 

Reflex  Epilepsy  from  Nasal  Disease  Successfully  Treated 
by  the  Removal  of  the  Intra-nasal  Cause,"  was  the  subject 
of  a  paper  read  by  Dr.  ,Tohn  O.  Roe.  of  Rochester.  N.  Y., 
in  which,  after  saying  that  the  pathology  of  epilepsy  is  as 
yet  an  unwritten  chapter  in  the  history  of  the  disease, 
and  that  the  exciting  cause  generally  resides  in  some  part 
of  the  body  outside  of  the  brain,  he  reports  several  cases 
which  had  come  under  his  observation  in  which  the  re- 
moval of  an  intra  nasal  cause  had  caused  a  cessation  of  the 
seizures. 

Dr.  Arthur  Ames  Bliss,  of  Philadelphia,  read  a  paper  on 
the  Supra-Lubial  Operation  ( Dr.  Harrison  Allen's)  for  de- 
flection of  the  nasal  septum.  The  cases  peculiarly  adapted 
to  this  operation,  are  those  in  which  there  is  a  straight  or 
but  slightly  curved  deflection  of  the  nasal  septum  above  the 
anterior  nasal  spine  with  no  overhang,  with  an  actual  bend 
of  the  spine  itself  to  the  narrower  side  of  the  nose. 

Henry  L.  Wagner,  M.  D.,  of  San  Francisco.  Cal.,  present- 
ed a  radiograph,  showing  a  large  metallic  disc  in  the  eso- 
phagus. The  home  remedy  of  inverting  the  boy  had  been 
tried,  with  no  result,  and  the  boy,  five  years  old.  had  been 
brought  to  the  clinic.  .\  suitable  diet  had  been  ordered 
in  hopes  that  the  telephone  check,  as  his  mother  said, 
should  take  the  orthodox  course  through  an  alimentary 
canal.  This  was  tried,  but  the  boy  constantly  complained 
of  a  metallic  taete,  and  an  incessant  pain  in  the  neck,  and 
in  the  stomach  (reflex)  and  had  at  last  vomited,  not  the 
telephone  check,  but  a  brass  disc  considerably  larger.  The 
disc  was  shown.  The  narrator  also  presented  a  case  of  Epi- 
pharyngeal Lymphosarcoma  in  a  boy.  This  is  rarely  found 
in  children.  The  growth  was  neither  lobulated  or  soft  to  the 
touch  of  the  probe,  as  sarcomata  are  said  to  be  in  this 
region,  but  its  surface  was  perfectly  round  and  smooth, 
and  its  texture  very  dense.  The  growth  was  removed,  with 
some  alleviation  of  symptoms.  Soon  after  there  was  par- 
alysis and  ptosis  of  the  left  eye.  showing  that  the  morbid 
process  had  invaded  the  brain.  An  otitis  media  purulenta 
afterwards  set  in.  and  the  patient  died  about  four  months 
after  being  first  seen. 

Dr.  John  Henry  Rhodes,  of  Chicago,  read  a  paper  on 
"Chancre  of  the  Tonsil."  with  report  o»  tour  cases  under 
his  own  observation,  and  a  table  of  31  others.  He  is  of  the 
opinion  that  there  are  many  of  these  cases  that  are  ac- 
quired innocently.  He  is  also  of  the  opinion  that  there  are 
many  of  such  cases  that  are  not  properly  diagnosed,  being 
taken  for  a  recurrent  tonsilitis.  He  arrives  at  the  following 
conclusions:  (1)  Chancre  of  the  tonsil  is  often  unrecog- 
nized because  hypertrophy  and  inflammation  are  so  fre- 
quent, and  are  so  closely  simulated  in  the  earlier  symptoms, 
which  often  differ  little  from  an  ordinary  sore  throat.  (2) 
An  enlarged  and  indurated  tonsil  with  a  superficial  ulcer 


on  its  surface,  accompanied  by  enlargement  and  induratioa 
of  the  continuous  submaxillary  gland,  and  which  is  un- 
changed by  a  long  course  of  treatment  renders  a  diagnosis 
of  chancre  probable.  (3)  The  character  of  the  chancre  de- 
pends upon  the  original  condition  of  the  tonsil  as  to  size, 
density,  the  amount  of  follicular  inflammation  and  the 
coincidence  of  a  mixed  infection.  (4)  A  certain  diagnosis 
cannot  usually  be  made  until  the  general  eruption  of  the 
disease.  (5)  The  explosion  of  the  disease  is  no  more 
severe  than  in  chancre  elsewhere.  (6)  The  disease  is  con- 
tracted by  direct  contact  or  by  various  media  carrying 
the  virus.  (7)  When  we  consider  the  frightful  contagious- 
ness of  syphilis,  and  the  frequency  with  which  it  is  con- 
veyed to  innocent  persons,  the  most  careful  use  of  throat, 
nose,  dental  and  other  surgical  instruments,  clinical  ther- 
mometers, etc.  is  necessary.  (8)  Separate  instruments 
should  be  used  for  examination  and  treatment  of  known 
syphilitics,  but  the  possibility  of  contamination  before  the 
existence  of  the  lues  has  been  recognized  make  it  impera- 
tive that  every  operator  should  employ  a  rapid  and  efficient 
disinfection  or  sterilization  of  instruments  after  the  ex- 
amination or  treatment  of  every  patient.  (9)  Most  careful 
instructions  should  be  given  patients  as  to  the  necessity 
of  sufficient  isolation,  the  methods  of  infection,  and  the 
period  of  danger,  and  the  use  of  individual  household  and 
other  utensils  should  be  enjoined. 

Dr.  Emil  Mayer,  of  New  Y'ork,  read  a  letter  on  Empyema 
of  the  Antrum  of  Highmore  in  Infants,  in  which,  after  not- 
ing that  the  literature  on  the  subject  was  excessively  mea- 
gre, he  reported  a  case  in  his  own  practice  in  a  child.  2^ 
years  old.  in  whom  the  general  symptoms  noted  were 
eversion  of  the  right  lower  lid.  fistulous  opening  in  right 
cheek,  from  which  pus  exuded  and  a  most  penetrating  odor 
from  the  right  side  of  the  nose.  The  child  was  operated 
on,  and  recovery  took  place  without  any  diflSculty  .  The 
writer  concludes  that  it  is  established  beyond  doubt  that 
empyema  of  the  antrum  of  Highmore  in  young  children 
is  not  merely  caries  or  tuberculosis  or  an  osteomyelitis. 
but  is  as  aistinct  an  affection  as  in  later  life. 

Dr.  H.  H.  Bryan,  of  Washington,  reported  a  very  Inter- 
esting case  of  .Abscess  of  the  Frontal.  Ethmoidal  and 
Sphenoidal  Sinuses  which  had  been  under  his  care  for  the 
last  two  years.  He  gave  the  different  steps  that  he  had 
pursued  in  the  effort  to  relieve  and  cure  this  condition. 
but  he  has  been  forced  to  come  to  the  conclusion  that  there 
is  but  one  outcome  of  the  condition,  and  that  is  pain, 
suffering  and  finally  death  coming  to  the  relief,  where 
medical  and  surgical  measures  have  failed. 

Dr.  Carl  Seller,  of  Scranton.  Pa.,  presented  a  paper  on 
The  Effects  of  Cinchonisra  Upon  Vocalization  and  .Articu- 
lations. He  found  in  the  first  place  that  the  ordinary 
tinnitus  aurium  due  to  middle  ear  disease  never  trans- 
gressed the  limits  of  pitch  from  D  1  (297  vibrations  as  the 
lowest  point  to  the  F  2  (704  vibrations)  as  the  highest,  as 
near  as  it  was  possible  for  him  to  determine,  and  that 
these  subjective  noises  although  variable  in  quality  or 
timbre  had  no  appreciable  effect  upon  vocalization  or  arti- 
culation, but  that  they  would  invariably  and  very  mater- 
ially effect  the  perception  of  sounds  which  had  the  same  or 
nearly  the  same  number  of  vibrations  per  second  as  the 
subjective  noises  of  the  patient.  The  subjective  noises  due 
to  Quinine.  Salycilate  of  Soda.  Alcohol.  Ether  and  many 
others,  were  invariably  of  a  very  high  pitch  varying  from 
as  low  as  the  G  3  (1584  vibrations)  to  as  high  as  (3960  vi- 
brations I  and  often  even  higher.  He  also  observed  that 
any  composite  noises  of  high  pitch  not  only  interfered  with 
the  pronunciation  of  those  consonants  which  according  to 
the  investigations  of  Helmholz  and  others  have  tor  their 
characteristic  sound  a  combination  of  high  pitche<l  sounds 
such  as  "th."  "S."  "Sh."  "Z,"  and  the  like  consonant 
sounds  of  articulate  speech,  but  also  caused  them  to  b? 
easily  obliterated  and  consequently  most  difficult  to  appre- 
ciate and  to  be  recognized  by  the  ear. 

Wyatt  Wingrave,  M.  D.,  of  London,  Eng.,  26  cases  of  ton- 
sillotomy rash.  This  is  somewhat  similar  to  the  (urgica. 
rash,  that  follows  some  operations  in  some  cases.  The  erup- 
tion generally  appears  on  the  second  or  third  day.  either 
papular,  roseolar  or  erythematous  in  type.  It  most  fre- 
quently attacks  the  neck,  chest  and  abdomen,  sometimes 
extending  to  the  face  and  extremities.  The  earliest  appear- 
ance noted  was  the  day  following  the  operation,  and  the 
latest,  the  sixth  day.  Its  duration  is  generally  two  or  three 
days,  but  it  may  extend  to  five  days,  .\tter  reaching  its 
maximum   intensity,  it  rapidly  disappears  without  deequ- 


JONE    8.    1901) 


SOCIETY  REPORTS 


TThe  Philadelphia 
Lmedical  Journal 


1075 


niation,  but  Is  sometimes  associated  with  intense  itching. 
It  may  occur  at  any  age.  the  youngest  of  his  cases  being  14 
months,  and  the  oldest  23  years. 

SECOND  DAY. 

Dr.  Francke  H.  Bosworth.  of  New  York,  presented  a 
paper  on:  "The  Tonsils  from  a  purely  Clinical  Point  of 
View."  In  this,  he  takes  the  ground  that  the  only  healthy 
tonsil  is  one  in  which  there  is  no  hypertrophy,  in  other 
vords.  the  tonsil  that  is  manifest  on  inspection  is  not  a 
normal  one.  He  advises  the  removal  of  this  tumor,  as  he 
■Rould  the  tumor  of  any  other  kind  that  might  present, 
■whether  benign,  malignant  or  otherwise. 

Dr.  C.  H.  Knight,  of  New  York,  read  a  paper  on  Vocal 
Nodules.  In  this  paper  the  writer  takes  the  ground  that 
the  cause  of  these  nodules  of  the  vocal  chords  are  due  to 
some  abnormal  condition  in  the  upper  air  tract,  rather  than 
to  any  abnormality  either  in  the  vocal  chords  themselves 
or  in  the  larynx.  He  does  not  mean  to  say  that  there 
are  no  cases  that  could  be  ascribed  to  any  other  cause,  but 
that  the  majority  of  these  cases  are  due  to  the  lesions 
higher  up.  He  thinks  that  the  nodule  is  the  secondary 
condition,  and  not  the  primary  one.  He  also  thinks  that 
the  condition  is  more  or  less  permanent,  in  spite  of  the 
fact  that  there  are  some  authors  that  incline  to  the  belief 
that  they  are  transitory  from  over  use. 

A  study  of  the  proper  application  of  intubation  in  chronic 
stenosis  of  the  larnyx,  was  the  subject  of  a  very  able  paper 
by  Dr.  W.  K.  Simpson,  of  New  Y'ork.  The  writer  divides 
these  cases  into  three  classes:  First,  those  of  gradual 
stenosis,  of  longer  or  shorter  standing,  in  which  immediate 
intubation  is  not  necessary.  Second.  Those  cases  in  which 
an  acute  exacerbation  renders  immediate  intubation  nces- 
sary  in  order  to  save  life,  and  third.  Those  cases  where  it 
is  desired  to  avoid  wearing  a  tracheal  canula. 

In  the  first  two  classes  of  cases,  unless  a  clear 
view  of  the  larynx  can  be  had  and  a  positive  knowledge  of 
the  immediate  cause  of  the  stenosis  obtained,  intubation  is 
not  to  be  thought  of,  but  tracheotomy  done  instead.  In 
doing  a  tracheotomy,  it  is  well  to  do  it  as  high  as  can  be 
done  with  safety  and  then  after  the  immediate  symptoms 
are  relieved  it  is  well  to  intubate.  An  intubation  tube  may 
be  worn  for  months  without  changing.  The  difficulty  in 
retaining  an  intubation  lube  has  been  overcome  by  Dr. 
John  Rogers,  who  has  added  to  the  original  O'Dwyer  tube 
a  right  angled  tube  which  is  allowed  to  protrude  from  the 
tracheal  opening.  This  secondary  tube,  is  added  at  the 
time  of  intubation,  after  the  tube  has  been  placed  In  posi- 
tion, and  marked  through  the  tracheal  opening.  As  the 
tubes  are  made  of  hard  rubber,  it  is  a  matter  of  only  a  short 
lime. 

Dr.  C.  C.  Rice  of  New  York,  read  a  very  interesting  paper 
on  the  subject  of  local  treatment  of  the  nasal  mucous  mem- 
brane in  Hay  Fever.  After  a  very  thorough  and  exhaustive 
review  of  the  theories  of  the  etiology  of  this  troublesome 
disorder,  he  explained  his  new  treatment.  It  is  well  known 
that  there  are  sensitive  areas  in  the  nose,  and  that  these 
are  the  iirimary  causes  of  hay  fever,  is  the  belief  of  the 
writer.  He  takes  the  ground  that  if  these  sensitive  areas 
are  rendered  less  sensitive  that  a  long  step  has  been  taken 
in  the  direction  of  the  prevention  of  a  recurrence  of  the 
fever.  He  was  led  to  this  line  of  reasoning  by  using  a  swab 
to  smooth  off  some  of  the  granulations  in  atropic  rninitis. 
The  method  of  treatment  is  to  rub  or  scrub  the  mucous 
membrane  of  the  nostrils  all  over,  with  some  solution  or 
even  with  simple  cotton  and  establish  a  tolerancy  of  the 
nasal  mucous  membrane  to  the  presence  of  the  irritant. 
In  all  or  nearly  all  of  the  cases  that  he  has  treated  by  this 
method,  he  had  to  accustom  the  membrane  to  the  touch  of 
the  probe.  The  first  applications  were  very  apt  to  cause 
more  or  less  violent  attacks  of  sneezing  or  coughing.  Af- 
ter a  few  applications,  this  intolerance  passed  away,  and 
he  was  able  to  obliterate  the  sensibility  very  markedly. 
The  applications  were  made  every  other  day  for  the  first 
month,  and  then  twice  a  month  after  that,  beginning  four 
months  before  the  time  of  the  expected  attack.  The  treat- 
ment was  carried  out  until  the  time  of  attack  had  passed. 

Dr.  Makuen,  of  Philadelphia.  Pa.,  read  a  paper  on  Cleft 
Palate  and  its  relation  to  speech.  This  paper  is  one  of  those 
that  cannot  be  abstracted,  or  even  described  to  another.  It 
was  a  very  able  paper  in  every  respect,  but  from  the  very 
nature  of  the  subject  it  is  seen  that  there  was  much  that 


pertained  to  the  sounds  of  the  various  vowels  and  conson- 
ants which  can  hardly  be  put  into  cold  type. 

Dr.  A.  AV.  DeRoaldes,  of  New  Orleans,  La.,  presented  a 
paper  on  the  subject  of  the  use  of  the  electro-magnet  for 
the  extraction  of  foreign  bodies  from  the  air  passages.  He 
also  pre-iented  some  instruments  that  he  had  had  con- 
structed for  such  use.  He  gave  the  results  of  the  treat- 
ment of  one  case  of  foreign  body  in  the  trachea,  in  which, 
after  having  started  to  perform  a  tracheotomy  the  point 
of  a  large  Haab  magnet  was  brought  near  the  wound,  and 
the  metallic  object  was  immediately  drawn  out  from  its 
place  of  lodgement.  In  addition  to  this  case,  he  had  con- 
ducted a  series  of  experiments  on  the  cadever,  and  had 
tabulated  the  results  of  these,  that  they  might  in  a  way  be 
a  guide  in  the  future  application  of  this  method.  This  is 
the  first  time  that  the  magnet  has  been  brought  to  the 
notice  of  the  profession,  in  such  cases. 

The  following  named  were  chosen  as  the  officers  of  the 
Association  for  1901-1902:  President,  J.  W.  Farlow,  M.  D., 
Boston,  Mass.:  first  vice-president,  J.  W.  Gleitsmann,  M.  D., 
New  York  City;  second  vice-president.  D.  B.  Kyle,  M.  D., 
Philadelphia:  secretary  and  treasurer,  James  E.  Newcomb, 
M.  D.,  lis  W.  69th  St..  New  York  City;  librarian.  Joseph  H. 
Bryan.  M.  D.,  Washington.  D.  C;  council.  Thomas  U. 
French,  M.  D.,  Brooklyn:  William  E.  Casselberry,  M.  D., 
Chicago:  Samuel  Johnson,  M.  D.,  Baltimore;  Henry  Li. 
Swain.  JI.  D.,  New  Haven. 

The  next  meeting  of  the  Association  will  be  held  In  Bos- 
ton, Mass..  in  Ma.y.  1902. 


GAZETTE    MEDICALE    DE    PARIS. 

March  16,  1901.     (72me.    Annee,  No.  II). 

1.  Clinical  Remarks  on  the  Death  of  Napoleon  the  First. 
MARCEL  BAUDOUIN. 
1. — Many  books  have  been  written  in  which  the  last 
years  of  the  great  Napoleon  have  been  depicted.  Though 
many  physicians  examined  and  treated  him.  they  drew 
different  conclusions.  He  was  ill  during  the  four  years 
before  his  death.  Cancer  would  most  probably  have  killed 
in  that  time.  Stokoe  had  diagnosed  chronic  hepatic  dis- 
ease, and  later  abscess  of  the  liver.  This  Baudouin.  from 
the  perusal  of  the  books  on  the  subject,  believes  to  have 
been  a  perihepatitis,  due  to  extension  from  the  evident 
existing  perigastritis.  For  Baudouin  believes  that  Na- 
poleon had  an  ulcer  of  the  stomach,  which  caused  his  death 
by  perforating.  Hematemesis  was  present  with  fever  oft 
and  on.  and  vomiting.  There  was  no  hypertrophy  of  the 
liver,  nor  any  signs  of  cancer,  while  a  gastric  ulcer  which 
had  perforated  was  found  near  the  pylorus  at  the  autopsv. 

[M.  O.] 

April  6,  I'Jiil.     (72me.     Annee,  No.  14.) 

1.     The  Pathogenic  Agent  in  Acute  Articular  Rheumatism. 
PIERRE  ACHALME. 

1. — In  1S91.  and  again  in  1S97,  Achalme  described  an 
anaerobic  bacclllus  found  in  cases  of  acute  articular  rheu- 
matism. It  resembles  the  bacillus  anthracis,  is  obligately 
anaerobic,  stains  with  Gram's  or  Claudius'  method,  lives 
only  between  21°  and  45°  C.  contains  ovoid  spores,  causes 
clotting  of  milk  with  gas  production,  and  acts  with  varied 
virulence  in  animals.  It  can  best  assimilate  nitrogen  in  the 
creatinic  bases.  It  easily  liquifies  gelatin.  Its  diastase, 
which  breaks  up  albumenoids.  is  a  trypsin,  the  action  of 
which  is  hindered  by  the  presence  of  acids.  Yet  with  carbo- 
hydrates the  bacillus  causes  the  formation  of  butjTic.  acetic, 
and  lactic  acids,  and  the  fermentation  of  the  sugars  and 
starches.  This  fermentative  action  prevents  the  trypsin 
from  destroying  the  fibrin  or  albumen,  and  limits  the  life  of 
the  organism:  foi*  sporulation  never  occurs  in  acid  media, 
in  some  cases  the  bacillus  has  been  found  in  the  synovial 
fluid,  the'  blood-clots  in  the  heart,  and  the  myocardium. 
In  others  it  cannot  be  found.  .Achalme  does  not  claim  that 
it  is  a  specific  bacillus.  He  believes  it  is  found  in  healthy 
individuals,  and  can  be  the  cause  of  acute  articular  rheuma- 
tism or  puerperal  fever:  or  in  animals,  of  abscess,  gangrene, 
appendicitis,  etc.  It  causes  that  vague  form  of  rheumatism 
in  which  there  are  few  arthritic,  mainly  cardiac  symptoms. 
In  these  cases  there  Is  often  an  eruption,  scarlatiniform  in 
character.  The  bacillus  causes  some  putrefaction,  and  the 
action  of  the  salicylates  in  curing  the  condition  is  ex- 
plained by  their  removing  the  products  of  putrefaction  in 
salicyluric  acid.     [M,  O.] 


ioj6 


The  Philadelphia-] 
Medical   Journal  J 


AMERICAN  NEWS  AND  NOTES 


[June  8,  isoi 


Hnicrican  mew0  m\i>  motes. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

World's  Heaviest  Baby. — Probably  the  heaviest  baby  in 
the  world  for  her  age  is  Francisca  Lillian  Minnis,  daughter 
of  George  Minnis,  of  Atlantic,  Crawford  county,  Pa.  She 
is  8  months  old,  her  Dust  measure  is  31  inches,  weighs  5IV2 
pounds  and  is  in  perfect  health.  Her  parents  are  below 
the  average  in  height  and  weight. 

State  Funds  for  Charity. — Twenty-four  bills  for  private 
charities  were  reported  in  the  House  at  Harrisburg,  Pa., 
May  27.  from  the  Appropriations  Committee,  as  follows; 

Pennsylvania  Home  for  Blind,  Philadelphia,  $2.5,000. 

Evangelical  Home  for  Aged,  Philadelphia,  $1000. 

Bethesua  Home,  Pittsburg.  $5000. 

Home  for  Aged,  Easton,   $2000. 

Rush  Hospital,  Philadelphia,  $10,000. 

Midnight  Mission,  Philadelphia,  $2000. 

Easton    Hospital,    $12,000. 

Children's  Aid  Society,  Philadelphia,  $10,000. 

Home  for  Aged,  Philadelphia,  $4000. 

West  I'hiladelphia  Hospital  for  Women,  $2500. 

Brookville  Memorial    Home,  $7000. 

Wagner  Free  Institute,  Philadelphia,  $2000. 

Lying-in  Charity  Hospital    Philadelphia,  $15,000. 

Maternity  Hospital,  Philadelphia,  $5000. 

Old   Ladies'   Home,   Philadelphia,   $4000. 

Home   of   Friendless^    Harrisburg.    $2500. 

Howard   Hospital,   Philadelphia.   $5000. 

Home  for  Aged  Veterans.  Philadelphia,  $6000 

Lniun  Home  for  Old  Ladies.  Philadelphia,  $4000. 

Home  for  'SVidcws,  Lebanon.  $2000. 

Children's  Aid  Society.  Pittsburg,  $10,000. 

Home  for  Infants,  Philadelphia.  $4000. 

Asylum  for  Indigent  Widows,  Philadelphia,  $5000. 

Colony  Farm,  $10,000. 

Jefferson  Medical  College.— The  class  of  1891  of  the  Jef- 
ferson Medical  College  will  hold  a  re-union  in  Philadelphia 
on  June  27,  28  and  29.  All  graduates,  and  especially  mem- 
bers of  the  Classes  of  1890  and  1892,  are  cordially  invited  to 
be  present. 

Almshouse  Removal  Urged  by  Citizens. — Repredenta- 
lives  of  nearly  every  medical  college  and  society  in  the 
city,  of  civic  organizations  and  many  well  known  citizens 
appeared  before  Councils'  Committee  on  Charities  and  Cor- 
rection, at  its  public  meeting  June  3rd,  to  recommend  the 
separation  of  the  Almshouse  and  insane  departments  of 
Blockley  from  the  Philadelphia  Hospital.  The  chief  ar- 
guments advanced  were  that  the  three  institutions  are  over- 
crowded, and  that  the  requirements  of  modern  science  de- 
mand open  air  and  work  for  the  insane.  Chairman  H.  R, 
Kneass,  of  the  committee,  presided.  At  the  close  of  the 
meeting  a  resolution  was  adopted  authorizing  the  Depart- 
ment of  Charities  and  Correction  to  select  suitable  sito.s 
for  the  Almshouse  and  insane  departments,  and  to  report 
to  the  committee  for  further  action.  Dr.  John  V.  Shoe- 
maker, President  of  the  Department  of  Charities  and  Cor 
rection,  showed  the  lack  of  accommodations  for  patients, 
and  spoke  of  the  feeling  of  abhorrence  with  which  many 
persons  in  need  of  medical  aid  regard  the  Philadelphia  Hos- 
pital, simply  because  it  is  connected  with  the  Almshouse. 
If  the  two  departments  were  separated,  he  thought  the 
city  would  be  able  more  widely  to  extend  its  usefullness. 

Vital  Statistics  of  Philadelphia  for  the  week  ending 
June  1,  1901: 

Total  mortality    372 

Cases.  Deaths. 

Inflammation    of    the    appendix    3, 
brain  21,   bronchi  7,  heart  1.  kid- 
neys 19,  lungs  37,   pericardium  1.  » 
peritoneum   6,   pleura   4,   stomach 
and  bowels  10   109 

Marasmus  8,  debility  4,  inanition  12  24 

Tuberculosis  of  the  lungs 50 

Apoplexy  18.  paralysis  6   24 

Heart-disease  of  36.  fatty  degenera- 
tion of  2,  neuralgia  of  2 40 

Uremia  8,  diabetes  2,  Brighfs  dis- 
ease  f.    15 

Carcinoma  of  the  breast  2.  eye  1, 
stomach  7,  uterus  1.  liver  1,  eso- 
phagus 1,  rectum  1 14 


Cases.    Deaths. 


10 


It 
10 


48 


Convulsions    9,    convulsions,     puer- 
peral 1    

Diphtheria    112 

Brain-abscess  of  1,  hemorrhage  from 
1,  softening  of  3  

Typhoid  fever   116 

Old  age   

Scarlet  tever    104 

Influenza  1,  asthma  2.  anemia  1, 
burns  and  scalds  2,  casualties  6, 
congestion  of  the  lungs  2,  cellu- 
litis 1,  cirrhosis  of  the  liver  3, 
croup  1,  diarrhea  1.  drowned  2, 
dropsy  1.  fever,  malarial  2,  gan- 
grene, senile  1,  homicide  1.  hem- 
orrhage from  bowels  1,  lymph- 
adenoma  1,  measles  2,  obstruc- 
tion of  the  bowels  1.  purpura  hem- 
orrhagia  1,  rheumatism  1,  shock, 
surgical  1,  septicemia  5,  suffoca 
tion  1.  suicide  2,  syphilis  1.  whoop- 
ing cough  4    

NEW    JERSEY. 

Proposed  Memorial  to  Dr.  Bartine. — The  erection  of  a 
tablet  is  proposed  by  some  of  the  prominent  citizens  of  Mer- 
<hantville.  X.  J.,  to  perpetuate  the  memory  of  the  late 
Dr.  D.  H.  Bartine,  who  practiced  his  profession  in  that 
town  for  thirty-five  years.  The  tablet  is  to  cost  not  less 
than  $1000. 

NEW  YORK. 

Cornell  University  has  established  an  infirmary  ex- 
clusively for  its  students.  The  building  which  is  to  be  used 
for  this  purpose  was  formerly  the  home  of  the  late  H.  W. 
Sage,  who  donated  the  building  and  $100,000  for  the  in- 
firmary. 

Institute  for  Medical  Research. — Having  conferred  with 
many  eminent  pathologists  as  to  the  best  method  of  setting 
on  foot  an  original  scientific  research  into  the  problems  of 
medicine  and  hygiene.  John  D.  Rockefeller  has  placed 
at  the  disposal  of  a  body  of  prominent  medical  men  $200,- 
000,  to  be  available  for  immediate  expenditure  by  an  asso- 
ciation incorporated  under  the  name  of  "The  Rockefeller 
Institute  for  Medical  Research."  The  home  of  this  insti- 
tute, with  such  laboratories,  staff  and  equipment  as  may 
be  found  necessary,  will  be  located  in  New  York  City.  The 
officers  and  Board  of  Directors  have  already  been  chosen. 
The  list  of  officers  is  as  follows:  Dr.  William  H.  Welch, 
Baltimore,  president:  Dr.  T.  M!  Prudden,  vice-president: 
Dr.  L.  Emmett  Holt,  secretary,  and  Dr.  C.  A.  Herter.  New 
York,  treasurer.  The  directors  are;  Dr.  H.  M. 
P.riggs,  New  Y'ork  City:  Dr.  Theobald  Smith,  of 
Boston:  Dr.  Simon  Flexner.  Philadelphia.  Indications 
are  that  the  $200,000  which  Mr.  Rockefeller  has  given  as 
the  capital  of  the  new  institute  is  a  trifling  sum  compared 
to  what  he  contemplates  giving  ultimately  to  the  same 
cause.  The  work  will  be  done  at  Columbia  University, 
Harvard  University,  the  University  of  Chicago,  the  Univer- 
sity of  Michigan,  the  University  of  Pennsylvania,  Johns 
Hopkins  University,  McGill  University,  of  Montreal,  and 
the  headquarters  of  the  New  York  Health  Department. 
The  directors  of  the  new  Rockefeller  Institute  will  have 
supervision  over  it,  but  it  will  be  performed  by  physicians 
whom  they  will  employ,  and  who  will  work  more  or  less 
independently  in  the  different  places  mentioned.  The 
heads  of  the  various  pathological  laboratories  will  have 
general  charge  of  the  investigation,  whether  they  happen 
to  be  directors  of  the  institute  or  not.  Periodically  the  di- 
rectors, whose  joint  judgment  will  be  the  sole  regulator  of 
the  expendinture  of  the  $200,000  provided,  will  meet  to  dis- 
cuss the  result  of  the  work,  and  will  jointly  give  out  the 
information  which  it  may  have  developed  through  the 
original  channels.  The  work  may  go  on  for  a  year  or  two 
before  definite  plans  are  made  for  a  permanent  institution. 
The  investigation  of  the  country's  milk  supply  will  be  the 
first  important  problem  of  which  the  directors  will  take 
hold.    Their  work  is  to  be  chiefly  bacteriological. 

Montefiore  Home  for  Consumptives  Dedicated. — The 
county  home  for  consumptives  of  the  Montefiore  Home 
for  Chronic  Invalids,  was  dedicated  May  30th  at  Bedford 
Station.  N.  Y.    After  preliminary  exercises  the  keys  were 


JUNE    S,    19011 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia 
Lmedical  Journal 


1077 


presented  to  Jacob  H.  Schiff.  president  of  the  home,  by 
Isaac  Eppinger,  chairman  of  the  building  committee,  Mr. 
Schiff  giving  a  history  of  the  home.  Theodore  Roosevelt, 
vice-president  of  the  United  States,  was  then  introduced 
and  spoke  of  the  magnificent  work  of  the  home. 

St.  Mark's  Hospital. — At  a  recent  meeting  of  the  Society 
of  the  Alumni  of  St.  Mark's  Hospital  of  New  York  the 
following  officers  were  elected  for  the  ensuing  year:  Nich- 
olas R.  Dann,  M.  D.,  president;  Conger  F.  Smith,  M.  D., 
vice-president;  Ephriam  K.  Dowd,  M.  D.,  treasurer;  Harry 
(i.  Watson,  M.  D.,  secretary 

NEW   ENGLAND. 

The  American  Laryngological  Society. — At  the  meeting 
of  the  American  Lai-yngological  Society  held  at  Yale  Uni- 
versity on  May  28,  the  committee  on  nominations  present- 
ed a  report  recommending  that  the  following  be  the  officers 
for  the  ensuing  year:  President.  J.  W.  Farlow,  of  Boston; 
first  vice-president,  W.  J.  Gleitsmann  of  New-  York;  second 
vice-president,  D.  Braden  Kyle,  of  Philadelphia;  secretary 
and  treasurer,  James  E.  Newcomb,  of  New  York;  librarian, 
J.  H.  Bryan,  of  Washington,  D.  C.  This  report  will  be 
acted  on  this  morning,  with  a  recommendation  also  that  the 
next  session  of  the  society  be  held  in  Boston  in  June,  1902. 
Papers  on  technical  subjects  were  presented  yesterday 
by  J.  W.  Geistmann.  T.  R.  French,  F.  H.  Bosworth,  C.  H. 
Knight,  W.  K.  Simpson  and  Wyatt  Wingrave  of  New  York, 
A.  W.  Watson  of  Philadelphia  and  J.  H.  Goodale  of  Eos- 
ton. 

WESTERN    STATES. 

St.  Peter's  Hospital  in  Helena,  Montana,  was  recently 
partly  destroyed  by  fire.  No  one  was  injured,  and  the  loss, 
which  was  ?10,000,  was  fully  covered  by  insurance. 

Military  Surgeons  Favor  the  Canteen. — The  Association 
of  Military  Surgeons  in  session  at  St.  Paul.  Minn.,  on  May 
31,  unanimously  passed  a  resolution  in  favor  of  repealing 
the  anti-canteen  law. 

Smallpox  in  Wisconsin. — Smallpox  has  caused  the  in- 
definite postponement  of  the  High  School  commencement 
at  Chippewa  Falls,  Wis. 

Leprosy  in  Wisconsin. — Two  cases  of  well-developed 
leprosy  have  been  discovered  in  Tustin,  Wis.  A  mother 
and  her  daughter  are  the  victims.  The  cases  are  being 
investigated. 

SOUTHERN   STATES. 

Elected     Professor    of    Dental     Pathology.-^Dr.    W.    H. 

McGehee  has  been  elected  Professor  of  Dental  Pathology, 
vice  Dr.  Ernest  Walker,  resigned,  in  the  University  College 
of  Medicine,  Richmond.  Va. 

Richmond. — The  affairs  of  the  Southwestern  Insane 
Asylum  in  regard  to  its  medical  management,  are  now 
under  investigation. 

Mosquuo  Pest. — The  Board  of  Health  of  the  city  of  Gal- 
veston, Tex.,  is  arranging  for  a  large  supply  of  oil  from 
the  Beaumont  wells  to  be  used  in  fighting  mosquitos.  The 
oil  will  be  distributed  in  all  the  stagnant  pools  in  the  city, 
sprinkled  on  the  surface  of  water  in  the  gutters,  and  dis- 
tributed free  to  owners  of  open  cisterns  for  use  in  destroy- 
ing mosquitos  and  the  fever-breeding  germs  which  collect 
in  the  ponds.  Experiments  made  by  the  Board  of  Health 
have  demonstrated  the  virtue  of  crude  oil  as  a  sanitary 
measure  if  properly  used  and  petroleum  water  as  healthful 
and  nourishing  for  drinking  purposes. 

Dr.  Richardson  Elected. — Dr.  Charles  W.  Richardson,  of 
Washington,  D.  C,  was  elected  president  of  the  American 
Laryngological  and  Otological  Society  at  its  meeting  in 
Baltimore,  Md.,  May  26. 


OBITUARY. 


Dr.  James  R.  Bayley,  at  Newport,  Ore.,  on  May  24.  aged 
82  years. — Dr.  Charles  St.  John,  at  Pericale,  Luzon,  on 
May  22. — Dr.  Dwight  Mereness,  at  Milwaukee,  Wis.,  on 
May  29,  aged  41  years. — Dr.  D.  C.  Thomas,  at  Adrian,  Mich., 
on  May  30,  aged  66  years.^Dr.  John  L.  Feeny.  at  Staten  Is- 
land, N.  Y.,  on  June  1. — Dr.  Edmond  Beale,  at  Philadelphia, 


Pa.,  on  June  1,  aged  81  years. — Dr.  R.  B.  Archibald,  at 
Purdy,  Mo.,  on  May  31,  aged  55  years. 

Dr.  George  B.  Noyes,  at  Waupaca,  Wis.,  on  May  25,  aged 
54  years. — Dr.  I.  P.  Hubert  Larose,  at  Indian  Orchard,  Mass., 
on  May  2S,  aged  31  years. — Dr.  J.  A.  Heald,  at  Denton,  Tex., 
on  May  29,  aged  80  years. — Dr.  J.  W.  Allen,  at  Guthrie, 
Ky.,  on  May  28,  aged  45  years. — Dr.  John  E.  Comfort,  at 
New  York  City,  on  May  29,  aged  64  years. 

Dr.  Edward  Sultan,  at  St.  Louis,  Mo.,  on  May  15. — Dr. 
John  A.  Wells,  Englewood,  N.  J.,  on  May  21,  aged  45  years. 
Dr.  George  Woodson  Scott,  near  Madison  Run,  Va.,  on  May 
14,  aged  35  years;  Dr.  Whitcomb  Pratt,  at  Richmond,  Va., 
on  May  16,  aged  52  years;  Dr.  Jacob  Derrickson,  at  Phila- 
delphia, Pa.,  on  May  17,  aged  75  years;  Dr.  Charles 
D.  Sherman,  at  Lancaster,  Pa.,  on  May  18,  aged 
52  years;  Dr.  A.  D.  Gibson,  at  South  Omaha,  Neb.,  on  May 
16,  aged  78  years;  Dr.  John  H.  Bruere,  at  St.  Louis,  Mo.,  oa 
May  16,  aged  34  years. 

Changes  in  the  Medical  Corps  of  the  Navy  for  Week 
ended  June  1,  1901. 

DR.  J.  H.  IDEN,  appointed  assistant  surgeon  in  the  Navy,  from 
May    4,    1901— May    25. 

MEDICAL  DIRECTOR  W.  S.  DIXON,  commissioned  medical 
director   from   April   2S,   1901— May   2S. 

MEDICAI,  INSPECTOR  C.  G.  HERNDON.  commissioned  med- 
ic.Tl   inspector,   from   April  28.   1901— May  2S. 

P.  A.  SUUGEON  E.  V.  ARMSTRONG,  detached  from  Ver- 
mont, and  ordered  to  Key  West  Nav-'jl  Station  for  duty  at 
Drv    Tortugas— May   2S. 

ASSISTANT  SURGEON  T.  M.  LIPPITT,  ordered  to  the  Wash- 
ington   Navy   Yard,   June   1— May   28. 

ASSISTANT  SURGEON  R.  B.  WILLIAMS,  detached  from 
duty  at  Dry  Tortugas,  and  ordered  home  to  be  in  readiness 
for   sea   duty— May   28. 

ASSISTANT  SURGEON  J.  H.  IDEN,  ordered  to  Naval  Hospi- 
tal,  Chelsea,    Mass.,    for  duty— May  28. 

PAST  ASSISTANT  SURGEON  J.  F.  COSTIGAN,  detached  from 
the  Yorktown  and  ordered  home.  Resignation  to  be  ac- 
cepted after  arrival— May  29. 

ASSISTANT  SURGEON  W.  M.  GARTON,  detached  from  the 
Washington  Navy  Yard,  June  1,  and  ordered  to  the  Indiana 
May  29. 

ASSISTANT  SURGEON  H.  O.  SHIFFERT,  ordered  to  the 
Nashville— May  29. 

ASSISTANT  SURGEON  E.  THOMPSON,  ordered  to  the  Solaca 
May   29. 

ASSISTANT  SURGEON  R.  K.  McCLANAHAN,  ordered  to  th* 
Culgoa— May  29. 

PHARMACIST  J.  COWAN,  detached  from  the  Manila  and 
Cavite  Naval  Station,  and  ordered  to  Naval  Hospital,  Yo- 
kohama, Japan— May  29. 


Health  Reports:  The  following  cases  of  smallpox,  yellow 
fever,  cholera  and  plague  have  been  reported  to  the  Sur- 
geon General,  U.  S.  Marine  Hospital  Service,  during  tbe 
week  ended  June  1,  1901: 

SMALLPOX— UNITED  STATES  AND  INSULAR. 


CALIFORNIA: 

ILLINOIS: 

IOWA: 

LOUISIANA: 

MARYLAND: 
MASSACHUSETTS: 


MICHIGAN: 

MINNESOTA- 

NEBR.tSKA: 
NEW  HAMPSHIRE 
NEAY  JERSEY: 


NEW   YORK: 
OHIO: 


PENNSYLVANIA: 


TENNESSEE: 

UTAH: 

WASHINGTON: 
WEST  VIRGINIA: 
WISCONSIN: 
PHILIPPINES: 
eORTO   RICO: 


San  Francisco May.  11- 

Chicago May  IS- 

Clinton    May  18- 

New  Orleans May  18- 

Shreveport    May  IS- 

Baltimore    Mav  IS- 

Boston May  IS- 

Fitchburg May  IS- 

Marlboro    May  18- 

New    Bedford   May  18- 

Detroit    May  18- 

Minneapolis May  18- 

Winona    May  11 

Omaha    May  11- 

Manchester May  18- 

Camden    May  IS- 

Newark    May  IS- 

Passaic    May  IS- 

New    York    May  18- 

Cincinnati May  17 

Cleveland  May  IS 

Brie    May  IS 

Lebanon   May  IS- 

Philadelphia:       May  18 

Williamsport May  IS 

Memphis May  18 

Nashville   May  18 

Salt   Lake   City   .    . .  May  U- 

Tacoma  May  12 

Huntington Apr.13- 

Green  Bay May  19 

Manila Mar.23- 

Ponce   Apr.27- 


-IS.    . 

.  5 

-25    .    . 

7 

-25    .. 

2 

-25    .    . 

7 

-25    .    . 

1 

-25    .. 

2 

-25     .     . 

S 

-25    .    . 

1 

-25    .    . 

1 

-25    .. 

2 

-25    .     . 

67 

-25    .    . 

9 

-IS     . 

1 

-18    .    . 

9 

-25    .    . 

5 

-26    .    . 

1 

-25    .    . 

2 

-26    .    . 

1 

-25    .    . 

134 

-24   .    . 

.  4 

-25  .  .  . 

39 

-25    . 

1 

-25    . 

S 

-25    .    . 

3 

-26    .    . 

1 

-25    . 

6 

-25    .. 

2 

-IS    . 

5 

-19    . 

1 

-May24 

4S 

-26    . 

K 

Apr.  13 

35 

-May  4 

5 

IS 


I  O/i 


The  Philadelphia' 

Medical   Journal 


AMERICAN  NEWS  AND  NOTES 


[June  8.  1901 


SMALLPOX— FOREIGN. 

AUSTRIA:                       Prague Apr.>7-May  4   ...3 

BRAZIL,:  Rio  ae  Janeiro Apr.  1-15 5 

BELGIUM:                      Antwerp Apr.27-May  4.    5       2 

CHINA:                             Hongkong Apr.B-lS    .     ...    6       li 

ECUADOR:                       Guayaquil    .     .    Mar.30-May  11  .         3 

EGYPT;                            Cairo Apr.l5-May  6  .  .         4 

FRANCE:                         Paris  Apr.27-May  4               S 

GIBRALTAR:  May  6-12 2 

GREAT  BRITAIN:       England— 

Loiiuon May  4-11    .     .      1 

Liverijool  May  4-11    ...    2 

ScoilanJ— 

L-unaee Apr.27-Mayll    10 

Glasgow  May  3-11  ...              4 

ITALY;                              Naples  Apr.30-Mayl2, 296      57 

MEXICO:                          Mexico    May  11-18    .     .    1 

NICARAGUA:               Granada May  16,     present. 

Masaya    May  16,    present. 

Managuas May  16,    present. 

RUSSIA:  Moscow    Apr.21-27 9       2 

Odessa  Apr.27-May  4  .    5       2 

St.   Petersburg Apr.20-May  4  .  21       ■! 

Vladivostock    Mar.  l-.'il   .     .    ..1 

Warsaw  Apr.20-27 7 

SPAIN:                            Malaga May  4-11  .   .                i 

Valencia    Apr.27-May  U,            2 

STRAITS 

SETTLEMENTS:      Singapore  Mar.30-Apr.13  .          3 

URUGUAY:                    Montevideo Mar.16-23    ....    5 

YELLOW  FEVER. 

BRAZIL:  Rio  de  Janeiro  Apr.  1-15  ,  .  .  .         31 

COLOMBIA:  Panama  May  6-20 7 

CUBA:  Havana   May  11-18 3 

PLAGUE— INSULAR. 

PHILIPPINES:  Cebu Apr.  4 1 

Manila Mar.23-Apr.l3    76      C4 

PLAGUE— FOREIGN. 

JAPAN:  Formosa Apr .21-28    .    .    170    111 

TURKEY:  Baara May  13 3 


MISCELLANY. 


The  Plague  is  becoming  very  widespread  in  its  distribu 
tion.  It  lias  appeared  in  Rio  de  Janeiro,  in  Cape  Colony,  and 
has  been  increasing.  The  same  is  true  of  Mauritius.  It 
has  appeared  in  West  Australia  and  Hong  Kong.  It  is 
present  in  Karigagua,  in  Russia,  but  is  decreasing  there. 
In  Argentine  a  number  of  cases  occurred  in  San  Nicolas, 
and  suspected  cases  appeared  in  Belleville  and  Marious 
Jaurez,  in  Cordova  Province. 

Leprosy  in  the  United  States. — According  to  scientific 
government  investigations  directed  from  Washington  for 
several  months,  there  are  at  least  275  cases  of  leprosy  in  the 
United  States.  That  number  have  been  reported,  but  it  is 
thought  probable  that  the  real  number  is  nearer  a  thous- 
sand.  For  various  reasons,  physicians  who  have  cases  of 
this  disease  in  many  instances  fail  or  refuse  to  report 
them.  But  the  number  reported  is  suft'ciently  large  to 
occasion  some  alarm.  Seventy-four  of  the  known  cases 
are  in  New  Orleans,  chiefly  among  the  Italian  population. 
There  are  twenty-three  in  Minnesota,  mostly  among  Scandi- 
navians in  the  rural  settlements.  There  are  fifteen  cases 
in  North  Dakota,  and  two  in  South  Dakota,  among  the 
same  people.  So  far  as  has  been  ascertained,  there  are 
none  in  Michigan  or  in  Indiana;  Chicago  has  five  cases, 
New  York  six,  Boston  none.  The  figures  now  compiling 
represent  a  great  deal  of  careful  work.  A  circular  letter  was 
sent  from  Washington  to  every  city  and  county  physician. 
every  health  officer,  ever  responsible  head  of  a  hospital,  in 
the  country.  It  called  for  volunteer  information  covering 
cases  of  leprosy  in  the  community  in  question:  the  name  of 
the  leprous  person,  the  sex.  age.  social  condition,  place  of 
residence — whether  town  or  country — and  name  of  attend- 
ing physician.  In  all,  S.OOO  of  these  letters  have  gone  out; 
replies  have  thus  far  been  received  from  only  2.000  of 
them.  There  may  be  several  times  275  cases  in  the  6000 
districts  from  w-hich  thus  far  no  replies  have  come.  It  is 
the  intention  of  those  who  are  compiling  the  figures  to 
make  the  report  to  Congress,  including  such  recommenda- 
tions as  may  seem  \v;irranted.  One  recommendation  will 
be  for  the  erection  of  two  large  Government  hospitals  for 
lepers,  one  in  the  South  and  the  other  in  the  North.  Emi- 
nent physicians  have  at  different  times  been  before  com- 
mittees of  Congress  in  the  interest  of  the  erection  of  leper 
hospitals,  but  nothing  came  of  these  visits,  the  Govern- 
ment having  no  reliable  data  covering  the  prevalence  of  the 


disease.  Next  winter,  howe\  er,  with  full  information  on 
the  subject,  it  is  believed  that  Congress  will  act  promptly. 
It  is  noteworthy  that  nearly  all  the  275  reported  victims 
are  foreigners.  The  Scandinavians  seemed  peculiarly 
susceptible  to  the  disease.  They  either  had  it  when  they 
landed  in  America,  or  contracted  it  soon  after  landing. 
Every  one  of  the  cases  in  the  Dakotas  and  Minnesota  is  in 
the  conutr}',  rather  remote  even  from  the  small  towns. 
The  disease  seems  to  be  spreading  most  rapidly  in  Louisi- 
ana, and  for  several  years  there  has  been  agitation  there  in 
favor  of  effective  public  supervision  and  control  of  all 
leprous  patients,  either  by  the  State  or  by  the  Federal 
Government. 

Alaska  Smallpox  Epidemic. — The  steamer  Victorian  from 
Skagway,  reports  considerable  excitement  in  the  north, 
caused  by  the  smallpox  epidemic,  and  various  settlements 
are  taking  every  precaution  to  check  and  wipe  out  the 
disease.  At  Skagway  the  Indians  were  driven  out  of  the 
city  and  a  strong  guard  placed  around  the  town  to  prevent 
their  return.  One  or  two  cases  of  the  disease  exist  among 
employes  of  the  Treadwell  mine  on  Douglas  island,  and 
according  to  reijorts  it  is  believed  that  the  big  mining  plant 
will  have  to  shut  down  until  the  disease  is  stamped  out. 

Plague  in  Manila. — All  vessels  leaving  Manila  for  other 
Island  ports  will  be  required  to  conform  to  the  regula- 
tions contained  in  the  following  circular; 

Manila,   P.    I.,   March   27.    1901. 

Sir: — In  view  of  the  increase  of  plague  in  Manila  and  in 
order  to  protect  other  ports  in  the  Philippines  from  the 
introduction  of  the  disease,  as  well  as  to  lessen  the  danger 
to  vessels  of  infection  and  the  liability  to  quarantine,  all 
vessels  leaving  Manila  for  other  island  ports  will  be  re- 
quired to  conform  to  the  following  regulations: 

All  vessels  will  be  required  to  secure  bills  of  health  be- 
fore sailing,  and  this  will  only  be  issued  after  an  examina- 
tion of  the  crew  and  passengers,  and  no  passengers  wiU 
be  allowed  to  embark  after  this  inspection. 

.\ny  passengers  found  sick  on  inspection  will  not  be  al- 
lowed to  sail  on  that  trip. 

All  passengers,  with  their  baggage,  and  crew  must  be 
on  board  three  hours  before  the  time  fixed  for  sailing. 

The  ofJlce  must  be  notified  three  hours  before  the  time 
fixed  for  sailing  of  vessel,  so  as  to  afford  ample  time  for 
inspection  and  disinfection  of  baggage  and  allow  the  vessel 
to  leave  on  schedule  time. 

You  will  notify  all  deck  passengers  that  their  baggage 
will  be  disinfected  on  board  of  vessel,  and  that  no  mat- 
tresses or  pillows  can  be  taken.  After  this  disinfection  the 
captain  of  the  ship  must  take  charge  of  the  baggage  and 
see  that  it  is  kept  closed  for  twenty-four  hours,  or  until 
the  end  of  the  passengers'  voyage  in  case  this  is  less  than 
twenty-four  hours. 

This  regulation  will  go  into  effect  on  April  1.  1901.  and 
continue  until  further  notice.  Thanking  you  for  your  co- 
operation. 

Respectfully.  J.  C.  PERRY, 

Passed  Assistant  Surgeon.  U.  S.  M.  H.  S.. 
Chief  Quarantine  OflBcer  for  the  Philippine  Islands. 

Plague  in  China. — -A.  communication  from  Robert  M. 
McWade.  V.  S.  Consul,  states  that:  The  plague  has  again 
begun  its  ravages  in  Canton  and  vicinity,  as  well  as  in 
other  parts  of  the  Kwangtung  province.  As  the  authori- 
ties are  averse  to  the  full  facts  of  the  ravages  of  the 
scourge  being  made  public,  no  official  records  are  kept 
and,  consequently,  no  adequate  idea  can  be  found  or 
anything  like  accurate  estimates  given  of  the  number  of 
;ts  victims  or  the  extent  of  its  ramifications.  He  is  satis- 
fied, however,  that  the  cases  in  Canton  are  few  in  number. 
In  the  large  village  of  Chan  Tsin.  about  12  miles  west  of 
Canton,  the  plague  is  prevalent,  from  20  to  30  deaths  oc- 
curring there  daily  for  the  last  two  weeks.  This  Tillage 
has  from  3.000  to  4,000  population.  Some  of  the  villages 
in  the  Shun  Tak  district  are  also  infected,  and  so  is  the 
city  of  Fatshan,  which  has  a  population  of  over  500.000 
The  filthy  condition  of  the  public  streets  and  byways  and  of 
the  residences  of  the  lower  classes  is  mainly  the  cause  of 
the  reappearance  of  this  awful  disease. 

A  Useful  Fly. — Experimenters  of  the  United  States  Gov- 
ernment saw  one  dragon-fly  eat  up  SOO  mosquitoes  in  an 
hour,  and  it  is  now  proposed  to  breed  the  "darning  needle" 
on  a  large  scale  to  see  if  they  cannot  be  made  sufficiently 
numerous  to  kill  the  mosquitoes  responsible  for  propagat- 
ing diseases. 


JUNE    8,    1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia 
L  Medical   Journal 


1079 


Abstracts  of  Papers  and  Discussions  at  the  Annual  Meet- 
ing of  the  American  Surgical  Association,  held  in  Balti- 
more on  May  7th,  8th  and  9th,  1901,  the  President,  Dr. 
Roswell    Park,   of   Baltimore,    in   the   Chair. 


(Continued  from  Page  1034.) 
Dr.  Eugene  L.  Opie.  of  Baltimore,  in  discussing  Dr.  Rob- 
son's  paper  on  pancreatitis  commented  on  the  relation  of 
gall-stones  to  the  disease  under  discussion.  He  considered 
that  there  are  two  mechanisms,  which  e.xplain  this  associa- 
tion, due  to  the  anatomical  features  of  the  region.  As  to 
acute  hemorrhagic  pancreatitis  he  stated  that  a  variety  of 
irritating  suljstances,  when  injected  into  the  pancreas  of 
animals,  will  produce  this  lesion  and  referred  to  the  exper- 
iments of  Flexner.  who  had  injected  artificial  gastric  juice, 
acids,  alkalies  and  dilute  formalin,  to  prove  the  fact.  An- 
other cause  of  hemorrhagic  pancreatitis  he  believed  to  be 
the  penetration  of  bile  into  the  pancreas,  which  will  con- 
llrm  the  fact  of  the  relation  between  pancreatitis  and  gall- 
stones. It  seems  to  be  true  that  in  the  cases  in  which 
chronic  interstitial  pancreatitis  accompanies  gall-stones  in 
the  common  duct,  the  pancreatitis,  which  has  been  at  times 
mistaken  for  malignant  disease  of  the  gland,  is  the  result 
of  this  obstruction. 

Dr.  Elliott,  of  Boston,  in  discussing  Dr,  Robson's  paper 
on  pancreatitis  referred  to  the  association  of  the  dis- 
ease with  gall-stones,  together  with  the  relation  of  jaun- 
dice to  these  conditions,  while  theoretically,  if  the  common 
duct  was  not  blocked,  there  would  be  no  jaundice,  yet  prac- 
tically with  stones  only  in  the  gall  bladder  jaundice  is  fre- 
quently present.  Cases  were  cited  where  these  conditions 
were  true  and  where  malignant  disease  had  been  diagnosed, 
although  not  present. 

Dr.  George  R.  Fowler  of  Brooklyn,  in  discussing  Dr. 
Robson's  paper  on  Pancreatitis,  reported  three  cases  with 
symptoms  and  treatment,  two  of  which  recovered,  while  the 
third  died.  He  laid  particular  stress  on  the  collapse  which 
occurred  in  his  cases,  in  one  being  so  bad  that  operation  had 
to  be  put  off  several  times. 

Dr.  Carson,  of  St.  Louis,  gave  the  details  of  a  case  oc- 
curring in  his  practice,  of  induration  of  the  pancreas  asso- 
ciated with  jaundice.     After  operation  the  patient  made  a 
good  recovery. 
I  Dr.  W.   L.  Bstes.  of  Easton,  Pennsylvania,  reported  two 

!  cases  of  operation  wi:h  recovery,  one  of  chronic  interstitial 
I  pancreatitis  simulating  carcinoma  and  the  other  following 
!        an  abdominal  injury. 

Dr.    Leonard    Freeman,    of   Denver,    reported    a    case   of 
jaundice,    which    he    had    believed    to    be    due    to    gall- 
stones, and  stated  it  had  not  occurred  to  him  that  pancro- 
'        atic  disease  was  probably  the  cause,  although  he  had  no 
doubt  such  was  the  case. 

Dr.  Robson  closed  the  discussion  and  stated  that  he  had 
never  seen  such  marked  and  frequent  attacks  of  collapse 
as  those  mentioned   ty  Dr.  Fowler.     He  reported  one  case 
where  the  collapsed  condition  of  the  patient  had  prevented 
j        operation  and   death  had  ensued,  and  he  believed  that  it 
I        was  a  common  symptom,  although  not  to  the  extent  in  in- 
dividual cases  observed  by  Dr.  Fowler.     He  felt  that  the 
bile   probably   offered   an   explanation   for   many   cases   of 
hemorrhagic  pancreatitis  and  he  believed  the  infected  na- 
j        ture  of  the  bile  was  often  the  most  important  factor. 

He  referred  brieflly  to  Dr.  Opie's  specimens  and  expressed 
himself  as  much  pleased  with  Dr.  Brewer's  description  of 
the  anatomy  of  the  region. 

Dr.  A.  W.  Mayo  Robson.  of  Leeds,  England,  read  a  paper 
entitled  "The  Surgical  Treatment  of  Chronic  Ulcer  of  the 
Stomach"  and  stated  that  the  treatment  of  these  cases  is 
at  first  essentially  medical.  He  compared  the  treatment  of 
ulcer  of  the  stomach  with  that  of  ulcer  of  the  leg  and 
pariiculprly  referred  to  the  tendency  to  relapses.  Twenty- 
three  affections  were  referred  to  as  complications  of  the 
condition,  which  were  looked  upon  as  serious  menaces  to 
the  treatment  of  ulcer.  He  believes  that  about  2.5%  of 
cases  of  gastric  ulcer  treated  medically,  died,  while  only 
about  16%  treated  surgically  died,  according  to  statistics  a 
year  ago.  but  at  the  present  time,  while  the  percentage 
death  rate  in  cases  treated  medically  remains  about  the 
same  it  has  been  reduced  to  5",  under  surgical  treatment.  A 
number  of  operations  were  mentioned  from  which  one  could 
take  his  choice  and  great  stress  was  laid  upon  the  im- 
portance of  the  proper  preparation  of  the  patient  before 
operation.     Each   operation   was  described   in  some  detail 


and  cases  illustrating  each  form  of  operation,  together  with 
the  results  obtained,  were  quoted.  The  number  of  opera- 
tions performed  by  the  author,  divided  up  according  to  the 
number  performeed  of  each  kind  were  given  and  the  method 
he  employs  in  stomach  and  other  operations  involving  the 
making  of  an  anastomotic  opening  between  the  hollow  vis- 
cera was  described.  The  author  demonstrated  the  method 
which  consisted  practically  of  the  employment  of  a  method 
of  suturing  over  a  decalcified  bone  bobbin. 

Ihe  original  article  was  published  in  the  Philadelphia 
Medical  Journal  of  May  2.5,  1901. 

The  advantages  claimed  for  the  method  are: 

1.  That  it  secures  the  opening,  being  of  the  exact  size 
intended  and  that  there  is  no  possibility  of  the  passage 
being  made  too  small  by  the  drawing  up  of  the  sutures  be- 
fore the  knots  are  tightened. 

2.  That  is  secures  an  immediately  patent  channel  be- 
tween the  two  anastomosed  viscera. 

3.  That  the  bobbin  protects  for  from  24  to  48  hours  the 
new  line  of  union  from  pressure  and  from  the  irritation  ot 
the  visceral  contents. 

4.  That  it  facilitates  the  application  of  the  sutures  and 
so  adds  to  the  expedition  of  union  by  suture. 

5.  That  no  foreign  material  is  left  in  the  alimentary 
canal,  which  may  irritate  or  cause  subsequent  trouble,  for 
the  bobbin  rapidly  dissolves  in  the  alimentary  juices. 

6.  That  the  method  has  now  been  proved  by  ample  ex- 
perience to  be  rapid,  easy,  efficient  and  safe. 

The  discussion  of  the  foregoing  paper  was  opened  by 
Dr.  William  J.  Mayo,  of  Rochester,  Minnesota,  who  con- 
sidered at  some  length  the  treatment  of  open  ulcer  of  the 
stomach  by  gastroenterostomy,  which  he  considered  the 
most  generally  indicated  oper.ation  for  this  condition  in 
view   of   the   following   reasons:  — 

1.  The  varying  extent  and  reasonable  probability  that, 
more  than  one  ulcer  exists. 

2.  The   common   location   of   the   ulceration. 

3.  The  impossibility  of  locating  the  exact  site  of  the 
ulcer   in   many   cases. 

In  some  few  cases,  presenting  special  features,  he  be- 
lieved that  excision  or  other  form  of  surgical  procedure  la 
indicEted, 

The  symptoms,  he  stated,  depend  somewhat  upon  the 
situation  of  the  ulcer,  the  most  common  location  beinfj 
near  the  pylorus,  which  position  may  introduce  certain  me- 
chanical features,  and  in  the  relief  of  these  secondary 
phenomena  in  his  opinion  the  operation  achieves  its  tri- 
umphs. The  relief  ot  hyperacidity  and  a  prompt  emptying 
of  the  ingesta.  preventing  irritation  and  aiding  nutrition 
is  secured  by  gastroenterostomy. 

Reference  was  made  to  the  fact  that  the  earlier  report.s 
on  this  subject  demonstrate  the  existence  at  that  time  of 
a  belief  that  the  stomach  was  always  contracted,  but  later 
reports  have  proven  the  error  of  considering  this  a  fixed 
condition,  although  it  is  no  doubt  true  in  a  majority  of 
cases.  In  acute  ulcer  the  stomach  is  usually  small,  and  if 
the  ulcer  is  not  in  the  vicinity  of  the  outlet,  it  will  probably 
remain  so.  On  the  contrary,  it  is  during  the  healing  pro- 
cess that  many  ulcers  in  the  pyloric  region  become  most 
troublesome. 

Ulcers  in  this  situation  are  often  extensive,  and  in 
chronic  cases,  perhaps  but  partly  cicatrized,  and  ob- 
struction of  the  pyloric  orifice  may  take  place  by  distor- 
tion or  narrowing  of  the  opening,  irregular  symptoms  of 
the  unhealed  portion  of  the  ulcer  being  manifest,  in  addition 
to  the  dilatation.  In  these  cases  periods  of  health  alternate 
with  symptoms  of  open  ulcer,  which  are  later  followed  by 
signs  of  open  ulcer  in  a  stomach  more  or  less  dilated. 
Most  of  the  cases  when  once  cicatrized  remain  healed, 
although  a  few  sometimes  develop  into  open  ulcer.  While 
the  capacity  of  the  stomach  is  not  usually  materially  altered, 
in  cases  of  gastric  ulcer,  when  this  condition  does  exist, 
it  has  a  surgical  significance. 

He  then  made  a  comparison  of  the  results  of  gastroente!> 
ostomy  in  (11  ulcers  in  the  pyloric  re.gion  with  a  normal  or 
eular,tfed  stomach,  and  (2)  ulcers  in  a  contracted  stomach, 
and  stated  that  in  cases  coming  under  the  first  group  gas- 
troenterostomy is  the  operation  of  choice,  as  it  delivers 
the  ingesta  at  a  point  sufficiently  remote  from  the  disease 
to  prevent  irritation,  and  the  healing  process  is  not  inter- 
fered with  and  develops  rapidly.  Immediate  and  satisfac- 
tory relief  for  the  mechanical  condition  is  obtained,  and 
in  five  gastroenterostomies  performed  under  his  observa- 
tion all  were  speedily  and  permanently  cu»-ed.  Reference 
was  made  to  a  pyloric  spasm  produced  by  a  email  ulcer  at 


io8o 


The  Philadelphia' 
Medical  Journal    . 


AMERICAN  NEWS  AND  NOTES 


IJu.vE  8,  ISM. 


the  pylorus,  by  which  symptoms  resembling  mechanical 
interference  are  produced.  While  the  author  considers 
that  pyroplasty  is  fairly  effective  in  this  form  of  the  dis- 
ease, he  states  that  it  does  not  compare  with  the  benefits 
derived  from  gastroenterostomy,  although  the  division 
of  the  pyloric  sphincter  stops  the  spasms  and  the  enlarge- 
ment of  the  opening  exerts  a  healing  Influence  on  the  ulcer. 
Gastroenterostomy  on  the  small  stomach  affected  by  ulcer 
does  not,  as  a  rule,  give  immediate  relief,  although  the 
ulcer  will  eventually  heal,  but  the  results  are  not  as  good 
as  in  the  other  class  of  cases.  The  author  then  referred 
to  the  use  of  the  Murphy  button  and  the  union  of  the  je- 
junum to  the  anterior  wall  of  the  stomach  as  near  the 
greater  curvature  as  possible,  which  operation  he  consid- 
ers equally  as  good  as  the  posterior  and  easier  of  per- 
formance. He  stated  that  three-fourths  of  the  cases  which 
had  come  under  his  observation  had  been  operated  on 
for  the  relief  of  non-malignant  disease,  largely  pyloric  ob- 
struction, the  result  of  healed  ulcer,  and  that  there  had 
•been  but  one  death  in  over  forty  cases.  In  malignant 
cases  the  death  rate  was  over  twenty-five  per  cent. 

Dr.  W.  G.  Macdonald,  of  Albany,  New  York,  reported  two 
tases  of  posterior  gastroenterostomy  for  the  relief  of 
chronic  ulcer  of  the  stomach.  One  case,  which  had  existed 
for  eight  years,  did  very  well  for  ten  months,  when  distinct 
symptoms  presented  themselves  of  a  well-developed  tumor 
in  the  region  of  the  pylorus,  the  patient  dying  shortly  after- 
ward of  carcinoma  of  the  stomach.  The  second  case  was 
very  similar,  except  that  the  improvement  following  the  op 
eration  lasted  for  a  somewhat  longer  time.  In  his  opinion 
the  ideal  operation  for  these  conditions  is  extirpation  of  the 
ulcerated  surface,  even  though  it  involves  resection  of 
the  stomach  or  partial   gastrectomy. 

Dr.  William  L.  Rodman,  of  Philadelphia,  called  attention 
to  the  fact  that  malignant  degeneration  frequently  takes 
place  on  the  site  of  an  old  benign  ulcer,  and  also  that  the 
great  majority  of  gastric  ulcers  is  situated  posteriorly, 
and  not  anteriorly.  In  his  opinion  adhesions  play  a  very 
Important  part  in  these  conditions,  but  he  felt  that,  if  the 
ulcer  is  anterior  and  free  from  adhesions  the  operation 
should  be  done,  while,  if  it  is  posterior,  it  is  out  of  the 
<luestion. 

Dr.  Robson  did  not  close  the  discussion,  except  to 
thank  the  gentlemen  present  for  the  interest  they  had 
taken  in  his  paper. 

Dr.  R.  Matas,  of  New  Orleans,  read  a  paper  on  "Artificial 
Respiration,"  and  demonstrated  a  new  apparatus  there- 
for. 

Third    Day,    Morning    Session. 

"The  Treatment  of  Arterio-Venous  Aneurysm  of  the 
Subclavian  Vessels"  was  the  title  of  a  paper  read  by  Dr. 
R.  Matas,  of  New  Orleans,  who  reported  a  case  of  perfora- 
tion of  the  right  subclavian  artery  and  vein,  through  the 
scalenus  anticus,  by  a  bullet:  the  patient  being  a  young  man 
aged  >4.  The  bullet  also  injured  the  brachial  plexus  and 
caused  paralysis  of  the  corresponding  upper  extremity. 
Ten  days  subsequent  to  the  injury  the  operation  was  per- 
formed. An  osteoplastic  resection  of  the  clavicle  with 
disarticulation  at  the  sternoclavicular  joint  was  made 
under  local  infiltration  anesthesia  with  Eucain  B.  and  a 
temporary  traction  loop  of  silk  was  applied  under  the  first 
poriion  of  the  anomalous  subclavian  artery,  the  inominate 
being  absent.  The  vein  was  provisionally  compressed 
above  and  below  the  anastomic  orifice.  Profuse  hemor- 
rhage occurred  when  the  vein  was  detached  from  the  artery 
In  spite  of  the  fact  that  complete  control  of  the  subclavian 
at  its  orifice  had  been  obtained,  the  bleeding  being  stopped 
by  the  application  of  double  ligatures  above  and  below  the 
perforation  of  the  artery.  Indirectly  the  bleeding  had  its 
source  in  the  vertebral  and  internal  mammary.  The  artery 
between  the  ligatures  was  divided,  the  orifice  in  the  vein 
closed  by  a  lateral  suture  and  venous  circulation  re- 
established. An  undeformcd  bullet.  38  calibre,  was  ex- 
tracted and  shock  followed,  the  patient  being  restored  by 
saline  infusion.  Primary  healing  of  the  operative  wound 
and  recovery  with  partial  loss  of  the  hand  and  forearm 
from  mortification  caused  arterial  ischemia  and  insufficient 
collateral  circulation  followed. 

In  a  review  of  the  literature  the  author  stated  that  but 
15  cases  had  been  recorded  since  1S29.  when  the  first  was 
published  by  Leary,  and  in  only  4  of  these  has  operative 
procedure  been  resorted  to.  In  concluding  the  indications 
for  intervention,  the  prognosis  and  the  details  of  the  oper- 
ative technique  were  considered. 


This  paper  was  discussed  by  Dr.  Arthur  Dean  Bevan,  of 
Chicago.  W.  S.  Halsttil.  of  Baltimore,  Theodore  A. 
McGraw,  of  Detroit,  and  closed  by  Dr.  Matas. 

Operative  intervention  in  tumors  of  the  liver  with  a  re- 
port of  cases,  was  the  title  of  a  paper  by  Dr.  W.  G.  Macdon- 
ald, of  Albany,  N.  Y.,  which  was  not  read. 

Dr.  E.  H.  Bradford,  of  Boston,  presented  a  paper  on 
Subtrochanteric  Osteotomy,  which  was  read  by  title. 

Dr.  A.  Vander  Veer,  of  Albany,  N.  Y.,  read  a  paper  on 
Phlebitis  following  abdominal  operations  in  which  he 
stated  that  acute  perforative  appendicitis  is  more  prevalent 
in  August  and  September,  because  of  the  diet  in  which 
young  people  indulge,  and  in  December  and  January  be- 
cause of  exercise  and  exposure,  but  it  was  only  of  late 
that  he  had  had  any  symptoms  of  phlebitis,  four  cases 
having  occurred  in  the  past  two  years.  He  referred 
briefly  to  the  history  of  these  cases  and  felt  that  possibly 
tight  bandaging  might  have  had  something  to  do  with  at 
least  two  of  them. 

There  was  never  any  delay  in  the  union  of  the 
wound,  and  attention  was  called  to  the  strange  coin- 
cidence that  the  cases  occurred  very  near  each  other  and 
immediately  after  beginning  work  in  a  new  Hospital.  He 
advised  careful  watching  of  the  bladder  and  the  bowels 
in  these  cases  and  stated  that  in  addition  the  treatment 
should  consist  of  rest,  elevation  of  the  limb,  anodynes  to 
control  pain  with  hypnotics  to  afford  sleep  and  diffusable 
stimulants  and  tonics,  as  may  be  required. 

This  paper  was  discussed  by  Dr.  George  R.  Fowler,  of 
Brooklyn,  and  Dr.  William  J.  Mayo,  of  Rochester,  Minne- 
sota, as  well  as  by  Dr.  Lange,  of  New  York,  Dr.  Vander 
Veer  closing. 

William  J.  Mayo,  A.  M.,  M.  D.,  of  Rochester,  Minn., 
read  a  paper  entitled,  "An  Operation  for  the  Radical  Cure 
of  Umbilical  Hernia,"  stating  that  patients  suffering  from 
umbilical  hernia  are  usually  obese  with  attenuated  mus- 
cles. It  is  sometimes  wise  to  reduce  the  weight  before 
operation.  The  neck  of  the  protrusion  should  be  exposed 
early  and  its  omental  contents  ligated  off  at  this  point 
saving  time.  The  wi-iter  has  made  the  following  method 
nineteen  times.  The  steps  of  the  operation  are  as  fol- 
lows:— 

A  traverse  elliptical  incision  is  made  at  the  base 
of  the  hernial  protrusion  to  and  through  the  peritoneum. 
Traction  upon  the  hernia  exposes  its  contents  at  the 
point  of  entrance.  Return  of  intestine,  if  present,  and  liti- 
gation of  extruded  omentum.  Exposure  of  the  aponeurosis 
above  and  below  the  margin  of  the  incision.  The  lower 
Hup  of  aponeurosis  and  peritoneum  is  slid  upward  three 
quarters  of  an  inch  into  a  pocket  previously  formed,  be- 
tween the  upper  margins  of  aponeurosis  and  the  peri- 
toneum. Retention  by  two  rows  of  buried  sutures.  The 
sliding  can  be  made  from  side  to  side  in  the  same  manner 
as  was  so  performed  in  ten  of  the  nineteen  reported  cases. 
If  the  ring  is  very  large  the  overlapping  from  above 
downward  is  easier  of  performance. 

Dr.  A.  J.  Ochsner,  of  Chicago,  opened  the  discussion,  in 
which  Dr.  F.  H.  Oerrish,  of  Portland.  Maine:  Dr.  DeForest 
Willard.  of  Philadelphia.  Dr.  A.  J.  McCosh  and  Dr.  W.  B. 
Coley.  of  New  York,  and  Dr.  J.  Collins  Warren,  of  Boston. 
participated.  Dr.  Mayo  closing. 

Dr.  James  E.  Moore,  of  Minneapolis,  read  a  paper  entitled 
"The  Prevention  and  Cure  of  Post-operative  Hernia,"  in 
which  he  stated  that  ventral  hernia  is  rare  among  good 
operators  except  after  operation  for  acute  appendicitis. 
He  believed  that  the  same  rules  should  govern  the  treat- 
ment of  post-operative  hernia  that  governs  the  treatment  of 
other  hernia.  Operation,  in  his  opinion,  is  the  only  treat- 
ment to  be  considered,  and  should  be  done  early,  the  prog- 
nosis being  almost  always  good. 

This  paper  was  discussed  by  Dr.  Arthur  D.  Bevan,  of 
Chicago,  and  closed  by  Dr.  Moore. 

Afternoon    Session. 

Dr.  S.  H.  Weeks,  of  Portland,  read  a  paper  on  "Fractures 
and  Dislocations  of  the  Spine."  which  was  discussed  by 
Dr.  John  C.  Munro.  of  Boston:  Dr.  S.  J.  Mixter.  of  Boston, 
and  Dr.  R.  H.  Harte,  of  Philadelphia.  The  author  did  not 
close. 

Dr.  W.  B.  Coley.  of  New  York,  read  a  paper  on  the  "Radi- 
cal Cure  of  Inguinal  and  Femoral  Hernia."  with  a  report  of 
SOO  cases  operated  upon  from  1891  to  1901.  which  was  di-;- 
cussed  by  Dr.  J.  Collins  Warren,  of  Boston,  and  Dr.  W.  S. 
Halsted.  of  Baltimore.  Dr.  Coley  closing. 


JUNE    S,    19011 


FOREIGN  iNEWS  AND  NOTES 


fTHB    pHILAbBLPBlA 

L Medical  Journal 


toSt 


A  paper  on  The  Use  of  Silver  Wire  and  Electricity  in 
the  Treatment  of  Aneurysms,  with  report  of  cases  was  read 
by  Dr.  Leonard  Freeman,  of  Denver,  and  discussed  by 
Dr.  J.  M.  T.  Finney,  of  Baltimore;  Dr.  DeForest  Willard,  of 
i'hiladelphia,  and  Dr.  R.  Matas,  of  New  Orleans;  Dr.  Free- 
man  closing. 

A  paper  on  Movable  Kidney:  Its  Cause  and  Treatment, 
was  read  by  Dr.  M.  U  Harris,  of  Chicago,  but  was  not  dis- 
cussed. 

Dr.  S.  J.  Mixter,  of  Boston,  read  the  following  pa- 
pers:— 

(1)  Two  cases  of  abdominal  contusion;  (1)  Frac- 
ture of  Spleen — Splenectomy — Recovery.  (2)  Fracture  of 
Kidney — Nephrectomy — Recovery. 

2.)   Nephrolithotomy  on  both  Kidneys. 

Dr.  Charles  A.  Powers,  of  Denver,  presented  with  photo- 
graphs a  paper  on  Uiant  Sacnicoccyyeal  Tiimnr.^.  The  sub- 
ject of  especial  observation  was  a  male  child  first  seen 
at  three  months  of  age,  at  which  time  there  was  found  an 
enormous  growth  occupying  the  sacrococcygeal  region, 
e.xtending  laterally  to  the  buttocks  and  forward  in  front  of 
the  anus.  It  was  irregularly  ball  shaped,  and  in  size  as 
large  as  the  head  of  a  child  of  six  years.  Below  and  in 
front  the  growth  was  cystic;  above  and  laterally  it  was 
firm,  and  in  places  nodular.  The  skin  over  the  tumor  was 
of  a  bluish-red  over  the  cystic  parts,  normal  above  and  at 
the  sides.  Deep  palpation  showed  no  gap  in  the  bony 
structures.  There  was  nothing  abnormal  about  the  rec- 
tum. The  tumor  was  moved  by  the  gluteal  muscles,  but 
the  tension  of  the  mass  was  not  changed  when  the  child 
cried.  There  was  no  paralysis  nor  anesthesia  of  the 
lower  extremities. 

No  operation  was  advised  and  the  growth  underwent 
spontaneous  contraction.  The  skin  did  not  ulcerate,  the 
contents  of  the  cystic  portion  were  absorbed,  and  when 
the  child  was  three  years  and  nine  months  old  the  tumor 
had  shrunk  to  the  size  of  a  man's  fist,  and  was  well  flat- 
tened out  over  the  sacrococcygeal  region.  The  boy  is  as 
strong  and  healthy  as  other  lads  of  his  age:  lies  on  his 
back  and  sits  like  other  children;  except  for  its  mer« 
presence,  the  tumor  gives  no  symptoms. 

While  this  growth  lacks  pathological  confirmation,  It  Is 
assumed  that  it  is  a  teratoma  or  embryoid  tumor  having 
a  double  germinal  substratum.  A  certain  number  of  such 
tumors  have  been  observed  by  German  and  French  writers 
and  when  pathologically  examined  have  been  found  to  con- 
tain the  neatest  diversity  of  tissue.  Cysts  lined  with  vari- 
ous forms  of  epithelium,,  intestinal  remnants,  masses  of 
gliomatous  tissue,  smooth  and  striped  muscle  fibre,  bone, 
cartilage,  etc. 

The  question  of  operation  must  be  decided  by  the  sur- 
geon in  the  individual  case.  In  general  it  is  recommended 
that  operation  be  deferred  until  the  child  reaches  such  age 
as  to  enable  it  to  successfully  withstand  operative  pro- 
cedure. The  author's  case  shows  that  spontaneous  contrac- 
tion may  occur. 

"Resection  of  the  Chest  Wall  For  a  Large  Sarcoma.  Suc- 
cessful Use  of  the  Anti-streptococcic  Serum." 

The  above  was  the  title  of  a  paper  read  by  Dr.  W.  W. 
Keen,  of  Philadelphia.  The  author  referred  very  fully  to 
the  details  of  the  operation,  together  with  the  condition  of 
the  patient  before  and  after.  In  concluding  his  remarks  he 
called  particular  attention  to: 

(1)  The  method  of  separating  the  tumor  from  the  chest 
wall  so  as  to  determine  more  exactly  the  limits  of  the  dis- 
ease and  lessen  the  size  of  the  opening  to  be  made  in  the 
chest.  (2)  The  division  of  the  ribs  anteriorly  and  poster- 
iorly prior  to  opening  the  peural  cavity;  this  diminished 
very  much  the  period  of  danger  in  the  collapse  of  the  lun^. 
(3)  The  use  of  Fetl's  apparatus,  which  was  not  satisfactory 
in  this  case  and  for  v/hich  he  prefers  to  substitute  the  ap- 
paratus of  Dr.  Bloom,  of  New  Orleans,  which  he  then 
showed  to  the  association,  or  the  apparatus  of  Matas  which 
was  then  demonstrated  by  its  inventor.  (4)  The  suture  of 
the  lung  to  the  chest  wall,  which  was  followed  by  no  untow- 
ard surgical  result.  It  diminished  very  greatly  the  amount 
of  post-operative  pneumo-thorax  and  in  fact  one  might  al- 
most say  abolished  it.  (3)  The  use  of  the  anti-streptococcio 
serum  and  as  to  whether  it  was  the  cause  of  the  fall  In  tem- 
perature or  only  a  coincident,  the  results  seeming  to  be  so 
striking.  (6)  The  examination  of  the  blood  which  was  of 
great  value  as  showing  ihe  reason  for  the  continued  high 
temperature  and  led  to  what  the  author  believes  to  have 
been  the  proper  treatment  for  the  condition. 


In  the  opinion  of  the  doctor  it  is  too  early  to  determine 
what  will  be  the  future  of  the  patient  but  up  to  the  prea- 
ent  time,  a  period  of  nearly  seven  months,  the  results  have 
been  entirely  satisfactory. 

Dr.  R.  Matas,  of  New  Orleans,  exhibited  an  apparatus  for 
local  infiltration  anesthesia. 

Drs.  Hearn  and  Roe  reported  and  exhibited  a  case  of  a 
large  abscess  of  the  lung,  of  22  years  duration,  probably  the 
result  of  local  gangrene  following  pneumonia.  (Patient 
male,  age  26). 

Pneumotomy  was  performed  and  the  abscess  drained  for 
two  years  with  much  improvement  in  general  health; 
marked  lessening  of  the  previous  horribly  offensive  odor, 
but  without  any  healing  or  reduction  in  the  size  of  the  cav- 
ity. 

They  again  operated  and  excised  a  portion  of  the  ab- 
scess wall, stitching  the  margins  of  the  remainder  to  the  skin 
surface,  thus  converting  it  into  an  open  cavity,  with  re- 
lief from  the  annoyance  of  wearing  a  drainage  tube  and  of 
cleansing  the  cavity  and  with  practically  entire  cessation 
of  odor. 

Although  about  six  months  have  elapsed,  the  cavity  re- 
mains unchanged  and  there  is  evidence  of  secondary  bron- 
chiectasis for  which  they  assign  two  probable  causes;  i.  e. 
cough  and  cirrhosis  of  lung  tissue.  To  obliterate  the  orig- 
inal cavity  and  to  relieve  the  bronchiectasis  or  cure  it, 
they  propose  to  remove  the  greater  portion  of  the  lower 
ribs,  with  their  periosteum,  in  this  way  allowing  the  chest 
wall  to  collapse  upon  the  lung. 

The  case  demonstrates  the  greatest  difficulty  of  definitely 
localizing  an  old  abscess  of  the  lung  with  tough,  elastic 
walls  which  collapse  when  empty,  by  either  of  the  two 
methods,  namely:  aspiration  and  palpation;  the  value  of 
the  X-ray;  the  practicability  of  giving  ether  as  a  general 
anesthetic;  the  absence  of  any  embarrassment  of  respira- 
tion by  the  entrance  of  air  through  drainage  tubes  intro- 
duced into  the  cavity,  although  they  freely  communicate 
with  the  bronchus;  the  ease  with  which  the  cavity  could 
be  flooded  with  different  fluids  or  solutions,  although  they 
entered  the  bronchus  and  caused  expulsive  paroxysms  of 
coughing;  the  advantages  gained  by  draining  the  cavity 
by  tubes  or  by  the  open  method,  but  without  any  evident 
obliteration  of  the  abscess  cavity. 

A  portion  of  the  ninth  rib,  in  this  case,  was  resected,  the 
third  time,  having  been  twice  performed. 

The  presence  of  pleural  adhesions  rendered  the  oper- 
ations in  this  case  free  from  the  dangers  of  pneumothorax 
and,  although  a  localized  pyothorax  occurred  subsequent  to 
one  of  the  operations,  it  did  not  delay  convalescence. 

Meeting  place  next  year.  Albanj',  New  York.  Date,  May. 
President,  Dr.  DeForest  Willard,  Phila. 


GREAT    BRITAIN. 

Gold  Medal  Awarded.  The  gold  medal  presented  to  the 
Royal  College  of  Surgeons,  Edinburgh,  by  Colonel  Lorimer 
Bathgate,  in  memory  of  his  father,  W.  M.  Bathgate,  F.  R.  C. 
S.  Ed.,  as  a  prize  in  Materia  Medica.  has  been  awarded  to 
Mr.  R.  B.  Johnston,  of  Edinburgh. 

Lieutenant-Colonel  Babtie,  V.  0.,  C.  M.  G.,  has  been  tem- 
porarily appointed  Assistant  Director  of  the  Army  Medical 
Service. 

Appointment.  Dr.  S.  West  has  been  appointed  Joint  Lec- 
turer on  Medicine  at  St.  Bartholomew's  Hospital,  in  the 
place  of  Sir  Dyce  Duckworth. 

CONTINENTAL    EUROPE. 

Dr.  Laveran,  the  discoverer  of  the  Plasmodium  of 
Malaria,  has  just  been  elected  a  member  of  the  French 
Academy  of  Sciences,  to  fill  the  chair  made  vacant  by  the 
death  of  Professor  Potain. 

Appointment.  Dr.  J.  J.  Dfijerine,  the  eminent  neurolo- 
gist, has  Just  been  appointed  Professor  of  the  History  of 
Medicine  and  Surgery  in  the  Medical  Faculty  of  the  Uni- 
versity of  Paris.  He  w-as  born  in  Geneva  in  1849,  and 
graduated  in  medicine  in  Paris  in  1879. 

Dr.  Troisier,  physician  to  the  Beaujon  Hospital  in  Paris, 
has  been  nominated  to  fill  the  chair  of  the  late  Professor 
Potain  in  the  Academy  of  Medicine  of  Paris. 


Tn8'7       T^E  Philadelphia") 
•!'-"-'-«       Medical   Journal  J 


THE  LATEST  LITERATURE 


LJujtz  8,  1901 


Appointment.  Dr.  Ollive,  Professor  of  Hygiene  and 
Medical  Jurisprudence  at  Nantes  has  been  appointed  Pro- 
fessor of  Clinical  Medicine. 

Dr.  Kirmission  has  just  been  appointed  Professor  of  Sur- 
gery of  Children  in  the  Medical  School  of  Paris. 

No  Passports  to  Lepers.  Germany,  Russia,  and  Rou- 
mania  have  decided,  that  in  the  future  no  passports  be  Is- 
sued to  lepers,  and  have  formed  an  agreement  to  that 
effect. 

The  Soemmering  prize  has  been  awarded  by  the  Senck- 
enburger  Natural  History  Society,  of  Frankfort,  to  Prof. 
Franz  Nissl,  of  the  University  of  Heidelberg,  for  his  dis- 
coveries in  the  finer  structure  of  the  nerve  cell. 

Baths  on  the  Trains.  Russia  proposes  to  have  baths  and 
douches  on  trains  running  long  distances.  An  innovation 
well  worth  considering. 

The  Prevalence  of  Tuberculosis  in  Russia.  Between 
1892  and  1894,  inclusive,  there  were  1,475  deaths  from 
cholera,  while  the  number  of  deaths  from  tuberculosis  dur- 
ing the  same  period  reached  lO, 650.  The  annual  mortali- 
ty from  tuberculosis  all  over  Russia  is  between  360  and  450 
thousand,  while  the  number  of  persons  affected  with  the 
disease  is  estimated  at  2-2>4  millions.  The  disease  is  con- 
centrated principally  in  large  cities,  such  as  Moscow  and 
St.  Petersburg. 

Tuberculsis  Barred  him  from  the  Position.  In  the  gov- 
ernment of  Poltawa  a  physician  applied  for  the  position  of 
district  physician.  When  the  application  came  up  for  con- 
sideration a  member  of  the  city  council  raised  objection 
on  the  ground  that  the  applicant  is  affected  with  tuber- 
culosis and  is  liable  to  infect  the  patients.  The  physician 
entered  suit  for  libel  and  secured  conviction  of  the  council- 
man, the  latter  having  been  sentenced  to  two  week's  im- 
prisonment. A  reconciliation  however  was  brought  about, 
and  the  sentence  commuted. 

A  Useful  Amusement  for  Hospital  Inmates.  The  hospi- 
tal of  Alafusoff  was  recently  fitted  up  with  an  expensive 
magic  lantern  for  the  amusement  as  well  as  instruction  of 
the  patients.  Once  a  week  pictures  are  thrown  on  the 
screen  and  descriptive  lectures  delivered  by  the  hospital 
physician. 

Engineers  Better  Paid  Than  Physicians.  It  appears  that 
in  Russia  an  engineer  commands  a  salary  of  four  to  five 
thousand  roubles,  while  a  physician  in  the  employ  of  the 
city  is  satisfied  with  750.  and  even  at  that  he  is  glad  to  get 
the   appointment. 

The  Plague  in  Kirgiz. — The  number  of  plague-stricken 
persons  in  Tubekai-Tubek  and  Merck  up  to  the  24th  of 
January  reached  136  Of  these  134  died.  The  place  is 
now  claimed  to  be  free  from  the  disease. 

A  Premium  for  the  Best  Paper  on  Rabies. — The  Moscow 
Society  of  Hunters  placed  in  the  hands  of  the  Physico- 
medical  Society  1000  roubles  (500  dollars)  as  a  price  for 
the  best  paper  on  the  subject  "Canine  Rabies,  its  Cause. Pre- 
vention and  Treatment."  The  paper  is  to  be  written  in  Rus- 
"sian  and  sent  not  later  than  November  1,  1901. 

Corporal  Punishment  Condemned. — The  medical  society 
of  Omsk  resolved  to  petition  the  authorities  to  abolish  cor- 
poral punishment  in  Russia. 


Atypical  Forms  of  Typhoid  Fever. — la.  M.  Bralnin  (Rus- 
ski  Mc(Iiri)i\h-i  M  rat  nil;.  Vol.  Ill,  No.  7),  in  speaking  of  the 
atypical  forms  of  typhoid,  quotes  the  late  Prof.  Botkin 
as  saying  that  typhoid  fever  may  last  only  several  hours. 
His  pupil  Borodulin  foimd  in  a  large  number  of  cases 
rose  spots  in  Si'~c.  diarrhea  in  6S<^,  sweating  in  Sl"^.  bron- 
chitis in  es^r  typhoid  state  in  62%.  and  enlarged  spleen  in 
64C,.  The  author  observed  an  epidemic  of  typhoid  fever 
affecting  about  300  persons,  with  a  mortality  of  10%.  The 
most  prominent  symptoms  were:  a  dull  headache  during 
the  entire  course  of  the  disease,  a  typhoid  state,  continuous 
and  occasionally  remittent  fever  and  a  slight  enlargement 
of  the  spleen.  No  abdominal  or  any  other  symotoms  char- 
acteristic of  typhoid  were  observed.  The  disease  ter- 
minated by  olsis  in  2-S  weeks.  Death  in  the  fata]  cases 
occurred  on  the  2-3  week,  preceded  by  co?na.     [A.  R  1 


^be  Xatest  Xiterature. 


BRITISH    MEDICAL  JOURNAL. 
May    18,    1901. 

1.  The  Ingleby  Lecture  on  the  Lower  Uterine  Segment 

and  the  Contraction  Ring.    W.  J.  SMYLY. 

2.  The  Dangers  and  Diagnosis  of  Breech  Presentation,  and 

its  Treatment  by  External  Version  Toward  the  End 
of  Pregnane}'.     HERBERT  R.  SPENCER. 

3.  Some  Instances  of  Cystic  Affections  of  the  Breast,  with 

Remarks.     A.  MARM.\DUKE  SHEILD. 

4.  Some   Remarks   upon   an   Analysis   of   5.000    Cases   of 

Death  from  Malignant  Disease.    E.  N.  NASON. 

5.  Erythema     Multiforme     and    Vaccination.      NORMAN 

WALKER. 

1. — Smyly  remarks  that  the  origin  of  the  lower  segment 
of  the  uterus  Is  still  uncertain,  and  four  different  theories 
are  held  in  regard  to  it:  (1)  That  it  develops  during  preg- 
nancy; (a)  From  the  lowest  part  of  the  corpus  uteri 
(Schroeder,  Hofmeier,  C.  Ruge) :  (b)  From  the  upper  part 
of  the  cervix  (Bandl,  Kustner,  Kaltenbach).  (2)  That  it 
forms  only  during  labor  (a)  from  the  cervix  uteri  fZweifel) ; 
(b)  both  from  the  body  and  the  cervix  (v.  Herff).  In  a 
third  stage  the  lower  segment  and  cervix  form  a  continu- 
ous thin-wall  collapsable  tube  which  affords  no  support  to 
the  upper  segment,  which  contains  the  placenta. 

The  lower  segment  of  the  uterus  is  the  part  most  fre- 
quently involved  in  rupture.  As  to  the  contraction  ring 
as  a  cause  of  dystocia,  Rossa  describes  three  varieties  of 
constriction.  (1)  The  contraction  occurring  during  a  few 
pains,  disappearing  in  the  intervals  and  easily  overcome  by 
the  advance  of  the  fetus.  (2)  A  permanent  stricture  asso 
ciated  with  tetanus  uteri.  (3)  A  constriction  which  occurs 
early  continues  during  the  intervals  but  increases  during 
the  pains  and  is  associated  with  a  diminution  of  the  entire 
contractile  portion  of  the  uterus,  and  therefore  only  met 
with  at  an  advanced  stage  of  labor.  As  regards  the  treat- 
ment Budim  advises  mechanical  dilatation,  but  Veit  believes 
that  patience  and  narcotics  will  suffice.     [W.  A.  N.  D.] 

2. — Spencer  presents  a  paper  on  the  dangers  and  diag- 
nosis of  breech  presentation,  in  which  he  states  that 
Hegar's  statistics  show  35%  of  still  born  children,  with  an 
additional  5%  dying  on  the  first  day.  His  maternal  mor- 
tality was  also  1%  in  breech  cases.  Ramsbotham.  whose 
statistics  deal  only  with  labors  at  term,  give  an  infantile 
mortality  of  18.7%.  and  Hecker  of  22%.  Pinard  had  a  mor 
tality  of  19.5%.  Spencer  gives  a  mortality  of  male  chil- 
dren of  30.827o  and  of  female  children  of  18.3%.  The  causes 
of  death  in  these  presentations  is  prolapse  of  the  cord, 
pressure  upon  that  structure,  attempts  at  respiration  before 
birth,  and  injury  of  the  body  from  its  being  subjected  to  the 
brunt  of  the  labor  resulting  in  visceral  injuries.  Hem- 
orrhages into  the  muscles  are  very  frequent  in  breech  pre- 
sentation, especially  when  traction  is  employed  to  deliver. 
Another  injury  which  not  infrequently  follows  the  presen- 
tation is  the  so-called  obstetrical  palsy  from  damage  to  the 
brachial  plexus  during  violent  traction  on  the  shoulders. 
Fractures  of  the  bone  especially  those  of  the  upper  limb, 
and  even  of  the  pelvic  bones  may  be  noted.  Spencer  fa- 
vors treatment  of  this  complication  by  external  version 
toward  the  end  of  pregnancy,  whereby  the  mortality  may 
be  reduced  to  as  low  as  12%  or  13%.  Contraindications  to 
the  performance  of  this  operation  are  twin  labor,  considera 
ble  flattening  of  the  pelvis,  a  dead  fetus,  a  malformed 
uterus,  and  placenta  praevia.    [W.  A.  N.  D.l 

3. — Sheild  reports  4  cases  of  cystic  affection  of  the  breast, 
which  closely  simulated  carcinoma  of  that  organ.  He  states 
that  these  deeply  seated  cysts  vary  in  size  and  sometimes 
spontaneously  disappear.  Two  important  points  in  the 
diagnosis  of  cysts  is  variation  in  size  and  variation  in  local 
tenderness.  The  tenser  the  cyst  the  more  is  the  sensation 
of  actual  hardness  simulated.  A  sensation  of  elasticity  is 
diagnostic  of  a  cyst.  Nothing  is  more  deceptive  than  to 
argue  of  the  nature  of  a  breast-tumor  from  the  condition  of 
the  axillary  glands.  Cancerous  infection  may  be  present 
and  yet  it  may  be  impossible  to  feel  the  glands  from  sur- 
rounding fat  or  deep  situations.  On  the  other  hand  in  those 
women  suffering  from  cysts  the  axillary  glands  may  easily 
be  felt  and  they  may  be  enlarged  if  the  part  has  been  much 
handled  or  painted  with  iodin.  With  re.gard  to  the  treat- 
ment of  simple  cyst  after  evploratory  incision  the  sac  may 
be  dissected  out  or  it  may  be  rubbed  with  carbolic  acid  or 


June  8,  1901] 


THE  LATEST  LITERATURE 


["The  Philadelphia 
L Medical  Journal 


1083 


iodine  or  packed  with  gauze.  The  exploring  trocar  and 
caniila  in  these  cases  of  doubtful  swelling  are  of  great 
value.     [W.  A.  N.  D.] 

4. — Nason  has  made  an  inquiry  into  the  influence  of  lo- 
cality on  the  prevalence  of  malignant  disease,  and  has  an- 
alyzed more  than  .5,000  cases  from  death  from  the  various 
forms  of  cancer.  Of  these  cases  1S37  were  males,  and  3.018 
were  females:  in  14-5  the  sex  was  not  stated.  The  great 
preponderance  of  female  cases  is  due  to  the  very  great 
frequency  with  which  cancer  attacks  the  uterus  and  fe- 
male breast;  of  all  the  female  cases,  in  40%  it  is  one  of 
these  two  organs  which  is  effected.  Many  of  what  may  be 
called  the  predisposing  causes  of  cancer  come  much  more 
frequently  into  operation  in  the  male  than  in  the  female, 
as.  for  instance,  trauma  and  syphilis.  Cancer  is  far  more 
common  in  the  male  than  in  the  female  in  the  following 
situations:  tongue,  bladder,  esophagus,  jaws,  face,  mouth, 
limbs,  lips  and  stomach.  A  large  proportion  of  deaths  from 
cancer  in  the  male  are  due  to  cancer  in  the  stomach  and  the 
pylorus.  About  three-fourths  of  all  the  cancer  occurring 
in  the  male  occur  in  the  alimentary  tract.     [W.  A.  N.  D.] 

5. — Walker  has  seen  four  cases  of  erythema  multiforme 
in  patients  who  had  been  recently  vaccinated,  all  of  which 
showed  features  that  made  it  seem  certain  that  the  vaccina- 
tion was  causally  related  to  the  eruption.  One  of  the  pa- 
tients was  a  nurse  whose  hands  presented  a  typical  pic- 
ture of  erythema  iris.  The  legs  were  also  affected  and  the 
eruption  spread  up  the  arm  beyond  the  usual  limitation  of 
erythema  iris.  The  vaccination  scabs  were  still  moist  and 
were  surrounded  by  a  raised  erythematous  patch  of  the 
same  character  as  the  eruption  elsewhere.  The  other  cases 
were  not  so  perfect  in  the  mimicry  of  the  real  disease.  All 
of  the  patients  had  been  vaccinated  with  glycerinated  lymph 
and  in  all  of  them  the  early  course  of  the  vaccination  was 
uneventful.     [J.  M.  S.] 


LANCET. 

Man  IS,  1901. 

1.  The  Erasmus  Wilson  Lectures   on  the   Pathology  and 

Diseases  of  the  Thyroid  Gland.  WALTER  ED- 
MUNDS. 

2.  A  Clinical  Lecture  on  Cases   Illustrating  the  Surgery 

of  the  Thyroid  Gland.  HENRY  BETHAM  ROBIN- 
SON. 

3.  A  Paryngeal  Pouch  of  Large  Size  Removed  by  Opera- 

tion. RICKMAN  J.  GODLEE  and  T.  R.  H.  BUCK- 
NALL. 

4.  Plies  and  the  Science  of  Scavenging.    G.  V.  POORE. 

5.  A  Case  of  Symmetrical  Retinal  Detachment  occurring 

during  Labor  and  Associated  with  Albuminuria  re- 
sulting in  Complete  Recovery.  REGINALD  G. 
HANN  and  R.  LAWFORD  KNAGGS. 

6.  Is   the    Murmur    of    Mitral    Stenosis    Systolic    or    Pre- 

systolic in  Rhythm?     HUGH  WALSHAM. 

7.  Opotherapy  in  Gynecology.     JOHN  PHILLIPS. 

8.  Some  Questions  with  Regard  to  Acute  Middle-Ear  In- 

flammation.    P.   McBRIDE. 

9.  A    Simple    Form   of   Electrical    Light   and   Heat,   with 

Eight  Cases  of  Osteo-arthritis  treated  by  it.     F.   C. 

EVE. 
2. — Henry  Betham  Robinson  reports  a  number  of  cases 
illustrating  the  surgery  of  the  thyroid  gland.  Case  1  is  a 
parenchymatous  goitre  which  was  reduced  by  the  admini- 
stration of  thyroid  extract.  Case  2  is  a  parenchymatous 
goitre  in  which  the  pyramidal  lobe  was  so  enlarged  as  to 
produce  serious  pressure  upon  the  trachea  and  greatly  em- 
barrass respiration.  The  isthmus  of  the  gland  was  re- 
moved without  ligation  laterally.  The  patient  became  as- 
phyxiated during  the  operation  and  tracheotomy  was  neces- 
sary. The  patient  suffered  at  first  from  some  thyroidism 
but  made  a  complete  recovery.  Case  3  closely  resembles 
case  2  in  symptoms  and  treatment;  here,  however,  the 
thyroidism  was  much  more  marked.  The  last  four  cases 
represent  cystic  adenomata  of  the  thyroid  gland,  each  of 
which  was  treated  successfully  by  operation.  The  au- 
thor remarks  that  the  removal  by  the  knife  of  these  cystic 
growths  is  far  more  satisfactory  than  other  methods  of 
treatment  such  as  tapping  and  injection.     [J.  H.  G.] 


3. — T.  R.  H.  Bucknall  reports  an  interesting  case  of  a 
large  pharyngeal  pouch  removed  by  operation..  The  sac 
had  its  attachment  at  the  top  of  the  larynx,  the  move- 
ments of  which  it  followed  during  deglutition.  The  patient 
was  31  years  of  age  and  had  experienced  symptoms  for  ten 
years.  During  the  past  three  years  he  had  had  repeated 
attacks  of  difficult  and  painful  deglutition  until  finally  it 
became  impossible  to  swallow  anything  but  liquids.  At  the 
end  of  an  attack  the  tumor  in  the  neck  disappeared,  some- 
times gradually  and  sometimes  suddenly.  Expectoration 
of  a  quantity  of  phlegm  was  frequent.  The  swelling  on 
admission  was  very  extensive,  reaching  from  the  middle 
line  in  front  to  the  posterior  border  of  the  sterno-mastoid 
behind,  and  extending  upwards  as  far  as  the  angle  of  the 
jaw,  and  downwards  as  far  as  the  clavicle.  The  percussion 
note  over  this  tumor  was  tympanitic.  The  patient  could 
slightly  inflate  the  tumor  by  holding  his  breath  and  blow- 
ing. The  tumor  was  dissected  out  with  considerable  dif- 
ficulty and  was  found  to  have  a  narrow  pedicle  which 
passed  through  the  thyro-hyroid  membrane,  but  no  pat- 
ulous opening  which  led  into  the  pharynx  could  be  dis- 
covered with  the  probe.  The  internal  opening  of  these 
abnormal  tracts  or  pouches  is  always  found  in  the  phar>'nx 
and  not,  as  was  formerly  stated,  in  the  larynx.  A  fre- 
quent site  of  the  internal  opening  is  on  the  side  of  the 
pharynx  close  to  the  margin  of  the  tonsil.  It  is  rare  for 
food  to  pass  into  the  cyst  as  frequently  happens  in  cases 
of  true  esophageal  pouches.  These  cysts  and  fistulae  are 
always  of  congenital  origin.     [J.  H.  G.] 

4. — Poor  writes  on  flies  and  the  science  of  scavenging.  The 
author  remarks  that  in  a  recent  debate  of  the  clinical  so- 
ciety of  London  on  enteric  fever  in  South  Africa,  the  general 
concensus  of  opinion  was  that  flies  may  convey  infection. 
He  informs  up  that  the  female  fly  lays  about  120  eggs 
and  that  the  developmental  cycle  from  egg  to  fly  requires 
less  than  three  weeks.  At  this  rate  the  female  fly  may 
have  some  25,000,000  descendants  in  the  course  of  a  hot 
summer.  The  plague  of  flies  can  be  lessened  by  the  proper 
removal  of  organic  refuse  matter,  so  that  it  cannot  serve 
for  feeding  these  insects.  He  recommends  immediate  col- 
lection of  all  organic  refuse  and  burying  this  matter  In 
the  earth.  He  believes  that  his  method  is  preferable  to 
chemical  disinfection  or  burning.     [F.  J.  K.] 

5. — Reginald  G.  Hann  and  R.  Lawford  Knaggs  report  a 
case  of  symmetrical  retinal  detachment  occurring  during 
labor  and  associated  with  albuminuria  resulting  in  com- 
plete recovery.  The  affection  occurred  in  a  woman  aged 
21  years  whose  personal  history  was  negative  up  to  the 
time  of  her  flrst  confinement,  excepting  an  attack  of  scarlet 
fever  in  childhood.  When  first  seen  after  having  been  in 
labor  24  hours,  there  was  edema  of  the  face,  hands,  feet 
and  legs  which  was  reported  to  have  been  present  for 
about  three  weeks.  As  far  as  could  be  ascertained  the 
blindness  was  sudden  in  onset.  Labor  was  terminated 
with  forceps.  The  following  day  she  remained  in  a  semi- 
comatose condition  and  for  30  hours  from  delivery  she 
passed  no  urine.  She  regained  consciousness  and  passed 
a  small  quantity  of  urine  containing  much  albumin.  Oph- 
thalmoscopic examination  under  atropin  showed  large  and 
distinct  attachment  occupying  the  lower  third  of  each  eye- 
ball. The .  edges  of  the  discs  were  well  defined  but  sur- 
rounded by  an  edematous  pallor.  About  a  month  later 
the  detachments  of  the  retinae  were  no  longer  visable  ex- 
cept a  doubtful  area  close  to  the  ora  serrata  in  the  lower 
part  of  the  right  eye-ball.  There  was  slight  tortuosity  ol 
some  of  the  vessels.  There  was  an  irregular  distribution 
of  pigment  granules,  spots  and  patches,  and  the  latter  In 
some  places,  especially  in  the  right  macular  region  were 
confluent.  A  subsequent  examination  failed  to  reveal  any 
remnants  of  the  detachment  in  the  right  eye.  The  fields 
still  showed  limitations  in  the  upper  portions.     [M.  R.  D.] 

6. — Walsham  has  made  a  routine  examination  of  all  his 
cases  of  mitral  stenosis  with  the  X-Rays  in  order  to  de- 
termine whether  the  murmur  is  systolic  or  presystolic  In 
rhvthm.     The  author  concludes  that  after  an  examination 


Tn8/1        The  Philadelphia-] 
■^'-"-'^       Medical   Journal  J 


THE  LATEST  LITERATURE 


[JlTSE   8,   1901 


of  a  number  of  cases  of  pure  mitral  stenosis,  he  is  con- 
vinced that  botti  the  thrill  and  the  murmur  are  presystolic 
in  rhythm.     [F.  J.  K.] 

7. — Phillips  in  speaking  of  opotherapy  remarks  that 
ample  clinical  evidence  shows  that  certain  nutritional  dis- 
orders associated  with  pelvic  disturbance  are  undoubtedly 
benefitted  by  the  administration  of  thyroid  extract.  It  is 
certainly  of  value  in  amenorrhea  accompanying  extreme 
obesity  and  as  a  complication  of  myxedema.  According  to 
some  authorities  it  is  beneficial  in  the  hemorrhages  of 
fibroid  tumors  of  the  uterus.  As  regards  the  ovarion  ex- 
tract the  methods  of  administration  appear  to  be  three:  1. 
That  followed  by  Knauer,  who  grafted  the  fresh  gland  into 
the  peritoneum  or  under  the  skin;  2.  Brown-Sequard's 
method  by  subcutaneous  injection  of  the  organic  extracts; 
3.  the  method  recommended  by  Horwitz  and  others  and 
now  in  general  use,  namely,  administering  the  extract  by 
the  mouth  or  the  rectum,  either  in  a  natural  state,  in  the 
form  of  ovarine  tabloids,  or  as  a  glycerin  extract.  Jayle 
has  observed  zona,  and  Schuster  general  urticaria,  after 
prolonged  ingestion  of  ovarian  extract.  Julien  finds  the 
drug  of  great  value  in  post-operative  menopauseal  symp- 
toms, in  amenorrhea,  dysmenorrhea,  anemia,  chlorosis,  and 
osteomalacia.  The  administration  of  mammary  abstract 
is  surrounded  by  greater  uncertainty.  It  is  best  given 
in  the  raw  state,  cow's  udder  being  cut  into  thin  slices 
and  made  into  a  salad.  This  method  has  been  frequent- 
ly prescribed  and  carried  out  by  Freudenberg.  [W.  A.  N. 
D.] 

8. — P.  McBride  reports  a  case  of  a  man  aged  48  years 
whom  he  treated  for  some  time  for  a  suppurating  middle 
ear.  The  usual  treatment  and  several  incisions  of  the 
drum  failed  to  relieve  the  condition  and  it  was  subsequent- 
ly discovered  that  the  patient  had  an  empyema  of  the 
antrum  of  Highmore.  The  empyema  was  on  the  right  side 
and  the  ear  affection  on  the  left.  The  antrum  was  thor- 
oughly opened  and  drained  and  when  it  had  healed  the  ear 
condition  promptly  subsided.     [J.   H.  G.] 

8. — Eve  recommends  an  apparatus  consisting  of  three  32- 
candle  power  lamps  surrounded  by  a  wire  cage,  in  order  to 
prevent  contact  with  the  skin  of  a  patient,  and  arranged 
upon  an  aluminum  base,  for  heating  a  part  or  the  whole  of 
the  body.  He  maintains  that  this  apparatus  possesses 
many  advantages  over  the  more  elaborate  contrivances 
now  in  use.  When  heating  a  limb  the  apparatus  and  a 
thermometer  are  placed  under  several  blankets  thrown 
over  a  cradle.  The  limb  is  protected  by  a  single  layer 
of  lint  to  prevent  scorching  a  particularly  tender  skin. 
The  temperature  may  be  raised  from  200°  F.  to  250°  F.  in 
from  15  to  30  minutes.  Eve  has  treated  8  cases  or  osteo- 
arthritis by  this  method  with  favorable  results.     [J.  H.  G.] 


MEDICAL   RECORD. 
June  1st,   1901. 

1.  The  Diagnosis   and    Surgical    Treatment   of    Prolapsed 

Kidney;  with  Demonstration  of  a  Simple  Method 
of  Examination  for  its  Detection.  AUGUSTIN  H. 
GOELET. 

2.  The  Climate  of  Long  Island.    LeGRAND  N.  DENSLOW. 

3.  Superheated  Air  in  the  Therapeutics  of  Chronic  Catarr- 

hal Otitis  Media.     GEORGE  W.   HOPKINS. 

4.  Three  Cases  of  Caesarean   Sections;    Recovery.     J.   F. 

BALDWIN. 
6.     Ether  as   an   Anesthetic.     EDWARD   JUDSON   WYN 
KOOP. 

6.  A  Few  Observations  from  the  Lorenz  Orthopedic  Clinic 

LEONARD  W.   ELY. 

7.  A  Case  of  Membranous  Angina,  due  to  Streptococci,  fol- 

lowed by  Paralysis  of  the  Soft  Palate.  MOSES 
KESCHNER. 

1. — Augustin  H.  Goelet  discusses  the  diagnosis  and 
surgical  treatment  of  prolapse  of  the  kidney.  True  floating 
kidney  Is  very  rare  and  is  always  congenital:  prolapsed 
kidney  is  very    common   and    always   acquired.      He    con- 


cludes:  (1)  That  prolapsed  kidney  is  more  frequent  than 
is  generally  supposed.     (2)   That  it  is  often  not  suspected 
because  it  does  not  always  give  rise  to  symptoms  directly 
referable  to  the  kidney.     (3j  That  frequently  it  is  not  dis- 
discovered  because,  by  the  usual  methods  of  examination, 
only  an  expert  can  detect  it,  unless  the  kidney  is  much  en- 
larged or  the  subject  is  thin  and  the  abdominal  walls  re- 
laxed.    (4)   That   palliative  measures,   such   as  abdominal 
supports,  are  of  no   avail   and   therefore   useless   and   un- 
wise if  the  degree  of  prolapse  is  suflScient  to  produce  sym- 
loms.     (5)   That  fixation  of  the  kidney  by  suture  to  the 
muscles  of  the  back  in  its  normal  position  is  the  correct 
method  of  treatment.     The  operation  is  simple,  devoid  of 
risk  and  successful  when  properly  executed  and  when  the 
patient  is  given  careful  preparation  to  avoid  vomiting  and 
retching  with  consequent  straining  after  the  operation  and 
if  proper  attention  is  given  during  convalescence  to  avoid 
strain  upon  the  kidney.     Prolapsed  kidney  the  author  has 
found  in  1  out  of  every  4  or  5  gynecological  cases  and  about 
one-half  of  these   suffer   sufliciently  to   require   operation. 
The  various  supports  recommended  for  this  condition  are 
productive  of  little  good  excepting  to  perhaps  limit  the  pro- 
lapse.    The  various   supposed   causes   of   prolapse   of   the 
kidney  are  referred  to  but  the  author  thinks  none  of  them 
perfectly  satisfactory.     The  symptoms  of  prolapse  are  as 
follows:      (1)    Chronic   digestive  disturbances,   manifested 
chiefly  by  intestinal  distention  and  irritability  of  the  stom- 
ach.    f2)  Nervousness,  restlessness  and  insomnia.     (3)  Un- 
usual fatigue  after  walking  or  standing.     (4)  Palpitation  of 
the  heart,  vertigo  and  syncope.     (5)   Pain  over  the  pit  of 
che  stomach  and  a  little  to  the  left  over  the  region  of  heart. 
(6)  Dragging  pains  in  the  loin  extending  down  the  thigh 
and  aggravated  by  standing  or  walking.     (7)   Inability  to 
rest  comfortably  on  the  opposite  side  from  the  prolapsed 
kidney.    (8)  Irritability  of  the  bladder,  aggravated  by  stand- 
ing or  walking.     (9)   Jaundice.     (10)   Pain  over  the  region 
of  the  appendix,    resembling    chronic    appendicitis.      (11) 
Pain    referred     to     the     ovarian     region     on     the     same 
side.      (12)     Acute    attacks     of     pain     resembling     renal 
colic,  which  come  on  suddenly  and  subside  quickly.     Fre- 
quently cases  are  referred  to  the  gynecologist  for  supposed 
pelvic  disease  when  the  real  trouble  is  a  prolapsed  kidney, 
in  all  gynecological  cases  Goelet  urges  that  an  examination 
of  the  kidneys  be  made  and  made  repeatedly,  as  under  un- 
favorable conditions  the  diagnosis  of  prolapse  of  the  kid- 
ney Is  not  easily  made.     His  own  method  of  examination, 
which  he  finds  very  satisfactory,  is  as  follows:     The  pa- 
tient is  directed  to  stand  with  her  back  to  the  wall  or  a 
table,  perpendicular  to  the  floor,  her  body  inclined  a  little 
forward,  so  as  to  relax  the  abdominal  muscles.    The  exam- 
iner sits  in  front  of  her  a  little  to  the  right  and  grasps  with 
his  left  hand  the  right  loin,  his  fingers  behind  and  his  thumb 
in  front,  just  below  the  border  of  the  ribs.     The  patient  is 
now  directed  to  take  several  deep  inspirations  and  to  ex- 
pire to  the  extreme  limit:  at  the  end  of  the  second  or  third 
inspiration  he  depresses  the  abdominal  wall  with  his  thumb 
so  as  to  diminish  the  distance  between  the  thumb  and  the 
lingers  behind,  in  this  manner  approximating  the  anterior 
and  posterior  walls  above  the  kidney  if  it  is  prolapsed.  With 
his  other  hand,  the  right  abdominal  region  is  depressed  by 
pushing  the  tips  of  the  fingers  inward  and  engaging  the  kid- 
ney if  prolapsed   between   the  tips   of  the   fingers   of  his 
right  hand  and  the  thumb  of  the  left  which  depresses  the 
abdomen  just  beneath  the  ribs.     In  this  manner  the  kid- 
ney, if  prolapsed,  may  be  outlined,  and  firm  pressure  upon 
it  will  cause  it  to  glide  under  the  thumb  and  up  into  po- 
sition.  When  the  degree  of  prolapse  is  insufficient  to  demand 
operation,  he  says  that  the  symptoms  may  be  relieved  by  a 
properly  adjusted  bandage  with  a  pad  over  the  kidney  but 
that  no  cure  can  result  from  this  treatment.     Operation  is 
indicated  where  symptoms  cause  positive  discomfort  or  in- 
terfere with  the  health  of  the  patient.     Where  the  patient 
suffers  from  attacks  of  acute  pain  denoting  obstruction  of 
the  ureter  operation  is  imperative.     The  author  uses  silk- 
worm gut  sutures  and  carries  out  his  fixation  in  the  follow- 
ing way:   The  needle  carrying  the  suture  is  first  inserted  sup- 
erficially on  the  lateral  surface  of  the  exposed   kidney   from 
above  downward  -in   a   direction   somewhat  oblique  to   its 
long  axis.    Then  it  is  inserted  deeply  through  the  kidney 
structure  transversely  and  again  superficially  on  the  oppo- 
.site  lateral  surface  from  below  upward.     The  free  ends  ot 
this  suture  are   passed   through   the  fatty   capsule  of  the 
kidney  and  muscles   and   skin  at  the  upper  angle  ot  the 
wound  so  that  when  they  are  drawn  upon  and  tied,  the 


JUNE    S,    1901] 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
Lmedical  Journal 


1085 


kidney  is  drawn  up  into  position  under  the  ribs.  This  meth- 
od of  inserting  the  suture  lessens  the  strain  upon  the  cen- 
tral insertion  through  the  kidney  structure.  To  obviate  the 
cutting  of  these  sutures  into  the  skin,  he  ties  them  over  a 
strip  of  several  layers  of  gauze  placed  lengthwise  over  the 
wound,  but  before  they  are  tied  he  inserts  a  roll  of  sterile 
gauze  down  into  the  wound  and  along  the  border  of  the  kid- 
ney, and  brings  it  out  at  the  lower  angle  of  the  wound.  The 
object  of  this  is  to  secure  drainage  and  to  excite,  by  con- 
tact with  the  kidney,  a  plastic  inflammation  which  aids  in 
its  fixation,     [T.  H,  G.] 

2. — LeCrand  N.  Denslow  presents  a  carefully  prepared 
paper  upon  the  climate  of  Long  Island.  In  his  summary  he 
states  that  the  configuration  of  the  land  is  good,  the  air  is 
both  from  the  ocean  and  the  shore,  with  great  mobility, 
due  to  the  constant  daily  ocean  winds.  The  water  from 
the  wells  or  springs  is  of  the  purest,  and  the  humidity  is 
not  excessive.  He  believes  that  it  compares  favorably  with 
some  of  the  most  celebrated  coast  climates.     [T.  L.  C] 

3. — George  W.  Hopkins  reports  the  beneficial  employ- 
ment of  superheated  air  in  the  therapeutics  of  chronic  ca- 
tarrhal otitis  media.  The  treatment  consists  in  thoroughly 
cleansing  the  ear  with  alcohol  for  several  days.  Narrow 
strips  of  dry  gauze  are  then  packed  into  the  ear  and  a 
large  pad  of  dry  gauze  placed  over  the  ear.  The  ear  is 
then  covered  with  the  canvas-sleeve  hot-air  conductor  and 
a  current  of  air  sent  into  the  canal  at  a  temperature  which 
gradually  attains  400  degrees  F.  The  temperature  is  easily 
borne,  but  a  severe  headache  usually  follows  treatment. 
This  is  speedily  relieved  by  a  dose  of  codein.  The  Eu- 
stachean  tube  is  always  inflated  with  a  warm,  stimulating 
vapor  from  a  nebulizer  after  the  treatment,  and  this  is  con- 
cluded with  vibratory  massage  with  the  nebulizer.  The 
writer  regards  arteriosclerosis,  serous  effusion  into  the 
tympanum  and  perforations  of  the  tympanum  as  contra- 
indications of  this  treatment,     [T,  L,  C,] 

7. — M.  Keschner  reports  a  case  of  membranous  angina 
due  to  streptococci  followed  by  paralysis  of  the  soft  palate. 
The  patient  presented  on  admission  a  thick,  yellowish-grey 
tenacious  membrane  covering  the  tonsils,  uvula,  and  an- 
terior and  posterior  pillars  of  the  fauces,  with  signs  of 
profound  systemic  infection.  The  appearances  resembled 
diphtheria,  but  bacteriological  examination  showed  only 
the  presence  of  streptococci.  On  the  11th  day,  paralysis  of 
the  soft  palate  was  noted.  There  was  also  a  distinct  loss  of 
sensibility.  The  patient  was  discharged  in  two  weeks  with 
only  slight  improvement  of  the  paralysis.     [T.  L.  C] 


NEW   YORK    MEDICAL   JOURNAL. 
June  1,  1901.     (Vol.  LXXIII,  No.  22). 

1.  On  Theories  of  Inheritance  with  Special  Reference  to 

the  Inheritance  of  Acquired  Conditions  in  Man.     J. 
GEORGE  ADAMI. 

2.  Appendicitis    Perforative   in   Irreducible   Right  Scrotal 

Hernia,  with  a  Report  of  a  Case.    O.  THIENHAUS. 

3.  Muscular  Action  of  the  Arteries.    ANDREW  H.  SMITH. 

4.  Hyperacidity    (Superacidity,    Hyperchlorhydria.    Super- 

aciditas  Chlorhydrica) ;   a  Clinical  Study.     H,  ILLO- 
WAY. 

5.  A  Case  of  Sarcoma  in  the  Muscles  of  the  Right  Shoul- 

der, with  Perforation  into  the  Spinal  Canal,  and  Para- 
plegia.    LEONARD  WEBER. 

2. — Thienhaus  concludes  his  article  with  the  following: 
(1)  As  it  is  almost  a  law  now-a-days  that  in  all  gj'n ecologi- 
cal abdominal  operations,  especially  in  cases  of  inflamma- 
tion of  only  the  right  annexa,  the  appendix  demands  strict 
observation  and  removal,  so  the  same  rule  must  be  followed 
in  operations  for  hernia,  and  when  we  take  into  considera- 
tion that  in  all  cases  of  appendicular  hernia  the  appendix 
was  found  in  a  state  of  chronic  folliculitis,  the  author  prob- 
ably does  not  go  too  far  when  he  says  that  in  every  case 
of  hernia  in  which  we  find  the  appendix  as  an  inmate  it 
must  be  removed  according  to  the  old  rule  in  prophylaxi 
est  salus  aegrotl.  (2)  Where  appendicular  inflammation  is 
present  in  a  hernial  sac,  operative  procedure  has  to  be  ad- 
vised immediately,  and  in  case  of  incarcerations  under  such 
conditions  every  palliative  method,  such  as  ether  refriger- 
ation, or  attempts  at  taxis,  are  entirely  objectionable  pro- 
cedures. (3)  In  cases  of  appendicular  abscess  in  a  hernial 
sac  or  gangrene  of  the  appendix,  resection  and  free  drain- 
age without  reduction  is  the  appropriate  treatment,  and  if 


incarceration  exists,  this  has  to  be  relieved  and  the  peri-        | 
toneal  cavity  walled  off  carefully  by  iodoform  gauze.     The 
radical  cure  of  the  hernia,  of  course,  has  to  be  delayed,  un- 
der these  conditions,  till  the   signs   of  inflammation  have 
subsided.     [T.  M.  T.] 

3. — Smith  thinks  that  not  enough  attention  is  given  to 
the  disease  of  the  Intima  and  the  fibrous  tunic  when  con- 
sidering the  various  coats  of  the  arteries.  The  effect  of 
calcification  In  destroying  the  elasticity  of  the  vessels  and 
making  their  walls  rigid  is  what  we  think  of  first  in  this 
connection.  The  mechanical  obstacle  which  this  condition 
necessarily  presents  to  the  forward  movement  of  the  bloo'l 
is  of  the  first  importance  and  this  is  entranced  when  fi- 
brosis of  the  outer  coat  is  added.  But  in  the  latter  case  the 
effect  goes  beyond  the  mere  impairment  of  elasticity.  The 
delicate  fibers  of  the  vasomotor  system  distributed  to  the 
muscular  coat  are  stretched  and  compressed  by  the  greatly 
thickened  and  condensed  outer  coat  through  which  they 
pass.     [T.  M.  T.] 


MEDICAL    NEWS. 


June  1.  1901.    (Vol.  LXXVIII,  No.  22). 

1.  Some  Factors  Relating  to  the  Etiology  of  Prostatic  En- 
largement.    J.  BENTLEY  SQUIER. 

i!.  Gastric  Ulcer  and  Muco-Membraneous  Colitis  at  the 
Paris  Congress.    JAMES  J.  WALSH. 

3.  Streptococcus    Bronchitis    in    Influenza.      F.      FORCH- 

HEIMER. 

4.  Fourth-of-JuIy  Tetanus.    H.  GIDEON  WELLS. 

.">,     The  Use  of  Methvlene-Blue  Injections  in  Pleurisy  with. 

Effusion.     CHARLES  H.  LEWIS. 
6,     The  Apearance   of  the   Soft   Palate   a   Pathognomonic 
Symptom  of  Epidemic  Influenza,     LOUIS  KOLIPIN- 
SKI. 

2. — Walsh,  in  his  article  on  Gastric  Ulcer  and  Muco- 
Membranous  Colitis  at  the  Paris  Congress,  states  that  it. 
it  a  well-known  fact  that  ulcers  having  the  typical  charac- 
teristics of  gastric  ulcers  have  been  found  in  the  digestive 
tract  in  which  there  is  free  acid  bathing  the  surface 
of  the  mucous  membrane.  He  says  there  is  little  doubt 
that  gastric  ulcers  are  due  to  self-digestion  of  the 
stomach  wall,  and  quotes  Rokitansky  and  Virchow,  who 
attribute  the  digestion  of  the  gastric  mucous  membrane  to- 
a  disturbance  of  the  circulation  in  the  gastric  mucosa  and 
consequent  lowering  of  the  resistive  power  of  the  tissues. 
He  also  names  two  conditions  of  the  blood  which  predis- 
pose to  gastric  ulcer:  (!)  .\nemia:  (2)  Blood  disturbance 
due  to  an  infection  somewhere  in  the  body.  He  divides  gas- 
tric ulcer  also  into  acute  and  chronic.  Most  all  gastric  ul- 
cers have  been  classed  under  the  head  of  chronic,  though 
the  acute  condition  is  noticed  not  infrequently  in  infec- 
tious diseases.     [T.  M.  T.] 

3. — Forchheimer  gives  as  his  reasons  for  calling  this 
condition  streptococcus  bronchitis  that  in  all  his  cases  this 
lower  form  of  life  predominated,  and  in  quite  a  number, 
notably  some  of  the  worst,  it  was  the  only  bacterium  found 
in  the  expectoration.  In  23  cases  studied,  the  streptococ- 
cus was  associated  with  staphyloccoci  alone:  in  three  cases 
streptococci,  staphyloccoci  and  the  influenza  bacillus  were 
associated;  in  27  cases  the  streptococcus  alone  was  found. 
In  the  author's  cases  he  noticed  that  the  influenza  bacillus 
disappeared  after  a  short  time  and  was  replaced  by  the  strep- 
tococcus. He  does  not  think  that  this  is  an  associated  life, 
f Symbiosis),  but  considers  the  condition  a  secondary  in- 
fection.    FT.  M.  T.] 

6. — Kolipinski  is  convinced  that  a  diagnosis  of  Influenza 
can  be  made  by  observing  the  peculiarity  of  appearance  of 
the  velum  palati.  This  appearance  was  found  to  precede 
the  initial  chill  and  fever  by  some  days  and  still  persisted 
when  convalescence  was  apparently  ended.  There  are  seen 
upon  the  mucous  membrane  of  the  soft  palate  small  con- 
vex projections  of  a  pearly  whiteness  or  transparency,  the 
size  of  a  grain  of  sand.  The  number  varies  and  they  are 
confined  to  certain  parts  of  the  velum  or  its  processes,  or 
else  abundantly  scattered  over  the  whole  of  its  anterior 
surface.  Best  seen  at  (1)  the  base  of  the  uvula:  (2)  the 
median  raphe:  (3)  the  lateral  border  of  the  same;  (4)  the 
anterior  surface  of  the  palatoglossal  fold  about  the  upper 
border  of  the  tonsil.  A  spatula  rubbed  over  them  gives  a 
hard,  rough  sensation.  They  are  distinguishable  in  very 
bright,  artificial  light,  but  are  best  seen  in  sunlight,  di- 
rect or  diffused.    They  must  not  be  confounded  with  small 


TCiRfi       I^HE    Philadelphia" 


Medical    Journal 


THE  LATEST  LITERATURE 


[June  «,  l»fl 


I  drops  of  mucus  or  saliva  often  present.  Sometimes  they 
are  obscured  by  a  tenaceous  secretion  covering  the  sur- 
face. It  is  thought  that  their  composition  is  that  of  con- 
gested or  inflamed  palatal  mucous  glands.     [T.  M.  T.] 


BOSTON   MEDICAL  AND  SURGICAL  JOURNAL. 

Mud  30tn,  1901. 

1.     The  Diagnosis  and  Surgical  Treatment  of  Renal  Tuber- 
culosis.    F.  JluUsl;^  brown. 

1. — There  are  no  cases  of  purely  localized  unilateral 
renal  tuberculosis  which  we  would  entrust  to  climatic 
change  as  the  best  treatment,  as  opposed  to  surgery;  and. 
on  the  other  hand,  there  are  no  such  cases  just  recovering 
from  nephrectomy  in  which  we  would  not  seek  for  the  pa- 
tient 12  months  or  more  of  this  climatic  benfit.  Despite  the 
immense  amount  accomplished  by  earnest  labor  in  the 
field  of  tuberculosis,  we  have  yet  to  hope  that  something 
more  specifically  curative  than  the  knife,  sanitation  or  the 
pine  woods  may  soon  be  hit  upon.  To  secure  more  satis- 
factory results  from  surgical  treatment,  renal  tuber- 
culosis must  be  detected  early.  Urinary  analysis  in  gener- 
al should  mean  as  careful  a  routine  search  for  tubercle 
bacilli  as  is  customarily  given  to  the  other  formed  ele- 
ments of  a  sediment.  Upon  this  Initial  evidence  the  sus- 
picion should  be  verified  and  the  smegma  bacillus  ex 
eluded  by  getting  the  bladder  urine  through  a  catheter, 
then  cystoscopic  ureteral  catheterization  may  at  once  be 
utilized  to  locate  the  lesion  in  the  bladder  or  kidneys. 
Brown  believes  that  there  is  no  more  accurate  and  simple 
"way  to  do  this  in  both  sexes  than  with  the  double-bar- 
reled ureter  cystoscope,  invented  by  him,  each  channel  of 
"which  conveys  a  flexible  sterile  catheter  to  its  respective 
ureter:  by  this  means  the  urine  from  both  kidneys  is  col- 
lected at  the  same  lime,  while  the  same  nerve  Influences 
and  the  same  physiological  conditions  pertain.  Many 
patients  state  that  they  were  never  ill  until  their  present 
trouble  began  with  having  to  urinate  too  often.  In  the 
majority  of  cases,  however,  frequency  of  urination  does  not 
appear  until  the  lower  segment  of  the  ureter  has  either  ac- 
quired a  genuine  tuberculous  lesion  or  until  marked  hyper- 
emlaandedemawiththe  accompanying  irritable  state,  have 
developed  about  the  mouth  of  the  ureter.  The  principal  ob- 
jective symptoms  are:  A  kidney  which  is  larger  and 
more  tender  than  normal:  all  grades  of  pyuria  and  hema- 
turia; a  just  appreciable  or  a  very  marked  diurnal  varia- 
tion in  temperature:  loss  of  color  and  weight;  a  reaction 
to  tuberculin;  and  the  presence  of  tubercle  bacilli  in  tht 
urine  derived  directly  from  one  or  both  kidneys.  In  the 
operative  treatment  a  considerable  amount  of  tuberculous 
ureter  can  be  left  with  comparative  safety:  because,  being 
In  a  functionless  state  of  repose,  this  particular  focus  is 
amenable  to  curative  systemic  processes.  In  cases  pre- 
senting tuberculosis  vesical  lesions  where  only  one  kidney 
is  similarly  diseased,  the  author  thinks  that  nephrectomy 
is  indicated  in  a  certain  number  of  individuals  as  offering 
the  best  chances  for  extension  of  life  and  comfort.  Short 
notes  of  18  illustrative  cases  are  given.     (J.  M.  S.) 


JOURNAL     OF     THE     AMERICAN     MEDICAL     ASSOCIA- 
TION. 

Jxne   1st,   1001. 

1.  Movable    Kidney;    its    Causes   and    Treatment.     M.    L. 

HARRIS. 

2.  The  Appendix  Vermiformis   and   Cecum.     A   Compara- 

tive Study.     B.  MERRILL  RICKETTS. 

3.  Zoology  in  the  Medical  School  Curriculum.     CHARLES 

WARDELL  STILES. 

4.  Antipneumococcic  Serum  Treatment  of  Pneumonia,  with 

Report'of  Cases.     G.  E.  TYLER. 
E.     How  to  Treat  Muscular  and  Joint  Sprains  of  Railway 

Employes.     HALDOR  SNEVE. 
€.     Diagnosis    and    Symptomatology    in      Appendicitis    in 

Children.     THOS.  H.  MANLEY. 

7.  Is  it  Possible  by  Proper  Dietetics  and  Hygiene  to  Ex- 

terminate Tuberculosis?     J.  E.  KINNEY. 

8.  Variola  and  Varicella.     M.  A.  AUSTIN. 

9.  Photographing  the  Eye-Ground.     SHIRLS  JACKSON. 


1. — M.  L.  Harris  discusses  at  length  the  subject  of  mov- 
able kidney,  its  causes  and  treatnnent.  The  author  holds 
that  many  of  the  generally  accepted  causes  of  movable 
kidney  are  incorrect.  He  attributes  the  cause  of  this  con- 
dition after  the  careful  study  of  a  large  number  of  cases 
which  he  has  tabulated,  to  the  particular  body  form  of  the 
individual.  This  form  consists  in  a  marked  contraction 
of  the  lower  end  of  the  middle  zone  of  the  body  with  a 
diminution  in  the  capacity  of  this  portion  of  the  cavity. 
This  constriction  tends  to  depress  the  kidney  and  as  it  is 
above  the  kidney,  such  acts  as  coughing,  straining.  Lifting, 
etc.,  which  tend  still  more  to  lessen  the  circumference  of 
the  body  at  this  point  crowd  the  kidney  down  further 
and  increase  its  range  of  motion.  These  conditions  which 
Harris  chooses  to  call  "internal  traumata"  gradually  pro- 
duce a  movable  kidney.  He  thinks  that  a  movable  kidney 
is  never  the  immediate  result  of  a  single  injury  or  ex- 
ternal trauma.  A  movable  kidney  discovered  immediately 
after  an  accident  is  oftentimes  attributed  to  the  accident, 
whereas  in  reality  it  had  probably  existed  for  a  long  time 
before.  The  overlooking  of  the  fact  that  movable  kidney 
is  extremely  common  in  women  often  leads  the  practitioner 
to  attribute  the  condition  to  a  traumatism.  When  a  pa- 
tient suffers  from  a  movable  kidney  any  traumatism  about 
the  trunk  is  very  apt  to  produce  hematuria.  In  the 
treatment  of  the  condition  the  author  thinks  that  the  mis- 
take is  made  too  frequently  of  fixing  the  kidney  too  high 
up,  because  if  this  is  done  the  condition  which  was  the 
original  cause  of  the  prolapse  of  the  kidney  still  pertains 
and  the  organ  is  again  apt  to  become  movable.  Great 
stress  is  laid  upon  the  removal  of  all  perirenal  fat  and  the 
obliteration  of  the  peritoneal  pouch  in  which  the  kidney 
has  been  moving.  The  outer  edge  of  the  prerenal  fascia  is 
then  sutured  to  the  lumbar  fascia  posterior  to  the  line  of 
incision  through  the  walls.     [J.  H.  G.] 

2. — B.Merrill  Ricketts  discusses  the  comparative  anatomy 
of  the  appendix  vermiformis  and  cecum.  The  author  says 
that  the  appendix  is  not  confined  to  mammals  but  is  also 
found  in  birds,  fishes,  etc.,  and  discusses  its  anatomy 
in  each  of  these  as  well  as  in  man.     [J.  H.  G.] 

3. — Stiles,  while  admitting  that  the  medical  school  cur- 
riculum is  already  full  to  overflowing  and  that  the  aim  of  a 
medical  faculty  is  not  to  give  a  man  a  general  educatioa, 
but  rather  to  teach  him  diagnosis  and  treatment  of  dis- 
eases, firmly  advocates  the  teaching  of  zoology  in  medical 
schools.  In  his  article  he  sets  forth  ample  evidence  to 
prove  this  statement  and  maintains  that  a  course  in  this 
branch  could  be  given  in  from  20  to  30  lectures  and  at 
least  three  laboratory  exercises.     [F.  J.  K.] 

4. — Tyler  discusses  the  value  of  antipneumococcic  serum 
in  the  treatment  of  pneumonia,  and  gives  a  report  of  a 
large  number  of  cases.  After  a  careful  study  of  the  litera- 
ture bearing  upon  this  ubject  and  his  own  cases,  he  con- 
cludes that  it  is  exceedingly  doubtful  whether  antipneu- 
mococcic serum  has  any  effect  upon  the  diseased  lung. 
He  maintains  that  this  serum  will  prevent  the  development 
of  toxic  symptoms  if  large  quantities  of  fresh  serum  are 
given  before  the  advent  of  the  pneumococcus  into  the 
blood.     [F.  J.  K.] 

5. — Haldor  Sneve  first  refers  to  the  treatment  and  path- 
ology of  sprains  of  joints.  He  thinks  that  tearing  or  rup- 
ture of  ligaments  is  extremely  rare  in  sprains.  The  path- 
ological condition  most  frequently  present  is  a  rupture 
of  the  areolar  and  connective  tissue  around  the  joint  and 
a  contusion  of  the  lining  of  the  joint  For  the  treatment  of 
this  condition  the  author  recommends  the  early  use  of 
cold  applications  and  massage,  to  be  followed  later  by 
compression  and  the  active  use  of  the  part  such  as  is  ob- 
tained by  the  use  of  the  Gibney  adhesive  strip  dressing 
He  condemns  very  strongly  the  use  of  the  plaster  cast  in 
these  conditions.  "The  ambulatory  treatment  of  sprains 
in  conjunction  with  massage  is  to-day  the  best  treatment." 

[J.  H.  G.] 

6. — Thomas  H.  Manley  reviews  briefly  the  history  of  ap- 
pendicitis and   refers  to  its   frequency   in   early  life.     The 


JUNE   8,    19011 


THE  LATEST  LITERATURE 


TThe  Philadelphia        to87 
L  Medical   Journal  iwu/ 


youngest  patient  on  record  operated  on  for  appendicitis 
was  a  child,  aged  61  days.  Here  a  large  perforation  of  the 
tip  of  the  appendix  was  found.  The  author  thinks  that 
children  bear  genral  septic  infection  much  better  than 
adults.  As  the  cecum  is  small  and  quite  movable  in  early 
life  inflammations  of  this  portion  of  the  intestinal  canal 
are  much  obscured  by  the  inlocation.  Two  con- 
ditions from  which  appendicitis  in  children  must  be 
differentiated  are  intussusception  and  tulierculous  peritoni- 
tis. The  author  has  not  found  the  examination  of  the  blood 
to  be  of  great  assistance  in  making  a  differential  diagnosis 
between  appendicitis  and  other  conditions;  the  most  re- 
liable source  of  information  lies  in  the  careful  examina- 
tion of  the  abdominal  wall  which,  in  a  child,  is  very  easily 
accomplished.  Abdominal  distension  and  frequent  and 
shallow  respiration  of  a  thoracic  type  are  very  common  in 
children.  The  author  produces  a  table  representing  the 
mortality  of  appendicitis  in  New  York  city.  The  author 
does  not  think  that  the  premonitory  symptoms  of  appen- 
dicitis in  children  are  more  subtle  and  insidious  than  in 
adults.  The  article  closes  with  a  discussion  of  the  various 
types  of  appendicitis.     [J.  H.  G.] 

7. — Kinney  maintains  that  it  is  possible  to  exterminate 
tuberculosis  through  proper  dietetic  and  hygienic  measures. 
At  the  present  time  there  are  two  obstacles  which  hinder 
advancement  in  this  line,  namely,  people  as  a  rule  who  are 
possessed  of  a  fair  degree  of  health  are  not  ready  to  make 
an  effort  to  preserve  it.  and  the  individuals  who  are  not 
affected  by  the  diseases  are.  as  a  rule,  not  willing  to  accept 
the  proper  measures  of  prevention.     [F.  J.  K.] 

8. — Austin  discusses  variola  and  varicella  and  gives  the 
important  points  in  the  diagnosis  of  each  condition,  with 
particular  reference  to  the  epidemic  character,  the  period 
of  incubation,  the  eruption,  and  the  duration  and  termina- 
tion of  these  diseases.  The  author  maintains  that  typical 
cases  are  to  be  found  only  in  text-books  and  rarely  in  gen- 
eral practice.  He  gives  an  account  of  an  epidemic  of  vari- 
ola which  occurred  at  Anderson.  Indiana.  The  total  num- 
ber of  cases  was  149.     [F.  J.  K.] 

9. — Jackson  gives  a  description  of  an  instrument  used  for 
photographing  the  eye-ground.  The  instrument  is  es- 
sentially composed  of  a  camera  placed  behind  an  illuminat- 
ing ophthalmoscope.  The  author  remarks  that  he  has 
met  with  numerous  failures  in  his  attempts  at  photograph- 
ing the  eye-ground.  The  best  results  have  been  obtained  in 
those  cases  in  which  light  perception  was  greatly  dimin- 
ished, or  entirely  lost.     [F.  ,T.  K.] 


AMERICAN    MEDICINE. 

.hnir    Ul.    Hli/l. 

1.  A  Case  of  Antrum  Infection  and  Sigmoid  Sinus  Throm- 

bosis, etc.       BAYARD  HOLMES. 

2.  Typhoid   Fever  and   Pharyngeal   Diphtheria.    MORRIS 

MANGES. 

3.  Practical  Thoughts  on  Pulmonary  Tuberculosis.   HOW- 

ARD S.  ANDERS. 

4.  The     Recognition     of     Tabes     Dorsalis.      THEODORE 

DILLER. 

5.  Simplicity  in  Therapeutics.    EDWIN  W.  PYLE. 

6.  The  Radical   Cure   of  Internal   and   External   Piles   by 

Excision.     JOHN  A.  HAWKINS. 

7.  Rigidity    of    the    Spine.      (Spondylose    Rhizomelique). 

MAX  H.  BOCHROCH. 

8.  Some  Notes  on  a  Case  of  Cerebral  Embolism.     ANNA 

M.   LITTLEFIELD. 

1. — Bayard  Holmes  reports  a  case  of  antrum  Infection 
and  sigmoid  sinus  thrombosis,  without  present  middle-ear 
disease:  presenting  the  symptoms  of  facial  neuralgia  and 
one  of  the  ordinary  symptoms  of  disease  in  the  petrosa; 
retropharyngeal  abscess,  general  sinus  thrombosis  with 
slight  impairment  of  cerebration.  Death  occurred  after 
three  months.  There  were  present  rigor  and  high  tem- 
perature without  apparent  cause,  and  neuralgia  of  the 
right  fifth  nerve  for  'ten  days,  and  a  septic  condition  re- 
sembling sinus  thrombosis  for  six  weeks.  The  absces.q 
appeared  suddenly  in  the  right  posterior  pharynx.  Six  weeks 
later  discharge  from  the  right  ear  occurred  together  with 


paralysis  of  the  right  leg  and  death.  The  necropsy  showed 
uniruni  and  general  mastoid  disease,  sigmoid  and  general 
sinus  thrombosis,  which  extended  into  the  cortex  of  the 
left  hemisphere.     [T.  L.  C. ) 

2.—  Morris  Manges  reports  6  cases  of  typhoid  fever 
complicated  by  pharyngeal  diphtheria.  Five  out  of  six 
Ccises  finally  recovered.  As  a  rule  the  prognosis  in  this 
complication  is  gloomy,  especially  in  children.  The  diph- 
theria antitoxin  was  well  borne  in  all  of  the  authors  cases. 

[T.  L.  C] 

4. — Theodore  Diller  discusses  the  means  of  recognition 
of  tabes  dorsalis.  The  following  leading  symptoms  ho 
names  in  the  order  of  their  importance:  (1)  Failure  of 
knee-jerks;  (2)  Romberg  symptom;  Ci)  Argyll  Robertson 
pupil;  (4)  Lightening  pains:  (5)  Loss  of  functions  of  the 
bladder  or  sexual  organs.  With  the  presence  of  any  three 
of  these  symptoms  the  diagnosis  may  be  made  with  cer- 
tainty. And  in  the  presence  of  any  two  with  probability, 
when  evidence  pointing  to  multiple  neuritis,  paretic  de- 
mentia or  cerebrospinal  syphilis  is  absent.  Among  the 
important  secondary  symptoms  or  signs  are,  (a)  pares- 
thesia, anesthesia  or  analgesia  of  the  legs,  (b)  Ixicomo- 
tor  ataxia,  (c)  Transient  ocular  palsies,  (d)  Paresthesia 
in  the  ulnar  distribution,  and  (e)  Optic  atrophy.  With 
the  presence  of  two  of  the  cardinal  signs  and  one  of  the  sec- 
ondary signs,  Diller  believes  the  diagnosis  may  be  made 
with  certainty.  With  the  presence  of  two  of  the  secondary 
and  only  one  of  the  primary,  it  may  also  be  made,  and 
even  in  the  absence  of  all  of  the  cardinal  symptoms. 

[T.  L.  C] 

6. — John  A.  Hawkins,  after  iliscussing  the  various  opera- 
tions for  the  relief  of  hemorrhoids,  describes  a  method  and 
an  instrument  of  his  own  which  he  has  employed  with 
great  satisfaction.  The  instrument  is  a  long,  thin-bladed, 
tongue-and-grooved  forceps.  The  hemorrhoid  is  grasped 
with  this  instrument  and  then  cut  off  close  to  Its  blades. 
A  suture  of  catgut  is  then  started  at  the  upper  part  of  the 
base  of  the  pile  and  carried  as  a  w-hipstitch  over  the  instru- 
ment until  the  lower  portion  of  the  pedicle  is  reached. 
The  forceps  is  removed  and  the  suture  tightened.  The 
author  says  that  he  has  never  had  any  hemorrhage  or 
complication  to  follow  this  method  of  operation. 

[J.  H.  G.] 


ANALES   DE  GYNECOLOGIE   ET  D'OBSTETRIQUE. 

■Junmiiij,  li)i)l. 

1.  Omphalotripsy  tumbilical  infections).     PORAK. 

2.  Cephalhematoma.     QUEIREL. 

3.  Report   on   the   Relationship   between   the   Mental   De- 

velopment and  the  Functional  Development  in 
Young  American  Girls.  Analysis  of  12,00u  Cases  of 
First  Menstruation.  A  Preliminary  Study.  G.  J. 
ENGLEMANN. 

4.  Rachidian  Anesthesia  by  Cocain  applied  to  Labor.     J. 

DUPAIGNE. 

5.  Blood-Infections  in  Nursing  Infants.     M.  DELESTRE. 

1. — Porak  remarks  that  umbilical  infection  holds  a  much 
a  much  more  considerable  space  in  the  pathology  of  the 
new-born  than  is  usually  accorded.  Durante,  who  has  made 
some  researches  on  the  subject,  has  concluded  that  umbili- 
cal infection  is  of  frequent  occurrence  and  considerable 
gravity.  Rigorous  antisepsis  comprising  dressings  placed 
over  the  umbilical  region  require  considerable  time  from 
the  accouchur,  while  omphalotripsy,  which  is  quicker,  gives 
excellent  results.  Porak  gives  a  comprehensive  review  of 
the  anatomy  of  the  umbilical  region,  and  especially  of  the 
umbilical  ring.  He  remarks  that  the  skin  terminates 
abruptly  by  a  border  sometimes  parallel  to  the  plane  of  the 
abdominal  wall,  but  ordinarily  obliquely.  The  umbilical 
ring  is  composed  of  the  elements  of  the  cord  which  are 
prolonged  into  it,  namely,  the  mucous  tissue  of  the  cord, 
arteries  and  veins.  The  region  is  very  rich  in  blood-vessels 
and  in  lymphatic  vessels.  The  former  are  especially 
abundant  in  the  skin  level  on  the  margin  of  which  they 
form  a  plexus.  Very  frequently  after  ligation  of  the  cord, 
owing  to  the  slow  separation  that  follows,  septic  changes 
will  occur.  Fungosities,  omphalitis,  and  abnormal  cicatri- 
zation constitute  some  very  frequent  complications  arising 
during  this  process  of  separation,  Porak  claims  that 
separation  of  the  cord  occurs  much  sooner  after  ompholo- 
tripsy  than  after  ligation,  and  that  this  process  will  be 
influenced  by  the  different  forms  of  dressing.  He  gives 
tables  showing  the  frequency  of  complications  following 


Io88       The  Philadelphia"] 
Medical,   Journal  J 


THE  LATEST  LITERATURE 


[June  8,  1901 


the  two  methods  of  treating  the  stump:  by  omphalotripsy 
and  by  ligation,  and  concludes  that  the  former  gives  better 
results.     [W.  A.  N.  D.] 

2. — Queirel  gives  an  interesting  article  on  cephalohema- 
toma,  which  he  mentions  as  one  of  the  risks  through  which 
the  child  must  pass  during  labor.  Usually  the  tumor  is  sin- 
gle, but  e.\ceptionally  it  may  be  double,  appearing  at  two 
symmetrical  points  on  the  parietal  bones.  It  is  difficult  to 
give  the  precise  proportion  of  frequency  of  this  complica- 
tion. The  tumor  consists  of  an  infusion  of  blood  between 
the  periostium  and  bone,  forming  either  two  projections 
over  the  parietal  bosses,  or  more  commonly  a  single  pro 
jection  upon  one  side.  It  is  important  to  distinguish  this 
condition  from  a  sero-sanguinolent  effusion  which  is  much 
more  common,  and  which  is  present  at  birth.  This  tumor 
is  soft,  but  less  fluctuating,  and  can  be  indented  by  the 
finger  as  in  edema.  It  appears  on  the  presenting  portion 
of  the  fetus,  therefore  is  formed  before  its  expulsion  and 
disappears  shortly  after  birth — wtihin  one  or  two  days.  It 
never  limits  itself,  as  does  the  cephalohematoma,  to  the 
border  of  the  bones.  The  characteristics  of  the  cerosan- 
guinolent  tumors  are  exactly  opposite  to  those  of  cephalo- 
mematoma.  It  is  due  to  a  circular  compression  at  the 
base  of  the  part  which  corresponds  to  the  ring  of  the  pelvis 
during  engagement,  and  always  appears  before  the  present- 
ing part.  As  to  the  prognosis  of  cephalohematoma,  it  is 
always  favorable.  The  tumor  usually  disappears  spon- 
taneously from  two  to  six  months,  or  it  may  be  a  year  after 
birth.  At  times  its  disappearance  is  much  more  abrupt, 
but  as  a  rule  the  progress  toward  cure  is  slow,  because 
the  vitality  of  the  part  has  been  weakened  and  blood  is  not 
absorbed  as  quickly  as  a  simple  serous  effusion.  [W.  A. 
N.  D.] 

3. — Engelmann  has  made  an  analysis  of  12,000  cases 
of  the  first  menstruation  in  young  American  girls  covering 
a  period  of  several  years.  He  has  given  especial  attention 
to  the  mental  development  of  these  girls,  a  factor  which  he 
claims  has  been  largely  neglected,  and  which  he  believes 
exercises  a  marked  influence  upon  the  functional  develop- 
ment of  the  girls.  The  intimate  relationship  existing  be- 
tween the  nervous  system  and  the  reproductive  organs  is 
oneofche  characteristics  of  the  feminine  organism  and  their 
reciprocal  influence  is  profound.  Of  the  12,000  cases  examined 
Kngelmann  has  collected  himself  6549.  He  has  found  that 
the  mental  development  as  a  primitive  factor  determines 
precocity  or  retards  the  establishment  of  the  menstruation. 
Race  and  heredity  exercise  but  slight  influence  upon  the 
function.  He  has  also  noted  that  in  all  its  existence  the 
development  of  puberty  is  a  little,  but  very  little,  earlier 
in  the  country  girl  than  in  the  working  girl  in  town,  no 
doubt  because  of  the  insufficient  nourishment  and  the 
poor  air  which  the  laboring  classes  of  large  cities  suffer 
from.  Of  all  the  influences,  therefore,  acting  upon  the 
development  of  puberty,  the  most  important  is  the  nervous: 
the  mental  state,  the  mental  development,  mental  activity, 
and  the  nervous  stimulus  are  especially  active  in  influenc- 
ing this  function.     [W.  A.  N.  D.] 

4. — Dupaigne  practiced  for  a  month  in  1900  the  applica- 
tion of  rachidian  anesthesia  by  cocaine  in  labor,  acting 
under  the  suggestion  of  Tuffier.  He  claims  that  he  has 
verified  its  possibility  and  innocuousness.  Two  conditions 
are  indispensible  for  obtaining  these  results,  namely,  the 
independence  of  the  uterine  contraction  and  the  extension 
01  the  anesthesia  to  the  pains  corresponding  to  tltis 
contraction.  He  claims  that  rachidian  anesthesia,  while 
altering  in  a  certain  proportion  vohmtary  contraction  of 
muscles,  still  more  so  affects  the  uterine  contractions.  The 
independence  of  the  nervous  ganglions  renders  this  result 
possible.  He  also  remarks  that  the  anesthesia  is  complete 
for  every  form  of  labor  pains,  namely,  the  pains  of  uterine 
contraction  and  of  dilatation  of  the  neck,  the  lumbar  radi 
ations,  pelvic  and  perineal  compression,  vulvular  disten- 
sion, tears,  muscular  cramps  of  the  lower  extremities, 
manual  expression,  touch,  irrigations,  sutures,  when  these 
are  necessary,  and  that  it  even  extends  to  all  obstetrical 
operations.  In  a  word,  he  claims  that  labor  may  be  ideal 
for  the  woman.  He  also  believes  that  the  method  is  per 
fectly  safe  under  all  circumstances.     [W.  A.  N.  D.] 

5. — During  his  service  in  Hutinal's  wards  in  the  Hospital 
for  Children.  Delestre  has  examined  into  the  frequency  of 
blood  infections  in  children  in  general,  particularly  in  those 
who  are  nursing,  and  principally  in  children  born  before 
term,  to  the  latter  of  which  he  has  especially  devoted 
himself.     His  method  of  making  examinations  was  as  fol- 


lows: When  a  child  appeared  sufficiently  ill  for  it  to  seem 
tbat  death  would  follow  in  a  few  days,  or  even  a  few 
liours,  he  drew  from  its  veins  2  c.cm.  of  blood,  which  he 
submitted  to  examination.  Special  care  was  taken  to  dis- 
infect the  hands  in  doing  this,  and  also  the  flap  of  the  ear 
from  which  the  blood  was  drawn.  The  parts  were 
washed  with  alcohol  and  ether  and  a  small  incision  made 
with  an  asceptic  bistoury.  This  was  repeated  on 
successive  days,  and  when  the  child  died  a  certain  quantity 
of  blood  was  removed  from  the  heart  and  cultures  in  gela- 
tine and  bouillon  made.  He  does  not  believe  that  it  is 
impossible  to  absolutely  disinfect  the  skin,  especially  In 
these  children,  as  has  been  claimed  by  some.  The  only 
precaution  is  to  use  an  aseptic  Brevaz  syringe  in  withdraw- 
ing the  blood.  In  40  children  of  from  a  few  days  to  4  years 
of  age  believed  to  be  infected,  and  from  whom  a  bacterio- 
logical examination  of  the  blood  was  made,  32  died  and  8 
recovered.  Of  the  eight  who  recovered  seven  gave  negative 
results;  the  other  showed  in  three  succssive  examinations 
the  bacillus  of  Pfeiffer.  Of  the  32  children  who  died,  ten 
gave  negative  results  and  22  positive  results.  Of  the 
latter  there  were  five  in  whom  the  blood  had  been  examined 
cmly  during  life,  but  upon  whom  no  autopsy  had  been  prac- 
ticed; nine  in  whom  the  blood  had  been  examined  during 
life  and  after  death;  and  eight  in  whom  the  blood  had  been 
examined  only  immediately  after  death.  The  microorgan- 
isms dicsovered  were  in  their  order  of  frequency,  the 
streptococcus  eight  times,  the  staphylococcus  five  times, 
the  colon  bacillus  five  times,  the  pneumoccus  once.the  bacil- 
lus of  Pfeiffer  once,  the  colon  bacillus  and  Pfeiffer's  bacillus 
once,  and  uncertain  cocco-baccilli  once.  Of  the  19  cases 
which  died  early  15  had  microbes  in  the  blood  and  four  had 
none,  which  gives  a  percentage  of  73-510%.  Of  the  15 
cases  the  streptococcus  was  found  six  times  and  the  coli- 
bacillus five  times,  staphylococcus  once,  pneumococcus 
once,  Pfeiffer's  bacillus  once  and  the  colon-bacillus  and 
Pfeiffer's  bacillus  once.  It  would  appear,  therefore, 
that  premature  children  are  especially  subject  to  the  action 
of  the  streptoccus  and  of  the  bacterium  coll.  and  less  to 
the  action  of  the  staphylococcus,  while  the  susceptibility 
to  the  latter  microbe  becomes  greater  in  nursing  babies  of 
some  months.     [W.  A.  N.  D.] 

Felriiarti,  1901. 

1.  Longitudinal  Cuneiform  Hysterectomy  in  the  Treatment 

of  Uterine  Lesions  Occuring  in  Cases  of  Deviation. 
DR.  MAUCLAIRE. 

2.  Rupture   of   Tubal    Pregnancy    at    the    Second    Month. 

Hasty  Laparotomy  During  Peritoneal  Irrigation.    An- 
atomic Examination  of  the  Left  Tube.    M.  G.  FIEUX 

3.  Uterine   Pregnancy   Taken   for   an   Exerauterine   Preg- 

nancy Because  of  Fixation  of  the  Gravid  Uterus  in 
Left  Lateroversion.    PAUL  SECOND. 

4.  Pregnant  Uterus  in  Lateroversion  Taken  for  Ovarian 

Cyst.     M.  H.  V.\RNIER. 

5.  Right    Lateroflexion    Mistaken    for   Extrauterine   Preg- 

nancy.    M.  A.  ROUTIER. 

6.  Vagino-fixation.     SABINO  COELHO. 

7.  Recurrence  of  Ectopic  Pregnancy.     M.  CHAPOT-PRE- 

VOST. 
S,     Primary  Tuberculosis  of  the  Vagina  and  a  Case  Cured 
by  Surgical  Treatment.     M.  JORFID.-i. 

1. — Mauclaire  remarks  that  several  principal  factors  must 
lie  taken  Into  consideration  in  order  to  explain  uterine 
deviations.  These  are:  (1)  Ptosis  generalized  to  all  the 
abdominal  viscera  or  localized  to  the  ligaments  and  organs 
which  maintain  the  fixity  of  the  uterus.  (2)  Inflammatory 
lesions,  congestive  or  infectious,  of  the  uterine  cavity,  and 
very  many  deviations  are  without  doubt  the  result  of  uter- 
ine infections;  (3)  Anatomic  lesions  of  the  deviated  uteri, 
which  are  consecutive  to  ligamentous  relaxation:  to  these 
may  be  added  vasculonervous  lesions  which  may  be  pri- 
mary; and  congenital  deviations  in  a  certain  number  of 
cases.  Anteflexlons  of  the  uterus  are  of  several  varieties. 
Thus,  there  is  an  anteflexion  of  the  body  in  which  the  axis 
of  the  neck  is  normal  but  the  body  is  inclined  anteriorly: 
anteflexion  of  the  neck  in  which  the  body  is  normal  but  the 
neck  is  carried  anteriorly:  and  anteflexion  of  the  neck  and 
of  the  body,  the  two  segments  of  the  uterus  making  a  very 
acute  opening  anteriorly.  The  angle  of  flexion  may.  there- 
fore, be  made  either  opening  by  the  body  or  by  the  neck 
or  at  the  level  of  the  isthmus,  and  this  angle  may  be  ob- 
tuse, right,  or  acute.    The  anteflexion  may  be  combined  with 


JUNE    S.    19011 


THE  LATEST  LITERATURE 


TThe  Philadelphia        rnSr* 
L Medical  Journal  i^oy 


an  anteversion,  a  retroversion,  a  latero-version,  a  latero- 
position  or  a  latero-flexion.  A  number  of  operations  have 
been  suggested  for  tlie  cure  of  anteflexion.  Some  correct 
the  cervical  stenosis  with  or  without  a  shortening  of  the 
neclv.  These  are:  crucial  incision  of  the  external  orifice 
(Galllard  Thomas) :  bi-lateral  discission  of  the  cervical 
canal  (Simpson) ;  antero-posterior  discission  of  the  neck 
(Sims) :  conical  excision  of  the  posterior  lip  (Kiister) ;  com- 
missural excision  of  the  neck  (Pozzi) ;  and  cervical  ampu- 
tation (Schroder).     [W.  A.  N.  D.] 

2. — Fieux  gives  a  scientific  study  of  a  ruptured  tubal 
pregnancy  at  the  second  month  in  which  an  urgent  laparo 
tomy  was  performed.  He  has  made  a  careful  anatomical 
examination  of  the  ruptured  tube,  which  was  on  the  right 
side.  Examination  showed  to  the  right  of  the  uterus  a 
hard  tumor  adherent  to  the  lateral  cul-de-sac.  which  it  had 
partly  effaced,  and  extended  thence  to  the  anterior  cul-de- 
sac.  During  the  process  of  laparotbmy  peritoneal  irrigation 
was  maintained.  He  insists  in  such  cases  upon  urgent  inter- 
vention as  soon  after  the  diagnosis  is  made  as  is  possible.  His 
examination  of  the  specimen  was  made  both  macroscopicaUy 
and  microscopically,  and  full  notes  are  given.  The  speci- 
men was  found  to  be  77  days  old.  The  rupture  occurred  on 
the  posterior  aspect  of  the  ampuUary  region  of  the  tube. 

[W.  A.  N.  D.] 

3. — Segond  reports  a  case  of  uterine  pregnancy  which 
was  mistaken  for  an  extrauterine  pregnancy  because  of  a 
fixation  of  the  uterus  in  the  position  of  left  latero-version. 
The  operation  was  performed,  the  true  condition  discovered, 
the  uterus  freed  from  its  abnormal  condition  and  replaced, 
and  the  patient  entered  a  normal  convalescence.  The  preg- 
nancy continued  without  interruption  but  was  ultimately 
discotinued  by  surgical  interference,  following  an  attempt- 
ed abortion  seven  weeks  after  the  operation.     [W.  A.  N.  D.") 

4. — Varnier  reports  a  case  of  pregnant  uterus  resting  in 
the  position  of  lateroflexion,  which  was  mistaken  for  an 
ovarian  cyst.  Notwithstanding  laparotomy  the  pregnancy 
continued  to  term  and  the  patient  was  delivered  of  a  living 
child  weighing  3,500  grams.  He  remarks  that  lateroflexion 
of  the  pregnant  uterus  may  be  confounded  v.-ith  ectopic 
pregnancy,  ovarian  cyst,  or  salpingitis.  He  agrees  with 
Mauriceau  in  the  importance  of  making  the  diagnosis  as 
early  as  possible  in  order  that  the  displacement  may  be  cor- 
rected. As  to  treatment  the  expectant  plan  may  be  adopted 
or,  if  the  flexion  is  so  strong  and  irreducable  as  to  be  in- 
compatible with  the  normal  evolution  of  the  pregnancy,  an 
exploratory  incision  should  be  performed  and  the  uterus 
freed.     [W.  A.  N.  D.] 

5. — Routier  records  a  case  of  right-sided  lateroflexion  of 
the  pregnant  uterus  which  was  mistaken  for  an  extrauter- 
ine pregnancy.  Laparotomy  was  performed,  the  uterus  was 
replaced  but  abortion  followed.  The  patient  made  an  unin- 
terrupted recovery  otherwise.     [W.  A.  N.  D.] 

6. — Coelho  in  1S96  presented  to  the  Congress  at  Geneva 
the  results  of  15  vagino-fixations  which  he  had  made  up  to 
that  time  while  performing  45  anterior  colpotomies.  Up 
to  the  present  time  he  has  performed  9S  anterior  colpoto- 
mies and  43  vagino-flxations  with  hut  a  single  fatal  case. 
The  simple  vaginal  fixations  without  treatment  of  other 
lesions  have  numbered  11.  From  1S95  he  had  attached  the 
uterus  to  the  vagina  at  3  points,  but  since  1898  he  has  fol- 
lowed the  method  perfected  by  Diihrssen.  He  makes  now 
a  single  fixation,  the  thread  passing  through  the  uterine 
wall  at  the  level  of  the  insertion  of  the  tubes  and  traversing 
the  upper  extremity  of  the  vaginal  incision  and  the  peri 
toneal  origin  of  the  vesicouterine  fold.  By  this  arrange- 
ment he  claims  that  diflScuIties  during  parturition  are  pre- 
vented and  the  cure  of  the  retrodisplacement  is  accom- 
plished without  danger  of  reproduction  following  subse- 
quent labor.  He  makes  the  vaginofixation  immediately  af- 
ter opening  the  peritoneum  or  after  treating  the  existing 
lesions,  according  as  t%  whether  the  retrodeviation  is  sim- 
ple or  complicated.     [W.  A.  N.  D.] 

7. — Chapet-Prevost  records  a  case  of  recurrent  extrauter- 
ine pregnancy  in  a  woman,  30  years  of  age.  The  patient 
first  menstruated  at  IS  years  of  age  and  always  suffered 
with  anti-dysmenorrhea.  She  was  married  when  28  years 
old  and  aborted  a  month  and  a  half  later  without  apprecia- 
ble cause.  Two  months  and  a  half  later  she  had  another 
abortion.  Her  menses  returning  25  days  after  the  second 
abortion  she  placed  herself  under  the  care  of  a  specialist. 


fearing  a  third  pregnancy  which  might  result  as  had  the 
other  two.  The  menstruation  which  usually  lasted  7  or  S 
days,  did  not  return  in  July  1894.  Another  pregnancy  soon 
followed  and  in  October  she  experienced  the  first  fetal 
movements,  which  continued  until  March  13,  1895.  They 
then  ceased  and  severe  pains  commenced,  simulating  labor 
pains.  The  physician  who  was  called  in  2  days  after  the 
first  pains,  declared  there  was  no  reason  why  he  should  con- 
tinue his  services.  These  pains  continued  at  intervals  for 
a  month.  Another  physician  was  then  called  in  and  on 
examination  discovered  a  mass  which  was  diagnosed  as  a 
uterine  fibroma.  Chapot-Prevost  saw  her  on  the  12th  of 
.\ugust,  at  which  time  the  abdominal  extension  was  about 
that  of  7  months  of  pregnancy.  However,  the  uterine  sound 
mersured  scarcely  7Vi  cm.  He  made  the  diagnosis  of  ec- 
topic pregnancy  and  performed  the  operation  on  the  18th 
of  August.  After  the  primary  incision  in  the  median  line 
of  the  abdominal  wall  a  tumor  was  discovered  which  was 
inclined  a  little  to  the  right.  This  contained  a  fetus  which 
was  extracted.  The  placenta  was  emplanted  upon  a  large 
part  of  the  anterior  face  of  the  uterus,  upon  a  portion  of 
the  bladder,  and,  extending  to  the  left  of  these  two  organs, 
was  attached  to  the  posterior  aspect  of  the  abdominal  wall.  It 
was  removed  and  the  patient  made  a  normal  recovery.  On. 
October  9th,  1896,  one  year  and  one  month  after  this  opera- 
tion, the  patient  returned,  believin.g  herself  again  preg- 
nant. Examination  showed  under  the  abdominal  wall  a 
fetus  corresponding  to  a  pregnancy  of  five  months,  move- 
ments of  which  could  be  readily  detected  under  the  skin. 
In  the  seventh  month  of  this  pregnancy  severe  pains  came 
on  associated  with  uterine  hemorrhage.  Fetal  movements 
stopped  and  one  month  later  a  second  laporotomy  was  per- 
formed. A  male  fetus  was  removed  from  a  cyst  implanted 
upon  the  opposite  side  of  the  abdominal  cavity  and  upon 
the  aspect  of  the  right  ovary  and  tubal,  the  ileocecal  appen- 
dix, upon  a  portion  of  the  cecum  and  the  large  intestine 
and  upon  the  posterior  face  of  the  anterior  wall  of  the  uter- 
us. This  was  removed  and  the  patient  made  a  good  re- 
covery.    [W.  A.  N.  D.] 

8. — Jorfida  reports  a  case  of  primary  tuberculosis  of  the 
vagina  in  a  young  married  woman,  23  years  of  age,  who  ap- 
parently gave  no  hereditary  history  of  tuberculosis.  Be- 
yond the  ordinary  exanthemata  of  childhood  she  had  had  no 
disease.  Her  menstruation  had  been  regular  in  its  appear- 
ance and  duration.  She  had  been  married  a  year  and  a 
lialf  and  had  given  birth  to  one  child  at  term,  which  had  a 
weight  a  little  above  the  average  after  a  spontaneous  la- 
bor. There  had.  however,  been  a  tear  in  the  posterior  com- 
missure. During  the  two  months  following  labor  she  had 
not  suffered  from  any  inconvenience.  After  this,  however. 
f;he  commenced  to  notice  a  sensation  of  burning  in  the  ex- 
ternal genitalia  which  became  more  severe  and  even  painful 
at  the  menstrual  epochs.  She  also  noticed  a  greenish  dis- 
charge, slight  at  first  but  becoming  more  and  more  abundant. 
Notwithstanding  this  condition  she  did  not  at  once  apply  for 
treatment.  Twenty  days  before  she  presented  herself  she 
noticed  evening  elevations  of  temperature  preceded  by  chills 
and  at  the  same  time  she  discovered  a  tumefacton  in  tho 
left  inguino-crural  region,  which  suddenly  increased  in 
volume.  Ten  days  after  this  appeared,  a  similar  tumor 
formed  in  the  right  inguino-crural  region.  This  was  fol- 
lowed by  an  increase  in  size  of  the  labia,  particularly  of  the 
right  labium  major.  Examination  showed  an  edema  of 
the  parts  which  pitted  on  pressure  and  were  covered  with 
an  abundant  greenish  secretion.  Numerous  ulcerations 
covered  the  vulva  and  the  vagina,  these  being  more  marked 
and  more  extensive  at  the  posterior  commisure  and  in  the 
anterior  portion  of  the  vagina.  At  the  vulvar  commissure 
there  existed  a  solution  of  continuity  the  size  of  a  two- 
centime  piece  elongated  in  its  transverse  diameter  am} 
with  irregular  and  broken  borders.  The  other  ulcers  were 
smaller  and  mainly  on  the  posterior  vaginal  wall.  The  va- 
ginal culs-de-sac  were  free  from  the  ulcerated  process,  as 
was  also  the  cervix  uteri  which  was  somewhat  hypertro- 
phied  and  reddened.  TTnder  appropriate  treatment,  consist- 
ing of  free  vagina!  irrigations  with  a  salycilated  solution 
and  bichlorid  of  mercury,  no  improvement  was  noted.  The 
tumefactions  were  then  extirpated  and  the  crural  hernia 
closed  by  Tricomi's  method:  with  the  exception  of  a 
fistulous  tract  in  the  left  side,  which  persisted  for  more  than 
a  month,  the  parts  rapidly  healed.  The  vaginal  ulcerations 
were  cauterized  with  iodine  and  silver  nitrate,  and  a  tam- 
pon of  iodoform  gauze  was  introduced.  The  patient  made 
■\  complete  recovery,     [W.  A.  N.  D.] 


1 090 


The  Philadelphia"! 
Medical   Journal  J 


THE  LATEST  LITERATURE 


[Jc-KE  8,  1901 


MUENCHENER  MEDICINISCHE  WOCHENSCHRIFT. 

March    Mill.    1901. 

1.  The  Etiology  and  Experimental  Production  of  Cirrhosis 

of  the  Liver.     MARCKWALD. 

2.  A  case  of  Mixed  Cirrhosis  of  the  Liver  Wtih  an  Acute 

Course.     ULLMAN. 

3.  Plasmon-Tropon.     HESS. 

4.  The    Influence    of    Coal    Upon   the    Tubercle    Bacillus. 

PAPASOTIRIU. 

5.  The  Equilibrium  and  Hearing  Organs  of  the  Japanese 

Dancing  Mouse.     PANSE. 
€.     A  Foreign  Body  in  the  Lung.    SPIBSS. 
7.     A  Rare  Case  of  Foreign  Body  in  the  Bronchial  Tubes. 

DIEHL. 
S.     The   Natural    Immunization   of   Tuberculous   Families. 

REIBMAYR. 
9.     Report   of   the    Medical    Polyclinic    in    Munich   in   the 

Year    1900.      MORITZ. 

1- — Marckwald  has  performed  a  number  of  experiments 
upon  frogs  in  order  to  determine  to  what  extent  the  de- 
generation of  the  parenchymatous  cells  of  the  liver  tends 
to  produce  the  cirrhotic  condition.  It  was  found  that  anti- 
pyrin  injected  hypodermatically  into  the  animals  produced 
a  degeneration  of  the  liver  cells  that  was  more  or  less 
rapid  according  to  the  dose  and  the  size  of  the  animal 
If  very  small  doses  were  employed  the  degeneration  was 
exceedingly  gradual.  In  the  first  series  of  frogs  this  de- 
generation took  place  without  any  increase  in  the  connect- 
ive tissue,  a  fact  that  the  author  explains  by  supposing 
that  the  poor  condition  of  the  frog's  nutrition  resulting 
from  their  refusal  of  all  food  in  captivity,  prevented  the 
proliferation  of  the  tissue.  He  therefore  fed  artiflcially  a 
number  of  frogs  and  subjected  them  to  the  same  treatment. 
He  found  that  the  connective  tissue  showed  marked  hyper- 
plasia. He  therefore  regards  the  cirrhotic  change  as  con- 
servative and  not  destructive.     [J.  S.] 

2.. — Ullman  reports  a  case  of  a  man  53  years 
of  age,  who  had  taken  from  1.5  to  2  liters 
of  "ScJmaps"  daily  for  many  years.  He  appeared 
to  be  perfectly  healthy  until  he  was  suddenly  at- 
tacked by  a  causeless  vomiting  and  diarrhea,  loss  of  appe- 
tite, and  chilly  sensations.  There  was  then  a  moderate 
icterus,  and  the  development  of  ascites  and  epistaxis,  but 
throughout  the  case  there  was  no  fever.  A  puncture  of  the 
abdominal  wall  withdrew  2,500  ccm.  of  yellow  fluid  with  a 
specific  weight  of  1009.  The  patient  died  and  at  the 
autopsy,  in  addition  to  myocarditis,  enlargement  of  the 
spleen,  intense  congestion  of  the  kidneys,  there  was  great 
enlargement  of  the  liver,  which  was  granular  and  hard. 
Microscopically  it  was  found  that  the  connective  tissue  was 
very  irregularly  hyperplastic,  and  that  there  was  even 
some  proliferation  of  the  hepatic  cells.  The  case  is  re- 
markable on  account  of  its  rapid  course.  The  etiology 
is  very  obscure,  that  is  to  say,  the  alsohol  probably  acted 
largely  as  a  predisposing  factor.     [J.  S.] 

3. — Hess  has  periormed  a  number  of  experiments  with 
plasmon  and  tropon  in  order  to  determine  whether  extir- 
pation of  the  pancreas  was  more  severe  than  simple  trans- 
plantation. It  was  found  that  total  extirpation  caused  a 
lass  of  56.8%  of  the  nutritional  material,  whereas  in  ex- 
tirpation with  transplantation,  although  under  those  cir- 
cumstances the  pancreas  no  longer  connected  with  the 
intestines,  the  loss  was  only  53.3%.  A  few  other  experi- 
ments gave  similar  results.     fJ-  S.] 

4. — Papasotiriu  has  performed  a  number  of  experiments 
in  order  to  determine  whether  charcoal  has  any  inhibitory 
action  upon  the  growth  of  the  tubercle  bacillus,  or  the 
pseudo-tubercle  bacillus,  the  so-called  mykobacterium  lac- 
ticola.  In  the  first  experiments  with  the  latter  micro- 
organism it  was  found  that  a  proportion  of  more  than  10% 
of  charcoal  had  a  slight  inhibitory  action  upon  the  growth 
of  the  germ.  As,  however,  subsequent  experiments  showed 
that  no  inhibitory  action  occurred  either  toward  this  germ 
or  toward  the  tubercle  bacillus  the  author  concludes  that 
carbon  is  not  an  antiseptic.     [J.  S.] 

5. — Pause  has  made  a  careful  study  of  the  hearing  organ 
of  the  dancing  mouse  of  Japan  in  order  to  determine 
whether  it  or  the  semi-circular  canals  exhibit  any  diver- 
sion from  the  usual  type,  that  would  serve  to  explain  the 
absence  of  vertigo  upon  rotation.  He  found  that  there 
was  absolutely  no  morphological  peculiarity  whatever. 
The  hearing  organ  of  this  mouse  resembles  in  all  respects 
that  of  the  ordinary  house  mouse.    However,  he  did  find 


a  small  accumulation  of  calcium  crystals  in  the  membrane 
of  the  oval  window,  but  as  this  also  appeared  in  the  ear 
fif  the  mouse  produced  by  crossing  a  common  mouse 
v.ith  a  dancing  mouse,  he  concluded  that,  as  this  off-spring 
did  not  rotate,  the  crystals  were  not  of  any  signifi- 
cance.    [J.  S.l 

6. — Spiess  reports  the  case  of  a  boy  17  years  of  age  who 
swallowed  a  bone  button.  Aside  from  a  slight  diminution 
of  the  respiratory  soimds  this  produced  no  alteration  for 
five  years.  Then  the  patient  suffered  from  dyspnea,  pain 
in  the  left  side,  and  cough  with  expectoration.  As  it  ap- 
peared that  the  foreign  body,  which  still  remained  in  the 
iung,  had  produced  a  severe  infiammation,  an  effort  was 
made  to  remove  it  through  a  tracheotomy  wound.  The  po- 
sition of  the  button  was  first  determined  by  a  Roentgen 
ray  picture  and  then  the  bronchioscope  employed.  Through 
this  it  was  possible  to  see  a  small  opening  in  the  main 
bronchus  that  was  almost  completely  filled  with  a  muco- 
purulent fluid  that  was  not  expelled  by  coughing 
The  sound  in  passing  throng  this  opening  came 
in  contact  with  a  hard  body.  It  being  impossi- 
ble to  withdraw  the  body  with  forceps,  other 
meanr  were  tried — passing  a  thread  around  it,  or  catching 
it  upon  a  blunt  hook.  All  these  failed  and  the  patient 
finally  died  of  pulmonary  tuberculosis  6%  years  after  in- 
spiring the  button.  At  the  autopsy  the  button  was  found 
lying  in  a  small  cavity  just  inside  the  main  bronchus, 
entirely  non-adherent.  No  adhesions  were  found  between 
the  lung  and  the  parietal  pleura,  and  therefore  an  external 
operation  would  have  been  a  failure.  Spiess  calls  atten- 
tion to  the  extreme  ease  with  which  the  bronchiascope 
can  be  employed  if  a  drop  of  a  10%  solution  of  cocaine  is 
allowed  from  time  to  time  to  trickle  down  the  mucous 
membrane  of  the  trachea.     [J.  S.] 

7.- — Diehl  reports  the  case  of  a  woman,  who,  as  a  result 
of  an  attempt  at  suicide,  had  so  injured  the  trachea  and 
larynx  that  it  was  necessary  to  employ  a  permanent 
tracheotomy  tube.  This  was  broken,  and  the  patient  was 
given  another,  which,  however,  was  slightly  too  long,  and 
therefore  uncomfortable.  Accordingly,  when  alone  she  re- 
inserted the  old  tube,  which  slipped  into  the  trachea  and 
was  pushed  further  down  by  the  insertion  of  the  new  tube 
to  relievo  the  dyspnea.  It  being  impossible  to  remove 
the  foreign  body  without  operation,  the  patient  was  pre- 
pared for  another  tracheotomy,  but  fortunately  she  expelled 
the  tube  during  a  violent  fit  of  coughing  before  this  was 
performed.     [J.  S.] 

8. — Reibmayr  believes  that  the  human  race  gradually 
acquires  a  greater  or  less  degree  of  immunity  against  all 
infectious  diseases,  that  consists  in  a  certain  constitutional 
alteration.  He  has  endeavored  for  some  years  to  discover 
what  are  the  symptoms  of  this  condition  in  the  human 
race,  and  has  finally  reached  the  conclusion  that  a  careful 
study  of  the  genealogy  in  each  individual  leads  to  the  most  . 
accurate  results.  In  the  treatment  or  prevention  of  tuber- 
culosis the  most  important  factor  is  the  preservation  of 
this  Immunity.     [J.  S.] 


Obliteration  of  the  Portal  Vein.— Eugene  Frailer.  (Gas. 
Hcb.  lie  ilcd.  ct  dc  Cliinir.  April  7,  litOl,  4S  me.  Ann§e, 
No.  28.)  (Nancy  Thesis,  1899-1900.  No.  9).  Frailer  has 
studied  2  cases  of  obliteration  of  the  portal  vein.  This  con- 
dition may  be  produced  by  compression  by  tumors  of  all 
Kinds  and  by  thrombosis  due  to  micro-organismal  infection 
or  to  the  extension  of  a  carcinoma.  It  is  favored  by  alco- 
holism, syphilis  and  all  the  diseases  that  may  cause  arterio- 
sclerosis. As  a  consequence  of  this  condition  of  the  portal 
\  ein,  anemia  may  be  produced  in  the  territory  supplied  by 
these  veins  in  the  liver,  which  may  be  followed  by  the 
disappearance  of  the  liver  cells  and  the  production  of  peri- 
portal sclerosis.  Congestions  may  also  be  produced  in  the 
tributaries  of  the  portal  vein  with  transudation  and  hyper- 
trophy of  the  intestine  or  its  walls,  intestinal  gangrene, 
ulcer  of  the  stomach  or  duodenal  ulcer.  Obliteration  of  the 
portal  vein  is  manifested  by  symptoms  that  are  common  to 
other  affections,  but  which  are  characterized  by  the  rapid- 
ity of  their  appearance,  such  as  sharp  pains,  which  usually 
appear  about  3  weeks  before  death  in  the  right  hypochon- 
driac or  epigastris  regions,  voluminous  ascites,  increase  in 
the  size  of  the  spleen,  edema  of  the  lower  extremities, 
hematemesis.  diarrhea,  hemorrhoids,  melena,  decrease  in 
the  size  of  the  liver  and  jaundice.  Occurrence  of  hema- 
temesis may  be  explained  by  venous  stastis  or  by  pneumo- 
gastric   reflex.      [J.   M.   S.] 


June  s,  1901] 


HYPERTROPHY  OF  THE  PROSTATE 


r.it     IniUAl^EJ-PHIA 
L  MElJICAL     JoVRNAL 


109 1 


©riOinal  Hrtkice. 


WHAT  I  HAVE  LEARNED  FROM  ONE  HUNDRED  AND 
SIXTY-ONE  OPERATIONS  FOR  THE  RELIEF  OF 
SENILE  HYPERTROPHY  OF  THE  PROSTATE 
GLAND/:= 

By  ORVILLE  HORWITZ,   B.   S.,  M.   D., 

of  Philadelphia. 

Clinical  Professor  of  Genito-l'riuary  Diseases.  JcfTtrson  Medical  College; 

Siirgeou  to  the  Phi.auelphia  Hospital,  JtfT^rsoii  Medical  College 

Hospital  and  biate  Hospital  lor  the  Insane. 

If  the  Student  consults  the  standard  text-books 
with  a  view  to  being  enhghtened  as  to  the  most 
satisfactory  operation  to  be  employed  for  the  relief 
of  senile  hypertrophy  of  the  prostate  gland  he  will 
in  most  instances  be  doomed  to  disappointment. 
It  is  true,  that  many  different  operations  designed 
for  the  relief  of  this  condition  will  be  found  fully 
described,  with  a  statement  of  the  probable  mor- 
tality attending  each,  but  it  is  left  to  the  option  of 
the  investigator  to  select  the  operation,  which  in 
his  judgment  will  prove  most  efficacious.  Not  only 
do  the  books  throw  but  little  light  on  the  subject, 
but  the  investigator  finds  himself  in  doubt  as  to  the 
best  method  to  be  pursued  under  the  man\-  condi- 
tions that  present  themselves,  he  will  also  observe 
that  the  surgeons  themselves  differ  widely  as  to  the 
most  suitable  operation  to  be  performed ;  each 
having  its  advocates  as  well  as  its  detractors. 

Although  much  has  been  written  on  the  subject, 
giving  rise  to  a  vast  amount  of  discussion  regarding 
the  merits  of  the  various  operative  procedures  sug- 
gested, it  would  appear  that  the  truth  is  to  be 
found  in  the  fact  that  the  writers  themselves,  as  well 
as  the  profession  at  large,  have  been  unable  to  ar- 
rive at  any  definite  conclusion  regarding  the  valuij 
of  the  various  methods  suggested.  So  far,  there 
has  been  no  attempt  made  to  lay  down  any  rule 
which  will  serve  to  guide  the  surgeon  in  his  choice 
of  operations,  every  individual  seemingly  relying 
upon  his  personal  predilections. 

An  experience  derived  from  the  treatment  of 
one  hundred  and  sixty-one  operations  for  the  relief 
of  prostatic  hypertrophy  has  caused  me  to  reach 
definite  conclusions  as  to  the  relative  value  of  the 
various  methods  suggested,  and  the  difficulty  that 
one  may  be  expected  to  encounter,  the  mortality 
that  attends  each  procedure,  as  well  as  the  re- 
sults that  may  be  expected  to  be  reached  in  each 
case. 

The  various  operations  performed  are  classified  as 
follows : 

No.Operations.  No.Deaths. 
Vasectomy,  28  — 

Bilateral    castration.  31  2 

Supra-pubic    cystotomy:    bilateral  cas- 
tration two  weelis  later,  13  — 
Supra-pubic      cystotomy,      permanent 

drainage,  33  — 

Supra-pubic     cystotomy     with     vasec- 
tomy, 5  — 
Supra-puliic    prostatectomy    (prostate 

Eiland    removed    piece-meal).  2  — 

Supra-pubic     prostatectomy     (Fuller's 

method),  3  1 

Supra-pubic  cystotomy  combined  with 
perineal  section  (Bellfield's  method),       6  2 

•Read  before  the  American  Association  of  Genitourinary  Surgeons,  at 
Old  Point  Comfort  May  2,  igoi. 


Perineal    prostatectomy    (Alexander's 

method). 

4 

Perineal  prostatectomy   (Pyle's  meth- 

od), 

3 

Bottinis  method. 

Hi 

By  examining  the  foregoing  classification  it  will 
be  seen  that  of  one  hundred  and  sixty-one  patients 
upon  whom  operations  were  performed  eight  died 
In  two,  deaths  ensued  from  bilateral  castration,  one 
died  of  uremia,  and  one  from  exhaustion ;  of  the 
six  remaining  deaths,  two  followed  suprapubic,  and 
four  followed  perineal  prostatectomy.  Of  the  su- 
prapubic operations  one  died  from  suppression  of 
urine,  and  one  from  uremia.  Of  the  deaths  follow- 
ing perineal  prostatectomy  one  died  from  sepsis- 
and  one  from  uremia. 

As  a  rule,  the  aged  withstand  operative  proced- 
ure badly.  The  danger  appears  to  be  greatly  in- 
creased if  an  extensive  operation  involving  any 
portion  of  the  genito-urinary  apparatus  becomes 
necessary.  The  dread  of  the  operation  frequently 
leads  the  patient  to  defer  the  ordeal  until  the  symp- 
toms indicate  that  further  postponement  is  imprac- 
ticable; unfortunately  the  delay  is  often  due  to  the 
advice  of  the  attending  physician,  who  usually 
recommends  that  a  course  of  palliative  treatment  be 
pursued  as  long  as  possible.  Thus  valuable  time  is 
lost,  so  that  it  is  not  unusual  for  the  patient  to  be 
seen  by  the  surgeon  for  the  first  time,  when  he  is 
already  debilitated  and  broken  down,  with  poor 
digestion,  diseased  kidneys,  chronically  inflamed 
bladder,  weak  heart  and  suft'ering  from  pain  and  loss 
of  sleep.  Such  an  individual  is  hardly  in  a  fit  con- 
dition for  even  palliative  treatment,  still  less  for  the 
radical  operation,  necessary  for  permanent  relief. 

Unfortunately  it  is  just  this  class  of  cases  that 
appeal  most  strongly  to  the  surgeon  for  relief;  fee- 
ble old  men  who  have  been  suffering  from  the  ef- 
fects of  prostatic  obstruction  complicated  with 
chronic  cystitis,  secondary  disease  of  the  kidne3-S- 
from  chronic  urinary  fever,  or  attacks  of  retention 
of  urine,  the  passages  of  the  catheter  becoming  diffi- 
cult owing  to  the  inflamed  and  congested  condition 
of  the  prostatic  gland.  The  physical  condition  of 
these  persons  is  so  wretched  that  any  radical  opera- 
tion is  not  to  be  thought  of. 

The  reason  for  allowing  these  unfortunate  peo- 
ple to  drift  along,  month  after  month,  without  at- 
tempting radical  relief  is  possibly  readily  under- 
stood, when  it  is  taken  into  consideration  that 
vasectomy,  or  bilateral  orchidectomy  as  a  means  of 
cure  is  repugnant  to  most  men  at  the  beginning 
of  their  prostatic  troul)le,  and  is  consequently  avoid- 
ed. The  other  operations  are  either  unsatisfactory 
or  attended  by  high  mortality,  and  are  consequently 
postponed  until  surgical  interference  is  an  abso- 
lute necessity;  this  delay  results  in  the  condition  of 
the  individual  being  such  as  to  render  any  operation 
dangerous. 

I  hope  to  be  able  to  demonstrate  that  the  Bottini 
galvano-caustic  radical  treatment  of  hypertrophy 
of  the  prostate  gland  proves  in  a  large  majority  of 
cases  to  be  entirely  satisfactory.  \\'hen  this  opera- 
tion is  performed  a  local  anesthetic  may  be  used : 
it  is  comparatively  safe,  especially  if  resorted  to  at 
the  onset  of  the  trouble;  under  favorable  circum- 
stances it  confines  the  patient  to  his  bed  but  for 


1092 


The  Philadelphia  i 
Medical  Journal    J 


HYPERTROPHY  oF  THE  PRoSTaTE 


CJUKE    8,    19U1 


a  few  days.  When  employed  at  the  beginning  of 
catheter  life  it  may  be  regarded  as  a  prophylactic 
measure,  being  followed  in  the  majority  of  instances 
by  absolute  cure.  From  personal  experience  I  am 
led  to  the  conclusion  that  if  cases  of  senile  pros- 
tatic hypertrophy  are  operated  on  at  the  outset  of 
the  trouble,  when  the  employment  of  the  catheter 
is  first  indicated,  the  use  of  this  instrument  may  in 
most  cases  be  relinquished,  and  the  evils  attendant 
on  the  introduction  of  the  tube  averted,  accom- 
panied as  it  is  by  so  much  pain  and  discomfort;  to 
say  nothing  of  the  chronic  invalidism  which  is  so 
frequently  an  attendant  upon  advanced  prostatic 
obstruction. 

As  will  be  shown  later  on,  the  cases  which  were 
operated  upon  at  an  early  period  of  the  disease, 
resulted  as  favorably  as  could  be  desired ;  in  every 
instance  not  only  was  the  obstruction  relieved,  but 
the  function  of  the  bladder  was  restored  to  its 
healthy  condition. 

Bottini's  method  is  likewise  applicable  to  a  large 
number  of  cases  of  advanced  prostatic  disease 
where  want  of  vitality'  and  poor  health  contra- 
indicate  the  employment  of  more  serious  radical 
procedure;  in  these  cases  reliance  is  to  be  placed 
either  on  frequent  catheterism  or  continuous  drain- 
age established  by  means  of  a  suprapubic  cystot- 
omy. Hut  in  some  cases  of  prostatic  hypertrophy 
of  long  standing,  even  if  the  obstruction  be  entirely 
removed  the  function  of  the  bladder  will  not  be  re- 
stored;  this  is  especially  the  case  where  the  folds 
of  the  mucosa  becomes  thickened,  from  inflamma- 
tion, giving  rise  to  the  formation  of  ridges  attended 
by  hernial  protrusions  of  the  mucous  membrane 
and  a  tendency  to  the  formation  of  sacs  or  pouches 
Reginald  Harrison  well  describes  this  condition 
when  he  says:  "Once  these  pouches  are  formed 
the  muscular  apparatus  of  the  bladder  is  thrown 
out  of  gear,  and  no  matter  what  is  done  the  normal 
muscular  contractility  will  never  be  restored.  Nor 
will  the  muscular  force  be  exerted  in  the  righ; 
direction,  consequently  there  will  be  always  more 
or  less  residual  urine."  I  have  verified  this  state 
ment  in  several  prostatectomies,  where  the  obstruc- 
tion was  entirely  removed,  and  yet  the  individuals 
were  quite  unable  to  evacuate  the  contents  of  the 
bladder,  and  were  compelled  to  rely  upon  the  cath- 
eter for  relief. 

When  this  sacculated  condition  of  the  bladder 
exists  a  Bottini  operation  will  remove  the  obstruc- 
tion, whilst  a  double  vasectomy  will  allow  the 
catheter  to  be  inserted  without  fear  of  giving  rise 
to  recurrent  attacks  of  orchitis,  a  state  so  often 
attendant  upon  frequent  catheterism. 

The  classification  heretofore  given  will  be  fol- 
lowed when  considering  the  results  obtained  in  the 
number  of  operations  recounted,  together  with  the 
conclusion  reached  as  to  the  relative  value  of  the 
many  methods  employed,  as  well  as  the  danger  ac- 
cruing from  each. 

Vasectomy. — Twenty-eight  individuals  were  sub- 
mitted to  this  operation,  all  of  whom,  with  the  ex- 
ception of  six,  were  over  sixty-three  years  of  age. 
and  the  sexual  functions  of  all  but  six  were  in  abey- 
ance. Vasectomy  was  performed,  whether  the  en- 
largement of  the  prostate  was  glandular  or  fibrous 


in  character.  Xo  deaths  resulted  from  the  opera- 
tion. As  a  rule,  the  reported  mortality  from  this 
operation  is  rather  large,  so  that  the  result  in  each 
instance  was  watched  with  eagerness,  and  the  for- 
tunate termination  was  a  gratifying  surprise. 

Of  forty-nine  reported  operations,  collected  by 
Dr.  A.  C.  Wood  (White  and  Martin)  there  is  a  mor- 
tality of  twelve  per  cent.  Why  the  death  rate  from 
so  simple  an  operation  should  be  so  great  is  incom- 
prehensible, when  it  is  remembered  that  in  each  case 
it  was  performed  under  the  influence  of  local  anes- 
thesia, and  that  but  a  few  minutes  are  needed  to 
complete  the  whole  process,  which  is  attended  by 
neither  shock  nor  loss  of  blood. 

Of  six  cases  operated  on  under  the  age  of  sixty - 
three,  the  sexual  power  was  preserved.  At  the  time 
of  the  operation  the  individuals  w-ere  at  the  en- 
trance of  "catheter  life,"  about  two  and  one-half 
ounces  of  urine  remaining  in  each  instance;  the 
patients  being  compelled  to  arise  more  than  once 
to  discharge  the  contents  of  the  bladder.  In  these 
cases  vasectomy  was  selected  as  the  least  dan- 
gerous and  simple  method  offering  a  chance  of  re 
lief. 

Sixteen  cases  were  retained  under  observation : 
of  this  number  four  were  greatly  benefited ;  they 
were  individuals  between  the  ages  of  fifty-five  and 
sixty-three,  and  were  at  the  beginning  of  their 
prostatic  troubles.  The  improvement  in  each  was 
very  gradual,  and  it  was  not  until  some  five  or  six 
months  had  elapsed  that  anj'  amelioration  in  the 
condition  of  the  patient  could  be  noted.  Three  of 
the  cases  still  retain  a  slight  quantity  of  residual 
urine,  and  employ  a  catheter  once  daily.  One  indi- 
vidual urinates  six  times  during  the  day  and  once 
during  the  night ;  he  has  discontinued  the  use  of 
the  catheter.  The  patients  in  whom  benefit  has 
resulted  from  the  operation  were  between  the  ages 
of  fifty  and  sixty ;  they  had  suffered  but  for  a  short 
time  from  the  symptoms  of  prostatic  obstruction 
and  their  general  physical  condition  was  excellent 
In  three  of  the  unsuccessful  cases  I  have  since  per- 
formed the  Bottini  operation  with  most  gratifying 
results.  Three  of  the  remaining  cases  have  been 
operated  upon  by  other  surgeons :  in  two  a  pros- 
tatectomy was  performed ;  one  died  and  in  one 
a  permanent  drainage  was  established  by  means  of 
supra-pubic  cystotomy,  he  is  living  and  is  com- 
fortable. Four  of  the  cases  were  not  benefited  and 
have  to  resort  to  the  frequent  use  of  the  catheter 
for  relief. 

Prior  to  operation  five  of  the  patients  suffered 
greatly  from  frequent  attacks  of  relapsing  orchitis : 
in  each  instance  relief  from  this  complication  was 
obtained  by  the  surgical  procedures.  In  no  instance 
was  either  atrophy  of  the  testicle  or  any  disturbance 
of  the  nervous  system  developed  after  division  of 
the  vasa  deferentia.  The  operation  was  not  fol- 
lowed by  sexual  weakness  in  any  of  those  cases 
where  the  sexual  powers  had  been  retained.  Thus 
out  of  the  twenty-eight  cases  upon  whom  the  opera- 
tion was  performed,  but  four  were  benefited,  and 
these  only  after  the  lapse  of  a  considerable  period. 

The  results  obtained  lead  me  to  the  following 
conclusions : 

I.  As  a  curative  measure  vasectomy  is  of  little 
value,  and  is  not  to  be  recommended.  ■ 


June  8,  1901J 


HVP£.RTROPHY  OF  THE  PROSTATE 


LThe  Philadelphia        toQ^ 
Medical  Journal  ^70 


2.  The  operation  appears  to  be  most  effective; 
when  performed  on  patients  between  fifty  and  sixty 
years  of  age,  in  whom  the  prostatic  enlargement  is 
of  the  soft  glandular  variety.  The  genital  organs 
of  patients  ot  this  age  are  usually  in  a  healthy  con- 
dition, and  the  individuals  usually  object  to  any  op- 
eration that  is  liable  to  interfere  with  their  sexual 
functions. 

3.  The  operation  is  serviceable  in  those  cases 
where  the  ph}  sical  condition  of  the  individual  ren- 
ders him  unfit  to  undergo  surgical  procedure,  who 
will  not  submit  to  a  more  serious  proceeding,  who 
has  to  depend  upon  the  frequent  use  of  the  catheter. 
I  ir  who  suft'ers  from  periodical  attacks  of  orchitis. 

4.  Sexual  vigor  is  not  diminished  by  the  division 
of  the  vasa  deferentia. 

5.  Atrophy  of  the  testicle  does  not  result  from 
the  operation. 

Castration. — In  forty-four  cases  bilateral  orchi- 
dectomy  was  performed,  irrespective  of  the  char- 
acter of  the  enlargement  of  the  prostate  gland.  All 
the  patients  were  men  in  advanced  years,  whose 
sexual  powers  had  disappeared ;  in  the  majority, 
the  heart  was  feeble,  the  arteries  atheromatous,  and 
they  all  suffered  from  general  debility,  the  result 
of  the  wear  and  tear  of  prolonged  misery.  In  a  few. 
a  far-adVanced  diseased  conaition  of  the  bladder 
and  kidney  existed.  Several  had  suffered  from  fre- 
quent attacks  of  retention  of  urine ;  catheterism  was 
necessary  in  all ;  the  insertion  of  the  instrument 
was  difficult  and  painful.  In  this  class  of  patients 
prolonged  anesthesia,  with  any  serious  operation  in 
addition,  would  in  all  probability  prove  immediate- 
ly fatal. 

Experience  has  taught  the  profession  that  cas- 
tration is  not  to  be  resorted  to  as  a  routine  method 
of  treatment.  Its  sphere  of  usefulness  is  unfortu- 
nately very  much  restricted.  But  in  properly  select- 
ed cases  the  relief  afforded  is  often  permanent  and 
most  gratifying.  It  is  now-  generally  conceded  that 
it  is  only  where  the  enlargement  of  the  prostate  is 
glandular  in  character,  or  where  there  is  a  chronic 
congestion  of  the  organ,  that  relief  is  to  be  obtained 
b}'  orchidectomy.  Unfortunatel)',  it  is  fre- 
quently impossible  to  distinguish  the  hyper- 
trophy of  a  pure  glandular  t3'pe  from  that  of 
the  other  varieties.  When  the  enlarged  pros- 
tate is  hard  and  fibrous  in  character,  due  to  hyper- 
trophy of  the  stroma,  atrophy  does  not  follow  cas- 
tration, and  no  benefit  is  derived  from  the  opera- 
tion, under  such  circumstances  some  other  method 
of  giving  relief  must  be  employed.  These  views 
representing  the  judgment  of  the  profession  as  to 
the  value  of  the  orchidectomy  for  the  relief  of 
prostatic  hypertrophy  are  in  accord  with  my  own 
personal  experience. 

A\'hen  an  enlarged  prostate,  glandular  in  charac- 
ter, is  engorged  with  blood,  castration  seems  to  give 
immediate  relief.  As  a  result  the  patient  begins  to 
void  urine  naturally  and  a  catheter  can  be  inserted 
with  less  difficulty  and  with  less  pain.  On  examina- 
tion the  prostate  will  seem  to  have  perceptibly 
diminished  in  size,  but  it  is  questionable  whether 
actual  atrophy  takes  place  until  some  months  after 
the  operat'on.  If  these  cases  are  carefully  watched 
it  will  be  found  that  in  most  instances  an  ameliora- 


tion of  the  urgent  obstructive  symptoms  occurs 
immediately  alter  the  operation;  then  comes  a 
period  of  abeyance  when  the  condition  remains 
quiescent  for  some  time.  The  patient  is  enabled 
to  evacuate  a  part  of  the  urine  contained  in  the 
bladder,  but  there  is  always  a  certain  amount  re- 
maining in  the  viscus.  Usually  several  months 
elapse  before  the  residuum  will  be  reduced  to  a 
minimum ;  then  it  will  be  found  that  the  prostate 
gland  is  atrophied  and  shrunken.  It  is  due  to 
the  subsidence  of  the  congestion  that  immediate 
relief  is  given  to  the  obstructive  symptoms 
after  operating  upon  suitable  cases.  1  he  mor- 
tality trom  the  operation  where  the  general 
health  is  good  has  been  proved  to  be  about  seven 
and  one-half  per  cent.  In  old,  feeble  men,  with  gen- 
eral arterial  sclerosis,  who  are  suffering  from 
pyelitis  and  chronic  cystitis,  the  mortality  reaches 
as  high  as  eighteen  per  cent.,  being  as  great  as 
that  of  prostatectomy  under  similar  conditions.  Cas- 
tration, therefore,  is  an  operation  by  no  means  free 
from  danger.  In  none  of  the  cases  was  there  any 
disturbance  of  the  nervous  system  following  the 
operations.  Quite  a  number  of  such  annoying  re- 
sults, however,  have  been  reported ;  hence  the  sub- 
sequent involvement  of  nervous  complications  is 
one  of  the  dangers  to  be  borne  in  mind  when  advis- 
ing" the  operation.  In  two  cases  in  which  I  consid- 
ered the  conditions  were  suitable  for  an  orchidec- 
tomy other,  more  serious,  operations  were  selected 
because  the  nervous  temperaments  of  the  individu- 
als were  so  exalted  and  their  dread  of  being  cas- 
trated so  great,  that  I  feared  that  removal  of  the 
testicles  might  be  followed  by  mental  disturb- 
ances. 

In  five  instances  where  patients  were  brought  to 
the  Jefferson  Hospital  suffering  from  retention  of 
urine,  due  to  prostatic  obstruction,  frequent  un- 
successful efforts  having  been  made  to  pass  the 
catheter,  on  whom  aspiration  of  the  bladder  had 
been  performed  several  times,  an  immediate  supra- 
pubic cystotomy  was  performed  and  drainage  estab- 
lished. In  three  the  enlargement  of  the  prostate 
was  found  to  be  glandular ;  the  remaining  two  were 
fibrous.  Two  weeks  later  orchidectomy  was  per- 
formed on  these  cases  with  the  result  that  in  those 
instances  where  the  prostate  was  of  the  soft  variety 
perfect  cure  had  resulted.  In  the  two  cases  in 
which  the  growth  was  hard  and  fibrous  no  benefit 
resulted  from  castration,  and  suprapubic  drainage 
had  to  be  re-established. 

The  gratifying  results  sometimes  obtained  b}- 
castration  in  suitable  cases  of  hypertrophy  of  the 
prostate  is  well  illustrated  by  the  brief  account  of  a 
case  seen  in  consultation  with  Dr.  Edwin  Graham 
in  March.  1897.  The  patient  was  sixty-three  years 
old.  He  stated  that  he  had  never  had  any  venereal 
disease,  but  had  suffered  from  a  rapidly  increasing 
irritability  of  the  bladder  for  the  past  four  years 
Previous  to  my  first  visit  he  had  been  passing  urine 
at  intervals  of  about  every  two  hours,  day  and 
night :  which  w'as  sometimes  attended  with  pain 
and  spasm,  at  the  neck  of  the  bladder.  The  urine 
was  thick  and  cloudy:  sometimes  a  few  drops  of 
blood  would  follow  the  termination  of  the  act 
About  thirty  hours  before  I  first  saw  him  he  had 
Cfotten  his  feet  wet,  which  resulted  in  a  desire  to  fre 


IOQ/1       "^BE  Philadelphia"! 
"^       Medical  Jocrnal   J 


HYPERTROPHY  OF  THE  PROSTATE 


[JCKE  8,  liOl 


quenth-  pass  water.  The  insertion  of  the  catheter 
was  at  first  difficult,  and  finally  impossible;  reten- 
tion of  urine  being  complete.  Everj-  effort  to  pass 
different  forms  of  catheter  had  been  unsuccessful : 
aspiration  had  been  performed  twice.  He  was  re- 
moved to  the  Jefferson  Hospital.  An  examination 
revealed  a  large  prostatic  growth  of  the  soft  va- 
riety. As  the  introduction  of  an  instrument  into  the 
bladder  was  impossible,  recourse  was  had  to  an 
immediate  suprapubic  cystotomy.  The  prostate 
was  found  to  be  adenomatous  in  character,  and  to 
project  into  the  bladder  like  a  cork  into  the  neck  of 
a  bottle.  The  bladder  was  the  seat  of  chronic  in- 
flammation. Two  weeks  later  castration  was  per- 
formed. When  last  seen,  March,  1901,  he  was  in 
robust  health ;  had  long  ceased  to  use  a  catheter, 
passed  urine  about  seven  tim.es  daily  and  occasion- 
ally once  at  night.  The  urine  was  normal.  The 
prostate  was  atrophied  and  there  was  about  one 
drachm  of  residua!  urine  in  the  bladder. 

In  four  cases  of  glandular  hypertrophy  the  ob- 
struction was  so  great  that  a  bicoude  catheter  (Xo. 
9172)  could  be  passed  with  difficulty;  in  these  all 
symptoms  of  stone  in  the  bladder  were  present:  a 
double  castration  was  performed.  The  obstructive 
symptoms  were  promptly  relieved.  Two  weeks 
later  a  stone  staff  could  easily  be  introduced  and 
the  stone  detected.  As  the  bladder  in  each  case 
was  in  a  state  of  advanced  disease  the  calculi  were 
removed  by  means  of  suprapubic  cystotomy.  These 
cases  were  reported  in  full  in  the  Therapeutic  Gasettc 
for  February  15.  1895. 

In  two  other  cases  of  glandular  hypertroph}-  dou- 
ble castration  was  followed  by  the  relief  of  all  path- 
ological symptomt.  Of  the  33  remaining  cases 
two  died,  leaving  31  to  be  accounted  for: 
13  were  lost  sight  of  shortly  after  convalescing 
from  the  operation,  but  were  unimproved  when  last 
heard  from.  In  three  of  the  remaining  operations 
were  performed  by  other  surgeons.  In  one  case  I  es- 
tablished a  permanent  suprapubic  drainage,  and  in 
two  others  relief  was  procured  by  a  Bottini  opera- 
tion. The  12  remaining  cases  are  unimproved; 
the  individuals  refused  to  submit  to  any  further 
operative  interference,  and  so  far  as  known  at  the 
present  time  they  have  still  to  resort  to  frequent 
catheterism  for  relief.  So  that  out  of  forty-four  cas- 
trations 9  who  suffered  from  an  adenoma  of 
the  prostate  gland  were  practically  cured.  Five 
were  operated  on  by  others,  unknown  method* 
being  employed.  Three  were  reoperated  on  bv  mv- 
self.  Ten  still  continue  to  rely  on  the  use  of  the 
catheter.  13  Xvere  lost  sight  of,  but  were  un- 
improved when  last  heard  from,  and  two  died, 
33  cases  were  either  unimproved,  or  so  slightly 
benefited  that  other  surgical  procedure  was  resorted 
to.  From  the  results  obtained  in  the  cases  just  de- 
tailed I  think  the  following  deductions  are  warrant- 
able : 

1.  In   selected  cases,  bilateral  castration  will  a! 
ways  hold  a  place  in  genito-urinary  surgery  as  a 
means  of  removing  the  obstruction  caused  bv  pros- 
tatic hypertrophy. 

2.  The  operation  is  indicated  in  men  of  advanced 
years,  whose  sexual  powers  are  lost,  the  overgrowth 
of  the  prostate  being  glandular  in  character,  or  who 
have  reached  that  period  of  life  where  the  passage 


4.  \\'hen  the  prostatic  enlargement  is  fibrous  in 
character  no  benefit  is  derived  from  the  operation, 
and  its  employment  under  these  circumstances  is 
not  to  be  recommended. 

3.  The  primar\-  eft'ect  of  castration  on  the  glandu- 
lar prostatic  hypertrophy  is  first  to  relieve  conges- 
tion, and  secondarily  to  cause  atrophy. 

4.  When  the  prostatic  enlargement  is  fibrous  in 
character  no  benefit  is  derived  from  the  operation 
and  its  employment  under  these  circumstances  is 
not  to  be  recommended. 

5.  Orchidectomy  in  ver}-  old  subjects  with  exten- 
sive disease  of  the  bladder  and  kidney  is  attended 
by  a  large  mortality,  and  is  a  very  serious  opera- 
tion. 

Suprapubic  Cystotomy. — Permanent  drainage  by 
means  of  suprapubic  cystotomy  was  selected  as  a 
method  of  treatment  in  thirty-three  cases.  Xo 
deaths  resulted.  The  operation  was  considered 
best  suited  to  emergency  cases  where  retention  of 
urine  existed ;  catheterism  being  irppossible  even 
after  aspiration  of  the  bladder  had  been  performed 
in  old  men  who  were  weak  and  debilitated,  the  pas- 
sage of  a  catheter  being  difficult,  and  who  were  not 
in  a  suitable  physical  condition  to  withstand  any 
severe  radical  measure  for  their  relief.  Twelve 
years  have  elapsed  since  the  first  case  of  t)iis  series 
was  operated  upon  by  me.  Many  of  the  individuals 
are  still  alive  and  comparatively  comfortable.  A 
specially  designed  metal  suprapubic  drainage  tube 
was  adjusted  by  means  of  which  they  were  enabled 
to  move  about,  their  bladders  being  respectively 
capable  of  holding  four  ounces  of  urine  without 
leakage.  In  two  instances  the  prostate  had  reached 
such  a  size  as  to  almost  completely  obliterate  the 
bafond  of  the  bladder,  making  it  impossible  to  keep 
the  drainage  tube  in  situ.  In  these  cases  an  appar- 
ratus  was  employed  known  as  the  Ransom  urinal 
which  has  proved  very  satisfactory  as  a  substitute 
for  the  metal  drainage  tube. 

At  best,  this  operation  is  merely  a  temporan.-  ex- 
pedient. In  order  that  the  drainage  tube  shouL! 
be  properly  managed  it  is  necessary  that  the  indi- 
vidual should  have  a  certain  amount  of  intelligence 
which  is  wanting  in  many  of  the  hospital  pa 
tients. 

Impressionable  men,  of  nerxL'U?  type,  arc  ba>1 
subjects  for  suprapubic  cystotomy.  They  are  con- 
stantly worried  and  depressed  by  the  presence  of 
the  tube  and  irritated  and  annoyed  if  the  slightest 
amount  of  leakage  takes  place.  In  fact,  the  estab- 
lishment of  a  permanent  suprapubic  fistula  is  a  very 
unsatisfactory  method  of  treatment  and  should  be 
avoided  if  possible,  although  at  the  present  time  I 
have  under  my  care  several  patients  who  are  well 
satisfied  with  their  condition,  drainage  having  been 
established,  and  their  general  condition  having  been 
greatly  improved. 

In  four  cases  upon  whom  suprapubic  cystotomies 
had  been  performed,  owing  to  the  diseased  condi- 
tion of  the  bladder,  daily  insertion  of  catheters  be- 
came necessar\-,  in  order  to  irrigate  the  viscus 
These  patients  suffered  from  frequent  attacks  of 
orchitis  for  the  relief  of  which  recourse  was  had  to 
a  double  vassectomv.  which  put  an  end  to  the  dis- 
agreeable complication.  In  eleven  cases  stone  in  the 
bladder  complicated  the  condition  of  prostatic  hv- 


JUNE    8,    1901) 


PROGRESS  OF  MEDICINE 


riHE 

Lmed 


Philadelphia 
ICAL  Journal 


1^95 


pertrophy;  the  foreign  bodies  were  easily  removed 
in  each  instance,  without  apparently  adding  to  the 
danger  of  the  condition,  tour  cases  were  in  such 
a  serious  condition  when  they  first  came  under  my 
care,  that  suprapubic  cystotomy  became  necessary ; 
drainage  was  continued  for  four  months,  so  as  to 
justify  operation  for  prostatectomy,  which  were 
successfully  achieved.  Cases  of  this  description 
where  a  fistulous  opening  in  the  bladder  is  present 
are  especial  subjects  for  an  Alexander  operation 
Suprapubic  prostatectomy  becomes  a  very  difficult 
and  even  dangerous  operation  in  those  cases  where 
a  fistulous  opening  has  been  established  temporarily 
to  relieve  the  urgent  symptoms.  Particularly  is  this 
the  case  if  the  fistula  has  existed  for  a  lengthened 
period.  In  attempting  to  reopen  the  bladder  in 
order  to  reach  the  prostate  gland  it  will  be  found 
that  all  the  prevesical  structures  are  so  bound  down 
by  cicatrical  tissue  that  it  is  well-nigh  impossible  to 
enlarge  the  opening  sufficiently  to  reach  the  prostate 
gland  without  wounding  the  perineum.  Conditions 
of  this  kind  are  most  suitable  for  a  perineal  prostatec- 
tomy, or  preferably  a  Bottini  operation.  When  at- 
tempting to  reach  the  bladder  a  transverse  incision 
recommended  by  Trendelenberg  should  be  made  in 
conjunction  with  the  one  in  the  median  line. 

In  three  cases  where  retention  of  urine  existed| 
strictures  of  small  calibre  complicated  the  prostatic 
obstruction.  In  two  of  the  patients  the  contraction 
was  located  at  the  bulbo-membranous  junction,  the 
calibre  being  only  sufficient  to  admit  the  passage  oi 
a  small  sized  Gouley  tunnel  catheter,  which  could 
barely  be  inserted  as  far  as  the  prostatic  urethra, 
In  these  cases  a  perineal  section  was  combined  with 
the  suprapubic  C3-stotomy.  In  the  third  instance  a 
stricture,  the  calibre  of  which  was  I2  M.,  was  found 
to  exist  about  the  middle  of  the  spongy  portion  of 
the  urethra.  After  the  bladder  had  been  opened  and 
drained,  internal  urethrotomy  was  performed.  The 
patients  made  uninterrupted  recoveries.  Had  tha 
strictures  in  the  membranous  urethra-  proved  im- 
passable advantage  would  have  been  taken  of  the 
suprapubic  opening  to  perform  retrograde  catheter- 
ism. 

The  mortality  of  the  suprapubic  C3^stotomy  for 
drainage  in  chronic  cystitis,  malignant  and  tubei> 
cular  disease  of  the  bladder,  prostate  gland  and  re- 
moval of  calculi  varies  between  eleven  and  fourteen 
per  cent.  Why  this  high  mortality  should  pertain 
in  so  simple  and  safe  an  operation  it  is  diffictdt  to 
determine.  The  operation  can  be  performed  in  ten 
minutes :  it  is  accompanied  by  little  shock  and 
scarcely  any  loss  of  blood  and  in  urgent  cases  either 
spinal  or  local  anesthesia  can  be  employed.  On 
three  occasions  I  have  opened  the  bladder,  making 
use  of  a  one  per  cent,  solution  of  cocain  as  a  local 
anesthetic.  I  have  performed  suprapubic  cystotomy 
for  the  purpose  of  exploring  the  bladder,  establish- 
ing permanent  drainage  in  conditions  of  cystitis 
stone,  tubercular,  malignant  disease  and  an  ob- 
structive prostatic  hypertrophy  one  hundred  and 
twenty-two  times  with  one  death,  making  a  mor- 
tality of  less  than  one  per  cent.  The  experience 
of  my  colleagues  at  the  Jefferson  Hospital  has  been 
similar  to  my  own.  .-Xnsendelf,  of  Russia,  published 
in  the  Langcnbcck  Arcliiz'.  fticr  Klin.  Cliirurgic. 
band  31,   i.  und  2.  heft.,  a  report  of  one  hundred 


and  two  cases  of  suprapubic  lithotomy,  with  but 
two  deaths.  I  have  come  to  regard  the  high  opera- 
tion for  opening  the  bladder  not  only  as  one  of  the 
simplest,  but  one  of  the  safest  of  surgical  proce- 
dures. The  high  mortality  sustained  bj^  some  sur- 
geons must  be  due  to  the  fact  that  the  patients  were 
either  not  properly  prepared  for  the  operation ;  that 
the  technique  was  faulty,  or  that  a  class  of  patients 
were  selected  whose  physical  condition  was  such 
that  any  surgical  procedure  would  have  been  one  of 
great  danger.  The  indications  for  a  suprapubic  cys- 
totomy in  prostatic  hypertrophy  may  be  summar- 
ized as  follows : 

1.  When  retention  exists  and  it  is  found  impossi- 
ble to  evacuate  the  urine  by  the  usual  methods  that 
are  employed  for  that  purpose. 

2.  As  a  temporary  palliative  means  in  those  pa- 
tients who  have  reached  the  "break-down  period 
attending  catheter  life,"  whose  resisting  powers 
have  disappeared  and  who  suffer  from  secondary 
involvement  of  the  bladder  and  kidneys ;  and  whose 
condition  is  such  to  preclude  the  resorting  to  any 
more  serious  operation,  but  require  immediate  re- 
lief from  the  symptoms  caused  by  the  obstructing 
prostate  gland. 

3.  In  feeble  old  men,  in  whom  the  enlargement  of 
.the  prostatic  growth  is  fibrous  in  character,  which 

renders  the  introduction  of  a  catheter  difficult,  and 
the  passage  of  the  Bottini  cautery  knife  impossible ; 
in  whom  there  is  long  standing  chronic  cystitis,  with 
probably  diseased  kidneys,  which  preclude  a  prosta- 
tectomy, suprapubic  cystotomy  may  be  selected  as 
the  least  dangerous  and  most  satisfactory  operation 
which  can  be  employed. 

(To  be  Continued.) 


PROGRESS  OF  MEDICINE  IN  THE  UNITED   STATES 
DURING  THE  NINETEENTH  CENTURY. 

By  CHARLES  W.  DULLES.  M.  D., 

of   Philadelphia. 

Lecturer  on  the  History  of  Medicine,  University  of  Pennsylva- 
nia. 

A  hundred  years  ago  the  United  States  was  com- 
prised of  colonies  scattered  along  the  Atlantic  coast, 
extending  not  very  far  from  the  seaboard,  as  we 
count  distance  now,  with  a  total  population  of  only 
about  four  million  persons,  with  a  few  cities  which, 
however  important  relatively,  were  absolutely 
small,  the  largest  being  Philadelphia  with  a  popu- 
lation of  about  65,000,  among  whom  were  reckoned 
210  slaves.  The  customs  and  habits  of  the  people 
were  still  those  of  the  middle  of  the  last  century ; 
and  among  medical  men,  the  cloak,  the  queue  and 
the  cane  still  marked  the  dignity  of  the  physician's 
office.  The  War  of  the  Revolution,  but  recently 
ended,  had  left  behind  it  a  singular  development  of 
the  art  of  surgery,  and  recent  struggles  with  epi- 
demics of  the  dreaded  pestilence  of  yellow  fever  had 
served  not  only  to  cultivate  the  skill  of  physicians 
in  this  country,  but  also  to  bring  into  a  bright  light 
their  courage  and  devotion  to  duty.  It  was  a  no- 
ble band  of  men  who  at  that  time  represented  the 
medical  profession  in  America,  in  every  way  the 
peers  of  Washington  and  Franklin,  and  Hamilton 

'An    address   delivered    before   the    Contemporary     Club     of 
Philadelphia. 


1096 


The  Philadelphia 
Medical  Journal 


] 


PROGRESS  OF  MEDICINE 


[June  8.  1301 


and  Adams.  Already  ,  since  the  first  colonists  had 
landed,  there  had  been  a  number  of  men  who  prac- 
tised medicine  in  New  England,  and  these  were 
not  unfrequently  clergymen,  who  practised  as  well 
as  they  preached ;  whde  it  is  recorded  of  Governor 
Winthrop,  of  Massachusetts,  that  he  was  generous 
in  distributing  to  his  confiding  fellow  colonists  what 
a  writer  of  1753  calls  "his  medicinal  Van  Helmont 
nostrums."  Of  medical  men  proper  there  had  been 
in  the  colonies  a  number  of  considerable  distinction, 
by  far  the  greater  part  of  whom  were  in  Pennsyl- 
vania, wdiere  many  things  had  combined  to  produce 
an  exceptional  stale  of  culture  and  refinement.  But 
this  was  the  result  of  years  of  preparation.  In  the 
earlier  history  of  the  colonies  medical  science  was 
at  so  low  an  ebb  that  Gabriel  Thomas  wrote  from 
the  colony  of  New  Amstel,  now  New  Castle,  Dela- 
ware, about  1650:  "Of  LawyersandPhysiciansIshall 
say  nothing,  because  this  country  is  very  Peacea- 
ble and  Healthy;  long  may  it  so  continue,  and  never 
have  occasion  for  the  Tongue  of  the  one  nor  the 
Pen  of  the  other — both  equally  destructive  to  Men's 
Estates  and  Lives;  besides,  forsooth,  they,  Hang- 
man-like, have  a  Licence  to  Murder  and  make  Mis- 
chief." Nearly  a  hundred  years  later,  as  a  cotem- 
porary  writer  asserts,  in  New  York  quacks  abound- 
ed "like  locusts  in  Egypt,"  and  any  man  at  his. 
pleasure  set  up  for  physician,  apothecary,  or  chi- 
rurgeon. 

Philadelphia  had  the  best  of  everything  in  those 
days,  for  William  Penn  brought  over  in  the  Wel- 
come such  physicians  as  Edward  Jones,  Griffith 
Owen  and  Thomas  Wynne,  and  after  them  a  num- 
ber of  other  English  physicians  found  Philadel- 
phia a  congenial  place  to  come  to;  so  it  is  no 
wonder  that  this  part  of  the  country  soon  passed 
far  beyond  those  sections  which  had  been  settled 
long  before  it.  One  of  the  early  physiciansof  Phil- 
adelphia was  John  Kearsley,  of  whose  wealth  and 
generosity  a  monument  remains  to  us  in  Christ 
Church  Hospital,  to  endow  which  he  gave  a  large 
part  of  his  fortune.  Kearsley  was  a  greater  public 
benefactor  from  the  training  he  gave  to  a  number 
of  young  men  who  afterwards  reached  the  highest 
distinction.  These  young  men  he  not  only  drilled 
in  the  principles  of  physic,  but  also  put  to  exercises 
of  much  plainer  sort.  His  apprentices  had  no  easy 
time,  for,  besides  having  to  put  up  his  pills  and  po- 
tions and  carry  them  round  to  his  patients,  they  had 
to  clean  his  offices  and  do  various  menial  services 
about  his  house.  But  he  made  men  of  them;  and 
they  were  all  heard  from   afterwards. 

It  is  hard  now  to  picture  to  oneself  the  conditions 
which  existed  in  Philadelphia  during  the  last  cen- 
tury: the  strip  of  houses  along  the  Delaware  shore, 
the  smallness  of  those  houses,  the  unlighted  streets, 
the  want  of  public  conveyances,  the  watchmen 
stalking  sleepily  through  the  town  at  night,  and 
greeting  from  time  to  time  the  doctor,  wrapped  in 
his  cloak  and  supported  by  his  cane,  as  he  went 
on  his  errands  of  mercy.  An  old-fashioned  repre- 
sentative of  this  day  was  Chovet,  of  romantic  his- 
tory and  of  sharp  wit.  which  he  often  exercised  in 
the  cofTee-houses  at  the  expense  of  his  townsmen 
— a  Tory,  and  loving  to  trap  and  annoy  even  his 
friends  who  were  devoted  to  the  cause  of  Indepen- 
dence. Until  old  age  carried  him  ofT,  he  went  afoot : 
for  he  never  rode  or  drove  to  his  patients.     Of  him 


they  say,  as  Uncle  Toby  said  of  "our  army  in  Flan- 
ders," that  he  swore  terribly ;  and  his  habit  fur- 
nished the  ground  for  a  story  of  a  pointed  repartee 
he  once  made  to  a  member  of  the  Society  of  Friends, 
who  administered  to  him  a  mild  reproof  in  regard 
to  his  profanity.  It  is  said  that,  being  caught  in  a 
rain  storm  at  the  house  of  a  Quaker,  Chovet  de- 
sired of  him  the  loan  of  a  cloak.  The  Quaker,  lend- 
ing his  cloak,  took  occasion  to  say:  "Friend  Chovet, 
I  hope  thee'll  not  swear  in  my  cloak."  The  next 
day  Chovet  brought  the  cloak  back;  when,  not  sat- 
isfied to  let  well  enough  alone,  the  lender  said: 
"Friend  Chovet,  I  trust  thee  did  not  swear  when 
thee  had  mj'  cloak  on."  To  which  Chovet  promptly 
answered  :  "No,  I  didn't  swear ;  but  1  felt  a  damna- 
ble  disposition  to  lie." 

Then  there  was  good  old  Thomas  Cadwalader, 
to  whom  John  Jones  paid  a  high  tribute  in  his  pre- 
face to  the  first  surgical  tract  published  in  this 
country,  called:  "Plain,  Concise  and  Practical  Re- 
marks on  the  Treatment  of  Wounds  and  Fractures" 
— a  little  book  put  out  in  1776  for  the  use  of  sur- 
geons in  the  armies  of  the  colonies.  Cadwalader's 
principal  literary  essay  was  a  monograph  on  the 
"Dry  Gripes,"  but  he  will  always  be  remembered 
as  the  first  public  instructor  in  anatomy  in  this 
country,  preceding  by  a  few  years  William  Hunter, 
of  Newport,  who  gave  instruction  on  the  same  sub- 
ject. After  Cadwalader,  William  Shippen,  Jr.,  lec- 
tured regularly  on  anatomy  in  Philadelphia,  using 
in  some  of  his  lectures  a  magnificent  set  of  draw- 
ings and  models  presented  to  the  Pennsylvania  Hos- 
pital by  the  famous  Dr.  Fothergill,  of  England. 
The  following  was  the  quaint  announcement  of 
these  lectures:  "Dr.  Shippen's  Anatomical  Lectures 
will  begin  to-morrow  evening,  at  six  o'clock,  at  his 
father's  house,  in  Fourth  Street.  Tickets  for  the 
course  to  be  had  of  the  Doctor,  at  five  Pistoles  each, 
and  any  gentlemen  who  incline  to  see  the  subject 
prepared  for  the  lectures  and  learn  the  art  of  Dis- 
secting. Injections,  etc..  are  to  pay  five  pistoles 
more."  Dr.  Shippen,  being  accused  of  robbing  the 
churchyards  in  order  to  obtain  bodies  for  his  dis- 
secting rooms,  published  in  the  Pcmtsyk'ania  Ga- 
ccttc.  October,  1765,  a  denial,  in  which  he  stated 
that  "The  bodies  he  dissected  were  of  persons  who 
had  wilfully  murdered  themselves,  or  were  publickly 
executed,  except  now  and  then  one  from  the  Pot- 
ter's Field,  whose  death  was  owing  to  some  partic- 
ular disease,  and  that  he  never  had  one  body  from 
the  church  or  any  private  burial  place."  About  the 
same  time  Dr.  Wright  Post,  who  lectured  on  anat- 
omy in  New  York,  was  assailed  by  what  is  known 
in  history  as  the  doctor's  mob.  which  was  excited  by 
stories  in  regard  to  his  robbing  the  graveyards  to 
procure  subjects  for  dissection. 

Bj'  the  beginning  of  the  nineteenth  century  med- 
ical schools  iiad  been  established :  in  Philadelphia  in 
1765.  in  New  York  in  1768.  in  Boston  in  1782.  in 
Darlniouth  in  1798.  and  in  Louisville.  Ky..  in  1800. 
while  the  Pennsylvania  Hospital  had  been  well 
started  in  its  great  work  for  humanity  and  medical 
science. 

At  that  time  Philadelphia  was  the  undisputed 
centre  of  medical  education  in  America,  and  Phila- 
delphia physicians  and  surgeons  excelled  those  of 
the  rest  of  the  countrv  in  number  and  attainments 


June  S,  1901] 


PROGRESS  OF  MEDICINE 


TThe  Philadelphia 
L  Medical   Journal 


1097 


and  reputation.  In  this  the  medical  profession  in 
Philadelphia  was  only  keeping  step  with  the  other 
departments  of  art,  science,  and  industry.  As  Mr. 
Sidney  Fisher  says:  "The  first  medical  school,  the 
first  hospital,  and  the  first  dispensary  ever  known 
in  North  America  were  established  in  Phila- 
delphia, which  in  colonial  times  and  long 
afterwards  was  the  centre  of  study  for  bot- 
any, astronomy,  natural  history  and  all  the 
sciences  that  were  pursued  at  that  age."  And, 
again :  "The  first  fire-company  was  started  there, 
the  first  circulating  library,  the  first  compa- 
nies for  insurance  against  fire,  the  first  local  peri- 
odical and  the  first  bank."  Philadelphia  a  hundred 
years  ago  furnished  most  of  the  material  to  form 
the  American  Philosophical  Society,  which  for 
many  years  was  to  our  country  very  much  what 
the  I'rench  Academy  has  been  to  France — the  focus 
of  learning  of  every  sort.  The  University  of  Penn- 
sylvania enjoyed  the  public  recognition  of  Wash- 
ington and  his  Cabinet,  as  it  had  enjoyed  the  recog- 
nition of  the  highest  officials  of  the  British  Govern- 
ment before  the  War  of  the  Revolution,  and  to  its 
halls  were  gathered,  from  all  parts  of  the  country, 
and  even  from  foreign  lands,  students  who  sat  at  the 
feet  of  men  like  Physick  in  surgery  and  Rush  in 
internal  medicine.  It  is  to  be  feared  that  they  bled 
and  purged  and  sweated  their  patients  with  alto- 
gether too  vigorous  a  hand.  Some  of  the  cotem- 
poraries  of  Rush  did  not  hesitate  to  say  that  he 
killed  more  than  he  cured,  and  one  of  them,  who 
took  the  pen-name  of  Peter  Porcupine,  assailed  him 
with  the  coarsest  venom,  devoting  successive  num- 
bers of  a  special  periodical  which  he  called  the 
"Rush  Light,"  and  published  in  New  York,  to  the 
abuse  of  this  famous  teacher.  Physick  had  no  en- 
emies, and  deserved  the  title  of  "Father  of  Amer- 
ican Surgery,"  because  of  his  fertility  of  resource, 
his  skill  in  practice,  and  his  wonderful  kindness  in 
dealing  with  his  patients,  though  he  showed  his  es- 
timate of  students  of  anatomy  in  those  days  by  di- 
recting that  his  tomb  should  be  carefully  guarded 
against  violation. 

The  great  advance  that  has  been  made  since  the 
beginning  of  the  nineteenth  century  in  the  depart- 
ment of  internal  medicine  has  been  marked  by  con- 
tributions to  our  knowledge  from  all  parts  of  the 
world.  To  this  American  physicians  have  contrib- 
uted their  full  share.  The  greatest  praise  should 
be  given  to  Dr.  Joseph  Parrish,  of  Philadelphia, 
who,  in  the  t3'phus  fever  epidenic  of  18 12- 13,  boldly 
broke  away  from  the  practice  of  his  predecessors 
and  totally  abandoned  bleeding  in  his  treatment, 
demonstrating  by  his  success  that  this  severe  meas- 
ure was  unnecessary.  Of  other  specific  achieve- 
ments of  American  medicine  during  this  century 
should  be  mentioned  the  remarkable  writings  of 
Dr.  Gerhard,  of  Philadelphia,  in  regard  to  diseases 
of  the  chest  and  the  distinction  between  typhoid  and 
ship,  or  typhus,  fever,  the  achievements  of  Drs. 
Weyman  and  Bowditch,  of  Boston,  in  prac- 
tising tapping  of  the  chest  for  evacuating 
flnids  produced  in  pleurisy,  and  the  inven- 
tion of  the  flexible  stethoscope  by  Dr.  Pennock,  of 
Philadelphia ;  while  no  history  of  this  period  would 
be  complete  that  did  not  include  the  names  of  such 
distinguished  men  as  George  B.  Wood,  one  of  the 


most  influential  writers  of  the  period  and  for  many 
years  Professor  of  Practice  in  the  University  of 
Pennsylvania,  of  Rend  La  Roche,  whose  study  of 
yellow  fever  has  never  been  excelled  for  accurate 
observation  and  keen  judgment,  of  Alonzo  Clark 
and  Austin  Flint,  of  New  York,  clinicians  and 
teachers;  of  Isaac  Ray,  of  Philadelphia,  one  of  the 
most  profound  students  of  insanity  that  the  world 
has  ever  produced,  of  the  learned  and  polished 
Alfred  Stills,  of  that  charming  writer  and  able 
practitioner,  J.  M.  Da  Costa,  and  of  that  won- 
derful genius  and  public  man.  Dr.  William  Pep- 
per, under  whose  guidance  the  University  of  Penn- 
sylvania made  such  gigantic  strides  in  material 
prosperity ;  while  different  American  medical  schools 
have  been  graced  by  the  teachings  of  Draper  and 
Dalton,  Francis  Gurney  Smith  and  Austin  Flint,  Jr., 
in  physiology,  and  of  Oliver  Wendell  Holmes  and 
S.  Weir  Mitchell,  whose  rank  in  literature  has 
equalled  that  which  they  attained  in  teaching  and 
practising  medicine.  In  other  branches  of  medical 
teaching  Dewees  and  Hodge,  both  Professors  in 
the  University  of  Pennsylvania,  published  works 
which  were  long  established  text-books  in  this 
country  and  highly  esteemed  abroad. 

The  early  period  of  the  study  of  anatomy  in 
America  was  marked  by  the  industry,  perseverance 
and  talent  of  those  who  devoted  themselves  to  this 
branch  of  work.  Their  worthy  labors  have  been 
continued  by  worthy  followers;  so  that  the  study 
of  anatomy  has  been  developed  until  it  is  conducted 
in  this  country  as  perfectly  as  anywhere  in  the 
world.  The  contrast  between  the  last  century  and 
this  may  be  seen  by  comparing  the  handful  of  stu- 
dents that  gathered  around  Cadwalader  and  Ship- 
pen  in  their  ill-lighted  and  narrow  apartments,  and 
the  hundreds  who  in  this  city  congregate  in  the 
spacious  lecture  halls  of  its  medical  schools,  and 
have  the  opportunity  of  studying  such  beautiful 
specimens  and  preparations  as  are  to  be  found  in 
the  Wistar  Institute  of  Anatomy,  a  gift  to  the  Uni- 
versity of  Pennsylvania,  by  General  Isaac  J.  Wis- 
tar, in  honor  of  his  grand-uncle,  Caspar  Wistar,  Jr., 
whose  invaluable  collection  and  that  of  Dr.  William 
E.  Horner  formed  the  nucleus  of  what  has  now 
grown  so  great ;  while  teachers  of  this  fundamental 
branch  of  medical  study  in  America  can  enjoy  a 
justifiable  pride  when  they  recall  that  of  their  num- 
ber was  Joseph  Pancoast  and  Joseph  Leidy. 

In  this  country  chemistry  has  been  studied  faith- 
fullv  from  1769,  when  Dr.  Benjamin  Rush  became 
professor  of  this  branch  in  the  University  of  Penn- 
svlvania,  the  first  full  recognition  of  the  science  in 
this  country  by  any  institution  of  learning.  Chemists 
here  feel  a' natural  interest  in  the  fact  that  Priest- 
ley, the  discoverer  of  oxygen,  who  may  be  said  to 
have  released  chemistry  from  the  antiquated  bonds 
of  alchemy,  when  driven  from  England  by  religious 
persecution,  came  to  America  in  1794  and  took  up 
his  abode  in  Northumberland,  Pa.,  where  he  died 
in  1804,  after  having  declined,  on  March  3,  1795,  be- 
cause he  wished  to  live  in  the  country,  the  Chair 
of  Chemistry  in  the  University  of  Pennsylvania,  to 
which,  on  November  11,  1794,  he  had  been  elected. 
In  1802,  Mr.  (afterwards  Dr.)  Robert  Hare,  who 
in  1812  became  Professor  of  Chemistry  in  the 
University    of    Pennsylvania,  contributed    to    this 


lO^ 


'J"HE     PHILaDELPHI 

.Vedicai. 


Journal  J 


PROGRESS  OF  MEDICINE 


[June  S.  1901 


department  of  science  the  invention  of  the 
oxy-hydrogen  blowpipe ;  while  in  1808  Profes- 
sors Silliman  and  Kingsley,  of  Yale  College, 
published  an  account  of  the  meteorite  that  fell 
at  A\'eston,  Conn.,  the  year  before — a  paper  which 
attracted  widespread  attention,  and  drew  from 
Thomas  Jeliferson  the  oft-quoted  remark  that  it  was 
"easier  to  belie^'e  that  two  Yankee  professors  could 
lie,  than  to  admit  that  stones  fall  from  Heaven." 
Among  chemists  that  ought  to  be  remembered  is 
James  Smithson,  of  England,  who,  in  1829,  be- 
queathed his  property  to  the  United  States  to  found 
an  institution  for  the  increase  and  diffusion  of 
K'nowledge  among  men — the  now  famous  Smithso- 
nian Institution,  at  Washington. 

The  most  shining  achievements  of  the  medical 
art  in  America  during  the  nineteenth  century  were 
those  in  the  line  of  surgery.  At  the  very  begin- 
ning of  the  century,  we  find  that  Physick,  with 
his  extraordinary  genius,  had  adopted  the  use  of 
what  has  since  been  universally  employed  under 
the  term  of  animal  ligatures.  In  his  day,  and  un- 
fortunately for  long  years  after,  the  usual  treatment 
of  wounded  blood-vessels  was  to  tie  them  with  silk 
or  linen  cords,  and  to  leave  one  end  of  the  ligature 
hanging  out  from  the  wound,  so  that  it  might  be 
withdrawn  after  it  had  been  separated  from  the 
blood-vessel  by  a  process  of  ulceration.  Only  those 
who  have  seen  this  method  employed  can  appre- 
ciate its  disadvantages  and  dangers.  Physick  con- 
ceived the  idea  that  he  could  introduce  ligatures 
made  of  animal  substance,  which  would  be  dissolved 
and  come  away,  or  could  be  withdrawn  without  the 
risks  run  when  the  customary  material  was  used. 
Unfortunately,  this  idea  was  never  fully  developed 
in  his  day,  and  decades  passed  before  the  practice 
of  surgery  was  revolutionixcd  by  the  introduction 
of  the  catgut  ligature. 

There  were  many  other  surgeons  in  .America  who 
contributed  to  place  the  practice  of  surgery  in  this 
country  in  every  respect  on  a  level  with,  and  in 
some  respects  above,  that  of  any  part  of  the  world. 
As  three  hundred  years  ago  the  patriots  of  Hol- 
land adopted,  and  flaunted  in  the  face  of  their  ene- 
mies, the  title  of  "l>eggars,''  which  had  been  scorn- 
fully applied  to  them,  so  in  this  country  it  has  long 
been  possible  to  refer  with  pride  to  the  taunt  attrib- 
uted to  Sidney  Smith,  uttered  in  the  early  part  of 
this  century:  "In  the  four  quarters  of  the  globe. 
who  reads  an  American  book?  or  goes  to  an  Ameri- 
can play?  or  looks  upon  an  American  picture  or 
statue?  What  does  the  world  yet  owe  to  Ameri- 
can phj'sicians  or  surgeons?"  Though  this  fling 
may  l)e  accounted  for  partly  by  the  inexcusable  ig- 
norance of  Sidney  Smith  in  regard  to  the  achieve- 
ments that  had  then  already  been  made  by  Ameri- 
can physicians  and  surgeons,  we  have  lived  to  see 
so  diiTerent  a  situation,  that  we  can  now  ask:  In 
what  part  of  the  four  quarters  of  the  globe  are  not 
these  tributes  paid  to  American  skill  and  genius? 
The  W^alhalla  of  the  healing  art  would  sadly  miss 
the  figures  of  Warren,  Mott.  Post,  Dorsey,  Gib- 
son, McDowell,  Horner,  McClellan,  Atlee,  Pan- 
coast,  Gross  and  Agnew.  There  is  not  an  operation 
in  surgerj'  in  connection  w'ith  which  some  one  of 
these  names  is  not  crowned  with  an  imperishable 
glory.  There  is  no  operation  so  delicate,  none  so  dif- 


ficult, that  it  has  not  been  thoroughly  mastered  by 
American  surgeons,  wdiile  American  surgeons  have 
originated  certain  operations  requiring  the  most  as- 
tonishingcombination  of  judgment, courage  andcon- 
science.  It  was  Ephraim  McDowell,  of  Kentucky, 
who,  in  1809,  first  of  all  the  world,  did  a  deliber- 
ately planned  ovariotomy,  and  in  three  successive 
and  successful  cases,  proved  the  practicability  of 
this  operation  which  has  saved  countless  lives. 
Since  then  it  was  the  two  Atlees,  of  Pennsylvania 
— Washington  and  John  L. — who,  by  their  indomi- 
table courage,  in  the  face  of  bitter  opposition  and 
violent  abuse,  placed  this  operation  on  a  firm  basis 
and  completed  the  work  which  McDowell,  to  the 
great  gain  of  mankind  and  the  great  glory  of  Ameri- 
can surgery,  had  begun. 

Of  other  special  advances  in  the  art  of  surgery 
might  be  named  the  improvements  made  in  this 
country  in  the  treatment  of  wounds  and  diseases  of 
the  contents  of  the  abdomen.  Xowhere  in  the  world 
have  more  brilliant  results  been  achieved  than  here 
in  the  management  of  those  formerly  almost  inva- 
riabh-  fatal  conditions ;  while  it  is  hard  to  estimate 
how  much  women  owe  to  the  skill  and  ingenuity 
of  iMarion  Sims,  who,  coming  from  South  Carolina 
to  New  York  not  only  became  a  most  conspicuous 
and  successful  operator,  but  also  founded  the  first 
Women's  Hospital  in  the  world ;  while  the  mven- 
tion  of  intubation  of  the  larynx  will  forever  pre- 
serve from  oblivion  the  name  of  O'Dwver,  of  Xew 
York. 

The  nineteenth  century  has  seen  remarkable  ad- 
vances in  the  science  and  art  of  medicine  as  shown 
in  the  establishment  of  medical  societies,  in  the  in- 
auguration of  instruction  in  veterinary  medicine, 
and  in  the  universally  admitted  first  place  America 
holds  in  the  teaching  and  practising  of  dentistry. 
The  greatest  perfection  has  been  attained  in  the 
construction  and  administration  of  hospitals,  of  mu- 
seums, of  libraries,  and  of  laboratories,  and  a  re- 
markably advanced  position  has  taken  in  the  train- 
ing of  women  for  the  practice  of  medicine.  Phila- 
<lelphia  has  the  first  medical  college  ever  established 
exclusively  for  women,  whence  has  gone  out  a 
large  number  of  women  to  carry  the  skill  of  the 
physician  to  their  sisters  sorely  needing  their  help 
in  foreign  lands. 

Probably  the  greatest  single  achievement  of  the 
nineteenth  century  was  the  application  to  surgery  of 
what  are  called  general  anesthetics.  Though  for 
centuries  surgeons  had  endeavored  to  lessen  the  pain 
of  operations  by  the  use  of  various  drugs,  some  of 
which,  we  are  told,  were  supposed  to  act  by  means 
of  their  odor,  it  was  not  until  1846  that  what  is 
now  known  as  general  anesthesia  was  properly 
practised.  In  1799  Sir  Humphry  Davy  inhaled  ni- 
trous oxide  to  quiet  the  pain  of  cutting  a  wisdom 
tooth ;  but  it  remained  for  an  American  dentist. 
Horace  Wells,  in  1S44.  to  use  this  gas  systemati- 
cally; while  in  1846  William  Morton — who  had 
learned  the  use  of  nitrous  oxide  gas  from  ^\'ell^ — 
at  the  suggestion  of  Dr.  Charles  T.  Jackson,  first 
used  ether  for  tooth-extraction  and  soon  after  suc- 
ceeded in  establishing  its  claims  as  a  general  anes- 
thetic. Four  years  earlier — that  is  in  1S42 — an  unpre- 
tending country  practitioner.  Dr.  Crawford  Long, 
of  Athens.  Georgia,  who  had  observed  the  effect  of 


JUNE  8,   liwn 


A  NEW  CLINOMETER 


TThe  Philadelphia 
LMedical  Jouknal 


1099 


an  accidental  total  anesthesia,  produced  by  giving 
what  was  considered  an  overdose  of  ether  by  in- 
halation to  a  negro,  employed  this  agent  in  the  re- 
moval of  a  tumor,  and  afterwards  several  times, 
with  entire  success.  But  as  he  did  not  publish  his 
operations  at  the  time,  it  was  not  known  that  he  had 
done  them  until  the  success  of  ether  led  to  discus- 
sions as  to  priority  in  its  use.  It  is  clear  that,  what- 
ever part  others  may  have  had  in  the  development 
of  this  idea,  it  was  William  Morton  to  whom  more 
than  to  any  one  else  the  world  is  indebted  for  it. He 
had  the  courage  to  propose  to  test  the  method  in 
public ;  and  on  October  16,1846,  the  first  public  op- 
eration under  ether  was  done  in  the  operating  room 
of  the  Massachusetts  General  Hospital  by  Dr.  John 
Collins  Warren.  The  scene  on  this  occasion  was 
a  most  interesting  one.  The  patient,  surrounded  by 
some  of  the  most  distingiushed  surgeons  of  Boston 
and  New  York,  was  instructed  by  Morton  to 
breathe  deep  and  long  and  to  have  confidence  in 
him.  He  soon  became  completely  unconscious,  and 
jNIorton,  turning  to  Dr.  \^'arren,  said :  "Your  pa- 
tient is  ready."  At  the  first  incision  there  was  no 
sign  of  pain;  a  pin  could  have  been  heard  to  fall, 
so  intense  was  the  silence.  Dr.  Warren  quickly 
completed  the  operation,  removing  the  tumor  and 
placing  the  stitches.  Still  there  was  no  sign  of 
pain,  the  patient  slumbering  as  peacefully  as  a 
child.  Dr.  Warren  turned  slowly  from  the  recum- 
bent figure,  and  scanning  the  eager  faces  about  him 
said:  "Gentlemen,  this  is  no  humbug."  Thus  was 
successfully  inaugurated  a  practice  which  revolu- 
tionized surgery  and  has  saved  immeasurable  suf- 
fering and  countless  lives.  This  glorious  achieve- 
ment belongs  entirely  to  America  and  to  the  nine- 
teenth century.  Its  description  may  fitly  serve  as 
a  conclusion  to  this  brief  summary  of  what  was  then 
accomplished  in  the  noble  work  of  those  devoted  to 
the  art  of  healing,  of  whom  Whittier  says : 

"So  stood  of  old  the  holy  Christ 

Amidst  the  suffering  throng: 
With  whom  his  lightest  touch  sufficed 

To  make  the  weakest  strong. 

That  healing  gift  he  lends  to  them 

Who  use  it  in  his  name: 
The  power  that  filled  his  garment's  hem 

Is    evermore    the    same. 


The  New  Gynecological  Pavilions  of  the  Broca  Hospital. 

— Dr.  Pozzi.  the  first  Professor  of  G.vnecology  in  the  Paris 
Faculty  of  Medicine,  is  the  chief  surgeon  of  the  new  gyne- 
cological pavilions  of  the  Broca  Hospital, which  have  beenre}- 
ceully  opened.  The  new  buildings  are  in  tliree  divisions, 
the  dispensary,  the  wards,  and  the  operating  rooms.  The 
dispensary  is  open  daily,  and  is  modern  in  appointment 
and  detail.  In  the  four  wards  there  are  44  beds,  and  there 
e.xist  18  more.  6  alone,  the  rest  two  or  three  in  a  room. 
All  the  furnishings  are  easily  sterilized.  There  are  sep- 
arate rooms  for  changing  the  dressings,  adjoining  the 
wards.  The  baths  and  water-closets  are  of  the  latest  pat- 
tern: and  there  are  running  water  and  electric  light.  The 
amphitheatre  is  up-to-date  in  its  equipment,  in  all  particu- 
lars superior  to  any  in  France.  Sterilizing  and  anesthetiz- 
ing rooms,  rooms  for  instruments  and  for  aseptic  opera- 
tions adjoin  it.  It  can  be  easily  flooded  from  above.  Be- 
side the  seats  for  the  students,  there  is  a  special  balcony 
for  visitors.  (Gazette  Mcditalr,  Oe  Paris,  1901,  Nos.  16  and 
17).    [M.  O.] 


A  NEW  CLINOMETER  FOR  MEASURING  TORSIONAL 
DEVIATIONS  OF  THE  EYE,  DELIMITING  PARA- 
CENTRAL SCOTOMATA  AND  METAMORPHOPSIA 
AND  DETECTING  SIMULATION  OF  BLINDNESS.^^ 

By  ALEXANDER   DUANE,   M.    D., 
of  N'ew  York. 

Although  the  usefulness  of  the  Maddox  rod  as  a 
means  of  estimating  torsion  of  the  eyes  has  been 
signalized  by  Maddox  himself,**  and  although  some 
have  employed  the  test  for  this  purpose  clinically,*** 
I  do  not  believe  the  advantages  that  it  offers  have 
been  fully  appreciated  by  the  profession  at  large. 
The  utility  of  being  able  to  determine  the  degree  of 
torsion  in  paralysis  of  one  of  the  vertical  muscles  is 
obvious,  and  the  Maddox  rod  is  admirably  adaptecl 
for  accomplishing  this  in  a  simple  and  efficient  man- 
ner. It  would  be  equally  applicable  for  the  deter- 
mination of  a  cyclophoria.  But,  apart  from  cases 
of  paralysis,  which  are  comparatively  few,  and 
apart  from  cases  of  cylophoria,  which  in  the  pres- 
ent state  of  our  knowledge  must  be  characterized 
as  supposititious,  the  test  seems  to  have  a  much 
wider  range  of  application.  For  it  can  serve  to  de- 
termine in  any  given  case  the  ability  of  the  eye  to 
judge  whether  lines  are  truly  vertical  and  horizon- 
tal or  not,  and  whether  two  given  intersecting  lines 
really  form  a  right  angle  or  not.  Having  thus  de- 
termined by  actual  measurement  how  near  the  truth 
the  patient's  estimates  of  these  things  are,  we  can 
then  proceed  to  ascertain  how  far  these  estimates 
are  affected  by  the  addition  of  glasses.  If  his  no- 
tions in  this  regard — i.  e.,  of  the  directions  and  re- 
lations of  horizontal  and  vertical  lines — are  much 
altered  by  the  glasses,  we  may  consider  it  as  at  least 
quite  likely  that  such  glasses,  even  if  they  seem 
otherwise  correct,  will  produce  distortion  when 
worn.  That  such  distortion  not  infrequently  results- 
form  the  use  of  cylindrical  glasses,  we  all  know.  It 
causes  the  patient  much  annoyance.  He  is  apt  to 
complain  of  it  a  good  deal,  even  when  the  glasses 
are  in  other  respects  acceptable.  Hence  it  would 
be  a  very  desirable  thing  if  we  had  some  means  of 
predicting  whether  or  not  in  any  given  case  a  dis- 
tortion of  this  sort  was  likely  to  ensue  with  a  cor- 
recting glass  such  as  we  wish  to  prescribe. 

Description  of  the  Clinometer. 

To  apply  the  Maddox  rod  to  the  determination 
of  these  problems,  I  have  had  constructed  for  me 
by  Messrs.  Gall  and  Lembke  the  following  instru- 
ment, which,  in  accordance  with  the  appropriate 
nomenclature  of  Dr.  Stevens,  I  have  denominated  a 
cliiioiiictcr. 

It  consists  of  two  Maddox-  rods  (the  multiple 
pattern),  each  mounted  so  as  to  revolve  freely  in  a 
frame  composed  of  a  square  metal  plate.  Each  plate 
has  a  spring  catch  c,  enabling  it  to  slide  freely  along 

'Read  before  the  Pan--Vmerican  Congress  In  Havana,  Feb- 
ruary, 1901. 

**Maddox.  "Tests  and  Studies  of  the  Ocular  Muscles,"  Chap.  xiii. 
♦**Dr.  Weeks  informs  me  that  he  has  so  used  it. 


IIOO 


The   Philadelphia 
Medical   Journal 


\  NEW  CLINOMETER 


[Jl-.s-e  8,  laoi 


A. 

the  horizontal  bar  of  a  Stevens  phoronieter.  One 
plate  (A)  is  designed  for  the  patient's  right  eye,  the 
other  (B)  distinguished  by  being  made  of  ruby  glass, 
for  the  left.  By  this  arrangement  a  Maddox  rod 
may  be  placed  before  the  right  eye  alone,  the  left 
alone,  or  before  each  simultaneously. 

That  side  of  the  plate  which  is  turned  away  from 
the  patient  bears  a  graduated  arc,  and  the  revolving 
piece  containing  the  Maddox  rod  has  two  indexes, 
so  disposed  that  when  the  index  marked  V  is  at  zero 
and  the  phorometer  bar  is  levelled,  the  line  of  light 
formed  by  the  Maddox  rod  is  strictly  vertical,  and 
when  the  index  H  is  at  zero,  the  line  of  light  is  hor- 
izontal. The  Maddox  rods  arc  revolved  by  means 
of  the  handles,  b.  b. 

Method  of  Using  the  Clinometer. 

The  ivay  of  using  the  instrument  is  as  follows: 
The  patient  is  seated  so  as  to  face  a  small  bril 
liant  point  of  light  on  the  other  side  of  the  room, 
and  the  room  itself  is  darkened  so  as  to  prevent  con- 
fusion with  other  sources  of  light.  The  patient  is 
directed  to  look  with  his  right  eye  through  the 
right  Maddox  rod,  which  is  then  rotated  until  he 
says  that  the  line  of  light  formed  by  it  appears  ver- 
tical. (In  making  the  test  in  this  way,  I  generally 
screen  the  other  eye,  so  as  to  eliminate  the  confus- 
ing effect  of  other  vertical  and  horizontal  lines  in 
the  room.)  If,  when  the  patient  alleges  the  line  of 
light  to  be  vertical,  the  index  V  stands  at  zero  or 
very  close  to  it,  we  know  that  his  vertical  merid 
ian  is  truly  vertical.  If,  on  the  contrary,  it  should 
point  to  8°  on  that  portion  of  the  arc  above  the  zero 
mark  (the  portion  marked  on  the  instrument  with 
the  letter  L),  we  would  know  that  his  vertical  me- 
ridian was  rotated  by  that  amount  to  the  left.  Sim- 
ilarly, if  the  index  pointed  to  5°  below  the  zero 
mark  (toward  the  letter  R  upon  the  instrument), 
we  would  know  that  the  vertical  meridian  was  ro- 
tated 5°  to  the  right. 

The  test  is  then  repeated  with  the  left  eye  alone 
(the  right  being  covered),  and  afterward  with  both 


eyes  simultaneously.  In  the  latter  case,  the  two 
rods,  one  before  the  right  eye,  the  other  before  the 
left,  are  turned  until  the  two  lines  of  light,  one 
white,  the  other  red,  both  appear  vertical  and  either 
coincident   or   at   least   parallel. 

The  behavior  of  the  ej-es  as  regards  vertical  lines 
being  thus  determined,  the  same  series  of  tests  is 
then  made  for  horizontal  lines,  the  Maddox  rods  being 
turned  until  the  patient  says  that  the  line  of  light 
is  horizontal,  and  the  amount  of  deviation  from 
true  horizontality  being  ascertained  from  the  read- 
ing of  the  index  H. 

To  determine  the  accuracy  with  wdiich  the  patient 
estimates  right  angles,  we  place  the  Maddox  rods  be- 
fore both  eyes  and  turn  the  rods  until  the  right  (or 
white)  line  appears  vertical  and  the  left  (or  red) 
line  appears  horizontal.     The  reading  of  the  index 

V  on  the  right  plate  and  of  the  index  H  on  the  left 
plate  should  be  the  same,  or,  at  all  events,  not  nota- 
bly different.  If  there  is  a  discrepancy  of  5°  or  more 
between  the  readings,  the  indication  is  that  the  pa- 
tient's estimate  of  perpendiculars  is  at  fault,  and 
that  a  true  right  angle  would  appear  to  him  oblique, 
i.  e.,  appreciably  distorted. 

To  confirm  this  suspicion,  we  would  set  the  right 

V  index  and  the  left  H  index  at  zero,  and  ask  the 
patient  if  the  lines  now  appeared  trulj'  perpendicu- 
lar or  not,  and  if  not  how  we  should  change  them. 

Lastly,  we  may  repeat  the  experiment  by  making 
the  left  (or  red)  line  the  vertical,  and  the  right 
(while)   line  the  horizontal  one. 

It  is  obvious  that  the  apparatus  may  also  be  used 
for  making  the  ordinary  Maddox  rod  test  for  hetcropho- 
ria.  In  this  case  one  eye  is  kept  uncovered,  and 
either  one  of  the  sliding  plates  with  its  Maddox  rod 
is  brought  before  the  other  eye.  The  indexes  H  and 
V  being  successively  set  at  zero,  so  that  the  line  of 
light  produced  by  the  rod  appears  successively  hor- 
izontal and  vertical,  we  determine  the  degree  of 
vertical  and  lateral  deviation  in  the  usual  manner. 


I 


JUNE    S.    19jl] 


A  NEW  CLINOMETER 


r'l'HE    rniLADELPHIA 

LMedicaj.   Jodrnal 


IIOI 


Precautions  to  be  Observed. 

Some  experimentation  with  tliis  apparatus  has 
taught  me  the  following  facts  with  regard  to  its 
use : 

While  we  naturally  aim  to  have  the  patient  with 
his  eyes  in  the  primary  position  when  we  are  making 
the  test,  no  essential  error  is  caused  if  he  tilts  his 
head  moderatelj-  to  one  side  or  rotates  it  moderately 
to  the  right  or  left.  In  my  own  case,  neither  in- 
clining the  head  toward  one  shoulder  nor  rotating 
it  laterally  causes  any  appreciable  tipping  of  the 
vertical  line  produced  by  the  Maddox  rod.  When, 
however,  I  turn  my  head  obliquely  so  as  to  look  up 
and  to  the  right  or  up  and  to  the  left,  I  get  in  ex- 
treme positions  a  torsion  corresponding  to  Bon- 
ders' law.  But  even  then  the  torsion  amounts  to 
not  more  than  4°  at  the  most.  In  the  oblique  posi- 
tions in  the  low'er  field,  the  torsion  seems  to  be  not 
so  marked. 

These  findings  are  quite  in  acordance  with  what 
we  know  of  the  torsion  movements  of  the  normal 
eye.  With  abnormal  eyes,  however,  a  greater  vari- 
ation in  the  torsion  may  be  caused  by  variations  in 
the  position  of  the  head,  and  hence  it  is  well  to 
start  the  examination  with  the  eyes  as  nearly  as 
may  be  in  the  primary  position.  Then  if  we  find  tor- 
sion of  some  considerable  amount,  we  can  by  shift- 
ing the  position  of  the  head  determine  -ivhcther  tlie 
torsion  zkirics  decidedly  in  different  directions  of  the  gaze 
and  from  this  perhaps  draw  important  conclusions 
as  to  the  cause  underlying  the  torsion. 

Ametropia  of  high  degree,  unless  corrected,  vitiates 
to  a  certain  degree  the  precision  of  the  test,  because 
in  this  case  the  line  of  light  is  converted  into  a 
broad,  uneven  band  or  into  a  series  of  separate 
beads,  the  situation  and  direction  of  which  are  not 
so  easv  to  appreciate.  This  difticulty  may  be  par- 
tially obviated  by  using  for  the  source  of  light  a 
very  small  luminous  point  instead  of  a  broad  flame. 

As  might  be  expected,  I  find  that  the  judgments 
of  verticalness  and  horizontality  are  more  accurate 
ivhcn  the  apparatus  is  used  zvith  both  eyes,  so  that  two 
parallel  lines  are  seen,  than  when  it  is  used  with  one 
eye  alone,  the  other  being  closed. 

Experiments  further  show  that,  on  the  whole, 
judgments  are  about  as  accurate  for  horizontal  as 
they  are  for  vertical  lines.  Thus,  out  of  33  cases 
there  were  16  that  designated  vertical  and  horizon- 
tal lines  with  equal  precision;  9  designated  vertical 
lines  more  accurately  than  horizontal ;  and  8  desig- 
nated the  horizontal  lines  more  accurately. 

As  far  as  can  be  judged  from  the  limited  number 
of  cases  examined,  the  ability  to  distinguish  the  di- 
rection of  lines  with  precision  is  not  more  pronounced 
in  or.e  eye  than  in  the  other.  Sometimes  the  right  eye 
was  more  accurate  in  its  discriminations,  sometimes 
the  left :  while  in  other  cases  still,  both  eyes  showed 
equal   ability. 

Results  of  its  Use  in  Normal  Cases. 
I  have  so  far  had  occasion  to  ajjply  the  test  in 
only  46  cases.  Of  these  34*  may  be  characterized  as 
perfectly  normal.  That  is,  in  no  case  were  the  va- 
riations from  the  truth  in  the  estimate  of  horizontal- 
ity or  verticalness  ever  greater  than  3°  for  either 
eye  tested  separately,  nor  greater  than  2°  when  both 

'To  U  ese  must  Ve  added  5  cases  examined  since. 


eyes  w^ere  used  simultaneously;  and  the  variation 
from  parallelism  when  both  eyes  were  used  simul- 
taneously was  never  greater  than  2°.  These  were 
the  maximum  variations,  and  in  many  instances  the 
patient's  estimate  was  not  more  than  1°  out  of  the 
way  or  was  absolutely  accurate.  It  seems  likely, 
indeed,  that  when  the  test  is  carefully  performed, 
the  limit  of  observational  error  should  not  exceed 
2°,  and  that  any  amount  of  torsion  in  excess  of  this, 
especially  if  constantly  present,  indicates  a  real 
tilting  of  the  vertical  meridian,  i.  e.,  a  condition 
actually  pathological. 

I  may  say  that  the  34  patients  in  this  series  were 
of  all  ages,  from  si.x  to  sixty,  and  were  taken  as  they 
came  without  regard  to  their  intelligence  or  to  any 
special  aptitude  that  they  showed  for  undergoing 
tests  of  this  sort.  As  a  matter  of  fact,  some  of  the 
most  accurate  answers  were  given  by  those  who 
had  the  least  intelligence  and  training.  All  condi- 
tions of  refraction  were  represented.  Several  of  the 
patients  had  muscular  anomalies  (principally  a 
convergence-insufticiency),  but  none  had  any  pro- 
nounced vertical  deviation,  except  a  single  case** 
which  had  a  high  degree  of  hyperphoria  with  devi- 
ation of  both  eyes  up  behind  the  screen. 

Of  the  remaining  cases,  one  (Case  35)  showed  at 
one  time  a  torsion  for  horizontal  lines  of  4°  or  5°  in 
each  eye.  But,  as  even  on  this  occasion,  the  verti- 
cal meridians  of  the  two  eyes  remained  parallel,  and 
as  subsequent  examinations  failed  to  reveal  torsion 
of  any  amount  in  either  eye,  it  is  probable  that  this 
case  was  also  normal,  and  that  the  single  observa- 
tion indicating  an  anomalous  torsion  was  errone- 
ous. 

The  same  explanation  may  p6ssibly  apply  to  the 
following,  although  two  examinations  (one  without 
and  the  other  with  the  correcting  glass)  showed  a 
somewhat  marked  torsion : 

CASE  36. — Mrs.  J.  G.  Torsion  without  her  correcting 
glass  was 

For  horizontal  lines,  R.  ej-e — 2';  L.  eye  0'.* 

For  vertical  lines,  R.  eye — 3.5°;  L.  eye — 2°. 

With  her  glass  (R— 0.75-1-1.75  cyl.  90°;  L.+0.75  cyl.  90', 
it  was 

For  horizontal  lines  R.  eye — 1°;  L.  eye — 1°. 

For  vertical  lines  R.  eye — 3.5°;  L.  eye, — 2°. 

In  the  following  cases,  the  moderate  degree  of 
torsion  indicated  may  also  have  been  simply  an  ap- 
parent, or,  at  most,  a  transient  condition,  although 
the  consistency  of  the  findings  in  both  cases  and  the 
fact  noted  by  the  second  patient  that  he  could  not 
draw  perpendiculars  accurately,  are  evidence  in 
some  degree  that  the  relations  of  the  vertical  merid- 
ians were  not  altogether  normal : 

CASE  37. — Ernest  S.  T.,  age  40.  Wearing  for  nearly  four 
years  R.— 0.50-t-1.75  cyl.  90°,  D.— 0.75-h2.25  cyl.  90°.  With 
these  has  V  of  15/15  in  right  eye,  15/20  in  left.  Marked 
convergence-excess  with  moderate  divergence-insufiBciency 
(representing  the  remains  of  a  left  strabismus  convergens 
which  existed  in  childhood).  Binocular  single  vision  with, 
however,  a  tendency,  especially  without  his  glasses,  to 
troublesome  homonymous  diplopia.  Both  the  tendency  to 
diplopia  and  the  convergence-excess  have  diminished  in 
the  four  years  during  which  he  has  been  under  observation. 
Torsion  for  horizontal  lines.  Right  eye — 2°,  Left  eye — 2'. 

Torsion  for  vertical  lines.  Right  eye — 2.5°,  Left  eye — 3°. 
In  estimating  perpendiculars,  says  that  the  intersecting 
lines  formed  by  the  two  Maddox  rods  are  truly  perpendicu- 

**.-^nd  another,  examined  since,  with  a  paresis  of  the  inferior  rectus. 

Tbroughout  this  p.iper  the  terms  -f  and — as  applied  to  tortion  ate 
nsed  in  HelmboUz's  sense  to  denote  respectively  nght  and  left  rotations 
of  the  verticBl  moridian. 


II02 


The  Phii-adelphia 
Medical   Journa 


i'] 


A  NEW  CLINOMETER 


[June  8,  ISOl 


lar  and  are  respectively  horizontal  and  vertical  when  the 
right  H  index  is  at  — 2°,  and  the  left  V  index  is  at  — 4°. 
1.  e.,  under  all  conditions  there  is  a  moderate  loevotorsion 
of  hoth  eyes. 

CASE  38. — Henry  P..  age.  47.  Myopia  of  5.5  and  6  D  with 
slight  astigmatism  against  the  rule.  Muscles  practically 
normal. 

Torsion  for  horizontal  lines. Right  eye — 2.5°,Left  eye — 2io'. 

Torsion  for  vertical  lines.  Right  eye — 1°.  Left  eye — 3°. 

In  estimating  perpendiculars,  calls  the  intersecting  lines 
respectively  horizontal  and  vertical  when  the  right  H  index 
is  at— 1°  and  the  left  V  index  is  at— 3°. 

Says  that  when  he  tries  to  draw  lines  with  a  ruler  he 
viakei  the  irrticiil  lini:<  hIiiih'  ton  nincli  la  the  left. 

Effects  of   Uncorrected  Ametropia. 

In  the  next  cases  there  was  considerable  uncor- 
rected ametropia,  which  probably  accounted  for  the 
indecisiveness  of  the  tests. 

CASE  39.- -Annie  G.  Age  19.  V.:  R.  15/100;  L.  15/50. 
Under  homatropine  shows  R.  — 0.75  ->,-  4.00  cyl.  110°;  L. 
— 0.7D  -t-  4.00  cyl.  70°. 

Without  glasses   shows  torsion: 

For  horizontal  lines,  R.  eye  0' ;  L.  eye  — 2°^. 

I'or  vertical  lines,  R.  eye  0°  to  — 5°;   L.  eye  0°. 

CASE  40. — Tinie  Y.  Age  IS.  Hyperopia  and  oblique  as- 
tigmatism (R.  4-1.75  -1-1.50  cyl.  axis.  30°;  L.  -fl.oO  -1-3.00 
cyl.  axis  140°).  On  two  different  occasions  shows  without 
her  correcting  glasses  a  laevotorsion  of  2°  to  6°  in  the 
right  eye  and  of  2°  to  4°  in  the  left  eye.  when  examined 
with  vertical  lines,  and  a  dextrotorsion  of  2°  to  3°  in  the 
R.  eje  and  0°  to  1°  in  the  left  eye  when  examined  with 
horizontal  lines.  Vertical  meridians  practically  parallel. 
V.  :  R.  15/40;  L.  15/70. 

Torsion    Produced    by    Ill-fitting    Glasses. 

In  the  following  cases  the  torsion  was  probably 
attributable   to  ill-fitting  glasses: 

CASE  41.— Mrs.  S.  D.     Myopia  of  8  D,  with  some  astig- 
matism against  the  rule.     First  test,  September  21,  1900, 
showed   torsion. 
For  horizontal  lines.R.eye — 1°  to — 4°;  L.eye — 1.5°  to — 2.3°. 

For  vertical  lines.  R.  eye  0°:   L.  eye  0°. 

Maximum  variation  from  parallelism  for  horizontal  lines 
1.5°. 

Maximum  variation  from  parallelism  for  vertical  lines 
0°. 

Second  test.  November  27.  1900. 
spherical  glasses  (- — 8  D),  show'ed 
from  parallelism  as  follows: 

Without   Correcting 
For  horizontal  lines.  R.  eye  — 1' 
For  vertical  lines.  R.  eye  0°  to  - 
Variation  from  parallelism  for  horizontal  lines.  2°. 
Variation  from  parallelism   for  vertical  lines,  3°. 

With   Her  Own  Glasses. 

For  horizontal  lines  R.  eye  — 2^  to  ^3°:  L.  eye  0°. 

For  vertical  lines  R.  eye  — 3°;   L.  eye  — 4°. 

Variation  from  parallelism  for  horizontal  lines  2°. 

Variation  from  parallelism  for  vertical  lines  1°. 

With  — 8  D  Set  in  Trial  Frame  and  Carefully  Centered. 

For  horizontal  lines  R.  eye  0' :  L.  eye  — 4°. 

For  vertical  lines  R.  eye  — 1'';   L.  eye  • — 4°. 

Variations  from  parallelism  for  horizontal  lines  3°. 

Variations  from  parallelism  for  vertical  lines  4°. 

CASE  -12.— M.  R.  Age  14.  Using  for  several  years  R. 
-I-  4.50  cyl.  axis  90°,  L.  +  n.oO  cyl.  axis  90°.  Right  glass 
now  bent,  so  that  axis  of  cylinder  is  tilted  inwai'd.  Left 
eye,  whether  with  or  without  glass,  shows  no  torsion  of  any 
amount;  right  eye  shows  without  glasses  torsion  varying 
from  0=^  to  -)-  8°.  and  with  glasses  torsion  of  0°  to  -t-5°. 
When  the  right  glass  is  properly  adjusted,  torsion  in  right 
eye  is  found  to  vary  from  — 2°  to  -1-3°. 

CASE  43.— Dr.  E.  S.  Wearing  R  — 0.75  —5.00  cyl.  axis 
35°;  L  — 1.75  -—4.25  cyl.  axis  165°.  Astigmatism  under- 
corrected  in  right  eye,  overcorrected  in  left  (0.750). 
V:  R  20/20;:  L  20/30.  Right  eye,  with  glasses  and  without, 
shows  no  special  torsion,  while  left  eye  shows  an  extor- 
sion  of  2°  to  5°.  In  binocular  vision  he  showed  little  or  no 
divergence  of  the  vertical  meridians  when  examined  with 
horizontal  lines,  but  a  divergence  of  4°  of  5°   (distorsion) 


after   using   ill-fitting 
torsion   and   variation 


Glass 
L. 


eye  — 3° 
L.  eye  — 


3°  to  —6°. 


when  examined  with  vertical  lines.  On  re-examination,  two 
months  later,  the  relations  were  much  more  nearly  normal, 
although  there  was  still  a  decided  tendency  to  Isevotorsioa 
in  the  left  eye. 

To  be  grouped  in  this  same  category  are  two  of 
the  cases  classed  as  normal.  In  these  two,  the  re- 
lations were,  indeed,  normal  as  long  as  no  glasses 
were  used,  but  seemed  to  become  slightly  abnor- 
mal when  glasses  were  put  on  for  the  first  time. 

One  was  a  myope  of  1.75D,  who  with  the  glass  showed  a 
slight  laevotorsion  (torsion  of  — 2°  or  — Z'' )  of  both  eyes, 
i:he  vertical  meridians  remaining  parallel:  in  the  other,  the 
correction  of  a  moderate  degree  of  oblique  astigmatism 
{0.75  and  1.25  D)  seemed  to  cause  the  vertical  meridians 
to  diverge  about  3°. 

True  Torsion  in  Non-Paralytic  Cases. 

In  the  following  case  there  seemed  to  be  a  true 
torsion,  which  was  not  dependent  upon  paresis  of 
any  of  the  ocular  muscles : 

CASE  44. — Dr.  J.  C.  C.  Very  slight  myopic  astigmatism 
(not  over  0.25  D).  Esophoria  moderate  for  distance  and 
near  I  slight  convergence — excess).  No  limitation  of  the 
ocular  movements,  and  no  diplopia  anywhere  in  the  field  of 
fixation  (true  binocular  single  vision  everywhere). 

Declination  for  vertical  lines.  Right  eye — 1',  Left  eye — 5°. 

Declination  for  vertical  lines.  Right  eye — 1".  Lett  eye — 5°. 

When  tested  for  perpendiculars,  he  declares  the  inter- 
secting lines  formed  by  the  two  Maddox  rods  to  be  truly 
perpendicular  and  respectively  horizontal  and  vertical.when 
the  right  H  index  is  at  -\-  1°  and  the  left  V  index  is  at 
— 4.."^°.  1.  e.,  he  still  shows  marked  lievoiorsion  of  the  leti 
eye.  and  his  estimate  of  perpendiculars  is  5.5°  in  error. 

The  deflection  in  this  case  was  apparently  con- 
stant, and  was  too  great  to  be  attributed  to  observa- 
tional error. 

Application  of  the  Clinometer  in  Cases  of  Paralysis. 
The  following  cases  show  the  application  of  the 
instrument  in  measuring  the  obliquity  of  the  images 
due  to  paralysis  or  spasm  of  the  ocular  muscles: 

CASE  45.—  Mrs.  J.  D.  Postoperative  insufficiency  of  right 
superior  recti  (old  I  and  of  left  superior  and  inferior  recti 
(recent).  Compensatory  spasm  of  obliques,  especially  of 
right  inferior  oblique,  producing  varying  and  temporary, 
but  very  annoying  obliquity  of  objects,  particularly  those 
seen  with  the  right  eye.  In  .-Vugust.  1900,  showed  for  both 
vertical  and  horizontal  lines  a  torsion  of  -rS°  in  the  right 
eye  and  of  — 3°  in  the  left,  giving  a  divergence  of  the 
vertical  meridans  (distorsion)  of  11°.  In  the  latter  part 
of  August  the  distorsion  had  diminished  to  3°.  In  Octo- 
ber, when  she  again  noticed  a  slant  in  the  images,  es- 
pecially those  seen  with  the  right  eye,  the  clinometer 
showed  that  the  torsion  for  this  eye  was  0=  for  horizontal 
lints  and  only  from  -1-1"  to  -t-3°  for  vertical  lines,  while 
in  the  left  eye  it  was  — 5°  for  horizontal  lines  and  — 1°  to 
— 2°  for  vertical  lines  (the  distorsion  being  thus  from 
3°   to  5°). 

C.-VSE  46 — Frank  R.  A.se  39.  Traumatic  paralysis  of 
left  superior  rectus  (complete)  with  traumatic  enophthal- 
raus.  Gets  characteristic  diplopia  with  characteristic  tilt 
ing  of  the  double  images,  but  always  declares  that  it  is 
the  image  of  the  right  eye  that  is  tilted,  while  that  of  the 
left  is  straight.  When  tested  with  the  clinometer,  torsion 
for  horizontal  lines  is  o°  in  the  right  eye.  about  — 10°  in  the 
left  (2  tests). 

These  cases  are  good  illustrations  of  the  fact  that 
when  there  is  tilting  of  one  of  the  double  images  in 
paralysis,  the  tilted  image  does  not  always  corre- 
spond to  the  paralyzed  eye.  In  Case  46.  for  exam- 
ple, the  paralysis  was  confined  to  the  left  eye.  and, 
nevertheless,  the  patient,  when  he  saw  the  two 
images  simultaneously,  and  he  compared  them  to- 
gether. re<>ardcd  that  formed  by  the  left  eye  as_ 
straight  ard  that  formed  by  the  right  eye  as  tilted. , 
That,  however,  the  tilting  was  really  altogether  in 
the  image  seen  bv  the  left  eve  was  clearlv  shown 


JUNE    8,    1901] 


A  XEW  CLINOMETER 


["The  Philadelphia 
LMedical   Journal, 


1 103 


by  the  clinometer.  This  instrumeiu,  in  fact,  by 
enabling  us  to  examine  either  eye  separately  or  both 
eyes  tOijctlKr,  furnishes  trustworthy  evitlcnce  as 
to  which  eye  is  the  seat  of  the  obliquity. 

The  Clinometer  as  a  Test  for  Binocular  Metamor- 
phopsia  and  for  the  Distortion  Produced 
by    Cylinders. 

Except  so  far  as  can  be  gathered  from  the  slight 
evidences  afforded  by  the  cases  cited  under  the 
heading  "Torsion  Produced  by  Ill-fitting  Glasses" 
(see  above),  I  have  not  yet  been  able  to  secure  any 
accurate  data  as  to  the  usefulness  of  the  clinome- 
ter in  estimating  the  degree  of  metamorphopsia  and 
tilting  produced  by  c}lindrical  glasses. 

To  a  patient  the  most  striking  evidence  of  the  dis- 
tortion produced  by  cylindrical  glasses  is  that  he 
sees  the  sides  of  a  rectangle  slope  toward  each 
other,  so  as  to  intersect  the  top  and  bottom  of  the 
rectangle  at  an  oblique  instead  of  a  right  angle. 
Whether  in  anj-  given  case  this  sort  of  distortion 
is  likely  to  occur  or  not,  I  have  thought  could  be 
determined  by  the  clinometer,*  the  test  being  made 
in  the  manner  already  outlined,  i.  e.,  by  making 
with  the  two  Maddox  rods  two  intersecting  lines  of 
light  and  rotating  the  rods  until  the  lines  appeared 
to  the  patient  perpendicular  to  each  other.  If  his 
judgments  are  decidedly  and  consistently  astray,  we 
infer  that  his  estimate  of  perpendiculars  is  per- 
verted, and  that  he  will  see  rectangular  objects  dis- 
torted. 

19  persons**  were  examined  in  this  way.  In  but 
two  of  these  was  there  any  possibility  of  there  be- 
ing a  distortion  due  to  glasses.  In  one  (Case  41,  al- 
ready cited),  both  vertical  and  horizontal  lines  ap- 
peared tilted  4°  or  5°  to  the  right,  but  both  still  re- 
mained at  right  angles  to  each  other.  In  the  other 
case,  the  use  of  oblique  cylinders  appeared  to  cause 
a  slight  torsion  of  both  vertical  and  horizontal  lines, 
and  there  was  some  distortion  of  a  rectangular  ob- 
ject seen  at  close  range  ;  but  the  estimate  of  perpen- 
diculars, as  judged  by  the  clinometer,  was  not  at 
all  abnormal. 

In  3  of  the  remaining  cases  (Xos.  37.  38,  and  43), 
although  there  was  moderate  torsion  in  one  or  both 
eyes,  the  estimate  of  perpendiculars  was  not  more 
than  2°  in  error,  i.  e.,  was  practically  normal. 

In  13  other  cases  the  judgments  in  this  regard 
were  perfectly  normal. 

In  a  single  case  onl}-  (Xo.  44)  was  there  any 
marked  error  in  the  appreciation  of  right  angles ; 
the  error  in  this  case  being  evidently  due  to  the 
pronounced  unilateral  torsion  present. 

The  number  of  cases  is  much  too  small  to  serve 
as  a  basis  for  deductions,  except  that  we  may  say 
that  the  ordinary  person,  tested  in  this  way,  esti- 
mates perpendiculars  with  considerable  precision, 
the  error  in  designating  a  right  angle  being  seldom 
as -great  as  3°  and  frequently  no  more  than  1°  ;  and 
that  the  presence  of  faulty  torsion,  even  when  uni- 
lateral, does  not  necessarily  produce  errors  in  one's 
judgment  of  right  angles. 

•This  application  of  the  test  I  owe  to  Dr.  W.  A.  Holden: 
••Including  X  -xamiiied  since  this  paper  was  presented. 


The  Clinometer  as  a  Test  for  Scotomata  and  for 
Retinal  Metamorphopsia. 

The  clinometer  may  furnish  a  ready  means  of  de- 
termining the  presence  of  scotomata  or  of  a  local- 
ized metamorphopsia  due  to  retinal  disease,  pro- 
vided the  areas  of  retina  involved  are  not  too  re- 
mote from  the  macula.  For,  if  the  patient  looks 
through  the  centre  of  one  of  the  Maddox  rods  with 
the  affected  eye  (the  other  eye  being  covered),  he 
will  see  a  line  of  light  extending  about  20°  on  either 
side  of  the  point  of  fixation.  By  revolving  the  rod 
in  its  frame,  we  can  make  the  line  of  light  sweep 
in  a  circle,  so  as  to  occupy  successively  all  points 
of  the  retina  about  the  macula  and  not  situated 
more  than  20°  from  it.  If  the  line  appears  inter- 
rupted in  any  part  of  its  length,  we  should  suspect 
a  scotoma,  and  if  it  appears  curved  or  otherwise 
distorted,  we  should  suspect  metamorphopsia,  the 
change  in  either  case  being  due  to  involvement  of 
a  corresponding  portion  of  the  retina. 

Suppose,  for  e.xample,  that  the  rod,  placed  before 
the  right  eye,  was  rotated  so  that  the  index  H 
pointed  to  30°  above  the  zero  mark,  and  the  patient 
said  that  a  portion  of  the  line  near  its  upper  end 
was  blotted  out.  We  would  then  believe  that  there 
was  a  scotoma  in  the  upper  and  outer  portion  of  the 
field  corresponding  to  a  defect  in  the  lower  and  na- 
sal portion  of  the  retina,  situated,  say,  io~  or  15'' 
from  the  macula.  By  revolving  the  line  of  light 
still  further,  and  ascertaining  when  it  became 
whole  again,  it  would  be  possible  to  gain  an  idea 
of  how  extensive  the  scotoma  was. 

The  method  would  seem  to  be  particularly  appli- 
cable in  the  case  of  ring  scotomata. 

I  have  had  an  opportunity  of  testing  these  rela- 
tions in  a  single  case  only,*  one,  namely,  of  detach- 
ment of  the  retina.  In  this  case,  the  behavior  of 
the  line  of  light  afforded  very  good  evidence  both 
of  the  scotoma  and  of  the  metamorphopsia  produced 
by  the  detachment.  That  is,  when  the  line  of  light 
was  set  vertical,  its  upper  half  was  cut  off  altogether 
and  its  lower  half  was  inclined  considerably  to  the 
left.  When,  on  the  other  hand,  the  line  was  set 
horizontally,  its  inner  half  was  cut  off,  while  its 
outer  half  was  not  only  visible,  but  also  ran  unde- 
flected.  The  situation  and  character  of  the  detach- 
ment were  such  as  to  account  for  these  appear- 
ances. 

Note. — In  the  course  of  this  paper  I  have  had  oc- 
casion to  use  some  terms  that  may  require  expla- 
nation. These  are  among  the  terms  which  I  have 
elsewhere  described**  and  which  are  used  to  denote 
the  different  movements  that  the  eyes  are  capable  of 
and  which,  so  far  as  the  torsion  movements  of  the 
ej^es  are  concerned,  are  as  follows : 

Torsion. — A  tilting  of  the  vertical  meridians  of 
one  or  both  eyes.     It  comprises : 

Iiitoisioii,***  or  the  tilting  of  the  vertical  meridian 
of  either  eye  inward ; 

Extorsloii***  a  tilting  of  the  vertical  meridian  of 
either  eye  outward ; 

Latcritorsion,  a  tilting  of  both  vertical  meridians 
to  one  side,  i.  e.,  either  to  the  right  (Dextrotorsion) 
or  to  the  left  (Lievotorsion). 

♦.And  in  two  other  cases  since  this  paper  was  presented. 
**Duane,  "The  Nomenclature  of  the  Ocular  Movements,"  Ophthalmic 
Record.  Febmarv.  1<Sq. 
*»*The  terms  intorsion  and  exiorston  are  due  to  Dr.  Maddox. 


II04 


The  Philadelphia 
Medical   Journal 


] 


HYPERTROPHY  OF  THE  PROSTATE 


[June  8,  ISOl 


Contorsioii,  tilling  of  one  or  both  vertical  merid- 
ians, so  that  their  upper  ends  converge; 

Distorsion,  tilting  of  one  or  Ijoth  vertical  merid- 
ians, so  that  their  upper  ends  diverge. 

By  the  use  of  these  terms  we  are  enabled  to  de- 
scribe in  a  single  word  any  one  of  the  changes,  nor- 
mal or  pathological,  that  may  take  place  in  the  tor- 
sion movements  of  the  eyeball,  and  thus  avoid  a 
clumsy  periphrase. 

Additional  Use  of  the  Clinometer. 

Since  the  above  paper  was  presented  the  clinome- 
ter has  shown  itself  adapted  to  the  following  addi- 
tional purposes : 

First,  it  may  be  used  to  measure  the  ability  of  the 
eyes  to  perform  torsion  movements  so  as  to  overcome 
slight  errors  in  declination.  For  this  purpose  each 
rod  with  its  index  V  set  at  o°  is  placed  before  its 
respective  eye,  when  the  patient  will  see  a  blended 
red  and  white  line.  One  rod  is  then  rotated  until  he 
just  begins  to  see  the  lines  diverge.  The  amount  of 
rotation  of  the  rod,  read  ofif  on  the  scale,  will  meas- 
ure the  patient's  ability  to  fuse  images  by  perform- 
ing torsion   movements. 

It  will  be  readily  seen  that  a  similar  manoeuvre 
can  be  employed  to  exercise  the  eyes  in  performing  tor- 
sion movements,  just  as  we  use  prisms  base  out  both 
to  measure  the  ability  of  the  eyes  for  performing 
convergence  and  also  to  exercise  the  eyes  in  con- 
verging. 

Second,  the  clinometer  ma\'  be  used  to  detect  sim- 
ulation of  iiniocnlar  blindness.  Suppose,  for  example, 
the  left  eye  is  alleged  to  be  blind.  The  instrument 
is  placed  with  one  rod  before  each  eye,  when  the  pa- 
tient will  see  two  lines,  one  red,  the  other  white, 
either  intersecting  at  an  angle  or  else  parallel  and 
then  blended  into  one.  He  cannot  tell  which  eye 
he  sees  the  red  line  with  nor,  in  fact,  whether  he 
does  not  see  both  lines  with  the  right  eye  alone.  To 
still  further  confuse  him  in  this  regard,  the  rods  may 
be  interchanged  (by  swinging  the  phorometer  bar 
round),  or  both  lines  may  be  made  to  appear  red  by 
sliding  a  ruby  glass  before  the  white  rod,  or  finally 
either  line  may  be  cut  off  by  shoving  a  card  in  front 
of  one  rod.  The  patient  who  alleges  blindness  of 
the  left  eye  is  detected  if  he  can  be  got  to  admit 
either  that  he  sees  two  lines,  or  simply  that  he  sees 
the  red  line  formed  by  the  left-hand  Maddox  rod. 

Probably  the  best  procedure  is  to  set  both  rods 
vertical,  and  then,  unknown  to  the  patient,  slip  a 
red  glass  before  the  right-hand  rod.  The  patient 
will  then  see  a  single  red  line,  and,  as  it  is  still  pres- 
ent, if  he  slyly  shuts  the  left  eye,  he  will  admit  that 
he  sees  it.  The  red  glass  is  now  slipped  a  little  aside 
and  the  left  rod  is  rotated.  The  patient,  who  now 
sees  two  intersecting  lines,  one  red,  the  other  white, 
will  think  the  white  line  is  seen  by  the  left  eye,  and 
while  still  admitting  that  he  sees  the  red  line,  will 
probably  deny  that  he  sees  the  white.  It  is  then 
evident  that  he  is  malingering,  and  the  imposition 
can  readily  be  demonstrated  to  a  bystander,  if.  leav- 
ing the  rods  in  position,  we  put  him  in  the  patient's 
place. 


MEMBRANOUS  ENTERITIS  ERRONEOUSLY  TREATED 
FOR  PHTHISIS— PRESENTATION  OF  PATIENT.- ■ 

By   J.   PRESTON    MILLER.   M.   D.. 

of  Washington,  D.  C. 

Member  of  the  Merlical  Society,  Di^^lrict  of  Columbia  and   Medical  As&o- 

vialion,  District  of  Columbia,  also  of  the  Medical  Society  of  the  Slate 

of  West  Virginia  li>>78),  American  Mrdical  Association  (ibbo;. 

International  Medical  Congress  (t^>s7;,  brilish  Medical 

Association  liScHy, 

This  paper  will  detain  you  with  no  learned  dis- 
course or  bibliographical  references,  though  I  con- 
fess to  having  read  extensively  on  the  subject,  and 
treated  cases  with  the  same  malady,  before  and 
since,  but  this  one  is  so  unique,  and  the  main 
disease  was  so  well  cloaked  that  I  think  the  clinical 
history  worthy  of  report  to  the  society.  Evidence 
as  to  result  of  final  treatment  is  presented  in  the 
appearance  of  the  patient,  who  has  graciously  con- 
sented to  appear  before  you. 

Mrs.  B.  act.  35,  widow,  'native  o£  Baltimore,  secured  a 
clerical  position  in  the  Government  Service  in  1891,  was 
in  good  health,  weight  150.  In  the  autumn  of  1895  she  be- 
gan suffering  with  severe  spells  of  belching  compelling 
the  leaving  of  her  desk  to  seek  seclusion  anywhere,  often 
in  the  water  closet,  where  after  a  half  hour  or  more  con- 
tinuous eructations  of  wind  she  would  break  out  with  pro- 
fuse and  exhausting  sweat.  These  spells  would  sometimes 
not  come  for  three  or  four  days,  then  three  or  four  times 
in  a  day.  The  severe  attacks  were  in  the  evening  after  din- 
ner, when  she  often  went  to  bed  stripped  of  all  clothing 
whatsoever  because  of  bloating  and  hyperesthesia,  propped 
up  in  bed  she  would  belch  until  exhausted  to  such  an  ex- 
lent  that  she  would  not  sleep  restfuUy,  sleeping  in  broken 
naps.  Cold  sweats  and  palpitation  of  the  heart  followed 
every  attack  from  the  beginning.  Before  long  asthma 
supervened  also,  and  in  December  1896  she  had  congestion 
of  the  lungs  which  confined  her  to  bed  nearly  four  weeks. 
After  this,  bronchitis,  cough,  and  asthma,  were  sufficiently 
abiding  to  require  constant  medical  treatment.  March 
4ih,  1897,  she  was  with  friends  watching  the  inaugural 
procession  from  a  window  for  five  hours.  She  suffered 
much  with  what  she  supposed  was  a  distended  bladder, 
but  when  opportunity  came  urination  brought  no  relief. 
Her  physician  found  peritonitis  over  the  cecum,  the  acute 
pain  requiring  frequent  hypodermics  and  opiates  internal 
ly.  for  throe  days.  After  three  weeks  she  got  out  of  bed 
-ind  went  to  Atlantic  City  to  reo\iperate.  On  the  way  she 
discovered  red  spots  on  her  hands  which  had  extended  up 
her  arms  when  she  arrived  at  the  sea  shore:  then  she 
had  inflammatory  rheumatism  which  kept  her  in  bed  three 
weeks.  She  resumed  her  duty  in  May.  In  October  asthma 
was  so  severe  she  could  no  longer  relieve  it  w^ith  pepper- 
mint in  water  as  she  had  done  hitherto.  All  spells  of 
belching  had  not  been  succeeded  by  asthma,  but  no  asthma 
came  except  during  or  immediately  after  belching.  But 
now  asthma  became  so  severe  she  would  be  confined  to  bed 
lor  10  days  or  2  weeks  at  a  time,  requiring  daily  attend- 
ance of  the  physician.  Within  four  months  she  had  three 
such  attacks.  The  oncoming  war  in  the  winter  and  spring 
of  1898  required  extra  time  and  she  worked  Sundays  and 
Holidays  without  ceasing,  every  day  from  9.00  A.  M.  to 
b.OO  P.  M.,  then  from  7.00  to  11.00  P.  M.  In  October  she 
sgaln  broke  down,  but  in  a  few  weeks  resumed  her  duty 
and  continued  work  until  March  1S?9.  when  her  physician, 
whose  reputation  and  ability  is  second  to  none  in  Washing- 
ton, told  her  she  had  but  one  chance  for  recovery,  and  that 
w:>s  to  quit  this  climate  and  live  permanently  in  the  moun- 
tains. This  eminent  specialist  had  treated  her  larynx  and 
lungs  nearly  two  years  and  finally  told  her  the  bronchial 
disease  had  extended  beyond  reach  of  medication.  Though 
lie  did  not  admit  to  her  she  had  tuberculosis,  his  treatment 
convinced  her  he  believed  she  had.  In  June  she  consulted 
a  well  known  specialist  of  pulmonic  diseases  of  Philadel- 
phia, who  has  several  sanitariums  out  of  the  city,  but  after 
a  month's  treatment  he  told  her  the  same  she  had  been 
told  here  as  to  her  only  chance  for  recovery  being  per- 
manent residence  in  the  mountains.  His  treatment  creo- 
sote and  explicit  directions  to  not  allow  her  to  expectora'-^ 

»Read  before  the  Meli-al   Society  of  the  District  of  CoUiraHa.    Ma- 

j-lh,  looi.  *  . 


June  S,  1901] 


MEMBRANOUS  ENTERITIS 


TThe  Philadelphia 
LaIedical   Journal 


1 105 


in  vessels,  but  in  cloths  which  were  immediately  burned, 
convinced  her  of  his  belief  that  she  had  tuberculosis.though 
he  would  not  tell  her  so  when  she  asked.  Her  cough  and 
expectoration  were  then  extraordinarily  severe  and  free, 
she  was  using  two  and  three  yards  daily  of  soft  stuff  cut 
up  into  expectorating  cloths.  Friends  then  prevailed  upon 
her  to  try  a  homeopath  of  Atlantic  City  who  was  highly 
extolled  in  the  treatment  of  pulmonic  diseases.  For  5 
weeks  she  grew  steadily  worse  under  his  treatment,  in 
July  and  August.  She  then  went  to  Berkshire  Hills,  in 
Massachusetts,  where  she  improved  for  several  weeks, when 
she  returned  to  Washington,  where  her  cough  became  se- 
vere, and  in  two  days  she  started  for  a  sanitarium  near 
Atlanta,  Ga.,  in  which  medicines  are  not  given.  Her 
stomach  was  washed  out  daily  and  she  was  much  mas- 
saged and  restricted  in  diet — mostly  "whole  wheat,"  bran 
bread,  scraped  beef,  etc.  The  doctor  told  her  she  must 
reside  in  some  mountain  of  the  south,  or  California,  that 
she  could  not  live  long  unless  she  left  Washington.  The 
cough  having  improved  she  returned  home  the  latter  part 
of  November,after  having  remained  in  Georgia  tv/o  months. 
Neurasthenia  had  been  very  marked  during  the  last  16 
months,  slamming  of  a  door  excited  violent  sneezing  and 
coughing,  she  had  cold  sweats  night  and  day.  extreme 
exhaustion  on  the  least  movement,  and  I  saw  her,  later, 
extend  her  hands  aloft,  exclaiming  "every  bone  and  muscle 
in  me  is  so  tired  it  makes  me  cry.  I  am  so  weak  I  cannot 
go  to  sleep,"  though  she  had  done  nothing  more  severe 
than  sit  up  in  a  chair.  January  16,  1900.  before  dawn  I 
v\-as  first  called  to  see  this  patient.  I  found  her  delirious, 
with  a  small,  ripid  fitful  pulse,  shallow  difficult  wheezing 
respiration,  requiring  a  second  hypodermic  hi  gr.  morphia 
to  relieve  asthma.  Rubefacients,  heat  and  moisture  were 
applied  to  the  thorax  for  symptoms  of  congestion,  and  ow- 
ing to  alarmingly  critical  symptoms  I  visited  her  three 
times  during  the  day,  when  threatening  symptoms  be- 
gan to  abate,  my  efforts  at  alimentation  and  medication 
were  baffled  by  a  stomach  which  rejected  literally  every- 
thing, though  it  was  washed  out  daily  with  stomach  tubes. 
Bromides  and  iodides  for  asthma  were  not  born,  and  even 
terpin  hydrate  and  heroin  for  cough  in  the  most  agree- 
able elixirs  nauseated  and  were  disappointing  in  every 
way.  Raw  eggs  with  pepsin  and  occasionally  milk,  was  the 
extent  of  diet  for  several  days.  The  stomach  was  washed 
out  daily  and  every  few  days  minute  doses  of  calomel 
and  enemas  were  administered  for  constipation,  I  sought 
to  destroy  pathogenic  germs  in  mouth  and  stomach  by 
cleansing  teeth,  mouth,  throat  and  especially  tongue  with 
ozonized  water  composed  of  hydrozone  one  part  to  four 
of  water,  used  at  bedtime  and  directly  after  rising  A  mix- 
ture of  hydrozone  1  oz.  to  sterilized  water  1  quart  was 
given  in  quantities  of  half  glass  before  food,  except  when 
peptonized  raw  eggs  were  taken.  The  frequent  nausea  and 
occasional  severe  vomiting  subsided,  but  the  anorexia  re- 
mained though  nux  vomica  with  brandy  and  various  appe- 
tizing stomachics  were  given.  Thei'e  had  been  no  tenes- 
mus, no  pain  before  or  during  defecation,  no  abdominal 
distress  below  the  gastric  region,  no  coliky  pain,  no 
shreadj'  stools — nothing  to  suggest  membranous  colitis. 
In  fact  the  family  and  friends  were  so  thoroughly  imbued 
with  the  belief  of  tuberculosis  that  talking  against  it 
was  in  vain.  A  lover  who  desired  her  in  marriage  came  to 
enquire,  and  when  I  assured  him  there  was  no  tubercu- 
losis he  remained  incredulous  because  every  doctor  who 
treated  her  for  years  prescribed  either  creosote  or  perma- 
nent abode  in  the  mountains,  or  both.  Her  normal  weight 
had  been  150.  now  it  was  10.5.  She  was  possessed  with  an 
abiding  belief  that  she  had  tape  worm.  Investigation  de- 
veloped no  evidence,  but  she  argued  "it  is  the  only  thing 
it  could  be — I  have  been  treated  for  everything  else." 
March  ICth  after  santonine  and  calomel  in  minute  doses 
for  24  hours  I  tried  pomgranate  infusion,  but  she  vomited 
this  and  other  remedies  for  tape  worm,  but  finally,  retained 

Ext.  Filicis  Fl. 

Chloroformi     aa  3  i 

M.  S.  a  dose. 

This  was  followed  after  four  hours  by  Olei  Ricini  grms. 
V  in  flexable  capsules  frequently  repeated  until  she  passed 
great  masses  of  shreds  which  she  believed  to  be  tape- 
worms. In  a  few  watery  stools  retained  for  investigation 
I  think  there  was  a  pint  or  more  of  these  shreds.  They 
were  white  and  as  bizarre  as  had  been  the  symptoms  they 
produced,    resembling   mostly    strips    of    rolled    dough,    or 


"noodles,"  rolled  and  bent  in  all  kinds  of  fantastic  shapes. 
I  unrolled  some  of  these  and  measured  one  piece  which 
was  18  inches  in  its  greatest  diameter.  My  patient  had 
seen  tape  worms  in  the  medical  museum  and  found  color 
and  other  appearances  identical  with  that  parasite.  1 
gave  specimens  for  microscopic  examination  to  Dr.  J.  B. 
Nichols  of  this  society,  who  kindly  made  analysis  and  re- 
ported "mucous  enteritis."  As  there  is  such  diversity  in 
the  treatment  it  may  be  of  interest  to  relate  mine:  Patient 
tolerated  two  quarts  per  enema  of  normal  salt  solution, 
used  as  hot  as  she  could  endure,  which  she  retained  five 
minutes,  and  immediately  repeated,  and  continued  until 
slireds  ceased  to  come,  though  this  required  tour,  five  and 
iomotimes  six  repititions  followed  by  introduction  of  flex- 
able  rectal  tube,  20  inches  long,  passed  well  up  into  the 
colon  for  the  injection  of  one  or  two  ounces  of  the  follow- 
ing: Iodoform  1  drachm,  Bismuthii  Subnitratis  oz.  1,  Olei 
Amygdalae  Dulcis  1  pint.  The  iodoform  and  bismuth  were 
increased  to  double  the  above  amount  in  the  third  pre- 
scription. The  tube  was  attached  to  the  nozzle  of  a  David- 
son syringe,  the  syringe  and  tube  were  filled  with  the  oil 
before  introduction  of  the  tube.  By  the  side  of  the  cup 
containing  the  medicine  was  another  containing  water, 
from  the  latter  the  syringe  drew  water  after  the  oil  was 
exhausted  to  drive  home  the  oil  without  intermingling  of 
air,  the  medicine  being  retained  permanently.  Before  us- 
ing this  oil  I  had  used  in  the  same  way  solutions  of  nitrata 
of  silver  and  gradually  withdrew  the  tube  while  injecting 
so  as  to  reach  all  parts  of  the  colon.  This  was  done  two 
weeks.  The  oil  perhaps  six  weeks,  and  after  shreds  dis- 
appeared, and  only  phlegm  remained,  I  used  Fluid  Hydras- 
tis. Internally  Argenti  Nitratis,  a  grain  a  day.  was  given 
in  three  doses,  an  hour  or  more  before  meals,  combined 
with  7  or  8  minims  of  terpintine  in  capsule.  This  was 
alternated  every  30  days  with  tannigen  grs.  6  before  each 
meal,  giving  at  the  same  time  olei  ricini  grms.  5  at  bed 
time.  Asthma,  cough,  anorexia  and  insomnia  had  disap- 
peared in  a  month,  and  excepting  occasional  insomnia  none 
of  these  symptoms  have  reappeared.  Shreds  in  stools 
steadily  diminished  and  totally  disappeared  in  ten  weeks. 
Phlegm  of  almost  gelatinous  consistence  came  in  great 
quantities  with  the  shreds  but  diminished  in  quantity  and 
density  after  shreds  no  longer  came  and  finally  ceased  to 
appear  in  September,  and  of  this  there  was  a  slight  recur- 
rence with  her  recent  attack  of  grippe.  Neurasthenia,  per- 
haps present  in  all  cases,  was  very  marked  in  this  one, 
and.  as  in  all  my  cases,  the  last  symptom  to  leave  except 
anemia.  For  this  I  gave: 
R 

Ext.  Sunibul  gr.    1 

Asafoetida  grs.  11 

Mistura  Bland  grs.  Ill 

Acidi  Arsenosi  gr.    1/30 

Strychninae  gr.    1/60 

Phosphori  gr.    1/100 

M.  Fit  pil  No.  1.  3.  3  to  4  pills  daily  on  empty  stomach. 
In  anemia,  cold  sweats,  feeble  heart,  especially  with  neu- 
rasthenia, I  know  of  nothing  equally  valuable.  Mrs.  B. 
suffered  for  years  for  want  of  peaceful  sleep,  desirable 
food,  abilits'  for  outdoor  exercise,  general  good  health  and 
appearance,  all  of  which  she  craved  and  now  enjoys. 

Discussion. 

In  closing  the  discussion  I  am  painfully  conscious 
of  limitations  in  my  ability  to  answer  satisfactorily 
all  interrogatories  and  criticism  made  here  to-night. 
I  shall  address  myself  here  first  to  what  appears  to 
me  most  difficult  in  this  rare  and  phenomenal  dis- 
ease;  that  is,  its  etiology.  While  this  is  admit- 
tedly not  yet  known,  the  teachings  of  books,  and 
the  faith  orthodox  of  this  society  as  just  revealed 
that  it  is  of  psychic  or  nervous  origin,  has  never  ap- 
pealed to  me.  The  pathology  is  too  gross.  The 
membrane,  while  resembling  a  croupous  formation, 
outstrips  the  latter  in  thickness  and  dimensions 
ten  to  one,  or  more.when  compared  with  laryn- 
geal croup.  The  lumen  of  the  gut  is  several  times 
as  large,  and  in  the  colon  the  membrane  may  be 
four  feet  long,  yet  croup  forms  in  the  larynx  and 
chokes    to    death    its    victim    when    the    infant    no 


iio6 


The  Philaxiei.phia"! 
Medical   Journal  J 


KXEE-JERKS  IX  CHOREA 


[June  8.  1901 


more  knows  it  has  a  soul  or  nerves  than  do  the 
lower  animals.  To  assert  that  this  croup  is  neurotic 
or  of  psychic  origin  would  seem  absurd,  and  to  me 
the  absurdity  is  infinitely  greater  when  such  origin 
is  alleged  where  a  similar  membrane  is  so  much 
larger.  I  find  a  suggestion  in  the  anatomy,  physi- 
ology and  histology  of  the  intestines,  as  to  how  this 
membrane  may  be  formed.  The  small  intestine  is 
20  feet  long;  the  chyme  is  one  and  a  half  to  two 
hours  in  passing  that  distance  from  pylorus  to 
cecum.  The  colon  is  four  to  four  and  a  half  feet 
long  from  cecum  to  rectum,  and  the  fecal  matter  is 
usually  24  hours  in  passing  over  this  short  distance. 
Covering  the  lumen  of  the  intestines  and  at  right 
angles  to  its  plain  there  are  in  every  individual  about 
45,000,000  tubular  grands,  the  principal  secreting 
organs  of  the  intestines — Lieberkuhn's  glands. 
These  glands  are  hollow  stems  having  lengths  sev- 
eral times  as  great  in  the  colon  as  in  the  small  in- 
testine. These  elongated  stems  become  entangled 
at  the  free  ends  like  blades  of  grass  in  wide  shallow 
lazy  streams,  and  the  slow  passing  of  excrement, 
permits  the  enmeshing  of  phlegmy  secretions  in  the 
colon  which  in  the  above  simile  is  not  unlike  the 
wold  of  the  sea  and  the  mild  eddies  of  its  sluggish 
tributaries.  In  this  phlegm  are  microorganisms 
producing  a  characteristic  material  which  can  be 
washed  out  of  the  colon  in  quantities  of  from  one  to 
two  pints  at  a  sitting.  In  consistency  and  general 
appearance  it  resembles  yeast,  producing  the  crack- 
ing noise  of  yeast  when  disturbed,  though  it  is  more 
stringy.  This  is  closest  of  kin  to  the  membrane,  be- 
ing present  in  many  times  the  quantity  and  density 
while  the  membrane  is  in  the  colon,  and  lingering 
in  diminishing  quantity  and  quality  after  disappear- 
ance of  membrane  under  the  best  of  treatment.  Just 
how  oxidation,  or  deposit  of  membrane,  is  formed 
from  this  sea-slime — yeast  like  material,  I  cannot 
explain,  but  that  the  phlegm  causes  the  membrane 
I  do  not  doubt.  The  rarity  of  membraneous  enter- 
itis is  conceivable  when  we  note  the  statement  of 
Einhorn,  probably  the  most  extensive  observer  of 
gastro  enteric  diseases  in  this  country,  who  of 
course  treats  diseases  of  stomach  and  bowel  only, 
and  found,  among  diseases  of  that  class,  this  disease 
in  less  than  |  of  one  per  cent,  in  the  male  and 
slightly  more  than  three  per  cent,  in  the  female.  I 
desire  to  express  my  thanks  to  the  members  of  the 
society  for  the  interest  manifested  in  my  paper  and 
patient.  To  Dr.  Acker's  inquiry  as  to  temperature, 
respiration,  pulse,  etc.  I  can  say,  none  bespoke 
tuberculosis,  but  distinctly  ashthma.  When  I  first 
saw  the  patient  she  had  a  temperature  of  103  with 
serious  symptoms  of  congestion  of  the  lungs.  The 
temperature  rapidly  fell,  hut  there  remained  an  af- 
ternoon rise  of  about  1°  for  perhaps  a  month.  To 
his  observation  that  membrane  did  not  pass  until 
after  I  gave  calomel.  I  think  it  proper  to  say  I 
do  not  think  that  brought  away  the  membrane, 
for  I  had  often  given  it  before.  The  first  membrane 
came  after  tape  worm  treatment  described  in  my 
treatment,  including  oil,  cathartics,  etc.  To  the  crit- 
icism that  I  uselessly  drugged  my  patient  and  that 
she  would  have  gotten  well  as  quickly  without 
drugs,  I  beg  to  submit  she  had  received  abundant 
no-drug  treatment.  Institutional  in  Georgia,  sea- 
side in  New  Jersey,  and  mountain  in  Massachusetts. 


as  reported  in  my  paper.  1  desire  especially  to 
thank  Dr.  Adams  lor  having  kindly  made  the  physi- 
cal examination  of  the  patient  this  evening  and  re- 
ported the  result  to  you.  He  has  elicited  informa- 
tion from  her  which  I  did  not  possess,  viz.,  that  the 
eminent  Philadelphia  physician  referred  to  in  my 
japer  examined  her  sputa  and  stools  microscop- 
ically, but  did  not  report  to  her  his  findings,  the  lat- 
ter very  naturally.  I  beg  to  remind  you  it  vi'as  he 
who  had  all  her  expectoration  cloths  immediately 
burned,  and  in  his.  private  sanitarium  forbade  her  1 
to  expectorate  in  any  vessel.  Among  my  critics  I 
was  astonished  at  being  told  by  a  doctor  that  I  could 
not  pass  a  tube  above  the  sigmoid  flexure,  and  find 
still  more  remarkable  his  statement  that  he  served 
as  interne  in  a  hospital  where  it  was  perfectly  well 
understood  that  no  tube  can  be  passed  up  into  the 
colon.  In  private  practice  I  do  not  find  this  a  diffi- 
cult feat,  and  in  a  recent  post-graduate  course  in 
Xew  York  at  the  Polyclinic  various  methods  of 
passing  above  the  sigmoid  were  demonstrated,  and 
sometimes  a  half-dozen  times  in  a  day  on  patients 
before  the  class.  I  teach  my  patients  how  to  pass 
the  tube  by  showing  them  about  how  far  the  flexure 
is  within,  and  instruct  them  to  press  the  bulb  of  the 
Davidson  syringe  once  or  twice  if  they  meet  with 
resistance  at  expected  distance,  and  thus  make  the 
fluid  force  the  way  for  the  tube,  which  must  be 
promptly  pushed  after  the  contents  of  the  sjTinge. 
The  tube  which  I  used  in  this  case  was  20  inches 
long,  and  I  passed  it  full  length ;  if  it  had  turned  as 
the  doctor  says  all  tubes  do,  its  point  would  have 
followed  the  line  of  least  resistance  down  by  the  side 
of  the  stem  of  the  tube,  the  point  projecting  two  to 
four  inches  from  the  anus.  If  retained  within  the 
rectum  the  injection  would  have  sureh'  escaped  or 
told  on  the  tube  when  withdrawn,  neither  of  which 
over  happened. 


THE  KNEE-JERKS  IN  CHOREA.* 

By  AUGUSTUS  A.  ESHXER.  M.  D.. 

of   Philadelphia. 

Professor  of  Clinical   Medicine   In   the   Philadelphia   PolycUnle: 
Physician   to   Ihe    Phil.-idelphia    Hospital:    Assistant    Phy- 
sician   to   the     Pnil.Tdelphia     Orthopedic     Hospital 
and  Infirmarj-  for  Nervous  Disease,  Etc 

While  ordinarily  easy,  the  diagnosis  of  chorea  is 
occasionally  attended  with  not  inconsiderable  dif- 
ficulty, and  it  would  be  a  great  advantage  did  we 
possess  some  distinctive  symptom  upon  which  de- 
pendence could  be  constantly  placed.  The  two 
conditions  most  likely  to  be  mistaken  for  chorea 
are  spasmodic  tic  and  the  athetoid  movements  at- 
tending various  cerebral  lesions.  The  differential 
features  are  briefly   as  follows: 

Chorea  is  a  self-limited  disease,  probably  of  in 
fectious  origin,  although  there  may  be  relapses  and 
recurrences.  Spasmodic  '  ic  is  of  uncertain  or  indefi- 
nite duration,  and  results  especially  from  reflex  in- 
fluences, from  habit  or  imitation  or  without  obvious 
cause.  Athetosis  also  may  persist  indefinitely  and. 
as  indicated,  is  usually  the  expression  of  some  cere- 
bral lesion.  The  movements  of  chorea  may  be  de- 
scribed as  involuntary,  irregular,  jerky,  incoordinate 
and  purposeless.  They  may  begin  in  one  member 
and  extend  to  the  other  member  of  the  same  side. 

•Read  before  the  Philadelphia  County  Medical  Society.  May  11.  1001. 


June  8,  1901] 


HEREDITY  OF  AIENTAL  DEFICIENCY 


[ 


The  Philadelphia 
Medical   Journal 


1 107 


to  which  they  may  remain  confined ;  or  they  may 
extend  successively  to  members  of  the  opposite 
side.  Commonly,  the  movements  preponderate 
upon  one  side,  and  there  is  often  associated  weak- 
ness of  the  affected  part.  The  movements  of  spas- 
modic tic,  on  the  other  hand,  appear  coordinate, 
purposive  and  repetitive.  They  are  generally  local, 
often  disappearing  from  one  situation  to  a]>pear  in 
another.  Athetoid  movements  also  are  involuntary 
and  incoordinate  and  peculiarly  vermicular.  They 
are  usually  confined  to  the  same  member  or  mem- 
bers, and  are  associated  with  paralysis  or  paresis, 
as  well  as  other  spastic  phenomena  and  mental  de- 
ficiency. The  knee-jerks  are  unchanged  in  cases  of 
spasmodic  tic  and  exaggerated  in  those  of  athetosis, 
while  in  cases  of  chorea  they  are  extremely  variable 
in  different  cases  and  even  in  the  same  case  at  dif- 
ferent times,  being  sometimes  increased  and  some- 
times enfeebled  or  wholly  wanting. 

Gordon  (British  Medical  Journal,  March  30,  1901. 
p.  765)  has  called  attention  to  a  peculiar  modifica- 
tion of  the  knee-jerk,  which  he  believes  to  be  com- 
mon in  cases  of  chorea.  In  his  experience  it  is  not 
constant,  Init  when  present  it  is  considered  distinc- 
tive. Go;  don  states  that  with  the  patient  recum- 
bent and  the  knee  raised,  while  the  heel  rests  on  the 
couch  and  the  muscles  of  the  extremities  are  re- 
laxed, if  the  patellar  tendon  be  struck,  the  foot  rises, 
but  instead  of  falling  back  immediately,  it  remains 
suspended  for  a  variable  time,  then  sinking  back 
slowly  to  its  original  position.  Sometimes  it  is  said 
there  is  merely  a  sluggish  descent  following  an  or- 
dinary ascent.  Sometimes  there  is  the  ordinary 
knee-jerk,  but  as  the  foot  is  beginning  to  descend 
it  is  caught  in  midair  and  held  for  a  time  or  is  even 
raised  to  a  higher  level  than  was  reached  in  the  first 
jerk.  Sometimes  the  knee-jerk  passes  at  once  into 
acti\-e,  more  or  less  persistent — even  aparently  vol- 
untary— rigid  extension  of  the  extremity. 

The  phenomenon  is  said  to  be  best  observable  in 
mild  cases,  because  in  them  it  is  not  interfered  with 
by  the  frequent  and  extensive  movements  of  severe 
cases.  In  cases  of  hemichorea,  it  is  said  to  appear 
only  upon  the  affected  side. 

The  opinion  is  expressed  that  the  manifestations 
noted  are  due  to  an  additional  involuntary  move- 
ment evoked  by  the  knee-jerk.  The  choreic  move- 
ments themselves  are  attributed  to  an  overflow  of 
impulses  evolved  for  the  purposes  of  ordinary  vol- 
untary activity.  In  support  of  this  proposition  the 
following  test  is  proposed : 

If  a  patient  with  suspected  chorea  raises  both 
arms  vertically  with  the  hands  held  open,  there  may 
or  may  not  be  slight  occasional  choreic  movement 
of  the  thumbs  or  fingers,  or  both.  If  now  the 
tongue  is  protruding,  existing  movements  in  the 
thumb  and  fingers  are  intensified,  or  if  not  previ- 
ously present  are  evoked. 

The  explanation  offered  for  this  phenomenon  is 
that  impulses  in  one  set  of  centers  necessary  to  in- 
duce voluntary  movement  overflow  or  are  con- 
veyed to  neighboring  centers  and  give  rise  to  in- 
voluntary movement.  The  peculiarity  of  the  knee- 
jerk  described  is  thoughtto  support  tliis  hypothesis 
of  the  mechanism  »i  the  movements  of  chorea 

I  have  repeated  the  observations  of  Gordon  on 
the  knee-jerk  in  a  small  number  of  cases,  and  am 


able  in  part  to  verify  his  statements  with  reference 
thereto.  The  phenomena  are  not  elicitable  in  every 
case.  When  present  they  seem  to  represent  an  in- 
tensification or  a  reenforcement,  or  in  some  in- 
stances to  act  as  an  excitant,  of  the  choreic  move- 
ments. Thus,  in  a  colored  child  with  mixed  blood, 
seven  years  old,  in  a  third  attack  of  chorea  with 
physical  signs  of  endocarditis  and  valvular  disease 
the  tap  on  the  patellar  tendon,  with  the  patient  in 
the  recumbent  posture  and  the  knee  raised,  was 
sometimes  followed,  not  only  by  the  double  jerk, 
or  a  belated  single  jerk  on  the  side  struck,  bur 
also  by  palpable  and  visible  contraction  of  the 
hamstring  muscles  with  flexion  of  the  leg,  some- 
times at  once,  at  other  times  after  a  little  delay.  The 
blow  on  the  tendon  seemed  further  to  set  up  a  series 
of  movements  also  upon  the  opposite  side  as  well 
as  in  other  parts  of  the  body. 


HEREDITY  AS  A  FACTOR  IN  MENTAL  DEFICIENCY. 

By  T.  ALEXANDER  MAC  NICHOLL,  M.  D., 

of  Ne'^  York. 

Were  men  as  careful  in  laying  the  foundations 
for  a  good  posterity  as  they  are  of  maintaining  the 
lineage  of  a  horse  or  the  blood  of  a  barnyard  fowl, 
such  a  human  monstrosity  as  the  16-year-old  mur- 
derer executed  in  Connecticut  last  July  would  be- 
come an  impossibility.  This  lad,  held  in  the  hered- 
itary clutch  of  two  or  more  generations  of  depraved 
ancestors,  started  life  a  moral  pervert,  cruel  and  re- 
morseless. His  father  was  weak-minded  and  a 
drunkard ;  his  father's  brother  was  an  epileptic ;  his 
mother  was  feeble-minded,  a  prostitute,  and  died 
drunk  in  the  street ;  his  mother's  sisters  were  all 
drunkards ;  his  mother's  brother  died  insane :  his 
paternal  grandfather  was  an  epileptic;  his  maternal 
grandfather  died  insane ;  his  maternal  grandmother 
was  an  epileptic,  a  drunkard,  and  a  prostitute. 

Heredity  prepares  the  soil  and  implants  the  ten- 
dencies ;  environment  may  modify  them. 

Devitalize  the  system  in  one  or  through  suc- 
cessive generations,  and  the  sum  total  is  mental  de- 
ficiency, loss  of  organic  integrity,  dipsomania,  epi- 
lepsy and  other  psychoses. 

Reformatory,  prison,  and  asylum  are  pictorial  vol- 
umes of  the  potency  of  hereditary  taint  in  producing 
a  degenerated  offspring. 

In  no  less  unmistakable  a  manner  does  mental 
deficiency  point  to  a  defective  origin.  This  is  evi- 
denced by  the  results  of  an  investigation  conducted 
bv  the  writer  for  the  purpose  of  determining  the 
bearing  of  heredity  upon  dullness.  Despite  the  dif- 
ficulties attending  such  an  investigation,  we  have 
secured  data  of  10.000  children. 

Of  this  number,  885,  or  8.8%  showed  more  or  less 
marked  mental  deficiency.  The  dullness  of  40  is 
reported  as  due  to  environment  and  physical  condi- 
tions, in  which  are  included  poverty,  defective  sight, 
deafness,  and  general  constitutional  weakness:  221 
are  classified  as  due  to  heredity:  471  others  as  chil- 
dren of  drinking  parents:  of  the  remaining  153.  no 
definite  information  was  procured.  The  children 
examined,  with  few  exceptions,  had  good  hygienic 
surroundings,  many  of  them  had  defective  eyesight 

•Prrsented  10  thf  Academy  of  Medicine,  N.  Y.  City.  April  18,  1901. 


iioS 


The  Philadelphia 
Medical  Journal 


] 


HEREDITY  OF  MENTAL  DEFICIENCY 


[Juke  8,  1301 


corrected,  difficulties  of  hearing  removed,  and  other 
physical  infirmities  improved,  but  the  mental  defi- 
ciency remained ;  a  distress  to  the  parent  and  a  con- 
stant irritation  to  the  teacher.  A  few  were  placed 
under  traine^hprivate  teachers,  but  the  progress  was 
far  from  ideal,  and  the  children  returned  to  school ; 
others  who  were  given  work  in  manual  training 
schools  developed  much  mechanical  ingenuity,  but 
showed  little  other  mental  improvement. 

Those  conditions  which  impair  the  integrity  of 
nerve  tissues  or  profoundly  affect  nutrition,  are  the 
active  agents  in  the  preparation  for  the  transmis- 
sion of  hereditary  ills. 

We  have  been  able  to  trace  the  family  histories 
of  463  children  in  150  different  families,  through 
three  generations.  17  (2  males  and  15  females) 
were  precocious  in  some  one  thing,  as  music,  draw- 
ing, etc.  403  were  generally  deficient  (193  males 
and  210  females)  ;  17  had  neurotic  fathers;  78  neu- 
rotic mothers.  313  had  drinking  fathers;  51  drink- 
ing mothers;  43  had  neurotic  grandparents;  265  had 
drinking  grandparents ;  246  had  drinking  parents 
and  grandparents.  2%  of  these  children  had  parents 
of  less  than  average  intelligence.  A  most  notable 
fact  in  these  families  was  the  constant  relation  of 
alcohol  in  the  ancestry  to  abnormal  physical  condi- 
tions in  the  descendants.  While  87%  of  these  chil- 
dren of  drinking  and  neurotic  ancestry  were  men- 
tally deficient,  76/f  suffered  from  some  neurosis  or 
organic  disease. 

The  contrast  between  these  and  abstaining  house- 
holds is  very  striking.  I  give  you  the  results  of  a 
study  of  51  families  of  231  children  having  total  ab- 
stinence antecedents.  Of  these,  less  than  3%  were 
dull,  and  but  i8%  suffered  from  any  neurosis  or  or- 
ganic disease. 

Such  facts  as  these  stamp  heredity  as  a  most  im- 
portant factor  in  mental  deficiency,  and  alcohol  as 
a  most  active  agent  in  the  production  of  hereditary 
degenerations. 

The  records  of  the  following  three  classes  of 
parents  and  their  families  would  be  of  more  than 
passing  interest  in  this  connection.  A  study  of  24 
families  of  drunken  parents  shows  113  children,  of 
whom  93  had  organic  diseases,  66  mentally  deficient. 
7  idiots,  8  dwarfs,  7  epileptics,  and  16  drunkards. 

76  families  of  moderate  drinkers  had  236  children, 
of  whom  186  had  organic  diseases,  169  mentally  de- 
ficient. 8  idiots.  8  insane,  and  21  drunkards. 

31  families  having  neither  neurotic  nor  drink- 
ing ancestry,  had  116  children:  20  had  organic  dis- 
eases, 3  mentally  deficient,  i  a  drunkard. 

In  other  words,  while  the  children  of  drinking 
parents  show  less  than  i2%normal  in  mindand  body 
the  children  of  total  abstainers  show  over  82*7^ 
normals.  Thus  the  families  of  drink  imbibers  in 
large  measure  augment  the  number  of  drunken,  dis- 
eased and  defective  members  of  society. 

Wealth  and  social  environment  cannot  always 
overcome  misdirected  biogenetic  forces,  as  illus- 
trated in  the  following  family  history: 

A  moderate  drinker  of  good,  sturdy  inheritance 
married  an  equalh'  healthy  woman,  an  abstainer; 
the  result  of  this  marriage  was  a  son  of  strong  phy- 
sique. The  father  died  of  cerebral  hemorrhage  at 
the  age  of  34 ;  the  mother  died  of  lung  trouble  at  the 
age  of  70.     The  son  became  a    moderate    drinker. 


married  a  moderate  drinker,  descendant  of  a  vigor- 
ous stock,  and  died  of  cerebral  hemorrhage  at  the 
age  of  70.  The  result  of  this  marriage  was  one  son 
and  two  daughters ;  one  of  the  daughters,  unmar- 
ried, died  of  cancer;  the  other  married  a  moderate 
drinker.  Two  precocious  daughters  were  the  result 
of  this  union  The  son,,  a  heavy  drinker,  mar- 
ried and  raised  a  family  of  one  boy  and  one  girl.  The 
boy,  in  spite  of  wealth  and  the  severe  discipline  of 
a  military  school,  is  vicious  and  mentally  deficient, 
while  the  girl  is  an  imbecile. 

It  is  self-evident  that  any  treatment  of  mental 
deficiency  which  disregards  cause  must  fail  of  per- 
manent results.  Segregation  of  at  least  90%  of 
these  pupils  in  special  classes  under  well  equipped 
teachers,  aside  from  the  lifelong  stigma  such  segre- 
gation entails  upon  child  and  parent,  will  at  best 
conceal  the  grosser  manifestations  of  the  evil  while 
the  cause  remains. 

The  child's  first  claim  upon  the  State  is  not  edu- 
cation, not  liberty,  not  even  happiness:  but  it  is 
life,  it  is  health.  No  human  agent  should  have  any 
right  to  the  indiscriminate  dispensing  of  that  which 
contaminates  the  fountain  head  of  citizenship,  im- 
plants disease  in  the  offspring,  and  casts  upon  the 
community  an  unnecessary  burden  of  defective  and 
degenerate  youth. 

Let  the  State  interdict  the  sale  of  alcohol  as  it 
does  other  narcotics,  and  prevent  or  control  the 
marriage  of  the  mentally  deranged  with  healthy 
members  of  society,  and  not  only  crime  and  insan- 
ity will  diminish,  but  there  will  be  a  rapid  reduction 
of  mentally  deficient  children. 

The  youth  who,  in  spite  of  a  vicious  environment, 
makes  of  himself  a  man,  thoroughly  furnished  unto 
good  works,  merits  our  praise ;  but  he  who,  cast  in  a 
defective  mould,  starts  life  in  the  implacable  grasp 
of  poverty  and  vice,  demands  our  sincerest  sympa- 
thy and  our  wisest  thought. 


Malaria  and  the  Sanitation  of  Malarial  Regions  In  Cor- 
sica.— Pitti-Ferrandi.  Ul'i:.  Hrh.  dc  Uft/.  et  de  Chirur.. 
April  14.  1901.  48me.  Ann^e.  No.  30).  (Paris  Thesis,  1900- 
1001,  No.  206).  Malaria  is  very  frequent  in  Corsica.  In 
order  to  prevent  the  further  development  of  the  disease 
Pitti-Ferrandi  believes  that  a  number  of  free  stations  for 
the  distribution  of  quinin  should  be  established  in  the 
malarial  regions,  that  the  government  should  supply  the 
inhabitants  with  mosquito-nets  and  frames,  and  that  the 
immediate  application  of  new  discoveries  concerning  the 
use  of  petroleum  should  be  made.  In  general,  the  mos- 
quitoes and  their  larvae  should  be  destroyed  by  all  known 
means.  Potable  water  should  be  introduced  and  stations 
for  the  distribution  of  mineral  water  should  be  established 
in  the  swampy  plains.  The  planting  upon  a  large  scale 
of  tho  eucalyptus  tree  and  the  retimbering  of  the  moun- 
tains, the  re-establishment  of  the  penitentiary  of  Casa- 
btana  and  the  establishment  at  other  points  of  practical 
schools  of  agriculture  or  other  agricultural  institutions  are 
further  means  of  combating  this  disease.     [J.  M.  S.] 


Aspirin  in  Pleurisy  with  Effusion. — N.  .\.  Savelieff  (iledi- 
chi^knic  Ohuxicni'',  April.  1901)  employs  aspirin  in  cases  in 
which  salicylic  acid  or  salicylate  of  soda  is  indicated,  with 
exceptionally  good  results.  The  untoward  effects  of  the 
latter  are  as  a  rule  absent  when  aspirin  is  used.  In  one 
case  of  pleurisy  this  drug  rendered  valuable  services  by  re- 
ducing the  temperature,  producing  profuse  diaphoresis  and 
diuresis  with  consequent  diminution  of  the  effusion.  The 
only  objection  to  the  drug  is  the  high  price.  The  author  ( 
reports  also  a  case  of  idiosyncrasy  towards  the  drug.  A 
woman  suffering  from  rheumatism  took  5  grms  of  aspirin 
in  fractional  doses.  On  the  second  day  ringing  in  the 
ears,  weakness  and  delirium  developed.     [A.  R,] 


The  Philadelphia  Medical  Jouinal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company   and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hendrie  Lloyd,  A.  M.,  M.  D.,  Editorin-Chiej 
Julius  I,.  Salinger,  M.  D.,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.  d.  F.  J.  Kaltever,  M.  d. 

D.  h.  Edsall,  M.  D.  T.  L.  Coley,  M.  D 

J.  M.  Swan,  M.  D.  W.  a.  N.  Dorlano,  m.  D. 

J.  H.  Gibbon,  M.  D.  T.  M.  Tvsox,  M.  D. 

M.  OSTHEiMER,  M.  D.  A.  Robin.  M  D 


Scientific  Articles,  Clinical  Memoranda,  Xews  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  publication.  Reprints  (250)  of  Original  Articles  will  l>e  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Phlladelpliia  3Ie<llcal  Journal.    1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8. 


Vol.  VII,  No.  24 


June  i?,  1901 


$3.00  Per  Annum 


The  Surgical  Treatment  of  Epilepsy. — We  recall 
very  well  the  wave  of  enthusiasm  which  swept  over 
the  professional  world  about  thirteen  years  ago 
with  reference  to  the  surgical  treatment  of  focal  epi- 
lepsy. In  1888  Dr.  David  Ferrier  and  Mr.  Victor 
Horsley  were  in  this  country,  and  when  they  vis- 
ited Philadelphia  were  taken  to  Blockley  (which 
Hospital  one  of  them  compared  with  the  Salpfi- 
trifere  for  wealth  of  clinical  neurology)  and  were 
there  shown  some  of  the  results  obtained  in  the  very 
earliest  work  in  local  cerebral  surgery  in  America. 
The  names  of  the  distinguished  visitors  were  names 
to  conjure  with  in  cortical  topography,  and  it  is 
not  to  be  wondered  at  that  their  visit  strongly  stim- 
ulated the  new-born  zeal  for  trephining  every  avail- 
able case  of  epilepsy.  The  enthusiasm  of  those 
days  was  felt  all  over  the  medical  world,  and  led 
to  an  immense  amount  of  operating;  and  thus.it 
has  happened  that  that  enthusiasm  has  since  been 
tempered  with  much  and  even  bitter  experience.  As 
in  the  case  of  all  extreme  movements,  this  one  has 
suffered  from  a  powerful  reaction,  until  it  has  al- 
most come  to  the  pass  that  the  neurologists  and  the 
surgeons  who  resort  to  trephining  in  Jacksonian 
epilepsy  are  obliged  to  assume  an  apologetic  tone. 
This,  perhaps,  has  been  inevitable,  but  it  should  not 
be  always  so.  We  are  convinced  that  the  operation 
in  certain  selected  cases  is  a  useful  one.  and  that 
the  time  has  come  when  the  judicial  opinions  of 
expert  neurologists  and  conservative  surgeons  can 
be  counted  on  to  favor  a  cautious  propaganda  of  this 
faith. 

We  publish  in  this  number  of  the  Journal  two  pa- 
pers which  are  contributions  of  this  sort.  Dr.  Put- 
nam is  not  one  who  looks  for  practical  results 
through  rose-colored  glasses.  His  paper  can  "he 
read  with  the  confident  belief  that  it  embodies  so- 
ber and  mature  reflections.  On  Dr.  \\'hite's  paper 
special  comment  is  called  for  from  the  fact  that  it 
contains  a  bold  and  entirely  original  suggestion. 
The  topical  treatment  of  focal  epilepsy  has  heretofore 
been  pursued  by  the  excision  of  the  offending  centers; 
this  was  a  surgical  treatment  that  was  especially 
popular  with  medical  men.  But  Dr.  White's  topical 
treatment,  although  suggested  by  a  surgeon,  is  es- 


sentially a  medical  one,  for  it  consists  in  injecting 
a  solution  of  eucaine  into  and  beneath  the  cerebral 
cortex.  In  other  words,  it  depends  upon  the  action 
of  a  drug,  and  the  only  surgical  element  in  it  is  the 
slight  operation  necessary  for  applying  this  medi- 
cament. It  is,  perhaps,  too  early  to  appraise  this 
treatment  at  its  true  value,  and  it  is  noteworthy  that 
Dr.  White  himself  is  exceedingl)'  conservative  and 
properly  cautious  in  recommending  it  to  the  pro- 
fession. It  lends  itself  easily  to  speculation,  es- 
pecially as  to  a  possible  antidotal  action  upon  a 
theoretical  toxin.  Can  it  be  assumed,  if  this  treat- 
ment is  found  to  lead  to  a  measure  of  permanent 
success,  that  it  antagonizes  the  action  of  an  auto- 
genous poison  or  of  an  invading  microbe?  Or  does 
it  act  by  impressing  nutrition  in  some  unknown 
way?  The  cytoplasm  of  a  neuron,  we  could  sup- 
pose, might  retain  the  impress  of  a  powerful  agent 
thus  introduced,  so  as  to  present  permanently,  or  at 
least  for  a  long  time,  new  combinations  in  its  bio- 
chemistry. Only  by  some  such  theoretical  sug- 
gestions could  the  treatment  be  explained.  But  em- 
pirically we  do  not  need  that  a  treatment  should  be 
categorically  explained,  and  Dr.  White's  sugges- 
tion opens  up  quite  a  field  for  cautious  experimenta- 
tion not  only  with  eucaine,  but  possibly  with  other 
drugs. 

The  Meeting  at  St.  Paul. — The  annual  meeting 
of  the  American  Medical  Association  should  always 
be  of  such  importance  as  to  be  an  object  of  interest 
and  instruction  to  every  medical  man  in  the  United 
States.  The  session  just  held  at  St.  Paul  was  of 
special  interest  and  of  historical  importance  be- 
cause the  Association  succeeded  in  reorganizing  it- 
self. This  was  a  most  significant  feat,  for  it  is  one 
which  has  failed  of  accomplishment  several  times 
heretofore  largely  for  lack  of  time.  This  reorgani- 
zation was  absolutely  essential  as  a  preliminary  to 
a  successful  career  for  the  Association  as  a  real  rep- 
resentative national  gathering.  Before  this  was 
accomplished  it  could  scarcely  be  said  that  the  As- 
sociation did  or  could  properly  represent  anything 
but  itself.  In  fact,  is  was  simply  a  huge  medical 
societv.  It  is  now  constituted  with  a  House  of  Del- 
egates, which  represents  the  State  Societies  and  by 


I  I  10 


The  Philadelphia 
Medical  JonR.VAL 


] 


EDITORIAL  COMMENT 


[JfNE    15,    IKOl 


them  the  general  profession,  and  which  has  a  defi- 
nite, determinative  and  effective  organization.  This 
Chamber  can  represent  a  policy,  pursue  a  course, 
transact  a  measure,  and  attend  to  business  in  a 
way  that  was  formerly  impossible  in  the  loosely  or- 
ganized association  at  large.  If  there  is  any  virtue 
or  force  in  representative  government  (and  who 
doubts  that  there  is?)  the  Association  will  now 
reap  the  benefits.  It  is  in  a  position  as  never  before 
to  influence  public  opinion  and  to  act  upon  legisla- 
tion, but  its  best  friends  should  not  forget  that  only 
that  form  of  government  "which  is  best  adminis- 
tered is  best."  The  new  House  of  Delegates  can 
soon  sink  to  the  level  of  some  of  the  State  Legisla- 
tures if  it  is  run  in  the  same  way. 

It  is  rather  too  early  to  judge  of  the  literary  and 
scientific  quality  of  the  meeting.  It  will  be  time 
enough  to  do  that  when  the  original  papers  are  put 
into  cold  type.  These  papers,  however,  were  evi- 
dently of  very  uneven  merit,  as  is  apt  to  be  the  case 
in  a  large  and  miscellaneous  gathering.  Perhaps  one 
of  the  functions  of  the  new  House  of  Delegates  will 
be  to  keep  a  jealous  eye  open  for  a  high  standard 
of  scientific  work. 

The  Association  put  itself  squarely  on  record 
in  favor  of  some  common  sense  legislation,  and  de- 
clined to  make  a  declaration  on  the  subject  of  mili- 
tary morality  in  the  Philippines  when  importuned 
to  do  so  by  some  elderly  parties  who  probably  were 
not  very  well  informed  on  this  delicate  subject. 

The  revision  of  the  code  of  ethics  was  not  fa- 
vored by  the  majority  present  and  was  voted  down. 
This  will  please  the  conservative  members  of  the 
profession  everywhere,  but  will  probably  not  dis- 
courage the  revisionists,  who  seem  to  be  in  an  eter- 
nal mood  of  hopefulness  and  determination. 

From  the  social  and  personal  standpoint,  the 
meeting  seems  to  have  been  fairly  successful.  We 
have  heard  some  complaints  about  lack  of  accom- 
modations and  about  the  great  distances  that  sepa- 
rated the  meeting  places  of  the  various  sections. 
Such  things,  we  suppose,  are  inevitable  when  the 
meetings  are  largely  attended  and  are  held  in 
smaller  cities  and  towns.  The  city  of  St.  Paul  dis- 
tinguished itself  for  courtesy  to  the  strangers  within 
its  gates. 

The  Relation  of  the  Physician  to  Legislative  Af- 
fairs.— The  President's  address,  delivered  by  Dr. 
Charles  A.  L.  Reed,  before  the  American  Medical 
Association  at  its  fifty-second  annual  meeting,  con- 
tains much  that  is  of  value  to  the  American  medi- 
cal profession  concerning  its  relation  to  state  and 
national  policy.  It  is  an  unfortunate  but  no  less  a 
well-known  fact  that  the  medical  profession  as  a 
body  in  the  United  States  has  too  little  influence ; 


in  all  probability,  because  it  lacks  efficient  organiza- 
tion and  capable  leadership.  Dr.  Reed  points  out 
that  this  lack  of  solidarity  was  the  cause  of  the  deg- 
radation of  the  army  medical  corps,  and  of  the  un- 
fair and  humiliating  discrimination  against  the  men 
who  compose  that  most  necessary  arm  of  the  ser- 
vice. 

The  present  law  grades  the  medical  department 
for  rank,  promotion  and  pay  far  below  every  other 
department  and  special  corps  of  the  army,  and,  with 
the  exception  of  second  lieutenants,  it  also  is 
graded  below  the  line. 

The  status  of  the  physician  in  the  army  seems  to 
be  similar  to  his  position  in  civil  life.  The  sick  and 
wounded  demand  the  time,  attention,  and  superior 
knowledge  of  the  physician,  but  when  the  wound  is 
healed  and  the  lost  health  regained,  the  beneficiaries 
often  wish  to  cut  down  the  remuneration  for  ser- 
vices rendered  to  the  least  possible  figure.  As  Dr 
Reed  properly  says :  "Physicians  are  citizens  of  the 
Republic.  As  such  they  are  intellectually,  socially, 
politically  and  officially  the  equal  of  any  other  ele- 
ment of  the  body  politic.  There  is  no  station  to 
which  they  may  not  attain ;  there  is  no  distinction 
of  which  they  may  not  be  the  recipients.  They  are, 
in  very  fact,  peers  of  the  realm  and  peers  of  any 
peers  of  any  realm." 

Let  us  reorganize  the  American  Medical  Associa- 
tion so  that  it  shall  have  a  leader  who  shall  be  in  a 
position  to  make  its  influence  eflFective,  and  a  legis- 
lative body  to  whose  acts  every  member  of  the  pro- 
fession will  adhere  loyally.  In  electing  the  man 
who  shall  be  the  executive  head  of  this  body,  let 
each  member  of  the  profession  cast  his  vote  intelli- 
gently, and  when  the  count  is  made,  let  the  minor- 
ity abide  by  the  decision  of  the  majority.  Let  there 
be  no  selfish  politics  in  our  campaigns,  but  rather 
let  us  be  broad-minded,  remembering  that  truth 
and  justice  cannot  be  found  coincident  with  the 
ideas  of  one  group  alone.  Then  let  us  raise  the 
standard  of  requirements  for  entrance  to  the  study 
of  medicine  and  for  graduation.  Give  the  young 
men  the  best  instruction  possible,  and  require  that 
they  shall  show  evidence  of  having  profited  by  that 
instruction.  Then  shall  we  have  a  profession,  the 
members  of  which  will  stand  shoulder  to  shoulder 
and  push  the  physician  into  the  front  rank  of  intel- 
lectual and  scientific  attainment  and  influence.  Let 
us  regard  the  example  set  by  France,  to  which  we 
make  editorial  reference.  Dr.  Reed's  address  was 
admirable  in  every  respect,  and  especially  in  its 
timely  discussion  of  problems  that  are  of  vital  im- 
portance to  the  medical  profession  in  this  country. 

The  Doctor  in  Politics. — The  British  Medical  Jour- 
nal publishes  a  list  of  the    medical    men    who    are 


June   15,   1901] 


EDITORIAL  COMMENT 


TThe  Philadelphia 

LMEDICAL  JpnBNAL 


1 1 1 1 


members  of  the  French  Parliament.     From  this  we 
learn,  much  to  our  enlightenment,  that  no  less  than 
42  physicians  are  members  of  the  French  Senate, 
and  no  less  than  53  are  in  the  Chamber  of  Deputies. 
We  think  these  numbers  will  surprise  most  of  our 
readers  on  this  side  of  the  Atlantic,  as  they  have 
surprised    us.      These    medical    members    of     the 
l-'rench  Legislature  form  an  important  Parliamen- 
tary group,  which,  by  its  size  and  the  united  influ- 
ence of  its  members,  is  able  to  effect  legislation  in 
many  ways.    This  group  is  regularly  organized,  and 
Professor   Cornil,   Senator  for   Allier,   is   chairman 
of  it.    Cornil  has  taken  a  leading  part  in  medical  and 
sanitary  legislation.     Professor  Labb^  was  a  fore- 
most promoter  of  the  medical  reform  bill ;  Dr.  Ped- 
ebidou  has  championed  the  cause  of  underpaid  doc- 
tors in  the  public  service;  M.  Dubuesson  has  agi- 
tated the  amendment  of  the  law  relative  to  acci- 
dents, and  M.  Dron  has  procured  the  removal  of  the 
tax  on  physicians'  carriages  as  objects  of  luxury. 
These  are  only  a  few  samples  of  what  can  be  done. 
In  this  country,  unfortunately,  there  is  a  sort  of 
prejudice  against  the  doctor  going  into  politics,  and 
a  more  irrational  prejudice  was  never  conceived.  We 
have  especial  need  in  America  for  the  services  of 
well-trained  physicians  in  the  legislative  services. 
This  is,  perhaps,   especially   true   in   municipal   af- 
fairs, but  it  is  also  true  in  State  Legislatures  and  in 
Congress  itself.    If  there  were  as  large  a  proportion 
of  well-educated   physicians  in   Congress   as  there 
are  in  the  French  Parliament,  we  might  secure  some 
much-needed  legislation  in  this  country,  and  might 
avoid  some  that  could  well  be  spared.     One  diffi- 
culty with  us  is  to  induce  the  better  men  to  run  for 
such  offices.     A  political  canvass  often  entails  loss 
of  practice,  and,  to  some  extent,  loss  of  prestige — 
but  this  latter,  at  least,  should  never  be  so.    They 
do  these  things  better  in  France. 

The  Army  Canteen. — No  one  need  be  surprised 
that  the  effects  of  the  law  abolishing  the  canteen 
from  the  United  States  Army  are  proving  disas- 
trous. No  man  with  average  worldly,  sense,  who 
knows  that  soldiers  should  be  treated  like  men  and 
not  like  school  boys,  need  hesitate  to  raise  his  voice 
in  protest.  The  action  of  Congress,  in  the  first 
place,  was  doubtless  insincere,  for  it  was  largely  in 
response  to  the  agitation  of  a  woman's  temperance 
organization,  and  was  evidently  not  in  accord  with 
the  personal  convictions  of  most  of  the  Congress- 
men who  voted  for  it.  The  attempt  to  make  men 
total  abstainers  by  act  of  Congress  will  fail,  as  it 
deserves  to  fail.  The  willingness  to  indulge  the 
impractical  ethics  of  a  private  organization  of  agi- 
tators at  the  expense  of  the  comforts  and  personal 
rights  of  the  soldiers  in  the  United  States  Army, 


will  evidently  soon  be  rebuked  by  an  enlightened 
public  opinion.  During  the  short  time  that  the  law 
has  been  in  force,  it  has  led  to  increase  in  drunk- 
enness and,  worse  yet,  to  increase  in  venereal  dis- 
eases. Dr.  L.  L.  Seaman,  in  a  paper  read  before 
the  Association  of  Military  and  Naval  Surgeons, 
quoted  in  the  New  York  Sun,  openly  declares  this 
to  be  a  fact.  The  men  who  are  obliged  to  leave 
the  post  for  the  saloon,  find  it  a  short  step  evidently 
from  the  saloon  to  the  brothel.  The  American  Med- 
ical Association  at  St.  Paul  has  put  itself  on  record 
in  a  resolution  in  which  it  deplores  the  action  of 
Congress  in  abolishing  the  army  post  exchange, 
or  canteen,  and  in  the  interest  of  discipline,  moral- 
ity and  sanitation,  recommends  its  re-establishment 
at  the  earliest  possible  date. 

The  effect  of  the  act,  as  we  understand  it,  is  to 
deprive  the  soldier  of  his  social  club  and  a  part  of 
his  social  life  within  the  precincts  of  his  post  or 
garrison.  If  such  a  law  is  to  stand,  we  should  all 
look  out  lest  every  club  in  civil  life  be  closed  ere 
long  by  some  more  of  this  grandmotherly  legisla- 
tion. 

The   Oldest   Printed   Medical   Book.— Dr.    Fred- 
erick P.  Henry,  the  Honorary  Librarian  of  the  Col- 
lege of  Physicians  of  Philadelphia,   has    the    true 
scholar's  instinct  to  range  himself  among  the  lauda- 
torcs  temporis  acti.    In  a  recent  address  delivered  be- 
fore the  Book  and  Journal  Club  of  the  Medical  and 
Chirurgical  Faculty  of  Maryland  {Maryland  Medical 
Journal,  June,  1901),  Dr.  Henry  started  to  describe, 
the  valuable  collection  of  Incunabula  in  the  College 
Library,  but  he  became  so  much  interested  in  one 
of  these  old  books  that  he  very  wisely  decided  to 
devote  himself  to  a  description  of  it  alone.    To  this 
fact  we  owe  his  most  interesting  account  of  a  vol- 
ume which  he  tells  us  is  reputed  to  be  the  first 
printed  medical  book.    This  is  the  Tractatus  de  Epi- 
dcmia  et  Pcstc,  of  Valescus  de  Tarenta.    About  this 
rare  and  venerable  tome,  which  is  one  of  the  price- 
less relics  of  primitive  typography.  Dr.  Henry  dis- 
courses in  a  most  instructive  way.    This  book  was 
printed  doubtless  before  1474,  but,  like  the  very  old- 
est incunabula,  it  is  without  date,  and  the  proof  of 
its  age  is  collateral.     Its  contents  are  appropriate 
to  the  present  time,  for  it  discusses  the  Plague  (that 
perennial  subject  in  medical  literature),  and,  as  Dr. 
Henry  tells  us,  it  is  redolent  of  the  past,  for  it  con- 
tains the  ancient  prescription   called   the  "theria- 
ca,"  which  was  composed  of  sixty  or  seventy  in- 
gredients.    The  "Incunabula"  are  the  books  that 
were  printed  before  the  beginning  of  the  Sixteenth 
Century,  and  Dr.  Plcnry  has  done  well  to  introduce 
the  patriarch  of  the  bibliological  fold  to  a  modern 
ami  somewhat  forgetful  medical  public.     Valescus 


J  J  ,  -,       The  Philadelphia"] 
'  '  '  —       Medical  Journal    J 


EDITORIAL  COMMENT 


[Juke   15,    UOl 


de  Tarenta  was  a  Portuguese  physician,  who  seems 
to  have  taught  in  the  ancient  university  of  Mont- 
pellier,  and  who  wrote  his  book  many  years  before 
the  invention  of  printing.  He  never  saw  the  child 
of  his  brain  in  print,  and  would  doubtless  have  been 
much  surprised  if  he  could  have  known  that  it  was 
to  be  distinguished  in  future  ages  by  being  num- 
bered in  a  favored  class  called  the  Incunabula. 

Retrospect  and  Prophecy. — In  his  able  r^sum^  of 
the  advances  made  in  internal  medicine,  in  the  19th 
century.  Dr.  N.  S.  Davis,  Jr.,  in  the  annual  ad- 
dress before  the  American  Medical  Association,  has 
touched  at  the  end,  upon  the  part  which  is,  perhaps, 
most  interesting  to  us  all,  namely,  the  probable  ad- 
vancement that  will  take  place  in  the  present  cen- 
tury. 

Prophecy  is  an  art  easily  learned.  To  acquire  it 
one  needs  as  capital,  assurance  and  imagination, 
added  to  a  more  or  less  intimate  acquaintance  with 
the  past.  With  these  it  is  possible  (for  such  is 
the  credulity  of  the  world)  to  acquire  a  large  and 
devoted  following.  Nevertheless,  the  perusal  of  Dr. 
Davis'  article  has  inspired  us  to  attempt  to  go 
a  little  further  than  he  has  gone. 

It  is  trite  to  mention  that  stagnation  never  occurs. 
Things  go  forward  or  backward.  For  instance, 
there  is  no  question,  since  the  discovery  of  elaborate 
surgical  instruments  at  Pompeii,  that  operations 
were  then  performed  whose  very  memory  has 
been  lost.  And  we  must  believe  that  at  that  time 
surgery  had  advanced  to  a  point  of  considerable 
efficiency.  Then  it  retrograded  with  the  fall  of 
Rome,  and  even  during  the  Italian  Renaissance  was 
probably  less  advanced  than  at  the  beginning  of  the 
Christian  era.  From  that  time  it  advanced  slowly, 
indeed  almost  imperceptibly.  Then  came  the  French 
Revolution,  and  to  the  terrific  stimulus  to  human 
activity  produced  by  it,  medicine  was  at 
once  the  debtor.  It  was  to  this  era  that  Corvisart, 
Bichat,  and  Laonnec  belonged,  who  founded  the 
sciences  of  diagnosis  and  pathology,  which  were  and 
are  inseparable.  In  the  vast  industrial  development 
that  has  followed  the  increased  facility  of  commu- 
nication, human  activity  has  again  been  stimulated 
to  the  utmost,  perhaps,  over-stimulated.  And,  ac- 
cording as  it  will  continue  to  develop  or  commence 
to  retrograde,  two  courses  are  possible  for  medi- 
cine. Either  it  will  stop  at  or  near  its  present  point, 
seemingly  on  the  threshold  of  great  discoveries ;  or 
it  will  advance,  the  discoveries  will  be  made,  and 
our  descendants  will  reap  the  reward  perhaps  in  the 
extirpation  of  infectious  processes,  and  a  knowledge 
of  human  physiology  that  will  render  possible  al- 
most continuous  health.  Let  us  look  for  a  moment 
on  the  pessimistic  side.     As  in  all  periods  of  retro- 


gression, exact  observation  will  gradually  cease. 
In  its  place  meaningless  terms,  the  most  extrav- 
agant theories  will  occupy  the  attention  of  physi- 
cians, who  will  have  numerous  cults  and  sects. 
Methods  which  we  now  regard  as  arrant  quackery 
will  flourish  among  the  most  distinguished  of  the 
profession.  Medical  morality  will  be  impaired, 
and  instead  of  cultivating  hygiene  and  prevention, 
the  profession  will,  at  least  negatively,  encourage 
the  increase  of  the  disease.  And  the  work  that  ad- 
vancing science  is  beginning  to  regard  as  useless 
will  be  done  over  and  over  again  in  a  routine  man- 
ner, and  obtain  much  applause.  There  is  a  certain 
amount  of  justification  for  this  gloomy  picture,  for 
the  condition  of  the  world,  the  unrest  of  the  masses, 
the  concentration  of  wealth  in  the  hands  of  the  few, 
is  not  unlike  that  which  commenced  in  the  last  days 
of  the  Roman  Republic,  continued  during  the  Em- 
pire, and  gradually  wrought  disaster. 

On  the  other  hand,  we  can  hope  that  Dr.  Davis' 
view  is  correct.  That  methods  of  investigation  as 
little  dreamed  of  as  was  the  Riintgen  ray,  will  be  dis- 
covered ;  that  the  medical  profession  will  awake  to 
the  importance  of  pharmacology  and  therapeutics, 
and  no  longer  allow  them  to  wither  in  neglect,  and 
that  our  medical  grandchildren  will  regard  us  as 
quite  as  hopelessly,  almost  wilfully,  ignorant,  as  we 
regard  our  medical  great-grand-sires. 

Gastroptosis. — Gastroptosis,  or  Glenard's  Dis- 
ease, is  one  of  the  most  complicated  in  medicine.  In 
the  first  place,  it  seems  quite  certain  nowadays  that 
this  condition  is  not  really  due  to  the  causes  that 
were  originally  supposed  to  produce  it,  that  is,  tight 
lacing,  repeated  pregnancy,  etc.,  for  it  is  by  no  means 
uncommon  in  men.  In  the  second  place,  although 
it  is  often  associated  with  the  gastro-intestinal  type 
of  neurasthenia,  not  infrequently  with  hypochlor- 
hydria  and  constipation,  and  a  moderate  degree  of 
anemia,  it  is  not  so  verj^  rarely  found  in  persons 
whose  health  and  nutrition  leave  nothing  to  be  de- 
sired, and  in  all  likelihood  would  be  more  frequently 
found  if  more  frequently  sought.  For,  as  a  matter 
of  fact,  the  position  of  the  stomach  is  rarely  deter- 
mined with  much  accuracy,  except  in  persons  suf- 
fering from  obvious  disturbance  of  that  organ.  Nev- 
ertheless, gastroptosis,  or  more  accurately  speak- 
ing, splanchnoptosis,  is  an  abnormal  condition  of  the 
abdominal  viscera.  Various  methods  have  been  de- 
vised by  which  reposition  may  be  affected.  Among 
the  most  drastic  of  these  is  the  operation  of  Beyea, 
which  consists  of  stitching  the  stomach  to  the  dia- 
phragm. As  this  can  be  employed  in  only  an  ex- 
cessively small  proportion  of  the  cases  (as  a  mat- 
ter of  fact,  we  believe  there  is  only  one  such  at- 
tempt on  record),  the  majority  of  physicians  will 


JV.NE     ir,     I'.'OIJ 


EDITORIAL  COMMENT 


TThe  Philadelphia 
Lmedical  Journal 


III3 


prefer  some  external  support  applied  to  the  abdomi- 
nal wall.  For  this  purpose  a  number  of  binders 
have  been  devised,  but  thej-  all  have  the  disadvan- 
tage of  having  a  tendency  to  slip  upward,  under 
which  circumstances  they  are  more  apt  to  depress 
than  support  the  organs.  To  obviate  this  an  inge- 
nious method  has  been  devised  by  Lincoln  (Tlw 
Medical  Nezcs,  Sept.  1st,  1900),  who  employs  straps 
of  rubber  adhesive  plaster  cut  in  a  peculiar  way,  the 
broader  portions  being  attached  to  the  ventral  sur- 
face and  the  narrow  portions  crossing  in  the  back. 
Bv  this  means  the  binder  remains  fixed  in  one  posi- 
tion, supports  the  lower  portion  of  the  abdomen,  and 
usually  gives  more  or  less  relief,  or  at  the  very 
least,  an  agreeable  sensation  of  support.  Such  me- 
chanical methods  can  at  least  do  no  harm,  and  if 
thev  accomplish  nothing  more  than  the  encourage- 
ment of  the  patient,  are  well  worth  a  trial. 

A  Liberal  Education  and  the  Study  of  Medicine. 
— The  Outlook  has  recently  published  a  laudatory 
notice  of  the  utterances  of  Dr.  Edmund  W.  Holmes, 
of  this  city,  in  respect  to  a  liberal  education  for 
professional  men,  especially  medical  men.  Dr 
Holmes  has  analyzed  the  figures  supplied  by  a  num- 
ber of  American  universities,  and  finds  in  some  of 
them,  especially  those  which  are  noted  for  their 
medical  curriculum,  a  distinct  tendency  away  from 
what  is  usually  called  a  "liberal  education."  He  at- 
tributes this  tendency  to  three  principal  causes. 
First,  the  desire  to  begin  professional  work  early. 
Second,  the  encouragement  of  the  belief,  held  by 
some  professional  men,  that  a  college  education  is 
a  waste  of  time.  Third,  the  popular  error  that  a 
professional  or  technical  education  is  of  itself  a  lib- 
eral education.  Dr.  Holmes  does  not  agree  with 
these  views,  and  we  agree  with  Dr.  Holmes.  We 
have  never  sympathized  with  the  opinions  of  those 
medical  teachers  who  are  constantly  declaiming 
against  a  liberal  education  for  the  medical  student. 
AVe  understand  fully  the  grounds  upon  which  they 
base  their  objections.  It  is,  if  we  mistake  not,  the 
utilitarian  objection  that  a  liberal  education  is  not 
necessary  to  success  in  the  practice  of  medicine.  \\  e 
do  not  attempt  to  combat  this  statement.  A\'e  know 
that  it  is  in  large  part  true.  It  is  easy  to  point  to 
very  many  men  who  have  been  eminent  in  our  pro- 
fession without  the  assistance  of  a  liberal  education. 
We  grant  this  without  dispute,  and  we  honor  these 
men  not  the  less,  but  rather  the  more.  We  think, 
however,  that  the  argument  is  doubly  fallacious  and 
unreliable,  and  that  in  fact  it  has  nothing  whatever 
to  do  with  the  real  question.  A  liberal  education  is 
not  intended  for  mere  utilitarian  advantages.  One 
might  as  well  speak  against  the  fine  arts,  or  litera- 
ture, or  ethics,  or  even  against  religion  itself,  be- 
cause these  are  not  absolutely  essential  to  a  techni- 


cal training,  as  to  decry  a  liberal  education.  Such 
an  education  is  not  intended  to  be  a  mere  aid  in  the 
winning  of  bread  and  butter,  neither  is  it  intended 
to  be  a  mere  accessory  to  a  technical  training,  al- 
though we  believe  the  time  is  coming  when  it  will 
be  more  and  more  a  necessity  for  success  in  some  of 
the  purely  technical  pursuits.  But,  laying  that 
aside,  it  can  be  broadly  stated  that  a  liberal  educa- 
tion has  an  entirely  different  object,  and  that  that 
object  is  the  cultivation  of  the  mind,  the  broadening 
of  the  intellect,  the  endowment  of  the  moral  sense, 
the  acquaintance  with  the  best  attainments,  history, 
cultivation,  literature,  and  development  of  the  race, 
and  that  it  is  far  above  all  considerations  of  mere 
utilitarianism. 

The  case  of  Huxley  is  well  in  point.  This  emi- 
nent man  suflfered  from  the  deficiencies  of  his  early 
education,  but  he  realized  this  so  fully,  and  devoted 
himself  so  assiduously  and  so  successfully  to  the 
remedy  of  these  defects,  that  he  became  a  man  of 
wide  cultivation,  not  only  in  science,  but  in  litera- 
ture, languages,  philosophy,  metaphysics,  history, 
and  even  theology,  to  all  of  which  he  added  the  ad- 
vantages of  a  fine  literary  style.  Was  this  liberal 
education  of  no  advantage  to  Huxley? 

With  respect  to  medicine,  which  is  a  profession 
that  brings  a  man  most  intimately  into  contact  with 
his  fellows,  we  believe  that  from  a  mere  personal 
standpoint,  a  liberal  education  is  a  desirable  and  ap- 
propriate thing  for  a  physician  to  have.  We  do  not 
contend  for  a  moment,"  however,  that  it  is  a  neces- 
sity for  his  success  or  profit.  We  think  it  should  be 
apparent,  nevertheless,  to  most  thoughtful  observers 
that  the  argument  that  a  young  man  cannot  spare 
the  time  to  be  liberally  educated  is  a  most  uncon- 
vincing one.  It  makes  practically  little  difference 
to  his  success  whether  a  young  man  receives  his 
medical  degree  at  twenty-two  or  twenty-three,  on 
the  one  hand,  or  twenty-five  or  twenty-six  years  of 
age,  on  the  other.  If  there  is  any  advantage  it  is 
on  the  side  of  his  not  taking  his  degree  too  early. 
Few  men  succeed  in  the  practice  of  medicine  until 
they  are  well  past  thirty,  and  the  years  before  thirty 
can  well  be  devoted  to  education  in  the  widest  sense 
of  that  word.  A  young  man  has  lost  nothing  who 
has  given  a  few  additional  years  to  the  cultivation 
of  his  mind!  Such  a  curriculum  certainly  does  not 
disable  him  for  anything,  while  as  a  rule  it  not  only 
makes  him  more  readily  efficient  as  a  student  of  the 
intricate  sciences  of  medicine,  but  it  gfives  him  a 
personal  endowment  which  is  of  inestimable  advan- 
tage to  him  as  an  individual  and  a  citizen.  The 
claim  that  z  3"oung  man  wastes  three  or  four  years 
of  his  life  in  the  cultivation  of  his  mind  in  attaining 
a  liberal  education  can  only  be  based  upon  an  erro- 
neous view  of  what  constitutes  one  of  the  highest 
aims  in  life. 


1 1 14 


The  Philadelphia"! 
Medical  Journal  J 


REVIEWS 


[June   i;.    IMl 


IRcvicws. 


"The  History  of  Medicine  in  the  United  States. — A  col- 
lection of  Facts  and  Documents  Relating  to  the  History 
of  Science  in  This  Country,  From  the  Earliest  Coloniza- 
tion to  the  Year  ISOO;  with  a  Supplemental  Chapter 
on  the  Discovery  o£  Anesthesia,"  by  Francis  Randolph 
Packard,  M.  D.  Philadelphia  and  London:  J.  B.  Lip 
pincott  Company,  1901. 

Those  who  have  read  the  interesting  articles  from  the 
pen  of  Francis  R.  Packard  on  various  subjects  relating  to 
the  early  history  of  medicine  can  imagine  the  value  of  this 
volume,  and  can  appreciate  the  author's  peculiar  fitness  for 
the  work  which  he  has  undertaken.  The  author  displays 
too  great  modesty  when  he  describes  his  work  as  a  "collec- 
tion of  facts  and  documents  relating  to  the  history  of  medi- 
cal science  in  this  country,"  for  although  this  in  some  de- 
gree describes  the  work,  yet  these  facts  and  documents  are 
so  placed  in  their  relation  to  one  another  and  with  such  en- 
tertaining comments  and  paragraphs  by  the  author,  that 
it  would  seem  to  us  that  the  simple  word  history  would 
best  describe  what  is  to  be  found  between  the  covers  of  this 
interesting  volume.  Not  only  will  the  reader  find  this  work 
pleasing  and  entertaining,  but  it  will  also  serve  a  most  ex- 
cellent purpose  as  a  book  of  reference,  being  filled  as  it  is 
with  such  accurate  accounts  and  notes  regarding  the  his- 
tories of  medical  men,  of  epidemic  diseases,  hospitals, 
medical  societies,  etc.,  during  the  colonial  period  and  the 
early  part  of  our  national  life. 

The  book  is  composed  of  11  chapters  and  5  appendices. 
The  illustrations  are  particularly  interesting  and  many  of 
them  are  produced  for  the  first  time.  The  thoroughness 
of  the  work  extends  through  the  index,  which  will  be  found 
most  satisfactory  by  those  wishing  to  refer  to  any  of  tht 
subjects  treated  in  the  text. 

Chapter  I  relates  the  medical  events  connected  with  the 
early  history  of  the  English  colonies  in  America.  In  it  are 
to  be  found  many  amusing  and  entertaining  accounts  of  the 
medical  treatment  received  by  the  early  colonists.  Chap- 
ters II  and  III  refers  to  the  history  of  the  various  epidemic 
sicknesses  which  were  prevalent  from  the  earliest  coloniza- 
tion to  the  year  1800.  Here  the  author  gives  an  interesting 
account  of  the  use  of  inoculation  with  smallpox,  and  of  the 
trouble  which  its  early  advocate.  Dr.  Zabdiel  Boylston. 
suffered  at  the  hands  of  those  who  were  opposed  to  this 
method  of  prevention  of  smallpox.  It  was  not  long,  how- 
ever, before  this  practice  became  very  popular,  many  prom 
inent  men,  among  whom  was  Benjamin  Franklin,  having 
undergone  the  most  radical  change  regarding  their  attitude 
toward  it.  So  prevalent  did  this  treatment  become  that 
inoculation  developed  into  a  specialty  and  houses  were 
especially  set  aside  for  the  care  of  those  undergoing  the 
treatment.  The  introduction  of  vaccination  into  the  United 
States  is  ascribed  to  Dr.  Benjamin  Waterhouse,  who  in 
ISOO  obained  some  vaccine  virus  from  England  and  vaccin- 
ated   bis   own   son. 

The  terror  and  ravages  of  yellow  fever  epidemics  so 
frequent  in  the  early  days,  and  the  various  methods  of 
their  prevention  and  control  are  interestingly  related,  par- 
ticularly the  experience  of  Philadelphia  with  this  disease 
In  this  connection  the  author  has  introduced  a  number  of 
interesting  anecdotes  regarding  the  controversies  in  rela- 
tion to  the  treatment  of  yellow  fever,  which  wre  indulged 
in  by  the  adherents  of  Dr.  Rush  on  one  side  and  of  Dr. 
Kuhn  on  the  other.  These  disputes  at  the  time  so  acri- 
monious now  afford  the  reader  only  amusement.  Canings, 
duellings  and  lawsuits  were  quite  common  among  medical 
men  at  this  time. 

The  courage  and  adherence  to  duty  displayed  by  the 
medical  men  of  Philadelphia  at  this  time  is  shown  by  the 
fact  that  many  lost  their  lives  by  remaining  in  the  city 
and  attending  to  the  stricken  at  a  time  when  everybody  who 
coukl  afford  it  went  to  the  country. 

Chapter  r\'  deals  with  medical  education  before  the 
foundation  of  medical  schools  in  this  country.'.  This  chap- 
ter is  illustrated  by  the  reproduction  of  a  number  of  inter- 
estlns;  certificates  granted  students  by  their  preceptors 
Many  American  students  went  abroad  at  this  time  to  com- 
plete their  education,  and  Packard  has  reproduced  some  of 
the  tickets  Issued  by  the  hospitals  and  universities  admit- 


ting students  to  the  lecture  and  clinics,  and  it  is  amusing 
to  find  there  permits  printed  on  the  back  of  playing- 
cards. 

The  first  medical  degree  in  this  country  was  conferred 
by  Yale  on  Daniel  Turner  in  1720.  This,  however,  was  an 
honorary  degree.  Packard  thinks  the  first  degree  conferred 
after  a  course  of  medical  study  was  that  of  John  Archer, 
from  the  College  of  Philadelphia  in  1768.  The  first  law  reg- 
ulating the  practice  of  physic  was  passed  by  the  Virginia 
Assembly  in  1736.  Philadelphia  seems  to  have  been  the 
center  in  these  early  days  for  medical  teaching,  and  Pack- 
ard goes  very  thoroughly  into  the  history  of  this  time.  The 
part  taken  by  the  Pennsylvania  Hospital  in  the  education  of 
students  of  medicine  is  carefully  reviewed  in  this  chapter. 
An  interesting  figure  in  the  medical  world  at  this  time  was 
Dr.  Abraham  Chovet.  of  whom  many  amusing  stories  are 
related,  and  a  reproduction  of  a  wax  medallion  made  "by 
his  servant.  Dr.  Eckhout"  inserted  as  an  illustration. 
Chapter  V  deals  with  the  early  medical  schools,  the  first  of 
which  was  the  Vniversity  of  Pennsylvania,  and  the  second 
the  College  of  Physicians  and  Surgeons  of  Xew  York.  Any- 
one interested  in  military  medicine  will  find  Chapter  VT 
full  of  entertainment,  for  here  the  author  in  a  pleasing 
style  has  gone  deeply  into  the  medical  men  and  methods 
of  the  Continental  Army.  Those  who  suffered  unjust  criti- 
cism and  abuse  during  our  recent  war  with  Spain  will  find 
comfort  in  these  pages.  In  Chapter  VII  the  early  hospitals 
are  discussed,  and  the  Pennsylvania  Hospital,  which  is  the 
oldest  institution  of  the  kind  in  America,  is  allowed  a  num- 
ber of  pages  in  which  are  described  briefly  but  entertain- 
ingly its  origin,  progress  and  its  benefits  both  to  suffering 
humanity  and  to  the  medical  profession.  The  improvement 
in  the  treatment  of  the  insane  in  this  institution  brought 
about  by  Dr.  Rush,  is  pleasingly  related.  The  history  of 
the  New  York  Hospital  is  also  briefly  reported.  Chapter 
VlII  deals  with  the  history  of  medical  societies  in  the 
United  States  before  the  year  1800,  and  Packard  tells  us 
that  the  oldest  medical  society  now  extant  is  that  of  the 
State  of  New  Jersey.  The  author  deserves  great  credit  for 
the  care  he  has  taken  in  the  preparation  of  this  chapter 
and  of  the  next,  which  refers  to  the  pre-revolutionary 
medical  bibliography.  Chapter  X  briefly  refers  to  the  laws 
passed  by  the  various  colonial  legislatures  regarding  the 
practice  of  medicine.  Chapter  XI  is  devoted  to  a  discus- 
sion of  the  discovery  of  anesthesia,  and  the  author  unre- 
servedly gives  to  Dr.  Crawford  W.  Long,  of  Georgia,  the 
honor  of  having  first  used  ether  anesthesia  for  the  perform- 
ance of  surgical  operations,  and  fortifies  this  position  with 
most  conclusive  arguments.  To  Dr.  W.  J.  G.  Morton  is. 
however,  accorded  the  credit  of  demonstrating  to  the 
medical  profession  and  to  the  world  the  use  of  ether. 

After  reading  this  interesting  book  one  can  but  feel  that 
the  medical  profession  owes  Packard  a  debt  of  gratitude 
for  the  great  amount  of  labor  which  he  has  spent  in  the 
preparation  of  this  work,  and  for  the  entertaining  manner 
in  which  he  has  related  the  many  facts  regarding  the  early 
history  of  medicine  in  America.  It  is  just  this  sort  of  work 
which  has  been  too  much  neglected  by  the  medical  profes- 
sion in  this  material  age.  and  it  is  a  pleasure  to  see  that 
one  of  its  members  has  been  willing  to  devote  so  much  of 
his  time  to  this  labor  of  love.     [J.  H.  G.] 


The  Walcher  Position  During  Parturition. — Dr.  Val&re 
Cocq.  (in  Lu  (Prcfxc  Mcilirah'  Bclne.  1901.  No.  19>,  has  re- 
viewed the  different  positions  suggested  during  labor.  The 
erect  position,  in  us?  yet  among  savage  tribes,  he  advo- 
cates in  primiparae  during  the  first  stage  of  labor.  The 
dorsal  position,  the  patient  lying  upon  her  back,  is  only  in- 
dicated when  great  weakness  exists.  In  normal  cases  he 
considers  a  reclining  position,  half  down  and  half  sitting 
up.  advantageous  until  the  head  reaches  the  perineum.  The 
genu-pectoral  position  is  only  indicated  when  certain  path- 
ological conditions  exist,  prolapse  of  the  cord,  or  difficult 
version.  The  lateral  position  is  the  best  when  the  head 
reaches  the  perineum.  The  Walcher  position,  extreme  hy- 
perextension,  is  brought  about  by  placing  a  cushion  under 
the  sacrum  to  elevate  it.  the  legs  being  allowed  to  hang 
freely.  In  this  position  the  true  conjugate  is  increased 
some  millimeters.  This  may  be  advantageous  when  the 
superior  strait  is  narrow,  or  in  cases  of  contracted  or  ky- 
photic pelves.  But  it  is  not  advised  after  the  head  passes 
the  superior  strait     [M.  O.] 


JUNE    15,    1901] 


AMERICAN  NEWS  AND  NOTES 


TThe  Philadelphia 
L  Medical   Journal 


III^ 


Hnicrican  H^cws  an^  Tllotcs. 


PHILADELPHIA,  PENNSYLVANIA,  ETC. 

The  Kensington  Hospital  for  Women. — During  the  month 
o£  May  seventy-one  patients  were  under  treatment.  There 
were  thirty-five  patients  in  the  Hospital  May  1st,  and 
twenty-nine  are  under  treatment  at  the  present  time. 
Fourteen  abdominal  sections  and  fifty-nine  other  opera- 
tions have  been  performed.  In  the  Dispensary  there  have 
been  thirty-three  new  patients,  who  have  made  one 
hundred  and  twenty-seven  visits. 

College  of  Physicians  of  Philadelphia. — At  the  meeting 
of  June  5.  Dr.  Jay  F.  Schamberg  e.xhibited  two  patients 
showing  epithelial  cancer  of  the  cheek  treated  by  chemi- 
cal caustics.  The  first  patient  was  a  woman  of  8.3,  who 
has  only  a  short  linear  scar  marking  the  site  of  an  epithel- 
ioma of  15  years  standing.  The  treatment  consisted  in  the 
application  of  25%  carbolic  acid  ointment  for  a  week  and 
then  a  50%  solution  of  caustic  potash  followed  by  25% 
arsenious  acid.  These  applications  were  made  after  swab- 
bing the  parts  with  cocaine.  In  4  weeks  the  growth  was 
completely  healed.  The  second  patient  was  a  man  who  is 
at  present  undergoing  the  same  treatment. 

Drs.  J.  S.  Jopson  and  R.  S.  White  reported  a  case  of 
sarcoma  of  the  large  intestine  in  a  boy  of  4  years.  Prac- 
tically all  the  abdominal  viscera  were  infiltrated  by  the 
growth.  The  literature  of  the  subject  was  reviewed,  22 
cases  being  recorded. 

Dr.  J.  M.  Spellisy  read  for  Dr.  Wilson  and  himself  the 
report  of  over  100  cases  of  thermic  fever  and  heat  exhaus- 
tion in  the  Pennsylvania  Hospital,  occurring  mainly  in 
the  year  1S92.  Dr.  Spellisy  reviewed  at  length  the  sta- 
tistics of  the  hospital  regarding  the  above  cases.  In  17G4 
the  first  case  was  recognized  and  was  recorded  under  the 
heading,  "Drinking  Cold  Water." 

In  the  discussion  Dr.  Morris  B.  Lewis  said  that  a  great 
deal  was  yet  to  be  done  in  the  study  of  these  cases  by 
examination  of  the  blood.  Dr.  J.  C.  Wilson  stated  that 
many  of  the  symptoms  were  due  to  auto-intoxication  and 
for  this  reason  injections  of  salt  solution  should  be  em- 
ployed in  addition  to  treatment  by  cold.  Dr.  F.  A.  Pack- 
ard spoke  of  some  features  of  these  cases  which  are  not 
noted  in  the  majority  of  the  text  books.  First  was  the 
curious,  mousy  odor,  which  he  considers  diagnostic  of  ther- 
mic fever.  Second  is  a  crooning  sort  of  groan  emitted, 
which  is  also  of  diagnostic  importance.  Third,  the  char- 
acter of  the  stools,  and  fourth  the  admixture  of  tonic  and 
clonic  convulsions.  The  lack  of  serosity  of  the  blood  is 
probably  the  cause  of  the  symptoms  and  for  that  reason 
hypodermoclysis  is  indicated.  Dr.  James  Tyson  said  that 
from  the  above  view  a  possible  explanation  of  the  good  ef- 
fect of  baths  in  the  treatment  was  that  submersion  caused 
a  certain  amount  of  absorption  of  fluid.  Recovery  is  gen- 
erally more  rapid  when  the  patient  is  immersed  than 
when  he  is  simply  rubbed  with  ice. 

Suicide  of  Dr.  W.  H.  Daly. — One  of  the  remorseless  on- 
slaughts of  fate  was  exemplified  by  the  pathetic  instances 
surrounding  the  death  of  Dr.  W.  H.  Daly,  at  Pittsburg, 
Pa.,  Chief  Volunteer  Surgeon  in  the  war  with  Spain  in 
1898.  Major  Daly  was  59  years  old  and  was  one  of  the  best 
known  physicians  in  Pennsylvania.  He  was  a  close  friend 
of  Lieut.  Gen.  Nelson  A.  Miles,  and  after  his  appointment 
as  chief  surgeon  of  volunteers  was  assigned  to  duty  on 
General  Miles'  staff  at  Tampa  while  the  head  of  the  army 
was  at  that  place.  His  friends  first  noticed  his  despon- 
dency when  the  beet  court  of  inquiry  submitted  its  volumin- 
ous report,  in  which  it  criticised  Dr.  Daly's  testimony  re- 
garding analysis  of  beef  he  had  made.  When  his  wife 
died  at  Garner,  Iowa,  several  months  later  he  became 
worse.  His  friends  advised  him  to  go  away  on  a  Rocky 
Mountain  hunting  trip  and  he  did  so.  He  fiequently  hunted 
with  General  Miles  and  William  Cody  ("Buffalo  Bill"). 
After  his  return  he  did  not  show  much  improvement.  He 
was  a  specialist  in  throat  disease,  but  lost  interest  in  his 
profession.  About  9.45  o'clock  on  the  morning  of  June 
9  the  body  of  Dr.  Daly  was  found  dead  in  the  bath  room 


of  the  house  in  which  he  lived,  and  a  38  calibre  revolver 
was  found  beside  him  with  one  chamber  empty,  the  bullet 
having  entered  his   right   temple. 

Poisoning  of  Dogs  a  Penal  Offence. — A  bill  was  intro- 
duced in  the  House  making  it  a  misdemeanor,  punishable 
by  a  fine  not  exceeding  $500  and  three  years'  imprisonment, 
to  wilfully  poison  dogs. 

Vital  Statistics  of  Philadelphia  for  the  week  ending  June 
8,  1901. 

Total   mortality    410 

Cases.  Deaths. 

Inflammation  of  the  appendix  3,  blad- 
der 1,  brain  16,  bronchi  2,  heart  3, 
kidneys  20,  larynx  1,  liver  2,  lungs 
41,  peritoneum  6,  stomach  and 
bowels  17,  uterus  1 113 

Marasmus    9,    debility    7,    inanition 

12    28 

Tuberculosis  of  the  lungs 61 

Apoplexy  10,  paralysis  8   18 

Heart-disease  of  34,  fatty  degener- 
ation of  3   37 

Uremia  10,  Bright's  disease  5 15 

Carcinoma  of  the  bowels  1,  breast 
4,  stomach  2,  uterus  1,  liver  1, 
neck   1    10 

Convulsions    7 

Diphtheria    63 

Brain-congestion     of     1,     softening 

of  2   3 

Typhoid  fever  120  12 

Old  age   7 

Scarlet  fever   77  5 

Influenza  1,  abscess,  of  breast  1, 
pelvic  1,  liver  1.  throat  1,  alco- 
holism 2,  asthma  2,  atheroma  1, 
casualties  7,  cerebro-spinal  menin- 
gitis 1,  congestion  of  the  lungs  2, 
cirrhosis  of  the  liver  3,  consump- 
tion of  the  bowels  2,  croup,  mem- 
branous 2,  cyanosis  3,  diarrhea  9, 
drowned  6  dropsy  1,  dropsy 
abdominal  1,  epilepsy  2,  ery- 
sipelas 3,  goitre  1,  gangrene, 
lungs  2.  hemorrhage  from 
uterus  2,  intussusception  1, 
jaundice  1.  leukemia  2,  measles  2, 
obstruction  of  the  bowels  3,  ede- 
ma of  the  lungs  2,  pyemia  1, 
rheumatism  2,  sclerosis,  spine  1, 
liver  1,  septicemia  4,  smallpox  1, 
sarcoma,  lungs  1,  pharynx  1,  suf- 
focation 1,  suicide  2.  teething  3, 
unknown  coroner  case  1,  whoop- 
ing cough  7   94 

NEW  JERSEY. 

Monmouth  Physicians. — The  Monmouth  County  Medical 
Society  held  its  annual  meeting  at  the  Monmouth  House. 
Freehold,  on  Monday,  May  20,  1901.  Dr.  C.  Knecht,  of 
Matawan,  was  the  presiding  officer.  After  dinner  the  so- 
ciety were  addressed  by  Dr.  Knecht,  the  retiring  president, 
upon  "An  advance  in  clinical  diagnosis."  Dr.  Forman  read 
a  paper  upon  appendicitis,  in  which  he  presented  the  con- 
census of  the  most  recent  views  of  the  leading  American 
surgeons  upon  this  disease,  and  gave  his  personal  experi- 
ence as  well  as  the  results  of  treatment  at  the  Monmouth 
Memorial  Hospital.  The  following  members  were  elected 
delegates  to  the  N.  J.  State  Medical  Society:  Drs.  Long, 
MacMillan,  Roberts,  Shaw,  Wooley  and  A.  G.  Brown.  Of- 
ficers for  the  ensuing  year:  Dr.  Ed.  F.  Taylor,  President; 
W.  M.  Hepburn,  Vice  President;  I.  S.  Long,  Treasurer;  D. 
M.  Forman,  Secretary;    Wooley,  Reporter. 

NEW  YORK. 

Cornell  Medical  College. — The  third  annual  commence- 
ment of  Cornell  University  Medical  College  was  held  June 
5  at  the  college  building  in  New  York  City.  The  degree 
of  M.  D.  was  conferred  upon  26  graduates  by  President 
Jacob  C.  Schurman. 


1 1 16 


The  Philadelphia" 
Medical  Journal    . 


AMERICAN  NEWS  AND  NOTES 


[JUN-E    15,    19J1 


Dr.  W.  E.  Young,  recently  in  charge  of  the  Randall's 
Island  hospitals,  has  been  appointed  superintendent  o£  the 
insane  pavilion  at  Bellevue  Hospital. 

Dr.  Frederick  Peterson  has  been  appointed  Clinical  Lec- 
turer in  Psychiatry  in  the  College  of  Physicians  and  Sur- 
geons, Columbia  University. 

NEW    ENGLAND. 

Smallpox  In  New  England. — It  is  stated  that  smallpox  is 
more  prevalent  in  New  England  than  it  has  been  for  many 
years.  At  Berlin,  N.  H.,  and  Cranston,  R.  I.,  the  number  of 
cases  is  large.  Smallpox  is  in  Boston,  13  cases  being  in  the 
Roxbury  district.  Galloupes  Island  in  Boston  Harbor  has 
19  cases  in  quarantine,  which  came  on  a  pest  schooner 
from  Cape  Verde  Islands.  There  are  cases  also  at  Provi- 
dence and  other  places  in  Rhode  Island:  Marlboro,  Worces- 
ter, Leominster,  Fitchburg  and  other  places  in  that  State, 
and  isolated  cases  in  Xew  Hampshire  and  Vermont. 

Narcotics  in  New  England. — Dr.  A.  P.  Grinnell,  of  Bur- 
Ington,  Vt.,  has  reported  upon  the  use  of  narcotics  in  that 
State.  He  finds  that  every  month  there  is  sold,  exclusive 
of  patent  medicines  and  physicians'  prescriptions,  3.300.000 
doses  of  opium.  Some  storekeepers  refused  to  state  the 
amount  of  sales  of  opium  or  its  derivatives.  These  are  not 
counted  in  the  estimate,  so  that  the  actual  amount  is  higher 
than  that  stated.  About  40,000,000  grains  of  opium  are  sold 
a  year. 

WESTERN     STATES. 

Fiftieth  Anniversary  of  the  Invention  of  the  Ophthalmo- 
scope.— The  section  on  ophthalmology  of  the  American 
Medical  Association  devoted  the  greater  part  of  its  morn- 
ing session  on  June  5th,  1001.  toward  observing  the  fiftieth 
anniversary  of  the  invention  of  the  ophthalmoscope.  Dr. 
H.  Friedenwald  of  Baltimore,  Md.,  delivered  an  address 
on  the  origin  and  development  of  the  instrument  together 
with  a  description  of  the  historic  exhibit  of  the  ophthal- 
moscope and  publications  on  opthalmoscopy  prepared  for 
this  meeting.  An  address  on  the  life  of  Helmholtz  was  de- 
livered by  Dr.  C.  A.  Wood  of  Chicago,  111.  In  a  room  ad- 
joining the  one  in  which  the  section  met  there  was  an 
exhibition  of  specimens  and  new  instruments  as  well  as 
some  noteworthy  publications,  and  especially  ophthalmo- 
whichwas  held  under  the  auspices  of  the  ophthalmic  section 
which  was  held  under  the  auspices  of  the  opthalmic  section 
will  be  remembered  with  much  gratification  by  those  who 
witnessed  it  The  original  pattern  of  Helmholtz  stood  out 
as  a  forceful  reminder  of  its  illustrious  inventor  and  was 
surrounded  by  the  models  of  its  successors  among  which 
there  were  the  patterns  of  Liebreich.  Yaeger.  Galezowski. 
Schweigger  and  others.  There  was  an  exhibition  of  the  tools 
used  in  making  the  first  American  model  of  the  Loring  oph- 
thalmoscope by  machinery.  The  original  article  by  Helm- 
holtz entitled  "Beschreibung  eines  Augen-Spiegels  zur 
Untersuchung  der  Netzhaut  im  lebenden  Auge"  was  also  ex- 
hibited. 

SOUTHERN  STATES. 

Dr.  William  Royal  Stokes,  City  Bacteriologist  in  Balti- 
more, has  been  elected  a  member  of  the  faculty  of  the 
College  of  Physicians  and  Surgeons  in  that  city,  and  has 
been  given  the  chair  of  pathology. 

Dr.  A.  H.  Kunst  has  been  elected  superintendent  of  the 
Weston  cW.  Va.)  Lunatic  Asylum  to  succeed  Dr.  W.  E. 
Stathers. 

Monstrosity  Resembling  a  Mermaid. — The  Baltimore  Sun 
states  that  there  was  exhibited  at  the  Health  Department 
at  Baltimore  recently  the  body  of  a  white  child,  normal 
from  the  waist  up.  but  having  instead  of  legs,  a  single 
appendage  terminating  in  a  four-toed  foot.  The  child  was 
dead  when  born.  The  monstrosity  is  a  source  of  much 
interest  to  physicians,  who  declare  it  the  most  remarkable 
ever  seen  at  the  department,  resembling,  as  it  does  in  gen- 
eral appearance,  the  mermaid  of  fable.    It  will  be  preserved. 


CANADA. 

(From  Our  Special  CorrtsjKjndent.  i 
The  Canadian  Nurses'  Association  which  has  been  seek- 
ing incorporation  at  the  hands  of  the  Dominion  Parlia- 
ment has  not  been  very  successful.  When  the  measure  was 
first  brought  before  the  House  Private  Bills  Committee 
strong  opposition  developed  against  it,  but  after  numerous, 
amendments  had  been  offered  and  the  board  of  examiners 
so  arranged  that  a  majority  of  medical  men  would  con- 
stitute its  personnell  the  Bill  was  permitted  to  go  before 
the  House  of  Commons.  Here,  many  and  great  objections 
were  urged  against  the  measure  becoming  law  as  it  was 
thought  to  infringe  on  the  rights  of  certain  English  and 
Welsh  nurses  now  carrying  on  their  profession  in  the 
Canadian  Northwest  Territories,  as  well  as  favoring  the 
larger  hospitals  at  the  expense  of  the  smaller.  Finally 
the  Bill  received  the  six  months'  hoist;  and  during  the  re- 
cess of  parliament  the  physicians  throughout  the  Do- 
minion are  to  be  made  more  thoroughly  acquainted  with 
the  scope  of  the  measure.  It  shall  probably  be  re-introduced 
the  next  session. 

The  Montreal  Foundling  Hospital  is  in  need  of  a  new, 
larger  and  more  modern  building.  At  the  recent  annual 
meeting  held  a  couple  of  weeks  ago.  it  was  stated  that 
the  requirements  of  the  hospital  and  the  need  of  extra 
accommodation  were  so  urgent  that  a  new  building  would 
be  absolutely  necessary  at  no  distant  date.  The  medical 
report  as  well  as  that  of  the  treasurer  was  submitted  to  the 
meeting.  The  latter  showed  that  the  receipts  had  beea 
$6,951  during  the  past  year  and  that  hte  disbursements 
had  amounted  to  $6,762.  leaving  a  balance  on  hand  of  $180. 
By  the  medical  report  it  was  shown  that  there  were  in  the 
hospital  on  the  15th  of  May.  one  year  ago.  thirty-six  ba- 
bies, and  there  had  been  admitted  since  one  hundred  and 
thirty-seven,  making  a  total  of  one  hundred  and  seventy- 
three,  or  an  increase  over  the  previous  years  of  twenty- 
two.  Very  nearly  one  half  of  the  babies  admitted  were 
under  one  week  old,  and  of  these  thirty-one  were  under 
twenty-four  hours  old.  There  were  removed  during  the 
year  by  adoption,  eight;  by  parents,  twenty-six;  death, 
one  hundred  and  six:  Protestant  Orphan  Asylum,  one;  and 
there  remained  in  the  hospital  on  the  15th  of  May.  1901. 
thirty-two.  Pneumonia  and  bronchitis  in  a  serious  form. 
subsequent  to  la  grippe,  carried  oft'  many  of  the  patients. 
An  out-<ioor  dispensary  will  shortly  be  opened  in  connec- 
tion with  this  instiution. 

The  Ottawa  Contagious  Disease  Hospital  seems  to  be  as 
far  off  in  being  established  as  it  was  over  a  year  ago.  Re- 
cently Mr.  Justice  Boyd.  Chancellor  of  Ontario,  has  given 
judgment  in  Toronto,  restraining  the  city  of  Ottawa  from, 
building  a  new  hospital  for  cases  of  this  character  on 
the  property  of  the  Parks  Commissioners,  a  judgment 
which  will  have  a  very  serious  effect  upon  the  city.  At 
the  present  time  there  are  numerous  cases  of  infectious 
diseases  in  the  city  and  no  hospital  to  isolate  them.  The 
provincial  board  of  health  has  condemned  the  old  site  at 
Porter's  Island  in  the  Ottawa  River.  From  the  judgment 
of  Chancellor  Boyd,  it  would  appear  that  the  city  and  its 
board  of  health  is  absolutely  powerless  in  the  matter  and 
can  only  expropriate  land  for  temporay  purposes  in  cases 
of  emergency,  but  can  do  nothing  towards  establis»iing  a 
permanent  hospital.  The  city  by-laws  regarding  the  prox- 
imity of  other  buildings  are  very  strict:  and  the  suburban 
places  object  to  the  presence  of  a  contagious  diseases  hos- 
pital in  their  midst. 

The  Doctors  of  Three  Rivers,  Que.,  met  on  the  30th  of 
May  in  that  city  in  response  to  a  call  to  meet  and  organize 
a  medical  association  for  the  advancement  of  the  profes- 
sion, the  study  of  Dominion  or  Interprovincial  Registra- 
tion and  other  such  like  measures.  The  meetings  will  be 
held  monthly,  the  next  assembly  to  be  held  on  the  24th  of 
June.  After  organizing  routine,  the  following  officers  were 
elected;  Hon.  President,  Dr.  Desaulniers  of  Nicolet;   Hon. 


June  15,  1901] 


AMERICAN  XEWS  AND  NOTES 


["The  Philadelphia 
LMedical  Journal 


I  I  17 


Vice-President,  Dr.  Grenier,  St.  Maurice;  President,  Dr.  L. 
P.  Normand;  1st  vice-president,  Dr.  Marchand;  2nd  vice- 
president.  Dr.  H.  Tnudel;  treasurer,  Dr.  J.  H.  Ledue;  secre- 
tary. Dr.  C.  E.  Darche;  E.xecutive  Committee,  Drs.  Fiset, 
Lacoursiere,  Planta,  H.  Desilets  and  Panneton.  A  com- 
mittee to  continue  ana  complete  the  organization  was 
named,  the  members  of  which  are,  Drs.  J.  E.  Desilets,  W. 
Ferron.  Planta.  Grenier,  and  Lambert. 

Medical  Research  at  McGill  University  is  said  to  form 
part  of  the  plan  which  the  newly  incorporated  Rockefeller 
Institute  of  Medical  Research  is  to  carry  on  in  several  of 
the  universities  of  the  United  States  and  Canada.  It  is 
understood  that  of  the  $500,000  at  the  disposal  of  the  Insti- 
tute that  McGill  will  have  the  use  of  150.000  to  commence 
work  with.  The  work  will  be  conducted  in  the  pathologi- 
<?al  laboratories  of  McGill  under  the  supervision  ot  Pro- 
fessor Adami. 

Western  Hospital.  Montreal. — The  annual  meeting  of  the 
Committee  ot  Management  of  this  hospital  was  held  on  the 
28th  of  May  when  the  various  reports  submitted  showed 
that  the  institution  had  just  passed  through  the  most  suc- 
cessful year  in  its  history.  The  medical  report  showed 
that  at  the  out-door  department  there  had  been  received 
for  treatment  3,500  patients,  as  compared  with  2.457  for  the 
previous  year.  In  the  in-door  department  396  were  treated, 
against  3S0  for  last  year;  there  were  133  private  patients  as 
against  162  in  the  preceding  twelve  months,  but  the  re- 
ceipts from  these  had  been  more  than  for  the  previous 
year.  Sixty-three  per  cent,  of  the  patients  in  the  wards 
were  surgical  cases.  There  had  been  twenty -four  deaths  or 
six  per  cent.,  and  if  the  eight  who  died  within  forty-eight 
hours  of  their  admission  were  deducted,  the  proportion 
would  be  only  four  per  cent.  The  average  daily  cost  of  all 
the  patients  was  90  cents;  of  the  public  patients.  45  cents. 
The  receipts  totalled  19.381.91  and  the  expenditure 
amounted  to  $8,944.79.  The  debt  was  decreased  from  $10,- 
000  to  S8.000  and  this  in  the  face  of  many  improvements. 

Sir  William  Hingston  is  again  the  recipient  of  dis- 
tinguished honor  but  this  time  by  His  Holiness,  the  Pope. 
The  honor  is  the  Papal  Cross  "for  the  Church  and  Pon- 
.  tiff"  in  recognition  of  his  eminent  services  in  the  cause 
cf  charity  and  his  unalterable  devotion  to  the  Church.  His 
Grace  Archbishop  Bruchesi  conveyed  to  Sir  William,  the 
gift  of  the  head  of  the  Church,  which  was  accompanied  by 
the  following  letter  from  Cardinal  Rampolla.  the  papal 
Secretary  of  State: — "His  Holiness  has  deigned  to  accord 
'the  Cross  for  the  Church  and  Pontiff',  to  Sir  William 
Hingston.  as  a  recognition  of  his  devotion  and  fidelity  to  the 
Church  and  its  Supreme  Head.  The  Cardinal  Secretary 
of  State  has  the  pleasure  to  transmit  him  the  diploma  and 
the  said  cross,  in  order  that  he  may  wear  it  on  his  breast, 
as  it  is  customary  to  do  with  other  decorations." 

Convocation  at  Toronto  University  was  held  on  the  after- 
noon of  the  7th  of  June  and  the  annual  banquet  of  the 
Alumni  Association  in  the  evening  thereof.  Dr.  R.  A. 
Reeve.  Dean  of  the  Medical  Faculty,  and  president  of  the 
Alumni  Association,  presided,  and  the  Chancellor  of  the 
University,  Sir  William  R.  Meredith  took  advantage  of  the 
occasion  to  review  the  work  and  developments  of  the 
year.  Speaking  of  the  progress  in  the  Medical  Depart- 
ment: Three  years  ago  the  number  who  entered  that  de- 
partment was  sixty-one.  Xow  it  has  reached  the  number 
of  one  hundred  and  twenty-four.  The  number  of  students 
enrolled  three  years  ago  was  230,  while  the  number  at  the 
present  time  is  340.  besides  fifty-five  occasional  students. 
The  department  of  pathology  has  during  the  past  year  had 
put  at  its  head.  Dr.  J.  J.  MacKenzie  in  whom  the  Chancellor 
expressed  the  utmost  confidence.  Two  recent  graduates 
have  received  appointments  as  assistants  in  the  depart- 
ment of  anatomy  of  Cornell  University.  Sir  William  then 
proceeded  to  score  the  Ontario  Government  for  unsatis- 
factory financial  assistance  to  the  university. 

Dr.  James  Third,  professor  of  medicine  at  Queen's  Uni- 


versity, Canada,  had  an  attack  of  apoplexy  recently  and 
is   not   expected   to  recover. 

Prof.  J.  George  Adami,  of  McGill  University,  Montreal, 
Canada,  has  been  appointed  vice-president  of  the  section 
of  pathology  and  bacteriology  of  the  International  Con- 
gress on  Tuberculosis,  to  be  held  in  London,  England,  in 
July,  under  the  patronage  of  his  Majesty,  King  Edward 
VII. 

MISCELLANY. 
Obituary. — Dr.  P.  A.  Harris,  at  Glendale,  Ore.,  on  May 
30. — Dr.  Allen  T.  Barnes,  at  Bloomington,  111.,  on  May  30. 
— Dr.  James  M.  Stone,  at  Baltimore,  Md.,  on  June  5,  aged 
80  years. — Dr.  Seth  B.  Sprague,  at  Jersey  City,  N.  J.,  on 
June  5,  aged  81  years. — Dr.  D.  C.  Frost,  at  Mount  Vernon, 
111.,  on  June  5.  aged  69  years. — Dr.  William  C.  Parsons,  at 
Chicago,  111.,  on  June  2.— Dr.  E.  Gansel,  at  Milwaukee,  Wis., 
on  June  2,  aged  27  years.— Dr.  Joseph  E.  Wright,  at  Phila- 
delphia, Pa.,  on  June  9,  aged  43  years. — Dr.  Edwin  R.  Lewis, 
at  Kansas  City,  Mo.,  on  June  8,  aged  48  years.— Dr.  A.  J. 
Bloch,  at  Denver,  Col.,  on  June  8,  aged  34  years. — Dr.  E. 
P.  Sale,  at  Memphis,  Tenn.,  on  June  8. 

Dr.  Van  Buren  Dixon,  at  Montevue  Hospital,  Frederick 
County.  Md..  on  June  10,  aged  62  years. — Dr.  D.  B.  Me- 
Kee.  at  Hutchinson,  Kan.,  on  June  10.  aged  62  years. 

A  Dangerous  Office. — According  to  the  London  Daily 
Eipress.  an  aurist.  who  was  lately  treating  the  Sultan, 
for  an  affection  of  the  ear,  accidentally  touched  the  drum 
membrane,  causing  his  patient  intense  pain.  His  Majesty, 
believing  that  an  attempt  was  being  made  on  his  life,  drew 
a  revolver  and  shot  the  physician  dead.  A  chamberlain, 
hearing  the  shot,  entered,  and  the  Sultan  fired  at  him, 
and  wounded  him. 

Plague  in  Turkey. — The  Public  Health  Reports  of  June 
7,  1901,  state  that  in  Bassora,  Turkey,  according  to  a 
supplementary  communication  of  April  26.  three  persons 
have  been  taken  sick  with  symptoms  suspicious  of  plague, 
and  have  been  strictly  isolated  in  the  hospital.  In  the 
house  of  the  first  2  persons  dead  rats  were  discovered. 
The  patients  had  not  left  Bassora  for  a  long  time  and 
had  never  been  in  contact  with  any  suspected  plague  pa- 
tients. The  rooms  which  these  patients  had  occupied  were 
at  once  disinfected  and  closed  up. 

The  American  Climatological  Association. — At  the  an- 
nual meeting  of  the  American  Climatological  Association 
held  at  Coronado,  Cal..  the  following  officers  were  elected: 
President,  Dr.  Samuel  A.  Fiske  of  Denver,  Col.;  Vice-Presi- 
dents, Dr.  Norman  Bridge,  Los  Angeles  and  Dr.  W.  F.  R. 
Phillips  of  Washington;  Secretary,  Dr.  Guy  Hinsdale  of 
Philadelphia. 

Chinese  Twins. — The  Medical  Press  and  Circular  states 
that  a  double  monster,  technically  known  as  "Xiphopagus," 
is  now  being  exhibited  on  the  Continent.  The  union  be- 
tween the  twins  is  by  a  sternal  band  which  is  of  a  fleshy 
character  situated  in  each  of  the  two  individuals  at  the 
lower  border  of  the  sternum.  By  means  of  the  X-rays  it 
has  been  determined  that  the  communicating  tissue  con- 
tains no  bones,  but  within  it  can  be  observed  the  peritone- 
um of  each  individual.  The  twins  are  described  as  very 
intelligent,  mirthful,  and  fond  of  each  other.  The  easiest 
position  for  the  two  to  walk,  run,  and  even  leap  is  when 
they  proceed  forward  side  by  side  in  a  manner  somewhat 
similar  to  two  men  forming  a  two-handed  seat  for  the 
transport  of  wounded.  Their  functions  are  quite  inde- 
pendent; in  each  the  urine  varies  not  only  in  regard  to 
time  but  also  in  regard  to  quantity.  While  one  sleeps  the 
other  may  be  awake,  and  there  is  great  difference  in  the 
appetite  of  the  two.  The  effect  of  alcohol  has  been  noticed 
on  the  twins,  for  when  on  one  occasion  whisky  was  given 
to  only  one  they  both  became  intoxicated,  and  the  one 
that  had  not  tasted  the  whisky  became  much  more  so 
than  the  other.  This  is  the  eleventh  known  living  in- 
stance of  this  peculiar  kind  of  double  monster,  and  it  is  a 
curious  fact  that  the  other  examples  have  been  born  In 
mountainous  districts;  the  present  Chinese  example,  how- 


iii8 


The  Philadelphia"! 


Medical  Journal 


AMERICAN  NEWS  AND  NOTES 


[JUN-E   15,    1301 


ever,  was  born  in  a  level  country  only  slightly  elevated 
obove  the  sea.  There  was  only  one  cord,  and  but  one  pla- 
centa. 

Health  Reports:  The  following  cases  of  smallpox,  yellow 
fever,  cholera  and  plague  have  been  reported  to  the  Sur- 
geon General,  U.  S.  Marine  Hospital  Service,  during  the 
week  ended  June  8,  1901: 

m     CO 

S    ■" 


SMALLPOX— UNITED  STATES. 


CALIFORNIA; 

DISTRICT  OF 

COLUMBIA: 

ILLINOIS: 

IOWA: 

KANSAS: 

LOUISIANA: 
MASSACHUSETTS ; 


MICHIGAN: 

MINNESOTA 

MISSOURI 
NEBRASKA: 


NEW  HAMPSHIRE 
NEW  JERSEY: 
NEW  YORK: 
NORTH  CAROLINA 
OHIO: 


PENNSYLVANIA: 

RHODE  ISLAND 

TENNESSEE: 
WEST  VIRGINIA: 

UTAH: 
WASHINGTON: 


Los  Angeles.  .. 
Stin  Francisco 

Washington   .   . 

Chicago   

Ottumwa 

Leavenworth  . 

Wichita 

New  Orleans.  . 

Boston 

Fitchburg.  .  .  . 
New  Bedford  .  . 

Quincy 

Detroit 

Grand  Rapids  . 
Minneapolis.  .  . 

Winona 

St.  Louis  .  .  .. 
Nebraska  City. 

Omaha 

South  Omaha  . 
Manchester.  .  . 
Jersey  City.  .  . 

Newark 

New  York 

Charlotte.   .   . 
Cincinnati  .... 
Cleveland.    .    . 
Youngstown   .    . 

Lebanon 

Philadelphia   .    . 

Pittsburg   

Providence  .   .    . 

Warwick 

Memphis    

Nashville 

Green   Bay   .   .    . 
Milwaukee    .    ... 
Salt   Lake  City 
Aberdeen 


.  May  18-25   .    ... 
.  May  18-25  .  ... 

May  25- June  1 
May  25-June  1 
Apr.27-June  1. 

■  May  1-31  .  .  . 

■  May  18-June  1. 
\  May  25-June  1. 

May  25-June  1 

.  May  17-24    .    . 

[  May  25-June  1 

.  May  25-June  1 

.  May  25-June  1. 

,  May  25-June  1 

,  May  18-June  4. 

,  May  25-June  1 

.  May  19-26  .  .  . 

Apr.2i-May  18. 

,  May  1(-June  1 

.  May  24-31  .  .  . 

May  25-June  1 

May  26-June  2, 

May  25-June  1 

May  25-June  1 

May  1-31   .    .   . 

May  1-31   .    .    . 

May  25-June  1 

May  18-25   .    .. 

May  25-31    .    . 

May  25-June  1 

May  18-June  1. 

May  25-June  1 

May  23-30   .    . 

May  25-June  1. 

May  25-June  1. 

May  26-June  2. 

May  25-June  1. 

May  IS-June  1 

May  21 


,    1 
5 

..1 

.  7 

16 

..3 

42 

4 

..1 

..1 

..1 

..1 

57 

.2 

15 

..1 

27 

6 

25 

26 

.  7 

4 

.2 

64 

11 

.10 

31 

1 

..5 

4 

7 

..1 

..1 

13 

6 

4 

2 

19 

..4 


SMALLPOX— FOREIGN. 


ARGENTINA; 

AUSTRIA: 

BELGIUM: 

CEYLON: 

COLOMBIA: 

FRANCE: 

GREAT    BRITAIN: 


15 


ITALY: 
INDIA: 


RUSSIA: 
SWITZERLAND: 
COSTA    RICA: 
INDIA: 


AFRICA: 

iNDIA: 


Buenos   Ayres  ....  Mar.  1-31.   .      ..76 

Prague    May  11-18 5 

Antwerp   May  6-11 7 

Colombo  Apr.  20 1 

Panama May  20-27 6 

Paris   May  11-18.    .. 

Glasgow    May  11-18 

Nottingham May  16.  case  appa- 
rently transmitted 
from  Salt  Lake 
City,  Utah,  by  fo- 
mltcs. 

Naples    May  3-10  .  ... 

Bombay   Apr.23-May7. 

Calcutta  Apr.20-May  4. 

Karachi  Apr.21-2S 

Madras    Apr.20-May  3 

Moscow  Mav  4-lS 29 

Odessa May  4-11 5 

Warsaw    Apr. 29- May  4. 

Geneva May  4-11 1 

YELLOW  FEVER. 

Liberia May  2.^,    Present. 


U4 


8 


12= 


CHOLERA. 


Bombay   . 
Calcutta 
Madras   . 


Apr.22-May  7. 
Apr.20-May  4.. 
Apr.20-May  3 


PLAGUE. 


Cape  Town  To  Apr.27   .    . 

Bombay   Apr.22-Mav  7. 

Calcutta Apr.20-Mav  4 

Karachi .-Vpr.L'l-iS.  ".... 


4 

121! 


377    160 


371 


Changes    in    the    Medical    Corps   of  the    Navy   for   Week 

ended  June  8,  1901. 

DOCTORS  J.  W,  BACKUS,  F.  A.  ASSERSON,  J.  F.  MUR- 
PHY, W.  SEAMAN  and  R.  R.  RlCH.\RL'SON  apoointed 
assistant   surgeons  in   the   Navv— June  1. 

SURGEON  F.  J.  B.  CORDEIRO,  letached  from  the  Buffalo 
June  10,   and  ordered   home  to  wait  orders— June  4 

SURGEON  L.  W.  CURTIS,  ordered  to  the  Buffalo.  June  10- 
June  4. 

P.  A.  SURGEON  E.  S.  BOGERT.  JR.,  commissioned  surgeon, 
from   December  15,   190O— June   4. 


ASSISTANT  SURGEO.V  R.  W.  PLCMMER,  detached  from 
the  Nashville  and  ordered  to  the  Princeton— June  6. 

ASSISTANT  SURGEON  W.  SEAMAN,  ordered  to  the  Inde- 
pendence,   June   17— June   6. 

ASSISTANT  SURGEON  H.  H.  HASS,  detached  from  Naval 
Hospital,  New  York,  and  ordered  to  the  Norfolk  Navy  Yard, 
June   10— June  6. 

..ASSISTANT  SURGEON  R.  R.  RICHARDSON,  ordered  to  Na- 
val  Hospital,   New  York,  June  10— June  6. 

ASSISTANT  SURGEO.X  J.  .M.  BRISTER,  detached  from  the 
Independence.  June  17,  and  ordered  to  the  Asiatic  Station 
via   Transport   Hancock— June  6. 

Official  list  of  the  changes  of  Station  and  Duties  of  Com- 
missioned and  Non-Commissioned  Officers  of  the  U.  S. 
Marine  Service  for  the  7  days  ended  May  30,  1901. 

H.  R.  CARTER,  surgeon,  to  inspect  the  local  quarantine  sta- 
tion  at    Baltimore,    Maryland— May   25,   1901. 

R.  M.  WOODWARD,  surgeon,  granted  two  -weeks'  extension 
of   leave   of  absence   from    May   23— May   25,   1901. 

G.  T.  VAUGHAN,  surgeon,  detailed  as  delegate  to  represent 
the  service  at  the  meetings  of  the  Association  of  Military 
Surgeons  of  the  United  States.  May  30,  and  American  Med- 
ical  Association,   June  4.    at   St.    Paul.    Minn— May   27.    1901. 

J.  C  COBB,  passed  assistant  surgeon,  relieved  from  duty  at 
Fort  Stanton,  N.  M.,  and  directed  to  proceed  to  Portland, 
Oregon— Mav   29,    1901. 

C.  P.  WERTENBAKER.  passed  assistant  surgeon,  detailed  to 
represent  the  ser\'ice  at  meetings  of  the  Association  of 
militarj'  surgeons  of  the  United  States,  May  30;  and  Ameri- 
can Medical  Association,  June  4,  at  St.  Paul,  Minn— Mav  27, 
1901. 

C.  P.  GARDNER,  passed  assistant  surgeon,  detailed  to  rep- 
resent service  at  meeting  of  the  ^'ashington  State  Medical 
Society  at  Seattle,  Washington,  June  18  to  20,  1901,  inclusive 
—May   27.    1901. 

C.  E.  DECKER,  assistant  surgeon,  granted  leave  of  absence 
for  10   days— May    28.   1901. 

W.  C.  HODBY,  assistant  surgeon,  to  proceed  to  Thomson.  Ga., 
for   special   temporary   duty— May   27,   1901. 

J.  W.  Hargis.  acting  assistant  surgeon,  granted  leave  of  ab- 
sence  for  4  days  from   May  28 — May  27.   1901. 

E.  T.  OLSEN.  hospital  steward,  granted  leave  of  absence  for 
15   days   from   June  13— May   22,   1901. 

L.  C.  SPANGLER.  hospital  steward,  to  proceed  to  Delaware 
Breakwater.  Del.,  and  report  to  medical  officer  in  command 
for  duty  and  assignment   to  quarters — May  28.   1901. 

APPOINTMENT. 
LEWIS    C.    SPANGLER,    of    Ohio,    appointed     junior     hospital 
steward  in  the  U.  S.  Marine  Hospital  Service— May  27,  1901. 

GREAT  BRITAIN. 
Dr.  Thomas  Bond  Commits  Suicide. — Dr.  Thomas  Bond, 
a  well  known  surgeon  and  analyst,  committed  suicide 
June  6,  by  throwing  himself  from  a  third  story  window  of 
his  residence.He  had  been  suffering  from  melancholia  for 
some  time.  Dr.  Bond,  who  was  the  late  Mr.  Gladstone's 
surgeon,  was  noted  in  connection  with  investigations  and 
discoveries  in  the  cases  of  several  sensational  crimes,  no- 
tably the  Lefroy,  Lamson  and  Camp  murders. 

CONTINENTAL     EUROPE. 

The  New  Siberia  a  Foul  Dungeon. — The  island  of  Sacha- 
lin  designed  by  the  Russian  Government  to  take  place  of 
Siberia  has  been  repeatedly  condemned  as  an  unsanitary 
place  even  for  exiles,  but  all  such  demonstrations  re- 
ceived denial  from  a  few  Russian  hirelings.  Now  an  official 
admits  that  the  condition  of  the  prisoners  is  far  from 
satisfactory. 

A  New  Journal  to  take  the  Place  of  the  Vratch.— The 
present  publishers  of  the  Vratch.  which  by  the  will  of  its 
late  editor  is  to  be  discontinued,  ask  permission  to  pub- 
lish a  medical  Journal  entiled  "Riisski  Vratch"  (Russian 
Physician).  Prof.  W.  W.  Podwisotski  and  Dr.  S.  W.  Wlad- 
islawlew  will  be  the  editors. 

Sanitary  Conditions  of  the  Russian  Isba. — Dr.  A.  Baloff, 
in  describing  the  peasant's  home  in  some  parts  of  Russia, 
gives  a  graphic  account  of  their  mode  of  life.  It  appears 
that  the  entire  family,  often  composed  of  ten  or  more 
persons,  lives  in  one  room  badly  heated,  poorly  ventilated 
and  meagerly  lighted.  In  this  room  they  eat.  sleep,  cook, 
work  and  entertain  themselves.  Here  the  smaller  domestic 
animals  find  a  resting  place,  while  the  larger  cattle  dwell 
in  a  basement  under  the  floor,  which  as  a  rule  is  made 
loosely  enough  to  admit  the  odors  from  below.  In  some 
houses  there  are  no  chimneys  and  during  the  process  ol 
heating  the  oven  the  smoke  finds  its  only  exit  through  the 
open  door. 


June    15,    1901] 


SOCIETY  REPORTS 


i-th 
Lme 


E  Philadelphia 
Medical  Journal, 


I  I  19 


Societal  IRcports. 


FIFTY-SECOND  MEETING  OF  THE  AMERICAN  MEDI- 
CAL  ASSOCIATION. 


GENERAL    SESSION. 

FIRST   DAY,   JUNE   4th,   1901. 

The  General  Session  convened  in  the  Metropolitan  Opera 
House.  St.  Paul,  Minn.,  at  10.30  A.  M.  The  meeting  was 
opened  with  prayer  by  Bishop  Whipple,  the  audience  join- 
ing with  him  in  the  Lord's  prayer.  The  Association  was 
welcomed  by  the  Mayor  of  St.  Paul.  The  State  of  Minne- 
sota, he  said,  showed  a  remarkably  low  mortality  record, 
due,  he  believed  largely  to  the  work  of  the  medical  pro- 
fession. He  suggested  that  any  patients  whom  the  visit- 
ing members  could  not  cure  be  sent  to  St.  Paul  and  that 
they  would  be  sent  back  in  such  condition,  if  not  living 
monuments  of  professional  skill,  at  least  they  will  live 
long  enough  to  be  useful  members  of  society.  The  Gov 
ernor  of  the  State  who  had  been  expected,  was.  through 
a  misunderstanding  of  two  invitations,  not  at  the  meet- 
ing. Dr.  Reed  requested  that  the  former  Presidents  and 
Vice  Presidents  come  to  the  platform.  In  approaching  the 
discharge  of  his  duties  as  President  of  the  52nd  meeting  of 
the  Association,  Dr.  Reed  expressed  his  appreciation  cf 
being  called  to  such  a  conspicuous  honor,  an  appreciation 
all  the  more  pronounced  when  he  reflected  upon  the  mag- 
nitude and  achievement  of  this  great  national  body,  and 
upon  the  lustre  of  the  distinguished  men  who  had  pre- 
sided over  these  deliberations.  A  sad  duty  was  to  bring 
to  the  attention  of  the  members  the  fact  that  since  the  last 
reunion  three  of  the  most  illustrious  predecessors  had 
been  called  to  their  reward.  They  were  Alfred  Stille,  Louis 
A.  Sayre,  and  Hunter  Maguire.  each  a  former  president, 
and  they  had  died  within  a  single  week.  It  was  urged  that 
steps  be  taken  to  secure  portraits  of  the  gentlemen  to  be 
placed  in  a  gallery  until  the  Association  shall  have  a  proper 
repository  for  them.  It  was  also  recommended  that  suita- 
ble formal  action  relative  to  the  life  and  distinguished  ser- 
vices of  these  lamented  confreres  be.  taken  by  the  Asso- 
ciation. In  his  address  the  President  called  attention  to  the 
satisfactory  condition  of  the  affairs  of  the  Association  as 
indicated  by  the  consolidated  report  of  the  Treasurer  and 
Board  of  Trustees,  showing  under  the  judicious  manage- 
ment a  balance  at  the  end  of  the  fiscal  year  of  $31,400.67, 
being  an  excess  of  over  $3,000.00  over  the  preceding  year. 
There  was  safely  invested  the  sum  of  $25,000.00,  to  be  ap- 
propriated to  the  purchase  of  a  home  for  the  Journal.  The 
circulation  shows  a  large  excess  over  any  other  weekly 
medical  journal  in  the  world.  An  expression  of  apprecia- 
tion of  the  valued  service  of  the  accomplished  Editor.  Dr. 
George  H.  Simmons,  was  tendered.  The  incorporation 
of  the  Association  was  highly  commended,  without  which 
much  of  the  success  could  not  have  been  attained.  Al- 
though the  circulation  of  the  Journal  was  so  satisfactory, 
it  was  a  matter  of  some  regret  that  it  exceeded  the  mem- 
bership of  the  Association  by  2%  times.  The  question  was 
considered  whether  the  accumulated  funds  should  be  ap- 
plied to  the  further  exploiting  of  the  Journal,  establishing 
a  home  for  the  Association,  should  the  members  receive 
annual  dividends,  or  should  the  money  be  devoted  to 
original  scientific  research  on  subjects  of  universal  inter- 
est to  the  profession.  The  President  ventured  the  sug- 
gestion that  a  reserve  should  be  held  in  hand  large  enough 
to  meet  possible  contingencies  in  connection  with  the 
Journal.  He  advocated  that  the  present  generous  policy 
regarding  the  conduct  of  the  Journal  be  continued.  The 
question  of  tuberculosis,  the  tenement  house  problem,  the 
prevention  of  endemic  diseases,  and  many  subjects  of  a 
specific  character  demanded  the  fostering  case  of  the  As- 
sociation. The  subjects  he  hoped  would  be  taken  up  sub- 
sequently under  auspicious  circumstances.  The  ineffic- 
iency of  the  profession  in  its  influence  upon  Congress  was 
deplored  and  special  mention  made  of  this  lack  in  connec- 
tion with  the  Army  Medical  Corps.  That  which  discrimin- 
ates against  the  status  of  the  Army  Medical  Corps  strikes 
at  the  status  of  every  medical  man  in  the  country,  and  it 
becomes  the  duty  of  every  medical  man  to  resent  as  a 
personal  stigma  legislation  adverse  to  the  Army  Medical 


Corps.  It  behooved  the  Association  to  put  itself  in  position 
to  influence  the  largest  number  of  votes;  every  physici?.n 
should  in  a  respectable  sense  become  an  active  politic- 
ian. The  status  of  the  medical  profession  in  relation  to 
ttio  Commonwealth  was  stated  to  be  that  of  the  largest, 
truest  and  most  intelligent  of  the  world,  moving  in  har- 
mony with  the  most  advanced  influences  of  civilization. 
The  necessity  for  complete  organization  of  the  profes- 
sion was  touched  upon.  Certain  results  could  only  be  at- 
tained by  the  unification  of  the  profession.  In  the  pro- 
gress of  the  profession  events  of  today  proclaim  the  ex- 
istence of  a  new  school  of  medicine  as  distinct  from  the 
schools  of  50  years  ago  as  is  the  Christian  dispensation 
from  its  Pagan  antecedents.  It  is  a  school  of  human  toler- 
ance and  scientific  research,  ready  to  abandon  a  truth  of 
yesterday  if  it  be  demonstrated  an  error  of  to-day.  It 
recognizes  that  he  is  the  greatest  among  men  who  reveals 
the  most  truth.  It  examines  all  things;  it  judges  all  things. 
Upon  the  deliberations  of  the  exponents  of  "this  new  school 
of  this  new  generation  of  this  new  century."  the  repre- 
sentatives of  the  democracy  of  science,  the  President  in- 
voked the  spirit  of  courage,  the  spirit  of  irogress,  the 
spiiit  of  truth.  On  motion  the  address  of  the  Pre.-ident 
was  referred  to  the  Executive  Committee  with  instructions 
to  report  to  the  Association  upon  its  ma»jy  vaUw.Dle  recom- 
mendations. A  portrait  of  Dr.  N.  S.  Davis  was  presented 
to  the  Association,  recognized  as  pre-eminently  the  founder 
of  the  American  Medical  Association,  and  for  more  th;;n 
50  years  its  most  constant,  eminent  and  faithful  guide  in 
every  department  of  its  work,  one  who  has  been  a  pioneer 
investigator  in  the  department  of  physiology  and  in  the 
field  of  preventive  medicine,  an  untiring  and  valuable  con- 
tributor to  medical  science  and  literature  and  who  has  en- 
joyed the  highest  honors  that  his  profession  could  bestow 
as  President  of  this  Association,  and  of  the  Ninth  Inter- 
national Medical  Congress;  one  who  in  his  own  city  organ- 
ized the  first  general  hospital  and  established  clinical  in- 
struction therein,  and  who  was  one  of  the  founders  and 
active  supporters  of  the  Chicago  Relief  Hospital  for  the 
I'oor,  the  Chicago  Academy  of  Sciences,  the  Historical  So- 
ciety and  the  Chicago  Medical  Society.  Though  Dr.  Davis 
is  in  his  85th  year  of  life  and  65th  year  of  medical  prac- 
tice, he  still  devotes  5  or  6  hours  daily  to  his  patients. 
He  is  happiest  when  contributing  most  to  the  happiness  of 
others.  A  motion  was  adopted  for  the  appointment  of  a 
Committee  for  securing  to  the  Association,  without  cost, 
the  portraits  of  the  ex-Presidents  of  the  Association.  The 
hope  was  at  the  same  time  expressed  that  the  time  might 
come  when  the  Association  would  have  a  magnificent 
home,  a  building  of  its  own  wherein  might  hang  the  por- 
traits of  the  living  ex-Presidents,  President  of  the  Asso- 
ciation and  those  of  the  noble  men  who  have  gone  be- 
yond. The  report  of  the  Secretary  showed  the  present 
membership  to  be  something  over  10.000.  an  increase  of 
1500  or  ICOO,  the  largest  increase  in  any  year  in  the  history 
of  the  Association.  There  had  been  submitted  to  the  Ju- 
dicial Council  for  action  the  correspondence  in  regard  to 
two  cases  of  membership.  The  report  of  the  Executive 
Committee  called  attention  to  a  gratifying  diminution  in 
the  number  of  papers  offered  in  the  different  sections  in 
accordance  with  a  former  recommendation.  The  total 
number  on  the  program  was  391  as  against  491  last  year 
and  615  in  1898,  the  largest  number  being  in  Practice  of 
Medicine — 43  papers.  Attention  was  called  to  the  rule 
that  abstracts  should  be  furnished  and  compliance  urged. 
The  report  further  stated  that  the  pathological  lecture  by 
Dr.  Simon  Flexner.  of  Philadelphia,  could  not  be  given.  Dr. 
Flexner  being  unable  to  be  present.  The  Report  of  the 
Board  of  Trustees  combined  with  it  the  report  of  the 
Treasurer  a  detailed  account  of  which  had  been  circulated. 
The  financial  policy  of  the  Journal  had  been  a  success.  It 
was  urged  that  there  should  be  no  change  in  the  program 
after  May  30th  of  each  year;  previous  changes  had  much 
increased  the  expenses  of  this  department.  It  was  suggest- 
ed that  too  many  papers  were  read  by  title  and  that  if  a 
man  on  the  program  for  a  paper  did  not  consider  it  of 
sufficient  worth  to  be  present  and  read  it,  it  should  be 
treated  as  a  volunteer  paper  and  should  so  appear  in  the 
paper  of  the  Journal.  Preference  should  be  given  to  the 
men  who  write  but  one  paper.  In  order  to  further  improve 
the  quality  of  the  work  the  Trustees  would  submit  that 
no  paper  presented  to  any  section  should  be  printed  until 
it  received  the  approval  of  three  members  of  the  Execu- 
tive Committee  of  that  section,  evidenced  by  their  signa- 
ture.    Dr.  Gordon,  of  Maine,  thought  the  Journal  had  been 


The  Philadelphia"! 


1  1  ZU       Medical   Journal 


SOCIETY  REPORTS 


[June   15,   1»1 


used  long  enough  as  an  advertising  medium  for  men  who 
sent  papers  to  be  published  and  did  not  attend  the 
meetings,  and  he  was  glad  the  Committee  had  talcen  the 
matter  In  hand.  He  also  hoped  that  the  violation  in  tak- 
ing 40  minutes  to  an  hour  for  reading  a  paper  and  20  to 
•10  minutes  for  discussion  would  be  corrected.  Dr.  J.  R. 
Fennington.  of  Illinois;  Dr.  Louis  Rodman,  of  Pennsyl- 
vania, ad  Dr.  Dandridg;e  were  appointed  a  Committee  to 
secure  portraits  of  the  ex-Presidents  of  the  Association  and 
invested  with  the  power  to  deposit  them  in  some  art  gal- 
lery until  a  proper  place  can  be  provided  by  the  Asso- 
ciation. The  Committee  on  National  Legislation  reported 
that  the  Anti-vivesection  Bill  had  probably  been  defeated; 
that  the  bill  giving  additional  power  to  the  Marine  Hos- 
pital Service  had  been  passed,  and  that  the  defeat  of  the 
bill  increasing  postal-rates  had  been  accomplished.  The 
Committee  further  reported  that  the  medical  societies  of 
the  several  States  and  territories  are  appreciating  the 
importance  of  State  co-operation  in  medical  matters.  The 
Committee  was  present  at  the  conference  held  in  Washing 
ton  in  February  and  appointed  a  standing  committee  of 
the  Annual  Conference  with  power  to  act  for  the  various 
States  and  territories.  It  was  recommended  that  the 
American  Medical  Association  request  affiliated  societies  of 
States  and  territories  to  provide  in  their  constitution  for 
the  appointment  of  their  State  Legislation  Committees, 
whose  duty  shall  be  to  consider  all  medical  legislation 
arising  in  the  State  Legislature  and  Congress  and  to  ad- 
vise the  constituent  members  thereon.  The  report  of  the 
Committee  on  Re-organization  was  on  motion  referred  to 
a  joint  committee  composed  of  the  General  Executive  Com- 
mittee and  the  enlarged  Committee  on  Reorganization  rep- 
resenting all  the  States,  with  an  opportunity  for  a  hear- 
ing of  those  who  desired  to  discuss  the  subject,  and  that 
a  report  be  made  in  the  General  Session  the  following 
morning. 

ORATION   ON   SURGERY   BY   DR.  JOHN   A.  WYETH. 

The  Value  of  Clinical   Microscopy,  Bacteriology  and  Chem- 
istry   in    Surgical    Practice. 

The  surgeon  of  experience  soon  learns  that  it  requires 
more  than  asepsis  and  the  rapid  and  skilful  performance 
of  an  operation  to  achieve  the  fullest  measure  of  success. 
It  is  essential  in  the  highest  degree  to  call  into  requisition 
the  invaluable  aid  which  laboratory  research  alone  can 
give  to  make  a  diagnosis  accurate,  and  to  indicate  the  ra- 
tional measures  of  treatment  before,  during  and  after  the 
operation.  Chemical  analysis,  clinical  microscopy  and  bac- 
teriology should  form  part  of  the  educational  requirements 
of  the  surgeon.  Laboratory  research  has  placed  not  only 
the  medical  profession  but  the  entire  human  family  under 
lasting  obligations,  and  has  done  more  than  all  else  in  ac- 
complishing the  revolution  in  surgical  thought  and  prac- 
ticve  that  has  taken  place.  The  discovery  of  the  bacillus 
of  diphtheria  alone  would  emphasize  this  statement,  since 
it  has  had  its  logical  sequence  in  Behring's  invaluable  dis- 
covery that  the  blood  of  animals  rendered  Immune  to 
diphtheria  by  inoculation  contained  a  substance  capable  of 
neutralizing  the  effects  of  this  bacillus  and  its  toxin,  re- 
ducing the  death  rate  of  diphtheria  from  its  former  mor- 
tality to  the  insignilicant  rate  of  the  ordinary  disease. 

What  is  true  of  diphtheria  is  undoubtedly  true  of  all 
pathog«nic  organisms,  the  spirillum  of  cholera,  the  pneu- 
mococcus.  tetanus,  and  other  similar  organisms.  The  elab- 
oration of  the  typhoid  bacillus  by  Eberth  and  Gaffky  with 
Widal's  demonstration  was  an  invaluable  discovery,  and 
will  be  the  means  of  saving  innumerable  lives  since  it  af- 
fords an  early  and  accurate  diagnosis  as  indication  for,  or 
against  a  surgical  operation.  The  laboratory  has  made 
clear  the  diagnosis  ami  treatment  of  actinomycosis,  an- 
thrax, malignant  edema,  bubonic  plague  and  other  dis- 
eases. 

Bacteriological  research  has  robbed  the  puerperal  state 
of  its  great  anxiety  and  dread;  not  only  by  preventing  sep- 
sis, but  by  recognizing  the  character  of  the  infection  al- 
ready established  in  time  to  prevent  general  peritonitis  or 
septicemia,  and  enables  us  to  determine  whether  or  not  the 
infection  is  of  a  typo  sufficiently  grave  to  justify  a  hyster- 
ectomy and  drainage  instead  of    curetting. 

Chemical  analysis  of  the  stomach  juices  and  of  the  con- 
tents clears  up  many  doubtful  conditions  of  this  organ,  and 
enables  the  surgeon  as  well  as  the  physician  to  deter- 
mine whether  or  not  free  hydrochloric  acid  exiists,  and  the 
quantity  of  this  fluid. 


The  test  breakfast  of  Ewald  and  Boas,  and  the  more  elab- 
orate test  meal  of  Germain  See  enables  us  to  determine  the 
exact  condition  of  the  organ;  as  in  the  presence  of  lactic 
acid,  which  is  dependent  upon  a  special  bacillus  thriving 
in  the  stomach  only  under  abnormal  conditions,  the  diag- 
nosis of  carcinoma  is  practically  established. 

In  the  differentiation  between  the  pathogenic  organisms 
of  specific  and  non-specific  urethritis,  microscopy  and  bac- 
teriology are  our  only  infallible  guides.  They  teach  us  to 
eliminate  the  various  bacteria  not  bearing  directly  upon 
the  etiology  of  urethritis,  anid  to  recognize  distinctly  the 
two  forms  of  diplococcus.  the  gonococcus  of  Neisser  and 
the  pseudo-diplococcus.  Bearing  in  mind  the  fact  that 
these  dangerous  organisms  may  remain  dormant  in  these 
passages  for  months,  or  for  years,  incapable  of  a  further 
inoculation  of  the  seemingly  Immunized  patient,  but  capa- 
bue  of  exciting  the  most  acute  and  injurious  inflammation 
in  an  innocent  victim,  it  becomes  a  matter  of  the  greatest 
importance  to  subject  to  most  careful  study  the  external 
genito  urinary  passages  where  an  infection  has  once  ex- 
isted. 

In  pyelitis  the  differentiation  between  simple  pyogenic 
infection  and  the  presence  of  the  bacilli  of  tuberculosis 
can  be  determined  by  laboratory  research  without  the  ex- 
treme measure  of  exploration.  In  fact,  pathological  condi- 
tions of  the  substance  of  the  kidney,  the  calices.  the  hilum, 
the  pelvis,  the  urethra  and  the  bladder,  and  important 
changes  in  the  tissues  beyond  these  organs  are  evidenced 
by  the  presence  of  oxyluria. 

Uric  acid  and  the  various  other  deposits  in  the  urine,  re- 
sults of  abnormal  conditions  of  the  digestive  and  assimil- 
ative apparatus,  are  made  evident  by  the  microscope  and 
by  chemical  analysis,  and  are  of  invaluble  aid  to  the  sur- 
geon. 

In  glycosuria  he  must  know  whether  he  is  dealing  with 
what  Pavy  designates  ■"alimentary  diabetes,"  in  which  the 
sugar  eliminated  by  the  urine  is  derived  solely  from  the 
food  as  result  of  defective  carbohydrate  assimilation,  or 
whether  that  almost  hopeless  condition  of  "composite  dia-  i 
betes,"  in  which  abnormal  disintegration  is  taking  place,  ■ 
is  present. 

No  less  important  is  the  estimate  of  the  amount  of  urea 
which  can  be  determined  by  the  simple  laboratory  process 
of  Doremus. 

The  presence  of  blood  when  not  made  clear  by  the  eye 
or  the  microscope,  is  now  evident  in  the  fine  chemical  test 
in  which  the  blood  crystals  of  Teischmann  may  be  recog- 
nized even  while  the  corpuscles  have  entirely  disappeared. 

One  of  the  most  attractive  subjects  of  laboratory  research 
is  the  blood,  and  although  hematology  is  practically  in  its 
infancy,  many  valuable  discoveries  have  already  been 
made,  and  in  the  proper  study  of  a  surgical  case  a  knowl- 
edge of  the  blood  is  as  essential  as  that  of  the  urine.  It 
gives  us  information  in  regard  to  anemia,  and  often  tells 
us  whether  it  is  a  type  of  blood  impoverished  which  can 
be  corrected,  or  whether  it  is  of  the  graver  or  more  per- 
nicious form  which  would  either  preclude  an  operation,  or, 
if  this  were  absolutely  necessary,  would  enable  him  to  an- 
nounce to  those  entitled  to  information,  the  gravity  of  the 
outlook. 

The  determination  of  the  richness  of  the  hemoglobin  by 
von  Fleischl's  hemometer,  or  a  count  of  the  red  cells  and 
of  the  leukocytes,  and  the  differentiation  of  the  various 
types  of  cells  all  point  clearly  to  certain  conditions  which 
it  is  the  duty  of  the  surgeon  to  comprehend. 

In  the  early  recognition  of  septic  process,  chiefly  p.vo- 
genic.   surgery  can   no  longer  disregard   the  value  of  the 
blood   count,   and   this   is   especially   valuabe  in   the  early  • 
stages  of  those  inflammatory  processes  which  occur  in  the 
peritoneal  cavity. 

We  know  that  in  a  certain  proportion  of  cases  of  inffHS 
tion.  temperature  does  not  always  indicate  the  increasing 
gravity  of  the  lesion,  while  the  degree  of  sepsis  can  be 
in  great  measure  determined  by  the  leukocyte  count.  In 
impaction  of  feces,  extrauterine  pregnancy,  floating  kidney, 
gall-stone  colic,  renal  colic,  ovarian  neuralgia,  intussus- 
ception, volvulus,  internal  hernia,  twisted  pedicle,  etc 
there  is  no  leukocytosis  unless  complicated  with  an  acute 
septic  process.  In  abscess  of  the  liver,  the  leukocyte 
count  ranges  from  12.000  to  4S.000.  while  there  is  a  marked 
increase  in  all  the  septic  pyogenic  processes  of  the  lungs 
and  the  pleura. 

In  osteomyelitis  the  leukocyte  count  ranges  as  a  rule 
from  15.000  to  2.5.000.  and  at  times  higher.  Since  in  the 
early  stages  of  this  disease  it  is  at  times  difficult  by  sub- 


June    15,   IMJ 


SOCIETY  REPORTS 


TTh 

Lme 


E    PHII^ADELPHIA 

EDICAL   Journal 


I  121 


jective  symptoms  to  differentiate  between  rheumatism  or 
gout,  the  leul<ocyte  count  is  invaluable  in  demonstrating  at 
once  the  pyogenic  process. 

In  that  very  rare  disease,  trichinlasis,  the  leukocytes 
register  sometimes  as  high  as  30,000,  but  the  special  fea- 
ture is  the  presence  of  a  large  number  of  eosinophile  cells, 
sometimes  as  high  as  50%,  and  in  rare  cases  67%  of  the 
total  number  of  leukocytes  being  reported  within  this  form 
of  corpuscle.  A  very  considerable  number  of  cases  have 
been  reported  within  the  last  year  in  which  the  diagnosis 
had  been  determined  by  the  presence  of  eosinophiles. 

Not  only  can  the  presence  of  the  Plasmodium  malariae 
be  recognized  between  the  different  varieties  of  the  malar- 
ial parasite.  It  has  shown  that  the  tertian  organism  takes 
forty-eight  hours  to  develop  and  undergo  sporulation.  the 
quartan  72,  while  the  estivo-autumnal  passes  through  ir- 
regular phases,  varying  from  forty-eight  hours  to  several 
days. 

We  are  enabled  to  demonstrate  also  the  presence  of  the 
spirochaete  of  relapsing  fever  discovered  by  Overmeier  in 
1873.  Although  the  cork-screw  or  spiral  threads  are  rarely 
seen  unless  the  blood  is  examined  in  the  height  of  the  fever 
paroxysms,  diplococcus-shaped  bodies  believed  to  be  th.3 
spores  of  this  organism  are  found  in  the  periods  of  re- 
mission. 

SECOND  DAY,  JUNE  5th,  1901. 

The  meeting  was  called  to  order  by  the  president  at  11 
A.  M.  President  Reed  then  introduced  Governor  S.  H. 
Van  Sant,  who  as  the  chief  executive  of  the  State,  stood 
for  every  interest  promotive  of  the  highest  and  most  ad- 
vanced stand  in  medicine;  who  exercised  a  fostering  care 
over  the  State  University,  the  fame  of  which  extends 
throughout  the  land.  Governor  Van  Sant  remarked  that 
his  welcome  was  none  the  less  cordial  from  being  24  hours 
late,  and  that  age  improves  some  things  used  in  the  medi- 
cal profession.  Referring  to  the  possibility  of  the  next 
meeting  being  held  in  the  South  he  stated  that  when  the 
Grand  Army  Reunion  was  held  in  Louisville  a  royal  wel- 
come was  given.  At  night  electric  lights  blazed  forth  with 
the  words,  and  even  over  the  jail  in  great  large  letters 
was  the  >vord  "Welcome."  The  mdical  profession,  he  some- 
times thought,  had  special  privileges.  For  instance  "if  I 
treat  you  I  pay  the  bill,  if  you  treat  me  or  my  family  I 
pay  the  bill  still."  The  address  closed  with  the  expression 
of  a  most  cordial  welcome  to  the  city  and  State.  The 
minutes  of  the  preceding  meeting  were  read  by  the  Sec- 
retary, Dr.  George  H.  Simmons.  The  report  of  the  Joint 
Committee  consisting  of  the  Executive  Committee  on  Or- 
ganization upon  the  report  of  the  Committee  on  Reorgani- 
zation was  read  by  Dr.  Walker,  of  Michigan.  The  Commit- 
tee recommended  on  motion  of  Dr.  Reynolds  that  the  in- 
strument of  the  whole  and  amended  was  adopted.  The 
President  stated  that  in  view  of  the  fact  that  some  modi- 
fications of  minor  Importance  had  been  made,  he  thought, 
in  the  interest  of  fairness,  it  would  be  well  for  the  assembly 
to  listen  to  a  reading  of  the  entire  document  as  about  to 
be  presented  for  final  consideration.  The  document  was 
read.  Dr.  L.  D.  Buckley,  of  New  York,  thought  that  all 
would  recognize  that  the  time  was  one  of  the  most  cruci- 
al in  the  history  of  the  organization,  one  to  test  the  wil- 
lingness of  the  members  to  do  that  which  seemed  best  for 
the  good  of  the  profession  at  large.  From  being  first  op- 
posed to  the  reorganization  he  had  been  convinced  after 
I'epeatedly  fighting  the  changes  proposed.  The  question 
had  been  fully  considered  by  representative  men  who  had 
been  most  patiently  heard  time  and  again  by  the  Committee 
in  going  over  the  sections.  Considerable  changes  had  been 
made:  one  of  particular  value  was  that  the  house  of  dele- 
gates should  .have  two  representatives  from  each  section 
instead  ot  only  one.  making  it  possible  for  a  large  number 
of  scientific  men  to  attend  the  meetings.  He  called  atten- 
tion to  the  fact  that  in  18S7  Dr.  Davis  had  wanted  the 
present  change  and  in  1S91  another  similar  effort  had  been 
thwarted.  A  number  of  things  ot  smaller  importance  were 
not  entirely  satisfactory,  but  these  could  be  adjusted  by  the 
house  of  delegates.  He  moved  that  the  recommendation  of 
the  Committee  be  unanimously  adopted.  Dr.  McCormack. 
of  Kentucky,  moved  that  if  the  question  was  to  be  dis- 
cussed those  holding  opposite  views  should  be  heard  al- 
ternately. He  wanted  the  Association  to  understand  that 
the  earnest  desire  of  the  Committee  was  that  those  op- 
posing or  favoring  the  recommendation  be  fairly  heard. 
The  motion  to  accept  the  report  of  the  Committee  on  Re- 


organization was  seconded  and  carried  by  a  large  ma- 
jority. The  oration  on  Surgery  was  afterward  given  by 
Dr.  Weyth. 

THIRD   DAY,  JUNE   6th,   1901, 

In  calling  the  meeting  to  order  Dr,  Reed  announced  that 
he  had  agreed  with  the  Commmittee  of  Arrangements  to 
allow  ten  minutes  to  the  representative  of  the  American 
Woman's  Christian  Temperance  Union  relative  to  enter- 
tain questions  of  sanitation  in  the  army.  The  meeting  was 
then  adressed  by  Miss  Susan  B.  Anthony  and  the  Rev.  An- 
na M.  Shaw.  Miss  Anthony  said  in  part:  "It  is  with  great 
fear  and  trepidation  that  I  come  before  you  this  morning 
to  speak  upon  a  question  very  near  the  heart  of  all  true 
women.  You  are,  many  of  you,  in  favor,  and  some  op- 
posed to  the  system  of  regulating  vice  in  Manila,  Hawaii 
and  Porto  Rico  and  our  new  possessions.  We  call  to  your 
attention  the  fact  that  when  you  gather  up  the  young  men 
for  the  army  you  take  them  from  the  care  and  protection 
of  the  home.  We  ask  yo\i  to  remember  that  these  are  the 
sons  of  mothers  who  are  watching  and  caring  for  their 
boys  and  care  more  that  they  should  be  returned  unpolluted 
than  that  they  shall  not  come  at  all.  If  need  be,  better 
their  death  than  their  ruin.  It  is  the  man  who  proves 
untrue  to  one  woman  who  loses  the  respect  for  all.  I  call 
your  attention  to  the  fact  that  when  our  Northern  army 
made  its  pilgrimage  through  the  South  with  Sherman's 
march  to  the  sea.  it  left  a  whole  army  ot  children  to  be 
born  of  the  mixed  races.  When  the  army  leaves  Manila 
and  the  Philippines  this  tract  is  left.  The  race  is  being 
degenerated.  We  shall  be  lost,  as  we  might  say,  in  this 
condition.  I  hope  you  will  in  making  or  influencing  any 
resolution,  for  you  know  your  opinion  will  go  far  in  influ- 
encing Congress,  take  the  position  that  it  is  your  own 
son,  your  own  daughter  who  is  involved."  Rev.  Anna  M. 
Shaw  then  addressed  the  meeting  urging  that  any  resolu- 
tions passed  by  the  American  Medical  Association  might 
stand  for  the  principle  that  virtue  must  always  be  pro- 
tected everywhere  and  under  all  circumstances,  for  there  is 
no  part  of  God's  universe  in  which  virtue  should  have 
greater  protection  than  under  this  government,  which 
stands  before  the  world  as  the  greatest  Christian  civiliza- 
tion under  the  light  of  the  sun.  Dr.  Seaman,  of  New  York 
stated  that  vital  statistics  of  the  army  in  Pekin  show  that 
50  per  cent,  of  the  patients  treated  were  affected  with 
venereal  disease,  and  since  the  abolition  of  the  army 
canteen  the  extent  of  these  diseases  had  doubled.  He 
thought  the  misguided  enthusiasts  who  had  opposed  the 
array  canteen  should  not  further  indulge  in  their  self- 
congratulation,  but  stop  interfering  with  matters  in  the 
army  which  they  did  not  understand.  Before  Dr.  Seaman 
had  finished  his  statements,  hisses  were  heard  in  some 
parts  of  the  audience,  and  cries  of  "Time."  "Time."  were 
being  shouted  from  all  parts  of  the  house,  while  cheers  and 
applause  came  from  other  sections.  President  Reed  de- 
clared that  the  session  would  proceed  with  its  usual 
business.  The  Trustees  were  authorized  to  grant  the  Re- 
organization Committee  $400.00  to  pay  the  expenses  they 
had  incurred  in  preparing  the  new  constitution.  The  Com- 
mittee on  Legislation  was  continued.  The  recommenda- 
tion of  the  Executive  Committee  that  a  committee  of  three 
be  appointed  to  revise  the  Code  of  Ethics  called  forth  a 
lively  discussion.  On  the  first  reading  of  the  report  Dr. 
Happel.  of  Tennessee,  had  demanded  that  this  recommen- 
dation be  considered  separately,  "We  haxe  had  enough 
railroading  at  this  meeting  of  the  Association,"  said  the 
doctor.  "If  the  Association  desires  a  new  code.  I  suppose  I 
can  live  as  I  did  in  the  sixties,  under  almost  anj-thing, 
but  let  us  have  the  action  fair  and  open."  It  was  moved 
that  the  recommendation  of  the  Executive  Committee  lay 
upon  the  table.  The  vote  seemed  about  evenly  divided  and 
the  Chair  could  not  decide.  Dr.  Happel  demanded  a  roU 
call.  The  Secretary  announced  that  there  were  about  1300 
delegates  whose  credentials  had  been  received.  Dr.  Happel 
stated  that  if  the  gentlemen  who  were  urging  revision  in- 
sisted upon  bringing  the  matter  to  a  vote  at  this  session 
he  would  stand  by  the  demand  for  a  roll  call,  and  that  the 
session  would  not  finish  its  business  today  or  tomorrow. 
Dr.  Bishop,  of  Pennsylvania,  moved  that  the  calling  of  the 
roll  be  postponed  until  the  next  annual  meeting  of  the 
General  Session.  This  brought  forth  a  hearty  round  of 
laughter  and  the  motion  was  carried  by  a  large  majority. 
The  recommendation  for  the  fusion  of  the  sections  on  path- 
ology and  bacteriology,  and  of  that  on  physiology  and  di- 
etetics, was  adopted,    A  motion  was  made  for  the  appoint- 


1  122 


The  Philadelphia"! 
Medical   Journal  J 


SOCIETY  REPORTS 


[JVKE    Lo,    i»n 


ment  of  a  committee  of  three  to  influence  the  appeal  of  the 
law  abolishing  the  army  canteen.  An  objection  v.as  made 
that  such  a  resolution  would  not  be  creditable  to  ths 
American  Medical  Association,  certainly  not  in  consonance 
with  the  sentiments  of  the  founder  of  the  Association.  Dr. 
N.  S.  Davis,  whose  portrait  had  just  been  presented  to  the 
Association.  The  object  was  over-ruled  and  the  matter 
referred  to  the  standin.e  committee  at  Washington.  A  reso- 
lution was  passed  that  the  American  Medical  Associa- 
tion disapproves  of  the  act  of  Congress  in  failing  to  pa.=3 
a  bill  which  provided  for  the  proper  and  adequate  recogni- 
tion of  the  medical  corps  of  the  United  States  Army.  .V 
resolution  was  passed  favoring  the  establishment  in  Wash- 
ington of  a  psycho-physiological  laboratory.  The  ora- 
tion on  Medicine  was  delivered  by  Dr.  N.  S.  Davis.  Jr.. 
of  Chicago.  Dr.  Davis  reviewed  the  advancement  in  medi- 
cine during  the  past  century  and  declared  that  progress 
had  been  more  rapid  than  in  any  other.  Death 
rates  from  many  causes  had  decreased  among  civil- 
ized people.  Some  diseases,  such  as  nervous  ailments, 
liad  been  more  rapid  than  in  any  other.  Death  rates  from 
any  cause  had  decreased  among  civilized  people. 
Bright's  disease  and  heart  disease  had  increased  owing  to 
more  rapid  ways  of  living.  Better  sanitary  regulations  and 
more  temperate  habits  had  checked  the  spread  of  diseases. 
The  public  must  be  educated  in  sanitary  and  health  truths 
in  order  to  better  prevent  disease.  It  is  to  be  hoped  that 
physicians  will  learn  to  measure  more  accurately  the  effect 
of  drugs  so  as  to  reduce  the  number  of  drugs  and  the 
quantity  used  Medical  men  must  depend  largely  on  the 
and  faith,  the  faith  of  the  patient  that  all  will  be  done 
for  him  that  can  be.  Antitoxin  for  diphtheria  had  reduced 
the  death  rate  and  led  to  hopes  that  an  antitoxin  would  be 
discovered  for  typhoid,  pneumonia  and  other  fevers.  The 
following  officers  were  elected  for  the  coming  year: 
President.  Dr.  John  A.  Wyeth.  of  New  York  City:  First 
Vice-President.  Dr  Alonzo  Oarcelon.  of  Maine:  Second 
Vice-President.  Dr.  A.  J.  Stone,  of  St.  Paul:  Third  Vice- 
President,  Dr.  A.  Y.  Jones,  of  \el)raska:  Fourth  Vice-Pres- 
ident, Dr.  John  R.  Dibrell,  of  Arkansas:  Treasurer.  Dr, 
Henry  P.  Newman,  of  Illinois:  Secretary,  Dr,  George  H, 
Simmons,  of  Illinois:  Librarian,  Dr,  George  W.  Webster, 
of  Illinois.  Board  of  Trustees:  Dr.  W.  W.  Grant,  Denver, 
Col.:  Dr.  John  F.  Fulton.  Minn.:  Dr.  T.  J.  Happel.  Tennes- 
see. Judicial  Council:  Dr.  George  Cook,  N,  H..:  Dr.  H.  H. 
Grant,  Kentucky:  Dr,  John  B,  Murphy,  Illinois:  Dr,  Philip 
Marvel,  of  New  York:  Dr,  Louis  H.  Taylor.  Pa.:  Dr.  John 
C  Dawson,  S,  C  and  Dr.  N.  Fred  Essig.  Washington.  The 
following  selections  were  made  for  preparations  of  the 
General  Session  for  next  year:  On  surgery.  Dr.  Henry 
Sherman,  Cal.:  on  medicine,  Dr,  Frank  Billings.  111.:  on 
State  medicine.  Dr.  J.  M.  Emmert.  Iowa.  The  place  of  the 
next  meeting  is  Saratoga.  N.  Y. :  Dr.  G.  Y.  Comstock  to  be 
Chairman  of  Committee  on  Arrangements, 

FOURTH    DAY,    JUNE    7th,    1901, 

The  final  session  was  called  to  order  by  the  President  at 
llo'clock,  A  vote  was  taken  in  favor  of  re-establishing  the 
army  canteen.  The  oration  on  State  medicine  was  deliv- 
ered by  Dr.  George  B.  Kober,  of  Washington,  D.  C.  Dr. 
Judson  Daland.  of  Philadelphia,  was  appointed  delegate 
to  the  World's  Tuberculosis  Congress  in  London  during 
,luly.  A  resolution  was  adopted  thanking  Mr.  John  D. 
Jlockefeller  for  his  generous  gift  of  $200,000  donated  to  the 
«ause  of  scientific  research  under  the  direction  of  Dr.  Wil- 
liam H.  Welch,  of  Johns  Hopkins  University.  President 
Tleed  named  ex-Presidents  Dr.  H.  O.  Marcy.  of  Boston,  and 
Dr.  Magruder.  of  Washington,  a  committee  to  escort  the 
President-elect  to  the  platform.  Dr,  Wyeth  said  he  was 
inclined  to  follow  the  precedent  established  the  previous 
•lay,  and  to  postpone  until  the  next  annual  meeting  of  the 
Association  any  remarks  he  might  have  to  make:  that  he 
appreciated  most  deeply  and  fully  the  honor  conferred  upon 
liim,  "It  will  take  my  best  efforts,"  he  said,  "to  repay  the 
Association  even  in  part  for  what  it  has  done,  but  such  as 
they  are  you  will  have  them,  and  I  will  do.  as  in  the  past, 
my  best  for  the  highest,  most  generous,  noblest  interests 
of  medicine  and  surgery  of  our  country,"  A  motion  was 
adopted  thanking  the  retiring  President,  the  Committee  on 
Arrangements,  and  the  physicians  of  the  Twin  Cities,  for 
the  splendid  management  of  the  convention,  Dr,  H,  O, 
Marcy,  of  Boston,  called  for  a  rising  vote  of  thanks  to  the 
President  who  had  presided  over  their  meetings  with  such 
courtesy  and  rare  fairness,  and  to  the  officers  of  sections. 


and  to  the  citizens  of  the  two  cities.  President  Reed  spoke 
of  the  extreme  harmony  which  had  prevailed,  and  of  his 
belief  that  the  meeting  would  redound  to  the  welfare  of  the 
profession.  In  returning  thanks  for  the  resolution,  he  said : 
"I  feel  a  sense  of  personal  obligation  to  you,  gentlemen, 
to  the  officers  of  the  sections,  to  the  faithful  and  efficient 
Secretary,  and  to  those  distinguished  gentlemen  from  all 
over  the  country,  who  have  come  to  this  convention,  bring- 
ing the  best  garnered  efforts  of  their  experience  whereby 
we  have  this  week  given  to  the  world  the  best  scientific 
program  in  the  history  of  the  American  Medical  Associa- 
tion. My  administration,  while  a  source  of  some  labor,  has 
been  a  source  of  constant  pleasure,  for  I  was  confident 
every  moment  of  the  co-operation  of  those  whose  co-opera- 
tion meant  success."  The  52nd  annual  meeting  of  the 
American  Sledical  Association  was  then  declared  ad- 
journed. 


Acute  Appendicitis: 


Chronic  Appendicitis: 


First — Catarrhal. 
Second^ — Interstitial. 
Third — Ulcerative. 
Fourth — Gangrenous. 
First — Catarrhal.' 
Second — Interstitial. 
Third — Obliterating. 


SECTION    ON    PRACTICE    OF    MEDICINE. 

FIRST  DAY.  JUNE  4th, 

J,  M.    Anders,  M.  D.,  of  Philadelphia,  in  the  Chair. 

Dr.  J.  M.  Anders,  of  Philadelphia,,  delivered  his  address 
and  attempted  to  point  out  a  few  lines  on  which  the  organi- 
zation and  professional  progress  should  be  conducted.  He 
believed  that  if  the  American  Medical  Association  hoped  . 
to  be  one  of  the  great  powers  of  the  country  it  was  of  great  I 
importance  that  the  proposed  reorganization  scheme  be 
promptly  efiecied  and  due  efforts  be  made  to 
establish  and  maintain  proper  respect  and  forbear- 
ance between  the  various  sections  to  the  end  that  they 
may  work  in  perfect  harmony  with  one  another. 

Dr.  John  B.  Deaver,  of  Philadelphia,  then  read  a  paper 
on  appendicitis.  He  stated  that  the  appendix  was  the 
most  vulnerable  of  all  the  abdominal  organs  for  the  fol- 
lowing reason:  It  is  a  structure  in  the  process  of  retro- 
grade metamorphosis:  it  is  deficient  in  blood,  nerve  and 
lymphatic  supply:  it  is  long  and  its  calibre  is  small,  hence 
its  drainage  is  easily  interfered  with:  it  is  subjected  to 
traumatism  by  the  movement  of  the  psoas  muscle  upon 
which  it  lies.  Therefore  it  is  apparent  that  the  appendix 
may  easily  become  the  target  for  the  destructive  micro-or- 
g^iUisms  where  from  any  cause  these  are  incited  into  activ- 
ity: and  it  is  especially  noteworthy  that  a  hollow,  glandu- 
lar organ  remains  intact  only  so  long  as  the  production 
and  evacuation  of  its  secretions  continue  normally.  When 
this  function  is  deranged  there  are  first,  retention,  stagnation, 
and  decomposition  offcheappendix  contents:  second,  pressure 
leading  to  impairment  of  the  appendix  wall:  third,  land  the 
most  important  i  the  bacteria,  especially  the  colon  bacilli 
are  so  increased  in  number  and  nrulence  that  they  are 
able  to  penetrate  the  coats  of  the  appendix  and  set  up 
their  irritant  processes  in  varying  degrees.  Such  he 
considered  to  be  the  brief  pathogenesis  of  appendicitis. 

The  following  classification  was  suggestea  as  convenient 
and  well  founded: 


He  had  never  seen  much  good  from  the  efforts  of  na- 
ture to  cure.  The  abscess  itself,  by  its  tendency  to  infect 
the  peritoneum,  is  a  grave  menace,  and  even  if  the  abscess 
ruptured  into  a  hollow  viscus  the  situation  is  not  much 
better.  The  speaker  then  considered  certain  features  of 
the  pathology  and  two  points  were  especially  emphasized: 
First,  the  practical  non-existence  of  any  form  of  inflamma- 
tion which  by  obliterating  its  lumen  rendered  the  appendix 
harmless  Second,  the  appalling  rapidity  and  suddenness 
with  which  the  appendix  may  suffer  bacterial  invasion  and 
necrotic  degeneration  with  resulting  general  peritonitis. 
Upon  these  two  facts  he  based  proper  treatment  and  the 
justice  of  claiming  appendicitis  as  a  purely  surgical  affec- 
tion. No  disease  presented  its  signs  and  symptoms  in  J 
such  varied  form  and  locality  as  appendicitis,  and  he  made.  1 1 
it  a  rule  therefore,  in  all  abdominal  cases,  to  first  exclude 
appendicial    irritation,    because    careful    examination    will 


June  13,  1901] 


SOCIETY  REPORTS 


TTF 
L-Mi 


HE  Philadelphia 
.Medical   Journal 


II23 


often  reveal  as  due  to  it  the  affections  otherwise  apt  to 
be  classified  as  "enterocolitis;"  "acute  dyspepsia;"  "chol- 
era morbus,"  etc. 

In  all  inJlammations  of  the  appendix  there  are  three 
cardinal  symptoms,  viz.:  pain,  tenderness  and  rigidity. 
Pain  is  by  all  means  the  most  significant,  so  much  so  that 
the  speaker  regarded  with  suspicion  every  clinical  history 
with  belly-ache,  infianimation  of  the  bowels,  neuralgia  of 
the  stomach,  etc.  The  pain  of  appendicitis  is  paroxysmal, 
cramp-like  and  colicky  and  may  at  intervals  almost  dis- 
appear. It  is  usually  first  referred  to  the  umbilical  and 
epigastric  regions  becoming  localized  in  the  right  iliac 
fossa,  only  after  the  lapse  of  several  hours,  and  that  not  in 
all  cases.  He  advised  that  we  should  at  first  examine  away 
from  the  disease,  and  then  slowly  and  gently  approach  the 
lender  area.  A  localized  spot  of  extreme  tenderness  he 
considered  to  be  surest  indication  of  pus  formation;  con- 
versely abrupt  cessation  is  apt  to  denote  complete  gangre- 
nous change  and  a  paralysis  of  peripheral  nerve  filaments 
by  toxin  absorption.  After  referring  briefly  to  some  of  the 
other  symptoms  of  appendicitis  he  stated  that  he  did  not 
depend  to  any  extent  upon  blood  examinations;  a  leuko- 
cytosis of  over  20,000  indicates  pus  usually  unless  either 
shut  off  by  adhesion  or  the  individual  is  overwhelmed  by 
septic  absorption.  The  symptoms  of  appendicitis  are  sel- 
dom in  proportion  to  the  appendix  regions,  therefore  it 
should  suffice  to  diagnose  early  the  inflammatory  involve- 
ment v.hich  is  of  itself  proper  enough  indication  for  ration- 
al treatment.  He  did  believe  there  was  but  one  treat- 
ment for  appendicitis,  viz.:  the  aseptic  scalpel  of  a  sur- 
geon, and  it  should  be  called  upon  as  promptly  as  the  diag- 
nosis  was   made. 

Dr.  DeLancey.  Rochester,  of  Buffalo,  N.  Y.,  made  a  strong 
plea  for  the  blood  count  as  a  diagnostic  aid  of  these  condi- 
tions during  the  acute  inflammatory  state  and  particularly 
during  the  development  of  pus.  With  an  elevation  of 
temperature  there  was  usually  a  higher  leukocytosis.  He 
also  believed  that  the  aseptic  scalpel  was  the  only  treat- 
ment for  appendicitis. 

Dr.  J.  B.  Kelley,  of  Philadelphia,  did  not  think  that  any 
medical  man  should  treat  a  case  of  appendicitis  after  the 
first  twenty-four  hours. 

Dr.  J.  B.  McElroy,  of  Mississippi,  read  a  paper  on  some 
phases  of  malaria.  In  this  he  related  in  detail  a  case  in 
order  that  he  might  discuss  some  of  the  phases  of  malaria 
that  were  suggested  by  it.  In  referring  to  the  pemicious- 
ness  in  malaria  he  said  that  it  was  a  well-known  fact  that 
in  these  affections  the  aestivo-autumnal  parasites  are  found 
jn  very  large  numbers.  There  are  usually  two  predominat- 
ing broods  of  parasites  in  the  blood  of  patients  with  perni- 
cious fever,  but  Marchiafava  and  Bignami  report  cases  in 
which  the  viscera  as  well  as  the  peripheral  circulation 
show  a  very  small  number  of  parasites.  It  is  evident  that 
we  must  look  for  the  causes  of  malignancy  in  some  other 
direction  than  merely  in  the  large  quantity  of  parasites. 
These  causes  may  be  found  in  what  has  been  termed  in  the 
biological  characteristics  of  the  aestivo-autumnal  parasites. 
The  first  of  these  is  their  capacity  for  rapid  propagation. 
It  is  another  characteristic  of  these  parasites  to  disappear 
from  a  peripheral  circulation  to  complete  their  cycle  of 
development  in  other  vascular  areas.  Another  factor  in 
the  forms  of  pernicious  malaria,  the  virulence  of  these 
parasites,  should  be  taken  into  account.  Many  attempts 
have  been  made  to  demonstrate  a  malarial  toxin,  and  there 
is  good  evidence  to  believe  that  such  exists  although  it 
cannot  be  demonstrated.  It  is,  therefore,  probable  that 
this  property  of  the  aestivo-autumnal  parasites  more  than 
any  other  accounts  for  malignancy  in  malaria.  Another 
proof  of  the  great  virulence  of  these  parasites  is  the  occur- 
rence of  hemoglobinuria  in  these  affections  than  the  mere 
offers  other  ertdences  of  malerial  infections  than  the  mere 
pigmented  leukocytes,  and  the  characteristic  leukocytic 
variation  of  malarial  infection.  In  all  the  cases  studied  by 
him  there  were  pigmented  leukocytes.  After  quite  an  ex- 
haustive consideration  of  this  subject  he  stated  that  if 
pigmentation  and  leukocytic  variation  are  evidences  of 
malarial  infections  where  the  parasites  are  few  or  absent 
in  the  peripheral  circulation,  hemoglobinuria  must  be  ma- 
larial, and  being  malaria,  is  a  most  striking  evidence  of 
the  virulence  of  the  aestivo-autumnal  parasites.  Pheno- 
mena occurring  in  these  infections  after  the  disappearance 
of  the  parasite,  which  have  been  termed  post-malaria,  are 
also  evidences  of  the  toxin  theory. 


It  has  not  infrequently  been  stated  that  the  negro  is 
relatively  immune  from  malarial  infections.  These  state- 
ments are  not  in  accord  with  his  experience  of  eight  years 
with  the  negroes  living  in  the  Southern  Mississippi 
vall-:;y.  On  the  plantation  where  he  resided  there  were  24 
whites,  of  whom  41  were  infected  with  malaria.  There 
were  1S4  blacks,  and  of  these  61  were  infected. 
■  In  considering  the  subject  of  gangrene  he  said  that  Pro- 
fessor Osier  divided  it  into  three  groups:  First,  in  con- 
nection with  Raynaud's  disease:  second,  multiple  spon- 
taneous gangrene  in  association  with  the  acute  infections 
like  measles,  typhoid  fever,  typhus  fever,  scarlet  fever, 
diphtheria  and  malaria.  Multiple  spontaneous  gangrene 
of  the  limbs  in  young  and  middle-aged  people  may  occur 
without  any  obvious  cause.  The  case  he  reported  was  one 
of  multiple  gangrene  in  aestivo-autumnal  infections. 

Dr.  E.  H.  Martin,  of  Mississippi,  said  that  hemoglobin- 
uria was  pernicious,  not  in  the  sense  that  pernicious  is 
usually  regarded;  it  was  malignant  in  that  the  germs  cause 
an  absolute  destruction  of  the  blood  cells.  In  the  other 
forms  he  considered  there  was  simply  an  overdose  of  the 
toxins.  In  the  negro  very  few  cases  of  pernicious  malaria 
were  seen  in  proportion  to  the  number  of  cases  of  malaria 
met  with.  In  small  children,  especially  among  the  whites, 
they  had  a  great  many  cases,  and  it  was  unusual  for  a  fam- 
ily to  raise  two  out  of  five  children  in  Mississippi  on  ac- 
count of  pernicious  malaria.  The  blood  of  the  children 
was  very  rich  in  the  necessary  pabulum  for  the  malarial 
germs,  and  the  child,  when  small,  having  but  poor  resist- 
ing power,  the  germs  attack  the  child  and  there  is  really  an 
overdose  of  malaria. 

SECOND  DAY,  JUNE  5th,  1901. 

Dr.  W.  D.  Kelly,  of  St  Paul,  read  a  paper  on  The  Clinical 
and  Microscopical  Examination  of  the  Blood.  The  blood 
serum  containing  serum  albumin  and  serum  globulin  is 
subject  to  chemical  changes  in  puerperal  septicemia.antj  in 
certain  febrile  diseases  the  globulin  is  less  subject  to 
change  than  the  serum  albumin.  Pathological  variations  in 
the  phosphates  are  but  slight,  and  of  the  chlorides  not  very 
great,  although  this  principle  is  chiefly  responsible  for  the 
isotonic  relation  of  cells  in  serum.  In  anemia  there  is 
usually  a  high  percentage  of  chlorides.  The  larger  the 
proportion  of  plasma  the  greater  is  the  percentage  of 
chlorides  in  the  blood.  In  the  plasma  are  chiefly  found  the 
sodium  salts:  these  are  usually  increased  in  watery  blood. 
Potassium  found  in  the  red  cells  is  diminished  in  hydremic 
conditions.  Chaureau.  Seegen.  Cavazanni,  and  others  found, 
in  normal  blood,  traces  of  glucose,  which  was  increased 
by  a  diet  of  carbohydrates  and  diminished  by  muscular  ex- 
ercise. In  the  red  cells  is  found  the  diastase,  also  in  the 
serum,  and  Precka  and  others  believe  it  to  have  the  power 
of  coagulating  the  blood:  it  is  inhibited  by  neuclein  and  in- 
creased by  sodium  sulphate  and  chloride.  Fat  has  been 
demonstrated  in  the  blood  after  a  hearty  meal.  Free  fat. 
both  in  health  and  disease,  has  been  frequently  found. 
Acetone  has  been  found  in  fevers.  V.  Taksch  demonstrated 
fatty  acids  in  the  blood  in  leukemia,  acute  yellow  atrophy 
of  the  liver  and  infectious  diseases. 

In  cholemia.  the  poisonous  symptoms  that  develop  have 
been  referred  by  most  authorities  to  the  presence  of  bil- 
iary acids.  Isotonic  tension  and  increased  resistance  of 
the  red  blood  cells  are  peculiar  characteristics  of  red  blood 
in  jaundice.  Bile  acids  affect  the  union  of  hemoglobin 
with  the  stroma  of  the  red  cell,  rendering  the  hemoglobin 
more  easily  soluble,  and  this  accounts  for  the  solution  of 
red  cells  in  jaundice,  as  well  as  in  other  conditions.  Ic- 
teric blood  has  also  an  increase  in  the  nitrogenous  bodies. 
Well  marked  cholemia  may  be  detected  by  the  inspection 
or  serum  or  foam  on  heating  to  50  degrees.  I.  C.  Biliru- 
bin may  be  changed  to  biliverdin  by  that  process.  In  the 
rabbit,  by  the  intravenous  injection  of  glacial  acetic  acid, 
he  had  been  able  to  get  an  acid  recation  several  hours  af- 
terward by  the  phenolphthalein  test.  The  specific  gravity 
of  the  blood  is  increased  by  sweating,  by  lack  of  food, 
muscular  exertion;  and  it  may  be  decreased  by  freely  im- 
bibing in  water  or  fluids.  Homberger  found  that  albumins 
and  chlorides  behave  differently  after  changing  osmotic 
conditions.  If  a  little  acid  is  added  to  the  blood,  albumin 
and  phosphates  pass  from  red  cells  to  the  serum,  while 
chlorides  pass  from  serum  to  cells:  but  when  alkalies  are 
added  the  opposite  conditions  are  induced. 

In  order  that  a  satisfactory  examination     of  the    blood 


1 124 


The  Philadelphia" 
Medical   Journal  . 


SOCIETY  REPORTS 


[June   15,   ij'Jl 


might  be  made,  the  following  things  were  requisite:  Appa- 
ratus must  be  absolutely  clean.  The  various  stages  of  the 
process  must  be  performed  rapidly  because  the  cell  coag- 
ulation of  the  blood  will  interfere  with  any  of  the  tests. 
The  work  must  be  done  accurately.  By  making  large 
quantities  of  the  stain  and  keeping  some  in  glass-stoppered 
bottles,  will  standardize  the  solution,  so  that  one  will  re- 
ceive the  minimum  variations  in  intensity  of  stain.  Fix- 
ing a  specimen  by  continuous  heat,  with  as  slight  a  degree 
in  variation  in  distributing  the  heat  as  possible,  is  of 
value. 

Dr.  Thomas  McCrae,  of  Baltimore,  read  a  paper  entitled 
"Pernicious  Anemia:  Report  of  a  Series  of  Cases."  In  this 
he  made  the  report  of  40  cases  that  had  occurred  in  the 
service  of  Dr.  Osier,  at  the  Johns  Hopkins  Hospital  in  a 
period  during  ten  and  eleven  years.  During  the  same  time 
there  were  about  12,500  medical  patients.  Of  the  40  pa- 
tients, 32  were  males,  and  8  females.  Two  were  colored. 
The  ages  varied  from  ten  to  seventy  years,  the  largest 
number  occurring  in  the  fifth  decade.  As  to  the  etiology, 
worry  and  mental  strain  were  only  present  in  3  cases. 
Pregnancy  was  associated  in  1.  Oral  sepsis  was  not  in- 
variably present  in  the  recent  cases.  Among  the  symp- 
toms, the  most  frequent  were  weakness,  change  of  color, 
and  loss  in  weight.  The  latter  symptom  occurred  in  more 
than  one-half  of  the  cases,  and  emaciation  was  marked 
in  10  cases.  Pigmentation  of  the  skin  was  found  in  8,  and 
petechiae  in  4  instances.  In  the  abdomen  the  liver  was 
felt  in  2  cases,  and  the  spleen  in  6,  but  in  none  was  the 
enlargement  at  all  marked.  When  the  cases  first  came 
under  observation,  the  hemoglobin  averaged  30  per  cent., 
the  red  cells  1.560.000.  and  leukoc.vtes  6929  per  cubic  milli- 
metre. Of  the  16  cases,  with  a  count  below  1,000,000,  only 
4  recovered.  The  average  differential  count  for  36  cases 
was:  polymorphoneuclears,  61%:  small  mononeuclears, 
31';^:  large  mononeuclears  and  thans'.tionals,  4%:  eosino- 
philes,  2%,  and  a  fraction  of  1  per  cent,  of  myelocytes. 
The.  average  number  of  nucleated  reds  per  1000  leukocytes 
was  37.  of  which  23  were  normoblasts,  5  were  megaloblasts, 
and  9  were  intermediary  forms.  In  a  comparison  of  the 
fatal  and  the  non-fatal  cases,  the  average  percentage  of 
small  normoblasts  was  rather  higher  in  the  cases  that  re- 
covered, but  the  number  of  megaloblasts  was  eleven  times 
greater  in  the  fatal  cases.  There  were  nervous  manifes- 
tations in  14  cases.  These  varied  from  slight  disturbances 
only  to  complete  paraplegia.  It  is  not  possible  to  group 
these  cases  under  any  division,  as  the  symptoms  were  so 
varied.  The  prevailing  type,  however,  was  of  a  more  or 
less  spastic  condition,  with  some  inco-ordination  and 
marked  sensory  disturbances.  In  some  the  nervous  symp- 
tom seemed  to  vary  with  the  state  of  the  blood.  As  to  dia'^ 
nosi.s.  the  distinction  from  gastric  cancer  may  be  difficult. 
In  this  the  higher  count  of  the  red  cells  usually  found, 
the  lower  color  index,  lower  percentage  of  small  raon<uiu- 
clear  and  absence  of  megaloblasts  are  all  important  fac- 
tors. Certain  cases  which  show  some  features  of  splenic  an 
emia  are  hard  to  place, of  which  3  were  cited.  They  had  a  pro- 
longed source,  marked  enlarged  spleen,  ascites  in  2,  and 
the  general  blood  conditions  of  pernicious  anemia.  They 
were  not  included  in  this  series.  The  average  duration  of 
17  fatil  cases  was  12  months.     In  S  the  course  was  und>  r 

6  months.    One  case  recovered  and  came  under  observation 

7  years  later  with  cancer  of  the  stomach,  and  one  is  in 
good  condition  6  years  after  the  onset.  Ho  summed  up 
the  treatment  into  rest,  fresh  air.  good  food  and  arsenic. 

Dr.  George  Douglas  Head,  of  Minneapolis,  read  a  paper 
on  "The  Leukocyte  Coun.t  in  Hemorrhage."  He  desired 
to  place  on  record  some  experimental  work  upon  the  leu- 
kocytes in  hemorrhage  which  had  given  results  some- 
what different  from  the  generally  accepted  views.  In  his 
experiments  upon  dogs  the  same  law  seems  to  govern 
the  increase  or  decrease  of  leukocytes  in  the  circulatin.; 
blood  as  in  man.  Where  there  is  a  leukocytosis  of  diges- 
tion, or  following  septic  infections,  it  is  the  same  in  dogs 
as  in  man.  The  variation  of  leukocytes  in  the  circulating 
blood  of  man  is  the  same  as  in  dogs.  In  all  probability  the 
conclusions  arrived  at  from  his  experiments  in  dogs,  Ue 
thought,  would  apply  equally  well  to  the  human  beings. 
Ho  formulated  his  results  as  follows:  1.  In  dogs  a  diminu- 
tion in  the  number  of  white  cells  in  the  circulating  blood 
immediately  follows  a  profound  hemorrhage.  2.  This  initial 
leukopenia  is  followed  sooner  or  later  by  an  increase 
in  the  number  of  leukocytes  in  the  circulating  blood.  This 
is  the  so-called   posthemorrhagic  leukocytosis  of  all  wri- 


ters.   3.    This  leukocytosis  of  hemorrhage  continues  for  at 
least  seven  days,  and,  in  some  cases,  much  longer. 

Dr.  W.  T.  Higgins,  of  Courtland,  N.  Y..  stated  that  Hun- 
ter's success  in  the  treatment  of  this  disease  seemed  to 
offer  something  in  favor  of  his  theory.  He  had  treated 
every  case  on  the  lines  laid  down  by  Hunter  with  success. 
Asepsis  of  the  mouth  should  not  only  be  secured,  but  also 
of  the  upper  air  passages  as  well. 

Dr.  McCrae.  of  Baltimore,  said  that  brilliant  results  h-iA 
been  obtained  from  the  use  of  arsenic.  In  1890  he  had 
a  case  who  is  alive  and  well  to-day.  Another  case  he 
had  treated  returned  six  years  after  with  cancer  of  the 
stomach.  Cases  he  had  seen  get  well  when  treated  by 
arsenic,  fresh  air,  good  food,  rest,  Epsom  salts  and  the 
employment   of  oral  asepsis. 

Dr.  Heinrich  Stern,  of  New  York,  read  a  paper  on  Osmot- 
ic Pressure  and  its  Relation  to  Uremic  Manifestations. 
He  believed  that  we  were  looking  in  the  wrong  directioa 
when  we  tried  to  fasten  the  origin  of  uremia  and  kindred 
affections  upon  a  purely  physiologico-chemical  basis.  Most 
of  the  effete  products  />')•  .w  were  little  toxic.  Potassium 
seems  to  exert  the  greatest  poisonous  qualities.  Urine,  in- 
jected into  the  veins  for  experimental  purposes,  has  showu 
that  uremia  is  not  the  consequence  of  one,  but 
of  the  retention  of  all  those  substances  which 
normally  enter  into  the  composition  of  the  urine. 
In  the  urine  we  do  not  encounter  any  other  factors 
but  those  that  are  prevalent  in  the  normal  state.  The  only 
difference  is  the  quantity.  Uremia  is,  therefore,  rather  a 
physical  than  a  chemical  anomaly. 

In  referring  to  osmotic  pressure  in  the  body  fluids  he 
stated  that  all  organic  matter  is  saturated  with  water:  that 
the  cells  of  the  body  are  more  or  less  permeable  for  water. 
If  the  contents  of  the  organism  are  soluble  salts  and  re- 
main unaltered  in  water,  so  that  for  a  certain  period  nei- 
ther salts  nor  water  are  introduced  nor  eliminated,  all  the 
watery  constituents  of  the  organism  would  become  one 
homogenous  liquid  and  the  same  osmotic  pressure  would 
prevail  over  the  entire  system.  The  molecules  of  a  number 
of  compounds,  when  dissolved,  were  divided  up  and  dissect- 
ed into  "ions."  The  higher  the  dilution  the  more  perfect 
tne  dissociation,  as  a  rule.  There  is  no  vital  process  in 
which  diffusion,  or  osmosis,  does  not  participate.  Condi- 
tions for  the  evolvement  of  osmotic  pressure  always  exist 
in  the  organism,  for  whenever  two  solutions  come  in  con- 
tact by  means  of  a  semi-permeable  wall,  osmotic  tension  is 
displayed.  When  the  excretory  activity  of  the  kidney  is 
niaterially  interfered  with,  the  products  of  catabolism  are 
retained  in  the  blood.  The  great  number  of  molecules 
dissolved  in  the  plasma  exert  a  high  osmotic  tension,  and 
tend  to  diffundate  (?)  toward  the  less  concentrated  body 
liquids.  Ultimately  all  the  fluids  of  the  body  exhibit  a 
similar  degree  of  concentration,  which  is  accompanied  by 
a  series  of  manifestations  co-ordinate  and  successive,  which 
have  been  grouped  together  under  the  term  "uremia." 
This  is  really  a  mechanical  intoxication,  not  one  of  chem- 
ical origin,  but  one  due  to  an  abnormal  increase  in  osmotic 
tension  of  the  blood  plasma  and  the  fluid  of  the  body. 

The  phenomena  which  occur  in  the  blood  after  the  injec- 
tion of  large  amounts  of  concentrated  salt  solution  are  the 
same  as  those  which  occur  in  uremia.  They  make  their 
appearance  together  with  the  increase  in  the  concentration 
of  the  blood,  when  the  elimination  of  the  accumulative 
qualities  of  the  tissues  does  not  occur  any  longer.  Noss 
noticed  in  dogs  tonic  and  clonic  convulsions  after  intra- 
venous injections  of  10  per  cent,  sodium  chloride  solution, 
and,  in  such  event,  that  the  blood  had  attained  twice  it 
former  concentration. 

Dr.  Charles  G.  Stockton,  of  Buffalo.  X,  Y..  read  a  p.iper 
entitled  Circulatory  Disturbances  Accompanying  Cirrhoses 
with    Inosculation   of  the    Portal    Branches   with   Systemi-; 
Veins.     Some  practical   conclusions   could   be  drawn   fm::^ 
the  data  given.    The  first  of  these,  to  which  it  would  see:: 
unnecessary  to  call  attention,  but  that  it  appeared  to  hav 
been    somewhat    overlooked,    is    that    the    normal    Woo' 
pressure  in  the  portal  vein  is  low:  that  when  it  is  suddenl 
raised,  it  is  apt  to  he  followed  by  symptoms  of  toxemia,  an  '. 
that  these  symptoms  may  he  promptly  relieved  by  purg,-. 
tion.     .\   second    important   conclusion   is   that  when   th 
vascular  changes,  and  the  raised  portal  blood  pressure  that 
permit  the  passage  of  the  portal  blood  into  the  systemi 
vein,  are  brought  about  gradually,  the  subject  is  better  ab]  - 
to  resist  the  toxemia,  becoming  as  it  were  immunized  to  th^ 
offending  portal  blood,  hence  symptoms  are  less  striking. 


ISill] 


SOCIETY  REPORTS 


("The  Philadelphia 
L  Medical  Joubnal 


II25 


and  w  ith  proper  care  as  to  diet  and  purgatives  may  be  prac- 
tically overcome. 

Dr.  Victor  C.  Vaughan.  of  Ann  Arbor,  Mich.,  made  a  few 
remarks  on  Cirrhoses  of  the  Liver  due  to  metallic  poisons 
and  said  that  lead  and  copper  were  the  substances  which 
should  be  considered  so  far  as  their  effect  upon  the  liver 
were  concerned,  and  particularly  upon  the  changes  in  the 
connective  tissue  of  the  liver.  Alcohol  is  one  of  the  most 
important  factors  in  the  production  of  the  cirhossis  of 
L'aennec.  Lead  and  copper  generally,  if  not  always,  pro- 
duce changes  in  the  liver  cells  which  are  characterized  by 
a  fatty  degeneration  or  fatty  deposit  in  the  liver  cells. 
There  had  been  considerable  discussion  as  to  whether 
the  first  changes  take  place  in  the  hepatic  cells  or  in  the 
connective  tissues.  But  so  far  as  the  metallic  poisons 
•were  concerned  he  thought  the  changes  in  the  liver  cells 
were  prior  in  time  to  the  changes  in  the  connective  tissues. 
Certainly  they  are  recognizable  earlier  than  the  other 
changes.  He  had  seen  a  number  of  cases  of  cirrhosis  of  the 
liver  due  to  lead  poisoning.  It  is  not  often  that  we  see 
cases  in  the  early  stages  of  liver  changes  at  autopsy:  there- 
fore we  must  rely  on  animal  experimentation  in  our  en- 
deavor to  trace  the  relationship  of  these  changes.  In  a 
number  of  cases  of  metallic  poisoning  there  occurs  subse- 
<iuently  an  overgrowth  in  the  connective  tissue  of  the 
liver. 

Dr.  John  H.  Husser.  of  Philadelphia,  spoke  on  the  sub- 
ject of  Treatment  of  Cirrhoses  of  the  Liver.  He  divided 
these  cases  of  cirrhoses  of  the  liver  into  (1)  those  in  which 
no  symptoms  occurred  during  life,  the  cirrhoses  having 
been  found  at  autopsy,  the  patient  dying  from  other  causes: 
(2t  those  cases  that  were  not  suspected  until  such  an  acci- 
dent as  hemorrhage  made  it  apparent,  i.  e.,  latent  cirrhoses 
of  the  liver:  (3)  cases  with  the  symptoms  of  portal  ob- 
struction and  (4)  on  the  other  hand  biliary  obstruction. 
The  lines  of  treatment  were  largely  dietetic  and  hygienic, 
great  care  being  taken  to  see  that  the  functions  of  the 
gastrointestinal  tract  were  kept  in  action  and  the  renal 
secretions  properly  regulated,  as  well  as  the  action  of  the 
skin.  He  raised  a  word  of  caution  in  regard  to  the  presence 
of  hemorrhoids.  He  had  seen  two  or  three  deaths  follow 
tlie  operative  treatment  of  hemorrhoids  and.  at  the  au- 
topsy, cirrhoses  of  the  liver  was  learned  of  for  the  first 
time.  In  all  cases  of  hemorroidal  disease  a  thorough 
knowledge  of  the  state  of  the  liver  should  be  known  before 
any  operative  interference  is  advised. 

The  treatment  of  ascites  occurring  in  cirrhoses  is  to- 
day particularly  interesting  because  of  the  recent  attempts 
to  cure  this  condition  by  operation.  The  speaker  was  ac- 
customed to  use  mild  purgation  and  calomel  from  time  to 
lime:  he  also  used  calomel  in  l-40th  of  a  grain  dose,  every 
three  hours,  as  a  diuretic.  He  also  relied  upon  the  old- 
fashioned  pill  digitalis,  squills,  and  calomel.  He  also  had 
considerable  confidence  in  the  use  of  the  oil  of  copaiba. 
In  any  case  of  ascites  he  resorted  to  tapping  early  and 
frequently.  The  question  of  permanent  drainage  was  then 
considered  and  he  referred  to  a  case  that  was  operated 
upon  by  Dr.  Frazer:  the  abdomen  was  opened,  the  perl- 
tcne'im  was  scarified  and  the  omentum  attached.  This  was 
done  12  months  ago  and  the  patient  is  cured,  there  having 
been  no  recurrence. 

■  Dr.  Thomas  D.  Futcher.  of  Baltimore,  read  a  paper  en- 
titled Cirrhoses  with  Pigmentation.  The  association  of 
pigmentation  of  the  skin  and  tissues  with  a  form  of  hyper- 
trophic cirrhoses  of  the  liver  rather  than  with  the  atrophic 
form  was  emphasized,  and  he  discussed  at  length  the  pig- 
mentation associated  with  hypertrophic  cirrhoses  of  the 
liver  which  occurs  in  the  disease  described  by  von  Reck- 
linghausen as  "hemochromatosis."  He  also  dwelt  upon  the 
source,  chemical  composition  and  distribution  of  the  pig- 
ment He  endeavored  to  show  that  diabetic  cirrhoses 
with  bronzing  of  the  skin,  ili'ihrlr-hronze  was  probably  Iden- 
tical with  von  Recklinshausen's  hemochromatosis.  So  far 
as  he  was  aware  but  4  cases  of  cirrhosis  of  the  liver  with 
general  pigmentation  fhemachromatosis!  have  been  re- 
ported from  this  country. 

Dr.  .Tames  J.  Walsh,  of  Xew  York,  read  a  paper  entitled 
Rheumatic  Stimulants,  in  which  he  stated  there  were  three 
terms  in  medicine  that  had  an  indefinite  signification — 
rheumatism,  gout  and  catarrh,  and  curiously  enough  theee 
terms  are  descriptive  of  the  same  idea.  Acute  rheumatic 
arthritis  we  have  come  to  realize  as  being  an  acute  infec- 
tious disease  of  miorooreanismal  origin.     Its  very  similar- 


ity to  gonorrheal  rheumatism  points  strongly  to  the  mi- 
crobic  origin  of  the  disease.  He  referred  to  a  series  of 
joint  symptoms  that  occurred  in  connection  with  certain 
toxemias.  Observations  were  made  pointing  to  the  fact  that 
there  might  be  serious  involvement  of  joint  structures 
without  there  necessarily  being  any  microbic  metas- 
tasis. Painful  affections  around  a  joint  point  to  two  facts, 
(IJ  the  nervous  mechanism  supplying  joints,  owing  to  its 
greater  use  than  most  of  the  other  groups  of  nerves  makes 
it  extremely  sensitive  to  disturbances  of  the  circulation: 
(2)  tissues  in  the  neighborhood  of  joints  being  much  used 
and  subjected  to  injury  are  liable  to  take  on  chronic  in- 
flammatory conditions.  In  a  series  of  cases  occurring  in 
the  service  of  Professor  Katzenbach  at  the  New  York 
Polyclinic  certain  observations  were  made.  These  cases 
presented  painful  symptoms  which  are  usually  referred  to 
the  neighborhood  of  joints  and  which  have  been  diagnosed 
as  rheumatism,  ^^^len  the  patient  was  not  able  to  give  a 
straight  history  of  acute  rheumatism  with  red  swollen 
joints,  fever  and  sweating,  the  case  was  at  once  assumed 
not  to  be  rheumatic  in  character  and  very  seldom  was  it 
necessary  to  retract  this  assumption.  Among  40  cases 
presented.  15  had  so-called  rheumatic  symptoms  of  the 
lower  limbs  due  to  flat  foot,  and  this  proportion,  a  little 
more  than  one-third,  represented  very  nearly  the  ratio  in 
which  flat  foot  symptoms  are  mistaken  for  rheumatism. 
Very  often  the  symptoms  are  worse  on  rainy  days  or  in 
damp  weather,  probably  from  the  fact  that  on  damp 
muddy  days  these  patients  are  apt  to  wear  old  shoes  which 
do  not  furnish  good  support  to  the  arch  of  the  foot. 
Again,  the  nerves  are  much  more  sensitive  when  there  is 
dampness.  In  speaking  of  occupation  neuroses  he  said  that 
there  was  no  occupation  that  involves  a  frequent  repetition 
of  muscular  movements,  but  what  might  produce  it.  For 
instance,  so  simple  an  action  as  sweeping,  if  done  as  a 
regular  occupation  and  constantly  performed  with  a  broom 
in  the  hand  will,  in  individuals  who  are  run  down  give  rise 
to  painful  feelings,  either  in  the  shoulder  if  the  broom  is 
grasped  too  high  up  to  enable  the  person  to  take  advantage 
of  the  proper  leverage  in  making  the  sweep,  or  in  the  leg 
if  the  body  is  constantly  supported  on  one  leg  during  the 
process  of  sweeping.  The  brachyalgia  that  occurs  in  con- 
nection with  frequent  and  badly  directed  use  of  the  small 
muscles  of  the  forearm  is  well-known,  occurring  in  tele- 
graphers, in  writers,  in  penmen,  in  typewriters,  in  piano 
players,  etc.,  as  a  result  of  a  sort  of  sympathy  with  the 
lower  arm.  and  the  shoulder  often  suffers  from  a  decided 
ache,  and  it  is  surprising  how  often  this  ache  is  treated  for 
rneumatism. 

Dr.  Charles  Lyman  Greene,  of  St.  Paul,  llinn.,  presented 
to  the  section  A  Case  of  Acromegaly  Presenting  Certain 
Features  of  Unusual  Interest.  The  young  man  was  2.5  years 
of  age  and  had  had  no  fixed  occupation  but  for  some  years 
prior  to  the  development  of  the  disease  had  spent  the 
winter  months  on  the  ice,  a  point  of  some  importance:  in- 
asmuch as  the  history  of  many  of  these  cases  has  strongly 
suggested  the  influence  of  long  exposure  to  cold  and 
dampness  as  a  predisposing  or  exciting  cause.  The  family 
history  was  negative.  Lues  was  denied.  At  five  years  of  age 
he  noticed  a  rapid  enlargement  of  the  hands  and  feet  and 
the  members  of  his  family  noticed  a  change  in  his  physiog- 
nomy. The  enlargement  of  the  hands  and  feet  steadily 
continued  and  progressed  quite  rapidly  up  to  the  time  that 
he  presented  himself  three  years  ago,  when  the  hands  and 
feet  were  found  to  be  of  enormous  size.  The  wrists  and 
ankles  were  free  from  inflammations. but  were  quite  bulky, 
thick  and  in  strong  contrast  with  the  forearms  and  legs. 
He  complained  of  languor  and  weakness  but  has  had  none 
of  the  severer  vertical  pains  so  common  in  acromegaly  nor 
did  he  comlain  of  pain  in  the  lumbar  region  of  limbs.  The 
senses  and  the  nervous  system  were  not  disturbed.  The 
skin  was  nearly  normal  and  lacked  the  hardness  of  myx- 
edema. The  appearance  of  the  face  was  especially  inter- 
esting the  skin  being  thickened  and  hypertrophied.  though 
not  rough.  The  upper  and  lower  eyelids  were  thickened, 
and  the  ears  appeared  clumsy  and  tumid,  as  also  did  the 
nose.  The  nasal  arch  is  prominent,  the  malar  bones  pro- 
ject and  the  lower  jaw  is  apparently  enlarged  from  the 
ankle  to  the  symphysis  and  vertically.  The  enlargement 
of  the  upper  jaw  had  no  doubt  masked  the  changes  in  the 
lower  jaw,  depriving  the  case  of  one  of  the  so-called  typi- 
cal signs  of  the  disease.  The  tongue  is  large,  the  larynx  is 
enlarged  and  its  cartilages  appear  to  be  the  seat  of  hyper- 
trophy.   The  radiograph  demonstrated  the  remarkable  en- 


1 126 


The  Philadelphia' 
Medical   Journal  . 


SOCIETY  REPORTS 


[June  13,  1301 


largement  of  the  bones.  The  feet  presented  the  same 
typical  characteristics  as  the  hands.  There  were  no  marked 
enlargements  of  the  great  toes.  The  hands  and  feet  were 
not  the  seat  of  pain  nor  were  their  movements  much  re- 
stricted. A  feature  of  especial  importance  is  the  marked 
increase  in  the  bulk  of  the  overlying  tissues  which  pre- 
sent the  appearance  and  sensation  of  a  hard  edema  ex- 
actly like  that  of  myxedema.  The  treatment  had  been 
solely  by  thyroid  extract,  the  result  being  an  immediate 
and  marked  amelioration  of  the  disease. 

The  Election  of  Officers:  For  Chairman,  Dr.  Frank  A. 
Jones,  of  Memphis,  Tenn. ;  for  Secretary,  Dr.  Robert  B. 
Preble,  of  Chicago. 

THIRD  DAY,  JUNE  6th,  1901. 

Dr.  T.  B.  Greenley,  of  Meadow  Lawn,  Tenn.,  read  a 
paper  on  The  Modified  Treatment  of  Typhoid  Fever,  in 
which  he  advocated  the  use  of  acetanilid  with  quinine; 
acetanilid  he  claimed  had  soothing  and  quieting  effect,  and 
prevented  the  possible  irritating  effects  of  the  quinine.  No 
depressing  effects  of  this  drug  upon  the  heart  had  ever 
occurred  among  his  cases.  The  dose  was  increased  or  di- 
minished according  to  the  rise  or  fall  of  the  temperature. 

Dr.  O.  T.  Osborne,  of  New  Haven,  Conn.,  read  a  paper  en- 
titled Mental  Shock.  He  did  not  wish  to  appear  as  ad- 
vocating the  use  of  this  term  for  conditions  of  failing  heart 
due  to  distinct  pathological  conditions,  or  due  to  a  grad- 
ual break-up  in  the  system  by  very  acute  or  prolonged 
intense  processes:  he  thought  the  term  was  justifiable 
when  a  badly  acting  and  gradually  weakening  heart  was 
the  most  urgent  cause  for  anxiety  and  its  weakness  was 
out  of  proportion  to  the  pathological  conditions  or  symp- 
toms present.  He  believed  that  w'e  were  justified  in  using 
the  term  surgical  shock.  The  symptoms  were  more  or  less 
rapid  heart,  irregular,  perhaps  dicrotic  or  intermittent 
pulse,  incomplete  respirations  without  much  actual  dys- 
pnea, interspersed  with  frequent  sighs,  and  the  subjective 
symptoms  of  precordial  oppression.  The  temperature  was 
generally  low,  the  flesh  cool  and  clammy,  if  quick  relief 
be  not  ohtained,  death  will  soon  take  place  by  heart  failure 
or  mental  shock.  He  believed  that  mental  shock  was  just 
as  certainly  a  vaso-motor  paralysis  as  is  surgical  shock,  and 
as  a  consequence,  the  major  part  of  the  blood  is  to  be  found 
in  the  abdominal  veins.  The  blood  flows  slowly  into  the 
dilated,  and  therefore  non-elastic  arterioles,  hence  slowly 
into  the  capillaries,  and  returning  slowly  in  the  veins  an.i 
Imperfectly  fills  the  heart  cavities.  The  heart  contracts 
irregularly, incompletely. and  arrhythmically.  The  aorta  has 
not  the  pressure  ahead  or  the  forcible  quota  of  blood  from 
behind  and  consequently  docs  not  give  enough  elastic 
rebound  to  force  blood  properly  into  the  coronary  arteries, 
and  the  heart  muscle  is  improperly  nourished.  By  the 
lowered  blood  pressure  the  functions  of  the  body  begin  to 
fall,  all  digestive  processes  are  impaired  and  molecular 
death  begins  to  take  place.  Severe  acute  nerve  pain  will, 
if  continued,  give  a  lowered  vasomotor  tension,  and  if  too 
long  continued  or  too  severe,  vasomotor  paralysis  or  shock 
perfectly  similar  to  that  due  to  profound  injuries  of  these 
nerves,  or  surgical  shock.  In  acute  feverish  processes 
our  aim  should  be  to  make  the  elimination  at  least  equal 
to  the  production  of  the  decomposing  and  fermenting  pro- 
ducts and  to  prevent  the  absorption  of  these  products  if 
possible.  In  all  diseases  and  conditions  there  is  a  piling  up 
in  the  blood  of  absorbed  poisons,  be  they  from  typhoid 
fever,  or  dysenteric  ulcers,  from  pus  collections,  from  ma- 
larial Plasmodia  or  hemoglobinnric  debris,  from  cancerous 
disintegration,  from  unhealthy  catarrhal,  edematous  mu- 
cous membranes,  etc.  any  treatment  which  hastens  the 
evacuation  of  the  extreted  bile  impregnated  with  toxins, 
will  prevent  systemic  and  nervous  poisoning,  and  ultimate- 
ly vaso-motor  disturbances  and  mental  shock. 

Dr.  L.  Napoleon  Boston,  of  Philadelphia,  read  a  paper 
on  Coughing  a  Means  of  Disseminating  Tubercle  Bacilli: 
A  Study  of  Fifty  Cases,  The  conditions  which  prompted 
him  to  investigate  as  to  the  degree  with  which  tubercle 
bacilli  were  disseminated  were  first,  that  from  the  mouth 
of  an  inmate  of  the  Philadelphia  Hospital  he  noticed  that 
fine  droplets  of  sputum  were  ejected  with  each  act  of 
coughing,  and  second,  that  coughing  was  often  excited  by 
eating.  He  thought  that  this  possibly  explained  why  pa- 
tients in  the  early  stages  of  the  disease  did  badly  in  this 
institution  where  every  possible  attention  was  given  to 
Ventilation,  light  and  the  disinfection  of  the  sputum.  The 
spray  was  collected  by  a  mask,  the  essential  features  of 


which  were  that  it  rt'as  made  of  German  silver  wire, 
one  piece  of  which  was  moulded  to  fit  the  face,  resting  on 
the  nose,  cheeks  and  chin.  To  prevent  irritation  it  was 
covered  with  rubber  tubing.  Suspended  from  this  wire  was 
a  second  oblong  portion  provided  with  two  lateral  grooves 
v.'hich  served  to  accommodate  two  microscopic  slides. 
When  the  mask  was  in  position  the  slides  v.ere  held  in 
front  of  the  mouth  and  nose  at  a  point  about  three  inches 
distant  from  the  lips.  The  piece  is  held  in  position  by  an 
elastic  band.  The  patients  were  allowed  to  wear  this 
about  an  hour  and  only  during  that  part  of  the  day  when 
they  coughed  the  least,  and  they  were  instructed'  to  re- 
move it  during  attacks  of  coughing.  Of  the  50 
.specimens  obtained  from  50  patients.  38  were  found 
to  contain  tubercle  bacilli  in  variable  numbers,  four 
to  six  being  the  smallest  found  in  any  specimen. 
In  3  of  the  12  negative  cases  the  patients  were  so  weak  that 
they  could  hardly  talk  while  wearing  the  mask.  It  was 
shown  that  the  secretions  of  the  mouth  and  respiratorj- 
Lract  are  atomized  and  given  off  in  the  form  of  sprays,  in 
both  health  and  disease,  and  that  this  spray  contains  bac- 
teria and  other  cellular  elements  known  to  be  common  to 
such  secretions,  and  therefore  it  was  rational  to  suppose 
that  many  other  diseases  wer»  conveyed  by  this  media, 
and  that  the  work  accomplished  through  the  study  of  con- 
sumptives was  but  a  step  in  a  direction  which  bids  fair 
to  modify  the  hygiene  of  infection.  Conditions  affecting 
these  organs  and  consequently  their  secretions  must  of 
necessity  be  spread  in  this  way;  especially  was  this  true 
of  diphtheria,  tonsilitis,  and  possibly  small-pox,  measles, 
scarlet  fever,  whooping-cough,  mumps,  etc.  Droplets 
alighting  on  clothing  must  serve  as  a  favorable  means  of 
conveying  the  disease  from  house  to  house:  and  men  may 
become  infected  by  the  spray  projected  by  horses,  cows, 
etc.,  and  other  domestic  animals  suffering  from  glanders, 
tuberculosis,  and  similar  affections,  and  this  appeared  to  be 
highly  probable. 

Dr.  M.  H.  Fussell.  of  Philadelhia.  presented  a  paper  en- 
titled The  Value  of  Throat  Cultures  in  Diphtheria,  in  which 
he  said  that  the  following  could  be  proven:  ill  True  cases 
of  diphtheria  may  have  few  or  no  clinical  symptoms.  (2i 
Cases  of  tonsillitis  or  pharyngitis  may  have  severe  symp- 
toms and  be  serious,  but  no  true  diphtheria  be  present,  or 
the  presence  of  the  Klebs-Loeffler  bacillus,  and  conse- 
quently the  patient  was  not  able  to  transmit  the  disease. 
(3)  A  diphtheritic  exudate  may  be  easily  detached  and 
leave  no  bleeding  surface.  (4i  An  exudate  due  to  some 
other  organism  may  be  true  membrane,  impossible  to 
detach  from  the  mucous  membrane.  He  said  that  culture.s 
can  most  surely  and  with  less  risk  of  mistake  be  made  at 
the  laboratories,  but  that  they  could  be  made  at  home,  and 
that  they  should  be  made  there  if  we  intend  to  keep 
pace  with  the  rapid  strides  of  recent  medicine. 

Dr.  Ferd.  C.  Valentine,  of  New  York,  presented  a  paper 
(m  Genito-Urinary  Examinations  by  the  General  Practi- 
tioner: With  Demonstrations  on  Patient.  It  was  his  desire 
to  show  <1)  that  all  genitourinary  examinations  should  be 
painless:  (2i  the  operator  should  conduct  no  examinations 
unless  his  arms  were  bared  to  above  the  elbows  and  his 
clothing  protected  by  a  gown  and  apron;  (3»  during  every 
examination,  the  physician  should  protect  his  eyes  w^ith 
spectacles  (not  eye-glasses)  even  if  he  had  no  visual  de- 
fects; (4)  ideal  examinations  are  made  in  the  morning  be- 
fore the  patient  has  passed  his  urine;  (5)  the  amount  and 
character  of  a  urethral  discharge  can  be  estimated  only  by 
correct  technique  in  expressing  the  urethral  contents;  '6) 
the  color  of  the  urethral  discharge  changes  when  it  dries 
upon  the  patient's  garments:  tTi  the  meatus  should  be 
cleaned  before  passing  urine  for  examination;  (SI  ths 
manner  of  urinating  is  often  pathognomonic:  (9)  the  epi- 
thelium found  in  the  urine  is  indicative  of  the  locality  tf 
the  lesion;  (10)  examination  of  the  urethral  adnexa  is  a 
necessary  part  of  the  steps  for  complete  diagnosis:  (111 
no  instrumental  ingression  of  the  urethra  should  be  at- 
tempted without  most  thorough  efforts  at  rendering  it 
aseptic;  (12)  the  technique  of  strirtng  at  urethral  asepsis 
is  neither  complicating  nor  difficult;  (13 (  the  soft  boug'^'- 
H-boule  is  the  only  instrument  that  can  be  used  for  tactile 
exploration  of  the  urethra;  it  is  purely  a  diagnostic  in- 
.<trument;  the  rigid  sound  is  wholly  a  therapeutic  in 
strument;  114)  urethroscopy  with  a  modern  instrument 
is  not  difficult;  (15)  the  general  practitioner  is  perfectly 
competent  to  examine  the  vast  majority  of  genito-urinary 
cases;  (1t^)  such  examinations  only  exceptioally  require 
extra-ordinary   skill  or  a  large  armamentarium;    (17 1   the 


June   1'„   VMi] 


SOCIETY  REPORTS 


TThe  Philahelphia 
L  Medical  Journai, 


1  127 


pathology  of  genito-urinary  diseases  in  no  wise  ditfers  fi'ora 
mat  ot  other  affections. 

Dr.  Frank  Billings,  of  Chicago,  read  a  paper  on  Clinical 
Observations  in  Pericarditis,  in  which  he  stated  that  peri- 
carditis is  essentially  a  secondary  process  occuring  in  the 
course  of  some  general  infection.  The  local  manifestations 
may  be  so  slight  as  to  escape  observation  and  the  general 
symptoms  to  which  the  local  disease  may  give  rise  may 
be  ooscured  by  the  constitutional  disturbance  of  the 
primary  general  infections.  Therefore  it  often  happens 
that  the  diagnosis  of  pericarditis  is  more  often  made  at 
autopsy  than  clinically.  The  histories  of  several  cases 
were  given  which  presented  clinically,  as  far  as  the  heart 
and  pericardium  were  concerned,  practically  the  same 
signs  and  symptoms.  The  cases  further  illustrated  the 
importance  of  the  three  cardinal  signs  of  pericarditis, 
namely,  the  pericardial  friction  rub,  the  form  ot  outline  of 
the  pericardial  dulness,  and  the  position  of  the  apex  beat 
especially  in  relation  to  the  left  border  of  pericardial  dul- 
ness. In  every  case  the  pericardial  friction  rub  is  doubtless 
present  in  some  period  of  its  course.  It  is  practically  the 
sole  local  sign  in  plastic  pericarditis.  In  pericarditis 
with  effusion  it  may  not  be  recognized,  although  it  is  prob- 
ably present  in  every  case  at  an  early  stage  of  the  disease, 
and  in  cases  of  recovery  after  the  disappearance  of  the 
effusion:  it  may  be  present  too  during  the  stage  of  effu- 
sion. The  form  of  this  outline  of  dulness  in  pericardial 
effusion  is  also  characteristic.  The  pear-shaped  outline 
with  the  base  downward;  the  dulness.  even  in  the  early 
stage  of  effusion,  in  the  fifth  right  interspace  close  to  the 
sternum, obliteratingtheresonantangle  formed  by  the  lung, 
heart  and  liver:  the  dulness  over  the  sternum  extending  to 
or  above  the  second  rib,  together  with  the  outline  of  the 
left  border  dulness  are  easily  recognized  and  are  almost 
pathognomonic.  It  is  also  true  that  a  greatly  enlarged 
heart  with  all  the  chambers  diluted  from  myocarditis  and 
a  weak  diffusible  apex  beat  may  present  an  outline  of  dul- 
ness which  so  nearly  resembles  that  of  pericarditis  with 
effusion  that  it  may  be  impossible  to  differentiate  between 
them  without  puncture.  The  location  of  the  apex  beat  in 
pericarditis  with  effusion  is  characteristic.  It  will  always 
be  found,  when  it  is  perceptible,  that  the  left  border  of  dul- 
ness is  relatively  far  removed  from  it  as  it  is  not  in  any 
other  cardia  disease.  It  may  be  obscured,  in  large  effusions, 
and  at  other  times  the  right  ventricle  may  strike  the  chest 
wall  in  the  region  of  the  nipple,  or  undulatory  waves  may 
be  seen  as  the  only  evidence  of  the  heart  beat  against  the 
chest  wall.  However,  it  matters  not  how  the  apex  beat  or  the 
impulse  of  some  other  part  of  the  heart  against  the  chest 
wall  be  ascertained  it  will  be  found  that  the  point  of  con- 
tact of  the  heart  against  the  chest  wall  is  always  relatively 
far  removed  from  the  left  border  of  precordial  dul- 
ness as  compared  with  the  relations  of  the  apex 
beat  to  the  left  border  dulness  in  all  other  condi- 
tions. The  signs  of  compression  of  the  left  lung 
evinced  by  the  left  subscapular  dulness  and  bronchial 
breathing,  the  relatively  rapid  respiration  and  dyspnea, 
the  rapid  heart  action,  the  pulsus  paradoxus  and  the  asym- 
metry in  size  of  the  pulse  of  the  radials.  the  irregular  type 
of  temperature,  the  paralysis  of  the  left  recurrent  laryngeal 
nerve,  the  unequal  pupils,  the  disturbed  mental  state  of  the 
patient  and  still  other  phenomena  are  signs  and  symptoms 
not  so  characteristic  as  the  three  cardinal  signs  first 
named  ,  but  are  important  and  significant  when  present. 
Frequent  careful  systematic  examination  of  the  precordium 
should  be  made  in  all  infectious  diseases,  and  if  this  is 
done  by  the  clinician  pericarditis  will  not  escape  him. 
Pericarditis  is  an   easily  recognized   condition. 

Pathology  and  Pathogenesis  of  pericarditis.  This  paper 
was  read  by  Dr.  Jos.  McFarland,  of  Philadelphia.  He 
said  that  it  is  more  frequent  in  men  than  in  women,  prob- 
ably because  they  were  more  exposed  to  its  causes.  It  Is 
customary  to  divide  the  cases  into  those  which  are  pri- 
mary or  idiopathic  and  those  which  are  secondary  or  me- 
tastatic. Concerning  the  relative  frequency  authors  vary. 
Traumatism  as  a  cause  of  pericarditis  is  of  importance 
only  as  it  affords  an  avenue  of  entrance  for  micro-organ- 
isms, or  produces  conditions  favorable  to  their  colonization 
in  the  tissues.  Lymphogenous  metastasis  may  occur  in 
many  of  the  local  affections  in  which  no  actual  traumatic 
lesions  existed.  In  this  manner  disease  of  the  mediastin- 
um, pleura,  etc,  may  occasion  pericarditis.  Hematogenous 
metastasis  is  seen  in  nearly  all  of  the  infectious  diseases, 


but  especially  in  rheumatism,  pyemia,  septicemia,  pneu- 
monia, chorea,  scarlatina,  etc.  There  is  no  specific  micro- 
organism of  the  pericarditis.  Breitung  collected  324  cases 
of  pericarditis  among  the  autopsies  of  the  Berlin  Charite 
between  the  years  1866  and  1876  and  found  them  dis- 
tributed as  follows:  Pericarditis  sero-fibrenosa,  108; 
pericarditis  heraorrhagia,  30:  pericarditis  purulenta,  24; 
pericarditis  tuberculosa  denteropathia,  24:  pericarditis 
tuberculosa  idiopathica,  2  pericarditis  adhesiva  partialis, 
111:  pericarditis  adheseiva  totalis,  23;  pericarditis  ossi- 
ficians,  2.  It  is  an  error  to  think  of  these  names  are  refer- 
ring to  distinct  forms  of  the  disease;  they  are  for  the 
most  part  stages  of  the  same  process.  In  39  cases  studied 
by  Louis  the  exudations  were  serous,  9;  purulent,  7;  sero- 
sanguinolent,  10:   sero-purulent,  13. 

The  effect  upon  the  heart  of  pericarditis  is  of  great  im- 
portance; no  considerable  disease  of  the  epicardium  is 
possible  without  involvement  of  the  heart.  The  super- 
ficial layers  of  muscular  fibres  usually  show  cloudy  swell- 
ing, later,  hyaline  or  tatty  degeneration.  The  pus  may  also 
gradually  work  its  way  between  the  muscular  bundles, 
in  cases  with  purulent  exudate.  The  changes  that  thus 
take  place  during  the  height  of  the  disease  predisposes  to 
acute  dilatation  of  the  heart  and  a  fatal  termination  of  the 
disease  may  thus  be  brought  about.  If  this  does  not  occur 
and  if  the  patient  recovers  from  the  pericarditis,  the  regen- 
erative cicatricial  processes  that  go  on  lead  to  fibroid  in- 
terstitial changes  in  the  wall  of  the  heart. 

Robert  B,  Preble,  of  Chicago,  read  a  paper  on  The  Gen- 
eral Etiology  of  Pericarditis.  He  made  the  following  con- 
clusions: 

1.  Cases  of  acute  pericarditis,  clinically  primary  occur, 
but  are  rare.  2.  Diseases  to  which  pericarditis  appears  as 
a  complication  are  in  order  of  their  frequency;  pneumonias, 
34% ;  rheumatism,  23.36% ;  chronic  diffuse  nephrites, 
11.2%;  tuberculosis,  10%:  sepsis.  4.7%:  aneurysm,  2,6%; 
typhoid.  1.7%.  3.  The  more  extensive  a  pneumonia,  the 
greater  the  danger  of  this  complication.  4.  The  danger  Is 
somewhat  greater  with  left  than  with  right  side  pneu- 
monia. .-).  Where  only  one  lobe  is  involved,  the  danger  is 
least  with  a  right  upper  lobed  pneumonia  and  greatest 
with  a  right  middle  or  left  upper  lobed  pneumonia.  6.  With 
a  unilobar  pneumonia,  the  changes  of  a  pericarditis  are  one 
in  forty,  with  a  bilobar  or  trilobar,  one  in  ten,  with  a 
quadrilobar,  one  in  five  and  with  a  pneumonia  of  the  entire 
left  lung,  one  in  eight.  7.  The  mortality  of  pneumonias 
with  pericarditis  is  92.4%.  7.  Rheumatic  pericarditis  is 
complicated  by  endocarditis  in  60%  of  the  cases,  i.  e..  three 
to  four  times  the  normal  rate  ot  cases  of  endocarditis.  9. 
The  danger  of  pericarditis  complicating  rheumatism  is  the 
greater  the  younger  the  individual,  and  is  somewhat 
greater  with  males  than  with  females.  10.  So  far  as  acute 
pericarditis  is  concerned,  the  site  and  extent  of  the  endo- 
carditis is  apparently  of  no  importance.  11.  Pericarditis 
appears  as  a  complication  of  all  forms  ot  nephritis,  but 
particularly  the  chronic  diffuse  nephritis  with  contraction. 
12.  It  is  an  extremely  ominous  thing,  tor  22,  i.  e.,  84.6%  of 
the  cases  died.  13.  It  is  still  uncertain  w'hother  the  peri- 
carditis is  toxic  or  infectious.  14.  Tuberculosis  excites 
only  1-10  ot  the  cases,  and  when  one  considers  the  extreme 
frequency  of  tuberculosis  pericarditis  must  be  regarded  as 
a  rare  complication.  15.  Pericarditis  may  be  a  part  of  a 
generalized  acute  tuberculosis,  but  is  more  often  the  re- 
sult of  a  chronic  tuberculosis  of  the  lungs  or  mediastinal 
glands.  16.  Septicemia  and  pyemia  contribute  a  very  con- 
siderable ntimber  ot  cases  of  pericarditis.  The  primary 
focus  may  be  remote  or  close  to  the  pericarditium.  17. 
Aneurysm  of  the  aorta  causes  2.6%  ot  all  the  cases,  a  very 
high  figure,  when  one  recalls  the  comparative  infrequency 
of  aneurysm.  18.  Typhoid  fever,  which  is  rarely  compli- 
cated by  inflammation  of  the  serous  membranes,  other  than 
the  peritoneum,  contributed  4  cases,  which  is  1.7%.  19. 
The  cases  of  obliteration  of  the  pericardium  are  due  to  the 
following  causes  arrtinged  in  order  of  importance:  endo- 
carditis, tuberculosis,  chronic  nephritis,  aneurysm.  20. 
More  than  onehalf  of  the  cases,  in  which  the  cause  was 
clear,  were  due  to  endocarditis,  or  rather  to  some  cause 
common  to  both  the  endocarditis  and  the  pericarditis,  and 
more  than  one  half  of  these  cases  showed  a  combined 
aortic  and  mitral  endocarditis.  21.  Relatively  six  times  as 
many  cases  of  obliteration  of  the  pericardium  occur  with 
aortic  and  mitral  endocarditis  than  with  either  lesion  sin- 
gle. 22.  Tuberculosis  causes  but  few  cases  of  obliterative 
pericarditis.     23.  Pericarditis,    accompanying   nephritis    is 


I  I  28 


Medical   Journal 


SOCIETY  REPORTS 


[June   V,,    L>/I 


not  always  fatal,  but  may  apparently  end  in  the  formation 
of  adhesions. 

A  paper  on  Adherent  Pericardium  was  given  by  Robert 
E.  Babcock,  of  Chicago,  in  which  he  stated  that  adherent 
pericardium  was  encountered  in  two  forms,  first  in  which 
adhesions  between  the  two  layers  of  the  sac,  but  not  of 
the  pericardium  to  the  surrounding  parts,  pericarditis  in- 
terna; and  second,  the  pericardium  adherent  to  the  epi- 
cardium  and  also  to  the  neighboring  structures,  pericarditis 
interna  et  externa.  He  then  considered  the  effects  on  the 
heart  and  general  circulation,  with  special  consideration 
of  its  effect  on  the  liver,  leading  to  the  so-called  pseudo- 
trophic  cirrhoses  of  the  liver.  Diagnosis,  in  the  first  form 
mentioned  was  usually  very  difficult  and  often  impossible. 
He  then  made  a  cursory  examination  of  signs.  If  the 
adhesions  are  limited  to  the  two  layers  of  the  sac,  and  if 
they  are  unassociated  with  valvular  diseases,  the  result 
may  be  only  hypertrophy  of  the  heart,  and  the  circulation 
will  be  carried  on  adequately  and  no  subjective  symptoms 
are  produced.  If  pericarditis  leads  to  adhesions  while  the 
heart  is  in  dilatation  from  endocarditis,  then  the  heart  is 
prevented  from  ultimately  returning  to  its  previous  size 
and  the  symptoms  are  lilcely  to  occur,  viz.:  those  to  stasis. 
In  the  second  form  mentioned  the  diagnosis  was  often  easy 
in  consequence  of  the  signs  resulting  from  the  pulling  of 
the  adhesions  upon  the  surrounding  soft  parts. 

Tuberculous  Pericarditis.  C.  F.  McGahan.  of  Aikin,  S.  C. 
read  this  paper,  in  which  he  stated  that  this  disease  was 
much  more  prevalent  than  had  heretofore  been  generally 
accepted.  He  believed  that  a  great  many  cases  of  obscure 
heart  troubles  occurring  in  the  anemic  when  we  could  find 
no  valvular  disease  without  marked  symptoms  of  peri- 
carditis, but  where  we  have  certain  marked  symptoms  of 
the  disease,  is  due  to  tubercular  pericarditis,  particularly 
if  later  the  patient  begins  to  lose  weight  and  assume  a 
cachectic  appearance.  This  condition  usually  progresses 
insidiously,  and  he  believed  that  it  was  communicated  to 
the  pericardium  through  the  lymp"hatics,  arterial  and 
venous  systems,  and  from  all  that  tends  to  cause  tuber- 
cular troubles  in  the  peritoneum.  The  symptoms  of  tuber- 
cular percarditis  are  those  that  we  would  get  from  en- 
larged heart,  together  with  the  general  symptoms  of  ma- 
laise, and  more  disturbances  of  the  general  system  that 
could  be  found  in  a  simple  pericarditis,  or  that  secondary 
to  rheumatism,  or  one  of  the  exanthematous  diseases. 

Cardiac  Lesions  as  Observed  in  the  Negro:  with  Special 
Reference  to  Pericarditis.  This  paper  was  read  by  Frank 
A.  Jones,  of  Memphis  Tenn.  He  made  the  following  re- 
capitulation: (1)  Aortic  regurgitation  in  the  negro  was 
the  most  frequent  and  most  dangerous  of  all  valvular  le- 
sions. (2)  The  most  frequent,  aortic  stenosis.  (3)  The 
next,  mitral  regurgitation.  (4)  Mitral  stenosis  had  not 
been  diagnosed  in  the  cases  he  reported  from  the  physical 
signs  and  symptoms.  (5)  Tuberculosis  and  syphilis  acted 
both  as  exciting  and  predisposing  causes  in  the  production 
of  muscular  and  valvular  lesions.  (6)  Syphilitic  history 
in  mitral  regurgitation  was  more  frequently  found  than 
that  of  rheumatic.  (7)  The  murmur  of  aortic  regurgitation 
was  most  frequently  musical. 

Some  Points  in  the  Treatment  of  Pericarditis.  Frank 
Parsons  Norbury,  of  Jacksonville,  Ind..  said  that  it  be- 
hooved us  in  the  treatment  of  rheumatism,  acute  infectious 
fevers  and  septic  processes  to  keep  ever  in  mind  the  possi- 
bility of  pericarditis  as  an  aftermath  and  govern  ourselves 
accordingly  by  insisting  upon  absolute  rest  and  quiet  until 
this  danger  is  past.  Each  case  must  be  treated  upon  Its 
individual  merits.  Quiet  surroundings  and  rest  must  be 
^-nforced:  this  is  important  because  it  "curbs  the  symptoms 
and  places  the  patient  under  the  most  favorable  condition 
for  speedy  recovery."  Milk  is  the  most  suitable  diet. 
It  should  be  given  in  small  quantities  every  two  or  three 
"hours.  It  is  well  to  remember  that  most  all  cases  ot 
rheumatic  pericarditis  get  well,  if  we  will  let  them  alone; 
keep  them  at  rest  and  carefully  meet  indications  as  they 
arise.  A  blister  over  the  periardium  will  be  suffi- 
cient for  the  relief  of  pain,  or  it  it  continues,  cold 
applications,  cold  cloths,  or  an  ice  bag  used  as  needed. 
When  other  means  fail  morphine  should  be  given,  guarding 
it  with  proper  cardiac  support.  For  the  restlessness  he 
preferred  bromide  of  soda  given  usually  during  the  day, 
usually  commencing  about  noon,  again  at  four  in  the 
afternoon,  and  at  bed  time.  For  the  sleep  he  used  trional. 
If  combined  with  sulphonal  its  effects  are  prolonged.  For 
the  cardiac  distress  strychnine  may  be  given  or,  if  neces- 


sary, digitalis  with  strophantus.  To  properly  care  for  the 
effusion  is  one  of  the  prime  essentials  of  treatment.  If 
moderate,  unless  septic,  it  will  be  absorbed,  and  even  if 
large,  the  chances  are  that  with  cautious  use  of  diu- 
retics and  purgatives  it  will  disappear.  The  indications  for 
surgical  interference  are,  according  to  Osier,  "dispnea, 
small,  rapid  pulse,  dusky  anxious  countenance,"  and  we 
will  add  the  physical  signs  of  extensive  effusion.  The  as- 
pirator was  recommended. 

PRACTICE  OF  MEDICINE.  HYGIENE,  AND  SANITARY 
SCIENCE. 
JOINT  SESSION,  JUNE  7th. 
..Dr.  T.  J.  Happen,  of  Trenton,  Tenn.,  read  an  interesting 
paper  on  "Further  Report  on  Pseudo  or  Modified  Small- 
pox." At  the  Atlantic  City  meeting  of  the  Association  last 
year  he  reported  to  the  Section  his  experience  with  300 
cases  of  pseudo,  or  modified  smallpox,  which  he  had  made 
from  a  bedside  study  ot  the  cases  in  all  stages  of  the  dis- 
ease. This  paper  dwelt  upon  some  of  the  anomalies  met 
with  in  400  cases  that  had  recently  come  under  his  ob- 
servation. In  many  cases  the  disease  was  not  communi- 
cable. Many  persons  that  had  been  vaccinated  had  the 
disease,  while  many  that  had  not  been  vaccinated  escaped 
the  disease.  He  considered  the  diagnostic  points  between 
this  epidemic  that  occurred  in  Gibson  county,  Tenn..  and 
variola  vera  of  the  writer's  prior  to  1895.  He  asked 
whether  this  could  be  called  variola  vera,  or  was  it  a  hy- 
brid? He  presented  the  following  differential  points  for 
the  consideration  of  the  Section:  In  the  modified  form 
there  did  not  appear  to  be  any  prevailing  types  of  the  dis- 
ease; they  had  the  same  general  character,  differing  ia 
degree  only;  the  incubation  was  from  fourteen  to  eighteen 
days.  In  smallpox,  the  types  were  varioloid,  discrete,  hem- 
orrhagic and  confluent,  and  the  incubation  period  was 
from  fourteen  days  to  twenty-one  days. 

Symptoms — From  the  first  to  the  third  day. — In  the 
modified  form  at  the  onset  the  patient  complained  of  cold; 
they  felt  as  though  an  attack  of  grippe  or  tonsilitis  was 
coming  on.  Temperature  102-105.  Little  or  no  vomiting, 
i-'ulse  rapid  and  full.  Little  or  no  prostration.  No  delir- 
ium. No  convulsions  in  the  young.  In  a  few  cases  there 
may  be  sleeplessness.  In  smallpox  the  onset  is  sudden, 
w  ith  violent  chill,  persistent  vomiting,  agonizing  pains  in 
the  back  and  limbs  and  head.  Temperature  103-104. 
Pulse  full,  strong  and  rapid.  Prostration  great  from  the 
onset.  Eyes  injected.  Sleeplessness,  delirium  and  con- 
vulsions in  the  young.  Third  Day. — In  modified  smallpox, 
no  coarse  red  spots  appear.  In  smallpox,  coarse  red  spots 
appear  on  the  lips  and  forehead.  With  the  appearance  of 
tiiese  spots  the  temperature  falls  to  the  normal  and  the 
patient  is  comfortable.  Fourth  Day. — In  the  modified  form 
the  eruption  appears,  whose  character  is  generally  that  of 
an  acne.  In  some  instances  the  shop-like  papules  appear, 
but  it  is  rare.  The  temperature  falls  to  the  normal  and  the 
patient  invariably  gets  up,  if  he  has  gone  to  bed.  and  he 
fciates  that  he  is  well.  The  eruption  first  appears  on  the 
face.  In  men  about  the  forehead,  cheek  and  chin;  in 
women  .md  children  irregularly  about  the  face.  There  is 
usually  a  sore  throat.  In  smallpox  the  small  red  spots  ap- 
pear on  the  forehead  at  the  juncture  of  the  hair,  and  is 
followed  by  their  appearance  on  the  extremities.  Papules 
follow  the  red  spots.  They  have  a  shot-like  feel.  Fifth 
Day. — In  the  modified  form  the  acne-like  eruption  develops 
into  vesicles  which  assume  an  opalescence  at  once.  These 
vesicles  are  unicellular  and  are  not  umbilicated.  The  se- 
rum which  exudes  at  their  apices  dries  and  turns  brown, 
which,  in  some  cases,  gives  them  the  appearance  of  urn- 
bilication.  There  is  no  puckering  of  the  vesicle  at  its 
border.  The  temperature  is  generally  normal  unless  it 
arises  from  abscesses  or  other  causes.  The  vesicle  may 
dry  up  and  the  disease  may  be  then  said  to  have  aborted. 
A  rapid  recovery  follows.  In  smallpox  papules  appear  on 
the  wrists  and  forehead.  Sixth  to  the  Ninth  Day. — In  the 
modified  form  the  vesicle  becomes  filled  with  an  opaque 
lymphoid  fluid:  in  some  cases  with  a  brown  nucleus  in 
the  center,  which  gives  it  an  umbilicated  appearance.  This 
vesicle  with  its  opaque  fluid,  miscalled  pus.  shrinks  to  ^ 
its  diameter  and  becomes  a  thin  brown  scab,  perfectly  cir- 
cular. There  is  no  stench.  The  patient  is  well  after  the 
appearance  of  the  eruption,  and  insists  upon  getting  up  and 
having  plenty  to  eat.  If  the  eruption  is  copious  he  looks 
bad.   but  he   will   tell   you  that   he  is   all   right   and   feels 


June   15,   IMil] 


SOCIETY  REPORTS 


rn 
Lai 


The  PhilaI'Elphia 
epical  journal 


I    129 


good.  The  eruption  in  a  few  cases  affects  the  conjunc- 
tivae. There  is  no  secondary  fever.  From  this  time  on 
it  is  simply  a  matter  of  scabs  falling  off.  By  the  tenth 
day  the  patient  is  entirely  well.  If  the  eruption  spreads 
over  the  entire  bordy  he  may  not  be  clear  from  scabs  until 
the  fourteenth  day.  In  true  smallpox  the  vesicles  appear 
in  place  of  the  papules,  and  the  eruption  spreads  gradually 
over  the  entire  body.  The  vesicles  are  umbilicated  and 
mukiiocular.  On  the  Sth  and  9th  days  the  vesicles  be- 
come pustular,  and  each  is  surrounded  with  broad,  red 
bandi,  or  efflorescence,  the  features  become  distorted, 
there  are  several  rigors  and  fever,  the  original  symptoms 
appear,  stench  is  beginning,  etc.  There  is  great  delirium 
and  convulsions  in  the  young.  This  is  the  critical  period. 
Tenth  to  Twelfth  Day, — In  smallpox  the  pus  oozes  and 
forms  scabs,  and  the  stench  is  particularly  bad.  Seven- 
teenth to  the  Tv^enty-first  Day.-— In  smallpox  the  scabs 
drop  off,  leaving  red  glistening  pits  which  soon  become 
white.  Ulceration  is  deep,  reaching  the  corium.  Ophthal- 
mia is  generally  present.  Pustules  pervade  the  mouth, 
larynx,  pharynx  and  treachea.  Petechiae  form  on  the 
lower  part  of  the  abdomen  and  inner  aspects  of  the  thighs 
on  tlie  first  and  second  days  in  some  cases.  Papules. —  In 
the  modified  form  papules,  when  present,  are  the  same 
size  as  in  sallpox,  perhaps  a  little  smaller,  but  fewer  In 
extent.  There  may  be  no  papules.  Vesicles  range  in  size 
from  the  head  of  a  pin  to  the  size  of  a  split  pea.  They  are 
not  umbilicated,  and,  when  punctured,  collapse.  The  vesi- 
cle is  unilocular.  Convalescence  begins  on  the  appearance 
of  the  eruption.  The  so-called  pustule  does  not  extend 
into  the  derma.  The  epidermis  is  the  only  structure  of  the 
sldn  involved:  there  is,  hence,  no  pitting.  The  vaccinated 
take  the  disease.  In  smallpox  the  pustules  are  about  the 
size  of  No.  4  shot  and  have  a  translucent  appearance,  en- 
croaching on  the  entire  body,  including  the  palms  and 
soles.  It  appears  first  on  the  face  and  hands.  Vesicles 
are  umbilicated  and  multilocular.  So  is  the  pustule,  and 
neither  will  collapse  in  toto  if  pricked  with  the  needle. 
. .  Dr.  W.  L.  Beebe,  of  St.  Cloud,  Minn.,  read  a  paper  enti- 
tled "The  Old  and  the  New."  He  said  that  he  had  been 
identified  with  two  epidemics  (20  years  apart),  and  though 
they  were  evidently  both  species  of  smallpox,  they  were 
dissimilar  in  many  characteristics.  He  thought  that  many 
of  the  recent  cases  of  smallpox  had  been  diagnosticated 
chickenpox. 

..Dr.  Louis  Leroy,  of  Nashville,  Tenn.,  read  a  paper  on 
"Remarks  Covering  the  Sanitary  Features  of  Smallpox." 
In  the  event  of  an  outbreak,  he  said  that  a  competent  phy- 
sician should  be  placed  in  charge  and  given  absolute  power 
to  act;  he  should  communicate  with  Boards  of  Health; 
he  should  have  police  backing  if  necessary.  Daily  official 
reports  should  be  made  to  the  newspapers,  stating  the  ex- 
act condition  of  affairs.  Smallpox  treated  in  private,  he 
considered  a  makeshift;  complete  and  perfect  isolation  he 
insisted  upon.  All  articles  should  be  disinfected  in  the 
usual  manner;  everything  possible  should  be  destroyed  by 
fire  after  the  patient  had  been  discharged  as  cured. 

In  Tennessee  this  year  he  had  introduced  on  a  large 
scale  the  hypodermic  needle  as  a  means  of  vaccinating. 
He  had  first  tried  this  method  in  Philadelphia  in  1895, 
using  then  the  aqueous  solution  he  now  uses  in  glycerinated 
lymph.  A  solid  piston  needle  was  used.  The  skin  was 
cleansed  in  the  customary  manner  and  the  needle  inserted 
into  the  skin,  not  through  it,  and  a  drop  of  the  lymph 
was  forced  between  the  epithelial  cells  and  it  diffused  at 
exactly  the  locality  required.  It  had  many  advantages;  in 
cases  of  compulsory  vaccination  it  cannot  be  washed  off; 
there  is  absolute  freedom  from  infection  at  the  time  of 
vaccination;  it  is  painless  and  no  immediate  dressing  is 
necessary. 

..Dr.  Heman  Spalding,  of  Chicago,  read  a  paper  on  "The 
Diagnosis  of  Mild  Smallpox  as  in  the  Present  Outbreak  of 
the  Smallpox  in  This  Country."  On  February  15th,  1899, 
smallpox  was  introduced  into  Chicago  from  Cincinnati;  in 
the  17  months  following  there  had  been  72  cases;  25  of 
these  from  direct  importation.  For  a  period  of  3%  months 
the  city  was  entirely  freed  from  the  disease.  Then  an- 
other outbreak  occurred.  These  two  outbreaks  gave  him 
an  opportunity  of  studying  310  cases  in  Chicago  in  the  Iso- 
lation Hospital. 


1  hemorrhagic    case    died  1 

13  confluent    cases    died  3 

24  serai-confluent   cases    died  2 

54  severe  discrete  cases died  0 

179     mild  discrete  cases   died  0 

39  modified  form  of  cases  died  0 

310  cases died.  6 

He  did  not  think  the  term  varioloid  should  be  used; 
many  persons  were  under  the  impression  that  varioloid 
was  not  smallpox,  and  think  that  if  they  are  taken  to  a 
hospital  while  sick  with  the  former  they  will  contract  the 
latter  disease.  It  was  a  useless  term  and  should  be  dis- 
carded. In  Chicago  they  placed  all  patient,  whether  af- 
flicted with  hemorrhagic,  confluent,  or  so  mild  that  they 
would  go  to  work  unless  prevented,  into  the  same  wards 
in  the  hospital.  271  of  the  cases  reported  had  never  been 
vaccinated.  None  of  those  afflicted  with  the  mild  form  of 
disease  contracted  smallpox  from  the  severer  typical  cases 
in  the  wards  where  the  exposure  had  been  long  and  cer- 
tain. The  mild  form  of  the  disease  gives  immunity  from 
smallpox  and  yet  will  transmit  typical  confluent,  or  hem- 
orrhagic, smallpox,  of  which  he  had  abundant  proof  in  Chi- 
cago. 

Dr.  Frederick  Leavitt,  of  St  Paul,  Minn.,  read  a  paper 
on  "The  Distinguishing  Characteristics  Between  Mild  Dis- 
crete Smallpox  and  Chickenpox,"  in  which  he  made  the 
following  summary: 


SMAi:,I,POX. 


CHICKENPOX. 


Age. 

Incubation. 

Invasion. 


Surfaces    at- 
tacked. 


Character  of 
the  eruption. 

Histology. 
Temperature. 


Contour  of 
eruption. 


Duration,  in 
eluding:  per- 
iod of  inva- 
sion and  des- 
quamation. 


Vaccination. 


I  Any  age. 
,  Two  Weeks. 


Marked  headache,  backache, 
fever,  general  malaise,  last- 
ing A-A  days. 

Worse  on  the  exposed  parts 
extremities.  Invariably  on 
the  palms. 


Progressive;  papules,  vesicles, 
pustules,  crusts. 


Childhood. 

1.3-17  days. 

Is  none,  or  at  most  only 
slight  indisposition. 


Worse  on  the  covered 
portions  -  thorax;  rarely 
or  never  seen  on  the 
palms  and  soles. 

Papules  and  crusts.  I,es- 
ion  very  superficial. 
Easy  to  rupture. 


I,esion     includes    the    lower  j  Unilocular, 
layers  of  the  derma.     Hard 
to  rupture.     Multilocular. 


Rises  with  the  severity  of 
the  attack. 


Pitting. 


Complicat- 
ions. 

Mortalitv. 


Remains  high  (103-10.5)  till 
the  eruption  appears  ;  then 
it  drops  and  does  not  rise 
again  for  a  week,  and  not 
then  in  mild  discrete  forms. 

Quite  uniform  in  size.  Has  a  Not  uniform.  Also  in- 
reddened  area  at  base.  Fre-  ,  flamed  area  about  the 
queutly  umbilicated.  vesicle,  but  less  marked. 

Painful  to  the  touch  ;  it  may    Not  painful  to  touch, 
itch. 

Two  to  four  weeks.  Seven  to  fourteen  days. 

I  Protects.  j  Does  not  protect. 

When  confluent  on  face  will  !  Seldom    unless  infected, 
occasionally    mark    in    the  ' 
discrete  form. 

Generally  none.  None. 


I  High  in  severe  confluent  and 
I      hemorrhagic  types. 


Bv  Ivsis. 


Resolution.         |  By  cnsis. 

..Dr.  H.  M.  Bracken,  of  St.  Paul,  read  a  paper  on  "Vari- 
ola," in  which  he  stated  that  Minnesota  had  reported  7211 
cases  of  variola  with  49  reported  deaths  during  the  past 
two-and-a-half  years.  He  did  not  think  we  could  be  gov- 
erned in  our  diagnosis  of  all  cases  in  this  present 
epidemic  by  the  usual  text-book  description  of  variola. 
Typical  prodromal  symptoms  may  be  present,  but  the  rash 
may  vary  in  degree,  in  form,  in  type  of  progress,  and  In 
final  disappearance  in  a  way  that  is  described  in  but  few 
text-books.      He    asked    if   vaccination    protected    against 


,„        The    Hhila 
1  >U        Medical    Jou 


delphia"! 

OUBNAL  J 


SOCIETY  REPORTS 


[J  U.SE 


the  disease.  Of  C62  cases  in  244  houses,  but  10  patients 
had  been  vaccinated  successfully  at  any  time  prior  to  their 
infection,  and  of  these  10,  over  30  years  had  elapsed  since 
successful  vaccination  for  2  of  them,  over  25  years  for  4 
of  them,  20  years  for  1  of  them,  and  6  years  for  1.  The 
Chicago  Board  of  Health  made  the  following  statement: 
■"Out  of  a  total  of  171  cases  of  smallpox  found  in  Chicago 
-"between  November  30th  and  April  10th,  1901,  140  had  never 
heen  vaccinated.  Of  the  remaining  31  cases,  29  were  in 
•adults  showing  faint,  poor  or  irregular  scars,  claimed  to 
tie  evidences  of  attempted  vaccination  in  infancy  or  child- 
liood — the  most  recent  being  23  years  old.  Only  2  out  of 
xhe  171  cases  exhibited  scars  of  successful  vaccination." 
Since  vaccination  had  been  made  compulsory  in  the 
-.schools  of  Chicago,  smallpox  had  disappeared  from  them. 
The  degree  of  immunity  depends  upon,  in  part  at  least,  the 
'Jntensity  of  the  infection.  Marson  gave  a  death-rate  as 
follows  among  those  who  have  been  vaccinated :  One  cica- 
trix 7.73  per  cent.;  two  cicatrices,  4.7  per  cent.:  three  ci- 
<catrices,  1.95  per  cent.;  four  or  more  cicatrices,  .55  per 
cent. 

SECTION  ON  SURGERY  AND  ANATOMY. 

FIRST  DAY,  JUNE  4th,  1901. 

Dr.  A.  J.  Oschner  read  a  paper  entitled,  "Cause  of  Diffuse 
Peritonitis  Ccmpiicating  Appendicitis  and  Its  Prevention." 
The  author  reviewed  the  anatomical  and  pathological  rela- 
tionship existing  between  the  appendix  and  the  adjacent 
or.iians.  He  showed  how  the  appendix  was  protected  and 
pointed  out  the  enormous  blood-supply  of  the  omentum. 
The  value  of  rest  as  a  preventive  to  the  extension  of  in- 
fection in  ;iRy  part  of  the  body  cannot  be  overestimated, 
and  if  thit.  is  gained  another  point  is  secured  in  the  right 
riiiectiou.  Ini'ection  of  the  general  peritoneal  cavity  is 
caused  by  disturbance  of  the  intestines.  Theorically  and 
practically  food  and  cathartics  should  not  be  taken  into 
the  stomach.  The  doctor  cited  cases  in  which  the  inges- 
tion of  these  products  greatly  irritated  the  condition.  His 
mortality  in  cases  of  perforative  peritonitis  was  less  than 
H  as  hifih  a?  cases  operated  at  once;  in  cases  of  diffuse 
IJerltonitis  there  has  been  a  great  decrease.  From  January 
ISJiS  to  May  1901  he  had  operated  505  cases  of  appendicitis 
■with  20  deaths,  a  mortality  of  3V^  per  cent.  Danger  of  rup- 
ture of  the  circumscribed  abscess  into  the  general  peri- 
toneal cavity  has  been  a  cause  of  great  anxiety.  There  is 
increased  safety  in  operating  during  the  quiescent  state 
and  as  a  result  of  this  treatment  fecal  fistulae  never  re- 
sult. The  doctor  advocated  gastric  lavage,  in  cases  of  food 
in  the  stomach  or  intestines,  above  the  ileo-cecal  valve. 
The  laity  should  be  taught  to  stop  feeding  and  giving  cath- 
artics to  patients  suffering  from  intra-abdominal  diseases. 
Or.  Andrew  McCosh  read  a  paper  on  "Remarks  on  the 
Surgery  of  the  Spinal  Cord,  with  Illustrative  Cases."  He 
"WHS  of  the  opinion  that  pressure  on  the  cord  was  urgent 
reason  for  operating  and  that  early  operations  are  impor- 
tant. He  likewise  believed  that  it  was  wiser  to  do  the 
■exploratory  operation,  because  there  the  danger  was  slight. 
It  was  the  routine  practice  to  cut  down  on  the  skull  to  find 
■out  if  there  was  fracture.  If  relief  is  to  be  expected,  oper- 
ation should  be  done  at  once.  He  had  performed  six 
laminectomies,  two  recovered  and  four  died,  but  not  as  a 
direct  result  of  operation.  He  did  not  think  it  was  incum- 
teiit  to  apply  any  special  support  to  the  spinal  cord. 
"Spina  Bifida  with  Report  of  an  Interesting  Case,"  was 
the  theme  of  Dr.  Paul  E.  Eve's  paper.  Associated  with 
spina  bifida  arc  hydrocephalus,  taliipes  and  hare-lip;  it 
may  consist  of  a  tumor  varying  in  size  from  a  marble  to  an 
adults  head,  occupying  the  central  portion  of  the  canal 
over  the  posterior  aspect  of  the  vertebral  column.  There 
are  three  varieties  of  this  disease,  namely-meningocele, 
the  protrusion  consisting  of  fluid  in  the  spinal  cord;  men- 
ingc-myocele.  where  there  is  a  portion  of  the  cord  In  the 
sac,  and  syringo-myocele,  the  central  part  of  the  spinal  cord 
being  dilated.  'Various  remedial  measures  were  suggested, 
such  as  acupuncture,  injection  of  iodide  of  potassium,  etc. 
Extirpation  is  unjustifiable  in  young  infants,  and  the  indi- 
cations for  operation  are  where  the  child  is  over  7  years 
amd  where  the  tumor  was  rapid  in  growth  and  rupture 
tlireatened.  The  subject  of  Dr.  Christian  Fenger's  paper 
•was  "The  IVlothcdioal  Exploration  of  the  Brain  for  Fluid." 
The  doctor  described  a  case  having  a  previous  history  of 
suppurating  disease  of  the  ear,  an  attack  of  appendicitis 
su'  s.^queutly,  of  short  duration,  anr'  then  swelling  of  the 


elbow  joint.  He  explored  the  brain  methodically,  going 
from  one  place  to  another.  There  was  a  cicatrix  behind 
the  ear,  which  was  the  only  guiding  point.  After  exploring 
the  brain  on  the  affected  side  of  the  head  with  no  results, 
he  then  tried  the  opposite  side,  where  the  pus  was  found, 
and  the  patient  recovered.  The  doctor  said  that  methodi- 
cal exploration  of  the  brain  was  preferable  to  all  others. 
Function,  he  said,  was  harmless,  as  Spitzka  had  previously 
proved  in  the  needle-tracings  in  the  brain  which  were 
aseptic.  The  author  illustrated  his  paper  with  photographs, 
instruments  and  human  skulls.  The  contribution  of  Dr. 
D.  S.  Fairchlld,  on  "The  Immediate  and  Remote  Effects  of 
Brain  Injury"  dealt  with  the  value  of  first  symptoms  in 
determining  the  nature  and  extent  of  the  lesion;  the  bear- 
ing on  the  question  of  treatment  and  prognosis;  the  possi- 
bility of  the  lesion  being  more  or  less  serious  than  is  indi 
cated  by  the  apparent  gravity  of  the  early  symptoms:  the 
danger  of  being  misled  on  these  points:  the  remote  effects 
of  trauma  on  the  integrity  of  the  brain-tissue  in  producing 
epilepsy  and  mental  impairment:  falls  from  a  height  or 
from  a  rapidly  moving  train.  If  the  first  symptom  of  in- 
tracranial hemorrhage  is  rupture  of  the  middle  menin- 
geal, the  immediate  effect  thereof  is  considered  serious, 
unless  surgery  intervenes.  The  doctor  reviewed  scar  prol- 
iferation from  scars  of  the  brain  and  said  that  these  cases 
were  amenable  to  surgical  treatment.  He  presented  the 
question  of  liability  and  medico-legal  aspect  of  cases  of 
brain  injury.  Dr.  Frazier,  Philadelphia,  presented  a  con- 
tribution on  the  subject  of  operation  for  the  relief  of  tic 
douloureux,  or  trifacial  neuralgia,  differing  from  the  opera- 
tions now  in  vogue,  in  that  it  depends  for  its  success  on 
the  division  of  the  sensory  root  of  the  ganglion  and  not  upon 
the  removal  of  the  ganglion  itself  The  doctor  very  inter- 
estingly covered  the  besetting  difiBculties  with  which  the 
surgeon  meets,  the  technic  of  the  operation  and  its  ap- 
plicability in   present  cases. 

Discussion:  Dr.  W.  "W.  Keen  believed  the  time  had  come 
when  cases  of  spina  bifida  should  be  submitted  to  opera- 
tive treatment.  In  relation  to  Dr.  Fenger's  paper,  he  wa.s 
sorry  that  he  limited  the  exploration  to  search  for  pus,  that 
there  should  be  a  very  clear  distinction  made  in  exploring 
the  brain  for  pus,  purulent  matter  or  serum.  Ten  years 
ago  he  had  proposed  a  methodical  operation  and  formulated 
several  routes  by  which  the  ventricles  could  be  reached. 
Dr.  Keen  cited  interesting  cases  of  exploring  the  brain  for 
fluid.  As  to  Dr.  Fairchild's  paper,  he  thought  the  doctor 
had  taken  the  right  ground,  that  interference  was  impera- 
tive. He  reviewed  the  phenomena  of  the  state  of  uncon- 
sciousness produced  by  trauma. 

Dr.  McLean  agreed  with  Dr.  Fairchild's  idea  of  going 
without  support;  he  had  found  it  difficult  to  keep  the  sup- 
port on;  he  thought  it  was  a  good  step  in  spina  bifida 
(Dr.  Eve's  paper)  to  attempt  closure  at  operation,  with- 
out aspirating  or  injecting  fluid.  He  believed  the  skull 
was  elastic  and  compressionable  in  both  young  and  adult, 
as  was  proved  by  clamping  it:  the  tissue  within  must 
change  and  there  must  be  movement  within.  The  spinal 
canal  is  not  a  bony  canal,  but  made  up  partially  of  fibrous 
tissue.  The  doctor  referred  to  concussion  and  compres- 
sion of  the  brain  and  subsequent  extra-dural,  subdural  and 
cranial  hemorrhage.  "Now,  I  think,  there  is  another  point, 
where  you  might  have  depression  of  the  skull.  In  that 
case  the  cerebral  fluid  will  escape  from  the  cranium,  les 
sen  the  cranial  tension  and  escape  in  the  spinal  cord. 
Doctor  Weir  did  not  believe  that  we  had  yet  arrived  at  a 
conclusion  with  regard  to  depressed  fractures  of  the  skull 
without  symptoms.  In  regard  to  wounds  of  the  scalp,  he 
had  recently  changed  his  ideas — he  did  not  now  let  them 
alone.  Surgeons  feared,  in  penetrating  the  dura,  making 
adhesions;  adhesions  must  be  expected;  the  discusser  ad- 
vocated the  use  of  celluloid  plates  at  the  time  of  operation 
or  at  a  secondary  operation.  Dr.  Frank  had  tapped  the  lat- 
eral ventricles  as  early  as  1890.  with  good  results.  He  did 
not  agree  wit'n  Dr.  McLean,  that  if  a  person  was  hit  on  the 
head  it  would  draw  the  fluid  Into  the  spinal  column,  but  it 
is  not  necessary  to  receive  a  blow  on  the  head  to  become 
unconscious  or  give  symptoms  of  concussion.  Doctor  Earl 
was  of  the  opinion  that  the  time  was  at  hand  when  surgi- 
cal treatment  for  injuries  of  the  skull  must  be  employed. 
Dr.  Moore  believed  in  the  surgical  treatment  of  spins 
bifida  rather  than  the  injections.  Dr.  Dawbam  related  an 
interesting  case  of  a  man  who  was  struck  on  the  side  of 
the  head,  with  symptoms  of  hemiplegia.  Operating  on  the 
paralyzed  there  could  not  be  detected  a  clot  or  anythia? 
abnormal.     At  the  autopsy,  however,  on  the  side  opposite 


June   15,   190!] 


SOCIETY  REPORTS 


ETbe  Philadelphia 
Medical  Journal 


II3I 


to  that  affected,  there  was  revealed  an  enormous  blood 
clot.  Others  who  joined  in  the  discussion  were  Drs.  Ber- 
nays.  Maxwell,  Means,  Crile,  Tagart,  McKnight,  Baldwin 
and  Vaughan,  St.  Louis. 

SECOND  DAY,  JUNE  5th.  1!)01. 
Paper  by  Dr.  John  B.  Deaver  (Philadelphia)  :"The  Mor- 
tality of  Appendicitis."  Dr.  Deaver  began  by  saying  that 
during  the  year  1900  there  were  reported  at  the  German 
Hospital  in  Philadelphia  268  cases  o£  appendicitis,  of 
which  144  were  acute  attacks  of  the  disease  and  124  were 
chronic.  Of  those  operated  during  the  acute  stage  26  died 
or  from  some  intercurrent  illness  arising  during  the  illness 
or  previously  existing.  In  the  cases  not  subjected  to  sur- 
gical treatment  by  far  the  largest  factor  is  septic  periton- 
itis. -AS  to  the  nuinher  of  attacks,  the  doctor  said,  that  the 
fatal  attack  may  be  the  "solitary  severe  one."  "Severe  at- 
tacks without  fatal  issue  subside  to  varying  degrees,  but 
commonly  render  the  internal  symptoms  more  aggravated." 
In  cases  complicated  with  adhesions,  but  without  septic 
infection,  the  mortality  is  very  low.  In  one  case  the  doc- 
tor operated  12  hours  after  the  onset  of  the  attack  and 
found  an  advanced  general  purulent  peritonitis,  a  condition 
from  which  I  have  never  seen  a  recovery,  and  believed 
that  where  there  is  located  pus  the  success  ofthooperatiou 
depends  upon  the  success  in  emptying  and  draining  every 
pocl.et:  merely  opening  and  draining  the  main  abscess 
will  not  do,  the  great  problem  being  how  to  drain  all  these 
collections  without  infecting  the  general  peritoneal  cavity. 
Post-caecal  collections  of  pus  offer  a  serious  problem.  As 
to  the  advisability  of  removing  the  appendix  in  the  pres- 
ence of  pus,  the  opinion  of  the  author  was  that  it  should 
be  removed,  except  in  certain  cases.  Another  very  com- 
mon cause  of  death  is  necrosis  of  the  bowel.  Dr.  Deaver's 
experience  showed  that  recurrent  attacks  of  appendicitis 
are  progressive  in  their  severity,  each  one  adding  fuel  to 
the  flame;  that  the  position  of  the  appendix  was  an  import- 
ant feature:  that  delay  in  operating  is  responsible  for 
more  deaths  in  appendicitis  than  all  the  factors  which  have 
to  do  with  the  disease:  that  operation  in  the  first  12,  and 
at  the  latest  18  to  24  hours,  would  save  patients,  without 
subsequent  complications,  as  fecal  fistula,  etc.  On  every 
case  of  appendicitis  that  dies  in  the  German  Hospital,  there 
is  made  an  autopsy.  Paper  by  Dr.  Ernest  LaPlace  (Phila- 
delphia): "Some  Unusual  Features  of  Appendicitis  and 
Their  Treatment."  The  doctor  said  that,  as  on  a  former 
occasion,  he  would  repeat  a  statement:  "In  every  case 
of  fatal  appendicitis,  there  was  a  time  when,  had  the 
operation  been  performed,  the  patient  would  have  sur- 
vived. He  was  of  the  opinion  that  it  was  not  the  appen- 
dicitis that  killed,  but  the  peritonitis  incident  thereto.  He 
divided  the  appendicitis  into  three  different  periods  or 
stages:  (1)  That  of  appendicitis:  (2)  That  of  peritonitis; 
1 3)  That  of  septicemia.  He  believed  in  rapid  operative 
procedure  in  peritonitis  from  chronic  appendiceal  abscess 
that  has  perforated  or  an  acute  peritonitis  set  up  by  ap- 
pendicitis. Careful  cleansing  of  the  operative  field  should 
be  instituted,  with  flushing  of  the  abdominal  cavity.  When 
septicemia  and  peritonitis  are  both  present,  then  simply 
wash  out  the  abdominal  cavity,  close,  and  drain  with 
gauze.  He  believed  that  it  must  be  taken  for  granted 
that  the  phagocytes  will  compete  more  successfully  with 
a  slight  amount  of  septicemia  than  with  septicemia 
which  is  continually  increasing  by  constantly  forming 
toxins  taken  up  from  the  peritonitis.  Flushing  continually 
the  peritoneal  cavity  for  at  least  a  few  hours  after  the 
operation  would  constitute  the  local  treatment,  whereby 
the  arrest  of  progressive  septicemia  may  be  hoped 
for.  Dr.  Homer  Gage,  of  Worcester,  Mass..  was  detained 
by  illness.  The  subject  of  his  paper  was:  "Abdominal 
Contusions  Associated  with  Rupture  of  the  Intestine."  Dr. 
F.  Greqory  Connell  (Chicago)  read  a  paper  entitled,  "The 
Knot  Within  the  Lumen  in  Intestinal  Suraery  with  Report 
of  Eight  Cases."  The  doctor  said  that  the  possibility  of 
placing  all  the  knots  in  enterorrhaphy  within  the  lumen 
is  no  longer  in  doubt,  but  the  advisability  of  such  a  proced- 
ure is  still  a  disputed  question  by  those  who  never  used  it. 
Perfornfion  of  all  coats,  when  the  knot  is  placed  within 
the  lumen,  are  not  the  same.  The  doctor  said  that  death, 
in  no  case,  can  be  attributed  either  to  the  method  of  suture 
employed  or  the  manner  of  employing  it:  to  include  all  the 
coats  of  the  bowel-wall  removes  the  danger  of  stitch  yield- 
ing: that  to  fail  to  include  the  snbmucosa  loaves  an  inse- 
cure stitch;  that  it  is  not  only  possible,  but  practical  to 
place  all  the  knots  of  an  enterorrhapy  of  the  lumen. 


Paper  by  Dr.  Roswell  Park,  Buffalo,  N.  Y.,  "The  Nature 
of  the  Cancerous  Process."  "Like  a  huge  and  frowniiig 
sphinx  at  the  very  gateway  or  entrance  to  the  field  of  sur- 
gical pathology  has  stood  for  centuries  the  great  problem 
of  the  nature  of  cancer.  This  has,  at  least  until  recently, 
remained  the  inscrutable  mystery  of  ages."  The  doctor 
reviewed  Cohnbeim's  theory,  and  said  that  the  parasitic  or 
infectious  theory  of  cancer  Is  the  only  one  which  satis- 
fies the  needs  of  both  pathologist  and  clinician.  In  the 
New  York  State  Laboratory,  with  which  Dr.  Park  is  con- 
nected, the  disease  is  studied  by  the  pathologist,  biologist, 
chemi,?t,  histologist  and  clinician,  all  working  in  close  as- 
sociation. As  to  causation,  the  doctor  was  of  the  opinion 
that  cancer  was  due  to  an  extrinsic  cause,  i.  e.,  to  be  par- 
asitic in  its  nature.  He  took  the  analogy  of  vegetable 
life  to  sustain  the  parasitic  theory,  stating  that  the  woody 
masses  or  xylomata  or  knots  in  trees  suggest  the  tumor 
or  cancer  idea,  which  destroy  the  tree;  they  are  frequently 
spoken  of  as  tree-cancers.  Tumors  are  also  common  in  the 
lower  animal  forms.  He  believed  that  tumors  in  man  and 
animal  are  due  to  the  same  general  causes,  and  said  that 
it  was  not  too  strong  a  statement  to  make  that  Dr.  Gay- 
lord  and  the  Laboratory  staff  have  absolutely  produced 
adenocarcinoma  by  inoculation  in  a  number  of  animals  and 
that  this  can  be  produced  in  such  a  way  as  to  afford  un- 
mistakable evidences  of  the  infectivity  of  the  disease. 
"The  Present  Status  of  the  Carcinoma  Question,"  by  Dr. 
Nicholas  Senn.  This,  the  doctor  considered,  is  the  most 
important  research  of  to-day.  Carcinoma  results  from 
atypical  proliferation  of  epithelial  cells.  As  carcinoma  or- 
iginates in  epithelial  cells  its  development  is  impossible  in 
meso-blastic  tissues.  Histology  does  not  support  the  para- 
sitic theory.  The  progressive  extension  of  a  tumor  into 
the  adjacent  tissues  is  proof  positive  of  malignancy.  This 
is  by  the  lymphatics  only.  The  increase  of  carcinoma  is 
more  imaginary  than  real.  There  is  more  basis  to  here- 
dity than  is  believed  by  the  profession  at  large.  The  age 
is  important,  although  usually  over  forty  it  may  be  below 
twenty  and  in  these  cases  it  is  almost  always  malignant. 
"Early  Diagnosis  of  Carcinoma — Methods,"  Dr.  Charles  A. 
Pow^r'^.  PeLver.  Col.  Th'j  salient  features  that  the  doc- 
'rr  desired  to  bring  forth  was  the  early  recognition,  thor- 
ough operative  removal  of  the  widest  possible  area,  and  a 
careful,  systematic  surveillance  of  the  patient  during  the 
rest  of  his  life.  The  laity  should  be  instructed.  The 
doctor  reviev.edthe  diagnostic  reaction  of  the  use  of  can- 
cer-serum and  auto-inoculation  as  an  aid  in  the  early  diag- 
nosis of  cancer.  "The  Pathology  of  Breast  Carcinoma  and 
Its  Relation  to  Early  Diagnosis  and  Treatment,"  Dr.  Wil- 
liam S.  Halsted  and  Dr.  J.  C.  Bloodgood.  The  doctor 
grouped  the  tumors  under  multiple,  malignant,  benign  and 
those  associated  with  various  acini  changes  in  the  tissues 
of  the  breast.  The  doctor  said:  "In  our  experience  of  some 
294  cases,  the  number  of  cases  of  malignant  tumors  which 
have  been  admitted  to  the  hospital  at  such  an  early  stage 
that  the  clinical  picture  was  suggestive  of  a  benign  tumor, 
is  about  9%.  or  about  23  cases.  What  it  will  be  in  the  fu- 
ture I  am  not  prepared  to  say."  "Carcinoma  of  the  Cecum." 
Dr.  William  J.  Mayo,  Rochester,  Minn.  The  doctor  said 
that  carcinoma  of  cecum  occurs  in  "%  of  all  cancers  of  the 
intestines  and  is  of  the  columnar  cell  variety.  Colloidal 
changes  are  frequent.  It  is  usually  annular  in  form,  but 
may  present  a  well  marked  tumor.  Glandular  infection 
occurs  in  less  than  one  half  of  the  cases  dying  from  that 
malady.  Age  is  not  so  important  a  feature  as  is  carcinoma 
of  other  organs.  It  is  not  infrequently  in  the  comparitively 
young.  This  disease  may  be  confused  with  chronic  appen- 
dicitis, tuberculosis  of  cecum,  fecal  impaction,  etc.  The 
results  of  radical  operations,  both  immediate  and  remote, 
are  good  and  compare  favorably  with  cancer  in  other  situ- 
ations of  the  body.  "Improved  Method  for  Resecting  High 
Rectal  Carcinoma,"  Dr.  Robert  F.  Weir,  New  York  City. 
The  doctor  considered  the  Kraslce  operation  unsatisfac- 
tory for  the  removal  of  high-seated  cancers  of  the  rectum, 
but  practices  Maunsell's  operation.  He  especially  covered 
the  technic  (illustrated  by  drawings),  surgical  cleanliness, 
the  anus  and  its  drainage,  with  a  list  of  cases.  "The  Treat- 
ment of  Malignant  Disease  by  Surgical  Operation."  Dr.Fred- 
eric  S.  Dennis,  New  York.  The  treatment  considered  in- 
cluded surgical,  toxins,  drugs,  caustics,  electricity.  Ront- 
gen  rays.  Surgical  operation  is  successful  only  when  it  is 
performed  early,  when  it  is  radical  in  character  and  when 
it  is  repeated  indefinitely.  Cases  are  not  considered  un- 
less three  years  at  least  have  elapsed  since  operation,  and. 


H3- 


The  Philadelphia"! 
Medical  Journal   J 


SOCIETY  REPORTS 


[June   15,   1991 


by  some,  this  period  is  estimated  as  too  short.  The  im- 
portance of  education  of  physicians  of  necessity  of  early 
operations  as  the  essential  feature  of  cure  should  be 
borne  in  mind,  as  well  as  the  importance  of  microscopical 
examinations  of  every  growth  as  the  only  means  to  obtain 
accurate  information  for  the  future  study  of  malignant 
disease.  It  is  necessary  to  keep  a  careful  record  of  every 
case  with  its  subbsequent  history.  He  proposed  that  the 
increase  of  cancer  is  not  explainable.  The  writer  was  of 
the  opinion  that  the  action  of  the  toxins  upon  malinant  tu- 
mors was  only  explainable  upon  the  theory  that  such  tu- 
mors are  the  result  of  some  infectious  micro-organism,  and 
this  view  is  strongly  supported  by  the  recently  expressed 
opinion  of  Czerny.  Surgical  intervention  is  the  only  re- 
source since  all  drugs  have  proved  IneflEectual. 

Discussion:  Dr.  Bernays,  St.  Louis,  believed  that  we 
were  to  face  an  epidemic  of  cancer  and  that  it  affects 
all  classes.  "Dare  we  hope  for  a  curative  remedy?  I  think 
not!"  Many  men  had  worked  on  this  question,  but  all  had 
failed  to  solve  the  nature  of  cancer.  As  to  etiology,  some, 
he  thought,  were  of  embryonal  nature,  some  parasitic  and 
others  rudimentary  developmental.  He  thought  we  might 
"hope  to  exercise  a  sort  of  prophylaxsis  as  we  now  do  in 
tuberculosis."  Dr.  Crile,  Cleveland,  spoke  of  a  screw- 
clamp  to  close  the  arteries,  and  thus  prevent  hemorrhage, 
in  operation  for  cancer  of  the  tongue.  Dr.  Rodman,  Phi'a 
dlphia,  said  that  there  was  accumulating  evidence  to  show 
that  carcinoma  is  due  to  parasitic  origin;  that  until  re- 
cently It  was  supposed  that  carcinoma  was  not  found  as 
frequently  in  the  Indian  and  negroes,  yet  it  is  found  in 
both  those  races  as  in  the  white,  certainly  carcinoma  of 
the  breast, and  in  the  negro  probably  a  little  more  than  in  the 
whites.  Dr.  Fritterer,  Chicago,  was  opposed  to  the  parasit- 
ic theory,  but  did  not  wish  to  discourage  research  along 
that  line.  He  referred  to  the  mechanical  theory,  the  dis- 
placement of  the  epithelial  cells  in  the  deeper  layers,  and 
the  Cohnheim  theory.  The  doctor  had,  in  the  exhibit,  a 
pathological  specimen — cancer  of  the  stomach — an  implan- 
tation from  an  ulcerating  carcinoma  in  the  esophagus 
high  up.  Dr.  Massey.  Philadelphia,  in  speaking  of  cancer, 
thought  that  there  was  a  separate  entity,  separate  from  the 
man  or  woman  on  which  the  disease  feeds.  He  spoke  of 
the  use  of  the  electric  current,  causing  chemical  disin- 
tegration of  the  growth  at  once  under  ether,  which  he 
had  presented  in  Philadelphia  in  1S9T.  Dr.  Dawbarn.  Xew 
York,  commended  the  joint  paper  by  Dps.  Halsted  and 
Bloodgood,  in  the  extirpation  of  tumors  or  lumps  in  the 
breast,  whatsoever  they  might  be.  In  operations  for  can- 
cer of  the  tongue  he  believed  death  was  caused  by  shock 
and  that  the  chief  cause  of  shock  is  hemorrhage.  The 
doctor  had  forty  personal  operations  in  the  region  of  the 
mouth  and  external  carotid.  Dr.  Leavings,  Milwaukee,  re- 
ferring to  cancerous  growths  coming  from  a  development 
of  epithelial  cells,  embryonal  or  post-natal  in  character, 
drew  an  analogy  between  that  and  the  embryology  of  the 
teeth  or  "enamel  organ."  Dr.  McKenzie,  Oregon,  from  the 
standpoint  of  the  clinician,  thought  that  in  considering  the 
origin  of  cancer,  the  point  of  locality  had  a  great  deal  to 
do  with  it:  that  when  it  develops  in  any  part  of  the  hu- 
man body  it  develops  in  tissues  which  are  not  normal 
anatomically  and  in  organs  which  are  not  normal  physi- 
ologically. 

At  the  close  of  the  morning  session  Dr.  C.  M  .Jackson, 
of  the  University  of  Missouri,  gave  an  interesting  talk 
no  the  subject  of  "A  Method  for  the  Study  of  Relational 
Anatomy,"  in  which  he  said  that  the  relative  inefficiency 
of  the  present  courses  of  instructions  in  anatomy  is  large- 
ly due  to  the  lack  of  a  practical  method  of  studying  the 
topographical  relations  of  the  various  organs.  For  this 
purpose  sections  are  necessary.  Method  of  frozen  sec- 
tions unsatisfactory.  The  author  has  obtained  excellent 
results  by  sectioning  bodies  hardened  by  arterial  injec- 
tions of  formalin.  .4.  detailed  account  of  this  method 
as  applied  in  teaching  relational  anatomy  in  the  University 
of  Missouri,  a  new  apparatus  for  making  rapid  and  ac- 
curate drawings  of  sections.  The  possibilities  of  this 
method  for  teaching  anatomy  and  surgery,  and  also  for 
the  study  of  relational  anatomy  by  the  practitioner. 

Officers  for  following  year:  Dr.  De  Forest  VTillard  (Phil- 
adelphia). Chairman.  Dr.  Jas.  B.  Bullitt  t Louisville),  Sec- 
retary. 

THIRD  DAY.   JUNE  6th.   li'Ol. 

Paper  by  Dr.  John  A.  Wyeth.  New  York  Citv:  "Hem""- 
tasis   in   Amputation    at   the    Hip-joint — A    Resume   of  262 


Cases  by  the  Author's  Method."  The  operation  has  had 
11  years  trial;  the  author  has  coUecter  267  cases,  in  which 
the  operation  had  been  done.  The  operation  was  first 
made  public  at  a  meeting  of  the  American  Medical  Asso- 
ciation at  Nashville  in  1890.  The  267  cases  are  classified 
as  to  neoplasms,  sarcoma,  epithelioma  and  osteo-caxcino- 
ma.  While  the  mortality  is  large,  the  injuries  were  of  a 
very  severe  type.  The  death  rate  In  1881  for  all  causes 
was  64%,  now  19.8%.  The  death  rate  20  years  ago  for  all 
causes  was  equal  to  that  for  crushes  from  railway  trucks  or 
heavy  machinery  at  this  date  Antisepsis  must  share  with 
the  improved  hemostasis  the  credit  of  tnis  diminished 
rate  of  mortality.  In  the  discussion.  Dr.  Means  of  Colum- 
bus, stated  that  his  experience  was  limited  to  two  cases. 
He  thought  that  the  use  of  these  pins  in  hemostasis  could 
be  extended  quite  as  well  to  various  other  portions  of  the 
body.  He  felt  that  the  profession  should  congratulate 
Dr.  Wyeth  for  the  principle  Involved  in  this  method  of  con- 
trolling hemorrhage.  Dr.  Henry  concurred  in  the  ex- 
pressions of  the  value  of  this  method  of  Dr.  Wyeth.  Dr. 
Walker  said  that  the  ease  with  which  hemorrhage  could 
be  controlled  was  a  revelation  to  him.  He  asked  why  the 
operation  could  not  be  done  without  the  use  of  the  pins — 
why  not  do  the  ligation  primarily?  Dr.  Sylvester  con- 
sidered it  a  very  scientific  and  satisfactory  operation. 
He  was  in  the  habit  of  tying  the  silk-worm  suters  In  bow 
knots,  and  the  bow  knots  can  be  untied  without  the  use  of 
an  anaesthetic.  Dr.  Wright,  of  Bridgeport,  Conn.,  uses  a 
heavy  rubber  bandage  and  converts  it  into  a  roll,  passing 
it  around  the  groin.  He  has  been  able  to  produce  a  he- 
mastasis  which  was  quite  satisfactory.  It  occluded  the 
vessels  and  saved  the  necessity  of  the  pins.  "Autoplastic 
Suture  in  Hernia  and  other  Ventral  Wounds,"  Dr.  L.  L. 
McArthur,  Chicago.  As  to  Suture  material,  the  Doctor 
said  that  he  would  not  have  presented  the  paper  if  he  did 
not  believe  that  it  possesses  additional  merits,  viz.:  d) 
The  obtaining  of  a  living  suture:  (2)  Lessened  chance  of 
failure  thorugh  avoidaiice  of  Introduction  of  dead  or 
foreign  tissue:  (3)  The  incori>oration  In  the  resisting  cica- 
trix of  organized  white  fibrous  tissue.  He  felt  that  failure 
of  cure  in  hernial  operations  by  any  of  the  recognized 
methods  is  practically  due  to  associated  infection,  for  the 
Rassini,  the  .\ndraws  or  the  Girard.  un-assoclated  with  in- 
fection can  be  said  to  be  practically  always  successful. 
Dr.  Powers  of  Denver  believed  that  Dr.  McArthur's  propo- 
sition was  well  worthy  of  trial.  He  did  not  know  whether 
the  essayist  had  operated  on  any  children  by  this  method. 
The  discussor  had  operated  on  a  boy  of  ten  years.  Dr. 
G.  F.  Shimonek  of  Milwaukee  believed  that  this  tissue 
so  imited.  was  of  rather  low  vitality,  as  all  tissues  of  that 
kind  are.  and  that  by  passing  it  through  the  opening  and 
putting  it  on  a  stretch  it  must  become  de-vitalized.  The 
Chair  remarked  that  an  important  point  to  observe  was 
that  after  it  was  sewed  there  was  no  tension.  That  in- 
stead of  being  constricted  the  way  the  tissues  are  when 
they  are  tied  with  catgut,  no  constriction  occurs.  Dr.  Mc- 
Arthur said  that  he  had  found  that  the  edge  did  not  tear 
out  any  more  than  it  would  in  using  any  other  suture  ma- 
terial. The  Doctor  reported  a  case  of  rather  a  rare  type 
of  hernia,  which  is  spoken  of  as  the  "sacless  hernia." 
"New  Method  of  Skiagraphic  Diagnosis  for  Renal  and 
Ureteral  Surgery."  Drs.  L.  E.  Schmidt  and  G.  Kolischer  i 
Chicago.  Skiagraphy  for  medical  purposes  was  especi.:"- 
advanced  and  perfected  in  America.  Calculous  deposits 
were  especially  attractive  for  X-Ray  diagnosis.  The  au- 
thors' paper  was  elucidated  by  illustration,  one  showing  a 
kidney  and  renal  stone.  By  their  method  they  are  :i!'%> 
to  determine  the  course  of  the  ureters,  location  on  •- 
renal  pelvis,  diagnosis  of  dilatation  of  the  renal  pe'.v:>. 
and  the  location  of  the  renal  calculi:  also  the  possibi'.-y 
of  differentiating  gall  stones  from  renal  stones.  "Prosta- 
totomy  versus  Prostatectomy  for  Prostatic  Hypertrophy.** 
Dr.  Raymon  Guiteras.  New  York  Ciri-.  The  Doctor  out- 
lined the  history  of  prostatectomy  and  prostatotomy.  say- 
ing that  each  had  been  developed  by  a  gradual  evolutloo. 
His  personal  preference  is  the  vesico-rectal  method  ;ui.1 
the  most  important  part  of  his  technioue  is  the  inserting  ^f 
two  fingers  high  up  in  the  rectum.  It  is  too  grave  a  con-  J 
dition — senile  hyperi;rophy  of  the  prostate — to  allow  of  I 
dogmatizing.  There  are  three  important  classes  of  th'-sff  ■ 
cases:  the  first,  the  physiology  young,  suitable  for  -i':- 
cal  operations:  the  second,  older,  can  withstand  p.ir.v- 
tive  bottiii.  The  third  class  fortunately  small,  and  cr^-.v- 
ing   smaller  are  able   to   stand  no   operation   whatsoev.^r. 


JCN-E    15,   1901] 


SOCIETY  REPORTS 


TThe  Philadelphia 
LMedical  Journal 


i'33 


statistics  show  the  mortality  of  prostatectomy  as  yet  to  be 
three  times  that  of  prostatotomy. 

"Prostatectomy,  the  Method  of  Choice  in  the  Manage- 
ment of  Prostatic  Obstruction,"  Dr.  Eugene  Fuller,  New 
Yoiiv  City.  The  Doctor  opened  his  paper  with  a  plea  for 
radical  operative  relief  in  these  cases.  At  the  present 
time,  if  practitioners  allow  a  patient  to  die  from  appendicitis 
without  resorting  to  surgery  or,  at  least  to  raising  of  sur- 
gical interference,  the  community  at  large  blames  him 
severely:  the  same  ought  to  apply  to  prostatic  obstruc- 
tions. The  Doctor  showed  how.  under  proper  surgical 
management,  the  mortality,  under  favorable  circumstan- 
ces, is  not  over  from  8  to  10%.  The  question  of  castration 
for  relief  of  this  condition  is  passed  over  and  cast  aside  as 
a  discarded  method.  The  Bottini  method  was  freely  con- 
sidered. "A  Further  Report  on  Permanent  Catheterization," 
Dr.  J.  R.  Eastman,  Indianapolis,  Ind.  Permanent  cathe- 
terization in  the  male  was  practiced  in  15  cases  in  each 
case  the  catheter  was  retained  for  10  days;  in  two  cases 
60  days.  Cystitis  was  not  produced  in  the  author's  cases 
sufficiently  severe  to  produce  symptoms.  Hydrogen  per- 
oxide was  introduced  into  the  bladder.  Regular  flushing 
of  the  bladder  was  not  done  except  in  two  cases.  It  is  es- 
sential that  the  catheter  be  introduced  just  far  enough, 
that  the  tip  project  into  the  bladder  and  be  accurately  se- 
cured. '-Fallacies  in  the  Treatment  of  Urethral  Diseases," 
Dr.  Robert  Holmes  Greene,  New  York  City.  The  Doctor 
covered  the  technique  pathology  quite  extensively  and  added 
to  the  realism  of  his  subject  by  well-defined  drawings  of 
cases.  "Perineal  Prostatectomy,"  Dr.  Parker  Syms,  New 
York  City.  The  Doctor  said  that  while  prostatectomy 
by  most  methods  hadshown  a  large  death  rate,  he  had 
so  far  been  fortunate  enough  in  not  having  lost  a  patient 
and  having  a  complete  cure  in  all  cases  except  the  second 
one. 

Discussion:  Dr.  Robert  H.  W.  Dearborn  presented  the 
subject  of  an  apparatus  of  his  own  for  supra-pubic  drain- 
age, which  had  already  had  the  test  of  ten  years.  He  thor- 
oughly described  the  technique  thereof  by  specimen  pre- 
sented. It  consists  of  a  fountain  syringe,  regulated  by 
either  an  artery-forceps  or.  as  the  Doctor  used,  the  catch 
that  comes  with  the  syringe.  Dr.  Rockery  considered  that 
the  question  of  prostatic  hypertrophy  was  one  of  vastly 
greater  importance  than  it  seemed  to  receive  from  the 
profession.  He  believed  the  operation  of  prostatectomy 
has  been  an  evolution,  and  that  the  question  to  decide  was 
the  method.  He  believed  that  the  information  was  to  al- 
low the  operation  to  become  one  of  last  resort,  that  it 
should  be  taken  up  much  earlier.  Dr.  McGowan,  of  Los 
Angeles,  had  operated  on  about  fifty  old  men  by  prostato- 
tomy and  prostatectomy:  the  men  varied  from  65  to  SI 
years:  the  results  were  not  perfect  by  either  method.  Dr. 
Guiteras.  speaking  of  retention  of  urine,  said  that  the  blad- 
der ought  never  to  be  emptied  at  one  time:  never  draw 
more  than  a  pint  the  first  time.  In  speaking  of  the  Bottini 
operation,  the  Doctor  said  that  it  held  the  same  position 
to-day  as  did  Hysterectomy  a  few  years  ago,  but  that  some 
day  a  good  operation  that  could  be  done  with  ease  and 
without  danger  to  the  patient  would  be  devised.  Other 
discussers  were  Drs.  Eastman,  Greene,  and  Syms. 

Paper  by  Dr.  J.  D.  Murphy,  Chicago,  "Pneumectomy  and 
Pneumotomy."  The  doctor  said  that  pneumectomy  is  fre- 
quently indicated.  It  can  be  performed  with  safety  to  the 
patient:  the  danger  of  pneumothorax  is  not  great,  and 
their  unpleasant  manifestations  are  entirely  overcome 
when  the  causes  of  the  symptoms  are  understood.  Por- 
tions of  the  lung  may  be  amputated  without  danger  o£ 
hemorrhage  and  without  danger  of  pneumothorax  from  di- 
vision of  the  branches  of  the  bronchi.  Pneumotomy  is  fre- 
quently indicated,  is  not  a  dangerous  procedure  and  may 
be  accomplished  with  or  without  adhesions  of  the  lung: 
the  hemorrhage  is  usually  controlled.  The  doctor  showed 
why  the  scalpel  should  be  used  in  place  of  the  Paquelin 
cautery  in  opening  pulmonary  abscesses,  interlobar  ab- 
scesses and  bronchiectatic  cavities,  and  portrayed  the 
probabilities  of  pneumectomy  and  pneumotomy.  Dr.  De- 
Forest  Willard.  Philadelphia.  "Removal  of  Foreign  Bod- 
ies from  the  Trachea  and  Bronchi."  Foreign  bodies,  the 
doctor  said,  such  as  seeds,  nuts,  toys,  food.  etc..  are  ex- 
ceedingly liable,  especially  in  children,  to  be  sucked  into 
the  trachea  during  laughing,  crying,  etc.  The  violent  ef- 
forts at  coughing  usually  dislodge  the  offender  if  it  has  not 


reached  the  larynx  but  it  may  be  arrested  at  the  vocal 
cords,  or  may  pass  on  and  become  impacted  in  one  of  the 
bronchi,  usually  the  right,  from  anatomical  reasons.  A 
low  tracheotomy  should  at  once  be  performed  and  a  large 
opening  made.  When  the  object  to  be  sought  for  is  me- 
tallic, an  X-ray  representation  may  prove  of  great  value. 
Should  gangrene  of  the  lung  occur,  a  free  incision  should 
be  made  down  to  the  pleura.  "Treatment  of  Empyema," 
Dr.  James  H.  Dunn,  Minneapolis.  The  doctor  said  that 
the  average  treatment  of  empyema  is  still  far  from  satis- 
factory and  decidedly  behind  the  present  state  of  surgi- 
cal science.  He  assigned  as  some  of  the  causes  of  failure, 
tardy  diagnosis,  inefficient  drainage  and  slovenly  after- 
treatment.  A  pleural  suppuration  should  be  at  once  re- 
moved. The  drainage  opening  should  be  large.  The 
doctor,  in  a  very  interesting  way.  covered  the  technique 
diagnostic  and  prognostic  features. 

Dr.  Vernays  said  that  he  believed  that  the  time  had 
come  when  surgery  would  attack  the  ravages  of  tubercu- 
losis in  the  lungs  and  that  it  would  be  done  successfully. 
The  doctor  then  related  postmortem  findings  of  tubercu- 
lous tissue,  which  proved  of  great  interest  to  the  Section. 
The  doctor  believed  that  this  department  of  surgery  is  in 
its  infancy.  Dr.  Willard  had  so  completely  covered  the 
subject  of  foreign  bodies  in  the  air  passages  that  he  had 
nothing  to  add.  As  to  Dr.  Dun's  paper,  he  said  that  the 
treatment  of  empyema  depends  on  the  microscopic  findings 
in  the  fluid  that  has  been  drawn  out  by  the  exploratory 
needle.  Dr.  Barbet  had  expected  to  present  a  paper  on 
thoracic  surgery.  He  had  performed  experiments  on  dogs 
and  had  devised  a  special  apparatus.  Dr.  Jopson,  of  Iowa, 
considered  that  the  removal  of  foreign  bodies  from  tho 
air  passages  forms  an  important  part  In  general  surgery; 
that  in  every  instance  of  foreign  bodies  in  the  air  passages, 
the  trachea  should  be  opened.  He  did  not  believe  that 
emetics,  holding  the  patient  upside  down,  were  availing. 
He  said  that  when  the  trachea  is  once  opened  we  imme- 
diately know  whether  it  is  distal  to  the  opening  or 
proximal,  whether  it  is  toward  the  lung  or  whether  it  is 
located  in  the  larynx  by  the  breathing,  and  the  thing  in 
the  larjTix   can   easily  be   removed  by  a  pair  of  forceps. 

Dr.  Frank,  of  Chicago,  said  that  he  had  had  experience 
in  lung  surgery  in  two  cases  and  that  he  found  from  these 
two  cases  and  from  experiments  on  dogs  that  surgery  of 
the  lung  is  not  as  easy  as  most  speakers  would  lead  one  to 
believe.  The  first  case  was  that  of  a  politician,  who  made 
a  good  recovery.  The  doctor  had  inserted  a  syringe  with  a 
catheter  into  the  trachea  and  made  suction.  Dr.  LeMoyne 
Wills,  of  Los  Angeles,  said  that  the  trouble  in  Southera 
California  and  all  parts  of  the  country  is  that  much  op- 
position to  anything  in  the  way  of  draining  the  superficial 
cavity,  or  anything  in  the  chest,  that  it  is  put  off  vmtil  It 
fs  too  late  to  do  any  good,  and  that  it  is  for  the  profession 
to  overcome  that  opposition  and  not  let  their  patients  go 
on  in  a  septic  dying  condition  and  then  send  them  away 
to  Arizona  and  New  Mexico  and  Southern  Califoria.  there- 
by putting  the  responsibility  on  the  other  fellow's  shoul- 
ders. Dr.  Norred,  Minnesota,  related  a  case  of  a  child  two 
and  a  half  years  of  age.  who  in  1S69.  had  swallowed  a  pea- 
nut kernel,  which  was  drawn  into  the  bifurcation.  His  two 
consultants  said  there  was  no  hope,  but  he  persisted  and 
suggested  that  they  relax  the  child  completely  and  thus 
prevent  any  muscular  contraction.  The  child  was,  there- 
fore, given  morphia  and  vomiting  was  provoked,  where- 
upon the  peanut  kernel  was  disloged  and  came  up.  And 
accommpanying  pneumonia  was  also  checked.  "And," 
said  the  doctor,  "I  have  to  say  with  great  gratification,  that 
the  young  man  recovered  and  is  in  your  presence  this  af- 
ternoon." (Applause).  Dr.  Keen,  of  Philadelphia,  spoke 
in  relation  to  puncturing  the  lungs.  The  points  which  he 
emphasized  was  the  means  of  obtaining  adhesions  where 
none  exist  in  puncturing  the  lung,  and  the  safety  of  a  very 
large  suture  of  lung  tissue  to  the  chest  wall,  in  the  first 
case  the  doctor  made  his  incision  parallel  to  the  ribs  for 
about  two  inches,  carefully  dissecting  the  muscles,  separ- 
ating them  as  he  went  down,  until  he  reached  the  pleura 
which  was  very  easily  recognized  and  the  muscles  very 
easily  separated  from  the  pleura.  The  other  was  the  case 
of  a  woman  who  had  a  sarcoma  of  the  chest-wall,  reaching 
from  the  outer  border  of  the  breast  nearly  all  the  way  back 
to  the  vertebral  column.  Dr.  Means,  of  Columbus,  had, 
within  the  last  18  months  two  cases,  one  of  them  demon- 
strating the  possibility  of  recovery,  after  a  fearful  gun- 
shot wound  of  the  chest:  in  the  other  he  was  unable  to 
reach  a  pus  cavity.     Dr.  Willard,  of  Philadelphia,  said  that 


1134 


The  Philadelphia  "1 
siedical  jovkxal  j 


SOCIETY  REPORTS 


[JrxE   15,    1901 


in  regard  to  secondarj'  emphysema,  which  is  liable  to 
occur  after  opening  a  bronchus  and  not  being  able  to 
close  it — if  one  can  close  it  simply  after  extraction  of  the 
foreign  body  by  stitches,  secondary  emphysema  is  not 
likely  to  occur.  If  that  opening  is  not  closed,  I  have  found, 
over  and  over  again  in  dogs  that  the  pneumothorax  con- 
stantly increases  after  the  closure  of  the  wound. 

FOURTH  DAY,  JUNE  7th,  1901. 

The  papers  of  the  afternoon  session  were  combined  with 
those  of  the  morning,  thereby  affording  early  adjournment. 

Paper  on  "Abdominal  Surgery,"  by  Dr.  Maurice  Richard- 
son, Boston.  (Author  absent).  Paper  on  "The  Indications 
for  and  against  total  Removal  of  the  Human  Stomach,"  by 
Dr.  G.  Childs  Macdonald,  San  Francisco,  i^ Author  absent). 
Paper  on  "Diagnosis  and  Treatment  of  Kidney  Stone,"  Dr. 
Charles  D.  Beven.  (Author  absent).  Paper  on  the  "Sur- 
gery of  the  Gall  Bladder  and  Gall  Ducts,"  Dr.  Alexander 
H.  Ferguson.  (Author  absent). 

Substitute  paper:  "Indications  for  Operation  in  Calcu- 
lus, Nepritis  and  Ureteritis,"  Dr.  Charles  L.  Leonard,  Phila- 
delphia. The  doctor  brought  out  the  facts  as  follows:  Re- 
cent advances  in  the  diagnosis  of  calculous  conditions  of 
the  kidneys  and  ureters  show  that  more  than  ^  the  calculi 
that  originate  in  the  kidneys  pass  into  the  ureters  before 
they  occasion  suflBcient  symptoms  to  make  their  presence 
known  and  the  Rontgen  method  of  diagnosis  has  shown 
the  greater  frequency  of  ureteral  calculi.  Their  detection 
does  not.  however,  constitute  the  indication  for  operation. 
The  differentiation  between  the  cases  that  demand  and  those 
offering  palliative  treatment  is  based  on  the  use  of  the 
Rontgen  method  of  diagnosis.  Its  accuracy  is  confirmed 
in  165  cases,  which  the  author  has  examined  by  this  meth- 
od. The  doctor  dwelt  at  some  length  upon  the  symptom- 
atology, as  well  as  the  radical,  conservative  and  expectant 
treatment.  WTiile  explorations  are  valuable  in  many  cases, 
yet  the  actual  incision  into  the  kidney  is  now  only  justi- 
fied by  the  previous  detection  of  a  calculus  by  the  Ront- 
gen method  or  some  macroscopical  pathological  lesion. 
Ureterolithotomy  has  been  successfully  performed  in  many 
cases.  One  of  the  greatest  problems  of  renal  surgery  Is 
the  determination  of  which  kidney  or  ureter  is  the  one 
upon  which  to  operate  and  at  what  point.  Paper  by  Daniel 
N.  Eisendrath.  Chicago,  on  "Acute  Infective  Cholangitis 
and  Cholecystitis  as  a  Complication  of  Gail-Stones."  The 
doctor  especially  referred  to  the  formation  of  stones  pro- 
duced by  colon  or  typhoid  bacillus.  These  infective  agents 
set  up  a  catarrhal  condition  in  the  gall-bladder  and  bile 
ducts.  Gall-stones  may  remain  in  the  gall-bladder  for 
years  without  giving  rise  to  the  least  suspicion  of  their 
presence.  Whenever  pus  is  present  in  the  gall-bladder, 
especially  if  the  symptoms  have  been  acute,  prognosis 
should  be  guarded.  There  should  never  be  delay  in  the 
treatment  of  an  empyema  of  the  gall-bladder  complicating 
gall-stones.  The  doctor  then  covered  the  pathology  of  in- 
fective cholangitis  and  cholecystitis  of  the  nonsuppurative 
type,  as  well  as  the  clinical  aspect  of  the  disease.  Paper  by 
Dr.  James  B.  Bullitt,  "Dissecting  abscesses  of  Abdominal 
Wall  Producing  Symptoms  Similating  Pott's  Disease  of  the 
Spine."  The  doctor  gave  a  recitation  of  an  illustrative 
case  following  typhoid  fever,  six  weeks  after  subsidence  of 
fever  (kyphosis).  Careful  examination  showed  deformity 
due  to  collection  of  pus  beneath  abdominal  wall  and  extra 
peritoneal.  The  lumbar  kyphosis  was  entirely  compensatory 
The  abscess  finally  ruptured  externally  at  the  umbilicus  to 
discharge  indefinitely  a  thin  pus.  The  doctor  gave  a  re- 
sume of  half  a  dozen  cases  collected  from  literature  with, 
remarks.  Paper  on  "Experimental  and  Clinical  Observa- 
tions on  the  Therapeutics  of  Abdominal  Surgery,"  Dr. 
George  W.  Crilfe,  Cleveland      (Author  absent). 

In  the  absence  of  Dr.  Howard  A.  Kelly,  Dr.  Frank  D. 
Smythe,  of  Memphis,  opened  the  discussion.  The  doctor 
reported  a  case  of  cystitis  and  kidney  stone,  for  which 
both  cystotomy  and  nephrectomy  were  performed,  the  kid- 
ney showing  signs  of  gonorrheal  infection.  He  said  that 
jaundice  was  not  a  contraindication  to  surgical  operation 
in  his  experience,  and  would  close  the  bladder  after  ex- 
cision of  the  fundus,  removal  of  the  gall-stones  and  drain- 
age. Dr.  McGowen  discussed  the  efficacy  of  the 
X-ray  in  diagnosis  of  the  kidney  or  ureter,  and  men- 
tioned two  serious  bums  that  had  occurred  in  his  hands. 
Dr.  Thomas,  of  Pittsburg,  mentioned  a  case  of  stone  in 
the  kidney,  in  which  an  X-ray  picture  was  taken,  hut  it 
did  not  show  the  presence  of  stone.    The  kidney,  however. 


was  cut  into  and  the  stone  discovered.  Dr.  Urane,  of  Ver- 
mont, had  had  considerable  experience  in  X-ray  work  and 
said  that  the  shadow  cast  is  dependent  on  the  atomic 
weight  of  the  substance.  As  regards  examination  for 
stone.different  kinds  of  stone  cast  shadows  of  varying  inten- 
sity. The  oxalate  of  lime  stone  would  cast  a  dense  shadow 
as  compared  with  uric  acid  stone.  I  think  the  danger 
comes  entirely  from  the  length  of  exposure  at  a  short  dis- 
tance from  the  Crooks'  tube.  Asked  by  a  member  what  he 
meant  bj'  length  of  exposure,  the  doctor,  replied  within  two 
or  three  inches  of  the  tube  and  exposure  of  not  more  than 
three  minutes.  A  longer  exposure  should  be  commensur- 
ate with  a  corresponding  distance  from  the  tube.  Dr. 
Means,  of  Columbus,  believed  that  the  bile  passages  nor- 
mally co'itain  micro-organisms.  He  said  it  was  a  danger- 
ous statement  to  make  that  the  gall-stones  might  be  in  the 
gall-bladder  for  j-ears  or  for  an  indefinite  period  and  pro- 
duce no  symptoms.  Dr.  Davis,  of  Omaha,  spoke  of  the 
"clumping"  of  the  typhoid  bacillus  which  constituted  a 
nucleus  around  which  the  stones  formed.  Dr,  Rodman,  of 
Philadelphia,  was  very  optimistic  as  regards  the  safety 
of  Rontgen  rays  in  relation  to  bums,  believing  that  in 
proper  hands  there  is  no  cause  for  alarm.  Dr.  Lemon,  of 
Milwaukee,  mentioned  two  cases.  In  both  cases  there  was 
an  entire  absence  of  jaundice;  the  possibility  of  suppu- 
ration of  the  gall-bladder  had  not  been  thought  of.  Dr. 
Bloodgood,  of  Baltimore,  spoke  of  the  acute  hemorrhagic 
pancreatitis,  also  of  "cases  in  which  we  have  history  of 
gall  stone  colic,  with  or  without  jaundice,  and  yet  when  we 
operate  we  find  no  stones  in  the  gall-bladder  or  ducts,  but 
we  find  an  indurated  pancreas,  or  chronic  interstitial  pan- 
creatitis, and  we  find  such  cases  are  relieved  by  tem- 
porary drainage  of  the  gall-bladder."  Others  who  spoke 
were:  Dr.  Porter,  Ft.  Wayne;  Dr.  Phillips.  Rockyford;  Dr. 
Mitchell.  Missouri:  Dr.  Maxwell,  Iowa:  Dr.  Bernays.  St. 
Louis:  Dr.  Leonard,  Philadelphia;  Dr.  Eisendrath  and  Dr. 
Bullitt.  Dr.  C.  E.  Ruth,  Keokuk.  la.,  read  an  interesting 
paper  on  "Fracture  of  the  Femoral  Neck."  The  doctor 
recited  many  cases,  but  particularly  of  a  man  72  years  of 
age.  who  sustained  a  fracture  of  the  femoral  neck  at  that 
time,  and  dying  at  90.  He  exhibited  the  specimen,  show- 
ing bony  union.  The  reality  of  any  fracture  immediately 
brought  several  fellows  to  their  feet,  contending  that  there 
was  no  fracture  present.  Dr.  Maxwell  from  whose  pa- 
tient the  bone  was  taken  postmortem,  had  the  history  of 
the  patient  and  could,  therefore,  support  the  statement  of 
fracture.  Dr.  Bernays,  of  St.  Louis,  said  that  when  he  saw 
the  specimen  at  the  Tri-State  meeting  several  months  ago 
he  was  very  sceptical;  he  did  not  think  it  was  the  bone  of 
a  man  90  years  of  age.  .\fter  he  returned  home  he  looked 
up  the  anatomical  collection  and  also  asked  the  superin- 
tendent of  the  poor  house  to  let  him  have  the  bones  of 
two  of  the  oldest  men  that  died  during  the  month.  They 
were  over  80  years  of  age  and  were  just  as  solid  in  tex- 
ture as  that  bone  presented,  which  convinced  him 
that  the  bone  shown  at  the  Section  was  one 
from  a  man  90  years  of  age.  The  Chair  thought  the  con- 
dition a  very  important  one.  if  true,  as  a  rarity  and  con- 
tribution to  surgical  science  and  suggested  that  the  es- 
sayist keep  a  record  of  these  cases  met  with  during  the 
interim  between  the  present  time  and  next  meeting  of 
the  Section  and  then  to  report  his  findings  accurate- 
ly and  in  detail.  Dr.  Grant  doubted  the  exis- 
tence of  complete  fracture  of  the  bone.  Dr.  Maxwell 
wanted  to  know  how  he  accounted  for  2  inches  shortening 
with  crepitation,  extension  and  rotation.  The  reply  was 
that  it  might  be  in  the  acetabulum,  without  fracture  of  the 
neck  of  the  bone;  the  extension  would  reduce  it  and  th-  -e 
would  be  no  shortening.  Dr.  Thomson,  of  Scrar.'  •  \- 
hibited  X-ray  specimen  of  the  fracture  of  the  ne. 
femur  in  a  miner  under  his  cnre.  The  patient  ev 
died  from  heart  trouble,  as  announced  by  the  local  coroner 
at  that  place.  Dr.  Listen  A.  Montgomery  presented  an  in- 
teresting discussion  of  the  subject,  with  presentation  of  a 
live  subject,  wearing  a  special  apparatus  or  brace.  Dr.  J. 
Rawson  Pennington,  of  Chicago,  gave  an  interesting  lalt. 
diagrammatically  elucidated,  on  "A  Simple  Operation  for 
the  Treatment  of  Hemorrhoids."  The  Section  this  year 
was  a  most  successful  one.  the  attendance  ranging  be- 
tween 500  and  1000  daily.  On  two  occasions  there  were 
present  1000.  Following  the  presentation  of  a  complimen- 
tary resolution  of  thanks  from  Dr.  Rodman,  of  Philadel- 
phia to  the  retiring  President  and  Secretary  and  speev-hes 
of  i-esponse,  the  Section  of  Surgery  and  Anatomy  adjourned, 
sine    die.    carrying    with    it    the    feeling    of    the    utmost 


June   15,   1901] 


SOCIETY  REPORTS 


I  The  Philadelphia 
L  Medical  Journal 


"35: 


F.atisfaction  at  the  success  of  the  meeting,  not  only  from 
the   interest   manifest,   but  by   the   high-class   papers   pre- 
sented and  scientific  nature  of  the  discussions. 
Adjourned. 


SECTION  ON  OBSTETRICS  AND  DISEASES  OF  WOMEN. 

FIRST   DAY,   JUNE   4th,   1901. 

The  Chairman,  Henry  P.  Newman  of  Chicago,  presented 
his  address  in  which  he  made  some  suggestions  on  the 
improvements  of  the  methods  of  conducting  the  section 
nifetings.  and  then  proceeded  to  review  the  year's  pro- 
gress In  gynecology  and  obstetrics  Among  the  most  note- 
worthy innovations  of  the  year  is  the  clinical  adoption  of 
the  method  best  known  as  cocainization  by  spinal  punc- 
ture. Bier,  of  Germany,  made  the  first  Injection,  and  Tuf- 
fier.  of  France,  followed  him.  The  latter  has  now  covered 
in  his  experience  400  cases  and  has  collected  the  records 
of  2000  cases  with  hut  6  deaths.  He  considers  the  method 
as  absolutely  safe,  but  in  this  he  is  opposed  by  others. 
Newman  claims  that  its  limitations  are  somewhat  re- 
duced, and  that  the  method  will  probably  never  be  so 
popular  here  as  abroad.  The  patient  plays  a  very  impor- 
tant part  in  the  method,  which  is  not  applicable  to  chil- 
dren and  sensitive  adults,  nor  for  grave  major  opera- 
tions. Full  consciousness  is  not  desirable.  In  obstetric 
operations  the  method  has  been  found  undesirable.  There 
is  no  relaxation  of  the  muscular  tissue  as  with  the  use 
of  other  ar.estetics.  The  Protozoan  of  Cancer.  Gay- 
lord's  experiments  seem  to  show  that  these  micro-organ- 
isms are  the  cause  of  cancer.  Until  a  specific  be  discov- 
ered, however,  wherewith  to  destroy  the  disease,  surgi- 
cal operation  will  not  be  contraindicated,  even  up  to  the 
eleventh  hour.  The  early  correction  of  all  epithelial  les- 
ions of  the  genital  tract  will  largely  prevent  the  subse- 
quent development  of  malignant  diseases,  which  is  now 
so  rapidly  growing  in  frequency.  Ovarian  grafting  or 
transplantation  has  gained  ground  during  the  year,  as 
evidenced  by  the  encouraging  reports  from  the  various 
expcrimentors  Cesarean  Section  for  placenta  previa  is 
valuable  if  done  under  aseptic  precautions  and  before  the 
patient  is  exhausted.  The  operation  is  probably  contra- 
indicated  in  eclampsia.  A  large  percentage  of 
the  gastric  symptoms  of  pelvic  disease  is  due  to  the 
accompanying  visceral  displacement,  as  is  also  a  large 
percentage  of  the  neurasthenia.  The  different  splanch- 
noptoses, such  as  floating  kidnej',  floating  spleen, etc..  also 
give  rise  to  grave  nervous  manifestations.  Uterine  fi- 
broids. The  use  of  saline  infusions  In  the  treatment  of 
the  hemorrhage  from  these  growths  has  grown  during 
the  year.  We  have  now  outgrown  the  dangerous  theory 
that  because  these  tumors  may  atrophy  at  the  time  of 
the  menopause  it  is  safe  to  leave  them  undisturbed  until 
that  time.  The  importance  of  prophylaxis  in  gynecolgic 
treament  was  emphasized.  The  trained  nurse  should 
supplant  the  monthly  nurse.  There  will  always  be  the 
need  of  intelligent  obstetrics,  while  nothing  but  gynecol- 
ogy will  eliminate  gynecology.  Dr.  A.  H.  Cordier,  of  Kan- 
sas City.  Mo.,  read  a  paper  on  Post-operative  Intraperi- 
toneal Hemorrhage.  He  remarked  that  no  condition  is 
more  horrifying  than  hemorrhage  after  an  abdominal  op- 
eration. The  use  of  unstable  ligature  material  has  cost 
many  patients  their  lives.  His  three  cases  of  post-  opera- 
tive hemorrhage  have  occurred  in  easy  cases.  The  symp- 
toms of  concealed  hemorrhage  very  closely  simulate  those 
of  shoclv.  hence  there  is  a  danger  of  making  a  fatal  mis- 
take. In  making  the  diagnosis  he  suggests  the  advisabil- 
ity of  cutting  one  of  the  abdominal  sutures  and  introduc- 
ing a  sterilized  tube  or  a  pair  of  hemostats:  if  hemorrhage 
be  present  the  blood  will  begin  to  flow  out.  Many  so- 
called  cases  of  shock  are  in  reality  cases  of  post-operative 
hemorrhage.  In  such  cases  the  only  duty  of  the  surgeon 
is  to  control  the  hemorrhage,  not  by  strychnin  and  hot 
applications,  but  by  relegation.  The  proper  use  of  the 
decinormal  saline  solution  is  of  great  value.  It  is  best 
to  introduce  the  fluid  in  two  sittings,  for  a  large  quantity  is 
needed.  Dr.  McMurtry.  of  Louisville,  remarked  that  post- 
operative hemorrhage  is  due  to  breaking  or  slipping  of  a 
I'gature.  and  almost  invariably  to  the  lattter.  He  does 
not  think  that  the  material  used  has  much  to  do  with  the 
accident.  It  is  rather  due  to  the  method  of  application. 
Intravenous  injections  of  salt  solution  should  never  be 
given  while  the  hemorrhage  is  going  on.  Profound  col- 
lapse or  death  may  follow  the  loss  of  a  very  little  blood 


after  an  operation:  hence  the  hemostats  must  be  prompt,, 
and  in  some  cases  packing  with  gauze  is  necessary.  Dr. 
Gordon,  of  Maine,  criticized  Dr.  Cordier's  paper  in  two 
ways.  First,  in  the  material  used.  He  has  used  no  liga- 
ture material  but  catgut  for  17  years,  and  thinks  only 
absorbable  ligatures  should  be  used.  He  prefers  ligating 
by  a  needle  only,  and  always  secures  the  first  ligature  by 
a  second  placed  below  it.  He  would  not  introduce  a 
drainage  tube  in  cases  which  do  not  need  such  a  tube.. 
Ivelly.  of  Baltimore,  reported  a  case  of  hemorrhage  re- 
sulting from  the  early  absorption  of  a  ligature.  He  does; 
not  care  for  any  other  substance  than  silk  (and  fine  silk> 
for  ligatures.  He  always  gives  a  good  pedicle  beyond  th& 
tie.  Most  important  is  a  thorough  review  of  the  field  after 
the  operation.  In  suspected  cases  of  hemorrhage  he  opens 
up  at  once,  and  the  salt  solution  is  given  as  the  patient 
goes  upon  the  table.  Marcy,  of  Boston,  believes  that  de- 
fectve  technique  is  the  most  common  fault  in  hemorrhage. 
He  favors  the  absorbable  sutures,  and  thinks  that  the; 
buried  animal  suture  is  the  best  contribution  to  surgery.. 
Rubber  gloves  and  silk  will  not  prevent  infection  and  ir^ 
ritation.  Frederick,  of  Buffalo,  has  used  catgut  exclu- 
sively for  10  years,  covering  nearly  1000  cases.  Forma- 
'in  catgut  will  remain  2  to  3  weeks  when  tied  taut.  He- 
applies  first  one  knot  and  then  a  double  knot,  leaving  the 
ends  from  %  to  %  inch  long.  Dr.  J.  G.  Clark,  of  Phila- 
delphia presented  a  paper  on  the  Contributing  Factors  in 
the  Production  of  Peritonitis.  He  stated  that  in  1S96  he 
suggested  the  natural  method  of  drainage  of  the  periton- 
eal cavity.  He  found  that  the  peritoneal  lymph  currents 
sweep  toward  the  diaphragm,  and  that  the  rapidity  of  ab- 
sorption is  so  great  as  to  render  impossible  the  localiza- 
tion by  mechanical  means  of  infectious  matter  in  any 
part  of  the  abdominal  cavity.  He  was  astonished  by  the 
remariiable  absorbing  power  of  the  peritoneum,  not  only 
for  liquids,  but  aiso  for  solid  granules.  Within  eight  min- 
utes after  the  introduction  of  granules  into  the  abdomin- 
al cavity  they  appear  about  the  diaphragm.  After  the- 
introduction  of  septic  organisms  in  the  peritoneal  cavity 
there  occurs  primarily  a  distribution.  Later  the 
leukocytes  begin  to  disappear,  and  when  found  they  con- 
tain the  granules.  This  proves  that  the  leukocytes  are 
the  phagocytes,  killing  the  parasites  and  carrying  them 
into  the  general  circulation.  Given  a  minimum  amount 
of  infection  at  the  end  of  an  operation,  it  is  proper  to 
wash  out  the  cavity  and  introduce  a  substance  which  will 
favor  absorption  of  the  poisons.  The  central  tendon  of 
the  diaphragm  absorbs  quickly,  and  some  of  the  poison  is 
elimnated  through  the  lungs,  liver,  intestines,  spleen  and 
kidneys.  There  is  no  possibility  of  limiting  the  infections 
material  to  any  portion  of  the  peritoneal  cavity.  Thor- 
ough irrigation  followed  by  the  leaving  of  one  liter  of 
6/10%  salt  solution  is  the  best  method  of  treating  pa- 
tients feared  to  be  septic.  Peritoneal  infusions  may,  how- 
ever, be  dangerous  in  ascitic  cases  in  which  the  natural 
peritoneal  drainage  is  already  deficient,  and  also  ia 
cases  of  general  surgical  peritonitis.  Wiggins,  of  New 
York,  has  found  that  his  section  cases  do  better  after 
using  irrigation,  and  have  less  adhesions.  Kelly,  of  Bal- 
timore, remarked  that  the  whole  status  of  drainage  is 
changed.  Formerly  9,5%  of  the  cases  were  drained,  now 
scarcel.v  any.  General  septic  peritonitis  from  appendi- 
citis must  be  drained.  He  occasionally  uses  gauze  in  the 
abdominal  cavity  to  sequestrate,  not  to  drain.  Baldy,  of 
Philadelphia,  states  that  Baer,  of  Philadelphia,  long  be- 
fore Johns  Hopkins  Hospital  took  up  the  subject,  closed 
the  abdomen  in  desperate  cases  without  drainage.  He 
does  not  drain  in  2%  of  his  cases,  and  he  never  leaves 
fluid  in  the  abdominal  cavity,  nor  does  he  have  much  sep- 
sis. He  does  not  believe  the  fluid  does  the  work.  If  the 
pus  be  streptococcic  the  patient  will  die  notwithstanding 
irrigation.  KoUischer,  of  Chicago,  stated  that  no  man 
could  say  in  what  direction  the  peritoneal  lymph  chan- 
nels drain.  Moreover,  the  poison  does  not  remain  on  the 
surface,  but  penetrates  the  serous  coat  and  is  carried  by 
the  subserous  lymph-chains.  Irrigations,  therefore,  can 
only  affect  the  surface  poison  and  not  that  which  has 
penetrated.  Deaver.  of  Philadelphia,  objects  to  the  doing 
away  of  abdominal  drainage.  If  we  fill  the  infected  ab- 
dominal cavity  nith  a  saline  solution  we  leave  the  last 
stage  of  our  patient  worse  than  the  first.  He  advocates 
practice  versus  theory.  By  invitation.  Dr.  M.  D.  Mann, 
of  I'uffalo.  N.  Y..  read  a  paper  entitled  A  New  Operation 
for  Extirpation  of  Cancer  of  the  Rectum  in  which  he  state'l 
that  Edoholds  has  recentlv  suggested  resection  of  the 
rectum  from  above.     The  operation  Mann  advocates  is  as 


1  1^6 


The  Philadelphia  1 
Medical  Jovkxal  J 


SOCIETY  REPORTS 


[JCKE  15.    !>•: 


follows:  The  rectum  and  vagina  are  well  cleansed,  and 
after  exposing  the  bo-wel.  tlie  rectum  is  clamped  above  the 
growth  and  cut  off;  the  meso-rectum  and  rectum  are 
then  cut  away  and  all  large  vessels  tied.  The  lower  end 
of  the  rectum  is  then  seized  and  drawn  up;  a  Murphy  but- 
ton is  inserted  and  the  two  ends  clamped,  the  lower  button 
being  held  up  by  1  or  2  nngers  introduced  into  the  rec- 
tum. 

SECOND  DAY.  JL'XE  5th,  1901. 

Dr.  O.  Thienhaus,  of  Milwaukee,  Wis.,  read  a  paper 
entitled  Atresia  hymenal  is,  and  presented  a  specimen  of 
iiematosalpinx  duplex  removed  from  a  girl  14  years  of 
age.  the  condition  resulting  from  atresia  of  the  hymen. 
Infection  of  the  vulva  and  vagina  and  inflammation  of 
these  structures,  he  claims,  is  the  main  cause  of  atresia. 
Traumatism,  pessaries  and  burnings  may  also  cause  the 
condition.  An  examination  should  be  made  in  all  cases 
of  delated  menstruation.  Hematokolpos  is  discovered 
and  a  hematosalpinx  suspected  and  abdominal  incision 
should  first  be  made,  and  the  tubal  tumor  be  removed  and 
then  the  incision  made  below.  Goldspohn.  of  Chicago, 
would  avoid  opening  the  abdomen  when  the  accumulation 
existed  in  the  vagina  only  as  it  usually  did.  Dr.  A.  Gold- 
spohn. of  Chicago,  presented  a  paper  on  The  Indications, 
Technique  and  Results  of  Salpingostomy  with  Ignipunc- 
ture  of  the  Ovaries.  He  remarked  that  ovarian  disease  is 
due  largely  to  inflammatory  action.  Conservative  work 
on  the  ovaries  was  commenced  by  Karl  Schroeder,  who 
was  soon  followed  by  A..  Martin,  Polk.  Dudley  and  others. 
Personally  he  has  been  able  to  follow  97  cases  after  con- 
servative processes  had  been  adopted.  An  examination 
of  27  of  these  showed  the  parts  in  perfect  health.  Case* 
without  pus.  extreme  adhesions  or  retroversion  of  the 
■uterus  may  be  operated  upon  through  the  vagina.  Nine  of 
such  cases  he  had  followed  and  5  are  well:  the  other  4 
are  ailing.  In  the  larger  number  of  cases  a  decided  re- 
tioversion  or  retroversiottexion  existed  with  adhesions, 
but  no  pus.  Such  cases  were  operated  upon  through  the 
vaginal  canal,  and  when  so  treated  they  stand  the  test 
of  pregnancy  and  do  not  permit  of  the  return  of  the 
abdominal  condition.  He  has  followed  56  cases  of  this 
class,  and  49  or  S7. oTc  show  perfect  results,  9%  give 
partial  results,  and  only  3%  showed  positive  failures. 
In  patients  who  are  not  near  the  menopause  and  who  are 
not  tainted  by  tuberculosis  or  malignant  disease,  a  part 
of  one  or  both  ovaries  should  be  retained.  Also  in  extir- 
pating dermoids  of  the  ovary,  a  part  of  the  organ  should 
be  retained  if  possible.  Asepsis  of  the  highest  degree  is 
necessary  in  the  removal  of  of  the  adnena.  and  the  small- 
est amount  of  suture  material  possible  should  be  used, 
as  should  also  sterile  rubber  gloves.  A  generous  medium 
ventral  incision  is  best  for  the  conservative  treatment  in 
those  cases  in  which  extreme  adhesions  and  pus  are  found. 
In  less  severe  cases  the  inguinal  ring  is  better.  The  va- 
ginal operation  does  not  provide  an  easy  access  for  ex- 
section  of  the  ovaries.  Ignipuncture  is  valuable  In  many 
cases.  The  writer  thea  presented  the  histories  of  typical 
cases.  Bovee  of  Washington  claimed  that  much  can  be 
done  by  the  conservative  surgery  of  the  ovaries,  and  less  in 
diseased  condition  of  the  tubes.  The  object  of  conserva- 
tive surgei-y  is  primarily  the  health  of  the  individual,  sec- 
ondarily function,  and  thirdly  mental  impression.  Many 
cases  of  simple  punctures  will  result  in  dense  adhesions. 
Sclerocystic  ovaries  are  not  suitable  for  resection,  but 
should  be  removed.  Eastman,  of  Indianapolis,  remarked 
that  the  retention  of  a  stormy  menstruation  is  better 
than  the  abolition  of  menstruation,  and  also  the  retention 
of  the  sexual  impulse. 

Goldsphon,  in  closing  the  discussion,  said  that  In  his 
97  cases  there  followed  10  pregnancies.  Ventral  suspen- 
sion by  the  sound  ligaments  is  next  in  value  to  the  in- 
guinal operation,  but  it  is  not  ideal. 

Dr.  A.  J.  Downes.  of  Philadelphia,  presented  a  paper  on 
Electrothermic  Hemostasis  in  Abdominal  and  Pelvic  Sur- 
gery. 

Dr.  Downes  defined  Ideal  Hemostasis  as  that  method 
oy  which  not  only  the  vessels  are  occluded  with  certainty 
but  so  that  no  complication,  either  immediate  or  remote, 
results.  He  pointed  out  how  no  correct  method  fulfilled 
the  definition.  Keference  was  made  to  Keith's  orieinal 
application  of  pressure  and  heat  to  blood  vessels  and  to 
Skenes  development  of  the  first  electro  forceps.  Dr. 
Downes  exhibited  new  instruments,  electro  thermic  an- 
giotribe  forceps,  electro  thermic  forceps,  and  artery  for- 
ceps  electro-therm.     They   are   rapid    and   certain   in   use 


and  free  from  the  objection  to  earlier  instruments.  The 
essential  requirements  in  electro  thermic  hemostasis  were 
pointed  out.  as  ^'.sc  the  safeguards.  A  number  of  ab- 
dominal operations  in  which  the  hemostasis  was  used 
were  reported,  including  appendectomies,  hystereoiornies. 
salpingo  oophorectomies,  ovarian  cysts,  ovarian  abscess'is. 
The  necessity  of  a  meter  in  the  circuit  and  mathematical 
exactness  was  insisted  upon.  Aseptic  nonadhering  stumps 
were  claimed  as  also  gieater  freedom  from  pain  after 
sections. 

Martin,  of  Chicago,  remarked  that  the  combining  of 
heat  with  a  crushing  instrument  is  a  distinct  advantage. 
.Anything  that  will  enable  the  surgeon»o  do  away  with  the 
ligature  is  great  progress.  The  white  material  fonncd 
l.y  the  electricity  is  .i  homogenous  tissue  without  jvide.ice 
of  blood  vessels  or  nerves  in  the  compressed  area. 

Dr.  E.  E.  Montgomery,  of  Philadelphia,  opened  the  sym- 
posium on  uterine  fibroid  by  a  paper  entitled  How  Shall 
we  Deal  with  Uterine  Myomata?  He  states  that  much  of 
the  good  apparently  done  by  the  animal  extracts  in  the 
treatment  of  uterine  neoplasms  is  due  to  suggestion.  The 
thyroid  extract  has  been  most  useful,  its  action  being  ex- 
erted upon  the  mucous  membrane.  He  would  not  use 
these  extracts  in  cases  in  which  surgery  should  be  used. 
In  removing  myomata  the  uterine  incision  should  b<j 
loiipituilinal.  the  trowth  seized  by  tenacula  an*!  ■•.\iir- 
pated.  -'ifter  removal  of  all  growths  the  ragged  tissues 
should  be  excised  and  the  uterine  wovmd  sutured.  In  ex- 
tensive wounding  of  the  uterus  a  gauze  drain  should  be 
introduced  through  the  abdominal  wall.  The  number  of 
growths  is  not  so  important  as  the  size  of  the  tumors. 
Small  fibroids  that  do  not  give  rise  to  symptoms  need  not 
be  removed.  Small  fibroids  producing  hemorrhage  are 
usually  submucous  and  should  then  be  removed  through 
the  vagina. 

Small  multiple  fibroids  inaccessible  to  the  vagina  should 
be  removed  from  above.  Eshman.  of  Indianapolis,  stated 
that  he  did  not  find  to-day  the  large  fibroids  seen  10-15 
years  ago.  He  regards  the  menopause  as  a  dangerous 
period  when  degenerative  changes  are  liable  to  occur  in 
these  uterine  tumors.  When  one  fibroid  is  present  no 
one  can  say  there  are  not  others.  Conservatism 
means  the  conservattion  o  of  the  woman's  health, 
and  this  is  best  done  by  hysterectomy.  Jfahlen. 
of  Louisville,  does  not  believe  every  fibroid  tumor  should 
be  removed.  But  only  when  they  give  rise  to  symptoms. 
He  does  not  believe  in  oophorectomy,  nor  in  myomectomy. 
He  would  only  do  a  hysterectomy  and  also  take  out  the 
cervix  in  order  to  avoid  subsequent  cancer.  He  gets  the 
best  results  per  vaginam.  if  the  tumor  be  not  too  large. 
He  removes  the  uterus  first  after  clamping,  and  then  U- 
gates  the  vessel.  Dudley,  of  New  York,  would  do  a  myo- 
mectomy provided  i.he  appendages  are  healthy  and  the 
uterus  will  not  be  so  scarred  as  to  give  rise  to  trouble. 
Dr.  J.  M.  Baldy,  of  Philadelphia,  read  a  paper  entitled 
Cancer  of  the  Uterine  Neck,  in  which  he  remarked  that 
this  disease  is  surgery's  disgrace.  The  best  statistics 
show  but  5'~c  recovery  .The  best  recorded  statistics  are 
those  of  Johns  Hopkins  Hospital,  with  20'~i-  recovery,  but 
this  does  not  include  a  large  number  of  inoperable  cases, 
and  again  some  of  the  cases  reported  as  cured  are  but  9 
to  14  months  old.  too  early  to  warrant  an  absolute  cure. 
1  he  microscope  is  not  a  sure  means  of  diagnosis,  and 
therefore  some  cases  are  operated  upon  that  are  not 
cancerous.  Winter's  statistics  from  Germany  show  that 
the  disease  is  almost  incurable.  The  early  discovery  of 
the  disease  is  most  important.  The  question  of  the  lab- 
oratory is  becoming  a  fad.  Clinical  observations  of  facts 
precede  the  laboratory,  and  are  more  important.  Hem- 
orrhage is  the  most  important  early  symptom.  Carsteus. 
of  Detroit,  and  Zinke.  of  Cincinnati,  believe  that  early 
operation  is  a  sure  cure.  Clark,  of  Philadelphia,  would  not 
trust  solely  to  clinical  evidence.  Ries.  of  Chicago,  ob- 
jected to  the  reader's  paper.  He  thinks  that  the  opera- 
tion of  total  extirpation  of  the  glands,  broad  ligament, 
round  ligament,  and  all  other  tissues  will  cure  the  pa- 
tient. Recurrence  occurs  in  a  large  majority  of  cases 
within  six  months.  Wertheims  primary  mortality  is  large, 
but  of  the  cases  that  have  r'^covered  no  recurrence  has 
taken  pl.ice.  The  mortality  of  this  extensive  operation  is 
10  ,i.  Kollischer.  of  Chicago,  claimed  that  Baldy's  statis- 
tics are  absolutely  correct  Cancer  of  the  portio.  how- 
ever, is  relatively  harmless,  since  21  "T-  can  be  cured. 
Baldy.  in  closing,  stated  that  recurrence  when  it  does  take 
place  does  so  in  the  wound  and  below,  not  above,  hence 


Juke   15,   1901] 


SOCIETY  REPORTS 


LTuE  Philadelphia 
Medical   Journal 


1 1 37 


the  extirpatiou  of  the  glands  is  uncalled  for.  No  man  can 
remove  every  gland  from  the  pelvis  of  a  living  woman. 
Or.  J.  Wesley  Bovee,  of  Washington,  D.  C,  presented  a 
paper  on  The  Relative  Merits  of  the  Different  Methods 
of  Utero-Ureteral  Anastomosis,  and  describes  some  of 
his  cxpiaimenial  work  in  this  line  of  surgery.  He  de- 
scribes the  four  methods,  namely  end  to  end,  side  to  side, 
end  to  side,  and  obliquely  end  to  end.  The  indications 
.ire  not  the  same  for  each  method. 

Most  of  the  reported  cases  of  ureteral  injury  requiring 
liiis  operation  have  resulted  accidentally  in  uterine  oper- 
ations. 

Dr.  A.  Plamer  Dudley,  of  New  York,  read  a  paper  on 
Some  Results  of  Ovarian  Surgery  with  Further  Report 
upon  Intra-uterine  Inflammation  of  Ovarian  Tissues.  He 
has  done  19U  such  operations  to  date  without  a  failure,  six 
cases  of  intrauterine  inflammation  of  the  ovary  being  in- 
cluded. In  almost  all  the  cases  some  other  work  was  per- 
formed in  addition  to  the  work  on  the  ovary.  He  cannot  be- 
lieve that  because  a  woman's  ovaries  are  gone  she  should 
also  lose  her  womb.  The  age  of  the  patient  and  her  social 
position,  her  previous  history,  the  patient's  wishes,  and  the 
diseased  condition  of  the  ovaries  found  will  all  influence 
the  operation.  Only  young  women  are  open  to  the  opera- 
tion. The  hard  working  woman  is  not  a  suitable  case. 
'1  he  history  of  a  hereditary  taint  of  syphilis,  tuberculosis, 
or  other  disease,  would  debar  the  operation.  Uterine  gon- 
orrheal infections  and  fibroidal  conditions  greatly  distorting 
the  uterus  would  prevent  conservative  work.  One  hundred 
and  thirty-seven  cases  of  the  190  are  cured,  and  only  42 
have  not  been  heard  from.  Twenty-eight  pregnancies  have 
followed  the  operation.  He  uses  a  tine  doss  silk  which  can- 
not be  bought  at  an  instrument  store.  He  does  not  use  cat- 
gut, nor  does  he  employ  the  thermo  or  galvanocautery.  Hs 
lias  had  no  case  of  ovarian  suppuration.  The  dangers  of 
ovarian  transplantation  are  three-fold;  the  implantation 
of  diseased  tissue;  the  development  of  ovarian  cystomata 
from  this  tissue;  and  the  development  of  an  abdominal 
pregnancy.  He  modifies  the  technique  as  follows;  He 
implants  the  ovarian  structure  attacked  to  its  own  liga- 
ments into  the  horn  of  the  uterus  and  stitches  the  graft 
su  that  the  ovarian  tissue  is  dependent  inside  the  uterus. 
(I'oldspohu,  of  Chicago,  would  never  use  any  suture  material 
upon  the  ovary  that  is  not  absorbable.  Golfe,  of  New- 
York,  prefers  doing  his  conservative  work  on  the  ovaries 
and  tubes  through  the  vaginal  vault. 

Dr.  Howard  A.  Kelly,  of  Baltimore,  presented  a  magic 
lantern  exhiuitionof  The  Various  Incisions  Appropriate  to 
the  Different  Renal  Operations.  He  showed  the  best  in- 
cisiou  for  suspension  of  the  kidney,  and  that  when  the  kid- 
ney is  enlarged  and  its  enucleation  liable  to  be  attended 
wiih  ditticulty.  Also  the  method  of  removing  the  kidney 
with  itb  ureter.  The  author's  plan  of  nephroureterectomy 
wilhout  division  of  muscular  fibers  avoids  the  extensive 
wouml  and  the  weakening  of  the  abdominal  wall  following 
the  long  incision  from  the  back  down  to  the  symphasis 
pubis,     fie  makes  two  incisions  instead. 

THIRD  DAY.  JUNE   Gth,   lUOl. 

Dr.  Emil  Ries.  of  Chicago,  read  a  paper  on  A  New  Opera- 
tion for  Retrodisplacement  of  *-ie  Uterus.  He  remarked 
that  shortening  of  the  round  ligament  met  with  consider- 
able favor  in  this  country  and  abroad.  Shortening  of  the 
ulero-sacral  ligament  was  not  received  with  favor.  The 
vaginal  operation  which  he  novv-  does  will  preserve  the 
mobility  of  the  uterus  and  will  not  depend  on  seroserous 
adhesions  nor  interfere  with  the  function  of  the  tube.  Jan- 
uary 13,  1S99,  he  operated  on  his  first  case.  Since  then  he 
has  operated  20  times.  The  patient  is  placed  in  the  lithot- 
omy position,  the  anterior  lip  of  the  cervix  is  seized  with 
vulsellum  forceps,  and  an  incision  made  in  front  of  the 
cervix  extending  up  to  the  uterus.  The  vault  is  then 
opened  posteriorly,- the  fundus  of  the  uterus  is  drawn  down 
into  the  vagina,  and  the  appendages  are  operated  upon, 
and  whatever  is  left  is  returned.  After  this  vaginal  celeot- 
omy  is  performed,  his  special  operation  is  done.  The 
round  ligament  is  detached  for  4  to  5  cm.,  and  a  long  cat- 
gut suture  passed  through  the  ligament  and  then  around 
the  ligament.  The  thread  is  left  long,  and  the  needle  re- 
mains attached.  The  same  is  done  on  the  other  side.  An 
incision  or  tunnel  is  now  made  across  the  uterus  from  one 
to  the  other  round  ligament,  midway  between  the  mucous 
and  serous  surfaces.  .After  this  tunnel  is  formed  a  curved 
artery    forcep   is    passed    through,   grasps   the   needle   and 


thread  on  that  side  and  pulls  them  through  to  the  opposite 
side.  The  same  is  done  with  the  other  thread.  Thus  far 
no  traction  has  been  made  upon  the  ligaments.  The 
thread  only  passed  through  the  tunnel  on  the  anterior  sur- 
face of  the  uterus.  The  fundus  is  now  pushed  back  into  the 
peritoneal  cavity  and  the  threads  are  pulled  upon,  where- 
upon the  ligaments  pass  through  the  tunnel.  They  are  thus 
shortened  the  length  of  the  tunnel  or  more.  They  pass 
through  a  raw  surface  so  that  adhesions  form  quickly  and 
the  ligaments  are  held  in  their  new  position.  The  periton- 
eum of  the  bladder  is  stitched  to  the  peritoneum  of  the 
uterus  by  catgut  and  a  vaginal  wound  is  then  sutured.  The 
after  treatment  is  the  same  as  after  an  ordinary  vaginal 
celeotomy.  There  were  14  operations  in  1899  to  1900.  In 
all  examined  (7)  the  uterus  remained  in  good  condition. 
In  one  case  pregnancy  followed  and  the  uterus  did  not 
fall  posteriorly.  Dr.  Franklin  H.  Martin,  of  Chicago,  read 
on  the  Surgical  Treatment  of  Retroversion  of  the  Uterus. 
He  gave  a  short  historical  sketch  of  Alexanders  operation. 
The  troubles  arising  from  suture  material  have  been  the 
cause  of  the  numerous  modifications  of  the  Alexander  op- 
eration. He  then  described  his  operation  for  this 
condition  which,  he  claims,  is  superior  to  all  others 
because  it  Insures  a  uniform  shortening  and  firm  fixation 
of  the  ligaments  w-ithout  ligatures,  and  hence  without  the 
formation  of  fistulous  tracts.  It  seldom  causes  pain  at  the 
traction.  He  has  performed  61  cases  up  to  September  29. 
1900,  with  7  cases  of  pregnancy,  6  of  which  passed  through 
a  normal  labor,  and  one  aborted  without  apparent  cause. 
Martin  then  gave  a  historical  sketch  of  the  operation  of 
ventral  suspension  which  he  states  was  first  practiced  by 
Olshausen  and  then  by  Kelly.  If  the  suspension  is  accom- 
panied by  an  absorbable  suture  the  operation  will  often 
fail.  Fow-ler's  suggestion  of  suspending  the  uterus  from 
the  urachus  was  a  distinct  advance.  Martin  prefers  to 
use  a  strip  of  peritoneal  tissue  which  is  not  so  firm  as  the 
urachus,  also,  the  urachus  may  be  absent  or  in  some  cases 
it  remains  pervious  from  the  bladder-end.  He  has  done 
173  operations  by  his  method  of  suspension  by  peritoneal 
strip.  No  permanent  buried  sutures  are  required.  The 
abdomen  is  opened  in  the  Trendelenburg  position,  the  uter- 
us is  freed  and  also  the  posterior  surface  of  the  broad  liga- 
ment. The  uterus  is  then  brought  forward  and  a  strip 
of  peritoneum  is  dissected  free  from  the  abdominal  wall 
one-half  inch  wide  and  three  inches  in  length.  A  needle 
is  passed  through  the  uterus  at  the  fundus  from  behind 
forward.  The  strip  of  peritoneum  is  grasped  and  drawn 
through  and  the  free  end  sutured  by  small  catgut  sutures 
to  the  peritoneal  surface  of  the  abdominal  wound  above  the 
uterus.  The  uterus  is  also  temporarily  held  forward  by 
small  catgut  sutures.  In  173  cases  there  have  been  9  fail- 
ures including  six  deaths.  Goffe,  of  New  York,  remarked 
that  a  misconception  of  the  dynamics  of  the  female  pelvis 
is  the  cause  of  much  of  the  wrong  treatment  of  retrodis- 
placement. The  symphysis  pubis  is  on  a  lower  level  than 
the  tip  of  the  coccyx  in  the  normal  condition.  The  uterus 
lies  on  its  anterior  face  and  is  held  in  place  by  its  liga- 
ments.   The  perineum  is  not  a  support. 

The  most  important  ligamentous  support  are  the  utero- 
sacral  ligaments  plus  the  utero-vesical  ligaments.  The 
ideal  operation  for  the  restoration  of  the  uterus  to  its 
normal  position  is  by  means  of  the  utero-sacral  ligaments. 
If  these  cannot  be  used  the  round  ligaments  are  next 
best,  and  then  ventral  suspension.  He  is  opposed  to  the 
operation  which  involves  opening  of  the  abdominal  w-all 
for  the  cure  of  retroversion.  He  denounces  Alexander's 
operation  in  toto.  Gordon,  of  Maine,  protested  against 
this  so-called  conservative  surgery.  After  removal  of  the 
appendages  the  uterus  is  a  gestation-bag  without  sub- 
sequent use.  He  would  therefore  remove  the  uterus  in 
these  cases.  Goldspohn,  of  Chicago,  claimed  that  the 
round  ligaments  are  the  only  structures  that  can  be  ra- 
tionally used  for  the  cure  of  this  condition,  because  they 
are  p;trt  of  the  uterus.  The  uterus  has  "arms,"  and  these 
arms  should  be  used.  The  round  ligaments  are  wedge 
shaped,  longer  near  the  uterus  than  at  the  abdominal  wall. 
When  the  round  ligaments  are  folded  upon  themselves  the 
thick  part  is  used  and  the  weak  part  left.  Alexander's 
operation  is  better  because  It  does  away  with  the  weak 
position  of  the  ligament.  Kelly,  of  Baltimore,  claimed 
that  the  ventral  suspension  was  more  rational  than  the 
operation  of  shortening  the  round  ligaments.  These  liga- 
ments, in  tile  normal  condition,  are  always  flaccid  struc- 
tures, with  a  kink  in  them.  He  has  performed  214  ventral 
suspensions.     43   of   the   patients    became   pregnant   with- 


1138 


The  Philadelphia"] 
Medical  Jocbnal  J 


SOCIETY  REPORTS 


[June 


1901 


out  trouble  following.     In  most  cases  the  uterus  remained 
in  good  position.     A  symposium  on  Obstetrics  was  opened 
by    Dr.   Joseph    Price,    of   Philadelphia,    whose    paper   was 
entitled  Obstetrics  as  a  Specialty.     Dr.   E.  Gustave  ZInke, 
of  Cincinnati,   followed  with  a  paper  on  The   Practice   of 
Obstetrics  as  It  is  and  as  it  should  be,  in  which  he  dwelt 
on    the   value   of   antisepsis   and    asepsis,    the   differences 
experienced  in  the  management  of  labor  at  the  home  of 
patients  versus  the  management  of  labor  in  lying-in  hos- 
pitals.    The  inadequency  of  obstetrics  fees  was  then  con- 
sidered and  the  very  important  question  as  to  whether  or 
not  the  training  and  practice  of  midwives  should  be  en- 
couraged.    Dr.  J.   F.   Moran,  of  Washington.  D.  C,  in  his 
paper   on    The    Prophylaxis    and    Treatment    of    Puerperal 
Sepsis,  made  a  bacteriologic  and  pathologic  study  of  puer- 
peral  sepsis   and   the   noi-mal   and   pathologic   vaginal   se- 
cretions before  and  after  labor.     He   reviewed   the  ques- 
tion of  the  treatment  of  puerperal  sepsis  including  the  un- 
satisfactory  results   obtained   from   the   antitonic   serums. 
Dr.  H.  D.  Fry,  of  Washington,  D.  C,  presented  a  paper  on 
The  Indications  and  Contraindications  for  the  Use  of  the 
Curette  in  Obstetric  Practice,  in  which  he  emphasized  the 
great  harm  that  results  from  the  too  indiscriminate  use 
of  the  curette.     He  believes  that  as  a  rule  there  is  too 
much    interference   with    the    uterus    in    puerperal    fever. 
The  curette  should  not  be  used  until  the  indications  are 
marked,   as   a   putrid   discharge   from   the   uterine   cavity, 
with  an  escape  of  a  grumous  material.     Dr.  W.  D.  Porter, 
of  Cincinnati,  in  his  paper  on  Position  of  the  Patient  dur- 
ing Delivery,  claimed  that  the  usual  obstetric  position  was 
an  unfortunate  and  even  bad  position  for  the  patient  to 
oc  upy.     He  favors  placing  the  patient  across  the  bed  on 
a  Kelly  pad,  with  the  hips  projecting  well  over  the  edge 
of  the  bed.     This  increases  the  size  of  the  conjugate  and 
renders  the  patient  easy  of  access  for  whatever  obstetric 
manipulation    or    operation    that    may    be    required.      Dr. 
George  J.  Engelmann,  of  Boston,  read  a  paper  on  The  In- 
creasing  Sterility  of  Annerican  Women,  on  which  he  made 
the  statement  that  the  percentage  of  sterility  in  the  United 
States   is   higher   now   than   that   reported    in    any   other 
ccuulry,    the    percentage    of   miscarriage    and    divorce    is 
likewise  higher,  while  that  of  fecundity  is  lower  than  in 
any  ether  country.     In  the  one  century  that  has  passed 
the  positions  of  American   women  as  regards   the  repro- 
ductive  function   have   been   relegated    from   that   of   pre- 
eminence to  one  inferior  to  that  of  women  of  all  other 
countries.     Sterility,  one  hundred  years  ago  the  least,  is 
now    the    greatest,    and    this    with    miscarriage,    have    in- 
cieased  as  gynecological  scienc-e  has  progressed.     Twenty 
per    cent,     of    miscarriages    are    now     sterile,     while    j. 
century     ago     only     2%     were     sterile.       The     fecundity 
one    hundred     years    ago     was     6     children     to    a     fam 
;iy;   now  it  is  not  two  children  to  a  family.    The  causes 
are  moral  rather  than  medical.     The  sterility  in  graduate- 
from  female  colleges  is  33%.     Greater  luxury  goes  han-J 
in  hand  with  higher  sterility.     The  European  general  fo- 
cundily    is    4.5%;    Ftench    Canadian    9.1%:    the    Colonial 
period  of  this  country  6%;   at  the  close  of  the  Eighteenth 
century  4V-i%;    now   in  this  country   1.8%   to  2%  and  for 
college   graduates   1.4%.     Miscarriage  occurs  once  to  5^ 
labors  at  full  term  according  to  the  books. 

In  Europe  it  occurs  once  to  3.3  labors  and  in  this 
country  once  to  2.8  labors.  Duff,  of  Pittsburg,  considers 
this  a  irost  important  subject.  He  remarked  that  civil- 
ili/.atiou  and  Christianity  increases  sterility.  We  are  past 
becoming  a  nation  of  abstinence,  and  herein  lies  the 
trouble.  Dr.  W.  H.  Nathan,  of  Louisville,  read  a  paper 
on  ectopic  gestation,  and  presented  some  specimens,  one 
oi  which  he  believed  to  be  ovarian  in  nature.  As  re- 
gards the  treatment  of  this  accident  before  rupture  he 
thinks  that  vaginal  method  is  preferable;  also  after  rup- 
tuie  when  the  blood  is  confined  between  the  broad  liga- 
ment layer  or  in  the  pouch  of  Douglas;  and  in  intraabdom- 
inal rupture  when  there  is  but  little  hemorrhage.  In  all 
other  conditions  the  suprapubic  method  should  be 
adopted. 


SECTION  ON  OPHTHALMOLOGY. 

FIRST  DAY,  JUNE  4th,  1901. 

The  meeting  was  called  to  order  at  2  P.  M.  by  the  Chair- 
man oi  the  Section,  Dr.J.A.  Lippincott,  of  Pitlsburg.Pa.  His 
address  embraced  a  historical  retrospect  of  ophthalmology 
and  the  achievements  of  Von  Graefe,  Donders,  Helmholiz, 
and  others.  He  called  attention  to  the  problems  still  to  be 
solved  in  the  treatment  of  the  extrinsic  ocular  muscle, 
heterophoria,  and  strabismus;  also  the  changes  produced 
by  toxic  agents.  He  referred  in  his  address  to  the  fiftieth 
anniversary  of  the  Invention  of  the  ophthalmoscope  and 
the  fifty  years  of  ever-increasing  usefulness  in  ophthal- 
mology that  followed  its  introduction  into  ophthalmic 
practice. 

"Treatent  of  Strabismus;  Measures  Other  than  Opera- 
tive." By  Dr.  Edward  Jackson,  Denver  CoL  The  author 
states  that  the  operative  treatment  of  strabismus  is  less 
applicable  than  non-operative  measures.  In  order  to  bring 
about  a  perfect  cure,  some  non-operative  treatment  is 
requisite.  The  objects  in  view  are:  1.  To  bring  about  nor- 
mal innervation  of  the  muscles  concerned  in  the  move- 
ments of  the  eyeball,  by  removing  abnormal  requirements; 
2.  To  keep  the  eyes  as  far  as  is  possible  upon  the  best 
plane  of  visual  acuity,  and  to  equalize  the  efforts  that  are 
required  of  them;  3.  To  eradicate  abnormal  ways  of  using 
the  eyes,  especially  when  one  eye  is  used,  to  the  practical 
non-use  of  its  fellow ;  4.  To  develop  normal  binocular  vision. 
In  the  majority  of  cases,  treatment  should  be  instituted  as 
soon  as  the  strabismus  is  first  noticed.  The  establishment 
and  perfection  of  binocular  vision  is  the  aim  of  the  non- 
operative  treatment,  and  from  a  practical  point  of  view, 
the  correction  of  refractive  errors,  stands  pre-eminent  in 
the  treatment  of  strabismus.  The  occlusion  bandage,  con- 
stantly and  correctly  applied  in  young  children,  is  of  value. 
Intelligently  performed  skiascopy  is  essential.  Mydriatics 
are  of  no  use  unless  they  absolutely  paralyze  accommoda- 
tion. Of  the  apparatuses  employed  for  the  development  of 
binocular  vision  (.the  primary  object  being  to  induce  the 
patient  to  see  with  both  eyes  at  oncej,  Jackson  prefers  the 
fusion  tubes  of  Priestly  Smith,  and  especially  in  the  form 
shown  by  him  before  the  Section.  Next  to  these  he  prefers 
the  reflecting  stereoscope  as  modified  by  Worth.  Ordinary 
stereoscope  lenses  are  so  decentered  that  they  practically 
act  like  prisms  with  bases  out. 

"Treatment  of  Strabismus;  Operative  Measures.  Dr.  C. 
F.  Clark,  of  Columbus,  Ohio,  the  author  of  this  paper,  calls 
attention  to,  and  discusses  the  variety  of.  opinions  that 
exist  among  ophthalmologists:  1.  As  to  the  degree  01  devia- 
tion and  the  character  of  the  cases  which  they  consider 
proper  subjects  for  operation:  2.  As  to  the  age  at  which 
an  operation  should  be  performed;  3.  As  to  the  choice  be- 
tween tenotomy  and  advancement:  4.  As  to  the  amount  of 
deviation  that  may  be  safely  corrected  by  tenotomy;  5.  As 
10  whether  the  operation  should  be  confined  to  the  eye 
which  most  constantly  deviates  or  its  effect  distributed 
between  the  two  eyes  so  as  to  preserve  ocular  balance;  6. 
-Vs  to  full  correction  of  the  error  in  the  first  operation  or 
delaying  a  portion  of  the  operative  procedure  until  the 
effect  of  the  first  division  may  be  properly  established;  7. 
.\s  to  the  practicability  of  partial  or  graduated  tenotomy 
or  advancement;  S.  As  to  the  value  of  orthoptic  exercise 
before  and  after  operation:  9.  As  to  the  value  of  tests 
made  with  prisms  and  otherwise  during  the  progress  of  an 
operation;  10.  As  to  the  importance  of  the  subconjunctival 
method  of  Snellen  and  of  suturing  the  conjunctival  wound. 
11.  As  to  the  necessity  of  bandaging  one  or  both  eyes  after 
an  operation  for  tenotomy  or  advancement;  12.  As  to  the 
relative  importance  of  operations  upon  the  superior  and 
inferior  recti-muscles  in  cases  of  hyperphoria  and  h>T)er- 
tropia  associated  with  lateral  deviations,  and  13,  As  to 
the  most  approved  form  of  operation  for  tenotomy  and  ad- 
\  ancement.  The  author  predicts  that  within  a  few  years 
many  of  those  who  have  heretofore  depended  mainly  upon 
tenotomy  for  the  correction  of  strabismus  will  find  them- 
selves adopting  the  more  tedious  but  far  more  conservative 
operation  of  advancementof  resection,  almost  as  a  routine 
practice.  The  peculiar  insertion  of  the  superior  and  in 
ferior  recti  muscles  should  be  taken  into  consideration 
Whether  tenotomy  or  advancement  are  adopted,  >.ui 
operative  effect  must  be  so  distributed  among  the  various 
ocular  muscles  as  to  preserve  the  control  of  the  eyes 
in   all   ordinary   movements.     The   well-marked   heterony- 


June   15,    1901] 


SOCIETY  REPORTS 


TThe  Philadelphia. 
LMedical   Journal 


1 1 39 


mous  diplopia,  with  the  images  widely  separated,  which 
not  infrequently  results  after  carefully  performed  opera- 
tions for  convergent  strabismus  and  dependent  upon  the 
presence  of  what  is  sometimes  called  a  false  macula, 
should  not  disconcert  the  surgeon,  as  it  rarely  causes  se- 
rious disturbance,  although  it  increases  the  difficulty  in 
determining  the  result  obtained  from  the  operation.  The 
author  is  convinced  that  in  the  operative  correction  of 
squint,  advancement  or  resection  combined  with  a  very 
limited  tenotomy  ought,  as  a  rule,  be  performed  in  place 
of  a  simple  tenotomy. 

"Strabismus:    Its  Treatment."     Dr.  A.   E.   Davis,  of  New 

York  City,  read  this  paper  by  invitation.  After  consider- 
ing the  different  tests  for  strabismus,  he  states  that  it  is 
desirable  that  a  uniform  or  standard  set  of  tests  be 
adopted  for  accurately  measuring  strabismus.  He  makes 
a  plea  for  a  better  understanding,  not  only  of  the  physio- 
logical action  of  the  ocular  muscles,  but  of  physiology  in 
general,  by  those  treating  cases  of  strabismus.  He  be- 
lieves that  in  most  cases  of  convergent  squint,  the  ambly- 
opia is  acquired  and  functional,  and  only  in  rare  instances 
is  it  congenital.  As  soon  as  the  strabismus  is  observed,  the 
non-operative  treatment  is  capable  of  doing  considerable 
good.  By  means  of  this  manner  of  treatment,  if  instituted 
in  time,  forced  fixation  and  suppression  of  the  image  in  the 
s(|uinting  eye  are  prevented,  fusion  of  the  images  assisted, 
and  true  binocular  single  vision  frequently  preserved. 
About  30%  of  all  cases  of  strabismus  may  be  cured  simply 
by  the  non-operative  treatment.  As  soon  as  non-operative 
measures  cease  to  bring  improvement,  operation  should 
be  undertaken;  but  if  operation  is  delayed  after  this,  it 
becomes  not  only  useless,  but  harmful,  increasing  the  am- 
blyopia, because  the  habit  of  suppressing  the  image  in  the 
squinting  eye  persists.  He  believes  that  after  operation 
the  stereoscope,  occlusion  bandage,  bar-readijig.  glasses, 
etc.,  are  very  useful.  He  recommends  Panas  method  of 
operating  for  strabismus  as  safe,  quick  and  efficient;  but 
it  should  never  be  performed  while  the  patient's  eyes  are 
being  influenced     by  a  mydriatic. 

"The  Cosmetic  and  Visual  Results  in  Squint.  Dr.  J.  M. 
Ray,  of  Louisville,  Ky.,  the  author  of  this  paper,  believes 
that  glasses  should  be  adjusted  to  the  eyes  of  children  af- 
fected with  strabismus  as  early  as  possible,  depending  upon 
the  power  of  the  parent  to  control  the  child.  The  glasses 
should  always  be  worn  for  a  long  enough  time  to  ascertain 
their  effect  upon  convergence  before  an  operation  is  un- 
dertaken. Dr.  Kay  considers  the  use  of  the  exclusion  pad 
and  orthoptic  exercises  as  advisable  steps,  principally  for 
preserving  the  power  of  simultaneous  action  of  the  muscles 
when  the  child  arrives  at  the  proper  age  for  operation. 
Parallelism  of  the  visual  lines  does  not  mean  single  binoc- 
ular vision,  and  the  latter  is  not  present  in  more  than  7% 
of  cases  of  strabismus.  Cosmetic  results  can  be  produced 
and  preserved  when  the  power  of  fusion  is  absent,  both  in 
monocular  squint  attended  by  considerable  amblyopia  as 
well  as  in  alternating  squint.  In  the  latter  variety,  if  the 
hypermetropia  is  high,  the  chances  for  the  production 
of  parallelism  are  better  than  when  the  hypermetropia  is 
low.  The  amount  of  abduction  present  in  the  correspond- 
ing externus  influences  the  effect  of  a  tenotomy  to  a  con- 
sidei'ablo  degree.  Two  tenotomies  on  the  same  internus  is 
to  be  considered  as  bad  surgery  on  account  of  the  resulting 
sinking  of  the  caruncle  and  the  divergence  which  later 
ensues.  From  a  cosmetic  point  of  view  the  operative  cor- 
rection of  strabismus  is  not  as  simple  as  supposed,  es- 
pecially when  one  considers  the  noticeable  exophthalmos 
and  the  l)oth  inward  and  outward  limitations  of  the  ocular 
excursions  which  sometimes  follow.  A  study  of  100  cases 
during  the  past  four  years  showed  that  binocular  vision 
was  rarely  produced.  Glasses  should  always  be  tried,  but 
stereoscopic  exercises  are  of  little  value. 

Discussion:  Dr.  C.  M.  Culver,  of  Albany,  N.  Y.,  believed 
that  the  operation  for  squint  was  like  that  of  talipes,  in 
that  it  does  not  cure,  but  provides  for  a  cure.  In  order 
to  be  fair  to  the  patient,  non-operative  treatment  should 
be  instituted  before  the  operation.  Dr.  F.  C.  Todd,  of  Min- 
neapolis, Minn.,  believed  that  the  length  of  time  prevented 
the  proper  execution  of  the  non-operative  treatment,  al- 
though it  appears  that  the  patients  ought  to  be  willing  to 
take  the  time  instead  of  subjecting  themselves  to  repeated 
operations.  He  is  of  the  opinion  that  the  operation  of 
advancement  is  steadily  gaining  ground,  notwithstanding 
that  tenotomy  is  still  in  vogue.    Dr.  G.  C.  Savage,  of  Nash- 


ville, Tenn.,  discussed  the  application  of  the  terms  "con- 
vergence," "planing,"  and  "parallelism."  Dr.  A.  R.  Baker, 
of  Cleveland,  Ohio,  considers  the  bandage  not  always 
necessary,  but  often  required,  that  alternating  squint  in 
young  individuals  is  not  so  difficult  as  is  supposed,  and 
that  it  can  be  cured  by  proper  glasses  and  exercise.  Dr.  F. 
C.  Hotz,  of  Chicago,  endorses  the  distribution  of  the  opera- 
tive effect  among  the  two  eyes  so  as  to  preserve  the  har- 
monious action  of  the  muscles.  He  advocates  simple  tenot- 
omy in  mild  cases,  advancement  in  cases  of  medium  de- 
gree, and  both  in  excessive  cases.  In  alternating  squint 
of  modern  degree  simple  tenotomy  will  do  the  work  per- 
fectly well.  Dr.  D.  M.  Campbell,  of  Detroit,  Mich.,  believed 
that  the  problem  varies  according  to  the  variety  of  stra- 
bismus. A  complicated  strabismus,  such  as  a  convergent 
strabismus  and  a  turning  up  of  one  eye,  is  a  different 
problem  than  a  simple  strabismus.  Many  cases  of  con- 
vergent strabismus  may  be  cured  with  a  tenotomy,  but  a 
post-operative  divergent  strabismus  cannot  be  treated  by 
tenotomy  of  the  external  recti 

Dr.  C.  A.  Veasey,  Philadelphia,  stated  that  the  method 
employed  in  the  service  of  Dr.  de  Schweinitz.  at  the  Jeffer- 
son Medical  Hospital,  was  a  combination  of  several  of  thn 
methods  described  with  some  modifications.  The  patient 
was  first  glassed,  and  it  was  insisted  that  the  full  correc- 
tion of  the  refractive  error  should  be  constantly  worn.  The 
angle  of  squint  was  carefully  measured  from  time  to  time 
to  note  improvement.  If  the  angle  was  small  orthoptic 
exercises  with  the  stereoscope  were  employed  at  once. 
If  the  angle  was  large,  operation  was  performed  after  the 
glasses  had  produced  their  full  effect.  A  tenotomy,  alone 
or  combined  with  advancement,  was  employed.  Conver- 
gent squints  were  slightly  undercorrected  and  divergent 
squints  slightly  overcorrected  and  orthoptic  exercises  used 
at  once.  By  this  method  the  cosmetic  effect  was  not  only 
good,  but  binocular  single  vision  was  frequently  obtained. 

"Concerning  the  Check  Ligament."  By  Dr.  J.  E.  Colburn, 
of  Chicago,  111.  The  author  presented  a  composite  draw- 
ing, the  result  of  many  experiments  on  the  cadaver,  and 
demonstrating  the  orbito-ocular  and  orbito-muscular  bands 
of  the  check  ligament,  with  a  discussion  of  the  various 
groups  of  bands  and  the  function  of  the  cheek  ligament. 

SECOND  DAY,  JUNE  5th,  lUOl. 

The  morning  session  opened  with  an  exhibition  of  speci- 
mens and  now  insirumenis,  consisting  ol  opniUaimoscopes 
aua  opniualmic  liieraiure,  as  an  ouservatiuu  oi  lue  ntiieiti 
anniversary  of  tue  inveuiion  ol  the  upbtnalmoscope  toee. 
western  iNews  oi  tuis  issuej.  Ur.  H.  hrieaenwaia,  of  lial- 
uuioie,  Mu.,  read  a  paper  entitled,  "AUdress  on  tne  urigm 
tiuu  jjevoiopment  oiiue  instrument,  logetner  wuu  a 
uescnpiion  oi  tne  Historic  Exhibit  of  Ophtnalmoscopus  ana 
JruuUcaiious  on  upnihalmoscopy  Preparea  lor  tuis  ivleeL 
lug,  followed  by  an  address  on  the  lale  or  Jblelmholiz,  uy 
ur.  Casey  A.  Vvood. 

■•  1  arsddenitis  ivieibomica,"  according  to  the  definition  of 
the  aumor,,  ur.  M.  t.  Weymann,  ol  fai.  Joseph,  Mo.,  is 
iiB  follows:  'A  subacute  chronic  iniecLion  of  the  Meibomian 
glands,  tending  to  periodical  acute  exaceruaiion,  and  sec- 
ouuanly,  altering  tue  whole  structure  ol  the  tarsal  carti- 
lages, cuieuy  the  upper.  '  According  to  Weymann  chala- 
zia may  undergo  suppuration  and  chronic  inflammatory 
buflemng.  U  is  the  latter  which  gives  rise  to  the  condition 
ue  calls  larsadenitis  Meibomica.  'ine  most  pronounced 
symptoms  are  smarting  and  itching,  the  appearance  of 
■nipple  oiihces"  which  cannot  be  squeezed  to  such  an  ex- 
tent as  to  disappear,  and,  above  all,  a  peculiar  alligator- 
leather  appearance  of  the  conjunctiva  lining  the  tarsal 
cartilage. 

"Keport  of  a  Case  of  Retroflexion  of  the  Iris."  Dr.  A.  A. 
HubDeil,  of  Buttalo,  N.  Y.,  reports  a  case  of  retroflexion 
01  the  iris  in  a  laborer,  aged  5b,  who  struck  the  left  side  of 
his  head  against  a  pavement.  I'he  eyes  had  previously  al- 
ways been  healthy.  The  patient  had  sustained  a  violent 
concussion,  and  when  he  first  presented  himself  there  was 
ecchymosis  of  the  left  eyelid  and  deep  congestion  of  the 
episcleral  tissues,  but  no  pain.  The  cornea  was  slightly 
hazy,  there  was  hyphemia,  and  tension  somewhat  dimin- 
ished notwithstanding  that  there  had  been  no  laceration. 
After  treatment  the  blood  became  absorbed.  Examination 
showed  no  trace  of  the  iris,  ciliary  processes,  or  crystallue 
lens.  The  invisibility  of  the  iris  was  explained  as  due  to 
its  being  reflected  against  the  ciliary  body,  and  Hubbell 
believes  that  the  lens  was  absorbed. 


140 


The  Philadelphia 
Medical   Journa 


i^] 


SOCIETY  ri<:ports 


[June   ID,   1901 


"Treatment  of  Heterophoria:  Non-Surgical  Measures," 
by  Dr.  George  M.  Gould,  of  Philadelpliia.  The  author  of 
this  paper  concludes  from  experience  in  his  private  prac 
tice  that  there  is  no  surgical  treatment,  properly  speaking, 
of  heterophoria.  He  states  that  for  six  years  he  has  ob 
served  no  case  of  heterophoria  requiring  operation,  and 
that  he  has  obtained  no  unsatisfactory  results  when  the 
eases  were  treated  with  common  sense  instead  of  with  ihc 
scissors.  He  believes  that  in  hyperphoria  accurate  refrac- 
tion, temporary  but  partial  prismatic  neutralization,  sup 
plemented  by  ocular  gymnastics  and  the  observance  of 
ophthalmic  hygiene  constitute  the  proper  treatment.  He 
strongly  advocates  the  nonsurgical  treatment  of  exo 
phoria  as  Indicated  by  the  following  remarks:  "If  words- 
are  not  minced,  then  tendon-cutting  in  exophoria  is  positive 
malpractice."  "Surgery  is  the  despair  of  medicine,  and  we 
should  never  adopt  surgical  methods  while  there  is  a 
glimmer  of  hone  by  natural  means  in  the  direction  indi 
cated  by  the  subtle  and  adherent  strivings  for  normality." 
The  other  ocular  insufflciencies  were  also  discussed  by 
him. 

"Treatment  of  Heterophoria:  Surgical  Treatment."  Dr.  (I 
C.  Savage,  of  Nashville,  Tenn.,  believed  that  no  operation 
should  be  done  in  cases  of  heterophoria  intrinsic  in  char 
arter  where  gymnastic  exercises,  even  if  required  for  a 
long  time,  would  cause  relief.  The  two  objects  in  view  in 
operating  on  eye  muscles  are  the  alteration  of  the  muscu 
lar  tension  and  the  change  of  plane  of  action.  The  exist- 
ence of  a  cyclophoria  should  be  first  excluded.  In  no  variety 
of  heterophoria  should  a  complete  tenotomy  ever  be  per- 
formed. The  plane  of  a  muscle  should  never  be  alterer) 
unless  a  correction  of  cyclophoria  is  required.  Cyclophoria 
may  be  present  alone,  and  so  high  as  to  require  operative 
relief  which  is  accomplished  by  operating  upon  both  supe- 
rior or  Inferior  recti  muscles.  He  describes  the  various 
operations  for  sthenic  and  asthenic  forms  of  heteroiJhorii! 
with  their  various  complications. 

Discussions:  Dr.  S.  D.  Risley,  of  Philadelphia,  stated 
that  the  profession  cannot  afford  to  be  dogmatic  on  this 
subject.  He  endorses  the  conclusion  of  Dr.  Savage.  He 
called  attention  to  the  direction  of  the  orbital  planes  which 
may  be  altered  by  distortions  of  the  skull  itself.  The 
aponeurotic  pole,  the  check  ligament,  the  orbital  attach 
ments,  all  may  be  modified  by  abnormalities  of  the  condi- 
tions in  the  orbit.  Dr.  M.  F.  Weymann,  of  St.  Joseph,  Mo., 
believed  that  we  cannot  be  entirely  guided  by  a  mathe- 
matical rule  in  cyclophoric  conditions.  Dr.  D.  S.  Reynolds. 
of  Louisville,  Ky.,  called  attention  to  the  fact  that  general 
nutrition  bears  a  definite  relation  to  ametropia  and  abnor- 
mal conditions  of  the  eyeball.  Age,  habit,  loss  of  sleep, 
coffee,  etc.,  must  all  be  taken  into  consideration.  The  phy 
sical  conformations,  as  stated  by  Dr.  Risley,  are  never  to 
be  lost  sight  of.  Even  the  bones  of  the  neck,  as  well  as 
extraneous  causes,  modify  these  conditions  of  the  eye.  Dr. 
J.  E.  Colburn,  Chicago,  111.,  believes  that  errors  of  refrac- 
tion cause  pseudo-heterophoria.and  that  in  many  instances 
general  debility  itself  is  not  the  cause,  but  it  nevertheless 
unveils  many  cases  of  heterophoria.  There  is  a  neuro- 
muscular condition  which  plays  an  important  part:  It  may 
remain,  and  can  only  be  overcome  by  improvement  of  the 
general  condition.  Dr.  C.  H.  Williams,  of  Boston,  Mass.. 
before  operating  on  the  external  ocular  muscles,  always 
ascertains  the  variety  and  the  amount  of  deviation.  He 
showed  before  the  section  an  instrument  devised  by  him 
for  this  purpose.  Dr.  F.  Allport,  of  Chicago,  111.,  rarely  per- 
forms a  tenotomy  for  asthenopia,  and  rarely  prescribes 
prisms.  Good  sanitary  surroundings,  the  correction  of 
ametropia  rarely  compels  one  to  do  a  tenotomy.  Dr.  H. 
Woods,  of  Baltimore.  Md.,  is  of  the  opinion  that  school  and 
home  hygiene  has  much  to  do  with  the  treatment  of  these 
conditions.  Although  the  non-operative  treatment  some- 
times gives  remarkable  results,  some  cases  which  in  a  few 
months  do  not  yield  to  a  non-operative  treatment  require 
tenotomy.  Dr.  L.  Connor,  of  Detroit,  Mich.,  believed  that 
the  following  causes  should  be  looked  for:  1,  reflex  causes, 
as  in  nasal  disease;  2,  malnutrition  of  some  portion  of  the 
eye  so  that  the  muscles  are  unable  to  perfcu-ni  their  func- 
tions, as  is  the  case  with  muscles  in  any  other  portion  of 
the  body:  3,  physiological  lack  of  power;  4,  anatomical  de- 
tects.    When  we  have  definitely  determined  that  anatomi- 


cal defect  is  the  cause,  operation  Is  the  only  procedure. 
The  influence  on  the  patient  by  the  operator  and  also  the 
I  fleet  of  the  operation  itself  frequently  benefit.  Dr.  A.  E. 
Davis,  of  New  York  City,  stated  that  it  is  not  only  the  mus- 
rjes.  but  nerves  that  should  be  considered. 

"Table  of  Paralysis  of  Ocular  Muscles,"  by  Dr.  H.  M. 
Starkey,  of  Chicago,  111.  The  author  of  this  paper  pre- 
sented a  table  reviewing  the  nomenclature  of  the  asso- 
ciated movements  of  the  eye,  the  muscles  producing  these 
movements  and  a  delineation  of  the  law  of  projection 

In  the  discussion.  Dr.  F.  C.  Hotz,  of  Chicago,  called  at- 
tention to  the  difliculty  which  is  frequently  encountered 
in  teaching  the  paralyses  of  the  ocular  muscles.  Too 
much  stress  is  laid  on  describing  the  paralysis  of  each  in- 
dividual muscle,  instead  of  practically  emphasizing  promi- 
nent combination  of  symptoms.  Dr.  W.  Wilder,  of  Chicago, 
i.elieved  that  the  difiiculties  are  not  in  ocular  paralysis, 
I'Ut  in  paresis  where  there  is  not  much  diplopia. 

The  Extraction  of  Hard  Cataract  Without  Iridectomy  by 
Dr.  S.  D.  Risley,  of  Philadelphia.  Until  recently  Risley  has 
performed  cataract  extraction  by  the  combined  method, 
hut  prompted  by  the  favorable  report  of  other  ophthalmic 
surgeons,  has  in  selected  cases  adopted  the  method  of  sim- 
jile  extraction.  The  requisites  for  the  selection  of  such  a 
case  are  the  absence  of  any  special  pathological  history. 
the  absence  of  pronounced  disease  of  the  uveal  tract,  an 
iiis  w-hich  reacts  promptlj'.  a  pupil  which  is  readily  re- 
sponsive, and  dilates  to  at  least  a  moderate  degree  under 
a  mydriatlc.and  a  ripe  cataract.  He  describes  the  operation 
in  detail.  After  the  last  sterilization  of  the  eye  he  instills 
:i  solution  of  salycylate  of  eserine.  He  states  that  this 
maintains  for  an  hour  or  more  the  contraction  of  the  pupil 
;ind  diminished  the  chances  of  prolapse  during  the  most 
critical  period  of  convalescence.  After  this  atropine  is  re- 
sumed. He^  prefers  to  trust  to  the  absorption  of  small 
remnants  of  cortex  rather  than  risk  rupturing  the  suspen- 
sory ligament  by  continuous  efforts  to  remove  the  debris 
by  manipulation  and  irrigation  of  the  anterior  chamber. 
He  appends  a  table  of  cases  showing  the  notes  of  the  opera- 
tion, the  description  of  convalescence,  the  complications. 
and  the  vision. 


THIRD  DAY,  JUNE  6th,  1901. 
The  first  paper  read  was  by  Dr.  H.  V.  Wuerdemann.  of 
Milwaukee,  Wis.,  on  Economic  Limitations  of  the  Visual 
Acuity  in  the  Various  Trades  and  Professions.  The  mean- 
ing of  blindness  as  used  in  daily  life  is  a  much  narrower  one 
than  is  embraced  in  the  scientific  term.  It  has  been  deter- 
mined that  ordinary  coarse  work  like  that  of  a  common 
laborer  does  not  require  more  than  one-half  of  the  normal 
for  a  condition  of  success,  but  on  the  other  hand  a  corres- 
ponding diminution  in  the  vision  of  a  skilled  mechanic 
would  so  decrease  the  clearness  of  the  retinal  impres- 
sions to  which  he  has  been  accustomed  in  the  performance 
of  his  duties,  as  to  seriously  hamper  him.  Individual  mem- 
bers of  certain  occupations  do  not  have  the  same  visual 
demands  exacted  from  them.  Dr.  Wuerdemann  divides  the 
occupation  into  two  groups.  The  occupations  requirins 
higher  degrees  of  visual  acuitv  and  a  range  from  0.75  to 

0  l.'i  are.  medicine,  theology,  law.  art.  engineering,  students 
cif  all  professions,  fine  mechanics,  iron  and  steel  workers. 

1  oiling  mill  workers,  machinists  and  metal  workers,  musical 
instrMment  makers,  the  linen  industry,  the  textile  industry. 
the  silk  industry,  paper  workers,  leather  workers,  garment 
makers,  printers,  marine  employes,  mine  workers,  railway 
and  steamship  employes  (including  city  roadsl.  soldiers 
nnd  sailors,  telegraph  operators  and  skilled  labor  generallv. 
nroup  2.  The  trades  requiring  lower  degrees  of  visual  acu- 
ity and  a  range  from  O.RO  to  o.o.^  are.  glass  Mowers,  mineral 
workers,  quarry  men.  builders,  pottery  makers,  brick  mak- 
ers, workers  in  the  chemical  industries,  employes  in  gas 
and  water  works,  paper  makers,  wood  workers,  mill  em- 
ployes, manufacturers  of  food  articles,  sugar  factory  em- 
ployes, brewers  and  maltsters,  tobacco  workers,  chimnev 
sweepers,  street  railway  employes  (horse  cars!  employes  of 
elevators  and  wine  cellars,  teamsters,  bargemen  on  inland 
waters  (rivers,  etc.t.  farmers,  dav  laborers,  unskilled  labor. 
etc.  The  author  compiled  a  table  showing  the  scientific 
standard  of  the  visual  acuity  converted  into  economic 
terms. 

There  was  then  a  report  of  the  railway  committee 
of  the  ophthalmic  section  of  the  American  Sledical  Associa- 
tion by  the  Chairman.  Dr.  Allport,  of  Chicago,  HI.,  followed 


June  ir,,  moij 


SOCIETY  REPORTS 


TThb  Philadelphia 
L  Medical   Journal 


I  141 


liy  Jir.AlIport.  who  rearl  a  paper  entitled     Furihsr     Report  on 
the  Visual  and  Aural  Qualifications  of  Transportation   Em- 
ployees.     The   autlior   obtained    statistics    from    numerous 
railroads  concerning  this  subject  and  shows  tlie  statistics 
and      answers  to     the     question.     "Do     you     require     ex- 
amination   from  time   to   time,    and    if   so,   at   what   inter- 
vals,   or    under    what    circumstances?"      Do    you    require 
perfect  vision,  color  sense  and  hearing  in  new  employes, 
and  what  concessions  do  you  permit  from  a  perfect  stand- 
ard in  the  case  of  old  employes?"     "Do  you  permit  old  em 
ployes  to  wear  glasses  while  on  duty?"     He  found  that  out 
iif  112  rovds  reported.  77  required  some  kind  of  systematic 
I've    and    ear    examination    of    those    employes     actively 
engaged  in  running  trains  and  in  giving  and  receiving  sig 
nals.     Twenty-nine  of  these  roads  required  such  examina- 
tions to  be  made  by  regularly  appointed  railway  surgeons: 
thirty-one  allowed  various  kinds  of  instructed  railway  em 
ployes   to    make    examinations;    nine   roads    sent   doubtf\iI 
cases  to  an  eye  and  ear  surgeon;  sixteen  required  examiua 
lions  to  be  made  by  regularly  appointed  eye  and  ea«    sur 
geons;   four  allowed  such  examinations  to  be  made  oi;  the 
medical  director  of  railway  relief  associations.  f 

Mules'  Operation,  with  Cases.     The  author  of  this  paper, 
Dr.    Frank    C.    Todd,   of   Minneapolis,    Minn.,    called  Aitten 
tion  to  the  various  operations  employed  as  substitu'es  for 
enucleation    and    called    attention    to    the    operations    of 
M\iles.    Frost   and    Lang.      The    failures    in    Mules'    opera 
tion  are  due  to  escape  of  the  globe,  sympathetic  inflamma 
tion.  and  irritable  stump.    He  quoted  the  valuable  statistics 
of  Dr.  G.  E.  de  Schweinitz  on  this  subject.  Among  the  condi- 
tions causing  failures  and  especially  escape  of  the  globe 
are:      Hemorrhage,  sepsis  with  consequent  sloughing,  im 
perfect  or  non-coaptation  of  the  sclera,  not  enough  sutures 
and  the  too  early  wearing  of  a  prosthesis.    Moist  dressinK.=. 
are  not  advisable,  as  they  promote  suppuration.     He  steri- 
lizes the  ball  in  hot  water,  carefully  examines  it  as  to  size 
and  admissibility  into  the  scleral  cup.     There  is  so  little 
vascularity  of  the  sclerotic  coat,  that  union  does  not  very 
easily  take  place.    It  is  best  to  wait  a  month  before  employ 
ing  a  prostlaesis. 

Discussions. — In  the  absence  of  Dr.  Fox,  of  Philadelphia. 
Dr.  F.  Allport,  of  Chicago,  111.,  opened  the  discussion.  He 
stated  that  ophthalmic  surgeons  are  usually  anxious  to 
completely  fill  the  scleral  cup  while  a  slack  of  scleral  tissue 
should  be  left.  He  never  uses  a  large  globe.  He  inserts 
plenty  of  stitches  into  the  sclera,  not  a  certain  definite 
number,  but  as  many  as  the  sclera  will  hold.  He  follows 
the  suggestion  of  Dr.  Prince,  of  Springfield,  111.,  by  swab- 
bing out  the  scleral  sac  with  95%  carbolic  acid  followed 
immediately  by  alcohol.  He  waits  until  hemorrhage 
has  practically  ceased  before  inserting  the  glass 
globe  and  controls  the  hemorrhage  by  very  hot 
bichloride  solution  and  then  wipes  out  the  scleral  cup 
with  iodoform  gauze.  He  does  not  like  the  aluminum 
globe,  neither  does  he  use  adrenalin  on  account  of  its  reac 
tionary  results.  Dr.  M.  Black,  of  Denver,  Col.,  has  aban- 
doned Mules'  operation,  and  has  used  the  Snellen  eye  with 
just  as  good  results.  He  prefers  even  filling  the  scleral  cup 
with  wax  and  thus  believes  that  all  the  disadvantages  re- 
sulting from  a  Mules'  operation  are  removed. 

The  Inverted  Image  and  Mirror  Writing.  This  paper  was 
read  by  Dr.Hale,  of  Chicago,  whose  name  was  omitted  form 
programme  by  mistake.  The  author  discussed  the  various 
theories  advanced  concerning  the  inversion  of  the  image 
and  mirror  writing.  He  states  that  the  theory  that  the 
image  is  transmitted  by  a  special  fibre  to  the  brain,  and 
that  the  upper  portion  of  the  retina  was  depicted  on  the 
corresponding  lower  portion  of  the  brain  and  vice  versa. 
cannot  be  accepted  either  by  physiologists  or  psychologists. 
While  the  phenomena  of  vision  are  well  known,  the  repro- 
duction of  the  visual  impressions  is  what  particularly 
interests  us.  Mirror  writin.g  is  not  a  pathological  process, 
per  .w,  but  is  frequently  found  in  healthy  children.  Mirroi 
writing  especially  has  been  more  studied  in  the  motor 
sense  than  in  the  psychical  sense.  The  adult  mind  has 
ai?quired  how  to  associate  tactile  sensation  with  visual  im- 
pressions as  is  exemplified  by  difilcult  movements  that  can 
be  co-ordinately  made  before  a  looking-glass.  The  paper 
was  treated  throughout  with  due  regard  to  physiological 
and  psychological  factors.  The  paper  was  discussed  by 
Drs.  Savage,  Weymauu  and  Hale. 

Report  of  Two  Cases  of  Orbital  Surgery  by  Dr.  Adeline 
rortnian.  Tlic  papci'  ccunprisi'd  a  rejiort  of  the  insertion 
of  a  glass  IkUI  into  the  orbit  sometime  after  the  enucleation 


of  the  eye.  Also  a  case  of  transplantation  of  mucous  mem- 
brane into  the  orbit  for  cicatricial  deformity,  following  a 
burn. 

The  Newer  Pathology  of  the  Retina,  with  Special  Refer- 
ence to  the  Changes  Produced  in  the  Ganglion  Cells  by 
Certain  Toxic  Agents,  by  Dr.  H.  Friedenwald,  of  Baltimore. 
Md.  The  paper  embraced  the  consideration  of  the  various 
patluilogical  clianges  caused  by  toxic  agents  and  the  mi- 
croscopical appearances  described  by  Nissl.  as  well  as 
original  investigations  upon  animals  made  by  the  author  by 
feeding  them  with  toxic  substances. 

Atrophy  of  the  Retina  by  Dr.  D.  S.  Reynolds  of  Louis- 
ville. Ky.  The  author  reports  two  cases  of  atrophy  of  the 
retina  uuassociated  at  first  with  ophthaltuoscopic  changes. 
In  one  case  beginning  with  headache,  failing  of  vision,  loss 
of  color  perception,  and  latter  progressive  contraction  of 
the  lield  with  central  scotomata.  The  patient  at 
last  could  not  recognize  any  objects.  The  second  case  be- 
gan with  failing  of  vision  that  no  glasses  woiild  improve, 
and  later  on  contraction  of  the  field  and  central  scotomata 
and  atrophy  of  the  retina. 

A  Case  of  Blindness  Due  to  Drinking  Bay  Rum  Compared 
with    Reported  Cases   Due  to   Methyl   Alcohol   and  Jamaica 

Ginger.— Dr.  H.  M(uilton  of  Fort  .Smith.  Ark.,  the  author  of 
tills  iiaper.  reported  twelve  cases  of  methyl  alcohol  ambly- 
r.pia  compared  with  eight  reported  cases  of  Jamaica  ginger 
amblyopia,  and  identity  of  symptoms  and  ophthalmoscopic 
findings  pointed  out.  In  recently  reported  cases  of  essence 
of  ginger  poisoning  the  toxic  agent  is  wood  alcohol  or  its 
deodorized  product.  Columbian  spirits.  .lamaica  ginger  es- 
sence not  considered  poisonous  until  Columbian  spirits  came 
into  use.  Report  of  a  case  of  blindness  due  to  drinking  bay 
rum. 

Complete  Recovery  from  Double  Neuroretinitis.  Clinically 
Resembling  Albuminuric  Retinitis,  in  a  Case  of  Prolonged 
Hematuria,  with  Symptoms  of  Bright's  Disease.  Dr.  C.  A. 
Veasey.  of  Philadelphia.  Pa.  reported  tlie  case  of  a  woman, 
aged  thirty-live,  who  had  for  eight  months  persistent 
hematuria,  vertigo,  dyspnea  and  loss  of  weight.  There  was 
occasionally  edema  of  the  legs  and  moderate  cardiac  hyper- 
trophy. Ophthalmoscopic  examination  showed  the  typical 
stellate  white  figure  in  the  macular  region.  The  fields 
were  slightly  contracted  for  form  and  color,  but  there  were 
no  scotomata.  P^xamination  of  the  urine  showed  conr.id 
eralile  blood  and  albumen,  but  no  casts.  Examination 
of  the  blood  showed  mild  secondary  anemia.  The  patient 
was  placed  on  a  strict  milk  diet  and  Basham's  Mixture, 
after  which  she  gained  in  weight,  and  nine  months  from  the 
time  of  the  first  examination  no  ophthalmoscopic  signs  of 
the  disease  remained  nor  any  loss  in  visual  acuity  or  con- 
traction of  the  visual  field. 

The  Election  of  officers  was  as  follows:  Chairman,  Dr. 
Frank  Allport,  Chicago,  111.;  Secretary,  Dr.  C.  A.  Veasey 
Philadelphia,  Pa.:  dele.gates  to  the  House  of  Delegates' 
Dr.  J.  A.  Lippincott.  Pittsburg,  Pa.,  and  Dr.  H.  V.  Wuerder- 
mann,  Milwaukee,  Wis. 


SECTION   ON    NERVOUS  AND   MENTAL   DISEASES. 

FIRST   DAY,   .JUNE   4th,    I'JOl. 

H.   A.   Tomlinson,   M.   I).,   of   St.    Peter.   Minn.,   Chairman. 

Address  of  the  Chainnau:  Dr.  Tomlinson  spoke  on  the 
subject  of  The  Relation  of  Nervous  and  Mental  Diseases  to 
General  Medicine.  He  called  attention  to  the  close  rela- 
tionship between  somatic  disturbances  and  chronic  nervous 
disease,  and  stated  that  while  the  symptoms  manifested 
may  have  their  origin  in  a  destructive  or  degenerative  pro- 
cess In  some  part  of  the  nervous  system,  the  real  disease, 
upon  the  cure  of  which  the  ultimate  recovery  of  the  pa- 
tient depends,  has  its  existence  in  the  vegetative  organs. 
He  said  it  may  be  safely  asserted  that  all  disease  pro- 
ces.ses  begin  as  intoxications,  and  that  this  is  so  even 
with  chronic  degenerative  processes  in  the  nervous  sys- 
tem. During  ten  years  of  careful  observation  of  the  phen- 
omena connected  with  the  development  and  manifestations 
of  insanity,  in  more  than  three  thousand  cases,  he  has 
never  failed  to  find  intoxication;   cither  the  result  of  im- 


The  PhiijiDelphia  "1 


I  1 42       Medical  Journal 


SOCIETY  REPORTS 


[Juke   15,    Vim 


perfect  elimination,  or  failure  in  the  process  of  digestion 
and  assimilation.  Failure  in  elimination  is  most  common, 
and  involves  most  frequently  the  kidneys,  then  the  lungs 
and  skin.  Etiology  of  Paretic  Dementia:  By  Dr.  Frank  P. 
Norbury,  of  Jacksonville,  111.  He  stated  that  the  lesion 
of  paretic  dementia  is  a  diffuse  parenchymatous  atrophy 
of  the  nerve  cells,  and  partly,  at  least,  of  the  neuroglia.  The 
process  is  essentially  chronic  and  involves  more  or  less 
the  whole  of  the  cortex,  even  extending  to  the  basal  ganglia 
and  cord.  The  question  of  the  cause  of  this  now  well  recog- 
nized degeneration  is  still  in  dispute,  but  in  the  light  of  the 
accumulated  knowledge  of  to-day  we  find  syphilis  para- 
mount as  an  etiological  factor.  In  fact,  it  is  the  one  factor — 
the  primarj-  factor,  and  with  Dana  we  can  say  that  "if  there 
were  no  syphilis  there  would  be  no  paretic  dementia."  It 
is  not.  in  truth,  a  syphilitic  disease,  but  a  para-syphilitic 
disease  due  to  the  effects  of  the  syphilitic  poison.  In  an 
etioloical  study  of  about  200  cases  of  paretic  dementia, 
the  author  obtained  a  history  of  syphilis  in  fully  60%- 
His  conclusions  were  as  follows:  1.  Syphilis  is  the  chief 
factor  in  the  causation  of  paretic  dementia.  2.  Infectious 
fevers,  with  their  toxic  Influences,  are  contributing  fac- 
tors. 3.  Heredity  is  a  potent  factor.  Dr.  Sydney  Kuh,  of 
Chicago,  said  there  was  much  evidence  to  show  that 
syphilis  is  by  far  the  most  important  etiologic  factor  both 
in  paralytic  dementia  and  in  that  other  disease  which  is 
so  closely  related  to  it,  namely,  tabes.  Whether  or  not 
syphilis  is  the  only  etiological  factor  it  is  impossible  to  say 
to-day.  We  should  recollect  that  in  countries  where  syphi- 
lis is  common,  paralytic  dementia  and  tabes  are  very  rare, 
but  this  cannot  be  used  as  an  argument  either  for  or 
against  the  theory  that  there  is  a  connection  between  the 
diseases  mentioned.  Dr.  Edward  E.  Mayer,  of  Pittsburg, 
thought  the  claim  that  paretic  dementia  was  dependent  upon 
syphilis  should  be  based  upon  a  more  scientific  basis. 
Because  a  patient  with  paretic  dementia  has  had  syphilis, 
we  should  not  take  it  for  granted  that  syphilis  is  the  etio- 
logical factor.  Many  years  have  usually  elapsed  between 
the  occurrence  of  the  two  diseases,  and  the  lesions  of 
syphilis  have  not  been  found  at  post  mortem  in  cases  of 
paretic  dementia.  Symptomatology  of  Cerebral  Hem- 
orrhage: Dr.  F.  Savary  Pearce,  of  Philadelphia,  said  that 
under  the  head  of  cerebral  hemorrhage  we  include  not 
only  an  extravasation  of  blood  in  or  about  the  brain,  but 
also  thrombosis  or  emboli  producing  symptoms  of  acute 
softening:  it  is  difficult  to  differentiate  the  latter  condition 
from  a  slow  exudation  of  blood  within  the  encephalon. 
The  symptoms  of  a  typical  case  of  cerebral  hemorrhage 
are  divided  into  those  of  the  acute  stage  and  those  of  the 
later,  or  chronic  stage.  While  the  patient  may 
have  some  premonitory  signs,  such  as  dizziness, 
headache  and  dulness  of  mentality  for  some  days  or 
weeks  before  the  onset  of  the  attack,  still  it  is  the  rule 
that  he  is  feeling  particularly  well  immediately  preceding 
the  apoplexy.  The  attack,  in  the  majority  of  instances, 
occurs  during  the  sleeping  hours  of  the  night.  This  is 
probably  explained  by  the  fact  that  inhibition  generally 
is  lessened  during  the  early  hours  of  the  morning,  and 
very  likely  there  is  much  less  resistance  within  the  ence- 
phalon, thus  allowing  over-distension  of  the  cerebral  ves- 
sels, which  produces  the  "breaking  strain"  in  sclerosed 
cerebral  arteries.  If  the  hemorrhage  has  been  massive 
the  patient  will  be  found  comatose.  The  conjugate  devia- 
tion will  occur  towards  the  affected  side.  Other  symptoms 
are  the  unequal  dilatation  of  the  pupils,  te  temporary  abo- 
lition of  the  reflexes,  the  peculiar  breathing,  and  the  dif- 
ference in  the  temperature  between  the  two  sides  of  the 
body.  The  paralyzed  extremities  may  be  hyperesthetic. 
If  the  patient  is  to  recover,  the  temperature  drops  at  the 
end  of  four  to  six  hours,  the  pulse  will  become  softer,  its 
frequency  will  be  but  slightly  above  the  normal,  and  the 
flushing  and  cyanosis  of  the  face  will  disappear.  Dr.  Hugh 
T.  Patrick,  of  Chicago,  said  the  common  belief  that  cerebral 
hemorrhage  is  apt  to  occur  more   frequently   during  the 


sleeping  hours  is  not  based  on  facts  and  has  been  dis- 
proven  a  number  of  times.  Dr.  F.  W.  Langdon,  of  Cin- 
cinnati, said  he  agreed  with  the  statement  made  by  Dr. 
Patrick  regarding  the  frequency  of  cerebral  hemorrhage  at 
night.  An  attack  coming  on  during  the  sleeping  hours, 
is  more  apt  to  indicate  thrombosis  than  hemorrhage.  The 
former  accompanies  low  blood  pressure;  the  latter  high 
blood  pressure.  Dr.  John  Punton,  of  Kansas  City,  referred 
to  the  importance  of  coma  as  a  prognostic  condition  in 
cerebral  hemorrhage.  The  longer  the  duration  of  the 
coma,  the  less  chance  has  the  patient  to  recover.  The 
symptom  of  coma  should  also  receive  more  attention  in 
studying  cerebral  hemorrhage  from  a  surgical  standpoint. 
Dr.  Punton  called  attention  to  the  fact  that  hemorrhage 
of  the  brain  not  infrequently  occurs  much  earlier  in  life 
than  formerly.  The  text-books  teach  that  it  is  a  disease  oc- 
curring rather  beyond  middle  life,  usually  between  50  and 
60.  The  speaker  said  he  had  seen  several  cases  which 
occurred  between  the  ages  of  30  and  35  years.  What  can 
be  done  for  the  Epileptic  in  a  Medical  Way?  Dr.  Robert  H. 
Porter,  of  Chicago,  presented  a  paper  with  this  title.  He 
said  that  the  utter  hopelessness  with  which  the  epileptic  is 
usually  regarded  has  retarded  very  much  the  proper 
study  and  treatment  of  the  disease.  A  thorough  and  care- 
ful examination  of  the  patient  should  be  made  in  every 
case,  in  order  to  discover,  if  possible,  the  primary  origin 
of  the  disease,  the  exciting  cause  and  any  complications 
that  may  exist.  The  speaker  said  he  favored  the  theory 
that  the  primary  origin  of  idiopathic  epilepsy  was  due  to 
a  degeneration  of  the  cells  of  the  central  ner\-ous  system, 
resulting  from  impaired  nutrition.  When  these  brain 
cells,  with  their  impaired  or  perverted  nutrition,  are  excited 
or  greatly  stimulated,  they  produce  incoordination  or  per- 
verted functional  activity.  Dr.  Porter  next  referred  to 
the  strong  physical  element  present  in  some  cases  of  epi- 
lepsy. Whatever  serves  to  stimulate  the  brain  circulation, 
such  as  excitement,  worry,  hard  study  or  close  mental  ap- 
plication usually  increases  the  severity  and  frequency 
of  these  attacks.  Remedies  that  stimulate  the  brain  or 
produce  an  increase  in  the  blood  pressure  generally  have 
the  same  effect.  On  the  other  hand,  the  various  measures 
that  diminish  the  brain  circulation  and  reduce  the  blood 
pressure  aid  greatly  in  controlling  the  seizures. 

In  the  treatment  of  epilepsy,  the  speaker  said,  it  is  a  well 
known  fact  that  a  mental  impression  is  often  sufficient  to 
arrest  the  convulsion,  even  in  the  worst  cases.  Dr.  L,am- 
bert  Ott,  of  Philadelphia,  said  he  had  listened  to  Dr.  Por- 
ter's paper  with  rapt  attention,  hoping  to  hear  of  some  new 
remedy  for  epilepsy,  but  he  was  disappointed.  The  speaker 
said  that  after  a  large  experience  with  this  disease  he  had 
come  to  the  conclusion  that  we  possess  absolutely  no 
remedy  which  cures  epilepsy,  and  we  have  but  one  which 
influences  the  epileptic  seizures  decidedly,  and  that  is  the 
bromide  of  potassium.  Dr.  Kuh  said  that  various  theories 
have  been  advanced  regarding  the  cause  of  the  epileptic 
seizure,  but  the  subject  is  still  in  doubt.  The  experiments 
that  have  been  made  have  given  absolutely  conflicting  re- 
sults. Some  claim  that  hyperemia  of  the  brain  is  the 
cause;  others,  anemia.  Dr.  Riggs  said  that  while  a  dis- 
cussion of  the  subject  of  epilepsy  was  a  good  field  for 
mental  gjmnastics,  it  was  not  vcr>-  profitable.  He  was  not 
in  sympathy,  however,  with  the  trend  of  opinion  that 
nothing  can  be  done  for  these  patients.  With  use  of  the 
bromides,  and  proper  attention  to  the  digestion  and  elimin- 
ation, as  well  as  the  correction  of  the  habits  of  life,  much 
can  often  be  accomplished.  One  cause  of  failure  in  the 
treatment  of  epilepsy  is  that  the  patients  are  not  kept  un- 
der observation  long  enough.  Dr.  S.  Savary  Pearce,  A 
Philadelphia,  said  he  believed  in  the  general  systemic  treat- 
ment of  epilepsy,  and  the  correction  of  all  reflex  causes  of 
irritation.  The  speaker  said  that  in  a  number  of  cases 
during  the  past  winter  he  had  given  the  fluid  extract  of 
solanum  carolinense  (horse-nettle)  in  fairly  large  doses 
with  apparently  good  results.     Dr.  C.  A.  Drew,  of  Massa- 


JnNB   15,   1901J 


SOCIETY  REPORTS 


TThe  Philadklphia 
Lmedical   Journal 


1145 


chusetts,  said  he  thought  the  epileptic  seizure  was  partly 
due  to  irritants  circulating  in  the  blood.  He  did  not  regard 
the  reflexes  as  the  basal  cause  of  epilepsy,  but  he  believed 
that  all  sources  of  reflex  irritation  should  be  corrected. 
His  experience  with  bromides  has  not  been  very  encourag- 
ing. 

SECOND  PAY,  .TUNE  nth,  1901. 
The  Treatment  of  the  Acute  Psychoses  in  Private  Prac- 
tice. By  Dr.  C.  Eugene  Riggs,  of  St.  Paul.  The  essayist 
said  that  since  the  representative  medical  schools  have  in- 
troduced a  course  of  Psychiatry  as  an  essential  part  of 
their  curriculum,  the  attitude  of  the  profession  has  radi- 
cally changed  with  reference  to  insanity.  It  is  now  be- 
lieved that  no  person  ought  to  be  sent  to  an  institution  who 
is  a  suitable  subject  for  home  treatment.  Dr.  Riggs  said 
he  was  convinced,  as  the  result  of  a  large  experience,  that 
home  care  in  properly  selected  cases  (by  home  care  mean- 
ing either  in  a  private  family  or  private  hospital)  would 
materially  shorten  the  length  of  an  attack.  He  said  there 
could  be  no  question  that  the  association  of  the  insane 
with  each  other  not  only  added  greatly  to  their  suffering  as 
the  result  of  personal  contact,  but  that  auto-suggestion  in- 
tensified and  prolonged  indeiiuitely  the  morbid  mental  state. 
It  is  the  absence  of  these  conditions,  together  with  the 
opportunity  for  individualization  of  treatment  which  makes 
home  care  so  desirable  and  successful.  Dr.  Richard  Dewey, 
of  Wauwatoso,  Wis.,  said  the  general  practitioner  very  sel 
rt(mi  considers  for  a  moment  the  possibility  of  keeping 
an  insane  patient  at  home.  The  speaker  said  he  had  seen 
such  patients  who  might  well  have  been  cared  for  in  their 
own  homes  sent  away  to  institutions.  Generally  speak- 
ing, however,  such  cases  are  better  taken  care  of  in  proper 
institution  than  they  could  be  at  their  homes  or  in  general 
hospitals.  A  physician  who  has  not  had  the  opportunity 
of  studying  this  class  of  patients  is  apt  to  fail  in  appreciat- 
ing the  necessities  of  the  case.  Dr.  Punton  said  in  the 
treatment  of  any  form  of  acute  psychosis  he  is  a  firm  be- 
liever in  the  importance  of  absolute  isolation  of  the  pa- 
tient, whether  the  treatment  is  carried  out  at  home  or 
away  from  home.  Many  general  practitioners  cannot 
realize  the  importance  of  this  measure  and  make  all  sorts 
of  compromises  with  the  family  which  prove  harmful  to 
the  patient.  Acute  insanity  rapidly  passes  from  a  curable 
to  an  incurable  stage,  and  it  is  upon  our  treatment  during 
the  first  three  months  that  the  patient's  chance  of  recovery 
largely  depends.  Dr.  J.  G.  Biller,  of  Cherokee,  Iowa,  said 
he  differed  somewhat  from  the  writer  of  the  paper  in  re- 
gard to  treating  cases  of  acute  insanity  at  home.  Such 
experiments  usually  result  disastrously,  and  generally 
speaking,  the  sooner  tBe  patients  are  removed  from  home, 
the  better  their  chances  of  recovery.  Such  patients  require 
constant,  intelligent  and  careful  watching,  and  this  they 
can  only  get  in  a  well  kept  hospital.  Dr.  P.  W.  Langdon, 
of  Cincinnati,  said  he  had  been  obliged  to  treat  a  number 
of  cases  of  acute  psychoses  outside  of  institutions,  and  a 
fair  portion  of  these  terminated  favorably.  We  know,  how- 
ever, that  the  environment  of  a  patient  in  which  his  ab- 
normal state  developed  is  not  the  best  for  his  recovery, 
and  while  under  exceptional  circumstances  such  cases  may 
be  successfully  treated  at  home,  the  wisdom  of  this  course 
is  open  to  doubt.  Dr.  Harold  N.  Moyer,  of  Chicago,  said 
that  while  he  was  in  accord  with  the  general  consensus 
of  opinion  that  cases  or  acute  psychosis  are  best  taken 
care  of  in  general  special  institutions,  there  are  some 
families  who  will  not  consent  to  having  the  patient  removed 
from  home,  and  under  those  circumstances  we  must  do  the 
best  we  can.  Nervous  IVIanifestations  of  Syphilis  of  the 
Brain:  Dr.  Hugh  T.  Patrick,  of  Chicago,  read  a  paper  on 
tliis  subject,  in  which  he  enumerated  the  various  popular 
fallacies  regarding  cerebral  syphilis  and  described  the  most 
characteristic  and  important  traits  of  the  disease.  The 
Psychoses  in  Cerebral  Syphilis:  Dr.  Richard  Dewey,  of 
Wauwatosa,  Wis.,  read  a  paper  on  this  siil)jeet.     He  said 


that  in  connection  with  it,  several  questions  arise  which 
must  be  taken  into  consideration.  One  is,  the  evidence  of 
syphilis.  Another,  the  very  frequent  existence  in  these 
cases  of  causes  other  than  syphilis  which  have  their  share 
in  determining  the  mental  state,  such  as  alcoholism,  senile 
changes,  arterial  disease,  kidney  and  heart  disease  and 
tumors  of  non-specific  origin.  The  speaker  gave  the  fol- 
lowing statistics  as  the  result  of  his  personal  observation: 
Among  1200  cases  of  all  forms  of  nervous  and  mental  dis- 
lase  he  found  45  cases  of  well-substantiated  constitutional 
syphilis.  There  were  doubtless  many  more,  which  were 
rejected  because  the  history  of  syphilis  was  not  positive. 
Of  the  45  cases  in  which  there  was  an  undoubted  syphilitic 
history,  17  were  diagnosed  as  paresis;  12  as  cases  ot 
syphilitic  brain  disease  with  symptoms  of  an  organic 
lesion;  seven  were  cases  of  psychosis  with  marked  de- 
lusional characteristics  and  without  symptoms  of  brain 
syphilis;  four  were  cases  of  hypochondriacal  melancholia 
and  two  were  cases  of  tabes  with  emotional  symptoms. 
In  addition  to  the  above  there  was  one  case  each  of  demen- 
tia, (slight),  melancholia,  and  dementia  paralytica  ot  the 
senile  type.  Dr.  C.  B.  Burr,  of  Michigan,  said  there  were 
two  interesting  varieties  of  cerebal  syphilis,  accompanied 
by  marked  disturbances  of  the  mental  operations.  There 
is  one  in  which  the  motor  symptoms  predominate:  the 
other,  in  which  the  symptoms  are  altogether  psychical.  In 
the  one  the  symptoms  are  clinically  difticult  to  distinguish 
from  those  of  paretic  dementia.  However,  there  is  apt  to  be 
expansive  delusions,  remissions  are  more  frequent  and  the 
disease  is  of  longer  duration.  Both  varieties  are  character- 
ized by  reduction,  this  being  their  most  conspicuous  quali- 
ty. In  the  second  variety  there  is  psychical  reduction, 
manifested  in  dementia,  the  symptom  of  loss  of  memory  be- 
ing the  most  prominent.  There  is  also  hebetude  and  the 
patient  is  dull  and  unresponsive.  Suggestions  for  Lessen- 
ing the  Frequency  of  Relapse  After  Treatment  of  Mor- 
phinism: Dr.  A.  J.  Pressey,  of  Cleveland,  spoke  in  favor 
of  the  gradual  reduction  of  the  amount  of  morphine  taken, 
but  he  reduction  must  be  so  effected  that  the  patient  will 
feel  better  during  the  entire  course  of  the  treatment  than 
he  felt  while  he  was  taking  the  drug  ad  libitum.  The 
quantity  of  morphin  taken  by  those  addicted  to  this  habit 
is  usually  largely  in  excess  of  what  is  required  to  make 
them  comfortable.  It  can,  therefore,  usually  be  reduced 
immediately  by  at  least  one-half.  From  that  time  on  Dr. 
Pressy  administers  the  drug  four  times  daily,  reducing 
the  dose  very  slightly  each  day  until  it  is  as  small  as 
1-1 20th  of  a  grain,  and  even  smaller  in  some  cases.  The 
morphine  should  never  be  discontinued  entirely  while  the 
dose  is  still  so  large  that  its  withdrawal  will  be  felt  by 
the  patient.  No  set  rules  can  be  laid  down  to  govern  all 
cases.  Each  case  must  be  treated  according  to  the  in- 
dications. In  addition  to  a  gradual  reduction  of  the  mor- 
phine, the  patient  should  be  given  nerve  tonics.  Static 
electricity  is  also  very  beneficial.  Dr.  T.  D.  Crothers,  of 
Hartford,  said  that  the  method  of  reduction  in  a  case  of 
morphinism,  wether  rapid  or  slow,  can  only  be  decided  by 
the  status  of  the  individual  case.  The  speaker  said  he 
had  seen  cases  where  a  rapid  reduction  of  the  drug  proved 
entirely  satisfactory.  After  a  patient  who  has  been  ac- 
c\i?tomed  to  take  from  ten  to  twenty  grains  daily  is  re- 
duced to  one  grain,  the  drug  can  usually  be  withdrawn 
entirely  without  causing  much  discomfort,  or  some  other 
alkaloid  substituted  if  necessary.  The  greatest  difficulty 
in  the  treatment  of  these  patients.  Dr.  Crothers  said,  was 
to  overcome  the  fascination  of  the  hypodermic  needle. 
Dr.  John  Punton,  of  Kansas  City,  said  that  the  majority  ot 
persons  who  are  slaves  to  morphine  are  usually  suffering 
from  mal-nutrition  and  are  greatly  reduced  in  flesh  as  the 
result  of  the  habit.  On  this  account,  attention  to  the 
nutrition  of  the  patient  is  just  as  imporant  as  the  with 
drawal  of  the  drug.  Injuries,  Feigned  and  Real,  with  tKelr 
Differentiation  and  Medicolegal  Aspect:  Dr.  Lambert  Ott, 
of  Philadelphia,  divided  injuries  into  two  classes: 


1144 


The  Paii-ADELPHiA"] 
Medical.   Journai.  J 


SOCIETY  REPORTS 


[June   li,   IJOl 


1.  Those  with  visible  signs  and  symptoms. 

2.  Those  with  invisible  symptoms. 

Thes  peaker  referred  to  the  frequency  with  which  cor- 
porations are  mulcted  for  heavy  damages.  With  the  in- 
creased number  of  accidents  incident  to  modern  methods 
of  transportations  this  abuse  has  grown  to  such  an  extent 
tliat  many  of  the  larger  corporations  even  pay  unjust  claims 
rather  than  submit  the  question  of  liability  and  damages  to 
a  prejudiced  jury.  The  speaker  referred  to  the  frequency  with 
which  a  verdict  in  these  eases  is  the  result  of  testimony  giv- 
en by  biased  or  mercenary  men.  He  spoke  of  the  opprobrium 
which  now  rests  on  medical  and  expert  testimony  and  con- 
cluded his  paper  with  a  plea  for  the  more  thorough  and 
scientific  examination  of  injured  persons,  so  as  to  discover 
whether  the  symptoms  of  which  they  complain  are  real 
or  feigned.  Dr.  Leo  M.  Crafts,  of  Minneapolis,  said  he 
would  not  agree  with  the  reader  of  the  paper  as  to  the 
common  occurrence  of  malingering  by  persons  who  have 
been  injured,  and  the  frequency  with  which  corporations  are 
mulcted.  The  statement  that  the  plantiif  is  more  likely 
to  be  influenced  by  a  moneyed  consideration  than  the  other 
party  certainly  does  not  obtain  in  the  West.  Dr.  Richard 
Dewey  said  the  even  a  patient  who  is  perfectly  honest  may 
complain  of  certain  symptoms  which  are  not  genuine.  This 
has  been  observed  in  cases  where  there  is  no  question  of 
damages  or  suspicion  of  fraud.  Dr.  J.  G.  Biller  said  that 
several  times  in  the  course  of  his  professional  career  he 
had  been  imposed  upon  by  persons  who  claimed  that  they 
were  suffering  from  certain  symptoms  as  the  result  of  in- 
juries received,  and  who  immediately  recovered  when  their 
claim  for  damages  was  paid. 

THIRD  D.XY,  JUNE  Cth,  1901. 
Treatment  of  Neurasthenia:  By  Dr  J.  G.  Biller,  of  Chero- 
kee, Iowa.  The  speaker  said  that  as  the  nervous  system 
controls  the  organs  in  the  body,  and  as  these  in  turn  affect 
the  nervous  system,  it  was  no  easy  task  to  tell  whether 
the  neurasthenia  was  the  result  of  disturbed  bodily  func- 
tion or  of  a  disturbance  in  the  nervous  system  itself.  The 
first  requirement,  in  the  treatment  of  a  case  of  neuras- 
thenia, is  to  make  a  thorough  examination.  Even  if  we 
accomplish  nothing  else  by  this,  it  will  at  least  aid  us  in 
gaining  the  confidence  of  the  patient,  which  is  perhaps  the 
most  important  element  in  bringing  about  a  cure.  Proper 
feeding  is  another  important  element  of  the  treatment, 
and  one  that  is  often  neglected.  A  plain,  nourishing  diet 
is  preferable  to  the  prepared  or  concentrated  foods.  On 
the  other  hand,  some  of  these  patients  are  suffering  from 
over-feeding,  or  improper  feeding.  In  addition  to  regulat- 
ing the  diet,  we  should  see  that  these  patients  get  plenty 
of  sleep.  Sulphonal  in  small  doses  may  be  necessary  to 
induce  sleep;  if  so,  the  drug  should  be  dispensed  by  the 
physician  himself  and  the  patient  should  be  kept  in  ignor- 
ance of  its  nature.  A  change  of  scene  may  prove  bene- 
ficial in  some  cases,  but  not  infrequently  it  does  harm. 
As  regards  drugs,  they  should  be  sparingly  used.  We 
should  not  depend  on  the  so-called  tonics.  The  best  reme- 
dies are  those  that  assist  the  digestion  and  increase  the  ac- 
tivity of  the  liver.  Small  doses  of  calomel  at  intervals 
often  prove  beneficial.  The  Psychoses  of  Chorea:  Dr.  Har- 
old M.  Moyer,  of  Chicago,  read  a  paper  with  this  title. 
The  following  were  his  conclusions:  1.  A  well-marked  al- 
ti'ration  of  the  character  and  mentality  can  be  noted  in  the 
majority  of  cases  of  chorea,  usually  preceding  by  some 
weeks  the  onset  of  the  choreic  movements.  2.  Distinct 
hallucinatory  phenomena  are  present  in  a  considerable 
number  of  cases,  which  are  not,  however,  of  sufficient 
severity  to  merit  being  called  a  distinct  psychosis.  3.  The 
mental  disturbance  in  chorea  usually  comes  on  after  the 
choreic  movements,  but  it  may  precede  them.  4.  The 
type  is  usually  maniacal,  though  it  may  be  melancholiac,  or 
present  the  character  of  acute  delirium.  5.  Mental  dis- 
turbances are  commoner  in  older  children;  they  are  rarely 
observed  before  the  lith  year.     G.  Choreas  which  are  ac- 


companied by  mental  disturbance  later  in  life  are  almost  al- 
ways accompanied  by  organic  changes  in  the  central  nerv- 
ous system.  7.  The  prognosis  is  favorable  where  the 
mental  disease  complicates  a  simple  acute  chorea  of  Sy- 
denham. Dr.  Augustus  A.  Eshner,  of  Philadelphia,  reported 
Three  Cases  of  Paralysis  of  the  Serratus  Magnus  and  the 
Trapezius.  Mirror  Writing  and  Inverted  Vision:  Drs.  Al- 
bert B.  Hale  and  Sydney  Kuh,  of  Chicago,  presented  a  paper 
upon  this  subject,  which  was  read  by  Dr.  Kuh.  They  dis- 
cussed the  optics  of  the  retinal  image  and  •  the  various 
theories  that  have  been  advanced  in  explanation  of  mirror 
writing  and  inverted  image.  The  authors,  in  the  main, 
agreed  with  the  theory  that  the  phenomena  were  the  re- 
sult of  a  disturbance  In  the  co-ordination  of  the  eye- 
muscles.  While  this  is  the  most  important  factor,  it  is  not 
the  only  one.  If  any  one  of  the  factors  that  aid  us  in  form- 
ing a  mental  picture  of  an  object  is  disturbed,  a  faulty 
image  must  of  course  result.  Fear  as  an  Element  of  Nerv- 
ous Diseases  and  its  Treatment:  By  Dr.  John  Punton,  of 
Kansas  City.  The  speaker  stated  that  morbid  leur  is  a 
common  and  potent  element  of  nervous  disease.  In  the 
treatment  of  this  factor,  we  must  take  cognizance  of  both 
the  mind  and  body  of  the  patient.  First,  we  must  endeavor 
to  gain  the  confidence  and  full  control  of  the  patient,  and 
study  the  cause  of  his  morbid  fear.  Isolatioin  is  essential, 
preferably  away  from  home,  but  the  isolation  in  on  lo 
cality  must  not  be  too  prolonged;  otherwise,  the  patient 
will  become  too  well  acquainted  with  is  new  surroundings 
We  should  endeavor  to  restore  to  the  will  its  normal  control 
uf  the  emotions  and  intellect,  and  teach  the  patient  to  be- 
i  onie  more  selfreliaut.  If  the  general  health  is  impaired, 
proper  medication  is  indicated.  In  addition  to  this,  the 
judicious  use  of  baths,  massage  aud  electricity  in  its  vari- 
ous forms  will  prove  beneficial.  Dr.  W.  A.  Jones,  of  Min- 
neapolis, reported  Ten  Cases  of  Multiple  Neuritis  which 
came  under  his  observation  in  the  city  of  Minneapolis  be- 
tween the  loth  of  Februarj-  and  the  loth  of  March  of  the 
present  year.  Six  of  the  ten  case  occurred  during  one 
week.  Two  of  them  proved  fatal.  Some  of  the  cases  cor 
responded  with  the  usual  description  of  multiple  neuritis, 
while  others  closely  simulated  Landry's  paralysis.  The  in 
iluenza  bacillus  was  regarded  as  the  etiological  factor. 
A  Case  of  Localized  Amnesia,  with  Remarks  Thereon:  By 
Dr.  Edward  E.  Mayer,  of  Pittsburg.  The  case  reported  was 
that  of  a  young  man,  who  was  born  in  Pennsylvania  in 
ISCO.  In  1S84  he  was  on  a  railway  train  which  was 
wrecked.  He  felt  himself  hurled  through  the  air  and  then 
his  mind  became  a  blank.  He  has  no  recollection  oi 
knowledge  of  anything  that  occurred  during  the  five  years 
following  the  accident,  and  no  one  could  be  found  who  can 
give  any  information  about  him.  Twelve  years  ago,  that 
is,  in  1889,  he  first  came  to  Pittsbu^  and  met  his  present 
wife,  and  two  years  later  married  her.  He  was  never  aoit 
to  give  her  any  information  regarding  his  previous  lire, 
although  he  had  not  forgotten  his  name.  Nine  years  ago. 
shortly  before  the  birth  of  the  eldest  of  his  four  children, 
he  wandered  away  one  Sunday  afternoon  aud  did  not  re- 
turn until  Monday  evening.  Upon  his  return  home,  he 
could  offer  no  explanation  for  his  absence.  As  he  was  a 
total  abstainer,  it  was  regarded  as  very  peculiar.  About 
a  year  later  he  again  disappeared  for  several  days,  and 
during  his  absence  he  wrote  a  postal  card  to  his  wife, 
telling  her  that  the  memory  of  his  mother  had  suddenly 
returned  to  him  and  he  had  gone  to  pay  her  a  visit.  He 
returned  home  a  day  or  two  later.  The  man's  occupation, 
before  he  met  with  the  railway  acicdent.  was  that  of  a 
carpenter:  subsequent  to  his  marriage,  he  was  employed  at 
different  times  as  a  farmer,  sawyer  and  painter.  About 
this  time  he  complained  of  symptoms  which  were  re- 
garded by  his  physician  as  evidences  of  a  hepatic  absc€>ss. 
In  February.  1901.  while  suffering  intensely  from  abdominal 
pain,  he  fell  to  the  floot  and  remained  unconscious  for 
several  hours.  When  he  regained  consciousness,  the  mem- 
ory of  the  last  seventeen  years  of  his  life  was  apparently 
t-utirely  obliterated.     His  mind  had  reverted  to  the  lime 


June  is.  i»n] 


SOCIETY  REPORTS 


TThe  Philadelphia 
LxiEDiCAL   Journal 


I  145 


previous  to  the  accident.  He  insisted  that  he  vras  24  years 
old,  and  had  neither  wife  nor  children.  The  surroundings 
among  which  he  had  lived  for  the  past  twelve  years  were 
apparently  strange  to  him.  and  it  required  much  persuasion 
to  induce  him  to  believe  the  story  of  the  true  state  of 
affairs.  From  that  time  on  all  his  symptoms  of  hepatic 
abscess  disappeared.  He  tried  to  resume  his  work  as  a 
carpenter,  but  had  forgotten  all  about  it  and  was  obliged 
to  begin  as  an  apprentice.  On  March  Sth  of  the  present 
year  he  disappeared  for  twelve  hours,  and  upon  his  re- 
turn home  he  stated  that  he  had  walked  about  thirty  miles 
in  the  country.  The  following  day  his  wife  gave  him 
S25.00  with  which  to  buy  some  groceries.  He  failed  to  re- 
turn home  and  no  trace  or  word,  has  been  received  from 
him  since.  Dementia  Following  Inebriety:  Dr.  T.  D.Crothers. 
of  Hartford,  read  a  papsr  on  this  subject,  in  which  he  dwelt 
strongly  upon  the  dangers  of  steady  moderate  indulgence 
in  alcoholic  stimulants.  He  stated  that  steady  drinking, 
even  without  intoxication,  was  injurious,  and  the  so-called 
"moderate  drinker"  was  certain  to  suffer  both  physically 
and  mentally  from  the  practice.  He  said  that  the  evidences 
of  dementia  were  more  often  apparent  in  the  moderate 
drinker  than  in  the  man  who  indulges  occasionally  to  the 
point  of  intoxication  and  then  sobers  up  and  regains  his 
mental  physical  balance.  The  life  of  the  moderate  drinker 
becomes  more  and  more  automatic.  He  has  less  spon- 
taneity; less  originality.  He  cannot  adapt  himself  to  new 
conditions  with  the  necessary  energy  and  judgment.  His 
digestion  becomes  impaired,  and  this  results  in  defective 
nutrition.  He  suffers  from  a  spirit  of  unrest;  there  is  a 
constant  craving  for  excitement  and  change.  There  may 
be  a  craze  for  powerful  drugs,  which  is  a  form  of  dementia; 
sometimes  there  is  a  craze  for  travel  or  for  gambling  and 
many  forms  of  immorality.  The  Importance  of  Heredity 
as  a  Cause  of  Insanity:  By  Dr.  Arthur  McGugan,  of  Kala- 
mazoo. The  reader  said  that  according  to  his  observations 
9.5  per  cent,  of  the  insane  had  a  family  history  of  im- 
paired mental  or  physical  health.  In  only  a  small  per- 
centage of  cases  was  insanity  due  to  physical  or  mental 
stress  apart  from  hereditary  weakness.  Dr.  Leo.  M.  Crafts, 
of  Minneapolis,  reported  a  case  of  Persistent  Brachial  Neu- 
ralgia resulting  from  a  hypodermic  injection  in  the  wrist. 
He  also  reported  a  case  of  Incipient  Lateral  Sclerosis,  with 
Recovery. 

.  .Election  of  Officers:  The  following  officers  were  elected 
for  the  ensuing  year: 

Chairman,   Dr.   J.   T.   Eskridge,  of  Colorado. 
Secretary,  Dr.  F.  Savary  Pearce,  of  Philadelphia. 

Members  of  the  House  of  Delegates. 

The  retiring  Chairman,  Dr.  H.  A.  Tomlinson,  of  Minn. 
Dr.  Harold  N.  Moyer,  of  III. 


A  Case  of  Simultaneous  Extra-and  Intra-uterine  Preg- 
nancy. L.  N.  Varnek  {iledicinskuie  Ohosrenie,  Fehrvary, 
101)1.)  after  pointing  out  the  rarity  of  the  condition,  re- 
ports a  case  of  a  widow,  34  years  old.  multipara,  who  pre- 
sented obscure  pelvic  symptoms  which  lead  to  a  diagnosis 
of  double  salpingo-oophoritis.  Severe  hemorrhage  super- 
vening, she  was  treated  with  hot  douches,  ergot  and  Hy- 
drastis without,  however,  any  marked  benefit.  These  symp- 
toms together  with  the  appearance  of  a  swelling  on  the 
right  side  of  the  uterus  gave  rise  to  a  suspicion  of  tubal 
pregnancy  which  was  confirmed  by  the  admission  of  the 
woman  that  such  a  condition  was  possible.  The  simul- 
taneous enlargement  of  the  uterus  however,  still  obscured 
the  diagnosis,  and  an  exploratory  laparotomy  was  decided 
upon.  The  operation  disclosed  a  pregnant  uterus  of  6 
months  and  a  ruptured  tube  filled  with  old  blood  clots.  The 
tube  was  removed  and  the  uterus  returned  into  the  ab- 
dominal cavity.  The  woman  made  an  uneventful  recovery 
and  was  delivered  at  term  of  a  healthy  child.  The  note- 
worthy feature  in  this  case  is  the  resistance  of  the  preg- 
nant uterus  to  the  action  of  hot  douches,  ergotin.  hy- 
drastis  and  the  surgical  intervention.     [A.  R.] 


TWENTY-SIXTH  ANNUAL  MEETING  OF  THE  AMERI- 
CAN ACADEMY  OF  MEDICINE. 
Held  at  the  Hotel  Aberdeen,  St.  Paul,  Minnesota. 
June  1-3,  1901. 
SECTION    ON    MEDICINE. 

The  meeting  called  to  order  by  the  President,  Dr.  S.  D. 
Risley  of  Philadelphia. 

A  short  Executive  Session  was  held.  Forty-two  new 
members  were  elected.  The  Nominating  Committee  was 
appointed  as  follows:  Drs.  L.  Duncan  Bulkley  of  New 
York;  Dr.  Thomas  D.  Davis  of  Pittsburg,  and  Dr.  G.  Hud- 
son Makuen  of  Philadelphia. 

The  scientific  business  was  then  take  up  in  open  session. 

THE  FIRST  YEAR  MEDICAL  CURRICULUM. 

Dr.  Thomas  D.  Davis  of  Pittsburg,  Pa.,  presented  this 
paper.  He  said  there  had  been  great  changes  in  the  cur- 
riculum of  the  academical  departments  of  all  our  institu- 
tions of  learning — changes — not  advances.  He  did  not 
agree  that  many  of  the  changes  had  been  improvements  in 
education.  It  would  appear  that  the  courses  in  arts  and 
sciences  had  been  arranged  mainly  to  give  a  short  cut  into 
the  profession  rather  than  to  broaden  and  deepen  the 
foundations  of  true  mental  development.  It  is  his  convic- 
tion that  no  plan  surpasses  for  true  professional  education 
foundation  the  old  severe  classical  course,  particularly 
valuable  in  developing  the  judgment  and  reason  and  form- 
ing the  habits  of  application  and  mental  concentration. 
Anj-thing  that  cannot  show  its  advantages  in  dollars  and 
cents  has  been  placed  in  the  background.  He  impressed 
the  importance  of  the  subjects  taught  in  the  last  two  years 
of  a  college  course,  and  believes  that  the  first  year  course 
of  a  medical  school  should  approach  the  last  year  course 
in  a  college.  A  four  year  medical  course  is  not  of  Itself  an 
advancement  in  medical  education.  An  entire  re-arrange- 
ment of  the  curriculum  in  our  medical  schools  is  necessary 
to  correspond  to  the  four  years  required.  Rhetoric  could 
be  taught  with  advantage.  Botany  should  be  taught,  to 
give  a  more  correct  foundation  for  the  vegetable  materia 
medica.  Logic,  if  not  taught  before,  should  be  taught  in 
our  medical  schools.  In  no  way  it  was  stated,  could  the 
practice  of  medicine  be  improved  more  rapidly  and 
thoroughly  than  by  training  men  to  think,  judge,  and  decide 
logically. 

Psychology  or  mental  pilosophy  were  mentioned  as  of 
greater  importance  than  all.  The  intimate  mysterious 
relation  of  the  mind  to  the  body  have  been  recognized,  but 
the  laws  governing  the  mind  and  the  many  phenomena  that 
have  been  observed  and  classified  are,  to  a  great  extent  un- 
known to  medical  men.  The  physician  who  fails  to  re- 
cognize and  use  mental  influence  loses  a  mighty  power, 
yet  our  medical  schools  teach  none  of  the  laws  of  this  in- 
fluence. In  the  opinion  of  the  author,  a  medical  college 
offering  a  course  for  the  first  nine  months  which  would 
embrace  rhetoric,  botany,  logic  and  psychology,  biology, 
osteology  and  general  chemistry  will,  at  the  end  of  its  four 
years  course  of  nine  months  each,  turn  out  far  better  equip- 
ped medical  men  than  are  to  be  found  at  graduation  now. 
Under  the  present  conditions  a  college  graduate  with  three 
years  in  a  medical  school  will  be  better  posted  in  medicine 
and  better  prepared  to  practice  it  than  a  common  school 
graduate  can  possibly  be  after  four  years  in  the  same  medi- 
cal school. 

Dr.  Connor  of  Detroit  believed  that  colleges  of  all  kinds 
were  committing  a  grevious  wrong  to  their  students  in 
not  having  them  taught  so  to  write  that  they  could  be  un- 
derstood clearly  and  forcibly,  as  well  as  in  not  teaching 
them  how  to  talk  when  upon  their  feet.  Without  this  train- 
ing they  are  handicapped.  If  necessary,  this  instruction 
should  be  put  in  with  the  study  of  anatomy  and  chemistry. 
Manual  training  in  that  their  fingers  might  be  able  to  follow 
out  the  students'  preceptions  was  also  advocated;   as  was 


1 146 


The  Philadelphia" 
Medical   Journal 


SOCIETY  REPORTS 


[Ju.NE    15,    1901 


also  "a  little  bit  of  business  training"  which  would  make 
the  physician  more  prosperous,  and  more  reputable  in  the 
minds  of  those  in  business  circles.  A  number  of  physicians 
are  wrecked  because  they  lack  business  training. 

Dr.  Vaughan  thought  it  a  mistake  that  our  students  were 
not  more  frequently  compelled  to  write  theses,  and  that 
tlie  abolition  of  the  requirement  was  a  backward  step.  Be- 
fore a  man  studies  medicine  he  should  know  mathematics 
through  plain  trigonometry.  Also,  the  man  who  will  get 
the  best  out  of  medicine  must  have  a  reading  knowledge  ot 
French  and  German.  He  should  have  some  knowledge  of 
both  Latin  and  Greek.  The  fact  that  a  man  has  an  A.  B. 
degree  may  mean  much  or  almost  absolutely  nothing.  He 
thought  it  time  that  those  interested  in  medical  education 
in  this  country  should  force  the  literary  school  to  give 
courses  that  properly  lead  to  medicine.  He  expressed  him- 
self in  sympathy  with  the  law  enacted  by  the  New  York 
legislature  compelling  every  student  to  stay  four  years  in 
a  medical  school,  no  matter  what  degree  he  may  have. 

Dr.  Goldspohn  of  Chicago  heartily  endorsed  Dr.  Vau- 
ghan's  sentiments  in  regard  to  a  knowledge  of  French  and 
German.  While  not  judging  England  and  all  she  represents 
in  science,  yet  more  original  productions,  more  real  con- 
tributions pertaining  to  pathological  anatomy  come  from 
Italy  and  Switzerland,  the  smallest  European  govern- 
ments, than  we  have  from  England  herself  in  the  last  five 
or  ten  years.  He  felt  that  there  is  no  possibility  of  a  man 
keeping  abreast  with  what  the  world  affords  unless  he  were 
a  thorough  student  of  German  and  French,  from  them 
getting  the  substance  of  what  the  rest  of  the  world  pro- 
duces. A  deficiency  in  the  medical  curriculum  of  to-day 
is  the  failure  to  apreciate  the  power  of  mind  over  matter, 
the  want  of  a  proper  understanding  of  this  psychological 
part  of  man.  The  amount  of  instruction  in  histology  is 
grossly  defective.  He  felt  that  a  good  thorough  college 
course  and  then  a  four  years  medical  course  likely  to  do 
the  most  good. 

Dr.  Jackson  of  Denver,  thought  that  the  study  of  logic 
and  psychology  as  carried  on  furnished  a  very  poor  outfit, 
or  a  very  insufficient  gauarantee  of  a  logical  mind  or  an 
ability  to  apply  psychological  principles  to  general  facts. 
In  illustration,  a  base-ball  or  billard  player  learns  to  do  a 
certain  thing  with  perfect  accuracy,  promptness  and  ease, 
and  yet  knows  nothing  perhaps  of  the  names  or  forms  ot 
classification  or  arrangement  of  the  muscles  by  which  he 
does  it,  still  less  of  the  nerve  paths  by  which  he  accom- 
plishes his  purposes. 

Dr.  L.  Duncan  Buckley  remarked  that  the  crowning  evil  of 
medicine,  the  advertising  drug  business,  was  due  to  faulty 
education  in  our  medical  schools.  Another  fault  was  in  too 
great  a  crowding  from  minutiae.  He  emphatically  approved 
of  the  suggestion  that  students  be  required  to  write  a  thesis 
at  the  end  of  each  year.  He  had  seen  too  often  in  young 
men  coming  up  for  hospital  examinations,  a  want  of  concen- 
tration of  thought,  and  of  logic. 

"Is  the  Demand  for  Reciprocity  Based  upon  Fact  or 
Fancy." 

Dr.  Charles  Mclntire  of  Easton,  in  this  paper  gave  the  re- 
sults in  the  examination  of  reports  of  the  various  state 
boards  of  medicine  examiners  for  1900,  in  order  to  form 
an  estimate  of  the  comparative  number  of  physicians  who 
seek  to  move  from  one  state  to  another.  The  figures 
quoted  in  the  paper  give  the  entire  number  examined,  the 
number  failing,  and  of  those  failing,  the  number  who  were 
not  graduates  of  the  last  class.  A  tabulated  statement 
showed  that  out  of  all  511  individuals.  292  could  have  had 
an  opportunity  of  taking  a  state  examination  elsewhere. 
A  considerable  number  failed,  and  were  coming  up  for  a 
second,  only  to  fail  again.  It  would  be  far  from  the  trutn 
to  infer  that  of  the  larger  number  who  were  sustained  in 
their  examinations,  the  same  proportion  of  older  m?n  pre- 
sented themselves:    at  the  same  time,  many  such  are  in- 


cluded in  those  who  receive  a  license,  and  it  will  not  be 
an  overstatement  to  assume  that  the  number  of  those  who 
passed  the  examinations,  who  would  have  had  the  privilege 
of  reciprocity  extended  to  them,  fully  offsets  the  number 
who  failed  in  the  examinations,  who  had  never  made  the 
effort  to  practice  elsewhere.If  so,  there  are  at  least  292  out 
of  the  total  number  examined  who  would  have  been  able 
to  avail  themselves  of  the  privilege  of  reciprocity,  or  about 
7%  per  cent. 

"The  Desirability  of  Reciprocity  In  Medical  Licensure." 
A  paper  with  this  title  by  Dr.  J.  N.  Hall  of  Denver,  was 
presented.  An  experience  of  six  years  on  the  Colorado 
State  Board  of  Medical  Examiners  demonstrated  that  many 
physicians  of  excellent  repute  seek  a  residence  in  that  State 
because  of  illness,  either  personal  or  otherwise.  Though 
such  men  are  fitted  to  practice  medicine  they  are  rusty  on 
the  details  of  the  foundation  studies.  Reciprocity  between 
States  having  stringent  requirements  would  be  of  the  ut- 
most benefit  to  men  of  this  type.  Reciprocity,  however, 
should  not  be  established,  except  among  those  states  where 
requirements  are  essentially  equivalent. 

Reciprocity  in  Medical  Licensure  from  the  Standpoint  of  a 
Physician  who  changes  his  residence. 

Dr.  Edward  Jackson  of  Denver,  in  this  contribution  said 
that  about  one  in  every  four  or  five  physicians  changes  his 
field  of  practice  from  one  state  to  another,  at  some  time 
during  his  professional  career.  In  making  such  a  change 
the  difficulty  is  not  with  the  practical  branches,  but  with 
passing  the  examination  in  what  may  be  regarded  as  the 
preliminary  studies, — chemistry,  anatomy,  etc.  The  phy- 
sician who  removes  across  state  lines  cannot  justly  be 
expected  to  keep  better  posted  in  those  branches  than  the 
most  of  those  who  do  not  move.  "Reciprocity"  seems  liable 
to  be  awaiting  for  others  to  do  something  rather  than  a  prac- 
tical measure  of  relief.  The  acceptance  of  the  certificate  of 
another  state  board,  as  evidence  of  a  proper  acquaintance 
with  much  preliminary  studies,  would  remove  the  chief 
hardship.  The  main  obstacle  to  this  is  fear  of  "lowering 
the  standard."  But  the  "Standard"  in  many  states  is  al- 
ready "so  high"  as  to  favor  evasion  and  special  legislation 
letting  in  all  sorts  of  irregular  practitioners  and  to  threaten 
the  permanence  of  laws  regulating  medical  practice. 

"Away  with   Reciprocity." 

Dr.  Charles  Mclntire  in  this  paper  stated  that  Reciprocity 
is  an  ingnis  fatus.  which  will  lead  us  far  astray.  Physi- 
cians already  possessing  the  legal  right  to  practice  in  one 
state,  should  have  privileges,  in  removing  to  another  state, 
not  accorded  to  those  who  have  not,  as  yet,  been  licensed 
to  practice.  These  privileges  must  not  be  such  as  to  act 
unfairly  either  to  the  people  of  the  state  or  the  physicians 
already  practising  in  the  state. 

It  is  well  to  remember  that  those  states  which  have  medi- 
cal practice  acts  at  all  worthy  the  name,  divide  into  two 
classes— those  which  accept  certain  diplomas  as  the  evi- 
dence of  fitness:  and,  those  which  require  an  examination. 
In  both  instances  the  text  is  an  educational  one.  The  first 
class  have  no  personal  interest  in  this  question,  since  they 
do  not  inquire  into  the  personal  knowledge  of  the  applicant. 
In  the  very  nature  of  the  thought,  there  is  concession  in 
reciprocity  which  precludes  the  idea  of  strict  equality.  If 
we  seek  reciprocity  we  must  seek  to  secure  an  agreement  be- 
tween the  various  boards,  for  each  to  accept  without  ques- 
tion the  licenses  issued  by  each  other.  Physicians  already 
possessing  the  legal  right  to  practice  in  one  state,  should 
have  privileges  in  removing  to  another  state,  not  accorded 
to  those  who  have  not.  as  yet.  been  licensed  to  practice.  It 
might  be  said  that  the  man  distinguished  enough  to  be 
called  SOO  or  1.000  miles  to  occupy  a  professor's  chair  might 
be  admitted  upon  his  reputation.  Unfortunately,  were 
this  done  in  one  case,  there  would  be  the  danger  of  pro- 
nouncing it  reputation,  but  spelling  it  i  n  f  1  u  e  n  c  e.  What- 
ever privilege  is  given  to  the  older  man.  a  favor  to 
him.  must  be  fair  to  all  concerned. 


June   15,   1901] 


SOCIETY  REPORTS 


[The  Philadelphia 
Medical   Journal 


1147 


ADDRESS  OF  THE  PRESIDENT,  DR.  S.  D.  RISLEY. 

"Some  of  the  Ethical  and  Sociologic  Relations  of  the  Phy- 
sician to  the  Community." 

Dr.  Risley  in  his  address  sliowed  ttiat  a  most  striking 
characteristic  of  the  medical  man  is  a  sense  of  obligation 
to  the  community,  that  this  ethical  attitude  finds  express- 
sion,  not  only  in  the  daily  routine  of  his  laborious  profes- 
sional service,  but  in  a  pronounced  educational  influence  on 
all  those  lives  which  pertain  to  the  healthfulness  of  the 
people  and  their  socio-medical  welfare;  that  this  influence 
is  signally  exerted  in  the  investigations  and  control  of  the 
relation  which  our  defective  classes  sustain  to  the  social 
body.  Almost  suddenly  the  student  of  social  evolution  has 
come  to  realize  that  through  the  altruisic  spirit  of  our  civili- 
zation a  rapidly  increasing  percentage  of  degenerates  have 
grown  up  in  our  midst,  a  fact  which  presents  a  serious  and 
most  complex  problem  for  solution  by  the  new  century. 
Two  suggestions  are  made  for  its  arrest.  First,  the  legali- 
zation of  means  to  prevent  propagation  of  defectives  by 
asexualization;  and, second,  by  a  wider  education  of  the  com- 
munity regarding  the  importance  of  selection  in  the  mar- 
riage contract  and  its  control  by  the  State.  To  solve  it 
wisely  and  humanely  will  require  the  best  efforts  of  the 
churchman  and  the  physician  and  the  statesman. 

SECOND  DAY. 

In  the  short  executive  session  preceding  the  scientific 
business  a  few  additional  names  were  numbered  with  the 
fellowship,  and  the  resignations  of  three  accepted.  Some 
slight  changes  in  the  by-laws  were  inaugurated  and  the  Sec- 
retary called  to  the  attention  of  the  Academy  the  work  of 
the  Bulletin,  the  official  organ  of  the  body. 

The  first  paper  was  entitled: 

Abuses  of  Institutionalism. 
by  Dr.  Eugene  G.  Carpenter  of  Columbus,  Ohio.  Dr.  Car- 
penter stated  in  regard  to  institutionalism  that  it  is  an  out- 
growth of  organization  and  is  the  result  of  routinism. 
Routinism  it  was  declared  develops  prefunctoryism,which  in 
turn  leads  to  automatism,  differing  little  from  that  which  is 
mechanical.  That  which  is  mechanical  moves  in  fixed  lines 
and  is  consequently  opposed  to  progress.  Too  often  the 
institutionalist  is  dominated  by  the  institution.  The  true 
institutionalist,  however,  remains  the  master  of  the  insti- 
tution. The  executive  of  the  institution  sets  the  pace  for 
the  other  participants  of  the  organization.  The  policy 
therefore  should  be  broad  and  liberal.  The  preventive 
measures  to  the  abuses,  above  every  measure  are  to  be 
kept  in  mind.  These  are  found  in  the  individual  equation 
which  goes  to  make  up  the  warp  and  woof  of  the  fabric. 
The  institutionalist  should  glean  everywhere  for  that  which 
makes  progress  and  gives  to  his  labors  the  widest  possible 
usefulness. 

Tendencies  in  Hospitals  for  the  Insane  with  Some  Sug- 
gestions, was  the  name  of  a  paper  by  Dr.  Robbins  of  Dan- 
ville. The  paper  was  read  by  title.  Dr.  Hill  was  unable 
to  be  present  owing  to  the  additional  duties  devolving  upon 
the  staff  members  from  the  death  of  Dr.  Johnson,  whom  it 
may  be  remembered  was  stabbed  by  a  patient  under  treat- 
ment. 

The  Advantage  of  Civil  Service  Principles  in  the  Conduct 
of  State  Hospitals  for  the  Insane. 

Dr.  Gcrshom  H.  Hill  of  Independence,  Iowa,  and  Super- 
intendent of  the  Iowa  State  Hospital  for  the  Insane  in  this 
paper  treated  of  the  benefits  resulting  from  the  system 
and  underlying  principles  in  having  a  board  of  three  in 
control  of  the  state  insitutions  of  Iowa,  in  practice  for  two 
and  a  half  years.  It  was  shown  that  the  system  was 
free  from  political  influence.  A  careful  supervision  Is  had 
over  the  expenses  of  supplies.  In  the  ho.spital  under  Dr. 
Hill's  supervision,  the  personal  element  in  the  treatment 
of  patients  is  preserved,  and  there  is  no  interference  with 
individually  approved  ways  of  treating  patients.  A  medical 
society  is  held  in  connection  with  the  hospital,  scientific  pa- 
pers are  read  and  discussed  and  a  quarteiiv  bulletin  pub- 


lished. Contributions  are  solicited  from  other  institution 
men  in  Iowa  and  other  states.  Solicitation  on  the  part  of 
the  board  for  the  selection  of  an  employe  is  counted  a  mis- 
demeanor. It  is  the  distinction  of  the  board  of  control  law 
to  do  the  business  of  the  state  institutions  on  the  same 
principles  and  methods  used  by  the  United  States  Govern- 
ment in  buying  supplies  or  by  the  up  to  date  business  man. 
The  tendency  is  for  the  legislature  to  trust  the  board  of  con- 
trol, to  adopt  their  recommendations  and  to  appropriate  all 
the  money  asked  for  as  the  resources  of  the  state  will  per- 
mit. Merit  is  the  criterion  in  selecting  help.  The  results 
under  these  civil  service  rules  is  to  secure  as  nearly  as  pos- 
sible perfection. 

The  Need  of  National  Co-operation  in  the  Establishment 
of  Sanatoria  for  Tuberculosis. 

Dr.  A.  Mansfield  Holmes  of  Denver,  detailed  the  advant- 
ages of  sanatoria  in  that  they  increase  the  chances  of  re- 
covery; afford  an  opportunity  for  rigid  sanitary  regulations 
among  patients,  and  furnish  a  means  of  educating  those  in- 
fected, and  the  public,  aginst  sources  of  infection.  He  di- 
vided the  varieties  of  sanatoria  into  three  classifications: 
for  patients  of  limited  means;  for  those  of  moderate 
means,  and  for  the  well  to  do.  The  methods  of  conduct- 
ing sanatoria  were  outlined  under  the  purely  charitable  in- 
stitutions; co-operative  institutions,  and  those  conducted  for 
profit.  In  considering  the  location  of  the  sanatoria,  there 
should  be  for  the  incurable  cases  sanatoria  located  near 
large  centers  of  population  regardlessof  climatic  conditions; 
for  the  incipient  cases  the  most  favorable  climatic  condi- 
tions should  be  chosen  for  the  location  of  the  sanatoria. 
Co-operative  sanatoria  established  on  the  proper  plan  and 
wisely  conducted  would,  in  the  author's  opinion,  overcome 
many  of  the  present  difficulties.  State  and  municipal  aid 
together  with  individual  philanthropy  could  do  much  in  this 
field. 

"Evils  in  some  Asylums,  Hospitals,  Infirmaries  and  Train- 
ing Schools  for  Nurses  that  might  be  avoided  by  placing 
them  under  Civil  Service  Rules,  and  by  Proper  Require- 
ments, Regulations  and  Inspections  on  the  part  of  a  proper- 
ly constituted  and  authorized  Board  of  Health  in  each  State." 
Dr.  Albert  Goldspohn  of  Chicago,  spoke  on  this  subject, 
contending  that  many  of  these  institutions  did  not  yield 
their  intended  degree  of  usefulness  because  of  too  exclu- 
sively lay  management  and  lay  selection  and  appointment 
of  medical  men,  which  very  frequently  resulted  in  the  ap- 
pointment of  inferior  men.  A  still  greater  evil  frequently 
occurred  in  the  public  hospitals  and  asylums  that  were 
under  political  infiuence.  Many  governors,  county  com- 
missioners, etc.,  regarded  medical  appointments  like  all 
others  as  something  with  which  they  had  a  right  to  re- 
ward their  political  henchmen,  who  among  doctors  were 
generally  of  an  inferior  grade  professionally.  He  advo- 
cated giving  the  State  Boards  of  Health  the  additional  du- 
ties, powers  and  emoluments  of  a  medical  civil  service 
board;  that  this  board  should  select  and  submit  all  the  can- 
didates for  political  medical  appointments;  that  it  should 
oblige  laymen  trustees  of  private  or  denominational  hospi- 
tals ,etc.,  to  have  their  candidates  for  medical  positions 
selected  by  some  creditable  local  medical  society;  that  it 
should  determine  the  fitness  of  all  superintendents  and 
matrons  of  hospitals  and  license  them  for  such  positions, 
and  that  a  representation  of  such  a  board  should  examine 
or  inspect  every  such  institution  at  least  once  a  year. 

"Hospitals  and  Sanatoria  Founded,  Owned  and  Con- 
trolled by  the  Medical  Profession:     A  Case  in  Hand.'" 

Dr.  H.  Bert  Ellis  of  Los  Angeles,  stated  in  this  paper  that 
hospitals  may  be  divided  into  three  broad  classifications: 
Charitable,  private,  and  a  hybrid  class,  where  private  wards 
and  free  beds  are  mingled  for  the  pecuniary  gain  of  the 
hospital.  The  description  of  a  hospital  owned  and  con- 
trolled by  physicians  is  given.  It  is  the  outgrowth  of  a 
corporation  known  as  the  California  Hospital  Company. 
The  first  building  erected  for  the  hospital  was  soon  found 


1148 


The  Philadelphia' 
Medical  Journal    . 


SOCIETY  REPORTS 


[June   15,   ISOl 


to  be  inadequate  and  was  added  to.     At  present  the  hos- 
pital owns  a  corner  property  323  feet  by  185%. 

Patients  select  any  reputable  physician  and  pay  him  for 
services.  Every  physician  prescribes  for  and  operates  upon 
his  patients  as  if  in  "the  patient's  own  home  and  prescrip- 
tions are  filled  at  the  drug  store.  Connected  with  the  hos- 
pital is  a  training  school  for  nurses.  The  absolute  man- 
agement of  the  Hospital  is  vested  in  a  Board  of  nine  direc- 
tors elected  annually  from  among  the  stockholders.  The 
plan  of  the  management  is  recommended  to  Eastern  con- 
freres because  the  construction  of  the  building  and  the 
hospital  service  are  entirely  in  accord  with  the  desires  of 
the  physicians;  patients  realize  that  they  are  in  a  hospital 
controlled  and  pratically  owned  by  their  own  physician, 
which  insures  confidence;  and  whatever  profits  accrue  from 
the  hospital  revert  to  the  physician,  thus  giving  safe  in- 
vestments. In  the  opinion  of  Dr.  Ellis  it  is  as  essential  that 
the  profession  own  and  control  the  hospitals  and  sana- 
toria as  that  they  should  own  and  control  their  medical 
journals  in  order  to  keep  them  as  free  as  possible  from  com- 
mercialism. 

"A  Supressed   Educational   Problem." 

Dr.  James  L.  Taylor  of  Wheelersburg,  Ohio,  urged  in  this 
contribution  an  enlightened  "Natural  Selection"  in  lieu  of 
the  ignorant,  haphazard  methods  of  selection  among  people, 
which  result  so  generally  in  physical  as  well  as  intellectual 
deterioration. 

"The  Relation  of  the  Clinical  Laboratory  to  Its  Hospital." 

Dr.  Henry  W.  Cattell  of  Philadelphia,  presented  a  paper 
under  this  title,  in  which  he  takes  for  granted  that  the 
time  has  gone  by  when  it  is  necessary  to  argue  for  the 
existence  of  a  clinical  laboratory  in  connection  with  a  hos- 
pital. The  questions  to  be  considered  in  the  internal  ad- 
ministration of  a  hospital  are  the  relations  of  the  clinical 
laboratory  to  the  board  of  managers,  the  medical  and  surgi- 
cal staff,  the  chief  resident  physician,  the  resident  physi- 
cians, the  superintendent,  the  nurses,  the  out-patient  de- 
partment, etc.  Questions  such  as  these  should  be  asked, 
discussed  and  answered.  How  shall  the  laboratory  be  built, 
equipped  and  conducted?  Shall  there  be  a  laboratory  at- 
tached to  each  ward,  a  general  laboratory,  or  a  combina- 
tion of  both?  Shall  the  director  and  his  assitants  be  paid 
for  their  work?  What  relations  shall  exist  between  the  la- 
boratory worker  and  the  clinician.  What  are  the  usual  causes 
of  friction  arising  from  the  new  state  of  affairs?  Should 
the  members  of  the  staff  be  expected  to  bring  urine,  sputum, 
blood,  etc.,  of  their  pay  patients  both  in  and  out  of  the 
hospital  and  make  the  laboratory  make  these  examinations 
free  of  charge?  Shall  original  investigations  be  carried  on 
in  such  laboratories?  Shall  the  workers  in  the  laboratory 
be  permitted  to  perform  and  to  charge  for  work  received 
from  their  own  patients  or  from  those  desiring  such  ser- 
vices for  money? 

From  personal  experience  extending  over  a  period  of 
twelve  years,  and  from  an  intimate  connection  with  a  num- 
ber of  hospitals  in  various  capacities,  Dr.  Cattell  gives  his 
personal  views  in  regard  to  the  answers  to  some  of  these 
questions. 

Dr.  W.  W.  Keen  of  Philadelphia,  said  he  was  glad  Indeed 
to  have  heard  the  paper  of  Dr.  Cattell.  He  was  less  inter- 
ested, perhaps,  in  the  clinical  laboratory  from  the  adminis- 
trative point  of  view  than  from  the  scientific  and  surgical. 
He  emphasized  the  statement  that  it  was  granted  that  at 
the  present  time  every  hospital,  small  or  large,  should  have  a 
clinical  laboratory,  and  more  than  that,  such  a  laboratory 
needs  a  larger  field  of  usefulness,  which  in  ten  or  twenty 
years  would  be  doubled  or  even  tripled.  Dr.  Keen  empha- 
sized also  the  fact  that  the  poorest  patient  to-day  receives 
better  care  in  a  well  managed  hospital  than  the  well  to 
do  or  even  rich  could  get  at  their  own  homes. 

"Necessity  for  Revising  Medical  Fees." 
Dr.   P.   Maxwell   Foshay   of   Cleveland   read   this   paper, 
stating  that  the  custom  of  charging  a  fixed  sum  for  each 


visit  was  a  relic  of  antiquity  and  illogical.  Other  callings 
are  differently  regulated  as  is  also  the  special  practice  in 
the  profession.  The  author  thinks  there  is  every  reason 
in  the  world  for  the  general  practitioner  to  proportion  his 
charge  in  all  cases  to  the  value  of  the  service  rendered  and 
to  the  ability  of  his  patient  to  pay.  The  need  of  a  "fee- 
bill"  is  stated  to  establish  a  standard  agreed  upon  by  phy- 
sicians in  their  societies  to  which  the  profession  can  appeal 
when  dealing  with  patients.  This  also  is  of  definite  ser- 
vice in  court  when  suing  to  recover  the  amount  of  a  bilL 
A  greater  object  urged  for  this  new  method  is  its  means 
of  checking  to  some  extent  the  pernicious  custom  of  giving 
"commissions."  No  present  retrogressive  tendency  in  the 
evolution  of  the  medical  profession  is  at  present  so  strong 
as  this  of  the  physician  dividing  fees  behind  the  patient's 
back.     It  saps  morality  to  its  foundations. 

"Refraction." 

A  paper  by  this  title  was  presented  by  Dr.  James  A- 
Spalding  of  Portland.  Me.  Dr.  Spalding  gave  a  personal 
experience  of  an  ophthalmologist  suffering  from  a  sudden 
loss  of  vision  and  consulting  first  the  optician  and  then  the 
oculist  for  aid.  showing  the  inefBcieney  of  the  former  and 
the  great  help  which  the  latter  gave  to  him.  In  view  of  this 
Dr.  Spalding  asks,  would  it  not  be  preferable  for  the  pro- 
fession to  address  the  public  through  the  public  press  re- 
garding all  sorts  of  ailments,  thereby  preventing  them  ac- 
cepting the  beguilements  of  charlatans.  Physicians  too 
ought  to  becarefud  in  referring  their  patients  only  to  those 
who  have  a  proper  knowledge  of  disease.  An  increase 
In  the  solidarity  of  the  profession  is  needed. 

Dr.  Tuckerman  of  Cleveland,  and  Dr.  Risley  of  Philadel- 
phia, referred  to  cases  in  which  grevious  damage  had  been 
done  through  failure  of  the  patients  to  be  referred  to  an 
oculist  rather  than  to  the  advertising  optician. 

The  meeting  at  his  point  went  into  executive  session. 
The  Nominating  Committee  named  the  following  officers 
who  were  elected: 

President,  Dr.  V.  C.  Vaughan:  1st  Vice-President  Dr. 
James  L.  'Taylor,  of  Wheelrsburg,  Ohio:  2nd  Vice-Presi- 
dent, Dr.  W.  A.  N.  Dorland,  of  Philadelphia:  3rd  Vice- 
President,  Dr.  H.  P.  Ritchie  of  St.  Paul,  4th  Vice-Presi- 
dent, Dr.  H.  Bert  Ellis  of  Los  Angeles  of  Cal.;  Secretary  and 
Treasurer  Dr.  Charles  Mclntire  of  Easton;  Assistant  Secre- 
tary, Dr.  A.  R.  Craig  of  Columbia.  Pa. 

After  a  few  remarks  by  the  retiring  President,  Dr.  S.  D. 
Risley,  the  meeting  was  declared  adjourned. 


A  Case  of  Barlow's  Disease. — Dr.  G.  Variet  reports  a 
case  of  infantile  scur%T  with  pseudo-paralysis  of  both  legs, 
in  a  boy  of  7  months  (Bullrlint  et  Memoires  de  la  Soriete  Ved- 
icalc  dot  Bopilauj-  dc  Paris.  1901,  No.  8).  The  child  had 
been  taking  Gaertner's  milk,  which  is  cow's  milk  with  half 
its  casein  deducted  and  lactose  added,  since  the  age  of  two 
months.  He  had  no  teeth.  Upon  diluted,  unboiled  milk 
and  orange  juice,  the  conditions  cleared  in  two  weeks.  Af- 
ter a  full  review  of  the  literature  of  the  subject.  Variot 
concludes  that  Barlow's  disease  bears  no  relation  to  adult 
scurvy;  that  it  is  probably  hemorrhagic  rickets:  that  it 
is  very  rare  in  Franco,  though  sterilized  milk  is  very  gener- 
ally used:  that  modified  milk  rather  than  pure  milk  causes 
it;  and  that  it  is  not  a  serious  condition,  as  change  of  diet 
will  effect  a  cure.     [M.  O.] 


The  Influence  of  Work.  Nourishment,  and  Dust  upon  Tu- 
berculosis.— I.annelongue,  Achard,  and  Gaillard  report  their 
experiments  upon  100  rabbits  inoculated  with  tubercle  ba- 
cilli, in  the  (Piiihtin  Mrdiral.  1901.  No.  361.  The  inhalation 
of  dust-laden  air  proved  fatal  to  17  out  of  20  animals.  Those 
which  were  left  alone  at  rest  are  still  living,  while  those 
which  did  the  most  work  died  first.  Insufficient  food  by 
itself  hastens  death  from  tuberculosis.  But  those  animals 
died  soonest  which  received  but  scanty  food  yet  did  hard 
work;  they  also  showed  great  loss  of  weight.  Whence  they 
conclude  that  the  emaciation  often  found  with  tuberculosis 
in  man  is  the  result  of  nutritive  disturbances,  especially 
alimentary,  not  of  the  tuberculous  process.     fM.  O.] 


June   15,   1901] 


THE  LATEST  LITERATURE 


rfHE 

Lmed 


Philadelphia 

ICAL  .IrtrRNAL 


1 1 49 


Cbc  Xatcet  literature. 


BRITISH    MEDICAL   JOURNAL. 
May  25th,  1901.  ■ 

1.  A   Clinical   Lecture   on   Appendicitis   and   its    Surgical 

Treatment.     J.  CRAWFORD  RENTON. 

2.  An  Address  on  the  Symptoms  and  Modern  Methods  of 

Diagnosis  of  Stone  in  the  Bladder,  Kidney  and  Ure- 
ter.    P.  J.  FREYER. 

3.  Notes  on  206  Operations  for  Stone.    W.  P.  ADAMS. 

4.  A  Method  of  Sterilizing  Soft  Catheters.     HERBERT  T. 

HERRING. 

5.  A  Case  of  Almost  Universal  Ankylosis.     T.  K.  MONRO. 

6.  Strangulation      of      Meckel's    Diverticulum.        KEITH 

CAMPBELL. 

7.  A  Case  of  Cancer  of  the  Larynx  with  a  Long  Course. 

E.  DONALDSON. 

8.  Furunculosis  of  the  External  Auditory  Canal  Simulating 

Mastoid    Periostitis.        JAMES    GALBRAITH    CON- 
NAL. 

1. — In  this  clinical  lecture  J.  C.  Renton  discusses  the 
various  forms  of  appendicitis  and  the  established  tr«at- 
ment  of  each.     [J.  H.  G.] 

2. — P.  J.  Freyer  discusses  the  symptoms  and  diagnosis  of 
stone  in  the  bladder,  kidney  and  ureter.  Hematuria,  al- 
though not  the  first  or  most  distressing  symptom  of  stone 
in  the  bladder,  is  usually  the  one  which  causes  the  patient 
to  seek  medical  advice.  It  comes  on  gradually  and  toward 
the  end  of  micturition.  The  amount  of  blood  is  Increased 
by  exercise.  The  stoppage  of  the  flow  of  urine  Is  not  the 
most  common  symptom  of  stone,  but  occurs  more  fre- 
quently in  the  earlier  than  in  the  later  stages.  Attention 
is  called  to  the  fact  that  frequent  micturition  occuring 
from  stone  in  the  bladder  takes  place  during  the  day  when 
the  patient  is  moving  about.  The  author  has  operated 
upon  over  1000  cases  of  stone  and  among  these  there  were 
only  23  females.  The  author  reminds  us  that  other  condi- 
tions than  stone  give  rise  to  reflex  pain  at  the  glans,  among 
these  being  enlarged  prostatic  middle  lobe,  tubercle  of  the 
prostate,  local  cystitis,  ulcer  of  the  bladder,  clots  of  blood, 
etc.  The  pain  of  stricture  when  it  does  occur  accompanies 
the  act  of  micturition  and  is  felt  at  the  location  of  the  stric- 
ture; pain  of  an  enlarged  prostate  precedes  the  act  and  is 
as  a  rule  referred  to  the  hypogastric  region;  whereas  the 
pain  of  a  vesicle  calculus  follows  the  act  of  urination  and 
is  felt  behind  the  glans.  It  must  be  remembered  that 
prostatic  enlargement  and  calculus  are  very  frequently  as- 
sociated. In  tumors  of  the  bladder  the  bleeding  is  more 
profuse  than  in  cases  of  stone,  and  the  urine  is  uniformly 
mixed  with  blood.  Tubercle  of  the  bladder  more  closely 
resembles  stone  than  any  other  condition.  The  sound  and 
the  cystoscope  here  will  enable  one  to  make  a  diagnosis. 
Always  a  rectal  examination  should  be  made  before  sound- 
ing. An  anesthetic  should  always  be  employed  in  chil- 
dren. There  is  no  better  sound  than  that  known  as  Mer- 
cier's.  When  all  other  means  of  diagnosis  fail  the  author 
uses  a  method  which  he  brought  out  a  number  of  years  ago 
which  consists  in  introducing  one  of  the  canulae  of  the 
Bigelow  apparatus  into  the  bladder  and  applying  the  aspi- 
rator. Finally,  Leiter's  electric  cystoscope  will  be  found 
of  the  greatest  advantage  in  making  diagnoses  of  bladder 
conditions.  The  symptoms  of  renal  calculus  are  next  de- 
scribed. Renal  colic  occurs  as  a  symptom  w^hen  the  stone 
is  small,  but  after  the  malady  has  existed  for  some  time, 
perhaps  two  or  three  years,  the  typical  renal  colic  attacks 
gradually  subside,  to  be  replaced  with  a  constant  heavy 
aching  pain  fixed  in  the  loin.  Hematuria  follows  attacks 
of  renal  colic  and  rarely  it  occurs  periodically  as  the  first 
symptom  noticed  by  the  patient.  As  a  rule  the  quantity 
of  blood  passed  is  not  large.  It  is  in  the  early  stages  that 
this  symptom  is  most  marked.     Attention  is  called  to  the 


fact  that  heredity  plays  a  considerable  part  in  the  causa- 
tion of  stone.  The  Rontgen  rays  may  be  employed  to  form 
a  diagnosis  of  stone  but  if  no  stone  is  found  by  this  means 
one  should  not  be  deterred  from  exploring  the  kidney  if 
the  symptoms  of  stone  are  well  marked.  Stone  in  the 
ureter  is  next  described  and  reference  is  made  to  the  use 
of  the  cystoscope  for  the  diagnosis  of  stones  lodged  in  the 
lower  extremity  of  the  ureter.     [J.  H.  G.] 

3. — W.  F.  Adams  reports  20B  operations  done  in  India 
for  stone.  The  author  used  lithotrity  in  153  males  and 
lithotomy  in  36.  He  has  never  found  a  stone  too  hard  to 
crush.  48  of  the  cases  were  in  boys  under  10  years  of  age, 
and  1.5  were  in  boys  under  3  years  of  age.  One  death  oc- 
curred in  a  boy  3%  years  of  age.  The  author  derived  great 
advantage  from  the  introduction  of  a  drachm  of  oil  into 
the  urethra  prior  to  the  passage  of  the  instrument  and  in 
young  boys  the  crevices  of  the  crushing  instrument  were 
filled  with  soap  before  introduction  to  avoid  scratching  the 
mucous  membrane.  When  the  instrument  cannot  be  readi- 
ly and  easily  passed  he  thinks  lithotomy  had  better  be- 
resorted  to.  Three  deaths  occurred  out  of  36  cases  of 
lithotomy  and  three  out  of  161  cases  of  crushing.  Two  of 
these  deaths  could  hardly  be  attributed  to  the  operation, 
which  was  lithotrity.     [J.  H.  G.] 

4. — Herbert  T.  Herring  recommends  moist  heat  as  a 
method  of  sterilization  of  soft  catheters.  Water  at  150- 
degrees  F.,  even  tor  ^^  minute  is  a  reliable  sterilization  for 
catheters  for  ordinarj'  work  (that  is  it  would  not  in  this 
time  kill  bacteria  with  spores,  but  these  are  not  likely  to 
be  met  with)."  The  author  then  describes  a  metal  case 
which  he  uses  for  heating  and  at  the  same  time  lubricating 
soft  catheters.     [J.  H.  G.] 

5. — Monro  reports  the  case  of  a  man  who  died  at  the  age 
of  46  years,  with  all  his  joints  ankylosed.  The  disease  be- 
gan when  the  patient  was  18  years  of  age.  He  was  an 
iron  turner  by  occupation  and  it  is  very  probable  that 
the  disease  was  caused  by  frequent  wetting,  as  the  patient 
was  going  to  and  from  his  work.  The  course  of  the  dis- 
ease was  very  painful  until  the  joints  affected  became  fixed,, 
and  then  the  pain  in  that  particular  joint  would  disappear. 
The  patient  was  obliged  to  give  up  work  2  years  after  the 
onset  of  the  disease,  and  2  years  later  became  bed  ridden. 
The  right  eye  was  the  seat  of  an  acute  iridocyclitis,  which 
rapidly  went  on  to  atrophy  of  the  globe  with  suosequent 
ossification  of  the  choroid  coat.  Death  occurred  during 
an  attack  of  bronchitis  and  pleuritis  from  accumulation  of 
bronchial  secretion.  There  was  no  autopsy.  The  author 
considers  the  case  to  be  one  of  universal  bony  ankylosis  or 
arthritis  ossificans.     [J.  M.  S.] 

8. — Keith  Campbell  reports  a  case  of  strangulation  of 
Meckel's  diverticulum  which  occurred  in  an  old  man  70- 
years  of  age  suffering  with  senile  dementia.  The  diverti- 
culum was  414  inches  long  and  was  herniated  into  the  left 
crurial  canal  and  here  adherent  to  an  inflamed  gland.  It 
closely  resembled  the  small  intestine  but  was  smaller  than 
this  gut.  Its  proximal  attachment  was  2?i  feet  from  the 
ileo-cecal  valve.  In  addition  to  the  strangulation  in  the 
hernial  sac  the  diverticulum  was  also  twisted  upon  itself. 
No  operation  was  done,  the  condition  described  being 
learned  post-mortem.     [J.  H.  G.] 

7. — E.  Donaldson  reports  a  case  of  cancer  of  the  larynx 
which  ran  over  a  course  of  10  years.  The  case  illustrates 
the  fact  that  a  warty  benign  growth  may  present  symp- 
toms of  a  benign  tumor  for  a  number  of  years  and  in  the 
end  become  malignant.     [J.  H.  G.] 

8. — James  Galbraith  Connal  reports  two  cases  of  ferun- 
culosis  of  the  external  auditory  canal  which  gave  rise  to 
symptoms  very  closely  resembling  mastoiditis.  In  these 
cases  without  an  examination  of  the  canal  one  would  have 
supposed  them  to  be  cases  of  periostitis  of  the  mastoid. 
The  swelling  and  edema  of  the  mastoid  area  is  due  to 
the  extension  of  the  inflammation  from  the  external  audi- 
tory canal  through  the  fissures  of  Santorini,  or  along  the 
fibrous  band  in  the  roof  of  the  canal.     [J.  H.  G.] 


1 1  50 


The  Philadelphia 
Medical    Journal 


THE  LATEST  LITERATURE 


[JUXE 


1901 


LANCET. 

May  35,  1001.     (No.   4056.) 

1.  An   Address   on   the   operative   Treatment   of  Abscess 

when  situated  on  the  Brain.     CHAS.  A.  BALLANCE. 

2.  The  Erasmus  Wilson  Lectures  on  the  Pathology  and 

Diseases    of  the   Thyroid    Gland.  W4LTER    ED- 

MUNDS. 

3.  The    Surgical    Treatment    of     Chronic      Ulcer    of   the 

Stomach.     A.    W.  MAYO  ROBSON. 

4.  Analyses  of  Stools  and  Urine  from  Epileptic  Patients 

under  Treatment  with  "Brominol"  compared  with 
similar  Specimens  from  Patients  under  Potassium 
Bromide.     V.  HARRISON  MARTINDALE. 

5.  Two  Cases  of  Carcinoma  treated   with  Cacodylate  of 

Soda.     EDWARD  MARTIN  PAYNE. 

6.  Acute  Colitis  in  Children.     EDMUND  CAUTLEY. 

1. — Charles  A.  Ballance  discusses  in  this  address  the 
operative  treatment  of  abscess  of  the  brain.  He  thinks 
that  it  is  important  to  determine  the  nature  of  the  micro- 
organism producing  the  abscess  at  as  early  a  period  as 
possible.  The  various  details  of  operation  from  the  steriliz- 
ing of  the  skin  to  the  application  of  the  dressing  are 
minutely  described.  He  recommends  very  strongly  a 
large  opening  in  the  skull  after  first  turning  down  a  large 
scalp  flap.  For  the  drainage  of  an  abscess  in  the  tempero- 
sphenoidal  lobe  the  trephine  opening  should  be  made  7-8" 
above  the  supra-meatal  spine.  In  operating  for  a  cere- 
bellar abscess  the  trephine  should  be  placed  with  its  upper 
edge  just  below  Reid's  base  line  and  its  anterior  edge  touch- 
ing the  posterior  border  of  the  mastoid  process.  In  in- 
cising the  dura  mater  the  opening  should  be  made  by  a  flap 
rather  than  by  a  crucial  incision.  Ballance  recommends 
the  use  of  a  long,  narrow,  straight  bistoury  for  the  purpose 
of  exploration  rather  than  the  use  of  the  exploring  needle 
or  canula,  as  the  incised  wound  of  the  brain  heals  better 
than  the  punctured  wound.  The  finger  is  also  to  be  used 
for  exploration,  irrigation  of  an  abscess  of  the  brain 
should  only  be  done  when  there  is  free  exit  for  the  fluid 
such  as  is  accomplished  by  the  use  of  a  tube.  The  au- 
thor does  not  approve  of  tamponing  these  cavities  with 
gauze.  Recurrence  of  symptoms  is  not  an  uncommon 
thing  a  few  days  after  the  opening  of  a  brain  abscess  and 
it  is  due  either  to  a  reaccumulation  of  the  fluid  or  else  to 
an  entirely  new  formation  of  pus  in  another  part  of  the 
same  lobe.     This   is   particularly   true   of  the   cerebellum. 

[J.  G.  H.] 
2. — Edmunds  delivered  three  lectures  on  the  pathology 
and  diseases  of  the  thyroid  gland  before  the  Royal  College 
of  Surgeons  of  England.  He  describes  the  histology  of  the 
thyroid  gland  stating  that  it  is  composed  of  closed  vesicles 
lined  with  epithelial  colls.  The  secreting  cells  are  cubi- 
cal and  elaborate  the  colloid  material,  which  may  be  readi- 
ly detected  by  microscopical  tinctorial  tests.  It  has  been 
demonstrated  that  the  nerves  of  the  gland  are  in  close 
proximity  to  the  secreting  cells.  He  also  states  that  the 
parathyroid  glands,  which  are  small  glands  in  relation  to 
the  thyroid  gland,  are  composed  almost  exclusively  of  cells, 
and  that  they  do  not  contain  vesicles  and  very  little,  if  any, 
colloid  material.  Four  of  these  glands  have  been  described, 
one  behind  and  above,  and  another  in  front  and  below 
each  lobe  of  the  thyroid  gland.  They  are  developed  prior 
to  the  thyroid  lobes.  The  parathyroid  glands  are  with  dif- 
ficulty differentiated  from  accessory  thyroid  glands;  the 
main  point  of  difference  being  that  the  parathyroid  tissue 
is  composed  almost  exclusively  of  cells.  Complete  re- 
moval of  the  thyroid  glands  and  the  parathyroid  glands  In 
a  dog  is  followed  by  well  defined  symptoms  in  forty-eight 
hours,  and  by  death  on  or  about  the  fifth  day  after  extir- 
pation. An  early  symptom  is  a  fibrillar  twitching  of  the 
muscles.  General  convulsions  may  occur.  During  these 
the  temperature  rises  and  the  respirations  are  hurried. 
These  seizures  may  last  for  about  an  hour  and  may  recur. 


In  a  day  or  two  the  animal  becomes  listless,  the  hair  falls 
out,  the  animal  has  difficulty  to  maintain  its  equilibrium, 
the  limbs  later  become  rigid,  the  urine  may  contain  al- 
bumin, less  commonly  sugar,  and  the  temperature  is  sub- 
normal. Occasionally  dogs  recover  after  total  extirpation  of 
the  thyroid  gland.  Removal  of  the  thyroid  gland  in  rab- 
bits produces  no  effect  whatever,  for  the  reason,  as  Gley 
has  demonstrated,  that  in  rabbits  two  of  the  parathyroid 
glands  are  separated  from  the  thyroid  gland  proper,  and 
when  the  latter  is  excised  these  two  structures  escape  re- 
moval. This  observer  also  showed  that  when  the  para- 
thyroid glands  and  the  thyroid  gland  were  removed  the 
rabbit  as  a  rule,  died.  Excision  of  the  thyroid  gland  in 
monkeys  produces  symptoms  which  are  almost  identical 
with  those  seen  in  dogs,  and  that  death  nearly  always  oc- 
curs in  these  animals  after  removal.  After  some  experi- 
ments Edmunds  pointed  out  that  thyroid-feeding  in  dogs, 
after  excision  of  the  thyroid  gland,  modified  the  symptoms 
somewhat  and  delayed  death  for  a  few  days  and  decreased 
the  mortality  slightly.  In  monkeys  similar  results  were 
obtained.  Removal  of  two  parathyroid  glands  and  a  single 
lobe  of  the  thyroid  in  dogs  was  not  followed  by  death,  but 
a  subsequent  removal  of  the  remaining  thyroid  lobe  and  its 
parathyroid  glands  was  followed  by  a  fatal  issue.  When 
but  a  single  lobe  was  excised  hypertrophy  occurred  in 
the  remaining  portion.  If  the  thyroid  gland  and  three 
parathyroid  glands  were  removed  in  a  dog,  care  being  taken 
not  to  interfere  with  the  blood  supply  of  the  remaining 
parathyroid  gland,  death  did  not  occur  as  a  rule,  and  no 
obvious  effects  followed.  The  parathyroid  gland  remaining 
became  hypertrophied  but  did  not  develop  into  thyroid  tis- 
sue,— vesicles  di  not  form.  The  subsequent  removal  of 
this  gland  and  two  parathyroids  was  followed,  by  death. 
In  rabbits  extirpation  of  the  thyroid  gland  and  two  para- 
thyroids was  followed  after  several  months,  by  im- 
pairment of  the  health,  falling  out  of  the  hair, 
and  swelling  of.  the  lower  part  of  the  face.  The 
palpebral  fissure  became  very  narrow.  Complete  parathy- 
roidectomy leaving  the  thyroid  lobes,  in  nine  dogs,  was 
was  followed  by  death  in  four  animals,  temporary-  symp- 
toms in  three,  and  no  ill  effects  in  two.  The  author  em- 
phasizes that  it  is  very  difficult  to  remove  all  of  the  para- 
thyroid tissue.  He  refers  to  the  conclusions  of  Vassale 
and  General!,  who  demonstrated  that  complete  parathyroi- 
dectomy in  dogs  was  followed  by  death.  After  excision  of 
the  parathyroid  glandsthethyroid  lobesdidnot  enlarge,  but 
the  secreting  cells  became  columnar,  the  vesicles  were  filled 
with  a  water>-  secretion,  and  the  colloid  material  diminished 
or  completely  disappeared.  He  maintains  that  the  para- 
thyroid glands  probably  secrete  a  material  which  is  stored 
in  the  thyroid  lobes,  and  that  the  thyroid  lobes  which 
are  left  after  the  removal  of  the  parathyroids  are  in  a 
state  of  what  may  be  termed  "compensatory  hypertrophy." 
Excision  of  one  thyroid  lobe,  in  the  five  dogs  which  sur- 
vived, after  total  extirpation  of  the  parathyroids,  produced 
death  in  two,  and  in  the  remaining  three  subsequently  the 
other  thyroid  lobe  was  removed.  Death  occurred  in  one, 
and  two  survived  and  recovered  after  temporary  symptoms. 
The  symptoms  developing  in  the  animals  that  subsequently 
died,  were  great  weakness,  emaciation,  tremors,  narrow- 
ing of  the  palpebral  fissure,  unsteadiness  of  the  gait,  fol- 
lowed by  paralysis  of  the  hind  legs.  Seven  dogs  were 
subjected  to  partial  parathyroidectomy; — one  died  after 
seventy-two  days,  and  four  developed  symptoms  from  which 
they  recovered.  In  one  of  the  six  remaining  dogs  the  re- 
moval of  both  thyroid  lobes  produced  death  in  three  days. 
One  thyroid  lobe  was  excised  in  the  remaining  five  dogs, 
and  death  resulted  in  three  instances,  while  two  recovered 
and  one  of  these  manifested  definite  symptoms.  Finally, 
th  removal  of  the  remaining  thyroid  gland  in  the  two  ani- 
mals that  survived,  produced  death.  Incomplete  extirpa- 
tion of  the  parathyroid  glands,  in  two  of  the  dogs  was  fol- 
lowed by  a  widening  of  the  palpebral  fissure,  and  after  a 
subsequent  operation  the  eyes  became  narrowed  and  re- 


June   15,   1901] 


THE  LATLST  LITERATURE 


El'HE  Philadelphia 
Medical   Journal 


II5I 


tracted.  In  one  of  the  dogs  in  which  incomplete  para- 
thyroidectomy was  performed,  the  animal  developed  no  oc- 
ular manifestations,  but  the  excision  of  one  thyroid  lobe 
and  parathyroid  gland  in  this  animal  produced  a  widening 
of  the  palpebral  fissure.  The  author  concludes  that  com- 
plete parathyroidectomyprobably  induces  exophthalmos  in 
the  non-fatal  cases,  while  in  those  instances  in  which  death 
results,  either  from  total  thyroidectomy  or  removal  of  the 
parathyroid  glands,  the  palpebral  fissure  becomes  very 
narrow.  The  author  emphasizes  that  these  observations 
lend  strong  support  to  the  view  that  the  parathyroid 
glands  are  involved  in  Grave's  disease,  By  a  series  of  ex- 
periments he  has  demon.strated  that  the  nerve  supply  of  the 
thyroid  gland  has  much  to  do  with  the  control  of  its  in- 
ternal secretion.  He  excised  a  part  of  the  supra-laryngeal 
nerve  and  a  portion  of  the  vago-sympathetic  on  one  side, 
and  removed  the  thyroid  lobe  with  its  parathyroid  glands  on 
the  opposite  side.  Of  nine  dogs  experimented  upon  three 
died,  four  of  the  remaining  animals  developed  athyroidic 
symptoms,  and  the  remaining  two  developed  no  symptoms. 
The  author  states  that  we  must  admit  the  possibility  of 
disturbances  with  the  nerve  supply  in  the  pathology  of 
thyroid  disease.  Reference  is  made  to  the  symptoms  which 
result  from  the  administration  of  large  quantities  of  thy- 
roid extract  in  man.  He  mentions  the  results  of  a  num- 
ber of  observers  who  have  shown  that  the  administration 
of  the  thyroid  gland  produces:  increase  in  the  pulse  rate 
and  respirations,  fever,  sensations  of  heat  and  increased 
perspiration,  tremors,  increased  secretion  of  urine,  often 
albuminuria,  and  mental  agitation.  He  fed  dogs  upon  large 
quantities  of  thyroid  extract  without  any  obvious  effect. 
In  monkeys  the  administration  of  the  thyroid  extract  pro- 
duced exophthalmos,  a  widening  of  the  palpebral  fissure,  dil- 
atation of  the  pupils,  emaciation  and  weakness,  falling  out 
of  the  hair  in  patches,  and  paralysis  of  one  or  more  ex- 
tremities. Seventy-six  days  was  the  average  duration  of 
life  of  the  monkeys  fed  upon  thyroid  extract.  The  effects 
produced  upon  the  eyes  were  undoubtedly  due  to  the  action 
of  the  thyroid  extract  upon  the  cervical  sympathetlcs. 
He  administered  thyroid  extract  to  two  monkeys  in  which 
the  cervical  sympathetic  had  been  excised  on  one  side. 
After  twelve  days  he  found  that  on  the  unoperated  side 
there  was  exophthalmos,  dilatation  of  the  pupils,  and  widen- 
ing of  the  palpebral  fissure;  while  on  the  other  side  the 
pupil  was  not  dilated  nor  was  the  eye-ball  prominent,  and 
the  palpebral  fissure  was  narrow.  The  author  states  that 
very  little  is  known  in  regard  to  the  action  produced  by  the 
administration  of  the  parathyroid  gland.  With  respect  to 
myxedema  and  cretinism  he  is  inclined  to  agree  with  the 
view  set  forth  by  Allen  Starr,  that  the  narrowing  of  the 
palpebral  fissure  cannot  be  attributed  to  the  swollen  con- 
dition of  the  eye-lids.  Edmunds  believes  that  the  admini- 
stration of  thyroid  extract  is  the  best  treatment  for  sporadic 
goitre.  In  regard  to  the  pathology  of  Graves's  disease  evi- 
dence points  strongly  to  the  view  that  the  symptoms  are 
due  to  the  secretions  from  the  goitre.  The  thyroid  gland, 
in  cases  of  Grave's  disease,  appears  to  be  in  a  state  of 
active  secretion.  Microscopically,  it  has  been  shown  that 
the  secreting  cells  lining  the  vesicles  are  columnar  in- 
stead of  cubical,  the  colloid  material  within  the  vesicles  is 
diminished  or  absent,  and  replaced  by  a  secretion  which  re- 
acts poorly  to  stains.  These  changes  are  practically  iden- 
tical to  the  compensatory  hypertrophy  in  animals  after  re- 
moval of  part  of  the  gland,  and  finally  he  suggests  that 
the  primary  lesion  may  possible  be  found  in  the  parathyroid 
glands.  The  article  is  concluded  with  a  discussion  of  the 
treatment  of  Graves's  disease.     [F.  J.  K.] 

3. — This  article  on  the  surgical  treatment  of  chronic  ulcer 
of  the  stomach  will  be  found  at  length  in  the  Philadelphia 
Medical  Journal  of  May  25th.     [J.  H.  G.] 

4. — Martindale  maintains  that  brominol,  a  compound  of 
bromine  and  sesame  oil,  containing  33V^%  of  the  halogen 
in  chemical  combination,  deserves  a  more  extensive  trial. 
He  believes  that  on  account  of  the  close  combination  of 


the  bromine  atoms  in  the  molecules  of  the  fatty  acids  there 
is  a  remarkable  stability  of  the  compound  brominol.  The 
effort  necessary  to  separate  and  absorb  the  bromine  from 
this  compound  is  probably  alvantageous  to  the  economy. 
It  may  be  argued  that  brominol  possesses  advantages  over 
the  potassium  bromide  on  account  of  its  more  stable  chemi- 
cal combination.  On  account  of  the  great  chemical  solu- 
bility of  the  alkaline  bromide,  it  is  absorbed  and  passes 
off  rapidly  without  inducing  its  full  action.  In  a  compara- 
tive table  the  author  gives  the  results  of  analysis  of  stools 
and  urine  from  epileptic  patients  who  were  under  treat- 
ment with  brominol,  and  others  with  potassium  bromide. 

5. — Payne  discusses  the  value  of  cacodylate  of  soda  in 
the  treatment  of  two  cases  of  carcinoma.  The  first  case 
was  that  of  a  woman,  45  years  of  age,  who  consulted  the  au- 
thor on  January  14,  1900,  and  complained  of  irregular  and 
profuse  hemorrhages  from  the  vagina.  On  October  5th  the 
patient  had  a  severe  hemorrhage  from  the  vagina.  The  ex- 
amination at  this  time  revealed  ulceration  of  the  cervix 
and  fixation  of  the  uterus.  The  morbid  process  was  so  ex- 
tensive that  operative  interference  was  deemed  unwise. 
On  December  16th  cacodylate  of  soda  was  used  hyporder- 
mically.  The  first  dose  was  2  centigrams.  On  January 
16th,  1901,  the  dose  had  ben  increased  up  to  7.5  centigrams. 
The  patient  refused  to  continue  the  treatment  on  March 
14th.  The  patient's  general  health  had  improved,  she  had 
gained  in  weight,  and  the  vaginal  hemorrhages  had  ceased. 
The  patient  declared  that  she  had  never  had  cancer  and 
for  that  reason  she  gave  up  the  treatment.  The  second 
case  the  author  reports  occurred  in  a  man  70  years  of 
age,  who  first  came  under  his  observation  on  August  2, 
1900,  complaining  of  a  sore  mouth  and  tongue.  On  ex- 
amination the  tongue  was  found  to  be  ulcerated.  The  di- 
agnosis of  carcinoma  was  made  on  March  17th  hypodermic 
injections  of  cacodylate  of  soda  were  begun.  After  six 
■weeks  of  this  treatment  the  author  is  convinced  that  the 
local  trouble  improved.  The  author  maintains  that  caco- 
dylate of  soda  is  a  valuable  palliative  remedy  in  the  treat- 
ment of  cancer,  and  that  this  drug  should  at  least  be  given 
a  trial  in  inoperable  cases.     [F.  J.  K.] 

6. — Cautley  writes  upon  acute  colitis  In  children  and 
gives  a  report  of  a  limited  outbreak  which  came  under 
his  observation.  All  of  the  cases  occurred  in  certain 
London  barracks.  In  this  dwelling  the  epidemic  began  on 
the  third  floor,  then  spread  to  the  ground  floor,  and  then  to 
the  first  floor.  After  a  most  careful  investigation  the  au- 
thor was  unable  to  ascertain  the  source  of  infection.  He 
gives  a  short  account  of  four  cases.  Case  1:  On  June  2Sth, 
1900,  a  girl,  5  years  of  age,  was  admitted  into  the  Belgrave 
Hospital  for  Children,  complaining  of  vomiting  and  diar- 
rhea. Her  temperature  was  normal  and  the  pulse  140.  The 
patient  did  not  complain  of  pain.  The  child  rapidly  grew 
weaker  and  died  on  July  1st.  Case  2:  This  patient,  a  boy 
3  years  of  age,  was  admitted  to  the  Hospital  on  July  1st, 
complaining  of  vomiting,  diarrhea,  and  abdominal  pain. 
Fever  continued  throughout  his  illness,  and  the  patient 
died  on  July  8th.  Case  3:  On  July  ISth  a  female  infant, 
2  years  of  age,  was  admitted  into  the  Hospital  suffering 
from  diarrhea  and  vomiting,  and  the  temperature  was  101° 
F.  The  diarrhea  continued  for  some  time,  the  child  grad- 
ually improved  and  recovered.  Case  4:  On  August  11th,  a 
male  child.  3  years  of  age,  was  admitted  into  the  Hospital 
also  complaining  of  diarrhea  and  vomiting.  The  tempera- 
ture was  100°  F.  and  the  pulse  rate  was  130.  This  pa- 
tient gradually  improved  and  was  discharged  recovered 
on  September  17,  1900.  Upon  postmortem  examination  in 
the  first  case  it  was  found  that  the  entire  large  intestine 
was  thickened,  affecting  especially  the  mucous  membrane. 
Superficial  ulcerations  were  present  and  small  hemorrhages 
were  found  in  the  coats  of  the  bowel.  Acute  inflamma- 
tion also  involved  the  last  few  inches  of  the  Ileum,  and  the 
mesenteric  glands  were  enlarged.  The  postmortem  ex- 
amination in  the  second  case  presented  similar  anatomical 


I  1^2 


The  Philadelphia"! 
Medical  Journal   J 


THE  LATEST  LITERATURE 


[Juke   15,    ISOl 


lesions.  The  author  concludes  the  article  with  a  discussion 
on  the  nomenclature,  suggesting  the  term  "acute  catarrhal 
colitis"  for  this  disease,  and  a  general  description  of  the 
condition,  outlining  its  course,  symptomatology,  and  treat- 
ment.    [F.  J.  K.] 


MEDICAL    RECORD. 
June  8th,  1901. 

1.  The  President's  Address.     CHARLES  A.  L.  REED. 

See  page  1119  Philadelphia  Medical  Journal  of  this 
week. 

2.  Internal   Medicine   in   the   Nineteenth   Centurj-.     N.   S. 

DAVIS. 

See  page  1122  Philadelphia  Medical  Journal  of  this 

week. 

3.  The   Value   of   Clinical    Microscopy,    Bacteriology   and 

Chemistry  in  Surgical  Practice.  JOHN  A.  WYETH. 
See  page  1120  Philadelphia  Medical  Journal  of  this 
week. 

4.  The  Progress  and  Tendency  of  Hygiene  and  Sanitarj' 

Science   in   the   Nineteenth    Century.     GEORGE    M. 

KOBER. 

See  page  1122  Philadelphia  Medical  Journal  of  this 

week. 


THE    NEW    YORK    MEDICAL    JOURNAL. 

June  SIh,  1001. 

1.  The  Address  of  the  President  of  the  American  Medical 

Association.     CHARLES  A.  L.  REED. 

See  page  1119  Philadelphia  Medical  Journal  of  this 

week. 

2.  Internal   Medicine   in   the   Nineteenth   Century.     N.   S. 

DAVIS. 

See  page  1120  Philadelphia  Medical  Journal  of  this 

week. 

3.  The    Value   of   Clinical    Microscopy,    Bacteriology    and 

Chemistry  in  Surgical  Practice.  JOHN  A.  WYETH. 
See  page  1122  Philadelphia  Medical  Journal  of  this 
week. 

4.  The  Progress  and  Tendency  of  Hygiene  and  Sanitarj- 

Science    in   the   Nineteenth   Century,     GEORGE    M. 

KOBER. 

See  page  1119  Philadelphia  Medical  Journal  of  this 

week. 


MEDICAL  NEWS. 
June  St?i,  1901. 

1.  The  President's  Address.     CHARLES  A.  L.  REED. 

See  page  1122  Philadelphia  Medical  Journal  of  this 
week. 

2.  Internal   Medicine   in   the   Nineteenth   Century.     N.   S. 

DAVIS. 

See  page  1120  Philadelphia  Medical  Journal  of  this 

week. 

3.  The    Value   of   Clinical    Microscopy,   Bacteriology   and 

Chemistry  in  Surgical  Practice.  JOHN  A.  WYETH. 
See  page  1122  Philadelphia  Medical  Journal  of  this 
week. 

4.  The  Progress  and  Tendency  of  Hygiene  and  Sanitary 

Science    in   the   Nineteenth    Century.     GEORGE    M. 
KOBER. 
L^See  page  1120  this  issue  Philadelphia  Medical  Journal. 
week. 


BOSTON    MEDICAL    AND    SURGICAL    JOURNAL. 

June  6,  1901. 

1.  The   Value   of   Clinical    Microscopy..    Bacteriology   and 

Chemistry  in  Surgical  Practice.     JOHN  M.  WYETH. 

2.  The  Surgical  Treatment  of  Gastric  Ulcer,  with  Report  of 

Cases.     F.  B.  LUND. 


3.  lopathic  Abscess  of  the  Kidney.     A.  T.  CABOT. 

4.  The  Effects  of  Training;   Second  Paper.     EUGENE  A. 

DARLING. 

1. — See  page this  issue  Philadelphia  Medical  Journal. 

2. — Lund  reports  a  case  of  perforating  gastric  ulcer  for 
which  he  operated  16  hours  after  the  symptoms  of  perfora- 
tion appeared.  A  general  peritonitis  of  such  marked  degree 
was  present  at  the  time  of  operation  that  it  was  necessary 
to  drain  both  flanks  through  the  wound  in  the  epigastrium 
and  the  pelvis  by  a  second  incision,  which  was  made 
below  the  umbilicus  and  through  which  a  tube  and  gauze 
were  passed.  The  patient  was  in  perfect  health  and  had 
normal  digestion  for  a  year  and  8  months  following  the 
operation.  Then  he  was  overcome  by  gas  while  working 
in  a  manhole,  but  was  rescued  and  resuscitated.  An  attack 
of  vomiting  ensued  later,  and  on  the  same  day  he  was 
seized  with  agonizing  abdominal  pain.  On  the  fourth  day 
after  the  attack  he  was  operated  upon  for  acute  intestinal 
obstruction  by  a  band.  On  opening  the  abdomen  the 
stomach  was  found  to  be  normal  in  size  and  entirely  healthy 
in  appearance.  The  pylorus  was  adherent  to  the  under  sur- 
face of  the  liver  by  firm  adhesion.  The  bands  that  caused 
the  obstruction  ran  from  below  the  pelvic  incision  to  the 
jejunum,  which  at  the  point  of  attachment  of  the  second 
band  was  sharply  kinked  and  completely  obstructed.  When, 
in  the  course  of  the  operation  the  intestinal  tension  was  re- 
lieved, the  patient  began  to  vomit  large  quantities  of  feces. 
He  stopped  vomiting  at  about  6  o'clock  on  the  night  of  the 
operation;  his  bowels  moved  the  next  morning,  and  he 
passed  a  very  satisfactory  convalescence.  There  can  be 
no  question  that  the  mortality  of  the  cases  operated  upon 
promptly,  that  is  within  12  or  34  hours  of  the  perfora- 
tion, is  and  will  be  remarkably  low.  The  importance  of 
such  early  operation  cannot  but  be  obvious  on  comparing 
perforating  ulcer  of  the  stomach  with  appendicitis.  The 
author  also  referred  to  a  case  of  a  single  girl,  aged  17 
years,  who  was  suffering  from  chlorosis  and  who  had  symp- 
toms of  gastric  ulcer.  She  was  operated  on  10  hours  after 
the  onset  of  the  pain  which  probably  signalized  perforation. 
After  the  operation  the  young  woman  had  no  serious  symp- 
toms except  a  left  femoral  phlebitis  and  she  left  the  hospi- 
tal in  5  weeks.  There  was  a  history  of  gradual  aggrava- 
tion of  the  symptoms  of  ulcer  during  the  week  preceding 
perforation,  that  probably  coincided  with  a  gradual  increase 
in  the  depth  and  extent  of  the  ulcer,  and  possibly  with  the 
formation  of  light  fibrin  deposits  upon  the  peritoneum 
covering  it.  These  symptoms  were  sufficiently  marked,  it 
would  seem,  in  case  they  had  been  observed  by  a  physician 
to  suggest  a  "preperforative  stage."  It  is  fortunate  for  the 
surgeon  that,  although  a  vastly  larger  number  of  ulcers  of 
the  stomach  are  situated  upon  the  posterior  than  the 
anterior  wall,  perforation  of  the  ulcers  of  the  anterior  wall 
is  much  more  frequent  than  those  of  the  posterior.  This 
fact  is  undoubtedly  due  to  the  greater  fixedness  of  the 
posterior  wall,  more  frequent  affording  opportunity  for  the 
formation  of  adhesion  that  prevent  perforation.  In  case  of 
chronic  or  intractable  ulcer  of  the  stomach,  when  the 
situation  of  the  ulcer  and  the  condition  of  the  patient  per- 
mit it.  the  surgeon  may  excise  the  ulcer  and  suture  the 
defect  in  the  stomach,  thus  getting  rid  of  the  diseased  tissue 
and  affording  the  most  favorable  conditions  for  healing. 
In  cases  in  which  the  ulcer  is  situated  near  the  pylorus^ 
excision  of  the  ulcer  may  be  combined  with  pyloroplasty, 
thus  relieving  the  constant  irritating  spasm  of  the  pylorus., 
which  does  so  much  to  keep  the  ulcer  in  an  active  state. 
If  on  account  of  the  situation  of  the  ulcer  or  the  condi- 
tion of  the  patient  excision  is  diffiult.  gastro-enterostomy 
may  insure  a  free  passage  of  the  stomach  contents  into 
the  intestines  with  the  minimum  of  work  on  the  part 
of  the  stomach  wall  and  the  maximum  of  rest,  therefore, 
for  the  ulcerated  surface  and  the  surrounding  infiltrated 
tissue.  During  the  first  attack  of  severe  hemorrhage  oper- 
ation is  contraindicated,  and  it  would  seem  that  treatment 
should  be  limited  to  rest,  opium  and  salt  infusion,  as  ir. 


June   1'.   mo:] 


THE  LATEST  LITERATURE 


tThe  Philadelphia 
L  JlEDicAL  Journal 


'•53 


hemorrhage  elsewhere.  When,  however,  a  first  copious 
hemorrhage  is  followed  by  a  second,  too  long  delay  is  haz- 
ardous. In  spite  ot  the  greater  complication  of  the  meas- 
ures required  in  dealing  with  a  bleeding  ulcer  of  the 
stomach  as  compared  with  a  ruptured  tube,  for  example, 
the  use  of  salt  infusion  and  stimulation,  and  such  measures 
as  prove  so  successful  in  intra-abdominal  hemorrhage  from 
other  causes,  will  save  a  certain  number  of  even  the  most 
desperate  cases  from  death.  The  author  concludes:  (1) 
That  in  perforation  immediate  operation  is  absolutely  in- 
dicated. (2)  That  in  cases  in  which  the  symptoms  fail 
to  yield  after  medical  treatment  for  a  reasonable  period, 
operation,  consisting  either  of  excision  of  the  ulcer  or 
gastro-enterostomy.  should  be  performed,  and  this  before 
the  patient  has  become  so  exhausted  as  to  render  surgical 
intervention  dangerous.  (3)  That  in  hemorrhage,  were 
slight,  frequently-repeated  bleeding  promises  to  produce 
grave  anemia  or  exhaustion,  similar  early  operation  should 
be  done.  (4)  That  in  case  a  patient  has  suffered  from 
more  than  one  copious  hemorrhage,  operation  should  be 
performed,  and  the  extent  and  nature  of  the  procedure 
should  be  decided  upon  according  to  the  power  of  the  pa- 
tient to  withstand  operative  manipulation  and  the  condi- 
tions found  during  the  progress  of  the  operation.  [J.  M.  S.] 
3. — Abscess  of  the  kidney  may  be  due  (1)  to  injury.  (2) 
to  the  direct  extension  of  inflammation  from  contiguous 
parts.  (3)  to  the  extension  of  inflammation  of  the  pelvis 
of  the  kidney  through  the  uriniferous  tubules  into  the 
substance  of  the  organ  and  (4)  to  organisms  brought  to  the 
kidney  by  the  blood.  In  the  latter  cases,  except  those  ab- 
scesses that  result  from  the  action  of  the  tubercle  bacillus, 
the  streptococcus,  the  staphylococcus  pyogenes  aureus,  the 
bacterium  coli  communis,  the  pneumococcus  and  the  ty- 
phoid bacillus  are  the  offending  organisms.      [J.  M.  S.] 


JOURNAL     OF     AMERICAN     MEDICAL      ASSOCIATION. 

June  Sth.   I'.iul. 

1.  The  President's  Address  delivered  at  the  Fifty-second 

Annual  Meeting  of  the  American  Medical  Asosciation, 
held  at  St.  Paul,  Minn.     CHARLES  A.  L.  REED. 
See  page  1119   Philadelphia   Medical   Journal  of  this 
week. 

2.  Internal   Medicine   in   the   Nineteenth   Century.     N.   S. 

DAVIS,  JR. 

See  page   1122  Philadelphia  Medical  Journal  of  this 

week. 

3.  The   Value   of   Clinical    Microscopy,   Bacteriology    and 

Chemistry  in  Surgical  Practice.  JOHN  A.  WYETH. 
Sec  page  1120  Philadelphia  Medical  Journal  of  this 
week. 

4.  The  Progress  and  Tendency  ot  Hygiene  and  Sanitary 

Science    in   the    Nineteenth   Century.     GEORGE    M. 

KOBER. 

See  page  1122   Philadelphia   Medical   Journal   of  this 

week. 


AMERICAN    MEDICINE. 

■June  Sth.  m>l. 

1.  The  Address  of  the  President  of  the  American  Medical 

Association.     CHARLES  A.  L.  REED. 

See  page  1119  Philadelphia   Medical  Journal  of  this 

week. 

2.  The    Value    of    Clinical    Microscopy.    Bacteriology    and 

Chemistry  in  Surgical  Practice.  JOHN  A.  WYETH. 
See  page  1120  Philadelphia  Medical  Journal  of  this 
week. 

3.  The  Progress  and  Tendency  of  Hygiene  and  Sanitary 

Science   in   the   Nineteenth   Century.     GEORGE    M. 

KOBER. 

Sec  page  1122  Philadelphia  Medical  Journal  of  this 

week. 

4.  Internal    Medicine    in    the   Nineteenth    Century.    N.    S. 

DAVIS. 

See  page  1122  Philadelphia  Medical  Journal  of  this 

week. 


DEUTSCHE     ZEITSCHRIFT     FUER     NERVENHEIL- 
KUNDE. 

Vol.    IS.     Deveniber  Jflh,  1900. 

The  present  volume  is  a  Frstsclmft  printed  in  honor  of 
Geheimrath  Wilbelm  Erb  at  the  completion  of  his  60th  year. 
It  contains  23  articles  written  by  his  friends  and  stu- 
dents. 

CONTENTS. 

1.  The  Pathology  of  Non-Suppurating  Encephalitis.  Twelve 

Cases  of  Encephalitis  of  the  Cerebrum  or  Cerre- 
bellum.  Two  wuth  Anatomical  Investigations, 
NONNE. 

2.  Erbs    Disease.      (Mvestheuia.    Pseudo-paralytica.    As- 

thenic Bulbar  Paralysis.)     GIESE  and  SCHULTZ. 

3.  The  Clinical  Characteristics  and  Pathological  Anatomy 

of  Beri  Beri.    RUMPK  and  LUCE. 
4. — Contribution  to  the  Knowledge  of  Allochiria.     DETER- 

MANN. 
5.     Contribution   to   the    Knowledge   of   Cerebellar   Cysts. 

SCHUELE. 
G.     Cases  of  Hemorrhagic  Encephalitis  Following  Influenza. 

STADELMANN. 
7.     Contribution  to  the  Svmptomatology  of  Tumors  of  the 

Mid-Brain  and  the  Tegmentum.    VON  OORDT. 
S.     The   Position   of   the   Fibres   in   the    Pyramidal    Tract 

That  Control  the  Movements  of  the  Hand.     HOCHE. 
U.     Casuistic  Contribution  to  the  Combined  Systemic  De- 
generations.    SCHOENEORN. 

10.  The  Inhibitorv  Paralyses  of  Early  Childhood   (Syphil- 

itic, Rachitic,  and  other  Palsies).     VIERORDT. 

1 1.  The  Relations  between  Impaired  Hearing  and  Word 

Deafness.    KAST 

12.  Thomsen's  Disease,   with   a  Special  Consideration  of 

the  Muscular  Atrophies  that  Occur  in  it.  HOFF- 
MAN. 
1. — Nonne  gives  the  histories  of  12  exceedingly  inter- 
esting cases  that  he  diagnoses  encephalitis.  It  is  difficult  to 
summarize  them.  In  the  abstract  they  are  as  follows: 
Case  1.  A  girl  14  months  of  age.  in  the  course  of  an 
influenza  epidemic  developed  fever,  loss  of  consciousness, 
vomiting  and  convulsions,  which  in  a  late  stage  of  the  dis- 
ease were  limited  to  the  left  side  of  the  body.  This  side  was 
was  paretic,  the  reflexes  were  exaggerated,  and  there  was 
no  disturbance  of  the  eyes.  Complete  recovery  ensued. 
Case  2.  A  woman  of  34,  had  an  attack  of  fever,  on  the  3d 
day  of  which  she  became  delirious,  had  headache,  paresis 
of  the  left  facial  nerve  followed  by  paresis  of  the  left  side 
with  exaggeration  of  the  knee-jerks.  The  Widal  reaction 
was  negative.  As  the  fever  disappeared  the  paresis  impi'oved 
and  the  patient  recovered  completely.  An  epidemic  of 
influenza  prevailed  at  the  time  of  the  attack.  Both  cases 
Nonne  regards  as  encephalitis  due  to  influenza.  Case  3. 
A  man  of  23.  became  confused,  was  brought  to  the  hospital, 
where  he  developed  lever,  followed  by  right  facial  paresis, 
sluggish  pupillary  reaction,  some  trismus,  and  on  the  5th 
day  an  attack  of  focal  epilepsy  beginning  in  the  neck 
muscles  on  the  right  side.  There  was  complete  aphasia. 
On  the  7th  day  the  fever  dropped,  and  the  patient  apparent 
ly  recovered  completely  with  the  exception  of  the  aphasia. 
On  the  9th  day  the  patient  was  capable  of  recognizing 
objects,  could  not  understand  words,  there  was  complete 
paraphasia  and  paragraphia.  On  the  12th  day  he  began 
to  be  able  to  repeat  words,  and  two  weeks  later  could 
understand  words  perfectly,  and  exhibited  only  a  slight 
degree  of  paraphasia.  All  forms  of  infection  or  intoxication 
could  apparently  be  excluded  in  this  case,  and  Nonne  sus 
ppcts  that  it  is  possibly  a  form  of  hemorrhagic  encephal- 
itis. Case  4.  A  man  of.  24.  had  a  severe  attack  of  head- 
ache followed  by  confusion,  diffuse  tenderness  of  the  skull, 
gradually  developing  stupor  and  slow  pulse.  There  was 
hyperemia  of  the  retina  and  inequality  of  the  pupils. 
The  reflexes  were  greatly  increased,  especially  on  the  right 
side,  and  there  was  ankle  clonus.  Later  the  patient  im- 
proved, and  with  the  exception  of  a  slight  disturbance  of 
equilibrium  and  occasional  vertigo,  recovered  completely. 
,\s  it  seemed  possible  to  exclude  brain  tupior  and  serous 
meningitis,  encephalitis  was  the  only  condition  that  could 
explain  the  symptoms.  Case  5.  A  man  of  2S,  after  a 
severe  journey,  appeared  much  exhausted,  then  suddenly 
developed  fever,  headache,  and  vomiting.    He  was  deliriouo 


1154 


The  Philadelphia"! 
Medical   Joubnal  J 


THE  LATEST  LITERATURE 


[Jltce   15.   IM) 


then  stuporous,  had  irregularity  of  the  pulse  and  ChejTi- 
Stokes  respiration.  Lumbar  puncture  was  negative.  Later 
he  had  transient  nystagaus.  strabismus,  mydriasis,  trys- 
mus.  and  developed  a  pleural  effusion.  In  the  4th 
v.eek  his  symptoms  rapidly  disappeared,  with  the  excep- 
tion of  a  slight  sluggish  reaction  to  light  in  the  left  pupil. 
As  in  the  other  cases  meningitis  was  apparently  to  be 
excluded  and  encephalitis  is  the  only  possible  diagnosis. 
Case  6.  A  boy  of  H.  developed  a  severe  headache  with 
vomiting,  became  confused,  delirious,  comatose,  had  se- 
vere coreic  movements,  and  on  the  second  day,  paresis 
of  the  left  leg.  with  loss  of  tendon  reflexes.  Lumbar  punc- 
ture was  negative.  On  the  4th  day  the  coma  w-as  complete, 
the  whole  left  side  was  paretic,  and  there  was  marked 
stifiness  in  the  muscles  of  the  neck.  Later  there  was  cutan- 
eous hyperesthesia,  but  consciousness  returned  and  the 
patient  complained  of  a  severe  headache  in  the  back  of  the 
head.  At  the  end  of  the  4th  week  there  was  slight  atrophy 
of  both  optic  nerves,  occasional  vomiting,  tenderness  of  the 
skull  and  headache.  At  the  end  of  11  weeks  the  patient 
was  discharged,  but  even  up  to  that  time  there  were  occa- 
sional attacks  of  headache  and  vomiting.  In  these  cases 
the  diagnosis  was  encephalitis  associated  with  basal  menin- 
gitis due  to  the  same  cause.  Case  7.  A  man  of  45.  was 
exposed  to  cold  and  had  an  attack  of  fever  followed  by 
headache  and  vomiting.  In  the  course  of  4  days  the 
only  nervous  symptom  was  diminution  of  the  muscle  tone. 
He  later  developed  a  typical  cerebellar  gait.  There  was 
exaggeration  of  the  tendon  reflexes,  but  at  the  end  of  a 
week  the  condition  improved  considerably  and  the  patient 
ultimately  recovered  completely.  This  is  probably  a  case 
of  encephalitis  in  the  cerebellum.  Case  8.  A  man  of  2S, 
had  for  three  months  been  rapidly  emaciating.  He  devel- 
oped severe  headache  with  vomiting,  inability  to  stand, 
and  was  quite  delirious.  From  time  to  time  there  were 
clonic  contractions  in  the  legs;  the  gait  was  typically  cere- 
bellar in  type:  there  was  diminution  in  power.  There  was 
ankle  clonus  on  the  right  side,  and  slight  nystagnus.  but 
the  patient  gradually  recovered,  and,  with  the  exception  of 
a  permanent  exaggeration  of  the  reflexes,  seemed  perfectly 
■n  ell.  This  is  also  probably  a  case  of  cerebellar  encephal- 
itis. Case  9  was  very  interesting,  showing  briefly  the  fol- 
lowing changes:  After  acute  cerebral  symptoms  in  the 
11th  year  of  age  there  developed  incoordination  of  mo- 
tion and  of  speech,  insufficiency  of  the  external  muscles  of 
the  eye,  impairment  of  intelligence,  active  tendon  reflexes, 
but  no  disturbance  of  sensation  nor  of  the  action  of  the 
sphincters.  Case  10.  A  man  of  29.  15  months  after  sun- 
stroke, showed  the  following  changes.  Incoordination  of 
the  extremities  and  speech,  although  mimicry  was  not 
disturbed.  Insufficiency  of  the  e.ve  muscles,  exaggeration 
of  the  tendon  reflexes,  hyper-tonicity  of  the  muscles,  but 
no  disturbance  of  the  action  of  the  sphincters.  These  sym- 
toms  persisted  unchanged  for  4  years.  These  2  cases 
present  great  difficulties  in  dia.gnosis.  Multiple  sclerosis 
and  spinal  disease  seem  to  be  excluded,  and  Nonne 
therefore  includes  them  in  the  group  of  forms  of  ence- 
phalitis. Case  11  had  inflammation  of  the  throat,  then 
weakness  of  the  muscles  of  the  neck,  intelligence  was  un- 
disturbed, respiration  was  very  rapid.  There  was  con- 
siderable pain  if  the  head  were  forcibly  bent  backward. 
The  left  arm  became  paralyzed,  then  the  face.  The  patient 
developed  nystagnus.  and  finally  there  was  paresis  of  the 
left  leg.  The  reflexes  remained  normal.  At  the  autopsy 
nothing  was  found  either  macroscopically  or  microscop- 
ically that  could  be  considered  pathological,  and  the  case 
therefore  is  suflioient  proof  of  the  fact,  hitherto  not  recog- 
nized, that  encephalitis  may  exist,  and  even  lead  to  death 
without  producing  any  recognizable  changes.  Case  12, 
A  woman  of  3S  had  felt  depressed  for  several  weeks,  then 
developed  weakness  in  the  left  leg.  There  was  headache, 
nausea,  and  clonic  contractions  in  the  left  side  of  the  face 
There  was  stiffness  in  the  neck,  diverging  strabismus, 
and  mydriasis  of  the  left  pupil,  and  total  loss  of  pupillary 
reaction.  Lumbar  puncture  gave  a  hemorrhagic  fluid  under 
considerable  pressure,  although  no  bacteria  were  found  in  it. 
The  patient  developed  convulsions,  the  left  hemoplegia 
became  complete,  and  death  occurred  as  the  result  of  in- 
crease in  the  temperature.  At  the  autopsy  there  were 
found  numerous  grayish-yellow  nodules  in  the  central  con- 
volutions and  brownish  discoloration  of  the  brainy  sub- 
stance on  the  left  side,  from  the  frontal  to  the  parietal 
regions.       Microscopically    there    was    inflammation    and 


infiltration  of  the  pia,  and  round  cell  infiltration  of  the 
brain  substance.  The  walls  of  the  arteries  and  capillaries 
were  infiltrated  with  round  cells,  and  many  of  them  were 
obstructed.  Tuberculosis  of  the  pleura  and  lungs  existed, 
and  Xonne  considers  this  a  form  of  encephalitis  due  to  the 
poison  of  this  microorganism.     [J.  S.] 

2. — The  following  is  reported  as  a  case  of  Erb's  disease. 
A  woman,  24.  with  negative  family  history,  had  an  attack  of 
coryza  and  bronchitis  associated  with  severe  pain  in  the 
right  side  of  the  head.  A  few  days  later  there  was  diplopia, 
then  difliculty  in  swallowing  with  regurgitation  of  fluids 
through  the  nose.  Shortly  after  this  there  was  difficulty  in 
speaking,  fatigue  after  chewing,  and  later  ptosis,  transient 
paralysis  of  some  of  the  fingers  after  use,  and  general 
fatigue  after  any  kind  of  exertion.  Intelligence  and  sen- 
sation were  not  affected.  When  examined  4  months  later 
there  was  ptosis  on  the  right  side,  the  right  internal  rec- 
tus was  completely  paralyzed:  there  was  paralysis  of  the 
soft  palate  and  paresis  of  the  tongue.  All  the  muscles  were 
well  developed:  there  was  no  fibrillary  tw-itching.  but  there 
was  distinct  paresis,  and  fatigue  occurred  very  rapidly. 
The  tendon  reflexes  were  present,  but  not  abnormjil.  There 
were  no  reactions  of  degeneration  in  the  muscles,  but  an 
imperfect  myesthenic  reaction  was  present.  The  voice 
showed  partial  aphonia,  otherwise  everything  was  nega- 
tive. The  patient  showed  slight  improvement,  although 
fatigue  occurred  so  rapidly  that  when  the  lips  were  ex- 
posed, the  upper  lip  would  sink  from  exhaustion  at  the  end 
of  a  minute.  Subsequently  the  patient  became  again  some- 
what worse:  the  tendon  reflexes  were  diminished,  but  the 
patient  left  the  hospital.  From  these  symptoms  a  diagnosis 
or'  asthenic  muscular  paralysis  was  made.  Subsequently 
the  aphonia  became  complete,  and  the  patient  developed 
dyspnea,  increased  rapidity  of  the  pulse  rate,  and  finally 
died.  The  autopsy  was  absolutely  negative,  both  micro- 
scopically and  macroscopically.  thus  confirming  the  diag- 
nosis. Schultz.  in  some  concluding  remarks,  approves 
the  name  "Erb's  disease '  because  we  know  so  little  about 
the  true  pathology  of  the  condition  that  a  more  accurate 
designation  is  not  at  present  possible.  He  believes,  how- 
ever, that  it  represents  some  form  of  intoxication,  and  calls 
attention  to  the  presence  of  cystinuria  as  a  proof  that 
intestinal  putrefaction  was  probably  present,  although  the 
earlier  symptoms  recall  those  of  diphtheria,  and  diphtheri- 
tic paralysis  might  have  been  suspected:  the  later  course 
oi  the  disease  was  sufficient  to  exclude  this  complication. 

[J.  S.] 

3. — Rumpf  and  Luce  have  had  the  opportunity  of  studying 
10  cases  of  beri  beri,  which  occurred  in  sailors,  chiefly  Chi- 
nese, arriving  from  the  Orient.  Nine  recovered  and  one 
died.  The  symptoms  were  those  ordinarily  described, 
that  is.  slight  disturbance  of  sensation,  paresis  or  paralysis 
in  the  limbs,  disappearance  of  the  tendon  reflexes,  and  qual- 
itative or  quantitative  disturbances  in  the  electrical  re- 
actions of  the  muscles.  It  is  perhaps  of  interest  to  note 
that  6  of  th3  patients  were  Chinese  stokers.  Microscop- 
ically, changes  were  found  in  the  peripheral  nerves  wit'n 
fatly  infiltration  of  the  connective  tissue  and  moderate 
reduction  of  the  myeline  sheaves.  In  the  spinal  cord  there 
was  a  recent  degeneration  of  the  myeline  sheathes, 
local  areas  of  degeneration,  and  a  very  slight  de- 
generation in  the  cells  of  the  anterior  comua. 
There  was  a  chronic  interstitial  neuritis  involving  the  pos- 
terior roots.  This  confirmed  the  findings  of  the  other  in- 
vestigators. They  therefore  concluded  that  the  disease 
represented  the  action  of  some  inflammation  upon  the 
peripheral  nervous  system.  All  the  cases  showed  the 
anemic  type:  the  symptoms  corresponded  to  those  of  poly- 
neuritis, complicated  in  all  probability  by  some  changes 
in  the  muscle  substance  itself.  A  curious  feature  is  that 
in  none  of  these,  nor  in  the  majority  of  recorded  cases,  was 
the  paralysis  absolute  in  any  of  the  muscles.  It  is  probable 
that  in  the  hydropic  form  there  is  serious  disturbance  of 
the  kidneys.     [J.  S.l 

4. — Determann  reports  the  following  interesting  case: 
The  patient,  who  had  had  luetic  infection,  had  diplopia. 
slight  feeling  of  numbness  in  the  hands,  and  slight  diflSculty 
in  their  use.  The  tendon  reflexes  were  abolished:  all  forms 
of  sensation  were  diminished  in  the  hands:  the  stereog- 
nostic  sense  was  diminished:  the  muscular  power  was  fairly 
good.  'U'hen  the  patient  was  stuck  with  a  pin  in  the  right 
hand  there  was  a  similar  sense  of  contact  about  two 
seconds  later,  if  slightly  larger  in  area,  in  the  left  hand. 
The  case  represents  one  of  locomotor  ataxia  affecting  chief- 


June   15,  1901] 


THE  LATEST  LITERATURE 


rXHE  Philadelphia 
LMedical   Jourkal 


••jS 


ly  the  cervical  region,  presenting  the  interesting  features 
01  allochiria.  The  case  represents  the  2  types  of  reflex 
and  sensory  allochiria.  and  is  interesting  because  the  pa- 
tient had  in  the  left  hand  the  sense  of  burning  pain  and 
contact,  moreover  because  the  sensations  commenced  grad- 
ually, although  the  irritant  in  the  right  hand  was  applied 
only  for  a  moment.  Determann  believes  that  the  theory, 
that  sensation  is  shifted  in  the  spinal  cord  to  the  wrong 
tract,  so  that  it  is  conveyed  to  the  hemisphere  on  the  same 
side  and  produces  the  sense  of  pain  in  the  opposite  side  of 
the  body,  applies  to  the  majority  of  cases,  but  not  to  those 
in  which  the  symptoms  are  purely  hysterical.     [J.  S.] 

5. — Schiile  reports  the  case  or  a  man  39  years  of  age.  an 
alcoholic.  He  had  a  severe  fall,  striking  the  back  of  his 
head,  and  after  this  complained  of  headache.  There  was 
loss  of  memory,  attacks  of  vertigo,  frequent  vomiting  and 
loss  of  weight.  There  was  slight  venous  hyperemia  of  the 
eyebrows,  but  otherwise  all  the  ocular  phenomena  were 
normal.  There  were  no  tremors,  but  slight  ataxia  in  the 
upper  extremities.  From  time  to  time  there  were  attacks 
in  which  the  patient  seemed  confused  and  groaned  loudly, 
and  appeared  to  be  extremely  restless,  but  no  true  convul- 
sions occurred.  Death  occurred  about  7  weeks  after  the 
injury.  .-V  diagnosis  was  made  of  tumor  of  the  cere- 
bellum, particularly  en  account  of  a  tendency  to  fall  back- 
ward. At  the  autopsy  the  skull  was  found  perfectly  nor- 
mal, and  the  cerebellum  appeared  normal,  but  w-as 
slightly  elastic,  and  upon  a  median  incision  a  large 
cyst    was    found     In     the     vermiform     process     lined     by 

smooth  wall,  and  about  3.5  by  4.-5  ecm..  The  floor  of  the 
>  St  formed  the  roof  of  the  4th  ventricle.  In  all  likelihood 
lafie  was  in  this  case  a  congenital  diverticulum  into 
which  as  a  result  of  the  injury  there  was  a  sudden  effusion 
of  liquid,  causing  the  symptoms.  Only  a  single  similar  case 
is  to  be  found  in  the  literature.     [J.  S.] 

6. — Stadelmann  reports  the  case  of  a  man  2S  years  of 
age  who  had  had  an  attack  of  influenza  that  had  com- 
menced with  headache,  fever,  and  vomiting.  This  lasted 
about  8  days  and  then  was  replaced  by  pain  in  the  back. 
When  admitted  to  the  hospital  there  was  moderate  fever, 
inability  to  bend  the  head  forward  and  backward,  although 
it  could  readily  be  hent  from  side  to  side,  some  stiffness 
in  the  back  of  the  neck,  and  tenderness  over  the  10th  to  the 
V2ih  dorsal  vertebrae.  A  diagnosis  of  neuralgia  following 
influenza  was  made,  and  the  patient  improved  upon  treat- 
ment. On  the  10th  day.  however,  he"  had  a  relapse,  and 
appeared  as  if  about  to  die.  The  temperature  rose,  then 
fell  suddenly,  and  the  patient  had  remittent  fever  with  in- 
creasing apathy,  bitter  complaints  of  headache,  right  hemi- 
:  !egia.  with  anesthesia  and  Anally  death.  10  days  after  the 
oillapse.  Spinal  pimcture  had  shown  the  existence  of  a 
reddish  fluid.  At  the  autopsy  there  was  found  chronic 
spina!  meningitis,  hemorrhages  into  the  brain,  hemorrhagic 
.-•nd   anemic   softening  in  the   left   hemisphere,   hematoma 

the  left  lateral  ventricle,  and  of  the  subarachnoid  space, 
^adelmann  regards  the  case  as  one  of  cerebral  softening 
following  Influenza  and  producing  hemorrhage.     [J.  S.] 

7. — Van  Oordt  reports  the  following  case:  The  patient,  a 
girl.  S'/^  years  of  age.  had  developed  slight  weakness  of 
the  muscles  of  the  right  side  of  the  face,  bilateral  ptosis 
and  disturbance  of  gait.  When  admitted  to  the  hospital 
it  was  found  that  the  speech  was  slow  and  scanning,  the 
eyes  were  normal:  there  was  no  disturbance  of  the  other 
muscles  excepting  slight  paresis  of  the  superior  and  inferior 
recti  on  the  right  side,  and  possibly  of  the  external  rectus. 
There  was  also  slight  paralysis  of  the  low-er  branch  of 
the  facial  nerve  on  the  right  side.  There  was  no  paresis 
of  the  extremities,  but  a  marked  extension  of  tremor,  and 
ataxia  of  both  arms,  more  pronounced  on  the  left  side. 
Occasionally  there  w  ere  athetoid  and  choreitoid  movements 
of  the  hands.  There  was  considerable  staggering  during 
walking.  There  was  alimentary  glycosuria,  and  subse- 
quently some  evidence  of  d'abetes.  This  improved  rapidly 
upon  suitable  diet.  About  3  months  after  the  first  s.vmp 
toms  Ihe  patient  had  violent  vomiting,  clonic  convulsions 
in  the  right  arm  and  died.  There  was  a  tubercle  of  the 
tegmentum  about  the  size  of  a  nut  that  obliterated  the  aque- 
duct of  Sylvius  and  destroyed  ihe  right  portion  of  this 
area,  the  right  posterior  longitudinal  tract  of  fibres,  and 
the  right  lateral  nucleus  of  the  fillet:  it  partially  destroyed 
the  right  posterior  corpus  quadrigemintini  and  a  consider- 
able portion  of  the  left  posterior  quadrigeminum.  and  the 
nucleus  of  the  oculomotorius.  There  was  some  compres- 
sion of  the  structures  on  the  left  side.    Van  Oordt  also  re- 


ports the  presence  of  a  nucleus  between  the  fibres  of  the 
lestiform  body  near  the  mesial  border  of  this  structure 
consisting  of  from  25  to  40  round,  pear-shaped  ganglion 
cells  similar  to  those  of  the  olive.  The  right  olivary  body 
was  degenerated,  but  this  nucleus,  remained  intact,  and 
its  cells  differed  slightly  in  size  from  those  of  the  normal 
olive.  Van  Oordt  regards  it  as  a  normal  structure.  After 
a  brief  description  of  the  secondary  degenerations  he  dis- 
cusses the  diagnosis  from  the  symptoms.  In  view  of  the 
paresis  of  the  right  eye  and  of  the  left  half  of  the  body  the 
localization  of  the  tumor  was  made  quite  readily.  The 
hypalgesia  of  the  left  side  can  be  explained  by  the  lesion 
of  the  tegmentum:  the  ataxia,  by  the  involvement  of  the 
corpora  quadrigemina  and  the  tracts  to  the  cerebellum. 
The  patient  had  complete  control  of  the  steriognostic 
sense,  probably  due  to  the  fact  that  the  median  fillet  was 
nearly  intact  on  both  sides.  There  was  no  diminution  in 
[he  visual  activity,  and  there  were  no  symptoms  of  brain 
compression  until  the  convulsions  just  before  death.  It 
was  doubtful  whether  the  glycosuria  was  due  to  the  tumor, 
but  ^'an  Oordt  has  collected  31  cases,  in  which  this  symp- 
tom appeared.  IS  of  these  involved  the  floor  of  the  4th 
ventricle,  and  some  the  pons  and  the  corpora  quadrigemi- 
num.    [J.  S.] 

8. — Hoche  reports  the  case  of  a  woman.  54  years  of 
age.  in  whom  the  symptoms  commenced  with  a  typical 
attack  of  epilepsy,  which  was  subsequently  followed  by 
attacks  of  twitching  and  paresthesia  of  the  left  arm. 
There  was  no  vomiting,  but  slow  development  of  weakness 
in  the  left  hand.  An  operation  was  accordingly  performed 
and  a  small  tumor  found  in  the  ascending  frontal  gyrus 
about  the  level  of  the  superior  sulcus,  which  extended 
more  than  1.5  cm.  into  the  brain  substance,  and  was  not 
sharply  delimited.  It  was  found  to  be  a  spindle-cell 
sai-coma.  The  patient  gradually  grew  worse:  the  paralysis 
or  the  left  side  extende<l.  and  finally  death  occurred.  An 
interesting  feature  is  that  the  typical  cortical  convulsions 
persisted  after  the  operation.  The  degenerated  fibres 
traced  from  this  area  formed,  in  the  cms.  a  triangular 
area  about  the  centre.  In  the  pons,  the  whole  pyramidal 
area  contained  degenerated  fibres.  This  was  also  true  of 
the  pyramidal  tracts  in  the  cervical  cord.  The  interesting 
feature  of  this  case  is  that  such  a  functionally  distinct 
group  of  fibres  as  those  supplying  the  hand,  are  not  collect- 
ed into  an  individual  bundle  at  any  point  below  the  crus. 

[J.  S.] 

9. — Schoenborn  reports  two  interesting  cases.  A  boy  of  10, 
the  son  of  nearly  related  parents,  with  4  healthy  broth- 
ers, and  one  who  suffered  from  the  same  disease,  at 
the  age  of  IS  noticed  some  twitching  in  the  knees.  This 
was  followed  by  some  uncertainty  in  gait  and  the  legs 
seemed  weak.  The  ataxia  was  more  pronounced  in  the 
dark,  and  there  was  scanning  speech.  The  patient  had 
bilateral  ptosis,  moderate  nystagmus,  no  muscular  atroph- 
ies, some  hyper-extension  of  the  fingers  and  toes,  no  dis- 
turbance of  sensation,  moderate  diminution  of  the  tendon 
reflexes,  slight  lateral  deviation  of  the  spinal  column. 
There  was  no  defect  of  intelligence.  The  "nd  patient,  a 
brother  of  the  one  just  described,  now  27  years  of  age.  de 
veloped  the  first  symptoms  at  the  age  of  25.  These  were 
essentially  the  same  as  those  of  his  younger  brother. 
Atrophy  in  the  legs,  some  pains,  slight  tremor  of  the 
arms,  scanning  speech,  and  static  ataxia  without  disturb- 
ance of  sensation  or  atrophy  of  the  muscles.  The  reflexes 
were  much  exaggerated  on  both  sides,  and  Babinski's 
reflex  was  present.  Regarding  the  nature  of  this  condition 
Schoenborn  is  inclined  to  believe  that  it  is  really  a  form 
of  combined  sclerosis  of  the  cord,  although  many  of  the 
symptoms  resemble  those  of  Kriedrich's  atax'a.  or  cerebel- 
lar atJixia.  ilauy  other  symptoms  and  characteristics  of 
the  disease  failed  to  agrae  w-ith  these  two  conditions,  par- 
ticularly the  exaggeration  of  the  reflexes,  and  the  late  onset 
of  the  second  case.     [J.  S.] 

10. — Vierordt  disctisses  the  pseudo-paralyses  of  children. 
He  criticises  Parrot's  idea  that  in  these  cases  syphilitic 
and  rachitic  disease  of  the  bone  is  sufficient  to  explain  the 
paralytic  symptoms.  He  reports  2  cases  which  were 
characterized  by  paralysis  of  the  lower  extremities,  coming 
on  at  the  age  of  Ui  and  2  years.  In  the  latter  case 
the  child  was  able  to  stand  before  the  disease  developed. 
The  limbs  were  not  especially  tender:  the  spinal  column 
was  excessively  mobile:  there  were  no  signs  of  syphilis, 
but  modern  rachitis  in  both.  The  paralysis  was  flaccid, 
but  there  were  no  reactions  of  degeneration.    Both  recov-- 


11^6 


The  Philadelphia"! 
Medical   Journal  J 


THE  LATEST  LITERATURE 


[JL-NE    15.    1") 


ered  completely.  Vierordt  regards  the  paralysis  as  the 
result  of  loss  of  power,  and  the  hypertonicity  of  the  mus- 
cles. He  e.xcludes  the  possibility  of  Chassaignac's  disease 
en  account  of  the  absence  of  pain.  He  also  calls  attention 
to  a  condition  of  paralysis  of  the  muscles  of  deglutition 
that  occurs  in  children  who  have  been  subjected  to  trache- 
otomy. He  has  observed  it  in  70%  of  the  children  under 
2%  years  that  have  had  this  operation  performed  upon  them 
in  his  clinic.  It  usually  persists  during  the  period  that  the 
canula  is  in  position.  In  conclusion  he  states  that  in  young 
cnildren  paralysis  may  occur  as  the  result  of  peripheral 
irritation,  especially  of  the  skeleton,  and  that  therefore  we 
are  justified  in  assuming  the  existence  of  a  pure  functional 
paralysis,  the  result  of  irritation  of  the  inhibitory  centres, 
and  that  this  paralysis  disappears  as  soon  as  the  peri- 
pheral irritation  discontinues.     [J.  S.] 

11. — The  following  case  is  interesting  because  there  is 
reason  to  believe  that  as  a  result  of  a  peripheral  affection 
of  hearing  the  patient  developed  a  certain  degree  of  word- 
deafness.  He  was  a  man  34  years  of  age,  who  in  pursuance 
of  his  occupation  of  letter-carrier  in  the  country,  was  ex- 
posed to  severe  weather.  He  had  2  attacks  of  pneumonia, 
both  of  which  were  associated  with  severe  cerebral  symp- 
toms. Convalescence  was  slow.  He  then  developed  weak- 
ness of  memory,  ataxia,  severe  headache,  and  gradually 
impaired  hearing  in  the  right  ear  that  soon  reached  com- 
plete deafness.  The  same  thing  occurred  a  short  time  later 
in  the  left  ear,  after  which  there  was  moderate  improve- 
ment. It  became  impossible  to  communicate  with  the 
patient  except  by  writing,  nevertheless,  careful  observa- 
tion showed  that  he  perceived  sounds,  and  testing  proved 
that  the  watch  could  be  heard  at  a  distance  of  60  cm.  on  the 
left,  and  30  cm.  on  the  right  side.  He  could  hear  distinctly 
all  musical  notes,  but  in  his  attempts  to  reproduce  them 
always  struck  an  octave  higher.  When  words  were  spoken 
he  perceived  only  an  indistinguishable  sound.  He  was  unable 
to  repeat  any  of  the  vowels,  could  not  understand  any  of 
the  consonants,  but  realized  that  there  was  more  of  a  blow- 
ing tone  in  "P"  and  "V"  than  in  the  others.  He  was  unable 
to  recognize  tunes,  hut  if  started  in  singing  one  that  was 
familiar,  could  carry  it  through  very  well.  He  could  recog- 
nize the  quality  of  voices  so  that  when  a  person  spoke  that 
he  could  not  see.  he  could  state  who  it  was.  He  was  also 
capable  of  distinguishing  whether  the  sound  was  made  by 
striking  wood,  metal  or  glass.  He  had  distinct  ataxia  in- 
creased by  closing  the  eyes.  As  a  result  of  careful  treat- 
ment considerable  improvement  took  place  in  his  hearing, 
and  he  was  able  to  make  an  attempt  to  imitate  words  that 
were  spoken  to  him.  The  ataxia,  however,  increased,  and 
later  the  deafness  was  stationary.  Kast  reports  the  case 
as  probably  due  to  meningitis  following  pneumonia  with  in- 
volnieut  of  the  labyrinth,  and  probably  a  functional  word 
deafness.     [J.  S.] 

12. — Hoffmann  reports  2  cases  of  myotonia  congenita  in 
a  brother  and  sister.  The  first,  a  man  of  26,  first  noticed 
the  symptoms  at  the  age  of  22,  after  3  years  service  in 
the  cavalry  during  which  he  was  exposed  to  very  cold 
weather.  He  noticed  that  his  hands  became  very  much 
weaker,  that  his  face  and  arms  got  thinner,  that  it  was 
difficult  for  him  to  speak  in  the  morning,  and  that  cold 
greatly  increased  his  weakness.  The  muscles  showed  some 
Quantitative  diminution  of  electric  excitability  and  distinct 
myotonic  symptoms.  These  symptoms  were  present  only  in 
the  muscles  of  the  face  and  arms.  A  sister,  32  years  of 
age,  had  had  rheumatism  at  the  age  of  24,  hut  believed  her- 
self to  be  perfectly  healthy.  There  was  atrophy  of  the 
muscles  of  the  face  and  fore-arms  and  hands,  distinct  myo- 
tonic reactions  in  these  muscles  and  in  those  of  the  lower 
extremities.  The  common  characteristics  of  the  2  cases, 
therefore,  were  the  myotonia  and  the  atrophy  of  the  mus- 
cles 111  the  upper  extremities  and  sterno  cleido  mastoid. 
Hoffmann  has  carefully  studied  the  literature,  and  has  been 
able  to  collect  5  cases  in  which  myotonia  was  associated 
with  muscular  atrophy,  and  3  cases  in  which  there  was 
reason  to  believe  that  the  loss  was  in  part  a  feature  of  the 
disease.  He  suggests  3  possible  hypotheses.  First,  that 
the  2  conditions  accidentally  occurred  in  the  same  individ- 
ual, that  there  is  progressive  muscular  atrophy  with  myoto 
nia.  or  that  there  is  myotonia  as  a  result  of  which  muscular 
atrophy  occurs.  He  does  not  decide  which  of  these  is  correct, 
although  he  believes  in  his  own  case  that  the  combination 
is  not  accidental.  He  calls  attention  to  some  other  interest- 
ing cases  in  which  the  myotonia  occurred  suddenly,  appar- 
ently as  as  a  result  of  excessive  exertion     In  conclusion  h«> 


mentions  the  case  of  a  man  42  years  of  age.  with  luetic  his- 
tory, whose  organs  were  apparently  normal,  the  pupils  re- 
acted well,  but  there  was  disappearance  of  the  patella  re- 
flex, some  paresthesia  in  the  extremities  and  difficulty  in 
walking  in  the  dark.  There  was  a  distinct  myotonic  reac- 
tion to  percussion.  Hoffman  makes  a  diagnosis  of  myotonia 
with  beginning  locomotor  ataxia.  [J.  S.] 
(To  be  Continued.) 


MUENCHENER  MEDICINISCHE  WOCHENSCHRIFT. 
April  ytli. 

1.  The  Transfusion  of  Blood,  Particularly  of  Blood  from 

Other  Animals,  and  Its  Applicability  For  Curative 
Purposes,  Considered  from  The  Latest  Standpoints. 
BIER. 

2.  The  Treatment  of  Gun-Shot  Wounds  of  the  Abdomen. 

PETERSEN. 

3.  Experiences   Derived   from   the   War   in    South   Africa 

Concerning  Wounds  and  Asepsis.     STHAMER. 

4.  Multiple  Primary  Malignant  Tumors.     NEHRKORX. 

5.  Further  Studies  Upon  the  Information  of  the  Serous 

Membranes.     HEINZ. 

6.  Two  Cases  of     Embolism  of  the     Abdominal     Aorta. 

BUEHRER. 

7.  The  Value  of  the  Glutoid  Capsules  for  the  Diagnosis  ot 

Inflammatory  Disease,  Especially  of  Diseases  of  the 
Pancreas.     FROMME. 

8.  Bismuth  Poisoning.     MUEHLIG. 

9.  Further  Contributions  to  the  Knowledge  of  Malign  Dis- 

eases of  the  Esophagus  Which  Give  the  Clinical  Pic- 
ture of  Stenosis.     SCHUETZ. 

10.  Severe  Cauterization  With  Soft  Soap  In  a  Child  of  18 

Months.     LANGER. 

11.  The  New  Principle  For  the  Treatment  of  Whooping- 

Cough.     SPIESS. 

12.  Unilateral  Dislocation  of  the  Lower  Jaw.  KAREHNKE. 

1. — Bier  has  performed  a  series  of  most  interesting  ex- 
periments by  the  transfusion  of  blood  from  an  animal  of 
one  species  to  one  of  another.  Starting  out  with  the  idea 
that  the  animal  organism  can  accustom  itself  to  very  varied 
conditions,  he  attempted  to  accustom  rabbits  to  injections 
of  lamb's  blood.  At  first  the  animals  appeared  to  agree 
w-ith  the  theory,  and  then,  as  the  dose  of  blood  was  in- 
creased, they  suddenly  died  with  alt  the  manifestations  of 
transfusion  collapse.  The  autopsies  showed  capillary  con- 
gestion of  the  intestines,  spleen,  liver,  lungs,  kidneys,  etc. 
The  symptoms  of  transfusion  are  dyspnea,  with  bloody  ex- 
pectoration, flushing,  subjective  heat  of  the  skin,  pain  in 
the  back,  and  increased  peristalsis.  Usually  there  is  also 
some  fever.  It  is  possible  that  the  increase  in  the  symp- 
toms is  due  to  the  fact  that  the  blood  of  the  receiving  ani- 
mal gradually  acquires  increased  hemolytic  qualities,  and 
may,  in  the  end,  dissolve  its  own  corpuscles.  Nevertheless, 
as  by  transfusion  it  is  possible  to  combat  severe  anemias, 
or  to  bring  about  conditions  of  hyperemia  Bier  undertook 
a  series  of  clinical  experiments.  These  were  performed  in 
the  following  manner.  Blood  was  obtained  from  a  lamb 
and  carefully  defibrinated  under  aseptic  precautions,  then  a 
needle  was  thrust  into  a  distended  vein  at  the  bend  of  the 
elbow,  the  pressure  above  removed,  and  injection  com- 
menced. As  a  rule  a  syringe  holding  50  cc.  was  employed, 
and  the  injection  continued  until  slight  symptoms  of  trans- 
fusion appeared.  It  was  found  that  at  first  larger  and 
larger  quantities  could  be  used,  then  suddenly  only  very 
small  quantities.  He  reports  in  great  detail  the  case  of  a 
man  22  years  of  age  who  had  severe  tuberculosis  of  both 
sacro-ili&c  synchondroses,  which  had  suppurated  and 
broken  through  the  skin  at  numerous  places.  He  was  given 
ascending  doses  of  lamb's  blood  until  10  ccm.  had  been  in- 
jected. After  this  it  was  found  that  only  smaller  and 
smaller  doses  could  be  used  until  finally  only  1.5  ccm.  could 
be  employed  with  safety.  The  general  condition  of  the  pa- 
tient improved  remarkably:  the  suppuration  almost  en- 
tirely ceased:   the  appetite  increased,  and  the  weight  im- 


June 


1001] 


THE  LATEST  LITERATURE 


CThe   Philadelphia 
Medical   Journal 


IK7 


proved  slightly.  The  patient  was  under  observation  about 
2'/2  months.  Further,  10  cases  of  other  forms  of  tuber- 
culosis, nearly  all  of  them  presumably  fatal,  with  the  ex- 
ception of  4  cases  of  lupus,  were  under  observation.  Three 
of  these  died,  one  of  starvation  on  account  of  the  tuber- 
culosis of  the  esophagus;  one  of  sepsis,  the  condition  ex- 
isting before  the  treatment  was  commenced,  and  one  of 
tuberculosis  of  the  brain.  The  others  improved,  or  at  least 
remained  stationary.  The  majority  of  cases  of  pulmonary 
tuberculosis  gained  considerably  in  weight.  The  4  cases 
of  lupus,  all  of  which  had  been  previously  subjected  to 
treatment  without  results,  showed  extraordinary  improve- 
ment. Whether  this  is  permanent  or  only  temporary,  re- 
mains to  be  seen.  Certain  clinical  observations  were  made: 
First,  there  was  generally  flushing  of  the  face;  the  majority 
of  patients  felt  a  desire  to  defecate  and  usually  expelled  a 
large  stool  some  time  after  the  injection.  Occasionally 
urticaria  appeared.  Nearly  all  the  patients  developed  ex- 
cessive appetite:  most  of  them  had  fever  and  chill  without 
any  subjective  signs  of  discomfort,  and  the  majority  had  a 
feeling  of  dryness  in  the  mouth,  and  very  severe  thirst. 
The  author  believes  that  the  action  is  due  to  the  following? 
changes.  First,  temporay  hyperemia  produced  by  capil- 
lary congestion,  giving  rise  to  a  serious  infiltration  of  va- 
rious parts  of  the  body,  and  probably  most  severe  in  the 
diseased  regions.  Second,  vigorous  stimulation  of  meta- 
bolism. Third,  an  aseptic  transfusion  fever.  Fourth,  pos- 
sible alteration  in  the  quality  of  the  blood.  As  lamb  blood 
appears  to  be  least  toxic  for  men,  it  is  probably  the  most 
available.     [J.  S.] 

2. — Petersen  calls  attention  to  the  great  difference  in  the 
stastics  of  gun-shot  wounds  of  the  abdomen  in  civil  and  mill- 
itary  practice.  In  the  first  the  mortality  appears  to  have 
decreased,  probably  chiefly  because  the  patients  are  seen 
earlier.  In  military  surgery  it  seems  to  be  the  chief 
opinion  that  a  conservative  treatment  gives  the  best  re- 
sults, but  even  in  civil  practice  there  is  much  diversity  of 
opinion  regarding  the  necessity  of  immediate  operation.  He 
reports  a  number  of  cases.  Eight  were  operated  upon  as 
soon  as  possible,  of  whom  3  died  and  5  recovered.  Two 
were  not  operated  upon.  One  of  these  died  of  diffuse  peri- 
tonitis; the  other  recovered.  However,  the  results  showed 
that  in  all  cases  in  which  operation  was  performed  It  was 
imperatively  necessary.  In  regard  to  the  indications 
for  operation,  he  believes  that  the  uhscnce  of  lircr  diiUiipfix  is 
of  less  significance  than  is  usually  believed.  The  difiap- 
pcaraiice  of  liver  didliicxs  is  however,  of  more  value.  The 
most  important  symptoms  were  tension  of  the  abdominal 
muscles,  local  meteorisms.  and  dulness  in  the  region  of  the 
wound.  The  general  symptoms  were  those  of  peritonitis.  He 
concludes  that  the  treatment  should  not  be  influenced  by 
the  statistics  of  military  surgeons,  but  that  in  all  cases 
in  which  there  is  a  suspicion  of  perforation,  operation 
should  be  performed  at  once.  As  delay  in  operation  is 
more  serious  than  an  exploratory  incision,  the  latter  is  al- 
ways indicated.  Expectant  treatment  should  never  be  em- 
ployed unless  the  patient  can  remain  under  constant  su- 
pervision.    [J.  S.] 

3. — The  result  of  the  war  in  South  Africa  in  regard  to 
wounds  produced  by  bullets  of  small  calibre,  are  exceed- 
ingly intersting.  Simple  perforative  wounds  of  the  soft 
parts  usually  heal  in  the  course  of  from  14  to  18  days, 
without  further  disturbance.  Occasionally  if  the  muzzle 
of  the  gun  was  close  to  the  flesh  at  the  time  of  discharge 
there  is  superficial  necrosis.  In  cases  where  there  is  hem- 
orrhage into  the  cavities  of  the  body  the  prognosis  is  rather 
less  favorable.  It  does  not  appear  that  nerve  trunks  are 
often  divided.  Injuries  to  the  diaphyses  of  the  bones  often 
causes  splintering;  those  to  the  epiphyses,  sometimes  sim- 
ple perfortaion.  The  joint  is,  however,  often  involved  in  the 
latter  case.  The  prognosis  in  these,  as  in  all  other  in- 
juries, is  favorable  provided  infection  does  not  occur.  How- 
ever, it  is  an  interesting  fact  that  vigorous  disinfection  of 
the  wound  does  more  harm  than  good.  Sthamer  has  been 
in  the  habit  of  cleaning  the  surrounding  skin  sufficiently 


to  fix  an  occlusive  dressing,  and  of  avoiding  any  contact 
with  the  opening  of  the  wound.  The  object  of  this  treat- 
ment is  of  course  to  admit  the  development  of  clots  and 
thus  prevent  the  entrance  of  an  infectious  element.  It  is 
not  even  necessary  to  have  the  bandage  antiseptic.  On 
the  other  hand  it  must  be  dry  and  capable  of  absorption. 
He  reports  some  remarkable  cases.  One  soldier  was 
shot  through  the  region  of  the  stomach.  He  then  rode  ;{i)00 
meters  and  was  obliged  to  remain  overnight  in  the  camp 
and  only  on  the  following  day  he  was  transported  to  the 
hospital.  There  was  no  fever;  the  pulse  was  strong  and 
slow.  Death  however,  occurred  suddenly  as  a  result  of 
bleeding  from  a  small  vessel  in  the  mesentery.  The  colon 
and  stomach  had  been  perforated,  but  there  were  no  signs 
of  peritonitis.  In  another  case  the  patient  was  shot 
through  the  stomach  and  kidney;  there  was  blooa  in  the 
urine,  but  no  other  symptoms  and  recovery  ensued.     [J.  S.J 

4..  .Discussing  the  theories  of  multiplicity  of  primary 
malignant  tumors.  Nehrkorn  calls  attention  to  the  great  im- 
portance of  multiple  carclnomaof  the  skin. which  may  be  due 
either  to  some  chronic  irritaion  or  multiple  implantation. 
He  reports  3  cases;  the  first,  in  wnich  2  small  carcinomas 
appeared  upon  the  left  temple  of  an  old  man;  the  2d  in  a 
man  of  52  when  3  small  carcinomas  were  found  also  in  the 
skin  of  the  head;  and  the  3d,  an  old  woman  with  tumor 
of  the  ear  and  upper  lip;  the  former  a  squamous  epithe- 
lium, the  other  an  adenoid  carcinoma.  The  reason  why 
skin  carcinomas  are  more  frequently  multiple  than  intes- 
tinal carcinomas  that  are  also  exposed  to  multiple  im- 
plantation, is  that  the  latter  more  readily  escape  observa- 
tion and  as  the  primary  growth  develops  more  rapidly,  the 
other  foci  do  not  have  time  to  appear.  Simultaneous  in- 
volvment  of  symetrical  glands  is  relatively  uncommon  for 
the  breast  and  quite  common  for  the  ovaries.  Tumors  may 
also  occur  simultaneously  in  different  parts  of  the  body. 
He  reports  the  case  of  a  woman  5S  years  of  age  who  had 
carcinoma  of  the  breast  and  uterus  at  tne  same  time.  An- 
other patient,  a  man  of  62  who  had  a  carcinoma  of  the  blad- 
der, and  subsequently  one  of  the  rectum.  Of  a  man  of  riJ, 
who  had  an  epithelial  tumro  in  the  pharynx,  and  another 
at  the  side  of  the  tongue,  and  finally,  a  woman  who  had 
a  melanotic  sarcoma  with  multiple  metastases,  and  carcino- 
ma of  the  uterus.  In  conclusion  he  laments  the  unsatisfac- 
tory state  of  our  theories  upon  this  subject.     [J.  S.] 

5. — Heinz  has  performed  a  series  of  studies  upon  the  ple- 
ural cavity  in  order  to  determine  certain  facts  regarding 
caustic  action.  Having  failed  with  turpentine  suspended 
in  water  to  produce  a  reaction  he  employed  the  aleuronat 
suspended  in  water,  and  was  able  to  produce  a  typical 
inflammation,  but  not  a  pure  leukocytosis.  On  the  second 
day  he  found  in  the  exudate  in  addition  to  the  white  and 
red  blood  corpuscles,  fibrin  and  plasma,  a  number  of  large 
mononeuclear  cells  evidently  from  the  endothelial  surface. 
When  these  were  examined  under  a  miscroscope  placed  in  a 
thermostat  he  found  that  they  exhibited  very  active  arao- 
bold  movements.  This  merely  proves  that  they  havethesame 
qualities  as  the  endothelium  lining  the  blood  vessels.  [,T.  S.J 

6. — The  first  case,  a  woman  41  years  of  age,  had  symp- 
toms of  mitral  stenosis.  While  under  observation  she 
suddenly  developed  cramp-like  pains  in  both  legs,  then 
pallor  and  cold,  with  loss  of  sensibility  and  active  move- 
ments. These  symptoms  rapidly  extended  upward,  and 
were  associated  with  extreme  pains  in  the  limbs.  Gangrene 
appeared,  the  pulse  in  the  ural  artery  was  lost.  At  the 
amputation  of  both  legs,  it  was  found  that  the  crural  ar- 
teries were  thrombosed.  The  patient  died,  and  at  the  au- 
topsy embolism  and  thrombosis  of  the  abdominal  aorta  was 
discovered.  The  2d  patient  also  had  the  symptoms  of  mi- 
tral stenosis  during  which  he  developed  severe  pains  in 
the  legs,  with  loss  of  power  and  sensation,  coldness  and  ab- 
sence of  pulse  in  the  crural  arteries.  Gangrene  occurred 
and  there  were  symptoms  of  peritonitis.  The  patient  had 
albumin  and  casts  in  the  urine.  .\t  the  autopsy  there  w.is 
embolism  of  the  left  artery  of  the  Sylvian  fossa  and  ab- 
dominal aorta,  and  numerous  infarcts  in  the  spleen  and 
kidneys.     These  cases  are  interesting  because  they  indi- 


-Q       The  Philadelphia-] 
J  1  5O       Medical   Journal  J 

cate  very  clearly  the  etiology  of  the  lesion,  that  is.  the 
mitral  stenosis.  In  one  case  the  thrombus  of  the  heart 
was  probably  dislodged  by  the  medication  with  digitalis. 
The  symptoms  of  embolism  of  the  aorta  are  variable, 
according  to  the  extent  and  location  of  the  obstruction  of 
the  aorta;  but  in  general  they  consist  of  cold  and  pallor, 
then  livid  discoloration  of  the  skin  of  the  limbs,  loss  of  sen- 
sation, motion,  and  pulse,  and  finally  gangrene.  It  is  interest- 
ing to  note  that  in  one  case  the  stethoscope  placed  over  the 
crural  artery  transmitted  a  dull  tone  that  evidently  came 
from  the  aorta.  Both  cases  showed  intense  pain  in  the 
limbs  throughout  the  course.  In  the  second  case  the  ab- 
dominal symptoms  were  due  to  occlusion  of  the  mesenteric 
artery.  The  prognosis  of  this  condition  is  fatal,  and  the 
treatment  of  course,  unavailing.     [J.  S.] 

7. — Fromme  has  endeavored  to  determine  the  value  of 
glutoid  capsules  for  the  diagnosis  of  gastric  motility.  He 
found  that  there  is  considerable  difference  in  the  time  in 
which  the  reaction  with  iodine  occurs,  and  concludes  that 
if  it  appears  between  ZV2  and  5  hours  it  indicates  good  gas- 
tric motility  and  good  pancreatic  function.  If  it  appears 
later  than  7  or  8  hours  this  may  be  due  to  various  causes. 
It  may  be  retained  in  the  stomach,  or  it  may  have  become 
dissolved  in  the  stomach,  for  there  is  no  way  of  proving 
that  the  capsule  itself  is  still  present  in  that  organ.    [J.  S.] 

8. — Muehlig  reports  2  cases  m  wnicu  as  tne  result  of  ex- 
tensive burns  upon  the  arm  bismuth  dressings  were  ap- 
plied causing  bluish  discoloration,  swelling  and  superficial 
ulcers  of  the  gums.  These  were  only  controlled  when  the 
bismuth  still  adhering  to  the  granulations  was  removed. 

9. — Schueltz  reports  the  ca.=e  of  a  man  62  years  of  age, 
who  after  an  attack  of  influenza,  had  diflSculty  of  degluti- 
tion, with  a  sensation  of  obstruction  just  above  the  stom- 
ach. The  passage  of  a  no.  22  sound  was  without  result. 
The  stomach  contents  contained  no  free  HCl,  but  there 
was  some  lactic  acid.  Microscopical  examination  showed 
masses  of  squamus  epithelium  and  some  blood.  A  soft 
stomach  tube  was  therefore  passed  every  day  and  partial 
faradism  applied  to  the  esophagus.  The  patient  was  soon 
able  to  swallow  without  difiiculty  and  recovered  his  health 
entirely.  After  excluding  ulcer  and  carcinoma.  Schueltz 
attempts  to  make  a  differential  diagnosis  of  atony  of  the 
esophagus,  and  esophagitis.  He  believes  that  the  latter 
was  present  partly  on  account  of  the  discovery  of  blood,  and 
partly  because  the  condition  of  the  stomach  predisposed  to 
this  affection,     [J.  S.] 

10. — Langer  reports  the  case  of  a  child  IS  months  old 
who  swallowed  a  considerable  amount  of  soft  soap.  Treat- 
ment was  unavailing  and  the  child  died  the  same  night. 
At  the  autopsy  changes  were  found  in  the  gastro-intestinal 
tract  that  indicated  the  presence  of  some  caustic  sub- 
stance, and  at  the  same  time  the  presence  of  an  inflam- 
mation of  the  lung.  It  was  not  certain  whether  the  poison 
was  sufficient  to  cause  this  inflammation,  but  the  latter 
was  evidently  the  immediate  cause  of  death.  The  amount 
of  potassium  or  sodium  hydrate  in  soaft  soap  from  S.5  to 
12%.  Administered  to  2  dogs  through  an  esophageal  sound 
it  caused  vomiting  in  a  short  time.  Both  animals  however, 
recovered  in  the  course  of  4  or  5  days.  In  one  dog  that 
was  killed  there  was  some  irritation  at  the  cardiac  end 
and  along  the  lesser  curvature.  The  results  prove  the 
great  danger  of  many  common  substances  to  children. 
ij.  S.] 

11. — Spiess  highly  recommends  orthoform  for  whooping- 
cough.  In  order  to  combat  the  local  alteration  in  the  mucous 
membranes  of  the  pharynx  he  insufllates2or  3  times  every  2 
hours,  and  in  small  children  3  or  4  times  in  the  course  of  a 
day.  It  causes  no  discomfort  and  apparently  relieves  the 
attacks.     [J.   S.] 

.  .12. — Karehnke  reports  the  case  of  a  man  72  years  of  age, 
who  in  attempting  to  bite  a  crust  of  bread,  dislocated  the 
left  maxillary  articulation,  but  it  was  replaced  without  dif- 
ficulty.    [J.  S.] 


THE  LATEST  LITERATURE 


[Ju.vE    15,    1901 


WIENER    KLINISCHE   WOCHENSCHRIFT. 

March  ?.l,  1901.     (XIV  Jahrgang.  No,  12.) 

1.  .Mushroom  Poisoning.     HUGO  GOLDMAN". 

2.  Affections  of  the  Joints  in  Scarlet  Fever.     EDMUND 

HOMA. 

3.  The  Primitive  Organs  of  Sight.     THEODOR  BEER. 

1. — Last  summer  Goldman  treated  11  cases  of  poisoning 
following  the  ingestion  of  the  agaricus  torminosus.  The 
ijrst  cases  were  three  children  from  2  to  14  years  of  age, 
who  had  gathered  the  mushrooms,  cut  them  up.  and  eaten 
them.  The  youngest  one  died  in  spite  of  all  treatment,  in 
24  hours.  Soou  afterward,  eight  Polish  laborers,  mis- 
taking the  agaricus  for  an  edible  mushroom,  collected  and 
ate  them.  Out  of  this  number,  two  women,  who  had  eaten 
most  heartily,  died  from  5  to  6  days  afterward.  Still,  they 
only  received  their  first  treatment  on  the  third  day  of 
illness,  while  all  the  rest  received  immediate  attention. 
The  agaricus  is  very  common  in  the  woods  about  Vienna 
all  summer,  it  is  yellowish  white,  stands  about  4  cm.  high, 
and  burns  slightly  when  tasted.  It  looks  much  like  the 
"champignon."  The  poison  in  it  is  unknown.  The  symp- 
toms are  those  ordinarily  seen  in  cholera  morbus,  coming 
on  about  four  hours  after  the  mushrooms  have  been  eaten. 
Goldman  found  the  skin  dry  and  icteric,  pupils  dilated, 
tongue  deeply  coated,  and  tremulous,  very  slight  fever, 
abdomen  and  epigastrium  somewhat  tender,  much  vomit- 
ing and  severe  diarrhea.  At  autopsy,  acute  gastrointes- 
tinal  catarrh  and  slight  fatty  degeneration  of  the  liver,  kid- 
neys, and  heart  were  found.  Goldman's  treatment  was 
tannin  by  mouth  and  rectum.  As  prophylaxis,  he  recom- 
mends that  the  market  officials  and  the  people,  especially 
the  children,  be  taught  to  recognize  the  poisonous  varieties 
of  mushrooms.     [M.  O.] 

2. — Joint  inflammation  is  not  uncommon  in  the  infectious 
diseases.  After  reviewing  the  literature.  Homa  reports  14 
cases  in  which  synovitis  occurred  during  scarlet  fever. 
In  only  one  of  these  was  the  effusion  purulent.  He  treated 
•506  cases  in  five  years.  The  joint  affection  appears  in  the 
first  or  second  week  of  scarlet  fever,  about  the  beginning  of 
desquamation,  in  severe  cases,  with  pain  and  some 
added  elevation  of  temperature.  Swelling  was  only  ob- 
s'^rved  in  5  cases.  The  symptoms  generally  disappear  in- 
side of  a  week.  6  of  the  cases  had  two  such  attacks,  one 
case  three.  The  wrist  was  affected  8  times,  the  elbow  7, 
knee  5,  ankle  4.  and  the  hip  and  shoulder  once  each.  In  10 
of  these  it  occurred  on  both  sides  of  the  body.  The  treat- 
ment was  rest,  moist  dressings,  and  in  four  cases  only,  so- 
dium salicylate.  Homa  could  not  find  any  peculiarly  fa- 
vorable action  of  the  salicylates.  The  histories  of  his  14 
cases  follow  in  detail.     [M.   O.] 

3. — Will  be  abstracted  when  concluded. 

March  28,  1901.     (XIV  Jahrgang.  No.  13.) 

1.  The  Pathology  and  Treatment  of  Migraine.    M.  SIHLE. 

2.  Three  Cases  of  Cataract   from  Lightning-Stroke.     JO- 

SEF PREINDLSBERGER. 

3.  The  Primitive  Organs  of  Sight.    THEODOR  BEER. 

1. — In  spite  of  the  frequency  of  migraine,  its  origin  is 
still  obscure.  Sihle  calls  attention  to  the  fact  that  the 
aura,  a  limited  area  of  paresthesia,  hyperesthesia,  etc..  is 
generally  found  upon  the  opposite  side  from  that  upoc 
which  the  migraine  occurs.  Sihle  reports  his  own  case 
He  is  now  38  years  old.  His  father  had  lung  trouble:  his 
mother  much  headache,  and  her  brother  was  epileptic.  His 
brother  had  migraine  and  rheumatism.  Sihle  had  pleurisy 
nine  years  ago.  followed  by  frequent  cough  and  hemopty- 
sis. It  was  at  this  time  that  he  first  noticed  "gleams  of 
light"  or  "bright  specks"  before  the  eyes.  This  has  often 
recurred  since,  succeeded  by  severe  migraine.  Tubercle 
bacilli  were  found  in  his  sputum  S  years  ago.  Pleurisy  oc- 
curred the  next  year  upon  the  other  side,  followed  by 
aphonia.  For  the  past  5  years  he  has  been  better  physi- 
cally, and  fully  able  to  work.  He  noted  that  the  appear- 
ance of  these  "bright  specks"  was  to  one  side  of  the  point 
of  fixation,  while  the  headache  which  followed  occurred 
over  the  temporal  bone  of  the  opposite  side,  and  was  very 
severe.  This  migraine  lasted  two  hours  or  longer.  These 
attacks  occurred  about  once  a  month,  growing  gradually 
more  seldom.  During  the  past  three  years  he  has  had 
none.  Of  the  10  attacks  observed  by  him  in  detail,  the 
"light"  appeared  7  times  to  the  right,  and  only  three  times 
to  the  left,  so  that  the  pathological  change  occurred  more 


JUNE    15.    1!>II1] 


THE  LATEST  LITERATURE 


TThe  Philadelphia 
Lmedical  Journal 


1 1 59 


often  in  the  left  hemisphere.  As  the  pain  occurs  after 
the  aura,  and  upon  the  opposite  side,  it  has  probably  but 
secondary  significance.  Omitting  the  pain,  the  position  of 
the  probable  CEULse  of  migraine  can  be  determined.  This  is 
a  hemjcranial  change,  probably  degenerative,  found  not  in 
any  one  especial  place,  but  in  several  parts  of  the  brain 
cortex.  The  degeneration  can  evidently  recover.  Tuber- 
culosis, or  any  other  toxic  condition  can  undoubtedly  'Je 
the  exciting  cause  of  the  migraine.  After  a  full  discussion 
of  the  theories  advanced  to  account  for  the  occurrence  of 
mi.graine.  he  suggests  that  the  pain  may  be  due  to  irrita- 
tion of  the  meninges,  secondary  to  the  effect  upon  the  cor- 
tex of  the  toxic  cause  of  the  migraine.  Intoxication  must 
be  the  main  cause  of  both  epilepsy  and  migraine,  and  the 
headache  in  migraine  and  in  epilepsy  is  but  the  secondary 
manifestation  of  the  toxin.  They  are  not  the  same  illness, 
though  they  have  the  same  causes.  Is  migraine  epilepsy 
without  convulsions,  or  is  epilepsy  an  advanced  stage  of 
migraine?     The  answers  Sihle  leaves  to  the  future.     [M.O.] 

2. — Two  of  the  three  cases  reported  which  had  been 
struck  by  lightning  had  cataract  develop  in  both  eyes. 
two  days  afterward.  One  was  a  boy  of  13,  the  other  11. 
Both  were  unconscious,  the  elder  for  a  short  time  only, 
the  younger  for  two  days.  He  had  also  been  burrfed.  In 
both  cases  linear  extraction  was  performed,  with  success. 
The  third  case  was  a  man  of  24,  who  had  been  struck  by 
lightning  6  years  liefore.  He  was  unconscious  for  10 
minutes  only.  A  cataract  developed  in  the  right  eye 
alone,  some  months  later.  Preindlsberger  performed  ex- 
traction with  iridectomy  with  success.  The  condition  is 
quite  rare.     [M.  O.] 

3. — Beer's  article  is  most  modern  and  complete,  yet  tech- 
nical. He  uses  an  entirely  new  nomenclature.  He  de- 
scribes the  primitive  organs  of  sight  in  the  lowest  animals, 
tracing  them  up  to  the  hieher,  from  the  simple,  pigment- 
less  cells,  to  the  pigmented,  highly  specialized  organs  of 
man.  He  minutely  gives  means  of  telling  whether  an 
animal  is  or  is  not  blind.     [M.  O.] 


ARCHIVES  DE  MEDECINE  EXPERIMENTALE. 

]fiinh.  19111.    (13me.  Annee,  No.  2.) 

1.  A  Case  of  Purpura  Simplex.     G.  CARRIERE. 

2.  Hemorrhagic  Pancreatitis  in  Typhoid  Fever.  A.  CHAUF- 

FARD  and  P.  RAVAUT. 

3.  The  Action  of  Typhoid  Bacilli  on  Human   Blood.     E. 

MAUREL. 

4.  Primary    Massive   Tuberculosis   of   the   Spleen.     F.   J. 

COLLET  and  LOUIS  GALLAVARDIN. 

5.  Arterial  Sutures.     J.  BOUGLE. 

6.  The  Histogenesis  of  the  Tubercle.     CHALES   MOKEi. 

and  DALOUS. 

7.  Carcinomatous   Lymphangitis  of  the  Lung.     E.   TROI- 

SIER and  M.  LETULLE. 

1. — Carriere  reports  a  case  of  purpura  simplex  occurring 
in  a  boy  of  14.  Anorexia  has  existed  for  a  month,  with 
some  emaciation  and  weakness.  There  has  been  slight 
pain  in  the  knees,  ankles,  and  legs  before  the  eruption  ap- 
peared. This  was  almost  symmetrically  arranged  about  the 
joints,  with  some  ecchymoses  on  one  nostril  and  eyelid,  and 
larger  spots  on  the  right  scapula  and  left  buttock.  There 
was  no  fever  or  edema ;  though  bleeding  from  the  gums  oc- 
curred. Blood  examination  showed  17,900  leucocytes  to 
4,350,000  red  corpuscles.  65%  of  the  leucocytes  were  poly- 
nuclear;  15%  were  eosinophiles;  and  there  were  no  large 
lymphocytes.  Cultures  from  the  blood  with  inoculation  and 
experiments  gave  a  bacillus,  aerobic  and  anaerobic,  simi- 
lar to  that  found  by  Achalme  and  Thirolix  in  acute  rheuma- 
tism. Carriere.  who  has  also  investigated  that  bacillus, 
believes  that  they  are  indentical.  It  shows  remarkable 
polymorphism,  and  is  probably  the  same  micro  organism 
taken  by  other  observers  for  staphylococci  or  diplococci. 
[M.  O.] 

2. — The  first  reported  case  of  hemorrhagic  pancrea- 
titis occurring  in  the  course  of  typhoid  fever  is  described 
by  Chauffard  and  Ravaut.  A  man  of  40  entered  the  hospital 
on  the  day  before  his  rose-spots  came  out.  Defervescence 
began  on  the  19th  day.  A  few  days  later  the  temperature 
rose  and  a  relapse  was  feared:  but  in  10  days  all  symptoms 
had  disappeared.     On  the  52nd  day  he  had  a  sudden  pain 


in  the  right  hypochondrium.  in  the  umbilical  line,  followed 
by  distension.  His  pulse  shot  up  to  120-160,  and  became 
small  and  filiform.  Fever  only  appeared  two  days  later. 
It  was  supposed  that  perforation  had  occurred,  yet  the 
symptoms  gradually  subsided.  66  days  later  dyspnea  ap- 
peared with  left  sided  bronchopneumonia,  and  he  died  a 
week  later.  The  pancreas  was  found  surrounded  with 
hemorrhagic  cellular  tissue.  There  was  no  trace  of  per- 
foration or  peritonitis.  Both  pancreas  and  lungs  showed 
marked  congestion.  Perforation  generallay  occurs  before 
the  52d  day.  Death  by  syncope  66  days  after  the  pancreati- 
tis was  perhaps  brought  about  by  the  sympathetic  nerve 
plexus.  Examination  of  the  pancreas  shows  the  absence 
of  fatty  degeneration;  evident  venous  stasis;  with  most 
hemorrhage  behind  the  pancreas,  in  the  tissue  about  the 
gland.  There  was  no  evidence  of  any  inflammation  of  the 
pancreas.  After  reviewing  the  literature  and  describing  a 
number  of  experiments  upon  the  liver  and  pancreas.  Chauf- 
fard and  Ravaut  conclude  without  giving  a  satisfactory  ex- 
planation for  the  occurrence  of  hemorrhagic  pancreatitis 
in  typhoid  fever.  Perhaps  the  lack  of  nourishing  food 
during  the  fever  and  the  activity  of  the  pancreas  neces- 
sary during  convalescence,  from  the  stronger  food  in- 
gested, may  account  for  the  possibility  of  hemorrhagic  pan- 
creatitis.    [M.  O.] 

3. — After  three  experiments,  with  control  tests,  of  hu- 
man blood  mixed  with  typhoid  bacilli.  Maurel  concludes 
that  human  leucocytes  absorb  typhoid  bacilli,  but  suc- 
cumb to  this  alisorirtion  in  less  than  a  half  hour;  there- 
fore this  bacillus  is  one  of  the  most  virulent  for  the  hu- 
man leucocytes;  that  in  these  experiments  the  leucocytes 
have  never  sought  or  fled  from  the  bacilli;  that  only  the  ab- 
sorption of  the  bacilli,  and  not  of  their  products,  is 
dangerous  to  the  leucocytes:  that  fever  from  103  to  104° 
F.  is  favorable  to  the  leucocytes  in  their  struggle  with 
the  bacilli;  and  that  the  typhoid  bacilli  precipitate  the 
fibrin  of  the  blood,  but  much  less  than  certain  other  mi- 
cro-organisms. Under  the  influence  of  the  conditions  in 
which  these  experiments  were  performed,  with  little  ox.v- 
gen,  and  some  contamination  of  the  surroundings,  the  num- 
ber of  typhoid  bacilli  decreased  rather  than  increased; 
whence  he  concludes  that  such  conditions  are  unfavor- 
able to  its  development.     [M.  O.] 

4. — Collet  and  Gallavardin  report  a  case  of  massive  pri- 
mary tuberculosis  of  the  spleen,  a  man  of  60,  in  whom 
a  tumor  had  excisted  for  two  years  in  the  left  hypochon- 
drium. For  two  months  gastric  symptoms  have  been  fre- 
quent. He  has  lost  20  pounds.  Examination  showed  a 
spleen  which  reached  into  the  left  hypochondrium  as  far  as 
the  spinous  process  of  the  ilium.  It  was  nodular,  but 
not  tender.  The  liver  extended  four  finger  breadths  below 
the  margin  of  the  ribs.  There  was  slight  fever,  but  no 
cachexia  or  malaria.  Bacteriologically  and  microscopical- 
ly, after  autopsy,  massive  primary  tuberculosis  of  the 
spleen  was  found,  which,  when  inoculated  in  a  rabbit,  pro- 
duced giant  cells.  The  liver  was  also  tuberculous,  and  an 
old  calcareous  tubercle  was  found  at  the  apex  of  one  lung. 
This  was  a  case  of  the  spleno-hepatic.  not  purely  splenic, 
nor  were  the  lymph-glands  affected.  The  literature  of  the 
subject  is  fully  reviewed.     [M.  O.] 

5. — Early  in  the  eighteenth  century  Lambert  advised 
suturing  arteries.  In  1757  it  was  first  attempted.  In  18S9 
Jassinowsky  first  succeeded  in  obtaining  permeability  of 
the  sutured  vessel.  Thus  far  sutures  applied  to  join  ar- 
teries which  had  been  cut  clean  across  have  failed.  This 
procedure  is  still  in  the  experimental  stage.  Gliick  covered 
the  artery,  after  suturing  the  ends  together,  with  a  cuff 
formed  by  a  fresh  vein  or  artery  sutured  about  it.  Brian 
and  Jaboulay  turn  out  the  edges  of  the  apposing  cut  ends, 
and  apply  sutures  tightly  through  the  edges.  Murphy  in- 
vaginates  one  end  in  the  other,  suturing  both  ends,  but 
not  passing  the  sutures  through  into  the  lumen  of  the 
vessel.  BougM,  after  numerous  experiments  upon  the  ar- 
teries of  dogs,  finally  sutured  the  ends  of  cut  arteries  to- 
gether with  sutures  which  did  not  pass  through  the  walls 
into  the  lumen  of  the  vessel.     He  found  that  investigation 


1 160 


The  Philadelphia' 
Medical  Journal    , 


THE  LATEST  LITERATURE 


[JtlNB   13,    IMl 


was   not   necessary.      He   advises    arterial    suture    in    man 
should  opportunity  present.     [M.  O.] 

6. — Morel  and  Dalous  have  performed  a  series  of  eight 
experiments  upon  rabbits  to  study  the  histogenesis  of  the 
tubercle.  From  their  minute  and  detailed  observations, 
after  the  staining  of  many  slides  and  the  preparation  of 
many  sections,  it  is  shown  that  in  the  alveoli  of  the  lungs 
and  the  bronchial  cavities,  tubercles  develop  exclusively 
at  the  expense  of  the  leucocytes,  especially  those  large 
mononuclear  cells  which  arrive  quickly  at  each  focus  of 
infection.  The  fixed  cells  of  the  alveoli  and  the  epithelial 
cells  of  the  bronchial  walls  play  absolutely  no  role  in  the 
histogenesis  of  the  tubercles.  [M.  O.] 
7. — Troisier  and  LetuHe  have  made  further  researches  upon 
carcinomatous  lymphangitis  of  the  lungs.  They  describe 
specimens  of  an  epithelioma  of  the  lymphatics  secondary 
to  visceral  cancer.  The  thoracic  duct  is  the  last  part  of 
the  lymphatic  system  to  become  affected.  The  vessel  in- 
vaded becomes  a  thick,  gray,  or  yellow  cord,  its  lumen  ob- 
structed by  a  caseous  mass  of  cancer  cells.  On  the  thor- 
acic duct  cancerous  nodules  may  appear,  as  the  lymph- 
glands  become  involved.  Sections  of  the  preparation  are 
described.     [M.  O.] 


REVUE    MEDICALE   LE   L'EST. 


.l;;/(7    /,    lUof. 


3Srae.     Annee,    No.    7.) 


1.     Histology.     A.  PREUAUT. 

1. — Histology  is  no  longer  the  simple  study  of  the  cells 
which  form  the  tissues.  It  is  rather  a  general  anatomy 
and  physiology  from  the  comparison  of  structure  and 
function  observed.  Two  theories  have  been  proposed  to 
explain  histology,  the  classic  vitalist  theory,  and  the  mod- 
ern physico-chemical  theory.  For  while  the  structure  stud- 
ied is  living,  it  is  composed  of  chemical  matter,  constituted 
physically.  A  histological  structure  is  what  is  actually 
observed  in  a  tissue  or  cell.  A  cell  is  an  elementary,  well 
limited,  organism,  living  alone  or  in  association  with  oth- 
ers. Protoplasm,  a  term  formerly  much  used,  no  longer 
holds  a  place  in  histology.  It  is  but  a  morphologic  idea, 
seen  only  through  the  microscope.  Physically  it  cannot  be 
found.  Living  matter  possesses  the  faculty  of  changing  its 
substance,  its  form,  and  its  energy.  But  these  changes  are 
possible  in  bodies  that  are  not  alive,  and  have  been  shown 
to  be  purely  chemical  in  character.  Thus  the  early  vitalist 
theory  has  been  disproved,  while  the  physico-chemical 
theory  not  only  is  better  understood,  but  is  now  considered 
the  only  scientific  theory.  With  physiology,  histology,  re- 
duced to  physics  and  chemistry,  joins  the  vanguard  of 
biology.     [M.  O.] 


REVUE    DE    CHIRURGIE. 

A/u-il.  mot.     (21me.  Annee,   No.   4.) 

1.  Hemothorax.     TH.  TUFFIER  and  G.  MIUAN. 

2.  Hydatid    Cysts.      HERRER.A.    VEGAS   and    DANIEL   J. 

CRANWELL. 

3.  Fractures  of  the  Upper  Jaw.    RENE  LE  FORT. 

4.  The  Perihepatic  and  Pleural  Complications  of  Appen- 

dicitis.    L.  LAPEVRE. 

5.  Primary  Tuberculosis  of  the  Parotid.     P.  LECENE. 

6.  Genital  Tuberculosis  in  Women.     MARIE  GOROVITZ. 

1. — A  man  of  37,  neurasthenic  and  syphilitic,  in  an  at- 
tack of  hypochondria  tried  to  shoot  himself  through  the 
heart.  The  bullet  entered  about  the  nipple  and  lodged  pos- 
teriorly, near  the  angle  of  the  scapula,  where  it  could  not  be 
palpated.  No  suppuration  occurred  and  the  wound  healed 
by  first  intention.  But  on  the  day  after  the  accident  slight 
hemothorax  was  found,  without  pneumothorax.  The  fur- 
ther evolution  of  this  hemothorax  has  been  most  carefully 
studied.  The  liquid  has  been  frequently  examined  bacter- 
iologically,  its  red  and  white  corpuscles  counted,  and  cover- 
glass  preparations  made.  Up  to  the  21st.  day.  the  liquid  in- 
creased in  volume  but  was  lass  dark  in  color:  then  the 
dulness  began  to  diminish  and  the  eft'usi-on  grew  percepti- 
bly lighter.  By  the  .>Sth  day  it  was  yellow.  On  the  44th 
day,  when  the  patient  loft  the  hospital,  there  was  but  three 
or  four  finger-breadths  of  dulness  remaining.  Fever  dis- 
appeared on  the  fifth  day  to  return  two  weeks  later,  with 


a  gradual  rise  to  101.5 °F.  From  the  bacteriological  exam- 
inations, no  bacteria  at  any  time  developed.  The  process 
was  absolutely  aseptic.  The  red  corpuscles  in  the  fluid  be- 
gan to  disappear  on  the  18th  day.  and  were  almost  gone 
on  the  32nd.  From  the  cover-glass  preparations  it  is  seea 
that  the  total  number  of  leucocytes  fell  on  the  18th  day 
from  6000  per  c.mm.,  reaching  1300  on  the  26th  day.  Oa 
the  37th  day  they  were  2700,  but  on  the  44th,  1500  again 
The  polynuclear  leucocytes  fell  on  the  16th  day  from  2600 
to  practically  nothing  on  the  26th  day.  The  later  increase 
in  the  leucocytes  was  due  to  the  lymphocytes.  The  fol- 
lowing conclusions  were  drawn  by  Tuffier  and  Milian:  the 
increase  in  the  effusion  about  the  15th  day  is  not  due  to 
hemorrhage,  but  to  a  serous  exudate,  as  is  easily  shown  by 
puncture.  This  is  therefore  not  a  cause  for  operation.  Nor 
is  the  fever  which  moderates  in  a  few  days  an  indication 
to  operate.  But  persistence  of  the  polynuclear  leucocytes 
in  the  effusion  after  the  21st  day  will  suggest  suppura- 
tion. Should  the  polynuclear  leucocytes  fail  to  decrease 
from  day  to  day.  remain  stationary,  or  increase,  suppuration 
is  to  be  suspected.  The  correct  treatment  tor  traumatic 
hemothorax  is  withdrawal  of  the  fluid  about  the  15th  day, 
when  the  bloody  effusion  is  well  diluted,  and  the  pulmonary 
wound  has  sufficiently  healed  to  prevent  renewed  hemor- 
rhage on  removing  the  pressure  of  the  liquid  in  the 
pleura.     [M.  O.j 

2. — During  the  past  13  years.  952  cases  of  hydatid  cysts 
have  been  recorded  in  the  Republic  of  Argentine.  Vegas 
and  Cranwell  believe  that  as  many  as  1500  cases  have  oc- 
curred. 914  cases  were  seen  in  Buenos  Ayres.  173  in  one 
year.  1898  .  The  causes  of  this  frequency  of  hydatids  is 
probably  the  immense  number  of  cattle  and  dogs  in  Ar- 
gentine, most  of  which  have  hydatids.  Of  the  952  cases 
recorded, Jiydatid  cysts  appeared  641  times  in  the  liver,  54 
times  in  the  lung.  30  times  in  the  spleen.  26  times  in  the 
cellular  tissue.  25  times  in  the  female  pelvis,  and  21  times 
in  the  mesentery.  There  were  also  multiple  cysts  in  the 
abdomen  in  21  cases.  27  cases  had  cysts  in  two  different 
organs.  The  liquid  in  hydatid  cysts  may  be  aseptic,  the 
pericystic  membrane  containing  the  germs:  the  liquid, 
even  though  clear,,  may  contain  the  germs:  or.  as  the  li- 
quid is  an  excellent  culture  medium,  it  may  contain  strep- 
tococci, staphylococci,  colon  bacilli,  or  typhoid  bacilli.  The 
mortality  from  hydatid  cysts,  with  operation  in  almost  all 
cases,  is  ll.ll'.r.  The  most  dangerous  cases  are  multiple 
cysts  of  the  abdomen  or  brain.  The  operation  to  be  pre- 
ferred is  the  slow  but  sure  method,  marsupialization  with 
drainage.  In  rare  cases,  in  hydatids  of  the  brain,  etc..  ex- 
traction of  the  cyst  with  its  entire  membrane,  without 
drainage,  is  done.     [M.  O.] 

3. — The  upper  Jaw  includes  most  of  the  bones  of  the 
skull  and  face.  Partial  fractures  are  quite  common  in  the 
nasal  and  superior  maxillary  bones,  (palatine  or  orbital.) 
I'hey  may  result  from  gunshot  or  sabre  wounds.  Fractures 
of  the  upper  jaw  may  be  direct,  occurring  at  the  point  of 
injury,  or  indirect,  occurring  at  a  distance  from  the  point 
of  injury.  Direct  fractures  are  generally  limited:  yet  an 
indirect  fracture  may  accompany  a  direct  fracture.  Botn 
kinds  of  fractures  are  due  to  severe  injury,  and  show  no 
displacement.  Le  Fort's  experiments.  35  in  number,  were 
made  upon  the  cadaver.  They  include  fractures  due  to 
violence  applied  anteriorly  at  the  level  of  the  upper  lip; 
laterally  on  the  lower  part  of  the  superior  maxilla:  from 
lielow  upon  the  superior  maxilla:  anteriorly  upon  the  lower 
part  of  the  face:  from  above  upon  the  root  of  the  nose: 
from  below  upon  the  inferior  maxillary  and  malar  bones, 
either  laterally,  the  head  not  being  supported,  or  the  mov- 
ing head  striking  a  resisting  body:  anteriorly  upon  the 
malar  bone,  the  head  resting  on  the  occiput:  externally  on 
one  malar  bone,  the  head  resting  on  the  other:  or  anter- 
iorly upon  the  front  of  the  face.  They  may  also  result 
from  force  applied  to  the  face  and  skull  together,  or  to 
many  blows  in  different  parts  of  the  face  from  different 
directions.  Seven  cases  are  reported  from  the  literature, 
and  one  of  his  own.  Le  Fort  believes  that  the  position  of 
the  superior  maxillary  bones,  with  the  malar  bones,  at 
the  base  of  the  skull,  is  the  cause  of  the 'frequent  frac- 
tures. Two  lines  of  weakness,  a  protection  for  the  skull, 
extend  across  these  bones  of  the  face.  Three  fragments 
may  be  found,  generally  immovable,  the  alveolar  arch,  the 
malar  bono,  or  the  upper  end  of  the  maxilla  with  the  nasal 
bone  occasionally.  Le  Fort  concludes  that  in  fracture  of 
the  upper  jaw,  the  character  and  signs  of  the  fracture  will 
be  simple  and  similar  to  one  another,  no  matter  whence 


JCNE   15,  1901] 


THE  LATEST  LITERATURE 


TTl 

Lm 


The  Philadelphia 
edical  jouknal 


I  i6i 


the  violence  came.  He  hopes  that  this  may  aid  in  forming 
a  precise  diagnosis  of  these  lesions,  so  difficult  to  deter- 
mine. [M.  O.] 

4. — Wlil  be  abstracted  when  completed. 

5. — Primary  tuberculosis  of  the  parotid  gland  is  very 
rare  in  man.  Lecene  having  been  able  to  collect  but  i? 
authentic  cases  with  histological  and  bacteriological  ex- 
aminations reported.  Lecene  reports  the  case  of  a  man  of 
29,  with  a  tumor  of  the  right  parotid  which  had  existed  10 
years,  slowly  growing  in  size.  There  was  no  pain,  but 
great  inconvenience  on  moving  the  head.  The  skin  was 
normal,  cner  a  tumor  about  the  size  of  a  large  nut.  It  was 
hard  internally  where  it  was  attached  to  the  parotid,  soft- 
er and  almost  fluctuating  under  the  skin.  There  were  no 
signs  of  tuberculosis  elsewhere.  It  was  diagnosed  a  mixed 
tumor  of  the  parotid,  and  was  operated,  the  tumor  being 
enucleated.  Twelve  days  later  he  left  the  hospital.  The 
wound  healed  quickly,  and  there  has  been  no  recurrence. 
Preparations  reveal  typical  giant  cells,  with  tubercle  bacilli. 
A  review  of  the  meager  literature  follows.  The  treatment 
of  tuberculosis  of  the  parotid  is  wholly  surgical.     [M.  O.] 

6. — Wlil  be  abstracted  when  concluded. 


RUSSKI    ARCHIV    PATOLOGII.    KLI NITSHESKOI    MEDl- 
CINII    BAKTERIOLOGII. 

March,  imi.     (Vol.  6,  No.  3). 

1.  Primary  Squamous  Epithelioma  of  the  Calyces  and  Met 

aplasia  of  the  Epithelium  of  the  Mucous  Membrane 
of  the  Calyces,  Pelvis  and  Ureters.  DM.  P.  KICHEN- 
SKY. 

2.  Iron  in  the  Liver  of  Healthy  Persons.    P.  BIELFELD. 

3.  A  Case  of  Affection  of  the  Skin  in  Pseudoleukemia.  S. 

K.  KIRKOROFF. 

4.  Morphologic  Observations  on  the  Pathogenesis  of  Tu- 

mors.    I.  G.  SAVTCHENKO. 
6.     On  the  Changes  in  the  Ganglia  and  Muscle  of  the  Heart, 

in  the  Liver  and  Kidnevs  Produced  by  Poisoning  with 

Digitalis.     X.  KLOPOTOVSKT. 
€.     Contribution  to  the  Study  of  Tumors  of  the  Corpora 

Quadrigemina  and   Some  Points   in  the  Differential 

Diagnosis   from   Tumors   of  the  Cerebellum.     V.  V. 

NI3SEN. 

1. — Kichensky  reports  a  rare  case  of  primary  squamous 
carcinoma  of  the  calyces,  pelvis  and  ureters  with  subse- 
oueut  invasion  of  the  kidneys,  liver,  adjoining  diaphragm, 
peritoneum  and  metastasis  into  the  right  knee  The  pa- 
tient was  a  woman,  32  years  old.  and  was  sick  only  IV^ 
months.  The  peculiarity  of  the  growth  was  that  wherever 
found  it  possessed  the  character  of  the  epithelium  from  the 
urinary  tract  and  showed  a  tendency  to  horny  metamor- 
phosis, thus  resembling  the  epidermis.  A  complete  de- 
scription of  the  pathological  findings  as  well  as  a  thorough 
review  of  the  literature  on  the  subject  are  given.     [A  .R.] 

2. — Bielfeld  made  a  number  of  analyses  of  normal  liver 
substance  with  a  view  of  determining  whether  the  hepatic 
cells  contain  iron.  He  claims  that  most  of  the  authors  who 
preceded  him  in  the  investigation  employed  faulty  methods 
which  were  responsible  for  the  discrepancy  in  their  re- 
sults. The  method  employed  by  him  was  that  devised  in  the 
laboratory  of  Alex.  Schmidt  and  is  performed  as  follows: 
After  removing  the  gallbladder  the  liver  is  cut  into  small 
pieces,  V2  cm.  thick,  by  means  of  a  piece  of  glass.  Both 
surfaces  of  each  piece  are  scraped  with  a  horn-spatula,  the 
scrapings  mixed  with  salt  solution  (7:1000)  and  strained 
through  a  clean  piece  of  linen.  The  contents  of  the  strain- 
er are  washed  2-3  times  with  the  salt  solution.  The  liquid 
•which  passes  through  the  linen  consists  of  liver  cells  sus- 
pended In  the  salt  solution.  This  liquid  is  then  placed  in 
a  cylinder  of  a  capacity  of  10  liters  which  is  filled  up  to 
the  brim  with  salt  solution  and  set  aside  in  a  cool  place 
(D-IO)  for  12  hours.  By  that  time  the  liver  cells  have  sub- 
sided. The  salt  solution  is  renewed  from  3  to  6  times  un- 
til the  spectroscope  fails  to  show  bands  of  hemaglobin. 
When  the  washing  is  completed  the  fluid  is  decanted  and 
the  solid  portion  subjected  to  centrifugilation  to  remove 
the  last  portions  of  fluid.  The  liver  cells  are  then  dried 
to  a  constant  weight  and  divided  into  two  parts:  one  for 
determining  the  amount  of  sodium  chloride,  the  other  for  the 
deterimnation  of  iron.  Both  parts  are  incinerated.  The 
sodium  chloride  in  one  is  determined  by  Mohr's  method, 
while  the  other  is  washed  with  hot  water,  filtered,  again 


incenirated,  together  with  the  filter,  the  ashes  dissolved  in 
hydrochloric  acid,  the  latter  evaporated,  the  residue  treated 
with  sulphuric  acid  and  a  piece  of  zinc  added  to  convert  the 
iron  into  an  oxide,  and  the  amount  of  the  latter  is  deter- 
mined by  titration  with  standard  permanganate  solution. 
The  conclusions  arrived  at  by  the  author  after  a  consider- 
able number  of  analyses  are  as  follows:  (1)  The  amount 
of  iron  contained  in  the  hepatic  cells  in  health  are  sub- 
ject to  considerable  variation  (2)  The  average  amount 
of  iron  present  in  a  normal  liver  is  0.169%.  (3)  There  is 
more  iron  in  the  liver  of  men  than  women  (4)  The 
amount  of  iron  in  the  liver  cells  is  increased  in  old  age. 
(5)  It  is  less  between  the  ages  of  20-2.5.    [A.  R.] 

3. — Kirkoroff  reports  the  autopsy  of  a  case  of  pseudoleu- 
kemia with  cutaneous  involvement.  The  lesions  in  the 
skin  resembled  lymphosarcoma.  The  condition  is  quite 
rare,  only  a  few  cases  having  been  reported.     [A.  R.] 

4. — Savtchenko  takes  up  the  consideration  of  the  mor- 
phology of  tumors  with  a  \iew  of  throwing  some  light  en 
the  subject  of  parasitology.  By  the  use  of  special  fixing 
reagents  and  stains  he  demonstrated  morphological  cellular 
elements  which  are  not  to  be  found  in  normal  cells.  Spec- 
imens of  elasto-fibroma  fixed  in  Flemming's  solution  and 
stained  by  the  ordinary  aniline  dyes  showed  Intracellular 
bodies  varying  in  size  from  that  of  a  micrococcus  to  a  red 
blood  corpuscle.  They  were  neither  mucoid,  colloid  or 
hyaline  in  character  and  could  easily  be  mistaken  for  para- 
sites, but  upon  further  examination  by  the  aid  of  differen- 
tial stains  they  proved  to  be  elastogennous  elements  which 
accummulated  in  the  protoplasm  of  the  cell  after  it  ceased 
to  perform  its  proper  function.  The  suggestion  is  made 
that  in  other  tumors  the  presence  of  intracellular  bodies 
may  be  explained  by  considering  the  latter  as  abnormal 
products  of  cells  possessing  perverted  function.  In  certain 
specimens  of  sarcoma  fixed  in  Flemming's  solution  and 
stained  by  the  Biondi  method  intracellular  formations  were 
observed  which  resembled  closely  the  parasites  of  cancer 
described  by  different  authors.  The  author  is  continuing 
his  studies  and  promises  future  communications  on  the 
subject.     [A.  R.] 

5. — Klopotovski  studied  the  effects  of  poisonous  doses  of 
digitalis  on  the  heart,  liver  and  kidneys  of  dogs.  An  in- 
fusion of  digitalis  or  digitalin  was  used.  In  acute  poison- 
ing the  neuclei  of  the  cells  of  the  cardiac  ganglia  are  more 
or  less  destroyed,  the  bodies  of  the  cells  are  increased  in 
size  and  lose  their  structure.  In  subacute  poisoning  the 
cell-body  is  retracted  and  the  protoplasm  becomes  homo- 
geneous" or  finely  granular.  This  change  is  still  more  pro- 
nounced in  chronic  poisoning  (8-15  days)  with  the  addi- 
tional formation  of  vacuoles  and  oil  globules  within  the 
protoplasm.  In  the  cardiac  muscle  fragmentation,  efface- 
ment  of  the  striation  and  fatty  degeneration  take  place. 
The  liver  shows  passive  hyperemia,  atrophy  of  the  cells, 
vacuolization  and  fatty  degeneration  of  the  protoplasm.  The 
kidneys  show  albuminous  and  fatty  degeneration  varying 
with  the  period  of  intoxication.     [A.  R.] 

6. — Will  be  abstracted  when  completed.     [A.  R.] 


Nodular  Erythema,  Rheumatic  Purpura,  and  Hydroa. — At 
a  clinic  given  recentlv  by  Dr.  DuCastel  at  the  Saint-Louis 
Hospital  in  Paris.  (Medf<-ine  Modfrnc,  1901.  No.  19),  a  pa- 
tient was  presented,  with  the  three  skin  lesions  associated. 
Two  weeks  before,  she  felt  111,  had  a  chill  and  fever,  fol- 
lowed by  the  appearance  of  the  eruptions.  There  were 
patches  of  nodular  erythema  upon  the  legs,  the  size  of  a 
dime,  round  or  oval,  elevated,  and  red.  disappearing  on 
pressure.  There  is  generally  some  pain  with  it  Then  ap- 
peared the  petechiae  of  rheumatic  purpura  upon  the  arms 
and  legs.  With  this,  too,  there  is  some  pain,  generally  about 
the  joints,  with  edema.  It  appears  in  successive  crops, 
each  lasting  about  a  week.  Hydroa.  or  hydroic  erythema, 
is  an  eruption  composed  of  erythematous  spots  in  the  cen- 
ter of  which  localized  edema  is  found.  It  appears  suddenly 
and  lasts  a  week  or  more.  DuCastel  believes  that  all  three 
eruptions  are  due  to  vascular  congestion  in  the  skin,  with 
some  tendency  to  edema.  The  common  cause  is  either  an 
infection  or  an  intoxication,  probably.  It  is  possible  that  a 
toxemia,  from  unknown  reasons,  will  act  disfterently  upon 
the  skin  of  different  parts  of  the  body.  He  recommends 
quinine  and  sodium  salicylate  internally,  with  soothin.g 
moist  applications  and  a  dusting  powder  locally,  as  treat- 
ment.   [M.  C] 


1 162 


The  Philadelphia 
Medical  Jr.vRXAL 


] 


TOPICAL  TREATMENT  EPILEPSY 


[JUN-E    la.    1901 


Crioinal  Hrtidcs. 


THE  TOPICAL  TREATMENT  OF  FOCAL  AND  JACK- 

SONIAN  EPILEPSY.=;= 

By  J.  WILLIAM  WHITE,  M.  D., 

of   Philadelphia. 

John  Rhea  Barton  rrofessor  of  Surgery-,  University  of  Pennsj-lvania. 

Before  describing  a  method  of  treatment  which 
may  prove  to  be  appropriate  to  those  forms  of  epi- 
lepsy in  which  a  distinct  motor  center  is  involved, 
and  recording  the  results  up  to  this  time  in  the  only 
two  cases  in  which  I  have  tried  it,  I  desire  to  state 
briefly  the  line  of  thought  which  led  me  to  make 
the  experiment. 

I  may  assume  without  argument  that  the  follow- 
ing propositions  would  be  generally  accepted  as  cor- 
rect:  I.  The  essential  cause  of  epilepsy,  exclusive  of 
demonstrable  sources  of  brain  irritation — as  tu- 
mors, bony  outgrowths,  depressed  bone,  foreign 
bodies,  tuberculosis  or  gum.matous  inriltration — is 
unknown.** 

2.  ^^'hat  seems  to  be  certain  is  that,  whatever 
the  cause,  a  greater  or  less  area  of  the  cerebral  cor- 
tex is  in  a  condition  of  unstable  equilibrium,  in 
which  normal  ph3'siological  action  in  response  to 
normal  stimuli  is  transformed  into  excessive  and 
irregular  outbursts  of  motor  and  sensory  phenom- 
ena. 

3.  That  it  is  the  universal  experience  that  this 
condition  is  aggravated  by  irritation  or  excitement 
of  all  sorts,  and  that  the  only  drugs  that  have  a 
fairly  uniform  controlling  influence  are  those  which, 
like  the  bromides,  are  cerebral  sedatives,  and  dimin- 
ish temporarily  both  reflex  excitability  and  normal 
ph3^siological  activity. 

4.  That  in  all  forms  of  epilepsy  medical  and 
h3gienic  treatment,  though  occasionally  producing 
good  results  in  isolated  cases,  is  unsatisfactory; 
and  that  this  is  also  true  of  surgical  treatment  ex- 
cept in  the  not  very  frequent  cases  where  a  physi- 
cal cause  that  is  removable  is  discovered. 

In  the  excellent  article  (alreadj^  quoted  from)  on 
the  modern  treatment  of  epilepsy,  Dr.  Clark  says: 
"\\'ithout  doubt  the  greatest  single  drug  in  the 
treatment  of  epilepsy  is  some  bromide  salt,"  and 
adds  that  to  be  effective  in  chronic  cases,  such  salts 
must  be  given  in  large  daih'  doses  (from  300  grains 
upward)  and  should  not  be  discarded  until  "salt 
starvation"  or  "semi-salt  starvation"  had  been  tried 
as  an  adjuvant. 

As  to  surgical  treatment,  he  makes  the  following 
very  sensible  remarks,  with  which  I  entireh"  agree : 

♦This  paper  is  published  simultaneously  with  its  appearance  in  the 
University  of  Pennsylvania  Medical  Bulletin. 

*»In  an  article  on  the  modem  treatment  of  epilepsy.  Dr.  Pierce  Clark 
records  as  follows,  the  pathological  findings  in  thirteeii  selected  cases: 

A  degeneration  of  the  nucleus  of  the  second  or  so-called  sensor\-  laver; 
further,  a  willingness  for  the  nucleus  to  suffer  extrusion  from  the  ner\e 
cell;  a  chromatolvsis  of  the  whole  cortex,  especiallv  in  the  motor  region; 
phagocytosis  of  the  constituent  nerxous  elements  bv  infiltrating 
leucocytes,  and  last  of  all.  in  the  most  progressive  cases, 'a  nodular  or 
disseminated  sclerosis,  new  formed  under  what  is  usually  termed  degen- 
erative repair,  a  proliferation  of  the  neurologia.  The  cortical  sclerosis'was 
unevenly  distributed  r.nd  was  probably  the'la.st  and  permanent  set  scene 
of  this  disease,  played  in  the  gray  mantle  of  the  epileptic  brain," 

He  adds:  "If  these  lesions  should  be  found  to  be  constant,  to  what  ex- 
tent would  they  solve  the  epilepsy  problem'  Thev  would  prove  onlv  that 
epilepsv  is  accompanied  and  followed  by  a  definite  organic  lesion  of  a 
marked  and  widely  degenerative  nature.  The  lesions  are  probablv  liotli  a 
cause  and  an  effect  of  the  disease.  We  would  know  that  the  nervous  storm 
had  occurred  and  left  a  tract  of  destruction,  but  our  knowledge  of  the 
exciter  of  the  storm  and  the  degree  of  resistance  it  had  met  from  the 
tissues,  would  be  but  little  or  not  at  all  euriched." 


"The  rules  which  govern  the  selection  of  cases  for 
trephining  need  to  be  more  restrictive  than  at  pres- 
ent conservative  medicine  demands.  If  this  were 
done,  a  much  better  prognosis  for  recovery  would 
obtain  for  the  traumatic  cases  than  the  present  4 
per  cent.  From  the  class  of  those  heretofore  sup- 
posed to  be  operable,  I  would  urge  that  idiopathic 
epileptics  in  whom  the  seizures  have  a  definite  form 
of  invasion  be  withdrawn.  True  or  essential  epi- 
lepsy frequently  takes  the  Jacksonian  form  in  point 
of  muscular  involvement  in  seizures.  Many  trau- 
matics  probably  owe  the  focalization  of  their  con- 
vulsions as  little  to  trauma  as  the  true  idiopathics 
with  Jacksonian  convulsions.  The  brain,  as  a 
whole,  in  such  cases  is  epileptogenetic,  one  zone  is 
onh'  a  little  more  excitable  than  another.  Much 
disappointment  has  been  experienced  by  surgeons 
operating  upon  these  idiopathics  disguised  as  Jack- 
sonian epilepsy." 

Taking  the  above  group  of  facts  as  a  basis,  I  was 
influenced  to  try  the  method  of  treatment  I  am 
about  to  describe,  b}'  some  other  facts  that  had  at- 
tracted m}-  attention  years  ago;  especially  the  influ- 
ence of  operation  upon  epileptics  in  whom  nothing 
abnormal  was  found  at  the  time  of  operation,  or 
in  whom  the  abnormality'  had  no  definite  relation  to 
the  epileps}'.  In  1891.  in  a  paper  entitled  "The  Sup- 
posed Curative  Effect  of  Operation  Per  Se,"  {/An- 
nals of  Surgery),  I  published  a  series  of  tables  con- 
taining 172  cases  of  epilepsy,  147  of  which  had  been 
subjected  to  operations  of  extraordinary  variety, 
and  with  the  equally  extraordinary  result,  accord- 
ing to  the  operators,  of  "improving"  or  "curing"  a 
large  percentage  of  the  cases.  In  56  cases  of  tre- 
phining, nothing  abnormal  having  been  found  to 
account  for  the  symptoms.  25  were  "cured  ;"  18  "im- 
proved." In  30  cases  of  ligation  of  blood  vessels, 
14  were  "cured;"  13  "improved."  In  10  cases  of 
castration,  all  were  "cured."  In  9  cases  of  trach- 
eotomy. 2  were  "cured  ;"  6  were  "improved."  In  24 
cases  of  removal  of  the  superior  cervical  sympa- 
thetic ganglia,  6  were  "cured."  In  6  cases  of  incision 
of  the  scalp  for  exploration  (nothing  abnormal  be- 
ing found),  all  were  "cured." 

Twelve  cases  of  epilepsy  are  reported  as  "cured" 
by  such  operations  as  stretching  of  the  sciatic 
nerv^e,  excision  of  the  musculo-cutaneous  nerve, 
cauterization  of  the  laryn.x  (2),  circumcision,  ap- 
plication of  a  set  on  to  back  of  neck  (4),  tenotomy 
of  external  recti,  burning  of  scalp,  puncture  of 
heart,  etc. 

Many  of  these  cases  were  reported  too  early  to  be 
of  much  use  as  evidence  of  a  genuine  and  perma- 
nent disappearance  of  the  disease,  or  even  a  lasting 
amelioration  of  the  symptoms.  Hence.  I  have 
put  the  words  "cured"  and  "improved"  in  quota- 
tion marks.  But,  even  admitting  this,  it  is  a  re- 
markable showing  which  is  deser%-ing  of  more 
thoughtful  consideration  than  it  has  yet  received. 
That  out  of  147  cases  submitted  to  diverse  opera- 
tions (which  in  the  great  majority  of  cases  re- 
vealed nothing  to  account  for  the  symptoms').  124 
should  have  been  apparently  so  much  benefited 
that  they  were  recorded  as  "cured"  or  "improved." 
is  certainly  extraordinary,  even  after  due  allowance 
has  been  made  for  the  invincible  and  not  unnatural 
tendenc}-  of  the  profession  to  put  on  record  chiefly 
its  favorable  results.     But  when  we  find  that  in  25 


June   15,   1901] 


TOPICAL  TREATMENT  EPILEPSY 


|Ti 

Lm 


The  Philadelphia 
EDiCAL   Journal 


I  165 


of  these  cases  the  improved  condition  was  present 
after  the  lapse  of  twelve  months,  it  is  evident  that 
something  which  had  at  least  a  beneficial  tendency 
in  many  cases  occurred  as  a  result  of  operative  in- 
terference. When  I  tried  to  account  for  this,  I  was 
able  to  conceive  of  but  four  possible  explanations 
dependent  on  the  four  following  conditions,  which 
were  common  to  all,  or  nearly  all,  of  the  cases: 

1.  Anesthesia,  on  the  theory  that  by  its  vola- 
tility or  diffusibility  the  anesthetic  might  reach  the 
nerve  centers  in  sufficient  quantity  to  destroy  a 
possible  microbe  or  neutralize  an  equally  hypotheti- 
cal toxin. 

2.  Psychical  influence  or  so-called  mental  im- 
pression. 

3.  Relief  of  tension. 

4.  Reflex  action  or  the  "reaction  of  traumatism." 
These  influences  were  operative  in  the  majority 

of  the  cases,  although  not  one  of  them,  except  the 
last,  applies  to  the  whole  list. 

1.  That  anesthesia  was  not  the  factor  producing 
the  improvement  was  shown  by  a  series  of  obser- 
vations made  by  me  upon  a  number  of  epileptics 
in  the  ward  for  nervous  diseases  of  a  large  hospi- 
tal. All  other  treatment  having  been  withdrawn 
and  the  cases  kept  under  observation  for  a  time, 
ether  was  given  t6  the  production  of  full  anesthesia 
at  intervals  of  from  forty-eight  to  seventy-two 
hours.  The  results  were  either  entirely  negative 
or  the  patients  grew  worse  in  consequence  of  the 
withdrawal  of  their  bromides,  and  after  a  trial  ex- 
tending over  some  weeks  and  in  a  considerable 
number  of  cases,  I  satisfied  myself  that  anesthesia 
alone  produced  little  or  no  effect  in  either  the  se- 
verity or  the  frequencjr  of  epileptic  convulsions. 
In  the  majority  of  these  patients  the  disease  was, 
of  course,  of  the  idiopathic  variety,  but  it  must  be 
remembered  that  in  cases  of  supposed  traumatic 
epilepsy  in  which  nothing  abnormal  is  found  on  op- 
eration the  diagnosis  has  probably  been  incorrect, 
aufl  the  type  of  the  disease  is  really  idiopathic.  The 
error  is  facilitated  by  the  frequency  with  which 
scars  and  other  relics  of  former  traumatisms  are 
found   on   the   scalps   of   epileptics,   injured   during 

♦  their  convulsive   attacks. 

2.  The  possible  effect  of  psychic  influence 
(through  imagination  and  mental  impression)  is 
not  so  easily  dismissed.  There  is  no  doubt  that  it 
is  possible  through  influences  acting  upon  the  emo- 
tional or  intellectual  nature  to  affect  the  organic 
processes  of  secretion,  nutrition,  etc.,  and  that  it  is 
therefore  conceivable  that  through  the  same  influ- 
ences pathological  change  may  be  arrested  and 
reparative  or  curative  action  established. 

The  normal  equilibrium  which  we  witness  be- 
tween the  cerebro-spinal  and  the  sympathetic  sys- 
tems, as  respects  their  influence  upon  the  blood  ves- 
sels, is  obviously  more  or  less  interfered  with, 
when  the  brain  transmits  a  more  than  wonted  im- 
pulse, allowing  the  unrestrained  action  of  the  sym- 
pathetic vaso-motor  nerves  or  paralyzing  their  in- 
fluence. 

When  this  equilibrium  is  already  unbalanced  and 
abnormal,  it  may  be  that  such  interference  through 
the  emotions  may  have  at  least  a  tendency  toward 
the  re-establishment  of  healthy  conditions.  This 
is  vague,  but  cannot  on  account  merely  of  vague- 
ness be  dismissed  from  consideration.     A  reference 


to  the  paper  I  have  quoted  above  (Annals  of  Sur- 
gery, August  and  September,  1891)  will  show  that 
examples  of  marked  physical  effects  of  purely 
psychic  impressions  are  numerous,  and  that, 
through  this  agency,  cures  of  disease  dependent 
upon  actual  pathological  conditions,  must  be  admit- 
ted to  be  possible. 

3.  Relief  of  tension  can  hardly  be  considered  as 
a  factor  in  this  relation.  The  added  tension  in  epi- 
lepsy follows  the  convulsion.  There  is  no  evidence 
that  it  precedes  it,  or  is  in  any  sense  a  chronic  cere- 
bral condition  associated  with  epilepsy. 

In  cases  that  were  not  drained  after  trephining, 
the  relief  of  tension  can  scarcely  be  a  factor  in  the 
resulting  amelioration.  In  cases  that  are  drained, 
as  in  some  recently  reported  by  Kocher,  the  reflex 
element  (or  the  element  of  counter-irritation  or  of 
the  "reaction  of  traumatism")  is  co-existent  and 
complicates  the  problem.  This  is  further  compli- 
cated by  the  fact  that  nearly  all  cases  receive  post- 
operative bromide  treatment. 

4.  As  to  reflex  action,  or  the  reaction  of  trau- 
matism, Verneuil,  in  a  paper  calling  attention  to 
the  influence  exerted  by  prior  lesions  of  the  liver 
on  the  progress  of  traumatic  lesions,  long  ago  em- 
phasized the  fact  that  any  traumatism,  however 
slight,  sometimes  excites  in  the  entire  economy  a 
general  perturbation  and  sometimes  by  a  kind  of 
selection  of  the  weak  point  a  sudden  and  violent 
aggravation  of  lesions  that  were  only  slight  or  that 
slumbered. 

It  seems  to  me  that  this  same  excitement,  usually 
prejudicial,  may  occasionally  be  curative,  although 
it  must  be  admitted  that  these  also  are  vague 
terms,  and  that  even  if  the  explanation  is  correct, 
it  is  yet  far  from  final. 

In  view  of  all  the  conditions  and  possible  factors 
thus  described,  the  problems  finally  took  this  shape 
in  my  mind : 

1.  "  Can  the  subjects  of  this  distressing  and  in- 
tractable disease  receive  without  undue  risk  to  life 
or  general  health  the  benefit  of  both  operative  in- 
terference and  sedation  of  the  affected  brain  area? 

2.  Can  operation  be  based  on  any  but  empirical 
grounds?  If  on  the  latter  only  does  the  evidence 
warrant  its  continuance? 

3.  Is  there  any  means  of  securing  sedation  (i.  e., 
of  applying  the  general  therapeutic  principle  of  rest 
in  such  a  way  that  natural  processes  may  have  an 
opportunity  to  eft'ect  a  cure),  without  at  the  same 
time  depressing  or  greatly  interfering  with  the  gen- 
eral health? 

I  mav  say  at  once  that  as  regards  idiopathic  epi- 
lepsies and  the  pseudo-Jacksonian  cases  already  de- 
scribed, the  answer  to  all  these  queries  should,  with 
the  evidence  now  before  us,  be  in  the  negative. 

There  remain  for  consideration  the  true  focal  or 
Tacksonian  cases,  whether  traumatic  or  not. 

In  these  the  results  of  operation,  while  more  en- 
couraging, are,  in  my  opinion,  not  sufficiently  so 
to  justifv.  us  in  ignoring  the  greatly  increased  risk 
and  the  post-operative  paralysis  following  excision 
of  the  epileptogenetic  center,  without  which  the 
trephining  becomes  an  incomplete  and  unsatisfac- 
torv  operation.  Clark  says  (and  my  observations 
lead  me  to  endorse  his  statement)  : 

"Idiopathics  in  whom  seizures  are  of  the  Jack- 
sonian  type,  should  be  trephined  only  when  infan- 


1 164 


The  Philadelphia 
Medical   Journal 


] 


TOPICAL  TREATMENT  EPILEPSY 


[June   15,    1901 


tile  cerebral  palsies  can  be  excluded,  and  when  the 
family  and  personal  degeneracy  is  at  a  minimum." 
He  adds,  however,  "if  operation  is  determined  upon 
in  such  cases,  a  very  thorough  removal  of  the  epi- 
leptogenetic  area  should  be  made ;  even  then  but  a 
fraction  of  one  per  cent,  recover  from  their  epi- 
lepsy," and  he  might  have  added  that  the  operation, 
apart  from  its  crippling  effect,  is  sure  to  have  a 
considerable  mortality. 

It  was  to  lessen  this  risk  to  life  and  to  try  to 
secure  the  chance,  however  slight,  of  cure  or  ame- 
lioration without  paralysis  of  important  muscular 
groups,  or  of  entire  limbs,  that  1  was  led  to  con- 
sider, and  finally  to  employ,  the  method,  which  may 
be  described   as  follows : 

The  affected  center  is,  of  course,  determined  in 
advance  by  the  most  careful  study  and  observation 
of  the  case.  Its  relation  to  the  cranium  is  indicated 
by  a  silver  or  iodine  mark  upon  the  shaven  scalp 
two  days  before  the  operation.  The  scalp  is  steril- 
ized and  re-sterilized  three  times  at  intervals  of 
twelve  hours,  not  only  before  the  trephining,  but 
also  before  each  subsequent  application  of  the 
treatment.  A  horse-shoe-shaped  flap  is  raised  and 
a  half-inch  button  of  bone  removed  with  a  small 
trephine.  The  dura  is  left  intact.  Thirty  minims 
of  a  sterile  two  per  cent,  solution  of  eucaine  is  then 
injected  into  the  brain  substance  at  the  center  of 
the  trephine  opening,  the  point  of  the  needle  being 
introducd  about  three-quarters  of  an  inch.  The 
needle  is  gradually  Avithdrawn  as  the  last  ten  min- 
ims of  the  solution  are  injected.  The  flap  is  re- 
placed. The  patient  is  returned  to  bed,  and-  on  the 
day  of  operation,  and  the  following  day,  should  re- 
ceive fidl  doses  of  bromides.  At  intervals,  the 
proper  length  of  \yhich  can  only  be  determined  by 
experience,  the  scalp  having  been  sterilized  as 
above,  the  injection  is  repeated.  The  patient  should 
be  kept  in  bed  at  least  four  hours  after  each  injec- 
tion and  should  take  bromides  for  from  one  to  two 
days. 

In  giving  these  directions,  I  beg  to  be  understood 
as  merely  submitting  the  method  to  the  profession 
for  further  trial  and  elaboration,  or,  perhaps,  for 
rejection.  I  am  not  myself  convinced  that  it  has 
any  real  value. 

i  append  from  the  records  of  the  University  Hos- 
pital the  histories  of  the  two  cases  in  which  I  have 
tried  it.  In  the  first  of  these  cases  the  prominence 
of  pain  as  a  symptom  led  me  to  disregard  the  con- 
traindication furnished  by  the  history  of  infantile 
paralysis : 

CASE  1.— White,  male,  Aet.  24. 

Admitteci  to  the  service  of  Dr.  H.  C.  Wood  at  the  Uni- 
versity Hospital.  February  15th,  1899. 

There  was  nothing  in  the  family  history  which  had  any 
bearing  upon  his  condition.  At  the  age  of  six  months  it  was 
found  that  he  had  infantile  cerebra'I  paralysis  affecting  the 
right  arm  and  right  leg.  He  began  to  walk  when  between 
two  and  three  years  of  age,  but  has  always  limped  as  a 
result  of  defective  development.  His  first  epileptiform  at- 
tacks began  at  the  age  of  twelve,  affecting  the  right  arm 
and  leg.  and  always  occurring  at  night.  They  are  asso- 
ciated with  sharp  needle-like  pains  starting  near  the 
shoulder,  passing  down  the  right  arm,  and  then  felt  in  the 
upper  part  of  the  right  thigh  passing  down  the  leg. 
These  are  very  severe,  and  are  apt  to  be  accompanied 
by  an  outcry.  At,  or  about  this  time,  there  Is  usually  a 
short  general  tonic  spasm  followed  by  clonic  convulsions. 
Each  attack  lasts  four  or  five  minutes.  He  has  never  fallen 
down  or  bitten  his  tongue  or  lost  consciousness.  During 
1lie    day   the   attacks   never   go    beyond    the    pain    in    the 


arm.  He  complains  of  a  continual  needle-like  pain  in  the 
right  arm,  which  he  thinks  he  lessens  by  wearing  a  tight 
'libber  band  around  the  wrist  and  hand.  He  also  thinks 
that  this  helps  in  aborting  the  attacks.  There  was  no  evi- 
dence of  any  organic  disease. 

On  March  9th,  having  had  four  attacks  in  the  interval, 
and  having  been  carefully  observed,  he  was  transferred  to 
Dr.  White's  ward  for  operation. 

On  March  11th,  the  operation  was  performed  (see  de- 
scription above).  The  injection  was  made  directly  over  the 
centre  for  the  arm.  After  operation,  the  pain  in  the  arm 
had  disappeared. 

On  the  12th,  an  epileptic  convulsion  occurred  which  is 
noted  as  peculiar  in  the  following  respects:  It  was  not 
painful:  it  had  no  aura:  it  began  in  the  upper  part  of  the 
arm  as  before  but  did  not  involve  any  muscles  outside  tha 
arm;  it  lasted  but  two  minutes,  and  was  not  accompanied 
or  followed  by  any  mental  phenomena  or  by  sleep. 

Between  March  12th  and  June  24th,  the  patient  re- 
mained under  observation  in  the  Hospital,  receiving  dur- 
ing this  time  five  intra-cerebral  injections,  the  quantity 
varying  from  ten  to  fifteen  minims,  the  eucaine  being  in- 
creased first  to  four  and  then  to  six  per  cent.  During  this 
time  (fourteen  weeks)  he  had  eight  convulsive  attacks, 
but  with  one  exception  they  were  all  milder  than  those 
that  had  preceded  the  beginning  of  the  treatment,  and 
there  was  thoroughout  a  greatly  lessened  complaint  of 
pain. 

He  was  readmitted  to  the  Hospital  on  October  10th,  1899. 
On  that  day  the  following  note  was  made:  Has  had  four 
attacks  since  his  discharge,  but  they  were  not  nearly  so 
severe  as  formerly,  and  were  not  accompanied  by  so  much 
pain.  He  has  now  some  motion  in  the  hand  and  arm.  which 
he  says  he  did  not  have  before.  He  took  potassium  bro 
mide  about  3ii  in  a  week  during  the  summer. 

On  the  17th,  he  had  his  first  convulsion,  which  was  fair- 
ly severe. 

On  the  18th,  fifteen  minims  of  a  two  per  cent,  solution  of 
eucaine  were  injected  as  before.  No  beneficial  effect 
was  observable.  In  fact,  he  had  a  series  of  very  slight 
convulsions  during  the  next  five  days. 

On  November  1st.  10th.  and  18th.  and  on  December  8lh 
and  21st.  these  injections  were  repeated.  During  this  time 
he  had  three  convulsions  of  very  slight  gravity.  He  was 
discharged  again  on  December  21st,  having  had  no  attacks 
or  threatenings  for  two  weeks. 

On  January  15th.  1900.  he  was  readmitted  on  account  of 
an  attack  which  he  had  on  the  10th. 

On  the  20th.  fifteen  minims  of  a  four  per  cent,  solution 
were  injected. 

On  February  5th,  he  was  discharged,  there  having  been 
but  one  convulsion  in  the  interval. 

On  June  12th.  1900.  there  having  been  no  attack  for 
thirteen  weeks,  he  received  one  injection  of  twenty  min- 
ims of  two  per  cent,  solution. 

On  October  6th.  1900.  the  treatment  was  repeated,  he 
having  had  but  one  slight  convulsion  in  the  interval. 

On  December  1st.  1900.  the  treatment  was  again  repeat- 
ed. He  had  had  several  threatenings  in  the  interval,  but 
upon  the  administration  of  an  emetic,  the  premonitory 
symptoms  had  disappeared  without  an  attack. 

CASE  2.— White.     Male.     Aet.  Zl. 

Admitted  to  the  service  of  H.  C.  Wood.  May  5th.  1900. 

There  was  nothing  in  the  family  or  previous  personal  his- 
tory having  any  bearing  upon  the  condition. 

In  June.  1899,  he  had  a  feeling  like  a  shock  in  the  right 
arm.  and  it  became  rigid  in  a  semi-flexed  position.  This 
was  the  first  attack  of  the  kind  he  ever  had.  For  about  a 
year  previous  to  this,  he  suffered  from  a  constant  dull  pain 
in  the  region  of  the  frontal  sinuses.    This  still  persists. 

The  attacks  have  continued  to  the  present  time,  occur- 
ring at  intervals  of  one  or  two  a  week,  to  one  every  two 
weeks.  They  usually  occur  after  he  has  gone  to  bed.  Al- 
most always  for  several  hours  prior  to  an  attack  the  pain 
in  the  frontal  region  is  worse,  and  there  is  usually  in  the 
right  arm  a  strange  feeling,  which  he  cannot  describe. 
-After  he  has  .gone  to  bed.  the  attack  comes  on  suddenly 
with  a  feeling  like  an  electric  shock  in  the  right  arm 
which  becomes  rigid  with  the  forearm  flexed  not  quite  at 
a  right  angle.  The  spasm  is  clonic,  and  lasts  from  a 
few  seconds  to  a  minute,  or  a  minute  and  a  half  (the 
longest!.  After  the  attack  is  over  there  is  no  drowsiness,  or 
pain  in  the  arm.  and  the  headache  is  usually  much  better. 

He   has    never   become   unconscious    during    an    attack. 


June  15,  19)1] 


treat:\iext  of  jacksoxian  epilepsy 


TThe  Philadelphia 
LMedicai.  Journal 


1 16^ 


There  is  no  pain  in  the  arm  during  the  attack,  but  it  is 
numb. 

On  May  20th,  he  was  transferred  to  Dr.  White's  service. 
He  was  kept  under  observation  until  June  1st,  during  which 
time  he  had  three  attacks.  On  that  day  trephining  was 
done,  and  thirty  minims  of  a  two  per  cent,  eucaine  solu- 
tion were  injected  into  the  arm  centre.  He  was  kept  under 
observation  for  two  weeks,  and  having  no  symptoms  what- 
ever, was  then  permitted  to  leave  the  hospital. 

He  was  readmitted  on  January  22nd,  1901,  at  which  time 
the  following  note  was  made: 

Since  discharge  on  June  13th,  1900,  patient  has  returned 
to  the  hospital  three  times  in  order  to  receive  the  hypo- 
dermics. The  first  hypodermic  was  five  weeks  after  dis- 
charge. Previous  to  that  and  following  it,  the  intervals 
averaged  between  fifteen  and  eighteen  days.  (Previous  to 
the  operation,  seizures  were  every  two  or  three  days,  the 
maximum  interval  being  nine  days).  Six  weeks  later  the 
second  hypodermic  was  given.  Intervals  between  seizures 
were  from  fifteen  to  eighteen  days.  Two  months  later  he 
returned  for  a  third  hypodermic  (latter  part  of  September). 
Since  then  the  attacks  have  averaged  about  the  same.  He 
has  gone  twenty-three  days  without  an  attack.  On  Decem- 
ber 2Sth  he  had  five  attacks,  coming  on  an  hour  apart,  each 
successive  attack  being  lighter.  On  December  29th,  he  had 
four  attacks,  lighter  than  on  28th. 

On  December  30th  he  had  three  attacks;  lighter  than  on 
the  29th. 

On  December  31st,  he  had  one  attack,  lighter  than  on  the 
30th. 

He  was  under  no  excitement  at  this  time. 

Last  attack  was  on  January  ISth,  1901.  This  attack  was 
severe,  lasting  thirty  to  forty  seconds. 

Operation  by  Dr.  White.  January  23rd,  1901. 

Thirty  minims  of  a  two  per  cent,  solution  of  eucaine 
were  injected  into  the  brain,  and  a  collodion  dressing  was 
applied.  Patient  was  returned  to  the  ward.  Fifteen  min- 
utes after  the  injection  patient  complained  of  nausea  and 
a  sensation  of  numbness  in  the  right  arm  and  leg.  One 
hour  and  a  half  after  the  injection  he  was  taken  with  a 
convulsive  seizure  which  involved  the  whole  right  side, 
with  the  exception  of  the  face,  lue  leg  and  arm  were 
thrown  about  violently  and  the  patient  made  frequent  out- 
cries. He  was  in  a  semi-unconscious  state  and  did  not  an- 
swer questions  coherently.  This  seizure  lasted  four  min- 
utes. Following  the  attack  the  patient  complained  of 
headache  and  a  sensation  of  numbness  in  the  right  half  of 
the  body. 

On  January  24th,  1901,  the  final  note  which  follows  was 
made:  Until  this  morning  patient  still  complained  of  feel- 
ing of  numbness  in  the  right  side.  States  that  the  attack 
he  had  yesterday  was  ty.e  most  severe  one  he  had  ever  had, 
and  i.aat  it  differed  from  his  usual  attacks  in  that  it  was 
a  general  seizure.  At  present  he  feels  perfectly  normal, 
and  is  discharged. 

He  has  not  since  been  heard  from. 
It  will  be  apparent  to  any  one  who  reads  these 
cases  critically  that  they  cannot  be  said  to  estab- 
lish even  the  entire  safety  of  the  procedure,  as  the 
convulsions  in  Case  2,  which  fc'llowed  one  of  the 
injections,  were  of  very  marked  severity.  Neither 
can  it  be  said  that  the  results  obtained  were  no- 
ticeably better  than  have  seemed  to  follow  the  very 
miscellaneous  operative  procedures  which  I  have 
mentioned  above.  It  still  seems,  however,  that 
there  are  possibilities  of  benefit  by  this  line  of 
treatment  which  justify  me  in  placing  it  conserva- 
tivelv,  as  I  have  tried  to  do,  before  the  profession. 


Hospital  at  Cesarea. — The  first  meeting  of  the  Board  of 
Trustees  of  the  American  Christian  Hospital  at  Cesarea. 
Asia  Minor,  was  recently  held  in  Albany,  N.  Y.  The  officers 
elected  are:  Allison  Dodd.  president:  Samuel  T.  Carter. 
Jr..  vice-president:  Charles  E.  Manierre,  secretary,  and 
James  M.   Speers,  treasurer. 

The  board  was  incorporated  to  hold  the  property  and 
give  perpetuity  to  the  work  of  the  Rev.  William  S.  Dodd. 
M.  D.  The  small  dispensary  over  a  stable  with  which 
he  began  in  1S86  has  now  grown  to  a  fine  stone  hospital 
building  of  three  stories,  capable  of  accommodating  seventy 
beds. 


THEORETICAL  AND  PRACTICAL  CONSIDERATIONS 
ON  THE  TREATMENT  OF  JACKSONIAN  EPILEPSY 
BY  OPERATION;  WITH  THE  REPORT  OF  FIVE 
CASES. 

By  JAMES  JACKSON  PUTNAM,  M.  D., 

of  Boston. 

Professor   of   Neurolog)',   Harvard   Medical   School. 

The  necessity  of  giving  advice  as  to  the  propriety 
of  cortical  excision  and  of  operation  in  general,  in  a 
case  of  non-traumatic  focal  epilepsy  which  came 
recently  under  my  observation,  has  led  me  to  re- 
view the  literature  bearing  on  this  interesting  dis- 
ease, and  to  scrutinize  afresh  the  results  of  my  per- 
sonal experience. 

It  is  now  more  than  a  quarter  of  a  century  since 
Hughling  Jackson  first  divined  the  localization- 
mosaic  of  the  Rolandic  convolutions,  and  many 
years  since  Horsley,  well  trained  by  experimental 
research,  had  the  courage  to  attempt  with  the  knife 
the  solution  of  the  question  whether  one  may  ar- 
gue that  epileptic  seizures  which  begin  with  a  "sig- 
nal symptom"  are  due  to  localized — possibly  remov- 
able— forms  of  disease. 

This  problem  is  still,  and  will  perhaps  long  re- 
main unsolved,  but  each  new  decade  brings  fresh 
data  to  renew  the  interest  of  the  inquiry,  as  waves 
of  hopefulness  or  discouragement  succeed  each 
other  in  the  professional  mind.  Among  the  more 
recent  advocates  for  the  view  .  that  focal  disease, 
discoverable  only  by  the  microscope,  may  be  the 
cause  of  so-called  "focal  epilepsy,"  and  that  the  re- 
moval of  portions  of  the  cortex  containing  this  al- 
tered tissue  and  constituting  the  "center"  corre- 
sponding to  the  initial  symptom  of  the  fit,  may,  if 
done  early  enough,  cure  the  disease,  is  Dr.  Joseph 
Collins  (i),  who  discusses,  in  the  autumn  number 
of  Brain,  1896,  the  histological  changes  in  two  inter- 
esting cases,  where  thorough  excision  had  been  done 
bv  Gerster  and  by  Curtis.  A  private  note  from  Dr. 
Collins  states  that  one  of  these  patients  has  re- 
mained free  from  disease  up  to  the  pre.sent  time,  that 
is,  for  six  3-ears  since  operation.  In  the  first  case 
the  pia  mater  was  thickened  and  adherent  to  the  al- 
tered cortex;  in  the  other  only  degeneration  of  the 
large  ganglion  cells  was  found.  Collins  speaks 
(page  384)  of  this  diseased  tissue  as  having  been 
"entirely  removed,"  but  in  regard  to  this  point,  one 
may  be'permitted  to  feel  a  grave  doubt  which  can- 
not be  removed  by  any  evidence  that  the  case  has 
thus  far  furnished.  And  this  to  my  mind  is  an  im- 
portant matter,  because  if  similar  tissue  has  been 
left  behind,  the  anatomical  conditions  for  a  renewal 
of  the  epileptic  attacks  still  exist,  and  if  the  at- 
tacks do  not  recur  we  may  have  to  seek  the  explan- 
ation in  the  inhibitory  effects  of  the  operation,  and 
then  the  question  arises  whether  similar  effects, 
might  not  have  been  produced  by  less  severe  meas- 
tircs.  Certainly  there  is  an  abundance  of  evidence 
that  fits  may  cease,  or  fail  to  occur,  in  spite  of  the 
presence  of  persistent  sources  of  irritation. 

The  object  of  this  paper  is  to  consider  some  of 
the  questions  here  involved,  which  I  will  state  as 
follow's : 


1  Dr.  Collins  expressly  repudiates  any  desire  to  generalize- 
rn  the  basis  of  these  cases,  and  it  Is  not  here  intended  to  im- 
ply that  he  dees  so. 


ii66 


The  Philadelphia 
Medical  Journal 


]      1  REATMENT  OF  JACKSONIAN  EPILEPSY 


[June   15,   ii>01 


1.  Is  the  removal  of  disease-foci  involving  the 
cortex  of  clinical  value? 

2.  Does  the  removal  of  the  cortex  itself,  when 
apparently  unchanged,  add  an  influence  of  material 
importance? 

3.  How  are  the  results  of  such  measures  as  these 
best  to  be  explained,  and,  especially,  is  the  benefit 
obtained  from  cortical  excision  necessarily  due  to 
the  removal  either  of  a  focus  of  disease  or  of  a  spec- 
ial "discharge-focus"'? 

4.  What  additional  light  has  been  thrown,  by  re- 
cent experimental  researches  and  clinical  observa- 
tions, on  the  physiology  of  the  cerebral  cortex? 

The  views  which  I  shall  maintain  are,  (i)  that  op- 
erations of  many  different  sorts  are  of  value;  (2) 
that  the  beneficial  action  of  these  operations,  al- 
though complex  in  character,  is  mainly  due  to  the 
induction  of  a  temporary  inhibition  of  the  morbid 
action  of  the  cortex,  which  permits  of  the  establish- 
ment of  a  more  normal  tendency ;  (3)  that  the  remov- 
al of  the  apparently  normal  cortex  is  rarely  advisable, 
and,  when  beneficial,  acts  mainly  as  above  indicated; 
(4)  that  the  cause  of  the  persistence  of  the  "epileptic 
habit"  is  not  to  be  sought  alone  in  anatomical  pecu- 
liarities of  the  brain,  but  that  it  shares  the  vitality 
and  independent  endurance  of  memories  in  general. 
Also,  the  symptom-groups  which  present  them- 
selves after  cortical  lesions  conform,  in  general,  to 
certain  special  types,  which  recur  without  being 
closely  dependent  on  the  localization  of  the  cerebral 
injury.  These  symptom-groups  represent,  in  fact, 
efforts  at  the  formation  of  a  new  equilibrium  on  the 
part  of  a  being  endowed  with  consciousness  and 
memory  on  the  one  hand,  and  with  a  complex  brain- 
mechanism  on  the  other.  The  principle  on  which 
this  readjustment  goes  on  in  cases  of  actual  cerebral 
lesion,  is  analogous  to  that  which  is  operative  in 
"hysteria." 

The  points  of  special  interest  in  my  own  cases, 
are  as  follows : 

C.\SE  1  is  that  of  a  young  man  of  21  who,  four  years  be- 
fore, had  suffered  from  a  continued  fever,  considered  at 
the  time  to  be  typhoid,  which  confined  him  to  his  bed  for 
13  weeks.  In  an  early  stage  of  this  illness,  and  while  the 
diagnosis  was  still  doubtful,  his  father  went  into  his  room 
one  morning  and  found  him  unconscious.  Three  weeks 
later,  while  the  illness  was  at  its  height,  he  complained  one 
day  of  numbness  of  the  hand,  and  almost  immediately  af- 
terward became  entirely  paralyzed  on  the  left  side,  even  to 
the  left  eyelid,  and  swallowed  with  difliculty.  He  suffered 
during  this  period  from  severe  pain  in  the  head  and  was 
thought  to  have  meningitis,  but  in  the  course  of  three  or 
four  weeks  he  could  use  the  arm  and  leg  pretty  well,  and, 
before  long,  all  signs  of  disease  seemed  to  have  entirely 
vanished.  It  was  six  months  later  before  indications  of 
cerebral  disorder  reappeared,  and  »ien  in  the  form  of  at- 
tacks of  numbness  of  the  left  hand,  often  confined  to  the  in- 
dex finger  and  thumb,  sometimes  associated  with  twitclv 
ing.  or  with  irregular  movements  of  the  fingers,  one  after 
another,  sometimes  with  a  greater  or  less  spreading  of 
these  feeling  and  movements  to  the  arm  and  face.  Only 
six  times  in  all  had  he  lost  consciousness,  but  the  numbness 
of  the  hand  was  sometimes  preceded  by  a  sense  of  fullness 
in  the  head.  The  leg  was  not  much  "involved,  but  on  re- 
covery of  consciousness  it  would  feel  heavy  and  helpless. 
Two  or  three  times  he  had  a  blurring  of  the  vision  in- 
stead of  the  "numb"  feelings,  before  the  severer  attacks, 
and  occasionally  the  forefinger  of  the  right  hand  would 
grow  slightly  numb  instead  of  the  left. 

Operation  was  advised,  and  was  done  by  Dr.  J.  C.  War- 
ren, at  the  Massachusetts  General  Hospital.  June  3.  1901. 
A  large  opening  having  been  made  over  the  "hand-centre." 
Dr.  Warren  proceeded  to  reflect  the  dura.  This  was  found 
to  be  united  to  the  pia  by  a  number  of  firm  adhesions,  be- 


sides which  the  two  membranes  were  separated  by  a  dark, 
soft,  velvety  layer  of  tissue  suggesting  an  organized  clot, 
which  covered  most  of  the  space  exposed  by  the  trephine 
opening  (about  2%  inches  in  diameter)  and  extended  be- 
yond it.  The  affected  area  was  in  fact  so  extensive  that 
the  removal  of  the  whole  of  it  seemed  impossible,  and  it 
was  more  for  the  sake  of  obtaining  a  specimen  for  a 
microscopic  examination  than  with  a  view  of  a  cortical  ex- 
cision for  therapeutic  purposes  that  a  small  bit.  about  1 
cm.  in  diameter  and  1  or  2  mm.  in  thickness,  was  snipped 
out  with  scissors  from  the  altered  pia  and  cortex.  This 
was  done  almost  at  random,  since  faradization,  even  wiih 
very  strong  currents,  had  failed  to  excite  any  response. 
Nevertheless,  immediately  after  the  operation,  the  hand 
was  found  to  be  wholly  paralyzed  and  the  sensibility  almost 
wholly  abolished.  The  sensory  defect  involved  the  lower  part 
of  the  forearm  but  faded  raidly  upward.  The  face  also  was 
paralyzed  to  a  considerable  degree  and  the  leg  very 
slightly.  Trifling  thickness  of  speech,  and  aphasia  to  the 
extent  of  forgetfulness  of  names,  were  present  for  a  time. 
It  is  of  course  possible  that  these  results  were  referable 
not  wholly  to  the  excision  but  also  to  the  slight  manipula- 
tions of  the  exposed  portion  of  the  brain  as  well  as  to  ede- 
ma and  small  hemorrhages  as  noted  by  Hitzig  (1 1  in  his  ex- 
periments. But,  in  either  case,  the  result  affords  one  illus- 
tration the  more  of  the  fact  that  in  any  given  area  many 
movements  may  be  more  or  less  represented, and  that  from  a 
given  impression  on  the  cortex  certain  parts  will  be  far 
more  affected  than  others;  the  hand,  for  example,  more 
than  the  arm.  This  fact  is  well  known  but  its  significance 
is  not  always  appreciated.  Many  interesting  features  of 
this  case  must  be  passed  over,  but  I  will  pause  to  refer  to 
the  fact  that  in  some  instances  the  attacks,  even 
where  the  most  prominent  initial  symptom  was  in  the  hand, 
were  ushered  in  by  a  blurring  of  vision  and  sometimes  a 
feeling  as  if  the  eyes  were  moving.  As  regards  the  further 
results  of  the  operation,  some  improvement  showed  itself 
before  the  end  of  a  week,  and  it  was  not  long  before  the 
motion  of  the  hand  was  regained  for  the  most  part,  though 
there  was  for  several  years,  and  perhaps  has  remained 
permanently,  a  trifling  diminution  in  strength  and  dexter- 
ity. The  attacks  continued  for  a  long  time  much  the  same 
as  before  as  regards  frequency,  but  became  less  severe  and 
somewhat  different  in  character.the  fingers  on  the  ulnar  side 
of  the  hand  sometimes  being  the  more  affected,  instead  o£ 
those  on  the  radical  side,  for  example,  besides  being  per- 
sistently somewhat  paresthetic.  The  forefinger  was  not 
noticed  to  twitch  except  once  or  twice  until  six  months 
after  the  operation,  though  paresthetic  attacks  were  fre- 
quent. After  a  lime  his  condition  began  to  improve  in 
every  respect,  and  a  letter  received  nearly  six  years  sub- 
sequently said  that  he  had  given  up  the  use  of  all 
medicine,  that  the  ill  turns  were  much  less  frequent,  the 
general  health  good,  and  that  on  the  whole  he  was  "quite 
another  man  since  the  operation."  Nevertheless,  it  should 
be  remembered  that  the  lesion  remains,  so  that  the  Im- 
provement, however  it  may  have  been  brought  about,  is  to 
be  laid  to  the  score  of  increased  cerebral  resistance  rather 
than  to  removal  of  irritation.  Another  letter  of  the  pres- 
ent month,  written  just  ten  years  since  the  operation, 
states  that  the  improvement  has  maintained  itself,  though 
he  is  not  perfectly  well. 

The  special  interest  attaching  to  this  case  lies  in 
the  fact  that,  on  the  one  hand,  a  large  and  persist- 
ent cortical  lesion  produced  highly  localized  and 
specialized  seizures,  of  somewhat  varying  sorts ; 
and,  on  the  other  hand,  that  a  trifling  injury,  of  in- 
discriminate localization,  consisting  in  exposure  of 
the  cortex,  and  the  snipping  out  of  a  small  piece, 
not  more  than  2  mm.  in  thickness,  induced  an  ex- 
tensive group  of  symptoms  corresponding  to  one  of 
the  several  definite  types,  such  as  is  apt  to  reproduce 
itself  from  brain  injuries  of  various  sorts,  not,  it  is 
true,  wholly  without  regard  to  the  seat  of  the  injury, 
but  without  close  correspondence  to  it. 

The  blurring  of  vision  observed  in  this  case  was 
apparently  due,  in  part  at  least,  to  a  temporary 
strabismus.    It  is,  however,  of  interest  to  note  that 


June  15,  1901] 


TREATMENT  OF  JACKSONIAN  EPILEPSY 


TThe   Philadelphia 
Lmedical  Journal 


I  167 


the  visual  deficit  was  always  referred  to  one  side, 
as  so  often  in  migraine. 

CASE  II  is  that  of  a  young  girl  of  eleven,  who  ever 
since  her  fourth  year  had  suffered  from  fits,  ushered  in  by 
numbness  of  the  right  hand  and  arm,  sometimes  to  be 
checlied  by  rubbing  the  affected  parts.  At  the  time  of  my 
examination  the  motions  of  the  right  hand  were  somewhat 
awlvward,  and  laclv  of  development  was  evident,  so  that  the 
case  was  assumed  to  be  one  of  infantile  cerebral  disease. 
During  the  attacks  consciousness  was,  as  a  rule,  not 
wholly  lost,  but  the  face  and  leg  were  frequently  involved 
to  a  slight  degree.  Operation  was  advised,  and  was  done 
by  Dr.  Warren,  at  the  Massachusetts  General  Hospital, 
on  February  25,  1890.  The  dura  was  found  strongly  ad- 
herent to  the  pia  over  an  area  the  size  of  a  quarter  of  a 
dollar.  After  separation  of  these  adhesions  faradic  stimu- 
lation, even  with  the  strongest  currents,  failed  to  excite 
movements,  except  at  one  point,  where  we  were 
able  to  introduce  stimulation  excited  twitchings 
about  the  mouth  similar  to  those  noticed  during 
the  seizures.  Since  it  had  not  been  possible  to  localize  the 
centre  for  hand  movements  nothing  further  was  done  at 
this  operation.  The  patient  did  very  well  for  a  time,  but 
after  a  few  months  the  attacks  returned  as  badly  as  be- 
fore or  worse.  Another  operation  was  therefore  attempted 
but  the  dura  was  found  still  more  adherent  to  the  under- 
lying parts  and  electrical  stimulation  again  failed  to  ex- 
cite the  cortex.  It  is  noteworthy  that  although  the  sur- 
face of  the  brain  was  considerably  torn  in  the  dissection  of 
the  dura  no  paralytic  symptoms  followed  the  operation, 
except  slight  difficulty  in  swallowing.  The  attacks  were 
again  relieved  for  a  time,  but  again  returned  later,  and  this 
time  with  mental  deterioration,  which  was  progressive  and 
necessitated  the  removal  of  the  patient  to  an  institution  for 
the  feeble-minded. 

One  is  tempted  to  explain  the  non-occurrence  of 
the  paralysis  by  assuming  that  the  exposed  portion 
of  the  brain  was  already  damaged,  or,  rather,  that 
its  coefficient  of  dynamic  efficiency  was  low,  in 
correspondence  with  the  impaired  use  of  the  hand. 
It  may  well  be  that  this  was  the  case,  but  it  would 
perhaps  involve  a  straining  of  this  explanation  to 
make  it  apply  to  cases  such  as  those  reported  by  Starr 
and  jNIcCosh,  where  the  resection  of  a  large  piece 
of  the  cortex  for  focal  epilepsy  did  not  excite  paraly- 
sis at  all,  but  only  a  moderate  disturbance  of  coor- 
dinated motion.  It  is  to  be  borne  in  mind  in  this 
connection  that  similar  operations  upon  dogs  may 
fail  to  e.xcite  paralysis,  although  this  is  exceptional. 
(Tonnini.)  The  case  reported  by  Sachs  and  Ger- 
ster,  where  even  bilateral  excision  caused  only  a 
trifling  impairment  of  function,  is  interesting  in  this 
connection. 

CASE  III. — The  next  patient  was  a  man  of  thirty-three, 
with  an  early  history  of  special  interest,  partly  because  he 
had  had  pulmonary  tuberculosis  in  a  mild  form;  next,  be- 
cause of  an  injury  which  may  well  have  been  the  starting 
point  of  his  later  illness.  When  a  boy  of  eight  or  ten 
years  old,  namely,  he  had  run  while  at  play,  headforemost 
and  with  great  violence,  against  the  projecting  end  of  a 
beam,  which  came  in  contact  with  the  left  side  of  his  head 
near  the  vertex.  He  was  knocked  senseless  by  the  blow, 
but  seemed  after  a  time  to  have  recovered  without  perma- 
nent injury.  Within  about  two  years  of  this  period  the 
first  symptoms  of  his  present  illness  showed  themselves, 
in  the  form  of  recurring  attacks  of  "prickly  feelings"  in 
the  thumb,  forefinger  and  middle  finger  of  the  right  hand 
and  the  adjoining  portion  of  the  palm.  Sometimes,  also, 
the  right  side  of  the  face,  in  the  parts  adjacent  to  the  angle 
of  the  mouth,  would  be  involved,  and  the  right  half  of  the 
tongue.  Occasionally  the  attacks  would  begin  with  par 
esthesia  on  the  inner  surface  of  the  upper  arm,  about 
midway  between  the  elbow  and  the  shoulder,  and  would 
spread  thence  both  up  and  dow^n  the  arm  and  to  the  ad- 
jacent portion  of  the  chest  (area  of  distribution  of  nerve 
of  Wrisberg?)  and  the  attacks  beginning  in  this  way  were 
the  ones  most  likely  to  termirwate  with  face  and  tongue  sym- 
toms,  and  were  therefore  the  most  dreaded.     With  slight 


variations  in  type  these  attacks  recurred  at  short  inter- 
vals, rarely  a  day  passing  without  one  or  more  of  them. 
Indeed,  their  frequency  had  gradually  increased  but  the 
tongue  was  less  often  involved  than  formerly.  Occasional- 
ly, though  rarely,  these  paresthesias  were  attended  with 
clonic  spasm,  or  flexor  cramp,  of  the  fingers  and  even  the 
arm,  of  moderate  severity.  The  first  occurrence  of  this 
sort  was  in  1896  and  in  the  three  years  following  it  was 
repeated  five  times.  Twice  only,  both  of  the  times  being 
on  the  same  day,  he  had  a  loss  of  consciousness,  preceded 
l>y  a  severe  jerking  of  the  arm,  and  by  a  painful  feeling 
as  of  a  series  of  blows,  delivered  successively  at  higher 
and  higher  levels  from  the  the  neighborhood  of  the  hand  to 
near  the  shouldei-.  It  felt,  he  said,  as  if  the  arm  was  being 
chopped  off  in  segments  with  an  axe  or  by  machinery.  On 
two  or  three  occasions,  also  a  temporary  embarrassment  or 
even  loss  of  speech  occurred,  generally  in  the  early  morn- 
ing. The  atacks  in  the  hand  repeated  each  other  with 
great  accuracy.  The  first  sign  would  be  a  stinging  sensa- 
tion in  the  end  of  the  thumb;  this  would  be  followed  by  a 
similar  feeling  at  the  end  of  the  forefinger;  and  then  by  a 
sensation  as  of  something  darting  down  the  length  of  the 
forefin.ger,  then  along  the  middle  finger  and  into  the  radial 
portion  of  the  palm  of  the  hand.  Finally,  the  face  near  the 
mouth  would  be  involved. 

My  first  examination,  in  August  1898,  revealed  a  very 
slight  paresis  of  the  right  side  of  the  face,  a  slight  but  defin- 
ite impairment  of  cutaneous  sensibility  over  the  palmar 
surface  of  the  thumb  and  forefinger,  as  tested  by  light 
contact  and  pricking,  and  a  slight  awkwardness  in  the  use 
of  the  fingers,  as  in  buttoning  the  clothes.  The  sensibil- 
ity of  the  right  side  of  the  face  was  affected  similarly  but 
to  a  less  degree.  There  was  no  considerable  gross  weak 
ness  of  the  hand,  except  for  a  time  after  each  attack. 

.Although  these  paresthetic  seizures  did  not  incapaci- 
tate the  patient  for  work,  yet  they  harassed  him  greatly, 
and  he  readily  consented  to  the  idea  of  an  operation,  which 
was,  however,  not  performed  until  December  15,  1899,  on 
account  of  the  presence  earlier  of  slight  tubercular  signs  in 
the  lung.i.  By  the  time  of  the  operation  these  signs  had  dis- 
appeared and  no  bacilli  of  tubercle  could  be  found. 

The  operation  was  performed  by  Dr.  J.  C.  Warren,  at 
the  Massachusetts  General  Hospital.  A  large  trephine  op- 
ening was  first  made  over  the  Rolandic  convolution,  but 
nothing  abnormal  w^as  seen  until  the  dura  had  been  re- 
flected, when  the  pia  toward  the  anterior  part  of  the  space 
was  found  to  be  opaque.  The  opening  being  enlarged  in 
that  direction  a  tough  adhesion  of  the  size  of  a  knitting- 
needle  was  discovered,  uniting  the  pia  and  the  dura  to- 
gether. This  was  excised,  together  with  a  small  bit  of  the 
cortex.  Dr.  Warren  having  first  assured  himself  by  a  care- 
ful exploration  with  the  probe  that  the  surface  of  the  brain 
for  some  distance  around  was  free  from  similar  lesions.  It 
may  be  stated  here  that  a  subsequent  microscopic  exam- 
ination of  the  excised  piece,  by  Dr.  W.  F.  Whitney,  con- 
firmed the  view  which  the  appearance  of  the  parts  had 
suggested,  that  the  changes  were  due  to  inflammation,  not 
to  new-growth. 

The  recovery  from  the  operation  was  satisfactory  in  all 
respects,  the  skin-wound  healing  by  first  intention. 

An  intensification  of  the  numbness  in  the  fingers,  and 
of  the  impairment  of  tactile  sense,  and  the  extension  of 
these  signs  to  the  ulnar  distribution,  which  was  manifest 
immediately  after  the  operation,  together  with  an  increase 
of  the  facial  paresis,  indicated  that  the  neighborhood 
sought  had  been  reached,  though  it  cannot  be  affirmed  that 
the  whole  lesion  was  removed.  The  opacity  and  edema 
of  the  pia,  slight  as  it  was.  would  indeed  suggest  a  wider 
extension  of  the  cortical  irritation. 

On  the  second  day  following  the  operation  he  had  a  bad 
attack  of  numbness,  with  cramping  of  the  hand,  then  two 
days  passed  without  attacks.  During  the  following  two 
weeks,  the  numbness  recurred  more  frequently  than  be- 
fore the  operation,  but  without  much  cramping,  and  with 
a  tendency  to  lessen.  The  facial  paresis  soon  became  less, 
ind  a  paresthesia  of  the  tongue  and  gums  on  the  right 
side,  associated  with  a  hesitation  in  speech,  which  were 
all  considerable  just  after  the  operation,  had  almost  dis- 
appeared by  the  end  of  the  third  week. 

In  the  two  years  which  have  elapsed  since  the 
operation  the  attacks  of  numbness  have  recurred 
abofiut  as  before,  and  there  has  been  in  addition  an 
almost  continuous  paresthesia  of  moderate  degree. 


I  lAR       The  PhilaLielphia  "I 
1  1  UO       Medical   Jovrnal   J 


TREATMENT  OF  JACKSOXIAX  EPILEPSY 


[June  15,  19ia 


not  exclusively  limited  to  the  median  nerve  distri- 
bution. The  left  foot  has  also  become  the  seat  of 
occasional  sensations  of  similar  sort — referred  es- 
pecially to  the  joints  of  the  toes,^  and  the  same  feel- 
ing has  been  present  in  the  right  side  of  the  neck. 

It  is  worth}-  of  remark,  as  recalling  the  observa- 
tions of  some  of  the  cerebral  physiologists  who 
found  that  the  tendency  of  cortical  irritation  to  pro- 
duce epileptiform  spasm  could  be  intensified  by 
gentle  stroking  of  the  limb,  that  this  patient  has  at 
times  noted  a  recurrence  of  the  numb  seizures  when 
the  ends  of  the  fingers  were  rubbed  or  knocked. 
Yet,  strangely  enough,  it  was  not  possible  to  pro- 
duce this  result  at  will,  the  admixture  of  conscious 
volition  seeming  to  exert  a  sort  of  inhibitory  efifect. 
Before  the  operation  it  was  only  the  end  of  the 
thumb  which  acted  in  this  way  as  an  epileptogen''.c 
zone,  but  since  then  the  same  peculiarity  has  been 
shared  by  the  ends  of  some  of  the  fingers. 

Cases  of  "Jacksonian"  Epilepsy  of  various  types 
have  been  so  often  reported  as  to  be  thoroughly  fa- 
miliar, and  the  fact  is  well  recognized  that  one  has 
no  right  to  infer  a  limitation  of  the  lesion  or  dis- 
ease-process to  the  cortical  area  corresponding  to 
the  "signal  symptom."  Sharply  localized  epilepti- 
form outbreaks  occur  with  tumors  of  considerable 
size  and  even  in  "idiopathic  epilepsy,"  and  this  oc- 
currence seems  to  indicate  no  more  than  that  a  cer- 
tain cell-area  is  abnormally  unstable,  whether  on 
account  of  disease  or  from  an  inherent  excitability 
due  to  the  nature  of  its  functions,  as  in  the  case  of 
the  areas  corresponding  to  the  mobile  hand-  and 
speech-organs. 

In  correspondence  with  this  is  the  interesting 
fact,  well  illustrated  by  the  present  case,  that  the 
irritation  due  to  a  given  lesion  may  induce, 
multiple  or  alternative  results,  represented  here  by 
the  occurrence,  now  of  the  thumb-numbness,  now 
of  the  upper-arm-numbness,  as  the  "signal  symp- 
tom." The  plausible  explanation  is  that  the  corre- 
sponding cortical  areas  are  particularly  irritable, 
so  that  a  discharge  may  easily  start  in  them  with 
sufficient  force  to  act  as  a  vortex  center. 

The  resemblance  of  this  case  to  Case  i,  especially 
as  regards  the  paralysis  after  operation,  yet  with  a 
lesion  of  far  less  extent  and  severity,  is  also  ob- 
vious. 

CASE  IV  is  that  of  a  boy  whom  I  had  the  opportunity  of 
watching  for  a  long  time  before  the  operation,  which  was 
done  by  Dr.  Keen,  of  Philadelphia,  and  have  had  under 
observation  ever  since.  He  had  had  from  early  childhood 
frequent  attacks,  of  short  duration,  and  not  always  attended 
with  entire  loss  of  consciousness,  in  which  his  head  would 
turn  to  the  right  and  make  a  rapid  series  of  nodding  move- 
ments, while  the  right  shoulder  would  rise  and  fall  rapidly. 
The  right  arm  was  also  more  or  less  involved.  Severe  or 
general  convulsion  did  not  occur.  There  was  no  reason 
to  suspect  localized  disease  of  the  cortex,  but  the  promiu 
ence  of  the  shoiilder  movements  suggested  the  hope  that 
excision  of  the  corresponding  part  would  be  of  some  avail. 
Localization  was  carefully  done  on  the  skull.and  afterwards, 
successfully,  by  faradazation  of  the  cortex,  and  the  cor- 
responding portion  was  then  excised  by  Dr.  Keen.  A  tem- 
porary weakness  of  the  arm  followed,  but  the  epileptic  at- 
tacks went  on  much  as  before,  though  somewhat  changed  in 
character,  and  all  that  can  be  said  ( which  is  perhaps  a 
good  deal)  for  the  effects  of  the  operation,  is  that  from  that 
time  the  signs  of  the  disease  have  been  somewhat  more 
manageable  by  bromides  and  other  treatment. 


1  In  Case  1,  the  hand  of  the  side  opposite  to  that  usually  al- 
tected  was  Involved   occasionally,   even   alone. 


CASE  V  is  that  of  a  young  man  of  seventeen,  of  excel- 
lent habits  and  good  previous  health.  His  previous  history 
shows  nothing  that  would  explain  the  present  symptoms 
unless  that  he  had  a  very  severe  v/hooping  cough  when  four 
or  five  months  old,  and  that  having  been  fond  of  athletic 
sports,  he  had  received  a  number  of  severe  blows  on  the 
head,  though  not  such  as  apparently  to  cause  permanent 
injury.  For  the  past  two  years  he  had  grown  very  rapidly. 
During  the  past  year  he  had  become  gradually  aware  of 
prickling  sensations  in  the  left  hand  and  fingers,  recurring 
from  time  to  time  and  lasting  about  fifteen  seconds.  Dur- 
ing these  times  the  sensibility  of  the  skin  would  become 
heightened,  so  that  a  rough  object  would  feel  still  more 
rough,  etc.,  while  at  the  same  time  the  hand  would  lose  its 
strength.  There  had  been  no  impairment  of  consciousness 
until  three  weeks  before  examination,  when  he  had  had 
two  convulsions  in  one  night.  Since  then  the  numbness 
of  the  hand  had  become  worse,  so  as  to  be  actually  painfuL 
and  the  fingers  would  become  cramped  in  a  position  of  ex- 
treme extension.  The  thumb  being  drawn  in  upon  the 
palm  of  the  hand.  The  pain  was  usually  confined  to  the 
last  two  joints  of  the  index  and  middle  fingers  and  the  end 
of  the  thumb. 

Without  entering  on  further  details,  I  will  say  that  after 
a  thorough  bromide  treatment,  under  which  the  attacks 
remained  absent  for  a  number  of  months,  again  recurring, 
however,  at  the  end  of  that  period,  it  was  decided  to  oper- 
ate, in  the  hope  that  some  cause  of  local  irritation  would 
be  found  as  in  some  of  the  other  cases. 

The  operation  was  done  by  Dr.  Warren  in  February  of 
the  present  year,  a  large  skin  and  bone  flap  being  turned 
Ijack  and  the  dura  incised  and  reflected.  The  cortex  pre- 
sented an  absolutely  normal  appearance  and  nothing  more 
was  done  than  to  palpate  for  underlying  tumor  or  cyst.  As 
a  result  of  this  manipulation,  or  of  the  simple  exposure,  a 
well-marked  paresis  of  the  hand  came  on,  with  impairment 
of  sensibility  in  all  modes,  including  the  sense  of  position 
and  the  steronostic  sense,  and.  a  slight  drooping  of  the 
left  side  of  the  face.  These  conditions  were  exactly  like 
those  which  were  reported  as  following  operation  in  the 
preceding  cases,  but  less  severe,  and  not  more  lasting. 
Only  four  months  have  elapsed  since  the  operation  was 
done,  and  I  report  the  case  only  tor  the  sake  of  complete- 
ness and  the  interest  of  the  diagnosis.  In  fact,  however, 
the  feelings  in  the  hand  have  been  much  less  frequent,  thus 
far.  and  no  severe  attacks  have  occurred.  He  is  on  a  thor- 
ough bromide  treatment  which  it  is  planned  to  continue  for 
a  long  time.  The  only  way  in  which  it  would  have  been 
possible  to  differentiate  this  case,  where  no  gross  lesion 
was  present,  from  those  where  localized  meningitis  was 
found,  would  have  been  by  the  entire  absence,  before 
operation,  of  any  trace  of  permanent  impairment  of  the 
functions  of  hand,  which  in  the  other  cases  was  present, 
though  to  a  very  trifling  extent. 

CASE  VI. — I  wish  finally  to  report  the  final  history  of  a 
very  Interesting  case  reported  by  Dr.  A.  T.  Cabot  i  Bnxton 
Mr<].  and  Siini.  Jtjiir..  1S97.  I.,  p.  433 1.  in  conjunction  with 
whom  I  had  the  opportunity  of  studying  it.  The  pathologi- 
cal diagnosis,  which  coiild  not  be  made  with  positiveness 
before  the  operation,  was  a  large,  subcortial  cyst,  be- 
lieved after  examination,  to  be  of  traumatic  origin.  The 
original  "signal  symptom"  was  a  paresthesia  of  a  certain 
area  on  the  right  thigh,  but  later  the  very  interesting  sign 
showed  itself  of  a  paresis  or  even  paralysis  of  the  leg.  and 
sometimes  the  arm  and  face,  coming  on  at  times  as  long 
as  fifteen  minutes  after  the  initial  symptoms  had  passed 
away.     Loss  of  consciousness  was  comparatively  rare. 

A  thorough  and  continuous  draining  of  the  cyst  seemed 
to  lead  to  its  filling  up  and  obliteration,  and  attacks  bt- 
came  slight  and  rare,  so  that  the  patient  felt  able  to  marry 
and  to  engage  in  active  and  responsible  occupations  which 
he  managed  for  several  years.  News  has.  however,  re 
cently  reached  Dr.  Cabot  that  the  attacks  returned  some 
six  months  ago.  and  still  more  recently  that  he  had  sud- 
denly died. 

It  is  noteworthy  that  the  "signal  symptom"  in 
this  case  was,  as  a  rule,  a  numbness  over  a  portion 
of  the  thigh,  instead  of  over  the  hand  or  foot. 
as  is  the  rule,  though  the  lesion  was  of  such  large 
size  as  necessarily  to  involve  extensive  areas..  It  is 
also  of  importance,  as  illustrating  the  occurrence 
of  psychical  phenomena  even  with  these  localized 


JONE    15,    1901] 


HYPERTROPHY  OF  THE  PROSTATE 


EThb  Philadelphia        ,  ,Zj, 
Medical   Journal  '  '^V 


lesions,  that  the  patient  would  sometimes  jump  up 
and  laugh  or  show  odd  behavior  for  a  moment  as 
the  sensation  was  first  felt.  Such  acts  recall  the  fa- 
miliar cases  where  a  dream  is  initiated  by  some 
slight  excitation,  such  as  a  knock  on  the  door,  yet 
develops  in  such  a  way  that  the  noise  seems  to  form 
the  last  stage  of  the  process  instead  of,  as  in  fact, 
the  first.  It  may  be  readily  conceived  that  the  psy- 
chical portion  of  the  attack  might,  on  some  subse- 
quent occasion,  initiate  the  process  in  its  turn. 

(To  be  Continued.) 


WHAT  I  HAVE  LEARNED  FROM  ONE  HUNDRED  AND 
•  SIXTY-ONE  OPERATIONS  FOR  THE  RELIEF  OF 
SENILE    HYPERTROPHY    OF    THE     PROSTATE 
GLAND. 

By  ORVILLE  HORWITZ,  B.  S.,  M.  D., 

of  Philadelphia. 

Clinical  Professor  of  Geuito-Urinary  Diseases,  Jefferson  Medical  College; 

Surgeon  to  the  Philadelphia  Hospital,  Jefferson  Medical  College 

Hospital  and  State  Hospital  for  the  Insane. 

(Continued.) 
Prostatectomy. — The  operation  of  prostatectomy 
is  at  this  time  being  carefully  studied  by  genito- 
urinary surgeons  throughout  the  civilized  world. 
I  am  in  accord  with  Guiteras  when  he  says :  "The 
subject  may  be  considered  as  still  in  its  infancy." 
There  is  much  to  be  learned  regarding  the  safest 
method  to  adopt  when  performing  the  operation, 
many  important  points  relating  to  it  are  still  sub 
judice,  and  open  to  discussion.  Some  authorities 
advise  that  the  suprapubic  process  be  selected,  oth- 
ers prefer  attacking  the  gland  through  the  peri- 
neum, whilst  many  believe  that  the  safest  and  best 
results  are  obtained  by  a  combined  suprapubic  cys- 
totomy with  a  perineal  incision.  It  still  remains  to 
be  demonstrated  whether  performing  a  partial  pros- 
tatectomy, removing  only  the  obstructing  portion  of 
the  gland,  or  a  complete  resection  of  the  organ,  is  to 
be  preferred.  The  latter  operation  is  still  on  trial. 
That  the  dangers  attending  a  complete  prostatec- 
tomy are  many  there  can  be  no  question.  Recov- 
ery is  always  prolonged.  Complete  removal  of  the 
prostate  must  appeal  to  anyone  as  a  brilliant,  but  at 
the  same  time  a  most  unsurgical,  procedure.  To  in- 
cise the  capsule,  and  then  entirely  by  the  sense  of 
touch,  violently  tear  out  the  entire  gland,  only 
leaving  the  mucous  membrane  surrounding  the  ure- 
thra, does  not  appeal  to  our  surgical  sense  as  a  ra- 
tional procedure.  After  the  gland  is  removed  noth- 
ing remains  but  the  capsule  and  the  mucous  mem- 
brane, forming  the  prostatic  urethra,  denuded  of  all 
the  tissue  which  surrounds  it.  It  is  a  question  as  to 
what  becomes  of  this  tube  of  mucous  membrane  af- 
ter the  operation  which"  is  left  free  in  the  capsule. 
It  appears  to  me  most  probable  that  in  many  in- 
stances it  undergoes  necrosis  and  is  cast  oflf  as  a 
slough  and  discharged  with  the  urine.  I  have 
known  it  to  be  frequently  damaged  by  the  opera- 
tion ;  in  two  instances  I  have  seen  the  entire  pros- 
tatic portion  of  the  canal  removed  with  the  gland 
This  is  not  to  be  wondered  at  when  we  consider 
how  intimately  connected  the  mucous  membrane 
of  the  prostatic  urethra  is  to  the  surrounding  struc- 
ture. That  a  portion  of  the  urethra  has  been  repeat- 
edly resected  and  on  recovery  having  taken  place 


the  canal  remaining  functionally  satisfactory,  is 
well  known.  Rollet  reports  a  case  of  traumatic 
stricture  in  which  he  excised  two  inches  of  the 
urethra;  successfully  restoring  the  canal  to  its  nor- 
mal condition.  I  have  on  several  occasions  per- 
formed urethrectomy  with  the  most  gratifying  re- 
sults. It  is  possible,  therefore,  that  by  leaving  a 
catheter  in  situ  for  a  long  period  of  time,  after  com- 
pletely removing  the  prostate  gland,  that  a  new 
urethra  forms  around  the  instrument,  just  as  we 
know  it  does  after  the  membranous  urethra  has  been 
excised.  That  the  profession  is  still  at  variance  as 
to  which  is  the  best  operation  to  perform  is  shown 
by  the  many  different  methods  that  are  advocated 
McGil,  Belfield,  Fuller,  Alexander,  Syms,  Pyle,  Von 
Dittel,  Fryer,  Warholm,  Nicoll,  Guiteras  and  Tobin 
recommend  a  different  way  of  attacking  the  prostate 
gland,  claiming  a  more  ready  access  to  the  organ, 
others  a  modification  in  the  technique,  asserting 
that  by  pursuing  the  method  advocated  that  the 
time  required  for  the  performance  of  the  operation 
is  thereby  minimized,  the  shock  lessened,  and  the 
hemorrhage  reduced ;  hence  decreasing  the  mortal- 
ity. The  neophyte  having  but  little  experience  in 
prostatic  surgery  is  naturally  at  a  loss  to  determine 
which  is  the  best  operation  to  employ. 

There  is  a  large  number  of  cases  where  the  pros- 
tatic obstruction  has  been  allowed  to  exist  for  such 
a  length  of  time  that  when  they  come  under  the  care 
of  the  surgeon,  the  tortuous  and  narrowed  calibre 
of  the  prostatic  urethra  prevents  the  use  of  the 
Bottini  incisor,  whilst  the  physical  condition  of 
the  individual  is  such  as  to  preclude  the  resort  to 
so  radical  a  procedure  as  prostatectomy;  these  must 
be  treated  by  a  resort  to  either  the  establishment  of 
permanent  suprapubic  drainage,  or,  in  suitable 
cases,  to  castration.  When  it  has  been  determined 
that  prostatectomy  is  the  proper  operation  the  first 
question  that  arises  is:  Shall  the  gland  be  removed 
by  a  suprapubic  incision;  through  the  perineum,  or 
by  a  combination  of  both  methods?  The  answer 
must  depend  upon  the  character  and  size  of  the 
growth,  its  form,  and  its  course.  Where  there  is 
an  interurethral  or  intercystic  pedunculated  tumor. 
a  suprapubic  cystotomy  is  the  operation  to  be  chos- 
en, when  both  the  lateral  and  median  lobes  are 
equally  enlarged  and  protrude  well  back  into  the 
bladder,  the  prostate  gland  is  more  readily  reached 
by  a  suprapubic  incision,  the  obstructing  portion 
being  removed  after  the  manner  suggested  by  Ful- 
ler, a  perineal  drainage  being  established  as  recom- 
mended by   Belfield. 

This  operation  is  likewise  indicated  if  the  lateral 
lobes  jut  into  the  bladder,  forming  multiple  tumors 
about  the  neck  of  the  viscus,  not  only  elevating  the 
internal  urinary  outlet,  but  usuallv  forming  two 
pouches,  one  above  and  the  other  below  the  project- 
ing gland.  An  enlargement  of  the  right  or  left  lobe 
alone  or  a  general  enlargement  of  both  lobes  is  best 
reached  bv  means  of  the  perineal  incision  ;  especially 
if  the  tendency  of  the  growth  is  towards  the  urethra 
or  rectum,  rather  than  towards  the  bladder.  When 
the  prostatic  enlargement  is  due  to  an  increase 
of  the  stromal  tissue,  and  does  not  impinge  upon 
the  bladder,  it  will  be  found  that  if  an  attempt  is 
made  to  remove  the  growth  by  means  of  the  supra- 
pubic opening  that  it  will  be  a  very  difficult  and 


1 170 


The  Philadelphia 
Medical  Journal 


] 


HYPFRTROPHY  OF  THE  PROSTATE 


[JUNE    li,    ISOl 


unsatisfactory  operation,  usually  resulting  in  the 
obstructing  portion  being  removed  piecemeal,  which 
requires  much  time  for  its  performance,  and  is  at- 
tended with  the  loss  of  a  large  quantity  of  blood.  It 
is  believed  for  this  reason  that  the  gland,  in  this 
class  of  cases,  is  best  reached  through  the  peri- 
neum. 

My  experience  coincides  with  that  of  \Vishard 
who  states :  "That  cases  are  not  suitable  for  com- 
plete perineal  prostatectomy  in  whom,  owing  to  the 
prostatic  hypertrophy,  the  posterior  urethra  ha.-; 
become  increased  in  length  to  such  an  extent  as  to 
prevent  the  surgeon  from  introducing  the  finger 
into  the  perineal  wound  to  reach  beyond  the 
growth."  The  lengthening  of  the  urethra  is  easily 
determined  bj'  taking  the  proper  measurements 
by  means  of  a  catheter,  and  making  a  digital  ex- 
amination of  the  prostate  gland  through  the  rec- 
tum. 

When  attempting  to  perform  a  perineal  prosta- 
tectomy we  have  our  choice  of  various  methods 
of  making  the  incision ;  Alexander  recommends 
a  median  incision,  together  with  a  suprapubic  open- 
ing, so  that  the  prostate  gland  may  be  pushed  well 
down  into  the  perineal  opening.  A  lateral  incision, 
beginning  at  the  tip  of  the  cocc%tc  passing  to  one 
side  of  the  sphincter  ani,  and  terminating  in  the 
perineum  has  the  high  endorsement  of  \'on  Dittel. 
A  transverse  cut  extending  from  one  tuberosity  to 
the  other  is  advocated  by  W'arholm  ;  finally  a  semi- 
circular flap  beginning  between  the  sphincter  and 
tuber  ischii,  one  side  crossing  the  center  of  the 
perineum  down  to  a  corresponding  point  on  the 
opposite  side  from  which  it  began,  is  suggested  by 
Pyle. 

In  four  operations  I  have  employed  the  median 
incision  advocated  by  Alexander  and  have  liked  it 
less  each  time  that  it  was  used.  When  attempting 
to  remove  the  lateral  lobes  the  operator  is  unable 
to  see  the  field  of  operation,  it  being  difficult  even 
by  touch  to  determine  exactly  what  structures  are 
being  incised.  The  surgeon  is  at  a  great  disadvan- 
tage from  having  to  work  in  the  dark.  The  lateral 
incision  of  \'on  Dittel  I  have  never  employed ;  it  has 
many  advocates. 

In  two  instances,  when  removing  a  prostate  gland 
which  had  undergone  malignant  changes,  the  trans- 
verse cut  was  found  to  be  most  satisfactory;  the 
room  afforded  was  ample,  the  gland  could  be  easily 
dealt  with,  and  hemorrhage  controlled;  it  has  much 
to  commend  it.  The  semi-circular  method  of  Pyle 
was  employed  in  three  cases ;  it  was  the  most  sat- 
isfactory of  any  employed  for  ordinarv  cases  of 
perineal  prostatectomy.  The  space  employed  was 
ample :  the  gland  could  be  readily  manipulated,  and 
the  surgeon  can  easily  observe  the  entire  field  of 
operation  after  the  capsule  has  been  incised  and 
the  gland  loosened. 

Anyone  who  has  frequent  occasion  to  perform 
perineal  prostatectomy  will  agree  that  it  is  often 
a  very  difficult  procedure :  the  most  important  step 
is  that  of  dividing  the  capsule  of  the  gland  in  order 
to  lay  it  bare,  and  at  the  same  time  loosening  the 
structure  sufficiently  to  permit  the  gland  to  be 
brought  into  view;  the  surgeon  to  do  this  must 
necessarily  rely  entirely  upon  the  sense  of  touch 
Working  in  the-  dark,  in  a  <leep  wound  in  the  per- 


ineum, is  necessarily  unsatisfactory,  and  is  one  of 
the  principal  objections  to  this  method  of  proced- 
ure. Even  after  the  gland  is  freed  sufficiently  to 
be  brought  into  sight,  it  is  often  difficult  to  separate 
the  lobes  from  the  urethra,  without  injurj'  to  the 
canal.  The  rectum  has  been  injured  in  some  cases 
giving  rise  to  perineo-urethro-rectal  fistula,  often 
difficult  to  cure.  I  ha\e  had  this  mishap  occur  to 
me  on  two  occasions  when  removing  a  prostate  that 
had  undergone  malignant  changes,  fortunately  in 
ijoth  instances  the  fistulae  closed  spontaneously. 
Both  patients  w^ere  invalids  for  a  lengthened  period 
after  the  operation. 

It  is  generally  understood  that  the  power  of  re- 
taining urine  in  the  bladder  depends  upon  three 
sets  of  muscles ;  two  involuntary ;  the  third  under 
the  control  of  the  will.  The  first  is  the  muscular 
structure  surrounding  the  internal  vesical  opening 
of  the  urethra  in  the  prostate  gland  and  is  know^n  as 
internal  prostatic  sphincter;  this  muscular  struc- 
ture has  sufficient  power  to  allow  from  three  to  four 
ounces  of  urine  to  accumulate  in  the  bladder,  when 
it  rela.xes  and  allows  the  urine  to  flow  into  the  pro- 
static urethra,  which  dilates  and  assumes  a  funnel- 
shape,  forming  the  neck  of  the  bladder. 

The  onward  passage  of  the  urine  is  then  arrested 
by  the  second  muscle,  which  is  the  external  prostat- 
ic sphincter,  it  appears  to  be  stronger  than  the  inter- 
nal sphincter  and  is  capable  of  retaining  the  urine 
until  the  viscus  is  well  distended :  it  then  relaxes 
and  the  retention  depends  on  the  contraction  of  the 
voluntary  fibres  of  the  compressor  urethra,  which 
is  the  third  muscle  of  the  series.  This  explanation 
of  the  retention  of  urine  in  the  bladder  seems  plaus- 
ible when  the  position  and  action  of  the  various 
muscular  structures  concerned  are  taken  into  con- 
sideration. There  must,  however,  be  some  other 
cause  of  which  we  yet  know  nothing,  otherwise  after 
a  complete  prostatectomy,  where  both  the  muscular 
.••tructures  connected  with  the  prostatic  outlets  are 
extensively  resected,  dribbling  of  urine  would  in- 
variabh'  follow;  this,  however,  is  not  the  case.  On 
several  occasions  I  have  known  trickling  to  follow 
the  operation,  but  it  invariably  ceased  after  a  few 
days.  In  many  of  my  own  cases  nearly  the  entire 
muscular  structure  composing  the  internal  and  ex- 
ternal prostatic  sphincters  were  cut  away,  yet  the 
power  of  retaining  the  urine  within  the  bladder  was 
retained. 

In  two  cases  when  attempting  to  partially  re- 
move the  lateral  lobes  of  a  hypertrophied  prostate, 
fibrous  in  character,  by  means  of  a  perineal  incision 
the  entire  organ  was  resected.  Both  patients  died 
of  sepsis,  one  living  for  three  weeks  and  the  other 
sur\-iving  two  weeks  after  the  operation.  In  neither 
was  any  difficulty  experienced  in  retaining  the  urine. 

Out  of  the  eleven  cases  of  suprapubic  prostatec- 
tomy, in  five  of  which  the  gland  was  completely  re- 
moved, three  died.  Of  the  remaining  eight,  two 
were  lost  sight  of  after  leaving  the  hospital,  four 
were  cured,  and  two  were  somewhat  improved,  hut 
had  to  rely  upon  a  catheter  that  could  be  inserted 
easily,  but  which  did  not  require  to  be  employed  as 
frequently  as  before  the  operations.  The  two  cases 
which  were  not  cured  were  greatly  benefited.  In 
these  patients  the  prostatic  obstruction  had  existed 
for  a  considerable  lenc^h  of  time,  associated  with 


JUNB  IB,  1901] 


HYPERTROPHY  OF  THE  PROSTATE 


CThe  Philadelphia 
Medical   Journal 


1  171 


long  standing  chronic  cystitis,  which  had  wrought 
extensive  changes  in  the  wall  of  the  organ,  with 
hernial  protrusions  of  the  mucous  membrane, 
giving  rise  to  a  sacculated  condition,  so  that 
even  if  the  obstruction  had  been  completely  re- 
moved the  function  of  the  bladder  would  never 
have  been  restored.  The  condition  of  these  cases 
seems  to  warrant  the  conclusion  that  if  a  prosta- 
tectomy is  to  be  performed  an  early  operative  inter- 
ference is  demanded  in  cases  of  prostatic  hyper- 
trophy with  rapidly  increasing  symptoms  of  ob 
struction. 

Out  of  seven  perineal  prostatectomies  two  died  of 
sepsis.  Of  the  five  remaining  cases  two  were  lost 
sight  of  three  weeks  after  they  left  the  hospital. 
Their  condition  was  most  satisfactory  when  last 
heard  from.  Of  the  remaining  cases,  two  were  cured 
and  one  improved  ;  in  this  individual  a  chronic  cys- 
titis had  existed  for  a  length  of  time  before  opera- 
tion. 

The  mortality  of  perineal  prostatectomy  is 
variously  estimated  from  14.3  per  cent,  up 
to  18  per  cent.  In  the  Transactions  of  the 
American  Surgical  Assiciation,  1895,  there 
is  an  article  by  Dr.  J.  William  White  on 
"The  Results  of  Double  Castration  in  Hypertrophy 
of  the  Prostate,"  in  which  he  places  the  mortality 
of  perineal  prostatectomy  at  14.3%  and  suprapubic 
at  about  7%.  If  selected  cases  only  are  chosen  for 
the  operation  of  perineal  prostatectomy  and  the 
most  recent  method  resorted  to,  together  with  the 
employment  of  spinal  anesthesia,  the  mortality  will 
be  much  less  than  the  stated  percentage.  The  sur- 
geon should  always  bear  in  mind  that  the  chances 
of  death  are  miich  greater  in  the  perineal  operation 
than  they  are  in  the  suprapubic.  Moreover,  after 
the  patient  has  undergone  the  nervous  shock,  pain 
and  prolonged  convalescence  concomitant  on  the 
resection  of  the  prostate,  there  is  a  certain  propor- 
tion of  cases  that  will  be  unimproved.  This  is 
shown  by  a  report  of  22  operations  by  Desnos  (An- 
nals des  Mai.  dcs  Org.  Gcn.-Urin.,  1895),  where  15 
were  cured,  4  not  improved,  i  became  worse  and  2 
died. 

The  high  mortalit}'  attentant  upon  excision  of  the 
prostate  is  sometimes  due  to  the  fact  that  a  radical 
operation  is  undertaken  without  preliminary  pre 
paratory  treatment.  Much  can  be  gained  by  con- 
tinuous catheterism,  irrigation  of  the  bladder,  the 
administration  of  remedies  that  will  have  a  tendency 
to  render  the  urine  innocuous  and  produce  recon- 
structive metamorphoses. 

Of  all  the  various  methods  of  performing  com- 
plete prostatectomy,  of  which  I  have  had  the  mos' 
experience,  the  safest  and  most  satisfactory  is  the 
suprapubic  operation  by  the  method  suggested  by 
Fuller.  It  has  the  advantage  of  requiring  a  shorter 
time  for  execution  than  an}-  other.  The  modifica- 
tion suggested  by  Guiteras  of  pushing  the  prostate 
up  towards  the  bladder  by  means  of  the  index- 
finger  of  the  left  hand  inserted  into  the  recti'm 
while  the  gland  is  being  enucleated  greatly  facili- 
tates the  removal.  My  conclusions  respecting  pros- 
tatectomy may  be  summarized  as  follows : 

I.  With  the  exception  of  ligation  of  the  internal 
iliac  arteries,  prostatectomy  is  the  most  dangerous 


of  any  operation  that  has  been  recommended  for  the 
relief  of  prostatic  obstruction  due  to  hypertrophy. 

2.  Suprapubic  prostatectomy  is  the  safest  method, 
especially  if  combined  with  perineal  drainage. 

3.  The  best  period  to  select  to  perform  this  op- 
eration is  early,  before  the  break-down  of  catheter 
life  and  serious  complications  have  supervened. 

4.  Either  an  atonied  or  contracted  bladder  of  long 
standing,  associated  with  chronic  cystitis,  attended 
by  the  formation  of  sacs,  or  pouches,  are  contra-in- 
dications  for  the  operation. 

5.  A  partial  prostatectomy  is  indicated  in  those 
cases  where  a  valve-like  lobe  exists,  which  interferes 
with  urination,  or  where  there  is  partial  hypertrophy 
of  one  of  the  lobes. 

6.  A  complete  prostatectomy  is  indicated  where  a 
hypertrophy  of  the  three  lobes  has  taken  place,  es- 
pecially if  the  condition  is  associated  with  tumor 
formation,  projecting  well  back  into  the  bladder,  or 
has  given  rise  to  a  stenosis  of  the  prostatic  urethra. 

7.  Perineal  prostatectomy  is  best  suited  to  those 
cases  where  the  enlargement  of  the  lateral  lobes 
has  a  tendency  to  grow  towards  the  rectum,  or  ob- 
struct the  urethra. 

8.  When  performing  a  perineal  prostatectomy 
the  semi-circular  incisions  advocated  by  Pyle,  or 
the  transverse  cut  of  Worholm  is  the  most  satisfac- 
tory. 

9.  The  removal  of  a  portion  of  a  small,  hard,  fi- 
brous prostate  gland  by  means  of  the  perineal  route 
is  a  very  difficult  operation.  There  is  danger  of  not 
onlv  extirpating  the  entire  gland,  but  the  prostatic 
urethra  as  well. 

Boftiiii  Operation. — Thirty-three  patients,  between 
the  ages  of  forty-nine  and  eighty-one  years,  were 
operated  on  by  me  by  the  "Bottini  Method."  No 
death  resulted.  .A^ccording  to  Dr.  Fredenberg  (Ber- 
lin"), the  most  recent  statistics  show  that  good  re- 
sults can  be  looked  for  in  86.63%  of  cases.  Failure 
in  7.6%  :  mortality  in  4.5%. 

For  convenience  of  description  the  cases  that  I 
have  treated  may  be  divided  into  three  groups : 

First,  comprising  individuals  who  were  commenc- 
ing to  suffer  from  the  effects  of  prostatic  obstruc- 
tion, and  w^ho  required  the  daily  use  of  the  catheter. 
These  were  between  the  ages  of  forty-nine  and 
sixty-one.  Heretofore  this  class  of  patients  would 
have  been  placed  upon  what  is  known  as  the  "Pal- 
liative Method  of  Treatment."  Of  fourteen  who  sub- 
mitted to  the  operation,  before  the  secondary  path- 
ological chano-es  that  follow  prostatic  hypertrophy 
had  taken  place,  all  made  prompt  recovery:  the 
period  of  convalescence  varied  from  four  to  eighteen 
days.  When  operating  on  patients  at  the  beginning 
of  prostatic  hypertrophy,  the  gland,  as  a  general 
rule  being  but  slightly  enlarged,  a  prostatic  incision 
with  a  smaller  blade  should  be  employed  than  that 
which  is  used  in  more  advonced  cases.  The  Bottini 
operation  performed  early  may  be  regarded  as  a 
radical  method  of  treatment  resulting  most  favor- 
ablv.  It  would  seem  as  though  the  time  had  passed 
when  the  physician  is  satisfied  to  advise  his  patient 
to  use  the  catheter  daily  and  patiently  wait  until 
the  obstruction  becomes  so  great  and  the  compli- 
cations so  grave  that  some  radical  surgical  pro- 
cedure is  necessary  to  five  relief. 

Second.     The  second  group  of  cases  comprises 


I  172 


The  Philadelphia 
Medical  Journal 


] 


THE  VALUE  OF  COMBINED  CLINICS 


[June  IS,  vm. 


those  where  the  obstructive  symptoms  have  existed 
for  a  lengthened  time,  where  the  bladder  is  begin- 
ning to  be  involved,  and  is  in  the  process  of  under- 
going pathological  changes.  Catheterism  is  daily 
requisite ;  the  physique  of  the  individual  being 
still  in  good  condition.  This  group  is  portrayed  by 
eight  operations ;  the  individuals  being  between 
fifty-nine  and  sixty-three  years  of  age ;  the  period  of 
convalescence  including  necessary  after-treatment 
was  from  two  weeks  to  four  months.  Of  the  num- 
ber operated  upon  five  were  cured ;  two  were 
improved,  and  one  was  benefited,  so  far  as  residual 
urine  was  concerned,  which  was  owing  to  the  blad- 
der being  atonied  and  paralyzed ;  the  catheter  was 
readily  inserted,  the  prostatic  spasm  having  been 
entirely  relieved  by  the  operation.  A  slight  amount 
of  cystitis  continued  with  a  persistence  of  residual 
urine,  rendering  the  use  of  the  catheter  necess- 
sary. 

To  the  third  group  belonged  men  more  advanced 
in  years,  their  ages  ranging  between  sixty-five  and 
■eighty-one  years,  in  whom  prostatic  hypertrophy  had 
existed  for  a  lengthened  period,  who  had  reached 
what  is  known  as  the  "Break-down  of  Catheter 
Life,"  whose  general  health  was  below  par,  with 
atheromatous  degeneration  of  the  blood  vessels,  and 
polyuria,  together  with  damaged  bladder  and  kid- 
neys, and  who  had  suffered  from  repeated  attacks 
of  retention  of  urine.  A  large  amount  of  residual 
urine  existed  in  each  instance.  All  were  in  too 
poor  a  condition  to  withstand  a  capital  operation 
•and  before  the  introduction  of  Bottini's  method 
would  have  had  to  rest  satisfied  with  some  palliative 
procedure. 

(To  be  Concluded.) 

THE  VALUE  OF  THE  COMBINED  MEDICAL  AND  SUR- 
GICAL CLINIC  TO  THE  STUDENT. 

By  ROBERT  G.  LeCONTE,  M.  D., 
of  Philadelphia. 

If  the  Student  of  a  few  years  ago  should  look  at 
the  changes  that  have  taken  place  in  our  medical 
schools,  particularly  with  reference  to  the  teaching 
of  medicine  and  surgery,  he  would  be  struck  with 
the  greater  number  of  hours  given  to  the  clinical 
(i.  e.,  bedside)  teaching,  either  in  large  classes  in 
the  amphitheatre  or  small  sections  in  the  wards,  and 
to  the  lesser  position  occupied  by  the  didactic  lec- 
ture. The  value  of  this  improvement  cannot  help 
but  appeal  to  him,  as  he  will  recall  how  well-ground- 
ed he  was  at  graduation  on  the  theory  of  medicine, 
and  how  wofully  ignorant  of  its  actual  practice. 
Such  was  my  own  experience.  I  felt  on  graduating 
that  I  had  climbed  some  of  the  rungs  of  the  ladder 
of  medicine,  but  twenty-four  hours  in  a  large  hospi- 
tal speedily  convinced  me  that  I  was  still  groping 
on  the  ground,  and  that  my  small  store  of  theoreti- 
cal knowledge  was  practically  useless.  The  pres- 
ent system  of  teaching  is  a  distinct  advance  in  mak- 
ing the  medical  course  more  practical,  but  cannot 
our  methods  be  still  further  improved  by  combining 
the  medical  and  surgical  clinics  in  such  diseases  as 
have  a  medical  and  surgical  aspect?  At  present 
it  is  the  general  custom  to  devote  two  consecutive 
hours  to  clinical  study,  the  first  to  medical,  the  sec- 
ond to  surgical  teaching,  but  the  professor  of  medi- 

*Read  before  the  Hhiladelohia  County  Medical  S'Xriety.  May  S.  1901. 


cine  does  not  arrange  his  lecture  with  a  view  to  the 
surgical  clinic,  nor  does  the  surgeon  inquire  into  the 
subjects  that  the  instructor  in  medicine  is  illustrat- 
ing. Each  has  his  own  wards,  his  own  cases,  and 
chooses  such  material  as  seems  best  to  him,  not 
knowing  or  caring  what  his  colleague  will  teach, 
and  so  keeps  the  two  branches  of  the  science  as  sepa- 
rate as  noon  is  from  midnight,  forgetting  the  har- 
monj'  of  a  dawn  and  a  twilight. 

There  are  many  diseased  conditions  which 
should  properly,  at  first,  undergo  medical  treat- 
ment, but  which  later  come  under  the  care 
of  the  surgeon ;  and  there  are  also  forms  of 
the  same  disease  which  should  from  the  be- 
ginning be  either  medical  or  surgical.  How  is 
the  student  to  differentiate  these  conditions,  or 
know  when  a  disease  ceases  to  be  medical  and  be- 
comes surgical,  unless  he  is  given  a  clear  and  defi- 
nite continuous  picture,  by  seeing  the  medical  treat- 
ment of  the  case  in  question  followed  by  the  surgi- 
cal treatment  that  would  be  applicable.  As  in- 
stances of  what  I  mean,  let  me  mention  some  of  the 
diseases  and  conditions  in  which  such  a  combined 
method  of  teaching  would  be  of  great  value  to  the 
student :  Diseases  of  the  pleura,  hydro-  and  pyo- 
thorax.  Diseases  of  the  lung,  abscess,  gangrene,  local- 
ized tuberculardeposits.  Diseasesofthe  pericardium. 
Ulcer  and  carcinoma  of  the  stomach.  Diseases  of 
the  intestine,  appendicitis,  malignant  disease,  intus- 
susception, typhoid  fever  and  perforation.  Abscess, 
cirrhosis  and  hj-datid  disease  of  the  liver.  Empyema 
of  the  gall-bladder,  gallstones.  Diseases  of  the  pan- 
creas, of  the  spleen,  of  the  lymphatics,  of  arteries 
(aneurism),  of  veins,  of  the  spinal  cord  and  the  re- 
sulting atrophies  and  deformities.  Diseases  of  the 
thyroid  gland,  Graves'  disease,  and  tumors.  Cranial 
neuralgias  with  tic  douloureux.  Epilepsy,  idiopath- 
ic, Jacksonian  and  traumatic.  Hemorrhagic  and  em- 
bolic apoplexy  contrasted  with  extra-  and  intra- 
dural hemorrhage.  Abdominal  enlargements  the  re- 
sult of  ascites,  tuberculous  peritonitis,  cysts  of  the 
ovary,  pancreas,  kidney,  etc. 

Each  disease  which  lends  itself  to  a  grouping  of 
this  character  should  be  carried  from  its  incipiency 
to  its  termination,  and  the  student  should  have  a 
picture  which  he  would  not  forget,  and  one  which 
no  single  text-book  could  furnish  him.  I  believe  in 
a  few  isolated  cases  this  sj'stem  of  teaching  has  been 
tried  in  Philadelphia.  Agnew  and  Pepper,  White 
and  Bruen,  White  and  Guiteras  have  given  com- 
bined clinics  on  empyema,  and  Agnew  and  Wood, 
and  White  and  Wood  on  brain  tumor,  but  I  know 
of  no  school  or  hospital  that  has  attempted  to  fol- 
low it  out  at  all  systematically.  It  would,  therefore, 
seem  expedient  to  relate  the  experience  of  Dr.  Fred- 
erick A.  Packard  and  myself,  who  tried  this  method 
at  the  Pennsylvania  Hospital  last  fall. 

We  were  associates  on  the  wards  of  the  hospital 
during  October  and  November,  1900,  and  gave  eight 
clinics  in  the  two  months.  We  arranged  seven  com- 
bined lectures,  but  at  the  last  moment  one  case  re- 
fused further  treatment  and  left  the  institution,  so 
that  only  six  combined  clinics  were  given.  These 
were  on  gangrene  of  the  lung,  cirrhosis  of  the  liver, 
epilepsy.  Graves'  disease  and  goitre,  diseases  of  the 
lymphatics,  and  diseases  of  the  pleura.  The  lectures 
varied  from  an  hour  and  three-quarters  to  possibly 
two  hours  and  a  quarter  in  length.    .\n  attempt  was 


June  15.  19011 


ABDOMINAL  PREGXA.XCY 


[ 


The  Philadelphia 
Medical  Journal 


117^ 


made  to  trace  these  diseases  from  their  incipiency 
to  their  various  terminations.  The  pathology  was 
freely  discussed  and  illustrated  with  such  specimens 
as  could  be  secured.  The  patients  themselves  were 
examined  before  the  students  and  the  diagnoses 
made.  They  were  then  removed  from  the  clinic 
and  anesthetized,  while  the  various  surgical  pro- 
cedures were  discussed  and  then  illustrated  on  the 
individual  case.  At  some  time  later  the  results  of 
our  treatment  were  shown  and  discussed,  whether 
the  case  terminated  favorably  or  fatally. 

At  the  risk  of  being  thought  too  explicit,  let  me 
describe  in  greater  detail  our  first  and  second  clinic. 
The  first  lecture  was  on  gangrene  of  the  lung. 
The  patient's  chest  and  also  the  hands  of  the  opera- 
tor were  carefully  disinfected  before  entering  the 
amphitheatre.  The  clinical  history  of  the  patient 
was  carefully  gone  into  and  the  physical  signs  de- 
monstrated with  the  hands  of  the  physician  covered 
with  sterile  rubber  gloves.  The  causes  and  pathol- 
ogy of  gangrenous  abscess  of  the  lung  were  spoken 
of,  and  the  statistics  of  medical  treatment  given, 
while  the  patient  was  removed  from  the  room, 
again  cleaned,  and  a  sterile  dressing  reapplied. 
As  ether  was  being  administered  the  surgery  of  the 
lung  was  reviewed,  its  dangers  and  complications, 
and  the  statistical  results  of  operation.  The  various 
methods  of  operating  were  detailed  and  the  course 
to  be  pursued  in  this  case  w^as  fully  explained.  The 
operation  was  then  performed  and  the  gangrenous 
cavity  opened.  The  immediate  and  the  probable  af- 
ter treatment  were  given.  One  week  later  he  was 
again  shown  to  the  class  and  his  condition  discussed. 
Later,  when  the  patient  died  from  progressive  sep- 
tic absorption,  the  post-mortem  findings  were  shown 
and  explained. 

Two  cases  of  cirrhosis  of  the  liver  were  the  text 
for  the  next  lecture.  The  same  antiseptic  precau- 
tions were  observed  in  the  preparation  of  the  pa- 
tients. The  clinical  histories  of  the  patients  were 
given,  and  the  causes,  varieties,  medical  treatment 
and  statistics  detailed.  The  physical  signs  present 
were  also  demonstrated.  The  theor\'  of  the  opera- 
tive treatment  was  then  discussed  and  the  statistics 
of  operation  given,  and  also  our  reasons  for  believ- 
ing these  cases  amenable  to  surgical  treatment.  The 
operative  technique  was  then  described  and  the  pa- 
tients operated  upon.  One  of  the  patients  died  in 
four  days.  At  the  next  lecture  the  death  was  re- 
ported, the  probable  causes  stated,  and  our  belief 
that  we  were  in  error  in  administering  ether  as  an 
anesthetic.  Two  months  later  the  second  patient 
died  and  the  post-mortem  findings  were  shown  to 
the  class,  and  the  causes  of  death  explained. 

Such  was  the  method  pursued,  and  the  attendance 
was  as  follows :  At  the  opening  clinic  less  than  forty 
students  were  present ;  at  the  second  about  a  hun- 
dred, and  thereafter  150  or  160  would  probably  rep- 
resent the  average  attendance.  Neither  Dr.  Pack- 
ard nor  myself  hold  positions  in  medical  schools, 
so  the  personal  element  did  not  influence  the  at- 
tendance, and  we  may  fairly  attribute  the  increase 
alone  to  the  system  pursued.  Several  students  told 
me  that  these  two  hours  saved  them  days  of  read- 
ing, and  that  the  mental  picture  retained  was  worth 
volumes  of  tvpe.  Two  physicians  also  told  me  it 
was  their  custom  to  rise  at  six  o'clock  on  our  clinic 
davs  in  order  that  they  might  save  the  two  hours 


to  hear  our  lecture.  1  trust  you  will  understand 
that  my  quoting  such  remarks  is  not  done  in  a  vain 
glorious  spirit,  for  I  know  full  well  that  my  quali- 
fications as  a  surgical  teacher  are  extremely  limited^ 
but  I  wish  to  emphasize  the  fact  that  with  this  sys- 
tem our  lectures  proved  very  valuable  to  the  stu- 
dents, although  the  surgical  instruction  was  possi- 
bly of  an  inferior  nature. 

The  drawbacks  to  such  a  system  are  (l)  the  ma- 
terial at  your  disposal  will  not  always  lend  itself 
to  this  method  of  instruction,  and  (2)  the  increase 
of  time  given  by  the  instructors,  for  it  is  expedient 
that  both  teachers  be  present  during  the  whole  of 
the  lecture,  the  surgeon  to  know  thoroughly  the 
medical  status  of  the  case  he  is  about  to  operate 
upon,  and  the  physician  to  see  the  advantages  or 
disadvantages  that  result  from  the  operation.  To- 
the  first  objection,  of  course,  there  is  no  answer,, 
for  if  you  have  not  the  material  you  cannot  ar- 
range the  lecture.  But  to  the  second  objection  I 
would  say,  that  an  instructor  who  cannot  afford  an 
extra  hour  for  the  purpose  of  saving  hours  of  work 
to  each  individual  student,  is  of  little  value  as  a. 
teacher,  no  matter  how  prominent  his  name  may  be 
in  the  profession. 

The  benefits  derived  from  such  a  system  seem, 
threefold,  (i)  to  the  student,  (2)  to  the  patient  who 
has  the  advantages  of  the  thoughts  of  two  minds- 
instead  of  one,  and  (3)  to  the  instructors,  for  it  cul- 
tivates in  them  qualities  of  the  highest  value  in  the 
practice  of  medicine. 

A  CASE  OF  ABDOMINAL  PREGNANCY. 

By  AUGUSTUS  C.  BEHLE. 
of   Salt   Lake  City. 

It  is  through  the  courtesy  of  Dr.  S.  H.  Pinkerton- 
that  I  am  able  to  exhibit  this  specimen  to  you  this 
evening.    I  will  give  you  a  brief  history  of  the  case. 

Mrs.  N ,  aged  2S:   general  health  good,  was  married 

eignt  years  ago.  Seven  years  ago  she  thought  she  was 
pregnant  as  she  had  missed  three  menstrual  periods.  At 
the  time  of  her  third  menstrual  period  she  had  a  severe 
pain  in  the  abdomen.  She  fainted  and  was  th^n  sick  in 
bed  for  over  a  month.  Her  menstrual  period  then  be- 
came reestablished  and  continued  fairly  regular  until 
March.  1900.  when  she  began  to  notice  an  absence  of  her 
usual  menstrual  flow.  She  thought  she  might  be  pregnant 
and  consulted  a  physician  who  informed  her  that  he 
thought  she  was  in  the  family  way.  Some  of  the  symptoms 
of  pregnancy  were  present — her  breasts  began  to  enlarge 
and  there  was  some  nausea.  In  June  1900,  she  began  to  flow, 
the  flow  being  slight.  There  was  no  clots  or  membranes 
passed.  This  flow  lasted  about  two  days  and  then  ceased. 
Milk  was  noticed  in  the  breasts  in  September,  the  breasts 
becoming  quite  full  so  that  there  was  oozing  from  them. 
Her  abdomen  continued  to  enlarge.  Fetal  movements 
were  noted  in  July.  The  patient  had  a  fall  in  October, 
which  started  some  pains  in  the  abdomen  and  it  was  sup- 
posed that  labor  was  approaching,  but  these  pains  sub- 
sided as  also  did  the  fetal  movements;  the  secretion  of 
milk  had  dried  up.  In  January  of  this  year  she  began  to 
flow  and  also  in  February  and  March.  Peculiar  pains 
throughout  her  abdomen  had  been  present  during  her 
whole  pregnancy  which  made  her  very  miserable  at  times. 
She  considered  those  pains  as  the  necessary  accompani- 
ment of  pregnancy.  What  she  had  considered  fetal  move- 
ments having  ceased,  her  menstrual  flow  being  re-estab- 
lished and  her  milk  drying  up  caused  her  to  decide  that 
something  was  wrong.  She  came  to  this  city  on  April  2. 
1901,  placing  herself  in  the  hands  of  Dr.  S.  H.  Pinkerton. 
who  sent  her  to  St  Mark's  Hospital.    On  April  3.  1901,  she- 


•Reported   before  the  S.-ilt    Ivike    County    Medical     Society. 

April    S.    1901. 


1 174 


The  Philadelphia"! 
Medical   Journal  J 


SPECIALISM  AND  ITS  RELATIONS 


[June   15.   1901 


was  examined  by  Drs.  Pinkerton,  Worthington  and  Lan- 
denberger,  under  ether  anesthesia.  I  was  asl<ed  to  exam- 
ine the  patient  on  April  4th,  and  found  the  following  con- 
ditions: I'atient  healthy,  very  well  nourished  and  somewhat 
browned  by  exposure  to  sunlight.  She  was  of  medium 
stature.  The  areola  around  the  nipple  was  well  marked 
although  there  was  no  pigmentation.  The  breasts  were 
somewhat  flaccid.  No  colostrum  could  be  expressed  from 
the  nipple.  The  abdomen  was  uniformly  enlarged.  The 
linia  alba  was  not  pigmented.  Striae  were  found  all  over 
the  abdomen  and  on  the  side.  A  tumor  was  noted  which 
extended  a  hand's  breadth  above  the  umbilicus.  It  was 
elastic,  semi-solid  and  non  fluctuating.  A  hard  globular 
mass  was  made  out  in  the  right  iliac  fossa  which  was 
smooth  with  the  exception  of  a  slight  depression  at  on'? 
side.  Above  the  umbilicus  and  toward  the  left  an  irregular 
mass  resembling  fetal  limbs  was  palpated.  The  balance 
of  the  tumor  seemed  somewhat  vague  and  diSlcult  to  out- 
line. Careful  auscultation  over  the  whole  abdomen  failed 
to  elicit  fetal  heart  sounds  or  the  placental  souffle.  Va- 
ginal exploration  demonstrated  the  vaginal  walls  smootli 
and  soft;  two  fingers  could  be  passed  into  the  vagina  with 
difliculty  because  of  a  resistant  perineum.  The  cervix  was 
soft,  round  and  not  shortened.  The  fundus  could  not  be 
outlined  definitely.  Rectal  examination  called  attention  to 
a  small  pseudo-fluctuating  body  about  the  size  of  an 
English  walnut  in  the  cul-de-sac  of  Douglas.  This  was  sen 
sitive  to  pressure  and  recognized  as  an  ovary.  A  diagno 
sis  of  ectopic  gestation  was  made  with  a  probable  death  of 
the  fetus.  The  position  of  the  child  towards  the  ab- 
right  iliac  fossa;  the  dorsum  of  the  child  towards  the  ab- 
dominal wall  and  to  the  right;  the  extremities  to  the  left. 
As  no  placental  souffle  could  be  heard  an  immediate  oper- 
ation was  advised.  It  was  performed  by  Dr.  Pinkerton  on 
April  6,  3  901.  A  median  incision  was  made  in  the  linia 
alba  which  was  afterwards  extended  to  about  4  Cm.  above 
the  umbilicus.  A  large  sac  was  found  with  some  adhesions 
to  the  great  omentum.  An  incision  was  made  through  the 
sac  which  passed  through  part  of  the  placenta.  The  knee 
Of  the  fetus  was  then  felt;  the  head  somewhat  extended 
and  lying  in  the  right  iliac  fossa,  the  dorsum  toward  the 
right.  The  cord  was  severed  and  the  child  was  delivered. 
The  fetus  showed  slight  signs  of  maceration.  About  a  pint 
of  thick  amniotic  fluid  was  in  the  sac.  Adhesions  were 
now  carefully  separated,  severed  and  tied  thereby  grad- 
ually freeing  the  sac  from  its  attachments  and  permitting 
of  its  removal.  Some  large  blood  vessels  were  encountered, 
catgut  being  used  to  tie  them  off.  Very  little  blood  was 
lost.  The  uterus  was  found  pushed  to  the  left  side,  the 
right  ovary  being  in  Douglas  cul-de-sac.  A  well  marked 
corpus  luteum  was  found  in  this  ovary.  The  right  tube 
seemed  normal  with  the  exception  of  its  end  being  firmly 
occluded.  The  left  tube  and  ovary  could  not  be  found. 
The  uterus  was  about  the  size  that  you  would  expect  to 
find  in  a  multiparous  non-pregnant  woman.  It  was  not 
deemed  wise  to  do  a  hysterectomy.  The  sac  was  very 
firmly  attached  to  the  uterus  at  the  position  of  the  left 
cornua  and  to  the  pelvis  on  that  side.  The  attachments  of 
the  round  ligament  to  the  uterus  could  be  noticed  in  front 
of  the  sac.  I  have  not  been  able  to  find  the  left  tube 
and  ovary  by  a  macroscopical  examination  and  have  not 
had  time  to  cut  microscopical  sections  from  the  sac,  but 
hope  to  be  able  to  do  so  as  I  think  they  are  incorporateil 
in  the  sac.  The  placenta  was  fairly  large  and  attached 
to  the  anterior  part  of  the  sac  as  it  lay  in  the  abdomen. 
The  abdominal  wound  was  closed  with  silk  worm  gut. 
Patient  withstood  the  shock  of  the  operation  very  well;  her 
temperature  reaching  its  highest  point  100.4°  Farenheit  at 
3  P.  M.  the  day  following  the  operation.  The  patient  at 
the  present  time  is  in  a  very  satisfactory  condition.  The 
foetus  is  a  male  child,  very  large,  weighing  6^4  pounds. 
The  child  is  plump  and  well  developed,  no  deformity  being 
noticed.  One  hand  is  quite  puffed  and  macerated.  There 
is  also  some  maceration  of  the  leg  and  back.  The  child 
measures  53  Cm  in  length:  around  the  hips  it  measures  23 
Cm;  around  the  shoulders  it  measures  43  Cm;  around  the 
head  (forehead  occiput)  35^^  Cm.  The  sole  of  the  foot 
measures  S  Cm. 

(The  patient  made  an  uneventful   recovery  and  at  the 
present  time,  May  29,  1901,  has  regained  her  former  health). 


SPECIALISM  AND  SOME  OF  ITS  RELATIONS  TO  THE 

GENERAL  PRACTICE  OF  MEDICINE. 

By  HENRY  WALLACE,  M.  D., 

of  Brooklyn,  X.  Y. 

As.sistant  Surgeon  to  St.  Johns'    Hospital,    Brooklyn,     and    Surgeon  to 
Department  of  Diseases  of  the  Throat  and  Nose,  Polhemus  Clinic. 

The  subject  of  specialism  and  its  relations  to  the 
general  practice  of  medicine  and  surgery  is  becom- 
ing more  and  more  a  matter  for  deep  and  earnest 
thought. 

As  the  field  of  medicine  broadens,  both  as  a  re- 
sult of  experience  in  practice  and  the  fruition  of  lab- 
oratory research,  so  to  every  conscientious  worker 
in  the  profession  must  come  the  thought  sooner  or 
later:  "How  is  it  possible  for  me  to  keep  up  to  date 
in  all  departments,  and  should  I  become  a  special- 
ist?" 

In  years  gone  by,  when  the  general  practitioner 
was  more  or  less  able  to  keep  pace  with  the  ad- 
vances in  these  special  lines,  the  subject  did  not 
command  the  attention  that  it  does  to-day,  and  with 
good  reason. 

To  be  an  all-round  good  man  in  those  days  was 
a  reputation  much  easier  to  hold  then  than  it  is  now. 
This  is  essentially  an  age  of  specialists,  and  rightly 
so,  from  the  standpoint  that  no  man  can  be  an  ex- 
pert  in    all   departments. 

The  great  mistake  at  the  present  time  is  that 
there  is  a  marked  tendency  for  a  man  to  enter  a 
specialty  too  early  in  his  career. 

A  four  years'  course  in  a  medical  college,  a  year 
or  two  as  interne  in  a  hospital,  with  possibly  a  few 
weeks  spent  at  a  post-graduate  school,  and  the 
young  man  starts  on  his  career  as  a  specialist. 

He  then  obtains  a  clinic  in  some  dispensary,  he 
attends  the  meetings  of  the  section  of  his  local  so- 
ciety which  is  devoted  to  his  specialty,  and  waits 
for  a  private  practice. 

The  result  of  all  this  honest  work  is  that,  although 
he  becomes  more  and  more  proficient  in  his  spec- 
ialty, he  becomes  narrower-minded  as  regards  med- 
icine in  its  broader  sense. 

The  specialist  of  to-day  should  be  the  product  of 
a  natural  development,  not  of  a  forced  growth. 

The  true  method  of  development  comes  through 
years  of  general  training  in  the  broader  fields  of 
medicine  and  surgery,  during  which  time  the  indi- 
vidual finds  a  line  of  work  which  interests  him  the 
most,  and  for  which  he  is  best  fitted  from  many 
standpoints. 

What  is  the  result  of  this  form  of  development? 
A  man  who  has  the  broadening  influences  of  sev- 
eral years'  work  in  the  larger  field  is  given  a:-  op- 
portunity to  discover  a  branch  for  which  he  is  spec- 
ially fitted  and  which  he  cannot  obtain  in  any  other 
way. 

If,  in  his  general  training,  he  has  had  especial  op- 
portunities of  a  surgical  nature,  and  he  is  fond  of  it. 
in  all  probability  he  will  be  most  interested  in  a 
specialty  where  his  surgical  training  will  be  of  the 
utmost  value  to  him. 

He  will  then  look  at  his  special  cases  with  a 
broader  range  of  vision  and  handle  them  with  a 
corresponding  skill  borne  of  this  experience. 

The  average  man  enters  the  profession  of  medi- 
cine with  the  object  first  and  foremost  of  earning  a 
living. 


June  15,  1901] 


SPECIALISM  AND  ITS  RELATIONS 


TThe  Philadelphia 
Lmedical   Jodrnal 


1175 


The  natural  history  of  this  man's  first  few  years 
will  necessarily  be  to  do  everything  that  comes  to 
him  which  he  can  conscientiously  handle. 

It  may  be  that  it  is  during  these  early  years, 
though  not  always,  that  he  sees  where  his  deepest 
interests  lie  in  the  broad  field  of  the  profession. 

On  the  contrary,  it  may  be,  and  very  often  is,  the 
case,  that  in  the  struggle  for  existence  and  recogni- 
tion not  only  by  the  public,  but  by  the  profession, 
that  he  has  not  the  time  to  discover  his  natural  bent, 
and  if  he  does  he  many  not  find  the  opportunities 
for  its  development. 

Then  there  is  a  class  of  men  who  have  been 
engaged  for  years  in  the  practice  of  their  profession, 
and  it  is  not  until  after  several  years'  experience 
that  they  find  they  have  by  opportunity  and  aptitude 
fitted  themselves  for  some  particular  line  of  pro- 
fessional work. 

The  medical  schools  of  to-day  are  certainly  mak- 
ing advances  in  the  right  direction  by  giving  their 
students  a  better  insight  into  the  specialties  than 
ever  before. 

The  well  trained  practitioner  should  be  able  to 
examine  and  in  a  general  way  at  least  make  a  diag- 
nosis of  many  of  the  special  conditions  and  know 
his  limits  in  the  case. 

How  often  the  throat  and  nose  specialist  will 
have  cases  come  to  him  with  the  statement  that  they 
have  catarrh,  and  were  told  by  their  family  physician 
to  wash  out  the  nost  with  a  solution  of  common  salt 
in  water  or  to  get  an  atomizer. 

When  asked  whether  the  physician  had  made  an 
examination  of  the  nasal  cavities,  they  frequently 
answer  in  the  negative,  and  that  they  were  simply 
told  they  had  catarrh  and  that  sim.ple  attention  to 
cleanliness  would   relieve  them  of  their  trouble. 

This  is  all  very  true  so  far  as  it  goes,  but  how 
often  we  find  that  catarrh  is  due  to  some  condition 
requiring  surgical   interference. 

Not  only  this,  but  the  laryngologist  of  the  high- 
est type  views  his  case  not  only  through  his  own 
particular  spectacles,  but  with  the  eyes  of  the  well- 
trained  physician,  who  can  look  upon  the  case 
broadly  and  sets  to  work  to  relieve  it  not  only  by 
local  treatment,  but  by  remedying  defects  of  hy- 
giene, treating  constitutional  dycrasiae,  and  general 
conditions  which  might  cause  or  aggravate  the  local 
disease. 

Many  disorders  of  the  nasal  and  laryngeal  mu- 
cous membranes  are  due  not  nearly  so  much  to  local 
causes  as  to  disorders  of  the  gastro-intestinal  tract. 

To-day  better  than  ever  before  the  young  grad- 
uate understands  that  every  cough  is  not  due  to 
pulmonary  disease,  but  may  be  caused  by  an  elon- 
gated uvula. 

Some  months  ago  I  remember  treating  a  case 
of  aparently  intractable  cough  which  had  been  un- 
der the  care  of  a  general  practitioner  for  a  consid- 
erable length  of  time. 

He  had  been  given  the  usual  cough  remedies 
without  benefit.  This  case  was  perfectly  relieved 
in  a  very  short  space  of  time  by  suitable  treatment 
directed  to  a  much  congested  and  edematous  turbi- 
nate body. 

I  have  another  case  in  mind  where  a  patient  was 
told  that  he  had  hay-fever  and  was  advised  to  go  to 
the  White  ^'ountains  for  its  relief.    He  did  so,  and 


on  his  return,  as  he  was  no  better,  it  was  suggested 
that  he  have  his  nose  examined. 

He  did  so  and  was  very  much  surprised  when 
told  that  he  was  sufTering  from  tertiary  nasal  syph- 
ilis which  had  gone  so  far  as  to  have  almost  de- 
.stroyed  the  nasal  mucous  membrane  and  already  to 
have  caused  a  large  perforation  of  the  septum. 

It  is  in  such  a  case  as  this  that  the  average  young 
practitioner  of  to-day  is  ahead  of  some  of  the  older 
graduates. 

He  has  learned  to  make  a  local  examination  and 
in  a  general  way  at  least  to  make  a  diagnosis  and  to 
decide  whether  the  case  in  question  is  one  requiring 
the  attention  of  a  specialist. 

As  in  the  case  just  referred  to,  the  simplest  kind 
of  an  examination  would  have  shown  that  the  trou- 
ble was  of  a  very  different  nature  from  hay-fever, 
which  disease  he  would  surely  know  could  not  pro- 
duce a  septal  perforation. 

Such  handling  of  the  case  would  probably  have 
saved  months  of  suffering  and  irreparable  destruc- 
tion of  tissue. 

So  much  from  the  standpoint  of  the  laryngolo- 
gist. 

These  general  statements  may  be  challenged,  and 
justly  so,  as  not  applying  with  equal  force  to  all  of 
the  special  departments  of  medicine  and  surgery. 

I  am  free  to  admit  that  there  are  at  least  two  ex- 
ceptions to  my  general  proposition  that  the  special- 
ist to  be  thoroughly  equipped  for  his  work  must 
have  a  general  medical  or  surgical  training. 

I  refer  to  ophthalmology  and  otology.  In  former 
years  much  more  frequently  than  at  the  present 
time  these  two  went  hand  in  hand.  This  associa- 
tion was,  of  course,  without  logical  foundation,  and 
we  are  now  accustomed  to  see  the  specialist  con- 
fine himself  to  one  or  the  other  of  these  two  depart- 
ments. 

In  neurology,  however,  the  broadest  and  most  thor- 
ough knowledge  of  the  anatomy  and  physiology  of 
the  entire  body,  combined  with  a  thorough  train- 
ing in  general  medicine,  is  essential  to  success. 

No  branch  of  medicine  requires  such  a  thorough 
groundwork  on  which  to  build  as  this.  The  ner- 
vous system,  with  its  complex  anatomy  and  physi- 
ology, its  intimate  relation  to  every  function  of  the 
economy,  not  to  mention  its  tremendous  literature, 
especially  in  foreign  tongues,  all  contribute  to  make 
this  line  of  study  dependent  on  the  most  extensive 
and  thorough  training  in   medicine. 

As  to  gynecology,  the  statement  may  be  made 
that  a  man  cannot  become  a  successful  gynecologist 
at  the  present  time  without  a  broad  experience  as 
a  general  practitioner. 

The  trained  gynecologist  must  be  able  not  only  to 
recognize  conditions  amenable  to  local  and  opera- 
tive treatment,  but  to  accomplish  much  by  his  abil- 
itv  to  recognize  and  treat  disorders  of  the  various 
svstems  of  the  body  bearing  a  close  relationship  to 
the  pelvic  organs. 

The  day  of  the  office  gynecologist  is  past.  Women 
do  not  have  to  submit  to  days  and  weeks  and  even 
months  of  local  treatment,  for  we  realize  now  how 
much  more  can  be  done  by  immediate  surgical  treat- 
ment and  within  a  comparatively  short  space  of 
time. 

The  gynecologist  of  to-day  must  be  a  skillful  sur- 
geon.   He  must  keep  in  touch  with  all  the  advances 


1 176 


The  PmijiDELPBiA 
Medical   Jocf.nai. 


] 


SPECIALISM  AND  ITS  RELATIONS 


[Jr.KE  1£,   ISCJl 


in  the  technique  of  general  surgery  that  he  may 
apply  them  to  his  own  work. 

The  field  of  the  gynecologist  has  changed  in  the 
last  decade.  Up  to  that  time  a  large  proportion  of 
his  work  was  in  the  line  of  plastic  surgery  of  the 
cervix  and  perineum. 

To-day  he  sees  fewer  of  these  cases  in  proportion 
to  those  demanding  an  abdominal  or  vaginal  incis- 
ion. 

This  may  be  explained  very  logically  by  the  fact 
that  there  are  now  more  men  competent  to  do  this 
work,  but  also  by  the  fact  that  the  student  of  to-day 
is  better  instructed  in  obstetrics,  and  in  the  operation 
for  the  immediate  repair  of  perineal  lacerations. 

A  few  years  ago  the  student  saw  possibly  a  few 
cases  of  immediate  perineorraphy  during  his  mater- 
nity course.  Not  only  has  he  this  experience  at  the 
present  day,  but,  thanks  to  modern  methods  of  in- 
struction, he  is  enabled  to  obtain  an  excellent  idea 
of  the  technique  of  this  operation  by  class-room  de- 
monstration. (I  refer  to  Dickinson's  plastic  cast 
method). 

In  former  days  a  man  could  hold  an  enviable  rep- 
utation as  a  gynecologist  on  the  strength  of  his 
ability  to  make  a  diagnosis,  to  institute  local  treat- 
ment, and  to  perform  plastic  operations. 

At  the  present  time,  the  worker  in  this  line  must 
be  a  surgeon  of  skill  and  experience  in  the  much 
larger  field  included  in  the  term  "abdominal  sur- 
gery." 

And  so  we  might  go  through  a  longer  list  of  the 
so-called  specialties,  and  we  will  find  that  the  same 
general  principle  holds  true. 

The  subject  of  the  relation  of  the  specialist  to  the 
general  practitioner  from  the  more  personal  stand- 
point is  one  upon  which  much  could  be  said. 

It  almost  appears  at  times  that  some  practitioners 
have  a  feeling  that  if  they  send  a  case  to  a  special- 
ist they  are  liable  to  lose  their  hold  upon  it.  Far 
from  this  being  the  case,  the  patient  of  average  in- 
telligence is  very  liable  sooner  or  later  to  go  to  some 
specialist  at  the  suggestion  of  a  friend. 

Here  the  physician  is  certainly  much  more  liable 
to  lose  his  patient  than  if  he  had  referred  the  case 
himself  to  the  specialist  and  conferred  with  him  in 
regard  to  it. 

It  is  possible  in  some  instances  that  the  practi- 
tioner fears  that  he  may  lose  his  patient  by  recom- 
mending some  one  else  by  apparently  acknowledg- 
ing that  he  himself  is  incompetent. 

This  is  most  certainly  not  the  case,  for  the  public 
is  intelligent  enough  at  the  present  time  to  realize 
the  fact  that  no  physician,  however  well  informed, 
can  be  as  competent  as  one  especially  trained  in  any 
given   branch. 

Not  infrequently  the  specialist  is  criticized  by  the 
practitioner,  who  has  referred  him  a  case,  because 
he  is  apparently  going  beyond  his  proper  limits  and 
not  confining  himself  to  the  purely  local  treatment 
of  the  case. 

In  such  an  instance  as  this,  or  where  it  is  not  de- 
sirable for  any  reason  that  the  specialist  should  have 
the  entire  handling  of  the  case,  and  as  it  were  taking 
it  entirely  out  of  the  physician's  hands,  the  special- 
ist is  competent  to,  and  should,  consult  with  the 
phvsician  as  to  a  line  of  general  treatment  and  the 
particular  indications  for  it  in  the  case  in  question. 

It  has  been  said  that  a  man  cannot,  and  should 


not,  practice  a  specialty  and  at  the  same  time  be  en- 
gaged in  a  general  practice. 

There  are  few  men  who,  although  desirous  of  be- 
coming specialists,  are  able  to  wait  for  a  special 
practice. 

They  are  obliged  to  attend  to  a  general  practice 
to  meet  expenses,  for  it  takes  a  longer  time  to  de- 
velop a  special  practice  than  a  general  one. 

On  the  other  hand,  it  is  very  possible  that  after 
some  years  spent  in  general  practice,  though  with  a 
growing  special  one,  it  may  be  advisable  for  him  to 
gradually  diminish  the  extent  of,  or  even  discon- 
tinue his  general  work  and  devote  all  his  time  and 
energies  to  his  specialty. 

It  is  perfectly  proper  and  possible  then  for  a  med- 
ical man  not  only  to  be  a  pure  specialist,  but  to 
practice  a  specialty  while  attending  to  a  general 
practice. 

That  in  the  latter  capacity  he  deserves  the  respect 
and  support  of  his  colleagues,  although  he  is  not  a 
specialist  in  the  strictest  meaning  of  the  word. 


Preliminary  Program  of  Papers  to  be  Read  at  the  Meet- 
ing of  tne  American  Neurological  Association,  to  be  held 
in  Boston,  June  19,  20  and  21,  1901. — il)  Chorea  with  Em- 
bolism of  the  Central  Artery  of  the  Retina  with  short  Re- 
view of  the  Embolic  Theorj-  of  Chorea.  By  Dr.  H.  M. 
Thomas,  of  Baltimore.  (2)  The  Course.  Prognosis  and 
Treatment  of  Hysteria.  By  Dr.  Theodore  Diller.  of  Pitts- 
burg. (3)  A  Case  of  Cerebral  Hemiatrophy  with  Hemi- 
plegia and  Aphasia,  in  an  adult.  By  Dr.  W.  L.  Worcester, 
of  Hathome.  Mass.  (4)  Report  of  a  Case  of  Brain  Tumor, 
Operation.  Recovery.  By  Dr.  Wm.  M.  Leszynsky.  of  Kew 
York  and  Dr.  James  H.  Glass,  of  Utica.  N.  Y.  (5j  A  Case 
of  Cerebellar  Tumor  causing  Pulsation.  Thrill  and  Murmur. 
By  Dr.  Joseph  Sailer,  of  Philadelphia.  (6)  A  Method  for 
Recording  Foot-prints  for  the  Study  of  the  Gait.  By  Dr. 
Joseph  Sailer,  of  Philadelphia.  (7j  A  Case  of  Dislocation 
Forwards  of  the  Seventh  Cervical  Vertebra.  By  Dr.  Frank 
R.  Fry,  of  St.  Louis.  (8)  A  Case  of  Cervical  and  Bulbar 
Tabes  with  Necropsy.  By  Dr.  Wm.  G.  Spiller  and  Dr.  S. 
Soils  Cohen,  of  Philadelphia.  (9p  A  Case  of  Simple  Serous 
Cyst  of  the  Cerebellum,  with  Autopsy.  By  Dr.  George  W. 
Jacoby  of  New  York.  (10)  Report  of  Two  Cases  of  Here- 
ditary Chorea.  By  Eugene  Riggs.  of  St.  Louis.  (Ill  The 
Early  Management  of  Epilepsy.  By  Dr.  Smith  Baker,  of 
Utica  N.  Y.  (12)  Hereditar>-  Cerebellar  Ataxia,  with  Re- 
port of  a  Case.  By  Dr.  Hugh  T.  Patrick,  of  Chicago,  111. 
( 10)  Two  Cases  Illustrating  the  Early  Association  of 
Mental  Aberration  with  Syphilitic  Infection.  By  Dr.  H.  A. 
Tomlinson,  of  St  Peter.  Minnesota.  (14)  The  Stadia  of 
Mental  Diseases.  By  Dr.  Theodore  H.  Kellogg,  of  New 
York.  (15)  Tumor  of  the  Superior  Worm  of  the  Cerebellum 
Associated  with  Corpora  Quadrigeminal  Symptoms.  By 
Dr.  H.  C.  Gordinier.  of  Troy.  X.  Y.  (161  Tumors  of  the 
Corpus  Callosus.  with  Report  and  Demonstration  of  Three 
Cases.  By  Dr.  James  J.  Putnam  and  Dr.  Edward  R.  Wil- 
liams, of  ISoston.  (17)  General  Paralysis  and  Symmetrical 
Gangrene,  with  Case.  By  Dr.  Henry  R.  Stedman  of  Boston. 
(IS)  Iraumatic  Convulsions.  Cranial  Operation.  An  In- 
teresting Pathological  Condition.  Recovery.  By  Dr.  Frank 
R.  Fry.  of  SL  Louis.  (1?1  The  Opium  Habit  Some  Notes 
on  Treatment  By  Dr.  Smith  Ely  Jelliffe.  of  New  York. 
(20)  Some  Studies  with  the  Ergograph.  By  Dr.  August 
Uoch.  of  Waverly.  (21)  A  Case  of  Myeloma  of  the  Spin* 
with  Compression  of  the  Cord.  By  Dr.  John  Jenks  Thomas, 
of  Boston.  (22)  Acute  Multiple  Neuritis.  By  Dr.  Charles 
W.  Burr  and  Dr.  D  J.  McCarthy,  of  Philadelphia.  (23^  A 
Case  of  Pseudo  Muscular  Hypertrophy  with  Autopsy.  Br 
Dr.  Graeme  M.  Hammond,  of  New  York.  (24)  Gunshot 
Wound  of  the  Spine.  Operation.  Autopsy.  By  Dr.  F.  W. 
Langdon.  of  Cincinnati.  (2.t*  Dispensair  Treatment  of 
Mental  Diseases.  By  Dr.  Walter  Channing.  of  Brookline 
Mass.  (26)  Two  Cases  of  Brain  Tumor  with  TTnusual 
Symptoms.  By  Dr.  Wharton  Sinkler.  of  Philadelphia.  (271 
Note  on  Chloretone  in  the  Treatment  of  Epilepsy.  By  Dr. 
Wharton  Sinkler.  of  Philadelphia.  (2S)  A  M*dico-LegB\ 
Case.    By  Dr.  James  Hendrie  Lloyd,  of  Philadelphia. 


The  Philadelphia  Medical  Jouinal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company   and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hendrie  Lloyd,  A.  M.,  M.  D.,  Edilortn-Chiej 
Julius  L.  Salinger,  M.  D,,  Associate  Editor 
Assistant  Editors 
Joseph  Sailer,  M.  D.  F.  J.  Kalteyer,  M.  D. 

D.  L.  Edsall,  M.  D.  T.  L.  Colev,  M.  D. 

J.  M.  Swan,  M.  D.  W.  A.  N.  Dorland,  M.  D. 

J.  H.  Gibbon,  M.  D.  T.  M.  Tyson,  M.  D. 

M.  OSTHEIMER,  M.  D.  A.  Robin,  M.  D, 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  puWication.  Reprints  (250)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  OflSces  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Fhiladelpliia  Medical  Journal,    1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8. 


Vol.  VII,  No.  2^ 


June  22,  1901 


$3.00  Per  Annum 


A  Contribution  to  the  Etiology  of  Epidemic  Cere- 
bro-Spinal  Meningitis. — The  April  number  of  the 
Journal  of  Hygiene  contains  a  valuable  contribution 
to  the  Etiology  of  Epidemic  Cerebro-spinal  Menin- 
gitis, by  Dr.  W.  J.  Buchanan.  In  this  study  especial 
attention  is  called  to  the  part  played  by  dust  in  the 
causation  of  this  disease.  The  fact  that  cerebro- 
spinal fever  is  prevalent  in  India  shows  that  the 
statement  of  Hirch,  made  in  1886,  that  the  south- 
ern distribution  of  cerebro-spinal  meningitis  is  lim- 
ited by  the  thirtieth  degree  of  North  latitude  does 
not  hold  good.  Indeed,  not  only  is  the  disease 
prevalent  in  India,  in  Khartoum,  in  the  Ashanti  field 
force,  but  in  the  West  Indies.  Dr.  Buchanan  has 
studied  carefully  the  three  epidemics  which  took 
place  in  the  Central  Prison,  Bhagalpur,  in  Bengal, 
from  1897  to  1900.  There  were  47  cases  recorded 
in  irregular  succession,  and  this  writer  divides  them 
into  three  separate  outbreaks.  No  new  facts  were 
obtained  which  throw  any  light  on  the  incubation 
period  of  the  disease.  The  experience  of  the  out- 
break at  Omdurnam  in  1898  and  1899  show  that  in 
some  cases  it  may  be  very  short,  from  52  to  76 
hours.  The  prognosis  is  usually  bad,  the  rate  of 
fatality  being  very  high.  Relapses  were  not  uncom- 
mon, and  in  some  cases  there  were  short  intervals 
of  complete  cessation  of  all  activity  of  the  disease. 
Lulls  and  temporary  improvements  were  not  at  all 
rare.  For  a  favorable  prognosis,  Buchanan  states 
that  the  following  symptoms  are  important :  The 
tongue  becoming  clean ;  the  disappearance  of  Ker- 
nig's  sign,  and  most  favorable  of  all,  a  prolonged 
and  quiet  sleep.  This  writer  believes  that  Kernig's 
sign  is  an  invaluable  aid  to  diagnosis.  Buchanan's 
conclusions  are  of  especial  interest.  He  mentions 
the  fact  that  what  is  called  cerebro-spinal  fever  in 
India  is  identical  with  epidemic  cerebro-spinal  men- 
ingitis, and  this  identity  is  established  not  only  by 
finding  the  diplococcus  intracellularis  meningitidis 
in  the  Indian  cases,  but  by  the  clinical  and  epidemic 
aspects  of  the  various  outbreaks  which  he  has  stud- 
ied. He  is  convinced  that  there  is  very  much  evi- 
dence to  connect  the  disease  with  dust,  either  wind- 
borne  or  accumulated  upon  roofs  or  evolved  in  the 
various  processes  of  grain  cleaning.  In  the  Bahag- 
pular  outbreaks  no    evidence    was    obtained    that 


pointed  to  direct  contagion,  and  in  no  instance  were 
those  in  attendance  upon  the  sick  attacked.  The 
disease  was  not  associated  with  any  prevalence  of 
pneumonia  or  influenza.  Strangely  enough,  the  dis- 
ease could  not  be  traced  to  any  infection  outside  of 
the  jail.  The  first  cases  in  all  three  outbreaks  were 
in  persons  who  had  been  inmates  of  the  institution 
from  six  weeks  to  a  year.  In  certain  wards  there 
were  larger  numbers  of  cases  than  in  otliers,  but 
there  was  no  direct  connection  between  the  cases 
in  these  wards  nor  between  the  different  wards,  and 
often  cases  in  the  same  ward  developed  at  long  and 
irregular  intervals.  It  was  found  that  in  only  three 
cases  out  of  the  47  studied  were  the  patients  not 
exposed  to  forms  of  labor  in  which  dust  was  plen- 
tiful. The  writer  states  that  this  fact  is  difficult 
of  explanation,  unless  we  believe  that  dust  either 
renders  men  more  susceptible,  or,  as  is  more  proba- 
ble, that  it  is  the  actual  vehicle  of  the  specific  germ 
of  the  disease. 

The  Development  of  Filaria  Nocturna. — ^The  two 
common  species  of  Culex  found  in  St.  Lucia  are  Cu- 
lex  fatigans  and  Culex  teniatus.  Low  (British 
Medical  Journal,  June  i,  1901)  has  studied  the  devel- 
opment of  the  filaria  nocturna  in  these  mosquitoes. 
The  insects  were  allowed  to  bite  a  patient  suffering 
from  filariasis.  At  the  end  of  from  twelve  to  twenty- 
four  hours  after  feeding  many  actively-moving  fila- 
ria embryos  are  seen  in  the  thoracic  muscles  of  Cu- 
lex teniatus.  But  these  embryos  develop  very 
slowlv,  and  after  reaching  a  stage  in  which  the  ali- 
mentary canal  is  differentiated,  an  evolution  requir- 
ing between  seven  and  nine  days,  the  embryos  be- 
gin to  degenerate  so  that  they  never  reach  matu- 
rity, and,  therefore,  never  pass  to  the  proboscis  of 
their  host.  At  fourteen  days  all  the  embryos  have 
disappeared,  only  small,  imperfectly-developed 
ones  remaining.  It  is  very  fortunate  that  the  Culex 
teniatus  is  not  an  efficient  ho^t  for  filaria  nocturna, 
because  the  insect  is  very  bloodthirsty  and  feeds 
b}'  day  as  well  as  by  night. 

On  the  other  hand,  Culex  fatigans  is  compara- 
tively rare  in  St.  Lucia  and  feeds  at  night  only.  In 
this  insect  the  filaria  embryos  rapidly  reach  matu- 
rity, so  that  in  eleven  and  one-half  days  the  meta- 


,  ,  _Q       The    Philadelphia"] 
'  '  /O       Medical  Journal    J 


EDITORIAL  COMMENT 


[JT-NE 


morphosis  is  complete  and  mature  forms  may  be 
seen  in  the  head,  neck  and  proboscis  of  the  mos- 
quito. In  St.  Lucia,  therefore,  filariasis  is  propa- 
gated by  the  bites  of  Culex  fatigans. 

Manson,  working  in  Amoy,  determined  the  cycle 
of  development  of  filaria  nocturna  to  be  eight  day?. 
Low,  who  studied  the  subject  in  St.  Lucia  in  March, 
thinks  that  if  his  experiments  had  been  made  in  the 
hot  weather  the  complete  metamorphosis  might 
have  taken  place  within  the  time  noted  by  Manson. 

Strong  {Circulars  on  Tropical  Diseases.  Xo.  i.  Chief 
Surgeon's  Office,  Division  of  the  Philippines)  has 
met  ivith  a  case  of  filariasis  in  Iloilo.  The  embryos 
began  to  appear  in  the  patient's  blood  in  small  num- 
bers at  six  o'clock  and  were  most  numerous  at  mid- 
night. The  patient  had  h-mphatic  swellings  in  the 
right  groin  and  irregular  fever.  It  is  not  at  all  im- 
possible, now  that  so  many  Americans  are  coming 
from  the  Philippines,  that  filariasis  may  become  do- 
mesticated in  the  Southern  portions  of  the  United 
States.  Low  shows  that  the  filaria  will  develop  in 
the  body  of  the  mosquito  when  the  atmospheric 
temperature  is  comparatively  low,  although  de- 
velopment is  slower  under  such  conditions.  Ac- 
cording to  the  Division  of  Entomology  of  the  De- 
partment of  Agriculture  {Bulletin  Xo.  4. — A^  S.)  Cu- 
lex fatigans  is  not  included  in  the  list  of  mosquitoes 
of  the  L'nited  States.  There  are,  however,  severa! 
varieties  of  Anopheles  within  our  borders  which 
may  prove  to  be  efficient  hosts  of  the  filaria  larva. 

The  New  President  of  the  American  Medical  As- 
sociation.— Dr.  John  A.  \\'yeth,  of  New  York,  is 
eminently  fitted  for  the  new  honor  which  has  been 
conferred  upon  him  by  the  only  representative  and 
really  national  medical  association  of  America.  He 
is  himself  to  be  congratulated,  and  the  American 
Medical  Association  is  to  be  congratulated  still 
more.  Dr.  Wyeth,  it  is  needless  to  say,  represents 
the  type  of  professional  men  from  whom  Presidents 
should  be  made.  He  has  attained  well  deserved  dis- 
tinction, not  only  as  a  practical  surgeon,  but  also  as  a 
teacher  and  an  author.  In  the  latter  class,  indeed, 
his  text-book  on  surgery  entitles  him  to  stand  in  the 
first  rank.  It  is  a  matter  of  especially  good  augury, 
we  think,  that  the  association  not  only  chose  a  Pres- 
ident from  New  York,  but  also  selected  a  meeting 
place  in  that  state.  Saratoga  is  a  delightful  resort, 
and  as  the  Americal  Medical  Association  has  to 
distribute  its  meetings  over  the  length  and  breadth 
of  the  land,  it  might  as  well  pick  out  the  best  spots. 
But  the  best  feature,  perhaps,  about  this  selec- 
tion is  that  it  will  tend  to  re-establish  the  entente 
eordiale  between  the  American  Medical  Association 
and  some  members  of  the  profession  in  the  Empire 
State  who  have  felt  that  they  had  a  grievance 
against  that  body.    This  consummation  is  devoutly 


to  be  wished.  Perhaps  now  that  the  Association 
for  several  years  has  honored  some  of  our  most  es- 
teemed surgeons,  it  will  in  the  not  distant  future 
let  the  lightning  of  its  favor  strike  some  equally  es- 
teemed medical  man. 

The  Pennsylvania  Epileptic  Hospital  and  Colony 
Farm. — It  is  hardly  to  the  credit  of  tlie  great  State 
of  Pennsylvania  that  the  only  institution  (with  the 
exception  of  a  small  Home),  which  aims  to  give 
proper  care  to  epileptics  within  her  boundaries,  is 
forced  to  rely  almost  entirely  upon  private  charity. 
The  Pennsylvania  Epileptic  Hospital,  at  Oak- 
bourne,  near  West  Chester,  is  striving  successfully  ' 
to  solve  the  problem  presented  by  the  needs  of  the 
epileptic.  In  a  circular  just  issued  it  announces  its 
plan  of  treatment.  This  consists  of  work,  occupa- 
tion, out-door  life,  and  a  blessed  freedom  from  that 
ennui  of  existence  which  is  so  often  forced  upon  the 
epileptic  sufferer.  The  men  work  on  the  farm  dur- 
ing the  summer.  They  cultivate  the  land,  care  for 
the  cattle  and  poultry,  make  roads,  and  keep  the 
grounds,  hedges,  fences  and  buildings  in  repair. 
In  the  winter  they  do  shoemaking,  carpentering^l 
brushmaking,  cane-seating,  etc.  The  women  do 
housework,  assist  in  cooking  and  laundry  work,  and, 
in  the  summer  do  light  work  in  the  garden,  culti- 
vating flowers  and  picking  vegetables.  The  circu- 
lar from  which  we  quote  says  farther  that  statistics 
show  that  with  regular  diet,  steady  employment  and 
an  out-door  life,  the  number  and  violence  of  the 
epileptic  attacks  diminish  greatly.  Toward  the  sup- 
port of  this  most  beneficent  (and  partly  self-sup- 
porting) work  the  State  this  year  appropriated  only 
$2500.00.  It  is  greatly  to  be  hoped  that  public 
bounty,  as  well  as  private  charity,  will  flow  in  large 
measure  to  the  support  of  this  colony  farm.  No 
other  institution  in  the  State  appeals  more  strongly 
to  the  sympathy  of  mankind,  while  none  of  the 
greater  charities  has  been  more  neglected  in  Penn- 
sylvania than  the  one  which  has  for  its  object  the 
rational  and  humane  care  of  the  epileptic. 

Smallpox  in  the  United  States. — I'p  to  the  time 
of  issue  of  the  latest  number  of  the  Public  Health 
Ref-orts.  there  were  reported  to  the  L'nited  States. 
Marine  Hospital  Service  a  grand  total  of  2841^ 
cases  of  smallpox  for  the  United  States.  The  period 
covered  was  from  December  28.  1900,  to  June  14, 
10.01.  For  the  corresponding  period  one  year  before 
onlv  12.092  cases  were  reported.  Thus  it  appears- 
that  smallpox  has  increased  very  greatly  in  its  fre- 
quency, being  more  than  twice  as  prevalent  as  last 
vear.  But  the  mortality  tables  show  a  strikingly 
different  result.  For  last  year  there  were  report* 
642  deaths,  while  for  this  year,  although  the  dis 
ease  is  more  than  twice  as  prevalent,  the  numbe 


JCXE  22.  1901] 


EDITORIAL  COMMENT 


TThi.    Philadelphia. 
L  Medical  Jocrxal 


I  179 


of  deaths  has  been  only  486.  In  other  words,  last 
year  there  were  about  5%  of  deaths,  while  this  year 
so  far  there  have  been  but  ii%  of  deaths.  For  sta- 
tistical purposes  these  reports  may  not  be  alto- 
gether reliable,  not  sd  much  from  lack  of  accuracy 
as  from  want  of  fulness.  We  very  much  doubt 
whether  all  the  cases  that  actually  occur  in  remote 
and  rural  districts  are  reported.  This  must  be  so 
especially  of  mild  cases,  for  man)-  of  these  may  e.s- 
cape  detection.  This  fact  only  tends,  however,  to 
make  it  probable  that  the  death  rate  in  realit}-  is 
even  lower  than  it  appears  on  paper.  Highly  malig- 
nant cases  and  fatal  cases  are  naturally  much  more 
likely  to  be  discovered  and  reported,  hence  we  do 
not  think  it  likely  that  the  percentage  is  too  low, 
but  rather  the  reverse.  To  what  the  low  mortality 
of  modern  smallpox  is  due,  we  cannot  say.  It  is  an 
interesting  subject  for  debate  and  investigation, 
and  we  wish  some  competent  observer  and  statis- 
tician would  undertake  to  elucidate  it.  We  respect- 
fully refer  it  also  to  the  anti-vaccinationists. 

The  Medical  Profession  of  California  and  the 
Plague. — Since  there  have  been,  during  the  course 
of  the  plague  epidemic  in  San  Francisco,  so  much 
misunderstanding  and  confusion  in  regard  to  the 
various  aspects  of  the  situation,  an  authoritative 
statement  has  long  been  desired.  We  believe  the 
following  statement  contained  in  a  letter  from  a 
well-informed  physician  of  San  Francisco,  to  be 
fair  and  to  give  to  the  eastern  members  of  the  pro- 
fession a  clear  idea  of  the  situation,  in  so  far  as  the 
medical  aspects  are  concerned.  Unfortunately,  the 
purely  scientific  question  was  converted,  in  large 
part,  into  a  political  and  commercial  one,  to  the 
great  detriment  of  the  solution  of  the  hygienic  prob- 
lem concerned. 

The  diagnosis  of  plague  was  first  made  in  the 
spring  of  1900  by  the  City  Bacteriologist,  Dr.  Kel- 
logg, and  the  Surgeon  of  the  ?^Iarine  Hospital  Ser- 
vice stationed  in  Angel  Island,  Dr.  Kinyoun.  There 
is  some  indirect  evidence  that  similar  cases  had  oc- 
curred before,  but  no  pathological  evidence  lies  at 
hand.  Other  cases  occurred,  and  upon  doubt  being 
thrown  upon  the  diagnosis,  other  local  scientists 
were  engaged  in  the  study  of  the  condition.  The 
cases,  some  or  all  of  thetn,  were  studied  by  the  fol- 
lowing pathologists  and  bacteriologists :  Dr.  Kel- 
logg, the  city  bacteriologist ;  Dr.  J.  J.  Kinyoun,  Sur- 
geon of  the  Marine  Hospital  Service ;  Dr.  Ophuels, 
Professor  of  Pathology  and  Bacteriology  in  Cooper 
Medical  College ;  Dr.  Ryfkogle,  Instructor  in  Bac- 
teriology in  the  University  of  California :  and  Dr. 
Pillsbury,  Professor  of  Pathology  and  Bacteriology 
in  the  College  of  Physicians  and  Surgeons.  These 
men,  all  trained  in  special  work  of  the  kind,  pro- 
nounced the  disease  in  question  to  be  plague. 


A  portion  of  the  profession  disputed  the  diagno- 
sis despite  the  authority  and  the  scientific  study 
of  the  men  mentioned.  The  opposition  to  the  diag- 
nosis was  led  largely  by  three  medical  men,  all  of 
whom  hold  professorial  chairs  in  San  Francisco, 
and  wield  great  influence  in  shaping  public  opinion 
in  California.  One  of  these  medical  men  had  him- 
self failed  to  find  the  plague  bacillus,  and  afterwards 
was  not  willing  to  acknowledge  his  error;  the  other 
two  are  not  bacteriologists,  and  based  their  criti- 
cism and  opposition  upon  their  mere  personal  opin- 
ions. The  whole  profession,  while  divided,  was,  in 
the  majority,  inclined  to  the  belief  that  the  disease 
was  plague.  The  State  Medical  Society  passed  a 
resolution  expressing  its  conviction  that  the  disease 
was  pla.gue.  Cultures  were  sent  to  many  eastern 
bacteriologists,  and  in  all  instances  the  replies  were 
in  the  affirmative.  And,  lastly,  the  special  Plague 
Commission  again  definitely  determined  that  the 
disease  was  plague. 

The  methods  employed  by  the  local  experts  for 
the  positive  diagnosis  were  the  same  as  those 
worked  out  by  Yersin,  Haflfkine  and  the  various 
plague  commissions  sent  by  European  governments 
to  Asia.  This  touches  the  most  signal  fact  of  the 
whole  situation,  to  wit. :  that  methods  unreservedly 
accepted  as  reliable  and  conclusive  by  the  whole 
scientific  world,  and  by  every  government  w'hich 
has  had  experience,  v.ere  rejected  by  a  portion  of  the 
profession  of  San  Francisco.  The  diagnosis  of 
plague  in  the  beginnings  of  an  epidemic,  has  in  mod- 
ern times  been  made  in  no  other  w^a}'  than  it  was 
made  in  San  Francisco.  Had  a  report  identical  with 
that  of  the  local  scientists  in  San  Francisco,  been 
handed  in  to  anj^  European  government  or  to  that 
of  their  colonies,  it  would  have  been  unreservedly 
accepted  by  the  government,  the  medical  profes- 
sion, the  commercial  interests,  and  the  public  at 
large.  In  San  Francisco  alone  has  the  modern  sci- 
entific diagnosis  of  plague  been  rejected  by  an  in- 
fluential portion  of  the  medical  profession  and  the 
public. 

The  City  Board  of  Health  accepted  the  diagno- 
sis from  the  first,  and  has  continued  to  stand  by  the 
diagnosis.  Though  actuated  by  the  best  of  motives, 
the  Board  nevertheless  erred  in  some  of  its  public 
acts.  This  was  so  especially  in  its  establishing  a 
quarantine  against  the  section  of  the  city  known  as 
Chinatown.  This  quarantine  was  declared  illegal 
and  directed  to  be  removed  by  the  courts  in  an 
opinion  b}-  Judge  Morrow,  who  is  reported  to  have 
declared  from  the  bench  that  there  w-as  no  plague 
in  San  Francisco.  The  quarantine  was,  in  the  light 
of  our  knowledge  of  plague,  an  error.  Into  this 
error  the  local  Board  was  led  partly  by  the  con- 
viction that  on  account  of  the  numerous  and  an- 


Q^       The    Ph:ladelphia 


Medical  Journal, 


1 


EDITORIAL  COMMENT 


[June  22,    13ta 


known  underground  passages  undermining  the  sec- 
tion known  as  Chinatown,  other  measures  could  not 
succeed.  Upon  the  failure  of  the  disease  to  spread 
after  the  quarantine  was  raised,  the  public  lost  con- 
fidence in  the  diagnosis,  and  it  then  became  impos- 
sible for  the  city  Board  of  Health  to  procure  the 
funds  necessary  for  the  adequate  management  of 
the  situation.  The  city  Board  of  Health,  however, 
has  maintained  the  diagnosis,  and  has  never  ex- 
pressed a  contrary  opinion  to  the  public. 

The  State  Board  of  Health  had  not  gone  on  record 
in  the  matter.  It  is  generally  supposed  to  be  op- 
posed to  the  diagnosis,  but  there  is  no  official  record 
of  the  fact.  The  Board  at  the  outset  was  supposed 
to  have  been  inclined  to  confirm  the  diagnosis ;  but 
by  means  of  new  appointments  the  personnel  of 
the  Board  was  so  altered,  that  the  unexpressed  neg- 
ative opinion  has  become  predominant. 

Our  correspondent  insists  upon  it  that  the  situa- 
tion in  San  Francisco  has  not  been  altered  in  the 
least  bj'  the  report  of  the  Plague  Commission.  He 
says  that  the  portion  of  the  general  public  and  of 
the  medical  profession,  which  previously  opposed 
the  diagnosis,  now  reject  the  findings  of  the  expert 
commissioners,  and  he  maintains  that  the  primary 
cause  of  this  lay  in  the  postponement  of  the  publi- 
cation of  the  report  of  the  Commission.  This  pe- 
riod of  delay  on  the  part  of  the  Government  authori- 
ties was  seized  upon  to  discredit  the  findings  of  the 
Commission.  On  this  subject  of  delay  we  expressed 
our  opinion  at  the  time.  We  could  conceive  no 
adequate  reason  for  it,  and  we  believed  then,  as  our 
correspondent  maintains  now,  that  it  was  a  mis- 
take. But  this  feature  of  the  case  we  do  not  intend 
to  discuss  here  and  now.  Our  intention  has  been 
chiefly  to  present  a  statement  of  the  situation  which 
■we  think  is  authoritative  and  will  go  a  great  way 
to  distribute  just  praise  to  some  of  the  local  physi- 
cians who  have  been  misrepresented.  In  this  con- 
nection we  may  say  that  it  appears  not  a  little  odd 
that  the  Public  Health  Reports  of  the  U.  S.  Marine 
Hospital  Service  have  published  no  report  of  a  case 
of  plague  in  San  Francisco  since  April  4th.  Before 
that  time  a  few  cases  were  being  reported  right 
along,  and  the  Plague  Commission  had  had  no  dif- 
ficulty in  picking  up  cases.  What  has  become  of 
the  Plague  in  San  Francisco?  Its  sudden  disap- 
pearance after  the  departure  of  the  Commission  has 
a  dubious  aspect. 

A  Retrograde  Movement. — The  Post-Office  De- 
partment of  our  Government,  like  the  United  States 
Constitution,  was  made  for  the  people,  and  not  the 
people  for  it.  It  was  not  intended  primarily  as  a 
money-making  business.  It  is  to  serve  the  conve- 
nience of  the  public;  to  promote  the  interests,  and, 
above  all,  to  serve  for  the  enlightenment  of  the  pop- 


ulace. But  there  is  great  danger  that  some  of  these 
objects  will  be  defeated  if  Third  Assistant  Post- 
master General  Madden  is  to  have  his  way  in  rul- 
ing out  of  the  privileges  of  second-class  matter  all 
periodicals  that  ofifer  premiums  to  their  subscrib- 
ers. Mr.  Madden  seems  to  be  worried  because  a 
certain  concern  sold  tea-sets,  claimed  to  be  worth 
two  dollars  apiece,  as  premiums  for  a  publication 
which  was  sold  for  one  dollar  a  j-ear.  That  cer- 
tainly looks  like  anything  but  a  literary  or  educa- 
tional enterprise,  and  may  have  been  an  imposition 
on  the  Department ;  but  it  does  not  follow  that  all 
the  legitimate  periodicals  in  the  country  that  do 
an  honest  business  by  offering  premiums  (which, 
in  most  instances,  are  books)  should  be  debarred 
from  the  privileges  of  going  as  second-class  mat- 
ter. Some  discrimination  should  certainly  be  made; 
some  judgment  and  common  sense  should  be  dis- 
played. We  enter  a  protest  here  in  the  name  of  all 
legitimate  journalism,  and  in  the  interest  of  the  pub- 
lic which  desires  and  must  have  its  reading  matter 
on  reasonable  terms.  Let  there  be  no  tax  on  let- 
ters. 

A  Venereal  Disease  of  Horses. — The  Sixteenth 
Annual  Report  of  the  Bureau  of  Animal  Industry, 
Washington,  D.  C,  contains  an  interesting  account 
of  the  "Maladie  du  Coit"  in  horses,  as  observ'ed  in 
Nebraska.  The  infection  in  this  case  was  traced 
in  part  to  a  stallion  of  the  Clydesdale  breed,  which 
had  been  used  for  breeding  purposes.  A  number 
of  autopsies  are  reported  in  animals  of  both  sexes 
which  had  been  killed  after  the  disease  was  discov- 
ered in  them.  In  the  male  the  affection  is  a  local 
one,  beginning  in  the  penis,  but  involving  some- 
times the  sheath,  scrotum,  and  testicles.  An  edema- 
tous swelling  extended  in  one  case  along  the  ab- 
domen nearly  to  the  forelimbs.  An  offensive  puru- 
lent discharge  occurs,  and  the  entire  end  of  the 
penis  may  slough  away.  The  local  sore  is  an  ulcer, 
covered  with  a  black  scale.  A  skin  eruption,  con- 
sisting of  large  white  maculae,  is  observed.  The 
animal  emaciates  and  has  to  be  killed.  In  the  mare 
the  infection  may  invade  the  whole  genital  tract 
and  all  the  reproductive  organs.  In  one  case  the 
white  spots  were  seen  on  the  perineum  and  mam-, 
mary  glands ;  the  vagina  was  highly  congested :  the 
walls  of  the  uterus  were  thickened,  the  inner  surface 
being  covered  with  a  thick  jelly-like  exudate ;  and 
the  ovaries  were  swollen  to  several  times  their  nor- 
mal size.  These  organs  were  the  seats  of  extensive 
changes.  There  may  be  some  sjstemic  infection  as 
shown  in  the  mesenteric  glands  and  spleen.  This 
report  contains  no  history  of  any  bacteriological  in- 
vestigations, the  accounts  of  the  autopsies  being 
confined  to  a  description  of  the  gross  pathologrical 
conditions.  The  disease  is  evidently  transmitted  by 
coitus,  and  beginning  as  a  local  sore  gradually  ex- 
tends, and  may  even  invade  the  general  system. 


June  22,  19ol] 


REVIEWS 


TThe    Philadelphia 
L  Medical  Journal 


I  I 


8i 


TRcvicws. 


The   Theory   and    Practice   of    Military    Hygiene.     By   Ed 

ward  L.  Munson,  A.  M.,  M.  D.     Illustrated.    William 
Wood  &  Co.     New  York.     1901. 

The  subject  of  military  hygiene  is  so  peculiar,  and  In- 
volves so  many  features  that  do  not  ordinarily  occur  in 
works  devoted  to  sanitation,  that  we  confess  we  have  read 
the   book  more   for  the  purpose  of  instruction  than  in  a 
critical  spirit.  It  is  an  imposing  volume  of  983  pages,  and 
appears  to  represent  not  only  the  experience  of  its  writer, 
but  the  concensus  of  opinion  of  all  who  have  considered  the 
subject,  and  the  array  of  authorities  cited  is  amazing.    The 
work  opens  with  a  long  chapter  devoted  to  the  selection  of 
the  recruit.     From  it  we  learn  that  the  great  majority  of 
enlisted  men  in  the  United  States  army  are  native  born, 
and  that  most  of  them  belong  to  the  laboring  class.     The 
commonest  causes  for  rejection  are  diseases  of  the  eye  and 
imperfect  physique.  The  most  desirable  men  for  soldiers  are 
short,  stocky  fellows,  between  21  and  25  years  of  age.     In 
the  British  army,  in  which  the  requirements  are  not  quite 
as  severe  as  in  our  own,  defective  development  caused  the 
rejection  of  182  men  in  1000,  just  twice  the  number  in  the 
United  States.     In  the  next  chapter  on  the  development  ol 
the  recruit,   Munson  strongly  urges  that  some  system  of 
rational  and  thorough  gymnastics  be  introduced  into  the 
United  States  army,  as  it  is  in  the  armies  of  Continental 
Europe,  particularly  those  of  France  and  Germany.     There 
are  a  number  of  interesting  illustrations  showing  the  bene- 
fit derived  from  systematic  exercise.     In  addition  to  gym- 
nasium exercise,  he  believes  that  competitive  games  and 
sports  are  of  the  greatest  value,  particularly  wrestling  and 
football.     A  long  chapter  is  devoted  to  marching.     One  of 
the  interesting  features  of  this  is  the  description  of  the  pas 
(In  fiction,  a  step  that  has  been  partly  introduced  into  the 
French  army,  and  which  is  derived  from  the  couriers  of 
the  Orient.     It  has  been  found  that   soldiers  accustomed 
to  it  can  march  further  and  more  rapidly,  than  they  can  by 
means   of   the  ordinary  marching   step.     It  is   curious,   if 
true,  that  for  so  many  centuries  we  have  been  misusing  our 
forces    in    walking.      Chapters    are    then    devoted    to    the 
water   supply,    rations,    and    the    clothing    and    equipment 
of  the  recruit.  Munson  is  unqualified  in  his  condemnation 
of  the  blanket-pack  now  employed  in   the  United   States. 
He  believes  that  in  all  respects  it  is  disadvantageous,  load- 
ing the  men  at  the  worst  point,  and  bringing — when  the 
canteen  and  haversack  are  in  position — so   much  weight 
across  the  front  of  the  chest  that  expansion  is  disturbed. 
Although  the  blanket  roll  was  so  satisfactory  during  the 
Civil  War,  he  is  not  inclined  to  revert  to  its  use,  but  sug- 
gests, instead,  one  of  the  more  scientific  packs,  such  as  the 
Merriam  or  the  Novior.     Some  very  ingenious  contrivances 
are   described    for   reducing   the  weight   and   bulk   of  the 
various  articles  that  must  necessarily  be  carried.     One  of 
the  most  attractive  is  the  Preston  mess-kit.    A  long  chapter 
is  devoted  to  camp  sites  and  camps,  and  another  to  posts, 
barracks,  etc.    Then  follow  chapters  upon  the  more  familiar 
subjects  of  ventilation,   heating,   the   disposal   of   excreta, 
and  personal  cleanliness.     The  discussion  of  the  diseases 
of  the  soldier  is  rather  conventional,  and  involves  the  repe- 
tition of  a  good  deal  that  can  easily  be  found  in  the  ordinary 
text-books   on   the   practice   of   medicine.      The  statistical 
tables  and  diagrams  are  exceedingly  interesting,  however, 
and  ought  to  be  extremely  valuable  to  anyone  discussing 
the  problems  of  infectious  disease.     The  mosquito  theory 
for  malaria  appears  to  be  adopted,  and  he  strongly  urges  the 
sterilization  of  stagnant  pools  in  the  neighborhood  of  bar- 
racks by  the  use  of  mineral  oil.     With  regard  to  the  can- 
teen the  author  has  no  two  opinions.     He  is  heartily  and 
enthusiastically  in  favor  of  it,  and  quotes  statistics  that  are 
seemingly  irrefutable.     What  satisfaction  the  various  so- 
called   religious  organizations  of  this  country  can   derive 
from  their  persistent  and  unintelligent  antagonism  to  this 
very  sensihl?  measure,  we  cannot  conceive.    There  Is  more 
reason  tor  antagonizing  the  ordinary  social  clubs  of  the 
larger  cities.     He  is  also  strongly  in  favor  of    the  exercise 
of  legal  control  over  other  forms  of  vice.    Venereal  diseases 
are  far  more  prevalent  in  the  British  army  than  in  any  oth- 
er.    Next  come  the  colonial  troops  of  the  Dutch,  and  then 
the  United  States.    All  the  other  countries  are  considerably 
below  these  three.     Chapters  indicating  the  gradual  exten- 


sion of  the  United  States  are  those  upon  hygiene  in  hot  and 
cold  climates,  and  aboard  the  troop  ship.  The  book  will 
necessarily  have  a  limited  circulation,  although  we  believe 
that  the  surgeons  of  many  of  our  military  organizations 
could  derive  great  benefit  from  its  careful  study.  It  is  to  a 
certain  extent,  a  pioneer  in  its  class;  it  appears  to  be  thor- 
ough, and  the  style  is  clear  and  polished.  We  sincerely 
congratulate  the  author.    [J.  S.] 


A  Syllabus  of  Nevy  Remedies  and  Therapeutic  Measures, 
with  Chemistry,  Physical  Appearance  and  Thera- 
peutic Application.  By  .J.  W.  Wainwright,  M.  D.  U. 
P.  Engelhard  &  Co.,  Chicago,  1901.  Pages,  229. 
Price,  $1.00. 

This  little  book  appears  to  have  been  prepared  con- 
scientiously, and  is  certainly  exceedingly  useful.  In  a  work 
of  this  kind  the  greatest  danger  exists  that  despite  the  ut- 
most caution,  use  will  be  made  of  it  by  the  manufacturing 
chemists  to  exploit  some  of  their  wares.  For,  as  is  well 
known,  the  profits  on  the  successful  preparations  are  so 
enormous,  that  they  justify,  in  the  minds  of  the  chemists, 
almost  any  method  that  will  bring  them  before  the  medical 
profession  in  a  favorable  light.  Dr.  Wainwright  has  en- 
deavored to  avoid  this  pitfall  as  far  as  possible,  by  includ- 
ing "only  those  products  whose  chemistry  is  known,  or 
whose  exact  formulas  are  given."  As  a  result,  some  of  the 
most  widely  advertised,  and  therefore  widely  used  prepara- 
tions, do  not  appear,  and  we  regard  this  as  a  most  desirable 
feature  of  the  book. 

In  addition  to  drugs  a  few  other  remedial  measures  are 
mentioned.  A  considerable  section  is  devoted  to  anes- 
thesia, another  to  animal  preparations,  a  third  to  cold  and 
heat,  a  fourth  to  the  hemostatic  properties  of  gelatine,  and 
others  to  hot  air,  saline  infusions,  the  Nauheim  treatment, 
the  Rontgen  rays,  and  serum  therapy.  In  addition,  new 
uses  of  familiar  remedies  are  included.  Thus,  he  men- 
tions the  hypnotic  effect  of  apomorphine:  the  use  of  car- 
bolic acid  in  tetanus,  and  the  value  of  picric  acid  in  burns. 
He  is  rather  opposed  to  the  payment  of  creosote  iu 
tuberculosis,  and  we  think,  is  unreasonably  positive  in  as- 
serting the  opinion.  A  few  defects  in  the  book  may  be 
noted.  Many  names  are  quoted,  some  of  them  familiar, 
and  some  quite  the  reverse.  In  either  case  the  statement  of 
their  views  is  necessarily  brief  in  view  of  the  considerable 
number  of  preparations  discussed,  and  therefore  it  is  not 
always  possible  to  do  justice  to  their  opinions,  or  to  include 
all  the  details  regarding  the  indication  and  administrations 
for  each  individual  preparation,  that  may  be  found  in  the 
oiginal  article:  and  yet,  in  the  great  majority  of  cases,  the 
journals  in  which  these  articles  appeared  are  not  men- 
tioned, and  when  they  are,  neither  date  nor  volume  is 
given.  This  we  regard  as  a  most  serious  blemish.  A  few 
lines  in  fine  print  appended  to  each  article,  in  which  should 
be  given  two,  three,  or  more  references  to  important  arti- 
cles on  the  subject,  especially  referring  to  those  in  which 
the  literature  has  been  given,  would  not  greatly  increase 
the  bulk  of  the  book,  and  would  enhance  its  value  very  con- 
siderably. We  hope  that  this  defect  will  be  supplied  in  the 
next  edition.  In  reading  the  various  articles  we  cannot 
help  being  impressed  by  the  very  favorable  tone  of  most  of 
the  criticisms.  This  is  due  to  a  defect  inherent  in  man- 
kind, which  consists  of  an  unwillingness  to  report  failures. 
It  the  medical  profession  could  be  persuaded  to  write 
condemnatory  reports  regarding  these  new  preparations, 
if  they  find  them  useless,  the  bad  ones  could  be  weeded  out 
much  more  rapidly  than  they  actually  are.  Our  personal 
experience  with  the  book  has  been  that  it  is  suggestive 
and  helpful.     [J.  S.] 


The  Acute  Contagious  Diseases  of  Childhood.  By  Marcus 
P.  Hatfield.  A.  M.,  M.  D.  142  Pages.  Price  $1.00. 
G.  P.  Englehard  &  Co.,  Chicago..    1901. 

It  is  very  difficult  to  understand  why  this  book  was  ever 
written.  There  does  not  appear  to  have  been  any  necessity 
for  its  existence.  As  the  author  himself  says,  it  contains 
no  original  work,  and  is  very  apparently  a  "composite," 
if  he  likes  that  word.  It  is  very  carelessly  thrown  to- 
gether, and  the  author  appears  to  have  used  only  one  or  two 
articles  in  the  preparation  of  the  account  of  each  disease, 
supplemented  by  some  text-book  on  the  practice  of  medi- 


Il82 


The    Philadelphia  ■ 
Medical  Journal    . 


REMEWS 


[JVKE  22,    liiCa 


cine.  The  author  seems  to  be  very  uncertain  how  diseases 
should  be  treated,  and  arranged  his  headings  rather  differ- 
ently in  different  instances. 

Of  the  diseases  discussed  the  greatest  amount  of  space 
is  devoted  to  scarlatina. 

The  illustrations  of  bacteria  which  accompany  this  arti- 
cle are  about  as  useless  as  any  illustrations  we  have  ever 
seen.  The  time  that  he  allows  for  the  quarantine  is,  we 
think,  rather  short,  that  is,  5  weeks  from  the  beginning  of 
the  attack.  He  admits,  however,  that  the  contagion  may 
remain  in  the  clothing  for  a  much  longer  period. 

In  the  discussion  of  measles  it  is  difficult  to  understand 
why  Koplik's  spots  are  described  in  connection  with  the 
pathology  of  the  disease — they  are  certainly  symptoms. 

He  is  rather  more  skeptical  regarding  the  etiology  of 
Czaplewski's  bacillus  in  pertussis,  than  are  most  writers  on 
the  subject.  As  he  bases  his  skepticism  upon  the  indisput- 
alle  fact  that  this  micro-organism  does  not  produce  disease 
in  the  lower  animals,  we  must  respect  his  opinion.  As  an 
example  of  the  curious  confusion  that  exists  throughout  the 
book  we  quote  the  following  sentence  in  relation  to  the 
treatment  of  smallpox.  "Threatening  septicemia  should 
be  promptly  combatted  by  the  free  use  of  quinine  and 
alcohol,  and  the  child  should  on  no  account  be  allowed 
to  escape  from  quarantine  until  the  last  traces  of  smallpox 
shall  have  disappeared  and  the  child  has  had  an  antiseptic 
bath."     [J.  S.] 


The  Peritoneum.  By  Byron  Robinson,  B.  S.,  M.  D.,  Author 
of  Practical  Intestinal  Surgery,  Landmarks  in  Gyne- 
cology, and  Life  sized  Chart  of  the  Sympathetic  Ner- 
vous System.  Pp.,  509,  with  247  illustrations.  Chi- 
cago Medical  Book  Co.,  1899.     Second  Edition. 

This  valuable  treatise  opens  with  a  chapter  entirely  his- 
torical, which  names  those  anatomists  and  students  of  Na- 
ture who  from  the  earliest  ti.mes  have  contributed  to  the 
knowledge  of  the  peritoneum  or  the  physiology  of  the  lym- 
phatic system.  A  brief  statement  of  the  work  of  each  in- 
vestigator is  given.  An  introductory  chapter  on  the  his- 
tology and  physiology  of  the  peritoneum  is  clearly  written, 
and.  like  the  remainder  of  the  work,  abundantly  illustrated 
by  drawings,  many  of  them  original.  The  writer  is  not  pre- 
pared to  accept  the  view  of  Kolossow  and  PaJadino  that  the 
peritoneum  is  lined  by  epithelium,  often  ciliated,  and  that 
the  term  endothelium,  should  be  confined  to  the  vascular 
tubes.    He  views  the  peritoneum  as  a  lymph  sac. 

The  consideration  given  to  perineal  structure  is  especial- 
ly full  and  complete.  No  less  than  240  pages  are  devoted 
to  the  subjects  of  the  endothelia  of  the  free  surface,  to  the 
subperitoneal  tissue,  and  to  the  blood  vessels,  nerves  and 
lymphatics  of  this  great  membrane. 

Under  the  heading  of  physiology  are  given  the  experi- 
mental and  other  evidence  which  leads  to  the  conclusion 
that  the  chief  locality  of  peritoneal  absorption  is  in  the 
diaphragmatic  serosa,  and  that  a  stream  appears  to  tend 
in  that  direction.  The  various  theories  which  would  ac- 
count for  this  absorption  are  considered.  The  author 
believes  in  the  existence  of  stomata.  and  gives  many  draw- 
ings which  show  them.  A  brief  chapter  on  technique,  giv- 
ing reagents,  methods  and  the  like,  is  followed  by  a  con- 
densed resumg  of  the  physiolo,gy,  as  well  as  brief  conclu- 
sions bearing  upon  the  problems  of  abdominal  surgery. 
Among  these  are:  That  irrigation  is  not  theoretically 
sound  practice,  that  the  vast  area  of  nerve  destruction  ac- 
counts for  prolonged  reflexes  and  shock,  that  the  enormous 
absorptive  power  of  the  diaphragm  makes  it  an  extremely 
dangerous  locality  for  infections. 

An  extensixe  bibliography  covers  no  less  than  103  pages, 
thus  completing  a  work  which  abounds  in  evidences  of 
great  labor  and  research,  and  which  cannot  fail  to  occupy 
the  position  of  classic  in  this  department  of  investigation. 

[G.    E.    S.] 


Manual   of  the    Diseases   of   Children.     By   ,Tohn   Madison 
Taylor,  A.  M..  M.  D.,  and  W.  Wells,  M.  D.     Second 
Edition:    Thoroughly  Revised  and  Enlarged.     Illus- 
trated.       P.    Blakiston's    Son    &    Co.,    Phila.      1901. 
$4.50. 
The  authors  have  undertaken  a  very  thorough  revision  of 
the  first  edition,  and  have  aildod  considerable  matter.  Thr 
book  as  now  published  is  quite  a  satisfactory  treatise  upon 


the  subject  of  children's  diseases.  Whether  we  needed  any 
more  treatises  upon  this  subject  is  of  course  a  question. 
bui  we  fear  that  very  little  literature  is  written  solely  for 
the  purpose  of  filling  a  distinct  need.  The  chapter  on  feed- 
ing occupies  61  pages.  It  Is  very  carefully  written,  and  is, 
in  some  respects,  thorough.  A  good  deal  of  it  is  conven- 
tional, but  of  course  that  is  necessary  in  a  book  of  this 
Ivind.  The  paragraphs  on  the  contra-indications  for 
lireast-feeding,  and  feeding  by  a  wet-nurse  are  decidedly  too 
Irief.  Both  subjects  could  be  treated  with  more  detail  to 
the  great  advantage  of  the  reader.  The  section  on  the 
chemistry  of  milk,  and  particularly  that  part  of  it  treating 
of  the  various  tests  employed  in  the  analysis  of  milk,  is 
very  unsatisfactory.  We  doubt  if  anyone  would  be  able  to 
make  an  analysis  that  was  at  all  trustworthy,  by  means  of 
the  directions  given  here.  We  are  not  at  all  sure  that  this 
subject  could  not  be  better  handled  in  a  special  work,  but  if 
introduced  at  all  it  should  at  least  be  sufficiently  clear  and 
complete  to  enable  a  physician  to  arrive  at  some  sort  of  a 
result.  On  the  other  hand,  the  section  on  the  modification 
of  milk,  particularly  home  modification,  and  that  on  the 
diet  of  children,  are  really  very  excellent,  and  betray  con- 
siderable practical  knowledge  of  the  subject.  And  this 
section  is  after  all  the  practical  one  for  the  physician. 
Of  the  other  sections  one  of  the  best  is  that  upon  the  ner- 
vous system.  The  article  on  infantile  convulsions  is  par- 
ticularly good,  and  the  treatment  suggested  is  sufficiently 
varied  to  apply  to  the  majority  of  cases.  The  others  are 
probably  beyond  our  therapeutic  resources.  The  section 
on  tetany  is  also  very  satisfactory.  That  on  epilepsy,  on  the 
other  hand,  appears  to  us  a  little  too  brief,  and  we  think 
that  a  little  more  attention  should  have  been  devoted  to  the 
general  hygienic  care  of  children  suffering  from  this  dis- 
ease. It  is  hopeless  enough  at  best,  but  there  are  probably 
more  chances  of  at  least  diminishing  its  effects  in  child- 
hood, than  at  any  other  period.  We  do  not  wish  to  be  con- 
sidered as  finding  fault  with  this  book:  the  points  that  we 
have  mentioned  appear  to  us  worthy  of  the  attention  of 
the  authors  when  they  prepare  the  third  edition.  On  the 
whole  we  can  cordially  recommend  the  volume  to  those 
whose  devotion  to  general  practice  prevents  their  making 
a  special  study  of  the  diseases  of  children  from  the  original 
sources.     [J.  S.] 


"Annual  Report  of  the  Smithsonian  Institution"  for  the 
year  ending  June  30th,  1899.  Government  Printing 
Office,  1901. 

This  is  a  very  escellent  publication,  and  is  one  to  which 
we  can  refer  with  pride,  because  it  is  published  by  our  own 
Government  for  the  purpose  of  facilitating  the  knowledge 
of  scientific  progress.  The  contents  consist  of  140  pages, 
devoted  to  reports,  expenditures,  etc..  and  an  appendix  of 
more  that  500  pages  consisting  of  a  "miscellaneous  selec- 
tion of  papers  (some  of  them  original)  embracing  a  con- 
siderable range  of  scientific  investigation  and  discussion." 
.\mong  the  most  interesting  of  these  are  the  papers  on 
Kadio-Active  Substances,  by  H.  C.  Bolton:  the  "People  of 
the  Philippines,"  by  Rudolf  Virchow,  "A  List  of  Native 
Tribes  of  the  Philippines,  and  of  the  Languages  Spoken 
by  Them."  by  Blumentritt  and  an  article  on  "Von  Zeppel- 
in's Dirigible  Air  Ship."  The  latter  is  a  reprint.  But  many 
of  the  other  papers  are  of  even  more  scientific  importance. 
We  note  with  regret  that  no  bison  were  born  in  the  Zoolog- 
ical Park  during  the  year  1899.  It  seems  as  though  this 
magnificent  animal  is  doomed  to  extinction.    [J.  S.] 


The  Practice  of  Charity,  Individual  and  Organized.  By 
Edward  Thomas  Devine.  Ph.  D.  of  Pennsylvania,  Gen- 
eral Secretary  of  the  Charity  Organization  Society  of 
the  City  of  New  York.  1901.  New  York.  LentilhOQ 
and  Company. 

In  this  little  book  the  practice  of  charity  is  discussed 
by  one  whose  liberal  education  enables  him  to  treat  the 
subject  intelligently  from  various  standpoints.  Wide  ex- 
perience, together  with  careful  discernment,  is  responsi- 
ble tor  the  clever  selection  of  material:  the  generalizations 
are  those  of  the  economist,  the  sociologist,  the  philanthrop- 
ist. If  the  practice  of  charity  needs  defence  from  the 
attacks  of  the  harsh  scientific  theorist,  read:   Charity  re.v 


June  22.   19  ]) 


CORRESPONDEX'CE 


PThe   Philadelphia 
L  Medioai.  Jourkal 


I  18^ 


sonabiy  bestowed  does  not  perpetuate  the  unfit  but  trans- 
foims  the  unfit  into  that  which  may  profitably  survive." 
This  reply  to  the  man  who  demands  for  his  every  action 
a  reason  involving  expediency.  Then  to  him  who  is  in- 
clined to  do  duty  for  duty's  sake,  but  who  allows  impulse 
to  master  reason:  "Although  it  is  not  the  duty  of  all  to  be 
scientifically  trained  in  science  or  medicine,  it  is  the  dutyof 
all  to  be  charitable,  and  no  one  is  charitable  whose  at- 
tempts at  relief  result  only  in  the  help  that  harms."  How 
can  a  given  amount  of  energy  on  the  part  of  those  charita- 
bly inclined  he  directed  most  advantageously?  By  an 
organized  corps  of  professional  relief  workers,  suggests  the 
writer.  "In  the  interest  of  the  Community  it  is  desirable 
that  organized  relief  work  should  be  recognized  as  a  dis- 
tinct profession."  After  discussing  "Organized  Charity." 
"Volunteer  Charity."  "Professional  Service,"  the  book 
concludes  with  a  chapter  containing  illustrative  Problems 
that  require  for  their  wise  solution  the  greatest  thought 
and  skill  of  clergyman,  educator,  physician.     [S.  J.  L.] 


Corrc6pon^cncc. 


A     FINAL     WORD     ON     SALINE     INFUSION     IN     PNEU- 
MONIA. 

BY   DR.  D.  E.  KEEFE, 
Springfield,  Mass. 

To  the  Editor  of  the  Philadelphia  Medical  Journal: — As 
Dr.  Penrose  in  his  reply  to  my  criticism  neglected  to  con- 
sider about  one  half  of  my  arguments,  we  must  assume  that 
they  met  with  his  approval  or  that  he  considers  them  un- 
assailable. 

I  admit  that  my  ideas  upon  saline  infusion  were  precon- 
ceived before  the  reading  of  his  interesting  paper,  just 
as  his  ideas  upon  this  subject  were  preconceived  before 
his  experiments  and  before  he  read  my  criticism. 

I  do  object  to  the  routine  employment  of  normal  saline 
infusions  for  1  consider  it  pernicious  and  unphysiological. 
I  believe  that  the  crest  of  the  wave  has  been  passed,  and 
even  in  septic  abdominal  cases  it  is  not  relied  on  nor  used 
as  much  as  formerly. 

I  assure  Dr.  Penrose  that  all  my  statements  are  based, 
not  on  theory  alone,  but  also  on  experience  and  much 
thought  and  study. 

Regarding  the  question  of  edema,  there  can  be  no  doubt 
that  in  pneumonia,  as  in  all  other  inflammatory  conditions, 
there  is  both  a  local  edema  surrounding  the  inflamed 
area,  and  a  stasis  of  the  circulation  in  the  midst  of  it. 
The  general  edema  of  the  lungs  is  sometimes  secondary  to 
heart  failure,  not  always,  as  Dr.  Penrose  says  in  the  first 
part  of  his  sentence,  and  sometimes  secondary  to  infectious 
or  toxic  processes.  We  agree  that  primary  edema,  if  such 
a  thing  can  be  said  to  exist,  is  of  very  rare  occurrence. 

Clinical  experience  has  sufficiently  shown  that  edema  of 
the  lungs  may  complicate  pneumonia  in  the  first,  second 
and  third  stages;  that.  Dr.  Penrose  to  the  contrary  notwith- 
standing, it  is  an  everpresent  danger;  and  that  therefore  Dr. 
Penrose's  proposal  to  increase  the  volume  of  the  circula- 
tory fluid  is  both  unphysiological  and  indefensible,  parti- 
cularly as  he  does  not  increase  its  carrying  power  for 
oxygen.  In  editorials  in  the  Philadelphia  Medical  Journal 
and  the  y'rir  Eiif/larid  Mcdii'nl  Maiitlilii.  attention  is  drawn  to 
the  great  danger  of  throwing  additional  work  on  the  heart 
and  thereby  causing  pulmonary  edema. 

It  is  unfortunate  for  Dr.  Penrose  that  he  has  laid  so  much 
stress  upon  Passler's  experiments;  because,  w-ithin  a  month 
of  their  appearance,  they  were  subjected  to  a  vigorous  cri- 
ticism by  Hornung  in  the  same  Journal  (April  16th.  1901.) 
He  called  particular  attention  to  the  inaccuracy  of  Passler's 
statement  in  regard  to  the  condition  of  the  right  ventricle. 
Passler's  work  therefore,  appeared  to  be  open  to  criticism 
at  least.  One  of  the  commonest  causes  of  heart  failure 
in  pneumonia  is  degeneration  of  the  myocardium.  That  it 
exists  is  a  sufficiently  well  recognized  fact  (Osier.  Stengel, 
Birch-Hirschfeld.  etc)  and  although  on  some  occasions  vas- 
omotor relaxation  or  disturbance  of  the  medullary  innova- 


tion may  contribute  to  the  production  of  heart  failure 
neither  should  be  considered  as  of  paramount  importance. 
But  even  if  they  were,  it  would  be  fully  as  dangerous  to  add 
more  burden  to  the  heart  weakened  by  disturbed  innerva- 
tion as  it  would  be  if  the  weakness  were  intrinsic  to  the 
heart  itself. 

There  is  much  doubt  as  to  whether  the  infusion  dilutes 
the  toxins  and  affects  the  septic  conditions.  It  is  very  dif- 
ficult to  understand  how  it  could  do  it.  But  the  whole  ques- 
tion of  toxin  and  antitoxin  formation  and  the  development 
of  immunity  is  at  present,  in  an  exceedingly  complicated 
state. 

In  my  first  criticism  the  sentence  regarding  this  sub- 
ject which  he  quotes,  was  printed  without  the  word  "germ."" 
It  should  be:  "in  the  lungs  where  the  germs  and  toxins  are 
mostly  situated,  where  most  of  the  damage  is  wrought, 
they  are  inaccessible."  It  is  obvious  that  the  toxins  must 
be  produced  in  the  lung,  and  that  they  must  therefore  ex- 
ist in  greater  quantities  in  the  pulmonary  circulation  than 
elsewhere,  w-hether  they  affect  this  tissue  more  serious- 
ly than  tissues  in  other  parts  of  the  body  or  not.  and  that 
therefore,  any  attempt  at  their  destruction,  would  be  most 
effective  if  it  reached  them  at  this  point.  As  however,  the 
circulation  in  this  portion  of  the  lung  is  sluggish,  indeed 
practically  nil,  the  diluting  effect  of  the  infusion  could  act 
least  at  this  point. 

Regarding  Dr.  Penrose's  claim  that  the  infusions  stimu- 
late respiration  and  increase  the  oxygen  carrying  power  of 
the  plasma,  I  can  only  state  that  the  stimulation  of  respira- 
tion is  of  verj'  short  duration,  indeed  almost  evanescent, 
and  might  be  claimed  as  rather  a  sign  of  asphyxiation  than 
true  stimulation.  It  is  also  obvious  that  the  free  oxygeir 
that  exists  in  the  plasma  is  merely  in  transit  between  the 
red  cells  and  the  tissues  that  are  to  absorb  it.  and  does  not 
represent  any  increased  absorptive  capacity  in  the  blood. 

As  to  the  value  of  the  accentuation  of  the  second  ptilmon- 
ary  sound,  as  an  indication  for  bleeding.  I  have  to  say 
that  if  we  accept  bleeding  as  one  of  our  regular  therapeu- 
tic measures  in  pneumonia,  then  I  acknowledge  it  is  of 
value,  but  I  am  not  aware  that  the  profession  is  yet  ready 
to  retrace  its  steps.  According  to  Osier,  and  my  experience 
accords  with  his  statements,  this  sound  is  always  accent- 
uated, and  therefore  the  saline  infusion  should  be  contra- 
indicated. 

In  conclusion  I  wish  to  express  my  opinion  that  the 
most  serious  danger  in  pneumonia  is  from  distension  of 
the  right  heart  and  heart  failure,  and  that  this  occurs  not 
infrequently  may  be  gathered  from  the  statements  of  Sten- 
gel. Roberts.  Osier,  Powell,  Hornung  and  many  others,  f 
did  not  oppose  Dr.  Penrose  in  his  efforts  to  cause  elimina- 
tion of  the  toxins,  but  because,  first,  he  could  not  ac- 
complish his  desire  by  the  means  proposed;  second,  be- 
cause the  dangers  of  overdistending  the  heart  and  dilut- 
ing the  hemoglobin  are  more  serious  than  that  he  sought 
to  avert;  and  third,  other  means  to  which  I  drew  attentioit 
were  quite  as  effective  and  much  less  dangerous. 

Finally,  in  spite  of  the  distinguished  company  before 
whom  Dr.  Penrose's  paper  was  first  read,  and  in  spite  of  the 
leader  in  the  llrilisli  Mrdlrnl  Journal,  inquiry  leads  us  to 
believe  that  his  methods  have  not  received  that  degree  of 
approval  and  imitation  that  would  indicate  that  t\xy  appeal 
to  the  profession  at  large  as  rational  or  effective. 


A  Case  of  Suppurative  Gastritis  followed  by  Recovery, — 
Ruber  (Orroxi  /.'ililnp.  IPOl.  No.  41  reports  an  interesting 
case  of  a  young  girl  of  24  years  who  was  seized  without 
apparent  cause  with  chills,  headache,  vertigo  and  gastric 
pains.  There  was  marked  tenderness  in  the  region  of 
the  left  lobe  of  the  liver.  The  temperature  was  below 
S.s-'  C  On  the  21st  day  she  x omited  24(iC  cc.  of  sanguineus 
material  containing  fetid  pus.  Soon  after  this  the  pains 
disappeared  and  the  appetite  returned.  Every  morning 
for  two  weeks  she  vomited  100  to  200  cc.  of  similar  mater- 
ial. At  the  6th  week  another  attack  of  vomiting  began, 
which  arrain  lasted  two  weeks,  and  pus  was  found  in  the 
stools.     Cure  was  complete.     [T.  L.  C.I 


ii84 


The    Phii.adei.phia  "I 
Medical   Journal    J 


AxMERICAN  NEWS  AND  NOTES 


[June  22,   1301 


Hmerican  IRews  anD  Hlotcs. 


PHILADELPHIA,    PENNSYLVANIA,    ETC. 

St.  Joseph's  Hospital  Residents. — The  following  are  th(^ 
successful  applicants  for  interneships  at  St.  Joseph's  Hos- 
pital: Drs.  Foulkrod,  Riegel,  Homer  Rhode,  Mervin  R. 
Taylor   and    Lamott. 

Scarlet  Fever  In  Darby. — .4n  epidemic  of  scarlet  fever  is 
existing  in  Darby.  About  40  cases  have  been  reported  and 
many  more  are  under  suspicion.  Several  have  died  of  the 
disease  and  it  may  be  necessary  to  close  the  schools  in 
advance  of  the  regular  vacation  period. 

The  1876  Class  of  the  Department  of  Medicine  of  the  Uni- 
versity of  Pennsylvania  held  its  First  .\nnual  Banquet  at 
the  University  Club,  Philadelphia,  at  seven  P.  M.,  on  Alum- 
ni Day.  the  11th  of  June,  and  effected  a  permanent  organ- 
ization for  the  benefit  of  its  Alma  Mater.  The  following 
officers  were  elected:  President,  Charles  A.  Oliver,  A.  M., 
M.  D. ;  vice-president.  William  H.  Klapp,  A.  M.,  M.  D.,  seo- 
letary,  Francis  M.  Perkins,  A.  M.,  M.  D.:  treasurer,  Ben- 
jamin F.  Baer,  M.  D.,  with  an  Executive  Committee  of 
twelve  members  who  will  meet  at  the  call  of  the  Presi- 
dent. 

Pathological  Society  of  Philadelphia. — At  the  meetinii 
held  June  13,  Dr.  William  FJ.  Roliertson  showed  a  specimen 
of  venous  thrombosis  in  cardiac  disease.  The  right  in- 
nominate, axillary,  braehiiil,  and  external  jugular  veins 
contained  thrombi.  The  unusufil  noints  in  the  case  were 
that  the  cardiac  lesion  was  aortic  instead  of  mitral  and  that 
the  thrombosis  was  on  the  right  side  instead  of  the  left. 

Drs.  W.  E.  Robertson  and  Ellis  E.  W.  Given  report<-d  a 
case  of  sarcoma  of  the  small  intestine  in  a  child  of  5 
years.  Operaiion  showed  the  impossibility  of  removal. 
Autopsy  revealed  a  tumor  ]5  cm.  in  diameter.  Involving  the 
jejunum.  The  growth  was  adherent  to  the  rectum,  3is- 
moid,  and  bladder  but  no  metasta,sis  was  present. 

Dr.  David  Riesnian  detailed  a  case  of  multiple  abscess  of 
the  liver.  The  case  was  remarkable  for  the  absence  of 
symptoms  found  at  autopsy  and  also  revealed  by  the  ex- 
ploring  needle  shortly  before  death.  There  had  been 
no  dysentery,  there  was  no  leukocytosis  or  jaundice,  and 
the  liver  was  not  enlarged  or  tender. 

Dr.  R.  M.  Pearce  exhibited  four  specimens  of  unusual  in- 
terest, i)  Cancer  of  the  esophagus  with  perforation  into 
the  trachea;  (2)  Tuberculosis  of  the  larynx  with  perfora- 
tion ir.to  the  esophagus;  ('■')  Cancer  of  esophagus  and  tu- 
berculosis of  the  larynx;   (1)  A  dilated  esophagus. 

To  Inspect  Institutions. — A  party,  consisting  of  Dr.  John 
V.  Shoemaker,  President  of  the  Department  of  Charities 
and  Correction;  Dr.  James  N  Tyson  and  Dr.  Simon  Fle:< 
ner.  University  of  Pennsylvania:  Dr.  Hobart  A.  Hare  and 
Dr.  Orville  Horwitz.  Jefferson  Medical  College;  Dr.  James 
Anders  and  Professor  William  Ashton,  MedicoChirurgical 
College;  Dr.  Ellwood  R.  Kirby  and  William  J.  McLaughlin, 
members  of  the  Department  of  Charities  and  Correction; 
Peter  E.  Costello,  Chairman  of  Finance  Committee,  City 
Councils;  Horn  R.  Kneass,  Chairman  of  Committee  on  De- 
partment of  Charities  and  Correction,  and  William  M. 
Geary,  Superintendent  linreau  of  Charities,  left  for  Boston, 
for  the  purpose  of  investigating  the  manner  of  conducting, 
locations  and  other  matters  connected  with  the  charitable 
institutions  owned  and  operated  by  the  cities  of  Boston  and 
New  York,  also  the  State  institutions  in  those  two  cities 
to  learn  any  facts  that  may  inure  to  the  benefit  of  the 
citizens  of  Philadelphia  in  the  reorganization  of  the  Bu- 
reau of  Charities,  namely  the  removal  of  the  Philadelphia 
Almshouse  and  the  Insane  ,\sylum  from  the  grounds  lo- 
cated at  Thirty-fourth  and  Pino  streets. 

Vital  Statistics  of  Philadelphia  for  the  week  endini] 
June  15,  1901: 

Total    Mortality    SSO 

Cases.        Deaths. 
Inflammation    of    tlie    appendix    3. 

bladder    1.    brain    11,    bronchi    S, 

heart  2.  kidneys  21,  liver  2,  lungs 

18,    peritoneum    •>,    stomach    and 

bov,-els  12.  spine  1   85 

Marasmus  9,  debility  5.  inanition  15  29 

Tuberculosis  of  the  lungs  . . . . ; 50 

Apoplexy  12,  paralysis  9   21 


Heart-disease  of  2C,  fatty  degenera- 
tion of  1 

Uremia  7,  Bright's  disease  11,  dia- 
betes 1   

Carcinoma   of   the   bladder   1,   breast 
1,    stomach    5,    uterus    1,    liver    4, 
neck  2,  pelvis  1,  rectum  2,  tongue  1 

Convulsions  6,  convulsions,  puer- 
peral 1   

Diphtheria 

Brain-abscess  of  1,  congestion  of  3, 
dropsy  1,  softening  of  6 

Typhoid  fever  

Old  age   

Scarlet  fever   

.\bscesE  of  throat  1,  alcoholism  3, 
asthma  1,  anemia  2,  burns  and 
scalds  3,  casualties  8,  cerebro- 
spinal meningitis  1,  congestion  of 
the  lungs  3,  cholera  infantum  10, 
cirrhosis  of  the  liver  2,  croup, 
membranous  2,  cyanosis  3, diarrhea 
1,  disease  of  the  liver  1,  dysentery 
1,  erysipelas  1,  fever,  malarial  1, 
fistula  1,  gangrene,  senile  1:  hem- 
orrhage from  stomach  1,  hemor- 
rhage from  uterus  1  hernia  2.  lo- 
comotor ataxia  1.  measles  1,  ob- 
struction of  the  bowels  2,  purpura 
hemorrhagica  1, sarcoma  of  the  kid- 
neys 1,  sclerosis,  arterial  2,  septi- 
cemia 3,  smallpox  1,  sore  mouth  1, 
suicide  4,  syphilis  1,  teething  1, 
tumor,  bladder  1,  unknown  coroner 
case  l.whooping  cough  10, wounds, 
throat  1  


Cases. 


Deaths. 

27 
19 


47 


94 


86 


18 


11 
7 
6 
5 


82 


NEW    YORK. 

Epidemic  of  Measles  Among  Eskimos. — An  epidemic  of 
measles  exists  among  the  Eskimos  at  the  Pan-American 
Exposition.  A  number  of  deaths  have  already  occurred 
from   this   disease. 

Sing  Sing  Prison  Condemned. — The  famous  State  prison 
at  Sing-Sing,  New  York,  has  been  condemned  by  the  Board 
of  Health  of  that  State  as  unsanitary,  and  its  removal  to  a 
higher  situation  is  recommended.  The  prison  is  situated 
near  the  edge  of  the  Hudson  river,  and  it  was  found  that 
at  high  tiue  the  floor  of  the  prison  is  only  four  feet  abovo 
the  water  level.  As  a  result  of  this  condition  the  sewage 
in  the  drain-pipes  is  backed  up  into  the  prison,  and  owing  to 
imperfect  discharge,  it  decomposes. 

NEW     ENGLAND. 

The  Massachusetts  State  Medical  Society  celebrated  its 
120th  anniversary  June  12.  Dr.  ?"rank  W.  Draper,  president 
of  the  society,  presided.  Among  the  prominent  men  and 
delegates  present  were:  President  Eliot,  of  Harvard. 
President  Capen,  of  Tufts;  Samuel  J.  Elder.  Dr.  W.  W. 
Eaton,  Dr.  David  W.  Cheever.  Dr.  J.  M.  Storer.  Delegates — 
Maine.  C.  D.  Smith.  Portland:  C.  J.  Marston,  Bath.  New 
Hampshire,  P.  W.  Parsons.  Portsmouth:  F.  A.  Stillings. 
Concord;  A.  G.  Straw.  Manchester.  Vermont.  A.  S.  M 
Chisholm,  Bennington:  E.  G.  Roberts.  Fair  Haven.  Rhode 
Island,  G.  L.  Collins,  Providence:  C.  V.  Chapin.  Providence. 
New  York.  Parker  Syms.  New  York  City:  I.  S.  Haynes. 
New  York  City.  New  Jersey.  S.  A.  Hefler.  Hoboken:  J.  A. 
Exton.  Arlington.  Pennsylvania.  J.  J.  Koser,  Shippens 
burg:  G.  O.  Harman,  Huntingdon. 

Smallpox  in  Maine. — .\nother  suspected  case  of  smallpox 
has  developed  in  Bangor  in  the  same  house  from  which 
four  suspects  have  already  been  taken  to  the  pest-house. 
One  of  the  men  in  quarantine  at  the  Queen  City  Hotel 
escaped,  and  has  not  yet  been  recaptured. 

Rhode  Island  Medical  Society. — The  annual  meeting  of 
the  Rhode  Island  Medical  Society  was  held  June  6  in  Provi- 
dence, R.  1.  The  annual  address. was  made  by  Dr.  G.  Alder 
Blumer,  of  Boston.  This  was  followed  hy  the  annual  ban- 
quet. The  Massachusetts  Society  was  represented  bv 
Dr.  T.  W.  Spencer,  of  Hingham.  and  Connecticut  by  Drs. 
C.  A.  -Allen  and  D.  W.  Richardson.  The  principal  officers 
i-locted  were:  President.  George  F.  Keene;  vice-presidents. 
William  R.  White  and  Christopher  H.  Banker. 


June  22,  1901] 


AMERICAN  NEWS  AND  NOTES 


EThe    Philadelphia        ,  .Qf 
Medical  Journal         1  ICJij 


WESTERN    STATES. 

Chicago  Pathological  Society,  May  13th,  1901.  Dr.  L. 
Hektoon.  president.  Dr.  I.  B.  Dismond  presented  a  paper 
on  "The  Cellular  Changes  in  Tuberculous  Meningitis.' 
Plasma,  lymphoid  and  phagocytic  cells  form  the  greater 
portion  of  the  cell-infiltrations  in  the  vascular  and  extra- 
vascular  areas  of  the  leptomeninx  in  acute  tuberculous 
meningitis.  The  plasma  and  lymphoid  cells  migrate  largely 
from  the  lymph  spaces  of  the  arterial  adventitia  and  from 
the  finer  capillaries.  They  proliferate  largely  by  indirect  di- 
vision, a  certain  number,  however,  are  derived  from  lym- 
phoid cells.  There  are  two  kinds  of  phagocytes  (1)  those 
which  proliferate  from  the  endothelical  lining  of  the  capil- 
laries and  lymph  spaces,  and  (2J  those  from  the  subendo- 
thelial  intimal  connective  tissue. 

The  most  important  of  the  vascular  changes — the  tuber- 
culous endarteritis— develops  in  the  following  manner: 
Plasma  and  lymphoid  cells  accumulate  underneath  the  en- 
dothelium of  the  intima;  later  the  subendothelial  intimal 
connective  tissue  cells  are  found  mixed  with  the  former. 
They  proliferate  next  to  the  elastic  coat,  are  to  a  certain 
degree  phagocytic  and  resemble  epithelial  cells.  They  also 
run  together  and  form  giant  cells,  and  in  this  manner 
characteristic  intimal  tubercles  develop.  Changes  of  the 
endothelial  lining  of  the  arteries  occur  later,  especially 
when  there  is  caseation  or  hyaline  degeneration  of  the  col- 
lection  underneath. 

Of  interest  is  the  great  production  of  plasma  cells  which 
is  analogous  to  the  cell  changes  described  by  Councilman 
in  acute  interstitial  nephritis,  while  on  the  other  hand, 
the  production  of  phagocytic  cells  is  analogous  to  the  cell 
changes  described  by  Mallory  as  occurring  in  typhoid 
fever. 

Dr.  Llewellyn  F.  Barker  presented  gross  and  microscopic 
specimens  of  the  buboes  and  internal  organs  removed  from 
Chinese,  dead  of  plague,  in  San  Francisco.  The  demonstra-' 
tion  was  accompanied  by  a  brief  description  of  the  path- 
ology and  pathogenesis  of  bubonic  plague.  In  the  bubonic 
form  of  the  disease  the  lesions  in  the  lymph  glands  and 
surrounding  tissues — edema,  hemorrhage  and  necrosis — are 
very  characteristic.  The  changes  in  the  spleen  are  more 
marked  in  the  septicemic  form  than  in  the  bubonic  form. 
The  specimen  of  spleen  under  the  microscope  showed  ex- 
tensive necrosis  of  the  splenic  framework  and  pulp,  with 
wandering  in  of  polymorphonuclear  leukocytes. 

Primary  plague  pneumonia  is  distinguished  from  aspira- 
tion pneumonia  and  from  embolic  pneumonia  occurring  as 
complications  of  plague.  The  enormous  number  of  bacilli 
present,  the  abundance  of  blood  in  the  exudate,  and  the 
small  part  played  by  fibrin  are  interesting  features. 

The  question  of  portal  of  entry  was  discussed  in  connec- 
tion with  the  various  clinical  types,  and  an  effort  was  made 
to  explain  the  fact  that  local  lesions  In  the  skin  and  mucous 
membranes  and  lymphangitis  are  rarely  present,  the  first 
outspoken  lesions  occurring  in  the  nearest  packet  of  lymph 
glands. 

Dr.  Leo  Loeb  demonstrated  microscopic  sections  showing 
the  difference  between  the  atresia  of  follicles  in  different 
stages  of  maturity;  also  microscopic  sections  of  two  ovaries 
of  a  guinea  pig  in  which  all  follicles  presented  the  picture 
of  hypertrophy  of  the  epithelium  and  in  which  the  atresia 
without  exception  started  by  the  ingrowth  of  connective 
tissue  and  capillaries  into  the  follicular  epithelium.  Two 
slides  were  demonstrated  showing  follicles  in  the  process 
of  atresia,  each  one  of  which  contained  two  ova.  In  one 
of  these  two  follicles  both  eggs  showed  progressive 
changes,  in  the  other  follicle  one  ovum  was  unchanged  and 
well  preserved,  the  other  ovum  was  segmented.  In  a  third 
atretic  follicle,  of  which  a  slide  was  shown,  in  which  three 
ova  were  present;  two  of  these  were  unchanged,  the  third 
ovum  had  undergone  certain  changes,  the  exact  nature  of 
which  could  not  with  certainty  be  determined.  Another 
specimen  showed  a  structure  resemliling  very  much  a  small 
corpus  luteum.  in  the  center  of  which,  however,  two  suc- 
cessive sections  demonstrated  the  presence  of  an  ovum. 
At  present  it  must  be  left  undecided,  if  in  this  case  the 
ovum  of  a  ruptured  follicle  was  retained  and  a  corpus 
luteum  had  formed  around  it,  or  if  under  certain  condi- 
tions a  follicle  which  had  not  ruptured  previously  might 
in  the  stage  of  .itresia  give  rise  through  hypertrophy  to  a 
structure  similar  to  a  small  corpus  luteum. 

Dr.  Maxmilian  Herzog  presented  a  gastrolith  composed 
of  persimmon  seeds  which  had  caused  perforation  of  the 


stomach  and  death  in  a  three-year-old  boy  in  the  practice 
of  Dr.  Cargile,  of  Bentonville,  Ark. 

Epidemic  of  Diphtheria. — There  is  quite  an  epidemic  of 
diphtheria  at  Svensen,  Ore.  Several  children  have  died 
of  the  disease,  and  a  number  more  are  seriously  ill  with  it. 

The  Mortality  Statistics  of  St.  Louis. — The  .S7.  Louis 
Mciliiiii  J{rricir.  commenting  upon  the  St.  Louis  mortality 
statistics.  Quotes  the  following:  The  greatest  mortality 
in  any  period  after  the  first  decade  was  over  70.  with  1140 
deaths;  the  next  greatest  was  from  35  to  40,  with  563 
deaths.  There  were  only  8  deaths  from  puerperal  fever, 
which  is  a  favorable  showing  for  the  obstetricians;  25 
deaths  are  ascribed  to  surgical  operations.  Heat  stroke 
caused  the  death  of  25.    There  were  130  suicides. 

The  Plague  Resolutions  of  the  California  State  Medical 
Society. — Through  the  kindness  of  Dr.  Emmett  Rixford, 
who  proposed  the  resolutions  which  were  passed  by  the 
Medical  Society  of  the  State  of  California  at  its  last  meet- 
ing, we  are  enabled  to  publish  a  correct  copy,  which  reads 
as  follows: 

"Whereas,  It  has  been  shown  by  our  local  bacteriolo- 
gists, and  by  the  Commission  sent  by  the  United  States 
Government,  that  the  bubonic  plague  has  existed  in  San 
Francisco,  and  probably  does  at  the  present  time;  there- 
fore, be  it 

"Resolved,  That  the  Medical  Society  of  the  State  of 
California  express  its  confidence  that  the  San  Francisco 
Board  of  Health,  the  State  Board  of  Health,  and  the 
United  States  Commission  will  be  able  to  watch  the  dis- 
ease, and  to  take  proper  measures  for  its  suppression." 

This  correction  renders  the  position  of  the  State  society 
much  more  satisfactory,  and  justly  gives  our  local  bacteri- 
ologists due  credit  for  their  very  efficient  and  thorough 
work.  In  this  note  Doctor  Rixford  very  appropriately 
says:  "I  wish  the  official  report  of  this  affair  to  contain 
reference  to  the  fact  that  our  local  bacteriologists  demon- 
strated the  presence  of  the  plague." — Ocriileiital  Medical 
Timrs: 

SOUTHERN  STATES. 
Christian  Scientists  Cannot  Practice  in  Georgia. — Judge 
Lumpkin,  of  the  Georgia  Superior  Court,  has  denied  the 
application  for  a  charter  for  "The  Atlanta  Institute  of 
Christian  Science,"  the  effect  of  his  decision  being  that 
Christian  Scientists  cannot  practice  their  treatment  of 
diseases  in  the  State  of  Georgia  without  having  regularly 
graduated  in  medicine  and  passed  an  examination  before 
the  medical  Examining  Board,  the  same  as  other  physi- 
cians. 

Delav\/are  State  Hospital  for  the  Insane. — At  the  meeting 
of  the  trustees  of  the  Delaware  State  Hospital  for  the 
Insane,  at  Farnhurst,  June  7,  Dr.  John  J.  Black  was  re- 
elected President  and  Dr.  Paris  T.  Carlisle  Secretary. 

Dr.  R.  J.  Preston,  Superintendent  of  the  Southwestern 
Hospital  for  the  Insane,  of  Marion,  Vt.,  has  been  elected 
president  of  the  American  Psychological  Society. 

Charlotte  Williams  Hospital. — Work  on  the  Charlotte 
Williams  Hospital  will  begin  this  week.  It  is  to  cost  $150.- 
000,  and  will  be  one  of  the  largest  and  best  equipped  insti- 
tutions of  the  kind  in  the  South. 

The  Trained  Nurses'  Association  of  Virginia  expect  to 
form  an  organization  in  the  near  future. 


MISCELLANY. 
Cats  and  Valerian. — It  is  a  m.atter  of  popular  knowledge 
that  cats  evince  curious  emotional  disturbances  when 
presented  with  the  valerian  plant,  so  great  is  their  fond- 
ness for  this  form  of  inebriety;  for  it  appears  to  induce  in 
them  a  species  of  intoxication,  that  the  plants  in  the  gar- 
den undergo  premature  decay  if  ther?  are  any  cats  about. 
Nor  is  this  influence  confined  to  cats,  for  rat-catchers,  it  is 
stated,  employ  the  roots  to  attract  rats  for  purposes  of 
slaughter.  In  a  novel  which  was  recently  reviewed  by 
our  contemporary.  Tlir  S^atiiidaii  h'nicir.  we  note  a  curious 
episode  which  turns  on  the  incident  of  acat  having  been 
attracted  to  a  corner  of  a  room  where  some  tincture  of 
v;.1eri;m  had  been  spilled.  Unfortunately  for  the 
probability  of  the  author's  ingenious  fancy,  the 
Galenical      preparation     of     valerians     do     not     possess 


ii86 


The     PHII.4DELPHIA  ■ 

Medical  Journal 


AMERICAN  NEWS  AND  NOTES 


tJcNE  22.    1301 


the  property  of  attracting  cats,  and  tbe  animal,  if 
offered  a  sniff  of  the  tincture  in  a  glass,  turns  from  it  with 
silent  contempt,  when,  indeed,  its  attitude  is  not  suggest- 
ive of  disgust.  The  author  may  be  pardoned  his  ignor- 
ance of  this  peculiarity,  which  is  doubtless  shared  by  many 
persons  who  pride  themselves  on  their  knowledge  of  ma- 
teria medica,  but  the  curious  inertness  of  pharmaceutical 
preparations  of  the  plant  in  this  direction  inspire  a  diffi- 
dence as  to  their  therapeutical  efficacy  when  administered 
to  human  beings.  The  action  of  valerian  in  man  is  not 
one  which  admits  of  ready  estimation,  and  we  would  com- 
mend this  doubt  to  the  attention  of  the  editors  of  the 
British  Pharmacopeia  who  may  think  it  worth  while  in- 
serting a  proviso  among  the  tests  to  the  effect  that  no 
preparation  of  valerian  which  fails  to  excite  the  cat  is  to 
be  regarded  as  orthodox. — Med.  Prenf  and  Circular. 

Obituary. — Dr.  L.  S.  Tesson,  at  Vancouver.  Wash.,  on 
June  7,  aged  59  years. — Dr.  C.  B.  Brooke,  at  Baltimore,  Md., 
on  June  11. — Dr.  Charles  Scott  Seebold.  at  Baltimore,  Md.. 
on  June  12.  aged  51  years. — Dr.  Arthur  J.  Dresser,  at 
Tewksbury.  Mass.  on  June  12.  aged  28  years. — Dr.  Freder- 
ick L.  Nutt,  at  Marengo.  111.,  on  May  23,  aged  49  years. — 
Dr.  Conrad  Wienges.  at  Jersey  City,  on  May  23,  aged  53 
years. 

Plague  in  Turkey. — In  Bagdad,  on  May  6th.  a  30-year-old 
Kurdish  woman,  the  wife  of  a  dealer  in  old  clothes,  died  of 
a  disease  which  showed  all  the  symptoms  of  plague.  All 
persons  who  had  been  in  contact  with  the  woman  were 
placed  under  strict  medical  observation.  By  the  orders 
of  the  supreme  sanitary  council  in  Constantinople,  2  tem- 
porary hospitals  have  been  erected  in  Bagdad  for  the  ac 
commodation  of  those  accompanying  the  passing  caravans, 
and  in  which  the  travelers  have  to  submit  to  five  days' 
quarantine.  The  effects  of  the  travelers  are  there  sub- 
jected to  a  chemical  disinfection  and  then  daily  exposed  to 
the  rays  of  the  sun.  Ships  which  have  to  leave  Bagdad  for 
the  South  have  to  undergo  five  days'  quarantine  in  Gavarah. 
Cavalry  patrols  are  to  keep  watch  over  the  country  between 
Bagdad  and  the  hospitals,  in  order  to  turn  back  any  fugi- 
tives. Official  doctors  and  military  physicians  are  to  be 
sent  into  the  neighboring  villages  of  Bagdad  in  order  to 
supervise  the  sanitary  condition  of  the  population.  Tbe 
duty  of  reporting  every  fresh  case  of  plague  will  be  strictly 
enforced. 

Plague  in  Egypt. — On  May  5  the  corpse  of  a  6-yearl-old 
girl,  who  had  apparently  died  of  the  plague,  was  brought  to 
the  Government  hospital  at  Alexandria  from  the  part  of 
the  city  known  as  Torabgieh.  Tbe  bacteriological  examina- 
tion confirmed  the  suspicion  that  the  plague  was  the  cause 
of  death,  and  the  necessary  precautions  were  taken  accord- 
ingly. 

Outgoing  vessels  have  been  ordered  to  enter  on  the 
ship's  papers  corresponding  remarks,  and  must  undergo 
medical  inspection  and   disinfection. 

Plague  in  British  East  India. — During  the  week  ended 
April  19.  there  occurred  in  the  Presidency  of  Bombay  164fi 
fresh  cases  and  1360  deaths  of  plague — that  is  to  say.  301 
cases  and  272  deaths  less  than  during  the  foregoing  week 
In  Karachi,  however,  a  decline  of  tbe  disease  is  not  to  be 
noted.  From  this  port  during  the  last  week  there  were  236 
fresh  cases  and  210  deaths  reported.  In  the  city  of  Bom- 
bay, during  the  week  ended  April  20.  there  were  reported 
704  fresh  cases  (67  less  than  during  the  previous  week), 
and  563  deaths  proved  to  be  due  to  plague.  In  addition,  of 
the  total.  1514  deaths  in  the  city.  428  were  designated  as 
suspected   plague. 

Changes  in  the  Medical  Corps  of  the  Navy,  week  ended 
June  15th. 


MAYERS,    appointed   assistant 
MURPHT,    ordered    to    Xaval 


ASSISTANT    SURGEON    C.    M. 

su-greon   from   June  1 — June 
ASSISTANT    Sl'RGEON    J.    F. 

Aca^emv.   June  15 — June  S. 
SURGEON    A.    R.    AVENTWORTH.    detached    from    the    Solace 

and    ordered    to   the   Alhanv— June  9. 
Sl'RGEON    H.    N.    T.    HARRIS,    detached    from     the     Albany 

and   ordered   to  the  Monocacv — June  9. 
P.   A.   SURGEON   S.   G.   EVANS,   detached   from  the   Monocacv 

and    ordered    to    the    Solace — June    9. 
ASSISTANT   SURGEON   J.   W.   BACKUS,   ordered  to  the  Ver- 
mont.  June  17 — Jt'ne  11. 
ASSISTANT    SURGEON    P.    A.     ASSERSON.    ordered    to    the 

Naval   Hospital.   New  York.  June  17— June  11. 
ASSISTANT  SURGEON   G.   M.   MAYERS,   ordered  to   the  Pen- 

sacola   Navy   Yard.   Ji:ne   IJ— Jure  11. 


Official  list  of  the  changes  of  Station  and  Duties  of  Com- 
misioned  and  Non-Commissioned  Officers  of  the  U.  S.  Mar- 
ine Hospital  Service  for  the  14  days  ended  June  13,  1901. 

J.    H.    WHITE,    surgeon,    to   report   at   Washington,    D.    C,    for 

conference— June    7,    1901. 
L.    L.    \VII.,LIAiIS,    surgeon,    granted    leave    of    absence    for   3 

days  from  June  6 — June  6,  1901. 

Granted  2  days  extension  of  leave  of  absence — June  8.  1901. 
A\'.   J.   PETTUS,   surgeon,   granted  leave  of  absence  for  3  days 

from    June    13.    1901— June    U,    1901. 
J.   A.   NYDEGGER.   pa.<=sed   assitant  surgeon,   granted   leave   of 
absence  for  30  days  from  June  8,  1901— June  S.  1901. 

E.  K.  SPRAGUE.  passed  assitant  surgeon,  granted  leave  of 
absence   for  30  days   from   May   30 — May  31.   19'31. 

H.  W.  WIClvES,  passed  assistant  surgeon,  granted  leave  of 
absence   for  4   days    from   June   3 — May   31,    1901. 

C.  E.  DECKER,  assistant  surgeon,  granted  leave  of  absence 
for   10   days,    on    account   of   sickness — .lune   6.   1901. 

AV.  W.  KING,  assitant  surgeon,  granted  leave  of  absence  for 
4  days— June  11.   1901. 

J.  E.  BREADY,  acting  assitant  surgeon,  granted  leave  of  ab- 
sence   for  1   day.    June   19— June   11.    19*1. 

HE.VRY  ECROYD,  acting  assitant  surgeon,  granted  leave  of 
absence   for  10  days  from  June  S— June  6.   1901. 

\V.  C.  MASON,  acting  assistant  surgeon,  granted  leave  of  ab- 
sence for  6  days   from  June  23— June  10.   1901. 

F.  R.  SMYTH,  acting  assistant  surgeon,  leave  of  absence  for 
3  days  granted  Acting  Assistant  Surgeon  Sm\-th  by  Bureau 
telegram    of    May    31.    1901.    revoked— June    10.    1901. 

J.  G.  ST.^NTON.  acting  a.^sistant  surgeon,  granted  leave  of 
absence    for   15   days    from   June  3 — June   6.   1901. 

BOARD   CONVENED. 

Board  convened  to  meet  at  Washington.  D.  C  on  June  7. 
19fn.  for  the  physical  examination  of  an  applicant  for  cadet- 
ship  in  the  U.  S.  Revenue  Cutter  Ser^-jce.  Detail  for  the  Board 
—Passed  Assistant  Surgeon  H.  D.  Geddings,  Chairman;  Assist- 
ant  Surgeon   B.    S.    Warren,    Recorder. 

Health  Reports:  The  following  cases  of  smallpox,  yel- 
low fever,  cholera  and  plague  have  been  reported  to  the 
Surgeon  General.  U.  S.  Marine  Hospital  Service,  during  the 
week  ended  June  15,  1901. 

SMALLPOX.— United    States    and    Insular. 


-\I_ASK.\:  Douglas  Citv Mav  35 5 

t.WLlFORNIA:               San    Francisco.    .    ..  MaylS-Junel  ..4 
DISTRICT    OF 

COLUMBI.\:  ^Vashington May  30 1 

ILLINOIS:  Chicago June  1-9. 6 

1ND1.\.NA:  Michigan   City June  3-10 2 

South   Bend Junel-S 1 

K.\NS.*S:  Wichita June  1-8 7       1 

LOUISIANA:  >•''«■  Orleans. June  1-9 5       1 

Shreveporl May  S-June  1  .  2 

M.\1NE:  Portland Junel-S 1 

M.A.RYLAND:  Baltimore Junel-S 1 

.M.\SS.\CHUSETTS:    Boston June  1-8 1 

Fall   River Junel-S 1 

Marlboro Junel-S 1 

New  Be<iford Junel-S 2S       1 

Somerville June  1-8 1 

MICH1G.\.\":                   Detroit Junel-S.   .   .    ..33 

West  Bav  City  Junel-S 1 

.MINXESOT.A.;  Winona June  1-8 1 

St.   Louis May  2S-June  2  .32 

NEW   H.A.MPSH1RE    Manchester June  l-$u 4 

NEW   YORK:  New   York. Junel-S.    35      IS 

OHIO:                                 Cincinnati May  31-June  7  .  5 

Cleveland Junel-S. 30 

Toledo Junel-S 1 

PENNSYLV.\NIA:      Lebanon June  1-8 1 

Philadelphia June  1-8. 1 

Pittsburg Junel-S. S 

RHODE    ISL-VND:      Providence Junel-S.     1       1 

IT.AJ4:                                Ogiien May  1-31.  .  .   ..U 

Salt   Lake  City Junel-S. 4 

\V.\SHlN3TON:           Tacoma May  3S-June  2    .1 

WISCONSIN:  Green   Bav June  2-9 2 

PHILIPPINES:  Manila.   ." Apr.  13-20 9 

PORTO     RICO:              San  Juan May  10.       extinct,     I 

cases  on   island. 
SMALLPOX.— Foreign. 

.AUSTRL\:  Prague May  18-S 3 

BELGIUM:  Antwerp May  18-25 3       1 

BK.\Z1L;  Pernambuco -Apr.  1-15 ?7 

I'HIN.X;  Hongkong \pr.  22-27 7       5 

CdLOMBLA;                    Panama May  27-June  3.   .5       1 

KR.XNCE:                         Paris .May  lS-25.   .                 L=i 

GRE.\T    BRIT.-VIN;     Glasgow May  i^Sl.    .     .  42       1 

GREECE;  .Aih»-ns May  lS-25 2 

INDLA.:  tta Mav  4-11 34 

■  hi .\pr.  2S-Mav  12    9       1 

IT.\LT:                               ^     :    'S May  19-26.   .    .  1«1      2? 

J.\P.-VX:                           Nagasaki M.iy  fi.      1  on     U.  S. 

S.   Indiana. 

Tokvo May  11 S 

M.\NlTOB.\:                   Winnipeg M.-iv  2S-June  1      2 

MEXICO:                          Mexico  City Mav  19-June  2.     .        " 

RUSSL4.;  Ode.<!,<5a May  11-26. 9       1 

St.    Petersburg.    .    ..   May  4-iS 24       " 

\\"ai-saw May  4-11 S 


June  22,  1901] 


SOCIETY  REPORTS 


TThe   Philadelphia 
L  Medical  Journal 


1187 


MEXICO: 


INDIA; 


AFRICA: 

CHINA: 

INDIA: 


JAPAN: 


YELLOW  FEVER. 

Vera  Cruz May  lS-2o. 

CHOLERA. 

Bombay May  7-14. 

Calcutta May  4-11. 

PLAGUE.-Foreign  and    Insular. 


3 

47 


PHIILIPPINES: 


Cape  Town To  Apr.  u.  .   ..412    181 

Hongkong    Apr.  20-27 65      55 

Bombav .May  7-14 2S9 

Calcutta May  4-11 V-'A 

Karachi Apr.28-May  12.657    5ii3 

Formosa May    19.     increasing 

From    May    3-June 
1 2157 


Manila. 


Apr.  i:!-20. 


27      16 


GREAT    BRITAIN,    ETC. 

Plague  in  Hong  Kong. — The  colonial  office  has  received 
a  dispatch  from  Sir  Henry  Blake,  Governor  of  Hong  Kong, 
announcing  that  215  cases  of  bubonic  plague  were  reported 
for  the  week  ended  June  1.  and  that  the  total  number  of 
deaths  thus  far  from  the  disease  is  207. 

CONTINENTAL     EUROPE. 

A  Festschrift  to  Professor  Bottini. — A  Festschrift  on 
surgery  will  be  presented  to  Professor  Bottini  with  a  gold 
medal  and  a  framed  parchment  list  of  all  subscribers  in 
honor  of  ihe  twenty-fifth  anniversary  of  his  appointment  to 
the  chair  of  surgery  at  Pavia. 

A  New  Method  of  Counting  the  White  Corpuscles  has 
been  devised  by  Kourloff  ^^  nitch).  It  is  a  dry  method,  and 
consists  in  drawing  the  blood  into  a  graduated  pipette,  de- 
positing a  thin  film  on  two  cover-glasses,  whose  surface  is 
measured  by  a  network  of  lines.  The  white  cells  are  then 
counted  and  the  area  measured  by  means  of  the  movable 
stage  and  Ehrlich's  diaphragm.  This  method  allows  the 
•operator  to  work  without  haste  and  the  results  can  be  veri- 
fied at  any  time.  The  writer  asserts  that  he  can  count 
from  1000  to  2000  more  white  cells  than  by  the  Thoma- 
Zeiss  cell,  the  dilutent  in  that  method  changing  and  destroy- 
ing some  white  cells. — Aiiieiicun  ildiilhly  Microscopiral  Jour- 
nal. 

A  Novel  Diversion  for  the  Insane. — In  one  of  the  city 
hospitals  for  the  insane  in  St.  Petersburg  a  stage  was 
erected  on  which  light  vaudevilles  are  produced.  The 
actors,  as  well  as  the  audience,  are  the  patients  them- 
selves, the  former  proving  in  every  respect  equal  to  the 
task,  while  the  latter  seem  to  derive  real  enjoyment  from 
the   affair. 

Drunkenness  in  St.  Petersburg. — Within  the  last  year 
8330  persons  were  arrested  on  the  streets  for  drunken- 
ness. 

Convicted  for  Rape. — A  former  professor  of  the  Warsaw- 
University  was  sentenced  to  2^4  years  in  the  workhouse 
followed  by  4  years  of  police  supervision  and  deprivation 
of  all  rights  and  privileges  for  having  committed  rape. 

The  Detection  of  Human  Blood. — A  method  for  detecting 
human  blood  has  been  suggested  by  M.  S.  Cotton  in  the 
BvU.  Hiif.  Cliiniiinir  ile  I'liris.  It  depends  upon  the  tact 
that  blood  will  liberate  oxygen  from  hydrogen  peroxide. 
Using  1  c.c.  of  blood  with  2.50  c,c.  of  hy.  per.,  he  obtained 
for  man,  580  to  (',10  c.c:  for  horse  and  pig,  from  320  to  350 
cc;  for  ox,  165  tn  170:  for  guinea  pig,  115  to  125,  and  for 
sheep,  from  60  to  65  c.c.  This  large  excess  in  man  over 
all  the  lower  species  would  seem  to  be  of  diagnostic  value. 


Pyloric  Obstruction. — In  demonstrating  a  specimen  of  a 
pylorus  excised  for  obstruction.  Dr.  E.  Lambotte  (Preste 
ilediralc  liclgv,  1901,  No.  IS)  called  attention  to  the  efficacy 
of  sodium  bicarbonate  in  gastric  affections,  and  to  the  extreme 
frequency  with  which  they  are  of  pyloric  origin.  He  be- 
lieves that  comparatively  few  cases  of  stomach  trouble  are 
of  nervous  origin.  The  specimen  shown  was  a  hypertrophic 
pylorus,  removed  by  Dr.  M.  Bernard  from  a  woman  of  37, 
in  whom  symptoms  of  gastric  disturbance  had  existed  for 
three  years.  Gastro-duodenorrhaphy  with  pylorectoniy  was 
performed,   and   she   went   home   two   weeks   later,   cured. 

[M,  0.1 


Society  IRcports. 


FIFTY-SECOND  MEETING  OF  THE  AMERICAN  MEDI- 
CAL  ASSOCIATION. 


rConclusion.] 


SECTION     ON     MATERIA     MEDICA,     PHARMACY     AND 
THERAPEUTICS. 

N.    S.    Davis,    Jr.,    Chicago,    Chairman;     Frank    Woodbury, 
Philadelphia,  Secretary. 

MEETINGS    HELD     IN     SENATE    CHAMBER,    STATE 
CAPITOU   ST.   PAUL. 

(('uiiiiiiiinUdtidnx.) 

FIRST  DAY,  JUNE  4th. 

"Experimental  Work  in  Intra-organic  and  Venous  Injec- 
tions and  Blood  Extracts  in  the  Cure  of  Acute.  Organic 
Diseases,"  by  W.  Byron  Coakley,  of  Chicago.  The  princi- 
pal Object  of  this  paper  was  to  show  the  great  therapeutic 
value  of  sodium  chloride,  and  especially  of  subcutaneous 
and  parenchymatous  injections  of  normal  salt  solution, 
with  instruments  specially  devised  for  the  purpose.  He 
claimed  that  the  injections  were  inocuous,  and  that  he  had 
not  produced  hematoma  even  in  solid  organs,  such  as  the 
liver,  the  kidney,  or  spleen.  An  instrument  used  for  the 
purpose  of  making  the  injections  at  the  proper  tempera- 
tare  and  at  a  slow  rate  of  speed  was  exhibited  and  its 
construction  explained.  It  consisted  of  an  apparatus  on 
the  principle  of  an  aspirator,  having  a  double  chamber, 
the  external  one  being  filled  with  water  at  a  temperature 
of  120°  F.  during  the  time  of  injection.  The  flow  of  the 
solution  was  regulated  by  the  slow  revolution  of  a  milled 
wheel  by  hand,  on  the  principle  of  the  microtome.  He  also 
presented  two  cannulas,  each  having  a  lateral  opening, 
the  inner  one  having  a  closed  extremity.  These  were 
introduced  into  the  selected  vein,  of  a  dog,  for  instance, 
in  opposite  directions  and  at  different  places,  so  that  their 
points  could  meet  and  pass  each  other,  the  closed  point 
slipping  into  the  open  one.  Being  fastened  in  this  posi- 
tion, it  was  only  necessary  to  give  the  inner  tube  a  quarter 
revolution  in  order  to  permit  the  blood  to  flow  through 
the  tube,  or  a  normal  salt  (seven-tenths  per  cent.)  solu- 
tion, injected,  as  might  be  desired.  Results  in  the  form  of 
increased  action  of  the  heart  and  strength  of  the  pulse, 
relief  from  shock  and  increase  of  vitality  were  reported. 
It  appeared  to  have  a  special  antidotal  effect  to  carbon 
dioxide  and  in  preventing  and  overcoming  asphyxia.  It 
takes  the  place  of  transfusion  of  blood,  especially  after 
loss  of  blood  by  hemorrhage.  The  lecturer  reported  an  ex- 
periment in  which  repeated  bleedings  were  made  until  a 
dog's  heart  action  was  so  weak  as  to  be  almost  extin- 
guished. After  the  injection  of  salt  solution  directly  into 
the  pericardium,  the  heart  beat  with  greatly  increased 
force:  and.  after  intravenous  injection  of  salt  solution,  the 
animal  in  a  few  hours  w'as  restored  to  a  normal  condition. 
In  this  discussion  the  lecturer  stated  that  he  had  only 
resorted  to  parenchymatous  injection  in  the  human  lung 
in  one  case  of  acute  lobar  pneumonia.  It  was  done  during 
the  stage  of  hepatization.  He  had  used  a  very  fine  needle 
with  which  to  inject  the  salt  solution  into  the  interior  of 
the  consolidated  lung.  The  next  day,  mucous  rales  could 
ne  heard  over  this  area,  and  the  patient  went  on  to  speedy 
recovery.  He  believed  that  the  injection  shortened  the 
course  of  the  disease,  and  that  this  treatment  deserved 
further   trial. 

Neglected,  but  Valuable,  Therapeutic  Measures,"  was 
the  title  of  a  paper  read  by  Geo.  F.  Butler,  of  .A.lma,  Mich- 
igan. After  reviewing  a  number  of  methods  and  remedies, 
wliich  were  popular  before  the  scientific  era  in 
medicine,,  many  of  which  were  deservedly  aban- 
doned, 0.  (/..  skatological  remedies,  animal  products, 
etc..  he  directed  attention  to  some  measures  which 
should  not  be  neglected  by  the  profession.  Promi- 
nent among  these  is  hlood-letting  in  a  class  of  oases 
in  which  its  powerful  physiological  properties  would  be 
desired.  .Vmong  these  he  cited  cases  of  toxemia,  in  which 
the  depleted  blood  could  be  substituted  by  normal  salt 
solution.  Counter  irr'tation  is  a  neglected,  but  a  valuable 
therapeutic  resource,  in  illustration  of  which  he  directed 


I    T  fiR  "^^^     PHILJkDEUHIA  -| 

*  lOO       Medical  Journai.    J 


SOCIETY  REPORTS 


[June   22,   1901 


attention  to  the  remarkable  change  for  the  better  in  the 
condition  of  some  cases  of  insanity  after  accidental  frac- 
ture of  a  bone.  Bathing,  used  in  typhoid  fever 
with  great  advantage,  is  also  very  valuable  in  yel- 
low fever.  The  combination  of  drugs  in  a  single 
prescription  has  fallen  into  undeserved  disrepute  as  poly- 
pharmacy, but  he  claimed  that  very  often  a  combination 
of  remedies  so  modified  their  action  that  a  new  and  super- 
ior theraupeutic  agent  was  obtained,  for  instance,  th'! 
combination  of  iron  with  the  simple  bitters  in  the  treat- 
ment of  chlorosis,  especially  for  overcoming  anemia  in 
children.  The  infusion  of  quassia  combined  with  aromatic 
sulphuric  acid  and  tincture  of  iron,  he  is  accustomed  to 
give  with  great  advantage  for  this  condition.  The  sexual 
erethism  seen  in  the  condition  of  auto-tosism,  is  relieved 
by  (1)  removal  of  toxic  agents  by  purgatives  and  (2)  by 
heart  toxics.  A  valuable  but  neglected  agent  for  the 
latter  purpose  is  copper  sulphate  and  copper  arseniate. 
given  in  small  doses.  Massage  is  also  a  measure  not  suffi- 
ciently apreciated.  He  especially  recommended  a  com- 
bination of  massage,  hydropathy  and  out-door  exercises  as 
having  great  restorative  value.  Suggestive  therapeutics  is 
worthy  of  more  study  as  a  potent  agent  for  good  and  of 
great  value  when  used  in  conjunction  with  other  measures 
just  referred  to. 

The  Therapeutic  Indications  Presented  by  the  Blood  in 
Disease,"  was  the  subject  of  the  nest  paper,  by  Dr.  O.  T. 
Osborne,  of  New  Haven,  Conn.  A  word  of  caution  was 
expressed  against  the  ultra-scientific  attitude  on  the  part 
of  physicians,  who  often  overlook  the  individual  element 
or  personal  factor  in  the  case.  We  should  never  forget  the 
man  who  has  the  disease  and  his  individual  condition  and 
needs.  Departures  from  health  do  not  always  conform  to 
clinical  types,  thus,  it  is  not  necessary  to  have  all  the  char- 
acters of  Grave's  disease  present  in  early  thyroid  disease; 
in  every  case  of  deficient  thyroid  secretion,  some  disturb- 
ance of  health  will  doubtless  be  produced  of  marked 
character.  For  instance,  he  believes  that  many  cases  of 
neurasthenia  have  their  true  explanation  in  this  deficient 
function  of  the  thyroid  and  such  cases  are  greatly  benefit- 
ed by  the  administration  of  the  thyroid  extract.  In  a  sim- 
ilar way,  other  patients  may  have  a  disturbance  of  the 
adrenal  function,  without  typical  symptoms  of  Addison's 
disease,  but  with  other  clinical  manifestations,  which 
improve  under  the  same  kind  of  treatment.  In  obscure 
conditions  of  disease  good  results  generally  follow  at- 
tempts to  correct  or  aid  the  normal  metabolism  of  the 
body.  Very  important  in  this  connection  is  the  condition 
of  the  blood.  The  increase  of  diminution  of  red  corpus- 
cles and  of  hemoglobin,  of  the  leukocytes,  or  lympho- 
cytes, may  be  accompanied  by  evidences  of  disturbance 
of  function.  Alterations  of  the  density  of  the  blood-plasma 
in  its  relations  to  osmosis  are  significant,  also  of  the  total 
quantity  and  the  distribution  of  blood  in  the  body.  Vaso- 
motor ataxia  plays  a  very  important  part  in  many  func- 
tional disorders,  notably  in  neurotics  and  neurasthenics, 
and  also  in  hysteria.  In  great  sudden  diminution  of  red 
blood  cells  from  hemorrhage,  or  in  malignant  infections, 
the  patients  die,  suddenly,  with  symptoms  of  acute  anemia, 
a  condition  which  the  author  termed  "medical  shock."  To 
prevent  this,  he  advised  the  administration  of  iron  in  acute 
infections,  especially  in  typhoid  fever,  the  tincture  of  the 
chloride  being  especially  applicable,  as  it  is  in  erysipelas, 
and  in  diphtheria. 

"On  Chronic  Myocarditis," by  Dr.  John  H.  Musser,of  Phila- 
delphia. In  this  com>nunication.  the  lecturer  differentiated 
between  the  forms  of  chronic  myocarditis,  so  commonly  oc- 
curring in  infectious  diseases,  and  the  primary  form  to 
which  he  especially  directed  his  remarks.  The  condition 
is  accompanied  by  sclerosis  or  endarteritis  of  the  coronary 
arteries  and  might  be  called  coronary  artery  disease.  la 
these  cases,  especial  attention  must  be  paid  to  the  hygien- 
ic management.  The  medicinal  treatment  depends  very 
much  upon  the  general  conditions  present  and  also  upon 
associated  lesions  which  have  taken  place  in  the  heart 
and  other  organs.  The  habits  of  life  should  be  carefully 
studied  and  regulated  according  to  the  case,  and  business 
either  abandoned  entirely  or  its  responsibilities  and  ac- 
tivity much  reduced,  according  to  the  ability  of  the  heart 
to  perform  its  work.  Careful  study  of  the  digestive  ca- 
pacity and  the  character  of  the  food  must  be  made.  Of- 
ten there  is  inability  to  digest  sufficient  food.  The  recu- 
perative power  of  the  individual,  as  indicated  by  his  abil- 


ity to  continue  his  work,  without  feeling  fatigue,  and  his 
response  to  bathing  also  must  be  considered.  Hot  bath.s, 
vapor  or  steam  baths  are  useful  where  the  gouty  or  rheu- 
matic diathesis  is  present,  but  ordinarily,  a  warm  sponge 
bath  at  night  with  moderate  friction  will  be  all  that  is 
necessary  in  the  line  of  hydrotherapy,  though  should  the 
patient  be  accustomed  to  the  shock  of  a  morning  cold 
bath  and  it  agrees  with  him.  it  may  be  continued.  As  the 
rule,  no  changes  are  made  in  the  habits  of  life  of  the 
patient  unless  they  are  considered  to  be  injurious.  The 
medical  treatment  depends  upon  the  amount  of  endarter- 
itis and  the  condition  of  the  heart  walls  present  in  the 
case,  and  whether  high  or  low  arterial  tension  exists.  If 
low,  then  digitalis,  sparteine,  strychnine  and  other  cardiac 
stimulants  are  called  for:  if  high,  arterial  tension  is  pres- 
ent, remedies  are  given  which  decrease  blood  pressure, 
such  as  nitroglycerin,  the  strontium  salts.and  similar  agents 
of  this  class.  Purgatives  also  reduce  blood  pressure,  and 
salines  are  advised:  magnesium  sulphate  is  very  useful, 
taken  each  morning  in  a  glassful  of  water.  The  treatment 
of  angina  pectoris  during  the  paroxysm  is  so  well  known 
that  he  would  not  speak  of  it,  but  he  approved  of  the 
prophylactic  treatment  between  the  paroxysms  by  nitro- 
glycerin and  iodide  of  potassium  especially,  and  the  avoid- 
ance of  digitalis  and  all  its  preparations  which  increase 
blood  pressure.  The  nitroglycerin  should  be  given  in  in- 
creasing doses,  until  the  physiological  effects  are  produced. 
He  had  patients  who  had  gradually  increased  the  dose  un- 
til they  took  half  a  drachm  of  the  centisimal  solution,  two 
or  three  times  a  day,  with  the  greatest  benefit.  The  great 
object  of  the  treatment  should  be  to  reduce  or  prevent 
cardiac  hypertrophy.  These  patients  must  be  placed  upon 
a  lowered  scale  of  life,  because  they  cannot  live  on  the 
ordinary  scale  of  other  human  beings,  with  ordinary  blood 
tension  without  having  attacks  of  angina  pectoris.  The 
dyspnea  of  myocarditis  is  of  two  kinds  (1)  that  due  to 
dilatation  of  the  heart,  (2)  that  caused  by  asystole.  The 
former  is  almost  continuous  but  is  increased  by  exertion. 
In  the  latter  case  the  attack  is  sudden  in  its  onset  and  is 
accompanied  by  frothy  expectoration,  pain,  and  the  usual 
s>Tnptoms  of  edema  of  the  lungs,  with  arhythmia  and  asys- 
tole. In  such  cases  small  doses  of  morphin  hypodermicallr, 
with  strychnia,  and,  if  there  is  high  arterial  tension,  nitro- 
glycerin will  give  relief.  If  there  is  venous  stasis  with 
lowered  tension,  the  use  of  stimulants,  with  digitalis,  is 
recommended.  Attention  must  be  directed  not  merely  to 
the  cardiac  condition,  but  also  to  the  cardio-vascular  con- 
dition, and,  in  fact,  to  that  of  all  the  organs  in  the  body,  in 
the  management  of  chronic  myocarditis. 

Discussion. — Dr.  Henry  Beates.  of  Philadelphia,  agreed 
with  the  lecturer  on  all  but  one  point.  He  contended  that 
the  condition  of  increased  arterial  tension  never  exists 
in  cases  of  chronic  myocarditis  and  therefore  that  nitro- 
glycerin and  all  cardiac  depressants  were  injurious.  The 
agent  that  had  produced  the  best  results  in  his  own  ex- 
perience with  a  large  number  of  these  cases,  was  a  pre- 
paration of  digitalis,  known  as  digitalin-Germanic  i  Merck) 
which  did  not  cause  gastric  disturbance  as  did  all  other 
preparations  of  digitalis.  He  had  found  the  administratioa 
of  this  remedy  sufficient  to  control  the  condition  and  cause 
great  improvement  in  the  general  condition,  with  assistance 
of  hygienic  management  laid  down  by  the  lecturer. 

Dr.  S.  E.  Solly  referred  to  the  effects  of  high  altitudes 
upon  this  disease.  As  the  rule  such  cases  should  not  bo 
sent  to  high  altitudes,  but  a  large  number  of  them  do 
risit  Colorado  Springs,  and  he  had  been  surprised  to  find 
how  well  they  kept  as  long  as  they  were  careful  to  avoid 
unnecessary  exertion  and  live  a  quiet  life  He  believed 
that,  all  things  considered,  the  best  climate  for  them  would 
be  one  of  moderate  altitude,  where  the  air  is  less  dry  than 
at  a  high  elevation,  or  is  moderately  moist. 

Dr.  Osborne  said  that  the  new  remedy  mentioned  by 
the  first  speakers  had  not  been  sufficiently  studied  to 
determine  its  physiological  action:  for  instance,  it  was 
not  yet  settled  whether  it  is  a  vaso-motor  dilator  or  con- 
strictor. 

Dr.  Beates  said  that  it  was  a  constrictor.  Dr.  Osborne 
said  that  some  of  these  cases  call  for  a  vaso-constrictor 
and  others  a  dilator,  but  almost  always  morphine.  He 
mentioned  adrenaline  as  a  useful  vaso-motor  constrictor. 
Xitro-glycerin  is  of  great  value  in  cases  needing  a  dil-^tor. 
He  suggested  that  cases  after  45  years  of  age.  might  show 
vascular  phenomena,  as  a  result  of  atrophy  or  diminished 
secretion  of  the  thyroid  gland. 

Dr.  Musser.  in  reply  to  a  question,  stated  that  he  gavg 


June  22.  1901] 


SOCIETY  REPORTS 


tThe    Philadelphia        i  i  fir, 
L Medical  Jocknal  '  ^'-^ 


iodide  of  potassium  in  a  glass  of  milk  or  in  a  preparation 
of  pepsin.  Some  patients  can  take  only  one  dose  a  day. 
He  hiad  never  been  able  to  get  satisfactory  results  from 
hydriodic  acid  and  much  preferred  the  potassium  salt. 

"Tile  Treatment  of  Obesity,"  by  Heinrich  Sterin,  of  New 
York,  directed  attention  to  the  different  forms  and  com- 
plications of  this  condition.  He  divided  polysarcia  into 
three  types  on  the  basis  of  the  specific  gravity  of  the  in- 
.  dividual.  (1)  Hyperplasmic  obesity,  or  lipomatous  hyper- 
'  plasma,  those  with  relatively  high  degree  of  cor- 
poreal specific  gravity;  (2)  Metabolic,  or  common,  obe- 
sity; those  with  normal  or  slightly  diminished  specific 
gravity;  and  (3)  hydroplasmic  obesity  or  lipomatous  hydro- 
plasma,  those  with  lessened  density  of  the  body.  The 
first  form  is  accompanied  by  high  arterial  tension  and 
often  is  associated  with  latent,  or  actual,  arterio  sclerosis. 
The  second  form  is  encountered  the  most  frequently,  and 
is  a  symptom  of  bodily  degeneration.  Obesity  of  itself  is 
not  a  disease,  but  is  a  link  in  a  chain  of  symptoms  path- 
ognomonic of  certain  nutritional  disorders,  and  is  due  fre- 
quently to  excess  of  nourishment  with  diminished  exer- 
cise. The  objection  to  the  dietaries  usually  given  is  that, 
by  their  rule  the  patient  is  underfed.  Muscular  exercise 
is  essential  to  the  treatment,  including  massage  and  all 
forms  of  outdoor  sports.  All  measures  favoring  oxidation, 
such  as  calisthenics,  hydrotherapy,  and  balneotherapy  are 
useful.  Anti-fat  remedies,  as  a  class,  are  to  be  condemned, 
because  they  are  useless  in  small  doses  and  poisonous  in 
large  ones,  causing  in  addition  to  deprivation  of  fat.  a 
melting  down  of  body  albumin.  Some  mineral  waters, 
thyroid  extract,  and  fucus  vesiculosis  are  exceptions,  and 
are  valuable  adiuvants.  W'ith  thyroid  extract  (gr.ii)  he 
combines  arsenious  acid  (gr.1-60)  and  adonidin  (gr.1-12), 
and  thus  avoids  the  distressing  symptoms  produced  by 
thyroid  alone.  Special  diet  lists  were  given  from  which 
each  case  could  have  its  own  selection,  but  laying  spec- 
ial stress  upon  the  necessity  for  exercise  and  attention  to 
the  secretions  and  the  circulation.  In  the  third  form, 
liydroplasmic  obesity,  reduction  of  the  amount  of  liquids 
in  the  food  is  advised,  and  also  remedies  directed  towards 
increasing  the  tonicity  of  the  heart.  In  this  condition, 
thyroid  is  generally  contra-indicated,  but  the  patient  will 
be  benefitted  by  strychnine  and  iron.  During  the  treat- 
ment, examinations  into  the  blood  density  should  be  made 
at  regular  intervals  to  determine  the  results  from  reme- 
dies and  the  progress  of  the  case. 

"The  Treatment  of  Neurasthenia,"  by  H.  N.  Moger,  of 
Chicago.  The  author  insisted  first  upon  the  necessity  of  cor- 
rect diagnosis.  Hysteria. hypochondria. and  other  conditions 
resembling  neurasthenia,  may  be  separated  from  it  by  at- 
tention to  history.  The  characteristic  phenomenon  of  the 
latter  is  the  "fatigue  symptom,"  or  an  excessive  amount 
of  fatigue  following  ordinary  exertion.  Attention  was  di- 
rected towards  the  importance  of  distinguishing  primary 
or  so-called  essential,  neurasthenia  from  the  secondary 
nervous  weakness,  which  results  from  organic  disease  or 
defective  nutrition.  The  latter  form  is  common  in  all  the 
acute  febrile  diseases  and  whenever  nutrition  is  impaired. 
The  diagnosis  of  the  primary  form  must  always  be  made 
by  exclusion.  In  the  therapeutic  management  especial 
value  is  derived  from  rest.  diet,  cold  bathing  and  strych- 
nine, which  is  the  sheet  anchor  in  the  drug  treatment.  Ex- 
posure of  the  patient  to  the  fresh  air  for  several  hours  a 
day,  even  in  the  middle  of  winter,  was  followed  by  remark- 
able benefit  and  increased  appetite  and  powers  of  assim- 
ilation. 

In  reply  to  questions  from  Drs.  Shelly,  of  Kansas;  Solly, 
of  Colorado  Springs;  Stern,  of  New  York,  and  Putney,  of 
West  Virginia,  the  lecturer  explained  that  all  cases  of 
neurasthenia  are  not  pure  cases  and  that  hysteria  may 
be  complicated  with  neurasthenia,  so  that  the  diagnosis 
of  neurasthenia  does  not  always  exclude  hysteria.  It  is  im- 
portant to  recognize  the  neurasthenia,  which  is  due  to 
obesity  or  kidney  disease,  as  a  secondary  affection,  and 
not  mistake  it  for  the  primary  form.  He  had  no  special 
diet  for  these  cases  except  that  he  insisted  upon  the  pa- 
tients taking  large  quantities  of  milk  and  cream.  The 
patient  is  instructed  to  keep  a  detailed  report  in  writing 
each  day  of  his  food  and  his  symptoms,  which  is  filed  away 
for  future  comparison,  if  the  patient  should  become  dis- 
couraged and  think  he  is  not  making  any  progress.  He  is 
encouraged  to  talk  freely  with  his  physician  about  his 
symptoms,  but  is  prohibited  from  discussing  them  with 
visitors  or  the  members  of  his  family. 


SECOND  DAY,  JUNE  5. 
"Report  on  Medicines  used  by  One  Hundred  St.  Louis 
Physicians,"  by  H,  M.  Wheepley,  of  St.  Louis.  Mo.,  was 
read  by  title  by  the  Secretary.  "A  Plea  for  More  Uni- 
formity and  Strength  in  our  Armamentarium,"  by  C.  F. 
Wahrer,  of  Fort  Madison,  was  an  interesting  and  earnest 
plea  for  loyalty  to  the  Pharmacopoeia  and  scientific  pre- 
scription writing.  He  condemned  in  caustic  language  the 
practice  of  using  ready-made  proprietary  compounds,  the 
composition  of  which  is  only  partly  revealed.  "The  Stan- 
dardization of  Crude  Drugs  and  Galenical  Preparations, 
was  the  subject  of  a  commvmication  by  A.  B.  Lyons,  of 
Detroit,  a  member  of  the  Committee  on  Revision.  He 
pointed  out  the  fact  that  vegetable  drugs  vary  greatly  in 
medicinal  activity.  Scientific  medication  therefore  re- 
quires that  their  preparations  be  brought  to  some  uniform 
standard  of  strength.  The  present  assay  methods  are 
confessedly  imperfect  and  unsatisfactory,  with  few  excep- 
tions. An  imperfect  method,  however,  which  is  approxi- 
matelv  correct,  is  better  than  none.  The  Pharmacopoeia 
of  IS&O  furnished  standards  and  assay  processes  for  opium, 
cinchona  bark,  and  nux  vomica  and  their  preparations. 
In  the  revision  of  1900  this  list  will  be  greatly  extended 
and  the  assav  processes  rendered  more  precise.  Standard- 
ization by  physiological  lists  has  not  been  adopted  by  the 
Committee,  but  in  his  opinion,  might  with  advantage  be- 
approved  to  a  limited  extent.  To  the  physician,  the  ques- 
tion is  of  vital  importance.  He  should  know  what  the 
standards  to  be  established  require,  and  should  insist  that 
thev  give  him  preparations  identical  therapeutically,  with 
those  he  had  been  accustomed  to.  when  the  latter  were 
skilfully  made  from  an  average  sample  of  good  drug. 
Among  the  important  questions  now  before  the  Commit- 
tee are  the  admission  of  the  newer  derivations  of  opium. 
In  the  case  of  nux  vomica,  an  improvement  will  be  made 
by  the  introduction  of  a  method  of  determining  the  pro- 
portion cf  strychnine,  instead  of  the  total  alkaloids  which; 
vary  in  their  quantity  and  in  their  proportion  to  each- 
other. 

C.  S.  N.  Hallberg  said  that  the  principle  of  standardiza- 
tion could  be  applied  to  only  a  limited  extent  at  present 
and  was  not  applicable  to  many  drugs,  like  aconite  and 
ergot,  in  the  present  state  of  our  knowledge  concerning 
their  active  principles.  F.  J.  ■fulling  said  that  if  the 
Pharmacopoeia  prescribed  tests  for  use  by  the  pharma- 
cist that  the  better  class  of  druggists  would  undoubtedly 
applv  them  and  that  the  others  would  do  so  if  they  found 
that"  phvsicians  were  interested  in  the  subject  and  re- 
quired them.  He  considered  the  subject  of  paramount 
Importance  to  therapeutists  as  well  as  to  scientific  phar- 
macv.  Dr.  E.  M.  Wilson  deplored  the  lack  of  knowledge 
of  pharmacy  and  of  the  Pharmacopoeio  by  physicians  gen- 
erally and  their  apparent  indifference  to  the  quality  of  the 
drugs  and  preparations  with  which  their  prescriptions  are 
filled.  The  same  prescription  might  be  filled  at  six  differ- 
ent dr'ic  stores  and  each  preparation  would  be  different 
from  the  other.  Dr.  Dickerson,  of  St.  I.ouis.  said  that  the 
studv  of  materia  medica  and  pharmacy  in  our  medical 
schools  is  too  much  neglected  in  favor  of  clinical  and 
laboratorv  work.  He  suggested  that,  instead  of  being 
dropped  at  the  end  of  the  first  year,  these  studies  should 
be  made  obligatory  during  the  whole  four  years  of  the 
medical  course. 

The  Chairman  pointed  out  the  fact  that  the  Pharma- 
copoeia appears  to  be  especially  constructed  to  be  a  work 
of  reference  for  the  druggist  and  is  not  made  as  useful  to 
the  physician  as  it  might  be.  In  his  opinion  all  the  new 
remedies  should  be  introduced  into  the  Pharmacopoeia, 
whether  thev  have  been  fully  tested  or  not.  so  that  the 
physician  might  find  in  it  all  the  most  recent  information 
about  drugs.  It  should  not  be  a  volume  of  standards,  but  of 
reference.  Possiblv  the  newest  drugs  might  be  placed  in 
an  appendix.  The  older  preparations  should  be  retained, 
although  onlv  employed  by  a  few  physicians.  As  regards 
teaching  materia  medica.  he  felt  assured  that  both  phar- 
macy and  pharmacology  are  given  a  proper  amount  of  at- 
tention in  our  leading  medical  schools.  Students  are  made 
acquainted  with  crude  drugs  and  are  taught  to  make  the 
preparations:  this  is  further  supplemented  by  laboratory 
studies  into  the  phvsiological  action  of  drugs.  The  recent 
graduates  are  much  better  informed  upon  these  topics  than 
those  of  earlier  years 

The  Chairman  introduced  the  Delegates  from  the  Amer- 
ican Pharmaceutical  Association,  of  whom  Mr.  C.  .T.  Wal- 


1 1  go 


The    Philadelphia' 
Medical   Journal 


SOCIETY  REPORTS 


[June  22,   IMl 


ling,  of  Detroit,  was  the  Chairman.  Dr.  A.  B.  Lyons,  of 
Detroit,  and  C.  N.  D.  Hallber.?  were  among  the  delegates  in 
attendance.  Upon  motion,  they  were  invited  to  take  part 
in  the  proceedings  as  members  of  the  Section. 

SECOND  DAY,  AFTERNOON  SESSION. 
Dr.  S.  E.  Solly  addressed  the  Section  on  the  subject  of 
the  Question  of  the  Theapeutic  Value  of  Residence  in  High 
Altitudes  for  Pulmonary  Tuberculosis  and  the  Indications 
for  this  Treatment."  The  attention  given  recently  to  the 
subject  of  home  treatment  does  not  detract  from  the  value 
o£  altitude  treatment.  There  are  many  persons  who  can- 
not leave  their  homes  and  the  present  methods  of  home 
and  sanitarium  treatment  are  much  better  than  any  which 
have  gone  before  them.  Nothing  that  could  be  said  in 
favor  of  altitude  treatment  should  be  construed  as  oppos- 
ing the  home  management  of  many  cases  of  pulmonary 
disease.  Altitude  possesses  certain  physiological  proper- 
ties owing  to  its  peculiar  conditions.  Among  these  are  di- 
minished barometeric  pressure.  A  physiological  effect  of 
this  is  increase  of  the  number  of  red  blood  cells  and  like- 
wise of  hemoglobin,  thus  overcoming  anemia  and  Improv- 
ing nutrition.  The  immediate  effect  of  altitude  is  to  in- 
crease the  rate  of  the  pulse  and  the  blood-tension,  but  in 
normal  individuals  the  pulse  soon  returns  to  the  normal 
and  the  change  of  arterial  tension  is  only  temporary.  There 
is  increased  rapidity  of  the  respiratory  wave,  especially 
after  exertion.  Both  pulse  and  respiration  are  influenced 
to  a  greater  degree  by  active  exertion  at  altitudes  than  at 
•ijea-level.  The  lungs  become  more  active  and  inspiration 
is  fuller,  increasing  the  chest  capacity  of  the  individual  who 
resides  in  altitudes,  such  as  in  the  city  of  Mexico.  (Henriot 
and  Lopez).  We  do  not  know  whether  the  improvement 
is  due  to  diminution  of  oxygen  supply  or  to  increase  of  res- 
piratory effort,  probably  the  latter,  at  least  in  great  part. 
Then  the  dryness  of  the  air  at  high  levels,  produces  more 
rapid  evaporation  from  the  lungs  and  the  skin,  and  re- 
duces expectoration.  The  influences  of  the  increased 
amount  of  sunlight  has  been  studied  a  great  deal,  and 
it  is  very  marked  in  benefitting  certain  diseases,  in  others 
it  is  too  stimulating.  The  marked  alterations  of  tempera- 
ture between  night  and  day  time,  the  lecturer  believed  to 
<-xert  a  strengthening  effect  upon  the  nervous  system,  the 
cold  nights  acting  something  like  the  cold  bath  in  typhoid 
fever.  The  aseptic  condition  of  the  air  and  its  freedom  from 
dust  are  great  advantages  in  the  treatment  of  tuberculo- 
sis. 

Altitudes  vary  in  temperature  according  to  remoteness 
from  the  equator  and  to  local  conditions.  They  may  be 
<livided  into  the  cold,  the  medium  and  the  hot  climate. 
In  the  health  resorts  of  Canada  and  the  North  of  Europe, 
the  winters  are  severe  and  long.  In  the  hot  climates  of 
Arizona  and  New  Mexico,  the  winters  are  mild,  but  the 
summers  are  too  hot  for  residence  for  most  patients,  and 
yet  there  are  some  consumptives  who  live  there  all  the 
year  round  with  lienefit.  In  the  hot  climate  there  is  more 
dust  than  in  the  cold  climates,  because  in  the  latter  the 
surrounding  ground  is  covered  with  snow.  Colorado  offers 
a  climate  between  the  two  extremes.  It  has  more  varia- 
bility of  temperature  than  the  others,  and  is  on  this  account 
less  well  suited  to  elderly  patients  and  feeble  persons  who 
tannot  exercise.  In  deciding  whether  or  not  a  tuberculous 
patient  should  be  sent  to  an  altitude,  something  must  be 
considered  besides  his  physical  signs.  Cases  may  be 
clinically  divided  into  purely  tubercular,  catarrhal,  and 
pneumonic,  which  is  convenient  but  not  beyond  criticism. 
Many  cases  present  symptoms  of  all  three  conditions.  But 
this  division  had  proved  very  useful  to  the  speaker  in  classi- 
fying these  patients,  in  his  practice.  The  purely  tubercu- 
lar cases,  usually  have  a  weak  heart  and  are  anemic. 
They  need  stimulants  and  the  climate  of  Colorado  usually 
agrees  with  them,  especially  if  they  are  properly  cared  for 
at  first.  The  catarrhal  cases  usually  have  some  disturb- 
ance of  metabolism,  or  uric  acid  excretion,  which  renders 
them  liable  to  mucous  membrane  inflammations.  When 
tliese  patients  come  to  Colorado,  they  have  to  be  care- 
fully guarded,  on  account  of  the  variability  of  the  climate. 
Often,  they  will  do  better  by  remaining  at  a  lower  level 
tor  a  time  preparatory  to  going  to  Colorado.  In  the 
pneumonic  cases,  there  is  marked  tendency  towards 
iiinammalory  action  of  sthenic  character.  They  are 
advised  to  remain  at  home  under  treatment  until  the  dis- 
ease is  less  acute  and  ceases  to  progress.  The  climate  of 
altitudffs  is  too  stimulating  for  such  cases  until  the 
inflammatory   action   has   subsiiled.     Hemoptysis   is  not   a 


bar  to  removal  to  Colorado,  but  if  the  patient  has  had  a 
recent  hemorrhage  he  should  remain  at  a  lower  level  until 
the  lung  tissues  have  recovered  from  it  and  the  condition 
is  stationary.  Patients  do  not  have  more  frequent  hem- 
orrhages at  altitudes  than  at  other  places,  with  proper  care. 
The  mental  state  of  the  patient  is  to  be  considered.  If  he 
suffers  from  home-sickness,  he  had  better  not  go  among 
strange  scenes,  where  his  mental  state  will  make  him  un- 
happy. The  social  state  of  the  individual  must  also  influ- 
ence the  judgment.  The  rich  who  can  supply  themselves 
with  every  comfort,  will  do  better  than  those  of  moderate 
means.  The  out-door  laborer  also  will  do  ver\'  well,  and 
indeed  better  than  those  who  are  accustomed  to  work 
indoors.  Most  patients  of  the  latter  class  are  better  suited 
for  home  treatment,  although  some  of  them  do  very  well 
in  Colorado.  As  regards  the  stage  of  the  disease,  if  the 
conditions  are  otherwise  favorable,  and  in  case  of  cavity, 
if  it  be  protected  by  thick  walls,  the  patient  will  do  well 
at  any  stage.  But,  if  in  cavity  cases,  the  disease  is  pro- 
gressing, the  patient  should  be  treated  in  a  hospital,  in  the 
open  air,  if  possible,  until  he  is  in  a  better  condition,  to  go 
to  an  altitude.  He  urged  that  the  patients  themselves 
should  be  studied  as  well  as  their  symptoms,  and  approved 
of  State  sanatoria,  where  a  proper  field  for  observing 
the  cases  is  provided,  and  the  cases  selected  which  arc 
most  likely  to  improve  after  removal  to  an  altitude. 

The  nc^xt  pap»r,  "The  Adaptability  of  Southern  Cali- 
fornia and  similar  Cii-^ates  to  the  Needs  of  Consumptives," 
was  read  by  Dr.  Norman  Bridge,  cf  Los  Angeles,  who  later 
also  read  another  <  ommunicaticn  entitled.  "The  Proper 
Management  of  the  Tuberculous  Lung."  In  the  former. 
he  extolled  the  advantages  of  that  portion  of  Southern 
California,  behind  the  foot-hills,  about  25  or  30  miles  from 
the  sea,  in  the  vicinity  especially  back  of  Pasadena,  at 
altitudes  of  from  S.iOO  to  6000  feet.  Strawberry  Valley. 
in  the  San  Jacinto  mountains,  at  an  elevation  of  5000 
feet,  has  been  selected  as  an  ideal  place  for  a  sanitarium 
for  the  treatment  of  pulmonary  disease.  The  slight  fluctua- 
tions of  the  barometer,  the  comparative  dryness  of  the  air, 
the  large  amount  of  sunshine  and  mildness  of  the 
(limate  the  year  round,  he  thought,  gave  the  climate  of 
southern  California  special  advantages  for  this  class  of 
cases.  In  the  second  paper,  he  approved  of  rest  for  the  af- 
fected lung  and  spoke  favorably  of  intra-pleural  injections 
or  nitrogen  gas.  Where  this  cannot  be  performed,  he  ad- 
vised fixation  with  bands  of  adhesive  plaster,  nearly  encirc- 
ling the  thorax,  so  a%  to  limit  the  movement  of  the  ribs. 

"Nineteen  Years'  Experience  with  Creosote  in  Tuber- 
culosis" was  the  titl.'  of  a  paper  read  by  Dr.  A.  Burroughs, 
Asheville.  N.  C.  The  author  gave  no  statistics,  but  asserted 
his  conviction  from  personal  observation  that  creosote  In 
larger  doses  has  a  curative  action  in  pulmonary  tubercn- 
losis.  The  ordinary  dose  of  five  or  ten  minims  is  too  small, 
except  to  benefit  a  feeble  digestion.  It  is  only  in  large 
doses  (60  to  100  minims)  three  times  a  day.  by  the  mouth 
(given  in  cod  liver  oil.  whiskey  or  creamL  supplemented 
by  the  inhalation  of  fifteen  to  twenty  minims  daily  (in  some 
hydro-carbon  oil),  that  the  curative  effect  upon  the  lungs 
is  obtained.  He  commences  with  a  dose  of  twenty,  and 
rapidly  runs  it  up  to  eighty,  minims  of  beech-wood  creo- 
sote, given  after  a  full  meal,  three  times  a  day.  He  had 
not  observed  any  cases  of  renal  disturbance  or  other  bad 
effects  from  these  large  doses,  but  had  seen  some  remark- 
able cases  of  recovery 

A  paper  on  "Specific  Therapeutics  in  Pulmonary  Tuber- 
culosis" was  read  by  Arnold  C.  Klebs,  of  Chicago.  The 
author  briefly  considered  the  various  methods  of  treatment 
now  in  vogue,  and  concluded  that  none  deserved  the  title 
of  specific,  but  in  conjunction  with  sanitarium  methods 
they  w-ere  of  unquestioned  benefit,  especially  the  serum 
treatment.  Attempts  at  immunization  have  not  left  the 
experimental  sta.ge,  and.  without  denying  the  possibility 
of  final  success,  he  would  decry  the  enthusiastic  support 
they  have  received  from  certain  observers,  as  being  pre- 
mature and  to  a  certain  extent  dangerous.  In  the  thera- 
peuti'^  management,  the  importance  of  open  air.  hygiene, 
and  diet,  is  universally  acknowledged,  but  the  reliance 
upon  some  supposed  specific  drug  leads  the  medical  attend- 
ant to  fail  in  paying  proper  attention  to  these  measures 
A  visit  to  a  sanitarium  in  whtch  all  the  details  of  the 
daily  life  are  systematically  and  scientifically  regulated 
would  convince  any  one  of  the  superior  importance  of  such 


Junk  22,  1901] 


SOCIETY  REPORTS 


V 


The    Philadelphia 
Medical  Journal 


I  191 


measures  over  the  ordinary  methods  of  drug  treatment 
of  pulmonary  tuherculosis. 

Di6cussion. — DeLancey  Rochester,  of  Buffalo,  thoroughly 
endorsed  the  remarks  commending  climatic  treatment. 
He  also  approved  of  the  use  of  creosote  in  large  doses  in 
the  treatment  of  tul)erculosis  and  mentioned  five  cases 
which  had  been  cured  under  his  observation.  The  advice 
to  Ifeep  the  affected  lung  at  rest  he  also  approved.  Harm 
has  been  done  by  pulmonary  gymnastics,  during  the  time 
when  the  disease  is  active;  later  when  the  lung  has  ci- 
catrized gymnastics  may  be  used  with  benefit. 

Dr.  S.  C.  Benney,  of  Denver,  said  that  it  had  been  his 
observation  that,  as  regards  hemorrhage  at  altitudes,  one 
case  out  of  every  four  which  has  had  bleeding  from  the 
lungs  before  arrival  may  expect  to  have  a  recurrence.  If 
a  patient,  however,  has  had  a  hemorrhage  very  recently, 
he  had  better  go  to  an  altitude  by  easy  stages,  for  the 
sudden  change  may  bring  back  the  bleeding.  The  altitude 
treatment  is  not  suited  to  cases  of  dry  bronchitis,  fibroid 
lung,  emphysema,  kidney  disease,  or  some  forms  of  heart 
trouble.  In  conclusion,  he  approved  of  the  method  of 
strapping  one  side  of  the  chest  where  only  one  lung  is 
affected,  as  a  measure  affording  much  relief  to  the  patient 
and  giving  partial  rest  to  the  lung.  In  cases  with  pleural 
elTusion,  complicating  tuberculosis,  he  did  not  consider  it 
advisable  to  aspirate  the  chest,  as  the  rule,  on  the  ground 
that  the  lung  should  be  kept  as  much  at  rest  as  possible. 
Where  the  straps  have  been  worn  for  some  time,  he  ad- 
vised that  they  sliould  be  removed  one  at  a  time,  at  inter- 
vals of  a  day  or  so.  He  mentioned  a  case  of  pneumo-thorax 
that  had  been  produced  by  coughing,  after  straps  had  been 
removed. 

Dr.  Jliner,  of  Asheville,  said  that  Dr.  Bridges  did  not 
sufficiently  differentiate  bis  cases,  in  speaking  of  giving 
rest  to  the  diseased  lung.  When  he  says  that  a  diseased 
lung  should  not  be  exercised,  the  speaker  took  issue  with 
him.  The  lung  is  not  ail  diseased  and  the  part  not  affected 
should  be  used.  Part  of  the  benefit  of  altitude  is  due  to  the 
increased  expansion  of  the  lung  which  it  produces.  The 
climate  treatment  is  only  an  adjunct  to  the  other  treat- 
ment. 

Dr.  Moore,  of  Nebraska,  said  that  a  life  in  fresh  air  and 
sunshine  are  the  curative  agents  that  are  most  important, 
and  that  drugs  and  climate  had  little  effect. 

Dr.  C.  S.  N.  Hallberg  said  that  with  regard  to  creosote. 
great  stress  had  been  laid  upon  the  necessity  of  the  purity 
of  the  agent,  and  upon  the  value  of  the  test  which  the  lec- 
turer relied  upon.  He  informed  the  reader  of  the  paper 
that  creosote  is  not  made  in  such  simple  method  as  that 
described,  nor  are  the  tests  which  he  gave  to  be  relied 
upon.  Creosote  is  one  of  the  most  insoluble  remedies,  and 
is  soluble  only  In  150  parts  of  water.  It  is  fortunate  that 
it  is  so.  when  such  large  doses  are  given.  It  is  broken  up 
in  the  intestinal  tract  into  guaiacol  and  creosote  and  forms 
more  soluble  compounds.  The  greatest  therapeutic  bene- 
fit is  to  be  obtained  from  doses  no  larger  than  4  or  5  to  10 
Cg.,  given  in  capsules  or  pill,  which  will  pass  through  the 
stomach  into  the  intestine,  and  be  there  gradually  dis- 
solved. A  saturated  solution  (IV2  percent.)  has  been  ad- 
vocated  by  Dr.  Hare,  for  internal  administration. 

Dr.  Klebs  approved  of  the  remarks  of  Dr.  Solly  upon  the 
necessity  of  discrimination  as  regards  the  social  and  finan- 
cial condition  of  patients.  It  has  too  often  happened  that 
patients  are  sent  as  far  as  El  Dorado,  to  an  altitude,  and 
have  nothing  to  live  on  when  they  get  there.  Such  pa- 
tients should  be  treated  in  hospitals  or  sanitaria. 

De  Lancey  Rochester,  of  Buffalo,  read  a  paper  on  "The 
Treatment  of  Pneumonia."  Recognizing  the  disease  as  a 
form  of  acute  infectious  disease  manifesting  itself  by 
septic  intoxication,  attended  with  a  local  disturbance  in 
the  lung  and  kidneys,  he  directed  the  treatment  towards 
favoring  elimination  of  toxins  and  excrementitious  prin- 
ciples, counteracting  the  depressing  effect  of  the  poison 
upon  the  heart,  and  sustaining  the  strength  of  the  patient. 
The  bowels  and  skin  are  the  avenues  of  excretion  which 
should  be  stimulated.  An  initial  dose  of  calomel  (0.,'iO  G) 
followed  by  a  saline,  not  only  opens  the  bowels,  but  re- 
lieves a  distended  right  heart:  it  may  bo  repeated  when 
the  indications  of  this  condition  present  themselves.  The 
hot  mustard  foot  bath,  followed  by  measures  to  obtain 
sweating,  is  also  very  useful,  and  may  be  repeated  at  four 
hour  intervals  during  the  disease.  The  diet  should  be 
fluid:  a  large  quantity  pure  water  should  be  administered. 


For  the  heart,  he  advised  strychnine  (0.004  G  every  two 
hoursj,  alcohol,  or  aromatic  spirits  of  ammonia,  given 
with  liquor  ammonii  acetatis.  Cupping  or  leeching  of  the 
affected  chest,  and  in  cases  of  over  distension  of  the  right 
heart,  with  increasing  cyanoses,  etc.,  venesection  was 
advised.  After  venesection,  or  in  cases  of  threatened 
heart  failure,  subcutaneous  injection  of  normal  salt  solu- 
tion may  be  resorted  to.  Oxygen  inhalations  may  be  re- 
quired, where  more  than  one  lung  is  involved.  Small 
doses  of  h.vpnotics,  chlorolamia,  chloral,  or  Dover's  powder, 
may  be  required  for  sleeplessness.  Digitalis  in  the  early 
stages  is  irrational  and  unscientific.  No  abortive  treat- 
ment is  possible  in  an  acute  infectious  disease.  The  serum 
treatment  may  prove  to  be  the  most  scientific  means  of 
treating  pneumonia. 

Dr.  W.  L.  Dickerson,  of  St.  Louis,  read  a  paper  on  "The 
Abortion  Treatment  of  Pneumonia;  a  Plea  for  the  Use  of 
Cardiac  Depressants  In  the  Treatment  of  the  Congestion 
Stage  of  Pneumonia;"'  in  which  he  advocated  the  use  of 
tincture  of  veratrum  viride  in  small  doses,  every  two  hours, 
in  the  congestion  stage  of  pneumonia,  and  reported  most 
favorable  results  from  this  treatment  in  his  own  experi- 
ence. 

The  discussion  was  a  general  one,  participated  in  by 
Dr.  J  F.  Spelman,  of  Anaconda,  Montana:  Moore,  of  Ne- 
braska: Carlton,  of  Tennessee:  Mary  McCoy,  of  Duluth: 
Hawkins,  of  St.  Paul,  and  the  Chairman.  The  trend  of  the 
remarks  was  in  support  of  the  position  taken  by  the  reader 
of  the  first  paper  and  in  opposition  to  that  of  the  second. 

THIRD    DAY,    THURSDAY.      MORNING    SESSION. 

"The  Influence  of  Certain  Common  Remedies  upon  Gas- 
tric Functions,"  was  the  title  of  a  paper  by  Boardman  Reed, 
of  Philadelphia.  He  concluded  that  among  dwellers  in  cit- 
ies, perfectly  normal  stomachs  are  rare,  especially  among 
persons  employed  indoors.  The  indiscriminate  adminis- 
tration of  bitter  tonics  and  of  hydrochloric  acid  is  capable 
of  doing  harm,  to  approximately  normal  stomachs,  if  kept 
up  for  even  a  short  time.  Hydrochloric  acid  (dilute),  if 
given  in  cases  of  hydrochlorhydria.  increases  the  acid  se- 
cretion: it  is  injurious  if  given  in  hyperchlorhydria.  Pep- 
sin is  of  little  value  if  given  alone,  if  combined  with  hydro- 
chloric acid,  it  aids  weak  digestive  powers. 

"The  Treatment  of  Gastric  Ulcer"  was  the  subject  of  a 
communication  by  Dr.  Gustav  Fuetterer,  of  Chicago.  The 
observation  was  made  that  the  prognosis  of  gastric  ulcer 
is  less  favorable  than  is  usually  believed,  it  is  very  slow  in 
repair  and  may  remain  unhealed  for  months.  Even  after 
cicatrization  has  taken  place  the  danger  is  not  over,  be- 
cause it  \ery  frequently  becomes  the  site  of  malignant  dis- 
ease. He  advocated  absolute  rest,  and  for  the  first  few 
days  feeding  with  beef  juice,  from  five  pounds  of  beef 
daily,  following  this  with  milk  diet  for  six  weeks.  The 
blood  should  be  examined  for  its  percentage  of  hemoglobin, 
and  when  this  is  below  normal  the  beef-juice  must  be  used 
until  the  normal  rate  is  attained.  The  treatment  is  based 
on  the  dictum  that  ulcer  of  the  stomach  can  form  only 
when  there  is  a  certain  amount  of  deficiency  of  the  hemo- 
globin, and  that  it  will  heal  when  this  deficiency  is  made 
up,  by  the  beef-juice  treatment.  In  cases  of  stenosis  of  the 
pylorus,  early  gastro-enterostomy  is  advised. 

Dr.  James  B.  Herrick,  of  Chicago,  opened  the  discussion. 
He  endorsed  the  statement  that  importance  of  gastric 
ulcer  has  been  underestimated  by  the  profession.  Many 
cases  terminate  by  hemorrhage,  peritonitis,  and  pyloric 
cicatricial  obstruction,  or  eventually  become  malignant.  He 
spoke  of  the  work  of  Dr.  Fuetterer  as  deserving  the  high- 
est praise,  and  approved  of  the  method  of  treatment.  Rest 
in  bed  with  milk  diet  are  essentials  in  the  management. 
Small  doses  of  morphine  hypodermically  not  only  relieve 
the  pain,  but  favor  the  healing  process  by  restraining  the 
motion  of  the  stomach. 

A  paper  on  "The  Treatment  of  Gastric  Hyperesthesia." 
was  read  by  Charles  C.  Stockton,  of  Buffalo.  The  condition 
referred  to  was  not  a  form  of  gastralgia  and  was  not  a 
symptom  associated  with  hyperchlorhydria,  but  was  due 
to  exaltation  of  normal  sensibility  of  the  gastric  mucous 
membrane,  usually  appearing  in  a  neurotic  patient.  Indi- 
gestion does  not  exist  although  this  condition  might  bo 
mistaken  for  a  symptom  of  indigestion.  A  positive  diag- 
nosis can  only  he  made  by  exclusion  and  after  a  resort  to 
gastric  chemistry.  In  these  cases,  the  slight  pain  or  dis- 
tress may  be  increased  by  taking  food,  and  patients  are 
iften   insufficiontiy   nourished   on   this   account.     In   some 


1 192 


Thk    Philadelphia  ' 
Medical  Journal   . 


SOCIETY  REPORTS 


[June  22,   190] 


the  presence  of  free  acid  in  the  stomach,  in  any  quantity 
whatever,  gives  rise  to  discomfort,  which  can  only  be  re- 
lieved by  alkalies.  Any  attempt  to  treat  such  cases  as 
instances  of  hyperchlorhydria  would  lead  to  an  aggrava- 
tion of  the  symptoms.  It  is  important,  in  the  management, 
to  increase  the  gastric  tolerance  and  improve  the  nutrition 
by  a  carefully  selected  diet.  Electricity  is  of  signal  ser- 
\ice,  with  the  negative  pole  in  the  stomach,  and  a  cur- 
rent 15  to  10  ma.)  of  low  voltage,  used  for  five  minutes, 
two  or  three  times  a  week. 

Hydropathic  treatment,  a  cold  douche  or  shower  bath 
to  the  spine,  the  Scotch  douche,  and  other  hygienic  meas- 
ures, are  as  important  as  in  the  treatment  of  neurasthe- 
nia. Antacids  are  used  symptomatically,  and  mistura  asa- 
fetida  may  be  given  by  the  rectum.  Dr.  Tomkins,  of  West 
Virginia,  said  that  mistakes  are  easily  made  in  diagnosis 
of  gastric  disorders,  and  mentioned  a  case  that  had  been 
pronovmced  carcinomatous  liv  a  specialist  eleven  years  ago. 
The  former  is  still  living  and  in  good  health.  He  did  not 
approve  of  gastric  surgery,  which  he  pronounced  a  crime, 
and  physicians  who  send  their  patients  to  be  operated  upon 
for  pyloric  stenosis  are  particeps  criminis.  He  advocated 
Fowler's  solution  in  small  doses,  and  some  prepared  foods. 

Drs.  f'uetterer,  of  Chicago:  Osborne,  New  Haven;  John- 
son, Clinton,  Iowa;  Heinrich  Stern,  New  York;  McCoy, 
Uuluth;  Westbrook.  of  Indianapolis;  Thomas  McCrae,  Bal- 
timore; Dora  G.  Wilson,  of  Kansas  City;  Boardman  Reed 
and  Stockton  continued  this  interesting  discussion,  which 
among  other  interesting  features  directed  special  atten- 
tion to  the  great  need  of  more  knowledge  of  the  principles 
of  dietetics  by  the  profession  and  especially  of  the  pre- 
vailing lack  of  knowledge  of  the  art  of  properly  prepairing 
food  tor  both  the  healthy  and  the  sick. 

"The  Theory  and  Practice  of  Organo-therapy,"  by  S. 
Solis  Cohen,  was  read  by  the  Secretary. 

"Acromegaly  Treated  w/ith  Pituitary  Body,"  was  the  title 
of  a  paper  by  Sydney  Kuh,  of  Chicago.  The  author  in- 
sisted upon  a  connection  existing  between  lesion  of  the 
pituitary  body  and  acromegaly;  in  nearly  all  cases  of  this 
disease,  sarcoma  has  been  found  involving  the  hypophosis. 
Some  influence  upon  the  growth  of  the  body  is  excited  by 
the  pituitary  body,  where  it  is  diseased,  giantism  is  pro- 
duced; where  it  is  atrophied  dwarfing  results.  Exophthal- 
mic goitre  and  acromegaly  are  associated  so  frequently  as 
to  make  it  unlikely  that  it  is  a  mere  coincidence.  Pow- 
dered pituitary  bodies  having  been  employed  in  these 
cases  of  acromegaly,  decided  improvement  was  noted, 
especially  in  the  headache.  When  the  powder  was  stopped 
the  headaches  returned  with  their  former  intensity.  In 
two  cases  decided  nutritional  improvement  was  noticed. 
While  the  treatment  cannot  affect  the  organic  changes 
in  the  tissues,  yet  if  the  subjective  symptoms  may  be  re- 
lieved the  treatment  is  of  benefit,  and  deserves  further 
trial. 

"The  Treatment  of  Graves's  Disease  with  Thymus  Ex- 
tract," was  the  topic  selected  liy  Jol-in  M.  Dodson,  of  Chi- 
cago, for  his  communication.  In  several  cases  the  author 
reported  marked  improvement  in  the  classical  symptoms 
of  exophthalmic  goitre  following  the  use  of  powdered  ex- 
tract of  thymus  gland. 

Discussion. — Dr.  Osborne  said  that  the  papers  had  car- 
ried out  his  own  idea  that  there  is  a  connection  between 
Graves's  disease  and  acromegaly.  In  autopsies  of  cases  of 
the  latter  disease  the  thyroid  gland  has  also  been  found 
to  be  enlarged,  in  every  instance.  He  had  recently  had 
two  cases  under  the  pituitary  treatment  at  a  dispensary, 
and  had  noted,  by  one.  a  remarkable  improvement;  the 
other  case  he  was  not  sure  of.  The  discussion  was  contin- 
ued by  Boardman  Reed,  the  Chairman,  the  Secretary,  D. 
Shelly.  Kansas;  Vauehan.  of  .Vnn  Arbor,  Stern,  of  New 
York,    Kuh    and    Dodson. 

"The  Pharmacology  of  the  Supra-renal  Gland,  and  a 
Method  of  Assaying  its  Products."  was  read  by  E.  IV1. 
Houghton,  of  Detroit.,  and  was  followed  by  one  on  "The 
Principle  of  the  Supra-renal  Glands."  by  Dr.  Jokichi  Taka- 
mine,  of  New  York.  There  admirable  communications 
well  suppleni'^ntcd  one  another.  Dr.  Takamine  detailed 
the  efforts  that  had  been  made  to  discover  the  active  prin- 
ciple of  the  adrenals  previous  to  his  own  work  upon  the 
subject.  Very  recently  he  had  succeeded  in  isolating  a 
uure  active  principle,  which  possessed  the  power  of  rais- 
ing the  blood-pressure:  this  substance  he  had  named 
"adrenaline."  He  descrMied  the  method  of  separating  it 
from  (he  crude  material  of  the  glands,  and  demonstrated 


several  characteristic  tests  by  which  it  can  be  recognized. 
A  specimen  of  pure  white,  crystalline  substance  was  pre- 
sented and  a  review  of  its  physiological  effects  given,  with 
suggestions  as  to  its  therapeutic  uses. 

Remarks  in  commendation  of  these  papers  were  made 
by  Dr.  Vaughan.  Dr.  Stern  inquired  if  any  cumulative 
effect  had  been  observed  from  adrenaline? 

Dr.  Boardman  Reed  desired  more  information  as  to  the 
poisonous  effects,  in  single  dose  or  after  long  administra- 
tion. 

Dr.  Osborne  asked  with  regard  to  its  absorption  by  the 
skin  and  adaptability  to  hypodermic  use.  Drs.  Vaughan. 
Dodson  and  Houghton  also  discussed  the  paper.  A  vote 
of  thanks  was  tendered  Dr.  Takamine  by  the  Sec- 
tion. 

Officers  for  the  ensuing  year: 

George  F.  Butler,  of  Chicago,  Chairman;  C.  S.  N.  Hall- 
berg,  of  Chicago,  Secretary. 

SECTION  ON  STOMATOLOGY. 

In  his  annual  address  the  Chairman  alluded  to  the 
symposium  of  last  year  as  having  shown  good  results.  It 
had  brought  advanced  conditions  to  the  schools  and  these 
advances  were  well  recognized.  We  have  a  right  to  ex- 
pect as  an  entrance  condition  a  degree  in  letters.  This  is 
an  age  of  progress.  We  need  larger  equipments  for  teach- 
ing. We  must  do  everj'thing  as  well  as  it  can  be  done. 
Each  investigator  must  in  his  own  way  solve  all  problems. 
We  must  never  wait  for  the  State  Society  to  do  it.  Many 
important  matters  need  solution.  Some  students  have  the 
happy  faculty  of  solving  whatever  presents  to  them.  But 
the  expense  is  often  too  great  for  individual  pockets.  Hence 
such  need  aid  in  this  particular  and  perhaps  compensation 
for  their  work. 

Dental  examiners  should  not  be  appointed  as  a  political 
gift.  The  best  man  should  be  appointed.  A  standard  should 
be  established  by  the  National  Association,  then  one  who 
passes  can  go  into  any  State  to  practice.  Again,  in  the 
case  of  those  who  have  practiced  for  years  and  are  not 
fitted  to  pass  an  examination  by  absence  from  college,  a 
certificate  should  be  awarded.  "The  department  of  prophy- 
laxis is  bright  with  possibilities:  a  fruitful  field  is  here 
opening.  One  writer  has  shown  the  existence  of  bacteria 
on  the  teeth  and  a  predisposition  to  the  formation  of  a  hard 
gelatinous  film,  a  culture  medium  for  micro-organism. 
He  calls  it  "gelatinous  microbic  plaque."  These  bacteria 
are  malign  or  benign  according  to  their  environment.  The 
saliva  when  abnormal  is  the  exciting  cause.  Another  writ- 
er tells  of  the  active  lives  of  bacilli  from  a  superabundance 
of  glycogen  as  found  in  the  saliva  making  it  alkaline,  pro 
ducing  glucose,  then  lactic  acid  which  unites  with  the  lime 
of  the  teeth  producing  decay  of  the  teeth.  Other  exciting- 
causes  are  the  improper  nutrition  in  many  cases.  An- 
other has  proposed  for  the  cleaning  of  the  teeth  a-  flat 
piece  of  orangewood  for  spaces  between  teeth  used  with 
pumice  by  which  the  teeth  are  thoroughly  cleaned  and 
polished.  This  also  stimulates  the  vital  functions.  The 
use  of  fine  salt  once  a  week  also  will  stimulate  the  gum 
tissue.  Another  subject  of  importance  is  the  Dental  Ser- 
vice ot  the  United  States  Army.  The  plan  proposed  is  not 
all  we  would  like.  We  fortunately  have  Dr.  Marshall  as 
the  President  of  the  Examining  Board.  He  is  eminently 
fitted  for  the  position.  We  should  demand  a  high  standard 
from  Contract  Dental  Surgeons  and  this  is  well  shown  by 
the  results  of  the  fact  that  but  two  passed  of  fourteen  ap- 
plicants. He  urges  none  to  come  up  but  those  who  are 
well  prepared. 

Science  has  made  vast  strides  in  Biology.  We  learn  that 
protoplasm  is  not  a  single  chemical  substance,  but  highly 
complex  and  that  continual  chemical  transformations  oc- 
cur. Protoplasm  is  supplied  by  the  egg.  hence  the  nitro- 
genous part  is  supplied  wholly  by  the  mother.  While  the 
nuclei  are  divided  and  from  both  parents  are  formed  groups 
of  chromsomes  which  are  respectively  paternal  and  ma- 
ternal in  their  origin.  Redivision  takes  place  and  so 
throughout  the  growth  of  the  animal.  Again  an  egg  may 
be  fertilized  by  chemical  stimulus  without  the  participa- 
tion of  the  male  element.  Thus  eggs  of  the  sea  urchin 
allowed  to  develop  in  sea  water  with  a  slight  excess  of 
potassic  chloride  develop  an  embryo  slightly  altered  from 
nature.  No  skeleton  is  formed  and  larvae  result,  living, 
vigorous,  hut  widely  differing  from  the  normal.  Or  lithium 
chloride  in  the  water  nvises  a  more  remarkable  change  de- 
veloping as   il   were   inside   out.     These  nions'ers   c.innot 


June 


1901] 


SOCIETY  REPORTS 


TThe    Philadelphia 
L  Medical  Journal 


119? 


redevelop  and  perish.  These  facts  are  interesting  as  thus 
creating  new  organic  forms.  Insects,  frogs,  etc.  thus 
show  that  sex  is  determined  by  conditions  of  nutrition. 
We  may  yet  succeed  in  fertilizing  the  egg  by  chemical 
means  and  produce  males  and  females  from  analogous 
methods. 

The  second  paper  was  by  Dr.  Wm.  Carr,  New  York  City, 
on  the  methods  of  appointment  on  boards  of  examiners. 
Diplomas  should  not  give  the  right  to  practice.  The  low 
standard  of  schools  is  due  to  the  lack  of  State  supervision. 
License  to  practice  should  only  be  given  after  a  careful 
examination  by  a  Board  of  Examiners  appointed  by  the 
State.  Charters  are  granted  recklessly  by  the  Legisla- 
ture, hence  the  teachers  are  not  selected  for  merit.  New 
York  fortunately  is  not  thus  hampered,  as  the  State  Uni- 
versities are  the  governing  body.  It  has  been  seen  that 
good  colleges  will  endorse  diplomas  of  bad  schools  out- 
side the  State.  Even  fraudulent  papers  were  endorsed. 
Hence  we  should  do  away  with  diplomas.  While  there  are 
Boards  in  nearly  every  State,  yet  as  some  refused  to  list 
all  schools,  litigation  followed,  causing  great  difficulty  in 
the  work  of  the  Board.  We  can  raise  the  standard  in  pro- 
portion to  the  demands  of  the  profession.  It  is  highly  im- 
portant that  Boards  are  properly  constituted  of  honest, 
competent  men  with  eyes  single  to  duty  and  then  admis- 
sion to  the  profession  would  be  confined  to  the  best,  to  the 
exclusion  of  the  incompetent.  Examiners  must  not  be 
identified  with  teaching  bodies,  yet  conversant  with  tho 
arts  of  instruction  and  examination,  able  to  frame  ques- 
tions which  shall  elicit  from  the  candidates  what  knowl- 
edge they  possess,  and  their  ability  to  apply  it.  An  ap- 
pointment to  this  post  should  he  regarded  as  an  honor,, 
never  depending  upon  politics  nor  influence  of  any  kind. 

The  third  paper.  Revenue  for  Conducting  the  Work  of 
Boardt  of  Examiners,  whether  by  taxation  of  the  people — 
by  fees  from  the  candidates — by  taxation  of  the  profession, 
was  considered  by  G.  I.  Parmelee,  Hartford,  Conn.  The 
effort  is  not  to  compel  men  to  live  up  to  a  code  but  to 
protect  people  from  improper  practitioners.  After  care- 
fully considering  the  subject,  all  points  to  the  conclusion 
that  revenue  should  be  from  the  candidate,  as  In  all  other 
matters  of  similar  character. 

V.  E.  Turner.  Raleigh.  N.  C,  also  considered  the  subject 
and  concluded  that  the  fees  of  candidates  alone  should  be 
the  source  of  revenue. 

The  next  paper, The  Dental  College  Standard,  is  it  What  it 
Should  Be?  If  Not.  What  Improvements  Should  be  Made? 
How  May  the  Requirements  be  Made?  Dr.  C.  Chittenden. 
Madison,  Wis.,  said  the  standard  is  not  the  same  in  all 
States.  Some  demand  a  high  education  for  entrance  before 
graduation,  eventually  this  will  be  adopted.  By  the  col- 
leges uniting  with  the  Boards,  it  can  be  adopted  at  once. 
Make  it  impossible  that  matriculants  can  be  given  standing 
in  any  college  on  credentials,  until  these  are  passed  upon 
by  the  State  Superintendent  and  then  by  a  joint  confer- 
ence of  committees  of  the  Colleges  and  Board.  And  if 
needed  a  probationary  clause  requiring  all  shortcomings  to 
be  made  up  without  abandoning  the  study  of  dentistry. 
Once  adopted,  let  all  schools  agree. 

The  next  paper,  by  J.  A.  Libby,  Pittsburg.  Pa.,  on  pre- 
liminary work,  A  college  is  chartered  by  the  State  for 
the  purpose  of  educating  students  in  specific  branches  as 
well  qualified  teachers,  who  are  thoroughly  earnest  and 
loyal  and  who  will  see  that  only  the  competent  are  al- 
lowed to  enter  and  who  count  the  qualities  of  the  student 
more  than  the  profits  of  the  school.  This  alone  should  bs 
the  rule,  but  unfortunately  all  are  not  so  constituted. 
Funds  are  needed  to  pay  expenses  of  the  school.  There 
should  be  a  reform  in  the  system  of  educating  students. 
When  this  is  realized  laws  will  be  adopted  and  the  time 
hastened  when  the  dentist  will  mean  the  worker  in  the 
mechanical  part,  and  the  name  Stomatologist  will  take 
the  place  and  he  will  rank  as  an  M.  D. 

Alice  Stevens,  Chicago,  read  a  paper.  Infectious  Diseases 
resulting  from  want  of  care  in  the  use  of  instruments,  es- 
pecially syphilis  of  the  mouth.  Hence  the  need  of  proper 
and  careful  disinfection  of  all  instruments  used  in  the 
mouths,  particularly  of  children.  She  explained  how  to 
recognize  these  affections  as  presented  in  the  tooth  cav- 
ity and  the  method  of  relieving  them. 

Dr.  James  G.  Kiernan,  Chicago,  read  a  paper.  Periods  of 
Stress  and  their  Dental  Marks.  He  explained  how  the  teeth 
showed  these  periods  by  their  irregularities  and  markings. 
©specially  in  the  case  of  children  who  are  borne  by  a 
mother  during  great  trouble,  etc. 


Dr.  Eugene  S.  Talbot,  Chicago,  presented  Preliminary 
Work,  introducing  the  symposium  of  degeneracy  of  the 
pulp,  followed  by  Vida  A.  Latham.  Rogers  Park,  111. 
Literature  of  the  Pulp.  Surgical  Treatment  of  Cleft  Palate, 
G.  X.  I.  Brown,  Milwaukee,  and  the  section  closed  its 
work  on  Thursday  with  a  discussion  of  Military  Dental 
Practice,  by  John  S.  Marshall,  Chicago.  This  section  held 
as  interesting  and  useful  a  session  as  perhaps  any  of  the 
sections.  We  mention  with  much  pleasure  the  continua- 
tion of  its  valuable  Secretary,  Dr.  Talbot,  in  office,  as  this 
is  the  only  way  the  work  of  a  section  can  be  maintained  to 
its  full  standard. 

SECTION  ON  HYGIENE  AND  SANITARY  SCIENCE. 
""Dr.  W.  H.  Heath,  Buffalo,  N.  Y.,  presented  a  paper, 
State  Supervision  of  Marriage,  its  possibility,  scope,  justifi- 
cation, possibilities.  After  demonstrating  the  necessity  of 
the  marriage  license,  and  that  the  State  is  the  proper  power 
to  issue  this,  proceeds  to  develop  a  modified  special  li- 
cense which  is  more  strict  in  its  requirements  than  at 
present.  He  suggests  that  special  certificates  be  issued 
showing  the  qualifications  of  the  persons  about  to  marry; 
as  to  health,  issued  by  the  physician;  as  to  education  re- 
garding especially  marital  duties.  This  license  not  to  he 
compulsory  at  the  outset  but  issued  to  such  able  to  meet 
the  requirements.  He  proposes  methods  for  educating 
the  masses;  as  series  of  lectures  in  hygiene  physiology, 
etc.,  of  a  popular  character.  He  suggests  inducements  of 
various  nature  to  contracting  parties  to  fulfil  requirements 
as  for  instance  governments  and  municipal  positions  for 
themselves  and  offspring,  etc. 

In  the  discussion  the  general  idea  prevailed  that  this 
like  many  other  schemes  is  visionary  and  perhaps  pre- 
mature. 

Dr.  W.  T.  English,  Pittsburg,  Pa.,  on  Pulmonary  Tuber- 
culosis presented  the  idea  that  fear  is  concomitant  with 
the  pulmonary  system  up  to  the  time  of  puberty.  The  very 
first  respiration  is  due  to  a  nervous  impulse  akin  to  fear. 
As  adult  life  is  reached  this  attitude  toward  the  pulmon- 
ary system  is  changed  to  one  of  fearlessness  and  dis- 
regard. The  author  then  comments  on  the  fearlessness  lu 
tuberculous  individuals  and  their  friends.  He  contrasts 
the  fearless  and  hopeful  attitude  of  these  with  the  appre- 
hension of  victims  of  carcinoma,  etc.  He  suggests  that 
the  absence  of  this  fear  is  detrimental  to  the  effecting  of 
cures  and  that  it  is  the  duty  of  the  conscientious  physi- 
cian to  instil  into  the  mind  a  normal  amount  of  feaj  for 
the  good  of  the  patient. 

SECTION    ON    LARYNGOLOGY    AND   OTOLOGY. 

JUNE,    1901. 

This  section  convened  in  the  Elk's  Hall,  June  4,  2.30 
P.  M.,  with  Dr.  John  M,  Mackenzie,  chairman,  in  the  chair, 
and  a  good  number  of  members  in  attendance. 

The  Chairman's  address  was  given  by  Dr.  John  M.  Mac- 
kenzie, Baltimore,  who  digressed  somewhat  from  the  cus- 
tom of  former  years  in  giving  an  address  on  "The  Study  of 
Laryngology  in  the  University  and  in  the  Higher  Medical 
Education,"  instead  of  reviewing  progress  in  the  special- 
ties for  the  year  past. 

Dr.  Mackenzie  dwelt  upon  the  importance  of  Laryngology 
and  upon  the  neglect  in  teaching  this  branch  in  the  Medi- 
cal Schools  of  America  as  well  as  abroad,  stating  that  the 
knowledge  of  this  branch  was  a  requisite  for  the  degree 
in  but  one  school  in  this  country. 

In  speaking  of  Laryngology  he  included  its  sister  spec- 
ialties, Rhinology  and  Otology.  He  held  that  this  branch 
should  have  a  well  equipped  tlep.artment  and  a  full  profes- 
sorship in  all  first-class  schools.  He  predicted  that  the 
laryngoscope  was  "going  the  way  of  the  stethoscope  and 
becoming  the  common  property  of  the  general  practitioner 
of  medicine,  and  that  it  would  become  an  absolute  neces- 
sity in  internal  medicine,  and  that  a  more  general  knowl- 
edge of  Laryngology  might  ha\e  a  salutary  effect  relegat- 
ing to  the  rear  that  element  whose  only  claim  for  spec- 
ial knowledge  resides  in  the  possession  of  the  necessary 
apparatus  which  go  to  make  up  the  armamentarium  of  the 
worker  in  this  field," 

The  essayist  carefully  reviewed  the  development  of  the 
study  of  Laryngology  and  outlined  the  present  excellent 
course  in  this  branch  in  Johns  Hopkins  Medical  School. 
He  urged  that  the  subject  be  looked  upon  by  the  student 
from  the  high  vantage  ground  of  .general  Pathology  and 
laws  of  health  and  not  from  the  level  of  a  narrow  special- 


•1194 


The    Philadelphia  "I 
Medical  Jourxal    J 


SOCIETY  REPORTS 


[Ju.vE   22,    l»Jl 


ist,  and  that  there  be  more  fraternity  and  co-operation 
among  the  different  departments  of  medicine,  and  not 
until  Laryngology  becomes  the  inspiration  of  a  higher  ef- 
fort and  a  loftier  ideal  would  it  reach  the  full  fruition  of 
its  hopes. 

The  next  paper  read  was  on  "The  Treatment  of  Laryn- 
atis,"  by  Dr.  O.  T.  Freer,  of  Chicago. 

Dr.  Freer  holds  that  the  metallic  astringents  are  better 
than  the  vegetable  ones,  since  they  form  a  protective  coat 
■which  limits  the  egress  of  secretion,  hence  the  drying  ef- 
fect of  these  astringents. 

This  paper  was  discussed  by  Dr.  Ingals,  of  Chicago,  and 
several  others. 

The  next  paper  was  a  very  interesting  report  of  four 
cases  of  Edematous  Laryngitis  by  Dr.  Jos.  S.  Gibb,  of  Phil- 
adelphia. 

This  paper  was  followed  by  some  remarks  on  "The  Total 
Extirpation  of  the  Thyroid  Gland,"  bv  Dr.  G.  F.  Cott  of 
Buffalo. 

The  morning  session,  on  June  ."ith,  was  opened  by  n 
paper  on  "Types  of  Membranous  Pharyngitis,"  by  Dr.  W. 
B.  Casselbury.  of  Chicago,  which  was  discussed  by  Drs. 
Mayer.  (Xew  York),  Shurley  and  Amberg,  (Detroit),  and 
Hollinger.   (Chicago). 

This  was  followed  by  a  paper  on  "The  Relation  of  the 
Middle  Turbinate  Body  to  the  Chronic  Nasal  Diseases,"  by 
Dr.  C.  S.  Baker,  of  Bay  City,  Mich.,  which  was  discussed 
by  Drs.  Barnhill,  Casselbury,  Ingals  and  Mayer. 

Dr.  J.  H.  Farrell.  of  Chicago,  then  read  a  paper  on 
■"Asthma  as  a  Result  of  Nasal  Condition,"  which  was  dis- 
cussed by  Drs.  Jack,  Casselbury,  Amberg  and  Barnhill.  Dr. 
Jack  holding  that  there  was  no  relation  between  Asthma 
and  Nasal  Conditions. 

Dr.  C.  M.  Cobb,  of  Boston  and  Lynn,  then  read  a  re- 
port from  Dr.  George  Richards,  of  Fall  River,  of  a  case  in 
■svhich  the  styloid  process  was  found  embedded  in  the  ton- 
sil, after  which  he  read  a  paper  of  his  own  on  "The  Effect 
■which  the  so-called  Catarrhal  Diseases  of  the  Nose  and 
Throat  have  upon  the  General  Health,"  in  which  he  brought 
out  the  interesting  point  that  rheumatic  pains  in  distant 
.parts  of  the  body  often  disappear  after  thorough  drainage 
of  the  diseased  accessory  nasal  sinuses  has  been  estab- 
lished. 

This  paper  was  discussed  Drs.  Casselbury,  Woolen. 
Kline.  Kuyt.  Roy.  Freer  and  Farrell,  Dr.  Casselbury  stat- 
in that  four  cases  of  Anomalous  Styloid  in  the  tonsile  had 
been  reported  to  this  section  in  the  last  few  years,  thus 
showing  it  was  not  an  uncommon  phenomenon. 

At  the  afternoon  session,  June  5,  the  Nominating  Com- 
mittee reported  the  names  of  the  candidates  for  Section 
Offices  for  the  following  year. 

Dr.  G.  H.  Makuen.  of  Philadelphia,  was  nominated  for 
Chairman,  and  Dr.  C.  S.  Barnhill.  of  Indianapolis,  for  Sec- 
retary. The  nominations  bein  closed,  these  two  gentle- 
Juen  were  elected  to  fill  the  positions  named. 

The  names  of  five  members  were  then  placed  in  nomina- 
tion from  whom  two  were  to  be  selected  to  represent  the 
Section  in  the  new  House  of  Delegates  of  the  Association. 
Dr.  Emil  Mayer,  of  New  York  City,  and  Dr.  George  C. 
Stout,  of  Philadelphia,  were  chosen  in  this  capacity. 

Dr.  E.  Fletcher  Ingals.  of  Chicago,  then  presented  a  most 
scholarly  paper  on  "Empyema  of  the  Frontal  Sinus,"  which 
was  freely  discussed.  This  was  followed  by  a  paper  on 
"The  Anomalies  of  the  Frontal  Sinus  and  their  bearing  on 
the  Chronic  Sinusitus."  by  Redmond  \V.  Payne,  of  San 
Francisco,    Cal. 

"New  Growths  in  the  Upper  Respiratory  Tract"  were 
freely  discussed  after  the  reading  of  the  following  papers 
on  this  subject; 

1.  Carcinoma  of  the  Nasopharynx,  by  Chevalier  Jack- 
son, of  Pittsburg. 

2.  Sarcoma  of  the  Nasal  Passages  with  report  of  a 
^Case,  by  Dunbar  Roy,  of  Atlanta.  Ga. 

3.  Epithelioma  of  the  Upper  Respiratory  Tract,  by  S. 
A.  Oren,  of  Illinois. 

The  afternoon  session  was  closed  with  a  paper  on 
"Changes  in  the  Facial  Bones,"  due  to  Adenoids,  by  A.  T. 
Mitchell,  of  Vicksburg. 

Thursday  morning  session  was  devoted  to  a  "Symposium 
on  Mastoiditis."  Dr.  Stout  being  in  the  chair. 

The  first  paper  was  that  of  Dr.  E.  P.  Dench,  of  New 
York  City,  on  "The  Diagnosis  and  Treatment  of  Mastoidi- 
tis." 

The  second  paer  was  by  Dr.  Hiram  Woods,  Jr.,  of  Bal- 


timore, on  "Mastoiditis  after  Subsidence  and  without  Re- 
currence of  Tympanic  Disease." 

These  interesting  papers  brought  forth  a  general  disctis- 
sion,  which  was  participated  in  by  twenty  members  of  the 
Section,  the  subject  being  thoroughly  discussed  in  a  most 
entertaining  and  instructive  manner. 

At  the  afternoon  session  on  this  day.  Dr.  G.  Hudson  Ma- 
kuen. of  Philadelphia,  reported  a  case  of  an  "L'nusual  and 
Interesting  Tertiary  Manifestation,"  after  which  the  Sec- 
tion adjourned,  after  a  most  interesting  program. 


American  Climatological  Association. — The  following  del (r- 
gates  have  been  appointed  to  represent  the  American  Cli- 
matological Association  at  the  British  Congress  on  Tubercu- 
losis. Dr.Edward  O.Otis.  Boston:  Dr.  Judson  Daland.  Phil- 
adelphia; Dr.  Henry  L.  Eisner,  of  Syracuse,  N.  Y.:  Dr. 
Charles  F.  McGahan,  A-iken.  S.  C:  Dr.  Thomas  D.  Cole- 
man, Augusta,  Georgia;  Dr.  Carroll  E.  Edson,  Denver.  Dr. 
Guy  Hinsdale,  Philadelphia,  has  received  a  notice  of  his 
appointment  as  honorary  member  of  Congress. 


JOURNAL  DES  PRATICIENS. 
April  l.i,  1001.     dome.  Annee,  No.  15.) 

1.  Recurrent  Intercostal  Roseola.       De  BEURMANN  and 

LOUIS  DELHERM. 

2.  Enteroptosis.     FRANTZ  GLENARD. 

1. —  Recurrent  roseola  shows  a  tendency  to  appear  along 
the  posterior  intercostal  spaces,  never  appearing  on  the  an- 
terior surface  of  the  thorax  or  abdomen.  This  has  been 
seen  in  syphilis.  As  the  eruption  is  fleeting,  all  syphilitics 
were  examined  twice  weekly.  Only  eight  typical  cases  were 
found  among  1089  patients.  Other  varieties  of  roseola 
occurred,  both  circinate  and  ovoid.  This  eruption  appeared 
in  distinct  lines  along  the  intercostal  spaces,  each  spot  dis- 
cret«,  the  whole  resembling  the  branches  of  a  tree,  of 
which  the  spine  was  the  trunk.  The  upper  branches  were 
shorter  than  those  lower  down.  The  eruption  was  visible 
from  one  to  two  weeks,  being  verj-  distinct  only  a  few  days. 
The  eight  histories  follow.  As  it  lasted  so  short  a  time,  it 
was  probably  not  due  to  circulatory  disturbance.  It  may 
have  been  due  to  syphilitic  action  upon  the  marrow,  cer- 
tain of  Head's  zones  being  affected.  It  recurs,  is  seen  from 
the  fourth  to  the  sixth  month  of  syphilis,  is  never  serious, 
and  yields  to  mercurial  treatment.     [M.  O.] 

2, — From  a  study  of  40  autopsies,  Gl^nard  found  that 
when  the  suspensory  ligaments  of  the  stomach  and  intes- 
tines are  relaxed,  with  the  descent  of  these  viscera,  ste- 
nosis will  occur.  But  as  the  cecum  has  no  suspensory  liga- 
ments, it  alone  will  retain  its  normal  shape.  The  result  of 
the  stenosis  of  the  intestines  will  naturally  be  a  diminution 
of  the  tension  of  the  abdominal  wall.  Then  the  descent  of 
the  kidney  or  liver  may  follow.  The  subjective  symptoms  of 
enteroptosis  are  sudden  pain  in  the  right  lumbar  region, 
weakness,  constipation,  emptiness,  dyspepsia,  neurasthenia, 
emaciation,  pallor,  etc.  The  objective  symptoms  are  tender- 
ness in  the  right  lumbar  region,  diminution  in  the  abdominal 
tension,  movable  kidney,  the  colon  felt  as  a  cord,  the 
cecum  being  normal  in  size,  prolapse  of  the  liver,  epigastric 
pulsation,  and  perhaps  plenoptosis  and  metroptosis.  Saline 
laxatives  are  given,  and  sodium  bicarbonate:  suppression 
of  all  acids,  wine,  cereals,  and  fats:  a  milk  diet  ordered, 
then  green  vegetables,  cold  bathing,  warm  alkaline  waters. 
First  the  intestinal,  then  the  gastric  or  hepatic,  finally  the 
neurasthenic  symptoms  appear.  .\n  abdominal  binder  must 
be  applied.  The  movable  kidney  is  not  due  to  corsets,  but 
the  constipation  and  enteroptosis  are.  This  primarj"  en- 
troptosis  occurs  commonly  in  women,  with  confinement 
or  traumatism.  Secondary  enteroptosis  is  seen  in  men. 
due  to  gastric  atony,  probably  hepatic  in  origin.  For  the 
liver  plays  an  important  role  in  all  cases  of  secondary  en- 
teroptosis. Only  after  years  of  treatment  do  these  patients 
recover  their  general  health.  Gl^nard  employes  his  "belt- 
tot"  in  the  diagnosis  of  enteroptosis.  The  physician  stands 
behind  the  patient,  encircling  the  abdomen  with  the  palms 
of  both  hands,  supporting  and  lifting  up  the  patient.  If 
this  affords  relief,  the  diagnosis  of  enteroptosis  is  cott- 
filmed.     [M.  O.] 


Juke 


1901] 


THE  LATEST  LITERATURE 


CThe    Philadelphia 
Medical   Journal 


1  19? 


^bc  latest  llitcratuvc. 

BRITISH    MEDICAL   JOURNAL. 
June  1st,   Will. 

1.  An  Adcli-ess  on  Theories  of  Inheritance,,  with  Special 

Reference  to  Inheritance  of  Acquired  Conditions  in 
Man.     J.  GEORGE  ADAML 

2.  The  Pathogenesis   of  Tabes   and   Allied   Conditions   in 

the  Cord.     CHALMERS  WATSON. 

3.  Case  of  Malignant  Disease  of  the  Lung,  with  Pseudo- 

Tuberculosis.     H.  BATTY  SHAW. 

4.  Sequel  to  a  Case  of  Pulmonary  Hypertrophic  Osteoar- 

thropathy:  Necropsy.     E.  FARQUHAR  BUZZARD. 

5.  The  Pulse-Rate  in  Pulmonary  Tuberculosis.     THOMP- 

SON CAMPBELL. 

6.  The  Position  in  which  the  Regurgitant  Aortic  Murmur  is 

most  clearlj'  Audible  at  the  base  of  the  Heart.     H. 
W.   SYERS. 

7.  The    Development    of    Filaria    Nocturna    in    Different 

Species  of  Mosquitos.     GEORGE  C.  LOW. 

8.  Notes  on  the  Value  of  Experiments  in  the  Question  of 

Food  Preservatives.     A.  S.  GHUi\iiAlJM. 

1. — In  his  discussion  of  the  theories  of  Inheritance,  Adaml 
believes  that  the  existence  of  hypothetical  "ids"  is  absolute- 
ly disproved.  It  is  to  the  germ  plasm,  the  active  matter 
in  the  germinal  cells,  and  to  the  propei-ties  of  the  germ 
plasm,  that  we  must  turn  in  order  to  gain  our  basis  for 
any  sound  theory  of  inheritance.  This  germ  plasm  it  is 
which  conveys  living  matter  from  generation  to  genera- 
tion. "Whatever  life  be,  the  fundamental  phenomenon  or 
possession  of  living  matter  is  the  performance  of  work 
coupled  with  growth.  Growth  is  essentially  a  chemical  pro- 
cess and  any  adequate  theory  bearing  on  the  phenomena 
of  growth  must  primarily  be  along  chemical  lines.  The 
matter  which  is  essential  to,  and  directly  concerned  in, 
activity  of  any  one  species  or  individual  is  a  single  sub- 
stance, which,  following  Nageli,  we  can  refer  to  as  "idio- 
plasm;" and  our  conception  of  the  individual  or  of  the 
separate  cell  units  forming  that  individual  must  be  that 
in  each  we  have  to  deal  with  two  constituents:  the  idio- 
plasm, or  essential  and  directive  living  matter  and  the 
cytoplasm,  which  is  in  the  strictest  sense  non-living,  or, 
certainly  unable  to  exhibit  the  whole  series  of  vital  proper- 
ties apart  from  the  idioplasm,  and  which  consists  of  various 
formed  elements  developed  and  influenced  by  the  controll- 
ing idioplasm,  intimately  connected  therewith,  it  is  true,  but 
at  the  same  time  not  an  essential  part  of  the  same.  That 
the  constitution  of  the  idioplasm  is  not  absolutely  but  only 
relatively  constant  has  also  to  be  assumed.  Then  we  must 
admit  that  the  idioplasm  of  the  highest  forms,  judging 
from  its  powers  of  controlling  and  directing  the  develop- 
ment of  highly  complicated  organs,  is  something  very  much 
more  complex  than  the  idioplasm  of  the  unicellular  or- 
ganisms; that  in  the  course  of  evolution  this  has  under- 
gone successive  accretions  of  properties,  and  this  accre- 
tion of  properties  is  the  manifestation  and  accompaniment 
of  increasing  complexity  of  constitution  of  that  idioplasm. 
We  can  imagine  a  chemical  substance  so  constituted  as  to 
be  capable  of  modification  in  its  molecular  constitution — 
and  so  in  sundry  of  its  pixjperties — without  undergoing  com- 
plete change,  without  other  properties  being  lost.  The 
mode  of  the  atomic  arrangement  in  the  idioplasmic  mole- 
cule may  therefore  in  part  explain  the  variation  in  the 
properties  of  that  idioplasm  seen  throughout  the  animal 
and  vegetable  kingdoms.  In  the  ovum  there  is  one  com- 
mon idioplasm  of  simple  type,  to  which  when  distributed 
in  the  various  cells  derived  from  that  ovum,  different  side 
chains  become  attached,  according  to  the  relationships 
assumed  by  those  cells,  so  that  the  cells  of  different  orders 
are  controlled  and  formed  around  protoplasmic  or  idioplas- 
ic  molecules  composed  of  these  central  rings  plus  varying 
series  of  side  chains.  Indeed  Adami  is  prepared  to  go 
further,  and  to  state  that  the  idioplasm  possessing  its  full 


complement  of  side  chains  must  be  regarded  as  ipso  facto- 
incapable  of  initiating  cell  multiplication.  Fusion  of  tho 
idioplasm  of  2  individuals  must  be  either  a  mere  admi.x- 
ture  or  a  true  chemical  combination.  We  may  regard, 
then,  the  idioplasms  from  the  2  parent  forms  as  undergo- 
ing a  true  chemical  combination,  the  resultant  idioplasm- 
of  the  new  generation  being  in  truth  a  new  idioplams  not 
possessing  the  identical  properties  of  that  of  either  parent, 
but  being  intermediate,  tending  in  its  characters  and 
constitution  towards  the  constitution  of  either  one  or  the 
other,  according,  it  may  be,  to  the  number  or  chemical  ac- 
tivity of  the  molecules  of  one  or  other  parent  entering  into 
combination.  If  the  germ  cells  of  both  parents  possess 
certain  loosely  attached  or  unstable  side  chains  of  more 
recent  acquirement,  which  are  of  like  nature,  there  is  no 
sufficient  reason  why  the  protoplasm  of  the  offspring  should, 
not  also  possess  them.  We  can  thus  realize  how  it  is  that 
abnormal  features  present  in  both  parents  may  be  equally 
or  more  prominent  in  the  offspring.  Two  orders  of  for- 
ces determine  the  structure  of  every  cell  in  the  body:  (1> 
The  previous  influences  acting  upon  its  idioplasm  and  caus- 
ing it  to  be  of  a  particular  consitution,  and  (2)  the  position 
in  which  the  cell  finds  itself  and  the  forces  acting  momen- 
tarily and  immediately  upon  its  idioplasm.  Or,  briefly,, 
these  2  series  of  forces  are  inheritance  and  environment, 
and  inheritance  and  environment  determine  the  constitu- 
tion of  the  idioplasm  and  the  structure  of  the  cells.  In- 
heritance essentially  depends  upon  the  chemical  constitu-> 
tion  of  the  idioplasm  or  the  life-bearing  or  biophoric  pro- 
toplasm of  the  germ  cells,  not  upon  the  number  of  the 
separate  ids  or  biophores  or  ancestral  plasms  or  pangenes 
contained  in  the  idioplasm;  and  variation  whether  slight 
and  individual  or  extensive,  and  leading  to  the  productiou 
of  species,  is  ultimately  the  expression  of  modification  iii' 
the  constitution  of  that  idioplasm  brought  about  by  en- 
vironment. This  conception  of  the  idioplasm  with  attached 
side  chains,  which  are  more  firmly  or  more  loosely  at- 
tached, affords  a  perfectly  adequate  explanation  of  atav- 
ism and  reversionary  degeneration.  We  cannot  conceive 
the  direct  transmission  of  identical  lesions  of  this  order 
from  parent  to  offspring.  Acquired  disease  and  the  effects 
caused  by  disease  cannot  in  general  be  transmitted  in  such 
a  way  that  the  offspring  presents  lesions  identical  with.- 
those  produced  in  the  parent  though  it  has  to  be  recognized 
that  there  is  the  possibility  of  modification  in  that  offspring 
due  to  the  parental  disease.  We  must  recognize  that  con- 
stitutional disease,  by  leading  to  disturbance  in  the  ac- 
tivity of  important  organs,  tells  not  only  directly  upott 
these  organs,  but  secondarily  upon  other  organs — that  it 
leads,  for  example,  to  altered  condition  of  the  blood,  and 
so  to  altered  nutrition  of  all  the  cells  of  the  body.  Among- 
other  cells,  the  germ  cells  may  be  directly  affected,  their 
idioplasm  modified,  and  the  offspring  directly  influenced. 
We  can  see  evidences  of  direct  transmission  of  acquired 
constitutional  states.  The  toxins  circulating  in  the  blood 
of  the  individual  undergoing  immunization  must  also  affect 
the  germ  cells;  they  must  acquire  immunity — and  the  in- 
dividuals developed  from  them  must  have  the  same  proper- 
ties. As  a  matter  of  fact,  this  transmission  of  acquired  im- 
munity has  been  noted  in  rabbits  which  have  been  rendered 
immune  to  the  Bacillus  pyocyaneus.  In  those  cases  in 
which  immunity  is  not  developed,  such  as  in  chronic  con- 
ditions like  tuberculosis,  we  can  comprehend  how  the  tox- 
ins weaken  the  germ  cells  along  the  same  lines  as  they 
weaken  the  general  tissues  of  the  body,  and  as  the  resist- 
ance of  the  body  in  general  to  a  special  micro-organism  and 
its  products  becomes  less  and  less,  so  also  the  idioplasm  ot 
the  germ  cells  becomes  less  and  less  resistant,  and  so 
from  parental  disease  the  offspring  gains  a  peculiar  suscep- 
tibility to  one  special  disease.  If  gout  and  the  gouty  dia- 
thesis are,  as  many  hold  them  to  be,  ot  the  nature  of  true 
autointoxications  we  are  at  liberty  to  regard  the  gouty- 
diathesis  as  an  example  of  truly  somatogenic  acquirement 
of  an  inherited  and  inheritable  constitutional  state.  [J.  M. 
S.] 


1 196 


The    Philadelphia  ■ 
Medical  Journal 


THE  LATEST  LITERATURE 


[Jv.vE    22.    IVh 


2. — Watson  believes  that  tabes  is  not  a  "nervous"  dis- 
ease in  tlie  sense  usually  apprehended,  and  that  the  lesions 
in  and  around  the  vessels  are  of  primary  importance,  the 
lesions  of  the  neurons  being  determined  by  local  interfer- 
ence with  the  blood  supply.  There  is  good  ground  for  the 
belief  that  the  condition  is  dependent  on  a  chronic  auto- 
Intoxication,  the  vascular  lesions  being  to  some  extent  gen- 
eral, but  tending  to  be  more  advanced  locally,  and  that  the 
more  advanced  local  changes  determine  a  failure  of  nu- 
trition in  the  adjacent  nerve  elements.  The  author  had 
an  opportunity  of  observing  a  horse  affected  with  ataxia, 
paraplegia  and  a  bilateral  affection  of  the  knee-joints  of  a 
nature  not  described  in  veterinary  literature.  The  com- 
bination of  clinical  features  led  him  to  diagnose  a  lesion 
of  the  cord,  most  marked  in  the  posterior  columns,  with  as- 
sociated neurotrophic  joint  lesions,  of  a  nature  akin  to 
tabes  in  the  human  subject.  The  lesions  found  at  the  post- 
mortem examination  were  of  a  grosser  and  more  wide- 
spread nature  than  had  been  anticipated,  but  the  diagnosis 
■was  found  to  be  substantially  correct.  The  author  de- 
scribes the  pathological  appearances  of  a  small  piece  of  the 
cord  from  a  case  of  tabes  of  2  years'  duration  in  a  patient 
who  died  from  malignant  disease.  Here  also  the  evidence 
was  confirmatory  of  the  primary  importance  of  vascular 
disease.  The  degree  of  vascular  change  was  profound, 
and  the  degeneration  of  the  nerve  structures,  as  indicated 
by  the  amount  of  softening  ,was  more  acute  than  obtains  in 
cases  of  uncomplicated  tabes.  He  believes  that  in  such  a 
case  we  find  additional  proof  of  the  general  view  of  vas- 
cular disease  as  the  primary  factor  in  the  pathogenesis 
of  tabes  as  advanced  in  this  paper.  Given  an  added 
toxemia  such  as  is  present  in  malignant  disease,  the  result 
■will  be  an  added  severity  in  the  local  lesions  through- 
out the  cord,  and  these  will  be  correspondingly  greater  in 
that  part  of  the  cord  which  is  more  susceptible  to  various 
toxic  influences.  In  cases  that  run  an  acute  course  a  care- 
ful investigation  of  the  history  will  reveal  the  previous  oc- 
currence of  conditions  similarly  capable  of  so  influencing 
the  tissues  as  to  render  them  more  susceptible  to  the  in- 
fluence of  the  toxins  at  work.  Evidence  can  be  adduced 
from  the  histological  study  of  cases  of  advanced  tabes 
in  support  of  the  view  that  the  primary  fault  is  to  be 
found  in  malnutrition  rather  than  in  primary  degeneration 
of  the  nervous  elements.  In  specimens  from  a  case  of  well 
marked  tabes  there  were  advanced  degeneration  of  the  pos- 
terior columns  and  slight  involvement  of  the  lateral  tracts, 
diffuse  degeneration  of  the  cornu-commissural  fibres,  and 
decided  marginal  degeneration  of  the  nerve  fibers  of  the  an 
terior  part  of  the  cord.  The  involvement  of  the  cord  was  a 
very  extensive  one,  and  in  the  opinion  of  the  author  the 
changes  in  the  various  columns  differ  only  in  degree.  The 
vessels  in  the  affected  areas  were  greatly  thickened  and  the 
capillaries  showed  extensive  thickening,  with  diminution  of 
the  lumen,  sometimes  to  obliteration.  The  space  in  some 
cases  were  mere  dilations  of  lymphatic  spaces,  determined 
by  traction  of  the  surrounding  cirrhotic  tissue,  and  in  others 
they  represented  spaces  from  which  nerve  fibres  had  dis- 
appeared. The  nature  and  extent  of  these  changes  indi- 
cated vascular  diseases  as  the  primary  disorder.  More 
especially  is  this  the  case  when  if  is  remembered  that 
disease  of  the  vessls  induced  by  the  long-continued  action 
of  some  irritant  will  cause  defective  nutrition  of  the  related 
oord,  and  that  defective  nutrition  accounts  simply  and  ade- 
quately for  degeneration  of  the  nerve  fibers.  We  find  in  the 
grey  matter  a  varying  degree  of  overgrowth  of  neuroglia. 
This  is  precisely  the  condition  that  occurs  in  the  cells  of 
the  grey  matter  in  the  cortex  in  general  paralysis,  which 
is  associated  with,  and  indeed,  dependent  upon  vascular 
changes  in  the  smaller  vessels  supplying  the  affected 
areas.  The  author  referred  to  the  case  of  a  man  who  was 
suffering  from  tabes  and  in  whom  previous  illnesses  afforded 
good  grounds  for  thinking  that  his  general  powers  of  re- 
sistance to  all  toxic  agents  might  be  materially  lowered. 
This  was  especially  true  of  the  digestive  tract.  The  life 
of  the  patient  and  his  dietetic  habtis  were  specially  favor- 


able to  progressive  diminution  of  the  natural  powers  of  re- 
sistance in  the  gastrointestinal  mucous  membrane.  The. 
initial  symptoms  which  extended  over  a  year,  were  direct- 
ly referable  to  the  digestive  tract.  The  continued  fetor 
of  the  patient's  stools  and  melena  in  the  intervals  be- 
tween the  paroxysms,  indicated  to  the  writer  the  primary 
importance  of  the  intestinal  lesions.  During  the  gastric 
crises  the  patient  presented  a  slightly  pathological  leuko- 
cytosis characterized  by  polymorphonuclears  88^ :  lympho- 
cj-tes,  11%;  eosinophiles,  1%.  Watson  thinks  it  possible 
that  the  crises  are  of  a  nature  akin  to  relapses  in  some  re- 
cognized infective  conditions,  the  difference  being  merely 
one  of  degree.  Anomalous  cases  are  most  readily  ex- 
plained by  the  vascular  theory  of  the  origin  of  the  disease. 

This  theory  will  also  readily  explain  the  relationship  be- 
tween the  onset  of  the  disease  and  traumatism,  exposure  to 
cold  and  the  like:  the  causal  relationship  between  tabes  and 
heart  lesions;  the  cases  of  tabetic  ecchymosis;  and  the 
great  variety  of  clinical  features  seen  in  advanced  cases. 
The  broadest  conclusion  that  we  can  deduce  concerning  the 
relation  between  tabes  and  syphilis  is  that  syphilis  alters 
the  physiological  condition  in  such  a  way  as  to  favor 
the  attack  and  operation  of  the  actual  cause  of  tabes  and 
allied  conditions.  In  this  respect  the  influence  of  syphilis 
is  similar  to  that  of  measles  or  scarlet  fever  in  leading 
to  the  development  of  tuberculosis,  and  similar  also  to  the 
action  of  the  influenza  bacillus  in  relation  to  other  patho- 
genic organisms.  The  proper  line  of  investigation  concern- 
ing the  pathogenesis  of  tabes  is  directed  to  the  discovery 
of  the  nature  and  source  of  the  toxic  substance  at  work. 
The  alimentarj-  tract  furnishes  the  chief  area  of  investi- 
gation, and,  in  all  probability,  it  will  be  proved  to  be  the 
original  source  of  the  toxemia.     [J.  M.  S.] 

3. — Shaw  reports  the  case  of  a  man.  aged  2T  years,  who 
suffered  from  pain  in  the  left  side  of  the  chest,  shortness  of 
breath,  and  weakness,  for  4  months.  The  disease  began  sud- 
denly in  an  attack  of  what  was  considered  to  be  influenza; 
ultimately  "pneumonia  and  pleurisy"  developed.  On  admis- 
sion to  hospital,  the  patient  was  distressed  in  breathing, 
and  had  a  short  spasmodic  cough,  which  caused  consider- 
able pain  in  the  left  chest  and  which  was  accompanied  by  a 
copious,  frothy  expectoration.  There  was  considerable 
flattening  at  the  left  apex,  and,  on  the  same  side,  the  vocal 
fremitis  was  weak  and  the  percussion  note  in  the  lower  part 
of  the  axilla  was  dull,  though  a  skodaic  note  was  obta.iDed 
at  the  apex.  The  breath  sounds  on  the  left  side  were  very 
weak,  more  especially  at  the  base.  The  temperature  ■was 
103.4°,  pulse  IcO,  and  respiration  36.  Fifteen  days  after  ad- 
mission the  patient's  condition  suddenly  became  much 
worse;  he  coughed  up  about  half  a  pint  of  ver>'  offensive, 
purulent  material,  had  great  dyspnea  and  cyanosis,  and 
died  a  few  hours  later.  The  pathological  diagnosis  made  at 
autopsy  was  sarcoma  of  the  root  of  the  left  lung,  producing 
stenosis  of  the  bronchus  and  the  vessels,  and  associated 
with  pneumonia,  probably  due  to  the  septic  organisms 
present.  The  lung  condition  closely  resembled  that  met 
with  in  tuberculosis,  with  the  exception  that  the  process 
was  more  marked  at  the  base  than  at  the  apex.     [J.  M.  S.J 

4. — Buzzard  referred  to  the  case  of  a  patient  who  was 
suffering  from  a  typical  form  of  pulmonary  hypertrophic 
osteo-arthropathy  which  was  published  in  the  British  J/fdi- 
cal  .Journiil.  February  8.  1836.  The  patient  died  of  gradual 
cardiac  failure.  At  the  necropsy  the  skull  was  found  con- 
siderably thicker  than  normal,  and  the  bones  were  very 
hard  and  dense.  There  was  edema  of  the  brain:  the  pitui- 
tary body  was  soft  and  a  little  purulent  material  appeared 
to  escape  from  it  There  was  a  marked  curvature  at  the 
level  of  the  third  and  fourth  dorsal  vertebrae.  An  abscess 
cavity  situated  at  the  root  of  the  right  lung  opened  into  the 
spinal  canal  from  the  front,  but  the  whole  of  the  disease 
lay  outside  the  dura  mater  which  was  covered  with  thick 
granulations.  The  cord  presented  a  somewhat  softened  ap- 
pearance at  the  level  of  the  disease.  Xo  changes  could 
be  found  in  the  internal  aspect  of  the  left  wrist  joint,  but 
examination  of  the  ends  of  the  ulna  and  the  radius  showed 


June 


1901] 


THE  LATEST  LITERATURE 


TThe    Philadelphia 
L  Medical  Journal 


I  197 


them  to  be  thicker  than  normal,  the  increase  in  thickness 
affecting  the  dense  bone  more  than  the  cancellous.  Ascend- 
ing and  descending  degenerations  could  be  seen  in  sections 
of  the  spinal  cord  above  and  below  the  lesion  in  the  upper 
dorsal  region.  The  median,  ulnar,  anterior  crural  digital 
and  sciatic  nerves  presented  no  degenerated  fibres.  There 
were  no  appreciable  alterations  in  the  bones  or  joints  of 
one  finger.  The  lungs  showed  marked  thickening  of  the 
pleura  and  a  very  fibrotic  condition  of  the  pulmonary  tis- 
sue, but  no  tubercles  or  definite  caseation.  Sections  of  the 
pituitary  body  showed  chornic  inflammatory  change  but 
no  tubercles.     [J.  M.  S.] 

5. — The  question  that  an  examining  physician  to  a  sana- 
torium for  tuberculous  patients  is  called  upon  to  decide  is: 
Can  recovery  or  an  approach  to  it  be  reasonably  expected 
after  treatment  of  the  patient  for  6  months?  After  a  care- 
ful consideration  of  the  extent  of  the  disease,  as  evidenced 
by  the  physical  signs,  and  the  acuteness  of  the  process 
indicated  by  the  course  of  the  temperature,  due  regard 
should  be  paid  to  the  pulse.  Having  noted  the  rate  when 
patients  presented  themselves  for  examination  prior  to  ad- 
mission, and  compared  it  with  the  record  obtained  during 
a  week's  confinement  to  bed  Campbell  finds  that  on  an 
average  there  is  a  decrease  of  20  beats  per  minute  in  the 
latter  case,  the  difference  being  naturally  sm'allest  when 
there  has  been  the  least  departure  from  the  normal  rate 
in  the  first  instance.  Thus  to  form  a  true  impression  of 
the  vita!  powers  in  the  caseofaphthisical  subject  presenting 
himself  in  the  consulting  room,  20  beats  can,  on  an  aver- 
age, be  subtracted  from  the  pulse-rate  observed  during  the 
examination.  If,  on  making  this  allowance,  the  pulse-rate 
exceeds  100,  the  case  is  not  likely  to  exhibit  an  approach 
to  recovery  in  the  time  mentioned  above,  and  is  therefore 
not  suitable  for  admission.  In  the  case  of  patients  under 
more  direct  observation,  if,  after  a  period  of  complete  rest 
in  bed.  the  pulse  continues  to  run  at  or  exceed  100  outlook 
is  not  promising.  In  cases  of  tuberculosis  complicated 
by  mitral  stenosis,  a  pulse-rate  exceeding  100  is  not  of  much 
grave  import  so  far  as  the  tuberculous  process  is  concerned. 
In  attaching  a  significance  to  the  pulse-record  in  cases  of 
pulmonary  tuberculosis,  allowance  must  be  made  for  the 
possibility  of  over-exertion,  excitability  under  examina- 
tion and  the  presence  of  mitral  stenosis;  but,  with  these 
reservations,  some  assistance  will  be  obtained  in  making 
a  pronouncement  regarding  the  probable  duration  of  life. 

[J.  M.  S.] 

6. — Syers  holds  that  in  at  least  95%  of  the  cases  in 
which  aortic  reflux  occurs  the  diastolic  murmur  is  heard 
much  more  loudly  at  the  second  left  interspace  close  to 
the  sternum  than  in  the  second  right  interspace.  This  un- 
doubtedly accounts  for  the  fact  that  aortic  reflux  murmurs 
are  constantly  overlooked.  The  mistake  has  arisen  partly 
in  the  growing  tendency  to  employ  the  binaural  instrument. 

[J.  M.  S.] 

7. — 'Will  be  treated  editorially. 

8. — Griinbaum  criticises  the  conclusions  of  Rosenheim 
and  Tunnicliffe  concerning  the  Influence  of  boric  acid  and 
borax  upon  tlie  general  metabolism  of  children.  Only  3 
experiments  were  made.  Obviously  very  little  weight  can 
be  attached  to  negative  results  of  3  experiments  even  if 
they  are  all  concordant,  especially  since  positive  results  of 
injury  are  on  record.  The  period  of  administration  was 
only  12  days.  This  is  rather  a  short  time  from  which  to 
draw  general  conclusions.  The  age  of  the  children  varied 
from  2y2  to  5  years— that  is,  well  over  the  age  in  which 
milk  usually  forms  tue  only  article  of  diet,  and  the  age 
at  which  the  alimentary  canal  is  most  sensitive.  But  the 
mere  fact  that  the  metabolism  remained  practically  un- 
altered is  not  per  sc  evidence  that  the  boric  acid  compounds 
caused  no  injury.  Boric  acid,  as  well  as  borax,  has  a  dis- 
tinctly inhibiting  effect  on  the  rennet  ferment  if  added  in 
proper  solution.  Although  it  is  correct  that  no  erythe- 
matous rashes  have  been  recorded  through  taking  borax 
with  food  the  authors  have  omitted  to  mention  the  far  more 


important  fact  that  other  more  serious  toxic  effects,  which 
could  hardly  have  been  due  to  anything  else,  have  been  re- 
corded as  the  result  of  taking  milk  drugged  by  the  dealer 
with  borax.  The  quatities  of  borax  given  were  certainly 
much  loss  than  that  required  to  inhibit  bacterial  growth  in 
milk  and  less  than  required  to  preserve  milk  for  24  hours 
in  summer.  It  is  impossible  to  judge  from  an  experiment 
of  2  or  3  weeks'  duration  whether  taking  a  drug  over 
a  lengthened  period,  especially  in  infancy,  may  not  affect 
the  length  of  a  man's  life.  There  is  no  reason  to  suppose 
that  any  ordinary  organic  or  inorganic  substance  which  will 
injuriously  affect  a  cell  like  a  bacterium,  does  not  also  in- 
jure the  cells  of  the  alimentary  canal.  The  specific  anti- 
toxins and  similar  bodies  are  of  course  exceptional.  The 
repair  of  these  injured  cells  throws  a  strain  on  the  or- 
ganism which  it  would  not  have  had  without  the  addition 
of  tiie  preservntive  to  the  food.  The  fact  that  the  commonlv 
employed  antiseptic  preservatives  are  rapidly  eliminated 
by  the  kidneys,  either  unchangea  or  only  slightly  changed, 
is,  to  the  author's  mind,  the  most  conclusive  evidence  of 
their  poisonous  character.  It  throws  an  uncalled  for  bur- 
den on  the  normal  kidney,  and  when  the  kidney  is  no  longer 
normal,  may  be  positively  dangerous.     [J.  M.  S.] 


LANCET. 


June  1st.   1!)01. 

1.  A   Clinical  Lecture  on  Acroparesthesia,   Erythromelal- 

gia,    Sclerodactylia,    and    other    Angio-neurotic    Dis- 
turbances, etc.     THOMAS  D.  SAVILL. 

2.  Arterial   Hypertonus   and    Arterio-Sclerosis;    their   Re- 

lation and   Significance.     WILLIAM   RUSSELL. 

3.  The  Bacteriology  of  Sporadic  Cerebro-spinal  Meningitis. 

WILLIAM  HUNTER  and  ALEXANDER  W.   NUTH- 
ALL. 

4.  On  the  Operative  Treatment  of  Corneal  Astigmatism. 

A.  BREUER. 

5.  A  Further  Note  on  the  Technique  of  the  Quantitative 

Estimation  of  the  Bactericidal  Power  of  the  Blood, 

etc.  A.  E.  WRIGHT. 
1. — Savill  delivered  a  lecture  at  the  West  End  Hospital 
for  Diseases  of  the  Nervous  System,  on  acroparesthesia, 
erythromelagla,  sclerodactylia,  and  other  angioneurotic 
disturbances.  The  author  defines  acroparesthesia,  as  a 
symptom,  characterized  by  tingling  and  numbness,  and  oc- 
casionally by  redness  and  swelling  of  the  hands  and  feet. 
This  condition  is  frequently  associated  with  such  condi- 
tions as  general  paralysis,  tabes  dorsalis,  or  gastric  dis- 
turbances, but  may  occur  without  these  morbid  states. 
The  main  features  of  the  disease,  erythromelalgia,  are 
painful  redness,  and  swelling  of  the  extremities.  The 
term  sclerodactylia  is  defined  as  meaning  a  localized  form 
of  scleroderma  affecting  the  fingers  and  toes,  and  occasion- 
ally the  ankles,  legs,  wrists,  and  fore-arms.  He  contends 
that  these  conditions  are  undoubtedly  related  to  Ray- 
naud's disease.  He  believes  that  acroparesthesia  and  ery- 
thromelalgia are  probably  closely  allied  with  Raynaud's 
disease,  and  during  the  past  two  years  the  author  has  met 
with  some  thirty-five  patients  presenting  more  or  less 
definite  symptoms  pertaining  to  this  class  of  diseases.  Af- 
ter giving  a  report  of  a  number  of  cases,  Savill  sug- 
gests the  following  clinical  classification  of  vaso-motor  dis- 
orders of  the  extremities:  (1)  Taxo-dilatnr  disturbances,  (a) 
the  early  chronic  stage  being  characterized  by  attacks  of 
redness,  tingling,  and  burning  (congestive  acroparesthe- 
sia); (b)  the  late  chronic  stage  is  characterized  by  perman- 
ent swelling  (erythromelalgia);  (c)  Should  these  condi- 
tions be  acute,  the  symptoms  go  on  to  gangrene  (congestive 
or  asphyzial  type  of  Raynaud's  disease).  (2)  Vam-eonxtrirtor 
dinturl)(uice.i.  (a)  the  early  chronic  stage  being  charaterized 
by  pallor,  numbness,  and  tingling  of  the  extremities 
(Ischemic  acroparesthesia);  (b)  the  late  chronic  stage  is 
characterized  by  thickening  of  the  skin  and  subcutaneous 
tissues  (sclerodactylia);   U)  If  these  conditions  should  be- 


..1 198 


The    Philadelphia 
Medical  Journal 


THE  LATEST  LITERATURE 


[JVNE   22.    ISCl 


come  acuae  dry  gangrene  probably  results  (syncopal  type 
of  Raynaud's  diseases.)      [F.  J.  K.] 

2. — Russell  read  a  paper  before  the  Medico-chirurgical 
Society  of  Edinburgh  on  May  1,  1901,  on  "Tlie  Relations  and 
Significance  of  Arterial  Hypertonus  and  Arteriosclerosis." 
The  author  gives  an  account  of  the  literature  of  this  sub- 
ject and  his  personal  observations.  He  contends  that  re- 
curring or  continued  hypertonus  is  finally  followed  by  hy- 
pertrophy of  the  muscular  media  of  the  arteries. 

3. — Hunter  and  Nuthall  discuss  the  bacteriology  of  cere- 
bro  spinal  meningitis.  They  give  a  report  of  ten  cases 
and  conclude  that  a  diplococcus  was  found  in  the  cerebro- 
spinal fluid  of  all  the  cases.  Morphologically  and  biolo- 
gically this  diplococcus  was  identical  with  Weicheslbaum's 
diplococcus  intracellularis  meningitidis.  In  some  of  the 
cases  bacillus  influenzEe  and  the  bacillus  of  tuberculosis 
■were  associated,  while  in  others  the  diplococcus  was  found 
in  pure  culture.  The  clinical  and  pathological  manifesta- 
tions, found  in  the  cases  they  analyzed,  were  identical 
■with  those  of  the  so-called  posterior  basal  meningitis.  They 
suggest  that  posterior  basal  meningitis  is  probably  a 
sporadic  form  of  cerebro  spinal  meningitis  due  to  the  dip- 
lococcus intracellularis  meningitidis.     [F.  J.  K.] 

4. — Breuer  has  obtained  good  results  from  cauterization 
in  corneal  astigmatism.  He  selected  only  such  cases  for 
operation  in  which  there  was  a  reasonable  chance  that  the 
patient  could  be  left  without  glasses  afterwards.  The 
operation  was  therefore  confined  to  cases  of  mixed  as- 
stigmatism  and  compound  hypermetropic  astigmatism,  the 
best  results  having  been  obtained  in  the  latter  cases.  An 
over-effect  should  always  be  produced,  and  according  to  the 
author  the  part  which  is  lost  seems  to  be  less  in  adults  than 
In  children.  The  more  superficial  and  peripheral  the  cau- 
terization, the  better  chance  is  there  for  the  result  to  dis- 
appear in  time.  But  if  cauterization  extends  through  one 
half  the  thickness  of  the  cornea,  a  permanent  result  will 
ensue.  He  advises  the  operation  in  cases  of  compound 
hypermetropic  astigmatism  of  high  degree.  He  employed 
the  ordinary  loop  of  fine  platinum  ■w'ire  connected  with 
the  electric  main,  (alternating  current)  by  a  transformer 
and  rheostat.  The  author  employs  red  heat  and  produces 
a  small  punctate  burn  in  the  limbus  of  the  cornea  or  in  the 
cornea  itself,  penetrating  about  one  half  the  thickness  of 
the  cornea.  The  cauterization  is  performed  under  local 
anesthesia.     [M.  R.  D.] 

5.— Will  be  treated  editorially.     [F.  J.  K.] 


MEDICAL    RECORD. 

.June   L'l.    I'.liil. 


1.  A  Note  on  the  spread  of  Yellow  Fever  in  Houses.     Ex- 

trinsic incubation.     H.  R.  CARTER. 

2.  On  the  Origin  of  Cancer:     What  Remains  to  be  Demon- 

strated.    SAMUEL  W.  BANDLER. 

3.  The  Redundancy  of  the  Preinsula  in  the  Brains  of  Dis- 

tinguished Educated  Men.     EDWARD  A.  SPITZKA. 

1. — H.  R.  Carter  discusses  the  extrinsic  incubation  of  yel- 
low fever.  He  mentions  instances  in  which  patients  visit- 
ing infected  houses  long  after  the  disease  is  supposed 
to  have  disappeared,  have  suffered  from  attacks  of  yellow 
fever.  Carter  concludes  that  the  intervals  between  the  in- 
fecting cases,  and  the  first  and  secondary  cases  are  habit- 
ually, considerably  greater  than  the  period  of  incubation  of 
yellow  fever.  Yellow  fever  is  then  not  contracted  in  any 
of  these  houses  by  those  residing  continually  in  them  un- 
til a  considerable  time  (in  days)  after  the  development 
of  the  infecting  cases,  although  these  same  inmates  had 
contracted  the  disease  in  the  same  houses.  Later  cases  of 
yellow-  fever  which  occurred  aboard  ship  after  detention  at 
marine  and  quarantine  stations  have  not  been  followed  by 
others  among  the  crew.    Cases  of  yellow  fever  which  occur 


in  houses  disinfected  soon  after  were  not  followed  by  other 
cases  among  the  inmates.  Cases  of  yellow  fever  which  oc- 
curred in  houses  vacated  soon  after,  have  not  been  fol- 
lowed by  other  cases  from  inmates  leaving,  although  cases 
occurred  among  those  who  remained  in  the  houses  or 
neighborhood.  Cases  of  yellow  fever  which  occur  in  clean 
houses,  are  not  often  followed  by  other  cases  among  the 
inmates  exposed  to  no  other  infection  until  after  such  time  as 
shows  that  the  disease  was  not  contracted  for  a  number 
of  days  after  the  development  of  the  first  case,  although 
the  same  inmates  had  developed  yellow  fever  from  these 
same  houses  later.  It  is  evident  that  a  knowledge  of  the 
interval  in  a  sufiBcient  number  of  instances,  is  sufficient  to 
determine  approximately  the  usual  period  of  intrinsic  incu- 
bation. He  concludes  that  from  10  to  17  days  after  the 
development  of  the  infecting  case  seems  to  be  about  the 
usual  limits  for  contracting  the  disease  by  the  first  of  the 
secondary  cases  when  there  are  many  of  such  cases  in  a 
house.  This  determination  of  the  period  of  intrinsic  incu- 
bation is  an  approximate  one  only.     [T.  L.  C] 

2. — Samuel  W.  Bandler,  apropos  of  the  Gaylord's  work  on 
the  origin  of  cancer,  touches  upon  some  of  the  investiga- 
tions which  have  been  made  in  this  field.  Leopold's  results 
are  expressed  in  the  following  chain:  1.  In  the  fresh  ovar- 
ian carcinoma  of  a  certain  patient  were  found  blastomy- 
cetee.  2.  From  this  fresh  carcinomatous  tissue  a  pure  cul- 
ture of  blastomyceta  was  obtained.  3.  This  pure  culture,  in- 
jected into  the  testicle  of  a  rat,  produced  a  large  number  of 
peritoneal  nodules  (but  not  corcinoma)  causing  the  death  of 
the  rat,  and  in  the  fresh  as  well  as  in  the  hardened  tissue 
were  a  large  numbers  of  blastomyceta.  4.  From  these 
nodules  a  pure  culture  of  blastomycetae  was  obtained.  If 
we  are  successful,  on  inoculation  of  this  last  pure  culture 
into  rats,  in  producing  in  them  again  neoplasms  which 
are  of  such  a  character  that  they  produce  death  of  the 
animal,  then  the  ring  is  complete  and  no  doubt  can  be 
well  entertained  that  blastomycetae  are  able  to  produce 
malignant  neoplasms.  The  causual  relation  of  blastomy- 
cetae to  the  growths  produced  in  animals  by  Leopold  must 
be  granted.  The  decision  concerning  the  character  of  these 
neoplasms  and  their  actual  relation  to  carcinoma  and  sar- 
coma is  to  be  the  controversial  point.     [T.  L.  C] 

3. — Edward  Spitzka  discusses  the  redundancy  of  the  pre- 
insula in  the  brains  of  distinguished  educated  men.  The 
insulae  of  the  human  brains  are  of  fundamental  importance 
in  the  interpretation  of  mental  stages.  The  writer  was 
afforded  exceptional  opportunity  in  the  study  of  the  brains 
of  the  Sequins  (father  and  son),  with  particular  reference 
to  a  region  whose  development  is  related  to  that  of  the 
regions  to  which  the  faculty  of  speech  is  referred.  In  the 
brains  of  Dr.  Edouard  Sequin  and  his  son.  Dr.  Edward  C. 
Sequin,  the  left  preinsula  is  exposed.  The  appearances  of 
the  brains  are  quite  indicative  of  high  intellectual  capacity 
nor  are  the  opercular  regions  in  the  least  defective, 
though  they  fail  to  come  into  typical  apposition  on  the  left 
side.  The  explanation  of  this  anomaly  is  corroborative  of 
Waldschmidfs  report  upon  the  brains  of  the  two  Professors, 
namely,  that  the  left  preinsula  is  better  developed  than 
its  fellow  on  the  right  side.  So  great  is  this  development 
in  the  two  brains  under  examination,  that  the  left  preinsu- 
las  are  virtually  thrust  aside  the  opercular  parts  and  made 
itself  visible.  Spltzka's  conclusions  are  that  in  the  highly 
intellectual  (for  example  the  two  Sequins)  owing  to  the 
excessive  growth  and  development  of  the  left  preinsula 
causing  a  displacement  of  the  opercula  thrusting  them 
apart,  as  it  were,  even  though  the  latter  be  very  well  de- 
veloped. In  the  defective,  exposure  of  the  preinsula  is  due 
to  deficient  development  of  the  opercula  and  because  these 
fail  to  approach  each  other.  In  such  cases  the  insula  itseU 
is  -nithout  a  single  exception  in  the  series  studied  by  this 
writer,  of  inferior  development,  indicated  not  only  by  the 
soundings  of  the  Sylvian  cleft,  but  also  by  the  flatness  ol 
configuration,  and  lesser  area  of  the  insula  cortex.  [T. 
L.  C] 


June  22.   1901] 


THE  LATEST  LITERATURE 


["The    Philadelphia 
L  Medical  Jourkal 


I  199 


NEW    YORK    MEDICAL   JOURNAL. 

Jinie  16,   I'JOl.      (Vol.   LXXIII,   No.   24). 

1.  An  X-Ray  Study  of  the  Causes  of  Disability  following 

Fractures    Involving    the    Elbow    Joint.      SAMUEli 
LLOYD. 

2.  A   Modified   Urethral  Dilator-handle.     FERD.   C.   VAL- 

ENTINE. 

3.  Hyperacidity     (Superacidity,    Hyperchlorydria,    Super- 

aciditas      Chlorhvdrica).       A   Clinical      Study.       H. 
ILLOWAY. 

4.  Penetrating  Wounds   of  the  Abdomen.     RUSSELL  S. 

FOWLER. 

5.  Paramyoclonus  Multiplex.     L.  J.  MORTON. 

6.  A  Case  of  Cerebellar  Apoplexv,  with  Autopsy.     LEON- 

ARD WEBER. 
2. — The  advantages  put  forth  by  Valentine  In  his  article 
on  modified  urethral  dilator-handle  are  the  following:  (1) 
While  being  guided  by  the  amount  of  resistance  for  each 
increase  of  dilatation,  the  dial  is  continually  under  the 
operator's  eye,  positively  guarding  against  any  excess  of 
dilatation  and  making  any  change  of  position  unnecessary; 
<2)  Having  no  dial  or  shield  at  its  sides,  this  modified 
dilator  is  more  easily  introduced  and  more  easily  held  in 
position  during  its  employment;  (3)  The  dial,  being  be- 
yond the  patient's  range  of  vision,  offers  him  no  inducement 
unnecessarily  and  even  dangerously  to  increase  its  calibre; 
(4)  The  improved  mechanism  of  this  dilator-handle  sim- 
plifies the  construction  of  the  instrument  without  increas- 
ing its  cost.     [T.  M.  T.) 

5. — Morton  describes  paramyoclonus  multiplex  as  a 
spasm  of  several  muscles  of  the  face,  neck,  arms  and  lower 
limbs,  as  well  as  of  the  muscles  of  the  trunk.  The  muscles 
of  the  hands  and  feet  are  not  involved.  The  spasms  are 
clonic  and  are  usually  symmetrical  and  at  times  more  vio- 
lent than  at  others;  the  contractions  vary  in  violence  and 
frequency,  the  latter  from  five  to  fifty  minutes.  The  ex- 
ternal muscles  are  most  frequently  involved.  This  kind  of 
tremor,  with  the  shifting  and  varying  forms  of  contraction, 
does  not  always  render  a  diagnosis  easy.     [T.  M.  T.] 


MEDICAL    NEWS. 
June  15.  laoi.     CLXXVIII,  No.  24). 

1.  Decortication    of    the    Lung    for    Chronic    Empyema. 

GEORGE  RYERSON  FOWLER. 

2.  A  Study  of  Some  Complications  and   Sequelae  of  Ty- 

phoid Fever.     H.  A.  HARE  and  H.  R.  M.  LANDIS. 

3.  "The  Porro-Cesarian   Operation,"  with  Report  of  Two 

Successful  Cases.     JAMES  H.  GLASS. 

4.  The   Treatment   of   Scarlatinal   Nephritis.     CHARLES 

GILMORE  KERLEY". 
1. — In  his  article  on  Decortication  of  the  Lung  for  Chron- 
ic Empyema.  Fowler  gives  the  following  conclusions;  (1) 
Decortication  of  ihe  lung  is  an  operation  adapted  to  all 
cases  of  old  empyema  in  which  extensive  and  pre-opera- 
tively  discoverable  tuberculous  lesions  of  the  lungs  are 
not  present,  and  in  which  the  patient's  condition  will  per- 
mit of  a  major  operation;  (2)  It  may  be  advantageously 
substituted  for  Estlander's  operation  in  the  majority  of  in- 
stances in  which  the  latter  has  been  considered,  up  to  the 
present  time,  as  bein.g  indicated,  since  it  is  more  a  rational 
procedure  in  that  it  combines  the  advantages  of  restora- 
tion of  function  of  the  lung,  so  far  as  this  is  possible,  with 
closure  of  the  empyemic  cavity;  (3)  It  should  replace 
Schede's  operation  in  all  cases:  (4)  The  method  of  extir- 
pation of  the  diseased  portion  of  the  pleural  membrane,  in- 
cluding the  visceral,  cortical,  and  diaphragmatic  portions, 
is  the  operation  of  choice:  (5)  Failing  this,  visceral  pleu- 
rectomy  should  be  selected:  (6)  Pleurotomy,  with  simple 
detachment  of  the  visceral  layer  of  the  diseased  pleural 
membrane,  gives  sufficiently  good  results  to  warrant  the 
surgeon  in  resorting  to  this  procedure  in  cases  in  which 
the  condition  of  the  patient  will  not  permit  the  application 
of  the  other  and  more  desirable  methods;  (7)  Whatever 
operative  method  is  adopted,  as  complete  access  to  the 
cavity  of  the  chest  as  possible  should  be  obtained,  and  rapid 
closure  of  the  opening  in  the  chest-wall  secured,  since  the 
complete  rec:\paiision  of  the  hmg  must  depend  largely 
upon  the  normal  respiratory  movements;  (8)  Pulmonary  or 
respiratory  exercises  should  not  be  neglected  in  the  after- 
tre.atment,  since  these  aid  greatly  in  the  restoration  of  the 
function  of  the  lung.     [T.  M.  T.] 


2. — Hare  and  Landis,  in  their  paper  on  Some  Complica- 
tions and  Sequelae  of  Typhoid  Fever,  take  up  the  various 
interesting  facts  as  follows:  (1)  Typhoid  Fever  in  Preg- 
nancy: (2)  Typhoid  Fever  in  Children;  (3)  Symptoms  in 
Children;  (4)  Temperature  in  Children;  (a)  Eruption  iu 
Children;  (6)  Circulatory  and  Nervous  Symptoms;  {T> 
Mildness  of  Onset;  (S)  Abrupt  and  Severe  Onset;  (9) 
Chills;  (10)  Abortive  Type;  (U)  Alimentary  Symptoms  at 
Onset;  (12)  Respiratory  Symptoms  at  Onset;  (13)  Nervous 
Symptoms  at  Onset;   (14)  Renal  Lesions  at  Onset.  [T.M.T.] 

3. — Glass  gives  the  following  indications  for  the  Porro 
operation  as  formulated  by  Howard  A.  Kelly:  il)  Where 
there  is  good  reason  to  anticipate  sepsis,  where,  for  ex- 
ample, the  patient  is  exhausted  from  protracted  labor,  and 
where  manual  or  instrumental  efforts  at  delivery  have  been 
made  repeatedly  or  without  due  antiseptic  precautions; 
(2)  Where  there  is  cancer  of  the  cervix  uteri:  i3)  Where 
the  uterus  contains  myomatous  tumors  which  block  the 
pelvis  or  which  canot  be  safely  removed  by  myomectomy: 
(4)  Where  there  is  an  extensive  atresia  of  the  vagina;  (5) 
Where  there  are  bilateral  ovarian  tumors  and  no  sound 
part  of  an  ovary  can  be  found  and  left;  (6)  When  hem- 
orrhage from  the  placental  site  is  uncontrollable.     [T.M.T.J 


BOSTON   MEDICAL  AND  SURGICAL  JOURNAL. 
June  13th.   Uml. 

1.  Internal   Medicine   in  the  Nineteenth   Century.     N.   S. 

DAVIS. 

See  Philadelphia   Medical  Journal,  Page  1120.     June 

15,  190L 

2.  Some    Observations    on    Chronic    Seminal    Vesiculitis. 

ARTHUR   L.   CHUTE. 

3.  lodophilia.    THEODORE  DUNHAM. 

2. — Chute  and  O'Neill  found  60  cases  of  seminal  vesicul- 
itis among  540  out-patients  presenting  various  sorts  of 
genitourinary  disease  in  a  clinic  that  has  a  wide  reputation 
among  gonorrheal  patients,  but  in  which  syphilis  is  not 
treated.  The  symptoms  of  seminal  vesiculitis  may  be  di- 
vided, perhaps  rather  artificially,  into  the  direct  and  the 
reflex.  Among  the  direct  symptoms  are  feelings  of  vague 
discomfort  in  the  rectum  and  perineum,  which  at  times 
become  actual  pain  and  discomfort  on  defecation:  persist- 
ence of  discharge  or  shreds,  in  patients  in  whom  stricture 
and  other  gross  urethral  lesions  can  be  ruled  out;  the  per- 
sistence of  small  comma-shaped  shreds  from  the  prostatic 
urethra;  the  recurrence,  without  any  indiscretion  on  the 
part  of  the  patient,  of  a  urethral  discharge  which  had 
nearly  or  quite  stopped:  frequency  of  micturition  some- 
times associated  with  more  or  less  tenesmus:  nocturnal 
emissions  slightly  streaked  with  blood,  and  the  persistence 
of  mucoid  discharge  from  the  glands  of  the  urethra.  The 
reflex  symptoms  comprise  all  the  symptoms  more  com- 
monly ascribed  to  sexual  neurasthenia.  The  most  charac- 
teristic symptoms  of  seminal  vesiculitis  are  the  occurrence 
of  irregularities  in  the  function  of  erection.  In  the  early 
stages  of  the  disease  it  is  common  to  have  a  great  increase 
in  sexual  desire,  which  in  later  stages  gives  way  to  sexual 
apathy  and  impotence.  Absolute  diagnosis  can  only  be 
made  by  rectal  examination.  The  examination  should  be 
made  with  an  empty  rectum  and  a  moderately  full  bladder; 
the  patient  should  stand  with  his  feet  apart,  bending  well 
forward  over  a  chair,  and  his  legs  should  be  straight  at  the 
knee.  The  examiner  should  make  suprapubic  pressure  with 
his  hand  or  closed  fist  so  as  to  crowd  the  pelvic  viscera 
down  so  that  the  vesicles  are  more  accessible.  When  the 
vesicles  and  ducts  are  diseased,  they  are  enlarged  and 
hard  to  the  touch,  and  the  patient  complains  of  tenderness 
when  they  are  palpated.  In  other  cases  one  feels  nothing, 
and  tlie  examination  will  show  only  unilateral  or  bi- 
lateral tenderness.  Various  irregularities  in  the  contour 
and  consistency  of  the  prostate  may  be  made  out.  After 
massage  the  material  that  drips  from  the  meatus  during 
the  stripping  process  is  milky  and.  on  immediate  examina- 
tion of  its  contained  detritus,  if  all  the  sperma- 
tozoa are  non-motile  it  Is  a  pathognomonic  sign  of 
vesiculitis.  Non-motile  spermatozoa  in  the  detritus 
washed  out  by  the  urine  is  not  decisive.  The  urine 
voided  after  massage  is  usually  more  or  less  turbid,  with  a 
slightly  opalescent  tint,  and  in  it  there  are  often  little  case- 
ous-looking masses  which  are  heavy  and  fall  to  the 
bottom  of  the  glass.  These  are  made  up  of  epithelial  and 
pus  cells,  and  frequently  contain  large,  partly-rolled  plates 


I200 


The    Philadelphia- 
Medical  Journal    _ 


THE  LATEST  LITERATURE 


[June  22.   1901 


of  mucus.  The  treatment  that  yields  the  best  results  in- 
cludes massage  of  the  prostate  as  well  as  of  the  vesicles 
and  ducts.  Massage  should  be  performed  by  the  terminal 
phalanx  of  the  right  forefinger,  which  should  gently  stroke 
the  diseased  tissues  in  a  downward  direction.  At  first  the 
patients  are  massaged  at  intervals  of  from  5  days  to  a 
week.  Later,  the  intervals  are  longer  and  the  massage 
more  thoroughly  done.  It  the  patient  has  emptied  his  blad- 
der and  cannot  pass  urine  after  massage  it  is  wiser  to  fill 
his  bladder  with  mild  corrosive. sublimate  permangamate  or 
nitrate  of  silver  solution,  and  then  allow  him  to  pass  it.  In  a 
few  instances  a  mild  cystitis  has  followed  massage  when  the 
refuse  has  not  been  washed  out  at  once.  When  the  dis- 
ease has  been  of  long  duration  dilating  seems  to  have  a 
beneficial  effect.  Hot  rectal  irrigations  through  a  double 
current  tube,  tonics  and  hygiene  are  useful  accessories  to 
the  treatment.  To  allow  sexual  intercourse  occasionally 
when  the  treatment  is  pretty  well  advanced  seems  probably 
not  harmful,  but  to  advise  it  as  a  therapeutic  measure  is  a 
great  mistake.     [J.  M.  S.] 

3. — Dunham  uses  a  solution  composed  of  3  parts  potas- 
sium iodide  and  1  part  of  iodine  in  100  parts  of  water,  which 
is  thickened  to  a  syrupy  consistency  by  the  additon  of 
lumps  of  gum  arable.  The  blood  smear,  prepared  in  the 
usual  way,  is  mounted  in  a  drop  of  this  syrup.  The  lympho- 
cytes and  the  eosinophiles  are  not  affected  by  the  stain. 
In  normal  blood,  the  polymorphonuclear  neutrophiles  are 
either  unaffected  or  their  protoplasm  is  tinged  a  faint 
pinkish  or  brownish  color.  Under  some  pathological  con- 
ditions the  protoplasm  of  a  certain  proportion  of  the 
polymorphonuclear  neutrophiles  takes  on  a  reddish-brown 
color;  in  some  it  is  a  diffuse  stain,  in  some  a  granular 
net-work,  while  In  others  the  color  is  confined  to  a  large  or 
small  refractive  granules,  varying  in  tint  from  a  light  pink 
to  a  dark  red.  When  one  or  more  such  leukocytes  can  be 
found  in  a  search  of  a  few  minutes  we  have  the  condition 
which,  for  the  sake  of  brevity,  the  author  calls  "idio- 
philia."  The  condition  is  apparently  always  present  in 
progressive  suppurations  and  in  progressive  pneumonias. 
In  acute  suppuration  the  intensity  of  the  reaction  is  said 
to  be  closely  related  to  the  intensity  of  the  process.  In 
cases  of  so-called  tuberculous  abscess  the  reaction  is  ab- 
sent. Abscesses  caused  by  the  germs  of  acute  suppuration, 
but  which  are  well  walled  off  and  have  assumed  an  indolent 
course,  rarely  give  tne  reaction.  In  2  cases  of  pneumonia 
the  reaction  appeared  before  physical  or  other  signs  were 
especially  suggestive  of  that  disease.     [J.  M.  S.] 


JOURNAL     OF     AMERICAN      MEDICAL     ASSOCIATION, 
June   1.7,    I'.inl. 

1.  The  Natural  Method  of  Teaching  the  Subject  of  Medi 

cine.     WILLIAM  OSLER. 

2.  Relation  of  the  Medical   Profession  in  the  Twentieth 

Century  to  the  Tuberculosis  Problem.     S.  A.  KXOPF. 

3.  Gumma  of  the  Spermatic  Cord,  with  Report  of  a  Case 

R.  R.  CAMPBELL. 

4.  Surgical    Shock.     WILLIAM    H.    GERMAN. 

5.  Non-Constrictivo  Dressing  for  Fractures.  J.  F.  PRITCH- 

ARD. 

6.  Acute  Glaucoma   Developing  in  a  Cataractous  Eye.  af- 

ter  Cataract   Extraction   in   other   Eye.     Iridectomy 
and  Cure.     H.  N.  RAFFERTY. 

7.  Sitophobia  of  Enteric  Origin.     MAX  EINHORN. 

8.  The  Relation   Existing  Between   Diseases  of  the  Con- 

junctiva. Nose  and  Throat.     HEMAN  H.  BROWN. 

9.  Round  Ligament  Ventrosuspension  of  the  Uterus,     D. 

TOD    GILLIAM, 

10.  JIagnetic  Foreign  Bodies  in  the  Eye.     E.  VILLIERS 

APPLEBY. 

11.  Variability  of  the  Tubercle  Bacillus.     CAR  RAMUS. 

12.  Medical  Colleges  and  Professional  Standards.     INEZ 

C.  PHILBRICK. 

13.  Philippine  Customs  and  Habits.     J.   C.   MINOR. 

14.  Medical  Departments  in  Public  Libraries.     C.  D.  SPI- 

VAK. 

1. — In  an  address  delivered  before  the  Society  of  Internal 
Medicine  at  Chicago.  Osier  discusses  the  natural  method  of 
teaching  the  subject  of  medicine.     He  groups  the  studies 


in  a  medical  school  into  three  classes.  The  first  pertains  to 
the  mechanism  of  the  normal  body;  the  second,  to  a  study 
of  the  abnormal;  and  the  third,  to  a  study  of  prevention 
and  rectification  of  deviations  from  the  normal.  The  de- 
partment of  medicine  at  the  Johns  Hopkins  Hospital  con- 
sists of  a  professor,  who  has  charge  of  the  medical  de- 
partment of  the  Hospital,  an  associate  professor,  instruc- 
tors, and  assistants.  The  medical  staff  is  composed  of  eight 
resident  physicians.  The  four  senior  residents  are  ac- 
tively associated  with  the  teaching.  Preliminary  instruc- 
tion in  physical  diagnosis  is  given  in  the  second  year  by 
Dr.  Thayer,  the  associate  professor  in  medcine.  The  third 
year  students  are  taught  chiefly  by  observation.  They 
are  given  courses  in  physical  diagnosis,  clinical  micro- 
scopy, practical  work  in  history-taking,  and  attend  the 
general  medical  clinic.  Much  attention  is  directed  to 
the  observation  class.  This  class  attends  the  out-patient 
department  at  12  o'clock,  three  days  of  the  week.  The 
third  year  student  is  required  to  devote  two  hours  twice 
per  week  to  the  study  of  physical  diagnosis  and  clinical 
microscopy.  Special  attention  is  directed  to  the  teaching 
of  history-taking.  The  third  class  participates  actively  in 
the  general  medical  clinic.  The  student  of  the  fourth 
year  serves  as  a  clinical  clerk  in  the  medical  wards  for 
two  months.  This  instruction  is  given  from  9  to  11  every 
morning.  Dr.  Osier's  criticism  as  to  the  ward  work,  is  that 
the  term  is  too  short,  suggesting  that  at  least  three  or  six 
months  should  be  devoted  to  this  particular  study.  Dr. 
Osier  meets  the  clinical  clerks  for  an  hour  or  two  once  a 
week  in  order  to  discuss  the  events  of  the  week.  The 
senior  students  attend  the  general  clinic.  Recitations  are 
also  held  in  the  fourth  year.     [F.  J.  K.] 

2.— Will  be  treated  editorially.     [F.  J.   K.] 

3. — Campbell  discusses  gumma  of  the  spermatic  cord, 
reviews  the  literature,  and  gives  a  report  of  a  case.  In 
1890  the  patient  had  a  chancre  which  was  followed  by 
many  of  the  secondary  lesions  of  syphilis.  When  the  pa- 
tient first  presented  himself,  in  1897,  he  was  suffering  from 
ulcerating  gummata  of  the  legs.  After  a  course  of  treatment 
the  lesions  disappeared,  and  in  .\ugust.  1899,  he  com- 
plained of  a  swelling  about  the  size  of  an  almond  which 
was  located  just  outside  of  the  right  external  abdominal 
ring.  The  swelling  disappeared  after  treatment  with  po- 
tassium iodide  and  mercury.     [F.  J.  K.] 

4. — William  H.  German  discusses  the  question  of  surgical 
shock  referring  first  to  its  indefinite  pathology.  The  author 
inclines  to  the  theory  that  shock  it  due  to  the  irritation  of 
peripheral  ends  of  the  sensor>-  and  sympathetic  nerves 
and  a  general  functional  paralysis  of  the  nerve  centers 
causing  a  disturbance  of  respiratory  and  circulatory  action. 
The  two  forms  of  shock  and  the  shock  with  excitement  are 
described  and  illustrated  by  cases.  The  author  shows  that 
the  same  injury  will  in  one  subject  produce  torpid  shock 
and  in  another  produce  prostation  with  excitement.  The 
author  thinks  it  difficult  to  account  for  death  occuring  sev- 
eral days  after  injury  or  operation  from  shock  which  has 
not  manifested  itself  until  this  time.  He  thinks  that  in 
most  instances  some  other  cause  for  death  can  be  found. 
A  case  is  reported  of  death  from  fat  embolus.    [J.  H.  G.] 

5. — J.  F.  Pritchard  urges  upon  the  profession  the  use  of 
non-constricting  dressings  in  fractures  and  condemns 
strongly  the  use  of  plaster-of-paris  as  a  preliminary  dres- 
sing.    [J.  H.  G.] 

6. — H.  N.  Rafferty  reports  a  case  of  acute  glaucoma  de- 
veloping in  a  cataractous  eye,  after  cataract  extraction  in 
the  other  eye.  Iridectomy  and  cure.  A  woman  SO  years  of 
age  developed  acute  glaucoma  in  the  right  eye  .i3  days  after 
cat.ir.-ict  extraction  in  the  left  eye.  The  latter  was  per- 
formed without  any  pressure  on  the  eye  ball  and  without 
capsulotomy,  the  lens  escaping  intact,  which  was  explained 
by  the  author  as  probably  due  to  the  over-ripe  and  atrophied 
condition  of  the  lens  and  to  an  absence  of  adhesions  of 
the  posterior  capsule  to  the  lenticular  fossa.  After  the 
employment    of    eserine.    hot    compresses    and      repeated 


b 


Juke  22.  19il] 


THE  LATEST  LITERATURE 


TTh 
L  M 


Phe    Philadelphia 
EDicAL  Journal 


I  20 1 


paracentesis  of  the  anterior  cliamber,  a  broad  peripheral 
Iridectomy  was  performed,  resulting  in  the  disappearance 
of  the  pain.     [M.  R.  D.] 

7. — Einhorn  read  a  paper  before  the  New  York  Academy 
of  Medicine  on  May  16,  1901,  on  "Stitophphobia  of  Enteric 
Origin."  The  author  defines  sitophobia  as  meaning  "fear 
of  food."  Ke  uses  the  term  sitophobia  only  tor  those 
conditions  which  result  from  bad  consequences  in  men- 
tally sound  people,  and  excludes  the  cases  which  occur  in 
the  insane.  He  uses  the  term  "sitophobia"  as  meaning 
"fear  of  food,"  when  due  to  some  intestinal  disorder.  He 
gives  a  report  of  three  cases  and  remarks  that  sitophobia 
of  moderate  degree  i=  if  common  occurrence.  The  author 
discusses  the  treatment  of  this  condition,  mentioning  that  it 
is  important  that  the  patient  should  be  made  to  eat  sufficient 
quantities  of  food.  The  bromides  in  nervous  conditions, 
and  codein  in  painful  affections  are  the  most  valuable  medi- 
caments.    [F.  J.  K.] 

8. — Heman  H.  Brown  discusses  the  anatomical  rela- 
tions of  the  conjunctiva  with  the  nose  and  calls  attention 
to  the  fact  that  in  treating  conjunctivitis  one  is  not  treat- 
ing an  isolated  structure.  He  calls  attention  to  the  im- 
portance of  recognizing  the  association  of  diseases  of  the 
conjunctiva  and  tlie  Schneiderian  membrane,     [M.  R.  D.] 

9. — Gilliam  claims  that  all  suspensions  of  the  uterus  of 
whatever  kind  are  makeshifts  and  that  anchorage  of  the 
uterus  by  means  of  the  round  ligaments  is  the  nearest 
approach  to  the  ideal.  As  a  choice  between  evils  the  round 
ligament  suspension  is  superior  to  all  others,  both  from  a 
physiological  and  from  a  utilitarian  standpoint.  He  has  de- 
vised a  method  of  operation  as  follows:  A  median  abdom- 
inal section  is  made  from  3  to  4  inches  long  and  at  the 
usual  site  between  the  umbilicus  and  pubis.  The  adhesions 
are  broken  up  and  the  fundus  brought  forward.  The 
patient  is  then  placed  in  the  Trendelenburg  position,  and 
the  round  ligament  on  one  side  seized  and  brought  to  the 
opening.  A  slik  thread  is  carried  under  the  ligament  by 
means  of  an  aneurysm  needle  at  a  distance  of  about  1% 
inches  from  the  uterus.  The  other  round  ligament  is  se- 
cured in  the  same  way  and  the  ends  of  the  thread  brought 
out  of  the  abdomen  and  held  in  the  bite  of  another  snap- 
forceps.  The  fascia,  muscle  and  peritoneum  at  the  margin 
of  the  incision  are  then  caught  with  a  volsellun  an  inch  or 
so  from  the  lower  angle  of  the  incision,  and  traction  is 
made.  This  pins  the  layer  together  and  prevents  retrac- 
tion of  the  muscle.  Specially  devised  perforating  forceps 
are  thrust  through  into  the  peritoneal  cavity  and  seize  the 
thread  which  holds  the  round  ligament.  The  clamp  forceps 
are  removed  from  the  latter  and  the  perforating  forceps 
withdrawn.  This  brings  the  thread  and  ligament  through 
the  perforated  wound  in  the  abdominal  wall.  The  ligament 
is  held  taut  and  fastened  into  the  wound.  The  opposite  side 
is  treated  in  the  same  manner  and  the  median  alidominal 
incision   closed.     [W.   A.   N.   D.] 

11. — Ramas  writes  upon  the  variability  of  the  tubercle  ba- 
cillus, and  concludes  that  this  bacillus  is  not  always  easy 
to  demonstrate.  The  staining  reagents  cannot  be  de- 
pended upon  absolutely.  The  bacilli  from  different  patients, 
and  occasionally  at  different  times  from  the  same  patient, 
may  react  to  stains  in  different  ways.  Physical  and  chemi- 
cal changes  in  the  bacilli  probably  influence  the  tinctorial 
variations.  When  distinct  physical  signs  of  tuberculosis 
exists,  even  in  the  absence  of  demonstrable  tubercle  bacilli, 
the  diagnosis  should  be  made  so  as  to  give  the  patient  the 
benefit  of  the  doubt,  and  treatment  instituted  prompt- 
ly.    [F.  J.  K.] 

12. — Philbrick  writes  upon  Medical  Colleges  and  Profes- 
sional Standards.  The  author  states  that  the  United  States 
Commissioner  of  Education  reported  that  in  1S94  there  were 
23,778  medical  students.  The  percentage  increase  of  medical 
students  between  the  years  1S75  and  1899  was  177.  Ac- 
cording to  the  United  States  Commissioner  of  Education, 
in  1899  there  were  151  medical  colleges,  and  according 
to  the  Secretary  of  the  American  Medical  Association  there 


were  173.  The  author  contends  that  the  medical  colleges 
exists  in  excess  of  public  demand,  and  that  this  great  in- 
crease of  colleges  tends  to  lower  the  standard  of  in- 
struction. He  concludes  the  article  with  a  protest  that  the 
profession  should  discourage  the  entrance  of  unfit  medical 
men  into  the  profession.     IF.  J.  K.J 

13. — Minor  gives  an  account  of  Phillipine  Customs  and 
Habits.  Sanitation  among  the  Philippines  is  much  neg- 
lected, this  being  especially  true  in  regara  to  the  disposal 
of  sewage  and  waste.  The  author  emphasizes  that  during 
the  next  decade  great  changes  will  undoubtedly  occur  In 
the  Philippine  medical  world,  as  well  as  in  the  manage- 
ment of  their  civil  government.     [F.  J.  K.] 

14. — Spibak  believes  that  the  work  of  establishing  medi- 
cal departments  in  public  libraries  which  has  already  been 
begun,  will  continue.  The  author  contends  that  every  pub- 
lic library  should  be  supplied  with  books  which  pertain 
to  medical  questions.     [F.  J.   K.] 


DEUTSCHE    ZEITSCHRIFT     FUER     NERVENHEIL- 
KUNDE. 


[Conclusion.] 

13.  A  Third  Contribution  to  the  Knowledge  of  Hereditary 

Progressive  Spinal  Muscular  Atrophies  of  Childhood. 
HOFFMAN. 

14.  The    Etiology    and    Pathological    Anatomy    of    Tabes 

Dorsalis.      DINKLER. 

15.  Another    Contribution    to    the    Knowledge    of    Tetany 

Originating  from  the  Stomach.     FLEINER. 
IG.     Brain  Tumor  and  Sclerosis  of  the  Posterior  Columns. 
HOFFMAN. 

17.  The  Condition   of  the  Tendon   Reflexes   in   Complete 

Transverse  Lesions  of  the  Spinal  Cord.     BRAUER. 

18.  Acute   Poliomyelitis   of   Adults,   and   the   Relation   of 

Poliomyelitis    to    Polyneuritis.      STRUMPELL    and 
BARTHELMES. 

19.  Isolated  Disease  of  the  Lower  Lumbar  and  First  Sacral 

Roots.     GIERLICH. 

20.  The  Skin  Diseases  of  Hysteria  and  Atypical  Zosters. 

BETTMAN. 

21.  Athetosis  as  a  Complication  of  Tabes  Dorsalis.    ARN- 

SPERGER. 

22.  Angioneurosis  and  Neurangiosis.     HANSER. 

23.  Brief  Communication.     GUTTMANN. 

13. — The  patient  already  described  in  Vol.  X  of  this 
Zeitschrift,  gradually  showed  progressive  involvement  of 
the  muscles  until  death  occurred  from  exhaustion.  The 
intelligei'ce  remained  normal  and  the  bladder  and  intes- 
tines were  not  involved.  The  autopsy  showed  that  the 
ganglion  cells  of  the  anterior  cornua  of  the  cord  had  almost 
entirely  disappeared:  the  anterior  roots  were  very  much 
smaller  and  paler  than  normal:  the  blood  vessels  and 
neuroglia  tissues  were  normal,  and  there  were  no  changes 
in  the  white  substances  of  the  cord.  The  degeneration  was 
also  found  in  the  peripheral  nerves:  the  posterior  roots 
were  entirely  normal.  The  muscles  showed  marked  degen- 
erative changes.  The  muscle  spindles  were  present  in  all 
the  muscles  in  excessive  numbers.  The  intra-muscular 
nerve  fibres  were  degenerated.  The  autopsy  therefore  con- 
firmed Hoffmann's  belief  that  the  disease  was  one  of  pro- 
gressive spinal  muscular  atrophy.  He  also  reports  2  cases, 
one  occurring  in  a  hoy  of  l!^i  months,  and  the  other  in  a 
girl  of  2  years.  They  both  presented  atrophy  of  the  mus- 
cles, and  in  the  boy  fibrillary  twitchings  had  been  observed. 
Tlie  muscles  give  the  typical  reaction  of  degeneration,  and 
the  reflexes  were  lest.  The  muscles  of  the  girl  failed  to 
show  any  fibrillary  twitchings.  The  electric  reactions  are 
not  given.     [J.  S.l 

14. — Dinkier  in  the  past  4  years  has  observed  37  cases 
of  tabes  dorsalis.  Thirty-one  of  these  admitted  venereal 
infection.  Three  of  the  others  had  undoubted  syphilitic 
manifestations.  The  remaining  3.  2  women  and  one  man, 
the  latter  having  also  signs  of  general  paresis,  failed  to 
present  any  syphilitic  lesions.  Seventy  per  cent,  of  these 
patients  belonged  to  the  laboring  class.  In  30%  there  was 
a  history  of  more  or  less  excessive  alcoholic  indulgenoa. 
and  in  20%  the  patients  had  used  tobacco  to  excess.  The 
other  alleged  causes  only  occun-ed  in  t  or  2  cases  each. 


I202 


The    Philadelphia- 
Medical    JOL'RNAL    _ 


THE  LATEST  LITERATURE 


[June   22,   19<jl 


Dinkier  calls  attention  to  the  fact  that  excessive  indul- 
gence in  alcohol  iind  tobacco  occurs  much  more  frequently 
in  neurasthenics  than  in  cases  of  tabes  dorsalis.  In  3  cases 
it  was  possible  to  obtain  an  autopsy  and  to  make  careful 
microscopic  examination  of  the  cord.  The  examination 
showed  moderate  alteration  in  the  dura,  pia  and  arachnoid. 
There  was  some  increase  and  thickening  in  the  fibrous  tis- 
sue, loss  of  the  endothelial  cells,  and  in  the  pia  some  round 
cell  infiltrations  occurring  in  groups.  In  a  2d  case  there- 
was  atrophy  of  the  dura,  thickening  of  the  arachnoid,  and 
round  cell  infiltration  of  the  pia.  particularly  around  the 
blood  vessels.  The  3d  case  showed  essentially  similar  con- 
ditions. The  author  also  reports  a  case  of  syphilitic  men- 
ingitis in  which  there  was  round  cell  infiltration  of  all  ?. 
membranes,  and  an  ascending  degeneration  in  the  posterior 
columns,  not  so  very  different  from  that  discovered  in  lo- 
comotor ataxia.  In  order  to  determine  whether  these 
changes  occurred  in  other  forms  of  nervous  disease  Dinkier 
examined  cases  of  syringomyelia,  muscular  distrophy, 
Friedrich's  disease,  amyotrophic  lateral  sclerosis,  multiple 
sclerosis,  etc..  and  in  none  of  them  was  there  any  distinct 
round  cell  infiltration  or  vascular  alterations,  with  the  ex- 
ception of  one  case  of  multiple  sclerosis  and  one  of  sarcoma 
of  the  pia     He  therefore  regards  these  changes  as  specific. 

[J.  S.] 

15. — J'leiner  discusses  gastric  tetany.  It  usually  occurs 
in  patients  whose  nutrition  has  been  grently  impaired,  and 
who  have  an  extreme  gastrectasis  as  a  result  of  stenosis  of 
the  pylorus  or  duodenum.  The  disease  it  probably  less 
common  than  formerly,  because  gastro-enterostomy  is  per- 
formed earlier.  When  the  complication  does  arise  it  usually 
occurs  suddenly.  He  has  already  reported  4  cases,  and 
now  adds  a  5th  to  these,  which  in  many  respects,  is  excep- 
tionally interesting.  The  patient,  a  man  of  51,  of  enormous 
strength,  had  had  gall-stones  and  adhesions  between  the 
gall  bladder  and  the  intestines.  The  gall  stones  had  also 
perforated  into  the  stomach  and  duodenum,  and  as  a  re- 
sult scars  had  been  formed  that  led  to  severe  pyloric  sten- 
osis. In  spite  of  careful  diet,  rest  in  bed  and  frequent  lav- 
age the  patient  gradually  grew  worse,  lost  in  weight,  and 
the  daily  quantity  of  urine  decreased.  It  was  decided  to 
perform  gastro-enterostomy,  but  just  before  this  was  done 
the  patient  developed  symptoms  of  complete  pyloric  sten- 
osis, profuse  vomiting,  and  upon  washing  the  stomach,  food 
was  found  that  had  remained  in  the  stomach  6  or  7  weeks. 
The  following  day  during  lavage  feces  were  obtained,  and 
the  patient  suddenly  had  a  severe  tonic  spasm  of  the  arms 
and  legs,  which  subsequently  involved  the  body  and  face, 
and  lasted  several  minutes.  At  the  same  time  there  was  in- 
tense pain  and  paresthetic  sensations  which  lasted  for  12 
days.  The  reflexes  were  lost.  Trousseau's  symptom  was 
easily  elicited.  Examination  of  the  stomach  contents  for 
amines  was  negative.  The  patient  after  this  attack  was  so 
weak  that  it  was  impossilile  to  perform  an  operation.  He 
remained  in  a  state  of  collapse  for  12  days  with  a  marked 
tendency  to  tonic  contractions  of  the  extremities.  The 
blood  gave  symptoms  of  anhydremia.  and  death  finally  oc- 
curred as  a  result  of  hypostatic  pneumonia,  without  fever. 
In  addition  to  these  tetanic  cramps  patients  sometimes  have 
simple  tonic  cramps  without  Trousseau's  symptom.  The 
attaclv  always  occurs  as  a  result  of  profuse  vomiting  or  la- 
vage in  which  large  quantities  are  obtained  from  the  stom- 
ach. The  symptoms  are  not  very  dissimilar  from  those  of 
the  tetanus  that  results  from  removal  of  the  thyroid  gland. 
An  associated  symptom  was  diminution  of  the  reflexes  and 
of  inipillary  activity.  Fleiner  regards  the  etiology  of  the 
condition  as  the  development  of  tonic  cramps  as  a  result  of 
muscular  exertion  and  possibly  as  a  result  of  the  poverty  of 
the  tissues  in  water.     [,T.  S.] 

16. — Hoffmann  reports  the  case  of  a  man  52  years  of 
age.  witliout  luetic  infection,  whose  sickness  commenced 
with  uncertainty  of  gait,  then  leCt-sided  hemiplegia,  dilir 
iuni.  hemianesthesia,  dis.appearance  of  the  tendon  reflexes, 
and  marked  ataxia  of  the  right  leg.  There  was  no  papilli- 
tis. Death  occurred  4  months  after  the  appearance  of  the 
first  symptoms  At  the  autopsy  a  glio-sarcoma  of  the  right 
hemisphtre  was  found  that  included  a  great  portion  of  the 
centrum  ovale,  had  compressed  the  right  lateral  ventri- 
cle and  anterior  portion  of  the  internal  capsule.  Above  this 
tumor  the  nerve  fibres  had  degenerated,  and  there  was  a 
descending  secondary  degeneration  in  the  pyramidal  tract 
from  the  internal  capsule.  In  the  spinal  cord,  this  degener- 
atioii  gradually  disappeared.  In  addition  there  was  do 
generation   in   the  posterior  columns,  most   pronounced   in 


the  lumbar  cord  where  the  whole  of  the  posterior  column 
and  Lissauer  s  zone  were  degenerated.  The  posterior  roots 
showed  moderate  degeneration  in  this  region.  In  the  dor- 
sal and  cervical  portions  of  the  cord  the  degeneration  was 
found  near  the  postei-ior  part  of  Goll  s  column.  The  nu- 
cleus fascculus  was  normal,  and  no  ascending  degeneration 
could  be  found  above  it.  It  appears  from  this  case  that  a 
diagnosis  of  brain  tumor  and  tabes  dorsalis  may  be  justi- 
fied. The  question  arises  whether  or  not  the  two  condi- 
Lions  are  entirely  independent.  As  the  March  stain  gave 
very  slight  traces  of  degeneration  in  the  posterior  col- 
umns, it  seems  reasonable  to  suppose  that  the  degenera- 
tion there  is  older  than  that  in  the  pyramidal  column. where 
the  black  fibres  were  very  numerous.  This  does  not  jeces- 
Kuiily  prove  that  all  the  degeneration  in  the  posterior  col- 
umn is  older,  and  even  if  it  were,  it  might  easily  occur 
sooner  as  a  result  of  the  tumor,  than  the  degeneration  in 
the  pyramidal  column.  Moreover,  there  Is  no  history  of 
syphilis.  The  disease  commenced  about  4  months  before 
death.  There  was  no  disturbance  of  sensation  on  the  non- 
paralyzed  side  and  the  patient  had  the  Arg>-l-Robinson 
pupil.  Hoffmann  concludes  that  the  case  is  not  one  of  true 
tabes  dorsalis.  Be  discusses  the  various  conditions  that 
might  give  rise  to  degeneration  in  the  porterior  cord,  among 
which  he  mentions  anemias  and  cachexias,  intracranial  in- 
crease of  pressure,  venous  congestion  or  thrombosis.  He 
concludes  that  although  we  do  not  know  the  mechanism  by 
which  this  is  brought  about,  brain  tumor  can  cause  changes 
in  the  spinal  cord  that  cannot  be  distinguished  from  pos- 
terior sclerosis.  He  suggests  that  perhaps  the  organic 
changes  in  one  part  of  the  central  organs  may  produce  dis- 
turbance of  nutrition  in  all  others.     [J.  S.] 

17. — Brauer  reports  the  case  of  a  girl  19  years  of  age, 
who  had  had  numerous  tuberctilous  lesions  in  the  body,  and 
who  finally  developed  kyphosis  resulting  in  complete  para- 
plegia with  paralysis  of  the  sphincters  and  loss  of  sensa- 
tion. On  the  right  Side  she  had  until  death  increase  in  the 
patellar  reflex  and  ankle  clonus.  On  the  left  side  the  pa- 
tellar reflex  was  obtained  with  much  difliculty.  The  left 
foot  had  been  amputated.  At  the  autopsy  a  tuberculous 
myelitis  of  the  upper  portion  of  the  dorsal  part  of  the  spinal 
cord  was  found,  causing,  as  was  proved  by  microscopic  ex- 
amination, complete  obliteration.  Complete  separation  of 
the  cord  had  occurred  in  the  most  affected  part,  the  dis- 
tance between  the  ends  being  not  less  than  4  mm.  The 
dura  was  thickened  and  there  were  the  typical  forms  of  as- 
cending and  descending  degeneration.  The  author  discusses 
the  reason  why  the  patellar  reflex  was  preserved,  suggest- 
ing that  perhaps  there  might  be  irritation  on  the  right  side 
as  the  result  of  the  amputation  on  the  left,  or  that  the 
tul  erculous  process  does  cause  enough  irritation  to  stimu- 
late the  cells  in  the  lumbar  enlargement,  and  whether  the 
irritation  conducted  along  the  peripheral  nerves  from  the 
lesions  in  the  ankles  could  be  sufficient.  He  is  unable  to 
decide  which  of  these  hypotheses  (if  any)  is  correct.  He 
also  reports  the  case  of  a  boy.  8  years  of  age.  who  fell  from 
a  tree  and  immediately  had  complete  paraplegia  with  loss 
of  sensation.  There  were  evidences  of  fracture  of  the 
spinal  column.  The  reflexes  were  absent  on  both  sides: 
there  was  complete  paralysis  of  the  sphincters,  and  decubi- 
tus appeared.  Two  months  later  suspension  was  com- 
menced. The  muscles  then  showed  considerable  irrita- 
tion, contracting  when  the  skin  was  struck,  and  in  the 
course  of  a  few  weeks  the  tendon  reflexes  reappeared  and 
there  was  ankle  clonus.  An  operation  was  performed,  but 
no  changes  were  found  in  the  spinal  cord  or  In  the  dura. 
The  latter  was  not  opened.  It  seems  reasonable  to  sup- 
pose that  in  this  case  there  was  a  complete  transverse  les- 
ion of  the  cord  on  account  of  the  absence  of  a  tendency  to 
recovery.  Numerous  experiments  showed  that  under  cer- 
tain circumstances  the  patellar  reflexes  reappear  some  time 
after  complete'  division  of  the  cord.  The  author  reports  a 
iiumber  ot  experiments  that  he  performed  upon  rabbits,  in 
which  this  result  was  obtained.  He  suggests  that  perhaps 
the  loss  of  the  reflex  is  due  to  the  accumulation  of  cere- 
brospinal fluid  in  the  lumbar  region,  and  that  as  this  is 
gradUi.Uv  absorbed  they  reappear.     [J.  S.] 

18. — Striimpell  and  Barthelmes  report  the  case  of  a  man, 
31  years  of  age,  without  significant  previous  or  family  his- 
tory, who  on  awakening  one  morning  had  severe  pain  in 
the  lumbar  region  and  in  the  thighs.  The  next  day  these 
were  much  more  severe.  Two  days  later  he  had  profuse 
perspiration  and  the  pains  ceased.  The  legs  were  then 
very  weak  and  finally  became  completely  paralyed.    'WTien 


June  21,  WOl] 


THE  LATEST  LITERATURE 


The    Philadelphia 
.  Medical  Journal 


I  20  J 


admitted  to  the  hospital  some  months  afterward,  it  was 
found  that  the  cranial  nerves  were  normal;  the  spine  was 
not  tender:  both  legs  were  emaciated;  there  was  flexion  at 
the  hips,  but  practically  none  at  the  knees  and  ankles.  The 
quadriceps  appeared  to  be  atrophied;  the  sartorii  were  still 
uorrna);  the  tendon  reflexes  were  lost  in  the  legs:  the 
plantar  reflex  was  active.  Sensation  was  not  disturbed. 
Electrically  all  the  muscles  of  the  abdomen  and  the  2 
sartorii  were  normal,  the  other  muscles  of  the  limbs,  the 
iidductors  on  the  right,  and  the  glutei  muscles  did  not  re- 
act to  any  current.  The  patient  improved  somewhat  un- 
der treatment,  but  no  essential  changes  occurred.  The 
authors  believe  that  this  is  a  case  of  acute  poliomyelitis  ou 
account  of  the  absence  of  sensory  symptoms,  the  acute  on- 
set, the  pains  in  the  back,  and  the  character  of  the  subso 
queut  paraljsis.  They  believe  that  the  lesion  involved  the 
4th  and  .")th  lumbar,  and  the  1st  sacral  segments  on  the 
right  side,  and  the  2nd,  and  3rd  lumbar  and  the  2nd 
sacral  se.Ements  on  the  left  side.  The  fact  that  the  sartor- 
ius  was  not  affected  shows  that  the  general  belief  is  cor- 
rect that  this  muscles  is  supplied  from  the  lumbar  segments 
The  cremastor  reflex  was  also  preserved,  which  accords 
with  the  localization  given.  They  give  a  classification  ot 
the  atrophic  forms  of  paralysis,  which  is  summarized  as 
follows.  First,  acute  local  neuritis;  second,  acute  local  poli- 
omyelitis: third,  hematogenous  toxic  degeneration  of  the 
motor  nerves;  fourth,  acute,  sub-acute  and  chronic  toxic  de- 
generations of  the  peripheral  motor  neurons;  fifth,  progres- 
sive atrophy  of  the  motor  neurons,  including  neuritic  and 
spinal  atrophy:  sixth,  progressive  muscular  atrophy;  and 
sevent.h,  amyotrophic  lateral  sclerosis.    [J.  S.] 

19. — Gierlich  reports  the  case  of  a  man,  38  years  of  age, 
who  suddenly  developed  intense  pain  extending  from  the 
right  hip  down  to  the  foot.  Subsequently  there  was  para- 
lysis and  atrophy  of  the  various  muscles  of  the  right  leg. 
Then,  8  weeks  later,  there  were  similar  pains  in  the  left 
hip  and  leg.  When  examined  there  was  loss  of  sensation 
on  the  anterior  surface  of  both  thighs,  both  legs,  and  the 
external  surface  of  both  thighs  and  legs,  and  the  back 
of  both  feet.  There  were  reactions  of  degeneration  in  the 
muscles  supplied  by  the  cranial  and  obturator  nerves. 
There  were  no  tender  points  over  the  nerves  and  there- 
fore, degeneration  of  the  sacral  roots  seemed  to  be  pres- 
ent. As  the  sphincters  were  not  involved  there  is  no  rea- 
son to  assume  involvement  of  the  spinal  cord.  The  roots 
affected  were  probably  those  proceeding  from  the  2nd  to  the 
5th  lumbar  segments.  The  nature  of  the  lesion  of  course 
cannot  be  known,  but  it  was  probably  tumor.  Possibly  the 
condition  was  syphilitic.  He  also  reports  the  case  of  a 
man,  20  years  of  age.  who  received  a  severe  injury  to  the 
lumbar  vertebra,  followed  by  intense  pain  in  the  small  of 
the  back  extending  down  the  right  leg  to  the  back  of  the 
foot.  This  was  followed  by  loss  of  sensation  in  the  right 
leg,  loss  of  movement  in  the  right  foot,  and  some  wasting 
of  the  muscles.  When  examined  5  months  later  there  was 
loss  of  sensation  in  the  anterior  portion  of  the  right  foot, 
and  hypesthesia  of  the  right  thigh.  It  appears  likely  that 
the  lesion  involved  the  roots  extending  from  the  4th  and 
5th  lumbar  segments  on  the  right  side.  Gierlich  discusses 
his  case  in  the  light  ot  recent  studies  in  the  localization  ot 
spinal  disease,  criticises  Wichmann's  work,  because  uo 
distinction  is  made  between  segmental  and  root  lesions, 
and  expresses  his  admiration  of  the  work  done  by  Head. 
He  draws  the  following  conclusion  regarding  spinal  local- 
ization, from  this  case.  The  iliapsoas  and  sartorius  muscles 
are  innervated  from  below  the  1st  lumbar,  the  gluteal  mus- 
cles and  the  flexors  of  the  knee  and  foot  have  no  innerva- 
tion from  the  2d  to  the  .=ith  lumbar  segments.  The  dorsal 
flexors  of  the  foot  receive  their  innervation  from  the  5th 
lumbar  segments,  although  the  extensor  communis  dig. 
brevis.  receives  its  innervation  from  the  deeper  segments. 
The  fact  that  touch  sense  is  less  extensively  lost  than  tem- 
perature and  pain  sense  indicates  that  these  fibres  pass 
from  a  given  area  to  the  spinal  cord  through  more  than  3 
dorsal  roots,  although  it  is  probbable  that  the  middle  root 
is  in  most  direct  association  with  the  area  involved.     [.I.  S] 

20. — Bettermann  reports  a  number  of  types  of  skin  dis- 
ease occurring  in  hysterical  patients.  He  mentions  par- 
ticularly dermatographismus.  erythcmia.  hemorrhages,  ur- 
ticaria, forms  of  edema,  solitary  and  multiple  ulcers,  gan- 
grene ami  eczema-like  eruptions.  He  reports  a  number  of 
cases  illustrating  various  types  of  these  conditions.  Among 
them  a  girl.  1!)  years  of  age.  who  during  her  first  preg- 
nancy had  severe  eruptions  all  over  her  body.     This  was 


soon  localized  to  the  right  arm  and  breast.  This  was  as- 
sociated with  an  erui)tion  limited  to  the  same  region,  in 
the  form  of  large,  roimd  red  plaques  slightly  elevated, 
sharply  limited,  with  some  blisters  and  papules  around  their 
edges.  There  was  moderate  dermatographia.  After  deliv- 
ery this  eruption  rapidly  disappeared.  The  hand  was  not 
involved.  The  patient  had  numerous  hysterical  stigmata, 
and  Bettermann  believes  that  the  eruption  was  purely  hys- 
terical in  character.  He  also  calls  attention  to  the  fre- 
quency with  which  hysterical  patients  will  mutilate  them- 
selves for  various  reasons,  and  reports  2  cases,  in  one  ot 
which  ulcers  were  produced  by  caustic  potash,  and  the 
other  by  hypodermic  injections  of  a  mineral  acid.  He  re- 
ports another  case  in  which  a  woman  during  her  second 
pregnancy  had  a  severe  eruption,  papillary  in  character,  in- 
volving the  outside  of  the  right  arm,  shoulder  and  lower 
portion  of  the  face  and  head  on  the  right  side.  She  had 
hysterical  stigmata.  It  is  possible  that  there  may  be  hys- 
terical affections  of  the  roots.      [J.  S.] 

21. — Arnsperger  reports  a  case  of  locomotor  ataxia  which 
l)resented  typical  athetoid  movements  olthe  fingers  of  both 
hands.  These  disappeared  during  sleep  but  reappeared 
on  awaking  and  were  increased  by  excitement  or  severe 
labor.  There  was  also  intermittent  Argyl-Robinson  pupil. 
Ho  reports  another  case:  a  man.  51  years  of  age,  who  iu 
addition  to  the  typical  symptoms  of  tabes  dorsalis  had 
athetoid  movements  of  the  hands  and  feet,  and  nystag- 
mus. It  was  possible  that  the  athetoid  movements  were 
due  to  the  frequent  involvement  of  the  optic  thalmus.  [J.  S.] 

22. — Hanser  in  a  long  article  upon  angioneurosis  and 
neurangiosis  discusses  the  anatomy  and  physiology,  the 
symptoms,  prognosis,  and  treatment  of  these  conditions. 
He  concludes  that  the  blood  supply  of  the  peripheral  nerves 
is  of  such  character  that  under  pathologic  conditions  the 
functions  of  the  nerves  may  be  impaired.  Thus,  severe  dis- 
turbance of  circulation  such  as  thrombosis  may  lead  to 
severe  degeneration.  Slight  disturbances  may  have  no 
effect  on  the  nervous  system.  Transitory  disturbances  may 
however,  cause  transitory  disturbances  in  the  peripheral 
nervous  system,  and  give  rise  to  the  so-called  angioneuro- 
ses  especially  in  individuals  with  neurotic  tendencies.  The 
venous  system  is  quite  as  important  as  the  arterial  sys- 
tem: the  nerves  chiefly  affected  are  the  sensory,  possibly 
also  the  secretory  but  practically  none  of  the  trophic 
nerves.  It  is  possible  that  intermittent  claudicaria  is  one 
of  the  manifestations  of  this  condition.  The  treatment 
consists  in  the  anti-rheumatic  and  anti-neuralgic  remedies, 
hpdrothcrapy,  electricity  and  very  rarely  narcotics.    [J.  3.1 

23. — A  child  of  7  had  an  attack  of  typhoid  fever,  and  on 
the  9i.h  day  of  the  disease  became  somewhat  stuporous. 
When  the  physician  approached  the  bed  she  closed  her 
eyes,  blushed  violently  and  could  not  be  persuaded  to 
speak.  This  condition  continued  until  the  58th  day.  when 
speech  suddenly  reappeared.  She  again  became  mute  and 
on  the  63rd  day.  when  for  the  first  time  she  was  without 
fever,  she  commenced  to  respond  to  questions  by  ges- 
tures. On  the  67th  day  she  was  hypnotized  and  sugges- 
tion was  made  that  she  could  speak  as  soon  as  the  faradic 
apparatus  began  to  sound.  From  this  time  she  spoke 
freely.  The  symptoms  were  not  those  of  amnesis  nor 
motor  aphasia,  and  therefore  a  diagnosis  of  mutism  was 
made.      There  were  no  other  hysterical  stigmata.     [J.  S.] 


A  Case  of  Pneumococcic  Endocarditis. — .\t  a  recent 
meeting  of  the  Medical  Society  of  the  Paris  Hospitals. 
HulhtiHX  (t  Mniioiris  dc  In  Sm-irtr  Mrtlirnic  ilr.s  llniiitau.r  dc 
J'aiiK,  1901,  No.  8),  Launois  and  Paris  reported  a  case  of 
pneumococcic  endo'carditis  in  a  man  of  46,  who  had  pneu- 
monia and  arthritis  of  the  wrist.  On  the  seventeenth  day 
of  his  illness  he  grew  decidedly  worse,  and  a  loud  diastolic 
murmur  appeared  at  the  aortic  area.  The  pulse  became 
typical,  distinctly  Corrigan  in  character.  With  this  there 
was  some  fever.  A  systolic  murmur  was  audible  over  all 
the  larger  vessels.  He  died  10  days  later,  with  meningitic 
symptoms.  At  the  autopsy,  beside  the  pulmonary,  pleural, 
arthritic,  and  meningitic  localization  of  the  pneumococcus, 
the  heart  showed  no  hypertrophy,  and  little  dilatation,  but 
largo  vegetations  upon  the  aortic  valves.  Microscopically 
they  consisted  of  fibrin  and  pncumococci.  The  endocardi- 
tis occurred  suddenly,  the  sphygmograms.  made  23  hours 
apart,  showing  a  striking  difference.  The  pathologic  lesion 
occurred  just  as  it  does  experimentally.  Pneumococci. 
when  thev  invade  the  heart,  generally  attack  the  aortic 
valve.      [M.   O.] 


T  90/1        The    Philadelphia  "I 
1  ^UZ|.       Medical   Journal    J 


SPECIAL  ARTICLES 


(June  22,    190! 


Special  articles. 

A  NEW  HEMORRHOIDAL  CLAMP. 

By  G.  MILTON  LINTHICUM,  A.  B.,  M.  D., 

of  IJaltinioro,  Md. 

Professor  ofRectal  Diseases  and  Physiology  at  Maryland  Medical   College 

Mr.  Henry  Smith,  in  speaking  of  the  clamp  and 
cautery  operation,  which  he  originated,  says  of  the 
clamp,  "that  it  is  very  essential  for  its  right  action 
that  the  blades  be  so  constructed  as  to  have  their 
parallelism  complete  when  they  meet,  otherwise 
the  enclosed  membrane  may  slip'."  This  is  the  ideal 
which  he  desired  to  obtain  in  his  clamp,  yet  fails 
to  accomplish.  For  in  clamps  constructed  like  scis- 
sors, when  the  portion  of  tumor  external  to  the 
blades  is  cut  off,  the  tissues  often  slip  through  ex- 
cept that  portion  which  is  near  the  heel  of  the  in- 
strument, where  the  pressure  is  greatest,  and 
thereb}'  permits  serious  bleeding.  Gantt's  clamp, 
by  having  the  handles  join  the  blades  at  a  right  an- 
gle, accomplishes  the  parallelism,  but  the  ar- 
rangement of  joint  at  the  ends  of  handles  makes  it 
imperative  to  use  the  thumb  screw  to  obtain  suffi- 
cient pressure  to  clamp  and  hold  the  tissues,  thus 
requiring  the  use  of  both  hands,  in  this  way  pro- 
longing the  time  of  the  operation,  and  necessitating 
an  assitant.  I  also  find  the  handles  to  be  in  the  way 
of  excising  the  excess  of  tissue  and  of  cauterizing 
the  stump.  The  scissor  joint  is,  of  course,  the  form 
of  leverage  in  which  the  greatest  degree  of  pressure 
may  be  obtained,  so  if  it  is  possible  to  get  paral- 
lelism with  this  form  of  joint  we  get,  in  mv  judg- 


ment, an  instrument  which  fulfills  all  the  condi- 
tions demanded  of  it. 

I  have  accomplished  in  my  clamp  parallelism  with 
crossed  joint  by  using  a  mechanical  arrangement 
somewhat  similar  to  Goodell's  Dilators. 

This  arrangement  is  clearly  shown  in  the  accom- 


panying cuts,  so  I  will  not  attempt  to  give  a  de- 
scription. 

In  this  clamp  the  greatest  pressure  mav  be  ob- 
tained, which  is  the  same  at  all  points  of  the  blades 
by  virtue  of  the  parallel  blades. 

The  parallel  position  is  maintained  in  all  the 
movements,  at  the  widest  separation  as  well  as  at 


the  closure.  I  feel  that  the  conditions  are  all  met  in 
my  clamp,  viz. :  great  pressure,  to  prevent  hemor- 
rhage, and  firm  hold,  to  prevent  slipping.  The  in- 
strument is  so  constructed  that  it  may  be  dis- 
jointed and  thoroughly  cleansed  and  sterilized  A. 
One  cut  shows  a  front  view  with  clamp  open  ;  be- 
sides it  are  the  blades  of  another  clamp  open,  show- 
ing a  relative  position  of  the  two  instruments,  de- 
monstrating how,  if  a  fibrous  mass  is  caught  in  heel 
of  blades  no  pressure  would  be  felt  at  the  ends  of 
the  blades 

B.  The  back  view  shows  clamps  closed,  with  its 
mechanism. 

I  am  indebted  to  the  Willins  Surgical  I.  Co.  for 
embodying  my  ideas  in  a  neat,  strong  and  compact 
instrument. 


A  Case  of  Acute  Hemorrhagic  Polymyositis. — K.  N. 
Georgievski  {IldliiilcliiKiia  (:(i::cta  UntkhDi.  Vol.  XII.  No.  16) 
reports  the  case  of  a  man.  32  years  old.  who  developed  an 
acute  fever  associated  with  marked  inflammatory  hemor- 
rhagic and  extremely  painful  infiltrations  of  the  skin  and 
muscles.  The  lesions  were  transient  and  migratory  in 
character,  involving  nearly  the  entire  body.  Tachycardia 
was  present  only  during  tlie  first  few  days  of  the  affee- 
tion.  On  the  14th  day  of  the  disease  the  patient  developed 
a  double  catarrhal  pneumonia,  the  sputum  having  been 
found  to  contain  pneumococci.  The  blood  obtained  from  a 
sunertic-ial  vein  showed  on  culture  the  presence  of  a  staphy- 
lococcus. The  serum  was  also  found  capable  of  neutral 
izing  the  ferments  obtained  from  a  dead  culture  of  staphy- 
lococcus, showing  that  the  patient  suffered  primarily  from 
a  general  staphylococcus  infection  which  was  responsible 
for  the  polymyositis.    The  patient  recovered.    [A.  R.] 


June  22,  1901] 


SPECIAL  ARTICI,ES 


tTHE    Philadelphia 
Medical  Journal 


1205^ 


A  NEEDLE  FOR  SILVER  WIRE. 

By  L.  J.  Y.  GEMELLA,  M.  D.,  B.  L., 
of  New  Orleans. 

Fig.    I    represents   the  needle   threaded   with   the 
silver  wire.     The  wire   is  passed  throue:h   the  can 


B  (fig.  2)  pinched  with  an  artery  forceps,  as  shown 
in  fig.  3.  The  cap  is  then  screwed  on  the  needle 
(C).    The  needle  can  be  made  in  any  model.     The 


i      ^ 


figures  represent  a  model  of  the  Hagedorn  needle. 
McDermott  &  Co.,  of  New  Orleans,  makers.  The 
advantages  offered  by  this  needle  are  cheapness,  no 


f\^     ^^^' 


.---.-■:< 


traumatism  of  tissue  in  passing,  and  it  can  be 
threaded  at  home,  put  in  a  test  tube  and  carried  in 
an  obstetric  bag  to  be  used  as  an  emergency  needle 
for  perineal  work. 


ARCHIVES    DE     MEDECINE     DES     ENFANTS. 

May,  1901.     (Volume  IV,  No.  5). 

1.  The  Pathogeny  ot  Rickets.     LOUIS  SPIl.LMAN. 

2.  The   Figured  'Elements   of   Colostrum   and    Milk. 

CHEL  R.  LOURIE. 


RA- 


3.  Rheumatic   Endocarditis   with    Patent   Ductus    Botalli. 

JEAN  HALLE  and  P.  ARMAND-DELILLE. 

4.  Two  Cases  of  Infantile  Hysteria.    JULES  COMBY. 

1. — Spillman  has  studied  rickets  in  a  great  number  of 
animals.  It  follows  the  same  course  in  animals  that  it 
runs  in  man.  It  begins  with  indigestion,  emaciation,  dis- 
tended abdomen,  delayed  dentition,  etc.  Then  follow  the 
bony  deformities,  rosary,  open  fontanelle,  etc.  These  were 
found  histologically  in  ducks,  chickens,  etc.  While 
rickets  is  rare  among  animals,  the  lesions  found  there 
and  those  formed  in  infants  are  identical.  Bad  hygiene  ap- 
pears to  be  the  main  cause.  Out  of  10  animals  In  which 
Spileman  atetmpted  to  produce  rickets  by  defective  feeding 
and  bad  hygienic  suroundings,  digestive  symptoms,  emacia- 
tion, etc.,  appeared  in  every  case,  yet  not  one  showed  any 
bony  changes.  Experiments  thus  confirmed  clinical  experi- 
ence, that  defective  alimentation  and  prolonged  indigestion 
can  cause  arrest  of  development  and  cachexia  without 
rickets.  Therefore  the  nutritive  theory  is  not  correct; 
nor  is  the  chemical  theory,  for  the  deficit  ot  lime  salts 
is  the  result,  not  the  cause  of  rickets.  There  remaia 
the  toxic  and  microbic  theories.  Spillman  made  more  ex- 
periments with  the  colon  bacillus.  While  symptoms  fol- 
lowed, there  was  never  any  bony  change.  Inoculation  to 
show  a  specific  microbe  or  intoxication  were  without  re- 
sult. Yet  it  is  possible  that  our  methods  are  hardly  yet 
perfect  enough  to  find  the  specific  microbe  of  rickets,  if  it 
exists.  After  reviewing  the  lesions  found  in  man.  Spillman 
concludes  that  rickets  must  be  a  specific  intoxication  from 
the  digestive  tract,  causing  widespread  ostitis,     [M,  O.] 

2. — Donng  first  discovered  the  figured  elements  of  colos- 
trum. They  are  nucleated  colostrum  corpuscles, and  appear 
during  pregaancy,  lasting  to  the  fifth  or  sixth  day  after 
confinement.  Then  the  protoplasm  disappears,  and  the 
crescent-shaped  nucleus  is  freed.  Leukocytes  are  also 
present,  few  until  labor  occurs,  and  they  disappear  a  few 
days  afterward.  When  milk  is  examined,  the  crescent- 
shaped  bodies  are  seen  next  to  fat  droplets.  These  colos- 
trum bodies  absorb  red  corpuscles  and  stains.  LouriS  sup- 
poses them  to  be  polynuclear  leukocytes,  transformed. 
They  resist  boiling  and  are  not  seen  in  cow's  milk.  They 
probably  contain  the  soluble  ferments.     [M.  C] 

3. — Hallg  and  Dellille  report  a  case  of  rheumatic  endocar- 
ditis in  a  boy  of  3.  His  mother  noticed  that  his  heart-beat 
was  always  rapid  and  strong.  Articular  rheumatism  had 
existed  a  week  before  he  was  admitted  to  the  hospital. 
Marfan  made  the  diagnosis  of  a  recent  endocarditis  with 
a  congenital  lesion.  The  apex  was  in  the  fifth  interspace. 
2  cm,  outside  the  edge  of  the  sternum  .the  dulness  reaching 
the  right  border  of  the  sternum.  At  the  apex  was  a  loud 
systolic  murmur,  transmitted  to  the  axilla.  Twelve  days. 
later,  the  child  had  an  attack  of  pulmonary  congestion, 
with  dyspnea  and  cyanosis,  and  died.  The  autopsy  re- 
vealed a  patulous  ductus  Botalli  and  a  mitral  vegetative 
endocarditis.  The  congenital  lesion  had  existed  without 
symptoms  until  the  organic  trouble  occurred.  When  or- 
ganic heart  disease  is  found  in  an  infant,  a  congenital  con- 
dition must  be  suspected  as  the  predisposing  cause.   [M.O.] 

4. — Comby  reports  two  cases  of  hysteria  in  children. 
The  first  was  a  girl  of  10,  whose  father  was  a  drunkard,, 
whose  mother  was  very  nervous  and  had  hepatic  colic. 
One  child  was  an  idiot.  This  one  had  always  been  emo- 
tional, and  had  an  attack  of  angioneurotic  edema.  For 
over  a  mon(h  she  had  been  in  bed,  unable  to  walk,  with. 
hysterical  convulsions.  P^xamination  revealed  nothing  ab- 
normal. In  bed  she  could  make  any  movement  asked. 
But  when  stood  up,  she  trembled  and  fell,  like  a  paraple- 
gic. This  became  worse  when  she  tried  to  walk.  But  she- 
could  move  wtU  upon  her  knees.  Comby  considers  it  a 
typical  case  of  hysteria,  pure  astasia-abasia.  Three  days 
treatment  with  baths,  isolation  and  electricity  cured  the 
condition.  The  other  patient  was  a  girl  of  twelve,  whose 
father  was  both  nervous  and  alcoholic.  After  typhoid 
fever  at  6  years,  she  had  complete  left  hemiplegia,  which, 
suddenly  cleared  up  after  having  lasted  two  months.  Two 
years  later  this  recurred  and  lasted  three  months.  At  ID 
years,  right  brachial  monoplegia  appeared,  disappearing' 
suddenly  six  months  later.  Now  she  again  has  right 
monoplegia,  her  fourth  paralytic  attack.  With  isolation. 
and  five  electrical  trestmcnts  she  was  cured.     [M,  O.] 


I206 


The    Philadelphia-] 
Medicai.  Journal   J 


A  CASE  OF  PERNICIOUS  ANEMIA 


[Juke  22,   1301 


©riotnal  articles. 


FURTHER  NOTES  OF  A  CASE  OF  PERNICIOUS 
ANEMIA  REPORTED  AT  THE  MEETING  OF  THE 
ASSOCIATION  OF  AMERICAN  PHYSICIANS  IN 
1900:  WITH  REMARKS  ON  THE  DIAGNOSIS  OF 
THE  DISEASE. 

By  FREDERICK  P.  HENRY,  M.  D., 

of  Philadelphia. 
Professor  of  the  Principles  ;ind  Practice  of  Medicine.  Woman's 
Medical    College     of    Pennsylvania;     Physician     to     the 
Philadelphia    Hospital,    etc. 

At  a  meeting  of  the  association  in  1900,  I  reported 
five  cases  of  pernicious  anemia,  eacii  of  which  pos- 
sessed features  of  unusual  clinical  interest,  and 
made  some  remarks  upon  the  diagnosis  of  the  dis- 
ease and  the  characteristic  alterations  of  the  blood 
which  it  presents.  Exception  was  taken  to  one  of 
my  cases  (case  IV.)*  on  the  ground  that  nucleated 
red  cells,  and  especially  megaloblasts,  had  never 
been  found  in  the  blood  of  the  patient.  In  reply  to 
my  ([uestion  as  to  how  my  critic  would  classify  sucli 
a  case  as  I  reported,  he  said  that  he  "shoulil 
regard  it  as  a  case  of  secondary  anemia  of  unknown 
origin".**  'He  also  stated  that  he  had  "had  a  num- 
ber of  such  cases  ending  in  recovery,"***  but  saw 
no  reason  to  regard  them  as  cases  of  pernicious 
anemia.  I  will  not  stop  to  discuss  the  question 
whether,  with  our  present  knowledge,  pernicious 
anemia  may  not  be  defined  as  a  "secondary  anemia 
of  unknown  origin,"  but  will  again  refer  to  the 
implication  that  such  cases  as  my  case  IV,  are  by 
no  means  rare. 

I  will  now  briefly  relate  the  main  clinical  feat- 
ures of  the  case  whose  progress  I  am  reporting.  In 
vol.  XV.  of  the  Transactions,  its  caption  is  as  fol- 
lows: Case  I\'^.  Under  observation  six  years,  dur- 
ing which  there  have  been  several  slight  and  two 
severe  relapses,  chronic  gastro-intestinal  catarrh, 
with  marked  exacerbations  preceding  and  during 
the  relapses  :  complete  restoration  to  health.  In  the 
extreme  reduction  of  the  red  cells  (to  1,237,500  per 
cubic  mm.,  i.  e.,  to  about  25  per  cent,  of  the  normal), 
the  increased  percentage  (30)  of  hemaglobin.  the 
hypoleucocytosis,  and  poikilocytosis,  as  well  as  in 
the  symptoms  both  positive  and  negative,  the  case 
was  a  typical  one  of  pernicious  anemia.  At  the  time 
of  my  report  last  year  the  patient  considered  himself 
in  the  best  of  health,  and  his  general  appearance 
was  "indicative  of  vigor  and  activity."  The  recent 
history  of  the  case  is  as  follows : 

I  was  asked  to  see  the  patient  in  consultation  with  Dr. 
L.  D.  Judti  on  March  29th,  :i>01.  and  found  him  in  a  state 
of  profound  anemia.  I  found  tliat  he  had  been  progressive- 
ly tailing  in  strength,  in  other  words,  becoming  more  and 
more  anemic,  during  the  autumn  of  1900,  and  that  in  De- 
ctmlier  he  had  had  another  attack  of  erysipelas.  A  week 
before  I  saw  him  he  had  returned  from  a  visit  to  Atlantic 
City,  where  he  had  been  under  the  care  of  Dr.  Philip  Mar- 
vel, who,  on  February  2Tth,  had  examined  his  blood  with 
the  following  result:  Number  of  red  cells  per  cubic  mm., 
1,240,000:  Hemoglobin,  32<~t;  white  cells.  3,000  per  cubic 
mm.;  marked  poikilocytosis.  A  differential  count  was  not 
made,  nor  is  anything  said  in  the  report  concerning  nuc- 
leated red  colls.  These  figures  are  almost  precisely  identi- 
cal with  those  of  a  count  I  made  on  February  3rd,  1S94. 

♦Read  at  the  meeting  of  the  Association  of    American    Physi 
cians,  April  30th,  1901. 

•'Transactions  of  the  Association  of  American  Physicians, 
vol..   XV.,    p.   352. 

•»»Loc.   cit.,   p.   3t;fi. 

••••Loc.   cit.,   p.   3(K. 


On  one  of  my  visits  in  March  of  the  present  year  I  made 
several  cover-glass  preparations  and  sent  them  to  Dr.  L.  N. 
Boston,  who  reported  the  presence  both  of  normoblasts 
and  megaloblasts.  Under  the  use  of  arsenic  and  iron 
the  patient  is  steadily  improving,  although  his  urine  con- 
tains a  considerable  quantity  of  albumen.  This  albumin- 
uria was  a  feature  also  of  the  last  relapse,  but  disappeared 
pari  passu  with  improvement  in  health  and  strength. 

I  presume  that  no  member  of  the  association  has 
now  an}'  doubt  that  this  is  a  typical  case  of  per- 
nicious anemia,  although,  in  mj"  opinion,  there  never 
should  have  been  the  slightest  question  concerning 
the  diagnosis.  The  demonstration  of  megaloblasts 
in  the  blood  was  not  at  all  necessary  to  confirm  it. 
There  is  a  tendency  at  the  present  time  to  regard 
the  presence  of  these  cells  in  the  blood  as  the  sole 
criterion  of  pernicious  anemia.  According  to  this 
view,  a  case  may  present  symptoms  and  signs  and 
blood  changes  such  as  are  not  found  united  in  anv 
disease, except  pernicious  anemia, and  j'et,  if  megalo- 
blasts are  not  detected  in  the  blood,  the  diagnosis  of 
pernicious  anemia  is  unwarranted.  Such  a  doc- 
trine appears  to  me  as  pernicious  as  the  disease 
to  which  it  is  applied,  and  for  the  following  reasons: 
1-irst,  because,  as  already  stated,  the  symptoms 
and  signs,  both  positive  and  negative,  and  the  blood 
changes  of  pernicious  anemia,  apart  frc>m  the 
presence  of  nucleated  cells,  distinguish  it  sharply 
from  all  other  diseases.  Secondly,  because  nucle- 
ated cells,  whether  large  or  small,  are  not  path- 
ognomonic of  pernicious  anemia.  A  symptom  or 
sign  to  be  pathognomonic  must  fulfil  one  of  the  re- 
quirements of  a  specific  germ :  i.  e.,  it  must  occur  in 
association  with  but  one  disease.  Now  this  is  not 
the  case  with  the  cells  called  megaloblasts,  which 
arc  found  in  leukemia,  in  bothriocephalus-aneinia. 
and  occasionally,  though  very  rarely,  in  cases  of 
carcinoma  ventriculi  and  syphilis.*  If  the  presence 
of  megaloblasts  in  the  blood  were  pathognomonic 
of  pernicious  anemia,  the  diagnosis  of  that  disease 
could  be  made  more  accurately  in  the  laboratory 
than  at  the  bedside.  Now  this  is  by  no  means  the 
case,  for  it  is  impossible  for  the  histologist  to  dis- 
tinguish a  specimen  of  blood  from  a  case  of  both- 
riocephalus-anemia  from  one  derived  from  a  case 
of  that  mysterious  disease  so  well  styled  by  Birch 
Ilirsclifeld   as  cryptogenetic   anemia. 

The  diagnosis  of  pernicious  anemia  is  most  firmly 
based  upon  the  tout  ensemble  of  signs  and  symp- 
toms, both  positive  and  negative.  The  presence  of 
megaloblasts  is  confirmatory  of,  but  not  indispensa- 
ble to,  the  diagnosis.  They  possess  a  prognostic 
rather  than  a  diagnostic  value,  for  they  often  ap- 
ju'ar  in  the  blood  in  large  numbers  shortly  before 
death,  and  often  are  absent  for  months  during  pe- 
riods of  remission.** 

With  reference  to  the  statement***  that  cases  of 
anemia  with  a  hemic  unit  of  25  and  a  hemoglobin 
percentage  of  30  are  not  rare  (they  cannot  be  rare 
if  any  individual  has  seen  "a  number"  of  them),  and 
that  they  often  end  in  recovery,  I  can  only  say  that 
in  a  continuous  service  in  large  hospitals  dating 
from  1874.  during  which  time  I  have  been  on  the 
alert  for  cases  of  pernicious  anemia  and  conditions 
resembling  it,  I  have  had  no  such  experience. 

•Ehrlich  and  Lazarus,  die  Anaemie.  Xothnag^els  Specielle 
PathoUiarie    und    Therapie.    I    Abthcilung.  S.  41. 

••I  azarus.  Die  Anaemie.  Nothnagel's  Specielle  Pathologie 
und    Therapie.    II    .-VhtheiUins.    S.    113.  • 

•••Tr.msactions  of  the  Association  of  American  Physician:? 
Vil    XV.,    p.    3tC. 


June  22.  19UU 


A  CASE  OF  SEVERE  ANEMIA 


tThe    Philade:.phi.v        ,  -,^^ 
L  -Medical  Journal  i-u/ 


ACASE  OF  SEVERE  ANEMIA  WITH  CHANGES  IN  THE 
SPINAL  CORD. 

By  WM.  E.  HUGHES,  il.  D.,  and  \VM.  G.  SPILLER,  M.  D., 

of  Pliiladelphia. 

Clinical    Report  by   Dr.   Hughes. 

Daniel  C,  white,  aet.  fi3  years,  a  native  of  Ireland,  was 
admitted  to  the  Philadelphia  Hospital,  Dec.  30th,  1899,  his 
chief  complaint  being  shortness  of  breath  and  swelling  of 
feet  and  legs.  There  was  nothing  In  his  family  history  of 
any  moment.  His  parents  both  died  of  old  age.  Three 
brothers  died  ot  wounds  received  while  in  the  army.  He 
had  the  usual  diseases  of  childhood.  Then  he  was  well 
until  five  years  ago.  when  he  had  a  slight  sunstroke,  the  es- 
pecial symptoms  connected  with  which  he  did  not  remem- 
ber when  questioned.  The  attack  was  not  deemed  of  any 
moment  at  the  lime  of  its  occurrence,  and  he  recovered 
from  it  perfectly,  remaining  well  until  his  present  Illness 
conimeuced.  In  July.  1899,  he  noticed  that  on  running,  or 
e\en  walking  fast,  he  would  become  suddenly  short  of 
breath  and  would  have  to  stop,  or  even  sit  down,  till  he 
had  recovered  himself.  This  became  steadily  worse  until 
any  effort  distinctly  inconvenienced  him.  Three  weeks  be- 
fore admission  his  feet  and  less  began  to  swell  toward  eve- 
ning. At  first  the  swelling  would  disappear  by  morning. 
but  by  the  time  of  his  admission  it  had  become  persistent. 
Uiough  worse  toward  night.  During  most  of  his  illness  he 
complained  of  feeling  cold  rind  chilly.  Throughout  this 
time.  too.  his  bowels  were  rather  loose,  though  not  persist- 
ently so.  1  here  had  been  no  hemorrhages.  On  admission 
his  skin  w.is  dry  and  glazed  and  of  a  peculiar,  uniform 
waxy  pE'.ilor.  There  was  some  pufliness  of  his  eyelids  and 
edema   of  his   face.     The  feet   and   legs   v.-ere   edematous 


condition.  The  urine  had  a  specific  gravity  of  1016.  was 
acid  in  reaction  and  contained  neither  sugar  nor  albumin. 
He  had  not  lost  much  flesh.  The  digestion  had  been  good. 
Jan.  4th.  1900.  a  blood  examination  gave  780,000  red  cor- 
puscles and  a  hemoglobin  value  of  20%.  The  next  day  an- 
other examination  gave  671.51  S  red  corpuscles.  3,000  white 
corpuscles,  hemoglobin  18%.  A  majority  of  the  red  cells 
were  larger  than  normal,  but  there  were  great  variations  in 
size  and  outline.  Normoblasts  and  megaloblasts  were  pres- 
ent in  numbers.  Jan.  7th,  reds  700,000,  whites  2.400.  hemo- 
globin 20%.  Gastric  disturbances  had  developed  and  he 
had  come  to  vomit  nearly  everything  ingested.  He  graJ- 
uallv  grew  worse,  his  dyspnea  amounted  to  orthopnea,  and 
he  "died  of  exhaustion  Jan.  16th.  The  temperature  ran 
about  normal,  the  highest  being  99.8. 

Autopsy.  The  pericardial  sac  contains  30  c.c.  of  straw 
colored  fluid,  in  which  float  numerous  threads  of  fibrin 
On  the  anterior  surface  of  the  right  ventricle  is  a  large 
white  patch  of  fibrous  thickening.  All  the  cavities  of  the 
heart  contain  dark  fluid  blood  and  a  few  currant  jelly 
clots.  The  valves  of  the  right  heart  are  normal.  The  mi- 
tral orifice  is  of  normal  size:  on  parts  of  the  free  margin 
of  both  leaflets  is  a  slight  thickening.  The  aortic  valve  is 
normal.  The  heart  muscle  is  dark  reddish  brown  in  color. 
In  the  papillary  muscles  of  the  left  heart  is  a  distinct  yellow 
mottling  showing  through  the  endocardium.  The  wall  of 
the  left  ventricle  Is  14  m.m.  thick,  the  right  9.  The  cor- 
onary arteries  are  slightly  thickened  but  their  lumen  is 
little  encroached  upon. 

The  pleural  cavities  contain  110  and  250  c.c.  of  clear  straw 
colored  fluid  respectively.  The  lungs  are  voluminous,  their 
anterior  edges  nearly  covering  the  pericardium  and  almost 
meeting.  On  their  free  edges  dilated  vesicles  are  plainly 
seen.  The  lung  substance  is  light  pink  with  consiaerable 
pigmentation,  and  exudes  from  its  cut  surface  large  quanti- 


hig  I.    Diffused  geucralioii  in  the  cervical  rirgion.  m  re  extensive  in  the  left  1  ter^I  cohinin  th  "n  in  the  right. 


I'ulse  was  slow  and  full,  but  had  very  low  tension.  The 
heart  was  slightly  enlarged,  the  apex  beat  could  scarcely 
be  felt  and  there  was  a  systolic  apex  murmur,  transmitted 
into  the  axill.t.  The  right  lung  ex!)anded  poorly,  there 
was  some  dulness  at  the  base  posteriorly  with  distant 
weak  breath  sounds  and  some  crackling  rales.  The  left 
lung  was  negative.  The  sight  in  the  right  eye  was  nearly 
gone,  the  result  of  an  accident,  while  in  the  left  it  was 
normal  and  this  pupil  reacted  well  to  light  and  distance. 
He  could  scarcely  walk  on  account  of  physical  weakness 
but  his  station  seemed  to  be  fair.  The  reflexes  were  pres- 
ent but  were  sluggish,  which  was  thought  to  be  due  to  his 
physical  weakness.  There  were  no  electrical  reactions 
taken.  Sensation  seemed  to  be  preserved  but  this  could 
not  be  absolutely  determined  on  account  of  his  low  mental 

•Read  before  the  Philadelphia  Neurological  Society,  .\pril.  I!t1l. 


ties  of  frothy  mucus.  At  the  apex  of  the  right  lung  are 
numerous  depressed  scars,  some  of  them  extending  deep 
into  the  substance.  The  bronchial  mucous  membrane  is 
covered  with  considerable  mucous  exudate.  The  bronchial 
lympli  glands  are  considerably  enlarged  and  deeply  pig- 
mented. 

.Spleen  is  of  moderate  size.  Its  capsule  is  thin  and  light 
colored.  Its  parenchyma  is  soft,  pulpy  and  easily  scraped. 
The  adrenals  are  normal  in  size  and  show  no  pathological 
condition.  The  kidneys  are  of  moderate  size.  The  capsule 
is  slightly  adherent  in  places  and  leaves  a  slightly  uneven 
surface.  The  cut  surface  is  pale,  the  pyramids  of  a  gray- 
ish white  color.  The  cortex  measures  7  m.m.  The  pan- 
creas shows  no  pathological  change.  The  liver  is  of  normal 
size  and  of  light  reddish  brown  color.  In  the  region  of  the 
gall  bladder  are  numerous  adhesions  between  gall  bladder. 


I208 


The    Philadelphia  "i 
Medical  Journal    J 


A  CASE  OF  SEVERE  AXEML\ 


fJuxE  22.    1901 


liver  and  intestines.  The  wall  of  the  gall  bladder  is  not  thick- 
ened and  it  contains  no  stones.  The  cut  surface  of  tha 
liver  is  light  reddish  brown  in  color,  mottled  with  yello\.' 
points  corresponding  apparently  with  the  centers  of  the 
lobules. 

The  mucous  membrane  of  the  colon  is  thx-kened  but 
otherwise  normal,  'i'hat  of  the  small  intestine  and  stom- 
ach is  healthy.  The  appendix  is  only  a  short  stump,  tha 
lumen  of  which  is  closed  by  scar  tissue.  The  mesenteric 
lymph  glands  are  dark  brown  in  color  and  of  a  moderate 
size.     The  cerebrospinal   fluid  is  increased  in  amount. 

PATHOLOGICAL    REPORT    BY    DR.    SPILLER, 

From    the    Wm.    Pepper    Clinical    Laboratory     (Phoebe    A. 
Hearst  Foundation). 

The  sclerosis  in  the  spinal  cord  is  most  pro 
notinced  in  the  upper  tlioracic  and  cervical  regions 
and  is  more  intense  in  the  left  lateral  column  than 
in  the  right  lateral  column  in  these  regions.  It  is 
diffuse  in  these  portions  of  the  cord,  i.  e.,  it  is  not 
confined  to  any  distinct  system  of  fibers.  In  the 
posterior  columns  the  degeneration  is  most  notice- 
able in  the  ventral  portion.  The  anterior  columns 
are  more  nearly  normal  than  the  other  portions  of 
the  white  matter  of  the  cord,  but  the  neuroglia  is 
proliferated  somewhat  here  also.  The  anterior  and 
posterior  roots  appear  to  be  normal.  The  crossed 
pyramidal  tracts  are  degenerated  as  far  as  the  sa- 
cral region, and  the  left  is  more  degenerated  than  the 
right,  because  the  diffuse  degeneration  high  in  the 
cord  is  more  extensive  in  the  left  lateral  column. 
The  degeneration  below  the  midthoracic  region  is 
systemic  in  the  lateral  columns,  i.  c,  it  is  confined 
to  the  crossed  pyramidal  tracts.     In  the  lumljar  rc- 


y 


^^ 


A^^ 


^:£^^^^S^ 


k 


m 


\'\%.  ^.    Elood-ves'iel  external  to  the  cord  near  the  posterior  roots  of  one 
ide.    The  walls  of  this  vessel  are  much  thicken  d. 

the  Marchi  method  reveals  no  recent  degeneration. 
No  swollen  axons  are  found.  The  nerve  cell  bodies 
of  the  cervical  and  lumbar  regions  stained  by 
thionin  are  not  distinctly  abnormal,  but  some  of 
them  are  intensely  pigmented.  The  blood  vessels, 
both  the  intramedullary  and  the  extramedullary, 
have  much  thickened  walls,  and  the  small  intrame- 
dullary vessels  arc  thickened  not  only  where  the 
sclerosis  is  dense,  but  also  where  the  tissue  of  the 
cord  is  normal.  The  walls  of  many  of  the  vessels 
have  a  hyaline  appearance,  and  the  thickening  im- 


y^fA'i^r 


I-'if;.  2.     Degeneration  o;  Ih     right  anterior  i  yranii '. 


gion  the  posterior  columns  are  \ery  slightly  scle- 
rotic. In  the  medulla  oblongata  the  right  anterior 
pyramid  is  much  degenerated,  l)ut  the  left  anterior 
pyramid  appears  to  be  normal.  The  degeneration  is 
traced  above  the  motor  decussation  as  high  as  the 
mid-portion  of  the  pons  on  the  right  side,  but  wheth- 
erit  extended  much  higher  or  not  I  cannot  say, as  the 
cerebrum  was  not  in  my  possession.  The  right  p3'r- 
amidal  tract  above  the  decussation  is,  therefore,  de- 
generated, while  the  left  is  intact;  but  the  left 
crossed  pyramidal  tract  in  the  cord  is  more  degen- 
erated than  the  right,  where  the  alteration  is  dis- 
tinctly systemic,  i.  e.,  in  the  lower  portions  of  the 
cord.    A  section  from  the  cervical  region  stained  bv 


plicates  all  the  coats  of  the  vessels.  Xo  round  cell 
infiltration  or  hemorrhage  is  found  in  the  spinal 
cord,  or  spinal  pia.  The  only  sign  of  a  hemorrhage 
I  have  been  able  to  detect  is  an  accumulation  of 
blood  pigment  about  a  small  vessel  in  the  motor 
tract  in  the  left  side  of  the  pons. 

The  literature  on  diffuse  degeneration  of  the  spi- 
nal cord  in  cases  of  severe  anemia  has  beeome  ex- 
tensive. Cases  in  this  city  have  been  reported  by 
Burr  and  Lloyd,  and  we  have  recently  had  in  the 
paper  by  Putnam  and  Taylor  a  careful  presentation 
of  this  subject.*     Credit  must  be  given  to  Putnam 

"Another  paper  on  this  form  of~9isease  has  been  published 
recently  by  Brown.  Langdon  and  Wolfstein,  Journal  of  the 
Amer.    Med.    Assoc,    Mjtrch   2,    1%!. 


June  22.  19(1] 


A  CASE  OF  SEVERE  AXEMIA 


CThe    Philadelphia 
Medical  Journal 


1209 


I       ^^^ 


Fig.  4.    A  stiucture  near  the  posterior  roots  of  oue  side  which  appears 
to  be  a  th  ckened  blood-vessel  containiug  an  organized  thrombus. 

and  Dana  for  first  showing  that  alteration  of  the 
spinal  cord,  similar  to  that  occurring  in  pernicious 
anemia,  may  result  from  malnutrition,  even  when 
intense  anemia  is  not  present.  Paresthesia,  ataxia, 
etc.,  may  in  these  cases  persist  many  3'ears  with  lit- 
tle alteration  of  the  spinal  cord,  and,  on  the  other 
hand,  the  intensity  of  the  alteration  in  the  cord  may 
be  much  greater  than  the  clinical  signs  would  lead 
us  to  expect,  and  in  some  cases  pathological  condi- 
tions of  the  cord  have  existed  without  clinical  signs. 
The  few  symptoms,  feebleness  of  gait  and  dimin- 
ished knee  jerks,  indicative  of  implication  of  the  ner- 
vous system  in  Dr.  Hughes'  case,  is  not  unlike  what 
has  been  observed  in  some  other  cases,  and  sensation 
could  not  be  determined  on  account  of  the  patient's 
mental  condition,  but  the  intensity  of  the  alteration 
in  the  spinal  cord  suggests  that  paresthesia  may 
have  existed.  In  case  2,  for  example,  of  Taylor's 
part  of  the  recent  paper  by  Putnam  and  himself, 
the  patient  is  said  to  have  had  some  numbness  of  the 
arm  occasionally,  and  of  the  lower  limbs,  and  tremor 
of  the  upper  limbs,  but  no  other  nervous  symptoms 
are  mentioned,  and  yet  the  alteration  of  the  spinal 
cord  was  intense.  This  case  is  not  alone  in  the  lit- 
erature. As  in  many  reported  instances,  the  altera- 
tion in  Dr.  Hughes'  case  was  more  marked  in  the 
cervical  and  upper  thoracic  regions  than  in  the  lower 
thoracic  and  lumbar  portions  of  the  cord,  and  the 
degeneration  was  diffuse  in  the  former  portions,  i. 
e.,  it  was  not  confined  to  definite  tracts,  and  systemic 
degeneration  was  present  only  as  a  result  of  diffuse 
lesions.  Descending  degeneration  in  the  crossed 
pyramidal  tracts  has  occurred  as  a  result  of  injury 
of  the  fibers  of  these  tracts  at  different  levels  of  the 
cord,  but  the  degeneration  in  the  lateral  columns  in 
the  cervical  region  extended  beyond  the  area  of  the 
motor  tracts,  and  in  the  posterior  columns  did  not 
invade  the  root  entrance  zones.  The  anterior  and 
posterior  roots  were  not  degenerated.  So  far  the 
findings  are  not  unlike  those  of  Putnam  and  Taylor 
and  some  other  investigators,  but  the  condition  of 
the  blood  vessels  makes  the  case  unlike  any  of  the 
five  studied  microscopically  by  Taylor.  In  only  two 
of  his  cases  was  there  any  alteration  of  the  spinal 
vessels,  and  in  those  it  was  slight.  In  one  case  many 
of  the  vessels  within  the  cord  had  moderately 
thickened  walls  and  were  in  a  condition  of  hyaline 
degeneration.  The  pia  and  its  contained  vessel.s 
were  normal.  In  another  case  a  slight  hyaline 
thickening  of  tdne  walls  of  the  smaller  vessels  was 
observed  in  the  degenerated  areas,  but  there  was 


no  general   arteriosclerosis.     Taylor  considers  the 
vascular  changes  he  found  of  very  little  importance. 
The  alteration  of  the  blood  vessels  in  diflfuse  degen- 
eration of  the  spinal  cord  has  varied  in  the  different 
cases  studied.  Minnich  found  diseased  blood  vessels 
in  the  cord,  and  Nonne,  in  a  recent  paper,  savs  he 
found   the  vessels  unaltered  when  the  cord  tissue 
was  unaltered  or  only  slightly  degenerated;  but  in 
the  advanced  cases  the  vascular  changes  were  pro- 
nounced, and  the  relation  of  foci  of  degeneration  to 
altered  vessels  was  striking.     In    advanced    cases 
Nonne  never  failed  to  find  vascular  alteration.  He 
believes  that  some  hypothetical  poison  causes  the 
anemia  and  degeneration  of  the  spinal  cord,  and  is 
conveyed  by  tlic  blood  vessels  of  the  cord,  and  tliat 
after  a  long  contact  of  this  poison  with  the  vessel 
walls  alteration  of  the  vessels  is  produced,  and  this 
alteration  of  the  vessels  contributes  to  the  formation 
of  a  vicious  circle.     He  has  even  observed  throm- 
bosis, followed  by  softening,  and  Dana  also,  in  a 
case  of  diffuse  degeneration    of  the  cord,    has    re- 
ported   softening   of    the    cord,    presumably    from 
thrombosis  of  the  artery  of  the  anterior  fissure.    Ja- 
cob and  iMoxter  foundin  all  their  cases  of  anemia 
multiple  foci  of  degeneration  in  the  cord  about  the 
vessels   and   septa.     They  found   alteration   of  the 
vessels  in  normal  as  well  as  sclerotic  portions  of  the 
cord,  and  observed  thickening  of  the  adventitia  and 
of  the  glia  surrounding  the  vessels.    The  vessels  in 
some  of  the  foci  were  unaltered.     They,  therefore, 
conclude  that  the  changes  in  the  walls  of  the  ves- 
sels were  not  the  cause  of  the  degeneration  of  the 
white  matter  of  the  cord,  but  they  believe  that  the 
process  almost  constantly  begins  in  the  formation 
of  perivascular  and  periseptal  foci  of  sclerosis.    The 
vessels  of  the  cord,  in  the  cases  examined  by  Rus- 
sell, Batten  and  Collier,  in  the  affected  areas  were 
engorged  and  their  walls  thickened,  but  there  was 
no  actual  thrombosis.     In  the  unaffected  areas  the 
vessels  were  neither  engorged  nor  thickened.  In  one 
of  their  cases  the  middle  coat  of  the  vessels  appeared 
to  have  undergone  a  hyaline  change.    Hemorrhages 
within  the  white  and  gray  matter  are  a  common 
finding  in   pernicious   anemia,   according   to   Jacob 
and  Moxter.  and  some  investigators  have  regarded 
the  hemorrhages  within  the  spinal  cord  as  a  partial 
cause  of  the  degeneration  of  the  white  matter,  while 
others  have  looked  upon  them  as  unimportant.  Thev 
were  entirely  absent  in  the    cord    in     Dr.  Hughes" 
case,    and    only    in    one     place    in    the     pons    was 
any  indication  of  a  former  hemorrhage  found.  What 
is  the  meaning  of  the  conflicting  statements  regard- 
ing the  condition  of  the  blood  vessels  in  diffuse  de- 
generation as  made  by  different  investigators?  In 
Dr.  Hughes'  case  the  vascular  alteration  was  exceed- 
inclv  pronounced ;  in  a  case  of  diffuse  sclerosis  re- 
posed by  Dr.  J.  Hendrie  Lloyd,  microscopical  sec- 
tions from  which  I  have  studied  in  order  to  deter- 
mine the  condition  of  the  vessels,  the  latter  were 
not  diseased,  and  in  an  unpublished  case  of  Dr.  Der- 
cum,  I  have  failed  to  find  much  alteration  of  the 
vessels  outside  of  the  sclerotic  areas.     It  must  be, 
therefore,  that  vascular  changes  may  aid  in  the  de- 
velopment of  sclerotic  tissue,  but  degeneration  of 
the  nervous  tissue  may  begin  before  any  thickening 
of  the  walls  of  the  vessels  is  detected,  and  it  seems 
not  improbable  that  some  toxic  substance  in  the  cir- 


I2IO 


The    Philadelphia 
JlEDiCAL  Journal 


J 


A  CASE  OF  SEVERE  ANEMIA 


[June  22.  Wn 


culation  is  the  cause  of  the  formation  of  sclerotic 
tissue  within  the  white  matter,  and  of  the  alteration 
of  the  walls  of  the  vessels — a  view  held  by  more  than 
one  student  of  the  pathology  of  this  disease.  Ac- 
cording to  Mott,  the  spinal  degeneration  occurring 
in  grave  anemia  cannot  be  produced  experimentally 
in  animals. 

It  is  important  to  know  to  what  extent  the  cen- 
tral nervous  system  is  implicated  in  these  cases  of 
•diffuse  sclerosis.  Mott  examined  three  cases  of  spi- 
nal alteration  in  grave  anemia  and  found  that  the 
degeneration  was  not  confined  to  the  spinal  cord. 
In  two  cases  examined  by  the  Nissl  method  he  found 
marked  changes  in  the  cortical  pyramidal  cells,  and 
when  his  material  was  studied  by  the  Marchi  meth- 
od he  found  in  all  his  cases  degeneration  of  the  en- 
tire pyramidal  tract  from  the  cortex  downward,  al- 
though it  was  more  marked  and  extensive  in  the 
spinal  cord  than  in  the  pyramids  and  pons.  These 
are  extraordinary  statements,  and  the  report  reads 
almost  like  that  of  amyotrophic  lateral  sclerosis  oc- 
curring in  anemic  persons.  Russell,  Batten  and  Col- 
lier, in  their  cases,  found  the  upper  part  of  the  pons, 
the  internal  capsule  and  the  cortex  of  the  brain  ap- 
parently perfectly  normal.  Extensive  degeneration 
of  the  pyramidal  tracts  was  found  by  them  as  high 
as  the  medulla  oblongata.  In  two  cases  Taylor 
studied  portions  of  the  nervous  system  above  the 
cord,  and  in  one  of  these  the  medulla  oblongata  and 
cerebral  cortex  were  normal,  and  in  the  other  small 
areas  of  degeneration,  having  no  relation  to  recog- 
nized neurone  systems  were  found  in  the  medulla 
oblongata,  but  the  pons  showed  no  noteworthy  ab- 
normality. I  have  been  able  to  study  the  central 
nervous  system  as  high  as  the  middle  of  the  pons, 
and  have  found  that  above  the  motor  decussation 
the  pyramidal  tract  on  the  right  side  is  degenerated 
at  least  as  high  as  the  middle  of  the  pons.  It  seems 
to  be  less  intensely  degenerated  in  the  pons  than  in 
the  right  pyramid.  This  is  probablj-  retrograde 
atrophy  from  the  sclerotic  area  in  the  left  crossed 
pyramidal  tract  of  the  upper  thoracic  and  cervical 
regions.  I  have  already  mentioned  that  in  these 
regions  the  left  lateral  column  was  more  degener- 
ated than  the  right,  and  that  the  sclerosis  caused 
more  intense  degeneration  of  the  left  crossed  pyra- 
midal tract  than  of  the  right  in  lower  regions  of  the 
cord.  The  alteration  of  the  cord  in  Dr.  Hughes'  case 
must  have  been  of  long  duration,  as  no  recent  de- 
generation was  detected  by  Marchi's  method.  Retro- 
grade atrophy  I  have  seen  repeatedly  in  long  stand- 
ing cases,  and  have  referred  to  it  several  times,  but 
I  am  not  aware  that  it  has  ever  before  been  observed 
in  a  case  of  diffuse  degeneration.  I  believe  that  in 
Dr.  Hughes'  case  the  alteration  was  a  retrograde 
atrophy,  because  it  was  confined  to  the  right  side 
above  the  motor  decussation,  and  appeared  to  be  less 
intense  in  the  pons  than  in  the  anterior  pyramid, 
and  the  alteration  of  the  lateral  column  of  the  cord 
was  more  intense  on  the  left  side. 

There  seems  to  be  little  evidence  in  support  of 
the  opinion  of  Rothmann  that  the  alteration  of  the 
white  matter  in  these  cases  of  diffuse  sclerosis  is 
the  result  of  changes  in  the  cell-bodies  of  the  gray 
matter  of  the  cord.  The  nerve  cell-bodies  have  been 
found  much  pigmented  by  Russell.  Ratten  and  Col- 
lier, by  Taylor,  by  myself  and  others:  but  the  pig- 


mentation probably  is  in  no  way  responsible  for  the 
degeneration  of  the  white  matter.  With  Taylor,-  I 
must  dissent  from  the  view  of  Bastianelli,  that  in 
cases  due  to  pernicious  anemia  the  sclerosis  is  not 
<o  compact  and  the  lateral  columns  are  less  affected  ; 
and  from  the  view  of  Russell,  Batten  and  Collier, 
that  in  none  of  the  cases  of  fatal  anemia  have 
changes  been  found  in  the  spinal  cord  in  any  way 
comparable  to  those  so  characteristic  of  the  subacute 
combined  degeneration. 

Changes  in  the  spinal  cord  very  similar  to  those 
occurring  in  anemia  have  been  fotind  by  several  in- 
vestigators in  very  different  diseases,  by  Nonne  in 
some  forms  of  secondary  anemia,  such  as  occurs  in 
chronic  interstitial  nephritis,  and  also  after  death 
from  sepsis.  In  spinal  cords,  from  cases  of  senility 
he  found  proliferation  of  the  glia  in  the  posterior 
columns,  increase  in  the  number  of  blood  vessels, 
with  thickening  of  their  walls,  and  diminution  of 
the  lumen,  and  the  proliferation  of  the  glia  was  es- 
pecially marked  about  the  blood  vessels  in  not  very 
advanced  cases.  Other  authors  have  reported  sim- 
ilar findings  in  senile  spinal  cords.  Changes  like 
those  of  grave  anemia  have  also  been  obser\-ed  by 
Henneberg.  as  the  result  of  disease  of  the  blood  ves- 
sels of  the  cord  from  nephritis.  In  one  of  his  cases 
secondary  degeneration  was  produced  by  numerous 
foci  of  sclerosis,  as  occurs  in  grave  anemia. 

I  am  indebted  to  Dr.  C.  K.  Mills  for  the  clinical 
history  and  necropsical  notes  of  a  case  with  symp- 
toms of  tabes  produced  by  senile  changes  in  the 
spinal  cord.  The  walls  of  the  small  vessels  of  the 
cord  were  much  thickened,  but  were  not  surrounded 
by  distinct  areas  of  sclerosis.  In  one  part  of  the 
posterior  columns  was  a  slight  sclerotic  zone,  and 
in  the  lower  thoracic  region  a  small  bundle  of  much 
swollen  axones  was  found  in  one  antero-lateral  col- 
umn, indicating  impaired  nutrition  of  the  cord.  A 
slight  diffuse  sclerosis  may  have  existed  in  the  cord, 
but  could  not  be  determined  positively.  Xo  systemic 
degeneration  v.as  found  in  the  cord,  and  the  poste- 
rior roots  and  lumbar  spinal  ganglia  appeared  to  be 
normal,  and  yet  Dr.  Mills  has  in  his  notes  that  the 
patient  had  some  pain  in  his  limbs,  Arg}-ll-Robert- 
son  pupils,  Romberg's  sign,  some  ataxia  of  the 
limbs,  lost  knee  jerks,  impairment  of  the  sensa- 
tion in  the  lower  extremities,  incipient  optic  atro- 
phy, etc.  Certainly  a  case  such  as  this  might  sug- 
gest tabes,  and  yet  the  pathological  sigss  of  tabes 
were  absent.    Dr.  Mills'  notes  are  as  follows: 

A  man.  69  years  old.  white,  shoemaker,  bom  in  Ger- 
many. T.-is  admitted  to  the  medical  wards  of  the  Philadel- 
phia Hospital.  April  20.  1S99.  and  was  transferred  to  the 
Men's  Nervous  Wards.  May  6.  1S99.  His  family  history 
was  negative,  and  he  had  no  history  of  syphilis  or  alco- 
holism. 

During  his  stay  in  the  medical  wards  the  following  record 
was  made.  The  patient  has  heen  sick  one  year:  he  com- 
plains of  headache,  pains  :n  the  chest,  through  the  back, 
and  in  the  legs:  he  also  complains  of  gradually  growing 
very  weak,  and  says  that  his  legs  will  not  support  him. 
His  general  apyiearanre  is  that  of  extreme  old  age:  his  ar- 
teries are  very  atheromatous:  and  arcus  senilis  is  marked. 
The  heart  is  enlarged:  the  apex  beat  is  at  the  sixth  inter- 
space: mitral  and  aortic  sounds  are  rough,  but  no  very 
distinct  murmur  can  be  detected.  Examination  of  the  legs 
is  negative.     He  has  the  signs  of  an  old  bronchitis. 

When  the  patient  was  transferred  to  the  nervous  wards. 
May  6,  1S99.  it  was  noted  on  the  transfer  papers  that  he 
complained  of  pains  in  the  legs:   that  there  was  marked 


June  22,  19ul] 


TEACHING  OF    CHEMICAL  PATHOLOGY 


TThe    Philadelphia 
L  Mkdicai.  Journal 


121  I 


ataxia  of  the  arms  and  legs:   knee  jerks  were  absent,  and 
that  the  pupils  were  Argyll-Robertson  in  type. 

A  note  was  made  by  the  resilient  physician  in  the  nerv- 
ous wards  on  May  8,  1899,  which  seems  partly  contradic- 
tory to  the  above  statement,  unless  it  indicates  that  the 
knee  Jerks  were  brought  out  Ijy  reinforcement.  The  note 
was  as  follows:  "Knee  jerks  present  and  reinforcible:  trem- 
or of  the  left  hand  on  motion:  station  fairly  good,  little 
sway:  ataxia  of  arms:  gait  slow  but  not  characteristic" 
(this  probably  meaning  not  characteristic  of  tabes  dor- 
salis).  It  was  also  noted  that  the  pupils  were  myotic,  did 
not  respond  to  light,  but  responded  in  accommodation  and 
convergence.  The  patient  complained  at  this  time  of  head- 
ache and  pains  in  his  joints. 

On  September  20,  1899.  the  following  ward  notes  were 
made;  the  patient  complains  only  seldom,  and  then  of  only 
slight  pains  in  the  joints.  His  tongue  is  protruded  straight 
with  slight  tremor.  Extraocular  movements  are  good,  but 
he  has  Argyll-Robertson  pupils.  He  can  read  small 
print.  Station  is  fairly  good,  but  there  is  slight  swaying 
which  is  more  marked  with  the  eyes  closed:  arm  move- 
ments are  slightly  ataxic. 

The  tendon  and  muscle  phenomena  were  as  follows,  being 
practically  the  same  for  both  sides.  Knee  jerks  absent; 
quadriceps  jerk  absent;  tendo-Achillis  jerk  slight:  gastroc- 
nemius jerk  present;  patellar  clonus  absent:  ankle  clonus 
absent:  biceps  jerk  present:  triceps  jerk  present.  Plantar 
reflexes  were  present,  and  cremasteric  jerks  absent.  Tac- 
tile, pain  and  temperature  sense  seemed  slightly  impaired 
in  the  lower  extremities,  the  sensory  response  being  prompt 
elsewhere.  About  the  same  date  (September  20.  1899),  an 
ophthalmoscopic  examination  was  made,  of  which  the  fol- 
lowing is  a  record.  Right  eye:  The  pupil  is  dilated  one- 
third  and  evenly:  incipient  optic  nerve  degeneration  is 
present;  the  deeper  layer  of  the  nerve  head  is  very  gray. 
especially  at  the  temporal  half:  retinal  veins  are  some 
what  small;  a  few  senile  degenerative  areas  are  seen  in  the 
retina  and  mark  off  old  retinal  extravasations:  a  fresh  and 
deeply  seated  hemorrhage  of  the  papillo-macula  region  is 
present  and  extends  well  out  into  the  macula  region  itself. 
There  are  small  isolated  areas  of  fatty  degeneration  and 
hemorrhage,  especially  down  and  out  from  the  disc.  The 
vessels  show  a  low  grade  of  endarteritis.  Left  eye:  The 
pupil  is  1..5  mm.  in  diameter,  immobile  to  light,  but  prompt 
in  accommodation  and  convergence. 

October  22,  1899,  six  days  before  his  death,  it  was  noted 
that  the  knee  jerks  and  tendo-Achillis  jerks  were  absent: 
that  the  Babinski  reflex  was  present  on  both  sides,  and 
that  the  resi)onse  to  touch  and  pricks  was  felt  in  the  feet 
and  legs,  although  no  accurate  determination  could  be 
made.     The  man  died  October  28.  1899. 

NECROPSY  NOTES. 

The  bod.v  of  an  aged  male,  emaciated,  showing  considera- 
ble greenish  discoloration  of  the  abdomen,  marked  suggila- 
tion  over  the  posterior  aspect  of  the  body  with  small  pete 
chial  hemorrhages.  Rigor  mortis  is  not  marked.  Subcutan- 
eous fat  is  scanty;   the  muscles  are  pale. 

The  left  pleura  shows  adhesions  at  the  apex  and  base, and 
is  dissected  loose  with  difficulty:the  right  pleura  is  likewise 
universally  adherent,  and  dissected  loose  with  difficulty.the 
pulmonary  tissue  being  torn  in  trying  to  loosen  the  pleura. 

The  left  lung  is  intensely  pigmented.  The  surface  of  the 
lower  lobe  shows  numerous  lobules  varying  in  size  from  a 
few  ram.  to  5  cm.  The  apex  contains  a  large 
number  of  small  greyish  nodules,  the  largest  of  which 
are  not  over  25  cm.  in  diameter.  Many  are  calcareous,  and 
In  a  few  places  small  masses  of  lung  tissue  are  found  which 
do  not  float  in  water. 

The  pericardium  contains  two  drachms  of  straw  colored 
fluid,  and  is  apparently  normal. 

The  right  auricle  is  distended  with  postmortem  clots:  the 
right  ventricle  contains  several  chicken-fat  clots,  which  ex- 
tend into  the  pulmonary  arteries.  The  left  auricle  is  also 
distended  and  contains  postmortem  clots.  The  valves  of 
the  right  side  are  normal.  The  auricular-ventricular  open- 
ing admits  three  fingers,  the  mitral  two  fingers.  The  aortic 
leaflets  show  considerable  thickening  at  the  free  margins, 
and  on  ventricular  margins  the  aortic  cusps  are  slightly 
thickened.  The  coronary  arteries  are  slightly  rigid,  but  not 
markedly  athfromatous.  The  left  ventricular  wall  is 
thicker  than  the  right,  the  left  being  4  cm.  and  the  right 
2.8  cm.  in  thickness.  The  myocardium  is  slightly  pale,  but 
is  dense  and  firm. 


The  splenic  trabeculae  seem  a  little  more  prominent  than 
usual,  and  the  organ .  somewhat  denser,  otherwise  it  is 
normal.  The  left  suprarenal  is  appari'Utly  normal.  The 
left  kidney  shows  some  diminution  of  the  cortex,  and 
contains  cysts.  The  capsule  is  extremely  adherent.  The 
surface  is  granular  and  there  is  some  fat  in  the  pelvis.  The 
right  kidney  shows  the  same  changes  as  the  left.  The  ure- 
ters are  normal.  The  bladder  is  slightly  ribbed  and  there 
is  faint  enlargement  of  the  middle  lobe  of  the  prostate,  not 
very  marked.  The  glandular  structure  of  the  pancreas  is 
normal.  The  liver  Is  cirrhotic.  'l"he  biliary  ducts  are  nor- 
mal. 

The  lumbar  nerves  were  dissected  out  continuous  with 
the  cord.  The  brain  and  the  cord  were  left  in  continuity, 
except  a  small  segment. 

Patient  died  4.45  P.  M.,  October  28.  1899.  Autopsy  3.45 
P.  M.,  October  29.  1899.  Path,  diagnosis;  chronic  tu- 
berculosis and  interstitial  nephritis. 

RKFKRENCES. 

Burr.    University    Med.    Mag.      lS94-l.S9.'i.      VII. 

Lloyd,  Journal   of  Nervous  and   Mental   Disease,   April,   189S. 

Putnam    and    Taylor,    Idem.,    Jan.    and    Feb.,    1901. 

Minnich,  Zeitschrlft  fuer  klin.  Med.,  Vols.  21  and  22.  1892: 
and    1S93. 

Dana.    Journal    of   Nervous   and    Mental    Disease,    Jan.,    1899. 

Jacob   and   Moxler,  Arch,    fuer   Psychiatrie.   vol.   32,    No.   1. 

Russell.    Batten    and    Collier,    Brain.    Vol.    23,    Spring.    1900. 

Mcitt.    The    Lancet,    July    14,    19(10. 

Roilimann  Deutsche  Zeitschritt  fuer  Nervenheilkunde,  Vol. 
7,    18'J.. 

Nonne.    Idem.,    Vol.    XIV.,    Nos.    3    and    4. 

Henneberg,  Archiv.   fuer  Psychiatrie,   Vol.  .32.   No.  2. 


THE  TEACHING  OF  CHEMICAL  PATHOLOGY. 

By  ALONZQ  ENGLEBERT  TAYLOR, 

of  San  Francisco. 

Professor   ot   P.ithology,    University   of   California. 

In  a  recent  article  in  this  journal  upon  the  Teach- 
ing of  Pathology,  Adaiiii  wrote:  "Pathological 
chemistry  gives  so  much  promise  of  throwing,  in. 
the  very  near  future,  so  much  light  upon  pathology 
in  general,  that  the  time  has  come  for  greater  ac- 
tivity in  the  teaching  of  this  branch  in  immediate 
connection  with  the  pathological  department."  The 
University  of  California  has  established  such  a 
course  in  chemical  pathology,  the  details  of  which 
may  be  of  general  interest,  particularly  since  in  the: 
series  of  articles  in  the  journal  devoted  to  the- 
teaching  of  the  various  branches  of  medical  science, 
there  was  no  especial  consideration  of  this  subject. 

The  laboratory  in  which  this  course  is  being  given 
was  installed  and  equipped  during  the  past  year.  It 
contains  desk  space  for  fifty  students,  the  space  al- 
lotted to  each  student  being  nearly  twenty  square- 
feet.  Each  student  has  an  individual  desk  and 
locker,  each  desk  containing  a  sink  ten  by  twelve 
inches,  and  is  fitted  with  four  shelves  for  the  reagent 
bottles.  Fitted  to  each  desk  are  three  water  spig- 
ots, one  large  valve  being  for  the  ordinary  supply,, 
and  two  small  cocks  for  the  supply  of  water-baths, 
etc.  The  gas  supply  for  each  desk  consists  of  twO' 
taps.  Each  desk  has  a  vacuum  pipe  exhausted  by  a. 
large  vacuum  pump.  There  are  six  hoods  in  the 
room.  One  is  devoted  to  the  generators  of  hydro- 
gen and  carbon  dioxide.  A  second  is  occupied  by 
the  blast,  the  compressed  air  for  which  is  furnished 
from  a  tank  filled  by  an  automatic  air-pump.  Two 
of  the  hoods  contain  each  a  copper  water-bath  five 
feet  long,  two  feet  wide  and  eight  inches  deep  ;  these 
baths  are  heated  either  by  live  steam  or  by  gas.  and' 
contain  together  50  openings,  one  for  each  student,. 
One  hood  is  devoted  to  the  Kjeldahl  digestion  appa- 
ratus. The  remaining  hood  contains  the  hydrogeir 
disulphide  generator.  There  are  further  two  large 
counters  for  distillations,  etc.     Each  student  is  sup- 


1212 


The    Philadelphia 
Medical  Journal 


]      TEACHING  OF    CHEMICAL  PATHOLOGY 


tJuNE    22.    1391 


plied  with  sixty  reagent  bottles,  a  test-tube  stand 
with  twenty  test-tubes,  test-tube  holder  and  cleaner, 
one  portable  water  bath,  two  gas  burners,  two  tri- 
pods, two  stands  with  rings,  one  burette  holder  with 
two  burettes,  one  wash  bottle,  two  Erlenmeyer 
flasks,  one  destination  flask,  one  vacuum  filtration 
flask,  twelve  beakers,  three  funnels,  two  porcelain 
dishes,  one  separating  funnel,  two  weighing  bottles, 
one  pylonometer,  one  distillation  apparatus,  one 
saphlet  extractor,  one  dessicator,  one  fractional  dis- 
tillation flask,  one  crucible,  crucible  tongs,  one  mor- 
tar and  pestle,  two  pipettes,  two  measuring  cylin- 
ders, one  thermometer,  one  aerometer,  and  the 
watch  glasses,  pinch-cocks,  files,  glass  rods,  glass 
tubing,  rubber  tubing  and  filter  paper  required  in 
the  work.  Each  student  has  upon  his  desk  the  rea- 
gents needed  in  work  of  this  character,  some  sixty 
in  number.  Upon  side  shelves  are  stock  bottles  of 
accessory  reagents  and  solutions  for  titrations.  In 
an  adjoining  room  are  ten  saxtorius  balances,  des- 
sicators,  spectroscopes  and  polariscopes  Three  af- 
ternoon sessions  per  week  are  given  throughout  the 
academic  year. 

The  instruction  is  determined  by  the  principle 
that  the  student  should  learn  to  consider  disturbed 
function  as  coequal  with  and  correlated  to  altered 
structure.  Morbid  anatomy  and  morbid  physiology 
are  considered  and  tauglit  together.  Such  a  course 
will  contain  a  great  deal  of  what  is  in  continental 
writings  called  general  or  experimental  pathology. 
The  courses  in  chemical  and  morphological  pathol- 
ogy are  given  to  the  same  class,  so  that  the  two 
points  of  view  are  constantly  corelated  in  the  mind 
of  the  student.  Chemistry,  so  far  as  its  technical 
aspects  are  concerned,  bears  to  the  one  course  the 
same  relation  which  microscopy  bears  to  the  other, 
that  of  handmaid.  It  is  not  pathological  histology; 
it  is  histological  or  morphological  pathology ;  it  is 
not  pathological  chemistry,  it  is  chemical  pathology 
— the  pathology  is  the  point  of  view.  That  consid- 
erations of  chemistry,  physics,  physiology  and  zool- 
ogy enter  into  the  study  and  teaching  of  pathology 
is,  of  course,  a  truism  ;  l)ut  for  the  student  of  path- 
ology and  for  the  teacher  in  his  duties  as  a  teacher 
of  pathology,  it  is  chemistry,  physics,  physiology 
and  zoology  to  the  end  and  for  the  sake  of  pathology. 

There  are  in  the  instructicin  three  directions 
which  are  followed  :  i.  The  consideration  of  the  re- 
lations of  the  disturbed  function  to  the  lesions.  That 
in  man)-  instances  we  are  not  able  to  define  such  re- 
lations is  all  the  more  reason  for  attempting  to  fix 
them  in  all  cases,  z.  The  determination  of  the  rela- 
tions between  the  particular  functional  disturb- 
ance and  the  general  metabolism,  perhaps  the  most 
valuable  aspect  of  the  subject.  3.  The  training  in 
the  diagnostic  procccdures  employed  in  the  studv 
of  the  chemism  of  disease,  and  instruction  as  to  their 
real  worth. 

The  course  consists  of  laboratory  work  supple- 
mented by  such  lectures  as  are  necessary  for  the 
elucidation  of  the  subjects  in  hand.  So  far  as  pos- 
silile  the  laboratory  work  is  individual  and  practi- 
cal for  each  student.  The  insufficiency  of  material 
in  certain  diseases,  however,  will  sometimes  pre- 
clude individual  exercises,  and  under  these  circum- 
stances demonstrations  (not  descriptions)  replace 
them.     The  course  includes  work  upon  the  saliva. 


the  gastric  secretions  and-  contents,  the  faeces,  the 
urine,  the  blood,  exudates  and  transudates,  the 
bones,  various  organs,  tumors,  ptomains,  toxins, 
antitoxins,  and  ferments.  It  is  planned  to  have  the 
entire  class  do  a  certain  amount  of  work  in  all  the 
general  lines,  following  which,  individual  subjects 
for  original  work  will  be  assigned  to  each 
student,  which  subjects  are  to  be  worked  out 
in  detail.  As  illustrations  may  be  cited  as 
subjects:  the  fats  of  the  stools  of  persons 
with  pancreatic  or  hepatic  disease;  the  stools  of 
diarrheas;  the  urinary  protein  in  the  diflferent  forms 
of  albuminuria ;  the  freezing  point  and  electrolytic 
resistance  of  nephritic  urine ;  the  am3'loid  sub- 
stance ;  the  fat  and  protein  in  the  kidnev  in  nephri- 
tis;  the  mineral  constituents  of  atheromatous  blood- 
vessels; the  protein,  fat  and  glycogen  in  pus;  the 
composition  of  the  fluids  in  ascites  and  edema ;  the 
organic  and  inorganic  constituents  of  the  bones  in 
rachitis  and  in  other  bone  diseases ;  abnormal  uri- 
nary pigments ;  the  protein  and  carbohydrates  in 
the  fluid  of  parovarian  cysts ;  the  dried  residue  of 
the  blood  and  plasma,  and  the  protein  of  the  plasma 
in  anemias ;  the  purin  bodies  in  the  urine  in  such 
conditions  as  leukemia;  the  glycogen  in  diabetic 
tissues  or  in  tumors :  chyluria ;  the  solvent  action  of 
the  serum  of  immunized  animals;  the  Calmette  an- 
tivevene  demonstration,  etc.,  etc.  These  original 
tasks  constitute  a  most  valuable  part  of  the  work, 
since  here  the  frame  of  mind  and  the  scientific 
method    are    cultivated. 

For  the  successful  completion  of  such  a  course 
thereare  twoprerequisites  :  the  student  must  be  ade- 
quately trained  in  physiological  chemistr\' :  and  ma- 
terial must  be  abundant.  A  certain  amount  of  ma- 
terial may  obviously  be  prepared  directly  for  the 
course.  It  will  never  be  possible  to  take  each  stu- 
dent over  the  whole  field,  just  as  it  is  not  possible 
to  give  each  student  work  in  all  the  lines  of  physi- 
ology or  to  demonstrate  all  the  lesions  of  morbid 
anatomy.  Nor  is  that  necessary.  If  each  student 
'.i'orhs  through  and  thinks  through  a  few  of  the 
conditions  of  disease,  the  mental  training  and  the 
grasp  upon  the  subject  thus  attained  will  be  of  high 
value,  above  and  beyond  the  training  in  diagnosis. 
And  for  the  later  development  of  the  student's  med- 
ical mind,  the  chief  object  of  the  course  is  to  teach 
the  student  to  view  disease  as  much  from  the  func- 
tional as  from  the  anatomical  point  of  view,  to  cor- 
rellatc  in  the  mind  morbid  physiology  with  morbid 
anatomy,  and  to  carry  this  association  into  practice 
and  into  original  work. 


Pulmonary  Sclerosis,  Probably  Syphilitic. — Raymond  Ber- 
nard reports  a  very  interesting  case  of  pulmonary  sclerosis 
found  in  a  young  man  admitted  to  the  hospital  with  inter- 
stitial keratitis.  It  was  impossible  to  obtain  any  syphilitic 
family  history.  Examination,  however,  revealed  marked 
thoracic  deformity  with  scoliosis,  adherent  pleura,  and  re- 
traction of  the  left  lung.  Exploratory  puncture  was  nega- 
tive. Over  the  entire  left  side  there  were  no  respiratory 
mo  vements.but  intense  pseudo-cavenous  breathing  was  hear  J. 
The  sclerosis  had  advanced  so  far  that  the  heart  was  drawn 
upward  and  further  to  the  left  side.  Subjective  symptoms 
were  present,  and  when  the  patient  was  dressed,  the  con- 
dition was  not  even  suspected.  He  had  never  had  an  acute 
pulmonary  disease,  nor  was  there  any  suggestion  of  tuber- 
culosis. Yet  the  presence  of  a  double  intestinal  keratitis 
decided  Bernard  in  making  the  diagnosis  of  pulmonary 
sclerosis,  probably  due  to  hereditarv  svphilis.  {^Oa:ctir 
Mviiicale  dc  Paris.  1901,  No.  18)      [M.  O.] 


June  22,  1901] 


treat:\iext  of  jacksoxian  epilepsy 


TThe    Philadelphia 
L  Medical  Journal 


I2I5 


THEORETICAL  AND  PRACTICAL  CONSIDERATIONS 
ON  THE  TREATMENT  OF  JACKSONIAN  EPILEPSY 
BY  OPERATION:  WITH  THE  REPORT  OF  FIVE 
CASES. 

By  JAMES  JACKSON  PUTNAM,  M.  D., 

ot  Boston. 

Professor  of  Xeurologry,   Harvard   Medical   School. 

[Conclusion.] 

To  return  now  to  the  consideration  of  the  ques- 
tions specified  at  the  beginninfj  of  the  paper,  it  may 
be  stated  as  a  fact  which  would  probably  be  gener- 
ally admitted,  that  operations  for  the  relief  of  focal 
epilepsy,  whether  these  aim  at  the  removal  of  lo- 
cal sources  of  irritation  or  of  diseased  areas  involv- 
ing the  cortex,  or  of  the  removal  of  the  apparently 
normal  cortex,  are  often  unquestionably  of  great 
benefit ;  although  they  have  not  accomplished  nearly 
all  that  was  hoped  of  them.  Not  to  speak  of  spec- 
ial cases  and  groups  of  cases,  some  of  the  best  of 
which  have  been  contributed  by  American  physi- 
cians, this  statement  is  substantiated  by  several  re- 
cent'and  careful  compilations  of  German  surgeons, 
as  Braun,'  Graf,-  and  ^latthiolus.' 

When  it  comes  to  the  important  question  of  the 
comparative  merit  of  cortical  excision,  as  against  op- 
erations of  less  magnitude,  such  as  simple  exposure 
of  the  cortex  or  loosening  of  dural  adhesions  and 
the  like,  which  sometimes  have  an  extraordinarily 
favorable  effect,  the  case  is  not  so  clear,  especially 
when  it  is  remembered  that  the  excision  is  likely 
to  cause  lasting  incoordination  of  slight  degree,  and 
that  the  resulting  cicatrices  may  be  by  no  means 
indifferent  for  the  health  of  the  surrounding  parts 
(i)  of  the  brain. 

Still,  the  figures  cited  by  Matthiolus,  taken  for 
what  they  are  worth,  indicate  rather  better  results 
from  operations  in  which  the  brain  has  been  includ- 
ed in  the  operation  than  where  only  lesions  of  the 
brain  coverings  have  been  treated. 

"Cures,"  i.  e.,  for  example,  a  cessation  of  fits  for 
five  vears  have  been  very  few  in  number,  and  al- 
though such  a  case  as  that  of  Collins  and  Gerster"s, 
is  encouraging,  where  six  years  have  elapsed  during 
which,  after  cortical  excision  but  under  continual 
bromide-treatment,  no  fits  have  occurred,  is  very 
impressive,  it  is  to  be  remembered  that  in  the 
first  case  of  the  series  reported  by  McCosh  an 
equally  good  result  followed  simple  trephining,  sep- 
aration of  the  adherent  dura  from  the  roughened 
bone,  and  the  removal  of  bone-fragments,  although 
there  can  be  little  doubt  that  the  broken  adhesions 
instantly  reformed,  so  that  the  local  conditions  of 
nutrition  probably  remained  in  the  end  unimproved. 

The  conclusions  which  seem  to  me  most  reason- 
able on  the  other  points  are  the  following: 

Epilepsv  of  the  "Jacksonian"  type  is  usually  set 
up.  in  the  first  instance, by  gross  sourcesof  irritation, 
either  peripheral  or  central,  but  for  the  most  part 


1  Deutsche   Z.    Schr.   f.   Chir.     1S98. 

2  Arch.    f.    Chir.     1$98.  ^„      „      ,.  .,    ^■ 

3  Deutsche  Z.  Schr.  f.  Chir.  1S99.  Such  compilations  have, 
to  hp  "sur^  only  a  liinited  statistical  value,  since  the  grounds 
for  a  valid  classification  and  comparison  of  the  different  cases 
are  ver>'  imperfect.  The  study  of  individual  cases  is  really  of 
neater   value. 

1  See  McCosh.  Amcr.  Jr.  of  Med.  Sc.  1S9S.  Tol.  115,  p.  549; 
and   othpr  writers. 


external  to  the  brain  tissue  itself.  Yet  there  is 
probably  one  form  which  has  the  same  pathology 
with  so-called  idiopathic  epilepsy  of  more  common 
types.'  The  anatomical  changes  found  under  these 
circumstances  are  to  be  regarded  as  usually  either 
secondary  to  the  convulsions  or  else  as  indications 
of  an  abnormally  developed  brain.  Perhaps  uremic 
and  other  toxic  convulsions  of  focalized  type 
should  be  classified  with  this  group,  inasmuch  as 
the  poison  is  distributed  through  the  brain  as  a 
whole,  and  the  localized  effect  is  not  to  be  sought 
in  the  localized  cause. 

It  is  doubtless  true, — as  Sachs^  and  Collins^  have 
pointed  out, — that  in  some  cases  of  Jacksonian  epi- 
lepsy degenerative  changes  may  be  found  in  excised 
pieces  of  the  cortex,  which  were  not  recognizable 
to  the  naked  eye.  On  the  other  hand,  however,  the 
evidence  that  these  changes  are  of  a  kind  likely  to 
excite  epileptic  seizures  seems  to  me  insufficient, 
and  it  is  especially  improbable  that  lesions  of  such 
a  character  would  be  limited  to  a  small  area  of  the 
cortex  to  such  a  degree  as  to  be  entirely  removable 
by  operation. 

Not  only  is  the  existence  of  such  changes  in  the 
form  of  circumscribed  focal  lesions  improbable,  but 
if  they  existed  we  have  no  clinical  criteria  by  which 
to  delimit  them  before  death.  To  take,  for  exam- 
ple, the  most  common  type  of  Jacksonian  epilepsy, 
that  which  begins  with  sharply  defined  hand-symp- 
toms, there  are  large  numbers  of  cases  to  show 
that  the  lesion,  when  gross,  may  be  of  great,  or  in- 
definite size,  and  may  vary  greatly  in  position  with 
relation  to  the  so-called  hand-area  of  the  cortex.  If 
then  a  large  tumor  or  cyst  or  a  patch  of  diffuse  men- 
ingitis may  cause  sharply  localized  symptoms,  why 
should  not  the  same  be  true,  a  fortiofi,  where  the  le- 
sion is  a  diffuse  degeneration  of  gangloin  cells? 

Again,  it  is  by  no  means  certain  that  in  the  fit  of 
the  Jacksonian  type,  the  morbid  cycle  of  which  the 
convulsion  is  the  most  obvious  feature,  always  be- 
gins with  a  "discharge"  at  the  point  corresponding 
to  the  signal  symptom.  If  we  bear  in  mind  the 
analogous  case  of  a  purposive  movement,  as  when, 
for  example,  we  put  out  the  hand  to  grasp  some  ob- 
ject or  clinch  the  fist  in  obedience  to  some  emo- 
tional impulse,  we  must  admit  that  these  movements 
are  preceded  by  a  series  of  cerebral  events  of  the  de- 
tails of  which  we  are  largely  unconscious.  In  a  sim- 
ilar way,  a  Jacksonian  attack  may  represent  the  ter- 
minal stage  of  a  complex  cerebral  action  as  well  as 
the  initial  stage,  and  the  persistence  of  the  "habit" 
mav  be  due  to  a  persistence  of  a  memory,  more  or  less 
independent  of  the  brain.'  This  reasoning  would 
applv,  of  course,  more  especially  to  the  Jacksonian 
tvpes  of  idiopathic  epilepsy,  but  there  is  room  for 
question  whether  it  does  not  apply,  in  some  meas- 
ure at  least,  to  the  cases  of  localized  lesion  as  well, 
especially  where  a  good  many  attacks  have  already 
occurred'  Thus  in  Case  i  of  this  series,  the  hand 
fits,  although  they  were  sharply  localized,  even  to 
the  thumb  and  fourth  finger,  as  a  rule,  and  sensory 
in  character,  were  often  preceded  by  blurring  of 
vision  and  strange  feelings  in  the  head.  Everyone 


1  See  the  report  of  a  case  with  apparently  negrative  finding 
by   McKendrick;    Brain.    Autumn.   1S99. 

2  American  Jour,    of  Med.    Sc.  IS*"-. 

3  Prain.    Summer  and    Autumn.   1J96. 
1  Cf.    Bergrson.   Maiiere   et    Memoire. 


I2I4 


The    Philadelphia 
Medical  Journal 


]      TREATMEXT  OF  JACKSONIAN  EPILEPSY 


[June  22,   isot 


has  been  inclined  to  admit  that  the  longer  the  time 
during  which  the  seizures  due  to  localized  irritation 
occur,  the  more  widely  the  brain,  as  a  whole,  be- 
comes involved,  and  although  it  has  been  amply 
proved  that  even  after  twenty  years  and  more  a 
suitable  surgical  operation  may,  in  favorable  cases, 
arrest  the  epileptic  tendency,  yet  it  is  also  pretty 
certain  that  the  co-operative  action  of  ever  widen- 
ing areas  of  the  brain,  or  even  of  the  brain  as  a 
whole,  may  show  itself  amost  from  the  very  outset, 
and  this  especially  in  children. ^  When  this  result 
has  been  reached,  the  case  of  the  patient  with  trau- 
matic or  focal  epilepsy  probably  differs  but  little, 
if  at  all,  from  that  of  a  patient  with  idiopathic  epi- 
lepsy. In  other  words,  the  epileptic  tendency  in  his 
case  has  become  one  of  the  regular  modes  of  activ- 
ity of  the  whole  brain,  and  the  destruction  of  a  sin- 
gle part,  the  hand  center,  for  example,  if  it  checks 
the  seizures,  must  do  so  through  some  influence 
such  as  we  are  apt  to  classify  as  "inhibitory."  If  the 
gathering  tension  which  precedes  the  epileptic  out- 
break had  been  in  the  habit  of  expressing  itself 
through  some  motion  or  sensation  of  the  hand,  the 
tendency  to  this  same  mode  of  expression  is  likely 
to  remain  even  after  mutilation  of  the  cortex,  though 
susceptible  of  being  checked  at  its  source  by  inhibi- 
tion or  otherwise.  If  the  fits  go  on,  however,  the 
motion  or  sensation  which  occurs  after  the  destruc- 
tion of  a  given  center  is  likely  to  be  more  coarse  in 
character  and  less  sharply  limited  in  extent  than  it- 
was  before  that  part  of  the  delicate  mechanism  of 
the  cortex  had  suffered  damaire.' 

In  advocating  the  importance  of  the  "inhibitory" 
and  formation-of-new-habit  theory  of  surgical  oper- 
ations in  Jacksonian  epilepsy,  as  against  that  which 
refers  the  bene!its  obtained  to  the  removal  of  dis- 
ease-foci, I  do  so  not  as  maintaining  that  the  former 
explanation  is  perfectly  satisfactory  or  intelligible. 
but  only  that  at  the  present  moment  it  is  the  liest 
one  available.  It  has  also  the  advantage  that  its 
provisional  adoption  encourages  us  to  study  and 
classify  the  cases  of  benefit  from  operations  of" other 
sorts,  instead  of  passing  them  by  with  a  shrug,  and 
may  thus  lead  to  more  profitable  modes  of  treatment 
of  analogous  sorts. 

As  a  step  in  this  direction,  the  fact  deserves  men- 
tion that  Eulenburg^  in  his  interesting  discussion 
of  some  of  these  points  in  1895,  '"  conection  with 
the  report  of  a  case  where  the  epileptic  attacks  held 
off  for  three  years  after  a  cortical  excision  and  then 
returned,  has  a  good  word  to  say  for  the  striking 
observations  of  Wetterstrand  on  the  treatment  of 
epilepsy  through  hypnotic  suggestion.  This  mode 
of  treatment  is  theoretically  iustifial)le.  since  it  is 
as  reasonable  to  believe  that  epilepsy  may  be  influ- 
enced favorably  by  one  sort  of  mental  attitude  as 
that  it  may  be  influenced  unfavorably  by  another, 
and  the  latter  has  always  been  accepted  as  a  true 
sequence. 

The  natural  history  of  all  the  neuroses  and  psy- 
choses is,  indeed,  marked  by  a  tendency  to  the  oc- 
currence, mider  favorable  conditions,  of  periods  of 
cessation   of  symptoms.     Tic   douloureux  and   mi- 

1  Cf.  Chipa\iU.  Traveaux  de  Xeurologie  Chinirgicale.  April- 
July,   laoO;    abstract    in  Jr.   of   Nervous  and   Mental    Dis.,   April. 

1900. 

1  Cf.    Eulenburg,    Berl.    Kl.    W.    Schr.,    1S95. 


graine  are  cases  in  point,  but  there  are  many  others. 
There  is  such  a  thing  as  temporary  "set"  or  'cv- 
clic"  action  in  the  nervous  functions  analogous  to 
the  vortex-tendency,  which  sets  up  the  ever-form- 
ing and  dissolving  eddies  on  a  swift  stream.  These 
temporary  inertia — or  habit — vortices  may  work 
for  good  or  evil,  and  it  is  on  the  possibility  that  the 
formation  of  one  tending  to  good  may  be  encour- 
aged that  a  large  part  of  the  hopefulness  of  thera- 
peutic endea\-or  is  based. 

It  is  possible,  of  course,  that  the  manifold  opera- 
tions which  have  been  done  for  epilepsy  and  have 
been  attended  with  a  considerable  measure  of  suc- 
cess, sometimes  do  good  in  one  way,  sometimes  in 
another.  But  the  mind  instinctively  and  justly 
seeks  to  cling  to  a  single  explanation  as  long  a's  pos- 
sible, and  it  would  be  fair  to  urge  that  if  the  excis- 
ion of  the  apparently  healthy  (even  though  reallv 
slightly  diseased)  cortex  effected  its  results  on  a 
wholly  different  and  more  rational  principle  from 
other  operations,  these  results  would  be  distinctly 
better,  which,  in  fact,  they  do  not  seem  to  be. 

It  is  common  to  see  the  inference  drawn  that  be- 
cause the  cessation  of  certain  clinical  symptoms 
follows  a  given  therapeutic  measure,  therefore  the 
cause  of  the  symptoms  has  been  discovered.  This 
is  the  diagnostic  argument  "ex  juvantibus,"  and  it 
reappears  in  a  thousand  forms.  In  fact,  this  reason- 
ing is  misleading  and  fallacious.  The  morbid  cycle 
of  disease,  especially  if  this  takes  the  form  of  a  neu- 
rosis, whether  epilepsy,  asthma,  Graves's  disease, 
or  any  other,  may  often  be  broken  in  upon  and  dis- 
pelled by  influences  and  impressions  which  had 
nothing  to  do  with  its  formation,  and  this  is  another 
justification  for  the  doubt  whether  a  cessation  of 
fits  following  an  operation  for  excision  of  a  supposed 
disease-focus  in  the  corte.x  proves,  or  even  strongly 
indicates,  that  we  thereby  remove  the  original  cause 
of  the  disease.  I  would  remark  in  passing  that 
the  presence  of  the  localized  meningitis  discov- 
ered in  three  of  the  above  cases,  as  in  several  others 
which  are  on  record,  not  to  speak  of  that  which  had 
developed  (possibly  as  the  result  of  meningeal  hem- 
orrhage) during  the  typhoid  fever,  in  Case  i.  seems 
to  me  of  distinct  clinical  interest.  It  is  not  com- 
monly accepted  that  this  lesion  is  apt  to  follow  such 
injuries  to  the  head,  as  these  patients  describe,  or 
to  occur  from  such  illnesses  as  those  from  which  ' 
they  had   suffered. 

Reasoning  from  the  conditions  above  stated.  I  be- 
lieve that  the  arrest  of  epilepsy  through  surgical  op- 
eration is  an  affair  primarily  of  inhibition,  and  next 
of  the  establishment  of  a  new  habit,  made  possibk- 
by  this  temporary  arrest  of  the  morbid  outbreaks.  I 
do  not  believe  that  it  is  necessary  to  look  for  a  focal 
lesion  to  account  for  focal  symptoms,  any  more 
than  it  is  necessary  to  look  for  a  focal  lesion  to  ac- 
count for  the  numbness  of  the  hand  or  the  hem- 
ianopsia which  usher  in  an  attack  of  migraine. 

If  this  reasoning  is  correct,  the  therapeutic  prob- 
lem is  how  best  to  secure  this  inhibitory  action. 
Cortical  excision  may  be  the  most  effective  means 
to  this  end.  but  it  sometimes  leaves  the  patient  with 
an  embarrassing  and  persistent  awkwardness  of 
movement,  and  should  therefore  not  be  undertaken 
if  other  means  will  serve,  which. are  not  open  to  tlv- 
same  objection.     Clinical   observation   and  labors- 


June  22.  1901] 


1  REATMEXT  OF  JACKSOXIAX  EPILEPSY 


CThe    Philadelphia 
Medical  Journal 


1215 


tory  experiment  seem  to  indicate  that  even  a  simple 
exposure  of  the  cortex  may  damage  its  nutrition 
enough  to  cause  temporary  paralysis  of  sensation 
and  motion,  in  many  cases,  yet  without  inducing 
permanent  impairment  of  functionof  serious  amount, 
and  any  one  who  will  take  pains  to  look  over  a 
large  number  of  important  cases  will  see  that  not 
only  the  moderate  degree  of  success  observed  by 

>Dr.  Warren  and  myself,  but  occasionally  a  much 
greater  degree  is  obtainable  in  this  way.  The  cause 
of  the  temporary  disturbance  of  motion  and  sensa- 
tion which  follows  simple  exposure  of  the  cortex 
is  attributed  by  Hitzig  to  the  occurrence  of  punc- 
tate hemorrhages  deep  in  the  cortex,  and  to  edema 
and  anemia  of  the  brain,  partly  resulting  from  its 
being  pressed  into  the  trephine  opening  by  the  un- 
compensated action  of  the  cerebral  circulation,  the 
counter  pressure  of  the  cerebral  spinal  fluid  in  the 
sub-dural  space  having  been  removed.  This  coun- 
ter-pressure may,  he  thinks,  be  re-established  if  the 
excised  bone  is  replaced  in  its  old  position,  as  by  the 
Wagner  bone-flap  method  of  opening  the  skull  for 
operations  of  this  sort,  which  is  now  so  common. 
Even  with  this  precaution,  however,  it  is  probably 
a  long  time  before  the  circulation  and  nutritive  con- 
ditions in  the  exposed  cortex  become  normal,  if,  in- 
deed, this  ever  happens. 

An  advantage  of  this  operation  of  simple  expos- 
ure of  the  cortex  is  that  it  can  be  repeated  if  neces- 
sary, and  that  it  does  not  shut  out  the  possibility  of 
doing  excision  of  the  cortex  later.  But  whatever  op- 
eration isdoneit  should, in  myopinion.be  considered 
that  the  arrest  of  the  symptoms  is  mainly  useful  as 
affording  a  better  opportunity  for  bromide  medica- 
tion, and-  this  opportunity  should  be  taken  advan- 
tage of  energetically.  It  is  not  necessary  to  con- 
sider here  the  details  of  the  bromide  treatment,  but, 
in  fact,  I  believe  that  the  best  method  is  that  orig- 
inally proposed  by  Charcot  and  recommended  by 
Tourette  in  a  recent  paper,  according  to  which  the 
dose  is  increased  for  three  weeks,  then  dropped  to 
the  starting  point,  and  then  increased  again,  and 
so  on.  The  bromide  treatment  should  also  be  re- 
inforced by  every  hygienic  influence  that  can  be 
devised. 

As  regards  the  question  of  the  physiology  of  the 
cerebral  cortex,  the  tendency  of  the  more  recent  re- 
searches has  been  on  the  whole  confirmatory  of  the 
generalizations  of  Goltz.  and  we  must  now  cease  to 
regard  the  cortex  of  the  brain  as  a  mosaic  of  special- 
ized centers,  and  consider  it  rather  as  a  net-work, 
standing  as  the  expression  of  closeh'  inter-depend- 
ent functions.  Furthermore,  real  light  has  now  been 
shed  upon  the  vexed  question  of  the  relationship 
between  consciousness  and  the  brain,  and  upon  the 
part  which  each  plays  in  producing  the  phenomena 
of  life  and  disease.  In  confirmation  of  these  state- 
ments. I  will  refer  to  the  investigations  and  inter- 
pretations of  J.  Richard  Ewald,*  of  Loeb,=  of  Hit- 
zig.^ and  of  the  psychologist,  Bergson.''  Ewald 
managed  to  arrange  the  conditions  of  his  experiment 
in  such  a  wav  that  the  surface  of  the  brain  of  dogs 
could  be  excited  here  and  there  long  after  the  shock 
of  the  first  trephining  operation  had  passed  away 


1  Verh.    <les   Cor.gr.    f.    Tnn.    Med..   1S97.     Vol. 

2  PhvsiolosA-   of   the   Brain.   Chicago,    1900. 

3  Arch,    fue'r   Psych.,    etc.,    1900. 

4  Matiere   et    Memoire. 


15.   p.   2-45. 


and  while  the  animals  were  running  about  in  per- 
fect health  and  inditterence.  Under  these  circum- 
stances he  found  it  possible  to  excite  localized 
movements  of  various  sorts  by  electrical  stimula- 
tion at  points  quite  removed  from  any  correspond- 
ing "center,"  and  he  points  out  that,  in  fact,,  ar- 
rangements must  exist  for  uniting  closely  the  func- 
tions of  such  a  part  as  the  hand  with  those  of  the 
eye  and  ear  as  well  as  the  touch.  He  shows  that 
the  strong  tendency  towards  recovery  from  the  ef- 
fects of  local  destruction  of  the  cortex  ordinarily 
implies  the  preservation  of  the  semi-circular  canals 
in  the  labyrinth,  and  that  where  these  have  been  re- 
moved the  recovery  is  incomplete  or  does  not  occur. 
These  facts  are  best  explained,  he  believes,  under 
the  view  that  the  semi-circular  canals  have  the 
function  of  maintaining  a  general  muscular  tonus, 
and  that  this  provides" a  sort  of  compensation  for 
the  loss  of  the  tactile  for  mainly  tactile)  functions 
of  the  Rolandic  convolutions,  like  that  obtained 
through  the  action  of  vision  in  tabes. 

The  cortex  of  the  brain  is  a  great  net-work,  an 
immense  telephone  switch-board,  by  means  of  which 
the  individual  seeks,  as  best  he  can,  to  place  himself 
in  active  relations  with  his  environment.    The  sense 
of  his  desires  and  needs  in  the  way  of  recognition 
and  expression  is  a  possession  of  his  whole  brain, 
and  a  possession   which  he  will   struggle  hard   to 
maintain,  and  which  cannot  be  excised  through  mu- 
tilation of  any  small  portion  of  the  cortex.     If  you 
damage  his    switchboard    at    one    point,  you     may 
make  it  more  difficult  for  him  to  accomplish  certain 
results,  but  unless  the  damage  be  too  great,  accom- 
plish it  he  will,  if  only  in  a  roundabout  fashion,  by 
a  process  of  readjustment  which  will  begin  to  as- 
sert itself  as  surely  and  as  promptly  as  that  which 
makes  the  epidermis  begin  to  grow  again  upon  the 
abraded  skin.    It  is  reasonable  to  suppose  that  the 
hand-center  is  also  a  center,  in  a  feebler  degree,  for 
the  arm,  the  face,  the  shoulder  and  the  leg,  and  it 
is  fair  to  suspect,  although  the  fact  has  not,  I  be- 
lieve, been  proved,  that  if  a  sufficiently  delicate  test 
were  emploved,  it  would  be  found  that  even  feeble 
electrical  excitations  of  this  area,  like  movements 
of  the  hand  itself  in  health,  would  be  attended  by 
feeble  contractions  of  the  muscles  which  fix  the  root 
of  the  limb.    And,  conversely,  after  excision  of  the 
apparent  hand-center,  the   readjustment   which    as- 
serts itself  forces  the  mechanism  which  had  pre- 
viouslv  been     correlated     principally    for    coarser 
movements  of  the  arm  to  substitute  itself  for  that 
which  had  been  destroyed.     It  is  certainly  true,  to 
use  the  term  emploved'  by  Loeb,  that  the  problem 
of  the  cerebral  activity  is  one  that  is  rather  dynami- 
cal than  anatom.ical.    It  is  like  the  case  of  a  quantity 
of  water  which  had  stood  in  a  complicated  system 
of  tubes,  graduallv  finding  a  new  level  when  one 
of  the  tubes  is  taken  away.    The  dynamic  excitabil- 
ity, if  the  expression  is  permissible,  of  the  parts  next 
related  to  that  which  had  been  previously  in  use. 
needs  oniy  to  be  raised  to  the  necessary  point,  for  the 
old  processes  and  functions  to  go  on  as  before,  at 
least  after  a  fashion.    The  case  is  more  or  less  like 
that  of  aphasia.     It  is  true,  namely,  as  Hughlings 
Tackson  long  ago  pointed  out,  that,  underlying  the 
bizarre  variations  of  the  speech  disturbance  in  dif- 
erent  forms  of  aphasia,  there  is  always  a  tendency 


I2l6 


The    Philadelphia 
Medical  Journal 


] 


HYPERTHROPHY  OF  THE  PROSTATE 


[June  22,   1901 


towards  a  readjustment  of  the  language-function, 
of  such  a  kind  that  this  function  is  found  at  the  end 
not  to  have  been  mutilated  in  parts  so  much  as 
weakened  as  a  whole.  In  the  struggle  for  the  re- 
establishment  of  a  new  equilibrium  the  verb,  which 
expresses  action  and  has  a  wider  hold  on  the  indi- 
vidual's life  of  relation  to  his  environment  will  al- 
ways be  recovered  first.  The  proper  names,  which 
stand  alone,  will  be  recovered  last. 

In  other  words,  if  the  individual  can  no  longer 
present  just  the  same  front  to  the  world  as  before,  he 
will,  nevertheless,  present,  so  far  as  possible,  the 
same  sort  of  front. 

It  is  interesting  and  important  to  note  that  this 
principle  which  underlies  the  readjustment  of  the 
cerebral  functions,  after  injury  or  disease,  on  a  plan 
modelled  on  the  conditions  of  health,  is  essentially 
the  same  with  that  which  underlies  the  readjust- 
ments in  the  case  of  the  hysterical  patient,  only  here 
the  process  is  seen  in  an  exaggerated,  often  gro- 
tesque form.  Take,  for  example,  the  case  of  the 
anesthesias  of  cerebral  origin.  The  modern  French 
view  has  recently  been  expressed  with  admirable 
clearness  by  Verger  (i)  that  in  all  cases  where 
complete  hemianesthesia  is  present  this  is  to  be  re- 
garded as  a  sign  of  hysteria,  though  perhaps  grafted 
on  to  the  symptoms  of  an  organic  lesion  of  the 
brain.  On  the  other  hand,  the  anesthesia  to  which 
a  structural  lesion  of  the  brain  gives  rise  in  its 
own  right,  i.  e.,  when  uncomplicated  by  hysteria, 
does  not,  he  thinks,  occupy  one  whole  half  of 
the  body,  but  only  the  extremities,  where  it  grad- 
ually increases  in  intensity  toward  the  distal  end. 
I  desire  now  to  point  out  that,  although  these  peculi- 
arities of  distribution  are  doubtless  of  clinical  im- 
portance, yet  the  two  conditions  which  we  call,  re- 
spectively, hysterical  and  organic,  resemble  each 
other  in  the  respect  that  neither  of  the  forms  of  re- 
adjustment of  the  sensory  functions  seen  in  them 
proceeds  on  anatomical  lines,  but  both  are  examples 
of  the  re-establishment  of  an  equilibrium  for  func- 
tsonal  ends,  for  the  benefit  of  the  individual  as  a 
whole.  It  is,  again,  an  afifair  of  dynamics,  and  not 
of  anatomv. 

Just  as  in  aphasia  a  patient  is  apt  to  lose  his 
isolated  names  first  and  to  retain  his  verbs  the  long- 
est, so,  when  his  sensori-niotor  cortex  is  injured  he 
retains  the  more  fundamental  use  of  his  limb  and 
loses  the  luxury-functions  of  the  hand  and  some- 
times the  sensory  functions  which  are  associated 
with  the  motor  functions  of  this  type.  I  maintain 
that  this  is  precisely  the  ground  on  which  the  hys- 
terical patient  is  supposed  to  lose  and  to  retain,  as 
the  case  may  be,  the  sensory  functions  of  his  skin 
and  special  senses.  There  is  a  difference  between 
the  two  sets  of  cases,  but  the  underlying  principle 
of  readjustment  is  the  same. 

It  is  a  merit  of  this  mode  of  regarding  the 
brain  functions  in  disease  that  it  brings  out  the 
dynamic,  self-adjustible,  so-to-speak  "fluid,"  proper- 
ties of  that  organ,  and  contradicts  the  tendency  to 
represent  it  as  an  inflexible  mechanism.  It  contra- 
dicts also  the  erroneous  theory  of  the  "storage  of 
memories"  in  the  cortex  (')  subject  to  being  de- 
stroyed piecemeal  bj^  disease.  It  is  just  because 
memories  exist   (in  a  certain  sense)   independently 

1  Arch.   Gen.   de  Med.,   Nov.   and   Dec,   1900. 


of  brain-action,  that  they  cannot  be  thus  destroyed, 
and  that  the  marvelous  readjustment  of  the  func- 
tions of  the  damaged  brain  on  the  old  lines  of 
health,  is  able  to  occur. 

It  is  also  of  interest  to  note  that  Hitzig  believes, 
on  the  basis  of  a  long  series  of  experiments,  that  he 
has  demonstrated  the  existence  of  a  visual  center  in 
the  frontal  lobe,  of  analogous  significance  to  that 
in  the  angular  gyrus.  Thus,  provision  is  made  for 
movements  of  the  eye  and  for  vision  in  two  widely 
different  portions  of  the  brain.  Neither  of  these 
centers  seem  to  be,  according  to  Hitzig,  primary 
centers  of  vision,  both  stand  in  a  similar  relation  to 
some  more  fundamental  visual  area. 


WHAT  I  HAVE  LEARNED  FROM  ONE  HUNDRED  AND 
SIXTY-ONE  OPERATIONS  FOR  THE  RELIEF  OF 
SENILE  HYPERTROPHY  OF  THE  PROSTATE 
GLAND. 

By   ORVILLE  HORWITZ,   B.   S.,  M.  D., 

of  Philadelphia. 

clinical  Professor  of  Genito-t'r^nary  Diseases.  Jefferson  Medical  College; 

Surgeon  to  the  Philadelphia  Hospital,  Jefftrson  Medical  College 

Hospital  and  Slate  Hospital  for  the  Insane. 

[Conclusion.] 

Twelve  cases  were  operated  upon,  four  being 
complicated  with  pyelitis ;  in  all  there  was  chronic 
cystitis  associated  with  either  atonied  or  contract- 
ed bladder.  Four  had  previously  submitted  to  cas- 
tration without  benefit.  The  period  of  convales- 
cence ranged  from  three  to  five  months,  including, 
of  course,  the  care  and  necessary  after-treatment. 
After  the  operation  the  individuals  were  respectively 
confined  to  bed  for  a  period  of  from  one  to  four 
weeks.  In  complicated  cases  of  the  character  here 
described  urethral  fever  is  a  very  common  occur- 
rence. Five  of  these  patients  had  been  subject  to 
chronic  urinary  fever  for  many  weeks  prior  to  com- 
ing under  my  observation.  Three  cases  were  mark- 
edly benefited  and  practicalh^  might  be  considered 
cured ;  though  a  small  quantity  of  residual 
urine  and  a  slight  amount  of  cj'stitis  still  exist. 
In  seven  cases  the  bladder  did  not  regain  its  tone^ 
and  the  continued  use  of  the  catheter  became  neces- 
sary. The  insertion  of  the  instrument  was  ren- 
dered easy  and  painless:  prostatic  spasm,  one  of  the 
most  painful  symptoms,  being  relieved.  In  four 
cases  there  was  marked  improvement  in  the  gen- 
eral condition,  indicated  by  increased  strength  and 
gain  in  weight.  Of  the  remaining  cases  no  improve- 
ment in  the  physical  condition  resulted.  In  the  un- 
improved cases  the  trouble  had  existed  for  such  a 
length  of  time  and  the  damage  to  the  bladder  and 
kidneys  was  so  great,  that  only  an  amelioration  of 
the  urgent  symptoms  could  be  hoped  for.  In  this 
group  the  age  was  so  great  and  physical  condition 
was  such  that  a  complete  prostatectomy  could  not 
have  been  performed  with  safety. 

These  cases  seem  to  demonstrate  that  in  prostatic 
hypertrophy  the  earlier  the  operation  is  performed 
the  greater  are  the  chances  of  permanent  cure,  dan- 
ger to  life  being  lessened,  and  but  a  short  time  for 
convalescence  being  required,  and  also  that  the 
operation    may   be    undertaken    in    advanced    cases 

(i)  Compare  Bergsoo.  Matiere  c».  Menio're. 


June  22,  1901] 


HYPERTHROPHY  OF  THE  PROSTATE 


TThe    Philadelphia 
L  Medical  Journal 


I217 


where  secondary  pathological  changes  have  taken 
place  with  less  risk  to  life  and  with  better  chances 
of  relief  than  any  other  radical  method  in  vogue  at 
the  present  time.     When  castration  had  been  per- 
formed the  Bottini  operation  was  followed  by  re- 
lief to  the  obstructive  symptoms.     Pyelitis  is  not  a 
contra-indication  to  the  performance  of  the  opera- 
tion, as  in  four  of  the  individuals  who  submitted  to 
this  process  this  condition  pertained  and  no  injur- 
ious result  followed.    When  the  bladder  is  hopeless- 
ly damaged  and  polyuria  exists,  the  operation  will 
be  followed  by  benefit,  but  cure  is  not  to  be  looked 
for.     Of  the  number  of  cases  of  this  kind  operated 
upon,  in  sixteen  the  enlargement  was  of  the  fibroid 
variety;  four  were  glandular,  and  thirteen  were  of  a 
mixed  type.    I  have  found  that  both  success  and  fail- 
ure will  follow  operations  where  any  of  the  varieties 
mentioned  exist.    Hence,  I  believe  that  the  charac 
ter  of  the  growth  has  little  or  no  influence  on  the 
results  obtained.     If  there  is  anj*  difference  it  is  in 
favor  of  the  fibrous  form.     Good,  as   well    as  poor, 
results    have    been    obtained    by    many    surgeons, 
when  operating  upon   either  the  hard   or  soft  va- 
riety   of    prostatic    hypertrophy ;    which    seems    to 
prove  that  the  character  of  the  growth  has  but  little 
influence  on  either  the  failure  or  success  of  surgical 
procedure.     The   results   obtained   in   cases   where 
incomplete  or  complete  retention  of  urine  existed 
were  about  equal ;  if  a  difference  subsisted  it  was  in 
favor  of  the  former  condition.     The  beneficial  re- 
sults to  be  obtained   from   the  operation   seem   to 
depend  upon  the  amount  of  damage  that  the  bladder 
has  sustained,  and  whether  or  not  the  kidneys  are 
involved,   and    also   the   physical    condition   of   the 
individual  at  the  time.    The  longest  period  that  any 
of  the  patients  had  employed  a  catheter  was  four- 
teen years ;  the  shortest  two  and  a  half  months.  In 
four  of  the  cases  catheterism  had  never  been  em- 
ployed:  in  six  individuals  there  was  frequent  urina- 
tion, the  residual  fluid  varying  from  two  to  eight 
ounces.      In    fourteen,    catheterism    was    necessary 
from  three  to  five  times  daily.    Five  of  the  patients 
had  suffered  from  attacks  of  retention  of  urine  from 
time  to  time.     In  nine  cases  the  individuals  were 
unable  to  evacuate  the  contents  of  the  bladder  with- 
out the  use  of  a  catheter.     In  six  patients  in  whom 
benefit  was  derived  from  the  operation  the  obstruct- 
ive symptoms  were  so  far  ameliorated  that  a  cath- 
eter could  be  readily  inserted,  without  pain  ;  physi- 
cal spasm  was  relieved,  and,  as  has  been  pointed  out 
by    Willymeyer,    obstinate    constipation,    which    is 
associated  with  this  condition,  disappeared.    There 
was  invariably  an  improvement  in  the  physical  con- 
dition  as   was   shown   by   increase    in   weight    and 
strength.     Five  of  the  cases  here  referred  to  were 
operated  upon  twice,  and  one  underwent  the  pro- 
cedure three  times. 

Regarding  the  length  of  time  which  should  be  al- 
lowed to  elapse  before  repeating  the  operation,  no 
fixed  rule  can  be  given.  It  depends  on  the  char- 
acter of  the  obstruction;  the  condition  of  the  pa- 
tient ;  the  results  following  the  first  operation  and 
whether  or  not  there  is  a  tendency  to  the  recurrence 
of  the  obstructive  symptoms  after  a  lapse  of  a  few 
months.  I  have  repeated  the  process  as  early  as 
three  vreeks  and  as  late  as  six  months  after  the 
first  procedure,  using  my  experience  and  judgment 


as  guides.    Dribbling  followed  the  operation  in  four 
instances;  this  state  continued  for  about  five  days, 
then  disappeared,  giving  no  further  trouble.     The 
only    other    complications    observed    were    prosta- 
titis and  urinary  fever.    The  former  occurred  in  five 
instances,   giving  rise   to  pain,   frequent   desire   to 
micturate,  with   retention   of  urine,  which   usually 
subsided  with  proper  treatment  in  the  course  of  a 
week   or   thereabout.      In   the    latter,   especially   in 
those  who  had  siiffered  from  urethral  fever  associ- 
ated with  a  co-existing  pyelitis  and  polyuria,  preced- 
ing the  operation,  chill  followed  by  a  fever  of  a  sep- 
tic type  was  often  an  alarming  symptom.    From  ten 
days  to  two  weeks  after  the  operation  the  urine  was 
frequently  tinged  with  blood,  and  contained  threads 
of  tissue  and  other  debris.    In  no  instance  did  hem- 
orrhage occur.     In  three  cases  a  stricture  of  small 
calibre  was  found  in  connection  with  the  prostatic 
obstruction;  in  these  internal  urethrotomy  was  per- 
formed before  inserting  the  prostatic  incisor.     In 
four   cases   preliminary   suprapubic   lithotomy   ^ya3 
performed.     In  one  instance  the  Bottini  operation 
was  accomplished  as  soon  as  the  calculi  had  been 
removed,  so  that  I  had  an  opportunity  of  observing 
the   result  of  the  incisions   immediately   after    the 
galvano-cautery  had  been  employed.     On  examina- 
tion  it   was   found   that    a   deep   groove   had   been 
burned  in  the  median  line  of  the  middle  lobe,  w^hich 
entirely  removed  the  obstruction  and  brought  the 
internal  urethral  orifice  down  to  a  level  with  the 
base  of  the  bladder.     The  incisions  in  both  lateral 
lobes  were  well  marked.    In  making  the  left  lateral 
cut  the  knife  had  apparently  slipped  into  the  groove 
made  in  the  middle  lobe,  and  had  incised  the  left 
lobe  at  its  lower  portion,  in  the  vicinity  of  the  base 
of  the  bladder.     In  one  case  I  had  the  opportunity 
of  performing  a  suprapubic  cystotomy  on  a  patient 
who  had   sulimitted   to   a   Bottini   operation   seven 
months  previously.     I  found  that  there  was  a  deep 
furrow  in  the  median  line  of  the  middle  lobe;  that 
the  vesical  outlet  was  at  the  normal  level,  and  that 
all    obstructions    were    apparently    removed.      The 
lateral  lobes  were  hard   and  contracted,  with   evi- 
dence of  dense  cicatricial  tissue.     When  a  supra- 
pubic  lithotomy   is   necessary,    arising   from    pros- 
tatic hvpertrophy,  I  believe  the  wisest  plan  is  to  be 
content   with   removing   the   stone,   and    defer   the 
operation  until  the  patient  has  entirely  convalesced. 
I  have  seen  death  follow  the  performance  of  the 
double  operation.    When  a  suprapubic  fistula  exists, 
it  is  well  to  postpone  the  Bottini  operation  until  the 
sinus  is  closed.     When  the  opening  exists  it  is  im- 
possible to  distend  the  bladder,  rendering  danger  of 
injuring  the  walls  very  great :  moreover,  the  sloughs 
and  debris  which  always  follow  cauterization  of  the 
prostate  arc  but  poorly  expelled.     Recently  certain 
surgeons  have  advocated  the  openinsT  of  the  bladder 
puprapubically  in   order  that  the  character  of  the 
obstructing  prostate  may  be  correctly  determined 
and  the  beak  of  the  instrument  placed  in  the  exact 
position  desired.    This  procedure  does  not  seem  to 
me  to  be  necessary.     'Everyone  should  be  able  to 
diagnose  the  character  of  the  enlargement  and  the 
cause  of  the  obstruction  in  prostatic  hypertrophy 
by    means    of    rectal    manipulation :    the    increased 
lengthoftheurethra.togetherwith  an  examniation  of 
the^-esical  aspect  of  the  gland,  can  be  readily  deter- 


I2l8 


The    Philadelphia"] 
Medical  Journal    J 


HYPERTHROPHY  OF  THE  PROSTATE 


[June  22,   1901 


mined  by  the  employment  of  the  stone  searcher  and 
the  cystoscope.  The  preliminary  suprapubic  cys- 
totomy in  these  cases  is  believed  to  be  unnecessary 
and  needlessly  adds  to  the  danger  attending  the 
operation,  tear  has  been  expressed  by  various 
^vriters  that  the  use  of  the  galvano-cautery  might 
be  followed  later  by  a  constriction  of  the  vesical 
outlet,  with  resulting  stricture.  Three  years 
have  elapsed  since  my  first  operation  was  per- 
formed, and  in  no  instance  has  any  difficulty  of  this 
kind  arisen.  I  believe  the  apprehension  felt 
regarding  this  suggested  complication  to  be  ground- 
less. Care  should  always  be  taken  to  properly  pre- 
pare the  patient  to  endure  the  operation.  In  sev- 
eral cases  the  patient  was  kept  under  preparatory 
treatment  for  three  months  before  he  was  considered 
to  be  in  a  fit  condition  to  undergo  the  operation.  In 
some  of  the  cases  the  prostatic  urethra  was  so  great- 
ly contracted  that  even  a  small  sized  catheter  could 
with  difficulty  be  inserted.  It  was  found  that  bv 
leaving  the  catheter  "k  demeure"  for  a  period  of 
two  weeks,  passing  small  bougies  about  every  third 
day,  that  the  prostatic  incisor  could  be  successfully 
passed.  In  several  instances,  when  the  constriction 
was  so  well  marked  that  the  insertion  of  an  instru- 
ment was  impossible,  it  was  observed  that  by 
placing  the  hips  of  the  patient  on  an  ordinary  bed- 
pan, thereby  arching  the  body,  that  the  curve  of  the 
urethra  would  be  so  much  changed  that  the  instru- 
ment could  be  readily  passed. 

When  it  is  desired  to  employ  general  anesthesia 
an  attempt  should  be  made  to  insert  the  instrument 
a  day  or  two  previous  to  the  operation,  so  as  to  be 
assured  that  it  can  be  made  to  enter  the  bladder 
otherwise  the  individual  might  be  etherized  un- 
necessarily. A  careful  examination  for  the  presence 
of  calculus  should  always  be  made  before  the  opera- 
tion is  undertaken.  Employment  of  the  cystoscope 
as  a  routine  method  of  making  an  examination  is 
not  necessary.  Its  use  is  frequently  attended  with 
pain  and  discomfort  and  its  employment  is  not  free 
from  danger  if  the  kidneys  be  extensively  diseased 
Its  use  should  be  reserved  for  exceptional  cases, 
where  the  existing  local  condition  is  difficult  to  de- 
termine. The  employment  of  the  Wossidlo  cysto- 
scopic  prostatic  incisor  has  been  found  to  be  value- 
less.   Its  use  is  not  recommended. 

Whenever  the  condition  of  the  patient  permits 
the  use  of  general  anesthesia  is  advisable,  either  be- 
ing employed  for  the  purpose.  Many  of  the  opera- 
tions^ were  performed  by  means  of  local  anesthesia, 
a  4%  solution  of  cocain  being  used.  In  nervous 
and  excitable  patients,  who  dread  an  operation  and 
complain  whenever  an  effort  is  made  to  insert  aii 
instrument  into  the  urethra,  spinal  anesthesia  is  the 
method  of  choice.  A  means  of  anesthetizing  the 
bladder  has  recently  been  suggested  by  Dr.  du  Chas- 
telet  (Ann.  d  Mai.  Org.  Genito-Uri.,  No.  7,  1899) 
which  is  worthy  of  trial.  It  consists  in  injecting 
into  the  rectum  forty-five  minutes  before  the  opera- 
tion, a  solution  containing  ten  drops  of  laudanum 
and  twenty-four  grains  of  antipyrin,  which  has  been 
dissolved  in  three  ounces  of  water.  It  is  claimed 
by  the  operator  that  by  the  use  of  this  mixture  in 
the  manner  described  he  was  enabled  to  spend  half 
an  hour  in  crushing  a  calculus  without  discomfort 
to  the  patient. 


My  first  two  operations  w-ere  successfulh-  per- 
formed when  the  bladder  was  empty.  Dr.  Freuden- 
berg  recounts  in  detail  the  result  of  operating  upon 
a  parient  when  the  viscus  was  empty,  in  which  he 
was  so  unfortunate  as  to  immesh  a  fold  of  the  mu- 
cous membrane  between  the  heated  platinum  blade 
and  the  prostate  gland,  thereby  burning  a  hole 
through  the  walls  of  the  bladder,'  this  was  followed 
l)y  extravasation  of  urine  and  the  death  of  the 
patient.  He  advises  that  a  warm  solution  of  boric 
acid  be  employed,  wherewith  to  distend  the  bladder. 
In  six  cases  following  the  two  to  which  I  have  re- 
ferred I  followed  the  suggestion  with  favorable  re- 
sults. 

In  the  Medical  Record  for  November,  1898,  there 
is  an  article  by  Bransford  Lewis,  in  which  he  re- 
commends that  the  bladder  be  inflated  with  air  as  a 
safe  and  satisfactory  means  of  preventing  injury  to 
the  walls  of  the  organ.  In  all  the  subsequent  opera- 
tions to  these  to  w-hich  I  have  just  referred  I  have 
followed  the  recommendation  of  Lewis  and  have 
employed  air  wherewith  to  distend  the  viscus  and 
have  had  every  reason  to  be  satisfied  with  the 
results.  One  of  the  most  important  adjuncts  in  the 
steps  of  the  operation  is  to  have  on  hand  a  battery 
that  will  promptly  bring  the  knife  to  a  white  heat 
For  this  purpose  there  is  nothing  more  satisfactory 
than  the  street  current  connected  with  a  "trans- 
former" which  has  an  Ampere  meter  also  introduced 
into  the  circuit.  The  best  battery  that  can  be  used 
is  the  one  advocated  by  Willymeyer,  which,  in  addi- 
tion to  a  rheostat,  is  connected  with  an  Ampere 
meter.  Fifty  Amperes  are  required  to  heat  the 
blade  and  maintain  it  at  a  white  heat.  In  five  in- 
stances the  blade  of  the  instrument  become  slightly 
bent  during  the  operation,  rendering  it  impossible 
to  return  it  completely  within  the  sheath ;  so  that 
the  removal  of  the  instrument  was  attended  with  a 
slight  amount  of  injury  to  the  urethra,  but  in  no 
case  did  any  detrimental  result  follow  the  accident 
1  he  bending  is  caused  by  using  the  blade  for  the 
purpose  of  making  the  second  and  third  cut  before 
the  whole  of  the  adherent  charred  prostatic  tissue 
has  been  burnt  off.  \\'hen  the  subsequent  cuts  are 
attempted,  the  portion  of  the  glandular  structure 
adherent  to  the  knife  serves  to  cause  sufficient  re- 
sistance to  the  blade,  when  it  is  softened  by  being 
brought  to  a  white  heat,  to  occasion  its  bending 
This  annoying  incident  can  be  obviated  by  removing 
the  instrument  after  the  first  incision  has  been  made 
and  burning  oft"  the  adherent  tissue,  leaving  the 
blade  clear  and  clean,  and  then  re-inserting  it  in 
order  to  make  the  second  cut.  This  should  be  re- 
peated after  each  incision.  That  the  burnt  tissue, 
which  is  adherent  to  the  knife,  interferes  with  the 
incision  is  evidenced  by  the  fact  that  the  last  cut 
is  harder  to  make  and  takes  longer  to  accomplish 
than  any  of  those  that  precede.  On  removing  the 
instrument  it  will  frequently  be  found  that  a  ful! 
minute  is  required  to  burn  off  the  uncon- 
sumed  portion  of  tissue  which  adheres  to 
its  blade.  That  the  cut  may  he  properly 
made  and  that  the  tendency  to  primary  hemorrhage 
may  be  lessened  it  is  necessary  that  the  knife  should 
be  at  a  white  heat.  If  it  is  found  that  fifteen  sec- 
onds are  required  to  heat  the  blade  before  the  instru- 
ment  is  inserted,  at  least   ten   additional   seconds 


June  22,  19  H] 


HYPERTHROPHY  OF  THE  PROSTATE 


CThe    Philadelphia 
Medipal  Journal 


I2I9 


should  be  allowed  to  elapse  after  the  instrument  is 
in  place  before  an  attempt  is  made  to  make  the  in- 
cision. A  certain  percentage  of  failures  is  due  to  the 
fact  that  the  cuts  are  made  too  rapidly.  In  my 
earlier  operations  about  one  minute  and  a  half  was 
taken  for  each  incision.  I  am  convinced  that  I  have 
obtained  better  results  when  I  have  allowed  from 
3  to  4  minutes  for  making  each  cut.  They 
should  be  made  very  slowly,  as  if  the  knife  were 
passing  through  a  substance  olTering  great  resist- 
ance;  when  it  is  finished  and  the  blade  is  being 
restored  to  the  sheath,  it  is  well  to  have  the  current 
made  somewhat  stronger,  the  blade  should  be  re- 
turned very  slowly  so  as  to  insure  the  consumption 
of  the  portion  of  tissue  that  may  be  adherent  to  the 
knife  It  is  essential  that  the  instrument  be  held 
firmly  and  steadily  whilst  it  is  being  used.  This  may 
be  insured  by  the  operator  placing  his  left  foot  on 
a  chair  in  front  of  him  and  resting  the  elbow  of  the 
left  arm  upon  his  knee ;  as  the  left  hand  holds  the 
instrument  during  the  operation  the  danger  of  shak- 
ing or  jarring  is  reduced  to  a  minimum. 

The  number  and  length  of  the  incisions  will  de- 
pend on  the  size,  as  well  as  the  character,  of  the 
enlarged  gland.  In  cases  of  commencing  prostatic 
hypertrophy,  where  the  organ  is  comparatively 
small,  a  median  and  two  lateral  incisions  are  all  that 
are  required.  In  cases  of  long  standing,  where  the 
gland  has  attained  considerable  dimensions,  three 
cuts  on  the  prostatic  floor  should  be  made ;  the 
median  being  from  three  and  a  half  to  four  centi- 
meters, whilst  two  and  a  half  centimeters  are  al- 
lowed for  each  lobe,  unless  one  should  be  markedly 
enlarged  when  the  cut  should  be  proportionately 
increased  in  length.  In  every  case  that  came  under 
my  control,  with  two  exceptions,  the  incisions  were 
made  on  the  lower  portion  of  the  gland.  In  the 
.two  cases  referred  to  there  was  general  glandular 
enlargement,  marked  projection  backward,  with 
two  pouches,  one  above  and  one  below.  In  these 
cases  one  upper  and  three  lower  cuts  were  made. 
The  upper  incision  is  seldom  necessary,  and  should 
be  avoided  if  possible.  In  many  of  the  cases  where 
hemorrhage  has  been  reported  as  one  of  the  imme- 
diate complications  following  the  operation  it  was 
probably  caused  by  the  incision  being  made  in 
the  upper  portion  of  the  gland.  The  reason  for  this 
becomes  evident  when  the  fact  is  recalled  that  the 
prostatic  urethra  is  one-third  nearer  the  upper  than 
the  lower  portion  of  the  gland ;  in  some  instances 
the  prostatic  tisstie  is  absent  for  a  short  distance  on 
the  roof  of  the  urethra,  its  place  being  occupied  by 
a  fibrous  and  elastic  tissue.  It  follows,  therefore 
that  an  incision  made  on  the  roof  of  the  prostatic 
urethra  is  more  liable  to  injure  the  prostatic  plexus 
of  veins,  which  lies  between  the  outer  and  inner 
capsille  of  the  gland,  than  when  the  incision  is  made 
on  the  lower  surface.  When  a  marked  projection 
of  the  hiiddle  lobe  backwards  exists,  four  cuts 
should  be  made  in  the  lower  portion  of  the  gland 
Two  V-shaped  incisions  should  be  made  through 
the  middle  lobe,  which  permits  it  to  fall  liack  out 
of  the  wav,  finally  becoming  shrivelled  and 
atrophied ;  the  lateral  cuts  are  then  made  in  the 
usual  manner.  After  the  instrument  is  in  place,  be- 
fore proceeding  to  make  the  incision,  the  index 
finger  of  the  left  hand  should  be  inserted  into  the 


rectum,  so  as  to  determine  |Whether  the  beak  of  the 
instrument  is  in  the  proper  position,  and,  at  the 
same  time,  to  be  sure  that  a  fold  of  the  bladder  has 
not  been  entangled.  The  expedient  which  lias  been 
suggtsled  of  inserting  the  finger  into  the  rectum 
and  pushing  the  prostate  gland  up  against  the  blade 
of  the  knife  during  the  operation  is  not  free  from 
danger,  as  a  recto-vesical  fistula  might  result.  It 
was  not  found  necessary  to  leave  a  catheter  in  the 
bladder  after  the  completion  of  the  operation,  ex- 
cept in  those  patients  who  had  suffered  from  chron- 
ic cystitis  associated  with  contracted  bladder,  or 
where  they  had  long  been  alTected  with  retention  of 
urine.  In  two  of  the  cases  after  the  completion  of 
the  operation  symptoms  of  uremia,  with  a  marked 
tendency  to  suppression  of  urine,  was  developed 
I'rom  these  patients  about  four  ounces  of  blood  were 
abstracted  from  the  vein  of  the  arm,  and  immedi- 
ately after  this  was  followed  by  a  venous  trans- 
fusion of  normal  salt  solution.  Two  and  a  half  pints 
were  transfused,  wdiich  was  repeated  in  the  course  of 
eight  hours,  as  the  dangerous  symptoms  had  not 
undergone  amelioration.  Both  patients  recovered. 
A  one-twentieth  of  a  grain  of  digitalin  combined 
with  the  same  amount  of  strychnia  was  administered 
every  third  hour,  the  action  on  the  heart  being  care- 
fully watched. 

Out  of  the  number  of  patients  operated  upon,  in 
three  there  was  a  slight  tendency  to  the  recurrence 
of  the  obstructive  symptoms  at  the  end  of  six 
months,  making  a  second  operation  necessary.  Two 
had  occasional  attacks  of  congestion  of  the  prostate 
gland  associated  with  temporary  retention  of  urine 
following  prolonged  dissipation  and  exposure.  From 
the  results  obtained  by  the  experience  that  I  have 
here  recorded  I  feel  that  I  am  warranted  in  forming 
the  conclusions  here  set  forth  : 

1.  Success  following  the  Bottini  operation  de- 
pends on  having  perfect  instruments :  a  good  bat- 
tery ;  the  necessary  skill,  and  the  employment  of  a 
proper  technique. 

2.  In  suitable  cases  the  Bottini  is  the  safest  and 
best  radical  operation  thus  far  advised  for  the  relief 
of  prostatic  hypertrophy. 

3.  It  is  often  very  efficacious  in  advanced  cases 
of  obstruction  as  a  palliative  measure,  rendering 
catheterism  easy  and  painless,  relieving  spasm  ;  les- 
sening the  tendency  to  constipation,  and  improving 
the  general  health. 

4.  It  is  of  especial  service  in  the  beginning  of  ob- 
structive symptoms  due  to  hypertrophy  of  the 
prostate  gland,  and  may  be  regarded  as  a  means  of 
preventing  catheter  life. 

5.  It  is  indicated  in  all  forms  of  hypertrophy  ex- 
cept wdierc  there  is  a  valvular  formation,  or  where 
tliere  is  an  enormous  overgrowth  of  the  three  lobes 
associated  with  tumor  formation  giving  rise  to  a 
pouch,  both  above  and  below  the  prostate  gland. 

6.  Where  the  bladder  is  hopelessly  damaged,  to- 
gether with  a  general  atheromatous  condition  of 
the  blood  vessels,  associated  with  polyuria,  results 
are  negative. 

7.  Pyelitis  is  not  a  contra-indication  to  a  resort  to 
the  operation. 

8.  The  character  of  the  prostatic  growth  has  no 
bearing  on  the  results  of  the  operation. 

The  ligation  of  the  internal  iliac  arteries  for  the 


1220 


'J'HE      PHILADELPHIA"! 

Medical  Journal   J 


HYPERTHROPHY  OF  THE  PROSTATE 


[June   22,   ISOl 


relief  of  hypertrophy  of  the  prostate  gland,  first 
rcommended  by  Bier,  has  been  tried  by  several 
surgeons  with  very  unfavorable  results.  The  ben- 
efit derived  from  the  operation  is  slight,  and  the 
mortality  higher  than  that  following  prostatectomy. 
Thus  far,  the  results  derived  from  aagioneurectomy 
have  been  negative.  I  have  frequently  witnessed 
the  operation  of  perineal  prostatectomy  when  per- 
formed by  others,  and  have  on  various  occasions 
resorted  to  it,  but  I  have  found  that  nothing  was 
gained  beyond  the  temporary  improvement  that 
might  naturally  be  expected  to  follow  rest  and 
drainage.  These  methods  have,  therefore,  not  been 
employed  in  the  cases  referred  to  in  this  paper. 


WIENER    KLINISCHE   WOCHENSCHRIFT. 

Ai)ril  11,  1901.     (XIV  Jahrgang,  No.  15.) 

1.  The   Poisonous  Effect  of  Alcohol   in   Certain   Nervous 

Diseases.     WAGNER  von  JAUREGG. 

2.  Alcohol  and  Insanity.     JOSEF  A.  HIRSCHL. 

3.  Carbonic  Acid  Gas  Applied  Locally  for  Disturbances  of 

Menstruation.     Gustav  Loimann. 

1. — Alcohol  does  not  affect  all  people  alike.  Yet  it  acts 
as  a  poison  upon  the  nervous  system,  whether  by  an  effect 
upon  the  nerve  centers,  or  upon  their  blood  supply.  Indi- 
vidual disposition  will  influence  the  occurrence  of  delirium 
tremens  which  is  seen  only  after  long  continued  alcohol- 
ism. Wagner  von  Jauregg  believes  that  in  chronic  alcohol- 
Ism  a  poison  is  produced  in  the  body  under  the  effect  of 
the  alcohol,  causing  tremor,  vomiting,  delirium,  etc.,  a 
poison  which  is  undoubtedly  due  to  the  alcohol, 
yet  it  is  not  the  alcohol  itself,  as  more  al- 
cohol will  cause  the  disappearance  of  the  symp- 
toms. Its  real  effect  is  seen  after  the  alcohol  has  all  been 
excreted.  This  he  calls  an  alcohologenous  poison.  It  re- 
sembles the  poisons  of  bacterial  origin  seen  in  the  infec- 
tious diseases.  Leucocytosls  occurs,  with  an  increase  in 
the  polynuclear  and  a  decrease  in  the  mononuclear  leuco- 
cytes, with  the  sudden  appearance  of  eosinophilic  cells 
after  the  delirium  is  over.  Then  the  polynuclear  leucocytes 
decrease  and  the  mononuclear  leucocytes  increase  rela- 
tively, while  the  eosinophiles  may  reach  an  abnormal 
amount.  These  changes  in  the  blood  are  much  like  those 
seen  in  croupous  pneumonia.  Albuminuria  also  is  seen. 
This  poison  has  its  maximum  effect  when  no  alcohol  is 
taken.  He  advises  continuing  enough  alcohol  to  prevent 
delirium,  decreasing  the  amount  gradually.  Polyneuritis  and 
the  polyneuritic  psychoses  are  also  explained  as  the  effect  of 
this  alcohologenous  poison,  just  as  they  can  be  caused  by  the 
infectious  diseases.  As  alcohol  also  causes  indigestion,  it 
acts  as  a  double  cause  for  the  polyneuritic  psychoses.  But 
it  is  possible  that  from  the  deleterious  influence  of  the 
alcohol  upon  the  liver,  secondary  poisons  are  elaborated  in 
the  liver  which,  entering  the  circulation,  cause  these 
psychic  manifestations.     [M.  O.] 

2. — Of  the  total  number  of  insane  patients  brought  to 
the  Vienna  General  Hospital,  30%  of  the  men  gave  a  his- 
tory of  chronic  alcoholism.  In  a  third  of  all  insane  men 
admitted,  then,  alcohol  was  an  etiological  factor.  Among 
the  women  only  4.4%  were  alcoholic.  The  diseases  most 
dependent  upon  alcohol  were  epilepsy,  paralytic  dementia, 
and  senile  insanity.  In  all  cases  alcohol  was  absolutely 
withdrawn,  except,  rarely,  in  delirium  tremens  with  cardiac 
complications.  4.3%  of  the  alcoholic  cases  died  from  delir- 
ium tremens.  2S%  of  these  alcoholics  had  to  be  confined 
in  insane  asylums  for  the  rest  of  their  lives.  Hirschl,  in 
closing,  shows  that  the  cost  of  supporting  the  alcoholic 
insane  is  far  greater  than  is  the  income  derived  by  the 
government  from  the  liquor  tax.  to  say  nothing  of  the  in- 
jury done  to  health,  morals,  and  society  by  the  excessive 
use  of  alcohol.     [M.  O.] 

3. — In  the  second  half  of  the  eighteenth  century,  car- 
bonic acid  gas  was  first  used  locally  in  baths  and  douches. 
Loimann  has  seen  excellent  results  from  its  use  in  the  dis- 
turbances which  accompany  menstruation,  dysmenorrhea, 
oligomenorrhea,  and  amenorrhea.  Most  of  the  towns  which 
boast  of  carbonic  acid  waters  have  arrangements  for  giv- 
ing carbonic  acid  gas  baths.  As  the  gas  penetrates  the 
clothing,   it  is  unnecessary  to  undress.     Vaginal   douches 


may  also  be  given.  Loimann  has  devised  a  practical 
contrivance  for  carbonic  acid  gas  douches.  The  mucous 
membrane  of  the  uterus  becomes  reddened,  with  a  great 
increase  in  the  secretion.  Menstruation  generally  appears 
earlier  and  more  copiously  than  usual,  after  repeated 
douches  of  carbonic  acid  gas.  Especially  are  those  women, 
who  show  no  abnormality  of  the  genitalia,  successfully 
treated.  Even  if  the  mucous  membrane  of  the  uterus  be 
altered,  carbonic  acid  gas  douches  may  cause  the  appear- 
ance of  menstruation.  It  must  not,  however,  be  attempted 
during  pregnancy,  or  abortion  will  occur.     [M.  O.] 


JOURNAL  DE  MEDICINE  DE  BORDEAUX. 
March  31,  1901.  (31me.  Ann6e,  No.  13.) 
1.  The  Dispensary  for  Children  in  Bordeaux.  EUGENE 
QUINTRIE. 
1. — The  first  infant  dispensary  in  Paris  was  opened  In 
1892.  by  Professor  Budin.  Since  then  nine  more  have  been 
established  in  Paris,  and  two  in  the  provinces.  Dr.  Saint- 
Philippe  started  this  one  in  Bordeaux  in  1899.  The  dis- 
pensary is  open  once  a  week  for  directing  infant  feeding. 
The  children  with  contagious  diseases  are  at  once  sepa- 
rated from  the  others.  As  the  mothers  are  generally  very 
young,  and  unmarried,  it  was  a  great  effort  to  interest 
them  in  their  own  infants.  That  the  children  benefited 
from  the  physicians'  advice  finally  made  the  dispensary  a 
success.  All  babies  were  weighed  at  the  first  visit,  and 
monthly  afterward.  A  complete  history  of  the  mothers 
past  is  obtained,  especially  of  venereal  troubles.  Histories 
of  the  father  are  as  a  rule  very  vague  or  impossible.  Signs 
of  tuberculosis  and  syphilis  are  always  sought;  malforma- 
tions in  the  infant  and  the  condition  of  the  mother's 
breasts  are  fully  noted.  A  printed  list  is  given  every 
mother,  w-hich  explains  the  toilet  of  the  child  and  its 
feeding.  During  the  past  two  years  almost  1000  infants 
have  been  treated.  Two  thirds  of  these  infants  were  ralseil 
on  the  breast  alone;  one  fifth  on  the  breast  and  bottle:  and 
over  a  tenth  were  bottle-fed,  upon  sterilized  milk  in  small 
quantities.  Babies  were  weaned  from  12  to  14  months. 
At  ten  months,  cow's  niilk.  boiled,  was  begun,  a  cup  full 
daily,  and  nothing  given  all  night.  From  14  months,  they 
had  milk  at  8  A.  M.  and  at  4  and  8  P.  M.,  with  soup.  egg. 
bread,  and  boiled  water  at  noon.  In  1899,  the  death  rate 
was  only  4.4%;  in  1900,  only  2.2%.  These  results  speak 
for  themselves.  It  is  to  be  hoped  that  more  such  dispen- 
saries will  be  established  throughout  France.     [M.  C] 


The  Role  of  the  Leukocytes  in  the  Absorption  of  Certain 
Medicines  Introduced  under  the  Skin  and  into  the  Peri- 
toneal Cavity.  Marie  Louis  Ren6  Montel.  ^(•^l^.  Heb.  <U: 
Mfil.  et  de  Chirur.,  April  21,  1901.  48  me.  Ann^e,  No.  32. 
rUjiilcaiix  r/if.vi.s,  1900-1901.     No.  2). 

Montel  has  studied  the  method  of  absorption  of  calomel, 
iodoform  oil  and  sodium  salycilate.  Calomel  injected  under 
the  skin  or  into  the  peritoneum  is  for  the  most  pan  taken 
up  by  the  leukocytes  either  in  the  form  of  reduced  mercury 
and  sublimate  or  in  the  form  of  small  crystals  of  calomel. 
Under  the  influence  of  the  cellular  activity  of  the  leuko- 
cytes., calomel  becomes  changed  into  sublimate  and  re- 
duced mercury.  The  nodules  that  result  from  the  subcu- 
taneous injection  of  calomel  are  due  to  a  defensive  process 
of  the  organism.  Under  the  skin,  as  well  as  in  the  peri- 
toneal cavity,  calomel  is  absorbed  during  a  stage  of  hyper- 
leukocytosis  due  to  a  positive  chematoxis  of  the  leuko- 
cytes which  is  preceded  by  a  stage  of  hypoleuko- 
cytosis  and  negative  chemotaxis.  The  stage  of  hypoleuko- 
c>-tosis  varies  in  length  depending  upon  the  size  of  the 
injected  dose,  Hyperleukocytosis  is  the  evolution  towards 
cure,  and  it  is  the  polymorphonuclear  and  the  large  mono- 
nuclear leukoc\-tes  that  seize  the  mercurial  salt.  Iodoform 
oil  is  absorbed  and  transported  by  the  leukoc>tes.  This  ab- 
sorption seems  to  be  due  particularly  to  the  large  mononu- 
clear elements.  It  is  accompanied  by  marked  hyperleuko- 
cytosis. In  an  animal  who  has  received  an  hypodennic  in- 
jection of  sodium  salycilate  the  white  bloodcorpuscles  treat- 
ed by  perchloride  of  iron  are  found  to  be  studded  with  black 
points  that  indicate  the  formation  of  salycilate  compounds 
of  iron.  For  these  different  substances  the  absorption,  al- 
most exclusively  cellular,  is  due  to  the  leukocytes  which, 
circulating  in  the  blood  current,  are  carried  to  the  point  at 
which  their  action  is  needed.     [J.  M.  8.] 


The  Philadelphia  Medical  Journal 

A  Weekly  Journal  Owned  and  Published  by  The  Philadelphia  Medical  Publishing  Company   and  Conducted 

Exclusively  in  the  Interests  of  the  Medical  Profession 


James  Hendrie  I,loyd,  A.  M.,  M.  D.,  Edilor-tn-Chiej 
Julius  I,.  Salinger,  m.  D„  Associate  Editor 
Assistant  Editors 
JOSEPH  Sailer,  M.  D.  F.  J.  Kalteyer,  \I.  D. 

D.  1,.  Edsall,  M.  D.  T.  L,.  Coley,  M.  D. 

J.  M.  Swan,  M.  D.  W.  a.  N.  Borland,  M  D 

J.  H.  Gibbon,  M.  D.  T.  M,  Tyson,  M.  D. 

M.  OSTHEIMER,  M.  D.  A.  Robin,  M.  D. 


Scientific  Articles,  Clinical  Memoranda,  News  Items,  etc.,  of  interest  to  the  profession 
are  solicited  for  publication.  Reprints  (250)  of  Original  Articles  will  be  furnished 
gratis  to  Authors  making  the  request. 

The  Editorial  and  Business  Offices  are  at  1716  Chestnut  St.    Address  all  correspondence  to 

The  Philadelphia  Medical  Journal,    1716  Chestnut  St.,  Philadelphia,  Pa. 
See  Advertising  Page  8. 


Vol.  VII,  No.  26 


June  29,  1901 


$3.00  Per  Annum 


The  Importance  of  the   Hemolymph   Glands.— 

In  1884  H.  Gibbes  described  the  presence  in  the  hu- 
man subject  of  certain  minute  lymph  glands  found 
in  the  connective  tissue  between  the  renal  artery 
and  vein.  They  differ  from  lymph  glands  in  the  fact 
that  they  contain  blood  sinuses  instead  of  lymph 
spaces.  In  1890  W.  F.  Robertson  described  similar 
structures  in  the  sheep  and  bullock,  also  mentioning 
their  presence  in  man.  He  developed  the  histology 
of  these  organs  which  he  named  "hemolymph 
glands,"  and  he  called  attention  to  the  difficulty  of 
distinguishing  between  lymph  glands  and  hemo- 
lymph glands  with  the  naked  eye.  Vincent  and 
Harrison  (1897)  studied  the  hemolymph  glands  in 
animals.  They  pointed  out  that  a  lymph  gland  has 
only  to  contain  blood  in  part,  or  all,  of  its  tissues  to 
be  considered  a  variety  of  hemolymph  gland,  and 
made  the  important  observation  that  there  is  a 
great  resemblance  between  certain  accessory  spleens 
and  hemolymph  glands.  W.  B.  Drummond  made 
a  careful  study  of  these  structures  last  year.  He 
expressed  the  opinion  that  there  is  not  sufficient 
evidence  that  they  play  an  important  part  in  the 
formation  of  red  blood  corpuscles.  He  believes  that 
they  take  part  in  the  destruction  of  these  cells  and 
in  the  liberation  of  the  pigment,  as  well  as  being 
•centers  for  the  formation  of  leukocytes.  A.  S. 
Warthin  has  recently  contributed  a  most  valuable 
paper  on  this  subject  based  upon  the  study  of  eighty 
autopsies  on  the  human  subject  (Journal  of  the  Boston 
Society  of  Medical  Sciences,  April  23,  1901).  He  has 
■determined  that  these  glands  are  found  in  greatest 
prevalence  in  the  connective  tissue  of  the  retroperi- 
toneal, prevertebral  region,  and  that  they  are  un- 
-common  in  the  mediastinal  tissues,  or  along  the 
thoracic  vertebra.  They  are  found  in  considerable 
number  in  the  cervical  region,  below  and  behind 
the  lobes  of  the  thyroid.  These  glands  vary  greatly 
in  size  and  number.  Warthin  states  that  the  ratios 
1-20  to  1-50  express  their  relation  with  the  lymph 
glands.  The  vascularity  of  the  hemolymph  glands 
is  very  remarkable  at  times,  and  they  are  found 
usually  near  large  blood  vessels.  Microscopically, 
this  author  describes  two  types  of  hemolymph 
glands,  to  which  he  has  given  the  names  splcnolymph 
gland   and  marrozvlyinph  gland,  as  indicating  their 


structure  and  probable  functions ;  but  be^een  these 
two  types  transition  forms  exist  as  well  as  between 
these  glands  and  the  spleen  on  the  one  hand,  and 
ordinary  lymph  glands  on  the  other.  Warthin  con- 
cludes that  under  normal  conditions  the  hemolymph 
glands  are  chiefly  concerned  with  hemolysis  and 
leukocyte  formation  and  play  but  little  part  in  the 
formation  of  red  blood  cells.  When,  however,  the 
blood  shows  marked  changes  a  condition  of  these 
glands  is  present  that  indicates  clearly  their  blood- 
forming  function.  The  careful  study  of  the  retro- 
peritoneal tissues  reveals  the  fact  that  the  lymph- 
adenoid  structures  are  constantly  undergoing  pro- 
gressive and  retrogressive  changes.  Warthin  points 
out  the  intimate  relationship  existing  between  adi- 
pose tissue  and  lymphadenoid  tissues,  which  is  here 
shown  strikingly;  and  the  probable  metaplasia  of 
the  former  into  the  latter,  as  in  the  case  of  splenic 
anemia,  confirms  the  observations  of  Bayer  and 
Tizzoni.  The  intimate  relationship  existing  also 
between  the  spleen,  lymph  glands,  and  bone  marrow 
is  indicated  by  the  power  of  the  hemolymph  glands 
to  assume  the  structure  and  function  of  these  or- 
gans in  certain  pathological  conditions.  The  fact 
that  transition  forms  of  cells  between  small  lympho- 
cytes and  erythrocytes,  as  well  as  between  hyaline 
mononuclear  leukocytes,  and  nucleated  red  cells  are 
found  in  these  structures,  seems  to  confirm  the 
views  of  Lowit  and  Howell.  The  further  study  of 
the  hemolymph  glands  promises  rich  results  in  con- 
tributing to  our  knowledge  of  blood  formation, 
blood  destruction,  and  the  physiology  and  pathology 
of  the  blood-for/ning  organs. 

The  Cases  of  Plague  at  Hull,  England. — This  out- 
break was  one  of  special  instructiveness,  partic- 
ularly because  of  the  masterful  way  in  which  it  was 
managed.  The'  steamship  Friary  left  Alexan- 
dria on  December  22,  1900,  and  touched  at 
Algiers  on  December  30  (Public  Health  Re- 
ports). On  December  31  she  left  Algiers  and 
sailed  direct  for  Hull,  England,  where  she  arrived 
on  January  10,  1901.  She  had  clean  bills  of  health 
from  both  Alexandria  and  Algiers,  the  captain  only 
having  gone  ashore  at  the  latter  port,  although  the 
ship  took  on  coal  there.     On  the  voyage  from  Al- 


1222 


The    Philadelphia"! 
Medical  Journal  J 


EDITORIAL  COMMENT 


[J,-VE   2S,    IVjI 


giers  to  Hull  one  of  the  crew  died  two  days  before 
reaching  port.  Death  was  believed  to  be  due  to 
natural  causes,  and  the  body  was  interred  in  one 
of  the  Hull  cemeteries.  Then  it  was  found  that  sev- 
eral of  the  crew  were  ill.  The  sick  men  presented 
rapid  pulse,  a  temperature  of  about  ioi°  F.,  head- 
ache and  articular  pains.  It  was  first  thought  that 
the  disease  was  influenza  with  lung  complications. 
Two  of  these  patients  died,  about  forty-eight  hours 
after  they  were  taken  ill,  and,  at  autopsy,  it  was 
found  that  the  cause  of  death  in  both  cases  was  pneu- 
monic plague.  The  diagnosis  was  confirmed,  subse- 
quently, by  bacteriological  examination.  The  ship 
was  then  moved  to  quarantine,  about  twelve  miles 
from  the  city,  and  the  patients  were  placed  in  isola- 
tion in  a  hospital  four  and  one-half  miles  from  the 
city.  In  this  hospital  eight  out  of  the  nine  patients 
affected  with  the  disease  died.  The  mortality,  how- 
ever, was  confined  to  the  members  of  the  crew  who 
had  lived  in  the  forecastle  of  the  ship.  Several  rats 
were  found  dead  in  the  hold  of  the  ship  during  the 
discharge  of  the  cargo,  and  mem.bers  of  the  crew 
stated  that  they  found  dead  rats  on  the  vessel  after 
leaving  Alexandria.  A  cat  that  had  lived  in  the 
forecastle  was  taken  sick  and  thrown  overboard 
during  the  voyage.  A  dog  that  lived  with  the 
crew  was  also  taken  sick.  This  animal  was 
killed,  but  bacteriological  examination  did  not  re- 
veal plague  bacilli.  It  is  evidently  entirely  due  to 
the  energies  of  the  port  physician  of  Hull,  Dr.  Ma- 
son, that  this  epidemic  of  plague  did  not  spread  to 
the  port  and  become  generalized.  The  form  of  dis- 
ease from  which  the  infected  members  of  the  crew 
suffered  was  the  form  most  difficult  to  diagnose  and 
the  most  ready  of  propagation  on  account  of  the  fact 
that  the  bacilli  are  thrown  off  in  large  numbers  with 
the  sputum.  The  fact,  however,  that  this  epidemic 
was  confined  to  the  ship  on  which  it  was  imported 
is  strong  evidence  that  contagfious  diseases,  the  mi- 
cro-organismal  cause  of  which  is  known,  can  be  sat- 
isfactorily treated  and  their  spread  prevented  bv 
modern  methods.  Furthermore,  there  is  no  reason 
why  the  inhabitants  of  a  port  into  which  a  conta- 
gious disease,  such  as  plague,  may  be  brought, 
should  become  panicstricken  and  adopt  measures 
that  tend  rather  to  lessen  than  to  advance  efficient 
prophylaxis.  The  recent  case  of  pneumonic  plague 
that  developed  at  Ann  Arbor  (Report  of  Proceed- 
ings of  Association  of  American  Physicians,  Phila- 
delphia Medical  Journal,  May  25.  1901)  in  a  lab- 
oratory worker  who  was  studying  the  bacillus  pes- 
tis  is  further  evidence  that  once  plague  is  diagnosed 
its  spread  can  be  prevented  by  modern  methods.  The 
student  in  question,  together  with  all  those  who 
had  been  associated  with  him,  was  isolated,  and  by 
the  use  of  Yersin's  serum,  was  cured,  and  no  other 


case  of  plague  developed  in  the  University  of  Mich- 
igan. The  individuals  who  were  exposed  to  plague 
at  Hull,  upward  of  sixty  in  number,  were  inocu- 
lated with  Haffkine's  prophylactic,  but  none  of 
those  actually  ill  appear  to  have  been  treated  with 
Yersin's  curative  serum.  The  evidence  points 
strongly  to  Yersin's  serum  as  the  only  hope,  once 
the  disease  has  developed,  and  it  seems  possible 
that  this  serum  might  have  resulted  in  saving  the 
lives  of  some  of  those  who  perished  in  the  Hull  epi- 
demic. 

The  Clergy  and  the  Doctors. — The  absolute  ina- 
bility of  some  religious  writers  to  appreciate  the  real 
force  and  trend  of  the  modern  science  of  pathology, 
is  curiously  shown  in  their  methods  of  criticising  so- 
called  Christian  Science.  They  naturally  fear  this 
new  cult  for  its  effects  on  existing  religious  systems 
rather  than  for  its  menace  to  the  public  health  and 
the  public  intelligence.  In  a  recent  contribution  to 
the  Churchman,  a  prominent  Anglican  divine  dis- 
cusses the  relation  of  the  early  church  to  the  treat- 
ment of  disease.  He  thinks  he  finds  evidence  that 
the  clergy  in  those  remote  times  exercised  the  func- 
tions of  the  physician,  but  he  adduces  no  adequate 
proof  whatever  in  support  of  this  claim,  for  it  is  not 
the  function  of  the  physician  to  cure  by  miracles  and 
wonder-working.  Lecky  (History  of  European  Morals, 
Vol.  i)  has  shown  that  the  early  church  relied  upon 
thaumaturg}',  just  as  Christian  Science  is  doing, 
whereas  legitimate  medicine  does  nothing  of  the 
sort.  The  Churchman,  commenting  on  this  paper, 
makes  the  astonishing  statement  that  "manv  a  cler- 
g>'man  is  already  a  consulting  physician."  It  seems 
to  think  that  the  two  offices — that  of  the  priest  and 
that  of  the  physician — should  be  combined  in  one 
and  the  same  person.  All  this  is  evidently  suggested 
by  the  progress  of  Christian  Science,  but  the  point 
of  the  whole  matter  is  curiously  missed. 

These  writers  should  at  least  understand  that  the 
whole  therapeutic  power  of  any  religious  system  lies 
simply  in  the  domain  of  mental  impression  or  sug- 
gestive therapeutics ;  that ,  this  p>ower  is  not,  and 
never  has  been,  confined  to  any  one  religion  or  sect, 
but  has  been  exerted  by  all  of  them  in  everj-  period 
of  history  and  in  ever}"  region  of  the  globe  in  which 
they  have  prevailed :  that  this  suggestive  therapeu- 
tics is  potent  for  good  in  only  a  limited  domain  of 
medical  practice ;  and,  finally,  that  suggestive  thera- 
peutics can  just  as  well,  if  not  better  and  more  ra- 
tionally, be  used  by  extra-theological  methods.  The 
Hindoos  and  the  Chinese,  as  well  as  the  ancient 
Greeks  and  Romans,  have  not  been  unfamiliar  with 
the  therapeutic  value  of  religious  emotion.  This  is 
shown  by  Regnier  in  his  work  on  hj-pnotism  in  the 
ancient  religions  (Hyf'notisvtc  ct  Croyanccs  Ancienncs, 


June  29,   1301] 


EDITORIAL  COMMENT 


tTHE    Philadelphia 
Medical  Joubxal 


I22J 


Paris,  1891),  and  by  Nevius  in  his  book  on  demon 
possessions  in  China  (Demon  Possession  and  Allied 
Themes,    1896). 

To  see  in  all  this  any  evidence  that  the  enormous 
fabric  of  modern  medical  science  will  be,  or  even 
can  be,  entrusted  to  the  hands  of  the  clergy  (as 
seems  to  be  the  idea  of  a  writer  in  the  Literary 
Digest)  is  an  evidence  of  a  critical  insight  that 
would  have  done  credit  to  a  mediaeval  monk. 

Six  Notable  American  Medical  Achievements. — 

In  an  interesting  address  recently  delivered  to  the 
graduates  of  the  Medical  and  Dental  Departments 
of  the  Columbian  University  in  Washington,  Dr.  G. 
E.  de  Schweinitz  picked  out  for  special  distinction 
the  work  of  six  American  doctors  in  medicine  and 
surgery.  These  contributors  to  science,  who  have 
each  done  some  epochal  work,  are  Beaumont,  for  his 
work  in  gastric  digestion ;  Gerhard,  for  his  observa- 
tions that  led  to  the  differentiation  of  typhoid  and 
typhus  fevers  ;  Gross,  for  his  pioneer  work  on  patho- 
logical anatomy ;  Oliver  Wendell  Holmes,  for  his 
recognition  of  the  contagiousness  of  puerperal  fever ; 
H.  C.  Wood,  for  his  work  in  therapeutics ;  and  S. 
W^eir  Mitchell,  for  his  rest  cure.  This  list  might, 
as  Dr.  deSchweinitz  justly  says,  be  somewhat  en- 
larged, and  we  should  certainly  not  omit  from  it  the 
names  of  Ephraim  McDowell,  who  performed  the 
first  ovariotomy,  and  of  that  greatest  benefactor  of 
all,  Morton,  to  whom  the  world  owes  the  first  prac- 
tical demonstration  of  ether  anesthesia.  As  Ameri- 
cans, we  cannot  too  jealously  guard  the  fame  of 
Morton,  for  there  has  been  at  times  some  tendency 
to  detract  from  the  honor  which  is  his.  Dr.  de 
Schweinitz's  address  was  an  eloquent  plea  for  the 
originality  of  some  of  the  best  work  that  has  marked 
the  progress  of  medicine  in  America,  and  was  es- 
pecially appropriate  to  the  occasion.  American 
medical  students  and  graduates  cannot  be  taught  too 
earnestly  to  respect  the  work  of  their  own  country- 
men, and  not  to  look  abroad  too  exclusively  for 
knowledge  and  initiative. 

Aerophagia. — Aerophagia  is  the  name  given  by 
Bouveret  to  a  spasmodic  swallowing  of  air,  followed 
by  frequent  noisy  eructations  of  gas,  seen  in  hyste- 
ria {Revue  de  Mcdecine,  1891,  p.  146).  Pitres  also 
found  the  condition  in  hysteria  (Progres  Medieal, 
January,  1895).  Lyonnet  and  Vincens,  students  of 
Bouveret's,  have  seen  aerophagia  with  nervous  dys- 
pepsia, and  call  it  false  flatulence,  due  to  the  deglu- 
tition of  air.  {Lyon  Medical,  February  10,  1901.)  At 
a  meeting  of  the  Medical  Society  of  the  Paris  Hos- 
pitals (Bulletins  et  Memoircs  de  la  Soeiete  Medicale 
des  Hopitaux  de  Paris,  1901,  Nos.  8  and  9)  Mathieu  de- 
scribed the  condition  as  a  continual  belching,  with 


much  noise,  some  time  after  meals,  accompanied  by 
epigastric  pain.  He  reports  a  number  of  cases  in 
nervous  dyspeptics,  with  enteroptosis  and  other 
gastric  diseases.  The  patients  soon  realize  that 
relief  follows  the  swallowing  of  air,  as  that 
opens  the  cardiac  orifice  enough  to  allow  the 
gas.  the  cause  of  the  distention  and  pain,  to 
escape.  When  once  established,  it  soon  becomes 
frequent.  Vomiting  occasionally  results.  Mathieu 
believes  that  a  simple  caution,  in  most  cases,  will 
cause  its  cure.  With  hysteria  a  more  severe  treat- 
ment will  be  necessary.  The  dyspepsia  and  enter- 
optosis should  be  treated  in  the  usual  manner.  Sire-- 
dey  reported  similar  cases.  Linossier  separates  dis-- 
tinctly  the  aerophagia  of  hysteria  from  that  of  dys- 
pepsia. The  former  resembles  rumination  ;  for,  when : 
rumination  occurs  in  man,  it  is  begun  by  aeropha.- 
gia,  with  eructation  following.  He  considers  aerO'- 
phagia  simply  gaseous  rumination.  Le  Noir  stated 
that  aerophagia  was  very  common  among  horses. 
Soupault  believes  that  aerophagia  may  be  volun- 
tary or  involuntary.  The  former  is  seen  among  ner- 
vous dyspeptics,  an  interesting  case  of  which  is  re- 
ported ;  the  latter  is  seen  in  hysteria.  Moderate 
aerophagia  is  also  found  with  flatulent  dyspepsia. 
Not  only  is  will  power  a  determining  force  in  pro- 
ducing this  loud  belching,  but  tapping  upon  differ- 
ent regions  of  the  abdomen  also  causes  it.  Rendu 
believes  that  aerophagia  is  always  physiological,  in 
no  way  pathological.  INIathieu  closed  the  discussion 
by  showing  his  results,  quick  recovery,  as  soon  as 
the  patients  understood  that  they  could  control  the 
eructations.  Both  Mathieu  and  Soupault,  who  have 
studied  the  subject  most  thoroughly,  insist  that  the 
treatment  ordinaril)'  given,  carminatives,  antisep- 
tics, and  absorbing  powders,  have  absolutely  no  ef- 
fect upon  the  condition. 

The  Accidents  Accompanying  the  Eruption  of  the 
Permanent  Teeth. — The  condition  of  the  teeth  has, 
in  the  past,  been  considered  the  sole  concern 
of  the  dentists.  But  it  may  be  stated  with 
considerable  degree  of  truth  that  the  physi- 
cian is  quite  as  much  interested  in  the  phe- 
nomena of  dentition  as  is  the  dentist.  Hunter's  ar- 
ticles, which  have  appeared  lately,  have  called  at- 
tention to  the  relation  between  oral  sepsis  and  the 
general  health,  and  now  Audy  (Paris  Thesis,  No.  253, 
Ga:.  Heb.  de  Med.  ct  de  Chirur.,  May  19,  1901),  calls 
attention  to  the  fact  that  the  oral  lesions  that  accom- 
pany the  eruption  of  the  permanent  teeth,  other  tlian 
the  third  molars,  are  frequently  of  an  infectious  na- 
ture. He  points  out  that  in  order  to  cure  such  le- 
sions the  same  rules  should  be  followed  that  apply 
to  the  treatment  of  infected  wounds;  free  incision 
and  local  antisepsis.  The  most  rigorous  possible  buc- 


1224 


The   PmLADBUPHiA"! 
Medical.  Journal   J 


EDITORIAL  COMMENT 


[JtJKZ   Z>,    XW'J 


cal  asepsis  is  the  only  method  for  the  prevention  of 
these  infectious  complications.  Buccal  asepsis  neces- 
sarily includes  brushing  the  teeth  of  children  after 
they  have  reached  the  age  of  three  or  four  years. 
We  should  be  inclined,  however,  to  advocate  the  in- 
stitution of  this  sanitary  arrangement  at  an  earlier 
time  in  life  than  the  third  year.  The  production  of 
painful  and  congestive  lesions  of  the  gums  escapes 
all  foresight.  Nervous  affections  of  reflex  ori- 
gin, which  Audy  has  seen  only  imperfectly 
produced,  evidently  cannot  be  influenced  by  preven- 
tive treatment.  It  is  undoubtedly  the  physician's 
duty  to  insist  to  all  his  patients,  especially  those  in 
whom  such  matters  are  frequently  neglected,  upon 
■the  importance  of  the  hygiene  of  the  mouth. 

The  Pancreas  of  the  Embryo  and  the  New-bom. 

—It  is  strange  that  after  all  that  has  been  written 
and  done  in  infant  feeding,  our  knowledge  of  the 
digestive  physiology  of  infants  is  still  very  limited. 
The  meagre  information  on  the  subject  is  repre- 
sented mostly  by  a  few  theories  based  on  a  priori 
Teasoning,  deductions  from  the  effects  of  various 
ioods,  or  dogmatic  statements  made  by  a  few  au- 
thorities. It  is  assumed,  and  correctly  so,  that  the 
natural  food  of  infants  is  milk,  ergo,  the  digestive 
•organs  of  the  infant  must  be  such  as  to  be  adapted 
to  the  digestion  of  that  particular  food  and  no  other ; 
in  othdr  words,  the  ferments  necessary  for  the  diges- 
tion of  starches  must  be  absent.  As  a  result  of  such 
Teasoning,  we  have  the  stereotyped  belief  that  the 
child,  during  the  first  few  months  of  infantile  life, 
possesses  no  amylolytic  ferment.  This  belief,  by 
the  way,  has  been  exploded  by  recent  investigations 
which  seem  to  prove  that  this  is  not  the  case.  Dr. 
E.  Garte  took  up  the  subject  in  an  experimental 
way  and  brought  to  light  some  facts  concerning  the 
tiigestive  functions  of  infants,  which  deserve  special 
mention.  The  results  of  his  work  were  embodied 
in  a  dissertation  delivered  before  the  Military 
Academy  of  St.  Petersburg  (summarized  in  the 
Bohiitchnaia  Gazeta  Boikiua,  Vol.  XII.,  No.  i).  The 
author  removed  the  pancreas  from  the  dead  bodies 
of  new-born  infants  and  placed  it  in  physiologic  salt 
solution  for  24  hours  in  the  incubator,  adding  thy- 
mol to  exclude  the  action  of  bacteria.  This  antisep- 
tic proved  quite  effectual,  as  shown  by  bacteriolog- 
ical examination  of  the  infusion,  which  remained 
Sterile.  He  then  tested  the  action  of  this  infusion 
of  the  pancreas  on  albumen,  starch  and  fats.  All 
these  substances  were  digested,  showing  that  the 
corresponding  ferments  are  present  in  the  pancreas 
of  the  new-born.  Moreover,  he  found  that  these 
ferments  make  their  appearance  on  the  third  month 
of  intra-'.iterine  life,  and  that  the  pancreatic  juice  is 
actually  secreted  on  the  fourth  month,  although  the 
amylopsin  in  the  new-born  is  four  times  less  than 


in  the  adult.  The  practical  conclusion  reached  by 
the  author  is  that  the  infant  from  its  birth  is  able 
to  digest  small  quantities  of  starch.  In  working 
with  pathological  material,  he  found  that  chronic 
diseases,  irrespective  of  the  location,  have  a  more 
depressing  influence  on  the  pancreas  than  the  acute. 
The  following  observations  are  of  considerable  in- 
terest from  a  biological  standpoint :  i.  A  trypsin-like 
ferment  was  found  in  the  liver,  kidneys,  spleen  and 
lungs  of  the  new-born.  This  ferment  was  already 
present  in  the  above-named  organs,  especially  the 
liver,  on  the  sixth  month  of  intrauterine  life,  prov- 
ing that  pancreatic  juice  is  secreted  and  absorbed 
by  the  organs  at  this  early  period.  2.  A  diastatic 
ferment  was  found  in  all  the  organs  and  even  in  the 
skin  of  the  abdomen.  3.  There  is  no  relation  between 
the  amount  of  glycogen  and  the  diastatic  ferment.. 

The  Recreations  of  Scientists. — With  men  in  our 
profession  all  seasons  are  times  of  work: 
therefore,  all  seasons  for  them  are  likely  to 
be  times  also  for  play.  How  else  can  your 
poor  overworked  doctor  (who  is  so  apt  to 
condole  with  himself)  even  things  up?  He 
must  snatch  his  moments  of  sport  even  from  the 
grasping  hours  of  toil  and  duty.  Who  shall  blame 
him  for  this?  If  he  hurries  from  the  sick  room  to  a 
game  of  cards,  he  is  not  to  be  charged  with  cynicism 
and  indifference.  The  season,  such  as  that 
just  passed,  for  the  meetings  of  the  numer- 
ous medical  associations  is  the  great  recrea- 
tion time  for  the  doctors.  There  is  no  use  in 
denying  the  fact ;  many  a  good  man  goes  to  the 
yearly  meeting  of  his  association  with  his  mind  bent 
on  pleasure  as  well  as  on  science.  And  we  are  not 
going  to  berate  him  for  this  in  these  columns.  If  we 
were  a  self-constituted  reformer  of  the  medical  pro- 
fession (which  we  are  not),  we  might  find  occasion 
here  for  some  labored  editorial  rhetoric.  But  a  fel- 
low feeling  makes  us  wondrous  kind,  and  we  confess 
that  the  humorous  side  of  this  whole  picture  appeals 
strongly  to  us.  That  doctors  should  travel  many 
hundreds  of  miles  to  attend  a  grave  assemblage  of 
their  colleagues,  and  then  should  rush  off  from  the 
meeting  at  a  moment's  notice  to  attend  a  horse-race 
or  to  take  a  ride  on  a  river,  strikes  us  as  being  pecu- 
liarly man-like.  We  recently  saw  a  big  base-ball 
match  deplete  an  afternoon  session  of  an  association 
of  specialists,  many  of  whom  are  well  known  to 
fame.  One  unfortunate  member  confessed  aloud 
that  he  would  like  to  go  with  the  sport-loving  dele- 
gation, but  could  not,  because  he  had  to  stay  and 
read  a  paper.  He  was  in  the  position  of  the  small 
boy  who  would  like  to  play  truant  but  dares  not. 
The  man  who  would  propose  on  such  an  occasion 
that  the  society  adjourn  in  favor  of  the  ball  match 
would  be  frowned  down.  He  would  be  judged  guilty 
of  levitv  and  would  be  voted  a  Philistine.     But  the 


June  29,   1901] 


REVIEWS 


PTHE     PHILArELPHlA 

L Medical  JotRNAL 


122^ 


man  who  deliberately  gets  up,  takes  his  hat,  and 
leads  off  a  coterie  of  his  weaker  brethren  to  the 
neighboring  ball  field,  is  envied  rather  than  scorned 
And  when  one  thinks  that  the  bold  man  has  come 
hundreds  of  miles  and  spent  much  money,  one  must 
at  heart  have  a  little  sympathy  with  his  desire  to 
get  some  fun  out  of  it  all.  And  then,  after  all,  the 
papers  can  be  read  just  as  well  when  they  are  pub- 
lished in  the  journals. 


IRcvicws. 


A  System  of  Practical  Therapeutics,  Edited  by  HobartAmory 
Hare,  M.  D..  Prof,  of  Therapeutics  and  Materia  Med- 
ica  in  the  Jefferson  Medical  College,   Philadelphia: 
Physician  to  the  Jefferson  Medical  College  Hospital. 
Published  by  Messrs.  Lea  Brothers  &  Co.,  Philadel- 
phia and  New  York.     1901. 
The  first  volume  of  this  valuable  work  was  reviewed  in  a 
former  number  of  this  journal.    Volume  Second  is  devoted 
to  fevers,  diseases  of  the  respiratory  and  circulatory  sys- 
tem, diseases  of  the  digestive  system  and  kidneys,  nervous 
diseases  and  diseases  of  the  skin. 

Dr.  Hare,  the  editor,  has  written  the  chapter  on  typhoid 
fever.  His  comments  upon  the  Brand  treatment  will  be 
especially  interesting  to  those  who  have  been  inclined  to 
give  this  treatment  their  unqualified  approval.  Dr.  Hare  is 
apparently  not  one  of  the  unqualified  advocates  of  the 
Brand  treatment.  He  takes  care,  however,  to  state  in  ital- 
ics that  he  would  have  made  himself  misunderstood  if  any 
reader  should  consider  that  he  was  opposed  to  cold  bathing 
in  fever.  The  aim  of  his  article  is  apparently  to  marshal 
all  facts  both  for  and  against  the  treatment,  and  thus  to 
draw  scientific  inductions.  Dr.  James  N.  Anders  writes 
an  article  on  malarial  fevers  and  describes  the  treatment 
of  that  disease  and  its  various  conditions  In  great  detail. 
Dr.  'SMlliam  M.  Welch,  of  Philadelphia,  a  well-recognized  ex- 
pert on  smallpox,  has  written  a  most  instructive  chapter  on 
that  disease.  The  article  on  varicella  by  Dr.  J.  P.  Crozer 
Grifiith.  on  yellow  fever  by  Dr.  D.  T.  Laine,  on  influenza  by 
Dr.  Frederick  A.  Packard,  and  on  diphtheria  by  Dr.  Floyd 
M.  Crandall.  are  a  few  of  the  chapters.  The  mere  mention 
of  the  names  of  the  authors  is  sufficient  to  guarantee  the 
value  and  accuracy  of  their  work.  The  chapter  on  diseases 
of  the  liver  is  written  by  Dr.  John  H.  Musser,  whose  name  is 
especially  identified  with  this  department  of  internal 
pathology.  It  is  hardly  fair  in  noticing  such  a  valuable 
encyclopaedic  work  as  this  to  merely  mention  the  chap- 
ters and  authors,  but  space  here  forbids  a  detailed  review. 
In  the  treatment  of  nervous  diseases  the  editor  has  made 
very  judicious  selections  of  writers.  Thus.  Dr.  Sinkler 
writes  on  the  treatment  of  headaches  and  neuralgia.  Dr. 
Dercum  on  the  drug  habit.  Dr.  Patrick  on  disorders  of 
sleep.  Dr.  Allen  Starr  on  locomotor  ataxia.  Dr.  Charles  K. 
Mills  on  apoplexy  and  brain  tumors,  and  Dr.  .Joseph  Col- 
lins on  spasmodic  affections  of  the  nervous  system.  The 
medical  treatment  and  hospital  treatment  of  insanity  are 
described  respectively  by  Dr.  Bannister  and  Dr.  Brush. 

Volume  Third  is  devoted  to  surgical  technique,  surgery 
of  the  genito-urinary  apparatus,  respiratory  and  digestive 
systems,  fractures  and  dislocations,  and  anesthesia.  It  is 
thus  seen  that  this  volume  is  practically  a  treatise  on  sur- 
gical treatment.  In  this  respect  the  work  is  a  departure 
from  mere  works  on  therapeutics,  and  this  departure  is  a 
decided  gain  to  all  practitioners  and  students  who  may  re- 
sort to  it  for  instruction.  Among  the  well-known  authori- 
ties whose  work  appears  in  this  volume  are  Dr.  William  T. 
Belfield.  Dr.  Edward  P.  Davis.  Dr.  George  R.  Fowler.  Dr. 
Charles  M.  Frazier.  Dr.  Andrew  J.  McCosh.  Dr.  Edward  Mar- 
tin. Dr.  E.  E.  Montgomery.  Dr.  Henry  R.  Wharton  and 
others.  Dr.  Leonard  has  written  an  unusually  full  chapter 
on  anesthesia  based  upon  a  large  clinical  experience. 

The  article  is  accompanied  by  illustrations  showing  the 
different  methods  for  artificial  respiration. 

Dr.  Frazer  describes  in  great  detail  surgical  technique. 
Dr.  Wharton  has  a  chapter  on  the  treatment  of  fractures 
and  dislocations,  which  is  of  course  a  complete  surgical 
paper  on  those  subjects  Diseases  of  the  rectum  and  anus 
are  treated  by  Dr.  Mathews;    and  the  practical   points  in 


minor  surgery  and  bandaging  are  considered  by  Dr. 
Spencer.  An  interesting  paper  the  one  on  cere- 
bral concussions  and  shock,  by  Dr.  Joseph  Ranso- 
hoff:  and  empyema,  which  is  a  subject  of  so  much  joint 
interest  to  both  physician  and  surgeon,  is  treated  of  very 
accurately  by  Dr.  A.  J.  McCosh.  Dr.  Fowler  has  written  a 
paper  on  appendicitis  which  is  also  nothing  more  nor  less 
than  a  complete  surgical  paper  on  this  subject.  He  does 
not  ignore  medical  treatment,  however.  Dr.  Martin  has  an 
unusually  able  paper  on  obstruction  of  the  intestines,  and 
Dr.  Belfield  has  thoroughly  discussed  the  infections  of  the 
genito-urinary  tract  in  a  very  important  paper.  Dr. 
E.  E.  Montgomery,  from  his  broad  clinical  experience, 
has  contributed  a  most  valuable  paper  on  the  genito-urinary 
diseases  of  women. 

Dr.  Davis  writes  on  the  therapeutics  of  pregnancy,  par- 
turition and  the  puerperal  state  with  all  the  care  and  detail 
which  always  characterize  his  work.  Dr.  Wood  has  writtea 
a  paper  on  the  remedial  agents  in  diseases  of  the  eye 
as  treated  by  the  general  practitioner.  This  volume  concludes 
with  special  chapters  on  the  diseases  of  the  ear.  by  Dr. 
S.  McC.  Smith,  the  nasal  chambers  by  Dr.  E.  F.  Ingal's  and 
the  larynx  by  Dr.  D.  Braden  Kyle.  These  chapters  for 
thoroughness  and  scientific  merit  are  in  full  accord  with 
the  general  character  of  this  important  work.     [J.  H.  L.] 

Year  Book  of  the  United  States  Department  of  Agriculture, 
1900.     Published  by  the  Government  Printing  Office. 

This  book,  published  by  the  United  States  Government, 
contains  a  great  quantity  of  most  valuable  reading  matter. 
Its  contents  are,  of  course,  of  primary  importance  to  the 
agriculturist,  but  there  are  some  interesting  things  in  It 
that  appeal  directly  and  indirectly  to  medical  readers. 

We  have  noted  especially  the  articles  on  the  dale-palm 
and  its  culture:  on  the  food  of  nesting  birds:  on  commer- 
cial pear  culture:  on  practical  forestry  in  the  southern 
Appalachians:  on  the  value  of  potatoes  as  food:  on  heat 
waves,  and  on  some  poisonous  plants  of  northern  cattle 
ranges.  The  several  articles  on  birds  are  especially  inter- 
esting and  important.  These  are  thoroughly  scientific  pa- 
pers intended  to  show  the  useful  work  done  by  birds  in  our 
orchards,  forests  and  fields  in  protecting  trees  and  plants 
and  thus  directly  protecting  the  farmer's  and  everybody's 
interests.  These  articles  should  be  distributed  broad- 
cast. If  they  were  more  thoroughly  known  there  might  be 
some  cessation  of  the  cruel  and  useless  destruction  of  bird 
life  in  this  country.     [J.  H.  L.] 

Municipal  Sanitation  in  the  United  States.  By  Charles 
V.  Chapin.  Superintendent  of  Health  of  the  City  of 
Providence.  The  Providence  Press,  Snow  and  Farn- 
ham.  Providence.  R.  I.  1901. 
This  volume  is  the  result  of  Dr.  Chapin's  long  labors  ia 
the  field  of  Sanitary  Science.  It  is  work  which  gradually 
grew  from  the  material  accumulating  in  his  hands,  and 
the  information  which  it  contains  is  of  a  decidedly  practi- 
cal character  and  will  prove  of  great  assistance  to  those 
interested  in  the  subject  of  hygiene  and  sanitation,  and  es- 
pecially to  those  whose  duties  pertain  to  Public  Health. 
The  volume  is  a  comprehensive  one.  and  while  it  does  not 
pretend  to  cover  the  entire  field  of  sanitary  science,  the 
information  conveyed  comprises  a  single  volume  of  con- 
siderable size,  some  950  pages.  To  give  the  reader  an 
idea  of  the  scope  of  Dr.  Chapin's  work,  we  might  mention 
some  of  the  general  headings:  such  as.  Sanitary  Organiza- 
tion. Registration  of  Vital  Statistics.  Nuisances.  Commu- 
nicable Diseases.  Dairy  Products  and  Refuse  Disposal.  In 
the  chapter  upon  Sanitary  Organization  will  be  found  a 
valuable  history  of  the  development  of  such  legislative 
regulation  in  the  United  States.  In  the  second  chapter  on 
the  Registration  of  Vital  Statistics  and  the  Disposal  of  the 
Dead,  the  author  emphasizes  the  value  of  properly  compiled 
statistics  and  furnishes  the  regulations  demanded  by  the 
various  States  for  the  returns  of  births  and  deaths,  to- 
gether with  the  legal  penalties  involved  in  falsifying  these 
returns.  The  chapter  on  the  Disposal  of  the  Dead  deals 
especially  with  the  regulations  governing  burial  in  the 
various  States.  The  author  discusses  Nuisances  and  Speci- 
fic Nuisances  in  two  comprehensive  chapters,  and  again 
furnishes  his  readers  with  the  different  State  methods  of 
the  abatement  of  nuisances  and  the  legislation  governing 
the  subject  in  general.  The  chapter  upon  Water,  Ice  and 
Sewage,  dealing  especially  with  the  disposal  of  sewage  and 
the  pollution  of  streams,  might  be  taken  to  heart  by  the 
citizens  of  many  of  our  municipalities  who  will  be  put  to 


1226 


The    Phh-adelphia-| 
Mejical  Journal,  J 


AMERICAN  NEWS  AND  NOTES 


[Jlsz  a.  L«>1 


shame  upon  learning  from  these  pages  what  advances 
sanitary  science  has  made  and  all  of  which  many  have 
yet  to  put  in  practice. 

The  Adulteration  of  Foods,  both  Dairy  Products  and 
Food  other  than  Dairy  Products,  comprises  two  interesting 
chapters  which  supplies  valuable  information  not  only 
as  to  the  legislation  governing  food  adulteration,  but  they 
are  teeming  with  suggestions  as  to  the  proper  methods  of 
inspecting  food-stufts  and  especially  measures  for  con- 
trolling the  Dairy  supply.  We  are  not  disappointed  In  the 
able  and  comprehensive  manner  in  which  the  subject  of 
Communicable  Diseases  are  treated.  The  legislation,  ad- 
ministrative work  and  the  subject  of  Hospital  Quarantine 
have  received  full  consideration.  The  wide  reading  of  this 
book  would  prove  a  valuable  argument  in  the  interests  of 
preventive  medicine.  Many  illustrations  are  given  of  ex- 
cellent hospitals  which  have  been  built  in  various  parts  of 
the  country  for  very  small  sums.  The  results  achieved  in 
controlling  epidemics  by  followiwng  out  the  definite  and 
well-known  principles  which  this  book  expounds  show  the 
necessity  for  thoroughly  grounding  all  those  who  have  to  do 
with  the  public  health  with  just  this  information.  Jhe 
quarantine  officer  who  reads  this  volume  thoughtfully  will 
be  acquainted,  not  only  with  the  regulations  adopted  in  his 
own  and  other  States,  but  with  a  thoroughly  practical 
knowledge  which  will  give  him  a  vantage-point  in  dealing 
with  the  intricacies  of  the  subject.  The  question  of  the 
disposal  of  refuse  is  taken  up  at  length,  and  the  various 
methods  adopted  by  different  municipalities  are  detailed. 
Grouped  under  Miscellaneous  Work,  we  find  the  Communi- 
cable Diseases  of  Animals,  the  problem  of  School  Hygiene, 
and  Medical  Inspection  of  Schools,  as  well  as  the  Inspec- 
tion of  Buildings,  including  the  laws  governing  the  erec- 
tion of  sanitary  buildings.  In  the  appendix  a  large  num- 
ber of  forms  of  permits  and  various  blank  forms  pertaining 
to  the  various  divisions  of  the  broad  subject  are  given. 
We  cannot  conclude  our  review  of  this  book  without  ex- 
pressing our  conviction  that  the  work  is  one  of  great  prac- 
tical value,  and  that  the  immense  amount  of  labor  which 
the  author  has  expended  upon  it  has  resulted  in  the  pro- 
duction of  an  indispensable  treatise  which  covers  with 
judgment  and  commendable  fullness  the  various  depart 
ments  of  sanitary  science.     [T.  L.  C] 


(Iorre0pon^cncc. 

SUBSCRIPTION   FOR   MONUMENT  TO  THE  LATE  PRO- 
FESSOR   OLLIER    IN    LYONS. 
By   DR.   W.   W.   KEEN. 
To  the  Editor  of  the  Philadelphia   Medical   Journal: 

Sometime  since  you  kindly  published  an  appeal  of  a 
Committee  soliciting  subsbcriptions  for  a  monument  to 
the  late  Prof.  Oilier  in  Lyons.  As  Treasurer  of  the  Com- 
lee,  I  beg  that  you  will  publish  this  letter  in  your  journal 
in  order  io  inform  the  profession  that  I  have  received  the 
sum  of  $i;49  from  103  subscribers.  I  have  forwarded  the 
same,  less  $4. fin  for  postage,  printing,  etc.,  to  Dr.  G.  Mon- 
dan,  27  rue  .larente,  Lyons.  France. 


Hmerican  IRcws  an^  TRotcs. 


THE   BRITISH   CONGRESS  ON  TUBERCULOSIS. 
By  WILLIAM  OSLER.  of  Baltimore. 
To  the  Editor  of  the  Philadelphia  Medical  Journal. 

Dear  i^ir: — I  should  like,  through  your  .Tournal,  to  call 
the  attention  of  members  of  the  profession  to  the  important 
Congress  on  Tuberculosis,  which  will  be  held  in  I„ondon 
from  July  23rd  to  2i;th.  It  is  much  to  be  desired  that  a 
large  coi>tingent  from  the  TTnited  States  should  participate 
in  the  work.  Many  pr.iminent  physicians  have  signified 
their  intention  of  joining  the  Congress.  Members  of  the 
profession  wishing  to  do  so  should  send  their  names,  en- 
closing five  dollars,  to  Dr.  St.  Clair  Thomson,  20  Hanover 
Square,  London,  W..  England. 


Large  Odontopathic  Cysts  of  the  Upper  Jaw. — It  Is  very 
rare  to  find  a  cyst  as  large  as  an  ornnge  at  the  root  of  a 
tooth  in  the  uvijer  jaw.  Or.  .1.  Chaminade  states  in  thy 
{Annnlfs  (If  hi  Pfihclinhpii-  dr  UnriJciin.r.  lOOL  No.  5).  He  re- 
ports two  such  cases  in  adtiUs.  originating  from  the  roots 
of  the  smaller  molar  teeth  of  the  upper  jaw.  In  both  cases 
these  roots  were  removed,  the  cyst  incised,  curetted,  and 
cauterized  with  tincture  of  iodin.  There  has  been  no  re- 
currence in 'either  case.  The  diagnosis  from  abscess  is  not 
diffloilt.  The  natient  will  rarelv  permit  total  extirpation 
of  the  cyst.     [M.  O.] 


Dr.  Henry  C.  Haden,  Clinical  Assistant  in  the  out-patient 
department  for  diseases  of  the  eye,  at  Jefferson  Medical  Col- 
lege Hospital,  Philadelphia,  at  the  recent  tenth  semi-an- 
nual meeting  of  the  South  Texas  Medical  Association  read 
a  paper  before  the  section  on  Ophthalmology,  entitled, 
Exophoria:   Its  Significance  and  Treatment. 

Site  for  the  Almshouse  and  Philadelphia  Hospital. — It 
it  stated  that  after  viewing  the  places  along  the  Delaware 
river  front  and  hearing  the  views  of  leading  physicians 
who  accompanied  the  members  on  the  trip  of  inspection, 
the  Department  of  Charities  and  Correction  agreed  to 
recommend  to  the  Mayor  and  City  Councils  that  Petty's 
Island  be  purchased  as  a  site  for  an  almshouse  and  a  hos- 
pital for  the  insane.  It  was  suggested  that  a  maternity 
hospital,  a  home  for  foundlings  and  a  hospital  for  con- 
tagious diseases,  also  could  be  erected  on  the  property. 
The  opinion  was  expressed  that  possession  could  be  ac- 
quired for  $500,000  or  less,  and  that  the  total  cost  of  con- 
struction would  be  about  $3,000,000. 

St.  Joseph's  Hospital  Residents. — The  following  are  the 
successful  applicants  for  interneships  at  St.  Joseph's  Hos- 
pital: Drs.  Foulkrod.  Rigel,  Homer  Rhode,  Mervin  R. 
Taylor  and  Lamott. 

Unclaimed  Bodies. — The  distribution  of  unclaimed  corpses 
to  the  various  medical  colleges  for  dissecting  purposes  has 
produced  friction  between  the  State  Anatomical  Board  and 
the  pathological  section  of  the  Medical  Board  of  the  Phila- 
delphia Hospital,  which  claims  that  mutilated  bodies  have 
been  given  to  the  colleges. 

The  Medical  Class  of  1881  of  the  University  of  Pennsylvania. 
— The  Medical  CMass  of  1881  of  the  University  of  Pennsyl- 
vania celebrated  its  twentieth  anniversary  with  a  dinner  at 
the  Hotel  Bellevue  on  Wednesday  evening.  June  12.  1901. 
At  the  conclusion  of  the  banquet  a  permanent  organization 
was  established  with  the  following  officers:  President, 
Dr.  G.  E.  de  Schweinitz:  vice-president.  Dr.  W.  Easterly 
Ashton,  secretary  and  treasurer.  Dr.  Daniel  W.  Nead. 

Vital  Statistics  of  Philadelphia  for  the  week  ending  June 
22,  1901: 


Total   mortality 


Inflammation  of  the  appendix  3, 
bladder  1.  brain  17,  bronchi  7, 
heart  2,  kidneys  19,  liver  1,  lungs 
22.  pericardium  1,  peritoneum  11, 
pleura  2,  stomach  and  bowels  10 

Marasmus  IG,  inanition  17,  debil- 
ity .1    

Tuberculosis  of  the  lungs   

Apoplexy  15.  paralysis  6   

Heart-disease  of  2''.  fatty  degener- 
ation of  1,  neuralgia  of  3 

Uremia  10,  Brighfs  Disease  8,  dia- 
betes 1    

Carcinoma  of  the  face  X,  breast 
2.  stomach  2,  uterus  2,  kidney  1, 
liver  2.  rectum  1 

Convulsions  17,  convulsions,  puer- 
peral 1    :. . 

Diphtheria    

Brain-disease  of  1,  hemorrhage  from 
1,  softening  of  2 

Typhoid  fever  

Old  age   

Scarlet  fever   

Abscess  of  back  1.  larynx  1.  lungs 

1,  asthma  2,  anemia  2,  burns  and 
scalds  3.  casualties  S.  congestion 
of  the  lungs  1.  child  birth  2,  chol- 
era infantum  11,  cirrhosis  of  the 
liver  5,  consumption  of  the  bow- 
els 1.  croup,  membranous  1.  di- 
arrhea 2.  hip  disease  1.  drowned  3. 
dropsy  1.  dysentery  1.  erysipelas 

2,  fever,  gastric  1.  malarial  1. 
puerperal  2,  hemorrhage  from 
uterus   1,  leukemia   1,   measles  1. 


410 
Cases. 


61 


Deaths. 


96 

38 
54 
21 

32 

19 

11 

IS 
11 


June  2D,   1901] 


AMERICAN  NEWS  AND  NOTES 


TThe   Philadelphia 
L Medical  Journal 


1227 


Cases. 


Deaths. 


S4 


obstruction  of  the  bowels  1,  ede- 
ma of  the  lungs  1,  pyemia  1, 
sclerosis,  arterial  3,  shock,  surgi- 
cal 2.  septicemia  4,  suffocation  1, 
suicide  4,  syphilis  1,  teething  2, 
tumor,  Ijladder  1,  unknown  coron- 
er case  2,  whooping  cough  5 

NEW  YORK. 

Money  for  Long  Island  College  Hospital. — George  Foster 
Peabody  and  his  brothers  have  agreed  to  contribute  $50,000 
for  the  building  and  furnishing  of  an  operating-room,  as  a 
memorial  to  the  late  Dr.  A.  J.  C.  Skene,  for  the  Long  Island 
College  Hospital,  which  is  to  be  practically  rebuilt. 

Manhattan  Dermatological  Society. — A  regular  monthly 
meeting  was  held  on  Friday  evening,  .June  7th.  1901,  at  the 
residence  of  Dr.  B.  F.  Ochs,  No.  120  W.  120th  street,  with 
Dr.  Wm.  S.  Gottheil  in  the  chair.  Dr.  R.  Abrahams  pre- 
sented a  child  of  seven  months  with  a  nevus  of  the  left 
side  of  the  nose  near  the  inner  canthus.  Electrolysis  was 
advised  for  treatment.  Dr.  Geyser  recommended  the  use 
of  the  positive  galvanic  current  with  a  gold  or  platium  nee- 
dle: the  needle  Is  to  be  inserted  to  the  depth  of  3  or  4 
lines  and  the  strength  of  the  current  to  be  1%  to  2  milli- 
ampheres.  Dr.  Bleiman  advises  radical  surgical  measures. 
Dr.  E.  L.  Cocks  prefers  the  negative  galvanic  needle.  Dr. 
J.  Sobel  remarked  that  electrolysis  would  benefit  the  su- 
perficial vessels,  but  that  there  was  a  bogginess  below 
which  would  be  rather  difficult  to  affect.  Dr.  Gottheil  con- 
sidered the  case  a  very  troublesome  one  on  account  of  the 
deep  seated  venous  dilatation.  Dr.  J.  Sobel  presented  two 
cases  of  congenital  Ichthyosis  in  a  boy  of  11  years  and  a 
girl  of  3.  Both  were  born  with  a  soft,  pliable  skin  and  de- 
veloped the  ichthyosis  three  months  after.  Dr.  B.  F.  Ochs 
presented  a  patient,  a  young  woman  of  25,  in  whom  psoria- 
sis guttata  recurred  every  summer  for  ten  years  and  dis- 
appeared spontaneously  in  the  fall  of  the  year.  Dr.  Gott- 
heil reported  a  case  of  psoriasis  in  which  the  attacks  im- 
proved and  disappeared  with  rest  in  bed  and  a  fluid  diet. 
Drs.  Oberndorfer,  Cocks  and  Abrahams  concurred  in  the 
diagnosis.    Dr.  A.  Bleiman  considered  the  case  atypical. 

Dr.  J.  Sobel  presented  a  patient  with  a  seborrheal  ecze- 
ma of  the  chest,  back  and  abdomen,  of  three  weeks  dura- 
tion. The  eruption  was  red,  scaly,  with  circinate  patches 
at  various  parts.  Dr.  A.  Bleiman  remarked  that  while  it 
was  not  a  classical  picture  he  would  agree.  Dr.  R.  Abra 
hams  considered  it  herpes  tonsurans  maculosus  et  squamo- 
sus..  He  said  that  seborrheal  ezcema  does  not  occur  in 
rings.  Dr.  Gottheil  would  diagnose  generalized  ringworm 
and  erythema  multiforme.  Dr.  E.  S.  Cocks  agreed  with 
the  diagnosis.  Dr.  B.  F.  Ochs  inclined  toward  a  diagnosis 
of  herpes  tonsurans,  but  admitted  that  there  was  seborrhea 
with  it.  Dr.  Oberndorfer  remarked  that  the  ring  form  does 
not  speak  against  seborrheal  eczema.  He  has  seen  many 
cases  of  annular  seborrheal  eczema,  many  cases  with  per- 
fect rings.  Dr.  Gottheil  presented  a  classical  case  of  acne 
neci'otica  in  a  man  of  45.  Since  childhood  he  has  had 
lesions  along  the  hair  margins,  temporal  region  and  naso- 
labial fold.  Patfent  has  been  treated  by  exposure  to  the 
arc  light.  All  were  agreed  as  to  the  diagnosis.  Drs.  Obern- 
dorfer and  Sobel  spoke  of  the  value  of  white  precipitate 
ointment  and  of  the  danger  of  recurrences.  Dr.  R.  Abra- 
hams recommended  iodide  of  potassium  internally.  Dr. 
Kruch  through  sulphide  of  calcium  might  benefit  these 
cases.  Dr.  R.  Abrahams  presented  a  case  of  lichen  planus 
in  the  declining  stages.  The  lesions  were  situated  on  the 
dorsal  surfaces  of  the  hands  and  the  extensor  surfaces  of 
wrist.  Drs.  Bleiman,  Ochs  and  Oberndorfer  remarked  that 
at  present  diagnosis  is  difiicult.  Dr.  J.  Sobel  said  that  at 
present  the  lesions  were  not  indicative  of  any  special  con- 
dition. The  extensor  surface  would  seem  to  speak  against 
lichen  planus.  Dr.  Kinch  would  call  it  eczema.  Dr.  Gott- 
heil states  that  in  the  retrogressive  stage  an  eczema  papu- 
le resembles  that  of  lichen.  Dr.  Gottheil  presented  a  case 
for  diagnosis.  The  left  hand  presented  a  complete  circle 
of  papules  progressing  from  the  center.  On  the  other  hand 
there  was  staining  and  some  old  scar  tissue.  On  the  face 
there  was  a  small  papular  elevation  with  sebaceous  crusts. 
Dr.  Kinch  said  it  looks  liiie  a  syphilide.  Dr.  R.  Abrahams 
considers  the  face  lupus  erythematosus  and  the  forearm 
herpes  tonsurans.  Dr.  Oberndorfer  would  call  it  syphilis. 
Dr.  A.  Bleiman  said  that  it  looks  like  a  tubercular  process. 
Dr.  Ochs  considers  it  syphilis  and  Dr.  Cocks  lupus  or 
syphilis.    Dr.  Sobel  prefers  to  watch  the  case.    Syphilis  is 


to  he  considered,  but  he  inclines  toward  erythema  multi- 
forme. Dr.Gottheil  said  that  the  history  and  staining  speak 
for  erythema  multiforme.  Dr.  B.  F.  Ochs  presented  a  case 
of  resolving  syphilis  of  the  papular,  ulcerative  type. 

Medical  Society  of  the  State  of  New  York. — Dr.  Henry 
L.  Eisner,  I'resident  of  the  Medical  Society  of  the  State  of 
New  York,  announces  the  appointment  of  his  Business 
Committee  for  the  ensuing  year,  consisting  of  Dr.  Nathan 
Jacobson,  Chairman,  430  S.  Salina  street,  Syracuse;  Dr. 
George  Ryerson  Fowler,  301  DeKalb  avenue,  Brooklyn;  and 
Dr.  William  C.  Krauss,  371  Delaware  avenue,  Buffalo.  All 
letters  and  inquiries  pertaining  to  papers  and  scientific 
communications  for  the  semi-annual  meeting  to  be  held 
in  New  York  City,  October  15th  and  16th,  1901,  and  the 
annual  meeting,  to  he  held  in  Albany,  January,  1902,  should 
be  addressed  to  the  chairman. 

American  Orthopedic  Association. — .'\t  the  meeting  of 
the  .Vmerican  Orthopedic  Association  held  at  Niagara 
Fails,  May  11,  12  and  13,  1901,  the  following  officers  were 
elected:  President.  H.  Augustus  Wilson,  M.  D.,  Philadel- 
phia, first  vice-president.  William  J.  Taylor,  M.  D.,  Phila- 
delphia; second  vice-president,  G.  G.  Davis,  M.  D..  Phila- 
delphia; secretary.  John  Ridlon,  M.  D.,  Chicago;  treasurer, 
E.  G.  Brackett,  M.  D.,  Boston.  Philadelphia  will  be  the 
place  of  the  next  meeting,  to  be  held  in  May,  1902. 

Influenza  Spreading  Among  Horses. — Reports  from  vet- 
erinarians in  New  York  are  to  the  effect  that  influenza  is 
spreading  alarmingly  among  the  horses  in  that  city.  At 
the  New  York  Veterinary  Hospital  it  was  estimated  that 
12.000  or  15.000  had  influenza,  5,000  of  these  being  actually 
under  treatment  by  doctors  or  their  owners,  while  the  re- 
mainder were  not  seriously  enough  affected  to  be  dis- 
abled. 

NEW    ENGLAND. 

Ten  Thousand  Dollars  for  New  England  Institutions. — 
The  will  of  Bssek  A.  .lillson,  of  Providence,  divides  $10,000 
among  the  Rhode  Island  Hospital,  the  Rhode  Island  His- 
torical Society  and  the  Home  for  Aged  Women  in  Provi- 
dence. 

Maine  Medical  Association. — At  the  meeting  of  the 
Maine  Medical  Association  held  June  13,  1901,  the  fol- 
lowing officers  were  elected:  President,  Dr.  Frederick 
H.  Gerrish,  Portland:  vice  presidents.  Dr.  C.  E.  Philoon, 
of  Auburn  and  Dr.  J.  M.  Willis,  of  Guilford. 

WESTERN  STATES. 
.  .The  Smallpox  Status  in  Cleveland,  Ohio. — It  appears 
that  Mayor  Johnson,  of  Cleveland,  Ohio,  although  he  stat- 
ed to  the  State  Board  of  Health  that  he  had  personal  objections 
to  vaccination,  nevertheless,  is  credited  with  the  following 
statement  to  the  Board  of  Health.  "I  have  no  thought 
of  setting  up.  my  opinion  against  yours,  and  I  desire  that 
you  decide  just  what  measures  shall  be  taken,  and  I  assure 
you  that  all  the  money  needed  for  carrying  them  out  shall 
be  forthcoming."  It  is  now  claimed  that  as  Mr.  Johnson 
has  been  Mayor  of  Cleveland  for  two  and  one-halt  months, 
while  smallpox  has  been  prevalent  for  three  years,  its  pre- 
valence is  largely  due  to  the  lack  of  business  ability  and 
methods  of  the  municipal  authorities,  and  not  to  any 
attempt  of  the  Mayor  to  put  his  personal  opinions  into 
practical  effect. 

West  Chicago  Medical  Society. — The  West  Chicago  Med- 
ical Society  was  organized  a  few  days  ago  by  a  large  num- 
ber of  west  side  physicians  and  the  following  officers  were 
elected.  Dr.  E.  D.  St.  Cyr,  president;  Dr.  O.  G.  Wernicke, 
vice-president;  Dr.  G.  M.  Silverberg,  treasurer;  Dr.  Gus- 
tavus  Blech,  secretary.  Executive  Council:  Dr.  A.  M. 
Shabad,  Dr.  F.  W.  Henkel,  Dr.  J.  M.  Abelio  and  Dr.S.Brown- 
stein.  The  society  will  apply  for  affiliation  with  the  Amer- 
ican Medical  Association. 

College  of  Physicians  and  Srugeons  Struck  by  Light- 
ning.— During  a  heavy  thunder  storm  on  June  25,  a  bolt 
of  lightning  struck  the  College  of  Physicians  and  Sur- 
geons, destroying  the  college  building,  which  was  one  of 
the  finest  of  its  kind  in  the  West.  The  rain  was  pouring 
heavily  at  the  time.  but.  fortunately,  there  are  so  many 
hospitals  and  medical  institutions  in  the  neighborhood 
that  it  was  necessary  to  remove  the  people  only  a  short 
distance,  most  of  them  being  taken  to  the  County  Hospital, 
one  square  distant.  The  College  of  Physicians  and  Sur- 
geons is  the  Medical  Department  of  the  University  of  II- 


,  ^^Q       The    Philadelphia"! 
IZZO        Medical  Journal  J 


AMERICAN  NEWS  AND  NOTES 


[June  29,   1901 


linois,  situated  at  Champaign,  III.  The  loss  on  building  and 
equipment  is  practically  total,  and  will  approximate  $200,- 
000. 

Doctor  George  E.  Ranney,  of  Lansing,  Michigan,  has  been 
awarded  a  medal  of  honor  by  President  McKinley  for  dis- 
tinguished gallantry  in  the  civil  war.  "On  this  occasion," 
according  to  the  war  department  record  of  the  action  at 
Resaca,  Georgia,  May  14.  18G4,  "Assistant  Surgeon  Ran- 
ney, at  great  personal  risk,  went  to  the  aid  of  a  wounded 
soldier  lying  under  heavy  fire  between  the  Union  and  Con- 
federate lines,  and  with  the  aid  of  an  orderly,  carried  him 
to  a  place  of  safety."  On  another  battlefield  the  doctor  was 
promoted  to  a  brigade  surgeoncy  for  bravery. 

Dr.  Joseph  Eisen,  of  California,  Attacked  by  Cancer. — 
Dr.  Joseph  Bisen.  who  has  been  doing  considerable  ex- 
perimental work  in  endeavoring  to  discover  the  alleged 
microorganism  of  cancer,  has  been  attacked  by  that  dis- 
ease himself.  Dr.  Eisen  is  of  the  opinion  that  he  con- 
tracted the  disease  while  performing  his  experiments.  He 
has  been  operated  upon  and  is  recovering. 

A  Surgeon  May  Perform  an  Additional  Operation  Without 
Consent  of  the  Patient.^-According  to  a  recent  decision  by 
Judge  Kavanagh,  of  Chicago,  a  surgeon  may  perform  an  addi- 
tional operation  without  the  consent  of  the  patient  if  he 
discovers  a  condition  which  renders  such  action  neces- 
sary to  preserve  life  after  a  first  operation.  The  decision 
was  rendered  in  the  case  of  Mrs.  Agnes  Muehern  against 
the  Post  Graduate  Medical  School  and  Hospital.  Mrs. 
Muehern  was  operated  upon  by  one  of  the  professor  of  the 
college,  and  while  she  was  under  the  influence  of  an  anes- 
thetic a  condition  as  indicated  was  discovered  and  a  sec- 
ond operation  was  performed.  When  the  woman  regained 
her  health  she  brought  suit  against  the  college. 

Meeting  of  the  Chicago  Pathological  Society,  June  10th, 
1901.  Dr.  L.Hectoen. President. — Dr.Alice  Hamilton  presenteil 
a  paper  dealing  with  cell  division  in  the  central  nervous  sys- 
tem of  the  white  rat  before  and  after  birth;  the  number  and 
distribution  of  the  mitoses,  the  period  up  to  which  they  per- 
sist, and  their  character.  Mitoses  were  found  along  the 
ventricular  surfaces  in  the  early  stages  of  development, 
gradually  ceasing  here,  and  increasing  in  the  outer  layers, 
until  at  birth,  almost  all  are  in  the  outer  layers.  At  birth 
mitoses  are  numerous  and  persist  up  to  the  end  of  the 
fourth  day;  beyond  this  period  no  examination  was  made. 
The  dividing  cells  are  of  two  kinds;  1st  small,  devoid  of 
visible  cell  body,  resembling  cells  of  the  neurolgia;  2nd. 
large,  with  abundant  cytoplasm,  round,  pear-shaped  or 
spindle-shaped.  These  are  in  the  gray  matter  of  the  cord 
and  brain  and  correspond  in  measurements  with  the  multi- 
polar and  pyramidal  cells. 

Conclusion:  In  the  later  stages  of  development  the  off- 
spring of  the  germinal  cells  become  partially  differentiated 
but  without  losing  their  powers  to  divide.  The  large  divid- 
ing cells  are,  then,  immature  nerve  cells;  the  small  are 
cells  of  the  neuroglia.  In  the  case  of  the  white  rat,  these 
cells  retain  their  power  of  division  until  after  the  fourth 
day  of  extra-uterine  life. 

Wm.  B.  Wherry:  A  case  of  so-called  malignant  (staphy- 
lococcus) carbuncle  of  the  upper  lip  followed  by  pyemia. 
A  barber,  twenty-three  years  old.  entered  Prof.  Bevan's 
service  in  the  Presbyterian  Hospital  on  the  7th  of  Febru- 
ary. 1901,  and  died  on  the  8th  at  11.15  P.  M. 

About  a  week  before  his  admission  he  extracted  a  "dead 
hair"  from  his  upper  lip.  This  was  followed  by  redness  of 
the  lip  and  swelling,  which  rapidly  extended  to  the  side 
of  the  face  and  shoulder.  He  rapidly  grew  worse  and  died 
■with  all  the  characteristic  symptoms  of  septicopyemia. 

The  post  mortem  examination  was  held  twelve  hours 
after  death  by  Prof.  Hektoen.  The  anatomical  diagnosis  is 
as  follows;  Acute,  diffuse. purulent  and  necrotic  staphylococ- 
cus inflammation  of  the  upper  lip  and  adjacent  p.arts  of 
face:  multiple  abscesses  and  hemorrhagic  pneumonic  areas 
in  lungs;  double  flbrino-purulent  pleuritis;  abscess  in 
spleen;  acute  splenic  swelling;  cloudy  swelling  of  kidneys 
and  liver;  persistent  thymus. 

Bacteriologically,  a  pure  growth  of  the  staphylococcus 
pyogenes  aureus  was  isolated  from  the  lip,  heart's  blood, 
pleural  exudate,  liver  and  spleen. 

Histologically,  the  lip  shows  dense  cellular  infiltrations 
with  foci  of  necrosis  containing  groups  of  cocci  which  stain 
by  Gram's  method.  The  lung  contains  many  pneumonic  and 
hemorrhagic  areas  and  mycotic  emboli.  The  other  organs 
show  the  characteristic  changes  of  a  severe  infectious  pro- 
cess. 


The  dangers  of  this  affection  depend  chiefly  upon  its  lo- 
cation and  the  virulence  of  the  infective  agent;  the  prog- 
nosis is  extremely  grave  on  account  of  the  liability  to 
thrombosis  and  embolism. 

The  treatment  of  the  early  stage  which  has  so  tar  givea 
the  best  results  is  excision  of  the  necrotic  area  and  pack- 
ing with  iodoform  gauze.  After  thrombosis  and  embolism 
have  occurred,  treatment  at  the  present  time  seems  to  be 
boneless. 

Wm.  B.  Wherry:  The  distrlbullon  of  segmentation  and 
fragmentation  in  the  myocardium.  Twenty  hearts  were 
carefully  preserved  and  eighteen  pieces  were  taken  from 
each  heart.  In  searching  for  changes,  the  divisions  into 
simple  segmentation,  and  degenerative  fragmentation  ajid 
segmentation,  made  by  J.  B.  MacCallum,  were  kept  in 
mind.  Degenerative  fragmentation  and  segmentation  oc- 
curred twice  ir  the  left  auricle.  Segmentation  was  distri- 
buted in  the  following  order  of  frequency:  Left  papillary 
muscles,  wall  of  left  ventricle,  right  papillary  muscles,  pos- 
terior surface  of  apex,  etc. 

The  changes  in  the  walls  practically  correspond  to  the 
changes  in  the  papillary  muscles. 

"Diffuse"  segmentation  of  both  left  papillary  muscles  ac- 
companied by  diastasis  and  displacement  of  the  segments 
seems  to  indicate  more  or  less  general  segmentation  and 
fragnientstion  throughout  the  ventricles. 

Dr.  E.  Friend:  Cyst-adenoma  of  ovary.  Patient  thirty- 
two  year.s  old;  married  five  years:  never  been  pregnant: 
menstruation  regular  and  painless;  family  history  nega- 
tive. About  eight  years  ago  severe  pain  developed  in  the 
region  of  the  left  ovary,  but  upon  examination  this  was  pro- 
nounced healthy.  About  one  year  ago  a  swelling  appeared, 
extending  from  the  symphysis  pubis  to  the  umbilicus,  but 
this  gave  no  pain  until  a  month  ago.  She  then  entered  the 
hospital  and  at  operation  there  was  removed  from  the  right 
ovary  a  small,  multilocular  cyst.  The  patient  made  an 
uninterrupted  recovery  and  was  discharged  from  the  hos- 
pital yesterday. 

Adenomas  develop  as  a  result  of  disturbance  in  the  for- 
mation of  Pflviger's  tubes  in  the  growing  ovary.  Cyst-aden- 
omas are  simplv  adenomas  which  have  undergone  cystic 
degeneration:  they  consist  of  long,  round,  tortuous  cavities 
separated  from  each  other  by  connective  tissue.  These 
cavities  may  become  obliterated  entirely  or  partly  by  papit- 
liform  growths 

The  present  officers  were  re-elected  tor  the  coming  year. 

SOUTHERN  STATES. 

Dr  T.  H.  Hancock  Elected. — Dr.  T.  H.  Hancock,  who 
for  some  time  has  been  secretary  of  the  association  of 
Southern  Railway  Surgeons,  has  been  elected  president  of 
that  body. 

Dr.  Peering  J.  Roberts  elected. — Dr.  Roberts,  a  military 
surgeon  during  the  Civil  War  and  editor  of  the  Soiithet-t 
I'rartitiouvr.  Nashville,  was  recently  elected  president  of 
the  Tennessee  State  Medical  Association. 

A  Mineral  Survey  of  the  State  of  Texjis. — Ten  thousand 
dollars  was  recently  appropriated  for  a  mineral  survey  of 
the  State  of  Texas,  to  be  conducted  under  the  supervision 
of  the  regents  of  the  University  of  Texas. 

Richmond  News. — Dr.  E.  Hill  has  been  elected  Demon- 
strator of  Chemistry  in  the  University  College  of  Rich- 
mond, Va. 

Old  Dominion  Hospital. — Ground  has  been  broken  for 
the  magnificent  new  Old  Dominion  Hospital,  at  Richmond. 
Va.     It  will  be  ready  for  occupation  in  about  18  months. 

MISCELLANY. 

Army  Medical  School. — The  following  officers  of  the  army 
have  been  detailed  a*  members  of  the  faculty  of  the  .^rmy 
Medical  School,  in  addition  to  the  present  members;  Col. 
William  H.  Forwood,  assistant  surgeon-general,  vice-Col. 
Charles  H.  Alden.  retired;  Col.  Calvin  DeWitt.  assistant 
surgeon-general,  as  professor  of  military  medicine:  Major 
John  Van  R.  Hoff,  surgeon,  as  lecturer  on  the  duties  of 
medical  officers  in  war  and  peace:  Major  William  C.  Bor- 
den, surgeon,  as  professor  of  military  surgery,  vice  Col. 
Forwood.  designated  as  President  of  the  faculty;  and 
Major  Frederick  P.  Reynolds,  surgeon,  as  instructor  in 
hospital-corps  drill  and  first  aid  to  the  wounded,  vice  Capt. 
G.   D.   DeShcn.  who  has  been  relieved. 


June   29.    ]90n 


AMERICAN  NEWS  AND  NOTES 


TThe    Philadelphia 
L  Medical  Journal 


Dallas  Medical  College. — Dallas  Medical  College,  the 
Medical  Department  Trinity  University,  held  its  first  exer- 
cises on  June  ISth,  graduating  eight  in  medicine  and  two 
in  pharmacy.  Acting-President  Riley,  of  Trinity  Univer- 
sity, conferred  the  degrees. 

OBITUARY. 

Dr.  W.  C.  Smith,  at  Linglestown.  Pa.,  on  June  16. 
aged  T.i  years. — Dr.  M.  Barton,  at  Alexiandria.  Va..  on 
June  19. — Dr.  R.  L.  Boggs,  at  Fairfield,  111.,  on  June  19,  aged 
91  years. — Dr.  Erastus  J.  Buck,  at  Platteville,  Wis.,  on 
June  20,  aged  73  years. — Dr.  Franklin  H.  Kerfoot.  at  Atlan- 
ta, Ga.,  on  June  22. — Dr.  Victor  Popper,  at  San  Francisco, 
Cal.,  on  June  22. — Dr.  John  H.  Groft.  at  Pennsgrove,  N.  J., 
on  June  19. — Dr.  Richard  Lingle,  at  Orloans.  Ind..  on  June 
10,  aged  63  years. — Dr.  Edward  Watson,  at  Grand  Rapids. 
Mich.,  on  June  17. — Dr.  J.  Henry  McCarthy,  at  Birmingham, 
Ala.,  on  June  12,  aged  50  years. — Dr.  William  L.  Worcester, 
at  Danvers.  Mass.,  on  June  10,  aged  56  years. — Dr.  A.  J. 
Baker,  at  Grafton,  W.  Va.,  on  June  24,  aged  40  years.— Dr. 
William  Geiger,  at  Forest  Grove,  Ore.,  on  June  16,  aged 
S3  years. 

Dr.  W.  Irving,  at  St.  Mary's,  Toronto,  Canada,  on  June 
,19. — Dr.  J.  G.  Jessup,  at  Berkeley,  Cal.,  on  June  19. 

The  Campaign  Against  Mosquitos. — It  is  stated  that  the 
sanitary  department  of  Havana,  in  its  campaign  against 
mosquitos,  proposes  to  plant  eucalyptus  trees  in  all  the 
marshy  and  malarial  districts  in  and  around  Havana,  and 
a  sum  of  £200  has  been  appropriated  for  that  purpose  and 
for  the  purchase  of  seeds.  We  are  pleased  to  see  a  sani- 
tary department  that  is  really  alive  to  the  necessity  for 
active  measures  against  mosquitos,  but  we  cannot  help 
feeling  somewhat  doubtful  of  the  wisdom  of  the  particular 
measure  which  is  to  be  adopted  in  Havana.  In  a  paper  by 
Professor  Celli.  which  appeared  in  the  Journal  of  the  Sani- 
tiirii  Institute  for  January,  that  distinguished  authority  say.'; 
that  the  eucalyptus,  so  far  from  being  a  protection  against, 
is.  like  other  trees,  rather  a  shelter  for  mosquitos,  and  in 
the  neighborhood  of  dwelling-houses  adds  to  the  danger 
of  malaria  infection.  A  different  plan  of  campaign  has 
been  adopted  in  a  New  Jersey  village  called  South  Orange. 
The  village  Improvement  Society  proposes  to  attempt  to 
get  rid  of  the  plague  of  mosquitos  during  the  coming  seo- 
son,  and  has  appointed  a  committee  to  instruct  the  inhabi- 
tants. The  abandonment  of  rain  barrels,  the  screening  of 
water  tanks  in  houses,  and  the  placing  of  a  thin  layer  of 
crude  oil  in  cesspools  and  in  pools  of  stagnant  water  which 
it  is  not  possible  to  drain,  will  be  advocated:  and  in  order 
to  enlighten  the  minds  of  the  native  population  as  to  the 
importance  of  people  safe-guarding  themselves  against 
mosquitos.  Professor  L.  O.  Howard,  of  the  Department  of 
Agriculture.  Washington,  who  has  made  a  special  study  of 
that  branch  of  entomology,  has  been  asked  to  deliver  a 
tree  lecture  on  the  subject. — British  Medical  Journal. 

Sanitarium  for  Consumptives  at  Teneriffe. — A  sanator- 
ium for  the  open-air  treatment  of  tuberculosis  has  recently 
been  opened  at  Teneriffe.  It  is  situated  at  an  elevation  of 
1,200  feet  above  the  sea  level,  and  is  surrounded  by  beauti- 
ful scenery.  This  is  the  first  institution  of  the  kind  to  be 
established  on  the  island. 

Rat  Extermination — The  Fort  Wayne  Medical  Journal 
states  that  one  of  the  large  manufacturing  firms  in  Chicago 
is  waging  war  upon  rats  by  means  of  virus  made  under  the 
direction  of  the  Pasteur  Vaccine  Company.  The  virus  is 
mixed  with  food  and  ijlaced  in  the  haunts  of  rats.  It  pro- 
duces a  fatal  disease,  which  spreads  rapidly  and  retains 
its  virulence  for  some  time.  The  virus  is  harmless  to  other 
species  of  animal  life  and  has  been  tested  officially  in 
France  and  in  this  country,  and  in  the  United  States  Ma- 
rine Hospital  in  San  Francisco,  where  the  results  of  the 
test  were  endorsed  by  the  Chief  of  the  Marine  Hospital 
service  at  Washington.  As  rats  are  great  carriers  of  con- 
tagion of  all  kinds. and  are  unusually  destructive  and  anno.v- 
ing  to  the  residents  of  our  large  cities,  it  is  to  be  hoped  that 
this  new  virus  for  the  extermination  of  rats  may  come  Into 
use  in  all  rat-infected  districts. 

Changes  in  the  Medical  Corps  of  the  Navy,  for  Week 
ending  June  22d,  1901. 

ASSISTANT  StIRGEOX  H.  M.  TOLFRIOE,  appointed  .assist- 
ant  surgeon   from   June   14.    1901.— June   IT. 

SURGEON  0.  F.  S'1'OKE.S.  ordered  to  the  Solace,  upon  arrival 
in    the    United    States.— June   18. 

ASSISTANT  SURGEON  R.  B.  WILLIAMS,  ordered  to  the 
Kearsarge,    June   24. — June   IS. 


ASSISTANT  SURGEON  F.  M.  FURLONG,  detached  from  duty 

at  Guam  and  ordered  to  the  Solace  for  transportation  home. 

-June   20. 
ASSISTANT  SURGEON  R.  K.  McCLANAHAN,  detached  from 

the  Culgoa  and  ordered  to  the   Vlcksburg.— June  2u. 
ASSISTANT  SURGEON  D.  B.  KERR,  detached  from  the  Vicks- 

burg,  and  ordered  to  the  Cuigoa;  to  wait  orders  en  route.— 

June  20. 

Official  List  of  the  changes  of  the  Changes  of  Station  and 
Duties  of  Commissioned  and  Non-Commlssioned  Officers  of 
the  U.  S.  Marine  Hospital  Service  for  the  7  Days  ended 
June  20,  1901. 

C.  T.  PECKHAM,  surgeon,  granted  extension  of  leave  of  ab- 
sence on  account  of  sickness,  for  thirty  days,  from  June 
20— June   19,    1901. 

R.  M.  WOODWARD,  surgeon,  granted  extension  of  leave  of 
absence   for  3  weeks  from   June  5— June  19,   1901. 

C.  11.  GARDNER,  passed  assistant  surgeon,  granted  leave  of 
absence  for  7  days  from  June  21— June  17,  1901. 

G.  M.  CORPUT,  assistant  surgeon,  relieved  from  duty  at  the 
port   of   St.    Louis,    Mo.— June   IS,    1901. 

Leave  of  absence  for  one  month  granted  by  Bureau  tele- 
gi-am  of  May  16  amended  so  that  said  leave  shall  be  for  21 
days    only— June    18,    1901. 

DUNl.OW  MOORE,  assistant  surgeon,  to  proceed  to  Port  Town- 
send,  Wash.,  and  assume  temporary  charge  of  service  dur- 
ing absence  of  Passed  Assistant  Surgeon  C.  H.  Gardner- 
June  17,   1901. 

B.  J.  BROWN,  JR.,  acting  assistant  .surgeon,  granted  leave  of 
absence  for  14  days  from  June  20— June  17,  1901. 

B.  W.  GOLDSBOROUGII,  acting  assistant  surgeon,  granted 
leave  of  absence   for  2  days— June  20,   1901. 

\V.  F.  SCHLAAR,  hospital  steward,  relieved  from  duty  in  the 
Hygienic  Laboratory,  and  directed  to  proceed  to  Key  West, 
Fla.,  and  report  to  the  medical  ofHcer  in  command  for  duty 
and   assignment   to   quarters— June  19,   1901. 

E.  B.  SCOTT,  hospital  steward,  granted  leave  of  absence  for 
12  days  from  June  24— June  19,  1901. 

Health  Reports:  The  following  cases  of  smallpox,  yellow 
fever,  cholera  and  plague,  have  been  reported  to  the  Sur- 
geon General,  U.  S.  Marine  Hospital  Service,  during  the 
week  ended  June  22,  1901. 


g  9 


SMALLPOX— UNITED  STATES  AND  INSULAR. 


CALIFORNIA: 
FLORIDA: 
ILLINOIS: 
INDIANA: 


IOWA: 
KANSAS: 

KEXTt;CKY: 
LOUISIANA: 
MASSACHUSETTS: 


MICHIGAN: 

MINNESOTA: 

MISSKT-RI- 
NKliUASKA: 
NEW    HAMPSHIRE 
NEW  JERSEY: 

NEW   YORK: 
OHIO: 


OREGON: 

pennsylvania: 

rhode  island: 

tf:nnessee: 

ITTAH: 
VERMONT: 
WASHINGTON: 
WEST    VIRGINIA: 
WISCONSIN: 

PHILIPPINES: 


San    Francisco.... 

Key  West 

Chicago 

F^'ansville 

Michigan  City.   : 
South  Bend.   .   . 

Clinton 

%\  lomta 

Lexington 

New    Orleans.    . 

Fall   River 

New  Bedford    . 

Worcester 

Detroit 

Sault  Ste   Marie. 
Minneapolis.    .    . 

Winona 

St.   Louis 

Omah.i 

Manchester.    .    . 
Jersey    City   .    .    . 

Newark 

Plainfleld 

New  York 

Y'onkers 

Cincinnati 

Cleveland 

Dayton 

Toledo 

Portia  mi 

Philadelphia.    .    .. 

Pittsburg 

Providence 

Memphis 

Nashville 

Salt   Lake   City    . 

Rutland 

Hoquiam   

Wheeling 

Greenb.ay 

Milwaukee 

Manila 


June  2-9.  . 
,  Junes.  .  .. 
.    June  8-15. 

June  8-15. 
.  June  10-17.. 
.  June  8-15. 
.  June  8-15. 
.  J  une  8-15.   , 

June  8-15. 
.  June  8-15.  . 
.  June  S-15. 
.  June  8-15. 
.  June  8-15. 
.June  8-15.  _ 
.  June  16.  prev 
.  June  8-16.  . 
.  June  8-15.  . 
.  June  2-9.  . 
.  June  S-15. 
.  June  S-15.  .  . 
.  June  S-16.  .  . 
.  June  S-15.  .  .. 
.  June  S-15.  .  . 
.  June  S-15.  .  .. 
.  June  7-14.  ... 
.  June  7-14.  ... 
•  June  1-15.  .  . 
-  June  S-15.  .  . 
.  June  8-15.  .  . 
.  May  1-June  5. 
.  June  S-15.  .  . 
.  June  8-16.   .   . 

■  June  8-15.    .    .. 

■  June  1-13.  .  . 
.  June  8-15.  .  . 
.  J  une  8-15.  .  . 
.  June  8-15.  .  . 
.  June  10.  .  . 
.  June  S-15.  .  . 
.  J  une  S-16.  .  . 
.  Jun.'SlS  .  . 
.  .^pr.20  May  11. 


...1 
....1 

...4 
....1 
.  ..2 
....1 
....1 

3 

....1 

..U 
....1 


.8 

.33 
'alent. 

..17 

...1 

..37 
,..12 


..2 
...3 
...1 
.102      11 


..5 

..5 
..45 
...1 
...1 

23 
...3 

..2 
...3 
..26 
...1 

..9 
...1 
...1 
...1 
..R 

.3 

18 


SMALLPOX— FOREIGN. 


AUSTRI.4: 
RETGIUM: 
cini.O.V: 
CHl.N'A: 


Prague.   . 
Antwerp.   . 
Colombo.    . 
Hongkong. 


. . .  May  25-June  1.    4 
..  May  S-June  1  ..2 

..   Ma v  4-11 

. .  Apr.26-May  U    .5 


1230 


The   Philadelphia-] 
Medical  Jour.sal  J 


AMERICAN  NEWS  AND  NOTES 


[JCNS  29,   1901 


COLOMBIA: 
FRANCE: 
GIBRALTAR: 
GREAT    BRITAIN: 


INDIA: 


ITALY: 
RUSSIA: 


SPAIN: 
STRAITS 

SETTLEMENTS: 
SWITZERLAND: 
SYRIA: 


Panama 

Paris 

fjlapgnw 

l-i\'erpool.     .     .. 

Loncioo 

Bombay 

Calcutta 

Karachi 

Madras 

Messina 

Naples 

Moscow 

St.   Petersburg. 

Warsaw 

Corunna 

Singapore.    .    . 

Geneva 

Beirut 


...4 


June  3-10 6 

Mm   :i5-June  1. 
May24-June2    .1 

June  1-7 35 

May  25-June  1.    2 
May  L'3-June  1.   .1 

May  14-21 

May  U-18. 
May  12-19. 
May  4-17.   .   . 
May  25-June  1.     . 
May  26-June  2  169 

Miiy  23-25 23 

May  18-25 15 

May  11-18 

May  25-June  1.     .. 

Apr.1-30 

May  18-25 5 

May  18-25,    a    few- 
cases. 


10 


31 

2 
22 
1 


CUBA: 


YELLOW  FEVER. 
Havana June  1-8. 


...1 


CHOLERA. 

INDIA: 

Bombay May  14-21 

Calcutta May  11-18 

Madras May  4-17 

PLAGUE— INSULAR. 

3 

77 
6 

PHILIPPINES: 

Cavite May  2 1 

Cebu May  2 1 

Manila Apr.20-May  11    94 

Santa  Rosa May  2 1 

PLAGUE— FOREIGN. 

79 

AFRICA: 
CHINA; 

INDIA: 

Cape  Town May  4-18.    .     ..463 

Hongl«ong Apr.27-May  11, 

11221 

Bombay May  14-21.    .    .. 

Calcutta May  11-18 

Karachi May  12-19 149 

209 

209 
224 
79 
144 

YELLOW  FEVER  IN  HAVANA. 

In  his  report  of  the  vital  .statistics  of  Havana  for  the 
month  of  May,  1901,  Major  W.  C.  Gorgas,  surgeon  U.  S.  Army 
and  Chief  Sanitary  Officer,  states  the  following:  "Our  last 
case  of  yellow  fever  occurred  May  7th.  Since  the  first  oc 
March  we  have  only  had  one  ilcath  from  yellow  fever,  which 
occurred  March  13th.  In  no  other  your  have  the  conditions, 
as  to  yellow  fever,  even  approximated  this.  I  cannot  but  hope 
that  this  exceptionally  good  condition  is  In  great  part  due  to 
the  large  amount  of  labor  and  money  we  are  e.xpending  in  the 
destruction  of  mosquitoes,  and  the  circumstances  of  tlie  case 
point  in  the  same  direction.  The  first  time,  April  21st  and  22nd, 
■we  had  two  cases;  and  again,  on  May  0th  and  7th,  four  cases. 
Each  time  the  Infected  houses  and  three  or  four  contiguous 
houses  on  every  side  of  the  Infected  house,  were  carefully  gone 
over.  Every  room  in  eacli  of  these  houses  was  closed  and 
sealed,  and  Insect  powder  burned  in  them  at  the  rate  of  1 
pound  to  1000  cubic  feet.  All  standing  water  was  drained  away, 
where  possible,  and  oiled  where  it  could  not  be  drained.  The 
results  look  as  if  the  focvis  of  infection,  at  that  particular 
point,  had  been  eradicnted.  In  the  c.iso  of  the  patient  taken 
sick  March  8th  after  our  disinfection,  we  went  42  days  until 
the  next  case.  Then  an  outbreak  occurred  April  21st  and  22n(3. 
We  again  disinfected,  and  have  gone  21  days  without  a  case. 
I  am  more  particularly  impressed  by  these  figures,  as  we  com- 
menced our  systematic  destruction  about  the  middle  of  Feb- 
ruary. Formerly  we  paid  no  particular  attention  to  the  mos- 
quito, merely  disinfecting  for  yellow  fever  as  we  do  for  other 
hifectious  diseases.  The  onl,v  part  of  tlie  process  that  killed 
the  mosquito  was  the  formaline  used  in  one  or  two  infected 
rooms." 

GREAT  BRITAIN. 
A  New  Kind  of  Sulphur  Bath. — Harrogate,  in  Yorkshire. 
EiiKland,  lias  ;i  novclly  in  the  way  of  a  snlphur  bath.  Brief- 
ly described,  liy  tlie  application  o£  electricity  in  a  sulphur 
bath  a  man  is  converted  into  a  "sulphur-coated"  being. 
In  other  words,  the  electricity,  acting  upon  the  sulphur 
latent  in  the  water,  deposits  the  latter  upon  the  skin  of  the 
patient  in  much  the  same  way  as  electrolysis  covers  metal- 
lic goods  with  a  plating  of  gold  or  silver.  This  process, 
according  to  the  local  practitioner,  whose  experiments  have 
led  to  its  discovery,  is  much  superior  to  the  ordinary  sul- 
phur bath  in  certain  skin  affections.  The  benefit,  he  says, 
is  both  greater  and  more  rapid,  for  he  finds  that  the  deposit 
of  sulphur  actually  placed  upon  the  skin  by  electric  influ- 
ence is  m\ich  more  effective  and  curative  than  that  nascent 
In  the  water.  It  is.  in  fact,  driven  into  the  skin,  and  thus 
keeps  up  the  cui-ative  action  until  the  next  bath.  The  physi- 
cian's experience  with  some  of  his  patients  is  cited  to  sup- 
port his  theory,  and  the  report  of  a  chemist  is  added  to 
show  that  an  electric  current  passed  thi-ough  water  will 
liberate  sulphur  at  the  positive  pole  by  indirect  electrolysis 


of  the  sulphides  and  of  the  dissolved  sulphuretted  hydro- 
gen, and  so  lead  to  the  deposit  of  sulphur  upon  the  skin. 
Is  not  this  method  of  treatment  worthy  of  investigation  by 
physicians  who  make  a  specialty  of  skin  diseases?  At  any 
rate,  the  accuracy  of  the  above-named  facts  could  be  deter- 
mined.— Interntdtc  Medicul  Journal. 

The  Victoria  Cross. — 7/ie  Londan  fimitle  of  June  5th 
contained  the  following,  dated  War  Office  June  4th; — The 
King  has  been  graciously  pleased  to  signify  his  intention 
to  confer  the  decoration  of  the  Victoria  Cross  for  conspi- 
cuous bravery  in  South  Africa  on  Captain  N.  R.  Huse, 
New  South  Wales  Medical  Staff  Corps,  who,  during  the  ac- 
tion at  Vredefort  on  July  24th,  190U,  went  under  a  heavy 
cross  fire  and  picked  up  a  wounded  man  and  carried  him. 
to  a  place  of  shelter. 

Special  Excursion  to  London  and  Paris. — An  excursion 
to  London  and  Paris  in  connection  with  the  Tuberculosis 
Congress,  July  23-26,  and  the  British  Medical  Association, 
at  Cheltenham,  which  meets  July  26  to  August  2.  1901  has 
been  mentioned  with  special  rates.  The  trip  has  been  care- 
fully designed  in  the  interests  of  medical  men  who  desire 
to  attend  the  two  great  medical  meetings  this  summer  in 
Great  Britain. 

CONTINENTAL     EUROPE. 

A  Woman  Appointed  Lecturer  in  Anatomy. — A  young 
Italian  woman.  Dr.  Rina  Monti,  who  has  published  several 
scientific  papers  and  who  gained  a  university  gold  medal, 
has  been  accepted  by  the  University  of  Pavla  as  a  lecturer 
in  anatomy. 

Dr.  Fedor  Krause,  Professor  of  Surgery  at  Halle,  has 
been  apijointed  Extraordinary  Professor  of  Surgery  at  the 
University  of  Berlin. 

Dr.  Alexander  Westphal,  of  Berlin,  has  been  appointed 
Extraordinary  Professor  of  Psychiatry  at  the  University 
of  Greifswald. 

At  the  University  of  Munich  the  following  Extraordin- 
ary Professors  have  just  been  appointed;  Dr.  Siegfried 
Mollier,  in  Anatomy:  Dr.  Max  Cremer,  in  Physiologj":  and 
Dr.  Rudolf  Haug,  in  Otology. 

Dr.  Otto  von  Franque  has  been  appointed  Extraordinary 
Professor  of  Obstetrics  and  Gynecology  at  the  University 
of  Wiirzburg. 

Dr.  E.  Graser,  Professor  of  Surgery  at  Erlangen.  has  been 
appointed  Professor  of  Surgery  at  the  University  of  Ros- 
tock. 


A  Case  of  Duodenal  Ulcer  Associated  with  Primary  Can- 
cer of  the  Tail  of  the  Pancreas. — B.  P.  Rutshinski  and  F. 
la.  Tshistovitch  {.ISdUiittUnnia  'iuzeta  ISotkina,  Vol.  XII,  Kos. 
13-11)  i-eport  the  case  of  a  man,  53  years  old,  who  pre- 
sented on  admission  to  the  hospital  symptoms  pointing  to 
duodenal  ulcer.  The  man  had  vomited  twice  masses  re- 
sembliug  coffee-ground,  but  there  were  no  other  evidences 
</f  canc(  r.  .Moreover,  in  the  course  of  the  first  43  days 
the  patient  gained  26  pounds,  and  was  free  from  pain. 
The  favorable  course  of  the  disease  was  interrupted  ab- 
ruptly by  a  peritonitis  which  terminated  fatally  within  3 
days.  The  autopsy  disclosed  a  perforated  duodenal  ulcer 
and  a  primary  cylindrical  carcinoma  of  the  t.iil  of  the 
pancreas.  The  tumor  was  cystic  and  encapsulated,  a  con- 
dition which,  the  authors  believe,  explains  the  fact  tha| 
I  lie  growth  did  not  spread.  The  urine  and  feces  examined 
during  life  showed  nothing  abnormal;  the  vomit  contained 
free  hydrochloric  acid  in  considerable  proportion.     [A.  R.] 


Herpes  Zoster. — Herpes  zoster  may  be  of  central  origin, 
either  primary  and  infectious,  or  symptomatic  of  a  medul- 
lary lesion;  or  it  may  be  of  peripheral  origin,  situated  in 
the  territory  of  the  injured  nerves.  It  is  in  the  latter  di- 
vision that  the  traumatic  cases  of  herpes  zoster  be- 
long. Professor  Gaucher  made  these  remarks  at  a 
recent  meeting  of  the  Medical  Society  of  the  Paris  Hospitals 
(Hiilletiii.i  ct  .l/cm(i(ir.«  dc  la  Sunrte  Mcdictilc  il<'.<  Hoitituux 
ilr  I'aris.  1901,  No.  7),  where  he  reporte(\  three  cases.  One 
was  a  man  of  46.  who.  after  being  struck  upon  the  cheek, 
developed  marked  herpes  zoster,  with  headache.  The  sec- 
ond case  occurred  in  a  child  of  three,  who  injured  the  left 
side  of  his  face.  The  third  was  a  man  in  whom,  after  an 
injury  to  his  left  side,  typical  shingles  appeared.  All  tliree 
cases  speedily  recovered      [M.  O.] 


June  29,   1901] 


SOCIETY  REPORTS 


The    Philadelphia 
Medical  Journal 


]        1231 


Society  IRcpouts. 


A  Correction. — Dr.  Osborne's  paper  on  "Medical  Shock," 
read  before  the  American  Medical  Association,  was  printed 
"Mental  Shock"  by  an  error  of  the  reporter. 


AMERICAN     MEDICAL    ASSOCIATION. 

Section   on    Physiology   and    Dietetics. 

FIRST    DAY,   JUNE   4,    IHOl. 

The  meeting  was  called  to  order  by  Dr.  Winfield  S.  Hall 
of  Chicago.  A  short  executive  session  was  held  in  which 
was  considered  the  feasibility  of  fusing  the  Section  on  Pa- 
thology and  Bacteriology  and  that  on  Physiology  and  Die- 
tetics. Subsequent  conferences  resulted  in  this  fusion  to 
take  effect  in  1902.      A  Joint  exhibit  will  aiso  be  given. 

Dr.  Charles  M.  Hazen  of  the  Medical  College  of  Virginia, 
and  Dr.  R.  Harvey  Cook  of  Oxford,  Ohio,  were  appointed  to 
All  vacancies  on  the  Executive  Committee.  The  Section 
then  adjourned  to  the  following  day. 

SECOND  DAY,  JUNE  5,  1901. 

The  meeting  opened  at  2  P.  M.  with  Dr.  Charles  M.  Hazen 
of  the  Medical  College  of  Virginia  in  the  Chair. 

Dr.  Winfield  S.  Hall  of  Chicago  read  a  paper  on  The  Eval- 
uation of  Anthropometric  Data.  It  was  stated  that  the 
collection  of  anthropological  data  Is  almost  universal  in  the 
practice  of  medical  men.  In  the  case  of  special  lines  of 
work  this  data  is  of  fundamental  importance.  Anthropo- 
logical data  have  potential,  but  no  practical  value  as  such; 
only  through  some  process  of  evaluation  can  the  potential 
value  be  made  practical  and  form  a  basis  for  general  con- 
clusions. That  method  of  evaluation  which  involves  the 
use  of  the  anthropometric  average  is  both  time  wasting 
and  inaccurate  while  one  hour  method  based  upon  Que- 
telet's  median  value  is  accurate  and  is  quickly  and  easily 
obtained.  The  median  value  is  the  value  represented  by  the 
middle  measurement  of  a  series  of  measurements,  1.  e.,  that 
measurement  which  has  as  many  values  above  it  as  below 
it.    The  median  value  is  within  the  median  group. 

Dr.  John  Madden  of  Milwaukee  supposed  the  purpose  of 
the  measurement  to  be  the  securing  01  a  definite  mean 
in  measure,  weight  and  general  condition  of  a  normal 
healthy  child  of  a  certain  age.  By  this  a  boy  could  be 
measured  as  with  a  rule  and  square.  Something  of  this 
sort  should  be  on  the  books  of  the  school,  that  from  the 
child's  entrance  to  his  going  out,  his  condition  could  be 
ascertained  and  any  trouble  traced  to  iis  cause.  Dr.  H.  S. 
Drayton  of  New  York  thought  this  modern  method  as  stated 
by  Dr.  Hall  demonstrated  very  definitely  the  crudity  of  the 
old  methods  of  anthropologists  and  ethnologists  and  proved 
their  statistical  value  to  be  nil.  Dr.  Hall  said  in  closing 
that  the  whole  object  of  the  method  was  the  application  of 
it  by  men  collecting  large  masses  of  data  for  statistical 
tables.  Though  considerable  data  had  been  obtained,  there 
had  not  yet  been  enough  real  accurate  and  scientific  group- 
ing done. 

Dr.  John  Madden  of  Milwaukee  read  a  paper  on  The  Edu- 
cation of  the  Degenerate.  A  Physicobiologic  Study.  The 
paper  as  read  was  a  synopsis  of  a  chapter  of  a  monograph 
and  dealt  with  "'tt'hat  is  the  Remedy?"  The  entire  paper 
was  a  plea  for  physical  exercises  to  receive  the  same  at- 
tention as  mental  training,  and  in  certain  cases  it  is  a 
means  of  education  where  all  other  fail.  Nerve  cells  de- 
velop by  increasing  dendritic  branches  and  this  takes  place 
by  physical  as  well  as  mental  activity.  Education  of  one 
group  educates  remote  cells.  Defectives  were  divided  into 
three  classes:  (1)  Those  intellectually  weak,  but  with 
self  control;  (2)  Those  who  are  bright  but  have  not  self 
control;  and  (3)  those  weak,  and  lack  self  control.  Great 
benefit  has  resulted  from  physical  training  especially  in 
those  under  number  two.  Physical  education  should  be 
used  in  schools  as  normal  children  need  it  and  defectives 


can  thus  be  reached  when  all  else  may  fail.  To  curtail 
the  production  of  defectives  by  mutilation  or  laws  seems 
impossible.  Attention  should  therefore  be  directed  to  en- 
vironment, the  well  spring  of  vicious  humanity.  Alcoholism 
was  stated  to  be  the  most  frequent  hereditary  taint.  Other 
taints  frequently  skip  a  generation,  but  it  is  not  so  with  al- 
cohol. The  fight  against  degeneracy  is  a  fight  against  alco- 
hol. When  faulty  development  is  such  as  to  warrant,  the 
child  should  not  be  taught  with  normal  children,  but  in  a 
suitable  institution.  The  paper  dealt  with  those  affected 
in  a  minor  degree.  The  school  should  be  "a  brain  condition 
house,"  and  detestable  studies  should  not  be  forced  on  the 
child.  The  plea  is  made  not  "to  make  a  poor  lawyer  out  of 
what  could  have  been  a  good  farmer."  There  should  be 
small  schools,  and  the  individuality  of  the  pupils  should 
be  known.  Education  is  not  merely  the  imprinting  of 
ideas  on  brain  cells;  it  is  a  biologic  process  with  cell  de- 
velopment and  increase  of  dendritic  fibres.  Man  is  born 
with  millions  of  cells  which  never  become  educated.  Some 
are  born  with  deficient  cell  development,  and  these  are  to 
be  brought  to  as  nearly  normal  condition  as  possible  by 
physical  and  mental  training.  Dr.  Winfield  S.  Hall  of  Chi- 
cago in  discussion  emphasized  the  necessity  of  physical 
development  in  the  development  of  the  mental,  and  re- 
ferred to  the  influence  of  heredity  on  degenerates;  especial- 
ly w-as  this  marked  in  alcoholism.  Dr.  H.  S.  Drayton  of 
New  York  City  thought  the  term  "degeneracy"  covered  a 
broad  margin.  Biological  experiment  had  shown  that  but 
few  of  these  degenerates  were  incapable  of  improvement. 
He  related  an  instance  of  one,  without  sense  or  sensibility 
complete  in  which  marked  improvement  had  been  obtained 
by  the  persistent  endeavor  of  an  asistant  in  the  Institution 
for  the  Blind  near  Boston.  Dr.  Joseph  Putney  of  .vest 
Virginia  from  bis  observations  believed  alcoholism  a  ruling 
factor  in  the  cause  of  degeneracy.  Dr.  Madden  in  closing 
said  he  tljought  we  were  nearer  to  the  appreciation  of  the 
actuality  of  an  education  when  we  stated  that  it  consits  In 
developing  the  nerve  cell,  giving  to  it  an  axis  cylinder 
and  some  dendrites;  the  more  dendrites,  the  better  the  edu- 
cation, that  is,  from  a  biologic  standpoint.  The  word,  de- 
generacy, he  thought  was  much  over-worked.  A  degener- 
ate, he  said,  is  something  indefinable;  generally  a  person 
of  bad  nutrition  and  one  who  does  not  recognize,  and  does 
not  act  in  harmony  with  his  environment. 

Dr.  H.  S.  Drayton  of  New  York  City  read  a  paper  on 
The  Nervous  Relation  in  Diseases  of  the  Nutritive  System. 
In  this  paper  reference  was  made  to  social  habits,  methods 
of  business,  irregularities,  excess  of  diet  and  nerve  excita- 
bility as  etiological  factors  in  the  causation  of  our  national 
dycrasia — dyspepsia.  A  brief  consideration  of  the  trend 
of  opinion  with  a  large  class  of  pathologists  concerning 
the  treatment  of  gastric  disorders  was  given.  In  the  zeal 
to  provide  aids  and  substitutes  for  digestion  the  proper 
value  and  capacity  of  natural  function  seems  to  be  over- 
looked. We  limit  the  power  and  quality  of  the  nervous 
apparatus  having  relation  to  gastric  function  and  need  to 
be  reminded  that  nature  has  endowed  it  with  a  very  broad 
field  of  adaptation  to  food  stuffs.  The  author  believes  that 
the  usefulness  of  the  various  ferments,  etc.,  in  gastric  dis- 
orders is  a  limited  one.  The  bio-chemistry  of  the  human 
body  is  quite  another  thing  from  the  best  type.  The  nerv- 
ous relation  of  alimentation,  the  vital  sources  of  gastric 
metamorphosis  is  not  sufficiently  considered.  That  nature 
has  reserves  should  also  be  remembered.  That  the  nerv- 
ous apparatus  of  the  stomach  must  play  a  large  part  in  the 
diabetic  expression  seems  clearly  made  out  by  the  exhibi- 
tion of  iodeine.  The  neglect  of  the  nerve  function  has  been 
responsible  for  treating  dyspeptic  cases  unnecessarily  or 
contributing  to  greater  disturbances  of  the  alimentary  or- 
ganism by  the  administration  of  excitants  and  stimulants 
when  that  which  was  most  required  was  rest.  Nature  in 
the  recesses  of  sub-conscious  activity  can  better  manage 
the  procedure  of  tissue  building  and  repair  than  can  be 
accomplished  with  tonics,  emulsions  and  extractives. 

Dr.  Winfield  S.  Hall  of  Chicago  believed  the  recommen- 


12^2 


The    Philadelphia 
Medical  Jon 


IILPHIA  "I 


SOCIETY  REPORTS 


[JUNE  29.   1901 


dations  of  Dr.  Drayton  to  be  in  line  with  a  general  move- 
ment In  the  medical  profession — a  less  degree  of  medical 
interference,  and  the  greater  chance  accorded  Nature.  Dr. 
Drayton  referred  in  closing  to  the  fact  that  among  the  old 
men  of  this  countrj-  we  would  find  the  majority  belonging 
to  that  class  indifferent  to  the  quality  and  quantity  of  their 
food,  and  certainly  indifferent  to  the  scientific  relation  of 
the  food. 

A  paper  on  Isolation  of  the  Active  Principles  of  the 
Suprarenal  Gland.  A  Review  of  the  Work  by  Dr.  T.  B. 
Aldrich  of  Detroit  was  read  by  Dr.  Houghton  of  the  same 
city. 

THIRD  DAY,  JUNE  6,  1901. 

Food  products  from  Diseased  Animals  was  the  title  of  a 
paper  by  Dr.  D.  E.  Salmon  of  Washington,  D.  C. 

In  this  paper  it  was  stated  that  the  question,  what  effect 
may  the  food  products  from  diseased  animals  have  in  dis- 
turbing the  digestion  and  in  causing  more  serious  disease 
in  the  human  consumer,  is  one  easily  asked  and  dismissed 
by  many  with  the  same  facility.  Too  little  consideration  is 
given  to  the  millions  of  cattle  and  sheep  and  the  greater 
number  of  swine  and  birds  consumed  each  year.  The 
Federal  meat  inspection  service  has  been  by  many  misun- 
derstood and  misrepresented.  It  is  a  sanitary  inspection 
rather  than  a  commercial  inspection.  The  great  difBculty 
in  meat  inspection  is  where  to  draw  the  line  between  meat 
that  shall  be  classed  as  fit  for  food  and  that  which  shall  be 
condemned.  There  is  great  need  for  the  inspector  being 
selected  for  his  knowledge  of  pathology  rather  than  his  effi- 
ciency in  politics.  The  desirability  that  the  shipment 
of  animals  advanced  in  pregnancy  for  slaughter  should  be 
discouraged  was  urged.  It  was  stated  that  the  inspectors 
of  the  Bureau  of  Animal  Industry  are  instructed  t,o  condemn 
all  animals  which  are  within  two  weeks  of  the  time  of  par- 
turition. Mention  was  made  of  certain  animal  parasites 
capable  of  infesting  man  and  causing  slight  illness  or  seri- 
ous disease.  Reference  was  also  made  to  inflammations 
of  all  organs  and  various  infectious  diseases  accompanied 
by  fever,  emaciation  and  organic  changes  which  affect  the 
quality  and  wholesomeness  of  the  flesh.  Unquestionably 
the  products  of  many  badly  diseased  animals  get  upon  the 
market  and  are  eaten.  What  proportion  of  the  cases  of  di- 
arrhea, cholera  morbus,  etc..  are  due  to  such  food?  What  :s 
the  extent  of  the  danger  from  taking  large  quantities  of  tu- 
bercle bacilli  in  either  rare  meat  or  in  uncooked  milk,  were 
dietetic  questions  which  it  appeared  to  the  author  might 
well  receive  more  attention.  More  efforts  should  be  put 
forth  to  secure  a  pure  food  supply.  Those  who  are  work- 
ing in  this  direction  need  the  encouragement  and  aid  of  the 
general  practitioner  of  medicine  and  of  the  whole  pro- 
fession. 

Dr.  Winfield  S.  Hall  of  Chicago  thought  the  paper  opened 
an  exceedingly  wide  field  for  research.  He  asked  to  what 
extent  the  experiments  had  been  carried  in  the  Washington 
laboratories  and  how  far,  in  the  opinion  of  the  author,  could 
tuberculous  milk  be  taken  with  impunity.  Dr.  Paulson 
of  Chicago  testified  to  the  good  work  done  in  the  Washing- 
ton laboratories,  and  deplored  the  successful  effort  in  the 
small  slaughter  houses  to  avoid  the  beef  inspection. 

Dr.  R.  Harvey  Cook  of  Oxford  asked,  why,  other  than 
from  an  esthetic  idea,  an  animal  before  parturition  is  not 
60  good  for  food.  Dr.  Salmon  in  closing  regretted  that 
there  were  many  questions  in  connection  with  the  subject 
he  was  unable  to  answer,  and  especially  with  regard  to 
the  effect  of  exhaustion  and  fright  on  the  flesh  of  the 
animal.  The  Federal  law  that  animals  in  transportation 
should  be  unloaded  every  28  hours  for  feed,  water  and  rest 
was  openly  violated.  He  had  seen  cases  in  which  the  ani- 
mals in  hot  weather  had  been  kept  in  stock  cars  for  96 
hours.  Consumption  of  meat  shipped  in  this  way  he  be- 
lieved must  have  a  considerable  effect  upon  the  health 
of  the  individual.  He  believed  firmly  in  the  danger  of 
milk  from  a  tuberculous  cow.  Experiments  have  shown 
that  a  considerable  proportion  of  tuberculous  cows  give  In- 


fectious milk  even  with  apparently  healthy  udders.  In 
regard  to  the  effect  of  the  physiological  changes  in  the  last 
stages  of  gestation,  he  believed  that  the  waste  products 
from  a  fetus  which  are  thrown  into  the  circulation  of 
the  mother  have  a  certain  effect  upon  the  flesh  of  the 
animaL  The  effect  must  be  as  marked  as  that  upon  the 
composition  of  the  milk.  There  were  as  yet,  however,  but 
little  data  showing  the  effect  of  the  meat  upon  the  con- 
sumer. 

A  paper  on  "Living  on  Bread"  Alexander  Haig,  M.  A. 
and  M.  D.  Oxon,  F.  R.  C.  P.,  London,  England,  was  read 
by   Dr.   Harvey   Cook. 

The  author  stated  that  there  are  several  forms  of  the 
Uric  Acid  Free  Diet  such  as  that  which  consists  of  milk, 
cheese,  potatoes  and  fruit,  and  contains  no  bread,  that 
which  contains  these  things  with  more  or  less  bread  and 
bread  stuffs,  and,  lastly,  the  form  in  which  bread  and 
bread  stuffs  form  the  chief  sources  of  nourishment  and  a 
small  quantity  of  fruit  and  vegetable  are  taken  merely  as 
sauces  for  the  bread.  In  comparison  were  given  the  ap- 
proximate quantities  required  in  each  of  these  diets  for  a 
man  of  140  lbs.  weight  who  is  supposed  to  be  young  and 
leading  an  active  life,  therefore  requiring  a  rather  full  diet, 
one  that  will  jield  3.3  grs.  of  urea  per  lb.  of  body  weight 
per  day.  It  had  long  appeared  to  the  author  that  bread 
which  is  preeminently  the  food  of  man  is  deserving  of  study 
and  attention.  Unfortunate  results  are  obtained  by  tak- 
ing uric  acid  containing  foods  on  one  band,  and  trying 
with  the  other  to  wash  out  its  excess  on  the  other  by  copi- 
ous libations  of  fluid  far  in  excess  of  thirst.  The  great 
advantage  of  the  bread  diet  in  certain  conditions  of  dys- 
pepsia and  especially  in  conditions  of  high  blood  pressure, 
is  that  it  is  a  dry  diet;  that  the  fluid  taken  can  be  reduced 
to  1%  pints  or  even  1  pint  in  24  hours  till  nature  asks  for 
more  by  making  the  patient  thirsty;  and,  then  alone  can  we 
be  sure  that  we  are  not  giving  too  much.  The  great  point 
in  the  taking  of  bread  stuffs  and  that  which  prevents  them 
from  causing  dyspepsia  is  their  thorough  complete  mixing 
with  the  saliva  in  the  mouth.  One  other  advantage  of 
bread  stuffs  is  their  relatively  slow  digestion  and  meta- 
bolism, in  virtue  of  which  they  give  a  steady  supply  of 
force  and  urea  over  a  number  of  hours,  this  accounting 
at  least  in  part  for  the  great  powers  of  endurance  shown 
by  the  animals  that  live  on  them.  Those  who  get  their 
albumens  from  milk  are  in  the  position  of  a  motor  sup- 
plied with  a  quick  burning  oil  which  gives  out  great  force 
for  the  first  two  hours  but  is  sooner  at  the  end  of  its  re- 
sources; while  those  who  get  albumens  from  bread-stuffs 
cannot  produce  so  much  force  in  the  first  two  hours,  but 
will  be  able  to  go  on  longer.  Bread  stuffs  form  a  very  con- 
venient diet  and  can  be  carried  in  the  form  of  grain,  meal 
rice,  maccaroni  or  biscuits.  Among  the  flesh-eaters  disease 
and  death  are  rampant,  the  natural  term  of  human  life  is 
but  rarely  attained.  Let  anyone  examine  how  many  meat- 
eaters  and  tea  drinkers  between  the  ages  of  17  and  23  have 
normal  blood;  how  many  from  the  age  of  forty-five  have 
normal  blood  or  normal  circulation  and  do  not  suffer  either 
from  dyspepsis.  depression  and  insomnia  (not  to  mention 
Bright's  disease  and  diabetes K  or  from  arthritis,  lumbago 
sciatica,  bronchitis.  Dr.  Winfield  S.  Hall  in  discussion 
believed  a  study  of  the  literature  of  the  influence  of  the 
metabolism  of  nitrogenous  food  showed  the  custom  of  taking 
too  much  of  this  food.  He  had  read  the  greater  part  of  Dr. 
Haig"s  writings  and  was  in  general,  in  accord  with  his 
statements.  One  or  two  apparently  antagonistic  points 
brought  out  in  the  paper  he  believed  Dr.  Haig  could  ex- 
plain were  he  present.  Dr.  Paulson  of  Chicago  thought 
the  medical  profession  gave  far  too  little  attention  to  die- 
tetics. He  related  an  experiment  he  had  made  to  determine 
the  necessary  amount  of  bread  per  day  consumed  in  a 
bread  diet.  In  a  class  of  ten  graduates  on  16  ois.  of  bread 
a  day,  as  water  dry  as  could  be  produced,  a  gain  in  weight 
was  made  by  every  one.  some  as  much  as  three  pounds 
in  two  weeks.  Another  experiment  with  a  diet  consisting 
of  starch  16  ozs..  nitrogenous  food  2U  ozs.  and  of  fat  IH 


Junk   29.    IfliH] 


SOCIETY  REPORTS 


U 


The    Philadelphia 
Medical  Journal 


12^3 


ozs.  proved  that  the  figures  set  down  by  Pettenkofer  was  en- 
tirely too  great  in  this  country  and  that  normally  we  use  a 
larger  amount  of  carbonaceous  food  that  is  generally 
tnought.  The  tendency  is  to  overstock  the  system  with 
nutrients  which  produce  uric  acid  diathesis.  Though  not 
agreeing  with  all  that  Dr.  Haig  says,  he  considered  the 
medical  profession  greatly  indebted  to  him.  Regarding  the 
powers  of  endurance  of  persons  living  an  a  uric  acid  free 
diet,  he  stated  that  a  number  of  the  most  successful  long 
distance  runners  live  upon  an  entirely  non-flesh  diet. 

Dr.  Joseph  Putney  of  West  Virginia  called  attention 
to  the  two  classes  of  uric  acid  cases — those  of  dietetic  ori- 
gin, and  those  of  tissue  destruction  origin.  Nothing  he 
thought  was  better  recognized  to  day  than  the  fact  of  the 
breaking  down  of  the  leukocytes  attended  with  the  develop- 
ment of  uric  acid.  This  indicates  the  distinction  between 
those  cases  of  disorders  of  nitrogenous  metabolism  trace- 
able to  the  short  cut  which  the  nitrogenous  elements  of  food 
in  excess  take,  and  the  long  course  which  the  nitrogenous 
metabolism  of  tissues  involves.  A  vote  was  taken  to  send 
Dr.  Haig  an  expression  of  the  thanks  of  the  Section  for  his 
paper. 

Dr.  R.  O.  Beard  of  Minneapolis  read  a  paper  upon  The 
Teaching  of  Practical  Dietetics  In  Medical  Schools.  In 
this  paper  was  urged  the  advisability  and  necessity  of  in- 
cluding in  the  medical  curriculum  a  course  of  instruction 
in  practical  dietetics.  Reference  was  made  to  the  estab- 
lishment and  successful  working  of  the  dietetic  laboratory 
in  the  Harvard  Medical  School. 

Dr.  Winfield  S.  Hall  of  Chicago  stated  that  he  had  seen 
the  laboratory  referred  to  by  Dr.  Beard  and  could  testify 
to  its  thorough  and  beautiful  equiptment.  Its  establish- 
ment he  believed  marked  an  epoch  in  therapeutics.  The 
fourth  year  in  the  medical  school  in  his  opinion  was  the 
place  for  it.  and  he  felt  that  hospital  internes  should  be 
held  resposible  for  qualification  in  such  instruction.  Dr. 
Paulson  of  Chicago  deplored  the  fact  that  the  text-books 
contributed  such  scant  instruction  on  dietetics,  a  subject 
upon  which  so  much  depended.  Dr.  Stewart  of  Michigan 
thought  the  paper  of  Dr.  Beard  very  timely,  and  that  the 
profession  should  have  recognized  long  ago  their  duty  in 
being  able  to  tell  their  patients,  how,  when,  and  what  to 
eat.  "To  be  careful  about  your  diet"  is  not  intelligent  in- 
struction to  a  sick  person.  He  stated  that  there  was  an- 
other school  in  which  practical  dietetics  were  taught,  the 
American  Medical  Missionary  College  of  Chicago  at  Battle 
Creek.  In  this  school  the  teaching  extends  throughout  the 
entire  course.  Dr.  Beard  in  closing  the  discussion  stated 
that  acknowledgement  of  the  success  of  dietetic  work  in 
Boston  was  due  to  Mrs.  Ellen  H.  Richards  of  the  Massachu- 
setts Institute  of  Technology.  It  was  largely  under  her 
suggestion  that  the  course  of  dietetics  at  the  Harvard  Uni- 
versity had  been  developed.  He  gave  several  Interesting 
instances  regarding  the  results  of  such  work  occuring  in  his 
own  practice. 

A  paper  on  The  Pontobular  Heat  Center,  by  Edward  T. 
Reichert.  M.  D.,  of  Philadelphia,  was  read  by  the  Secretary. 
Professor  Reichert  said  that  although  our  knowledge  of 
the  thermogenic  machanism  is  still  in  a  formative  state, 
we  nevertheless  have  sufficient  experimental  data  to  war- 
rant the  conclusion  that  in  the  higher  animals  the  heat 
formed  arises  in  part  as  a  product  incident  to  the  activi- 
ties of  all  forms  of  vital  processes,  and  in  part  as  a  specific 
product  of  specific  heat  producing  structures.  The  re- 
sults of  Rubner's  researches  leave  no  doubt  as  to  the 
skeletal  muscles  possessing  besides  their  motorial  proper- 
ties a  specific  thermogenic  function,  and  as  a  consequence, 
that  these  structures  besides  producing  heat  as  an  inci- 
dent to  repair,  growth  and  motor  activity,  also  give  rise  to 
it  as  a  specific  product.  They  further  show  that  the 
quantity  of  heat  which  arises  by  virtue  of  this  special  func- 
tions bears  a  recipi-ocal  relationship  to  the  amount  formed 
as  an  incident  to  the  activities  of  the  body-structures  gen- 
erally, increasing  or  decreasing  in  adjustment  to  the  varia- 
tions in  thermogenesis  caused  by  rest  and  activity,  etc.,  and 


to  the  alterations  in  thermolysis  which  are  dependent  upon 
ever-changing  internal  and  external  conditions,  so  that  as 
the  output  of  heat  incidentally  produced  increases  or  de- 
creases, the  quantity  resulting  from  the  specific  thermal 
function  of  the  skeletal  muscles  varies  cooperatively  In  sup- 
plying the  number  of  heat  units  required  by  the  organism 
at  any  given  time.  Moreover,  thore  can  be  no  doubt  that 
this  specific  thermal  function  Is  direcUy  controlled  by 
specific  thermogenic  centers  which  are  located  in  the  cere- 
bro-spinal  axis,  although  very  little  is  known  of  their  exact 
positions,  functional  relations  and  characteristics.  A  num- 
ber of  conclusions  are  drawn  from  the  researches  of  many 
investigators. 

Dr.  Beard  referring  to  Dr.  Reichert's  conclusions  sug- 
gested as  a  possible  source  of  error  arising  from  the  stimula- 
tion incident  to  section  of  afterent  as  well  as  efferent  fibres 
related  to  the  thermotaxic  centres.  The  fillet  from  the  as- 
cending lateral  tract  of  Gowers,  which  is  believed  to  carry 
impressions  of  temperature  to  these  centres,  passing  up- 
ward through  the  bulb  and  pons,  might  easily  be  in- 
volved in  Dr.  Reichert's  pontins  and  bulbar  sections,  while 
lying  in  the  lateral  fillet,  beyond  the  pons.  It  might  escape 
in   section  of  the  crura.  Adjourned. 


AMERICAN  NEUROLOGICAL  SOCIETY. 
Morning  Session. 
WEDNESDAY.  JUKE  19th.  1901. 
(From  Our  Special  Correspondent). 
The  first  paper  presented  after  the  address  of  the  presi- 
dent. Dr.  George  I...  Walton,  of  Boston,  described  an  inter- 
esting case  of  myeloma  of  the  spinal  column  by  Dr.  Thomas, 
of  Boston.  In  the  course  of  this  Dr.  Thomas  discussed  the 
value  of  albumosuria  as  a  symptom  of  bone  disease,  and 
was  inclined  to  attach  considerable  value  to  it.  Although 
disassociation  of  sensation  existed,  a  diagnosis  of  extra- 
medullary  growth  was  made  and  an  operation  was  per- 
formed, with  the  result  of  relieving  the  paraplegia.  The 
after-treatment  has  consisted  of  the  administration  of  bone 
marrow  and  Coley's  serum,  and  the  patient  is  still  doing 
well.  In  the  discussion  Putnam  mentioned  a  case  of  sar- 
coma of  the  vertebrae  benefited  by  operation,  and  another 
in  which  pain  in  the  back  had  been  the  chief  symptom, 
and  which  had  also  been  improved  by  operation.  Thomas 
in  closing  called  attention  to  the  microscopical  preparations 
on  exhibition.  Spiller  and  Cohen  reported  a  case  of  cervl 
cal  and  bulbar  tubes  The  symptoms  commenced  in  1872 
with  incontinence  of  urine,  and  distinct  eye  symptoms 
were  noted  in  1877.  Later  there  was  difficulty  in  degluti- 
tion, atrophy  of  the  tongue,  disassociation  of  sensation^ 
Argyll-Robertson  pupils  and  severe  pains  in  the  abdomen. 
The  knee  jerks  persisted,  and  ataxia  did  not  develop. 
At  the  necropsy  the  upper  posterior  roots  and  the  column 
of  Burdach  in  the  cervical  region  were  degenerated. 
erated  and  the  column  of  Burdach  in  the  cervical  region. 
There  was  also  degeneration  of  some  of  the  cranial  nerves 
and  of  the  oculo  motor  nuclei.  The  changes  were  atypical. 
Among  the  interesting  special  features  were  ths  springing 
mydriasis  and  the  very  slow  course.  Very  few  cases  of 
this  condition  have  been  recorded.  In  the  discussion  Mills 
stated  that  he  had  seen  the  case  in  1SS9  and  had  then  sus- 
pected syringomyelia.  He  had  seen  five  or  ten  cases  of 
high  tabes  characterized  by  paresis  of  the  eye  and  facial 
muscles,  and  disassociation  of  sensation  on  the  trunk, 
iind  sometimes  by  symptoms  of  lumbar  involvement.  He 
suggested  the  term  cervicobulbar  tabes.  Thomas,  o<  Bal- 
timore, inquired  regarding  the  frequency  of  disturbances 
of  speech  in  these  cases.  Jacoby  stated  that  his  clinical 
experience  does  not  indicate  that  these  cases  are  very  rare, 
and  mentioned  two  cases.  Collins  observes  about  5  cases 
in  100  of  this  type.  In  Dr.  Spiller's  case  the  syphilitic  virus 
had  affected  both  the  motor  and  sensory  nerve  fibers,  a 
very  rare  feature,  resembling  bulbar  palsy.  Sailer  men- 
tioned a  case  of  this  nature  with  typical  eye  symptoms, 
fulgurant  pains  and  ataxia  in  the  arms.  loss  of  sexual 
power  and  difficult  micturtation.  The  patient  suffered 
from  frequent  severe  laryngeal  crises.  He  inquired  if  these 
wore  more  frequent  in  high  tabes.  In  concluding  SpUler 
stated  that  cervical  tsbes  was  probably  not  rare  clinically. 
He  did  not  know  whether  early  involvement  of  the  eighth 
nerve  was  a  valuable  sign,  and  doubted  whether  laryngeal 


1234 


The    Philadelphia  ■ 
Medical  Journal 


SOCIETY  REPORTS 


[JUNS    29,    I*)! 


crises  were  more  common  in  this  variety.  Dr.  Collins,  of 
New  York,  reported  a  very  remarkable  case.  Some  time 
after  an  attack  of  sore  throat  the  patient  observed  atrophy 
iif  the  intreossei  of  the  right  hand,  followed  by  weakness, 
the  process  then  gradually  extended  to  the  other  limbs. 
There  was  difBculty  of  micturation,  loss  of  sexual  power, 
intense  formication,  and  spasms  in  the  lower  extremities. 
There  was  no  spasticity  and  only  quantitative  alterations 
of  the  electrical  reactions.  There  were  no  objective  sen- 
sory disturbances.  The  course  lasted  IVe  years.  At  the 
necropsy  the  muscles  showed  extensive  degeneration,  the 
nerves  chronic  interstitial  neuritis,  and  the  cord  degenera- 
tion in  the  posterior  columns.  The  cells  of  the  anterior 
cornua  and  of  the  spinal  ganglia  were  normal.  Dr.  Knapp. 
of  Boston,  exhibited  a  case  with  muscular  atrophy  in  the 
arm  and  shoulders,  analgesia  in  the  shoulders  and  Argyll- 
Robertson  pupils,  also  two  brothers  suffering  from  pseudo- 
hypertrophic muscular  atrophy.  Mills  mentioned  a  case 
occurring  in  a  man  of  75  characterized  by  weakness  and 
pain  in  the  back,  and  later  in  both  legs.  There  was  dis- 
association  of  sensation  upon  the  dorsal  surfaces  of  both 
feet.  The  reflexes  were  exaggerated,  and  at  the  necropsy 
only  degeneration  of  the  peripheral  nerves  was  found.  Der- 
cum  suggested  that  there  might  be  some  relation  between 
neurotabes  and  primary  neurotis  atrophy.  .Tacoby  sug- 
gested that  Collins'  case  was  really  one  of  multiple  neuritis, 
and  therefore  doubts  if  reactions  of  degeneration  neces- 
sarily occur  in  chronic  neuritis.  Dana  remarked  that  tabes 
may  be  superimposed  upon  progressive  muscular  atrophy, 
but  the  pathological  changes  in  Collins'  case  do  not  accord 
with  Luis  view.  Spiller  regarded  the  case  as  one  of  com- 
bined systemic  disease.  Diller  called  attention  to  the  fact 
that  a  powerful  grasp  may  persist  in  progressive  muscular 
dystrophy.  Thomas,  of  Baltimore,  mentioned  a  case  of 
bilateral  facial  palsy  that  he  regarded  as  really  one  of 
lu-ogressive  muscular  dystrophy.  Dercum  stated  that  he 
had  reported  a  case  of  progressive  muscular  dystrophy 
commencing  in  the  face.  Knapp.  of  Boston,  mentioned 
the  case  of  a  woman  who  had  fallen  upon  the  floor  at  birth, 
and  had  always  had  complete  paralysis  of  the  face.  She 
was  otherwise  normal.  Collins,  in  closing,  said  that  he 
regarded  the  case  as  one  of  degeneration  of  both  motor 
neuros  commencing  at  the  peripheral  ends. 

AFTERNOON  SESSION. 

Dercum  and  Spiller  reported  the  case  of  a  man  who  had 
had  a  right-sided  hemianesthesia  and  right  homonymous 
hemianopsia  for  seven  years  as  a  result  of  an  attack  of 
apoplexy.  At  the  necropsy  a  cyst  was  foimd  in  the  carre- 
four  sensitif  on  the  left  side,  not  involving  the  thalamus 
nor  the  motor  fibers  of  the  internal  capsule.  Mills  dis- 
cussed the  localization  of  sensory  and  motor  functions  in 
the  cortex.  He  referred  to  his  own  book  and  to  Schaetfer's 
physiology,  and  mentioned  several  points  in  favor  of  sep- 
arating the  two  areas,  laying  especial  stress  upon  astereog- 
nosis  and  several  cases  that  have  been  reported.  He  does 
not  believe  that  the  Rolandic  region  is  concerned  in  sen- 
sation. Dercum  agreed  that  the  areas  were  separate.  Wal- 
ton did  not  believe  that  definite  conclucions  should  be 
drawn  from  single  cases.  The  stereognostic  sense  is  some- 
times lost  in  pure  Rolandic  lesions.  Knapp  congratulated 
Dr.  Mills  upon  his  change  of  opinion.  He  does  not  believe 
that  the  evidence  is  sufficient  to  enable  us  to  localize  the 
center  for  stereognosis.  Langdon  mentioned  a  case  of 
■Tacksoniau  epilepsy  upon  which  operation  was  performed. 
The  arm  center  was  involved,  and  after  breaking  up  ad- 
hesions about  it,  astereognosis  occurred  and  persisted  for 
10  days,  during  which  time  there  was  some  weakness. 
Sinkler  had  a  case  of  dural  tumor  extending  into  the  Ro- 
landic region  without  astereognosis.  Burr  insisted  upon 
the  obscurity  of  the  whole  subject,  but  he  believes  that  the 
motor  region  does  not  receive  sensory  impressions.  Ster- 
eognosis is  a  conception  and  not  a  sensation,  and  therefore 
must  have  a  center.  Dercum  has  observed  astereognosis 
in  three  cases  with  parietal  lesions.  Diller  has  observed 
a  case  with  astereognosis.  1.,loyd  urged  that  the  subject  is 
at  present  insoluble.  He  believes  in  separate  areas  for  mo 
tion  and  sensation,  and  in  a  center  for  the  stereognostic 
sense.  Collins  believes  that  the  motor  and  sensory  areas 
are  identical,  but  that  they  may  involve  the  parietal  lobe. 
He  does  not  think  that  a  center  for  the  stereognostic 
sense  has  been  urovcn.  Patrick  tho\ight  that  more  facts 
were  needed.     He  reported  a  case  in  which  there  was  a 


superficial  lesion  of  the  Rolandic  region  with  sensory  dis- 
turbances. Dercum  mentioned  that  astereognosis  can  oc- 
cur in  other  conditions  than  parietal  lesions.  Sailer  re- 
ported a  case  of  locomotor  ataxia  with  astereognosis  in  one 
arm.  He  thought  that  sufficient  attention  was  not  always 
given  to  the  associated  sensory  disturbances.  Hammond 
believed  that  there  was  probably  a  definite  cen- 
ter posterior  to  the  Rolandic  region,  but  that  le- 
sions elsewhere  could  produce  astereognosis.  Dana 
held  to  the  essential  identity  of  the  sensorj-  and 
motor  areas.  Mills,  in  concluding,  stated  that  the 
opinion  regarding  the  separation  of  the  two  areas  is  gain- 
ing ground.  Burr  and  McCarthy  reported  a  case  of  acute 
multiple  neuritis  (alcoholic)  with  incontinence  of  urine  and 
fever  during  life.  At  the  necropsy  the  characteristic 
changes  were  found,  and  degeneration  of  the  vesical  plex- 
us, of  the  pneumogastric  and  phrenic  nerves.  There  was 
also  degeneration  of  the  anterior  and  posterior  spinal  roots, 
perivascular  sclerosis  in  the  cord  and  chromatolysis  of  the 
cells  and  changes  in  the  Gasserian  ganglia.  Collins  in- 
quired if  there  had  been  anemia.  Burr  replied  that  the 
changes  were  not  similar  to  those  found  in  anemic  cords. 
Patrick  inquired  if  vesical  symptoms  were  common  in  mul- 
tiple neuritis.  Fisher  and  Knapp  replied  that  they  were 
not. 

THURSDAY,    JUNE    2IJTH,    MORNING    SESSION. 

Dr.  Henry  J.  Stedman  of  Boiton  gave  an  elaborate  report 
of  a  case  of  general  paralysis  in  the  course  of  which  gan- 
grene had  occurred  in  the  fingers  of  the  right  band  and 
in  the  toes.  The  first  symptoms  had  been  loss  of  the  radial 
pulse.  After  operation  the  mental  condition  of  the  patient 
had  improved.  The  arteries  in  the  amputated  parts  were 
aproximately  normal.  Dr.  Hammond  exhibited  photo- 
graphs of  a  case  of  general  paralysis  in  which  extensive 
sloughing  of  the  sacrum,  heels,  trochanters  and  gluteal 
region  nas  occurred.  There  were  tabetic  symptoms,  but 
he  regards  the  gangrene  as  the  result  of  alterations  in  the 
cord,  possibly  of  myelitic  nature.  Dr.  Jacoby  regarded  the 
case  of  Dr.  Stedman  as  exhibiting  two  manifestations  ot 
the  action  of  the  syphilitic  virus,  the  general  paresis,  and 
the  peripheral  gangrene.  Dr.  Riggs  mentioned  a  case  of 
general  paresis  and  symmetrical  gangrene,  but  the  patient 
had  also  Brights  disease.  Spiller  mentioned  a  case  ot 
general  paresis  in  which  gangrene  of  the  band  had  oc- 
curred. There  were  changes  in  the  ulnar  arter>-,  and  de- 
generation of  the  nerve  trunks,  possibly  secondary.  The 
central  nervous  system  was  normal.  Dana  stated  that 
some  of  the  manifestations  of  symmetrical  gangrene  re- 
sembled those  of  hemorrhagic  rheumatism  and  were  amen- 
able to  the  same  forms  of  treatment.  Knapp  saw  a  case  of 
symmetrical  gangrene  in  a  child  of  8  who  had  also  otorrhea 
so  that  there  was  possibility  of  infection.  Knapp  stated 
that  Raynaud's  disease  was  not  a  morbid  entity.  Arterial 
changes  played  a  large  part  in  its  production.  In  closing 
Stedman  stated  that  he  considered  syphilis  a  large  fac- 
tor. Dr.  Knapp  exhibited  a  patient  with  muscular  dystro- 
phy involving  the  muscles  of  the  face.  He  called  attention 
to  the  fact  that  many  of  these  patients  were  able  to  work 
when  the  disease  was  far  advanced.  Dr.  Putnam  and  Dr. 
Williams  reported  three  carefully  studied  cases  of  tumor 
of  the  corpus  callosum.  presenting  various  symptoms, 
some  of  which  were  due  to  the  involvement  of  neighboring 
structures.  They  then  gave  a  very  thorough  analysis  of  the 
literature  of  the  subject.  Dr.  Sinkler  reported  four  cases 
of  brain  tumor.  The  first,  a  neurotic  individual,  had  had 
trouble  for  8  or  9  years  with  the  left  arm.  several 
years  later  there  was  a  history  of  a  severe  injury 
to  the  head.  There  were  later  attacks  of  melancholia, 
spasticity  on  the  left  side,  and  optic  neuritis.  .\stereo- 
.gnosis  did  not  exist.  A  spindle  cell  sarcoma  of  the  dura 
was  removed  from  the  right  Rolandic  region.  The  second 
had  optic  neuritis,  hemianopsia  and  other  symptoms,  the  re- 
sult of  a  secondary  carcinoma  of  the  occipital  lobe.  The 
third  case  had  complex  symptoms  as  a  result  of  two 
growths,  one  in  the  motor  region  and  another  at  the  base. 
The  fourth,  a  man  of  50.  had  lost  sexual  desire  for  three 
years.     He  developed  symptoms  of  dementia,  increased  re- 


June  29.   19011 


SOCIETY  REPORTS 


[The    Philadelphi-a. 
Medical  Jottrnal 


1235 


flexes,  eroticism,  etc.  A  large  tumor  was  found  in  the 
right  frontal  region  involving  the  corpus  callosum  and  the 
left  frontal  lobe,  and  a  small  growth  in  the  left  occipital 
lobe.  Dr.  Leszynsky  and  Dr.  Glass  reported  a  case  that  had 
presented  weakness  and  spasticity  on  the  left  side,  slowly 
increasing  for  several  years.  A  dural  endothelioma  press- 
ing upon  the  arm  and  leg  center  of  the  right  hemisphere 
was  removed  and  the  patient  recovered  with  a  slight  re- 
sidual hemiparesis.  Dr.  Hammond  exhibited  a  case  of  a 
brain  with  a  tumor  that  compressed  the  right  half  of  the 
pons  and  the  fifth  nerve.  Dr.  Knapp  exhibited  a  specimen 
of  a  large  tumor  of  the  brain.  In  the  discussion  of  these 
cases  Dr.  Sachs  called  attention  to  the  adaptability  of 
the  brain  to  pressure,  not  only  the  motor  and  sensory,  but 
also  the  mental  functions  adapting  themselves  to  the 
changed  conditions.  He  mentioned  a  case  with  mental 
symptoms  varying  from  dementia  to  normal,  whilst  the 
optic  neuritis  gradually  progressed  to  blindness.  Also  a 
case  of  trigemenial  pain  due  to  pressure  from  a  tumor  in 
the  parietal  lobe,  relieved  by  trephining.  Knapp  men- 
tioned two  cases  with  tumor  of  the  corpus  callosum  and  a 
third  case,  probably  of  this  nature,  now  under  observation. 
I.loyd  mentioned  a  case  of  tumor  of  the  corpus  callosum  in- 
vading the  paracentral  lobule  that  gave  rise  to  lock  spasm, 
the  patient  being  unable  to  relax  his  grasp;  this  he  regards 
as  a  symptom  of  cortical  irritation.  It  is  possible  that  slow- 
ly increasing  tumor  does  not  cause  epileptic  attacks.  Diller 
suggested  that  operation  upon  cerebral  tumors  be  done  In 
two  stages,  and  reported  a  case  successfully  treated  in  this 
manner.  The  trephining  relieved  the  headache.  Spiller 
had  seen  three  operations  upon  dural  tumors  in  which  there 
was  considerable  hemorrhage,  and  also  a  case  of  probable 
cerebellar  tumor  in  which  the  symptoms  were  relieved  by 
trephining,  although  no  tumor  was  found.  Browning  stated 
that  trephining  often  gives  only  temporary  relief,  and  the 
same  result  may  be  obtained  by  the  administration  of 
gelsemium.  Mills  believed  that  the  chief  symptoms  of 
callosal  tumors  were  due  to  the  involvement  of  neighboring 
parts.  He  urged  that  all  cerebral  operations  should  be 
done  rapidly.  Jacoby  agreed  that  speed  was  important. 
He  had  observed  that  operations  upon  dural  tumors  gave 
rise  to  considerable  hemorrhage.  Langdon  mentioned  four 
cases  of  cerebellar  tumor  improved  by  operation.  He  be- 
lieves operation  desirable  if  there  is  any  chance  at  all, 
especially  if  there  is  optic  neuritis.  Sailer  suggested  that 
prophylactic  gelatine  injections  might  be  of  advantage 
in  cerebral  operations  in  which  hemorrhage  was  expected. 
Sinkler  urged  speed  in  cerebral  operations.  Putnam  also 
ui'ged  speed.  Lumbar  puncture  was  often  valuable  as  a 
preliminary  measure.  He  approved  of  the  use  of  gelatine 
Dr.  Ayres  exhibited  a  specimen  of  osteoplaque  of  the  dura. 

AFTERNOON    SESSION. 

Dr.  Sailer  reported  a  case  of  cerebellar  tumor  occurring 
In  a  child  of  three.  Sometime  after  a  severe  fall  the  pa- 
tient developed  strabismus,  impaired  vision, staggering  gait, 
lost  reflexes  and  a  pulsating  tumor  upon  the  occipital  bone 
with  thrill  and  murmur.  A  meningocele  was  suspected, 
but  operation  disproved  its  existence.  The  patient  died  and 
a  tumor  of  the  cerebellum  was  found.  There  was  no  scler- 
osis in  the  spinal  cord.  Gordonier  reported  a  case  of  cere- 
bellar tumor  with  staggering  gait,  nystagmus,  headache,  ex- 
aggerated reflexes.  At  the  necropsy  a  tumor  of  the  super- 
ior vermiform  process  was  found  involving  the  corpora 
quadregemina.  The  histological  findings  were  very  care- 
fully reported.  Knapp  considered  operation  justifiable  in 
cerebellar  tumors.  The  knee  jerks  are  usually  exaggerated, 
their  loss  may  be  due  to  cord  lesions.  In  a  case  of  tumor  of 
the  frontal  lobe,  cerebellar  symptoms  had  been  present. 
Dercum  stated  that  the  knee  jerks  are  variable  in  cere- 
bellar tumors.  Their  loss  is  perhaps  due  to  irritative,  their 
return  to  destructive  lesion*.  Browning  mentioned  a  case 
with  intermittent  toxic  contractions  of  the  muscles  of  the 
neck.  Fisher  inquired  regarding  the  situation  of  pain  In 
cerebellar  disease.     Langdon  mentioned  a  case  in  which 


the  headache  had  been  frontal.  In  closing  Sailer  stated 
that  eases  had  been  reported  in  which  the  loss  of  knee 
jerks  was  unilateral.  He  quoted  the  views  of  Beesor.  His 
own  case  had  not  complained  of  headache.  Dr.  Pierce 
Bailey  read  a  paper  on  traumatic  hysteria  with  the  report 
of  a  number  of  cases  and  the  effect  of  ligation  upon  their 
condition.  He  stated  that  he  regarded  hysteria  as  a  form 
of  delusional  insanity.  Dr.  Langdon  mentioned  the  case 
of  a  man  who  some  years  after  an  injury  had  developed 
astasia  abasia.  He  had  hemianesthesia  transferable  by 
hypnotism.  Diller  mentioned  a  case  that  presented  symp- 
tom 41*  years  after  settlement.  These  were  cured  by  sug- 
gestion. He  also  mentioned  other  cases.  Knapp  urged 
that  hearsay  evidence  was  useless.  He  mentioned  a  case 
injured  by  foot-pads,  that  had  shifting  anesthesia  and 
varying  visual  fields.  Later  he  developed  typical  dissemin- 
ated sclerosis.  He  regards  the  physical  condition  of  the 
patient  as  more  important  than  heredity.  Herrick  inquired 
to  what  extent  Dr.  Bailey  employs  the  educational  method. 
Riggs  mentioned  a  case  of  traumatic  hysteria  with  de- 
mentia. Bailey  in  closing  said  that  it  is  very  difficult  to  ob- 
tain subsequent  histories  in  these  cases  and  that  we  must 
depend  upon  the  ability  of  the  patient  to  work  or  not. 
Dr.  Lloyd  reported  as  a  hypothetical  case,  the  instance  of  a 
man  employed  to  etch  glass  who  developed  the  form  ot 
wrist  drop  characteristic  of  lead  poisoning.  There  were 
none  of  the  other  symptoms.  He  had  prertously  worked  in 
lead,  and  the  question  arose  whether  hydrofluroic  acid  could 
have  produced  the  condition.  Courtney  suggested  that  lead 
was  liberated  in  the  etching  of  glass.  Knapp  inquired  if 
lead  had  been  found  in  the  urine.  Lead  does  not  always 
produce  typical  wrist  drop,  it  may  cause  paralysis  of  the 
shoulder,  foot  drop  and  even  of  the  whole  arm.  Lloyd,  in 
closing,  did  not  believe  that  enough  lead  was  liberated  in 
etching  glass  to  cause  poisoning.  The  supinators  are 
rarely  involved  in  lead  paralysis.  Hydrofluoric  acid  is 
purely  corrosive.  Dr.  Dercum  read  a  paper  on  the  classifi- 
cation of  insanity  to  which  the  unusual  honor  of  an  exten- 
sion of  the  time  limit  was  accorded.  His  classification  is 
purely  clinical  and  can  perhaps  be  called  a  grouping;  in 
brief  it  consists  of  five  groups.  1st  delirium,  confusion  and 
stupor;  2d,  mania  and  melancholia,  to  which  circular  in- 
sanity may  be  added;  3d,  paranoia;  4th,  neuresthenic  in- 
sanity; oth,  dementia.  Lloyd  admits  that  the  present  clas- 
sification of  insanity  is  unsatisfactory.  He  is  not  sure  that 
mania  and  melancholia  are  closely  associated,  although 
both  may  occur  in  the  same  case.  Many  phychoses  are  de- 
generative in  type,  and  he  does  not  believe  that  the  true 
psychoses  should  be  so  sharply  separated  from  ihe  degen- 
erative insanities  as  Kraft  Ebing  suggests.  Knapp  believes 
that  we  should  agree  in  methods  of  examination,  and  that 
the  localization  of  the  process  is  more  important  than  its 
nature.  Dementia  is  a  terminal  process  as  the  results  of  an 
active  process  that  interferes  with  the  function  of  the  neu- 
rons. He  has  observed  systemic  delusions  unattended  by 
delirium,  produced  by  alchohol.  Mills  is  not  prepared  to 
admit  the  close  relationship  of  mania  and  melancholia.  He 
regards  Dercum 's  classification  as  useful.  Fisher  believes 
that  no  clinical  classification  can  be  satisfactory.  Mania 
and  melancholia  differ  clinically.  Dercum  in  closing  argued 
that  a  clinical  classification  was  the  simplest  and  clearest. 
Dementia  is  a  clinical  entity  and  must  be  classified.  He 
does  not  believe  that  a  poison  can  ever  produce  paranoia 
although  alcohol  may  predispose  to  it. 


Torticollis  Treated  by  Suture  of  the  Sterno-mastold  Ten- 
don.— Dr.  B.  Sengenesse  reports  two  cases  of  torticollis  in 
children,  which  were  cured  by  open  division  of  the  mastoid 
tendon,  after  which  a  collar  was  applied.  This  was  re- 
moved daily  while  movements  of  the  head  were  practice<l. 
In  both  cases  permanent  recovery  resulted.  Sengenesse 
oDjects  to  subcutaneous  tenotomy,  thinking  an  incision 
large  enough  to  see  the  tendon  is  necessary.  This  is  sewed 
up  at  once  and  the  collar  applied.  Movements  of  the  head 
are  to  be  begijn  the  day  after  operation. —  (AHiinles  dv  In 
rnlitliiii<iii-  lie  lioKli'iiij:  1901,  No.  5).     [M.  O] 


12 


?6 


Medical  Journal 


] 


THE  LATEST  LITERATURE 


[JUNE  29.   1903 


^be  Xatest  literature. 


BRITISH    MEDICAL    JOURNAL. 
June  8th,   1901. 

1.  An  Address  on  Some  of  the  Anatomical  Associations  of 

the  Kidneys,   from   a  Surgical   Point  of  View.     ED- 
MUND OWEN. 

2.  Remarks  on  Skiagraphy  and  Fractures;   Especially  in 

their  Medico-Legal  Relation.     C.  H.  GOLDING-BIRD. 
S.     A  Case  of  Oblique  Fracture  of  Tibia  aud  Fibula  with 
Skiagraphs  Showing  Repair.     BENJAMIN  DUKE. 

4.  Deformity     of     Chinese     Lady's     Foot.       J.     DUNCAN 

THOMSON. 

5.  A  Case  of  Cervical  Rib.    T.  E.  GORDON. 

6.  The  Kffect  of  the  Rontgen  Rays  in  a  Case  of  Chronic 

Carcinoma  of  the  Breast.     ANDREW  CLARK. 

7.  Note    on    the    Pathology    of     Toxic    Amblyopias.      J. 

HERBERT  PARSONS. 
S.     Paralysis     of     the     Cervical     Sympathetic.       PURVIS 
STEWART. 

1. — Edmund  Owen  discusses  the  anatomical  associations 
of  the  kidney  from  a  surgical  standpoint,  dealing  first  of 
all  with  the  nerve  associations  of  the  kidney.  Under  this 
head  is  mentioned  the  association  of  pain  in  the  tostiele 
in  cases  of  renal  disease,  which  is  accounted  for  by  the 
fact  that  the  testicle  is  developed  in  close  association  with 
and  proximity  to  the  kidney.  The  question  of  vomiting 
is  mentioned,  and  its  possible  origin  in  a  disturbance  of  the 
pneumogastric  due  to  kidney  infection.  The  vascular 
associations  of  the  kidney  are  next  described  and  the 
relation  between  the  kidney  and  the  peritoneum.  In  speak- 
ing of  the  associations  of  the  kidney  with  the  colon  the 
author  cites  several  instances  in  which  a  malignant  disease 
of  the  colon  has  been  improperly  diagnosed  as  disease  of 
the  kidney.  Because  of  the  relationship  between  the 
stomach  and  the  left  kidney  diseases  of  these  organs  have 
not  infrequently  been  mistaken  for  one  another.  In  speak- 
ing of  rupture  of  the  kidney  the  author  thinks  that  ne- 
phrectomy should  not  be  done  unless  absolutely  necessary 
since  the  more  conserrative  methods  of  treatment  preserve 
the   kidney.      [J.   H.   G.] 

2. — Treated  editorially. 

3. — Benjamin  Duko  reports  a  case  of  oblique  fracture  of 
th«  tibia  and  fibula,  in  which  at  the  time  of  the  accident 
and  during  the  subsequent  treatment  of  the  case  up  to  the 
SOth  day  only  a  fracture  of  the  fibula  was  suspected.  A 
skiagraph  at  thi.s  time,  however,  showed  that  there  had 
also  been  an  oblique  fracture  of  the  tibia,  and  that  separa- 
tion of  the  fragments  was  quite  marked.  The  patient  re- 
covered with  most  excellent  function  of  the  part,  being 
able  to  dance,  play  tennis,  and  walk  great  distances.  The 
case  illustrates  the  fact  that  X-ray  pictures  are  no  indica- 
tion as  to  the  subseouent  outcome  of  cases  of  fracture. 

[J.  H.  G.] 

5. — T.  E.  Gordon  reports  a  case  of  cervical  rib  in  which 
there  occurred  obliteration  of  the  arteries  of  the  right  arm 
with  a  re.sulting  gangrene  of  a  portion  of  several  fingers, 
and  in  wliich  excision  of  the  rib  was  productive  of  great 
improvement.  Tlio  author  discusses  at  great  length  the 
question  of  obliteration  of  the  blood  vessels  in  its  relation 
to  pressure,  and  quotes  extensively  from  the  literature  of 
the  subject.     The  conclusions  reached  are  as  follows: 

1.  The  cervical  rib  was  in  some  way  the  cause  of  the  ar- 
terial obliteration. 

2.  The  circulation  through  the  subclavian  was  not  ob- 
structed. 

3.  The  occurrence  of  embolism  may  be  excluded. 

4.  The  manner  of  the  obliteration  suggests  thrombosis, 
which  in  turn  implies  a  preceding  disease  of  the  endo- 
thelium. 

.').  The  cause  of  this  arterial  disease  is  very  probably,  in 
part,  the  carrying  of  heavy  weights. 

t).  If  the  rib  acted  directly  on  the  artery,  it  must  have 
done  so  in  some  way  upon  which  present  pathology  throws 
no    light. 


7.  The  rib  may  have  acted  indirectly  on  the  artery 
through  the  nerves. 

8.  The  nerves  are  more  likely  to  have  suffered  than  the 
artery,  and  nervous  symptoms  are  much  more  common 
than  circulatory. 

9.  A  nerve  lesion  is  capable  of  causing  gangrene. 

10.  A  nerve  lesion  may  cause  structural  changes  in  the 
blood  vessels. 

11.  The  absence  of  clear  signs  of  a  peripheral  neuritis 
is  a  striking  argument  against  the  theory  of  nerve  origin. 

12.  The  case  resembles  the  local  phenomena  of  Raynaud's 
disease,  which  is  almost  certainly  a  neurosis,  and  here 
there  is  commonly  an  absence  of  usual  symptoms  of 
neuritis. 

13.  In  Raynaud's  disease,  however,  the  arteries  are  stated 
to  be  usually  healthy. 

14.  From  the  occurrence  of  such  changes  in  Raynaud's 
disease,  we  may  conclude  that  not  only  from  nerve  lesions 
generally,  but  from  disease  of  vasomotor  nerves  in  par- 
ticular, structural  changes  in  arteries  may  arise. 

l.j.  In  cases  of  cervical  rib  there  occasionally  occur 
symptoms  which  may  possibly  be  explained  by  injury  to 
the  cervical  sympathetic.  Such  are  (1)  increased  heart  ac- 
tion; (2)  excessive  subclavian  pulsation,  and  sometimes 
fiisiform  dilatation  of  the  artery;  (3)  abnormal  sensitive- 
ness of  the  arm  affected  to  external  cold;  (4)  thyroid 
enlargement. 

A  study  of  the  anatomy  of  the  region  concerned  sug- 
gests that  the  abnormal  rib  may  have  excited  its  evil  ef- 
fects not  at  its  distal,  but  at  its  proximal  extremity;  here 
the  rib  is  an  intimate  relation  not  only  of  the  seventh  and 
eighth  cervical  and  first  dorsal  nerves,  but  also  of  the  in- 
ferior cervical  sympathetic  ganglion  and  its  branches.  The 
number  of  these  s.vmpathetic  connections  is  much  greater 
with  the  lower  than  the  upper  brachial  nerve  trunks." 

[J.  H.  G.] 

6. — Andrew  Clark  reports  a  case  of  carcinoma  of  the 
breast  too  far  advanced  for  operation  in  which  the  use  of 
the  X-ray  for  nine  weeks  produced  a  marked  Improvement. 
In  this  case  the  rays  were  applied  for  15  minutes  at  a  time 
for  5  days  out  of  a  week.  The  ulceration  and  discbarge 
greatly  diminished  and  the  axillary  glands  became  smaller 
and  general  improvement  followed.     [J.  H.  G.] 

7. — A  contribution  by  J.  Herbert  Parsons  to  the  path- 
ology of  toxic  amblyopias  and  a  brief  r6sum6  of  the  re- 
searches that  have  been  conducted  since  Samelsohn  in- 
vestigated the  changes  occurring  in  the  papillo-macular 
bundles   of  the  optic   nerve  in  tobacco  amblyopia. 

[M.  R.  D.]  • 

8. — Stewart  reports  the  case  of  a  man  30  years  of  age 
who  presented  to  a  marked  degree  nearly  all  the  classic.M 
S.N  mptoms  of  the  paralysis  of  the  cervical  sympathetic,  and 
who  presented  to  a  marked  degree  nearly  all  the  classical 
limits  of  anidrosis.  The  patient  was  a  soldier  who  had 
been  wounded  in  the  left  side  of  the  neck  by  a  Mauser 
bullet.  The  bullet  entered  1'.^  inches  below  the  mastoid 
process  and  came  out  through  the  seventh  right  interspace 
in  the  posterior  axillary  line.  At  the  time  of  the  injury 
he  felt  an  "electric  shock"  all  over  his  body,  but  especially 
in  the  right  arm.  which  immediately  became  totally  para- 
lyzed .  At  the  same  time  he  suffered  from  hemoptysis, 
which  persisted  for  3  days,  together  with  dysphagia.  The 
patient's  temperature  became  normal  on  the  fourth  day. 
and  he  was  soon  able  to  go  about.  The  right  arm  gradu- 
ally recovered  its  lost  power  so  that  it  nearly,  but  not 
quite,  reached  the  normal.  Vision  in  the  right  eye  was 
slightly  impaired.  The  patient  did  not  sweat  on  the  right 
side  of  the  face  and  neck,  nor  on  his  right  upper  extremity. 
Thera  was  no  atrophy  of  any  of  the  muscles.  There 
was  an  area  of  slight  analgesia,  along  the  inner 
side  of  the  whole  right  upper  extremity  to  the 
fingers.  On  the  dorsal  surface,  the  ane.sthetic  area 
extended  quite  to  the  outer  border  of  the  arm  and  forearm, 
and  on  the  anterior  surface  it  extended  down  the  center 
of  the  limb,  passing  longitudinally  through  the  ring  finger, 
both  on  its  palmar  and  dorsal  surfaces.  The  right  pupil 
was  smaller  than  the  left,  as  was  also  the  right  palpebral 
tissue.  There  was  also  slight'euophthalmus  on  the  right 
side.  The  lesion  was  evidently  one  which  affected  the  en- 
tire right  brachial  plexus  as  well  as  the  right  *>-mpathetic 
nerve.     [J.  M.  S.] 


June  29.   1901] 


THE  LATEST  LITERATURE 


[The    Philadelphia 
Medical  Journal 


1237 


LANCET. 

Juiw  8th,   1901. 

1.  An  Address  ou  Some  of  the  Anatomical  Associations 

of    the    Kidneys,    from    a    Surgical    Point    of    View. 

EDMUND  OWEN. 

See  abstract  of  liritisli  Medical  Journal. 

2.  A  Clinical  Lecture  on  Retention  of  Urine.     CHRISTO- 

PHER HEATH. 

3.  An  Early  Experience  Concerning  the  Therapeutic  Vir- 

tues of  Iodide  of  Potassium  in  Asthmatic  Affections. 
SIR  W.  T.  GAIRDNER. 

4.  Rat  Plague;  A  Preliminary  Communication  on  an  Out- 

break of  Disease  in  Rats  at  Cape  Town.     ALEXAN- 
DER EDINGTON. 

5.  Alcohol  and  Arsenic  in  the  Etiology  of  Alcoholic  Neu- 

ritis.    E.  FARQUAR  BUZZARD. 
li.     All  E.xplanatiou  of  the  Vulnerability  of  the  Apices  in 

Tuberculosis   of  the   Uungs.     E.   H.   COLBECK   and 

ERIC  PRITCHARD. 
7.     The    Surgical    Treatment    of    Ulcers    of   the    Stomach 

which   are  or  have  been   Complicated   with   Severe 

Hemorrhage.     C.  B.  KEETLEY. 
S.     Vitality     After     Severe     Injury.       W.     H.     CLAYTON 

GREENE. 
s.     The  Morbid  Anatomy  and  Origin  of  the  Various  Presys- 
tolic Murmurs  Heard  at  the  Apex.     C.  C.  GIBBES. 

2. — Christopher  Heath  makes  retention  of  urine  the 
rubject  of  a  clinical  lecture.  Reference  is  first  made  to 
retention  occurring  at  birth  from  a  tight  prepuce.  Later  in 
life  obstruction  may  occur  in  a  child  from  impaction  of  a 
calculus.  This  is  not  infrequent  and  should  always  be 
thought  of.  Reference  is  also  made  to  retention  following 
a  tight  thread  about  the  penis  placed  either  by  the  child 
or  the  parent  or  the  nurse  to  prevent  nocturnal  enuresis. 
A  case  is  recalled  in  which  gangrene  of  glands  resulted 
from  this  cause.  Gonorrheal  retention  may  be  due  to  an 
inflamed  prostate.  A  digital  examination  of  the  rectum 
should  always  be  made  when  retention  occurs  in  the 
course  of  this  disease.  It  must  net  be  forgotten,  however, 
that  a  prostatitis  may  result  from  other  causes  thau  from 
gonorrhea.  Spasmodic  retention  occurs  later  in  the  course 
of  gonorrhea,  and  is  usually  the  result  of  excessive  indulg- 
ence in  alcohol.  In  retention  from  stricture  after  the 
condition  has  been  relieved  with  the  catheter  it  is  well 
to  leave  the  instrument  fixed  in  the  urethra.  Where  it  Is 
Impossible  to  empty  the  bladder  by  means  of  a  catheter 
aspiration  above  the  pubes  is  recommended.  The  author 
asserts  that  it  is  a  safe  method  of  procedure  if  properly 
and  aseptically  done,  and  that  unless  too  frequently  repeat- 
ed, is  not  apt  to  produce  infection.  Retention  from  anato- 
my of  the  bladder  is  next  described.  In  this  connection  it 
must  be  always  remembered  that  dribbling  of  urine  indi- 
cates a  distended  bladder,  and  in  such  instances  the  blad- 
der should  always  be  emptied  every  6  to  8  hours  for  several 
days  and  strychnia  administered.  Sometimes  the  electric 
current  is  of  value  in  these  cases.  Retention  from  an  en- 
larged prostate  is  finally  mentioned,  and  the  author  calls 
attention  to  the  fact  that  retention  may  occur  from  en- 
larged prostate  after  exposure  to  cold  when  before  the 
,  enlarged  gland  had  given  rise  to  no  trouble.  The  use  of 
the  catheter  in  those  cases  will  nearly  always  bring  away 
some  blood,  and  it  is  well  to  prepare  the  patient  for  this 
before  the  instrument  is  passed.  The  hemorrhage  in  these 
cases  is  seldom  serious.  Occasionally,  however,  it  may  be 
found  that  the  bladder  is  filled  with  large  clots.  In  these 
cases  great  benefit  will  follow  the  administration  of  opium. 
Hysterical  retention  is  mentioned,  and  the  use  of  the  cath- 
eter in  these  cases  is  to  be  avoided.  The  condition  usu- 
ally occurs  in  young  females  and  and  is  relieved  by  a  hot 
bath  or  by  suddenly  throwing  cold  water  over  the  head  and 
shoulders.     [J.  H.  G.] 

3. — Gairdner  gives  an  account  of  an  early  experience 
concerning  th(^  therapeutic  virtues  of  potassium  Iodide  in 
asthmatic  affections.  The  author  gives  a  detailed  acount 
of  a  case  that  was  treated  with  the  iodides  with  favorable 
results.     [P.  J.  K.] 

4. — Ediugton  has  contributed  to  medical  literature  a  pre- 
liminary communication  on  an  outbreak  of  rat  plague  at 
Cape  Town.  Upon  the  author's  arrival  at  Cape  Town  he 
was     informed     by     the     Colonial     Secretary     that     rats 


were  dying  of  bubonic  plague.  The  author  examined  a 
rat  that  had  died  in  one  of  the  docks  and  Isolated  from 
this  animal  a  bacillus  with  rounded  ends,  its  size  varying 
from  4  micromillimeters  to  L.5  micromillimeters  in  length, 
and  from  1.2  to  1  micromillimeters  in  breadth.  This  micro- 
organism did  not  show  the  well  marked  bipolar  staining 
reaction  which  is  so  characteristic  of  the  bacillus  pestis. 
In  the  primary  culture  there  was  great  morphological  vari- 
ation in  the  bacteria.  Some  of  the  micro-organisms  were 
diplococci  or  diplobacteria,  while  others  were  somewhat 
spherical.  This  rat  bacterium  was  found  to  be  pathogenic 
to  guinea  pigs,  the  animals  dying  a  few  days  after  inocula- 
tion, but  the  micro-organism  was  not  pathogenic  to  rab- 
bits. Rabbits  inoculated  by  this  rat  plague  were  not  pro- 
tected from  bubonic  plague  when  subsequently  inoculated 
with  the  bacillus  pestis.  Pigeons  were  highly  susceptible 
to  the  rat  disease.  The  author  concludes  that  there  are 
marked  differences  between  this  rat  disease  and  bubonic 
plague.     [F.  J.  K.] 

5. — Buzzard  discusses  alcohol  and  arsenic  in  the  etiology  of 
alcoholic  neuritis,  and  concludes  that  clinical  observation 
is  responsible  for  alcoholic  neuritis,  and  further,  that  in 
London  alcoholic  neuritis  more  often  follows  spirit-drinking 
than  from  other  kinds  of  alcoholic  beverages.     [F.  J.  K.] 

6.— Colbeck  and  Pritchard  suggest  an  explanation  for  the 
vulnerability  of  the  apices  of  the  lung  to  tuberculosis. 
These  authors  conclude  thai  alteration  in  the  shape  of  the 
chest  combined  with  misplacement  and  deficient  musculat- 
ure of  the  shoulder  girdle  are  largely  responsible  for  the 
susceptibility  to  tuberculosis.     [P.  J.  K.] 

7. — C.  B.  Keetley  discusses  the  surgical  treatment  of 
ulcer  of  the  stomach  in  which  there  occurs  hemorrhage. 
The  author  differentiates  between  severe  hemorrhage  and 
slight  hemorrhage,  the  danger  of  the  former  being  immedi- 
ate and  remote  and  of  the  latter  only  remote.  Four  cases 
are  reported.  Case  No.  1 — Female,  aged  20  years:  a  gast- 
tric  ulcer  adherent  to  the  diaphragm  and  pancreas.  The 
patient  had  had  considerable  hemorrhage,  the  last  being 
nearly  fatal.  The  ulcer  was  severed  and  sutured,  the  pa- 
tient recovering.  The  pain  returned  and  gastroenteros- 
tomy was  done,  w-hich  cured  the  patient.  Case  No.  2 — Fe- 
niale.  aged  32.  suffered  from  a  severe  gastric  hemorrhage. 
In  this  case  rest  and  opium  and  rectal  feeding  were  em- 
ployed; no  operation  was  done  and  the  patient  died  on  the 
12th  day.  Case  No.  3 — Woman,  aged  39  years,  had  suffered 
from  gastric  trouble  for  a  long  time  and  had  had 
numerous  severe  hemorrhages  In  this  case  Loreta's  op- 
eration was  done,  the  pylorus  being  stretched  to  4% 
inches,  internal  circumference.  This  operation  was  fol- 
lowed by  recovery.  Case  No.  4. — Was  one  which  was  not 
under  the  author's  care.  The  patient  was  a  man  of  40  years 
of  age  who  suffered  from  a  duodenal  ulcer  which  perforated 
the  pancreaticoduodenal  artery  and  produced  death.  No 
operation  was  done  in  this  case.  The  author  thinks  that 
the  bleeding  vessels  in  the  gastric  wall  should  be  tied,  and 
that  pressure  alone  should  not  be  relied  upon.  The  benefit 
following  operation  for  gastric  ulcer  is  discussed  at  some 
length,  and  particularly  the  question  of  keeping  the  stom- 
ach contents  in  an  aseptic  condition.  It  has  been  suggested 
that  the  good  results  following  gastro-enterostomy  are  due 
to  the  fact  that  the  bile  and  pancreatic  secretion  pass  into 
the  stomach  in  small  quantities  and  produce  there  an 
aseptic  effect.  If  there  be  any  truth  in  this  theory  the  au- 
thor suggests  the  possibility  of  administering  orally  the 
secretions  of  the  liver  and  the  pancreas  or  the  fresh  glands 
themselves  in  the  medical  treatment  of  gastric  ulcer.  At- 
Intion  is  called  to  the  very  excellent  results  following  the 
operative  treatment  of  gastric  ulcer,  particularly  when 
hemorrhage  is  present.     [J.  H.  G.J 

8. — W.  H.  Clayton  Greene  reports  a  case  of  a  man  who 
fell  some  distance  and  was  impaled  upon  an  iron  railing. 
Vi'ith  stimulation  the  patient  lived  for  9  hours.  At  the 
post-mortem  there  was  found  a  fracture  of  the  sixth,  sev- 
enth, eighth,  ninth  and  tenth  ribs,  complete  perforation 
of  both  walls  of  the  stomoch,  perforation  and  laceration  of 
the  diaphragm,  collapse  of  the  left  lung  and  perforation 
of  the  pericardium  and  of  the  left  ventricle.     [J.  H.  G.] 

9. — Gibbes  writes  upon  the  morbid  anatomy  and  the 
origin  of  the  various  presystolic  murmurs  heard  at  the 
apex.  The  author  states  that  the  presystolic  murmurs 
heard  at  the  apex  cannot  be  regarded  as  pathognomic  of 
mitral   sounds.     The   presystolic   murmur  has   been   heard 


12^8 


The    Philadelphia  "] 
Medical  Journal  J 


THE  LATEST  LITERATURE 


[Jl-ke  29,  !»« 


(luring  life  under  the  following  conditions:  ll)  mitral 
disease  (stenosis):  (2)  a  thrombus  in  the  left  auricle  ob- 
structing the  mitral  orifice;  (3)  dilatation  of  the  mitral 
orifice  without  valvulitis,  the  heart  being  dilated  and  hy- 
pertrophied:  (4)  hypertrophy  and  dilatation  of  the  ventri- 
cles without  thickening  and  roughening  of  the  mitral  seg- 
ments: (5)  hypertrophy  of  the  left  ventricle  with  aortic 
insufficiency:  (6)  aortic  stenosis  with  fusion  of  the  aortic 
cusps,  permitting  regurgitation:  (7)  hypertrophy  of  the 
left  ventricle  from  nephritis  with  slight  thickening  of  the 
anterior  mitral  flap,  and  thickening  of  the  chordae;  (8) 
hypertrophy-  and  dilatation  of  the  right  ventricle  from 
atheroma  of  the  pulmonary  artery,  with  the  right  ventricle 
from  atheroma  of  the  pulmonary  artery,  with  dilatation  of 
the  mitral  orifice,  and  pericardial  adhesions.  The  author 
emphasizes  that  the  presystolic  murmur  cannot  entirely 
arise  from  the  auriculo-systolic  blood-current.     [F.  J.  K.] 


MEDICAL    RECORD. 

June  ?,?,  IDlll. 

1.  Hernia  of  the  Urinarv  Bladder.     W.  S.  CHEESMAN. 

2.  The  Nauheim  Treatment.     H.  NEWTON  HEINEMAN. 
.■5.     Nephrorrhaphy  with  Flap  Fixation.    ARNOLD  STRUM- 

DORF. 

1. — W.  S.  Cheesman  reports  a  case  of  hernia  of  the  urin- 
ary bladder  and  includes  the  discussion  and  review  of  ISO 
cases  collected  from  the  literature.  The  bibliography 
is  especially  valuable.  The  principal  cause  of  bladder  her- 
nia is  direct  traction  exercised  through  the  peritoneal  coat 
by  the  weight  of  the  hernial  mass,  or  by  pull  on  the  sac 
during  ligation  in  operations  for  radical  cure.  In  one- 
sixth  of  tile  cases  symptoms  occur  sufficient  to  arouse  sus- 
picion, sometimes  amounting  to  certainty  of  the  existence 
of  the  abnormality.  In  about  one-fourth  of  the  cases,  it 
may  be  possible  during  operation  to  recognize  the  bladder 
and  avoid  injuring  it,  and  after  one  hernial  sac  has  been 
found,  any  structure  resembling  a  second  should  be  re- 
garded as  bladder,  until  proved  otherwise.  When  the  blad- 
der is  wounded,  the  best  procedure  is  immediate  suture 
by  two  layers  of  catgut,  and  closure  of  the  hernial  wound 
by  Hassini's  method: a  small  drain  only  being  left  leading 
to  the  bladder  suture  line.  The  bladder  wall,  when  thin, 
may  be  freely  resected  preparatory  to  closure.  It  is  found 
ibat  urinary  fistula  nearly  always  closes  spontaneously. 
Injuries  of  the  bladder  have  been  directly  responsible  for 
death  in  only  10%  of  the  hernia  cases  in  which  they  oc- 
curred.    LT.  L.  C] 

2. — H.  N.  Heineman.  of  New  York,  contributes  a  carefully 
prepared  article  on  the  Nauheim  treatment.  This  paper 
is  based  upon  the  author's  personal  experience  at  Nauheim 
for  two  months  for  each  year  for  ten  successive  years.  The 
method  of  the  treatment  is  given  in  detail.  The  factors  in 
applying  the  baths  which  constitute  an  important  ele- 
ment are:  First.  The  warmth  and  the  fact  that  it  is  a 
natural  warmth,  avoiding  any  injurious  application  of 
heat  by  which  important  elements  are  dissipated.  Second. 
'I'he  presence  of  alkaline  salts  and  of  metals  in  large  Quan- 
tities, and  of  rarer  elements  whose  exact  value  is  uncertain. 
Third.  The  large  quantity  of  carbolic  acid  held  in  an  ic- 
live  form  and  its  coincident  combination  with  salts  and 
other  elements.  Finally.  A  certain  quantity  of  electro- 
magnetism  or  magneto-electricity  wljich  these  waters  have 
in  common  with  other  springs.  When  patients  with  weak 
hearts  are  placed  in  a  Nauheim  bath  of  the  usual  tempera- 
ture of  ?>?,%°  to  35°  C,  they  first  experience  a  feeling  of 
oppression  of  the  sternum,  which  is  at  times  somewhat  un- 
comfortable, but  is  never  serious  and  soon  passes  off.  The 
patient's  pulse  becomes  slower  and  fuller  in  the  bath  and 
the  respirations  are  likewise  fuller  and  fewer  in  number. 
The  bath  promotes  relaxation  of  the  skin  and  dilation  of 
arterioles  and  so  relieves  internal  engorgement  for  the 
time  being.  It  is  not  to  be  wondered  at  that  in  a  certain 
number  of  cases  in  which  the  chest  walls  are  so  thin  as  to 
permit  the  mapping  out  of  the  exact  size  of  the  heart,  we 
find  the  heart  occupying  a.  smaller  area  in  some  of  its  di- 
mensions, at  times  in  all,  and  evidently  contracted  as  a 
result  of  the  greater  ease  with  which  it  drives  the  blood  in 
consequence  of  the  internal  disengorgement.  Heineman 
regards  the  bath  treatment  as  an  excellent  nerve  tonic,  and 
believes  that  there  is  an  important  electric  or  magnetic  in- 
fluence. Tissue  metabolism  is  remarkably  affected.  Rheu- 
matic and  gouty  conditions  are  remarkably  improved  under 
this  treatment.     The  exercises  are  a  most  important  ad- 


junct to  the  baths.  General  directions  for  the  resistant  e.x- 
erc.'ses  are  given.  The  importance  of  proper  diet  is  insisted 
upon.  Alcohol  being  especially  contraindicated  as  well  iis 
coffee.  In  arteriosclerosis  the  diet  should  be  largely  milk 
and  not  less  than  two  or  three  liters  daily  should  be  taken 
Starchy  food  is  to  be  avoided.  The  Nauheim  treatment  i? 
indicated  for  rheumatism  and  gout,  inflammatory  exudates, 
whether  pleuritic,  abdominal,  or  pelvic.  In  nervous  disor- 
ders such  as  functional  and  incipient  organic  spinal  di.'s- 
orders  spinal  congestion,  neurasthenia.  locomotor  ataxia 
in  its  early  stages,  chorea,  sciatica  and  certain 
forms  of  neuritis,  circulatory  disorders  and  cardi- 
ac disorders.  It  is  contra-indicated  in  chronic 
Bright's  disease,  aneurysm  in  any  advanced  form 
as  well  as  arteriosclerosis.  A  number  of  sphymographic 
tracings  are  given  illustrating  the  changes  in  the  pulse 
brought  about  by  this  treatment.     [T.  L.  C] 

3. — Arnold  Strumdorf  reports  a  case  of  nephrorrhaphy  with 
flap  fixation.  An  incision  was  made  obliquely  downward 
and  somewhat  outward,  extending  from  the  lower  border 
of  tlie  last  rib  at  a  point  corresponding  to  the  edge  of  the 
erector  spinae  group  to  the  iliac  crest  and  through  to  th'> 
perirenal  fat.  Incision  of  the  fat  capsule  was  made  along 
tiie  whole  length  of  the  kidney,  the  edges  of  the  incised  fat 
being  drawn  out  of  the  wound  as  far  as  possible,  and  this 
rodundan*:  fat  being  ablated  on  both  sides  flush  with  the 
bottom  of  the  wound.  The  kidney  was  pushed  as  near  to 
the  surface  as  possible,  and  steadied  there  by  pressure  ex- 
erted through  the  abdominal  wall  by  the  hand  of  an  as- 
sistant. The  capsula  propia  was  incised  longitudinally,  ex- 
actly in  the  median  line  to  within  about  three-fourths  of 
an  inch  from  either  pole.  A  pair  of  closed,  curved,  blunt- 
pointed  scissors  was  introduced  beneath  this  capsular  in- 
cision, and  the  capsule  was  carefully  separated  from  the 
kidney  sustance  for  an  area  corresponding  to  the  longitu- 
dinal capsular  incision  in  length  and  to  the  lateral  bor- 
ders of  the  kidney  in  width.  The  free  capsule  was  now 
raised  by  mouse-tooth  forceps:  two  flaps  were  formed  with 
blunt-pointed  scissors  by  splitting  the  capsule  laterally  at 
each  end  of  the  longitudinal  incision.  The  flaps  were  se- 
cured in  the  grasp  of  T-shaped  forceps,  while  two  silk- 
worm retension  sutures.  cQui-distant  from  each  other  and 
from  either  pole  of  the  kidney,  were  passed  through  skin, 
superficial  fat.  the  tendons  of  the  abdominal  muscles,  the 
cut  and  trimmed  edges  of  the  perirenal  fatty  capsule,  the 
fibrous  capsular  flaps,  and  the  parenchyma  of  the  kidney 
at  a  depth  of  about  three-fourths  of  an  inch  from  its  sur- 
face, and  left  untied  for  the  time  being.  The  object  of 
these  sutures  was  not  only  to  aid  in  relieving  tension,  but 
to  obliterate  any  possible  hollow  spaces,  thus  obviating  the 
necessity  for  drainage,  and  at  the  same  time  securing  firm 
coaptation  of  broader  surfaces  for  subsequent  cicatrical 
union.  Longitudinal  slits,  corresponding  in  location  and 
length  to  the  position  and  width  of  the  fibrous  capsular 
Haps,  were  next  made  through  the  adjacent  muscular 
tissue,  and  the  flaps  drawn  through  these  slits 
were  secured  in  place  by  running  suture  of  fine  chromi- 
cized  catgut.  Three  interrupted  sutures  of  No.  3  chromi- 
cized  gut  were  next  passed  so  as  to  embrace  muscle  and 
kidney  substance  at  a  level  with  and  equi-distant  from  the 
above-mentioned  silk-worm  sutures,  and  tie<i.  The  final 
suture  included  skin,  superficial  fat.  .and  fascia,  after  whicii 
the  silkworm  sutures,  originally  left  hanging  loose,  were 
drawn  taut  by  means  of  shot  and  plate.  Primary  union 
occurred,  the  removal  of  the  silkworm  sutures  being  ef- 
fected on  the  eighth  day.     [T.  L.  C] 


NEW   YORK   MEDICAL  JOURNAL. 
■Iiim-  Jj,  /!«//.     Vol.  LXXIII.  No.  2.i>. 

1.     Syphilitic  Fever,  with  a  Report  of  Three  Cases.     (From 
the  Service  of  Professor  William  Osier).    THOMAS 
B.  FUTCHER. 
:!.     The  Evolution  of  the  Ophthalmoscope,  and  What  it  has 

done  for  Medicine.     SAMUEL  THEOBALD. 
3.     An  Introduction  to  the  Psvchological   Studv  of  Back- 
ward Children.     WILLl.AM  B.  NOVES. 
4      Inguinal    Bubo   as   a   Complication   of   Malarial    Fever. 
A.  C.  SMITH. 
1.— Thomas  H.  Futcher  reports  three  cases  of  syphilitic 
fever,  giving  the  various  periods  at  which  it   may  occur 
during  the  course  of  infection:    (1)   It  may  occur,  in  very 
rare  instances,  so  long  as  three  or  four  weeks  before  the 
onset  of  the  secondary  skin  eruption.     This  early  fever  is 


June   20,   VMl\ 


THE  LATEST  LITERATURE 


TTHE     PHILADEr.PHIA 

L  Medical  Journal, 


1239 


jiuzzling,  and  Is  likely  to  be  attributed  to  some  other  cause 
until  the  eruption  maizes  its  appearance;  (2)  It  may  pre- 
(  ide  or  be  coincident  with  the  appearance  of  the  secondary 
'  riiption.  This  is  the  so-called  "fever  of  invasion,"  and  it 
IS  a  \ery  common  and  important  symptom  of  secondary 
syphilis:  (ij)  the  fever  may  occur  at  any  time  during  the 
course  of  the  secondary  or  tertiary  stages.  The  late  occur- 
rence of  the  fever  is  a  most  striking  feature.  It 
generally  precedes  the  appearance  of  the  secondary 
eruption  by  a  week  or  ten  days.  Rarely  does  it  antedate 
it  by  more  than  two  weeks.  The  authorities  now  agree 
that  this  fever  is  a  symptom  of  the  invasion  of  the  sys- 
tem by  the  organism  believed  to  be  the  cause  of  syphilis 
or  by  its  toxic  products.  At  the  onset  of  the  fever  there  is 
often  a  transitory  erythema  of  the  skin  which  appears,  to 
be  followed  by  the  true  syphilitic  roseola  a  few  days  later. 
The  fever  may  be  present  in  any  of  the  following  clinical 
types:  (1)  A  mild  continuo\is  pyrexia,  where  the  tempera- 
ture langes  in  the  neighborhood  of  101°  F.  Osier  states 
that  this  type  is  not  uncommon  in  the  fever  which  ushers 
in  the  constitutional  symptoms;  (2)  A  remittent  type  of 
fever,  with  morning  drops  toward  normal  and  evening 
exacerbations.  This  is  considered  the  usual  character  of 
the  fever  of  invasion;  (3)  A  definite  intermittent  fever. 
This  is  the  most  remarkable  form  of  all,  and  is  the  type 
which  is  most  likely  to  lead  to  error  in  diagnosis.  The 
author  emphasizes  the  following  points  in  connection  with 
syphilitic  fever;  (1)  In  all  cases  of  fever  of  obscure  ori- 
gin the  possibility  of  its  being  syphilitic  should  be  borne  in 
mind;  (2)  Experience  has  shown  that  physicians  of  repu- 
tation, as  well  as  those  of  limited  experience,  are  prone  to 
mistake  the  condition  for  one  of  the  acute  specific  fevers; 
(3)  The  affections  for  which  syphilitic  fever  is  most  often 
mistaken  are  malaria,  typhoid  fever,  tuberculosis,  sepsis, 
and  occasionally  rheumatic  fever;  (4)  The  fever  may  oc- 
cur as  early  as  four  weeks  previous  to  the  appearance  of 
secondary  skin  eruption,  or,  what  is  of  greater  importance, 
late  in  the  disease  after  tertiary  manifestations  have  exist- 
ed probably  for  years;  (5)  The  fever  may  be  continuous, 
remittent,  or  intermittent.  The  remittent  type  is  regarded 
as  the  most  frequent  form  in  the  fever  of  invasion.  The 
fever  is  often  associated  with  chills  and  sweating.  (6) 
Careful  examination  of  the  long  bones  and  viscera  for  evi- 
dences of  tertiary  lues  should  be  made  in  all  cases  of  fever 
of  obscure  origin.     [T.  M.  T.] 

3. — William  B.  Noyes,  in  his  article  on  an  introduction 
to  the  psychological  study  of  backward  children  gives 
the  following  points  to  be  distinguished:  (1)  Those  in 
whom  the  faculty  of  perception  is  deficient,  including  all 
those  who  have  been  born  defective  in  their  special  senses. 
In  extreme  types,  he  states,  are  included  the  so-called 
idiots  by  deprivation,  who  are  idiots  because  they  lack 
certain  special  senses  and  power  of  perception,  lack  the 
power  of  attention,  without  which  the  most  painstaking 
instruction  is  without  result:  (3)  This  class  is  character- 
ized not  Iiy  defect  of  special  senses  or  the  power  of  atten 
tion,  liut  by  defect  or  diseases  of  the  will.     [T.  M.  T.] 


MEDICAL    NEWS. 


■JiDie  2:,',   mill.     (Vol.  LXXVIII.  No.  25). 

1.  Psychic  Epilepsy,   with  the  Report  of  a  Case.     J.   W. 

COURTNEY. 

2.  The  Medical  Expert  Evidence  in  the  Case  of  the  Davis 

Bellevue  Hospital  Homicide.     R.  L.  PRITCHARD. 

3.  Obstipation.     STERLING  B.  TAYLOR. 

4.  A   St\idv   of  Some   Complications   and   Sequelffi   of   Ty 

phoid  Fever.  H.  A.  HARE. 
1. — J.  W.  Courtney  defines  Psychic  Epilepsy  as  a  pecu- 
liar pathological  alteration  of  consciousness  and  memory 
which  may  precede,  accompany,  follow,  or  even  according 
to  certain  observers,  take  the  place  of  the  epileptic  fit, 
Pathophysiologically.  such  states  of  mind  are  regarded  as 
the  result  of  inhibitory  or  irritative  explosions  within  that 
portion  of  the  cerebral  cortical  territory  which  presides 
over  psychic  processes.  Hence,  simultaneous  motor  dis- 
turbances, the  result  of  a  synchronous  inhibitory  or  irrita- 
tive explosion  primary  wilhin  the  motor  cortical  territory, 
are  constrintly  lacking.  Nevertheless,  associated  motor 
phenomena,  sometimes  of  the  most  complicated  and  pur- 
posive types,  do  occur  and  to  account  for  them  properly  we 
must  consider  them  as  end  results  of  psychic  processes, 

[T.  M.  T.] 


3.— Sterling  B.  Taylor  describes  obstipation  as  an  ob- 
.>tructive  costiveness  due  to  a  stuffing  or  cramming  against 
:in  oiistiuction  which  may  be  found  under  any  one  of  the 
following  heads:  (I)  Compression  from  without;  (2)  Block- 
ing up  of  lumen  of  canal;  (3)  Constriction  arising  from 
disease  of  gut  wall;  (4)  Hypertrophy  of  normal  rectal 
valve,  with  consequent  interruption  of  lumen  of  canal  and 
accompanying  distortion  of  gut  above  obstruction,  the 
latter  condition  begetting  an  atonic  state.     .fT.  M.  T.] 


BOSTON   MEDICAL  AND  SURGICAL  JOURNAL. 

./line  ..'Olli.  f.till. 

1.  A  Study  of  the  Food  Consumed  and  Digested  by  Four 

Members  of  the  Harvard  University  Boat  Crew  in 
.lune.  1900.  W.  O.  ATWATER  and  F.  G.  BENE- 
DICT. 

2.  Puerperal  Insanity.     EDWARD  B.  LANE. 

3.  The  Home  Treatment  of  Tuberculosis  vs.  The  Climatic 

Treatment.     EDWARD  O.  OTIS. 

1. — Atwater  and  Benedict  have  made  a  study  of  the 
dletery,  digestion  and  nitrogen  metabolism  of  4  members  of 
the  Harvard  University  Boat  Crew.  The  ages  of  the  four 
men  were  20.  22,  19  and  25  year.-;,  respectively,  and  their 
weights  174,  163,  176  and  167  pounds.  The  men  were  in 
normal  condition  throughout  the  period  of  the  study.  The 
quantities  of  solid  and  liquid  excreta  were  determined  for 
eacli  subject,  but  the  food  consumed  was  determined  only 
for  the  4  men  taken  together.  These  4  men  used  a  food 
supply  on  the  average,  per  man  per  day,  consisting  of  l.^>4 
gm.  of  protein.  159  gm.  of  fats,  474  gm.  of  carbohydrates. 
This  food  furnished  a  total  energy  of  4.279  calories,  and  a 
fuel  value  of  3.925  calories.  Tables  are  given  comparing 
the  results  of  this  study  with  the  results  of  similar  studies 
made  on  the  Harvard  and  Yale  University  crews  while  in 
training  in  1.S98,  on  the  foot-ball  teams  at  Wesleyan  Univer- 
sity and  the  University  of  California,  and  on  Sandow.  The 
studies  show  that  athletes  eat  considerably  more  than 
people  in  ordinary  life,  and  that  their  food  contains  a  m\ich 
larger  amount  of  protein  in  proportion  to  the  fuel  valvie 
than  is  found  in  the  food  of  people  with  ordinary  muscular 
strain.  Why  and  to  what  extent  the  large  percentage  of 
protein  represents  is  not  yet  fully  known.  It  seems  very 
natural,  however,  that  where  great  muscular  strength  and 
effort  are  needed  there  should  be  corresponding  muscular 
development,  and  this  would  be  most  naturally  attained  by 
the  use  of  nitrogenous  food.     [J.  M.  S.] 

2. — Lane  objects  to  the  term  puerperal  insanity  to  define 
a  distinct  type  of  mental  trouble.  He  is  of  the  opinion  that 
the  alienist  going  through  the  wards  of  a  hospital  for  the 
insane  tor  the  first  time  cannot  name  the  cases  of  puerperal 
insanity  from  objective  symptoms.  We  can  diagnose  gen- 
eral paresis,  mania,  melancholia  and  katatonia  objectively: 
but  w'e  must  receive  the  history  of  recent  childbirth  before 
we  can  make  a  diagnosis  of  puerperal  insanity.  The  author 
believes  that  the  puerperal  condition  is  not  an  important 
factor  in  the  causation  of  insanity.  Two  hundred  and  tw-o 
women  patients  were  received  at  the  Boston  Insane  Hos- 
pital during  the  past  year,  of  whom  only  3%  were  consid- 
ered as  puerperal  cases.     [J.  M.  S.] 

3. — Otis  is  in  favor,  in  the  average  case,  of  employing 
hygienic  measures  for  the  treatment  of  pulmonary  tuber- 
culosis at  home  rather  than  at  health  resort.  In  the  home 
climate  there  is  the  indubitable  advantage  of  retaining  the 
patient  in  the  same  climate  in  which  he  has  previously 
passed  his  existence  and  in  which  he  must  live,  at  least  in 
a  large  majority  of  the  cases,  the  remainder  of  it.  Further- 
more, by  treating  the  patient  near  his  usual  and  accus- 
tomed residence  we  take  advantage  of  the  psychic  influence 
of  familiar  surroundings.  Again,  the  pecuniary  factor  is  a 
very  important  consideration  with  a  large  number  of  pa- 
tients. Comparing  sanitorium  treatment  at  home  with 
non-sanitorium  treatment  in  a  health  resort  the  author 
doubts  whether  the  additional  climatic  excellence  compen- 
sates for  the  absence  of  the  sanitorium  regime.  It  is  a 
source  of  great  congratulation  to  all  who  are  engaged  in  the 
treatment  of  tuberculosis  that  the  prospects  of  success  in 
the  home  treatment  appear  so  auspicious..  It  is  the  very 
small  minority  of  the  tuberculous  who  are  able  or  willing 
to  travel  far  afield  foi'  a  resort  in  which  to  take  the  cure. 
The  majority,  for  one  reason  or  another,  must,  if  the  hy- 
gienic cure  is  attempted  at  all,  undertake  it  near  home. 

[J.  M.  S.] 


1240 


The    Philadelphia  ■ 
Medical  Journal 


THE  LATEST  LITERATURE 


fJUNE    ».    l»-\ 


JOURNAL  OF  AMERICAN  MEDICAL  ASSOCIATION. 

June  ^.^   nxji. 

1.  The  Cause  of  Diffuse  Peritonitis  Complicating  Appen- 

dicitis and  its  Prevention.    A.  J.  OCHSNER. 

2.  Section     on     Obstetrics     and     Diseases     of     Women. 

HENRY  P.  NEWMAN. 

3.  Oral  Manifestations  and  Allied  States.  E.  S.  TALBOT. 

4.  Anthrax,  with  Report  of  a  Case.     WILLIAM  ROUSH. 

5.  Interesting  Throat  Paralyses  in  a  Case  of  Locomotor 

Ataxia     of     an     Irregular     Form.       JOHN     EDWIN 
RHODES. 
B.     The  Diagnosis  of  Diaphragmatic  Hernia.  E.  FLETCHER 
INGALS. 

7.  The  Value  of  Calcium  Carhid  in  the  Treatment  of  In- 

operable Carcinoma  of  the  Uterus.     I.  C.  CHASE. 
S.     Morphinism:  An  Unusual  Case.    WESLEY  E.  TAY'LOR. 

8.  Spasm  of  the  Glottis  and  Esophagus  in  .\dult  Life.     A 

Report  of  Two  Cases.    L.  D.  BROSE. 

10.  Magnetic   Foreign  Bodies   in  the  Eye.     E.   VILLIER3 

APPLEBY. 

11.  The  Importance  of  Instruction  in  Medical  Schools  upon 

the   Modification  of  Milk  for  Prescription   Feeding. 
ANDREW  H.  WHITRIDGE. 

12.  A  New  Proctoscope  and  Sigmoidoscope.    WILLIAM  H. 

BEACH. 

1. — A.  .1.  Ochsner  discusses  the  cause  of  diffuse  periton- 
itis complicating  appendicitis  and  its  prevention.  Diffuse 
peritonitis  is  the  one  complication  of  appendicitis  which 
produces  most  deaths.  Attention  is  first  called  to  the  ana- 
tomical relations  of  the  appendix,  and  It  is  shown  that 
this  organ  is  surroimded  by  more  or  less  immovable  tis- 
sue excepting  in  the  direction  of  the  general  abdominal 
cavity  and  here  it  is  in  relation  with  the  constantly  mov- 
ing small  intestine.  The  peristaltic  motion  of  the  intes- 
tine tends  to  the  extension  of  the  inflammation.  Nature 
attempts  to  put  the  inflamed  parts  at  rest  by  diminishing  the 
peristalsis.  The  point  which  the  author  emphasizes 
throughout  his  whole  address  is  the  fact,  that  the  intro- 
duction of  food  or  cathartic  into  the  stomach,  by  producing 
peristalsis,  has  the  effect  of  Increasing  the  spread  of  the 
inflammation.  Great  stress  is  laid  upon  the  value  of  gastric 
lavage  for  the  purpose  of  entirely  emptying  the  stomach 
and  of  withholding  all  food  or  medicines  by  the  mouth, 
rectal  feeding  being  depended  upon  entirely.  The  cases  in 
which  this  mode  of  treatment  has  been  most  satisfactory 
are  those  in  which  the  appendix  is  gangrenous  or  per- 
forated and  in  which  there  is  already  a  beginning  general 
peritonitis.  The  author  maintains  that  if  this  form  of 
treatment  is  closely  adhered  to  that  the  inflammation  will 
in  most  instances  become  circumscribed.  The  nausea  and 
vomiting  will  ontiroly  cease  after  one  or  two  gastric  irri- 
gations. The  pain  will  decrease  together  with  the  disten- 
sion and  the  temperature  and  pulse  will  both  fall.  There 
is  also  noticed  a  marked  difference  in  the  abdominal  rigid- 
ity after  the  irrigations.  The  author  gives  extensive  statis 
tics  of  his  ow'n  work  at  the  Augustana  Hospital  where  this 
treatment  has  been  rigidly  carried  out  and  records  care- 
fully kept.  A  marked  decrease  in  the  mortality  of  the 
cases  of  gangrenous  and  perforative  appendicitis  has  fol- 
lowed his  treatment.  The  author  warns  surgeons  against 
the  mistake  of  returning  too  quickly  to  gastric  feeding.  It 
is  also  mentioned  that  peristalsis  can  very  easily  result 
in    the    rupture    of    an    already    localized    pus    formation. 

[J.  H.  G.] 

2. — Newman  in  his  opening  address,  gives  a  review  of  the 
scientific  progress  of  the  year  in  gynecology  and  obstet- 
rics. In  speaking  of  anesthesia  by  lumbar  ptmcture  he 
states  that  our  own  writers  seem  to  agree  in  preferring 
general  anesthesia  by  chloroform  or  ether  except  when, 
for  any  reason,  these  are  positively  contraindicated  and  a 
substitute  may  be  found.  Reclus.  of  France,  is  a  vigorous 
and  logical  opponent  of  the  method.  The  past  year  has 
done  much  to  establish  the  operation  of  ovarian  grafting 
or  transplantation  as  a  logical  procedure  and  one  worthy 
of  careful  and  conscientious  experiment.  Mauclaire  con- 
cludes from  his  experiments  that  auto-  and  hetero-grafting 
will  be  successful  if  properly  performed  and  the  ovary  is 
aseptic.  Such  grafts  should  result  in  modifying  menstrual 
troubles  and  those  consecutive  to  ovarotomy.  Newman 
quotes  the  report  of  Gersnny  on  his  work  with  injections 
of  paraffin  for  incontinence  of  urine  due  to  traumatism.  The 
results  have  been  satisfactory.  Cesarean  section  for  pla- 
centa previa  is  advocated  by  Dudley  on  the  ground  that  It 
offers  a  method  of  saving  two  lives  in  place  of  risking  one 
or  bcth,  and  is  practically  free  from  danger  it  thorough 
asepsis  is  observed.     Among  the  improved  agents  for  sur- 


gical hemastasis  should  be  mentioned  the  angiotribe,  whose 
claims  for  recognition  rest  upon  facility  of  use,  greater 
certainty  of  hemostatis,  more  rapid  and  smooth  convales- 
cence, and  the  avoidance  of  such  objectionable  after  re- 
sults as  hematoma,  granulating  and  sloughing  stumps,  ad- 
hesion and  cicatrition,     [W.  A.  N.  D.] 

3. — Will  be  abstracted  when  completed. 

4. — William  Roush  reports  an  interesting  case  of  anthrax 
occurring  in  a  farmer.  The  patient  was  switched  in  the 
face  by  the  tail  of  a  horse  which  at  the  time  was  suffering 
from  an  extensive  edema  of  the  head  and  part  of  the  neck, 
together  with  a  profuse  purulent  discharge  from  the  nos- 
trils, mouth  and  eyes.  The  animal  recovered  after  two 
months.  The  patient  developed  considerable  edema  fol- 
lowed by  pustules  over  the  cheek.  A  tube  of  agar-agar 
inoculated  with  the  discharge  from  the  wound  showed  the 
presence  of  the  bacillus  of  anthrax  in  large  numbers.  The 
case  was  treated  according  to  the  recommendation  of  Vock- 
recensy,  which  consisted  in  the  administration  internally  of 
large  doses  of  carbolic  acid.  Great  improvement  imme- 
diately followed  the  administration  of  this  drug  and  thy 
patient  made  a  good  recovery.     [J.  H.  G.] 

5. — .J.  E.  Rhodes  reports  an  interesting  case  of  throat 
paralysis  occurring  in  locomotor  ataxia  of  an  irregular  form. 
When  the  mouth  was  opened  and  the  tongue  depressed  for 
examination  of  the  throat  the  soft  palate  was  in  the  nor- 
mal pesition.  On  irritating  it  with  a  probe,  however,  the 
right  side  of  the  palate  was  contracted  strongly  to  the 
pharyngeal  wall  drawing  the  uvula  toward  the  right.  The 
left  side  of  the  palate  did  not  respond  at  all  to  the  irrita- 
tion but  remained  relaxed  and  stationary.  There  was  no 
anesthesia  of  the  parts.  On  examination  of  the  larynx 
the  right  vocal  cord  was  stationary  in  the  median  line, 
there  being  a  paralysis  of  the  posterior  crico  ar>-tenoid  on 
the  right  side.  .All  other  conditions  of  the  throat  were  normaL 
The  diagnosis  was  an  ascending  sclerosis  causing  ptosis 
of  the  right  eyelid  and  divergent  squint  of  the  right  eye, 
paralysis  of  the  left  half  of  the  palate  and  abductor  para- 
lysis of  the  right  vocal  cord.     [T.  L.  C] 

6. — E.  Fletcher  Ingals  discusses  the  difficulties  of  diag- 
nosing diaphragmatic  hernia.  The  greatest  difficulty  arises 
in  differentiating  this  condition  from  pncumo-thorax.  With 
the  history  of  traumatism  and  the  symptoms  of  strangula- 
tiim  the  diagnosis  may  possibly  be  made  but  in  the  ab- 
.^ence  of  these  it  becomes  a  difficult  question.  The  condi- 
tion is  congenital  in  about  3S''c  of  the  cases.  In  nearly  all 
thf  rest  it  is  of  traumatic  origin.  The  most  important 
symptoms  of  the  condition  are  dyspnea,  metallic  tinkling 
oSbociated  with  rumbling  and  gurgling  of  gas.  the  dis- 
place ment  of  the  heart,  the  retraction  of  the  abdomen  anl 
sometimes  succussion  sounds.  The  author  then  relates  a 
case  of  his  own  in  which  many  of  the  symptoms  of  dia- 
phragmatic hernia  developed  suddenly  upon  the  patient, 
distending  the  chest  by  a  full  inspiration.  Many  surgeons 
aiid  physicians  saw  this  patient  but  no  positive  agreement 
could  be  reached  regarding  his  condition,  some  maintain- 
ir.g  that  it  was  pneumothorax  and  others,  together  with 
the  author,  thinking  it  to  be  diaphragmatic  hernia.     [J.H.G.] 

7. — Chase,  from  his  study  of  the  value  of  calcium  carbid 
In  the  treatment  of  inoperable  carcinoma  of  the  uterus 
concludes  as  follows:  (1)  The  mass  of  literature  on  this 
subject  is  misleading:  (2)  the  originators  of  the  treatment 
were  ignorant  of  the  real  action  of  calcium  carbid,  and  had 
insufiiclent  clinical  experience  to  pass  judgment  on  its 
^•alue;  (3)  acetylene  has  no  effect  on  protoplasm  sufficient 
to  support  a  theory  of  any  specific  annihilative  action  on 
cprcinomatous  cells:  (4>  acetylene  has  no  escharotic  ef- 
fect: (5)  acetylene  has  no  bactericidal  action  upon  patho- 
genic bacteria  of  putrefaction:  16)  the  principal  action  of 
calcium  carbid  results  from  liberated  quicklime:  (71  lime 
is  not  a  rational  caustic  to  select,  if  one  is  desired,  because 
of  its  superficial  action,  the  character  of  the  necrosis  and 
the  tendency  to  promote  hemorrhage.  The  metallic  salts 
are  more  styptic,  and  their  action  may  be  better  graduated 
by  proper  selection:  (S1  the  amoimt  of  heat  evolved  may 
be  sufScient  to  slightly  cauterize  the  tissues.  In  most 
oases  it  has  slight  therapeutic  effect  save  counteracting  the 
tendency  to  hemorrhage  and  promoting  contraction:  (9) 
tl.e  heat  of  the  actual  cautery  promises  better  results  bo- 
ci.use  of  the  firmer  cicatrices  resisting  carcinomatous  in- 
vasion and  more  complete  contraction  of  the  wound:  (10) 
calcium  carbid  is  open  to  the  same  dangers  as  other  caus- 
tics when  improperlv  or  too  zealously  applied:  those  of 
vroducing  its  corrosive  action  in  the  wrong  place,  fistulae. 
Iicrforation  and  fatal  peritonitis  or  occlusion  of  the  ure- 
ters;   til)    tVie   treatment   does   not   reduce   odor   or  hem- 


June   29,   1901] 


THE  LATEST  LITERATURE 


LTHE      PHiLADELPHIA 
Medical   Journal 


I24I 


orrhage  nor  give  more  comfort  to  the  patient  than  other 
rational  lines  of  treatment:  (121  the  claims  of  advocates 
have  not  been  realized  in  experience.  There  is  no  evi- 
deiire  in  theory  or  practice  warranting  the  conclusions  that 
calcium  cai  bid  could  ever  cure  a  case  of  really  inoperable 
cancer  of  the  uterus:  (13)  the  facts  regarding  the  sub- 
ject should  be  more  widely  disseminated  to  expurge  medi- 
cal literature  and  to  avoid  false  expectations  and  fatal  de- 
lays in  inoperable  cases      [W.  A.  N.  D.] 

8. — W.  E.  Taylor  reports  an  unusual  case  of  morphinism. 
The  patient  was  a  man  of  43  years,  who  had  used  whisky 
to  excess  from  boyhood.  In  1SS4  he  began  to  take  pow- 
dered opium  in  small  amounts  to  allay  a  pain  due  to  dis- 
ease of  the  left  shoulder  joint.  Gradually-  the  amoimt  of 
the  drug  was  increased  until  he  was  taking  30  grains  of 
powdered  opium  per  day.  With  this  he  took  a  considerable 
amount  of  alcohol.  The  patient  became  fearful  of  losing 
his  mind  and  stopped  taking  the  drug  suddenly,  and  of  his 
own  volition     He  made  a  complete  recovery.     [T.  L.  C] 

9. — L.  0.  Brose  reports  two  eases  of  spasm  of  the  glottis 
and  esophagus  In  adult  life.  His  first  case  was  in  a  pa- 
tient of  .■)4  years  who  was  suddenly  seized  with  an  attack 
of  dyspnea  attended  by  spasmodic  crowing  inspiration  and 
great  mental  distress  and  anxiety.  The  attack  lasted  sev- 
eral minutes.  The  examinations  of  the  throat  was  abso- 
lutely negative.  These  attacks  became  frecpient  and  us- 
ually occurred  between  midnight  and  4  o'clock  in  the  morn- 
ing Finally  the  symptoms  of  dysphagia  set  in  with  un- 
mistakable evidences  of  carcinoma  involving  the  lower  end 
of  the  esophagus  and  stomach.  The  post-mortem  findings 
confirmed  this  diagnosis.  The  second  case  was  that  of  a 
man  of  31  years  who  suffered  from  an  acute  attack  of  dys- 
phasia, and  in  this  case  also  no  evidences  of  local  disease 
were  found.  Later,  however,  positive  evidence  of  tubercu- 
lar involvement  of  the  upper  lolie  of  the  left  lung  was 
found,     [T,  L.  C] 

12, — ^^■illiam  M,  Beach  describes  a  new  proctoscope  and 
sigmoidoscope  which  contains  an  Illuminating  attachment 
which  greatly  aids  in  the  examination  of  the  lower  bowel, 

[J,  H,  G.] 


AMERICAN  MEDICINE. 

June  15,  1901. 

1,  Pulsation  of  the  Uvula  in  Aortic  Insufficiency,     DAVID 

RIE8MAN, 

2,  Prevention  and  Cure  of  Postoperative  Hernia.    JAMES 

E,  MOORE, 
S,     A  Few   Useful  Points  in  the  Symptomatology  of  Eye 
Diseases  Aoplied  to  General  Practice.    HENRY  BAS- 
SETT  LEMERE, 

4,  Formalin  in  the  Treatment  of  Suppurative  Otitis  Me- 

dia,    NATHAN  G,  WARD. 

5,  Synchronous  Amputation  of  Both  Thighs  for  Gangrene 

of  Feet   under  Special  Cocainization,     GEORGE   G. 
HOPKINS, 

6,  Permanent  Gold  Preparations,     EMMA  L,  BILLSTEIN. 

7,  An  Improved  Bedstead  for  Invalids,    E.  E.  MUNGER. 

8,  Excessive  Eosinophilia  in  Trichinosis,    A.  .T.  PATEK, 

1. — David  Riesman  reports  the  case  of  pulsation  of  the 
uvula  in  a  patient  suffering  from  aortic  insufficiency. 
This  condition  is  present  in  a  smaller  number  of  cases  of 
aortic  regurgitation.  Much  caution  is  necessary  in  order 
to  reveal  it,  as  attempts  of  retching  or  swallowing  may 
simulate  the  pulsatile  phenomena.  The  patient  should  be 
instructed  to  hold  the  mouth  open  steadily  and  breathe 
quietly.  Riesman  records  here  three  cases.  The  phen- 
omenon   is    of    the    same    nature    as    the   capillary    pulse. 

[T.  L.  C] 

2. — Nathan  G.  Ward  discusses  the  use  of  formalin  in  the 
treatment  of  suppurative  otitis  media.  He  concludes  that 
by  the  use  of  formalin  the  following  results  may  be  ob- 
tained. There  is  an  early  cessation  of  the  discharge.  It 
breaks  up  the  formation  of  the  granulations  and  small 
granulations  are  discharged  by  alcoholic  solutions.  It  pro- 
motes the  healing  of  ulcerated  mucous  membrane, 
abrasions  and  inflammation  of  the  external  auditory  canal. 
It    retards,    but    does    not    entirely    check    bone    necrosis. 

[T,  L,  C] 

5. — George  G,  Hopkins  reports  a  case  of  synchronous  am- 
putation of  both  thighs  for  gangrene  of  the  feet  under 
special  cocainization.  The  patient  was  a  man  of  6S  years. 
20  minions  of  2%  solution  of  cocaine  hydrochlorate  were 
employed.  The  needle  being  entered  between  the  fourth 
and  fifth  lumbar  vertebrae.  The  result  was  in  every  way 
satisfactory.     [T.  L.  CI 


6. — Emma  1,.  Billstein  advises  the  following  method  for 
making  permanent  gold  preparations:  \  mixture  of  8 
parts  of  1%  solution  of  gold  chloride  ;ind  2  parts  of  formic 
acid  is  boiled  three  times,  then  cooled.  Very  thin  pieces 
of  tissue  are  put  into  the  cooled  mixture,  which  must  be 
kept  in  the  dark.  After  one  hour  the  tissue  is  washed  iu 
distilled  water  and  then  placed  in  a  mixture  of  10  parts  of 
formic  acid  and  40  parts  of  the  distilled  water  and  exposed 
to  diffuse  dayli.ght.  The  reduction  occurs  in  from  24  to  48 
hours  when  the  violet  tissue  is  transferred  to  70%,  and 
after  24  hours,  to  90%  alcohol  and  kept  in  the  dark  for  at 
least  a  week.  It  is  then  ready  for  the  final  manipulations 
and  may  be  teased  and  mounted  in  acidulated  glycerol  or 
cut  into  sections,     [T.  L.  C] 

8. — A.  J.  Patek  reports  a  case  of  a  young  man  of  21  who 
sufiered  from  trichinosis,  whose  blood  count  showed  30% 
of  eosinophilcs.  This  is  in  accord  with  the  observations  of 
Dr,  T,  R,  Brown,  corroborated  in  20  cases,  that  in  trichinosis 
the  eosinophiles  undergo  an  enormous  increase.    [T,  L,  C.J 

June  ,li,  1001. 

1.  Treatment    of    an    .\bdominal    Aortic    Aneurysm,    etc. 

RUDOLPH  MATAS. 

2.  The     So-called     Traumatic     Neurosis.       HAROLD     N. 

MOYER. 

3.  Resection  of  Superior  Sympathetic  Cervical  Ganglion 

for  Noninflammatory  Glaucoma,     JOSEPH  MULLEN. 

4.  The  Bacteriologic  Examination  of  Clinical  Thermome- 

ters,    RANULE  C.  ROSENBERGER, 

5.  Atypical  Pneumonia  and  Pulmonary  Tuberculosis.     W. 

H.  BERGTOLD. 

6.  Electrolysis  in  Disease  of  the  Skin.    F.  E.  WISECUP. 

7.  The  Nervous  Exhaustion  due  to  West  Point  Training. 

CHARLES  E.  WOODRUFF. 

1. — Will  be  abstracted  when  completed. 

2. — Harold  M.  Moyer  discusses  the  so-called  traumatic 
neurosis  which  he  defines  is  any  deviation  from  the  nor- 
mal in  the  nervous  system,  caused  by  violence.  Trauma- 
tism may  cause  disturbance  in  the  central  nervous  system 
which  may  be  organic  or  functional,  although  the  latter  is 
by  far  the  more  frequent.  The  traumatic  disturbances 
which  follow  traumatism  will  be  found  to  follow  in  cer- 
tain groups,  hysteria,  anesthesia  and  hypochondria.  It  ap- 
pears to  Moyer  that  concussion  neurosis  in  all  its  various 
appellations,"  is  an  unfortunate  and  misleading  term:  that 
clearer  understanding  of  functional  nervous  troubles  ren- 
ders such  a  term  unnecessary:  that  pain  and  tenderness  of 
the  spine  is  rarely  an  evidence  of  change  in  the  cord,  but 
it  usually  due  to  the  fatigue  of  the  spinal  muscles,  or  sprain 
and  concussion  of  the  spinal  column:  that  most  of  the 
symptoms  of  spinal  concussion  are  cerebral  in  origin,  and 
that  a  correct  diagnosis  and  prognosis  may  usually  be 
reached  by  analyzing  all  such  cases  after  the  same  manner 
that  we  do  functional  nervous  troubles  having  their  origin 
iu  nontraumatic  causes,    [T,  L.  C] 

3. — Joseph  Mullen  reports  a  case  of  resection  of  the  su- 
perior sympathetic  cervical  gangMon  for  noninflammatory 
glaucoma.  It  is  claimed  that  removal  of  this  ganglion  is 
sufilcient  in  glaucoma,  because  all  the  sympathetic  fibers 
go  to  the  eye  from  this  ganglion,  Panas  opposes  this  view. 
The  operation  itself  may  be  performed  in  two  days:  First, 
reaching  the  ganglion  by  the  posterior  triangle,  and  sec- 
ond, by  penetrating  the  anterior  triangle.  The  immediate 
effects  of  excision  are  relief  from  pain,  contraction  of  the 
pupil,  increased  lacrimation  and  sweating  of  the  same  side 
of  the  face.  There  is  always  conjunctival  injection  and  of- 
tentimes immediate  reduction  of  intraocular  tension.  The 
author's  case  is  similar  to  the  one  reported  by  Panas,  and 
like  his,  shows  a  decline  in  vision.     [T.  L.  C] 

4. — R.  C,  Rosenberger  has  made  a  bacteriologic  examina- 
tion of  clinical  thermometers.  His  conclusions  are  of  inter- 
est. It  is  possible  for  the  thermometer  to  be  laden  with  the 
usual  flora  of  the  oral  cavity.  Such  bacteria  may  retain 
their  capability  of  growth  for  an  indefinite  time,  at  least 
2  months,  as  shown  by  Rosenberger's  experiments.  Many 
pathogenic  bacteria  possess  similar  capabilities,  and  it  is 
not  unreasonable  to  assume,  although  the  above  experi- 
ments are  not  conclusive  upon  this  point,  that  transmission 
of  bacterial  disease  by  the  thermometer  is  possible.  Ther- 
mometers are  easily  disinfected.  Where  for  reasons  of 
economv  or  otherwise  it  is  impossible  to  carry  out  the  rec- 
ommendations of  this  investigator,  the  thermometer  shoulil 
be  disinfected  before  and  after  using.  The  custom  now- 
prevalent  in  the  hospitals  of  keeping  thermometers  in  dis- 
infecting solutions  is  to  be  commended.    [T,  U  C] 


124:2 


The    Philadelphia 
Medical  Journal 


] 


SOME  TROPHO-XEUROSES. 


[June  IS,   ISOl 


Original  Hrticlce. 


SOME  TROPHONEUROSES    AND   THEIR    RELATION 

TO  VASCULAR  DISEASE  OF  THE  EXTREMITIES..^= 

By  B.  SACHS,  M.  D.. 

of  Xew  Yort. 

Professor  of  Mental  and  Nervous  Disease  in  the  Xew  York  Polyclinic,  etc. 

and  ALFRED  WIENER,  M.  D., 

of  New  York, 
Adjunct  Professor  of  Nervous  Disease  in  the  New  York  Polyclinic,  etc. 

In  an  article  on  erythromelalgia,^  published  a  few 
years  ago,  it  was  shown  that  marked  changes  had 
taken  place  in  the  blood-vessels  of  the  affected  ex- 
tremity. The  amputation  of  the  leg  above  the  knee 
furnished  the  opportunity  for  a  careful  examination 
of  the  nerves  and  blood-vessels  of  the  diseased  part, 
and  it  was  found  that  these  marked  changes  in  the 
blood-vessels  occurred  not  only  in  the  immediate 
vicinity  of  the  most  aftected  region,  but  were 
equally  pronounced  in  the  blood-vessels  at  some  dis- 
tance from  the  site  of  the  disease.  From  this  the 
conclusion  was  drawn  that  in  some  instances  the 
symptom  group  known  as  erythromelalgia  may  be 
due  to  disease  of  the  arteries,  rather  than  to  disease 
of  the  peripheral  or  central  nervous  system.  The 
anatomical  findings  in  this  case  were  a  surprise  to 
us.  but  have  encouraged  us  to  study  in  somewhat 
greater  detail  the  relation  of  vascular  disease  to 
tropho-neuroses  of  various  types.  These  special  af- 
fections have  in  the  minds  of  all  of  us  been  asso- 
ciated far  more  with  disease  of  the  nervous  system 
than  with  disease  of  the  arteries  or  the  veins,  and  it 
is  probably  due  to  the  surprise  occasioned  by  the 
findings  reported  by  us,  that  our  former  publication 
met  with  some  criticism. 

It  has  been  claimed  by  several  writers" — among 
others,  by  Cassirer,'  in  his  recent  able  monograph 
on  vaso-motor  and  tropho-neuroses — that  the  case 
of  erythromelalgia  in  which  these  marked  changes 
were  found  did  not  conform  to  the  type  of  the  dis- 
ease, but  could  be  interpreted  as  a  form  of  obliterat- 
ing endarteritis.  A  careful  review  of  the  entire 
course  of  this  case  of  erythromelagia  shows  that  it 
conforms  to  the  type  as  described  by  Wen  Mit- 
chell.*The  patient  was  a  man  only  36  years  of  age. 
a  Russian,  who  had  had  vague  rheumatic  pains  for 
some  years,  which  he  connected,  in  part,  with  the 
necessity  of  working  ten  or  twelve  hours  at  a  time 
at  a  sewing  machine.  At  first  there  were  spasmodic 
attacks,  redness  and  swelling  of  the  left  foot,  partic- 
ularly noticeable  when  the  leg  was  hanging  down ; 
later  on  the  "red  neuralgia"  became  persistent.  For  a 
period  of  over  six  months  there  was  not  a  single 
symptom  except  those  that  we  are  accustomed  to 
find  in  this  disease.  There  was  lively  pulsation  of 
the  arteries,  and  the  color  of  the  foot  changed  from 
a  bright  red  to  a  violaceous  tint.  The  only  symptom 
in  the  case,  which  was  a  little  unusual,  and  which 
A\'eir  Mitchell  did  not  include  in  the  symptomatol- 

•Re^d  before  the  .\ssociation  of  .\nitricaa  Physicians,  May.  looi. 

1.  Deutsche  Zeit^hrift  fuer  Nervenheilkunde  1890.  Bd.  XV.  p.  2S6. 

2.  cf  Schroetter  in    Nolhnagel's  Sp-ciell"  Patholoaie  u.  Therapie  Vol. 
XV.  m.  Theil  p.  397. 

3.  Cassirer  Die  vaso-motoriscH-trop'iischen  Neurosen.  Berlin.  S,  Karger, 
1901. 

4.  Clinicil  I.essons  on  Nervous  Diseases.  Philadelphia,  1S97,  p.  iSo, 

5.  N.  Y.  Med.  Record,  Vol.  51.  1S9T,  p.  172. 


ogy  of  the  disease,  was  the  gradual  development  of 
a  large  ulcer  on  the  dorsum  of  the  foot,  which  grew 
worse  and  worse,  and  finally,  in  addition  to  the  pain, 
necessitated  the  amputation  of  the  leg.  But  other 
writers,  including  Eisner,  have  reported  cases  of  un- 
doubted erythromelalgia  associated  with  gangrene, 
and  even  Cassirer  has  to  allow  that  such  marked 
trophic  disturbance  may  occur  in  this  disease. 

German  authors  in  particular,  who  took  up  this 
subject  a  few  years  ago,  have  insisted  on  a  priori 
grounds  that  erythromelalgia  must  necessarily  be 
due  to  disease  of  the  trophic  ner\'es,  and  were  of  the 
opinion  that  it  would  prove  to  be  a  disease  of  the 
posterior  gray  matter  of  the  spinal  cord.  Xo  evi- 
dence of  this  has  been  furnished,  and  the  only  com- 
plete autopsy  in  a  case  of  erythromelalgia  was  in  one 
complicated  by  tabes  dorsalis.  In  view  of  this  it 
still  remains  doubtful  whether  the  changes  in  the 
lower  lumbar  and  upper  sacral  roots  in  this  case  can 
be  held  responsible  for  the  trophic  changes  in  the 
extremity.  Weir  Mitchell,  in  one  of  his  latest  stud- 
ies, allows  for  the  possibility  of  a  central  origin  of 
the  disease,  but  pleads  much  more  strongly  in  favor 
of  a  ner\-e-end  neuritis  as  a  direct  cause  of  the 
S3-mptoms  of  erj-thromelalgia ;  and  in  a  paper  pub- 
lished in  conjunction  with  Spiller,  it  was  shown  that 
there  were  slight  vascular  changes  in  addition  to  the 
evidences  of  a  terminal  neuritis. 

^^  e  have  no  intention,  however,  at  the  present 
moment  of  proving  or  disproving  the  diagnosis  of 
er}'thromelalgia  in  the  case  previously  reported. 
Whatever  name  one  chooses  to  give  to  the  series  of 
symptoms  met  with  in  many  of  these  cases,  it  is 
very  certain  that  erythromelalgia.  Raynaud's  dis- 
ease, akroparesthesia,  and  even  scleroderma  often 
merge  into  each  other,  or  are  associated  with  one 
another;  and  whether  these  various  types  be  due 
to  ner\'e  disease  or  not,  the  fact  stands  out  clearly 
for  the  present  that  marked  forms  of  arterio-  and 
phlebo-sclerosis  occur  in  association  with  these  so- 
called  tropho-neurotic  diseases.*  It  is  the  special  ob- 
ject of  this  paper  to  refer  to  a  number  of  cases  of 
vaso-motor  and  tropho-neurotic  disturbances,  in 
which  the  condition  of  the  nprv-es.  arteries  and  veins 
of  the  affected  extremity  has  been  carefully  studied. 
Incidentally,  we  shall  be  able  to  refer  to  the  fact 
that  the  lesser  stages  of  the  disease  are  in  all  proba- 
bility responsible  for  many  cases  of  vague  "rheu- 
matoid" pains  in  the  arms  and  legs,  for  parethesia 
in  cases  of  diabetes,  and  for  conditions  resembling 
those  of  local  syncope  in  pronounced  cases  of  arterio- 
sclerosis. Medical  men  haveforyearsgiven  most  care- 
ful consideration  to  endarteritis  as  \t  occurs  in  the 
brain, but  have  troubled  themselves  far  less  about  the 
same  condition  as  affecting  the  peripheral  parts  of 
the  body,  and  have  not  held  these  arterial  changes 
responsible  for  symptoms  which  might  better  be  at- 
tributed to  them  than  to  the  influence  oi  trophic 
nerve  fibres,  the  distribution  and  function  of  which 
are  still  but  vaguely  known.  A  closer  study  of  peri- 
pheral arterial  changes  is  bound  to  follow.  Spiller 
has  referred  to  them  in  an  article  published  in  the 
Journal  of  Expcrimcuta!  Mcdicir.c.  on  a   report  of  a 

6.  Reported  bv  Auerbach.  Deutsche  Zeitschrift  fuer  Ntrveaheilknade, 
Bd.  XI.  p.  143- 

♦Somewhat  similar  views  were  expressed  in  an  article  just  brou^t  to 
our  notice.  "  On  Svmmelrica,  Oargrene."  bv  A.  Sturmdorf .  Med.  Rrc,. 

Aug.  1.  linn. 


JVNE   29,    191I1J 


SOME  TROPHO-NEUROSES. 


CThe    Philadelphia 
Medical  Jolhnal 


I24J 


case  of  dermatitis  vesiculo-bullosa,  and  has  con- 
sidered the  relation  of  vascular  nerve  changes  to 
spontaneous  gangrene  and  Raynaud's  disease;  and 
more  recently  Wulft',  of  Berlin,  has  reported  similar 
disease  of  the  blood-vessels,  causing  spontaneous 
gangrene  in  a  youthful  subject.  Some  will  contend 
that  however  great  the  arterial  or  vascular  changes 
may  be,  they  are  secondary  to  some  mysterious 
trophic  influence.  There  is,  of  course,  much  to  be 
said  in  favor  of  this  view. 

Lewaschew's*  experiments  on  animals  have 
shown  that  five  months  after  irritating  the  sciatic 
nerve  of  an  animal  distinct  changes  were  noted  in 
the  blood-vessels  of  the  part  experimented  upon, 
that  there  was  a  constriction  of  the  vessels  due  to 
the  marked  changes,  first  in  the  adventitia  and 
muscular  coat,  and  later  on  in  the  intima  of  the 
smaller  blood-vessels.  FraenkeP  found  changes  in 
the  blood-vessels  three  or  four  weeks  after  sec- 
tion of  the  sciatic  nerve.  It  was  his  opinion  that  the 
nerve  lesion  produces  a  condition  of  chronic  irrita- 
tion ;  that  this  in  turn  was  responsible  for  a  spasm 
of  the  arteries,  resulting  in  a  hypertrophy  of  the 
walls  of  the  blood-vessels.  Among  the  most  recent 
writers  on  the  subject  is  Lapinsky,^"  who  has  shown 
conchisively  that  section  of  the  vaso-motor  nerves 
produces  a  change  in  the  walls  of  the  blood-vessels. 
He  operated  upon  14  rabbits,  removing  various 
sympathetic  ganglia,  and  also  performed  resection 
and  ligation  of  the  cervical  sympathetic.  Following 
upon  these  operations  he  observed  a  dilatation  of 
the  blood-vessels,  more  marked  pulsation,  and  in- 
creased blood  pressure.  The  animals  were  kept 
alive  for  varying  periods,  from  between  ten  to  ninety 
days.  In  seven  out  of  the  fourteen  cases  there 
were  marked  changes  in  the  larger  blood-vessels, 
consisting  of  the  thickening  of  the  muscular  coat 
and  of  the  elastic  membrane.  The  changes  in  the 
smaller  blood-vessels  and  in  the  capillaries  were  still 
more  marked.  The  muscular  coat  was  either 
atrophic  or  had  disappeared  entirely.  The  intima  was 
thickened  and  proliferated,  the  lumen  of  the  blood- 
vessels being  frequently  closed.  If  the  animals  were 
killed  before  six  weeks  had  elapsed  since  the  opera- 
tion, the  degeneration  of  the  walls  was  not  so  evi- 
dent. The  nature  of  the  lesion  itself  and  of  the  sym- 
pathetic did  not  seem  to  be  of  any  special  impor- 
tance, and  it  mattered  little  whether  or  not  the 
ganglia  had  been  removed  at  the  time  the  sympa- 
thetic was  experimented  upon.  Lapinsky  has  also 
done  excellent  work  in  showing  the  dependence  of 
vaso-motor  changes  upon  neuritis.  He  was  able  to 
furnish  accurate  anatomical  evidence  of  a  prolif- 
eration of  the  intima  with  obliteration  of  the  lumen, 
and  of  hemorrhages  into  the  surrounding  tissue  fol- 
lowing upon  an  experimental  neuritis.  But  granted 
that  the  sympathetic  and  the  peripheral  nerves  ex- 
ercise an  important  influence  upon  the  blood-ves- 
sels, the  question  arises  whether  disease  of  the 
blood-vessels  may  not  occur  independentlv  of 
nerve  lesions  or  possibly  coincident  with  them.  Such 
coincidence   would   not  be   unnatural   if  we   reflect 


7.  Ueber  Spontano  Gangraeii  hei  jngendlichen  Individuen,  Berlin  Surgi- 
cal Society,  Dec.  lo,  1900;  reported  in  Deutsche  Med.  Wochenschr.  No.  9 
1901,  p.  68. 

8.  Virchows  .\rchiv.  Vol.  Q2,  p.  152-  . 

9.  Centrallnlati  f.  allg.  Pathologi";  ""d  Path.  .-Vnatomie  iS9\  i,— qunt.-d 
by  Cassirer.  .    .,  ,   ...,,, 

10.  Deutsche  Zeitschr.  f.  Nervenheilkunde  Vol.  XVI,  p.  240. 


that  there  are  several  organic  and  inorganic  poisons, 
such  as  syphilis  and  alcohol,  which  exhibit  their 
deleterious  effects  upon  the  bloud-vessels  as  well 
as  upon  the  nerves. 

\\  hile  Lapinsky  is  inclined  to  attach  greater  im- 
portance to  reflex  neurotic  influences,  Thoma  has 
established  the  doctrine  that  the  degeneration  of 
the  blood-\essels  is  largely  due  to  a  simple  mechan- 
ical condition,  and  that  the  retardation  in  the  rapid- 
ity of  circulation  and  the  variations  in  intravascular 
pressure  are  primarily  responsible  for  the  changes 
in  the  walls  of  the  blood-vessels.  Cassirer,  who 
has  tried  in  an  impartial  way  to  review  the  entire 
literature  of  the  influence  of  the  trophic  nerves  upon 
the  disease  of  the  blood-vessels,  is  only  able  to  state, 
as  a  final  conclusion,  that  "there  is  at  least  every  rea- 
son to  consider  the  condition  of  the  vaso-motor  sys- 
tem in  cases  of  disease  of  the  blood-vessels,  par- 
ticularlj'  of  the  smaller  ones."  If  this  be  the  result 
of  years,  of  controversy,  it  will  be  more  fruitful  to 
quit  the  field  of  speculative  physiology  and  path- 
ology and  to  record  for  the  present,  in  sober  fash- 
ion, the  widespread  changes  in  the  vascular  system 
of  patients  affected  with  various  forms  of  so-called 
tropho-neuroses.  To  this  end  a  few  histories  and 
anatomical  studies  will  be  briefly  reported : 

CASE  1. — W.  S..  27  years  of  age,  born  in  Russia:  seen  for 
the  first  time  in  January,  1S98.  At  that  time  he  complained 
of  a  peculiar  numbness  and  tingling  sensation  in  his  feet. 
These  would  occur  at  various  times  during  the  day  and 
were  followed  by  severe  pain  and  a  distinct  bluish  discol- 
oration of  the  feet.  The  patient  thinks  that  for  four  years 
before  this  first  examination  he  has  suffered  in  a  similar 
way.  He  was  employed  in  a  silk  factory  and  was  compelled 
to  stand  on  his  feet  all  day  long.  The  pain  was  paroxysmal, 
sometimes  lasting  only  a  few  moments,  at  other  times  it 
would  continue  for  several  hours.  He  suffered  more  dur- 
ing the  winter  than  during  the  summer  months,  although 
never  entirely  free  from  pain.  Holding  his  occupation  re- 
sponsible for  his  symptoms,  he  changed  the  character  of  his 
work  and  was  busy  at  a  sewing  machine.  After  working 
m  this  way  only  a  short  time  and  occasionally  treading  the 
machine  with  his  bare  feet,  occasional  pain  set  in  in 
both  feet,  and  he  soon  noticed  that  the  right  one  assumed 
H  dark  purplish  color.  The  paroxysmal  attacks  of  pain 
became  more  and  more  frequent,  the  individual  attacks  last- 
ing longer  and  longer,  until  the  pain  became  practically 
continuous.  There  is  no  history  of  syphilis  in  this  case. 
The  urine  was  normal,  free  from  sugar  or  any  foreign  mat- 
ter. He  had  been  a  heavy  drinker  for  some  time,  never  be- 
coming intoxicated,  but  rather  proud  of  the  fact  that  he 
could  consume  large  quantities.  The  toes  of  the  right  foot 
at  the  time  of  the  first  examination  had  assumed  a  dark 
purplish  color.  When  pricked  with  a  pin  the  blood  that 
exuded  from  the  toes  was  almost  black.  The  veins  over 
the  arch  of  the  toot  were  prominent;  pulsation  could  be 
felt  in  the  arteries  at  the  ankle  joint,  but  not  very  dis- 
tinctly. The  feet  were  not  sensitive  to  pressure,  even  at 
the  time  of  greatest  pain.  The  left  foot  was  similar  in 
every  way.  though  all  the  phenomena  were  somewhat  less 
marked.  No  sensory  disturbance  could  be  detected  In 
either  foot  in  the  interval  between  the  attacks.  The  elec- 
trical condition  of  the  nerves  and  muscles  was  practically 
normal.  Various  therapeutic  measures  were  employed,  but 
without  avail.  The  patient  was  evidently  discouraged  and 
disappeared  from  observation. 

He  returned  a  year  and  a  half  later  with  the  history  that 
he  had  gone  to  his  home  in  Warsaw.  R\issia.  and  had  placed 
himself  under  the  care  of  a  physician.  While  there,  gan- 
grene appeared  and  one  toe  after  the  other  of  the  right  foot 
had  to  be  removed  during  a  period  of  two  months.  Soon 
the  toes  of  the  left  foot  began  to  give  the  same  trouble,  and 
the  big  toe  of  this  foot  was  also  removed  on  account  of 
gangrene.  Later  on  the  little  toe  was  removed.  The  other 
toes  were  extremely  cyanotic,  but  were  not  amputated.  The 
patient  felt  better  and  decided  to  return  to  New  York. 
'.Vhen  examined  after  his  return,  the  following  condition 


1244 


The    Philadelphia" 
Medical  Journal 


SOME  TROPHO-NEUROSES. 


[June  29.  1901 


■was  noted:  The  right  foot  presented  a  reddish  purplish  ap- 
pearance, with  veins  still  prominent  and  arteries  with  dis- 
tinct but  weak  pulsation.  The  left  foot  was  of  a  much 
darker  appearance:  the  only  three  toes  which  had  not  been 
amputated  were  extremely  cyanotic. 

At  this  time  the  patient  was  working  in  a  cigar  factory. 
He  was  under  observation  just  one  month  when  severe  pain 
and  gangrene  appeared  on  the  inner  and  plantar  surface  of 
the  left  foot.  On  account  of  the  pain  and  marked  cyanotic 
appearance  of  the  foot,  amputation  had  to  be  resorted  to, 
and  this  was  done  by  Dr.  Lilienthal,  the  patient  making 
an  uneventful  recovery.  Previous  to  the  amputation  of  the 
foot,  the  patient  began  to  complain  of  pain  and  numbness 
in  the  index  and  middle  finger  of  the  right  hand.  These  fin- 
gers would  get  perfectly  white  and  were  practically  corpse 
fingers,  in  marked  contrast  to  the  deep  cyanotic  color  of 
the  other  fingers  and  rest  of  the  hand.  The  pulse  at  the 
wrist  did  not  alter  its  character  appreciably  during  the 
entire  attack.  It  was  of  great  interest  to  us,  however,  that 
at  this  same  time  a  marked  phlebitic  swelling  occurred 
just  below  the  elbow.  This  gradually  disappeared  under 
proper  treatment. 

The  paroxysmal  attacks  of  pain,  the  recurrent 
forms  of  local  syncope  and  asphyxia,  followed  by 
symmetrical  gangrene,  the  absence  of  marked  sen- 
sor}-  changes  and  of  a  reaction  of  degeneration 
in  the  nerves  and  muscles  of  the  affected  parts,  made 
the  diagnosis  of  Raynaud's  disease  certain  enough. 
But,  even  if  there  were  to  be  a  difference  of  opinion 
as  to  the  exact  labeling  of  this  special  case,  the 
marked  arterio-  and  phlebo-sclerosis  was  of  special 
interest.  On  carefully  examining  the  removed  tis- 
sue, we  could  not  find  a  single  artery  or  vein,  large 
or  small,  that  was  not  diseased.  Slight  degenera- 
tive changes  were  found  in  some  of  the  nerve  fibres. 
Excessive  alcoholic  indulgence  and  the  peculiar  oc- 
cupation of  the  individual  must  be  considered  the 
chief  etiological  factors.  With  alcohol  as  a  predis- 
posing cause  of  vascular  disease,  the  constant  use 
of  the  extremities  may  be  considered  to  be  the 
additional  exciting  cause.  Moreover,  as  soon  as 
the  patient  changed  his  occupation  and  became  a 
cigarmaker,  necessitating  the  more  active  employ- 
ment of  the  hands  and  fingers,  the  disease  became 
evident  in  the  upper  extremity.  Exposure  to  cold 
may  also  have  played  a  role,  and  in  view  of  the  dis- 
eased condition  of  the  blood-vessels,  reactive  circu- 
lation could  not  be  easily  established  in  parts  that 
were  improperly  nourished,  the  obliterating  endar- 
teritis in  this  case  was  evidently  not  of  recent  date. 
An  examination  of  the  specimens  showed  some  of 
the  vessels  almost  completely  obliterated  by  dense 
sclerotic  tissue,  while  all  possible  and  advanced 
stages  of  an  obliterating  endarteritis  could  be  made 
out.  The  presence  of  phlebitic  swelling  in  the  right 
fore-arm,  coincident  with  the  first  symptom  of  the 
Raynaud  type  in  this  same  extremity,  would  also 
go  to  prove  the  intimate  dependence  of  the  latter 
upon  the  former.  The  patient,  on  close  questioning, 
also  stated  that  he  had  frequently  had  these  lumps 
in  the  lower  extremity  before  the  later  symptoms 
had  been  carefully  noted.  It  will  not  be  necessary 
to  claim  that  Raynaud's  disease  is  always  due  to 
vascular  changes,  though  Barlow,  Dehio,  and  even 
Raynaud  himself  have  reported  such  changes  in  sub- 
jects of  this  disease.  Allowing  for  marked  trophic 
and  vaso-motor  influences,  the  case  jvtst  reported 
seems  to  us  to  furnish  good  evidence  of  the  intimate 
relation  between  the  vascular  changes  and  the 
grave  disturbances  in  the  nutrition  of  the  peripheral 
parts. 


CASE  2. — S.  L.,  a  tailor,  31  years  of  age,  married  7 
years.  Family  history  negative,  as  far  as  any  neurotic  taint 
is  concerned.  Smokes  a  pipe  and  drinks  beer  very  freely. 
No  history  of  any  venereal  trouble.  Has  worked  at  a  sew 
ing  machine  tor  4  years,  but  gave  up  this  occupation  Z 
years  ago.  Has  never  suffered  any  exposure  to  cold.  Four 
years  before  the  first  examination  he  claims  that  he  ha<I 
suffered  with  occasional  burning  pains  along  the  inner  bor- 
der of  the  left  foot  and  drawing  pains  of  the  left  calf.  These 
attacks  were  infrequent  at  first  and  lasted  about  half  a 
day.  He  noticed  that  at  times  a  red  patch  would  appear 
over  the  inner  border  of  this  same  foot,  without  any  dis- 
tinct pain  in  walking.  Two  and  a  half  years  ago  he  began 
to  suffer  from  redness  and  swelling  in  the  big  toe  of  the 
left  foot,  which  was  accompanied  by  a  marked  burning  sen- 
sation. The  pain,  the  redness  and  the  swelling  were  con- 
stant, but  were  made  distinctly  worse  on  walking.  The 
trouble  was  supposed  to  be  rheumatic,  and  the  treatment 
was  in  accordance  with  this  supposition.  This  treatment 
was  interrupted  by  the  appearance  of  an  ingrowing  nail  on 
this  same  toe.  The  nail  had  to  be  removed,  and  a  black 
suppurating  slough  developed,  the  gangrenous  area  spread- 
ing toward  the  end  of  the  toe  on  the  outside.  This  area  was 
excised  and  the  bone  thoroughly  scraped.  Gangrene,  how- 
ever, continued  to  spread,  so  that  it  became  necessary  to 
remove  the  nail  and  one  phalanx,  which  was  done  on  Jan- 
uary 21,  1809.  The  patient  had  been  in  the  hospital  three 
weeks,  and  as  the  amputation  wound  refused  to  heal,  the 
sloughing  skin  and  a  piece  of  the  proximal  phalanx  were  re- 
moved. During  all  this  time  the  patient  had  severe  pain, 
and  the  other  toes  of  the  same  foot  became  reddish  blue, 
were  swollen  and  were  more  or  less  painful.  In  May  1899 
the  proximal  phalanx  was  removed  under  chloroform  and 
the  wound  bid  fair  to  heal.  Later  on  numerous  incisions 
had  to  be  made  for  evacuation  of  the  pus.  The  patient  in- 
sisted on  returning  to  his  work,  but  ulcers  were  developed 
between  the  base  of  the  second  and  the  third  toes  on  the 
dorsum  of  the  foot.  The  blueness,  pain  and  swelling  were 
growing  constantly  and  were  especially  severe  when  the  foot 
was  in  a  dependent  position.  The  heart,  lungs  atid  kid- 
neys were  normal;  the  patient  weighed  about  141  lbs.  and 
was  emaciated  in  appearance.  There  was  a  general  atro- 
phy of  the  left  limb  from  the  hip  down.  This  atrophy  may 
partly  have  been  due  to  disuse,  as  the  patient  had  practi- 
cally not  used  this  limb  for  a  period  of  four  and  a  half 
months.  The  deep  and  superficial  reflexes  were  normaL 
The  left  foot,  when  in  a  dependent  position,  became  cyan- 
otic; when  elevated,  it  gradually  grew  paler,  but  remained 
painful.  The  great  toe  is  absent,  and  the  others  are  swol- 
len, so  that  the  lines  over  and  around  the  articulation  are 
lost.  The  nails  are  thick,  round  in  shape  and  with  a  ten- 
dency to  become  ingrown.  Under  the  dorsum  of  the  right 
foot  at  the  head  of  the  first  metacarpal  bone  is  a  round 
circumscribed  ulcer,  three  centimetres  in  diameter,  which 
involved  the  entire  thickness  of  the  skin.  The  borders  are 
not  undermined,  but  sharp,  and  bleed  easily  when  the  foot 
is  dependent.  At  the  base  of  the  muscles  is  a  yellow-gray- 
ish slough  that  does  not  bleed  easily.  Around  tht  u'cf-r  th(> 
skin  has  a  reddish  blue  color,  which  disappears  slowly  and 
returns  slowly  on  pressure.  On  the  dorsum  of  this  foot 
and  base  of  the  second  and  third  mediodorsal  phalangeal 
articulation  is  another  ulcer  similar  in  every  respect  to 
the  one  just  described,  only  differing  in  size  and  shape. 
The  pain  became  so  severe  in  this  case  and  the  ulcers  re- 
fusing to  heal,  various  therapeutic  measures  were  tried,  and 
the  leg  was  amputated  above  the  knee  joint  by  Dr.  Gerster. 
The  popliteal  arts-ry.  vein  and  nerve  the  anterior  and  pos- 
terior tibial  arteries,  veins  and  nerves,  together  with  the 
plantar  arteries  and  nerves  and  various  tissues  of  the  fi-fct. 
were  immediately  removed  and  examined. 

In  this  case  also,  all  the  veins  and  arteries  were 
in  a  condition  which  might  best  be  designated  as  a 
marked  arterio-  and  phlebo-.sclerosis.  The  under 
popliteal  nerve  was  entirely  normal.  Only  in  the 
neighborhood  of  the  ankle  joint  were  a  few  degen- 
erated fibres  in  the  anterior  and  posterior  tibial*. 
Thcrewasadistinctinflammationof  the  nerves  on  the 
dorsal  and  plantar  portion  of  the  foot.  In  this  case 
again,  if  we  were  interested  in  the  diagnosis  of  ery- 
thromelalgia.  a  hue  and  cry  would  be  certain  to  be 
raised  :  although  the  swelling,  the  redness,  the  pain. 


June   29.   19011 


SOME  TROPHO-NEUROSES. 


TThe    Philadelphia 
L  Medical  Jovrnal 


1245 


the  marked  hyperesthesia,  all  increasing  when  the 
foot  was  in  a  dependent  position,  would  be  in  agree- 
ment with  that  diagnosis.  But  we  will  not  insist 
on  it,  since  the  clinical  picture  was  evidently  altered 
through  the  presence  of  an  ingrowing  nail,  and  pos- 
sible infection  of  the  foot  leading  to  the  ulceration 
and  gangrene.  There  would  be  no  objection  to  clas- 
sifying this  special  case  as  a  representative  of  the 
simpleobliteratingendarteritisof  Friedliinder  ;and  to 
meet  all  just  criticisms,  it  may  simply  be  inferred 
that  the  earlier  stages  of  obliterating  endarteritis 
give  rise  to  symptoms  which  are  very  similar  to 
those  included  under  the  term  of  erythromelalgia. 
The  occurrence  of  marked  pain  in  these  cases  is  of 
some  interest.  It  would  be  natural  to  connect  this 
with  a  terminal  neuritis,  as  Weir  Mitchell  has  done 
in  his  classical  accounts  of  erythromelalgia:  but  one 
cannot  escape  the  conclusion  that  the  terminal  neu- 
ritis may  at  times  be  secondary  to  this  marked  al- 
teration of  the  blood-vessels,  with  subsequent  mal- 
nutrition of  all  the  tissues,  including  the  nerves.  In 
the  case  just  referred  to  the  parent  trunks  were 
normal,  and  changes  were  found  only  in  the  more 
peripheral  portions.  When  gangrene  and  ulceration 
appear  the  neuritis  may  be  attributed,  in  part,  also 
to  the  efifects  of  the  infection. 

CASE  3. — The  patient.  Mrs.  S.  I..  29  years  of  age,  was 
referred  to  Dr.  Wiener  by  Dr.  Goldenberg.  She  was  born 
in  Germany;  married  8  years:  inclined  to  obesity,  and 
presented  gouty  manifestations.  Short  and  thick-set  in 
stature,  she  easily  tires  and  suffers  from  palpitation  and 
dyspnea  when  she  attempts  to  walk  rapidly  or  to  climb 
a  flight  of  stairs.  Of  the  tour  children  born  to  her  none  is 
living.  During  first  pregnancy  she  had  a  bad  tall  in  the 
seventh  month.  The  child  was  born  at  term  and  died 
shortly  after  birth.  With  the  second  child  labor  was  dif- 
ficult; the  child  was  born  alive,  but  died  on  the  following 
day.  The  third  was  born  at  full  term  and  died  a  few  days 
thereafter  in  convulsion.  The  fourth  child  lived  to  be  six 
months  of  age  and  then  died  in  an  attack  of  pneumonia. 
The  patient  has  never  had  any  serious  illness  and  gives  no 
history  of  syphilis  or  of  any  venereal  infection,  however 
suspicious  the  history  may  be.  Her  mother  died  at  a  very 
early  age  of  unknown  disease  Father  is  living  and  well. 
The  parents  of  the  patient  have  had  seven  children;  of 
these  seven,  live  are  living  and  perfectly  healthy.  In  re 
gard  to  the  other  two,  one  died  of  meningitis,  complicat 
ing  influenza,  and  the  others  of  pernicious  anemia.  The  pa- 
tient's husband  is  living  and  has  been  free  from  serious 
illness.  In  the  spring  of  1900  the  patient's  foot  began  to 
itch  in  a  very  annoying  manner,  so  that  she  often  was 
compelled  to  remove  her  shoes  during  the  day  to  relieve 
the  itching  by  scratching.  It  was  especially  severe  in  the 
neighborhood  of  the  small  and  middle  toes  of  the  right  foot 
and  the  small  and  big  toes  of  the  left  foot.  At  first  there 
v.as  no  pain,  but  gradually  the  pain  appeared  attor 
scratching.  After  a  period  of  three  weeks,  following  upon 
the  mechanical  irritation  produced  by  scratching,  excor- 
iated areas  appeared  over  the  left  foot.  The  ordinary 
treatment  by  dry  pov,'ders  was  of  no  avail;  the  excoria- 
tions gradually  developed  into  ulcers,  and  the  patient  re- 
quested treatroent  at  the  Vanderbilt  Clinic.  She  was  put 
under  thorough  anti-syphilitic  treatment,  which  had  no 
effect  on  the  healing  of  these  ulcers.  The  pain  became 
continuous,  was  burning  in  character  and  so  severe  that 
she  was  unable  to  obtain  a  night's  sleep.  After  further 
treatment  by  Dr.  Goldenberg.  consisting  of  ichthyol  oint- 
ment and  cold  dressings,  which  also  proved  unavailing, 
the  patient  was  sent  to  Mount  Sinai  Hospital,  where,  af- 
ter remaining  at  rest  for  a  few  weeks,  the  ulcers  gradually 
healed:  but  as  soon  as  she  was  up  and  about  again,  the 
same  condition  returned  .  It  was  then  decided  to  amputate 
the  big  and  second  toes  upon  which  the  ulcers  existed.  Con- 
siderable relief  followed  upon  this,  and  the  patient  has 
been  up  and  about  for  six  months.  The  urine  was  exam- 
iued  several  times  and  found  to  be  normal,  only  once  a 
very  slight  trace  of  sugar  was  made  out.  to  which,  how- 


ever, no  importance  could  be  attached.  No  distinct  sen- 
sory disturbances  were  ever  detected.  The  deep  and  sup- 
erficial reflexes  *ere  always  normal.  Distinct  and  good 
pulsation  was  present  in  this  foot.  The  toes  just  before 
amputation  were  ver>-  much  swollen  and  of  a  reddish  pur- 
ple appearajice.  The  base  of  the  ulcers  was  covered  by  a 
thin  grayish  purulent-looking  mass.  The  edges  were  not 
undermined  or  thickened. 

A  microscopic  examination  of  the  tissues  taken 
from  the  amputated  toes  shows  an  obliterating  en- 
darteritis in  its  earlier  stages,  and  also  a  nerve 
end  neuritis.  No  normal  nerve  fibres  could  be  made 
out  in  the  many  specimens  that  were  examined.  The 
tissues  were  infiltrated  with  round  cells  and  showed 
an  active  inflammatory  condition.  This  case  de- 
monstrates the  earlier  presence  of  vascular  disease 
in  association  with  nerve  endneuritis  and  with  troph- 
ic disturbances.  It  is  not  unimportant  to  note  the 
early  and  persitent  itching.  The  scratching,  the 
mechanical  irritation,  as  well  as  the  infection,  evi- 
dently led  to  the  development  of  ulcers  in  parts  em- 
barrassed by  a  defective  circulation,  due  to  diseased 
blood-vessels. 

In  the  three  cases  just  reported  somewhat  in  de- 
tail, the  relation  to  the  trophic  disturbances  and  the 
vascular  disease  seems  to  be  evident  enough ;  but 
since  our  attention  has  been  directed  to  the  obser- 
vation of  the  blood-vessels  in  the  extremities,  other 
and  lesser  conditions  have  been  met  with  which  may 
properly  be  attributed  to  lesser  and  possibly  recov- 
erable affections  of  the  peripheral  blood-vessels. 
Some  time  ago  we  had  under  observation  a  lady  of 
55  years  of  age,  who  had  been  treated  for  an  attack 
of  hemiplegia,  due  to  embolism.  The  patient  had 
a  marked  general  arterio  sclerosis  in  addition  to  the 
valvular  lesion,  without  any  renal  complications. 
She  had  recovered  from  the  hemiplegia  and  is  now 
able  to  get  about  without  assitance.  Her  general 
health  is  good,  but  she  is  troubled  from  time  to  time 
by  spasmodic  attacks  of  severe  pain  in  the  fingers 
of  the  right  hand,  followed  by  numbness  and  pallor 
of  these  fingers.  The  attack  generally  does  not  last 
more  than  a  few  hours.  During  several  such  at- 
tacks one  of  us  was  called  to  see  her,  and  found  that 
the  fingers  were  absolutely  numb  and  resembled  in 
every  respect  the  corpse  fingers  of  Raynaud's  dis- 
ease. Each  one  of  these  attacks  has  been  promptly 
relieved  by  the  administration  of  hot  baths,  vigorous 
massage,  and  small  doses  of  iodides.  The  attacks 
could  justly  be  likened  to  those  of  Raynaud's  dis- 
ease, but  the  matter  is  referred  to  here  merely  to 
show  the  probable  dependence  of  such  symptoms 
upon  arterio  sclerosis  of  the  peripheral  vessels.  It 
is  a  matter  for  surprise  that  such  attacks  are  not 
more  frequently  referred  to  in  association  with  car- 
diac and  arterial  disease  in  the  senile  period. 

In  another  elderly  lady  of  60,  suffering  from  se- 
vere diabetes  and  treated  in  conjunction  with  Dr. 
Janewa}'.  the  most  distressing  symptoms  were'  fre- 
quent burning  sensations,  numbness  and  occasion- 
ally a  cold  feeling  in  the  lower  extremity.  We  might 
have  been  satisfied  merely  to  record  these  as  ordi- 
nary rheumatoid  pains,  for  there  was  also  a  goutv 
rheumatic  element  in  this  case  ;  but.  bearing  in  mind 
the  possible  disease  of  the  peripheral  arteries,  we 
watched  carefully  the  pulsations  of  the  dorsal  arter_\- 
of  the  foot  and  often  found  its  beat  feeble.  Relief 
in  this  case  was  only  to  be  had  from  active  massag.' 


1246 


The    Philadelphia 
Medical  Journal 


] 


THE  FREEZING-POINT  OF  URINE 


[Jl-.ve  29,   1>11 


and  the  application  of  intense  heat.  There  can 
be  little  doubt  that  such  symptoms  as  these  are  due 
to  interference  with  the  peripheral  circulation.  If 
we  bear  in  mind  the  frequency  of  gangrene  in  dia- 
betes, the  occurrence  of  such  symptoms  as  we  have 
jtist  described,  denoting  a  lesser  degree  of  vascular 
disease,  becomes  a  matter  of  more  than  passing  in- 
terest. 

It  would  indeed  be  well  to  pay  greater  attention 
to  the  arteries  of  the  lower  extremities,  for  not  only 
are  such  rare  types  of  disease  as  intermittent  claudi- 
cation known  to  be  associated  with  arterio  sclerosis 
in  the  lower  extremities,  but  Thoma's  interesting 
researches  have  shown  quite  conclusively  that  many 
of  the  vague  rheumatoid  affections  may  be  consid- 
ered to  be  due  to  an  angiosclerosis. 

Whatever  theory  we  may  hold  with  regard  to  the 
influence  of  trophic  and  vaso-motor  fibres  upon  dis- 
ease of  the  blood-vessels,  the  experiences  here  re- 
ported seem  to  argue  in  favor  of  an  intimate  rela- 
tion between  the  disease  of  the  peripheral  blood- 
vessels and  many  of  the  tropho-neuroses ;  but 
whether  such  disease  be  primary  or  secondary  must 
be  left  to  further  investigation. 


THE  FREEZING-POINT  OF  URINE:  ITS  DETERMINA- 
TION AND  THE  INFERENCES  WHICH  MAY  BE 
DRAWN  FROM  IT.* 

By  J.  H.  HUDDUESTON,  M.  D., 
of  New  York. 

History. — The  determination  of  the  freezing- 
point  is  called  more  technically  cryoscopy  from 
kryos,  cold,  and  skopein,  to  see. 

As  early  as  1870  Bouchard  employed  this  method 
in  the  examination  of  the  urine,  and  in  1872  and 
1873  Malasser  and  Hamburger  followed  in  the 
work.  In  1891,  after  an  interval,  Dreser  added  his 
name  to  the  list  of  investigators,  and  in  1894  Koran- 
yi,  of  Buda  Pesth,  began  the  careful  studies  which 
culminated  in  an  elaborate  paper  published  in  the 
Zcitschrift  fiier  Klinische  Mcdicin  in  1897  and  1898. 
Since  then  there  has  been  some  steady  progress 
along  the  line  of  this  work,  and  at  the  Interna- 
tional Medical  Congress  in  1900  the  mt>^od  of  in- 
vestigation received  its  first  extensive  public  notice. 
Bouchard,  Vaqucz,  Bousquet,  and,  most  recently, 
Claude  and  Balthazard  ha\-e  all  published  notable 
papers.  Outside  of  Germany  and  France,  however, 
there  has  been  comparatively  little  attention  paid 
to  the  results  obtained,  and  this  is  mv  excuse  for 
the  following  paper: 

Theory. — The  theory  of  l^rinary  Cryoscopy  is 
based  on  (A.)  Raoult's  theorem,  now  an  accepted 
law  of  chemistry,  much  used  since  1888.  and  (B.) 
Koranyi's  theory  of  molecular  exchange  in  the  con- 
voluted tubules  of  the  kidney. 

A.  Remsen,  in  his  theoretical  chemistry,  states 
Raoult's  law  as  follows :  "One  molecule  of  any 
compound  when  dissolved  in  one  hundred  mole- 
cules of  a  liquid  lowers  the  freezing  point  of  the 
liquid  by  an  amount  which  is  nearly  constant."  In- 
ferenlially  the  same  number  of  molecules  of  urea 
or  of  sodiimi  chloride  dissolved  in  urine  cause  the 
same  lowering  of  the  freezing  point.    This  marks  at 

*Re«d  heforcthe  New  York  .\cadeiiiy  of  Me<licine.  June  6,  1901. 


once  a  significant  difference  from  the  specific  grav- 
ity of  the  urine.  A  few  heavy  molecules  would 
notably  increase  the  specific  gravity,  but  would 
affect  but  little  the  lowering  of  the  freezing  point. 
Blagden  has  stated  the  law  in  this  form :  "If  two 
different  substances  are  contained  at  the  same 
time  in  the  same  solution  the  lowering  of  the  freez- 
ing point  of  the  solution  is  the  sum  of  the  lowering 
of  the  freezing  point  which  one  substance  would 
cause  and  that  which  the  other  would  cause."  The 
experiments  of  Koranyi  on  mixtures  of  solutions 
of  sodium  chloride  and  of  urea  have  confirmed  this 
law  for  those  substances,  and,  to  a  certain  degree, 
therefore,  for  urine.  If  T  =  the  temperature  of  the 
freezing  point  of  urine,  and  therefore  the  lowering 
of  the  freezing  point  below  o°,  then  C  T  (in 
which  C  represents  some  constant)  =  the 
number  of  molecules  in  unit  volume  of  urine, 
and  if  V  =  the  amount  of  urine  passed  in  twenty- 
four  hours,  C  T  V  =  the  total  number  of  mole- 
cules of  all  sorts  passed  in  solution  in  that  time. 
Urea  and  the  other  organic  compounds  form  about 
7-12  of  the  average  solid  content  of  urine,  sodium 
chloride  about  3-12  and  the  sulphates,  phosphates 
and  metallic  bases  about  2-12.  Of  these  sodium 
chloride  is  the  only  one  which,  passing  unchanged 
through  the  body,  does  not  represent  anj^  metabol 
ism.  If  T'  =  freezing  point  of  a  solution  contain- 
ing the  same  amount  of  sodium  chloride  as  the  par- 
ticular specimen  of  urine,  T  —  T'  =  T"  =  the  low- 
ering of  the  freezing  point  due  to  the  rest  of  the 
dissolved  matter  including  all  the  complex  matter 
of  the  urine,  and,  as  before,  C  T"  V  =  the  total 
number  of  the  complex  molecules,  those  concerned 
in  metabolism,  passed  in  twenty-four  hours.  If 
W  =  weight  of  the  person  expressed  in  Kilos. 
(C  T  V)  -T-  W  =  the  number  of  molecules  excreted 
per  kilo  of  weight  or  the  total  molecular  diuresis, 
and  (C  T"  V)  -=-  W  =  the  number  of  complex 
molecular  diuresis. 

These  symbols  may  be  put  in  figures ;  in  an 
actual  normal  urine  T  was  found  to  be  —  1°  .50; 
\,  1500;  and  W,  60;  —  0°  .613  has  been  found  to  he 
the  freezing  point  of  1%  of  sodium  chloride,  and 
the  freezing  point  of  any  per  cent.  CI  of  sodium 
chloride  is  CI  X  .613.  In  this  specimen  CI  was 
:^=  .4904  and  T"  ^=  T  —  T'  =  1.50  —  .49  ^  i.oi ; 
.008  and  the  freezing  point  was  therefore  .8  X  -613 
—  .4904  and  T"  =  T  —  T'  ^  i.so  —  .49  =  i.oi ; 
(C  T  V)  -^  W  then  was  (C  X  1^0  X  isoo)  -^  60 
=  3750  C  and  (C  T"  V)  -^  W  =  (C  X  loi  X  1500) 
-;-  60  =  2525  C.  In  each  case  C,  of  course,  is  a  con- 
stant which  is  eliminated  in  comparisons.  Normally 
T  varies  from  —  1°  .30  to  —  2*^  .20  centigrade,  (C 
T  ^■)  -^  W  roughly  from  3000  C  to  4000  C  and  (C 
T"  V)  -H  W  from  1000  C  to  2600  C. 

B.  Koranyi's  theory  is  first,  that  there  is  filtered 
through  the  walls  of  the  glomeruli  of  the  kidney 
water  containing  sodium  chloride  in  such  amount 
that  the  solution  has  the  same  osmotic  tension  and 
therefore  the  same  freezing  point  as  the  blood 
plasma,  and  second,  that  as  this  solution  flows 
through  the  convoluted  tubules  and  Hcnlc's  loops. 
it  there  returns  to  the  blood  a  certain  amount  of 
water  and  a  certain  number  of  molecules  of  the 
sodium  chloride  and  receives  c.vacfly  the  satm 
number  of  molecules  of  more   complex   substances. 


June   29,    1901] 


THE  FREEZING-POINT  OF  URINE 


CThe    Philadelphia 
Medical  Journal 


1247 


In 


language,  the     solution  there     becomes 


coiicentratt'd  and  takes  on  the  character  of  urine. 
If  the  glomerular  filtration  is  rapid  the  flow  of  urine 
is  rapid  and  the  rate  of  molecular  interchange  in 
the  tubules  per  unit  of  urine  is  slow.  Such  v/ould 
be  the  case  with  high  arterial  tension.  On  the 
other  hand,  if  the  glomerular  filtration  is  slow  the 
flow  of  urine  is  slow  and  permits  a  high  rate  of 
molecular  interchange  in  the  tubules  per  unit  of 
urine.  Such  would  follow  in  renal  stasis  or  in  in- 
jury to  the  glomerular  wall  as  in  glomerulo-nephri- 
tis.  Again,  no  matter  what  the  rate  of  urinary  flow, 
if  the  epithelium  of  the  tubules  performs  its  work 
imperfectly  or  obstructs  the  interchange,  the  rate 
of  that  molecular  interchange  must  be  lowered. 
Such  would  naturally  follow-  in  tubular  nephritis 
or  in  any  other  organic  or  functional  affection  of 
the  tubules. 

(C  T  V)  -=-  W,  as  was  said,  represents  the  total 
molecular  diuresis,  i.  e.,  it  represents  the  glome- 
rular filtration,  increasing  in  value  when  that  is 
rapid,  decreasing-  when  it  is  slow.  With  high  ar- 
terial tension,  for  example,  it  may  go  up  to  6000: 
with  renal  stasis  it  maj'  go  down  to  300.  The  com- 
plex molecular  diuresis  is  represented  by  (C  T"  V) 
-f-  ^^'  and  the  rate  of  molecular  exchange  by  the 
ratio  of  the  total  molecular  diuresis  to  the  complex 
molecular  diuresis,  i.  e.,  bv  the  ratio  of  (C  T  V)  -=- 
A\'  to  (C  T"  V)  ^  W  or"  T  ~  T".  If  the  swift- 
ness of  the  urinary  flow  diminishes  (C  T  V)  -=-  W 
is  less,  and  there  is  opportunit)'  for  greater  mole- 
cular interchange,  so  (C  T"  V)  -=-  W  increases  and 
the  ratio  T  ^-  T"  therefore  diminishes.  A  ne- 
phritis limits  molecular  interchange,  and  T  -:- 
T"  therefore  increases.  Normally  this  ratio  varies 
from  1.49  to  1.69,  Another  ratio  which  was  studied 
in  great  detail  by  Koranyi  is  T  --=-  CI,  in  which 
CI  is  the  per  cent,  of  sodium  chloride  in  the  urine, 
and  the  ratio  therefore  represents  the  total  number 
of  molecules  in  unit  volume  compared  with  the 
number  of  chlorine  containing  molecules  in  the 
same  volume.  This  ratio  was  found  to  vary  nor- 
mally between  1.23  and  1.69.  Still  another  ratio 
of  importance  is  that  expressing  the  amotmt  of 
sodium  chloride  which  is  equivalent  to  all  the  mat- 
ter dissolved  in  urine.  As  the  freezing  point  of  a 
one  per  cent,  solution  of  salt  is  .613  T  would  be 
the  freezing  point  of  a  T  -^  .613  per  cent,  of  salt 
and  (V  T)  -^-  61.3  grams  would  be  the  amount  of 
salt  in  \^  c.  c.  of  a  solution  freezing  at  T,  i.  e.,  (V  T) 
-^  61.3  represents  the  equivalent  desired.  This  va- 
ries normally  from  30  to  50. 

We  have,  therefore,  according  to  Raoult's  law 
and  Koranyi's  theory,  certain  ratios,  each  capable 
of  being  expressed  in  figures,  each  representing  the 
abilitv  to  perform  a  special  renal  function,  each 
varying  naturally  within  certain  limits,  and  each 
denoting  by  its  variation  outside  of  those  limits  a 
definite  failure  of  function. 

Arguments. — The  theory  is  too  precise  and  too 
valuable  if  true  not  to  demand  the  closest  exami- 
nation. 

A.  Raoult's  law  is  not  universal  in  the  form 
stated :  it  is  exact  for  a  very  large  number  of  or- 
ganic substances,  but  it  is  not  found  to  hold  good 
for  the  watery  solutions  of  inorganic  salts,  acids 
and  bases :  such  solutions  act  as  if  thev  contained 


a  larger  number  of  molecules  than  is  indicated  by 
their  formulas ;  in  fact,  with  these  substances,  "the 
number  of  'active  molecules'  is  increased  by  the 
dissociation  of  the  compoimds  into  their  ions;  when 
the  degree  of  the  dissociation  is  determined,  how- 
ever, the  lav/  holds  exactly  when  applied  to  these 
solutions  also." 

On  the  other  hand,  it  is  probable,  according  to 
Loomis,  that  molecules  of  albumen,  and  perhaps 
of  certain  normal  urinary  constituents,  lump  them- 
selves together — several  acting  with  reference  to 
freezing  like  a  single  molecule — and  therefore  low- 
ering the  freezing  point  less  than  would  be  ex- 
pected. CI  X  -613  does  not  without  some  correc- 
tions represent  the  exact  freezing  point  of  any  per- 
centage of  sodium  chloride,  as  the  reduction  of  the 
freezing  point  is  not  exactly  proportional  to  the 
per  cent.  It  is  probable,  therefore,  that  the  results 
are  not  precise,  but  that  they  are  comparable 
among  themselves.  Further  confirmation  of  the 
applicability  of  the  law  to  all  of  the  complicated 
bodies  in  urine  is  needed. 

B.  That  the  important  glomerular  function  is 
to  filter  a  salt  solution  from  the  blood  seems  to  be 
supported  by  the  best  evidence  obtainable.  Starling 
recounts  a  number  of  experiments  made  by  himself 
which  tend  to  show  that  the  glomerular  epithelium 
may  be  looked  on  as  a  simple  filtering  membrane 
resembling  a  membrane  of  gelatine,  and  that  when 
the  pressure  in  the  glomerular  capillaries  rises 
above  25  to  30  m.  m.  of  mercury  filtration  takes 
place  through  the  epithelium  into  the  tubules — the 
filtrate  representing  simply  plasma  minus  proteid. 

C.  That  the  water  excreted  in  the  glomeruli  is 
partly  absorbed  in  the  convoluted  tubules  is  sup- 
ported by  the  facts  (i)  that  in  a  general  way  the 
convoluted  tubules  of  animals  which  pass  a  concen- 
trated urine  are  long  and  of  those  which  pass  a 
dilute  urine  are  short,  and  (2)  that  the  concentra- 
tion of  urine  lessens  with  the  rapidity  of  excretion. 

D.  On  the  other  hand,  the  theory  of  an  exact  in- 
terchange of  one  complex  molecule  for  one  salt 
molecule  in  the  convoluted  tubule  is  supported  by 
little  direct  evidence.  The  physical  law  of  the  con- 
serA-ation  of  energy  is  the  principal  support.  By 
the  general  theory  of  osmosis  the  work  performed 
through  the  tubular  membrane  is  least  if  we  as- 
sume that  exact  exchange.  No  vital  action  is  nec- 
essary for  this,  but  it  is  not  possible  to  assert  that 
none  takes  place.  Koranyi,  however,  performed 
certain  animal  experiments  which  involved  the 
analysis  of  the  blood  serum  as  well  as  of  the  urine 
and  found  that  the  ratio  of  chlorine  to  non  chlorine 
holding  molecules  in  the  blood  is  inversely  what 
it  is  in  the  urine,  and,  therefore,  in  accordance  with 
the  theory. 

E.  The  principal  proofs  of  the  value  of  cryoscopy 
must  naturally  be  found  in  clinical  experience  with 
the  method  in  the  accordance  of  its  results  with 
those  of  chemical  observations  made  in  other  ways 
as  with  the  methylene  blue  test,  and  with  autopsies. 
A  certain  number  of  autopsies  are  on  record  in 
which  the  conditions  present  in  the  heart  and  kid- 
neys were  predicted  by  the  results  of  cryoscopy, 
but  too  few  have  employed  the  method  for  the  clin- 
ical comparisons  to  be  regarded  as  at  all  well 
worked  out.     Koranyi's  papers  of   1897  and    1898 


1248 


The    Philadelphia"! 
Medical  Journal    J 


THE  FREEZING-POIXT  OF  URINE 


[June  29,   THjl 


were,  however,  founded  on  some  thousand  obser- 
vations: Bouchard  added  a  great  number,  and  ob- 
servations are  now  being  made  by  many  competent 
workers.  The  writer's  own  experience  is  limited, 
but  as  far  as  it  goes  certainly  testifies  to  the  agree- 
ment of  inferences  from  c'ryoscopy  with  those 
drawn  from  more  usual  clinical  methods.  Compari- 
sons are,  however,  often  extremely  difficult.  Uri- 
nary cryoscopy  is  a  test  of  function'  A  kidney  may, 
for  exatnple,  have  a  large  portion  useless  from  dis- 
ease and  yet  be  able  to  perform  its  work  perfectly. 
It  is  quite  within  the  range  of  probability  that  dur- 
ing certain  periods  of  chronic  nephritis  there  may 
be  no  renal  insufficiency,  and  yet  during  those  time's 
crj-oscopic  examination  would  point  to  a  normal 
condition.  Finally,  a  milk  diet,  an  excess  of  salt 
ingested,  excessive  sweating,  pregnancy  and  con- 
valescence from  acute  disease,  may  furnish  figures 
suggesting  a  renal  insufficiency  which  maj-  or  may 
not  exist. 

Uses. — It  would  be  unjust  to  urinary  cryoscopy 
to  omit  paying  some  attention  to  its  pre-eminence 
as  a  test  of  function  quite  independent  of  structure. 
Startling  revelations  in  gross  or  microscopic  inves- 
tigation of  the  pathological  anatomy  of  an  organ 
are  hardly  now  to  be  expected,  but  intimate  studies 
of  the  constantly  varying"  capacity  of  an  organ  to 
do  work,  at  least  of  such  an  organ  as  the  kidney, 
have  the  merits  of  rarity  and  novelty  and  inspire  the 
hope  which  springs  from  a  new  field. 

A.  It  is  in  uncomplicated  disease  of  the  heart  that 
the  new  method  has  won  its  greatest  approval. 
Koranyi  even  insists  that  the  investigation  of  a 
cardiac  case  is  incomplete  until  the  freezing  point 
of  the  urine  and  the  per  cent,  of  sodium  chloride  in 
the  urine  have  been  determined.  He  has  found  that 
passive  hyperemia  of  the  kidney  is  earliest  and  most 
clearly  demonstrated  by  a  high  value  of  the  ratio 
T  -f-  CI,  and  that  therefore  the  ratio  mav  be  tised 
as  a  test  of  the  effect  of  activity  on  a  cardiac  case. 
If  in  a  patient  doing  a  certain  amount  of  work  this 
ratio  is  over  1.7,  the  person  should  be  kept  quiet, 
person  should  be  put  to  bed.  This  is  true  quite  re- 
person  should  be  put  abed.  This  is  true  quite  re- 
gardless of  whether  dyspnea  or  cyanosis  are  pres- 
ent or  absent.  The  reason  for  this  variation  is  ad- 
mirably explained  by  the  theory ;  if  the  circulation 
in  the  kidney  is  hindered  in  the  slightest,  there  is 
less  rapid  excretion  of  serum  into  the  glomeruli, 
a  less  rapid  flow,  therefore,  down  the  tubules,  a 
longer  stay  in  the  convoluted  tubules,  a  more  pro-, 
longed  and  extensive  interchange  of  complex  mole- 
cule for  salt  molecule,  a  diminution  in  the  salt  left 
in  the  urine  and  an  increase  in  the  fraction  T  -— 
CI.  In  uncomplicated  disease  of  the  heart  the  ratios 
(T  V)  -^  W  and  T  ~  T"  are  both  high  if  there 
is  high  arterial  tension,  and  both  low  if  there  is  low 
arterial  tension,  and  the  same  is  true  if  the  tension 
is  due  to  arterial  sclerosis,  intoxication,  or  nervous 
derangements. 

B.  In  imcomplicated  diseases  of  the  kidnevs  a 
study  of  the  comparative  values  of  certain  of  the 
ratios  named  may  reveal  a  glomerular  nephritis  as 
distinguished  from  a  tubular,  a  distinction  hitherto 
hardly  possible.  The  former  form  of  nephritis  is 
inferred  from  a  low  value  of  (T  V)  -i-  W  and  a  nor- 
mal value  of     T     -^  T".     The  degree  of  glomeru- 


lar or  of  tubular  obstruction  may  be  estimated  to 
some  extent  by  the  value  of  the  ratios,  and  espec- 
iallj'  the  gravity  of  the  prognosis  mav  be  judged  by 
the  value  of  the  ratio  ( T"  V)  ~  W  ;'if  this  falls  be- 
low 500  death  is  said  to  be  imminent. 

C.  In  combined  disease  of  the  heart  and  kidneys 
the  values  of  certain  ratios  point  to  the  organ 
chiefly  at  fault — or  insufficient  at  any  moment. 
Even  the  freezing  point  alone  is  of  service  here. 
If,  for  example,  there  is  anasarca  and  a  freezing 
point  lower  than  normal  the  kidneys  are  not  at 
fault ;  if  the  freezing  point  is  within  the  normal  lim- 
its the  kidne3-s  are  somewhat  affected,  and  if  the 
freezing  point  is  above  normal  the  kidneys  are  nota- 
bly diseased.  It  is  of  importance,  too.  that  the  fig- 
ures show  that  a  large  flow  of  urine  following  medi- 
cine may  not  mean  a  large  elimination  of  the  com- 
plex  molecules. 

D.  In  effusion  into  a  serous  cavity  the  ratio 
T  -r-  CI  indicates  by  its  value  whether  absorption 
or  exudation  is  going  on,  diminishing  in  the  former 
case  and  increasing  in  the  latter.  In  this,  of  course, 
the  observation  is  similar  to  that  long  made  about 
the  increase  or  decrease  of  chlorine  in  the  urine. 

E.  It  is  to  Bouchard  that  we  owe  the  application 
of  the  method  to  the  study  of  metabolism.  The 
molecule  of  albumen  with  an  atomic  weight  of 
six  thousand  is  split  up  in  the  body  in  the  course 
of  the  various  nutritive  processes,  part  of  the  car- 
bon going  off  through  the  lungs,  part  through  the 
intestines,  and  part  through  the  kidneys;  the  sul- 
phur goes  off  partly  as  sulphate,  and  the  phospho- 
rus partly  as  phosphate  through  the  kidneys.  In 
the  process  of  breaking  up  the  molecule  tends  con- 
stantly to  what  may  be  called  its  lowest  term,  the 
molecule  of  urea,  with  an  atomic  weight  of  sixty. 
All  urine  contains  by-products  produced  in  the 
course  of  this  reduction,  but  where  the  processes  of 
nutrition  are  incomplete  the  urine  contains  more  of 
these  by-products ;  where  the  processes  of  nutrition 
are  complete  the  urine  contains  less.  All  these  by- 
products have  atomic  weights  which  are  higher 
than  that  of  urea.  In  other  words,  the  average 
atomic  weight  of  the  various  organic  molecules  of 
the  urine  tends  toward  sixty  as  a  limit,  a  limit  which, 
however,  is  not  reached  in  any  case.  If  by  any 
means,  as  by  cryoscopy.  one  may  obtain  the  number 
of  molecules  in  a  specimen,  obviously  by  taking  the 
weight  of  all  the  matters  dissolved  and  dividing 
that  by  the  number  of  molecules,  the  average  mole- 
ctilar  weight  may  be  obtained.  This  can  be  done, 
and  in  the  same  way  the  average  molecular  weight 
of  the  complex  molecule  can  be  obtained.. 

(If  the  lowering  of  the  freezing  point  of  a  solu- 
tion is  proportioned  to  the  quantity  oi  the  sub- 
stance in  solution  and  to  its  molecular  weight  the 
following  proportion  has  been  found  to  be  true :  If 
M  =:  the  weight  of  the  substances  in  100  c.  c.  of 
water  and  m  =  the  average  molecular  weight  and 
T  the  freezing  point.  T  :  M  =  K  :  m.  where  K  is 
a  constant  established  for  every  solvent  and  for 
water  equal  to  18.5. :.  m  =  ( 18.5  H-  T  M.  If  m'  = 
average  molecular  weight  of  the  complex  molecule, 
m'  =  (18.5  (M — CD)  -^T"=  for  the  normal  urine 
earlier  quoted  (18.5  (4.6 — .8)1  H-  lOl  =60  M  is  ob- 
tained by  multiplying  the  last  two  figures  of  the 
specific  gravity  1021  by  HsPser"s  coefficient  2.33.) 


June   29,   1901] 


THE  FREEZING-POINT  OF  URINE 


TThe    Philadelphia 
L  Medical  Jocrsal 


1249 


Bouchard  has  found  that  normally  this  molecular 
weight  of  the  average  complex  molecule  varies  from 
62  to  68  and  that  pathologically  it  may  reach  130: 
it  is  regularly  high  in  certain  fevers  and  diseases 
of  the  lungs,  liver,  and  kidnej's.  It  is  a  confirmation 
of  the  theory  of  cryoscopy  that  these  normal  figures 
62  to  68  are  also  obtained  by  calculating  them  from 
the  known  composition  of  urine.  The  importance 
of  this  use  of  cryoscopy  lies,  of  course,  in  the  esti- 
mate it  gives  of  the  power  of  the  body  to  assimi- 
late. 

Practice. — The  values   sought  are  the  following: 

T  =  freezing  point  of  the  urine;  normally  — 
— 1°  .30  to  2°  .20  C. 

CI  =  percentage  of  sodium  chloride  in  the  urine, 
usually  .80  to  1.50. 

V  =  24  hour  amount  of  urine. 

W  =  weight  of  person  in  kilos. 

M  =  weight  of  matter  dissolved  in  100  C.  C.  of 
urine,  =  2.33  X  the  last  two  figures  of  the  specific 
gravity.  Of  these  five  values  only  T  and  CI  are  es- 
sential. 

■From  these  are  obtained  the  following : 

T'  =  freezing  point  of  a  solution  containing  the 
same  amount  of  sodium  chloride  as  the  urine,  = 
.613  X   CI. 

T"  =  lowering  of  freezing  point  due  to  the  non- 
chlorine  containing  molecules  of  the  urine,  =  T — 
T'. 

m  =  average  molecular  weight  of  M. 

m'  ^  average  molecular  weight  of  M  less  the 
chlorine  molecules  =  (18.5  (M  —  CI))  ~  T" :  nor- 
mally 62  to  68. 

The  following  ratios  are  diagnostic : 

fa)  (V  T)  -i-  W  =  total  molecular  diuresis:  nor- 
mally 3000  to  4000. 

(b)  (V  T")  ^-  W  =  complex  molecular  diuresis; 
normallv  2000  to  2600. 

(c)TVT"=  [(VT)  ^  W]  -4-[(VT")  -^W]=. 
ratio  of  total  to  complex  molecular  diuresis:  nor- 
mally 1.49  to  1.69. 

(d)  T  -^-  CI  =  ratio  of  total  molecules  to  chlorine 
containing  molecules:  normally  1.23  to  i.6g. 

(e)  (V  T)  -f-  61.3  =  the  sodium  chloride  equiva- 
lent of  the  non-chlorine  molecules  dissolved  in  the 
24-hour  urine :  normally  30  to  50. 

It  is  obvious  that  T  ^-  T"  (Bouchard's  ratio) 
and  T  -^  CI  (Koranyi's  ratio)  differ  in  that  the 
denominator  in  the  first  fraction  represents  the  num- 
ber of  molecules  not  containing  chlorine,  and  in 
the  second  fraction  the  number  of  molecules  con- 
taining chlorine.  Obviously,  too.  T  -e-  T"  will  in- 
crease just  in  proportion  as  T  -=-  CI  diminishes,  and 
vice  versa.  >'oreover,  as  T"  cannot  be  obtained 
with  as  much  exactness  as  CI,  the  Koranyi  ratio 
seems  preferable  for  use.  The  advantage  of  the 
Bouchard  ratio  is  in  the  concept  to  which  it  gives 
rise  by  its  formation  of  the  actual  comparison  be- 
tween the  numbers  of  molecules  which  pass  the 
glomerular  diaphragm  and  the  number  which  pass 
the  tubular  diaphragm. 

Method. — .\s  has  been  pointed  out,  there  are  two 
determinations  especially  needed:  (a)  the  freezing 
point  T.     (b)  the  percentage  of  sodium  chloride  CI. 

(a)  The  method  of  obtaining  the  freezing  point 
with  which  the  writer  began  was  one  advised  by 
Prof.  E.  H.  Loomis,  of  Princeton,  who  has  for  a 


long  time  been  interested  in  the  observation  of 
freezing  points  of  solutions.  His  recommendations 
are  as  follows: 

1.  Use  a  double-walled  test  tube, — that  is,  place 
the  test  tube  in  another  tube,  which  is  a  trifle 
larger,  keeping  them  apart  with  a  rubber  band.  The 
inside  tube  should  be  bottle-shaped  at  the  bottom 
so  that  the  stirrer  may  go  to  the  lowest  point  of  the 
tube  and  dislodge  any  ice  that  would  otherwise  tend 
to  mass  itself  there.  It  should  be  about  seven 
inches  long  and  one  inch  wide.  The  thermometer 
may  be  held  in  place  by  thrusting  it  through  a  cork. 
The  tube  is  provided  with  a  "ring  and  feather"  stir- 
re.  This  is  easily  made  by  taking  a  piece  of  wire 
and  bending  it  at  one  end  into  a  round  loop  about 
I  of  an  inch  across.  Then  one  side  of  a  goose  feath- 
er is  stripped  of!  and  the  feather  is  wired  to  the 
outside   of   the   ring. 

2.  There  is  then  prepared  a  mixture  of  finely- 
pounded  ice  and  water  of  the  consistency  of  a  thick 
slush.  This  is  put  in  a  vessel  of  glass  heavily 
wrapped  with  felt.  Salt  enough  is  added  to  this 
mixture  so  that  the  temperature  of  the  mixture  after 
thorough  stirring  is  approximately  that  of  the  freez- 
ing point  of  the  urine,  determined  roughly  by  a  pre- 
liminary experiment. 

3.  The  test  tube  is  filled  about  one-third  full  of 
urine.  The  thermometer  and  stirrer  are  inserted, 
the  whole  is  exposed  to  the  freezing  mixture  until 
its  temperature  has  fallen  about  three  to  four-tenths 
of  a  degree  below  the  temperature  at  which  the 
urine  freezes.  The  tube  and  contents  are  then 
transferred  to  the  bath  described  in  2,  and  a  tiny 
crystal  of  ice  is  dropped  into  the  over-cooled  urine. 
This  at  once  begins  to  freeze  and  the  temperature 
rises,  finally  stopping  at  the  freezing  point.  This 
requires  about  one  minute  and  a  reading  of  the  ther- 
mometer is  then  taken.  Uniform  stirring  is  main- 
tained. Loomis  has  found  it  necessary  for  the  fine 
work  involved  in  determination  of  molecular 
weights  to  have  an  electric  vibrator  tap  the  ther- 
mometer continually  so  as  to  ensure  perfect  mobility 
to  the  mercurial  column.  This  method  enables  one 
to  determine  the  freezing  point  within  i-iooo  of  a 
degree  centigrade.  The  exact  reading  is  taken 
through  a  microscope  focussed  on  the  thermometer 
scale.  Prof.  Loomis  says  that  the  instruments 
made  by  R.  Fuess,  of  Berlin,  Germany,  are  the  only 
ones  which  have  given  him  satisfaction.  A  suitable 
one  graduated  in  i-ioo  degrees  centigrade  may 
be  imported  for  about  $25.  As  the  writer  had  never 
seen  a  thermometer  intended  for  this  purpose  he 
had  one  constructed  by  a  reputable  New  York  man- 
ufacturer of  scientific  instruments,  which  registers 
in  tenths  the  degrees  from  0°  to  —  4°  centigrade. 
The  divisions  are  sufficiently  large  to  enable  one  to 
read  to  fortieths,  and  the  thermometer  is  a  little  less 
than  six  inches  long.  It  has  a  lens  front,  but  this 
proved  to  be  a  distinct  disadvantage.  Otherwise  it 
was  a  most  convenient  instrument,  but  after  some 
use  it  was  compared  with  Dr.  Loomis'  standard 
thermometer  and  found  to  have  so  large  an  error 
that  all  work  done  with  it  was  useless^  It  has  been 
found  helpful  to  use  for  the  double  tube  two  vials 
with  flat  bottoms,  and  to  put  in  the  outer  sufficient 
absolute  alcohol  so  that  its  level  is  practically  the 
same  as  that  of  the  urine  in  the  inner  tube  .    A  sim- 


12^0 


The    Philadelphia"! 
Medical  Journal   J 


THE  FREEZIXG-POIXT  OF  URIXE 


[Ju.VE  29,   1901 


pie  spiral  of  wire  works  very  well  as  a  stirrer,  and 
the  thermometer  may  be  hung  in  the  urine  by  a 
cord.  Foreign  workers  have  advised  cooling  the 
urine  by  ether  or  carbon  bisulphide  rapidly  volatil- 
ized by  a  current  of  air,  but  with  this  method  the 
writer  has  had  no  experience.  The  mercury  falls 
slowly  to  a  certain  point  and  then  suddenly  with  or 
without  the  addition  of  the  particle  of  ice  rises  to 
the  freezing  point ;  while  it  is  rising  it  is  especially 
necessary  to  keep  the  urine  well  stirred.  After  a 
moment  when  more  or  less  of  the  urine  is  frozen 
the  temperature  gradually  falls  again  to  correspond 
with  that  of  the  freezing  mixture.  It  is  necessary, 
therefore,  to  take  the  highest  point  to  which  the 
mercury  ascends  as  the  freezing  point.  The  time 
necessary  for  this  observation  varies  from  fifteen 
to  twenty  minutes.  Certain  precautions  are  neces- 
sary: the  urine  must  not  have  undergone  any  fer- 
mentation, as  the  number  of  molecules  and  the 
freezing  point  are  affected  by  that  change :  if  the 
freezing  throws  down  a  precipitate,  the  urine  must 
be  diluted  until  that  action  is  avoided ;  no  antisep- 
tics and  no  medicines  must  be  in  the  specimen. 

(b)  The  percentage  of  sodium  chloride  is  deter- 
mined by  Volhard's  method,  and  this  is  described 
in  Hammarsten's  Text-book  of  Ph\'siologica] 
Chemistry  as   follows : 

"All  the  chlorine  from  the  urine  acidified  with 
nitric  acid  is  precipitated  by  an  excess  of  silver  ni- 
trate, filtered,  and  in  a  measured  part  of  the  filtrate 
the  quantity  of  silver  added  in  excess  is  determined 
by  means  of  a  sulphocyanide  solution.  This  excess 
of  silver  is  completely  precipitated  by  the  sulpho- 
cyanide, and  a  solution  of  some  ferric  salt,  which, 
as  is  well  known,  gives  a  blood-red  reaction  with 
the  smallest  quantity  of  sulphocyanide,  is  used  as 
an  indicator. 

'■\\'e  require  the  following  solutions  for  this  titra- 
tion:  I.  A  silver-nitrate  solution  which  contains 
29.075  grms.  AgXOs  per  litre  and  of  which  each 
c.  c.  corresponds  to  o.oi  grm.  XaCl  or  0.00607  grm. 
CI;  2.  A  saturated  solution  at  the  ordinary  temper- 
ature of  chlorine-free  iron  alum  or  ferric  sulphate ; 
3.  Chlorine  free  nitric  acid  of  a  specific  gravity  of 
1.2 ;  4.  A  potassium-sulphocyanide  solution  which 
contains  8.3  grms.  KCXS  per  litre,  and  of  which 
2  c.  c.  corresponds  to  i  c.  c.  of  silver-nitrate  solu- 
tion. 

"The  determination  of  the  chlorine  in  the  urine 
is  performed  by  this  method  in  the  following  way : 
Exactly  10  c.  c.  of  the  urine  is  placed  in  a  flask 
which  has  a  mark  corresponding  to  100  c.  c. ;  5  c.  c. 
nitric  acid  is  added  ;  dilute  with  about  50  c.  c.  water, 
and  then  allow  exactly  20  c.  c.  of  the  silver-nitrate 
solution  to  flow  in.  Close  the  flask  with  the  thumb 
and  shake  well,  slide  off  the  thumb  and  wash  it 
with  distilled  water  into  the  flask,  and  fill  the  flask 
to  the  100  c.  c.  mark  with  distilled  water.  Close 
again  with  the  thumb,  carefull}'  mix  by  shaking, 
and  filter  through  a  dry  filter.  Pleasure  off  50  c.  c. 
of  the  filtrate  by  means  of  a  dry  pipette,  add  3  c.  c. 
ferric-salt  solution,  and  allow  the  sulphocyanide  so- 
lution to  flow  in  until  the  liquid  above  the  precipi- 
tate has  a  permanent  red  color.  The  calculation  is 
very  simple.  If  we  always  use  10  c.  c.  for  the  deter- 
mination, and  always  20  c.  c.  AgXO,,  and  dilute 
with  water  to  100  c.  c,  we  find  the  quantity  of  XaCI 
in  1000  parts  of  the  urine  by  subtracting  the  number 


of  c.  c.  of  sulphocyanide  (R)  required  with  50  c.  c. 
of  the  filtrate  from  20.  The  quantity  of  XaCl  p.  m. 
is  therefore  under  these  circumstances  =  20  —  R, 
and  the  percentage  of  XaCl  =  (20  —  R)  -i-  10." 

This  determination  takes  about  ten  minutes. 

\\'e  have  then  T  and  CI ;  V  should  be  accurately 
measured  for  the  twenty-four  hours ;  the  specific 
gravity  should  be  corrected  for  the  temperature  at 
which  it  is  taken  ;  the  determination  of  W" ,  of  course, 
usually  requires  that  the  patient  should  be  able  to 
be  out  of  bed.  The  valuation  of  the  ratios  is  then 
a   matter   of   arithmetical    calculation. 

Summary. — This  paper  will  miss  its  object  if  it 
does  not  convey 

(a)  That  the  method  represents  a  notable  ad- 
vance in  the  application  of  quantitative  physico- 
chemical  methods  to  clinical  work. 

(b)  That  the  ratio  T  -f-  CI  may  furnish  informa- 
tion of  considerable  value  in  diagnosis  and  prog- 
nosis in  cases  of  cardiac  disease  and  to  a  less  extent 
in  other  cases. 

(c)  That  it  is  distinctly  a  laboratory  method  re- 
quiring time  and  care. 

In  conclusion,  it  is  a  pleasure  to  express  my  ob- 
ligation to  Prof.  E.  H.  Loomis,  of  Princeton,  for 
much  kind  advice  as  to  method,  and  to  Dr.  J.  J. 
Walsh,  of  Xew  York,  for  the  stimulation  he  gave 
me  to  studv  the  subject  of  mv  paper. 

1.  KoranvT:    Zeltschr.    f.    Klin.   lied..   ISST,   Vol.   JI,   p.   1.    . 

2.  Koranyi:   Zeitschr.   f.   Klin.   Med..  ]Si*,   Vol.  34.   p.   1. 

3.  ^'aquez    et    Bousquet:    La    Presse    Medicale.    1899.    April    5. 

4.  Claude   et   Ballhazard:    La    Presse   Medicale.    ISuO,   Feb.    IT. 

5.  Starling:   Jour,    of    Physiolog>-.    1>99.    June    13. 

6.  Bouchard:  Jour,  de  Physiol,  et  de  Pathol,  gen..  1899.  May- 
15. 

7.  Claude  et  Balthazard:  Jour,  de  Physiol,  et  de  Pathol,  gen., 
ISOO.    pp.   767.   &>».   Srn.   963. 

8.  Dre?er:  Archiv.   I.   Eip.   Path.  u.   Phanna.  V.  29.   p.  MJ. 

9.  Lindemann:  Deut.  Archiv.  f.  Klin.  Med..  1900.  Vol.  (a.  p.  1. 
10.  Loomis:   Physical  Review,  1SS3,  1SS6,  1S97,  ISOL 


Soaps,  their  Chemical  Composition  and  Disinfecting  Prop- 
erties.— F.  K.  Rogengagen  i  Holnitihn'jiu  (Jo:eta  Botkina, 
Vol.  XII,  No.  S>  found  that  domestic  soaps  are  injurious  to 
the  skin,  inasmuch  as  they  contain  a  large  proportion  of 
free  alkali.  To  be  beneficial  a  soap  must  be  perfectly  neu- 
tral. The  carbolic  acid  soaps  ;uialyzed  by  him  were  found 
to  contain  from  9.45  to  22.10"yc  of  water  and  considerable 
free  alkali.  The  amount  of  carbolic  acid  in  these  soaps  var- 
ied and  usually  did  not  come  up  to  the  claims  made  by  the 
manufacturers.  Thus,  instead  of  4'~c  only  1.32<~'c  was  found: 
instead  of  lO'^c  only  2.34^c.  H  was  observed  that  if  the 
soap  is  made  by  the  cold  process  from  cocoanut  oil  the  pro- 
portion of  carbolic  acid  is  more  likely  to  correspond  to  the 
label.  On  the  other  hand,  when  the  soap  is  made  by  the 
hot  process  a  considerable  amount  of  phenol  is  lost  by 
evaporation.  In  the  bichloride  of  mercury  soaps  a  marked 
discrepancy  was  found  between  the  statements  of  the  man- 
ufacturers and  the  amount  of  bichloride  actually  present. 
Some  samples  contained  only  one-fourth  the  amount  stated 
on  the  label.  This  difference  is  dwo  to  the  reduction  of  the 
bichloride  of  mercury  which  takes  place  in  the  soap  on 
keeping.  Regrarding  the  antiseptic  properties  of  soap,  the 
author  found  that  plain  as  ^vell  as  carbolic  acid  or  bichlor- 
ide of  mercury  soap  fnils  to  kill  anthrax  spores  in  10  days. 
The  vegatative  forms  of  the  colon  bacillus  are  destroyed 
by  plain  soap.  lOTc  solution  of  the  latter  possessing  an  anti- 
septic value  equal  to  O.S^r  solution  of  carbolic  acid.  The 
addition  of  a  small  amount  of  bichloride  of  mercury  to  a 
10%  solution  of  plain  soap  (OOo^r  of  HgC121  does  not  en- 
hance the  antiseptic  value  of  the  latter.  Bichloride  of  mei^ 
cury  in  the  soap  seems  to  lose  its  antiseptic  properties  to 
:t  considerable  extent.  Thus.  0.1%  of  bichloride  added  to 
10%  solution  of  soap  is  less  active  than  a  0.05%  pure  solu- 
tion. The  same  results  were  obtained  with  carbolic  acid. 
This  is  explained  by  the  fact  that  these  germicides  form 
salts  with  the  f.Ttty  acids  of  the  soap,  which  possess  weaker 
eermicidal  properties.     [A.  R.  I 


JUVE  29,   law) 


UNCINARIOSIS 


[The    Philadelphia 
Medical  Journal 


1251 


A  PRELIMINARY   REPORT   UPON  A  CASE   OF  UN- 
CINARIOSIS  cANKYLOSTOMIASIS.) 

By   THOMAS  A.   CLAYTOR, 

of  Washington,  D.  C. 

Profes'sor  of  Clinical  Medicine,  Columbia  University,  Attending  Physician 

to  Garfield  Hospital,  etc. 

Uncinariosis  (ankjlostomiasis)  is  a  chronic  dis- 
ease due  to  infection  by  a  small  thread  worm 
known  as  the  Uncinaria  Duodenalis  (Ankylostona 
Duodenalis),  which  fastens  itself  to  the  mucous 
membrane  of  the  small  intestine  and  sucks  the 
blood  from  its  host.  The  most  prominent  symptoms 
are  intense  anemia,  weakness  and  dyspnea  with 
anorexia  and  gastro-intestinal  disturbances. 

The  presence  of  a  genuine  case  of  uncinariosis 
in  this  latitude,  and  occurring  in  a  native  American 
who  has  spent  his  life  in  Virginia,  renders  the  mat- 
ter worthy  of  report. 

\\'hile  uncinariosis  is  extremely  common  and  a 
very  serious  disease  in  many  tropical  and  subtrop- 
ical countries,  it  has  been  diagnosed  but  rarely  in 
the  United  States.  W.  L.  Blickhahn  Med.  News, 
Dec.  9th,  1893)  reports  a  case  in  a  German  who  had 
probably  brought  the  infection  with  him  from  Ger- 
many. 

C.  H.  Tebault,  Jr.  (iVctc  Orleans  Medical  and  Sur- 
gical Journal.  1899-1900,  LII.)  reports  a  case  which 
must  have  had  its  origin  in  New  Orleans,  and  I 
find  in  Blanchard  {Zoologie  Medical)  reference  to 
articles  bj-  Chabert  and  Duncan  in  Louisiana,  Lyell 
in  Alabama  and  Georgia,  and  Heusinger  and  Ged- 
dings  in  South  Carolina,  and  Little  and  Leather- 
man  in  Florida.  Blanchard  doubts  the  authenticity 
of  the  last  two.  I  have  so  far  been  unable  to  find 
the  above  articles  in  the  Surgeon  General's  Library, 
i.  e.,  those  referred  to  bj'  Blanchard. 

The  importance  given  to  progressive  pernicious 
anemia  of  late  and  the  impossibility  of  making  the 
differential  diagnosis  between  it  and  uncinariosis 
without  examination  of  the  feces  for  ova  is  another 
factor  which  has  led  me  to  bring  my  case  before  the 
profession  as  soon   as  possible 

George  E,  aged  nineteen  years,  of  Westmoreland 
County,  Va.,  occupation,  light  farm  work,  was  admitted  to 
the  Garfield  Hospital  of  Washington,  D.  C,  on  May  31, 
1901.  The  history,  obtained  principally  from  his  sister,  as 
the  boy  is  extremely  stupid,  is  as  follows: 

Nothing  worthy  of  note  in  the  family  history  except  that 
there  is  another  brother  who  also  is  said  to  be  pale  and 
anemic.  The  patient  was  a  small  baby  when  horn,  but 
developed  normally  until  about  three  years  ago,  since 
which  time  development  has  been  tardy  both  in  mind  and 
body,  his  development  and  appearance  at  the  present 
being  that  of  a  boy  imder  14  years  of  age.  This  point  is 
worthy  of  note,  since  it  is  a  characteristic  of  the  diseasa 
"Should  serious  Ankylostomiasis  occur  before  puberty,  the 
growth  and  development  are  apt  to  be  delayed  and  stunt- 
ed." Patrick  Manson  (TropUal  Di.'icases).  This  fact  is 
also  noted  by  F.  M.  Sand  with.  (Observations  on  400  cases 
of  Ankylostomiasis"'  (Lancet.  Vol.  I.  1894). 
At  school,  the  boy  seemed  as  bright  as  any  of  the  other 
children.  He  had  been  employed  at  light  work  about  the 
farm  until  he  became  so  weak  that  he  was  obliged  to  go  to 
bed.  He  has  never  had  any  of  the  diseases  of  childhood, 
nor  has  he  had  malaria,  which  is  common  in  his  neighbor- 
hood. About  three  years  ago,  he  became  pale:  one  year 
later,  the  anemia  became  very  marked  and  there  was 
swelling  of  the  face,  abdomen,  and  feet.  This  condition 
did  not  last,  however,  and  he  seemed  to  get  somewhat  bet- 
ter until  this  spring.  As  far  as  can  be  learned,  there  have 
at  no  time  been  any  symptoms  of  gastro-intestinal  disturb- 
ance, which  is  contrary  to  the  rule.  The  boy  was  sent  to 
the  hospital  because  of  his  great  weakness,  pallor,  and 
dyspnea  on  slight  exertion. 


The  appearance  of  the  patient's  face  was  remarkable, 
and  differed  from  that  seen  in  any  other  disease  with 
which  I  am  familiar.  The  expressiun  was  dejected,  the 
skin  very  pale  with  a  faint  yellow  tint,  not  the  lemon  yellow 
of  pernicious  anemia,  nor  yet  the  chalky  white  of  advanced 
nephritis.  The  face  looked  bloated,  especially  about  the 
eyes.  The  mucous  membranes  were  extremely  pale.  The 
body  well  nourished,  but  the  muscles  extremely  flabby. 
The  tongue  was  clean.  The  hearts  impulse  was  widely  dif- 
fused, the  apex  beat  was  in  the  fifth  interspace  and  almost 
as  far  to  the  left  as  the  midaxillary  line.  Over  the  base 
there  was  a  loud  systolic  murmur,  the  point  of  maximum 
intensity  being  in  the  pulmonary  area.  This  murmur  was 
also  heard  in  the  vessels  of  the  neck.  The  second  pulmon- 
ary sound  was  accentuated.  At  the  apex  there  was  heard 
a  systolic  murmur  which  was  transmitted  to  the  axilla  and 
to  the  angle  of  the  left  scapula  A  faint  diastolic  murmur 
was  also  present  over  a  small  area  near  the  apex.  The 
feet  and  ankles  were  edematous.  The  urine  was  pale, 
clear,  acid  and  showed  a  Sp.  g.  of  1010  (urine  of  low  sp. 
g.  is  the  rule  in  severe  cases).  Sandwith,  Loc.  Cit.  The 
blood  examination.  May  31,  showed  the  number  of  red  cor- 
puscles to  be  1,577,000  (31%  of  normal),  the  whites  4400. 
Because  of  an  accident  to  the  hemoglobinometer,  the  hem- 
oglobin was  not  estimated  until  four  davs  later,  when  it  was 
found  to  be  307o. 

Dr.  J.  B.  Nichols,  Pathologist  to  the  Garfield  Hospital, 
has  kindly  furnished  me  with  the  following  report  on  the 
stained  coverslips,  June  9th:  Macrocytes  and  microcytee. 
a  fe«;  polychromatophilia,  not  observed:  poikilocytes,  a 
few;  microblasts,  normoblasts  and  megoblasts,  none. 

LeuEocytes:  Small  mononuclear,  15%:  large  transi- 
tional, 9%;  polynuclear,  71%;  eosinophile,  57o;  myelo- 
cytes, — %. 

Unler  the  circumstances  it  is  not  surprising  that  we 
strongly  inclined  to  the  diagnosis  of  idiopathic  pernicious 
anemia.  However,  an  order  was  given  that  the  evacuations 
be  examined  for  the  ova  of  the  uncinaria  duodenalis  on 
the  bare  possibility  that  it  might  be  a  case  of  that  most 
unusual  disease,  at  least  in  the  United  States,  of  uncinari- 
osis. Great  was  my  surprise  to  learn  that  Mr.  Henry  M. 
Jewitt,  the  Assistant  Pathologist,  had  indeed  found  the 
object  of  his  search,  the  ova  of  the  uncinaria. 

The  eggs  were  so  numerous  that  scarcely  a  field  could 
be  found  which  did  not  show  several  specimens.  On  June 
3d,  Ihymol  gr.  xxx,  was  administered  at  3.30  P.  Sf.  Two 
hours  later,  the  dose  was  repeated  and  followed  in  two 
hours  by  castor  oil,  and  the  nest  morning  by  magnesium 
sulphate.  Examination  of  the  evacuations  on  the  the  4th 
revealed  14  uncinaria,  on  the  6th,  23  were  found,  on  the 
10th.  7,  and  as  the  ova  were  still  present,  the  thymol  was 
administered  as  before.  Dr.  C.  W.  Stiles,  of  the  Depart- 
ment of  Agriculture,  confirmed  the  diagnosis  of  uncinari- 
osis. 

The  patient  seemed  to  improve  from  the  date  of  the 
first  expulsion  of  the  parasites.  The  edema  of  the  feet 
and  to  a  marked  degree  of  the  face  disappeared,  and  he 
claimed  to  feel  much  better. 

The  administration  of  iron  and  arsenic  was  at  once  In- 
stituted with  a  full,  nourishing  diet.  Patient's  weight 
has  increased  in  a  week  from  85  to  90  pounds  and  the 
blood  count  has  also  improved  slightly. 

I  wish  to  express  my  thanks  to  my  resident.  Dr.  Bennet 
and  to  Dr.  Nichols  and  Mr.  Jewett,  of  the  Pathological 
Department,  for  their  aid  and  interest  in  the  report  of  this 
case,  a  more  complete  and  detailed  account  of  which  I 
hope  to  publish  later. 


Orthostatic  Albuminuria. — This  condition  is  the  subject 
of  a  thesis  by  Dr.  J.  Vire.  (quoted  in  I.'Indcpcndance  ilcdi- 
ailf.  1901,  No.  19).  It  is  caused  simply  by  standing.  It  is 
found  in  young  people,  accompanied  by  vague  vasomotor 
symptoms  only.  T'nder  a  gram  of  albumin  is  found  in  the 
urine,  accidentally  as  a  rule,  generally  serum-albumen.  Ly- 
ing down  will  cause  its  disapearance.  Recovery  occurs  as 
the  patient  grows  stouter.  It  is  seen  in  growing  young 
men  or  girls  who  are  anemic  or  nervous.  Walking  will  not 
often  cause  it,  long  standing  being  the  main  cause.  Vire 
explains  it  as  a  slight  vasomotor  disturbance  in  the  renal 
circulation.  The  treatment  is  hygienic,  strengthening,  and 
anti-nervous.      Milk    diet    is    absolutelv    contraindicated. 

[M.  O.] 


12^2 


The    Philadelphia"! 
Medical  Journal   J 


THE  ROLE  OF  INFECTION 


[Juke  29,  1901 


THE   ROLE  OF   INFECTION     AND    INTOXICATIONS 

IN  DISEASES   OF   THE   SPINAL  CORD. 

By  ALFRED  GORDON,   M.   D., 

of   Philadelphia. 

Assistant  in  Neurology,  Jefferson   Medical  College. — Member  of 
the  Philadelphia  Neurological   Society. 

If  in  the  history  of  medicine  the  cellular  theory 
reigned  a  long  time,  it  could  not  continue  to  do  so 
with  the  progress  of  pathology,  bacteriology  and 
chemistry.  1  he  clinical  observations  could  no  more 
be  in  accord  in  all  their  aspects  with  the  old  views. 
Bchring  opened  the  way  for  new  researches,  which 
led  to  the  discovery  in  the  humoral  substances  of 
immunized  individuals  of  chemical  principles  that 
now  play  the  most  important  rdle  in  the  action  of 
antitoxins.  Chemistry  and  bacteriology  replaced 
therefore,  the  old  cellular  theory  which  seemed  un- 
til recently  to  be  the  dominating  one.  These  two 
sciences  brought  out  very  important  though  com- 
plicated points  in  the  life  of  the  cells. 

In  physiological  or  pathological  conditions  the 
cells  present  a  complicated  chemical  laboratory  of 
normal  or  abnormal  organic  metabolism.  A  loss  of 
equilibrium  in  the  normal  condition  of  the  cell  is  al- 
ways characterized  by  the  presence  of  abnormal 
chemical  substances  accompanied  by  microbes  or 
products  elaborated  by  these  microbes — toxins.  This 
last  condition  we  call  infection. 

To  Ehrlich  we  owe  largely  what  we  know  of  the 
character  of  toxins  and  antitoxins.  His  theory  of 
lateral  chains  is  remarkable  in  its  simplicity,  and 
explains  the  phenomena  of  immunity.  According 
to  his  views,  each  protoplasmic  molecule  of  the  cell 
contains  a  central  part  essentially  necessary  to  life 
and  controlling  the  specific  function  of  the  cell  and 
lateral  chains  or  receivers.  l"he  function  of  the  last 
is  to  receive  various  substances  in  a  dissolved  state, 
with  which  they  enter  into  chemical  combinations 
and  thus  take  part  in  the  intra-cellular  life.  The 
molecules  of  toxins  introduced  into  the  organism 
are  received  by  some  of  the  lateral  chains,  and  as 
a  result  we  have  the  antitoxins.  Therefore,  between 
toxins  and  antitoxins  there  is  a  chemical  and  spe- 
cific relationship,  and  the  antitoxins  constitute  an 
integral  part  of  the  cells.  That  antitoxins,  accord- 
ing to  Ehrlich,  Bouchard  and  Charrin,  are  cellular 
products,  and  that  immunity  which  they  create 
might  persist  for  years,  is  proven  by  Roux  and 
Waillard- :  After  having  bled  profusely  horses  pre- 
viously immunized  so  that  a  new  blood  was  substi- 
tuted, they  observed  that  the  antitoxic  power  did 
not  disappear. 

The  microbes  or  bacteria  do  not  possess  the  mo- 
nopoly of  producing  an  infectious  disease  ;  their  pro- 
ducts are  also  the  cause  of  infection.  In  order  that 
an  infection  should  take  place,  two  elements  are 
necessary:  the  infectious  agent  and  the  predisposing 
cause  which  diminishes  the  resistance  of  the  organ- 
ism temporarily,  like  trauma  or  cold,  or  permanently 
like  chronic  intoxications  (alcohol,  lead,  etc)  and 
debilitating  diseases  of  long  duration. 

During  a  very  long  time  there  was  a  belief  that 
each  organ  lived  separately  from  the  rest  of  the 
body,  and  that  its  sufTcring  did  not  have  any  influ- 
ence on  the  rest.    An  entirely  different  view  is  held 

•Read  before  the  Phil.idelphia  Neurological   Society,   March 

28.  ]901. 


now :  There  is  a  unity  and  solidarity  among  various 
parts  of  the  living  organism ;  when  one  organ  is 
affected,  the  entire  system  suffers.  A  bacillus,  ty- 
phoid, for  example,  produces  a  local  focus  of  in- 
fection in  the  intestines,  but  the  toxins  circulating 
in  the  vascular  system  will  have  an  influence  on  the 
whole  economy  by  means  of  their  chemical  combina- 
tions with  the  lateral  chains  of  the  cells.  The  char- 
acteristic feature  of  toxic  agents  is  that  each  has  a 
special  affinity  for  certain  protoplasmic  molecules 
and  cells  of  certain  organs :  An  infectious  agent  will 
attach,  with  preference,  a  certain  organ  primarily, 
the  poisons  secreted  by  it  will  show  their  secondary 
effect  throughout  the  entire  system.  Whatever  the 
infection  is,  one  is  almost  certain  to  find  histological 
changes  in  many,  if  not  all,  organs. 

The  nervous  system,  like  any  other  organ,  might 
be  attacked  primarily  or  secondarily.  Much  has 
been  accomplished  in  regard  to  infections  in  diseases 
of  other  organs.  The  attention  directed  towards  the 
chemical  reactions  which  take  place  in  the  living 
cells,  the  discovery  of  toxins  and  antitoxins  within 
the  cells,  the  logical  consequence  of  prophylaxis  in 
infections,  and  the  great  question  of  serotherapy — 
all  the  benefit  derived  from  these  studies  were  al- 
most exclusively  applied  to  infections  localized  pri- 
marily in  any  organ  except  the  nervous  system.  In 
reading  very  attentively  the  histories  of  a  great 
number  of  cases  of  diseases  of  the  spinal  cord,  the 
writer  was  impressed  with  the  lack  of  etiological 
causation.  It  is  remarkable  how  many  writers  re- 
port histories  of  their  cases  without  the  slightest 
attempt  to  elucidate  the  etiological  factors,  or  if 
one  or  two  points  in  that  direction  are  mentioned, 
they  are  not  at  all  taken  in  consideration,  and  no 
relationship  is  found  between  them  and  the  disease 
itself.  We  endeavored  to  investigate  the  etiology 
of  all  the  diseases  of  the  spinal  cord  coming  under 
our  observation  at  the  hospital,  and  almost  in  every 
case  we  were  able  to  detect  some  infection  passed 
unnoticed  by  the  patient  or  his  physician,  whether 
it  was  a  mild  attack  of  measles,  or  a  plain  cold,  or 
some  febrile  condition,  a  malaise  due  to  auto-intoxi- 
cation. In  reading  up  the  histories  of  cases  re- 
corded, we  could  find  in  a  good  number  of  them 
some  infection  in  connection  with  the  onset  of  the 
diseases.  I  do  not  speak  exclusively  of  the  second- 
ary intoxications  produced  by  certain  modifications 
manifested  in  other  organs,  which  are  due  to  some 
perturbation  of  the  whole  nervous  system  by  vir- 
tue of  the  presence  of  toxins  in  circulation.  We  also 
have  in  view  the  initial  attacks  of  infections  on  the 
spinal  cord,  like,  for  instance,  the  primary  effect  on 
the  cord  of  tubercular,  typhoid,  gonorrheal,  diphthe- 
ritic infections,  etc.  We  mentioned  above  that  some 
toxic  agents  go  directly  to  some  organ  primarily  and 
enter  into  chemical  combinations  with  certain  lat- 
eral chains  of  certain  cells.  If  it  is  true  of  any  other 
organ,  it  is  also  true  of  the  spinal  cord,  and  this  we 
will  endeavor  to  prove  with  clinical  as  well  as  path- 
ological facts. 

Considering  the  nature  of  the  phenomena  which 
cliaractOrize  an  infection,  we  see  that  an  intoxica- 
tion takes  place  by  means  of  microbes.  The  very 
first  and  constant  result  isinflammation.  which  repre- 
sents the  reaction  of  the  organism  against  the  in- 
toxication. The  spinal  cord  presents  a  feeble  or- 
ganic resistance  ;  moreover,  it  seems  to  us  that  intox- 


iuNE   29,    1901] 


THE  ROLE  OF  INFECTION 


r  The    Philadelphia 
L  Medical  Journal 


12^5 


ications  produce  more    deleterious    effects    on    the 
spinal  cord  than  on  any  other  organ.    An  acute  in- 
fectious intoxication  of  the  spinal  cord  is  character- 
ized by  a   primitive  alteration  of  the  nervous  tissue, 
consisting  of  congestion,  but  with  a  toxic  vascular 
exudation,  the  contact  with   which  is   sufficient    to 
produce  foci  of  necrosis,  hemorrhages ;  sclerosis  fol- 
lows almost  inevitablv.     The  difference  between  a 
new  and   an  old   inflammation  is  that  in   the   first 
case  we  shall  have  an  immediate  and  rapid  reaction, 
whereas,  in  toxic  lesions,  due  to  an  old  inflamma- 
tion, we  shall  have  no  general  reaction  and  less  rapid 
involvements,  but  the  result  will  always  be  identi- 
cal.    If  inflammatory  changes  are  the  result  of  in- 
fection, are  all  the  diseases  of  the  spinal  cord  due 
to  inflammation,  and  if  it  is  so,  are  they  all  due  to 
infection  ?     In  their  studies  on  the  pathogenesis  of 
multiple  disseminated  sclerosis,  Charcot  and  his  pupils 
considered  the  disease  as  a  primary  and  chronic  in- 
flammation of  the  interstitial  tissue.     Rindfleisch,* 
on  the  contrary,  placed  the  initial  lesion  in  the  walls 
of  the  vessels,  while  others  believe  that  the  nerve 
element  is  first  affected  and  interstitial  inflammation 
is  secondary  ;  but  most  authors,  according  to  Strum- 
pel,  consider  it  as  a  primary  disease  of  the  vessels. 
As  to  the  etiology,  Ebstein*  was  first,  who,  after  a 
clinical  and  pathological  investigation  on  a  man  44 
years  of  age,  who  died  from  typhoid  fever,  found 
the  effects  of  the  infectious  disease  on  the  spine,  ex- 
pressed  in  a  disseminated   sclerosis.     Later,  other 
observations  were  added, ^  and  they  all  tend  to  prove 
that  microorganisms,  with  their  chemical  products, 
are  apt  to  produce  a  disseminated  sclerosis.     The 
chemical  combinations  found  in  the  toxins  are  nu- 
merous ;    we    find    carbonic    acid,    hydrogen    sul- 
fide, ammonia  gas,  etc.  On  the  other  hand,  cases  of 
multiple  sclerosis  were  reported  as  a  result  of  in- 
toxication with  carbonic  acid  gas."    This  gives  us  a 
clue  to  explain  the  fact  why  an  infectious  disease 
might    give    place  to  multiple  sclerosis.     Not  only 
typhoid  infection  is  the  cause  of  multiple  sclerosis, 
but  also  other  infections.    Cases  reported  by  Schoen- 
feld"  prove  to  be  true.    Marie  observed  the  same  af- 
ter typhus,  variola,  scarlet  fever,  measles,  dysente- 
ria,  pneumonia,  Charcot  after  cholera  and  diphthe- 
ria.   Wispham'  observed  clinical  symptoms  of  mul- 
tiple sclerosis  after  variola,  and  as  the  patient  im- 
proved, although  very  slow-ly,  he  called  it  false  dis- 
seminated sclerosis.     The  same    type    of    sclerosis 
was    observed  by    Marie    after    typhoid  fever,'    by 
Sparks  after  whooping-cough,'"  and  after  grippe, '^ 
by  Stadhagen  after  diphtheria,'-  by  S.  Lotsch,'^  after 
lung  infection  (2  cases),  after  tj-phus  (4  cases),  af- 
ter influenza  (i  case),  by  D.  Williams,'''  after  mea- 
sles, by  Colcott,"  after  some  eruptive  disease.  Lan- 
nois  and  Paviot'*  report  a  case  of  multiple  sclero- 
sis subsequent  to  tubercular  arthritis  of  the  shoul- 
der.    Rendu'^  reports  a  case  of  transitory  hemiple- 
gia, followed  by  symptoms  of  disseminated  sclero- 
sis, which    developed    after  some    infection.     Four 
years  later  the  patient  died,  and  the  autopsy  cor- 
roborated the   diagnosis.     Multiple   sclerosis,  with 
symptoms  of  progressive  mtiseular  atrophy  after  influ- 
enza,  is   reported    by    Hammond.'*.       In    Landry's 
paralvsis  we  always  find  a  history  of  infection.    Al- 
though the  pathological  findings  are  various  as  to 
the    localization,  they    always    show  engorgement    . 


of    blood-vessels,    exudation,    foci,     in    one     wora 
— inflammation    produced   by   an    infectious   agent. 
In  the  cases  reported  by  Knapp-Thomas'"  was  al- 
ways a  condition  of  some  infection.     The  same  we 
find  in  Langdon's  case.'"    Spiller  '"  reports  a  case  of 
Landry's    paralj'sis    occurring    after    an     abortioa 
which  was  followed  by  a  purulent  uterine  discharge. 
O.  Soltman-"  reports  a  case  beginning  with  symp- 
toms of  infection.    Boinet"'  reports  a  case  of  a  marr 
who  suddenly  took  cold  and  developed  the  disease ;. 
microscopical  examination  revealed  vacuoles  in  the 
ganglion-cells,  thickened  meninges,  nerve-fibers  in  a- 
state  of  degeneration ;  bacilli  were  found.    Kapper^ 
reports  a  case  of  Landry's  paralysis  due  to  auto- 
intoxication   (dyspepsia).     Remlinger-^    reports    a_ 
case  due  to  streptococcus :  A  soldier  in  the  Colonies- 
had  previously  malarial  fevers.  All  of  a  sudden  he 
was  taken  with  paraplegia;  a  typical  Landry's  paral- 
ysis developed.    The  microscope  showed:  inflamma- 
tion and  dilatation  of  blood-vessels  of  anterior  horns., 
streptococci  in  the  parenchyma  of  the  anterior  horns- 
between  the  cells.     Baumgarten,  Curschman,  Eis- 
enlohr,  (J^antanni,  Marinescoand  Marie — found  in  the- 
cord  various  microbes, as  bacillus  anthracis,Eberth's- 
staphylococci,    streptococci.       In   anterior  poliomye- 
litis, Marie  thinks,  that  the  cause  of  inflammationi 
lies  in  an  infectious  virus  and  commences  in  the 
blood  and  vessels;  the  degeneration  of  the  cells  is- 
a  secondary  phenomenon.     The  whole  clinical  pic- 
ture of  this  disease  points  to  the  presence  of  an  in- 
fectious element.     In  Sinclair''s-*  case  it  was  due  to- 
a  cold.     Dercum"*  speaks  of  a  child  who,  after  a  se- 
ries of  infectious  diseases,  as  rubeola,  varicella  and- 
scarlatina,  sustains  a  trauma  and  develops  the  dis- 
ease.    In  muscular  atrophies  of  spinal  type,  we  often- 
find  a  history  of  some  acute  infection  or  chronic  in- 
toxication.   G.  Campbell"^  reports  a  case  of  a  man 
who  had  several  attacks  of  sciatica  and  was  also  al- 
coholic: developed  the  peroneal  type  of  the  disease.. 
W.  J.  Alorton"*  speaks  of  a  man  who  contracted  fe- 
vers in  Africa,  had  chills  and  developed  a  multiple 
neuritis  with  atrophy,   fibrillary  twitchings,   exag- 
gerated   K-J.      Muscular   atrophies   of   spinal    type- 
were  seen  following  gonorrhea.  Limasset-'  publish- 
ed 12  cases,  Spillnian  and  Haushalter""  refer  to  two- 
cases  of  spinal  manifestations  with  muscular  atro- 
phies due  to  gonorrheic  infection.     Sulzer-"  reports- 
a  case  of  bilateral  Erb's  scapulohumeral  palsy  with- 
atrophv  due  to  fever  with   suppurative   inflamma- 
tion of  ilio-cecal  region.  Tubercular  infection  might 
also  have  its  effects  on  the  spinal  cord.    Two  cases- 
were     published     in     Deut.     Zeitsehr.,  Nervenheillc, 
1899.  One  is  a  case  of  a  9-year-old  boy,  where  the 
tuberculous  changes  were  characterized  by  inflam- 
matory changes  of  arteries  and  veins  of  the  dura, 
pia.  infiltration  along  the  vessels  in  the  white  sub- 
stance and  celts,  swollen  axis-cylinders.  The  second" 
case  of  a  two-year-old     child    presents     the     same 
changes.     Decrol'y-'  reports  a  case  of  multiple  neu- 
ritis with  spinal  involvement  of  tuberculous  nature  r 
complete  palsy  of  the  muscles  of  the  leg  with  atro- 
phy and  RD.  loss  of  K-J,  Aran-Duchenne's  type  of 
atrophy.    A  similar  case  was  reported  by  Finizio,"* 
who  found  outside  of  other  lesions  involvement  of 
the  cells  of  the  anterior  horns.     Cases  of  ataxia  of 
spinal  character  were  reported    after    measles    hy 
Colcott  Fox,^  after  scarlfet  fever  by  Bruns."  after 


,  -y  r  A       The   Philadelphia"] 
'-)4       Medical  Journal   J 


THE  ROLE  OF  INFECTION 


[Jt-.s-E  29.   i&o; 


typhoid  fever  by  Clement/-  and  Kiihn.^^  after 
mumps  by  Munro  and  Healy/*  after  influenza  by 
Tumpowski.^^  If  we  now  consider  the  natural  his- 
tory of  myelitis,  it  seems  to  us  that  its  infectious  ori- 
gin is  an  established  fact.  Its  vascular  and  infec- 
tious nature  is  proven  beyond  doubt.  At  the  last 
Congress  of  Paris,  this  question  was  brought  up  by 
various  authorities  with  pathological  and  bacterio- 
logical proofs  in  favor  of  it.  .\iarinesco  found  in 
two  cases  the  streptococcus,  in  one  case — pneumoc- 
occus,  and  in  one — bacillus  anthracis.  His  conclu- 
sions in  regard  to  Landry's  paralysis,  are  that  the 
last  is  dependent  upon  an  infectious  ascendant  and 
descendant  m\'elitis.  iNleyer^'^  reports  a  case  of  a 
cellulitis  and  subsequent  meningitis  with  strepto- 
coccus, where,  apart  from  various  lesions  of  the 
brain,  he  found  unilateral  lesions  of  the  cord  in  the 
region  corresponding  to  the  muscles  affected :  mul- 
tiple degeneration  of  the  cells.  Dogliotti^'  reports 
a  case  of  an  abscess  of  the  right  half  of  the  medulla 
due  to  onychia  of  the  right  thumb ;  cultures  showed 
staphylococcus  aureus.  Leprous  infection  was 
found  to  show  its  effect  on  the  spinal  cord.  Homen^' 
saw  two  cases  of  lepra  which  produced  lesions  of 
the  cord  approaching  those  of  Tabes.  So  did 
L^sage  and  Thiercelin.^"  The  microscope  showed 
a  total  degeneration  of  columns  of  Goll  and  of  the 
septomarginal  tract;  the  walls  of  the  vessels  were 
thickened  and  veins  presented  inflammatory  throm- 
bosis. Colella  and  Stanziale^"  found  in  a  case  of 
leprosy  foci  of  myelitis.  Looft"''  found  atrophy  of 
the  sensory  roots,  sclerosis  of  spinal  ganglions,  and 
much  pronounced  degeneration  of  posterior  col- 
umns. Jeanselme^"  found  degeneration  of  Goll's 
columns  and  septomarginal  tracts.  Bab^s,^°  in  22 
autopsies,  found  Hansen's  bacilli  in  anterior  horns; 
the  chromatin  was  broken  up,  cells  presented  vacu- 
■olation.  In  Pellagra,  Marinesco"'*  found  tlie  cells  of 
Clarke  involved,  degeneration  of  the  pyramidal  and 
anterolateral  tracts.  In  a  case  of  diphtheritic  paral- 
vsis,  L.  Richon  /  found  lesions  of  the  cells  of  the  an- 
terior horns,  atrophy  with  disappearance  of  the 
chromatin,  involvement  of  the  roots.  Clark's  cells 
were  globular.  Crocg^*  studied  the  histological 
changes  of  the  nervous  system  in  a  dog  suffering 
from  rabies,  and  at  the  same  time  in  different  other 
infections,  and  arrived  at  the  conclusion  that  rabies 
is  an  acute  myelitis.  Transzrrsc  lesions  of  the  spinal 
cord  were  studied  by  Bastian  :*"  in  two  cases  sec- 
ondarily to  cancerous  tumors  of  the  breast,  in  one 
case  following  smallpox,  and  in  one  case  after  some 
unknown  infection.  The  microscopical  pictures 
were  almost  all  identical  as  to  the  character  of  in- 
fectious inflammation :  softening  of  the  cord,  great 
\ascularity,  desceniling  and  ascending  degenera- 
tions. In  a  case  of  tetanus,  Marnesco"  found  dif- 
fuse hemorrhage  in  the  gray  matter,  change  in  the 
chromatin  of  the  cells,  degeneration  of  the  white 
matter.  The  lesions  produced  by  syphilitic  infec- 
tion are  too  common  and  too  well  known  to  dwell 
upon.  The  syphilitic  agent  or  its  toxin  is  carried 
by  the  blood  like  in  any  other  infectious  disease.  In 
addition  to  the  direct  effect  of  this  specific  toxin 
upon  various  portions  of  the  cord  through  the 
blood-vessels,  there  is  another  point  to  be  consid- 
ered. It  happens  that  the  obnoxious  specific  agent 
reacts  in  a  latent  manner,  as,  for  example,  in  para- 


syphilitic  lesions,  and  we  have  a  weakening  of  the 
whole  nervous  system  in  its  nutrition  and  its  power 
of  resistance.  According  to  the  most  modern  views 
pernicious  anemia  is  supposed  to  be  the  result  of 
an  hypothetical  poison.  If  the  spinal  cord  becomes 
involved,  the  following  changes  similar  to  those  of 
infectious  spinal  diseases  were  found :  dilatation  of 
perivascular  spaces,  which  are  filled  with  leuko- 
cytes, thickened  walls  of  the  vessels,  foci  of  acute 
myelitis,  proliferation  of  vessels,  degeneration  of 
posterior  columns  (Hom^n).  E.  Bloch*-  reports  a 
case  of  an  eight-months'  child  suffering  from  leuke- 
mia, where  autopsy  showed  myelitic  foci  followed 
by  degeneration  of  fibers  w^ith  diffuse  sclerosis  and 
increase  of  neuroglia.  Lichtheim^^  considers  dis- 
eases of  the  spinal  cord  in  pernicious  anemia  as  due 
to  some  toxic  agent,  and  finds  degenerative  foci.  The 
writer  contented  himself  in  presenting  but  a  few  ex- 
amples. If  one  takes  the  trouble  to  read  the 
literature  for  the  past  few  years,  he  will  be  sur- 
prised to  see  how  large  is  the  number  of  spinal  dis- 
eases caused  by  infection ;  and  if  the  histories  re- 
ported were  read  or  taken  carefully,  one  would  al- 
most always  detect  some  infection  as  etiological 
factor.  The  clinical  and  pathological  conditions  of 
cases,  where  infection  is  not  mentioned,  and  of 
those  where  it  is  stated,  are  identical.  The  micro- 
scope gives  the  same  picture :  inflammation,  with 
all  its  consequences,  is  present.  Let  us  turn  our  at- 
tention for  a  moment  to  experimental  medicine  in 
this  field.  Myelitis  was  produced  by  Roux  in  1883 
with  toxins  of  rabies ;  by  Babinski  and  Charrin,  in 
1888,  with  bacillus  pyoceaneus :  by  Roux  and  Yer- 
sin,  in  1888-1889,  with  diphtheritic  bacillus;  by  Gil- 
bert and  Lion,  in  1888  and  1892.  with  bacteria  coli ; 
by  \incent,  in  1893,  with  typhus  bacillus;  by  Bal- 
let and  Lebon.  in  1895-1896,  with  diplococcus  of 
pneumonia.  Autopsies  in  all  these  experiments 
showed  vascular  alteration  in  the  first  place,  hy- 
perem.ia,  hemorrhages,  foci  of  myelitis,  alteration 
in  the  gray  matter,  degeneration  in  the  white  mat- 
ter, proliferation  of  neuroglia.  Bourges**  experi- 
mented on  a  dog  with  streptococcus  erysipelatosis 
and  obtained  the  clinical  pictures  of  amyo- 
trophic paralysis,  and  at  autopsy,  myelitis  with 
alteration  of  cells.  \'idal  and  Berzancon*'  in- 
oculated in  the  blood-vessels  cultures  of  strepto- 
cocci of  various  origin,  with  the  result  that  paraly- 
sis took  place,  and  at  the  autopsy  they  found  dif- 
fuse degeneration  mostly  in  the  anterior  horns. 
Morel  and  Rispal.*"  in  a  case  of  experimental  mye- 
litis with  a  culture  of  streptococcus,  found  bacteria 
in  vessels,  anterior  horns  and  central  canal.  As 
to  bacteria,  it  seems  to  us  that  it  is  not  sufficient  to 
look  for  them  only  in  sections,  because  one  might 
not  find  them,  but  also  cultures  should  be  made : 
the  last  procedure  is  more  correct  and  rapid.  Rem- 
linger,  in  the  case  mentioned  above,  could  not  see 
the  streptococcus  in  dorsal  and  lumbar  sections,  but 
did  obtain  them  from  cultures.  Hom^n  and  Laiti- 
nen,*"  in  their  studies  of  the  influence  of  streptococ- 
cis  and  their  toxins  upon  the  spinal  cord,  described 
the  following  observation  :  hyperemia,  hemorrhages 
in  the  first  place,  infiltration  of  leucocytes  in  the 
spinal  ganglia,  change  of  nerve  fibers  and  neuroglia: 
anterior  cells  are  destroyed  in  lumbar  region,  fibers 
become  degenerated  ;  bacteria  in  the  cord  in  the  first 


I 


June  29,   1901] 


THE  ROLE  OF  IXFECTIOX 


TThe    Philadelphia 
L  Medical  Journal 


12^^ 


five  days ;  streptococci  reach  the  spinal  cord 
through  lymphatic  spaces  of  posterior  roots  and  fill 
up  the  intermeningeal  spaces  of  the  whole  cord  ;  the 
pathological  effect  of  injections  of  hacteria  or  their 
toxins  is  the  same.  Remlinger^"  produced  an  exper- 
imental muscular  atrophy  with  paralysis  by  means 
of  a  sterilized  culture  of  pneumococcus :  12  days  af- 
ter the  injection  he  observed  in  a  rabbit  symmetric 
atrophy  of  the  muscles  of  the  shoulder  and  anterior 
extremities ;  8  days  later — complete  atrophy.  Car- 
riere**  described  a  case  of  myelitis  due  to  pneumo- 
coccus. with  autopsy.  Ballet  and  Lebon  produced 
a  paraplegia  with  injections  of  cultures  of 
pneumococcus.  Moltchanoff"*  experimented  on 
mice  with  cultures  of  gonococcus,  and  obtained 
an  acute  ascending  paralysis ;  autopsy  re- 
vealed that  the  cells  of  the  anterior  horns  presented 
sn  acute  degeneration  and  vacuolation.  We,  there- 
fore, see  that  the  pathological  aspect  of  experimen- 
tal diseases  of  the  spinal  cord  is  identical  with  that  we 
mentioned  above.  Here  and  there  inflammation  is 
the  first  phenomenon,  and  the  other  lesions  are  a 
natural  consequence  of  it.  If  we  wish  now  to  char- 
acterize the  nature  of  the  phenomena  of  infection, 
we  must  say  that  the  microbes  always  show  their 
^-ffect  through  a  process  of  intoxication.  If,  on  the 
other  hand,  we  give  a  glance  at  the  lesions  produced 
in  the  spinal  cord  by  poisons  of  organic  or  inorganic 
chemical  bodies,  we  find  identical  phenomena  of  in- 
toxication. Lead,  alcohol,  arsenic,  mercury,  etc., 
introduced  into  the  system,  are  capable  of  producing 
the  sam.e  lesions  in  the  spinal  cord  as  intoxications 
due  to  microorganisms.  We  often  observe  that  in 
chrotiic  intoxications  due  to  lead  or  alcohol,  the 
blood  and  the  tissues  being  chronically  in  contact 
with  the  poison  are  so  altered  that  any  added  acute 
m"crobic  infection  gives  an  immediate  and  easily 
produced  affection  of  the  spinal  cord.  Any  trauma 
■or  cold  in  an  individual  with  a  lowered  resistance 
will  aid  the  development  of  an  infection;  sometimes 
even  without  any  apparent  exciting  cause,  these 
poisons  give  place  to  the  same  phenomena.  It  is 
a  question  in  my  mind  whether  the  lesions  are  pro- 
duced directly  by  these  organic  or  inorganic  intoxi- 
cations, or,  rather,  by  some  microorganism  which 
has  found  a  favorable  ground  to  develop.  Hom^n 
found  in  seven  cases  of  alcoholism  changes  in  Goll's 
columns  and  Lissauer's  tracts,  but  always  a  thicken- 
ing of  the  walls  of  the  vessels  and  diffuse  sclerosis. 
Bastian  (loc.  cit.)  reports  a  case  of  an  alcoholic  who 
subsequently  to  an  insignificant  trauma  within  two 
years  developed  tremor,  pain  in  the  back,  involve- 
ment of  the  sphincters.  Autopsy  showed  that  the 
dorsal  cord  was  very  vascular  and  soft:there  was  also 
ascending  degeneration.  Lead  intoxication  gives 
almost  identical  results.  Onuf*"  reports  a  case  of  a 
painter  who  had  a  fall ;  later  he  became  suddenly  ill, 
and  in  three  days  developed  paralysis  of  the  lower 
extremities  and  left  arm.  Autopsy  showed  poliomye- 
litis of  the  anterior  horns,  infiltration  of  blood-ves- 
sels and  involvement  of  the  anterior  roots.  A  case  of 
amyotrophic  lateral  sclerosis  due  to  lead  intoxication 
was  reported  by  Ch.  T.  Potts.'"  Mercury  and  ar- 
senic are  apt  to  give  rise  to  the  same  symptoms. 
Donetti^'  and  Gilbert  ''-  report  cases  of  tabes  due 
to  intoxications  with  these  two  minerals.  Lesions 
of  the  spinal  cord  might  be  due  to  toxins  not  intro- 


duced from  the  outside  world.  I  speak  of  so-called 
auto-intoxications.  Alteration  of  blood,  toxic  or 
any  irritative  substance  developed  secondarily  to 
digestive  disturbances  give  place  to  auto-intoxica- 
tion, which  is  apt  to  predispose  to  some  degenera- 
tive condition  of  the  cord.  Sedentary  life,  mental 
and  physical  strain,  are  likely  to  bring  on  an  intesti- 
nal atony ;  various  toxins,  like  scatol,  indol,  etc., 
develop  and  are  carried  to  the  spinal  cord  through 
the  lymphatic  system.  Feinberg'^  reports  a  case  of 
asthenic  bulbar  paralysis  following  auto-intoxica- 
tion due  to  obstinate  constipation.  Lichtheim  {loc. 
cit.)  speaks  of  a  case  of  diabetes  and  of  three  cases 
of  grave  icterus,  followed  by  spinal  symptoms. 
Sougues  and  Marinesco'*  found  at  the  autopsy  of  a 
woman,  who  died  from  diabetes,  degeneration  of 
the  posterior  columns.  They  express  an  opinion 
that  the  lesion  of  the  cord  is  due  to  toxins  of  auto- 
intoxication. Ettlinger  and  Nageotte^'  produced 
an  experimental  Addisonian  auto-intoxication  and 
found  in  the  spinal  cord  changes  similar  to  infec- 
tious alteration.  The  preceding  stud}'  permits  me 
to  arrive  at  one  conclusion,  that  whether  the  dis- 
eases of  the  spinal  cord  are  due  primarily  or  second- 
arily to  a  microbe  introduced  from  the  outside 
world,  to  organic  or  inorganic  intoxication,  or  to 
auto-intoxication — the  general  term  that  we  could 
use  to  express  the  effect,  is  iutcvication.  As  soon  as 
the  organism  is  attacked,  it  begins  to  defend  itself 
by  means  of  its  cellular  secretions.  The  cell  can 
triumph  over  the  pathogenic  agent  only  when  it 
contains  ferments  capable  of  digesting  and  destroying 
that  agent.  The  leukocyte  is  not  the  only  cell  that 
contains  phagocytic  elements ;  there  are  other  cells 
that  produce  chemical  substances  for  protection 
against  the  enemy.  The  antitoxins  meet  in  battle 
the  toxins  and  render  the  organism  indifferent  to 
their  influence.  As  soon  as  infection  sets  in,  these 
antitoxins  begin  to  be  formed  in  Ehrlich's  lateral 
chains,  and  the  morbid  condition  will  be  shortened 
or  prolonged,  aggravated  or  attenuated,  according 
to  the  amount  of  the  protective  substance.  When 
the  disease  is  conquered,  profound  chemical  modi- 
fications take  place  in  the  system  and  produce 
invnunity.  These  modifications  depend  upon  the 
accumulated  toxins  and  production  of  defensive 
substances.  The  therapeutist's  duty  is  to  combat 
the  effect  of  toxemia  by  helping  the  destruction  and 
elimination  of  toxins,  and  at  the  same  time  to  stim- 
ulate the  defensive  reactions  and  therefore  increase 
the  resistance  of  the  organism.  The  last  can  be  ac- 
complished by  serotherapy,  which  has  already  given 
such  admirable  results  in  many  cases.  This  method 
does  what  the  organism  should  have  done ;  it  pro- 
vides with  substances  which  the  enemy  had  not  time 
yet  to  produce ;  it  shortens  the  course  of  the  disease, 
and  in  some  cases  succeeds  in  arresting  it.  It  is 
permitted  to  hope  that  serotherapy  will  be  utilized 
in  all  sorts  of  infections.  For  that  it  is  necessary  that 
we  should  be  completely  familiar  with  the  evolu- 
tion of  infectious  processes,  and  in  all  cases  succeed 
in  finding  the  primary  cause  of  a  given  infection. 
The  nervous  system  in  general  and  the  spinal  cord 
in  particular  can  be  attacked  by  infections  second- 
arily and  primarily.  The  writer  firmly  believes  that 
it  takes  place  more  frequently  than  it  is  generally 
thought,  and  that  infections  and   intoxications    of 


12^6 


The    Philadelphia 
Medical  Journal 


] 


THE  ROLE  OF  INFECTION 


[June  2S,   1»i1 


various  character  present  in  diseases  of  the  cord 
the  most  frequent  and  the  most  active  causative 
element.  Since  his  attention  was  directed  to  it,  he 
finds  an  infectious  element  or  some  intoxication  al- 
most in  all  the  cases  with  which  he  comes  in  con- 
tact. The  examples  presented  by  him  from  the  lit- 
erature, clinical,  pathological  and  experimental,  are 
very  few,  indeed ;  in  reality  they  are  numberless. 
The  object  of  this  essay  is  to  plead  for  a  more  thor- 
ough investigation  in  etiology  of  diseases  of  the  spi- 
nal cord  and  applj'  the  same  principle  in  treatment 
as  in  diseases  of  any  other  organ  of  an  infectious  na- 
ture. Serotherapy  has  accomplished  a  great  deal  in 
therapeutics,  and  the  day  is  not  far  distant  when  it 
will  be  applied  in  diseases  of  the  nervous  system. 
It  is  not  sufficient  to  treat  the  symptoms,  one  must 
ascend  to  the  initial  cause. 

REFERENCES. 

1.  Ehiiich  Der  Saueistoff— Eeduerfniss  des  Organlamus.  1S86. 

2.  Annales  de  V   Instit.  Pasteur.    1S93. 

3.  Virchow's    Archlv.    Bd.    23,    18(3. 

4.  Deut.   Arch.   f.    Klin.   Med.   Bd.   ix,  x,  1872. 
0.  Schoenfeld.   Neurol.   Centralbl.     1888. 
6.  B.   Becker.     Deut.   Med.    VVchn.     1888;  Etienne  Rev.  Neux. 


1900. 


7.  Loc.  cit. 

8.  Clln.   Soc.   Transac.     18S6. 

9.  Prog.    Med.     1884. 

10.  Med.    Times    and    Gaz.     1877. 

11.  Brit.    Med.     1893. 

12.  Neur.    Centralbl.      1884. 

13.  Prog.   Med.    Wchn.     1899. 

14.  Royal   Med.   and   Chir.    Sec.     1894. 

15.  Ibid. 

16.  Rev.   de   Med.   1899. 

17.  Presse   Med.     1900. 

IS.  Jour.   Nerv.   Ment.   Dr.     1900. 

19.  Jour.    Nerv.    and    Ment.      D.    1900. 

20.  Jahrb.  d.    Kinderheilk,   Bd.  1. 

21.  Gaz.    d'    Hopit.      1899. 

22.  Wlen.    Klin.    Wohn.     1900. 

23.  Compt.    rend.    Soc.    Biol.      1896. 

24.  Jour.    Nerv.    and    Ment.    D.    1900. 

25.  Rev.    Neurol.      1900. 

26.  Rev.    d.    Med.      1891. 

27.  Deut.    Zeitschr.    f.    Nerv.    1900. 

28.  Rev.    Nenrol.    UW. 

29.  Riforma    Medioa.    1900. 

30.  Lancet,    1887,    v.    1. 

31.  Neur.    1.    Centralbl.    18SS. 

32.  Lyon    Med.      l'<77. 

33.  Deut.    Arch.    f.    Klin.    Med.    Bd.    34. 

34.  Lancet.    1883. 

35.  Neur.    Cent.     1900. 

36.  Arch.    f.    Psvch.,    1900.  • 

37.  Gazzetta   Medica   di   Turino.     1899. 

38.  Rev.    Neurol.     1900. 

39.  Jeanselme    Pre.'ise    Med.    1900. 

40.  Roval    Med. -Chir.    Trans.    1900. 

41.  Compt.    Rend.    Soc.    Biol.    1S9B. 

42.  Zeitschr.    f.    Klin.    Med.    Bd.   31. 

43.  Deut.    Med.    'W'chn.    18S9. 

44.  Arch,    de    Med.    Exp.    1893. 

45.  Ann.    d.    I    'Instit.    Past.    1S9.5. 

46.  Congres    Franc,    de    Med.    Bowcaux.    1895. 

47.  Zie§ler's    Beitraege   z.    Path.    Anat.    Bd.    XXV. 

48.  Compt.    Rend.    Soc.    Biol.    1896. 
49.  Muench.   Med.   Wchn.     ^f^9. 

60.  .Tour.    Nerv.    and    Ment.    Dis.    1900. 

52.  Riforma    Medica.    1900. 

53.  Neurol.   Centr.   1900. 

54.  Presse    Med.    1S97. 

55.  Compt.    Rend.    Soc.    Biol.    1896. 


JOURNAL   DES   PRATICIENS. 

April  20.  1901.     (15m.   Ann6e,  No.   16.) 

1.  Cardiac  Asthma.     M.  MERKLEN. 

2.  Enteroposis.     FRANTZ   OI.RNARD. 

3.  The  Pest  in  Alexandria  in  1899.     VALASSOPOULO. 

1. — Cardiac  asthma  may  occur  in  small  attacks  or  In 
larger  paroxysms.  The  smaller  attacks  are  seen  in  almost 
all  cases  of  cardiac  insufficiency.  They  occur  suddenly 
at  night,  on  account  of  the  greater  tendency  to  venous 
stasis  at  that  time,  with  dyspnea  lasting  at  most  a  half 
hour.  They  generally  reappear  night  after  night,  rarely 
twice  in  one  night.  These  attacks  are  seen  in  cases  of 
mitral  insufficiency  with  loss  of  compensation,  and  in  cases 
of  advanced  arteriosclerosis  with  cardiac  dilatation,  myo- 
carditis, and  renal  insufficiency.  When  the  aorta  or  coro- 
nary arteries  are  affected,  the  attacks  may  resemble  angi- 


na pectoris.  The  larger  paroxysms  occur  at  night,  too, 
with  Intense  dyspnea,  lasting  several  hours.  Anginoid  pain 
may  be  felt  with  these,  or  edema  of  the  lungs  may  follow, 
with  expectoration,  due  to  aggravated  venous  stasis.  As- 
phyxia may  come  on.  Pulmonary  edema  is  commonly  seen 
in  those  with  arteriosclerosis  or  kidney  disease.  Cardiac 
asthma  has  been  theoretically  explained  as  due  to  sudden 
weakness  of  the  left  ventricle,  to  renal  insufficiency,  or  to 
toxins  absorbed  from  the  gastro-intestinal  tract.  In  the 
paroxysms,  Merklen  advises  counterirritation,  with  bleed- 
ing should  pulmonary  edema  exist.  Heart  stimulants  will 
be  needed,  and  morphin  with  ether,  hypodermically.  For 
the  smaller  attacks  digitalis  or  chloral  can  be  given.  The- 
obromin  may  also  do  good.  Rest  with  diet  and  care  will  ef- 
fect excellent  results.  The  iodides  should  only  be  given 
guardedly.     [M.  O.] 

2. — In  his  third  and  last  lecture  upon  enteroptosls,  Glen- 
ard  defines  enteroptosls  as  a  disease  characterized  by  the 
signs  and  symptoms  of  ptosis  of  one  or  more  abdominal 
viscera.  It  may  be  primarj-  or  secondary.  Among  the  pre- 
disposing causes  he  places  corsets,  parturition,  long  stand- 
ing, laparotomy,  liver  disease,  nervous  disease,  etc.  The 
exciting  causes  may  be  traumatic,  puerperal,  infectious, 
toxic,  or  nervous.  Enteroptosls  may  appear  in  four  dif- 
ferent forms,  gastro-intestinal,  lithemic,  neurasthenic,  or 
cachectic.  It  passes  through  three  stages,  the  gastric, 
mesogastric  or  hepatic  (lithemic),  and  neurasthenic  or 
cachectic.  If  no  diagnosis  be  made,  the  duration  will  be 
indefinite;  otherwise  its  duration  depends  upon  the  treat- 
ment. The  diagnosis  is  easily  made  from  the  symptoms, 
which  are  again  fully  described.  An  abdominal  binder 
must  be  worn,  saline  laxatives  and  alkalies  given,  and  a 
strict  diet  observed.  Cold  douches,  massage,  static  elec- 
tricity, etc.,  will  also  aid  in  treatment.  The  prescriptions 
and  a  full  diet  list  follow.     [M.  O.] 

3. — In  May.  1899,  the  pest  appeared  in  Alexandria.  The 
rats  had  already  been  affected.  In  one  grocery  over  200 
dead  rats  were  found.  Cases  were  found  all  over  the  city. 
During  the  three  months  epidemic.  92  cases  occurred.  In  all 
but  one  case  there  w-as  little  fever.  About  the  fourth  or 
fifth  day  the  temperature  fell  to  normal  as  a  rule,  with  per- 
spiration, diarrhea,  etc.  Then  the  patient  began  to  improve, 
or  complications  were  noted  in  a  few  days.  The  buboes 
suppurated  in  from  7  to  10  days,  without  fever.  One  case 
began  with  vulvovaginitis  due  to  the  pest  bacilli.  Pest- 
pneumonia  occurred,  both  primary  and  secondary,  as  did 
the  gastro-intestinal  form.  Buboes  shonld  be  incised,  with 
care,  under  chloroform,  when  decided  fluctuation  has  ap- 
peared. Yersin's  serum  treatment  was  tried  in  11  cases, 
with  7  cures.  The  Haffkine  prophylactic  serum  confers 
about  three  weeks'  immunity,  but  causes  marked  reaction, 
both  local  and  general.  Valassopoulo  prefers  using  5  c.c.  of 
the  Yersin  antipest  serum,  which  causes  much  less  reac- 
tion. While  pest  may  occur  in  the  individuals  inoculated, 
it  is  always  attentuated  in  character  and  they  recover  eTen- 
tually.     [M.  O.] 


On  the  Disturbances  of  Speech  In  Intermittent  Fever. — 
I.  E  .Tikanadze  ([tulnitrlinnia  (!ii:rta  liutkina.  Vol.  XII.  N'o. 
13  >  reports  3  cases  of  malaria  in  which  disturbances  of 
speech  occurred  during  the  attack.  In  one  aphasia  devel- 
oped without  any  other  involvement  of  the  nervous  sys- 
tem: in  the  second  the  aphasia  was  accompanied  by  para- 
lysis of  the  right  upper  extremity,  while  in  the  third  there 
was  only  stammering.  The  conclusions  drawn  by  the  au- 
thor from  his  own  cases  and  those  collected  from  the  liter- 
ature are  as  follows:  (.1)  The  disturbances  of  speech 
mostly  observed  in  malaria  occur  in  the  form  of  atactic 
aphasia.  (,21  A  simple  difficulty  of  speech  or  stammering 
is  of  rare  occurrence.  (31  Disturbances  of  speech  are 
more  frequently  observed  in  connection  with  the  malig- 
nant forms  of  the  disease.  They  occur  either  together 
with  the  paroxyms  or  at  the  height  of  the  disease;  rarely 
at  the  end  of  it.  (4)  Jlalarial  aphasia  is  more  frequent  in 
man  than  in  women.  (.St  It  is  frequently  accompanied  by 
paralysis.  (6t  Malarial  aphasia  is  usually  temporary,  is  of 
short  duration  and  entirelj-  recoTered  from.     [A.  R,] 


INDEX. 


A  aron,  Dr.  Charles  D.,  26G 

Abdomeu,  contusion  of  the,  91G 

surgical  diseases  of  tUc,  importance,  of 
early  diagnosis  In,  840 
Abdominal   muscle,    reflex-twitching   of,   In 
pleurisy,  210 

operations,  shocli  in,  622 

pain  in  typhoid  fever,  915 

pressure,  •"Gebaermantel"  apparatus  for 
increasing,  66 

surgery,  335,  379 

drainage  in,  694 

tumors,  surgical  diagnosis  of,  805 
Abortion,  from  medico-legal  standpoint,  295 

aseptic  bougie  for  inducing,  285 

occurrence  of,  269 

with  poisons,  919 
Abscess,  of  the  brain,  surgical  treatment, 
1150 

cerebellar,  461 

circumtonsillar,  hemorrhage,  464 

fixation,  706 

of  the  liver,   psoas  treatment  of,   1001 

of  the  liver,  312 

of  the  orbit,  961 

of  the  pancreas,  468 

otitic  extra  dural,  50  operations  for,  932 

peritonsillar,  273 

perityphlitis,  193 

retropharyngeal,  273 

spinal,  treatment  of,  55 

subphrrenio,   312,  603,  714. 
Acetic  acid,  508 

Acetone,   the  influence  of  food   on   the  se- 
cretion of,  723 

from  albumen  origin,  340 
Achillotomy.  a  simple  method  of.  888 
Acne  talangieotodes,  a  case  of,  881 
Acoumeter,  normal.   64 
Acromioclavicular  dislocation,  treatment,  60 
Actinomycosis,  treatment,  961 

notes.  148 
Acute  diseases,  on  the  prognosis  of.  878 
Adami,  Professor  J.  George,  997,  1117 
Adams  Stokes'  disease,  290 
Addison's  disease.  606 
Adenoids,  diagnosis  and  treatment,  652 

growths,  294 
Adolescents,  muscular  exertion.  461 
Adrenalin,   the  active  principle  of  adrenal 
extract,  POl 

and  adrenalin  chloride,  notes  on,  855 

antidote  to  morphine  and  opium  poison- 
ing, 850 

clinical  experience  with,  819 
Agar,  method  to  clear,  656 
Aged,  surgery  in  the,  615. 
Asglutimatious,    theoretical    considerations, 

649 
Air  illness,  compresssed,  observations,  57 

superheated,   in  the  therapeutics  of  oti- 
tis media.  758,  lObS 
Air-passages,  foreign  bodies  in  the,  7 
Akromclagy.  69,  ISO.  771 
Albany   Hospital,  365 
Albumen  and  its  artificial  oxidation,  208 
Albumin,  vegetable,  as  nourishment,  309 

decomposed  by  boiling,  611 
Albuminosnrla,   Hence-Joncs.  111.  425 
Albuminous  nutrltiou   and   nutritious  albu- 
men, 590 
Albuminuria,  orthostatic.  1251 

febrile,  938 

orthostatii-.  1064 
Alcohol,  as  a  dislnfoc-taut.  60n_ 

some  recent    rescnrches.  87S 

the  effect  of.  on  inmuinity.  74S 


Alcohol,    poisonous    ell  eels    of,    in    certain 
nervous  diseases,  1220 
and  insanity,  1220 
the  nervous  system.  006 
Alcoholism  in  childhuud,  293 
Aldred,  Dr.  John  White.  199 
Aldrlch,  Chas.  J.,  M.  D..  Ephemeral  insan- 
ity, with  report  of  two  cases,  035 
AUochiria.   contribution   to   the   knowledge 

of,  1153 
Almshouse  and  Philadelphia  Hospital,  1226 
Almshouse.   Philadelphia,  the  proposed   re- 
moval. 903.  KHIO.  1076 
Alopecia  of  pseudoaiupecia  in  syhpilis,  295 
-Vlopecla,  experimental  knowledge,  381 
Amblyopia,    intoxicating   use   of     Jamaica 

ginger,  64 
Amblyopias,  toxic,  1236 
Ambulance  service  by  trolley,  1022 
Amenorrhea,  296 
primary.  609 
.\merican  filters  considered  bad  in  Russia. 

800 
American  Medical  achievements,  six  nota- 
ble. 1223 
Association,  committee  on  scientific  re- 
search.  29 
.\merican    Medical    .\ssociation,    the    new 

president  of,  1178 
American  Medical  Association,  the  reorgan- 
ization of,  1021 
meeting.  1110 
.Vmerican  Medical  Hospital  In  Peking.  830 
.\mmonium  persulfate  solution,  607.  872 
.\inputation.  through  hlp-jolnt,  1001 
of  both  feet,  spinal  anesthesia.^BO 
stumps,  construction,  335        •^ 
Amyloid    degeneration,    in    regara    to    the 

kidney.  ^^39 
Analgesia,    spinal,   61,   338,   916 
.\naplasia,   427 

.Vnastomosis.   urethro-intestinal,  S35.  1000 
a    method   to   perform,    of.   hollow   vis- 
cera.  874 
between  bladder  and   rectum,   23 
Anatomical  teaching  in  ISOO,  102 
.\natomy.   prizes,  409 

teaching,    49 
Anders.  Howard  S.,'  M.  D..  The  Individual 

Communion  Cup.  138 
Andrews,   Dr.   Burt,  98 
-\neniia.  a  further  report  on  a  case  of  per- 
nicious. 1206 
heavy  metals  In  treatment  of,  295 
pernicious,  spinal  c(»rti.  188 
pathogenesis  of  conditions.  188 
secondary  becoming  pernicious,  998 
severe,  with  changes  in  the  spinal  cord, 

1207 
simple,  an  extreme  cose,  851 
splenic,  105 
Anerobic    bncterla.    918 
Anesthesia,    general,    advisability     of    Its 
study,  955 
from  subarachnoid  Injection  of  cocaine, 

,'..59.  957.  980 
general,  1»0 

hysterical  and  analgesia,  8T8,  723 
local.    285.    601.    10:!9 
operating  during  the  first  ether,  611 
paralysis,    peripheral,   851 
rhaibldlan.  In  lalir.r.  1088 
remarks  on,   8.53 
rcinnrks    on.    other.    &';9.    1045 
sidnal     3«    70C    kW.    I>ie.    1027 


Anesthetics,  Committee  of  the  British  Med- 
ical  Association,   509 
diflicultles  and  dangers  of,  1002 
for  an  elephant,  997 
how   to   acquire   deep,   quiet   breathing, 

802 
some  recent  developments,  757 
the  influence  of  air,  802 
the  report  of  the  committee  on,  586 
Aneurysm,  rhythmical  shocks  to  the  head, 
431 
ruptured  traumatic  of  the  femoral  art- 
ery,   due   to   gunshot   wound,    735 
Angina,  epiglottidean  anterior,  152 
Ludovici,  264 
membranous,    9.    1085 
ulceromembranous,   361 
Angionm.    cavernous,    of   the   orbit,    848 
venous,    of   the    flexor   muselei   of   the 
fingers,    737 
Angioneurotic  disturbances,  on,  1197 
.Vugioneurosis  and  neuroangiosis,  120S 
Angiotripsy,  experience.  282 
Animal  lite,  influence  of  sterilized  air,  496 
Anisometropia,   978 

Ankvlosls.  a  case  of  almost  universal,  1149 
Ankylostomiasis.  Thymotal  remedy,  466 
Anopheles    maculipeuuis,    330 
Ano-recta'  flstula  as  sign  of  phthisis,  295 
Anthrax.  1240 
Anthrax,  in  Philadelphia,  1070 

cured  by  injection  of  carbolic  acid.  977 
Antipneumococcus  serum  in  the  treatment 

of  pneumonia.   1086 
Antisepsis  now  and  in  antiquity,  279 
Antiseptic,    telephoning.    50 
Antispitting  crusade,  710 
Antitoxin,  unit,  the,  633 

results   of,    194 
Antrum,  infection  and  sigmoid  sinus  throm- 
bosis.  1087 

maximillary  diseases  of  the,  1039 
Anus,   Imperforate,   a  rare   case  of,  966 
Aortic  aneurysm.  263,  962,  1064 
treatment  of.  24 
aneurysm,       varicose,       communicating 
with  the  pulmonary  artery,  14 
.\ortic    aneurysm,    Oliver's,    277 

insuQiclency.  movements  in  the  mouth 

and   throat.   157 
murmur,  position  in  which  best  to  hear, 
1197 
Aphasia,   with   letter  blindness,   467 

traumatic,  a  complete  anomla,  etc.,  917 
with  reference  to  the  naming  centre.  15 
.Appendicitis,    abscess   formation   and   rup- 
ture into  the  bladder.  294 
American  treatment  of,  955 
and  neurasthenic  tendency.  256 
and   right-sided  adnexal  disease.  452 
complicated  by  subphrenic  abscess.  604 
diseases  of  the  uterine  appendages,  369 
drainage  in.   740 
dullness.    335 
fulminating.    71C 
In  earlv   life.  10S7 
In  the  female.  272 
medical  and  surgical.  378 
observations   and   tabulated   reports   of 

InO  tases.  S'Jl 
perforation  of,  followed  by  peritonitis, 

914,  999 
perforative  In  Irreducible  scrotal  hernia, 

1085 
phlcsmonous,  from  tonellltls.  28i 


,258 


protracted,  and  its  results,  884 
question  of  operating  lu,  104i  961 
recurrent,    55 

vermiform,  377,   510,  806,  1086 
worms  in,  893 
Appropriations,    144 
Aqueous    extract,    335 
Arizona,  climatoiogy  of,  339 
Army   Canteen,   the,   1111 
Army  Medlcai  Sciiool,  1228 
Arsenic,    actions  -of,    during   epidemic  of  a 
toxicolOKicai  detection  of,  1344 

poisoning,    900 
eiiminatiou  of  arsenic  througli  tlie  bair, 

716 
question,  tlie,  893 
toxicoiogical,  detection  of,  644 
Arterial    livpertonus   and    arterio   sclerosis, 

1197' 
Arterial    sutures,    1159 
Arteries,  muscular  action  of  the,  1085 
Artery,   superior   mesenteric,   occlusion   of, 

212 
Arthritis,  pneumococcus,  202 
rheumatic,  treatment  of,  802 
suppurative,  of  the  knee,  703 
Ascites,  a  ease  of  and  prolonged  fever  as 
a  result  of  syphilis,  850 
chylous,  1119 
early    indications,    66 
trentnient    of,    in    cirrhosis    of    the    liver, 
051,    724 
Aspergillus   in   urine,   cultivation,   440 
Aspirator,  a  plea   for  the.  832 
Aspirin    and    heroin.    1045 

in    pleurisy,    1108 
Astereognosls.    498 
Asthma,   hronehial,   296 
cardiac,    1250 
dyspeptic,   104 
experience   in   search   of  a   cure   for  in 

the  far  southwest.  853 
therapeutic   value  of   potassium   Iodide, 
1237 
Asylum  for  prematurely  born  children.  800 
Atiirepsia  neonatorum,  a  severe  case.  601 
Athyreosls  In   childhood    and   Infancy,    162, 

200 
Atmuliausis.   its  value  in  the  treatment  of 
severe   and   uncontrollable   bleedings 
(uterine  a).  013 
Atresia   avis,  a  rare  anomaly,   8 
Atropiu    poisoning.    120 

upon  the  intestines,  etc.,  280 
Attorney  apologizes,   12 
Aural  surgery,  602 

Auscultatory  pheuonieiui  in  a  suckling,  723 
Austin,    Dr..    The    furiuation    and    distribu- 
tion of  combined  hydrocliloric  acid  in 
Autocystoplasty        and        kolpocystoplasty. 

vesico-vaginai    wall.    472 
Autointoxication,  diseases  produced  by.  420 

from  renal  insutllcieucy,  334 
Autopsychorhythmia,   914 
Axilla.  liyiMiidnisis  of  the,  treatment  with 

thfnuociuitcry.    59 
Ayers.    Edward    A.,    M.    D.,    Physical   diag- 
nosis  in   obstetrics.    201 
Azoospermia  and  paternity,  409 
to   cystitis,    423 


Bacilli    Boas    Ka  jfmann,  C,     diseases  of 
the  stomach.  381 
lactic  ai'id  from  granules,  519 
typhoid,   their  action   on   human   blood, 
n.-i9 
Bacillus  coll  communis  in   relation  to  cys- 
titis. 423 
Backward  children.  IMiiladelphla  school  for. 
787.    903 
ackward  Children.  Institute  for,  474 
psychological  study   of,   1239 
Bacteria,   chemistry  of,  .'141 
clliuiiiatiou  of.    l.'IJ 
ill    lilirai-y    books.    411 
a  method  to  ascertain  the  virulence  of. 

883 
pass  through  intestinal  wall,  340 
postmortem   vit;illty.   ."OS 
variability     and     pleomorplilsiH.    279 
witli    two    proiinimced    examples,    16 
Bacterial    toxins.    420 
Bactericidal   action   of  light,   etc..  517 
Bacteriological   diagnosis.  Mft 
Bacteriologist   appointed.    140 
Bacteriology    In    relation    to    quarantinabic 

diseases.   4S3 
Bally.    I'lerce.    M.    !>..    The    etiolog.y  of  ar- 
rested mental  ile\eiopmeut.  924 
Baker,   Dr.   txcorge  Pales.   10 
Balaraitic    livpospadlas.    1003 
Baiiingor.    William    Lincoln.    M.      D..    The 

functional  tests  of  hearing,  972 
Baltimore    Tension    Hoard.    197 

University   Hospital.   32.". 
Bandages,  the  application  in  fractures,  889 
Inexpensive,  Si'^ 


INDEX 


Bandler,    Samuel    W.,    M.    D.,    Atmokansis, 
its  value  in  the  treatment  of  severe 
uterine   arteriosclerosis,    013 
a   criticism   of  the  diagnosis  composite 
teratonlc  of  the  ovary  made  by  Dr. 
E.    A.    Jones.   38 
Barbers,  the.  and  the  surgeons,  788 
Bardin,   Dr.   D.   B.,  50 
Barlows  disease,  a  case  of,  1148 
Barrow,   Dr.   T.   W..  265 
Bassian.    Dr.  John.  841 
Baths  on  the  trains,   1082 
Bazan.    Dr.    Feruand.   504 
Becton.  death  of.  Dr.  E.   P..  144 
Beer  poisoning,  investigation  of,  208 
Behle,   Augustus  C.   A  case  of  abdominal 

pregnancy,  1173 
Behrend,  Moses,  M.  D.,  Biceps  tendon  Jerk 

in  locomotor  ataxia,  1062 
Belladonna  poisoning  with  morphia  as  anti- 
dote. 957 
Bell's    palsy,    associated      with      complete 
anesthesia    in    the    territory    of    the 
fifth    nerve.   02S 
Bellevue  Maternity  Hospital,  503 

Hospital,  141 
Benedict,  A.  L.,  M.  D.,  Tuberculosis  among 
Russian  Jews.  93 
aIl>uminous    nutrition      and      nutritious 
aiimmen.  591 
Benzin  in  surgery,  889 
Bequests.   145 
Beriberi,    the    clinical    characteristics    of, 

1153 
Bertiilon's  metliod  for  measurement  of  the 

liody.    208 
Biceps  tendon  jerk  in  locomotor  ataxia.  1002 
Bile,   antitoxic  action  of.  703 

ducts.  I'ongeiiital  obliteration  of  the.  7.5fi 
influi'iiccs  of.  on  metai)ollsm,  875 
secretions.  Ill 
Bilirubin   In   the  urine,   the   demonstration 

of.  8.89 
Biologic  reactions,  sppcific.  744 
Bishop  Medical  College.  Montreal.  843,  1030 
Bismarck,  fellow  students  of,  506 
Bismuth   poisoning.   1158 
Blzzozero.  death  of  Guilio.  954 
Bladder,  contraction  of  tiic  ni'ck  of  the.  lOOn 
complete  inguinal  extra-peritoneal,  1003 
double,  a  case  of.  1003 
ectopion  of  the.  21 
eplsiiadlc  exstrophy  of  tbc,  16 
female.   40.5 
hemorrhage  of  the,  21 
hernia   of  the.  902 
IntrautiTlnc  rupture  of  the,  55 
the  male.  472 

strength  of  liypertrophled.  55 
and  ureters,  injuries  in  radical  surgery. 
05 
nicedini.   Indb-iMons  for.  25 
Blepharitis,  treatment.  24 
Blindness  due  to  sphenoidal  and  ethmoidal 

sinus  disease.   55 
Blindness    from    sympathetic    ophthalmitis, 
297 
prevention  of.  835 

the   sometimes   successful   treatment  of 
incurable.  9.5(5 
Blood,  the  alkaliuilv  of  tlie.  902 
cells,   tlic  red.   ii\-i 
concentration.  1,30 
condition  In  zona.  725 
examinations  as  an  aid  to  surgical  diag- 
nosis.   1042 
specillc.   10.39 

In  relation  to  surgery  of  scientific  but 
not  always  of  practical  value.  1055 
f.-iilacics  ill  the  chemist rv  of  the.  9;i9 
fat  in  tlie.  28S 
forming  organs,  the  condition   of,   etc., 

009 
freezing  point  in  typhoid  fever,  C.55 
morphology  in  diphtheria,  etc.,  747 
new    mctliod    of   dinvrentlatlng   human 

and  animal.  919 
pressure,  lymph  circulation,  283 
stain.  448 
the  transfusion  of  and  Its  applicability 

for  curative  purposes.  1150 
in  the  urine.  512 
vessels.  3S1 
Bloo.llcss  work.  te<-hnique  of,  338 
Bodies,  unclaimed.  1220 
Bimd.  Dr.  Thomas,  commits  suicide,  lllS 
Bone,  atrophy  of  the.  acute  inflammatory.  08 
Booth's  body,   disposal,  413 
Booz,    Cadet.   itO 
Boston  Modiial  Library.  98 

.Society  for  Medical  Improvement,  9S 
Bottinl    operation,    the.    20 
Bougie,  aseptic.   Dr.  Kapp's.  381 

eusrachian.  50 
P"»»"e  au  'n»v»ro»"'^.  f<^?  *jo?*J  extension,  S74 


Brain  abscess,  multiple,  437 

compression,  caused  by  rupture  of  the 

slnns,  892 
examination  of  300  suicides,  844 
injury.  380 
of  two  more  celebrities,  791 

"    distinguished  physicians,  father 
and  son,  080 
tumors  and  cysts,   274 
the    localization      of,    especially      with 
reference    to    the    parietal    and    pre- 
frontal  regions,   704 
the  editorship  of,  938 
Breast,  contusion  of  the,  882 

during  lactation,  infection  of  the,  103 
funnel,  891 

milk,  conservation  of,  913 
Brlghfs  disease,   some   clinical  aspects  of 
chronic,    756 
climatic  treatment,  204 
clinical  varieties,   148 
Brinkman.   Leon.  obser\'ations  and  tabulate 
ed  report  of  the  results  of  150  opera- 
tions for  appendicitis,  821 
Erister,   Dr.  John  W.,  50 
Brockway,  death  of  Dr.  Fred  J.,  893 
Bromide.    sutHcient   dose    in    treatment   of 

nervous  diseases.  611 
Bronchial  affections,  by  the  reoumbent  po- 
sition, treatment.  112 
cysts  and  fistulae.    178 
Bronchiectasis,    congenital.    288 
Brown,  Dr.    Benjamin,   143 
Brubns,  Professor  Dr.  von.  the  disinfection 
of  wounds  with  pure  carbolic  add, 
964 
Budapest,  170 

Buffalo  Academy  of  Medicine,  141,  458 
Accident    Hospital,    a   new    In,    10 
General  Hospital.   10 
German    Hospital,    10 
University.    205 
Bulbar  palsv.  asthenic,  359. 
Burkham.  H.  H..  53 

Bussy,  Dr.  Samuel,  memorial  tribute,  505 
Butt.   Dr.   A.   W.,   10 
Butyric   acid   forming  bacteria,   469 
Buxley  professorship,  504 


Cabot,  Jr.,  Foilen.  M.  D..  Percentage  of 
silver  in  sliver  nitrates,  283 
Calcium  lodate  as  an  iodoform  substitute, 

103 
Calculi,   blllarv,   treatment   with   olive  oil, 
208 
Impacted  In  the  ureter,  960 
vesical,  150 
Callous,  resilient  strictures,  treatment,  159 
Camden   City  Dlsjiensar.v,   795 
Camp,  Dr.   Samuel.  411 
Canada,   post-graduate  course,   460 
Canadian  Nurse,   the.    947 

Nurses'    Association,    the.   1116 
Cancer,  of  the  bladder.   Infiitrated,  723 
auto-iuocuiatlon  of.  t*82 
of  the  common  bile  duct.  514 
Buffalo   Investigation   regarding,   1000 
home,   367 

In  Canada  (Ontario),  596 
Increasing,  841 
laboratory.   309 
of  the  larynx,  running  over  a  course  of 

10  years.  1149 
of  the   face.   415 
of  the  jiylorus.  721 
of  the   stomach,   digestion   leukocytosis 

in,   043 
on  the  origin  of.  11'18 
the  cause  of.  1007 
the  protozoon   of.   786 
treatment,   497 
of   the  uterus.    643.    1044 
Cancerous  and   other  growths,   the  cans»- 

tion   of,   64;{ 
Cannabis  indlca.  three  eases  of  poisoning. 

10-27 
Carboformal  dislnfeotion.   lo<5,  280 
Carbonic  acid  lialh,  the  effects  of,  on  cli^ 
cuiation.    791 
oxidf .  minimum  quantities  absorbed  by 
the  blood.   896 
Carcinoma  of  the  breast.  762.  S4S,  1236 
coexistence    of.     and    fibroma    In    the 

corpus  uteri.  618 
occurring  in  a  dermoid  cyst,  SS4 
of  tile  ampulla  ..f  Cater.  463 
of  the  uterus  In  pregnancy,  SS7 
primary  branchiogenic.  29 
two   cases,    treated   with   cocodylate   of 
soda.   1151 
Cardiac  affectlonsi.   etc..   1.16 
anomalies,   rare,  63* 


INDEX 


1259 


dilation,    849 
diseases,    treatment,    160 
in  militarv  men,   tbe  primary   stapes, 
SOS 
movements  by  systematic  exercises,  427 
pathology,  a  review  of  the  history,  983 
Cardiorenal  theory,  5S1 
Carles,  dental,   etc.,  110 
Carotid  artery,  ligation  of.  as  an  operation 
preliminary   to   resection  of  the   su- 
perior maxilla,  726 
Carpenter,    John    T.,    Purulent    choroiditis 
following  an  attack  of  mumps, 
diagnosis  metastatic  choroiditis,  9.*i3 
Carr,  Major  L.  C,  Surgeon  U.  S.  A..  Santi- 
ago as  a  yellow  fever  centre.   68S 
Carter,  H.  K..  H.  D.,  a  correlation  of  some 
facts   in  the   propagation   of   yellow 
fever  by  the  cuiex  fasciatus.  094 
Casualty  surgery,  459 
Casuistical  communications.  2S7 
Catalepsy,  alternating  with  violent   mental 

excitement.  914 
Cataract,  discission  of  soft,  etc.,  103 
extraction.  928 
operation,  105,  808 

three  cases,  from  lightning  strolte,  1159 
Catheters.  888.  980.  1149 
Catheterization,  permanent,  761 
Catrell,  Dr.  A.  C  50 
Cats  and  valerian.  1183 
Cauterization,   severe,    with  soft  soap  in  a 

child  of  IS  months.  115S 
Cauterv.  the  neglect  of  actual,  in  surgery, 

Cavite  fever,  301 

Cecum,  tuberculosis  disease  of,  1038 

Cephalhematoma,  403,   1088 

Cereals,    emulsions   and   proteids  in   infant 

feediuj,  203 
Cerebellar  hemorrhage,  418 
Cerebellum,    the    relations   of,    to   multiple 
sclerosis.  722 
diseases  of.  724 
Cerebral  circulation.  423 

tumor,  treated  by  lumbar  puncture,  895 
Cerumen,  432 

Cervical  sympathetic,  the  influence  of,  1026 
cord,    a   little  known    tract    of   fibres  iu 
the  periphery    of   the    antero-lateral 
portion,  890 
paralysis  of,  1236 
Cervix,  h  cerated    etc..  433 
Cesarean  hysterectomy,  269 
Cesareau  section,  266,  2;o,  915.  917.  917 

placenta  previa.   379 
Chaille.  Dr.  Santord  E..  946 
Chancre,    primary    of    the   septum    of    the 
nose.  95S 
soft,  treated  by  cautery,  389 
Charcoal,  the  Influence  of.  on  the  tubercle 

bacillus.  1090 
Charitv  hospital.  593 

State  funds  for.   1076 
Cheek,  a  new  pl.astic  operation  of  the,  with 

double  flaps.  888 
Chemistry,  uusolved  problems,  313 
Chester  hospital.  502 
Chickenpox.  421.  700.  913 
Children's  hospital.  Philadelphia,  new  quar- 
ters for  the,  319.  1027 
fire  in  children's  Tee  hospital.  53 
school.    Chicago,    for   nervous   and   deli- 
fate  children.  596 
Chinese  twms.  753.  1117 
Chlrol.  888 

Cliloral  and  hemorrhage,  2S1 
Chloralose,   716 

Chloretone  as  a  hypnotic.  419 
Chloroform,    apparatus   for   administration 

of.  9 
Chlorosis.    155.    Gil 
Cholecystectomy.    S47 
Cholelithiasis  with  al)scess,  128 

relation  of.  to  disease  of  pancreas.  10 1 
Cholera,    and    the    prevalence   of   the   coma 
bacteria   in   well   water  in   Gujerat. 
914 
the  recent  epidemic  in  Kashmir,  13 
Cholesteatoma  formation.  156 
Chorea  during  pregnancy.  853 

Sydenham's,   localization   of  symptoms, 
427 
Choroid,  melanosarcoma  of  the,  607 
Choroiditis,   iniruleut.    following   an   attack 
of     mumps;     diagnosis     metastatic 
Ciioroiditis.  revised  by  study  of  enu- 
cleated eyeball.  933 
Christian  science.  Uishop  Fallows.  450 
scientists  barred.  787,  1185 
in  Canada.  412.  843 
inoculation.   'U4 
Christie.   Miss  M.   M.  T..  M.  D..  20S 
Cigarette,  a  word  tor.  791 
Cigars,   headless.   -^OO 
Cirrhosis,   obstructive  biliary.   108 
City  life  in  ISOO.  102 


Classification  of  disease.  704 

Claude.  Dr.  Ahram,  de.ith  of.  99 

ClaiMlication   intermittent.  890.  1043 

Clavicle   Clutch,    a.    697 

Clavtor.    Thomas   A.,   a   preliminary  report 

upon  a  case  of  un.iuareosis.  1251 
Clergv,  the,  and  the  doctors,  1222 
Clinics,     the    value    of    combined    medical 

and   surgical,  to  the  student.    1172 
Clinometer,   a    new.    for    measuring   trioual 

deviations  of  the  eye.  lipi>9 
Ciltoridian  crises,  tbe  kuowledge  of,  654 
Club    foot.    4t» 

operation  in.  763 
toe.    origin   and   treatment,   891 
Cocain.    432 

habit.    304 
Cocaiuization   of   spinal    cord,    61,    91,    150, 

208,  314 
Cod   liver  oil   with  phosphorus,  381 
Coffee.    It.    C,    M.    D..   A   new   tenaculum, 

697 
Coffee  as  a  beverage,  104 
Cogswell.    Dr.    George,    death   of.   841 
Coincidence,   an  odd,    Ssll 
Colds,    the  phvslologic  care  of.   805 
Cole.    Dr.    R.    Beverly.    143 

Carter  S.  M..  a  clavicle  clutch,  697 
Dr.  \V.  AV..  53 
Colgan.    .1.    E..    M.    D..    A    question   of   pri- 
ority.   1070 
Colic  hepatic,  treated  by  nephrorrhapy,  148 

renal.  148 
Colitis,  hyperplastic,  854 
in  children.    1131 
mucous.  2iU.  295 
College  for  Phvsicians  and  Surgeons.  Cham- 
paign, ill.,  struck  by  lightning.  1227 
College  of  Phvsicians.  i'hiiadelphia.  library 
report.  986 
women,    susceptibility    to    disease    and 
physical  development  in.   778 
Colleges  to  nominate  candidates.  1027 
Coiles  fracture,  dressing  for.  IJ43 
Colloids  as  nourishment  for  children.  740 
Colon,  bacillus,  the  toxins  of  the,  1042 
irrigation  of.  467 
parenchymatous    hemorrhage.    18 
Color    perception,    hereditary,    516 

tests,    qnantitative.    ."lo 
Coloronietric  methods,  nitric  acid  in  water, 
69 

Colostomv.  inguinal,  some  remarks  on.  806 
Colostruiu   an!   milk,   the  figured   elements 

.>f.   1'205 
Columbia    I  uiverslty.    53 
Coley.    t\illiam  B..   M.  D..   Late  results  of 
the  treatment  iu  inoperable  sarcoma 
with  the  mixed  toxins  of  erisypelas 
and  bacillus  prodigiosus.  1013 
C<ima.    malarial.    153 
•  'ouinamion    cup.    individual.    1.38 
Compensation,    process  of,   208 
Couard,    Rev.    Charles.    M.    D..    143 
I'lmjunctlva.  tuberculosis  of  the.  283 
Conjunctivitis,    gonorrheal,   1001 
Connective  tissue.  427 

Constipation,   habitual,  treatment  of,  761 
treatment.   207 
with  flatulence.   296 
Consumption,  drugs  In  the  management  of. 
421 
in  check.  325 

management    and    treatment    of.    150 
Consumptives'  Sanitarium  at  Teneriffe.  1229 
Consumptives.   State  sanitarium  for.  11 
home,    11 
poor,  514 
Contagious   disease  hospital.   11 
Contempt    of    Court    versus    contempt    of 

human   life.  2.58 
Convulsions.   515.   876 
Cooper  hospital  physicians.  .50 
Copper  for  internal  use.  295 
Corneal   astigmatism,    results   from  cauter- 
ization In.  119S 
Cornell    Medical     College    commencement, 
1115 
Tnlvcrsity  infirmary  for  students,  1076 
Corpses,  appearance,  282 
Correction.  318 

Correspondents,   anonymous.   316 
Corrosive  sublimate  poisoning,  722 
Conical   sclerosis,   608 
Cough.  1042 

Counter    prescribing   by   druggists   In    To- 
ronto. 732 
Cows'   milk,  prevalence  of  streptococci   in. 

800 
Coxitis,  shortening  after.  184 
Cremation  in  Quebec.  7.52 
Cretinism,    sporadic,    treatment    with   thy- 
roid extract,  282 
Crofts    J    M.  S.,  M.  D.    lieutenant  colonel, 

'146 
Croskey.  Dr.  J.  W.,  resignation  of,  96 
Crura  cerebri.  22 


Crurare  poisoning,  electrical.  290 
Cms  cerebri,  tumor  of  the  right,  448 
Cryposcopy,  1023 
Cutaneous  diseases,  diabetes.  206 
Cyanosis  of  peripheral  origin,   288 
Cyst,  suppurating,  of  the  ovary,  294 

endocarditis,   rheumatic,   1205 

piu'umoccic.    1203 

subdued  serous,  430 
Cystadenoma    mammae,    relation    to    carci- 
noma of  the  breast,  113 
C.vstlc  affections  of  the  breast,  1082 
Cystitis,  gonorrheal,  105 

typhosa.   46 
Cystocele.   718 
Cystotomv.   suprapubic,   improved   method, 

104 
Cysts,  cerebellar,  1155 

dermoid.  305 

liydaUd,  1038,  1160 
Cytotoxins,  cellular  poisons  or,  836 
Czar's  physicians,  3ti9 

r\  alias  Medical  College.  1229 

Dalv,  Dr..  suicide  of.  1115 

Dana,  Charles  A.,  A.   M.,  M.  D..  disorders 

of  sleep.  669 
Dancing  mouse  of  Japan.  1090 
Davidson,  Dr.  Alexander,  death  of,  13 
Deafness,    catarrhal,    systemic    factors    In, 

605 
Deaths   in   anesthetics,   864  _ 

Ueaver,  John   B.,   M.   D..   the  examinaUon 
of  tbe  blood   In  relation  to  surgery 
of  scientific  but  not  always  of  prac- 
tical value.  1053 
Deciduoma  maiignum.  clinical  study  of,  bJi. 
Dejerine,  Dr.  J.  J..  1081 
Delaware  Hospital,  145 

law   governing  physicians.  4o» 
opposition    to    the    Abbott    law,    btate- 
Board  of  Health,   ilO 
Delirium    tremens,    treatment,     saline    In- 

tusious,   466 
Deliverv.    difficulty    of.    on    account    of    a 

(iouble  monstrosity.   635 
Demadea  folliculorum  in  the  eyelid,  2ii 
Dempsey,  Dr.  iiartin  J.  P.,  3tj9 
Dental  diplomas,   bogus  American  in   Ger- 
many, 831 
Dentition,   uisoiders  of,   191 
Deunstry,    relation    to    medical    educaUon. 

■4:2'-* 
Dermatitis,  acute,  caused  by  hair-dye,  1002. 
arsenical.  '271 
biastoiu.N  cetic,  651 
Dermatologic   laboratory,   147 
Detroit  Mi-dicai  Journal,  9uo 
L.ialietes.   Baillie  lectures,   o.b,  416 
cutaneous  diseases,   2Jb 
due  to   hereditary    syphilis,   89o 
iu  a  boy,  SOS 

a  nursling,  653.  SOS.  S95 
mell.tus,    •■i05..,206,  20.,    2S2  ^i  -8'- 
673,    719,   73'2.    i3t.,    102,   820,   S<o 
general  metaLolism  In,  6i3 
Rose's  d.  milk,  159 
traumatic,  42» 

SlSi^Ti/ ir^^^'Sr^'k  JL  method 

DlagnoSs'*^^""t-e^r    in    laboratory 

clinical,  916 
Dialvsis  of  the  toxins,  lj»  „„ 

Diarrhea  and  vomiting  treatmeiit    2.9 
Digitalis  and  its  derivatives,  b,  334,  *&. 

commulative  action  of.  91J 

"ood  and  bad  euects.  8o3  , 

us  eflects  on   the   liver   and   kidney  ot 
of  dogs.  1161 

leaves,  the  active  principle  of,  .19 
Diphtheria,  10,  .43,  XM,  423,  431,  60O,  804 

antitoxin,  150,  '299,,  60..  *>0l.   f^'''-  -i-l-* 
as  a  treatment  of  pneumonia,   .00 

apnea  in.  lo2 

diagnosis.   514  .  .,., 

dilbcultles  from  the  restriction  of.  00-. 

96;! 

laryngeal,  coiuplicating  measles.   .1. 

not   quarantlnable.   IMl 

pathology  and  Imctoriol.igy  in,  h29 
Diplegia,  hysteric  facial.  471 
Discovery,    valuable.    954 
Diploma  mill  exposed.  11 
Disease,    relations   between   cause   and   ef- 
fect.   15 

■what  is  a,  15 
Diseases,    infectious,   419 
Disinfection  of  the  hands.  2S0,  1044 

new  mode.  646 

steam   In  surgery.  469 

with    alcohol.    l~i^' 

with   formalin.   055  .      .^. 

with  pure  carbolic  acid,  of  wounds,  964 
Disorders  of  <•  •■«■■'■  on  -•■-tain.  ti69 


126o 


IXDEX 


Diuresis,    432,   879,    880 
Divers'  diseases  and  perils,  954 
Diverticula,    lalse   of   the  Intestlue,   G49 
Dividing  tbe  responsibility,  y;i7 
Dobbs  Ferry   Hospital,   2UG 
Doctor,  as  major  general,  358 
must  not  leave  patient,  5UU 
the.  In  politics,  1110 
Doctors,    fee,    the,    a    plea    for    honorable 

dealins,  920 
Dogs,  poisoning  of,  a  penal  offense,  1115 
Dorland,   W.   A.   N.,  A.   M.,   M.  D.,   the  co- 
existence of  carcinoma  and  flbroma 
In  the  corpus  uteri,  018 
Douche,    treatment    of    ophthalmia    neona- 
torum,  64 
Downey,  Dr.  Martin  J.,  10 
Dropsy,   abdominal,   surgical  treatment  of, 
following  cirrhosis  of  the  liver,  004 
Drug  concern.  .">3 
good   year  in,   11 
habits  in  tbe  United  States,  712 
standardization  and   what  it  means  for 
tbe  physician.  701 
Druggif^t  censured,  ?19 

Duane.    Alexander,    il.    D.,    A    new    clino- 
meter for  measuring  torsional  devia- 
tions of  the  eye,  1099 
Duckworth.   Sir  Dyce.   4S3 
Ductus  arteriosus,  315,  490 
Dulles,    Charles    W.,    M.    D.,    Progress    of 
medicine  in  the  United  States  during 
the  19th   century,   1095 
Dunglislon,   Dr.  Richard.  454 
Duodenal  ulcer  in  an  infant  of  10  months, 

870 
Duodenum,  carcinomatous  stricture  of  the, 
914 
dilation  of  the  first  part  of  the,  1038 
Dupuytrens    contraction,    202 
Dysbasia.  intermittens,  augiosclerotica,  420 
Dysentcri'-  iliseases,  420 
Dysentery,  etiology,  02.  341 
in  South   Africa.   331 
treatment  with  salines,  848 
tropical,  03,  IJ07,  045 
Dysmenorrliea.    33S 
Dy.spepsia.    432 

in  older  i-hildron.  059 
Dysphagia,  amyotactlc,  890 
Dyspnea  ;  nd  angina  pectoris,  059 
Dystinuria,  a  case  of,   ending   in  recovery, 

S03 
Dystrophy,   653,   877,   SSI 

Ear,   as   factor   in   systemic   distrubance, 
59 

disease,    60.    238.    606 

disease  of.  l.')6,  100.  2S0.   75S 

disease,  the  nasal  factor  In.  1042 

eczema  of  the   external.  280 

middle  ear,  acute  Inflammation  of.  1084 
Eat  everything,  when  should  patient  be  ad- 
vised to,  850 
Echinococcus    of   the    kidney,    loS 
Eclampsia  at  the  sixth  mouth,  423 

induced   labor   in,    132 
Ectokelostomy,  429 
Ectopic  pregnancy,  339 
Eczema  in  relation  to  age,  999 

the  treatment  of.  (150 
Editorship  of  '■Brain."  938 
Edsall,    David    1^..    General    metabolism    in 

diabetes  mellitus.  073 
Education,    a     liberal,    and    the    study    of 

medicine,  lll.'t 
Egbert's  hygiene   and   sanliation,    S 
Egle.  Dr.  ■\Villiani  II..  .■!04 
Ehrlich  and  Weigert.  I'rofessors.  147 
Eiselsberg.   I'rufessor  von.   147.  9.")4 
Eisen,  Dr.  Joseph,  of  California,  1228 
Electric  shock,  a  case  of,  001 
Electricity  and  nerve  force,  899 

workers,    280 
Elizabeth,  mavor  of.   dead,  90 
Elliott.   President,  rumor  of.  53 
Ely,    Thomas    C.    diabetes    mellitus    as    a 

cellular  fault.   7:i,S 
Embolism  of  the  abdominal  aorta,  1158 

arteria    centralis   retinae,    761 
Embolus,  death   from.   54 
Embryological  basis  of  pathology,  040 
Emphysema   of     the    eyelid      from      nasal 

causes,    003 
Empyema   in  children,   430 

technique  of,   429 
Encephalitis,    nou-snppurating.    the    pathol- 
ogy of.  hemorrhagic.  1153 

following    inlluonza,    11.55 
Endoca.-dltis,  acute  vegetative,  894    . 

gonorrheal  lUceratlve,   108 

malignant,  ti,'! 

multiform.   877.  893.  10S3 

rheuniallc  purpura,  1161 
Endometritis,  purulent,  treatment  of.  501 

simulating   cancer,    1044 
Endophlebltls.    4115 

I'nterectoray.    the    question    of    limit.itlon. 
936 


Enteric    fever    among     British     troops     In 
South  Africa,  309,  644,  913 
antiseptic    treatment,    403 
at  Xew  Haven,  780 
Immunity   of  Asiatics,  331 
in   children.    877 
in   Ceylon.  199 
inoculation,    201 
thermol    treatment,    204 
water-borne,  333 
Enterals  membranous,  erroneously  treated 

for  phthisis,    1104 
Enterocolitis,    190 
i:nterollths,   a   rare  case  of,  837 
Enteroptosis,  759,  856,  980,  1194,  1236 

surgical  treatment,  23 
Enlcrorrhaphy,     technique,    210 
Epidi'rmoid    cancer,    treatment,    720 
Kpidural   hemorrhage,  334 
lOpllciisy,    the      influence    of      intercurrent 
disease,  834 
the  psychic  equivalent  of,  980 
the  surgical  treatment  of,  1109,  1162,1165 
the    surgical    and      medical      treatment 

of.   104 
psychic,  1239 
i;idlejitii-   patients,    analysis  of  stools   and 

urine  of,  1131 
Epiphyses,  separation  of  the,  7.58 
Epistaxis,   cause  and  treatment  In   people 
be.vond   middle   age,    914 
treatment   with   suprarenal  gland,   409, 
955 
i;pUhelioma,    developed    on    the    basis    of 
healed    lupus    vulgaris,    1042 
cxiision  for,  55 
primary  squamous,  1161 
ICpityphlitIs  and  its  present  treatment,  655, 

057 
Epizooiic,    epidemic  of.    among   laboratory 

guinea   pigs,   649 
Equilll)rium,   disturbance,   156 
i;i'li,    William,  '280 
Erlis  dLsease,  1154 
lOrrata,    50,    93 
ICrysipelas  In  Asia,  984 

treatment,    356 
i;rythema,   mercurlale,  207 
lOshner.  Augustus  A.,  M.  D.,  bilateral  pare- 
tills    as    a    complication    of    pneu- 
monia, 318 
the  knee  jerks  in  chorea,   1106 
i:soi)liagllis,   membranous,   149 
ICsopbagoscopy   and     gastroscopy,     history 

of.  SS4 
Esophagus,  carcinoma,  138 
cast  of  the.  149 

electric    treatment    In    spasmodic,    803 
malignant    diseases   of   stricture,    1156 
removal  of  artlOclal  teeth  from.  610 
skiagram  of  a  metal  spoon,  161 
sounding    In    stricture  of,    883 
supertidal  glands  of  the,  649 
tumors,  280 
ICsoplioria.  or  latent  squint,  866 
ICstlvoamumnal   fever,   60 
Ether  as  an   anesthetic,   1043 

and  chloroform,   335 
Euthanasia,  medico-legal  study  of,  107 
Excursion,    special   to    London    and    Paris, 

12.i0 
Exertion  Interval,  clinical  observations,  809 
Exomi)halos,  69 

Expccloratlon    ordinance,    anti,    144 
Eye.  effect  of  gout  and  rheumatism,  296 
left    and  frontal  lobe  of  brain,  shotgun 

explosion,  515 
loss  of  an.  $7000,  503 
magnets,    112 

muscles,   examining  the,   1040 
rheumatic    diseases.    338 
ball,    therapeutic    measures   to   promote 
absorption      of     conditions      within 
the.  961 
rupture  of  the,  from  contuElon,  977 

Caclal    paralysis,    symptomatology,    211 

EalUires.   percentage  of,  7 

Fallacies  In  the  chemistry  of  the  blood.  939 

Ealloplan  lubes.  Inflammation  of  the,  878 

Family  doctor,  the,  must  he  go';  634 

l''angothcraphy,   708 

I>'araboeufs  dorsal  incision,  etc.,  202 

Farrlngton,  Sir  W.  H.,  Bart.,  M.  D..  199 

Fat,  Indifferent  dyes  as  stains  for,  892 

Febrile  albuminuria.  93S 

Fenger.    Dr.   Christian,    honored,  997 

Feces,  crystals  In  the.  157 

Fermentation  of  the  feces.  292 

Fetal  head  In  Walclier's  position,  469 

Fetuses  dead,  remaining  In  the  uterus  for 

considerable  time.  641 
Fever,  black  water,  630,  716 

hysteric.  156 

intermittent  biliary,  881 

metabolic.  15 

West  African,  330 


1  evers,  intermittent  and  black  water,  876 
I-  Ibromata,  multiple  of  the  nerves,  107 
!•  ibromyoma  and  pregnancy,  1004 
Filarla  found  in  Sierra  Leone.  331 

noctuma,    development    of,    1177 
Filarlasls,  its  consequence  In  Fiji,  149 
Fllatow's  spots  in  morbilli.  377 
Finger,  avulsicn  of  the,  466 

first  phalanx  of  little,  etc.,  202 
pseudoarthrosis    of    the    terminal    pha- 
lanx, 828 
Fischer,  Dr.  Louis,  943 
Fisher,  Henry  M..  M.  D..  Partial  traumati'- 

paralysis  of  the  trifacial  nerve.  194 
Fissure,  inflected,  mesial  relations.  59 
Fiechslg's  opium-bromide  cure,  211 
Flesh  foods,  etc.,  317 

Florida  peninsula,  winter  health  resort,  204 
Files  and  the  science  of  scavenging,  1083 
Floersbeim,  Samuel.  M.  D..  Suprarenal  cap- 
sule and  organic  heart  disease,  137 
Fly,  a  useful,  1078 

common,  a  factor  in  germ-transmission. 
49 
Fodor,  Professor  Joseph  von,  death  of,  755 
Folic  communique,  a  case  of,  841 
Foillcniitis,  acute  suppurative  of  the  scalp, 

643 
Food   consumed   and   digested  by   Harvard 
boat  crew,  1239 
prescribing,  practical.  958 
preservation,    value   of   experiments   in 
the  question  of,  1197 
Forceps,  axis  traction.  4tJ4 
Forearm,  left,  amputation,  202 
Foreign  appointments,  268,  508 
Foreign  body  In  the  abdomen,  463 
air  passages,  7,  848,  895,  1090 
nose,  279 
r«'tum,  431 
migratory,  149 
Fonnaldehyde  disinfection,  157 
Formalin  in  glycerin.  463 

poisoning.  136,  278 
Foster,  Dr.,  resigns,  53 
Fracture,  oblique,  of  tibia  and  fibala.  1236 
astritis,  suppurative,  followed  by  recov- 
er}-, 1183 
Fracturej  and  deformities,  treatment,  380 
complicated,    diagnosis    and    treatment, 

874,  884.  1057 
ciimpouud,  13.  919 
new  methods  of  treating,  648 
niin-coustrlctlve.    dressings   for,    12iJ0 
of  femur.  149.  961 
resulting  fmni  force,  form  of,  19 
simple,  276 
France,  a  French  philanthropist.  1037 

the  decline  In  population,  789 
Franklin,  Dr.  Benjamin.  319 
Eraser,  Dr.  Edward  Clarence,  death  of.  3!<.'t 
I'rear,  E.  D..  M.  D..  another  factor  in  the 

transmission  of  disease  germs,  137 
Freckles,  treatment,  29ij 
Frontal  autoplast.v.  295 

gyrus,  atrophy  of  right  second,  202 
sinus  growth.  '207 
Funnel  breast.  891 

Furuuculosis  of  the  external  lauditory  ca- 
nal simulating  mastoid  periostitis. 
1149 

/^alllpolls,   the  trouble  at.  1025 

Gallowav,  D.  H..  M.  D.,  Death  from  anes- 
thetic.  864 
Gallstones.  470.  6,59.  805 
Galveston  storm,  aspects.  273 
(ianglia.  nltra-tendinous.  2S2 
Ganglions,    the   occurrence   of.    in   the   tri- 
ceps tendon  resection  of  the  super- 
ior   cervical    sympathetic    for    glau- 
coma and  its  results.  716 
Gangrene,    fulminating.      pathology      and 
etiology  of.  210 
of  lower  extremities.  68 
puerperal,  of  the  lower  extremities.  SS7 
spontaneous  In  younger  Individuals.  ss'> 
Gas-polsonlng.  llU-mlnating.  318 
Gaston.  Dr.  John  M..  OS 
Gastric    analvsls.     a    critique    of    certain 
methods  of.    8.">4 
carcinoma,  pathology.  2^ 
crises  and   syringomyelia.   212 
diseases,   291 

chronic,    relief.   S7o 
fermentation.    296 
fistula.    715 
hemorrhage.  416 
juice.    2SS.    290 
mucous   membrane.    159 
tetany.   970 

ulcer.  375.  40S.  51S.  601.  S9l,   1154 
(Gastroenteric  snrgerv.  two  technical  proi>o- 

sltlons,   SSS 
Gaptro-entero-anastomosis,    mechanical   ap- 
pliances.   884 
liastroenterostomy,  67,  203 


INDEX 


1261 


Gastro-intestinal  autointoxication.   1.   132 
fermentation    and    its    relation    to    indi- 

eanuria,  718 
hemorrhage,    334 
Gastrojejunostomy  in  gastrectosis,  762 
Gastroptosis,  854.   1112 
Gaylord's  paper.  Dr.,  on  cancer,  SOS 
Gelatine     injections,     subcutaneous,    renal 

pelvic   hemorrhage.  4U9 
Gemella.  L.  J.  y.,  M.  1>.,  B.  L.,  a  needle  for 

silver  wire,  1205 
Gemmali,  Dr.   S.,  14H 
Genitalia,  female,  423 

malignant  diseases  of,  269 
Genito  urinary  surgery,  602,  604 
Genu  valgum,  apparatus  used  for,  849 
German  clinics  of  to-day,  862 

hospital  election,  104 
Germantown  hospital,  96 
Germs,  transmission  of  disease  germs.  137 
Gersuny's  method  of  paraffine  injections  in 

incontiLence  ol  urine.  886 
Gestation,  ectopic,  full  term,  65 
Gibbons,    Uichard    N.,    M.    D.,    A    cure    of 

urethrarectal  fistula,  138 
Gibbs,  Edward  N.,  Memorial  prize  fund,  945 
GirdanskT,  M.,  M.  D.,  About  the  red  blood 

cells,  194 
Glanders,  subacute,  463 
Glaucoma,  acute,  developing  In  cataracteous 

eye,  1200 
Glioma  of  the  optic  nerve,  105 
Globe,  removal  of  piece  of  steel.  107 
Glottis  and  esophagus,  spasm  of.   in  adult 

life.   1241 
Glycogen  after  jse  of  levulose,  290 
Glycolysis  in  diabetes  and  functional  neu- 
roses, 289 
Gl.vcosolvol.  on.  896 

Glycosuria    and    diabetes    mellitus    treated 
with  sodium  salicylate.  756 
dyspeptic  and  diabetic,  660 
practical    modification    of    the    phenyl- 

hydrazin  test  for,  624 
tobacco  as  a  factor,  851 
Goelet,    Angustin    H.,    M.    D.,    N'on-surgical 
treatment    of  fibroid   tumors  of   the 
uterus.  769 
Goiter,   exophthalmic,   of  syphilitic  origin, 
302 
on  operating,  16,  998 
Gold  preparations,  permanent,  1241 
GoDococcus  and  its  toxins.  132 
bacteriological  diagnosis,  336 
elimination  of.  182 
Gonorrhea,  chronic.  .337,  603.  1000 
and  marriage.  603 
diagnosis  and  prognosis.  655 
in   women.  336 
pressure  irrigations.  284 
prophyl.ixis  and  abortive  trcalment.  280 
rectal,  517 
seminal  vesicles,  337 
treatment.  .336 

with  protargol,  1044 
when  cured,  337 
Gonorrheal  conjunctivitis,  337,  1001 
endocarditis,  284 

followed  liv  sexual  Impotence,  955 
Infection,  ?,?.n 
myelitis.  341 
prostatitis.  3S7 
stricture  of  the  nrethra,  1001 
Gordon.  Alfred.  M.  D..  the  role  of  infection 
and  Intoxications  In  diseases  of  the 
spinal   cord,   1252 
Gould's  retirement.  Dr..   89 
Gout,  causation,  prevention  and  cure.  204 

China  acid,  a   new  remedy,  6.56 
Grace  liospital.   459 
Graefe  and   Schwelger,  unveiling  of  Inists. 

54 
Grafting,  ovarian.  150 

Grafting   of   rib    cartilage   into   the   larvnx 
and  healing  of  saddle  nose  by  carti- 
laginous transplantation.  20 
Granulations,    basonhlle,    of   the   red    blood 

corpuscles.   517 
Grave  robbing  case.  1030 
Grip.    In    Chicago.    98 
New   York,   100 
Princeton.  96 
seven  thousand  cases,  99 
Gross    prize.   265 
Grove.  Dr.  J.  H..  Death  of.  708 
Gulteras.    Ramon.    M.    D..    Operative  treat- 
ment for  prostatic  hypertrophy.  779 
Gunshot  wounds.  430.  872.  913.  11.56 
Gynecological  massage.  887 

surgery  among  insane.  505 
Gyneocology  and   obstetrics,   scientific  pro 
gress   of  the   year.    1240 
opotherapy.  1084 
resource  of  modern  minor.  32 
surgical.   110 
Gyromele,  the,  in  the  diagnosis  of  stomach 
and  Intestinal  diseases,  917 


Maden,  Dr.  Henry  C.    li;26 

Haden,    Dr.    John    B.,    412 
Haegler,    Dr.    Kane,   32'; 
Haggard,    Dr.    William    D.,  Jr.,   267 
Hahn,  Dr.  Martin,  326 
Hands,  disinfection  of.  277,  280,  472 
Hancock,  Dr.  T.  H.,  1228 
Harlan.    George  <'.,   M.   D..   Abscess  of  the 
orbit  from   disease  of  the  ethmoid, 
932 
Harris.   Dr.,   death  of.  99 
Hartwig,    Dr.   M..  52 
Harvard    rniversit.v,    14.3,    144 
Hatfield  prize.   Nathan  Lewis,  986 
Havana   improving.    842 
Hay  fever,   610 
Hayes,    Dr.   Melville  D..  265 
Head,   injuries  to.   151,  270,  959 
Headache   treated    by   acetate   of   ammon- 
ium. 295 
nodding  associated  with  spasmodic  tor- 
ticollis.  877 
Healer,  a,  in  the  meshes  of  the  law,  1029 
Health   and   housing,    lectures   and   public, 
710 
department  .system  and  its  chances  for 

a  medical  graduate,  852 
of   the   army,   538 
olflcers'  association,  596 
Hearing,    functional   test  of,   972 

impaired  and  word  deafness,  1156 
Heart,    abnormal,    sounds,   429 
abnormality,    congenital,    652 
atheroma  of  the  valves,  427 
diseases.   6,   106    273.  oiS 
Lettsomanian  lectures  on,  600,  715 
Canadian  hemp   in.  642 
fattv  change  of.  in  mankind,  7S4 
degeneration  of  the.  273,  2S3,  856 
idiopathic    enlargement,    156 
in  infectious  diseases.  341 
index   interval.    461 

percussion  of  the,  I'otoin's  method,  £57 
re-education   of    movements   of    the,    by 

exercises.    725 
reflex,    clinical    value.   61 
suprarenal  capsule  in,  137,  916,  1001 
sutures  in  the,  763 
tonics,    606 

with  a  bullet  in  the,  and  living,   797 
Heat,   instantaneous   dry,   for  external  ap- 
plication, 1070 
regulator,  automatic,  for  baths,  182 
Hedonal,   clinical  experiments,   162 
Heel,  fractures  of  the,  SSo 
Heidelberg.    414 
Hematemesis.  use  of  the  stomach  tube  in, 

919 
Hematobia.    423 
Hematuria,  cure.  157 
Hemiplegia,  congenital,  cerebral.  895 
sensation  in  trophic  disorders,  114 
Hemmeter,   John   C,  Phil.    D.,   M.   D.,   The 

German  clinics  of  to-day,  862 
Hemoglobin,  crystallization  of,  426 
Hemoglobinuria,   150,  424 
in  typhoid  fever,  119 
Hemoglobinurie  fever,  330 
Hemolymph  glands,  the  importance  of  the, 

1221 
Hemoptysis  in  tuberculosis,  24.  296 
parasitic  in  the  United  States,  45 
Hemorrhage,    spontaneous    from    iris    and 

ciliary  body,  448 
Hemorrhagica  purpura,  156 
Hemorrhoidal  clamp,  a  new,  1204 
Hemorrhoids,   external,  4.32 
Hemothorax.   1160 

Henry,    Frederic   P.,   M.    D.,    further   notes 
of  a   case   of  pernicious   anemia    re- 
ported in  1900.  with  remarks  on  the 
diagnosis  of  the  disease,  1206 
Hepatic  cirriiosis.  experimental.  704 

colic,  medical  treatmcut,  212 
Hepatopex.v,  23 

Heredity  as  a  factor  In  mental  deficiency, 
1107 
Innuence.  316,  408 
Hernia,  autoreiinction  of,  cause  of  abdomi- 
nal obstruction,  714 
appendix  verlformis,  807 
diaphragmatic,    1240 
femoral.    375 
gangrenous.   723 

inguinal.  88,  102.  272.  293,  312,  889.  914. 
918 
and    femoral,    mechanical    treatment, 

889 
complete,  extraperitoneal,  of  the  blad- 
der,  1003 
Infantile,    .379 
obturated.  429 

of  the  anterior  vaginal  wall.  113 
postoperative.  .305 
radical  cure.  375 

operation,  for.   In  children,  723 
retroperitoneal,    287 


strangulated,  518,  S04,  869 
postoperative,      prevention     and      cure, 

1241 
umbilical,  congenital,  393 
operations  for,  658,  1040 
spontaneous  rupture,  763 
and  ventral,  68 
ventral.  303 
following  abdominal  section,  422 
radical  cure.  889 
Heroin  and  aspirin,  1045 
Herpes  frontal,  999 

zoster,  24 
Hcrrick,  Dr.  Henry  J.,  197 
Highet,    H.    Campbell,    Otomycosis   In    the 

tropics.  55 
Hill,  Dr.  E.  G.,  324 
Iliugston.  Sir  William,  946,  1117 
Hip,  chronic  dislocation  of  the,  1045 
congenital  dislocation  of  the.  1064 
disease,  hysteric,  a  sign  of,  917 
Hip-joint  disease,  409 
Histology,  1160 

Historical  club  of  the  department  of  medi- 
cine of  the  University  of  Pennsylva- 
nia, 840 
Holstein,  Mrs.  Anna  Morris,  50 
Holt,  Dr.  Emmet,  appointment,  945 
Holzknecht,   Dr.  G..  369 
Home  for  friendless  women,  267 
Horwltz,    Orville,    B.    S.,    M.    D.,    What    I 
have  learned  from  161  operations  for 
the    relief    of  senile   hypertrophy   of 
the"  prostate  gland,  1091,  1169 
Hospital,  Anna  Jaques,  504 
Association  Jewish,  1027 
Baker  City,  Ore.,  324 
California  Eye  and  Ear,  1029 
Cambridge,  144 
cars  for  railway  service,  1115 
Chicago,  197 

Contagion  in  typhoid  fever,  1026 
Corps,  more  men  needed  in  Norfolk,  144 
for  army  nurses,  197 
insane,   report,   143 
tuberculosis,  197,  364 
women  in  West  Philadelphia,  592 
Kensington,  for  women,  1115 
new,  53 

in  Shelton,  Ccnn..  1029 
ship  for  the  Philippines.  101 
Maine  reaches  England,  93 
site  proposed,  504 

causes  protest,  1027 
staff   additions,    194 
to  te  independent,  98 
work  in  Labrador,  752 
Hospitals,  history  of,  599 
Hot-air  treatment  of  otitis  media,  1085 
ulcers,  340 
apparatus  for,  Tallcrman's,  963 
Hot  springs,  indigent  visitors  at,  534 
Hour-glass  stomach,  956 
Howard.  D.  C.  M.  D.,  Capt.  Med.  Depart- 
nvnt  U.  S.  A.,  Spontaneous  (?)  rup- 
ture of  the  spleen.  934 
Hughes,  Wm.  E.,  M.  D..  and  Wm.  G.  Spll- 
ler.  M.  D.,  a  case  of  severe  anemia, 
with  changes  in  the  spinal  cord.  1207 
Huddleston.  M.  D.,  J.  H.,  the  freezing  point 
of  urine;  its  determination,  and  the 
inferences  which  mav  be  drawn  from 
it,   1246 
Human  blood,  detection  of,   1187 
Humerus,  fracture  of,  159,  886 
Humphreys,  Dr.  W.  J.,  99 
Hunterian  oration.  4ti2 
Huxlev,  Professor,  6-;i,  842,  1037 

and  Leidv.  238 
Hydatid,  cysts.  1160 

primarily  affecting  the  lung.  103 
Hydrocephalus.  424 
Hydrochloric  acid  Indigestion,  132,  491,  591 

therapy,  807,  8.53^ 
Hydrocvanic  acid  as  a  disinfectant.  962 
Hydrophobia,  133   158,  900 
Hygiene  and  sanitary  science,  1067 

Imperial  Council'  of,  508 
Hygroma,   purulent.  428 
Hyperacidity,  dietetic.  2,'!3 

skin  disease  causing.  648 
Hypcrchlorh.vdrla  in  Infants.  286 
Hyperemia  of  the  conjunctiva  palpebralls, 

279 
Hyperkeratosis  dlfluse   congenital.    896 
Hyperphoria,    151 

TTvpertrophy   idiopathic  cardiac,   157 
HvpeiT>vrexia  unusual,   12 
Hypospadias    balaultlc.    1003 
Hypophysis  cerebri.  3;^ 
Hvpospasla.   .^50 

Hvstercctomv.   110.  148.  20.3.   1044 
Hysteria,  In  children.  191.  1203 

obscure  case,  with  complications,  162 
prognosis.   61 
traumatic,   661 
Hysterical   diseases.   313 
cblupagus,  n  case  of,  654 


1262 


INDEX 


Icbtbyol  treatmout,  iuflamniutiuus,  513 

Icteric  oliild,  the   swiue    erysipelas  bacillus 

discovered  in  tlr>  stools  of  an,  722 
Ileus,   treatnieiii    wuU   alroiriu,    280,    1U44 
Illegal  practitioners,  crusade  against,   2tiy 
Illness  in  rarefied  air,  287 
Iniini.:;rants.  medical  certificates  for,  325 
luiniigratiou,  U.  S.  commissioners  of,  145 
luiujuuity  acquired,  *JU8 
Imuuization,   natural,   of   tuberculous   fam- 
ilies, llXli) 

existing  after  enteric  fever,  8U2 
Impotence,  sexual  tolluwiiig  gouorriiea,  955 

utility    of    Joliimbin    in    the    treatment 
ot,   1004 
Index  finger,  replaced  by  the  second  toe,  20 
India,  the  census  of,  74G 
Indic-an  iu  the  urine,  341 
Induration,      i>lastic,      of      the      ca\ernous 

bodies,  471 
Infancy  and  childhood,  physiology  and  hy- 
giene,  5 
Infant   dispensaries,    1220 
Infanlile  colic,  242 

scurvy,    189 
Infants   etiology    of   large,    807 

examination  of.  Hi) 

feeding   of.    35,    104,    203,    223,   281,    286, 
419,  910 

premature,   856 
Infectious  diseases,  335 

natural  immunity,  340 
Inflammation   disease,    especially   pancreas, 
the  value  of  the  glutoid  capsules  for 
diagnosLs.    1158 

fixed  cells.  111 
Influenza,    89,   93,    100,    140,    642 

and   the  nervous  system,  200 
hay   fever,    46 

bacillus,  208 

cause    of    appendicitis,    405 

diagnosis  of,  1085 

epidemic,   12 

in  a   child   of  ^V^   years,    805 

in  St.   retersburg,  54 
Sweden.  507 

pneumonic   attacks,    274 

rate  of  death,  899 

spreading  among  horses,  1227 

treatment,  203 
Inguinal    glands,    the    enlargement    of   the, 
in  connection  with  diagnosis  of  prim- 
ary syphilis.  849 
Inheritance,    theory    of.    1105 
Injuries,  healltig  of.  132 

Injury,  effects  of.  to  ijeripheral  nerves,  718 
Innominate  artery,    ligature  of,   171 
Inoculation   and    serum,    511 

antityphoid,  416 

compulsory,    411 
insane,    gynecologic,    treatment   of,   111 

or  criminal,  517 

useful    anuiseuient   for   the,    1082 

under  Slate  care,  418 
Insanity   early   diagnosis  of,    722 

ephemeral,  935 

heredity,  961 

importance   of   teaching   of,    1039 

periodical.   347 
Inspection   of   inslltutlons.    11S4 
Instruction  and  hygiene.  894 
Intemperance    and    its    Inllm-uce    upon    the 

death  rate,  (Ki2 
Interference  of  sensations.   2.SS 
Intermittent    ami    hlackwatcr    fever.    S7R 

biliary   fever.  .'^Sl 

fever    and     symptoms     of     mediastinal 
tumors,  656 

disturbances   of    speech,    1256 
Internal   medicine.   Berlin.  326 

secretions,      physiology      H^id      chenils- 
Iry.  900 
Internatlontil    clinics,   40S 
Intestinal    antiseptics,    the   value   of,    with 
simple    aseptic    pads    In    obstetrical 
practice,  8.53 

catarrh  of,    in   infants.   St 

disease,    symptoms   of,   8 

hemorrhage.    110 

Indigestion.    CO 

llp<ima.  210 

loops,    displacement.   67 

obstruction.  19.  22,  60,  67,  208,  291,  334, 
715 

rupture,  20 

tract,   protective  Influence.   291 
Intestine,   rupture  of  the  small,   1038 

stenosis   of   Ihc   small.    715 

surgery  of  the  large.  847 
Tntestlnes  and    serous   membranes.    426 

holder   of    the.    422 

nuivements  of  the,  380 


Intracranial  hemorrhage,  226,  263 
Intubation    followed   bv   injuries,   884 

in    iirivate,    200,    278 

prolonged,   919 
Intussusception,  caused  by  cyst,  21 

diagnosis,    714 
Invagination,   Intestinal.   294,   1004 
Iodide  of  jiotash,  on  the  decomposition   in 

the  digestive  tract.  890 
lodiplne.   means  of  diagnosis.  .516 

motor  power  of  the  stomach,  289 
loilofiirm  poisoning,  206 

substitute.    284 
lodopliilia.    1200 

Ionization    in   its   physiological   and   patho- 
logical   duration.    045 
Ireland,    Dr.    David    Caldwell,    99 
Iron    therapy,    experimental    contributions, 
209 

I  ackson,    Edward,    il,    D.,    cataract    ex- 
»*  traction,  928 

Jacksonlan  epilepsy,  considerations  on  the 

tiTatment  of,  by  operation,  1213 
Jacobi's  address.    Dr.,   l.':7 
James,   Dr.   Bushrod  W.,   96 
Jaundice,     chronic,     associated     with    gas- 
troptosis.    607 
in  typhoid  fever,  200 
obstructive,    762 
Jaw,  fractures  of  the,  283 
lower,    dislocation.    11.58 
upper,  fracture  of.  116') 
large  odontopathie  cysts  of  the,  1226 
Jeft'erson    Medical    College,    707,    003.    042 

1076 
Jencke.  Dr.  Paul,  267 

Jenkins.    Norburne   B.,    M.    D..   anisometro- 
pia, 978 
Jenner  Institute,  374 
Jentzer,  Dr.  A.,  147 

Jewitt,  Charles  S.,  notes  on  leukemia,  816 
Johimbin,    the   physiological   action   of,   on 

the  animal  organism.  1004 
Johns  Hopkins  Hospital.  459 
Johnston.   Dr.  Ralph  Krskine,  a  martvr  to 

science,  749 
Joint  affections,  diagnosis.   511 
bodies,   a   study  of.   .S.S3 
rheumatic   and'   allied   diseases,    465 
sprains  of  the,   10,S(i 
surgery    of,    110 
tUblTi-uIcisis.     761 

Jones,    Arch.    D.,    M.    D.,    angina    ludovlcl, 
264 
Dr.  W.  A..  367 

Jopson.  John  J..   M.   D.,  anthrax  In  Phila- 
delphia. 1070 

Jugular  vein  ligation  in  thrombosis  of  the 
lateral   sinus,    763 

l^alser,    assault   on    the,    407 

Kiefe,    Dr.    D.    K.,    a    final   wi>rd   on    saline 
Infusion    In    i)n>'umonia,    1183 
Infusion   of  salt  solution  In   pneumoui.i 
treatment,   592 
Keen,   W.   W.,  XI.  D.,  364 

subscription  for  monument  to  Professor 

Oilier,  1226 
two  successful  cases  of  secondary  suture 

of  nerves,   1046 
Intracranial    hemorrhage    lo    the    new- 
born,  263 
presentation  of  Dr.    K.'s  portrait,  707 
Kelly,   Dr.  Aloysius  O.  J..  986 
Keloid,    pathology    of.    7(2 

trauiuatlc.  of  the  median  nerve,  422 
Kelsey,   Charles  B.,  M.   D..  an  exceedingly 

rare  case  of  Imperforate  anus.  060 
Kenned.v,    Uobert.    restoration  of  hiwer  lip 

after  excision  for  epilhelioma,  55 
Kensington  Hospital   for  AVomcn,  708,   986 
Keys,  Henry  Sheridan.   M.  D.,  1029 
Kidneys,    anatomical    .issoclations    of.    12.'t'» 

succussion  of  the,  424 
Kidney,  amyloid  degeneration  of,  11.5,  284 
cystic  degeneration  of.  873 
enucleation    of   the,    17 
movable.    148.    339.    410,    1086 

in    children.    850 
operation    of    the.    Importance    of    the 
freezing  point   of   urine   and   blood, 
20s 
primarilv  Infected,   etiology,   468 
prolapse  of  the,   10S4 
rupture   of   the,   058 
Kindred,   the  case  of  Dr.,  11 
Klrchhoff,    Dr.    Theodore.    147 
Kirk,  Thomas  A.,  prolapse  of  rectum,  suc- 
cessfully treated,  55 
Klrmlsslon,   I)r.,  1082 


Klelnes  Journal   of   Hygiene,   268 
Knapp'g  Dr.,   gift,  52 
Knee  jerk  after  cerebral  Injury,  516 
iu   chorea,   757,    1106 
joint,   bloody  ettugloua  Into  the,   treat- 
ment, 889 
quiet  efluslons  into  the.  In  women  and 
young  girls,   510 
Knee  joints,    treatment   of   contraction   of 
the,  889 
suppuration  of  the,  048 
tuberculosis  of   the,   107 
linees.  hemarthrosis  of  the,  149 
Knopf,  Dr.  S.  A.,  IJeeeives  firsl  prize,  594 
Kolpeurysis  and  metreurysis,  4i2 
Kost,  Dr.  John,  14a 
Kress,  P.  J.,  A  hat  pin  in  the  male  urethra, 

03 
Kuust,  Dr.   A.,  1116 

I   abia  minora  adherent,  001 

Laboratories,  new,   in  University  of  Penn- 
sylvania, 1024 
psycho-physical,  S82,  988 

Laboratory  feeding,  percentage  and,  526 
new,  90 

Lachrymal  disease,  105 

Lakewood  as  a  winter  resort.  204 

Lance,  the,  as  implement  of  war,  883 

Laparotomy  of  peritoueuui,  377 

Larrabee,    J.    D.,    M.    D.,    Case    of    aortic 
aneurysm,  203 

Laryngeal  tuberculosis,  treatment,  115 
whistling,   voliiuiary,   8U5 

Laryngectomy    under     eucaine   anesthesia, 
422 

Laryngologist,    limitations   of    the.    In    the 
general  treatment  of  nose  and  tbroac 
diseases,  017 
Larynx.  Intubation  of,  805 
malignant  disease  of,  513 
neuralgia,    278 

total  extirpation,  pseudo  voice,  67 
Lathrop.   Walter,  M.  D.,   Strangulated  her- 
nia, 800 
Le  Conte,  Uobert  G.,   M.   D.,  The  value  of 
combiueU  medical  and  surgical  clin- 
ics to  the  student,  1172 
Lee,  Dr.  Lucius  J.  \\".,  52 
Leffmann,   Henry,    M.   D.,   The  medical   re- 
lations   of    the    prevailing    forms   of 
food  adulterations,  734 
Legg,  Mr.  T.  P..  300 
Legs,  same  length,  why?  403 
support  of,  00 

treatment    of    the    shortening    In    frac- 
tures, 887.  886 
Leldy,    Jos..    The    common    fly.    factor    In 

transmission  of  disease  germs,  49 
Loland,  Dr.  Thomas  B.  \V..  143 
Lemalne,    James.    The    first    to    recognize 

wound  Infectious,  805 
Leontlasis  os.sea.  148 

with  generalized  fibroma  molluscnm,  866 
Leper  coUany.  197 
Lepers,  no  passports  to.  10S2 
Lepra  bacillus,  marble  bust  for  the  discov- 
erer of  the.  509 
Leprosy,  mixed  variety,  1^39 
in  Canada.  412 
in  the  Canarv  Islands.  99S 
in  the  United  States.  li17S 
nerve,  the  treatment  of.  OOS 
rattlesxiake  venom,  cui-e,  517 
Leukemia,  acute.  (WO 

and   splenic   pseudo-leukemia,   75 
diagnosis,  blood  changes.  275 
lymphatic.  2S9 
notes  on,  816 
spleno-medullary.  33:! 
Leukocytes,  in  cases  of  cancer.  430 
marrow  of  bone.  212 
the  role  of,  in  absorption  of  certain  med- 
icines.   Introduced    under   the    skin, 
1220 
I.eukocythemla.  clinical  lecture  on.  147 
Leukoc.vtosis  and  typholdal  perforation.  805 

pneumonia  aiul  diphtheria.  430 
Lewltt.    Dr..    takes    his    seat    on    Health 

Board.    143 
Library,    the.    of    the   Medical    Society   of 

Kings  County.  1028 
Licenses   refused,    797 

Life   assurance,    the    after    history    of   re- 
jected applicants,   14 
Insurance,   medical   aspect   of,   60S 

medical  directors,   Nat.   Assoc.   H''29 
saving   service,   the   founder  of   in   the 
United  States.  707 
Light  and  seating  In  school,  152 
Linderiuan,  Dr.  Richard,  50 


Lintbicum,  G.  Milton.  A.  B..  M.  D.,  a  new 

liemorrh.iidal    clamp.    1201 
Lip.   lower,  restoration  of,  55 

upper,  carbnnolps  and  furnneles  of,  303 
Lipoilirome  <>(  the  ganglion  cells,  81)2 

nerve  cells.   427 
Lipoma,    retroperitoneal,    113 

arbnresoens.  Sltii 
Literarv  piracv,  400 
Lithemia    in    children.    430.    612 
Litholapaxy  in  a  child  four  years  old,  962 
Liver,   abscess  of  the.   961 

acute  yellow  atrophy  of  the,  609 

apoplexy   to   cirrliosis  of  the,   163 

calcareous  infiltration  of  the,  199 

cirrhosis,  593.   1000 

cirrhosis,    atrophic.    69 

echinococcus  of  the.   11.".  610 

gas   formation   in   the,  881 

regeneration.    661 
Liverpool  tropical  school  on  yellow  fever. 

495 
Lloyd.    .Tames    Hendrie.    Bells   palsy,    asso- 
ciated  with   complete   anesthesia   in 
the  territory  of  the  fifth  nerve,  628 
Locomotor  Ataxia,  throat  paralysis  in.  1240 
Lodge  practice  in  British  Columbia,  506 
Loeb,   defense  of   Dr.,   596 
Lonir   Island    College   Hospital.    1227 

Hospital,  411 

the  climate  of.  1085 
Loomis  Sanitarium.  New  York,  638 
Los  Angeles  Board  of  Health.   197 
Lumbar,   lower,   and  first  sacral   roots,   iso- 
lated disease  of.   I2i13 
Lunacy  and  its  treatment  in  1800.  102 

commission.    11,    982 

laws,    10 
Lung  apices,  vulnerabilit.v  of.  1237 

Carcinom-itrus  lymphangitis  of  the.  1160 

cavities,  external  drainage.  63 

circulation,    disturbance   of,    740 

decortication    of    the,    for    chronic    em- 
pyema.   1199 

disease    of,     with    pseudo-tnberculosis, 
1196 

unilateral   atrophy  of  the,   288 

Lupus.    379.    1042 

and    rodent   ulcer.    Finsen's  light  treat- 
ment. 415 

Lvmphangitis  of  the  long,   carclnomatons, 
1160 

Lyon,  Dr.  Samuel  K..  death  of,  945 

Makuen.    G.    Hudson,    to    prevent    stam- 
mering and  general  paralysis.  295 

Malaria,    295 

and  mosquitos,   17.   160,  204,  330 

and    sanitation.    1108 

diagnosis  of,  586 

etiologv.  etc.,  876 

expedition.    161.    208 

in    British   Central  Africa.   330 

In  Buffalo?,  why  is  there  no,  260 

investigation.    844 

legislation   for   prevention   of,   599 

presenting    symptoms    of    disseminated 
sclerosis.   17 
Malarial  mosquito  In  Italy,  protection  from, 

984 
Malignant  disease.  1083 
Malp'ractiee.   a   suit  for.   1030.   1031 
Mammary   glands,   hypertrophy  of,   658 

tumors,    diagnosis.   204 
Manasein.  Professor  W.  A..  Death  of.  642 
Mania   with  depression.   470 
Maniaco-melancholv  insanity  of  Kraepelin. 

940 
Manila  hospital  corps.   197 
Manley.  Thomas  H..   Ph.  D..  M.   D.,  Com- 
plicated  fractures,    their     diagnosis 
and  treatment.  1057 
Marine  hospital  inquiry.  460 
Marion  Sims  college,  144 
Marriage  laws,   266.  639 

the  control  of.  bv  the  State,  634 
Martin.   Dr.    Z.   T,.   504 
Martyr  to  duty.  a.  742 
Marx.  S..  M.  D..  Oxrtonic  action  of  spinal 

anesthesia.  706 
Maryland  State  Board  of  Health.  99 
Massage,   brush.   380 
Mastin.    William    M.,    Infantile    scorbutus. 

776 
Mastitis,   adolescentium.  517 

suppurative.  In  the  newborn.  786 
Mastoid  disease  and  complications,  235 

operations.    421 

process,    inflammation   of   the.    400 
Mastoiditis.  207.  421 

suppurative.  961 
Materia  n.edica,  the  proposed  national  bu- 
reau   of.    SCO.    981 
Maternal  impressions  in  lower  life.  463 
Mayer,    Emil,    M.    D.,    clinical    experience 


INDEX 


with  adrenalin,  SIS 
McCarthy,   Dr.   Brendan.  414 
McClelland,   Dr.   Wm.   F..   death   of,  751 
McDonald.  Arthur,  susciptibility  of  disease 
and  physical  dovi-iopment  of  college 
women,  778 
McFarland,  Joseph,  M.  D..  volvnlos  and  In- 
tussusception  of    Mrckels   diverticu- 
lum, 863 
McGee,  Dr.,  resignation  of.  12 
McGehee.  Dr.   W.  H..  1077 
McGill  University,  596.  752,  1117 

."Oldiers.  842 
ifcGrath.  Dr.  John  J.,  n20 
McKellops.  Dr.  Henry  P.ryon,  841 
McXlcholl.  T.  Alexander.  Si.  D..  heredit.v  as 

a  factor  in  mental  deflcieney,  1107 
Measles  among  Kskimos  in  Buffalo',  1184 
diagnosis.  431 

royal  personages  contract.  268 
with  reference  to  K<<plik*s.  etc.,   110 
Meat  inspection,     pathological     conditions 
found  in,  648 
rations  in  the  tropics.  605 
Meatus,  external,  bony  defects,  467 
Meckel's  diverticulum,   anatomy  and  surg- 
er.v  of.  714 
case   of   strangulation.    1149 
gangrenous  inflammation,  104 
Mecray.   Dr.   Paul  M.,  410 
Median  nerve,  laxation  of.  294 
Medical  alliance  of  America.   505 
and  botanical  notes.  656 
appointment   to  the   King   of   England, 

507 
book,  the  oldest  printed.  1111 
colleges  and  professional  standards.  1200 
congress  in  Cuba.  100 
corps,  examination.  534 
council   for  the  dominion.   597 
editors.    American,    meeting.    945 
examination  of  school  children,  350,  358 

before  marriage.  36 
inspectors,  appointed  by  Louisiana.  905 
journal,   a   new.    49 

laboratories  of  the  rniversity  of  Penn- 
sylvania. 1024 
laws.  new.  in  Kansas.  11 
legislation.,  rrospective,  97.  495 

uniform.  948 
library.  New  Jersey,  503 
man  in  the  Xavv  and  the  Marine  Hos- 
pital. 852 
men  want  laws.  99 

sketches  of.  854 
notes  from  the  imperial  yeomanry  hos- 
pital in  Pretoria.  912 
organization.  Western.  143 
practice.  633 

In  New  South  Wales.  599 
profession   and  its  relation   to  the  pub- 
lic. 967.  1001 
In  America.  .'i06 
in  Germany.  268 

of  California   and  the  plague.  1179 
registration  board.  367 
relations,  the.  of  the  prevailing  forms  of 

food  adulteration.  7.34 
research.  Institute  for.  1076 
schools,    instruction  on  modification   of 

milk  In.  225 
view  of  the  Chinese  Boxers.  788 
witnesses,  404 
worthies,   three,  745 
Medicine,    colonial,   268 
in  1800,   102 
manual  of.  407 
mllitarv.    in   ISOO.    102 
natural  method  of  teaching  the  subject 

of.  1200 
practice   of.   bill.   196 
study  of.  1113 
Medico   Chirurgical    Co'lege.    96.   1031 
legal  notes.  6.54 

point,  an  intercstlne.  S41 
relations  of  the  Roenf.ren  ray,  1 
Meeting,  a  noteworthy.  SOS 
Melllnger.    Dr.    Henry    S..    319 
Membranes,    serous    studios.    1156 
Memphis    Medical    .■Society.    ."iS 
Mendota    Insane  Asylum.    411 
Meniere's    disease.    1002 
Meningeal  hemorrlige,  88 
Meningitis,  basic.  463 
spinal.  6.53.  877 
treated  by  lumbar  ptincture,   l>04 

the  baotei-lolog  r  of.   ll'.'S  

the  etiology  o'  cerebro  spinal,  llii 
pseudo,  7 
Menopause  fallacies.  72 
Menorrhalsia    of    pelvic    origin.    .t39 
Menstruation,      disturbances    of.      carbonic 
acid,  gas  applied  locally  for.  1220 
pseudo.  7 
the  first,  in  young  American  girls,  loss 
Mental  and  nervous  diseases.  380 

developmeut,  etiology  of  arrested.  924 


I  26  J 


disease,  judgment  of  persons,  suffering 
from.  610 

dcflclenc.v,   heredit.v  as  a  factor,   1107   ' 

fatigue   in    school    children.    IC.'iO 
Menthol  inhalations  in  inflammation  of  the 

throat.   752 
Mercurial  affection  of  the  throat,  705 
Mercury,  idiosyncrasy  as  to,  207 
Mercy  Hospital.  53 
Metabolism,  in  obese  subjects.  290 

Investigations  concerning  nuclein.  878 
Metacarpal    boce.    skiagraph   of    Bennett's 

fracture  of  the.  481 
Metatarsal  fracture.  807 
Methylin  blue,  examination  of,  881 
Metric   system.  .3S0 
Metrophlebitis.   963 
Metrorrhagia.  464.  512 
Michigan.  University  of.  504 
Micro  organism  and  their  relation  to  stone 

In  calculous  pyelonephritis.  1003 
Microphthalmia,    conirenital.   663 
Microtomists"  vademecum.  5 
Midwifery  and  gynecology  in  l.SOO.  102 
Migraine,  preventative  treatii.»nt.  339 

pathology  and  treatment,  1158 

surgical  treatment.  416 
Military   step.   the.   954 
Milk,   cows  and  human.   468 

for  prescription  feeding.  225 

inspection.    319 

morpholog.v  of.  426 

rendering  cow.s'   milk  digestible,  280 

sterilization  of.   272 

thermophor.  112 
Miller.  G.  Victor,  blindness  due  to  sphenoid- 
al sinus  disease.  55 

J.  Preston.  M.  D..  membraneous  enteri- 
tis erroiieously  treated  for  phthisis, 
1104 
Mills.  Clark  K.,  M.  D.,  the  localization  of 
brain  tumors,  especially  with  refer- 
ence to  the  parietlcal  and  prefront- 
al regions.  764 
Milwaukee  Hospital  for  Insane.  459 

Medical   College.   459 
Miners'    Hospital.   413 

Mirror  writing  and  diffuse  hypertrophy,  130 
Missouri   State  Board  of  Health.  53 
Mitral,    regurgitation,    functional,    651 

stenosis,  2 
Mollietles  ossinm.  149 
Monstrosity.  712.  1116 

Monteflore  Home  for  Chronic  Invalids.  945 
Montfort.  Dr.  R.  V.  K..  10 
Montreal  Foundling  Hospital.  1116 

General  Hospital.  1116 

Civic    Hospital.    HOo 
Moore.   Dr..   reinstated.  141 
Morgan.  Wm.  Gerrv,  M.  D..  gastric  tetany, 

970 
Morphine  as  an  antidote  to  belladonna.  9o< 

campaign   against.    1229 

poisoning,  transitory  glycosuria,  290 

replaced  by  heroin.  211 

upon  metabolism,   actions   of,   474 
Arorpbinism.    unusual    case   of.    1241 
Morris   Plains  Hospital.   458 
Morrow.    Prince    A.,    the    prophylaxis    or 

venereal    diseases.    663 
Mosquitoes  and  disease.  98.  135 
campaign  against.  1229 

method  for  destroying.  132 

study  of.  by  Orleans  Parish.  La..  Med- 
ical Society.  752 
Mount  Sina'  Hospital.  141.  365.  1028 
Mountain  fever.  S06 

Mover.    Harold.    M.    D..    Dr.    JacoM's    ad- 
dress.  137 
ilnhlenberg  Hospital.   502 
Mnllins.   Dr.  Willi.im  Hoskins.  143 
Murmur  of  mitral  stenosis.  1083 

vesicular  and  its  relations.  lOOS 
Murphv.    Dr..  367 

Button,  use  of  the.  715 
Muscle  sounds,    normal.  2.SR 
Mushroom    poisonlnir.    115S 
>Iva    Professor  G..   147 
Mvasthenia  srravls.  417.  6.59.  917 
Mvers.  Dr.  Walter.  .326 
Mvkosls  fungoides.  293 
Myocarditis,  acute.  6.52 

"  clinical  study  nf.   106 
M.vocanlinm.   Induration   of  the  connective 
tissue.  17 

fattv   degeneration.   936 

diseases  of  the.  720 
Myokymia    or    persistent   muscular   qulver- 

"  Ing.    15 
Mvopathr.  primitive  progressive.  427 
Myositis,    multiple   non-suppnritlng.   292 
Myxedema  of  varied  type.  1039 

^  aphtha  (coal  tar)  poisoning.  3.33 

Napoleon    the    First,    clinical    remarks    on 

the  death  of.  1075 
Narcolepsy,  96'. 


1264 


INDEX 


Narcosis,  ethyl  chloride,  602,  719 

Narcotics   in   England,   1116 

Nasal  accessory  sinus  affection.  1002 

catarrh,  1040 

fossae,  diagnosis,  etc.,  of  foreign  bodies 
in,  91J 

intra,  lesions,  ocular  expressions  of,  1002 

mucous  membrane,  471 

polypi.  2ut 

septum,  correction  of,  using  cocain,  801 
de\iations    of,    759 
deflections  of,  516 
treatment,   59 
Nasi,   ala,   collapse  of,   758 
Nasopharyngeal  examinations,  472 
National    legislation.    4.59 

Sanitarium  Association,    Canada,   413 
Naval  surgeons,   325 
Nanheim  treatment,   the,  1238 
Neck,  congenital  absence  of  muscles  of  the 

neck,  23 
Necropsy,  202 

Needle  for  silverwire,  a,  1205 
Nefl,     Wallace,    A.    M..    M.     D.,    ruptured 
traumatic  aneurysm  of  the  femoral 
artery  due  to  gunshot  wound,  735 
Neglected  children.  452 
Nephrectomy   for  pj-elonephritis  calcnlosa, 

160 
Nephritis,    acute    interstitial   character   of 
cells  in.  650 
effects  of  methylene,  599 

gravid,  427 

in  secondary  syphilis,  158 

tuberculous,    612 
Nephroptosis,   bandages  for,  91.") 
Nephrotomy,  anatomy  of  the  renal  vessels, 

etc.,  721 
Nephrorrbapby    with    flap    fixation,    1238 
Nerve   cell   staining.   162 

degeneration.  830 

disease,  functional,  998 

grafting  one  upon  another,  884 

leprosy,  998 
Neries.  the.  of  the  capillaries.  875 

operation  for  the  median  and  ulnar,  648 
Nervous  disease,  211,  283 

excitement  treated  by  dionln,  725 

patients,   physical  labor,   963 

phenomena,  postoperative    or    artificial 
menopause,  717 

system,  central,  157 
functions,   516 
influenza,  200 
Neuralsia  of  the  larvnx,  278 

triflacial,  607 
Neurasthenia  and  melancholia  of  toxic  ori- 
gin,   957 

extent   of.    21.   205 

hematology  of.  806 

subjective  nymptoms.  278 

treatment,  206 
Neurectomy,   union  of   fractures,   369 
Neuritis,    alcoholic,    alcohol      and    arsenic 
lu,    1237 

alcoholic,  848 

and  beri-beri  in  Alabama,  17 

arsenical  peripheral.  271 

complication   of  typhoid  fever.    125 

multiple,  caused  by  trional,  S56 

peripheral,  55 

recurring  after  atrophy  of  nerves,  1001 
Neuropathology.   50.   162 
Neuroses,  so-called  traumatic,  1241 
Neurosis  of  the  stomach,  259 

value  of  measurement  of  blood  pressure 
in  the  diagnosis  of  traumatic,  659 
Neurotropism,   4 

Newborn,  treaiment  of  urgent  and  serious 
conditions,  220 

pathology  of,  761 
New  Eujriand  appointments,  266 

Baptist  Hospital.  411 
New     England    instilutions,    donations    to, 

1227 
New  Haven  Hospital,  4.59 
New  Jersey  State  Board  of  Health.  .365 
New   Orleans   Charity   Hospital.   005 

Parish  Medical  Society,  267 
Newtown   physicians.    319 
New  York.  Academy  of  Medicine.  266 

Board  of  Health  and  the  barbers.  52 

Eye  and  Ear  Infirmary,   410 

German   Hospital.    365 

Health  Commissioner,  459 

Hospital  for  the   Crippled,   903 

Lunacy  Commission,   458 

Orthopedic  Dispensary,  141,  320 

Pathological   Institute.  833 

School  of  Clinical  Medicine.  710.  795 

Skin  and  Cancer  Hospital,  411 

rniversity.    10.    503 
New  Zealand  Medical  Journal,  54 
Nitrite   treatment   in  syphilis,    16 
Nitrogen   metabolism.  210 
Norrls,    George    William.    A.    B.,    M.    D., 
parotitis     complicating     pneumonia, 
790 


Norristown    deadlock    ended.    140 
Nose,  dermoid  cyst  of.  149 

saddle,  grafting.  20 

secretion  of  water>-  fluid  from.  724 

and  throat   disease.  60.5 
Noses,  syphilitic,  suggestion  for  the  recon- 
struction of,  761 
Nott,  Dr.  Eliphalet,  141 
Nova  Scotia,  consumption  sanitarium,  505 
Nurse  obtained  a  mandamus,  502 
Nurses,    congres.^    of.    367 

decorations    conferred.    507 

graduate  at  I  hila.  Hospital,  50 

home,  503 

Victorian  order.  948 
Nursing  bottles,  468 
Nutrition  and  nutrition  albumen,  485 
Nutritive  enemata,  277 
Nystagmus,  756 

rjdkland  Medical   Colleie.  41 
'-'Obesity  transportation,   369 

treatment,    pathological,   1003 
Obituary.   12.   100.   144.    197.    597,    637,    749 
753,  798.  840,  841,  903,  944,  945,  1031, 
1034,   1117 
Objectionable  names  for  institutions,  836 
Obstetrical  amphitheater,  for  an,  903 
hemorrhage,  644 
Instruction.    66 
operations,  379 

principles   for     first      nourishment     of 
child,  278 
Obstetrics  advance  In.   during  the   last  50 
years.  850 
self  infection  In,  281 
value  of  intestinal  antiseptics,   854 
Occipital  lobe,   lesion,  270 
Ocular  muscles,  external.  516 
Oil  clysters,  assimilation  tests.  Ill 
Oklahoma  anti-cigarette  law,  905 
Oliver.   Dr.  Charles  A..  194 
Oilier,    Professor,    of    Lyons,    subscription 

for  monument   to   the   late,    1^6 
Olllve.    Dr..    1082 
Omaha  Medical  Socletv.   411 
Omeja  Upsllon  the  fraternity,  267 
Omentum  and  mesentery,  20 
Omphalorrhagia,    spontaneous   In   a   hemo- 
philic infant,  278 
Ontario,  a  bill  for  the  treatment  of  inebrl- 
atlsm.  596 
death    report  of,   842.   1030 
hospital  report,  annual,  752 
Medical  College.  1030 
Operating  under  Roentgen  rays,  961 

new  hand  table  for.  888 
Ophthalmia  neonatorlum.  64,  65 
Ophthalmic  test  types.  268 
Ophthalmometer,    new.    .377 
Ophthalmoscope,   4.W.   1116 
Opiates,  111 

Opinion    evidence,    the,    of      medical      ex- 
perts.  804 
Opotherapy  In   gynecology,   1083 
Oppenhelmer.  Dr.  Sevmour,  265 
Opstlp«ti<.n.  1239 
Orange  Memorial  Hospital,   458 
Orbit,    heteroplasty  of  the,    with   use  of   a 

rabbit's  eye,  6.'i9 
Orcein,  elastic  fibres  In  the  sputum.  292 
Orchitis,  and  epididymitis  in  typhoid  fever. 

1040 
Organic    extracts,    therapeutic    application 

of,  605 
Organotherapy,  cell  problems,  112,  158 
Orlginalit.v.  409 

Orphan  Asylum.  Rochester  fire,  52 
Orthopedic   dispensarv.    141 
Osborn.    Dr.    Charles.    266 
Oshkosh  Hospital.  459 

Osier,   Wm..   Dr.,   British   Congress  on  tu- 
berculosis.  1226 
surgical   Intervention    In  perforation  in 
t.vphoid  fever.   138 
Osseous  and  osteoarticular  tuberculosis.  408 
Osteitis   of   the  skull,   traumatic   purulent, 

112 
Osteoarthritis,    treated    bv    electric    heat, 

1084 
Osteo,    orthropaty,    pulmonary,    hvpertrop- 

Ic.    1196 
Osteomalacia,    661 
Osteomyelitis   of   the   long   bones,   882 

vertebrae,    886 
Osteopathlsts,   not   physicians,   143 
Osteopathy,  a  judge's  opinion  on.  1086 
Ottawa    contagious   hospital.    1116 
titltls.   extra   dural  abscess,   50  operations 
for,  S.'i4 

In  children.  231 

media,   caused  by   bacillus  pvocvaneus, 
784 
Otitis  media  suppurative,  421.  1040 

Purulent,  prevention  and  treatment,  &4P 


Otitltls    media,    suppurative,    formalin    In 

1241 
Otomycosis  In  the  tropics,  55 
Otorrhea   chronic,    466 
Ovarian  carcinoma  in  ll-year-cld  girl,  264 

cysts,  interperltoneal  rupture,  tXA 

organotherapy,    25 
Ovulation  and  menstruation,  338 
Oxygen  inhalation,   110 
Ox.vhemogiobin  in  the  blood,  211 
Oxyuris  vcrmicnlaris,  331 

Dachyderma  laryngis  with  salicylic  add 

*^  treatment.  279 

Packard.  Francis  K..  409 

Page,    Dr.    John    Randolph.    505 

Palate  soft,   adhesion   to   pharyngeal   wall, 

355 
Pan-American  medical  congress,  third,  88, 

101,  327 
Panarthritis,    treatment,    893 
Pancreas,    antidotal   action,   291 

Cysts  of.  operative  treatment.  68 

difficulty  of  diagnosis  in  disease  of,  882 

enlargement    of,    55 

necrosis  of.   19 

of  embryo  and  newborn,  1224 

sarcoma  of  the,  1041 
Pancreatic   disease,    estimation   of  urinary 

sulphates    and    fecal    fat    in    diagnoslg. 

856  o       — 

Pancreatitis,    1021.    1048 

chronic   interstitial,   taO 

experimental,  257 

hemorrhagic  In  typhoid  fever,  1159 
Panophthalmitis,  case  of  post  partem  met- 

astasic.    9<j'2 
Paraffine,  subcutaneous  injections  of,  882 
Paralysis  agitans,  380,  653,  877 

anemic,  21 

ascending,   acute,    802 

facial,  symptomatology  of.  160 

Inhibitory,   of   early    children,    1155 

Landry's,  16,  99b 

of  the  facial  nerves,  194,  29 

post  anesthetic.  206 

recurrent  oculomotor.    1040 

trauma  as  an  existing  cause  of,  1017 

unilateral,   299 

ulnar,  isolated.  147 

venereal  of  horses.  162 

with   congenital   syphilis,   461 
Paramyoclonus  multiplex.   1199 
Paraplegia,   spasmodic,   115 
Parasite  In  the  ear,  !^57 

malarial  estivoautumnal.  467 
Parasitology,    malarial,    874 
Paresis,  simulating  brain  tumor,  478 
Paris  Medical  Club.  199 
Parotid    gland,    primary    tuberculosis    o^ 

1161 
Parotitis  and  croupous  pneumonia,   500 

bilateral,    318 

in  pneumonia,  O^X),  790 

Infective  after  abdominal  section,  271 
Parturition,   the  Walcber  position  In,  1114 
Pasteur  Institutes.  639.  751 
I'atella.  fracture  of.  2o6,  888,  889 
Patellar  reflex,  elicitatlon  of.  2U9 
Pathology  bio-chemical.  441.  449 

chemical,   th^;  teaching  of,  1211 

in   ISUO,   102 

of  the  Jews,  719 
Pearce,   F.    Savary,   M.   D.,   trauma   as  an 
existing  cause  uf  paralysis  agitans, 
1017 
Peking,  siege  of.  medical  aspects,  380 
Pelvic   and   abdominal    surgery.    434 

hematocele   in   relation    to   tubal   preg- 
nancy. & 

origin,   menorrhagia  of.  339 

pain,  significance  of  right-sided,  92 

relations,   960 

sarcoma.    418 
Pelvis,  bad  position  of,  productive  of  pelTtc 

cunature.    653 
Pemphigoid   measles.   340 
Pemphigus,  neonatorum.  2S4,  6u2 

of  the  external  skin.  609 
Pencil   indelible,   413 
Penis   gangrene  of.    271 

sarci'ma    of.    S^i 
Pennsylvania  epileptic  hospital  and  colony 

"  farm,    1178 
Pennsvlvania    Hospital,   409,   454.   502.   638, 
■}«<;>.    937.    941 

TTniversitv  of.  Medical  Alumni,  364 

medical  bulletin,  497,  502 
Penrose,  Clement  A.,  M.  D..  The  treatment 
of  pneumonia  with  saline  Infusions. 
790 
Percussion  of  the  heart,   Potatn's  method. 
957 

a    new    method    for    the    detection    of 


cystic   or   loeculated   fluid   In   abdo- 
men, 1043 
Percussory   transsonance,   288 
Perlatipblltlc  abscesses  of  Douglas   pouch, 

opening  of,  G09 
Perineal   rupture,   rare  form,  CG 
Perlneorrhapby,   886 

Peritoneum    functions      and      anatomy      of 
10-14 

sensation    In.    809 
Peritonitis,   diffuse,    complicating   appendi- 
citis  and   prevention,    11>40 

following  perforation  of  appendix,   014, 
999 

In  typboid  fever,  51,  lUi 

perforative    wben    to    operate    in,    914 

pneumococclc,    7C3 

purulent,  surgical  treatment  of,  6C1 

suppurative,    histology,    427 

thoracic    paid,    429 

tuberculous.    377 
Peritonization  in  laparotomy,  061 
Perivesical    inflammatory   processes   In   the 

female,    514 
Peroneus  tendons,   treatment  of   luxations, 

888 
Perspiration   of   the   feet,    24 
Pest  bacillus,  the  priority  of  discovery,  938 

house  at    Fargo,    143 
Peterson,    Dr.    Frederick,    1116 
Peterson,  Dr.  Reuben.  841 
Petroleum,    bacillus    of    diphtheria,    156 

drlnliiug,    ,599 
Pettenkoter,   Professor,  407,  414,  642 
Pharmacist,   woman,    in   Uussia,   13 
Pharmacy    erroneous,    135 

state  board  of,   143 
Pharyngeal  adcuoids,  272,  420 

pouch,  large,   removed,  1083 
Pharynx  and   larynx,   scalding,  517 

cicatricial    stricture    of    the,    cured    by 
plastic  opcratiou,  873 

hyperplasia    of   the.    802 
Pheuyehydraziu  test  for  sugar,  211,  509 

Fisher's      test,      Neumann's      modifica- 
tion,  111 
Philadelphia  Bureau  of  Health,  454 

hospital,    1(1.    708 

lying-in    hospital,    941 

maternity  hospital.  409 

medical    club.    140 

polyclinic.    -94.   986 

polyclinic  and  college   for  graduates   in 
medicine,  708 

Presbyterian  hospital,  454 

school  for  backward  children,  903 

specialty,  a   1024 
Philippines,   army   surgeon,   64 

fevers  in  the,  959 

physical  fllness  for,  989 
Philippine  customs  and  habits,  I'JOl 
Phlebitis  of  left  leg  with  appendicitis,  429 
Phloridzin  diabetes.  1.88 
Fbonograiib,  the,  in  patbologv.  10(j4 
Pbnspliatr    of    lime    in    the    lungs,    333 
I'botuKr.Mphiug  Ihe  eye  gmuud.   1087 
Phthisis,  an  early  diagnostic  sign  of,  985 

open   air  treatment,   914 

pulmonary,     prognosis    and    treatment, 
423 

pulmonary,  the  Influence  of  the  soil.  fiOS 

pulmonary,   treatment.   157 

wind  exposure  and.  200 
Physical  education  In  Japan.  894 
Physician     falls    from    window,     dead,    00 

killed.  11 

killed   by  insane  patient,   707 

oldest  qualifled,  541 

restrictions  for  a.   in   Indiana.   711 

the   relation    of   the,    to   legislative   af- 
fairs.  1110 
Physicians  and   temperance,  405 

choose  officers,  50 

for  Newfoundland  sealing  fleet,  1037 

guarantee  conipanv.  266 

holiday   at    K.irlsbad.    Austria.    26 

license   law,    11 

not  obliged  to  attend  patients,  946 

of  Havjma,    145 
oldest,    54 

work.    the.    and    Its      relations     to     the 
purely  scientific  studies,  746 
Physiology  In  I.StW.  102 

textbook    of.    6 
Plckover.    Mr.     .-Mexander.    146 
Piles,    the    i-adii'Ml    cure    of    external    and 

internal.    1087         • 
Plrigoff  Congress.  367 
Pistol  shots,  407 

Pltfleid.  Kobert  L..  M.  D..  ammonium  per- 
sulphate solution ;  a  new  decoloriz- 
ing fluid  fur  staining  spores  and  si)U- 
tnm.  872 

Pityriasis,  rubra  pilaris.  280,  281 
verslcular,   851,   1061 


INDEX 


Placenta,  previa,  cesarian  section,  379 
paralysis  of  the  point  of  Insertion,  893 
previa,  801 

separation  of  the,  in  third  stage  of  la- 
bor,  801 
I'laguc,   bubonic,  10,  94,  309,  414,  498,  586 
005,    641,    1078 
among  troops,   199 
bacillus,    bacteriolysis   of   the,    806 
blood,  462 

ended   in   I!io   de  Janeiro,   753 
in  Alexandria  in  1899,   1256 
California,  504 
Canada,  white,  413 
Capetown.   508 
China.    1078 
Hiiii.  England,  1221 
India,    316 
Japan,    742 
Klrgiz,   1082 
Manila,   47,   1078 
San   Francisco,   11,  631,   639 
Turkey,   1117 
in  various  places,  1180,  1187 
lecture,  332 

prophylactic    measures,    408 
prophylactic      and  curative,  330 
situation,   treatment,    786 
victims  in  Canton.  10.000,  753 
resolutions  of  the  California  State  Med- 
ical  Society,    1185 
Plantar,   reflex,  etc.,  207 
Plasmon  and  tropon.  2.S2.  1090 
Pleen,  Professor  William,  411 
Pleura   and    lung,    surgery   of,    44 
Pleurisy,   311 

seroflbrlnous,    513 
typhoid,    108 

pleurotyphus,  due  to  bacillus  of  Eberth, 
212 

Plexus,   brachial,   17 

cervical  and   brachial,   19 
Pneumococclc  endocarditis,   1203 
Pneumonia,   115 

abscess,   156 

acute  lobar,  343 

appendicular,    316 

creosote  in,  645 

croupous,   340,  467 

treatment  by  antidipbtheria  serum,  836, 

cough  and  fever,  432 

historical  review  of  treatment  of,  854 

In  Alaska.    12 

lobar,    following  ether  anesthesia,   1019 

saline  infusions,  408,  449,  592,  790,  057 
700 
Pneumonias  of  Influenza,  314 
Pneumothorax  with  valve  mechanism,  114 
Poisoning,  acute  and  chrt.mic,   104 

arsenical,     148 

by   arsenetted    hydrogen,'  462 

by  cream  tarts,  962 

by  shoe  polish,   659 

cobra,    treatment    with    Caimette's    an- 
tlvenine,    149 

fatal  case  of  zinc  sulphate,  15 

from  auto-intoxication,  8.50 

investigations  in  the  study  of,  809 

of  dogs,   a   penal  offence,   1115 
Poisons  in  relation  to  diseases  of  the  ner- 
vous systems,   332 

predisposition  to,  963 

sale  of,    458 

some    convulsive,     and    their    influence 
upon   tile  temperature,   879 
Poliomyelitis,  acute  of  adults,  1202 

anterior,  6,54 
I'oilufiou  of  streams,  the.  and  the  purifica- 
tion of  puhlic  water  supplies.   850 
Polyneuritis.    630,    892 

Polyorromenifis    or    combined      serous    In- 
flammations,   14 

Polymyositis,   acute  hemorrhagic,   1204 

Polyp  of  the  tonsils.   840 

Poor  law  iu  ISOO.  102 

T'oporo.     Professor.    147 

Porro    operation,    1197 

Portal   vein,   obliteration  of  the.  1000 

I'ostheniiplegie    intention    tremor,    1.58 

Post-influcMiza    iiolyneuritis.    431 

Postpartum  hemorrhage.   103 

Pofain.    Dr..   gold  medal  for.   13 

Potassium    Iodide    in    ophthalmic    practice. 

4.'t2 
I'lizzl.     Dr.     of    P.nris,     honored    American 

surgeons.  997 
T'racfitinners'   socicf.v  of  Orange,   140 
I'rager  medlcinische  Wochenschrift.  193 
rreliacillary    stage    in    tuberculosis,    106 
I'recordial     area,     respiratory     movements, 

1000 
Pregnancy,     abdominal.     1173 
and  fll>romyoina,  10O4 
labor  surgery,  417,  462,  510 
myxedema,    473 


1265 


complicated  by  a  fibroid  tumor,  111,  1042 
ectopic,  801,  802,  960 
complicated  by   vomiting,  1003 
extra-uterine,    722,    962 
extia    and    Intra-uterlne    simultaneous, 
1145 

occlusion  of  the  Intestine  in,  113 
recurrent,   808,   108'.) 

removiil  of  both  ovaries  and  tubes,  205 
subseijuent  to  double  salplngo-oonhoree- 
toniy,  701 

upon  enteroptosls.  Influence,  472 

the    dangers    and    diagnosis    of    breach 

presentation,    1082 
the  toxemia  of,  804 
tubal,    pelvic   hematocele,    65 

ruptured,     1089 
uterine  mistaken  for  extra-uterine,  lOSO 
I'reiusnla,  redundancy  of  the,  |b  the  brains 
of  distiuguished  educated  men,  119& 
I'resbyterian  Hospital.   99 
Pressure  congestion,    4(i9 
Preston,   D.    K.   J.,   1185 

Presystolic  murmur,  further  report  and  a 
case  of,  associated  with  pregnancy, 
965 

Presystolic    murmurs    heard    at    the    apex. 

origin  of,   1237 
I'revosf,  Dr.  Chapot,  367 
I'rizc   essay,   4.59 

I'rocfitis,    hemorrhagic,    886  • 

I'rofessionai   devotion,    11 

secrecy,  411 
Progress  of   medicine   iu   the  U.    S.   during 

the   19ih    ccnturv.    1095 
Pro-maternity  Hospital,  a  plea  for,  801 
Propliylactic   measures   against   pest,    408 
Prophylaxis   individual,    718 
Prosampter,    Dr.    Anton.    147 
Prostate  gland,   what  I   have  learned   from 
161  operations  for  the  relief  of  senile 
hypertrophy  of  the,  1090,  1169 

enlargement,  201,  269 
Prostateetom.v,  case  of  suprapubic,  847 
Prostatic,      abscess     opening      both     Into 
urethra   and   rectum,   936 

hypertrophy,    106,   603,   779 

obstruction,  Bottini  operation,  513 
Protein   metabolism    in   the   aged,    784 
Proteolysis,    (luanfativi^   tests   tor,    648 
Protoscope  and  sigmoidoscope,  a  new,  1241 
Pruritus,  senile,  508 
Pseudoarthrosis    of    the    terminal    phalanx 

of   the  flnger,   828 
Pseudohypertrophic     muscular    circulation. 

423 
Pseudoleukemia     with     aflectlons    of     the- 

skin,   1161 
Psoas  abscess,  treatment  of,  1001 
I'sychiatry,     scleutiflc,     134 
I'sychoses,     following      pelvic      abJomiual 

operation,    81 8 
I'sychotueraphy    of    pain,    329 
I'tumaiue   poisouiug  on   perforation,   418 
I'losis,   congenital,    au   easy    operation    for. 

756 
Public  works  health  regulations,  1030 
I'uerperal    eclampsia,    159,    269 

fever,   272 

hcmoiThage,  salt  sulufiou  Injections,  431 

lulection,    i21,    &U1,    i.Uu 

Insanity,   414.   1239 

polyneuritis,   etc.,  857 

sepsis.  273,  414 

septicemia,  898.  917 
I'ublic    libraries    and    medical    books,    1201 
Pulmonary     sclerosis,     probably     syphilitic: 

I'uise  retlex  excitation  of  the,  889 
Pulsus  paradoxu,s,  956 
I'upiliary  and   visual  fibers,  22 
re-aciiou.    therapeutic,    277 
Puray,  Dr.  Charles  Wesly.  143 
Pure    food    legislation,    il8 
Purpura    rheumatica   and   angina,    160 

simplex,    n.iii 
Putuaiu.   James   Jackson,    M.    D.,    theoreti- 
cal  and   practical   considerations  ou 
the  treatment  of  Jaeksonlan  epilep- 
sy by  operatiiiu,   1165,  1213 
Pyelonephritis   In    children,    153 
Pyemia  of  otic  origin,   295 
I'yioric  obstructions.  1187 

tuiuor,  disappeared  alter  gastro  enteros- 
tomy, 802 
Pylorus,  congenital  hypertrophy  with  sten- 
osis, 55,  757 
stenosis,    152 
stricture  of,  67 
Pyonephrosis,    a    case   of   calcnious,    60° 
occurring  In  kidneys  with  double  pelvis 
and   two  ureters,  883 


1266 


INDEX 


Pyramiiliil    tracts,    after    ilecussatioii,    de- 
struction of  the,  19 
position    of    the    Bbres     that     control 
movement  of  hand,  1155 

Pyramidon,    893 

Pyrexia,  occurrence  of  in  cancer,  etc..  ^3 


Q 


uackery  dangers,  324 


Quarantine  station,  Pan  Francisco,  11 
Quebec  Board  of  Health  report,  iOT 
Queen  Victoria,   189,   258,   4U9 
■Quinine  hemoglobinuria,  15 
Qulnlan.  Professor  Francis  J.,  M.  D.,  321 
Quint,  Dr.  S.  J..  197 

n  abies,  451 

experinlints    with    an    epidemic    of,    in 

liutTalo,   717 
premium  for  the  best  paper  on,  1082 
rapid  diagnosis,  275 
report  of  a   case.   187 
specific   lesions,   275 
treatment  and  phophyiaxis,  CSS 
Eailway  surgery,  458 

Kandall,  B.  Alexander,  M.  A.,  M.  D.,  502 
localization  of  sound  and  its  bearing  on 
bearing,      especially      In      unilateral 
deafness,  SGI 
Randall's  Island  Hospital.  365 
Kanney,  Dr.  George  E.,  of  Lansing,  Mich., 

1228 
Rat   extermination,    1229 
Kat  plague  at  Capetown,   1237 
Recreation   of   scientists,    1224 
Rectal  carcinoma,  radical  operation,  B9 
injections,   339 

operations,  progress  in  the  technique,  21 
Rectum,    prolapse  of,   55,   048 

resection   per   vaguuim,   383 
Red    Cross   Hospital,    305 
Retlex,   the,   scapulo-humeral  of  von   Becu- 

terow,   1043. 
Regensburger,    Dr.,    53 
Reid,    Sir  James,    Bart,  507 
Reindeer    tendon     tor    stitches    and    liga- 
ments, 277 
Remedies,   proprietary,  467 
Uemingion,   Dr.  Arthur,  96 
Removal    of    the    suixrlor    cervbal    sympa- 
thetic ganglion  tor  glaucoma,  743 
Renal  edema,   the  role  of  renal  plexus   in 
the   pathogenesis  of,   600 
function,    424  ^  _ 

some  observations  on,  71 1 
surgery,  the  history  of,  802 
Resection  of  the  cervical  sympathlc,  719 
Resorcin  as  a   preservative,   etc.,   513 
Respiratorv    passages,    on   the   aCfeclion    of 

the  "upper,    in   iheumati.'<ln,    724 
Responsibiliiy  in  spirit  and  drag  takers,  759 
Uetinal  meridians,   declinations,  418 

detachment,  a  case  of,  1083 
Uetinitls,   albuminuric,   in   pregnancy,  So2 
Retrograde  movement,  a,  1180 
Kelroperitou.'al  cyst,  3i5 
Retropharyn:;eal  ab^.cess  and  adenitis.  132 
lietrospect    and   prophecy.   1111 
Kettotarsal   fold,   excision  of,   1004 
lieviews 

Abrams.  Albert,  A.   M.,  M.  D.,  diseases 

of  the  heart,  407 
Agriculture    Department   of   the   U.    S. 

vear   book,    1225 
AUchln,  W.  H.,  M.  D.,  manual  of  med- 
icine. 407 
Ayers,    Edward   A.,   M    D.,    physical   di- 
agnosis In  obstetrics,  261 
Bobn,  A.  A..   M.  D.,  and  M.  von  DaviU- 
oll,    M.  D.,    textbook    of      histology, 
etc.,   317 
Borden.  W.  C,  use  of  the  Koentgen  ray 
by  the  medical  department  of  the  L". 
S.  .\rmy  in  war  with  Si)ain.  262 
Carpenter,    George,    M.  D.,    Byphllis    of 

children,  1069 
Cattel,    Henry    W.,    A.    M.,    M.    D.,    In- 
ternational   cliulcB.    137,    408,    985 
Chapiu,    Charles  W.,   Municipal  sanita- 
tion  in   the   U.    S.,   1225 
Davis.  E.  P..  A.  M.,  M.  D.,  obstetric  and 

gyucMi'ologlcal   nursing.   362 
Devlne,   Edward  Thomas,    Ph.    D.,   The 
practice  of   charity,   individual   and 
organized,    1182 
Dorlaud.  A.   JI..  M.  D.,  W.   A.  Newman 
American    illustrated    medical      dic- 
tionar.T,  317 
Estes,   W.   L..   A.  M.,  M.  D.,  the  treat- 
ment of  fractures,  589 
Fischer.  Louis.  M.  D..  rofav*  ^^ediiig  in 


health   and  disease,   747 

Frost.  William  Dodge,  a  lalwratory 
guide  in  elementary  bacteriology,  747 

Goelet.  -\UKUstln  H.,  the  technique  of 
surgical  gynecolog.v,  902 

Gould.  George  M..  M.  D.,  American  year 
book  of  medicine  and  surgery.  317 

Grandln  Egbert  H..  M.  D.,  textbook 
on  practical  obstitrics.  363 

Haab,  O..   Professor  Dr..  atlas  and  epi- 
tome   of    ophthalmoscopy    and    oph- 
•   thalmoscoplc  diagnosis.  902 

Hare.  Hobart  Armory,  M.  D..  system 
of   practical   therapeutics,   30.3 

Hare,  Hobart  Armory,  M.  D.,  a  system 
of   practical   therapeutics,    1225 

Hatfield,  Marcus  P..  A.  M..  M.  D..  the 
acute  diseases  of  childhood,  1181 

Diternational  medical  annual,  a  year 
book  of  treatment  and  practitioner's 
index.   985 

Jacob.  Professor  Dr.  Chr.,  atlas  and 
epitome  of  the  nervous  system  and 
its    diseases.    985 

Jones,  H.  McNaughton,  points  of  prac- 
tical interest  in  gynecology.  941 

Kemp,  Robert  Coieman.  M.  D.,  enter- 
oclysis.  hypodermociysis  and  infu- 
sion,   137 

Kronig,  Dr.  B.,  die  Th?rapie  belm  engen 
Becken,  407 

Leftwltch.  Ralph  WiDnington.  an  in- 
dex as  a  clew  t"»  dinirnosis.  1067 

Locke.  Charles.  M.  D,.  assisted  liy  Fred- 
eric J.  Cotton.  M.  D..  the  treatment 
of  fractures.   i>8ii 

Luiistan.  G.  Frank.  M.  D.,  Panama 
and  the  Sierras.  .■i62 

Mays.  Thomas  J..  M.  D..  pulmonary 
consumption,  pneumonia  and  allied 
tl'seases  of  the  bug,  ."it'O 

McKay,  W.  J.  Stewart,  M.  B.,  M. 
Ch..  B.  Sc.  history  of  ancient  gyne- 
cology.  362 

Mitchell,  C.  Alnsworth,  B.  A.  F.  I.  C. 
F.  C.  S..  flesh  foods,  etc..  .^17 

Munson,  Edward  L..  A.  M..  M.  D., 
The  theory  and  practice  of  military 
h.vglene,    1181 

Packard.  Francis  Randolph,  the  his- 
tory of  medicine  in  the  United 
States.  1114 

Phillips.  Dr.  G.  M..  a  handbook  of 
genitourinary  surgery  and  venereal 
diseases.  1069 

I'orter.  William  Townsend,  M.  D.,  an 
introduction  to  physiology,  453 

I'owell,  \Vm.  M..  .M.  D.,  essentials  of 
the  diseases  of  children.  941 

Ueed,  Chas.  A.  L.,  A.  M..  M.  D.,  a  text- 
book of  gynecology.  10C9 

Robinson,  B.  S.,  M.  D..  -The  periton- 
eum, 1182 

Rosse.  Dr.  Irving  C,  a  list  of  publica- 
tions. 137 

Ruhemaun,  Dr.  J.,  Aetiologle  and  I'ro- 
phylaxe  der  Lungen  Tnberciilose,  793 

Salinger,  Julius  L.,  M.  D.,  and  F.  J. 
Kalteyer,  M.  D.,  modern  medicine, 
261 

Schaniberg.  Jay  F..  A.  B..  M.  D.,  com- 
pend.  of  diseases  of  the  skin.  137 

Senn,  Nicholas.  M.  D.,  Lloutcn.int-Ool- 
onel,  medico-surgical  aspects  of  the 
Spanish--\meri<an  war.  362 

Smithsonian  Institution's  annual  re- 
port, 1182 

Taylor,  John  Madison,  A.  M.,  M.  D., 
Manual  of  the  diseases  of  children, 
1182 

Three  thousand  five  hundred  questions 
on  medical  subjects  for  self  educa- 
tion.   7!i2 

Tirard  Nestor.  M.  D..  a  text  book  of  the 
medl'_'al  treatment  of  dlsetlses  nnd 
symptoms.    747 

Tyson.  James,  M.  D..  the  practice  of 
metlicine.   589 

Wainwrlght.  J.  W..  M.  D.,  A  syllabus 
of  new  remedies  and  therapeutic 
measures,  physical  appearance  and 
therapeutic  application,  1181 

AVebster,    J.    Clarciue.    B.    A..    M.    D., 
Edin.   T.   R.    C.    P.   E..   T.   K.   S.   E.. 
huiuan  placentatlon,  792 
Reynolds,    Dr.    Dudley    S.,    suing    Centcal 

University.  Louisville,  1030 
Rhachitis.   phosphorus  treatment,  425 
Rheumatic  fever,  caase  of.  10'26 

effects  of.  on  the  heart.  154 

epidemiology  of,   153 

In  children,  153.  I'.Hi 

In  relation   to  the  thmat.  154 

pathology    of.    153 

treatment,    IBo 


Rheumatism  chronic,    and   its  relations   to 
acute  infective  Rh.,  644 
acute  articular,  etiology  of,  611 
acute   articular,    the    pathogenic    agent 

of,    1075 
etiology  and  pathology  of,  1002 
in   children.   155 
Rhinitis   fibrinous.  290 

purulent  in  children,  106 
Rhodan  in   the  nasal  secretion.  278 
Rice.  Dr.  Charles.  New  York,  death  of,  944 
Richardson.    Dr.    A-    B.,   99 
Richmond  news,   1228 
Richmond.  Va..  news,  53,  99,  144,  197.  324. 

412.  905,  12-28 
Rickets,  pathogeny  of,  1205 
Rifle   experiment   and    experience    with.    C2 
Ringworm  infection.  415 
Risiey.  Dr.  Samuel  D..  resigned,  794 
Rltter.  a  controversy.  10 
Roberts,   Dr.    Deering  J.,   1228 
Roberts.   John  B..   M.    D..   multiple  tumors 
of  the   sciatic   nerve,   737 
The  doctor's  fee,  a  plea  lor  honorable 

dealing,  920 
venous   augioma   of   the  flexor  muscles 
of  the  fingers.  737 
Robinson.    Dr.    .\rthur.    54 
Robson,  A.  W.  Mayo,  T.  C,  C.  S. 
Pancreatitis.    1048 

the  surgical  treatment  of  chronic  ulcer 
of  the  stomach,  1005 
Rockefeller's  gift,  J.  D.,  1065 
Rohe,   Dr..  325 

Romanowskv's  stain  in  malaria,  644 
Roentgen   rays.    12.   53.   889 
economics  of.  759.  853 
examination,   161 
method  of  diagnosis  of  fractures.   419, 

605 
In    practical    medicine.    423 
in  the  U.   S.  -Vrm.v.  2  ^2 
review  of  the   literature   of  the  thera- 
peutic value  of.  760 
tube  in  surgery  prize.  199 
upon  the  skin.  283 
urlnarv  calculi,  271 
Williams,  151 
Roseola,   recurrent   intercostal,   1194 
Ross,  Dr.  John   D..  364.  464 
Rost   J.    M..    S..    Capt.    R..    147 
Royal    College    of    Phvsicians,    320 

hospital.    Belfast.    13 
Royce,    Chas.    B..    suprarenal    capsule.    Its 

use  In  rbluologlcal  operations.  »3J6 
Rubber  dam.   adhesive,   for  the   preven:Ion 

of  Infection.  918 
Rubeola  and  rubella.  192 
Rudolf.    R.    D..    M.    D..    Thennol    In    the 

treatment  of  enteric  fever,  204 
Rush   hospital.   364 

Russian       news.       California's      Governor 
noted.  997 
engineers  better  paid  than   pbrslclans. 

1082 
navy  assistant  surgeon.  454 
new    chlldrt^n's     hospital.     St.     Peters- 
burg. ia't7 
new  medlc.ll  school.  13 
typical  Russian  episode.  642 

Cachs.  B.,  M.  D..  and    Alfred  \Vlener.  M. 
*-'         n.    Some   trophoneuroses   and   their 
relation   to   vascular  disease  of  the 
extremities,  1242 
Sacral   first   and   lower   lumbar   roots.   Iso- 
lated disease  of,  1203 
Sactosalpinx,   with  torsion  of  the  pedicle, 

658 
Saline    Infusion    In      pneumonia,      a    final 

word   on.    1183 
Salpetriere    Hospital.    381 
Salpingitis,  bilateral.   472 
Salutatorv.  1 
Sanitarium.  143 

Sanitary  condition  of  Havana,  136 
Sanitation  and  progress,  313 
Peking.  648 
knowledge  in  1800.  102 
Santiago  as  a  yel.ow  fever  centre,  SSS 
Santonin,  a  wider  range  for  the  therapeu- 
tic employment  of.  786 
Sarcoma  of  the  lUnH-ccal  region,  426 
intestines.   51.'^ 
liver,  congenital,  t>51 
pancreas,  "1041 
penis.  885 
rllis.  390 

stomach,  463.  103S 
testicle,    13J 
thish,  witn  disarticulation  performed. 

Co3 
tri-atment  of.   with   toxins.   i»Sl 
ureter,  fibroma  of  the  round  ligament. 
65 


uterus.  873,  999,  1044 
inoperubk"    saicruiias    with    the    mixed 
toxins  i)t'  ('risypcias  and  bacillus  pro- 
di^iusus,   lulB 
Sarvei),   will  of  James  D.,  141 
Savannah    Hospital,   99 
Saville,  Dr.  Lillie,  decorated.  lu.'iT 
Scapulohumeral  reflex,  the  siguiticance  of. 

18 
Scarlet  fever,  140,  407.  11,S4 

affections  of  the  joints  In,  lloS 
new  type  of.  SOI 
with  convulsions,   41U 
Schafcr,   Professor,  414 

Schlatter.    I'rotessor   Carl.    llKation    of   the 
earotiil  artery  as  an  operation  prelim- 
inary   to    resection    of    the    superior 
maxilla.  726 
Schley,   Dr.    Fairfax,   266 

W.    S..    Dr.,   two  cases   of   lobar   pneu- 
monia   following     ether     anesthesia 
with  unusual  course,   1019 
Schnitzler,  Dr.  Emil,  502 
SchofleUl,   Walter  K.,  medical  director,  re- 
tired, 842 
Schott  exercises,  proper  administration  of, 

1000 
Schweluitz,  G.  E.  de..  M.  D..  correction,  31S 
Sciatic  nerve,   multiple  tumors  of  the,   737 

phenomenon   crossed.   381 
Science,  between  acts.  45 
Sclerosis,  multiple,  an  atypical  case,  17 
of  Lichtheim,  etc..  467 
symptoms  of  disseminated,  occurring  in 

malarial ' affections.   oSG 
with  hypersplenomegaly.  114 
Scoliosis   hysteric,    of    the    Wertheim    Salo- 
monson  type,   891 
treatment   by  plaster  jacket,  278 
of  chronic.  279 
Scorbutus  infantile,  a  clinical  note  on,  77G 
Scrofulosls  and  tuberculosis,  283 
Scurv.v  and  rickets  in   young  children,  378 
artificial   feeding,   418 
in  infants,  810 

the  Island  of  Cuba,  Infantile,  91 
not  rheumatism,  213 
Seasickness,    402 

Sea-voyage,    beneficial   effects   of   a,   918 
Sebaceous    glands    in    the    mucosa    of    the 

cheek,    340 
Selenium   compounds,   beer  poisoning,   377, 

758 
Seminal   vesiculitis,   on  chronic,   1199 
Seminal  vessels  and  prostate  giund,  a  new 
method   to   expose,    for   extirpation, 
917 
and  vasa  deferentia.  a  new  method  for 
extirpation.   883 
Senses   hospital,    53 
Sensory  disturbances  of  the  skin,  408 
Septic  disease  in  graduated  attacks  In  the 

same    patient.    644 
Septicemia,   etc..   203 
Serum.  antl-l)Odies  in  I  lie  normal.  162 
autidiphtheritic,  833 
human  agglutination  power  of  some,  789 
normal.   162 

ox.  use  of,  in  rectal  feeding,  801 
Sessile  and  ovarian  cysts,  380 
Sewage,  liacterial  treatment  of,  635 
as  a   feriilizer   tor   seaweed,   5 
farm    in   Montreal,   842 
Sewing  machine  for  the  skin  invented,  800 
Sexual    intemperance,     60 
Shalleross,  W.  G..  M.  D.,  acromegaly,  with 

reports  of  two  cases,  771 
Sheaff.  r.  A.,  prevention  of  tuberculosis,  49 
Sheffield,  bacteriological  laboratory,  199 
Sherer,   J.    W..    M.   D.,   report   of  a  case  of 
rupture  of  the  eye  ball  from  contu- 
sion of  the  lens,  etc.,  977 
Sherrlll.    Dr.    L.    W..    905 
Shouider.  congenital  dislocation  of  the,  045 
dislocation  of.  67 
irreducible,   894 
Joint  luxation  treatment,  136 
Siamese  twins,  the  new  livingi  832 
Sight,    primitive    organs    of    sight,    11159 
Sigmoid  flexure  and   rectum,   inflammation, 
strictures   of,    19 
sinus  thrombosis,  infective,  602 
Silver    in    silver    nitrate,    263 
Sing    Sing    prison    condemned,    1184 
Sinus    durae    matris    from    a    rare    cause, 

thrombophlebitis,   19 
Slriasis,    202 

Sitophobla  of  enteric  organ.  1201 
Skiagraph  of  Smith's  fracture  of  radius.  482 
Skiagraphy,    surgical,    63 
Skin   dl-seases   In   Infants   and    children,    ef- 
fects of  diet   nnd   hygiene,    61 
edema    of   the,    with    laryngeal    Involve- 
ment,  2S2 
therapeutics,    208 


INDEX 


Skull  closure  of  defects,   210 
and  contents   of,.  274 
deformity    of,    Ha 
of  the  new  born,  260 
Sleeplessness,    a    remedy    lor,    1023 
Sloan.  IJr.  \Vm.  H.,  died,  53 
Smallpox,  10,  266 

caused  by  a  letter,  711 
epediniic,    197 
in  summer  1900,  281 
Alaska, 

Canada,  843,  1038 
C'nieago,     197 
Delaware,    638 
Enrfl..-!.  1116 
Frederk  ksburg.    90 
Galveston.    99 
JtJiasgow,  199,  26S,   710 
Gloucester    City,    '.ill 
infant,  3  days  old,  1020 
Iowa.     197 
Kansas,  53,  98,  504 
lumber  camps,  11 
In   Maine,   1184 
Missouri,    98,    144 
ocean   steamer.  63S 
Oswego.    N.    Y.,    196 
Status  In  Cleveland.   1227 
Soldiers'    Home.   53 
United  States,  741,  1178 
University  of  Virginia,   197 
Virginia,  197 

waiver    in    life    Insurance,    947 
the  way  they  manage  it  In   Utah,  S.'iO 
Wisconsin.     411 
Woodbury.    3Co 
Smith,    Dr..    411 

Chauncey  Pelton,  10 
Smokers'  gingivitis,  432 
Sneezing,    continuous    for    seven    months, 

IOCS 
Soaps,     their    chemical     composition     and 

disinfecting    properties.     1250 
Sobel,    .laeob.    M.    D.,    pityriasis    versicolor 
with    special    reference    to    Allen's 
Iodine    test.    1061 
Social  evil,  the,  in  the  New  York  tenement 
houses,    705 
timely    words    about    the,    632 
Society    reports:— 

American  Academy  of  Medicine,  1145 
Assoiiation    of    Physicians,    906,    952, 

989.  1034 
Climatologieal    Society,    1117 
Congress  of  Tuberculosis,  903,  987 
Dermatological  Association.   450,    1020 
Gastro  Enterological  Association.  949 
Genito-Urinary    Surgery    Association, 

951 
Laryngological   and   Otlological  Socie- 
ty. 1077 
Laryngological  Association,  904.  1077 
Medical   .Association,   1119.   1122,   1128, 

1130,  1138,  1141,   1187,  1221 
Medico  Legal   Society,  987 
Medico  Psychological  Association,  266 
Neuroloeical  Society.  1176.  12.33 
Orthopedic  Society.  1028.  1227 
Pedriatic    Society.    794.    1071 
Proctological  Society,  905 
Surgical  Association.  991.  1031.  1079 
Therapeutic  Society.   946 
Arkansas  Medical  Society.  988 
.\tlantic  City  Medical  Society.  319,  365 
Baltimore    College    of    Physicians    and 
Surgeons.  197 
County  Medical  Association.  412.  98S 
Berks  County  Medical  Society,  50,  364, 

749 
British   Congress   of   Tuberculosis,    137, 

146,   507.   641.  799.   1226 
Brooklyn  Society  for  Neurology.  10 
Canadian  Association  for  Prevention  of 

Tuberculosis.    842 
Cape  May  County  Medi<-al  Society.  9o3 
Cecil  County  Medical  Association.  79S 
Central  Illinois  Medical  .\Bsoclation.  90S 
Chicago  College  of  Physicians  and  Sur- 
geons. 53 
Patholosrlcal  Society,  144,  411,  595,  797, 

1185.  122.« 
West.    Medical   Society.   1227 
Clinical    Society   of  Ihe   District  of   Co- 
lumbia.  988 
Delaware  County  Medical   Society.  90 
Duhring  Dermatological  Society.  637 
Erie  County  Medical    Society.   .50 
Florida    Medical   Association.   711 
Fox  River  Valley  iledlcal  Society,  197 
French  Canadian  Medical  Congress,  367 

Gynecological  Congress.  1037 
German  Cnnnress  for  Internal  Medicine. 
911.   9.53.  993 
Congress  of  Otiolosv.  474 
Surgical   Society.  844.  909.  996.  10.36 
GnlC  Coast  Medical  Society.  .307 
Historical    Club   of   the    Department    of 
Medicine  of   Pennsylvania,   840 


1267 


Idaho  (So.)  Medical  Association,  752 
Indian    Medical   Association,    199 
International   .Vssociatlou     of     Hallway 

Surgeons,   1029 
Iowa  Physicians'  Association,  459 
Italian  Pedriatic  Congress.  507 
Johns  Hopkins  Hospital  Medical  Socie- 
ty, 99 

Kentucky  State  Medical  Society,  459 
Maine    State    Medical    Association,    504, 

1227 
Manhattan   Dermatological   Society,   97, 

266,    458,    710,    945,    1227 
Mussachu.sctts    Stale    Medical     Society, 

120th  Auniversaty,  11.S4 
Medical  Society  of  Mexico,  997 
Medical    Society   of    the    State    of    New 
York.    1227 
the  State  of  Pennsylvania.  986 
Mississippi  Valley  Medical  Association, 
946 
■  Missouri    State   Medical    Society,    797 
V.illey  Medical  Society,  459 
New    York   Academy    of   Medicine,    141, 

321,   750 
Neurological   Society,  97,  321,  365,   708, 

795,    1028. 
Obstetrical  Society.  322,  502,  594 
Rhode  Island  Medical   Society,  1184 
State  Medical  Society,  52,   196,  320,  986 
Woman's   Medical    Association,    196 
Ohio   State   Medical   Society,  266 
Orange   (N.    J.)    Practitioners'    Society, 

140 
Orleans   Parish    (La.)    Medical    Society, 

752 
Pennsylvania  Society  for  the  prevention 

of  Tuberculosis,   640 
Philadelphia  Academy  of   Surgery,  265, 
637,  942 
College    of    Physicians.    140,    265,    319, 
410,  455.  503,  707,  "08,  793,  838,  943, 
986,  1115 
County  Medical  Sociotv.   51,   195,  364, 

457,    638,    839,    943,    1027 
Neurological  Society,  140,  196,  319,  364, 

409 
Obstetrical  Society,  52,  320,  502.  944 
Pathological   Society.   96.    195,   365,   454, 
637,  840,  941,  1028.   1184 
Pedriatic  Society.  50.  311 
Pomona  Valley  Medhal  Association,  439 
Ptolemy  Society,  749 
Kappahannock   Valley   Medical  Associa- 
tion, 711 
St.  Louis  Academy  of  Science,  144 
Medical  and  Surgicil  Society,  53 
Salem  Cotlnty  Medical  Society,  903 
Tennessee  State  Medical  Society,  751 
Thurber  Medical  .\ssociati(m.  53 
Toronto  Clinical   Society,   948 
Thi-State  Medical  Society,  459 
Western   Ophtbalniolojic  and   Otolaryn- 
gologic   Association,    367,    459,    504, 
841 
Will's  Hospital  Ophthalmic  Societ.y.  748 
Witman  County  Medical  Society.  143 
Sound,   localization   of.   and  Its   bearing  on 

hearing.  861 
South    .African    War,   medical   department, 

276 
Specialism    and    some    of   Its    relations   to 
the    general    practice    of    medicine, 
1174 
Dangers,   315 
Specialty,  a  Philadelphia,  1024 
Specific    grayit.T,    334 
Spectrum,   artificial.   54 

Subjective    response    of    the    colors    of 
the,    18 
Speculum.    Breiske.    2,SS 
Speech,   defective,  251 
SpcMiUiitic  cord,  gumma    of  the.   1200 
Sulphur  bath,  new  kind  of.   1230 
Spina   bitida   treatment.   156.   587 
Spinal    Cord,    aneloma    of    the.    15 

changes,    produced    by    compression    of 

the  spinal  cord  by  vertebrae,  S90 
chronic  inflammation.  892 
diffuse  degeneration.  380.  608 
disease,  associated  with  anemia.  62 
Investigation  ni.on  senile  changes  of.  21 
the  rate  of  Infection   and    Intoxications 

In  diseases  of  the.  12,52 
surgery,  present  status  of.  761.  SM.  918 
transverse    lesions,     tendon    effects    In, 
1202 
Spinal    muscular    atrophies    of      clilldhood 

heredltar.v    progressive.    1201 
Spinal    muscnl'ir   atronliy.    279 
Spine,  fractures  and  dislocations.  1042 

lateral  curvature.  59 
Splrltus  saponls.    hnrd  disinfectant,   65 


1268 


INDEX 


Spltzka,  Edward  Anthony,  preliminary  com- 
munication of  a  study  of  tbe  brains 
of  two  distinguished  physicians, 
father  and  son.  080 
Spleen  and  the  albumin  ferment  of  the 
pancreatic  gland.  C62 
primary    massive    tuberculosis    of    the, 

1159 
spontaneous  (?)  rupture  of.  934 
surgery,  68 
Splenectomy    for     movable      hypertrophied 

spleen,  286 
Splenic    myelogenous    leukemia,    with    pul- 
monary   tuberculosis,    Uol 
Splenomegaly,  primary,  855 
Spring  Grove  Hospital,  09 
Sputum   examinations,    ^82 
St,  John's  Ambulance  Association,  London, 

268 
St.    Joseph,   Mo.,   county  jail,  367 
St.   Joseph's  Hospital,  454      1184 
St.    Louis    Hospital    Alumni.    197 

Medical  Society  of  City  Hospital  Alum- 
ni, 99 
St.  Luke's  Hospital  at  St.  Louis  to  be  re- 
built, 11 
St.  Marks  Hospital,  New  York.  1077 
St.  Mary's  Hospital,  London,  268 
St.    Peter's    Hospital.    Helena,    Mont.,    de- 
stroyed  by   fire.   1077 
Stain,  a  new  Silver,  658 

for  fat,  in  different  dyes  as,  892 
Staining,   dried  blood,  425 

of    fiagella,    330 
Stammering,  to  prevent,  627 
Staphylococcus,  Allen's,  morphology,  210 
Starch,  iodized,  as  therapeutic  agent,  24 
Starr,   Louis,  M.  D.,  scurvy  in  infants,  810 
State    Board    examination,    194 
Statistics,  Havana  health,  120 
Steel,  \Vm.  A.,  M.  D.,  Illuminating  gas  poi- 
soning,  318 
Stereognosis  and  allied  conditions,  651 
Sterilizing  money,  904 

Stern,  Dr.  Heinrich,  elected  Professor.  795 
points  connected  with  the  general  etiol- 
ogy and  pathogenesis  of  diabetes  mel- 
litus,    825 
Stcthophonometry,   377 
Stethoscope,  the  up-to-date,  3 
Stevens,   Capt.   A.   !•'.,  I.  M.   S.,  147 

Dr.    Charles    \V..    197 
Stewart,  Dr.  G.  T.,  bead  of  Bellevue,  52 
James,    M.    D.,    I'uerperal    polyneuritis 
and   poliuueuritis,    857 
Stlcren,   Dr.    Edward,  194 
Still-born,    physiologic    resuscitation,    339 
Stllle,    Dr.    Alfred,    273 
Stokes,  Dr.  Wm.  Uoyal,  1116 
Stomach,     atrophy    of    the    mucous    mem- 
brane of  the,  805 
carcinoma  of  posterior  wall,  464 
dilation   of,    113 

a    new   physical   sign  in   cases  of,    740 
hair-cast  of,  378 

hour-glass  contraction  of,  715,  956 
inferior  border,  341 
photographing   the,    753 
sarcoma  of,  873,  1038 
surgery,    67,    164 
ulcer,    perforated    of    the,    715 
Stomatite    ulcer    complicated     with    acute 
hemateuesis,  715 
erucique,  997 
Stomatitis,  diphtheric,  a  case  of,  660 
Stone,    in    the   bladder,    kidney   and   ureter, 
1149 
notes  on  206  operations,  1149 
Stoppage  of  tear  passages,  operation,  272 
Strabismus,    ccmvergenl,   980 
Streptococcus    bronchitis,     1085 

pyogenes  in  gynecologic  diseases,  1002 
Streptothrix  infections,  1027 
Strictures,   callous,   resilient,   159 
Strike  of  physicians  in  Leipzig,  755 
Stylus,  460 

Subcutaneous   rupture   of    tendons,   210 
Succus  capricornus,   C93 
Sugar  in  the  urine,  517 
test.   469 

sensitive,   424 
the    dietetic    value    of.    955 
Suicides,    aulopsy   on,   309 

study  from  300  autopsies,  279 
Sulphur,  electrolytic  deposit  of,  462 
Sunstroke.    340 

Superficial   temporal  arterj-,   279 
Superior  mesenteric  artery,  212 

vena   cava,  compressl<^u  of,   114 
Supernumerary   digits,    367 
Suppuration,  soda  compresses  in.  936 
Suprarenal  capsule.   Its  use  in  rhinological 
oiterations.   696 
diseases  of   the  heart.  916.    1001 
Suprasmyphyseal  cross  section  after  Kues- 

ter.    SS7 
Surgeon   uui.v  perform  additional  operation 
V  ithout  patient's  'joTisent.  mm 


Surgeons,  royal  college  of,   Dublin,  363 
Surgery  in  1800,  102 

photographs   of,    141 

relations    of    art    and    science    of,    1066 

some  disappointments,  57 
Surgical  cases.  Interesting,  58 

communicatlcns,  298 

instruments  taxed,  751 

operation,   a  told,  753 

operations  in  female  subjects,  378 

shock,  1200 
Suture,     absorbable,    l.'^S 

for  the  patella,   105 
Sutures,    arterial,    3159 

two  successful  cases  of  secondary,  one 

of  the   posterior   interosseous    nerve 

and    two   of    the    median    and    ulnar 

nerves,   1046 

Suturing  of  blood  vessels,  67 

Swimming   pools   as   an   etiological   factor, 

255 
Symptomatology  of  facial  paralysis,  160 
Syringomyelia,   symptomatology  of  trophic 
disturbances  in.   22 

alopecia    in,  295  ■ 
Syphilis,  aural  manifestations,  274 

as  a   non-venereal  disease,  717 

case  of  malignant.  8.56 

cerebro  spinal.  274.  MS 

circulatory  organs.  292 

circumcision  as  a  preventative.  103 

clinical  Investigations  upon  the  circula- 
tory organs  in  the  early  stages  of, 
881 

hereditary.  158 

In  the  well-to-do.  957 

mercurial  Injections.  430 

of  the  nose  and  pharvnx,  333 

refractory,  650 

secondary,  with  Itching  of  the  fauces, 
999 

spinal,   precocious,    etc.,    114 

treatment  at  Hot  Springs,  204 
during  pregnancy.  660 
Syphilitic  fever,   1238 

gummata,  superficial,  416 
Syringe,  a  shielded  piston  for  urethral  and 

vesical    irrigation,    759 
Systemic  degenerations,  combined.  1153 

tabes  dorsalls.  recognition  of,  1087 

study  of  a  case,  1043 

"yabes   dorsalls,    1201 

Tabes    dorsalls,    athetosis    as    a    complica- 
tion.  l'J03 
Tabes,  pathogenesis  of.  1196 
Tallerinan's  hot  air  apparatus.  963 
Talma's  operation,  success  following,   8ft4 
Tannalbln.    tannlgen  and  tannlform  In  in- 

testiu.ii   diseases,    747 
Taylor,     \lonzo     Engelhert,     the     teaching 

of  chemical    p.iihology,    1211 
Tea  and  alcohol  lu  Uussia,  54 
Tears,  on  the  secretion  of.  18 
Teeth,  permanent,  accidents  accompanying 

eruption   of,   1223 
Temperature,  effect  of  high,  on  the  casein 

of  milk,  654 
influenced  by  some  convulsive  poisons, 

879 
of  apparently  healthy  children,  654 
reduction  by  bath  in  fevers.  1001 
the  upper  limit  of  lower  forms  of  life, 

657 
Temple  of  Aesculapius,  the,  753 
Temporal  artery,  etc..  .'iuperflclal.  279 
Temporary  ligation  of  the  common  carotid 

as  a  preliminary  to  resection  of  the 

npi  er  maxilla,  743 
Tenaculcm.   a  new,  6'.»7 
Tendou  Jerks,   biceps,  in  locomotor  ataxia, 

1062 
Tendon    reflexes,    condition    of,    in     spinal 

cord    transverse    lesions,    1202 
Tendons,  subcutaneous  rupture  of.  210 
transplanting  of,    functional   results  of, 

656 

Tenoutltls.    and    tenontothecltis    prollfera 

calcarea,   851 
Teratology,  a  rare  case  of.  763 
Teratoma,  composite,  of  the  ovary,  38 

Tetanus,   cured   by  Tizzoai's  tetanus  anti- 
toxin, 2S5 

rtes'ending,  340 

due  to  auti-liphtheria  serum,  315 

following  clean  operation  wounds,  352 

neonatorum.   757 

puerpernlis.   957 

treatiueut  of.  S07 
Tetanv.   ease  of.  278 

gastric.   970 


occurring  in  acute  enterocolitis.  661 
originating  from  the  stomach,  1201 
Texas    Medical    Gazette,    459 
Texas,  mineral  survey  of  the  State  of,  1228 
Theobromin,  the  behavior  of.  880 
Therapeutic  Monthly,  589,  636.  741,  897,  961 
Therapeutics  of  organic  diseases,  147 
psychic,  516 
reflections   on,   149 
simplicity   in,   1087 
some  fallacies  of,  645 
Thermometers,  clinical,     bacterlologlc     ei- 

aminuiions,   1241 
Thighs,    amputation      of    both,      for    gan- 
grene.  1241 
Third,   Dr.   James,  1117 
Thirst  essay,  318 
Thomsens   disease,    286,   1156 
Thomson,  Wm.  H.,  M.  D.,  LL.  D..  the  re- 
lations of  tbe  public  to  the  medical 
profession,  967 
Thoracic  paralyticus,  significance  of,  612 
"Thread"    serum   reaction,   285 
Throat,  mercurial  affection  of  the,  705 
Throat  paralysis  in  locomotor  ataxia,  1240 
Thrombosis   In  cardiac  disease.  1043 
Thumb,  dislocations  of.  465 
Tonometer,   arterial  tension,  514 
Tonsilltis,  2!)6 

Tonsils  as  portals  of  infection,  205 
Tooth,  extraction  of  wrong,  364 
Tophi,   gouty,   881 
Toronto  Medical  School.  505  * 

University,  convocation,  597,   1117 
Torticollis,  spasmodic,  associated  with  bead 

nodding,  877 
Torticollis    treated    by    suture    of    stemo- 

mastold    tendon,    1235 
Touch,  sense  of.  107 
Toxic  effects  of  common  drugs,  203 
Trachea   wounds.  74 
Tracheoplasty,    805 
Tracheotomy,    experiences    with,    851 

intrathoracic,  333 
Trachoma,  study,  158 

treatment  by  bichloride  of  mercury,  713 
Trapezoia,  dorsal  dislocation  of,  109 
Trauma  as  an  existing  cause  of  paralysis 

agitans.  1017 
Traumatic    malignancy,   acute,   804 
Traumatism  during  intubation,  206 

of    pharyngeal    and     laryngeal     mncous 
membrane,    703 
Trichinosis.    1241 

Tropho— neuroses,      some     of      their      re- 
lations  to   vascular  diseases   of  ex- 
I  remit  ies.    1'242 
Thymotal,   406 
Thymus    gland,   341 
Thyroid    extract.    461 
In  Insanlt.v,  25 
Gland,    neoplasms   of   the.    16 
Pathology  and   diseases  of.   1150 
Surgery   of   the.    1083 
Tissue  in  the  larynx  and  trachea,  64S 
Tumors,    statistics   of   operative    treat- 
ment of,  16 
Tibia,    a    new    leg    splint    for    transverse 

fracture   of  the,   717 
Tics   convulslfs.   517 
Tinea    versicolor.    717 
Tissue,    lost,    161 

Tobacco  as  a  factor  in   glycosuria.  S51 
Toe-reflex,    great.    157.   2lW  . 
Tokio   hospital   burned.    413 
Tongue,    extirpation   of,    and   Boor  of   the 
mouth,  23 
Syphilitic  diseases  of.  55 
Trapezoid,    dorsal  dislocation   of,    109 

461 
Trichinosis  as  an  e<*onomlc  problem.  1022 
Trigeminus    svmptoms   as    initial    signs    of 

tabes,    892 
Trigger  finger,   surgical  clinic.  15S 
Trional,  a  case  of  causing  multiple  nearitis, 

856 
Trolley  ambulance  service.  1022 
Tropical    diseases,    school.    26S 

In   the   Philippines,   1065 
Tropon  and  plasmon,  2S2,  1090 
Trunk  deviations  etiology.  S91 
Tubercle,  the  histogenesis  of  the.  1160 
Tubercle    liadlli    question    of    destruction 
In  fatty  foods,   893 
In  Vienna  butter  and  buttcrlne,  723 
Ttiberole  bacillus,  variability  of,  1201 
Tubercular  lyniphoniata.  479 

Lesions  of  the  joints,  1M2 
Tuberculin   test,   tbe   value  of.   <iOS 


INDEX 


1269 


Tuberculosis  administrative  control,  83 
And  Uussian  Jews.  7.  04 
Anti-society.   507 
Bill.    196 
Bone.     lO-l 
Canada.  3t)7 

Conference   on.    in   (.'anada.    702 
Discipline   in.    1U2(> 

Extermination  through  dietetic  and  hy- 
gienic measures,   10.87 
Of   Fascia.    1041 
Failure  of  the  consensus  judgment  with 

reference    to,    Iti 
Forest  camps,  3(51 
Germany,    42.    234 
Hereditary,   588.    1004 
Hospital,    52 
Infantile,    etc.,    660 
Influence  of  work,  etc.,  114S 
In  prisons,   465 
In  sanatoria,  58 
Inherited,  53 

Intestine,   ileo-cecal   resection   in,   S84 
Iritis.   1040 
Laryngeal.    6,    115 
Of    pericardium,    active, 
Peritonitis,    treatment    of,    044 
Prevention   of.    49 
Primary  of  the  vagina.   1089 
of    the    parotid    gland,    1161 
Massive  of  the  spleen,  1159 
Pleuropulmonary,     499 
Pulmonary,  152.  1041.  1197 
and    board    of    health,    500 
In  childhood,   57,    109 
Prebacillary  stage,  106 
Prognosis    and    treatment,    14 
Racial    predisposition.    260 
Surgical   treatment  of,  611 
Symptomatic    treatment.    60 
Tracheal   injections.   334 
treatment  of.  152,  1239 
Pure  urea  in  the  treatment  of,  602 
Quarantine,    267 
Registration,    455,    497 
Renal.    1086 
Roentgen  ravs.  464 
Russia,    1082 
Serum  reaction,   160 
Simulating   appendicitis,    611 
Of  skin,  958 
Society  to  study,  266 
Submaxillary    gland.    642 
Tenement    house    problem,    379 
New  treatment  of,   47 
Treatment,    280,    609 
With  cinniamic  acid,  287 
Cinnamate  of  soda,   1045 
Use  of  tiokol  in.  641 
Value  of  Aroling  and  Courmont's  serum 

reaction    for.    723 
Widal   reaction   and.  959 
Tuberculous    convicts,  farm  for,  in  Texas, 
711 
Cows,  451 

Disease  of  the  upper  air-passages,   151 
Patients,     injection    of      sodium      cin- 
namylate.    662 
Tumor   of    the    brain,    653,    848 

Midbrain  symptomatology  of.   1155 
Multiple   primary   malignant,   1157 
Tumor    of    the    brain  and    sclerosis  of    the 

posterior    columns,    1202 
Tumors,  chorloepithelial  vaginal,  66 
Conjugal,   762 
Of  esophagus,  280 
Of    the    lung    malignant,    809 
Mammary,    204 
Pathology    of,    1161 
Pelvis.    763 
Turbinal  bodies  surgery,  513 
Turkey,  dangerous  office  in,  1117 
Turpentine    poisoning.    642 
Typhoid  afebrile.   215 

bacillus,   hemorrhagic   infection   due   to, 
16 
at  Goettineen,  1900.  891 
bacteria.    209 
Ijacteriology    of.    958 
bowel  lesion.  202 
among    British    troops.    99S 
clinical  use  of  therniol.  121 
colotyphus  with  the  lesions  in  the  large 

intestines.   725 
diagnosis.  290.   9.59 
dietetic  management.  ."^OS 
due   to   contaminated    oysters.   0."0 
dysentery    and    association    of.    725 
epidemic  of.  98 
fetal  and  infantile.  109 
fever  atypical  forms  of.  1082 
hemoglobinuria  complicating,  119 
hemorrhagic,    651 
hemorrhagic  diathesis.   376 
hemorrhagic  pancreatiti.s  in.  1159 
hospital  contagion  in.   1026 
human  blood  and  ba<-illi  of.  1159 


imuiunizafion.   466 

infeciion.  means  of.  9.')9 

.laundice.   200 

in   Manchester,  46.'! 

Leukoc.vtosls  and  the  variations  of  the 

polyomorphonuclcar  in,  793 
mutism  in.  1203 

orchitis  and  epididymitis  in,  1040 
pain  in.   915 

perforation.   1.38.   262.   417,   603 
pleurisy    and,    659 
peritonitis  in,  11(1 
and  pharyngeal  diphtheria,  1087 
some    complications    and     sequelae     of, 

1199 
surgical     intervention     in       perforati\'e 
cases  of.  90 
tendon  reflexes,  428 
treatment.  274,  .377 
of    gastrointestinal    symptoms.    207 
sustaining.  420 
urine,    disinfection.    81 
Tvphoid    psychoses,    279 
Typhus  bacilli,   ect..    162 
Tyson.    James.    M.    D..    Thoughts    on      the 
treatment  of  diabetes  nielUtus.  732 
further  report  on  a  case  of  presystolic 
murmur  associated  with   pregnancy, 
etc..  965 

I  I  leer,    chronic   of   the   stomach.   1005 

Of   the    stomach,    treatment,   1066 
Gastric.    150.    1045.     11.52 

And   mucomembranous  colitis,   1085 

Perforating,  61,  342.  714.  999,  1038 

Sex   of  patient,  148 
Of  the  leg,   treatment.   1044 
Peptic.    285 

Medical   treatment   of,   761 
Rodent.    136 

Roentgen    ray    treatment,    316 

rilman.   Dr.   Julius,  10 

Umbilical  cord   in  new-born   infants,    471 

Infection.    1087 
Umiliion    murder,    the,    805 
Unbroken   skin   as   an    absorbing   medium, 

207 
Unciaariosis,    preliminary    report    upon    a 

a   case  of,   1251 
Union    State    Hospital.    367 
Universal  language  for  science,  no,  588 
University,    Beiruth    medical,    54 
Of    Moscow,    414 
of   Pennsylvania,    122.    1027 

Medical  Class  of  1881,  1226 
Sued    by    Dr.    Hartigan,    12 
Urea,    metliods    of    quantitative   determina- 
tion in  the  urine,  896 
Urelae,    465 

Moore's    and    its    physiological    action, 
642 
Ureter,    divided,    treated    bv    direct    sutur- 
ing,  888 
Double,    422 
Ligature  of  the,  and  enucleation  of  the 

kidney,    17 
Obliteration   of   the   right,    by   calcified 

fibroid,   205 
Treatment  of  injuries  to  the,  16 
■Valve    formation,    followed    by    opera- 
tions,  882 
Vesical   implantation  of  the,  205 
Urethra  and  bladder,  self  inflicted  injury, 
58G 
gonorrheal   stricture  of  the,   1001 
Surgical   asepsis,   106 
Urethral    dilator-handle,    modified,    1199 

Implantation,   1042 
Urethrorectal    fistnla,    cured.    70.    138 
Urinary    bladder,    hernia    of,    1238 
C;alculi,    diagnosis,    271 
Constituents   oxidation.    284 
Hyperacidity,  435 
Stone,    417 
Tract,   histology  of,   600 

Urine   in   cardiac   affections:— 
Containing    bile    pigment,    2'28 
The    freezing    point    of    urine.    Its    de- 
termination     and      the      inferences 
which  may  be  drawn  from  It,  124G 
Incontinence   of,    12.'i7 
Incontinence  of,  Gersinui's  method,  886 
Some  errors  In  examiuation  of.  804 
Sul)Stance    agglutinating       blood      cor- 
puscles.  381 
Sugar    in    the.    Ill,    517 
Yeast    formation    in    sugar    containing 
In,    156 
Urotroplne  as  a  urinary  antiseptic.  271 
Ussher.    Clarence    D..    erysipelas    In    Ajla, 

984 
Uterine  deviations,   1088 
Fibroids.  55 


intrauterine   death,    the    pathology    of, 

803 
Myoma,  complicated  by  diabetes,  886 
Uterus,   atresia   of,    10(J4 

Bicornis  unicullls,  changes  In  two  cases 

of.   1043 
Cancer  of.  65.  148.  284.  872.  999,  1043 
Carcinoma   of.    Inoperable,       treatment 

with  calcium  carbid.  1240 
Of.    in    pregnancy.    887 
Congenital  cystic   degeneration  of.   800 
IHsease  of  and  gastric  aflfection,   188 
Fate  of  the.  in  abdominal  section.  1024 
Fibromatous.    in   labor.    (;5 
(iravid    uterus    with    fibroid,    impacted 

and  displaced,  269 
Hysterectomy    jfor   cancer,    10-44 
Indication   for  treatment  of,   805 
In   lai)or.   79 
Operation      on      an,      cootaioing      120 

fibroids,    657 
Pregnant,  in  position  of  latero  flexion, 

1089 
Supporting  the,  apparatus  for,  656 
Ventrosuspenslon,  round  ligament,  120i) 
Uvula,    pulsation    of    the,    1241 

VTaccinated  burglar  and  detectives,  458 

Vaccination  act,  constitutionality  of,  upheld 
in  Pennsylvania,  831 
aseptic,    importance   of.    719 
clinically  considered,   640 
compulsory.  742 
convicts.  595 
crusade   of.   98 
in   Bavaria  in  1899.  281 

public  schools.  316.  325 
of  hogs   and   sheep,   341 
Vaccine,    animal,    etc..    431 

virus,    an    undescribed    reaction    follow- 
ing.  1042 
Vaccinia   and   variola.   509.    701 

probable  relationship  of,  to  the  inoculat- 
ed form  of  smallpox  In  man,  1(538 
serous,    in    connection    with    cretinism 
and  rickets.  990 
Vachell.  Dr.  T.  C.  268 
Vagina   fixations.   1089 

Vagina,    extirpation   of   through    the    abdo- 
men. (57 
prim,  tuberculosis  of  the.  1089 
Vaginal  ablations.  918 

and  abdominal  section,  relative  advant- 
age. 65 
false  membrane,  due  to  bacterium  coll, 

injections.  Dr.  Kronig  "remarks.     66 
the  use  of  hot  water.  803 

obliteration  for  prolapse.  6(1 
Vallc.   Frances.   M.   D..   esophoria  or  latent 

squint.  866 
Vapo-cresolene,  poisoning.  110 
Varicocel;^.    the  treatment   of.   6.34 
Variola   and  varicella.   10S6 
Vein,  interna!  jugular,  ligature.  466 

varicose  of  the  lower  extremities,  opera- 
tive treatment.  15 
Veld  sore.  913 
Velde.    Dr..    147 

Vona  cava,   superior,   compression  of.  114 
Venereal  dise.ises.   control  of.  984 

of  horses.   118(1 

of  lower  animals.  260 

pliophylaxis  of.  663 

struggle  against  among  students.  654 
Ventricular  septum.  "24 
Veratnim.    vlride.    465 
V.>rnon.  B.nvater  John.  F.  R.  C.  S..  .326 
Version,    indication,    technique,    limitation, 

915 
Vertigo,   gastric  and   aural.  606 

mechanical    treatment.    516 
V.Tworm.  Professor  Max.  147 
V<>feiinarv  .\ssoilr,tion  of  Virginia.  12 
Virchow.   Rudolph,  birthdav  of.  954 

collection  destroyed.  507 

fund.  712 

stiftung.  S31 
Virginia  State  Board.  367 
VIsibilitv  of  the  ciliary  processes.  469 
Vision    In    the    dog.    cortical    disturbance, 
1.59  „ 

Visual  appar.itus.  net;ronlc  architecture.  467 

cortical  centres.   157 
Vital  statistics  of  Havana.  6.39 
Vitalitv  after  severe  injury.   1237 
Vitiligo,  etiology,  211 
Vivisection    and   antivlvlsection.    370 
VIvlsectionlst,   anti-,   literary   morals,  .358 
Volsollum  forceps.  Injury  caused  by,  lu  the 

cervix  uteri.  887 
Volvulus,  operation,  471 

and  Intussusception  of  Meckel's  diverti- 
culum, 86i 
Vomiting,  complicating  pregnancy,  1003 

imperative,  18 

recurr-^nt.  of  nervous  origin.  851 


1 270 


INDEX 


Vrateh,  new  journal  in  place  of.  1118 
Vulva,   elephantiasis  of  the,   295 

Walcher,  position  the,  during  parturition 
1114 

Walker,  Dr.  Anselle,  50 

Wallace,  Henry,  M.  D.,  specialism  and  some 
of  Its  relations  to  the  general  prac- 
tice   of    medicine,    1174 

Walled  off,   64 

Washington  Asylum  Hospital,  2C7 
Children's  Hospital,  197 

Water,   to   determine   the   oxldizal)illty   of, 
612 
value  of  Schumburg  method  of  purifica- 
tion for  military  purposes,  16 

Weiss,   Professor  Leopold,  414 

West,  Dr.  S.,  appointment,  1081 

Western  Hospital,   Montreal,   1117 

Wheeler,  Dr.  Thomas  Brown,  100 

Whey,  cream  modifications  in  Infant  feed- 
ing, 218 

White  blood  corpuscles,  new  method  of 
counting,    1187 

White,  J.  William,  The  topical  treatment 
of  focal  and  Jacksonlan  epl- 
lep.»y,  1102 


Whooping   cough,    430,999 
Essential  nature  of,  4S 
Paroxysmal   stage,   432 
Treatment,    78,ll,''i8 

Widal   test,   530,959.1042 

Wiener  mediclnisehe  Wochenschrift, 
136,147 

Wilde,  Dr.   E.,  .54 

Willard,  De  Forest,  M.  D.,  instantaneous 
dry  heat  for  external  application, 
electric  substitute  for  hot  water 
bag.    1070 

Wiilcox,  Dr.  W.  H.,  326 

Wilson,  Kobert  N.,  M.  D..  a  practical  mod- 
ification  of  the  ph^'nylbydrazin  test 
for  glycuria,   ('.24 

M'lnn.    Dr.  James  Mitchell,   death  of.  13 

M'innipeg    general    hospital,    505,1030 

MMnslow,   Dr.    Fred.   ('..   1.W9 

Winsum  Skull,  a  cranial  malformation,  601 

Wollenberg,    Professor,    54 

Woman  appointed  lecturer  on  anat- 
omy.  1230 

Womb  cancer  of  the  body  of  the,  269 

Women   doctors   in    South   Carolina,    946 
the  latest  on,  787 

Wood.  Major  General.  450,  598 

Woodbridge    treatment,     145 


Wounds,  cutaneous,  closure  by  suture,  334 

Infected,    treatment,    429 
Wrist,    congenital    deformity,    806 

Verosis  -bacillus    in  spreading   phlegmon, 

vrale   medical   school,   504,638 

Yeast,  fermentation  by,  404 

In   the    digestive    tract,    428 

therapeutic  value.  451 
Yellow   fever,    192.   512,   753,   1198 

In  Havana,   1230 

Incubation.     513 

Propagation  by  culex  fasclatus,  694 

Transmission.  3.">7 
i'ellowstone   Park  and  the  St.   Paul  meet- 
ing.   751 
Yohimbin  and  its  salts,  466 
Y'ukon   health,    412 
Y'oumans,  Dr.  William  Jay,  death  of,  751 

yiegler,    Dr.    S.    Lewis,   941 

Zoology,    the      teaching      of    In      medical 

schools.    1086 
Zymotic  disease,  immunity  against,  762 


1968 


R      The  Philadelphia  medical 
11        journal 
P5 
V.  7 

&  Medical 


PLEASE  DO  NOT  REMOVE 
CARDS  OR  SLIPS  FROM  THIS  POCKET 

UNIVERSITY  OF  TORONTO  LIBRARY 


«-,-